General Flashcards
Treatment of Hepatorenal syndrome
First give volume to make sure not intravascular depletion. once confirmed, Midodrine and Octreotide
BM Biopsy findings in multiple myeloma
> 10% monoclonal plasma cells
T/F: Technetium-99m bone scans are used in patients with multiple myeloma
False, these are good for blastic lesions not lytic. Need a xray skeletal survey
Tx of hypercalcemia in MM
Hydration and dexamethasone; if severe, bisphosphonates
Hyperviscosity syndrome
MM patients p/w blurry vision, headache/confusion (neuro), nasal/oral bleeding, heart failure. Tx with plasmapharesis
Reversal of coumadin in patient with life-threatening hemorrhage
Need Prothrombin complex concentrate. This is a must, works in <10 minutes. need the vitamin k alongside but this takes 12-24 hours to work. Use FFP when PCC not available
lab test in smoker with polycythemia
carxboxyhemoglobin ; r/o carbon monoxide poisoning
____ can be used to follow SLE disease activity and predict lupus nephritis
anti-dsDNA
tx for Rayanuds
CCB - nifedipine or amlodipine
tx of gout in patients with renal failure or renal transplant
avoid nsaids because of renal flow; use intraarticular glucocorticoids
Next step when you suspect Ankylosing Spondylitis (progressive back pain which improves with exercise, limited chest expansion, reduced forward flexion lumbar spine)
Xray of SI joint - can’t make a dx of AS without sacroilitis . While HLA-B27 is frequently positive, its not specific
extraarticular manifestations of ankylosing spondylitis
acute anterior uveitis, aortic regurgitation, apical pulmonary fibrosis, IgA nephropathy, and restrictive lung disease
who needs a tetanus toxoid vaccine after cut?
last tetanus vaccine > 10ya (>5 for dirty/severe wound) or who have unimmunized, uncertain or incomplete vaccination status (<3 doses)
who needs tetanus immunoglobulin in addition to tetanus toxoid vaccine after cut?
IG if dirty severe wound + immunocompromised, uncertain or incomplete tetanus vacicnation status (<3 doses)
most common reaction to transfusion
febrile nonhemolytic reaction - 1-6 hours post - fevers/chills/malaise without hemolysis. prevent with leukoreduction
dermatomyositis is often associated with
malignancy. all patients with new dx need cancer screening
neck mass in Sjogren’s patient
B cell non-Hodgkin’s lymphoma
scoliosis eval: significant angle of rotation and cobb angle
- angle of rotation (exam): >7 degrees = xray spine
- cobb angle (xray) <10 degrees is normal, f/u prn. >40 = surgical eval. in between, back brace/observation
side effects of Methotrexate
-hepatotoxicity
-stomatitis
-cytopenia
supplement with folate
what to check before starting TNF inhibitor (etanercept, infliximab)?
IFN gamma assay or TB skin test to screen for latent Tb
BP mgmt in gout patients
Use ACE-I or ARB as they can lower uric acid Avoid diuretics (HCTZ, lasix) and asa (all decrease uric acid excretion)
Treatment of choice for polymyalgia rheumatica
low dose prednisone. nsaids not v effective here
T/F: PMR has normal inflammatory markers
False, elevated ESR and CRP typically
scleroderma is an abnormal deposition of ________ in multiple organ systems
collagen
why do you need to monitor BP in patients with Raynauds?
Scleroderma renal crisis - can present with malignant hypertension. most scleroderma patients have some renal involvement. Tx with ACE-i
Spinal stenosis vs radiculopathy: pain decreases with flexion of spine and increases with extension
this is spinal stenosis. in contrast to radiculopathy.
post injury, pain out of proportion, temperature change, edema, abnormal skin color
Complex Regional Pain Syndrome. Dx by MRI or autonomic testing with increased resting sweat output; tx nerve block or iv anesthesia
c-peptide if excess insulin injection
low! C-peptide is from endogenous insulin…if abuse suspected and high c-peptide, oral hypoglycemic agents
thyroid nodule, when do you need iodine 123 scintography?
