IM mix UWQ - may30th 2021 Flashcards
chemotherapy at risk for opportunistic pathogens?
gram-negative bacillus Pseudomonas aeruginosa.
-> ecthyma gangrenosum
Pyoderma gangrenosum
sym?
neutrophilic dermatosis
-> seen with IBD and arthropathies.
dev rapidly –> begin as a cutaneous papule/nodule–> quickly matures into a painful, purulent ulcer with violaceous borders.
lose weight to achieve and maintain a healthy weight.
rx?
each 10 kg (22 lb) of weight loss can lower blood pressure by ~6 mm Hg;
-> weight loss is one of the most effective nonpharmacologic interventions
Pain in the groin, buttock, or lateral hip (trochanteric) region and can radiate to the lower thigh or knee.
- > mild pain and brief stiffness with prolonged rest <30 mins
- .> worst pain usually occurs with activity and weight bearing
dx?
XR finding?
osteoarthritis of the hip
x-ray:
loss of joint space, osteophyte formation, and subchondral sclerosis.
loc: Knees Hips DIP joints 1st carpometacarpal joint
Lower back pain
rx?
acute <4 weeks: moderate exercise, NSAIDS
subacute/ chronic >12 wks:
exercise rx, TCA, duloxetine
secondary prevention: exercise therapy, education
Vs/ back brace not useful for preventing LBP
high dose drug prolong use>3 month
Constitutional symptoms (eg, fever, malaise)
Arthralgias
Serositis (eg, pleuritis, pericarditis)
Rash (less common compared with SLE)
Dx?
rx induced?
Drug-induced lupus erythematosus
procainamide, hydralazine, penicillamine
Others:
minocycline,
TNF-α inhibitors (eg, etanercept, infliximab),
isoniazid
RF: slow acetylator status
Hypertrophic osteoarthropathy
sym?
- > underlying lung disease (eg, adenocarcinoma, chronic pulmonary infection)
- > arthralgia.
- > skin thickening and digital clubbing
Microscopic polyangiitis and granulomatosis with polyangiitis
(wegener)
-> necrotizing, small-vessel vasculitides
sym?
lab?
- > acute-onset fever
- > tracheopulmonary disease.
- > rhinosinusitis, hematuria, and rash (eg, palpable purpura)
- > saddle nose , hearing loss
lab: c-ANCA: PR3+, MPO+
Osteogenesis imperfecta
defective formation of type 1 collagen,
- > bone, tendons, ligaments, skin, teeth, and sclera.
- > childhood with fragility fractures, short stature, impaired hearing, blue sclera
osteomalacia
-> fatigue, bone pain, and hypophosphatemia
lab?
Asso with: celiac dx, CKD, Chronic liver dx, bypass surgery
↑ Alkaline phosphatase ↑ PTH ↓ Serum calcium & phosphorus ↓ urinary calcium ↓ 25 OH-D levels
X-rays: thinning of cortex with reduced bone density
-> reduced mineralization of the osteoid matrix
Bilateral & symmetric pseudofractures (Looser zones)
amiloride
moa?
sym?
rx?
potassium-sparing diuretic that blocks the epithelial sodium channel (ENaC) in the renal collecting system.
sym:
hyperkalemia
met acidosis
rx: switch rx -> CCB recheck in 1-2 wks
severe hyperkalemia rx:
IV ca + insulin + glc
Goodpasture syndrome)
sym?
hx?
hx:
anti–glomerular basement membrane (anti-GBM) disease
renal bx: formation of antibodies to the alpha-3 chain of type IV collagen
-> linear IgG deposition along the glomerular basement membrane IF
sym:
1. renal : pnuria <3.5g/day, hematuria
2. resp: hemoptysis , SOB
PCP
sym?
HIV patients with CD4 counts <200/mm3.
- > Fever, dyspnea, and nonproductive cough
- > Fatigue, weight loss, and chills
acute-onset, severe headache
vomiting, photophobia, neck stiffness, and lethargy
dx?
Rx?
subarachnoid hemorrhage (SAH) -> ruptured saccular aneurysm
isolated CN palsies -> sign of a compressing aneurysm: Oculomotor nerve (CN III) palsy -> pupillary dilation: loss of PNS, ptosis and down and out due to loss of somatic innervation.
