Inservice 2016 Flashcards
1
Q
J Osborn Waves =
A
Hypothermia
2
Q
Causes of Torsades de Pointes:
A
- NOT hyperkalemia|o
- HYPOmagnesemia|
- Prolonged QT syndrome
- Hypokalemia
- Hypothyroidism
- Amiodarone, lithium, methadone, erythromycin, sotalol, procainimide, quinidine, celexa, haldol, prozac (all prolong QT interval)
3
Q
Formula for LDL =
A
Total Cholesterol - HDL - (TG/5)
4
Q
Pt with HR 188s, but hemodynamically stable, you give adenosine > rapid deterioration of the pt and Vfib…whats was patient’s initial rhythm?
A
WPW
5
Q
Pt with hx of atrial fibrillation is on amiodarone for rhythm control but he also has structural heart disease. Which med should he be on for rhythm control?
A
Sotalol (Betapace)
6
Q
Treatment of Beta-Blocker toxicity:
A
Glucagon
7
Q
CHF with AS =
A
Poor prognostic sign
8
Q
Criteria for metabolic syndrome:
A
- Elevated waist circumference:
- Men — Equal to or greater than 40 inches (102 cm)
- Women — Equal to or greater than 35 inches (88 cm)
- Elevated triglycerides: Equal to or greater than 150 mg/dL
- Reduced HDL cholesterol:
- Men — Less than 40 mg/dL
- Women — Less than 50 mg/dL
- Elevated blood pressure: Equal to or greater than 130/85 mm Hg|o
- Elevated fasting glucose: Equal to or greater than 100 mg/dL|
9
Q
Side effects of amiodarone? (related to dose and duration of tx)
A
- CNS
- Demyelinating polyneuropathy
- Pseudotumor cerebri
- Eyes
- Corneal deposits > irreversible blindness
- Thyroid
- Hyper (Thyrotoxicosis) and hypothyroidism (Iodine is component of Amiodarone)
- Pulmonary
- Pulmonary fibrosis/infiltrates (pulm toxicity)
- Pneumonitis, hypersensitivity
- Pulmonary hemorrhage
- ARDS
- Cardiac
- Complete AV block
- Prolonged QT interval
- Ventricular arrhythmias are worsened
- Hepatic
- Fatal hepatotoxicity
- Renal
- Rhabdomyolysis
- Skin
- Photosensitivity
- Brown, blue-gray discoloration
- Yellow-brown granules macrophages on biopsy (Amiodarone sequestered in M0)|
10
Q
Cholesterol emboli syndrome:
A
- Precipitated by invasive arterial procedures in pts with atherosclerosis.
- ATN after a cardiac catherization
- Features include: fever, livedo reticularis, eosinophilia, renal failure
- Blue Toe Syndrome
11
Q
Know the timing of dye toxicity vs. cholesterol emboli associated with cath/renal stenting.
A
What I found is dye toxicity happens within 48 hours and cholesterol emboli can happen weeks to months later
12
Q
Blue toe syndrome
A
Find answer (cholesterol embolism?)
13
Q
Pt had cardiac cath, 48h later develops AKI (sounded like ATN), lace-like rash, fever and eosinophilia. What is the likely cause?
A
Cholesterol embolism
14
Q
ST elevation in II, III, aVF with hypotension. Diagnosis? Tx?
A
- Right sided infarct
- Tx: fluid resuscitation
15
Q
Pt with HTN on ACEI, walks 3 miles a day, needs to get cataract surgery. What to do next?
A
Proceed with surgery because it is low risk surgery, minimally invasive
16
Q
Atrial fibrilliation can’t take amiodarone due to wheezing, but needs rhythm control what to use?
A
Propafenone vs. Sotalol- cant use in structural heart disease
17
Q
ASA and Plavix for 1 yr drug eluding stent, this pt now needs a tooth extraction, what to do?
A
ACC: Maintain ASA if possible, stop Plavix 5 days before surgery and restart 24 hrs Post-op
18
Q
Mitral regurgitation murmur characteristics? S/Sx?
A
- Holosystolic murmur radiating to axilla
- S/Sx: dyspnea, pulm HTN, L axillary hypertrophy, afib
19
Q
Mitral valve replacement pt, needs anticoagulation before procedure. Whats the choice of anticoagulation?
A
Lovenox 1mg/kg q12hrs x 5 days
20
Q
CHD equivalents:
A
DM II, PVD
21
Q
Antidepressant that leads to HTN:
A
Venlafaxine
22
Q
Post-MI syndrome & Tx:
A
- Myocarditis/Pericarditis (Dressler’s syndrome)
- Fever, pericardial rub, effusion, pleuritic CP all 4-6 weeks after MI
- Tx: colchicine, corticosteroids
23
Q
Atrial fibrillation that is postural?
A
Atrial myxoma: most common is R atrium
24
Q
Duke’s criteria:
A
- 2 major criteria
- 1 major + 3 minor criteria OR
- 5 minor criteria|o
- Major criteria includes:
- Positive blood cultures (coxiella burnetti, staph A, HACEK)| + ECHO (endocardial involvement)|
- Minor criteria includes:
- Fever
- IVDU/predisposition
- Vascular phenomenon: embolism (janeway lesions)
- Immunologic phenomenon: glomerulonephritis, +RF, osler nodes, roth spots
- Blood cultures + not meeting major criteria
25
After heart valve replacement read Post-Pericardiotomy syndrome (Sx & Etio):
* Fever, pericardial effusion, pleural effusion
* 1st Question = Diagnosis (i.e. Dresser Syndrome when after MI)
* 2nd Question = Etiology (i.e. Autoimmune)
26
16yr old with heart murmur:
Hypertrophic Cardiomyopathy
27
Dilated Cardiomyopathy causes:
* Alcoholics, Thiamine Deficiency
* Hemochromatosis, Amyloidosis
* Postpartum, Thyroid & Parathyroid disease
* Infection (Chagas, Coxsackie, HIV), Lyme Disease
* Doxorubicin, Cocaine|CAD
28
C1 esterase deficiency:
Acquired angioedema usually happening after 4th decade of life
29
Multiple asthma attacks with central bronchiectasis what to do next?
* Check skin test for aspergillosis (ABPA)
* Tx with itraconazole (antifungals)
30
BOOP = COP
* Bronchiolitis Obliterans Organizing Pneumonia = Cryptogenic organizing pneumonia (COP) is often confused with bronchiolitis obliterans
* Nonresponsive to antibiotics, but presents like a pneumonia (fever, chills, dyspnea, cough), patchy uni or bilateral infiltrate on CXR
* See more often in rheumatoid disease
* Treat with steroids, Prednisone x24 wks
* Bronchiolitis Obliterans **not as predictably responsive** to steroids
31
Noncaseating granulomas, erythema nodosum, increased T cells on lavage
Sarcoidosis
32
If you suspect OSA:
* Obtain a sleep study (polysymnography test)
* There were 3 questions:
* All patients were obese
* One was fatigued with daytime somnolence and headaches.
* Another was refractory hypertension.
* Another was atrial fibrillation.