when low TSH –> hyperfunctioning nodule. will tell you hot or cold nodule
hot vs cold nodule thyroid
hot = hyperfunctional –> rarely malignant so just tx hyperthyroidism
cold = hypofunctional –>need FNA to eval malignancy
initial staging for differentiated thyroid cancer i.e. papillary or follicular
need US of neck and cervical LN before any surgery
MEN 1: 3 P’s
Pituitary adenoma (prolactinoma) Primary hyperparathyroidism (hypercalcemia, PT adenoma) Pancreatic/GI neuroendocrine tumors (gastinoma i.e. recurrent peptic ulcers)
MEN 2
Medullary thyroid cancer Pheochromocytoma ---------------------------- Men2A: + primary hyperparathyroidism Men 2B: +mucosal neuromas/marfanoid
How can 11 and 17 hydroxlase def be distinguished from 21?
11 and 17 have hypertension
Patients with Graves hyperthyroidism should be started on what alongside antithyroid drugs (PTU, methimazole)
a beta blocker to reduce hyperthyroid sxs, i.e. propranolol
Lab findings of adrenal insufficiency
hyponatremia, hyperkalemia, hyperchloremic metabolic acidosis.
vs hypoaldosteronism = asx hyperkalemia with mild metabolic acidosis, no hyponatremia.
how do you dx Addison’s dz
Primary adrenal insuff.
Low morning cortisol, high ACTH (ACTH stim test)
PTH affect on vit d
Stimulates conversion from 25-hydroxyvitd to 1,25 - dihydroxyvitamind in the kidneys
how does sarcoidosis affect calcium?
granulomatous disorders cause hypercalcemia d/t extra-renal production of 1,25 - hydroxyvitd
antithyroid peroxidase antibodies
Hashimoto’s (risk for thyroid lymphoma)
side effects to monitor of valproic acid
hepatoxicity
thrombocytopenia
T/F: ACE levels used to dx sarcoid
False; need bx showing noncaseating granuloma
first line pharm tx for cognitive impairment of dementia
acetylcholinesterase inhibitors = Rivastigmine/Donezapil/Galantamine. can also use memantine (NMDA receptor antagonist)
T/F: Can confirm suspected pulmonary TB with IFN gamma or skin test
false; those can’t differentiate latent vs active dz; need sputum acid-fast smear, mycobacterial cx, NAAT
tx for close contacts of neisseria meningitis
Rifampin, Ciproflaxocin or Ceftriaxone
polyarthralgias, rash, fever within 1-2 weeks of exposure to a responsible agent and stop when removed
serum sickness
which infection as a serum sickness like prodrome? define sxs
Hepatitis B. Rash, fever and polyarthralgia.
how is malaria dx?
peripheral smear
fever, headache and thrombocytopenia in a traveler
consider malaria
fever in a returning traveler <10 days
Typhoid fever, Dengue fever, Chikugunya, influenza, legionellosis
fever in a returning traveler 1-2 weeks
Malaria, Typhoid fever, schisto, ricketssial
fever a returning traveler > 3 weeks
TB, leishmann, enteric parasites
stepwise fever, rose spots, relative bradycardia in returning traveler
typhoid fever
Tx of fulminant C dif (shocky)
IV Flagyl + high dose vanco PO
Tx of recurrent C dif
- prolonged PO vanc course
- fidaxomicin
- Vanc PO followed by Rifaximin
tx for cryptococcal meningitis (HIV)
initial: Amphotericin B + Flucytosine for 2 weeks til CSF sterilized
: Transition to PO Fluconazole for 8 weeks
Maintenance: lower dose Fluconazole for 1 year to prevent recurrence
sxs of dengue fever
flulike febrile illness + joint pains and myalgia (BREAK-BONE FEVER), orbital pain. thrombocytopenia, spontaneous bleeding, vascular permeability. resp, circ failure
travel diarrhea + pseudoappendicitis
campylobacter jejuni
travel diarrhea > 2 weeks
Cryptosporidium (immunosuppressed), cyclospora, giardia (common in boonies)
HIV PeP
2 NNRTIs (Tenofovir, Emtricitabine, Lamivudine, Zidovudine) \+ Integrate-i (raltegravir), PI (Ritonavir), non-nrti (rilpivirine)
triad for pulm aspergillus
hemoptysis, cough, pleuritic CP . serum markers galactomannan, beta d glucan. tx voriconazoleMOST
Most common side effect of isoniazid
hepatotoxicity
why do you give vitamin b6 (pyridoxine) with isoniazid?
