1st Flashcards
What are causes to have high alkaline phosphatase with all other normal labs
This value will be high in hepatobiliary tissue (cholestatic liver disease) and in bone.
What is most likely diagnosis for elderly pt who is asymptomatic with an elevated alkaline phosphatase
Paget disease of the bone.
Clinical features of pagets disease
- bone pain (due to mircro fractures)
- Increased hat size
- hearing loss ( impingement of cranial nerves)
- lion-like faces (involvement of craniofacial bones)
Complications of Paget disease
- High output heart failure ( AV shunts in bone)
- Osteosarcoma
What is best diagnosis for pt with proximal muscle weakness starting in lower extremity first and anxiety, tremor (similar to essential), fatigue, weightloss
Hyperthyroidism
What are the common traits of Cryptosporidium infection and and what area is it most likely to be found in
- high volume,
- watery,
- nonbloody stools
- occur for 2 weeks or greater
- it is a protozoan that occurs in other countries such as eastern europe where their water is not extremely clean
What will be the levels of ACTH, Cortisol, and Aldosterone in a pt who has been on glucocorticoids for a long period of time.
- Low cortisol
- Low ACTH
- Normal Aldosterone
What is most likely cause of a patient who comes in with blunt force trauma to the chest and in less than 24 hrs has tachypnea, tachycardia, hypoxia with rales and decrease breath sounds?
Most likely suffered from a Pulmonary Contusion which causes an intraalveolar hemorrhage and edema. With CT you will see patchy nonlobular opacifications ( not restricted to the anatomical landmarks)
What tx for graves disease could cause worsening of opthalmopathy
Radioactive Iodine
Side effects of PTU for Graves disease
hepatic failure
- ANCA associated vasculitis
- Agranulocytosis
Fine needle aspiration is not reliable for which thyroid cancer type
Follicular
What are risk factors for thyroid cancer
Head and neck radiation
Gardner syndrome and cowden syndrome (papillary)
MEN type 2
How does follicular thyroid cancer spread
Hematogenous route
How do you tell follicular carcinoma from a benign adenoma
Expansion through tumor capsule or vascular invasion
What are the urine and serum lab values for pt with diabetes insipidus
urine- Low specific gravity and low osmolality
plasma osmolality- high osmolality ( 280-310)
What is tx of pt with central diabetes insipidus and pts with nephrogenic
- Central- Give desmopressin
- Nephrogenic- salt restriction and thiazide diuretics ( which deplete the body of sodium so that more is reabsorbed in the proximal tubules)
What is the diagnosis when patient has widened mediastinal silhouette, inc aortic nob, tracheal deviation. with vague chest discomfort in pt with HTN, Hypercholesterolemia, smoking
Descending aortic aneurysms
What is the diagnosis for patient with frequent itching after bathing, heacaches and dizziness
Polycythemia vera
What will you see with erythropoietin in pt with polycythemia vera
low serum erythropoietin
What is the mutation in polycythemia vera
JAK2 mutation
What are treatments for polycythemia vera and why would you use them
phlebotomy
Hydroxyurea (if increased risk of thrombus)
What is diagnosis for pt that is older than 60, dysphagia, coughing, regurgitation, halitosis and neck mass which increased after liq.
Zenker Diverticulum
What are causes of Zenker Diverticulum
Sphincter dysfunction and esophageal dysmotility
What is study used to diagnose Zenker Diverticulum
Barium esophagram
What are the ocular and neurology symptoms of pts with graves disease
- protosis, inpaired extraocular motion, diplopia, irritation (gritty), photophobia,
- tremors, hyperreflexia, proximal muscle weakness.
What is cause of exophthalmos in graves disease
T cell activation and stimulation of orbital fibroblasts and adipocytes results in orbital tissue expansion and lymphocytic infiltration.
What is pseudogout? And when will you see it?
calcium pyrophosphate dihydrate crystals.
- Can see it in patients with hypercalcemia sometimes due to hyperparathyroidism
What is pseudogout also associated with?
- hypothyroidism
- Hemochromatosis
What are the characteristics of synovial fluid analysis of pt with pseudogout
- rhomboid shaped positively birefringent crystals
What is screening test for Lupus
ANA
What is screening test for Rheumatoid Arthritis
Rheumatoid factor and Anti-CCP
What does positive double stranded DNA mean?
Sensitive for Lupus
What does positive Histone mean?
Drug induced Lupus
What does positive Anti-Centromere mean?
Scleroderma, CREST
What does positive Topoisomerase mean?
Scleroderma, Systemic
What does positive smooth muscle antibodies mean?
