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0
Q

Leriches syndrome

A

Atheromatous occlusion of distal aorta just above bifurcation

Causes:
bilateral claudication, (low back, hip, buttock, thigh)
impotence,
and absent or diminished femoral pulses.
atrophy of lower extremities

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1
Q

Normal ankle to brachial index

A

Ratio of systolic at ankle to arm

.9 to 1.3 is normal

Pts with increased ABI usually due to calcified vessels and false readings.

Claudication because of peripheral vascular disease has lower ABI

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2
Q

Gold standard diagnosing peripheral vascular disease

A

Arteriography

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3
Q

Gold standard diagnosing acute arterial occlusion

A

Arteriogram

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4
Q

Homans sign

A

Calf pain on ankle dorsiflexion

Sign of DVT

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5
Q

Most accurate test to dx DVT

A

Venography

But invasive and not used a lot

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6
Q

Initial test for DVT

A

Doppler analysis and duplex US

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7
Q

Phlegmasia cerulea dolens

A

Extreme cases of DVT

Severe leg edema compromises arterial supply

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8
Q

Signs and symptoms common to all forms of shock

A

Hypotension
Oliguria
Tachy
Altered mental status

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9
Q

Address what for all pts in shock

A

ABC

Airway
Breathing
Circulation

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10
Q

Number one cause of bronchiectasis

A

Cystic fibrosis

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11
Q

Pleural effusion with elevated pleural fluid amylase

A

Esophageal rupture
Pancreatitis
Malignancy

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12
Q

Pleural effusion with elevated blood

A

Malignancy

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13
Q

Causes of liver failure

A

Hepatitis a-e

Drugs - acetaminophen, alcohol, phenytoin, valproate, carbamazepine, ecstasy, cocaine, rifampin, INH, HAART

Ischemia

Autoimmune

Wilson’s, hemochromatosis, fatty liver in preg, HELLP sx

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14
Q

Pleural effusion with elevated mostly lymphocytes + adenosine deaminase marker

A

TB

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15
Q

Can you see cardiomegaly on AP CXR?

A

No

Heart is further from film so always looks bigger. Do PA to see

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16
Q

Difference on CXR between alveolar and interstitial pneumonia

A

Alveolar is fluffy and lumped together

Interstitial is linear streaking

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17
Q

What are the mediastinal masses and where are they?

A

Anterior mediastinum

Thyroid cancer
Teratoma
Lymphoma
Thymoma

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18
Q

Eggshell calcification a on CXR

A

Silicosis

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19
Q

Pleural plaques

A

Asbestosis

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20
Q

Pneumoconiosis with increase risk of TB

A

Silicosis

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21
Q

What looks like berylliosis and how do you tell the two apart?

A

Sarcoidosis

Good social history

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22
Q 
Causative agent of hypersensitivity pneumonitis in:
Farmers lung
Air conditioners lung
Bagassosis
Mushroom workers lung
A

Sorcerers of thermophillic actinomycetes

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23
Q

CXR with ground glass appearance with bilateral alveolar infiltrates that resemble a bat shape

