Boards Part 2

Question 1

Pacemaker for

Answer 1

• Third degree AV block or equivalent
(e.g., first degree AV block with LBBB and RBBB)
• Heart rate 3 seconds
• Sick sinus syndrome with symptoms (e.g., syncope)

Question 2

Most common cause of tachycardia

Answer 2

re-entry

Question 3

types of supraventricular tachycardia

Answer 3

• Sinus tachycardia
• Paroxysmal supraventricular tachycardia (PSVT)
• Sick sinus syndrome (SSS)
• Wolff-Parkinson-White/Lown-Ganong-Levine (WWW/LGL)
• Atrial flutter
• Atrial fibrillation

Question 4

sinus tachycardia cause and tx

Answer 4

irritable SA node or atrial focus

Treat primary disorder (rehydrate, o2)

Question 5

PSVT tx

Answer 5

Vagal manuevers (80%)
IV Adenosine or overdrive pacing

BB, CCB, Dig are preventitive

Question 6

Short PR interval (<.12 sec)
Congenital accessory AV pathway

Tx for it

Answer 6

Wolff-Parkinson Whjite

Radiofrequency ablation is TOC

Question 7

Sawtooth pattern seen in mitral stenosis, pericarditis and ARF

Answer 7

Atrial flutter

Question 8

Irregularly irregluar rhythm

tx

Answer 8

Atrial fib

Rate control with BB or CCB
CVA proph with warfarin if chronic

Question 9

> 3 cons PVCs

Answer 9

Vent Tachycardia

can be paired, multifocal or frequent

can lead to v fib

Question 10

v tach etiology

Answer 10

• Usually due to ischemic heart disease and/or an acute myocardial infarction
• Prolonged QT syndrome
• Familial

Question 11

* Typically presternal chest pressure radiating to the jaw and down the ulnar aspect of the 
forearm
* Typically EXERTIONAL
* Stress related
* Cold temperatures 
* Following a heavy meal

Tx too

Answer 11

Stable Angina

• Relieved with rest, O2, nitroglycerin

Question 12

medical tx for CAD

Answer 12

• Treat risk factors
• (e.g., treat HBP, elevated LDL, DM, stop smoking)
• ASA 81 mg daily
• Sublingual nitroglycerin
• Beta blockers
• Calcium channel blockers - verapamil
• Long-acting nitrates transdermal nitroglycerin patches

Question 13

interventional tx for CAD

Answer 13

• PTCA/stent
• Atherectomy
• CABG

Question 14

• Progressively diminished exercise tolerance
• Increasing frequency and severity
• Relatively recent onset
  (unstable angina with elevated biomarkers)

tx

Answer 14

Unstable Crescendo
Non-ST elevation MI

Immediate Hospitalization
O2, nitrates, BB, Anti-thrombotic tx

Question 15

• Usually abrupt, severe and persistent
• EKG
• Biomarkers (CPK-MB; troponin-I; SGOT; LDH)

Tx

Answer 15

MI

• 9-1-1
• O2, nitroglycerin, and ASA to limit infarct size
• Early intervention/reperfusion
• tPA (tissue plasminogen activator)
• PTCA/stent, etc.
• Beta blockers: Acute and chronic benefit
• ACE inhibitors/statins: Chronic benefit/plaque stabilization

Question 16

• Usually younger patient; at rest
• Usually few risk factors
• Occasional history of additional vasospastic disorders (e.g., migraine; Raynaud’s phenomenon)
• Focal spasm of an epicardial artery with ST elevation or spasm on coronary angiography

tx

Answer 16

Prinzmetal’s Angina

• Nitroglycerin
• Calcium channel blockers

Question 17

• Asymptomatic MI
• May present with post MI complications (e.g., CHF)
• Frequent in diabetics
• “Autonomic dysfunction” prevents chest pain sensation during M

Answer 17

Silent MI

Question 18

• Similar to angina, but not EXERTIONAL (It’s POSITIONAL)
• Often at night (supine position)
  – Heartburn
  – Pyrosis
  – Dysphagia
• Often relieved with nitroglycerin and antacids
• Often midepigastric tenderness on Px

Answer 18

GERD

Question 19

Causes of Chest Wall Pain

Answer 19

• Usually some form of trauma/strain
  – ? Severe coughing paroxysm
  – ? Heavy lifting, etc.
• Often pleuritic

Question 20

• Pain may radiate to left shoulder
• Often relieved with sitting up and leaning forward
• Physical exam:
  – ? Pericardial friction rub
  – ? Pulses paradoxus (decrease in BP with inspiration)

Answer 20

Pericarditis

Question 21

• Severe, abrupt, radiating to the back
• Physical exam:
  – ? Loss of lower extremity pulses
  – Possible murmur of AI

Answer 21

Chest Pain Secondary to Aortic Dissection

Question 22

Chest Pain

• Variable and usually atypical pattern
• Often associated with a history of anxiety and depression
• Often precipitated by situational factors
• Diagnosis by exclusion

Answer 22

Psychophysiological Chest Pain

Question 23

HTN goals for blacks w/ and w/out organ damage

Answer 23

135/85 if none

130/80 is evidence

Question 24

HTN definitions

Answer 24

• Normal BP 120.

* Isolated systolic hypertension: Systolic BP >139, normal diastolic BP

Question 25

aldoseterone does what

Answer 25

Causes Renal Na retention to increase blood volume

Question 26

Hypertension with not direct cause ``` Risk factors – Genetics – Sodium consumption – Obesity – Alcohol abuse – Type 2 diabetes – Type “A” personality ```

Answer 26

Essential HTN

Question 27

HTN worsened with sodium consumption types and treatment

Answer 27

Salt Sensitive – Low renin essential hypertension • ? Excess production of unknown mineralocorticoid which does not waste potassium • Dietary sodium restriction helpful • Diuretics helpful – Normal / high renin (nonmodulating) essential hypertension • Possible renal defect (inadequate sodium excretion) • 25-30% of essential hypertension • ACE inhibitors helpful – High renin essential hypertension • Probably due to increased catecholamine activity • Beta blockers helpful • Renin blockers helpful

Question 28

2ndry HTN causes

Answer 28

``` • Renal hypertension – Renovascular hypertension – Primary renal disease • Endocrine hypertension – Aldosteronism (usually primary aldosteronism) – Cushing’s disease – Pheochromocytoma – Contraceptive-induced (estrogen stimulates hepatic angiotensinogen production) – Hyper- or hypothyroidism – Hyperparathyroidism • Aortic coarctation • Obstructive sleep apnea ```

Question 29

HTN with hypokalemia tx

Answer 29

Spironolactone

Question 30

– Rapidly escalating hypertension – Borderline elevated / rising creatinine – Abrupt creatinine rise following ACE inhibitors – History of diabetes, dyslipidemia, smoking, ASCVD dx and tx

Answer 30

Renovascular HTN • Diagnosis – Renal artery ultrasonography; MRA; spiral CT scan – Renal artery angiography +/- renal vein renins • Treatment – Ideally, stenting

Question 31

– Hypokalemia • ACTH; renal artery ultrasonography – Plasma aldosterone concentration and plasma renin activity levels • PAC > 20 and PAC/PRA > 30 highly suggestive – Imaging: CT/MRI

Answer 31

Hyperaldosteronism

Question 32

– Symptoms usually include a severe headache, vomiting, visual disturbances, CNS findings (paresis, convulsions, lethargy, coma) cardiac decompensation and oliguria – Diastolic BP generally >130 mm of mercury, papilledema, retinal hemorrhages

Answer 32

Malignant HTN furosemide IV 40mg and either nitroprusside 0.25mcg/kg/mm or nitroglycerin 5mcg/min Caustion do not lower diastolic BP to

Question 33

– No evidence of end organ damage (e.g., normal CMP or chronic abnormalities, normal UA, troponin I, no acute EKG changes, symmetrical pulses, no papilledema or retinal hemorrhages:

Answer 33

Severe HTN Clonidine 0.1 every 2-3h

Question 34

– Pregnancy with hypertension, proteinuria and hyperreflexia; may present with convulsions tx

Answer 34

Eclampsia mg sulfate 4gIV for convulsions Hydralazine 5-10 mg IV for HTN (to d < 95) Consider urgent delivery

Question 35

HR that compromise perfusion

Answer 35

Generally HR 140 compromises perfusion due to inadequate time for sufficient preload

Question 36

Physiologic / Cardiac Compensation for CHF

Answer 36

Renal: – Increased sodium and water retention with renin angiotensin system activation to increase blood pressure for perfusion and to augment preload Autonomic nervous system: – Increased heart rate to increase cardiac output Cardiac: – Muscular hypertrophy – Maladaptive cellular remodeling / fibrosis

Question 37

systolic CHF and Diastolic CHF

Answer 37

Systolic CHF – Primarily contractility and/or afterload problem (e.g., acute hypoxemia) Diastolic CHF – Primarily preload problem (e.g., “stiff” fibrotic ventricle) NOT to be confused with right heart failure and left heart failure

Question 38

CHF symptoms

Answer 38

– Primarily dyspnea on exertion – Orthopnea / paroxysmal nocturnal dyspnea Increased pulmonary capillary pressure due to fluid shift from the extremities when supine; possible impaired apical pulmonary arteriolar oxygenation due to pulmonary effusion – Dependent edema – Cheyne-Stokes’ respirations Primarily CNS symptom likely

Question 39

CHF physical findings

Answer 39

– Bibasilar inspiratory rales – Cardiomegaly / laterally displaced PMI; S3gallop – Dependent edema / pleural effusions / ascites – Hepatomegaly / positive HJR / JVP >8 cm (major criteria: >16 cm) / jaundice

Question 40

Lab for CHF

Answer 40

Blood work: CBC, CMP, TSH, UA, NT pro-BNP (byproduct of stretching myocytes)

Question 41

tx for CHF

Answer 41

``` Diuretics Sodium restriction BB ACEi Digoxin Vasodilators ```

Question 42

RV failure usually due to increased RV afterload / pulmonary vascular resistance – Usually due to COPD and increased pulmonary capillary pressure from hyperinflation – Interstitial pulmonary disease / fibrosis – Pulmonary vasoconstriction (e.g., hypoxemia; altitude sickness) SOB, light head, palpitations, Chest pain, blue skin

Answer 42

Cor Pulmonale

Question 43

50% mortality in 60 minutes from acute pulmonary embolism Usually due to acute pulmonary embolism – Possible high altitude pulmonary edema (HAPE); acute pulmonary inhalation injury, etc. Physical findings: – Right heart failure signs; S4 gallop tx

Answer 43

Acute cor pulmonale O2 diuretics, treat underlying cause

Question 44

Pulmonary Hypertension Treatment

Answer 44

Treat underlying cause Oxygen Vasodilators – Calcium channel blockers; ? sildenafil (Viagra)

Question 45

Classifications of cardiomyopathies

Answer 45

* Dilated * Hypertrophic * Restrictive

Question 46

* Signs and symptoms of CHF * Usually die within three years from onset of symptoms * Rule out ischemic heart disease; work-up like CHF

Answer 46

Dilated Cardiomyopathy

Question 47

* Second most common cause of CHF after ischemic heart disease * Reversible if alcohol consumption is discontinued before advanced disease * “Holiday heart syndrome” * Arrhythmias (usually AF) after a binge

Answer 47

Alcoholic Cardiomyopathy

Question 48

* First symptom may be sudden death with strenuous activity (esp in kids and young adults) * May be slowly progressive and present as atrial fibrillation or CHF in older patients * Physical findings Include late systolic ejection murmur along the LLSB radiating to the apex * EKG findings LVH and often diffuse broad Q waves from increased muscle mass opposite the electrode; possible LAE; possible atrial fibrillation * Echocardiogram: Diagnostic Septal hypertrophy, left ventricular hypertrophy and systolic prolapse of the anterior mitral valve leaflet and Tx

Answer 48

Hypertrophic Cardiomyopathy BB or diltiazim (opposite of CHF)

Question 49

* Diastolic CHF due to infiltrative disorders such as amyloidosis and hemachromatosis; idiopathic; familial endomyocardial fibrosis * Signs and symptoms of CHF * Treatment * Treat diastolic CHF; arrhythmias

Answer 49

Restrictive CM

Question 50

* Cardiac muscle inflammation * Usually infection (e.g. viral, bacterial, lyme carditis; Chagas’ disease * Rarely autoimmune (giant cell myocarditis) * Symptoms and signs of CHF * Treatment * Treat systolic CHF, arrhythmias, underlying disorder

Answer 50

Myocarditis

Question 51

from multiple etiologies (e.g., infection, acute MI, uremia, trauma / Dressler’s syndrome, metastatic disease, drugs like INH) * Symptoms * Usually chest pain referred to the back with dyspnea * Usually relieved with sitting and leaning forward * Physical findings * Pericardial friction rub; pulses paradoxus * EKG findings: Often diminished QRS amplitude and Tx

Answer 51

Pericarditis Treat underlying cause Pericardiocentesis: pericardial window

Question 52

``` Opening snap rumpble augmented with exercise right CHF findings EKG: LAE Can have A fib ```

Answer 52

Mitral stenosis

Question 53

• Increased left atrial pressure with symptoms of pulmonary hypertension and cor pulmonale • Regurgitated LV preload and symptoms of reduced cardiac output (e.g., dyspnea on exertion) – Physical findings • S3and occasional S4gallop • Holosystolic murmur at the apex radiating to the left axilla – EKG findings: LAE; +/- RAE; +/- LVH – Echocardiogram: Diagnostic

Answer 53

Mitral regurgitation

Question 54

``` – Symptoms: • Usually none • Occasional PSVT due to LA “stretch” – Physical findings: • Midsystolic “click–murmur” augmented with isometrics and valsalva (reduced LV preload and leaflet angle with increased papillary muscle “slack”) – EKG: Usually normal – Echocardiogram: Diagnostic ```

Answer 54

Mitral valve prolapse * SBE prophylaxis if MR present * Beta blockers for PSVT

Question 55

Angina Exertional Syncope (hypotension from vasodilation and exercising muscles with compromised cardiac output) Pulses parvus et tardus Reduced S1-S2 interval and possible paradoxical splitting of S2 S4 Systolic ejection murmur

Answer 55

Aortic stenosis

Question 56

often asymptomatic • “Water hammer” pulse with widened pulse pressure (e.g., 140/60); “Quinke’s pulse” with gentle pressure on nail bed; markedly augmented PMI with lateral displacement (e.g., head bobbing/”bed spring” pulse) • Diastolic decrescendo murmur EKG: LVH

Answer 56

Aortic Regurgitation

Question 57

SBE prophylaxis indications

Answer 57

– Previous history of SBE; prosthetic heart valves; prosthetic material used for cardiac valve repair; unrepaired cyanotic congenital heart disease; repaired congenital heart disease with residual defects at the site of a prosthetic device; cardiac valvular disease in a transplanted heart • Treatment prior to dental procedures: – Amoxicillin 2 gm orally one hour before procedure – Clarithromycin 500 mg one hour before procedure if penicillin allergic • Treatment prior to procedures on infected skin or musculoskeletal tissue – Infections often polymicrobial but only staph and beta hemolytic strep bacteremia are likely to cause endocarditis – Treat as above pending culture results and consider the addition of TMP SMX DS if suspicious of MRSA

Question 58

Categories of hyperlipoproteinemia

Answer 58

• Type II-a hyperlipoproteinemia – Elevated cholesterol; normal triglycerides • Type II-b hyperlipoproteinemia – Elevated cholesterol; elevated triglycerides • Usually seen with type 2 diabetes

Question 59

Acquired dyslipidemia

Answer 59

``` obesity Type 2 DM Hypothyroidism Liver Disease Renal Disease ```

Question 60

Treatment goals for risk factors

Answer 60

0 – 2 <70

Question 61

Risk factors for LDL elevation

Answer 61

``` – Cigarette smoking – Hypertension (BP 140/90 mmHg or on antihypertensive medication) – Low HDL cholesterol [<65 years – Age (men 45 years; women 55 years) – Lifestyle risk factors • Obesity (BMI 30 kg/m2) • Physical inactivity • Atherogenic diet – Emerging risk factors • Lipoprotein(a) • Homocysteine • Prothrombotic factors • Proinflammatory factors • Impaired fasting glucose • Subclinical atherogenesis ```

Question 62

tx for elevated cholesterol

Answer 62

``` • Nonpharmacologic treatment – Smoking cessation – increases HDL – Weight control – decreases LDL – Exercise – increases HDL – Treatment of underlying problems such as diabetes and hypothyroidism – Dietary treatment • Low saturated fat • No dietary sweets ```

Question 63

combo therapy for elevated cholesterol beware of what combo and why

Answer 63

Beware of statin/fibrate combination (myositis; rhabdomyolysis; elevated CPK)

Question 64

meds for cholesterol and what they target

Answer 64

LDL only - Statin LDL, HDL, TG - Niacin TG only - Fibric acid derivatives LDL - Ezetimibe

Question 65

Big QRS | Compensatory pause

Answer 65

PVC

Question 66

PVC falls on what wave cause vent tachycardia

Answer 66

T wave

Question 67

torsade de pointes (Vent fib with twisting axis) cause

Answer 67

Congential QT syndrome

Question 68

Long PR consistently prolonged

Answer 68

1 deg AV block

Question 69

PR interval consistently increases in successive cycles | lack of QRS

Answer 69

Wenkenbach 2 AV block

Question 70

2:1 P to QRS

Answer 70

Mobitz 2 AV block

Question 71

3:1 P to QRS

Answer 71

Mobitz 3 AV block

Question 72

PR interval not the same | Normal QRS

Answer 72

3 AV block

Question 73

bunny ears

Answer 73

Bundle branch block

Question 74

Diphasic P wave

Answer 74

RAH or LAH

Question 75

Large R wave in V1

Answer 75

RVH

Question 76

Large S wave in V1 | Large R wave in V5

Answer 76

LVH

Question 77

t wave inversion

Answer 77

ischemia

Question 78

ST elevation

Answer 78

Injury

Question 79

ST depression

Answer 79

subendocardial infarction positive stress test digitalis

Question 80

significant q waves

Answer 80

infarctions

Question 81

infarct leads

Answer 81

sig q waves I and AVL = Lateral V1, V2, V3, V4 = Anterior II, III, AVF = inferior

Question 82

U waves

Answer 82

hypokalemia

Question 83

A-a gradient

Answer 83

• Difference between alveolar O2and arterial O2 • For arterial PaO2of 80 97-80 = 17 A-a gradient of 17 • Normal A-a gradient is 7-14 on room air

Question 84

Arterial Blood Gas Analysis PaO2: Measure of Oxygenation | Arterial Blood Gas Analysis PaCO2: Measure of

Answer 84

Ventilation

Question 85

Pulmonary Function Testing | Major Types of Tests

Answer 85

* Spirometry (pre and post dilator) * Forced inspiratory maneuvers * Lung volumes * Diffusing capacity * Maximal respiratory pressures * Pulse oximetry – rest and exercise

Question 86

Major Types of Pulmonary Disease Identified by PFTs

Answer 86