33
If a pt has a normal A-a gradient then you think:
* Central suppression, Hypoventilation
* Normal A-a = Age/4 + 4
34
Hypoxia that can’t be corrected with O2 therapy with nasal cannula:
Shunt physiology should be suspected
35
Chronic RML infiltrate with bronchiectasis:
BOOP = COP
36
65 yr old mechanic that has malignant thoracentesis:
Mesothelioma; asbestos is the primary cause
37
Occupation = engraver:
* Silicosis
* Can occur in any occupation that disturbs the earths crust & causes mixed obstruction/restrictive lung disease
38
Occupation = dry cleaner:
* Pulmonary Fibrosis
* "Think a dry cleaner cleaning velcro & velcro crackles on exam"
39
Lower ext laceration with cellulitis on a pt walking in fresh water, failed antibiotic treatment. Bug =
Aeromonas hydrophila
40
HIV pt who is placed on statin develops proximal muscle weakness:
Immune-mediated necrotizing myopathy
41
Black necrotic looking nasal lesion =
* Mucormycosis
* Sx: fever, headache, sinus pain
* Found in leaves and rotting wood
* Causative agent is Rhizopus
* Risk factors:
* DM- uncontrolled
* Neutropenia
* Renal failure
* Deferoxamine therapy
* Others: CA, organ transplant, skin trauma|
* With pulmonary and GI involvement they die w/in 2 weeks
* Confirmed with biopsy
42
Gram negative rod that is lactose negative and oxidase positive?
Pseudomonas & Aeromonas
43
Tx for severe legionellosis?
* Polymorphonuclear leukocytes usually present
* Macrolides and fluroquinolones
* Other options: ampicillin, tetracycline, (as per previous review sheet) – erythromycin and rifampin
44
35 y/o male has bumps on his arm, dies two days later. Dx and poss bugs?
* Group A strep (S. pyogenes) causing necrotizing fasciitis. Other causes?
* Staph a, clostridium perfringes, bacteroides, aeromonas
45
Heart Block with tick bite:
Lyme Disease
46
HIV ELISA is positive, indeterminate western blot, what to do next?
Repeat western blot w/in 6-12 weeks or check PCR
47
Young guy with severe cough, who then takes his girlfriend’s cipro notices his cough worsening…whats the cause of his cough?
Pertussis
48
Hantavirus (Camper in Southwest Colorado w/ Pulmonary Edema):
* Hantavirus: associated with sinobrae virus
* Pulmonary edema, hemorrhagic fever, cough, myalgia, lethargy, but NO rash
49
Rocky Mountain Spotted Fever:
* Diffuse maculopapular rash typically present (but not always), high fevers
* **D**ermacentor (**D**oxy) **T**ick (**T**etracycline) vector for Rickettsia
50
Staph Saprophyticus is most common in...
Young Women
51
Sulfur granules think:
Actinomyces
52
19 yr old female presents with fever, hypotension and macular rash:
* DIC from Toxic Shock Syndrome
* Fever \>102, SBP\< 90, macular rash, usually 3 organ systems involved
53
Whipple’s Disease:
* Involves CNS, heart, kidneys, and small bowel, joints "Whips around your body!"
* White males
* Gram negative bacillus: Trophyerma whippelii
* Diarrhea from malabsorption, wt. loss, LAD, arthritis (organism in synovial fluid), neurologic sequelae
* Steatorrhea on 72 hr stool sample
* Diagnosed with small bowel biopsy showing PAS (periodic acid schiff) positive granules in macrophages
* Tx: tetracycline or PCN for 1 year
* **T**rophyerma/**T**etracycline/**T**welve months. **W**hippeli/**W**hipples/**W**hite poop (steatorrhea)
54
Jones criteria for diagnosis of Rheumatic fever requires:|
* 2 Major OR
* 1 Major, 2 Minor + Evidence of prior strep infection (ASO Ab, + rapid strep, recent scarlet fever)
55
Major Jones Criteria for Rheumatic Fever:
* Major criteria:
* Carditis
* Polyarthritis
* Chorea-CNS
* Erythema marginatum
* Subcutaneous nodules
56
Minor Jones Criteria for Rheumatic Fever:
* Minor criteria:
* Fevers
* Arthralgias
* Previous rheumatic heart disease or Previous rheumatic fever
* Acute phase reactants (increased ESR/CRP/leukocytes)
* Prolonged PR
* "FAAPR!"
57
Tx for Neutropenic Fever:
* Mult. right answers - pick Pseudomonal coverage
* Imipenem vs Cefepime
* High-Risk (Cefepime or Imipenem + Vanco if central line/unstable)
* Inpatient
* Clinically unstable or sig. medical comorbidity
* Anticipated ANC ≤100 (UTD \<500) & ≥7 days
* Hepatic/Renal Insufficiency
* CA, uncontrolled
* PNA or complex infection
* Mucositis grade 3-4
* MASCC risk index \<21
* Alemtuzumab
* Low Risk: \<7 days neutropenia, no comorbidities, can take PO and have access to ED = Cipro + Augmentin
58
Tx of Meningitis (2-50 y/o):
* MCC strep pneumo or N. meningitides
* Vanco + 3rd gen cephalosporin
59
Tx of Meningitis (\>50 y/o):
* MCC: strep, neisseria, listeria, G- bacilli|-vanco + amp + 3rd gen cephalosporin
60
Tx of Meningitis (immunocompromised):
vanco + amp + cefepime/meropenem
61
LP findings for Bacterial Meningitis:
* Opening p \>250
* Leukocytes \>1000
* Glucose \<40
* Protein 100-500
* G stain + 60-90%
* Culture +
62
Early finding in Lyme Disease:
Erythema Migrans (Bull's Eye Rash)
63
Early findings in disseminated Lyme Disease:
* Weeks-Months after infection
* Cardiac (e.g. heart block) and Neurologic (e.g. Bell's palsy)|
64
What are late findings in Lyme Disease?
migratory arthritis, encephalopathy (decreased cognition and short term memory loss)
65
What is the Tx for Lyme Disease?
oral with doxycycline BID, cefuroxime BID, or Amoxicillin TID
66
Erlichiosis....go!
* Rickettsial, more in southern states, rash similar to RMSF
* Fever, HA, myalgias, fatigue, skin lesion in 30%, decreased WBC and platelets, increased LFT
* Tx = Doxycycline
* "Lick the spots off....down south."
* "Lick the leuk's."
67
MCC of Pneumonia:
* S. pneumoniae [G+, alpha-hemolytic, lancet-shaped diplococci]
* M. catarrhalis [G-, diplococci]
* H. influenzae [G- rods, oxidase+, catalase +
68
MRSA Pneumonia (resident at a NH):
* Tx with vancomycin
* Influenza can lead to MRSA pneumonia
69
Endocarditis and prosthetic heart valve a/w...?
* Staph epidermidis/Staph aureus
70
Streptococcus bovis infection a/w:
Colon CA & Endocarditis
71
Cat bite (Bug & Tx):
* Pasteurella Multocida, S. aureus
* Tx: Augmentin or Ceftin, Doxy, PCN
* 80% of cat bites get infected; P. multocida infxn develop in 24 hrs
72
Cat Scratch FEVER a/w & Tx:
* Bartonella henselae
* Tx: Azithromycin
* "Throw the cat....a là Monty Python"
73
Bad breath, EtOH & Dental Caries = Bug & Tx?
