Emma Holliday Medicine Flashcards
Typical physical exam findings of Prinzmetal angina
CP worse at night or upon waking in middle aged F, also w/ migraines
-transient ST elevations during episodes
How to differentiate TTP from DIC
PT and PTT are normal in HUS/TTP (microangiopathic hemolytic anemias)
MC cause of death from endocarditis
CHF
-valve destruction => heart failure
Name some causes of DIC in addition to sepsis
- rhabdo
- heatstroke
- pancreatitis
- snake bites
- adnocarcinoma
- OB stuff (amniotic fluid embolism)
- Tx of AML (Auer rods!!)
Main side effects of CMV tx
(a) Ganciclovir
(b) Foscarnet
(a) Ganciclovir- neutropenia
(b) Foscarnet- renal tox
Hilar lymphadenopathy w/ elevated ACE
(a) Dx
(b) Skin finding
(c) Why hypercalcemic
(d) Important referral
(e) Dx
(f) Tx
(a) Sarcoidosis
(b) Erythema nodosum
(c) Macrophages in granulomas produce vitD like substance
(d) Optho- 25% chance of uveitis
(e) Dx by biopsy
(f) Tx = steroids
Type I RTA
(a) Problem
(b) Etiology
(c) K status
(d) Tx
Type I RTA = distal
(a) Kidneys cannot excrete H+
(b) Etiology = Lithium, amphotericin
(c) Hypokelamic serum
(d) Tx by repleting K+ and oral bicarb
2 branched microorganisms
a) Gram stain
(b) O2 use?
(c) Key clinical features
(d
Nocardia = branched, (a) gram positive, partially acid fast staining bacteria
(b) Aerobic => residse in lungs
(c) Cavitary lung disease (purulent sputum) in immunosuppressed pt w/ wt loss and fever
(d) Tx = Trim-Sulfa
Actinomyces = branched (a) G+ (b) Anaerobic
(c) Neck or face infection w/ draining yellow material
(d) High dose penicillin
Cardiac pt s/p ticlopidine (ADP receptor inhibitor) w/ renal failure, thrombocytopenia, fever and AMS
(a) Dx
(b) Tx
(a) TTP
b) Plasmapheresis- don’t give plts (they’ll just get consumed by whatever process is underlying
Who needs endocarditis ppx?
Ppx for endocarditis: prosthetic valve, history of endocarditis, any congenital lesion
Enveloped shaped crystals
Ethylene glycol intoxication (causes anion gap metabolic acidosis)
Tx w/ dialysis or NaHCO3 if PH under 7.2
Light’s criteria
If all 3 met then pulmonary effusion is transudative
- LDH under 200
- LDH effusion/serum under .6
- protein effusion/serum under .5
25 yo w/ acute onset sxs CHF
Consider myocarditis (coxsackie B?)
3 key causes of sickle cell crisis
Hypoxia, dehydration, acidosis
Tx for
(a) Hyponatremia
(b) Hypernatremia
(a) Fluid restriction, only 3% saline if Na under 120 or seizures
(b) Replace w/ water w/ D5W or other hypotonic fluid
Feurea cutoff for prerenal
FEurea under 35% = prerenal acute renal failure
-use instead of FENa for pts on diuretics
ECG findings of
(a) Hyperkalemia
(b) Hypokalemia
(a) Obv peaked T waves, but also
- prolonged PR
- short QT
- widened QRS
(b) Hypokalemia: ST depression and U waves
First line med for WPW
Procainamide
50 yo “meat-a-tarian” s/p 2 weeks of clinda p/w hemarthroses and oozing from venipuncture sites
Vit K deficiency
-clinda wiped out gut flora => no vit K produced
Complication of silicosis
(a) Tx
- increased risk to Tb => need annual Tb test
(a) Tx = INH for 9 mo
Define neutropenic fever
(a) MC cause
(b) First step
(c) Key contraindication
Neutropenic fever = single temp over 101.3 or sustained over 100.4 for 1 hour in pt w/ ANC under 500
(a) Mucositis causing bacteremia, usually from gut translocation
(b) Get BCx then start Cefipime or ceftazidime
(c) DONT do DRE- can translocate gut flora and induce bacteremia
Kidney stone in child w/ leukemia on chemo
Uric acid
-tumor lysis releases tons of urate
Pt w/ seizure w/ deja vu aura and meningitis sxs
Deja vu aura means the seizure started in the temporal lobe, so if +meningitis (w/ RBC in LP) = HSV encephalitis
Crohns vs. UC