Autoimmune hepititis
What does positive Roa and La mean?
Sjogrins
What does positive Jo mean?
Polymyositis- dermatomyositis
What does positive Mitochondrial antibody mean?
Primary- biliary sclerosis
What will you see in septic joint tap?
- cloudy
- greater than 50,000 WBC
- Possible positive gram stain
- No Crystals
What is normal patient and common complaints of pt with Rheumatoid arthritis?
- Women greater than 45 yrs
- Morning stiffness longer than an hour
- Symmetric joints of hands, wrist, feet. Spairs DIP
- Nodules: if you biopsy them they will be colesterol
What do you do for Diagnosis of Pt with Rheumatoid Arthritis?
- First look at serologic markers: Anti-CCP> RF
- then get xray= look for erosions ( pariarticular osteopenia)
What is primary tx for Rheumatoid Arthritis
- NSAIDS ( Ibprofin or Meloxicam)
-Plus- - DMARDS ( Methyltrexate) : if this does not work then try to add more DMARDS then going to biologics such as
( Leflunomide, Hydroxycloroquine, Sulfasalazine) - If severe symptoms after DMARDS are biologics ( TNF-alpha, Infliximab, Rituximab)
What is protocol for Tx of RA
all patients on NSAIDs and DMARDS
If this doesnt work then add DMARDS then
You can go on to Biologics
What do you need to do before placing a patient on Biologics for severe RA?
test for TB and Fungus
What is Feltty’s syndrome
RA + Neutropenia + Splenomegally
What is the treatment of patients with Actinomyces infection
Penicillin 2-6 months
What is best test for diagnosis of Bronchiectasis?
High resolution CT scan
What are characteristics of patient with Bronchiectasis
- Chronic cough
- Mucopurulent sputum
- Common respiratory infections.
What is rapid tx of patient with hyperkalemia
Calcium gluconate
What is first step for patient with fever and acute monarticular arthritis that has had worsening symptoms over last three days?
- Synovial fluid analysis
WHat is the normal time frame for symptoms of patient with gout
12-24 hours (abrupt onset)
What is diagnosis of pt with 2 weeks of weakness, SOB, fingertip pain and urine has been cloudy.
Infective endocarditis
What is tx for patient with paget disease?
Bisphosphonates
Would the lab results be high or low for patient with pagets disease?
- Ca
- Phosphorus
- Alkaline Phosphatase
- Urine Hydroxyproline
- Normal
- Normal
- High
- High
What is diagnosis of patient with bone pain, deformity and mixed lytic/sclerotic lesions.
- Patients may have headaches, cranial nerve dysfunction and hearing loss, fracture of bones
- Pagets disease of bone.
What is diagnosis for pt with fever, cough, weight loss and cavitary lesion in lung, who now has hypotension, hyperkalemia, and hypoglycemia?
Pt has TB that has spread to the adrenal glands and has caused addison’s disease. Pt will have hyperkalemia and high hydrogen ions causing metabolic acidosis. They will also have hypoglycemia.
What are symptoms of patient with optic neuritis?
- Common in women 20-45, rapid impairment in vision, changes in color perception and pain with eye movement
What is a common symptom of a patient with type 2 DM with a physiologic stressor
Nonketotic hyperosmolar syndrome.
Patients with cirrhosis should undergo what screening test?
Endoscopy to exclude varices, and indicate the risk of variceal hemorrhage.
What are treatments for patients with esophageal varices?
endoscopic variceal ligation or non-selective betablockers such as propranolol or nadolol
What are possible diagnosis and what is next best step for patient who has trouble swollowing solids and liquids and dilated esophagus with smooth tapering of distal esophagus on barium studies?
- Primary achalasia
- Pseudoachalasia (due to esoph cancer)
- To differentiate between two should do an endoscopic evaluation.
What is diagnosis of patient with chronic gastoesophageal reflux with new dysphagia of solids but not liquids and symmetric lower esophageal narrowing
- Esophageal stricture
you can also see improvement of acid reflux with this because as they grow they block reflux
What are presenting symptoms of patient with gonococcal septic arthritis?
- asymmetric polyarthralgias ( associated with tenosynovitis and skin rash) OR
- Isolated purulent mono- or polyarthritis
What is likely diagnosis of pt who was intubated and had witnessed aspiration event and then within hours has hypoxemia
- Aspiration pneumonitis
- gastic acid induces a chemical burn and consequently inflammatory response.
- No tx needed
What are 3 primary tumors seen in patient with MEN1
- Parathyroid
- Pituitary
- Gastrointestinal/pancreatic
What are symptoms you would see for pt with MEN1.
