COMBANK IM COMAT Flashcards
H Pylori treatment
triple therapy: PPI (omeprazole), clarithromycin, and amoxicillin
— twice daily dosing
O-CLAM
What is H Pylori quadruple therapy? When to use?
Quadruple therapy is less preferred and is currently used if there is recurrence.
It consists of omeprazole 20 mg twice daily, bismuth subsalicylate 2 tabs four times daily, tetracycline 500 mg four times daily, and metronidazole 500 mg three times daily
H pylori chronic gastritis predisposes to what?
MALT Lymphoma (MALTomas)
Pathophys:
- accumulation of CD4+ lymphocytes and mature B cells in the gastric lamina propria in H pylori-induced gastritis.
- antigens produced from H. pylori activate T and B cell proliferation, and lymphoid follicle formation
- If this is persistent if can become a monoclonal lymphoma (B cells)
deficiency in vitamin B3
(niacin)
Pellagra
4 D’s: dermatitis, diarrhea, dementia, and death
— (photosensitive pigmented dermatitis in sun exposed areas)
deficiency in vitamin B1
(thiamine)
Wernicke-Korsakoff syndrome
- – Wernicke’s encephalopathy is manifested by necrosis of the mammillary bodies in the periventricular region of the brain. Symptoms include progressive dementia, confusion, ataxia, and paralysis of the extraocular muscles. This causes ophthalmoplegia of the bilateral lateral rectus muscles, which results in a sixth nerve palsy.
- – Korsakoff psychosis is a thought disorder that results in retrograde memory failure and confabulation. The most common causes of thiamine deficiency include poor diet and chronic alcoholism.
deficiency in vitamin B12
(cobalamin)
subacute combined degeneration
— of the dorsal and lateral spinal columns due to a defect in myelin formation. Peripheral neuropathy can result, which is SYMMETRICAL in nature and affects the LEGS more than the arms. It manifests with paresthesias, ataxia, and loss of vibration and position sense.
who gets vit B12 deficiency
Get Cobalamin (vit b12) from animal products so think of this in vegans or due to inadequate absorption associated with pernicious anemia or Crohn’s disease
deficiency of vitamin B2
(riboflavin)
cheilosis or angular stomatitis (scaling lips with fissures), and glossitis.
— cracked and red lips, inflammation of the tongue, mouth ulcers, cracks at the corners of the mouth, and a sore throat.
may also cause dry and scaling skin, fluid accumulation in the mucous membranes of the mouth, and an iron-deficiency anemia. The eyes may also become sensitive to bright light. Additionally, patients may develop seborrheic dermatitis on the face or genitalia
who gets vit B2 deficiency
patients with anorexia nervosa or with malabsorptive syndromes such as celiac sprue.
deficiency in vitamin B6
(pyridoxine)
stomatitis, glossitis, cheilosis, irritability, confusion, and depression
— inflammation and fissuring of the lips, cheilosis occurring at the corners of the mouth, atrophy of the mucosa of the tongue, and seborrheic dermatitis.
can also lead to polyneuropathy in adults. Also microcytic, hypochromic sideroblastic anemia with the presence of basophilic stippling seen on a peripheral blood smear.
who gets vit B6 deficiency
pregnancy or therapy with certain medications, such as the anti-tuberculosis drug isoniazid.
Another common cause of vitamin B6 deficiency is chronic alcoholism.
