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Loie Fuller: The Art of Illusion * Known for her innovative use of fabric, light, and color to create captivating visual illusions in performance. * Her work emphasized the image created rather than the physicality of the dancer's body, marking a shift in performance art. * Patented several costume and set designs, including the iconic Serpentine dress and the glass floor for Fire Dance, showcasing her ingenuity. * Premiered notable works such as The Serpentine (1889) and Fire Dance (1895), which were pivotal in her career. * Succeeded in creating an aesthetic transformation, emphasizing individual interpretation of visual experiences. Isadora Duncan: The Mother of Modern Dance * An eccentric figure who rejected traditional ballet, favoring movement inspired by emotion and nature's rhythms. * While she did not create a new dance technique, she introduced a new motivation for movement, rooted in nostalgia for Ancient Greece. * Her philosophy emphasized that motion should be driven by emotion and expressed through the entire body, leading to a more natural form of dance. * Duncan's choreography was improvisational, focusing on feeling over form, and drew inspiration from her childhood innocence. * Her performances in St. Petersburg (beginning in 1904) inspired contemporaries like Fokine and Nijinsky, influencing the broader dance community. * Left a legacy of natural, emotional dancing, characterized by bare feet and flowing costumes, as seen in works like Ballspiel (1906) and Five Brahms Waltzes. The Denishawn School and Its Legacy Ruth St. Denis and Ted Shawn: Pioneers of Dance * Ruth St. Denis was captivated by exotic and oriental themes, famously inspired by an Egyptian cigarette poster featuring the goddess Isis. * Her dance Radha was a significant work that launched her career, showcasing her understanding of spectacle and audience engagement. * Ted Shawn played a crucial role in introducing men to professional dance, emphasizing powerful and athletic movement. * He founded an all-male dance company, Ted Shawn and His Male Dancers, and was a driving force behind the Denishawn School. * Shawn established Jacob’s Pillow, a significant dance venue in Massachusetts, which remains influential today. * Their collaboration and individual contributions helped shape the landscape of American dance. The Denishawn School: A Foundation for Modern Dance * Established in Los Angeles in 1915, Denishawn was the first dance school in the U.S. to produce a professional company. * The curriculum included a variety of styles, with a typical day comprising stretching, ballet, Oriental dance, and yoga meditation. * The school closed in 1919, but the Denishawn Company continued to tour, becoming the first U.S. company to perform in the Orient in 1925. * The school created a lineage of dancers, including Martha Graham and Doris Humphrey, who would further develop modern dance. * Denishawn's approach combined various techniques, allowing for a diverse exploration of movement and expression. * The legacy of Denishawn is evident in the evolution of modern dance and its emphasis on personal expression. The Big Four: Shaping Modern Dance Doris Humphrey: The Architect of Dance * Studied at Denishawn from 1917 to 1928, where she formed a creative partnership with Charles Weidman. * Known for her movement theory of 'fall and recovery,' which emphasizes the dynamics of balance and gravity in dance. * Established the Humphrey-Weidman Company in 1928, focusing on structure and technique in choreography. * Authored The Art of Making Dances, which codified choreographic design and emphasized ensemble work over solo performance. * Her choreography often explored themes of human experience and emotion, as seen in works like Water Study (1928). * Left a significant impact on modern dance through her innovative techniques and teachings. Martha Graham: The Psychological Pioneer * Studied at Denishawn from 1916 to 1923, where she developed her unique style of modern dance. * Her first concert as an independent artist in 1926 marked the beginning of the 'Heroic Age' of modern dance. * Graham's choreography often drew from psychoanalysis, focusing on the inner emotional landscape and reinterpreting patriarchal narratives. * Developed the Graham Technique, centered on contraction and release, which became the first codified modern dance technique. * Her company is recognized as the first truly modern dance company, celebrating its centennial milestone. * Graham's legacy includes a profound influence on the perception of dance as a serious art form. Ausdruckstanz and Its Influencers Rudolf Laban and Mary Wigman: Movement Innovators * Ausdruckstanz, or 'expressive dance,' emerged as a response to the cultural movements of the early 20th century, paralleling American modern dance. * Rudolf Laban, a movement scientist, developed a system of movement training and Labanotation for dance notation. * Laban's Movement Choirs allowed for structured improvisation, making dance accessible to all, regardless of training. * Mary Wigman, Laban's student, became a leading figure in German dance, known for her harsh and grotesque style. * Wigman's work often explored apocalyptic themes and the validity of all movement, including the ugly. * The rise of Nazism interrupted the development of Ausdruckstanz, impacting both Laban and Wigman's careers. Hanya Holm: Bridging Cultures in Dance * A student of Mary Wigman, Holm opened the Wigman School in NYC, later renamed the Hanya Holm School of Dance. * Known for her teaching talent, she blended American objectivity with German subjectivity in her methods. * Holm's approach produced highly skilled dancers, emphasizing detailed movement and expression. * Her influence extended through her students and the techniques she developed, contributing to the evolution of modern dance. * Holm's legacy is marked by her ability to adapt and innovate within the dance community. Key Influential Choreographers José Limón * Notable works include The Moor’s Pavane (1949), There is a Time (1956), and Missa Brevis (1958). * Developed the Limón Technique, which emphasizes movement through positions rather than the positions themselves. * Integrates breath (inspired by Doris Humphrey) and gesture (inspired by Charles Weidman) into dance. * Core principles include breath, fall and recovery, succession, and opposition, promoting a holistic approach to movement. * Describes the body as an orchestra, highlighting the importance of coordination and expression in dance. Lester Horton * Born in Indianapolis and moved to Los Angeles in 1928, where he became influenced by Native American cultures. * Inspired to pursue dance after witnessing a Denishawn performance, leading to the creation of the Horton Technique. * Established the first interracial dance company and the Lester Horton Dance Theater, which was the first venue dedicated to modern dance. * Horton Technique focuses on body actions viewed artistically, emphasizing anatomy and conditioning in exercises. * Known