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
