Cephalosporins

Cephalosporins

Chronic obstructive pulmonary disease -- chronic bronchitis & emphysema

COPD 

Clinical Lab Values

Cushing's Syndrome

Cushing’s syndrome

Syndrome: increase in glucocorticoids (primarily cortisol).

-Disease: happens when the pituitary releases ACTH. ACTH will cause other stuff to be elevated as well such as androgens, and MSH (POMC splits up into ACTH and MSH or melanocyte stimulating hormone)… get other symptoms like hirsuitism and hyperpimentation. Will respond to high dose dexamethasone suppression test.

-Ectopic ACTH ( small cell carcinoma of the lung – bronchial carcinoma & thymoma). Will not respond to dexamethosone.

-Adrenal tumor: get low ACTH but high Cortisol.

Hypothalamus—PVN (paraventricular nucleus) à CRH à Pituitary à ACTHà Adrenal glands à Cortisol

Diagnosing Diabetes

 Diagnosis of Diabetes is done using one of the following criteria:

1) glucose lvl of 125mg/dL or higher after an 8 hour fast.  Have to see this on two separate occasions.

2)  Random glucose of >200 mg/dL

3) HgA1C >6.5 %.  Have to see this on two separate occasions.  Although you can still use the 8 hour fast, using the HgA1C is now becoming preferred.

4)  Glucose tolerance test  >200mg/dL within 2 hours of giving 75g oral glucose.

Diseases of Heart Muscle

Disease of Heart Muscle

EKG values

1 small box = 1 mm = 40ms = .1mV amplitude

1 large box = 5 mm = 200ms = .5mV amplitude

Normal PR = 120-200 ms (3 to 5 small boxes)
.... prolonged in incrased K or Mg, first degree heart block (AV node block)
.... shortened in pre-excitation via accessory pathway (Wolff-Parkinson-White sydnrome)

Normal QRS = 60-100ms (3 small squares or less)
...widened in increased K or Mg,

Q wave should be less than 1/3 the height of the R wave.  If its higher.... think Myocardial Infarction.

T waves
-peaked --> hyperkaelemia
-negative... normal in lead aVR. (also possible in aVL, aVF, III) Lead V1 may have a positive, negative, or biphasic T wave.
..otherwise, can indicate Coronary ischemia, LVH.

U waves -- come right after T waves
-in hypokalemia, hypercalcemia, thyrotoxicosis

Endocrine & Metabolic disturbances in Chronic Renal Failure

Chronic renal failure--> decreased clearance of phosphate --> hyperphosphatemia --> decreased production of activated vitamin D (1,25 dihydroxy) --> hypocalcemia --> hyperparathyroidism --> hypercalcemia, renal osteodystrophy

hyperphosphatemia --> vascular calcifications --> calciphylaxis (necrotic skin lesions)

Men:  decreased testosterone
Women: amenorrhea, infertility, hyperprolactinemia

Pruritis

Heart Sounds

Hematology

Hepatic Biliary and Pancreatic ducts

How does the HIV virus infect host cells?

How does AIDS virus infect?

• HIV virus has gp120 (a surface protein) that has binding sites for CD4 molecule on the surface of CD4+ T cells. 
• HIV virus gp120 also is able to bind to coreceptors CCR5 and CXCR4 on the surface of CD4 T cells.  These coreceptors are invovled in allowing HIV entry into the cell.
• Individuals with homozygous mutations of CCR5 become resistant to HIV.
• Other cells that HIV infects:
• Monocytes and macrophages (serve as reservoirs of HIV and may allow entry into CNS)
• Neural cells (by two ways:  through CD4 receptors OR through receptor sites for neuroleukin.
• Microglial cells of CNS
• Dendritic cells, Langerhans cells,

Proviral DNA is integrated into the Host genome (Latent stage)... it can remain like this for a while producing low-level virion production.  However, it can be reactivated (possibly by infection of EBV or CMV).

Spread:  blood, semen, vaginal secretions, breast milk, saliva

ID Gram+ and Gram- Organisms

Increased intracranial pressure and hyponatremia

We normally experience symptoms of hyponatremia when sodium levels fall below 120 mEq/L.  However, an exception to that is during states of increased intracranial pressure (as in a head injury). 

The Monro-Kellie hypothesis states that the cranial compartment is incompressible, and the volume inside the cranium is a fixed volume. The cranium and its constituents (blood, CSF, and brain tissue) create a state of volume equilibrium, such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another.^[5]

So, if somebody gets hit in the head with a bat and start bleeding (thus having an increased ICP) and then on top of that has hyponatremia...which causes the brain to swell (brain cell uptake water)... the ICP will rise even more... so the patient will experience symptoms of hyponatremia earlier than somebody without increased ICP to begin with.

Increased ICP is a clinical feature of hyponatremia (so somebody without any increase in ICP will eventually have an increased ICP given that the Na goes down enough to cause the brain to swell).  Increased ICP and cerebral edema are the cause of the neurological features in hyponatremia:  headache, delirium, brisk DTRs, weakness, seizures, coma.  Increased ICP will also cause hypertension.

