13 Flashcards
DDx - obstructive pattern (FEV1/FVC <70%) + divide by low, normal, and increased DLCO
Low: emphysema
Normal: chronic bronchitis, asthma
Increased: asthma
DDx - restrictive pattern (FEV1/FVC >70% predicted, FVC <80% predicted) + divided by low, normal, and increased DLCO
Low: ILD, sarcoidosis, asbestosis, heart failure
Normal: MSK deformity, neuromuscular disease
Increased: morbid obesity
DDx - normal spirometry with low DLCO
Anemia
PE
Pulmonary HTN
DDx - normal spirometry with increased DLCO
Pulmonary hemorrhage
Polycythemia
Define chronic bronchitis.
Productive cough for 3+ months over 2 consecutive years
What is bronchiectasis?
Disease of abnormal bronchial widening in the setting of recurrent infection and inflammation
Drug of choice for stabilizing bony metastatic lesions to prevent hypercalcemia of malignancy and pathologic fractures?
Bisphosphonates
___ injury can occur from blunt force injury but typically results in immediate coma. It is usually diagnose dwith ___.
Diffuse axonal; MRI
___ presents with rapidly progressive dementia, myoclonus, mood symptoms, and hypersomnia. How is it diagnosed?
Creutzfeldt-Jakob disease; high levels of 14-3-3 protein in the CSF
Other diagnostic findings in CJD?
Periodic sharp wave complexes on EEG
Caudate nucleus/putamen findings
Spongiform changes and neuronal loss without inflammation (path)
High anti-Hu Ab titers are seen in ___, a syndrome associated with ___.
Paraneoplastic encephalomyelitis; small cell lung cancer
Pathologic cause of nephrogenic DI?
Impaired renal RESPONSE to ADH
Infants born to women with ___ are at risk for thyrotoxicosis due to passage of maternal TSH receptor Ab across the placenta. How do these infants present?
Graves’ disease
Warm, moist skin, tachycardia, poor feeding, irritability, poor weight gain, low birth weight or preterm birth
Rx neonatal thyrotoxicosis?
Methimazole + beta-blocker to prevent AE on the developing nervous system; will self-resolve as the Ab clears from the infant’s circulation
Management of blunt abdominal trauma leading to suspected abruptio placentae?
- Aggressive fluid resuscitation with crystalloids + place patient in LLD position if the spine is stable to displace the uterus off the aortocaval vessels and maximize CO
- Emergency transfusion if fluid resuscitation is unresponsive or if bleeding is persistent (CBC should be repeated after IVF)
What is the Kleihauer-Betke test used for?
To determine the necessary dose of Rh(D) anti-D Ig after delivery of an Rh-positive fetus to an Rh-negative mother
Hypomagnesemia can lead to refractory hypokalemia - why?
Intracellular Mg2+ is thought to inhibit potassium secretion by renal outer medullary potassium (ROMK) channels in the collecting tubules
Therefore, low intracellular Mg results in excessive renal K loss and refractory hypokalemia
Define fetal tachycardia
> 160/min
Cause of a sinusoidal fetal heart tracing?
Fetal anemia
What is an early deceleration? What causes them?
Shallow decrease in the fetal HR that is a mirror image with the uterine contraction
Autonomic response to alterations in intracranial pressure caused by fetal head compression during contractions
What is a late deceleration and what causes it?
Smooth and subtle drops in fetal heart rate that occur after contractions due to transient fetal hypoxia caused by placental hypoperfusion during contractions
What are variable decelerations and what causes them?
Abrupt drops in the fetal heart rate of varying length and duration; compression of the umbilical cord causing transient fetal hypertension that triggers a parasympathetic response and slows the HR
Clinical features of intrahepatic cholestasis of pregnancy?
3rd Trimester
Generalized pruritis worse on the hands and feet
No associated rash
RUQ pain
Lab abnormalities seen in intrahepatic cholestasis of pregnancy?
Increased total bile acids (>10)
Increased transaminases
+/- increased total and direct bilirubin
Obstetric risks of intrahepatic cholestasis of pregnancy?
Intrauterine fetal demise (>100 bile acids)
Preterm delivery
Meconium-stained amniotic fluid
Neonatal RDS
Management of intrahepatic cholestasis of pregnancy?
Delivery at 37 weeks gestation
Frequent monitoring
Ursodeoxycholic acid
Antihistamines
Features of Turner syndrome?
