761 Exam 3

• 25-29 
• 20-24
• 30-34

• blacks
• hispanics

• Kaposi sarcoma
• pneumocystitis jiroveci pneumonia
• pulmonary tuberculosis
• recurrent pneumonia
• cadidiasis of bronchi, trachea or lungs
• esophageal (not oral) candidiasis
• invasive cervical cancer
• Coccidioidomycosis, disseminated or extrapulmonary
• Cryptococcosis, extrapulmonary
• Cryptosporidiosis, chronic intestinal for longer than one month
• Cytomegalovirus disease (other than liver, spleen or lymph nodes)
• Encephalopathy (HIV-related)
• Herpes simplex: chronic ulcer(s) (for more than one month); or bronchitis, pneumonitis, or esophagitis
• Histoplasmosis, disseminated or extrapulmonary
• Isosporiasis, chronic intestinal (for more than one month)
• Kaposi sarcoma
• Lymphoma Burkitt's, immunoblastic or primary brain (but not leukemia)
• Mycobacterium avium complex
• Mycobacterium, other species, disseminated or extrapulmonary
• Pneumocystis jiroveci pneumonia (formerly Pneumocystis carinii)
• Pneumonia (recurrent)Progressive multifocal leukoencephalopathy
• Salmonella septicemia (recurrent)
• Toxoplasmosis of the brain
• Tuberculosis
• Wasting syndrome due to HIV

• classic: fever over 38.3 on several occasions for more than 3 weeks. Dx uncertain after 3 days despite inpatient workup or 3 outpatient workups
• nosocomial: fever over 38.3 on several occasions, pt hospitaliexed >24 hours but no fever present or developing on admission, eval of 3 days at least without finding cause
• immune-deficient/neutropenic: fever 38.3 or more, neutrophils <500 per mm3, 3 days eval without cause found
• HIV associated: recent fevers over 4 week period in outpatient or 2 days hospitalized with confirmed HIV. Dx uncertain after 3 days appropriate investigation (cbc, liver, ua, cxr, blood cultures)

• both pneumococcal conjugate (PCV13) and 23-valent pneumococcal polsaccharide vaccine (PPSV23)
• hep A
• hep B 3 dose primary series
• yearly flu inactive
• tdap/td q10

• both pcv13 and PPSV23
• PCV13: 1 dose for 19-64, 1 dose over 65 if no previous vaccination
• PPSV23: 2 doses for 19-64 (1st at least 8 weeks after PCV13, second at least 5 weeks after first dose PPSV), For those 65 and up they should get 1 dose at least 8 weeks after PCV13 and then another dose at least 5 years after any PPSV23 that was given under 65

• pap at time of dx, 
• another 6-12 months after
• if normal, than paps annually, 
• if 3 in a row, normal then q3 years

• if over 30 and positive, you can do cotesting (pap and hpv)
• if they get a negative cotest they can have their next cervical cancer screening in 3 years

• mouth lesions very common
• fungal, viral, bacterial infections

• CMV retinitis
• cd4 count <100 is highest risk patients
• do fundoscopic exam if advanced HIV

• blood culture
• cd4 count
• chem7/cmp
• hiv load
• u/a and uc
• hepatitis panel
• cxr (if never done before)- not needed if sx havent changed since last

• if abd symptoms
• ct abdomen, liver test, stool studies

• systemic non-hodgkin lymphoma: fever, sweats, weight loss, lymphadenopathy, hepatosplenomegaly
• primary central nervous system lymphoma: confusion, lethargy, memory loss, hemiparesis, aphagia, seizures
• primary effusion (body cavity) lymphomas: pleural, peritoneal, pericardial or joint effusions with highgrade malignant lymphocytes
• kaposi sarcoma: skin lesions on lower extremities, face, and genitals (can also be in mouth, gi tract or resp tract)

• serum aminotransferases
• usually elevated in liver diseae and in other diseases involving the liver like heart failure, infections, and malignancies
• ALT more specific to liver disease
• AST can be associated to other tissue like RBCs, muscle and kidneys
• meds can raise these

• elevated in biliary obstruction, cholestasis, infiltrative liver diseases (ie tuberculosis), alcoholic steatonecrosis, cirrhosis and CF
• also may be elevated in bone disorders, pregnancy or from meds
• in HIV: can be elevated by CMV, MAC, microsporidosis and TB

can develop reistance

• NRTIs: nucleoside/neucleotide reverse transcriptase inhibitors. abacavir, zidovudine, lamivudine, stavudine, didanosine, emtricitabine, tenofovir. 
• NNRTIs: Nonnucleoside reverse transcriptase inhibitors. efavirenz, nevirapine
• Protease inhibitors: Aprenavir/fosamprenavir, atazanavir, lopinavir, indinavir, nelfinavir, ritonavir, tipranavir, saquinavir

• entry or fusion inhibitors: enfuvirtide
• integrase inhibitors: end in "gravir"
• chemokine coreceptor (CCR5) antagonist: maraviroc

• lactic acidosis
• hepatic stenosis
• body fat redristibution with wasting in face, arms and legs, accumulates in upper back

• rash
• steven johnson syndrome
• toxic epidermal necrolysis
• interact with many other drugs

• metabolic abnormalities: dislipidemia, hyperglycemia, insulin resistence, lipodstrophy
• increased bleeding risk in hemophiliacs
• interactions with other drugs

• fasting blood glucose
• lipid panel
• genotyping
• rpr
• trichomoniasis if female
• toxoplasma gondii IgG (will need bactrim if cd4 <100)
• hep panel
• mammogram and pap

CD4 count

viral load used to lookong at response to therapy

• 16-24 weeks
• check q3-6 mo

• cd4 > 200: strep pneumo
• cd4 50-200: pneumocystitis pneumonia
• cd4 < 50: mycobacterium ayium complext pneumonia

• total protein fluid to serum ratio > 0.5 and LDH fluid to serum ratio greater than 0.6
• serum effusion albumin of 1.2 or less
• malignancy
• bacterial infection
• TB
• connective tissue disease
• PE/infarction
• trauma
• radiation
• drugs/injuries

• total protein fluid to serum ratio less than 0.5
• total LDH fluid to serum ratio less than 0.6
• serum effusion albumin over 1.2
• chf
• cirrhosis
• nephrotic syndrome
• profound hypothyroid myxedema
• constrictive pericarditis

• a four drug regimen that includes always isoniazid and rifampin
• the other 2 could be pyrazinamide and ethambutol to cover other areas if culture not done and its resistant
• length of treatment depends on clinical presentation, HIV status and the acid fast status of the sputum at 2 months

