7/25/16 Flashcards
what is cilostazol?
phosphodiesterase inhibitor occasionally used for symptomatic management of pts with INTERMITTENT CLAUDICATION
criteria for oxygen use in COPD
pO2 below 55 mmHg or oxygen saturation below 88%. if there are signs of right heart disease OR elevated hematocrit, pO2 below 60 mmHg or oxygen saturation below 90%
what are the major difference between IgA nephropathy and poststrep glomerulonephritis besides time course after URI?
- IgA nephropathy has normal complement levels whereas PSGS has low C3 complement
- kidney biopsy in IgA nephropathy show mesangial IgA deposits, whereas biopsy in PSGS show subepithelial humps consisting of C3 complement
a child with erythematous and papular skin rash involving the dorsal aspect of lower extremities, abdominal pain, arthralgia/arthritis, and microscopic hematuria/proteinuria
henoch schonlein purpura
hearing loss, ocular abnormalities, hematuria, progressive renal insufficiency = what dx and what is the kidney biopsy finding?
alport syndrome (defect in collagen; can’t see, can’t pee, can’t hear a buzzing bee); thinning of glomerular basement membrane
what are the drug options for pts with AFib that have a CHADS2 score of 2 or more?
warfarin, dabigatran, rivaroxaban, or apixaban
conjugated hyperbilirubinemia, dark granular pigment in hepatocytes on liver biopsy
dubin-johnson syndrome
what are the inherited forms of conjugated and unconjugated hyperbilirubinemia?
conjugated: dubin-johnson syndrome, rotor syndrome
unconjugated: gilbert’s syndrome, crigler-najjar syndrome (decreased or absent UDP-glucuronosyltransferase, respectively)
jaundice and unconjugated hyperbilirubinemia after fasting
gilbert’s syndrome
pain between third and fourth toes on plantar surface with a clicking sensation that occurs when simultaneously palpating this space and squeezing metatarsal joints
morton neuroma
runner with local point tenderness on plantar aspect of foot who complains of burning pain in plantar area of the foot that worsens with the first steps in the morning; pain decreases as activity increases during the day but worsens at end of day with prolonged weight bearing
plantar fasciitis
burning, numbness and aching of distal plantar surface of foot/toes that radiate up to calf
tarsal tunnel syndrome (compression of tibial nerve as it passes through the ankle) usually caused by a fracture of ankle bones
bilateral lower extremity weakness, loss of sensation, hyperreflexia, and positive Babinski sign
spinal cord compression (get MRI!)
most common pathologies of analgesic/NSAID nephropathy
papillary necrosis and chronic tubulointersstitial nephritis
what kind of casts are seen in acute tubular necrosis vs tubulointerstitial nephritis?
acute tubular necrosis: muddy brown granular casts
tubulointerstitial nephritis: WBC casts (or sterile pyuria)
how can you calculate PAO2 from PaCO2?
PAO2 = 150 - (PaCO2/0.8)
what is a normal A-a gradient? what causes a normal A-a gradient and respiratory acidosis vs an elevated A-a gradient and respiratory acidosis?
normal is less than 15; NORMAL A-a gradient and resp acidosis is caused by ALVEOLAR HYPOVENTILATION, whereas ELEVATED A-a gradient and resp acidosis is caused by pulmonary embolism, atelectasis, pleural effusion, and pulmonary edema (all cause V/Q mismatch)
how can you distinguish between Klinefelter syndrome and exogenous steroid use?
anabolic steroids contain exogenous androgens that inhibit GnRH release by the hypothalamus which causes decreased LH and FSH release by the pituitary gland. Klinefelter syndrome is caused by testicular fibrosis, which leads to low testosterone which leads to high FSH and LH levels
vertical diplopia that worsens when looking down and toward the nose (walking downstairs, reading)
trochlear nerve palsy
where is the lesion: right pupil that is fixed and dilated and is nonreactive to light or accommodation
right edinger-westphal nucleus
best initial tx for pts with tumor-related SIADH?
fluid intervention (limiting fluids to less than 800 mL/day will allow serum sodium concentration to gradually rise)
what are the symptoms and lab findings of prolactinomas in men?
hypogonadotropic hypogonadism due to suppression of GnRH secretion from the hypothalamus by prolactin, causing low testosterone levels and low or inappropriately normal LH. TSH may be normal or low depending on compressive effect on thyrotroph cells
rhomboid crystals = what is the pathogenesis?
pseudogout; calcium pyrophosphate crystal deposition causing calcification of the cartilagenous structures of the joint
what are the risk factors for pseudogout?
hyperparathyroidism and hemochromatosis
rouleaux formation on peripheral smear
multiple myeloma
sharp, localized pain and tenderness at the upper tibia below the knee joint with no associated redness, warmth, or swelling; negative valgus test, normal gait
pes anserinus pain syndrome
what is the most common cause of AA amyloidosis? AL amyloidosis?
