10 Flashcards
AE of what rheum drug - macrocytic anemia +/- pancytopenia
MTX
Other AE: nausea, stomatitis, rash, hepatotoxicity, ILD, alopecia, fever
AE of what rheum drug - GI distress, visual disturbances, hemolysis if G6PD deficiency
Hydroxychloroquine
AE of what rheum drug - pancreatitis, liver toxicity, dose dependent bone marrow suppression
Azathioprine
Presentation - transient vision loss lasting a few seconds with changes in head position, blind spot enlargement on visual field testing
Papilledema 2/2 increased ICP
Work-up of suspected papilledema?
Urgent diagnostic evaluation (ophthalmologic exam, neuroimaging, and/or LP) to prevent vision loss
Cause of amaurosis fugax?
Usually vascular (eg, embolus to ophthalmic artery)
Presentation - peripheral visual field deficits, extensive cupping of the optic disc on fundoscopy
Glaucoma
Cause of glaucoma?
Increased intraocular pressure
Fundoscopic exam finding of optic neuritis?
Optic disc edema
Compare the presentations of anterior vs. posterior uveitis.
Anterior: eye pain and redness
Posterior: painless, floaters/reduced visual acuity
Vaccines for adults with HIV?
HAV: chronic liver disease, MSM, IV drug use, travel to countries where HepA is prevalent
HBV: all patients without documented immunity
HPV: all patients age 11-26
Influenza (inactivated): everyone annually
MCV (A, C, W, Y): all
PCV13 1x
PPSV23: 8 weeks later, 5 years later, age 65
Tdap: 1x, Td Q10 years
When are live vaccines (MMR, VZV, etc.) contraindicated in patients with HIV?
CD4 <200
Dx and Rx PMS/PMDD
Symptom/menstrual diary over 2 cycles
SSRIs; combined OCs are an option
Define preterm prelabor rupture of membranes (pPROM).
ROM <37 weeks gestation
Before the onset of labor
4 major risks associated with pPROM?
- Placental abruption
- Intraamniotic infection
- Umbilical cord prolapse
- Preterm labor
Patients with familial adenomatous polyposis have a significantly increased risk of colorectal cancer. What is the standard of care by way of prevention?
Frequent colonoscopic screening starting in childhood and elective proctocolectomy
- Annual screening sigmoidoscopies starting at age 10-12
- Annual colonoscopies once colorectal adenomas are detected or if age 50+
- Regular screening for upper GI tract tumors
- Proctocolectomy if presentation with CRC or adenomas with high-grade dysplasia
Presentation - palpable tender mass on the anterior vaginal wall with associated purulent discharge; may present as dyspareunia, dysuria, post-void dribbling
Urethral diverticulum
Dx and Rx urethral diverticulum
MRI to confirm
Rx - surgical excision
___ is commonly characterized by an acute illness involving the skin/mucosa and either respiratory or CV compromise.
Anaphylaxis
Other manifestations include GI, neuro, and ocular symptoms
What labs can be drawn if the diagnosis of anaphylaxis is unclear?
Serum tryptase
Plasma histamine
Why can medications such as NSAIDs or beta-adrenergic blockers exacerbate anaphylaxis?
Cause non-immunologic mast cell activation or unopposed alpha-adrenergic effects respectively
Features of neonatal abstinence syndrome due to infant withdrawal to opiates?
Presents in the first few days of life
Irritability, high-pitched cry, poor sleep, tremors, seizures, sweating, sneezing, tachypnea, poor feeding, vomiting, diarrhea
Note - prenatal exposure can lead to increased risk of IUGR and SIDS
Lab findings suggesting primary hyperaldosteronism (aldosterone-producing tumor or bilateral adrenal hyperplasia)?
HTN
Hypokalemia
Decreased renin
Increased aldosterone
Lab findings suggesting secondary hyperaldosteronism (renovascular or malignant HTN, renin-secreting tumor, diuretic use)?
HTN
Hypokalemia
Increased renin
Decreased aldosterone
4 possible causes of HTN + hypokalemia + decreased renin + decreased aldosterone
- CAH
- Deoxycorticosterone-producing adrenal tumor
- Cushing syndrome
- Exogenous mineralocorticoids
Although aldosterone causes increased renal reabsorption of sodium, most patients with PH do not have edema or clinically significant hypernatremia - explain.
Aldosterone escape - increased Na leads to HTN and increased blood volume -> increased renal blood flow, GFR, and atrial natriuretic peptide -> Na+ excretion
Triad - congenital heart disease, T-cell deficiency, hypocalcemia
DiGeroge syndrome
List the 3 types of thyroiditis.
- Chronic autoimmune (Hashimoto)
- Painless (silent)
- Subacute (de Quervain)
Compare the clinical features of the 3 types of thyroiditis.