• anti-neuclear antibody ANA: 95-98% will be positive, also seen in sjogren and scleroderma
• anti-ds DNA antibodies: highly specific for SLE when moderate to high titre
• c3 and c4: lupus tests, not highly specific, but sensitive
• anti-cyclic citrulinated peptide antibody (anti-CCP): excludes Rheumatoid arthritis
• CBC: look for hematological involvement- leukopenia, lymphopenia, anemia, thrombocytpenia, cooombs positive hemolytic anemia often is SLE
• ESR: r/o rheumatoid arthritis, but also elevated in SLE 
• rheumatoid factor: to rule out rheumatoid arthritis
• cr/urinalysis: look for renal involvement- proteinuria, rbcs and rbc casts show glomerular disease which is common in SLE. also decreased GFR and elevated cr can be seen in SLE
• fasting lipids: if sle, they have much higher CVD risk
• glucose: prednisone can alter

• molar "butterfly" rash
• livedo reticularis- mottling rash from inflammed blood vessels

• hydroxychloroquine for arthritis and rash, reduces flare ups
• corticosteroids- prednisone 7.5
• high spf sunblock for photosensitive rash
• nsaids for msk pain, fever, headaches

• 20-45 years old
• black or hispanic
• male to male sexual contact (after blood transfusion)

• florida
• california
• texas
• georgia
• new york

• EVERYONE aged 13-64 at least once regardless of risk
• all pregnant women at every pregnancy
• those with risk

• if no risk factors- once
• as needed depending on risk behavior
• q3 months if risk factor snd not on prep/pep (q1mo if super high risk)

• 4th generation test
• can detect within 2 week window period
• use this one to verfiy a home or rapid test

• 2 weeks at the earliest
• can differentiate type 1 vs 2

• first will be pos or neg for 1/2. if negative done
• if positive, it will go into if the HIV1 antibodie or HIV2 antibiodies or both are positive, or none
• if you get a positive, you know your diagnosis, if negative, then youll go into a viral load

• can detect within 7-10 days 
• peaks at 4 weeks then plateaus
• not ordered for every patient because its expensive

• RNA viral load: 7-10 days
• 4th gen: 2 weeks
• Antibody test: 4 weeks

• detectable at 7-10 days
• peaks around 10-24 then plateaus but is still detectable

• FRAT
• Fever
• Rash: maculopapular
• Adenopathy
• Sore Throat

• NO cough, rhinorrhea, etc. can have n/v diarrhea, arthralgia/myalgia. 
• more resembles mono (dry) than cold/flu

• lasts 1-3 weeks
• onset 2-6 weeks after infection
• 40-90% are symptomatic

• N/V/D
• headache
• myalgia/arthralgia
• weight loss
• thrush, neurological symptoms
• hepatosplenomegaly
• mouth ulcers

cough, congestion, rhinoorhea

NOT like a flu or cold

its a dry ilness

remember to consider the risk. is it likely they have HIV

• HIV RNA will be high druing days 15-25
• HIV p24 antigen peaks just after detection
• HIV antibody rises after acute phase

• detectble at 2 weeks antigen and RNA
• Antibody better detected towards end or after acute

• goal is that....
• 90% of ppl know HIV status
• 90% are on ART
• 90% of people are suppressed

complete plus in mouth, nodes, genitalia, anus

• cd4
• viral load
• genotype to see if transmitted resistance. you can pass resistance to others with the virus
• CBC
• bmp
• lfts
• ua
• lipids
• a1c
• preg test
• all STIs
• toxo
• CMV
• varicella
• IGRa
• GC/chlamydia 
• hep A, B and C (vax for a and b if needed)
• HLA-B5701- only needed if using abacavir
• G6PD (bactrim and dapsone can cause hemolytic anemia so need to know if they have this) if african or mediterranean decent

• cervical pap smear
• anal pap smear

• < 30y: no HPV cotest needed. get at basleline, 6mo, yearly then if 3 are normal q3 years
• 30 or older: HPV cotest needed, baseline, 6mo, then if thats normal q 3years
• at any age if HPV positive or if LSIL or higher: Colpo
• no guideline on when to stop

• annual anal pap if receptive anal intercourse or if history of cervical dysplasia or cervical high risk HPV (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68)
• start at age 40 for anyone who has anal receptive intercourse or anyone with a cervix who has CIN
• start if HIV+ at 35

• hiv + and 35 or older
• hiv- and 40 or older
• hiv+ and active cervical HRHPV

NO, start ART immediately

• If CD4 < 200: Bactrim DS daily to prevent PJP pna
• If CD4 < 100: Bactrim DS daily to prevent toxoplasmosis
• If CD4 < 50: Azithromycin 1200mg weekly to prevent Mycrobacterium Avium Complex (MAC)

aim for >95%, one missed dose per month

• if new dx, start ART, check viral load in 1 mo (should be suppressed)
• if doing well, then re check q 3mo for 1 year, q4mo for 1 year then q6mo if stable viral suppression
• if on q6mo schedule CD4 >300 can go to q12 mo CD4s then if >500 can stop checking all together

• <200 after 1 mo
• < 20 within 6mo after any med change

• yearly lipids
• yearly a1c

yearly UA

• annual GC/chlaymydia/syphilus in sexually active pts
• annual TST or IGRA in pt at risk for TB
• HCV screening once, retest more frequently if risk factors
• DEXA in postmenopausal women and men 50 or older
• annual lipids, a1c, ua
• one time screening AAA with ultrasound in men 65-75 if ever smoked

• STIs
• Hep B and C
• smoking
• CVD risk double
• elevated cancer risk
• Neuruologic impairment
• osteopenia and osteoporosis

• cvd risk is double in those with HIV, however no valid calculator shows HIV as a risk factor
• HIV pts are underprescribed ASA
• get lipids and look at ASVD risk, if not a smoker, you can add this to the tool to get a more accurate risk

• Viral load
• CD4
• BMP
• LFTs

• annual GC/Chlamydia/Syphillus in sex active
• annual TST/IRRA at pts at risk for infeciton with TB
• repeat HCV screening PRN if risk factors
• Lipids, A1C, U/A annually + 2-3 mo after med changes
• one time AAA screening ultrasound men 65-75 who ever smoked

no, not if CD4 below 200, might not get a reaction, do an IGRA

• annual flu shot
• PCV13- once, followed by 2 PPSV pneumovax
• COVID fully and boost
• hep a and b if non immune
• tetanus q10
• mmr/varicella ONLY if nonimmune and CD4 > 200 for 3 mo 
• shingrix once if 50 or higher
• hpv series for 9-26 yo
• meningococcal 0 and 2 months old and booster q5 years

• pneumovax (PPSV23): twice. 1 dose then another 5 years later
• meningococcal: regular 0 and 2 mo then boost every 5 years

• cervical (women with CD4 <200)
• kaposi sarcoma
• nonhodgkins lymphoma
• primary central nervous system lymphoma

• anal
• vaginal
• hodgkins lymphoma
• liver
• lung
• melanoma
• oropharyngeal
• leukemia
• colon
• renal

• HAND spectrum- HIV associated neurological disorder
• no ARTS have been shown for better outcomes

• entry inhibitors: not really used anymore, neeeds tropism to be only CCR5 dominant, not CXCR4 or mixed
• Fusion inhibitors: 100% get injection site reactions, not used
• Nuceloside/Nucleotide Reverse transcriptase inhibitors: commonly used
• Non-nucleoside Reverse Transcriptase Inhibitors: commonly used
• Integrase inhibitors: our main tool now, used all the time
• Protease inhibitors: commonly used
• Pharmacologic enhancers/boosters: used, but not part of a regimen. enhance a regimen
• Post-attachment inhibitor or monoclonal antibody: newer, consider if they have a lot of resistance to most other classes

• an integrase Strand transfer inhibitor 
• PLUS 2 nulceoside reverse transcriptase inhibitors

OR

(dovato) Dolutegravir-lamivudine: first 2 drug regiment. except for individuals with HIV RNA over 500,000 copies/mL, hep b, or who ART is to be started before getting their genotyping results (this is an integrase strand transfer inhibitor + 1 NRTI.)

as long as not pregnant.

