Internal Medicine Flashcards
acute angle-closure glaucoma
symptoms: headache, ocular pain, nausea, decreased visual acuity
signs: conjunctival redness, corneal opacity, fixed/mid-dilated pupil
dx: tonometry (intraocular pressure) and goniscopy (measures corneal angle)
treatment
1. topical- multidrug (timolol, pilocarpine, apraclonidine)
2. systemic- acetazolamide (consider mannitol)
3. laser iridotomy
what can lead to hepatorenal syndrome
risk factors: advanced cirrhosis with portal hypertension and edema
precipitating factors: reduced renal perfusion, GI bleed, vomiting, sepsis, excessive diuretic use, spontaneous bacterial peritonitis, reduced glomerular pressure and GFR possibly by NSAIDS (constrict afferent arteriole)
what maneuvers increase parasympathetic tone to the heart
carotid sinus massage
cold water immersion or diving reflex
valsalva maneuver
eyeball pressure
Chronic Lymphocytic Leukemia
Clinical
- lymphadenopathy and hepatosplenomegaly
- mild thrombocytopenia and anemia
- could be asymptomatic
Diagnostic
- severe lymphocytosis and smudge cells
- flow cytometry (clonality of mature B cells)
Prognostic
- median survival 10 years
- worse with: multiple chain lymphadenopathy, hepatosplenomegaly, thrombocytopenia, anemia
Complications
- infection
- autoimmune hemolytic anemia
- secondary malignancies (richter transformation)
how to evaluate elevated alk phos
- check GGT (if normal then its likely due to bone abnormality)
- if elevated then its likely due to biliary problem so check RUQ ultrasound and anti-mitochondrial antibody
- AMA+ or abnormal hepatic parenchyma on US do liver biopsy
- dilated bile ducts do ERCP (endoscopic retrograde cholangiopancreatogram)
- both normal then consider liver biopsy, ERCP, observation
asymptomatic patient with elevated alk phos, normal AST and ALT, normal RUQ ultrasound, and positive anti-mitochondrial antibody assay, severe hypercholesterolemia
patient might have pruritus and fatigue
primary biliary cholangitis (previously, primary biliary cirrhosis)
- chronic progressive liver disease with cholestasis and autoimmune destruction of intrahepatic biliary ducts
- give patient ursodeoxycholic acid (hydrophilic bile acid)
- down the line most of these pts will need liver transplants
- complications: malabsorption of fat-soluble vitamins, metabolic bone diseases (osteoporosis/malacia), hepatocellular carcinoma
kidney problem that causes persistent activation of the alternative complement pathway
membranoproliferative glomerulonephritis, type 2
-immunofluorescence will show C3
patient with loss of motor and sensory function, loss of rectal tone, and urinary retention
acute spinal cord compression
-manage with emergency surgical consultation, neuroimaging, and possibly IV glucocorticoids
what is the most common cause of ascites
liver cirrhosis/chronic liver disease
next step for all patients who newly present with ascites
paracentesis is required to determine the cause
main complications after MI
0-24hrs: arrhythmia
1-3days: fibrinous inflammatory pericarditis
3-14days: pseudoaneurysm of inferior wall, free wall rupture, papillary muscle rupture, septal/VSD rupture
2weeks-3months: Aneurysm in anterior wall, dressler syndrome/immune pericarditis
intermittent claudication, diminished pulses, and abnormal (<1) ankle brachial index
-can be in one limb
Peripheral artery disease
-intermittent claudication = 20% 5-year risk of nonfatal MI and stroke AND 15-30% 5-year risk of death due to CV causes AND 1-2% critical limb ischemia with risk of limb amputation
-treat pt with statin and low-dose aspirin then start supervised exercise therapy
nonpupil sparing cranial nerve 3 palsy is concerning for what
aneurysmal compression (get MR or CT angiography immediately)
- most commonly caused by microvascular ischemia
- associated with diabetes mellitus, hypertension, hyperlipidemia
what are the nonosmotic reasons ADH can be stimulated for release
nausea pain physical/emotional stress hypotension hypovolemia hypoxia hypoglycemia
localized pain and tenderness over the medial tibial condyle in a runner
pes anserinus pain syndrome
- associated with overuse
- risk factors: obesity, DM, knee osteoarthritis, angular deformity
- dx: clinical
- treatment: quad strength training and NSAIDs
what does a third heart sound indicate
decompensated heart failure
-give dobutamine which stimulates myocardial contractility leading to improved ejection fraction, reduce LVESV, and symptomatic improvement
most common skin malignancy in US
basal cell carcinoma
-slow growing papule with pearly rolled borders
what is primary sclerosing cholangitis associated with
ulcerative colitis
how to diagnose multiple sclerosis
- T2 MRI lesion disseminated in space and time
- oligoclonal IgG bands on CSF lumbar puncture
patient with acute onset headache, sensation of the room spinning, nystagmus
stroke or hemorrhage affecting the cerebellum
pt with flank pain and hematuria and palpable abdominal mass
-left scrotal varicoceles
renal cell carcinoma
-paraneoplastic syndromes: anemia/erythrocytosis, thrombocytosis, fever, hypercalcemia, cachexia
aquagenic pruritus
polycythemia vera
-treat with phlebotomy
-one major complication is budd-chiari syndrome
budd-chiari syndrome
hepatic venous outflow obstruction usually due to myeloproliferative disorders (PV), malignancy (hepatocellular carcinoma), OCP use/pregnancy
acute signs: jaundice, hepatic encephalopathy, variceal bleeding, prolonged INR/PTT, elevated transaminases
chronic signs: abdominal pain, hepatosplenomegaly, ascites, elevated bilirubin and transaminases
dx: abdominal doppler ultrasound showing decreased hepatic vein flow then investigate for underlying causative disorders
single most important prognostic consideration for pts treatment with cancer
TNM staging, stage 4 is the worst
good and bad prognostic factors in breast cancer
good
ER+
PR+
bad
overexpression of HER2/neu oncogene
poorly differentiated tumors
endemic locations of systemic mycoses
histo- mississippi and ohio river valleys
blasto- eastern and central US and great lakes
coccidio- southwestern US and california
paracoccidio- latin america
clinical features of blasto
lung- acute/chronic pneumonia
skin- wart like lesions, violaceous nodules, skin ulcers
bone- osteomyelitis
genitourinary- prostatitis, epididimo-orchitis
CNS- meningitis, epidural or brain abscesses
what does an S4 mean?
-AKA atrial gallop
indicates a stiff LV (the sound is atrial contraction and blood is hitting the stiffened LV)
-restrictive cardiomyopathy
-can be heard in acute phase of myocardial infarction
OR
-LV hypertrophy from prolonged hypertension
acute lead toxicity vs chronic
GI: constipation
Neuropsych: sensorimotor neuropathy, short-term memory loss
Heme: microcytic anemia with basophilic stippling, hyperuricemia
treat with chelation therapy with calcium disodium EDTA
Chronic is the same but it can also lead to hypertension, nephropathy, hyperuricemia, and microcytic anemia
pronator drift
both arms out and palms up then one arm drifts down and palm turns toward the floor
sensitive and specific for upper motor neuron or pyramidal/corticospinal tract disease
how to treat secondary raynaud phenomenon
first the patient should get tested for autoantibodies and inflammatory markers
-CBC, metabolic panel, urinalysis, ANA antibody, rheumatoid factor, ESR, complement levels (C3 and C4)
- evaluate and treat underlying disorder
- CCB for persistent symptoms, aspirin for patients at risk for digital ulceration
patient with AIDS, progressive blurred vision, floaters, yellow-white exudates adjacent to the fovea/retinal vessels
cytomegalovirus (CMV) retinitis
- most common end-organ complication of CMV in pts with advanced AIDS
- treat with valganciclovir and in severe cases intravitreal infections
- pts should start on antiretroviral treatment to prevent recurrence and progression
what ratio to look out for in prerenal acute kidney injury
BUN/creatinine ratio (>20:1)
three most common causes of aortic stenosis
- senile calcific aortic stenosis
- bicuspid aortic valve
- rheumatic heart disease
adverse effect of antithyroid drugs
agranulocytosis
- methimazole: 1st trimester teratogen, cholestasis
- propylthiouracil: hepatic failure, ANCA-associated vasculitis
telogen effluvium
- acute, diffuse, noninflammatory hair loss
- scalp and hair fibers appear normal
- hair shafts easily pulled out (hair pull test)
- triggers: severe illness, fever, surgery, pregnancy/childbirth, emotional distress, endocrine/nutritional disorders
- management: address underlying cause, reassurance (self-limited)
serum to ascites albumin gradient
> 1.1 = portal hypertensive etiologies (cardiac ascites, cirrhosis)
<1.1 = non-portal hypertensive etiologies (malignancy, pancreatitis, nephrotic syndrome, tuberculosis)
dietary recommendations about pts with renal calculi
- increased fluid intake
- decreased sodium intake
- normal dietary calcium intake
urine cytology
checks for cancer cells in the pee
patients with idiopathic isolated thrombocytopenia should be tested for what?
-patient may also present with large platelets
they likely have ITP but you have to test them for hepatitis C and HIV before cause its kinda a diagnosis of exclusion
-test for ITP with antinuclear antibody screen
what can trigger distal symmetric polyneuropathy
- DM, long-standing HIV, uremia, toxicity
- damage to distal sensory peripheral nerve axons
- treat underlying cause cause and use pain management with gabapentin, tricyclic antidepressant, duloxetine, or capsaicin cream
how to define high grade carotid stenosis
70-99% occlusion
-pts should be considered for carotid endarterectomy to reduce future stroke risk
what is brain natriuretic peptide and what is it used for?
natriuretic hormone released from ventricular myocytes in pts with CHF in response to high ventricular filling pressures
-elevated BNP has high sensitivity (>90%) for dx of CHF… levels of over 400 are diagnostic (below 100 has a high negative predictive value)
hodgkin lymphoma
epidemiology: bimodal peak incidence (15-35 and over 60), associated with EBV in immunosuppressed pts
clinically: painless lymphadenopathy, mediastinal mass, B symptoms (fever, sweats, weight loss), pruritus,
labs: elevated LDH and eosinophilia
testing: PET scan with 18-fluorodeoxyglucose
dx: lymph node biopsy and reed-sternberg cells on histology
supraventricular tachycardia
regular but narrow QRS duration < 120ms with rate of 160bpm
-any tachy above bundle of His
paroxysmal supraventricular tachy
PSVTs are SVTs with abrupt onset and offset
-inclduing AVNRT, AVRT, atrial tachy, and junctional tachy
most common cause of cor pulmonale in united states
COPD
-you will hear a third heart sound
if youre looking at past records what two types of studies can you use and whats the difference?
retrospective cohort —> (looks at risk factors first) review past records and look for + and - risk factors then compare incidence
case control —> find diseased and control cases (look at outcome first) then compare risk factor frequency
worsened pain with alcohol and mediastinal mass
hodgkin lymphoma
tophaceous gout
multiple white nodules in hands with history of painful arthritis in fingers and feet
-uric acid crystals in joints –> enough urate crystals can form tophi tumors causing ulceration and chalky material
how does a pt with pneumocystis pneumonia present?
HIV with CD4 count less than 200
- subacute dyspnea, fever, dry cough, elevated LDH, diffuse bilateral pulmonary infiltrates
- dx with bronchoalveolar lavage
how to treat pneumocystis pneumonia
TMP-SMX and add corticosteroids for pts with PaO2 <70, A-a gradient >35, or pulse ox <92% on room air to reduce risk of respiratory decompensation
-dx with bronchoalveolar lavage
CREST syndrome
Calcinosis cutis Raynauds Esophageal dysmotility Sclerodactyly Telangiectasia
- anti-topoisomerase I antibodies
- strongly associated with limited cutaneous systemic sclerosis
- pulmonary arterial hypertension is associated with this
wide, fixed splitting of S2
ASD
systemic sclerosis
results from intimal hyperplasia of pulmonary arteries causing pulmonary hypertension
painless loss of monocular vision
central retinal artery occlusion causing ischemia of inner retina
-emergently treated with ocular massage and high-flow oxygen
essential tremor
- action tremor
- bilateral action tremor of hands, head is usually also involved, without leg involvement
- possible isolated head tremor without dystonia
- usually no other neurological signs
- relieved with alcohol in many cases
- treat with propranolol (first-line), primidone, or clonazepam
pill-rolling resting tremor that starts on one hand and progresses to other extremities, jaw, face, tongue, and lips
parkinsons disease
-give anticholinergic –> trihexyphenidyl
what improves mortality in pts with ARDS
lung protective strategies like low tidal volume ventilation (LTVV)
-lower pulmonary pressures decreasing likelihood of overdistending alveoli
acute respiratory distress syndrome
risk factors: infection, trauma, massive transfusion, acute pancreatitis
pathophys: lung injury leading to fluid and cytokine leakage into alveoli with impaired gas exchange, decreased lung compliance, PHTN
dx: new/worsening respiratory distress within 1 week of insult, bilateral lung opacities not due to CHF, hypoxemia with PaO2/FiO2 ratio < 300
management: mechanical ventilation (low TV, high PEEP, permissive hypercapnia)
parvo virus rash in adults
nonspecific morbilliform exanthem
postictal pH disturbance
anion gap metabolic acidosis after tonic-clonic seizure
-resolves without treatment within 90 minutes
normal pressure hydrocephalus
symptoms: gait instability, cognitive dysfunction, urinary urgency/incontinence, depressed affect (frontal lobe compression), UMN signs in lower extremity
dx: miller fisher (lumbar tap) test– marked improvement of gait with spinal fluid removal, enlarged ventricles out of proportion to sulci and underlying brain atrophy on MRI
treatment: ventriculoperitoneal shunting
acute interstitial nephritis
causes: drugs (penicillins, TMP-SMX, cephalosporins, NSAIDs)
3 main clinical features: acute renal failure, maculopapular rash, fever…. also new drug exposure, arthralgias
labs: urinary eosinophils, eosinophilia, inflammation, pyuria
treat: discontinue offending drug, systemic glucocorticoids
what pathology do you see in the brain of a pt with lewy body dementia?