``` • Obstructive lung diseases - Asthma, COPD, CF • Restrictive lung disease - Pulmonary fibrosis, sarcoidosis, neuromuscular disease, pulmonary edema • Mixed pattern ```

Question 87

PFTs in Obstructive Lung Disease

Answer 87

• Spirometry | - Low FEV1/FVC (12%) in asthma

Question 88

PFTs in Restrictive Lung Disease

Answer 88

``` • Spirometry: Reduced FVC but normal or even increased FEV1/FVC ratio (>70%) • Lung volumes: Decreased total lung capacity (<80% predicted) • Diffusing capacity: Usually decreased Use of Pulse Oximetry in Clinic Setting • Measure oxygen saturation at rest • Monitor oxygen saturation . . . - With exercise - With sleep - During procedures ```

Question 89

Hyper-responsiveness – response to triggers->Obstruction – usually fully reversible-> Symptoms – cough, wheeze, dyspnea, dec breath sounds - Airway bronchspasm - Airway inflammation and mucus • Bronchospasm - Airway narrowing - Usually worse at night - Triggers: Pollen, drugs, dust, exercise, smoke exercise, cold, stress, colds/flu

Answer 89

Asthma

Question 90

Assessment of bronchospasm of Asthma

Answer 90

``` • Spirometry: FEV1 • Peak flow meter • Use of bronchodilators • Symptoms - Particularly nighttime awakenings ```

Question 91

FEV1/FVC improves with dilator

Answer 91

Asthma

Question 92

Signs of poor control of asthma

Answer 92

(rule of 2s) - Use “rescue” meds >2 times/week - Nighttime awakening due to breathing >2 times/month

Question 93

• Defines a severe asthmatic episode that is not responsive to repeated treatments with usual inhaled medications

Answer 93

Status Asthmaticus

Question 94

Treatment of Asthma

Answer 94

``` • Mild disease - Avoid triggers - Use of short-acting inhaler as needed • Moderate-severe disease - Inhaled corticosteroids - Inhaled long-acting bronchodilator - Leukotriene receptor antagonist Especially for aspirin sensitive asthma - Oral steroids - Anti-IgE therapy (Xolair - IgE antagonist injection every 2 weeks) ```

Question 95

best way to improve COPD

Answer 95

smoking cessation

Question 96

Low flattented diaphragm increased AP diameter Air trapping

Answer 96

COPD

Question 97

Therapy in COPD

Answer 97

``` • Smoking Cessation • Drug Therapy --B2 agonists, anticholinergics • Oxygen Therapy • Exercise/Nutrition • Lung Volume Reduction • Lung Transplantation ```

Question 98

``` • Respiratory manifestations - Persistent, productive cough - Airflow obstruction - Bronchiectasis-dilated airways • Physical findings - Wheezing - Clubbing of digits • Sweat chloride: Sweat chloride level of >60 meq/L - Pancreatic insufficiency with malabsorption • Infertility ```

Answer 98

Cystic Fibrosis

Question 99

Restrictive lung diseases

Answer 99

* Interstitial Lung Disease * Neuromuscular Disease * Severe Obesity * Chest Wall/Spine Deformity * Pleural Disease

Question 100

interstitial lung dieseases causes

Answer 100

``` • Drugs - Chemotherapy, amiodaronenitrofurantoin • Toxic Dusts - Asbestos, silica • Hypersensitivity Pneumonitis - Organic dusts Interstitial Lung Disease:Associated with Systemic Disease • Rheumatoid Arthritis • Scleroderma • Systemic Lupus Erythematosis Interstitial Lung Disease:Idiopathic • Sarcoidosis • Idiopathic Pulmonary Fibrosis ```

Question 101

``` • Shortness of breath - Particularly with exercise • Cough - Usually non-productive • Radiographic - Diffuse linear (reticular) or nodular markings in lung parenchyma • PFTs - Reduced lung volumes - Reduced diffusing capacity (usually) ```

Answer 101

Features of ILD

Question 102

* Military Exposure (ships/tanks) * Ship-Building * Boiler worker * Electrician * Brake Repair * Construction * Building Remodeling

Answer 102

ILD: Asbestos

Question 103

* Mining * Sand-blasting * Metal working * Glass workers

Answer 103

ILD:Silica

Question 104

Drug induced ILD

Answer 104

• Cancer patients - Many chemotherapeutic agents cause ILD, some not until years later • Cardiac patients - Amiodarone: Used for arrhythmias • Arthritis patients: Methotrexate • Urinary tract infections: Nitrofurantoin

Question 105

Hypersensitivity Pneumonitis ILD

Answer 105

exposure to organic dusts | agriculture, moldy hay

Question 106

most common cause of reduction in lung volumes, particularly total lung capacity • Diffusing Capacity (DLco) is generally not affected

Answer 106

Obesity and restrictive Changes in PFTs

Question 107

``` Idiopathic Interstitial Lung Disease - Increased frequency in African-American • Clinical Presentation - Cough, Short of Breath (Lung involvement in 95% of Sarcoid pts) - Skin Rash Erythema Nodosum - Eye symptoms (iritis) - Neurologic symptoms - Joint pains -“Potato” hilar adenopathy -Facial sarcoid granulomatous nodules - “Lupus pernio” - facial sarcoid granulomatous plaque ```

Answer 107

Sarcoidosis

Question 108

Sarcoid Dx

Answer 108

``` • Radiographic - Hilar/Mediastinal Adenopathy - Pulmonary Infiltrates • Pathologic - Granulomas: Non-caseating ```

Question 109

• Increased prevalence in older ages • Progressive fibrosis of the lungs • Mean survival is only 3-4 years • Clinical Features - Crackles in Chest - Clubbing of Digits is Common • Exclude Other Causes of Pulmonary Fibrosis • Characteristic Features on CT: may make diagnosis Interstitial fibrosis with adjacent normal lung tissue, extensive honeycombing

Answer 109

Idiopathic pulmonary fibrosis

Question 110

Treatment of ILD

Answer 110

``` • Known Causes - Avoid/eliminate exposure - Corticosteroids • Sarcoidosis - Corticosteroids - Methotrexate • Idiopathic Pulmonary Fibrosis - No proven therapy, ? Pirfenidone - Transplant ```

Question 111

ARF types

Answer 111

• Hypoxemic Respiratory Failure - Low Oxygen Level • Hypercapnic Respiratory Failure - High Carbon Dioxide Level

Question 112

• Acute Lung Injury: Milder injury to lung • Acute Respiratory Distress Syndrome (ARDS): Severe disorder where oxygenation is markedly abnormal (A-a gradient >200) - Approx 150,000 cases/year mortality 35-50% • Can be caused by direct injury to lung - Aspiration gastric contents - Toxic inhalation – smoke - Severe pneumonia - Exposure to drugs toxic to lungs • Systemic Injury - Shock/trauma, sepsis, drug overdose, pancreatitis, burn injury

Answer 112

Hypoxemic Respiratory Failure

Question 113

Pathophysiology of Hypoxemic Respiratory Failure (ARDS)

Answer 113

• Alveoli fill with fluid, become unstable and collapse • Collapsed alveoli results in V = 0 which is definition of shunt • Characteristic feature of ARDS is low oxygen that does not respond to supplemental oxygen (A-a gradient >200)

Question 114

Treatment of ARDS

Answer 114

• Ventilation: usually an endotracheal tube, occasionally by mask • Positive pressure throughout ventilation • Positive end-expiratory pressure (PEEP) - Supplemental oxygen - IV fluids and nutrition - Antibiotics if needed

Question 115

Cause of death in Hypoxemic Resp failure

Answer 115

infectious complications

Question 116

* May present as drop in SaO2 since increase in PaCO2 will cause decrease in PaO2 * Diagnosed by arterial blood gas demonstrating increased PaCO2 * If acute, patient will have respiratory acidosis (pH 7.2

Answer 116

Hypercapnic Respiratory Failure

Question 117

some causes of hypercapnic resp failure

Answer 117

``` • Advanced COPD - Severe COPD Exacerbation • Severe Asthma - Status Asthmaticus • Neuromuscular Disease • Hypoventilation - Trauma, stroke, drug effect, over-sedation ```

Question 118

most common presenting symptom of lung cancer

Answer 118

cough

Question 119

syptoms of lung cancer

Answer 119

- cough - Hemoptysis - Wheeze, shortness of breath - Dysphagia - Weight loss - Chest discomfort - Signs of metastatic disease

Question 120

types of lung cancer

Answer 120

``` • Adenocarcinoma • Squamous Cell Carcinoma • Small Cell Carcinoma (“oat cell”) • Large Cell Carcinoma • Bronchoalveolar Cell Carcinoma (BAC) type of adeno-ca that occurs as often in nonsmokers as in smokers ```

Question 121

Staging of Lung Cancer

Answer 121

• Stage 1 - Small (, 3 cm) disease without involvement of any lymph nodes (N0) • Stage 2 - Larger disease, possible hilar node involvement (N1) • Stage 3 - Mediastinal lymph node involvement (N2) • Stage 4 - Metastatic disease (M)

Question 122

Therapy of lung cancer

Answer 122

• For Non-small Cell Lung Cancer, surgery is the only therapy that offers a significant chance at long-term survival (>5 years) • Surgery is possible in Stage 1 disease and in selected patients with Stage 2 disease • Surgery is generally not recommended except in experimental trials in Stage 3 disease

Question 123

Methods to stage lung cancer

Answer 123

CT scan | PET scan

Question 124

ddx of lung nodule

Answer 124

``` • Granuloma - Usually due to fungal infection - Most often Coccidoidomycosis in Az • Lung Neoplasm - Primary or metastatic • Other unusual causes - Benign tumors including hamartoma, fibroma, etc. ```

Question 125

what if you see a neoplasm in the airways

Answer 125

neoplasm (not cocci)

Question 126

early diagnosis of lung cancer

Answer 126

Routine CT scans

Question 127

lung cancer metastases sites

Answer 127

bone brain liver adrenal glands

Question 128

cancer of surface of lung (pleura) often related to asbestos exposure

Answer 128

Mesothelioma

Question 129

metastatic disease to lungs

Answer 129

Breast Colon Kidney Melanoma

Question 130

common cold causes and tx

Answer 130

rhinovirus no antibiotics treat with tylenol, etcc

Question 131

• Constitutional symptoms are more prominent than in cold - Fever, malaise, myalgias - Often seasonal • Treatable within first 2 days - Oseltamvir (Tamiflu): 75 mg bid for 5 days • Influenza prophylaxis - Oseltamvir (Tamiflu): 75 mg once daily for 6 days - Flu shots

Answer 131

Influenza

Question 132

• Usually viral • 15% Strep - Exudate with fever and lymphadenopathy tx

Answer 132

Acute pharyngitis Penicillin or erythromycin

Question 133

* Usually posterior cervical adenopathy, a dull white exudate and possible hepatomegaly or splenomegaly * Rash if given amoxicillin

Answer 133

Mononucelosis Penicillin or erythromycin

Question 134

• Primarily results from sinus ostial obstruction (“ostiomeatal complex” obstruction) -

Answer 134

Acute sinusitis Narrow spectrum antibiotics Amoxicillin or Bactrim

Question 135

sinus obstruction > 12 weeks cause

Answer 135

bacterial or fungal get sinus CT

Question 136

Achy ear - Often due to pseudomonas aeruginosa and occasionally staph aureus - Generally treated with ciprofloxacin– HC drops topically and debridement; occasionally with systemic antibiotics - Avoid Q-tips

Answer 136

Otitis externa (Swimmer's ear)

Question 137

usually bacterial following a viral URI - S. pneumoniae; H. influenza; M. catarrhalis - RX: amoxicillin although 1/3 resistant; treatment debatable

Answer 137

otitis media

Question 138

tx for serous otitis media

Answer 138

- Consider antibiotics and/or myringotomy tubes if significant hearing loss and effusion > 3 mo

Question 139

- Potentially fatal | - Dx: Lateral neck films ; cherry red epiglottis with fiberoptic rhino-laryngoscopy

Answer 139

acute epiglottiis ampicillin/sulbactam or 2/3 cephalosporin maybe hospitalization

Question 140

usually viral • Characterized by cough, usually with sputum production • The absence of abnormalities on chest radiography distinguishes from pneumonia

Answer 140

acute bronchitis

Question 141

severe bronchitis symptoms

Answer 141

- Increased amount of sputum - Change in color of sputum - Increased shortness of breath • Treat severe bronchitis with antibiotics for 7-10 days - azithromycin or levofloxacin • May need to treat associated bronchospasm (e.g., albuterol; steroids)

Question 142

• Primary symptom is chest pain, worse with inspiration • Usually viral • Treat symptomatically - Non-steroidal anti-inflammatory drugs

Answer 142

Pleurisy

Question 143

URI and LRI | What are LRIs

Answer 143

pneumonias

Question 144

• Infection that extends beyond airways into pulmonary parenchyma (lobe, lobules) • Characterized by more change in gas exchange (shortness of breath), and presence of abnormal findings on chest radiograph or CT scan • Associated morbidity/mortality is much higher than bronchitis

Answer 144

pneumonia

Question 145

symptoms of pnuemonia

Answer 145

* Cough, usually productive * Fever, chills * Dyspnea * Malaise * ? Confusion * Symptoms may vary from severe to absent

Question 146

Physical Findings in Pneumonia

Answer 146

• Fever and tachycardia • Tachypnea (RR > 20) • Auscultation of chest - Common: Crackles (“rales”)

Question 147

Types of pneumonia

Answer 147

• Bacteria (most often) - Gram positive: Strep pneumonia, - Gram negative: Klebsiella, pseudomonas, • Fungal - Coccidioidomycosis (Valley Fever), histoplasmosis, blastomycosis, aspergillis • Mycobacteria - Mycobacterium tuberculosis, mycobacterium avium-intracellulare • Viral - Respiratory syncytial virus, adenovirus, influenza

Question 148

Clinical Signs of Severe Pneumonia

Answer 148

``` • Hypoxemia - SaO2 < 92% • Tachycardia • Hypotension • Altered mental status - Obtundation - Confusion ```

Question 149

diagnosis of pnuemonia

Answer 149

• Primarily from history and physical exam • Chest x-ray / chest CT scan • Sputum Gram stain and culture - ? Acid fast bacilli stain, KOH, fungal cultures, mycobacterial cultures, etc. • Blood cultures • Serologic testing - e.g., coccidiomycosis antibody titers

Question 150

walkling pneumonia

Answer 150

- Some organisms (mycoplasma or chlamydia) may cause mild symptoms

Question 151

tx for pneumonia

Answer 151

• More severely ill pt, initial empiric coverage w/multiple antibiotics for a variety of pathogens - e.g., ceftriaxone 2 g IV daily with levofloxacin 750 mg orally daily • In immuno-suppressed patients, consider bronchoscopy with lavage (bronchoalveolar lavage) to evaluate for atypical pathogens • Usual outpatient treatment: Empiric macrolide (e.g., azithromycin) for mild sy mptoms or quinolone (e.g. levofloxacin) if moderate symptoms

Question 152

• May present as community-acquired pneumonia; possible history of soil dust exposure (e.g., lives in a developing suburban subdivision) • Often causes a cavity to form within the lung • Can be associated with severe constitutional symptoms • Diagnosis: Serologic test or culturebof organisms Miliary pattern on CXR eosinophilia tx

Answer 152

coccidiomycosis * Most cases will resolve without any treatment * Can use Diflucan (fluconazole) 200 mg twice daily for therapy * In severe cases, may use Amphotericin B by IV administration

Question 153

- Evidence of tuberculosis organisms multiplying in pulmonary or extra-pulmonary site - Often infectious to others

Answer 153

active TB

Question 154

- Cough and minor symptoms for 2-4 weeks and central infiltrates on chest x-ray - Usually not infectious

Answer 154

Primary TB

Question 155

- “reactivated” tuberculosis; symptoms may be similar to pneumonia with peripheral and apical chest x-ray infiltrates - Infectious

Answer 155

2ry TB

Question 156

* Cough * Weight loss * Fatigue * Fever and night sweats * Sputum production * Hemoptysis (usually late in disease) * Dyspnea

Answer 156

TB symptoms

Question 157

reactivation TB usually involves what

Answer 157

upper lobes | cavity will form

Question 158

• Patients with a positive Tb skin test, but no evidence of active tuberculosis have what is termed

Answer 158

latent tb

Question 159

Approach to Patient with Suspected Latent or Active Disease

Answer 159

• Latent disease: Tb skin testing (PPD-“purified protein derivative” or “Mantoux” testing) - mandatory in certain occupations • Suspect active disease - Isolate the patient - Sputum AFB smear and AFB culture x 3 - Occasionally will need bronchoscopy • If find active disease: Skin test all contacts

Question 160

TB test interpretation

Answer 160

• Positive - ≥ 10 mm induration - ≥ 5 mm if: * HIV * Immunosuppressed * Recent close contact * Radiographic evidence of old TB

Question 161

Latent TB tx

Answer 161

isoniazid 9 months with B-6

Question 162

Active TB tx

Answer 162

isoniazid plus B6 Ethambutol Rifampin Pyrazinamide

Question 163

DVT study

Answer 163

Duplex ultrasound

Question 164

1. Pleuritic pain or hemoptysis 65% 2. Isolated dyspnea 22% 3. Circulatory collapse 8% No dyspnea is present 27% Tachypnea (>20) 70% Tachycardia (>100) 43% Crackles (rales) 53%

Answer 164

PE

Question 165

Interventions to Reduce Risk of DVT/PE

Answer 165

• Early ambulation after surgery • Avoid prolonged immobilization • Compressive stocking or mechanical compressing devices • Prophylactic treatment with low-dose heparin in high-risk patients - e.g., low-dose heparin or Lovenox postoperatively then 4-6 weeks of Coumadin following a total knee arthroplasty or total hip arthroplasty