A

Pulmonary alveolar proteinosis

Accumulation of surfactant like protein and phospholipids in alveoli

DO NOT give steroids because patients at risk for infection

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24
What is best imaging to detect radiation pneumonitis and what is treatment
CT scan Corticosteroids
25
Effects of severe hypoxia
Irreversible organ damage (CNS, cardio)
26
Effects of severe hypercapnia
Dyspnea | Vasodilation of cerebral vessels causing increased ICP, papilledema, headache, impaired consciousness, coma
27
CPP =
MAP-ICP
28
What do you need to determine mechanism of hypoxemia?
PaCO2 level Aa gradient Response to supplemental O2
29
Normal aa gradient by hypoxia
Hypoventilation Low inspired PO2
30
What is ventilation monitored by
PaCO2 Vs oxygenation monitored by PaO2
31
PaCO2 and Aa gradient increased
VQ mismatch or shunting VQ mismatch improves with O2 Shunt (collapsed lung, ARDS) does not improve with more O2
32
EF in CAD
>50% is normal | Less than 50 has increase in mortality
33
Stress ECG diagnostic value in CAD
75% sensitive if pts can exercise to 85% of max HR for age 220-age = max HR
34
Is perfusion imaging useful for LBBB?
No
35
What tx increases mortality for CAD? What is first line for CAD?
CCB increases HR so increases mortality Use nitrates or beta blockers
36
Diagnostic tool for prinzmetals angina
Coronary angiography + ergonovine shows vaso spasm Ergonovine is alpha Adernergic, dopaminergic, serotonergic, uterine and smooth muscle agonist
37
Chronology of acute appendicitis pain
Periumbilical to right lower quadrant Visceral then somatic pain
38
When do you need screening for ovarian cancer. And what kind of screening is done?
When increased risk secondary to hereditary factors like BRCA Don't do screening for pts of average risk Screening is ab US or CA125
39
How do you manage exercise induced asthma?
Short acting beta Adernergic agonists 20mins before exercise
40
Treating trigeminal neuralgia
Carbamazepine
41
Tx for TTP HUS
Idiopathic, usually has Ab against ADAMTS13 which cleaves vWF so platelets will aggregate more Plasmaporesis to get rid of antibody DO NOT give platelets
42
Orthostatic hypotension
Decrease systolic by more than 20 when stand Diastolic decreases by more than 10
43
Ramsay hunt
From of herpes zoster infection Causes Bell's palsy Vesicles seen on outer ear
44
Pseudo tumor cerebri symptoms, diagnosis, treatment
Headache, blurry vision or loss,papilledema, pulsatile tinnitus, abductees nerve palsy, nausea, vomiting CT scan then LP if doesn't show a bleed Acetazolamide to tx
45
Chest CT showing wedge shaped infarction is most likely what?
PE
46
Parvovirus in adults
CNN get anti-b19 antibody Arthritis affecting MCP, PIP, wrists, ankle joints Acute onset of symptoms, lack of redness and swelling (vs slow in RA)
47
What looks like an ST elevation but is not?
Left bundle branch block
48
If a pt has a suspected PE but kidney failure too, what do you use to detect PE?
VQ scan, NOT CT
49
Light's criteria
Lights criteria says a pleural effusion is likely to be exudative if one of the following exists Pleural fluid protein to serum protein > 0.5 Pleural fluid LDH to serum LDH > 0.6 Pleural fluid LDH > 0.6 or 2/3 times the normal upper limit for serum.
50
Most common cause of thyroid nodules
Benign colloid nodules Then follicular adenoma
51
What electrolyte abnormality do you worry about after surgery needing lots of transfusions?
Hypocalcemia Hyperactive deep tendon reflexes
52
What mimics hypocalcemia?
Hypo magnesia that is severe becaus less PTH secreted
53
Diagnosis of diffuse esophageal spasm
Esophageal motility studies (manometric readings)
54
Beta 2 agonists can cause what side effect and why
Hypokalemia because drive potassium into cell Muscle weakness arrhythmias, EKG changes
55
Porcelain gallbladder
Calcium deposits in gallbladder wall with bluish color and brittle consistency Rim like calcification in area of gallbladder with central bile filled dark area on CT At increased risk for gallbladder cancer
56
Most sensitive test to dx disseminated histoplasmosis
Antigen detection in serum or urine
57
First line DMARD for Rheumatoid arthritis
Methotrexate
58
Muddy brown cast
Acute tubular necrosis
59
RBC casts
Glomerulonephritis
60
WBC casts
Interstitial nephritis and pyelonephritis
61
Fatty casts
Nephrotic syndrome
62
Broad and waxy casts
Chronic renal failure
63
Gold standard for osteomyelitis diagnosis
Bone biopsy
64
What did the AFFIRM study show?
Management of afib with rhythm control offers no survival strategy over rate control There are potential advantages such as lower risk of adverse drug effects with rate control strategy. Better to rate control
65
Never give to Wolff Parkinson white patient
Beta blockers Calcium channel blockers
66
Causes of afib
PIRATES Pulm disease (COPD, PE) Ischemia (ACS) Rheumatic heart disease (mitral stenosis) Anemia (high output failure, tachycardia), atrial myxoma Thyrotoxicosis Ethanol / endocarditis Sepsis / sick sinus syndrome
67
How do you know you are hemodynamiclly unstable (eg for using cardioversion in afib)
Hypotension Angina Heart failure
68
What is the RE-LY trial?
Dabigatran vs warfarin Dabigatran superior to warfarin to inhibit ischemic stroke and decreases risk of intracranial bleed. However, dabigatran has increased risk of GI bleed
69
Diffuse bilateral pulmonary infiltrates in CXR Hypoxemia refractory to oxygen therapy
ARDS PaO2 / FiO2 ratio < 200
70
Necrotic migratory erythema High blood glucose
Gucagonnoma
71
Checking if endotracheal tube is in correct place
CXR Tip of ET should be 3-5cm above carina Bilateral breath sounds
72
Minute ventilation =
RR x Tidal volume
73
What's the usual I:E ratio?
1:2
74
Cor pulmonale
Usually secondary to pulmonary disease and not LHF Usually secondary to COPD Polycythemia may be present if COPD is cause
75
Prospective investigation of pulmonary embolism diagnosis (PIOPED)
Guides tx if V/Q performed
76
Christopher study
Guides tx if spiral CT performed
77
1. What is mortality of PE in first 60 mins if diagnosed? 2. How many die of recurrent PE if left untreated? 3. Anticoag tx deceased mortality to....
1. 10% 2. 30% 3. 2-8%
78
Gold standard to diagnose PE
Pulmonary angiography Is invasive VQ scan only finds a ventilation but not perfusion in 50% of cases
79
Goals for aPTT, PT
1.5-2.5times normal aPTT 2-3 PT 2.5-3.5 PT for mech valve
80
How does Na bicarbonate help in wide QRS (like TCA OD)?
Narrows the qrs because it increases extra cellular Na for action potential. TCAs act on Na channels and inhibit them
81
SAAG value saying it is peritonitis
> 1.1
82
Guillain barre csf findings How do you assess lung function in GBS?
High protein Normal cell count (Albumino-cytologic dissociation) Vital capacity serial measurements GBS can lead to respiratory muscle weakness --> respiratory failure
83
Primary HIV infectious can look a lot like mono. How do you tell the difference?
Mono has LESS rash (unless you used an antibiotic) and diarrhea EBV has more tonsilar exudates
84
Most common type of diabetic neuropathy
Symmetric distal sensorimotor polyneuropathy
85
Mono neuropathy most often due to
Vascular
86
When do you stop INH?
If patient gets symptoms that look like viral hepatitis so damage to liver Cand get asymptomatic mild increases in AST and ALT. this is okay and continue drug. This is subclinical hepatic injury and self limited
87
Dyspnea, tachypneic, normal lung evaluation, right axis deviation
Pulmonary embolism
88
A pt has PCP. What do you give them? What is an alternative?
TMP SMX + steroids. Steroids decreases mortality in severe PCP. This is switch PaO2< 70 or Aa > 35 Pentamidine works less well but used for severe cases that intolerant to TMP SMX
89
Pt has abrupt mental status changes and hallucinations. CSF has mildly deceased glucose and increase in lymphocytes and negative gram stain. What is the gold standard of testing? Start should you do?
CSF PCR. This is most likely viral encephalitis by HSV You should give acyclovir STAT
90
What is DDx for high serum Ca and normal PTH? How do you tell the difference between DDx?
Primary hyperPTH Hypocalciuric hypercalcemia 24 hr urinalysis calcium excretion and creatinine clearance FHH has decreased urinary calcium excretion edges life increased serum calcium. Primary hyperPTH has increased 24 hr Ca excretion.
91
Selenium deficiency
Cardiomyopathy
92
Zinc deficiency
Alopeia Weird taste in mouth Bulbous pustule lesions surrounding body offices and/or extremities Impaired wound healing
93
What do you use CT with contrast for?
Structural abnormalities Mass lesions Not ok for blood because blood already shows up as white and can't see it with contrast. MRI is best for no emergency situations where you want to ID vascular malformations, epilepsy foci, etc
94
How do you diagnose myasthenia gravis?
Eectromyogram Ach captor antibody test both confirm Then do CT of chest to look for thymoma
95
Autosomal dominant Diffuse telangectasias Recurrent epistaxis Widespread AVM
Osler weber rendu syndrome (hereditary telangectasias) Usually in mucous membranes, skin, GI tract If in lungs, can do right to left shunt and cause chronic hypoxemia and reactive polycythemia.
96
First step in managing case of pleural effusion. What is the exception? What do you do if you suspect malignacy but cytology is negative?
Thoracentesis See if exudative or transudative. EXCEPT in cases of pts with clear cut evidence of CHF where you use diuretics and Echo If cytology is negative, an then negative - you keep going 3 times until you totally rule out malignancy
97
Type of anemia associated with tea and toast diet
Folate
99
Leukocytes that h ave undergone partial breakdown during prep of stained smear or tissue section, because of their greater fragility.
Smudge cells of CLL
100
Most sensitive and specific test for colorectal cancer
Colonoscopy Do this after have + FOBT
101
IS fecal occult blood testing sensitive or specific for CRC?
NO Predictive vlue is only about 20%
102
Does UC or Crohns have greater risk for CRC?
UC
103
Familial adenomatous polyposis
AD disease Colon always involved 90% have duodenum too 100% risk CRC by 30 Prophylactic colectomy
104
Gardner;s syndrome
Polyps + osteomas + detal abnormalities + benign soft tissue tumors
105
Turcot's sydnrome
AR | polyps + cerebellar medulloblastoma or glioblastoma multiforme
106
Hamartomas through GI tract, pigmented spots around lips, oral mucosa, face, genitalia, and palmar surfaces, inussusception risk
Peutz Jeghers Hamartomas have low malignant potential
107
HNPCC
Lynch 1 - early onset CRC Lynch 2 - Lynch 1 + increased number and eary occurence of other cancers (female GU, skin, stomach, pancreas)
108
Most common presenting sx of CRC
Ab pain
109
Most common cause of large bowel obstruct in adults
CRC
110
Common R sided CRC symptoms
Melena obstruction is more rare b/c larger luminal diameter Change in bowel habits uncommon
111
Triad of R sided CRC
Anemia Weakness RLQ mass
112
Common L sided CRC symptoms
Hematochezia obstructino more comon b/c smaller luminal diameter CHANGE in bowel habits - yes! Pencil stools
113
Most common sx of rectal cancer
Hematochezia Rectal cancer has higher recurrent rate and lower 5 year survival rate than colon cancer
114
ACTH stimulation test
Cosyntropin test = During the test, a small amount of synthetic ACTH is injected, and the amount of cortisol, and sometimes aldosterone, the adrenals produce in response is measured
115
If pts are hypotensive due to adrenal sufficiency, can:
+ hydrocrotisol 100 mL TID + normal saline if the above two don't work, add fludrocortisone
116
SIRS criteria
SIRS is a serious condition related to systemic inflammation, organ dysfunction, and organ failure. It is a subset of cytokine storm, in which there is abnormal regulation of various cytokines Temp < 96.8 or > 100.4 HR > 90/min RR > 20/min or PaCO2 < 32 mmHg WBC 12x10^9/L (>12,000/mm³), or 10% bands
117
CHADS2 score
``` C = CHF H = HTN A = age >=75 D = Diabetes S = previous TIA or stroke or thromboembolism ```
118
What is heparin induced thrombocytopenia?
``` In HIT, the immune system forms antibodies against heparin when it is bound to a protein called platelet factor 4 (PF4). These antibodies are usually of the IgG class and their development usually takes about five days ```
119
4T score for HIT
Thrombocytopenia +2 if > 50% fall in platelet count Timing +2 if fall is betwen 5-10 days after commencement of treatment Thrombosis +2 in new thrombosis, skin necrosis, or systemic reaction alTernative cause possible (liver function, chemo) +2 if no other cause possible
120
#1 cause of systolic CHF
MI
121
#1 cause of diastolic CHF
HTN
122
CHF treatment to decrease mortality
Beta blocker (carvedilol, bisproplol, metoprolol) ACE --| / ARBs - Candesartan is the only one for diastolic heart failure Spironolactone (stage 3 or 4 CHF) Hydralazine + nitrate - If african american good for it - use this also if can't use ACE --| or ARBs AICD (EF < 35%) Biventricular AICD Wide QRS and EF < 35% can use this wide QRS because ventricle desynhrony
123
CHF treatment for symptoms, not decreasing mortality
Digoxin Diuretics Millrinone - For end stage heart failure
124
What's a bad prognostic factor in heart failure?
Hyponatremia t give more Na!)
125
Cardiorenal syndrome
1) Can have primary heart failure or renal failure that cause failure of the other organ. - if this is due to heart failure and decreased perfusion of kidney, look diuretics do not help the worsening kidney fuction 2) Can also have kidney congestion when you have too much volume to kidney and the kidney will get more blood - this gets better wafter diuretics
126
Takotsubo cardiomyopathy
- ST elevation - + troponins - when look at with cath, there are no coronary blockages - This is really due to increase in catecholamines - can lead to cardiogenic shock and vfb
127
LE edema differential
- cirrhosis - CHF - DVT - venous insufficiency (ACE wraps up to thigh, compression stockings) - cardiac cirrhosis (bad RHF can cause liver cirrhosis) - Nephrotic syndrome
128
VRE colonization
VRE, check for colonization via rectal swab
129
MRSA colonization
MRSA, check for colonization via nares swab
130
Third spacing
Third-spacing refers to a situation in which fluid shifts out of the blood into a body cavity or tissue where it is no longer available as circulating fluid.
131
Pathogenesis for normal pressure hydrocephalous
increase in ICP causing ventricular enlargement Due to: - diminished CSF absorption at arachnoid villi - obstructive hydrocephalus
132
What meds do you hold before cardiac stress testing for: 48 hrs: 48 hrs before vasodilator stress test: 12 hrs before vasodilator stress test: Continue taking:
48 hrs - beta blockers - CCB - nitrates 48 hrs before - Dipyridamole 12 hrs before: - Caffeine Continue: - ACE ---| - ARBs - digoxin - Statins - Diuretics
133
What can cause a false + on stress test
Diuretics | - diuretic-induced hypoK can cause ST segment depression and false +
134
Photopsia + floaters + curtain coming down over eyes
Retinal detachment
135
Blurred vision + blunt trauma
Choroidal rupture Reveals: central scotoma, retinal edema, hemorrhagic detachment of macula
136
Infectious mononucleosis
EBV TRIAD: High fever + lymphadenopathy + pharyngitis Also: fatigue + maculopapular rash + posterior cervical lymphadenopathy + splenomegaly not as much anterior cervical lymphadenopathy Leukocytosis + atypical lymphocytes Heterophile antibodies are negative early in illness Autimmune hemolytic anemia (IgM cold agglutinin) Thrombocytopenia
137
Focal vertebral pain + no neuro sx
Compression fracture (vertebral body demineralization) Happens in osteomalacia, osteoporosis
138
Back pain with movement + feel best in morning + perispinal pain
Ligamentous sprains
139
Low back pain + worse as day goes on + relieved with rest
Lumbar disk degeneration hallmark of lumbar osteoarthritis
140
Pain and progressive limitation of back motion + young men + worse pain in AM
Apophyseal joint arthritis of ankylosing spondylitis
141
testicular fibrosis + azospermia + gynecomastia + increased LH and FSH
Kleinfelter's
142
small testes + normal testosterone + low LH
exogenous steroid use
143
Liver mets characteristics
Colon #1 site mets is to liver Lung and breast also love to go here RUQ pain MILDLY elevated liver enzymes Firm hepatomegaly Confirm w/ CT
144
Hypercalcemia secondary to malignancy - how does this happen?
Osteolytic mets PTrH secretion increased Vit D formation Increased IL6 levels
145
Most common COD of pts w/ acromegaly
Cardiovascular Can get Coronary artery disease, cardiomyopathy, arrhythmias, LVH, diastolic dysfunction
146
Reversible causes of asystole/pulseless electrical activity
5H's and 5 T's ``` Hypovolemia Hypoxia H+ (acidosis) Hypo/hyperkalemia Hypothermia ``` ``` Tension pneumo Tamponade (cardiac) Toxins (narcotics, benzos) Thrombosis (pulm, coronary) Trauma ```
147
Tx for pulseless electrical activity w/o palpable pulses
CPR | Epi
148
When do you use early defibrilation?
V fib | Pulseless V tach
149
When do you use synchronized electrical conversion?
Symptomatic / sustained V tach | hemodynamically unstable afib
150
Back pain initial diagnostic test
Plain film Xray
151
Acid fast staining organisms
Nocardia (partly) TB
152
Tx for nocardia
TMP-SMX (can be used as prophylaxis too) Minocycline (2nd line)
153
Tx for paget's disease
Bisphosphonates
154
Attributable risk percent
(RR - 1) / RR
155
Inpatient tx of community acquired pneumonia Outpatient tx of community acquired pneumonia
Inpatient: NEW fluoroquinolones (levofloxacin, moxifloxacin) Ceftriaxone + azithromycin Outpatient: azithromycin, doxycycline Outpt w/ comorbidities - fluoroquinolones
156
What is absolutely contraindicated to give first to pt w/ pheochromocytoma
Beta blocker - will get reflex HTN Block alpha first, then beta
157
Best initial eval for gallstones
Abdominal ultrasound ERCP after if US doesn't reveal anything but there is a high suspicion
158
Risk factors for gallstones
``` Native american diabetes obesity rapid wt loss oral contraceptive use ``` Fat, female, forty, fertile
159
Best to dx biliary obstruction
ERCP
160
Best to confirm suspected cholecystitis
HIDA scan
161
usual cause of renal artery stenosis in young adults? older?
YOUNG: fibromuscular dysplasia OLD: atherosclerosis
162
Contraindications of ACE ---|
Hyperkalemia | bilateral renal A stenosis
163
Tx of choice for fibromuscular dysplasia
Percutaneous angioplasty + stent placement
164
Classic heart sound in MI
S4 Ischemic damage of heart --> diastolic dysfunction --> stiff LV --> atrial gallops (S4)
165
Behcet syndrome
Recurrent oral ulcers + 2 of the following: - recurrent genital ulcers - eye lesions (anterior uveitis, etc) - skin lesions (erythema nodosum, etc) - + pathergy test
166
``` #1 cause of hypercalcemia in ambulatory pts #1 cause of hyperCa in hospitalized pts ```
Ambulatory: primary hyperPTH Hospitalized: malignancy
167
Milk alkali syndrome
Risk of this w/ taking in too much Ca or using old absorbable alkali for tx peptic ulcer disease TRIAD: hyperCa, metabolic alkalosis, renal insufficiency
168
Pathogenic factors involved in developing hepatic encephalopathy What is hepatic encephalopathy characterized by?
1. Accumulate NH3 in blood 2. Produce false neurotransmitters 3. Zinc deficiency 4. Increased sensitivity of CNS to inhibitor neurotransmitters (eg GABA) reversal of sleep cycle asterixis progressive coma characteristic delta waves on EEG
169
Malignant potential of polyps
Size (larger --> malignant) Histo type (villous --> malignant) Atypia of cells Shape (sessile = flat --> malignant)
170
Complications of - diverticulosis - diverticulitis
Diverticulosis - painless rectal bleeding - diverticulitis Diverticulitis - bowel obstruction - abscess - fistula - free colonic perforation
171
Dx - Diverticulosis - Divertiulitis
OSIS - Barium enema ITIS - CT w/ contrast (NOT scope or enema)
172
Angiodysplasia of colon - What is it? - What are its associations?
Dilated, ectatic thin-walled vessels Lined by endothelium Prone to recurrent and chronic PAINLESS bleeding Assoc w/ aortic stenosis, ESRD - aortic stenosis --> turbulent blood flow through valve --> disrupt vWB multimers --> increased risk of bleeding --> angiodysplasia - Uremic platelet dysfunction from ESRD --> increase bleeding risk --> angiodysplasia
173
Acute mesenteric ischemia types
1) Embolic - usually from heart emboli - sx SUDDEN + painful 2) Arterial thrombosis - usually happens w/ CAD - sx gradual + less severe than embolic 3) Nonocclusive - due to low CO - usually in critically ill pts 4) Venous thrombosis - sx present for many days + gradual worsening
174
Acute Intestinal infarction signs
``` HypoTN Tachypnea Lactic acidosis Fever Altered mental status ``` Can lead to shock CHECK LACTATE LEVELS IF SUSPECT MESENTERIC ISCHEMIA!!!! Mesenteric ischemia has > 50% mortality rate!?!?!
175
Dx acute mesenteric ischemia
Mesenteric angiography
176
Chronic mesenteric ischemia
usually due to atherosclerosis abdominal angina, usually postprandial Wt loss b/c of fear of eating
177
Ogilvie's syndrome
signs, sx, radiograph shows large bowel obstruction but there is no mechanical obstruct Causes: recent surgery, trauma, malignancy, anticholinergics, etc Decomrpress!
178
Most frequent cause of pseudomembranous colitis
Clindamycin Ampicillin Cephalosporins
179
Dx pseudomembranous colitis
C diff toxins is stool is diagnostic (need 24 hrs)
180
Dx sigmoid volvulus
sigmoidoscopy sigmoid colon #1 site for volvulus
181
Dx cecal volvulus
Barium enema???
182
Which volvulus needs surgery? When do you NOT give barium enema in volvulus
--> cecal volvulus --> don't give BE if suspect stranulation
183
Most common causes of cirhosis
EtOH liver disease Chronic viral infection (esp Hep C) Others: - drugs - acetaminophen, methotrexiate - PBC - autoimmune hepatitis - R heart failure congestion, constrictive pericarditis - a1-antitrypsin deficiency - NASH
184
What do you useto classify severity of liver disease?
Child's Classification A is mild, C is severe Factors - Ascites - Bilirubin (higher is worse) - Encephalopathy - Ntritioalstatus - Albumin (lowe is worse)
185
Gold standard to Dx liver cirrohsis
Liver biopsy
186
Classic sgns of chronic liver disease
``` Ascites Varices Gynecomastia, testicular atrophy Pamar erythema, spider angiomas Hemorrhoids Caput medusae ```
187
Tx for esophageal/gastric varices
1) Hemodynamic stabilization - give fluids to maintain BP 2) Variceal ligation/banding - endoscopy when stabilized or 2) Enoscopic sclerothrapy - inject sclerosingitem into varices - more risk of rebleed than ligation 3) IV octreotide + prophylactic antibiotics - cause splanchnic vasocontrit and lower portal P or 3) IV vasopressin - not as good as octreotide --> lots of complicatons