(a) Terminal ileum
(b) Continuous involving rectum
(c) Associated w/ some biliary duct d/o
(d) Fistulae likely
(e) Granulomas on biopsy
(f) Higher risk of
(a) Terminal ileum = Crohn’s (can mimic appendicitis)
(b) Continuous involving rectum = UC
(c) UC associated w/ PSC (=> increased risk of cholangiocarcinoam)
(d) Fistula likely in Crohns (whenever have fistula, tx w/ metronidazole)
(e) Granulomas on biopsy Crohns
Antimitochondrial Ab vs. antismooth muscle Ab
(a) Tx difference
Antimitochondrial anitbody = PBC
(a) Won’t be helped by steroids
Antismooth muscle Ab = autoimmune hepatitis
(a) Tx w/ steroids
Crohns vs. UC
(a) Transmural inflammation
(b) Cured w/ colectomy
(c) Lower risk in smokers
(d) Higher risk of colon cancer
(e) Associated w/ p-ANCA
(a) Transmural inflammation in Crohns
(b) UC cured w/ colectomy
(c) Smoking decreases risk of UC, smokers have higher risk for Crohns
(d) Higher risk of colon CA in UC (another reason for colectomy, to prevent the cancer)
(e) UC associated w/ p-ANCA
Post-exposure ppx for HIV
Stuck w/ HIV needle: triple drug (not one or two…three drugs) therapy for 4 weeks
ex: AZT, lamivudine, nelfinavir
Lung cancer causing the following paraneoplastic syndromes
(a) Kidney stones
(b) Ptosis that improves w/ 1min of upward gaze
(c) Euvolemic hyponatremia
(a) Squamous cell carcinoma produces PTHrP
(b) Small cell carcinoma => Ab to pre-synaptic Ca (Lambert-Eaton)
(c) SIADH from small cell
2 clotting factors not depleted in severe cirrhosis
factor VIII and vWF b/c made by endothelial cells
MC cause of meningitis in HIV pt
Still Strep pneumo
HIV pt on HAART p/w macrocytic anemia
Zidovudine (AZT) causes leukopenia and macrocytic anemia
Pneumonia
(a) Old smokers w/ COPD
(b) Alcoholic w/ current jelly sputum
(c) Old M w/ HA, altered mental status, diarrhea
(d) Just had the flu
(e) Farmer w/ vom/diarrhea
(f) Just skinned a rabbit
(a) H. influenza, tx w/ 2-3rd gen ceph
(b) Current jelly sputum = Klebsiella
(c) Legionella
(d) After the flu- c/f staph
(e) Coxiella burnetti (Q fever)
(f) Tulleremia
2 dx: CXR w/ thickened peritracheal stripe and splayed carina bifurcation
- LA enlargement (2/2 bad mitral stenosis)
- Mediastinal lymphadenopathy (2/2 cancer)
ECG finding associated w/ bad pulmonary disease
MAT (multifocal atrial tachycardia)
Gram positive bacteria that is partially acid fast staining
Nocardia
Meningitis
(a) 3 most common
(b) Old and young, add what to tx
(c) In ppl w/ brain surger
(a) H. flu, N. meningitides, strep pneumo
(b) add ampicillin for listeria coverage in old and young
(c) Worry about staph aureus in those w/ recent instrumentation- tx w/ Vanc
Causes of metabolic acidosis
Anion gap = MUDPILES
Nonanion gap = diarrhea, diuretics, RTA (I, II, IV)
Contrast induced nephropathy timeline
48-72 hrs
Tx for RV infarct
NO NITROOOO- will drop preload and can put pt into cardiogenic shock
Instead need aggressive fluid resuscitation
First test if suspecting rhabdo
(a) Tx for rhabdo
EKG and serum K+
(a) Tx for rhabdo: bicarb to alkalinize urine to prevent precipitation
Obstructive vs Restrictive lung disease
(a) Asthma
(b) Obesity
(c) emphysema
(d) sarcoidosis
(a,c) Asthma, emphysema, COPD = obstructive
(b,d) Obesity, sarcoid/asbestosis/silicosis, scoliosis = restrictive
Most concerning cause of meningitis in HIV+ pt
(a) Stain for diagnosis
(b) Tx
Cryptococcus neoformans (fungi)
(a) India ink stain- black background, organisms light up, stains the gelatinous capsule
(b) Amphotericin IV for 2 weeks, then fluconazole maintenance
Side effects of Tb drugs
(a) Rifampin
(b) INH
(a) Rifampin: orange/red body fluids, cyt p450 inducer
(b) Hepatitis, neuropathy (so give B6 w/ it) and sideroblastic anemia