Question 166

Diagnosis of PE

Answer 166

Spiral CT! (contrast enhanced) VQ scan D-dimer (sensitive to rule out)

Question 167

Treatment of Pulmonary Embolism

Answer 167

``` • Initial therapy: Heparin • In unstable patient – may consider thrombolytic therapy or surgical embolectomy • Long-term therapy: Warfarin (Coumadin) - 1stepisode: 6 months of therapy - 2ndepisode: Lifelong - Predisposing factor: Lifelong ```

Question 168

MICROCYTIC ANEMIAS

Answer 168

* IDA * ACD * Hemoglobinopathy (eg THAL) * Sideroblastic anemias (lead poisoning)

Question 169

``` • Most common anemia • Most common cause: blood loss • Occasionally malabsorption from: – Gastric surgery – Malabsorptive disorders High Transferring Low serum Iron Low Ferritin ```

Answer 169

Iron Def Anemia dietary iron - meat oral iron

Question 170

``` • Characterized by: – ↓Fe – ↑↑Ferritin – ↓ EPO • Develops in: – Chronic infections – Chronic inflammatory disease – Neoplastic disease ```

Answer 170

anemia of chronic disease

Question 171

Macrocytic = megalo & non-megalo Name causes of megaloblastic (oval) anemias

Answer 171

``` • B12/Folate def • Drugs: – dilantin/OC – hydrea/methotrexate • Some marrow disorders ```

Question 172

``` – ↑ RBC Mass – Normal O2 – Splenomegaly – Increased: WBC / PLTS / B12 / LAP score – JAK-2 Mutation – Bone Marrow Hypercellularity ```

Answer 172

Primary Polycythemia vera

Question 173

polycthemia vera tx

Answer 173

– Phlebotomy (do it until hct under 45) • H/H < 15/45 – decreases thrombotic risk – Hydroxyurea

Question 174

``` Anemia from reduced RBC survival (<100 days) Bone marrow unable to replace RBCs Etiologies Immune - Coomb’s Positive Non-immune - Coomb’s Negative ```

Answer 174

Hemolytic anemia

Question 175

``` – Rapid pallor / anemia – Jaundice – Splenomegaly – Increase: MCV - macrocytosis • Reticulocytes – IMMUNE: (+) Direct anti-globulin test(Coomb’s) – History of pigmented(Bilirubin) gallstones ```

Answer 175

hemolytic anemia

Question 176

HEMOLYTIC ANEMIA – ACQUIRED ETIOLOGIES | IMMUNE (Coomb’s +)

Answer 176

```  Autoimmune Hemolytic anemia(AIHA)  Warm: Idiopathic & CLL  Cold: Idiopathic & Mycoplasma  Alloimmune: Transfusion  Drug-induced ```

Question 177

– Antibody or complement on RBC (looking for abs on RBC) – Diagnosis of: • AIHA • Hemolytic transfusion reaction

Answer 177

direct coombs

Question 178

``` – ATB in SERUM NOT bound to RBC – Patient serum & Donor RBC – The screen in: “type & screen” – In autoimmune hemolysis • both DAT & IAT may be (+) • ATB may be in SERUM & ON RBC ```

Answer 178

indirect coombs

Question 179

– Auto-ATB against RBCs | – Warm & Cold Auto-ATB

Answer 179

AIHA

Question 180

```  Any Age  Usually IgG  Variable anemia Etiologies:  65% - Idiopathic  25% - CLL  20% - NHL  Other – Meds Clinical  Anemia  Jaundice  Splenomegaly ```

Answer 180

warm auto ATB

Question 181

``` – IgM – Etiologies: • Idiopathic • Mycoplasma • Lymphoma • Mononucleosis – Clinical • Acrocyanosis at cold temperatures • Jaundice • Splenomegaly ```

Answer 181

cold auto atb

Question 182

acquired clonal stem cell disease – Cell membrane anchor defect – Hemolytic anemia – Screen using: CD55 and CD59 and treatment

Answer 182

Paroxysmal Nocturnal Hemoglobinuria Elulizumab -binds complement C5

Question 183

Inherited hemolytic blood disease resulting from a mutation in the alpha globin gene • Normal HGB = “A1” • Hemoglobin “S”

Answer 183

Sickle Cell Disease

Question 184

Sickle Cell Types

Answer 184

``` – “Trait” = Heterozygous = A>S • 8% of Aas • Malaria protection – “Anemia” = Homozygous = SS • sickle cells in PS – Sickle cell – Hemoglobin C = “SC” • fewer sickle cells - more Target / Spherocytes – Sickle-Thal ```

Question 185

Vaso-occlusive disease of sickle cell

Answer 185

– SC accumulate in any vascular bed – Infarction of Marrow/Spleen/Kidney – Painful crises in long bones • MOST COMMON PRESENTATION

Question 186

sickle cell skeletal presentation

Answer 186

* Marrow hyperplasia=osteopenia=fractures * “Hair-on-end” on skull * Marrow infarction = osteonecrosis * Dactylitis * Osteonecrosis * Bossing

Question 187

``` – 8% of African Americans – A always > S – Under physiologic conditions no vaso-occlusion – Carriers have normal life expectancy – Compared to the general population: • Same risk for: – Heart disease – Stroke – Anesthetic agents ```

Answer 187

sickle cell trait

Question 188

``` – Imbalanced globin chain synthesis: • Ineffective hematopoiesis • Defective Hgb production • Hemolysis • Variable anemia ``` types and explian

Answer 188

``` • Beta Thalassemia – Beta reduce or absent – Alpha excess • Alpha Thalassemia – Alpha reduced or absent – Beta excess • Quantitative NOT Qualitative disorder ```

Question 189

heinz bodies

Answer 189

excess alpha chains

Question 190

``` – Heterozygous carrier – Usually no clinical symptoms – Asymptomatic Splenomegaly 20% – CBC/peripheral smear • Mild anemia(Hct>30) • MCV ```

Answer 190

B-Thal Minor

Question 191

``` • Anemia later and milder than major • Requires less transfusion • Retarded growth/development • Skeletal deformity – EPO increases marrow expansion – Deformities of skull / long bones – Pathologic fractures • Splenomegaly • Milder forms: – Asymptomatic & xfusion independent – Hgb 10-12 ```

Answer 191

B thal Intermedia

Question 192

``` • Homozygous “Cooley’s Anemia” • Symptoms begin at 4-6 months • Clinical: – Gallstones – Leg ulcers – Skeletal disease – Anemia Laboratory features • Microcytic anemia • Target cells / Tear drop cells / Basophilic stippling / NRBCs ```

Answer 192

B thal Major

Question 193

Pathophysiology Alpha Thalassemia

Answer 193

``` – 4 copies of α globin gene • 2 copies each Chr. 16 – 1 Deletion = AT Minima – 2 Deletions = AT minor • TRANS: A/- A/-• CIS: AA / --– 3 Deletions = Hgb H Disease – 4 Deletions = Hgb Bart’s ```

Question 194

``` – Silent carrier = (α - / α α) – Trait • Similar to β Thal trait • Mild heme changes • No clinical abnormality ```

Answer 194

a Thal (silent carrier)

Question 195

* Mod-severe hemolytic anemia – hypo/micro –retic counts to 15% * HSM / Gallstones / Leg ulcers * RBCs contain Hgb H precipitates

Answer 195

– Hgb H Disease (α - / - -)

Question 196

– Hgb Bart’s (- - / - -) (γ4) =

Answer 196

incompatible with life

Question 197

other names for myelodysplastic syndromes

Answer 197

– Refractory anemia • No improvement with Fe / B12 / Folate – Pre-Leukemia – Senile anemia

Question 198

Ringed sideroblasts

Answer 198

myelodysplasia

Question 199

``` • Heritable mutation = RUNX-1 • Tobacco • Ionizing Radiation – Highest rate of progression to AL – 75% – Low response to treatment – Median survival ~ 9 MOS. – Chromosome abnormalities: • -5 / -7 = Alkylating Agents • 11 = Topo-II inhibitors Clinical: – Signs / symptoms usually from cytopenias • Anemia • Infection • Bleeding – Usually absent: • Lymphadenopathy • Hepatosplenomegaly Peripheral smear: • Macrocytosis • Hypolobar neutrophils – (Pseudo Pelger-Huet) • Circulating micromegakaryocytes ```

Answer 199

Myelodysplasia

Question 200

myelodysplasia therapies

Answer 200

Bone Marrow Transplant is only curative

Question 201

``` – van den Berghe Nature 1974 – severe anemia – mild leukopenia – normal or increased platelets – atypical megakaryocytes – indolent – <5% blasts ``` 5q treatment

Answer 201

5q syndrome Lenalidomide

Question 202

Myeloproliferative Disorders

Answer 202

• BCR/ABL(+): Chronic Myelocytic Leukemia • BCR/ABL(-) & JAK2(+): – Essential Thrombocythemia – Myelofibrosis with Myeloid Metaplasia – Polycythemia rubra vera • JAK2(+/-): Chronic Myelomonocytic Leukemia

Question 203

``` • 10% of all leukemias • Adults>>>children • Median age = 50 • M>F • IR only known causative factor (Ionizing Radiation) MPD - CML • BCR/ABL • “Philadelphia Chromosome” Basophilia – Fatigue / weight loss / night sweats – Splenomegaly – Leukostasis from Hyperleukosis 3 phases (Chronic, accelerated, blastic - acute leukemic transformation) ```

Answer 203

CML

Question 204

CML treatment

Answer 204

Imatinib (Gleevec)

Question 205

``` •Most common MPD •Age at diagnosis: 50-60 JAK + Bone Marrow = increased MEGS •Near-normal life expectancy – PLTS > 600K – Microvascular Thrombi – Bleeding – Splenomegaly – Recurrent first trimester abortions – Leukemic transformation very low ```

Answer 205

Essential Thrombocytopenia

Question 206

• 33% asymptomatic at diagnosis • Fatigue / Weight loss / Fever / Night sweats • Anemia • Splenomegaly – Leukoerythroblastosis – Single or multiple cytopenias • Bone marrow - fibrosis - “Dry tap” – Fibrous tissue takes place of normal BM tissue • Leukemic transformation in 20% during first decade

Answer 206

MYELOFIBROSIS WITH MYELOID METAPLASIA

Question 207

``` • Affects all 3 cell lines - RBCs the most • Proliferate without EPO • Serum EPO levels are low • Median age = 60 • Increased HGB/HCT/RBC mass • Bone marrow: Hypercellular • B12 increased from increased WBCs producing B12-binding protein • Symptoms related to increased viscosity – Plethora – Erythromelalgia – Pruritus • Arterial/Venous Thrombosis • Thromboses: » Renal/portal veins » Budd-Chiari » Mesentery ```

Answer 207

Polycthemia Rubra Vera

Question 208

– Most common neoplasm in

Answer 208

ALL

Question 209

ALL sites

Answer 209

Marrow usually

Question 210

ALL presentation

Answer 210

– Bulky adenopathy – Mediastinal mass – Pleural effusions – +/- hyperleukocytosis

Question 211

ALL Lab

Answer 211

– ↑ WBC or Pancytopenia +/- Blasts – LDH (= tumor burden) – Hypercalcemia – ↑ Uric acid / LFTs / BUN

Question 212

ALL treatment phases

Answer 212

– Induction – CNS – Consolidation – Maintenance

Question 213

``` • Uncontrolled prolifeation of myeloid progenitors • Replaced hematopoietic elements • Ineffective hematopoiesis • Majority de novo • Treatment related – Chemotherapy: CHR: -5 / -7 / 11 – RT Auer Rods ```

Answer 213

``` – Bone marrow failure – Abnormal hemostasis • Thrombocytopenia • Coagulopathy • DIC most common with APL ```

Question 214

``` • Lymphoid Neoplasm • Binucleate giant Reed-Sternberg cell • 75% of pts can be cured • Origin – Germinal B Center lineage • Other adenopathies – Mononucleosis -EBV ```

Answer 214

Hodgkin's Lymphoma

Question 215

Hodgkin's Lymphoma clinical features

Answer 215

``` – Adenopathy • 80% Cervical • 50% mediastinal • Nontender / firm-pliable – B symptoms • Fever • Night sweats • Weight loss – Other symptoms • Fatigue • Weakness • Anorexia • Etoh induced node pain • Pruritus ```

Question 216

review difference between B cells and T cells

Answer 216

``` • B cell – Produced and mature in marrow – B cell receptor – Antibody production – Plasma cells • T cell – Produced in marrow – Mature in Thymus – T cell receptor – CD4: Helper T cells – CD8: Cytotoxic T cells ```

Question 217

t(2;5) t(8;14) t(14;18) t(11;14)

Answer 217

ALCL Burkitts Follicular Mantle

Question 218

``` – Family History – Previous neoplasm – Immune suppression – Infection – “B” symptoms – Weight loss: >10% weight in 6 months – Fever – Night sweats • Physical examination – All node bearing regions including Waldeyer’s – Organomegaly – Skin involvement ```

Answer 218

NonHodgkins Lymphoma

Question 219

Non Hodgkins types

Answer 219

* INDOLENT * Chronic Lymphocytic Leukemia * Follicular Grade 1/2 * MALT * Lymphoplasmacytic Lymphoma * AGGRESSIVE * Follicular Grade 3 * Diffuse Large Cell * Anaplastic Lymphoma * Mantle Cell Lymphoma * Primary CNS Lymphoma * Acute Lymphoblastic Lymphoma

Question 220

``` • Median seventh decade • BM-PB-LN/L/S • SLL = tissue equivalent of CLL • Incurable/median survival ~ 10 YRS • Can transform to: – Prolymphocytic leukemia – Large B Cell lymphoma (Richter’s) • Treatment • Oral agents - Chlorambucil • IV/Biologics - Rituximab ```

Answer 220

CLL

Question 221

``` • Also called Waldenstrom’s macroglobulinemia • median seventh decade • BM/LN/S • Rarely – PB / extranodal • IgM elevated Very high = hyperviscosity • Generally incurable • MS ~ 9 YRS ```

Answer 221

Lymphoplasmacytoid Lymphoma

Question 222

``` • Median sixth decade • 35% of NHL • BM/LN/S/Extranodal • May transform to aggressive • Early stage - therapy • Advanced stage not curable – Initial treatment may be surveillance t14:18 ```

Answer 222

Follicular Grade 1 or 2

Question 223

* Median seventh decade * Three subtypes: MALT/Nodal/Splenic * Can be nodal or extranodal * Extranodal often with Autoimmune disease * Sjogren’s * Hashimoto’s * H.pylori gastritis * Incurable – MS ~ 10 YRS. * Early MALT treat with antibiotics

Answer 223

Marginal Zone

Question 224

* Median seventh decade * M>>F * t(11;14) * Increased Cyclin D1 * BM/LN/Extranodal sites * Lymphomatous polyposis * Incurable * Shorter MS – 3-5 YRS

Answer 224

Mantle Cell

Question 225

``` • 30% of lymphomas • Median age sixth decade • Extranodal in 40% • Curable with chemotherapy – Most with early stage – 50% with advanced • CNS prophylaxis occasional ```

Answer 225

Diffuse Large B cell lymphoma

Question 226

``` • Most common Pediatric NHL • African = “Endemic” Form = EBV + • Western – Adults – Sporadic – EBV -– Mesenteric LN – Ileum – Cecum – Liver - Spleen • Curable with aggressive therapy • CNS prophylaxis required t8:14 ```

Answer 226

Burkitts

Question 227

``` – Cutaneous & systemic – Systemic form • children & adults • Expresses t(2;5) • Mainly T cell – Cutaneous • Mostly adults • Isolated skin nodules • Is more indolent and incurable ```

Answer 227

Anaplastic Large Cell

Question 228

* Cutaneous T Cell lymphoma * Multiple cutaneous plaques – nodules * Generalized erythroderma * Treatment often topical

Answer 228

Mycosis Fungoides

Question 229

``` • In HTLV-1 areas: – Japan – Carribean • Presentation: – High WBC – HSM – Hypercalcemia – Lytic bone lesions • CD-30+ = Ki-1 • t(2;5) • Four clinical presentations: – Smoldering – Chronic – Lymphomatous – Acute ```

Answer 229

Adult T cell Leukemia/Lymphoma

Question 230

* Incidence 60x greater than general population * Median age fourth decade * Usually ST III/IV * Often extranodal: GI/BM/CNS * Primary CNS lymphoma common in this group * 70% = large B Cell / other = Burkitt-like

Answer 230

Lymphoma HIV associated`

Question 231

Typles of plasma cell neoplasms

Answer 231

``` • Clinically Benign: – MGUS • Indolent: – Waldenstrom’s – Indolent Myeloma • Malignant: Plasma Cell Myeloma • Malignant Aggressive: Plasma Cell Leukemia ```

Question 232

``` • Definition: – M Protein(G,A,M)Value < 3.0 g/dl – No Urinary Light Chains – Normal • CBC • Renal function • Calcium • Bone – Bone marrow plasmacytosis < 10% ```

Answer 232

MGUS

Question 233

1. Monoclonal protein serum a/o urine 2a. Plasmacytoma OR 2b. Marrow plasmacytosis > 10% 3. CRAB: • Calcium • Renal - light chain tub interst nephritis • Anemia • Bone - osteoporosis Rouleax formation

Answer 233

Multiple Myeloma

Question 234

Myleoma symptoms

Answer 234

``` back pain headache blurry vision CHF Sausage retinal veins ```

Question 235

Collection of plasma cells usually in vertebral body

Answer 235

Solitary Plasmacytoma (treat with bisphosphonates)

Question 236

virchows triad

Answer 236

– Venous stasis – Blood vessel damage – Hypercoagulability

Question 237

Disorders of Thrombosis -Prophylaxis in Podiatric Surgery | 3 significant risk factors

Answer 237

– Prior VTE – Hormone replacement/Oral Contraception – Obesity

Question 238

``` – Most common heritable risk factor – Factor V resists lysis by Prot C – Caucasians: 5% incidence • Majority = no thrombosis – 20% with VTE + – VTE risk increased by other risk factors ```

Answer 238

Activate Protein C Resistance

Question 239

* Increase O2 carrying capacity * Not for volume replacement * Symptomatic anemia / acute hemorrhage * Increase HGB in adult ~ 1 GM / DL