- Parathyroid: Constipation, polyuria and abdominal pain due to hypercalemia
- peptic ulcers
What are symptoms of pt with Meniere disease
- Tinnitus
(accompanied by feeling of ear fullness) - Episodic vertigo
- Hearing loss
What is cause of Meniere disease?
- Inc volume and pressure of endolymph.
Back pain in (IV drug user or sickle cell anemia or immunosuppressed patients) with pain that is unrelieved by rest or tenderness to gentle percussion most likely has what?
Osteomyelitis
Lactose intolerance is characterized by what?
- positive hydrogen breath test
- low stool pH
- inc stool osmotic gap
What test should you order when you are worried about a pt having pancreatic cancer with jaundice?
ultrasound to rule out cancer in the head of the pancreas
What test should you order to rule out pancreatic cancer without jaundice?
- abdominal CT
body or tail
What is first tx you give pt who you think has spinal cord compression?
- IV glucocorticoids should be given without delay (even for imaging)
- Then MRI
What are common symptoms of patient with cyanide toxicity after tx with nitroprusside?
- altered mental status, lactic acidosis, sizures and coma
What are the metabolic abnormalities seen in hypothyroidism?
- Hyperlipidemia
- Hyponatremia
- asymptomatic inc of Creatine kinase
What are the cardiac symptoms you can see in a patient with acromegaly?
- concentric hypertrophy as well as mitral and aortic regurgitation
What is a sever side effect of antithyroid drugs
- agranulocytosis
What is most likely diagnosis of pt with fever, jaundice and right upper quadrant abdominal pain
acute cholangitis
What is best test to diagnose pt with ankylosing spondylitis?
xray of SI joints
How do you make diagnosis of acute liver failure?
- elevated aminotransferases
- encephalopathy
- INR greater than or equal to 1.5
- cirrhosis or underlying liver disease
What drugs do you have to give folic acid for?
- phenytoin
- Methotrexate
- trimethoprim
What is most likely diagnosis of a young patient with expanisve lytic area seen in distal femor or proximal tibia?
Giant cell tumor
What is first line tx of patient with giant cell tumor
surgery
what are goals of care for patients with aortic dissection?
- pain relief (morphine)
- Decrease systolic BP
- Decrease L ventricle contractility
- Can do last two with beta blockers such as labetalol, propranolol or esmolol
What is most likely diagnosis in pt with metabolic alkalosis and low urine chloride that is saline responsive
vomiting or prior diuretic use
What is most likely diagnosis of pt with metabolic alkalosis and high urine chloride, hyopvolemic and responsive to saline ?
diuretic use
What is the most likely diagnosis of pt with metabolic alkalosis, high urine chloride and unresponsive to saline
Bartter or Gitelman syndrome
What will you see for diagnosis of CML
- > 60000 WBC
- Absolute basophilia with high numbers of myelocytes more than metamyelocytes.
- MOST IMPORTANT Is LOW leukocyte alkaline phosphatase
What is tx of patient with CML
- Imantinib ( tyrosine kinase inhibitor)
- CML is due to a translocation between 9:22 BCR-ABL
What are factors that will help you make diagnosis of CLL
- absolute lymphocytosis on peripheral blood smear with smudge cells
what is the diagnosis of patient who has unilateral orbitofrontal headache with nausea and vomiting and conjunctival injections with dilated pupil that is not responsive to light.
acute angle-closure glaucoma.
What can cause acute angle-closure glaucoma
- Anticholinergics
- dim light
What are tx of choice for patients with hypertrophic cardiomyopathy
Negative inotropic -agents such as beta blockers or verapamil or disopyramide
- avoidance of volume depletion
What are common symptoms you will see in pt with hyperkalemia
- ascending muscle weakness with flaccid paralysis
- ECG changes such as peaked T waves, short QT interval or QRS widening.
What are causes of acute hyperkalemia
- Tumor lysis syndrome
- uncontrolled hyperglycemia
- beta blockers
- potassium sparing diuretics
- ACE or ARBs
- Cardiac glycosides (digoxin)
What is diagnosis of pt with longstanding smoking and chronic productive cough for
> than or equal to 3 months in 2 years
Bronchitis
What is diagnosis of pt with frequent recurrent respiratory tract infections and chronic cough with copious mucopurulent sputum ?
- Bronchiectasis
What are labs you need to get to analize the contents of pt with pleural effusion. and what will certain values mean?
Look at Lactate dehydrogenase (LDH) and protein.
- LDH will be less than 200 in transudative and more than 200 in exudative.
