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MKSAP > Deck 2 > Flashcards

Deck 2 Flashcards

1
Q

Giardiasis

A 
prlonged GI illness watery diarrhea, wt loss, camping trip no running water - giardia cysts in water
large volume smelly stools
Dx: Giardia stool antigen
Tx:
Prev - boil water

O&P less sensitive

Modified acid staining - cryptosporiduium, isospora, cyclosproa

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2
Q

Asymptomatic VSD as adult

A 
small perimembranous defect
No pulm HTN, no chamber enlargment
close f/u and observation
No abx ppx
Dx: TTE
(if suboptima CMR)

Tx: iF Qp:Qs >2:1 and evidence of LV overload closure
If 1.5: 1 and net left to right then close

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3
Q

Autoimmune bullous disease

A 
Bullous pemphigoid
Tense subepidermal blisters
non-mucosal surfaces
aw RA, DM, SLE, thyrotitis
W/u: Skin bx with immunoflorescence
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4
Q

Delirium in ICU

A

acute state of confusion - reduced conciouslness, cognititsion, emtional distrubance, , hyperactive, hypoactive

Acute CVA does not cause flucutaing conciousness

Opiods take some time to develop dependence and cause withdrwaal

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5
Q

Risk factors for damaging veins in pts with CKD

A

If pt with bad CKD - don’t use PICC/central lines if avoidable - stenosis of central veins may make unsuitable for dialysis catheter or av fistula

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6
Q

Limited stage small cell lung CA

No cure

A

rarely present early enough to have surgical resection
Dz limited to one hemithorax, with hilar and mediastinal adneopathy that can be encompassed in one tolerable radiofield
Tx: Chemo+chest radiation
If good response - ppx brain radiation done
Advaced dz - chemo along

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7
Q

Small cell lung CA (early stage surgically treatable)

A

mediastinoscopy for staging for suitability for surgical cure

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8
Q

Acute digit ischemia in systemic sclerosis

A

Warm environment
Pain control
**Vasodilating tx - IV epoprostenol (prostacyclin analgog)

sequelae = raynaud, ptting, ulceration, gangrene

Bosentan - preventing recurrences of digital ulcers
no benefit in treating acute digit ischemia

ACEi - sclerodermal renal crisis

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9
Q

Colonoscopy with inadequate prep

A

re prep and repeat colonoscopy do not wait

q3yr colonoscopy for: 3-10 adenomas all <1cm) tubular adenoma, low grade dyplasia

q10yr - hyperplastic polyp or none

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10
Q

Manage diabetic ketoacidosis

A

Admit to ICU - insulin, fluids, serial abd exams

No imaging or testing unless abd pain does not resolve with correction of met acidosis

Can cause elevated WBC, fever, elevated amylase

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11
Q

Manage peripheral verigo

A

referral for vestibular rehab if epley maneuver fails

improves sx, balance and ADL

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12
Q

Menieres dz

A

Tinnitis, hearing loss, vertigo - episodic vertigo, not positional

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13
Q

Acute viral hepatitis

A

Marked jaundice - marked elevation of AST/ALT

short duration on sx (acute)

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14
Q

Fulminant Hepatic failure

A

hepatic encephalopathy w/in 2 months of jaundice,

abnormal INR

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15
Q

hemochromatosis

A

chronic liver dz muchlower LFT levels

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16
Q

Primary biliary cirrhosis

A

chronic liver inflammation - lower LFTs, disproportionaly high alk phos

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17
Q

Chorea gravidarum

A

self limited chorea during pregnancy
quick muscle jerks in random pattern
(DDX - huntingtons, HIV, encephalidies, poprhyoria etc, etoh, hyperglycem…

Huntington’s - hereditary progressive neurodeg d/o cogniftive decline with chorea - ataxia, dystonia, slurred speech,myoclonus - psych sx halluc, irrit agitation, dyphoria, disinhibition

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18
Q

Tardive diskinsesa

A

2/2 mes that block dopamine rcts
twitching movememnts, abn postures
choreiform movmeemnt of face

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19
Q

Takotsubo’s CM

A

Stress CM - transient ST elev, +CE normal coronaries with apical balooning, basal hypercontractility
catecholamine induced
Tx: BB, ACEi

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20
Q

Pericarditis

A

PR seg depression
diffuse ST elev
Twave changes
CP postional

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21
Q

HYperthyroid in pregnancy

A

Tx with PTU in 1st trimester -> methimazole after
presence of vilitigo, suggests automimmunte graves
r/o fetal growth retardation, miscarriage, prmature delivery, preeclampsia

Only thyroidectomy if toxic gointer, large malignant thyroid nodule, toxic adenoma

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22
Q

**Hydroxurea cause of macrocytosis

A

decrease incidence of sickle cell crisis
RNA reductase inhibitor
dec’s DNA synthesis

Cobalamin def - high MCV, glossitis, wt loss, hypersg PMNs, takes years to manifest

Myelodyplastic syndrome =- infeff hematopoesis, transformationi to AML - need to be dificent in all cell lines

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23
Q

Ankylosing spondylitis

A

Can occur in 20’s
Need radiographic evidence for dx
can be neg in xray
Pain/morning stiffness relieved with ACTIVITY

MRI sarcoilliac jnt - bone marrow edema, synovitis, erosions, CT can’t detect early bone edema (don’t MRI lumbar spine, affected LATER)

Tx: NSAIDS, tnf alpha, phys tx/surgery

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24
Q

Rotator cuff tendonitis/impingement

A

pain in shoulder began after rpeitive activity
pain occurs in range of abduction only
neg drop arm test
+hawkins test

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25
Q

Acromioclavicular joint degeneration

A

aw trauma or osteoarthritis - palpapbel osteophytes on xray with deg changes - pain with shouler movememnt up and down after 120 deg

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26
Q

Adhesive capsulitis

A

thickening of capsule surrounded by glenohurmoral joint
loss of both passive and active ROM
multiple planes and stiffness
slow in onset, near insertion of deltoid

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27
Q

Rotator cuff tear

A

+drop arm test
weakness, Loss of function
wk external rotation

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28
Q

Manage anemia in CKD pt

A

Start EPO
CKD pt with Hg <10
r/o IDA, vit B12 def, GI blood loss, hemoglobinopathy
target Hg 10-11

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29
Q

Mild pulm Histoplasmosis

A

No tx needed in healthy host
ohio river valley/misippi valley
pulm infiltrates mild hilar LAD

If tx needed: ie immunoompromised HIV
Itraconazole

more serious lipid amphotericin B
(NO FLUCONAZOLE)

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30
Q

Pulmonary embolism

A

Intermediate to high risk - get CTA chest
lack of contraindication and str abn lung (no V/Q scan)

Don’t use D-dimer in intermed to high risk (only to r/o low risk patients)

If contraindictation to CTA chest then get duplex LE US r/o DVT

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31
Q

Mechanical heart valve and microangiopathic hemolytic anemia

A

elev LDH, dec’d haptoglobin, decreeased Hg, inc’d retics = evidence of microangiopathic hemolytic anemia + schistocytes on smear
10 year old valve with new murmur
TTE to check for valve dysfxn

TTP - adamts-13 assay - would have low plts and more acute course

Not DIC - no signs of sepsis

Direct coombs - warm or cold autoimmune hemo anemia - would show spherocytes

Osmotic fragility test - hereditary spheroctyosis
personal or family hx jaundice, splenomeg, gallstones, spherocytes on smear

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32
Q

Cryptococcal meningitis

A

In pt with HIV and immune reconstitution inflammatory syndrome

sweating diplopia, left gaze, somnolence

immune response increases dramatically to fight crytococcus - (diss fungal infxn) - CSF (elev lymphocytes, inc’d protein low normal glucose)

Check crytococcal antigen -
Tx: IV amphotericin B then long term fluconazole

CMV also OI in AIDS but with CD4<100, MRI multiple ring enhancing lesions, h/a mental status chagne, focal deficits

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33
Q

Telogen effluvium

A

common cause of non-scarring hairloss
common in young post partum women
body brings lots of hair from anogen to telgoen phase under stress - hair loss diffuse
No tx required (also cuase by sehorreic dermatiits, psoriasis, IDA, thyroid dz)

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34
Q

Allopecia areata

A

patches of total hair loss no scarring - autoimmune

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35
Q

Androgenta alopecia

A

chronic loss of hair in crown positon - male pattern baldness

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36
Q

Lichen planpilaris

A

scarring alopeicia -

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37
Q

Lupus

A

chornic cutaneous lupus - would have scaring with dyspigmentation

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38
Q

REfractory temporal lobe epilepsy

A

Right temporal lobectomy
Unlikely that addition of meds will help

Corpus callosotomy palliateive surgery for kids with syptomatic generalized epilepsy or atonic seizures

Vagal nerve stimulation doesn’t put seizures into remission

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39
Q

Eosinophllic esophagitis

A

slowly progressive solid food dysphagia in young person with asthma and allergies
food impaction
Mucosal bx with infiltration by EOS >15/hpf
exclusion of GERD by ambulatory pH monitoring or non response to PPI trial
proximal strictures on endoscpy
Tx: swlalowed aersolized corticosteroids

Achalasia - solid and liquid dyphagia aw CP and regurg
(motiiity d/o not mech obstruction)

Esophageal infection - in pts who use swallowed/aero corticosteroids - usually with oropharyngeal candidiasis

Malignancy - less likely in young pt with no wt loss

oropharyngeal dysphagia - difficulty swallowing phase/formation of food bolus

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40
Q

Hypogonadism in pts with obesity

A

total testosterone >350 excludes hypogonadism
<200 confirms hypogonadism
200-350 is grey zone
Need free testosterone level - obesity can cause DECREASE in sex binding globulins so low total testosterone level can be normal in free testosterone
then need to r/o other caueses ie meds

karyotype not needed -normal FSH/LH (used to exlude klinefletsers)

Pituitary MRI not needed because 2ndary hypogonadism not confirmed

Sperm count not needed as pt with normal sperm count cna have low testoterone and vice versa

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41
Q

Informed consent

A
  1. understanding proposed tx
  2. understanding alternatives
  3. understanding risks and benfits of both tx and alternatives

Applies to all health care decisions not just procedures

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42
Q

Dx Glomerular hematuria

A

See dysmorphic erythrocytes (acanthocytes) on urine microscopy (eruthrocytes retain ring shape but have blebs of membrane protruding) - acanthocytes in blood have spikes not blebs)

Then check urine protein-cr ratio - determine degree of proteinuria

If + then check complement, hep panel, bctx, ANA, ANCA, anti basement membrane ab, anti streoptolysin ab, then kidney bx

If microscopic hematuria non-glomerular then check kidney US

UCtx not needed if U/A neg

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43
Q

Amyloidosis in pt with heart failure

A

heart failure, hepatomegaly,proteinuria, bruising - low voltage on EKG despite LVH - infiltrative process
Serum/urine spep/upep, fat pad bx -> amyloid
Endomyocardidal bx for dx of myocardial amyloid

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44
Q

Giant cell myocarditis

A 
pw significant hf or cardiogenic shock
high mortality rate
refractory ventricular arrythmias
may present over montsh or acutely
NOT aw systemic sx
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45
Q

Saroidosis

A

if inovlves heart - patchy areas of inflammation/fibrosis from granuloma formation - no low voltage (not infitrative)
No pulm dz in this patient or skin fidings of sarcoid
No proteinuria/bleeding abn in sarcoid

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46
Q

Takayatsu arteritis

A

aorta and major branches
young women
low grde fever, wt loss, fatigue, myalgia, arthralgia, elevated ESR/CRP, mild anemia/thrombocytosis
Fusiform narrowing of involved blood vessels
Bruises -> pulse deficits -> organ/limb ischemia

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47
Q

Adult onset STILLS dz

A

high eSR, CRP, high spiking fever, serositis, arthritis, RASH

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48
Q

Microscopic polyangiitis

A

mononeuropathy, glomerulnephritis, pulm hemorrhage, p-ANCA(myeloperoxidase)

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49
Q

Polyarteritis nodosa

A

aw Hep B

fever, myalgia, HTN, mononeuropathy, abd pain

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50
Q

Polymyositis

A

elevated CK, prox muscle wk, myalgia, wt loss

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51
Q

Pulmonary mets from Colonrectal CA

A

Stage II CRC - periodic H&P, exam, CEA
Annual CT surveillance - colonoscopy
Resection of primary mets to lung (limited to lung)
No data on additional chemo/rad

Nochemo/rad as primary tx for lung mets from CRC II

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52
Q

Peripheral manifestations of psoriatric arthritis

A

Methotrexate - can treat both arthritis and peripheral manifestations of psoriasis
Polyarticular, DIP, nail changes, arthritis mutilans, nail changes, dacylitis,

Rituximab (CD20) may worsen psoriasis
steroids may worsen psoriasis
ibuprophen doesn’t help

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53
Q

sx Multiple myeloma

A 
>10% plasma cells
Need evidence of end organ damage
1. Kidney bx - myeloma cast neuroapthy
2. Hyper Ca+
3. Anemia
4. Bone dz

Abd Fat pad aspiration - dx amyloid - nephrotic range proteinuria, peripheral sensomotor neuropathy, autonomic neuropathy, carpel tunnel, heart failure, macroglossia

Chemotx only if end organ damage

F/u M protein in 12 months only if <10% plasma cells

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54
Q

Erythasma

A

well defined pink to brown patches, ofthen in moist skin folds, leisons floresce bright coral red under WOOD lamp
Etio - coryneobacterium minitusimum - groin, axilla, intergluteal fold
asx or mild pruritis,

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55
Q

Cutaneous candidiasis

A

red itchy, inflamed skin, satelite pustules

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56
Q

Inverse psoriasis

A

psoriasis in intertrignous areas (inguinal, perneienal, genital, axillary) ie not in extensors
No scaling
Tx: topical steroids

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57
Q

Tinea

A

has ring with clearing center

KOH scraping branching hyphae

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58
Q

Cushing syndrome - secondary cause of DM

A

DM, HTN, central obesity, hypokalemia, proximal muscle weakness

CHeck 24 hr urine cortisol, overnight dexameth supp,

Other secondary causes - meds, pancreatic dz, genetic conditions

Causes of cushing - corticosteroid use, secrtion of ACTH by pituitary adenoma (cushing dz), hyperfxn adrenal adenoma

Adrenal CT only if non- ACTH dep cushing

Confirm autoimmune type I DM - glutamic acid decarboxylase Ab

Type II DM high normal C-peptide from insulin resisitance

Pancreatic imaging if jaundice, back pain, chronic diarrhea

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59
Q

Screen for CKD in DM pts

A

CHeck spot albumin creatnine ratio annual testing
Type I Dm - 5 years after dx
Type II DM - immediately upon dx

Microalbum 30-300 - need ACEi/ARB

24 hr urine protein too cumbersome (gold standard)

Kidney US - once CKD dx

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60
Q

Rumination syndrome

A

effortless regurgitation of undigested food and reswallowing of contents

30min to 1-2 hrs after meals
Rome III criteria - persistent or recurrent regurgistation and swallow/spit, regurgitation not preeceded by wretching, 3-6 months

Tx: deep breathing post prandial

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61
Q

Cannaboid hyperemsis syndrome

A

h/o marijuana use with recurrent n/v abd pain - better with marijuana cessation or hot bath

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62
Q

Cyclic vomiting syndrome

A

vomiting and feelin gwell between periods - (less than 1 week), fhx migraine

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63
Q

Gastroparesis

A

n/v/bloating, postprandial fullness, early satiety, abd discomfort, DM >10 years

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64
Q

Manage pressure ulcer

A

Stage III (full thickness no bone/tendon/muscle), Stage IV (Muscle/bone/tendon)
Needs debridement
Add abx as needed
moiste wound environment

No role for hyperbaric, EM or US therapy

Neg pressure wound vac - not better than standard tx

Surguical flaps only in refractory ulcers, vit c/zinc don’t work.