Answer 239

Packed RBCs

Question 240

* Replaces volume and O2 carrying capacity * <1% of all xfusions * Large amount of plasma

Answer 240

Whole Blood

Question 241

* Wash with saline to remove plasma | * Indication – repeated hypersensitivity reactions

Answer 241

Washed RBCs

Question 242

* Remove WBCs by filtration | * Indication – multiple non-Hemolytic transfusion reactions

Answer 242

Leukoreduced RBCs

Question 243

``` – From whole blood – Preserves labile proteins except Factors V & VIII – Efficacy limited by: • Shortest ½ life of factor being replaced(Often Factor VII) • Degree of factor deficiency – ABO compatible – Indications: • Replace coagulation factors • Factor deficiencies – With bleeding – Scheduled for surgery • DIC • Liver disease • Rapid reversal of warfarin ```

Answer 243

Fresh Frozen Plasm

Question 244

``` – Cold soluble proteins left when FFP is thawed. • FVIII / FXIII / Fibrinogen • vonWillebrand’s Factor – Replacement of Fibrinogen – ABO not needed – Indications: • Deficiencies: – Fibrinogen – F XIII • DIC • Hemophilia A or vWD (when no FVIII concentrate) ```

Answer 244

Cryoprecipitate

Question 245

``` • Diagnosis of exclusion • Common: – 1% of RBC – Up to 30 % of PLT xfusions • inc temp. ≥ 1 deg F near end or following • Recipient ATB vs. Donor leukocyte ATG • Symptoms: – Hallmark is fever – Chills / Hypertension / Tachycardia • Usually transient ```

Answer 245

Febrile Nonhemolytic Transfusion Reaction

Question 246

``` – Most=ABO incompatible • Often mislabeling or wrong ID – 1:25,000 – Mortality 17-60% – Fever/chills/dyspnea/chest pain – Shock-death – Hallmark = Intravascular hemolysis: • Complement fixation by IgM • Hemoglobinemia - Hemoglobinuria – Direct Coomb’s = + – Indirect Bili – Jaundice – ATN ```

Answer 246

Acute hemolytic transfusion reaction(immune

Question 247

``` • Rapid extravascular clearance of xfused RBCs – Immunized prior xfusion(“primary”) – Days or weeks • May be mild and unnoticed • More common than acute: 1:7000 • Hallmark = unexplained decrease in Hgb • Fever / chills • Lab: – Increase Bili / LDH / reticulocyte count – Jaundice – DAT usually + – Decrease in Haptoglobin ```

Answer 247

Delayed Hemolytic Transfusion Reaction

Question 248

``` • Small amount • Sudden onset & rapid progression – Respiratory distress – Vascular collapse – Afebrile • IgE response to transfused proteins • Particularly susceptible IgA deficients ```

Answer 248

Anaphylactic Reaction

Question 249

* Noncardiogenic pulmonary edema * Usually ~ 2 hours after xfusion * Acute respiratory insufficiency & hypotension * CXR = bilateral white out * Fatality 7%

Answer 249

TRALI

Question 250

Platelets are involved in _________ hemostasis

Answer 250

primary

Question 251

How does thrombocytopenia present

Answer 251

– SPONTANEOUS BLEEDING – PERSISTENT BLEEDING – EASY BRUISABILITY(WITH OR WITHOUT TRAUMA) – OOZING OF BLOOD - OFTEN FROM MUCOUS MEMBRANES – UNEXPLAINED GI OR GU TRACT BLEEDING – UNEXPLAINED RED FLAT PINPOINT RASH - OFTEN LOWER EXTREMITIES

Question 252

- Intravascular purpura - Platelet disorders - <3mm - Non-palpable

Answer 252

Petachia

Question 253

thrombocytopenia bone marrow smear

Answer 253

increased cellularity | megakaryocytes

Question 254

* Most common cause of easy bruising in a healthy adult * Females > Males * Decades 2 & 3 * Easy Bruising * Diagnosis of exclusion * Bone Marrow = Megakaryocytes OK * No Splenomegaly * Rx:Prednisone/Splenectomy/IVIG/Neumega/Romiplostim/Eltrombopag

Answer 254

Immune Thrombocytic Purpura

Question 255

``` – dec Platelets and fibrinogen – inc FDP - PT - PTT - Thrombin Time – inc D-Dimer: • degradation of stabilized fibrin • confirms thrombin generation & FXIII cross-linking Non-immune get Schistocytes – thrombosis - smaller vessels – bleeding = Factor Consumption & Plasminolysis – treat etiology ```

Answer 255

DIC | Diffuse Intravascular Coagulopathy

Question 256

``` • Large vWF multimers – Lack protease • Thrombi: CNS - Kidneys - Myocardium • Peak = 20s F = 65% • Clinical: – Fever – MAHA - Thrombocytopenia – Neurologic - Renal – Hematuria – Proteinuria – Schistocytes - NRBCs – Normal: PT/PTT/fibrinogen ```

Answer 256

TTP

Question 257

* Children>Adults * Prior Infection * vWF protease normal * MAHA / Thrombocytopenia (< TTP) * ARF (renal > TTP) * No Neurologic or Fever

Answer 257

HUS

Question 258

Platelet Transfusion - Parameters

Answer 258

– 60,000

Question 259

Definitions of Hemostasis

Answer 259

* Primary: Platelet Plug: * Platelets + vascular injury = platelet plug * Requires VWF + FVIII * Activates secondary * Secondary: Fibrin Plug: * Activation of the coagulation cascade = fibrin plug

Question 260

Disorders of Hemostasis - Coagulation Cascade

Answer 260

``` • Extrinsic (Checked with PT/INR) – Tissue Factor + FVIIa – Converts X -> Xa – PT/INR • Intrinsic • Initial sequence – Vascular injury – Kallikrein activates F XII – Cascade follows • aPTT ```

Question 261

– Prolongation: dec in Fs II/V/VII/X/Fibrinogen – Extrinsic system abnormalities – INR(Int. Normalized Ratio) for Warfarin patients

Answer 261

Prothrombin Time(PT

Question 262

Prolongation is dec for factors II/V/VIII/IX/X/XI/XII – Intrinsic system – Rarely affected by fibrinogen

Answer 262

aPTT

Question 263

Disorders of Hemostasis - Mixing Studies

Answer 263

– Prolonged PT / aPTT from deficiency? – Mix patient and control plasma – Correction • qualitative or quantitave factor abnormal – Noncorrection = factor inhibitor • Lupus anticoagulant (Mix w/normal control. If PTT is corrected it means there is a deficiency (Present with bleed, bruise) If it doesn’t correct then SLE (these will present with thrombosis)

Question 264

Abnormal PT

Answer 264

``` – Vitamin K deficiency • Vitamin K dependent factors measured by PT = II/VII/X – Coagulopathy of liver disease • Initial = Decreased F II/VII/X • Factor V – NOT Vitamin K dependent. – Hepatic disease vs. other prolonged PT ```

Question 265

abnormal aPTT

Answer 265

``` – Hemophilia • A = congenital def of F VIII • B = congenital def of F IX – von Willebrand’s disease • dec vWBF = dec FVIII = inc aPTT • Corrects on mixing – F XII Deficiency – LA • no correction with mixing ```

Question 266

Abnormal PT + aPTT

Answer 266

``` – Coagulopathy of liver disease – Deficiencies of individual factors • Factor II (Prothrombin) • Factor X (Stuart-Prower) • Factor V (Proaccelerin) – DIC – LA ```

Question 267

cuases of ataxic gait

Answer 267

posterior column disease cerebellar degeneration peripheral neruopathy

Question 268

Steppage gait causs

Answer 268

LMN disease such as neuropathies (syphillis) Tabes dorsalis

Question 269

Stiff spinal cord gait - circumduction gait

Answer 269

UMN disease

Question 270

Magnetic gait

Answer 270

Normal Pressure Hydrocephalus

Question 271

glasgow coma scale

Answer 271

``` Eye Spon 4 resp to speech 3 resp ot pain 2 No respons 1 ``` ``` Motor Obeys 6 Localizes 5 Withdraw 4 abn flxr 3 abn ext 2 no response 1 ``` ``` verbal oriented 5 confused 4 inappropriate 3 incomprehensible 2 no response 1 ``` 15 = wnl, < 8 fatal, 3 = dead

Question 272

``` Resting tremor unilateral cogwheel rigidity Bradykinesia asymmetric onset treatment ```

Answer 272

Parkinsons disease start with levodop or dop agonist first to control symptoms

Question 273

``` Less tremor than parkinsons vertical gaze impaired Stiff gait --Fall backward Axial rigidity, hyperextended Falling is big concern ```

Answer 273

Progressive supranuclear palsy

Question 274

An action tremor with a high amplitude and high-frequency. Tremor kicks in when you use your hands for example Bilateral, postural and action tremor Duration > 3 years Family history Alcohol response – worse with alcohol Otherwise neurologically normal

Answer 274

Essential tremor treatment mysoline and BB

Question 275

Usually occurs in young people (mean is 29 years) Optic neuritis (Loss of vision, double vision, Internuclear Opthalmopelgia) Vertigo/Diszziness & Insomnia, Oropharyngeal problems – dysphagia, slurred speech Demyelinating lesions are found in the brain and spinal cord Deep white matter plaques Test to order

Answer 275

Multiple Sclerosis cranial MRI with Gadolinium

Question 276

Types of MS

Answer 276

Relapsing – Remitting (RRMS) Seconary progression (SPMS) RRMS with multiple increasingly frequent relapses Primary Progressive MS (PPMS) Clinically Isolated Syndromes suggesting MS (CIS) Isolated single episode Benign MS 15% don’t relapse 15% may have plaques at autopsy with no history of MS

Question 277

acute flares of MS treated with

Answer 277

IV glucocortricoids

Question 278

ACh Receptor Antibodies 10 to 15% of MG patients have thymoma (benign) Fatiguibility that IMPROVES with rest Ptosis – usually bilateral, but may be unilateral Diplopia Fluctuating weakness Testing includes: Tensilon tests, EMG/NCV, Chest CT, ACh Receptor antibodies Repetitive stimulation -> NCV decrement – due to ACh depletion

Answer 278

Myasthenia Gravis Mestinon, Immunosuppressant Avoid NM blocking drugs

Question 279

Antibodies against voltage gated calcium channels – impairs Ach release Almost all are > 40 y/o Most are paraneoplastic in nature Think Cancer! -> Small cell of lung, Lymphoproliferative disorder, pancreatic cancer, ovarian cancer, Breast cancer LEMS precede cancer by 1 year Looks just like MG Proximal weakness (LE > UE) Easy fatigubility Strength and DTRs may improve after isotonic exercise Dysautonomia more common than MG -> especially dry mouth! EMG/NCV Increment on NCV after repeat stimulation (not decrement) Treat by finding cancer and treating that

Answer 279

Lambert Eaton Myasthenic Syndrome

Question 280

UMN and LMN disease; CNS & PNS Loss of Motor neurons in corticospinal tract Eventually may get frontal lobe dementia Hyperreflexia, Atrophy, Fasciculation, Weakness, Spastic, Painless usually Skeletal muscles -> eventually diaphragm EOM only muscles spared Pure motor disease Above levels also affected Dx via EMG!! – not NCV Supportive Care; Riluzole may prolong life expectancy by 3 months

Answer 280

ALS

Question 281

Can be Compressive myelopathy Motor and sensory symptoms Below level affected

Answer 281

Spinal stenosis

Question 282

Meylopathy "Cape-like numbness", Symptoms of myelopathy include paraparesis and a sensory level Intraxial widening of the central canal

Answer 282

Syringomyelia

Question 283

Pathology of the spinal cord

Answer 283

myelopathy

Question 284

myelopathy signs and symptoms

Answer 284

``` Spasticity Upper motor neuron Sensory level Bladder and bowel incontinence Pain Characteristic gait: Stiff and erect (Stiff Man Gait) ```

Question 285

A febrile diabetic with back pain and myelopathy has what?

Answer 285

epidural abscess til proven otherwise

Question 286

Acute; (+) Straight leg test Front of leg = L3/L4; Lateral = L5; Radiates to heel = S1 Sensory & reflex changes usually immediate w/ onset of pain

Answer 286

sciatica

Question 287

Confused w/ cellulitis & DVT Usually post-op  Severe hypersensitivity w/ swelling & sweating

Answer 287

CRPS/RSD/Causalgia

Question 288

``` Desire to move legs Feeling of motor restlessness Worse with rest or at night Better with activity dx by history ```

Answer 288

Restless leg syndrome

Question 289

Drugs taht cause tremor

Answer 289

beta agonists (sympathomimetics) Lithium Antipsychotic Valproic Acid

Question 290

Drugs associated with PerNeur

Answer 290

amidoraone vincristine metrnidazole halothane Vincristine B-6 INH are the biggies

Question 291

drugs with myopathis

Answer 291

statins steroids accutane chloroquine

Question 292

General myopathy symptoms

Answer 292

``` Painful Myalgias Cramps Contractures Myotonia - Stiff Myoglobinuria No weakness, fatigue, exercise intolerance, muscle atrophy ```

Question 293

``` Boys Absent dystrophin Pseudohypertrophy Positive Gowers sign Cognitive imparitment Waddling gait Cardiac probs High CPK ```

Answer 293

Duchenne's

Question 294

myopathies vs NMJ

Answer 294

NMJ Diseases generally involves proximal muscular weakness and is symmetrical. See MG and LEMS above

Question 295

Endocarditis or arrhythmia associate with what stroke

Answer 295

embolic

Question 296

HTN with what stroke

Answer 296

Lacunar

Question 297

CAD with what stroke

Answer 297

thrombotic

Question 298

Collective term that refers to different types of motor behaviors that are present in patients who have lesions of the descending corticospinal system

Answer 298

Spasticity always think brain or spinal cord

Question 299

common causes of spasticity

Answer 299

``` Stroke Cerebral Palsy Traumatic brain injury Anoxia Spinal cord injury MS ALS, PLS, MSA Metabolic diseases (Leukodystrophies) ```

Question 300

treatments for spasticity

Answer 300

``` Benzodiazepines, Baclofen, Tizanadine (Zanaflex) Botox. Also PT, serial casting, orthoses, orthopedic procedures ```

Question 301

``` Unilateral pulsating moderate to severe aggrevated by activity Photo & or phonophobia prodrome -> aura -> HA -> post drome ```

Answer 301

migraine

Question 302

types of migraine

Answer 302

common - no aura classic - aura complex - focal neuro deficity basilar - HA, N, vertigo

Question 303

tx for migraine

Answer 303

non pharm - foods, etoh, caff acute - nsaids, ergot, steroids, narcotics preventative - TCA, CCB (2nd) BB, Depakote, botox

Question 304

``` Unilateral severe ice pick retroorbital stiffness, rhinorrhea, occur in clusters smoker ```

Answer 304

cluster 02, steroids, lithium CCB

Question 305

``` base of skull to temporal region band like palpable muscle tension stress overlap with migrain 30 min to 7 days pressing or tightening ```

Answer 305

tension

Question 306

worst HA of my life

Answer 306

sub-arachnoid hemorrhage neuro emergency

Question 307

``` parkinsonisms frontal visuospatial dementia fluctuating cognition recurrent visual hallucination lang and mem still good ```

Answer 307

Lewy body dementia

Question 308

magnentic gait | incontinenc

Answer 308

normal p hydrocephalus

Question 309

How are peripheral neuropathies classified?

Answer 309

``` Acute Chronic Motor Sensory Compression Hereditary Axonal – Lower Amplitude Demyelinating – Slower amplitude ```

Question 310

myelinopathies types

Answer 310

acute - guillian barre | chronic

Question 311

Antibodies cross react with antigens on Schwann cells Associated with infections above Progression over course of 2 to 4 weeks with nadir by 2 weeks If longer than 8 weeks think CIDP Ascending symmetric weakness* DTRs absent* Tingling dysesthesia EMG/NCV shoe conduction block or prolonged motor velocities CSF shows elevated protein and pleocytosis of 10 lymphocytes Treatment is Plasma exchange or IVIG within 7 days of onset

Answer 311

guillan barrre

Question 312

NM disease DTR intact Perioral numbness dysphagia

Answer 312

botulism

Question 313

rule of 9's for glial based tumors

Answer 313

grade 4 - GBM - 9 mo to live grade 3 - astrocytoma - 18 mo to live grade 2 - glioma - 27+ mon

Question 314

Signs and symptoms of osteoporotic fracture

Answer 314

height loss, kyphosis, or unexplained back pain | previous or current facture

Question 315

mechanism of bisphonsphonates

Answer 315

*1. Inhibition of osteoclast formation *2. Inhibition of osteoclast activation *3. Inhibitation of mature osteoclast activity *4 Reduction in osteoclast life span-apoptosis Can cause Jaw osteonecrosis & frozen bone

Question 316

PTH analog

Answer 316

Teriparatide

Question 317

Actions of cortisol

Answer 317

• Primary active glucocorticoid • Antagonizes insulin secretion and action • Stimulates gluconeogenesis • Impairs protein synthesis in bone, skin, muscle and connective tissue • Impairs macrophage production of inflammatory cytokines • < 5% cortisol is free, physiologically active, and still filterable by the kidney • Circadian cycle – Peak before waking; nadir before sleeping

Question 318

Actions of aldosterone

Answer 318

• Primary mineralocorticoid • Stimulates Na+ / K+ sodium pump in the renal collecting duct – Minor Na+ retaining actions also on salivary ducts, sweat glands and GI tract

Question 319

actions of androgens

Answer 319

• DHEA and androstenedione are produced mainly in the Z. reticularis – Weak androgens, but converted to testosterone (a more potent androgen) in the testes • In males, adrenal androgens of little significance • In females, adrenal androgens are the major source of androgens and responsible for the development of pubic and axillary hair and for libido

Question 320

Stimulation testing

Answer 320

• For adrenal cortical insufficiency • ACTH (cosyntropin) stimulation test – IV ACTH stimulates an appropriate cortisol response in normals • Furosemide stimulation test – IV furosemide then 3 hours upright stimulates an appropriate aldosterone response in normals • Metyrapone stimulation test ( for secondary adrenal cortical insufficiency) – Oral metyrapone impairs cortisol production resulting in an appropriate ACTH rise in normals