Proteinuria
(a) MC cause in adults
(b) Heroin use and HIV
(c) Chronic hepatitis and low complement
Proteinuria
(a) Membranous (thick capillary walls w/ subepithelial spikes)
(b) Mesangial IgM deposits = focal-segmental glomerulonephritis
(c) Membranoproliferative (tram-track basement membrane w/ subendothelial deposits)
Concern if nephrotic pt suddenly develops flank pain
Suspect renal vein thrombosis
-peeing out ATIII (antithrombotic protein), protein C and S => do CT or U/S stat
What size kidney stones get lithotropsy
5mm - 2cm
under 5mm just gotta pass it, just hydrate them
stones over 2cm get endoscopic surgical removal
Kid eats a hamburger then has diarrhea w/ renal failure, microangiopathic hemolytic anemia, and petechiae
(a) Tx
Dx = HUS = hemolytic uremic syndrome
-E. coli or shigella
(a) Tx w/ just support- NO ABX will just release more toxin
Cold agglutinin
(a) Ab
(b) Location of destruction
(c) Association
Cold agglutinin
a) IgM
(b) Destruction in the liver
(c) Mycoplasma (walking PNA
Elevated alk phos, normal GGT, normal Ca
Paget’s disease
-associated hearing loss (b/c of ossicle damage)
Pulm disease
(a) Eggshell calcification nodule in upper lobe
(b) Patchy lower lobe infiltrate, Culture thermophilic actinomyces
(a) Silicosis
(b) Hypersensitivity pneumonitis = farmer’s lung
3 diagnostic criteria of ARDS
ARDS (sepsis 2/2 LPS, pancreatitis, trauma)
- Radiologic evidence: b/l alveolar infiltrates on CXR
- PaO2/FiO2 under 200 (if under 300 = acute lung injury)
- PCWP under 18 (aka r/o cardiac cause of pulmonary edema)
Features of large cell lung cancer
(a) Location
(b) CXR finding
(c) Prognosis
Large cell
a) Peripheral
(b) Peripheral cavitation (likely to cavitate
(c) CT w/ distant mets- poor prognosis
Sxs of ventricular wall aneurysm after MI
Persistent ST elevations for a month w/ systolic MR murmur
Differentiate murmur heard w/ HOCM and MVP
Both HOCM and MVP give systolic murmur and are louder w/ valsalva (decreases preload)
- while AS gets softer w/ valsalva
- HOCM: softer w/ squatting and handgrip
- MVP louder w/ handgrip (increased afterload), softer w/ squatting (increased preload), also MVP w/ late systolic click
Microcytic anemia: differentiate labs for anemia of chronic disease vs. sideroblastic
Anemia of chronic disease: low Fe and TIBC, low retic, normal ferritin (normal stores)
Sideroblastic: high iron, high ferritin, low TIBC
So diff is the iron level- sideroblastic you’re not making protoporphyrin so iron builds up in blood
HIV pt w/ hemisensory loss, visual impairment, pos Babinski
(a) Dx
Presents like MS- but in HIV pt = PML = JC polyomavirus = demyelinating at gray-white junction
(a) Dx gold standard = brain biopsy
Polyarteritis nodosa
(a) MC organs involved
(b) Lab abnormality
(c) Tx
Polyarteritis nodosa
(a) everywhere EXCEPT lung
(b) Associated w/ hep B
(c) Cyclophosphamide
Hereditary spherocytosis
(a) mutation
(b) Tx
(c) Clinicaly presentation
(a) Autosomal dom mutation in spectrin
(b) Treat w/ splenectomy
(c) Splenomegaly, family hx, bilirubin gallstones, elevated MCHC
- high LDH/indirect bili and low haptoglobin b/c hemolytic
When to use hypertonic saline in the tx of hyponatremia
Only if Na is under 120 or pt has seizures
Type II RTA
(a) Problem
(b) Etiology
(c) K status
(d) Tx
Type II RTA = proximal
(a) PCT cant reabsorb bicarb
(b) Etiology = Fanconi anemia
(c) Hypokalemic
(d) Replete K+
- oral bicarb doesn’t help here
Best prognostic indicator for COPD
(a) Only 2 ways to improve survival
(b) Goal O2 sats
FEV1 = best prognostic indicator for COPD pts
(a) Stop smoking, constant (over 18 hrs/day) of O2 therapy
(b) Goal O2 sat 92-94% b/c these chronic CO2 retainers need hypoxia to maintain respiratory drive
