All Questions 401-600 Flashcards
Type 1 RTA (distal)
H secretion. Low K. pH > 5.3. Rx: HCO2 + K. Hereditary, amphotericin, collagen vascular disease, cirrhosis, nephrocalcinosis.
Type 2 RTA (proximal)
Bicarb reabsorption. Low K. pH < 5.3. Rx: HCO3 + K + thiazide. Hereditary, sulfonamides, carbonic anhydrase inhibitors, Fanconi syndromes.
Type 4 RTA (distal)
Aldosterone defiency. High K. pH < 5.3. Rx: Fludrocortisone, K restriction, HCO3. Hyporeninemic with diabetes, HTN, or chronic interstitial nephritis; aldosterone resistance.
Hyperchloremic metabolic acidosis (no anion gap)?
Diarrhea, RTA, spironolactone/acetazolamide, TPN
Respiratory acidosis?
Foreign body, pneumothorax, flail chest, hypoventilation d/t sedatives/narcs, obstructive/restrictive pulmonary disease, pleural effusion.
Metabolic alkalosis?
NaCl responsive = vomiting, villous adenoma, contraction alkalosis, diuretics. Rx IVF + K. Not NaCl responsive = Conn’s & Cushing’s, adrenal hyperplasia, licorice, Bartter’s syndrome. Rx: KCl and spironolactone or acetazolimide (enhance HCO3 excretion)
Respiratory alkalosis?
Hyperventilation (anxiety/pain), CVA, head trauma, asthma, PE, CHF, pneumonia, pregnancy, hepatic insufficiency, ASA toxicity, thyrotoxicosis, mechanical ventilation. Rx = treat underlying cause.
Hyponatremia?
High osmolality = hyperglycemia or hypertonic infusion. Normal osmolality = Pseudohyponatremia, hyperlipidema, hyperproteinemia. Low osmolality = hypotonic hyponatremia.
Hypotonic hyponatremia?
Check FeNa: > or < 1%.
Hypotonic hyponatremia with FeNa >1%.
Hypervolemic = renal failure; Euvolemic = SIADH, hypothyroidism, renal failure, drugs; Hypovolemic = diuretics, RTA, adrenal insufficiency, ACE inhibitors.
Hypotonic hyponatremia with FeNa <1%.
Hypervolemia = nephrosis, CHF, cirrhosis; Euvolemic = polydipsia; Hypovolemic = vomiting, diarrhea, third spacing, dehydration.
Treatment fo hypotonic hyponatremia?
Hypervolemic = salt & water restrict; Euvolemic = salt & water restrict; Hypovolemic = normal saline.
Hyperkalemia signs and symptoms?
Intestinal colic, areflexia, weakness, peaked T wave, prolonged QRS and PR, low P.
Causes of hyperkalemia?
Cellular shifts: (tissue injury, acidosis, insulin deficiency, drugs including succinylcholine, digitalis, beta-agonists, arginine); Decreased excretion: renal insufficiency, drugs (spirlonolactone, triamterene, ACE-I, trimethoprim, NSAIDs), mineralocorticoid deficiency; Iatrogenic and spurious: hemolysis, fist clenching, leukocytosis, thrombocytosis.
Treatment of hyperkalemia?
C BIG K = Calcium gluconate (cardiac membrane stabilization); Bicarb, Insulin, Glucose; Kayexalate and loop diuretics (furosemide).
Hypokalemia symptoms?
muscle weakness, cramps, ileus, hyporeflexia, parasthesias, flaccid paralysis.
Causes of hypokalemia?
Transcellular redistribution (alkalosis, insulin excess, beta-adrenergic agonists, hypokalemic peridodic paralysis, pseudohypokalemia), potassium depletion
Linear calcification on x-ray of the knee?
Pseudogout. Positive birefringent crystals. Associated with hemachromatosis.
58yo F with long history of RA develops splenomegaly and leukopenia.
Felty’s syndrome.
meningococcemia
septic shock, pustules, organisms on gram stain
gonnococcemia
prositutes, urethritis, joint pain with effusion
typhoid fever
poor sanitation, prolonged fever, constipation, bradycardia, rose spots
staph sepsis
vesicles and bullae, IVDA
vibrio vulnificus
raw seafood, lesions on legs > arms, cirrhotics most susceptible
folliculitis
hot tubs: pseudomonas; swimmer’s itch: schistosomes
streptococcal infection
scarlet fever: sandpaper texture of rash, cellulitis, palms peeling
staph
Toxic shock = palmar desquamation
rocky mountain spotted fever
ascending purpuritic rash on palms and soles
HIV
maculopapular rash, viral syndrome
Diagnosis of amyloidosis?