Question 321

Suppression Testing

Answer 321

• For adrenal cortical hyperfunction • Dexamethasone suppression test – 1 mg of dexamethasone orally at midnight lowers 8 AM plasma cortisol level in normals • Saline suppression testing – Normal saline at 500 cc/hr for 4 hours lowers serum aldosterone level in normals

Question 322

– Muscle weakness; fatigue; weight gain; possible diabetic symptoms; menstrual changes; emotional changes; skin changes • Signs – Cushingoid facies; centripetal obesity; “buffalo hump”; edema; abdominal stria; hirsutism; HBP; osteoporosis

Answer 322

Cushing's Syndrome Iatrogenic most common

Question 323

Cushing’s Diagnosis

Answer 323

– Elevated plasma cortisol – Dexamethasone suppression test failure – ACTH may be elevated or low

Question 324

Cushing’s Treatment

Answer 324

– Pituitary or adrenal surgery • Adrenalectomy with replacement therapy conveys a 10% risk of a pituitary tumor w/in 10 years – Steroidogenesis inhibitors (e.g., ketoconazole, mitotane) • Generally reserved for poor surgical candidates

Question 325

adrenal adenomas are common | t/f

Answer 325

true

Question 326

• Usually 2° to an adrenal adenoma – possibly 2° to cortical nodular hyperplasia • Generally presents as hypertension with hypokalemia – Possibly accounts for up to 5% of hypertensive patients – Usually no edema 2° to “escape phenomenon” • Diagnosis – Elevated aldosterone levels • Plasma aldosterone concentration (PAC) and plasma renin (PRC) concentration: – PAC / PRC > 30 highly suggestive – Failure to suppress aldosterone with normal saline suppression testing

Answer 326

Primary aldosteronism (Conns syndrome)

Question 327

Secondary aldosteronism

Answer 327

• Usually renovascular disease (e.g., renal artery stenosis) – Rare renin producing tumors (e.g. juxtaglomerular cell tumor) • Edematous conditions (e.g., cirrhosis; nephrotic syndrome; CHF) – “third space” fluid but arterial hypovolemia prompts aldosterone release

Question 328

• Symptoms and signs – Fatigue; weight loss; nausea and vomiting; “bronze hyperpigmentation”; hypotension • Diagnosis – Low serum cortisol; elevated ACTH – Hyponatremia with hyperkalemia – Inadequate cortisol response to ACTH stimulation test

Answer 328

Primary adrenocortical insufficiency | Addison's Disease

Question 329

treatment for addisons

Answer 329

– Hydrocortisone 20-30 mg daily | – Fludrocortisone 0.05-0.1-mg daily

Question 330

• Possible panhypopituitarism • Generally iatrogenic – Rapid withdrawal from long-term steroid therapy • Especially fluorinated steroids – Medications (e.g., Dilantin, ketoconazole, rifampin, mitotane) • Alternate day prednisone to preserve HPA axis – e.g., prednisone 20 mg every other day; tapering from 10 mg of prednisone daily to 10 mg and 5 mg on alternate days, then 10 mg every other day, etc.

Answer 330

2ry adrenocortical insufficiency

Question 331

• Hypovolemic cardiovascular collapse | – Fatal if unrecognized

Answer 331

addisonian crisis

Question 332

addisonian crisis tx and prevention

Answer 332

• Treatment – IV Hydrocortisone 100-mg bolus followed by 10 mg / hour continuous infusion • Prophylactic stress steroids – 75-100 mg of hydrocortisone daily – Hydrocortisone 100 mg IV preoperatively

Question 333

``` – Symptoms • Paroxysmal beta adrenergic symptoms – Laboratory findings • Urinary free catecholamines, VMA, metanephrines – CT scan tumor localization ```

Answer 333

Pheochromocytoma

Question 334

treatment for pheochromocytoma

Answer 334

phenoxybenzamine

Question 335

type 1 DM clinical manifestations

Answer 335

``` polydipsia polyuria polyphagia Ketosis-prone absolute insulin deficiency ```

Question 336

infants and children first manifestation of Type 1 DM

Answer 336

ketoacidosis

Question 337

type 2 clinical manifestation of type 2

Answer 337

``` recurrent infections genital pruritis hyperglycemia, visual changes parasthesias and fatigue ```

Question 338

effects of hyperglycemia

Answer 338

glycation of proteins (hemoglobin, collagen) accumulation of sorbitol and fructose (nerves, lens) activation of protein kinase C (vascular cells)

Question 339

Diagnositc criteria for DM

Answer 339

 Hemoglobin A1c 6.5,  FBS 126,  2 hour postprandial glucose 200  Diagnostic criteria for IFG (FBS 100-125);  Diagnostic criteria for IGT (2-hour postprandial glucose 140-199);  Hemoglobin A1c 6.0-6.5 "high risk" for diabetes

Question 340

type 1 general treatment

Answer 340

insulin lifestyle modification --no glycemic control

Question 341

General treatment of type 2

Answer 341

diet, exercise, drugs | Glycemic control

Question 342

 Mechanism of action: Decrease hepatic glucose production  Little risk of hypoglycemia;  Lactic acidosis with CHF and renal failure;  Weight neutral Insulin secretagogues:

Answer 342

metformin

Question 343

insulin secretagogues names

Answer 343

sulfonylureas (glyburide, glipizide) repaglinide nateglinide

Question 344

 Mechanism of action: Increase basal and/or postprandial insulin secretion  Hypoglycemia can happen  Weight gain can happen

Answer 344

Sulfonylureas/glyburide:

Question 345

Possibly useful before the heaviest meal of the day

Answer 345

Meglitinides/nateglinide

Question 346

 Suppresses appetite;  Weight loss;  Improved insulin sensitivity;  Injectable

Answer 346

GLP-1 agonists/Exanatide:

Question 347

 Oral; similar to GLP-1 agonists but weight neutral

Answer 347

DPP-4 inhibitors/sitagliptin:

Question 348

 Mechanism of action: Enhance tissue response to insulin  Weight gain  CHF risk  long bone fracture risk

Answer 348

TZDs/pioglitazone:

Question 349

generally start type 2 DM meds with what

Answer 349

metformin and/or a sulfonylurea

Question 350

insulins - short, normal and long acting

Answer 350

``` aspart, glulisine, lispro - 4-6 hrs regular - 6-8 hrs NPH 12 -20 hrs Ultraiente 18-24 hrs Glargine 24 hrs ```

Question 351

70/30 dosing

Answer 351

most common insulin regimen 70% NPH and 30% regular morning dose covers glucose values before dinner evening covers fasting glusoce

Question 352

explain 70/30 dose adjustment

Answer 352

the patient takes 20 unitls of 70/30 before breakfast and supper but has hypoglycemic symptoms before supper but a consistent fasting Adjust 70/30 to 15 before breakfast and 25 before supper

Question 353

basal bolus isulin

Answer 353

basal one dose bolus based on carbs 1:15 CHO --short acting

Question 354

other DM goals

Answer 354

 Diabetic LDL <125/70 if nephropathy

Question 355

polydipsia, polyuria, polyphagia, fatigue, dyspnea, nausea / vomiting, abdominal pain, dehydration and may have been precipitated by an acute illness, fruity breath, tachycardia, tachypnea met acidosis hyperglycemia

Answer 355

Diabetic ketoacidosis

Question 356

tretment for DKA

Answer 356

IV fluid replacement --noarmal saline at 1000 cc/hr --expect rapid K+ decline with insulin and add 20-30 mEQ KCl/hour if K+ < 5.3 ----hold insulin therapy if admision K+ is < 3.3 Regular insulin NaHCO3 - only if pH < 6.9

Question 357

DKA stymptoms but without met acidosis and diff in treatment

Answer 357

Hyperglycemic Hyperosmolar State Never give bicarb

Question 358

most common cause of hypothyroidism

Answer 358

iodine worldwide | hashimotos in developed countries

Question 359

t4 low | tsh normal

Answer 359

2ry hypothyroidism

Question 360

``` tired dry skin cold poor memory constipagtion weight gain t4 low tsh high ```

Answer 360

hypothryoidism

Question 361

``` floppy baby umbilical hernia large tongue neuro damage pericardial effucsion ```

Answer 361

cretinism

Question 362

hypothyroid tx

Answer 362

t4 replacement levothyroxine at 50mcg wait 3 to 6 weeks to equilibriate

Question 363

``` AI dissorder HLA DR4 may have FH of AI dsease females TSI TSH low t4 high hyperactive heat intolerant palpitations fatigue wt loss thryomegaly tachycardia exopthalmose ```

Answer 363

hyperthyroidism

Question 364

graves treatment

Answer 364

beta blockers (propranolol) sometimes tpo inh --propylthriuracil, methimazole

Question 365

``` average age 60 goiter thyroid lymph infiltrate elevated TSH, low t4, TPO and anti-TG antibodies enlarged cystic nodular thyroid hypothyroid symptoms ```

Answer 365

hashimotos

Question 366

``` Acute onset mimic pharyngits/URI Thyroid tender to palpation hyperthyroid 1 mo - then hypoth 1 mo initially elevated ESR ``` tx

Answer 366

Viral thyroidits Treat with nsaids

Question 367

What compounds and medications interfere with a thyroid uptake and scan

Answer 367

Imaging Studies – Radioactive iodine uptake reflecting thyroid activity; also helpful for thyroid nodules – Beware of iodine-containing contrast media, thyroid medications, etc. for about 6 weeks prior to the scan** – “Hot” (autonomously functioning) nodules are nearly always benign – “Cold” nodules are usually benign, but are more likely malignant than “hot” nodules

Question 368

``` “stones, bones and groans” sually caused by adenoma hypercalcemia hypophospatemia high PTH osteoporosis osteomalcia kidney stones muscle waekness ```

Answer 368

hyperparathyroidism

Question 369

 “classic” subperiosteal bone resorption with prolonged disease, often involvin phalangeal tufts – rarely seen in developed countries anymore

Answer 369

 Osteitis fibrosa cystica | primary hyperparathyroidism

Question 370

gold standard for primary hyperparathyroid

Answer 370

surgical treatment can use calcitrol vit D cinacalcet

Question 371

```  Hypocalcemia  Hyperphosphatemia  Tetany; increased nerve excitability; uncontrolled cramp-like spasms of hand, feet, arms, face Usually Iatrogenic  Convulsions  Trousseau’s Sign positive ``` tx

Answer 371

primary hypoparathyroidism calclium and vit D

Question 372

 Excessive calcium intake along with absorbable alkali (e.g. baking soda) overwhelms kidneys ability to excrete excessive calcium  Hypercalcemia, metabolic alkalosis and renal insufficiency

Answer 372

Milk Alkali syndrome

Question 373

Hypercalcemia Treatment

Answer 373

 Normal saline  Sodium increases calcium excretion; treats (the usually underlying) dehydration  Furosemide  Impairs calcium reabsorption  Bisphosphonates  Impair bone resorption  Calcitonin  Impairs renal calcium reabsorption and bone resorption  Corticosteroids  Increase renal calcium excretion and impair calcium absorption from the gut

Question 374

 Myalgias, muscular weakness, cramps and fasciculations; ultimately tetany  Irritability and paresthesias; ultimately seizures and increased intracranial pressure  Signs  Chvosteck and Trousseau signs May be caused by mg def, vit d def

Answer 374

Hypocalcemia

Question 375

Most common cause – H. Pylori Duodenal (90%) and gastric ulcers (70%) PUD NSAIDs – 2nd tx

Answer 375

ulcers antisecretory therapy plus antibiotics

Question 376

Reflux disease treatment

Answer 376

Antacids (Tums) -intermittent mild symptoms H2 blockers (ranitidine, cimetidine, famotidines) -Mild to moderate, more consistent symptoms -Heals erosive esophagitis in 8 weeks Sucralafate (Carafate) -Bile Reflux Proton Pump inhibitors (Omeprazole, lansoprazole, -prazoles) -All levels of symptoms severity -Heals erosive esophagitis in 4 weeks in 70% of patients -Heals erosive esophagitis in 8 weeks in 90% of patients

Question 377

Difficulty swallowing Most often due to esophagitis, peptic benign stricture Less often cancer of the esophagus or a motility disorder like achalasia usually caused by reflux

Answer 377

dysphagia

Question 378

``` Painful swallowing Most often due to infectious esophagitis Viral like herpes or CMV Fungal like Candida esophagitis Pill induced esophagitis tetracycline, potassium; quinidine and bisphosphonates ```

Answer 378

Odynophagia

Question 379

what do you do first for dyshpagia

Answer 379

If you suspect the dysphagia is due to an esophageal origin should undergo an upper endoscopy If unsure if it is esophageal or pharyngeal do an upper endoscopy to rule out an esophageal cause You don’t want to miss an esophageal malignancy

Question 380

But not in place of endoscopy | Will show Stricture, Mass in esophageal cancer and in peptic stricturs

Answer 380

barium swallow

Question 381

Classic dilated esophagus Bird’s beak appearance Due to tight LES Best seen on Barium Swallow

Answer 381

achalasia

Question 382

History of Reflux or Barrett’s esophagus Now has Solid food dysphagia Weight loss

Answer 382

adenocarcinoma

Question 383

History of Reflux Now has Solid food dysphagia NO weight loss

Answer 383

peptic stricture

Question 384

History of intermittent dysphagia Solids, especially breads and meats No weight loss

Answer 384

Schatzki’s Ring or a Cervical Web

Question 385

scc of esoph

Answer 385

tobacco and alcohol women proximal to mid esop

Question 386

adenocarcinoma of esoph

Answer 386

barretts white males distal esoph/gastric cardia

Question 387

History of intermittent dysphagia Liquids or Solids & Liquids No weight loss

Answer 387

achalasia

Question 388

If patient has rectal Bleed first check

Answer 388

if orthostatic | may need to give fluids or resescetate

Question 389

``` Intermittent Diarrhea without blood Especially young woman May be associated with bloating and abdominal cramps No weight loss Rarely nocturnal diarrhea ```

Answer 389

IBD

Question 390

``` Middle age or eldery Blood mixed with stool Several months Now has lightheadedness Iron Def anemia ``` how to diagnose

Answer 390

Colon cancer colonoscopy

Question 391

``` Elderly History of Coronary Heart disease Few episodes of bloody bowel movement for 1 to 2 days Occurred with abdominal pain Hgb typically drops only 1 or 2 grams ```

Answer 391

Ischemic colitis

Question 392

Any age Very Short duration of bloody diarrhea Associated with ab pain and fever

Answer 392

infectious diarrhea

Question 393

``` Elderly Mult episodes of painless! large bloody bowel movements Primarily made up of blood May be orthostatic Labs show decreased hgb and hct Hgb may drob several grams from baseline If no evidence of upper GI bleed Most common cause of hemodynamically significant lower GI bleed in elderly Aorto-enteric fistula ```

Answer 393

diverticular bleeding

Question 394

Massive bleeding from rectum History of repaired abdominal aortic aneurysm Very unstable due to large amount of bleeding

Answer 394

Aorto-enteric fistula

Question 395

``` Microscopic Found only by positive hemoccult test Clinically significant If Cecal AVM – Red blood or melena If Small Bowel AVM – Melena ```

Answer 395

Bleeding from Arteriovenous Malformations

Question 396

Hematemesis Ab pain History of being on NSAIDs May have coffee grounds as well

Answer 396

PUD

Question 397

History of recurrent non-bloody vomiting followed by bloody vomiting

Answer 397

Mallory Weiss tear

Question 398

Coffee Ground emesis | History of heartbur

Answer 398

esophagitis

Question 399

``` Significant LLQ ab pain Fever No rectal bleeding Middle aged or elderly No diarrhea usually Diagnosed by CT scan NO colonoscopy or barium enema Can cause perforation ```

Answer 399

diverticulitis

Question 400

``` Infection with C difficile Multiple watery bowel movements With or without blood Ab pain and fever Febrile with ab tenderness Nursing patients on oncology floor, following chemo OR any patient following a course of broad-spectrum antibiotics Treat with metronidazole or vancomycin ```

Answer 400

Pseudomembranous colitis

Question 401

Small bowel, especially terminal ileum Transmural inflammation Not usually continuous involvement of the bowel Skip arease – areas of affected bowel interspersed with normal bowel ASCA Cobblestone Colon not usually involved Though it can be Diarrhea but no blood Pain more of a problem for them Diagnosed with colonoscopy Biopsies of terminal ileum, small bowel follow through, and capsule endoscopy Treated with immunosuppressants and immune modulator therapy

Answer 401

Crohns

Question 402

Only affects the colon No small bowel p-ANCA Crypt abscess Superficial ulceration of mucosal lining of colon No skip areas – continuous Rectum always involved Multiple bowel movements every day Small, frequent, soft, water, and can have blood Diagnosed by colonoscopy with biopsies Treated with anti-inflammatory agents and immunosuppression & (at times) immune modulator

Answer 402

Ulcerative colitis

Question 403

Ulcerative colitis and Crohns | Extra-intestinal manifestations

Answer 403

``` Erythema nodosum Pyoderma gangrenosum Arthritis, Iritis Episcleritis ```

Question 404

``` Small bowel disease Presents with diarrhea Large volume No blood Precipitated by ingestion of gluten Protein losing eteropathy due to gluten Actually sensitivity to gluten Diagnosed by blood test for tissue transglutimase antibody AND biopsy of small bowel during an endoscopic exam Biopsy will show flattening of villi AND accumulation of lymphocytes in lamina propria and epithelium Treatment: Avoid food with gluten ```

Answer 404

celiac sprue

Question 405

Used to detect a bleeding site when endoscopy or colonoscopy can’t find OR when patient is bleeding too rapidly to safely do endoscopy Often done prior to angiogram Radio-isotope injected IV into patient Images obtained at different time intervals to determine if a bleeding site can be found To be positive, patient should be bleeding 0.5 cc’s per minute

Answer 405

Tagged RBC scan or Bleeding scan

Question 406

Used to find and treat a bleeding site Catheter into femoral artery Dye injected into superior mesenteric, inferior mesenteric and celiac axis, & vessels they supply If bleeding site found, can use a special coil or glue to embolize the artery (stop the bleeding) To be positive, patient should be bleeding 1.0 cc per minute

Answer 406

angiogram

Question 407

``` History of excessive alcohol use Presents very ill Jaundice and even febrile AST > ALT; neither > 200 Bilirubin > 10, or even 20 High white count, like they have an infection (even though they don’t ```

