HY Review #4 Flashcards
Distributive shock = any shock with
low SVR
(Septic, Anaphylactic, Neurogenic)
Septic Shock: origin is massive vasodilation s/t inflammatory response resulting in ____ BUT that causes a _____
↓ SVR
↑CO (reflex tachycardia)
Cardiogenic shock: The Heart doesn’t work so start with ___
↓ CO
(↑ SVR)
Hypovolemic shock: the problem is ↓ Preload s/t to ↓ Total blood volume so start with ____ & ____
↓ CVP (low preload)
↓ CO (low total blood volume)
↑ SVR (b/c body tries to increase preload)
Neurogenic shock: The SNS doesn’t work so No Tachycardia and no Vasoconstriction so start with ___ & ____
↓ CO (pt Bradycardic b/c PSNS dominates)
↓ SVR (no vascular tone from SNS)
Anaphylactic shock: origin is mass vasodilation s/t histamine and Bradykinin release resulting in ____ BUT that causes a _____
↓SVR
↑CO (reflex tachycardia)
Tx: Epinephrine
Cardiac Tamponade (Obstructive shock):
origin is Extrinsic compression of heart by fluid in pericardium
Resulting in ___ & ___
↑ CVP
↑ PCWP (opposite of TPX/PE)
──
↑ SVR ↓ CO
TPX/PE (Obstructive shock):
origin is Extrinsic compression of heart by air in thoracic cavity
Resulting in ___ , but a ___
↑ CVP
↓ PCWP (opposite of cardiac tamponade)
──
↑ SVR ↓ CO
Septic Shock tx
IVFs + Antibiotics
→ If necessary add Pressors (Norepinephrine)
Cardiogenic shock tx (3)
What to avoid giving?
Give either:
1. Dobutamine (Beta 1 agonist ionotrope)
2. Milrinone (PDE-1 inhibitor)
3. Digoxin (↑ Ca for muscles)
Avoid IVFs
Hypovolemic shock tx:
Normal saline
(if Hemorrhagic, consider transfusion)
Neurogenic shock tx:
IVFs (NS) & Pressors (Norepinephrine)
TIP: In all forms of shock except Neurogenic (where ALL values go down) SVR and CO are always ____.
opposite direction to each other.
(↓ CO in cardiogenic, Hypovolemic, & Neurogenic shocks)
HBV algorithm
1st always look at ____
2nd look at ____
3rd look at vaccination or infection hx via ____
Always look at HepB-sAg first
─
If HepB-sAg (+) = Active Infection
Next look at HepB-c Ab
- Acute Infection → (+) IgM
- Chronic Infection → (+) IgG
─
If HepB-sAg (–) = No infection
Next look at HepB-c Ab
- Core Ab (+) → cleared old infection
- Core Ab (–) → vaccinated (vaccine does not have core antigen)
In the window period of HBV infection a pt has
symptomatic HBV infection (↑ LFTs ± Jaundice)
HBV serologies with show ____.
All Negative,
Except Core Ab IgM (+)
Pemphigus Vulgaris vs Bullous Pemphigoid
Blisters
Pemphigus Vulgaris (flaccid, Rupture +Nikolsky)
─
Bullous Pemphigoid (tense, Bullae, no rupture)
Both present in 40+ yo)
Pemphigus Vulgaris vs Bullous Pemphigoid
Antibodies & Prognosis
Pemphigus Vulgaris (anti-Desmosome/Desmoglein Abs) → between intraepithelial cells → fishnet → bad prognosis higher mortality
─
Bullous Pemphigoid (anti-Hemidesmosome Abs) → between subepidermal cells below the epithelium→ linear pattern → better prognosis
Pemphigus Vulgaris vs Bullous Pemphigoid
Treatment
Pemphigus Vulgaris → ± High-dose systemic steroids; prednisone)
(supportive care + Burn Center referral)
Bullous Pemphigoid → ± High-dose topical steroids; clobetasol, betamethasone
(supportive care + Burn Center referral)
22M was found unconscious (± Headache) by his family.
His neighbor saw him grilling indoors yesterday as temperatures were sub-zero at the time.
Dx/Dxt/Tx/Imaging findings?
