IM SHELF Flashcards
Pulmonary infiltrates d/t bacterial pnuemonia take how long to resolve?
Weeks to Months
If it resolves right away, likely CHF exacerbation (CHF exacerbated by URI)
CHF causes bilateral pulmonary infiltrates
When do you use LMWH Vs. Unfractionated Heparin?
LMWH = PREVENTING DVT’s
Unfractionated = TREATING DVT’s
Digital rectal exam BPH vs. Prostate cancer?
BPH = Enlarged but smooth prostate
Cancer = Nodules, induration, & asymmetric prostate enlargement
Next test of choice is UA to r/o UTI or hematuria
Most important Prognostic factor for melanoma?
Tumor Thickness
Membranoproliferative Glomerulonephritis description & association?
Double layered basement membrane (Tram Track)
Subendothelial deposits
Associated with Hepatitis C infection (Type 1)
Type 2 = High levels of c3 nephritic factor
Membranous Nephropathy description & association?
Thickening of GBM w/ IgG deposits & c3
Associated with Hepatitis B
Large bowel ischemia causes & presentation?
Rapid onset (focal) tenderness in the affected bowel w/ rectal bleeding
Most important risk factor is aortic surgery (IMA ligation)
Commonly in the LEFT colon (watershed) areas
i.e. splenic flexure / rectosigmoid
Small bowel ischemia causes & presentation?
SEVERE abdominal pain out of proportion to physical exam findings
Also vomiting will be present
Patient trying to quit nicotine but w/ known seizure disorder, what medication?
Varenicline
Nictoinic ACh receptor partial AGONIST
Nephrotic syndrome important complication in men?
Renal Vein Thrombosis
Hematuria, Flank Pain, Scrotal enlargement
The Hypoalbuminemia causes patients to become hypercoaguable due to the loss of Protein C, S, Plasminogen, & Antithrombin III in their urine
Celiac disease is suspected, what is the most appropriate next step in management?
Testing for Tissue-Transglutaminase IgA
Duodenal biopsy can then be used to confirm the diagnosis – Villous atrophy & crypt hyperplasia
Lactose Intolerance diagnostic tests?
Increased stool Osmolarity
Decreased Stool pH
(+) Lactose-Hydrogen breath test
Normal appearing Villi on biopsy
Inflammation within the brush border of the small intestine = 2nd LI
Pancreatic insufficiency diagnostic tests?
Normal absorption of D-Xylose
Decreased Duodenal Bicarbonate
Decreased Duodenal pH
Decreased Fecal Elastase
What complication is most strongly associated with permanent transvenous dual-chamber pacemaker implantation?
Severe Tricuspid Regurgitation
Holosystolic murmur @ left sternal border & signs of right-sided HF i.e. JVD & Peripheral Edema
What virus is a known trigger for Psoriasis?
HIV
Can cause sudden-onset severe disease
Fun little list of dermatological manifestations of disease
Acanthosis Nigricans = Insulin resistance
Disseminated molluscum contagiosum = HIV
Lichen Planus = HCV
Oral Candidiasis = HIV
Porphyria Cutanea Tarda = HCV
Sudden Seborrheic Keratoses = GI malignancy
Presentation of Adrenal crisis? Glucose, sodium, potassium, ABGs?
Treatment?
Hypotension, N/V,
Hypoglycemia & Hyponatremia
Hyperkalemia
Normal anion gap metabolic acidosis
TX = Volume resuscitation w/ crystalloid solutions i.e. Normal Saline or LRs & IV corticosteroids i.e. Hydrocortisone & Dexamethasone
When is IV Colloid solution used?
i.e. Albumin
In patients w/ significant third spacing i.e. liver failure, burns
A common use is during a therapeutic paracentesis – given in order to prevent compensatory fluid shifts & severe hypotension following the procedure
Asbestosis presentation? MC complication?
20-30 years after exposure
Bibasilar reticulonodular infiltrates & bilateral pleural thickening
Bronchogenic Carcinoma MC than Mesothelioma
Bronchogenic carcinoma is a blanket term for cancer that arises within the lungs
Mesothelioma is not a form of bronchogenic carcinoma given that it arises within the pleura
Cardiac Tamponade triad? ECG?
Beck’s triad = Hypotension, Muffled heart sounds, JVD
Pulsus paradoxus
Alternating QRS amplitudes
TX = Pericardiocentesis to drain pericardial fluid
When do you use Ursodeoxycholic acid?
TX of cholesterol gallstones i.e. gallstone induced biliary colic
When patients are poor surgical candidates or decline surgery
Why do you see Hyperkalemia in the setting of DKA?
Primarily due to underlying insuiln deficiency – this leads to impaired cellular uptake of potassium
Prosthetic valve thrombosis presentation?
How to confirm DX?
