ABIM October 2021 Flashcards
ALS signs
40s-60s, bilateral extremities, hyperreflexia (upper motor neurons), fasciculations (lower motor neurons). Cramping
West Nile transverse myelitis
anterior horn cells, polio like. Reflexes decreased not increased.
CIDP (chronic inflammatory demyelinating polyneuropathy)
lower motor neuron weakness, areflexia, GBS
ALL
> 45y, blasts stain for TdT, CD19, CD20.
AML
CD13, CD33, CD34
DM diagnosis
- sxs + glucose >200
- FBG >=126 (two occasions) or post OGTT >200
- HbA1c >=6.5%
Thrombosis and prolonged aPTT
APLA. performed 1:1 mixing study. With APLA, doesnt correct with addition of normal plasma. Mixing study clots blood if due to clotting factors (need only half), not if due to inhibitors.
DVT ppx high risk surgeries
TKR then THR then pelvic/cancer
CAH
CYP21A2 (17-hydroxyprogesterone not converted). high cortisol and DHEAS. Increase ACTH -> hyperpigmentation, advanced bone age, precocious puberty.
Yersinia pestis
necrotizing pna, contagious - can cause epidemic
OSA-HS
neck circumference >16 inches (women), >17 inches (men)
AHI 5-14: mild, 15-30 moderate, >30 severe
Associated with latex allergy
spina bifida
Nasal polyps: ASA allergy
Eos gastroenteritis: food allergies
signs of OA
DIP (heberden nodes)
knee (genu varus)
bunion (lallux valgus of great toe)
neutropenic fever
Vanc and Cefepime. Day 4-7 if still febrile, add fungal coverage.
subacute thyroiditis
After vial illness AKA de Quervain, granulomatous. Hyperthyroid sxs (cell destruction) then euthyroid then hypothyroid then back to euthyroid when resolved. Causes tender thyroid. uptake low as thyroid released via destructive process rather than increased uptake. Hashimotos : chronic autoimmune, nontender
Increased RAI uptake
more synthesis of thyroid hormone
Graces, Toxic multinodular goiter
Tropical sprue
macrocytosis, glossitis, decreased folate. Causes malbsorption with partial villous atrophy. Carribean, SA, Venezuela, India. Rx: tetracycline and folate replacement.
Other diarrhea:
C. Diff: fidoxamin
H. Pylori
14d OCLAM: omemprazole, clarithromycine, amox
fu: urea breath test or stool antigen.
confirm cure 4-6w after. Cannot be on PPI for breath test, off abx for 4 wks.
Anti seizure during pregnancy
AVOID valproate (high risk of neural tube defects) Phenytoin and topiramate also associated with brith defects.
delayed hypersensitivity (type 4)
days later.
Examples: TB, contact dermatitis.
Type 1: immediate, mast cells (peanut allergy)
Type 2: drug induced cytopenias, antibody ITP and hemolytic anemia)
Type 3: serum sickness, Ag-AB complexes (vasculitis, drug fever, arthus reactions)
High iodine causes…
decreased thyroid RAIU bc gland saturated and cannot take up more.
Thyroiditis - destroy cells and causes low RAIU
Pleural tests and lights criteria
Cholesterol>45 high sensitivity and specificity for exudative effusions.
LDH: elevated in setting of chronic diuretic use.
Lights criteria:
pleural fluid to protein >0.5
pleural LDH to serum LDH >0.6
pleural fluid LDH >2.3ULN of serum LDH
HF: transudative
parapenumonic: exudative (low glucose, high neurtrophils)
Exudative:
pleural chol>45
pleural LDH> 0.45 ULN
chylous if TG>110. THINK NON-HODGKINS IF CA
Adenosine deaminase = TB!
acoustic neuroma
HA, vertigo, tinnitus, cerebellopontine signs
weber test
lateralized hearing loss, tuning fork on head
blastomycosis
lung and draining skin/bone lesions.
Central, southeast and mid-atlantic states.
Inhalation of spores via soil.
Histoplasmosis: Mississipi and Ohio River (erythema nodosium or erythema multiforme). Similar to Coccidoidiomycosis (seen in SW US).
Aspergillosis: immunocompromised
Strep
Strep Pneumoniae - skin and soft tissue infections
Strep pyogenes - skin infections, impetigo, erysipelas.
HCC
paraneoplastic syndrome
elevated AFP
hyperca, hypoglycemia, erythrocytosis, FUO, watery diarrhea.
screen for liver cancer in cirrhosis
AFP and US
Caused by cirrhosis and hepC, not hepB
Testicular
15-35y, germ cell tumors, curable with 5-year survival 90-95%. solid painless mass. >50y -> lymhoma No biopsy (can seed) Do us and if solid do orchiectomy
hemochormatosis
iron stored intracellularly.
liver, heart, pancreas, pituatary
rx: phlebotomy
(wilson’s rx: penicillamine)
Factor 7 deficiency
prolonged PT
normal aPTT
increased risk of bleeding.
C. diff relapse
if flagyl, use po vanc
if vanc, use fidaxoxcicin or pulsed vanc
IV flagyl and po vanc if fulminant disease - ileus, megacolon, hypotension.
Stool transplant after 2nd relapse.
Critically ill patients with low TSH
- Rule out adrenal insuff (random cortisol)
- Replace thyroid.
Avoid IV T3 in those wth cardiac disease. T4 is safer.
Pregnant vaccines
Tetanus with Tdap ok (after 20 w)
Inactivated flu ok.
NO: MMR, Varicella (live), nasal flu, zoster, polio, typhoid, yellow fever.
PMR
giant cell arteritis
20% develop GCA (visual changes, jaw pain, HA)
PMR - limb girdle pain
Rx PMR: low dose prednisone.
Rx GCA: high dose prednisone.
MV surgery
sxs or LVEF <60% of LVESD >= 40 mm
Tb testing
No controls.
Never choose 250 TU
2 step for those who work in prisons
Impingement syndrome
impingement of surpspinatus tendons
passive abduction to 90 degrees causes pain in deltoid region.
subacromial bursitis - pain at rest and with motion
rotatory cuff tear: pain during active than passive abdiction, positive drop arm test.
TOS: pain from base of neck to top of shoulder, down the arm
Sensitivity
TP/(TP+FN)
those who have disease, how many will test positive.
Test sensitivity not affected by disease prevalence
Asthma PFTs
response to bronchodilator.
mild increase in DLCO
HF PFTs
decrease DLCO
no repsonse to bronchodilators
Emphysema PFTs
decreased DLCO
increased TLC (hyperinflation)
no repsonse to bronchodilators
ILD PFTs
reduced DLCO
lower TLC
no response to bronchodilators
Sarcoidosis PFTs
reduced DLCO
no response to bronchodilators
treatment of rashes
erythema multiforme - targetoid lesions on palm: HSV - valcyclovir
erythema migrans - doxycycline (lyme)
latent syphilis - PCN
testicular seminoma
AFP not elevated (elevated in nonseminoma germ cell tumor)
Testicular ca: check AFP, beta subunit of HCG and LDH
AFP - not elevated, b-HCG infrequently elevated. LDH usually elevated.
AFP half life 5-7 days. b-HCT 1.5-3 d
klinefelters
high FSH and LH and small testes
prolactinoma
low FSH and LH
testicular tumor
elevated b-HCG and estradiol
sarcoidosis
AA
lung involvement
arthritis (symmetric and LEs)
anterior uveitis
pseudocyst
recurrence of pain after pancreatitis
never do ERCP
Rx: bowel rest and IVF, drain or surgery only after 3-6 mo
RA
doesn’t affect lumbar spine
Hairy cell leukemia
dry tap splenomegaly pancytopenia CD11c+, CD20+, CD103+ BRAF mutation (~100%) Rx: cladrabine, pentostatin. --- Philadelphia t (9;22):CML t(14;18) DLBCL, follicular lymphoma JAK2- PCV, ET, myelofibrosis
alzheimers Rx
cholinestarese inhibitor (donepezil).
hyperparathyroidism
elevated PTH despite elevated Ca
vit D suppresses PTH
pseudohyperparathyroidism
shortened 4th and 5th metacarpals.
protein in urine
Albumin: Cr ratio:
<30 mg/g - normal
30-300 - microalbuminuria
>300 - macroalbuminuria
PFTs
If FEV1/FVC <0.7 the COPD is classified as obstructive: FEV1: >=80% - mild obstruction 50-80% - moderate obstruction 30-50% - severe obstruction <30% - very severe obstruction.