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65
Q

Evaluate acute chest pain

A 
Serious 6
ACS
Pericarditis with tamponade
PE
PTX
Aortic dissection
Esophageal rupture
diastolic murmur - poss dissection with aortic root rupture and AI

CHest CT for pt iwth widened mediastinum, CP, and difference in BP L vs R arm and diastolic murmur (not TTE - not good to assess ascending aortic aneursym) - TEE better for that

Posterior EKG - dx of isolated posterior wall MI - would have +myoglibin

No V/Q as pt does not have si sx PE

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66
Q

Critical illness myopathy

A

Severely ill pt in ICU>7 days - inability to extubate, prox flaccid limb wk - elevated CK
worse iwth use of steroids, hyperglyemia, NMJ agents

Guillane barre similar but NO HIGH CK

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67
Q

Corticosteroid myopathy

A

prox weakness - normal CK, only mild myopathic findings on EMG

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68
Q

Myasthenia gravis

A

worse with activity
post synaptic aceetylcholie rct ab
pstosis, diplopia, slurred speech, weakeness incrases with repeated testing (on EMG)

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69
Q

Prosthetic joint infection

A

prosthetic joint infection not loose and pt doesn’t want replacement - lifelong abx suppression with bactrim (no sulfa allergy)
(IDeally removal of hardware and abx therpay followed by replacement)

Don’t use rifampin - develops resistance quickly

don’t repeat abx regimen already used (IV)

observation with sx relief but no abx will cause extension of local infection/systemic infxn

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70
Q

Stage I rectal CA

A

Midrectal CA into mucosa but not trhough, no LN mets - surgery ALONE

Low anterior resection - if further staging shows T3-4 or any postive nodes then chemorad/chemo needed

Chemo, radiation or combination not shown to help stage I dz - RFA doesn’t cure CRC primary tumors

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71
Q

Asbestosis

A

b/l interstitial fiborsis of lung parenchyma 2/2 inhallation of asbestos fibers - latency 10-15 yrs
Crackles on exam
Work in shipyard without adequate respiratory protection
CT with b/l peripheral and basal septal thickening with pleural thickening and calcified pleural plaques
Breathlessness and restrictive pulmonary physiology
Hypercapnic resp failure as lungs can’t expand 2/2 stiff pleura
Tob inc’s risk of lung CA

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72
Q

Hypersensitiveity Pneumonitis

A

acutely after exposure to antigen - fever, flulike sx, cough waxes and wanes with exposure
Mid upper lung involvement (not basal)
centrolobar nodules (not pleural plaques)

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73
Q

IPF

A

pt with interstital lung dz

NO exposures

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74
Q

Severe knee osteoarthritis

A

not responding to conservative mesures and have functional limitations - refer for total knee replacement

No benefit from knee arthroplasty (is good with meniscal injury)

Osteootomy for valgus/varus deformity or younger pts with unilateral

Hyalronate injections only for mild to mod OA

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75
Q

NSTEMI not candidate (or wants) angiography

A

BB, ASA, plavix, statin, LMWH - TIMI risk =4
would need angiogram but pt does not wish it

Contraindication to LMWH - obesity, kidney dysfxn and need for invasive procedure

Only use CCB when pt contraindicated for BB

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76
Q

Glioblastoma Multiforme

A

MC and aggressive intraparenchymal brain tumor
ring enhancing lesion with central necrosis and hemorrage

Meningiomas - extraparenchymal / extradural - enhance diffusely with dural tail - slow growing, better prognosis thank gliobastoma MF

Oligodendroglimoas - rare - intraparenchymal lesions - No enhancement, no necrosis/hemorrhage

Schwanomma - tumors of nerve sheath - CN VIII, hearing loss, tinniis, enhancing lesion at cerebellopontine angle - better prognosis than gliomas

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77
Q

Squamous cell CA

A

malignancy of lips/oral cavity
Risk factors etoh, smoking, sun exposure
red plaques/nodules - crust/erosions
Need bx and excision

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78
Q

Actinic chelitis

A

chronic erythema and scaling of lower lip - sun damage - PRECANCEROUS - SCC can evolve
Tx: cryothrapy, topical 5FU, Laser ablation

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79
Q

Herpes simplex (orolabial)

A

cold sores HSV 1 - found around vermillion of lip - prodrome tingling prior to onset of vesicles then crust over

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80
Q

Impetigo

A

S aureus - yellow crusted surface - tx topical abx or systemic

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81
Q

Lichen planus

A

lips and buccal mucosa - may ulcerate - Wichham striae - white lacy rash on buccal mucose - r/o evolving SCC

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82
Q

Diffuse esophageal spasm

A

Chest pain
Corkscrew esophagus on barium swallow (multiple simultaneous contractions on manometry) esophageal dysmotility
dyphagia to solids/liquids both
Tx: CCB

Achalasia - birds beak esophagus - needs surgical myotomy

Eosinophillic esophagitis - multiple rings/strictures - h/o asthma/atopy

Schatzi ring - isolated ring in GE jnc - intermittent dysphagia no CP

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83
Q

IgA nephropathy

A

gross hematuria, h/o resp/GI illness (recent) and normal complement
Infections precipitate production of Ab - IgA depostis in glomeruli causing injury and bleeding
(ATN from tubular congestion)
Glomerular cresents on kidney bx bad prognosis

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84
Q

Analgesic nephropathy

A

NOT DUE TO Glomerular damage (chornic interstitial nephritis, renal papillary necrosis)

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85
Q

Post infectious glomerulonephritis

A

Preceding GI/resp infection weeks before (strep/staph)
Decreased complement
elevated anti steptolycin O ab

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86
Q

Rhabdomyolysis

A

pigment induced nephropathy
muscle injury releases CK/myoglobin
elevated CK, elevated urine myoglobin

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87
Q

ACEi induced cough

A

non productive cough after starting ACEi - normal CXR
d/c ACEi (cough from bradykinin)
Substitute ARB + smoking cessation + re-eval in 4 wks

(can consider GERD, asthma, upper airway cough syndorme (post nasal drip))

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88
Q

Babesia

A 
Camping trip new england
Tick borne dz
Ioxides tick
1. Lyme (borriella burgdorferi)
2. Babeesiosis (Babesia microti)
3. Human granulocytic Anaplasmosis (anaplasma phagoctyophilium)

Only Babesiosis have HEMATURIA
Tx: atovaquone or azithro
severe - exch tx

RMSF - rash no hematuria - blanching erythematous macuoles wrists and ankels -> petechiae

West Nile virus - fever, CNS SX not HEMATURIA

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89
Q

Cardiac sarcoid

A

Dx with cardiac MR

Echo findings suggestive - restrictive filling, biatrial enlargement,
MR would show delayed gadoinium enhancement in atypical distribtuions for coronary artery disease
MR also looks at pericardial thickness r/o constrictive pericarditis

IF cardiac sarcoid confirmed -> ICD

ENdomyocardial bx warranted if MR neg

TEE only if TTE inadequate

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90
Q

High grade dysplasia in pt with barretts

A

Pt with Barrett esophagus
High grade dysplasia
Tx: Esophagectomy if surgical candidate
Endoscopic ablation (ie bad heart failure) - alternative

If no precedure - endoscopic surveillance q3m - adenoCA then surgery (high grade-> adeno 6%/yr)

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91
Q

Macroprolactinoma

A 
Dopamin agonist (carbergoline better tolerated than bromocriptine) if no sx (no visual field changes despite being on optic chiasm) will decrease tumor size
OCP do not use - may increase tumor size
Surgery only with intolerance of dopamine agonist, unstable vision changes
Radiation last resort tx
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92
Q

External spinal cord compression by epidural hematoma on warfarin

A

Pt on warfarin with INR 3
Discontinue warfarin reverse A/C in prep for surgical decompression
Cauda equina syndrome form cauda equa compression 2/2 epidural hematoma

Do not lumbar puncture prior to AC reversal

Without fever and WBC elev, epidural abscess unlikely so no abx

If no signs of inflammaotry process then no need for high dose solumedrol

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93
Q

Staph aureus infection

A

G+ organisms MCC infectious arthritis
monarticular usually
affect large joints, rapid (1-2 hrs)
Otherwise healthy patient with skin breakdown in trauma
Fever, swollen knee with effusion -> stayph aureus septic arthritis
hematogenous spread of skin infection to knee

Gout rare in healthy young women

Onset of chronic lyme gradual

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94
Q

Patient hospital dispostion options

A

Skilled nurinsing facility - IV meds, low level rehab - when gets better can reassess for better dispo

Inpatient rehab - intensive physical and occupation therapy - need to be medically stable and able to participate in 3 hrs /day at least

Long term acute care hospital - will need hospital based interventions - need for significant medical monitoring>25 days - overseen by physicians

Hospice care - prognosis < 6 months

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95
Q

Hematuria - low risk patient

A

Risk factors >40, h/o uro d/o, analgesic abuse, pelvic irrad, UTI, smoking, occupational exposure chem/dyes
(FHx does not increase risk)

Repeat U/A if +
Glomerular - dymorphic erythrocytes (acanthocytes) on urine microscopy, erythrocyte casts

Non-glomerular - isomorphic/normal RBCs on urine microscopy (UTI, bladder/renal CA)
Dx: Upper urinary tract imaging - CT, US, IV uropgraphy (CT Urography best) ->cytoscopy / urine cytology

No Uctx if no WBC no dyuria

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96
Q

Vocal cord dysfxn

A

inspir and exp wheezing
respiratory distress, anxiety
difficult to distinguish from asthma during exacerbation
Clues: sudden onset and abrupt termination of attacks - lack of response to asthma tx, promient neck discomfort, lack of hypoxemia, lack of hyperinflation
FLow volume loop: Inspiratory (lower) limb cut off 2/2 extrathoracic obstruction - vocal cord - expiratory (upper limb) prserved
TX: speech therapy, relaxation techniques, tx of anxity, post nasal drip, gastroesophageal reflux

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97
Q

Acute asthma

A

cxr not needed unless doesn’t respond to asthma therapy or evidence of concurrent condition (PNA< HF, PTX)

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98
Q

Bullous pemphigoid

A

autoimmune bullous disorder
Tx: prednisone initially then transition to steroid sparing ageng (azathroprine, mycophenolate motif)

Dx: skin bx (infection, contact dermatitis, allerigc, drug reaction)

Monitor skin for signs of superinfection (antihistoamien hydroxazien may not help

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99
Q

Manage GI Bleed in patient taking warfarin

A

Upper endoscopy to be performed right away in pts with UGIB with INR <3

Gnawing pain and characteristic coffee ground emesis = pepcid ulcer dz

Weigh risk of thrombosis from A/C rev against riks of bleeding - in pt with prosthetic valve and recent TIA should NOT reverse or sthop A/C (pt HD stable)

If need to reverse - FFP immediate, oral or IV vit K delayed

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100
Q

Profound hypoglycemia in older patients

A

Sulfonyureas with longer half lives in older pts
prolonged hypoglycemia
focal neuro signs(coma, hemiplegia), sweating (A1c level HCT if + and within window consider TPA

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101
Q

Prevent varicella zoster in pt with leukemia

A

Give varicella IgG (VZIG) or IVIG if not available for ppx w/in 96hrs

No varicella vaccine (live vaccine) in leukemia immunocompromized pt (under therapy)

Acyclovir not proven to help for post exp ppx

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102
Q

HTN in pt with DM2

A

keep < 130/80 - already on arb (irbesartan), HCTZ - add BB or CCB

If GFR <30 and need better diuresis change HCTZ to loop diuretic

Only add spironolactone as 4th drug if 3 drugs already on board at optimal doses

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103
Q

Paroxysmal nocturnal hemoglobinuria

A

Unprovoked vein thrombosis unusual location (splenic vein)
Hemolytic anemia
mild to mod pancytopenia
Dx: flow cytometry CD55, 59

Direct coombs - to evaluate autoimmune hemolysis, splenomegaly, spherocytosis, reticulocytosis, elevated unconjugated bili, elev LDH, dec’d haptoglobin

Factor V Leiden - thrombophilia

Antiphospholipid syndrome - inc’d risk of arterial and venous TE - correlation to pregnancy loss

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104
Q

dermatitis herpetiformis

A

aw celiac dz!!!
autoimmune bullous dz
intensly itchy small papulovesicles on scalp, elbows, knees, back buttocks
Skin bx: deposition of granular IgA in dermal papillary tips

Tx: gluten free diet (Dapsone for skin lesions only)
follow TTG ab
will improve anemia

Sarcoid - skin - maculopapular eruption, waxy nodule, erythema nodosum

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105
Q

manage epistaxis

A

apply uninterupted pressure x 15-30 minutes then avoid blowing nose, stop nasal steroids

Etio (viral/bact rhinositis, nose pickign, dry air, intranasal steroids)

No need for blood count or coags

Cauterization/nasal packing or nasal artery emboliz for sevre cases not responsing to pressure

Only posterior nasal bleeds need ENT

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106
Q

Acute ischemic stroke treatment

A

Tx with ASA at least 160mg daily

dpeending on size of stroke transition to warfarin

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107
Q

Obesity hypoventillation syndrome

A 
Daytime hypercapnia PCO2>45
(dimineshd ventilaotry drive 2/2 obesity)
Pulmonary HTN, polycythemia
OSA
Sleep study to determine CPAP vs bipap
Tx: weight loss

Cheyne stokes breathing - central sleep apena - cresencdo decresendo pattern
men with advanced LV dysfxn

COPD long standing - carbon dioxide retnetion and hypercapnia

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108
Q

Treat aortic disease in patient with bicuspid aortic valve

A

Sx aortic regurg
-> already indicated for AVR regardless of LV fxn
if aorta > 45mm then repair at time of AVR indicated

Bicuspid aortic valve aw ascending aortic dilation -

Don’t wait on intervention (BB can slow progression of aortic dilation in marfans)

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109
Q

Tennis elbow/lateral epicondylitis

A

Periarthritic d/o pain at elbow-> forewarm
repetitive motion of forearm injury and inflammation of the tendon - carrying/lifting/grasping objects (overuse syndrome)
Pain on lateral elbow
Tx: counterbrace

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110
Q

Cervical radiuclopathy

A

pain-> forarm but also aw numbness, tingling, wk

Sx reproduced by bending neck

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111
Q

Olecron bursitis

A

Pain at the olecron process at tip of elbow aw bursa swellign
etio - trauma, septic (staph aur), gouty
Tx: aspiration

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112
Q

OA of elbow

A

rare - occurs with prior injury to elbow - pain localized to elbow joint only

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113
Q

Tx Younger pt with AML with high risk features

A

High risk AML=complex karyotype, 5q deletion
Best tx: allogenic stem cell tx

(no advantage with autologous stem cell tx)
(Azacitindine - high risk MDS)

Favorable young patients - t(8;21), inv 16 - chemo/cytarabine

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114
Q

Radiation induced aortic valve regurgitation

A

Common in post radiation patients (10-25years) - r/o valve fibrosis
Corrugan pulse (rapid carotid upstroke, rapid decline)
high pitched blowing diastolic decrescendo murmur heard to left of sternum at 3rd ICS
Displaced PMI
Widended pulse pressure (155/43)
Dypnea from inc’d LVEDP from AR
CP from low coronary filling pressures
low diastolic aortic pressure

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115
Q

Constrictive pericarditis

A

prior radiation with DOE

findings of RV failure (JVD, peripheral edema)

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116
Q

Restrictive CM

A

signs of RV prossure overload

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117
Q

Tricuspid regurg

A

large retrograde V waves/hepatojugualar reflux

systolic murmur

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118
Q

Manage non-cardiac chest pain

A

2wice daily PPI x 8 to 10 weeks if no alarms sx (if so then directly to EGD)
Pt with non-anginal CP with neg stress and neg echo