Full or partial oculomotor nerve palsy: enlarging or ruptured aneurysm of the adjacent PCA
Dx: CT angiography
Cavernous sinus thrombosis
sym?
fever, headache, and periorbital swelling.
-> palsy of ICA, CNs III, IV, and VI , V1, v2 resulting in ophthalmoplegia.
JC virus reactivation
untreated AIDS
dx?
Progressive multifocal leukoencephalopathy
MRI:
asymmetric white matter lesions;
no enhancement/ edema
Community acquired pneumonia (CAP)
- > pulmonary parenchymal infection, focal consolidation
sym: develop acutely and include fever, cough, pleuritic chest pain, and dyspnea. - > Tachycardia, tachypnea, focal crackles (right lower lobe)
dx?
> caused by bacterial (majority), viral (30%), or fungal pathogens.
-> strep pneumonia
dx: CXR
- > Symptomatic treatment alone insufficient due to the risk of secondary bacterial pneumonia
chronic pancreatitis
CT: pancreatic atrophy and calcifications
RF: smoking + Etho
rx?
destruction of acinar and islet cells
-> pancreatic exocrine insufficiency.
Pancreatic secretion is stimulated by cholecystokinin (CCK).
Normally, pancreatic enzymes breakdown CCK-releasing protein, thereby limiting CCK release.
pancreatic insufficiency, pancreatic enzyme deficiency
- > release of high volumes of CCK
- > pancreatic hyperstimulation
rx:
Pancreatic enzyme supplementation, lipase, protease, and amylase
obstructed pancreatic duct
dx?
Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and/or stent placement
burning or itching of the lids, discharge (which may be associated with crusting of the eyelashes in the morning),
- > often a foreign body sensation in the eye
- > scaling at the lid margin
Dx?
Blepharitis
-> inflammation at the eyelid margin, usually most prominent at the opening of the meibomian glands.
Asso with:
seborrheic dermatitis
Allergic conjunctivitis
sym?
conjunctival edema
-> prominent (often with papilla formation)
primarily at the conjunctivae rather than lid margin,
Asso with:
seasonal allergies or other atopic disorders.
TCA overdose
- > anticholinergic effects (eg, hyperthermia, flushed skin, dilated pupils, decreased bowel sounds)
- > seizures
- > cardiac toxicity (eg, prolonged QRS interval, hypotension)
antidopt?
Hypotension is treated with isotonic saline boluses;
refractory hypotension may require vasopressors (eg, norepinephrine)
->IV NaHco3:
decreases the incidence of ventricular arrhythmia
anticholinesterase toxicity
sym?
antidopt?
Atropine and pralidoxime
sym:
- > cholinergic toxicity
-> bradycardia, miosis, and salivation.
Hyperkalemia
-> peaked T waves, followed by lengthening of the PR and QRS intervals, and eventually resulting in a sine wave.
-> Bradycardia and muscle weakness
rx?
Calcium gluconate
Systemic sclerosis:
severe hypertension and acute renal failure
-> scleroderma renal crisis
Thrombocytopenia and microangiopathic hemolytic anemia
rx?
renal ischemia
-> activation of the renin-angiotensin-aldosterone system (RAAS).
rx: ACEi
elevated serum creatinine level is not a contraindication for ACE inhibitors
Hemodialysis
-> Urgent indications hyperkalemia, volume overload with respiratory impairment
multiple sclerosis
-> neurologic symptoms (eg, weakness, incontinence)
rx?
interferon beta-1a
MDD
-> anhedonia, feelings of worthlessness, weight loss, low energy, impaired ability to think) accompanied by memory impairment
rx?
depression-related cognitive impairment
rx:
- > selective serotonin reuptake inhibitors (eg, escitalopram)
-> psychotherapy.
AD
rx?
- > Cholinesterase inhibitors (eg, donepezil)
- > NMDA receptor antagonist memantine
treatment of dementia (eg, Alzheimer disease)
-> congenital narrowing of the descending aorta, just distal to the left subclavian artery.
creates a proximal arterial pressure load affecting the upper body
dx?