for the 17 Fortifications, which include movements like flat backs and lunges, producing versatile and articulate dancers. Katherine Dunham * A pioneer in integrating Black dance traditions into modern dance, she is recognized as the first dance anthropologist. * Conducted research in the West Indies, studying dance as a cultural expression, supported by fellowships from the University of Chicago. * Founded the Katherine Dunham Dance Company and the Dunham School for Arts and Research in 1945. * Major contributions include paving the way for Black dancers and establishing dance anthropology as a field of study. * Developed the Dunham Technique, which combines ballet and modern dance with Afro-Caribbean movements, often accompanied by jazz or polyrhythmic percussion. Modern Dance Techniques Horton Technique * Focuses on the body and its basic actions, viewed through an artistic lens, with a strong emphasis on anatomy and conditioning. * Inspired by 'primitive' cultures, it incorporates movements that reflect these influences. * Training includes foundational movements such as flat backs, lateral T, and lunges, aimed at creating dancers who are 'long and strong'. * The technique promotes versatility and fluidity in movement, allowing for detailed expression. * The Horton class at Butler University exemplifies the application of this technique in a structured learning environment. Limón Technique * Emphasizes movement through positions rather than static positions, focusing on the flow of movement. * Integrates breath and gesture, creating a dynamic interplay between the two. * Built on principles of fall and recovery, succession, and opposition, which are essential for expressive movement. * The concept of the 'body as an orchestra' highlights the importance of coordination and musicality in dance. * Instruction in this technique encourages dancers to explore their physicality and expressiveness. Dunham Technique * Combines principles of ballet and modern dance with a focus on torso isolations and Afro-Caribbean movements. * Musical accompaniment typically features jazz or polyrhythmic percussion, enhancing the cultural fusion in the dance. * The technique showcases a blend of American dance and Black dance heritage, enriching the modern dance landscape. * Dunham's work emphasizes the importance of cultural context in dance, reflecting her anthropological background. * The technique has influenced many dancers and choreographers, expanding the scope of modern dance. Postmodern Dance Movement A Postmodern America * Emerged in 1945, following WWII, characterized by skepticism and socio-political unrest. * Youth culture began to rebel against the traditional values of their parents, leading to significant cultural shifts. * Key events of the 1960s, such as the Women's and Civil Rights Movements, shaped the artistic landscape. * The assassinations of prominent figures like JFK, MLK, and Malcolm X, along with the Vietnam War and Cuban Missile Crisis, influenced the themes in postmodern art. * This period marked a departure from traditional narratives in dance, paving the way for new forms of expression. Merce Cunningham * Regarded as a revolutionary figure in the arts, comparable to Picasso and Stravinsky, he danced with Martha Graham from 1939 to 1945. * Challenged the necessity of meaning in dance, often at odds with the groundedness of Graham's technique. * Founded the Merce Cunningham Dance Company in 1953, which continued until 2011, following his wishes for a legacy tour. * His technique blends ballet and modern styles, emphasizing verticality and clarity of form. * Cunningham's choreography often utilized chance methods, allowing for equality among movements and ideas. Paul Taylor * Danced with Graham, Cunningham, and Balanchine, becoming a significant figure in modern dance. * His choreography reflects a unique blend of influences, resulting in a distinctive style that remains relevant today. * Taylor's work is characterized by openness to movement possibilities, creating a varied body of work. * While he did not codify a specific technique, his signature style incorporates balletic ideas with a more connected performance feel. * His choreography often features a two-dimensional aesthetic and specific movement shapes, such as the Taylor V. The Judson Dance Theater and Grand Union Characteristics of Postmodern Dance * Rejects the boundaries between high and low art, promoting a more inclusive artistic dialogue. * Emphasizes process over product, focusing on the exploration of ideas rather than traditional narratives. * Disregards the boundaries between different art mediums, allowing for a fusion of styles and expressions. * The Judson Dance Theater served as a public performance space for experimental movement artists, fostering innovation in dance. * Grand Union furthered these ideals, creating a collaborative environment for diverse artistic expressions. Overview of Postmodern Dance Key Characteristics of Postmodern Dance * Emphasizes process over product, valuing the journey of creation rather than the final performance. * Rejects formalism and traditional labels, allowing for a broader interpretation of what dance can be. * Embraces the ephemeral nature of dance, recognizing that each performance is unique and transient. Historical Context and Key Figures * The dominant period of postmodern dance was from 1962 to 1964, with significant performances starting on July 6, 1962. * Key artists include Yvonne Rainer, Steve Paxton, and Trisha Brown, who were instrumental in shaping the movement. The Grand Union Collective * Formed from a project initiated by Yvonne Rainer, emphasizing collaboration and close working relationships among members. * Operated from 1970 to 1976, with performances that were entirely improvised, showcasing the spontaneity of the art form. * Members included prominent figures like Rainer, Paxton, and Brown, who contributed to the collective's innovative approach. Influential Artists and Their Contributions Yvonne Rainer * Rainer is considered the most significant figure of the Judson Dance Theater era, known for her shift from traditional techniques to more accessible forms of dance. * Her 'No Manifesto' articulated the principles of postmodern dance, advocating for a rejection of conventional aesthetics. * 'Trio A' (1966) is her most famous work, characterized by its minimalist approach and focus on movement rather than narrative. Steve Paxton and Contact Improvisation * Paxton founded Contact Improvisation (CI) in 1972, which emphasizes a shared experience between dancers, alternating roles of giving and receiving weight. * CI encourages uninhibited movement and connection, allowing for personal expression and exploration. * The lack of codification in CI promotes diverse teaching methodologies, making it adaptable to various styles. Trisha Brown * Brown is a leading figure in postmodern dance, known for her innovative use of improvisation as a choreographic tool. * Her technique focuses on gravity, exploring how to release into it and its effects