If PPI unsucessful then endoscopy (r/o erosive esophagitis, achalaisa
or manometry (DES/esoph motilitly d/o)
ambulatory pH monitoring

MSK CP - focal, sharp localized to one area

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119
Q

Multiple sclerosis

A

partial demyelinnating myeltis
Cervical cord
Electrical sensation with neck movment (Lhermmete sign)
Prior eposide of vision loss (optic neurtis)
daytime fatigue
Dx: MRI brain ovoid white matter lesions from MS

Not cardioembolic CVA - no language deficit in setting of large motor def/sens def

Not migraine - would have h/a, would caurse subtle neuro deficits only

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120
Q

CVID

A

h/o recurrent respiratory tract infections with encapsulated bugs, H flu, S.pneumoniae, giardiasis
autoimmunie hemolytic anemia, pernicious anemia (high MCV), RA, d/o of GI tract -> malaborption
r.o sinopulm d/o, lymphoma,

If titers low, check response to protein/protein sacc vacines
If very low then then vaccine response unnecessary

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121
Q

Low total hemolytic complement

A

complement def
Early compoent of complement - SLE
(recurrent infxn wtih encapsulated bugs or diss neissria

Def in terminal complement - recurrent neisserial infxn, ie meningitis and DIG

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122
Q

NNT

A

Absolute risk=pt with event in one group/total pt’s in group
ARR=AR1-AR2
NNT= 1/ARR

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123
Q

Primary hyperparathyroidism

A

h/o fragility fx
inappropriately high PTH in setting of hyperCa+
Need PTHectomy

Indications for PTHectomy

  1. Sx hyperCa (arrtymias, nephrolithiasis)
  2. Cr Cl < -2.5
  3. Ca+ > 1mEq abov normal
  4. age< 50
  5. Fragility fx

Bisphosp only if pt refuses surgery
No bone scan, no PTHrP needed

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124
Q

Actinic keratosis

A

sun exposed areas in older people
Premalignant -> SCC
erythematous scaley macules

Cryotx, 5FU, photodynamic tx

Easier to papate and dx

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125
Q

Basal cell CA

A

pearly, waxy - fair skin, sun exposure

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126
Q

Sebhorriec kearatosis

A

brown, warty waxy plaques - stuck on appearance - benign

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127
Q

Solar lengintes

A

brown macular patches in fair skined with sund damage - benign but could be hiding cancer underneath

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128
Q

Porphorya cutanea tarda

A

blistering d/o - def o enzyme uroporphyingen decarbox - bullae on dorsum of hands after sun exposre - dyspigmentation, scaring, tender

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129
Q

End stage kidney dz and alport syndrome

A

GFR 13 -
Xlinked dz collagen synthesis
sensoneural hearing loss, ocular abn, fhx kidney dz and deafness
Kidney tx is only therapy - dz does not recur in tx
(ACE/ARB can slow decline, not tx)

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130
Q

Manage CVD risk in pt with CKD

A

LDL target in pts with CKD not on HD is < 70
Increase lipitor dose

Lowering PTH in CKD patients not aw dec’d mortality

Keep bicarb >23

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131
Q

Corticosteroid refractory idiopathic tranverse myelitis

A

Plasmapheresis
PE: bl leg wk, loss of sensation below umbilicus, hyperreflexia LE, leukocytosis in CSF, inflammation in MRI,
Probably autoimmune transverse myelitis
First line tx: high dose steroids
2nd line: plasmapheresis or cyclophosphamide
(NOT MTX)

Glatiramer acetate - Disease mod agent in tx of MS - reducees immune resposes that exacerbate MS

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132
Q

Treat multinodular goiter

A 
thyroidectomy if impinging
partially solid and cystic nodules
Goiter grows over time
FNA rules in or out CA
If no CA
Growing goiter can compress trachea, esophagus, laryngeal nerve

Ext beam radiation doesn’t work
synthroid will make pt thyrotoxic
No need for PTU/methimazole

Radioactive iodine only used in pts with MN goiter with autonomous fxn

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133
Q

Metastic melanoma

A

sx brain mets
If symptomatic - resect brain mets or stereotactic surgery
chemo and/or radiation won’t work without surgery
Melanoma relatively radio resistant

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134
Q

Schizophrenia

A

Neg sx: withdrawal, flat affect, lack of interest
Pos sx: paranoia, hearing voices

Sig/sx at least 1 month
Fhx schzophrenia inc’s risk

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135
Q

Sebhorreic keratosis

A

flesh colored to yellow, tan, irregularly pigmented
waxy/veruncous intexture
BENIGN - no premalignant potential

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136
Q

Atypical nevi

A

located on torso more macular (ie flat), lack verruncous texture of seborrhic keratosis

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137
Q

Melanomas

A

irreg borders, darkly pigmented black lesion

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138
Q

Solar lentignes

A

completely flat in areas of sun exposure

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139
Q

Dx amiodarone induced pulm toxicity

A

HRCT
chronic dypnea, dry cough, restrictive lung physiology
temporaly related to start of amiodarone
Chroic intersticital pneumonits, organizing PNA, ARDS, pulm mass,
Risk - inc’d age, dose, duration of tx, pre-existing lung dz

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140
Q

Psoriatric arthritis

A

various pattern of joint/nail involvement
DIP, enthesitis, dactylitis, tenosynovitis, nail pitting, symmetric polyarthritsi - arthrtiis mutilans, spondylitis - onchymyolysis

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141
Q

Lyme arthritis

A

med or large joints - NO NAIL CHANGES

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142
Q

OA

A

DIP no nail findings

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143
Q

RA

A

usually symmetric - PIP, MCP, NO NAIL CHANGES

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144
Q

Tuberculin skin testing

A

> 10mm - IVDA, persons from countries with high prev < 5ya, employees of NH, hospit, homeless shelter, mycobacterium lab, ppl with inc’d risk of TB (DM, CKD, siolosis, cancer of head/neck, gastric bypass

> 5mm - recent contact with active TB pt, HIV, fibrotic changes on prior CXR c/w old healed TB, organ tx or other immunocomprimised

Asx person of both groups if cxr neg then need latent TB tx

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145
Q

Afib in setting of HF after MI

A

Amiodarone
One of few agents safe for sx afib with LV dysfxn
(alternate= dofetilide - ok with afib and HF - monitor QT)

No flecanid - inc’d r/o polymorphic VT
NO disopyramide - neg ionotrope
No dronedarone - inc’d mortality in NYHA III, IV
No soltolol - more BB than amio, bad in HF

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146
Q

Proliferative glomerulonephritis

A

active SLE and abn urine
new onset HTN/edema
+ANA, dec’d complement, proteinuria, hematuria
Need prompt bx - wil lthen start on high dose corticosteroids + immunosupp agent (cyclophos or mycophenilate moteifil)

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147
Q

Severe COPD

A

Pulmonary rehab for…
Sx COPD with FEV1t walk, recent MI or UA)

Morphine only for pt with severe dypnea at rest for palliation

O2 only for 88% or lower

Steroids only for acute exacerbation - change in baseline cough, sputum

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148
Q

Cryptococcal meningitis in pt with AIDs

A

Disseminated cryptococcus - with meningitis
Tx: conventional amphoteriicin B and flucytosine
h/a, skin lesions (molloscum like) - CSF paucity
If pressure>250 then drainage needed
1: induction - amphoter B + fluctyocine
2: consolidation - oral fluconazole x 8 wks
3: maintenanc/suppression
(lipid amphoter for kidney dz pts)
no echiochinocandins - (caspofungin) as no activity against crypto and no CSF penetration

(also amphot B+ fluconazole, flucon along, fluc + flucytocine)

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149
Q

Sx pulmonary valve stenosis

A

Contraindications to pulm baloon valvulopastic
Sub or supra pulm valvular stenosis
Severe PR
hypoplastic pulm annulus
going in anyway for other cardiac dz - fix valve while in there (need pulm valve replacement)

Sx patients with >50mm instant grad (30mm mean)
Asx pt with >60mm/40mm mean wihtout mod or greater PR

Pulm vasodilator therapy for PAH

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150
Q

Atypical parkinson’s dz

A

typical parkinson’s responds to high dose levodopa

Sx: resting tremor, bradykinesia, rigidiy, postural instability
absense of olfaction
w/o response to levodopa - more extensive dz

Tremor absent in 30%
Most parkinson’s patients have autonomic dysfxn

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151
Q

Manage pt with secondary iron overload from B thal minor

A

Hct 25% - can’t do phlebtomy - need iron chelation (deferasirox)

B thal major with iron overload from excessive tx and inefective EPpoesis
elev ferritin and transferrin saturation indication for tx

Complications from second iron overload - HF, liver failrue, arthraligia, pitutiary, islet cell dysfxn

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152
Q

Chronic neuropathic pain

A

mod to severe
if did not respond to non-opiod meds
transition to sustained release morphine

don’t use tramadol for chronic pain - weak opiod
don’t use methadone in pt with ischemic CM and conduction dz (can cause long QT -> VT)

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153
Q

HTN in black patient with CKD

A

Stage 3 CKD - add ramipril
blacks with more end organ damage from HTN at any level than other groups
Absense of end organ damage goal < 135/85
+end organ damage - ing diuretic will improve bp but not proetinuria and kidney dz progression)

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154
Q

Tx superficial lacerations in elderly adult

A

Non-adherent dressing over plain petrolium - cheap and good

Atopic skin (Polymyalgia rheumatica - pain in neck,shoulder, hip aw temporal arteritis - tx with low dose prednisone)
Minimize risk of damage to skin with adherent tapes

(no need for hydrocolloid, hydrogel, calcium angonate, foam dressings)
No need for topical abx - risk of allergic contact dermatitis and drug resistance

Don’t leave wound open - escar can form - prolong healing time

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155
Q

Evaluate diarrhea not meeting criteria for irritable bowel syndrome

A

IBS - abd pain, diarrhea, imporovment with defecation, onset with change in stool frequency,
Dx: flex sig with bx - r/o microscopic colitis
thickened subepithelial collagen band (collangenous colitis) or subepithelial lymophcytic infiltrate (lymphocytic colitis)

Don’t use antispasmotic agents - dicyclomine - GI smooth muscle relaxants -

Pt with normal IgA unlikely to have celiac dz
If needed to use TTG NOT antigliaden ab to dx celiac dz

Don’t give loperimdie without dx

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156
Q

Small intestinal bowel overgrowth

A 
diarrhea, bloating, weight loss
Macrocytic anemia 2/2 B12 def
Elevated folate (bacteria consume B12, synthesize folate)
Pt with sclerosis high risk for SIBO 2/2 intestinal dysmotility
Risk factors - altered gastric acid (gastrectomy, achlorohydria, str abn (strictures/diverticula blind loops), intestinal dysmotility (DM, NM d/o)
Dx: hydrogen breath test, upper endo with ctx

Celiac dz unlikely with normal TTG

Microscopic colitis - chagnes ONLY in colon so fat absorption should not be affected, vit def not present

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157
Q

Acute sinusitis

A

tx with anti histamine for mild case, no abx
usually resolves 7-10 days

Abx only for worsening sx and HIGH fever
No need for nasal ctx
No need for imaging - not very sensitive
role of nasal steroids unclear

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158
Q

Hypothyroid in critically ill adult

A

High TSH, low T3, T4 in ICU pt with PNA
amiodarone also causes hypothyroid
start treating hypothyroid

Adrenal insuff -

Nonthyroidal illness causing hypothyroid - euthyroid sick syndrome - from cytokine inc - TSH shouldn’t be above 10,

TSH secreting tumor inc’d TSH and T3/4

159
Q

Folliculitis

A 
pustules caused by bacteria around follicles
topcial abx (clinda, benzoyl peroxide) or doxy

Acne would have comedones - pustule of acne usually sterile

Miliria - heat rash - erythematous papules occulsion of sweat ducts, no pustules

Rosacea - papules and pustules - central face only!

160
Q

Acute disseminated encephalomyelitis

A

inflammatory demyelating d/o young adults
post infectious phenomenon
simultaneous demyelinateing in multiple areas
h/a, fever, ENCEPHALOPATHY (not c/w MS)
lymphocytic prolif in CSF (not c/w MS)
usually SELF limited

161
Q

CKD patient with HTN

A

Sodium restriction, keep BP <130/80
Start with CE in CKD patients with proteinuria
nonproteinuric CKD - focus on BP control not specific agent

Nabicarb in pt with CKD and bicarb 15-20

No need to tx mild elev PTH with normal Ca+/Phos

162
Q

Sarcoidosis

A

Idiopathic d/o with UPPER LUNG infiltrates (better seen in lateral view)
Non-necrotizing granulomatous infection
Dx requires tissue

Asbestosis, organizing pna iPF all lower lobe predominant

163
Q

Gestational anemia

A

red cell mass increases (inc’d EPO)
inc’d plasma

HELLP (hemolysis, elevated liver ezymes, low plts) - RUQ pain, elev LFTs, pre-eclampsia,
Abn blood smear with throbocytopenia, fragmented erythrocytes

No signs sx of IDA, normal smear, normal MCV not IDA

EPO inc’d during preg

164
Q

Intercritical gout, hyperuremcemia

A

HCTZ INCREASES serum uric acid levels, inc’s risk of gout
change to urate neurtral or lowering anti HTN agen

Low fat dairy dec’s urate
Fruit inc’d urate, wine is the least gout precip etoh

165
Q

Pt with HIV exposed to active TB

A

should get INH/pyridimine regardless of inf gamma/TST testing results/CXR

need pyraxidine with DM, HIV, uremia, etoh, malnutrition, sz d/o, pregnant women

Don’t use rifampin and pryridmime together - hepatoxicity

166
Q

doxorubicin induced dilated CM

A

decompensated HF - S3 gallop, pulm crackles
years to decades after chemo
cumulative dose >550
risk factors age >70, other cardiotoxic agent (cyclophosphamide)
Radiation tx to thorax

No cardiac tamponade without JVD, or pulsus >10
No COPD exacerbation without cough/sputum
Radiation induced constrictive pericarditis -RHF signs, relatively normal BNP

167
Q

potential cardiotoxicity in breast CA requiring trastuzumab tx

A

HER2+
Check LVEF before initiating for baseline and during tx
No Exc stress test prior to radiation
radiation can lead to premature CAD, valve fibrosis, abn in LV fxn/mass

168
Q

Dermatomyositis

A 
Elev CK
prox muscle wk
heliotrope(violacious color eyelids with periorbital edema), shawl sign, V sign, gottron papules (violacious to pink plques with scalling over extensor surfaces of hand joints, knees, elbows
Raynauds, perungal erythema, 
arthritis, pulm/GI involvement
\+ANA

SLE - discoid, malar rash

Polymyositis - no rash

MCTD - overlap systemic sclerosis, SLE, myositis

Inclusion body myositis - older pts, both prox and distal wk

169
Q

SCC in kidney tx patients

A

immunosupp agents increase r/o cancer
SKin CA, melanoma, SCC, basal cell CA, Kaposi’s
Occur at younger age, more met potential
Thick adherent scale and eroded areas

170
Q

Fixed drug eruptions

A

repeated exposure to same agents

rash recurrening at same areas each day

171
Q

Nummular eczema

A

circular/coin shaped eczema

172
Q

Psoriasis

A

think pink plaque, silvery scale

elbows, gluteal cleft

173
Q

Tinea corporis

A

pruritic, annular patch, thin plaque fine scaling

174
Q

Post hypoxic myoclonus

A 
prolongued cerebral hypoxia/anoxia
syndrome of generalized myoclonus
shokclike muscle jerks
negative myoclonus
Cariac arrest with delayed resucitation
cortex hyperexcitable after hypoxic injury
VPA, levecitram, clonezepam
175
Q