* Bacteroides Pneumoniae
* Anaerobic, G- bacilli, common in mouth & GI tract
* **Tx:** Clindamycin
74
MCC of HIV Encephalitis:
Herpes
75
If HIV is initially negative and person has risky behavior:
* **Check PCR**, if not a choice, then wait for 6-12 wks and recheck the Western blot prior to starting tx with HAART
* First check EIA when screening
* If negative, check RNA PCR if suspect infection (can be falsely elevated if levels \<100,000)
* If positive, check with repeat test and western blot before you can actually diagnose them with it
76
PCP is positive with:
Methenamine Silver staining
77
An organism that causes reactive arthritis:
* Yersinia NOT listeria or serratia
* Other causes: shigella, salmonella, chlamydia, campylobacter
* Answer on test will be Yersinia
78
E.coli H157
* Schistocytes and infectious diarrhea
* Causes HUS
* Causes hemorrhagic diarrhea
* Must perform specific lab test on stool, bacteria isolated on sorbital-macconkay agar
79
MCC for Bacillary angiomatosis a/w HIV:
* Bartonella henselae
* Occurs in immunocompromised
* Can cause hemangiomas, nodules, friable masses, plaques, easily confused with Kaposi sarcoma
* CD4 usually less than 50
* Tx: Erythromycin or Tetracycline
80
Kaposi Sarcoma:
* HHV-8
* MSM HIV pt
* Red, purple, brown macules/papules/plaque on skin
81
Toxoplasmosis in HIV patient:
* Encephalitis with CD4 \<100
* Treat with Bactrim
* MAC and CMV \<50: prevent with azithromycin
* PCP \<200: prevent with bactrim
* Cryptococcus \<100
82
Midwest differential (4):
* **Lime Babies born in the Rockies and raised by Hanta.**
* **Lyme disease:** MW
* **Babesia**: MW (Hunter in Wisconsin)
* Intraerythrocyte replication: causes hemolytic anemia
* think Babesia/Baby Jesus on a cross (maltese cross on histology)
* Hepatosplenomegaly, jaundice, AKI, DIC, heart failure
* Tx with atovaquone and azithromycin ("b**A**bies = **A**tovaquone & **A**zithromycin")
* **Rocky Mountain Spotted Fever:** continental
* Petechial rash, fever, HA, myalgia, confusion, thrombocytopenia, increased liver enzymes
* CSF: lymphocytic
* Doxycycline is the treatment (**"Doxy for the Roxy"**)
* **Hantavirus**: no rash, hemorrhagic fever, cough, pulm edema, myalgia, lethargy, hypotension \> renal failure (**"Hant had no rash"**)
83
Pt had cholecystectomy 6 wks ago, he now presents with 2 wks of abdominal pain, mild alk phos elevation, positive bilirubin 4.0. What is the cause of the problem?
Biliary leak? OR choledocolithiasis or bile duct stricture?
84
Fatty liver disease is a/w:
* Metabolic syndrome
* EtOH
* Abdominal obesity
* Diabetes mellitus
* Hyperlipidemia
85
Alcoholic hepatitis and cirrhosis a/w:
2:1 ratio of AST: ALT
86
Pt with carcinoid tumor on octreotide tx:
* Leads to Niacin Deficiency
* 4 D’s: diarrhea, dementia, dermatitis, death
87
How does Octreotide work in treating Carcinoid Syndrome?
* Decreases serotonin levels by breaking down 5-HIAA (usually elevated 24 h urine level is diagnostic of carcinoid syndrome)|
88
DM with hemachromatosis:
Check ferritin level
89
Gene mutation for hemochromatosis:
HFe and C282Y and H63D
90
Celiac sprue
* Blunting of the villi
* Young girl with bloating, hypocalcemia, iron deficiency, abdominal exam is tympanic on percussion
91
LFTs greater than 1000s:
* Acetaminophen toxicity
* Ischemic hepatitis
* Viral hepatitis
* Autoimmune hepatitis
92
Achalasia (definition, Dx, Tx):
* Loss of peristalsis in distal 2/3rd of esophagus and impaired relaxation of LES
* Bird beak sign on barium swallow
* Diagnosis confirmed by esophageal manometry
* Tx is botox, surgical myomectomy or dilation, oral nitrates or CCB
93
Suspect gastroparesis from diabetes mellitus:
* Check a gastric emptying studying
* Must have negative EGD and negative imaging for obstruction
* Dx of exclusion
94
H. pylori infection (a/w, Dx, Tx):
* a/w MALT (mucosal associated lymphoid tissue), PUD, dyspepsia, early gastric cancer
* Urease breathe test (less S&S) and fecal Ag test
* Rapid urease test on endoscopy
* Can be treated with antibiotics against H. pylori and retest with endoscopy 4-6 weeks later
* Triple therapy: PPI, clarithromycin, amoxicillin (or flagyl) for 10-14 days
* Second line: PPI, tetracycline, flagyl, bismuth for 10-14 days
95
Extraintestinal manifestations of IBD:
* NOT a/w pemphigous vulgaris
* IS a/w: pyoderma gangrenosum, PSC, ankylosing spondylitis, erythema nodosum (crohn’s), nephrolithiasis, thrombosis
96
Radiologic findings in UC:
* lead pipe”- toxic megacolon
* NOT fistulas
97
ESR \>100:
* Occult infection (osteomyelitis, abscess)
* Connective tissue disorder
* Malignancy
* Temporal arteritis (Giant cell arteritis)
* If suspected – immediate tx with steroids – if delayed can lead to irreversible blindness
* Confirmatory dx: temporal artery biopsy
98
Triad & Stages of Churg-Strauss angitis:
* Triad of asthma, eosinophilia, and positive p-ANCA suggests Churg-Strauss Syndrome
* First stage: asthma and allergic rhinitis
* Second stage: eosinophilia
* Third stage: vasculitis
* I think question stem was something like pt presents with recurrent asthma attacks, found to have eosinophilia in the blood, which of the following will the pt also have?