AA: rheumatoid arthritis
AL: multiple myeloma
ddx of large kidneys on sonogram/CT scan
amyloid, HIV nephropathy, polycystic kidneys, and diabetes
what are the manifestations of amyloidosis in the different organ systems?
renal: NEPHROTIC syndrome, ENLARGED KIDNEYS
cardiac: restrictive cardiomyopathy, arrhythmias
hematologic: easy bruising, splenomegaly
GI: HEPATOMEGALY
neurologic: neuropathy
hallmark MRI finding in a pt with prolonged seizures
cortical laminar necrosis (cortical hyperintensity on diffusion-weighted imaging suggesting infarction)
what are the most appropriate markers to test for in acute hepatitis B infection? what is the window period?
HBsAg and IgM anti-HBc; window period is the disappearance of HBsAg
what dx should you consider in an HIV pt who is an IV drug user who has nodular pulmonary infiltrates with cavitation?
septic pulmonary emboli from tricuspid endocarditis caused by Staph aureus (HIV greatly increases infective endocarditis risk in IV drug users, most commonly at the tricuspid valve; no murmurs or peripheral manifestations are usually seen)
hypotension, distended neck veins, and muffled heart sounds
beck’s triad of cardiac tamponade
what happens to cardiac contractility and HR in cardiac tamponade
cardiac contractility and heart rate are increased due to sympathetic stimulation as a compensatory mechanism to maintain adequate cardiac output
pathogenesis of beck’s triad of cardiac tamponade
hypotension, distended neck veins, muffled heart sounds are due to an exaggerated shift of the interventricular septum toward the left ventricular cavity, which reduces left ventricular preload, stroke volume, and cardiac output
does respiratory alkalosis cause hyper- or hypocalcemia and why?
functional hypocalcemia. increased extracellular pH causes hydrogen ions to dissociate from albumin molecules, thereby freeing up the albumin to bind with calcium = less ionized calcium (physiologically active form) causes clinical sx of hypocalcemia (paresthesias, carpopedal spasm) even though total calcium is unchanged. this is why hyperventilation can cause signs of hypocalcemia.
how can you tell if hypovolemia is causing orthostatic hypotension in a pt?
BUN to creatinine ratio will be greater than 20 due to a decline in the GFR and an increase in urea reabsorption (prerenal azotemia)
what is the study of choice for diagnosing multiple sclerosis?
brain MRI with and without gadolinium
what is the algorithm used to determine whether a pt needs to be hospitalized for CAP tx?
CURB65: score of 2 or more = hospitalization
Confusion
Uremia (BUN greater than 20)
Respiratory rate greater than 30/min
Blood pressure less than 90/60 (hypotension)
age greater than 65
compare outpt tx of CAP vs inpt tx
Outpatient:
-Healthy = macrolide (azithro or clarithromycin) or doxycycline
-Comorbid conditions = fluoroquinolone (moxi or levofloxacin)
Inpatient: fluoroquinolone OR ceftriaxone and azithromycin
tx for atrial fibrillation due to hyperthyroidism
beta blockers (controls heart rate and hyperadrenergic sx, decreases conversion of T4 to T3 in peripheral tissues)
what is required to make a dx of follicular thyroid cancer?
invasion of the tumor capsule and blood vessels (otherwise it is a follicular adenoma)
what thyroid cancer causes local lymph node involvement?
papillary thyroid cancer
what thyroid cancer secretes calcitonin?
medullary thyroid cancer
what thyroid cancer has psammoma bodies?
papillary thyroid cancer
what thyroid cancer causes large cells with ground glass cytoplasm and pale nuclei with inclusion bodies and central grooving (orphan annie eyes)
papillary thyroid cancer
what pathogen most commonly causes endocarditis associated with nosocomial UTIs?
enterococci
what pathogen most commonly causes endocarditis associated with procedures involving incision and biopsy of respiratory tract?
strep viridans
what pathogen most commonly causes endocarditis associated with dental procedures?
strep viridans
what pathogen most commonly causes endocarditis associated with implanted devices (pacemakers, defibrillators)?
staph aureus
what medication can cause angioedema?
