HY Review #2 Flashcards
Epigastric pain radiating to the back
Dx/ATx/ChTx?
acute pancreatitis
Acute
1st Normal Saline
NSAIDs → Hydromorphone
NGT → Start early Oral feeding as soon as tolerated
Chronic
Insulin (likely has DM)
Pancreo-lipase (pancreatic enzyme replacement therapy)
Imaging finding in Pancreatitis
Calcifications in Pancreas
Bad prognostic factors in pancreatitis?
(3)
Very High Wbc (>16k)
Low Hb
Hypocalcemia
Indicate → Hemorrhagic Pancreatitis
HTN that has remained poorly responsive to amlodipine, HCTZ, and prazosin therapy.
Labs are notable for: K 2.9L, Bicarb 29H, and Na 139.
Dx/Tx?
Conn Syndrome
(Primary hyperaldosteronism s/t adrenal adenoma)
Tx based if unilateral or bilateral
Unilateral ↑ Aldosterone on adrenal vein sampling: → unilateral adrenalectomy
Bilateral → MR antagonist (Spironolactone/Eplerenone)
In Primary hyperaldosteronism (s/t adrenal adenoma)
Renin levels: ___
Angiotensin 1 and 2 levels: ___
PAC/PRA: ___
Response to saline infusion: ___
↓ Renin
↓ Ang I & II
↑ >30 (High Aldo/Low Renin = High ratio)
Saline will not suppress aldosterone levels (Diagnostic)
BP is 250/140 with AMS.
NBSIM?
HTN emergency
Clevidipine, Nicardipine, Nitroprusside, Labetalol, or
Phentolamine (alpha 1 blocker)
(HTN urgency = no end organ dmg. same tx)
SBO + air in the wall of the biliary tree (Pneumobilia)
Dx/Tx?
Gallstone illeus
Entero-lithotomy (incise terminal illeum)
Hypodense hepatic mass with peripheral enhancement (Halo) on arterial phase and centripetal filling on delayed phases.
Dx/NBSIM?
Hepatic hemangioma
Liver finding that YOU DO NOT TOUCH
Stellate scar on liver seen abdominal CT
Dx/NBSIM?
Focal nodular hyperplasia
DO NOT TOUCH MASS
Heterogeneous enhancement in Liver on CT.
Dx/NBSIM?
Hepatic adenoma
Avoid Estrogen containing contraceptives
DO NOT TOUCH
Animal/Human Bite wound
NBSIM?
Debride (clean)
Amoxicillin
→ DO NOT stitch closed bc anaerobes present
→allow to heal via secondary intention
MCCOD in refeeding syndrome?
HYPOPHOSPHATEMIA
(causes cardiac problems)
RUQ pain, direct hyperbilirubinemia & scleral icterus (jaundiced).
No fever
Dx/NBSIM/Tx (2)?
Choledocolithiasis
RUQ abd U/S
If CBD dilated → ERCP → Cholecystectomy
(stone obstructs bile duct trapping bilirubin → jaundice)
RUQ pain, direct hyperbilirubinemia (jaundiced) & FEVER
± AMS & Hypotension
Dx/Tx (2)?
Acute Cholangitis
ERCP (diagnostic and therapeutic ) + Ceftriaxone
(Ascending biliary tract infection)
RUQ pain and FEVER
Winces upon deep palpation of the RUQ.
Labs: ↑ wbcs, mild↑AST/ALT
normal bilirubin, ALP/GGT
Dx/Tx?
Acute Cholecystitis
RUQ U/S
Cholecystectomy
pt with 30 pack year smoking history with rapidly developing digital clubbing and diffuse joint pain
Dx/NBSIM?
Hypertrophic Pulmonary Osteoarthropathy
Chest CT (r/o likely lung cancer; paraneoplastic)
Small Cell Lung Cancer Paraneoplastic Complications:
SIADH causes ____.
Lambert Eaton Myasthenia Syndrome ____.
Bonus: can also cause ____
SIADH → Hyponatremic seizures
LEMS → Proximal muscle weakness
(Difficulty combing hair/raising from chair)
Hypercortisolism (Cushing’s Syndrome)
auto anti-bodies against PRE synaptic voltage gated Ca channels
Facial swelling, headaches, and bilateral JVD
Dx/Tx?