188
Long term tx for esophageal/gastric varices
Beta blockers to prevent releed
189
Ascites from liver cirrhosis - what causes it?
- too much fluid b/c of portal HTN so increased hydrostatic P - hypoalbuminemia (reduced oncotic P) ONLY get ascites w/ portal HTN
190
Serum ascites albumin gradient (SAAG)
> 1.1 = portal HTN ver likely <1.1 = portal HTN less likely
191
Tx ascites
Bed rest Low Na diet Diuretics (furosemide, spironolactone)
192
Monitoring pts w/ cirrhosis
- LABS: CBC, renal fnt tests, electrolytes, LFTs - Endoscopy to see if esophageal varices - CT guided biopsy to see if HCC
193
Tx hepatic encephalopathy
1) Lactulose - Gut bacteria met of lactulose causes acifification of colonic contents, causing NH3 ---> NH4 (not absorbable --> ammonia trap) 2) Neomycin - kills gut bacteria so dec ammonia production 3) Diet limiting protein
194
Features of hepatic encephalopathy
- dec mental function, confusion, stupor, coma - asterixis - rigidity, hyperreflexia - fetor hepaticus = musty odor of breath
195
Complications of Liver failure
AC, 9H Ascites* Coagulopathy ``` Hypalbuminemia portal HTN* Hyper NH3 Hepatic encephalopathy* Hepatorenal sx HYPOglycemia (b/c liver stores glycogen) HYPERbilirubinemia/jaundice HyperESTROGEN HCC ``` * = most serious complications
196
Causes of spontaneous bacteral peritonitis. SIgns?
E. coli Klebsiella Strep pneumo SIGNS: - fever - change in mental stauts - ab pain - rebound tenderness - all happens in pt w/ known ascites
197
Spider angiomas - what are they?
Dilated cutaneous arterioles w/ central red spot
198
How long abstain from EtOH before get liver transplant (eligibility)?
6 months
199
Wilson's disease
Liver can't excrete copper b/c deficiency of ceruloplasmin Ceruloplasmin is Cu-binding and needed for excetion
200
Do Kayser fleischer rings interfere w/ vision?
No
201
Tx Wilson's disease
- D- penacillamine - Zinc (prevents Cu uptake from diet) - Liver transplant
202
Dx hemochromatosis
ALT and AST Iron studies Liver biopsy --> needed for Dx
203
Complicatons of Hemochromatosis
1) Cirrhosis - increase risk of HCC 2) Cardiomyopathy - CHF, arrhythmias 3) DM - iron deposits in pancreas 4) Arthritis - usually in 2nd and 3rd MCP, hips, knees 5) Hypogonadism 6) Hypothyroidism 7) Bronze like skin "CHAD CHuB"
204
Complications of hepatocellular adenoma
Usually asymptomatic Rupture --> hemoperitoneum and hemorrhage is major risk Resect tumors > 5cm that don't regress after stopping OCP
205
#1 benign liver tumor #1 malignant liver tumor
Cavernous hemangioma Malignant - HCC Cholangiocarcionmas
206
Dx cavernous hemangioma
US CT w/ contrast NOT biopsy b/c risk rupture and hemorrhage
207
Hepatic tumors assoic w/ OCP
Hepatocellular adenoma NOT focal nodular hyperplasia - but this is in women usually
208
Types of HCC
1) Nonfbrolamellar - more common - assoc w/ Hepb B and C - usually not resectable, short time 2) Fibrolamella - no Hep assoc - often resectable, longer survival time
209
HCC risk factors
``` Cirrhosis Aflatoxin Vinyl chloride Thorotrast AAT deficiency Hemochromatosis, Wilson's Schistosomiasis Hepatic adenoma Cigs Glycogen storage disease type 1 (Von Gierke's) ```
210
Paraneoplastic sx of HCC
``` Erythrocytosis Thrombocytosis HYPER Ca Carcionid Hypertrophic pulmonary osteodrystrophy HYPO glycemia High cholesterol ```
211
HCC tumor marker
AFP
212
Heyde's syndrome
Syndrome of aortic valve stenosis associated with gastrointestinal bleeding from colonic angiodysplasia.
213
Hemobilia
Blood drains into duodenum via common bile duct Bleed starts anywhere in Hepatobilliary system. Diagnose with arteriogram
213
GIST marker
c-kit
214
Causes of hemobilia Clinical features
Trauma, tumors, infection Papillary thyroid carcinoma Surgery like cholecystectomy GI bleed so melons or hematemesis, jaundice, RUQ pain
215
Budd chiari
Block hepatic vein outflow getting hepatic congestion and micro vascular ischemia Hepatomegaly, RUQ pain, jaundice Dx via hepatic venography, SAAG Tx usually needs surgery because thrombocytes may not work. Liver transplant if cirrhosis
216
3 major causes of jaundice
Hemolysis Liver disease Biliary obstruction
217
Bilirubin metabolism
Hbg to bilirubin in spleen Unconjugated bilirubin in plasma bound to albumin and not water soluble so NOT excreted in urine Conjugated in liver Excreted into intestine and made into urobilinogen and urobili by gut bacteria
218
Dark urine and pale stools means what?
Conjugated bilirubinemia Conjugated is soluble so it is the only one to get into the urine.
219
Where are ALTs and ASTs
ALT - liver ALT is more specific for liver damage AST - in many tissues like brain, kidney, heart, skeletal muscle Alcoholic hepatitis usually has higher increase in AST (a scotch and tonic)
220
If AST and alt are mildly elevated.... Moderate.... Severe...
Mild = Think chronic viral hepatitis or acute alcoholic hepatitis Moderate = acute viral hepatitis Severe = extensive hepatic necrosis due to ischemia, shock, Tylenol, severe viral hepatitis
221
LFT pearls
Increase in ALP and GGT, small ALT and AST increase = cholestatitic disease Normal or increase in ALP, very big increase in ALT and AST = hepatocellular necrosis or inflammation
222
ABCDEFGHI of AST or ALT increase
``` Autoimmune hepatitis Hepatitis B Hepatitis C Drugs or toxins Ethanol Fatty liver Growths (tumors) Hemodynamic disorders (CHF) Iron (hemochromatosis), copper (Wilson's), or aat deficiency ```
223
Cholesterol stone associations
Obesity, diabetes, hyperlipemia Multiple preggers, OCP Crohns, illegal resection Old age Native American Cirrhosis Cystic fibrosis
224
Pigment stone associations
Black - hemolysis, alcoholic cirrhosis Brown - biliary tract infection
225
Boas sig
Cholelithiasis Referred right Subcapsular pain of biliary colic
226
Pain from Acute cholecystitis Biliary colic Is secondary to what?
Acute cholecystitis - gallbladder wall inflammation - several days Biliary colic - contraction of gallbladder against obstructed duct - only a few hrs
227
High sensitivity and specificity test for cholelithiasis
RUQ ultrasound
228
Best for dx acute cholecystitis. What do you see?
RUq ultrasound Thickened gallbladder wall Pericholecystic fluid Distended gallbladder Presence of stones CT good for ID complications of acute cholecystitis HIDA if US inconclusive. Sensitivity and specificity are about the same.
229
Choledocholithiasis
Stones an originate in common bile duct and in gallbladder. Most come from gallbladder Use ERCP (vs US for cholelithiasis) to dx Can be asymptomatic for years but if there are symptoms, it is much more threatening than when you get symptoms from cholelithiasis.
230
Charcots triad Reynolds Pentad
Sign of cholangitis RUQ pain Jaundice Fever Only in 50-70% cases Charcots triad + septic shock + altered mental status
231
To do for pts with cholangitis
Blood culture IV fluids IV antibiotics after blood cultures obtained Decompress CBD when patient stable
233
Primary biliary cirrhosis Features Clinical presentation Dx Tx
Intrahepatic duct destruction leading to portal inflammation and cirrhosis Vanishing ducts! Antimitochondrial antibodies Usually in middle aged women Can get xanthomas or xanthelasmata, osteoporosis , hepatosplenomegaly, jaundice, statorrhea, portal HTN, osteopenia Test for AMAs, liver biopsy to confirm disease Tx with liver transplant. Ursdeoxycholic acid can slow progression of disease Cholestyramine for pruitus relief
233
Where are most of cholangiocarcinoma tumors?
Proximal third of CBD Bad prognosis. Associated with clonorchis sinensis infection in Asia, choledochol cysts
234
Primary biliary cirrhosis Features Clinical presentation Dx Tx
Intrahepatic duct destruction leading to portal inflammation and cirrhosis Vanishing ducts! Antimitochondrial antibodies Increased IgM Increased ALP, cholesterol Usually in middle aged women Can get xanthomas or xanthelasmata, osteoporosis , hepatosplenomegaly, jaundice, statorrhea, portal HTN, osteopenia Test for AMAs, liver biopsy to confirm disease Tx with liver transplant. Ursdeoxycholic acid can slow progression of disease Cholestyramine for pruitus relief
236
Carcinoid tumors originate from
Neuroendocrine cells usually in appendix Secrete serotonin
237
Drugs to increase RBC count. How do you tell which one a person took?
Steroids -- will have gynecomastia, HTN EPO --will NOT have gynecomastria, but will have HTN
238
What alcohol poisonings can you do hemodialysis for?
Methanol Ethylene glycol
239
[Na] in normal saline
154
240
Tx nephrogenic diabetes insipidus
amiloride HCTZ Amiloride causes excretion of lithium if that is the cause
241
Amount of fluid restriction to correct hypoNa
800-1000cc
242
Coccidiodomycosis clinical features
SW US Central and S America ``` Fever Fatigue Dry cough Weight loss Pleuritic chest pain Erythema multiforme Erythema nodosum arthralgias ```
243
Histoplasmosis clinical features
SE, mid atlantic, and central US Acute pneumonia - cough - fever - malaise
244
Blastomycosis clinical features
South-centrl and north-central US ``` Lungs Skin Bones Joints Prostate ```
245
What is the Well's score most useful for?
people with low probabiliyt of PE
246
Hemochromatosis iron panel
Increased - Fe - Ferritin - Transferrin saturation Decreased TIBC
247
Cephalization on CXR
= redistribution of blood into the upper lobe vessels. If hydrostatic P > 10 mHg, fluid begins to leak into interstitum of lung --> excess fluid compresses the lower lobe vessels, perhaps as a result of gravity. As a result, upper lobe vessels are recruited to distribute a greater volume of blood. In order to carry a greater volume of blood, the upper lobe vessels increase in size
248
Cause of pancreatiis
``` EtOH Gallstones post-ERCP Viral(mumps, coxsackie) Drugs (Sulfas, thiazides, furosemide, estrogens, HAART) Pancreas divism HYPER TGs Uremia ```
249
Ranson's Criteria
To assess prognosis of acute pancreatitis ``` Admission Criteria (GA LAW) Glucose > 200 mg/dL Age > 55yo LDH > 350 AST > 250 WBC >16,000 ``` ``` Initial 48 hrs (C HOBBS) Ca < 8 mg/dL Hct decrease > 10% PaO2 < 60 mm Hg BUN increas > 8 mg/dL Base deficit > 4mg/dL Sequestration of fluid > 6L ``` 5-6 criteria has 40% mortality
250
How does hypo Ca of pancreatitis happen?
Fat saponification Fat necrosis binds calcium
251
How do you dx acute pancreatitis
clniical presentation lab studies are supportive - Serum amylase and lipase are most sensitive and specific tests for dx acute pancreatitis CT is confirmatory (most accurate)
252
Acute pancreatitis ab radiograph findings
Sentiel loop - air filled bowel in LUQ - sign of localized ileus Colon cut off sign - air filled segent of tarnsverse colon cutoff at region of pancreatic inflammation
253
Pancreatic pseudocyst
encapsulated fluid collection appearing 2-3 weeks after acute attack Has no epithelial lining Can rupture, get infection, hemorrhage Dx w/ CT and drain if > 5cm Can be present at sites distant from pancreas
254
Tx for acute pancreatitis
Most only need supportive pain control, bowel rest, IV fluids, electrolyte corrections Most don't need more therapy ERCP if it is severe biliary pancreatitis -- can remove stone. NOT for EtOH pancreatitis
255
Pain control in acute pancreatitis
Fentanyl and meperidine Not morphine b/c itcauses increase in sphincter of Oddi pressure
256
When give antibiotics for acute pancreatitis
If > 30% of pancreas is necrosed imipenem
257
#1 cause of chronic pancreatitis
Chronic alcoholism Methanol can also cause!
258
Classic signs of chronic pancreatitis
steatorrhea diabetes pancreatic calcification on CT scan is diagnostic usually have constant pain radiating to back ERCP is gold standard to dx NO elevation of amylase or lipase NOT pancreatic cancer if this has been ongoing for > 1 year
259
What vitamin deficency can you get with chronic pancreatitis?
Vit B12
260
Classic chronic pancreatitis picture on ERCP
Chain of lakes areas of strictre and duct dilatation throughout pancreatic duct
261
Tx chronic pancratitis
INsulin Pancreatic enzymes ( ---| CCK release to decrease secretions from bad pancreas) H2 blockers (prevents gastric acid made so it doesn't degrade pancreatic enzyme supplements)
262
Pancreatic cancer - risk factors
#1 - SMOKING ``` Male sex Black race Obesity FH of pancreatic cancer chronic pancreatitis CHRONIC diabetes benzidine, b-naphthylamine ``` NOT ALCOHOL
263
Painles or painful jaundice in pancreatic cancer?
PAINFUL jaundice
264
Courvoisier's sign
palpable gallbladder indicates cancer of head of pancreas
265
Dx pancreatic cancer
CT preferred for diagnosis and assessment of spread ERCP most sensitive but invasive
266
Pancreatic cancer tumor marker
CA 199 | CEA (less sensitive and specific)
267
Aortoenteric fistula
Hx of aortic graft surgery who has small bleed of the duodenum Quickly turns massive and fatal hemorrhage
268
Dieulafoy's vascular malformation
Submucosal dilated arterial lesions causing massive GI bleed Upper GI bleed
269
Melena
black, tarry liquid foul-smelling stool due to degradation of Hb by bacteria in colon - further bleed is from rectum, more likely melena happens - usually upper GI bleed
270
Hematochezia
Usually a lower GI bleed Can be upper GI if it is massive and bleeding is so fast it does not stay in GI tract for long
271
BUN/Cr in GI bleed
BUN/Cr usually increased w/ upper GI bleed, esp if pt has no renal insufficiency
272
When do you use arteriogrpahy for GI bleed?
For pts w/ lower GI bleeding Perform during active bleeding
273
GI bleed indicatons for surger
- hemodynamicallnstable pts not responding to IV fluid, transfusion, endoscopy intervenions, coagulopathy correctins - severe inital bleed or recurrence of bleed after endoscope - continued bleed > 24 hrs - visible vessel at base of ulcer - ongoing transfusion requirement
274
Staging esophageal cancer
1 - invades lamina propria or submucosa. nodes - 2a - invades muscularis propria or adventitia; nodes - ---> surgery up to here --> palliative below 2b - invades up to muscularis propria; nodes + 3 - invades adventita or tumor invades adjacent structions 4- distant mets
275
Achalasia causes
``` US: #1 - idiopathic #2 - adenocarcinoma of proximal stomach ``` ``` World: #1 - Chagas ```
276
Esophageal squamous cll cancer causes
``` EtOH Tobacco Nitrosamines, hot food ingestions HPV Achalasia Plummer Vinson sx ```
277
Types of esophageal hiatal hernias
Type 1 - Sliding Type 2 - Paraesophageal Type 3 - Sliding + Paraesophageal; tx like it is paraesophageal (surgical)
278
Where is Mallory weiss tear?
at Gastroesophageal junction tear is only mucosal
279
Plummer vinson syndrome
Upper esophageal web --> dysphagia Iron deficiency anemia Koilonychia (spoon nails) Atrophic oral mucosa
280
Schatzki's ring usualy accompaniedby
sliding hiatal hernia
281
Platypnea
Dyspnea relived by laying down, exacerbated by sitting up Platypnea is due to either hepatopulmonary syndrome or an anatomical cardiovascular defect increasing positional right-to-left shunting (bloodflow from the right to the left part of the circulatory system).
282
Sitophobia
food fear
283
Screening for lung cancer
National Lung Screening Trial - > 30 pack year smoking history - low dose chest CT yearly for those who are still smoking or smoked in the past 15 years - shows to have decreased motality but no long term data
284
Transudative pleural effusion causes
Due to increased hydrostatic or decreased oncotic P ``` CHF Cirrhosis PE Nephrotic syndrome Peritoneal dialysis Hypoalbuminemia Atelectasis ```
285
Exudative pleural effusion causes
Caused by increased capillary permeability ``` Bacterial pneumonia, TB Malignancy, mets Sarcoidosis Rheumatoid arthritis Viral infection PE ```
286
Paraneoplastic syndrome of Small cell lung cancer
SIADH ACTH Lambert Eaton Hypertrophic osteoarthropathy - It is characterized by new bone formation on the outside of the diaphyses of long bones of the limbs, without destruction of cortical bone
287
Chylothorax pleural effusion - what is in the fluid? Common causes of it
Triglycerides >110mg/dL Cancer Trauma ``` TB Chronic mediastinal infections Sarcoidosis Lypmhangioleiomyomatosis Radiation fibrosis ```
288
Absolute neutrophil count
(% neutrophils + % bands) * WBC / 100
289
Chemtherapy transfusion reaction - what do you do?
Shortness of breath, rash are red flags Give - all things to inhibit all histamines (benadryl, pepcid) - epinephrine - steroids Evaluate Call oncologist
290
Traction diverticula
true At midpoit of esophagus near tracheal bifurcation Due to traction from contiguous mediastina inflamation and adenopathy (pulmonary TB) --> TB causes hilar node scarring causing retraction of esophaus
291
Epiphreic diverticula
- lower 1/3 of esophagus | - usually assoc w/ spastic esophageal dysmotility or achalasia
292
Associated blood type of duodenal ulcer? Gastric ulcer?
Duodenal - O Gastric - A
293
Risk factors of duodenal ulcer? Gastric ulcer?
Duodenal - NSAIDs Gastric - Smoking
294
#1 nephrotic syndrome associated w/ Hodgkin's lymphoma
Minimal change disease
295
#1 nephropathy associated w/ carcionma
Membranous glomerulonephritis
296
Conn's syndrome lab values
HTN Mild hyper Na HYPO K Metabolic alkalosis (decreased bicarb)
297
Reason for oxalate stones in Crohn's, small bowel resection
Happens in IBD, small bowel resection, other malabsorption syndromes Increased intestinal fat binds dietary calcium --> can't bind oxalate in gut --> oxalate gets reabsorbed adn precipitates in kidney
298
# Define the following therapies: - Salvage - Adjuvant - Consolidation - Induction - Maintenance - Neoadjuvant
Salvage = form of tx for disease when standard tx fails Adjuvant = therapy given in addition to standard tx Consolidation = given after induction therapy to really wipe out tumor cells Induction = initial tx to kill tumor cells to send pt into remission Maintenance = given after induction and consolidation to ensure remission Neoadjuvant = tx given before standard tx
299
Reddish nodule --> ulcerates --> spreads forming subQ nodules and ulcers No adenopathy or systemic signs What is the offending agent?
Sporothrix schenckii
299
Reddish nodule --> ulcerates --> spreads forming subQ nodules and ulcers No adenopathy or systemic signs What is the offending agent?
Sporothrix schenckii
300
Elderly + dementia + severe depression + very concerned about memory loss Tx?
Pseudodementia SSRIs
301
HTN Hx + unilateral weakness + no changes on CT
Lacunar infarct microatheroma and lipohyalinosis Most commonly in internal capsule
302
HTN Hx + unilateral weakness + no changes on CT
Lacunar infarct microatheroma and lipohyalinosis Most commonly in internal capsule
304
Severe symptomatic hyper Ca - What happens? - How do you tx?
Hypercalcemia --> induces salt wasting --> significant volume depletion Volume depletion causes more reabsoption of solutes, hence more reabsorb of Ca Tx w/ normal saline (200 mL/hr) + calcitonin + bisphosphanates to reduce serum Ca levels and restore back volume
305
Sudden loss of vision Onset of floaters Fundus is difficult to visualize
Vitreous hemorrhage #1 cause of vitreous hemorrhage is diabetic retinopathy
306
Sudden painless, unilateral loss of vision HTN hx perhaps Disk swelling, venous dilation, cotton wool spots, retinal hemorrhages
Central retinal vein occlusion
307
Pellagra - what is it - causes of it - symptoms
It is niacin deficiency Corn based diet Alcoholics Carcinoid sx patients Hartnup's disease Diarrhea + Dermatitis + Dementia - skin rash in sun exposed areas (can look malar rash!) REMEMBER PELLAGRA when you see malar rash + diarrhea. SLE doesn't have diarrhea
308
Fever in neutropenic patient
> 100.9 F | > 100.4 F for more than 1 hr
309
Febrile neutropenia
Happens when neutrophil count is low | Neutropenia = absolute neutrophil count < 1500/microL
310
What should tx of febrile neutropenia cover? Monotherapy? Combo therapy
Pseudomonas Monotherapy: ceftazadine, imipenem, cefepime, meropenem Combo: aminoglycoside + anti-pseudomonal beta lactam
311
#1, #2 muscles involved for myasthenia gravis
1 - extraocular muscles 2 - muscles of jaw (bulbar muscles) CPK usually normal in myasthenia gravis
312
Myasthenia gravis vs. primary muscle problem - what lab value is helpful to distinguish?
CPK normal in MG
313
Myasthenia gravis vs. ALS
normal reflexes in MG
314
Toxoplasmosis - Tx - Prophylaxis
Tx = Sulfadiazine + pyrimethamine Prophylaxis = TMP-SMX
315
Rapid plasma reagin test
Screens for syphillis
316
anti-thyroperoxidase antibodies + enlarged rubbery goiter - What am I at risk for?
Hashimoto's Lymphoma of thyroid (60x) Dx via core biopsy as FNA may miss diagnosis
317
Normocytic anemia + Hyper Ca + Renal failure + Elevated total serum protein w/ normal albumin
Multiple Myeloma Mnemonic: CRAB - Calcium - Renal impairment - Anemia - Bones (pain, lytic lesions) HyperCa because of bone lysis from plasmocyte-released humoral factors and expanding plasma cell mass Hyper Ca can present as CONSTPATION!
318
Can you see MM lesions on bone scan?
No There is no associated new bone formation Use skeletal survey (xray)
319
Thrombocytopenia + Hemolytic anemia (increase in indirect Bili, decrease Hg, increase retic count) + Altered mental status + Renal failure
TTP-HUS Peripheral blood smear to tell if there are schistocytes
320
Colloid solutions used to..
in burns or conditions w/ hypoproteinemia
321
Classic signs of dehydration
Dry mucosa Marginally high Hct, electrolytes BUN/Cr > 20 Tx w/ intravenous crystalline solution (normal saline)
322
How does respiratory alkalosis happen in preggers?
Progesterone stimulates medulla respiratory centers This leads to tachypnea --> resp alkalosis
323
Digital Rectal Exam signs for - BPH - Prostate cancer
BPH - smooth, firm enlargement of prostate PC - palpable nodule at periph of prostate
324
If get ROS and PE suggestive symptoms of BPH, what is the first thing to do?
Ab ultrasound to look for hydronephrosis | - put in catheter if needed
325
What test do you use to evaluate spinal stenosis?
MRI
326
Alterations in consciousness + disorganized speech + visual hallucinations + Extrapyramidal symptoms
Lewy Body Dementia
327
Pickwickian syndrome (obesity hypoventillation syndrome)
Obesity impedes expansion of chest and ab wall during breathing Underventillation of lungs and chronically elevated PaCO2, decreased PaO2 Abnormal ABG
328
Causes of blood diarrhea - bacterial
CSS YE ``` Campylobacter Shigella Salmonella Yersinia E. coli ```
329
HIV pt + bloody diarrhea + normal stool exam
Highly suspicious for CMV
330
Electrolyte risk with immobilization (eg paralysis)
Hypercalcemia - possibly due to increased osteoclastic bone resorption - tx w/ hydration + bisphosphonates
331
