csv-export-part2 Flashcards
Tremor that is worst at rest and improves with intentional movement?
Resting tremor associated with Parkinson’s.
Most common malignancy of the liver?
Metastasis from another primary source
Most common cause of hydatid cysts of the liver?
Cystic echinococcosis is cuased by the tapeworm Echinococcus granulosus mostly in immigrants or pts that live in the SW region of the country and are exposed to SHEEP and DOGS. Microscopic exam reveals encapsulated and calcified cyst that contains fluid and budding cells.
alpha feto protein is commonly elevated in which liver dz?
hepatocellular carcinoma
Suspect what if there is a solitary epithelial tumor of the liver (usually in the right hepatic lobe) in a middle-aged woman with a lengthy hx of oral contraceptive usage?
hepatic adenoma (benign condition)
Neoplasm of the liver characterized by vascular spaces that are lined with malignant cells?
hepatic angiosarcoma - rare neoplasm more common in older men exposed to toxins such as vinal chloride gas, arsenic compounds, and thorium oxide.
vomitus gastric contents are rich in?
hydrogen, chloride, and potassium
Remember what about heterophile antibodies used to dx infectious mono?
very sensitive and specific but may be negative early in illness.
Mechanism of hypercalcemia in pts with tumors that are metastatic to bone?
local osteolysis by production of CYTOKINES such as IL-1 and tumor necrosis factor (TNF).
Pathogenesis of chronic cough 2ndry to ACE-I?
Related to an accumulation of the inflammatory or proinflammatory mediators bradykinin, substance P, thromboxanes, and prostaglandins.
In mechanical ventilation, pO2 provides a measure of oxygenation and is influenced by _______ and ________ while pCO2 provides a measure of ventilation and is affected mainly by ________ and ________.
pO2: FiO2 and PEEP levels
Typical goal FiO2?
Initially, pts are usually given high FiO2 (~ 80% or 0.8), pending the results of the first blood gas analysis. Based on results, FiO2 should be decreased to prevent oxygen toxicity; typically below 50-60% is desirable. Goal is to maintain paO2 >/= 60!! PEEP can also be adjusted to increase/decrease the number of alveoli available for gas exchange and maintain adequate oxygenation.
Criterion for initiating home oxygen in COPD patients?
PaO2 < 55 mmHg or SaO2 < 88%.
Acidosis accompanied by hypercarbia (elevated pCO2) and a normal/elevated serum bicarb is diagnostic of a?
respiratory acidosis (often caused by hypOventilation)
Pathogenesis of aspirin sensitivity syndrome?
a ‘psuedo-allergic’ reaction due to prostaglandin/leukotriene misbalance. Aspirin is a cyclooxygenase inhibitor –> arachidonate diverges from blocked COXs to a 5-lipoxygenase pathway –> accumulation of leukotrienes and changed prostaglandin/leukotriene balance triggers characteristic reactions (bronchoconstriction, polyp formation).
Common cause of upper lobe cavitary lung lesions in immigrant patients?
TB
Recommended therapy for an acute bacterial exacerbation of COPD?
supplemental oxygen, inhaled bronchodilators (beta-2 agonests or anticholinergics such as ipratropium), broad-spectrum ABX, a 2-week corticosteroid taper, and smoking cessation.
An important cause of pneumonia in HIV/AIDS patients?
Pneumocystis jiroveci (carinii) pneumonia - hypoxia occurs 2ndry to alveolar and interstitial inflammation causing areas of V/Q mismatch. This manifests as an increase in the alveolar-arterial oxygen gradient.
Symptoms that help distinguish Legionella from other causes of community acquired pneumonia?
1) high-grade vever
What will be a common finding on sputum gram stain for Legionella pneumophila?
Many neutrophils but no organisms bc it is a Gram-negative rod that stains poorly and is primarily intracellular.
Diagnosis and treatment of Legionella pneumophila CAP?
Dx is confirmed by urine antigen testing or culture on charcoal agar. Tx with azithromycin or levofloxacin.
NEW clubbin in a pt with COPD often indicates?
lung cancer - interestingly finger clubbing is RARELY a feature of COPD.