on the body. * 'Set and Reset' (1983) is a hallmark of her work, showcasing collaboration with artists like Robert Rauschenberg and Laurie Anderson. The Evolution of Dance Styles The Balanchine Legacy * George Balanchine's neoclassicism transformed ballet, making it more athletic and less courtly, influenced by modern and jazz dance. * His work laid the foundation for the New York City Ballet (NYCB) and inspired emerging choreographers like William Forsythe. * Arthur Mitchell, the first African American ballet star at NYCB, founded the Dance Theatre of Harlem, integrating African American traditions into ballet. Twyla Tharp's Innovations * Tharp emerged from the postmodern movement, merging its ideas with ballet to expand the boundaries of both forms. * Founded Twyla Tharp Dance in 1965, focusing on space, time, and pedestrian movement. * Her work emphasizes creativity and improvisation, showcasing a blend of various dance styles. Contemporary Dance Practices Contemporary Training Techniques Technique Name Description Countertechnique Investigates principles of dynamic balance. Gaga Improvisational, rooted in descriptive imagery. Flying Low Focuses on using the body’s natural spiralic energy. Release Technique Centers on breath and fluidity through the joints. FoCo Technique Merges concepts from Chinese classical and modern. Somatic Practices Prioritizes feeling and sensing over visual cues. Commentary Through Choreography * Dance serves as a vessel for social commentary, addressing various social, political, and global issues. * The universal language of the body allows for a performance platform that transcends cultural barriers. * Choreographers often engage in deep research to elevate their work beyond mere entertainment, creating pieces that are literal, abstract, or metaphorical. Social Justice in Dance Bill T. Jones and His Impact * Bill T. Jones is a prominent choreographer known for using dance as a vehicle for social change, particularly during the AIDS epidemic. * His work often incorporates elements of performance art, including spoken word and multimedia. * Founded the Bill T. Jones/Arnie Zane Dance Company in 1982, which continues to thrive today. Notable Works by Bill T. Jones * 'D-Man in the Waters' (1989) addresses the aftermath of personal loss and the AIDS crisis. * 'Last Supper at Uncle Tom’s Cabin/The Promised Land' (1990) explores themes of suffering and faith. * 'Still/Here' (1994) emerged from workshops with terminally ill individuals, gaining notoriety for its poignant exploration of mortality. * His recent work, 'Deep Blue Sea' (2021), reflects on social justice issues during the COVID-19 pandemic and the Black Lives Matter movement. Undergraduate Study in Dance Degree Types and Focus Areas * Bachelor of Fine Arts (BFA): Emphasizes performance and choreography, preparing students for careers in dance performance and creative roles. * Bachelor of Arts (BA): Balances performance with a broader liberal arts education, allowing for a more diverse academic experience. * Bachelor of Science (BS): Focuses on scientific and quantitative studies, often including courses in dance sciences like kinesiology and movement therapies. Core Coursework in BFA Programs * Dance Technique: Varies by program, covering various styles and foundational skills. * Choreography: Includes practical experience in creating dance pieces, often with a focus on Dance for Camera. * Dance Pedagogy: Prepares students for teaching dance, covering methods and educational theories. * Anatomy and Kinesiology: Essential for understanding the physical body in relation to dance, enhancing performance and injury prevention. Additional Opportunities in Undergraduate Programs * Performance Opportunities: Students can perform in works by faculty, guest artists, and peers, gaining practical experience. * Masterclasses and Guest Lectures: Exposure to industry professionals enhances learning and networking. * Internships: Provide real-world experience and professional connections in the dance field. Graduate and Doctoral Study in Dance Types of Graduate Degrees * Master of Fine Arts (MFA): A terminal degree focusing on performance and creative research, essential for advanced artistic careers. * Master of Arts (MA): Often a stepping stone to Ph.D. work, focusing on liberal arts research or non-performance areas like Movement Therapy. * Ph.D. in Dance: Terminal degree for those pursuing research in educational, historical, or anthropological aspects of dance. Importance of Terminal Degrees * Terminal degrees are crucial for teaching positions in higher education, ensuring educators have advanced knowledge and skills. * They provide a pathway for specialized research, contributing to the academic field of dance. Transferable Skills from Dance Training Key Skills Developed * Time Management: Balancing rigorous training schedules with academic responsibilities. * Teamwork and Collaboration: Essential for group performances and choreographic projects. * Creative Thinking: Developing innovative solutions in choreography and performance. * Leadership: Opportunities to lead projects or direct performances enhance leadership skills. Career Opportunities in Dance Diverse Career Paths * Performance: Opportunities as company dancers or freelance artists in concert and commercial settings. * Choreography: Roles as resident choreographers or freelance artists, including dance filmmaking. * Teaching: Positions in private studios, public schools, and higher education, including curriculum development. Complementary Fields * Physical Therapy and Exercise Science: Important for injury prevention and rehabilitation for dancers. * Technical Theater: Involves stage management, costume design, and lighting design, supporting dance productions. * Nutrition and Dietetics: Essential for maintaining health and performance levels in dancers. Challenges in the Dance Industry Key Challenges Faced * Funding: Securing financial support for training and performances remains a significant hurdle. * Societal Perception: The relevance of artists is often questioned, impacting funding and support. * Job Stability: Economic factors and the nature of the industry can lead to instability in careers. The Evolution of Dance Categories Traditional Definitions * Concert Dance: Focuses on artistic expression in formal settings, traditionally dominated by ballet and modern styles. * Commercial Dance: Aimed at mainstream audiences, includes hip hop, street dance, and Broadway, requiring different training focuses. Blurring the Lines Between Categories * The rise of versatile training in the 1980s and 1990s has led to a blending of concert and commercial styles. * Shows like So You Think You Can Dance have increased exposure for dancers, allowing them to cross between genres. Dance as Sport Athleticism in Dance * Professional dance requires physical attributes similar to those in traditional sports, including strength, endurance, and flexibility. * Cross-training is essential for dancers to enhance their physical skills and performance