Coarctation of the aorta
- > Congenital
- > Acquired (rare) (eg, Takayasu arteritis)
- > hypertension
- > continuous murmur
- > S4
CXR:
notching of the posterior third of the third to eighth ribs
-> bony erosion due to enlarged intercostal arteries.
Upturning of the cardiac apex (“boot-shaped heart”)
dx?
tetralogy of Fallot due to pulmonic stenosis and consequent right ventricular hypertrophy.
Diffuse vascular calcifications
dx?
premature ATS with advance renal failure
Prominent right atrial contour
dx?
Ebstein congenital abnormality
-> apical displacement of the tricuspid valve with atrialization of the right ventricle
MM
-> back pain, normocytic anemia, and arm pain
Hx?
dx?
Osteolytic lucent lesion
Dx:
serum pn electrophoresis , M spike
bone marrow biopsy confirm
warning signs consideration of early imaging:
- Neurologic findings: Seizure, changes in consciousness, specific deficits
- Differences compared to prior headaches: Change in frequency, intensity, characteristics
- Other: New at age >40, sudden onset, trauma, present on awakening
Dx?
Dx: MRI
- > lymphoplasmocytic malignancy
- > excessive production of monoclonal IgM antibody.
sym:
- > hyperviscosity syndrome (diplopia, tinnitus, headache, dilated/segmented funduscopic findings),
-> neuropathy (electric sensation), infiltrative disease (hepatosplenomegaly, anemia, thrombocytopenia)
dx?
Waldenstrom macroglobulinemia (WM
dx: monoclonal spike (M-spike) of IgM
- > bone marrow biopsy showing >10% clonal B cells
Multiple myeloma (MM)
lab?
monoclonal IgG, IgA, or light chains
-> CRAB
bone pain
Psoriatic arthritis (PsA)
sym?
X-ray:
narrowing of the proximal phalanx with erosion of the distal phalanx (pencil-in-cup deformity) and new bone formation
cyclical/episodic
–> rather than chronic/slowly progressive.
- > Prolonged (>30 min) morning stiffness and pain lessen, not worsen, with activity.
- > involves the DIP and PIP joints;
AR
RF?
sym?
Backflow from aorta into LV → ↑ LV end-diastolic volume
LV initially compensates with eccentric hypertrophy → ↑ SV & CO
–> bring ventricular closer to chest wall -> pounding snesation and pounding in left decubitus position
Eventual LV dysfunction → ↓ SV & CO → heart failure
- Congenital bicuspid aortic valve
Postinflammatory (eg, rheumatic heart disease, endocarditis) - Aortic root dilation (eg, Marfan syndrome, syphilis)
sym:
Decrescendo diastolic murmur
Widened pulse pressure (↑SBP & ↓DBP)
Rapid rise-rapid fall (“water-hammer”) pulsation
Abrupt carotid distension & collapse, “pistol-shot” femoral pulses
constrictive pericarditis
sym?
dx?
etio: idiopathic viral pericarditis (>40%) radiation therapy (~30%) cardiac surgery (~10%) connective tissue disorders
eg. TB
impairs ventricular filling during diastole,
- > decreased cardiac output (fatigue and dyspnea on exertion)
- > venous overload (elevated JVP, ascites, and pedal edema).
- > Kussmaul’s sign, lack of the typical inspiratory decline in central venous pressure, pericardial knock (early heart sound after S2)
- > Sharp x and y descents on central venous tracing.
Pericardial calcification
normal thyroid function with an estrogen-induced
lab?
-> increase in T4-binding globulin (TBG), transthyretin, and albumin.
increase the level of TBG by decreasing its catabolism and increasing its synthesis in the liver.
- > more TBG binds more TH
- > TH production inc to maintain a euthyroid state;
- > slight elevation in total T4 level
Only the free (ie, unbound) thyroid hormones are biologically active
ankylosing spondylitis (AS)
Rx?
Nonpharmacologic
measures:
Exercise (postural exercises, ROM/stretching exercises)
Physical therapy
Initial treatment:
- NSAIDs (eg, ibuprofen, naproxen)
- COX-2 inhibitors (eg, celecoxib)
Rx fails:
1. TNF-α inhibitors (eg, etanercept, infliximab)
- Anti–IL-17 antibodies (eg, secukinumab)
prevent rejection in patients with allogeneic transplants
rx?