• biktarvy (one pill): bictegravir, tenofovir and alafenamide-emtricitabine: tenofovir and emitricitabine are the nrti backbone and biktarvi is the integrase inhibitor
• dolutegravir-abacavir-lamivudine: if HLA-B*5701 negative. you need HLA testing for this one. abacavir and lamivudine are NRTI 
• Dolutegravir PLUS tenofovir alafenamide or tenofovir DF PLUS emtricitabine or lamivudine

• contains 2 NRTIs
• emtricitabine and tenofovir

• maraviroc or MCV (selzetry)
• ccr5 antagonists
• bind the CCR5 receptor and change it to prevent HIV protein binding and prevent entry
• not used, sucks bc binding sites change overtime and not everyone has the same binding site

• enfuvirtide (ENF) and T-20 Fuzeon
• Binds to the heptad region and prevents the folding of the protein and prevents fusion to the host cell
• an injectable
• sucks and rarely used- TONS of injection site reactions

• most common: emtricitabine (emtriva), lamivudine (epivir), tenofovir alafenamide (Vemlidy), tenofovir disoproxil fumarate (viread)
• mimic human nucleotides and can be interchangably taken up by reverse transcriptase
• they dont have a 3-hydroxyl group so more nucleotides cant be added after and they terminate the chain
• a fake nucleotide/nucleoside
• the backbone of HIV meds. Very effective, few side effects, safe

• doravirine (Pifeltro), Efavirenz (Sustiva), Rilpivirine (Edurant)
• these go in the middle of the reverse trascriptase and prevent it from sqeezing and clipping the newly made DNA so it cant go on to do further things
• like NRTIS, very commonly used and safe

• bictegravir (Biktarvy)
• dolutegravir (Tivicau)
• Elvitegravir (Vitekta)
• "gravirs"
• our main tool
• stops the enzyme that helps the HIV integrate its DNA into the host DNA

• darunavir (Prezista) most commonly used 
• "navirs"
• good for those with resistance to NRTIs and NNRTIs
• sit in the middle of the protease and stops it from snipping. stops arrest and maturation of proteins. 
• Prevents infection of new cells

• ritonavir and cobicistat
• Boosters. help boost another drug once it gets into the cells
• used to boost another HIV regimen- keeps more in the cells
• inhibits hepatic metabolism to boost drug levels, watch for drug interactions. acts at p450
• allow pts to take lower doses with same effect

• ibalizumab-uiyk (Trogarzo)
• blocks HIV infected cells from spreading the virus to others
• IV drug
• given to ppl with significant resistance to other HIV drugs

dolutegravir-lamivudine. 

can be used first line for those starting therapy for the first time

• if you dx them and want to start right away and not wait for genotype, you should use
• Biktarvy (BIC/TAF/FTC): VERY likely to work
• Symtuza 
• Darunavir/cobicistat + tenofovir/emtricitabine
• dolutegravir + tenofovir/emtricitabine

sometimes, some need acidic gastric pH for effective absorption

• Integrase inhibitors: mg, al, ca, zn, fe. electrolytes. check antacid use
• Doltegravir: metformin. increases concentration. they can only take 500mg bid max of metformin
• boosters: statins- myopathy. atrovastatin ok only at 20mg/day
• boosters: fluticasone (Cushings) other steroids too
• atazanavir, rilpivirine: PPIs. these need acidic ph for absorption. Use H2 blocker instead

• yes
• and child should be treated 4-6 weeks post delivery

• post exposure prophylaxis
• for those without HIV that have been exposed
• used for postcoital, work exposure, contact with open wound, IVDU

• percutaneous (ie needle stick)
• risk is 0.2-0.3%

• wash area with soap and water
• avoid squeezing "milking"
• refer immediately to health
• Get HIV status of source (4th Gen)
• dont delay PEP while waiting for results

• integrase inhibitor + NRTI combination
• raltegravir 400BID + tenofovir disoproxil fumarate and emtricitabine (descovy) 300mg-daily

OR

dolutegravir 50mg DAILY + TENOFOVIR DISOPROXIL FUMARATE-EMTRICITABINE 300MG daily

• ideally start 30-90 in after exposure
• no longer than 72 hours after exposure
• if >72 hours, less likely to be effective, refer to expert
• take for 28 days
• can d/c if source comes back negative

• nausea
• fatigue
• headache
• very few se

• preg
• hep B
• hep C (Retest in 6 mo too)

• Repeat after 2 weeks initiation
• CBC, Renal function, liver test

• repeat HIV testing at 6 weeks and 4 months after exposure
• if non 4th gen test used, 6 weeks, 12 wks and 24 weeks after exposure

• more than 72 hours since exposure
• unknown source (ie sticked from a sharps container)
• known/suspected ART drug resistance
• preg/breastfeeding
• serious comorbidity
• toxiicty from PEP
• coinfected with Hep B or C

• if a negligible risk for HIV: dont use
• if substancial risk and 73 hours or more since exposure: dont use
• if substantial risk and 72 hours or less since exposure: look at source. if source known HIV+, do PEP, if unknown, case by case determination. look at behaviors and risk

• substantial: exposure of vagina, rectum, eye, or mucous membranes or cut with blood, semen, vag secretion, rectal secretion, breast milk or blood when source is known HIV positve
• negligible: exposure of same areas, but with urine, nasal secretion, saliva, sweat or tears not contaminated with blood regardless of the known status of the source

exposure to blood, genital secretions, or other body fluids in a known HIV+ person within 72 hours of exposure and substantial risk for transmission

• highest: receptive anal intercourse and needle sharing
• lowest: biting, spitting, sex toys, oral intercourse

raltegravir 400bid + tenofovir DF-emtricitabine 300 dailly

OR

dolutegravir 50 daily + tenofovir DF-emtricitabine 300 daily

for 28 days. same as occupational exposure

• hiv serological testing (pt and source)
• cbc
• liver
• kidney
• STIs (pt and source)
• hep b and C (pt and source)
• preg
• viral load and resistance testing (source if infected)

