HY review #4 Part 2 Flashcards
What is the biggest risk factor for the following disorders?
Bladder cancer:
Lung cancer:
Pancreatic cancer:
Prostate cancer:
*Of all the Above, which causes blastic bone lesions?
*Which cancer (listed above or not) can cause both blastic and lytic lesions?
Bladder cancer: → smoking
Lung cancer: → smoking
Pancreatic cancer: → smoking
Prostate cancer: → Age
Blastic bone lesions → Prostate cancer
Both blastic and lytic lesions → Breast cancer
Bladder, Lung, Pancreatic cancer → lytic lesions (chew up bone)
-What is the biggest risk factor for Renal cancer?
-What paraneoplastic syndrome is assoc w/ renal cancer ?
-Initial imaging test?
-Next step after imaging?
Smoking
[Paraneoplastic: ↑ EPO = ↑ Hct aka 2º Polycythemia]
Initial dx test → CT A/P with contrast
Next step in management → Nephrectomy
──
FYI: Can’t biopsy bc if you rupture it you’ll spread cancer all over.
Same goes for ROTA cancers
(RCC, Ovarian, Testicular, Adrenal)
HY HY HY
43F + BMI is 48.
Has tried 2 hrs of daily exercise and eats a low carb/fat diet.
What is the next best step in the management of this patient?
Gastric Bypass
(HY HY HY)
2 main indications for Gastric Bypass:
Does this surgery reduce mortality?
BMI> 40
BMI>35 + Co-morbidities (HTN, DM, HF)
Reduce mortality → YES
24 hr history of abdominal pain, severe vomiting, &
no bowel movement 4 years after gastric bypass
Dx/Tx?
SBO s/t Adhesions from abdominal surgeries (mcc of SBO)
Tx: NGT and suction
If Peritoneal signs are present = Laparotomy
Fevers and worsening epigastric pain with peritoneal signs 3 days after gastric bypass
dx/tx?
Anastomotic leak
Ex-Lap
1 month after Gastric Bypass, the patient returns for follow-up.
She complains of episodes of diarrhea, nausea, and dizziness that occur 2 hrs after she eats a meal.
Dx:
Dx testing:
Tx strategies:
Type of diarrhea:
Dumping Syndrome
Gastric Emptying Study (gastric scintigraphy)
Small frequent meal and low-carb diet (less osmotically active)
osmotic diarrhea
──
Rapid gastric emptying → pyloric sphincter is bypassed after surgery → once food enters stomach it goes immediately to the small intestine → this attracts water into intestine →osmotic diarrhea (resolves itself)
Mild bone pain, mild QT prolongation on EKG after gastric bypass surgery, tapping the cheek produces facial muscle spasms.
Dx:
Pathophysiology:
Expected PTH levels:
Tx strategies:
Hypocalcemia
s/t Decreased duodenal reabsorption
↑ PTH
Tx: Calcium + VitD supplementation
Shortness of breath and generalized fatigue in a menstruating female 1 year after gastric bypass surgery who was lost to follow up.
Dx:
Pathophysiology:
Tx strategies:
Iron def anemia
Poor iron absorption in duodenum
Tx: Iron supp + Orange Juice
What should be supplemented in pts who’ve had a gastric Bypass when they present with SBO symptoms to reduce the risk of neurologic sequelae?
Give Thiamine [vit B1]
(bc high risk for Wernickes)
(+) Babinski & Romberg tests (Dorsal column disfunction)
2 years after Gastric Bypass surgery in an individual lost to follow up?
Dx?
Vitamin B12 def
(UMN + Dorsal Column sxs = Subacute combined degeneration of the spinal cord s/t B12 deficiency)
Hemidiaphragm elevated after inserting a central line
Dmg to Phrenic Nerve (paralysis of diaphragm)
Feeling of ear fullness + vertigo + Tinnitus + episodic hearing loss
dx/tx(2)?
Menier’s dz (endolymphatic hydrops)
Tx: Diuretic or Gentamicin ablation of CN8 (when diuretics no work)
Management of rotator cuff injury
1st line/2nd line tx?
