Deck 1 Flashcards

1
Q

Diffuse itching in absence of rash

A

Do general labs search for systemic cause (TFT, iron, CBC, CMP)
Liver dz, CKD, thyroid, HIV, IDA, age appropriate cancer screening

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2
Q

Psoas sign

A

pain on extension of hip - lumbar plexus compression from iliopsoas hematoma

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3
Q

FHx of mucocutaneous bleeding, no prolonged PTT, on OCP

A

vW dz

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4
Q

Newly Dx DM2 - what to do to screen

A

Urine alb-Cr ratio now

Do not use MDRD (only in pts with CKD - not accurate with preserved glomerular fxn)

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5
Q

Mycobacterium Avium Complex in middle aged woman with no pre-existing lung condition, has discrete nodules - exposed to soil in SW US, no smoking

A

Need to repeat sputum ctx for MAC - if still positive then BAL or video assisted thoraoscopy for bx

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6
Q

COPD tx FEV<60%

A

1st recommendation - long acting broncodilator (tiotropium)

don’t use budesonide (ie inhaled corticosteroid) - no benefit compared to long acting broncodilator

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7
Q

Depression screening

A

screen all adults as long as appropriate support available

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8
Q

Hep B screening

A

not routinely recommneded except pregnant women

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9
Q

Osteoporosis screening

A

Women > 65 or high risk (3 month corticosteroid, etoh, low body mass, smoking, dementia, anticonvulsant use)

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10
Q

Screening for H pylori in setting of GIB or PPI current use or abx use

A

ONLY H. Pylori serology

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11
Q

Cardiorenal syndrome

A

fluid overload from inpt saline/abx use decreases ability to excrete sodium - heart can’t compensate for inc’d preload in setting of CHF -> IV lasix (even with elev Cr)
Don’t use lisinopril, don’t use BB in setting of acute decompensated HF

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12
Q

Vaginal atrophy - pale walls, petechiae, whiff neg, no clue cells - no response for vaginal itching from lubricants

A

low dose vaginal estradiol/ring

don’t use oral estrogen (inc’d r/o CVA, CAD, VTE, breast CA)

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13
Q

Bacterial vaginosis

A

inc’d vaginal pH, clue cells, +whiff test, vaginal d/c

Tx: metronidazole

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14
Q

Yeast infections

A

thick white d/c, KOH + with hyphae

Tx: vaginal clomitrazole

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15
Q

Posterior mediastinal mass

A

schwannoma - benign neoplasm from NEURAL tissue - usually located in posterior mediastinum
could also be esophageal tumor/cyst
(cough, venous distention, hoarsness, CP, Back pain, asx)
Usually need removal if sx don’t regress or if dx in question

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16
Q

Anterior mediastinal mass

A

thyroid, thymus, lymphomas

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17
Q

Middle mediastinal mass

A

broncogenic cysts, pericardial cysts, LAD

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18
Q

Allergic contact dermatitis

A

eczema caused by environmental exposure, unusual geographic pattern (ie oval, rectangular patch) -> edematous erythematous then vesices/bullae if severe -> chornic - > lichenified, scaly, hyperpigmented

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19
Q

Ecthyma

A

saucer shaped ulcers, legs, feet -> strep

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20
Q

Nummular dermatitis

A

pruritic eczematous - annular coin shaped erythematous plaque - pinpoint vesicles, honey colors serous crusting

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21
Q

Pulmonary valve stenosis

A

JVD prominent A wave, RV heave, systolic thrill, ejection click (rapid opening of stenotic pulmonary valve leaflets) - click decreases with inspiration but INCREASES systolic murmur (R sided murmurs increase with inspiration) - 2nd LEFT ICS -> left clavicular region, dilated pulmary artery on CXR

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22
Q

ASD

A

fixed split S2,

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23
Q

Bicuspid aortic valve

A

with more AS, click less audible, diminished, delayed carotid pulsation (pulsus parvus et tardus), apical impulse sustained, late peaking murmur -> carotids, LVH

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24
Q

MVP/regurg

A

early systolic click, mid systolic murmur - with valsalva murmur longer but click moves closer to S1