vit B2 vs vit B6 deficiency
both can have cheilosis or stomatitis
- B6 has irritability/confusion and polyneuropathy
- anemias are different:
- – B2 is IDA
- – B6 is microcytic hypochromic sideroblastic anemia
long term management of Afib
rate control + anti-coagulation tx
- – rate: Ca channel blocker or B-blocker
- – anti-coag based on CHADS2VASC
When to do electrical cardioversion for Afib
Afib with RVR in hemodynamically unstable pts or for new-onset Afib of <48hrs
acid-base status in DKA
high anion gap metabolic acidosis (with respiratory compensation)
what to watch out for in pt on aldosterone antagonist and ACEi or ARB
hyperkalemia
HCTZ common side effects
hypercalcemia hyperuricemia hyperglycemia hypokalemia hyponatremia hypomagnesemia
Carvedilol common side effects
bradycardia heart block hyperglycemia weight gain impotence
Enalapril common side effects
hyperkalemia
renal insufficiency
cough
angioedema
Spironolactone common side effects
hyperkalemia
gynecomastia
renal insufficiency
Aspirin common side effects
tinnitus
bleeding
interstitial nephritis
manifestations, causes, and corrections of every electrolyte disturbance
**look up****
Electrocardiogram shows a wandering baseline and irregular complexes with a faint pulse
V fib
- characterized by irregular, random waveform with no discernible p waves or QRS complexes
atrial fibrillation rate
> 400/min
atrial flutter rate
typically ~300bpm
electrocardiogram remarkable for varying R-R intervals and a wavy baseline
A fib
best way to differentiate A fib from A flutter
A flutter has clear presence of p waves in a regular rhythm
main causes of atrial flutter
rheumatic heart disease (mitral valve involvement), chronic obstructive pulmonary disease, pericarditis and atrial septal defect
F waves on EKG
correspond to the sawtooth pattern of atrial flutter and are best appreciated in leads II, III, and aVF
Wolff-Parkinson-White (WPW) EKG
- narrow complex tachycardia with a short PR interval and a delta wave.
- delta wave is pathognomonic
- – early depolarization of the ventricle
Clinical manifestations of WPW syndrome
sudden onset of tachycardia, rapid pulse and fatigue
Selenium deficiency dz & sx
Keshan disease
presents as congestive cardiomyopathy with an enlarged heart in children and young female living in endemic areas with low soil concentration of selenium
where do you see Selenium deficiency
some parts of China, New Zealand and Finland
foods rich in selenium
fish, shellfish and eggs.
Dry beriberi
symmetrical peripheral neuropathy with both motor and sensory impairment
Wet beriberi
(in addition to neuropathy) signs consistent with CHF including cardiomegaly, lower extremity swelling, and tachycardia.
Acute calcium deficiency sx
various manifestations of neuromuscular dysfunction including peri-oral numbness, paresthesias, muscle spasms, muscle cramps and seizures
foods rich in Zinc
oysters, beef, crabs and cereal.
where are zinc deficiencies seen
middle eastern countries
mild zinc deficiency
decrease taste sensation (hypogeusia), night blindness, and decreased spermatogenesis.
severe zinc deficiency
diarrhea, alopecia, pustular dermatitis, and decreased immunity with frequent infections
chronic zinc deficiency
stunted growth in children with hypopigmented hair
presentation of pulmonary embolism on ECG
- most commonly sinus tachycardia
- right-axis deviation
- a S1Q3T3 (S wave in lead I, lead III with a Q wave and inverted T wave) pattern can also be noted as well
pulmonary popcorn-like calcification
pulmonary hamartoma
– typically benign
first step in tx acute COPD exacerbation
causes respiratory acidosis so correct the hypercapnia first. This will resolve the other common sx (hypoxia, tachycardia, dyspnea).
“serious six” of acute chest pain in ER
acute coronary syndrome pericarditis with acute tamponade aortic dissection pulmonary embolus pneumothorax esophageal rupture
gold standard for dx PE
pulmonary angiography
– really only used in hemodynamically unstable or high clinical pretest probability w/ equivocal noninvasive test findings (contrast CT)
when to do aortic valve replacement
patient presenting with symptoms consistent with aortic stenosis (chest pain, exertional dyspnea, and syncope) and having a valve area of less than 1 cm2
- otherwise medical
HCM murmur characteristics
systolic murmur
heard best over the left sternal border
murmur improves with squatting
Characteristic urine finding for prerenal azotemia
hyponatremia:
Prerenal acute renal failure stimulates release of aldosterone which leads to resorption of sodium from the collecting ducts. This will cause a fall in urine sodium to < 20 mOsm/L and fractional excretion of sodium to 1% or less. The urine becomes more concentrated than plasma.
what does a urine creatinine: plasma creatinine ratio of < 20 indicate?
intrarenal cause
– >20 in prerenal, postrenal, and acute glomerulonephritis
most likely electrolyte abnormality in DKA
HYPONATREMIA
- via plasma dilution of [Na+]
Note: likely to also have hypokalemia due to urinary losses (note that insulin may cause severe hypokalemia)
best test for overt type II diabetes mellitus
fasting plasma glucose,
as hemoglobin A1C can have approximately a 20% false negative in the screening setting.
common causes of peptic ulcer disease
Helicobacter pylori, NSAIDs, elevated acid secreting states, and Crohn’s disease.
most common cause of splenic vein thrombosis
chronic pancreatitis
Chronic somatic dysfunction
thin, smooth, dry, ropy/stringy.