SVC syndrome
EMERGENT RADIOTHERAPY
(SVC external compression from tumor)
2 mm L sided pupils with a droopy eyelid and L sided hand (or shoulder) pain.
Dx s/t ___
Horner Syndrome
s/t Pancoast Tumor ( aka Superior Sulcus Tumor)
Tumor compresses cervical sympathetic chain
TIP: Always check the apical lung tumor in smokers CXR
NBSIM in lung nodule seen on CXR
Chest CT
(don’t bother with the old CXR)
How to biopsy Central Lung lesions:
Endobronchial ultrasound + biopsy
or
Mediastinoscopy + biopsy
How to biopsy Peripheral Lung lesions?
percutaneous CT guided biopsy
(if lesion on the outer edge)
Pt with lung nodule on CXR and pleural effusion
NBSIM?
Thoracentesis (w/ cytology)
Where to insert needle when doing a
1. Thoracentesis
2. Nerve Block
- ABOVE the rib to avoid intercostal bundle under the rib
- BELOW the rib to reach the intercostal bundle
Pt has thickened lung pleura and/or hemorrhagic pleural effusions
Dx?
Mesothelioma
(cancer of pleura)
(+) Psammoma bodies
(concentric, lamellated microscopic calcifications)
Squamous Cell Lung Cancer treatement?
Chemotherapy only
(all other lung cancers can have any treatment)
Major determinant of successful TB tx?
Medication Adherence
Pt presents with (+) TB skin test, but negative chest X-ray.
NBSIM?
Latent TB
Isoniazid + Vit B6 (9m)
Asymptomatic patient with INR of 9 on Warfarin
NBSIM?
prothrombin complex concentrate (PCC)
± oral vitamin K
Pt presents with abdominal pain
Takes chronic Warfarin
Labs: ↓ Hgb 9 & INR 9
Dx?
Intra-abdominal hematoma
65M with 6 mo history of progressively worsening dyspnea, dry cough, and bibasilar fine crackles heard on lung auscultation.
Dx/NBSIM?
Idopathic pulmonary fibrosis
High Resolution CT Chest
(on NBME: Fine crackles = Fibrotic lung disease)
60M with 1 week h/o of blurry vision and severe headache. PE shows splenomegaly and markedly swollen/tender hand & feet joints with overlying erythema.
Labs: ↓↓↓ Hgb (6.5), ↑↑↑ Plts (900k), ↓↓ WBC (1.2K)
Dx/Tx(2)?
Essential Thrombocytosis
Platelet-pharesis + Aspirin
(JAK 2 mutation; hypercoagulable)
– Only one cell line is absurdly high, while all others are low → think myeloproliferative d/o
60M 3 week of worsening pruritus (not improved with diphenhydramine) & worse when showering.
PE shows flushed/roddy pt & spelnomegaly
Labs: ↑↑↑ Hct (70%)
Dx/Tx?
Polycythemia Vera (PV)
Phlebotomy
In PV: ↓EPO b/c negative feedback from ↑Hct
(vs paraneoplastic 2º polycythemia where EPO is incr.)
Myeloproliferative d/o + JAK 2 mutation
• PV
• Essential Thrombocythemia
• Myelofribrosis (dry tap/teardrop rbcs)
List 2 common causes of Budd Chiari Syndrome on NBMEs
Polycythemia Vera
PNH
(Paroxysmal Nocturnal Hemoglobinuria)
Intermittent & fatigable proximal muscle weakness
(initial evaluation may be normal bc comes & goes)
worsens with repetitive/prolonged motions
improves with rest
± ocular/oral sxs
Dx/Tx
Myastenia Gravis
Pyridostigmine (AChE inhibitors)
Auto-ABs to postsynaptic acetylcholine receptors of NMJ
Myasthenic crisis → exacerbation leads to respiratory failure
tx: serial spirometry + IVIg or plasma exchange
Elderly pt presents with Fever + acute LLQ abd pain + change in bowel movements.
Leukocytosis
Dx/NBSIM/Tx(2)?