eosinophilic intracytoplasmic inclusion
-a lot of alpha-synuclein protein
widespread pain, fatigue, cognitive/mood disturbances
fibromyalgia
foundation of management: exercise
medications only really used for pts who fail initial measures —> use amitryptilline
unsteadiness, shock sensation in spine, atrophy/weakness in upper extremity, and increased tone/reflexes in lower extremities
spinal cord compression (myelopathy) in cervical spine
-these pts usually have cervical spondylosis– degenerative condition associated with spinal cord narrowing due to formation of osteophytes in lateral vertebral bodies and ossification of posterior longitudinal ligament/ligamentum flavum
top 3 causes of the common cough
- upper-airway cough syndrome (postnasal drip) –> give H1 blockers
- asthma –> give anti-inflammatory meds
- GERD –> give PPIs
myasthenic crisis
causes: infection, surgery, pregnancy/childbirth, tapering of immunosuppressive drugs, meds (aminoglycosides, fluoroquinolones, and beta blockers)
signs: increased generalized and oropharyngeal weakness, respiratory insufficiency/dyspnea
treatment: intubation for deteriorating respiratory status, plasmapheresis or IVIG as well as corticosteroids
2 most common causes of microcytic anemia
iron deficiency and thalassemia
how to treat MS
IV glucocorticoids and use plasmapheresis if they dont respond to steroids
how to treat alopicia areata
mild/moderate hair loss: topical intralesional corticosteroids
severe hair loss: topical immunotherapy or oral corticosteroids
explain the difference b/w spironolactone and epleronone
spironolactone: progesterone and androgen receptor antagonist that can cause decreased libido and gynecomastia
epleronone: very selective mineralocorticoid antagonist with very low affinity for progesterone or androgen receptors so it has very few of the same side effects
how to diagnose and treat carcinoid syndrome
- elevated 24-hour urinary excretion of 5-HIAA
- CT/MRI of abdomen and pelvis to localize tumor
- octreoscan to detect metastases
- echocardiogram if symptoms of carcinoid heart disease are present)
- clinical features: skin flushing, diarrhea, valvular lesions, bronchospasm, niacin deficiency
- treat with octreotide before surgery and surgery for liver metastases
how to treat for cyanide poisoning
hydroxycobalmin or sodium thiosulfate or with nitrates to induce methemoglobinemia
mechanism of cyanide poisoning
-presents with altered mental status, lactic acidosis, seizures, and coma
cyanide binds to ferric iron in cytochrome oxidase a3 in mitochondrial ETC, blocking oxidative phosphorylation and promoting anaerobic metabolism –> causing lactic acidosis
-can occur in pts treated with nitroprusside with higher doses, prolonged infusions, or renal impairment
three major differences b/w actinomyces and nocardia and how to treat each
- actinomyces = anaerobic / nocardia = aerobic
- actinomyces is not acid-fast
- actinomyces has sulfur granules
treat actinomyces with penicillin
treat nocardia with tmp-smx
most common cause of hemoptysis in adults
pulmonary airway disease
- chronic bronchitis
- bronchogenic carcinoma
- bronchiectasis
bronchiectasis vs chronic bronchitis
both can cause hemoptysis
bronchiectasis: irreversible dilation and destruction of bronchi, resulting in chronic cough and inadequate mucus clearance… associated with chronic respiratory tract infections and chronic cough with copious amounts of mucopurulent sputum
chronic bronchitis: chronic cough for more than 3 months for 2 years… usually due to smoking
MEN1 vs MEN2a vs MEN2b
MEN1
- pituitary adenoma
- pancreatic/gastrointestinal tumors
- parathyroid hyperplasia
MEN2a
- parathyroid hyperplasia
- medullary thyroid carcinoma
- pheochromocytoma
MEN2b
- medullary thyroid carcinoma
- pheochromocytoma
- mucosal neuroma
- marfanoid habitus
fluctuating, fatigable muscle weakness that worsens with repetitive motions and improves with rest
- weakness with proximal muscles, ocular and bulbar muscles (ptosis)
- causes of exacerbations: medications (abx, nmb agents, cardiac meds, mgso4, penicillamine, child birth, surgery, infection)
- dx via ice pack test (bedside) or another highly specific test
myasthenia gravis
-dx via AChR-Ab (highly specific) or CT scan of chest showing thymoma
what should be considered in a pt with molluscum contagiosum with widespread and/or facial lesions
HIV testing or some other reason for immunocompromise
patient presents with dysphagia, chest/epigastric pain, reflux/vomiting, food impaction, associated atrophy
- throwing up immediately after drinking a cup of water
- refractory heart burn
eosinophilic esophagitis
- chronic immune mediated esophageal inflammation
- dx via endoscopy/esophageal biopsy (>15 eosinophils per high-power field)
- treat with dietary restriction and possible topical glucocorticoids
treatments for urgency incontinence
- bladder training
- pelvic floor exercises
- antimuscarinic (oxybutinin) to decrease detrusor activity
old lady presents with unilateral headache and jaw claudication
giant cell (temporal) arteritis
- may lead to irreversible blindness due to ophthalmic artery occlusion
- associated with polymyalgia rheumatica
- increased ESR
- treat with high dose corticosteroids to prevent blindness and then get temporal artery biopsy (will see focal granulomatous inflammation)
UC vs Crohns
UC- mucosal inflammation and crypt abscesses (complication is colorectal cancer)
Crohns- transmural inflammation, cobblestone mucosa, creeping fat (complication is fistulas)
cough, hypercalcemia, hilar lymphadenopathy
sarcoidosis
-lungs follow restrictive pattern
cluster analysis
grouping of different data points into similar categories
-randomization at group (not individual) level
parallel study
randomizes 1 treatment to 1 group and another to a different group
-usually just wanna see how the treatment works and nothing else is measured
factorial design studies
randomization to 2 or more groups and studying 2 or more variables
bartter syndrome hallmark finding
metabolic alkalosis with high urine chloride
slowly expanding, circular, itchy rash with raised border and central clearing
tinea corporis
-treat with topical antifungals
colonoscopy with melanosis coli- dark brown discoloration with pale patches of lymph follicles
laxative abuse
-these pts will usually have diarrhea in the middle of the night
acute bronchitis
- preceding respiratory illness (90% viral)
- cough for 5days – 3weeks, possibly with sputum
- absent systemic findings
- wheezing or rhonchi, chest wall tenderness
dx and treatment
- only get CXR if pneumonia is suspected
- symptomatic treatment, NSAIDs or bronchodilators
- NO abx
gynecomastia and small testes in a tall male pt struggling to conceive with his wife
Kleinfelters (XXY)
-infertility due to testicular fibrosis with seminiferous tubule dysgenesis, azoospermia, hypogonadism, and elevated FSH and LH levels
what is on your differential if you have a mediastinal shift
- pleural effusion (away from effusion, if large)
- pneumothorax (away from tension, toward spontaneous)
- atelectasis (toward, if large)
increased tactile fremitus
consolidation, like lobar pneumonia
hyperresonance to percussion
pneumothorax
carboxyhemoglobinemia
carbon monoxide poisoning
- due to smoke inhalation
- main symptom is headache… also nausea and dizziness
- dx via arterial blood gas: carboxyhemoglobin level
- treatment: high flow 100% O2 // use intubation and hyperbaric O2 if severe
when to prophylatically treat HIV patient for and with what?
CD4 count < 200
-give TMP-SMX for pneumocystis jirovecii
CD4 count < 150
-give itraconazole only if youre in an endemic area for Histo
CD4 count < 100
-give TMP-SMX only if positive IgG antibody positive
*give IVIG within 4 days of exposure to pts with exposure
upper respiratory tract: perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis, saddle-nose deformity
lower respiratory tract: lung nodules/cavitation, hemoptysis, cough, dyspnea
renal: hematuria, red cell casts, rapidly progressive GN
skin: livedo reticularis, nonhealing ulcers
Granulomatosis with polyangitis (Wegeners)
DX ANCA, PR3, MPO, c-anca biopsy -skin (leukocytoclastic vasculitis) -kidney (pauci-immune GN) -lung (granulomatous vasculitis)
management: corticosteroids and immunomodulators
what is likely associated with a transudative pleural effusion
- congestive heart failure
- cirrhosis
- nephrotic syndrome
- peritoneal dialysis
- common cause of red eye
- localized/patchy distribution and generally mild associated pain and discharge
- can be associated with rheumatoid arthritis and other autoimmune disorders
episcleritis
-usually self-limited and does not affect vision or involve the cornea
- painful red eye with opacification and ulceration of cornea
- similar to contact lens-associated keratitis
- usually due to gram-negative (pseudomonas or serratia), but can also be positive
pseudomonas keratitis
- medical emergency can lead to corneal perforation, scarring, and permanent vision loss
- remove and discharge contact lens then use topical broad-spectrum antibiotics
when to start statin therapy for lipid levels
primary prevention in pts with 10-year ASCVD risk > 7.5-10%
what to look at when considering nonalcoholic fatty liver disease
pts usually only have hepatomegaly and…
- steatohepatitis presents with AST/ALT ratio < 1
- treat with diet/exercise then consider bariatric surgery if BMI > 35
methotrexate mechanism and adverse effects
- folate antimetabolite
- hepatotoxicity, stomatitis, cytopenias
leflunomide mechanism of action and adverse effects
- pyrimidine synthesis inhibitor
- hepatotoxicity and cytopenias
hydroxychloroquine mechanism of action and adverse effects
- TNF and IL-1 suppressor
- retinopathy
sulfasalazine mechanism of action and adverse effects
- TNF and IL-1 suppressor
- hepatotoxicity, tomatitis, hemolytic anemia
adalimumab certolizumab etanercept golimumab infliximab
-mechanism of action and adverse effects
- TNF inhibitors
- infection, demyelination, congestive heart failure, and malignancy
patient with exertional dyspnea, pounding heart sensation (water hammer pulse)– made worse when lying on left side, and widened pulse pressure
chronic aortic regurgitation
if someone has low calcium what is the next step?
check magnesium levels
- if its low or due to medication or due to recent blood transfusion then treat underlying cause, replete magnesium, and give IV calcium for severe symptoms
- if magnesium is normal then measure serum PTH
nonallergic (vasomotor) rhinitis
- usually has later age of onset
- nasal congestion, rhinorrhea, sneezing, postnasal drainage
- no obvious allergic trigger
- perennial symptoms (may worsen with seasonal changes)
- erythematous nasal mucosa
- mild gets treated with intranasal antihistamine or glucocorticoids
- moderate to severe gets treated with combination therapy
when do you start antibiotic therapy for a pt with suggested infective endocarditis
3 separate blood cultures should be obtained from 3 different venipuncture sites
-if pt has severe symptoms then get these 3 w/i 1 hour before beginning empiric abx therapy
seborrheic dermatitis
dandruff and greasy-looking scaly rash involving nasolabial folds.. usually on face and scalp
- associated with CNS disorders (parkinsons) and HIV
- treat with topical antifungal agents
AV nodal blocking agents
adenosine, beta blockers, calcium channel blockers (especially verapamil), and digoxin
-not to be used in pts with a.fib cause it can promote conduction across accessory pathway and lead to degeneration of a.fib into v.fib
when is lidocaine used for cardiac purposes
ventricular arrhythmias
acute treatment of pts in a.fib in pts with WPW is aimed at prompt control of ventricular response and termination of a.fib…
hemodynamically unstable –> electrical cardioversion
hemodynamically stable –> IV procainamide or ibutilide
proximal vs widespread muscle pain
proximal (polymyalgia rheumatica) –> pain and stiffness , often with fever, malaise, weight loss, NO WEAKNESS, women > 50, associated with giant cell (temporal) arteritis, bilateral, increased ESR/CRP/normal CK/normal strength testing, rapid response to low-dose corticosteroids
*note that proximal can also be polymyositis/dermatomyositis —> WEAKNESS
widespread (fibromyalgia) –> women 20-50, chronic widespread musculoskeletal pain associated with tender points/stiffness/paresthesias, poor sleep, fatigue, cognitive disturbance, treat with regular exercise, antidepressants, neuropathic pain agents (tricyclic antidepressants)
what is the heart murmur with aortic dissection
acute aortic regurgitation which leads to an early diastolic murmur
- acute/aggressive
- fever, nasal congestion, purulent nasal discharge, headache, sinus pain
- necrotic invasion of palate, orbit, brain
- dx via: sinus endoscopy with biopsy and culture
Rhino-orbital-cerebral mucormycosis
treatment: surgical debridement, liposomal amphotericin B, eliminate risk factors (DM with ketoacidosis, hematologic malignancy, solid organ/stem cell transplant)
acute intermittent porphyria vs porphyria cutanea tarda
AIP- porphobilinogen deaminase, 5Ps: painful abdomen/port-wine colored urine/polyneuropathy (proximal muscle weakness)/psych disturbances/precipitated by drugs alcohol or starvation, treat with hemin and glucose
PCT- uropurphorinogen decarboxylase, blisters, bullae, scarring, hypo/hyperpigmentation on sun exposed areas, scarring and calcification similar to scleroderma, associated with hep C/HIV/alcohol/estrogen use/smoking, mildly elevated liver enzymes and iron overload, elevated plasma or urine porphyrin levels, treat with phlebotomy, sun avoidance, and antimalarials
how to treat uric acid stones
oral potassium citrate
when to no longer give HIV pts a live vaccine
CD4 count below 200
curtain descending over visual field of the eye
amaurosis fugax/retinal detachment
- painless rapid transient monocular vision loss
- due to retinal ischemia from atherosclerotic emboli originating from ipsilateral carotid artery
- pts with vascular factor should receive duplex ultrasound of neck
how to treat lyme disease in pregnant women
- you cant give doxycycline cause shes pregnant and you dont want tooth/skeletal discoloration
- give oral amoxicillin
- if theres an allergy to that then give azithromycin
how to treat secondary amyloidosis
colchicine for prevention and treatment
-diagnose with abdominal fat pad aspiration biopsy
pt has subarachnoid hemorrhage, what are you concerned about and what can you give to prevent this
concerned about vasospasm leading to infarct
-give nimodipine to prevent this
what characterizes lactose intolerance
-lactase is as a brush border enzyme
- positive hydrogen breath test
- positive stool test for reducing substances
- low stool pH
- increased stool osmotic gap
- no steatorrhea
triggers: trauma, sprain, fracture, surgery
clinical features: severe, regional, burning/stinging pain, vasomotor changes with altered skin temperature, tropic skin/hair/nail changes
Complex regional pain syndrome
- dx mainly clinical but x-ray will show patchy demineralization and bone scintigraphy will show increased uptake in affected limb
- treat with exercise/PT/OT and for meds you can use NSAIDs and antineuropathic meds (pregabalin and TCAs)
enthesitis
inflammation and pain at sites of tendon and ligament attachment to bone
-common finding in ankylosing spondylitis and other spondyloarthropathies
methanol intoxication
epigastric discomfort, vomiting, blurred vision, vision loss, coma
optic disc hyperemia
anion gap metabolic acidosis (VERY low bicarb)
increased osmolar gap
ondansetron mechanism of action
serotonin antagonist used for chemo induced nausea and vomiting
positive anti-U1 ribonucleoprotein antibody
mixed connective tissue disease
- raynauds
- hand/finger swelling
- arthritis/synovitis
- inflammatory myopathy
shooting jaw pain treatment
trigeminal neuralgia
-treat with carbamazepine (can cause n/v and leukopenia/aplastic anemia)
HIV patient with hematochezia
cytomegalovirus
-if they have this then they need to get an eye exam right away to rule out CMV retinitis
corrected calcium level =
measured total calcium + 0.8 x (4 - serum albumin)
- rheumatoid arthritis (severe erosive joint disease/deformity, rheumatoid nodules, vasculitis with skin lesions)
- neutropenia
- splenomegaly
Felty syndrome
- anti-CCP and RF positive in > 90% of pts
- markedly elevated ESR, often > 85
- peripheral smear and bone marrow biopsy to rule out other causes of neutropenia
cardiovascular drugs that shouldnt be used in pts with hypertension management
beta-blockers due to the side effect of increased insulin resistance/impaired glucose control and increased weight gain
immunocompromised pt gets indurated pustules and then punched out gangrene, what do you think of
ecthyma gangrenosum due to pseudomonas
-get blood cultures and give IV abx
if a pt is aggressively treated for an asthma attack (with beta-2 agonists) what do you worry about
watch for muscle weakness/arrhythmias/EKG abnormalities likely due to hypokalemia
-other common side effects are tremor, palpitations, and headache
patient with history of asthma or chronic rhinosinusitis with nasal polyposis taking aspirin
aspirin-exacerbated respiratory disease
- pseudoallergic reaction due to prostaglandin/leukotriene misbalance
- treat by avoiding NSAIDs
when to screen for osteoporosis with dual energy x-ray absorptiometry
all women >65 and younger women with equivalent risk of osteoporotic fracture
TCA toxicity
Convulsions, Coma, Cardiotoxicity
-give supportive treatment, monitor ECG, give sodium bicarb to prevent arrhythmia (sodium load alleviates depressant action of myocardial sodium channels), activated charcoal
what is very important in the pathogenesis of MALT
H. pylori
-pts usually go into complete remission after abx use with quadruple therapy
numbness or pain b/w the 3rd and 4th toes
clicking sensation when palpating space b/w 3rd and 4th toes while squeezing metatarsal joints
morton neuroma
- mechanically induced neuropathic degeneration of interdigital nerves
- symptoms worse with walking on hard surfaces and in high-heels or tight shoes
differentials for thyrotoxicosis with normal or increased radioactive iodine uptake
graves
toxic multinodular goiter
toxic nodule
painless thyroiditis
starts with hyperthyroid phase then you go to hypothyroid and you can give beta-blockers to help with the hyperthyroid phase symptoms
tick from southeastern and south central united states
amblyomma/lone star tick
- causes flu like illness, confusion, and rarely but sometimes a rash
- leukopenia and thrombocytopenia
- elevated liver enzymes and lactate dehydrogenase
- dx via intracytoplasmic morulae in monocytes and PCR testing for E. chaffeensis and E. ewingii
- treat with empiric doxycycline while awaiting confirmatory testing
how to slow down the growth of varicies and bleeding due to liver pathology only given to those with already medium or large varicies
beta blockers
octreotide
somatostatin agonist causing splanchnic vasoconstriction and stops variceal bleeding while its happening by inhibiting glucagon release
pt with tinea that becomes widespread… what do you think
compromised immunity
- diabetes mellitus
- systemic glucocorticoids
- HIV infection
intermittent chest pain that radiates to interscapular area with difficulty swallowing liquids and solids during these episodes
-can be precipitated by food or emotional stress
diffuse esophageal spasms
- corckscrew pattern
- esophageal manometry for dx
- treat with calcium channel blockers (nitrates or tricyclics can be used if needed)
dacryocystitis
- infection of lacrimal sac
- inflammatory changes to the medial canthal of the eye
- usually due to staph aureus
patient with normal colonoscopy and painless GI bleeding
angiodysplasia
- can be seen in pts with advanced renal disease and aortic stenosis
- can be treated with cautery
elevated BNP
patient likely in cardiac heart failure
- increased heart filling pressures
- audible third heart sound
patient gets vascular procedure then has cutaneous findings (blue toes or livedo retularis), cerebral or intestinal ischemia, acute kidney injury, and hollenhorst plaques… what do you think of
atheroembolism (cholesterol embolism)
- complication of cardiac catheterization and other vascular procedures
- treat/prevent with statin therapy
how to prevent anginal episodes and how does it work
beta-blockers
-decrease myocardial contractility and heart rate
most common cause of sudden cardiac arrest in immediate post-infarction period in patients with acute myocardial infarction
reentrant ventricular arrhythmias (v. fib)
hemoglobin goal for nonelderly pts and why
A1c = 7%
-a more strict goal of 6.5% is associated with good microvascular outcomes (decreased retinopathy) but NOT good macrovascular outcomes (increased hypoglycemia and cardiovascular mortality)
unexplained congestive heart failure, proteinuria, left ventricular hypertrophy without history of hypertension
amyloidosis
-the congestive heart failure is a restrictive cardiomyopathy
acute respiratory distress syndrome
risk factors: infection, trauma, massive transfusion, acute pancreatitis
pathophysiology: lung injury causes fluid and cytokine leakage into alveoli, impaired gas exchange, decreased lung compliance, PHTN
diagnosis: new/worsening respiratory distress within 1 week of insult, bilateral lung opacities (pulmonary edema) NOT due to CHF or fluid overload, hypoxemia with PaO2/FiO2 ratio < 300mgHg
management: mechanical ventilation (low TV, high PEEP, permissive hypercapnia)
what is a normal urine albumin/creatinine ratio
less than 30
how to diagnose sjogrens?
