11 Flashcards
What causes GVHD?
Recognition of host major and minor HLA-antigens by donor T-cells and consequent cell-mediated immune response
Organs typically affected in GVHD + symptoms?
Skin (maculopapular rash involving palms, soles, and face), intestine (blood + diarrhea), liver (abnormal LFTs, jaundice)
What mediates graft rejection?
Activation of host T-cells
GnRH, FSH, and estrogen findings in hypothalamic hypogonadism?
All decreased
GnRH, FSH, and estrogen findings in primary ovarian insufficiency?
GnRH and FSH increased
Estrogen decreased
GnRH, FSH, and estrogen findings in PCOS?
GnRH: increased
FSH: normal
Estrogen: increased
GnRH, FSH, and estrogen findings in exogenous estrogen use?
GnRH and FSH decreased
Estrogen increased
Management of preterm prelabor rupture of membranes?
If <34 weeks -> expectant management with prophlyactic latency ABX, steroids, and inpatient monitoring
If <34 weeks + complications develop -> deliver + IAI Rx, steroids, Mg if <32 weeks
If 34 to <37 weeks: deliver, GBS PPx, +/- steroids
What is amnioinfusion used for?
Variable fetal HR decelerations in labor
When are tocolytics indicated in PPROM?
Never - they are contrindicated because contractions often indicate a complication requiring delivery or intervention
Management of dyspareunia due to hypoestrogenism in the setting of postpartum breastfeeding?
Non-hormonal lubricants and moisturizers
Presentation - hematuria, renovascular congestion (enlarged kidney on imaging), flank pain, possible elevated ADH and/or AKI
Renal vein thrombosis
Common causes/risk factors of renal vein thrombosis?
Hypercoagulability: nephrotic syndrome, malignancy, OCPs
Volume depletion (infants)
Trauma
Dx renal vein thrombosis
CTA or MRA
Renal venography
Rx renal vein thrombosis
Anticoagulation
Thrombolysis/ectomy if AKI present
There is significant overlap between presentation of renal infarction and acute RVT - distinguish between them.
Infarct - cardioembolic disease -> incomplete infarction -> wedge-shaped area of ischemia, often report abdominal pain + flank pain
Nearly all patients with CF develop ___. Most male patients develop ___. ~20% develop sensorineural hearing loss - why?
Sinopulmonary disease; infertility (only 20% of females have fertility problems)
Frequent treatment with aminoglycosides for GN infections
When comparing iron studies in the 3 main microcytic anemias (iron deficiency, thalassemia, and anemia of chronic disease), what are the key distinguishing findings?
[MCV: decreased in all three; may be normal in chronic disease or very decreased in thalassemia]
Iron: INCREASED in thalassemia; decreased in the other 2
TIBC: INCREASED in iron deficiency; decreased in the other two
Ferritin: DECREASED in iron deficiency; increased (both) or normal (chronic) in the other two
Transferrin saturation: VERY INCREASED in thalassemia, decreased (both) or normal (chronic) in the other two
Transferrin saturation = ?
Iron/TIBC
Key findings in iron studies suggesting iron deficiency anemia?
Decreased ferritin
Increased TIBC
Key findings in iron studies suggesting thalassemia?
Increased iron
Very increased transferrin
Key findings in iron studies suggesting anemia of chronic disease?
Decreased iron + decreased TIBC
Rx hereditary spherocytosis?
Splenectomy
Rx anemia of chronic disease?
Rx underlying condition (Fe supplementation is not helpful, because the problem involves USING iron rather than a deficiency of iron)
Presentation - micrognathia, microcephaly, prominent occiput, low-set ears, rocker-bottom feet, overlapping fingers, absent palmar creases, heart and renal defects
Trisomy 18 (Edward syndrome)
Holosystolic murmur best heard at the LLSB
VSD
What causes the fixed split S2 heard in ASD?
Delayed closure of the pulmonic valve
Truncus arteriosus is associated with what syndrome?
DiGeroge
Acute rheumatic fever is a complication of untreated S. pyogenes pharyngitis. List 5 major clinical features.
- Carditis
- Chorea
- Erythema marginatum
- Subcutaneous nodules
- Migratory arthritis
Minor - fever, arthralgias, elevated ESR/CRP, prolonged PR interval
Late cardiac sequelae of acute rheumatic fever?
