7/26/16 Flashcards
tx for trigeminal neuralgia
carbamazepine
what dx should be suspected in a pt with long-term use of 1 or multiple analgesics (e.g., aspirin, ibuprofen) for chronic pain who presents with painless hematria, sterile pyuria, WBC casts, and trace proteinuria?
tubulointerstitial nephritis (hematuria is due to papillary necrosis)
acute, severe retroorbital pain that wakes pt from sleep, accompanied by redness of ipsilateral eye, tearing, and ipsilateral horner syndrome
cluster headache
what class of abx is associated with tendinopathy and tendon rupture?
fluoroquinolones
where are broca’s and wernicke’s areas?
broca: dominant FRONTAL lobe
wernicke: dominant TEMPORAL lobe
recurrent sinusitis and otitis, bloody/purulent nasal discharge, arthralgias, oral or auditory canal ulcers, hematuria, proteinuria, renal insufficiency = what is the dx and initial test?
granulomatosis with polyangiitis (Wegener granulomatosis); check serum autoantibodies (antineutrophil cytoplasmic antibodies [ANCA])
what should a pt found to have chondrocalcinosis (pseudogout), diabetes, and hepatomegaly be checked for?
hereditary hemochromatosis
what are the important secondary causes of pseudogout that should be investigated in pts with chondrocalcinosis?
hyperparathyroidism, hypothyroidism, and hereditary hemochromatosis
pts with hereditary hemochromatosis are at risk for what infections?
Very Yucky Liver: Vibrio vulnificus, Yersinia enterocolitica, Listeria
pathogenesis of milk-alkali syndrome
caused by excessive intake of calcium and absorbable alkali; the resulting hypercalcemia causes RENAL VASOCONSTRICTION and decreased glomerular blood flow. in addition, inhibition of the Na-K-Cl cotransporter and impaired ADH activity lead to loss of sodium and free water, which leads to hypovolemia and increased reabsorption of bicarbonate. Findings include METABOLIC ALKALOSIS, ACUTE KIDNEY INJURY
what pathogen is associated with infective endocarditis related to colonic polyposis?
strep gallolyticus (strep bovis biotype I)
what pathogen is associated with infective endocarditis related to peridontal infection or dental procedures that involve manipulation of gingival or oral mucosa?
Eikenella corrodens
what predisposes pts to calcium oxalate kidney stones?
small bowel disease, surgical resection or chronic diarrhea that leads to malabsorption of fatty acids and bile salts (fat malabsorption leads to increased absorption of oxalic acid because the unabsorbed fatty acids chelate calcium, making oxalic acid free for absorption)
recurring attacks of severe pain in the back of the throat, the area near the tonsils, the back of the tongue, and part of the ear
glossopharyngeal neuralgia (CN9)
what is the presentation, lab findings, and treatment of ehrlichiosis?
flu-like illness, confusion, THROMBOCYTOPENIA, LEUKOPENIA, ELEVATED LIVER ENZYMES a few weeks after tick bite; doxycycline
best abortive tx for cluster headaches
100% nasal oxygen
how can you distinguish between plantar fasciitis and tarsal tunnel syndrome?
tarsal tunnel syndrome pain WORSENS WITH USE whereas pain of plantar fasciitis is WORST IN THE MORNING and IMPROVES WITH WALKING A FEW STEPS
episodic anterior knee pain in an athlete who jumps a lot, tenderness at inferior patella
patellar tendonitis
young female athlete with subacute to chronic pain increased with using stairs, running, prolonged sitting
patellofemoral syndrome
young obese pt with headaches, vision disturbances (diplopia, transient vision loss), tinnitus, papilledema, CN 6 palsy (lateral rectus palsy) = dx, test, and tx
pseudotumor cerebri; LP (after MRI has ruled out intracranial mass); weight loss and acetazolamide
tx for urge incontinence refractory to bladder training and pelvic floor muscle exercises
oxybutynin (antimuscarinic agent)
unilateral neck pain and numbness over posterior surface of ipsilateral arm, limited neck rotation and lateral bending = dx and radiographic findings
cervical spondylosis (sensory deficit is due to osteophyte-induced radiculopathy); radiographic findings include BONY SPURS and sclerotic facet joints, narrowing of disk spaces and hypertrophic vertebral bodies
what are the sx of drug-induced interstitial nephritis? what drugs commonly cause this?