Mycophenolate
cluster headaches
rx?
100% o2 + sumatriptan
hereditary hemochromatosis
sym?
rx?
elevated iron studies.
Diagnosis: genetic analysis of HFE mutations
- > hepatic fibrosis and cirrhosis
- > skin pigmentation (sun-exposed areas, scars, genitalia),
- > diabetes mellitus (“bronze diabetes”),
- > arthropathy
- > hypogonadism (diminished libido, erectile dysfunction [ED])
Serial phlebotomy to deplete excess iron stores
-> reduce the risk for cirrhosis and HCC.
Hemolytic anemia due to intravascular erythrocyte trauma
lab?
schistocytes or helmet cells
Intravascular erythrocyte destruction-> free hemoglobin in the serum (hemoglobinemia) + urine (hemoglobinuria)
-> increased serum lactate dehydrogenase
Haptoglobin is a serum protein that binds free hemoglobin -> excess amount of free hemoglobin in the serum decreasing the level of haptoglobin
deep venous thrombosis (DVT)
wells score?
dx?
rx?
Patients with a score ≥2 (eg, pitting edema, calf swelling >3 cm compared to the other leg) more likely to have DVT
dx: compression ultrasonography
rx: anticoagulation
Medications for osteoporosis?
- Bisphosphonates
(eg, alendronate,
risedronate)
-> First-line treatment for most patients
2. Selective estrogen receptor modulators (eg, raloxifene) -> Less effective -> May lower risk of breast cancer -> Increased risk of DVT, hot flashes, endometrial ca, uterine sacroma
Rx induce EPS ?
sym?
moa?
rx?
metoclopramide
prochlorperazine
moa:
DA antagonist
sym:
EPS : ADAPT
acute dystonia
-> muscle spasm/ stiffness , oculogyric crisis, laryngeal dystonia
akathisia
parkinsonism
tartive dyskinesia
rx:
benzotropine (antiAch rx) / diphenhydramine
aprepitant
moa?
sub P NK1 receptor antagonist
self induce vomiting
diuretics overuse
lab?
Loss HCl-
hypochloremic
met alkalosis
ph>7.45
hco3 >24
low urine chloride < 20
persistent diarrhea
RTA
lab?
severe hypokalemia
low Ph ( met acidosis) low Hco3 non-AG met acidosis
MC community-acquired bacterial meningitis?`
dx?
rx?
Streptococcus pneumoniae
dx:
Blood cultures + lumbar puncture.
Rx:
- > third-generation cephalosporin (eg, ceftriaxone), -> vancomycin,
- > dexamethasone (to reduce inflammatory morbidity)
atelectasis
BS?
percussion?
tactile fremitus?
-> BS: dec
-> percussion: dull
-> tactile: dec
mesiastinal shift: towards
Bacterial pneumonia
BS?
percussion?
tactile?
BS: inc
percussion: dull
tactile: inc
mediastinal shift: none
Lymphoma / sarcoidosis
sym?
-> bilateral hilar lymphadenopathy
Raising the cut-off point ?
sens?
spec?
increasing the inclusion criteria) of a screening test:
- > increase in specificity (SpIN)
- -> TN/TN+ FP
- > decrease in sensitivity (SnOUT)
- -> TP/TP+FN
- -> higher cut off pt : dec TP, dec FP
** TP close to =1
FP : 1- specificity =
Bells pasly, unilateral facial paralysis
sym?
rx?
dx?
sym:
- > acute (over the course of hours) and progressive
- > within 3 weeks.
- > auricular pain or dysacusis (distortion of sound)
rx:
- > prednisone
- > corneal protection strategies
dx: NOT needed if classic presentation!!!
pre-renal azotemia ( renal hypoperfusion)
lab?
inc BUN/Cr > 20:1
inc Urea absorption
-> systemic hypovolemia / impaired CO
erectile dysfunction
rx?
PDE-5 inhibitor ( sildenafil)
etio: CVD
** not remove current medication
Pneumothroax
etio?
sym?