New onset / worsening murmur
Stroke / TIA
Increase D-Dimer (nonspecific)
Echo = CONFIRMATORY
Target INR for patient’s with prosthetics is higher (2.5)
What finding is almost always present in a patient w/ PE?
Sinus Tachy will always always be present on a question
Chron’s affects which location?
Buzz words?
Hematologic association?
Ileum is the MC site of involvement
RLQ pain vs. diverticulitis (LLQ)
B12 is absorbed in Ileum, so CD patients develop macrocytic anemia secondary to B12 deficiency
2 peaks of disease incidence:
1. 15-30 YO = MC
2. 2. 60-80 YO = Less common
Buzz words = Noncontinuous skip lesions, noncaseating granulomas, & lymphoid aggregates
Transmural inflammation, kidney stones, gallstones
Nitrofurantoin MOA?
Use?
SE?
Bind to bacterial ribosomes & inhibit protein, DNA, & RNA synthesis (Bactericidal)
Acute uncomplicated UTIs
UTI in pregnant women
NOT used in pyelonephritis because it does not concentrate in renal tissue
SE = Nitrofurantoin induced lung disease w/ eosinophilia
Pulmonary fibrosis w/ chronic use
Why is tumor lysis syndrome an oncologic emergency?
What is Pathognomonic for TLS?
Because there is a massive release of intracellular components such as Potassium, Phosphate, & Uric acid, all of which damage the kidneys & cause renal failure (AKI)
Decrease in calcium d/t increase in phosphate (binding to calcium) = Hypocalcemia = PATHOGNOMONIC = Risk of seizure
That increase in phsophate binds calcium & can also cause calcium phosphate crystals that obstruct the renal tubules = AKI
Hyperkalemia = Arrhythmias
Prophylaxis = Rasburicase (Breaks down UA into allantoin)
How to prevent febrile nonhemolytic reaction?
Leukoreduction – removes leukocytes to prevent cytokine release
What complication do you need to worry about months out from an MI?
LV aneurysm
ECG shows deep Q waves
Warfarin-induced skin necrosis MC seen in what type of patients?
Patients with Protein C deficiency
First step in management of respiratory TB?
Immediately in respiratory isolation
MCC of painless lower GI bleeding in adult patient?
Diverticulosis
Differentiate from hemorrhoid because this causes pruritis
Acute Cholangitis patho?
Presentation?
Ascending infection of the biliary tree d/t biliary obstruction by gallstone, malignancy, or stricture
Charcot Triad (First 3) & Reynolds Pentad = Fever, Jaundice, RUQ pain, Altered mental status, & Hypotension
Sarcoidosis presenting symptoms?
Systemic Granulomatous Inflammation
Peripheral Lymphadenoapthy & Hypercalcemia
How do you treat hepatic encephalopathy i.e. an alcoholic presenting with jaundice & asterixis?
Nonabsorbable disaccharides i.e. Lactulose
This lowers serum ammonia
Asterixis – a tremor in the hands that is seen when the arms are held outstretched with the wrists dorsiflexed (As if stopping traffic) = MC physical exam finding
TX-resistant HTN w/ Hypokalemia home run?
Hyperaldosteroneism
After checking plasma renin & aldosterone – the next step is to do adrenal imaging because treatment varies
Bilateral adrenal hyperplasia is treated w/ drugs i.e. aldosterone antagonist (Spironolactone)
Unilateral adrenal adenoma is treated with surgery
Granulomatosis w/ Polyangiitis classic symptoms?
Concomitant hemoptysis & hematuria are the hallmark
Chronic Sinusitis
C-ANCA
Clinical presentation of fibromuscular dysplasia?
Resistant HTN
Hypokalemia
Cervical bruit
Patients with secondary hypothyroidism will have a medical history of what usually?
Pituitary tumors, Brain surgery, or Cranial radiation
Labs will show DECREASED TSH (as opposed to primary, increased TSH to try & compensate)
ABCDE of Malignant Melanoma
Asymmetry, Border irregularity, Color, Diameter (>6), & Evolution
Hypokalemic patient’s characteristic finding on ECG?
U Waves
Flattened or Inverted T waves
Zollinger-Ellision Syndrome classic triad?
Neuroendocrine tumor that results in
1) Excess gastrin (Gastrinoma)
2) Excess acid production
3) Severe Peptic ulcer disease
Very acidic environment, stomach pH is very low
MEN-1 Association – PPP = Parathyroid, Pancreas, Pituitary
B12 deficiency presentation?
Megaloblastic anemia w/ Hypersegmented Neutrophils
Elevated homocysteine & Methylmalonic acid
B12 binds to Intrinsic factor (Produced by gastric parietal cells) & is absorbed @ the Ileum
Pernicious anemia, chronic gastritis, PPI, & gastrectomy are all common causes
MCC of CKD?
