IM Shelf Exam Flashcards
1
Q
Diagnosing MI in patient with acute chest pain
A
ECG: 2mm ST elevation immediately, T-wave inversions hours later, Q-waves or new LBBB (wide, flat QRS)
2
Q
ST elevations seen in occlusion of LAD leading to anterior infarct?
A
V1-V4
3
Q
ST elevations seen in occlusion of circumflex leading to lateral infarct?
A
I, aVL, V4-V6
4
Q
ST elevations seen in occlusion of RCA leading to inferior infarct?
A
II, III and aVF
5
Q
ST elevations seen in occlusion of RCA leading to RV infarct?
A
V4 on right-sided ECG
6
Q
Window for delivery of thrombolytics for MI?
A
Within 6 hours of arrival
7
Q
Contraindications for thrombolytics?
A
Current bleed, history of hemorrhagic stroke, recent ischemic stroke and recent closed head trauma
8
Q
A patient presents to the ED with chest pain, hypotension, tachycardia and JVD with clear lungs. How do you treat this patient?
A
They have a RV infarct and need fluid resuscitation. Don’t give NO because their RV cannot pump efficiently and decreasing preload will worsen the RV’s ability to pump blood through the pulmonary circulation.
9
Q
Next step if ECG is normal in a patient with chest pain (r/o NSTEMI)?
A
Serum troponin q8 hours x 3.
10
Q
Most sensitive cardiac biomarker for repeat infarct in the hospital?
A
Myoglobin peaks first within 2 hours and drops by 24 hours. This is much faster compared to CK-MB which rises over 4-8 hours, peaks at 24 hours and drops by 72 hours and Troponin-I which rises over 3-5 hours, peaks by 24-48 hours and drops by 7-10 days.
11
Q
Treatment for patient with NSTEMI on admission? What do you send them home on?
A
ON ADMISSION: Morphine, oxygen, nitrates, ASA/clopidogrel, beta-blocker and cath within 48 hours to determine need for stenting or CABG. SEND HOME: beta-blocker, ASA (+ clopidogrel for 9-12 months if stent in place), statin, nitrates prn and ACE-I if CHF or LV dysfunction.
12
Q
When is CABG indicated over PCI?
A
Left main disease or three-vessel disease (2 vessels in DM)
13
Q
Work-up for unstable angina?
A
Exercise ECG
14
Q
Meds to stop before undergoing exercise ECG?
A
Beta-blockers and CCB
15
Q
When can’t you do an ECG to assess a patient with unstable angina? What do you do instead?
A
LBBB, baseline ST elevation or currently taking digoxin, must do exercise echo instead.
16
Q
Work-up of unstable angina if patient cannot exercise?
A
Chemical stress test with dobutamine or adenosine.
17
Q
Drugs to avoid prior to nuclear myocardial perfusion scan?
A
Caffeine or theophylline
18
Q
When is a stress test positive and what do you do next?
A
Chest pain is reproduced, ST depressions produced or hypotension in response to exercise. This merits a cath.
19
Q
Most common cause of death in post-MI period?
A
V-fib
20
Q
New systolic murmur 5-7 days after MI?
A
Mitral regurgitation from papillary muscle rupture.
21
Q
Acute severe hypotension 5-7 days after MI?
A
Ventricular free wall rupture
22
Q
Step up in O2 concentration in RV compared to RA after MI?
A
Septal wall rupture.
23
Q
Persistent ST elevations 1 month after MI with a systolic MR murmur?
A
Ventricular wall aneurism
24
Q
Cannon A-waves after MI?
A
AV dissociation due to third degree heart block (AV valve remains closed when atria contract)
25
Pleuritis chest pain 5-10 weeks after MI?
Dressler syndrome, treat with NSAIDs and ASA.
26
Dx Prinzmetal’s angina
Ergonovine stimulation test
27
Tx Prinzmetal’s angina
CCB or nitrates
28
Progressive prolongation of the PR interval with a dropped beat.
2nd degree AV block: Wenckebach or Mobitz type I heart block.
29
Regular P-P interval, regular R-R interval without association of the P wave with the QRS?
3rd degree heart block
30
Varying PR intervals with 3 or more morphologically distinct P-waves in the same lead. Why is this bad?
MAT. Associated with chronic lung disease and impending respiratory failure.
31
3+ consecutive beats with QRS 120. Tx?
Ventricular tachycardia. Unstable = cardioversion. Stable: lidocaine or amiodarone.
32
Alternate beat variations in direction, low amplitude QRS in a patient with pulsus paradoxus in a patient with distant heart sounds and JVD?
Electrical alternates from pericardial effusion.
33
Delta waves, short PR interval, QRS \> 120
WPW with early ventricular activation through the bundle of Kent.
34
Drug of choice for WPW? Tx? Contraindicated medications in WPW?
Tx with procainamide. CCB (diltiazam, verapamil), beta-blockers, digoxin.
35
Regular rhythm with ventricular rate of 125-150 and atrial rate of 250-300 bpm? Tx?
Atrial flutter. Tx with beta-blockers and digoxin.
36
Peaked T-waves, wide QRS, short QT and prolonged PR interval? Causes?
Renal failure, crush injury, burn victim leading to hyperkalemia.
37
Prolonged QT leading to undulating rotation of the complex around the ECG baseline? Causes?
Torsades: low K, low Mg, Li or TCA overdoses can cause this.