Mitral regurgitation/stenosis
Diagnostic criteria for acute rheumatic fever?
2 major
1 major + 2 minor
Anything with chorea or carditis present
Why do we give patients penicillin when they have GAS pharyngitis?
TO PREVENT ARF
Follow-up management of patients with ARF?
Prophylactic long-acting IM benzathine PNC G for several years
Most common virus causing peri/myocarditis
Coxsackievirus
List 6 ECG findings suggesting an arrhythmias as the cause of syncope.
- Inappropriate sinus bradycardia
- SA block
- Sinus pauses
- AV block
- Non-sustained ventricular arrhythmias
- Short or prolonged QTc interval
NOT isolated premature ventricular beats
___ is due to polymorphic ventricular tachycardia in the setting of a prolonged QT interval.
Torsades de pointes
What crystals cause gout and how are they identified?
Monosodium urate crystals: needle shaped, negatively birefringent (YELLOW when PARALLEL, BLUE when PERPENDICULAR)
True or false - the presence of synovial crystals rules out septic arthritis.
False - they can be present between flares - look for other signs of septic arthritis
What crystals cause pseudogout and how do they appear?
Calcium pyrophosphate crystals - smaller, rhomboid, weakly positive birefringent (opposite gout)
Synovial fluid findings in gout?
Leukocytosis (2000-100,000 with >50% neutrophils)
Presentation - normal internal genitalia, external virilization, undetectable serum estrogen, polycystic ovaries in an adolescent female patient
Aromatase deficiency
How does aromatase deficiency first manifest?
In utero -> placenta cannot convert androgens into estrogens -> transient masculinization of Mom that resolves after delivery
Presentation - females with ambiguous external genitalia, normal internal female reproductive organs, electrolyte abnormalities
Classic congenital adrenal hyperplasia
Presentation - females with primary amenorrhea and virilization at puberty, normal genitalia at birth
Non-classic late-onset CAH
Features of Kallman syndrome?
X-linked
Hypogonadotropic hypogonadism + anosmia
Delayed puberty, LH and FSH low or absent
What is McCune-Albright syndrome?
Cafe au lait spots
Polyostotic fibrous dysplasia
Autonomous endocrine hyperfunction -> gonandotropin-independent precocious puberty
Rx ethylene glycol poisoning?
Fomepizole (competitive inhibitor of alcohol dehydrogenase)
Sodium bicarbonate
Hemodialysis
What is methylene blue used for?
Rx methemoglobinemia (ingestion of dapsone or anesthetics)
Antidote for cyanide poisoning?
Sodium thiosulfate
Calcium oxalate deposition in the kidneys + hypocalcemia?
Ethylene glycol ingestion
Lifestyle changes to decrease risk for gout?
Dairy product intake Vitamin C (>1500 mg/day) Coffee intake (6+ cups/day)
Etiology of allergic conjunctivitis?
IgE-mediated acute hypersensitivity to environmental allergens
Exercise recommendations for healthy women with uncomplicated pregnancies?
Moderate-intensity exercise for 20-30 minutes on most or all days of the week + avoid contact sports and activities with high fall risks. Also don’t scuba dive or do hot yoga.
Contraindications to exercise in pregnancy?
Risk of preterm delivery
Preeclampsia
Severe caridopulmonary disease
Pathophysiology of ARDS?
Lung injury -> fluid and cytokine leakage into alveoli -> impaired gas exchange, decreased lung compliance, and pulmonary HTN
Management of ARDS?
MV (eg, low TV, high PEEP, permissive hypercapnia)
Dx ARDS?
New/worsening respiratory distress within 1 week of insult
Bilateral lung opacities (pulmonary edema) NOT due to CHF/fluid overload
Hypoxemia with PaO2/FiO2 ratio of 300 mm Hg or less
Patients with upper GI bleeding often have an elevated BUN and BUN/Cr ratio - why?
- Increased urea production from intestinal breakdown of Hgb
- Increased urea reabsorption from hypovolemia
The aldosterone/renin ratio is elevated in ___.
Primary hyperaldosteronism
___ toxicity is a severe adverse effect of long-term amiodarone use and can occur months to several years after the initiation of therapy.
Pulmonary
Presentation of interstitial pneumonitis due to amiodarone toxicity?
Progressive dyspnea, non-productive cough, new reticular or ground-glass opacities on chest XR
What is amiodarone used for?