Carbon Monoxide (CO) Poisoning
Check Carboxy-Hemoglobin levels
100% O2 or Hyperbaric O2 (to displace CO)
Neuroimaging: Globus Pallidus abnormalities
A 19 yo with a history of Diffuse Large Cell Lymphoma on chemotherapy is brought to the ED with a 3 day history of high fevers and flu like sxs.
Exam → Febrile and Nutropenic
Dx/Dxt/Tx?
ppx?
Neutropenic fever
NBSID: → blood cultures
Tx: Anti-pseudomonal ABs (Ceftazidine 3º, Cefepime 4º, Gentamicin, Carbapenem, Or Pip-Tazo)
Ppx → G-CSF/ GM-CSF analog
(Filgrastim, Saragranostin)
Diagnosis:
Neutropenic fever + Diarrhea + RLQ tenderness + abdominal distention
Necrotizing Enterocolitis (Typhlitis)
- Tx of HTN in an CKD patient with proteinuria:
- BP target for HTN in CKD:
- CKD pt w/severe Normocytic anemia of ch dz:
- ACE-i/ARB
- <130/80
- EPO def (kidneys make this)
Renal transplant pts
Hirsutism and dental/gingival anomalies on immunosuppression
= ______ Toxicity
Most likely malignant complication s/t immunosuppression
= _______ cancer
Cyclosporin Toxicity
Squamous Cell Skin Cancer
Down syndrome (40F)
Early onset Alzheimer’s dementia
Intra-cerebral hemorrhage on CT
Diagnosis?
amyloid angiopathy (Aneurysm rupture)
39F
h/o RA + Enlarged tongue
Progressive increases in Cr
Dx/MCCOD?
Amyloidosis A
Amyloidosis can cause:
•Restrictive Cardiomyopathy (mccod)
• Nephrotic Syndrome
Elderly pt w/ Tingling of lateral 3 fingers
hypercalcemia, anemia, High Cr
Dx?
Carpal Tunnel
s/t Amyloidosis triggered by Multiple Myeloma
(Classic MSK problem in amyloidosis)
54M who has been on dialysis for 2 years and has amyloidosis
Patho?
Dialysis cant filter
Beta 2 Microglobulin
so it increases in blood
Old person >70 w/restrictive heart dz. Dx?
Senile Amyloidosis (Transthyretin accumulates)
25M Asian
Chronic diarrhea, skin hyperpigmentation and nail atrophy
multiple flesh polyp in stomach and large intestines
no malignancy detected on biopsy
dx?
Cronkhile Canada Syndrome
Stool studies → lots of protein
Heritable → no, sporadic mutation
25M
Chronic diarrhea, skin hyperpigmentation and nail atrophy
multiple flesh polyp in Colon and Rectum ONLY
no malignancy detected on biopsy
dx?
Familial adenomatous polyposis (FAP)
Gene mutation associated with FAP
APC gene mutation (tumor suppressor)
APC → KRAS → p53 (adenoma to tumor mutation)
mnemonic: AK-53
Colon cancer screening guidelines for pts with FAP?
Colonoscopies every 1-2 years
starting at age 10 or when diagnosed
Pt has Familial adenomatous polyposis (FAP)
& Bony and/or soft tissue tumors
Dx?
Gardner syndrome
(Osteomas of mandible or skull/ Fibromas on skin)
Syndrome causes Malignant brain tumors
Medulloblastomas in Familial adenomatous polyposis (FAP)
Turcot syndrome
FYI: causes Gliomas in Lynch syndrome
Hyperpigmented macules on the lips w/multiple colonic polyps
Dx:
Puetz Jeghers (AD)
NBME Peds presentstion→ Intusseception (polyp lead point)
7 yo boy & Tanner 5 body
Tx/Cx?
Continuous Leuprolide (GnRH analog and shuts down HPG axis)
↓ bone mineral density
82F w/pruritus and a thin labia (thin paper-like skin).
Dx/Dxt/Tx?
Lichen Sclerosis (can happen to teens)
Punch Biopsy of vulva (bc in 20% it is CANCER so need to r/o)
High potency Topical Steroids
(Clobetasol, Halobetasol)
HPV 6/11 → causes
HPV 16/18/30s → causes & is the BRF for
Most important prognostic predictor in vulvar cancer?