fever, MACULOPAPULAR RASH, renal failure, UA with WBC casts (may have eosinophiluria), RBCs, mild proteinuria; PENICILLINS, TMP-SMX, CEPHALOSPORINS, NSAIDS
tx for penicillin-sensitive Strep endocarditis
IV ceftriaxone or penicillin G (NO ORAL ABX)
diabetic pt with severe ear pain that radiates to temporomandibular joint, ear discharge, granulation tissue in ear canal, UNRESPONSIVE TO TOPICAL ABX = likely pathogen?
malignant otitis externa caused by PSEUDOMONAS AERUGINOSA
RA-like sx of bilateral, polyarticular arthritis involving hands, knees, ankles, morning joint stiffness, along with fever, diarrhea, mild skin itching and patchy redness
parvovirus B19
most common cause of bloody diarrhea without fever
E. coli (EHEC)
what are the important PFT findings in asthma?
decreased FEV1 and FVC (with a greater decrease in FEV1), decreased ratio of FEV1:FVC, increase in FEV1 of more than 12% and 200 mL with albuterol, decrease in FEV1 of more than 20% with methacholine or histamine, INCREASED diffusion capacity of lung for carbon monoxide
tx for acute asthma exacerbation
oxygen, albuterol, steroids
role of magnesium in acute asthma exacerbation
helps relieve bronchospasm, only used in acute, severe asthma exacerbation not responsive to SEVERAL rounds of albuterol while waiting for steroids to take effect (takes 4-6 hours)
what type of agent helps control sx in COPD but not in asthma?
anticholinergic agents (tiotropium, ipratropium)
recurrent episodes of VERY HIGH VOLUME PURULENT SPUTUM production with hemoptysis, dyspnea and wheezing = what is the most likely finding on CXR? what is the tx?
bronchiectasis; DILATED, THICKENED BRONCHI, sometimes with “TRAM-TRACKS”; CHEST PHYSIOTHERAPY and ABX
asthmatic pt with recurrent episodes of brown-flecked sputum and transient infiltrates on CXR = dx and tx
allergic bronchopulmonary aspergillosis (ABPA); ORAL STEROIDS (inhaled steroids are NOT EFFECTIVE), ITRACONAZOLE for recurrent episodes
what is a pilocarpine test?
test used to diagnose cystic fibrosis; pilocarpine increases acetylcholine levels which increases sweat production. increased chloride levels in sweat is diagnostic for CF
what pathogen causes community-acquired PNA associated with COPD?
haemophilus influenzae
what pathogen causes community-acquired PNA associated with alcoholism and diabetes?
klebsiella pneumoniae
what pathogen causes community-acquired PNA associated with animals at time of giving birth, veterinarians, farmers?
coxiella burnetii
what pathogen causes community-acquired PNA associated bullous myringitis (multiple reddened, inflamed blebs on tympanic membrane)?
mycoplasma pneumoniae
what pathogen causes community-acquired PNA associated with GI sx (diarrhea, abdominal pain) and CNS sx (headaches, confusion)?
legionella
what are the 5 agents that cause atypical PNA?
mycoplasma, coxiella, pneumocytis, chlamydia, viruses
what are the criteria for an exudate? what are the causes of exudate?
LDH greater than 60% of serum or protein greater than 50% of serum suggest an exudate. exudates are caused by infection and cancer.
what pathogens are more commonly seen in HAP compared to CAP? what is the preferred abx therapy?
gram negative bacilli such as E. coli and Pseudomonas. NO MACROLIDES! Antipseudomonal cephalosporins (cefepime or ceftazidime) OR antipseudomonal penicillin (piperacillin and tazobactam) OR carbapenems (imipenem, meropenem, or doripenem)
tx for ventilator-associated PNA
antipseudomonal beta-lactam PLUS a second antipseudomonal agent (aminoglycoside or fluoroquinolone) PLUS a MRSA agent (vancomycin or linezolid)
aspiration pneumonia occurs in the _____ lobe when lying flat
upper
what are the alternative tx for PCP pneumonia if TMP/SMX causes toxicity?