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25
VSD
holosystolic murmur at left lower sternal region
26
DISH - diffuse idiopathic skeletal hyperostosis
male, obese, DM calcification of enthesis region (where tendons insert near bone) Osteophyes on at least 4 contiguous vertebrae (anterolateral)
27
Ankylosing spondylitis
Younger patients sarcoilitis vertical bridging syndesmophytes
28
Lumbar spinal stenosis
chornic lower back pain pseudocladication - pain radiating down both legs on walking better with rest - BUT ALSO RELEIVED leaning forward over shopping kart, walking uphill, climbing stairs Narrowing spinal canal on MRI
29
Spondylolisthesis
subluxation of on vertebrae over another - lax or damaged ligaments - > anterior posterior movement
30
Parkinson's dz - wearing off syndrome
wearing off motor flucutuations, drug induced dyskinesia -> indication for deep brain stimulation (can't use further meds will cause further wearing off symoptoms and more dyskinesia Subthalamic nucleus or globus pallidus DO NOT DO ACUTE DRUG HOLIDAY - can cause acute parkinsonian sx
31
Functional hypothalamic ammenorrhea
stress, excessive weight loss, excessive excercise Tumor/infiltrative lesion, lymphoma, sarcoid Low FSH, normal prolactin, TSH Neg preg, neg progestin challenge (no withdrawal bleeding - estrogen low) Pit MRI no lesion
32
PCOS
look for hyperandrogenism (hirsuitism) | PCOS has good estrogen levels so progestin challenge would cause withdrwawal bleeding
33
Primary ovarian insufficiency
FSH would be elevated (trying to raise levels of estrogen)
34
Ceftaroline IV
B lactam abx with activity against CA-MRSA (only 5th gen cephalosporin active against MRSA) complicated soft tissue infection
35
Pregnant pt with VTE/PE
LMWH at least 6 months and 6 weeks post partum | NO WARFARIN - teratogenic
36
Polymyositis
anti-Jo abs Tx: Prednisone, azathroprine r/o ILD - need HRCT and PFTs to dx (can have normal CXR) PFT restrictive defect with decreased DLCO If HRCT neg then check Echo (RHC) r/o PAH as cause of isolated dec in DLCO
37
Primary adrenal insufficiency
nausea, wt loss, salt craving hypontremia, hyperkalemia, low cortisol, high ACTH hypopigmentation dec'd production of mineralocorticoid (hyponatremia, hyperkalemia) Dec'd prodxn androgens (low DHEA) Random cortisol inappropriately low for level of hypotension Random cortisol >17 would r/o primary adrenal insuff If ACTH >100 (random) then confirms dx Likely autoimmune given fhx thyroid, premature gray hair, scleroderma don't need MRI pituitary - high ACTH normal in response to low cortisol/DHEA etc Tx: hydrocortisone
38
Calcium oxalate kidney stones
envelope shaped crystals s/p bypass surgery - dec'd fatty absortion (binds Ca in gut) inc'd oxalate absorbtion 2/2 dec'd Ca absorption Tx: low fat diet, CaCarbonate supp to dec oxalate absorbption, aggressive oral hydration
39
Hypercalciuria
Thiazide diuretics
40
Migraine with aura
unilateral, pulsatile, mod to severe intensity, nausea, photophobia -> visual sx = aura tx: if NSAIDs don't work -> sumitriptan Propranolol ONLY FOR PPX not tx (>10 attacks/month) Migraine MRI - white matter hyperdensities
41
Molluscum contagiosum
Pox virus firm umbilicated pearly papules waxy surface sexually active adult Henderson-patterson' bodies on bx
42
Bacterial folliculitis
pustules centered on hair follicles
43
Large esolphageal varices
Needs ppx Primary tx: endoscopic ligation (NOT SCLEROTX) and/or non-selective BB (propranolol) No BB if contraindication (ie asthma) large varices >5mm despite air insulfation and red whale marks (inc'd r/o rupture)
44
When to use TIPS
Varicieal bleeding - if no effect with endo ligation | Gastric bleeding - if balloon tamponade ineffective
45
Prevent surgical site infection
abx 30-60min prior to incision - maintain therapeutic level thru procedure - no reason to continue 24 hrs after procedure Control/eliminate modifable risk factors - DM, obesity tob use, avoid shaving hair, chorohex prep, minizize traffick, check list
46
Prevention of neonatal GBS
decolonization of strep in vagina/rectum, no role in sugical site infection prev
47
hypoactive sexual disorder
Sex therapy lack of sexual thought, dec'd desire individual or couples therapy ok
48
Lofgren sydrome
known sarcoid d/o =- fever, erythema nodosum - hilar LAD - usually spontanous resolution - no need for tissue dx
49
STEMI
``` If PCI facility >1.5 hrs away then give thrombolytics unless contraindication: prev IC hemorrheage Known CVA ischemic stroke 3 months suspected aortic dissection active bleeding significant closed head or facial trauma 3 months Relative contraindication HTN >180/110 ichemic strove >3monthas ago CPR/major surgery w/in 3 wks recent internal bleeding (2-4 wks) Previous steptokinase active PUD current use of A/C ```
50
Manage life sustaining care in critiaclly ill pt
Pt needs dialysis acutely - said initially that didn't want to be on long term machines but wants to attend graduation in 3 weeks - wife willing to consent for HD - can always make decsision to stop ethically/legally - also pt can then participate in decision
51
Obscure GI bleeding aw severe AS (angioectasia) - Heyde syndrome
AVR - mechanical disruption of vWF during non-laminar flow thru stenotic AV No need to repair diffuse angioectasis - resolves post AVR
52
Hyperandrogenism in pt with neoplasm
TVUS r/o ovarian neoplasm first total testosterone elevated DHEA normal Rapid inc in sx and high testosterone suggest OVARIAN source, if neg then image adrenals (if adrenal mass then likely elevated DHEA
53
Hemolytic uremic syndrome
microangiopathic hemolytic anemia, low plts, AKI E coli 0157 H7 Shiga toxin glomerular damage (erythrocytes/ertyrocyte casts) Trip to endemic country inc'd LDH, dec'd haptoglobin, schistocytes dysentery (bloody diarrhea, dec'd UOP, fever, chills)
54
Post strep glom nephr
weeks after strep/staph infxn - dec'd complement
55
Chemotx induced myeloblastic syndrome
ineffective hematopoesis and various cytopenias multiple chromosomal abnormalities lack of LAD, HSM hypercellular marrow, dyerythropoesis
56
ALL
7th decade - lymphocytosis, neutropenia, anemia, throbocytopenia, LAD, HSM
57
Parvovirus B19
NOT A/W cytogenic changes
58
Recurrent Hodgkins lymphoma
2-12 years - palpable mass, lymphomas sx (fever, anorexia, wt loss, pruritis) - NO CHROMOsomal abn
59
Post infarct VSD
p/w delayed STEMI acute respiratory distress New harsh holosystolic murmur LSB palpable thrill (thrill makes VSD more likely than acute MR)
60
Acute aortic dissection
aw IWMI, asymmetric BPs, early diastolic murmur of AI
61
Rupture ventricular free wall
``` electromech dissociation, hemopericardium Risk factors Female First MI Anterior infarct ```
62
RV infarct
hypotension, clear lung fields elevated JVP | not likely with AWMI
63
Acute ischemic MR
prominent V wave in PCWP from inc'd reguritant volume into LA - need TTE
64
Acanthosis nigrans
DM pt (obese) - asx lesion velvety, hyperpigmented skin thickening in axilla/neck fold area - multiple skin tags (fibroepithelial polyps) Tx: wt loss, improved DM control
65
Tinea corpis
scaling annular patches with erythema - pruritic
66
Lichen simplex chroicus
thickening of skin with exencuation of normal skin markings - pruritic
67
Inverse psoriasis
atypical psoriasis areas (axilla/groin) - raw pink patches
68
Allergic contact dermatitis
pruritis, erythematous, well demarkated border
69
Chronic thromboebolic pulm HTN (CTEPH)
recurrent small PE over extended time with progressive dyspnea - inc'd PAP, gas tx defect (low DLCO) Tx: long term A/C, pulm artery endarectomy NO NEED FOR D-dimer, CTA chest or LE Duplex
70
Rheumatoid arthrtis
Can present with carpel tunnel syndrome (confirmed with EMG testing) prolonged morning stiffness >60min b/l wrist sx synovitis of wrists can cause entrapment of median nerve Pregnant women, thyroid dz, DM Overuse DOES NOT CAUSE carpel tunnel OA DOES NOT cause wrist sx typically (PIP/DIP)
71
Renovascular HTN w/u
pt with resistent HTN and inc'ing Cr w/ b/l epigastric bruits -obtain renal doppler arteries underperfusion of kidneys - inc'd renin-angiotensin - sodium retention - HTN ALready on 3 drug HTN tx including a diuretic (do not do kidney angio - bad for kidneys and can dislodge plaque from aorta)
72
Restrictive CM
dyspnea, edema, fatigue, Right sided failure, Echo restrictive ventricular filling, atria dilated - systolic fxn preseverved, small to normal size ventricles
73
Cardiac hemochormatosis
cause of restrictive CM but if iron levels low can be ruled out
74
Constrictive pericarditis
restrictive filling less severe atrial enlargement BNP only mildly elevated h/o acute pericarditis, TB, malignancy or chest radiation
75
Male hypogonadism
First step is morning TOTAL testosterone (morning most accurate) if abn, 2nd test indicated before further w/u (no reason for free testosterone - not older or obese) (no reason for testicular US if testicles normal volume)
76
Subacute cuteanous Lupus erythematosis
Anti Ro/SSA + (or anti la/SSB) erythematous circular papules with central clearing neck, trunk, extensor surfaces can be aw meds - HCTZ, CCB, ACEi, terbenafine 50% no systemic manifestation of SLE
77
Levido reticularis
lacy, purple motling of skin - pt with cholesterol emboli syndrome, SLE, raynaud, antiphospholipid syndrome, worse with cold, better warm (decrased local skin blood flow with dilated cappillaries
78
Colonoscopy screening UC pts
Dx'd with UC beyond rectum Colonoscopy 8-10 years after dx and every 1-2 years with bx (UC arises from mucosa - inc'd risk of adneoCA) If flat low grade dysplasia noted - colectomy or at least more frequent surveilalnce colonoscopy warranted
79
Colonoscopy screening normal
General - age 50 then q10yr Pt with 1st deg relative colong CA after age 60 (or two 2nd deg relative) - age 40 then q10yr Pt with 2 first deg relatives with colon CA or one 1st dg relative with colon cA before age 60 - age 40 or 10 years prior to youngest affected relative then Q5yr HNPCC fhx - 25y or 10 years yonger than youngest affected relative then q2yr up to age 40 then q1yr FAP - sigmoidoscopy age 12 q1-2 yr Post colonoic resection for Colon CA - start 1 yr post, then 3yr then q5 yr UC/Crohns - colonscopy 8yr after dx then q1-2 yrs
80
Extrapulmonary blastomycosis
Mild disseminated - oral itraconazole - verricus lesion -> central clearing -> scar formation -> depigmentation (broad based budding yeast) also osteoarticular, genitourinary and CNS manifestations Severe dz - CNS, mod to severe pulm, disseminated - tx with amphotericin B/lipid formulation Fluconazole DOES NOT WORK WITH BLASTO No reason for surgical exicision
81
Suspected melanoma
``` ABCDE Asymetry borders irregular Color varied Diameter >6mm Evolving Dx: Excisional bx - breslow depth analysis ```
82
Prevent pressure ulcers in elderly
Pressure distributing mattress and position changes high risk for ulcer - limited mobility, low albumin, ascites Stage I pressure ulcer - non-blanching erythematous plaque
83
Tx of pt with acute DVT in post op period with renal insufficiency
Use Unfractionated heparin in pt with low GFR (cleared by reticuloendothelial system not kidneys) and reversible by protamine so good in post op setting) Only add warfarin after heparin therapeutic since initially aw hypercoagulablity - warfarin skin necrosis No fonduparinux with low GFR (cleared by kidney) Enoxiparin - not entirely reveersible so not good in post op setting and 80 BID too high dose for low GFR
84
DVT dx
Pt with high pre-test probability of VTE given immobility, age, tachycardia so NO D DIMER CTA Chest high cost and uneccearly exposes to contrast US Duplex legs best and most cost effective test
85
Non-dermatophyte (fungus) onchymycosis
thickened yellow or white nail with scaling DX: KOH or PAS staining of nail clipping Candida, yeast Usual tx terbinafine, fluconazole, itraconazole Can be non-fungal cause (trauma, psoriasis,lichen planus) so need nail clipping PAS
86
Aplastic anemia in young patient
Aplastic anemia dx ANC < 20, Tx: if age 40yo or no HLA matched or medically fit for tx then tx is anti-thymocyte globulin and cyclosporin/corticosteroid No growth factors
87
High risk NSTEMI
TIMI>4 - (age>65, >3 risk factors, ST seg dev, +CE, >2 anginal episodes in 24 hrs, ASA in last 7 days) A/C heparin, Plavix, ASA, lopressor, SLN + lipitor and IIb/IIIa (eptifiptide - block final common pathway of plt aggregation) and early invasive approach NO PPX LIDOCAINE (use BB instead) NO throbolytics with NSTEMI (tenecoplase) - ok for STEMI if no PCI available but no dec'd mortality with NSTEMI
88
Respiratory failure in pt with COPD
tachycardic, hypoxic despite 6L O2, CP, clear CXR - CTA Chest r/o PE
89
Evaluate pt for TB that has been treated with BCG for bladder CA, vaccine or unlikely to return for f/u of TB skin test