HPV 6/11 → Genital warts (condyloma accuminata)
HPV 16/18/30s → Cervical Cancer
Prognostic vulvar predictor → LN involvement
Pap smear guidelines: (HY)
21-65 → pap-smear every __ years
or
30-65 → Pap smear + HPV testing together every __ years
HIV pts → pap-smear ___
21-65 → every 3 years
30-65 → co-test every 5 years
HIV pts → Yearly
Atypical squamous cells of undetermined significance (ASCUS) on Pap-Smear NBSIM?
> 30 yo ____
< 30 yo have 2 options
1. ______
2. _____
30+ → Colposcopy + Biopsy
<30
Colposcopy + Biopsy
or
<30 High-Risk HPV testing
27F High-Risk HPV testing
NBSIM for Negative Results?
NBSIM for Positive Results?
Negative → go back to regular pap-smear screening
Positive → Colposcopy + Biopsy
Low/High Grade Squamous Intraepithelial lesions on pap-smear. NBSIM?
LSIL/HSIL → Colposcopy + Biopsy
At any age
Atypical glandular cells on pap-smear.
NBSIM?
Prognosis?
Colposcopy w/ Biopsy
+
Endocervical Curettage
+
Endometrial Biopsy (Sampling)
(WORST finding on pap-smear; cancer everywhere)
Ovarian tumor markers
Endodermal sinus/Yolk Sac:
Granulosa cell:
Sertoli-Leydig:
Choriocarcinoma:
Endodermal sinus/Yolk Sac → AFP
Granulosa cell → Estrogen
Sertoli-Leydig → Testosterone
Choriocarcinoma → Beta HCG
22F Sudden onset R sided lower abdominal pain, N/V
pt has h/o ovarian cysts.
Dx?
Ovarian torsion
(Bc cysts can make ovary bulky)
(Transvaginal U/S + Doppler)
22F Sudden onset R sided lower abdominal pain, N/V
pt has h/o ovarian cysts.
Free fluid is seen in the cul-de-sac
Dx/Dxt?
Rupture of Ovarian Cyst
Transvaginal U/S
(abdominal if option not there)
Supportive care (if blood flow is okay)
An ovarian cyst on NBMEs should be interrogated with __ & __
NBSIM for:
•benign, asymptomatic cysts
• cysts with malignant featurs
Transvaginal U/S
CA-125 levels
NBSIM:
•monitor for a few cycles (2-3) then resect
•Laparoscopy/Laparotomy
MCC of Ovarian cyst during pregnancy (especially 1st trimester).
Corpus Luteal Cyst (self resolves)
12F w/ Calcified, smooth walled ovarian mass
Dx?
Teratoma (Dermoid Cysts)
(Mets to → Anterior Mediastinum)
(neurogenic tumors → posterior mediastinum)
20s Female presents with severe nausea/vomiting & found to have an ovarian mass.
Dx?
Choriocarcinoma
(mass must be making B-HCG → hyperemesis)
7F with Precocious puberty found to have an adnexal mass.
Dx?
Granulosa cell tumor
(mass must be making estrogen that makes girl go into puberty)
Psammoma bodies in the ovaries
mcc of ovarian cancer
Serious Cystuadenocarcinoma
20F with hirsutism & voice deepening found to have an adnexal mass.
Dx?
Sertoli Ley-dig cell tumor
(mass must be making Testosterone)
20F with hirsutism & voice deepening
Pt has no adnexal masses and normal Testosterone levels
Dx?
Adrenal mass making DHEAS
Signet ring cells pathognomonic for what cancer?
Krukenberg Tumor
(GI malignancy mets to ovary)
Most likely presenting complaint in endometrial cancer?
Dx testing→
Tx→
Abnormal vaginal bleeding
Endometrial biopsy
Hysterectomy
Endometrial cancer screening guidelines for pts with Lynch Syndrome (HNPCC)?
Annual endometrial biopsy
(ouch)
BRF for uterine sarcoma?
h/o pelvic radiotherapy
- Most important health hazard associated with menopause.