- LDH to effeusion/serum ratio
.6 is exudative - Protein effusion/serum ration
.5 is exudative.
What is treatment of runner who has midshaft posteromedial tibial stress fracture who can walk without pain and cannot run without pain.
- rest from running or other activities that cause pain. but can weight bear
- also pneumatic stirrup leg brace
what is screening test for decreased sexual desire and spontaneous erection in male who you are worried for late-onset male hypogonadism
- total testosterone
What is diagnosis and first line treatment for pt with heel pain that is sharp, searing and severe and is worse when she first bears weight on it after being off her feet
- plantar fasciitis
- over-the-counter heel inserts.
how do you treat a COPD exacerbation?
oxygen, antibiotics, bronchodilators as well as systemic corticosteroids
What is the treatment of pregnant woman with eclampsia
Magnesium sulfate
What is best to use in pt with nausia and vomiting who is preg?
doxylamine and B6
When a child is otherwise developmentally normal however is older than 2 and is not able to walk what disease are you worried about? and what test would you do to diagnose it?
Duchenne muscular dystrophy
- it is X linked
- you get a serum creatine kinase level
If a pt is having increased hair growth, acne, irregular menstraul periods what would be first test you would do?
- laboratory testing (look for androgen excess)
- elevated early morning total testosterone is associated with PCOS
What are three best treatments for people with claudication are
- walking
- stop smoking
- Cilostazol
What is the care for pt with recurrence of C diff once vs. severe recurrence or multiple recurrences?
- mild recurrence can try original agent.
- severe or multiple then use both agents
What are the diagnostic criteria to diagnose DM?
- A1c greater or equal to 6.5
- fasting glucose greater or equal to 126
- random glucose greater or equal to 200 with symptoms
- 2 hour oral glucose tolerance test greater or equal to 200.
When should screening be done for both men and women for osteoprosis
65 for women or 70 for men
American coming back from middle ast has ulcer on forearm that will not heal for 3 months what is likely diagnosis?
Leishmaniasis
pt was wading in water in caribbean when felt sting of her foot. few days later she has increased itching and redness of area? What is likely diagnosis
hookworm. Dogs and cats are most often infected and when they deficate and people step in same are they can get hookworm on feet.
What is the likely diagnosis of pt with a large red path that is itchy. About a week or two they then notice more itchy similar looking spots all on the abdomen. Not associated with any exposure or allergy
pityriasis rosea
What is the target glucose level of critically ill patients?
140-180
What is the duration of time and type of drugs used for dual antiplatelet therapy following placement of drug-eluting coronary artery stent?
- 1 year
- Asprin 162-325
- Clopidogrel or prasugrel
What is the treatment of pregnant woman with pruritus and elevated serum bile acids and elevated bilirubin?
- Ursodiol
What is the reason for antibiotic treatment of pertussis?
- It reduces the risk of transmission but does not reduce duration or severity of the disease.
- tx with macrolide such as azithromycin or clarithromycin
What is the treatment of patients who have frostbite?
- rewarm with bath with mild antiseptic at 40-41.
- tense or hemorrhagic blisters aspirate in sterile field
- simple non-tense of clear blisters leave alone
What is best antidepressant when worried about pt gaining weight
Bupropion (wellbutrin)
What movement will increase pain for lumbar spinal stenosis
- lumbar spine extension
bending back like when walking down a hill
yes or no should NSAIDS be avoided in pt with hepatic cirrhosis
yes as they increase the risk of bleeding in cirrhotic patients as they further impair platelet function
What drugs are best to use for generalized anxiety disorder?
SSRI ( escitalopram, paroxetine, sertraline)
SNRI ( duloxetine, venlafaxine)
What is the diagnosis of 4 year old with low grade fever, decreased oral intake and shallow ulcerations to posterior pharynx
Herpangina caused by coxsackieviruses and echoviruses.
What is diagnosis of woman in 30s who has facial erythema and telenagietasias sometimes papules worse with spicy food, sun, stress, alcohol.
- Rosacea
What is treatment for pt with rosacea
Metronidazole gel, doxy or tetracycline
At what age should children ride in the back seat of the car? About what age should they be in a booster seat till?
- In back till 13
- Booster seat till 8-12 when regular seat belt fits them well
What are most likely bacteria infecting untreated acute superficial foot.
Staph aureus
B-hemolytic strep
Will the urine excretion of calcium be high or low in patients with familial hypocalciuric hypercalcemia
- Urine Ca excretion will be low. unlike in primary hperparathyroidism.
