Internal medicine uworld Flashcards
Charcot triad for Acute cholangitis
- Jaundice
- Fever
- RUQ pain
Diagnosis and treatment of Acute cholangitis
Diagnosis:
- Biliary dilation on U/S or CT scan
- High Alk phos, gamma-glutamyl transpeptidase, direct bilirubin
- Leukocytosis, High CRP
Treatment: Biliary drainage: ERCP with sphincterotomy or percutaneous transhepatic cholangiography
- Broad spectrum antibiotics: Beta-lactam/lactamase inhibitor, 3rd generation cephalosporin + metronidazole
Oropharyngeal dysphagia vs. esophageal dysphagia
Oropharyngeal presents as difficulty with initiating swallowing assocaited with cough, choking or nasal regurgitation
Esophageal dysphagia can initiate swallowing but have difficulty passing food down the esophagus.
Dysphagia of both solids and liquids at onseit favor which type of disorder vs. Initial dysphagia to solids and now liquids
Motility disorder vs. mechanical obstruction (tumor – progressive, rings)
what kind of test can you evaluate motility disorders of esophagus?
Barium swallow
Distinguish Cholecystitis vs. Cholendoclithiasis
Cystic duct obstruction = RUQ/ epigastric colicy pain 2/2 fatty meal that radiates to scapula.
Common bile duct can cause obstructive jaudice
75 yo male presents to ED with BP: 70/40. He is treated for pneumonia with IVG, abx, vasopressors, and mechanical ventilation. The next day on lab : Ast and ALT are in 2,000s, AlkP 162, Bili is 1.2. What accounts for this abnormal liver function?
Ischemic hepatic injury ( aka liver shock due to hypotension). Liver enzymes usually return to normal within 1-2 wks
What is D-xylose test used to diagnose? how dose it work?
Celiac disease
- pt with celiac cannot absorb the D-xylose in the intestine, and urinary and venous D-xylose levels will be low (blunting of villi).
_ patients with malabsorption due to enzyme deficiencies (chronic pancreatitis) will have normal absorption of the D-xylose.
32 yoM in ED with CP and diaphoresis of 4hr duration. N/V after party prior to CP. Alcohol abuse, alcohol hepatitis, Cocaine. CXR: widened mediastinum and moderate left-sided pleural effusion. Pleural fluid is yellow, high amylase. Diagnosis?
Boerhaave Syndrome – transmural esophageal tear. Leakage of fluid to pleura. Very high amylase (>2500IU/L due to saliva).
CT or contrast esophagography with Gastrografin confirms diagnosis.
Status epilepticus can cause what type of necrosis in brain?
cortical necrosis
Parkinson disease
-symptoms:
Mask-like facies Bradykinesia Hypokinetic mobility cog-wheeling resting tremor
Pure motor hemiparesis
- location?
- clinical features?
- Posterior limb of the internal capsule
- contralateral weakness (face, arm leg)
- No sensory deficit
Ataxic hemiparesis
- location?
- Clinical features?
- Posterior limb of internal capsule
- contralateral weakness and limb ataxia (leg>arm)
- No sensory deficits.
Pure sensory stroke
- location?
- Clinical features?
Posterior thalamus
- contralatereal hemisensory loss (face, arm, leg)
- no motor deficits
Dysarthria-clumsy hand syndrome
location
clinical symptoms
- Basis pontis
- facial weakness and dysarthria
- contralateral hand weakness and clumsiness
- No sensory deficits
Shy-Drager syndrome:
- Parkinsonism
- Autonomic dysfunction – postural hypotension, abnormal sweating, disturbance of bowel or bladder control, abnomral salivation / lacrimation, impotence, Gastroparesis
- Widespread neurological signs (cerebellar, pyramidal or lower motor neuron)
Parkinson symptoms + orthostatic hypotensions, impotence, incontinence, autonomic symps.
* multisystem atrophy
tx: intravascular volume expansion with fludrocortisone, salt supplementation, alpha-adrenergic agonists, and application of constructive garments to the lower body.
What is a myasthenic crisis and how to do you treat it?
respiratory failure with hx of MG
Tx: plasmaphoresis (therapeutic plasma exchange) + corticosteroids
drug-eluting stent anticoagulation
Dual antiplatelet therapy: asparin and P2y12 receptor blocker for at least 12 months
Chalazion
meiobmian gland becomes obstructed. Recurrent may be due to meibomian gland carcinoma.