clindamycin and primaquine OR pentamidine (pentamidine is esp indicated if pt has G6PD deficiency)
side effects of TMP/SMX
RASH, BONE MARROW SUPPRESSION (HEMOLYTIC ANEMIA in pts with G6PD DEFICIENCY!), type 4 RTA (hyperkalemia), megaloblastic anemia (antifolate drug), teratogen, photosensitivity, drug-induced lupus
explain effect of TMP/SMX on levels of other drugs
displaces drugs from albumin, causing increased toxicity. for example, warfarin can be displaced from albumin, increasing risk for bleeding. it can also displace bilirubin from albumin causing kernicterus in neonates who were exposed in utero during last month of pregnancy. it also inhibits cytochrome P450 system so it can increase toxicity of many drugs.
alternate abx for PCP prophylaxis in those with TMP/SMX toxicity
ATOVAQUONE or DAPSONE
RIPE therapy for TB: list the side effects and management
Rifampin: red color to body secretions
Isoniazid: peripheral neuropathy; prevent with pyridoxine (vit B6)
Pyrazinamide: hyperuricemia (tx if symptomatic)
Ethambutol: optic neuritis/color vision (decrease dose in renal failure)
when should steroids be used in TB?
pts with pericardial involvement or meningitis (decrease risk of constrictive pericarditis and decrease neurologic complications, respectively)
what is considered a positive test on PPD?
5 mm: HIV pts, glucocorticoid users, close contacts of those with ACTIVE TB, abnormal calcifications on CXR, organ transplant recipients
10 mm: recent immigrants (past 5 years), prisoners, healthcare workers, close contacts of those with TB, hematologic malignancy, alcoholics, diabetics
15 mm: those with no risk factors
what should you do if a pt who has never had a PPD skin test before and their test comes back negative?
get a second test within 1-2 weeks
what should you do if PPD test was positive and CXR ruled out active disease?
isoniazid therapy for 9 months
medication management for TB
RIPE for 2 months, then rifampin and isoniazid only for 4 more months (6 total months of tx)
6 drugs that cause pulmonary fibrosis
ABC BMN (ABC Big Man Now): Amiodarone, Bleomycin, Cyclophosphamide, Busulfan, Methylsergide, Nitrofurantoin
pneumoconiosis associated with shipyard workers, pipe fitting, insulators
asbestosis
pneumoconiosis associated with cotton
byssinosis
pneumoconiosis associated with electronic manufacture
berylliosis
pneumoconiosis associated with moldy sugar cane
bagassosis
what are the important PFT findings in pulmonary fibrosis?
decreased FEV1, FVC, TLC, residual volume, NORMAL ratio of FEV1:FVC (greater than 70%), DECREASED diffusion capacity of lung for carbon monoxide
which pneumoconiosis shows granulomas on biopsy?
berylliosis
likely and possible sx of sarcoidosis
likely: young African American female with dyspnea on exertion, erythema nodosum, and lymphadenopathy
possible: parotid gland enlargement, facial palsy, heart block, restrictive cardiomyopathy, CNS involvement, iritis and uveitis
biopsy of sarcoidosis
noncaseating granulomas
lab findings, PFT findings, and tx of sarcoidosis
elevated ACE level, hypercalciuria, hypercalcemia (granulomas in sarcoidosis make vitamin D!), PFT shows restrictive pattern; tx with PREDNISONE
what are the options for pts with PE/DVT who experience HIT?
fondaparinux, argatroban, lepirudin
which drugs can be used instead of warfarin that do not require INR monitoring after DVT/PE?
rivaroxaban and dabigatran
what is obesity/hypoventilation syndrome?
sleep apnea with increased bicarbonate
how much tidal volume should be given for mechanical ventilation for ARDS?
6 mL per kg
what should you suspect in a pt whose pneumonia has not cleared up after 4-6 weeks on follow-up CXR?
bronchoalveolar carcinoma (type of adenoma)
tx of acute gout attack in a pt with renal insufficiency
steroid injection or oral steroids (triamcinolone)
what medications should be stopped in a pt found to have gout?
THIAZIDE DIURETICS, ASPIRIN, and NIACIN
gout medications: ______ is effective at preventing second gout attack. _____ decreases production of uric acid.
colchicine is effective at preventing second gout attack. allopurinol decreases production of uric acid
what antihypertensive is best in gout pts?
losartan (lowers uric acid)
positive straight leg raise test
herniated disk
knee jerk reflex lost = what nerve root impinged?