Answer 407

alcoholic hepatitis

Question 408

History of IV drug use, mult sex partners w/ prostitutes, or dirty needle for tattoo (neighbor) Relatively ill on presentation Viral syndrome – achy all over, febrile Jaundice RUQ tenderness ALT > AST; both in high hundreds or thousands

Answer 408

Hep B acute

Question 409

Presents same as Hep B History of eating in questionable place Or in contact with someone with disease Or workers in Day Care

Answer 409

Hep A

Question 410

Chronic disease Usually asymptomatic, don’t know they have disease History of blood transfusions, IV drugs, tattoo many years ago ALT > AST but only mildly elevated; 100 to 250 Bilirubin normal

Answer 410

Hep C

Question 411

History of attempted suicide or history of injury Took more than recommended dose If alcoholic, less need to have toxic effect ALT > AST; usually very high, like in thousands High bilirubin

Answer 411

Acetaminophen Hepatitis

Question 412

``` History of significant hypotensive event Heart attack or sepsis Asymptomatic relative to liver disease ALT > AST; usually very high, like in thousands Bilirubin normal or slightly elevated ```

Answer 412

Ischemic hepatitis

Question 413

You want to do an elective procedure on a patient with cirrhosis t/f

Answer 413

false

Question 414

hep b vaccinated vs immunity

Answer 414

vaccinated are positive for anti-HBs but not anti-HBc | Immune are positive for both

Question 415

pharm and elderly

Answer 415

elderly have decrease in hepatic and renal metabolism so may need to decrease those drugs

Question 416

bladder innervation

Answer 416

• Parasympathetic (cholinergic) – S2-4: bladder contraction • Sympathetic (alpha adrenergic) – T11-L2: Bladder relaxation; bladder neck and urethral contraction • Somatic – Pudendal nerve: Pelvic floor muscular contraction

Question 417

• Females – Poor anatomic support / urethral dysfunction • e.g., Multiparous female with pelvic floor relaxation (groceries, sneeze, pee) • Males – Sphincter damage • e.g., Urethral sphincter damage from prostate surgery or radiation therapy

Answer 417

stress incontinence

Question 418

• Local GU conditions – e.g., tumor, stone, early obstruction, chr infection, adjacent GI inflamm or diverticulitis • CNS disorders – e.g., stroke, dementia, parkinsonism, SC lesions with impaired sympathetic innervation • Idiopathic – e.g., detrusor instability without GU or CNS disorder Spastic bladder and UTI is usual cause

Answer 418

Urge

Question 419

Dribblers • Anatomic obstruction – e.g., prostate hypertrophy, urethral stricture, large cystocele • Poor bladder contractility – e.g., diabetes, levels spinal cord injury with impaired parasympathetic innervation • Neurogenic – e.g., detrusor-sphincter dyssynergy

Answer 419

Overflow

Question 420

```  Chronic impairments of o Cognitive function o Mobility, Dexterity  Environmental factors  Psychological Factors ```

Answer 420

Functional incontinence

Question 421

Post void residual volume

Answer 421

• BladderScan PVR – Normal is < 200 cc • Very helpful in distinguishing between overflow incontinence and either urge or stress Normal UA but PVR is 300 -> Think overflow like a BPH

Question 422

Treatment for Stress inco

Answer 422

behavior therapis alpha adrenergic estrogen surgery*

Question 423

treatment for urge

Answer 423

behavioral therapies | bladder relaxent drugs

Question 424

treatment for overflow

Answer 424

surgery | catheterization*

Question 425

 Nearsightedness |  Difficulty seeing objects in the distance

Answer 425

myopia

Question 426

 Farsightedness |  Difficulty seeing near objects

Answer 426

hyperopia

Question 427

 Impaired accommodation (ability to focus on close objects)  Greek: “older vision”  Universal; begins at about age 40  Due to gradual age-related lens hardening & dimin muscular effectiveness of the ciliary body  “PERRL” treatment

Answer 427

presbyopia reading glasses or bifocals

Question 428

```  Blurry vision (“dirty glasses”)  Glare / “prism effect”, making it especially difficult to drive at night  Age-related opacities tend to migrate centrally until they interfere with vision  Predisposing factors  Increasing age  Diabetes  Smoking  Alcohol abuse ``` tx

Answer 428

cataracts  Phacoemulsion with intraocular lens implants  YAG laser capsulotomy in about 15% for subsequent capsular opacifications

Question 429

 Most common cause of blindness in the elderly  Characteristically central blindness  Usually excellent peripheral vision

Answer 429

macular degeneration

Question 430

 Drusen (yellow byproducts of metabolism) accumulate under the macula

Answer 430

dry macular degeneration

Question 431

 Increasing drusen accumulation with angiogenesis and choroidal neovascularization

Answer 431

wet macular deg

Question 432

treatment for macular deg

Answer 432

 Ocular vitamins (beta carotene 25,000 units, vit E 400 units, vit C 500 mg and zinc 80 mg)  Laser phototherapy for neovascularization  Intra-vitreal vascular endothelial growth factor inhibitor injections  Stem cell research

Question 433

 Characterized by ischemia, neovascularization, microaneurysms and hemorrhage.  Importance of annual ophthalmologic examinations for diabetics  Glycemic and antihypertensive control are both important

Answer 433

diabetic retinopathy

Question 434

 Optic nerve head damage and visual field loss even with normal intraocular pressures  Usually normal central vision with deteriorating peripheral vision  “Tunnel vision”; “blinders”  Aqueous drainage impairment leads to increased intraocular pressures

Answer 434

glaucoma

Question 435

 aqueous drainage / filtration is slowed  Usually asymptomatic and found on a screening exam by an eye professional  Peripheral visual loss is slow and subtle

Answer 435

open angle glaucoma

Question 436

 Aqueous drainage is blocked  Usually acute and symptomatic  Eye pain; headache; noticeable visual deterioration; possibly nausea and vomiting overshadowing eye pain  Conjunctival injection  May be provoked  Mydriatics; darkness; lens enlargement from growing cataracts; infection; inflammation; trauma, etc

Answer 436

closed angle glaucoma Give emergent treatment acetolzaolmide while in ER

Question 437

Glaucoma Treatment

Answer 437

 Eyedrops to suppress aqueous production (e.g.,beta blockers; alpha agonists)  Beware of systemic beta-blocker effects from eyedrops  Eyedrops to facilitate aqueous outflow (e.g., epinephrine, miotics such as pilocarpine, prostaglandins)  Emergency iridectomy for closed angle glaucoma

Question 438

* Common | * Thinning skin in an older persons external auditory canal produces thicker, drier and more adherent cerumen

Answer 438

Cerumenosis

Question 439

 Generally results from past noise exposure, ototoxic drugs, cochlear neural atrophy or damage (e.g., encephalitis)  Presbycusis (Greek: “older hearing”) • Generally relatively symmetrical and bilateral • High-frequency hearing loss predominates  Phonemic regression • Permanent hearing loss at the CNS level due to lack of stimulation (i.e., the brain “forgets” a frequency, and amplification is no longer helpful) treatment

Answer 439

Sensorineural Hearing Loss programmable digital amplification not hearing aids

Question 440

review rinne / weber

Answer 440

conductive - bone > air (cba) ----localizes to affected ear ssn - air > bone -----localizes to unaffected ear

Question 441

the pathobiology of alzhiemeirs is characterized by

Answer 441

amylid plaques | neurofibrillary tangles

Question 442

summary of dementia/depr/delirium

Answer 442

• Dementia – Progressive cognitive decline; often, the patient “forgets that he forgets” • Depression – “vegetative” symptoms such as lack of motivation (“anhedonia”), sleep disturbances, appetite and weight changes; flat affect • Delirium – Acute onset; delusions and hallucinations

Question 443

A healthy 70-year-old man drank a little more than usual with his friends at the American Legion. He fell, fracturing his hip, which was successfully pinned 3 days ago. His nurse calls you at 10:00 PM because he is agitated, and he claims that the CIA has bugged his hospital room. He most likely has:

Answer 443

delirum

Question 444

An 80-year-old woman complains of memory problems and lightheadedness with exertion during the past year, but she is otherwise healthy, and she takes no medications except for eyedrops for glaucoma. She most likely has:

Answer 444

• C. Beta-blocker-induced dementia

Question 445

• A depressed 80-year-old widow complains that her memory has worsened over the past 6 months. She has also noted generalized muscular weakness, a worsening exercise tolerance, visual disturbances, pedal edema, cold intolerance and easy bruisability during the past 6 months. She most likely has:

Answer 445

hypothroidism

Question 446

A 76 year-old man’s wife complains that his memory has never been the same since his previous doctor gave him “rat poison” for several “spells” of confusion and incoordination. He has an irregularly irregular heart rhythm. The most likely diagnosis is:

Answer 446

• D. Multi-infarct dementia

Question 447

Test Question #2 • A 70 year-old man’s wife complains of his increasingly worsening memory over the past 1 - 2 years. He is becoming more irritable, and he gets lost occasionally when driving his car. He most likely has:

Answer 447

alzheimers

Question 448

A 75 year-old widow who gives a detailed account of her poor memory ever since the death of her husband 6 months ago most likely has:

Answer 448

• C. Pseudodementia / depression

Question 449

spastic hemiparises gait cause

Answer 449

CVA

Question 450

Scissors gait cause

Answer 450

lower extremity spastic paresis from cervical spondylosis

Question 451

assistive devices and uses

Answer 451

``` ASSISTIVE DEVICES • 3- or 4-wheeled walker – e.g., ataxia, hemiparesis, scissors gait • 2-wheeled walker – e.g., Parkinson's • Cane – Antalgic gait • Maladaptive devices – e.g., Don’t use a cane for an ataxic patient ```

Question 452

hyponatreamia def

Answer 452

Na < 133 | determines intravascular volume

Question 453

hyponatremia types and causes

Answer 453

•Hypovolemic hyponatremia: Diuretics, GI losses (e.g. nausea, vomiting, diarrhea, nasogastric suction), severe burn wounds, marathon runner, etc. •Hypervolemic hyponatremia: CHF, nephrotic syndrome, cirrhosis, excessive IV. •Euvolemic (90% of all cases): SIADH, hypothyroidism, Addison's disease • Pseudohyponatremia: Hyperproteinemia, hypertriglyceridemia, hyperglycemia. • Psychogenic: Urine osmolality < 100

Question 454

Hyponatermia treatment

Answer 454

– Acutely altered mental status: 3% saline at 40-50 cc/hr (<12 mEq/24 hr) adjusting rate to increase Na+ by 0.5-0.6 mEq/hr until symptoms improve – Hypervolemic: Fluid restriction, diuretics – Euvolemic: Fluid restriction; treat underlying cause – Psychogenic: Fluid restriction. – Hypovolemic: Normal saline – Pseudohyponatremia: Treat underlying cause

Question 455

Law of consistency: If the pCo2 and HCO3 rise or fall in the same direction and at the rate expected

Answer 455

(HCO3= [1.1 to 1.3] x pCO2

Question 456

how to correct for hypoalbuminemia in met acidosis

Answer 456

– (Expected albumin – observed albumin) x 2.5 + (observed anion gap) is the actual anion gap.

Question 457

metabolic alkalosis causes

Answer 457

»likely diuretics, vomiting, hypokalemia (e.g., aldosteronism)

Question 458

creatinine and GFR relationship

Answer 458

inversely

Question 459

Acute Renal Failure causes

Answer 459

1. Pre Renal 2. Post Renal 3. Renal

Question 460

1. Mucous membranes are dry 2. Tenting of the skin- Where? • Thigh and calf 3. Flat neck veins 4. Orthostatics- Laying/Sitting/standing SBP >20 mm Hg fall,DBP>10 mmHg fall, Pulse increase of >20 5. Wait 3 min between each maneuver Fe Na 20/1 1. Volume loss (GI- N-V-D and diuretics) 2. Relative Vol Loss (CHF,Cirrhosis, Nephrosis, Pancreatitis, Burns, etc) 3. Gastro Intestinal Bleed 4. Hypercatabolic state (Prednisone, Sepsis Neoplasia, Burns) 5. TPN

Answer 460

Pre-Renal Azotemia

Question 461

Post Renal ARFCauses

Answer 461

 Obstruction-Acute, Chronic, Complete, Partial  Hydronephrosis  Usually takes days to develop or to resolve  Ultrasound  Dx- Age related- Reflux,UPJ, Radiation, Prostate cancer, Retroperitoneal Fibrosis

Question 462

```  Fe Na > 3  Bun/Cr < 15/1  U Na >20 1. No Tenting 2. Normal Membranes 3. Hypotension 4. Could be anything ```

Answer 462

Renal ARF

Question 463

Renal causes of ARF

Answer 463

```  Acute Tubular Necrosis 1. Toxins Vs. Ischemia (hypotension) 2. Oligouric Vs. Non-oliguric ARF Oliguria ≡ < 400 cc/24 hours Non-oliguric much better prognostically Glomerulonephritis Glomerulonephritis  Acute- RPGN- Crescent formation  Chronic  Primary Idiopathic  Secondary  Hypocomplementemic  Nephritic  i.e., active urinary sediment with RBCs, etc.  Nephrotic  Overlap ```

Question 464

1. Proteinuria (>3.0 Gms/day)… actually albuminuria 2. Edema 3. Hyperlipidemia ( why?)

Answer 464

Nephrotic syndrome

Question 465

acute interstitial nephritis causes

Answer 465

 Medications- ABX = 71%  Infection = 15%  TINU Syndrome (Tissue interstitial nephritis uveitis syndrome) = 8%  Sarcoidosis = 1%  Drugs = Methacillin/PCNs/Cephalosporins/Cimetidine (rare in other H2 blockers)/ Allopurinol/Rifampin NSAIDS !!!!!!

Question 466

Hyponatremia |  Symptoms- Basically, Altered Mental Status

Answer 466

 Rx- 3% saline at a rate to have serum Na increase by .5 to .6 meq/hr until symptoms improve

Question 467

Again, does not reflect Na stores,rather, total body H20 deficit Sx = Altered mental status  why?- brain cells “shrink”

Answer 467

Hypernatremia

Question 468

hypernatremia treatment

Answer 468

D5W; NOOOOO Salt!!! (e.g., NS, D5 1/2 NS, D5 1/4 NS)

Question 469

 EKG = “U” waves = prolonged QT interval  Muscle weakness  Muscle weakness may be profound; may not be able to walk  Cardiac Arrest K+

Answer 469

hypokalemia treat with K+

Question 470

 K+ 6.0 - 6.5 = Peaked T waves (all leads)  K+ 6.5 - 7.0 = Loss of P waves (EMERGENCY). Increased PR, wide QRS (>120 ms)  K+ of greater than 5.5  Symptoms - same as hypokalemia  Muscle weakness / cardiac arrest / death  Acute hyperkalemia is an urgent problem  Chronic hyperkalemia is not urgent

Answer 470

Hyperkalemia

Question 471

treatment for hyperkalemia

Answer 471

Ca Gluconate immediatley

Question 472

Anion Gap Metabolic Acidosis - MUDPILES

Answer 472

``` Methanol Uremia DKA Paraldehyde Isopropyl alcohol Lactic Acidosis Ethylene Glycol Salicylates ```

Question 473

met acidosis symptoms

Answer 473

 Severe Metabolic acidosis/Resp. Alkalosis  Stimulation of respiratory center tachypnea  Altered mental status = “Salicylate Jag”  Hypokalemia, elevated PT/PTT, hypouricemia, fever  Tinnitus

Question 474

Treatment for met acidosis

Answer 474

```  Alkalinize urine  Cathartic  Replace electrolytes  Dialysis  Bezoar - 35hr peak levels  NEVER SEDATE PATIENT ```

Question 475

Respiratory Acidosis causes

Answer 475

 COPD  End stage ARDS  Iatrogenic  Inability to remove CO2 with ventilation Turn up O2

Question 476

Respiratory Alkalosis

Answer 476

 Hyperventilation |  Causes- Anxiety, Sepsis, Fevers, Gram negative bacteremia, Iatrogenic, Aspirin toxicity

Question 477

Expected changes between co2 and hco3

Answer 477

 Say HCO3- is 14… 24-14 = 10  Expected PCO2 would be: 40 – (a range of 1.1 to 1.3) x 10 = 27 to 29. Expected PCO2 should be between 27 to 29. If higher = Respiratory Acidosis; if lower, Respiratory alkalosis or if C02 is 50, bicarb is 35 to 37

Question 478

4 kinds of kidney stones

Answer 478

calcium - hyperpara, uric acid - hyperuricemia cystine struvite - bacterail enzyme degredation

Question 479

struvite stone tx

Answer 479

remove stone and antibiotic

Question 480

* Generally asymptomatic until stones began to pass into the ureter. * Pain varies from mild to severe (“worse than childbirth”), and generally develops in paroxysms lasting 20-60 minutes. * Upper ureteral or renal pelvic obstruction generally causes flank pain; lower ureteral obstruction causes pain radiating to the ipsilateral testicle or labia, and both pain patterns may be present * Often associated with nausea and vomiting * Occasionally associated with dysuria and urgency when the stone enters the bladder or urethra what imaging do you get

Answer 480

noncontrast helical CT scan ultrasound if preg urinanalysis x-ray if calcium stone