TLC> 120% c/w hyperinflation.
TLC <80% restrictive pattern
medullary thyroid cancer
sporadic or familial
RET protooncogene
Rx: screen family, thyroidectomy
Zollinger Ellison Syndrome
gastrin secreting
serum calcium level after gastrin test
MEN1
tularemia
Arkansas, Missouri, Oklahoma Franciesella Tularensis goats, sheep, cows can go in skin, eyes, LN dx: serial serologies. -- Brucella - FUO - goats -- Ehrlichia - missouri and arkasnsa, fever, HA, thrombocytopenia, leukopenia, pancytopenia rash is ~30% Morulae in white cells
Photosensitivity
Flouroquinolones, tetracycylines, NSAIDs, HCTZ, furosemide, amiodarone, diltiazem, statins
dermatitis herpetiromis
gluten senstivity (celiac disease)
Rx: dapsone
–
zinc deficiency: acrodermatiis enteropathica (dry patches and plaques) on mouth and anus
depression meds - qt prolongation
TCA, CELEXA, LEXAPRO, VENLAFAXINE (SNRI), mirtazapine, bupropion
RMSF
Fever, arthralgia, maculopapular rash-> petechial rash on trunk. Rx: doxycycline Dx: biopsy and IF on petechiae.
sinusitis
augmentin. if PCN allergic, then doxy>levofloxacin
pseudogout
calcium phyrophosphate deposition
positive birefringent, rhomboid crystals
gout: monosodium urate crystals
aplastic anemia
parvovirus B19, high epo
acute pap muscle rupture
crescendo-decresendo at apex
vsd
holosystolic LSB thrill
neurosyphilis
pcn g iv - crosses bbb
acute dystonic reaction (i.e haldol)
Rx: benztropine or benadruyl
CRC screening
every 5 yrs if CRC in first degree relative or adenoma <60 years
occult GERD
24 h ph probe
esophageal contraction over normal peristalsis.
babesia mircoti infection
Northeast USA like malaria hemolytic anemia in splenectomized people RX: moderate - atovaquone and azithro severe: clindmycin and quinine
ADHD
before 12 years of age
sleep, social interactions, outbursts
PD - after 12 years of age
retina detachment
floaters or flashing lights
thyroid cancer risk factors
FH, XRT to neck, pain in anterior neck, dysphagia, <20 or >70 y, hoarseness (vocal cord paralysis), fixed, growing, LAN, M>F.
Pregnancy
no floroquinolones, ok to use macrolides, vancomycin, cephalosporins
ok to use erythtromycin
avoid: ACe, statin, doxy, cipro
iron deficiency anemia >50 yrs
colorectal cancer
AIDS associated malignancy
EBV associated CNS lymphoma in immunocomprommised
HPV oral cancers
HHV-8 Kaposis sarcoma
Merkel cell polyoma virus - merkel cell carcinoma
gout
“marginal erosions” on XR, hyperuricemia
HCTZ increases UA
negatively birefringent crystals
Correction of prolonged aPTT with 1:1 mixing (provides 50% of normal factor)
Prolongation after normal correction = inhibitor (takes a while to kick in).
Prolongation sustained = Factor deficiency (assay each of them).
Warfarin - prolonged PT
Coagulation cascade
PT: Vitamin K dependent (2,7,9,10 or fibrinogen)
PTT: 8,9,11,12
Factor 12 def: normal PT, prolonged aPTT (AR, no bleeding issues)
RA
anti-CCP and RF antibodies portends poor prognosis and extra-articular manifestations (vasculitis, rheumatoid lung and skin nodules). Rx: dmard
Metabolic acidosis
expected PCO2 = (15 + bicarb). Does it equal the actual PCO2. (Tells you if respiratory acid base disorder)
Anion gap = (Na+K)-(HCO3+Cl). Normal 12.
High anion gap metabolic acidosis: renal failure, lactic acidosis, ketosis, ingestions, D-lactic acidosis (short gut).
Lab assays only measuere L-lactic acid.
ethylene glycol
antifreeze, calcium oxalate crystals in urine, elevated osmol gap
hereditary retinoblastoma
associated with osteosarcoma (metaphyseal region of long bones, lytic lesion).
Crohns stricture
if >5 cm, cant do balloon dilation with colo; need surgery
Measles
Kopliks spots and rash
cough, conjunctivitis and coryza
rash: back of neck and goes downwards
Needs two shots of MMR
Anemia
Decrease production or increased destruction.
IDA: if ferritin <40, microcytic, hypochromic
Decreased EPO: normocytic
B12 or folate: macrocytosis
lithium
reduced suicide in bipolar
hypothyroidism is a side effect (inhibits secretion of thyroid)
ZES
gastrinoma (gastrin secreting tumor) - diarrhea
stop PPi and check gastrin
If see multiple ulcers, think ZES
Lyme carditis
3rd degree AVB, Rx: CTX and temp pacer (permanent not required)
hyponatremia
normal BUN and glucose - hypoosmolar hyponatremia.
During hypoN, the urine OSM should be low to pee out free water. If urine inapprorpiate concentrated, then SIADH (high urine Na and urine OSM>200).
acid base
expected PCO2 = 1.5xHCO3 + 8 +/- 2 (to see if respiratory disorder)
To see if nonanion gap, see if the drop in HCO3 (normal 24) is the same as the increase in AG (normal 6).
sarcoidosis
noncaseating granulomas (also seen in beryllium exposure)
uveitis, arthritis, fever, erythema nodosum
vitamin d excess, PHTN, cardiac sarcoid
proteinuria, inflammatory arthritis.
cullen sign (bluish near umbilicus)
hemoperitoneum in pancreatitis
also flank discoloration
carcinoid
mostly occur in jejunum, duodenum, ileum, right colon
Endocarditis
MSSA (nafcillin or oxacillin) or strep viridans (beta lactam and aminoglyocisde)
false positive HIV test
SLE, HLA antibodies, pregnancy
Dx: (p24 antigen/antibody), viral load, antigen testing
PPD interpretation
> 5 - immunocompromised (HIV, prednisone >15 mg)
parapneumonic effusion
ph<7.2, pleural fluid glucose <60, LDH>3x ULN.
Organisms/pus -> chest tube
Vitamin A intoxication
causes hypercalcemia, increases resorption of bone, causes muscle pain.
aplastic anemia Rx
ATG –> serum sickness.
caused by drugs (sulfa, valproate, chloramphenicol) or virus (HIV, Parvovirus B19)
dx: hypocellular (<20% marrow), low retic, pancytopenia
CJD
dementia and myoclonus, precipitated by startle
14-3-3 protein in csf
Prolactinoma
macroadenoma prolactin usually >200
if <100, look for other effects like thyrotroph (hypertrophies thyrotroph cells in repsonse to high TRH).