* p-ANCA in biopsy of blood vessels
99
Henoch-Schonlein Purpura
* Vasculitis
* Increased IgA and platelets
* Palpable purpura
* Involves kidneys, GI (usually abd pain), joints (hemarthrosis) and lungs
* There was a question that sounded like it but correlated better with another answer choice so be careful
100
Slightly negative birefringent crystals in synovial fluid
* Pseudogout:: rhomboid or coffin shaped
* Gout: negatively birefringent crystals in synovial fluid, needle shaped
101
Specific test for Rheumatoid Arthritis (RA):
Check Anti-CCP (anti-citrullinated protein Ab)
102
Limited Sclerosis most associated with:
Pulmonary Hypertension
103
Wegener’s granulomatosis: (now called granulomatosis with polyangiitis)
* C-ANCA 90%
* Optho involvement is common: Conjunctivitis, Sclerosis, Uveitis, Retinal Vasculitis, Retro-orbital pseudotumor (proptosis)
* Saddle nose deformity: also with leprosy/ septal perforation, Replasing polychondritis, Congenital syphilis
* Upper and Lower Respiratory: Cough, Hemoptysis, Pleurisy, Granulomatous infections in the respiratory tract \> Multiple infiltrates with diffuse opacity; Usually some kind of sinus problem in clinical vignette
* Associated with FSGS and hematuria
* Mononeuritis multiplex
* Skin: purpura/ulcers
* Tx: corticosteroids and cyclophosphamide for 3-6 months "weCener's: C+C 6-month factory"
104
Mixed Cryoglobulinemia:
* Decreased C3 and C4
* a/w Hepatitis C – type II- monoclonal IgM or IgA
* Immunoglobulins that reversibly precipitate in cold temperatures
* Meltzer’s triad: palpable purpura, arthralgias, and myalgia
* Mononeuritis multiplex and immune complex glomerulonephritis
105
Cryoglobulins a/w:
* Infective endocarditis
* Lymphoma- type I (monoclonal immunoglobulins)- vasculitis, nephritis
* Myeloproliferative disorders
* Connective tissue disorder
* Autoimmune diseases- type III- SLE, sjogren’s syndrome
* Hypocomplimentemia
106
Anti-histone Ab a/w:
* Drug-induced lupus
* procainamide and hydralazine, methyldopa are the most common|
* ANA, anti-single stranded DNA usually positive too
* Rash, arthritis, pleuropericarditis, cytopenia, fever
107
Male with visual disturbances, mm weakness and dysuria:
* Reiter’s syndrome/arthritis
* Oligoarticular arthritis, urethritis, conjunctivitis
108
Patients with SLE usually die from:
Late = MI
Infections- early and late from immunosuppression
109
4 immunologic factors for SLE include:
* anti- ds DNA
* anti- Smith
* false positive VDRL
* ANA
110
Criteria for Diagnosis of SLE:
* 4 out of 11 = 95% specificity & 75% sensitive
* DOPAMINE RASH
* D: Discoid rash
* O: Oral Ulcers
* P: Photosens
* A: Arthritis
* M: Malar
* I: Immuno markers (anti sm, dsdna, ro, la, histone for drug induced etc)
* N: Neuro changes (psychosis, personality changes, seizures)
* E: Elevated ESR
* R: Renal
* A: +ANA
* S: Serositis (Pleurisy, pericarditis)
* H: Hematologic (Hemolytic anemia, thrombocytopenia, leukopenia)
111
Treatment of SLE:
- NSAIDS for arthralgias,
- hydroxychloroquine prevents flares and increases survival; decreases organ damage, thrombosis and bone loss
- cyclophosphamide- restricted to lupus nephritis, severe disease
112
CREST Syndrome (Limited Sclerosis):
o Calcinosis|o Raynaud’s syndrome/phenomenon|o Esophageal dysmotility|o Sclerodactyly|o Telangiectasia|usually with postive anti-centromere Ab and anti- Th/To
113
Diffuse Sclerosis:
• ILD \> PHTN, Kidney dz, Serositis|• Proximal skin involvement to distal forearms and knees|o At risk for PBC (primary biliary cholangitis)|o Anti-Scl 70 (anti-topoisomerase)| |
114
Primary Sclerosing Cholangitis:
Pruritis, abd pain, jaundice|Alk phos 3-10x ULN|AST/ALT 2-3x ULN|+ANA and smooth muscle Ab, p-ANCA (in 2/3)|cholangiocarcinoma high risk|A/w UC \> Both = risk of Colon CA|dx with cholangiography (MRCP "string of beads")|
115
Testicular tenderness, hematuria, fever and leg numbness:
Check throat cultures; PAN?
116
Diastolic heart murmurs, ears hurt, myalgias:
Polychondritis |-Affects ears, nose, resp. tract|-Ocular inflammation, Polyarteritis|-Vasculitis, aortic/mitral valve insufficiency
117
What is the Tx for Polychondritis?
-NSAIDs |-Dapsone |-Immunomodulators
118
Behcet’s disease:
-Mouth and perianal aphthous ulcers|-a/w erythema nodosum|-Japanese and middle eastern descent|-uveitis \> meningoencephalitis \> arteritis \> arthritis \> phlebitis \> VTE|-High risk for VTE- migratory, superficial|-Hemoptysis from pulmonary vascular involvement
119
What are the symptoms of Primary Biliary Cirrhosis?
Fatigue, pruritus, loose stools, jaundice (rare), hepato/splenomegaly, dry eyes, dry mouth
120
What are common lab findings with Primary Biliary Cirrhosis?
• Asx elevation of alk phos \>1.5x ULN|• AST/ALT \>5x ULN|• anti-mitochondrial Ab in 90%- liver biopsy is next step if detected
121
What is Primary Biliary Cirrhosis associated with?
Hashimoto's Thyroiditis & Sicca Syndrome
122
What is the Tx for Primary Biliary Cirrhosis?
• liver transplant|• urso-deoxycholic acid offers survival benefit
123
Tx of Acute vs Chronic Gout:
Acute = Colchicines|Prophylactic = Allopurinol||Remember...Gout = Needle-shaped, Negative-birefringence crystals
124
Polyarteritis Nodosa (PAN):
Medium and small muscular arteries|40-60 yo|a/w Hep B infection|Fever, arthralgias, myalgias, abd pain|Peripheral nerve involvement, testicular pain, skin (livedo reticularis, pupura, ulcers)|Labs = pancytopenia, increased ESR|1/3 of the time renal artery is involved|Dx: necrotizing vasculitis on biopsy of skin, muscle or sural nerve|
125
PiZZ gene a/w:
Developing alpha-1 anti-trypsin deficiency
126
Anti-histone Ab =
Drug-induced Lupus
127
Ankylosing Spondylitis:
o HLA-B27, elevated ESR|o Can be a/w Crohn’s disease, anterior uveitis, psoriasis |• Bamboo spine- proliferative changes (syndesmophytes and calcification of longitudinal ligament)|• Pain/stiffness of spine, low back, buttocks, posterior thighs, forward posture, fx, radiculopathy, myelopathy|o M \> F in Teens & twenties|• Tx = NSAIDS, steroids, TNF-α inhibitors
128
What are some causes of Membranous Glomerulonephritis?
* **Hepatitis B**
* Also, other chronic infections: Hepatitis C, syphilis, subacute bacterial endocarditis, OM, mastoiditis,
* autoimmune
* malignancy
129
Urine osmolarity 350, given DDAVP \> urine osmolarity 360...
o Central diabetic insipidus - \<200 and increases \>10% after vasopressin given|o Nephrogenic diabetic insipidus - \<200 and does not increase after vasopressin, treat with thiazide (reduces intravascular volume and polyuria)|o Osmotic diuresis- usually urine osm \>300
130
Which of the following is most consistent with ATN?||o BUN \>20 :1|o FeNa \< 0.9|o RBC casts|o Urine Na \> 40|
For ATN:| BUN/Cr \<20:1| FeNa \>2| Urine Na \>40| Muddy brown granular or epithelial cell casts| Urine osmolality \<350-450|
131
IgA nephropathy in 16yr old with renal failure
Absent in 40% of patients with Rheumatoid Arthritis
132
Pt on digoxin + hyperkalemia do not give:
Calcium Gluconate \> worsens Digitalis Toxicity
133
18 yr old on HD with hyperkalemia of 7.0 what is the quickest way to resolve hyperkalemia?
Albuterol Tx peak effect = 90 min |o 50% dextrose/regular insulin- onset in 10 min, sustained for 4-6h|o Bicarb- only use if acidotic|
134
Thiazides lead to...