Alveolar hypoventilation (as in COPD exacerbation) can cause?
confusion, somnolence, coma, and tonic-clonic seizures. Sedatives should be avoided in these pts as they can exacerbate alveolar hypoventilation.
Only two modalities shown to decrease mortality in COPD?
home oxygen therapy and smoking cessation
Non-cardiogenic pulmonary edema aka ARDS can develop in what settings?
sepsis, severe bleeding, pneumonia, toxic ingestion, or burns when release of inflammatory mediators cause increased alveolar capillary permeability and resultant pulmonary edema.
How can cardiogenic pulmonary edema be distinguished from non-cardiogenic?
Measurement of pulmonary capillary wedge pressure (PCWP).
Non-invasive positive pressure ventilation (NIPPV) should be tried before intubation and mechanical ventilation in a pt with respiratory distress because?
Better alveolar ventilation and less fiatigue of respiratory muscles.
When is non-invasive positive pressure ventilation contraindicated?
pts who are septic, hypotensive, or dysrhythmic.
Characteristic change in FEV1/FVC in COPD patients versus restrictive lung dz?
decreased in COPD due to reduction of mainly FEV1.
DLCO (diffusion capacity) may help distinguish between what two COPD entities?
it is decreased in emphysema and normal in chronic bronchitis
Suspect what with presence of a mobile cavitary mass (crescent radiolucency next to a rounded mass) in the lung which presents with intermittent hemoptysis?
Aspergilloma - cavitations are due to destruction of underlying pulmonary parenchyma. Mobile mass is due to debris and hyphae coalescing to form a fungus ball.
Number one cause of chronic cough in nonsmokers?
postnasal drip
Most specific test available for GERD?
24-hour pH recording - usually used in pts with chest pain or chronic cough when esophagoscopy is negative.
Suspect what in COPD pts with catastrophic worsening of their respiratory symptoms?
spontaneous secondary pneumothorax - destruction of alveolar sacs and formation of large airspaces (generally in the UPPER lobes) are predisposing factors.
In addition to panlobular emphysema, pts with alpha-1 antitrypsin deficiency are also at risk for _________?
liver disease
Goal INR in pts with prosthetic heart valves?
2.5-3.5
how long should a pt with a VTE be treated with oral anticoagulation?
At least 3 months if there is a reversible risk factor and for 6-12 months in pts with idiopathic DVT.
The proximal deep veins include?
iliac, femoral and popliteal
Potential therapies for patients with obesity hypoventilation syndrome?
weight loss, ventilator support, oxygen therapy and progestins (a respiratory stimulant).
cause of obesity hypoventilation sydrome aka Pickwickian sydrome?
decreased lung compliance
Suspect what if a loculated, abnormally contured effusion with adjacent pulmonary consolidation is seen on CXR?
empyema, an intrapleural collection of pus - most commonly due to bacterial seeding from an untreated pneumonia.
How can bronchiectasis be identified on CT?
presence of dilated bronchi with thickened walls. Hemoptysis, sometimes massive to the point of requiring bronchial artery emoblization is a potential complication.
Treat an ANaerobic lung infection (suspected due to foul-smelling sputum) with what ABX?
Clindamycin
Common responsible antigens in hypersensitivity pneumonitis?
aerosolized bird droppings (“bird facier’s lung”) and molds associated with farming (“farmer’s lung”)
Typical presentation of hypersensitivity pneumonitis?
acute episodes of cough, breathlessness, fever, and malaise that occur within 4-6 hours of antigenic exposure. Chronic exposure may cause weight loss, clubbing, and “honeycombing” of the lung. Management is avoidance of the responsible antigen.
In pneumonia pts, placing the consolidated lung segment in a dependent position can increase right-to-left shunt. Why?
Alveoli of consolidated lung segments are filled with exudate and do not participate in pulmonary gas exchange, so their ventilation is essentially zero, i.e. blood perfusing consolidated areas is not oxygenated. These positions decrease the patient’s oxygen saturation levels which is the same theory as an increased R-to-L shunt.
Mainstay therapy for ARDS?