Mild prolactin elevation - nipple stimulation, pregnancy
hep c
associated with porphyria cutaneous tarda
resolved with hepatits Rx
sickle cell
parvovirus b19, cva, avn
PMR
20% develop GCA
Rx: asa, steroids 60 mg/d
if visual sxs, solumedrol 1g/d X3d, then oral
menieres
vertigo, hearing loss, tinnitus
hyperthyroid before surgery
delay and give bb
if cannot delay, give bb, ptu, iodine and steroids
B12 deficiency
hypersegmented neutrophils, impaired DNA synthesis
MDS
hypercellular marrow, dysplastic maturation
Myelofibrosis
teardrop cells on smear, “dry” tap
ACD
inhibition of absorption of iron from GI tract (hepcidin) (normal or increased iron stores)
G6PD- reduced glutathione so oxidative stress
hereditary sphreocytosis - memrabe fragility
acute cholangitis
biliary colic, fever, jaundice
Rx: IV abx and ERCP
osmolalality
= 2xNa + glu/18 + BUN /2.8
osmolal gap = measured vs calculated
>10 is increased
HAGMA
toxic ingestion
“GOLDMARK”
glycols: propylene hlycol, ethylene glycol
oxoprolyine: acetaminophen
L-lactic acidosis - shock, tissue ischemia
D-lactic acidosis - short gut, malabsoroption.
Methanol (also increases osmolal gap)
Aspirin (salicylates)
renal failure (uremia)
ketoacidosis: DM, etoh, starvation
sle
ANA TITER >1:160
GIARDIA
watery frothy diarrhea,
dx: antigen in stool
tetanus rx
tetanus toxoid (vaccine), tetanus IVIG, flagyl
postpartum thyroiditis
1 mo hyper then hypo measure TSH (high), FT4 (low) check anti-TPO ab Rx: thyroxine check tsh monthly as this may resolve
risk factors for osteoporosis
BMI<19, menopasue <40y, wt <127
chemo agents side effects
trastuzamab - cardiotoxicity vincristine - nerves cisplatin - nephrotoxicity capecitabine - diarrhea and volume loss eGFR (cetuximab)- acneiform skin rash
Retin-A
pancreatitis and hyper Tg
Can give with fibrate
Contraindicated: doxycycline (pseudotumor cerebri)
alports disease
X linked, hematuria, sensorineural deafness, progresses to ESRD
tramadol
associated with seizures
cancers with hyperCa
Rx: IVF, then lasix
squamous cell, breast, MM, T cell lymphoma, renal cell
dermatomyositis
“shawl sign”, proximal muscle weakness, +myositis Ab, , photosensitive rash.
Newly dx polymyositis - dermatomyositis - possibly paraneoplastic (especially if ANA with anti-ANA p-155/p140). LOOK FOR CANCER -
Takayasus arteritis
fatigue, ha, weight loss, fever
large vessel vasculitis
womem
behcets
HLA-B51
UVEITIS, oral/genital ulcers
flushing ddx
hereditary angioedema - C1-INH level Urine metanephrine and VMA - pheo 5-HIAA - carcinoid tryptase - systemic mastocytosis elevated vasoctive intestinal polypeptide, VIPoma.
silicosis
upper lung lobes
thryroid nodule
TSH. if low, then scan. “HOT” nodule
If high or normal, then biopsy.
breast cancer
HR+ positive prognosis
erythromycin-clindamycin D test x
inducible resistance of MRSA isolate
+ test - susceptible to clinda in vitro, resistace in vivo
cushings dx
2 negative 24h urinary free cortisol or dst
SIADH
urine osm high
urine na >40
postpartum thyroiditis
tsh low
do RAIU to see if graves (high) or acute or subacute thyroiditis (low RAIU) - improves on its own.
Can’t do RAIU if nursing.
Sestamibi for PTH
pseudolymphoma
secondary to phenytoin use
fever, elevated ALT/AST and LAN.
peritonsillar abscess
Group A strep or anaerobes
fever, throat pain, “hot potato” voice (muffled), uvular deviation.
vs.
RP abscess - fever, drooling, dysphagia
nephrotic syndrome/membranous GN
hypercoag
renal vein thrombosis or PE
asa overdose
resp alkalosis
fever and hyperventilation.
chronic - tinnitus, vertigo and hearing loss
specificity
those who do not have the disease
TN/ (TN+FP)
sensitivity
those who do have the disease
TP/(TP+FN)
asa overdose
resp alkalosis
fever and hypervent
chronic - tinnitus and hearing loss.
grapefruit juice
CYP3A4
simvastatin, nifedipine and lovastatin
pcp rx
bactrim + steroids (if PaO2<70)
blastomycosis
ohio and mississipi valley
rx: itraconazole
always Rx as colonization does not occur.
Lithium
interacts with CCB - may increase or decrease lithium, need to monitor lithium levels.
Thiazide increase lithium, ace inhibitors increase lithum,, MRA decrease lithium, loop can increase or decrease lithium
AKI from NSAIDS
prerenal azotemia (benign ua with hyaline casts and low fena)
AIN (weeks to months) -> nephrotic syndrome, biopsy with minimal change disease (urine eos).
ATN - abnormal US (dirty brown or cellular casts) increased FeNa.
Acute papillary necrosis - flank pain like renal colic.
pityriasis rosea
self limited rash
Rx; UVB, steroid
solitary oval patch on trunk (herald patch) –> 7-10d small, oval pink papules on trunk, extremeties and neck. last 6-8 wks. Follow lines of skin cleavage (christmas tree pattern).
prolonged aPTT
factor 8,9,11,12 deficiency or inhibitor.
1:1 mixing. If corrects, factor def. If corrects then prolongs, then inhibitor.
vWD - prolonged aPTT but mucocutaneous bleeding.
(ristocetein-platelet aggregation).
howell-jolly bodies
after splenectomy (black pellets on smaer)
B12 - hypersegmented polys
schistocytes - heart lave
basophilic stippling (blue granules in cytoplasm) - thalassemia or etoh abuse.
hand-schuller-christian syndrome
langerhans histiocytosis.
Triad: lytic bone lesions, DI, exopthalmus.
Treacher-Collins - malar hypoplasia, cleft in zygoma.
Loefflers- pulmonary infiltrates and peripheral eos.
pituitary apoplexy, hemorrhage
Rx: steroids.
1st: Polyuric, DI, hyperenatremia
2nd: transient SIADH, hyponatremia (cells release ADH).
3rd: recurrence of DI
renal sediment
no - edema - minimal change unlikely. memranoproliferative GN (assoc with hep C) and IgA nephropathy - hematuria MM - hypercalcemia, mismatch between proetinuria on dipstick (trace) and urine protein:cr ration (high).
endocarditis ppx
none for gi or gu procedures
positive exercise challenge test
FEV1 falls by >10%
(flow-volume loop - upper airway obstruction).
sulfasalazine
reversible cause of infertility with low sperm count
uncomplicated salmonella gastroenteritis
no abx unless very old, very young or immunocompromised.
skin testing vs allergen-specific IgE testing
better NPV with skin testing
hereditary angioedema
A/D C1-INH function decreased nonpitting edema 1-3 days, face and lips doesnt respind to epi NEVER USE ACEI in these pts
antibiotics in pregnancy
macrobid (after 1st trimester), PCN, cephalosporin, aztreaonam, fosfomycin.
HIT
5-10d, plts<50% baseline, thrombosis
PF4
Rx: stop hepatin and start DTI
(DIC: measure fibrin degradation products)
sputum with salty taste
adenocardcinoma (BAC)
peripheral loctaion, growth along intact alveola septa (“lepidic” growth pattern).
lipoid pneumonia
“cholesterol pna”
RAIU interp
low - subacute thyroiditis
high diffuse - Graves (rx: methimazole for 18 mo then see if remission)
focal - hot nodule (rest low due to suppression). Rx: 131I
If laryngeal nerve changes, get thyroid us
auer rods
azurophilic needle-shaped crystals in the cytoplasm of immature cells = myeloblasts (AML).
(light blue granules in neutrophils = Dohle bodies, infection or inflammation).
AML
median age 65y, pancytopenia.
CD 117, CD33
(CD19 - lymphoblastic cell lineage).
eggshell calcifications
silicosis (shell-like calcifications in hilar nodes).
CVT
thrombophilic state (SLE), APLAS
OCP, pregnancy, infection, caner
Sxs: HA, focal neurological signs, papilledema.