prevent neurotoxicity (ataxia, neuropathy, weakness)
DKA patient with periorbital swelling, black eschar/necrotic nasal turbinate, headache, nasal congestion
Mucormycosis. Need liposomal Amphotericin B + surgical debridement
LV apical thrombus in south american
Chagas disease (protozoan)
treatment of lyme in patients <8 years, pregnant/lactating women,
Amoxicillin (doxy causes teeth discoloration and skeletal deformities)
nec fas
strep pyo
then staph aureus, c. perf (crepitus if gas producer)`
chronic bacterial prostatitis and tx
> 3 months UTI, pain in genitourinary, pain with ejaculation. 6 wk cipro or bactrim
3 criteria for acute liver failure
hepatic injury (LFTs), encephalopathy, INR>1.5
treatment of lyme in patients <8 years, pregnant/lactating women,
Amoxicillin (doxy causes teeth discoloration and skeletal deformities)
thyroid stimulating immunoglobulin
cause Graves dz
thyroid nodule with normal tsh next step
straight to FNA to r/o malignancy despite sxs
tx of hyperthyroidism
Graves: Methimazole > PTU (except pregnancy trimester uno); radioiodine ablation (I-131)
Toxic multinodular: I-131 radioiodine ablation only
most common cause of hypothyroidism
Hashimoto (anti-TPO)
when do you do I-123 scan?
if TSH is suppressed, to evaluate for a hot nodule
thyroid nodule with normal tsh next step
straight to FNA to r/o malignancy despite sxs
thyroid nodule with low/no tsh
I-123 scan. Hot nodule: meds. Cold nodule: FNA
thyroid nodule with high tsh
normalize tsh with thyroxine; if nodule still palpable, get FNA
first line treatment for toxic megacolon?
Steroids (medical management)! not surgery.
management of esophageal variceal bleed
IV Octreotide + EGD (dx and tx)
dx of chronic pancreatitis
usually on MRCP (pancreatic calcifications); labs are not typically elevated
gallbladder wall calcifications on imaging
bad…porcelain gallbladder. increased risk for cancer, needs a chole
treatment of intussusception for kids
air or water soluble (NOT barium b/c risk peritonitis with perf) enema
tx of dematitis herpeteformis (celiac)
Dapsone + gluten-free diet
management of patient with diverticular bleeding
IV fluids +/- transfusion. Patients should get a colonoscopy for tamponade or cauterization, could also do angiography with embolization
Heyde’s syndrome
Angiodysplasia + aortic stenosis
risk factors for angiodysplasia (common cause of hematochezia)
ESRD, Aortic stenosis, vWD
dilation of submucosal venous plexus
hemorrhoids
eroded small artery of the colon
diverticular bleed
early complication of acute pancreatitis with fever, leukocytosis and recurrence of abdominal pain
pancreatic necrosis or peripancreatic fluid collection –>get a repeat CT
abdominal pain + fat malabsoption
chronic pancreatitis (dx MRCP, or CT)
metaplastic columnar epithelialization of esophagus
barret’s esophagus
triple therapy if penicillin allergy
PPI + clarithromycin + metronidazole (instead of typical amoxicillin)
chronic malabsorption + iron deficiency anemia. diarrhea not noted to be associated with specific foods
Celiac disease
what should you monitor in celiac patients
iron/hgb, folate, calcium, vitamins (A, E, D, B12). Dexa to eval bone loss (vit d def) and receive pneumococcal vaccine (hyposplenism)
cancer in upper esophagus vs lower esophagus
upper: SCC, tobacco and EtOH
lower: adenioCA, barretts and gerd
dyspepsia age cutoff
<60: test and tx H pylori
>60: EGD
when do you start colonoscopy for patients with first degree relative?
10 years before OR age 40 whichever comes first
if 1st degree was >60 just start at 50
which age group do you worry about angiodysplasia and ischemic colitis?
