Nephrology
Most common cause of euvolemic hyponatremia.
SIADH
A 29 yo M presents with pleuritic chest pain and diffuse ST elevation of EKG.
Pericarditis
What are the indications for outpatient oxygen use in COPD?
SpO2<88% or PaO2<55%
What class of antibiotics is used to treat Prostatitis?
Fluoroquinolones or Bactrim
Fever, weight loss, constipation, muscle weakness, bone pain, normocytic anemia, renal insufficiency, lytic bone lesions.
Multiple myeloma
Dx= M spike on serum electrophoresis
A 26 yo F marathon runner presents with seizures and AMS. Her coach swears she hydrated aggressively both before and during the marathon. What is this?
50 Bonus points: pathophysiology?
Exercise induced Hyponatremia—
large amount of hypotonic fluid ingestion + Excessive ADH excretion from non-osmotic stimuli (exertion, pain, nausea, hypoglycemia)
What two medication classes have been shown to decrease morbidity and mortality in heart failure and how?
Beta-blockers and ACE-i
Both slow cardiac remodeling:
-B-blockers--decrease epinephrine and norepinephrine)
-ACE-I--decreased aldosterone
List four causes of ARDS.
Treatment of ascites in decompensated cirrhosis?
Sodium restriction, spironolactone, and furosemide improve ascitic and peripheral fluid retention;
Avoid ACE-I, ARBs, NSAIDs, and EtOH (ACE-I and ARBs cause organ hypoperfusion in those with decomp cirrhosis)
Pathophysiology of anemia of chronic disease?
Increased Hepcidin (acute phase reactant) --> decreased iron absorption and decreased iron release from Reticuloendothelial system --> decreased iron available to make RBCs --> microcytic to normocytic anemia and decreased reticulocyte count
What medication class offers renoprotection in diabetic nephropathy and renal artery stenosis and how? What do you need to monitor?
-ACEi: decreases angiotensin II --> dilation of efferent arterioles --> reduced intraglomerular pressure and ischemia
-Decreased GFR leads to a higher risk of AKI, so need to monitor renal function (Cr rise <30% acceptable)
-also monitor for hyperkalemia
You respond to a first team for a pt on the cardiology floor. Pt is a 71 yo M that is s/p acute MI 5 days ago. He had a 95% left main coronary occlusion and underwent a Coronary Artery Bypass Graft at that time. He began complaining of abrupt chest pain and shortness of breath 5 minutes ago. He is diaphoretic, pale, and appears to be in shock (JVD, tachycardia, hypotension). He has no audible murmur, but heart sounds are very distant. He then loses consciousness. What is the source of this patient’s sudden decline?
Ventricular free wall rupture --> cardiac tamponade (post-MI complication = 5 days-2 weeks)
Name the Light’s criteria? (3/3)
Transudative vs exudative pleural effusion. Transudative only if all three are met:
1. Pleural fluid protein/ serum protein = 0.5 or less
2. Pleural fluid LDH/Serum LDH ratio = 0.6 or less
3. Pleural fluid LDH < 2/3 upper limit of normal serum LDH
Low glucose = empyema, malignancy, or RA
Describe the pathogenesis of Hepatorenal syndrome.
Portal HTN --> splanchnic nitric oxide production --> systemic vasodilation --> end-organ hypoperfusion (decreased renal perfusion) --> Activated RAAS, sympathetic NS, and ADH release --> worsening volume overload
Name four antibiotics with Pseudomonas coverage.
A 40 yo F with a history of SLE is followed by medicine for massive proteinuria (3.6 g/24hrs), periorbital and peripheral edema, and hypoalbuminemia. On day two of hospitalization, the patient has sudden onset unilateral flank pain and hematuria. What should you be concerned about and what is the etiology?
First line medication for Hypertrophic cardiomyopathy?
Metoprolol: Increases filling time and end-systolic volume --> decrease LVOT obstruction
Name 4/7 components of the Wells criteria for PE.
What is the grading scale used to assess survival rate and likelihood of complications in cirrhosis? Name the 5 components.
Child-Pugh Score
Components: Albumin, Bilirubin, INR (coag), Ascites (distended abdomen), Encephalopathy; ABCDE
A 55 yo male is brought in by his wife with chief complaints of headache, chest pain, and altered mental status after he had been working in his garage. The pt is confused, drowsy, and weak on exam. Labs reveal severe metabolic acidosis (pH 7.14, lactate= 10mmol/L), normoglycemia, and you see ST-elevation on EKG.
What is the initial and definitive management for this patient?
Carbon monoxide poisoning
Carboxyhemoglobin: >3% (non-smokers), >10-15% (smokers)
Initial management: 100% oxygen via non-rebreather
Definitive: Hyperbaric oxygen (neurologic manifestations, Acute MI, severe acidosis)
Sodium Bicarbonate delays clearance of CO
A 56 yo M presents with sudden onset SOB that is worse while lying flat. He had a similar presentation 6 months ago and responded well to diuretics. He has a history of HTN, CAD, a TIA, and a carotid endarterectomy. He is a current smoker with a 30 pack year history. His blood pression is 205/100, oxygen saturation is 87%, he has jugular venous distention, and bilateral lung crackles. His extremities are without edema. Labs show elevated serum bicarbonate, hypokalemia, and a creatinine of 2. What is the Dx?
-Flash pulmonary edema from Renal Artery Stenosis
- Renal ischemia --> activated RAAS --> sympathetic NS, ADH --> Na+ and water retention, generalized vasoconstriction, and HTN; Labs show secondary hyperaldosteronism (high bicarb/metabolic alkalosis and hypokalemia), can have flash pulmonary edema
75 yo M presents with occasional palpitations and episodes of sudden dizziness followed by syncope. He also complains of as generalized fatigue, dyspnea, and exercise intolerance. He had an anterior MI one month ago. On exam, you notice obvious pulsations in the jugular veins. What is the best next test? What are you likely to see?
EKG--Third degree heart block
Anterior myocardial infarcts can affect the AV node and are more likely to progress to third degree AV block
-obvious bounding jugular veins = canon A waves from AV dissociation --> Right atrium contracting against closed tricuspid valve
-Syncopal episodes = “Stokes-Adams attacks” = LOC from ventricular asystole
How is ARDS diagnosed (Berlin criteria)? (3/4)
1. Acute onset respiratory failure within a week of known predisposing factor or worsening symptoms.
2. Bilateral opacities on imaging
3. Hypoxemia (PaO2/FiO2 <300 mmHg
4. Cannot be accounted for by HF or fluid overload (PCWP<18)
How is ascites fluid evaluated to determine the etiology?
Serum albumin to ascites fluid albumin gradient (SAAG)
1.1 or more = portal HTN
<1.1 = not due to portal HTN; malignancy, TB, nephrotic syndrome
Total protein < 2.5 = cirrhosis or nephrotic syndrome
Neutrophils 250 or greater = SBP
What lab can be used to differentiate between an androgen secreting neoplasm of the ovary versus the adrenal gland in women?
DHEAS.
Both ovarian and adrenal neoplasms secrete testosterone and DHEA. Only adrenal neoplasms secrete DHEAS (dehydroepiandrosterone sulfate)