Valsava
increase VR
increase HCM and MVP, all others get softer
Standing
Decrease VR,
HCM, MVP louder
Squating
Increase VR, increase Afterload, Increase regurgitant fraction
- increase AR, MR, VSD
- decreases HCM, MVP
Hand grip
Increase afterload
Increase BP
Increase Regurgitant fraction
- increase AR, MR, VSD
- decrease HCM, AS
Polycythemia vera tx
Phlebotomy
Hydroxyurea (if high risk of thrombus)
Malignant otitis externa
discharge and severe ear pain
- radiates to temporomandibular joint
- granulation tissue
- caused by pseudomonas aeruginosa
Person on ventilation and signs of ARDS. What vent change do you do?
Increase Peep so that it can re-open the alveoli that have collapsed due to ARDS
Amaurosis Fugax
retinal emboli
“a curtain falling down”
Microbiology of Infectious endocarditis: (6)
- Staph aureus – prosthetic valves, IV catheters, implanted device, IV drug users
- Viridans group/ Streptococci – dental procedures, procedures involving incision and biopsy of respiratory tract
- Strep epidermis: prostetic valves, pacemakers/ defibrillators
- Enterococci: nosocomial UTI
- Strep bovis: colon carcinoma, IBD
- Fungi: chronic indwelling catheters, prolonged antibiotic therapy
Cyanide toxicity from house fire. Treatment?
hydroxocobalamin or sodium thiosulfate OR nitrates to induce methemoglobinemia
Polymyalgia rheumatica
age >50, bilateral pain and morningin stiffness Involvement of 2 of the following: Neck or torso, shoulders or proximal arms, thigh or hip, constiutionaly( fever, malase, weightloss)
ESR >40
Elevated CRP
Tx: glucocorticoids
which type of nephrotic syndrome is associated with Hep B, C and lipodystrophy?
Membranoproliferative glomerulonephritis
Pharmacological treatment for cancer-related anorexia/cachexia syndrome?
Progesterone analogues (megestrol acetate)
or
Corticosteroids
both increase appetite
Management for symptomatic hypertrophic cardiomyopathy
Beta blockers as monotherapy
If suspicious of follicular thyroid carcinoma, what is necessary to make the diagnosis of follicular thyroid carcinoma after FNA biopsy?
Invasion of tumor capsule and blood vessels.
- early hematogenous spread to lung, brain and bone
Classical presentaiton of lewis body dementia:
- AMS
- Disorganized speech
- Visual hallucinations **
- Extrapyramidal symptoms
- alpha-synuclein protein
Rx: acetylchoinesterase inhibitors (rivastigmine) or atypical antipsychotics for refractory hallucinations
CML
- clinical
- diagnosis
- complications
- lymphadenopathy (cervical, supraclavicular, axillary)
- Hepatosplenomegaly
- Anemia and thrombocytopenia
- Severe lymphocytosis and smudge cells
- flow cytometry
- infections, Autoimmune hemolytic anemia and secondary malignancies
statistical test to compare two means?
two-sample T test
Statistical test to comparetwo means of population variances?
two-sample Z test
statistics test to compare three or more means?
ANOVA
Statistical test to compare categorical data/proportions?
Chi-square test
Meniere disease tx:
- benzodiazepines, antihistamines, and antiemetics can relieve acute symptoms. Diuretics can be considered for long-term management.
what is another name for wilson disease?
hepatolenticular degeneration
treatment of toxic megacolon:
- IV fluids
- Broad-spectrum antibiotics,
- bowel rest
- IV corticosteroids are preferred for IBD induced TM
- NG decompression
manifestation of cyanide toxicity
- cherry-red facial flushing, cyanosis later
- CNS: HA, AMS, seizures, coma
- Arrhythmias
- tachypnea followed by respiratory depression, pulm edema.
- GI: abdominal pain, nausea, vomiting
- Renal: metabolic acidosis (form lactic acidosis), renal failure
medications that cause hyperkalemia
- non selective BB
- ACEi, aldosterone inhib such as K+ sparing diuretics, ARBs
- TMX-SMP (blocks epitherlial sodium channel in collecting tubule)
- Digitalis
- Cyclosporine (blocks aldosterone activity)
- Heparin : blocks aldosterone production
- NSAIDs: decrease renal perfusion resulting in decreased K+ delivery to the collecting ducts
- Succinylcholine: causes extracellular leakage of potassium through acetylcholine receptors.
Signs of caustic poisoning
- no CNS alterations
- dysphagia, heavy salivation and mouth burns
- severe pain
White tongue, drooling, necrosis of the GI tract. Watch out for peritonitis or mediastinitis
Carcinoid syndrome
skin: flushing, telangiectasias, cyanosis
GI: diarrhea, cramping
Cardiac: valvular lesions (right>Left)
Pulm: bronchospasm
Miscellaneous: Niacin deficiency (DDD)
Treatment of joint point associated with Osteoarthritis:
1 . exercise, weight loss
2. NSAIDS: Diclofenac are the drug of choice for relief of pai in OA but do not alter the progression of the disease.
Pronator drift in physical exam
Upper motor neuron or pyramidal/corticospinal tract disease
upper motor neuron = more weakness in supinator muscles – arm drifts downared and the palm turns toward the floor (pronates)
ARDS causes what type of alveolar damage:
- cytokines released – alveolar collapse due to loss of surfactant, and diffuse alveolar damage. Gas exchange is impaired
- Lung compliance is decreased due to loss of surfactant and increased elastic recoil
- Pulm arterial pressure is increased (pulm HTN) due to hypoxic vasoconstriction, destruction of lung parenchyma, and compression of vascular structures from positive airway pressure in mechanically ventilated patients.