Acute somatic dysfunction i
boggy and rough with lasting erythema.
first step in management of acute pancreatitis
early and aggressive fluid administration
— prevents organ hypoperfusion secondary to third spacing of fluid from vascular damage
Patients at high risk for refeeding syndrome
hronically malnourished and those at high risk for malnutrition, such as in the case of cancer, prolonged starvation, chronic alcoholism, elderly, and postoperative patients.
hallmark electrolyte disturbance of refeeding syndrome
hypophosphatemia
– which leads to widespread dysfunction of cellular processes
Other electrolytes are also deranged, including sodium and potassium, as well as thiamine, protein, glucose, and fat metabolism
equation for calculation of anion gap
[Na+] - ([Cl−] + [HCO − 3])
when re-feeding pt, important to remember to also replace
thiamine
how uremia predisposes toward bleeding
platelet dysfunction with an inability to aggregate and adhere to the endothelium
Alpha-fetoprotein (AFP) elevated in
gonadal germ cell tumors or hepatocellular carcinomas.
CA-125 elevated in
arious malignancies including ovarian, endometrial, breast, and some lymphomas
CEA elevated in
adenocarcinomas of the colon, pancreas, lung, breast, and ovary
LDH elevated in
various malignancies as cancerous cellular growth is escalated to a point that metabolism takes place anaerobically.
LDH may also be elevated in dysgerminomas, lymphoma, and Ewing’s sarcoma
CA 19-9 elevated in
pancreatic cancer
—- level above 1000 is diagnostic of pancreatic cancer
Churg-Strauss syndrome distinguishing features
asthma
eosinophilia
p-ANCA
- can present as pulmonary-renal syndrome like Wegner’s
Microscopic polyangiitis distinguishing features
p-ANCA
triggered by infection
- can present with hemoptysis and hematuria like Wegners and similar to Churg
Goodpasture’s syndrome distinguishing features
aka anti-GBM dz
c-ANCA
elevated creatinine, hematuria, RBC casts
hemoptysis
- also presents pulmonary-renal syndrome
Wegner’s granulomatosis
c-ANCA
saddle nose deformity (causes granulomas)
- also pulmonary-renal syndrome (hemoptysis and hematuria)
- can cause +RF
what is anti-ccp for?
rheumatoid arthritis
- more specific than RF
what is raloxifene for
JUST vertebral fx prevention (not non-vertebral)
DRESS syndrome presentation
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome
extensive rash, fever above 38°C, lymphadenopathy, hematologic abnormalities, hepatitis, and involvement of at least one internal organ. The onset of symptoms occurs 2–6 weeks after drug initiation
what causes DRESS syndrome
multiple medications, including allopurinol, anticonvulsants, sulfa derivatives, antidepressants, nonsteroidal anti-inflammatory drugs, and antimicrobials.
Brown-Sequard syndrome symptoms
ipsilateral weakness (corticospinal tract), ipsilateral loss of vibration and proprioception (dorsal column tract) along with contralateral loss of pain and temperature sensation (spinothalamic tract).
Nikolsky sign
epidermis easily separates upon gentle pressure due to skin necrosis
- seen in TEN and pemphigus vulgaris
TEN vs pemphigus vulgaris
TEN is acute onset dz with clear inciting acute event like drug rxn
what is Behcet’s syndrome
immune-mediated, small-vessel multisystem disease that presents with recurrent oral and genital ulcers and possible skin and/or ocular lesions.
- see in young adults (25-30)
initial step in the work-up of suspected lead poisoning
obtain a whole blood lead level (BLL).
A plain film radiograph of the abdomen is recommended in children to detect retained lead objects that may require surgical intervention for removal.
herald patch that is described as a single oval lesion with a salmon colored center with a red border
pityriasis rosea
multiple erythematous patches usually in the face, not one lesion and then multiple after weeks. These erythematous patches evolve into hypopigmented areas that eventually resolve after time.
Pityriasis alba
multiple lesions and not just one. It may be over the trunk, buttocks, or extremities. These lesions are described as papules that become vesicles and may even develop into hemorrhagic crusts.