Question 481

medical treatment for kidney stone

Answer 481

``` Encourage fluids for spontaneous passage Pain control – Opioids frequently necessary – NSAIDs fairly effective and may decrease ureteral smooth muscle tone, but might induce ARF and not feasible if vomiting Strain urine for stone analysis ```

Question 482

 May occur spontaneously in younger men  More common after an indwelling Foley catheter  Fever, chills, dysuria / usually very tender prostate*  Usually mild pyuria (8-10 WBCs/HPF)  Positive urine culture more likely following prostate exam treatment

Answer 482

acute prostatitis Usually oxyquinolone or third-generation cephalosporin antibiotics x 10 days

Question 483

 Recurrent acute prostatitis symptoms and/or chronic perineal pain and/or chronic dysuria  Symptoms and rectal tenderness frequently not as pronounced as with acute prostatitis; usually afebrile  Laboratory findings usually unrevealing  PSA not infrequently “artifactually” elevated treatment

Answer 483

chronic prostatitis  Generally requires at least 12 weeks of oxyquinolone antibiotics

Question 484

 Acute pain and often marked swelling of the epididymis  May be associated with prostatitis  Antibiotic treatment as for acute prostatitis  Usually oxyquinoline or third-generation cephalosporin antibiotics x 10 days  Warm baths and NSAIDs usually helpful acutely

Answer 484

Acute Epididymitis

Question 485

• Slow urinary stream • Incomplete emptying • May have urge incontinence early on and then develop overflow incontinence  Usually an enlarged slightly firmer prostate on rectal exam • Possible to have relatively isolated middle / transitional prostate lobe hypertrophy  Post void residual volume is usually increased

Answer 485

BPH

Question 486

BPH treatments

Answer 486

 Alpha adrenergic antagonists (e.g., doxazosin/Cardura; tamsulosin/Flomax) • Reduce prostate smooth muscle tone about the prostatic urethra  5-alpha reductase inhibitors (e.g., finasteride/Proscar) • Inhibit conversion of testosterone to free testosterone, inducing prosthetic atrophy  May result in diminished libido and erectile dysfunction  Usually reduces PSA values by about half; may reduces prostate cancer risk TURP, TUMP, PSV, TVP TIP

Question 487

 Largely obstructive; may be asymptomatic  Signs  Usually a firm nodular mass on rectal exam • Generally, all nodules must be biopsied  PSA usually elevated and/or rising • May be normal (normal values: 0.0-6.2)

Answer 487

Prostate cancer

Question 488

– Hematuria most common, usually painless – Occasional urgency, frequency and dysuria • Diagnosis – Usually by cystoscopic or flexible ureterorenoscopic biopsy – MRI / CT scan

Answer 488

Bladder or renal cancer usually transitional cell cancer

Question 489

• Primarily occurs between ages 20-40 – A testicular mass over age 50 is most likely lymphoma • 2-3 times more likely in an undescended testis – Orchiopexy prior to puberty reverses increased likelihood • Symptoms – Usually a painful testicular mass • A painless testicular mass is very likely cancer if not clearly a varicocele (bag of worms) or hydrocele (transilluminates)

Answer 489

testicular cancer

Question 490

if BRCA-1 or BRCA-2 – “Too late” if discovered on a pelvic exam – Ca-125 tumor marker with transvaginal ultrasonography helpful but debatably reliable

Answer 490

ovarian cancer

Question 491

Usually an abnormal vaginal discharge and abnormal vaginal bleeding, especially postmenopausal bleeding

Answer 491

Endometrial uterine cancer

Question 492

how to diagnose and treat

Answer 492

endometrial biopsy | hysterectomy

Question 493

• Increased risk with multiple sexual partners, likely due to HPV (human papilloma virus) • Diagnosis – Pap smear / colposcopy

Answer 493

cervical cancer

Question 494

most common organism in UTI

Answer 494

e coli

Question 495

– Urgency, freq, dysuria; occasional hematuria and/or an odiferous urine and/or suprapubic pain • Diagnosis – Clinical symptoms; urinalysis and urine culture

Answer 495

Cystitis 3 days of bactrim

Question 496

– Similar to cystitis but may include a vaginal | discharge in females

Answer 496

urethritis caused by chlamydia, gonorrhea and genital herpes

Question 497

– Usually fever, flank pain, nausea and vomiting – Possible present or antecedent symptoms suggesting lower urinary tract infection – May lead to sepsis or renal papillary necrosis • May present as sepsis / septic shock, especially in the elderly and in debilitated and/or demented patients – Often requires hospitalization, IV fluids and IV antibiotics

Answer 497

pyelonephritis

Question 498

gold standard to diagnose uti

Answer 498

urine culture | get a UA too

Question 499

flank pain and intractable vomiting

Answer 499

kidney stone

Question 500

WBC casts ... what is it and what to do

Answer 500

pyelonephritis --- need hospital and IV antibiotics to avoid septic shock

Question 501

Fatty casts

Answer 501

nephrotic syndorme

Question 502

RBC casts

Answer 502

nephritic syndrome

Question 503

ideal BP for a diabetic

Answer 503

125/75

Question 504

where to aim on xray images

Answer 504

``` AP - base of 2nd met lateral - lat cun/cuboid MO - lateral aspect of 3rd met/cun J LO - 1st met cun joint sesamoid - 3rd MPJ calc - achilles insertion ```

Question 505

x-rays rapiopaque and radiolucent

Answer 505

* Radiopaque - Bright | * Radiolucent- Dark

Question 506

filter used in podiatry

Answer 506

2.5mm total

Question 507

how many screens used in podiatry

Answer 507

one

Question 508

controls radiographic contrast.

Answer 508

kvp

Question 509

kvp and subject contrast

Answer 509

high kvp = lower subject contract low kvp = high subject contrast low kvp increases pateint dose

Question 510

determines the number of x-rays produced how much used in podiatry

Answer 510

mA | 15-30

Question 511

exposure time

Answer 511

1/60sec

Question 512

• Patient dose is therefore a function of

Answer 512

mAs

Question 513

• 15% rule

Answer 513

15% change in KVP is equivalent to 2 times of a change in MA | inversely

Question 514

Inverse Square Law

Answer 514

• Radiation intensity is inversely proportional to the square of the distance from the source

Question 515

common source to image distances

Answer 515

40" or 100cm

Question 516

focal spot sized used in podiatry

Answer 516

1MM

Question 517

greatest tool in keeping patient exposure as low as possible

Answer 517

Collimation

Question 518

Summary • Moderate to large SID • Small OID • Collimate to smallest field of view • Heel effect ( cathode side for thicker part) • Grids ( decrease scatter/ increase dose • Screens ( less x-rays needed)

Answer 518

physics

Question 519

words for bright on xray

Answer 519

Synonyms Radiopaque Sclerosis* Eburnation*  opaque -- increase in subject density leads to decrease in optical density. Film appears white.

Question 520

words for dark on xray

Answer 520

Radiolucent Rarefaction* Osteopenia* Osteolysis*  lucent - black areas on film. A decrease subject density leads to increase in optical density.

Question 521

 Bone apposition on xray

Answer 521

 100% is normal  0% is dislocated  Anything between is subluxed

Question 522

m/rems per years for workers

Answer 522

Thus a 20 year old radiology tech is allowed 5 (20-18) which is 10 m/rems per year total body exposure

Question 523

bipartite bones seen

Answer 523

sesamoides med cun navicular (rare)

Question 524

anteater signs

Answer 524

CN coaltion

Question 525

Sclerotic halo usually with flat foot

Answer 525

TC coalition

Question 526

os veselanium

Answer 526

off of 5th met base

Question 527

os peroneum

Answer 527

lateral to cuboid

Question 528

os eccentric interphalanges

Answer 528

prox lateral distal phalanx of hallux

Question 529

os naviculare

Answer 529

deeper in TN joint

Question 530

type II accessory navicular

Answer 530

against navicular but not joint

Question 531

growth plate appearances of foot bones

Answer 531

``` –Base of the phalanges (6 months-3 years) –Heads of the lesser metatarsals (2 years) –Base of 1st metatarsal (1 year) –5th metatarsal base (9-11-years) –Calcaneus (5 years) –Tibia (3 months) –Fibula (6 months) –Posterior talus (8 years) –Sesamoids (10 years) ```

Question 532

primary growth centers are all present at birth except

Answer 532

``` navicular cuboid? lat cun med cun int cun 2ry ossification centers ```

Question 533

apophysis vs epiphysis

Answer 533

• Epiphysis – part of bone that develops separately and then ankyloses. –Common in tubular bones. • Apophysis – outgrowth or swelling of bone. –Tuberosity

Question 534

multiple primary turn into what

Answer 534

bipartites

Question 535

common locations of a pseudoepiphysis

Answer 535

head of 1st met | bases of 2, 3, 4

Question 536

TC coaltion usually seen in 2nd decade and

Answer 536

–Anterior facet – MO –Posterior and middle – calcaneal axial –“C” sign –Talar beaking

Question 537

TN coalition best seen on what view

Answer 537

lateral

Question 538

how does a bone scan work

Answer 538

 Radioisotype (tracer) introduced by IV  WBC may be tagged to specifically address concerns of infection  Tracer is delivered via the vascular system  Tracer attracted to areas of new bone activity/formation  Localization to hydroxyappetite crystals of the bone matrix  Tc --A disruption of bone turnover by a pathologic process on the order of 5 to 15% from normal can be detected by bone scintigraphy - Specificity increases by performing an indium 111-labeled white blood cell test combined with a Technetium-99m-MDP injection.  A“Geiger”gamma camera counter picks up areas of radioactivity  Hot spots = Increased Uptake = Dark Areas  Cold spots = Decreased Uptake = Light Areas  Photograph taken over time (paper chromatography)  Cleared by kidneys and excreted in urine

Question 539

most commonly used bone scan radionuclides | why use

Answer 539

tech 99 good marker of inflammation Good for tumor localization and infection

Question 540

3 phases of a bone scan

Answer 540

Phase I-within 5 min after injection of Tracer – Blood flow phase Phase II-3-5 hrs post injection - Blood Pool/Inflammatory phase Phase III –approximately 24 hrs post injection – Delayed phase 6 hr ½life ½

Question 541

WBC labeled

Answer 541

WBCs migrate to areas of infection localization to bone implies a bone infection Indium-111 labeled WBC, Technetium - 99 labeled WBC (Ceretec) ((HMPAO-Hexamthylpropylamine)  Pts’ leukocytes are separated out and labeled with indium and reinjected into pt  hopefully can be used to assist in differentiation between between OM and Charcot Compare 4 hr tracer to 24 hr tracer, at 24 hrs if tracer still lights up then it is most likely OM

Question 542

bone scan diagnostic value

Answer 542

Any process that induces hyperemic regional blood flow will result in positive in the 1st and 2nd phase Active bony modeling is positive in 3rdphase Infection highly sensitive, but not specific

Question 543

indications for a CT

Answer 543

Imaging of complex structures or pathology Fractures of Midfoot and Rearfoot STJ imaging e.g. tarsal coalitions Evaluation of malunion/nonunions. Preoperative workupof Rearfoot and forefoot reconstruction

Question 544

CT potential problems

Answer 544

Metal may degrade image can give“star burst” Patient has to remain still for up to 30 minutes, may require IV/oral sedation Issues w/possible claustrophobia - unlikely for foot/ankle

Question 545

MRI is good for

Answer 545

 Inflammation, damage to soft tissue especially ligaments and tendons  Soft tissue masses, abscesses and osteomyelitis  Bone lesions (within bone and in cartilage)

Question 546

diff between T1, Spin, T2

Answer 546

```  T1 weighted images  Fat weighted/water suppression  Fat has high intensity signal (white)  Short TR (500ms or less)  Short TE (40ms or less)  Spin Echo  “Stir image”- short time inversion recovery  Water weighted  Long TR (1500ms or greater)  Short TE (40ms or less)  T2 weighted images  Water weighted/fat suppression  Water has high intensity (white)  Long TR (1500ms or greater)  Long TE (90ms or greater) ```

Question 547

MRI Danger

Answer 547

1- Small metal objects may move in the magnetic field and cause damage. Pacemakers and Cochlear implants are typically a contraindication to MRI. 2- Torpedo effect- Magnet can pull any metal object in room into the MRI field( pens, scissors, even wheelchairs 3- TATOOS MAY cause minor discomfort to patient during process.

Question 548

Metal implants

Answer 548

High grade stainless steel, titanium, metal alloys may cause artifacts to show up on image causing blurred image

Question 549

muscle on all mri is always

Answer 549

dark grey

Question 550

MRI with contrast

Answer 550

Contrast increases sensitivity to fluid  E.g. sinus tracts, small abscesses Gadolinium, Iodinated contrast Can be placed IV or into a joint

Question 551

tendon disease on MRI

Answer 551

Tendon DISEASE manifests itself as increased signal intensity- representing edema, myxoid degeneration, inflammation or tear. MRI helps to distinguish acute vs chronic tendonopathy.

Question 552

Magic Angle Effect/ tendon tear Pitfall

Answer 552

Magic angle effect is the phenomenon of anisotropic rotatioin or the 55 degree artifact, giving the false appearance of a tear on T1 On the T2 spin echo dataset, this great signal becomes hypointense and disappears TIPOFF: the normal appearance of surrounding fat and absence of fluid in sheath A true Tear is nearly always accompanied by tendon expansion and inflammatory reaction around the tendon

Question 553

Tendon Tear Classification

Answer 553

 0 Hypointense T1/T2  I. Hyperintense T1, hypointense T2= chronic tear/inflammationor MAE  II. Hyperintense T1&T2= acute a. < 50% tendon area (usually hypertrophic) b. >50% tendon area (hypertrophic or atrophic)  III. Rupture a. Supramalleolar b. Inframalleolar c. Juxtamalleolar

Question 554

- hyperthyroid induced osteopenia: - chronic use of anticonvulsant medication: - deficiency states: - vitamin-D deficiency: (strict vegetarians, no sun or an extremely low fat diet) - gastrointestinal and biliary causes; - renal osteodystrophy - fibrous dysplasia BONE NEVER GETS MINERALIZED FROM GET-GO – SOFT BONES

Answer 554

osteomalacia

Question 555

child Cupping, sclerosis and fraying of metaphysis Pseudofractures-LOOSER’S LINES Poorly mineralized epiphyseal centers with delayed appearance Widening osteoid seams  osteopenia Bowing deformities

Answer 555

rickets

Question 556

EXISTING BONE IS DEMINERALIZED/HYPERMINERALIZED Renal insufficiency and vitamin D deficiency disorders are most relevant Resultant high PTH leaches out the bone Medial side demineralization Sub-periosteal bone resorbtion distal tufts Periosteal lifting Ground glass Lace-like Vascular calcifications

Answer 556

parathyroid disorders osteitis fibrous cystica (browns tumors calcium replaced with fibrous tissue)

Question 557

``` DELAYED FUSION OF EPIPHYSIS DEFORMED OSSIFICATION CENTER/FRAGMENTATION WITH HETEROGENOUS APPEARANCE SHORT SLENDER SHAFTS OF LONG BONES DENSE TRANSVERSE BANDS IN METAPHYSIS WIDE CUPPING OF METAPHYSIS OSTEOPOROSIS OF METAPHYSIS ```

Answer 557

cretinism

Question 558

``` Over 40 male Increasing hat size Bone pain Familial incidence Chronic build-up and break-down of bone A-V shunts CHF Osteosarcoma can result Flame-shaped lesions/”blade of grass” in long bones Osteolytic lesions-OSTEOPOROSIS CIRCUMSCRIPTA Sclerotic bone mixed with lytic bone Bowed limbs, fail; Fractures, including "banana" or "chalk" transverse fractures “picture frame” vertebral body ```

Answer 558

Pagets disease (osteitis deformans)

Question 559

BONE RESORBTION – OSTEOPOROSIS EXOSTOSES ON LATERAL BORDER OF THE METAPHYSIS-Pelkan Spur “GROUND GLASS” INCREASED DENSITY AT METAPHYSIS-Frankel line SCURVY LINE: lucent line on shaft side of Frankel line CALCIFICATION OF SUBPERIOSTEAL HEMORRHAGE WINBERG’S SIGN - sclerotic line surrounding epiphysis

Answer 559

scurvy

Question 560

``` DECREASED DENSITY IN LONG BONES TRABECLAR COARSENING CORTICAL THICKENING DESTRUCTIVE LESIONS-INFARCTS MOTTLING-moth eaten Long slender bones SALMONELLA OSTEOMYELITIS PERIOSTEAL NEW BONE-BONE WITHIN A BONE BRACHYMETATARSIA from infarcts at growth centers DACTYLITIS with edema ```

Answer 560

sickle cell

Question 561

ELONGATION & THINNING OF LONG BONES ARACHNODACTLY ABNORMAL COLLAGEN

Answer 561

marfans

Question 562

* EXOSTOSIS * Joint Mice * Lipping * “Dorsal Flag” * Eburnation * Sub-Chondral * Sclerosis * Joint Space Narrowing * Joint Surface * Flattening * Ankylosis * Arthrodesis * Heberden’s Nodes * Bouchard’s Nodes

Answer 562

OA

Question 563

* Juxta-articular Cysts * Juxta-articular * Erosions * Joint Subluxation * Joint Dislocation * Osteoporosis * Osteopenia * osteomyelitis * Demineralization

Answer 563

RA

Question 564

* Effusion--Early * Joint Space Narrowing--Late * “Punched Out Lesions” * Overhanging Margins * Martel’s Sign

Answer 564

Gout

Question 565

* “Fluffy Heel Spur” * Ankylosing Spondylitis * Sacroiliitis * Vertebral Squaring * SHINING CORNERS * Syndesmophytes * Bony Bridging * Bamboo Spine * “Fluffy Heel Spur”

Answer 565

Reactive Reiter's

Question 566

* Erosions * Sacroiliitis * Terminal Whittling of Proximal Bone * “Pencil in Cup” * ARTHRITIS MUTILANS * Sausage Toe

Answer 566

Psoriatic arthritis

Question 567

Factors to be considered on all chest x-rays include

Answer 567

``` Inspiration Penetration Rotation Angulation Orientation ```

Question 568

Fluffy upper lobe infiltrates | Could be cocci, but can’t make that diagnose on xray

Answer 568

TB

Question 569

airspace disease associated with consolidation (coming together to form a mass). There is no volume loss. The air spaces are filled with a water density from the inflammation associated with microorganisms and pus. Most common infectious cause of death in U.S

Answer 569

Pneumonia

Question 570

Thin walled cavity think what | Thick

Answer 570

thin - TB, Cocci, WB | Thick -> lung/mass tumor

Question 571

enlarged heart on cxr, what test do you get next

Answer 571

Echo | could be pericardial effusion or cardiomegaly

Question 572

pneumothorax treatment

Answer 572

Treatment is to put on O2 or a breathing tube | Recognize if mediastinum is shifted (Tension

Question 573

SOB, previous DVT | get what test

Answer 573

CT angiography | VQ scan is second but a poor choice

Question 574

COPD signs on chest x-ray

Answer 574

enlargement of retrosternal space and diaphragm flattening

Question 575

CT considerations

Answer 575

Check all menstruating Female pt pregnancy status. Please note many teens will not be truthful about sexual activity. CTs irradiate the pt! •Think twice before ordering. •Only order when necessary. •Don’t do imaging without a purpose. •Know what you’re going to do with the information. •Will the results change your management?

Question 576

Contra-Indications to IV Contrast

Answer 576

Iodine Allergy | Renal Failure & Not on Dialysis (Based on BUN/Cr and GFR)

Question 577

Foreign Bodies imaging choice

Answer 577

ultrasound

Question 578

Salter Harris Classifications

Answer 578