- decreased lacrimation
- positive anti-Ro (SSA) and/or anti-La (SSB)
- salivary gland (minor gland of lip) biopsy with focal lymphocytic sialoadenitis
- classification: primary if no associated CTD, secondary if comorbid CTD (SLE, RA, scleroderma)
describe early septic shock
hyperdynamic cardiovascular state that occurs in response to peripheral vasodilation with capillary leak and intravascular hypovolemia
-leading to increased stroke volume, heart rate, and pulse pressure
ptosis, diplopia, down and out gaze, normal pupillary gaze
Ischemic ocular motor palsy
- damage to inner somatic nerve fibers while sparing the more peripheral parasympathetic fibers
- commonly associated with poorly controlled diabetes
- acute, peaks at 2 weeks –> starts with smudge in center of eye
- monocular vision loss
- eye pain with movement
- “washed out” color vision
- afferent pupillary defect
*usually in young women, assocaited with MS, immune-mediated demyelination
Optic Neuritis
dx —> MRI of orbitis and brain
treatment —> IV corticosteroids
35% of cases recur
psych history, fever, confusion, muscle rigidity, autonomic instability
neuroleptic malignant syndrome
extrarenal features of autosomal dominant polycystic kidney disease
cerebral aneurysms hepatic and pancreatic cysts mitral valve prolapse and aortic regurgitation colonic diverticulosis ventral and inguinal hernias
*pts present with flank pain, hypertension, and polyuria
why can mixing a lot of alcohol with cocaine cause muscle weakness?
even just a lot of alcohol at once can cause rhabdomyolysis
idiopathic pulmonary fibrosis
- due to excessive collagen deposition in peri-alveolar tissues
- decreased lung volumes with preserved or increased FEV1/FVC ratio
- impaired gas exchange resulting in reduced diffusion capacity of carbon monoxide and increased A-a gradient
work up for HIV associated diarrhea
sending stool for culture, ova/parasites, acid-fast stain, and c.diff antigen
-CD4 count, chronicity, and presence of absence of colitis symptoms help narrow the differential
criteria for initiating long term oxygen therapy in pts with COPD
- resting PaO2 < 55mmHg or SaO2 < 88% on room air
- PaO2 < 59mmHg or SaO2 < 89% in pts with cor pulmonale or hematocrit > 55%
- dose should be titrated so that SaO2 is maintained at >90% during sleep, normal walking, and at rest
- survival benefits of home oxygen therapy are significant when its used for > 15hrs/day
who is at risk or a cholesterol emboli
pts with risk factors for aortic atherosclerosis (hypercholesterolemia, diabetes, PVD) who undergo cardiac catheterization or vascular procedure
first line therapy for postmenopausal osteoporosis
bisphosphonates
-treatment is usually discontinued after 5 years due to risk of atypical fracture with prolonged use
acute lower back pain while lifting a heavy object
- lower extremity strength, sensation, and reflexes are intact and straight leg test is negative
- mainly lumbar and paraspinal area pain
lumbosacral strain
*if it were radiating pain down the leg then it would be herniated disc (straight leg test would be positive)
most common cancer found in pts with asbestos exposure
bronchogenic carcinoma
indication for statin therapy
primary prevention
- LDL > 190
- age > 40 with DM
- estimated 10-year risk 7.5-10%
secondary prevention
-established ASCVD (acute coronary syndrome, stable angina, arterial revascularization, stroke, TIA, PAD)
patients with primary hypoaldosteronism are more prone to waht
diuretic-induced hypokalemia
first step after any pt presents with hypertension and hypokalemia
likely hyperaldosteronism so the first step is to get a plasma renin and plasma aldosterone level
meds for alzheimers
mild to moderate —
moderate to severe —
mtm — donepezil, galantamine, and rivastigmine (cholinesterase inhibitors)
mts — memantine (NMDA receptor antagonist)
what does S3 sound like and what does it mean
kentucky
- increased filling pressure
- mitral regurg
- heart failure
- dilated ventricles
- can also be normal
what does S4 sound like and what does it mean
tennessee
- increased atrial pressure
- ventricular hypertrophy and noncompliance
decreased active and passive motion in arm with possible stiffness with normal x-ray findings
adhesive capsulitis (frozen shoulder)
types of cancers associated with lynch syndrome
colorectal cancer
endometrial carcinoma
ovarian cancer
familial adenomatous polyposis
colorectal cancer
desmoids and osteomas
brain tumors
von hippel-lindau syndrome
hemangioblastomas
clear cell renal carcinoma
pheochromocytoma
what happens when a pt has membranous nephropathy
urinary loss of several anticoagulant proteins resulting in hypercoagulability
-associated with renal vein thrombosis
other symptoms to reactive arthritis besides the main 3
mucocutaneous lesions
enthesitis (where tendon hits bone is inflamed)
asymmetric oligoarthritis
NSAIDs are first line treatment
what is more likely to occur after an acute MI of RCA and LAD
RCA- right ventricular failure, papillary muscle rupture
RCA or LAD- interventricular septum rupture (pt presents with sudden cardiogenic shock)
LAD- free wall rupture, left ventricular aneurysm
pts with uncontrolled diabetes and opiate use disorder are at risk of what
Small Intestinal Bacterial Overgrowth (SIBO)
- pts present with abdominal pain, bloating, flatulence, and watery diarrhea
- dx with carbohydrate breath test
- treat with oral antibiotics (rifaximin or neomycin)
what are the chemotoxicities of drugs
cisplatin/carboplatin- ototoxic, nephrotoxic vincristine- peripheral neuropathy bleomycin/busulfan- pulmonary fibrosis doxorubicin/trastuzumab- cardiotoxic cyclophosphamide- hemorrhagic cystitis
wilsons disease
- presents b/w 5-35
- liver disease
- neuropsych problems (parkinsonism, dysarthria, choreoathetosis, ataxia, personality changes, depression)
- low ceruloplasmin with high copper levels
hemochromatosis
hyperpigmented diabetic person
-liver disease, arthropathy, cardiac enlargement
adverse side effect of long term amiodarone use
pulmonary toxicity
- progressive dyspnea
- nonproductive cough
- new reticular/ground-glass opacities on chest radiograph
gout triggers
alcohol use surgery/trauma dehydration diet with lots of meat and fat and fructose certain medications (diuretics)
how to diagnose tinea pedis
potassium hydroxide of skin scrapings
first line for rheumatoid arthritis
disease modifying drug —> methotrexate
how to treat disseminated histoplasmosis
IV amphotericin B then after 1-2 weeks of clinical improvement switch them to oral itraconazole for > 1 year of maintenance therapy
what can cause cyanide poisoning and what does it look like
etiologies: combustion of carbon/nitrogen compounds like wool or silk, industrial exposure like mining, and medications like sodium nitroprusside
symptoms
skin- flushing first then cyanosis
cns- headache, altered mental status, seizures, coma
cv- arrhythmia
respiratory- tachypnea followed by depression and pulmonary edema
gi- abdominal pain, nausea, vomiting
renal- metabolic acidosis (from lactic acidosis) then renal failure
how to treat foodborne c. botulism
- check for toxin in blood
- supportive care
- for anyone over age 1 also give passive immunity via horse-derived antitoxin
when/how to treat cataracts
indicated when loss of vision affects daily life
lens extraction and artificial lens implantation
convexed nail beds
nail clubbing due to hypoxia and possible lung pathology
DHEAS is where..
if female pt has virilization and high testosterone with high DHEAS then you know its likely adrenal cause
if DHEAS is normal then its likely ovarian tumor or something
urine shows... what do think muddy brown granular casts? RBC casts? WBC casts? Fatty casts? Broad and waxy casts?
muddy brown- ATN RBC casts- glomerulonephritis WBC casts- interstitial nephritis and pyelonephritis Fatty casts- nephrotic syndrome broad waxy casts- chronic renal failure
how to treat pericarditis after a pt has an MI vs viral pericarditis
called Dresslers syndrome and give NSAIDs
-if youre treating viral pericarditis give NSAIDS + colchicine
what should be on the differential if a pt has pica for ice/paper?
iron deficiency
hereditary hemorrhagic telangectasias (osler weber rendau)
- autosomal dominant
- telangectasias
- recurrent epistaxis
- widespread AV malformations with shunting
which antihypertensive medication causes peripheral edema
CCB (ex: amlodipine)
- due to peripheral dilation of precapillary vessels
- adding ACE or ARB can help with these side effects
ACA vs MCA infarct
ACA- contralateral somatosensory and motor deficit (predominantly in lower extremity), dyspraxia, emotional disturbance, urinary incontinence
MCA- contralateral somatosensory and motor deficit of face, arm, and leg, conjugate eye deviation toward infarcted side
unilateral neck pain that radiates to the shoulder/arm and sensory, motor, and reflex abnormalities in a dermatomal distribution
cervical radiculopathy due to underlying cervical spondylosis
-spine imaging (MRI) shows abnormal facet joints, including the presence of sclerosis and osteophytes
leukemoid reaction vs CML
LR
- leukocyte count > 50,000
- severe infection
- high LAP (leukocyte alk phos) score
- more metamyelocytes than myelocytes (more mature)
- no absolute basophilia
CML
- leukocyte count > 100,000
- BCR-ABL fusion
- low LAP score
- more myelocytes than metamyelocytes (less mature)
- absolute basophilia
how to diagnose cavernous sinus thrombosis
MRI
antiphospholipid syndrome
- patients have lupus anticoagulant
- prolonged PTT that stays prolonged even with a mixing study
- higher risk of thromboembolism and recurrent miscarriages
common triggers of drug induced acne
glucocorticoids, androgens
immunomodulators
anticonvulsants, antipsychotics
antituberculosis drugs (isoniazid)
delayed muscle relaxation after contraction
myotonic dystrophy (CTG repeat)
- starts with facial and distal muscle weakness and myotonia
- cataracts, testicular atrophy, and sleep disturbances are also common
calcific uremic arteriolopathy (calciphylaxis)
pathophys: arteriolar and soft tissue calcification with local tissue ischemia and necrosis
risk factors: ESRD (MAINLY SEEN IN THESE PTS), hypercalcemia, hyperphosphatemia, hyperparathyroidism, obesity, diabetes, oral anticoagulants
clinical manifestations: painful nodules and ulcers, soft tissue calcification on imaging, skin biopsy includes arterial calcification/occlusion with subintimal fibrosis
fatigue, weight loss, hypotension, and hyperpigmentation of the skin and mucous membranes
deficiency of mineralocorticoids, glucocorticoids, and androgens
where is the most common place for lung cancer to spread to
brain
-presents with headache
initial treatment of chronic venous insufficiency
conservative measures: leg elevation, exercise, compression therapy
what is a major cause of isolated systolic hypertension
arterial stiffness or decreased elasticity
metoclopramide and prochlorperazine
dopamine antagonists which can cause extrapyramidal symptoms such as acute dystonias, akathisia, and parkinsonism
-metoclopramide is used as promotility
if you get one of these 3 skin conditions what should you test for?
- sudden-onset severe psoriasis
- recurrent herpes zoster
- disseminated molluscum contagiosum
HIV infection
if pt gets severe seborrheic dermatitis, what do you look for?
HIV infection or parkinsons disease
if pt gets explosive onset of multiple itchy seborrheic keratoses, what do you look for?
GI malignancy
pt presents with pyoderma gangrenosum (painful pustules and nodules that ulcerate and grow- NOT INFECTIOUS), what do you look for?
IBD
pt with asymptomatic hypercalcemia with normal labs and low urinary excretion
familial hypocalciuric hypercalcemia
- benign autosomal dominant disorder cause by mutation of calcium sensing receptor (CaSR)
- will also have higher-normal PTH
- potential complications: pancreatitis and chondrocalcinosis
headache, malaise, low-grade fever, incessant cough, and nonexudative pharyngitis
chest x-ray shows interstitial infiltrate +/- serous pleural effusion
atypical mycoplasma pneumonia
-give empiric azithromycin
how to manage hypercalcemia in each of these ranges
- severe/symptomatic (> 14)
- moderate (12-14)
- mild/asymptomatic (< 12)
- severe-
short term: normal saline hydration + calcitonin and avoid loop diuretics unless pt also has fluid overload HF
long term: bisphosphonates (zoledronic acid) - moderate- nothing immediate unless symptomatic then refer to severe
- mild- nothing, just avoid diuretics/lithium and keep hydrated and avoid best rest
what are the systematic effects of exertional heat stroke
seizures, ARDS, DIC, hepatic/renal failure
pemphigus vulgaris vs bullous pemphigoid
PV
- antibody against desmosomes (desmoglein 1 and 3)
- oral lesions
- separation of epidermis (+ Niklovkys sign)
BP
- antibody against hemidesmosomes
- NO oral lesions
- separation of epidermis and dermis junction (- Niklovkys sign)
how to treat diabetic nephropathy (early sign is increased albuminuria)
ACEi or ARB
chronic intermittent epigastric pain with symptoms of malabsorption and diabetes mellitus
pain gets better with leaning forward
chronic pancreatitis
- dx with abdominal CT
- decreased fecal elastase is also diagnostic
- use lipase levels in ACUTE PANCREATITIS
why do NSAIDs make anaphylaxis worse?