Webbed neck
Horseshoe kidney
Nail dysplasia
Congenital lymphedema
Narrow high-arched palate Low hairline Broad chest with widely spaced nipples Cubitus valgus Short stature Coarctation of the aorta Bicuspid aortic valve Streak ovaries, amenorrhea, infertility
How does congenital lymphedema present?
Non-pitting carpal and pedal edema
Severe obstruction of lymphatic vessels can result in ___ of the neck.
Cystic hygroma
What causes NONPITTING edema?
High protein content of interstitial fluid
Beta-hCG levels become undetectable ___ after delivery.
2-4 weeks
Presentation of rotator cuff impingement or tendinopathy
Pain with abduction and external rotation
Subacromial tenderness
Normal range of motion with positive impingement tests (eg, Neer, Hawkins)
Presentation of rotator cuff tear
Similar to above, but weakness with external rotation and age >40
Presentation of adhesive capsulitis (frozen shoulder)
Decreased PASSIVE AND ACTIVE ROM
Stiffness +/- pain
Presentation of biceps tendinopathy/rupture
ANTERIOR shoulder pain
Pain with lifting, carrying, or overhead reaching
Weakness less common
Presentation of glenohumeral OA
Uncommon, usually caused by trauma
Gradual onset of anterior or deep shoulder pain
Decreased active and passive abduction and external rotation
What is the key pathogenic factor in the development of DM2 and associated abnormalities?
INSULIN RESISTANCE
Next step in work-up of hemarthrosis after minor trauma?
Coagulation studies (suspicious for a bleeding disorder)
Coag studies in hemophilia?
Prolonged PTT
Normal PT
Normal platelet count
Absent or decreased factor 8 (hemophilia A) or 9 (hemophilia B) activity
Rx hemophilia A and B
Factor replacement
Desmopressin for mild A
The receiver operating characteristic curve of a quantitative diagnostic test demonstrates the trade-off between sensitivity and specificity of a test at various cutoff points. How does changing the cutoff point affect the sensitivity and specificity?
Increasing the true-positive rate (increases sensitivity) also increases the false-positive rate (decreases specificity)
Presentation of hereditary angioedema?
Recurrent episodes of edema (face, limbs, genitalia, bowel, larynx, etc.) WITHOUT associated pruritis or urticaria
Laryngeal edema
Colicky abdominal pain, vomiting, diarrhea
Cause of heredtiary angioedema?
Deficiency or dysfunction of C1 inhibitor -> excessive bradykinin
Dx hereditary angioedema
Low C4 level
Low C1 inhibitor protein or function
Management of hereditary angioedema?
C1 inhibitor concentrate
Pathogenic mechanism of immune hemolytic anemia (for example)?
Antibody-mediated (type II) hypersensitivity
IgG/M react with cell-bound Ag -> complement activation and cell destruction
Pathogenic mechanism of tuberculin skin test and allergic contact dermatitis?
Cell-mediated (type IV) hypersensitivity
Pathogenic mechanism of anaphylaxis?
IgE-mediated (type I) hypersensitivity -> mast cell and basophil degranulation
Pathogenic mechanism of serum sickness?
Immune complex-mediated (type III) hypersensitivity
Ab complexes activate complement wherever IC deposit
What is unique about a STEMI in the inferior leads (and what are these leads)?
II, III aVF, RCA occlusion
50% chance of involving the R ventricle
Management of RV MI?
Leads to impaired RV filling and creates high sensitivity to intravascular volume depletion
AVOID nitrates (venous dilation -> decreased preload -> profound hypotension), diuretics (volume depletion), opiates (venous dilation)
GIVE BOLUS with IV saline to increase preload
Otherwise - standard STEMI management
-Inotropes (dopamine, dobutamine) if persistent hypotension
Which antibiotic can exacerbate MG and why?
FQs
Block neuromuscular transmission
How does the body compensate for chronic hypercapnia?
Increasing renal bicarbonate retention; creating a compensatory metabolic alkalosis
Main cause of hypercapnia in COPD?
Increased dead space ventilation
Cause of positive Trendelenburg sign?
Weakness or paralysis of the gluteus medius and minimus muscles, which are innervated by the superior gluteal nerve
Features of primary sclerosing cholangitis?
Fatigue and pruritis
Majority asymptomatic at diagnosis
90% have underlying IBD (mainly UC)
Complications of PSC?
