IM SHELF Flashcards
1
Q
Pulmonary infiltrates d/t bacterial pnuemonia take how long to resolve?
A
Weeks to Months
If it resolves right away, likely CHF exacerbation (CHF exacerbated by URI)
CHF causes bilateral pulmonary infiltrates
2
Q
When do you use LMWH Vs. Unfractionated Heparin?
A
LMWH = PREVENTING DVT’s
Unfractionated = TREATING DVT’s
3
Q
Digital rectal exam BPH vs. Prostate cancer?
A
BPH = Enlarged but smooth prostate
Cancer = Nodules, induration, & asymmetric prostate enlargement
Next test of choice is UA to r/o UTI or hematuria
4
Q
Most important Prognostic factor for melanoma?
A
Tumor Thickness
5
Q
Membranoproliferative Glomerulonephritis description & association?
A
Double layered basement membrane (Tram Track)
Subendothelial deposits
Associated with Hepatitis C infection (Type 1)
Type 2 = High levels of c3 nephritic factor
6
Q
Membranous Nephropathy description & association?
A
Thickening of GBM w/ IgG deposits & c3
Associated with Hepatitis B
7
Q
Large bowel ischemia causes & presentation?
A
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
8
Q
Small bowel ischemia causes & presentation?
A
SEVERE abdominal pain out of proportion to physical exam findings
Also vomiting will be present
9
Q
Patient trying to quit nicotine but w/ known seizure disorder, what medication?
A
Varenicline
Nictoinic ACh receptor partial AGONIST
10
Q
Nephrotic syndrome important complication in men?
A
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
11
Q
Celiac disease is suspected, what is the most appropriate next step in management?
A
Testing for Tissue-Transglutaminase IgA
Duodenal biopsy can then be used to confirm the diagnosis – Villous atrophy & crypt hyperplasia
12
Q
Lactose Intolerance diagnostic tests?
A
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
13
Q
Pancreatic insufficiency diagnostic tests?
A
Normal absorption of D-Xylose
Decreased Duodenal Bicarbonate
Decreased Duodenal pH
Decreased Fecal Elastase
14
Q
What complication is most strongly associated with permanent transvenous dual-chamber pacemaker implantation?
A
Severe Tricuspid Regurgitation
Holosystolic murmur @ left sternal border & signs of right-sided HF i.e. JVD & Peripheral Edema
15
Q
What virus is a known trigger for Psoriasis?
A
HIV
Can cause sudden-onset severe disease
16
Q
Fun little list of dermatological manifestations of disease
A
Acanthosis Nigricans = Insulin resistance
Disseminated molluscum contagiosum = HIV
Lichen Planus = HCV
Oral Candidiasis = HIV
Porphyria Cutanea Tarda = HCV
Sudden Seborrheic Keratoses = GI malignancy
17
Q
Presentation of Adrenal crisis? Glucose, sodium, potassium, ABGs?
Treatment?
A
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
18
Q
When is IV Colloid solution used?
A
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
19
Q
Asbestosis presentation? MC complication?
A
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
20
Q
Cardiac Tamponade triad? ECG?
A
Beck’s triad = Hypotension, Muffled heart sounds, JVD
Pulsus paradoxus
Alternating QRS amplitudes
TX = Pericardiocentesis to drain pericardial fluid
21
Q
When do you use Ursodeoxycholic acid?
A
TX of cholesterol gallstones i.e. gallstone induced biliary colic
When patients are poor surgical candidates or decline surgery
22
Q
Why do you see Hyperkalemia in the setting of DKA?
A
Primarily due to underlying insuiln deficiency – this leads to impaired cellular uptake of potassium
23
Q
Prosthetic valve thrombosis presentation?
How to confirm DX?
A
New onset / worsening murmur
Stroke / TIA
Increase D-Dimer (nonspecific)
Echo = CONFIRMATORY
Target INR for patient’s with prosthetics is higher (2.5)
24
Q
What finding is almost always present in a patient w/ PE?
A
Sinus Tachy will always always be present on a question
25
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
26
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
27
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)
28
How to prevent febrile nonhemolytic reaction?
**Leukoreduction** -- removes leukocytes to prevent cytokine release
29
What complication do you need to worry about months out from an MI?
**LV aneurysm**
ECG shows deep **Q waves**
30
Warfarin-induced skin necrosis MC seen in what type of patients?
Patients with **Protein C deficiency**
31
First step in management of respiratory TB?
Immediately in respiratory isolation
32
MCC of painless lower GI bleeding in adult patient?
Diverticulosis
Differentiate from hemorrhoid because this causes pruritis
33
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
34
Sarcoidosis presenting symptoms?
Systemic Granulomatous Inflammation
Peripheral Lymphadenoapthy & Hypercalcemia
35
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
36
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
37
Granulomatosis w/ Polyangiitis classic symptoms?
Concomitant **hemoptysis** & **hematuria** are the hallmark
Chronic Sinusitis
C-ANCA
38
Clinical presentation of fibromuscular dysplasia?
Resistant HTN
Hypokalemia
**Cervical bruit**
39
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)
40
ABCDE of Malignant Melanoma
Asymmetry, Border irregularity, Color, Diameter (>6), & Evolution
41
When are you suspicious for squamous cell carcinoma?
**Chronic wounds** or **scars** -- Any wound that fails to heal with appropriate therapy
42
Hypokalemic patient's characteristic finding on ECG?
**U** Waves
**Flattened** or **Inverted** **T** waves
43
Patient with Hypokalemia & attempt at replacement doesn't normalize levels, what do you check for?
**Magnesium** levels -- Probably also low
44
ECG changes for a patient with Hyperkalemia?