use IFN gamma release assay if + then assess sign's sx and CXR, sputum Two step TST only in pt with remote TB infection or remote BCG (not recent)
90
Diagnose secondary h/a
unstable or progressive temporal sx - long h/o migraine with aura - new neuro sx of blurring vision - more frequent recently Obtain brain MRI Not medication overuse as pt with new and more frequent sx Before LP need to r/o mass lesion in brain
91
Evaluate pt with high BP
If see end organ damage in eye then check EKG check for LVH or q waves, check for microalbumuria 1st line tx without other factors would be thiaizide ACEi, arb, CCB in gen non-black pop In Blacks thiazide or CCB Age >60 goal <150/90 Secondary HTN Primary hyperaldo - spontaneous hypokalmeia - check aldo, plasma renin activity
92
Chronic pelvic pain - interstitial cystitis
noncyclic pain >6 months DDX: Interstitial cystitic pelvic adhesions - no h/o surgeries or STDs endometriosis - no masses or TVUS neg, no cyclic pain Irritable bowel syndrome - no GI sx Pt here with persistent urinary sx -> interstitial cystitis - Ctx and U/A can be neg Tx: stress management, diet modification PT oral meds (TCA, cimididiene, hyroxazine)
93
Type I cryoglobulinemic vasculitis
monoclonal immunoglobulins complication of monoclonal paraproteins - seen in Sjogren's pts +palpapable purpura, mononeuritis complex, low C3/4, immune complex glomerulonephropathy
94
Microscopic polyangiitis
p-ANCA No immune depostis L
95
Lupus associated Glom nephritis
immune complex GN, dec'd complememnt - need clinical features of systemic lupus
96
Type II cryoglobulinemic vaculitis
active Hep C (RNA +)
97
Painful DM neuropathy
``` better glucose control+ TCA (Desipramine) + capsacin cream Remyelination can occur with better glucose control NO SSRI Nerve conduction studies NOT needed ```
98
Acute stroke
even if hemorrhage suspected - Do CTH first impaired conciousness and h/a suggest cerebral mass lesion with elevated ICP No LP until mass lesion r/o
99
Post Roux en Y gastric bypass abn CBC elev MCV
B12 deficinecy macrocytic anemia mild neutropenia low retic lack of IF production from bypasesed gastric tissue Monitor b12 post op and supplement (500-1000 oral daily or 1000 q monthly IM) Also check ferritin, folate, vit D, Ca q6month first 2 years NO BM bx (too early) NO suspicion for GIB or CRCA with guiac neg stool,no fhx, MACROcytic anemia
100
Excercise induced broncospasm
short acting B2 agonist 15 min prior to excerise Mild intermittent asthma aw excercise only Normal baseline FEV (>80) with drop after excercise
101
Inhaled corticosteroids
>twice daily sx, weekly nightime sx
102
Type A acute aortic dissection
proximal aorta through arch to desecending with diastolic murmur, distant heart snds, CP-> back Not necesarily divergent BP in arms Emergency surgery evaluation (not stenting) Bicuspid Aortic valve aw dilated prox asc aorta - inc'd risk aneurysm or dissection No IABP - worsens AI
103
Histoplasmosis
``` Bat droppings Ohio river valley Hilar LAD with infiltrates SE US/ohio river valley bird/bat droppings Asx, or flu like sx, dyspnea ```
104
Blastomycosis
NO hilar LAD aw soil exposure with decaying vegetation - NOT BATS/BIRD droppings Ohio river valley
105
Coccoidomycosis
SW US | Acute pulmonary, erythema nodosum, joint pain
106
Flat warts
HPV autoinnoculation from shaving flat, flesh colored
107
Actinic keratosis
PRE-cancerous -> SCC erythematous with overlying hyperkeratosis irregular edges, gritty
108
Lichenoid keratosis
inflammed sebhorrhic keratosis (benign - stuck on, do not resolve)
109
Dermatofibromas
firm dermal nodules - button hole when pinched - legs adult women
110
Hypoparathyroidism
s/p thyroid surgery perioral anesthesia - muscle cramping tx: first oral Ca+ Eventual calcitriol since with lack of PTH no conversion of 25 to 1,25 D3
111
Treat pt with kidney stone
inc chance of kidney stone 10 mm won't pass without intervention) Urine collection and analysis only several weeks after stone passage for w/u of nephrolithiasis May require intervention if no stone passage after period of time
112
Cancer of unknown primary site
Tx for GI cancer - primarily abdominal districtuion (liver, ascietes) NOT germ cell tumor (undiff) if ID'd as adenoCA - platnum chemo NOT neuroendocrine (would be poorly differentiated) - platnum chemo NOT prostate (bony mets/ elevated PSA) - anti androgen tx NOT lung (would be distrubed over diaphragm)
113
Manage carpel tunnel
EMG and nerve conduction first (+- NSAIDs) sx - parasthesia hand, weakness grip strength, loss of sensation in median nerve territory, thenar atrophy Wrist splint/conservative measures If all this fails and after EMG/nerve studies- consider surgical release
114
Tx pt with recurrent chemo sensitive diffuse b cell lymphoma
Initial tx - RCHOP recurrent high dose chemo, autolougous stem cell tx no radiation, not just recurrent chemo
115
Hypercalciuric patient with nephrolithiasis
U Ca >300 (normal serum Ca+) FHx nephrolithisis Tx: distal reabsorbption of Ca+ with Thiazide don't use Ca citrate - will exacerbate calciuria (if want to alkalzye urine - use POTASSIUM CITRATE) Don't restrict CA (makes Ca Oxilate worse)
116
CAP in outpt
Tx with azithromycin (H.Pneumo, H.flu, mycoplasma, chlamydia) NEVER USE CIPRO (poor activity against S. Pneumo) Risk factors for drug resistant age >65, B lactam tx in last 3 months, medical comorbidies, immunocompromised
117
Pt with advanced HF
Pt with end stage cardiac failure refractory to tx - mechanical support and cardiac tx indicated Relatively young, no other comorbidities IF QRS OK then no indication for BIVICD upgrade
118
Pusatile tinnitis
pt with whooshing sound in ear louder when excerciseing - listen over r eye, ear, neck for bruits for vasc abnormality (tumor, stenosis) -> confirm with doppler or MRA If no cause found - external noise generator
119
Pull test
quick pull - pt should compensate by stepping backward if not predictive of future falls
120
Dix Halpike
peripheral vs central verigo
121
Abnormal proprioception
do not fall backward - have abnormal gait | loss of proprioception - peripheral neuropathy, spinal cord dz, severe hemicranial cortex dz
122
Rhomberg test
ataxia and proprioception loss - cerebellum, cerebellar, vestibular issue
123
Utricarial Vasculitis
Lesions that last > 24hrs and resolved with bruising concerning for vasculitis SKIN BX NEEDED 50% have underlying SLE No role for RAST (no clear allergin)
124
Malignant pleural effusion
former smoker - pw sx concerning for malignancy (cough, wt loss, unilateral effusion) Pleural fluid cytology used for dx - if neg first then repeat (inc's with serial taps) If nothing then pleural bx
125
Evaluate GIB with endoscopy
``` Neg NGT does NOT r/o UGIB First resucitate then EGD (first) if neg then colonoscopy then tagged RBC scan then video capsule ```
126
PCOS
PCOS - irreguular menses, elevated testosterone, hirsuitism, tx: estrogen-progesterone OCP - dec'd LH, inc'd sex binding hormone-> dec's avaiable testosterone
127
Prolactinoma
tx'd with bromocriptine
128
Congential adrenal hyperplasia
17 hyroxyprog abn - tx with dexamethasone - reduces hyperplasia and reduces prodxn of testosterone
129
Non-purulent cellulitis - B hemolyitic strep
B lactam agent - Cephalexin CAMRSA (doxy/bactrim)
130
Apraxia
inability to perform previously learned motor task despite intact motor and sensory systems, clear comprehension, full cooperation (need to r/o parkinsons, severe wk etc)
131
Hemiparkinsonianism
``` asymmetric rigidity, bradykinesia, dystonia Corticobailiar degeneration (hemiparkinson combined with hand moving independent of voluntary control = alien hand syndrome) ```
132
Asomatognosia
pt doesn't recognize body part as part of himself (R parietal cortex)
133
Routine f/u in breast CA survivor
Early stage breast CA survivors Routine clinical f/u - no intensive lab surveillance H&P, Mammo in otherwise asx patients
134
Humoral hyperCa of malignancy
severe hyperCa in setting of lung mass Tumor prodcution of PTHrP - acts on skeletal Ca release Usually SCC Lung
135
Sx PAD tx
Best therapy - supervised excercise program 30 min/day 3 days x 12 wks - inc pain free walking time and distance Cilastoazole - contraindicted EF<40% Surgery (bypass) only for limb thretening ischemia - or severe life limiting dz on maximal medical tx
136
Miliaria
Heat rash - skin get hot and occulded exocrine sweat glands - need active cooling measures - hospitalized pt with rash limited to dependent parts of body (vesicles, papules, pustules) No need for oral steroids
137
Fibromuscular dysplasia
``` Angiogram - beads of strings MC women 15-30 nonatherosclerotic, noninflammatory (suspicious in pt with severely resistant HTN, high renin/angiotensin) TX: PTCA Don't use drugs in this young patient ```
138
Obese patient needing weight loss
reduce calories by 500-1000/day 1-2 lbs/week (excercise alone will not work) (Bariatric only BMI>35 with comorbidity (DM, OSA, joint dz) or >40 anyone Med supplement is secondary ie orlistat (lipase inhibitor)
139
Manage acute PE
Unfractionated heparin Only throbolysis if still hypotensive after fluid bolus (alteplace) DOn't use LMWH if with CKD or possible need for revesal (ie if need to thrombolyse)
140
Dyspepsia
with no alarm sx (wt loss, blood) -> PPI empiric tx
141
If H. pyori
test and treat ok if no heartburn, alarm sx or area of high h pylori prevenlance If alarm sx then EGD (onset after 50, aemia, odynophagia, dysphagia, wt loss fhx GI malignancy, h/o PUD, abd mass, LAD)
142
Thiamine deficiency s/p gastric bypass
wernike's encephaloptahy (nytagumus, opthalmoplegia, ataxia, confusions) - needs IV thiamine - can have irreversible damage - thiamine depletes quickly much faster than B12 gets deficient (starts with parasthesia/ataxia
143
CMV after kidney tx
pt with seroneg for CMV, seropositive donor - few months after tx (after CMV ppx completeted) - so CMV is correct pw low grade fever, body aches, cytopenia, colitis, hepatitis, pneuonitis (CMV), leukopenia, thrombocytopenia
144
Polyoma BK virus post tx
LATE complication of tx, p/w neuropathy, organ rejection, uteretral strictirues - decoy cells (with intranuclear inclusions)
145
Listeria mono post tx
usually causes meningitis, h/a, MS change
146
EBV post tx
usually pw LAD
147
hemodynamically stable WC tachycardia
regular wctachy with LBBB w/ AV dissociation -> VT (h/o cad or CM) cannon a waves from AV dissociation (atria contracting against closed TV) Tx: IV amiodarone -2nd line procainamide, sotolol, lidocaine If unsuccessful - cardioversion DO NOT GIVE BB/CCB - > can deteriorate in VT Will need ICD for 2ndary prevention
148
Breast CA with mets to brain (>1) and inc'd ICP
corticosteroids and radiation - reduce ICP h/a sx of inc'd ICP, papilledema on exam also sz, focal neuro findings, cognitive changes Will need chemo, not surgery (>1 lesion) NO LP
149
Axial spondyloarthritis
Dx: pt with inflamm back pain without radiographic evidence of sarcoilliitis or spondylitis, clean MRI Dx of spondyloartritis without radio evidence - HLAB27+ and two of the following with elevated CRP, fhx spondyloartritis, good response to nsaids, crohn/UC, dacyliasis, psoriasis, NO RF + in spondyloartritis
150
Centor criteria
Fever>100.5, sore throat, tonsillar exudate, tender cervical LAD 2 criteria - obtain rapid strep antigen testing 0-1 risk factors - no abx or culture 2 or 3 - throat culture/antigen test and tx if + 4 or 5 - treat empirically (and get ctx)
151
Plasma osmolality
Sz caused lactic AG met acidosis Dec'd breathing from etoh intoxication caused respiratory acidosis + etoh ketoacidosis If pt improves with supportive measures - no HD or fomizpezole Fomipezole if pt has methanol or ethylene glycol poisoning (competitive inhibition of etoh dehydrogenase) - prevent conversion to toxic metabolites 2x [Na]+ glucose/18+ BUN/2.8+ ethanol/3.7 if present Supplemental bicarb if pH <7.15 HD if severe ethylene glycol or methanol poisoning, severe propylene glycol poisoning, severe isopropyl -
152
Delayed hypoglycemia in pt with Type I DM
Need to eat complex carbs at bedtime to avoid nighttime hypoglycemia after evening excercise - etoh reduced ability of liver to release glucose into blood (no need to avoid evening excercise, omit insulin in evening or light beer only)
153
Lichen planus
white reticulated network on buccal mucosa (wickham striae) - does not scrape off - can ulcerate also affects skin, scalp, nails incd with liver dz, hcv or drug induced (BB, diuretics, ACE, PCNamine, lasix) autoimmune Skin - small violacious papules
154
Candidiasis
Usually immunocompromised or corticosteroid use | scrapes off
155
Oral hairy leukoplakia
aw HIV | lateral tongue - adherent doesn't remove from scraping - no ulceration
156
MAP
2x DBP + SBP) /3 - if < 65 -> or CVP < 8-12 - if fluid resucitation does not get MAP>65 then vasoactive agent (norepi) ok If that doesn't work - hydrocortisone next step
157