Pityriasis lichenoides
descending rash that is described as redness and scaliness. This is found on the face and descends to where they may even have thickening of the skin on the soles of their hands and feet.
Pityriasis rubra pilaris
hypopigmented lesions on darker skinned patients and hyperpigmented lesions on lighter skinned patients on chest and back
tinea versicolor
Findings consistent with brain death
non-reactive pupils,
lack of corneal reflex,
lack of oculocephalic (doll’s eyes) reflex,
loss of respiratory drive even with elevated partial pressure of carbon dioxide.
Note: movements originating from the spinal cord or peripheral nerves may persist
Exanthematous drug eruption
Rash appears 5-14 days after initiation of the medication.
Rash starts distally and spreads centrally.
Rash is self-limiting and resolves 1-2 days after discontinuing the medication.
red rash that looks like a sunburn with a rough texture like sandpaper, most often starting on the chest and stomach then spreading to the rest of the body
Scarlet fever
rash may last between 2-7 days and is associated with red, swollen lips with a strawberry-like tongue. Skin may peel on hands and feet after the rash fades.
rash following the fever is a raised, red, pinpoint rash that starts on the face and spreads downward. The rash can itch and last up to 3 days
German Measles
(rubella virus)
low grade prodromal fever with swollen, tender lymph nodes
fever, usually greater than 39.5°C (103.1°F), with a rash developing as the fever is resolving. The rash is rosy pink, blanchable and develops first on the neck and chest before spreading to the rest of the body
Roseloa infantum or Sixth Disease,
(HHV-6)
children ages 6-36 months
raised red rash that first appears on the child’s cheeks (“slapped cheek”). A lace-like rash starts on the torso and arms after 1-4 days then spread to the rest of the body
Fifth Disease (erythema infectiosum) is caused by human parvovirus B19
preschool to young school-aged children
Flu-like symptoms may be present 7 days prior to appearance of the rash
Essential tremor
benign familial tremor
usually bilateral hands
most often confused with Parkinson’s disease
Physiologic tremor
very low amplitude and high frequency (10 to 12 Hz) tremor that is usually invisible under normal daily circumstances but exaggerated in certain circumstances.
Rubral tremor
result of a midbrain or cerebellar injury which produces a mixture of posture, intention and resting tremor with a low-frequency of 3 to 5 Hz only.
EKG in STEMI vs acute pericarditis
STEMI EKG has 2-3 consecutive leads of ST elevation but not diffuse ST elevation that is seen in pericarditis
— ex pericarditis EKG: ST elevation in leads I, II, III, and V2-V6
tx for acute pericarditis
NSAIDs
clinical manifestations of adrenal crisis
nausea, vomiting, abd pain, CV collapse, and/or hypovolemic shock
can be triggered by physiological stress like trauma, infection, GI upset, surgery (ACTH can’t respond)
Addison’s disease
destruction of adrenal glands. In US, most commonly caused by autoimmune diseases
polyglandular autoimmune syndrome type II
Hashimoto thyroiditis
T1DM
Addison’s disease`
management goals in tx of adrenal crisis
adequate replacement of fluids, electrolytes, and circulating glucocorticoids
ideal AV fistula location
the most distal vessels in the non-dominant upper extremity
– ex/ radial artery and cephalic vein
how are symptoms caused in carcinoid syndrome
serotonin-producing tumor converts niacin to tryptophan and serotonin
— can result in niacin deficiency
elevated 5-HIAA sign of
carcinoid syndrome
factor V leiden deficiency
- most common hereditary hypercoaguable disorder
- is protein C resistance -> increase risk for thrombotic dz
common cause of syncope in pt with normal phys exam
must r/o arrhythmias with a 24hr Holter monitor
SIADH causes what electrolyte abn
isovolemic hypotonic hyponatremia
– most common cause of this
what is pseudohyponatremia
isotonic hyponatremia. Normal amount of serum sodium just lower plasma sodium concentration due to increased plasma solids.
Seen in HLD, hyperproteinemia, and hyperglycemia
Asymptomatic
Sarin: MOA & toxicity
potent inhibitor of acetylcholinesterase which results in toxic accumulation of acetylcholine at the post synaptic cleft,
causing miosis, rhinorrhea, bronchospasm, diaphoresis, nausea, vomiting and urinary incontinence
–> apnea, coma, convulsions or death
Ricin sx
severe nausea, diarrhea, seizure, tachycardia and hypotension followed by cardiovascular shock and death within 3-5 days of exposure
Phosgene sx
laryngospasm with inspiratory stridor and partial airway obstruction and irritation of the eyes, nose and throat.
