furosemide to spironolactone ratio

- 2/5

triad of acute interstitial nephritis

-fever

-eos

-rash

etiology- drugs, infection

angioedema and rash (urticaria)

IgE mediated

direct mast cell mediated (nsaids, contrast)

vasculitis

Pulmonary infiltrates

farmer's lung

parasitic (strongyloides, aspergillosis) - eos!

loeffler's endocarditis - eos

autoimmune churg strauss

HCV + rash = type II cryoglobulinemia (30-40%) can get palpable purpura and cidp (chronic inflammatory demyelinating polyneuropathy), type I membranoproliferative

what is the classic paraneoplastic syndrome w/dermatologic manifestations?

dermatomyositis (lung cancer)

asymptomatic eosinophilia? could be strongyloides DONT give steroids - causes devastating sepsis

give ivermectin

DRESS- drug rash w/eosinophilia and systemic symptoms

eosinophilic leukemia? very rare entity but when happens ^^^^^^eos

eosinophilia mnemonic

Neoplasm (ovarian)

Asthma

ASA/adrenal

Connective tissue disorder

Parasitic

chronic urticaria think thyroiditis

^^^B12 seen in polycythemia vera

hypereosinophilic syndrome marker - anti-PDGRFalpha/beta

aspirin allergy - nasal polyps

what estimates risk of stroke in non rheum a-fib?

CHADS2

chf

htn >140/90

age >75

dm

stroke (prior)

nares swab for influenza - 66% specific 100% sensitive

causes of A-fib mnemonic

Pulmonary (pe/copd)

Iatrogenic

Rheumatic

Atherosclerotic

Thyroid (hyper)

Endocarditis

Sick sinus

cardinal rule for history if you suspect environmental exposure - anyone else w/same sickness?

cholesterol emboli can mimic vasculitis.

wegener's patients may have a neuropathy

two cases in which you would expect a thrombocytosis?

1. anemia

2. thrombocytosis as an acute phase reactant

bacterial causes of hemoptysis

klebsiella, tb, pneumococcus, staph aureus

UGIB is 80% of all GI bleed

dx pud, avm, varices, gastritis, gave

surgeons ask for the hematocrit, physicians ask for the hemoglobin - hemoglobin is better because it is measured

shingles vaccine is a live vaccine, its more effective when you give it younger, effective even if you've already had an outbreak of shingles

heart rate best way to test for orthostasis, not bp

fecal antigen test for h. pylori ~100% sensitive

anti dsDNA levels used to monitor severity of lupus

which antibiotics cross the BBB?

azithromycin at high doses

vancomycin

zosyn does not cross bbb

tubes and lines radiology

icu tubes and lines

endotracheal tube should be ~T4-T5 on portable chest xray for good position

flexion/extension can move the ETT as much as 2cm

complications of ET tubes

dislodgment

vocal cord injury

mainstem bronchus

put in esophagus

laceration

tracheostenosis/malacia

tracheostomy tube put in level of 3rd tracheal cartilage, not effected by motion of head

complications

emphysema, pneumomediastinum, pneumothorax

get xray after putting them in

central venous catheter

usually from IJ, tip should be in SVC, not atrium b/c can cause arrhythmias

malposition

air embolism

pneumothorax/hemothorax

cardiac perf

sepsis

venous perf

picc

small caliber

can left for long duration

preferred to end in svc

do NOT ever attempt power injecting into these lines

malposition

ectopic infusion into mediastinum or pleural space

catheter breaking/embolism

puncture blood vessel

clot

air embolization

chest tube

should always run medial to inner margins of ribs

chest tube

posteoinferior for effusion

anterosuperior for pneumothorax

complications

bleeding/laceration, rapid expansion leads to flash pulmonary edema

bp fistula

ng tubes

at least 10 cm should be in stomach

risk malposition, perf the esophagus, over time indwelling tubes reflux

intra-aortic balloon pump

inflate during diastole - increase return to coronary arteries,

pulmonary artery catherter aka swan ganz

dx cariac and non cardiac pulmonary edema

should be in pulmonary artery WITHIN THE MEDIASTINAL SHADOW

can cause pulmonary infarction (balloon inflated for long time)

embolization (tip breaks off)

perf the artery

more clinical tips in internal medicine

metastatic thyroid looks like miliary on cxr

miliary cxr?