Intrahepatic or extrahepatic biliary stricture Cholangitis and cholelithiasis Cholangiocarcinoma Cholestasis Colon cancer
Distinguish PBC from PSC?
PBC - middle-age women, no association with UC, +serum antimitochondrial Ab
Cause of TRALI?
Donor anti-leukocyte Ab
What is a primary hypotension reaction to blood transfusion?
Transient hypotension often in patients taking ACEIs that occurs within minutes of transfusion and is caused by bradykinin in blood products
What are the HIV-associated neurocognitive disorders and how do they present?
Impaired memory and attention/concentration, personality and behavior changes, motor symptoms (eg, ataxia, slowed movement)
Asymptomatic neurocognitive impairment
Mild neurocognitive disorder
HIV-associated dementia
Distinguish PML from HIV dementia.
PML - AMS, motor deficits, ataxia, vision abnormalities, FOCAL ASYMMETRIC lesions on MRI
CHA2DS2-VASc Score?
CHF HTN Age 75+ (+2) DM Stroke/TIA/thromboembolism (+2) Vascular disease Age 65-74 (+1) Sex category (F)
Anticoagulation in NONVALVULAR AF based on CHA2DS2-VAsc
0 -> none
1 -> none or aspirin or oral anticoagulants
2+ -> oral anticoagulants
Secondary amyloidosis is a complication of a chronic inflammatory condition (eg, chronic infection, IBD, RA) resulting in extracellular tissue deposition of fibrils into tissues and organs. Patients can develop multi-organ dysfunction (eg, kidneys, liver, GI tract). Treatment?
Treat the underlying inflammatory disease
Colchicine for prevention and treatmen
Define SGA?
<10th percentile for gestational age at birth
Complications of SGA infants?
Hypoxia Polycythemia Hypoglycemia Hypothermia Hypocalcemia
How is PEA of asystole managed?
CPR and vasopressor therapy (eg, epinephrine or vasopressin)
+assess for reversible causes
NO role for defibrillation or synchronized cardioversion
Reversible causes of asystole/pulseless electrical activity?
Hypovolemia Hypoxemia Hydrogen ions (acidosis) Hypo/hyperkalemia Hypothermia Tension pneumothorax Tamponade (cardiac) Toxins (narcotics, benzos) Thrombosis (pulmonary or coronary) Trauma
Indications for imaging in low back pain (X-ray)?
Osteoporosis/compression fracture
Suspected malignancy
Ankylosing spondylitis (eg, insidious onset, nocturnal pain, better with movement)
Indications for imaging in low back pain (MRI)?
Sensory/motor deficits
Cauda equina syndrome
Suspected epidural abscess/infection (eg, fever IVDU, concurrent infection, hemodialysis)
Red flag features prompting consideration for imaging in low back pain?
Sudden onset of pain associated with midline spine tenderness Hx cancer or recent infection Constitutional symptoms Trauma Significant/progressive neuro defects
What can increase sensitivity of XR in patients with low back pain?
ESR/CRP
Fever and sore throat in any patient taking antithyroid drugs suggests ___. What should be done?
Agranulocytosis
STOP the drugs and check the WBC count. If agranulocytosis has occurred, give broad-spectrum ABX +/- granulocyte colony stimulating factors
Long-term medical therapy in patients with an NSTEMI?
- Dual antiplatelet therapy (aspirin and P2y12 receptor blocker aka clopidogrel etc)
- Beta blockers
- ACEIs or ARBs
- Statins
- Aldosterone agonists if LVEF of 40 or less with heart failrue symptoms or DM
Who else gets dual antiplatelet therapy?
Drug-eluting stent (minimum 12 months)
Outcome of radioiodine therapy for Graves disease?
Resolution of hyperthyroidism in 6-18 weeks
Gradually leads to permanent hypothyroidism in most patients
Can acutely worsen Graves ophthalmopathy
Features of digitalis toxicity?
Increased atopy + increased vagal tone (and thus decreased conduction through the AV node) -> atrial tachycardia + AV block
Presentation of patients with MASSIVE PE?
Low arterial perfusion (hypotension, syncope), acute dyspnea, pleuritic chest pain, tachycardia
Thrombus increases pulmonary vascular resistance and RV pressure -> RV hypokinesis and dilation and hypotension
Language delay without an attempt to compensate through non-verbal means?