capabilities. Dance Competitions * Competitions are organized regionally and nationally, with categories based on age, level, and genre. * Scoring systems evaluate technique, performance, and choreography, with awards given for various achievements. Pros and Cons of Dance Competitions Advantages of Dance Competitions * Dance competitions elevate the visibility of dance as a sport, engaging both dancers and audiences in a competitive atmosphere. * They provide young dancers with valuable experiences in handling rejection and understanding the subjective nature of performance evaluation. * Competitions encourage versatile training, which can serve as a launchpad for professional careers, emphasizing the importance of time management, personal responsibility, and teamwork. * Many competitions offer scholarship opportunities and conventions, enhancing training, networking, and exposure for participants. Challenges and Criticisms of Dance Competitions * Technical training may be compromised in competitive studios, focusing more on choreography and tricks rather than foundational skills. * The emphasis on sports elements can overshadow the artistic aspects of dance, influencing teaching practices in studios. * Choreography may lack individuality as dancers often follow trends that are more likely to win competitions. * Issues of hypersexuality in young dancers and the appropriateness of choreography/music are prevalent during competition seasons
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Primary adrenal insufficiency = problem at level of adrenal glands Causes? Addison’s disease Pathophys? Autoimmune destruction of the adrenal glands Associated with hyperpigmentation POMC is precursor to both ACTH and MSH PAI → lack of negative feedback → high ACTH Lab findings? ACTH high Aldosterone low Destruction of zona glomerulosa Renin high Hypotension → RAAS activation Electrolytes Na+ low, K+ high CBC Eosinophils high Pathophys? Glucocorticoids → eosinophil apoptosis. Lack of glucocorticoids cause eosinophilia. Dx? Cosyntropin testing → no rise in cortisol Adrenal glands aren’t working, so no response to ACTH. Tx? prednisone/hydrocortisone/dexamethasone + fludrocortisone (mineralocorticoid) Stress-dose steroids for surgery, serious illness, etc. Secondary adrenal insufficiency = problem at level of pituitary, reduced ACTH release Causes? MC is prolonged steroid use → ACTH suppression Sheehan’s syndrome (infarction of pituitary) pregnancy Pituitary tumors (ACTH-producing tumor) Lab findings? ACTH low Anterior pituitary is being inhibited Aldosterone normal Zona glomerulosa under control of RAAS system Renin normal Electrolytes Na+ & K+ unaffected (Aldosterone levels are normal) CBC Neutrophilia due to demargination (if pt was recently taking steroids) Dx? Cosyntropin testing → rise in cortisol Adrenal gland is functional Tx? Glucocorticoids Do not need to replace mineralocorticoids since adrenals are functional and aldosterone is under RAAS control Stress-dose steroids for surgery, serious illness, etc. AI with a history of nuchal rigidity and purpuric skin lesions → Waterhouse-Friedrichson syndrome Pathophys? AI 2/2 hemorrhagic infarction of the adrenal glands in the context of Neisseria meningitidis infection Adrenal synthesis enzymes If the enzyme starts with 1 → HTN (high mineralocorticoids) and hypokalemia If the second # is 1 → virilization (high androgens) E.g. 11-beta hydroxylase deficiency → HTN & virilization E.g. 21 hydroxylase deficiency → virilization only E.g. 17-alpha hydroxylase deficiency → HTN only B12 deficiency Where does B12 come from? Animal products VS folic from plants Physiology R factor in saliva binds to B12 and protects it from acidity in the stomach. R factor protector -B12 travels to the duodenum. Parietal cells produce intrinsic factor, which travels to the duodenum. Pancreatic enzymes cleave B12 from R factor and B12 then binds IF. B12-IF complex is reabsorbed in the terminal ileum Reabsorption where? Terminal ileum Causes of B12 deficiency Extreme vegan Pernicious anemia Pancreatic enzyme deficiency Cystic Fibrosis Can’t cleave B12 from R factor Crohn’s Affects terminal ileum Lab markers Homocysteine HIGH MethlyManoicAcid HIGH Presentation? Megaloblastic anemia Subacute combined degeneration (of dorsal columns + lateral corticospinal tract) Peripheral neuropathy Dx of pernicious anemia? anti-IF Ab Folate deficiency Where does folate come from? Leafy things Causes of folate deficiency Poor diet (e.g. alcoholics, elderly) Phenytoin Lab markers Homocysteine HIGH MMA normal Presentation? Megaloblastic anemia Prophylaxis in HIV+ patients CD4 < 200 → PCP TMP-SMX, inhaled pentamidine, dapsone, atovaquone CD4 < 100 → Toxoplasm Treat: TMP-SMX CD4 < 50 → MAC Treat: Azithromycin If live in endemic area, CD4 < 250 → Coccidioides Immitis E.g. Arizona, Nevada, Texas, California Treat: Itraconazole If live in endemic area, CD4 < 150 → Histoplasma Capsulatum E.g. Kentucky, Ohio, Missouri Treat: Itraconazole Diabetes insipidus Dx? Water deprivation test Measure serum osmolality & urine osmolality Deprive pt of water Remeasure serum osmolality & urine osmolality If urine osmolality doesn’t go up → suspect DI Central DI → deficiency of ADH Pathophys? Supraoptic nucleus not making enough ADH Dx? Give desmopressin → urine osmolality increases significantly Nephrogenic DI → kidneys are not responding to ADH Dx? Give desmopressin → urine osmolality doesn’t change much Tx? Hydrochlorothiazide Unless 2/2 lithium, use amiloride or triametere Causes? Lithium SSRIs Carbamazepine Demeclocycline Tx of normovolemic hypernatremia? D5W to correct free water deficit Divine says NS, but most other resources I found said correct free water deficit Tx of hypovolemic hypernatremia? Give NS first until normal volume, then give D5W Consequence of correcting hypernatremia too rapidly? Cerebral edema Osteoarthritis Presentation? Old person with joint pain that gets worse throughout the day Risk Factr? Obesity vs decreases osteoporosis Imaging findings? Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophytes Arthrocentesis findings? <2000 cells Tx? 1st line acetaminophen 2nd line NSAID (e.g. naproxen) 3rd line joint replacement surgery Returned from a business conference 1 week ago + Fever + Nonproductive cough + Abdominal pain + Hyponatremia → Legionella Dx? Urine antigen Tx? FQ or macrolide MaCroLide mnemonic = Mycoplasma, Chlamydia, Legionella What are the common causes of atypical PNA? Mycoplasma, Legionella, Chlamydia MC cause? Mycoplasma CXR findings? Interstitial infiltrates HY associations C. Psittaci → birds C. Burnetii → cows, goats, sheet Mycoplasma → college student w/ walking pneumonia Midsystolic click heard best at the apex. → mitral valve prolapse “Stenosnap & Proclick” Risk Factor? Connective tissue disease Marfarn Ehlers-Danlos ADPKD bilateral renal masses Classic demographic? Young woman psychiatric Pathophys? Myxomatous degeneration MVP vs aortic dissection: cystic medial necrosis Exam maneuvers Anything that increase amount of blood in LV → murmur softer Increase preload Increase afterload Anything that decreases amount of blood in LV → murmur louder Dx? Echo Scaly, itchy skin with yellowish crusting in the winter. → seborrheic dermatitis Tx? Topical antifungals e.g. ketoconazole or selenium sulfide shampoo Classic disease distribution? Hair → e.g. cradle cap Eyebrows Episodic/intermittent HTN + HA → pheochromocytoma Genetic disease associations MEN2A MEN2B VHL in brain (hemangioma) NF-1 growth in skin Pathophys? Catecholamine-secreting tumor Location? Adrenal medulla Posterior mediastinum Organ of Zuckerkandl (chromaffin cells along the aorta) Dx? 1st step: urine metanephrines If elevated → CT abdomen If nothing found on CT → MIBG scan Tx? Alpha blocker (e.g. phenoxybenzamine, phenotaline) THEN beta blocker Most common cause of a Lower GI Bleed in the elderly → diverticulosis Dx? Colonoscopy or barium enema Recall that you acutely do a CT scan for diverticulitis, then 6 weeks later colonoscopy to r/o cancer Ppx? Eat fiber Megaloblastic anemias Blood smear findings? Hypersegmented neutrophils MCV > 100 Classic patient demographic with folate deficiency? Alcoholics Elderly person with poor nutrition Folate synthesis inhibitors Pt with molar pregnancy → methotrexate Pulmonary issue? Pulmonary fibrosis HIV+ pt with ring-enhancing lesions → pyrimethamine-sulfadiazine Pyrimethamine inhibits DHFR AIDS pt on ppx for toxo → TMP-SMX TMP inhibits DHFR Use of leucovorin? Rescue bone marrow in setting of methotrexate toxicity Mechanism? Folinic acid analog CMV presentations Esophagitis → linear ulcers Colitis → post-transplant pt Retinitis → HIV pt with CD4 < 50 Congenital CMV → periventricular calcifications + hearing loss calcifications elsewhere → toxo Histology? Owl’s eye intranuclear inclusions Tx? Gancicyclovir Resistance? UL97 kinase mutation Tx for resistance? foscarnet CD4 < 200 + severe peripheral edema + frothy urine. → FSGS in HIV pt Variant classic in HIV+ pts? Collapsing variant Tx? Steroids + cyclophosphamide + ACE-I Indinavir AE? Kidney stones triad of fever, rash, and eosinophiluria → acute interstitial nephritis Drugs cause? Penicillins Tx? Stop the drug! Can add steroids if severe Vitamin D metabolism Liver converts Vit D to calcidiol (25OH-Vit D). Calcidiol goes to kidney. Alpha-1 hydroxylase converts calcidiol to calcitriol (1,25-OH Vit D). Common causes of Vitamin D deficiency CKD → 1-alpha hydroxyalse deficiency Liver disease → can’t make calcidiol CF → malabsorption Crohn’s → malabsorption Osteomalacia vs Rickets Osteomalacia in adults Rickets in kids Tx? Calcium + vit D Lab findings? Ca++ low Phos low Low in liver disease High in kidney disease (kidneys can’t get rid of phos) PTH high (2ary hyperpara) vs liver dx PTH low Alk phos Aspiration pneumonia Risk Factor? Alcoholism Dementia Neuromuscular problems (e.g. MG, ALS) Bugs? Anaerobes foul smelling Bacteroides FUsobacterium Peptostreptococcus Klebsiella → currant jelly sputum alcoholic Tx? Clindamycin CURB-65 criteria Purpose? Who to admit Cutoff? 2+ → hospitalize C = confusion U = uremia (BUN > 20) R = RR > 30 B = BP < 90/60 Age > 65 Drugs commonly used in PNA treatment Ceftriaxone Levofloxacin fluoroquinolone Macrolides - great for atypical PNA Pharmacological management of pulmonary arterial HTN Endothelin antagonists Bosentan ambrisentan PDE-5 inhibitors Sildenafil Tadalafil Prostacyclin analogs Iloprost Epoprostenol Treprostinil Causes? Young female → idiopathic PAH Mutation? BMPR2 55 yo F presents with a 5 week history of a rash on her forehead. PE reveals scaly macules with a sandpaper texture. → actinic keratosis Risk Factor? Sun exposure Tx? Topical 5-FU Possible dangerous sequelae? Squamous cell carcinoma Most likely disease sequelae? Resolution 1ary hyperparathyroidism 2ary hyperparathyroidism 3ary hyperparathyroidism Autonomous PTH production Causes? Adenoma Parathyroid hyperplasia PTH high Ca++ high Phos low Low Ca++ → PTH production Causes? CKD PTH high Ca++ low Phos high PTH production despite normalized of Ca++ levels Causes? CKD s/p transplant PTH high Ca++ high Phos low Tx? Parathyroidectomy (remove 3.5 glands) Cinacalcet (CSR modulator) Hypercalcemia Presentation? bones, stones, groans, psychic overtones Tx? 1st step: Normal Saline Hypercalcemia of malignancy → bisphosphonates EKG finding? Shortened QT Periumbilical pain that migrates to the right lower quadrant. → appendicitis PE findings? McBurney’s point tenderness Psoas sign (flex hip pain) Obturator sign (pain with internal rotation of hip) Rovsing’s sign (palpation of LLQ → pain in RLQ) Dx? CT scan Pregnant → US Kid → US Tx? Surgery Classic drug and viral causes of aplastic anemia. Drugs? Carbamazepine Chloramphenicol Viral? Parvovirus B19 (single stranded DNA virus) Fanconi anemia Pathophys? Problems with DNA repair Fanconi anemia vs Fanconi syndrome Fanconi anemia → cytopenias + thumb anomalies + short stature + cafe-au-lait spots Fanconi syndrome → type 2 RTA (proximal) CD4 count of 94 + MRI revealing ring enhancing lesions in the cortex → toxoplasmosis Tx? Pyrimethamine-sulfadiazine Rescue agent for pt who becomes leukopenic with treatment? leucovorin Who should get steroids? Increased ICP For PCP pneumonia: O2 sat < 92 PaO2 < 70 A-a gradient > 35 Ppx? TMP-SMX for CD4 < 100 Congenital toxo Hydrocephalus Chorioretinitis Intracranial calcifications Classic methods of transmission? handling cat litter Lupus nephritis Associated autoantibody? anti-dsDNA Classic “immunologic” description? “Full house” pattern Tx? Steroids + cyclophosphamide Osteoporosis Screening population? women > 65 Screening modality? DEXA scan Dx? T-score < -2.5 Risk Factor? Postmenopauseal Low BMI Smoking Alcohol Preventive strategies? Weight bearing exercise Smoking cessation Reduce alcohol consumption Tx? 1st line: bisphosphonates + Ca/Vit D supplementation Raloxifene (SERM) Agonist in bone Blocker Antagonist in breast Classic locations of osteoporotic fractures Vertebral compression fracture Hip fracture Name the PNA Red currant jelly sputum. → Klebsiella Rust colored sputum. → Strep pneumo PNA in an alcoholic. → Klebsiella Post viral PNA with a cavitary CXR lesion. → Staph aureus PNA in a patient that has chronically been on a ventilator. → Pseudomonas MC cause of Community Acquired Pneumonia. → Strep pneumo Pharmacological management of MRSA. Vancomycin Clindamycin Linezolid Ceftaroline (5th gen cephalosporin) Tigecycline, tertracycline Pharmacological management of Pseudomonas. Ceftazidime (only 3rd gen cephalosporin) Cefepime (4th gen cephalosporin) Pip-tazo Fluoroquinolones Carbapenems Aztreonam Aminoglycosides JVD and exercise intolerance in a patient with a recent history of an URI. → dilated cardiomyopathy 2/2 viral myocarditis MC cause? Coxsackie B VS Coxsackie A: Hand foot mouth dx Drug causes myocarditis Clozapine Anthracyclines Prevention? Dexrazoxane (iron chelator) Trastuzumab reversible tx for breast cancer Classic cause in a patient with recent history of travel to S. America? Chagas T. Cruzi Potential sequelae? Achalasia Dilated cardiomyopathy Megacolon (2/2 degeneration of myenteric plexus) Massive skin sloughing (45% BSA) in a patient that was recently started on a gout medication? TEN Dx? <10% BSA → SJS >30% BSA → TEN Tx? STOP the drug IVF Topical abx to prevention infection Tetany and a prolonged QT interval in a patient with recent surgical treatment of follicular thyroid carcinoma. → hypocalcemia due to removal of parathyroids Recurrent viral infections + QT prolongation + tetany → DiGeorge syndrome Pathophys? Failure of development of 3rd/4th pharyngeal pouches Trousseau and Chvostek signs. Trousseau → inflation of BP cuff causes carpopedal spasm Chvostek → taping on cheek causes facial muscle spasm Hypocalcemia that is refractory to repletion → consider hypomagnesemia Electrolyte/drug causes of prolonged QT intervals Electrolytes? Hypocalcemia Hypomagnesemia Hypokalemia Drugs? Macrolides FloroQunlones Haloperidol Ondensatron Methadone Hypoalbuminemia and Ca balance Hypoalbumenia → decrease in total body Ca++, no change in ionized Ca++ Drop of 1 in albumin → add 0.8 to Ca++ Abdominal pain radiating to the back → acute pancreatitis Causes? #1 = Gallstones #2 = Alcohol Hypertriglyceridemia Hypercalcemia Scorpion sting Handlebar injuries Lab markers? Lipase - most sensitive Amylase Physical exam signs in pancreatitis. Cullen’s sign = periumbilical ecchymosis Grey Turner sign = flank ecchymosis Tx? NPO + IVF + pain control Meperidine is a good agent because it doesn’t cause sphincter of Oddi spasms Management of gallstone pancreatitis Dx? US then ERCP Tx? DELAYED cholecystectomy What if the patient becomes severely hypoxic with a CXR revealing a “white out” lung? ARDS noncardiogenic pulm edema PCWP? <18 mmHg NORMAL 20 yo M with red urine in the morning + hepatic vein thrombosis + CBC findings of hemolytic anemia. → paroxysmal nocturnal hemoglobinuria Pathophys? Defect in GPI anchors, which attach CD55 and CD59 to cell (they prevent complement from destroying RBC) Sleep → hypoventilation → mild respiratory acidosis → activation of complement cascade Gene mutation? PIGA Dx? Flow cytometry Tx? Eculizumab (terminal complement inhibitor) Vaccine required? pnemococal Neisseria meningitidis Chronic diarrhea and malabsorption in a HIV+ patient + detection of acid fast oocysts in stool. → cryptosporidium parvum Acid-fast organisms Cryptosporidium TB MAC Nocardia Dx? Stool O&P Tx? Nitazoxanide Route of transmission? Contaminated water Muddy brown casts on urinalysis in a patient with recent CT contrast administration (or Gentamicin administration for a life threatening gram -ve infection) → Acute Tubular Necrosis Woman with morning joint stiffness > 1 hr → Rhematoid Arthritis. Antibodies? Rheum Factor (IgM against IgG) anti-CCP - more specific HLA? DR4 Pathophys? IgM constant region activates complement → inflammation → formation of pannus (hypertrophied synovium) → damage to cartilage and bone Caplan syndrome = RA + pneumoconiosis Felty syndrome = RA + neutropenia + splenomegaly (“RANS”) Classic hand/finger findings/distribution? MCP & PIP joints of hands (DIP joints spared) Imaging findings? Symmetric joint space narrowing Tx? Methotrexate (DMARDs) If no response → TNF alpha inhibitor (e.g. infliximab) Required testing prior to starting methotrexate? PFTs Required testing prior to starting infliximab? TB Hep B/Hep C Differentiating Strep pharyngitis from Infectious Mononucleosis LND distribution Anterior cervical → Strep Posterior cervical → Mono Disease onset Acute → Strep Over weeks → Mono Organ involvement Splenomegaly → Mono Pt with sore throat takes amoxicillin and gets rash → mono NOT allergic rxn! CENTOR criteria C = absence of Cough E = tonsillar Exudates N = nodes/anterior cervical lymphadenopathy T = temp (fever) OR <15 → +1 >=45 → -1 Using CENTOR score 0/1 → don’t test, don’t treat 2/3 → rapid antigen test Positive → treat Negative → throat culture 4/5 → treat empirically Tx of Strep pharyngitis? Amoxillcin If PCN allergic → azithromycin Potential sequelae of Strep pharyngitis RF - preventable with abx PSGN Endocarditis MC cause of endocarditis? IVDU Bug? Staph aureus Valve? tricuspid Prosthetic valve endocarditis Bug? Staph epidermidis Endocarditis after dental procedure? Viridans group streptococci Strep viridans, Strep mitis, Strep mutans, Strep sanguineous Patient with malar rash and echo showing vegetations on both sides of the mitral valve → Libman-Sacks endocarditis Presentation? Fever + night sweats + new murmur Splinter hemorrhages Roth spots (retinal hemorrhages) Painless Janeway lesions + painful Osler nodes (immune phenomenon) Dx? 1st step: blood cultures TEE Tx? Abx that include Staph aureus coverage (e.g. vancomycin) for WEEKS Bugs implicated in culture negative endocarditis HACEK H = haemophilus A = actinobacillus C = cardiobacterium E = eikenella K = kingella Coxiella burnetii Blood cultures in a patient with endocarditis reveal S. Bovis (or S. Gallolyticus bacteremia). NBS? Colonoscopy Who needs antibiotic prophylaxis? Hx endocarditis Prosthetic valve Unrepaired cyanotic congenital dz Heart transplant with valve dysfunction Erythematous salmon colored patch with silvery scale on the elbows and knees. → psoriasis Tx? Topical steroids If this patient presents with joint pain (especially in the fingers)? Psoriatic arthritis Imaging? Pencil-and-cup deformity Tx? NSAIDs T of 104 + tachycardia + new onset Afib in a patient with a history of Graves disease. → thyroid storm Lab findings? TSH low T3/T4 high Tx? 1st step: propranolol 2nd step: PTU Then: Prednisone Potassium iodide (Lugul’s solution) Wolff-Chaikoff effect → large amounts of iodine inhibit thyroid hormone synthesis Biopsy revealing tennis racket shaped structures in cells of immune origin. → Langerhans cell histiocytosis Electron microscopy? Birbeck granules (tennis rackets) Marker? S100 Small bowel obstruction in a HIV patient with purple macules on the face, arms, and lower extremities. → Kaposi’s sarcoma Bug? HHV8 Tx? HAART Pathophys of vascular lesions? Overexpression of VEGF Fever + rash + eosinophiluria 10 days after a patient started an antistaphylococcal penicillin. → acute interstitial nephritis Tx? STOP drug + steroids SLE SOAP BRAIN MD S = serositis O = oral ulcers A = arthritis P = photosensitivity B = blood disorders (cytopenias) R = renal A = ANA/anti-dsDNA I = immunologic N = neurologic findings M = malar rash D = discoid rash Type 2 vs 3 HSRs in lupus Type 2 → cytopenias Type 3 → all other manifestations Lupus Ab? ANA anti-dsDNA anti-Smith Lupus nephritis → full house pattern on IF Antiphospholipid antibody syndrome → recurrent pregnancy losses Pathophys? Thrombosis of the uteroplacental arteries. MC cause of death in lupus patients? What I’ve read recently: CV disease Per Divine: Treated → infection Untreated → renal dz Also 40x risk MI Endocarditis in lupus pt? Libman-Sacks endocarditis Neonatal 3rd degree heart block → neonatal lupus Maternal autoimmune dz? Sjogren’s SLE Ab? anti-SSA/anti-Ro anti-SSB/anti-La Tx? Steroids Cyclophosphamide Hydroxychloroquine → good for skin lesions Pulmonary abscesses Bugs? Staph Anaerobes Klebsiella RF? Alcoholism Elderly Post-viral pneumonia MC location