Diverticulitis
CT A/P
Peritoneal sxs → Colectomy sigmoid
Conservative (bowel rest & analgesia)
or FQ+Metronidazole
Elderly pt presents with acute LLQ abd pain & bloody diarrhea
low-grade fever + mild Leukocytosis
Recent hx of MI or A-fib
Dx/tx (3)?
Ischemic Colitis
(supportive care + Abxs + anticoagulation)
Opioid adverse side effects include (3):
Miosis (Constricted pupils)
Sedation (AMS)
Hypotension
Constipation
Bradycardia
Depressed respiratory drive
Mnemonic: MS. CBD
Normal rate of Respiration: 12 –16 bpm
Elderly woman presents with painless gross hematuria.
UA significant for many RBCs pHpf.
Cytoscopy reveals bladder mass
Dx/BRF?
Transitional cell carcinoma of the Bladder
(mc urinary tract tumor)
presents with painless gross hematuria
BRFs: Smoking, cyclophosphamide &
aniline dyes
(to dye fabric, leather, and wood. Rubber manufacturing)
Pelvic unstable s/p MVC
Ecchymosis over the pelvis and scrotum
Blood at the urethral meatus
NBSIM?
Retrograde Urethrography
Urethral Injury
━
Urethral injury diagnosis is confirmed via retrograde urethrography before bladder decompression via supra-pubic catheter
(if complete urethral injury) ± surgery.
Pelvic unstable s/p MVC
Gross hematuria
no blood at urethral meatus
Dx & Confirmatory test?
Cystography is used to evaluate suspected
Bladder rupture
Compare Myasthenia Gravis to Lambert Eaton
ABs to what?
Repetitive use causes?
MG:
* Fatiguable muscle weakness worse at end of day
*muscle strength worsens with increased use & improves w/ rest
* Antibodies to postsynaptic ACh Receptors → impaired acetylcholine release in the NMJ
─
LE:
*Proximal muscle weakness
* muscle strength improves with repetitive or ongoing use
*Autoantibodies to presynaptic voltage-gated calcium channels → impaired acetylcholine release in the NMJ
RUQ abdominal pain +
- No Fever + Jaundice (↑ Bilirubin)
- Fever + Jaundice (↑ Bilirubin)
- No Fever + No Jaundice (nl Bilirubin)
- Fever + No Jaundice (nl Bilirubin)
NBSIM → RUQ abdominal U/S
- Choledocolithiasis → ± ERCP & Cholecystectomy
- Acute Cholangitis → ERCP
- Cholelithiasis → schedule elective Lap-Chole
- Acute Cholecystitis → Cholecystectomy
25M with Psych sxs (Depression, Dementia, etc)
Found to have Hepatomegaly & ↑ LFTs
↓ serum ceruloplasmin
± parkinsonism
Dx/Tx?
Wilson disease (HepatoLenticular degeneration)
Penicillamine (chelating agent)
Impaired copper excretion → copper accumulates & deposits in the liver, brain, & eyes
good prognosis if found/treated early
Kayser-Fleischer rings: brown copper deposits near iris & ↑ urinary copper excretion
87M war-vet
6m, Dyspnea
Lung bx → brown dumb bells (ferruginous bodies)
dx/PFT pattern?
Asbestosis
–Osis = Restrictive Lung Disease
F:F ↑/–
(↑F1 & ↓Fc)
A-a: ↑
↓ lung residual volume
↓ complaince =↑ elastance
Pt w/ well controlled history of Asthma
receives treatment for acute MI in ED
Has now developed shortness of breath
Why?
s/t Beta Blocker for MI in Asthmatic
Not s/t Aspirin bc pt doesn’t have nasal polyps or h/o worsening asthma with NSAIDs.
─
Generally try to avoid beta blockers in asthmatics, but this was an MI so risk/benefit.
35F with 8m h/o SOB now worsening
+ R heart strain
+ High Pulm Artery pressures
dx/tx (3)?
Idiopathic pulmonary HTN
Bosentan, Ambrisentan (endothelin receptor antagonist)
Sildenafil (PDE inhibitor)
───
s/t BMPR2 mutation
Excess smooth muscle proliferation in arteries
49M presenting for erectile dysfunction
MEDS: Prazosin, Metformin, Lisinopril
NBSIM?
avoid Sildenafil (PDE inhibitor)
which is usually tx for ED
BUT this pt is on Prazosin (Vasodilator)
both these drugs combined will tank BP
33F presents with severe bleeding from her nose. Started after she tried to “clean out” her nose.
