12 Flashcards
2 best predictors of post-operative outcomes following lung resection surgery?
- FEV1
2. DLCO
Based on pre-operative FEV1 and DLCO measurements, the % of planned resection is used to estimate post-operative FEV1 and DLCO. Patients with an estimated post-operative FEV1 or DLCO of less than ___% are at elevated risk of post-operative morbidity.
40
2 uses for capnography (aka end-tidal CO2 measurement)?
Indicative of aerobic metabolism; monitor correct endotracheal tube placement, measure effectiveness of CPR
Maximal inspiratory pressure (or negative inspiratory force) is a measurement of inspiratory muscle strength - what is it used for?
Monitor patients with hypoventilation due to neuromuscular disease (MG, GBS, etc.); assess need for MV
Features of Marfan syndrome?
AD Tall stature, long thin extremities Arachnodactyly Joint hypermobility Upward lens dislocation Aortic root dilation Kyphosis and/or scoliosis Skin hyperelasticity Pectus excavatum
Cause of Marfan syndrome?
Mutation or the fibrillin-1 gene -> systemic weakening of connective tissue
What is the most life-threatening finding in Marfan syndrome, how does it present, and what are complications to monitor for?
Aortic root dilation
Aortic regurgitation (diastolic murmur)
Echo for development of aneurysms and aortic arch dissection
May also have MV prolapse (mid-systolic click, late systolic murmur)
What autosomal recessive disorder caused by deficient cystathionine synthase mimics Marfan syndrome? How is it different?
Homocystinuria
Fair complexion, thromboembolic events, intellectual disability, DOWNWARD lens dislocation
What is caused by defective collagen production and how does it present?
Ehlers-Dnalos
Scoliosis, joint laxity, aortic dilation; do not have tall stature, lens problems, etc.
If you see something that looks like Marfan, but the patient has joint contractures + no ocular or CV symptoms, suspect ___.
Congenital contractural arachnodactyly (AD condition 2/2 mutations is fibrillin-2)
Presentation - within 1 year of Roux-en-Y gastric bypass, progressive nausea, postprandial vomiting, GER, dysphagia
Stomal (anastomotic) stenosis
Dx and Rx stomal stenosis?
EGD to diagnose + balloon dilation to treat
Surgery if this fails
Define preeclampsia and preeclampsia with severe features.
New-onset elevated BP (140/90+) + proteinuria OR signs of end-organ DYSFUNCTION at 20+ weeks
Severe if signs of end-organ damage (severe HTN, Plt <100,000, transaminitis, Cr 1.1+, headaches/visual changes)
Sever eHTN in pregnancy?
Systolic 160+ or diastolic 110+ for 15+ minutes
First-line drugs for maternal hypertensive crisis?
IV hydralazine (vasodilator) IV labetalol (beta blocker with alpha-blocking activity) Oral nifedipine (CCB)
Rx chronic hypertension in pregnancy?
Methyldopa
True or false - it is ethical for students to perform procedures on deceased patients for training purposes with permission of the family or the patient prior to death.
True
Patients with hypoalbuminemia may have a significant deficit in total body ___.
Calcium
___ use is associated with tendinopathy and tendon rupture (Achilles most commonly).
Fluoroquinolone
Yellow-green malodorous discharge
Trichomoniasis
Malodorous thin white discharge
BV
First-line alternative to stimulants for child and adolescent ADHD?
Atomoxetine (SNRI)
Pathology of coarctation of the aorta?
Thickening of the tunica media of the aortic arch near the ductus arteriosus following CLOSURE of the ductus (normally)
Findings of coarctation of the aorta?
Upper extremity HTN
Lower extremity hypotension and hypoxia
Diminished/delayed femoral pulses
Systolic ejection murmur at the L interscapular area
Presentation - fever, pleuritic chest pain, hemoptysis in an immunocompromised patient
CT scan with pulmonary nodules + surrounding ground-glass opacities
Invasive aspergillosis
May also have positive cultures and positive cell wall biomarkers (galactomannan, beta-D-glucan)
Rx invasive aspergillosus
Voriconazole + an echinocandin (eg, caspofungin)
How does chronic pulmonary aspergillosis compare to invasive?