Cerebellar degeneration

A

spinocerebellar ataxia
autosomal dominent
40’s
gait unstadiness, uncoordination

176
Q

Myoclonic epilepsy

A

generalized tonic-clonic seizures

177
Q

Wernickes encephalopathy

A

ataxia, opthalmoplegia, confusion, peripheral neuropathy, seizures
Thiamine def
Etoh abuse, bariatric surgery, fasting, vomiting, TPN without vitamins

178
Q

Cocaine associated CP

A

No BB - unopposed alpha
Tx with CCB and lorezepam (benzos)
lower HR, BP and myocardial demand

No thrombolytics if no ST elevation

No nitroprusside - no reason to acutely lower BP

179
Q

Palliative care

A

focuses on maintining quality of life not limited to terminal illness
Non-hopsice palliative care DOES NOT exclude tx (just ensure they are what patient wants)

Morphine only with severe dsypnea at rest without reversible cause

180
Q

Asx hyponatremia

A

absence of neurofindings
chronic - rapid correction undesired
1st fluid restriction

3% NS if menstal sattus hcange and Na d r/o variceal bleeding

SIADH - (would have high urine Na), use demecyclocine

181
Q

Secondary hypogonadism

A

Central hypogonadism - low serum testosterone, FSH, LH
r/o prolactinoma
r/o hemochromatosis - iron/ferritin levels (h/o OA, inc’d LFT)

Reason to suspect inc’d sex biding globulin (obesity, DM, older age)

Karyoytpe and testiuclar US in pt with primary hypogonadism (inc’d gonadotrpin level (inc’d LH/FSH)

182
Q

Dyspepsia without alarm sx from developing country

A

Young pt with dypepsia from endemic area for h pylori without alarm sx (wt loss, anemia, dyphagia, fhh/o UGI malig)
Test and treat
h pylori stool antigen - if + then tx h pylori
if neg trial PPI

EGD for pt’s that do not respond to H pylori tx and PPI
or pt’s pw alarm sx

183
Q

Manage adrenal fxn during critical illness

A

Need stress dose steroids if appropriate abx not solving fever, hypotension
(repeated steroid injections probably mad adrenally insufficient)
Cortisol level though normal inappropriately low for stress condition ie sepsis

Don’t wait for ACTH stim, don’t add vasopressors before giving steroids

184
Q

Patient with hypokalemic met alkalosis

A

net loss of acid
or retention of bicarb
Saline responsive hypokalemic met alkalosis - hypovolemic - corrects with saline
UClt correct with Saline
active diuresis or gnetic tubular d/o - bartter or gitelman

Pirmary hyperaldo - aldo renin ratio 20 to 30

Mineralocorticoid excess - both renin and aldo suppressed

Plasma aldo and renin levels elevated in patients with malignant HTN, renin secreting tumores and renovasc htn

UOsm gap - used in estimating ammonium excretion

185
Q

Brachioradial pruritis

A

neuropathic itch
inflammation in cervical spine causes recurrent itching in upper extrem
Response only to cold pack
Skin bx neg - NO RASH
Not histamine related so antihistamine creams don’t help
Tx: gabapentin/pregabalin

Polymorphous light eruption - skin lesion after light exposure - wheals, papules, plaques vesicles
Skin lesions + itch

Prurigo nodularis - itchy skin, licenified nodules where been repeatedly scratched (pickers nodules)

Solar utricaria - sunlight hives

186
Q

OSA in post op period

A

pts with mild risk of OSA should be screened pre-op - (Snoring, tired, observed stop breathing during sleep, big neck, BMI>35, male

Pushed over edge by anesthesia and narcotics

187
Q

Acute severe pancreatitis

A

Aggressive hydration by IVF - acute necrotizing pancreastitis - avoids end organ damage

No need for broad spectrum abx even with necrosis
no benefit for ppx either

Only abx if pancreatic infection noted with sample

ERCP only if gallstone lodged in pancrease

188
Q

Post concussion syndrome

A

somatic, neurologic and psychatric sx after head injury - h/a fatigue, sleep distrubances, diff concentration and memory - depression, anxiety irritability, dizziness, tinnitis
abn on fxn neuroimaging,

189
Q

Meniere dz

A

tinnitis, vertigo, hearing loss

190
Q

Post traumatic stress d/o

A

cognitive and emotional sx, memory loss, irritabliity, h/a flahsbacks of events

191
Q

Manage inadequately observed asthma 2/2 improper inhaler technique

A

Observe pt using inhaler
on observed inhaler sx PFTs improve
reduce sx of oral thrush and dysphagia

Add leukotriene rct antag if using inhaler properly (corticosteroids and long acting beta agonist)

Prednisone therapy only if lung fxn not improved after proper inhaler technique - lots of systemic s/e don’t use if topical/inhaled meds work

Peak flow diary can document loss of asthma control prior to onset of sx

192
Q

DM related osteomyelitis

A

vancomycin/meropenum
septic syndrome with limb threatening foot infection
spreading cellulitis far beyond wound/ulcer
staph, strep enteric g neg,pseudomonas, anaeroboes
Bx of deep bone ideal
Need surgical debridement

NOT aztreonma/flagyl - no cov vs step/staph
No cefazolin - no coverage of MRSA
No gentamycin/aminoglycosides - very toxic, little activity in necrotic aorobic environtmnet

193
Q

Treatment of mild systolic HF (LVF) in black pt

A

Needs BB and ACEi - NYHA I-II mild HF sx resolved with diuresis

No need for CCB
1st gen CCB inc’d r/o HF

Hydralazine and nitrate only added to all patients intoleratnt of ACEi/ARB - also blacks with NYHA III/IV HF - addition of these two to ACEi reduces mortality

Spironolactone for severe SHF NYHA III/IV added to BB/ACEi - if pt has only mild sx no need for spironolactone

194
Q

Iron defiicency anemia with anisopoikilocytosis

A

variation in RBC size and shape (anisopoikilocytossi) inc’d RDW, inc’d central pallor
Iron def anemia (throbocytosis as well)
DOE/chest pain from dec’d O2 carrying capacity of blood

G6PD def - bite or blister cells - MCV normal
eccentricaly located hemoglobin to one side of cell - MCV normal or slightly high 2/2 inc’d recitulocytosis 2/2 G6PD mediated hemolysis

Myelofiboriss - sign sx anemia + night sweats, wt loss - leukoerythroblastic picture - nucleated eruthrocytes and left shift in leukocytes - TEARDROP CELLS, MEGATHROMBOCYTES.

TTP - fragmented erythrocytes (schistocytes) + AKI + MS changes + ecchymoses

195
Q

Treat chronic HCV infection

A

Pt with chronic HCV and advanced bridging fibrosis and no cirrhosis
Start peginferon and ribavirin
can progress to HCC
(If Genotyope I HCV - NS3/4A protease inhib)
Candidates for thearpy - detectable virus - some indication of hepatic inflamm - elev LFTs, inhflamming/bridging fibrosis on bx, NO CONTRAINDICATON to therapy - decompensated liver dz (ascietes, hpe encep, jaundice)preg, psych dz, cytopenia
Goal therapy to sustain response - non-detectable virus w/in 6 months - lot of morbidity from tx

Corticosteroid tx for extrahep manifestations of HCV - mixed cryoglobulinemia, lymphoma, skin dz, autoimmune dz (thyroididits), don’t give unless indicated otherwise worsens HCV (inc’s replication)

Liver tx for HCV pt with DECOMPENSATED cirrhosis, -

No reason to wait - should not reeval in 6 montsh - treat now!

196
Q

ARDS mechanical ventillation

A

hypoxemia corrected with mech ventillation, suppleemntal O2 and PEEP - limit barotrauma by ventilating 6mL/kg IDEAL body weight prevent ventilator associated lung injury then stepwise dec till pleateau pressure <0.6

IBW= 50Kg +2.3Kg for men each inch over 60 (45.5+2.3 women)

197
Q

Interpret thyroid fxn test in older pt

A

observe with TSH 6.5 and low normal T4 (free)
monitor for signs of hypothyroid
Repeat test over months to ensure stability
In pts over 80 elevated TSH no aw adverse outcomes (depression, impaired cognition),
Normal reference TSH 1-7
Don’t give older pts levothyroxine just for mildly elevated TSH without other clinical sx

TPO normal and exam normal except mild fatigue
No advantage of liothyroxine (T3) over levothyroine (T4)

198
Q

Pyoderma granulosum

A

uncommon, neutrophilic, ulcerative skin dz - multiple lesions - begin as tender papules/pustules or vesicles -> spontaneously ulcerate to painful ulcers with purulent base with ragged violacious borders
Sharp cliff cutoff face compared to normal skin
Etio - inflamm bowel dz, -> RA, seroneg spondlyloarthritsi, hematologic dz/malignancy - AML

199
Q

Caliphylaxis

A

ectopic Ca of arteries feedign skin - always in pts with ESRD on HD in setting of high Ca+/Phos products, - reticulous dusky erthema that then ulcerates from cutaenous ischemia

200
Q

Ecthyma gangrenosum

A

perivascular bacterial infection of blood vessel walls with secondary ischemic necrosis, - multple lesions in diff stages of dev - infecting agent psedomonas - in immunocompromised patients that are ill

201
Q

Necrotizing fasciitis

A

rapidly progressive infxn of SQ tissue - strep or poly microbial bacteria - pts are critically ill - progresses over HOURS (not days or weeks) - pale dusky skin with creptus - sepsis

202
Q

Evaluate pt with metastatic non small cell lung CA

A

Pt with metastatic adenoCA and NO SMOKING HX -
Need Epidermal growth factor rct analysis - can benefit from biologic agents targeting this gene factor
Chemotx + erlotineb/gefitinib (EGFR ab) - sruvival 8-10 months longer than standard chemo

Bx of liver not recommended with multiple mets (only if soltiary lesion because if you can resect can change STAGE of dz)

Medistinoscopy with bx of LN in pts with potentially resectable non-small cell lung cA (not if pt has multiple mets)

Serum chromografin levels in pt with neuroendocrine tumors (carcinod) or small cell lung CA

203
Q

Manage side effects of corticosteroid use

A

Alendronate indicated for pts being tx for giant cell arteritis with corticosteroids - if tx >3months >7.5mg/day
Ca+, vit D

No HRT (estrogen or estrog+prog) for prev of chronic dz like osteoporisis in post menopausal woemn - r/o VTE, CAD, CVA

204
Q

Epididymitis

A

Pain in superior and posterior aspect of testicle
dysuria, urgency, frequency, gradual onset of pain
fever, leukocytosis
Risk factors - rec sexual activity, heavy exertion, bike riding
55/MSM - ecohli, pseduomonas

Orchitis - direct palpation of testicle gives pain, testicuular enlargmemnt

Acute prostatitis - pelvic pain, lower UTI sx - fever, WBC - TENDER PROSTATE

Indirect hernia - discomfort and fullness in scrotum, unlateral - scrotal mass - NO FEVER OR WBC

Testicuular torision - testicle twists on spermatic cord - acute pain - cut off blood supply - SURGICAL EMERGENCY - n/v high riding testicle

205
Q

HIV in pregnancy

A

Zidovudine, lamivudine, lopinavir-rotinavir NOW when HIV detected lowers transmission to 2%

NO EFAVIRENZ - teratogenicity

Do not withhold tx till CD4<500

206
Q

Postinfectious glomerulonephritis

A

weeks after staph infection
decreased complement (C3 and 4) - activate classic and alt pathways
acute nephrotic syndrome, edema, HTN, oliguria, erythrocyte casts

207
Q

Diabetic nephropathy

A

steady decline of GFR not sudden

208
Q

IgA nephropathy

A

normal complement
AKI macro/micro hematuria
within days of staph/strep infxn

209
Q

Primary membranous glomerulpathy

A 
nephrotic syndrome
hypoalbumin
NORMAL COMPLEMENT
HLD
asx protienuria
erythrocyes and granular casts
NO ERYTHROCYTE CASTs
210
Q

Acute Severe MR

A

ruptured mitral valve cord
flail leaflet, severe MR
pulm edema - sx
urgent surgery MVR

BRIDGE could be IABP, IV vasodilator tx
NOT ORAL afterload reducer (captopril)!!
NO BB - tachy is compensatory and maintaining CO
No sign’s/sx endocarditis so NO ABX

211
Q

Bacterial meningitis s/p NSx

A

Empiric tx for NOSOCOMIAL bacterial meningitis
Vanc + agent that penetrates CSF well
MEROPENUM (for g neg bacteria/pseduomonas)

CFtx and bactrim NO EFFECT vs pseudomonas
Gentacmycin doesn’t get into CSF
Flagyl only vs anaorobes

212
Q

Hypokalmeic distal RTA I

A

Normal AG with nephorcalincosis
metabolic acidosis and hypokalmeia
can’t acidify urine - > pH alkalotic (>5.5)
Etio: SLE, Sjogrens, RA, lithium, , amphotericin B
hypercalciuria, hyperglobulinemia
Inc’d pH increase r/o kidney stones

213
Q

Gitleman’s syndrome

A

hypokalemic met alkalosis
BP low to normal
defect in thiazide channel ie acts like thiazide

214
Q

Laxative abuse

A

hypokalmeic normal AG met acidosis
inc’d GI losses - compensted by kidney by urine ammonium prodxn - acid secrition by kidney
Urine amm estimated by UCl gap
15 - decreased acid secrtion

215
Q

Proximal RTA II

A

defect regenerating bicarb in prox tubule
normal AG met acidosis
hypokalemia
glycosuria in setting of normal blood sugar
renal phosphate wasting
LMW proteinuria
Distal acidification is intact so pH urine <5.5
No kidney stones

216
Q

Manage menopausal sx in pt on tamoxifen therapy

A

Venlafaxine and gabapentin
hot flushes, ameorrhea
NO fluoxetine or paroxeteine (inhibits liver enzymes)

Hormone RT contraindicated in pts with hormone rct + breast CA

No evidence that excerise or herbal meds help

217
Q

Lambert eaton

A

progressive proximal muscle wk
depressed dTRs
improve with repeated excercise
Autonomic dysfxn
P/Q Calcium voltage gated ioin channel Ab
Dx: motor nerve conduction studies - inc of potential after stimulation

218
Q

Myastenia gravis

A 
Acetylcohlinesterase Ab
Post synaptic
Muscle use and stimuulation WORSENS strength
NO AUTONOMIC dysfxn
normal DTR
219
Q

Chronic inflammatory demyelinating polyneuropathy

A

elevated protein level
progressive prox muscle weakness and hyporeflexia
No autonomic dysfxn

220
Q

Tx SBP with significant hepatic and kidney injury

A

+ascitic fluid with >250PMN
Cefotaxime
If Cr >1.5 then also ALBUMIN
If advanced liver dz then also ALBUMIN

DOn’t use diureteic or large volume paracentesis - worsen kidney fxn

221
Q

Evaluate rheum arthritis

A

AFter therapy with MTX/biologics get
XR of hands and wrists to reevaluate erosive changes

Don’t use anti CCP for monitoring RA (just to dx)
Only do TB screening yearly

222
Q

Secondary causes of HLD

A

LDL and TC really elevated despite statin
statins ineffective in setting of hypothyroid
Check TSH
(sx fatigue, constipation, dry skin)
Also check for DM, obstructive liver dyfxn, nephrotic syndrome

don’t add gemfibrozil to statin unless needed - inc’d conc of statin and inc’s r/o statin induced myopathy

Don’t ever give zocor 80 - change to lipitor or rosuvastatin instead

If fasting glucose and TG normal - don’t need to check HgA1c for now.