Shoulder strengthening exercises
2nd line: inject steroids
Teenager presents with rapid onset and offset neuro deficit or consciousness (resolves within seconds to an hour). Perioral rash noted on exam.
Dx?
inhalant abuse (Glue, Taulene)
neuro deficits → pass out → wake up and are okay
FYI: can cause Parkinson sxs
Histological correlate of ARDS
Diffuse alveolar damage
Enlarging breast mass in a 55 yo F on hormone replacement therapy. NBSIM?
c/f Breast cancer
get Mammogram
Then stop HRT
2 modes of emergency contraception.
Which is most effective?
Copper IUD (better)
Uripristol (Plan B)
Rising Cr and K after starting candesartan.
Diagnosis?
Renal Artery Stenosis
───
(this is how it is tested)
Glomerulus is drained by efferent arteriole
In Renal a stenosis you bring in less blood via afferent a. to glomerulus → thus lowering Hydrostatic pressure.
→ Adding an ACE-I or ARB → dilates the efferent arterial → further reducing hydrostatic pressure in glomerular capillaries → resulting in ↓ GFR and ↑ Cr
Neurologic sxs present in a pt with a hx of small bowel resection
Diagnosis (cause of sxs)?
Vitamin B12 deficiency
(especially if Crohn’s hx)
2 yo boy that screams and cries profusely when he begins kindergarten.
Separation anxiety
Provide reassurance
Predominant mode of physician compensation in the US
Fee for Service
Method of CMS (center for medicare services) physician reimbursement that emphasizes quality improvement
→ Value- Based Care
Classic drugs used in the management of HIT on NBMEs?
Direct Thrombin (2a) inhibitors (agatroban, dabigatran)
───
or rarely Factor 10 inhibitor (apixiban)
40 yo obese F presents with painful draining lesions under the axilla that have not responded to 1st and 2nd line treatment.
Dx/NBSIM/ List the 1st & 2nd line tx
What Glands affected?
Hidradenitis Supparativa
1st Antibiotics (Topical Clindamycin or PO Tetracycline)
2nd Steroid injection
NBSIM IS 3rd line tx, Surgery
apocrine sweat glands are inflamed
Most susceptible region of colon to infarction from vessel thrombosis/systemic hypoperfusion
Left Colic Flexure (Splenic flexure) watershed area of supply
Right heart failure s/t Pulmonary HTN, COPD, CF, OSA etc.
Cor Pulmonale
(RHF s/t pulmonary cause)
Management of seborrheic dermatitis
Selenium sulfide shampoo
Most common location of a carcinoid mass?
Spreads to ____ becoming symptomatic.
Appendix
Spreads to Liver causing sxs:
Flushing
Wheezing
Diarrhea
RH valve issues
high levels of 5-HIAA
Most important nutritional intervention in the treatment of hemorrhoids
add FIBER
E’lyte abnormalities found in a patient vomiting.
Hypocholermic, hypokalemia metabolic alkalosis
(volume depletion causes high aldosterone)
Risk of a boy becoming a hemophiliac if his mom is a carrier and his dad is not.
50%
Perioral cyanosis 3 hrs after receiving bupivacaine in an axillary nerve block
dx/tx?
Methemoglobinemia
Tx: Methylene Blue
SaO2 low + PaO2 nl
───
CN poisoning = SaO2 nl + PaO2 nl
CO poisoning = SaO2 low + PaO2 nl
What should be done on NBMEs in a HIV negative individual who is a partner of a HIV+ individual?
Pre-Exposure ppx
Emtriatabine + Tenofovir
± Raltegravir
Treatment of herpetic whitlow?
PO Acyclovir
Diagnostic test for BP-Positional Vertigo.
& Treatment maneuvers
Dxt: Dix-Hall Pike test
Tx: Epley or Semont Manuever
In a patient with a stroke, what is the Blood Pressure value you should aim to stay below of?
What drug should be used in achieving this goal?