38
Regular rhythm with a rate between 150 and 220 with sudden onset palpitations and dizziness that resolve suddenly? Tx?
SVT. 1st line treatment = carotid massage. 2nd line = adenosine
39
Undulating baseline without appreciable p-waves, irregular R-R intervals? Causes? Tx?
A-fib. Causes - hyperthyroidism, CHF or valvular disease. Tx with rate control with Metoprolol XL or digoxin in patients with CHF.
40
SEM crescendo/decrescendo murmur louder with squatting, softer with Valsalva and associated parvus et tardus? Tx?
Aortic stenosis. Tx with valve replacement.
41
SEM louder with Valsalva and softer with squatting and handgrip.
HOCM
42
Late systolic murmur louder with Valsalva and handgrip, softer with squatting, associated click
MVP
43
Holosystolic murmur that radiates to axilla with left atrial enlargement
MR
44
Holosystolic murmur with late diastolic rumble in kids
VSD
45
Continuous machine-like murmur
PDA
46
Wide fixed and split S2
ASD
47
Rumbling diastolic murmur with opening snap, left atrial enlargement and a-fib?
MS
48
Blowing diastolic murmur with wide pulse pressure
AR
49
Next step if you suspect PE?
Heparin before work-up with V/Q scan or spiral CT.
50
Treatment of acute pulmonary edema?
Nitrates, furosemide and morphine
51
Young patients with recent viral illness and worsening dyspnea on exertion/orthopnea?
Coxsackie B myocarditis.
52
How to differentiate between pHTN and CHF?
CHF = elevated PCWP. pHTN = elevated PAP.
53
Reversible cause of systolic heart failure?
Alcoholic dilated cardiomyopathy (stop drinking)
54
Reversible cause of diastolic heart failure?
Hemochromatosis restrictive cardiomyopathy (phlebotomy)
55
Meds that improve survival in CHF?
ACE-I (prevent aldosterone remodeling), Beta-blockers metoprolol/carvedilol (prevent EPI/NE remodeling), spironolactone (NYHA III and IV), Hydralazine/nitrates
56
Opacification, consolidation and air bronchograms
PNA
57
Hyperlucent lung fields with flat diaphragms
COPD
58
Heart \> 50% AP diameter, cephalization, Kerly B lines and interstitial edema
CHF
59
Cavity containing air-fluid level
Lung abscess
60
Upper lobe cavitations, consolidation +/- hilar adenopathy
Tb
61
Thickened paratracheal stripe and splayed carina bifurcation?
LA enlargement and mediastinal lymphadenopathy
62
When to tap a pleural effusion?
\>1cm on lateral decubitus film
63
Common causes of transudate
CHF, nephrotic syndrome, cirrhosis
64
Transudate with low pleural glucose
Rheumatoid arthritis
65
Transudate with high lymphocytes
Tb
66
Blood transudate
PE or malignancy
67
Most common cause of exudative effusions?
PNA, cancer
68
Definition of a complicated parapneumonic effusion? Tx?
+ gram stain, pH
69
Light’s criteria for transudates
LDH
70
Gold standard for PE diagnosis
Pulmonary angiogram
71
Causes of ARDS? Tx?
Gram negative sepsis, aspiration, trauma, low perfusion, pancreatitis. Oxygen with PEEP.
72
Diagnostic criteria for ARDS
1) PaO2/FiO2
73
Conditions associated with reduced DLCO?
ILD due to scarring and fibrosis. COPD due to alveolar destruction.
74
COPD treatment?
Ipratropium -\> Salmeterol -\> Theophylline. Home O2 if SpO2
75
COPD exacerbation criteria
Change in sputum, worsening dyspnea. Tx with macrolide/fluorquinolone, IV steroids, duonebs and oxygen.
76
Best prognostic indicator of COPD?
FEV1
77
Tx that improves mortality in COPD?
Smoking cessation and home O2 \> 18 hours per day.
78
Next test in hypertrophic osteoarthropathy (rapid onset clubbing)?
Chest x-ray to rule out cancer.
79
Daytime asthma sx 2x per week, 2x per month with normal PFTs? Tx?
Intermittent = albuterol prn
80
Asthma sx 4x per week, night sx 4x per month and normal PFTs? Tx?
Mild persistent = albuterol + inhaled ICS
81
Asthma sx daily, night sx weekly and FEV1 60-80? Tx?
Moderate persistent = Albuterol + ICS + salmeterol
82
Asthma sx daily, night cough frequently and FEV1
Severe persistent = Albuterol + ICS + salmeterol + montelukast + oral steroids
83
Tx of asthma exacerbation?
Inhaled albuterol, IV steroids and intubation if PCO2 normalizes.
84
1cm eggshell calcifications in upper lobes with restrictive lung disease? High risk for what?
Silicosis, predisposed to Tb, so do yearly Tb tests and give INH if \> 10mm induration
85
Reticulonodular process in lower lobes with pleural plaques and restrictive lung disease? High risk for what?
Asbestosis, at higher risk for bronchogenic CA and mesothelioma.
86
Patchy lower lobe infiltrates and thermophilic actinomyces with restrictive lung disease?
Hypersensitivity pneumonitis
87
Hilar lymphadenopathy, increased ACE and erythema nodosum with restrictive lung disease. At high risk for what?