PEEP vent: alveolar damage, pneumothroax, hypotension
–> sudden SOB, tachycardia, hypotension, tracheal deviation
-> unilateral absence BS, impaired ventricular filing
Atelectasis
sym?
cough , dyspnea dec PaO2 stats
-> NO hypotension cuz not compression mediastinum
pul embolism
sym?
sudden-onset SOB , tachypnea, hypoxia, hypotension
cardiac tamponade
sym?
beck’s traid:
hypotension, elev CVP, muffled heart sound
etio: build up of fluid around heart compressing
** NOt have unilateral absence BS
high output HF
sym?
- > dec SVR –> inc CO
- > brisk ocarotid upstroke
- > widened pulse pressure
etio:
1. bypass SVR -> AV fistula
- inc peripheral vessels -> morbid obesity (MC); paget dx
- vasodilation unmet metabloism demands in tix -> hyperthyroidism, sever anemia, thiamine def
sym:
- > eccentric LVH -> inc VR + venous hydrostatic pressure inc
- > peripheral edema
- > pul edema
Dual antiplatelet therapy
moa?
DAPT with ASA
-> P2y12 receptor blockers : clopifogrel, prasugrel , ticagrelor
additional rx:
- > beta blockers
- > ACEI
- > statins
- > aldosterone antagonist
apixaban
mao?
FXa inhibitor
rx: DVT + PE
chlorpheniramines
moa?
asso with allergic rhinitis
postnasal drip, asthma, GERD induce
–> chronic cough >8 wks
moa:
reduce H1 receptors –> blocking histmine relase mast cells
–> blocking nasal secretion
** inhaled corticosteroids: dec airway inflammation
mucosal neuroma
risk for?
MEN2B
-medullary thyroid ca
- pheochromocytoma
- marfanoid habitus
mucosal neuroma
Tuberous sclerosis
sym?
HARMOTOMS
- > seizures
- > ash-leaf sopts
- > facial angiofibromas
- > shagren patches
hereditary hemorrhagic telangiectasis ( osler weber rendu syn)
sym?
- > AVM
- > massive hemoptysis, GI bleeding
- > mucosal telangiectasias
acute otitis externa
etio?
moa?
sym?
rx?
“swimmers ear”
-> water exposure
-> trauma
foreign bodies ( earbuds, hearing aid)
etio: pseduomonas , s. aureus
sym:
- > otalgia, pruritus, discharge, hearing loss
- > pain with auricle manipulation
- > ear canal erythema, edema, debris
rx: topical fluroquinolone
otitis media with effusion
sym?
ear pain + fullness
-> drainage in presence TM perforation
-> less common
osmotic / sevretory diarrhea
stool osm gap?
moa?
lab?
osmotic diarrhea: moa: nonabsorbed Osm active solute
- > polyethylene glycol, sorbitol, lactose
- > inhibits water resorption
- -> SOG > 125
lab:
SOG = 290 - 2 x (stool Na + stool K)
<50 secretory diarrhea -> toxin ( v. cloria , hormones, CF, bile acid, postsurgical bowel resection)
–> persistent while fasting at night
50-125 indetermin
> 125 Osmotic diarrhea ( lactose intolerance)
–> after ingestion
SIADH
Sq call Ca ( inc ADH)
lab?
rx?
inc ADH –> inc water reabsorption
- > high Urine Na
- > low renin, low aldo
-> euvolemic hyponatremia ( diluted by excess water reabsorption)
lab:
- > serum osm < 290 ( diluted by water)
- > urine Osm >100 ( more concentrated )
- > high urine Na >25 (concentrated with water all reabsorbed)
rx:
- > fluid restriction
- > hypertonic saline (3%) -> careful infusion
- -> <8 mEq/L over 24 hours avoid Osmotic demyelination syn
DI central
lab?
rx?
low ADH -> losing water
- > low ADH
- > low urine Na ( diluted urine with excess water)
- > polyuria, polydypsia
rx: desmopressin ( ADH analong)
BZD
se?
occur within a hour after ingestion:
paradoxical agitation -> in elderly
-> taper off
PEEP effects?