223
Q

Body areas

A

leg 18%, arm 18%, front torso 18%, back torso 18%, head 9%

Need 30gm topical med to cover body in 70kg person

224
Q

Tx Myedema coma

A

IV levothyroxin and IV hydrocortisone
Non-responsive, hypotension, hypoglycemic, hypothermic, bradycardic
tx of sepsis - /PNA - ventillation tx of cardiac issues
With severe hypothyroid also hypopituitarism - need IV hydrocortisone(glucocorticoid) replacement also

Check for adrenal insufficinecy as tx occurs

Don’t use liothyroxine (T3)

225
Q

Hypotension in pt with Hypertorpic CM

A

Stop dopamine
cw IVF
START PHENYEPHRINE
LVOT obstruction from SAM
Worsen with ionotropic agens (dob/dopamine)
WOrse with volume depletion, vasodilators, sustained atrial arrythmia and sinus tach
Worse with withdrawwal of BB, CCB
Phenylephrine alpha agonist - raises afterload by peripheral vasoconstriction
Esmolol decrases dynamic outflow tract obstruction raising SBP

DOn’t use milronone - vasodilator effect worsens obstruction of LVOT

226
Q

Treat central sleep apnea in pt with HF

A

Cheyne stokes breathing/Central sleep apnea
2/2 HF
Needs diuresis
improvement in cardiac fxn 2/2 dieuresis improves CSA

If CSA persists after medical optimization of HF - adaptive seroventillation (ASV)

CPAP only if obstructive element to sleep apnea

If O2 low then supplement only

Oral appliances only with obstructive sleep apnea element

227
Q

Dx SLE

A

Anti- DSDNA Ab

\+ANA
arthritis
ulcer
photosensitive rash
livido reticularis - antiphopholipid Ab

ANti ro/SSA, anti la/SSB - Sjogrens, slcerosis , RA

Anti U1-ribonucoprotien (RNP) - MCTD - features of systemic slcerosis, polymyositis, SLE

c-ANCA (antiprotienase 3 ) - granulomatosis weith polyangiitis (wegeners)
necrotizing vasculitis lungs and kidneys

228
Q

Tx pt with acute VTE

A

LMWH 5 days overlapped with warfarin INR 2 or more x 24hrs or risk of recurrent thromboembolism

229
Q

cellulitis

A

rapidly spreading subcutaneous infection
warmth, swelling, tenderness, erythema, fever chills
Strep
Never b/l
Risk factors - h/o cellulitsi, chronic leg ulceration, varicose veins, DM, thrombophlebitis, lymphedema, obesity, tinea pedis, onchymycosis

Bullous tiniea - inflammatory and erthematous
scales in mocassin distriubtion
localized to foot -> ankle

Contact dermatitis - swelling erythema, warmth - also PRURITIS, - can get secondarily infected

Stasis dermatitis - usually b/l NOT TENDER

230
Q

Suspected SAH

A

sudden onset severe h/a
Neg HCT
Need LP to dectect xanthochromia

No use for MRI, MRA, repeat HCT with contrast (if mass lesion large enougth for headache would have shown up without contrast)

231
Q

Primary biliary cirrhosis

A

Tx: ursodeoxycholic acid
women >25yo
cholestatic liver enzymes - alk phos 1.5x, AST/ALT 1:40 (bigger is more +)

Tx: monitor with alk phos reduction
don’t give ursodeoxycholic acid with bile binders (cholestyramein)

232
Q

Screen for HIV infection

A

HIV ab enzyme immunoassay
HIV screening for all those 13 to 64 once
with risk factors annually
confirm + with HIV western blot (if EIA is +)
(don’t use HIV wetern blot as initial screen)

If acute sx and suspect in window phase -> HIV nucliec acid amplication (PCR)

233
Q

Graves opthalmopathy

A

Thyroidectomy + local measures,/steroids
proptosis, diplopia, chemosis, conjuntival injection - optic nerve compresssion can cause blindness

WIth graves dz - surgery for those severe allergy or intol of anti-thyrod drugs (methimazole, PTU, iodine), large obstr goiters or opthalmopathy

If oral iodine taken reduces TFTs but without antithroid drug will cause hyperthryoid

Don’t use PTU if adverse rxn to methimazole

**Don’t use radioactive iodine for graves -> worsens!!

234
Q

Dronedarone

A

increases Cr BUT DOES NOT DECREASE GFR
(partial inhibition of tubular tx of creatinine itself)
measured value shoudl be new baseline on dronedarone

DO NOT USE DRONEDAREONE with CHF NYHA IV or NYHA II-III with recent decompensation and hospitalization

235
Q

de Quervain tenosynovitis

A

swelling/stenosis of abductor pollicus longus/brevis tendons at level of wrist
Etio - repetive motion of thumb
Pain and swelling over radial syloid
Pain with resisted thumb flexion and extension
Finklestein +

Carpometacarpal arthritsi - pain at base of thumb during gripping - tenderness on doral and palmar joint surface
loss of ROM/joint stiffness
Older patients

Ganglion cyst - in tendon shealth from inflammation following TRAUMA

Scaphoid fx - h/o injury with wrist dorsiflexion

236
Q

Dx type II DM

A

HgA1c dx of DM, FBS not - so recheck test dx of dm - ie HgA1c

(has risk factors - fhx CAD, DM, obesity)

If both tests dx’d DM then no reason to repeat either

237
Q

Manage influenza during outbreak in community

A

Mild illness otherwise healthy - does not need tx

Those at high risk for influenza - CVD, active CA, CKD, chronic liver dz, hemoglobinopathy, immunocompromise - neurologic dz impairing handling of resp secrtions - ]

Agents should be given with 48hrs
(Oselamavir, zanamivir)

Don’t use amatadine, rimanitidine (high reistance)

238
Q

Dermatomyositis

A

heliotrope rash - erythema of malar area, nasolabial fold, periorbiatl skin
gottron sign - erythema over extensor joint spaces
Gottron papules - pink t skin colored papules DIP/PIP, lacy or reticulate erythema of v-neck - shawl sign
Exacerbated by sun

Psoriasis -pink papules, silvery scale - elbows/face
improved withsun exposure

RA - a/w rheum nodules - SQ nodules over ext joints - no muscle weakness

SLE - malar rash - NO MUSCLE weaknes, no guttron papules

239
Q

Tardive dystonia

A

facial grimacing, akasthesia(restlessness) induced by dopamine rct agoneists - (metocloproamide) and antipsych drugs
Tx: slowly taper off offending agent, antichol or dopamine rpeleting agen and botox injections

Huntington - familial d/o - generalized chorea, dementia, behavioral changes

Juvenile parkinsons - in child

240
Q

Wilson’s dz

A

copper accum in basal ganglia and liver - progressive parkinsons or dystonia. onset in teens - keisher flyscher rings

241
Q

Stage IIB lung CA

A

Surgical candidate - isolated, growing nodule
Calculating lung fxn post op - take percentage of lung removed and multiple by FEV1 and DLCO if >40% then ok

neoadjuvant chemo good too

No need to bx as high probability that patient has malignancy

242
Q

Pt with BRCA gene and inc’d risk for ovarian CA - sister ovarian CA young

A

b/l salpingoooprhectomy and ppx b/l mastectomy
(multiparity and OCP protective against ovarian CA)

(Pelvic exams, CA125 screening only in pts declining surgery)

243
Q

Hepatic encephalopathy

A

neuropsych d/o (minmal MS change to coma/confusion)
Oral lactulose was stnadard tx
Rifaxamin equiv or superior to lactusose
(infection, dehydration, electrolyte disturbances, GI bleeding, constipation and use of narcotics)
No dose adjustement for kidney needed

DO NOT PROTEIN RESTRICT - causes malnurtrition and further infxn

244
Q

Kidney fxn decline in pt with HTN

A

ARB/ACEi may lead to inc’d serum cr and uncover previously undx kidney dz -
Pt had kidney dz when started ACE/ARB but treatment decrease GFR from efferent vasodilation - inc’s serum Cr (renal perfusion pressure maintained by inc’d angiotensin)

245
Q

Peripheral manifestations of inflammatory bowel dz (UC/Crohns)

A

IBD arthritritis
1st NSAIDs
Can’t use NSAIDs 2/2 GIB
first line = sulfasalazien (also treats diarrhea, tenesmus)
2nd line if sulfasalazine does not work: MTX
3rd line - biologic (TNF alpha - etanercept, infliximab adulimabib)
No corticosteroid for long term…

246
Q

Premature CAD in CA survivor s/p radiation therapy

A

typically in ostial/prox sites - fibrous
intimal prolif
poor candidates for PCI 2/2 fibrous nature

Antiphospholipid syndrome - prolonged aPTT - inc’d r/o VTE/arterial thromboembolism and preg loss - aw SLE

Cocaine induced vasospasm - more likely ST elevation and only in case of +cocine labs

Kawasaki dz - fever, conjunctivitis - eyrthema oral mucosal mem, ertyma of LE, cervial LAD, coronary aneurysm /throbmosis of Coronaries- childhood

247
Q

MS related fatigue

A

Amantadine or modafnil
exacerbated by hot weather
need to exclude anemia, sleep d/o, hypothyroid, depression,
Adeuqte rest and physical exc importnat too
DON”T USE MEMANTIDINE
only change therapy to INFN beta if relapse (fatigue is not relapse)

248
Q

Dx acute kidney injury

A

If BPH with suprapubic illness - suspect obstructive uropathy and get kidney US
h/o irradiation, pelvic tumors, congential urinary abn, prostate enlargment all inc risk

Don’t rely on U/A - FENA may be variable (low in early obst but high later on with tubular damage) - can cuase hyperkalmic metabolic acidosis -

Kidney bx only for kidney injury of unknown cuase

Rhabdo can cuase AKI but need h/o crush injury, muscle pain, meds that cause rhabdo etc

249
Q

Aortic coarctation

A

discrete aortic narrowing distal to subclavian artery - discrpance in UE & LE BP - UE HTN, delayed/diminished femoral pulses -
AW bicuspid aortic valve - early systolic click 2/6 murmur RUSB - pt can also have aortic regurg with diastolic murmur

250
Q

ASD

A

Fixed split S2 (inc’d L->R R vol overload, pulm HTN)

holosystolic murmur with flow across TV (TR)

251
Q

Mitral valve prolapse

A

midsystolic clikc - late systolic murmur DECREASE with squat - if regurg with LVH - displaced PMI

252
Q

VSD

A

harsh holosystolic murmur inc’s with isometric exc (inc’d afterload)
+thrill

253
Q

Inflammmatory muscle/joint pain aw systemic sclerosis

A

Methotrexate
systemic digit swelling in pt with GERD, systemic sclerosis, dilated nailfold capillaries
pruritis/skin induration - scl-70
MSK features - dcSSc - symmetric synovitis - peripheral joints, tendon sheaths, mild inflamm myopathy

Cyclophosphamide - alveolitsi (low DLCO) aw dcSSc

Hydroxychloroquine - tx SLE - need to be dx with anti DS DNA ab or anti smith -

NSAIDs - no effect with inflammatory myopathy or dermal inflammation

254
Q

Manage constipation with alarm sx

A

Colonoscopy
change in bowel habits with recent blood in stool or wt loss, Fhx colon CA or age of onset >50yo

Fiber supplement for uncomplicated constipation without alarm features

Don’t check TSH if TSH already normal

Anorectal mamometry - suspected pelvic floor dyfxn (sensative of blockage in anorectal region), paradoxical contraction of anal sphincter)

No stool guiac if blood on finger…

255
Q

Chronic Fatigue Syndrome

A

medically unexplained fatigue that persists for 6 months or greater - subjective memory impairment, sore throat, tender LN, muscle or joint pain, h/a, unrefreshing sleep, post excercise malaise>24hrs

No dx test for CFS - check sleep hx, r/o OSA, frequent limb movements during sleep (restless leg syndrome) - check for depression, check for hypothyroid (if dx of hypothyroid) - CBC r/o anemia/lymphoma, r/o DM, CKD

Don’t test for EBV, parvo B19

256
Q

Pitted keratolysis

A 
caused by kytococcus sedenarius
in ppl with hyperhidrosis
warmth, moisture, occlusion
Malodor, smelliness of skin
Pressure bearing areas (balls of feet)
257
Q

Ecthyma

A

Superficial sausage ulcers with overlying crusts
legs and feet
Staph aureus - IVDA and HIV pts at higher risk

258
Q

Tinea pedis

A

silvery scale and dull erythema of whole foot, interdigit scaling and maceration

259
Q

Kertadoerma blenorrhagia

A

hyperkeratotic skin lesions on palms and soles

aw reactive arthritis

260
Q

Murcomycosis in pt with DKA

A

rhino-orbital murcomycosis - emergency surgical debridement and amphotericin B
Posaconazole as steop down to ampho B (or salvage)
Inhalation of spores - can proceed rapidly from orbit to brain - high mortality rate if not treated
Periorbital edema with escar in nasal turbinate
Rhino orbtial or rhino cerebral infxn

DO NOT USE zosyn (no fungal activity)

261
Q

High altitude periodic breathing

A

cyclic central sleep apneas and hyperapenas during sleep aw ascention to high altitude
hypoxemia stiulates ventillation
resolves with acclimatization >2500m
dyspnea, waking from sleep, poor sleep quality

Not asthma - no cough or wheeze
HIgh altitude cerebral edema - exterme of high altidudie sickness - encephalopathy in response to brain swelling
High altitude pulm edema - capillary leak in response to hypoxia - no cough or signs of pulm edema

262
Q

Chronic myeloid leukemia

A

Sx: fatigue, night sweats, wt loss, early satiety
BASOPHILIA on smear
-> CML
Dx: t(9,22) in situ hybridization

263
Q

Flow cytometry

A

good for dx malignancy with homogenous cell population
ALL, CLL, NHL, AML
Check for specific CD markers

264
Q

Heterophile ab test

A

infectious mono

check for pharyngitis, LAD

265
Q

JAK2 Mutation

A

95% P Vera

60% essential thombocytosis, primary myelobfibrosis (tear drop cells, nucleated cells)

266
Q

End stage COPD

A 
Palliative/hospice care
Dypsnea - 
Etio PE, PNA, lung mets
continue broncodilators if on them
MORPHINE for relief of dypnea

Transfusion only severely anemic

Benzos only for anxiety

Oxygen for pts with hypoxemia

267
Q

Acute UNCOMPLICATED diverticulitis

A

Oral abx - cipro and flagyl (if able to tolerate oral intake)
obstruction of diverticula neck with fecal matter
mucous/bacterial overgrowth
LLQ pain, n/v
inc’d WBC, mild fever tachy

DO NOT DO COLONOSCOPY RIGHT AWAY - r/o malignancy in 6 weeks

CT guided percutanous bx if peridivertiucular abscess >4cm

Hospitalization and IV abx only with peritonitis or significant comorbidies or no oral intake tolerating

Surgical consultation if unresponsive to abx therapy
or COMPLICATED - abscess, fistula, obstrction, peritonitis/stricture

268
Q

Dural sinus venous thormbosis

A

Magnetic resonance venography
h/a worse in AM and valsalva, c/w inc’d ICP
h/a, papiledema, visual problems, focal neruo, MS changes, Sz
NOrmal MRI, h/o tobacco and OCP use -> dural sinus venous thrombosis
Tx: d/c OCP, tob and systemic A/C x 6 months

No lupus A/C if coag panel normal

269
Q

Adverse effects of glaucoma drugs

A 
Pt brady and low energy/libido
inc'd IOP
Timolol should be d/c'd
decreases inflow of aqueous humor and generally well tolerated - 
broncospam, depression, mood swings

Amlodipine - s/e hypotension, peripheral edema, dizziness, h/a,

Carbonic anhydrase (Dorlozamine) - acidosis, malaise, diarrhea, hirsuitism, bloody dyscrasia

lantoprost - flu like sx

ACEi - cough hyperkalemia, kidney failure.