Wernickes aphasia
word salad
lesion in posterio temporal gyrus of dominant hemisphere
toxic shock syndrome
diffuse rash, multiorgan injury
S. aureus (purulent skin lesions) or S. pyogenes (hours to days incubation).
Pasteurella - colonizes dogs but causes local reaction
Bartonella - cat scatch disease - cellulitis and LAN,
lesions initially vesicular then papular.
hypoPTH
can be due to hypo MG
pseudoPTH - low Ca, high Phos and high PTH (abnormal PTH receptor)
AVN
long term steriod use
Anthrax
Bacillus anthracis
incubation 1 to 6 days
influenza like illness followed by respiratory distress and septic shock.
SIRS
Enlarged mediastinal nodes (wide mediastinum)
yersinia pestis (plaque)
airbone precautions.
via rodents from flea bite or infected animal.
Tularemia
francisella tularensis
hemorrahci PNA no hilan LAN
Rabbit carcasses.
no isolation needed
eyrthema nodosum
sarcoidosis, IBD, TB, drug alelrgy, strep infection.
Arrthralgias/arthritis + LNA = lofgen syndrome
cluster headache
15-180 min unilateral, stabbing autonomic sxs on that side - tearing, rhinorrhea, horners, (miosis or ptosis), Male>female Rx: O2, triptans.
scleroderma
> 80% have esophageal involevement
reduced LES pressure (achalasia - high)
decreased contraction amplitude and peristalis.s
Raynaud’s, dry MM
esophageal high grade dysplasia
dont do esophagectomy 1st line - do RF ablation or photodynamic therapy along with endoscopic mucosal resection (if nodule present)
hereditary sphreocytosis
A/D chronic hemolysis jaundice, splenomegaly, anemia. Cholelithiasis due to bilirubin stones Dx: osmotic fragility test or EMA binding test.
g6pD deficiency
hemolytic anemia
ppt by oxudative stressors, infections, meds (dapsone, sulfa drugs,antimalarial), fava beans, DKA.
Dx; Heinz bodies or bite cells
TDAP booster
dirty wounds and Tetanus >5y
cyclosporine
can increase UA and cause gout
Hodgkins lymphoma
chemo and xrt
ABVD
CELLULITIS
purulent - s aureus
nonpurulent - s pyogenes
Moderate purulent - bactrim
severe - vanco, linezolid
murmurs
R sided - louder with inspiration
HOCM- increase with valsalva. decrease with leg raise or squatting.
AS - increase with squatting
mucormycosis
rhizopus, mucor and rhizomucor
DM
necrosis in nasal cavity, palate
spororhyrix schenckii
gardner pricking finger on thorn
serotonin syndrome
SSRI (fluoxetine) + MAOi (selegiline)
confusion, agitation, hallucination, diaphorsis, HTN, hyperthermia, dilated pupils, hyperreflexia, myoclonus
GCA
dx: temporal artery biopsy
ESR high
50% have PMR, (20% PMR develop GCA)
histoplasmosis
bird/barn cleaning
self limited
no Rx unless HIV or chemo or disseminated
Rx: itraconazole.
diarrhea
E coli O157:H7 and shigella - blood
Enteroxigenic E.Coli (travelers nonbloody, veggies or ice)
food poisoning
B Cereus (rice) or S.aureus (eggs, produce, meat) toxin mediated, within 2 hours
Salmonella -1-3 day incubation, nonbloody diarrhea
hyponatremia in lung cancer
Small cell
lung cancer
small cell - central, SIADH, dermatomyositis
Large cell - peripheral
AdenoCa- less association with smoking
squamous cell - central, cavitary, hyperCa
photosensitive rash with drugs
tetracycline = doxycycline fluroquinolones amiodarone thiazide furosemide
CO poisoning
normal pO2 and high pulse Ox.
HA and nausea
Check carboxyhemoglobin.
acid-base
Write down teh variables: ph, AG, HCO3, pCO2 (expected PCO2 - winters: Expected pCO2 = 1.5 x [HCO3] + 8 (range: +/- 2) 1. acidosis or alkalosis? 2. expected PCO2 vs actual? 3. HCO3< 22 --> met acidosis 4. Calculate AG: Na - (Cl + HCO3) 5. Has HCO2 FALLEN BY AMT THAT AG HAS INCREASED?
DM screning
Annually:
urine spot albumin:cr
eye screen (DM 1 after 5y, DM 2 immediately, regardless of HbA1c)
sick euthyroid
TSH low or low-normal
low T4, low T3, low or low normal FT4
high rT3
gilberts
elevated TB due to indirect (unconjugated)
diffuse proliferative lupus nephritis
induction rx:
solumedrol 250-1000 mg IV daily x3d then..
prednisone 1mg/kg/d then..
cyclophasphamide or cellcept
(azathioprine and cyclosporine for maintenance but not induction rx)
PITUATARY INCIDENTALOMA
- is it inhibiting pituatary hormones
2.is it secreting something.
<1 cm –> hypersecretion
>1 cm –> hyper-, hypo-, visual field.
dx: igf-1m prl, dst
NPH
magnetic gait, urine incontinence, dementia
emphysema
high TLC, low DLCO
large breast tumors, HR+
mrm, adjuvant chemo (if >1mm, +LN), hormone rx
- local control: lumpectomy, xrt
- systemic control: chemo, hormonal therapy
PTLD
post transplant lymphoproliferative disease
5% after solid organ
usu in 1st year
EBV in setting of chronic Tcell immunosuppression.
LDH high, fever, LAN, night sweats
(H. pylori - MALT)
GBS
Campylobacter infections
Reactive arthitis
shigella, salmonella, campylobacter
painless thyroiditis
silent thyroiditis TPO antibodies positive Variant if chronic hashimotos. sometimes s/p pregnancy hyperthyroid -with low 123I uptake, then hypothydoi then euthyroid
vaccinations
Tdap >7y HPV 9-26y Hep A >1y Hep B at birth MMR Meningococcal if in college. Pneumococcal >65y or if <65y and smoke, CHF, COPD, alcoholic
Wiscott Aldrich syndrome
X-linked recessive
thrombocytopenia, atopic dermatitis, recurrent infections
EBV associated malignancy (B-cell lyphoma and leukemia)
Cure with BMT
Parvovirus B19
slapped cheek rash
expsoure to children
adults can have small joint arthritis and lacy reticular rash
dx: Parvoirus B19 IgM Ab
isoelectric axis
I or aVF show positive=negative deflection
SVC SYNDROME
small cell lung, lymphoma, mediastinal germ cell
wasp sting anaphlaxis
do immunotherapy
erythema migrans rash
start doxy
dont check Lyme IgM
eosinophilic granulomatosis with polyangiitis (EPGA)
medium-small vessel vasculitis with necrotizing granulomas with eos.
adult onset asthma
eos>10%
fever, malaise, weight loss
arthrotos, skin rashes, peripheral neuropathy, sinusitis.
p_ANCA, elevated EST
PAN
abdominal pain, rash, peripheral neuropathy, acute renal failure
not ANCA positive
small to medium vessels
spares the lungs
ANCA associated
small vessel
p-ANCA/anti-MPO:
1.Microscopic polyangiitis - necrotising, crescentic GN
2.Eosinophilic granulomatosis with polyangiitis (EGPA)
c-ANCA/anti-pR3
Granulomaosis with polyangiiti
upper respiratory (sinuses)
renal papillary necrosis
ischemia of distal renal papillae
Risk fxs: Pyelo, DM, sickle cell, chronic analgesic use (acetaminophen, salicylates, NSAIDs).
when to admit PID
tubo-ovarian abscess pregnant no response to Rx after 72h unable to tolerate op therapy fever, n/v
AV infections
MRSA
2ND common: staph epideriditis
Prolactin microadenoma
<2% chance of growth during pregnancy
Prolactin levels increase during pregnancy
neck pain
retropharyngeal abscess - hurts on flexion of neck
epiglotitis - hurts on extension of neck
Ludwig angina - infection of submandibular space beneath the tongue.
acid base
- write down the ph, pco2 and the HCo3-
- Look at HcO3 - what is the disorder?