Invasive aspergillosis in pt with leukemia after chemo
``` halo sign on CT galactomannan antigen immunoassay + BAL or TT percutaneous bx, VATS Tx: Voriconazole Salvage Tx: amphotericin, itraconazole, caspofungin/micofungin (echinocandin) ```
158
Toxic epidermal necrolysis
Drug reaction (bactrim) Stop bactrim or offending drug Burn unit - wound care, supportive care Fluids Skin bx DO NOT USE SYSTEMIC STEROIDS - worsens mortality No role for ppx abx (only if evidence of infxn)
159
A/C preg pt with mechanical MVR
Warfarin - despite teratogenicity | or LMWH or UFH
160
VTE after intracranial hemorrhage stroke
UFH low dose or LMWH after day 4 if no ongoing bleeding | IVC filter only if absolute contraindication to heparin
161
Axial Spondyloarthritis
Inflamm back pain, Tx: NSAID (diclofenac) only after several diff NSAIDS - then try etanercept
162
Evaluate obscure GIB
If pan endoscopy neg - repeat EGD (or colon) whichever more likely source If neg then other modality (wireless capsule, single balloon enteroscopy)
163
Asess for recurrent PE
A/C x 3 months f/u D-dimer 3-4 weeks after dx if elevated inc'd risk for recurrent PE Restart A/C
164
Manage hyperparathyroid in CKD
CKD with low 25OHD3 and high PTH-> maybe be just vit D deficient If this does not work and 25OHD3 >30 (normal) with PTH still high then give 1,25OHD3 (calcitriol)
165
Febrile neutropenia
Begin broad spectrum abx (zosyn, cefepime) - G pos and neg coverage Only start antifungals after 4-7 days of no response to zosyn cefepime
166
Chronic pain in elderly
First line tylenol (chronic non-cancer pain) if no underlying liver problems No TCA NO NSAID if h/o PUD
167
Metabolic syndrome
``` 3 of 5 Waist circumference >40 men, >35 F SBP >130>85 HDL< 50 F TG>150 Fasting glucose>110 ```
168
Tx for severe etoh hepatitis
Should add corticosteroid unless contraindictated (GIB, kidney failure, active infection (has this - SBP)) Maddrey discriminant score >32 Add pentoxyfyline
169
Reactive arthrtiis
acute arthritis + urinary symptoms Despite not being sexually active in one month - check urine for gonnorhea and chlamydia -> symptoms point to DIG (arthritis, urethritis, conjunctivitis) - sx 2-4 wks after infxn Sexual partners should be dx and treated
170
Infection control in pt with strep pyogenes (invasive)
necrotizing fasciitis and TSS clinda + PCN CLose contacts can get infected so-> CONTACT PRECAUTIONS needed PCN ppx for household contacts at high risk (Age>65, DM, cardiac dz, varicella, CA, HIV, coriticosteroid use, IVDA)
171
Airborne precautions
TB, avian influenza, disseminated zoster, smallpox
172
Droplet precaustions
>5micrometer droplets 3 to 10 feet | Neiserria meningitidus, pneumonic plague, diptheria, H flu b, pertussus, influenza, mumps, parvo b19
173
Erythema Multiforme
``` INfections or drug rxn target/iris lesions palms, soles, mucous membranes Tx: suppressive acyclovir (doesn't shorten course) (if also respiratory sx then consider mycoplasm pneuoniae -> tx with azithro) ```
174
Erythema migrans
``` hallmark cutaneous lesion of lyme centrifical spreading ring - bullseye much bigger than erythema multiforme lack of mucosal invovlement amoxicillin or doxy ```
175
Erythema nodosum
strep infection | PCN tx
176
Recurrent breast CA with possible bony mets
first bx bone to see HER2neu and hormone status | Tx: IV bisphosphonate -
177
Hypothyroid during pregnancy
thyroid supp requirement inc'd by 30-50% | Goal first trimester <2.5 TSH (less fetal complications)
178
AL Amyloidosis
``` frequently affects kidney and heart progressie HF from restrictive CM Nephrotic syndrome Hepatomegaly (congestion from RHFx painful b/l sensory neuropathy (distal) monoclonal light chain - lambda DX: fat pad bx congo red stain rectal or kidney bx if non dx SPEP/UPEP detect monoclonal light chains 20% have concurrent MM or lymphoprolif dz ```
179
Polyarteritis nodosa
fever, abd pain, arthraliga, mononeurtis multiplex, livido reticularis
180
Occupational lung dz
ground glass diffuse nodules on CT, SOB cough, low grade fevers no exposures, no relief with abx Always get detailed history of current work exposures, timing of ezposure to symptoms, if co-workers also getting affected, MSDS Metal workers - lipoid PNA, hypersensitivity pneumonitis, occupational asthma
181
Cardiovascular risk in elderly women
Start ASA in women 55 to 79 with several risk factors (older age, DM2, HTN) - dec's risk of stroke, MI, CV death - outweighs risk of GI hemmorhage
182
Stroke risk reduction
ASA alone Plavix slightly more effective or if allergic to ASA ASA + dipyramidole even more effective ASA + plavix - high bleeding risk
183
Myopericarditis
Acute pericarditis with +CE unrelated to MI Regional ST elev with new global or seg WMA Prodromal URI or other sickness (fever, etc) could have effusion
184
Cardiac tamponade
SOB complication of pericarditis JVP, pulsus paradoxus RV/RA collapse during diastole
185
Post myocardial infarction syndrome
Pericardidits preceeded by cardiac injury (ST e MI) | Does not usually cause HF
186
Takutsubo's CM
Chest pain, STE on EKG, LV dysfxn, normal cornoaries - deg of biomarker elev mild compared to myopericardiits - ballooned apex, hypokinetic base
187
Concurrent primary cancers - cancerization field effect
H&N cancer rare mets to lung - lung mass found can be another early stage primary - need to bx to find out Chemo and radiation spares voice
188
Dx Male infertility
1st step: Semen analysis (abstain 2-3 days) | 2nd step: if semen analysis abn - FH, LSH, total testosteroine (asess leydig and sertoli cell fxn)
189
Young woman, mild nephritis, outpt setting
mild flank tenderness, +U/A, fever, dysuria Tx with floroquinolone ie cipro (no nitrofurantoin - not good in renal tissue)
190
Step down therapy for asthma
If asthma sx stable with little need for rescue meds then try step down (ie stopping inhaled corticosteroid - use just rescue short acting B agonist)
191
Drug induced myopathy
Recent increase in statin or drug that inc'd statin blood levels can cause myalgia (PI, azole anti fungals, macrolides)
192
Polymyositis
prox muscle wk, elev CK, inflamm changes on muscle bx
193
Drug reaction with eosinphils and systemic sx (DRESS)
Generalized papular eruption, facial edema, fever arthalgia, LAD, elev EOS, LFTS Anti-convulsants, sulfa, minocycline, allopurinol
194
Acute generalized exathematous pustulosis (AGEP)
acute onset pusutules, fever, elev WBC poss EOS | B-lactam, ampicillin, floroquin, anti malarial agents, sulfa, terbafine, diltiazem
195
Erythema Multiforme
acute recurrent mucocutaneous eruption following acute infection (recurrent herpres simplex), or could be drug related Erythematous plques with concentric rings of color
196
Levido retiucularis
pink mottled netlike pattern | aw drug rxn to amantadinie, quinidine, warfarin, minocycline
197
Pre-op Rheum Arthritis
Pt with longstanting RA need to rule out atlanto axial subluxation -> could cause paraplegia No need for pre-op spirometry If pt demonstrates 4 mets no need for stress test
198
Manage GERD that does not respond to PPI trial
Pt failed PPI trial and has (wt loss, dyphagia, men >5 yrs sx, bleeding, anemia (no need for H2 blocker next) r/o eosinophilic esophagitis, mlaignancy, stricture, achalsia
199
When to use ambulatory pH monitoring
After neg endoscopy and still with GERD sx
200
Functional urinary incontinence
Pt's with cognitive decline may not be getting to toilet fast enough - prompted voiding
201
Overflow incontinence
obstruction vs neurogenic bladder | Check residual urine
202
Stress incontinence
pelvic floor muscle excercises
203
Urge incontinence
anticholinergic ie tolterodine
204
Inc'd risk of CV events in CKD pts
CKD pts may not have other risk factors but if symptoms occur then ACS should be ruled out
205
Unstable angina in pt with contraindication to BB
Diltiazem (not nifedipine - can inc HR) contraindic to BB - sx brady, AV block (advanced), SBP<80, shock, pulm edema, sx reactive airway
206
TCA overdose
can cause arrythmias blocks fast Na channels, -> VT/VF Sodium bicarb infusion - narrows QRS dec r/o arrythmia Procainamide contraindicated (also blocks sodium channel - makes arrythmia worse) Amio also bad - prolongues QT
207
Sjogren's associated lymphoma
44 fold inc in incidence of lymphoma risk factors - dissappearance of RFactor, mixed monoclonal cryoglobulinemia, cutaneous vasculitis, LOW C4 Bx mass! Sjorens sx - dry mouth (pilocarpine), inflamm sx - arthritis, cytopenia, vasculitis (steroids), arthrisits - hydroxychloroquine
208
Ectopic ACTH
Cushing syndrome - hypercortisolism, melanonchya) - signs of malignancy wt loss, temporal muscle wasting, new onset DM (excess mineralocorticoid), HTN, met alk, excessive urine K+ loss Ectopic ACTH secrtion from lung CA (small cell) NOT pituitary adenoma - ACTH levels lower
209
Adrenal adenoma/CA
suppressed ACTH
210
Autism spectrum d/o
impair communication, impaired social interaction, restrictive, repetitive stereotyped behaviors and interests learning disability or mental retardation, high functioning autism or Asberger variant
211
Obsessive compulsant d/o
recurrent obsessions and compulsions at least 1 hr per day that cuase marked distres or functional impairment, peristnt idea, thoughts, impulses, images
212
Schizophrenia
psychosis, delusions - hallucinations, disorganized speech, catatonic behavior At least 6 months of sx, 1 or more month of active sx (hallucination, delusion, d/o speech) and neg sx (flat affect)
213
Social anxiety d/o
severe/persistent fear of social or performance situation
214
Severity of acute pancreatitis
Dx: amylase/lipase | Predictiing severity : BUN
215
Allergic contact dermatitis
Delayed type allegic rxn - red edematous, weepy, crusted Dx: Patch testing Pinprick and RAST only for immediate type hypersensitivity rxn
216
Migraine without aura
``` Migraine 4-72hrs pulsatile unilateral mod - sev aggreva by activity ``` N/V or photophobia No neuroimaging if stable h/a sx for years Tx with triptan (sumatriptan)
217
Locally advanced high risk cervical CA
Pelvic radiation with chemo Surgical resection then adjuvant chemo/radiation HPV now would not help Pelvics every 3-6 months for 2 years, then q6 m x 3 years then annually + serial CT scans
218
Incidental high risk gallbladder polyp
High risk >10mm, gallstones >3cm, porceline gallbladder Cholecystectomy Risk factor for gallbladder CA, cholelithiasis, fhx gallbladder CA, If < 10mm then serial imaging
219
Manage prostate CA screening
Start with informed discussion risks/benefits of prostate CA screening Screening would be DRE+PSA (after discussion)
220
Tuberculous pericarditis
``` Treat TB (rifampin, INH, ethambutol, pyrazinamide) Add prednisone to decrease recurrence (indometh/colchisine only viral/idopathic pericarditis) if recurrent effsuinons then periocardial window or pericardectomy ```
221
Dx obstructive lung dz in coal miner
Coal dust can activate inflammatory cascade Check PFTs first Asx patients should get imaging q5yrs
222
Recurrent pericarditis
colchicine, ASA Pleurtic CP worse supine partially relieved leaning forward - pericardial friction rub, h/o acute pericarditis avoid corticosteroids (more recurrence) 3rd line azathroprine/cyclosporin CT Chest if suspect constrictive pericarditis (RHF JVD, pedal edema etc)
223
Sickle cell pain episode
Treat iniitally with IVF, spirometry and IV morphine If stroke/acute chest -> erythrocyte exchange tx avoid if possible in this patient has multiple alloantibodies NO meperidine - low sz threshold, short half life
224
Basic Calcium phosphate deposition dz
destructive inlfammaotory arthritis aw milwaukee shoudler Pain, large non-inflamm effusion after trauma destruction of articular cartilage ROM limited Dense Ca on Xray BCP crystals NOT seen under polazized light - only alizarin red staining
225
Calciphylaxis
soft tissue calcium deposition - ESRD pts
226
CPPD
see postivelty biregringent crystals (Gout neg birefringent crystals) OA fluid <2K WBCs
227
Hep C associcated cryoglobulinemic vasculitis
HCV Viral load elev, Low serum C4, elevated RF Palpable purpura +cryoglobulins - cold precip immunoglob - tend to occur in periphery extrem Skin bx: leukoplastic vasculitis Can also aw CTD, waldenstogm, MM
228
Henloch-schoen purpura
cutaneous small vessel vasculitsi (leukocytoclasic vasculitis) young children after strep infxn
229
Porphorya Cutanea tarda
vessicles/bullae on sun exp skin - 50% aw HCV
230
Necrolytic acral erythema
discrete erythematous to hyperpigmented plaques with scale/erosion in HCV pts, aw zinc def
231
Hypokalemic metabolic alkalosis from Gentamycin
Diuretics, gastric fluid loss, gentamycin toxicity, gittleman/barrtler Gentamycin toxicity - barrtler like - mimick effect of LOOP diuretic Urine pot/cr ratio 50 -> c/w urine potassium losses 2/2 tubular dysfxn Without elevated BP, primary hyperaldo less likely If Urine potasium/Cr ratio < 15 then might be seroquel induced shift of K to intracellular space, no met alkalosis Vancomycin induced nephrotox -> aw HYPER K+