Is allopurinol a cause of steven-johnson syndrome?
yes
What is most likely diagnosis of person olger than 50 who all of a sudden starts having stiffness and pain in bilateral joints (most commonly shoulders) worse in the morning (may say them have trouble rising hands above shoulders) may have a high ESR
- Polymyalgia Rheumatica
- tx with oral prednisone
What other disease does Polymyalgia Rheumatica commonly occur with?
- Giant cell arteritis
What are drugs indicated for PCOS to cause ovulation
- Metformin
- Clomiphene
What is another diagnosis for a pt who was diagnosed with exercise asthma who do not have a good response to B-agonists.
- vocal cord dysfunction.
What will you see on pulm function test with vocal cord dysfunction?
- flattening of the inspiratory portion of the flow volume loop but normal expiratory phase.
what is most likely diagnosis of pt with gradually worsening pain in hip when going from sitting to standing or when pivots the hip when running. no trauma to area.
- femoroacetabular impingement
Prozac (SSRI) with what over the counter cough and cold can cause seritonin syndrome with shivering, tremors and diarrhea?
- Dextromethorphan
What is the best test to initially exclude adrenal insufficiency?
- morning cortisol level. (>13 excludes adrenal insufficiency)
- If lower than 13 then further eval with cosyntropin (ACTH) test.
What drug would decrease respiratory secretions but does not cause sedation?
- Glycopyrrolate ( inhibits muscurinic acetylcholine receptors, it does not cross the blood brain barrier)
What should you do for a pt that is a smoker but no known CAD who has multiple Premature ventricular contractions (PVC)
- presence of PVCs in pt with no known CAD has increased risk of MI or death. So evaluation for CAD is warranted.
What are the symptoms and how do you treat Lichen Sclerosus?
- It is an imflammatory skin condition in the anogenital region. you get vulvar itching
- You treat with corticosteroids
What is the most accurate imaging study for assessing osteomyelitis?
- osteomyelitis is infection of bone.
- most often diabetic foot infections
- MRI is best test
What is the preferred anticoagulant for venous thrombosis during pregnancy ?
low molecular weight heparin
pain medication that is best for pts with renal disease?
Fentanyl and methadone best opioids as they are metabolized by the liver.
What is condition that is more common in women between 5-15 and 40-60 who have a purple rash on the top of their knuckles or in between joints and may have muscle weakness
Dermatomyositis
What is the treatment of pt with suspected TB
- 4 drug treatment until cultures results are available ( INH, ethambutol, rifampin and pyrazinamide
What are the screening results for asymptomatic bacteriuria?
- asymptomatic pregnant women at 12-16 weeks or at first prenatal visit.
What is the treatment of pt with dystonia after taking a dopamine antagonist.
- Diphenhydramine or benztropine.
What is screening for lung cancer?
- Low dose CT
- 55-80
- 30 pack year smoking history.
- Quit in the last 15 yrs or less
What is most likely pathogen and treatment for pt age 14-35 with epididymitis?
- What if patient is less than 14?
- 14-35 then you think neisseria gonorrhoeae and chlamydia and tx is ceftriaxone and doxycycline
- less than 14: more likely due to urinary tract pathogens and can use levofloxacin
What organ systems will show an elevated Alkaline phosphatase?
- Which organ is it that is affected when you have high alk phos and 5-nucleotidase
- Bone, small intestine, liver, placenta
- Liver
What are EKG changes you will see with occlusion of circumflex artery
I and AVL and possibly V5 and V6
What is Telogen effluvium?
After a stressful event such as illness or pregnancy a pt might notice 3 months later large amounts of hair loss. This is due to a large amount of hair moving from the Anagen (growing) to Telogen (dead phase) lasts 6 months after removal of stressor
What is the concern for a pt over 65 who has an increased TSH level?
They are at increased risk for hip and vertebral fractures.
What is the best choice for tx of pt with less than 50 percent area of hair loss ( alopecia areata)
- Intralesional triamcinolone
What is best antibiotic for community acquired pneumonia in a young adult?
- Macrolide such as azithromycin
What treatment has the highest cure rate of toenail fungus ?
- oral terbinafine for 12 weeks
What does the s3 gallop normally mean and why does it occur.
- It is indicative of congestive heart failure and it is caused by sudden deceleration of blood flow into the left ventricle.
What is the term for percentage of patients with a disorder who have a positive test for the disorder
Sensitivity
What is the term for the number of patients without a disorder who have a negative test for the disorder
Specificity
What treatment which is used to treat gout should you not start when someone is having a gout flare?
- Allopurinol which decreased the production of uric acid and is effective in reducing the frequency of acute gouty flare-ups but fluctuating levels of uric acid during flare can make worse.