Biopsy of abdominal fat pat or rectal biopsy.
ATPW hypocalcemia?
Serum Ca and Mg. Serum PTH, 25 and 1,25-D, phosphate, Cl, creatinine, amylase & lipase. Obtain EKG to look for prolonged QT.
Causes of hypocalcemia?
HIPOCAL: Hypo-PTH, Infection, Pancreatitis, Overload (rapid IV volume expansion), Chronic renal failure, Absorption abnormality, Loop diuretics.
Causes of hypercalcemia?
MISHAP-F: Meds/malignancy, Intox (vit D or A) or Immobilization, Sarcoidosis, Hyper-PTH or Hyperthyroid, Addison’s or milk-Alkali, Paget’s or Pheochromctoma. Familial hypocalciuric hypercalcemia (benign autosomal dominant condition)
Symptoms of hypercalcemia?
abdominal moan, psychiatric groan, kidney stone, and urination zone.
Most common cause of hypercalcemia?
malignancy or hyperparathyroidism.
Sideffect of lithium?
Hyperparathyroidism: alters setpoint for PTH secretion.
Thiazide diuretic sideffect?
hypercalcemia d/t increased renal reabsorption.
PTH-related peptide secreting tumors?
breast, lung, renal cell
Why does sarcoid and other granulomatous disease cause hypercalcemia?
increased conversion of 25-hydroxyvitamin D to 1,25 in macrophages. Occurs in TB, berylliosis, and lymphoma.
Most common hyperparathyroidism?
Solitary adenoma > 80% of cases. Four-gland hyperplasia 10%, multiple adenomas 5%, MENI or II.
50M dilated cardiomyopathy after travel to South America
Chagas - CM–> SOB, swelling + weight gain, trypanosome cruzii, reflux + megacolon
25M midsystolic murmur, louder with Valsalva
HOCM -
65M drug for NYHA class 2 systolic dysfunction
ACE -
55F AA restrictive cardiomyopathy, arrhythmia, wheezing
Sarcoidosis -
25M CP on recumbency, diffuse 2 mm ST elevations on EKG
Pericarditis - Most commonly viral
58M hyperlipidemia, diffuse weakness
Statin induced myopathy - increased CPK, LDH, aldolase, maybe AST and ALT
70 M orthopnea, PND, BP 160/90, HR 110, crackles, sinus tach, LVH, normal EF, what drugs to give?
diuretic, B blocker, Ca blocker - stiff LV with normal EF is diastolic dysfunction, from long standing HTN
72F CHF, EF 25%, blurry yellow vision
dig toxicity -
45M a fib, hospitalized, sudden SOB, afebrile, HR 110, RR 28, BP 95/60, new R axis deviation and RBBB
PE - Most common EKG with PE is sinus tach, classic is R axis deviation, S1 Q3 T3
25M hepatitis C, develops CHF, what hx?
IV drug use, HIV -
30W 34 weeks pregnant, tearing sensation in chest radiates to back
aortic dissection - secondary to HTN
58M hx of v tach, on meds, develops SOB, fatigue, and cold intolerance
amiodorone - check PFTs, TFTs, and LFTs for patients on amiodorone
25M intermittent palpitations, baseline ECG his wide QRS and short PR
WPW - delta wave, early contraction of ventricle
45F palpitations, HR 190, narrow QRS, no P waves
SVT -
80M chest pain, 3/6 harsh murmur at RUSB, diagnosis and other sx?
Aortic stenosis - assoc with angina (35-50%), syncope, and HF, delayed carotid upstroke, soft S2, S4, may reflect to mitral area- Gallavardin’s phenom
36 IV drugs LLSB systolic murmur, louder with inspiration, what wave most prominent in JVP
v wave - tricuspid regurgitation
58F decrescendo diastolic murmur LSB, uvula pulsations, wide pulse pressure
aortic insufficiency -
70M ST elevation in 2,3,avf, what additional ECG analysis?