- Winters formula if metabolic acidosis.
If respiratory alkalosis - look at formula.
metabolic change for respiratory alkalosis
ACUTE: decrease in HCO3 is 2 per 10 in PCO2
CHRONIC: decrease in HCO3 is 5 per 10 in PCO2.
paresthesias
tingling, carpopeal spasm
Toxic shock syndrome
Toxic shock: fever, rash and 3 organ dysfunction.
staph aureus or group A beta hemolytic strep.
strawberry tongue (also in Kawasaki and scarlet fever)
Rx; Clinda and nafcillin or vanc
S. viridans
endocarditis.
lithium toxicity
N/V/D and ataxia on exam, fasciultaions, cogwheel rigidity, hyperreflexia.
Ace inhibitors inhibit renal excretion of lithium.
Carbamazepine toxicity
dose dependent.
>20 mg/kg, mild to moderate CNS and anticholinergic effects
>50 mg/kg - delta MS, intermittent agitation
lithium drug interactions
ace inhibitors inhibit renal excretion
neuroleptic malignant syndrome
blockade of central dopamine receptors
hyperthermia, autonomic dysfunction, muscular rigidity
Resembles serotonin syndrome (nausea, vomiting, shivering, hyperreflexia)
NMS: elevated CK, LDH, AST and WBC; myoglobinuria from rhabdo (normal in serortonin syndrome).
seen in patients with rapidly escalating doses of neuroleptics, like haldol.
RX; bromocriptine, amantadine, dantrole, stop haldol
CLL (small lymphocytic lymphoma) in elderly
indolent non-hodgkins lymphoma
incurable.
treat only symptomatic patients (painful LAN, fever, cytopenias)
Diagnose with peripheral flow cytometry; dont need BM biopsy.
Is not PET avid as it is indolent (vs. Hogkins or DLBCL).
acute rheumatic fever
strep infection untreated (ASO titer) 1 major + 2 minor: MAJOR: arthritis, polyarthritis (migratory) carditis and valvulitis CNS (syndehams chorea) subcutaeneous nodules erythema marginatum
MINOR: previous RF arthralgia fever ESR or WBC eleveated prolonged PR on ecg.
Rx: IM PCN or oral PCN for 10 days
PMR
shoulder and hip girdle weakness
ACD
elevated ESR
Rx: prednisone 15-20 mg/day (use 60 mg if GCA present)
fibromyalgia rx
TCAs
homosexual men
give Hep A and B vax
pneumococcal vaccine
chronic liver, lung, heart dx, DM, asplenia, immunocompromised.
gram positive rods
listeria, clostridia (skin infection), erysipelothorix, bacillus, corynebacterium (acne or line sepsis), nocardia, actinomyces (rods in branching chains)
listeria monocytogenes - bacteria diarrhea, bactermia, meningitis, decreased cell mediated immunity.
RX; PCN or AMP. If allergic, Bactrim. Dont use after 32 weeks due to increased risk of fetal hyperbili and kernicterus
pseudoa-achalsia
cancer that looks like achalasia (birds beak).
usually GE jxn
also see weight loss, older, smoking.
viral meningitis
In viral meningitis, the opening pressure is 90-200 mm H2 O, and the WBC count is 10-300/µL. Although the glucose concentration is typically normal, it can be below normal in meningitis from lymphocytic choriomeningitis virus (LCM), herpes simplex virus (HSV), mumps virus, and poliovirus. The protein concentration tends to be slightly elevated, but it can be within the reference range.
HSV encephalitis
HSV Type 1
CSF with lymphocytic predominance and increased RBcs
dx: HSV PCR in >90%
rapid onset delta ms and focal EEG or exam (frontotemporqal area)
MRI abnormal
pseudohyperkalemia
small increase in K with normal platelets
more pronounced in thrombocytosis.
pseudohyponatremia
thiazide diuretics (falsely low Na measurements)
irregular menstrual bleeding
<18d interval = luteal abnormality
Rx: OCPs
prolonged bleeding with normal intervals = fibroids
SCD (sick cell disease)
hemoglobin SC (heterozygous) - less pain crisis, can have splenic sequestration; hemolysis when RBCs trapped in spleen Presents with painful splenomegaly, drop in Hb of >2 g/dL, low platelets and reticulosytosis.
Rx: fluids, blood transfusion. consider splenectomy when resolved. Hemoglobin SS (homozygous)
RX in emergences (aplastic critis, acute chest) = exchange transfusion.
sjogrens and associated malignancy
40X higher risk of B cell lymphoma.
associations of diease
IBD = Akylosing spondylitis
Scleroderma = esopageal involvement
Aortic aneurysm = GCA
5mm PPD positive
after close contact with known case
organ transplant, HIV or when fibrotic changes on CXR present (i.e prior TB).
> 10 mm: healthcare workers, IVDU, prisoners, homeless.
OA
PIP and DIP
No chondrocalcinosis
RA spared the DIPs.
Psoriatic can present with “pencil in cup” deformities.
Gout: marginal erosions with “rat bite” erosions or no radiographic changes
transfusion reactions
febrile, nonhemolytic - fever, chills, subjective dyspnea, no hemolysis on labs
Rx: tylenol
hemolytic transfusion reactions- hyptension, ARF
Dx: DAT and measurement of free plasma Hb
Others:
delayed hemolytic, analphylactic, urticarial, TRALI.
severe poison ivy reaction
give 2-3 weeks steroids.
addisons disease
hypotension, weight loss, chronic abd pain, hyponatremia
primary adrenal insuff.
asymptomatic bactiuria (>100,000 CFU) in pregnancy
treat bc of risk of pyelo, low birth weight etc.
PCN, cephalosporin or fosfomycin.
Macobid ok after 1st trimester
Screen all women at least once in early pregnancy
MV repair
severe MR with sxs or asx with LV dysfunction (LVESD >= 40 mm)
alcoholic ketoacidosis
hypoglycemia, hx of alcohol binge, HAGMA
Refeeding syndrome can occur - severe hypophasphatemia which can lead to rhabdomyolysis (3+ blood on urine dipstick)
Ethylene glycol intoxication
calcium oxalate crystals in urine
like methanol and isopropyl alcohol with increased osmolal gap (>10 mOsm/L)
calculated osmolal gap: 2XNA + glucose/18 + BUN/2.8
HRS
with cirrhosis
low urine Na (<10)
no response to volume resuscitation
microscopic colitis
Dx: colo with biopsy (grossly normal mucosa).
older, stool output 500g/day
hypokalemia ecg changes
STD, decreased T wave amplitude, prolonged QTc, U wave (vs. digoxin where all the same but with short QT)
Normal U is smaller than T and usually seen in v2 and v3.
U wave
Normal U is smaller than T and usually seen in v2 and v3.
negative U wave is ischemic or systemic HTN
Increase amplitude with hypokalemia, dig effect, ICH and Class I and III antiarrhythmics and bradycardia.
hypocalcemia ecg
prolonged QT (due to st prolongation)
nonsmall cell lung cancer adjuvant chemo
> 3 cm
LN+ (stage IB or II)
antidote for TCA poisoning
sodium bicarb
empiric abx for animal bites
use if high risk for infection (face, tissue destruction, edema or near joint or on hand). Empiric Augmentin (covers cats/dogs and pasteurella)
Tetanus toxoid if >5yrs since immunization or toxoid + IG if not had at least three prior tetanus shots.
muscle pain vs weakness
pain: think PMR if ESR up (vs. fibromyalgia) and try prednisone 12.5-15 mg and check SPEP (if weight loss present)
weakness: test for Ach R antibodies (for myasthenia, which worsens with use and imrpves with rest), CK (myositis)
flu antiviral
oseltamivir, zanamavir
PE ECG
ST
S1Q3T3
HTN crisis in scleroderma
renal crisis
use IV ace inhibitors (also treat renal crisis) even in setting of ARF
renal crisis usually in AA
exercise induced hyponatremia
low serum Na
high urine Osm
Due to excess fluid with high ADH from prolonged exercise
WPW with orthodromic tachycardia or AVRT
RP >100 msec.
vs.