Rhabdomyolysis electolyte imbalance
HYPO Ca | Ca preceipitates w/ PO4 b/c it is released from damaged muscles
332
Prinzmetal's angina - Risk factors - Tx
Smoking is risk factor Tx - CCB - nitrates
333
Prior sensitization is needed for phototoxic or photoallergic drug?
Photoallergic Phototoxic does not need prior sensitization for drug eruption - an example is tetracyclines
334
Prior sensitization is needed for phototoxic or photoallergic drug?
Photoallergic Phototoxic does not need prior sensitization for drug eruption - an example is tetracyclines
335
Strk + no hemorrhage on CT w/o contrast + within 4.5 hrs after onset, what is best med to give to improve neuro outcomes?
tPA | NOT STREPTOKINASE
336
Endotracheal intubation common common complication
Right mainstem bronchus intubation causng asymmetric chest expansion during inspiration and markedly decreased or absent reath sounds on the L side
337
Endotracheal intubation common common complication
Right mainstem bronchus intubation causng asymmetric chest expansion during inspiration and markedly decreased or absent reath sounds on the L side
338
Manifestatons of Sarcoidosis
Pulm - Bilateral hilar adenopathy Eye - uveitis Heme - Lymphadenopathy, Hepatomegaly, splenomegaly MS - polyarthriis CNS/Endo - Central DI, Hypercalcemia (makes a1-hydroxylase), increased ACE Lofgren's syndrome - erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever
339
Lofgren's sydnrome
erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever
340
Lofgren's sydnrome
erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever
341
NF-2 genetics
Autosomal dominant Severe disease casued by frameshift or NONSENSE mutations Less severe are missense
342
Bradycardia + AV block + HypoTN + Diffuse wheezing
Beta blocker toxicity Tx w/ glucagon Wheezing indicative of bb toxicity Can also get cold and clammy due to cardiogenic shock from bradycardia and hypoTN
343
Most common origin of ectopic foci for afib
Pulmonary vein
344
#1 cause of atrial flutter
reentrant circuit rotating around tricuspid annulus
345
Analgesic abuse nephropathy
Tubulointerstitial disease | Characterized by focal glomerulosclerosis
346
Hyperglycemic nonketotic state is not symptomatic until what glucose level
600 mg/dL of glucose in blood get altered mental state
347
Cardiac cath complications
Arthroembolism (cholesterol) --> dislodges anywhere Common sequelae of embolism: - Blue toes - Increase Cr
348
Optic neuritis sx
- Pain with eye mvmt - Change in color perception - Afferent pupilary defect and field loss - papilledema - more in fems, multiple sclerosis
349
Tx Bacillary angiomatosis
Oral Erythromycin
350
How long does heart transplant last?
~10 years Nerves severed so be careful of atypical MI - palps, diaphoresis, but no chest pain
351
When do you admit a pyelonephrtis patient?
Usually if they can't meds PO b/c vomitting too much
352
Emphesematous cholecystitis - what is it? - how does it happen? - clinical manifestaitons
Acute choecystitis arising b/c of infection w/ gas forming bacteria (Clostridium, Escherichia, Staph, Strep, Pseudomonas, Klebs) - Due to vascular compromise (stenosing of cystic A), immunosuppression (DM2), gallstones - Crepitus in ab wall adjacent to gallbladder is occasionally detectable - NO peritoneal signs though Dx w/ ab radiograph only a small increase in bilirubin or AST/ALTs
353
underlying path of lateral epicondylitis
Degeneration of extensor carpi radialis brevis tendon near the lateral epicondyle
354
What restrictive lung disease doesn't respond to steoids?
Idiopathic Pulmonary FIbrosis
355
#1 finding in interstitial lung disease on PFTs
Decreased diffusion capacity to CO
356
What kind of age distribution for diagnosis does Crohns have?
Bimodal
357
How much blood do you ave to lose to become tachycardic? Orthostatic?
Tachy - 15% | Ortho -30%
358
#1 cause of septic arthritis
Staph aureus
359
Beck's triad
Cardiac tampanode - hypotension - distended neck veins - muffled heart sounds - pulsus paradoxus
360
Young black male + painless hematuria. What do you expect? How does it happen?
Sickle cell trait Episodes of painless hematuria are classic Papillary ischemia is possible cause
361
Tx of stroke in sickle cell patient
Exchange transfusion - decreases % of sickle cells in blood and another stroke of happening Continue hydroxyurea
362
EKG finding of supraventricular tachycardia
Narrow QRS complex
363
Renal artery stenosis occurs most commonly w/ which nephrotic syndrome?
Membranous glomerulonephritis Sudden onset - ab pain - fever - hematuria
364
Most specific arrhythmia for digoxin toxicity
Atrial tachycardia w/ AV block Digoxin increases vagal tone thus decreasing conduction through AV node Digoxin also increases ectopy in the atria and venticles Rare for atachy + AV block together so pretty specific for dig toxicity
365
Secondary AA amyloidosis
Results from deposition of acute phase reactants (serum amyloid A) in setting of chronic inflammatory disease (psoriasis IBD, rheumatoid arthritis) Nephrotic syndrome common, hepatomegaly
366
Elevated BUN + no increase in Cr OR Increased BUN/Cr
Pts receiving steroid treatments Prerenal renal fail GI bleed
367
Most common feature of hemophillia
Hemarthroses
368
Acute monocytic leukemia features
Bleeding gums Leukocytosis + lots of blast forms Staining - + alpha-naphthyl esterase peroxidase (-) b/c lack auer rods
369
How do you tell the difference between peripheral vascular disease (arterial stenosis) and venous insufficiency?
Artery - shiny, hairless skin Vein - skin discoloration (purple/pink), hair is ok, edema
370
Normal skin at birth --> dry skin w/ horny plates over extensor surfaces of limbs
Ichthyosis vulgaris
371
``` Blood transfusions received before 1992 1986 1980s Should be screened for...? ```
1992 - Hep C 1986 - Hep B 1980s - HIV
372
Essential tremor
Stable at rest Usually noticeable when pt attempts to do something requiring fine movement Tx w/ beta blocker - propanolol anticonvulsants - primidone topiramate benzos - clonazepam
373
Parkinson's tremor
Worse at rest (4-6 Hz) Better when try to do something Asymmetric, assoc w/ rigidity
374
Dx acute MI Dx reoccurence of MI
Acute - Troponin T (takes longer to return to normal) Reoccurence - CK-MB
375
What do you give for all that have high risk of developing aplastic crisis
Folic acid
376
If someone says they got something in their eye
High velocity... - don't see anything with penlight - use fluorescein exam (slit lamp, etc) - never use MRI because it will risk dislodging the item - use CT or Ultrasound
377
Dyspnea + fever + cough (nonproductive) Tachypnea + cyanosis + minimal chest findings Bilateral diffuse interstitial infiltrates beginning in perihilar region
P. jirovecei
378
Most common places for perihilar involvement of P. jiroveci
lymph nodes spleen liver bone marrow
379
HIV pt with CD4 count < 50 / mm3 should receive what prophylaxis against what?
Mycobacterium avium complex -->Azithromycin CMV (but also if serum CMV IgG is +) --> Ganciclovir
380
Metabolic syndrome diagnosis
3/5 present: 1. Ab obesity (> 40 inc men, > 35 inc women) 2. Fasting glucose > 100 -110 mg.dL 3. BP > 130/80 mm Hg 4. Triglycerides > 150 mg/dL 5. HDL (Men < 40 mg/dL; women < 50 mg/dL)
381
Bloody diarrhea bacterial causes
``` Campylobacter Shigella Salmonella Yersinia E coli ``` E coli doesn't have a fever sometimes (vs the other) and has more ab pain than the others - that's how you tell the difference
382
Pts w/ cirrhosis - what do you do for them first?
Endoscopy ASAP - esophageal varicies are a big bleed risk. Use beta blockers to prophylactically decrease risk of bleeding.
383
SLE + anti-ds DNA antibodies First step in tx?
Kidney biopsy - informs different nephritis treatments - is baseline to compare other biopsies to monitor disease progression
384
Equation for anion gap
AG = Na - (HCO3 + Cl)
385
What is cor pulmonale most commonly caused by?
COPD Less frequent: - Pneumoconiosis - Pulmonary fibrosis - Kyphosis - Primary pulmonary HTN - repeated episodes of PE
386
Cause of S3 Reasons for S3 Tx for symptoms for abnormal S3 Tx for long term for abnormal S3
Inflow from L atrium strikes blood already in LV causing an extra sound Normal in younger athletes and preggers Abnormal - usuall sign of left ventricular failure Tx symptoms - diuretics Tx long term - beta blockers
387
Atypical lymphocytes Ddx
VACTER RM ``` Viral hepatitis Acute HIV infection CMV Toxoplasmosis EBV (mono) Rubella ``` Roseola Mumps
388
What diabetes medication do you hold on hospital admission? Why?
Metformin Metformin gets processed by liver and excreted by kidney. If kidney excretion is bad, will build up metformin and get lactic acidosis. If pt needs CT w/ contrast, can possibly get renal damage and will decrease ability to excrete metformin.
389
When do you stop colonoscopy screenings?
85 yo
390
Best test to evaluate pt w/ epigastric pain
``` Upper GI endoscopy Can diagnose: - PUD - gastritis - esophagits - rule out cancers of esophagus and stomach - H. pylori infection w/ biopsy ```
391
Mets of gastric carcinoma
Krukenberg - mets to ovary Blumer's shelf - mets to rectum (can feel on rectal) Sister mary joseph's node - mets to periumbilical lymph node Virchow's node - mets to supraclavircular ofssa nodes Irish's node - mets to left axillary adenopathy
392
Risk factors for gastric carcionma
``` atrophic gastritis gastric polyps H. pylori Pernicious anemia Nitrates diet Blood type A ```
393
Most common malignancy in asbestosis patients
Bronchogenic carcionma
394
Causes of renal transplant dysfunction in early post-op period Tx?
``` Ureteral obstruct acute rejection cyclosporine toxicity vascular obstruct ATN ``` IV steroids best tx
395
Effects of an AV fistula
Decreases systemic vascular R Increases cardiac preload INcrease cardiac output ``` Widens pulse pressure Strong arterial pulsation (brisk carotid upstroke) Systolic flow murmur Tachy Flushed extremities ``` LV hypertrophy PMI displaced to left
396
How can you have heart failure in AV fistula pts?
Heart still pumps lots of CO but circulation is unable to meet O2 demand of peripheral tissues
397
High output cardiac failure causes
``` Thyrotoxicosis AV fistula Paget disease Anemia Thiamine deficiency ```
398
Congenital AV fistula causes
PDA Angiomas Pulmonary AVF CNS AVF
399
Acquired AV fistula causes
Trauma Femoral cath Aortocaval fistula (eg atherosclerosis) Cancer
400
Tx Meniere's disease
Decreasing triggers that increase endolymphatic retention Avoid: - EtOH - Caffeine - Nicotine - Foods high in salt
401
Do you need to bridge heparin and warfarin in pts w/ afib? DVT?
A fib - NO! - Your protein C and S levels are normal so if start warfarin without bridging, will have a slight depletion of C and S but not enough to cause necrosis - heparin use if want to cardiovert someone DVT - yes! - Body is actively depleting protein C and S to try and break up clots - if add warfarin without heparin, you're going to decrease C and S even more and will definitely have necrosis
402
Hypertension in pts w/ thyrotoxicosis
Predominantly SYSTOLIC HTN, w/ increase in pulse pressure Caused by hyperdynamic circulation due to hyperTH. Possibly due to increased expression of myocardial SR Ca-dependent ATP
403
Managing Nephrolithiasis
Imaging - helical CT highest sensitivity and specificity Pain - Narcotics and NSAIDs if have normal renal function - NSAIDS better because narcotics can worsen N/V Size of stone - < 5 mm = pass spontaneously, drink lots of fluids Urology consult - if anuria, urosepsis, acute renal fail
404
Multiple sclerosis CSF findings
Oligoclonal bands (mostly IgG)
405
Most important contributor to CHF edema
Increased renal sodium retention Results from RAAS due to renal hypoperfusion secondary to decreased CO
406
Pathophysiology of non-EtOH fatty liver disease
Insulin resistance --> fat accumulation in hepatocytes by increasing rate of lipolysis and elevating circulating insulin levels --> intrahepatic fatty acid oxidation --> increase in oxidative stress --> local increase in proinflammatory cytokines TNF-a --> liver inflammation, fibrosis, cirrhosis
407
Immediate goal of managing pt w/ confusion if hx is limited
Tx potentially reversible causes of confusion Thiamine --> Wernicke's encephalopathy Dextrose --> hypoglycemia Supplemental O2 --> hypoxia Naloxone --> Opiate OD
408
Major cause of morbidity and mortality in SAH pts
Vasospasm of arteries at base of brain Signs of ischemia happen about 7 days after SAH Use CCB to prevent!
409
Warm agglutinin disease - what is it - causes - tx
IgG Extravascular hemolysis --> splenomegaly May have spherocytes Causes - lymphoma, leukemia (CLL) - SLE - a-methyldopa tx w/ - steroids - rituximab - splenectomy - immunosuppressive drugs
410
Cold agglutinin antibody disease - what is it - causes - tx
IgM Intravascular (activates complement --> hemolysis) Causes: - Mycoplasma pneumoniae - EBV tx w/ - supportive care - RBC transfusions - NOT steroids
411
Common causes of priapism
Sickle cell Leukemia Perineal or genital trauma (laceration of cavernous artery) Neurogenic lesions (spinal cord, cauda equina compression) Meds - trazodone, prazosin (#1)
412
What spinal process are diabetics prone to develop? | - How do you dx?
Epidural abscesses Do an MRI to eval cord compression
413
Spontaneous bacterial peritonitis - Ascitic fluid Dx - When do paracentesis? - Most commonly cultured organisms - Empiric therapy?
Dx: + ascitic culture, PMN > 250 / mm3 When: Before antibiotics Org: E coli, Klebsiella Empiric tx: 3rd gen cephalosporin
414
Acute aortic dissection presentation
HTN (not HYPO) Tearing chest pain Unequal pulses Early diastolic murmur - dissection causes aortic regurg
415
Presentation of influenza When does tx need to start?
Leukopenia Acute onset fever, chills, cough, malaise, myalgias, coryza Antiviral therapy (ostltamivir) must be started w/in 48 hrs to significantly decrease duration and severity
416
SLE hemotologic abnormalities
Anemia (warm agglutinin hemolysis) Thrombocytopenia (like ITP in Ab formed against platelets) Neutropenia (Ab-destruction of WBC)
417
Medial medullary syndrome
Occlusion of vertebral artery/branch Contralateral paralysis of arm and leg Contralateral loss of tactile, vibratory adn position sense DEviation of tongue to injured side
418
Wallenberg syndrome
Lateral medulla injury Ipsilateral Horner Contralateral loss of pain and temperature sensation on body Loss of pain and temp of face weakness of palate, pharynx, vocal cords cerebellar ataxia
419
Acute pericarditis EKG
Diffuse ST elevations PR depressions
420
Breath sounds over consolidated lung retions
LOUDER + more prominent expiratory component if airways are patent - egophony also present - crackles - decreased if airways are blocked
421
Acalculous cholecysititis commonly seen in pts...
1. Extensive burns 2. Severe trauma 3. Prolonged TPN 4. Prolonged fasting 5. Mechanical ventillation
422
Zenker's diverticulum - Where? - Why? - Dx? - Tx?
Happens right above UES by herniating POSTERIORLY between fibers of crcopharyngeal muscle Motor dysfunction and incoordination responsible for problem Can sometimes see the outpouching in the neck! Dx - contrast esophogram to clearly show diverticulum Surgical tx = excision and cricopharyngeal myotomy
423
When do you do a carotid endarterectomy?
``` "Symptomatic" carotid stenosis of 70-99% Asymotompatic stenosis of 60-99% Low surgery risk Good 5 year predicted survival Accessible lesin ``` <50% - just aspirin
424
When do a carotid angioplasty w/ stenting?
High surgical risk Poor 5 year survival NOT for asymptomatic pts
425
DVT anticoagulation contraindications How do you tx?
Recent surgery Hemorrhagic stroke Bleeding diathesis Actve bleeding IVC filter
426
Cluster headache features
Intense unilateral retroorbital pain, usually waking pt up from sleep Starts suddenly, peaks rapidly, lasts 2 hrs More in men Redness of ipsilateral eye, Horner's, runny nose, tearing
427
Causes of macrocytic anemia
Folate deficiency B12 deficiency Orotic aciduria Myelodysplastic syndrome Acute myeloid leukemias Drugs Liver disease EtOH abuse HYPO thyroid
428
Pernicious anemia
#1 cause of B12 deficiency Usuall have other autoimmune d/o (thyroid, vitiligo) ``` Shiny tongue (atrophic glositis) Ataxia (shuffling, broad based) DCMLS deficit ```
429
How long do you have to be on a pure vegan diet to replete your B12 stores? Folate stores?
B12 - 4-5 years Folate - 4-5 months
430
Extraintestinal manifestations of UC
Sclerosing cholangitis Uveitis Erythema Nodosum Spondyloarthropathy Toxic megacolon Colon cancer
431
#1 valvular abnormality in infective endocarditis (not IV drug use related)
Mitral regurgitation
432
``` Urinalysis: Gluc - negative Ketones - trace LE - negative Blood - Large RBC - 0-1 WBC - 5-10 ``` What do you suspect?
Rhabdomyolysis --> myoglobinuria ALWAYS suspect this if test results have large amt of blood on UA but absence of RBCs on microscopy
433
Altered mental status causes
Decreased glucose Decreased Na HYPO thyroid Increased Ca Uremia NH3 Increased CO2
434
Can you gain wt with cancer?
YES! Hyper ACTH of small cell --> Cushings --> fat redistribution
435
Ectopic ACTH causes
Lung cancer Carcinoid Pancreatic cancer Neuoendocrine tumors
436
Important electrolyte disturbance w/ SAH
Hyponatremia --> Cerebral salt wasting syndrome 1) Inappropriate secretion of vasopressin --> water retention 2) Increased secretion of ANP/BNP --> cerebral salt wasting 3) SIADH also commonly seen
437
What lab values are best representations of acid base status?
pH | PaCO2
438
Pronator drift
Sensitive an specific for UMN lesion UE supinators naturallyw eaker than pronators - exaggerated in pts w/ UMN lesion Extend arms wti palms up, affected arm will tend to pronate ad drift down
439
Most common site of hypertensive hemorrhage (intracerebral) | - features on PE
Putamen (35%) - BASAL GANGLIA! Internal capsule lying adjacent almost always involved--> hemiparesis Cerebellum (16%), thalamus, and pons also common Motor deficits opposite site of lesion Gaze deviation TOWARDS side of lesion
440
What's the best way to improve LV function in pt with tachysystolic afib?
Control rhythm or rate
441
Uremic coagulopathy
Abnormal hemostasis seen in pts w/ CRF Abnormal bleeding and bruising are characteristic Guanidinosuccinic acid is #1 uremic toxin implicated in pathogenesis of platelet dysfunction seen in CRF PTT and PT and TT usually normal Bleeding time usually prolonged Platelet count normal, platelet dysfunction present
442
Extrarenal complicatins of ADPKD
Hepatic cysts (#1) Berry aneurysm MV prolpse Aortic regurg Colonic diverticula Ab wall and inguinal hernia
443
Extrahepatic sequelae of chronic hep C
``` Chronc arthralgia (false + RF or ANA) Cryoglobulinemia Porphyria cutanea tarda Membranoproliferative glomerulonephritis B cell lymphomas Plasmacytomas Sjogren's, thyroiditis Lichen Planus Idipathic thrombocytopenic purpura (ITP) ```
444
FeUrea
< 35% = pre-renal azotemia > 35% = intrinsic renal failure
445
FeNa
< 1% - prerenal - the physiologic response to a decrease in renal perfusion is an increase in sodium reabsorption to control hyponatremia, often caused by volume depletion or decrease in effective circulating volume (e.g. low output heart failure). > 2-3% - ATN or kidney damage - either excess sodium is lost due to tubular damage, or the damaged glomeruli result in hypervolemia resulting in the normal response of sodium wasting.
446
Risks for contrast induced nephropathy
FeNa < 1 Diabetes Decreased GFR
447
Black currant jelly stools
Intusuception
448
How do you decide how and where to tx a patient with pneumonia?
``` CURB-6 C = Confusion U = Urea (BUN > 20) R = RR > 30 B = systolic BP = 65 ``` 0-1 = outpt, 2 = admission
449
Facticious thyrotoxicosis - labs
Hyperthyroidism signs (no goiter or exophthalmos though) LOW TSH HIGH T3 and T4 Dx w/ 24 hr radioiodine uptake test --> diffusely decreased iodine uptake by thryoid Biopsy = follicular atrophy
450
Reasons for pain postcholecystectomy
1) Sphincter of oddi dysfunciton - abnormal ALP - dilatation of biliary tree - high pressure of sphincter on manometry 2) common bile duct stone - abrnomal ALP - dilatation of biliary tree 3) functional pain - normalLFTs - no dilatation of biliary tree - diagnosis of exclusion
451
When do a cholecystectomy?
Indicated for all pts w/ symptomatic gallstones (eg pancreatitis) who are medically stable enough for surgery
452
Mass in anterior mediastinum
Thymoma Retrosternal thyroid Teratoma Lymphoma Dx w/ CT scan
453
Mass in middle mediastinum
``` Bronchogenic cysts Tracheal tumors Lymph node enlargement Aortic aneurysms of arch Pericardial cysts ```
454
Mass in posterior mediastinum
``` Neurogenic tumors - meningocele lymphoma diaphragmatic hernias esophageal tumors aortic aneurysms ``` Dx w/ MRI
455
How do you decrease risk of contrast-induced nephropathy?
Use non-ionic contrast agents
456
Tricuspid valve endocarditis + pleuritic pain + cavitating lung nodules on xray
Staph aureus septic embolism to lungs from staph IV use
457
Dilated cardiomyopathy causes
``` Alcohol Adenovirus Beri beri Coxackie Chagas Cocaine Doxorubicin/Danorubicin Enterovirus ``` Hemochromatosis HHV 6 Parvovirus B19 Peripartum cardiomyopathy
458
Tx after diagnose solid testicular mass suggestive of cancer (via US)
Radial orchiectomy | - remove testis and associated cord
459
Diabetes insipidus features
Polyuria Polydipsia DILUTE urine w/ increased serum osmolality Pts prefer cold water
460
Primary polydipsia features
Excessive water drinking Both plasma and urine are diluted
461
SIADH features
``` Hyponatremia Low serum osmolality Inappropriate high urine osmolality Hypouricemia and low BUN Normal or reduced Cr b/c of dilution Euvolemia ```
462
Osmotic diuresis features
Happens w/ hyperglycemia, glucosuria, mannitol admin Urine and serum osmolality elevated Urine > serum
463
Pap smear screening guidelines
Start at 21 no matter if sex active 21-30: - screen every 2 years > 30 w/ 3 consecutive (-) paps, screen every 3 years If have CIN II/III, screen w/ pap smear every 6 months until 3 negatives obtained - then resume standard (annual) screening
464
What should all chronic hep C people get?
Vaccinations to Hep A and B if not already immune
465
Heat stroke - characteristics - consequences
Body temp > 105 Dehydration common --> hot, dry skin and hypotension, tachycardia, tachypnea, hemoconcentration Seizures ARDS (scattered rales on exam) DIC (low platelets, increased PT/PTT) - eg epistaxis Hepatic/renal failure
466
Electrical alternans
Pathognomonic for pericardial effusion Due to swining motion of heart in pericardial cavity causing beat to beat variation in QRS axia adn amplitude EA + sinus tachy very specific for pericardial effusion