decomp LHF with cardiogenic pul edema
- S3, crackles, hypoxemia
PEEP effects: 5-20cm H2O
- > inc Intrathoracic pressure -> drop in VR to RH
- -> dec RV preload ( dec CVP)
- -> inc RV afterload (PCP) compresses alveolar capillaries
- -> dec LV preload (less blood voln returning to LA)
- -> dec MAP thru baroreceptor effects by lowering adrenergic tone-> dec neurohormonal activation
- -> dec LV transmural pressure
- -> dec LV afterload
- -> inc PaO2, LV performance, CO
- -> inc end-organ O2 delivery + survival
primary polydipsia
lab?
etio:
schizo, excess water intake
excess hypoNa -> excess ADH secretion
hyponatremia and dilute urine with urine osmolality <100 mOsm/kg.
significant hyponatremia can develop confusion, lethargy, psychosis, and seizures
MDD with psychotic features
sym?
rx?
MDD in which the patient develops psychotic symptoms during a depressive episode.
rx:
- > combined antidepressant and antipsychotic
- > electroconvulsive therapy
- -> faster response in elderly patients unable to eat/ dink with suicidal thoughts
Persistent complex bereavement disorder (complicated grief)
sym?
intense yearning for the deceased that persists for at least 6 months to a year after the loss.
-> It is not associated with psychotic features.
Spironolactone and eplerenone
mineralocorticoid receptor antagonists (MRAs)
chi-square test
testing?
relationship between 2 categorical variables. –> qualitative (gps/ categories)
- > categorical INdependent variable (eg, exposure or intervention)
- > 2 groups and a categorical dependent variable (eg, outcome).
Two-sample t-test
- > Compares the MEAN of a quantitative variable of 2 independent groups
- -> quantitative ( # value )
eg. comparing serum ferritin concentrations (ie, quantitative variable) in male and female patients ( qualitative -gps)
correlation analysis
testing?
- > correlation coefficient to describe the LINEAR relationship between 2 quantitative variables
- > evaluating the linear relationship between stress level and irritability score
Exercise-associated postural hypotension
sym?
moa?
- > sudden decrease in VR after cessation of exercise, which fails to meet increased cardiac demand.
- > collapse (with no loss of consciousness) immediately after completion of exercise.
Exertional hyponatremia
sym?
- > excessive fluid intake (weight gain).
- > confusion, headache, and swollen hands after prolonged heat exposure
- > seizure, collapse.
Phencyclidine intoxication
sym?
- > psychosis in addition to combative behavior
- > delirium: hallucinating immediately
- > dissociative symptoms,
- > ataxia
- > nystagmus
Alcoholic hallucinosis
sym?
time frame?
Visual, auditory, or tactile; intact orientation; stable vital signs
time:
12-48 hrs
rx: BZD
Delirium tremens
sym?
time frame?
- > Confusion, agitation, fever, tachycardia, hypertension, diaphoresis, hallucinations
time: 48-96 hr
Acute bacterial prostatitis
sym?
dx?
rx?
sym:
- > perineal pain: Lower UTI
- > systemic symptoms (eg, fever, chills, acute illness),
- > tender, swollen prostate on digital rectal examination
dx: U/C
rx: 6 wks of AB (eg, trimethoprim-sulfamethoxazole, fluoroquinolone
Roux-en-Y gastric bypass
complication sym?
dx?
rx?
- > stomal (anastomotic) stenosis
- > progressive narrowing of the GJ anastomosis that leads to obstruction of gastric pouch outflow.
dx:
- > esophagogastroduodenoscopy (EGD),
- > balloon dilation can be performed to open the narrowing.
Acute nitrofurantoin-induced pulmonary injury
sym?
->
hypersensitivity that can present with fevers, shortness of breath, dry cough, and erythematous rash
-> begin 3-9 days from medication initiation
XR: bil basilar opacities, pleural effusion (unilateral)
AIN
sym?
fever, eosinophilia
-> nonsp sym , n/v
RCC
sym?
- > ASX
- > flank pain, hematuria, abd renal mass
- > varioceles fails to emply -> tumor ob gonadal vein
- > inc EPO: polycythemia asso with anemia
dx:
- > abd CT scan