resulting in nonimmunologic mast cell activation
main causes (ranked) of acute pancreatitis
- alcohol
- gallstones
- hypertriglyceridemia
* others include medications (valproic acid, diuretics, azathioprine, metranidazole, tetracyclines), infections, and trauma
what does an echo show in viral myocarditis
4-chamber dilation
when do pick defibrillation vs cardioversion
fibrillation or tachycardia –> defibrillation
that + hemodynamic instability –> cardioversion
diagnosis via renal biopsy showing lymphocytic infiltration of the intima
T-cell mediated acute renal allograft rejection
-treat with high-dose IV glucocorticosteroids
patient with vision changes, headaches, vertigo, dizziness, ataxia, peripheral neuropathy, cryoglobulinemia, and/or renal insufficiency
waldenstrom macroglobulinemia (B-cell neoplasm)
- associated with elevated monoclonal IgM
- high IgM can cause hyperviscosity syndrome
- dx requires serum protein electrophoresis and bone marrow biopsy
patient with hypercalcemia, anemia, renal insufficiency, bone/back pain, protein gap (diff b/w total protein and albumin > 4) C- hyperCalcemia Renal involvement Anemia Bone lytic lesions and Back pain
possible multiple myeloma
- plasma cell neoplasm which can cause hypogammaglobulinemia
- will see rouleax formation on blood smear and clonal plasma proliferation in bone marrow
patient with nausea, vomiting, constipation, polyuria, polydispsia, and neuropsychiatric symptoms
lab findings: hypercalcemia, metabolic alkalosis, acute kidney injury, suppressed PTH
Milk-alkali syndrome
- excessive intake of calcium and absorbable alkali (usually in the form of calcium carbonate)
- renal vasoconstriction and decreased GFR
- renal loss of sodium and water, reabsorption of bicarbonate
treat with discontinuation of causative agent and isotonic saline followed by furosemide
panacinar emphysema causing more lower lobe destruction leads to what possible diagnosis
alpha-1-antitrypsin deficiency
erythema multiforme
acute inflammatory disorder of skin that causes targetoid lesions
- if severe can affect oral mucosa
- associated with infections like HSV as well as medications, malignancies, and connective tissue diseases
what is ascorbic acid
vitamin c
how does parvo b19 present in adults
multiple joints with arthralgias
-may present like RA but with normal ESR
stenosis or occlusion of proximal subclavian artery
subclavian steal syndrome
- reversal of blood flow in ipsilateral vertebral artery
- may have symptoms of upper extremity ischemia (fatigue, paresthesias) or vertebrobasilar insufficiency (dizziness, ataxia, disequilibrium) that are worsened by upper extremity exercise
atypical presentation of acute coronary syndrome
more common in women and patients with diabetes
- chest pain
- dyspnea
- nausea
- vomiting
- epigastric pain
euthyroid sick syndrome
- aka low T3 syndrome
- any pt with acute/severe illness
- fall in total and free T3 due to decreased peripheral conversion of T4 to T3
- normal T4 and TSH levels
riedels thyroiditis
inflammatory disorder characterized by fibrosclerosis of the thyroid, surrounding tissues, and remote nonthyroid structures
- subclinical or overt hypothyroidism may be seen
- patients usually have a hard goiter
subclinical hypothyroidism
elevated TSH with normal T4
-T3 is usually normal until very late stages
multiple system atrophy (Shy-Drager syndrome)
degenerative disease w/
- parkinsonism
- autonomic dysfunction
- widespread neurological signs
familial dysautonomia (Riley-Day syndrome)
- AR, Ashkenazi jew population
- present at birth with feeding problems and low muscle tone
- gross dysfunction of autonomic nervous system (no tears)
- severe orthostatic hypotension (severe hypertension to postural hypotension)
dark/black hepatocytes on biopsy
dubin-johnson syndrome
- defect in hepatic excretion of conjugated bilirubin
- benign hereditary condition resulting in chronic or fluctuating hyperbilirubinemia and intermittent jaundice
shooting eye pain headache and how to treat it
cluster headache
- acutely: subq sumatriptan and 100% O2
- prophylaxis: verapamil
tension headache and how to treat it
bilateral stead “band-like” pain
- acutely: analgesics, NSAIDs, acetaminophen
- prophylaxis: TCAs and behavioral therapy
essential elements when evaluating brain death
- evaluating cortical and brain stem functions
- proving the irreversibility of brain activity loss
-spinal cord may still function so deep tendon reflexes may occur
behcet syndrome
multisystem inflammatory condition (mainly with recurrent oral and genital ulcers)
epidemiology: young adults, turkish/middle eastern/asian
clinical findings: recurrent painful aphthous ulcers, genital ulcers, uveitis, skin lesions (erythema nodosum, acniform lesions), thrombosis
evaluation:
pathergy- exaggerated skin ulceration with minor trauma (needlestick)
biopsy- nonspecific vasculitis of different sized vessels
major symptoms in a patient with sarcoidosis
significant respiratory symptoms
commonly used drugs with photosensitivity reactions
abx- tetracyclines
antipsychotics- chlorpromazine, prochlorperazine
diuretics- furosemide, hydrochlorothiazide
others- amiodarone, promethazine, piroxicam
what can be assumed in a case-control study if the outcome is uncommon in the population
that the odds ratio is a close approximation of the relative risk (rare disease assumption)
injury to nerve at elbow vs wrist?
elbow- decreased grip strength
wrist- numbness and paresthesia called clumsiness of medial hand
to add anaerobic coverage for pneumonia what meds should you consider
metronidazole + amoxicillin
amoxicillin + clavulanate
clindamycin
if pt has hypercalcemia and youve done the test twice to check then what do you look at…
measure PTH levels
if HIGH (PTH-dependent)
- primary hyperparathyroidism
- familial hypocalciuric hypercalcemia
- lithium
if LOW (PTH-independent)
- malignancy
- vitamin D toxicity
- granulomatous disease
- drug induced (thiazides)
- milk-alkali syndrome
- thyrotoxicosis
- vitamin A toxicity
- immobilization
grid lines appear wavy on visual test
macular degeneration
when someone has a stroke of this area it can lead to sudden onset contralateral burning pain exacerbated by touch
thalamic pain syndrome
-thalamus
beta blocker overdose treatment
first-line: IV fluids and atropine
if that doesnt work: glucagon
tenosynovitis
inflammation of the tendon and its synovial sheath
- usually in hands and wrists due to overuse or bite or puncture wound
- pts have pain and tenderness along the tendon sheath, particularly with flexion and extension movements
hypertension + high calcium
hyperparathyroidism
- pts also have renal stones, abdominal pain, neuropsych symptoms
- also LV hypertrophy, arrhythmias, vascular and valvular calcification
what medications can trigger G6PD deficiency symptoms
infection or medications (dapsone, tmp-smx, nitrofurantoin, antimalarials)
acute coronary syndrome due to unstable angina or NSTEMI… what do you give the patient?
antiplatelet, antithrombotic, beta-blockers, nitrates, high-intensity statins
*note that no fibrinolytic therapy is used
watery diarrhea (secretory)
hypokalemia
weakness and muscle cramps
mass in pancreas
VIPoma
- watery diarrhea with VIP level > 75
- abdominal CT or MRI to localize tumor in pancreatic tail usually
flushing
diarrhea
bronchospasm
mass in small intestine
carcinoid syndrome
what are the risk factors and how to tell if a pt is likely to get another foot ulcer
risk factors: diabetic neuropathy most important, previous foot ulceration, vascular disease, foot deformity
monofilament testing predicts risk of future foot ulcers
what lab value is most important in patients with beta cell tumors (insulinoma)
elevated c-peptide levels and proinsulin levels > 5
how to manage colonoscopy in pts with IBD with colonic involvement
- 8-10 year postdiagnosis (12-15 if only in left colon)
- repeat every 1-3 years
when do you decide to intubate
pH < 7.1
hemodynamic instability
how to treat pts with CHADVASC score > 2
warfarin or specific oral anticoagulants (rivaroxiban, apixaban, dabigatran)
-pts with score 0 need no therapy
classic triad of spinal epidural abscess
- fever
- focal/severe back pain
- neurologic findings (motor/sensory change, bowel/bladder dysfunction, paralysis)
- dx via spinal MRI
- treat with vanc + ceftriaxone along with spinal aspiration and decompression
hepatic hydorthorax
- pts present with dyspnea, cough, pleuritic chest pain, and hypoxemia
- due to liver cirrhosis
- results in transudative pleural effusions and is thought to occur due to small defects in the diaphragm
- more common on the right side due to a less muscular hemidiaphragm
- dx involves documentation of the effusion and testing to occlude other causes
- definitive treatment is liver transplant
brief (< 1min) episodic vertigo triggered by head position changes (looking up)
BPPV
-crystalline debris in semicircular canal
-if pt had lightheadedness or syncope then it would be true vertigo due to some cardiac problem or something
extraintestinal manifestations of IBD
arthritis (spondyloarthritis, sacroileitis, etc)
eye (uveitis, episcleritis)
skin (pyoderma gangrenosum)
hepatobiliary disease (psc)
fibromuscular dysplasia
- noninflammatory and nonatherosclerotic condition caused by abnormal cell development in the arterial wall
- can lead to vessel stenosis, aneurysm, or dissection
- can involve any artery but commonly the renal, carotid, and vertebral arteries
- pts can present with resistant hypertension (if renal artery involvement)
- headache, pulsatile tinnitus, and dizziness (if carotid or vertebral involvement)
- dx with computed tomography angiography or duplex ultrasound
- do f/u bp and creatinine every 3-4 months and renal ultrasound every 6-12 months
what happens to the kidney in diabetic nephropathy and what do you see clinically
glomerular hyperfiltration, basement membrane thickening, and mesangial nodules (KW-nodules)
-pt will present with persistent proteinuria and poorly controlled hypertension
what type of study is best to determine the incidence of a disease
cohort study design
- comparing incidence of disease in 2 populations (with and w/o a given risk factor)
- allows for relative risk calculation
how can you tell bells palsy from central nervous system problems?
- upper face receives input from bilateral motor cortices
- CNS lesions typically cause unilateral facial weakness that spares the muscles of the forehead
- bells palsy affects the entire side of the face
how to differentiate AIHA and hereditary spherocytosis
AIHA- positive coombs test and negative family history
HS- negative coombs test and positive family history
blood smear of both can cause spherocytes with central pallor
what to suspect when patient placed on ACEi or ARB then gets diffuse atherosclerosis, asymmetric kidney size, recurrent flash pulmonary edema, or elevated serum creatinine > 30% from baseline
renovascular hypertension
-continuous periumbilical bruit
first-line treatments for uncomplicated cystitis then complicated cystitis
nitrofurantoin 5 days
bactrim 3 days
fosfomycin single dose
if complicated… give floroquinolones 5-14 days
fomepizole
competitive inhibitor of alcohol dehydrogenase
-used in ethylene glycol poisoning (associated with hypocalcemia and and calcium oxalate crystal deposition in kidneys)
prolonged, profuse, and watery diarrhea after traveling (10-14 days)
think of something parasitic
- cryptosporidium parvum (due to ingestion of contaminated water via drinking or swimming)
- cyclospora
- giardia
*immunocompromised pts are at risk of chronic infection
when should you NOT give a pt sildenafil (or another PDE-5 inhibitor)
when they are also taking an alpha-blocker (-zosin) or a nitrate because that can cause severe hypotension
what is your main concern if patients hypercapnia gets to around 70-80
delirium, confusion, lethargy, and eventually coma (CO2 narcosis) or seizures
-can test for this with arterial blood gas
diabetic retinopathy patient with sudden loss of vision and onset of floaters
vitreous hemorrhage
what meds improve long term survival of pts with LV systolic dysfunction
ACEi –> reduces cardiac remodeling and improves survival of pts with MI and low ejection fraction
ARBs
beta-blockers
mineralocorticoid receptor antagonists
*hydralazine and nitrates combo used in black patients
theophylline toxicity
CNS stimulation (headache, insomnia, seizures) GI disturbances (nausea, vomiting) cardiac toxicity (arrhythmia)
-inhibits cytochrome oxidase by other meds, diet, or underlying disease due to the small therapeutic window
how to test for/diagnose infectious mononucleosis (prolonged fever, fatigue, pharyngitis, and lymphadenopathy)
- positive heterophile antibody test (monospot)- note that this is negative in 25% of patients early on
- atypical lymphocytosis
- transient hepatitis
which CN controls corneal sensation
V1 of trigeminal nerve
normocytic MCV, what do you think of?
look at reticulocyte count
IF LOW
- leukemia
- aplastic anemia
- anemia of chronic disease
IF HIGH
- hemorrhage
- hemolysis
- -spherocytosis
- -G6PD deficiency
- -autoimmune
- -microangiopathic
how to define asthma
reversible airway obstruction (> 12% increase in FEV1)
normal CO diffusion capacity
what type of gait is seen in parkinsonism
hypokinetic/shuffling gait
how to treat premature atrial complexes
only needed when symptoms cause distress or supraventricular tachycardia
-precipitating factors —> tobacco, alcohol, caffeine, stress
when to give packed RBCs
less than 7 for stable patients
less than 9 for unstable patients
what diabetic medication has positive effects on patients cardiac and weight-related problems
SGLT-2 inhibitors (-flozin)
- blocks proximal tubule glucose reabsorption
- causes increased urinary glucose excretion
- less nephropathy, albuminuria, CV mortality/morbidity, and can help with weight loss
- can put pts at risk for euglycemic ketoacidosis, increased risk of genitourinary infections
- contraindicated in pts with T1DM, history of DKA, impaired renal function
GLP-1 agonists do the same thing (-tide)
how does acute colonic ischemia present
- due to hypoperfusion
- affects watershed areas
- presents with crampy, left-sided abdominal pain and overt hematochezia during or shortly after (<24hrs) episodes of hypotension
pt in ICU and can cause occult or gross GI bleeding
-risk factors: shock, sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/brain injury, burns, and high-dose corticosteroids
stress ulceration
blepharospasm
- form of focal dystonia where eyelids (bilateral and symmetric)
- bright lights may trigger muscle contraction
-tx: botulinum toxin may be used for very bad cases otherwise just try to block bright lights for mild cases
when are live vaccines contraindicated in pts with HIV
MMR, zoster, and varicella are contraindicated if CD4 count is < 200
who should get the Hepatitis A vaccine
people at increased risk
- men who have sex with men
- travelers to areas of increased incidence
- adults with chronic liver disease
chikungunya fever
viral illness via aedes mosquito
- flulike illness (3-7 day incubation period)
- symmetric severe polyarthralgias
- macular/maculopapular rash on limbs and trunk
- peripheral edema
- cervical lymphadenopathy
- lymphopenia, thrombocytopenia, transaminitis
- treat with supportive care (usually resolves in 7-10 days)
- chronic arthralias/arthritis in 50% of pts that may require methotrexate
tender, indurated, erythematous nodules on anterior legs
-usually after an infection, IBD, sarcoid, or certain meds (abx or OCPs)
erythema nodosum
- septal panniculitis without vasculitis
- spontaneous resolution (weeks) with residual hyperpigmentation
serum sickness
- immune reaction against blood products or antigens from nonhuman species
- fever, joint pain, urticarial or vasculitis like rash
thrombotic thrombocytopenic purpura
PENTAD: petechial rash w/ fever, renal failure, abdominal pain, and neurological manifestations
-decreased ADAMTS13 level, uncleaved vWF multimers causing platelet trapping and activation
manage with plasma exchange, glucocorticoids, and rituximab
HIV patient with multiple ring enhancing lesions on brain imaging
TMP-SMX couldve been used for prophylaxis
primary adrenal insufficiency
due to: autoimmune, infection, metastatic infiltration
clinical features: fatigue, weakness, anorexia/weight loss, n/v, abdominal pain, salt craving, postural hypotension, hyperpigmentation
acute adrenal crisis –> confusion, hypotension, shock
lab findings: hyponatremia, hyperkalemia, eosinophilia, low morning cortisol, high ACTH
dx with cosyntropin stimulation testing
treatment: glucocorticoids and mineralocorticoids
what spinal problems are most likely in pts with degenerative joint disease
lumbar spinal stenosis
- neuropathic claudication
- worse when walking
- pain relieved by spinal flexion
- dx via spinal MRI
how often should you screen lipids in average risk patients
every 5 years
when to start steroids for pts with pneumocystis pneumonia
pulse ox < 92%
PaO2 < 70
A-a gradient > 35 on room air
-meant to reduce risk of worsened hypoxia with treatment initiation
whatre two meds when used together that can cause rhabdo
statins and colchicine
if patient has persistent bradycardia with one of the following then whats the next step?