467
Mixed cryoglobulinemia
Palpable purpura Proteinuria Hematuria (RBC casts) Arthralgias Hepatospelnomegaly Low complement HCV infection usually
468
Colon cancer screening
Start age 50 or 10 years before 1st diagnosis in family member Do every 10 years for average risk
469
Mammogram screenings
age 50 - 75 - every 2 years >75 - NONE!
470
Common complication of CABG
Afib Rate of afib increases w/ CABG + aortic valve replacement
471
Pickwickian syndrome (Obesity Hypoventilation syndrome)
Severe obesity + alveolar HYPOventilation during wakefullness + thick neck Low voltage QRS on EKG Polycythemia secondary to hypoventilation
472
Smoking cessation cardiovascular benefits
LITTLE effect on BP reduction Significantly reduce risk of cardiovascular disease
473
Risk factors for osteosarcoma
Radiation Chemo Paget's
474
Osteitis fibrosis cystica
Due to HYPER PTH | Osteoclastic resorption --> replace bone w/ fibrous tissue (brown tumors)
475
Wernicke's encephalopathy
Triad Altered mental status Ataxia Nystagmus, conjugate faze palsy DOES NOT cause asterixis
476
Chalazion
Painful swelling --> nodular rubbery lesion Is a chronic granulomatous condition happening when meibomian gland becomes obstructed - chronically can be due to sebaceous carcinoma Need to do biopsy-histo to see what it is so make sure it's not basal cell carcinoma
477
Hordeolum
Stye Acute infection of gland of eyelid Use antistaph meds
478
Indicators for severity in pancreatitis
Hgb | Cr
479
Clubbing
Chronic hypoxia NOT in COPD though If COPD has clubbing, there is another hypoxic event happening on top of the COPD
480
UA vs. NSTEMI vs. STEMI features on EKG and Labs
UA - (-) trop, nonspecific EKG NSTEMI - (+) trop, ST depressions, T wave inversions STEMI - (+) trop, Q waves
481
Electrolyte abnormalities of chronic alcoholism
Hypomagnessemia Hypokalemia Hypophosphatemia
482
Hypomagnesia - consequences - importance of Mg - how to correct - causes of it
Can cause refractory hypokalemia Mg is important cofactor for K uptake and maintenance of intracellular K levels NEED TO GIVE Mg first for hypoK Get hypo Mg also with - diuretics - poor nutritoin - malabsorb - alcohol
483
Hypophosphatemia effects
Weakness Rhabdomyolysis Paresthesias Respiratory failure
484
Hypoalbuminemia effects
Decreased oncotic pressure --> edema Hypocalcemia (b/c Ca bound by albumin)
485
INTRAVASCULAR hemolytic anemia | - panel of lab results
Increased - indirect bilirubin - urinary urobilinogen - hemoglobinemia - hemoglobinuria - LDH Decreased - Haptoglobin (binds up the free Hg)
486
Tumors almost NEVER mets to brain
Non-melanomatous skin cancer Oropharyngeal cancer Esophageal carcinoma Prostate cancer
487
Do you screen for bladder cancer?
Never Even w/ smoking history or family history
488
Common cause of lactic acidosis in pts w/ atherosclerotic disease and afib
Bowel ischemia Lactic acidosis b/c lactate is end product of anaerobic metabolism in ischemic tissue
489
Common infectious cause of adrenal insufficiency
TB Histoplasmosis Coccidiodomycosis Cryptococcosis Sarcoidosis
490
What should all pts complaining of asthma like sx be questioned about as well?
Reflux! GERD in 75% of asthma pts
491
Dystonia
sustained muscle contraction resulting in twisting, repetitive mvmts or abnormal postures Torticolis is a focal dystonia
492
Akathisia
Sensation of restlessness causing pt to move frequently
493
Athetosis
Slow writing mvmts affecting hands and feet Characteristic of Huntingtons and goes wtih chorea
494
Myoclonus
involuntary jerking of muscle or muscle group
495
``` Sore throat Odynophagia Drooling Progressive airway obstruction Stridor Fever ```
Epiglottitis! Common pathogens: - Hib - Strep pyogenes
496
BNP diagnosing CHF
> 100 pg/mL diagnoses CHF w/ high sensitivity
497
Common causes of thyrotoxicosis
You get increased TH but decreased radioactive iodine uptake - Subacute lymphocytic thyroiditis (painless) - postpartum relation usually - Subacute granulomatous thyroiditis (De Quervain's) - Levothyroxine OD - Iodine-induced thyrotoxicosis - Struma ovarii (teratoma in ovary producing thyroid hormones)
498
When do you think pancreatic pseudocyst?
A few weeks (~4) post acute or chronic pancreatitis Dx via US Resolves spontaneously; only drain if persists for more than 6 weeks, infected, or > 5cm
499
Best way to dx disc herniation/abscess
MRI of spine
500
Bacterial overgrowth in small bowel has what manifestations?
Assoc w/ hx of ab surgery ``` Tetany (b/c vit D deficiency so dec Ca) Night blindness (vit A def) Neuropathy (vit B12 def) Dermatitis Arthritis Hepatic injury ```
501
Subclavian atherosclerosis prefers which artery?
Left artery subclavian
502
Myasthenia crisis
Life-threatening Weakness of resp and pharyngeal muscles Usually caused by intercurrent infection Can be caused by anticholinesterase overdose Need to do: - endotracheal intubation - w/d anticholinesterases for several days
503
Osteomyelitis - most common cause
Staph aureus
504
Osteomyelitis - sexually active
N. gonorrhae | Septic arthritis more common
505
Osteomyelitis - Diabetics and IV drug users, stepping on a nail
Pseudomonas aeruginosa Serratia For IV drug users, spine is usual place for osteomyelitis Will have tenderness to gentle percussion over spinous processes of involved vertebrae
506
Osteomyelitis - Sickle cell
Salmonella
507
Osteomyelitis - prosthetic replacement
Staph aureus | Staph epi
508
Osteomyelitis - vertebral disease
M. tuberculosis (pott's)
509
Osteomyelitis - cat and dog bites or scratches
Pasteurella multocida
510
Flank pain Poor urine outflow w/ intermittent episodes of high volume urination UA - occasional RBCs, WBCs, NO CASTS
Obstructive uropathy due to renal calculi
511
Anterior blood supply to brain
Internal carotid --> branches --> ACA, MCA
512
Posterior blood supply to brain
Paired vertebral arteries --> basilar artery --> paired PCA
513
ACA stroke
``` Contralateral motor and/or sensory deficits more in the lower limb Urinary incontinence Gait apraxia Primitive reflexes Abulia (lack of will/initiative) Paratonic rigidity ```
514
MCA stroke
Contralateral motor and/or sensory deficits more in the upper limb Homonymous hemianopia IF dominant lobe (left) --> aphasia IF nondominant lobe (right) --> neglect and/or anosognosia
515
PCA stroke
Homonymous hemianopia Alexia w/o agraphia (dominant hemi) Visual hallucinations (Calcarine cortex) Sensory sx (thalamus) 3rd nerve palsy w/ paresis of vertical eye mvmt Motor deficits *cerebral peduncle, midbrain)
516
Internal carotid stroke
MCA stroke + amaurosis fugax
517
Lacunar infarcts
Pure motor hemiparesis Pure sensory stroke Dysarthria-clumsy hand Ataxic hemiparesis
518
Difference in PFTs b/n Ankylosing spondylitis and restrictive lung diseases
Both have decreased - FEV1 - FVC - FEV1 / FVC AS has increased FRC b/c fixation of chest wall in inspiratory position Restrictive lung disease has decreased FRC
519
Lupus anticoagulant features
PTT normal or increased vWF, bleeding time, platelet count normal D-dimer normal or high
520
``` Pain with neck extension Trismus (inability to open mouth normally) Fever Sore throat Dysphagia Odynophagia ```
Retropharyngeal abscess Do CT of neck
521
Best initial test for squamous cell carcionma of mucosa of head and neck
Panendoscopy - esophagoscopy - bronchoscopy - laryngoscopy to detect primary tumor
522
Signs of cerebellar dysfunction
``` Ataxia Broad based gait Dysmetria Intention tremor Difficulty with rapid alternating movements Nystagmus Muscle hypotonia ```
523
Causes of atypical pneumonia
``` M. pneumo C. pneumoniae Legionella Coxiella Influenza ```
524
Erysipelas
Specific type of cellulitis Inflammation of superficial dermis --> prominent swelling - sharply demarcated, erythematous, edematous, tender Usually caused by S. pyogenes
525
Cellulitis after a puncture wound- what org do you suspect?
Pseudomonas
526
MPGN type 2 - pathophysiology
Unique among glomerulopathies Caused by IgG antibodies (C3 nephritic factor) against C3 convertase of alternative complement path - antibodies reacting w/ C3 convertase --> persistent complement activation --> kidney damage
527
Common causes of UTIs in ppl w/ catheters | - which ones produce alkaline urine?
Alkaline: - Proteus Candida Pseudomonas Klebs
528
Pleural fluid glucose: < 30 mg/dL 30-50 mg/dL
< 30 mg/dL - empyema or rheumatic effusion - decreased glucose b/c high met activity of WBC in fluid 30-50 mg/dL - malignancy - lupus - esophageal rupture - TB
529
Pica causes
``` Iron deficiency (blood loss) Psych disease ```
530
Vit D toxicity
Constipation Ab pain Polyuria Polydipsia
531
Pneumococcal (PPSV) vaccine indications
Given once all adults >=65 Give to all adults < 65 w/ chronic diseases: - Cardio - pulm - hepatic - renal - metabolic (eg diabetes) - immunosuppression Need booster 5 years later if vaccinated before age 65 HIV pts whose CD4 > 200 need pneumovax
532
Granulomatosis w/ polyangitis - Features - Tx
Triad - systemic vasculitis (subQ nodules, palpable purpura, pyoderma grangenosum) - upper and lower airway inflammation (saddle nose deformity, epistaxis, otitis, sinusitus) - glomerulonephritis (RBC casts, proteinuria, sterile pyruia) +c-ANCA (vs proteinase-3) Tx w/ cyclophosphamide
533
Proximal weakness of lambert eaton vs. polymyositis
Both have proximal weakness CPK high in polymyositis CPK normal in LE Polymyositis - anti Jo1 and ANA Lambert eaton - anti voltage gated Ca channels
534
Cocaine use - Clinical features - Complications
Features - tachy, HTN, dilated pupils - chest pain b/c coronary vasoconstrict - psychomotor agitation, seizures Complications: - MI - Dissection - Intracranial hemorrhage
535
Temporal arteritis pt - tx w/ steroids - now comes in with myopathy - what does pt have? If no tx w/ steroids for TA and came in with morning stiffness and pain in shoulders, hip girdle and neck, what does pt have?
Myopathy - steroid-induced myopathy - ESR normal Pain/stiffness - polymyalgia rheumatica - in 50% of TA - ESR elevated
536
Choriocarcinoma loves to spread to
Lungs
537
RCC triad
Hematuria Abdominal Mass Flank Pain Also can have left sided scrotal varicocele
538
Abnormal labs in Paget's
Increased ALP Urinary n telopeptide
539
Dermatomyositis - Findings - Autoantibody - Associations
Findings - proximal extensor muscle inflammatory myopathy - periorbital edema = hemiotrope sign - violaceous poikloderma on chest and lateral neck = shawl sign - poikloderma on knuckles, elbows, knees = Gottron's sign - Gottron's papules = lichenoid papules over joints = pathognomonic - more in females Autoanitbody - anti-Mi-2 (against helicase) Associations - Malignancies (ovarian, breast, lung, urogenetal female)
540
Inflammatory diseases assoc w/ aoritc aneurysms
``` Behcet Takayasu arteritis GCA Ankylosing spondylitis RA Psoriatic arthritis Relapsing polychondritis Reactive arthritis ```
541
Inflammatory disease assoc w/ carpal tunnel
RA Sarcoidosis Amyloidosis
542
Criteria for starting long term O2 therapy in COPD
PaO2 < 55 mmHg OR SaO2 < 88% on room air Pt w/ cor pulmonale OR Hct > 55% If become hypoxic during exercise or sleep
543
Grave's disease | - specific signs
Exophthalmos Pretibial myxedema Thyroid bruit
544
HYPERthyroidism features
Nervousness, insomnia, irritability Hand tremor, hyperactivity, tremulousness Excessive sweating, heat intolerance Weight loss, increased appetite Diarrhea, frequent defecation Palps Muscle weakness
545
Graves Proptosis pathophys
Autoimmune attack on extraocular muscles Lymphocytes infiltrate EOM and orbita fat --> edema, proliferaion of local interstitial fibroblasts, and deposition of glycosaminoglycans --> fibrosis and increased edema w/ EOM enlargement
546
Thyroid storm
Med emergency usually precipitating factor like infection, DKA or stress high mortality rate ``` Fever Tachy Agitation or psychosis Confusion N/V, diarrhea ``` Tx - supportive (IV fluids, cooling blankets, glucose) - + antithyroid agents - b-blockers
547
Myxedema coma
Depressed state of consciousness + HYPOthermia + respiratory depression Can develop after years of severe untreated hypoTh Med emergency Tx - supportive to maintain BP and respiration - IV thyroxine and hydrocortisone
548
HYPOthyroidism features
Fatigue, weakness, lethargy Menorrhagia, wt gain Cold intolerance Constipation Slow mentation, inability to concentrate Muscle weakness Depression Diminished hearing Dry skin, coarse hair, hoarseness, nonpitting edema, Bradycartia Goiter
549
Hashimoto's thyroiditis
Rubbery, nontender goiter Antimicrosomal antibodies Can also have increased LDL, decreased HDL, normocytic anemia
550
Papillary carcinoma of thyroid - Features - Tx
MOST COMMON Least aggressive RIsk factor: hx radiation to head/neck Spreads via lymphatics in neck - distant mets are rare Tx - lobectomy w/ isthmusectomy - total thyroidectomy if tumor > 3 cm, bilateral, advanced, or distant mets - TSH suppression theapy, radioiodine therapy
551
Follicular carcinoma of the thyroid - Features - Tx
``` Loves to absorb I Prognosis worse than follicular spread HEMATOGENOUS Distant mets common Tumor extension past capsule distinguishes it from benign adenoma ``` Tx - Total thyroidectomy - Postop I ablation
552
Medullary carcinoma of the thyroid - Features - Tx
1/3 assoc w/ MEN II Arises from parafollicular C cells - makes calcitonin Stains w/ congo red More malignant than follicular cancer! Tx - Total thyroidectomy
553
Anaplastic carcinoma of the thyroid - Features - Tx
Mostly in elderly Highly malignant CAn arise from longstanding follicular or papillary thryoid carcinoma Death usually in months Tx - chemo and radiation - palliative surgery for airway
554
Hurthle cell tumor
Variant of follicular cancer but more aggressive Spread by lypmhatics Tx - total thyroidectomy
555
Felty syndrome
Form of RA w/ splenomegaly and granulocytoenia Usually happens if A present fore more than 10 years
556
Lab values w/ glucocorticid use
Decrese: - Eosinophil - Lymphopenic Increase bone marrow release and mobilize marginated neutrophil pool (neutrophilia)
557
What makes a Q wave pathologial?
If it is greater than 1/3 of the R wave
558
Albumin charge change | - Example w/ Ca
Increase pH of blood - more negative charge on albumin - increase affinity to Ca - increase albumin-bound ca - decreases levels of ionized calcium
559
Hypocalcemia signs
``` Crampy pain Paresthesias Perioral tingling Tetany Carpopedal spasm Seizures Prolongation of QT interval on EKG ```
560
Hypo K + alkalosis + normotension - what do you suspect?
``` Surreptitious vomitting (urine Cl low) Diuretic abuse (Cl urine high) Bartter syndrome (Urine Cl high) Gitelman syndrome (Urine Cl high) ```
561
Presbycusis
Sensorineural hearing loss w/ age symmetrical high freq hearing impairment
562
Otosclerosis
Chronic conductive hearing loss w/ bony overgrowth of stapes Usually starts as low freq hearing loss
563
Pancoast tumor
Shoulder pan radiating into armin ulnar distribution Caused by tumor ivasion of 8th cervical - 1st thoracic nerves
564
What can an apical pulmonary tumor cause in terms of symptoms?
Horner's - sympathetic trunk compression Pancoast - brachial plexus compression Hoarse voice - R recurrent laryngeal N compression SVC syndrome - compress SVC ad decrease blood return from head
565
Normal distribution of statistical values
Mean = median = ode
566
Positive skew (tail on right) distribution
Mean > median > mode
567
Negative skew (tail on left) distribution
Mean < median < mode
568
Rapidly developing hirsutism - Best test to dx - how to interpret the results?
Suggestive of androgen-sereting neoplasm of adrenal or ovary Serum testosterone and DHEAS (sulfated form of DHEA) Increased testosterone, normal DHEAS = ovarian source Increased DHEAS, normal testosterone = adrenal source DHEA is secreted from both ovaries and adrenals DHEAS is made only in adrenals
569
Hairy cell leukemia - What is it? - Markers?
Type of B lymphocytic derived chronic leukemia Tartrate-resistant acid phosphatase stain CD11c marker
570
Hypo K+ effects - physio effects - EKG
``` Weakness Fatigue Muscle cramps Flaccid paralysis Hyporeflexia Tetany Rhabdomyolysis Arrhythmias (afib, torsades) ``` Broad flat T waves, U waves, ST depression
571
Cystinuria
Impaired amino acid transport of dibasic amino acids (csteine, lysine, argiine, ornithine) Cysteine is poorly soluble in water --> get renal stones + urinary cyanide nitroprusid test
572
Cysteine kidney stones
Usually due to cystinuria Hard and radioopague stones UA shows hexagonal crystals + urinary cyanide nitroprusside test
573
Pt presentation: - lower ab pain, bloody diarrhea, tenesmus over several weeks - acute fever, leukocytosis, hypoTN, tachy What are you worried about?
Probably has undiagnosed IBD Now has toxic megacolon Can be lethal
574
Dx toxic megacolon
Radiographic evidence of colonic distension + 3 of the below: - Fever > 38C - HR > 120 - Neutrophilic leukocytosis > 10,500 - Anemia Plus at least one of the below: - vol depletion - altered sensorium - electrolyte disturbance - hypoTN Dx w. abdominal Xray to confirm dilated colon > 6cm
575
SIADH tx
Hypertonic (3% saline) SLOWLY Rate of correction not more than 0.5-1 mEq/L/hr
576
Normal pressure hydrocephalous
Abnormal gait Incontinence Dementia (memory loss w/o focal neurologic changes)
577
Toxoplasmosis CNS
Mass lesions Usually multiple In basal ganglia and at cortical grey[white matter interface Ring-enhancing
578
Common causes of brain abscesses
Anaerobic Strep | Bacteroides
579
On CT: - isolated, round smooth bordered ring enhancing intracranial lesion on contrast CT - immunocomp pt - known extracranial bacterial infection
this is a brain abscess
580
Chlamydia trachomatis screening
Screen all sexually active women age 24 and younger Screen other asymptomatic women at increased risk for STIs
581
Sources for PE clots
LE DVT most common - proximal deep veins (iliac, femoral, popliteal) = > 90% - calf vein is less than proximal
582
Cavernous sinus thrombosis - symptoms - how do you tell the difference w/ orbital cellulitus?
CST happens b/c facial/ophthalmic venous sys is valveless ``` Headache Binocular palsies Periorbital edema Hypoesthesia or hyperesthesia in V1/V2 distribution CAN BECOME BILATERAL ``` Dx w/ magnetic resonance venography Orbital cellulitus DOES NOT have headache, bilateral cranial nerve findings, or bilateral periorobital edema
583
VIPoma
``` Diarrhea Hypo K --> leg cramps Decreased H+ in stomach Dehydration Ab pain Wt loss Facial flushing Redness ``` Tx - ocretotide to help w/ diarrhea
584
Glucagonoma
Necrotizing dermatitis Wt loss Anemia Persistent hyperglycemia
585
Role of spleen in immune system
Blood borne antigens enter spleen via splenic A --> phagocytosed by dendritic cells in WHITE PULP Dendritic cells present antigens on MHC 2 --> TH cells --> activated TH cells go to marginal zone of spleen --> contact B cells in primary follicles B cell activation --> secondary follicles --> germinal centers w/ lots of plasma cells form --> make antibodies --> bind antigen --> facilitate phagocytosis by opsoniziation
586
Leukocyte adhesion defect
Chemotaxis impaired Autosomal recessive Defect in integrin B2
587
``` Osteonecrosis = aseptic necrosis = avascular necrosis = ischemic necrosis = osteochondritis dessicans ```
Vasculature of bone disrupted --> bone and bone marrow infaction Bone can't remodel --> trabecular thinning --> collapse of affected bone Use MRI to dx (most sensitive) Precipitating factors: - steroid use - chronic EtOH - hemoglobinopathies - trauma - antiphospholipid syndrome
588
Liver main functions
Synthetic - make clotting factor, cholesterol, proteins Metabolic - met drugs and steroids - detoxify Excretory - bile excretion
589
Isolated systolic HTN
Caused by decreased elasticity of arterial wall - increase in SBP but not DBP - get widened pulse pressure Always treated b/c assoc w/ increased risk for CV events Tx: thiazide, ACE-I or CCB
590
What abnormal labs are indications for thyroid function tests?
Hyperlipidemia (increased LDL) Unexplained hypo Na Elevated serum muscle enzymes Anemia (normocytic, normochromic)
591
How do you tell between NPH and atrophy of brain?
Sulci - enlarged in atrophy, not enlarged in NPH Both have increased ventricle size Clinical symptoms different though
592
MMSE < what is suggestive of dementia
24
593
Pt w/ PID - what else should you test them for?
HIV Syphilis Hep B Pap smear Hep C if IVDU
594
Liver main functions
Synthetic - make clotting factor, cholesterol, proteins Metabolic - met drugs and steroids - detoxify Excretory - bile excretion
595
Tx calcium stones
Hydrocholorthiazide (NOT FUROSEMIDE) Hydration
596
Typical renal colic but no stone on flat film of abdomen and pelvis - what do you consider?
1. radiolucent stone (uric acid) 2. calcium stones < 1-3 mm in diameter 3. Non stone causes (obstruction via blood clot, tumor)
597
Tx uric acid stones
Hydration Alkalnize urine - oral KHCO3 or potassium citrate Low purine diet w/w/o allopurinol
598
Secretin stimulation test
Done if suspected Z-E but gastrin values not diagnostic Secretin stimulates release of gastrin from GASTRINOMA cells Normally, secretin ----| g cell and gastrin release
599
Indications for parathyroidectomy in hyperparathyroidism
Symptomatic OR Asymptomatic + 1 of features below: - serum calcium `> 1 mg/dL above upper limit of normal - < 50 yo - Bone mineral density < 1-2.5 at any site - reduced renal function
600
Small bowel obstruction: | Proximal vs. distal obstruction
Proximal - frequent vomiting, severe pain, minimal ab distention Distal - less frequent vomitting, LOTS Of ab distention
601
Tx hypo PTH
Calcium gluconate in severe cases Oral Ca Vit D supplementation
602
What is diagnostic of hyper PTH?
Chloride/phosphorus ratio of > 33 Cl high secondary to renal bicarb wasting
603
Causes of Cushing's syndrome
- Iatrogenic (prednisone) - ACTH secreting adenoma of pituitary --> bilateral adrenal HYPERPLASIA - Adrenal adenoma - Ectopic ACTH from tumor
604
ACTH secreting adenoma of pituitary--> changes in adrenals?
Bilateral adrenal hyperplasia
605
Helpful signs for increased cortisol in a pt
Impaired collagen production - easy bruising - striae Myopathy Virilization Anti-insulin effects (glucose intolerance) Protein catabolism - periph muscle wasting Impaired immunity Enhance catecholamine activity - HTN
606
Whcih cushings syndromes do you see masculinization?
ACTH secreting adenoma | Ectopic ACTH
607
Pheochromocytoma - features - labs
Features - HTN - headache - sweating - tachy, palps - anxiety Labs - HYPER glycemia, lipidemia - HYPO K
608
Rule of 10s for pheochromocytomas
FaCEBk Me ``` 10% are... Familial Children Extraadrenal Bilateral Malignant ```
609
Are plasma or serum emtanephrines better for pheo dx?