- MCC of Death in a postmenopausal female:
- Osteoporosis
- Cardiovascular Disease (HY)
30F with Ehlers Danlos (Type 3/5 collagen problems) has chronic vaginal “heaviness”.
Dx/Tx?
Pessary
Pelvic organ prolapse
Tx of common postmenopausal complications
Hot flashes:
Vaginal atrophy:
Osteoporosis:
Hot flashes→ HRT or Venlafaxine (if HRT c/i)
Vaginal atrophy → Estrogen creams/ Lubricants
Osteoporosis → Bisphosphonates (Risedronate Alendronate Zoledronic acid)
17F is Depressed and irritable starting few days before her period has Pre-Menstrual Syndrome (PMS)
NBSIM?
1st Line Tx?
Start Symptom Diary
SSRIs (1st Line)
OCPs (2nd Line)
In Adrenal Cortex Hemorrhage (Waterhouse Friederichsen syndrome) what is true of the following lab markers?
Cortisol:
ACTH:
Aldosterone:
Renin:
Angiotensin I & II:
Potassium:
Sodium:
Cortisol: ↓
ACTH: ↑ (no neg feedback)
Aldosterone: ↓
Renin: ↑
Ang 1/ 2: ↑
Potassium: ↑ (bc low aldosterone)
Sodium: ↓
Per the NBMEs, when should colonoscopies be started?
45yo every 10 years
1º relative (+) FMH: start at 40 yo or 10 years earlier than when family was dx
Per the NBMEs, when should breast cancer screening (mammogram) be started?
40yo
Every 1-2 years
(up until 74 then re-evaluate need)
Per the NBMEs, how is osteoarthritis managed?
First line:
Second line:
3rd line:
First line: Weight loss and Exercise
Second line: Acetaminophen
3rd line: NSAIDs
If all these measures don’t work
First line: Injecting Steroid into Joint
2nd line: Joint Replacement
Per the NBMEs, how is carpal tunnel syndrome managed?
1st line:
2nd line:
Dx test:
3rd line:
Wrist splint/straightening devices/ergonomic positioning
Inject steroids
Dx test: Nerve conduction study (before 3rd line tx)
Carpal tunnel release sx (cut Flexor Retinaculum)
36M with 3 day history of fevers and arthralgias.
Has a red, itchy, non-tender rash on trunk and thighs
Recently, started rituximab 2 weeks ago for gastric maltoma.
Dx/Tx?
T__HSR
Serum sickness
T3HSR)
Tx: Stop offending agent or (if cant) steroid tx
Other Serum sickness causes: Antivenoms Anti-toxins
Drugs containing proteins/ABs
Pt presents with RUQ pain + Fever & No Jaundice
Pt recently lost a lot of weight
Dx/Dxt (2)/Tx?
Acute cholecystitis
RUQ U/S (pericholecystic fluid, Bladder wall thickening)
If unclear → HIDA Scan (Hepatobiliary Scintigraphy)
Tx : Cholecystectomy + Ceftriaxone
(Cefotaxime or Ampicillin-Sulfabactam)
─────
Patho: Rapid weight loss produces high cholesterol → stone forms & occludes cystic duct
Pt presents 2w post cholecystectomy w/ Abd pain
Elevated GGT/ALT
Dilated CBD on ultrasound
Dx?
High Yield
Retained Stone
(obstructive pattern ↑ GGT/ALP & ↑ D.Bili → dilates CBD)
Pt presents 2w post cholecystectomy w/ Abd pain
Elevated GGT/ALP &
↑ Direct Bilirubin
Normal CBD on ultrasound
Dx?
Bile Peritonitis
(failed anastomosis → bile anastomotic leak)
Dx test is the right answer when choledocolithiasis is highly suspected but U/S is negative for CDB dilation.