- hypotension/signs of shock
- acute mental status changes
- chest discomfort concerning for cardiac ischemia
- acute heart failure
if none of those then just observe
if at least one of those then give IV atropine 0.5mg bolus and repeat every 3-5 mins up to 3.0mg max
strep bovis
used to be strep gallolyticus
strep sanguins
part of strep viridins family
if someone has trigeminal neuralgia bilaterally what do you think?
they likely have MS (demyelination of nerve axon)
how to treat sporotrichosis
itraconazole
classic triad for pheochromocytoma
episodic headache
sweating
tachycardia
- pts have resistent hypertension and unexplained increase in blood glucose with possible family history
- check urine or plasma metanephrines
myelofibrosis
collagen or reticulin deposition in bone marrow
- presents with fatigue, fever, and hepatosplenomegaly from extramedullary hematopoiesis
- peripheral blood cell counts may be either elevated or decreased
causes of aplastic anemia
pathogenesis: bone marrow failure due to hematopoietic stem cell deficiency (CD34) – can be acquired
causes: autoimmune, infections (parvo, ebv), drugs (carbamazepine, chloramphenicol, sulfonamides), exposure to radiation or toxins (benzene, solvents)
pancytopenia and hypocellular bone marrow with fat and stomal cells seen on biopsy, no splenomegaly seen
triad of acute liver failure
elevated aminotransferases (often > 1000) hepatic encephalopathy (confusion/asterixis) synthetic liver dysfunction (increased INR)
*no cirrhosis or underlying liver disease
- acetaminophen toxicity is a common cause due to build up of NAPQI
- pts with this need to get a liver transplant (only 50% without the transplant with survive)
what type of medication is chlorthalidone
thiazide diuretic
- can cause hyperglycemia, increased LDL, increased triglycerides, and hyperuricemia
- also hypo-everything except hypercalcemia
- glucose intolerance is a side effect in pts with metabolic syndrome or diabetes mellitus
you diagnose someone with alcoholic liver cirrhosis, next steps?
get upper GI to make sure they dont have esophageal varices to indicate strategies to prevent future hemorrhage
-primary prophylaxis is either endoscopic variceal ligation or nonselective beta-blocker like nadolol
what virus is progressive multifocal leukoencephalopathy associated with?
reactivation of JC virus
erysipelas
skin infection of the upper dermis and superficial lymphatic system
- most common caused by group A strep pyogenes
- manifests with fever and chills, regional lymphadenitis, warm tender erythematous rash with raised sharply demarcated borders
what type of urine is seen in DM vs DI
DM –> high urine osmolaltiy and high urine specific gravity (osmotic diuresis)
DI –> low urine osmolality and low urine specific gravity (< 1.006), dilute urine
diabetes insipidus
central- ADH deficiency
nephrogenic- ADH resistance (renal disease), can be due to longterm lithium use
triad of aspirin-exacerbated respiratory disease
- asthma (often severe and presenting in adulthood)
- bronchospasm or nasal congestion following ingestion of aspirin or NSAIDs
- chronic rhinosinusitis with nasal polyposis
why is norepi used as first line treatment for septic shock
acts on a1 and b1 receptors to cause vasoconstriction, increase MAP so that you can optimize blood flow to critical organs like the brain but as a result it decreases blood flow to distal digits
what parts of the eye changes vision
cornea- astigmatism
lens elasticity- near/far sightedness
lens opacity- cataracts
painless hematuria
think likely bladder cancer
how to tell the difference b/w vasovagal syncope and orthostatic hypotension
vasovagal (aka neurocardiogenic)- starts with nausea, diaphoresis, and pallor before passing out (usually in response to stress)… bradycardia with sinus arrest
orthostatic- usually when you go from lying or sitting to standing
most common site of metastasis for colon cancer
-patient will have abdominal pain, microcytic anemia, positive fecal occult blood, and hepatomegaly with a hard liver edge
goes to the liver
- presents as RUQ pain, mildly elevated liver enzymes, firm hepatomegaly
- confirm with CT
vascular dementia
- stepwise decline
- early executive dysfunction
- cerebral infarction and/or deep white matter changes on neuroimaging
upper motor neuron problems distal to the site of compression
spinal cord compression
- weakness, hyperreflexia, and extensor plantar response
- medical emergency and requires prompt diagnosis by spinal MRI
patient with chondrocalcinosis, pseudogout, chronic arthropathy, diabetes, and liver disease
hereditary hemochromatosis
patient with any of the following…
-crush injury or prolonged immobilization
-intense muscle activity (seizure, exertion)
-drug/med toxicity (opioids, colchicine, statins)
what do you think of?
clinical features: muscle pain, weakness, dark urine, blood on urinalysis and no RBCs on microscopy, increased serum K and PO4, decreased serum Ca, increased AST/ALT, acute kidney injury
dx: serum creatinine kinase > 1000
management: aggressive IV fluid resuscitation, sodium bicarb in some cases
patient has a history of difficulty initiating swallowing with cough, choking, or nasal regurgitation… next step?
likely oropharyngeal dysphagia- video fluoroscopic modified barium swallow
if they dont have that hx then likely esophageal dysphagia…
- if solids and liquids at onset –> motility disorder (do barium swallow followed by manometry)
- if solids then liquids –> mechanical obstruction (either barium swallow or upper endoscopy)
euvolemic hypotonic hyponatremia, what do you think of
SIADH
- can be caused by carbamazepine, SSRIs, NSAIDs
- is associated with small cell lung cancer
- serum osmolality < 275 // urine osmolality > 100 // urine sodium > 40
- manage with fluid restriction +/- salt tablets and hypertonic 3% saline for severe hyponatremia
risk factors for MS
- female, caucasian, HLA-DRB1
- environmental factors: location (US and Europe), colder climates
- low vitamin D levels
- smoking
patients with long standing RA are at higher risk of what
amyloidosis
what ligament can cause compression of the lateral femoral cutaneous nerve
inguinal ligament
most common cause of elderly pt with anemia
GI blood loss
-endoscopy and colonoscopy
first line treatment in pt with aortic dissection
IV beta blockers
myasthenia gravis vs lambert-eaton
MG
- autoantibodies to postsynaptic ACh receptor, ligand gated
- ptosis, diplopia, weakness with respiratory muscles
- worsens with muscle use
- associated with: thymoma, thymic hyperplasia
- AChEi reverses symptoms, so give pyridostigmine
LE
- autoantibodies to presynaptic Ca2+ channel leads to decreased ACh release, voltage gated
- proximal muscle weakness (difficulty walking, risking in chair, combing hair), autonomic symptoms (dry mouth, impotence)
- improves with muscle use
- associated with: small cell lung cancer
- AChEi have minimal effect
triad of normal pressure hydrocephalus and what it makes the brain look like
wet, wobbly, wacky
-urinary incontinence, gait dysfunction, dementia
- also presents with UMN signs
- neuroimaging/CT presents with large ventricles with normal sulci
- patient with distinct P waves with > 3 different morphologeis
- atrial rate > 100
- irregular rhythm
Multifocal atrial tachycardia
- precipitated by acute respiratory illness with underlying lung disease
- treatment directed at correcting underlying inciting disturbance
most common cause of abnormal hemostasis in pt with chronic renal failure (uremic coagulopathy)
platelet dysfunction
- all labs are normal but bleeding time is prolonged
- DDAVP is treatment of choice (not platelet transfusion cause they quickly become inactive anyways)
risk factors below are risk factors for what…
- acyclovir
- sulfonamides
- methotrexate
- ethylene glycol
- protease inhibitors
- uric acid (tumor lysis syndrome)
crystal-induced acute kidney injury
- usually asymptomatic
- aki < 7 days of starting drug
- UA: hematuria, pyuria, and crystals
- increased risk with volume depletion, CKD
mangement
- discontinuation of drug
- volume repletion
- loop diuretic
most common cardiac problem in pts with lupus
pericarditis
cardiac tamponade (Becks) triad
- hypotension
- distended neck veins
- muffled heart sounds
*exaggerated shift of intraventricular septum toward left ventricle (reduces LV preload, SV, and CO)
ototoxic medications
aminoglycosides
cysplatin/carboplatin
salicylates
loop-diuretics
patient with hyperviscosity syndrome (diplopia, tinnitus, headache, dilated/segmented funduscopic findings), neuropathy, and infiltrative disease (hepatosplenomegaly, anemia, thrombocytopenia)
waldenstorms macroglobulinemia
-lymphoplasmocytic neoplasm with excessive IgM, end-organ damage, and > 10% clonal lymphocytes by bone marrow biopsy
how to treat prolactinoma
asymptomatic- no treatment
symptomatic- dopamine agonists (cabergoline, bromocriptine) or resection if > 3cm or still growing on treatment
how to treat hyperosmolar hyperglycemic state
IV fluids with normal saline
what should be the follow up for pts with syncope and possible structural heart disease
echocardiogram
undiagnosed pleural effusion (excess quantity of fluid in the pleural space) is best evaluated how
thoracentesis
- except in pts with clear-cut evidence of congestive heart failure
- diagnostic can be done at bedside and provides decision making info (if exudative then you need to do more)
patient with lung infiltrate, coughing up blood, and nothing found on gram stain… what should be on your differential
invasive aspergillosis
- immunocompromised (neutropenia, steroids, HIV)
- triad (fever, chest pain, hemoptysis)
- pulmonary nodules with halo sign
- positive cultures and cell wall biomarkers
- give voriconazole +/- caspofungin
chronic pulmonary aspergillosis
- look above but for > 3 months and with likely tb or other cavitary lesion
- cavitary lesion with possible fungus ball
- positive IgG serology
- resect, give voriconazole and embolize if severe hemoptysis
first-line medication treatment for idiopathic intracranial hypertension
acetazolamide +/- furosemide
-optic nerve sheath decompression or lumboperitoneal shunting for pts refractory to medication
costochondritis
musculoskeletal chest pain
- tenderness of > 1 sternochondral joint
- sharp, localized chest pain that is reproducible with palpation
- treatment: reassurance and symptomatic pain management
what is the likely etiology of the following back pain
- insidious onset
- symptoms > 3 months
- relieved with exercise but not rest
- nocturnal pain
inflammatory back pain
- ankylosing spondylitis
- dx with x-ray of sacroiliac joints
what causes condyloma acuminata
anogenital warts caused by Human Papilloma Virus (HPV)
-associated with increased risk of squamous cell carcinoma
normal blood pressure readings in clinic but elevated bp throughout the day and at night
-pts have left ventricular hypertrophy
masked hypertension
-dx made by ambulatory bp monitoring in pts with clinical evidence of hypertension
most common complication of influenza
secondary bacterial pneumonia due to staph aureus or strep pneumo
- MRSA can cause multilobar cavitary infiltrates
- if due to staph it can cause rapid-onset, severe, necrotizing pneumonia with high risk of death
if someone has complications months after an MI what is on your differential
pericarditis or left ventricular aneurysm
what underlying mechanism causes the following in pts with liver cirrhosis
- gynecomastia
- testicular atrophy
- decreased body hair
- spider angiomas
- palmar erythema
hyperestrinism
-liver cant remove estrogens
inheritance pattern of hypertrophic cardiomyopathy
AD
initial evaluation of hypertension
identifying complications and comorbid conditions
- serum chemistry panel (lipid panel, fasting serum glucose, hemoglobin A1c)
- hemoglobin/hematocrit
- urinalysis
explain the difference b/w 13 and 23 valent pneumococcal vaccines
23: T-cell independent B-cell response (IgM)
13: T-cell dependent B-cell response (IgG)
pt with dermatomyositis, what do you screen them for?
occult malignancy, they are at an increased risk
what are patients at risk for with untreated hyperthyroidism
rapid bone loss and osteoporosis
-increased thyroid hormones leads to increased osteoclast bone resorption
acute persistent vertigo that can last days
- often follows viral syndrome
- abnormal head thrust test
vestibular neuritis (labyrinthitis) -associated with unilateral hearing loss
patient with painless lymphadenopathy and B symptoms
non-hodgkin lymphoma
-pts with chronic autoimmune diseases are at increased risk due to chronic b-cell stimulation, immune dysregulation, and use of immunosuppressive medications
if they have no B symptoms then consider follicular lymphoma which has an indolent course and presents with waxing and waning lymphadenopathy
common medication that can cause iron deficiency anemia
NSAIDs because they can cause chronic blood loss from the GI tract
male patient presents with severe LLQ pain radiating to groin, vomiting… what do you think of if abdominal exam is normal?
obstructive ureterolithiasis
-get ultrasound or non-contrast spiral CT
if a patient has hyperplastic polyps on colonoscopy how often should they get checked
every 10 years like normal, those dont increase the risk of cancer
-if it were adenomatous then it would require more frequent checks
what do you see on ECG if someone has taken too much digoxin
- increased ectopy (adds extra heartbeat) and increased vagal tone
- atrial tachycardia with AV block
side effects:
CV- life-threatening arrhythmias
GI- anorexia, n/v, abdominal pain
Neuro- fatigue, confusion, weakness, visual color changes
how to workup a possible aortic dissection
if chest x-ray and ECG suggest something else then fix that
- if they lead to likely aortic dissection then check serum creatinine and see if they have a contrast allergy
- if they cant take contrast dye then do TEE
- if they can take contrast dye then do one of these, whichever is available (TEE, chest CT with contrast, MRI only if non-emergent and pt can still lie still)
if you have severe liver cirrhosis and systemic/renal hypoperfusion… what do you think of?
hepatorenal syndrome
post-op complication of a Roux-en-Y gastric bypass
stomal (anastimotic) stenosis
- nausea
- postprandial vomiting
- GERD
- dysphagia
Treatment: EDG is both diagnostic and treatment for these pts
how to treat lichen planus
high potency glucocorticoids
-disorder is self-limited and usually resolves w/i 2 years
ventilation is defined as a product of what two things
respiratory rate and tidal volume
how long is a typical gout flare
abrupt onset with maximal symptoms within 12-24 hours
patient with super rapidly progressive nonspecific infection, myalgias, and poor perfusion
early meningococcal infection
-dx with lumbar puncture
what is a synthetic cathinone
bath salts (amphetamine analogues)
- norepi, dopamine, serotoinin
- agitation, combativeness, psychosis, delirium, myoclonus, seizures
- you can tell its this because it can take days to a week o subside*
what do leafy green vegetables and grapefruit do to warfarin
vegetables decrease warfarin
grapefruit increases warfarin (ginseng also does but much less)
when you see that someone has a metabolic acidosis, next step?