• Hypercalcemia|• There was a question that asked what is the cause of hypercalcemia and the pt was on a thiazide but I think it was a different answer, probably malignancy
135
Workup for painless hematuria (\>3 ery/HPF):|
Repeat UA if pt is \<40 yo||If erythrocytes are normal in size and shape \> Cystocopy|If amorphic erythrocytes \> need glomerular workup \> Imaging & Bx
136
Low anion gap acidosis causes:
Increased K, Ca, Mg, lithium intoxication|o Think of gammaglobulinemia|• Hyperparaproteinemic states (e.g. MM)||AG= 2.5 x change in albumin + calculated AG|
137
HAGMA causes:
GOLD MARRK||Glycols|\*Ethylene|\*Propylene|\*\*Metabolized into D-Lactate & L-Lactate|\*\*Used as a solvent for Lorazepam, Phenobarbital and other infusions|Oxoproline (5-oxoproline; aka pyroglutamic acid)|\*Chronic Paracetamol use (i.e. Acetaminophen), esp. in malnourished women|L-Lactate|\*Iron, Isoniazid|D-Lactate|\*Short Bowel Syndrome|Methanol|Aspirin|\*Especially if pH is very low (e.g. 6.8)|Renal Failure|\*Buildup of sulfates & phosphates|Rhabdomyolysis |Ketoacidosis|\*Diabetic|\*Alcoholic|\*Starvation|\*Isoniazid ||Isopropyl Alcohol does NOT cause HAGMA but is metabolized into acetone (only other things that cause serum acetone are recovering DKA or starvation ketosis)|
138
Delta Gap =
Delta Gap = change in AG/change in HCO3||\<1 NAGMA + HAGMA |\>2 metabolic alkalosis + HAGMA |
139
In working up NAGMA, you should check:
Check Urine anion gap= (Na+K) – Cl||If negative= increased Cl and likely increased NH4 à kidney responding appropriately to loss of bicarb and cause is something other than kidney (e.g. diarrhea)|
140
Differentiate between Types I-IV RTA:
Step one: Determine it is RTA (hyperchloremic acidosis with a normal anion gap and near normal GFR in the absence of diarrhea = RTA) |Step two: Look at the potassium level, if it is higher than the normal range (3.5-4.5) then it is automatically RTA-IV. If it is lower, rule out RTA-IV and go to step 3. |Step three: Look at urine pH. If it is lower than 5.5 it is automatically RTA-II. If it is higher than 5.5 go to step 4. |Step four: Look at the bicarb level. If the bicarb level is near normal it is RTA-I. If the bicarb level is markedly decreased it is RTA-II. |Step five: confirm diagnosis as follows: -RTA-I: administer ammonium chloride (an acid). If urine pH does not drop below 5.5 as serum pH decreases, you have your diagnosis. -RTA-II: administer bicarb. If the urine pH continually rises as bicarb is given, you have your diagnosis. -RTA-IV: salt restrictive diet. If urine sodium is persistently high, while serum sodium begins to decrease, you have your diagnosis. ||Type I- urine pH \>6.0, decreased serum K, increased kidney stones from potassium wasting|Type II- proximal, urine pH\<5.5, rare by itself, K normal|Type IV- increased serum K|pH \<5.5- decreased aldosterone level or activity|pH \> 6.0 tubulointerstitial injury (obstruction or interstitial dz)
141
Increased osmolar gap causes:
o Ethylene glycol toxicity (oxalate crystals in the urine)|o Ethanol|o Isopropyl alcohol|o Methanol|o Methanol and ethylene glycol also causes AG metabolic acidosis
142
ATN causes:
-ischemia |-tubular toxicity from meds| -aminoglycosides, amphotericin B, foscarnet, tenovovir, IV dye, NSAIDS, chemo, heavy metals|
143
Alport Syndrome:
* disrupted glomerular basement membrane with type IV collagen|
* usually family history of deafness and kidney disease
* Sensorineural hearing loss (musician in stem?)
* Hematuria|o Progressive renal disease
* ESRD in teen years or 4th decade of life
* Ocular lesions: **early-onset cataracts**
144
Polycystic Kidney Disease is a/w:
Berry aneurysm|Diverticulitis|Hernias|Cysts: pancreas, spleen, thyroid, seminal vesicles, liver
145
What is an example of drug dosing that doesn't change with CKD?
Penicillin G
146
What are 3 medications that cause Hyperkalemia by inhibiting potassium excretion in the kidney?
Gentamicin |Bactrim |Cisplatin
147
Necrolytic migratory erythema from zinc deficiency:
Red, blistering rash on lower abd, buttocks, perineum and groin |A/w liver disease |Elevated Glucagon, malabsorption \> dec amino & fatty acids |
148
What is the most common cause of Vitiligo?
Thyroid disease
149
Pt has a reaction to poison ivy. This is an indication of which part of immune system is intact?
Cell mediated immunity is intact (T cell mediated)
150
Pt has blisters on the dorsum of the hand then think porphyria cutanea tarda:
Photosensitivity \> Facial reddening \> Hyperpigmentation |A/w EtOH, Hepatitis C, Fe, Estrogen |NO GI or Neuro manifestations
151
Ash-leaf spots on skin =
Tuberous Sclerosis
152
Seborrheic Keratosis is a/w:
GI malignancy!!
153
Tx of long-term Urticaria:
H1RA \> H2RA \> Steroids \> TCA \> Immunomodulators
154
What are the most common underlying causes of long-term Urticaria?
Infection |Allergies |Meds: | PCN, Beta-Lactams, Vanco | ASA, NSAIDs
155
DDx for hand blisters:
Vitamin C or B12 Deficiency |Hypothyroidism |Hepatitis C |Porphyria
156
Rapidly fatal dementia =
Creutzfeldt-Jakob Disease
157
What is the Tx for Trigeminal Neuralgia?
Carbamazepine (Tegretol)
158
Triptans are used for...
Migraine Abortive Tx||Prophylaxis = SSRI
159
Causes of Bell's Palsy:
Pregnancy |Lyme Disease |Viruses: CMV, EBV, HSV, VZV
160
What is the most common cause of dementia?
Alzheimer disease - biggest risk factor is AGE
161
When to treat BP in patients with stroke:
o BP \>185/110 mm Hg in pt being treated WITH tPA|o BP \>220/120 in pt being treated WITHOUT tPA
162
25yr old with supracellar mass with calcification and lack of peripheral vision:
o pituitary adenoma OR|o craniopharyngioma-calcified on Ct|o tumor grows too large for blood supply \> pituitary apoplexy|o sudden HA, visual changes, AMS, hormone dysfunction (affects multiple endocrine systems)
163
Differentiating central lesion vs Bell's Palsy:
Differentiated with frontalis muscle- cannot wrinkle forehead with peripheral Bell's Palsy
164
Monoplex Neuritis (mononeuritis multiplex) definition & causes:|
Damage to peripheral nerves (asymmetric)||RA, SLE|MS, DM|Amyloid|Vasculitis, PAN|Lymphoma/Leukemia, Paraneoplastic|
165
Normal Pressure Hydrocephalus (NPH):
• Wide-based gait with urinary incontinence and dementia|• “wacky, wet and wobbly”|• Tx: shunt|
166
Pseudotumor Cerebri:
• Benign intracranial hypertension – increased ICP in absence of tumor or other cause|• HA, visual changes (visual loss), tinnitus|• Treat with Diamox|
167
Miller Fisher variant of Gullian Barre:
Often confused with botulism |Descending rather than ascending paralysis
168
Multiple Sclerosis is a/w:
Scanning speech |Optic Neuritis |Monoplex Neuritis |Increased IgG |Oligoclonal bands in CSF
169
Worst HA of my life =
AV malformation with ICH or SAH
170
Schmidt’s syndrome (autoimmune polyendocrine syndrome type 2):
Addison’s disease|Hashimoto’s thyroiditis|DM||APS type I = gonadal failure, hypoparathyroid, hypothyroid, vitiligo
171
Familial Hypercalcemic Hypocalciuria:
o lack of calcium sensing receptor in the parathyroid gland|autosomal dominant|o hypocalciuria ( \<50mg/24hrs); urine Ca/urine Cr \<0.01|o variable hypermagnesemia|o minimally elevated or normal levels of PTH|o good prognosis, usually asymptomatic and do NOT need treatment
172
Which oral hypoglycemic causes acute pancreatitis: Pioglitizone vs. Sitagliptin?