R sided EKG for RV infarcts -
35F Raynaud’s, GERD, increasing DOE
pulm HTN 2ndary to CREST -
55F diabetes, arthritis, cirrhosis, arrhythmia, runs in family
hemochromatosis -
30 fatigue, weight gain, cold intolerance
hypothyroid -
40F obesity, HTN, new hyperglycemia
metabolic syndrome -
60F hypercalcemia, hyperphosphatemia, health food junkie
vitamin D toxicity -
50 HTN, tachycardia, flushing
pheochromocytoma - HTN may be intermittent
65M diarrhea, weight loss, a fib
hyperthyroid -
60M fasting blood sugar 130 on 2 different ocassions
diabetes - fbs>126 two times
60M galactorrhea
prolactinoma -
50M thyroid ca and neurofibromas
MEN 2b - also includes pheo, MEN2a= thyroid, parathyroid, pheo, MEN1= parathyroid, pancreatic, pituitary
75 hypercalcemia, long tobacco hx
squamous cell lung ca -
18F hypoglycemia, mom has DM2
factitious -
40F proptosis and palpitations
Graves -
30F has 8 month old, increased fatigue
postpartum thyroiditis -
50F hypokalemia, HTN
Conns - aka primary hyperaldo
25F hirsutism, amenorrhea
polycystic ovarian dz -
55M bilat visual field loss, headache
pituitary tumor -
60M meningococcemia, severe hypotension and hyperkalemia
Waterhouse Friderichsen - due to meningococcemia, hemorrhage into adrenal glands
35M wheezing while working on assembly line
occupational asthma -
65M heavy tobacco, sputum each morning for 3 months each year
chronic bronchitis -
55M, thin smokes 1ppd, pursed lip breathing
emphysema -
45M large bullae at bases on CXR, fam hx of lung dz
alpha 1 antitrypsin deficiency -
30F tender nodules on shins, intermittent wheezing, arthralgias
sarcoidosis - see cardio 4
66M sinus tenderness, 2+ blood on UA, caviation on CXR
Wegeners - positive c-ANCA
50 severe wheezing, peripheral eosinophilia
Churg-Strauss - aka allergic asthma or angiitis
30M nonsmoker, hemoptysis, hematuria
Goodpastures -
45F ulnar deviation, MCP stiffness, SOB, pleural effusion and lung nodules
rheumatoid lung dz -
35 IVDA cannonball lesions peripherally on cxr
septic pulmonary emboli -
65 nephritic syndrome, acute SOB, tachypnea, tachycardia, normal cxr
PE - nephritic syndrome –> decreased protein c and s
35F comm acquired pneumonia, bilateral infiltrates, Na 130, transaminases slightly high, diarrhea
Legionella -
30F photosensitivity, alopecia, pleuritic chest pain
SLE -
50M obese bilateral 2+ pitting edema, wife claims he is “lazy”
cor pulmonale due to OSA - other serious OSA complications- arrhythmias, pulmonary HTN
25F progressive chest pain and SOB over months
primary pulmonary HTN -
65M diffuse basilar crackles despite diuresis, interstitial infiltrates on baseline cxr
interstitial pulmonary fibrosis -
60M methotrexate therapy for psoriasis, progressive sob
pulmonary fibrosis -
35M homeless, pleural effusion
TB -
55M recent CABG, L sided pleural effusion on cxr one month post-op
Dressler’s Syndrome - aka post MI syndrome, 1-12 weeks after infarction, autoimmune, pericarditis and possible effusion
25M HIV, chest pain, pneumothorax
PCP -
23F photosensitivity, arthralgias, pleuritic chest pain
SLE -
50M dry mouth, arthralgias, peripheral neuropathy
Sjogrens -
60F one hour of morning stiffness in bilateral wrists, effusion on CXR
rheumatoid arthritis -
70M alcohol abuse, tender warm left ankle, no fevers
gout -
20 student R knee swelling and warmth
gonorrhea -
50M new heart murmur, red warm L elbow
septic emboli -
73F swollen DIP joints for months
OA -
45M sausage digits, scaly skin plaques
psoriasis -
25 eye irritation, ankle swelling, dysuria
Reiters - conjunctivitis, arthritis, urethritis
50 oral and genital ulcers, arthralgias
Behcets - a type of vasculitic syndrome
35F purpuric lesions on shins, renal insufficiency
HSP or cryoglobulinemia - cryo- many pts have HCV in the immune complexes
40F reflux, digits get painful in cold, sob
scleroderma/ CREST -
50F difficulty brushing hair, rash around eyes
dermatomyositis -
50F dermatomyositis, what further eval?
