IM4 Flashcards
What is sympathetic opthalmia aka “spared eye injury”?
Immune mediated inflammation of one eye (sympathetic eye) after the penetrating injury to the other eye. Manifestations most commonly is anterior uveitis, but panuveitis, papillary edema, and blindness can also result.
Pathophys: Uncovering “hidden antigens” resulting in autoantibodies attacking these antigen
What drugs cause a drug-induced liver disease via cholestasis?
Chlorpromazine, nitrofurantoin, erythromycin, anabolic steroids (CONE)
What drugs cause a fatty liver disease?
Tetracycline, valproate, and anti-retrovirals (VAT)
What drugs cause a hepatitis?
Halothane, phenytoin, isoniazid, alpha methyldopa (HAPI)
What drugs cause a fulminant or toxic liver failure?
Carbon Tetrachloride and acetaminophen
What lab results suggest an alcoholic hepatitis?
AST/ALT >2
What are signs of multiple sclerosis?
Optic neuritis Lhermitte sign Onset at age 15-50 Internuclear ophthalmoplegia Fatigue Uhthoff's phenomenon (heat sensitivity) Sensory symptoms (numbness, parathesia) Motor symptoms (paraparesis & spasticity) Bladder/bowel dysfunction
Disease pattern: Relapse and remitting (majority)
Dx of multiple sclerosis
T2 MRI lesions disseminated in time and space (periventricular, juxtacortical, infratentorial, or spinal cord)
Cerebral and spinal plaques composed of clusters of demyelinated axons appear as hypo/hyperintense lesions on MRI involve the subcortical white matter in the brain
Oligoclonal IgG bands on CSF analysis
Management of caustic (lye) ingestion
Will cause immediate esophageal injury with liquefactive necrosis and potential reformation. Endoscopy should be performed within 12-24 hours. Activated charcoal, corticosteroids, emetics and acid neutralization should not be given.
What are the symptoms of hypokalemia?
Muscle weakness, cramps and if severe, flaccid paralysis., EKG shows u-waves.
What are the symptoms of hyperkalemia?
Muscle weakness, flaccid paralysis, and ECG changes. Asystole can occur with severe hyperkalemia
Hyponatremia symptoms?
Normally asymptomatic. Prolonged significant hyponatremia may cause weakness, lethargy, delirium, and seizures.
hypermagnesemia symptoms?
Mild - Decrease deep tendon reflexes. Severe - loss of deep tendon reflexes
Hypocalcemia symptoms
Hyperactive deep tendon reflexes, muscle cramps, and rarely, convulsions. Hypomagnesemia can also mimic hypocalcemia because it decreases PTH secretions and decreased peripheral responsiveness to PTH. Can happen after a major surgery with transfusion due to citrates which binds the calcium and causes hypocalcemia.
Complications of Acute Pancreatitis?
Pleural Effusions, Acute respiratory distress, ileus, and renal failure
Squamous cell carcinoma of the lungs
20-40% Central Necrosis and cavitation are common Hypercalcemia Smokers
Adenocarcinoma of the lungs
20-40%
Peripheral, as solitary lesion
Clubbing and hypertrophic osteoarthropathy
Women and non-smokers
Small cell carcinoma of the lungs
central
Cushing Syndrome
SIADH
Lambert Eaton Syndrome
Non-Allergic rhinitis
Presents with one of the chronic rhinitis symptoms (i.e. nasal congestion, rhinorrhea, sneezing, postnasal drainage) Predominant nasal congestion and stuffiness, postnasal drip (dry cough) and no identifiable triggers. In contrast to patients with allergic rhinitis who have predominant eye symptoms. Patients are treated with intranasal antihistamines and glucocorticoids or combination therapy
What are the ABCDE’s of melanoma
Asymmetry Border irregularities Color variegations Diameter (>6mm) Enlargement
What is the greatest traditional risk factor for a stroke?
Hypertension
What is the most common cause of age-related hearing loss?