Risk factors -> lung disease/damage (cavitary TB)
Presentation: >3 months of weight loss, cough, hempotysis, fatigue
Cavitary lesion +/- fungal ball
+Aspergillus IgG serology
Rx chronic pulmonary aspergillosis
Resect if possible
Azole (voriconazole)
Embolization if severe hemoptysis
Next step if positive screen for critical CHD in a newborn (+ pre- and post-ductal pulse oximetry)?
Echo
What is the hyperoxia test used for?
Distinguishing between cyanosis due to pulmonary disease (improves with O2) and CHD (persistent cyanosis)
Rx SCFE?
Surgical screw fixation for stabilization of the physis to prevent further slippage
Dx SCFE?
Posteriorly displaced femoral head on frog-leg lateral hip radiograph
Mechanisms of physiologic jaundice due to indirect hyperbilirubinemia in newborns?
- High RBC turnover
- Hepatic bilirubin clearance is decreased
- Enterohepatic recycling is increased
Patients with an acute COPD exacerbation and continued symptoms despite medical management should be considered for what next step?
Non-invasive ventilatory support
- Start with non-invasive PPV (facemask)
- If they fail a 2-hour trial of NPPV or decomponsate, consider intubation
Oxygen in hypercapnic and hypoxemic patients should be titrated gradually with a goal arterial oxygen saturation of ___ or PaO2 of ___.
88-92%
60-70 mmHg
Why is NPPV in patients with acute exacerbation of COPD helpful?
Decreases mortality, rate of intubation, hospital length of stay, and incidence of nosocomial infections
Pathologic hallmark of diabetic nephropathy?
Nodular glomerulosclerosis (diffuse glomerulsclerosis is more common)
Pathologic mechanism of COPD?
Progressive expiratory airflow limitation (manifests as FEV1/FVC <0.7) which causes air trapping, decreased vital capacity, and increased total lung capacity (due to air trapping)
FEV1 is disproportionately decreased as compared to VC.
Note - the alveolar-capillary membrane is also destroyed in COPD
Rx patients with early syphilis + severe penicillin allergy
Oral doxycycline
Pathophysiology of diffuse esophageal spasm?
Uncoordinated contractions of the esophageal body
Findings of diffuse esophageal spasm on manometry?
Intermittent peristalsis, multiple simultaneous contractions of the middle and lower esophagus
Finings of diffuse esophageal spasm on esophogram?
Corkscrew pattern
Rx diffuse esophageal spasm
CCBs
Alternates - nitrates or TCAs
Management following a caustic ingestion?
ABCs
Decontamination: remove contaminated clothing and visible chemicals, irrigate exposed skin
CXR if respiratory symptoms
Serial CXR/KUB to identify any signs of perforation
Endoscopy within 24 hours in the absence of perforation
What can be done to reduce the progression of diabetic nephropathy?
- Strict BP control (ACEIs, ARBs), target <130/80
2. Tight glycemic control with target AC <7%
Recommended screening colonoscopy schedule for patients with UC or Crohn with colonic involvement?
8-10 years after initial diagnosis + repeat every 1-2 years thereafter
Recommended screening colonoscopy schedule for patients with HNPCC (Lynch syndrome)?
Start at age 20-25
Repeat every 1-2 years
Recommended screening colonoscopy schedule for patients with classical FAP?
Start at age 10-12
Repeat annually
Recommended screening colonoscopy schedule for patients with a FAMILY HISTORY of adenomatous polyps or CRC -> 1 first-degree relative age <60, 2+ first-degree relatives at any age
Age 40 or 10 years before the age diagnosis in the affected relative (whichever is earlier)
Repeat Q5 years
3 steps to reduce risk of long-term prescription opioid misuse?