PMH: severe allergies (on fexofenadine)
Dx:
BRF:
Immediate NBSIM:
Most common type:
What if pt also had Hemoptysis/Significant hemorrhage:
Despite initial measures, the patient’s nose continues to bleed profusely. NBSIM?
Epistaxis
BRF: nose picking
Tx: Apply pressure to the nose
MC Type: Anterior nose bleed from Kissel-bach plexus
Hemoptysis present: Posterior nose bleed
Persistent bleeding → Electrocautery
Potential nasal packing complication:
Genetic cause causing recurrent nose bleeds:
Toxic shock syndrome (s/t nasal packing)
Hereditary hemorrhagic telangiectasia (AD)
(aka Osler-Weber-Rendu syndrome)
Hereditary hemorrhagic telangiectasia (AD)
(aka Osler-Weber-Rendu syndrome)
HY Cardiovascular complication/mechanism?
High-Output Heart Failure
AV malformations result in limited capillaries for gas exchange → tissue hypoxia → triggers ↑ cardiac output → chronically this results in HOHF
44M w/ PNA develops
Polyuria, Polydipsia, dry mucus membranes
Hyponatremia
Hyperglycemic (>600)
Dx/Tx (specify 1st & 2nd step)
HHS
(Hyperosmolar Hyperglycemic State)
Step 1→ Normal Saline
Step 2 → Insulin infusion
K+ regimen rules in HHS
(K+ range → 3.5 – 5.0)
Group 1:
Group 2:
Group 3:
< 3.3 → give K+ & NS (No insulin)
3.3 – 5.5 → give K+, NS, & Insulin
> 5.5 → give NS & Insulin (No K+)
Per the NBME, how can DM be diagnosed?
Method 1
Method 2:
Method 3:
Method 4:
Can DM be diagnosed on the basis of 1 test result?
*Fasting BGL > 125
* A1c > 6.5%
* Oral Glucose Tolerance Test + BGL > 199 (Most Sensitive)
* Polyuria & Polydipsia + BGL > 199
No, Diagnosis requires repeat testing on a another day
(except for A1c test)
Per the NBME, how can T1DM be differentiated from
early T2DM by way of C-peptide levels?
T↓DM = ↓ C-peptide
T2DM = ↑ C-peptide
────
(↑ bc making lots of insulin that’s being resisted)
Macrovascular complications of DM: (4)
Microvascular complications of DM: (3)
────
Best method for reducing the microvascular cx of DM?
Macro → MI, PE, DVT, Stroke
Micro → Neuropathy, Retinopathy, Nephropathy
────
↓ Micro Cx → Tight Glycemic control
What kind of DM has the strongest genetic concordance?
Strongest predictor of progression to diabetic nephropathy ?
Screening in T1DM vs T2DM?
How
When
Frequency
Management of diabetic nephropathy?
Genetic → T2DM
Predictor → Microalbuminuria
Urine albumin to creatinine ratio (>30 = albuminuria)
T1DM Urine alb:cr → 5 years after dx
T2DM Urine alb:cr → at the time of dx
For both screen → Annually
Tx → ACE-I/ ARBs
MCC of ESRD in the US:
T2DM
32M with a h/o T1DM
3 week h/o of numbness in his bilateral feet.
Shake his feet a few times to feel better.
Dx:
Tx, if painful:
Screening guideline in T1DM:
Screening guideline in T2DM:
Screening intervals:
Collapsed midfoot arch on foot XR:
Diabetic neuropathy
Tx: Pregabalin, Gabapentin, TCA, SNRIs (Duloxetine)
──
T1DM: → screen 5 years after dx
T2DM: →screen at the time of dx
Screen Annually
──
Collapsed midfoot arch: →Charcot joint s/t neuropathy
(Flat foot & Mal-aligned)
T2DM patient develops a foot ulcer.
A sterile probe through the ulcer goes all the way to bone.
Dx/Bugs?