pcp

tb

histoplasmosis

varicella

sarcoid increased cd4/cd8 ratio

increased AST/ALT + ^MCV + ^GGT = alcohol

BNP is falsely low in obese and falsely high in kidney failure

^K+? tx kayexolate, calcium gluconate

rifaximin - to treat hepatic encephalopathy

lasix/aldactone ratio is 2/5

spontaneous bacterial peritonitis ppx = ceftriaxone 1mg iv daily

triad of acute interstitial nephritis = fever, eosinophilia, rash

etiology mostly likely drugs or infection

angioedema + urticaria etiology is...

IgE mediated

direct mast cell activation (contrast nsaids ...)

vasculitis

Pulmonary infiltrates + eosinophilia

farmer's lung

parasitic (strongyloides, aspergillus, loeffler's)

autoimmune (churg strauss..)

cxr 101

chest x-ray 101

methodology - look at

bones, soft tissues, heart/mediastinum, lungs, airways, upper abdomen

pa view preferred because doesn't magnify the heart

spine sign - decreasing intensity of spin as you go caudal on the lateral view xray

silhouette sign - loss of margins bc two structures of similar densities sitting next to each other

atelectasis - incomplate expansion of portion of lung

sail sign - silhouetteing of left diaphragm for left lower lobe atelactasis, mass

s sign of golden - right upper lobe collapse, (anterior collapse), reverse s sign on pa, right side - obstructive mass causing collapse

pneumonias -

PCP pneumonia seldom if ever cause pleural effusion

with PCP you get sharp costophrenic angles and possible cystic structures (PCP)

septic emboli - rh valves peripheral thrombophlebitis etc.. predominant peripheral lung disease, ct more sensitive than cxr, see nodles, feeding vessel sign, cavitation, wedge lesions

tb can look like anything!

ghon complex, cavitary, miliary, they appear everywhere- (spread by blood)

left hilum normally higher than right hilum, if reversed indicates potential atelectasis

intersitial edema - kerley b lines (transverse near lower lung fields, septal lines)

alveolar edema - begin to lose vessels

medicine day one odds and ends

volvulus - section of bowel twists on itself creating and obstruction and proximal dilation

ogilvie's syndrome - an acute pseudo obstruction of colon in absence of any mechanical cause normally 2/2 neuro, post-op, parkinson's

infxs megacolon picture is more tenderness/sick/fever

Sinemet can give decrease peristalsis

Amitiza (lubiprostone) ^NaCl secretion in lumen of GI used for constipation/hard stool

Miralax = polyethylene glycol, an osmotic agent for constipation/hard stool

Colace - coats stool to help movement

Pericolace - docusate +senna

decubitus ulcer tx - wound vac/pack it w/gauze, keep off it!

calling a consult?

1. identify yourself

2. patient name and mrn

3. one-liner, relevant labs/imaging

4. whats the question??

start medicine rotation tomorrow

in church today i was reading 1 timothy a few interesting points

"do not muzzle an ox that is treading grain" in reference to letting those that are doing god's work be able to preach teach talk etc..

don't speak harshly

speak to older men and women as if they were your fathers or mothers

speak to younger men and women as is they were brothers and sisters

sins can be conspicuous and precede a man into judgment, other mens' sins follow them into judgment

and the sermon had a message i agreed with, the central thesis was "do not prepare your defense in advance" in my opinion referring to the mental emotional state of having a clean conscience such that your positions on matters of the past and present are at your fingertips, unified with your own personal integrity, there is no clever planning or posturing or trying to create a defense. if you have to defend your position, just draw from what you know thinking "on your feet"*, which is the truth, hopefully that you are in harmony. that spoke to me.

*if there are details that you need to remember that are subtle i think its ok to go over those in advance

internal medicine rotation starts tomorrow!