ASD
Absence of joint attention (ie, spontaneous attempt to share interests with others by eye gazing and pointing at objects)
ASD
What is the primary predisposing factor for vulvulus in children?
Malrotation of the midgut during early fetal development
The evaluation of clinically stable neonates with bilious emesis begins with what?
- Cessation of enteral feeds, NG tube decompression, IV fluids
- XR to r/o pneumoperitoneum
If there is no evidence of free air and the bowel gas pattern is not suggestive of duodenal atresia (double bubble) or distal obstruction (dilated loops of bowel), then ___ should be performed.
Upper GI series
Dx malrotation vs. volvulus based on upper GI series (aka barium swallow)
Malrotation: Ligament of Treitz on the R side of the abdomen
Volvulus: corkscrew pattern
What are the 3 major types of fetal heart rate decelerations seen on tracing?
- Early
- Late
- Variable
Describe the relationship of early decelerations to contraction.
Symmetric to contraction
Nadir of deceleration corresponds to peak of contraction
Gradual (30+ seconds from onset to nadir)
Etiology of early decelerations?
Fetal head compression
Describe the relationship of late decelerations to contraction.
Delayed compared to contraction
Nadir of deceleration occurs after peak of contraction
Gradual (30+ seconds from onset to nadir)
Etiology of late decelerations?
Uteroplacental insufficiency
Describe the relationship of variable decelerations to contractions.
Can be but not necessarily associated with contractions
Abrupt (<30 seconds from onset to nadir)
Decrease over 15+ seconds/minute, duration 15+ seconds, but <2 minutes
Etiology of variable decelerations?
Cord compression
Oligohydramnios
Cord prolapse
Normal baseline FHR?
110-160
Define moderate variability?
Average amplitude of 6-25/min
Why are variable decelerations common after ROM/decreases in amniotic fluid volume?
Umbilical cord compression
When do variable decelerations due to umbilical cord compression require intervention?
Intermittent (decelerations with <50% of contractions) are well-tolerated, no intervention
50+% of contractions can result in lack of fetal placental blood flow -> maternal repositioning, then amnioinfusion
Category I tracing?
ALL: -Baseline 110-160 -Moderate variability (6-25/min) -No late/variable decelerations \+/- early decelerations \+/- accelerations
Category III tracing?
1+ of the following:
-Absent variability + recurrent late decelerations
-Absent variability + recurrent variable decelerations
-Absent variability + bradycardia
Sinusoidal pattern
What is the purpose of fetal scalp stimulation?
Evaluate fetal acidosis in patients who have no accelerations on FHR monitoring
CONTRAINDICATED in patients with decelerations
Which opioids do not show up on standard UDS?
Standard UDS measure morphine (breakdown product of all natural non-synthetics)
Not on UDS: semi-synthetic (hydrocodone, hydromorphone, oxycodone, etc.) and synthetic: (eg, fentanyl, meperidine, methadone, tramadol)
What testing can be used to very false-positive and possible false-negative results obtained on initial UDS.
Gas chromatography/mass spectometry
Presentation - severe microcephaly, thin cerebral cortices, multiple intracranial calcifications, neuro and ocular abnormalities, ventriculomegaly
Congenital Zika syndrome
Presentation - generalized erythema, superficial flaccid blisters, epidermal shedding with light pressure in infants and young children
Staphylococcal scalded skin syndrome
Rx Staphylococcal scalded skin syndrome?
Antistaphylococcal antibiotic (eg, nafcillin, vancomycin) Wound care
Presentation - well-demarcated, warm, tender area of erythema, +/- constitutional symptoms
Erysipelas (bacterial infection of the dermis)
Fine pink sandpaper-like rash following an episode of pharyngitis in children, prominent in flexural areas, often desquamates
Scarlet fever (GAS)
“Sail sign” on X-ray?
Thymus
Presentation - abdominal pain, jaundice, palpable mass in chidlren <10 y/o
Biliary cyst (dilation of the biliary tree)
Managementof biliary cyst?
Surgical resection to relieve the obstruction and reduce the risk of malignancy
Maternal management of HCV in pregnancy?
Avoid ribavirin (teratogen)
No indication for barrier protection in serodiscordant monogamous couples
Hepatitis A and B vaccination
Prevention of vertical transmission of HCV in pregnancy?