Presbycusis defined as sensorineural hearing loss that occurs with aging. Noticed in the 6th decade of life, and begins with symmetrical, high frequency hearing impairment. Difficulty hearing in noisy crowded rooms.
Meniere’s disease
tinnitus, vertigo, and sensorineural hearing loss.
Wernicke’s encephalopathy
Triad of encephalopathy, gait ataxia, oculomotor dysfunction (Lies, eyes, and capsize). If chronic thiamine deficiency - Korsakoff’s syndrome: irreversible amnesia, confabulation, and apathy
What are medications are cause hyperkalemia?
Non-selective B-blockers (interferes with B2 mediated intracellular potassium uptake)
ACE inhibitor (decrease in aldosterone secretion)
ARBs
K-sparing diuretics (i.e. amiloride, spiranolactone)
Digoxin and cardiac glycosides (inhibits the Na-K ATPase)
NSAID impaires local prostaglandin synthesis reducing renin and aldosterone secretion (prostaglandin are produced by macula dense, which causes increase release of renin and aldosterone)
Effect of prostaglandins on the afferent arterioles
Causes vasodilation of the afferent arterioles. Nsaids can cause unopposed constriction of the afferent which causes renal hypoperfusion.
What are the changes of hyperkalemia on EKG?
Peaked T waves, prolonged QT intervals and narrow QRS intervals
Non-medicine causes of hyperkalemia?
Chronic kidney disease, RAAS axis impairment
What is hypertrophic osteoarthropathy?
Digital clubbing is associated with osteoarthropathy. The condition is often associated with lung cancer.
What is characteristic of pneumonia by Legionella?
Associated with lobar pneumonia, diarrhea, hyponatremia, mild LFT elevations
What is the triad that is highly suspicious of Infectious Mononucleosis?
Fever, pharyngitis, lymphadenopathy
Heterophile antibody test (monospot test)
Anterior cerebral artery stoke symptoms
Contralateral motor and sensory deficits which more pronounced in the lower limb than in the upper limb. Other features include urinary incontinence, gait apraxia, primitive reflexes, abulia, emotional disturbances
Lacunar infarcts Symptoms
Small vessel infarcts typically affecting the deep subcortical structures due to occlusion of a deep penetrating branch of a large cerebral artery. Well recognized symptoms: pure motor hemiparesis, pure sensory stroke, sensorimotor, dysarthria-clumsy hand, and ataxia hemiparesis.
Middle cerebral artery stroke Symptoms
Contralateral motor or sensorial deficits that are more pronounced in the face and upper limbs than the lower limbs. If the dominant side is affected, patient may have aphasia. If the non-dominant side is affected, patient may have hemineglect or anosognosia (lack of awareness regarding one’s illness)
Posterior cerebral artery stroke
Homonymous hemianopsia, alexia (unable to understand written word) without agraphia (inability to write written word) (dominant hemisphere), visual hallucination, sensory symptoms (thalamus), third nerve palsy with paresis of vertical and horizontal eye movements, and contralateral motor deficits
What are some causes of thrombocytopenia due to decrease production?
Viral (Epstein Bar, HIV, Hep C) Myelodysplasia Disease Congenital (Fanconi) Alcohol use Vitamin B12, folate deficiency Chemotherapy
What are the causes of thrombocytopenia due to increase platelet destruction?
SLE, medications idiopathic thrombocytopenic purport disseminated intravascular coagulation thrombotic thrombocytopenic purpura hemolytic uremic syndrome Antiphospholipid syndrome
Waldenstrom’s macroglobuminemia
IgM spike on electrophoresis and hyper viscosity due to increase in immunoglobulins. Also, easy bleeding, night sweats, hepatosplenomegaly, tiredness due to anemia
ESCC (Epidural spinal cord compression) management?
Malignancy that affect the spine: breast, prostate, lung, multiple myeloma. Progressively worsening back pain, that is worse in the recumbent position. Show upper motor neuron signs below the level of the lesion. Bladder incontinence are late findings
Give glucocorticoids to decrease vasogenic edema, and then do an emergent MRI.