NO. transistion without a gap

Truvada (tenofovir DF + emtricitabine) 300-200mg daily

OR

descovy (TAF + emtricitabine) 25-200mg daily

these are both NRTIs

• interrupts HIV replication, stops reverse transcriptase
• when taken daily, concentration is enough to protect against infection if exposed

• ivdu
• multiple partners
• inconsitent condom use
• recent STI
• sex work
• hiv+ partner not suppresed

EVERY 3 MONTHS

• 4th gen HIV test (1 week prior to starting)
• viral load (if exposed and it hasnt been 2 weeks)
• BMP
• Gon/chlamyd: men who have sex w men and sex workers swab throat, urine and rectum) urine alone isnt enough
• syphilis
• HEpatitis: both truvada and discovy treat Hep B too, so you want to make sure they dont stop this if they have it
• preg

• HIV: if you suspect, get a viral load, they need a full regimen. 
• GFR <60ml/min: for truvada
• cant take daily or follow up routineline

• use with caution osteoporosis or hx fragile fracture
• hep B +- make sure they stay on the regimen and get their tx

• 7 days in rectum, 20 days in vaginal and blood
• daily use required
• NOT ENOUGH to treat someone with actual HIV and can cause resistance, make sure they dont have it
• return if exposed and >7 days off PrEP, may need PEP

• 1 month adherence after starting and baseline labs
• q3 mo: HIV test, preg
• q6mo: STI tests, BMP for med sfety (can do STI q3 mo if high risk)

• Unlikely unless not taking consistently
• get: HIV RNA level, CD4 count, genotype
• refer to specialist and STOP PreP. they may have resistance

• could cause hepatitis flare since HBV dna levels can increase dramatically
• keep them on it

• Before sex: 2 PrEP tablets at least 2 hours and ideally 24 hours before sex
• After sex: 1 PrEP 24 hours after the 1st dose you took, and then another PrEP tablet 48 hours after the 1st dose you took (total 2 tabs after sex)
• not FDA approved

odds ratio

known outcome, look retrospectively to see if they had the exposure

• post-test probability depends on pre test probability
• if you want to know the probability of developing lung cancer in a population, that risk is not evenly distributed- it depends if you smoke work in high risk environment etc bc those increase your pre-test probability
• if your initial risk was 30% ands smoking increases risk by 3%, your new risk is 33%
• pre test probability also affects positive and negative predictive values: if pre test probability is very low, even someone who gets a positive result has a good chance its a false positive, bc the pre test probability is low. alternatively if youre in an area with a high pre test probabiliyt, even if somone is negative,

• can be prospective or retro
• you choose the exposure, and see if they get the case

• true positives/(true positives+false negatives) 
• aka true positives / everyone who really is positive

• true negatives / true negatives + false positives
• aka true negatives / everyone who really is negative, regardless of what they tested

• if a false negative or a positive test is dangerous
• to confirm that someone does not have the disease
• if its negative it rules out

• for confirmation testing
• if a false positive result is dangerous

• the probability that a person who tests positive actually has the disease
• true positives / all who tested positive
• a form of post test probabily, depends on pre test probability

• the probability that someone who tests negative actually is negative
• true negatives / all that tested negative
• tells how reliable a test result is
• a form of post test probability, depends on disease prevlance

high POSITIVE predictive value with high sPecificicity

high NEGATIVE predictive value and high seNsitivity

• measures how predictive a finding is for a disorder
• tells you how much your post test probability changes based on the finding
• independent of prevalance, once you know the ratio you can apply it to any population
• if more than 1: increased probabily that the disorder is present
• if 1: test result does not change the probabily of the disease at all
• if less than 1: an decreased probbility that the targt disorder is present

• lr >10 = high likelihood that disease is present
• lr <0.1 = greatly decreased liklihood of disease presnce

lr of 0.1 means the liklihood was decreased by 90%, where an LR of 10 means the likelihood increased 10x

no, their numbers are always positive, but it will be described as pos or neg depending on if the finding is present or absent

• if ddimer is positive, you have a positive liklihood ratio of DVT occurance
• if ddimer is negative, you have a negative liklihood ratio for DVT occurance

• gives you a precision of the point estimate
• a range of values
• if the range crosses 1 it is NOT significant

• adulteration: making sure the plants in things are good quality and not contaminated. ie where they are made. Chemical compounds, other botanicals, pharmaceutical drugs
• contamination: heavy metals, pesticides, microbial contaminants

these top 2 are addressed by good manufacturing practices (GMPS)

• safety of the plant itself
• herb interactions with other drugs or food

• yes! this is a myth that they arent
• the regulation is somewhere between food and drugs- like vitamins

• dietary supplements
• foods
• topicls
• some are active ingredients in  OTC product

senna leaf

• good manufacturing practices: all ingredients must be identified, batches mixed properly, good testing
• claims must be true
• must report adverse events to the FDA- you have to notify them, but no pre-market approval needed

• chamomile 
• lemon balm 
• raspberry leaf
• milk thistle (hepatic protective)

• senna leaf
• licorice
• coffee
• comfrey

• foxglove- digoxin tox
• aconite
• hellebore

• abnormal sign, symptom or worsening of health
• happens after taking a product
• may or may not be related to the product

ie if you had a cup of throat coat and your pinky toe hurt after- could be related, could not be

• an adverse event 
• the relationship between the product and the event is at least plausible
• ie you take senna and get bad cramping

• any unintended effect of a product
• occurs at the standard therapeutic dose
• effects are related to the product

• temporal relationship
• other diseases/drugs/supplements that could have caused
• biological plausability
• rechallenge results- they take it again see if it happens again

• certian
• probable
• likely
• possible
• unlikely
• unassessable

• no, 
• its related to coumadin but not the same. 
• aromatic compound found in many herbs including tonka been, sweet woodruff, sweet grass
• can be converted to dicoumarol which is warfarin by mold so watch out

• no
• think of foxglove, livertoxins, etc

no, very low risk

• more concentrated, like in a pill form
• rather than just eating the food

• to help with memory
• so old ppl take it, more falls may falsely look like more bleeding

• additive effects to a drug
• opposing effects

often prescribed together bc they enhance each other

means it metabolizes more so theres less drug in the body

cant metabolize as fast so there is more drug in the blood

• ones metabolized by cyp450 
• ones with narrow therapeutic window

• a protein in cell membrane
• transports drugs out of cells
• when inhibited, more drug in the cell
• when enhanced, more drugs pushed out of the cell

• 1: herbs that can be safely consumed whe used appropriately
• 2: herbs wehre use restrictions apply unless otherwise directed. such as: a-external use only, b- not in preg or c- breastfeeding, or other specifics
• 3: herbs with significant data to recommend label that says "use only under supervsion of qualified expert"
• 4: herbs with insufficient data for classification

• a: can be safely consumed with any prescription or non prescription drugs or other supplements
• b: herbs for which clinically relevant interactions are biologically plausible
• c: herbs for which clinically relevant interactions are known to occur