calculate plasma anion gap
how to diagnose perforated peptic ulcer
chest x-ray will allow you to see the perforation via subdiaphragmatic free air
if pt has primary hyperthyroidism (low TSH and high free T4) but no signs of graves (goiter or ophthalmopathy) then…
radioactive iodine uptake and scan
HIGH
- diffuse pattern: graves
- nodular pattern: toxic adenoma or multinodular goiter
LOW then measure serum thyroglobulin
- high: thyroiditis or iodide exposure
- low: exogenous hormone
if pt has high TSH and high free T4 and T3 then…
secondary hyperthyroidism
-do MRI of pituitary
lung and kidney problems without a fever, what do you think of
anti-GBM disease (Goodpasture syndrome)
kidney- nephritic proteinuria, acute renal failure, urine sediment with dysmorphic red cells and red cell casts
pulm- shortness of breath, cough, hemoptysis caused by pulmonary hemorrhage
-dx made via linear IgG seen on renal biopsy
definition of status epilepticus
seizure lasting > 5 mins or > 2 seizures where the pt does NOT regain consciousness
- usually due to pts with structural brain abnormality (tumor or stroke), metabolic abnormality (hyponatremia, hypoglycemia), infection (meningitis), or drug withdrawal (alcohol or benzo)
- give lorazepam or diazepam to stop the seizure then give a non-benzo seizure med to prevent future seizures
when is pituitary imaging indicated
elevated prolactin
mass-effect symptoms
very low testosterone levels
disruptions in other pituitary hormone levels
what is the most common adverse transfusion reaction
febrile nonhemolytic transfusion reaction
- transient fever, chills, malaise
- caused by release of cytokines from leukocytes in stored blood product
- symptoms develop w/i 1-6hrs
- leukoreduction of donor blood
next step for a pt with torsades de pointes (TdP)
type of polymorphic v. tach usually due to QT prolongation
- if pt is hemodynamically unstable then do immediate defibrillation
- if pt is hemodynamically stable then give magnesium
when to give pts adenosine
used for acute termination of paroxysmal supraventricular tachycardia
how does clostridium tetani work
(toxin mediated) blocks release of inhibitory neurotransmitters glycine and GABA across synaptic cleft
-leading to fever, painful muscle spasms, and trismus (lockjaw)
empiric treatment for community-acquired pneumonia
OUTPATIENT
healthy- macrolide or doxycycline
comorbidities- fluoroquinolone or beta-lactam + macrolide
GENERAL INPATIENT
fluoroquinolone
beta-lactam + macrolide
ICU
beta-lactam + macrolide
beta-lactam + fluoroquinolone
*you can give moxi or levo as a fluoroquinolone cause they are respiratory specific
how to determine if a patient should be hospitalized
CURB-65
Confusion Urea > 20 mg/dL Respirations > 30/min Blood pressure (systolic < 90 or diastolic < 60 mmHg) age over 65
1 point for each of the following
0- low mortality - outpt treatment
1-2- intermediate mortality - likely inpatient treatment
3-4- high mortality - urgent inpt admit, possible ICU if score > 4
scleroderma renal crisis
presents with: acute renal failure, malignant htn, mild proteinuria, MAHA with schistocytes and thrombocytopenia
rapidly progressive myelopathy
- motor weakness
- autonomic dysfunction (bowel/bladder incontinence/retention and sexual dysfunction)
- sensory deficits with distinct sensory level
transverse myelitis
-immune mediated disorder with infiltration of inflammatory cells into a segment of the spinal cord leading to cells death and demyelination
tetanus prophylaxis rules
if they had the 3 vaccine series as a child
- clean wound: give vaccine if been > 10 years
- dirty wound: give vaccine if been > 5 years
if they didnt have all 3 vaccines
- clean wound: give vaccine only
- dirty wound: give both vaccine and TIG
what is diabetic gastroparesis
delayed gastric emptying
-pt presents with anorexia, n/v, early satiety, postprandial fullness, and impaired glycemic control
how does mixed cryoglobulinemia present
fatigue, palpable purpura (that do not blanch with pressure), arthralgias, renal disease, peripheral neuropathies
with positive rheumatoid factor, hypocomplementemia, elevated transaminases, and kidney injury
-associated with Hep C, HIV, and SLE
which medications interfere with digoxin metabolism
amiodarone, verapamil, quinidine, and propafenone
- increases serum level of digoxin
- if they need to be on one of these meds then decrease the digoxin dose by 25-50%
causes of myoclonus (involuntary muscle contraction)
genetic disorder
seizures
medications
prolonged hypoxia (usually occurs after cardiac arrest)
Lance-adams syndrome
chronic form of posthypolxic myoclonus
- presents days to weeks after initial insult once pt has regained consciousness
- typically focal in nature and exacerbated by action leading pts to drop objects or fall
giving a pt estrogen can cause what
increase in TBG, so if they are on thyroid replacement therapy then they will need more to make up for the extra TBG
obese pt with increased hematocrit
likely has increase in EPO due to OSA
- pt may also complain of erectile dysfunction and arterial hypertension
- fat and tired patient with hypertension think OSA
what acid-base disturbance do pts have in DKA
metabolic acidosis due to rapid accumulation of ketoacids (beta-hydroxybutarate and acetoacetate)
-pH can be brought close to normal but never fully corrects
patients gets admitted to hospital then 6-24hrs later has hallucinations of bugs on them
alcoholic hallucinations
give them a benzo
if they give you total protein and albumin labs when what do you think of
subtract them and if its > 4 then they likely have a monoclonal gammopathy due to multiple myeloma
-get serum protein electrophoresis
complications of radioactive iodine treatments for graves disease
- permanent hypothyroidism
- worsening ophthalmopathy
- possible radiation side effects
risks of surgery for graves disease
- permanent hypothyroidism
- risk of recurrent laryngeal nerve damage
- risk of hypoparathyroidism
bacilliary angiomatosis
- occurs when an immunocompromised pt presents with bartonella (gram - bacillus)
- bright red, firm, friable, exophytic nodules
- systemic b symptoms
- rarely includes organ involvement
- give oral erythromycin or doxycycline
how to treat papulopustular rosacea (super red face that gets worse after sun exposure)
first-line: topical metronidazole, azelaic acid, ivermectin
second-line: oral tetracyclines
- pt under 50
- possible smoker
- recurrent chest discomfort
- -occurs at rest or during sleep
- -spontaneous resolution in < 15mins
vasospastic angina
- hyperactivity of coronary smooth muscle
- dx by ambulatory ECG showing ST elevation and coronary angiography shows no CAD
- prevent with CCB
- abort with sublingual nitroglycerin
if a pt has clostridum septicum/group D strep/strep bovis, what is your next step
colonoscopy cause theyre associated with colon cancer
what vaccinations do you give to pts going to north africa
hep A
hep B
typhoid
polio booster
patient with severe onset thats the worst of their life and has neck stiffness, what do you think of
subarachnoid hemorrhage
- thunderclap headache
- get urgent noncontrast CT and if negative then get lumbar puncture (high RBC count that does not decrease with each tube collected)
what do you see on peripheral blood smear for pts with CLL
leukocytosis
mature lymphocytes
smudge cells
patient has a firm thyroid nodule with no other symptoms, next step?
get serum TSH and ultrasound
- if normal or elevated TSH: consider fine needle aspiration given other findings
- if low TSH: radioactive iodine scintigraphy
- -if hypofunctional node then do FNA
- -if hyperfunctional node then treat hyperthyroidism
patient presents with some form of optic neuropathy, elevated intraocular pressure, abnormal (increased) cup/disc ratio
open-angle glaucoma
- pts will eventually lose peripheral vision
- vision loss is irreversible
- first-line is topical prostaglandin (latanoprost, bimatoprost) –> acts by increasing drainage through aqueous humor through uveosclerar pathway
- -if needed you can also topical beta blockers (timolol)
HIV patient presents with headache, fever, and malaise that develops within a week or two
- normal MRI
- bilateral papilledema
cryptococcal meningitis
LP findings
- high opening pressure
- low glucose, high protein
- wbc < 50/uL w/ mononuclear predominance
- transparent capsule seen with india ink stain
- cryptococcal antigen positive
- culture on sabouraud
treatment
- initial: amphotericin b with flucytosine
- maintenance: fluconazole
which medications cause acute angle glaucoma
can be due to anticholinergics for parkinson disease
- pts present with sudden onset of severe eye pain, n/v, unilateral conjunctival injection, dilated pupil with poor light response
- untreated can develop blindness within 2-5 years
how does leprosy present and what do you do
- due to mycobacterium leprae
- primary developing world (asia, africa, south america)
- due to respiratory droplets/nine-banded armadillo
- low infectivity
clinically
- macular, anesthetic skin lesions with raised borders
- nodular, painful nearby nerves with loss of sensory/motor function
diagnosis
- full-thickness biopsy of skin lesion (active edge)
- cannot be cultured
treatment
- dapsone + rifampin
- add clofazimine if severe (multibacillary)
patient has damage and vision loss in one eye then develops spots in their other eye… what do you think?
sympathetic ophthalmia
- immunologic mechanism involving recognition of ‘hidden’ antigens because natural barriers are broken
- can manifest as anterior uveitis, panuveitis, papillary edema, and even vision loss
- autoantibodies and cell-mediated
in a UTI what do nitrates mean and what do leukocyte esterases mean
nitrates- presence of enterobacteriaceae
leukocyte esterases- pyuria (pus in urine)
when to use synthetic cannabinoids vs progesterone analogues to increase appetite in pts
synthetic cannabinoids- advanced HIV cachexia
progesterone analogues- cancer related cachexia
(megestrol acetate and medroxyprogesterone acetate)- can also use corticosteroids but they have worse side effects
herpes zoster ophthalmicus vs herpes simplex keratitis
HZO- by vzv infection, in elderly, fever, malaise, burning, itching in periorbital region, vesicular rash in cutaneous region of V1 branch of trigeminal nerve. eye has conjunctivitis and dendriform corneal ulcers
HSK- pain, photophobia, blurred vision, tearing, possible history of same thing in past, corneal vesicles and dendritic ulcers. can occur more in pts with excessive sun exposure, outdoor occupation, or immunodeficiency
when to screen for abdominal aortic aneurysm
man
age 65-75
ANY smoking history (even if they quit a while ago)
-do 1 time abdominal duplex ultrasound
differentiate the following 4 causes of diarrhea in HIV patient
- severe watery diarrhea, low-grade fever, weight loss
- watery diarrhea, cramping abd pain, weight loss, NO FEVER
- watery diarrhea, weight loss, HIGH FEVER > 102.2
- frequent small volume diarrhea, hematochezia, abd pain, low-grade fever, weight loss
- cryptosporidium
- mircosporidium/isosporidium
- mycobacterium avium complex
- CMV
how to interpret relative risk
if over 1 is positive association
if less than 1 its negative association
super high ESR, normocytic anemia, glomerulonephritis, fatigue, arthralgias, dyspnea, possible embolisms
infective endocarditis
pts presents with fatigue/dyspnea upon exertion, peripheral edema/ascites, increased JVP, pericardial knock (mid-diastolic sound), pulsus paradoxus, kussmal breathing
-nonspecific ECG
constrictive pericarditis
-pericardial thickening and calcification
when do pts with aortic stenosis start to experience symptoms
when it becomes severe
-valve area < 1cm2
most common type of megaloblastic anemia in pts with chronic alcoholism
folate deficiency
patients presents with fall in blood pressure ( > 10 mmHg) during inspiration, what is this called and what does it mean
pulses paradoxus
-ddx: severe asthma, COPD, cardiac tamponade
why do you have to worry when you give O2 to a COPD patient
- can worsen hypercapnia due to combo to increased dead space perfusion causing v-p mismatch and decreased affinity for oxyhemoglobin for CO2 and reduced alveolar ventilation
- o2 sat goal is 90-93%
what are pts with nephrotic syndrome at risk for
- atherosclerosis due to hyperlipidemia
- av thrombosis due to loss of antithrombin III –> also increases risk for MI and stroke
what type of medication is escitalopram
ssri
how to diagnose cushings
- 24hr urinary cortisol excretion
- late-night salivary cortisol assay
- low-dose dexamethasone suppression test
if hypercortisolism is confirmed then check ACTH to see if its dependent (cushing, ectopic ACTH) or independent (adrenal adenoma)
pt with alcoholic history
- temp 100
- abdominal pain/tenderness
- altered mental status
- hypotension, hypothermia, paralytic ileus with severe infection
spontaneous bacterial pneumonitis
- do paracentesis (PMNs > 250, positive culture, gram - like ecoli or klebsiella, protein < 1, SAAG > 1)
- give empiric abx: third gen cephalosporin, then use fluoroquinolones for prophylaxis
describe CMV retinitis
painless
no keratitis or conjunctivitis
fundoscopically you will see hemorrhages/fluffy or granular lesions around retinal vessels
most common signs and symptoms of pulmonary embolism
dyspnea pleuritic chest pain tachypnea tachycardia *chest radiograph usually isnt but CAN be normal
main opportunistic infections in solid organ transplant pts
pneumocystis and CMV
-pts with systemic illness affecting a ton of organs should get tested for CMV viremia
what is present in a pt with aortic regurg
bounding pulses
pts who just had an anterior STEMI are at high risk for what to form even after stent placement
-what you think of if they present with acute limb ischemia
LV aneurysm formation especially when reperfusion therapy is unavailable or delayed
- muscle then fails to contract and balloons up
- this can lead to LV thrombus that can embolize
all pts who present with ALI should undergo a transthoracic echo
explain malaria prophylaxis
note: choloroquine resistance is common use one of these for > 2 weeks before travel and continue for 4 weeks after you get back atovaquone-proquanil doxycycline mefloquine
prolonged PR with normal QRS
first degree AV block
- just do observation
- get electrophys testing if they also have prolonged QRS
how does arsenic poisoning present
mechanism: binds to sulfhydryl groups, disrupts cellular respiration and gluconeogenesis
sources: pesticides/insecticides, contaminated water from wells, pressure-treated wood
clinically
acute- garlic breath, vomiting, watery diarrhea, QTc prolongation
chronic- hypo/hyperpigmentation, hyperkeratosis, stocking-glove neuropathy
treatment: dimercaprol or DMSA
where is TBG produced
by the liver so pts with liver failure have normal TSH and high T3 and T4
what is the problem if the pt had a stroke and now has one sided hemineglect
parietal lobe of the nondominant side
-responsible for spatial organization
if pt has bloody diarrhea what do you think of
e.coli
shigella
campylobacter
truncal coordination impaired
likely cerebellar problem
how to reverse warfarin
IV vitamin K and prothrombin complex concentrate (contains factors 2, 7, 9, 10)
tranexamic acid
antifibrinolytic that can help with heavy menstrual bleeding and prevent excessive blood loss during surgery
explain the following terms:
- breast cyst
- fibrocystic changes
- fibroadenoma
- fat necrosis
- solitary, well-circumscribed, mobile mass +/- tenderness
- multiple, diffuse nodulocystic masses with cyclic premenstrual tenderness
- solitary, well-circumscribed, mobile mass with cyclic premenstrual tenderness
- post trauma/surgery, firm, irregular mass +/- ecchymosis, skin/nipple retraction
most common form of drug-induced chronic renal failure
analgesic nephropathy
-most common pathologies: papillary necrosis and chronic tubulointerstitial nephritis
*patients with chronic analgesic abuse are more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer
when to use the following tests
Chi-squred
ANOVA
chi-squred: compares proportions and uses categorical data
ANOVA: used to compare means of 3 or more variables
how does riluzole work
glutamate inhibitor approved for ALS
what is included in initial workup for pt with suspected dementia
neuropsych: montreal cognitive assessment
labs: CBC, CMP, TSH, vitamin B12
neuroimaging: MRI or CT scan
if pt has specific risk factors then you can do the following labs: folate, syphilis, vitamin D
patient presents with sensory ataxia, lancinating/stabbing pains, neurogenic urinary incontinence, and small irregular pupils that poorly constrict to light but constrict normally with accomodation
those are argyll robinson pupils and pt has tabes dorsalis (neurosyphilis) –> develops more rapidly in HIV pts
- syphilitic damage to dorsal sensory roots and damage to dorsal columns
- give IV penicillin
3 main categories of diabetic retinopathy
*leading cause of blindness in USA
- background or simple retinopathy: consists of microaneurysms, hemorrhages, exudates, and retinal edema
- pre-proliferative retinopathy: with cotton wool spots
- proliferative or malignant retinopathy: consists of newly formed vessels
*argon laser photocoagulation is preformed for proliferative complications
diabetic sensory polyneuropathy… how do you know its small vs large fibers
small fibers cause positive symptoms —> pain, paresthesia, allodynia
large fibers cause negative symptoms —> numbness, loss of proprioception and vibration sense, diminished ankle reflex
expected lab abnormalities in pts with pagets
high alk phos and urine hydroxyproline due to increased bone turnover
serum calcium and phosphorous are normal as long as there are no other complications
how to reduce recurrent MI and cardiovascular death in pts after heart attack
dual antiplatelet therapy —> aspirin + P2y12 receptor blocker
how does thyrotoxicosis cause increased sensitivity to catecholamines
due to increased expression of beta-1-adrenergic receptors as well as changes in proteins controlling post beta-1-adrenergic receptor activity
pt (age 50-70) presents with slowly progressive dyspnea, dry cough, and fine crackles
idiopathic pulmonary fibrosis
what organs are most affected in GVHD
skin, liver, intestines
what diabetes med is known to help with weight loss and have shown mortality benefits in pts with cardiovascular disease
GLP-1 agonists
sodium levels can indicate what about heart failure
severity and its an independent predictor of adverse clinical outcomes
-more hyponatremic = more severe heart failure
pt is an obese woman presenting with headache, vision changes (blurriness and diplopia), CN 6 palsy, papilledema
idiopathic intracranial hypertension
-dx confirmed by lumbar puncture with elevated opening pressure and normal cell counts
how does tympanic membrane fibrosis present
asymptomatic, usually an incidental finding on ear exam due to otitis media or barotrauma
what can cause cochlea ossification and how does it present
- due to severe otosclerosis, meningitis, temporal bone fracture
- presents with permanent high frequency hearing loss
how to treat acute DVT/pulmonary embolism
oral Xa inhibitors or warfarin (if they are currently on one then give the other one)
- Xa inhibitors work w/i 2-4 hours
- warfarin works w/i 5-7 days and with warfarin you need to give some form of heparin for 5ish days
how to approach wide-complex tachycardia
if its ventricular tachycardia
- if pt is stable give IV amiodarone
- if pt is not stable (hypotension, altered mental status, respiratory distress) give synchronized cardioversion