Osteomyelitis
Polymicrobes
51M h/o poorly controlled DM with a 6 mo hx of impaired vision.
Dx:
Screening guideline in T1DM:
Screening guideline in T2DM:
Screening intervals:
DM retinopathy
T1DM: → screen 5 years after dx
Screening guideline in T2DM: → screen at time of dx
Screening intervals: Yearly
What is the MC complication of DM?
DM Neuropathy
A diabetic male goes to ophthalmologist for preventive screening.
What is the most likely dx given fundoscopic exam findings?
Cotton wool spots:
Neo-vascularization:
Tx for Neo-vascularization:
Cotton wool spots →Non-proliferative retinopathy
Neo-Vasc → Proliferative retinopathy
Tx for Neo-Vasc → Laser photocoagulation
(never use VEG-F inhibitors on test)
Sudden onset, painless vision loss in a diabetic:
Retinal detachment
Abdominal pain radiating from the mid back in a band like distribution:
Thoracic Poly-radiculopathy
Tx for difficulty maintaining a steady erection:
Sildenafil
55M h/o poorly controlled T2DM
3 mo hx of N/V and a “fullness” after small meals.
Abdominal imaging reveals no evidence of obstruction.
Dx:
Tx (2):
Gastric Paresis (Stomach Neuropathy)
Metoclopramide (D2 blocker- EPS effects)
Erythromycin (Motilin agonist)
What kind of diabetic should get a statin?
> 40 yo
Contraindications to using Hb-A1c test?
Hemolytic anemia
(rbcs don’t live long)
First line tx for T2DM:
Contraindications to this Med:
Weight loss + Metformin
Contraindications: Liver or Kidney disease
(if getting contrast for imaging hold metformin)
DM drugs and their side effects
Highest risk of hypoglycemia:
Weight gain:
Weight loss:
Flatulence and diarrhea:
Hypoglycemia→sulfonylureas (-rides)
Weight gain → sulfonylureas
Weight loss → SGLT2-I (-ozins) & GLP-1 agonist (liraglutide, Exenatide, -tides)
Flatulence and diarrhea → 𝛼- glucosidase inhibitors
(Acarbose, Miglitol)
DM drugs and their side effects
Contraindicated in ischemic cardiomyopathy:
Necrotizing fasciitis of the perineum:
UTIs:
Bicarb of 4 (from lactic acidosis):
c/i in cardiomyopathy → TZDs (-glitizones cause fluid retention)
Nec fasc of perineum → SGLT2-I
UTIs: → SGLT2-I
Lactic acidosis → Metformin
DM drugs and their mechanisms of action
K channel blocker:
Decreases hepatic gluconeogenesis:
PPAR ɣ activators (↑ glucose uptake):
K channel blocker → Sulfonylureas
↓Gluconeogenesis → Metformin
PPAR ɣ → Thiazolidinedione
History of MEN2A/B Contraindicated Diabetes Medications?
(2)
GLP-1 agonist (–tides)
DPP4 inhibitors (–gliptins)
Autoantibodies in T1DM (3)
anti-Glutamate Decarboxylase (GAD)
Anti-Insulin
Anti-Islet polypeptide
No Question. Just look at it.
Now look at this
Epidemiology Mnemonic for
Primary Biliary Cirrhosis
vs
Primary Sclerosing Cholangitis
PBC → Ursodiol & anti-mitochondrial antibodies (AMA)
Intrahepatic bile duct affected
PSC → Liver Transplant & P-Anca
Extrahepatic + Intrahepatic bile duct affected
Confirm dx → MRCP/ERCP
Butterfly rash beneath the nose/lower lip that worsens with sun exposure + chronic joint pain.
────
Dx/Tx:
Rapid ↑ Cr NBSIM:
────
Hb is 8 & + Coombs test:
SLE
Hydroxychloroquine
Renal Biopsy (Lupus nephritis)
────
Auto-immune Hemolytic Anemia
(T2HSR s/t ABs against own blood)
33F with 3 day h/o dyspnea and abdominal pain.
s/p Cardiac Transplant 8 weeks ago for sarcoidosis
PE → JVD + S3
Labs & EKG normal
Dx/NBSIM?
