1. Tx of HTN in an CKD patient with proteinuria: 2. BP target for HTN in CKD: 3. CKD pt w/severe Normocytic anemia of ch dz:

1. ACE-i/ARB 2. <130/80 3. EPO def (kidneys make this)

HY Review #4 Flashcards by Stephanie Escobar

Distributive shock = any shock with

low SVR
(Septic, Anaphylactic, Neurogenic)

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Septic Shock: origin is massive vasodilation s/t inflammatory response resulting in ____ BUT that causes a _____

↓ SVR
↑CO (reflex tachycardia)

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Cardiogenic shock: The Heart doesn’t work so start with ___

↓ CO

(↑ SVR)

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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)

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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)

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Anaphylactic shock: origin is mass vasodilation s/t histamine and Bradykinin release resulting in ____ BUT that causes a _____

↓SVR
↑CO (reflex tachycardia)

Tx: Epinephrine

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Cardiac Tamponade (Obstructive shock):
origin is Extrinsic compression of heart by fluid in pericardium
Resulting in ___ & ___

↑ CVP
↑ PCWP (opposite of TPX/PE)
──
↑ SVR ↓ CO

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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

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Septic Shock tx

IVFs + Antibiotics
→ If necessary add Pressors (Norepinephrine)

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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

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Hypovolemic shock tx:

Normal saline

(if Hemorrhagic, consider transfusion)

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Neurogenic shock tx:

IVFs (NS) & Pressors (Norepinephrine)

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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)

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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)

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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 (+)

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Pemphigus Vulgaris vs Bullous Pemphigoid
Blisters

Pemphigus Vulgaris (flaccid, Rupture +Nikolsky)
─
Bullous Pemphigoid (tense, Bullae, no rupture)

Both present in 40+ yo)

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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

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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)

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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

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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)

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Diagnosis:
Neutropenic fever + Diarrhea + RLQ tenderness + abdominal distention

Necrotizing Enterocolitis (Typhlitis)

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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)

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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

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Down syndrome (40F)
Early onset Alzheimer’s dementia
Intra-cerebral hemorrhage on CT
Diagnosis?

amyloid angiopathy (Aneurysm rupture)

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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

1. Most important health hazard associated with **menopause**. 2. MCC of Death in a **postmenopausal** female:

1. Osteoporosis 2. 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?

**45**yo 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?

**40**yo 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)