<220/120 (permissive HTN)
Labetalol
—-
FYI: AHA guidelines say stroke pts not qualified for TpA or thrombectomy are allowed permissive HTN to < 22/120. Pts who are qualified should have BP lowered to <185/110 before treatment is initiated.
In acute ischemic stroke pt with cardiac comorbidities may need emergent BP reduction no more than 15% of initial BP within 24 hrs)
Long time smoker with bilateral calf pain
Dx/Dxt/tx(3)?
Peripheral Artery Disease
1st → do ABI
*if less than 0.7 = PAD confirmed
*if ABI is ↑/wnl → Toe Brachial Index → Monkeberg Calcific sclerosis
Tx strategies:
1st line: Supervised walking/ exercise program
2nd line: Cilastozole (antiplatelet + vasodilator)
3rd line→ get CT Angio of extremity for Surgical planning
If pt with suspected PAD has an
Elevated or Normal ABI
NBSIM/Dx?
(Normal ABI: 0.9 –1.4)
Toe Brachial Index
Monkeberg Calcific sclerosis
Pt presents with calf pain on exertion + Buttock pain + Erectile Dysfunction.
Dx?
Aorto-iliac disease
(aka Leriche syndrome)
Pt diagnosed with PAD and started on supervised exercise program.
NBSIM?
start a STATIN
to prevent CVD events
──
(technically, they also need an Aspirin, but NBME doesn’t care)
Treatment for pancreatitis s/t hyperTG
Fibrates
Sudden onset severe chest pain
Widened mediastinum
Left Pleural effusion
± Hoarse voice
Dx/ NBSIM (if pt is stable vs unstable)
Aortic Dissection
unstable: TEE
stable: CT Angio chest
───
R. Laryngeal n. dmg → vocal cord paralysis, respiratory failure, hoarse voice
Management of Aortic Dissection
Type A → ascending aorta ± descending aorta involved
Type B → only descending involved
A → Surgery + Beta blocker
B → Beta blocker + Observation
(labetalol, sotalol, metoprolol)
Aortic Dissection BRFs (~4)
HTN
Marfans
Ehler’s danlos
3º Syphilis (Aortitis)
Infertility in a Cystic Fibrosis male vs Cystic Fibrosis female is due to what?
Male → Agenesis of Vas Defrens
Female → Thick Cervical Mucus
Female with Benign adnexal mass, ascites & pleural effusion (TRIAD)
Sxs resolve after resection of mass
Dx?
Meig’s Syndrome
5F child + foul smelling vaginal discharge
↑ Wbcs
Dx?
Vaginal Foreign Body
(kids do the grossest things)
Loss of peripheral vision first then central vision
dx?
Glaucoma
Risk factors include → Steroid use + Diabetes
Loss of central vision first then peripheral vision
dx?
Macular Degeneration
Presents with headache, eye pain, nausea, and decreased visual acuity.
Exam → Red eye + Rock Hard , Firm Eyeball + fixed, mid-dilated pupil
dx/tx(2)?
Angle Closure Glaucoma
Muscarinic Agonist (Pilocarpine)
+
Laser Iridotomy
Contraindicated exam in pt’s with Acute Angle- Closure Glaucoma?
Dilated Eye Exams
───
pupillary dilation from anticholinergic medications (Tolterodine), sympathomimetics, or low ambient light.
Open Angle Glaucoma (Chronic)
Treatment options (4)
- Prostoglandin analogs (Latanoprost, Bimatoprost)
- Alpha 2 agonist (Aproclonidine, Brimonidine)
- Beta Blocker (Timolol)
- CAH inhibitor (Acetazolamide, Dorzolamide)
───
Prostaglandin analogs dilate canal of schlemm to incr drainage → it also increases eye-lash growth :)
33 F presents with a 12 hour history of severe groin pain.
Recently received Cefazolin for an infection.
Urine pH 7.1 (basic)
CT pelvis → Large stone in renal pelvis
Dx/Bug/NBSIM?