malignancy -
60F lupus, pain out of proportion to abdominal exam
mesenteric ischemia - due to vasculitis
25F 3 pregnancies with 3 miscarriages
antiphospholipid ab syndrome - coagulation abnormalities
30F depression, multiple tender areas
fibromyalgia -
35F angioedema, hx in father
C1 esterase deficiency -
50M low back pain, sacroiliitis on pxr
ankylosing spondylitis -
70M h/o iron overload, joint pains in wrists
pseudogout -
65F painless jaundice
pancreatic head tumor -
45F pruritis, xanthelasmas, AP 8x normal
primary billiary cirrhosis -
50M ulcerative colitis, newly elevated AP
primary sclerosing cholangitis -
40M IVDA purpuric lesions on shins, jaundice, arthralgias
cryoglobulinemia - assoc with Hep C
60M tan, arrhythmia, mild elevation of liver enzymes, blood glucose 200, arthralgias
hemochromatosis -
25F new liver dz, no alcohol, fam hx
autoimmune hepatitis -
25M homosexual, new jaundice, dark urine, mild RUQ discomfort, vaccinated for Hep B with proven Ab
Hep A -
18M elevated liver enzymes, new gait dysfunction
Wilsons -
35M homosexual, severe odynophagia, white plaques in oral cavity
esophageal candidiasis, thrush -
70M LLQ cramping pain, similar episodes in past, heme positive
diverticulitis -
70 pencil thin stools
rectal mass around anus -
45F Roux-en-Y for weight loss, greasy malodorous stools
malabsorption - aka dumping
50M copious diarrhea, skin flushing
carcinoid -
65F 30# weight loss in past year, iron deficiency anemia, heme pos stools, no abd pain
colorectal cancer -
68M CAD, PVOD, post prandial pain 30 minutes after eating
mesenteric ischemia -
55M rheumatoid arthritis, gnawing pain radiating to back, improves with eating
PUD - duodenal ulcers usually feel better with food
35 alcoholic severe epigastric pain after recent binge episode
acute pancreatitis -
18 3 days of abd pain, shifted from umbilicus to RLQ
appendicitis -
18F LLQ pain, vaginal discharge, sexually active
PID -
80M h/o nocturia, suprapubic tenderness, rising creatinine, hydronephrosis
obstruction - eg. BPH, prostate ca
30F fevers to 102, renal failure, thrombocytopenia, schistocytes
DIC - may see mental status changes
65M CAD, PVOD, started on lisinopril, Cr from 1 to 4.5
renal artery stenosis -
65F unstable angina, rising Cr, microscopic hematuria, 2 blue toes
atheroemboli - see decreased complement levels
70M LE edema to waist, lost weight over 18 months, intermittent BRBPR
membranous glomerulopathy - assoc with carcinoma, also with infection, autoimmune dz or drugs, most common primary nephrotic syndrome in adults
16F recent URI, Cr 3.0 three weeks later, red cells on UA
poststrep GN -
67M CAD, 4 drugs to get bp control, what will renal US show?
renal artery stenosis -
55M DM, retinopathy, nephropathy, neuropathy, Cr 1.7, what antihypertensive should he get?
ACE I -
60M unasyn for pneumonia, 10 days later pyuria and peripheral eosinophilia, Cr from 1.1 to 2.5
Allergic Interstitial Nephritis -
60M s/p MVA, hypernatremia, UA specific gravity 1.002
diabetes insipidus -
55 diabetic, non-anion gap hyperchloremic metabolic acidosis and hyperK
Type 4 renal tubular acidosis - hyporeninemic hypoaldo
25F fever to 102, R flank pain, pyuria
pyelonephritis -
55M primary hyperparathyroidism, left flank pain, hematuria
nephrolithiasis -
17M abdominal pain, arthralgias, hematuria, elevated serum IgA
HSP -
65M pancytopenia, back pain, rising Cr, elevated protein/albumin ratio
multiple myeloma -
55F neuropathy, arthralgias, renal failure, pANCA positive
PAN -
25 microscopic hematuria becomes macroscopic after flu like illness
IgA nephropathy - aka Bergers
35F 3rd trimester, hyperreflexia, edema, proteinuria
pre-eclampsia -
70M 3 days IV piperacillin and gent for pneumonia, oral cipro, Cr at discharge was 1.2, Now Cr 2.5 one wk later, BUN unchanged
Aminoglycoside toxicity -
15 diarrhea, renal failure, after eating at Jack in the Box
HUS - 0:157 H:7 E Coli
35 resident of UP, epigastric discomfort and copious diarrhea, neg fecal leukocytes
Giardia - treat with flagyl, stool ova and parasites, from well water, kids in day care
50 alcoholic fatigue, gradual increase sob, fevers, pleural fluid that doesn’t layer on decubitus films
aspiration pneumonia - think anaerobes, treat by drainage, empyema doesn’t layer
18 new hematuria and rising Cr 2 weeks after severe URI
post strep GN - low complement
21 LUQ discomfort, sore throat, fatigue, post cervical LAN
mono -
parasitic cause of vit B12 deficiency
fish tapeworm - Diphyllobothrium
2 infections by Ixodes tick vector
Lyme dz, Babesiosis - treat Lyme with doxy, treat Babesiosis with clinda
40M severe R flank pain, 100+RBC/HPF, ph9.0, what org?