Sarcoidosis. High risk of hypercalcemia (due to high vitamin D levels secondary to granulomatous macrophage production) and uveitis.
88
Dx and tx sarcoidosis
Dx with bx and tx with steroids
89
Benign SPN characteristics? How to follow up with these?
Popcorn calcification (hamartomas), concentric calcification (old granulomas), age
90
Malignant SPN characteristics? How to follow up with these?
Elderly, smoker, \> 3cm, spiculated and eccentric calcification. Follow-up with open lung biopsy and remove the nodule.
91
Most common lung cancer in non-smokers? Where do these metastasize?
Peripheral adenocarcinoma (often in scars of old PNA). They metastasize to liver, bone, brain and adrenals.
92
Characteristic pleural effusion seen in adenocarcinoma?
Exudative with elevated hyalurinidase.
93
Patient with central lung mass, renal stones, constipation, malaise, low PO4 and low PTH?
Squamous cell carcinoma with PTHrP release.
94
Patient with central lung mass, shoulder pain, ptosis, constricted pupil and facial edema?
Small cell carcinoma leading to superior sulcus syndrome (Pancoast tumor)
95
Patient with central lung mass and ptosis better after 1 minute of upward gazing?
Lambert-Eaton syndrome secondary to small cell carcinoma production of antibodies to the pre-synaptic Ca-channel.
96
Central lung mass in an old smoker with Na of 125, moist mucus membranes and no JVD? Tx?
SIADH from small cell carcinoma. Treat with fluid restriction +/- 3% saline if
97
CXR with peripheral cavitation and CT showing distant metastasis?
Large cell carcinoma.
98
Tx for Crohn’s patients with ulcers, abscesses or fistulae?
Metronidazole
99
IBD associated with p-ANCA and PSC?
UC
100
TX IBD
Corticosteroids to induce remission. ASA and sulfasalazine to maintain remission. Azathioprine, 6-MP and MTX for severe disease.
101
Tx pyoderma gangrenosum in patients with UC?
Treat underlying UC, no abx! It’s just granulation tissue and WBCs
102
AST:ALT \> 2 + elevated GGT
Alcoholic hepatitis
103
ALT \> AST and both in 1000s
Viral hepatitis
104
AST and ALT in 1000s after hemorrhage
Ischemic hepatitis
105
Elevated D-bili
Biliary obstruction, Dubin-Johnson and Rotor syndrome
106
Elevated I-bili
Hemolysis, Gilbert, Crigler-Najjar
107
Elevated alk phos and GGT
Biliary obstruction. GGT is more specific for biliary tree
108
Elevated alk phos, normal GGT and normal Ca? Tx?
Paget’s disease, look for hearing loss, increasing hat size. Tx w/bisphosphonates.
109
Anti-mitochondrial Ab. Tx?
PBC. Tx with urosdeoxycholic acid (not steroids)
110
ANA + anti-smooth muscle Ab. Tx?
Autoimmune hepatitis. Tx with corticosteroids.
111
High Fe, low ferritin, low TIBC. Tx?
Hemochromatosis. Tx with phlebotomy.
112
Low ceruloplasmin, high urinary Cu. Tx?
Wilson’s disease.
113
Most common bugs in meningitis? Tx?
S. pneumo, N. meningitides, H. flu. Give ceftriaxone and vanc for coverage.
114
Abx to add on if meningitis in elderly or young?
Ampicillin for listeria coverage.
115
Abx to add on if meningitis in patient with recent brain surgery?
Vanc to cover staph
116
Random causes of meningitis and tx?
Meningeal Tb (add steroids to RIPE tx) and Lyme meningitis (give IV ceftriaxone to penetrate BBB)
117
Best 1st step in patients with suspected meningitis
Start empiric tx -\> check PE findings for elevated ICP or do head CT -\> LP with gram stain -\> \>1000 WBCs is diagnostic, high protein and low glc support bacterial etiology.
118
Tx for roommate of the kid with N. meningitis
Rifampin for prophylaxis
119
Best 1st step in patients with suspected pneumonia?
CXR
120
Most common bug in all pneumonias? Tx?
S. pneumo. Tx with macrolide, fluoroquinolone or doxycycline.
121
Most common bug in pneumonia in young healthy people? Associated findings? Tx?
Atypical. Cold-agglutinin associated with mycoplasma. Tx with macrolide abx first. Then fluoroquinolones or doxy.
122
Common PNA in patients hospitalized for \> 1 week or in past three months? Tx?
HCAP: pseudomonas, klebsiella, MRSA and E. coli. Tx with pip-tazo or imipenem-vanc.
123
Old smokers with COPD have what common type of PNA? Tx?
H. flu. Tx with 2nd or 3rd generation ceph
124
Alcoholics with currant jelly sputum have what common type of PNA? Tx?
Klebsiella. Tx with 3rd generation ceph
125
Old men with headache, confusion, diarrhea and abdominal pain have what common type of PNA? Dx? Tx?
Legionella. Dx with urine antigen. Tx with macrolide, fluoroquinolone, doxy.
126
Patients who recently had the flu can develop what common type of PNA? Tx?
Staph (MRSA) tx with vanc
127
A farmer who delivered a baby cow who now has vomiting and diarrhea may have what type of PNA? Tx?
Coxiella burnetti (Q. fever). Tx w/doxy
128
A boy who just skinned a rabbit may have what type of PNA? Tx?