AVNRT (RP usually <70 msec)
(WPW with antidromic = WCT)
Bactrim interaction with…
MTX
increase in marrow suppression
(use doxyclycline instead for S. Aureus coverage)
Dicloxacillin
doesnt cover MRSA
like doxy or bactrim
prognosis for DLBCL
Poor: age >60y, LDH, > nodal involvement site (both sides of diaphragm or DM involement) and functional status.
ostium secundumum defect
diastolic murmur rarely heard
flow murmur in PA heard because of high flow.
fixed splitting of S2.
primary adrenal insuff
thin, decreased body hair, hyperK with met acidosis. low glucose
dx; cosyntropic/ACTH stimulation test (nromal >20; if low, then confirms)
rx; start dexamethasone
Tan skin: from excess ACTH to overcome adrenal insuff.
Loses aldo activity too so use hydrocort instead of dexa (as hydrocort has mineralocorticoid activity).
CML
t(9;22) - Philadelphia chromosome low leukocyte alkaline phosphatase (LAP) score BCR-ABL neutrophilia HSM uncontrolled mature neutrophils
HUS
diaeehar E. Coli
increased immune complement
ADAMTS13 activity (low in TTP but normal is aHUS)
RX; plasmaphresis but less responsive to plasmaphresis than TTP
vs. DIC - coagulopathy in setting of hemolytic anemia and thrombocytopenia.
tularemia
pna unresponsive to CTX - consider “strange” organism.
Dx: serologically or through indirect fluorescence AB; not on blood cxs.
Rx: streptomycin
Yersinia pestis
bubonic plague - GNR (coccobacillaus - safety pin)
W and SW USA.
rats/fleas, rodents
raidly progressive and fatal
CXR with bilateral infiltrated and effusions
Rx: IV gent or IV doxy
mycobacterium marinum
saltwater and freshwater pathogen
infect skin, joints, bone after traumatic inoculation
chronic bone and join infections
Nodular skin lesions and noncaseating granulomas
Rx: clarithromycin, Bactrim or doxycycline
nocardia brasiliensis
soil contamination.
noncaseating granulomas
purulent cellulitis
gram positive branching chains
blastomyces dermatidis
soil exposure and verrucous skin lesions.
gram stain/fungal stain
MALT
linked to H. pylori
Burkitts lymphoma
linked to EBV
Whipple disease
diarrahe and dementia
Tropheryma whipplei
Hepatocellular carcinoma
HBV
Castleman disease
HHV
diffuse systemic LAN
ZES
gastrinoma, multiple ulcers in upper jejunal region, diarrhea.
Dx: fasting gastrin level or secretin stimulation test
PPI can cause vitamin B12 deficiency, so check B12 annually
Rx: B12 supplementation
sideroblastic anemia
usually microcytosis
Hb usually <7 g/dL
renal infarct
acute flank pain and elevated LDH
look for AF
renal papillary necrosis
rare severe form of ATN
with analgesic abuse, sickle cell, pyelo or postpartum hemorrhage
reactive arthritis
seronegative spondyloarthropathy
ReA triad: urethritis, conjunctivity, arthritis (esp with achilles tended) - cant see, cant pee and cant climb a tree.
Infections: Chlamydia, salmonella, shigella, yersinia, campylobacter, C. Diff.
target cell microcytic anemia
iron def (reduced serum ferritin, low iron sat)
or
hemoglobinopathy.
Dx: get iron studies.
(dx for thalassemia - Hb electrophoresis, normal iron and normal or elevated ferritin should get this)
ACD: low iron, low to normal TIBC, elevated ferritin
internuclear opthalmoplegia
small stroke on ipsilateral medial longitudinal fasciculus
ipsilateral eye cannot adduct. convergence is preserved.
old patient: stroke
young: MS
tylenol overdose
NAC within 8-16h of ingestion
charcoal if within 4 hours
burr cell
echinocyte -
uremia, pyruvate kinase deficience, lymphosarcoma, GN and ulcers.
acid- base disorder.
HTN urgency
lower BP by no more than 25% in first hour, then to 160/100 in 2-6 hours then to normal over 24-48h.
RCC
secondary erhythrocytosis in 1-5%
clots (Budd-Chiari, PE, migrating IVC vlot)
sudden painless loss of vision with cherry spot
retinal artery occlusion.
common with carotid athero
RMSF
Rickettsia rickettsii
Myalgias, HA, petechial rash with centrifugal distribution (due to vasculitis)
May to October - eastern coast, southeasterm, far western
Labs: Hyponatremia, thrombocytopenia, elevated ALT/ASK, leukopenia and anemia
Rx: doxycycline.
(Legionella also with HypoNa)
metformin risks in inpatient
AKI, Lactic acidosis, contrast
Sulfonylureas
cause hypoglycemia if fasting.
thiazide diuretics and kidney stones
reduce urinary calcium and prevent recurrent stones.
To reduce stones: DRINK H2O!
(increased risk with: sodium, protein and oxalate)
opioids in renal dysfunction
fentanl and methadone safest
dilaudid and oxycodone ok
dont use morphine.
headache
migraine: abortive - triptan
ppx: propanolol, valproate, amitryptiline
Cluster rx: verapamil
SIBO
due to poor peristalsis
assoc with scleroderma
bacteria impair carbohydrate metabolism -> distention
Vitamin Def common
Scleroderma and gi tract: decreased esoph peristalsis, decrease LES tone, reflux, barretts, stricture, decreased peristalsis.
Rx: rifaximin, augmentin, flagyl, bactrim, cipro, doxy/tetracycline
Ataxia-telangiectasia
A/R
neurodegeneration, immunodeficiency, sensitive to radiation, predisposition to cancer.
Cerebellar atxia and telangecctasias
Chronomose 11 - ATM gene
defects in celluar and humoral immunity and chronic lung disease (bronchiectasis) and sinopulmonary infections.
SCID
T and B cel immunity
p/w severe bacterial, viral, fungal infection, ILD, diarrhea, FTT, Ear infections, PJP PNA, oral thrush.
fatal unless treated with BMT.
Freidrichs ataxia
A/R
progressive limb and gait ataxia, sensity loss, weakness and dysarthria.
CF
CFTR gene
abnormal sodium and chloride transport
lung, live, pancreas and intestinal disease.
von Willebrands disease
normal PT, elevated (or normal if mild) pTT
normal CBC
reduced ristocetin induced platelet aggregation
prolonged bleeding time.
normal aPTT, prolonged PT
Vit K def
Factor 7 def.
Bernand-Soulier
giant platelet syndrome
have abnormal RIPA but giant platelets.
A-a gradient
Different between alveolar concentration (A) of oxygen and arterial concentration (a)
calculated PAO2= 150 - (pCO2X1.25)
A-a gradient: calculated - measured (normal 5-20, elevated 25).
Elevated A-a: suggests a defect in V/Q perfusion, diffusion, R to L shunt or intrapulmonary shunt.
ovarian tumor
germ cell tumors most common in young women (10-30y).
Ovarian Ca: 4th leading cause of cancer death; >50% of cases in pts >65y, epithelial or germ cell.
Only 5% of ovarian cancers are germ cell; 85% epithelial
breast cancer
risk is 3X higher with first degree relative
BRCA 1 and 2 -> 30-50% of inherited cancers.
only 5-10% due to genetic abnormality.
pyoderma gangrenosum
neutrophilic dermatoses
associated with MM, RA, IBD
Rx: steroids, dapsone, TNF inhibitors, immunosuppressive.
Worse with trauma
Hepatitis tests interpretation
Anti-HAV IgM - looks for acute Hep A
HbsAg - acute infection and carrier states
Anti-HBc IgM - acute infection in “window”
Anti-HBc IgG - hepB infection in past. Doesn’t tell you if still infectious (required HBsAg).