Plasma
610
What does it mean if epi levels are high in suspected pheochromocytoma?
Tumor is in adrenal or near adrenal (organ of zuckerandl at aortic bifurcation) Nonadreanal tumors can't methylate norepi --> epi
611
MEN I
Parathyroid hyperplasia Pancreatic islet cell tumor - ZE, insulinoma Pituitary tumors
612
MEN IIa
Medullary thyroid carcionma Pheochromocytoma Parathyroid
613
MEN IIb
Mucosal neuromas + Marfanoid habitus Medullary thryoid carcinoma Pheochromocytoma
614
Causes of primary hyper ALDO
- Conn syndrome = adrenal adenoma making aldo - Adrenal hyperplasia - Adrenal carcinoma
615
Dx primary hyper ALDO
screen w/ early AM plasma aldosterone to plasma renin activity ratio --- > 30 --> hyperaldo Saline infusion test - should dec aldo but won't in primary aldo Oral sodium loading - high NaCl diet for 3 days - High urine aldo + high urine Na = primary aldo
616
Why is it impt to differentiate adrenal adenoma from hyperplasa? How do you tell the difference?
HTN assoc w/ hyerplasia NOT benefited by bilateral adrenalectomy HTN assoc w/ adenoma is usually cured by removal of adenoma Adrenal venous sampling for aldo levels - high aldo on one side indicates adenoma - high level on both sides = bilateral hyperplasia
617
#1 cause of Addison's disease worldwide? #1 cause of adrenal insufficiency?
Addison - TB Insufficiency - exogenous glucocorticoids, abrupt stop in usage
618
Clinical findings of adrenal insufficiency
``` Wt loss Weakness Pigmentation Anorexia Nausea Postural HYPO TN Ab pain Hypo glycemia ```
619
What appears in primary but not secondary adrenal insufficiency?
Hyperpigmentation | Hyperkalemia
620
Alcoholic liver cirrhosis | - Labs
Labs - AST > ALT by 2x BUT usually less than 500 IU/L. If more, some other hepatic injury happened - modest hepatic transaminitis - modest inc GGT
621
Why does AST increase more than ALT in alcoholic hepatitis?
Hepatic deficiency of pyridoxal-6-P, a cofactor for ALT enzymatic activity
622
Pleural fluid studies in pleural effusion | - what studies tell you when you need a chest tube?
pH - low pH usually means empyema - need thoracostomy w/ low pH Glucose - need thoracostomy w/ low glucose - low in RA, TB, empyema, malignancy, esophageal rupture Protein Gm stain Cell count Cytology
623
Empyema
collection of pus within a naturally existing anatomical cavity, such as the lung pleura Usually in context of pneumonia + empyema if: - has pus - has + gm stain - has pH < 7.2 but serum pH is normal
624
Blood in urine - at beginning of stream - at end of stream - throughout stream
Beg: - injury in urethra (urethriti, for ex) End: - disease in prostate or bladder All throughout: - Ureter or kidney disease
625
Polyarthralgia Tenosynovitis Painless vesiclopustural skin lesions
Dissemnated gonococcal infection
626
What side of the heart is most restrictive cardiomyopathy on?
Right
627
When is it best to use bronchoalveolar lavage?
Eval suspected malignancy and opportunistic infection (eg PCP)
628
Bilateral sacroilitis LImited spine mobilit > 3 mo duration 20-30 yo
Ankylosing spondylitis
629
Modified acid-fast stin showing oocysts in stool suggestive of...
Cryptosporidium parvum Isosporal belli (not as common in US)
630
Presence of spores in stool | Severe malabsorption and persistent diarrhea in HIV pts
Microsporidia Enterocytozoon bieneusi Encephalitozoon intestinalis
631
Symptoms of intracranial hypertension (> 20 mm Hg)
``` Headaches worse in AM N/V early in day Vision changes Papilledema Cranial nerve deficits Somnolence Confusion Unsteadiness Cushing's reflex (hypertension and bradycardia) ```
632
New onset RBBB can suggest....
PE
633
Dietary recommendation for pts w/ renal calculi
1. Decreased dietary protein and oxalate 2. Decreased sodium intake 3. Increased fluid intake 4. Increased dietary calcium Vit C will increase oxalate stone formation -- don't take too much! Esp if have renal failure
634
Herpetic whitlow
Common viral infection of hand Caused by HSV1 or 2 Self limiing Health care workers coming in direct contact w/ infected orotracheal secretions are at high risk of developing whitlow
635
Most important cause of torsades de pointes
Hypo Mg
636
Prolonged QRS suggests... Prolonged QT suggests...
QRS:bradyarrhythmia (eg BBB) QT: tachyarrhythmia
637
Older pt with new diagnosed achalasia + wt loss - what do you do next for the pt?
Endoscopy Achalasia could be secondary to systemic diseases (Chagas, amyloidosis, sarcoid) or due to mass at GE junction Use endo to rule out mass!
638
Dawn phenomenon vs. Somogyi effect
Both cause morning hyperglycemia Dawn - due to inc in nocturnal secretion of GH Somogyi - rebound response to nocturnal hypoglycemia --> morning hyperglycemia
639
Diagnosis of diabetes
1 of the following: - 2 fasting glucose > 125 mg/dL - 1 gluc level = 200 mg/dL w/ symptomes - Inc gluc level on oral gluc tolerance testing - HbA1c > 6.5%
640
Optimal tx for DM type 2 pts
Glycemic control BP < 130/85 LDL < 100, HDL > 40 Smoking cessation Daily aspirin (if not contraindicated)
641
#1 COD in diabetic patients
Coronary artery disease
642
Autonomic neuropathy of DM
Impotence in men Neurogenic bladder - retention, incontinence Gastroparesis - chronic N/V, early satiety Constipation and diarrhea Postural hypoTN
643
Defense against HYPOglycemia
Insulin decreases Glucagon increases Epinephrine increases next Cortisol also helps Glucose < 50 --> symptoms
644
Main organ at risk w/ hypoglycemia
Brain Brain can't use free fatty acids as energy source
645
Hypoglycemic unawareness
Diabetics w/ severe neuropathy --> autonomic response (epi) to decreased glucose is not activated - these reactions are supposed to be sweating, tremors, increased BP and pulse, anxiety, palps Can lead to neuroglycopenic symptoms - headache, visual distrubances, confusion , seizures, coma Therefore, if hypoglycemic, can go into seizure or coma
646
Whipple's triad
Used to dx Insulinoma Hypoglycemic sx broung on by fasting Blood glucose < 50 during symptomatic attack Glucose admin brings relief of sx
647
Where are most gastrinomas?
Gastrinoma triangle - cystic duct (superior) - junction of 2nd and 3rd duodenum portions (inferior) - neck of pancreas (medially)
648
Dx Zollinger Ellison syndrome
Secretin injection test - usually prevents gastrin secretion - ZES, gastrin will increase a lot after secretin
649
Glucagonoma manifestations
``` Necrotizing migratory erythema (below waist) Glossitis Stomatitis BM Hyperglycemia ```
650
Somatostatinoma features
Malignant, poor prognosis Gallstones Diabetes Steatorrhea
651
VIPoma features
Watery diarrhea --> dehydration, hypo K, acidosis Achlorhydria (VIP ---| gastric secretion) Hyperglycemia Hypercalcemia
652
Bartonella henselae - features - treatment
Localized cutaneous and lymph node d/o near site of inoculum Vesicular, erythematous and papular phases - can be pustular or nodular Dx w/ clinical or + B henselae antibody test or tissue w/ + Warthin-Starry stain Tx azithromycin
653
Toxic epidermal necrolysis - features - vs. Stevens Johnson? - drug causing
Erythematous mobilliform eruption ----> exfoliation of skin (+ Nikolsky's sign) > 30% of body skin involved 10% involved only in SJS Oral mucosa has blisters ``` Common drug causes: sulfa barbs phenytoin NSAIDs ```
654
Best imaging for vertebral osteo
MRI can also see if there is abscess or cord compression
655
Most common site of ulnar nerve entrapment
Elbow, medial to epicondylar groove
656
Gene mutation for hemochromatosis
AR disease C282Y on chromosome 6
657
Complications of GCA
``` Aortic aneurysms (do serial CXR) Blindness ```
658
Causes of membranous glomerulonephritis
``` Hep B, C Syphilis Gold Penicillamine SLE Rheumatoid ```
659
What bacteria can cause food poisoning in short time? How do you tell the difference between what bacteria it is?
Bacteria w/ PREFORMED toxins - Staph aureus - B. cereus Tell by what food the person ate Staph: - poultry and eggs - meats - mayos - pastries - milk and daily B. cereus: - starchy foods (rice)
660
Generalized myxedema of hypothyroidism | - where can it go?
Deposition of mucopolysaccharides (matrix substances, mucin) - perineurium of median nerve and tendons passing through carpal tunnel - skin - heart - nerves
661
Carpal tunnel due to deposition of substances. What do you see this in?
Hypothyroidism Dialysis (beta-2-microglobulin)
662
Accumulation of fluid in carpal tunnel can cause carpal tunnel syndrome. When does this happen?
Preggers 3rd trimester
663
Carpal tunnel syndrome due to: - tenosynovial inflammation - synovial tendon hyperplasia When do each happen?
Tenosynovial - RA Hyperplasia - acromegaly
664
Essential measures in managemetn of DKA
Restore intravascular volume - NS Correct hyperglycemia - Regular insulin IV Correct electrolyte abnormalities - K correction crucial Tx precipitating factors - use antibiotics for infections
665
Baker cyst
Assoc w/ RA Tender mass in popliteal fossa Happen b/c excessive fluid production by inflamed synovium Can burst and look like a thrombophlebitis (DVT)
666
Heart burn, wt loss, chest pain unrelated to eating, dysphagia, regurg of food What is this?
Esophageal cancer, most likely Use barium swallow, EGD and biopsy, and PET scan to evaluate
667
Common etiologies of constrictive pericarditis
Idiopathic Viral Cardiac surgery and radiation therapy TB pericarditis
668
Clinical presentation of constrictive pericarditis
Fatigue and dypsnea on exertion Periph edema and ascites Increased JVP Pericardial knock
669
Diagnostic findings of contrictive pericarditis
Increased pericardial thickening and calcification Prominent x and y descents on JVP
670
How do you first evaluate pts w/ probably prostatic hyperplasia?
Hx Rectal exam Urinalysis Serum Cr measurement ----> if increased, US of kidneys or CT of abdomen for reason for obstruction, hydronephrosis or underlying renal disease
671
#1 middle ear pathology in pts w/ acquired immunodeficiency
serous otitis media conductive hearing loss dull tympanic membrane that is hypomobile
672
How best do you alter course of diabetic NEPHROpathy once azotemia occurs?
Intensive BP control < 130/80 ACE inhibitors preferred tx You would want to control glucose once proteinuria/albuminuria happens
673
Suddenet onse vertigo, vomiting, occipital headache in HTN pt
Cerebellar hemorrhage (strong suspicion) ``` Can also see: 6th nerve paralysis conjugate deviation Blepharospasm Coma ```
674
If a young pt presents w/ stroke, look for... Order...
Vasculitis Hypercoag state Thrombophilia ``` Order Protein C, Protein S, antiphospholipid antibodies Factor 5 leiden mutation ANA ESR Rheumatoid factor VDRL/RPR Lyme TEE ```
675
PUpillary findings in intracerebral hemorrhage and corresponding level of involvement
Pinpoint pupils = pons Poorly reactive pupils = thalamus Dilated pupils = putamen
676
Top causes for COPD exacerbation
Smoking Environmental pollutants/exacerbators Pneumonia - S. pneumo - H. influenza - M. catarrhalis
677
How do you dx renal artery stenosis?
Captopril renal scan
678
Parkinson's disease - pathophys - how this is logical for treatment
Dopaminergic path of basal ganglia is compromised Cholinergic system operate unoppossed Lewy bodies (hyalin inclusion bodies) are key neuronal finding in brains Tx will enhance dopamine's influence or inhibit Ach influence
679
When do you not do a LP on a suspected SAH?
If slit lamp exam reveals papilledema May cause herniation - repeat CT scan before LP
680
Parkinson's clinical features
Pill rolling tremor @ rest - worse w/ emotional stress - gone w/ doing tasks Bradykinesia Cogwheel rigidity Shuffling gait Expressionless facies Dementia in advanced disease Personality changes early on - withdrawn, apathetic, dependent, depression
681
Complicated GERD - Manifestations - Diagosis
Manifestations - dyphagia - odynophagia - wt loss - bleeding - Fe deficiency anemia - typical sx: heartburn, regurg, bitter/sour taste Diagnosis - Endoscopy (esophagoscopy) - ---also do endo if complicated GERD or antacids/meds don't control the codition
682
Contraction alkalosis
Intracellular volume contraction Increased aldo functions to restore intravascular volume but also causes increased H+ and K+ loss --> alkalosis!
683
Thyroid myopathy
- predminant PROXIMAL symptoms - can have a tremor (action) - can happen in hyper or hypo thyroid
684
Central vs 7th nerve palsy of face
Central - forehead wrinkling is ok b/c LMN is bilaterally innervated by both UMN; one is knocked out, the other still works 7th nerve - LMN knocked out, doesn't matter that it is bilateral, the signal will not go through. So forehead and lower face both out.
685
Irreversible causes of dementia
``` Alzheimer's Parkinson's Huntington;s Multi infarct dementia Dementia w/ lewy bodies, Pick's disease Unresectable brain mass HIV dementia Korsakoff's PML CJD ```
686
Broca's aphasia
Comprehension ok, can't speak or write Posterior part of dominant frontal lobe infarct
687
WBC count in synovium of - crystal induced arthritis - septic arthritis
Crystal: 10-50,000 Septic: 50-150,000
688
#1 cause of prosthetic joint septic arthritis #2?
1 -Staph aureus 2 - Strep Salmonella can cause in elderlyand immunocompromised
689
#1 cause of septic arthritis in young sex active ppl
Neisseria gonorrhea
690
Syringomyelia - Characteristics - Pathophys - Acquired causes
Areflexic wakness in upper extremities Loss of pain and temp w/ preserved position and vibration in cape ditribution Presence of cord cavity that communicates w/ central canal of spinal cord Usually in lower cervical or upper thoracic region Acquired causes: - trauma - inflammaory spinal cord d/o - spinal cord tumors
691
Monoclonal gammopathy of undetermined significance
- NO anemia, hyper Ca, lytic lesions, and renal insufficiency - serum monoclonal protein < 3 g / dL - < 10% plasma cells in bone marrow Dx w/ metastatic skeletal bone x rays to exclude MM 1% risk of progression to MM
692
Multiple Myeloma
- Presence of anemia, hyper Ca, lytic lesions, and renal insufficency - Serum monoclonal protein > 3 g/dL - > 10% plasma cells in the bone marrow - Elevated beta-2 microglobulin
693
Dx amyloidosis
Serum Immunoelectrophoresis (SIEP) Biopsy ab fat pad, rectum, organ involved
694
Diagnostic test to dx MS
MRI - sensitive in ID demyelinating lesions in CNS - # lesions on MRI NOT necessarily proportional to disease severity or speed of progression
695
Gm - bacteria causing pneumonia
``` E coli klebs Pseudomonas Enterobacter Proteus Serratia Acinetobacter ``` Rare in healthy individuals
696
What space in the neck carries the highest risk of spreading an infection to the mediastinum?
Retropharyngeal space - between alar and prevetebral fascia
697
Complication of infection in paapharngeal space
Involvement of the carotid sheath --> erosion of carotid artery and jugular thrombohlebitis
698
What does it mean when it says toe webs are fissured and macerated?
Tinea pedis!
699
Complication of infection in paapharngeal space
Involvement of the carotid sheath --> erosion of carotid artery and jugular thrombohlebitis
700
What does it mean when it says toe webs are fissuredand macerated?
Tinea pedis!
701
Top causes for COPD exacerbation
Smoking | Environmental pollutants/exacerbators
702
Gold std for dx SAH
Xanthochromia | - results from RBC lysis and implies blood has been in CSF for hours and not due to traumatic tab
703
Parkinson's disease - pathophys - how this is logical for treatment
Dopaminergic path of basal ganglia is compromised Cholinergic system operate unoppossed Tx will enhance dopamine's influence or inhibit Ach influence
704
When do you not do a LP on a suspected SAH?
If slit lamp exam reveals papilledema May cause herniation - repeat CT scan before LP
705
Parkinson's clinical features
Pill rolling tremor @ rest - worse w/ emotional stress - gone w/ doing tasks Bradykinesia Cogwheel rigidity Shuffling gait Expressionless facies Dementia in advanced disease Personality changes early on - withdrawn, apathetic, dependent, depression
706
Progressive supranuclear palsy
Degenerative condition of - brainstem - basal ganglia - cerebellum Like parkinson's: - bradykinesia - limb rigidity - cognitive decline NOT like parkinson's - no tremor - ophthalmoplegia
707
Huntington's | - pathyophys
Autosomal dominant, chromosome 4 trinucleotide repeat Loss of GABA producing neurons in striatum
708
Huntington's - clinical features - diagnosis w/....
Chorea Altered behavior - irritable, personality changes, psychosis, OCD Dx w/ MRI - atroph of head of caudate - DNA testing confirms diagnosis
709
Seizure causes
4M's, 4I's Metabolic / electolyte disturbances - hypo Na, water intox, hypo glycemia, hyperglycemia, HYPO Ca, uremia, thyroid storm, hyperthermia Mass lesions - brain mets, tumors Missing drugs - noncompliance w/ antiseizures - w/d from EtOH, benzos, barbs Misc - Eclampsia - HTN encephalopathy Intoxications - cocaine, lithium, lidocaine, theophylline, Mercury, lead, CO Infections - septic shock, meningitis, brain abscess Ischemia - stroke, TIA Increased ICP - trauma
710
Alzheimer's pathophys
Decreased Ach synth --> impaired cortical cholinergic function Diffuse cortical atrophy on CT or MRI
711
Features of Cushings
``` Central obesity Hirsutisum Moon facies Buffalo hump Purple striae on abdomen Lanugo hair Acne Easy bruising ``` ``` HTN Diabetes Hypogonadism Masculinization in fems Proximal muscle wasting and weakness Osteoporosis Aseptic necrosis of femoral head ``` Depression Mania Decreased immunity
712
What is arousal dependent on? Cognition?
Arousal - Intact brainstem - reticular activating system in brainstem Cognition - cerebral cortex
713
Causes of delirium
SMASHED (Coma) + P DIMM WIT Postop state Dehydration and malnutrition Infection Meds - TCAs, steroids, anticholinergics, hallucinogens, cocaine Metals W/D states Inflammation, fever Trauma, burns
714
DDx of coma or stupor
SMASHED Structural brain pathology (stroke, bleed, tumor) Meningitis, mental illness Alcohol, acidosis Seizures, substrate deficiency (thiamine) Endocrine (Addisonian crisis, thyrotoxicosis, hypoTH), encephalitis, extreme disturbances in Ca, Mg, PO4 Drugs (opiates, barbs, benzos, sedatives), dangerous compounds (CO, CN, MeOH)
715
Unilateral fixed dilated pupil
Herniation w/ CN III compression This is anisocoria
716
Spinal lesion - how can you tell it is in the spinal cord?
Decrease in sensation below a sharp band in the abdomen/trunk Pinprick felt above level but not below it Pathognomonic for spinal cord disease Level of lesion = sensory level
717
Intranuclear ophthalmoplegia
Strongly assoc w/ MS Lesion in MLF --> = ipsilateral medial rectus palsy on attempted lateral gaze (can't adduct) = horizontal nystagmus of abducting eye (contralateral to size of lesion)
718
Diagnostic test to dx MS
MRI - sensitive in ID demyelinating lesions in CNS - # lesions on MRI NOT necessarily proportional to disease severity or speed of progression
719
Guillain Barre - characteristics - treatment
Inflammatory demyelinating polyneuropathy - ascending paralysis/weakness Usually follows infection: C. jejuni, Herpes, Mycoplasma, H. influenzae, HIV Tx: - NOT steroids b/c can be harmful - monitor pulmonary function - IV IgG if pt has significant weakness - plasmaphoresis
720
Principles of using Ultrasound
Images muscle, soft tissue, bone surfaces very well - can delineate interfaces b/n solid and fluid filled spaces - shos structures of organs Has trouble penetrating bone - has difficulty if there is gas b/n transducer and organ of interest (eg seeing pancreas under the bowel is hard)
721
Clinical features of neonatal lupus
Skin lesions Cardiac abnormalities (AV block, transposition of great vessels) Valvular and septal defects Increased risk for neonatal SLE if have anti-Ro (SSA) antibodies
722
Duchenne's Muscular Dystrophy - pathophys - lab values
X linked recessive - mutation on gene coding for dystrophin protein --> muscle cells die then No inflammation Labs: - Serum CPK HIGH
723
Tuberous sclerosis
AD Cognitive impairment Epilepsy Facial angiofibromas, adenoma sebaceum Retinal hamartomas Renal angiomyolipomas Rhabdoomyomas of heart
724
Sruge Weber
``` Acquired disease Presence of capillary angiomatoses of pia mater Facial vascular nevi (port wine stain) Epilepsy and mental retardation - tx epilepsy mainly ```
725
+ Ro (SS-A) and La (SS-B)
``` Sjogren's Subacute cutaneous Neonatal lupus Complement deficiency ANA negative lupus ```
726
Horner's syndrome
Ipsilateral - ptosis miosis anhidrosis Causes: - pancoast - internal carotid dissection - brainstem stroke - cervical spine injury
727
Poliomyelitis
- Anterior horn cells and motor neurons of spinal cord and brainstem involved - LMN involvement Asymmetrical muscle weakness Normal sensation
728
Peripheral vs central vertigo
Periph - hearing loss and tinnitus only occur here Central - focal neuro problems only occur here
729
Seronegative spondyloarthropathies HLA
HLA B27
730
Difference between lupus and drug-induced lupus
NO Renal or CNS involvement in drug induced lupus | - also no butterfly rash, alopecia, and ulcers
731
Pathophys of scleroderm
Cytokines stimulate fibroblasts --> abnormal amt of collagen deposition It is quantity of collagen that causes the problems assoc w/ this disease (composition of collagen is normal)
732
Most important thing to do in syncope workup
Differentiate b/n cardiac and noncardiac causes Always get an EKG
733
Seizure causes
4M's, 4I's Metabolic / electolyte disturbances - hypo Na, water intox, hypo glycemia, hyperglycemia, HYPO Ca, uremia, thyroid storm, hyperthermia Mass lesions - brain mets, tumors Missing drugs - noncompliance w/ antiseizures - w/d from EtOH, benzos, barbs Misc - Eclampsia - HTN encephalopathy Intoxications - cocaine, lithium, lidocaine, theophylline, Mercury, lead, CO Infections - septic shock, meningitis, brain abscess Ischemia - stroke, TIA Increased ICP - trauma
734
When do you tx a person who has 1st seizure
DO NOT Tx Tx w/ antieplipetics if EEG abnormal brain MRI abnormal Patient is in status epilepticus
735
Amyotrophic lateral sclerosis - features
D/o of anterior horn cells and corticospinal tracts UMN and LMN signs ``` Progressive muscle weakness noticed 1st in legs or arms Fasiculations Impaired speech and swallowing Respiratory muscle weakness Wt loss, fatigue ``` ``` OK throughout: bladder, bowel sensation cognition EOM sex functions ```
736
Features of Cushings
``` Central obesity Hirsutisum Moon facies Buffalo hump Purple striae on abdomen Lanugo hair Acne Easy bruising ``` ``` HTN Diabetes Hypogonadism Masculinization in fems Proximal muscle wasting and weakness Osteoporosis Aseptic necrosis of femoral head ``` Depression Mania Decreased immunity
737
Sjogren's classic triad