Staghorn Calculi
Proteus Mirabilis (Ureas bugs → makes urine basic)
Surgical Removal of stone
~normal urine pH: 5– 7
(approaching these values is concerning)
Aside from not moving position for long periods of time what else is a big risk factor for the development of Pressure (Decubitus) ulcers and their impaired healing?
NBSIM if muscle or bone are visible in the ulcer?
Poor protein/nutrition
Caloric Nutritional Support is necessary for wound healing
Debride Ulcer
————-
FYI: poor nutrition impairs wound healing after surgeries too
23 yo Norwegian immigrant presents with a 6 hr history of severe RUQ pain & N/V.
Physical exam: tachycardia & scleral icterus
↓ Hct is 24%
↑ Total bilirubin 8 (Indirect>direct)
Multiple family members have required blood transfusions
Patient is up to date on the pneumococcal, meningococcal, and H.Flu vaccine series.
Dx/Tx?
Hereditary Spherocytosis (AD)
Splenectomy
(Autosomal Dominant congenital hemolytic disorder → RBC are vulnerable to osmotic stress)
Negative Coombs test in HS eliminates autoimmune Hemolytic Anemia
note: TTP is also coombs Negative however HS has ↑MHHC unlike TTP
Hereditary Spherocytosis (AD)
results from a mutation in __ & ___ proteins
resulting in excessive hemolysis of RBCs by splenic macrophages (MQs).
SPECTRIN
ANKRIN
(band proteins)
Finding can be seen in Cushing dz and Addison’s dz
Hyperpigmentation
Cushing Syndrome: Adrenal cortex adenoma
Buffalo Hump & Moon Faces
__ Cortisol & __ ACTH
Addison: Adrenal insufficiency
Hyperpigmentation, Fatigue, GI sxs
Hyperkalemia/Hyponatremia (low Aldo)
↓ Bicarb
__ Cortisol & __ ACTH
+ one unique lab value in Addison’s that may be given?
Cushing: ↑ Cortisol & ↓ ACTH
Addison: ↓ Cortisol & ↑ ACTH
+ ↑ Eosinophils
Diagnostic test for pt w/ suspected Addison’s dz?
Treatment for Addison’s (2)?
Cosynotropin (synthetic ACTH analog) test
If Cortisol does not rise = confirms Addison’s dz
Tx: Hydrocortisone (Replaces cortisol) & Fludricortisone (replaces Aldosterone)
Diagnostic Steps for suspected Cushing’s dz
1st: Confirm they have adrenal excess (3)
2nd: Get serum ACTH levels to see if
-↓ ACTH Independent → NBSIM
- ↑ ACTH Dependent → NBSIM
1st pick one test
-Dexamethasone suppression (cortisol will not suppress)
-24hr urine cortisol
-Late night salivary cortisol
——————
2nd is it ACTH Independent or Dependent
↓ ACTH (independent) = adrenal adenoma making cortisol → CT or MRI Abdomen/Adrenals
↑ ACTH (dependent) = pituitary or lung tumor secreting too much ACTH → High Dose Dexamethasone suppression test
———
Results of high dose Dex test
↓ Cortisol → Pituitary adenoma making ACTH (Cushing’s dz) → MRI Brain
↑ Cortisol → Paraneoplastic disorder (Small Cell Lung Cancer) → Chest CT
Acute cholangitis Pentad:
____ + ____ + ____ + RUQ pain + Jaundice
Labs/Imaging findings :
↑ Direct Bilirubin
↑ LFTs
± Anion gap metabolic acidosis s/t LDH in sepsis.
Dilated CBD
Tx ?
Fever + Hypotension + AMS
Tx: ERCP
Abdominal Pain + N/V
Abdominal x-ray shows dilated loops of small bowel and air in the intrahepatic bile ducts
Dx/Tx?
gallstone ileus (s/t biliary-enteric fistula)
Enterolithotomy
a form of mechanical small bowel obstruction causing pneumobilia (air in the biliary tree)
infection of the gallbladder wall with gas-forming bacteria &
Air within the gallbladder wall
Requires emergency cholecystectomy
Dx? Risk factors (2)
emphysematous cholecystitis
BRF: DM, Atherosclerosis
(Clostridium, E. coli )
Teenager with episodic jaundice provoked by physiologic stress like illness or hunger.