ACE inhibitors
angioedema: pathogenesis, dx, and acute and long-term tx
deficiency of C1 esterase inhibitor (complement); diagnosed by decreased levels of C2 and C4 as well as deficiency of C1 esterase inhibitor; acute tx = fresh frozen PLASMA or ECALLANTIDE (does NOT respond to steroids!), long-term management with ANDROGENS (danazol, stanazol; increase liver production of C1 esterase inhibitor)
pathogenesis and presentation of common variable immunodeficiency
normal number of B cells but they do not make effective amounts of immunoglobulins; presents as recurrent SINOPULMONARY infections
common variable immunodeficiency increases risk for what condition?
lymphoma
pathogenesis and presentation of bruton (x-linked) agammaglobulinemia
low or absent B cells and lymphoid tissue; presents in MALE CHILDREN with absent tonsils, adenoids, lymph nodes, spleen causing recurrent SINOPULMONARY infections
recurrent sinopulmonary infections, spruelike condition with fat malabsorption, and vitiligo/thyroiditis/RA
IgA deficiency (watch out for anaphylaxis to blood transfusion!)
what is the presentation of Wiskott-Aldrich syndrome?
WATER: Wiskott Aldrich = Thrombocytopenia, Eczema, Recurrent infections. T-cells are markedly deficient in blood and lymph nodes
recurrent skin infections by Staph, Burkholderia, Nocardia, Aspergillus, lymph nodes with purulent material leaking out
chronic granulomatous disease
recurrent strep and staph infections, ALBINISM
chediak-higashi syndrome
what medication should be avoided in a pt with nasal polyps?
aspirin; may precipitate severe asthma attack
what drugs classically cause autoimmune hemolytic anemia?
methyldopa, penicillins, sulfa drugs
what type of hypersensitivity is contact dermatitis?
type IV (T-cell mediated)
define the 4 types of hypersensitivities
type I = anaphylactic; type II = cytotoxic (preformed IgG and IgM); type III = immune complex-mediated; type IV = T cell mediated
what type of hypersensitivity is hyperacute transplant rejection vs chronic transplant rejection?
hyperacute = type II (cytotoxic, mediated by preformed IgG and IgM) chronic = type IV (T-cell mediated)
how long is the window period for HIV to be detectable via ELISA?
6 months (retest in 6 months if pt wants testing because of risk-taking behavior and initial test was negative)
classic cause of SCID
adenosine deaminase deficiency
immunodeficiency syndrome with giant granules in neutrophils
chediak-higashi syndrome (defect in microtubule polymerization)
risk of which type of blood cell cancer is increased with HIV?
non-hodgkin lymphoma (usually primary B-cell lymphoma of CNS)
ddx for ring-enhancing lesions in brain in HIV pt
toxoplasmosis, cystericosis (taenia solium), lymphoma
what are the only two pathogens that cause chronic diarrhea only in AIDS?
cryptosporidium and isospora
what disease is chronic mucocutaneous candidiasis associated with?
hypothyroidism
red hair, fair skin, eczema, recurrent staphylococcal infections of the skin
hyper-IgE syndrome
what are the sx of Kallman syndrome?
decreased LH and FSH (from decreased GnRH), anosmia, renal agenesis in 50%
what electrolyte abnormality is common in panhypopitiutarism?
hyponatremia secondary to hypothyroidism and isolated glucocorticoid underproduction
2 products of posterior pituitary
oxytocin and ADH
what electrolyte abnormalities can cause nephrogenic diabetes insipidus?
hypokalemia or hypercalcemia
tx for nephrogenic diabetes insipidus
thiazide diuretics (has paradoxical effect of decreasing urine output!)
what two medications classically cause nephrogenic diabetes insipidus?
lithium and demeclocycline
best initial test for acromegaly and most accurate test
best initial test: elevated insulin growth factor (IGF-1) levels
most accurate test: glucose suppression test (normally, glucose should suppress GH levels)
medications that tx acromegaly
cabergoline (dopamine inhibits GH release), octreotide/lanreotide (somatostatin inhibits GH release), PEGVISOMANT (GH receptor antagonist, inhibits IGF release from liver)
how is prolactin level related to thyroid hormone level?
HYPOTHYROIDISM leads to HYPERPROLACTINEMIA because extremely high TRH levels will stimulate prolactin secretion
what calcium channel blocker causes hyperprolactinemia?
verapamil
what tests should be performed once prolactin level is found to be high (other than pregnancy test) and why?