if its an SVT with aberrancy
- if pt is stable do carotid massage, rate control, treat
- if pt is unstable give cardioversion
HIV pt with infective endocarditis in pt with IVDU, what is the most common bug
staph aureus
what are patients with heparin induced thrombocytopenia at increased risk of
arterial and venous clots
-need to be on alternate forms of anticoagulation
what do you have to watch for in a pt with an acute asthma exacerbation that means they are getting worse
they should have a respiratory alkalosis (due to hyperventilation) but if their pH and PCO2 starts to normalize then they are no longer able to compensate anymore and that is suggestive for impending respiratory collapse
side effect of hyperparathyroidism
pseudogout (CPPD)
pt presents with psych symptoms, cognitive impairment, and chorea
huntingtons
- AD, CAG trinucleotide repeat
- preferential atrophy of caudate and putamen (neostriatum)
when to think of secretory diarrhea
due to toxins, hormones, congenital disorders, or after bowel resection/cholycystectomy due to bile acids reaching bowel
-pt has low stool osmotic gap (< 50) and nighttime awakenings
*osmotic diarrhea will present after ingestion of a causative source
what D-dimer level excludes PE
< 500
-if its more than do a CT pulmonary angiography
what type of bias occurs when you dont have follow up from pts in a study
attrition bias –> a subset of selection bias
epidermolysis bullosa
- group of inherited disorders characterized by epithelial fragility (mutations in epidermal/dermal proteins in basement membranes)
- bullae, erosions, ulcers on palms, soles, oral
- triggered by minor trauma
- dx via biopsy with immunofluorescence microscopy and genetic testing
- treatment is supportive
main symptoms for strep pneumo meningitis
headache
fever (> 100.4)
nuchal rigidity
altered mental status
how to treat tinea versicolor
give topical selenium sulfide or ketoconazole or terbinafine
- fungal skin infection with hyper/hypo/salmon-pigmented macules on upper trunk and extremities
- more common in summer months
if someone is given heparin for DVT but then they have heparin induced thrombocytopenia and the DVT gets worse what is happening
heparin platelet factor 4 + antibody immune complex causes 2 things
- splenic sequestration and thrombus formation causing thrombocytopenia
- platelet activation –> making thrombus symptoms worse due to platelet aggregation and procoagulant microparticle release
underlying pathology to a lacunar stroke and major risk factors
microatheroma formation and lipohyalinosis leading to thrombotic small-vessel vasculitis
major risk factors
- hypertension
- hyperlipidemia
- diabetes
- smoking
uremic pericarditis
BUN > 60 + symptoms of pericarditis
adverse effect of TMP
Treats Marrow Poorly
- megaloblastic anemia
- leukopenia
- granulocytopenia
- may be avoided with leucovorin (folinic acid)
patient presents with progressive peripheral edema, elevated JVP, hepatomegaly, and ascites
-possible etiologies: idiopathic or viral pericarditis, cardiac surgery or radiation therapy, tuberculous pericarditis in endemic areas
Constrictive Pericarditis
- complication of mediastinal irradiation and an important cause of right heart failure
- other findings include: hepatojugular reflux, kussmauls sign (increase or no change in JVP on inspiration), and pericardial knock (mid-diastolic sound)
echocardiograph on patients with viral myocarditis
dilated ventricles with diffuse hypokinesis
why is there increased incidence of orthostatic hypotension in elderly
progressively decreasing baroreceptor sensitivity and defects in myocardial response to this reflex
what is recommended for infants with MEN2B
thyroidectomy cause of possible medullary thyroid cancer
patient with transient chest pain who smokes and randomly gets transient ST elevation as well
vasospastic/prinzmetal/variant angina
- smoking is a risk factor
- triggers are cocaine, alcohol, and triptans
- prevention: CCB and smoking cessation
- abortive: nitrates
hammer and claw toe deformities
- reflect imbalance in strength and flexibility b/w flexor and extensor muscle groups
- sign of diabetic peripheral neuropathy
discoid lupus erythematosus (chronic cutaneous lupus)
scaly, erythematous plaques, leading to atrophy, hypopigmentation, and scarring
-most commonly affects sun-exposed areas of the head and neck
necrobiosis lipoidica
confluent annular lesions with yellowish-brown hue, dilated blood vessels, and epidermal atrophy
-typically affects pretibial skin and is most common in pts with DM
where does porphyria cutanea tarda usually occur
blistering and skin fragility in sun-exposed areas
FACE AND DORSUM OF HANDS
how to manage COPD exacerbation
- target O2 = 88-92%
- bronchodilators
- glucocorticoids
- abx if 2 cardinal symptoms
- oseltamivir if influenza
- NPPV if vent failure
- trach if NPPV failed or contraindicated
what do cannon A waves represent
- jugular venous pulsation waveform
- regular, wide complex tachycardia
- occurs due to right atrial contraction against closed tricuspid valve (atrioventricular dissociation)
- right atrial hemodynamics throughout the cardiac cycle
what urine osmolality should lead you to think of diabetes insipidus
urine osmolality < 300
serum osmolality will be increased
patient clearly has pyelonephritis, when do you get a CT
if they show no clinical improvement within first 48-72 hours on treatment, have a history of nephrolithiasis, or have unusual urinary findings (gross hematuria or thoughts of a stone)
patient has lingering cough and wheezing after a viral prodrome
acute bronchitis
- give NSAIDs and/or bronchodilators
- NO abx
patient presents with burning or itching of the lids, discharge (could lead to crusty eyes in the morning), and foreign body sensation in the eye
blepharitis
-common contributors: seborrheic dermatitis, rosacea, allergic disorders, bacterial infection, viral infection, and demodex mite infestation
normal distribution standard deviations
1 sd: 68%
2 sd: 95%
3 sd: 99.7%
at what glucose level are you worried about hyperosmolar hyperglycemic state symptoms
> 600 (but usually its over 1000)
when would a celiac patient have a negative anti-tissue transglutaminase
if they have a concurrent selective IgA deficiency
-confirm with biopsy: villous atrophy
what non diabetes drugs can cause hypoglycemia
quinolones
quinine
beta-blockers
how to treat SIADH
fluid restriction (< 800mL/day) or salt tablets for asymptomatic or mildly symptomatic patients
how to treat subacute thyroiditis
- same as de quervian (painful)
- usually after URI
- hyper then hypothyroid then normal once inflammation goes away
- treat symptomatically with beta-blockers with NSAIDs
patient gets CT with contrast then gets high fever, tachy, n/v, hypertension, agitation… what do you think of
possible thyrotoxicosis from thyroid storm triggered by contrast in CT
patient with pericarditis within 2-4 days after MI…
peri-infarction pericarditis
-best prevented by early coronary reperfusion to minimize myocardial necrosis
what pathology to think of in hyperpigmented patients
look at symptoms too but it could be due to increased pituitary release of ACTH and melanocyte-stimulating hormone (they are made with the same larger precursor molecule)
how to test for obstructive sleep apnea
nocturnal polysomnography
what are some of the clinical symptoms of tuberculous meningitis
possible cranial nerve palsy and stroke due to inflammation and exudative pressure
most common cause of constrictive pericarditis in developing countries and what are the expected findings
TB
-nonspecific afib, low voltage QRS complexes, pericardial thickening and calcifications, and JVP tracing showing prominent x and y descents
when to consider surgery in pts with infective endocarditis
- stroke
- significant valve dysfunction
- persistent/difficult to treat infection
- recurrent embolism
what does an increased gamma gap (total protein - albumin) mean
high levels of autoantibodies
patient with heart failure has acute kidney injury, what do you think of
cardiorenal syndrome
- elevated central venous pressure leading to reduction in renal perfusion
- decreased renal perfusion due to reduced cardiac output plays a small role as well
dyshidrotic eczema
aka acute palmoplantar eczema
- recurrent, acute episodes with deep-seated pruitic vesicles and bullae at hands and feet
- complications can be desquamation, chronic dermatitis, secondary infection
- treat with topical emollients and super high potency topical corticosteroids
someone with both upper and lower motor neuron degeneration signs with widespread fibrillations and positive sharp waves (reflecting spontaneous depolarization) on electrophysiologic studies
ALS
- progressive, fatal neurodegeneration disease
- UMN: corticospinal neurons in primary motor cortex
- LMN: cranial nerves, anterior horn cells
female with recurrent rectal pain unrelated to anything and randomly occurs for up to 30 minutes at a time with no pain b/w episodes and normal physical exam/labs
proctalgia fugax
- spastic contraction of anal sphincter due to pudendal nerve compression
- manage with reassurance and possibly nitroglycerin cream +/- biofeedback therapy for refractory symptoms
If someone has high-altitude illness, what do you do
-the body’s first response will be to hyperventilate
give acetazolamide
- prevents and treats it by increasing renal HCO3- excretion to reduce blood pH and alleviate central chemoreceptor inhibition of hypoxic ventilatory response
- increases the ventilatory ceiling placed by the chemoreceptors
how to treat syphilis pt with severe penicillin allergy
give doxycycline for all stages except if they have cardiovascular problems or gummas then give ceftriaxone
-give penicillin G IV for neurosyphilis and desensitize them if they are allergic
when to be concerned about giving PEEP to a pt
patients with any sort of underlying lung disease (ARDS, pneumonia, or obstructive airway diseases) are more likely to have barotrauma cause the lung is already messed up
Possible complications: alveolar damage, pneumothorax, and hypotension
elderly pt with bradycardia presenting with fatigue, dyspnea, dizziness, syncope, afib, palpitations
Sick Sinus Syndrome
- most commonly due to degeneration of sinus node and replacement with fibrous tissue
- ECG will show sinus brady, pauses, and dropped P waves
- treat with pacemaker and possible rate-controlling meds if tachyarrhythmias
patient with skin that kinda looks like less severe (no bleeding with picking of skin) atopic dermatitis/eczema but its more diffuse
ichthyosis vulgaris
- chronic inherited skin disorder characterized by diffuse dermal scaling
- caused by mutations in filaggrin gene and much worse in homozygotes
- treat with emollients, keratolysis, and topical retinoids
most common cause of spontaneous lobar hemorrhage in elderly
cerebral amyloid angiopathy
- due to beta-amyloid deposition in walls of small to medium sized cerebral arteries
- associated with Alzheimers
what is the next best step after confirming likely cholestasis
anti-AMA
-to test for primary biliary cholangitis
whipple disease
- rare multisystem illness due to infectious Trophyrma whippelii
- GI: abdominal pain, weight loss, diarrhea, malabsorption, distension, flatulance, steatorrhea
- extra-intestinal problems: migratory polyarthropathy, chronic cough, myocardial/valvular involvement
- later stages include: dementia, supranuclear ophthalmoplegia, myoclonus, intermittent low-grade fever, pigmentation, lymphadenopathy
-PAS POSITIVE IN LAMINA PROPRIA OF SMALL INTESTINE IS CLASSIC BIOPSY FINDING
how to treat hyperkalemia
rapid calcium gluconate
possible stroke pt, what is the FIRST TEST you do
head CT without contrast to look for hemorrhage
- you can do MRI but its more expensive, takes longer, and is less available
- if normal you can do a CT angiography of head and neck
physostigmine
cholinesterase inhibitor
most reliable and predictive sign of opioid intoxication
decreased respiratory rate
preferred imaging modality in pt with possible multiple sclerosis
MRI T2-weighted
what do you think of when you see anemia with reticulocytosis
acute bleeding or hemolysis
-make sure to also look at iron and B12 levels
what hemolytic disease is associated with CLL
warm autoimmune hemolytic anemia
what class of immunosuppressants are used after solid organ transplants and what are the side effects
tacrolimus and cyclosporine –> calcineurin inhibitors
-adverse effects: nephrotoxic (hyperkalemia, hyperuricemia, increased gout), hypertension, neurotoxicity (tremor), glucose intolerance (needing more insulin), gingival hypertrophy, hirsutism, alopecia, and some GI disturbances
key value to confirm primary polydipsia or malnutrition (beer drinkers potomania)
urine sodium < 100 mOsm/kg
which electrolyte abnormality coincides with poor oral intake and hypokalemia
hypomagnesemia
what should be on your differential if you see a pt with low hemoglobin and MCV and with a low reticulocyte count
anemia of chronic disease
something in the bone marrow disrupting a proper response
what is Conn’s syndrome
primary hyperaldosteronism (adrenal mass)
- secretes aldosterone so you’ll have a low renin and high aldosterone
- this also causes a metabolic alkalosis
complication of sjogrens syndrome that causes metabolic acidosis
renal tubular acidosis
electrical alternans with sinus tachycardia, what do you think of
specific sign for pericardial effusion (can start from pericarditis)
- can confirm with echo
- if pt has hemodynamic instability/cardiac tamponade or it seems bad then do emergency pericardiocentesis
common cause of stroke in young patients
internal carotid artery dissection
- causes unilateral headache/neck pain/transient vision loss with ptosis and miosis along with focal weakness
- dx with CT angiography
- tx with thombolysis or antiplatelet therapy/anticoagulation
initial criteria for extubation
-first they should undergo spontaneous breathing trial to help confirm candidacy for successful extubation
- pH > 7.25
- adequate oxygenation on minimal support (FiO2 < 40% and PEEP < 5)
- intact inspiratory effort and sufficient mental alertness to protect the airway
amiloride
potassium-sparing diuretic
hypertrophic osteoarthopathy
digital clubbing along with painful joint enlargement
pseudotumor cereri
idiopathic intracranial hypertension common in obese women < 45 and presents with headache, transient vision symptoms, and pulsatile tinnitus
-also papilledema, and 6th nerve palsy
patient has recent T2DM diagnosis then has weight loss, necrolytic migratory erythema (erythematous papules that coalesce to form large indurated plaques with central clearing), hyperglycemia, anemia, and diarrhea/anorexia/abdominal pain
Glucagonoma
- pancreatic neuroendocrine tumor characterized by unregulated release of glucagon
- necrolytic migratory erythema due to amino acid deficiency (painful/pruritic papules that end up having central clearing)
- serum glucagon > 500 confirms dx
- abdominal imaging can localize tumor and evaluate for mets
patient who is either pregnant, obese, has DM, wears tight clothes/belts, or does abdominal straining movements has localized pain and paresthesia in the lateral thigh
Meralgia Paresthetica
- caused by compression of the lateral femoral cutaneous nerve where it passes under the inguinal ligament into the thigh
- NO weakness cause nerve has no motor fibers
- conservative treatment by avoiding tight garments and weight loss
patient with internuclear ophthalmoplegia (disorder of horizontal gaze)… what is damaged?
medial longitudinal fasciculus (MLF)
-this is what happens in pts with MS (bilateral) or can indicate a lacunar stroke in pontine artery distribution if unilateral
pt tests positive for neisseria gonorrhoeae, what else should you test for
chlamydia
HIV
syphilis
Hep B
what is miller fisher syndrome
variant of Guillain-Barre syndrome
- group of immune-mediated polyneuropathies caused by molecular mimicry
- characterized by ophthalmoplegia, ataxia, areflexia, strength often preserved
- high associated with anti-GQ1b antibody
what can be the cause of a pt having JUST bells palsy
thought to be reactivation of herpes simplex virus
- give glucocorticoids (prednisone)
- acyclovir or valacylovir may also help
what are the HACEK organisms
- Haemophilus aphrophilus
- Aggregatibacter actinomycetmcomitans
- Cardiobacterium hominis
- Eikenella corrodens (usually due to poor dentition/periodontal infection)
- Kingella Kingae
*these make up 3% of infective endocarditis cases
side effect of aminoglycoside medications (gentamicin)
hearing loss, imbalance, sensation of objects moving (oscillopsia)
-treat by discontinuing drug immediately
inflammatory back pain in pt < 40 that could be chronic or insidious in onset and might get worse or better with activity
-positive spinal tenderness
ankylosing spondylitis
- treat with exercise, NSAIDs, COX-2 inhibitors
- if those dont work then try TNF inhibitors or anti-IL-17 antibodies
when pt places hand on top of head and their arm/neck symptoms get better what is this dx and tx of?
cervical radiculopathy
-if symptoms get worse when bringing arm up think of thoracic outlet syndrome
torticollis in adults
focal dystonia of sternocleidomastoid muscle (sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures)
-can be idiopathic but is very often medication related
athetosis
slow, writhing movements affecting hands and feet
-think of huntingtons when you hear this
hemiballismus
unilateral violent arm flinging caused by damange to contralateral subthalamic nucleus
-disruptive and self limited usually
classic triad for disseminated gonococcal infection
- polyarthralgia
- tenosynovitis
- painless vesiculopustular skin lesions
what is amiodarone and what are its side effects
class 3 antiarrhythmic- K channel blocker
- increase AP duration, ERP, and QT interval
- side effects: pulm fibrosis, hepatotoxic, hypo/hyperthyroidism, corneal deposits, blue/grey skin, neurologic effects, constipation, cv effects like bradycardia/heart block/heart failure
- check PFT, LFT, and TFT when using this drug
D-xylose test
its a monosaccharide that can be absorbed in proximal small intestine and is excreted in the urine
-if they dont pee a lot out then you know they have an absorption problem/some intestinal problem
square envelope shaped crystals
ethylene glycol poisoning
if patient gets a partial or total gastrectomy what is the FIRST thing on your differential
vitamin B12 deficiency due to intrinsic factor losses
- vitamin B12 is necessary for purine synthesis (so DNA synthesis will also be impaired)
- results in ineffective erythropoiesis presenting as megaloblastic anemia
what is one of the most common risk factors for lower extremity cellulitis
tinea pedis
-causing fissures, erosions, and ulceration that allow bacterial entry into the tissue
transverse myelitis
- immune mediated destruction. of the spinal cord (can be post-infectious)
- bilateral motor weakness that can become spastic
- unlike G-B it has a DISTINCT sensory level
- autonomic dysfunction with bowel/bladder dysfunction
- dx with MRI (no compression lesion) and Lumbar puncture will show increased WBCs and IgG index
- treat with high dose IV steroids and plasmapheresis
normal looking colon but then you end up with biopsy showing mononuclear infiltrate within lamina propria and subepithelial collagen band
microscopic colitis
what to be concerned about if a pt with chronic pancreatitis or pancreatic resection is having hypoglycemic episodes?