Tularemia. Tx with streptomycin, gentamicin
129
Best test if patient has symptoms and high suspicion for Tb? Screening?
Sx = CXR. If CXR is positive, do AFB sputum stain and treat if positive. Screening is done with PPD. If PPD is positive, then do CXR. If CXR is negative, do AFP sputum culture x 3.
130
Tx for Tb
RIPE = rifampin, isoniazid, pyrazinamide and ethambutol for 6 months (12 for meningitis and 9 if pregnant)
131
Who gets prophylactic Tb meds?
Kids
132
RIPE side effects?
Rifampin: orange fluids, induces CYP450. INH: peripheral neuropathy and sideroblastic anemia (prevent by giving B6), mild increase in LFTs. Pyrazinamide: benign hyperuricemia. Ethambutol: optic neuritis
133
Most common bug in acute IE
Staph
134
Most common valve affected in subacute native valve IE? Which bug?
Mitral valve infection by S. viridians
135
Most common valve affected in IE in IVDU? Bug?
Tricuspid (murmur worse with inspiration) by staph.
136
How do dx IE?
Blood cx and echo
137
IE complications?
Emboli to lungs and brain. Most common cause of death = local valvular destruction -\> CHF.
138
Tx of IE?
S. viridans = PCN 4-6 wks. Staph = nafcillin + gentamicin or vanc.
139
Prophylaxis for IE?
Needed if you have a prosthetic heart valve, past history of IE or uncorrected congenital heart lesion
140
Next step if you find strep bovis bacteremia in a patient with heart murmur?
Colonoscopy due to association with colon cancer.
141
When should you suspect HIV?
Mono-like syndrome 2-3 weeks after exposure, new bilateral Bell’s palsy, unexplained thrombocytopenia and fatigue, young patient with unexplained weight loss \> 10% and young patient with thrush, Zoster or Kaposi sarcoma.
142
HIV drug with side effects of GI sx, leukopenia and macrocytic anemia?
Zidovudine
143
HIV drug with side effects of pancreatitis and peripheral neuropathy?
Didanosine
144
HIV drug with side effects of rash, fever, N/V, muscle aches and SOB?
Abacavir (if this happens, never use again)
145
HIV drug with side effects of nephrolithiasis and hyperbilirubinemia?
Indinavir
146
HIV drug with side effects of somnolence, confusion and psychosis?
Efavirenz
147
Post-exposure prophylaxis for HIV needle stick
AZT, lamivudine and nelfinavir (HAART) x 4 weeks
148
Best test after CXR in patient with HIV and bilateral fluffy infiltrates?
BAL to dx PJP.
149
Tx of PJP in a patient with HIV?
TMP-SMX. TMP-dapsone or primaquine-clindamycin or pentamidine may be used second line. Add steroids if PaO2
150
Prophylaxis for PJP in HIV patients?
TMP-SMX is first line. Dapsone is second. Atovaquone is third and aerosolized pentamidine is fourth because is can cause pancreatitis.
151
DDx for HIV patient with diarrhea and CD4 count less than 50? How to differentiate between these? Tx?
CMV = dx’d with colonoscopic bx and visualization of intranuclear inclusion bodies. Tx with gancyclovir or foscarnet. MAC = diagnosis of exclusion, tx with clarithromycin and ethambutol +/- rifampin. Cryptosporidium = acid-fast stain positive for oocysts.
152
Prophylaxis for MAC in HIV patients
CD4
153
HIV patient with multiple ring enhancing lesions? What if there is only one lesion? Tx?
Toxoplasmosis. One lesion - primary CNS lymphoma. Tx with empiric pyrimethamine sulfadiazine for 6 weeks, if no improvement in 1 week -\> bx to r/o CNS lymphoma due to EBV infection of B-cells.
154
HIV patient with seizure, de ja vu aura and RBCs in CSF? Tx?
HSV encephalitis. Tx with acyclovir as soon as suspected.
155
HIV patient with signs and symptoms of meningitis?
Strep pneumo is most common. Opportunistically, worry about cryptococcus and stain with india ink. If positive, treat with amphotericin IV for 2 weeks and then fluconazole for maintenance.
156
HIV patient with hemisensory loss, visual impairment and Babinski sign?
PML from JC polyomavirus demyelinating in the grey-white junction. No treatment, only brain bx to define cause.
157
HIV patient with memory problems or gait disturbances.
AIDS-dementia complex.
158
Patients that never get a DRE who have a fever?
Neutropenic because you can induce bacteremia.
159
Definition of neutropenic fever
T \> 101.3 once, sustained temp \> 100.4 for 1 hour and ANC
160
Most common bugs in neutropenic fever
Pseudomonas and MRSA, especially if a port is present
161
Work-up of a patient with neutropenic fever?
1) blood cx 2) start 3rd or 4th generation ceph (ceftaz or cefipime) 3) Add vanc if line infxn suspected 4) Add amphoB if no improvement in 5 days
162
Tx of lyme disease
1) Doxy 2) Amoxicillin in kids
163
Tx of RMSF
Doxy in everyone, even kids because amoxicillin doesn’t work
164
A patient presents with a tick bite, no rash, myalgia, fever, HA, low platelets, low WBC and elevated ALT? Tx?
Ehrlichiosis. Dx with morale intracellular inclusions. Tx with doxy.
165
Patient who is immunosuppressed with a cavitary lung lesion, weight loss and fever with aerobic, branching and partial acid fast staining bugs? Tx?