Normal Anion Gap? And what contributes to an anion gap
6-12
Inorganics: Sulfates, Phosphates
Organics: Ketoacids, lactates, uremic organic anions
Exogenous: Salicylates, ingested toxins
Associations with splenic abscess
Hematological spread such as from infective endocarditis, IV drug use, hemoglobinopathy, immunosuppression (HIV), trauma
Triad: LUQ pain, fever, leukocytosis
Tinea versicolor
Pink velvety pale macules caused by Malassezia furfur. on KOH show large blunt hyphae with thick walled budding spores “spaghetti and meatballs”. Tx: Selenium sulfide and ketoconzole
Blastomycosis
BLAStomycosis
Bone, lung and skin involvement.
From the Great Lakes, and Ohio area
Broad-base budding yeast
Very similar to TB-like symptoms
Tx: Amphotericin B, intraconazole
Pleural fluid pH
Normal pleural fluid pH = 7.6
transudative 7.4-7.55
exudative = 7.3-7.45
Acne Vulgaris treatment
Mild: topical retinoid, salicylic, benzoyl peroxide
Moderate: Topical antibiotics (erythromycin, clindamycin)
Severe: oral antibiotics
Unresponsive severe: Oral isotretinoin
Brain abscess causes
50% due to extension of infection in the head and neck caused by Strep Viridans (intermedius, mitis, orals, mutans) and other anaerobic bacteria (i.e. Peptostreptococcus, Bacteroides). Hematological causes are the other 25% due to bacterial endocarditis or lung infection
Kussmaul sign
Paradoxical rise in JVP on inspiration
Location of aspirational pneumonia
Posterior segments of the upper lobe if the patient aspirates when recumbent.
The superior and basilar segment of the lower lobes.
Antibiotic great for anaerobic lung infections
Clindamycin
What murmurs get stronger and softer with squatting and hand grip?
Increase in venous return (preload), increase in afterload:
Softer: HCM and mitral prolapse
Louder: Aortic Regurgitation and Mitral Regurgitation, VSD
What effect does standing and valsalva maneuver have?
Decreases venous return: causes all murmurs to get quieter except for mitral valve prolapse and HCM
What paraneoplastic phenomenon are associated with small cell carcinoma of the lungs?
SIADH and ACTH production, Lambert Eaton myasthenia syndrome.
Smoking is the most important risk factor
What is associated with amino cytological dissociation?
Guillan Barre Syndrome; Campylobacter Jejeuni
treatment: IVIG, plasmaphersis
How do you figure out what kind of Supraventricular Tachycardia?
Supraventricular tachycardia is anything above the bundle of His. By doing the vagal maneuvers or give adenosine, we slow down the AV node and aid in diagnosis by unmasking hidden P-waves in patients with atrial flutter or atrial tachycardia. They cause a transient AV nodal block and terminate AV node-dependent arrhythmias including AVNRT and orthodromic AVRT.
Primary mechanism of nitroglycerin that causes anginal relief for patients?
Dilation of capacitance vessels (veins) resulting in decrease ventricular preload and decrease in heart size
Agents to push potassium into the cell
bicarbonate, insulin + glucose, and B2 agonist (albuterol)
What stabilizes the cardiac membranes from hyperkalemia?
calcium gluconate
Ectopic ACTH causes what symptoms
Hypertension, hypokalemia, metabolic alkalosis, and pigmentation without characteristic features of Cushing’s syndrome (i.e. moon facies, dorsal hump, central obesity, and striae)
What are the phases of CML?
Chronic phase: basophils seen on peripheral smear
Blast phase: >20% blasts in the bone marrow or the peripheral blood. Extramedullary blast proliferation
Do CML downstream myeloid cells have low or high alkaline phosphatase activity?
low leukocyte alkaline phosphatase activity
What is the management of COPD exacerbation?