• Sitagliptin—|• Serious reaction:|o Stevens Johnson syndrome|o Angioedema|o Pancreatitis|o Pancreatitis, acute hemorrhagic|o Pancreatitis, necrotizing||• Pioglitizone—|• Serious reaction:|o CHF|o Hepatotoxicity|o Fractures in female patients|o Diabetic macular edema|o Bladder cancer "Pee-oh-glitazone!"||
173
18-hydroxysteroid and postural changes in serum levels:
Aldosterone increases normally with standing
174
Pt with hypotension and septic shock. Her sepsis resolved but she is still hypotensive what is the reason?
Adrenal Insufficiency
175
MIBG (iodine meta-iodobenzylguanidine) scan:
Confirm the presence of pheochromocytoma and neuroblastoma
176
Hyperosmolar state, glucose 1200. Whats the initial treatment?
NS 1000 ml/h WITH insulin 0.1 U/kg bolus and 0.1 u/kg/h infusion after
177
Know hyperparathyroidism well!
-Primary: increased PTH (adenoma MCC), increased Ca, decreased phos, increased vitamin d|-Secondary: increased PTH from decreased vitamin d or renal osteodystrophy- increased phosphate, decreased or increased ca|-Tertiary: increased PTH from ESRD and loss of feedback, increased Ca, vitamin d level varies|
178
With respect to thyroid function: Decreased total T4, normal T3
• think of hypothyroidism in pregnancy|• T3 levels fluctuate, free T4 in normal pt is only relevant, total T4 in pregnancy is only relevant
179
1.5 cm Thyroid Nodule....what do you do, Jack?!?
Check an ultrasound and biopsy if TSH increased|Risk factors that support biopsy: strong family history, history of neck radiation|• check RAIU if TSH decreased|
180
Where is Acanthosis Nigricans usually found and what are some things it is a/w?
Found in intertriginous areas ||A/w: insulin resistance, PCOS, Obesity, DM, Cushings, Prednisone, Thyroid disease, Adenocarcinoma of GI tract, Acromegaly||If found in thin pt \>40 yrs THINK MALIGNANCY!
181
How is PCOS diagnosed and treated?
• Diagnosis of exclusion, confirmed with US|• Rotterdam criteria- oligoovulation, excess androgen (hair), polycystic ovaries|Tx = Metformin |
182
What's a lab that can differentiate b/w Primary & Secondary Adrenal Insufficiency?
ACTH
183
Findings a/w renal osteodystrophy:
Inc PO4, Dec Vit D & Ca |Secondary Hyperparathyroidism |Bone pain, Fx
184
DeQuervain thyroiditis:
* Preceded by viral URI
* Initially causes hyperthyroidism but may develop into hypothyroidism after thyroid burn out
* Decreased uptake on thyroid scan
* Tx- BB and NSAIDS|
185
What lab findings hint that pt is using exogenous thyroid hormone to lose weight:
Iodine uptake scan shows 0% activity|Dec TSH and thyroglobulin|
186
Jod-Basedow phenomenon:
• Iodine-induced hyperthyroidism|• Usually there's pre-existing iodine deficiency goiter, followed by increased iodine uptake
187
Wolf checkov phenomenon:
• Decreased hormone levels from increased iodine uptake|• Drug-induced hypothyroidism: usually from Tx in Graves disease
188
RN with hypoglycemia:
Check C-peptide
189
Which type of DM is more hereditary?
NIDDM
190
Small Cell Lung cancer (SCC) is a/w what paraneoplastic syndrome?
SIADH
191
Increased Calcitonin think...
Medullary Thyroid Carcinoma
192
What is a Krukenberg tumor?
Metastatic CA involving the Ovaries usually mets from the GI tract
193
What is Bowen's disease?
Squamous Intraepidermal Carcinoma, often involving the penis
194
What is Mycoses fungoides and Sezary Syndrome?
Aggressive skin cancer with mets to lymph nodes and blood a/w cutaneous T-cell lymphoma|
195
What is associated with Sipple syndrome?
MEN IIa (autosomal dominant)||4 C's:|o medullary Carcinoma of the thyroid|o pheochromocytoma (inc Catecholamines)|o hyperparathyroidism (inc Ca)|o occasionally Cutaneous lichen amyloidosis
196
Tartrate Resistant Acid Phosphatase is diagnostic of:
Hairy Cell Leukemia ||"IT'S A TRAP!!"
197
Tx of Hemolytic Anemia:
Autoimmune = Corticosteroids |Drug-induced = discontinue offending agent
198
Pt with hx of sickle cell disease is shown to have aplastic anemia on bone biopsy what is the cause of this?
Parvovirus B19
199
Tx for Prostate CA:
Lupron (Leuprolide)
200
Before starting Infliximab (Remicade) you must:
Must do a PPD (Mantoux) test \> Immunosuppression can make TB worse|
201
Myelofibrosis:
Fatigue (anemia), night sweats|Wt loss, abd pain, early satiety (Hepatosplenomegaly d/t extramedullary hematopoiesis)|Anemia, increased or decreased WBC and platelets|Usually accompanied by previous Jak 2 mutation|
202
Nose/gum bleeding, thrombocytopenia, fragmented red cells:
TTP/HUS (+schistocytes)|-Check von Willebrand factor|-Usually check ADAMTS 13
203
What is AML Type 3 a/w?
Promyelocytic anemia |Auer rods can cause DIC
204
If a pt has multiple 3rd trimester miscarriages, you should workup:
Antiphospholipid Ab Syndrome||Check for anticardiolipin Ab|Need 2+ blood tests, 3 months apart|A/w rheumatologic disorders|Can also cause: Thrombocytopenia, sterile endocarditis, and recurrent thromboembolic disease
205
TRALI =
Donor against recipient
206
What vitamins can cause Coumadin toxicity?
Vitamin E (large doses) & of course Vitamin K
207
What are 2 common hypercoagulable states:
1) Factor V Leiden |2) Prothrombin G20210A mutation
208
What are two potent congenital hypercoagulable states?
Protein C & S Deficiencies and Antithrombin III Deficiency
209
Inc PT, nml PTT =
Liver disease |Vitamin K deficiency |Dec Factor VII |Coumadin
210
Tell me about Factor XII:
Hagerman factor |Prolonged aPTT, but no bleeding |If elevated though, can cause thrombus!!
211
Multiple Myeloma (MM):
o check congo red staining because of high association with secondary amyloidosis|• no need to check complement levels|• three criteria|o monoclonal protein in urine/serum (“M” spike) ≥3 g/dL|o 10% or more clonal plasma cells on BM biopsy|o evidence of end-organ damage|• • Lytic lesions on Xray with a negative bone scan:|o o Multiple myeloma NOT prostate cancer|• Smoldering/Asymptomatic- Abscense of EOD|• MGUS- \<3 g/dL, \<10%, no end organ damage
212
Paclitaxel side effects:
o Myelosuppression- pancytopenia|o Peripheral neuropathy|o Hypersensitivity rxn|o Cardiac conduction disturbances- bradycardia|o Steven’ Johnson syndrome, extravasation, alopecia|• Neuroencephalopathy- Grand mal seizures|• Renal impairment|o Arthralgia/myalgias
213
What is the goal INR for Antiphospholipid Ab Syndrome?