270
Q

Low solute intake

A

h/o anorexia/wt loss
clinical eurvolemia
low plasma AND urine Na/osmolarity
hypotonic hyponatremia

NOT hypovolemia - no postural chagnes - if hypovolemia, urine OSM would be high as ADH would decrease free water diuresis

271
Q

Pseduohyponatremia

A

low serum sodium due to measurement in falsely large volume -
Inc’d LIPIDS and PARAPROTEINS
shows lower than real measure of serum sodium
If no osmal gap then no pseuodohyponatremia

272
Q

Hyponatremia with primary adrenal insuff

A

mineralocorticoid and inc’d vasopressin

hypotension, hypovolemia, hyperkalemia, low morning cortisol

273
Q

Sx Severe TR

A

Tricuspid valve replacement either sx or signs of
RV overload dilation, reduced fxn
Severe RH failure - dyspnea
Pulm HTN

Don’t cardiovert as TC annullar dilation will preceipate flutter

Don’t treat RHF with digoxin

Don’t treat with abx for endocarditis - no fever wbc etc

274
Q

Tx chronic venous insufficiency

A

Knee high compression stockings 20-40mmHg/leg elevation
persistent venous HTN caused by venous incompetence or occlusion
Edema, hyperpigmentation, stasis dermatitis, varicose veins, cellulitis,ulceration
avoid bx (non-healing wound)
Etio also meds CCB/thiaziediones -> dependent edema
Elevation of leg and comrpession
avoid compression with PAD, decompensated HF

Abx only if signs of infection

Diuretics only if systemic signs of volume overload

Patch testing only if allergic contact dermatitis (disrupted skin barrier or use of multiple topical meds)

275
Q

Immunizations prior to administration of biologic anti-inflammatory therapy

A

Rituximab
Give IM flu shot prior

No live attenuated in immunocompromised, pregnant women, chornic met dz, DM, kidney dysfxn, hg opathy
prolbem with respiratory secretion handling

Biologics may blunt dendritic or b cell fxn in terms of vaccine response (antigen presentation or ab formation)
Only contraindication is egg allergy, vaccine intolerance

Anti flu tx (oseltamavir, zanamavir) - bridge to therapy with vaccine in immunocompromised
Assistd living during outbreak, close household contact, heathcare works

276
Q

Delayed hemolytic reaction

A

Sickle cell anemia pt
Blood tx 1 week ago
jaundice, inc’d indirect bili, lower Hg - worsening pain crisis
If pt with new alloantibody then at risk to develop more
5-10 days later

(not IgA - would have had anaphylaxis)

277
Q

Tranfusion related acute lung injury (TRALI)

A

pulm edema/infiltrates
antibodies against neurtrophils in donor plasma
fever/hypotension

278
Q

HLA alloimmunization

A

rxn from plt exposure

new plt tx doesnt inc level appropriately

279
Q

Pt with adrenal insufficiency with mild illness

A

increase hydrocortisone dose to avoid addison crisis x 3 days

Hospitalization only if hypotensive and not taking oral meds/fluids

Don’t need mineralocorticoid (flucortisone)

280
Q

Manage implanted cardiac device infection

A

PPM generator eroded thru skin
extraction PPM and leads needed EVEN WITH NO SIGNS OF INFECTION
visible generator means entire PPM system infected
(microbes track down leads)
temp wire if ppm dep abx for at least 72hrs
Neg BCx followed by 7-14 days abx directed by cultures from PPM pocket
coagulase neg staph, staph aureus MCC
With endocarditis or bacteremia better to wait longer b4 replant (extend abx therapy)

Prior to explant abx may be used to limit systemic spread of infection but still need explant

In pts with localized pocket inflammation but no erosion DO NOT ASPIRATE could spread infxn
TEE if bacteremia present check for lead or valvular veg

DO NOT JUST CLOSE EROSION

281
Q

Early stage ductal breast CA - breast conservation tx

A

Excision of primary tumor, sentinal LN bx, radiation
overall survival same with lumpectomy vs mastectomy but better cosmetic results

Sentinel = first LN draining after cancer site (inject blue dye and radioactive colloid into tumor)

If sentinel LN neg then further nodes likely no mets
NO FURTHER SURGERY

If sentinel LN + then axillary node dissection done to determine number of LN involved

If pt with scleroderma, prior chest wall radiation - can’t have breast conservation tx - NEED MASTECTOMY and LN bx/radiation

Always do sentinel LN bx not just surgery - for decision on adjuvant chemo

Most pts undergoing mastectomy don’t need radiation therapy unless large tumors (>5cm)

282
Q

Validity of medical study

A

Primary threat to validity in CASE SERIES is NO CONTROL GROUP to compare tested intervention to…

Also randomization not possible

283
Q

Balkan nephropathy

A

chornic tubulointerstitial condition of unclear cause in patients of southeastern european origen (Balkan region)
?aristolocholic acid - plant alkaloid from region etio?

Dec’d GFR, urine protein <1gm /day, relative with same dz
CKD, minimal proteinuria, benign urine sediment

Analgestic nephrophathy - h/o analgestic heavy use over years

HTN nephrophathy - long h/o poorly controlled HTN

IgA nephoropathy at later stage of kidney dz should have hematuria and more proteinuria

284
Q

Venous stasis ulcers

A

provide compression, minimze vascular HTN, minimize edema -> promote healing
(Unna boot)
medial maleolus classical area
surrounding skin thickened with hemisderin deposition
venous stasis dermatitis

No arterial vasc - not PAD (ABI 0.9) - arterial ulcers at LE affected limb cool with poor cap refill, pulses may not be palpable - over bony prominances or post calf

contact casing - redistribute pressure in neuropathic feet

cellulitis should have fever/ inc WBC and should respond to abx

285
Q

Hyperaldosteronism diagnosis

A

Biochemical evidence of hyperaldo: HTN, hypokalemia
No cushings featers (so not cushing syndrome) so no dexamethasone suppression or 24 hr urine cortisol
No CAH features (no hirsuitism, amenorrhea) -
No pheo sx so no plasma catecholamines
DX: check aldo to renin ratio (except if on spirono/eplero)
(should be inc’d aldo, suppressed renin

No need for imaging yet

286
Q

Behcet’s dz

A 
vasculitis in multiple organs
mucous membrane ulcerations
occular involvement
GI, pulm, neuro manifestations
erythema nodosum, arthritis, pan uveitis, retinal vasculitis, pulm artery aneurysm
287
Q

Granulomatosis with polyangiitis (Wegeners)

A

small blood vessel involvememnt
NO aneursyms
h/o upper airway dz (sinusitis, epistaxis) and glomerulonephritis

288
Q

Polyarteritis nodosa

A

medicum size vessel vasculitis
mesenteric/renal arteries - intestinal ischemia and renovasc HTN
aw Hep B

289
Q

Sarcoidosis

A

arthritsi/uveitis
CXR hilar LAD
no aneurysm

290
Q

Pt on multiple NSAIDS wtd?

A

put on PPI
h/o PUD
>65, high dose NSAID, use of ASA also, AC or steroids

Enteric coated ASA doesn’t really help GI ppx

Don’t d/c ASA in CAD pt s/p MI

291
Q

Subdural hematoma

A

Pt with recent head/neck trauma
SDH (unlike epidural hematoma) require only mild injuries to cervical spine or head
Disruption of bridging veins - sx incidious in onset
Older pts, use of AC
(mental cloudiness, dizziness, ataxia, h/a)
IMAGE HEAD (HCT)

cyclobenzaprine only helps with neck spasms

Meclizine - only helps dizziness of vestibular origin

292
Q

Flu ppx in pregnant pt

A

use inactivated trivalent flu vaccine
dont give if allergy to eggs or h/o guillan barre

osetlamavir zanamavir and amantadines only effetive in prev after exposure in close contacts
Can use osteltamavir or zanamavir in pregnancy if confirmed flu infection

NO LIVE flu vaccine for preg women or chornic met dz, DM, Hg opathy, immunosupp, CKD

293
Q

Manage patients with etoh abuse

A 
connect drinking with negative consquences
physical or psychosocial harm
serious illness, DWI
needs f/u and reassessment
identify barriers

Adjunct - disulfuram, AA, pscyh

Etoh abuse >14 drinks/wk, 4 drinks per occasion (3 for women)

294
Q

Suspected advanced stage testicular CA

A

orchiectomy and chemo (platnum based good with germ cell tumors and mets)
Lung mass and pleural effusion in young pt with testicular tumor is likely mets
High AFP/HCG= nonseminoma

Platnum, etopside, bleomycin

do chemo before resecting mets

295
Q

Churg Strauss

A

+eos, migratory pulm infiltrates, purpuric skin rash, mononeuritis multiplex, glomerular nephritis, alveolar hemmorrage
Antecedent asthma, allergic rhinitis, sinusitis
pANCA (MPO)
fever, arthralgia, myalgia

296
Q

Granulomatosis with polyangiitis

A 
Wegeners
c-anca (antiproteinase 3)
necrotizing vasculitis resp/kidney
inflitrates/nodules CXR, pulm hemorr
No eos, no antecedent asthma/allergic rhinitis/sinusitis
297
Q

Microscopic polyangiits

A

necrotizing vasculitis lungs/kidney
RPGN
pulm hmorrhage
No eos, no antecedent asthma/allergic rhinitis/sinusitis

298
Q

Polyarteritis nodosa

A 
Hep B
fever abd pain, arthralgia, wt loss
mononeurtiis multiplex
nodules, ulcers, purpura, erythema nodosum
No lung invovlemnt
ANCA NEGATIVE
299
Q

Exclude PE with d-dimer

A

low risk patietn neg D-dimer no need for further testing
strong h/o asthma - may have come back
check peak flow
No physical signs of abd issue so no need for CT abd

300
Q

Systolic HF tx with BB

A

Can start with systolic HF
DO NOT START IF IN ACUTE Decompented HF
B1 selectives (metoprolol, biosprolol)

Don’t replace MV if 2/2 to dilated CM in decompensated HF

Epleronone should replace spironolactone if +gynecomatia

BIVI ICD upgrade - NYHA III/IV, EF120

301
Q

Malaria ppx pregnant pt

A

NO DOXY during pregnancy
Mefloquin better in africa (chloroquin resistant strains)

No atovaquin-proguain in pregnant women

302
Q

Dx Nephrolithiasis

A

Non contrast helical CT
sx of renal colic
pain rad to testicle or labia majora
Can ID all stones

KUB only with Ca containing stones
follow stone burden or pre-op planning

No further use for IV pyelography with non contrast helical CT

Testicular US if abn of testicle, turmor hernia abscess

303
Q

Grover dz (acantolytic dermatosis)

A

transient rash
self limiting, waxing and waning chronic
50yo
pruritis when hot and sweaty
bx acantholysis - dissociation of keartinocytes in epidermis
Tx: reassurance, cooling measures, mild topical steroids,

304
Q

Miliaria

A

red papules on skin without scales - occlued and hot such as neonates and hospitalized patients - eruption can be asx, pruritic, burning, stinging - self limited and would not persist

305
Q

Pityriasis rosa

A

spring/fall
pink oval shaped plaque - thin collarette of scale (herald patch)
christmas tree pattern of smaller plaques
asx/mildly itchy
4-10 weeks

306
Q

Tinea versicolor

A

Malasezzar Furur

scaly slightly hyperpigmented or hypopig macules on trunk/ torso, don’t itch typically don’t itch

307
Q

Dx complications after SAH/repair

A

CT angiography urgent
Early complications - aneursymal re-rupture, hydrocephalus
Late complications (5+ days) - cerebral artery vasospams - decline in neuro exam, - cerebral infarction -
CT Angio can show cerebral vasospam -tx with intraarterial CCB or angioplasty of spasm vessel

EEG if CT angio net - r/o status epilecticus (conv/non-conv)

Lumbar pct to measure ICP or r/o post surgery meningitis but neuroimaging first to r/o mass effect (don’t want cerebral herniation)

MRI - cerebral infarction - less accurate for vasospasm AND slow…

308
Q

Pituitary tumor apoplexy

A

Bleeding into tumor in pituitary - ie pt on A/C for afib - high risk
Need to give glucocortocoid supp immediately (acute ACTH def) (hypotensive) and surgery to remove tumor

Pan hypopit hx - wt gain, ED, hyponatremia
Acute h/a, neck stiffness - hemmorage

Insulin tolerance test - adrenal insuff, GH insuff
Prolactin - r/o proloactinoma

Lumbar pct - meningitis or SAH for xanthochromia

309
Q

Arrythmogenic RV dysplasia (ARVD) with syncope

A 
disorder of desmosome
fibrofatty infiltrate of myocardium
syncope 2/2 monomorphic VT from RV
Syncope=ICD placment!!
discourage competitive sports - increase in sudden death from mech stress on RV, inc'd sympathetic tone - RV strech progresses dz
RV failure/LV failure eventually

No need for pre-icd EPS but VT ablation option to decrease indicdence of VT

Ambulatory holter - >500 PVCs in 24 hrs = ARVD no need if already dx’d

Can use BB (sotolol) to reduced VT and ICD shocks but still need ICD

310
Q

Advanced symptomatic follicular lymphoma

A

chemo - rituximab, vincristine, dobxorubcin, prednisone- > reituximab maintenance

If relapse - hemtopoetic stem cell tx

311
Q

Acute adrenal insufficiency

A 
hemorrhage - trauma, A/C, 
emboli (afib)
sepsis
Sx: b/l flank pain, hypotension, fever, n/v - hyponatremia, hypokalemia low hct
Tx: IVF, hydrocortisone replacement - 
Abd CT confirm dx
312
Q

TB Drug s/e

A

Pyrazinamide - hyperurecemia/gout (inhibits tubular excretion of urate), hep, rash, GI upset

Norvasc - peripheral edema, muscle pain, nausea, palpitations, dizziness

INH - hep, rash, peripheral neuropathy, lupus like syndorme

Rifampin - rash, hepatitis, GI upset, ORANGE BODY FLUIDS, - enhances renal excretion of urate

313
Q

Isolated triglyceridemia

A

very high >500
fenofibrates
Non-HD chol=total chol - HDL chol

Covelesam - ok for preg pts
can raise TG

nicotinic acid - red tg and inc HDL
-precip gout

Omega 3 fatty acid - lower TG - reduce hepatic secrtion -

314
Q

Tuberculous arthritis of spine

A

immunosupp’d pt (HIV no meds)
area where TB endemic
Vertibral bx to dx
can have normal CXR

CT Mycelography - only for demonstrating compression after dx made

Tn 99 bone scan - areas of inflamm no microbiail dx -

TsT too slow

315
Q

Space occupying cerebral infarction

A 
surgical decompression (mannitol could be first)
w/in 48hrs of stroke

No ASA

Dexamethoasone and steroids could help with mass effect of tumores and inffection

ICP monitoring after surgery

No lumbarpnct in pt with mass effect

316
Q

Constipation predominant irritable bowel sydrome

A

First laxatives and fiber
Lubiprostone - Cl Ch acitivator - secretes salt water into intestine

Hycoscyamine - IBS as antisposmotic blocks acetylcholine at GI smooth muscle - CAN WORSEN constripation

TCA for abd pain in IBS but anticholilnergic effects worsen constipation

Metochorlproamide - only for gastropariesis

317
Q

HTN emergency

A

ENd organ damage - encephalaopathy, AKI, retinal hemorrhage, exudates, papiledema,
Decrase BP 25% in 1st hour

318
Q

Lentigo maligna

A

slow growing melanoma
pt with signfiicant sun exposure
prolonged radial growth phase - can be present for many years before vertical invasive phase

319
Q

Actinic Purpura

A

well demarcated smooth violacious red patches in elderly pt with sun damaged skin - skin fragility - arise from trauma - may heal with post inflamm hyperpigmentation

320
Q

Actinic keratosis

A

PREMALIGNANT
in sun damdaged areas
may be pigmented and be mistaken for lentigo malgna
progreses to SCC

321
Q

Sebhorreic keratosis

A

barnicles of the old
Benign
brown scaly waxy

322
Q

Solar lentignes

A

brown macules and patches occur in elderly pts sun damaged areas - more homogenous pigmentation and lighter color than lentigo malgna

323
Q

Acromegaly after transspenoid surgery

A

elevated IGF-1 and sx of acromegaly
Octreotide

Don’t just observe

324
Q

Reactive arthrtis

A

Tx: sulfasalazine (after NSAIDs/steroids fail)
inflamm arthritis that occus within 2 months of bacterial gastroenteritis or non-gonoccoal urethriis or cervicitis
arthritis, uveitis, conjunctivitis
Usually self limited - 25% develop chronic arthrtiis
(refractory to NSAIDS or steroids)
Sulfasalazine also useful in peripheral arthritis forms of IBS associated arthrtis, psoriatic arthritis, ankylosing spondylitis

No colchicine - only for crystal arthropathies

No glucosamine - OA

No role for abx

325
Q

Carcinoid tumor

A 
low grade malignancy
Young, never smokers
evidence of bronchial obstruction
recurrent PNA
tx: surgical resection

AdenoCA is most frequent CA in non-smokers but INFREQUETN cause of endobrochial obstrution

Small cell and SCC do cause endobronchial obstruction but rare in young non-smokers

326
Q

Cat Scratch Dz

A

Bartonella Henslae
red papules then tender LAD near site of scratch
AZITHROMYCIN
(or doxy, rifampin, clarithro, bactrim, cipro)

Linezold/dicloacillin - G+ activity - not good again gram neg

Sporotrochosis - itraconazole is tx

327
Q

Chronic stable angina

A

If BP and HR can tolerate increased BB then increase

CCB - 1st line antianginal if contraindication to BB
can be added if maximal at optimal dose of BB/nitrates

Ranolazine added if optimal doses of BB, CCB, nitrates
don’t give with hepatic impairment, baseline long QT,

Don’t cath if not medically optimiezed

328
Q

Bed bug bites

A

itchy - topical steroids/antihistamines

grouping in linear pattern, don’t need ivermectin or topical permethrin or doxy as dont infest skin..