(Class III antiarrhythmic)
Management of ventricular arrhythmias in patients with CAD and ischemic cardiomyopathy
Loop diuretics cause what 2 electrolyte abnormalities, which can cause what EKG abnormality?
Hypokalemia; hypomagnesemia
Ventricular tachycardia
___ is a potassium sparing diuretic with proven mortality benefit in patients with severe CHF.
Spironolactone
Both Crohn disease and UC have multiple extraintestinal manifestations - list 4.
- Arthritis - axial or peripheral
- Eye (uveitis, episcleritis, etc.)
- Skin (pyoderma gangreonsum, etc.)
- Hepatobiliary (PSC, etc.)
4 major causes of HF with preserved LVEF.
- LV diastolic dysfunction (HTN w/concentric LVH, restrictive, hypertrophic)
- Valvular heart disease (AS/AR/MS/MR)
- Pericardial disease (constrictive pericarditis, tamponade)
- Systemic disorders -> high-output failure (thyrotoxicosis, severe anemia, large AV fistula)
Manage HFpEF?
Control BP and HR
Address concurrent conditions (AF, MI)
Rx volume overload with diuretics
Exercise training/cardiac rehab
2 general causes of diastolic dysfunction?
Impaired myocardial relaxation
Increased LV wall stiffness (decreased compliance)
Both of these cause LV end-diastolic pressure -> back-up
Type of selection bias - study population differs from target population due to non-random selection methods
Ascertainment (sampling) bias
Type of selection bias - disease studied using only hospital-based patients may lead to results not applicable to target population
Berkson bias
Type of selection bias - exposures that happen long before disease assessment can cause study to miss diseased participants that die early or recover
Prevalence (Neyman) bias
Type of observational bias - subjects with negative outcomes are more likely to report certain exposures than controls, common in retrospective studies
Recall bias
Type of observational bias - subjects over- or under-report exposure history due to perceived social stigma
Reporting bias
Type of observational bias - risk factor itself causes increased monitoring in exposed group relative to unexposed group, which increases probability of identifying a disease
Surveillance (detection) bias
3 strongest predictors of AAA expansion and rupture?
- Large aneurysm diameter
- Rapid rate of expansion
- Current cigarette smoking
Current indications for operative or endovascular repair of AAA?
Size >5.5 cm
Rapid rate of expansion (>0.5 cm in 6 months or >1 cm/year)
Symptoms regardless of size
Presentation - 46XY, phenotypically female at birth with female external and male internal genitalia + virilization at puberty
5-alpha-reductase deficiency
Pathogenesis of 5-alpha-reductase deficiency?
Testes produce T -> male internal genitalia
T converted to DHT via 5-alpha-reductase; DHT -> male external genitalia and prostate
Without 5-alpha-reductase, no external genitalia
Dx 5-alpha-reductase deficiency?
Elevated T/DHT ratio
Pathogenesis of androgen insensitivity syndrome?
Defect androgen receptor -> prevents virilization during embroygenesis
Testosterone resistance -> absent male external genitalia
Distinguish between 5-alpha-reductase deficiency and androgen insensitivity syndrome
5-alpha-reductase: NO breast development (T binds receptor and inhibits proliferation)
AIS: ++Breast development (defective androgen receptor unable to inhibit breast tissue proliferation)
Bilateral labial masses
Undescended testes
Features of Takayasu arteritis?
Female, Asian, age 10-40
Constitutional symptoms
ARTERIO-OCCLUSIVE (claudication, ulcers, etc.) in upper extremities
Arthralgias/myalgias
BP discrepancies
Pulse deficits
Arterial bruits
Dx and Rx Takayasu arteritis
Elevated ESR/CRP
CXR with aortic dilation and widened mediastinum
CT/MRI: wall thickening and narrowing of lumen of large arteries
Rx - systemic glucocorticoids
Fundoscopy - blood and thunder appearance, cotton wool spots, disc swelling, hemorrhages, venous dilation
Central retinal vein occlusion
Unlike sensitivity and specificity, PPV and NPV depend on the ___ of the disease in the population being tested.
Prevalence
A change in a test cutoff point that causes an increase in the number of false positives and true positives will have what effect on PPV?
Decrease
PPV = ?
TP/(TP + FP) = (a/a+b)
High PPV -> positive test more likely to be true