Clearly, the something is wrong with her new heart
She got it 2m ago and now it is not working (heart failure)
Dx: Acute Rejection → Biopsy heart (Echo guided)
(less than year)
Perioral cyanosis + normal SaO2?
dx/tx (3)/drugs causing this (3)?
BRF?
Methemoglobinemia (drug induced)
* TMP-SMX
* Nitrates (for MI/Chest pain) → BRF
* Dapsone (for leprosy or dermatitis herpetiformis)
Methylene blue + vit C + Cimetidine (H2 blocker)
What is the biggest RF for ARDS?
What is the biggest RF for DIC?
BRF Vit K deficiency in hospitalized pt (bleeding gums/nose)?
Sepsis
Sepsis
Broad-spectrum ABX
BRF bladder CA (transitional cell carcinoma)
BRF for squamous cell bladder cancer
Smoking
Schistosoma haematobium
What’s the BRF Budd Chiari
s/t hepatic vein thrombosis
Polycythemia vera
(PNH is a cause, but not BRF. Other causes are hyper-coagulable states)
Renal Cell Carcinoma
Paraneoplastic syndrome →
Can cause →
Histology →
Most likely mets →
Most important predictor of prognosis →
Paraneoplastic→ EPO ↑ Hct
Causes → L varicocele
Histology → clear cells
Mets → lungs
Pprognosis = renal vein involvement to systemic circulation
OSA (obstructive sleep apnea) BRF by age
Kid →
Adults →
Kid → adenotonsillar hypertrophy
Adults → obesity
MCC of CAH = 21 Hydroxylase deficiency
HY overall Lab finding
__ Aldosterone (associated 3 labs?)
__ Cortisol = (associated symptom?)
__ DHEA
*Girls → ____
* Boys → ____
↑ ↑ 17 Hydroxy Progesterone
↓ Aldosterone
(hyponatremia, hyperkalemia, met acidosis)
—-
↓ Cortisol
(Hyperpigmentation s/t ↑ MSH/ACTH)
—–
↑ ↑ DHEA
Girl → Virilized
Boys → Super boys (peripheral precocious puberty)
Mirena IUD (Progestin)
thickens cervical mucus
c/i (2)
Breast cancer hx
STI <6m ago
Copper IUD
oxidizes sperms
c/i (3)
Wilson disease (copper excess d/o)
STI <6m ago
heavy menses hx
REVIEW:
Total cycle length (–) 14 (luteal phase length)
= follicular phase length
Total cycle length (–) 14 (luteal phase length)
= follicular phase length
Pt gets biopsy on day X of cycle
how do you know if pt was in the follicular (proliferative) vs luteal (secretory) phase
Total cycle length (–) 14 (luteal phase length)
= follicular phase length
If X is in last 14 days of cycle → luteal phase
ex: 30 day cycle → 1-16d Follicular & 17-30 Luteal)
Withdrawal/ Challenge test: to localize amenorrhea
P2 given & w/d bleeds = (+) test
No w/d bleeding after P2 = (–) test → NBSIM?
give E2 then P2
and see if they w/d bleed then
Pt receives P2 and has w/d bleeding
why?
Anovulation
(ex: PCOS)
Pt receives E2 then P2 and has w/d bleeding
why?
Estrogen deficiency
(Ex: Turner syndrome & Primary Ovarian Failure: ovaries don’t work don’t make E2 or P2 so both will be low.)
Pt receives P2 and does not w/d bleed.
Pt then receives E2 & P2 and still does not bleed
why?
Decidua Basalis (endometrial stem cells) are missing
(Ex: Asherman syndrome (Synechial) s/t recurrent dilation and curettage → scrape off stem cells)
3 Causes of bilious emesis → get upper GI series
Duodenal Atresia → ___ Bubble
Jejunal Atresia → ___ Bubble
Midgut volvulus → Mal-rotation of midgut around ___
Duodenal = Double
Jejunum = Triple
Malrotation around SMA
Meckle’s diverticulum
failed obliteration of the ___ (terminal illeum)
Painless bloody stools In first few years of life s/t ___ mucosa
dxt/tx?
vitelline duct
ectopic gastric mucosa
Dxt: TC-99m scan (Meckle’s scan)
Tx: Surgery