Norcardia. Tx with TMP-SMX.
166
Patient has neck or face infection with draining yellow material, sulfur granules and branching anaerobes? Tx?
Actinomyces. Tx with high dose PCN for 6-12 weeks.
167
Next step in patient with low Na.
1) Check osmolarity 2) Check volume status.
168
Causes of hypervolemic hyponatremia? Tx?
CHF, nephrotic syndrome and cirrhosis. Tx with fluid restriction.
169
Causes of hypovolemic hyponatremia? Tx?
Furosemide, vomiting. Tx with NS, 3% saline if seizures or Na
170
Causes of euvolemic hyponatremia?
SIADH, Addison’s and Hypothyroidism. Tx with fluid restriction.
171
How fast should you correct hyponatremia?
No faster than 12-24 mEq/day to avoid central pontine myelinolysis.
172
How fast should you correct hypernatremia?
No faster than 12-24 mEq/day to avoid cerebral edema
173
Numbness, Chvostek/Trousseau, prolonged QT
Hypocalcemia
174
Stones, bones, groans, psycho and short QT
Hypercalcemia
175
Paralysis, ileus, ST depression and U waves
Hypokalemia. Tx with K+ replacement at a maximum of 40mEq/hr.
176
Peaked T waves, long PR/QRS and sine waves? Tx?
Hyperkalemia. Tx with Ca-gluconate to stabilize cardiac membrane. Give kayexalate, insulin + glucose and albuterol to reduce K+. Dialysis is last resort.
177
Common acid-base disturbance in a patient with high pH, high HCO3 and high PCO2? Next step?
Metabolic alkalosis. Next check urine Cl. If \> 20 = Conns if associated with HTN, Barter/Gittleman’s if no HTN. If
178
Common acid-base disturbance in a patient with high pH, low pCO2 and low HCO3? Common causes?
Respiratory alkalosis: hyperventilation, increased ICP, fever, pain and ASA
179
Common acid-base disturbance in patient with low pH, low HCO3 and low pCO2? Next step? Common causes?
Metabolic acidosis. Next calculate anion gap. If + gap = MUDPILERS (methanol, uremia, DKA, paraldehyde, INH, lactic acidosis, ethylene glycol, rhabdo, ASA (late)). If - gap = HARDUP (hyperalimentation, acetazolamide, RTA I, II, IV, diarrhea, uretosigmoid fistula, pancreatic fistula)
180
Common acid-base disturbance in patient with low pH, high pCO2 and high HCO3? Common causes?
Respiratory acidosis. Hypoventilation from opiate overdose, brainstem injury or ventilation problems.
181
Cause of type I RTA? Dx? Tx?
Li is most common cause of distal RTA (type I). Dx with urine pH \> 5.4, low K+ and renal stones due to inability to excrete H+. Tx with HCO3-.
182
Cause of type II RTA? Dx? Tx?
Multiple myeloma is common cause of proximal RTA. Dx with low K+, osteomalacia due to inability to resorb HCO3-. Tx with K+ repletion and mild diuretic.
183
Cause of type IV RTA? Dx? Tx?
\> 50% are due to diabetes, resulting in hyper-reninemic, hypoaldosteronemic syndrome. Dx with high K+, high Cl-, high urine Na+ in the face of salt restriction. Tx with fludrocortisone.
184
Fanconi’s anemia?
Hereditary or acquired proximal tubule dysfunction causing defective transport of glucose, AA, Na, K, PO4, uric acid and bicarbonate.
185
Definition of acute renal failure?
Overall serum Cr increase by 25% or 0.5 rise over baseline.
186
Work-up of acute renal failure?
BUN:Cr -\> greater than 20:1 = pre renal. Check urine Na and Cr, if FeNa
187
Calculating FeNa?
[Urine Na/Serum Na] / [Urine Cr/Serum Cr] x 100
188
When can’t you rely on FeNa to help find the cause of acute renal failure?
When the patient is taking diuretics. If they are on diuretics, you need to calculate FENurea, if \> 35% = pre-renal.
189
Tx pre-renal azotemia
IVFs and treat underlying cause (CHF, GN, cirrhosis or renal artery stenosis)
190
Patient in renal failure with muddy brown casts? Causes? Tx?
ATN: caused by amphoB, ahminoglycosides, cisplatin and prolonged ischemia. Tx with fluids, avoid nephrotoxic drugs +/- dialysis.
191
Patient in renal failure with proteinuria, hematuria, eosinophiluria, fever and rash who took TMP-SMX 1-2 weeks ago? Tx?
AIN. Stop offending agent. Add steroids if no improvement.
192
Patient in renal failure who was a crush victim with CPK \> 50K and hematuria without RBCs on dip? Next step? Tx?
Rhabdomyolysis. Next step = check K+ or ECG. Tx bicarb to alkalinize urine to prevent myoglobin precipitation and renal damage.
193
Patient in acute renal failure withe enveloped shaped crystals on UA?
Ethylene glycol intoxication (associated anion gap metabolic acidosis)
194
Patient in acute renal failure with increased Cr 48-72 hours after CT scan?
Contrast-induced nephropathy…note the timeline!
195
Indications for emergent dialysis?
Acidosis, Electrolytes (K+), Ingestion (ethylene glycol, Li), Overload (CHF), Uremia (sx of pericarditis, confusion or bleeding)
196
Common causes of CKD?