Oxygen targeting saturation at 88-92%
Inhaled bronchodilators (i.e. albuterol) (long acting B-agonist are not used in exacerbation)
Inhaled anticholinergic (i.e. ipratropium)
Systemic glucocorticoids
Antibiotics (i.e. levofloxacin) for 2/3 cardinal symptoms, moderate to severe exacerbation, mechanically ventilated patients
Non-invasive positive pressure ventilation for moderate-severe exacerbation (BiPAP)
Tracheal intubation who do not improve with NIPPV or pharmacotherapy
What is the treatment for parkinson’s?
BALSA
Bromotriptine Amantidine L-dopa and carbidopa Selegine Anticholinergics
What is the therapy for Isolated Systolic Hypertension?
Ace Inhibitor
HCTZ
or
Long acting calcium Channel blocker
How does macular degeneration present?
progressive and bilateral loss of central vision
What physical exam findings are consistent with brain death?
Absent corneal reflex, absent gag reflex, and absent oculovesicular reflex. The pupils are fixed and dilated; patient will not spontaneously breath when ventilator is turned off for 10 mins. Must be confirmed by two physicians.
What is the most serious side effect of hydroxychloroquine, a drug for SLE?
Retinopathy - must have eye exams every 6 months
What are the features of Chronic Hepatitis C?
Fluctuations in liver transaminases
Extrahepatic manifestations: membrane glomerulonephritis, porphyria cutanea tardea, cryoglobuminemia (deposits in the small-medium vessels, decreased complement levels), palpable purpura, arthralgias.
How does adrenal insufficiency (Addison’s disease)
Weight loss, fatigue, abdominal symptoms, hyper pigmentation, hypotension, and hyponatremia/hyperkalemia.
Clinical presentation of gonococemia?
Polyarthralgias, Tenosynovitis, and vesiculopustular skin lesions.
Features of atrial fibrillation
irregularly irregular R-wave intervals, absent p waves, and narrow QRS complexes
What agents tend to cause acute drug-induced interstitial nephritis?
Sulfonamides, NSAIDs, antibioitics (penicillins, cephalosporins, rifampin, trimethoprim)
How is the therapy of asthma and COPD different?
Asthma: Inhaled corticosteroids are the primary long-term intervention
COPD: Anticholinergic inhaler - ipratropium
What does Brain Natiuretic Peptide measure (BNP)?
Responds to ventricular stretch and wall tension when cardiac pressures are elevated. Differentiates dyspnea from heart failure from that of non-cardiac etiology.
What is used in tricyclic antidepressant overdose?
Sodium bicarbonate because it shortens the QRS complex and decreases the likelihood of arrhythmia
What are the common causes of Aortic Regurgitation caused by leaflet disease?
Bicuspid aortic valve Rheumatic heart disease Endocarditis Trauma Myxomatous degeneration Ankylosing Spondylitits
What are the common causes of Aortic Regurgitation due to ascending root, aortic root disease?
Hypertension Aortitis Ankylosing Spondylitis Dissecting Aneuryms Ehler-Danlos, Inflammatory Bowel Disease Reactive arthritis Marfan's Syndrome
What medications should be held before a stress test?
Calcium channel blockers (amlodipine, nefedipine), beta blockers, nitrates
What is the treatment of Euvolemia or hypervolemic hypernatremia?
0.5% dextrose
What is the treatment of mild hypovolemic hypernatremia?
0.5% dextrose + 0.45% saline
Treatment of severe hypovolemic hypernatremia?
0.9% saline
Features of papilledema?
Increase in size in blind spot in the visual field. Momentary vision loss according to the change in head position. Leads to rapidly permanent vision loss.
Amarosis fugax
Painless, transient monocular blindness that lasts a few seconds, usually vascular (embolus to ophthalmic artery) in origin.
Anterior uveitis
Redness and eye pain
What are the treatment levels of cancer?