- thyroid function tests (hypothyroidism causes elevated prolactin)
- BUN/Cr (kidney disease elevates prolactin)
- liver function tests (cirrhosis elevates prolactin)
what is the pathogenesis and tx for subacute thyroiditis?
viral infection causing tender thyroid, early hyperthyroidism followed by hypothyroidism; tx is aspirin (self-limited disease)
when do you need to FNA a thyroid nodule?
if the pt is euthyroid
what drug can cause hyper- or hypothyroidism as a side effect?
amiodarone
what tumor outside the thyroid can cause hyperthyroidism?
struma ovarii (ovarian teratoma that secretes thyroid hormone)
how does hypothyroidism affect menstruation?
increases menstrual flow (menorrhagia)
what conditions increase TBG and what conditions decrease TBG?
increase: pregnancy, estrogen, OCPs
decrease: nephrotic syndrome, cirrhosis, corticosteroid tx
This is the reason why free T4 is always measured instead of total T4
tx of acute hypercalcemia
saline hydration and bisphosphanates (calcitonin in refractory cases, bisphosphonates take several days to work)
how can hyperparathyroidism cause peptic ulcer disease?
calcium stimulates gastrin
what is the pathogenesis and presentation of paroxysmal nocturnal hemoglobinuria?
increased sensitivity of RBCs to complement in acidosis. defective gene for phosphatidylinsoitol class A (PIG-A) leads to deficiency of complement regulatory proteins CD 55 and 59 (decay accelerating factor) = overactivation of complement system, leading to hemolysis and THROMBOSIS. presents with episodic DARK URINE, pancytopenia and iron deficiency anemia, and CLOTS IN UNUSUAL PLACES
tx for paroxysmal nocturnal hemoglobinuria
prednisone for hemolysis, ECULIZUMAB (complement inhibitor) for hemolysis and thrombosis
EKG changes with hypercalcemia vs hypocalcemia
hypercalcemia: short QT
hypocalcemia: long QT (HYPOCALCEMIA IS MORE DANGEROUS!)
tx for hyperparathyroidism when surgery is not possible
cinacalcet
what electrolyte abnormality can cause hypoparathyroidism?
hypomagnesemia; magnesium is necessary for PTH to be released from the gland, low magnesium also leads to increased urinary loss of calcium (just like potassium!)
what are the “groans” caused by hypercalcemia?
abdominal pain secondary to nausea vomiting, ileus, nephrolithiasis, peptic ulcer disease, constipation, or PANCREATITIS
what is pseudohypoparathyroidism? how does it present?
genetic end-organ unresponsiveness to PTH with normal PTH levels; presents with shortened metacarpal bones, short stature, mental retardation
electrolyte abnormalities and CBC findings of hypercortisolism
hyperglycemia, hyperlipidemia, hypokalemia (cortisol has aldosteronelike effects), metabolic alkalosis, leukocytosis (from demargination of WBCs)
tx options for diabetic neuropathic pain
pregabalin, gabapentin, or TCAs
young girl with multiple fractures, cafe au lait spots, and precocious puberty
mccune albright syndrome
empirical tx for native valve endocarditis vs prosthetic valve endocarditis
native valve (antistaphylococcal): OXACILLIN/NAFCILLIN plus AMINOGLYCOSIDE prosthetic valve: VANC plus GENT plus CEFEPIME or carbapenem
IV drug users are more likely to have ____-sided endocarditis, whereas ____-sided endocarditis is much more common in the general population
IV drug users are more likely to have RIGHT-sided endocarditis, whereas LEFT-sided endocarditis is much more common in the general population
most common neurological sequelae of meningitis
hearing loss
which types of bacterial meningitis require abx prophylaxis in close contacts? what abx should be given?
Neisseria meningitidis and Haemophilus influenzae. Rifampin can be used for both! Close contacts of Neisseria can also be given ciprofloxacin, ceftriaxone, or azithromycin
tx for pertussis
azithromycin or erythromycin
tx for bite by an animal with confirmed rabies
rabies vaccine and immunoglobulin
tx of impetigo vs erysipelas
impetigo: topical mupirocin (limited number of lesions) or dicloxacillin, cephalexin, or clindamycin (bullous or many lesions)
erysipelas (red, shiny, swollen): penicillin/amoxicillin
pathogen and tx for cellulitis after dog or cat bite
pasteurella multocida; ampicillin
pathogen and tx for cellulitis in fishermen or other pts exposed to salt water
vibrio vulnificus; tetracycline
abx options for cellulitis
TMP/SMX, doxycycline, clindamycin, linezolid
most likely pathogen and tx for endometritis
streptococcus species; CLINDAMYCIN plus GENTAMICIN
what is the tx of choice for staphylococcal infections?
MSSA: dicloxacillin
MRSA: vancomycin, clindamycin, doxycycline, TMP/SMX, linezolid
what are sx of pyridoxine deficiency that should be watched for in a pt being treated with isoniazid for TB?
neuropathy, confusion, angular cheilitis, seborrheic-dermatitis like rash