``` 1 – transverse thru GP 2 – GP and Meta 3 – GP and Epiphysis 4 – GP and Meta and Epiphysis 5 – Crush injury ```

Question 579

Fracture from FOOSH from normal height

Answer 579

Refer to orthopedic surgeon | Dexa scan if fragility fracture

Question 580

MRI considerations

Answer 580

No metal allowed Dress in hospital gown No bras or hair clips Orthopedic implants ok (except eye for brain) Welders -> get plain film of orbit! Most pacemakers and defribillators not allowed Beware of shrapnel Closed Scanner -> better image quality, but can cause claustrophobia Open -> more comfortable but poorer image 30 to 60 mins Loud noise 400 to 3000 dollars

Question 581

Acute Appendicitis imaging

Answer 581

US in kids | CT in adults

Question 582

Gallstones imaging

Answer 582

ultrasound

Question 583

DVT Dopper things to look for

Answer 583

Compression Color Flow Augmentation

Question 584

metastasis to bone | sclerotic and lytic

Answer 584

Sclerotic: Prostate, Lung, Breast Lytic: Breast, Lung, Renal Cell, Thyroid, MM

Question 585

Complications of pagets

Answer 585

``` Pathological fractures 2ry Osteoarthritis Bony deformities Deafness Spinal Stenosis High output CHF Osteosarcomas ```

Question 586

how to differ bakers from dvt

Answer 586

Ultrasound | MR if ruptured

Question 587

atlanto-axial subluxation seen in what

Answer 587

rheumatoid

Question 588

avn commonm places

Answer 588

1. Femoral Head 2. Humerus 3. Knee 4. Talus

Question 589

``` SI involvement bilateral syndesmophytes enthsitis whiskering bamboo spine \ ```

Answer 589

ankylosing spondylitis

Question 590

``` asymmetry DIP early widening of joint later narrowing pencil in cup ```

Answer 590

psoriatic arthritis

Question 591

grading edema

Answer 591

* 0- no edema present * 1- mild * 2- moderate * 3-moderate to severe * 4-severe

Question 592

• Valleix Phenomenon

Answer 592

– Percussion of the nerve causing proximal and distal radiation or paresthesias

Question 593

muscle strenght testing

Answer 593

0 No muscle contraction is detected 1 A trace contraction is noted in the muscle by palpating the muscle while the patient attempts to contract it. 2 The patient is able to actively move the muscle when gravity is eliminated. 3 The pt may move the muscle against gravity but not against resistance from the examiner. 4 The patient may move the muscle group against some resistance from the examiner. 5 The patient moves the muscle group and overcomes the resistance of the examiner. This is normal muscle strength

Question 594

inflammation of vein with blood clot (thrombus) formation (superficial & deep

Answer 594

thrombophlebitis

Question 595

painless, insidious swelling of the Tissues leadiang to decreased function of the lymphatic system. May be congenital or acquired

Answer 595

lymphedema

Question 596

Arthritic classes by synovial class

Answer 596

``` I - non-inflmmatory (OA, ON, Charcot) II - inflammatory (RA, etc) III - septic IV - hemorrhagic ---trauma, PigVillSyn, TB, Neoplasia, Charcot, coagulopathy ```

Question 597

Class I synovial fluid findings

Answer 597

``` Clear/yellow Transparent WBC < 2,000 <25% pMNs Culture negative ```

Question 598

ClassII Synovial findings

Answer 598

``` Yellow/White Translucent/opaque WBC 2,k to 100k > 50%pMNs culture neg ```

Question 599

Class III synovial findings

Answer 599

``` yellow/white Opaque > 100k WBC > 95% PMNs Culture positive ```

Question 600

Class IV synovial findings

Answer 600

Red | Opaque

Question 601

physical findings of OA

Answer 601

firm swelling around joint crepitus restricted ROM

Question 602

OA common joints

Answer 602

``` hips knees 1st carpal metacarpal joint 1st MTP PIP, DIP ```

Question 603

RA common joints

Answer 603

wrists MCP ankles MTP

Question 604

lab tests for RA

Answer 604

``` high ESR high CRP' post rf pos ccp anemia ```

Question 605

ACR criteria for RA

Answer 605

``` Morning stiffness > 1 hour 4 or more Arthritis of >3 joint areas Arthritis of hand joints (MCPs, PIPs, wrists) Symmetric swelling (arthritis) Serum rheumatoid factor Rheumatoid nodules Radiographic changes ```

Question 606

extra-articular features of RA

Answer 606

``` Anemia (most common extra-articular feature) Nodules – elbows, achilles Lung disease: fibrosis, nodules, pleural Cardiac: pericarditis Vasculitis FeltySyndrome Sjogrens syndrome Lymphadenopathy ```

Question 607

treatment for RA

Answer 607

- NSAIDS (pros and cons) - Corticosteroids (lowest dose possible) - Methotrexate – start at 7.5 or 10mg/week, monitor CBC, Renal, LFT, albumin - DMARDS

Question 608

``` Foreign body sensation (sandy or gritty) Dry or decreased tearing Burning Photosensitivity Itching Filmy sensation ```

Answer 608

sjogrens syndrome

Question 609

``` RA Splenomegaly Neutropenia Other Features Anemia Thrombocytopenia Lymphadenopathy Leg Ulcers Skin Pigmentation ```

Answer 609

Felty Syndrome

Question 610

5 clinical syndromes of Psoriatic arthritis

Answer 610

``` Asymmetric oligoarticular Symmetric polyarticular Arthritis Mutilans DIP Only Axial Skeleton ```

Question 611

definitive diagnosis of gout

Answer 611

“the definitive diagnosis is possible only by aspirating and inspecting synovial fluid or tophaceous material and demonstrating needle shaped monodsoium urate crystals with negative birefringence under polarized microscopy

Question 612

treatment for asymptomatic hyperuricemia

Answer 612

nothing

Question 613

uricosurics

Answer 613

probenicid

Question 614

xanthine oxidase inh

Answer 614

allopurinol (start at 100) Feuxostat - hepatic glucoronidation 40mg start

Question 615

``` PMales over 60 Knee chondrocalcinosis often degenerative Crystalls CPPD Small rod like positive birefringence ```

Answer 615

pseudogout

Question 616

``` Inflammatory back pain: Lumbar or buttock pain lasting> 3mo. pg Alternating buttock pain Pain worse c rest Pain improves c activity Back stiffness> 30 min Pain awakening pt. in the second half of the night* Consider what ```

Answer 616

spondyloarthropathy

Question 617

Seronegative Diseases Share

Answer 617

``` 1. Enthesitis 2 Axial arthritis 3. Peripheral arthritis 4. Tendency toward new bone formation 5. Extraarticular features 6. THE HLA B27 ANTIGEN ```

Question 618

Prototype of the seronegative spondyloarthropathies Clear link c HLA Clear link c HLA--B27 mechanism ??? Usually presents c backpain Male predominance but women do get it (3:1) Enthesitis -- enthesopathy Peripheral arthritis New bone formers  Extraspinal manifestations: Eye-acute anterioruveitis Heart-- aortic insufficiency Lung--apical disease

Answer 618

ankylosing spondylitis

Question 619

Seronegative asymmetric arthropathy (predominantly lower extremity) Plusone or more of the following –– Urethritis/cervicitis –– Dysentery Dysentery –Inflammatory eye disease –– Mucocutaneous disease: balanitis, oral ulceration, keratodermia

Answer 619

reactive arthritis

Question 620

diabetic complications

Answer 620

heart disease blindness kidney disease amputation

Question 621

Tissue changes in diabetes

Answer 621

 Altered protein function and turnover, cytokine activation  Osmotic and oxidative stress  Reduced motor and sensory nerve conduction velocity  Increased glomerular filtration rate and renal plasma flow

Question 622

pedal complications in diabetes

Answer 622

``` Neuropathy Vasculopathy Immunopathy Limited Joint Motion Ulcerationi Infection Gangrene Charcot Collapse ```

Question 623

unholy triad

Answer 623

Neuropathy….….loss of sensation to extremities Vasculopathy …..decreased blood flow Immunopathy…..inability to fight infection

Question 624

risk stratification for diabetics

Answer 624

0 - normal - q12 m 1 - PN - q6 m 2 - LOPS, deformity, PAD, q3m 3 - Previous ulcer or amp q1-3m

Question 625

wagner wound classification

Answer 625

 Grade 0: No open lesions  Grade 1: Superficial Ulcer  Grade 2: Deep Ulcer  Involves ligament, tendon, joint capsule or fascia  No abscess or osteomyelitis  Grade 3: Deep ulcer with abscess, osteomyelitis, or joint sepsis  Grade 4: Local Gangrene of forefoot or heel  Grade 5: Extensive gangrene of entire foot

Question 626

UNIVERSITY OF TEXAS WOUND CLASSIFICATION

Answer 626

Stages  Stage A: No infection or ischemia  Stage B: Infection present  Stage C: Ischemia present  Stage D: Infection and ischemia present Grading  Grade 0: Epithelialized wound/no wound  Grade 1: Superficial wound  Grade 2: Wound penetrates to tendon or capsule  Grade 3: Wound penetrates to bone or joint

Question 627

* ‘Pain arising as a direct consequence of abnormalities in the somatosensory system in people with diabetes.’ * A diagnosis of exclusion and is a clinical diagnosis

Answer 627

diabetic neuropathy

Question 628

PN large fiber vs small fiber

Answer 628

``` Large fiber ▫ Large myelinated fibers (5% of nerves) ▫ Touch, vibratory sense, proprioception ▫ Late finding ▫ Severe disease ▫ Stabbing or shooting symptoms are most common of nerves) ``` ``` Small Fiber ▫ Unmyelinated and small myelinated nerves (95% f ) ▫ Pain, temperature ▫ Earliest finding ▫ Documentable changes precede symptoms ▫ Burning is most common ```

Question 629

diabetic PN motor neuropathy

Answer 629

``` Proximal Amyotrophy-presents with pain, atrophy, and weakness (difficulty standing up, climbing stairs) Unilateral Weight loss Distal Intrinsic muscle wasting Hammertoes Hallux limitus Equinus ```

Question 630

= Rapidly reversible sensory symptoms in poorly controlled diabetic patients during episodes of elevated blood sugar.

Answer 630

hyperglycemic neuropathy

Question 631

= Asymptomatic neuropathy becomes temporarily symptomatic with rapid drop in blood sugar

Answer 631

“Insulin Neuritis”

Question 632

PN best prevention tool

Answer 632

normoglycemia

Question 633

therapeutic options for PN

Answer 633

``` •Symptom Relieving Only ▫ Physical modalities ▫ Antidepressants ▫ Anticonvulsants •Disease Modifying ▫ Intensive glucose management ▫ Antioxidants/nutriceuticals ▫ Decompression ```

Question 634

meds used for PN

Answer 634

TCA (amitriptyline) SNRI (cymbalta, effecxor) anticonvulsants (gabapentin, Lyrica) Opiods (tramadol) Membrane stabilizers (Lidocaine, Mexilitine) Nutriceutilcals (b-complex, alpha lipoid acid, folate, vit C)

Question 635

Major predisposing factor for DFI is

Answer 635

DF ulcer

Question 636

evidence of infection in DFU

Answer 636

Redness, warmth, swelling, tenderness, or pain | Purulent secretions, undermining of skin edges, foul odor

Question 637

Factors that increase risk of infection:

Answer 637

Probe-to-bone test +, >30 days, recurrent ulcer, PVD | LOPS, renal insufficiency, barefoot walker

Question 638

Clinical Classification of a Diabetic Foot Infection

Answer 638

Uninfected or Grade 1: No signs of infection. Mild or Grade 2: Locally infected ulcer Moderate or Grade 3: Foot or limb threatening. Severe or Grade 4: Life threatening.

Question 639

• Granulation tissue base • No deep tracts • No cellulitis o Most diabetics will respond with cellulitis • No purulence o Serous drainage = normal • Wound lacking purulence or anymanifestation of inflammation.

Answer 639

Grade 1

Question 640

* Presence of ≥2 manifestations of inflammation. * Cellulitis that extends ≤2cm around the ulcer. * Infection is limited to skin or superficial subcutaneous tissues. * No other local complications or systemic illness.

Answer 640

Grade 2

Question 641

• Infection in patient who is systemically well and metabolically stable. o Has ≥ 1 of the following characteristics: o Cellulitis extending ≥2cm, o Lymphangitic streaking, o Spread beneath the superficial fascia, o Deep tissue abscess, o Gangrene, o Involves the muscle, tendon, joint and/or bone.

Answer 641

Grade 3

Question 642

Signs of a Limb-Threatening Infection

Answer 642

``` Evidence of systemic inflammatory response Rapid progression of infection Extensive necrosis or gangrene Crepitus on examination Soft tissue gas on imaging Bullae, especially hemorrhagic New onset wound anesthesia Pain out of proportion to clinical findings Recent loss of neurologic function Critical Limb Ischemia Extensive soft tissue loss Extensive bony destruction Failure of infection to improve with appropriate therapy ```

Question 643

Infection in patient with systemic toxicity or metabolicinstability. Examples include; fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycemia, or azotemia.

Answer 643

Clinical Classification of a DFI Grade 4: Severe

Question 644

avoid prescribing antibiotic for what

Answer 644

uninfected ulcers

Question 645

when treating DFU as outpatient

Answer 645

``` Stabilize the patient In office I&D Deep tissue culture Appropriate antibiotic coverage –this may be adjusted on follow up or with culture results Appropriate shoe wear/off-loading Appropriate wound care ```

Question 646

Treatment of Infection -When treating in hospital;

Answer 646

Stabilize patient Obtain appropriate labs, studies and consults. Surgical I&D, deep cultures, post-op management and appropriate antibiotics. Discharge as soon as patient able.

Question 647

if patient had MRSA in past.....

Answer 647

treat them for MRSA

Question 648

common topicals and how long to use

Answer 648

``` IDSA recommend use for 1-2 weeks only. Common examples: Mupirocin Silver compounds (incl: Silvadene) Iodine compounds (incl: Betadine) Gentamicin/Triple Abx preparations Transition to wound gel once infection controlled ```

Question 649

IDSA indication for soft tissue infections with oral meds

Answer 649

2-4 weeks of oral antibiotics. | For osteomyelitis: up to 3 months combined therapy.

Question 650

indications for IV antibiotics

Answer 650

Typically reserved for Limb or Life Threatening DFI’s. Generally started in a hospital setting. The selection of the antibiotic is often hospital directed. If MRSA suspected, or patient history, the patient will be empirically covered. Infectious disease (ID) consults helpful in determining appropriate coverage.

Question 651

mild Staph aurues infection

Answer 651

Keflex Augmentin (amox/clav) Clinda

Question 652

mild MRSA infection

Answer 652

Doxycycline | Bactrim

Question 653

moderate staph infection

Answer 653

ampicillin-sulbactam ertapenem imipenem

Question 654

moderate to severe MRSA

Answer 654

Vancomycin Linezolid Daptomycin

Question 655

Pseudomona infection

Answer 655

mild - quinolones | mod - Pipercillin tazobactam (zosyn) (broad)

Question 656

definitive diagnosis of osteomyelitis

Answer 656

bone biopsy

Question 657

plain radiographs for osteomyelitis

Answer 657

``` Periosteal reaction/elevation Loss of cortex with bony erosion Loss of trabecular pattern or marrow radiolucency New bone formation Bone sclerosis with or without erosion ```

Question 658

```  Classic periwound signs  Brawny edema  Hyperpigmentation  Lipodermatosclerosis  Located in the gaiter (supramalleolar) region  Irregular borders  Copious drainage  Beefy red base  Painful ```

Answer 658

venous ulcers

Question 659

```  Classic peri-wound signs and symptoms  Weak pulses/delayed capillary refill  Skin shiny, atrophic, dry  Intermittent claudication or rest pain  Location typically dorsal, distal and over bony prominences  No drainage  Pale base  Black eschar often found  Very painful ```

Answer 659

Arterial (Ischemic) Ulcers

Question 660

``` Classic associated findings Diminished sensation Poorly controlled DM Located plantarly Round with peri-wound callus and undermining Painless Base is variable Drainage is variable ```

Answer 660

diabetic ulcers

Question 661

``` Classic historical findings Institutionalized patient Immobile or confined to bed May have DM, VI, or PAD Always located over bony prominences Often painful but not always Base may be pale/black if ischemic Often very deep ```

Answer 661

Pressure ulcers

Question 662

Most common cutaneousmarker of diabetes (present in 40 -50% of diabetic patients) Sign of increased likelihood of internal complications Males > females (2:1) Shins & feet Round, flat red papules Fine Scale Depressed hyperpigmented areas may appear later Caused by microangiopathy May be confused with psoriasis (different histopathology) and with NLD (not waxy or shiny) Rarely symptomatic but may respond to corticosteroid cream (use care in the pretibial region) Keep skin moisturized Control blood sugar

Answer 662

diabetic dermopathy

Question 663

``` Abrupt appearance Acral location (Acral = away from central trunk) Porphyrin levels Immunoflourescence Intraepidermal Subepidermal no hx of trauma ```

Answer 663

bullosis diabeticorum

Question 664

``` Clear, non hemorrhagic Non-inflammed base Tips of toes and fingers Long--standing diabetes Peripheral neuropathy Good circulation Heals without scarring NO HISTORY OF TRAUMA ```

Answer 664

intraepidermal blisters of BullDiab

Question 665

``` May be hemorrhagic Non-inflammed base Tips of toes & fingers, NWB Areas Heals with scarringand atrophy NO HISTORYOF TRAUMA ```

Answer 665

subepidermal blisters of bulldiab

Question 666

``` Collagen degeneration w/ granulomatous response Initial lesion often red or violaceous papule/patch Lesions enlarge into -–Sharply demarcated ––Indurated, waxy appearing –– Depressed or atrophic –– Yellow-brown plaques –– Raised borders –– Telangiectasia common Most common on shins Most commonly bilateral May precede precede the diagnosis of diabetes in 15% Lesional anesthesia is a hallmark ```

Answer 666

Necrobiosis Lipoidica (Diabeticorum)

Question 667

considerations for Necrobiosis Lipoidica

Answer 667

``` malignant transformation (biopsy it) biopsy ```

Question 668

treatment of NLD

Answer 668

topical steroids | intralesional steroids