Strongly associated with maternal viral load
C/S not protective
Avoid scalp electrodes
Encourage breastfeeding unless maternal blood is present
___ occurs in 25% of patients with severe factor 8 deficiency. When should it be considered?
Inhibitor development (recognition of the infused factor as foreign, forming antibodies); bleeding refractory to replacement therapy or with increased bleeding frequency
Most common AE of inhaled corticosteroid therapy?
Oropharyngeal thrush
Most common cause of a non-reactive non-stress test (eg, no accelerations)?
Quiet fetal sleep cycle (up to 40 minutes)
Define a reactive stress test.
Baseline of 110-160/min
Moderate variability (6-25/min)
2+ accelerations in 20 minutes each peaking 15+ minutes about baseline and lasting 15+ seconds
Acute unilateral motor weakness WITHOUT sensory deficits or higher cortical dysfunction is suggestive of what type of stroke? Common cause?
Lacunar stroke affecting the posterior limb of the internal capsule; chronic hypertension
Rapidly growing volcano-like nodule with a central keratotic plug
Keratoacanthoma
Presentation - early adolescence to young adulthood - herald patch (erythematous annular lesion on the trunk) that may increase in size and develop scaling around the edge; within a week, clusters of smaller, erythematous oval lesions appear on the trunk, typically distributed obliquely along the lines of tension +/- pruritis +/- viral produrome
Pityriasis rosea
Management of pityriasis rosea?
Supportive (self-limited)
Clinical findings of milk-alkali syndrome?
Symptomatic hypercalcemia (N/V, constipation, polyuria, polydipsia, neuropsych symptoms)
Metabolic alkalosis
AKI
Rx milk-alkali syndrome?
D/C of causative agent
Isotonic saline followed by furosemide
Dx Wilson disease?
Decreased ceruloplasmin
Increased urinary copper excretion
Kayser-Flesicher rings
Increased copper content on liver biopsy
In a patient with suspected infective endocarditis, what is the most appropriate next step?
Serial blood cultures from separate venipuncture sites over a specified period prior to initiating antibiotic therapy
Then TTE or TEE
Presentation of organophosphate poisoning?
Inhibition of AChEsterase -> cholinergic excess -> bradycardia, miosis, rhonchi, muscle fasciculations, salivatino, lacrimation, urination, defecation
Reverse organophosphate poisoning?
Atropine
Rx hepatic encephalopathy?
Identify the underlying precipitant and lower serum ammonia with non-absorbable disaccharides (lactulose, lactilol, etc.)
New-onset SOB, fevers, dry cough, bilateral mid- and lower-lung reticular opacities, possible maculopapular rash, recent UTI
Acute nitrofurantoin-induced pulmonary injury (acute hypersensitivity pneumonitis in the short-term, 3-9 days after medication initiation)
Note - long-term use can lead ot ILD
Most common cause of healthcare-associated infective endocarditis?
Staphoylococcal
Most common cause of community-acquired infective endocarditis?
Streptococcal
Infective endocarditis after a dental procedure
Viridans group streptococci
Cause of acute anterolateral STEMI?
Left anterior descending artery occlusion
Causes of thyrotoxicosis with normal or increased radioactive iodine uptake?
Graves disease
Toxic multinodular goiter
Toxic nodule
Causes of thyrotoxicosis with decreased RAIU?
Painless thyroiditis Subacute thyroiditis Amiodarone-induced thyroiditis Excessive dose of levothyroxine Struma ovarii Iodine-induced Extensive thyroid cancer mets
Presentation - unilateral head and neck pain, transient vision loss, ipsilateral partial Horner syndrome (ptosis + miosis without anhidrosis), signs of cerebral ischemia
Carotid artery dissection (suspect in the setting of trauma, can be spontaneous, HTN, smoking, connective tissue disease, OCs contribute)
Dx carotid artery dissection?
Neurovascular imaging (CTA, etc.)
Rx carotid artery dissection?
Thrombolysis (if within 4.5 hours of symptom onset)
Antiplatelet therapy +/- anticoagulation
3 most common causes of aortic stenosis in the general population?
Senile calcific aortic stenosis
Bicuspid aortic valve
Rheumatic heart disease
Most common cause of aortic stenosis in patients under 70 y/o?
Bicuspid aortic valve
Distinguish HCM murmur from AS.
HCM is best appreciated in the LLSB and does not typically radiate tot he carotids
Rx acute bacterial prostatitis?
6 weeks TMP-SMX or FQ