Lung Neoplasms

Lung Neoplasms

Managing DKA and HHNS

DKA (Diabetic ketoacidosis)

-make sure not hypokalemic,  give k 1-2 hr after starting insulin
-hydration -- start immediately
-insulin -- .1u/kg infusion, then .1/kg/hr till you get to 250 mg/dL glucose.. then add 5% glucose D5 1/2 NS.

HHNS (hyperosmolar hypeglycemic nonketotic syndrome)

-1 L NS fluids in first hour, then 1 L NS over next 2 hours
-1/2 NS once patient is stable
-give D5 1/2 NS (add 5% glucose) once the glucose level is down to 250 mg/dL.
...> you dont want to lower glucose too fast as it can cause cerebral edema
-give Insuline 5-10 U bolus.  then 2-4U/hr

Meningitis

Acute Bacterial Meningitis
causes::
Neonates  -- Group B strep > E. Coli > Listeria monocytogenes
Children>3m -- Neisseria meningitidis > Strep Pneumo > Listeria
Adults (18-50) -- S. Pneumo > Neisseria > Haemophilus Influenza
Elderly (>50) --  S. Pneumo > Neisseria > Listeria
tx: ceftriaxone or cefotaxime+vancomycin+ampicillin
Immunocompromised -- Listeria > gram-neg bacilli > S. pneumo
tx:  ceftazidime+ampicillin+vancomycin

CSF::
Aseptic -- mostly lymphocytes and monocytes, WBC <1,000, normal glucose.
Bacterial -- mostly PMNs. high WBC (>1,000), Low glucose.

Clinical:
symptoms:  headache, fever, stiff neck, n/v, photophobia, Altered mental status.
signs:  stiff nech, Rashes (neisseria-> purpura), vesicular lesions (HSV, Varicella), increase in ICP (causes papilledema, seizures), CN palsies,
Kernig's sign-- cant extend knees when lying down with hips flexed 90 degrees
Brudzinski's sign-- passive flexion of the neck causes flexion of the legs and thighs.

Pleural Diseases

Disease of the Pleura

Reading Flow volume loops

Reading Flow volume loops

... can be somewhat confusing.  the axis are all screwed up in my opinion... thats what i determined after looking at this for the past 10 minutes.

Anyhow, you wanna look at things like TLC (total lung capacity), FEV1 (amount of air the person can blow out in the first second), and FEF50%.
FEF50% -- forced expiratory flow (the average speed of air coming out of the lung during middle portion of expiration)... which is low in both obstruction and restriction (but especially in an obstruction).
TLC is increased in obstructive.
 

A- normal
B-obstructive
C-restrictive
D-obstruction of upper airway.

Skin conditions

Small bowel obstruction vs. Large bowel obstruction

Comparison of small bowel obstruction (SBO) and LBO features :
Small bowel------------------------Large bowel

Bowel diameter (cm)
>3 and <--------------------------- >5

Position of loops
Central-----------------------------Peripheral

Number of loops
Many-------------------------------Few

Bowel markings
Valvaulae---------------------------Haustra
(all the way across)-----------------(partially across)

Vasculitis diagnosis symptoms

Diagnosis and symptoms of vasculitis.

There are 3 main categories of vasculitis.  In all types, the blood vessels get inflammed and the organ supplied by that blood vessel can get necrosed (so you can even have tongue necrosis in something like Temporal arteritis if the blood vessels).   Symptoms are based on the endorgans affected.  Diagnosis usually requires measuring lvls of ESR, certain antibodies (p-ANCA, c-ANCA) and most importantly biopsy of effected tissue.

Large Vessel:
-Temporal arteritis (aka Giant Cell arteritis, older females, associated with polymalgia rheumatica, involves most commonly the temporal artery, biopsy is 90% sensitive, elevated ESR)
-Takayasu's (young Asian women, involves aortic arch and its branches, diagnose with arteriogram)

Medium Vessel:
-Kawasaki's (in kids)
-Churg-strauss (involves many organ systems, p-ANCA association, poor prognosis, biopsy of lung or skin tissue to confirm diagnosis)
-Wegner's granulomatosis (involves mainly the kidneys and upper/lower respiratory tracts, nodules/infiltrates on chest radiographs, c-ANCA association, very high ESR, open lung biopsy to confirm diagnosis)
-Polyarteritis nodosa or PAN (No pulmonary involvement, involves GI and nervosus system vessels, biopsy of involved tissue or mssenteric angiography)
-microscopic polyangiitis

Small Vessel:
-Henoch-Schonlein purpura
-Hypersensitivity vaculitis (caused by drug reaction, infection or other stimuli, Skin involvment: palpable pupura, macules, or vesicles, have to do biopsy to diagnose)
-Bechet's syndrome (oral and genital ulcers, have to do biopsy to diagnose)
-Buerger's disease (aka Thromboangiitis Obliterans, associated with smoking, affects arms and legs,