of aspiration pneumonia? Superior segment of RLL Chest pain worsened by deep inspiration and relieved by sitting up in a patient with a recent MI or elevated creatinine or URI or RA/SLE. → pericarditis EKG findings? Diffuse ST elevations + PR depression PE finding? Friction rub (“scratchy sound on auscultation”) A few days after MI → fibrinous pericarditis Weeks after MI → Dressler’s Tx? NSAIDS Consider adding on colchicine Cardiac tamponade Beck’s triad = hypotension + JVD + muffled heart sounds EKG findings? Electrical alternans Type of shock? Obstructive cardiogenic (Amboss) CO low SVR high PCWP high Tx? Pericardiocentesis or pericardial Pearly lesion with telangiectasias on the ear in a farmer. → Basal Cell Carcinoma MC type skin cancer Location? Upper lip Dx? Biopsy Tx? Mohs surgery Cold intolerance in a 35 yo white F → hypothyroidism MC cause? Hashimoto’s Histology? lymphoid follicles w/ active germinal centers Lab findings? TSH high T3/T4 low Ab? anti-TPO Anti-thyroglobulin HLA? DR3/DR5 Tx? Levothyroxine Future complication? thyroid lymphoma Massive hematemesis in a patient with a history of chronic liver disease. → ruptured varices Pathophys? L gastric vein has anastomosis with azygos veins. Increased portal pressure → backward flow from L gastric veins to azygous vein (which empties into SVC). Acute tx? IVF + octreotide + ceftriaxone/cipro + EGD w/ ligation/banding Do NOT give a beta blocker for acute tx Prophalaxsis? Beta blocker + spironolactone Other manifestations of elevated portal pressures Caput medusa Internal hemorrhoids Tx for cirrhotic coagulopathies? FFP If uremia → give desmopressin Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH Hemophilia A Pathophys? deficiency of factor 8 Inheritance? XLR Coag labs? Bleeding time normal PTT HIGH b/c clotting problem PT normal Hemophilia B Pathophys? deficiency of factor 9 Inheritance? XLR Coag labs? Bleeding time normal PTT HIGH PT normal Hemophilia C Pathophys? deficiency of factor 11 Inheritance? AR Coag labs? Bleeding time normal PTT HIGH PT normal Bernard Soulier Syndrome Pathophys? Deficiency of GpIb Coag labs? Bleeding time HIGH PTT normal PT normal Glanzmann Thrombasthenia Pathophys? Deficiency of GpIIbIIIa Coag labs? Bleeding time HIGH PTT normal PT normal Von Willebrand’s disease Pathophys? Deficiency of vWF Inheritance? AD Coag labs? Bleeding time HIGH PTT HIGH vWF is a protecting group for factor 8 PT normal ITP Pathophys? Ab against GpIIbIIIa Classic pt? Pt with SLE Tx? Observation Steroids IVIG Splenectomy TTP Pathophys? Deficiency in ADAMTS13 enzyme → cannot cleave vWF multimers → activation of platelets → thrombosis → thrombocytopenia Presentation? microangiopathic hemolytic anemia + thrombocytopenia + renal failure + fever + neurologic problems Tx? Plasma exchange transfusion****** HUS Bugs? Shigella or E. coli O157:H7 Presentation? Fever+ microangiopathic hemolytic anemia + thrombocytopenia + renal failure + neurologic Platelet deficiency vs coagulation factor bleeds Platelet deficiency → mucosal bleeds, petechiae, heavy menses Coag factor deficiency bleeds → hemarthrosis Why do patients with CKD develop coagulopathy? Uremia → platelet dysfunction Tx? Desmopressin Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH Exercising caution with transfusion in patients with Bernard Soulier syndrome Do NOT give transfusion that includes platelets They can have an anaphylactic rxn to GpIb (since they don’t have GpIb) Oropharyngeal candidiasis. RF? HIV Chronic ICS use TNF inhibitor Micro finding? Germ tubes at 37 C Tx oral candidiasis? Nystatin swish-and-swallow Tx invasive candidiasis? Amphotericin B Prevention of Amphotericin B toxicity? Liposomal formulation Pleural effusions Light’s criteria (must meet all 3 to be considered transudative!) LDH < 2/3 ULN LOW Pleural LDH/serum LDH < 0.6 LOW Pleural protein/serum protein < 0.5 LOW Causes of transudative effusion CHF Cirrhosis Nephrotic syndrome Note: Per UW 2021: Mechanism of transudate effusion? Decreased pulmonary artery oncotic pressure, e.g. hypoalbuminemia in nephrotic syndrome Increased pulmonary capillary hydrostatic pressure, e.g. volume overload in heart failure Causes of exudative effusion Malignancy Cancer Parapneumonic effusion Tb Note: Per UW 2021: Mechanism of exudate effusion? Inflammatory increased in vascular permeability of membrane (increased flow of interstitial edema into pleural space) Unique cause of both transudative & exudative effusions? PE Classic Pleural Effusion findings? Decreased breath sounds Dullness to percussion Decreased tactile fremitus Tx? Chest tube Chylothorax = lymph in the pleural space Pathophys? Obstruction of thoracic duct or injury to the thoracic duct Pleural fluid findings? High Triglycerides Holosystolic murmur heard best at the apex with radiation to the axilla in a patient with a recent MI. → mitral regurg 2/2 papillary muscle rupture Dx? Echo Why widely split S2? Aortic valve is closing earlier (LV is emptying into both aorta & LA) Maneuvers that increase intensity Increase preload (putting more blood in that can be regurgitated) Increase afterload Decubitus ulcers RF? Elderly Paraplegic Fecal/urinary incontinence Poor nutrition Staging Stage 1 = non-blanchable erythema Tx? Repositioning q2hrs Stage 2 = loss of epidermis + partial loss of dermis Tx? Occlusive dressing superficial Stage 3 = involves entire dermis, extending to subQ fat Does NOT extend past fascia Tx? Surgical debridement Stage 4 = muscle/tendon/bose exposed Tx? Surgical debridement General tx strategies? Repositioning + good nutritional support Marjolin’s ulcer = non-healing wound that is actually squamous cell carcinoma T1DM Pathophys? Autoimmune destruction of pancreas Ab? anti-GAD 65 (glutamic acid decarboxylase) anti-IA2 (islet tyrosine phosphatase 2) Islet cell autoantibodies Insulin autoantibodies Dx? A1c > 6.5% (twice) Fasting BG >= 126 (twice) Oral glucose tolerance test >= 200 (twice) Sxs of DM + random glucose > 200 Tx? Long-acting insulin + mealtime insulin Long-acting Glargine Detemir Rapid-acting Lispro Aspart Glulisine 3 HY complications Nephropathy Retinopathy & cataracts Neuropathy Chronic DM care A1c q3 months Foot exam annually Eye exam annually Microalbumin:Cr ratio annually Nephroprotection in DM? ACE-I GI bleed algorithm 1st step: ABCs + 2 large-bore IVs + IVFs 2nd step: NG lavage Clear fluid → go deeper Blood → UGIB → upper endoscopy Bilious fluid → have ruled out UGIB → proceed to colonoscopy See source → intervene as needed See nothing → CT angiography for large bleed Tagged RBC scan for smaller bleed Antiplatelet Pharmacology Aspirin Mechanism? Irreversibly inhibits COX-1 and COX-2 Clopidogrel/ticlopidine = P2Y12 (ADP receptor) blockers Mechanism? Inhibit platelet activation Abciximab/eptifibatide/tirofiban = GpIIbIIIa receptor blockers Mechanism? Inhibit platelet aggregation Ristocetin cofactor assay Issues with adhesion step → abnormal result Abnormal ristocetin cofactor assays: Von Willebrand disease Bernard Soulier disease Normal ristocetin cofactor assay: Glanzmann Thrombasthenia Von Willebrand disease