-they might be having a glucagon deficiency cause they lost glucagon-secreting alpha cells as well
what medical therapy to you use for ascites management in cirrhosis
medical therapy
- spironolactone and furosemide
- alcohol abstinence and sodium restriction
- avoid ACE inhibitors, ARBs, and NSAIDs
if refractory
- large-volume paracentesis
- transjugular intrahepatic portosystemic shunt
first-line treatment for shingles for postherpetic neuralgia
this is the pain from shingles after the rash is already gone
-give anticonvulsants like gabapentin or tricyclic antidepressants like amitriptyline
pt is on phenytoin or they tell you they have a seizure disorder thats being treated
-and pt has megaloblastic anemia
THINK FOLIC ACID DEFICIENCY
-pt will also have gingival overgrowth/hyperplasia
-if pt on phenytoin PUT THEM ON FOLATE AS WELL
patient presents with hypopituitarism/hypogonadism and a large liver… what do you think of
hereditary hemochromatosis
three common causes of esophagitis in pts with HIV
- candida (white lesions)
- HSV (round lesions with multinucleated giant cells)
- CMV (linear uclcers with intranuclear/cytoplasmic inclusions)
hypothyroidism most common pathology
antithyroid peroxidase antibodies with high titers and over hypothyroidism with increased risk of miscarriages
normal values for ejection fraction
normal = above 55 boarderline = 50-55 decreased = less than 50
heart failure with preserved ejection fraction
diastolic dysfunction
MULTIPLE ring enhancing lesions (dont think of this if there is just one)
toxoplasma gondii
antibiotic therapy for pts with infective endocarditis
DO NOT USE ORAL FOR IE (pick IV answer)
- look at susceptibilities and if penicillin then…
- IV aqueous penicillin G (every 4-6hrs or continuous) or IV ceftriaxone (once daily) for 4 weeks
bilateral abdominal masses in 30-40 year old with hypertension
ADPKD
-get ultrasound to see multiple renal cysts
how does HIV-nephropathy present
heavy proteinuria, rapidly progressive renal failure, and edema
-most common in pts of sub-Saharan African descent with advanced HIV infection
immediate postprandial epigastric pain (intestinal angina), food aversion, and weight loss
chronic mesenteric ischemia
- due to atherosclerosis of mesenteric arteries
- get CT angiography (preferred), or doppler ultrasound
- smoking and dyslipidemia are risk factors
patient on chronic metformin therapy, what do you think of after >5 years of treatment
about 30% of these pts will develop vitamin B12 deficiency
if a pt clearly has HIV but they also have cryptococcal meningoencephalitis how do you treat them
- treat cryptococcus first with amphotericin B and flucytosine followed by fluconazole for consolidation and maintenance therapy
- then at least 2 weeks later you can consider HIV treatment and HAART
what to think of if a pt has a medullary thyroid cancer and a family history of it…
MEN 2A or 2B
-look for a pheochromocytoma by looking for plasma fractionated metanephrine assay
how to approach a pt with febrile neutropenia (especially if they are getting chemotherapy)
- these pts are at a higher risk of overwhelming bacterial infection due to absent or blunted PMN-mediated inflammatory response
- usually infection caused by bacterial infection (pseudomonas)
- treat empirically for pseudomonas
person with chronic, poorly localized anterior knee pain (usually young women)
patellofemoral pain syndrome
- pain with isometric contraction of the quadriceps
- treatment: strengthening quads and hip abductors
ototoxic medications
aminoglycosides
loop diuretics
carbo and cis-platin
metabolic syndrome criteria
- abdominal obesity (waist >40in in men and >35in in women)
- fasting glucose >100-110
- blood pressure > 130/80
- Triglycerides > 150
- HDL cholesterol <40 men <50 women
why would someone on high-dose niacin get itchy
prostaglandin-related reaction causing vasodilation
-also histamine gets released as well
-can be reduced by aspirin
- woman over 40
- pelvic mass, ascites, or abdominal pain
- thyroid gland not enlarged
struma ovarii
very rare cause of thyrotoxicosis due to production of thyroid hormone by ovarian teratoma
how to distinguish b.w graves disease and painless thyroiditis
both have hyperthyroidism and suppressed TSH
-at this point you need to get a thyroid radioiodine scintigraphy
painless thyroiditis –> decreased radioiodine uptake suggesting the release of preformed thyroid hormone
graves –> hyperthyroidism due to increased synthesis of thyroid hormone
what medications can cause male secondary hypogonadism (low libido, ED, low testosterone, low or normal LH)
opioids, glucocorticoids, exogenous androgens (withdrawal phase)
-opioids suppress GnRH and LH secretion leading to reduced Leydig cell testosterone synthesis
most common cause of primary adrenal insufficiency in developed countries
autoimmune adrenalitis
how to differentiate primary adrenal insufficiency vs central adrenal insufficiency
PAI have hyperpigmentation and hyperkalemia
what drugs can cause vitamin D deficiency
phenytoin, carbamazepine, and rifampin
-via p450 system in liver which degrades vitamin D to inactive metabolites
how to tell the difference b/w decreased PTH and decreased vitamin D intake
serum phosphorous is low in vitamin D deficiency
what serum prolactin level is diagnostic for. aprolactinoma
> 200
transient foot drop and sensory changes over dorsal foot and lateral shin
common fibular neuropathy
-impaired ankle dorsiflexion and great toe extension with preserved plantar flexion and reflexes
what is the one word to associate with each of these
polymyalgia rheumatica
fibromyalgia
polymyositis
PR- stiffness
fibromyalgia- pain
polymyositis- weakness
how does seborrheic keratosis work
- benign epidermal tumor
- tan/brown/black round lesion with stuck-on appearance
- dx made on clinical appearance only
- pt over 60
- back pain radiating to thighs worse with lumbar extension and persists while standing still
lumbar spinal stenosis
what do you think of if you see multiple erythema migrans
erythema migrans- ring of red with dot in the middle
if someone has multiple this is pathognomonic for early disseminated lyme disease
-treat with doxycycline
when to look for secondary causes of hypertension
resistant htn
- > 3 antihypertensive agents rom different classes
- <30 years old
- neither obese nor black pt
when and why is leucovorin given
given to pts recieving methotrexate or another folic acid antagonist
-prevents adverse events from damage to rapidly dividing cells in the GI system and liver
if pt is about to get chemotherapy what do you do to prevent renal injury
give lots of NS to avoid tumor lysis syndrome which can cause precipitation of uric acid and calcium-phosphate
-NS will flush out the kidneys
when antivenom is indicated after a snake bite
- unstable vital signs (hypotension, tachypnea)
- rapidly progressing changes in wound
- abnormal coagulation studies
*only give for these reasons due to risk of life-threatening allergic reaction
if a pt with pyelo has been hospitalized what do you do if they are feeling better after 2 days
switch them to an oral abx if susceptible and send them home
how to deal with a.fib with rapid ventricular response in hemodynamically stable pt
rate control with beta blockers or CCB
pt has chronic cough and lung infections, what do you dx with
chest CT with high resolution to see bronchial dilation, lack of airway tapering, and bronchial wall thickening
pt has chronic cough and lung infections, what do you dx with
chest CT with high resolution
how to treat ankylosing spondylitis
start with nonpharm options like exercise and PT
then try NSAIDs and COX-2 inhibitors
then if that doesnt work try TNF-alpha inhibitors and anti-IL-17 antibodies (secukinumab)
manifestations of tumor lysis syndrome
electrolytes: increased Ph, K, uric acid // decreased calcium
AKI: due to acid,calcium phosporous stones
cardiac arrhythmias
what commonly used medication should be discontinued if a pt becomes acutely ill with renal/liver failure or sepsis
metformin due to the increased risk of lactic acidosis
what commonly used medication should be discontinued if a pt becomes acutely ill with renal/liver failure or sepsis
metformin due to the increased risk of lactic acidosis
what antibiotics do you have to be concerned about due to nephrotoxicity
aminoglycosides
-amikacin
how to treat trigeminal neuralgia
carbamazepine
pt with subacture gi symptoms (diarrhea, nausea, cramps) and systemic manifestations (fever, weight loss, night sweats), lymphadenopathy, and transient rash
acute HIV infection
- usually causes a mono-like syndrome
- oral ulcerations and transient rash
pt with subacture gi symptoms (diarrhea, nausea, cramps) and systemic manifestations (fever, weight loss, night sweats), lymphadenopathy, and traniet rash
acute HIV infection
what to think of if a pt has hyperkalemia and low bicarb
Renal tubular acidosis
-think of metabolic acidosis nonanion gap
pt overdoses on something that causes tinnitus, fever, tachypnea, nausea, gi irrtation.. what do you think of
aspirin overdose
-primary respiratory alkalosis
followed by….
-primary anion gap metabolic acidosis
what to be concerned about when a pt has one or more blood transfusions or packed red blood cells over 24 hours
pt presents with low calcium
may develop elevated plasma levels of citrate (a substance added to stored blood)
-citrate chelates calcium and magnesium and may reduce their plasma levels causing parethesias
how to manage caustic ingestion
- secure ABCs
- decontamination to remove clothes, chemicals, and irrigate exposed skin
- chest x-ray if respiratory symptoms
- endoscopy within 24hrs
patient with infective endocarditis then develops AV block
perivalvular abscess
if pt has muscle weakness and diplopia randomly then what should you think of
myasthenia gravis
- great with AChE inhibitors (pyridostigmine) with/out immunotherapy
- thymectomy
how to deal with a recurrent tinea cruris infection
suggests reexposure to external source or autoinfection from concurrent dermatophyte infection elsewhere (search the body for it) and treat everywhere with topical antifungals like miconazole or tolnaftate
what is essential for renal excretion of bicarb
chloride is essential and will be low in serum and urine if the pt is vomiting a lot or has diuretic overuse
how to manage guillain-barre syndrome
- monitoring of autonomic and respiratory infection
- IVIG or plasmapheresis
what do you see on imaging of pts with tuberculous meningitis
basilar meningeal enhancement, hydrocephalus, and stroke due to vasculitis
-risk increases with immunocompromise
patient with erythema nodosum (red/pink bumps on legs that kinda look like mosquito bites)
-subcutaneous nodules
check for sarcoidosis with CXR
how to treat lichen planus
associated with hep C, ACEi, beta blockers, hydroxychloroquine, and thiazides
meniere disease
disorder of inner ear with increased volume/pressure of endolymph
- recurrent episodes lasting 20 minutes to 3 hours
- sensorineural hearing loss
- tinnitus and feeling of fullness in the ear
what do target cells mean on blood smear
HbC disease
Anemia
Liver disease
Thalassemia
what antiarrhythmic drug can cause pulmonary toxicity after longterm use
amiodarone
- chronic interstitial pneumonitis (cough, fever, dyspnea, pulmonary infiltrates,)
- most common*
pt presents with HTN, tachycardia, dilated pupils, and chest pain
cocaine use
- chest pain is due to coronary vasocontriction –> treat with benzos
- psychomotor agitation and seizures as well
up to 90% of pts with REM sleep behavior disorder develop what
-characterized by dream reenactment
alpha-synuclein neurodegenerative disorders
- parkinsons
- dementia with lewy body
- multiple system atrophy
how to empirically treat native-valve endocarditis
geared toward MRSA, strep, and enterococci
-use Vancomycin
what to lookout for in pts taking isoniazid
associated with hepatotoxicity so check LFTs
-can look like viral hepatitis with aminotransferases >10x upper limit of normal or it can be mild and self limiting
macrocytic anemia with thrombocytopena/leukopenia, and glossitis (smooth shiny tongue)
vitamin B12 deficiency
- leading cause is pernicious anemia (antibodies against intrinsic factor)
- glossitis is due to impaired replication of GI epithelium
what medication should be given upon discharge of a pt with an asthma exacerbation
give albuterol and prednisone
-prednisone will help prevent relapse of symptoms
besides blindness whats another complication (less commonly seen) in pts with giant cell arteritis
aortic aneurysm due to large vessel involvement
EEG findings show sharp, triphasic, synchronous discharges… what do you think
prion disease aka creutzfeldt-jakob disease
- pts will also have rapidly progressive dementia and myoclonus
- most pts die within a year of onset
pt presents with weakness and numbness (maybe upper and lower motor neuron problems) and possible bowel or bladder dysfunction but there is nothing found on imaging besides increased T2 signal in cervical spinal cord
idiopathic transverse myelitis
- lumbar puncture shows increased WBCs and IgG index
- treat first line with high dose IV steroids and then plasmapheresis if needed
what will you see on imaging of a pt with acute cholangitis
dilation of the intrahepatic and common bile ducts
fever, back pain, FOCAL spinal tenderness
vertebral osteomyelitis
-get blood cultures and inflammatory markers (ESR and CRP)
progressive sensory loss in distal symmetric stocking and glove distribution… what to think of if it occurs acutely
toxin or medication mediated
- metronidazole
- fluoroquinolones
- chemo
- toxicity: alcohol abuse or heavy metal exposure
pt with anemia related to chronic kidney disease what do you do
give erythropoietin
- htn is a common side effect when they receive large doses
- these pts need close bp monitoring
vaccinatio for yellow fever is recommended prior to travel to central Africa but who should not get this live attenuated vaccine and should get a waiver instead?
- allergy to vaccine components (eggs)
- AIDS CD4<200, immunodeficiency (like a thymus disorder), recent stem cell transplant
- immunosuppressive therapy (TNFantagonist, high dose steroids)
what is the routine for meningitis vaccines
11-12: primary vaccination
16: booster
what ends up killing most people with ALS
respiratory failure
- inspiratory muscle (diaphragm) atrophy and weakness
- expiratory weakness so an ineffective cough to clear out lungs/bronchi
- bulbar muscle weakness leading to dysphagia and chronic aspiration
Note: it kinda looks like obstructive sleep apnea so you can treat it will noninvasive positive-pressure ventilation
if someones ferritin level is over 1000 what do you do
-may also have hepatomegaly, elevated liver transaminases, and transferrin saturation
they probs have hereditary hemochromatosis and you wanna do a phlebotomy asap
increased levels of homocysteine indicate what
its a highly reactive amino acid and increased levels predispose to venous thrombosis and atherosclerosis likely due to vascular damage
-give pyridoxine (B6) to these pts
narrow-complex tachycardia
supraventricular tachycardia
-if pt has this and is hemodynamically unstable then do synchronized cardioversion
rounded swelling at the posterior elbow with a fluctuant mass on palpation
olecranon bursitis
- can be due to chronic overuse/microtrauma
- just rest and use NSAIDs
overuse of crystalloids and the “lethal triad”
hypothermia, acidosis, coagulopathy