Induction Therapy - initial dose to rapidly kill cells and send patient into remission (<5% tumor burden)
Adjuvant therapy - Treatment given in addition to standard therapy
Consolidation therapy - Multidrug regimen to further reduce tumor burden
Maintenance therapy - Given after induction and consolidation, to kill residual tumor cells
Neoadjuvant - Treatment given before the standard treatment
Salvage treatment - Treatment for a disease when standard therapy fails
What type of heparin is used in renal impairment (<30ml/min/1.73m^2)?
Unfractionated heparin.
LMW Heparin should not be used (enoxaparin, fondaparinux)
What types of murmurs should always be investigated?
Diastolic mumurs, continuous murmurs
Side effects of Ace Inhibitors
cough, angioedema, hyperkalemia, and acute renal failure in those with bilateral renal stenosis
What are arteriovenous fistulas (AVF) and what are the effects?
Cause high-output heart failure by shunting the blood from the arterial to the venous side and therefore increasing the cardiac output.
What are the diagnostic values for Acute Tubular necrosis?
BUN/Cr 20
Urine osmolarity 300-350
FeNa > 2%
What medication prevents ventricular remodeling after an MI?
Ace Inhibitor
What is the treatment for Hepatitis C?
Peginterferon + ribavirin. Those with genotype 1 also receive protease inhibitor.
Antibiotic for a fight-bite injury?
Amoxicillin-Clavu - covers gram +/- and anerobes
What is the management of exertional heat stroke?
Fluid Resuscitation Electrolyte balancing Immersion in cold water Management of end-organ damage No role for anti-pyretics
What is a common complication of Adult Polycystic Kidney disease?
Berry Aneurysms
What is the significance of a leukocyte alkaline phosphatase score that is elevated?
Leukemoid reaction. Leukocyte alkaline phosphatase score is normally low in CML.
What is status epilepticus? And what is the effect?
Seizures lasting > 5 mins. Can lead to cortical necrosis and permanent neurological deficits. Will show up as hyper intensity regions on MRI on diffusion weighted imaging suggesting infarction.
DMARDS: Methotrexate
Antimetabolite. Side Effects: Stomatitis, hepatotoxicity, cytopenia
DMARDS: Leflunomide
Pyrimidine synthesis inhibitor: Hepatotoxicity, cytopenia
Hydroxychloroquine
TNF-1, IL-1 suppressor; retinopathy
Sulfasalazine
TNF, and IL-1 suppressor ; hepatotoxicity, stomatitis, hemolytic anemia
TNF inhibitors: Adalimumab, Certolizumab, Etanercept, Golimumab, Infliximab
Side Effects: Infection, demyelination, Congestive heart failure, malignancy
What should be given with methotrexate?
Folic Acid (Leucovorin = reduced folic acid)
What muscular condition is associated with giant-cell arteritis?
Polymyalgia Rheumatica
What are the indications for hemodialysis?
- Reflractory Hyperkalemia
- Uremic pericarditis
- Uremia –> neuropathy
- Refractory metabolic acidosis
- Coagulopathy due to renal failure
- Volume overload/pulmonary edema refractory to diuretics
What is Behcet’s syndrome
Multisystem inflammatory condition characterized by recurrent oral and genital ulcers, skin lesions; commonly seen in Turkish, Asian and Middle eastern population.
What is commonly associated with Calcium pyrophosphate dihydrate deposition in joints (chondrocalcinosis)
Hemachromatosis
How does cerebellar dysfunction present in chronic alcohol abusers?
Gait instability, truncal ataxia, difficulties with rapid alternating movement, hypotonia, intention tremors
When is avascular necrosis of bone often seen?
Corticosteroid use, SLE, heavy alcohol use, and sickle cell.
What are some opportunistic causes of diarrhea in HIV patients?
CMV, cryptosporidium, Isopora, Blastocystis, MAC, HSV
How does a cerebellar tumor present?
Patient falls to the side with the lesion, ipsilateral ataxia, walking with a sway to affected side. Also includes nystagmus, intentional tumor, ipsilateral muscle hypotonia, and difficulty in coordinating and rapid alternating movements.
What is the criteria for brain death?
Absent cortical and brain stem function. DTR may be present.