Hepatitis C Ab - tells if infected (not chronic or resolved)
animal bites
staph, strep, gram negatives, anaerobes, Pasteurella
Rx: amp-sulbactam (IV), augentin (PO)
Tetanus >5y
chlamydia pna
fever, malaise, hoarseness, nonproductive cough
uri sxs 1-2 wks before pna onset.
Rx: macrolides, cipro.
legionella
hyponatremia, gi tract vomiting, diarrhea
what to check when a woman is pregnant
RPR
HIV
urine culture
bleomycin
IPF in up to 10%
doxorubicin
cardiac toxicity; CHF
cyclophasamide
hemorrhagic cystitis
vincristine
neuropathy
vomiting, myelosuppression
psoriatic arthritis
nail pitting
sausage digits
Wiskott Aldrich syndrome
X-linked
eczema, thrombocytopenia, recurrent infections
low IgM and high levels of IgA and IgE
Rx: BMT
prostate cancer staging
do a bone scan
TNM
vaccines in HIV
annual influenza
dual pneumococcal vaccination
Hep A
Tetaunus
travelers bloody diarrhea
Entamoeba histolytica - protozoan
(vibrio, norovirus, B. cerus and S. aureus produce watery, not bloody).
brain abscess
HA, fever, and focal neurological defects
reactions to antipsychotics
acute dystonic reaction - abnormal posture, twisting
Tardive dyskinesia - chronic expsosure
(NMS: diffuse rigidity, delta MS and high temps)
CMV retinitis
(usually a reactivation so CMV IgM may be negative)
pizza pie eye
HIV with CD4< 50 (AIDS-defining illness)
(fluffy exudates and scattered hemorrhages)
Rx: IV ganciclovir
Meningitis
Empiric rx: Vanc and CTX bc 5-10% of S. pneumoniae is resistant to CTX.
S. pneumo > N. meningitis
hematuria
Decide if upper or lower urinary tract
If see casts, it is GN and send for biopsy and check complement, lupus seroloy, ANCA, hep serology and anti-GMB testing
conjunctivitis
adenovirus
Parvovirus B19
Kids: slapped cheek
rash worse in sun
adults: arthritis
worry if: pregnant (risk of fetal loss), HIV (red cell aplasia) and those with chronic hemolysis (sickle cell, who can have aplastic crisis)
Roseola
HHV 6
Pna and meningitis in immunocompromised adults
crohns disease
early osteo from disease and steroid use
consider BMD.
IgA deficiency
recurrent sinoupulmonary and GI illnesses
Rx: abx as needed, avoid blood and plasma products (as anti-IgA antibodies can cause anaphylactic reactions).
chronic granulomatous disease
CGD disease, rare immunodeficiency
severe bacterial infections.
DiGeorge syndrome
complete - in infancy with hypocalcemia due to hypoparathyroidism, thymic hypoplasia, congenital heart defects, facial features.
normal anion gap
toluene ingestion, severe diarrhea, renal failure.
necrotizing fasciitis
rapid onset cellulitis, systemic infection (fever, hypotension, tachycardia, tachypnea), risk factors (like DM)
rheumatic MS
opening snap (heard after S2) followed by low pitched diastolic rumble. caused by Group A strep
sensitivity
of those with the disease, how many test positive.
specificity
of those without the disease, how many test negative
PPV
Of those with + tests, how many are true positives
NPV
of those with - tests, how many are true negatives
prevalence
# cases at a given time. the higher the number, the higher the PPV
grid
Test Result on Left
Disease state on Top
morphine iv to po
1 mg IV = 3 mg PO (SR) = 2 mg oxycodone.
dilaudid iv to po
1.5 mg IV = 7.5 po dilaudid
fentanyl
0.1 mg IV fentanyl = 1.5 IV dilaudid = 10 mg morphine
HCAHPS survey
hospital consumer assessment of healthcare providers and systems.
hospital inpatient experience survey tied to reimbursement and required by CMS.
Asks about: communication with doctors, cleanliness and nurse communication.
Pts surveyed after discharge.
RA scoring system
- # and site of involved joints
- RF or anti-CCP Ab positive
- Elevated ESR or CRP
- symptom duration
neurofibromatosis
10% will have sarcoma
fabry disease
lysosomal storage disorder with stroke and neuropathy
germ cell tumor of testes
pulmonary mets
increased estrogen production (gynecomastia)
acute angle-closure glaucoma
painful red eye with reduced visual acuity
associated with symphatomimetics like pseudoephedrine.
Rx: urgent reduction of elevated IOP
constipation
fiber and water
2nd line: polyethylene glycol.
kidney stones with crohns, bypass, small bowel resection.
calcium oxalate stones
mechanism: increased oxalate excretion into urine
bifid pulse
HCM
water-hammer pulse
chronic AR
thready pulse
acute AR
Giant R sided a waves
tricuspid stenosis
MEN1
multiple parathyroid adenomas
(serum calcium and PTH levels) p/w asx hypercalcemia or kidney stones, weakness, arthralgia.
PPP - parathydoi, pitutary, pancreas (gastrin producing)
multiple lipomas
CREST
cutaneous systemic sclerosis
calcinosis, Raynauds, esoph dysmotility, sclerodactyly and telangectasias.
Dx: anticentromere AB specific for limited cutaneous systemic sclerosis
noncaseating granulomas in lung
ddx: sarcoid, hypersensitivity pna, aspiration pna, infectious granulomatous disease, berrylium/aluminum expsire, rarely Wegeners (granulomatosis with polyangiitis)
chronic eosinophilic PNA
fever, night sweats, eosinophilia.
More common in women
50% have asthma
CXR: “negative” of pulmonary edema.
ABPA (allergic bronchopulmonary aspergillosis)
coughing brownish sputum and mucus plugging
segmental atelectasis on CXR
Type 4 RTA
due to bladder outlet obstruction or prostate hypertrophy.
also possible due to diabetic nephropathy.
Defect in renal acidication.
hyperkalemia due to hyporeninemic hypoaldo
Type 1 and 2 RTA
hypokalemia
cancer of unknown primary
70% adeno
do PET-CT
shock and “menses”
think TSS or disseminated gonococcal infection.
RA effusions
pleural fluid <30 mg/dL
low glucose, normal protein, normal WBC
statistics
disease prevalence increases –> # FP decreases and FN increases.
Prevalence increases –> PPV increases
Sensi and speci not affected by prevalence (qualities of test).
PPV and NPV affected by prevalence
drug induced lupus
procainamide arthritis/arthralgias prsenr anti-histone Ab in 95% rash less common renal involvement rare
clues that it is ZES
unusual location of ulcer - past the duodenal bulb
FH of ulcers
having diarrhea
refractory to medical rx
ulcer recurrence after acid reducing rx
frank complications (bleeding, obstruction, perforation)
thyroid drug interactions
levothyroxine poor absorption with iron and calcium.
also PPIs and sucralfate or cholestyramine
lower effects: SSRIs (sertraline) - monitor thyroid function.
levothyroxine can enhance warfarin effect.
“red flag: sxs of low back pain
cancer hx, IVDU, immunocompromised, osteoporosis
MRI if severe or progressive neuro deficits
CML
splenomegaly
theombosis
stage based on % blasts: chronic <10%, accelerated 10-19%, blast phase (>19%)
Rx: TKI (remission in 90%); imatinib, bosutinib, ponatinib
t9;22 - good prognosis
SLE in pregnancy
Increased risk of preeclampsia, IUGR and premature delivery.
Anti Ro/SSA antibodies cross placenta and can cause neonatal lupus (congenital heart block). Rx: hydroxychloroquine.
pregnancy increases sle flares as does HTN, APLA Ab,
dsDNA Ab associated with higher risk of renal involvement but not neonatal lupus.
PDE5 inhibitors
sildenafil, avanafil
hearing loss
2nd line rx for ED: alprostadil penile injections
anorexia nervosa
low phos, K, Na, Cl
sick euthyroid
hidradenitis suppurativa (HS)
sterile abscesses, scarring
Rx: topical and systemic antibiotics, intralesional steroids, anti-TNF agents or other biologics.
