3, 4, 5 Star topics 2 Flashcards
Cushing’s triad (4)
HTN, bradycardia, bradypnea
Sign of increased ICP
Glasgow coma scale categories (3)
Eye opening (4): spontaneous, to voice, to pain, none Verbal response (5): oriented, confused, inappropriate words, incomprehensible sounds, none Motor response (6): obeys commands, localizes pain, withdraws from pain, flexion w/ pain (decorticate), extension w/ pain (decerebrate), none
GCS total scores and diagnoses (3)
12+ minor brain injury w/ probable recovery
9-11: moderate severity requiring close observation for changes
8 or less: coma, intubate, assoc w/ 50% mortality
Post-op fever causes (3)
Wind, Water, Walking, Wound, Wonder drugs
PNA (after day 3)
UTI (after day 3-5)
DVT/PE (any time)
Wound (after day 5-8)
Medications
Also transfusion rxn, thrombophlebitis, sinusitis (NG tube)
Mild intermittent asthma (3)
Symptoms < 2x/week
Night symptoms < 2x/month
Inhaled short acting B2 agonist
Mild persistent asthma (3)
Symptoms 3-6x/week
Night symptoms > 2x/month
Inhaled short acting B2 agonist +
Daily inhaled low-dose steroid
Moderate persistent asthma (3)
Symptoms daily Night symptoms > 1x/week Inhaled short acting B2 agonist + Daily inhaled low to medium dose steroid + Long-acting B2 agonist
Severe asthma (3)
Symptoms constantly, w/ minimal activity Awake multiple times/night Inhaled short acting B2 agonist + Daily inhaled high dose steroid + Long-acting B2 agonist + Consider systemic steroids, LT inhibitors, theophylline
Crohn’s site (4)
Entire GI tract (perianal fistulas, oral ulcers)
MC site: distal ileum
Skip lesions
Entire bowel wall (transmural inflammation)
IBD - watery diarrhea (4)
Crohn’s
IBD - bloody diarrhea (4)
UC
Crohn’s PE (4)
RLQ abdominal mass
Perianal fissures and fistulas
Oral ulcers
Fever, abdominal tenderness
Crohn’s radiology (4)
Cobblestoning
Skip lesions
String sign
Crohn’s treatment (4)
Azathioprine or Mercaptopurine
Anti-TNFa (infliximab, adalimumab)
Steroids and abx for acute exacerbation
Try to avoid surgical resection
UC treatment (4)
Total colectomy is curative
Sulfasalazine
Supplemental iron
Steroids, immunosuppressives
IBD complications (4)
Crohn’s - abscess, fistula, fissure, malabsorption, toxic megacolon
UC - significantly increased risk of colon cancer, hemorrhage, toxic megacolon, bowel obstruction
UC radiology (4)
Lead pipe colon w/o haustra, colon shortening
Continuous involvement
Pseudopolyps, friable mucosa
UC site (4)
Continuous disease, rectum to distal ileum
Only mucosa and submucosa
CRC risk factors (4.5)
Colonic polyps (esp adenomas), fam hx, personal hx, hereditary polyposis syndromes, UC, low-fiber/high-fat diet, alcohol, smoking, DM
CRC MC mets (4.5)
Lung, liver
CRC radiology sign (4.5)
Apple core lesion
CRC treatment (4.5)
Surgical resection + regional LN resection (at least 12)
Adjuvant chemo if +LN
CRC monitoring post treatment (4.5)
CEA q3 months
CT chest/abd q1 year
Colonoscopy at 1, 3, q5 years
CRC prevention (5)
Starting at 50 yo (if family hx in first degree relative, start at 40 yo or 10 years before family member dx)
Annual FOBT
Colonoscopy q10 years OR
Flexible sigmoidoscopy + FOBT + double barium enema q5 years
If polyps are found, colonoscopy q3-5 years
Stop screening at 75 years old or <5 yr life expectancy
GI bleed most likely upper (4.5)
Hematemesis, coffe-ground emesis, melena
GI bleed most likely lower (4.5)
Hematochezia, lightheadedness, hemodynamic instability
Next step GI bleed (4.5)
IVF, transfusion if unstable (HR, BP, UO)
Hematocrit >30%, INR <1.5
Next step GI bleed + hemodynamically stable (4.5)
NG tube w/ lavage
EGD or colonoscopy
Common causes upper GI bleed (4.5)
MCC = PUD Mallory-Weiss tears Esophagitis Esophageal varices Gastritis
Common causes lower GI bleed (4.5)