Side effects of zidovudine (AZT)
AZT = NRTI (nucleoside reverse transcriptase inhibitor):
- GI
- leukopenia
- macrocytic anemia**
Cause of megaloblastic anemia that is not folate/B12 deficiency
(a) Finding on peripheral smear
Severe liver disease (ex: cirrhosis)
a) Acanthocytes (spikey RBCs
Tick bite w/o rash
(a) Other symptoms
(b) Tx
Tick bite w/o rash- think Ehrlichiosis
(a) Tick bite w/ no rash, +myalgia, fever, headache (flu like symptoms). Also hematologic (low plts and WBC) and elevated ALT
(b) Doxy
- tick bite? tx w/ doxy
Cuttoff values for positive PPD
- normal: 15mm
- prison, healthcare, nursing home, DM, EtOH, chronically ill: 10mm
- AIDS or immunosuppressed: 5mm
Test to differentiate CHF from pulm HTN
R. heart catch, CHF will have high PCWP while PCWP (surrogate for LA pressure) is normal in pulmonary HTN
Asbestosis
(a) CXR finding
(b) MC cancer
(c) Increased risk for what cancer
Asbestosis
(a) Reticulonodular process in lower lobes w/ pleural plaques
(b) MC bronchogenic carcinoma
(b) Increased risk mesothelioma
Hematuria + deafness
= Alports- X-linked recessive mutation in collagen IV
MC cancer in non smokers
(a) Location
(b) Mets
(c) Characteristic effusion
MC nonsmokers: adenocarcinoma (can occur in scars of old PNA
(a) Peripheral
(b) Liver, bone, brain, adrenals
(c) Exudative w/ high hyalurinidase
Kidney stone in pt s/p bowel resection for volvulus
Pure oxylate stone
-Ca is not reabsorbed by the gut
Rash on wrists/ankles/palms/soles w/ fever and headache
(a) Tx
(b) Tx in kids
Rickettsia- rocky mtn spotted fever
(a) Doxy
(b) Doxy anyway! can’t use amox (like can in Lymes) so use doxy anyway
Clinical signs of RV infarct
Hypotension, tachycardic, JVD w/ clear lungs (so not CHF), no pulsus paradoxus
Clinical features suspicious for squamous cell carcinoma
Squamous cell carcinoma (central)
-kidney stones, constipation, malaise (bones, groans,…) and low PTH b/c of paraneoplastic from PTHrP release
Side effects of Tb drugs
(a) Pyrazinamide
(b) Ethambutol
(a) Pyrazinamide = benign hyperuricemia
(b) Ethambutol = optic neuritis, other color vision abnormalities
Which type of renal tubular acidosis:
(a) Hyperkalemia
(b) Improves w/ oral bicarb repletion
RTA
(a) Type IV = hyperkalemic (b/c hypo-aldo)
(b) Type I improves w/ oral bicarb b/c the problem is that kidneys can’t excrete H+
Indications for CABG over PCI
CABG over stent if
- L. main disease
- 3 vessel disease, or 2 vessel disease in diabetic
- over 70% stenosis despite optimal medical management
Kidney stone in pt w/ chronic indwelling foley and alkaline pee
Struvite stone (Mg/Al/PO4) from urease positive organism = proteus, staph, pseudomonas, klebisella
PCP pneumonia
(a) Serum abnormality
(b) 1st line tx
(c) 2nd line tx
(a) Elevated LDH
(b) Trim-sulfa
(c) Sulfa allergy? Trim-dapsone or primaquine-clinda, or pentamidine
- Add steroids if PaO2 under 70
Type IV RTA
(a) Problem
(b) Etiology
(c) K status
(d) Tx
Type IV RTA
a) Hyperrenin hypoaldo
(b) Diabetes
(c) Hyperkalemia (b/c hypoaldo
(d) Replete mineralocorticoid
Murmur worse w/ inspiration
Right sided murmurs are always worse w/ inspiration
HIV+ pt w/ ring enhancing lesion(s) on CT head
Start pyramethamine sulfadiazine (+folic acid) for 6 weeks
- if improves = Toxo
- if doesn’t improve = think CNS lymphoma
5-7 days post-MI, new systolic murmur
Regurg from papillary muscle rupture
Pt w/ lung tumor and
(a) Ptosis, constricted pupil, facial edema
(b) Ptosis that improves after 1 min upward gaze
(a) Pancoast tumor = superior sulcus tumor, from small cell tumor
(b) Lambert Eaton syndrome (also from small cell)
- Ab to pre-synpatic calcium channel
HIV pt w/ diarrhea- what tests? Top 3 dx?