• piper methylsticum
• a muscle relaxant and eases stress
• heavy long term use >6g/day causes scaley yellowing skin
• myth that it causes liver tox
• safety class 2b, 2c, 2d, interaction class B

• safety class 1, interaction class c (bc concentrated for weight loss)
• liver toxicity when in ethanol extract
• reduces risks liver disease
• dont use with CNS stimulants, bronchodilaters, adrenergic drugs

• safety class 1 interaction class c
• antiplatelet activity, but no increased bleeding risk with warfarin
• safe at dietary levels, dont conentrat
• dont use therapeutic doses with anticoag or antiplatelets
• infants like it in breast milk

no

• purple coneflower 
• safety class 2b, 2d, interaction class B
• used for flu, sore 
• myth that it has bad heart effects

• safety: 2b, 2d
• interaction: b
• no adverse effects at standard therapeutic dose with less than 5g daily for 6 weeks
• excessive use depletes K, raises Na, high bp, tachycardia, temp loss of vision, temp paralsis
• often happens from too much candy

• preg
• HTH, liver disese, water retention, kidney disease, low K, CF

• for menopause
• safety: 2b
• interaction: A
• good safety
• similar species in china caused toxicity

• for mental function, memory, anxiety
• safety: 1 inteaction: b
• no effect on bleeding
• induced cyp

• for dep
• safety: 2d
• interaction: C
• causes photosensitivity
• induces p-gp and cyp
• decreases many drug levels

• safety: 1
• interaction: A
• safe to use
• can decrease fasting blood glucose

• higher breast cancer in lesbians- nulliparity
• less likely to have insurance
• more likely to be homeless
• higher cancers of gentials if they keep their original
• Older LGBTQ adults have a higher prevalence of obesity, cardiovascular disease, arthritis, asthma, and depression.
• Older LGBTQ adults with depressive symptoms have lower rates of access to healthcare services including preventative care services.
• Higher prevalence of anal cancer among gay men than the general population. 
• higher obesity lesbians

• 2-3 x likely to attempt
• almost 2 x as likely to complete

this pop has the highest rates of alcohol, tobacco and drug use

• 16
• however, need parental consent for transgender therapy and meds

• tanner stage 2-3
• kids at 12-13
• need parental consent

breast bud development

• enlargement of testes first
• may be some pubic hair or penis growth

• have they had a behavioral health consult
• hx of gender identiy incongruence and dysphoria
• hx of gender affirming measures
• Growth charts (these will suppress growth hormones- watch esp in kids on stimulants- weight loss)
• look at pubertal development, make sure they are tanner 2-3

• yes
• you can defer initially, but cant start the meds til you see

• serum estradiol and/or testosterone depending on birth sex
• LH
• FSH
• renal/liver function
• consider bone age with Xray of Left hand if there are height concerns
• vit d screening in pts with disrodered eating, low bmi, inactivity, poor calcium intake, bad diet

• gonadotropin releasing hormone (gnRH) agonists
• put the pause on pubety
• activate GNRH receptors and cause decreased or suppressed gonadotropin secretion
• suppress gonads from making estrogen, progesterone or testosterone

• leuprolide (lupron): IM q28 days. start at 7.5mg-11.25mg if under 25kg. 11/25-22.5 if over 25kg. most common
• luprolide acetate: IM q12 weeks (3 mo). 11.25-22.5
• histrelin acetate: sub q implant 50mg q12 mo

• yes- if elevated testosterone or estradiol, FSH/LH or clinical evidence that they are still going through puberty
• watch out, this can initially worsen- flare expression of gonadotropin- can accelerate puberty before blocking effect takes action
• if doing lupron q28: increase by 3.75mg q4 weeks til desired response
• if leuprolide acetate q12 weeks: increase to 22.5mg or 20mg, and shorten time between injections

• to suppress testosterone in boys wanting to stop puberty or become girls
• not enough to suppress testosterone alone, you also need GNRH
• starting 25mg- 300 mg, day. can adjust by 20-50 mg intervals per day til desired effect (suppression of testosterone). watch BP and electrolytes (K)

• 1 month after start
• q3 mo after that
• check growth, tanner stage to see if pub was blocked or continued
• talk to them about affirming around 15-16. they cant stay on this forever they need to grow

• LH, FSH, total testosterone or estradiol, liver function: we check these to assess adequate suppression of hypothalamic-pituitary-gonadal axis 6-8 weeks after lupron q28 start or 8 weeks after 3 month dosing
• repeat the lh, fsh, estradiol/testosterone, renal and liver function q3-4 mo
• annual labs: a1c, lipids, glucose, insulin, alk phos, calcium, vit d
• annual xray bone age: if concerned about height/weight

if on GNRH agonists for more than 2 years

• if female at birth: depo provera q12 weeks to suppres menses. IUDs too but they may not want invasive
• if male at birth: spironolactone 25-300mg daily to suppress testosterone. watch bp and electrolytes

• lots of weight bearing excercise for their bones
• diet adequeate in calcium and vit d

• if age appropriate development of secondary sex characteristics
• persistent, stable and well docd gender identity, 6+ months per dsm5
• stable mental health and medical conditions
• pubertal suppresion has allowed pt to integate their gender more fully and decide

no, not in general. specific meds might

• around age 16
• start before 16 if: bone health worries, going through puberty in late adolescence/college
• data shows that if they still have gender dysphoria at adolescence they are unlikely to want their birth sex

• used to induce male secondary sex characteristics: muscle mass, body/face hair, voice change, enlargement of clitoris
• suppresses estrogen production- uncessary if on a GnRH agonist, thats already doing it
• historically given IM, now SC better
• topical ok for adults, not kids

• Subq: 12.5mg weekly x 8-12 weeks, then increase to 25mcg weekly
•        check levels in 3 mo and adjust by 12.5mg weekly as needed. most reach desirable results and appropriate blood levels at 50-75 mg weekly
• IM: 25mg IM weekly or biweekly x 8 weeks then increase to 50mg weekly. if dosing is biweekly, double dose
•          most do well on 50-100 weekly or 100-200 biweekly. takes longer than sc to get into your system so higher dose needed

• 3-6 mo: testosterone levels q3-6 mo until levels stable. goal testosterone 320-1000 ng/dL; hematocrite
• 12 mo: serum testosterone, total testosterone, hematocrit, lipid profile
• yearly: hematocrite, once stable serum T not needed anymore. lipids, glucose, a1c

• 18g 1in for drawing up
• 25g 5/8 in for adminstration

inject to thigh, flank switch sides every week

• no
• you can get lipodystrophy so belly not good for image. 
• rotate injection sites!
• induration of the area can happen, massage after injection

• 18g 1 inch for drawing up
• 21-25g 1in needles for injection. mostly 23 or 25
• inject into thigh, switch sides each time

suspended in cottonseed oil, check allergies

• yes, a controlled med
• pt needs ID to pick up from pharmacy

• 17b estradiol induces female sex characteristics: breasts, redistribution of fat, softening facial features
• does not completely suppress testosterone function: so you can use a GnRH agonist to do this or another agent like spironolactone
• oral, IM or transdermal

• transdermal: 6.25ug patch twice weekly, increase dose q3-6 mo to adult dose of 200-400ug twice weekly. NOT RECOMMENDED ROUTE
• oral/sublingual: 0.25mg daily, increase dose q3-6 mo until adult dose of 4-8mg daily
• IM: estradiol valerate 5mg biweekly, increase q3-6mo until adult dose of 10-40mg biweekly OR parental IM estradiol cypionate 2mg/week increase q3-6mo to adult dose 10mg weekly

yes, but dosing is different!