L4
ankle jerk reflex lost = what nerve root impinged?
S1
tx for sciatica
NSAIDs with continuation of ordinary activities (NO BED REST!)
tx for fibromyalgia
AMPed up for fibromyalgia!!: Amitriptyline, Milnacipran, or Pregabalin (NOT STEROIDS!)
what is dupuytren’s contracture and what conditions is it associated with?
hyperplasia of palmar fascia leading to nodule formation and contracture of the 4th and 5th digits; alcoholism and cirrhosis
anti-cyclic citrullinated peptide = what dx
rheumatoid arthritis
rheumatoid arthritis, splenomegaly, neutropenia
felty syndrome
rheumatoid arthritis, pneumoconiosis, lung nodules
caplan syndrome
what is the most important thing to do with pts with RA before surgery
cerivical spine x-ray (RA is associated with C1/C2 subluxation)
what DMARD for RA causes retinal toxicity?
hydroxychloroquine
what DMARDs are safe in pregnancy?
hydroxychloroquine and sulfasalazine
presentation of juvenile RA
high, spiking fever in a young person associated with a salmon-colored rash on chest and abdomen that occur only with fever spikes. splenomegaly, pericardial effusion, joint sx, anemia, and leukocytosis may also be present
is complement decreased or increased in SLE?
decreased
what are the laboratory findings that can specify acute lupus flare vs an infectious cause?
DECREASED complement and INCREASED anti-dsDNA
what drug can control progression of SLE?
BELIMUMAB
PT and PTT findings in antiphospholipid syndrome
ELEVATED PTT and normal PT
what are the two best tests (initial and most specific) for antiphospholipid syndrome?
initial: mixing study (PTT will remain elevated even when normal plasma is added because of the APL antibodies)
specific: Russel viper venom test (prolonged with APL antibodies and does not correct on mixing with normal plasma)
when should a mother be investigated for anticardiolipin antibody as cause of spontaneous abortion?
two or more first-trimester events or a single second-trimester event
what should be given to prevent recurrence of spontaneous abortion caused by anticardiolipin antibody?
HEPARIN and ASPIRIN (remember – warfarin is contraindicated in pregnancy!!)
sx of limited scleroderma
CREST syndrome: Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasias
what are the serious manifestations of scleroderma in lung and renal systems?
lung: restrictive lung disease and pulmonary hypertension
renal: sudden HYPERTENSIVE CRISIS (may lead to microangiopathic hemolytic anemia)
what antibodies are extremely specific to scleroderma? what test is most specific?
specific: antiCENTROMERE antibodies
most specific: antiTOPOISOMERASE (SCL-70) antibodies
tx for following parts of scleroderma: long-term, renal crisis, pulmonary fibrosis, pulmonary HTN
long-term: methotrexate
renal crisis: ACE inhibitors
pulmonary fibrosis: cyclophosphamide
pulmonary HTN (same with idiopathic pulmonary HTN): bosentan, sildenafil, prostacyclin analogs (iloprost, treprostenil, epoprostenol)
what is the most dangerous complication of Sjogren syndrome?
lymphoma (evaluate in everyone)
best initial test for Sjogrens
Schirmer test: filter paper is placed against eye
peroneal neuropathy leading to foot drop in a young pt vs asthma plus foot drop in an adult
polyarteritis nodosa
all pts with polyarteritis nodosa should be tested for what disease?
hepatitis B and C
what is mononeuritis multiplex?
sx of polyarteritis nodosa where there is multiple peripheral neuropathies of nerves large enough to have a name
pt over age 50 with pain and stiffness in shoulder and pelvic girld muscles, difficulty combing hair and rising from chair, elevated ESR
polymyalgia rheumatica; Churg-Strauss
expected lab findings of polymyalgia rheumatica
elevated ESR, normochromic normocytic anemia, normal CPK and aldolase
child recovering from recent URI with GI bleeding, painless palpable purpura, arthralgias, and hematuria
henoch schonlein purpura
biopsy shows leukocytoclastic vasculitis
henoch schonlein purpura
presentation of cryoglobulinemia
pt with hepatitis C who has joint pain, glomerulonephritis, non-blanching purpuric skin lesions, and neuropathy
abnormal lab tests in cryoglobulinemia
positive RHEUMATOID FACTOR and COLD PRECIPITABLE IMMUNE COMPLEXES
what diseases are cold agglutinins associated with?