**Widened QRS**
**Peaked T** waves
**Prolonged PR**
For hyperkalemic patients presenting with ECG changes, administer **Calcium Gluconate**, as it is cardioprotective
Followed by admin. of **insulin** & **glucose**
45
The presence of a 4th heart sound (S4) indicates what?
Left Ventricular Hypertrophy
S3 = HF
46
How will ventilator associated pneumonia present?
Fever, **crackles** on ausculation, leukocytosis, & infiltrates on CXR
Community acquired = MC = S. Pneumo
Aspiration pneumonia = More likely to be anaerobic since the bacteria are coming from the stomach
VAP = MC = **Pseudomonas** / **MRSA**
2 best ways to prevent VAP = 1) **Elevate** the patient's head of the bed & 2) obvi stop ventilation as soon as it's no longer required
47
Urine dipstick (+) for blood but without RBCs on microscopic examination?
**Rhabdomyolysis** -- especially with **statin** use
**Serum Creatinine Kinase** is test of choice
Treatment is **Isotonic saline** to maintain kidney perfusion & prevent AKI
| Urine is dark in color
48
Aside from HSV-1 induced viral encephalitis, what will you see in a patient with West-Nile viral encephalopathy?
Present in the **warm months** when mosquitos are present
**Flaccid paralysis** & **tremors** on physical exam
DX = **ELISA**
TX = Supportive
49
How do you DX SIRS? When does SIRS become sepsis?
SIRS = Systemic inflammatory response syndrome
Must have 2 or more conditions:
**Fever** greater than 100.4 or hypothermia less than 96.8
**Tachypnea** (More than 20)
**Tachycardia** (More than 90)
**Leukocytosis** or Leukopenia
SIRS becomes sepsis if the patient has a known or suspected **site of infection** i.e. consolodation on CXR, abnormal UA, or (+) blood cultures
50
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
51
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
52
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
53
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**
54
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
55
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%**
56
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**
57
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**
58
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
59
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
60
DOC for hyperthyroidism in a pregnant patient?
**PTU** is the DOC in the **1st trimester**
Entering the **2nd trimester**, it is standard to switch the patient from PTU to **Methimazole** to **avoid the hepatotoxic effects of PTU**
**Avoid Propranolol** in pregnancy unless there is a significant increase in HR
61
X-rays in RA, OA, Gout, & Psuedogout (descriptors)
**RA** = Bony **erosions** & Joint space **narrowing**
**OA** = **Subchondral** cysts & **Osteophyes** (Bony spurs)
**Gout** = Punched-out erosions w/ overhanging bone
**Pseudogout** = Cartilage calcification
62
Unless otherwise indicated, when should women get their first DEXA?
**65 YO**
Consider earlier w/ chronic glucocorticoid use or hx of fracture
63
Colonscopy screening requirements?
**45 YO**
Every 10 years until age 75
Begin earlier / do more frequently obviously with family hx or any abnormal colonscopy
64
Pap smear with HPV screening age?
Once **every 5 years** for women b/t **30 YO** & 65 YO
2 normal pap tests in the last 10 years, can stop screening at 65 YO
65
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**
66
Tension Pneumothorax presentation?
Displacement away from the side of the pneumothorax
Diaphragm is flattened on the side of the pneumothorax
Immediate needle thoracotomy
67
After hyperparathyroidism what is the next MCC of hypercalcemia?
**Malignancy**
Calcium levels in **hypercalcemia of malignancy are typically much higher** than that of hyperparathyroidism (usually around 13-15)
68
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
69
Test of choice for suspected osteomyelitis?
TX?
**MRI** -- will reveal bone marrow edema
X-ray can miss the dx in early stages of infection
TX = **IV abx** for at least **4-6 weeks i.e. Nafcillin or Vanco**
70
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)
71
Acute Intermittent Porphyria
**Unexplained abdominal pain** with **psychiatric** abnormalities
Pinkish urine w/ **increased urine Porphobilinogen**
Associated w/ **Alcohol**, **OCPs**, & **Hepatitis C**
72
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
73
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**
73
What is the most important cell line in the progression of Osteoarthritis?
**Chondrocyte**
74
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**
74
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**
74
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
75
Elevations in both Postprandial & fasting blood glucose levels in a diabetic patient is suggestive of what?
That the patient is **not getting enough** **basal (long-acting) insulin**
76
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**
77
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**
78
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)
79
Synchronized cardioversion is done when?
When the patient **has a pulse**
80
Prerenal disease causes & lab values?
**True volume depletion**
UA is normal
Fractional excretion of sodium <1%
Urine sodium <20
81
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
82
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
83
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**
84
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
85
Clinical manifestations of VHL?
**Bilateral Renal Cell Carcinoma**
**Hemangioblastomas** all over (retina)
**Pheochromocytomas**
## Footnote
Hamartomas = Tuberous sclerosis
85
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)
86
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
87
MC presenting symptoms of Sheehan syndrome?
Hypotension, fatigue, & **failure of lactation**
**Pituitary Necrosis** -- Complication of childbirth that results in acute blood loss
88
Abdominal Pain by location:
LUQ = Splenic rupture / Pancreatitis
RUQ = Hepatitis
LLQ = Diverticulitis
RLQ = Appendicitis
89
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**
90
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
91
When to start TMP-SMX in HIV (+) pt
When CD4 count **< 200**
92
Toxoplasma gondii vs. Taenia Solium?
Both have ring-enhancing lesions
If the **cyst** contains a **Punctate**, this is considered pathogonomic for **Neurocystericosis**
93
Non-hemolytic febrile transfusion reaction treatment?
Centrally acting cyclooxygenase inhibitor i.e. **Aceteaminophen**
94
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
95
When would you ever start a patient on a fibrate vs. a statin?
Only when TGs exceed 500... otherwise the answer is always a statin
96
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
97