232
Acute exacerbation of multiple sclerosis
High dose IV methylprednisolone (NOT PO) If refractory - plasmaphereiss Phyical/occup/speech therapy
233
Dermatomyositis (can occur without myalgia)
Need age appropriate cancer screening poikilodermatous erythema inc'd abd girth, fhx ovarian CA - need TVUS only bx if has myalgia - blind bx low yield
234
Patient presenting late with STEMI
``` Primary PCI (NOT EMERGENCY CABG) No thrombolytics >12hrs STEMI ```
235
Fundic gland polyps
Need colorectal eval for Familial Adenomatous polyposis | Multiple small 1cm
236
COPD pt immunizations
Can have both influenza and pneumococcal vaccines same visit diffierent sites Pneumococcal vaccine in routine pts >65yo At any age if COPD, asthma, DM, liver dz (chronic), etoh, fxn/antomic asplenia, immunocomprimizing conditions, smokers, NH One time revaccination for those vacc >5ya or <65 at time of vacc Only influenza vacc aw decrease in mortality
237
Antiepileptic in pt who wants to get pregnant
Carbamazepine, lamotrigine, levetiricem | No VPA, phenobarb or phenytoin
238
Risk factors for RA
Smoking increases risk of developing RA No change with etoh, obesity, excercise Dec'd risk with OCP
239
NSAID induced nephropathy in MM patient
MM pts particularly vulnurable to nephrotoxic meds ie NSAIDs, IV dye Pt's particulary vul baseline CKD, vol depletion, hyper Ca Cast nephropathy - filtered light chains intratubular obstruction/precipitation - unlikely if severe AKI but improved cast burden Palmidronate AKI - low indcidnece Focal segmental glomerular sclerosis +proteinuria Renal amyloidosis - highly unlikely as would have significant non-selective proteinuria
240
Nonpurulent cellulitis outpt therapy with systemic symptoms
Clindamycin active against CA MRSA and B hem strep risk factors for le cellulitis - DM, leg ulcers, tinea pedis, obesity, phlebitis Doxy/bactrim NO B hem strep coverage - if used need amoxicillin No rifampin - lots of resistance
241
Minimal change glomerulonephropathy
aw lithium use - fusion of podocytes on EM, no immune depostis, massive proteinuria aw mono, malignancies, NSAIDs, lithium rifampin Hep C ass glomeruloneph, lupus nephr, membran glomeruplopneph - > immune deposits
242
Benign positional vertigo
breif severe vertigo with position change episodes 1min and VERTICAL (not horizontal) Menieres - vertigo (nonpostional), unlateral hearing loss, tinitis Vestibular neurontis - aw viral infxn, more extended sx
243
Pustular psoriasis
pinpoint pustules coalescing into lakes of PUS h/o psoriasis Fever sheets of pustules Erythroderma - generalized erythema >90% skin - drug eruptions, psoriasis, atopic dermattis, cutaneous T cell lymphoma (high risk psoriasis tx by corticosteroids) Tx: underlying dz, general supportive care
244
Candida
localized in immunocompromized | erytmmatous base with white stuff
245
Sweet syndrome
acute febrile neutrophillic dermatosis (neutrophil granulocytes on histo) +arthralgia, myalgia Edematous red-purple plaques in trunk/extremites Can be aw AML Tx: corticosteroids Reactive syndrome preeceding viral syndrome (resp/GI)
246
Toxic shock syndrome
diffuse erythroderma resembling sunburn | Nasal packs, wound care
247
Dx Celiac dz with IDA
if upper/lower endoscopy neg and pt still anemic (pt with down syndrome) even if TTG neg - repeat endoscopy with small bowel bx r/o celiac dz, capsule endoscopy if neg Meckel diverticulum - pw acute bleeding, ft's of obstruction,
248
Normotensive acute ischemic kidney injury (ATN)
Pt with vascular risk factors and HTN now with lower than normal BP - renal hypoperfusion Elevated FENA, granular casts on u/a, normal kidney US
249
Acute intersitial nephritis
1 week after offending drug hypersensitity rxn rash WBC, erythrocytes in U/A
250
Cholesterol emboli syndrome
after conoary angio | bland urine sediment
251
Pre-renal azotemia
h/o fluid losses, dec'd fluid intake FENA >2% FE uria >50%
252
Osteoarthritis
subchondral sclerosis, asym joint space narrowing, osteophytes No h/o inflamm attacks - not gout RA would have symmetric joint space narrowing, no subchonral sclerosis or osteophytes
253
Calcium pyrophosphate deposition dz
chondrocalcinosis - in fibrocartillage (menisci)
254
Agitation and confusion in pt with alzheimers
r/o occult infextion, head trauma, CVA, meta abnormality If w/u neg D/c sedatives/anticholinergics don't need risperodone yet (not indicated for delirium) Donezepil , acetycholinesterase inhib, rivasstigmine - tx alzhemiers but not delierum
255
Hyperprolinemia
pt with h/a and low libido-pituitary MRI r/o mass (Sellar) Eventual tx with cabergoline (dopamin agonist) No need for testosterone tx - secondary hypogonadism
256
Acute cervical radiculopathy
without evidence of weakness or myelopathy - conservative tx with analgesics and avoidance of triggering activity ok (neck collars, corticosteroids, cervical traction don't show any superiority) EMG only if surgery being considered to pinpoint what nerve If wk/hyporeflexia then CT/MR myelograpy needed
257
Malaria -
``` Plasmodium falicparum - most malaria cases Can be from resistance or non-compliance fever, cyclical every 48-72hrs Giemsia blood smear Banana shaped gametocytes, ring forms ```
258
Plamodium Maraliae
fevers q72hrs | band form - trophozite
259
Plasmodium ovale, vivax
trophozoit, schizont forms - Shuffer dots inside enlarged RBCs
260
COPD exacerbation with NIPPV
reduces mortality, need for intubation (if has mental status or risk of aspiration) if RR<88%
261
Evaluate asx heart murmur
check TTE for any systolic lout (3 or >/6, any diastolic or continuous MVP (click) - reduction in LV volume, valsava prolongs murmur, shortens S1 to click inc in LV vol and preload by squatting dec's murumur, delays systolic click
262
Calciphylaxis
ESRD patients on HD elevated serum Ca, Phos Elev PTH Purpuric non-blanching patches associated soft tissue nodules -> bullae->ulcerate->escar From metastic calcium deposit in skin, vesicular CA - skin necrosis
263
Nephrogenic systemic fibrosis
yellowish thickened papules, and nodules, progressive skin tightening and sclerosis - pt with ESRD on HD exposed to GADOLINIUM
264
Polyarteritis nodosa
reticuloform purpura and SQ nodules - not aw ESRD
265
Pyoderma granulosum
p/w ulceration no SQ nodules, violacious, overlying edge, NOT AW ESRD
266
Inaccurate HgA1c
may be postprandial hyperglyemia if all preprandial and fasting FBS are normal and HgA1c elevated HgA1c falsely high with inc'd survival of RBC - untreated iron, B12, folate deficiency HgA1c falsely low survival of RBC (shorter) - hemolytic anemai, tx'd for B12, iron or folate def
267
Manage giant cell temporal arteritis
IF suspected GCA with neg bx on one artery - repeat bx on other side needed Don't use MRI with GAD in pt with CKD - npehrogenic systemic fibrosis
268
Cough variant asthma
Chronic cough - cough triggered by cold air and excercise Bronchial challange can exclude asthma if neg Pertussis - tx with macrolide/floroquinolone
269
HFPEF
preseved EF with HF sx LVH on ekg Tx: diuretics and ARB (candesartan) - reduced hospitalizations No digoxin in HFPEF
270
Normal Pressure hydrocephalus
gait shuffling, urinary incontinence, cognitive change | -check Brain MRI - look for ventriculomegaly
271
Hormone Rct + breast CA pre-menopausal
Tamoxifen x 5 years if ER/PR + in PRE-menopausal S/E endometrial CA, , VTE, hot flashes, cataracts Aromatase inhibitors if hormone + POST=menopausal woemn (anastrazole, letrozole) DCIS - no chemo needed Raloxifene - no study indicating for adjuvant tx - just prevention of cancer in pt with high risk/osteoporosis
272
HTN in women of childbearing age
``` d/c lisinopril - > start labetolol No spironolocatone(anti androgenic) and does need SOME antiHTN med ``` ACEi-> cardiac abn, kidney abn, death
273
Short bowel syndrome
surge of gastric acid after small bowel resection - incactivaes pancreatic lipase - > diarrhea Need suppressive PPI tx No cholestyramine - will worsen diarrhea by binding remaining bile salts
274
Palliative care discussion
Early referral preferred, emphasize NOT withdrawal of care, just improving quality of life Longer mean survival in study in patients with SCLC
275
Hypoactive sexual desire d/o
persistent lack of sexual desire/thoughts Tx: sex therapy Tx: post menopausal dryness vaginal estradiol Dysparenunia - infx, cystitis, pelvic adhesions, endometriosis, Sexual Aversion d/o - aversive response to any genital contact, nausea, SOB, Vaginismus - involutary spasm of vagina
276
Beau lines
transverse lines on nails in setting of systemic stress ie chemo or sepsis (disruption of nail natrix prodxn)
277
Lichen planus
pitting, onchyolysis, longitiudinal ridging
278
Median nail dystophy
longitudinal (not transverse) depression in center of nail and traverses whole length of nail - one or two nails - trauma
279
Psoriasis
Nail changes like pitting, oncylolysis
280
Concussion management
Grade 1 - Amensia/MS change < 15 min no LOC - may return to competetion if ok same day Grade 2 - Amnesia/MS change >15 min no LOC - remove from competition that day Grade 3 - Brief LOC - remove from competition and for 1 week asymoptomatic CT for grade 2 or 3 if sx return within week Hospitalization if traumatic findings on neuroimaging or persistent abn on physical exam
281
GERD
If no alarm sx (weight loss, dysphagia, bleeding, melena, anemia) then PPI trial first for GERD inc'd r/o GERD with obesity, tob use, OSA Reassss in 6-12 wks Ambulatory pH monitoring if fail PPI trial and neg EGD to confirm dx GERD Fundoplication if still GERD after PPI trial and neg EGD
282
Smallpox
Variola - respiratory tract infxn initially - high fever, vomiting, buccal/pharyngeal mucosa (Kolip spots) - > hands/face same stage maturation - contagious till all scabs crusted/shed Give smallpox vaccine for exposure of health worker CHicken pox - lesions in crops Cidofovir - outbreak of smallpox
283
NSTEMI/UA pt
If no stent - ASA + plavix x 1 month to 1 year (ideally) aw OMT
284
Severe asthma exacerbation
ICU - PCO2>42, FEV1<40% despite broncodilator
285
TSH secreting tumor
``` Hyperthyroid - elevated radio iodide uptake - Thyrotoxicosis with inappropriately elevated TSH -> TSH secreting tumor -> pituitary MRI needed NSx resection No thyroiectomy, methimazole, PTU ```
286
HTN pregnant pt
HTN before 20 weeks - presence of chronic HTN NOT HTN aw pregnancy Cr usually falls during pregnancy so does BP Gestational HTN - after 20 wks no proteinuria Pre eclampsia - HTN and proteinuria after 20 weeks
287
G6PD
Acute hemolytic anemia after oxidative drug (Bactrim) Bite cells on smear also dapsone and primaquin Cold agluten dz - high MCV - agglutination of erythrocytes Hereditary spherocytosis - no central pallor spherical on smear Thallesemia - target cells on smear
288
Older pt with seizures
Lamotrigine best tolerated Complex partial seizures/generaized Don't use carbamazepine (hyponatremia) phenytoin (dizzinesslethargy gait instability)
289
Selective IgA deficiency
Chronic/recurrent resp tract infections Atopic disorders (eczema) autoimmune dz (RA, SLE) Anaphylaxic rxn to blood products/immunoglobulin - > ab vs IgA
290
C1 Inhibitor def
Hereditary angioedema | fhx angioedema - subcut edema
291
Terminal complement deficiency
susceptible to neiserrial dz - meningiococcal
292
Uninterpretable ABI
ABI 1.4 - uninterpretable - | need great toe pressure or <0.7 = PAD
293
Spinal stenosis
leg discomfort with walking relieved lying down or waist flexion
294
Kawasaki dz
LN syndrome particularly with HIV infxn fever, nonexud conjunctivitis, desquamanting erythematous rash, mucositis, LAD - vasculitis of med vessles Tx: Immunoglobulin + salicylates - > corticosteroids
295
TSS
bacterial toxins - septic shock | hypotensive, fevrile, diffuse malar rash, severe myalgia, elevated CPK, hyperemia, AKI, acute liver injury
296
Newly dx breast CA with risk of BRCA
Counseling and genetic testing Pt with h/o ovarian and breast CA decide on local surgery vs ppx mastectomy/BLSO
297
Keloid tx
``` Intralesional triamincolone (several injections over weeks) claw like beyond confine of area of trauma - tender or itchy, do not resolve on own - nodule like laser excision/radiation if recalcitrant ``` No abx, oral steroids don't work, topical steroids don't work Hypertrophic scars at surgery site/trauma - flatten out and resolve over 2 years
298
Hypothyroid after central hypopituitarsim from surgery/radidation
Fatigue and wt gain - suspect hypothyroid, check free T4 with central hypothyroid - have low TSH since it is produced in pituitary Tx: levothyroxin Morning cortisol will be low because pt taking glucocorticoid replacement OCP will lower LH /gonadotropin levels Check IGF-1 to assess GH deficiency (GH directly measure is bad - GH is surge hormone)