Can't see, can't spit, can't climb a tree Xerophthalmia Xerostomia Arthritis
738
Broca's aphasia
Expressive, nonfluent aphasia Speech is slow and needs effort Good comprehension of language
739
COnduction aphasia
Can't repeat | Pathology involves connections b/n Wernicke's and Broca's areas
740
Global aphasia
Disturbance in all areas of language function | Often assoc w/ R hemiparesis (damage of L hemisphere)
741
Spinal lesion - how can you tell it is in the spinal cord?
Decrease in sensation below a sharp band in the abdomen/trunk Pinprick felt above level but not below it Pathognomonic for spinal cord disease Level of lesion = sensory level
742
Principle of imaging of MRI
Good for tissues w/ many H nuclei and little density contrast Good to detect differences between 2 similar but not identical tissues Brain Muscle Connective tissue Most tumors
743
Principles of imaging of CT scans
CT of the head - detects infarction, tumors, calcifications, hemorrhage, bone trauma - dark structure = infarction and edema - bright structure = calcifications and blood
744
Causes of - dematomyositis - polymyositis - inclusion body myositis
derm - humoral immune response poly - cell mediated process inclusion body - cell mediated process
745
Fibromyalgia
Multiple trigger points (tender to palpation) 11/18 to diagnose Stiffness, body aches, fatigue, sleep disrupted, anxiety, depression
746
Clinical features of neonatal lupus
Skin lesions Cardiac abnormalities (AV block, transposition of great vessels) Valvular and septal defects
747
Positive ANA conditions
``` SLE RA Scleroderm Sjogren's syndrome Mixed connective tissue disease Polymyositis and dermatomyositis Drug-induced lupus ```
748
Risks for skin cancer
Recent changed mole - 10x Family hx melanoma - 8x Sun sensitivity - 2x Previous sunburns - 2x
749
Graft vs host disease
Common after bone marrow transplatntation T cell mediated immune response by donor Targets - skin - intestine - liver
750
+ Ro (SS-A) and La (SS-B)
Sjogren's Subacute cutaneous Neonatal lupus
751
SLE HLA
HLA DR2, 3
752
Sjogren's HLA
HLA DR3
753
RA HLA
HLA DR4
754
Facticious diarrhea (laxative abuse)
Watery Increase in freq and vol of stool 10-20 bowel mvmts / day Characteristic biopsy finding: - dark brown discoloration of colon w/ lymph follicles shining through as pale patches (melanosis coli) - can return to normal after laxative
755
Difference between lupus and drug-induced lupus
NO Renal or CNS involvement in drug induced lupus | - also no butterfly rash, alopecia, and ulcers
756
Pathophys of scleroderm
Cytokines stimulate fibroblasts --> abnormal amt of collagen deposition It is quantity of collagen that causes the problems assoc w/ this disease (composition of collagen is normal)
757
Ways to Dx sjogren's
ANA, Anti-Ro, Anti-La Schirmer test - filter paper to measure lacrimal gland output Salivary gland biopsy (lip or parotid)
758
If someone has dysphagia to solids only, what test do you do to eval?
Barium esophagram w/ tablet Liquid barium may not see obstruction
759
Rheumatoid arthritis clinical features
Inflammatory polyarthritis - NO DIP joints - PIP, MCP, wrists, knees, ankles, elbows - ulnar deviation of MCP - Boutonniere deformities of PIP joints - Swan neck deformities of MCP Morning stiffness Constitutional symptoms Cervical spine involvement - life threatening Pericarditis, conduction abnormalities, valvular incompetence Pleural effusions (low glucose) Episcleritis, scleritis
760
Poor prognostic indicators in RA
High RF titers SubQ nodules Erosive arthritis Autoantibodies to RF
761
Antibodies in RA Radiologic findings
rheumatoid factor Anti citrullinated protein antibody Erosions + periarticular osteoporosis
762
Sjogren's classic triad
Can't see, can't spit, can't climb a tree Xerophthalmia Xerostomia Arthritis
763
Pathogenesis of gout
Increased prod of uric acid - HGPRT deficiency - PRPP synthetase overactivity - chemo, hemolysis, heme malignancies Decreased excretion of uric acid - renal disease - NSAIDs, diuretics - Acidosis
764
Pathophys of gout
ECF saturated with uric acid --> uric acid crystals collect in synovial fluid --> IgGs coat monosodium urate crystals -- > phagocytosed by PMNs --> release inflammatory mediators and protelytic enzymes from PMNs --> Inflammation
765
Tophi
Happens w/ uncontrolled gout for > 10 years Aggregations of urate crystals surrounded by giant cells in an inflammatory reaction Common locations: - forearms - elbows - knees - achilles tendons - pinna of external ear
766
Diagnosis of gout
Joint aspiration + synovial fluid analysis - needle shaped and negatively birefringent urate crystals Radiographs - punched out erosions w/ overhanging rim of cortical bone
767
Pseudogout vs. gout
Different crystals Pseudogout usually in larger joints (knee) Pseudogout classically monoarticular
768
Pseudogout Dx
Joint aspirate - weakly + biregringent rhomboid crystals (calcium pyrophosphate) Radiograph - chondrocalcinosis (cartilage calcification)
769
Causes of - dematomyositis - polymyositis - inclusion body myositis
derm - humoral immune response poly - cell mediated process inclusion body - cell mediated process
770
Fibromyalgia
Multiple trigger points (tender to palpation) 11/18 to diagnose Stiffness, body aches, fatigue, sleep disrupted, anxiety, depression
771
Test to confirm prostatitis
Mid-stream urine sample Give antibiotics Prostate is tender and boggy
772
Treatment for acute mechanical back pain
Without significant neuro deficit - mobilization + NSAIDs (not bedrest) W/ lots of neuro deficit - early surgical decompression
773
Risks for skin cancer
Recent changed mole - 10x Family hx melanoma - 8x Sun sensitivity - 2x Previous sunburns - 2x
774
Graft vs host disease
Common after bone marrow transplatntation T cell mediated immune response by donor Targets - skin - intestine - liver
775
Methanol vs ethylene glycol poisoning
Methanol damages vision Ethylene glycol damages kidneys - oxalic acid binds ca --> hypoCa and Ca-oxylate crystal deposits - Glycolic acid injures the renal tubules
776
Pancreatic cancer clinical features - tumor in body/tail - tumor in head
Body/tail - pain adn wt loss Head - stetorrhea, wt loss, jaundice
777
Most sensitive screen for diabetic nephropathy
Random urine for microalbumin/creatinine ratio 24 hr collection best but inconvenient
778
Dx rotator cuff tear
MRI
779
Facticious diarrhea (laxative abuse)
Watery Increase in freq and vol of stool 10-20 bowel mvmts / day Characteristic biopsy finding: - dark brown discoloration of colon w/ lymph follicles shining through as pale patches (melanosis coli) - can return to normal after laxative
780
Dx acute aortic dissection
TEE | CT w/ contrast
781
Rotator cuff tear vs .tendonitis
Happens usually w/ fall out on outstretched hand Shoulder pain and weakness Tendonitis is helped by lidocaine injection - tear is not
782
Which pleura has nerve endings that give you pleuritic pain?
Parietal pleura
783
If someone has dysphagia to solids only, what test do you do to eval?
Barium esophagram w/ tablet Liquid barium may not see obstruction
784
Fulminant liver failure
no previous liver disease + Jaundice + hepatic encephalopathy
785
When monitoring DKA, and response to treatment, what is most reliable index to monitor response to tx?
Serum anion gap pH Fall in serum and urinary ketones lags behind changes in arterial pH or anion gap
786
#1 macrocytic d/o in sickle cell disease
Folate deficiency
787
Causes of toxic megacolon
ulcerative colitis | CMV colitis in HIV pts
788
Korsakoff's syndrome
Irreversible amnesia Confabulation Apathy
789
Indicators for surgery in pts w/ aortic stnosis
SAD - Syncope Angina Dyspnea (from CHF) Pts w/ severe AS going for CABG Asymptomatic pts w/ severe AS + poor LV sys function, LV hypertrophy ? 15 mm, valve area < 0.6 cm2 or abnormal response to exercise
790
When should DM screening start?
age 45 w/ no risk factors earlier if have risk factors
791
Managing dysphagia/odynophagia in HIV pts
``` #1 cause of this is candida - 1-2 wk course empiric oral fluconazole ``` If doesn't work...endoscopy to investigate other etiologies #1 cause of ulcerative esophagitis = CMV
792
CMV esophatitis
Evidence of large, shallow superficial ulcerations Focal substernal burning pain w/ odynophagia Presence of intranuclear and intracytoplasmic inclusions Tx = ganciclovir
793
HSV esophagitis
Multiple, small, well circumscribed w/ small and deep appearance of ulcers Cells show ballooning degeneration + eosinophilic intranuclear inclusions Tx = acyclovir
794
Cancer assoc w/ pernicious anemia
Gastric intestinal-type cancer Gastric carcinoid tumors
795
Pathophys of senile purpura
These are ecchymotic lesions in areas susceptible to trauma in elderly Happens b/c perivascular CT atrophies as ppl age No tx needed
796
Lupus anticoagulant
IgM or IgG that PROLONGS activated PTT - binds phospholipids used in assay - it is NOT an anticoagulant though and increases risk of thrombosis and spontaneous abortion
797
How do you change the urine pH to prevent gouty attacks?
Urine alkalinization
798
Spinal stenosis
Pain is posture-dependent Flexion of spine = widening of canal Extension - narrowing of canal Pain exacerbated by standing still, walking Pain improved by sitting, lying down Normal arterial pulses Straight leg test negative Dx w/ MRI Tx laminectomy
799
Herniated disc
Low back pain sciatica presentation - radiates to thighs adn below knee Pain worsens w/ sitting + straight leg test
800
PFTs of COPD
Decreased - VC - FEV1 / FVC Increased - functional residual capacity - total lung capacity
801
Nephrotic syndrome - etiology of hypercoagulation
``` Loss of antithrombin 3 in urine altered levels of protein C and S Increased platelet aggregation Hyperfibrinogenemia b/c increased hepatic synth Impaired fibrinolysis ``` RENAL VEIN thrombosis most common manifestation of coagulopathy
802
Complications of nephrotic sydnrome
Protein malnutrition Fe-resistant microcytic hypochromic anemia b/c lose transferrin Vit D deficiency b/c lose cholechalciferol-binding protein Decreased thyroixin levels b/c loss of TBG Increased susceptibility to infection
803
Solitary nodule that is....on CXR: - popcorn calcification - bulls eye
Popcorn - hamartoma Bulls eye - granuloma
804
How can TIA produce syncope?
This is rare Needs to affect posterior circulation and brain stem in order for syncope to occur
805
Pt receives transfusion - then in 1 hr, gets fever, chills, flank pain, hemoglobinuria. What happeend?
Acute hemolytic transusion reaction ABO mismatching from clinical error or blood mistyping hemoglobinuria present!! Can get DIC, acute renal fail, shock Tx - supportive
806
Pt receives transfusion - fevers, chills, malaise. What happened?
Reaction to cytokines in transfused blood products OR Antibodies in pt's plasma reacting w/ donor's leukocytes Febrile nonhemolytic reaction Prevent using leukoreduced blood prods (wash RBCs)
807
Pt receives tranfusion - within seconds - minutes, gets anaphylactic reaction. What happened?
IgA deficiency
808
CMV vs. EBV mononucleosis
Both - atypical lymphocytes (large, basophilic w/ vacuolated appearance) CMV only: - no pharyngitis - no cervical lymphadenopathy - negative monospot test
809
Bartter syndrome
Polyuria, polydipsia, growth and mental retardation - usually presents early but can present late Defective Na and Cl reabsorb in TAL Causes hypovolemia --> activates RAAS Increased urine Cl level
810
Gitelman syndrome
Defect in DCT in reabsorb Na and Cl Causes hypovolemia --> activates RAAS Increased urine Cl level
811
#1 complication of PUD
Hemorrhage - upper GI bleed
812
Shifts K+ out of cell (causing hyperkalemia)
DO Insulin LAB ``` Digitalis HyperOsmolarity Insulin deficiency Lysis of cells Acidosis B-adrenergic antagonist ```
813
Shifts K+ into cell (causing hypokalemia)
Hypoosmolarity Insulin (increases Na/K ATPase) Alkalosis B-adrenergic agonist INsulin shifts K INto cells
814
Renal Cell carcionma (RCC) paraneoplastic conditions
``` Anemia / erythrocytosis Thrombocytosis Fever Hyper Ca Cachexia ```
815
Dx RCC
CT scan of abdomen
816
Progressive multifocal leukoencephalopathy - cause - pathophys - symptoms - dx
JC virus (polyomavirus) Loves cortical white matter Onset of symptoms gradual - hemiparesis, distrubances in speech, vision, gait MRI confirms diagnosis - multiple demyelinating, nonenhancing lesions w/ no mass effects No tx available
817
Most common mass lesion in HIV pts
Cerebral toxo #2 = primary CNS lymphoma Both are ring enhancing lesions Toxo loves basal ganglia Lymphoma loves periventricular
818
Dizziness vs vertigo
Dizziness - imbalance and unsteadiness Vertigo - illusion of head mvmt, head spinning - actute vertigo usually due to dysfunction of labyrinth
819
Leukomoid reaction - what is it? - whcat can it look like? - how do you tell the difference?
Marked increase in leukocytes due to severe infection or inflammation Key is increased leukocyte ALP (LAP) It can look like CML - LAP is decreased in CML though
820
Nontender gallbladder + biliary obstruction evident on US + direct bilirubin elevation + disproportionate elevation of ALP What is this? How do I eval it?
Pancreatic cancer CT of the abdomen
821
Basal cell carcinoma
Slow growing papule w/ pearly, rolled borders and overlying telangiectasia #1 malignant tumor of eyelid (lower margin) Tx w/ surgical excision using microscopically-controlled margins (Mohs technique)
822
Squamous cell carcinoma
Less common than basal Faster growing Often arises from precursor (eg actinic keratosis) Usually has overlying hyperkeratosis
823
Keratoacanthoma
Rapidly growing volcano-like nodule w/ central keratotic plug Usually self limited but treated like SCC
824
Secondary bacterial pneumonia most commonly due to
Strep pneumo Staph aureus H. influenzae
825
Which is the pathogen to cause post-viral URI necrotizing pulmonary bronchopneumonia w/ multiple nodular infiltrates --> can cavitate to small abscesses?
Staph aureus blood streaked sputum
826
Legionnaire's disease
Can cause intersitial infiltrates on CXR
827
How do you see amyloidosis deposits in nephrotic syndrome?
Deposits are revealed under polarized light Apple green birefringence under polarized light after staining w/ congo red
828
Psammoma bodies?
PSMM Papillary carcinoma of the thyroid Serous cystadenoma of the ovary Meningioma Mesothelioma
829
Which thyroid carcionma has hematogenous spread?
Follicular thyroid cancer
830
Carcinomas spread via....
Lymphatics
831
Sarcomas spread via....
Hematogenous
832
Carcinomas that love to spread hematogenously
``` RCC HCC Follicular thyroid carcinoma Choriocarcionma Prostate adenocarcionma ```
833
Hypertrophic osteoarthropathy
Digital clubbing accompanied by sudden-onset arthropathy, commonly affecting wrist and hands ``` Can be attributed to pulm etiologies like: lung cancer TB Bronchiectasis Emphysema ```
834
HNPCC Amsterdam Criteria I
At least 3 relatives w/ colorectal cancer (1 is 1t degree relative of the other 1) Involvement of >=2 generations At least one case diagnosed before 50 yo Family adenomatous polyposis excluded
835
Which lynch syndrome is associated w/ high risk of extracolonic tumors? What is the most common extracolonic tumor?
Lynch syndrome II Endometrial carcinoma
836
1st line tx of anal fissure
Local anesthetic + stool softner + dietary modification (high fiber diet and fluids)
837
Pt w/ prostate cancer who underwent orchiectomy has bone pain - mets! What do you d to manage bone pain?
Radiation therapy
838
Caudia equina syndrome
Surgical emergency Absent rectal tone Urinary incontinence Motor and sensory loss in extremities
839
S/E of PEEP in person w/ ARDS
Alveolar damage Tension pneumo Hypotension This happens if pressures are too high! Can rupture fragile lung parenchyma --> air leakage into pleural space
840
``` Risk factors: HTN Smoking Elevated cholesterol Alcohol DM ``` Which has highest risk for - CVA? - CAD
CVA --> HTN (4x risk) CAD ---> hypercholesterolemia
841
Immune thrombocytopenic purpura
DECREASE platelet count INCREASE bleeding time Decrease platelet survival b/c anti GpIIb/IIIa antibodies Increased megakaryocytes on labs
842
Thrombotic thrombocytopenic purpura
DECREASE platelet count INCREASE bleeding time Decrease platelet survival Deficiency of ADAMTS 13 ---> decrease degradation of vWF multimers --> increase platelet aggregation and thrombosis Labs: Schistocytes, increased LDH Sx - neuro symptoms - renal symptoms (more in HUS) - fever - thrombocytopenia - microangiopathic hemolytic anemia
843
What MI is most commonly assoc w/ sinus bradycardia? Why?
Inferior MI Increased vagal tone in 1st 24 hrs after infarction Decreased RCA blood supply to SA node
844
How does afib happen in grave's? How do tx?
Increased sensitivity of beta-adrenoreceptors to sympathetic stimuli Beta blocker (propanolol) to tx
845
If kidneys want to icnrease bicarb retention (perhaps to fight alkalosis), what will reabsorb less?
Chloride
846
Common fungal meningitis is AIDS pts
Cryptococcus
847
Situational syncope
Middle age man Lose consciousness after urination Lose consciousness during coughing fits
848
Grover disease
Acantholytic dermatosis Pruiritus Erythematous to brown keratotic papules over the anterior chest, upper back, and lower rib cage Etiology unknown
849
Most common electolyte abnormality in adrenal insufficiency? | How does it happen?
Hyponatremia ``` Volume contraction b/c mineralocorticoid deficiency Increased vaspressin (ADH) b/c lack of cortisol suppression ```
850
Features of primary hyperaldo
HYPER TN HYPO K Metabolic alkalosis Decreased renin Elevated aldo
851
Diastolic decrescendo murmur @ L 3rd intercostal space that increases with handgril
Aortic regurgitation
852
Corrected Ca value - when do you use it? - how does it get calculated?
Corrected Ca = 0.8 (normal albumin - measured albumin) + measured Ca
853
Impetigo #1 cause
Staph aureus + Strep pyogenes Bullous impetigo has bullae and usually Staph aureus Nonbullous impetigo more common
854
Hyperkalemia causes
Tumor lysis syndrome Renal insufficiency ACE inhibitor
855
What is quickest way to decrease serum K concentration?
Insulin/glucose administration
856
#1 cause of primary adrenal insufficiency
TB Autoimmune in developed countires
857
Vision abnormality assoc w/ NF 1
Optic glioma
858
Risk factors assoc w/ ab aorta aneurysm expansion and rupture
Large diameter Rate of expansion Current cigarette smoking
859
Indications for surgery on AAA
aneurysm > 5.5 cm Rapid rate of aneurysm expansion (> 0.5 cm in 5 mo or > 1 cm / yr) Presence of sx (ab, back, flank pain; limb ischemia)
860
PaCO2 needed to compensate for pt's metabolic acidosis
PaCO2 = 1.5 (HCO3-) + 8 If CO2 lower, cannot be due to physio compensation alone - mixed acid base present
861
Why is there malabsorption in ZE syndrome?
Inactivation of pancreatic enzymes b increased stomach acid
862
Goal oxyhemoglobin saturation in COPD pts?
90-94%
863
Glucagonoma sx
Hyperglycemia Necrotizing dermatitis (erythematous plaques on skin) Wt loss Often mets to liver, is malignant DOES NOT respond to chemo - need surgery
864
How to tell the difference between cardiac or liver related LE edema?
Hepato jugular reflex | - positive in ppl w/ heart disease
865
Pt presentation: - drank unknown bottle of lye - retrosternal/epigastric pain, hypersalivation, and odynophagia/dysphagia What do you worry about? What should you give? How do you manage?
Worry a/b liquefactive necrosis of esophageal wall --> perforation and mediastinitis Give IV hydration and get serial ab and chest XRAYS Endoscopy to see extent of esophageal damage --> determines if need more tx If perforation, Gastrografin study performed DO NOT neutralize alkali w/ acid as can exacerbate injury by releasing heat
866
When do you do a urine culture for a suspected cystitis?
When complicated. - infections in women who are preggers, young, old, diabetic, immunocompromised, abnormal anatomy No need for uncomplicated.
867
Serum ascites albumin gradienet (SAAG)
Serum albumin - ascites albumin >= 1.1 g/dl = transudative = portal HTN
868
Persistent muscle pain Gets worse w/ exercise Joints not swollen Palpation over affected muscles--> tenderness ESR WNL What does she have?
Fibromyalgia Radiograph and labs have no abnormalties
869
Infection that begins to drain fluid (yellow) Gm + branching bacteria What is it? What do you tx with?
Actinomyces israelii - sulfur granules draining Tx w/ high dose IV penicillin for 6-12 wks
870
Scrofula
Draining infection caused by TB
871
Conditions needing hyperbaric O2 tx
The bends (deep sea diving) CO poisoing Slow healing ulcers
872
Causes of primary hypo parathyroidism
Post surgical - during thyroidectomy Congenital absence of parathyroid glands - Digeorge Autoimmune - In APECED syndrome = mucocutaneous candidiasis in polyglandular autoimmune endocrinopathy type 1 Defective CaSR on parathyroid glands - pseudohypoparathyroidism
873
Common causes of steppage gait/foot drop
Most commonly due to peripheral neuropathy Trauma to common peroneal nerve or spinal roots contributing to peroneal nerve (L4 - S2) Charcot Marie Tooth (congenital)
874
Postoperative cholestasis - How does it happen? - How does the jaundice happen? - lab abnormalities
Benign condition happening after major surgery w/ hypoTN, lots of blood loss into tissues, massive blood replacement Jaundice happens b/c 1) Increased pigment load (b/c of transfusion) 2) decreased liver functioning (b/c hypoTN) 3) Decreased renal bilirubin excretion (b/c tubular necrosis) ALP very high AST, ALT usually normal/slightly elevated
875
In spinal cord injury, you need to cath a pt. What can you do to decrease UTI?
Intermitten cath rather than indwelling cath Indwelling can form biofilm along catheter wall
876
Type 2 diabetes w/ increasingly blurred vision over 1 week - what is happening?
Nonketotic hyperosmolar syndrome Acute hyperglycemia --> cause myopic increase in lens thickness and intraocular hypoTN secondary to hyperosmolarity --> blurred vision!
877
De Quervain's tenosynovitis
Classically affects new moms holding infants w/ thumb abducted + extended Inflamm of abductor pollicis longus adn extensor pollicis bevis as pass through fibrous sheath at radial STYLOID process Tenderness on direct palpation + Finkelstein test
878
A pt has suspected bacterial pneumonia. What do you do 1st? After that?
CXR Antibiotics ASAP w/o waiting for sputum Gm stain or cx
879
Best way to eval liver damage in - acute hepatitis - chronic hepatitis
Acute - LFT, viral serology Chronic - liver biopsy
880
Types of neuropathies in diabetes mellitus
Symmetrical: peripheral neuropathy mononeuropathy - cranial (CN 3 most often - ischemic neuropathy, usually only motor, not PSNS b/c have diff blood supplies) - somatic autonomic neuropathy