> 60
50% of patients with anal abscess will develop
fistula
90-day mortality in patients with advanced liver disease
MELD score: Na, Cr, Bilirubin, INR
tx hepatic hydrothorax
sodium restriction and diuretics; TIPS if refractory
mgmt of delivery with HIV mom
viral load <1000: ART + vaginal delivery
>1000: ART + zidovudine + c-section
dx/tx of latent tb
positive testing, neg cxr and neg sxs
9 months isoniazid (if allergic, rifampin)
abdominal pain, fecal urgency, bloody diarrhea
colonic ischemia
thyroid cancer with elevated calcitonin levels
Medullary thyroid cancer (MEN)
first line therapy for persistent cluster headaches vs acure
Verapamil; 100% oxygen
treatment of catatonia
benzos, ECT
tx antipsychotic EPS: Acute dystonia
benztropine or benadryl
but NOT a benzo
EPS: how do you treat anti-psychotic induced akathisia (restlessness, anxiety type)
try reducing the dose
use a beta blocker
tx antipsychotic EPS: Parkinsonism
Benztropine
amantadine
triad for fat embolism
neuro sxs (confusion), petechial rash, hypoxemia (normal cxr usually). vs pulmonary contusion after injury will be some irregular opacification and can be 24 hours later
why don’t you use St John’s wort along with SSRI’s to treat depression?
risk of serotonin syndrome. also other drug interactions: induces p450
what to screen for when starting varenicycline for smoking cessation?
neuropsychiatric history
asthma PFT
no exacerbation: normal PFT, admin of methacholine reduced FEV1 >20%. negative methacholine challenge is reliable in ruling out dx.
active sxs: obstructive PFT; albuterol gives >15% improvement in FEV1
how do you treat anti-psychotic induced akathisia (restlessness, anxiety type)
try reducing the dose
use a beta blocker
when do you need to taper steroids?
when used for > 3 weeks (risk of adrenal insuff)
actinic keratosis is a pre-malignant skin condition (SCC) caused by
sun exposure (UV light). of note, BCC is also associated with sun exposure but not AK and also has low metastatic potential (usually fleshy appearance for bcc vs scaly/rough etc for AK)
when do you give antibiotics to patient with acute bronchitis?
COPD patient, with 2/3: increased sputum production, increased sputum purulence, increased dyspnea
asthma PFT
no exacerbation: normal PFT, admin of methacholine reduced FEV1 >20%. negative methacholine challenge is reliable in ruling out dx.
active sxs: obstructive PFT; albuterol gives >15% improvement in FEV1
postherpetic neuralgia timeline
4 months after initial shingles still having allodynia. tx with TCA/gabapentin/pregabalin
risk factors for TTN (transient tachypnea of the newborn)
c/section, maternal diabetes, prematurity. resolves within 72 hours.
actinic keratosis is a pre-malignant skin condition (SCC) caused by
sun exposure (UV light). of note, BCC is also associated with sun exposure but not AK and also has low metastatic potential (usually fleshy appearance for bcc vs scaly/rough etc for AK)
patient develops bunch of muddy brown looking skin spots, can be pruritic or inflamed. what are the spots, whats the sign, what should you be worried about
seborhheic keratosis; Leser-Trelat sign; internal malignancy, most commonly GI adenoCA
how long is shingles (zoster) transmissable to contacts?
until the lesion is completely crusted over, patients should keep lesions covered but they can do their activities without restriction
postherpetic neuralgia timeline
4 months after initial shingles still having allodynia. tx with TCA/gabapentin/pregabalin
options for skin SCC
surgical excision, radiotherapy, cryotherapy, electrosurgery
next step in workup of normocytic anemia
RETICULOCYTE count
High: hemolysis
Low: hyproprolif state (renal dz, hypothyroid, aplastic anemia)
mgmt of ITP
Platelets:
>30k: observe if no bleeding
<30K: steroids
IF bleeding/hemorrahge: IVIg + plt transfusion
what does HiB vaccine help prevent?
epiglottitis
most common cause of stroke in kids
sickle cell vaso-occlusive dz. dx with transcranial doppler
buspirone vs buproprion for anxiety
buspirone: non benzo anxiolytic; can be used monotherapy in nondepressed patients
buproprion: antidepressant inhibits reuptake dopamine and norepinephrine. not effective in GAD and may worsen insomnia and anxiety
tight glucose control in diabetics helps with _____ vascular complications
Micro i.e. retinopathy, nephropathy. unclear effect on macrovascular i.e. MI, stroke