- Review state prescription drug-monitoring program data
- Random UDS
- Regular follow-up at least every 3 months
Presentation - adolescent patients with cyclic lower abdominal pain in the absence of apparent vaginal bleeding, defecatory rectal pain, blue bulging vaginal mass/membrane that swells with increased pressure
Imperforate hymen
Presentation - subacute, severe, unilateral limb pain (burning or tingling, out of proportion, non-dermatomal, allodynia) presenting within 4-6 weeks following trauma or surgery
Complex regional pain syndrome (CRPS)
May also include edema/sudomotor changes (eg, sweating) and vasomotor changes (eg, erythema, altered skin temperature)
If advanced -> trophic changes
XR findings of CRPS?
Patchy demineralization
Bone scintigraphy findings of CRPS?
Increased uptake in the affected limb
Management of CPRS?
PT/OT, exercise
NSAIDs, antineuropathic meds
Type of bias - Prolongation of apparent survival in patients to whom a test is applied without changing the prognosis of the disease
Lead-time bias
Medications that can cause idiopathic intracranial HTN?
Growth hormone
Tetracyclines
Excessive vitamin A and its derivatives (eg, isotretinoin, all-trans-retinoic acid)
[Manage by stopping meds]
What is vitiligo?
Acquired depigmentation disorder that occurs due to melanocyte destruction
Appearance of vitiligo? Associations?
Flat hypopigmented macules with distinct borders that can expand and coalesce; autoimmune disease
Rx vitiligo?
Corticosteroids and phototherapy
Rx acute cluster headache (abort)?
100% O2 by facemask
Second line - subQ sumatriptan (so long as there are no contraindications), ergotamine
Prophylaxis for acute cluster headaches?
Verapamil
Lithium
Preferred treatment in adjustment disorders?
Psychotherapy
Pathogenesis of VW disease?
Impaired activity/quantity of VWF -> poor platelet-endothelial binding and reduced factor 8 levels due to increased destruction
___ therapy for RA is associated with hepatotoxicity. Serum liver studies should be checked prior to initiation and periodically thereafter. How can this and other toxicity related to this drug be mitigated?
MTX; concurrent folic acid
AE of RA DMARD leflunomide?
Hepatotoxicity
Cytopenias
AE of RA DMARD sulfasalazine?
Hepatotoxicity
Stomatosis
Hemolytic anemia IN PATIENTS WITH G6PD DEFICIENCY
AE of RA DMARDs TNF inhibitors?
Infection
Demyelination
CHF
Malignancy
Joints affected by RA?
Symmetric polyarthritis -> MCPs, PIPs, wrists
Before starting a TNF-alpha inhibitor, what pre-testing should be done and why?
Interferon gamma release assay to assess for latent TB
Rx patients with CAP who are hospitalized?
FQ (eg, moxifloxacin, levofloxacin)
or
Beta-lactam + macrolide (eg, ceftriaxone + azithromycin)
CURB-65?
Confusion Urea >20 mg/dL Respirations 30+/min BP (systolic <90 or diastolic <60) Age 65+
0 - outpatient
1-2 - likely inpatient
3-4 - urgent inpatient, possible ICU if >4
The standard meds for CAP treat what 4 most common bacterial CAP organisms?
S. pneumoniae
H. influenzae
Legionella
M. pneumoniae
Lab findings in prerenal AKI (Serum Cr, urine output, BUN/Cr ratio, FENA, urine sediment)?
Increased serum Cr
Decreased urine output
BUN:Cr ratio >20:1 (increased resorption of Na and H2O leads to increased passive resorption of urea)
FENA <1%
Unremarkable or bland urine sediment (unless acute tubular necrosis occurs)
What causes incisional hernias?
Fascial closure breakdown
Distinguish rectus abdominis diastasis from incisional hernia.
Rectus abdominis diastasis is not a true hernia, so it has no fascial defect. therefore, it is not palpable while supine, unlike an inguinal hernia.
Abdominal U/S or CT findings of acute cholangitis?
Dilation of the intrahepatic and common bile duct
Management of acute choalngitis?
Supportive care
Broad-spectrum ABX
Biliary drainage (preferably by ERCP with sphincterotomy)
U/S finding of primary sclerosing cholangitis?
Short, annular strictures alternating with normal bile duct (beads on a string)
What uterine surgical history = contraindicated trial of labor?