299
Hyperkalemia in setting CKD worsening
Hyperkalmemia - tx with gluc/insulin, calcium carbonate, If peaked twaves or other signs of cardiac conduction abn in setting of hyper K -> needs emergent HD Don't use lasix in setting of AKI and low UOP Pt with hyperkalmeia, hypovolemia and met acidosis -> sodium bicarb No kayexalate with recent bowel surgery risk of interstitial necrosis
300
Recently resolved acute diverticulitis
AFter therapy with abx and settling period of few weeks-> Colonoscopy - r/o crohns/adenoCA Elective colon resection not warranted with one attack of diverticuosis
301
Acute Angle closure glaucoma
narrowing or closure of anterior chamber angle - impedes trabecular drainage - elevated IOP/ optic nerve damage Ophthalmic emergency Sx: halo eyesite, decreased visiual acuity, pain on eye, n/v, sluggish mid range pupil, corneal cloudiness, cupping of optic nerve Tx: Topical B adrnergic agents, pilocarpine, carbonic anhydrase inhibitor
302
Central rentinal artery occulsions
50-70yo painless unilateral vision loss embolic/thrombotic event afib (No red eye, pain, n/v)
303
Occular migraine
Fhx/pmhx migraine flahsing lights, visual blurring/unilateral vision loss <40yo
304
Temporal arteritis
Pt older than 50 severe new h/a visual loss PAINLESS (no red eye, n/v)
305
Chronic severe MR
Surgical indications preserved LVEF with New onset afib concurrent maze/PVI +warfarin for afib (Rhythm control with amio, DCCV, not likely to work)
306
OSA therapy
Apnea/hypopnia index 5-15 = mild 16-30 = mod >30=severe CPAP for anyone with OSA + sx (daytime somnolensce) Mild to mod can use oral device (not as effective) Surgery if nasal sept dev, polyps, tonsillar enlargement, retrognathia (not willing to do CPAP)
307
Acute pseduogout
Positively biregfringent - rhomboid shaped crystals linear calcium dep in cartilage (chondroCA) Pt with DM, CKD, PUD Tx: best= intraarticular steroids don't want oral steroids 2/2 DM, don't want NSAIDS 2/2 PUD No abx as infection not likely (neg gram stain, low wbc in synovial fluid)
308
Drug induced erythema nodosum
Non-specific inflammatory cutaneous rxn - inflamm in fat pads - septal panniculitis - red brown nodules in anterior shins Etio - infections (Hep C, TB, EBV, cat scratch), drugs (OCP, PCN, sulfa), systemic dz's (IBD, behchets, sarcoid, NHL Tx: D/c OCP Tx infection
309
Wilson's dz in young pt
``` Presents with parkinson's rigidity, bradykinesia cramped handwrited, masked faces psycomotor retardation, depression Dx: CHeck serum ceruloplasmin Slit lamp exam kleiser fliester rings ``` Other causes parkinsonianism in young ppl CO poisoning, trauma, brain tumor, hydrocephalus
310
Pt with breast CA and h/o VTE
Pt with hormone rct + breast CA but contraindication for aromatase inhibitor (h/o VTE) Tx: Ovarian ablation ONly use trantuzumab in HER2Neu + patients
311
Thyroid storm
temp elevation, tachycardia, HF, abd pain, diarrhea, n/v, jaundice Can be from non-compliance with anti-thyroid meds or precip by surgery, truama or radiocontrast Tx: PTU/methimazole, BB, iodine solution Myxedema coma - hypothyroid - hyponatremia, hypoventillation how T3, T4
312
Subacute (de Quervain) thyroiditis
transient destructiono f thyroid tissue - release of pre-formed T3/T4 - initially hyperthyroid then hypotheyroid s/p viral infct, tender thyroid
313
Budd Chiari syndrome
``` hepatic vein thrombosis risk factor PCVera (also have TIA, MI/CVA, erythromyalgia Dx: Doppler US check for hepatic flow Tx: A/C - oral diuretics if not fully controlled - TIPS -> liver tx ``` Splenic vein thrombosis - isolated gastri varices no tender Hepatomegaly or ascites
314
HTN in pt with CKD
Thiazide diuretics less effective than loop diureteics if GFR < 30 (resistent HTN - 3 agents diff classes including diuretic) Change HCTZ-> loop
315
Dx Acute retroviral syndrome
Pt with high risk features for HIV HIV test neg, strep and mono neg Check HIV RNA to dx HIV
316
Manage AC for pt with mech AVR preop
Short term risk small D/C warfarin 3 days before surgery and restart evening of surgery Risk factors = afib, more than one valve, valve position, hypercoag state, LVEF<2, stop 4 hrs prior to surgery then restart after with warfarin until INR therpautic If needs emergent surgery then use FFP to reverse coumadin
317
Henloch Schloen purpura
Palpable purpura of legs after strep pharyngitis (raised violacious non-blanching papules) Cutaneous small vessel vasculitis elevated risk of kidney dz
318
Disseminated gonnococcal infxn
fevers, tenosynovitis, arthritis, skin lesions - hmorrhagic pustules -
319
Sweet syndrome
neutrophillic dermatosis - bright erythematous well demarcated papules Idiopathic or aw underlying dz (hem malignancies)
320
Treat carpel tunnel syndrome
avoid repetitive wrist motions start wrist splinting Local corticosteroid inj for 3 months releif not durable ->contraindicated with thenar hypertrophy, lot of sensory loss, acute carpel tunnel NSAIDS not effective Surgical intervention if medical/nonpharm tx fails - progresive sensory and motor defects, severe EMG findings
321
Manage sellar mass
Incidental sellar mass Check for hormone hypersecretion IGF-1(to measure GH fxn), morning cortisol AND prolactin IF inc'd prolactin - > dopamine agonist tx
322
DMSupp
used to locate tumor in ACTH dependent cushings
323
SIADH
check serum and urine sodium
324
Acute ischemic stroke with HTN
initial stroke >3-4.5 hrs out - no Tpa no end organ damage (no LVH, ACS, kidney dz, encephalopathy, preeclmapsia, CHF, aortic dissection keep BP<220/120 No oral meds (dysphagia risk)
325
Inpt with risk for VTE
immobilized and two risk factors for VTE low dose HSQ (not ASA, warfarin 1mg) - don't use SCDs unless contraindication for HSQ
326
Complicated parapneumonic effusion
pleural fluid cw exudate | Complicated = large effusion, loculation, +pleural fluid g stain, pleural fluid glucose < 60, pH tube thoracostomy)
327
Esophageal candidasis
Oral fluconazole plaques in mouth and dysphagia Nystatin swish/swallow only in pt with oral dz and NO dysphagia (indicating esophageal inovlvment) Do not d/c inhaled steroids yet - tx candidasis
328
Kidney bx contraindication
``` Uncontrolled HTN (r/o post bx hemorrhage) <160/95 (take all antiHTN preprocedure - short acting BB/clonidine during procedure also mild sedative (lorezepam) ``` Other contraindication - coagulaopathy, low plt, hydronephrosis, atroptic kidney, kid cyst, acute pyelo
329
Hereditary hemochormatosis
C282Y mutation - risk factors ferritin >1000, age>40 r/o cirrhosis - if dx then liver bx to r/o cirrhosis -> r/o HCC If cirrhosis - > EGD r/o varices, HCC Tx: phlebotomy Observation only if ferritin low <50, no end organ damage Yearly checkups for iron level and labs If genetic hemochormatosis with iron overload wihtout end organ damage still needs phlebotomy
330
Reactivation of HSV by UV radiation
latent HSV in trigeminal nerve activated by sunlight UV - immunosupp by UV localized cluster of vesicles on vermillion border of lip - vesicles rupture and heal tx: oral acyclovir, lip balm with sunblock
331
Actinic chelitis
premalignant in people with significant sun exposure | on lip - ulcers, vermillion border
332
Contact dermatitis
from lip balm usually pruritic
333
Coxsackie
``` hand foot mouth dz intraoral, palmar, plantar lesions oval flesh colored papules with erythema rim fever/sore throat Spare lips - different than HSV ```
334
HLD tx in pt wants to get pregnant
colesevelam (welchol) bile acid sequestrant - dec CV mortality Risk factors for CVD - DM, HTN, HLD, FHx MI s/e constipation - binding and dec absorbtion of other drugs ``` No ezetimeibe (doesn't dec mortality and preg cat X) Gemfibrozil not efficiacious enough No statins (cat x) ```
335
Clinical manifestation of sickle cell TRAIT
Only hematuria, risk fo splenic rupture high altidute, VTE, sudden death during extremem condidtions, renal medually CA Hematuria - renal papillary necrosis (local microinfarcitons) - painless gross hematuria Need well hydration during strenous excercise r/o stones/urinary tract neoplasms Pt with SC trait don't get acute chest, bone/joint sx, LE swelling
336
Treatment of Tic d/o
If no effect on social /academic or occupational fxn no need to treat Tourette's syndrome No ADHD or O/C d/o If does disrupt ADL - block dopamine with clonidine, pimozole, haldol
337
Lymphangiolyomyomatosis (LAM)
``` rare cystic lung dz rare in women of childbearing age aw tuberous sclerosis Spontaneous PTX/chylothorax Young woman with dyspnea and chest CT with cystic findings/hyperinflation on CT Diffuse think walled cysts Etio - smooth muscle cells in lung infiltrating lung with inactivating TS gene tx: sirolimus ```
338
Organizing PNA
sx over 4-6 wks no more than 6 months | patchy airspace dz, ground glass, consoidation (no cysts)
339
Repsiratory bronciolitis associated ILD
smokers | centroloar nodules, air trapping scatterd gound glass
340
Sarcoidosis
reticulonodular abn in central distribution along lymphatics b/l hilar and mediastinal LAD
341
Padget's dz of bone
osetitis deformans focal abn of bone metabolism - compromoised bone integrity Dx: confirmed by plain Xray - coarsened bone trabeculae elev alk phos (bone isoform) traumatic / pathoogic fx, hearing loss impringemneet CN VIII, bone bx, audiology after confirmation or denial of padgets
342
Diffuse cutaneous systemic sclerosis
Pt's w/ SCL70 - antitopoisomerase + high risk of ILD - check HRCT chest (low dlco, restrictive pattern (low FEV1)) ILD w or w/o alveolitis No risk factors for PE, no RH strain No RHC if normal TTE
343
Achalasia
Tapering esophagus - birds beak surgical myotomy No endoscopic dilation in young pt (recurs and r/o rupture) No botox injection - only temp relief - only if not candidate for surgery or endo dilation No medical tx - no consistent results
344
Cardiac monitoring for INFREQUENT arrythmia episodes
Implantable loop recorder concern for arrythmia given occupation Up to 3 years when shorter duration monitors non-dx
345
Lead nephrotoxicity
Pt with normal lead levels but still suspect lead poisoning Use chelation mobilization testing - measure in urine Lead nephrotoxicity - chronic intersititial nephorlithiasis - low grade proteinuria, - Fanconi like syndrome - glycosuria in normal glucose, hyperurecemia, hypophosphatemia, aminoaciduria Erythrocyte protoporphy measurement - acute lead exposure Lead lines - long bone radiography - only in kids Basophilic stippling in peripheral smear - non-specific
346
Colonscopy screening ulcerative procitis
if confined to colon then like general population (q10yr)
347
Coccoidomycosis
SW US/S/Central america | Pulmonary infxn, joint pain, erythema nodosum
348
Blastomycosis
Mississipi/Ohio river valley, great lakes
349
Histoplasmosis
ohio river valley Hilar LAD with pulm infiltrates Bird/bat droppings
350
Sporotrochosis
rare cuase of PNA - can have erythema nodosum, cavitations, lung nodules, hilar LAD
351
Ischemic stroke treatment
Contraindication for TPA - DM, ischemic stroke hx Tx: not candidate for tPA (keep BP < 220/120) Use high dose statin
352
Adrenal fxn during critical illness
Random cortisol >12 makes adrenal insuff unlikely in pt with hypoalbumin/ critically ill continue current therapy abx/IVF Cosyntropin stim not useful in setting of sepsis (stressful arleady) No reason for morning cortisol in pt with sepsis as maximally stimulated all day No need for hydrocortisol
353
Lentigo malina
Melanoma in situ uniformly pigmented light brown patch in area of sun exp skin grows slowly over years Broad shave biospy Not an excisional bx because lesion is large and likely lentigo maligna and NOT melanoma so likely minimally invasive
354
High risk myelodyplastic syndrome
Refractory anemia with excess blasts 10-19% tx with azacitidine (nucleoside analogue) Abnormal cytogenetics
355
TTP
``` thombocytopenia microangipathic hemolytic anemia fever kidney impairment neurologic deficits +schistocytes on smear ```
356
MM and AKI
MM - production of abnormal immunoglobulin (paraprotein) Pw bone pain, hyperCa, anemia, AKI - precipitation of paraproteins in kidney Clue: Urine dipstick low protein (only measures albumen) Total protein HIGH Use SPEP/UPEP to dx MM If was ANCA vasculitis then u/a would be active
357
Disseminated gonnoccocal infection
Young, sexually active adults prodrome tenosynovitis, polyarthralgia Cutaneous lesions papule/macule -> pustule, frank arthritis, gram stain/ctx usually neg tendinitis, PAPULOPUSTULAR skin lesions
358
Staph arthritis
usually monoarhritiss | no tenosynovitis or skin findings
359
Thromboembolic ppx after afib ablation
First 2-3 months ALL pts take warfarin AFter that period give according to CHADS2 (don't know if pt having asx pAF) NOAC not studied in post afib ablation setting
360
Symptomatic BPH