HIV pt w/ diarrhea
(a) CMV colitis- can see on colonoscopy/biopsy
(b) Watery diarrhea w/ mucus, oocysts are acid fast positive = Cryptosporidium
(c) Night sweats, wasting, fevers, dx of exclusion = MAC
Crohns vs. UC
(a) Painful lesions on shins
(b) String sign on barium study
(c) Pyoderma gangrenosum
(a) Erythema nodosum- UC and sarcoid
(b) String sign- Crohns
(c) Pyoderma gangrenosum- UC, inflammation tissue and WBCs (not infectious)
ASD murmur
Wide fixed and split S2
Physical exam finding of AV dissociation
3rd degree AV block => cannon A waves
-neck waves: atrial blood hitting closed tricuspid valve b/c atria and ventricles are totally out of sync
Causes of metabolic alkalosis w/
(a) High urine chloride
(b) Low urine chloride
Metabolic alkalosis (high HCO3 and high pCO2)
(a) Urine [Cl] over 20 and hypertension = Hyperaldo (Conns). W/o HTN think Barter/Gittlemans (congenital inability to reabsorb Na)
(b) Low urine Cl = vomiting/overaggressive NG suction, antacids, diuretics
Valve abnormality that widens pulse pressure
Aortic insufficiency
After exposure to Tb who gets ppx?
Most don’t!!! Only kiddos under 4 who are exposed to Tb get ppx
Ppx = INH for 9 mo
Indications to start supplemental O2 in COPD pt
- PaO2 under 55 (or under 59 if core pulmonale)
2. Sats under 88%
New onset clubbing in COPD pt
Get CXR for cancer
Rate of correcting sodium abnormalities
Don-t correct faster than 12-24 mEq/day (.5-1 mEq/hr) in either direction or else
- central pontinue myelinolysis if correct hyponatremia too quickly
- cerebral edema if correct hypernatremia too quickly
When to start HAART
Start HAART when CD4 under 350 or viral load over 55,000
CXR characteristics of benign pulmonary nodules
- popcorn calcification = hamartoma
- concentric calcification = old granuloma
- well circumscribed
Concerning findings
- eccentric calcification
- over 3cm
Pleural effusion buzzwords
(a) High LDH
(b) Low glucose w/ negative gram stain
(c) High lymphocytes
(d) Bloody
(a) High LDH (exudative) = bacterial pneumonia or malignancy
(b) Low glucose not infectious consider rheumatoid arthritis (high inflammatory cells use up tons of glucose)
(c) High lymphs = Tb
(d) Bloody = PE or cancer
Mycoplasma pneumonia
(a) Associated hematologic d/o
(b) First line tx
(a) Cold agglutinin
b) Macrolide (azithromycin
Define nephritic syndrome
Proteinuria but not nephrotic range (under 2g over 24 hrs)
Hematuria
Edema
Azotemia
Change in meds if get stent
Already on ASA, if stented give clopidogrel for 9-12 mo
Kidney stones
(a) Best test
(b) MC type
(a) CT
(b) Calcium oxalate
Churg Strauss
(a) MC organs involved
(b) Lab abnormality
(c) Tx
Churg Strauss = p-ANCA vasculitis
a) Renal failure, asthma (upp resp tract
(b) eosinophilia
(c) Cyclophosphamide
Warm agglutinin
(a) Ab
(b) Location of destruction
(c) Association
Warm agglutinin
(a) IgG
(b) Destruction in spleen
(c) Associated w/ drug rxn (PCN, ceph, sulfa, rifampin) or cancer
Etiologies of Torsades
- Electrolyte abnormalities: hypoK, hypomag
- Drugs: lithium, TCA