• 4-6 weeks: if on spironolactone- check K, BUN, cr, then check these 4-6 weeks after any dosing changes of this
• 6 months: estradiol level goal 100-200pg/mL, total testosterone should be 50-50 ng/Dl (normal female range). Potassium, BUN, cr
• annually after stable dose and goal concentration met: serum K, bun/cr, estradiol, total testosterone, prolactin (more often if sx of hyperprolactinemia or pituitary adenoma), lipids, glucose, a1c

• VTE risk
• worry if tobacco use or hx VTE 

if a smoker AND hx VTE: CONTRAINDICATED. 1 or other is okay in youth. not adulthood

no and no

same as testosterone

slow delivery- transtermal

• no consensus when to stop if they have started affirming therapy
• you can continue into early adulthood, may help
• if they are on GnRH alone WITHOUT affirming therapy, at 2-3 years talk to them about time to make a decision. or around 16. earlier if bone risks, etc

• same initial dosing
• may need to increase initial doses and increase dosing more frequently bc the pt has already gone through sex of origin puberty

not in MA- 1 parent ok, but try to get both bc this can be used against parent in custody battles

similar to kids

• yes 
• in DSM5
• dont code for this, can create stigma

• fat deposits from injection of street collagen
• can get infected or ulcer or silicon embolization

• estrogens
• antiandrogens
• prgestagens- improve breast development, mood, libido

• spironolactone 200-400mg daily. caution with kidney problems
• 5-apha reductase inhibitors (finasteride and dutasteride). good choice if cant tolerate spironolactone

• testosterone
• thats it

no, but it can cause ammenorhea

active sex hormone receptive cancer

• dermatology: hair removal, silicone injections, cosmetic procedures, acne
• endocrine: bone issues, DM, complex hormone therapy
• ID: HIV or other STI
• reproductive endocrinology: fertility
• plastics: gender affirming procedures
• behavioral health

• if they have breasts do it- so trans women and trans men that have not had mastectomy
• start screening after 5 years of starting femininzing therapy, regardless of age
• transgender women over 50: screen 5-10 years after starting hormone therapy start
• mammogram q 2 years

• not a requirement to start testosterone
• same screening as cis women
• start at 21 regardless of sex activity or homones
• higher liklihood of unsatisfactory result while on testosterone

• lots of lube
• 1 week vaginal estrogen before exam
• have them get a ride and give a benzo

• active: mycobacterial infection spread via droplets. can affect lungs or body. Fever, weight loss, night sweats, fatigue, LAD, cough, hemoptysis, CP. can spread. positive CXR and smear/culture
• latent: m. tuberculosis infection but no active disease. no sx, not contageous, but positive TST/IGRA, neg CXR or sputum cult/smear

• 10%
• most likely 1-2 years after exposure
• if HIV: 10% PER YEAR

• identify high risk
• screen them
• if positive test, CXR and symptom screen
• if negative sx and CXR start Latent TB treatment
• folow up monthly and complete full therapy regimen

• Everyone who is asymptomatic, over 18 and at increased risk, meaning
• born to an endemic country and lived there over 1 mo, regardless of when they came here
• immunosuppressed (hiv, organ transplant, biologic use)
• close contact to active infection
• IVDU, homeless, prison, healthcare worker

anything other than US, puerto rico, canada, australia, new zealand or weast north europe

• intradurmal purified protein
• read after 48-72 hr
• rxn measured in mm

• common myth that BCG gives positive skin test. if they got it in infancy and its been 10+ years, very unlikley
• however if they got it after 1 year old, and even if its been 10+ years, can have pos result

• types: quantiferon Tb gold, and T-spot
• looks at how your immune system responds to the antigen. in the blood not skin
• draw blood and put in a tube with the antigen and look for cd4 cell response. if + your body has seen the antigen before
• 8-30 hours to get results

• both highly sensitive, tst a little more
• igra highly specific, very few false positive

• pros: single visit, results in 24 hours, prior bcg vaccine ok
• cons: limited data in kids under 2, expensive, samples must be processed in 8-30 hours

• 15mm or more: positive for anyone over 4
• 10mm or more: ppl with conditions that increase risk of reactivation (HD, silicosis, malignancy, DM, malnutrition, jejunal bypass, IVDU), residents/emp in high risk settings (hospital, jail, homeless, labs), kids under 4, and foreign born or immigrated from endemic country
• 5mm or more: HIV+ (regardless of CD4), close contact with active case, abnormal CXR with fibrotic changes, immunosuppressed

• bcg vaccine
• another non tb mycobacterium- bcg vaccine is made from another myco

• immunosuppressed: HIV, steroids, cancer, tnf alpha, malnourished, ckd
• active TB
• recent TB
• recent live vaccine MMR
• improper test technique or protein

if negative, repeat in 8 weeks to look for conversion, may be a false negative

• positive: +mitogen, -Nil, + result in EITHER tube 1 or 2. tube 1 or 2 minus nil is >0.35iu/mL
• negative: + mitogen, -nil, - result in BOTH tubes 1 and 2
• indeterminate result: - mitogen (immunosuppresed), +nil (high background noise)

• false neg: window of new infection. can take 8-12 weeks after new infection to test pos
• false pos: a different type of mycobacterium infection (not BCG tho)

no. just infection. dont know if active or not

• yes. both are positive FOR LIFE. 
• dont recheck

no, go straight to CXR and symptom eval

• cxr
• symptom eval: cough, fever, night sweat, weight loss, cp, lymph node well
• ask if prior tb treatment
• trend weight, pulm exam, lymph and abd exam
• look at risk

if no positives, its ruled out

• PA view adults
• PA and lateral view kids to look for subtler changes and lymphadenopathy

• yes
• need a negative cxr within 2 mo prior to starting tx
• bc we want to be really sure they dont have active TB

no, unless they have concerning symptoms- do cxr and get sputum

yes, to MA DPH

very urgent: contact with confirmed + case, documented conversion from negative to positive test within 2 years (something has changed), immunosuppression (current or planned), HIV

remember 2 years after exposure is highest risk for active

• rifampin 600 mg daily x 4mo
• isoniazid 300mg daily 6-9 mo
• isoniazid 900mg + rifapentine 900mg AKA 3HP weekly for 3 months

• rifampin: less liklihood for hepatotoxicity, shorter course, however inhibits ocp and turns fluids orange
• isoniazid: no interaction with ocp, safe in pregnancy, however longer course
• 3HP: only 3 months, only once a week, less liklihood for liver toxicity, also DOT so low risk of non adherence

6 mo shown to work but NOT approved by Mass DPH, they want 9

• 600mg/day for 4 mo
• good for adults and children with no med interactions who can take daily meds. use in preg ONLY if Isoniazid cant be used. ok for breastfeeding
• causes orange discoloration body fluids
• se: rash, flu sx, hepatitis, fever, thrombocytopenia
• cyp INDUCER- lower drug levels such as ART, hormonoal contraceptives, anticonvulsants, glucocortioicds, coumadin, oral DM meds 

CONTRAINDICATED IF HIV TREATMENT

• 300 mg daily x 9mo
• fewest drug interactions, but longest regimen
• ok for adults and kids unable to take rifamycin/3HP
• preferred for preg, ok for breastfeed
• se: rash, hepatotoxicity, peripheral neruopathy, CNS effects
• few drug interactions- phenytoin and disulfiram
• CHECK LFTS- hepatotoxicity risk.