combination therapy with alpha blocker (tamsulosin, doxazosin, terazosin) and 5 alpha reductase inhib (finasteride) - shrink prostate takes time (no reason to change 5 alpha red i, or for abx
361
Meralgia paresthetica
Nerve entrapment of lateral femoral CUTANEOUS nerve BURNING, numbness - anterolateral thigh PURELY sensory DM, obesity, wearing of tight fitting pants/belts dysthesia/hypothesia in distribution of lateral thigh No tenderness to palpation
362
Greater trochanteric bursitis
Pain in region of greater trochanter worse on affected side | Pain to palpation
363
Illiotibial band syndrome
pain in anterolateral knee worse with running/cycling absent in rest pain to palpation of femoral lateral epicondyl
364
L5 radiculopathy
back pain -> lateral thigh weakness in foot all three (eversion, inversion, dorsiflexion) +straight leg test
365
Dopamine agonist induced COMPULSIVE behavior
excessive repetive tasks 2/2 dopamine agonist meds dysregulation of brains dopamine rewards system Tx: reduce dopamine agonists
366
Demntia with lewy bodies
80% parkinson's pt affected cognitive decline, parkinsons Bizarre visual hallucinations
367
Frontotemporal dementia
apathy, impulsivity, hoarding, disinhitibtion | obsessionality
368
Prevent ventillator associated PNA
48-72 hrs after intubation maintain head of bed 30 deg daily wheening assessment chorohexadine mouth washes No need for early trach, chorlox baths,
369
Symptomatic rapid afib
hemodynamically unstable -> DCCV (hypotension, pulm edema, - loss of atrial kick dec's BP and CO) - recent sx development - no A/C needed Adenosive to dx SVT Amiodarone only for cardioversion of stable afib pt or long term afib prevention No metoprolol or diltiazem in setting of acute HF and unstable afib
370
Lofgren syndrome
anterior uvietic, fever, acute lower extrem arthritis, erythema nodosum, -> check for hilar LAD on CXR to confirm Lofgren without tissues bx
371
Granulomatosis with polyangiitis
Wegeners - arthritsi, uveitis, pw URI - glomerulonephritis and mononeuritis multiplex,
372
Disseminated gonnococcus
fever, tenosynovitis - usually no uveitis | No erytema nodosum
373
Pityriasis rosea
young ppl single pink oval shaped plaque (herald patch) -> surrounded later by smaller lesions (christmas tree pattern) Pruruits Tx: none - self limited (only mild low dose topical steroids if pruritic)
374
Fungal
Expanding ring like lesion central clearing | scrape and KOH lesions
375
Treat vent failure 2/2 opiods
Non-focal neuro exam, pinpoint pupils, RR < 12, - needs escalating doses of naloxone Stroke less likely given non-focal findings
376
Hepatorenal syndrome
``` Setting of SBP doubling of Cr Cirrhosis with ascites No concurrent nephrotoxic drugs Tx: Albumin ``` (no benefit of octreotide or vassopressin)
377
Diabetes inspidis
Central DI: Urine Osm < 200 in setting of hypernatremia Response to ADH/despmospressin UOsm>600 CMV Nephrogenic DI: foscarnet tx, lithium Desmopressin does not inc UOsm
378
Cerebral salt wasting
HYPOnatremia, HYPOvolemia
379
Pt with DVT and cancer
LMWH (not coumadin, not UFH (needs labs)) No IVC (no contraindic for A/C or failed A/C)
380
Acute utricaria likely 2/2 levofloxacin
cetirzizine, ranitidine, diphenylhydramine (h1, h2 tx) No concerning features (stridor, eyelid swelling, breathing comfortably - these would warrant admission to hospital) Topical corticosteroid impractical NO NSAID - mast cell degranulation - worsen utricaria
381
Spasmodic torticollis
focal dystonia of neck occupational overuse syndrome characterized by directionality Tx: botox injection
382
Elevated chol in pt with DM
With DM - LDL goal LDL<70 To dec LDL always try to inc statin if possible (other drugs do not dec mortality)
383
Mild congential asymptomatic neutropenia
ANC 1000-1500 common among certain groups able to do ADL NOT aw inc'd infections No tx needed, repeat CBC in 2 months (If need to r/o autoimmune neutropenia then antineutrophil Ab assay) BM aspirate if neutropenia worsesns (Flow cytometry only in lymphoprolif d/o)
384
Tb tx
With meningitis - 9-12 months 4 drug regimen (meningeal involvement on CT) CSF lymphocytic pleocytosis, dec'd glucose Regular pulm/extrapulm TB - 6 to 9 months INH, rifampin, ethambutol, pyrazinamide 2 months of all 4 then 4 or 7 more months depending on pyrazinamide or not during first 2 months >12 months for drug resistance
385
Non etoh steatohepatosis
Wt loss, excercise, agressive control of lipids, BP, glucose
386
Nodular lung infiltrates suspected vasculitis
lung infiltrates with hemoptysis, p and c ANCA + rapidly progressive GN Need lung bx for dx (nasal/rhin tissue dx insufficient, no indication for kidney bx if no protein in urine)
387
Secondary Osteoporosis
Fragility fx r/o causes of osteopenia Check for hypogonadism, vit D def, pirmary PTH, Ca malabsorbtion, Ca+ malaborb, MM H/o IDA with low urine Ca - possible celiac dz start bisphosphonates when dx certain
388
Upper airway obstruction 2/2 angioedema from ACEi
No signs and sx of anaphylaxis or allergic rxn (no role for steroids or epinephrine) Need intubation
389
Generalized anxiety d/o
excessive anxiety and worry about Variety of events on most days for at least 6 months fatigue, irritability, restlessnes, insomnia SOmatoform sx (high utilizer of heathcare)
390
Major depressive d/o
5 or more depressive sx in 2 week period
391
Bipolar d/o
manic or hypomanic mood epsisodes and depressive ones (manic = delusions of granduer, elevatd mood, dec need for sleep,, hypersexual, spending sprees)
392
ADHD
inattention in childhood, hyperactivity, impulsivity in work/home/school (2)
393
Chronic stable angina
despite optimal medical therapy and no options for revascularization (already on BB, nitrate, CCB) Ranolazine (don't give to long QT pt, inhibits met of dig/zocor, dose ajust with Kidney dz, )
394
Primary glomerulous nephropathy
Nephrotic syndrome Microscopic hematuria, no erythrocyte casts HBC, HCV, SLE, malaria, syphillus, malignancies (breast, lung, kidney, stomach, colon, NSAIDS, ACEi, RA, DM Kidney bx: LM: diffuse glomerular thickening, no inc'd cellularity Immuno: granular IgG C3 deposits along capillary loops EM: mod foot process effacement
395
Asymptomatic gallstones
Observation unless symptomatic (or undergoing procedure that will make syptomatic) Most asx gallstones benign course
396
Superior vena cava syndrome
Need tissue dx - mediastinoscopy and bx can be caused by lymphoma, mediastinal germ cell tumors, lots of pt with malignancy have this as presentring syndrome Progressive dyspnea, facial swelling, distention of neck/veins, facial edema, mediastinal widening, pleur eff
397
Dx Vit D deficiency
Pt with osteoporosis, high PTH, low Ca+ and Phos -> secondary hyper PTH 2/2 vit D deficiency Check 25OHD3
398
Chronic fatigue syndrome
unexplained fatigue that lasts more than 6 months - subj memory impairment, sore throat, tender LN, h/a, unrefreshing sleep tx: CBT, graded exc, sleep hygene,
399
Osteomyelitis
Deep bone bx cultures more accurate | Sinus tract drainiage could be contaminated from surface
400
Discoid lupus
dyspigmented atrpohic patches on scalp/ears, black women, hair loss, leave scars usually no systmeic SLE
401
Allopeica areata
NON-scarring process - no skin changes in ears
402
Tension headaches
``` Non disabling h/a 30 min to 7days Need brain imaging - done, net b/l steady, unaffeted by physical activity, no photopobhia, n/v Tx: NSAID> ASA or tylenol (no role for TCA, cyclobenzaprien, ```
403
Early Rheum arthritis
CRP, +CCP, +RF, lots of joints, early morning stiffness >60min, Tx: DMARD (MTX) (NSAIDs, shoe inserts and colchicine NOT better)
404
Adult with repaired tetralogy of fallot (pulmonary infundibular stenosis, Overrding aorta (AV connected to both L&R Ventricle), VSD, RVH) pw sx afib
Pulm valve replacement, TV repair, Maze procedure (afib) MC post op problem - afib from severe PV Regurg 2/2 patch over RVOT - well tolerated for years but causes RVH, TV annular dilation, TR, dilation of RA causing afib RFA/DCCV won't work without fixing PV/TV Tx onlywith biventricular failure
405
Treat anaphylaxis
IM/SQ epi for anaphylaxis and inhaled albuterol for wheezing need high flow o2, cardiac monitor, IV access, No IV epi - only treats hypotension (r/o MI, HTN, CVA, r/o arrhythmia) Antihistamines or corticosteroids won't help anaphylaxis Mechanical ventillation only in drooling, stridor, facial/tongue swelling, inability to talk
406
Nephrogenic systeic fibrosis
(nephrogenic fibrosing dermopathy, scleromyxedema like illness of renal dz) Seen in some pts with ESRD on HD after MRI with GAD, Progressive tightening and thickening of skin, fleshy/yellow plaques/papules, pruritis, Skin bx CD34, dermal fibroblasts
407
Lipodermatosclerosis
Significant venous insufficiency darkly pgimented indurated skin +venous ulcers, dependent edema
408
Scleroderma
should be in face, periooral, fingers, +SCL70, +anticentromere Ab
409
Scleromyxedema
widespread ertyemaouts, indurinated skin with fleshy papules, face, fingers, extremities, aw serum paraprotein seen on SPEP
410
Parapneumonic effusions
Pt's with CAP and large pleural effusion (>1/2 hemithroac or 1cm lying) - should undergo prompto thoracentesis, exclude complicated parapneumonic eeff (pH<60, G stain +) Delay may cause loculation and need for VATs Small pleural effusions do not require drainage
411
Cancer of unknown primary
symmetric around midline mediastinum and retroperitonium - poorly diff CA LIKELY Extragonodal GERM CELL TUMOR (given young man) Check AFP, HCG Tx: Cisplatin chemo
412
Palliative care discussion with family of cancer pt
Communicate with family to assess understanding of patient's condition Don't start with advanced directives Don't say cure intent is futile
413
Overcorrection of hypotonic hyponatremia
Correct 4-6 meq in 24hrs if more then need to correct backward with 5% dextrose (high UOP suggests rapid water diuresis which will worsen correction) Tolvaptan would also block ADH which would make overcorrction worse (same with fluid restriction, NS) - cells shrink, water out, central pontine myelolysis
414
Generalized convulsive status epilepticus | jerking all 4 extremities tonic clonic >5 min
First Lorazepam (benzo) Then Phenytoin/fosphenytoin Acute complication - rhabdo, hypoxia, met acidosis Chronic - cognficitve defects, future seizures CTH needed levecitram (keppra) not used in general convulsive status epilepticus
415
Fungal arthritis
In immunocompromised (ie DM) subacute monoarthritis gardener scraping knees (sporothorax) Synovial fluid culture, synovial bx
416
Basic calium Phophate dz
usually chronic crystals invisible in polarized light alizen red stains them should have Ca+ seen on xrays
417
Fasting hypoglycemia in pt without DM
Pt with lab documented HYPOglycemia inappropriately high insulin level (without inappropriately high C-peptide) -> hypoglyemia due to EXOGENOUS insulin injection -> needs PSYCH eval also r/o sulfonyurea If suspect insulinoma - abd CT Gastric emptying delay rarely causes SEVERE hypoglycemia (also with h/o altered Gastric anatomy ie bypass) - no need for gastric emptying study
418
Pt with active TB that discontinued all meds on 2 month initial regimen
If meds d/c'd more than 2 or more weeks in initial 2 month tx then restart from beginning with SAME meds If < 2 weeks missed then continue regimen as long as all planned doses taken within 3 months REgardless if sputums neg pt needs initial 2 month phase followed by 4 month continuation phase SInce all meds dc'd at once no reason to change meds suspecting resistance
419
Acute exacerbation of IPF
Some patients with IPF develop acute exacerbation Dx criteria - unexplanined worsening of dyspnea in < 30 days, CT new GG appearance, consoldation Only intervention = lung tx Diffuse alveolar damage on bx - pt age and lack of comorbid condition - good tx candidate Diffuse alveolar hemorrage can show as ground glass on CT however would show blood in BAL PJP PNA - would show organisms on BAL, pt should be immunocompromised Pulm edema 2/2 tachy - would have S3, elevated BNP, JVD
420
Myasthenia gravis
``` immune attack on post-synaptic nm jnc Ab vs acetylcholin rect Muscle spectific tyrokinase rect ab CT chest r/o thymoma - needs surgical resection Tx: plasma exchange or immunosuppression ``` If muscle sp tyros kinase Ab + then less responseive to pyrostigmine Ephodrium - check if clear cut muslce strengthening after injection -> dx MG not good with just opthalmic and mild limb weakness
421
Manage white coat HTN
White coat HTN with no evidence of end organ damage (no LVH on EKG, normal Cr/labs) Dx: 3 sep office measurement above 140/90 and two at home below f/u q6month, continue HOME measurements - still at risk for sustained HTN No benefit to pharm tx of white coat HTN Normal labs, normal ekg no need for TTE or urine studies
422
Nocturnal hypoglycemia
HgA1c lower than avg blood sugars measured - so i hypoglycemic at unmeasured times of day 70/30 insulin peaks 6-8 hrs h/a, morning fatigue, sweating in DM I pts