#1) DM #2) HTN
197
Most common cause of death in CKD?
Cardiovascular disease, hence the target LDL
198
Complications of CKD?
Increased aldosterone causes HTN and fluid retention that lead to CHF. Loss of EPO leads to normocytic anemia. Low Ca, high PO4 and high K leads to secondary hyperparathyroidism. Elevated PO4 causes renal osteodystrophy and caliphylaxis. Uremia causes confusion, pericarditis, pruritus and easy bleeding.
199
Best 1st test in hematuria?
UA
200
Dx in patient with terminal hematuria?
Bladder cancer or hemorrhagic cystitis (cyclophosphamide use)
201
Dx in patient with painless hematuria?
Bladder/renal cancer until proven otherwise
202
Dx in patients with dysmorphic RBCs or RBC casts on UA?
Glomerular source
203
Definition of nephritic syndrome?
Proteinuria
204
Hematuria 1-2 days after runny nose, sore throat and cough?
IgA nephropathy
205
Hematuria 1-2 weeks after sore throat or skin infection? Making the Dx?
Post-strep glomerulonephritis. Next test - ASO titer. Bx will show sub epithelial IgG humps.
206
Hematuria + hemoptysis?
Goodpasture’s (anti-BM abs against type IV collagen)
207
Hematuria + deafness?
Alport’s (X-linked recessive mutation in collagen IV)
208
Child with hematuria, abdominal pain, arthralgia and purpura after viral URI? Tx?
Henoch-Schonlein Purpura (IgA-mediated). Tx with steroids.
209
Child who gets microangiopathic hemolytic anemia, renal failure and petechiae after eating a burger? Tx?
HUS from E. coli 0157:H7. Don’t tx with abx, just supportive.
210
Cardiac patient s/p ticlopidine with renal failure, microangiopathic hemolytic anemia, low platelets, fever and altered mental status? Tx?
Ticlopidine can cause TTP. Tx with plasmapheresis, BUT DON’T GIVE PLATELETS because more platelets will be consumed.
211
Patient with hematuria, c-ANCA, renal, lung and sinus involvement? Dx? Tx?
Wegener’s. Dx with biopsy. Tx with steroids or cyclophosphamide.
212
Patient with p-ANCA, hematuria, renal failure, asthma and eosinophilia? Dx? Tx?
Churn-Strauss. Dx with lung bx. Tx with cyclophosphamide.
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Patient with p-ANCA, no lung involvement and hepatitis B? Tx?
Polyarteritis nodosa (vasculitis that affects all small and medium arteries in the body except the lung). Tx with cyclophosphamide.
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How to differentiate TTP and HUS from DIC?
Although platelets will be low for both, DIC will have abnormal coags.
215
Most common type of kidney stone?
Ca-oxalate
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Kid with FHx of kidney stones?
Cysteine
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Kidney stone with chronic indwelling foley and alkaline pee?
Mg/Al/PO4 = struvite stones from proteus, staph, pseudomonas or klebsiella infection.
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Kidney stone in patient being treated with chemotherapy?
Uric acid stones
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Kidney stone in patient s/p bowel resection for volvulus?
Pure oxalate stones (can’t adequately reabsorb Ca)
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Tx of kidney stones
2cm = surgery. In between = lithotripsy.
221
Best 1st test in a patient with proteinuria?
Repeat UA in 2 weeks, then do 24-hour urine collection
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Definition of nephrotic syndrome?
Proteinuria \> 3.5g/24 hours, low albumin, edema and hyperlipidemia (fatty, waxy casts)
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Most common cause of nephrotic syndrome in kids? Dx? Tx?
Kids - minimal change disease. Dx with fusion of foot processes on bx. Tx with steroids.
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Most common cause of nephrotic syndrome in adults? Dx?
Membranous nephropathy. Dx with thickened capillary walls and sub epithelial spikes on bx.
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Nephrotic syndrome in patient with heroin use and HIV? Dx?
FSGS. Dx with mesangial IgM deposits.
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Nephrotic syndrome in patient with chronic hepatitis and low complement? Dx?
Membranoproliferative. Dx tram-track basement membrane with sub endothelial deposits on bx.
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Worry in a nephrotic patient with sudden onset flank pain? Dx?
Renal vein thrombosis due to urinary loss of ATIII, proteins C and S. R/o with CT or u/s ASAP.
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This patient presents with MCV 70, low Fe, low TIBC, normal ferritin and low retic?
Anemia of chronic disease
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This patient presents with MCV 60 and low RDW?
Thalassemia. Note that there is a low RDW because there is little variation in the size of the RBCs due to genetic component.
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This patient presents with MCV 70, high Fe, high ferritin and low TIBC in a patient taking INH for Tb?
Sideroblastic anemia. Typically you’d see ringed sideroblasts in the bone marrow.
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This patient presents with MCV 100, low retic, high homocysteine and normal MMA.
Folate deficiency
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This patient presents with MCV 100, low retic, high homocysteine and high MMA.
B12 deficiency
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This patient presents with MCV 100.
Note the acanthocyte (spur cell) from liver disease.
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Sickle cell kid with sudden drop in Hct and hemolysis?
Aplastic crisis due to hypoxia, dehydration or acidosis
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Hemolysis, cyanotic fingers/ears/nose and recent mycoplasma infection?