EBV, mycoplasma, lymphoma, waldenstrom macroglobulinemia
presentation of behcet syndrome
asian or middle eastern person with:
- painful oral and genital ulcers
- erythema-nodosum like lesions of skin
- ocular lesions leading to uveitis and blindness
sterile skin pustules from minor trauma like a needle stick
pathergy = BEHCET syndrome
tx for ankylosing spondylitis refractory to NSAIDs
anti-TNF drugs (infliximab, adalimumab, etanercept)
presentation of psoriatic arthritis
psoriasis, SAUSAGE DIGITS, NAIL PITTING, “PENCIL IN A CUP” deformity on x-ray
tx for psoriatic arthritis refractory to NSAIDS
methotrexate or anti-TNF drugs (NO STEROIDS)
triad of reactive arthritis
JOINT pain, OCULAR findings (uveitis, conjunctivitis), GENITAL abnormalities (urethritis, inflammation of foreskin and head of penis)
scary side effect of bisphosphonates
osteonecrosis of jaw
empiric tx of septic arthritis
CEF and VANC
tx for septic arthritis of prosthetic joint
remove the joint, give abx for 6-8 weeks, then replace joint
recurrent gonorrhea infections = what should you test for?
C5-C9 (terminal complement) deficiency
what are the unique sx of gonococcal arthritis compared to septic arthritis?
POLYARTICULAR involvement, TENOSYNOVITIS (inflammation of tendon sheaths, making finger movement painful), petechial RASH
best initial test to order for osteomyelitis and best second test to order if the first one is negative
x-ray; if x-ray is normal, order MRI
arthritis in an adult that resembles RA but is RF negative
psoriatic arthritis or parvovirus B19
arthritis in a child that resembles RA but is RF negative
JRA (rheumatoid factor is often negative in a pauciarticular variant)
anemia with high iron
sideroblastic anemia (inability of iron to be incorporated with heme; most commonly caused my alcohol’s suppressive effect on bone marrow)
in iron deficiency anemia, is the platelet count high or low?
high
how can you distinguish iron deficiency anemia from a thalassemia?
both are microcytic anemias, but thalassemia has normal RDW, normal iron and ferritin, RBC count is normal, and target and teardrop cells are seen on smear
what deficiencies are seen in celiac disease?
B12, folate, and iron
what can cause macrocytic anemia other than folate and B12 deficiency?
direct alcohol effect on bone marrow or liver disease (always get a peripheral smear before ordering folate or B12 labs!)
only way to distinguish B12 deficiency from folate deficiency by labs
increased methylmalonic acid levels
how does pancreatic function relate to B12 deficiency?
pancreatic enzymes are needed to absorb B12. they free it from carrier proteins so it can bind with intrinsic factor
what electrolyte abnormality do you need to watch for when replacing folate or B12?
hypokalemia
what are the manifestations of sickle cell trait?
defect in ability to concentrate urine (isothenuria), occasional hematuria
best initial therapy for parvovirus B-19 infections in sickle cell pts
IVIG
tx for cold agglutinins
rituximab, other immunosuppressive agents (cyclophosphamide, cyclosporine). STEROIDS AND SPLENECTOMY DO NOT WORK!
distinguishing features of cryoglobulins from cold agglutinins
cryoglobulins are associated with hepatitis C, joint pain, and glomerulonephritis
does renal cell cancer cause increased EPO or decreased? is Hct low or high?
increased EPO, so high hematocrit
most accurate test for polycythemia vera
JAK2 mutation
what is the tx for essential thrombocytosis and who should be treated?
hydroxyurea; if pt is over age 60 and there are thromboses OR platelet count is above 1.5 MILLION
tx for myelofibrosis
TNF inhibitors THALIDOMIDE and LENALIDOMIDE
sudden pain and redness in medial canthal region with purulent discharge
dacryocystitis
hereditary hemochromatosis increases risk of what?
hepatocellular carcinoma
tx for aplastic anemia in pts too old for BMT (over age 50) or there is no matched donor
antithymocyte globulin (ATG) and cyclosporine (goal is to suppress T cells!)