Proteus - struvite stone, treat with quinolone
35M HIV fever, chills, rigors, LLL infiltrate on CXR
strep pneumo -
55F HIV CD4 count 100, sudden onset sob, pneumothorax
PCP - treat with IV bactrim and steroids
65M colon ca, fevers and chills, GPC in chains
strep bovis - gut gram positive bug
20M interstitial infiltrates, fever, nonproductive cough
mycoplasma - treat with azithromycin
40M exposure to prostitutes, maculopapular skin rash, sore on penis 2 months earlier
syphillis -
parasitic cause of portal hypertension and bladder ca
schistosomiasis -
35M sepsis, widespread purpura, DIC, adrenal insufficiency
meningococcemia - Waterhouse Friedrickson
40M immunocompromised, respiratory complaints and skin lesions, broad based budding yeast in sputum
blasto -
65F s/p BMT, new hemoptysis, cavitary lesion with fungus ball on cxr
aspergillus -
60M 2 wks on Abx, watery diarrhea
C diff -
45M duodenal ulcer bx
H pylori -
55M homeless, weight loss, fatigue, sterile pyuria on UA persists despite Bactrim and Augmentin
tb -
35M rash, arthralgias, Cape Cod
Lyme dz -
Newly diagnosed diabetes, hepatomegaly, and arthropathy
Hemochromatosis
Worsening postprandial pain that leads to food avoidance
Abdominal angina (atherosclerosis of the mesenteric arteries)
low hgb, high bili, low haptoglobin, venus thrombosis
Paroxysmal nocturnal hemoglobinuria
hypotension, JVD, muffled heart sounds (also pulsus paradoxus)
Cardiac tamponade
action tremor, suppressed at rest, abssence of additional neurologic signs
Essential tremor
pneumonia with loose stools, hyponatremia, and mildly elevated LFTs
Legionella pneumoniae
diarrhea transmitted by seafood (bloody)
Vibrio parahaemolyticus
diarrhea transmitted by seafood (watery)
Vibrio cholerae
most frequent cause of hypercalcemia in pts w/ non-metastatic CA
PTHrP (parathyroid relate protein)
most frequent cause of hypercalcemia in pts w/ metastatic CA to bone
Cytokines (e.g. IL1, TNF)
hypertension, palpable bilateral abdominal masses, microhematuria, concern for berry aneurysm
ADPKD (autosomal dominant polycystic kidney disease)
abnormal gait, incontinence, dementia
NPH (normal pressure hydrocephalus)
flushing, valvular heart disease, diarrhea, elevated 5-HIAA (related to niacin synth)
Carcinoid syndrome
altered mental status, temperature > 40, inadequate/failure of thermoregulation
Exertional heat stroke
drug of choice for dementia in the elderly
Haloperidol (low dose)
drug of choice for agitation in the young
Lorazepam
bridges the exposure and the outcome of interest in case-control studies
Confounders
thrombophlebitis of atypical sites (e.g. arm, chest) caused by an occult tumor
Migratory thrombophlebitis (aka Trousseau’s syndrome)
fluid resuscitation followed by loop diuretics
Treatment of hypercalcemia
stones, bones, abdominal groans, and psychiatric overtones
Sx of hypercalcemia
presence of anti- Ro (SSA) and/or La (SSB) antibodies
Sjogren syndrome
absent pain and temp sensation in a cape distribution
Syringomyelia
loose, foul smelling stools within the context of antibiotic use
C.diff colitis
gynecomastia, spider angiomata, abdominal distension, edema
Cirrhosis
B-lymphocyte derived chronic leukemia, postive TRAP stain, treated by cladribine, dry bone marrow taps
Hairy cell leukemia