MC complication of CKD?
Diabetes & HTN
Hyperphosphatemia is the MC complication as the kidneys are unable to excrete the phosphorus
CKD is diagnosed when serum creatinine is constantly greater than 1.4
Other disturbances: Metabolic acidosis, Hyperkalemia, Hypocalcemia, Decreased Calcitriol, & Increased BUN
Patient who has BPH & can’t sleep d/t having to wake up to urinate 5-6x a night. What is the most important next step?
Administer Alpha-1 adrenergic antagonist
i.e. Zosins
Finasteride (5-alpha reductase inhibitor) is important & given concurrently w/ a Zosin, however, this medication takes 5-6 months to acheive desired effect. Therefore, A-1 antagonist should be given first
Finasteride works by reducing the size of the prostate gland by reducing production of DHT
Polyarteritis Nodosa classic presentation – Must not miss??
Tender subcutaneous nodules
Medium-sized arteries affected
Microaneurysms d/t transmural necrosis
Short term TX if severe = Glucocorticoids & Plasma exchange when there’s associated Hepatitis B or C (HY)
Mild cases = Antivirals, even in severe cases you use antivirals but also the above to give time for it to kick in
Patients who have underwent coronary catheterization studies & few days later present with renal symptoms, concern for what?
ATN = Muddy brown / Granular casts = Intrinsic renal failure
Sodium absorption is impaired, therefore sodium excretion in the urine is increased
Fractional excretion of sodium > 2%
On PFT’s, the diffusion capacity for carbon monoxide (DCLO) in asthma is what vs. emphysema?
DCLO is normal in asthma
DCLO is decreased in emphysema
Thyroid Storm Presentation & treatment?
Basically clinical Hyperthyroidism on steroids
Altered mental status & Temperature b/t 104 & 106
Propranolol, PTU (works faster than Methimazole), Hydrocortisone, & Stable iodine 1 hour after PTU administration
Presentation of Gastric Carcinoma?
Clinically silent until it has progressed
Start with EGD & staging is done with abdominal CT
TX is Gastrectomy w/ or w/o chemo
Timing of Cardiac biomarkers in the setting of acute MI?
Myoglobin is first to appear (although unspecific) within 2 hours
CKMB arises 3-6 hours after acute MI & returns to normal in 2-3 days
Troponin arises 2-6 hours after onset & peaks 2 days later. Troponin elevation lasts for 4-10 days. Making it useful for both acute MI & recent MI
Classic sx to look out for in pancreatic cancer?
Painless jaundice, abdominal pain (may or may not radiate to the back)
Labs will show increased ALP, & bilirubin d/t biliary duct obstruction from the tumor
CT of abdomen is first line
CA-19-9 is NOT used for dx but for staging & prognosis
Tension Pneumothorax presentation?
Displacement away from the side of the pneumothorax
Diaphragm is flattened on the side of the pneumothorax
Immediate needle thoracotomy
Characteristic findings for Multiple Myeloma?
Fractures, bone pain, anemia, recurrent infections
Plasmacytosis on bone marrow biopsy
Remember, that this is an overproduction of IgG, not IgM – Therefore, IgG spike on electrophoresis
Seborrheic Dermatitis classic presentation?
“Seborrheic” refers to sweat glands
Therefore, this rash presents in sweat rich areas you stupid fuck i.e. face, scalp, cheeks, armpits, groin
White / yellow scales
This condition is chronic, so look for periods of relapse & remission
TX = Topical antifungal i.e. Ketoconazole (Believed to be caused by Malassezia yeast)
Acute Intermittent Porphyria
Unexplained abdominal pain with psychiatric abnormalities
Pinkish urine w/ increased urine Porphobilinogen
Associated w/ Alcohol, OCPs, & Hepatitis C
Important SE of ACE inhibitors?
Hyperkalemia – by reducing the amount of aldosterone acting on the distal tubule – resulting in sodium loss & potassium retention
Potential reduction in GFR by reducing the constriction of the efferent arteriole
Cardiac Myxoma classic presentation?
Females
More commonly affects the LA – mimicing mitral valve disorders
IL-6 production by the tumor
Early diastolic “tumor plop” mimicing mitral stenosis – murmur changes in frequency w/ changes in body position
Increased risk of Embolic stroke
Treatment for Hyperkalemia?
Calcium Gluconate = NOT for correcting the hyperkalemia, but for it’s cardioprotective effects in preventing arrthymias
Sodium Zirconium Cyclosilicate = GI cation exchanger that binds K+ in GI tract & exchange it for other cations & potassium elimination in stool
Insulin w/ glucose to cause intracellular K+ shift
Sodium Bicarb should NOT be used in the absence of Metabolic acidosis
MCC of small bowel obstruction?
DX?
TX?