• pyridoxine (vitamin B6) 25-50mg/day to prevent peripheral neuropathy
• esp if DM, HIV, kid failure, alcoholism, or preg/breastfeed

• 3x the upper limit and symptomatic
• 5x the upper limit regardless of symptoms

• 1 dose a week x 12 weeks (900mg iso, 900 rfapentine) 
• DOT- low chance of nonadherence, but must commit
• in adults in kids over 2 with no drug interactions
• not safe for preg, ok for breastfeed
• se: flu like rxn, hepatotoxicity, peripheral neuropathy, all the other isoniazid and rifampin sx
• many drug interactions- rifampine has cyp induction

• excess nitrosamine impurities found in rifampin and rifapentine
• carcinogenic potential, but risk EXTREMELY low. needs long term exposure

• ocps dont work
• arts dont work- CONTRAINTICATED IF HIV

• defer if you can, and same if less than 3mo postpartum
• UNLESS high risk- confirmed contacted case. 
• isoniazid

• all hormonal yes. 
• only paraguard or condom use safe

• HIV
• pregnancy
• liver diseae
• alcohol/hepatotoxic drug use
• chemo
• over 50 years if you think risk

• monthly
• check adherence, s/sx adver reactions
• look for s/sx hepatotoxicity- check LFTs
• check LFTs perioridically, dont need to follow if no sx

• measures how fast RBCs settle to bottom of test tube
• inflammation and infection have extra proteins that make this happen faster
• rises as people age- upper limit changes

• infection
• malignancy
• anemia (up to 40-45)
• age
• ckd
• autoimmune
• obseity

• lab lists at 20, but depends on age
• males: age/2
• females: age/2 + 10

• a protein synthesized by the liver in response to factors released by macrophages and fat cells
• 2 types: inflammatory and high sensitivity (hs)

• inflammatory: used for rheumatic diseaes and inflammation
• High sensitivity (hs): used for cardiac testing. Not rheumatic disease

• SMOKING
• obesity (high IL6 from adipose tissue increases it)
• dm
• inactivity
• hrt
• htn
• depression
• preg
• malignancy
• autoimmune
• infection

• also elevates with age
• male: age/50 mg/Dl; age/5 mg/L
• female: age/50+ 0.6 if mg/dL; age/5 + 6 if Mg/L

• painful shoulder & hip girdle for 1 mo, worse at night. starts in shoulders then might involve hip girdle
• swelling in joints, upper arms/neck, hips, butt, groin, thighs. Occasionally wrist, sternoclavicular joint, knee. NO swelling in small joints of hands/feet/ankle
• pain and stiffness at night. they go to sleep fine but wake up in middle of night due to discomfort takes 45+ min in the AM to get going
• no objective weakness, may be guarding
• fever, weight loss mailase

• over 50 years, most in the 70s
• more in women
• more in caucasion, north climate

• pt with PMR sits for a while an then they try to get up and are really stiff
• takes 10 ish mins to loosen up from sitting
• different from OA where its just a few step

• pain with ROM of shoulder an hips, but they look normal
• they dont want you to abduct the shoulder more than 80 deg
• normal x ray no fracture. migt see OA, but likely wont be in all affected joints

• elevated ESR  over 40, often over 100
• elevated CRP
• WBC
• platelets are elevated- means systemic inflammation and autoimmune
• decreased H&H

• mostly no, self limiting about 2 years
• can reoccur in 10% patients, some will have lifelong disease (can try methotrexate)

• temporal arteritis
• steroid induced osteoporosis

• 20mg prednisone daily
• they should have a rapid positive response to this
• methotrexate in those with recurrent disease/lifelong

• start at 20mg daily
• start at 10-15 if uncontrolled DM
• make sure no NSAID use or warfarin
• taper by 2.5 mg daily q2-4 weeks down to 10mg then by 1mg monthly
• NO BURST
• if cant taper steroids you can add methotrexate
• some will need lifelong steroids

• SECRET
• S tiffness and pain
• E lderly
• C onstitutional sx (fever, weightloss, malaise), C aucations
• E levated ESR
• T emporal arteritis

• RA will have rheumatoid facture pos, PMR wont, however, other things like hepatitis can raise it
• RA will have CCP (cyclic citrullinated peptide), PMR wont. this lab is VERY specific to RA

• calicum and VIT D
• 600mg BID calcium0 from diet is best. needs to be BID cant absorb more than 600 at a time
• vit d 1000 units daily, maybe 2,000-5000 u
• potentially bisphosphonates for osteoporosis

• temporal artery in front of ear is enlarged and tender
• EMERGENCY r/t blindness

• high correlation with PMR
• over 50, 10x more common at age 80 than 50-60
• females 2x
• genetic corrlation 
• whites of norther european

• insidious onset- PMR comes on quickly, this takes a week or 2
• headache- temporal or occipital, does not get better with tylenol or NSAID
• scalp tenderness
• jaw/tongue claudication- trouble chewing, jaw hurts
• visual loss- diplopia, in and out, black lightening, shade over eye
• joint pain- shoulder neck, hip girdle bc tied to PMR
• fever weight loss mailase- vasculitis of the med and large vessels- a step up and more severe than PMR
• cant put head on a pillow (may indicate occipital artery involved)

• vision loss
• often irreverible

• need a temporal artery biopsy
• need a big area bc you can miss it- its intermittent in the arteries
• send to ED for this

• scalp tenderness
• tortuous arteries
• absent pulses- scalp arteries, brachial, radial, femoral depending on where inflammation is
• bruit
• > 10mmHg bp difference in the arms
• abdominal pain if affected here

• 60mg prednisone
• should have rapid response

• affects medium and large vessels- including aorta and branches
• increased aneruism risk, blindness, CVA, MI, Htn

• esr: elevated
• crp: high
• ferritin: high
• platelets: high

• 3-6cm
• bilateral if possible
• if + they have gca
• if - either negative or you missed it. slowly taper of steroids but if comes back, start up again and get another biopsy