329
Q

Manage pt with asymptomatic advanced follicular lymphoma

A

NHL - if asx and normal blood counts then watchful waiting

If sx develop - rituximab, chemo, prednisone

No LN radiation (just circulate and come back)

330
Q

diarrhea predomiant IBS

A

Test for celiac dz

also correlation between celiac, DM1, autoimmune thryoitiis

331
Q

Smoking cessation

A

If pt needs nicotine replacement and failed one form then try another form
Can add bupriprion BUT NOT WITH SEIZURE HISTORY

No need for benzoes - need nicotine replacement

332
Q

Acute bell’s palsy

A

could be 2/2 human herpes virus type I
Upper and Lower face - inability to close mouth AND raise eyebrows
antecedent viral infection
dry mouth, impaired taste, pain/numbness in ear
abrupt onset over 1-2 days
Tx: PREDNISONE within 72 hrs

No role for acyclovir
High dose IV steroids for MS not bell’s (if this was MS would have history of recurrent neurologic epsisodes)

Migraine associated weakness upper face spared…

333
Q

Tx pt with resistent HTN and systolic HF

A

Pt already on ACE, BB, diuretic and HR 50
Add norvasc (doesn’t lower HR)
not 1st line as neutral in mortality effect for HF (but other CCB - diltiaem, nifedipine, verapamil are neg ioniotrpes so worsen mortality)
So norvasc/feldopine only used for HTN or angina in pts with systolic HF when pt already optimized on ACE/BB

334
Q

Post op VTE ppx in high risk patients (cervical Ca hyster)

A

5 weeks enoxaparin
High risk = prior VTE, orothopedic surgery, cancer (esp gyn malig) - extended ppx

Non-pharm therapy - in all post surgical pts
(early ambulation, compression stockings, SCDs) - only when very low risk (outpt surgery) or bleeding risk (neuroscurgery)

IVC in high risk patients with known VTE or who can’t get ppx 2/2 bleeding risk

SQH is ok but in high risk pt LMWH better and needs to be after d/c also

warfarin only in perioperateive stting in ortho pts

335
Q

Hirenadrnous suppurativa

A

(acne inversa)
Painful, recurrent chronic sterile abscesses - sinus tract formation, scarring of axilla/inguina, perianal, inframmammory area

Tender SQ nodules tha tcoalesce and rupture - deep dermal abscesses - can become secondarily infected
AW smoking and obesity

Not acne - double comedones and sinus tracts

No pyogenic gangrenosum - bright red friable papules - resulting from capillary proliferation and NOT infection

Sweet syndrome - acute febrile neutropenic dermatosis - middle aged women after URI
fever arthraliga, myalgia and cutanous lesion - salmon colored papules/plaque trunk, neck extremities

336
Q

Intrahepatic cholestasis of pregnancy

A

2nd or 3rd trimester
mildly elev bili and alk phos (maybe ast/alt)
generalized prurutis
sex hormone induced inhibition of bile salt export from hepatocytes
tx: Ursodeoxycholic Acid

Acute fatty liver of pregnancy - 3rd trimester - need early delivery - liver failure adn coagulaopathy

HELLP - microangiopathic hemolytic anemia, elevated liver enzymes and low plt - 3rd trimester - early delivery

337
Q

Hyperemesis gravidum

A

1st trim - unrelenting n/v - elev LFTs but resolve when sx abate

338
Q

Travelors diarrhea

A

enterotoxogenic e coli - self limited, mild diarrheal illness
Sx treatment, no testing
from eathing fruits - ingestion of unprocessed water

Stool ctx only if diarrhea >72hrs (esp if tenesmus, fever, blood instool)

Ova & Parasite dx - if >7 days sx

No role for fecal leukocytes

339
Q

Opiate induced secondary hypogonadism ie methadone

A

Downregulates GnRH, low FSH, LH, decreased testosterone

Anabolic steroid use pts typically c/o infertility - may have pusutular acne and are big not thin

Citalopram cuases low libido but DOSE NOT DECREASE TESTOSTERONE levels

340
Q

Spinal cord compression in pt with parkinsons

A

Compressive cervical myelopathy
MRI cervical spine
acute onset of leg weakness in pt previously able to walk, ankle clonus HYPER reflexia,upgoing toes, leg weakness (arm strength normal)
-> suggest spinal cord compression

Not CT myelography - harder to perform, worse images

No inc’d carvidopa/levodopa

341
Q

Acute interstitial nephritis

A 
hypersensitivity to a medication
presentation variable - dependent on type of med - 
Fever, rash eosinophilia 10% only
leukocytes or leukocyte casts on U/A
PPI induced AIN is subacute

Bisphosphonats - ATN - muddy brown casts, no leukocytes

Glomerulonephritis - dysmorphic erythrocytes, erythrocyte casts, proteinuria

TTP - cancer/chemotx agents - cyclosporin, tacrolimus, quinidine - ticlodipine, quinine
AKI can happend but with hemolytic anemia and low plts, elev LDH

342
Q

Inflammatory anemia

A

normal or low normal iron, low TIBC, ELEVATED FERRITIN - microcytic hypochromic anemia
Elevated hepcidin in response to inflamm cytokines from inflamm dz (SLE, Tb, OM, malignancy, colagen vasc dz)
Tx: Treat underlying condition

Warm antibody mediated hemolysis - small spherecytes
Microcangiopathic hemolytic anemia - schistocytes

343
Q

Suspected osteoporotic fracture - young pt on steroids

A

SLE/steroids - high risk for osteoporosis and fx
avoidane of sun
Even if XR neg -> CT thoracic spine r/o fx
Tylenol and NSAID for pain

PT after fracture r/o and pain controlled
NO BEDREST
DOn’t continue cyclobenzaprine - can cause dependence

344
Q

Cutaneous T cell lymphoma (indolent course)

A

erythematous eruption >90% body= ERYTHRODERMA
etio: drug eruptions, psoriasis, atopic dermatidis, cutaneous t-cell lymphoma
Patches, plaques, tumors, allopecia, nail dystrophy, thickening palms and soles
Bx skin

Drug hypersensitivity - usually acute in onset 3-6 weeks,
MCC allopurinol, anticonvulsants, dapsone, NSAIDs, sulfonamides, - also facial edema, LAD, HSM

Pustular psoriasis - h/o psoriasis tx’d with steroids - erythrodermic flarie days to weeks after d/cing steroids

SSSS - children or adults with immunosupp, AKI - have peiroral crusting, fissuring - confirm with isolation of staphy (dx clinical)

345
Q

Serologic testing for lyme (borreilia burgdorferi)

A

vague constitutaional sx of several months duration - non-focal, nonsp - not suggestive of lyme
Initiate further eval for faigue and weakness

Lyme +IgM, neg IgG - clinical correlation
If findings <1 month after sx then delayed seroconversion - repeat testing in one month

Do not treat for lyme

346
Q

OMT for severe HF

A

SHF 2/2 peripartum CM - during preg start BB, digoxin, diuretics
Start acei after delivery
Also with severe sx will also need spironolactone

If after OMT and is euvolemic still with symptoms - and LVEF < 35%, QRS>120 - Cardiac resyncronization tx

Can’t titrate BB up if HR low

Endomyocardial bx only if suspect infiltrative process (amyloid, hemochromatosis, sarcoid) - no LVH, no low voltage

347
Q

New onset crohns dz

A

mod to severly active crohns (transmural)
weight loss and significant sx
Treat aggressively with Anti-TNF (infliximab) with or without immunomodulator (azathropine or 6MP)

Abx only if associated abscesses/wound infections

5ASA (mesalamine) more effective in UC (mucosal) than in crohsns (transmural) - used in mild dz for crohns

DOn’t just use corticosteroids - may improve some sx but most pts need maintenance

Surgical eval only if performation, abcess, obstruction or medically refractory dz

348
Q

Cryptogenic ischemic stroke

A

when infarct appear embolic suspect pAF
will need prolonged cardiac monitoring
25% cryptogenic ischemic stroke have pAF

No reason to close PFO - no diff in stroke risk vs OMT (ASA)

Warfarin only if pt in pAF

349
Q

Estimate GFR in low risk healthy person

A

Use chronic kidney disease epidemiology collaboration equation -
MDRD UNDERESTIMATES GFR at higher (normal) values
(especially with patients of normal or higher muscle mass)

Crockfeld gault ALSO UNDERESTIMATES GFR at normal values

Only need 24 hr Cr urine collection or radionuclide kidney clearance scanning when evaluating living kidney donor candidates

350
Q

Hypoglycemic unawareness

A

Reduce insulin dosages
HgA1c below target
adrenergic response blunted after hypoglyemic episode for 2-3 days - inc’d likelihood of 2nd hypoglyemic episode

Don’t increase carbs - on healthy diet, wants toget pregnant and could cause weight gain

Alpha lipoic acid helps with painful Dm nephropathy no effect on hypoglycemic awareness

Pramlintide - analogy of amylyn decrases stomach emphyting speed - promotes satiety - inc’d r/o hypoglycemia

351
Q

Treat dypnea at end of life

A

end of life dypnea common
cardiopulm pathology - ie pleural eff, HF, COPD, PE, PNA, lung mets
If underlying lung dz on broncodilator - c/w those and ADD MORPHINE

Abx and steroids won’t immediately help - not c/w comfort only measures

Benzos don’t always help

352
Q

Diagnose Rheum Arthritis

A

Anti-CCP - dx 40-60% RA including pt with neg RF
95% specific for RA
Synovitis >1hr in AM

353
Q

Anti mitox ab

A

autoimmune hepatitis - can have arthralgia but also with LFT abnormalities

354
Q

ANCA+

A

granulomatosis with polyangiitis (wegers), microscopic polyangiitis, Churg strauss, drug induced vasculitis - woul dhave some other systemic involvement

355
Q

ANA

A

suspicion for autoimmune dz ie SLE

women of child bearing age,

356
Q

Respiratory muscle weakness

A

NM dz - reduced TLC - increased residual volume due to inability to fully exhale
Restrictive pattern, no obstruction
increased RESIDUAL VOLUME -
Dypnea as presenting sx for NM dz

COPD - would have increased residual volume but also inc’d TLC,

HF - no JVD, no edema, abn cardiac exam

ILD - reduction in both TLC and residual volume

357
Q

Diagnose brain death

A

Apnea test only test required to dx brain death
Cerebral hemorrhage
coma, absense of motor response, pupillary resonse, corneal reflex, jaw jerk, gag reflex, rxn to pain, cough while suctioning trach, suckign or rooting reflex
Initiate apnea test when PCO2 40-60, pt normothermic and off sedation
Pt off vent to obtain baseline PCO2, O2 supp by other methods, serial blood gasses and observe spontaneous resp
POSITIVE APNEA TEST: if pCO2 inc’d by >20 without spontaneous respiration

No CT angio when brain death dx - even if find hematoma expansion no reason to tx with severe neuro damage

EEG/Transcranial doppler - not required unless apnea test tolerated

358
Q

Manage asx ostium secondum ASD defect

A

ASD closure in asx pt (TTE 2/2 murmur) indicated with R side chamber enlargement, no evidence of pulm HTN
Also if sx attributable to ASD - afib, paradox embolism, cyanosis (L-> R shunt) - pt also has mild inc in RV pressure

Device vs surgical ussualy physician preference but if no associated CV dz device closure better tolerated, faster recovery

ASA can be used to prevent paradox embolism in pt with PFO or ASD (Small)

No warfarin unless pt has afib or has paradoxical embolism

Don’t just observe - needs closure - pt already has enlarged right sided chambers - inc’d risk of complications (arrhythmias)

359
Q

Preop care of pt with COPD and intermedicate risk procedure

A

Incentive spirometry - reduces risk of peri op pulm complications (or deep breathing)
begin pre op
Risk factors chornic lung dz, older age, spinal or general anesthesia, surgery arond diaphragm

Positive airway pressure only for pts who can’t do incentive spirometry (MSK or NM limitations)

CXR pre or post op without any clinical suspsicon of lung issues does not help

PFTs only when cause of dypnea unknown (pt known to have COPD)

360
Q

Manage newly dx HIV

A

combination HAART now (tenofovir, emtricitabine, efavirenz) since CD4< 500, HIV nephropathy, co-infct HBV, pregnancy, CV dz or Hep C

No Viral load indications (just CD4)

361
Q

Hypercalcemia Tx

A

Severely sx hyperCa in setting of metastatic breast CA
polyuria, polydipsia, dry MM, low bp, tachy- dehydration -
START normal saline
High Ca impairs nephorons to concentrate urine - need to restore euvolemia with saline diuresis - aids in delivery of calcium to distal tubule which will excrete excess Ca with excess Na from NS

HyperCa of malignancy induces skeletal resorbtion - liver mets likely secreting PTHrP - need control of tumor with chemo

Bisphosphonate may be needed if hyperCa+ after normal saline - also IV lasix may also be needed after euvolemic
Glucocorticoid also can lower Ca if bisphosph don’t work.