IgM-mediated cold agglutinins that lyse RBCs in the liver.
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Hemolysis with sudden onset after PCN, ceph, sulfa, rifampin or cancer? Tx?
IgG-mediated warm agglutinins and destroy RBCs in the spleen. Tx with steroids 1st, then splenectomy.
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Hemolysis with splenomegaly, FHx, bili gallstones and high MCHC? Tx?
Hereditary spherocytosis. Tx with splenectomy.
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Hemolysis with dark urine in the morning and Budd-Chiari syndrome?
PNH due to defect in PIG-A resulting in lysis by complement. Note increased risk for aplastic anemia.
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Hemolysis after primaquine, sulfa or fava beans with Heinz bodies, bite cells and low platelets?
G6PD deficiency
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Patient with recurrent epistaxis, heavy menses and petechiae with only low platelets? Tx?
ITP. Tx with prednisone 1st, then splenectomy. IVIG if
241
Patient with recurrent epistaxis, heavy menses, petechiae, normal platelets and increased bleeding time and aPTT? Tx?
vWF deficiency. PTT is elevated because vWF is bound to factor VIII. Give factor VIII if bleeding continues.
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Patient with recurrent bruising, hematuria, hemarthroses and increased aPTT that corrects with mixing studies?
Hemophilia. Tx with DDAVP if mild, otherwise give cryoprecipitate.
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Meat eater with hemarthroses and oozing at venipuncture sites after finishing two weeks of clindamycin tx?
Vitamin K deficiency
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Alcoholic with severe cirrhosis and bleeding. How will their coags change over time?
In early liver failure, factor VII is the first one to go and the PT rises first. Later on, all the rest of the factors go except for factor VIII and vWF.
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A patient presents with elevated PT/aPTT, low fibrinogen and D-dimer and fibrin split products. What are causes? Tx?
Note the schistocytes that supports the dx of DIC: this can be caused by sepsis, rhabdo, adenocarcinoma, heatstroke, pancreatitis, snake bites, OB stuff and treatment of M3 AML. Tx with FFP, platelet transfusion and correction of the underlying disorder.
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A patient presents with normal PT/aPTT, low fibrinogen and D-dimer and fibrin split products. What are causes? Tx?
HUS or TTP can be secondary to E. coli O157:H7, ticlopidine, quinine, cyclosporine, HIV and cancer. Tx with plasmapheresis and don’t give platelets.
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7 days post-op, a patient has an arterial clot and downtrending platelets. Cause? Tx?
HIT due to heparin binding to PF4 and inducing platelet destruction via IgG. Treat with stopping the heparin, reverse warfarin with vitamin K if it was started and starting lepirudin.
248
Hint of SLE in pt with unprovoked thrombus.
High PTT, multiple abortions and false-positive VDRL test.
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Hint of protein C/S deficiency in pt with unprovoked thrombus.
Skin necrosis after warfarin tx.
250
Hint of factor V Leiden deficiency in pt with unprovoked thrombus.
Most common cause of hypercoaguable state.
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Hint of AT III deficiency in pt with unprovoked thrombus.
Heparin does not work in these patients.
252
Hint of OCPs/HRT in pt with unprovoked thrombus.
Contraindicated in women \> 35 or smokers.
253
What can a joint aspiration tell you in patient with a swollen and painful joint?
WBC 50k = septic arthritis (gonococcal w/tenosynovitis and pustules, staph)
254
Treat acute gouty arthritis
Indomethacin + colchicine, steroids if poor renal function
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Treat chronic gouty arthritis
Probenecid or allopurinol
256
Negative ab screen that r/o SLE?
ANA
257
Most sensitive ab for SLE
Anti-dsDNA or anti-smith ab
258
Ab for drug-induces lupus
Anti-histone
259
Ab for Sjogren’s syndrome?
Anti-ro (SSA) and anti-la (SSB)
260
Ab for CREST syndrome?
Anti-centromere
261
Ab for systemic sclerosis?
Anti-scl 70, anti-topisomerase ab
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Ab for mixed CT disease?
Anti-RNP
263
2 tests to dx RA?
RF (anti-Fc of IgG) and anti-CCP
264
Tx of actinic keratosis?
5-FU, it is a precursor lesion to SCC
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4 types of melanoma
Superficial spreading (best prognosis and most common), nodular (poor prognosis), lentigo maligna (good prognosis) and acrolentiginous (poor prognosis)
266
#1 prognostic indicator of malignant melanoma?
Depth
267
Tx of malignant melanoma?
Excision with 1cm margin if 4mm thick. May also use high does IFN or IL-2.
268
Most common pituitary adenoma? Presenting symptoms? Tx?
Prolactinoma. Presents with amenorrhoea or hypothyroidism. Tx with bromocriptine or cabergoline.
269
Which hormones go first in hypopituitarism?
#1) FSH/LH #2) GH #3) TSH #4) ACTH
270
Central DI
low urine osmolality after water deprivation, but osmolality increases with ddAVP.
271
Nephrogenic DI. Tx?
low urine osmolality after water deprivation AND ddAVP. Tx with HCTZ/amiloride.
272
Psychogenic DI
Urine osmolality rises after water deprivation.
273
Next step if patient has low TSH and high T3/T4?
Iodine RAIU scan. Will show increased uptake if Grave’s and decreased if thyroiditis or factitious.