No RUQ pain
↑ Unconjugated (Indirect) bilirubin
Normal LFTs/CBC
Dx?
Gilbert syndrome
No treatment required
↓ UDP glucuronosyltransferase activity = ↓ conjugation of bilirubin
Pregnant patient
Acute Jaundice
Hypoglycemia
Fulminant liver failure & DIC
dx?
Acute fatty liver of pregnancy
pRBC transfusions are recommended in acute GI bleeds for patients with hemoglobin <__ g/dL.
Hgb < 7
Elderly pt + anemia + FOBT (+)
NBSIM?
Colonoscopy
chronic (>2w) diarrhea + Anemia + ↑ESR/CRP
Dx/NBSIM?
Inflammatory bowel disease (IBD)
(Crohn disease, Ulcerative colitis)
Colonoscopy
Elderly Pt + worsening LLQ pain + peritoneal signs
(rebound, rigidity, guarding)
Free air under diaphragm (KUB)
Dx?
Diverticular Perforation
Elderly + chronic constipation + anemia + intermittent painless blood in stool/hematochezia
dx/NBSIM?
Diverticulosis (causing Diverticular Bleeds)
Colonoscopy
mcc of lower GI bleeds in adults
Elderly pt + fever + LLQ abdominal pain + recent change in bowel habits
Labs
↑ Wbcs ± ↓ Hb
↑ BUN + Cr
↑ ESR/CRP
(+) FOBT
± tender, palpable mass
± Pyuria
Dx/NBSIM/Contraindicated test?
Diverticulitis
CT abdomen with IV contrast
colonoscopy is contraindicated
colonoscopy recommended 6–8 weeks after the resolution to r/o malignancy
Typically asymptomatic but occasionally presents in elderly pt as changes in bowel habits + abdominal discomfort (usually LLQ sigmoid)
Diverticulosis
can result in diverticular bleed
+ anemia
+ Hematochezia
± abdominal pain
hepatocellular pattern of liver injury (elevated AST/ALT, normal ALP).
List 7 causes for this pattern of liver injury
Viral Hepatitis
Alcoholic Hepatitis
nonalcoholic fatty liver disease (NAFLD)
Autoimmune Hepatitis
drug-induced liver injury
Ischemic hepatic Injury
Wilson dz
Hemochromatosis
Intermittent scleral icterus + ↑ Direct Bilirubin + normal LFTs
dark granular pigments in hepatocytes
dx?
Dubin-Johnson syndrome
Impaired hepatic excretion of conjugated bilirubin
Diabetes + Arthralgias + hyperpigmentation
↑LFTs
dx/tx?
Hemochromatosis (hepatic iron overload)
tx: Phlebotomy
Can be seen in Post-Menopausal women b/c no monthly bleeding (biological phlebotomy lol)
anti- ADAMTS-13 antibodies are present
Thus there is not enough ADAMTS-13 around to combine w/ vWF Matalloprotease in order to inactivate vWF resulting in _______ .
Dx/finish describing the rest of the dz pathology
TTP
vWF is always active → ↓PLTs
(auto-immune dz)
Fever + Neuro sxs +Hemolytic Anemia
+ Shistocytes (due to MAHA)
↓ PLTs ↑ Cr
dx/tx(2)?
TTP
1. Plasmapheresis
2. IvIg
- How does TMP-SMX cause Hyperkalemia?
- How does it impede the degradation of Warfarin
- Sodium Channel blocker
- CYP2C9 inhibitor (which breaks down Warfarin)
-↑ Warfarin
-↑ INR (supratherapeutic)
List one cause of Secretory Diarrhea
HY on NBME
Cholera Toxin
(Adenylate Cyclase)
List one cause of Osmotic Diarrhea
HY on NBME
Lactose Intolerence
Dumping syndrome
Enteric cancer associated with Celiac Dz (gluten-intolerence)
T-cell Lymphoma