effects on PTT? Increased Pathophys? vWF is a protecting group for Factor 8. Treatment of VWD? Desmopressin Mechanism? Increases release of vWF from Weibel-Palade bodies of endothelial cells Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH HSV1 vs HSV2. Oral herpes → HSV1 Genital herpes → HSV2 Dx? PCR (most up-to-date) Tzanck smear (outdated, not very sensitive, nonspecific) → intranuclear inclusions Brain area affected by HSV encephalitis? Temporal lobes CSF findings in HSV encephalitis? RBCs******* Tx herpes encephalitis? Acyclovir AE? Crystal nephropathy Can’t see, can’t pee, can’t climb a tree. → reactive arthritis HLA? B27 Classic bug? Chlamydia Tx? steroids Need abx? Only if ongoing infection Can’t see, can’t pee, can’t hear a bee → Alport syndrome Inheritance? X-linked dominant Tx of NG & CT NG → treat empirically for both → ceftriaxone + azithro/doxy CT → azithro/doxy Hypovolemic Septic Neurogenic Cardiogenic CO low PCWP low SVR high*** CO high PCWP normal SVR low Tx? norepi CO low SVR low CO low PCWP high*** SVR high*** Tx anaphylactic shock? epinephrine Melanomas ABCDE A = asymmetry B = irregular borders C = color variation D = diameter > 6 mm E = evolving Dx? Full-thickness biopsy Excisional for small lesions Punch for larger lesions Most important prognostic factor → Breslow depth DM pharmacology Lactic acidosis → metformin Decreases hepatic gluconeogenesis → metformin Hold before CT w/ contrast → metformin Weight gain → sulfonylureas & TZDs (-glitizones) Diarrhea → acarbose & migliton Inhibits disaccharidases (can’t reabsorb disaccharides) Recurrent UTIs → SGLT-2 inhibitors Weight loss → GLP-1 agonists (e.g. liraglutide, exenatide) & DPP4 inhibitors (-gliptins) Contraindicated in pt with HF → TZDs PPAR-gamma receptor found in kidney → water retention Contraindication in pt with MTC → GLP-1 agonists Biggest risk of hypoglycemia? Sulfonylureas RF esophageal adenocarcinoma Barrett’s esophagus RF esophageal squamous cell carcinoma Smoking Drinking Achalasia Location esophageal adenocarcinoma? Lower 1/3 Location esophageal squamous cell carcinoma? Upper 2/3 MC US? Adenocarcinoma MC worldwide? Squamous cell carcinoma Presentation? Dysphagia to solids → dysphagia to liquids Dx? EGD Staging? CT scan or esophageal US Factor V Leiden Pathophys? Resistance to protein C Dx? Activated Protein C resistance assay Patient needs super large doses of heparin to record any changes in PTT → AT-III deficiency Recall that heparin is a AT-III activator 35 yo with a hypercoagulable disorder that does not correct with mixing studies. → antiphospholipid antibody disorder Anaphylaxis in a patient with a long history of Hemophilia A → Ab against factor 8 that cause type 1 HSR with transfusion Hx of hemophilia, diagnosed 5 years ago. Before you would give them factor 8 concentrate and PTT would normalize. Now they’re requirizing larger doses of factor 8 to normalize PTT. → inhibitor formation (antibodies against clotting factors) Skin necrosis with Warfarin → protein C/S deficiency Prothrombin G20210 mutation → overproduction of factor II Rash in dermatomal distribution → VZV infection Contraindications to VZV vaccination? Pregnant woman Kid < 1 year Severe immunosuppression (e.g. HIV with CD4 < 200) Tx? Acyclovir If resistant, foscarnet Tzanck smear findings? Intranuclear inclusions Shingles vaccination guidelines? Adults over 60 #1 cause of ESRD in the US → DM nephropathy Histology? Kimmelsteil-Wilson nodules #2 cause of ESRD in the US → hypertensive nephropathy Pt with BP 240/150. How fast should you lower BP? 25% in first 24 hrs Drugs for hypertensive emergencies? Nicardipine Clevidipine Nitroprusside AE? Cyanide poisoning Tx? Amyl nitrate + thiosulfate OR hydroxocobalamin Labelol Renal protective medications in patients with DKD or hypertensive nephropathy? ACE-I Anemia + Cranial Nerve deficits + Thick bones + Carbonic Anhydrase 2 deficiency + Increased TRAP + Increased Alkaline Phosphatase. → osteopetrosis Pathophys? Carbonic anhydrase is defective → osteoclasts cannot produce acid to resorb bone Tx? IFN-gamma Osteoclasts are a specialized macrophage IFN-gamma is an activator of macrophages Clinical diagnostic criteria for Chronic Bronchitis Diagnostic criteria? 2 years 3 months/year of chronic cough PFT findings FEV1 low FEV1/FVC ratio low RV high TLC high Which PFT market can differentiate CB from emphysema? DLCO DLCO normal → CB DLCO low → emphysema ****** Tx acute exacerbation? Abx + bronchodilators + corticosteroids (“ABCs”) Prevention? Stop smoking! Afib #1 RF? Mitral stenosis #1 RF MS? Rheumatic fever #1 RF CAD and AAA: smoking #1 RF stroke and aortic dissection: HTN MC arrhythmia in hyperthyroidism → Afib MC site of ectopic foci in Afib → pulmonary veins EKG findings? “Irregularly irregular” + no P waves Location of emboli formation? LA appendage Who should be cardioverted back to sinus rhythm? New onset (<48 hrs) Afib Anticoagulated for 3 weeks + TEE negative for clot Afib that’s refractory to medical therapy Afib & HDUS Q on T phenomenon? Depolarization during T wave (repolarization) can cause QT prolongation → Torsades → death Prevention? SYNCHRONIZED cardioversion Tx? Rate control Beta blockers ND-CCB (e.g. verapamil, diltiazem) Rhythmic control Amiodarone Reducing stroke risk in Afib? Anticoagulation for CHA2DS2VASc score >= 2 Anticoagulation options Valvular cause (e.g. MS) → warfarin Any other cause → warfarin or NOAC (apixiban) Reversal of AC Warfarin → Vit K, four-factor PCC Heparin → protamine sulfate Dabigatran → idarucizumab Crusty, scaly, ulcerating lesion with heaped up borders → squamous cell carcinoma Classic location? Below Lower lip Precursor lesion? Actinic keratosis What if it arises in a scar or chronic wound? Marjolin ulcer Hypothermia + hypercapnia + non pitting edema + hyponatremia + HR of 35 + hypotension in a patient with a history of papillary thyroid cancer → myxedema coma Tx? Levothyroxine + steroids Lab findings? TSH high T3/T4 low LDL high Acute onset “dermatologic” breakout in a patient with a recent history of weight loss and epigastric pain. → Leser–Trélat sign associated with visceral malignancy pancreatic cancer Lymph node associations Supraclavicular → Virchow’s node Periumbilical → Sister Mary Joseph What are mets to the ovaries called? Kruckenberg tumor Classic bug associated with gastric cancer? H. pylori (MALToma) Classic histological finding in the diffuse type of gastric cancer? Signet ring cells RBCs without central pallor + elevated MCHC + anemia. → hereditary spherocytosis Inheritance? AD Pathophys? Deficiency of spectrin, ankyrin, or band 3.2 Intravascular or extravascular hemolysis? Extravascular (RBCs bound by IgG, attacked by splenic macrophages) Dx? Osmotic fragility test Eosin-5-maleimide Acidified glycerol lysis test Tx? Splenectomy Post-splenectomy preventative care? Strep pneumo Hinflue vaccine Neisseria Septic shock Hemodynamic parameters CO high SVR low PCWP normal MvO2 high Tx? IVF + norepi + broad-spectrum abx (cover MRSA + Pseudomonas) E.g. vanc + pip-tazo E.g
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