Classical C-section (vertical incision)
Abdominal myomectomy WITH uterine cavity entry (during removal of intramural or submucosal fibroids)
PID typically presents with fever, lower abdominal tenderness, mucopurulent cervical discharge, and cervical motion and uterine tenderness. Describe two other presentations to watch out for.
- Intermenstrual spotting (cervicitis) and abdominal pain that worsenes with menses
- Fitz-Hugh-Curtis disease (perihepatitis) -> liver capsule inflammation causing pleuritic RUQ pain, vomiting, and slightly elevated transaminases +/- symptoms of acute PID
What are the 5 main ulcerative STDs?
- Chancroid
- Genital herpes
- Granuloma inguinale (donovanosis)
- Syphilis
- Lymphogranuloma venereum
Which of the 5 main ulcerative STDs are initially painful?
- Chancroid
2. Genital herpes
Presentation - single, indurated, well-circumscribed non-exudative ulcer with a clean base (may start as a papule)
Syphilis (T. pallidum)
Presentation - multiple deep ulcers, base may have gray to yellow exudate
Chancroid (Haemophilus ducreyi)
Presentation - small, shallow ulcers with large, painful, coalesced inguinal lymph nodes
Lymphogranuloma venereum (C. trachomatis)
Presentation - multiple, small, grouped ulcers that are shallow with an erythematous base
Genital herpes (HSV 1 and 2)
Presentation - extensive and progressive ulcerative lesions without LAD, base may have granulation-like tissue
Granuloma inguinale (Klebsiella granulomatis)
One possible cause of hammer toe and claw deformities?
Diabetic peripheral neuropathy
Among patients with meningitis, a viral etiology is suggested when CSF analysis reveals what?
Mildly elevated WBC count and protein level
Normal glucose concentration
Why is doxycycline contraindicated in young children and pregnant/lactating women?
Permanent discoloration of teeth and retardation of skeletal development
Rx Lyme disease (pregnant women and children <8 y/o)
Oral amoxicillin
3rd line treatment for Lyme?
Azithromycin
All patients with smoke inhalation should be suspected to have acute CO poisoning and treated with ___.
100% O2 via a non-rebreather facemask
Dx CO poisoning?
ABG - carboxyhemoglobin level
Why is human milk considered to be the ideal nutritional source for full-term infants?
Protein is 70% whey and 30% casein, more easily digested and helps to improve gastric emptying
Contains lactoferrin, lysozyme, and secretory IgA (immunity)
Main carbohydrate is lactose
Ca2+ and Ph are better absorbed
Less reflux and colic than formula
What happens to RA pressure (aka preload), PCWP (aka preload/LA pressure/LV EDP), cardiac index (aka pump function), SVR (afterload), and mixed venous O2 saturation in hypovolemic shock?
All decrease except SVR, which increases (in response to the hypovolemic state)
What happens to RA pressure, PCWP, cardiac index, SVR, and mixed venous O2 saturation in cardiogenic shock?
RA pressure (fluid backup), PCWP (fluid backup), and SVR increase (in response)
Cardiac index decreases significantly (pump failure)
MVO2 decreases
What happens to RA pressure, PCWP, cardiac index, SVR, and mixed venous O2 saturation in septic shock?
RA pressure and PCWP are normal or decreased
Cardiac index and MvO2 increase
SVR decreases
Stridor that increases with exertion and improves with prone positioning?
Laryngomalacia
When are breath sounds increased on pulmonary auscultation (the only major pathology that doesn’t decrease)?
CONSOLIDATION
When is tactile fremitus increased?
Consolidation
Which 2 pathologies cause hyperresonant lungs?
Pneumothorax
Emphysema
Rx unilateral adrenal adenoma
Surgery (preferred)
Rx bilateral adrenal hyperplasia?
Medical therapy preferred -> aldosterone antagonists (eplerenone, spironolactone)
Condylomata acuminata vs. condylomata lata?