423
Dawn phenomenon
Elevated glucose 4-8am with morning cortisol surge (co release with GH) - dx with perisistent hyperglycemic morning readings
424
Somogyi phenomenon
the lower the glucose at night, the higher the rebound hyperglycemia in AM
425
Risk of death for women
Greatest problem is cardiovascular dz more than all other cuases (ie cancer) combined Post menopausal, HTN, obseity, inc'd waist circumference, (CAD, PAD, CVA) Even women with DM will diet of CAD or CVA not DM
426
Tinea corporis
``` asx or puritis/burning Often annual growing circumferentially Topical steroids reduce temporatily but do not tx condition and will recur dx: KOH skin scraping Tx: topical antifungals ```
427
Atopic dermatitis
would not be worse when cream d/c'd | FHx atopy - eczema, asthma, seasonal allergies, atopic deramatisi - on flexor areas
428
Nummular Dermatitis
coin shaped eczematous lesions - pruritic - well demarkaced - can be acutely inflammed and weeping - dx by skin bx if needed
429
Psoriasis
round scaled lesions thicker scale - removal causes pinpoint bleeding (Auspitz sign)
430
Sclerodermal renal crisis
setting of diffuse cutaneous systemic sclerosis etio - acute HTN, AKI - microangiopathic hemolytic anemia Tx: ACEi Bosentan - tx pulm HTN or digital ulcers in pt wit syst sclerosis Plasma exchange for TTP, HUS Sildenafil - PDE inhib, Pulm HTN/ raynauds
431
Sycope in elderly male
Cardiac causes of syncope have high mortality - inpt cardiac monitoring needed likely with prodrome of palpitations and immediate recovery Neuro etio of syncope rare - no need for HCT or carotids NO TTE unless suspect structural heart dz
432
Risk of ampullatory adenoCA in pt with FAP or Peutz Jehurers
Need regular upper endoscopy even after colon resection r/o ampullary CA Tx: whipple DOn't just monitor LFTS - when elevated likely too late!
433
Manage early septic shock
Empiric abx therapy - within 1 hr of dx sepsis (after cultures obtained) crystalloids to maintain preload O2 to prevent hypoxia Vasoactive agents if persistent hypotension after IVF - go with epi first Tx of PRBC if needed (if Hct < 30 or CVO2<70%
434
Salicylate toxicity
respiratory alkalsosis tinnitis, tachpnea, confusion, fever AG met acidosis (salicylate anion and lactic acid/ketoacid) Alk of serum pH to decrease cellular uptake of salicylate IV glucose to stop salicylcate induced neuroglycopenia correct hypokalmeia to prevent salicylate absorption in distal tubule Don't use acetazolamide - decreases serum pH which increases cellular uptake of salicylate/toxicity HD if salicylate >80, AMS, AKI, pulm edema, Avoid mech ventillation if possible - decreases serum pH increasing salicylate tox/uptake
435
Dx Scabies
confirm with scraping and microscopy mites, eggs, feces KOH/oil unexplained itching and rash finger web spaces, wrist, nipples, axilla, small excoriated papules, vesicles, linear burrows EOS is non specific Serum TTG - r/o dermatitis herpetiforms aw celiac dz No need for skin bx
436
MEN I
Parathyroid, Pituitary, pancrease - genetic | (gatrin secreting pancreasic neuroendocrine tumor
437
Autoimmune polyglandular syndorme
chronic mucocutaneous candidiasis, autoimmune hypoPTH, adrenal insufficiency
438
MEN II
parathyroid, Pheo, medullary thyroid CA
439
Convulsive syncope
cardiogenic/vasovagal syncope similar events in past - prodrome during blood draw Reassurance - no tx needed No anti epileptic drugs needed Even if seizures - only if has risk factors or focal findings on EEG/MRI
440
Acute chest syndrome in Sickle cell dz
New pulmonary infiltrates on CXR CP temp t use lasix - can increase sickling Hydroxyurea only for prevention of acute chest not tx
441
Risk factor management in pt with CAD
Smoking cessation best risk factor modification approach non-smoker status after 3 years excercise at least 3x/wk 20min/day <70 if CAD+DM
442
Botulism
symmetric descending flaccid paralysis with bulbar palsies, (diplopia, dyarthria, dyphagia), normal body temp, clear sensorium ``` Injestion of botulism toxin from home canned foods, wound contamination 1-5 days of ingestion respiratory dysfxn (Diaphragmatic wk) Detect toxin in stool, serum No abx needed ```
443
Guillane barre
oculomotor dysfxn - h/o antecedent infection (GI illness from campylobacter), ASCENDING paralysis, paresthesia,
444
Paralytic shellfish poisoning
ingestion of filter feeeders clams, oysters... sx few minutes to hours Tingling lips, paraesthia hand/feet, loss of contrl of arms/legs
445
Tick paralysis
ASCENDING paralysis, large muscles
446
Colonoscopy screening
Nonsyndromic colon CA 1st deg relative with colon CA age 54 Get screened age 40 or 10 years prior to 1st deg relative dx (whichever earlier) - ie 40
447
Manage ADHD inadult
not paying attendtion, impulsivity, motor restlessness manifest social/academic dysfxn at least in 2 settings If few sx then drug holiday q2yr for reassessment warranted If needs drug after holiday - atomoxidene warranted other SSRI not shown to help
448
Guillane barre
Plasma exchange and IVIG to prevent respiratory failure acute inflammatory demyelnating polyneuropathy Not phrenic nerve pacing (only with high C spinal injuries) No cpap - bulbar dyfxn r/o aspiration No benefit with steroids
449
Thyroid lymphoma
older pts h/o hashimotos presents as enlarging neck mass Local , systemic sx Local compression (dyphagia, stridor, JVD, facial edema) B symptoms Bleeding of thyroidd would show cystic mass no h/o trauma Thyroid CAs grow slowly
450
Atopic hand dermatitis
``` pts with atopic eczema prolongued contact water/harsh substances pruritic skin conditioin intermittent flares skin bx non sp ```
451
Keratoderma blenorrhagica
hyperkeratotic skin condition | erythem scaley plaque palms and soles aw sponyloarthropathy
452
Scabies
intnese itching | burrows interdigital web space, wrist, nipples
453
Tineas Mannum
infect stratum corneum (epidermis)
454
Pigment nephropathy from rhabdo
CK>5000 heme + urine, few RBCs (dipstick detects myoglobin) High urine sodium High FENa/granular casts suggests intrinsic renal damage Hx suggestive of muscle damage Acute interstitial nephritis - suspicious mediciine exposure Hepatorenal - liver dz, low urine sodium Intrabd compartment - surgery or massive fluid rescuitation
455
Ambulatory arrythmia monitoring
Presyncope few times a month Looping event recorder - will record pre-sx rthym but store when pt indicates feeling sx Holter (continueous 24 hr) - good for frequent asx arrythmia Post symptoms event recorder - No preeceeding rhtym - takes a while to place and record
456
Creutzfeld Jacob rapidly progressive dementia
``` progressive dementia aw myoclonus rapdi deterioration of mental status no trauma, infxn, fever Prion d/o Spongioform incephalopathy without inflammaotry signs - neg neuro imaging ``` Frontotemporal dementia time course longer herpes simplex encephalitis - fever, hemicranial h/a, memory impairment, seizures - neuro imaging with edema, hemorrhage in temporal lobes b/l temporal involvmenet -> pathomnemoic for HSV enceph
457
Henloch scholen purpura
``` Purpuric rash lower extrem arthritis, abd pain, hematuria Skin bx: Iga Depostis, leukocytoclasic vasculitis aw solid tumors or MDS ```
458
Churg Strauss
vasculitis - h/o asthma peripheral EOS p-ANCA
459
Microscopic polyangiitis
small arterioles glomerulonephritis and purpuric skin lesions NO IMMUNE deposits +ANCA
460
Polyarteritis nodosa
small to med vessel vasculitis renal artery involvement and HTN No immune depostis
461
Subacute cutaneous lupus
maculopapular rash, anti ro/SSA no glomerulonephritis
462
Preg pt with VTE and aquired protein S deficiency (anticoagulant)
dec'd protein S activity dec'd free protein S Ag normal TOTAL protein S antigen During preg (or warfarin use) conc of C4b binding protein inc's - binding free protein S Ag - dec'ing protien S activity -> hypercoag state - > more VTE Congneital protein S def shows just dec in protein S activity
463
Periop risk assessment
3 or more cardiac risk factors (Revised Cardiac Risk index) unable to achieve 4 mets If above met - proceed to surgery
464
Dx severe CAP
Urine antigen for S pneumo and legionella
465
Treat hospitalized patient with DM and basal insulin
Type I DM should have basal insulin + premeal (aspartate) | Don't resume pre-mixed 70/30 basal /bolus
466
Manage patietn with rhabdo
First trial of NS (rapid infusion) Inc'd sodium delivery to tubules will also excrere K+ No immediate need for HD as no EKG changes
467
Manage pt with Vfib arrest
after defib shock - CPR x 2 min - 5 cycles of 30 then 2 breaths then rnythem check CPR @ 100/min IV epi, after 2nd dose then IV vassopressin If multiple shocks then amio /lido considered offer ICD if survives arrest
468
Manage meds in pt who MAY become pregnant
``` Metformin ok for DM (class B) IF becomes preg then prossibly change to insulin ``` No ASA, ACEi, zocor (ACEi/statin class X)
469
Localized impetigo
Bullous impetigo = staph aurueus -use mupirocin if not systemic If systemic use cephalexin
470
Complex liver cyst
Complex=irregular, septations REfer for surgical resction (r/o malignant transformation) heaptic cystadenoCA Cyst asp not appropriate Do not just observe or repeat US
471
Asx hyperurecemia
mod elev serum urate NO sx Dietary/lifestyle mod only (avoid meat, shellfish, etoh) inc dairy, wt loss Don't use HCTZ - inc'd reabsorp urate, inc's r/o gout
472
Gout drugs
Allopurinol XO inhib - urate lowering Probeneicid - inc'd urate excetion Colchicine - anti-inflamm
473
Treat elevated BP after IC hemorrhage
IC hemorrhage after HTN, cocaine and ASA BP goal with IC hemorrhage - 160/90 (if ICP elev <140/90) Pt on cocaine so IV labetolol (not lopressor) IF unconcous or AMS - ventricular drain
474
Idiopathic pulmonary fibrosis (IPF)
Progressive dypnea with worsening dry cough >6mo smoking hx, inspiratory crackles dust exposure (ie wood) CT septal thickening, honeycombing, traction bronciectasis No COPD - normal FEV1/FVC
475
Hypersensitity pneumonitis
allergic inflamm lung dz exp to airborne antigens sx w/in 4-12 hrs
476
Clenched fist injury pt allergic to PCN
Person bite Augmentin if NOT PCN allergic Clindamycin/moxifloxacin if PCN allergy Alt is bactrim with flagyl
477
ethylene glycol intoxication
envelope shaped crystal (Ca Ox) flank pain, kidney failure, coma, seizures, noncardio pulm edema, Tx: fomipezole (competitive inhib of etoh dehydrogenase - presents converstion to more toxic compount) and hemodialysis to REMOVE present toxic compounds Metabolic acidosis (AG) with resp alkalosis and met alk (vomiting)
478
psychogenic nonepileptic seizures
Dx with inpt EEG video monitoring 2-7 days - continuous monitoring Antiepileptic drugs withdrwan
479
Patient with cyanotic heart disease and anemia
With cyanotic HD - goal Hg 60-65% In this pt Hct 52 but ferritin low Iron therapy needed Atrial septostomy - ES pulm htn tx without intracardiac shunt Pulm vasodilator tx if still sx after iron therapy
480
Advanced stage ovarian CA in complete remission after initial adjuvant chemo
H&P, pelvic and CA125 q4month x 2 years -> restart chemo if relapse No role for surveillence CT
481
Fuliminant liver failure
Refer for liver tx hepatic encephalopathy in setting of jaundice without pre-existing liver dz MCC FLF - medication (esp tylenol), viral infxn No need for FFP unless bleeding No ERCP - bile ducts NOT dilated
482
Pulmonary artery HTN in pt with MCTD
``` MCTD - sx of SLE, high ANA and RNP ab PAH occurs +Raynauds Isolated low DLCO Elev PAP on TTE Needs RHC ```
483
CA-MRSA skin infection
Bactrim Large pustular abscess with purulencea nd drainage Azithro, augmentin no activ vs MRSA Rifampin - rapid resistance
484
Prevent DM2 in overweight pt
Weight loss, excercise | impaired fasting glucose 100-125
485
Acute HIV infection
nonspecific consitutuional sx non specifici morbiliform exanthum/rash trunk/prox exttrem oral ulcers
486
Typhoid fever
fever, constitutional sx 1 -3 weeks afgter ingesting contaminated food/water faint salmon colored rash diarrhea, abd pain Dx: salmonella typhi in blood, urine
487
EBV
heterophile Ab test pharyngitis and LAB (cerv) mailaise, h/a Rash RARE
488
parvovirus B19
Flu like sx, rash/arthralgia, slapped cheeck rash, No oral ulcers or gen LAD Parvoviurs B19 ab titers
489
Lymphocytic Hypophysitis
uncommon autoimmune d/o enlargment of sellar contents central adrenal insuff (low ACTH), central hypothyroid, central hypogonadism Tx: glucocorticoid replacement - mass should decrease surgery if visiual field defect
490
Craniopharygioma
rare mixed solid cystic lesion WITH CALCIFICATION | aw panhypopit and DI
491
Sheehan syndrome
pituitary infarction in setting of hemorrhage during complicated delivery
492
Prolactinoma
with such large lesion likely would have much higher prolactin =- inc'd size pituitary in preg does not cause sx or mass effects