Mechanical ventilation with LOW tidal volumes and PEEP. Levels up to 15 of PEEP may be necessary in ARDS pts.
What may help distinguish asthma from COPD?
FEV1 measurement before and after bronchodilator treatment - demonstrates reversibility if greater than 15% improvement of FEV1 is seen. Reversibility is more consistent with asthma; however a certain subset of pts with COPD also show positive bronchodilator response indicating an overlap of pathophysiology may exist.
Presentation of blastomycosis?
pulmonary and CXR findings similar to TB and histoplasmosis however systemic blastomycosis may cause skin ulcerations and lytic bone lesions.
Coccidiodomycosis is endemic to what part of the US?
Southwestern
Definitive diagnostic test for bronchiectasis?
high-resolution CT scan
Suspect what in a pt with an asymptomatic pulmonary nodule that resides in Mississippi?
Histoplasma capsulatum - endemic to Mississippi and Ohio River valleys and Central America. Found in soil with a high concentration of bird or bat guano droppings.
Bacteria commonly responsible for acute exacerbation of COPD?
S. pneumoniae, H. influenza, and M. catarrhalis. All pts suspected with a bacterial pneumonia should have a CXR as the first step and then ABX wo waiting for sputum gram stain or cultures.
How long before Warfarin becomes therapeutic in treatment of a VTE?
4-5 days which is why concurrent heparin for 5 days should be used.
Drugs of choice for in-patient treatment of community acquired pneumonia?
newer antipneumoccocal quinolones like levofloxacin or moxifloxacin.
What is an important interaction of ciprofloxacin and erythromycin with theophylline?
decreases theophylline clearance and raises plasma concentration with possibility of theophylline toxicity. Toxicity manifests as CNS timulation (headache, insomnia), GI disturbance (N/V), and cardiac toxicity (arrhythmia). Mechanisms responsible for toxicity may include phosphodiesterase inhibition, adenosine antagonism, and stimulation of epinephrine.
Typical FEV1/FVC ratio in COPD?
less than 0.7
Suspect what with asymmetric breath sounds immediately after intubation?
Right mainstem bronchus intubation - a relatively common complication of endotracheal intubation. Ideally the tip of the endotracheal tube should be between the vocal cords and the carina. CXR confirms diagnosis and slight withdrawal of the tube resolves the complication.
Left-sided endocarditis commonly sends septic emoli to where?
regions rich in blood supply such as the brain, kidneys, liver, and spleen.
Drug of choice in a pt who presents with stable angina AND hypertension?
beta-blocker - increases the threshold for the development of an anginal episode and controls the hypertension. They are also believed to be cardioprotective bc they decrease the sympathetic output to the heart.
What makes a test reliabile?
similar results on repeat measurements. reliability is maximal when random error is minimal.
What makes a test valid or accurate?
The test’s ability to measure what it is supposed to measure. To determine validity, results must be compared to those obtained from the gold standard test.
When should a patient be screened for bladder cancer?
never due to its relatively low incidence and poor positive predictive value.
The two phases involved in the pathogenesis of metabolic alkalosis?
generation phase - vomiting results in the loss of gastric fluids high in HCl, NaCl, and water. The loss of hydrogen ions as HCl results in unbalanced retention of HCO3- leading to a metabolic alkalosis.
Possible mechanism of adverse effects such as myopathy of statins?
decreased synthesis of products unrelated to cholesterol products such as reduced CoQ10 production.
Mechanism of action of statin?
inhibits HMG-CoA reductase which is the rate-limiting enzyme in the synthesis of cholesterol that converts HMG-CoA to mevalonate.
When is an AIDS pt at risk for CMV retinitis?
When CD4 count falls below 50. Pts may be asymptomatic with characteristic fundoscopic findings of yellow-white patches of retinal opacification and hemorrhages. Tx is ganciclovir or foscarnet.
Suspect what if there is necrosis involving the inner layers of the retina that appear as white, fluffy lesions surrounded by retinal edema and vitritis?
ocular toxoplasmosis in an immunocompromised host. More than 50% will also have encephalitis.