HPV 6/11 vs. secondary syphilis
Presentation - unilateral conjunctivitis with NO symptoms or allergies
Subconjunctival hemorrhage - benign condition, just observe
Presentation - cyclical fever with non-specific constitutional and GI manifestations, anemia, and thrombocytopenia
Malaria
Dx malaria
Thin and thick peripheral blood smears
Presentation - fever, headache, marked muscle and joint pain, retro-orbital pain, rash, and leukopenia
Mosquito-borne dengue fever
Presentation - acute febrile illness, myocarditis, chancre, progresses to CNS involvement
Sleeping sickness transmitted by the testes flies (African trypanosomiasis - East Africa)
Most common cause of neoanatal sepsis?
GBS
Why is it possible for infants born to mothers with appropriate GBS management to get GBS meningitis?
These measures do not decrease the risk of late-onset (>7 days) GBS sepsis from horizontal transmission (vs. vertical)
Presentation - chorioretinitis, hydrocephalus, intracranial calcifications
Congenital toxoplasmosis
What is hyposthenuria and in what illnesses is it seen?
The inability of the kidneys to concentrate urine; sickle cell disease and trait
Cause of central DI?
Insufficient ADH production
A relative risk of 0.71 shows that the drug/intervention decreases the risk by ___%.
29%
Phenytoin is highly protein-bound and metabolized by what system?
Hepatically by the CYP450 system
Features of acute phenytoin toxicity?
Horizontal nystagmus Ataxia N/V Hyperreflexia may occur Can progress to AMS, coma, death
How do beta blockers treat stable angina?
Decrease exertional HR and myocardial contractility -> reduces oxygen demand
First-line treatment of chronic stable angina?
Beta-blocker
Alternative to beta-blocker for treatment of chronic stable angina? MOA?
Nondihydropyridine CCBs (V, D)
Same a beta-blockers
How are dihydropyridine CCBs used in chronic stable angina? MOA?
Added to beta blocker if needed
Coronary artery vasodilation + decreased afterload via systemic vasodilation
Rx persistent angina? MOA?
Add long-acting nitrates (isosorbide MONOnitrate)
Decrease preload by dilation of capacitance veins
Alternative Rx for refractory chronic stable angina? MOA?
Ranolazine
Decreased myocardial Ca2+ influx -> reduced ventricular wall stress and myocardial O2 demand
Most common heart defect in Down syndrome?
Complete AV septal defect
Possible auscultation findings of complete AV septal defect?
- Fixed split S2 (ASD)
- Systolic ejection murmur (increased flow across the pulmonary valve due to L->R shunt across the ASD)
- Holosystolic murmur of VSD
- Holosystolic apical murmur (AV valve regurgitation)
Coarctation of the aorta is associated with ___ syndrome.
Turner
Symptomatic ___ presents with cyanosis and heart failure due to severe tricuspid regurgitation. Auscultation reveals a widely split S1 and S2 + a loud S3 and/or S4 and a holosystolic or early systolic murmur at the LLSB.
Ebstein
PDA is strongly associated with ___ syndrome.
Congenital rubella
Transposition of the great arteries is strongly associated with ___ syndrome.
DiGeorge
Gout is a common complication of myeloproliferative disorders - why?
Excessive turnover of purines -> increased uric acid production
4 causes of gout related to increased urate production
- Primary gout
- Myeloproliferative/lymphoproliferative disorders
- Tumor lysis syndrome
- HGPT deficiency (Lesch-Nyhan syndrome)
2 causes of gout related to decreased urate clearance?
CKD
Thiazide/loop diuretics
Features of vasculitis neuropathies?
Assc. with systemic vasculitis
Patchy, asymmetric neuropathy affecting several nerves
Severe pain
Systemic symptoms
Features of alcoholic neuropathy?
Symmetric distal polyneuropathy (paraesthesia, burning pain, ataxia)
Loss of DTRs and light touch and vibratory sense
Presentation - developomental delay, sensorineural deafness, cataracts, HSM, purpura
Congenital rubella syndrome
Presentation - cutaneous findings (blue toe syndrome, livedo reticularis), cerebral/intestinal ischemia, AKI, Hollenhorst plaques
Cholesterol embolism
Rx cholesterol embolism?
Supportive
Statin therapy for risk factor reduction and prevention of recurrent embolism
Distinguish between chronic bronchitis vs. emphysema-predominant COPD.
DLCO - normal in chronic bronchitis, decreased in emphysema