274
Graves Tx
Propranolol + PTU/MTZ. Iodine ablation surgery follows.
275
Thyroid storm tx
PTU + iodine + propranolol
276
Thyroid nodule work-up
1) Check TSH, if low do RAIU to find the hot nodule and excise it. If normal, do FNA. If FNA is malignant, excise and send to path. If FNA is benign, leave it alone. If FNA is indeterminate, do RAIU and excise if nodule is cold.
277
Types of thyroid cancer
Papillary is most common, spreads via lymphatics and has associated psammoma bodies. Follicular spreads hematogenously and you must excise the entire gland. Medullary is associated with MENII. Anaplastic has 1-year mortality of 80%. Thyroid lymphoma associated with prior Hashimoto’s.
278
Best screening test for Cushing's
1mg overnight dex suppression test or 24-hour urine cortisol. If abnormal, perform 8mg overnight dex suppression test.
279
Dx of Cushing’s disease
\> 50% cortisol suppression with high dose dex suppression test.
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Dx of cortisol-secreting adrenal adenoma or ectopic ACTH-secreting tumor?
Check plasma ACTH, abdominal and chest CT. Check DHEA-S for adrenal secreting adenoma.
281
Best screening test for Addison’s?
Cosyntropin stimulation test. Positive if there is insufficient cortisol rise after injection of ACTH. Also suspect in patients with high K+, low Na+ and low urine pH.
282
Most common cause of Addison’s? Tx?
Autoimmune. NaCl supplementation and long-term dexamethasone and fludrocortisone replacement.
283
When to cut out an adrenal mass?
\>6cm or functional
284
MENI
pituitary adenoma, pancreatic cancer (gastronoma) and parathyroid hyperplasia
285
MEN IIa
Parathyroid hyperplasia, Pheochromocytoma and Medullary thyroid carcinoma
286
MEN IIb
Pheochromocytoma, medullary thyroid carcinoma and Marfanoid habitus
287
Tx DKA
High volume NS, insulin bolus, insulin drip. add K+ once patient urinates and add glucose.
288
Tx HHS
High volume fluid and replace electrolytes +/- insulin drip
289
Tx of status epilepticus
Lorazepam + loading dose of phenytoin
290
Simple vs complex partial seizures
Simple - no LOC. Complex - LOC. Both can generalize.
291
1st line tx for partial seizures
Carbamazepine or phenytoin
292
Absence seizure tx? EEG?
Ethosuximide. 3 Hz spike-and-wave
293
General seizure tx
1st line - valproic acid
294
Psychosis vs delirium EEG?
Delirium - diffuse background slowing
295
Triphasic bursts on EEG?
CJD
296
HA worse with coughing or bending forward and wakes the patient up at night
Intracranial tumor
297
Bugs that can cause Guillain-Barre
Campylobacter, HHV, CMV and EBV
298
Chronic tx for myasthenia gravis?
Pyridostigmine, thymectomy if
299
Patient with fatigue, petechiae, recurrent infections, bone pain, hepatosplenomegaly and \> 20% blasts?
Acute leukemia
300
Patient with fatigue, petechiae, recurrent infections, bone pain, hepatosplenomegaly and CALLA or TdT?
ALL, most common cancer in kids.
301
Patient with fatigue, petechiae, recurrent infections, bone pain, hepatosplenomegaly, Auer rods, MPO and esterase? Risk factors? Tx? Complications associated with treatment?
AML, more common in adults. Risk factors include radiation, Down’s and myeloproliferative disorders. Tx with danorubicin, arak and give all trans retinoic acid if M3. M3 tx causes DIC.
302
Patient with fatigue, petechiae, recurrent infections, bone pain, hepatosplenomegaly, TRAP, low monocytes, CD11 and CD22+? Tx?
Hairy Cell Leukemia. Tx with cladribine 5-7 days once.
303
Patient has fatigue, night sweats, fever, splenomegaly, elevated WBCs with low LAP and basophilia? Tx?
CML - 9;22 translocation. Tx with imantinib to inhibit tyrosine kinase. 2nd line = bone marrow transplant.
304
Patient is asymptomatic with elevated WBC and 80% lymphs?
CLL. No tx if only lymphadenopathy. Tx with fludrabine if stage 2 and splenomegaly. Tx with steroids if stage 3/4 and anemia/thrombocytopenia.
305
ALL tx
Danorubicin, vincristine and prednisone. Add MTX for CNS recurrence.
306
Best initial test to rule out lymphoma
Excisional bx followed by staging chest/abdominal CT or MRI. Bone marrow bx necessary in NHL.
307
LN bx shows centripetal spread and RS cells
Hodgkin’s lymphoma
308
Lymphoma with best prognosis
Lymphocyte predominate
309
Lymphoma most likely to involve extra-nodal sites?
NHL
310
Tx of NHL?
Stages I/II (1-2 groups of LN on same side of diaphragm) = radiation. III/IV (both sides of diaphragm with organ penetration) = ABVD chemo.
311
Confirmatory test after SPEP showing IgG monoclonal spike?
Bone marrow bx showing \> 10% plasma cells confirms MM.
312
Pt with dizziness, HA, hearing/vision problems and monoclonal IgM M-spike?
Waldenstrom Macroglobulinemia
313
Asymptomatic patient with routing Ig spike on exam?
MGUS
314
Tx polycythemia vera
Scheduled phlebotomy and hydroxyurea.