Suspect what in an older pt that presents with fever, malaise, and a burning/itching sensation of the periorbital region with examination revealing a vesicular rash in the distribution of the cutaneous branch of the first divison of the trigeminal nerve?
Herpes zoster opthalmicus caused by varicella-zoster. Usually in the elderly but may also be a presenting sign in HIV pts that predict increased risk of progression to AIDS.
A saw-tooth pattern of P waves that do not all conduct QRS complexes?
atrial flutter due to a re-entrant rhythm within the atria. A 2:1, 3:1, or 4:1 heart block is often seen.
A P-wave that is morphologically distinct from those originating in the sinus node; will also occur prematurely and may not conduct to the ventricles?
atrial ectopy
Suspect what in a pt with diffuse telangiectasias, recurrent severe epistaxis, and widespread AV malformations in the mucous membranes, skin, GI tract or even the liver, brain, and lung?
Osler-Weber-Rendu sydrome aka hereditary telangiectasia.
The use of anti-estrogen, tamoxifen, reduces the risk of recurrence of breast cancer from the original site or a new breast site, but increases the risk of ________, _______, and _______?
endometrial cancer, uterine sarcoma and venous thrombosis.
Diarrhea due to Vibrio parahaemolyticus is usually transmitted by the ingestion of ?
seafood including shrimp, crab, and raw oysters
Post-splenectomy pts are at increased risk for sepsis from encapsulated organisms due?
impaired antibody-mediated opsonization in phagocytosis - antibodies produced by germinal center plasma cells enter the systemic circulation to bind specific antigens and facilitate phagocytosis via opsonization which is not possible in asplenic pts.
Fever every 48 hours occurs with what type of malaria?
P. vivax and P. ovale
Fever every 72 hours occurs with what type of malaria?
P. malariae
Type of malaria with no periodicity?
P. faciparum - most malaria deaths are due to faciparam malaria
Smudge cells are characteristically seen in?
CLL - a disease of mostly older patients. Pts are often asymptomatic and diagnosed due to incidental finding of lymphocytosis with a peripheral blood fil showing small, mature-appearing lymphocytes. Symptomatic pateints usually c/o lymphadenopathy.
What indicates a poor prognosis in CLL?
thrombocytopenia
Chronology of disease progression in measles caused by Paramyxovirus?
1) exposure to the virus transmitted via respiratory droplets.
What type of thyroid cancer has the propensity for early hematogenous spread to the lung, brain, and bones?
Follicular thyroid cancers - they can be differentiated from follicular adenomas by histopathological demonstration of invasion of the capsule and blood vessels.
Most common thyroid malignancy?
Papillary throid cancer characterized by psammoma bodies. Fine needle aspiration biopsy reveals large cells with ground glass cytoplasm, and pale nuclei with inclusion bodies and central grooving.
Prognosis of papillary thyroid cancer?
excellent even in the presence of metastasis
sensory and reflex abnormalities on PE generally indicate?
neuropathies due to peripheral nerve problems
What should be suspected with absent/diminished reflexes at rest but improved muscular strength with repetitive tasks?
PREsynaptic membrane damage, i.e. Lambert-Eaton syndrome
paraplegia/quadriplegia with sensory abnormalities and urinary retention/incontinence on PE generally indicates?
some type of myelopathy originating from damage to the spinal cord
Even with therapeutic range INRs, there is significant risk of _______ with warfarin treatment?
Retroperitoneal hematoma - should be suspected with back pain and hemodynamic compromise. Dx with an abdominal CT.
DOC for trigeminal neuralgia?
carbamazepine - effective in approx 80% of cases.
Tx for cluster headaches?
Sumatriptan and high-flow oxygen
Untreated hyperthyroid pts are at risk for?
Rapid bone loss resulting from increased osteoclastic activity (from direct effects of the thyroid hormones) AND cardiac tachyarrhythmias including A-fib.
Toxic adenomas causing hyperthyroidism do not cause proptosis as in Grave’s disease bc?
there is no autoimmune process underlying the disease
Glucocorticoids cause what classic changes on blood cells?
1) Leukocytosis due to neutrophilia
DOC for treatment of myasthenia gravis?
oral anticholinesterase such as pyridostigmine or neostigmine. Atropine (anticholinergic agent) can be used to prevent muscarinic side effects of anti-ACh therapy.