- Hashimoto: HYPOTHYROID, diffuse goiter
- Painless: mild brief hyperthyroid phase, small NONTENDER goiter, spontaneous recovery
- Subacute: post-viral, prominent fever, HYPERTHYROID, PAINFUL goiter
Compare the Dx testing results of the 3 types of thyroiditis.
- Hashimoto: TPO Ab, variable radioiodine uptake
- Painless: TPO Ab, low uptake
- Subacute: elevated ESR, CRP, low radioiodine uptake
Rx thyrotoxicosis in subacute thyroiditis
Beta blockers to control thyrotoxic symptoms
NSAIDs for pain relief; steroids if pain does not respond
Findings of suppurative thyroiditis?
Rare condition
High-grade fever, pain, palpable enlargement due to abscess formation
EUTHYROID
Oral emergency contraceptive options that prevent pregnancy by delaying ovulation?
Levonorgestrel (progestin)
Ulipristal (anti-progestin)
Progestin OCPs
Distinguish between breastfeeding jaundice and breast milk jaundice.
FEEDING: first week of life, insufficient quantity (decreased bili elimination, increased enterohepatic circulation) + SUBOPTIMAL breastfeeding, signs of DEHYDRATION
MILK: peaks at 2 weeks, deconjugation of intestinal bili due to high levels of beta-glucuronidase in milk + ADEQUATE breastfeeding, NORMAL exam
Normal frequency of breastfeeding?
At least 10-20 minutes per breast Q2-3 hours
Normal # of wet diapers in the first week of life?
At least the infant’s age in days
ABO hemolytic disease almost exclusively affects infants with blood types ___ who are born to mothers with type ___.
A or B; O
Management of breastfeeding jaundice?
- Increase frequency and duration of feeds, maintain adequate hydration, promote bilirubin excretion
- If bilirubin continues to rise despite such efforts -> formula supplementation (do not discontinue breastfeeding)
(If bilirubin levels are below the phototherapy threshold)
What causes vasospastic angina and how is it treated?
Hyperreactivity of intimal smooth muscle -> intermittent coronary artery vasopspasm
CCBs (diltiazem, amlodipine, etc.) - preventive
Sublingual nitroglycerin - abortive
Smoking cessation
Presentation of vasospastic angina?
Young patients (<50)
Smoking + minimal other CAD risk factors
Recurrent chest discomfort at rest or during sleep, resolves spontaneously within 15 minutes
ECG: STEMI
Coronary angio: no CAD
What is cilostazol?
PDE III inhibitor that causes arterial vasodilation and inhibits platelet aggregation; used for patients with intermittent lower extremity claudication
What is ranolazine?
Antianginal drug that decreases myocardial Ca2+ level by inhibiting late-phase sodium influx into ischemic cardiomyocytes; effective in treating stable angina due to atherosclerotic CAD
List the 7 initial interventions involved in stabilization of acute STEMI.
- Supplemental O2 (if <90% or dyspnea)
- Aspirin 325 mg
- P2Y12 inhibitor (eg, clopidogrel)
- Nitrates (sublingual)
- Beta blocker (unless hypotension, bradycardia, chronic heart failure, heart block)
- High-dose statin (eg, atorvastatin 80 mg)
- Anticoagulation (depends on planned revascularization)
After initial stabilization of acute STEMI - if there is persistent pain, HTN, or heart failure, what is done?
IV nitroglycerin (except if hypotension, RV infarct, or severe aortic stenosis)
Vasodilators
After initial stabilization of acute STEMI - if there is persistent severe pain, what is done?
IV morphine
Anxiolytic + preload reducing
After initial stabilization of acute STEMI - if there is unstable sinus bradycardia, what is done?
IV atropine
After initial stabilization of acute STEMI - if there is pulmonary edema, what is done?
IV furosemide (not if patient is hypotensive or hypovolemic)
Decreases preload -> decreases pulmonary capillary pressure
Venodilates -> further decreases preload
Reperfusion options for acute STEMI?
Percutaneous transluminal coronary angioplasty within 90 minutes (preferred)
Thrombolysis (if PCTA no available within 120 mintues)
2 major uses of digoxin?
Rate control in patients with rapid AF
Improve symptoms in CHF
Presentation - delirium, elevated vitals (hypertermia, HTN, tachycardia), diaphoresis in the setting of multiple SUDs
DT
Where does atopic dermatitis present in infants vs. children/adults?
Infants: extensor surfaces, cheeks
Children/adults: flexor surfaces (neck, antecubital fossae, volar wrists, popliteal fossae, dorsal ankles)
Presentation - total or segmental non-obstructive colonic dilation, severe bloody diarrhea, systemic findings
Toxic megacolon
Dx toxic megacolon
Plain abdominal XR (dilated R or transverse colon, thick haustral markings that do not extend across the entire lumen) + 3 or more of the following: fever >38 C, pulse >120, WBCs >10500, and anemia
Rx toxic megacolon
Medical emergency
IVF, broad-specrum ABX, NPO, IV steroids if IBD-induced
R-sided colon cancer tends to present with ___; L-sided colon cancer tends to present with ___.