• usually lifelong
• at least years to treat
• after GCA, the artery is scarred, it doesnt go back to normal

• ultrasound: look for halo sign
• if they have abdominal signs- MRA, PET, CTA

• start at 60mg daily and immediate biopsy
• after 1 mo taper to 55 for 2 weeks then 50 for 2 weeks etc
• all on steroids for 2 years, 40% will need for life
• if visual changes 1mg/kg IV methylprednisolone x 3 days

• bactrim: prophylaxis against pneumocystitis bc high risk infection when on steroids
• Aspirin 81 mg daily: prevent blindness and ASCVD
• methotrexate: used as steroid sparing
• tocilizumab: may allow pts to stop steroids. an il-6 inhibitor. stops gca associated inflammation. sub q or IV for severe. will make CRP normal always, do sed rate, even tho this normalizes a bit too

• methylprednisolone
• prednisone goes through liver TWICE, methoprednysolone only once
• more side effects with prednisone- so avoid in those with psych issues
• methylprednisolone is 25% stronger than prednisone, lesser doses do more

• steroid stuff
• osteoporosis- may need bisphosphonates
• dm
• mood disorders
• weight gain
• cataracts, glaucoma
• HTN
• infections- double dose on sick days

• chronic autoimmune diseae where autoantibodies and complemetn deposit in the tissues leading to inflammation
• where the deposition occurs determines the s/sx. ie skin lesions, renal failure, cva, pulm lsions

• sle
• lupus profundus
• lupus timidis
• subacute lupus
• lupus dermoidis

• YES, 5-7%
• but the closer you come to a decade of having derm lupus, the less likely you will get SLE

• women childbearing age 15-45
• 14x higher in klinefelters (xxy)- something x linked
• 3-4x more common in black, asian, hispanic 
• 8:1 females to male

• SMOKING
• virus (ebv, cmv, silca exposure)
• pesticides
• demethylating cancer drugs
• genetics - fam hx autoimmune probs
• histocompatability complex DR2 and DR3
• C1q, C2 C4 deficiencies

• antinuclear antibody
• NOT SPECIFIC FOR LUPUS. only 5% of those with + ANA actually have sle
• do not order for joint pain or fatigue- need other sx like reynaudes, pleurisy, pericarditis, or cytopenias

• 1:160 or more
• only order if they have connective tissue symptoms: reynaud, pleurisy, lymphopenia, anemia, thrombocytopenia, alopecia, photosensitive rashes. not just for fatigue/joint pain. its not specific
• centromere pattern is specific for CREST syndrome

• calcinousis 
• reynauds
• esophagyl dysmotility
• sclerodactylity 
• talangiectasias

• double stranded DNA
• anti-smith antibody
• ribosomal P protein- highly specific for SLE when elevated
• complement- total hemolytic complement- ch50, c3 and C4 will be low
• anti-histones in drug induced lupus (procainamide, minocycline, hydralazine, INH, methyldopa, TNF)

• check anti histones- elevateed
• hydroxychloroquine or prednisone may be required until theyve been off the offending agent for months

• complex, depends on system
• general: fever, fatigue, weight loss

• not elevated, only elevate if infection
• can be used if they have a fever to rule out infection
• fever can be lupus or infection

• renal
• end stage renal disease more likely in black, hispanic, males poor med compliance, htn, dm, failure to normalized Cr or still proteinuria after 6mo treatment

• proteinuria more than 1g in 24 hours OR
• Proteinuria more than 0.5g in 24 hours PLUS hematuria or cellular casts

• avoid nsaids- dont want to raise bp and decrease nephron perfusion more
• stop smoking
• control BP
• many pts die from renal or cv complications
• get a urine q3 mo on all lupus pts and refer to nephrology

• autoimmune hemolytic anemia: cbc- spherocytes, haptoglobin; bilirubin, lactate dehydrogenase, reticulocyte count, direct coombs
• lymphopenia, neutropenia: exclude med cause first (ie celsat)
• thrombocytopenia: dont treat unles PLT under 30 or having bleeding
• antiphospholipid antibody syndrome: beta 2 glycoproteins and anticardiolipans should be tested. if high, repeat in 3mo, if high again, this is your dx
• anemia of chronic disease
• thrombotic thrombocytopenic purpura: schistocytes on CBC, high LDH
• macrophage activation syndrome (MAS): fever, cytopenias, organ dysfunction, splenomegaly, low ESR
• Elevated triglycerides

• a manifestation of lupus sometimes
• aka lupus anticoagulant syndrome
• doesnt always mean they have lupus if they have this
• increases risk of clotting
• test beta 2 glycoproteins, anticardiolipans- if high, repeat in 3 mo, if high again, DX it
• increases risk of preg loss- loosing many pregs? think this maybe
• anticoagulation, not aspirin can prevent clotting event

• nonerosiver arthritis
• swan neck deformities
• ulnar deviation
• lupus and steroid use lead to avascular necrosis- often bilateral- shoulders and hips
• laxity in joint capsule and laxity of extensor tendon causes deformity

• erosive systemic arthritis with + RF and cyclic citrullinated peptide antibody
• rare
• positive rheumatoid factor and ccp
• the artrhitis here is erosive and damages bone
• symmetrical

• butterfly malar rash
• hand rash BETWEEN, not over joints
• stomatitis on upper palate, tongue, or cheeks/lips
• alopecia

• very well circumscribed slightly raised boarder with dry skin or scale in middle
• does not bleed if picked like psoriasis does
• get a biopsy, send to derm

• ringworm like rash, no central scab
• well circumscribed boarders but with central clearing

• pericarditis
• myocarditis
• vasculitis
• reynauds
• mi
• cad
• htn
• valvular disease
• antiphospholipid antibody syndrome

• color of hand changes white with temp change to cold
• absence of blood to the extremity
• usuallystarts in one finger from tip to DIP joint then over time will develop in other fingers
• when colder temp, triggers system to clamp arteries so no blood
• they rewarm and things might turn blue then red and is painful

• mittens
• heated steering wheel
• calcium channel blockers
• dress as if its 20 degrees colder than it is

• lupus, systemic scleroderma, mixed connective tissue disease, CREST syndrome
• not really seen with RA

• modified allens test
• clench their fists 5x see if blood returns

• pleuritis
• pneumonitis with and without hemorrhage
• interstitial lung disease
• pulmonary fibrosis
• pe
• can affect anywhere on the lung

• cva
• seizure
• psychosis and psych problems
• memory issues

• prednisone
• hydroxychloriquine- for EVERY PT
• cyclophosphomide- for nephritis. causes infertility and bladder CA- low doses
• mycophenolate mofetil (cellcept)- antiimmune
• azothioprine, cyclosporine, tacrolimus- antiimmune
• benylsta
• rituximab
• ACE/ARB for kidney protection
• statins for ascvd
• smoking cessatino

• yes but HIGH risk
• we need to know if theyre planning this, some drugs ie cellcept not safe