ARDS
low tidal volume ventilation
(<6 mL/kg) and Plateau <30
prone
paralyze
Naive B cells
first produce IgM
E. Coli O157
No abx (can make worse and cause HUS)
ischemic colitis
IVF and if severe, abx (flagyl)
surgery if evidence of gangrene
painless hematochezia (diverticular)
nasal foreign body
malodorous, sometimes bloody discharge.
hot tub folliculitis
psuedomonas folliculitis
48h to 5d
papules and pustules around hair follicles
No Rx, self limied
multinodular goiter and normal TSH/euthyroid
get thyroid us not RAI uptake to determine biopsy
high risk features for pulm nodule
large
noncalcified
in a smoker
nail in tennis shoe
pseudomonas (colonizes glue in shoe)
rx: cefepime if osteo present
pseudomonas coverage
cefepime, ceftaz
cipro
others: zosyn (pip/tazo), aztreonam, carbapenem (except ertapenem), aminoglycosides
BACTRIM DOES NOT COVER
addisons
adrenal insuff
rx: dexamethasone and ACTH stim test (also hydrocort ok but ALL STEROIDS EXCEPT DEXA cross react with ACTH stimulation test)
Clues: hypotension tanned male (excess ACTH) with sparse hair hypoNa and hyperK (low aldo) pre-renal
steroid equiv
4 dexa = 50-100 hydrocort
stress doses
treponema whipplei
whipple disease
present after a long time.
weight loss, diarrhea, arthopathies
skin hyperpigmentation in sun exposed areas
LAN
REMEBER: PAS STAIN with FOAMY MACROGHAPES
Rx: IV Ctx or PRN for 2 wks, then bactrim X 1yr
Q fever
Coxiella burnetii
flu-like illness, hepatitis, PNA
Dx; serology
Multiple Myeloma Clues
CRAB Calcium (elevated) Renal dysufnction Anemia Bone pain or lesions (lytic not blastic)
acute angle glaucoma
increased IOP due to obstruction of outflow from aqueous humor
visual loss
colorful halos
needs gonioscopy to diagnose with slit lamp
HIV-related thrombocytopenia
treat the HIV.
NPH peak effect
8 hours
meth use
associated with HIV
idiopathic intracranial hypotension
obese
visual changes
papilledema.
HA
can be caused by OCPs
urine sxs Rx
stress incotinence: kegel
overactive bladder: oxybutynin
BPH: doxazosin
A-a gradient
alveolar-arterial gradient
distinguishes hypoventolation, poor gas exchange and circulation issues.
acute rhinosinusitis indications for Rx
7-10 daus
high fever, purulent discahrge or facial pain
worsening after initial improvement.
autosomal dominant polycystic kidney disease
increase in cerebral aneurysms.
screen patients
hematuria, proteinura, kidney stones. HTN, UTIs
alport syndrome
sensorineural hearing loss
hematuria with renal cysts.
Nonanion grap acidosis
RTA or GI losses (diarrhea or laxative misuse
UAG = (Na +K) - Cl.
If neGUTive, then NH4 present which makes RTA unlikely.
leukemoid reaction
has expansion of the myeloid cell line
think CLL
persistently elevate lymmphocytes (mature but dysfunctional, no blasts)
HIV ppx
blood, semen, vaginal fluids
(possibly CSF, synovial, pleural, peritoneal, pericardial, amniotic)
NONINFECTOIUS: urine, sweat, stool, saliva, nasal secretions, tears, sputum and vomit.
If intact skin, no ppx needed
if nonintact or mucus membranes, need ppx
PPX: bictergravir + tenovifir + efavirenz
when to do ECG for epigastric pain
Healthy/young and no “alarm” sxs: check H. Pylori
Do EGD if anorexia, dysphagia, GIB, >60y or mass, anemia, weight loss, vomiting.
affects INR
bactrim, raises it!
antibiotics
cystic fibrosis
recurrent sinusitis, bronchitis, P. aerugonisa.
Dx: sweat Cl- testing and genetic testing.
hearing loss
Rinne test - checks for conductive hearing loss in affected ear (bone conduction louder than air conduction in affected ear).
Weber test - lateralized to ear with conductive hearing loss.
Conductive hearing loss = otosclerosis
AG toxicity/Menieres: sensory hearing loss.
hypothyroid sxs
dry skin
elevated cholesterol
constipation
muscle pain
iron interacts with levothyroxine absorption.
IgA deficiency
IgA 1st line of defense - lungs, GI tract, GU tract
1/300 (common)
frequent URIs, diarrhea, chronic bronchiectasis,
Asthma, alllergies, autoimmune
indications for intubation in astham
“normal” ABG - pt tiring (should see resp alkalosis early)
accessory muscles
leabing forward.
pregnant patient with AF and pulm edema
think MS or secundum ASD
Sjogrens associated with which lymphoma
NHL (20-40X higher risk)
look for fever, malaise, weight loss, LAN and new anemia
Most MALT - amenable to treatment.
perioral dermatitis
variant of rosacea
Rx:
Mild - metronidazole or calcienueuin inhibitors
Severe - doxycycline.
ethambutol toxicity
problems with visual acuity, especially color perceptions.
ethambutol toxicity
TB drug toxicity
problems with visual acuity, especially color perceptions.
INH, rifampin, pyrazinamide - hepatotoxic.
prior to starting biologics for RA…
check for TB
skin or blood
Liddle syndrome
hypokalemia and HTN
Autosomal dominant
lactoferrin in stool
iron binding protein
present in PMNs in pts with bacterial and IBD diarrhea
Shigella, Salmonella, EHEC (O157), Campylobacter, Yersinia
essential tremor
resting and action bilateral seldom interferes with function improved with alcohol familial
(Parkinsons. pill rolling at rest, improved with action and unilateral)
thyroid nodules
FNA if risk features: >1 cm in size and microcalfications.
TPO Ab
Hashimotos (can have goited)
Increased risk of thyroid cancer with Hashimotos
when to get a RAIU
if TSH is low
If just nodule, get US or do FNA
dermatomyositis
periorbital heliotrope rash proximal muscle weakness erythema and telangectasias of cuticle palmar arythema papules over joints (Gottron papules) >50y - think canccer (GU, GI, lung)
cluster headache Rx
young to middle aged males
unilateral, lacrimation, facial flushing, nasal discahrge
several times a day
Rx; O2 (15-20 min by face mask), short-acting triptans
Prevention: verapamil, valproic acid, lithium, topiramate
IgA nephropathy
hematuria after viral illness.
Recur for months/years intermittently
Serum completment normal. Microscopic hematuria can persistent.
Post-strep GN: 1-3 weeks following pharyngitis
complement low, ASO titer high
PNH
fatigue, jaundice, red urine
hemolysis and hemogliobinuria
Rhabdo
false positive on dipstick for blood
actually myoglobinuria.
symptomatic anemia in CKD
treat with EPO
Target Hb 10-11.5
osteoporosis
goal: reduce fx in femoral neck
Rx if T score
SSRIs and sex
delayed ejaculation, difficult orgasm
endocarditis ppx
prosthetic valves
previoue IE
CHD - unrepaired, repaired w/in 6 mo or repaired with residual defects
Transplant with regurgitation
None for GU or GI unless biopsy
cushings syndrome
dont do 1 mg DST if on OCP (can give FP due to change in cortisol binding globulin).
diagnostic cutoff of >1,8 mcg/dL
1st line tests: 24h urinary free cortisol, late-night salivary cortisol (not influenced by OCP)
anklylosing spondylitis
lumbar Xrays
Associated with HLA-27
reactive arthritis
ankylosing spondylitis
IBD
anterior uveitis
Behcets
HLA-B51
androgen secreting tumor of adrenals (secreting DHEAS)
increased testosterone higher estradiol (peripheral aromatization)