What is a complication that can arise in pts requiring multiple blood transusions or immediately after surgery that manifests as hyperactive deep tendon reflexes, muscle cramps, and sometimes convusions?
hypOcalcemia resulting from volume expansion and hypOaluminemia PLUS decreased IONIZED calcium due to citrate binding.
When is aspirin indicated as the ONLY antithrombotic therap in a pt with atrial fibrillation?
IN an otherwishe healthy pt with “lone” atrial fibrillation in the absence of other risk factors for stroke (CHADS2).
Indications for thyroid function tests?
1) hyperlipidemia, esp high LDL
Drugs of choice for treating/preventing chemo-induced N/V?
serotonin ANTagonists that block 5HT3 receptors such as ondansetron. Corticosteroids are sometimes added to the regimen for better prophylaxis.
A rare malignancy that often arises in Hispanic and Southwestern Native American females with a hx of gallstones?
Gallbladder carcinoma - typically diagnosed after cholecystectomy. If discovered while still confined to the lamina propria of the gallbladder, a simple cholecystectomy results in a cure rate of 73-100% and is considered sufficient treatment.
Negative predictive value varies with?
pretest probability of a dz - a pt with high probability of having a dz will have a low NPV whereas a pt with low probability of having a dz will have a high NPV.
Known side effects of anti-tubercular therapy?
peripheral neuropathy due to pyridoxine deficiency (Vit B6) and hepatitis
Light’s criteria to distinguish an exudative pleural effusion from one that is transudative:
1) pleural fluid protein/serum protein ration > 0.5
How to determine if a pleural effusion is complicated?
Complicated fluids have:
Prophylaxis for a cluster headache?
prophylaxis is key to mgmt and includes verapamil, lithium, and ergotamine. Tx of acute attacks is inhalation of 100% oxygen and subcutaneous sumatriptan.
Tx for acute exacerbations of MS?
corticosteroids; beta-interferon or glatiramer acetate is used to decrease the frequency of exacerbations.
Evaluation for diarrhea in HIV-infected pts should include?
stool culture, examination for ova and parasites, and test for C. difficile toxin.
Suspect what in a pt over 50 years old with pain and stiffness in the neck, shoulders, and pelvic girdle with an elevated ESR and morning stiffness lasting OVER 1 hour?
polymyalgia rheumatica - treatment when NOT associated with giant cell arteritis is low-dose prednisone.
Characteristic findings in brain death?
ABSENT cortical and brain stem functions such as pupillary light rxn, heart acceleration after atropine injection, or spontaneous respiration.
Management of pts with probable benign prostatic hyperplasia based on hx and rectal exam?
urinalysis and serum creatinine to assess for infection, obstruction, or hematuria. Abnormalities warrant furter investigation.
Life threatening complication of succinylcholine used during rapid-sequence intubation?
Hyperkalemia leading to life-threatening arrhythmias - should not be used in pts at high risk for hyperkalemia such as those with crush/burn injuries more than 8 hours old (due to high risk of rhabdomyolysis), demyelinating syndromes like Guillain-Barre, and tumor lysis syndrome.
Most common cause of death in acromegaly?
cardiovascular accounting for ~ 38-62%.
What can help prevent contrast-induced nephropathy in pts with a hx of DM or chronic renal insufficiency (elevated baseline creatinine)?
Adequate IV hydration with isotonic bicarbonate or normal saline AND administration of acetylcysteine.
Suspect what in a pt older than 60 years with back pain that radiates to the buttocks/thighs and numbness/parasthesias that are worse during walking and lumbar extension and better with lumbar flexion?
Lumbar spinal stenosis due to two factors:
Common extracolonic manifestations of inflammatory bowel dz?
1) skin findings such as erythema nodosum and pyoderma gangrenosum.
What do inflammatory bowel dz and ankylosing spondylitis have in common?
HLA-B27 and presentation of arthritis is similar (low back pain/stiffness worse in the morning and improved with activity; plain radiographs show sacroiliac joint inflammation).