SLE
RASH and PAIN – female of reproductive age, AA descent
Rash: malar Arthritis Soft tissues/serositis Hematological disorders (cytopenia) Photosensitivity/ +- VDRL/RPR Antinuclear antibodies Immunosuppressants Neurologic disorders (seizures, psychosis)
leydig cell tumor
- most common testicular sex cord stromal tumor
- all age groups (including children)
- testosterone
- Estrogen
- gynecomastica in men; precocious puberty in boys
Seminoma
malignant Painless Homogenous testicular enlargment most common in 3rd decade, never infancy beta-HCG may be elevated
Glucagonoma
rare pancreatic neuroendocrine tumor.
Erythematous papules/plaeus that coalesce to form a large, painful, and inflammatory blister/cursting with central clearing. – usually onperineum, extremities, and face.
Extrahepatic manifestations of chronic hep C
- Heme: essential mixed cryoglobulinemia – low serum complement levels due to circulating immune complexes that deposit into small/medium vessels. Develop palpable purpura, arthralgias and renal complications
- Renal: membranoproliferative glomerulonephritis
- Skin: porphyria cutanea tarda, lichen planus
Tabes dorsalis – clinical findings?
Neurodegeneration of posterior spinal columns and nerve roots
- sensory ataxia
- Lancinating pains
- Neurological urinary incontinence
- Argyll Robertson pupils (miotic and constriction with accomodation but not with light).
Tx: IV penicillin 10-14 days
Juvenile angiofibroma:
Nasal obstruction
Visibile nasal mass
Frequent nose bleeds
bony erosion on the back of nose
Dangerous for surgery: bleed readily.
Infectious Endocarditis – Duke’s criteria
Major:
- blood culture of usual microorganisms
- Echocardioram showing valvular vegetation
Minor:
- predisposing cardiac lesion
- Fever > 38C
- IV drug use
- Embolic phenoma
- Immunologic phenomena (glomerulonephritis)
- Positive blood culture not meeting above criteria
Definitive IE:
2 major + 1 minor or 3 minor
Possible IE:
1 major + 1 minor or 3 minor
Clinical signs of endocarditis
Fever Heart murmur (new) Petechiae Subungual splinter hemorrhages Olser nodes, Janeway lesions Neurologic phenomena (embolic) Splenomegaly Roth spots (retinal hemorrhages)
Milk-Alkali syndrome
patients (usually women with osteoporosis) take excessive amounts of calcium and absorbable alkali. ex calcium bicarbonate
- results in hypercalcemia, metabolic alkalosis, and acute kidney injury.
- nausea, vomiting, constipation, polyuria, polydipsia, neuropsychiatric symptoms.
Spread of rubella rash:
Cephalocaudal spread of blanching, erythematous maculopapular rash
(head to toe).
Drug of choice for hairy cell leukemia:
cladribine
Attributable Risk percentage
excess risk in a population that can be explained by exposure to a RF.
ARP: (risk exposed- risk unexposed)/risk exposed
or
ARP: (RR-1)/RR
Relative Risk
RR=1
RR1
Risk of an outcome in the exposed group
R=1 (null value) then there is no assocaition between the exposure and outocme
R1 exposure is associated with increased risk of disease.
First line therapy of reactive arthritis:
NSAIDS
*recall these are seronegative spondyloarthropaty
Clinical findings of acute bronchitis
Diagnosis:
Tx:
- cough >5 days to 3 weeks
- cough can be productive ( yellow, green, or purulent)
- Absent systemic findings (fever, chills)
- wheezing or rhonchi, chest wall tenderness
-CXR only if suspected pneumonia
-Tx: NSAIDs/ acetaminophen or bronchodilators
ANTIBIOTICS ARE NOT RECOMMENDED
Recommended treatment for ALS
Riluzole: glutamate inhibitor – slows progression and time needed to do tracheostomy
Treatment for botulism
Equine serum heptavalent botulinum antitoxin
treatment of acute pyelonephritis in adults
mild-moderate vs severe
mild to moderate:
- TMP-SMX, Fluoroquinolones orally
Severe:
- ceftriaxone, fluoroquinolones, TMP-SMX IV