– via free radicals
Anthrax - inhalation exp sx
flu-like symptoms followed by pneumonia and severe respiratory collapse
anthrax - dietary exp sx
(via infected meat with spores)
hematemesis, severe diarrhea and gastrointestinal inflammation
Sulfur mustard sx
Within 24 hours of exposure, victims experience skin irritation followed by fluid filled blisters in the areas of contact or first and second degree burns. Eye exposure results in miosis and conjunctivitis which can result in temporary blindness. If inhaled in very high concentrations, damage to the mucous membranes causing bleeding, blistering and pulmonary edema.
Hypophosphatemia sx
neuromuscular instability including seizures and coma
lung cancer with hypercalcemia
squamous cell carcinoma
normal range common bile duct dilation
avg 4.1mm
signs of ascending cholangitis
charcot’s triad (RUQ p, f, jaundice)
reynold’s pentad (+ hypotension, AMS)
otitis media tx of choice
amoxicillin 80-90 mg/kg/day for 10 days
cyclophosphamide side effects
hemorrhagic cystitis
SIADH
cisplatin side effects
nephrotoxicity
neurotoxicity
ototoxicity
first line tx for cellulitis of dry skin
Nafcillin
covers Strep and Staph
risk factors for MRSA
recent hospitalization, long hospital stay, resident of a long-term care facility, hemodialysis, recent antibiotic therapy, HIV, men who have sex with men, sharing sports equipment, diabetes, IV drug use, incarceration, military service, sharing needles, razors or other sharp objects
condition that predisposes to warfarin skin necrosis
protein c deficiency
chronic meningitis likely caused by
cryptococcus, esp in immunocompromised
bowel perforation in HIV pt
CMV
classic presentation of HUS
hemolytic uremic syndrome
anemia
thrombocytopenia
acute renal failure
and NO neuro findings
also can have prodromal bloody diarrhea
how to tell HUS from TTP
TTP has focal neuro findings
marker for TTP
ADAMTS-13 (deficient)
ALL vs sickle cell
ALL has petechiae
both have anemia, fever, pain
ALL presentation
2-5yo kid
fever
pallor
petechiae
(can have high WBC)
cellulitis vs nec fasc
Cellulitis is not associated with skin coloration and necrosis, as seen in nec fasc.
Nec fasc has involvement of the deep fascial layers, which are not involved in cellulitis.
when do you see Basophilic stippling ?
thalassemias, alcohol abuse, iron overload, and lead poisoning.
Indications for urgent dialysis in patients with CKD
pericarditis or pleuritic,
severe metabolic acidosis,
severe hyperkalemia (refractory to conservative treatment),
progressive uremic encephalopathy,
intractable volume overload (despite diuretic therapy),
failure to thrive/ malnutrition,
peripheral neuropathy,
a bleeding tendency, and
intractable gastrointestinal symptoms (e.g., nausea, vomiting)
kidney stones that form in alkaline urine
calcium phosphate > struvite stones
Initial management of pulmonary embolism
supplemental oxygen,
acute anticoagulation with unfractionated or low-molecular-weight heparin, and
initiation of long-term anticoagulation therapy with oral warfarin
when to consider thrombolytic therapy and embolectomy in PE
patients with massive PE who are hemodynamically unstable or have evidence of right heart failure
tx for acute hepatitis B infection
tenofovir disoproxil fumarate
hypocalcemia symptoms
paresthesias, muscle cramps, chvostek sign, troussea’s sign, decreased cardiac contractility, prolonged QT interval, T-wave inversion, heart block, and V fib
hypocalcemia tx
first: magnesium
then: IV calcium gluconate
What distinguishes vertigo types from each other?: labyrinthitis Meniere's dz Vestibular neuritis BPPV
all have vertigo, tinnitus, hearing loss
labyrinthitis - after recent infection
Meniere’s dz - attacks last for several months
Vestibular neuritis - auditory function preserved
BPPV - only specific positions / changes
Central pontine myelinosis: cause
- cerebral edema due to rapid over correction of chronic hyponatremia
Central pontine myelinosis: sx
- altered mental status including lethargy, obtundation, dysphagia and even paraparesis or coma