362
Q

Drug induced SLE

A

d/c offending agent (HCTZ) drug or light induced
HCTZ commonly implicated drug in SLE
anti histone Ab+
ANA titer +
Anti Ro/SSA, Anti La/SSB (photosensitive conditions)
onset of rash after drug starts
annnualar polycyclic erutyenatous scaling patches in sun exposed areas with sharp cutoff at clothes

No MTX as drug induced lupus usually not systemic - normal other labs
CK and aldolase not needed as pt does not have signs of polymyositis or dermatomyositis
(heliotrope rash - violacious dusky erythem rash periorobial with or without edema
, goutrrons papules - violacious scaley papules over bony prominances MCP, PIP, DIP
, prox muscle wk)

Topical terbinafine - KOH neg not fungal - only needed if tinea corporis

363
Q

Laxative abuse

A

normal anion gap metabolic acidosis
kidney ability to exrete acid correlates with urine ammonium (hard to measure)
Urine anion gap estimates ammonium excretion
Urine amm=UAG/2
UOsm= 2x UNa + UK+ + Uurea/2.8+ Ugluc/18=176(no gluc)
UAG=176, UAmmonium = 88
UAm >80 = extrarenal losses of bicarb
UAm < 30 = primary kidney losses of bicarb (

Chronic diarrhea from laxative abuse dumps bicarb - causing systemic acidemia - kidneys try to dump extra acid by making ammonium so ammonium levels increase, increasing UAG

Diuretic abuse and surrepticious vomiting are metabolic alkaosis - Vomitting is cloride resopnsive - so UCl- < 10
Diuretic abuse is chloride unresponsive so UCl>20

Hypokalemic RTA (distal type I) - renal tubular acidosis - impairment of urine ammonium excretion (can’t acidfy urine) pH>6, urine ammonium levels >30

364
Q

Long term f/u for Stage III colon CA

A

Physical exam, CEA monitoring q3-6 months
Annual CT for 3-5 years (dx relapse tha tis potentially curable)
Colonoscopy 1 year after resection and then q3-5 years

PET only if abn seen on CT

365
Q

Inclusion body myositis

A

MC form of myositis >60yo
proximal AND distal muscle wk (can be assymetric)
quads, wrist, finger flexor muscles
incidious onset, modest CK elevation (<1000)
No autoAb (ANA neg)

Dermatomyositis - symmetric prox muscle wk, +autoab and rash (gottrons papules, heliotrope rash), shawl sign

Polymyositis - younger pts, MC women, + autoab/+ANA
symmetric prox muscle wk - extramusc manifestations (fever, pulm inovlvmenet)

Statin induced myalgia - asx CK elevation or myalgia, rhabdo -
ONset of muscle pain tenderness/cramping - withini 6 months of starting statin, resolve 2 months after stopping - dose related

366
Q

Evaluate 2cm calcified lung nodule in smoker

A

Smooth bordered, centrally calcified - c/w granuloma
Benign : nodules with smooth borders, popcorn, lamellar, cetral and diffuse Ca
Malignant: spiculated borders - ecentric/off center CA - needs further w/u

Bronchial carcinoid tumor - low grade neuroendocrine neoplasm - pw hemoptysis - bronchial obstruction or asx
Central airway location
SMOOTH BORDER, not calcified

Lung mets - breat, head/neck, colon, thyroid, kidney
Usually multiple and smoothly bordered - NOT calificied

NSCLC - Calcium within nodule unusual - if there would be eccentric

367
Q

Chronic tubulointerstitis nephritis 2/2 lithium use

A

Ideally change lithium to other agent
If not possible then add amiloride - decreaes lithium uptake in renal tubule cells decreasing damage
Lithium - decreased GFR - distal renal tubular acidosis - partial nephorgenic DI - high urine output inability to concentrate urine - lithium is uptaken in renal cells along with sodium so concentrates and causes damage

DO not fluid restrict - will make hypernatremia worse in lithium Nephorgenic DI

Prednisone only if tubulointersitial nephritis not improved by dc ing offending agent or adding amiloride

Tolvaptan - hypervol or euvolemic HYPOnatremia -in chronic HF, cirrhosis, SIADH - blocks effect of ADH and causes free water diuresis

368
Q

Basal cell CA

A

MC type cutaneous malignancy
Head and neck of older ppl
Sun exposed areas
Smooth, pearly, asx telecangiectatic papules - grow slowly but cause siginficant tissue destruction if not removed - rarely metastasize - bleed when traumatized

Actinic keratosis - PRECANCEROUS
sun damdaged skin - large numbers
-> SCC
flat with prominent scale
easier to plpate than see

Epidermal inclusion cyst
firm SQ nodules with prominent central punctum
copious amount of keratinaceous material - malodoorous when extruded

Melanoma - malignancy of pigment producing cells of epidermis - darkly pigmented - ABCDE (assymetric, irreg border, color variation, diameter >6mm, evolution/enlargment)

SCC - scalier, grow radipidly, tender
lack pearliness/teleangietatic features
areas of sun damage but cna co=exist with BCC
lots in immunosuppressed
Higher tendency to metastasize
369
Q

Manage impending respiratory failure in patient with asthma with intubation

A

Life threatening asthma exacerbation despite aggressive B2 agonist (16 puffs) - pulse 132, RR 32, accessory muscle use - only speak 1 word at a time, reduced breath sounds
Intubate to avoid respiratory arrest

Continuous nebs only with MODERATE broncospam
Not just IV steroids - will take 4-6 hours to fully work- still need intubation

Don’t use lorezepam - will likely exacerbate respiratory acidosis

370
Q

Treat PFO

A 
Platypnea-orthodeoxia - positional sx cyanosis/dypnea when patient sitting up - resolve when sitting down
Sitting up changes shunt to R->L when sitting up 2/2 deformation of atrial septum and redirection of shunt - all 2/2 pneumonectomy
CLOSE PFO (is an indication)

Ambulatory O2 may relieve sx but won’t fix problem
Warfarin not indicated as pt has not has paradox embolism (even if he did -> ASA then PFO closure if recurs)

No diuresis as no signs of volume overload

371
Q

Capgrass syndrome - delusional thinking as primary sx of dementia

A

Capgrass syndrome - bleieves daughter is imposter replaced by imposter, delusions fixed, false ideas, paranoid aspect, delusional misidentifiaction, believe home is not really his house
Right hemisphere lesion = role in recognition and emotioinal familiarity
Can also occur in alzhimers with diffuse neurogeneration
Tx: antipsychotics (reassuance wont work)

Anosognosia - hemiplegia or vision
Confabulation - disortorded or invented statements WITHOUT intent to deceive (brain fills in detials at random) - retrograde amnesia
Etio - etoh induced korsakoff

Reproductive paramnesia - opposite of capgrass - delusion of familiarity in which pt in hospital bed insists they are at home

372
Q

Evaluate patient with osteomyeltis and contraindication to MRI

A

USE CT SCAN if +ICD (MRI would be ideal) when xray normal but still suspicious of OM
local pain/fever, h/o trauma

If xray neg and still suspicious -> MRI or CT

Nuclear imaging ok but can have false + from bone healing, inflammation from non-infx cuases ie trauma, neoplasm, deg bone dz,

Gallium scans stick to neurtrophils and goto site of inflammation or infection

Three phase bone scan not as good as MRI or CT

373
Q

Primary ovarian insufficiency

A

Must exclude turner syndrome - pt has elevated FSH and no period
Check karyotype
if + r/o AV dz, aoritic dilation, coarct, renal malformation(horseshoe kidney), autoimmune d/o, thyroid dz,
Short stature, stocky build, square chest, webbed neck

Pelvic US not needed yet - elevated FSH indicates low estradiol prodxn from ovaries

No progesterone challenge - only when ammenorrhea in normal estrogen state (pt is low estrogen)

Don’t need to measure estadiol as elevated FSH already shows that pt is low estrogen state

374
Q

Avoid NSAIDS with CV toxicity in pt with OA

A

1st line is tylenol
2nd line tramadol - low addictive poteintial opiate and does not cuase constipation

don’t use COX-2 - inc’d CV risk (pt already has PAD)

Don’t use indomethacin - HTN/kidney dz induction - r/o CVD

Don’t use oral prendisone (inejctions ok for temporary releif)

No colchisine (potent anti inflamm for gout or fam med fever)

375
Q

Decompensated cirrhosis

A 
Refer for liver tx if:
acute liver failure
hepatic decompensation due to chronic liver dz
primary liver cA
inborn errors of metabolism
HCV, cirrhosis from NASH, etoh liver dz

If patient has manifestation of etoh liver cirrohosi (ascietes, encephaloptahy, gastroesophagela variceal hemorrhage )-> refer for liver tx - 50% 2 year mortality
abstain from etoh x 2 years

Nonselective BB (propranol, nadolol) for medium or large varicies - DO NOT NEED IF NO VARICES

Protein restriction only if encephalopathy not managed with lactulose alone

376
Q

Older patient with cobalamin (vit B12) def

A

Vit B12/cobalamin def = elevated homocystine AND MMA
oval macrocytes, basophilic stippling, hypersegmented neutrophils (>5 lobes), elev LDH, bili, megaloblastic anemia, loss of vibratory sense, parastheisia, loss of position sense, wk spasiticity, paraplegia, bladder incontinence,
MCC - malabsorbtpion
Best way to supplement = oral (less expensive and easier that shots)

Folate def = elevated HOMOcystine ONLY
same peripheral smear as B12 def
No neurologic findings
If deficient replace ORALLY

377
Q

Hypopituitarism aw Sheehan syndrome

A

Adrenal insufficiency
Immediate hydrocortisone replacement
low morning cortisol
Sheehan syndrome - pitutary infarct/hemorrhage in setting of complicated delivery with significant blood loss and hypotension
Will need brain imaging to r/o sellar mass (though no prior sx suggestive of pre-exisiting pitutiary lesion)
Subacute progressive hypopituitarism - inability to lactate 2/2 prolactin def, ammenorrhea

DI rare in sheehan syndrome so argine vasopressin (ADH) replacement not needed

Hyponatremia should correct with replacement of pituitary hormones - don’t neeed hypertonic saline

No need for synthroid unless free thyroxine low (not urgent as no signs of hypothyroid

378
Q

Reduce risk of lung cancer with smoking cessation

A

risk down by 1/2 with quitting smoking compleletly

No mortality benefit in CXR surveillence

No decrease in mortality with B carotein suppleemtation

Isotreetioin supp does not decrease mortality in smokers

379
Q

Treat erythema nodosum aw UC

A

Intensify therapy for UC to treat erythema nodosum
follicular non-infectious panniculitis of SQ tissue
one or more tender, erythematous nodules on anterior shin easily palpated and visualized
Prodrome of fever, malaise, arthralgia
Lot of cases are idiopathic
others: infectious, drugs, systemic dz (inflamm d/o UC, sarcoid)
Self limited with tx of underlying d/o
Recurrent may require corticosteroids or immunosupp’s

Don’t tx EN with abx unless underlying cuase is infectious

NSAIDs only if idiopathic - don’t use NSAIDS with inflamm bowel dz - can exacerbate and cause flare

No role for TOPICAL steroids - doens’t treat underlying cause

380
Q

Manage tick borne ricksettial infxn

A

Start empiric doxycycline now
serologic testing for any tick borne ricksettial infxn often neg in acute phase - high suspeicion with multiple tick bites requires tx - inc’d morbiidity if wait

Human granulocytic Analplasmosis - few get rash
Human monocytic erylichosis - few get rash
Rocky Mtn spotted fever - has rash (blanching erythematous macules start at wrist and ankles, spread centripetally and becaome petechial)
Initiate tx empirically as 2/3 won’t get rash (HME, HGA)
All non-focal febrile illenss with cytopneia and elev LFTs

Tick vector for HGA is same as one for lyme dz - in NE US/great lakes , tick vector for HME in south central US, RMSF througout US (continental)

Amoxicillin doesn’t treat these tick dz’s

381
Q

Diagnose resistant HTN

A

blood pressure above goal with 3 classes of anti HTN meds including diuretic
Need to document real resistent HTN with ambulatory BP monitoring
(older age, high BMI, high baseline BP, DM, blacks)
If still high then search for secondary cuases, - salt intake,, use o fNSAIDs, OSA

No TTE needed for HTN w/u

Onlly add another med if resistant HTN confirmed with montioring

Only look for secondary caues (r/o pheo) if resistent HTN confirmed

382
Q

Chronic paroxysmal hemicrania

A

trigeminal nerve related pain - ipsilateral automonic features, lacrimation, ptosis, injection, nasla congestion, rhinorrhea
Cluster h/a last 15-80 min, 1-8x/day
Chronic paroxymal hemicrania - 15 min 8-40x/day
tx: INDOMETHACIN

Carbamazepine - Trigeminal neuralgia - severe pain along distribution of Trigeminal nerve
Pain paroxymal, lasting seconds, volley/jabs of sharp pain
trigger zones around mouth/nostrills
2nd and 3rd branches of CN V no autonomic fts

Not prednisone - not giant cell arteritis given pattern and timing of pain and normal ESR

Topiramte for migrain ppx - no use in cluster/Chro Parox Hemicrainia

Verapamil - for cluster h/a not chronic paroxymal hemicrania

383
Q

Eisenmenger’s syndrome in adult

A

Eisengener’s - aw Down syndrome
EKG RAD with RAE
RVH with strain
CXR central pulm artery enlargement, reduced pulm vasc

Longstanding cardiac shunt with eventual reversal of shunt - Eisenmenger’s physiology - digital clubbing, cyanosis, RV hypertrophy, dec’d pulm vascularity

Downs - half have congential HDz - AV septal defect - develop pulm HTN, reversal of shunt -> eisenmengers

384
Q

Aortic Coarctation

A

HTN in upper extrem, systolic murmur or continuous murmur in left infraclavicular area, LE pulses reduced, radiofemoral pulse delay, LVH on EKG, CXR 3 sign - aortic narrowing with rib notching

385
Q

Ebstein anomaly

A 
RV enlargement, Tricusupid regurg
ASD or PFO - cyanosis
Tall peaked p waves (himalyan waves)
QRS prolonged, RBBB, pre-excitation 
CXR - RH enlargement, clear lungs
386
Q

Tetralogy of Fallot

A

cyanosis/clubbing

loud systolic murmur - severe RVOT obstruction

387
Q

Association of Herpses Simplex virus with erythema Multiforme

A

recurrent mucocutaneous eruption that follows acute infection
HSV infection
erythematous plaques with concentric rings of color - dusky center might become necrotic and can blister or eschar
Few to hundreds of lesions - extensor surfaces of extremiteis (hands/feet) -
Mucosal lesions - lips, gingival sulcus, sides of tongue
painful erosions or bullae
1-2 weeks - can have residual hyperpigmentation
Recurrences common
systemic corticosteroids can provide relief but
Abx only if identified bacterial cuase
If 2/2 new drug - d/c drug

EM not caused by staph but abx used to treat can cuase it

EM not caused by Parvo B19 ,or varicella zoster

388
Q

Prevent medication errors from occuring

A

Pt need specific instructions on increase in pre-hospital meds
Need to communicate with PCPs on changes
Need list of medication at d/c with med changes, discontinuation and addition

Diuretic resistance uncommon, highly unlikely as pt inc’d pre admission lasix and added spironolactone

Hosptial f/u for CHF exacerbation - 1 week

Spironolactone won’t cause CHF exacerbation (decreases mortality in patients with Systolic HF)

389
Q

Warm autoimmune hemolytic anemia

A

incidious sx of anemia, jaundice, splenomegaly, peripheral blood smear with spherocytes
(erythrocytes losing central pallor)
Strong + coombs for IgG, weak for C3

390
Q

COLD agglutin dz

A

Coombs test
IgG neg
+ complement - pathogenic IgM ab

391
Q

G6PD def

A

peripheral smear shows BITE CELLS
eccentrically located hemoglobin NO SPHEROCYTES
No + direct coombs

392
Q

Hereditary spherocytosis

A

fhx anemia, jaundice, splenomegaly, gallstones
Spherocytes on smear
NEGATIVE direct coombs
would always have abnormal CBC (spherocytes)

393
Q

TTP

A

microangiopathic hemolytic anemia
schistocytes on smear
inc’d LDH
thrombocytopenia

MKSAP (4 decks)

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