MCC is post-surgical adhesions
Patient’s present w/ Abdominal distension w/ hyperactive bowel sounds
Periumbilical pain w/ exacerbations every 5-10 minutes. N/V after the onset of pain and is MC w/ SBO than colon obstruction
DX = Abdominal radiograph showing dilated small bowel loops & air-fluid levels
Lactic acidosis is a poor prognostic sign, indicating necrotic bowel
TX = Place NG tube for Decompression
TX for acute exacerbations of MS?
TX for long term / chronic MS?
Methylprednisolone for acute attacks
Interferon-beta is 1st line for long-term relapsing-remitting MS
How do you calculate the serum ascites albumin gradient? (SAAG)
Serum Albumin - Albumin level in ascitic fluid
SAAG Greater than 1.1 suggests portal HTN as the cause
If varices is present, start TX w/ propranolol as prophylaxis for variceal hemorrhage
Any patient’s with diabetes who presents w/ severe sinusitis should be immediately suspected for what?
Mucor Amphibiorum
Necrosis of the palate / nasal turbinates
Immediate debridement & IV Ampho B
What is pulseless electrical activity?
TX?
The presence of organized rhythm on caridac monitoring in the absence of a palpable pulse of measurable blood pressure
TX = Chest compressions & Epinephrine
This is a non-shockable rhythm, therefore no cardioversion or defib (like asystole)
Synchronized cardioversion is done when?
When the patient has a pulse
Prerenal disease causes & lab values?
True volume depletion
UA is normal
Fractional excretion of sodium <1%
Urine sodium <20
If you suspect T2D in a patient, what test can you use to confirm if the patient is symptomatic?
Random glucose check – 200 or greater can confirm the diagnosis if patient is symptomatic
Type 1 RTA Patho? Lab findings? TX?
Defect in hydrogen ion secretion in the distal tubule
Severe hypokalemia can result in muscle weakness / arrthymias
Urine pH > 5.5 w/ Hypokalemia
TX = Sodium Bicarb to correct the metabolic acidosis & replace the potassium
If diarrhea persists while fasting, what type is it? What is the diagnostic method?
Secretory diarrhea
Low stool osmotic gap = < 50
Patients w/ history of ileal resection
Patients receiving mechanical ventilation w/ refractory increase in ICP, what is the best course of action?
Hyperventilation – Increasing the respiratory rate
This decreases the amount of paCO2 – Which causes vasoconstriction, this vasoconstriction decreases cerebral blood flow & therefore decreases ICP
Clinical manifestations of VHL?
Bilateral Renal Cell Carcinoma
Hemangioblastomas all over (retina)
Pheochromocytomas
Hamartomas = Tuberous sclerosis
Mallory-Weiss vs. Boorhaeve syndrome?
Mallory-Weiss = Longitudinal submucosal tear w/o full thickness perforation (typically hemodynamically stable & appear well)
Boorhaeve = Full thickness, transmural tear (More unstable than MWT)
What other autoimmune diseases tend to roll w/ celiac disease?
T1D, Selective IgA deficiency
Dermatitis Herpetiformis
Biopsy of celiac will show intraepithelial lymphocytes, villous atrophy, & crypt hyperplasia
MC presenting symptoms of Sheehan syndrome?
Hypotension, fatigue, & failure of lactation
Pituitary Necrosis – Complication of childbirth that results in acute blood loss
Abdominal Pain by location:
LUQ = Splenic rupture / Pancreatitis
RUQ = Hepatitis
LLQ = Diverticulitis
RLQ = Appendicitis
What is Pathognomomic for Lyme disease?
Complications if left untreated?
Erythema Migrans – Circular erythematous macular rash w/ clearing surrounding an erythematous center w/ target apperance = “Bull’s eye”
Untreated = Lymphocytic Meningitis, facial palsy, & Heart block
Alpha-1-Antitrypsin deficiency presents how?
Look for a non-smoker in their 40s & 50s who present w/ COPD sx – Productive cough & progressive dyspnea or FHX of simultaneous Pulmonary & liver disease
A-1-AT will be very low in severe forms of disease
When to start TMP-SMX in HIV (+) pt
When CD4 count < 200
Non-hemolytic febrile transfusion reaction treatment?
Centrally acting cyclooxygenase inhibitor i.e. Aceteaminophen
Acute hemolytic reaction pathogenesis?
Lab findings?
Intravascular or extravascular?
Caused by ABO incompatibility – Patients AB attack the donor blood
Labs = Increased Lactate dehydrogenase & Decreased Haptoglobin – Hence, Intravascular hemolysis
TX = IV fluids + Mannitol or Furosemide to maintain urine output
Closed angle vs. open angle glaucoma?
Closed angle is more acute – Presents w/ unilateral eye pain, corneal clouding, patient’s say they see halos around lights