INR 2-3, if recurrent disease = 3-4
214
Some drugs that affect Coumadin levels:
• Major ones are antibiotics and antidepressants|• Amiodarone|o Statins|o Rifampin|o Ketoconazole|o Ranitidine|o Quinidine|o Propanolol
215
Lung CA + Hypercalcemia =
Squamous Cell Carcinoma (SCC)
216
Tumor Lysis Syndrome:
• usually caused by malignancy with rapid cell turnover- leukemia, burkitts lymphoma|• can be spontaneous or treatment induced|o usually elevated potassium, phosphate and uric acid, decreased Ca, pt goes into DIC and AKI|• Tx = Hydration and Allopurinol, can use risburicase if uric acid significantly increased for quicker action|• Hemodialysis if severe|
217
Steroid side effects:
o Adrenal insufficiency, CV collapse, arrythmias|o Cushing’s syndrome \> Acne, rash, DM|o Immunosuppression \> Infection|o Neutrophilia, Lymphopenia|• Myocardial rupture after MI|• Thromboembolism|• Fluid and electrolyte imbalance \> Edema, Elevated BUN with normal Cr|• Increase liver enzymes, Pancreatitis, Peptic ulcers|• Bone marrow suppression/stimulation \> Osteopenia/ osteoporosis \> Osteonecrosis of femoral head|• Muscle loss/weakness/myopathy |-Steroid psychosis|
218
X-ray shows a calcified strip of spine with medial elbow & foot pain. Diagnosis =
DISH (Old DM bear hunter image) = Diffuse Idiopathic Skeletal Hyperostosis
219
DiGeorge Syndrome:
CATCH-22, mentally retarded ||Cardiac = Tetralogy of Fallot, Truncus Arteriosus, VSD, ASD, Pulmonary Atresia, Interrupted Aortic Arch |Abnormal facies = micrognathia, microcephaly |Thymus hypoplasia |Cleft palate |Hypoparathyroidism = low PTH, low Ca |22 = chromosome 22q11 deletions ||
220
Elevated serum Tryptase is due to what?
o Mastocytosis|o Tryptase is a marker of mast cell degranulation released in parallel with histamine. Total tryptase levels in plasma correlate with the density of mast cells in urticaria pigmentosa lesions in adults with systemic mastocytosis. Total tryptase values are recommended by the WHO as a minor criterion for use in|the diagnostic evaluation of systemic mastocytosis.
221
Pt on Coumadin presents with skin necrosis:
Protein C Deficiency
222
6 wks pregnant female with her Td updated last week comes to your clinic in October which other immunization is she qualified for?|
Influenza vaccination- inactivated (subq)||Can’t give live (nasal) or MMR, HPV, VZV
223
Pt develops altitude sickness at the start of a ski/mountain vacation in utah or something, how to prevent this in the future?
* Acetazolamide (Diamox) 2 days before leaving
* "Dos days of Diamox"
224
How can Delirium Tremens kill you?
Arrhythmias (V-tach)
225
Causes of Hypophosphatemia:
Refeeding Syndrome |Hyperparathyroidism |Respiratory Alkalosis |EtOH \> malabsorption |Vitamin D deficiency
226
What findings are a/w Hypophosphatemia?
AMS |Weakness, Diplopia |Dysphagia
227
Vitamin B12 Deficiency:
CNS demyelination: mania, psychosis, neuropathy \> ataxia|Inc Homocysteine & MMA |Need gastric IF |Common in IBD
228
Thiamine Deficiency (B1):
Beri-beri|Dry = Korsakoff (confabulation) & Wernicke encephalopathy (Nystagmus, EOM palsies, vomiting)||Wet = Cardiovascular collapse
229
Niacin Deficiency:
Pellagra = 4D's||Diarrhea \> Dermatitis, Dementia, Death
230
Folate Deficiency:
Weakness \> Depression \> Palpitations |Megaloblastic anemia
231
Vitamin B6 Deficiency:
|"6 Signs of low B6" 1,2,3 + CCB: Bloody Nerves and Skin|Anemia |Peripheral neuropathy, CNS depression |Dermatitis, Seborrheic Keratosis, Conjunctivitis ||"More like amNOdipine"|CCB worsen deficiency \> neuromuscular disease, peripheral edema, proteinuria
232
Tx for Torticollis:
Botulinum toxin injection
233
Alendronate is a/w:
Esophageal ulcers & dysphagia \> do NOT give GERD|Osteonecrosis of the jaw |Atypical femur fracture
234
Marfan Syndrome:
o Defect in fibrillin gene causing decreased elastin deposition|o MVP, MR, AR, aortic root aneurysm \> Acute aortic dissection|o Tall stature, hypermobile joints, arched palate, scoliosis, arachnodactyly|o Subluxation of the lens (ectopia of lens) \> myopia, retinal detachment
235
Older man at church, shaking hands, turns his head to one side then becomes nauseous, diaphoretic and passes out. Diagnosis? Tx?
-Carotid Hypersensitivity|-Reassuranced
236
Man c/o left leg pain after walking 2 blocks. ABI on left is 0.8 and right is 1.0. What do you do?|A) Peripheral angiography & Stenting|B) Conservative mgmt|C) Increase walking program
\<0.9 = Risk Factor Mod (quit smoking, walking program, etc)|\<0.8 = Vascular Surgery Referral
237
EKG changes, "small" Q's in II, III, aVF with T-wave inversions; Trop 1.0 & chest pain s/p knee arthroscopy. BP 196/120 with tachycardia, SpO2 95% on NRB. Diagnosis?||A) Pulmonary Embolism|B) Myocardial Infarction|C) Elevated Troponin 2/2 Tachycardia
PE with Right Heart Strain (recent surgery, pos Trop, etc)
238
1st line treatment for A-fib w/RVR, HR 110? With LVH?
Diltiazem vs. Metoprolol (LVH I'm guessing implying structural heart disease - maybe Metoprolol?)
239
-pulmonary wedge pressure questions x2 in hypotensive ICU pt, one with cardiogenic shock and ok BP. Both had cardiac output 3.0L (low) and cardiac index 1.8 (low) - Just flip and review
- Dobutamine if high PCWP and low cardiac index, SBP 70-100 and no clinical signs of shock
- Dopamine if signs/symptoms of shock
- for the question with ok BP, probably Lasix drip
- PCWP (Pulmonary Capillary Wedge Pressure) is used to estimate left atrial pressure in heart failure. Normal pulmonary artery pressure is 25/10. Normal PCWP is 6-12 or 2-15mmHg. \>20 means acute pulmonary edema.
- Cardiac output should be 4-8 liters, and cardiac index 2.5-4.0L/min/m^2
240
Older male p/w A fib with RVR, elevated troponin (1.0), BP 80/50, what to do next?
Cardiovert (unstable A-fib)
Other options were Cardizem, Amiodarone, Digoxin
241
Pt with CHF and NYHA class 2 or 3, (on ACE-I and BB) which additional medication would provide mortality benefit?