881
Paroxysmal supraventricular tachycardia - What is it? - How to alleviatae?
#1 paroacetxysmal tachy in ppl w/o structural heart disease Usually due to re-entry into AV node To dec conduction through AV node: - valsalva - carotid sinus massage - immersion in cold water - --> these all are vagal manuevers
882
Liver cysts w/ daughter eggs - What is this due to - What occupation do you worry about this?
Echinococcus granulosus Sheep farmers! Loves to go to lungs too
883
Simple renal cyst - what should it NOT look like - what is it?
Benign, only observation needed. Make sure mass does not have: - multilocular mass - thickened irregular walls - thickened septae within mass - contrast enhancement
884
What is Wilson's disease assoc w/?
Fanconi syndrome Hemolytic anemia neuropathy
885
How do you dx Wilson's?
Liver biopsy --> hepatic cover level > 250 mg /gm dry wt | Low serum ceruloplasmin w/ high urinary Cu excretion
886
Trousseau's syndrome
migratory thrombophlebitis usually due to adenocarcinoma - most in pancreas - lung - prostate - stomach - acute leukemia - colon cancer Thrombophlebitis of atypical sites like arms and chest is impt clue to underlying carcinoma
887
Smudge cells
CLL
888
Paravertebral tenderness = ? Spinal tenderness = ?
Para - lumbosacral strain Spinal - compression fracture, etc
889
Acute, afebrile, blood tinged sputum. Young pt. no smoking hx PE revealed b/l wheezes No findings on CXR What is the dx? What is the cause?
Acute bronchitis Usually viral in etiology
890
How to histoplasma cause cytopenias, lymphadenopathy, adn hepatospenomegaly?
B/c it targets histiocytes and reticuloendothelial system
891
Dx herpes encephalitis
PCR of HSV DNA in spinal fluid is gold standard
892
PPD testing Inducation > 5 mm is + in...
HIV Recent TB contact Signs of Tb on CXR Organ transplants, pts on immunosuppression
893
PPD testing Induration > 10 mm is + in...
``` Recent immigration from TB endemic area IVDU Residents/employees of high risk settings (prisons, homeless shelters) Diabetes CKD Heme malignancies Fibrotic lung disease Kids < 4 yo, teens exposed to high risk adults ```
894
PPD testing Inducation > 15 mm is + in...
Healthy ppl w/ no TB infection risk factors
895
Pts w/ hemochromatosis and cirrhosis are at increased risk of infection with...
Listeria monocytogenes Yersinia enterocolitica Vibrio vulnificus Possibly b/c impaired phagocytosis due to iron overload in reticuloendothelial cells
896
Romberg test
Proprioception test Ataxia, (+) romberg = ataxia is sensory in nature - DCMLS damaged Ataxia, (-) romberg = cerebllar dysfunction Romberg is NOT a test of cerebellar function
897
Pronator drift
+ pronator = spasticity Can happen w/ UMN lesion If pronates, person have pronator drift on that side - tehrefore CONTRALATERAL pyramidal tract lesion A lesion in the cerebellum = upward drift
898
If history and physical suggestive of ankylosing spondylitis, how do you confirm the dx?
Plain film X ray demonstrating fused sacroiliac joints and/or bamboo spine
899
How do you explain sx of P vera? - dizziness/headache - pruritus - PUD
Dizziness/headache - hyperviscosity Pruirtus - increased histamine (mast cell degranulation) and prostaglandins (stimuli from RBC0 PUD - increased histmine, activates more acid prod by stomach
900
TImeline to tx acute acetaminophen OD
If eaten within 4 hrs, can give activated charcoal Obtain acetaminophen level @ 4 hrs (1st timepoint where hepatotoxicity evident) Then decide to give N acetylcysteine based on result - ok if given wtihin 8 hrs of ingestion
901
How does syphillis rash spread?
Secondary syphilis Start on trunk --> palms and soles
902
#1 cause of glomerulonephritis in adults
IgA nephropathy serum complement levels normal LOW in post-strep
903
If you have chronic UTI w/ Klebs, what kidney stone are you more prone to?
Struvite stones
904
How does aspirin cause an anion gap metabolic acidosis?
1) Uncouples ox phos --> increase rate of O2 consumption in periph tissues --> hyperpyrexia 2) Inhibits enzymes for carb and lipid metabolism --> accumulate pyruvate, lactic, and acetoacetic acid 3) Impair renal fx --> accumulate organic acids like sulfuric and phosphoric acid
905
Fever, tinnitus, and tachypnea - what do you suspect?
Aspirin intoxication
906
How does preggers or oral contraceptive increase gallstone formation?
Estrogen --> increase cholesterol secretion Progesterone --> reduce bile acid secretion, slows gallbladder emptying (stasis)
907
#1 site of mets #2?
1 - Lymph nodes 2 - Liver --> GI, lung, breast, melanoma loves to go here
908
Aspirin exacerbated respiratory disease
All 3 features: ASthma Chronic rhinosinusitis w/ nasal polyps Bronchospasm/nasal congestion after Aspirin/NSAID use Can also have anosmia b/c nose messed up
909
What shown to prolong survival in pts w/ COPD and hypoxemia?
Long term supplemental O2 therapy
910
What serum omsmolality does neuro manifestations happen?
> 310 U osm = 2 (Na) + glucose / 18 + BUN / 2.8
911
Bone marrow transplant pt ~45 days s/p transplant who has lung adn intestinal pathology. What microbe is this?
CMV - pneumonitis - lower GI ulcers --> ab pain and diarrhea
912
Suspected melanoma - what do you do to tx?
Excisional biopsy After confirm dx of melanoma, excise w/ wide margins
913
Melanoma - what are the work ups for diff size lesions?
Depth < 1 mm - excise w/ 1 cm tumor free margin Depth > 1 mm - sentinel lymph node study
914
Cerebellar tumor
Ipsilateral ataxia Fall toward side of lesion Nystagmus intention tremor ipsilateral muscular hypotonia
915
Festinating, shuffling gait
Parkinson's
916
Broad based gait | Feet lifter higher than usual and make slapping sound w/ floor
Tabes dorsalis
917
During walking, keep affected arm adducted adn affected leg extended Will swing leg in semicircle
Hemiparetic patient from stroke
918
Waddling gait
Muscular dystrophy | - b/c weakness of glut muscles
919
Metabolic abnormalities of tumor lysis syndrome
Hyper PO4 Hyper K Hyper uricemia --> high PO4 and K b/c both intracelluar and released w/ lysis Hypo Ca --> decreased b/c freed PO4 binds Ca taking down the [ ]
920
Age distribution of craniopharyngioma
Biomodal kids - stunted growth age 55-65 yo - sex dysfunction
921
Presenting symptoms of craniopharyngiomas
Suprasellar tumors Hypopituitarism Headaches Bitemporal blindness
922
Mediastinal widening
Often in aortic dissection
923
Folate vs. B12 deficiency - how do tell the difference?
Both have increase homocysteine ONLY Cobalmin has elevated methylmalonic acid (folate does not convert methylmalonyl coa --> succinyl Coa)
924
Type A lactic acidosis
Lactic acidosis from poor O2 delivery to tissues CO poisoning Shock
925
HIV needle stick - what do you do? - how do you test?
Test for HIV ASAP - repeat after 6wks, 3 mos, 6 mos Ppx of 2-3 drugs - 2 NRTIs + Protease inhibitor
926
Difference between drug induced liver injury and isoniazid induced liver injury
Both have liver injury like viral hepatitis BUT INH doesn't have rash, arthralgias, fever, leukocytosis, eosinophilia
927
Vanishing duct (ductopenia) in liver causes
``` Primary biliary cirrhosis Failing liver transplant Hodgkin's GVHD Sarcoid CMV HIV Medication tox ```
928
Characteristic LP finding of SAH
Xanthrochromia Happens b/c RBC go into CSF and have time to be lysed and digested into bilirubin, thus making a yellow color If blood in LP b/c damaged BV while doing it, would be red rather than yellow b/c not enough time to digest
929
Only ilicit drug to cause vertical nystagmus
Phencyclidine Use benzos to tx severe psychomotor agitation
930
Seborrheic dermatitis
Assoc w/ parkinsonism or HIV Fine, loose, waxy scales w/ underlying erythema on scalp, central face, presternal region, interscapular areas, umbilicus, body folds
931
Type 4 RTA
Can happen in diabetic nephropathy Aldo deficiency or renal tubular insensitivity to aldo Retain K Waste Bicarb Nonanion gap metabolic acidosis
932
How do you tell b/n cardiac and noncardiac pulmonary edema
PCWP > 18 --> impaired LV function < 18 --> noncardiac etiology (eg ARDS)
933
Correcting hypernatremia
Usually water deficit in relation to sodium --> hypotonic fluid loss and decreased access to free water Isotonic 0.9% saline Once normal volume, switch to 0.45% saline Don't correct more than 1 mEq/L/h or cerebral edema
934
What's a quick and easy way to tell b/n COPD and asthma?
Bronchodilator response test - measure FEV1 before and after bronchodilator - significant FEV1 improvement --> reversible etiology --> asthma
935
HIV ppx for CD4 count less than: 50 100
50 - Azithromycin, clarithromycin or Rifabutin for ppx against mycobacterium avium complex 100 - Itraconazole for histoplasmosis (if live in endemic area)
936
What do you do for solitary brain met w/ stable extracranial disease? Multiple mets?
Single - surgical resection, brain radiation Multiple - palliative whole brain radiation
937
How big is a pituitary microadenoma?
< 10 mm in diameter
938
Rabies post exposure prophylaxis
1. If dog NOT captured, assume rabid ++++give post-exposure ppx 2. If dog captured and NO features of rabies, keep to observe for 10 days. +++++see signs in dog, give post-exposure ppx immediately 3. Post exposure ppx for bites on head and neck
939
Recommendation for screening for AAA
65-75 yo M w/ PMH smoking benefit most from screening Should do 1x abdominal US in pts
940
What's the logic behind the timeline for A1c showing you glucose values?
tells you glucose levels over past 100-120 days This correlates w/ RBC survival time
941
Person comes in w/ stroke...first thing you do?
CT noncontrast of the head
942
Winter's formula for PaCO2 compensation of metabolic acidosis
PaCO2 = 1.5 (HCO3-) + 8
943
Chronic epigastric pain suddenly worsens and becomes diffuse Pneumoperitoneum What is it?
Gastric ulcer perforation
944
If a pt has an UGIB w/ depressed level of consciousness, + hematemesis, what do you do?
Intubation! Stabilize first with ABCs Then endocscopy w/ band ligation or sclerotherapy to stop bleeding
945
What kind of effusion is CHF?
Transudative pH = 7.35 for transudative
946
What is the pH for pleural effusion in - empyema - normal - inflammation - transudative
empyema - 7.2 normal - 7.64 inflammation - 7.3 transudative - 7.35
947
Always include in workup of acute delirium in elderly?
UA Serum electolytes
948
When do you start colonoscopy screening for UC?
Once disease present for at least 8 years regardless of age of pt Do exam every 1-2 years Need prophylactic colectomy if evidence of dysplasia
949
Dejerine Roussy syndrome
Thalamic stroke Usually of VPL nucleus Contralateral hemianesthesia w/ transient hemiparesis, athetosis or ballistic mvmt Thalamic pain phenomenon
950
W/ diabetic peripheral neuropathy, how do you get the paresthesias pain? How about the numbness?
Small fiber neuropathy --> pain, allodynia, paresthesias; sensory OK Pure large fiber --> more numbness, ankle reflex lost
951
Psoriatic arthritis | - signs adn symptom
DIP usually involved Morning stiffness Deformity of involved joints Dactylitis Onycholysis (Separation of nail bed)
952
Eggshell calcification of liver cyst
Hydatid cyst! Echinoccoccus granulosus
953
Well's criteria (Modified)
3 pts PE as likely or more likely than alternate dx clin s/s of DVT 1.5 pts HR > 100 bpm prior DVT or PE Immobilization (>3d) or surgery w/in 4 wk 1 pt Hemoptysis malignancy 6 = High prob for PE
954
Previous hx of rheumatic fever Dental cleaning procedure Then get infective endocarditis What order do you do your tx? What if it is a person who was IVDU who get IE?
Blood cx 1st Then empiric antiboiotics Then Transesophageal echo to see valvular vegetations Transthoracic Echo if tricuspid endocarditis - IVDU
955
Dukes major criteria
For IE diagnosis + Blood Cx Evidence of endocardial involvement on echo
956
Dyspepsia
1 or more of sx: - epigastric pain - postprandial fullness - early satiety w/ ab burning, nausea, bloating NOT HEARTBURN b/c that is GERD - usual etiology is GERD, meds, etc
957
Pt > 55 yo w/ dyspepsia - what are the alarm sx? - what do you do for this pt? - what do you do for pt w/ alarm sx?
``` Alarm sx: unexplained wt loss vomiting dysphagia GI blood loss odynophagia FH GI cancer ``` No alarm sx - test for H pylori or empiric H pylori tx (PPI) Alarm sx - upper endo
958
Alcohol w/d timeline
6-24 hrs - reflex hyperactivity in brain --> anxiety, insomnia, tremors, diaphoresis 48 hrs - hallucinations - w/d seizures 48-96 hrs DTs HTN, agitation, tachy, hallucinations, fever
959
What's the best marker for opioid intoxication w/ suggestive clinical feature?
Bradypnea NOT miosis - sometimes don't have miosis
960
Hepatorenal syndrome
Complication of ES liver disease Decreased GFR in absence of shock, proteinuria, or clear cause of renal dysfunction - als no response to 1.5 NS bolus Type 1 - rapidly progressive, pts die w/in 10 wks w/o tx Type 2- slower; survive 3-6 mos Usually die of infection and hemorrhage Need to get liver transplant to survive
961
Pruritic elevated serpiginous lesions on skin - what caused this? how did you get it?
Ancylostoma braziliense - hookworm! Sandy beaches, sandboxes
962
Can you get mild elevations in transaminases, bilirubin, and amylase in cholecystitis?
Yes! Even w/o obvious common bile duct or pancreatic disease - sludge or pus into CBD causes these elevations BUT ALP is not increased unless cholangitis or choledocholithiasis
963
Tx acute cholecystitis
NPO IV antibiotics analgesics Laparoscopic cholecystectomy soon after hospitalization
964
Sx hypercalcemia
``` Confusion Lethargy Fatigue ANorexia Polyuria Constipation ```
965
What type of pericarditis does not present w/ classic EKG diffuse ST segment elevations?
Uremic pericarditis Inflammatory cells don't penetrate myocardium Tx uremic pericarditis w/ dialysis
966
What's a normal decreased reflex finding in elderly?
Decreased achilles tendon
967
What sx are typical for asbestosis? Uncommon?
Typical - progressive dyspnea Uncommon - cough, sputum prod, wheezing
968
Large exophytic papule w/ collarette scale - what is this? - how do you dx? - what do you have to be careful of? - Tx?
Bartonella henselae! Tissue bx + microscope ID of org Biopsy can cause hemorrhage - be careful! Abx to regress lesion
969
Pt works in daycare - acute onset of polyarticular (MCP, PIP, wrist) and symmetric arthritis - resolves in 2 months What is it?
Parvovirus
970
How long do you have arthritis before diagnosed as RA?
at least 6 wks
971
pANCA positivity
Anti-MPO Microscopic polyangitis Churgg strauss Ulcerative colitis
972
Factorial design study
Randomization to diff interventions w/ additional study of 2 or more variables
973
Diarrhea in HIV pt - what do you do 1st?
ID causal organism Then do antibiotic
974
Tx pts w/ diabetic gastroparesis
Diabetes control + dietary mod Small frequent meals Metoclopramide - improve gastric emptying Erythromycin Cisapride (not used in US)
975
``` Anorexia N/V Early satiety Postprandial fullness bad glucose control ``` What is this?
DIabetic gastroparesis
976
Macrocytic anemia - causes - what does it look like?
``` Vit B12 deficiency Folic acid deficiency Hypothyroidism Liver disease Antimetabolites ``` Macroovalocyte RBCs, hypersegmented neutrophils, anisocytosis, poiklocytosis, basophilic stipling Retic count decreased Bone marrow hypercellular
977
P vera can be associated with what? And why?
Gout! 40% w/ pvera have gou Myeloprolif d/o are common causes of uric acid overproduction - increased catabolism and turnover of purines
978
Delayed sleep phase syndrome
Circadian rhythm d/o Can't fall asleep at normal bedtimes (10 or midnight)
979
Advanced sleep phase disorder
Circadian rhythm disorder Can't stay awake in evening (usuallya fter 7 pm) so social functioning difficult pts complain of early AM insomnia
980
What is a sensitive marker of dehydration?
BUN/Cr ratio
981
What do you risk giving bicarb in tx lactic acidosis or ketoacidosis?
Bicarb may paradoxically depress cardiac performance and worsen acidosis by enhancing lactate production
982
What do you suspect w/: - decreased haptoglobin - increased LDH - decreased Hg - venous thrombosis
Paroxysmal nocturnal hemoglobinuria - abnormal anchor protein GP1 which usually binds CD55 adn CD58 which stop complement from destroying RBC - intravascular hemolytic anemia - PNH have tendency towards venous thrombosis, particularly hepatic veins - mild thrombocytopenia too Use flow cytometry tests to dx - find if cells have CD 55 and 59 on surface
983
When do you do a DEXA scan for women for osteopororsis?
65 yo - one time ``` Osteopenia = T score -1.5 to - 2.5 Osteoporosis = T score less than - 2.5 ```
984
Monoarticular or asymmetric arthropathies
Seronegative spondyloarthropathies Septic arthritis Crystalline arthritis
985
Symmetrical polyarthritis
Viral arthritis (mumps, rubella, parvovirus) Rheumatoid arthritis SLE --> tell the difference b/c viral will resolve but RA and SLE do not resolve in less than 4 weeks
986
Live vaccines are NOT recommended in HIV pts. But which is the only one that is?
MMR - measles is life threatening in HIV pts - usually ok for counts > 200 (CD4)
987
Causes of aortic aneurysm - ascending - descending CXR findings
ascending - cystic medial necrosis or CT d/p descending - atherosclerosis CXR - widended mediastinal silhouette - increased aortic knob - tracheal deviation
988
Tx acute cholangitis
CBD blockage --> infection up the bile duct w/ increased ALP Supportive Broad spectrum antibiotics No response, Biliary drainage w/ ERCP
989
Types of polyps in colon
Hyperplastic - nonneoplastic, no further work up needed Hamartomatous - juvenile, peutz jeghers - usually not malignant Adenoma - most common, can be premalignant
990
Probability of adenoma progressing into cancer
Sessile vs/ stalked (pedunculated) - sessile more cancerous Tubular, tubulovillous, villous - villous more malignant Size - bigger size, more liekly malignant (>2.5cm)
991
Intraepidermal blisters + erosions w/ multinucleated giant cells w/ molded stell gray nuclei
HSV VZV vessicles
992
Extensor weakness Chronic interstitial nephritis Anemia w/ low-normal MCV What is happening?
Lead poisoning
993
How can you tell if someone syncopized vs. seized?
Confused following episode = seizure
994
Tx pt w/ radioactive iodine - what hyperthyroid d/o is most likely to become hypothyroid after?
Grave's The whole thyroid gland is hyperfunctional so will have diffuse take up - complete thyroid ablation
995
Bronchiectasis vs. chronic bronchitis
Bronchiectasis - chronic, recurrent cough - mucoPURULENT expectoration - occasional hemoptysis - episodes respond to antibiotics Chronic bronchitis - NONPURULENT expectoration
996
Dx bronchiectasis 1st?
High rest CT scan of chest
997
Which kidney is easier to palpate if it is enlarged?
Right kidney Lies lower than L kidney
998
Rapidly progressive dementia Myoclonus Sharp, triphasic synchronous discharges on EEG
CJD
999
Most common cause of death in pts w/ acute MI
Reentrant ventricular arrhythmia (vfib)
1000
Conjugated or unconjugated hyperbilirubinemia
Conj - direct bilirubin > 50% of total bili Unconj - indirect > 90% of total bilirubin
1001
Recent travel in water area High grade fever GI sx Neuro sx Rales + CXR = focal lobar consolidatin What is it? How to dx? How to tx?
Legionella pneumophilia Sputum stain = lots of neutrophils, no organisms b/c intracellular Cx on charcoal agar Urinary antigen testing Tx - azithromycin (macrolides) - levofloxacin (newer fluoroquinolones)
1002
``` Low back pain Difficulty starting urination LE sensory and motor loss Sciatica Loss of sensation in medial thigh Poor rectal tone, perineal anesthesia ```
Cauda equina syndrome Spinal nerve roots issue - LMN issue
1003
Parasellar signs due to pituitary adenoma more commonly seen in...? Why?
Men Early sx in men (eg impotence) are often attributed to psych causes and med eval is delayed --> larger tumor growth
1004
Dx acromegaly
Oral glucose suppression test - glucose doesn't suppress GH (normally does) IGF1 is increased - GH not useful b/c wide physio fluctuation of GH levels
1005
Calcification of suprasellar region on brain imaging
Diagnostic of craniopharyngioma
1006
Which hormones in pituitary lost first usually?
LH, FSH, GH then... TSH, ACTH
1007
DDx polyuria + polydypsia
DIabetes mellitus Diuretic DI Primary polydipsia
1008
Diabetes insipidus causes - Central - Nephrogenic
Central - trauma - tumors - sarcoidosis - TB - syphilis - encephalitis Nephrogenic - Lithium - Hyper Ca - Pyelo - Demeclocycline - mutations in ADH receptor
1009
Hypoosmotic hyponatremia types
HypoVOL HypoNa = volume contracted HyperVOL Hypo Na = volume expanded w/ edema SIADH = volume expanded w/o edema
1010
Why don't you see edema in SIADH?
Natriuresis still happens despite hypoNa Vol expansion --> increase ANP --> increase Na urine excretion Vol expansion --> dec PCT Na abrosption Vol expansion ---| Renin-angiotensin-aldo system
1011
Manifestations of Hyper PTH / increased Ca
Stones - Nephrolithiasis Bones - Osteitis fibrosa cystica - bone aches adn pains Groans - Muscle pain and wekaness - Pancreatitis - PUD - Gout - Constipation Psych - depression, fatigue, anorexia, sleep issues ``` Other - polydipsia, polyuria - HTN - short QT 0 wt loss ```
1012
Characteristics of rheumatic heart disease
JONES ``` Joints Pancarditis SubQ nodules Erythema Nodosum Syndenhams chorea ``` 2 major criteria or 1 major and 2 minor criteria to dx Minor: fever Increased ESR Proplonged PR
1013
Dx endocarditis
TEE TTE for R heart valve endocarditis Dukes criteria (2 major, 1 major + 3 minor, 5 minor) Major: sustained bacteremia Endocardium involved on echo ``` Minor: predisposing condition fever janeway lesions, pulmonary emboli Glomeruli nephiritis Oslers nodes ROths spots + blood cx ```
1014
When is feNa most useful
If oliguria present
1015
3 vessel opathies in diabetes
``` Nephropathy Neuropathy - autonomic - peripheral - retinopathy ```
1016
What should you order for most pts with aki?
Renal ultrasound
1017
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest | Pulm edema
1018
What is microalbuminuria measured by
Microalbumin: Cr ratio
1019
What should you order for most pts with aki?
Renal ultrasound
1020
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest | Pulm edema
1021
What lab value can you find on lupus antiphospholipid?
increase PTT
1022
Cryprecipitate
Factor 8 Fibrinogen vWF Factor 12
1023
What should you order for most pts with aki?
Renal ultrasound
1024
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest | Pulm edema
1025
What should you order for most pts with aki?
Renal ultrasound
1026
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest | Pulm edema

Surgery (12 decks)

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