Anemia; bowel obstruction
Symptoms of SIBO?
Bloating, flatulence, water diarrhea, abdominal pain +/- malabsorption and nutritional deficiencies
Causes of SIBO?
Anatomic abnormalities (eg, strictures, surgery) Motility disorders (eg, DM, scleroderma) Alterations in gastric/pancreatic secretions (eg, atorphic gastritis, chronic pancreatitis)
Dx SIBO
Jejunal aspirate and culture showing >10E5 organisms/mL
Carbohydrate breath test
Organisms involved in SIBO?
Streptococci
Bacteroides
Escherichia
Lactobacillus
Rx SIBO?
ABX (eg, refaximin, amox-clav) Avoid antimotility agents (eg, narcotics) Dietary changes (high-fat, low barb) Promotility agents (eg, metoclopramide)
What is dumping syndrome?
Complication of gastric bypass, occurs when high-carb foods are rapidly emptied into the small bowel, leading to osmotically driven fluid shifts from the plasma to the intestines
Abdominal pain, diarrhea shortly after meals + sympathetic activation (tachycardia, diaphoresis, flushing, hypoglycemia)
What is androgen insensitivity syndrome?
Complete defect in androgen receptor function
Phenotypically female
Primary amenorrhea due to absent uterus
No pubic or axillary hair
Features of 5-alpha-reductase deficiency?
Impaired conversion of testosterone to dihydrotestosterone
Initially have female external genitalia and male internal genitalia until puberty -> virilization due to increased levels of T
Emergent management of central retinal artery occlusion?
Ocular massage and high-flow O2 administration
Management of acute angle closure glaucoma?
Topical pilocarpine and beta-blockers
Infants who receive oral macrolide should be monitored for what AE?
Pyloric stenosis
Describe the administration of PPSV23 and PCV13 in adults.
Age 65+: 1 dose PCV13, then PPSV23 6-12 months later
Age 19-64:
-PPSV23 alone: chronic heart, lung, or liver disease, DM, current smokers/alcoholics
-PCV13 + PPSV23: CSF leaks, cochlear implants, SCD/asplenia, immunocompromise, CKD
Reverse hypochloremic hypokalemic metabolic alkalosis 2/2 gastric loss?
Isotonic NaCl and K
Features of ankylosing spondylitis
Insidious onset of inflammatory back pain at age <40
Symptoms >30 months
RELIEVED WITH EXERCISE, but not rest
Nocturnal pain
Associated exam findings:
- Arthritis (sacroiliitis)
- Reduced chest expansion and spinal mobility
- Enthesitis
- Dactylitis
- Uveitis
3 complications of ankylosing spondylitis?
Osteoporosis/vertebral fractures
Aortic regurgitation
Cauda equina
Describe the T3, T4, TSH, and reverse T3 findings in early/mild + prolonged/severe euthyroid sick syndrome.
T3: decreased
T4: normal -> decreased
TSH: normal -> decreased
RT3 -> elevated
Characteristic thyroid lab findings in euthyroid sick syndrome caused by?
Low T3 with normal TSH and T4 in patients with acute illness due primarily to decreased peripheral conversion of T4 to T3
What is the major cause of delayed morbidity and mortality in subarachnoid hemorrhage and what can it cause? How can it be prevented?
Vasospasm; cerebral infarction; nimodipine
What is the major cause of death within the first 24 hours of presentation of SAH?
Rebleeding
Dx post-SAH vasospasm?
CTA
In patients with ARDS, how does mechanical ventilation improve oxygenation?
By providing an increased fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) to prevent alveolar collapse
Goal PaO2 in MV?
PaO2 at 55-80 mmHg; corresponds roughly to O2 saturation of 88-95
What vent settings primarily influence PaO2?
FiO2
PEEP
What vent settings primarily influence PaCO2?
RR
TV
Prolonged high FiO2 can cause ___. It should be reduced as soon as possible below levels that predispose to this problem, approximately ___%.
Oxygen toxicity; 60
Management of stable vs. unstable ectopic pregnancy
Stable - MTX
Unstable - surgery
What physical exam finding is highly specific for epileptic seizure?
Tongue biting (especially the lateral tongue)
What is the most specific symptom of giant cell arteritis?
Jaw claudication
Rx open angle glaucoma?
Acetazolamide
What is calciphylaxis (aka calcific uremic arteriolopathy)?
Systemic arteriolar calcification and soft-tissue calcium deposition with local ischemia and necrosis; presents with painful nodules and ulcers, soft tissue calcification on imaging
Risk factors for calciphylaxis?
ESRD on hemodialysis Hypercalcemia, hyperphosphatemia Hyperparathyroidism Obesity, DM Oral anticoagulants