Spironolactone
242
Pt has hypertension, no family history, Na 146, bicarb 28, potassium 3.0, urine potassium 60 (normal 25-125), what is the most likely diagnosis?
Primary Hyperaldosteronism
243
Older woman with CAD and recurrent angina is on multiple meds: nitrates, aspirin, bblocker, etc and still has exertional angina but she doesn't want any surgery, what do you recommend?
Ranolazine for symptomatic Tx
244
Man with stable angina who was nearly maxed out of meds but was borderline hypotensive so another agent could not be added. What do you prescribe?
Ranolazine
245
Likely lab finding on question with Sarcoidosis:
Hypercalciuria
246
Plaques on lungs describing mesothelioma but states mild fibrosis. What is the patient’s likely occupation?
Plumber
247
Patient with COPD, GOLD stage 3 on albuterol and ipratropium, what tx to add?
Inhaled steroids
248
Patient with CREST type picture, normal FEV and FEV/FEV1 with DLCO 44% (\<45% is severe respiratory impairment), dx?
* Pulmonary HTN
* Low DLCO and low lung volumes indicate interstitial lung disease, but the question had normal spirometry, so pulmonary hypertension seems to be the answer. Also seen with normal spirometry and low DLCO are rheumatoid arthritis and vasculitides, or anemia
249
Pt has implied unilateral transudative effusion, what the cause?
* Lytes criteria: pleural/serum LDH ratio ≥0.6 or protein ≥0.5, oir LDH \> 2/3 upper limit of normal: If any then is exudative
* In question, believe it was transudative by Lytes, so CHF
250
Pulmonary condition a/w widened mediastinum on CXR?
* Anthrax
* G+bacillus, box-shaped
* Occupations that handle wool
251
Non-Hodkins Lymphoma (NHL) patient post chemotherapy, has meningeal symptoms, lumbar puncture shows organism seen on India ink stain(crytococcus). Initial tx with?
Liposomal Amphotericin B
252
Pts with late compliment deficiencies are prone to _________ infections.
Gonococcal
253
Which persons with valvular replacements need prophylaxis for endocarditis?
Bioprosthetic Valves
254
Dog bite (Bug & Tx):
* Pasteurella canis, S. aureus
* Capnoctyophagia caniformis (asplenia \> sepsis w/DIC)
* Bacteroides sp. Fusobacterium sp.
* **Tx:** Augmentin or Clinda + Fluoroquinolone
255
Pt from a hotel with infiltrates on CXR, diarrhea, hyponatremia and positive Dieterle silver stain. **Dx?**
Legionella
256
22y/o male solider returning from Afghanistan had a leg papule turn into a large ulcer. Causative agent?
Leishmaniasis from sandlfy
257
**HIV** pt presents for vaccination with recent Tdap 8 years ago. Which vaccination is **contraindicated** at this time?
Don’t give live viruses in immunocompromised patients (**VZV**, MMR).
258
Ashkenazi Jewish female, stem says MFEV (Mediterranean Familial Fever) gene? But has AA amyloidosis, what med to both prevent and treat it?
Colchicine
259
What medication could cause hypercalcemia 13, hypophosphatemia, and hypomagnesemia
Lithium
260
Diet to recommend in epiloeptic patient?
Ketogenic
261
Diet to **_avoid_** in Parkinson's pt?
High-Protein
262
What pre=op test should you get in a Down Syndrome pt?
Cervical X-ray (rule out atlanto-axial instability)
263
What are Down Syndrome with atlatno-axial instability at risk for?
C1-C2 myelopathy; ALL
264
Kleinfelter syndrome, gynecomastia, hypogonadism, at increased risk for what?
Germ Cell Tumor
265
Menstruating woman p/w severe mastalgia with menses (cyclic mastalgia), treatment?
Danazol (picture Tony Danza being like, "Boobs hurt? Alriiight....I got ya!"
266
People with acromegaly are at increased risk for:
Colon CA
267
Chlorthalidone is protective against \_\_\_\_\_\_.
Osteoporosis
268
Pt has a hemorrhagic stroke, is now quadriplegic, mute, and can only move his eye vertically. What's the location of the stroke?
Pons
269
Multiple sclerosis is a/w:
* **_Oligoclonal band in CSF_**
* Scanning speech
* Optic neuritis
* Mononeuritis multiplex
* Increased IgG
270
Central lesion vs. peripheral Bell’s palsy
Cannot wrinkle forehead in Bell's palsy
271
25yr old with suprasellar mass with **_calcification_** and lack of peripheral vision:
Craniopharyngioma
272
Pt has zoster infection of T5 dermatome, they are at increased risk for what?
**CVA** (or MI)
273
1cm, nummular lesions, erythematous with red/violet centers, most associated with which drug?
**Sulfa**, Anticonvulsants
274
Renal involvement with **_hemoptysis_**. Clear lung sounds on exam with benign CXR, with chest and epigastric pain?
Goodpasture's (anti-GBM)
275
Older guy comes in for gross hematuria, UA is done and shows like +1 protein and many RBCs. What is it?
We put (hemorrhagic) cystitis (CA); otherwise If dysmorphic \> glomerular
276
Recurrent pneumococcal pneumonia with hx of giardia infection?
CVID (Common Variable ImmunoDeficiency)
277
Frequent URI with diarrhea?
IgA deficiency? CVID again? Not sure
278
Gout, tx in a patient with chronic gout who is allergic to allopurinol?
Febuxostat
279
Insidious onset of respiratory symptoms/vague and over 1 months , central sparing, what is it?
Chronic Eosinophilic Pneaumonia
280
Pt has hand pain (bilaterally?) with hook like osteophytes on imaging, what is the diagnosis?
**Hemochromatosis,** CPPD if that's not an option
281
Pt described with Restless Leg Syndrome picture, asks for next step in the workup?
B12
282
P/w high fever, joint pain, and salmon colored papular rash, lymphadenopathy, elevated ferritin, negative ANA and rheumatoid factor:
Adult onset Still Disease
283
Older male, maybe 60 y/o p/w leg pain and swollen legs improved with elevation. CT shows distal tibial periosteal hypertrophy. Diagnosis?
Hypertrophic Osteoarthropathy (periostitis of long bones, digital clubbing, arthritis)
284
Younger female patient with nonspecific fever, myalgia, weight loss, has arm pain with lifting overhead objects (arm claudication, ?subclavian steal). What's the diagnosis?
Takayasu Arteritis
285
Anti-Smith most specific for:
SLE
286
Linear hyperdensities B/L knee joint space
CPPD
287
Young male (teenage or 20s) with painless? rectal bleeding, negative scope, third presentation with negative past 2 rectal exams, now has objective blood within rectum, dx?
Meckel's Diverticulum
288
60yo female p/w fecal incontinence. She had 4 kids but the largest was only 7 pounds. What was her biggest risk factor for this?
Episiotomy
289
Female in her 20s on birth control has a vascular lesion in the liver (likely hemangioma, the most common benign hepatoma), what to do next?
* If lesion is \<5cm and **asymptomatic**, no f/u imaging needed
* \>5cm, f/u imaging 6-12 months
* If painful or it's compressing structure, then surgery
290
Guy who works in a warehouse c/o bloody stools for couple of months, non healing ulcer on his leg (pyoderma gangrenosum). What is is?
Ulcerative colitis
291
45yo Male with 4cm salmon colored lesion in esophagus (Barrett's esophagus) how should you treat it?
PPI (Don't think esophagecetomy)