MCC = diverticular disease (<40 yo) Neoplasm UC Mesenteric ischemia AVMs Hemorrhoids Meckel diverticulum
Common causes of acute pancreatitis (4.5)
BAD HITS Biliary (gallstones, ERCP) (40%) Alcoholism (35%) Drugs (HIV esp didanosine, diuretics, valproate, azathioprine, estrogens) Hypertriglyceridemia/Hypercalcemia Idiopathic Trauma Scorpion sting
PE signs of acute pancreatitis (4.5)
Acute epigastric pain radiating to back, N/V
Grey Turner sign (bluish discoloration of flank)
Cullen sign (periumbical discoloration)
Radiology signs of acute pancreatitis (4.5)
Sentinel loop (loop of dilated bowel near pancreas) Colon cutoff sign (R colon distended until pancreas) Pseudocyst or enlarged pancreas
Acute pancreatitis complications (4.5)
Pancreatic abscess, pseudocyst Necrosis, fistula formation Renal failure Chronic pancreatitis Hemorrhage Shock DIC Sepsis Respiratory failure
Chronic pancreatitis complications (4.5)
Ductal obstruction, pseudocyst
Malnutrition
Glucose intolerance
Pancreatic cancer
Most sens/specific lab for chronic pancreatitis (4.5)
Low fecal elastase
Treatment acute pancreatitis (4.5)
Hydration, NG suction, NPO
Pain control w/ opioids
+/- prophylactic abx
Cholecysectomy if gallstones
Treatment chronic pancreatitis (4.5)
Stop alcohol use, smoking
Opioids
Enzyme and vitamin supplementation
Change diet to low-fat, small meals
Hemochromatosis - cause (3)
AR, excess iron absorption
Rarely chronic blood transfusions or alcoholism
Hemochromatosis - s/sx (3)
Iron deposits in liver, pancreas, heart, pituitary
Abd pain, hepatomegaly
Dilated/restrictive cardiomyopathy
Polydipsia, polyuria; testicular atrophy, impotence
Arthralgias, pigmented rash (bronze hue)
Lethargy
Hemochromatosis - screening test (3)
Increased serum ferritin
Hemochromatosis - treatment (3)
Weekly/biweekly phlebotomy until iron normalizes, then monthly
Maybe deferoxamine for chelation
Avoid excess alcohol consumption
Neonatal jaundice - physiological (5)
Day 2-3
Bili <10, peaks day 3-5
Usu self-resolves within 2 weeks
Neonatal jaundice - exaggerated physiologic (breastfeeding) (5)
1st week
Bili <15
Caused by dehydration
Rx: 10+ tube feeds/day w/ proper technique
Neonatal jaundice - breast milk jaundice (5)
2nd week Bili >5.5 Caused by substance(s) in breast milk Dx: disappears w/ formula 48-72 hrs Rx: self-resolves / resolves w/ d/c breast feeding
Neonatal jaundice - immunological causes (5)
ABO incompatibility
Rh (or other antigen) incompatibility (erythroblastosis fetalis)
Neonatal jaundice - traumatic causes (5)
Trauma
Cephalohematoma
Bruising
Neonatal jaundice + fever, lethargy, poor feeding, +RR, any sign of infection (5)
Sepsis until proven otherwise
Neonatal jaundice - hereditary causes (5)
Polycythemia
Hereditary spherocytosis
G6PD deficiency
Dubin-Johnson, Rotor syndrome, Byler disease (direct)
Jaundice + pale stools after 2 weeks old (5)
Biliary atresia
Direct >20% of total bili (6-12)
Rx: surgical repair <2 months essential for preventing biliary cirrhosis
Antibiotic C/I in neonates w/ hyperbilirubinemia (5)
Ceftriaxone (displaces bili from albumin)
Characteristics of pathological newborn jaundice (5)
Any jaundice in 1st 24 hrs Rise in total bili by >0.5 mg/dL/hr or >5 mg/dL/day Direct >20% of total bili or >1.5 Total bili >13 Jaundice after 2-3 wks old
Jaundice + NO scleral icterus >6 months old (5)
Hypercarotemia (carrots, sweet potatoes, etc)
Treatment of newborn jaundice (5)
Phototherapy of physiologic jaundice lasting several days
Workup nonphysiologic causes, may need exchange transfusion
IVIG may reduce need for transfusion if blood type incompatibility
Nonrandom assignment of subjects to study groups (4)
Enrollment (selection) bias
Subjective interpretation of data by investigator deviates towards ‘desired’ conclusions (4)