MRCP
Increased indirect bilirubin causes (3)
Hemolysis
Gilbert Syndrome (mild def of UDP-GP; illness get juandiced. No tx)
Crigler Najar (Def of UDP-GP)
Increased direct bilirubin causes (3)
Obstructive liver disease
(PBC, PSC, Choledocolithiasis)
Elevated hematocrit (2)
P. Vera (EPO low)
EPO tumor (RCC, HCC, Hemangioblastoma)
CSF Xanthochromia (>900) causes
HSV encephalitis/meningitis
Subarachnoid Hemorrhage
Increased alkaline phosphatase
(some causes- not all)
•Obstructive liver disease
•Cholangiocarcinoma,
•Pancreatic Cancer
Increased Gamma glutamyl transferase
causes
(list 2, not an exhaustive list)
•Alcoholic liver dz
• Obstructive liver dz
CSF opening pressures > 200 Crazy High
Fat + Female
dx/dxt/tx?
Pseudotumor Cerebri (Idiopathic intracranial HTN)
Dx via LP
Tx: Serial LP
Acetazolamide (bc Carbonic Anhydrase is needed for CSF production)
↑ 200 wbc’s in CSF
90% lymphocytes
slightly ↑ opening pressures
dx?
Viral aseptic meningitis
↑↑↑ 800 wbc’s in CSF
90% Neutrophils
markedly ↑↑↑ opening pressures
↓ Glucose
dx?
Bacterial meningitis
↑↑ 700 wbc’s in CSF
90% lymphocytes
markedly ↑↑↑ opening pressures
Dx?
Fungal or TB meningitis
Elevated homocysteine levels in a 12 yo F with a h/o sickle cell dz
Folate Deficiency
Antibody against the constant region of the IgG antibody
RF Factor
IgM against constant IgG part = rheumatoid factor
Why Elevated BUN in a patient with hemoptysis
bc GI bleed causes increased BUN (bc bacteria broken down to urea)
Elevated Calcium in an old guy with bone pain and pathologic fractures
Prostate cancer
Decreased calcium in a 25 yo F with a history of foul smelling diarrhea and pernicious anemia .
Malabsorption s/t Celiac disease (young pt)
Elevated creatine kinase after surgery of any sort .
Dx/Tx?
Malignant Hyperthermia s/t Anesthesia
Dantrolene (Ryanodine Ca channel blocker)
Decreased bicarbonate 3 days after admission to the hospital in a diabetic. All his home medications were continued on admission .
Metformin toxicity (lactic acidosis)
Elevated FSH in a 38 yo F .
Pre-mature ovarian failure
Under age 40 FSH should not be high.
Markedly elevated serum ferritin in a patient with new onset diabetes and restrictive cardiomyopathy.
Dx/Tx/Mutation?
Hereditary Hemochromatosis → Bronze Diabetes
(have ↑ Ferritin & Iron)
HFE gene mutation C282y mutation
Tx: Phlebotomy regularly
_____ can cause hand arthritis that looks exactly like OA
(joint narrowing, osteophytes, calcifications),
but presents at <40 yo.
Tx: Phlebotomy.
Hemochromatosis
Elevated PT/INR → (3)
Warfarin, Heparin, DIC
Elevated PTT → (6)
Warfarin, Heparin, DIC
vWB dz
Hemophilia A & B
Flank pain radiating to the groin in a Crohn’s disease patient?
Crohn’s always messes up terminal ileum → so you reabsorb more Oxalate → Calcium Oxalate stones
(Anti-freeze causes these stones too)
Fever, abdominal pain, and leukocytosis
after colectomy with ileoanal anastomosis for Ulcerative Colitis
Dx/NBSIM?
Anastomotic Leak → Ex-Lap
Initial treatment of hypercalcemia is
normal saline
(after that you can start calcitonin)
Osteopenia can hide the detection of small fractures on x-ray, if they are suspected after a fall/trauma NBSIM is:
MRI or CT scan
Wernicke’s encephalopathy
Confusion, Ataxia, Nystagmus (CAN of beer)
↑ MCV
± abnormal B12 (cobalamin) & B9 (folate) levels
tx/cx
Tx: Thiamine supplementation
Cx: Korsakoff Dementia (irreversible)
confabulation, amnesia, psychosis
Chronic osteomyelitis
soft tissue infection ± purulent draining sinus tract to skin
indolent infection with gradually increasing pain + weight loss
confirmatory test →
bone biopsy
Most common Long-term pediatric complication of bacterial meningitis
Hearing loss
(rarely, seizures)