Investigator bias
Screening test provides earlier diagnosis but does NOT increase time of survival (4)
Lead-time bias
Screening test detects slowly progressive cases of disease but misses rapidly progressive cases (4)
Length bias
Subjects respond differently because of awareness of being studied (4)
Observational bias
Studies that show a difference are more likely to be published than those that don’t (affects meta analyses) (4)
Publication bias
Subjects’ memory errors produce incorrect data, esp because of prior confounding experiences (4)
Recall bias
Patients with certain medical hx are more likely to enroll in studies (type of selection/enrollment bias) (4)
Self-selection bias
Risk factors RCC (3)
Smoking (1st)
Cadmium, asbestos exposure
Age
Associated w/ RCC, ~15% (3)
Scrotal varocele
Treatment RCC (3)
Nephrectomy or resection w/ LN dissection (usu w/o biopsy if good imaging)
Immunotheraphy, radiation, chemo if nonresectable or metastatic (poor prognosis)
Central pontine myelinolysis (4)
Too rapid correction of hyponatremia (no faster than 12-20 meq/24 hrs)
Hyponatremia treatment (4)
Treat underlying condition
Salt and free water restriction
Loop diuretics or hypertonic saline if severe (correct slowly)
Hyponatremia causes (4)
High glucose/mannitol/hypertonic intake
High lipids/proteins
Renal failure; cirrhosis, CHF, nephrotic syndrome
SIADH, hypothyroidism; polydipsia
Diuretics, ACE; vomiting, diarrhea, fluid sequestration (eg pancreatitis)
Central DI causes (4)
Failure of PP to secrete ADH
Cerebral trauma, pituitary tumors, hypoxic encephalopathy, anorexia, idiopathic
Nephrogenic DI causes (4)
Failure of kidneys to respond to ADH
Hereditary renal disease, lithium, hypercalcemia, hypokalemia
Dx DI (4)
Water deprivation test (2-3 hrs): NL = urine osmolality increases
DI = urine osmolality stays low
Then give ADH
Central DI = urine osmolality increases
Nephrogenic DI = urine osmolality stays low
Central DI treatment (4)
Desmopressin (DDAVP)
Nephrogenic DI treatment (4)
Salt restriction, increased water intake Thiazide diuretics (1st line) Indomethacin (2nd line) Amiloride (for lithium-induced)
Monitor heparin (3.5)
PTT
Monitor LMWH (3.5)
Not needed
Could use anti-Factor Xa (renal disease, obese, elderly)
Monitor warfarin (3.5)
PT/INR
Drop in platelets >50% in hospital (4)
HIT
HIT treatment (4)
Stop heparin
Use direct thrombin inhibitors (lepirudin, argatroban) until platelets >100K, then warfarin ~3 months
Drugs causing thrombocytopenia (4)
Familiar don’t memorize
Usu cause absent/reduced megakaryocytes Heparin, abciximab Carbamazepine, phenytoin, valproate Cimetidine Acyclovir, rifampin Sulfonamides Procainamide, quinidine Quinine, gold compounds
Platelets <50K (4)
ITP (r/o other causes)
Autoimmune B-cell antiplatelet antibodies
Treatment ITP (4)
Children - self-limited
Adults - steroids, IVIG, plasmapheresis, splenectomy
Hemolytic anemia + uremia + thrombocytopenia (4)
HUS
TTP pentad (4)
Hemolytic anemia Uremia Thrombocytopenia + Neuro sx (coma, seizures) \+/- Fever
HUS-TTP treatment (4)
Steroids, plasmapheresis, FFP
Causes TTP-HUS (4)
Assoc w/ endothelial injury and E. coli O157:H7
HUS or TTP lab abnormalities (4)
Low platelet number -> +BT
Hemophilia lab abnormalities (4)
+PTT
von Willebrand disease lab abnormalities (4)
+BT, +PTT
DIC lab abnormalities (4)
Low platelet number -> +BT
+PT, +PTT
Warfarin lab abnormalities (4)
+PT, +PTT
End stage liver disease lab abnormalities (4)
+PT, +PTT
Normal/low platelet count -> normal/+BT
Aspirin use lab abnormalities (4)
+BT
Mono cause (4)
EBV affecting B cells
Mono labs (4)
+Heterophile antibodies
+EBV serology (Monospot test)
+LFTs
Maybe hemolytic anemia, thrombocytopenia
Treatment Mono (4)
Self-limited (supportive)
No contact sports for 4 weeks
