Medicine Flashcards
What is the most common cause of interstitial nephritis?
Medications, with penicillins, cephalosporins, sulfonamides (such as trimethoprim-sulfamethoxazole), and NSAIDs being among the top offenders
What are the signs/symptoms of interstitial nephritis?
Fever
Rash
Increased Cr
Eosinophiluria, WBCs, white blood cell casts
What is the most common mechanical complication following an MI?
Ventricular free wall rupture
What is the difference between simple febrile and complex febrile seizures?
Simple: last less than 15 minutes, occur once during a single illness, and are non-focal
Complex: prolonged, recurrent (with more than one seizure during an acute illness), or focal
Gemfibrozil (used to treat hypertriglyceridemia) use is contraindicated in patients with what disease?
Biliary disease
Patients with HIV infection, a CD4 count of < 100 cells/µL, and Toxoplasma gondii IgG antibodies should be treated with what antibiotic as prophylaxis against reactivation?
Trimethoprim-sulfamethoxazole (bactrim)
What condition is associated with low-output heart failure?
Dilated cardiomyopathy
What qualifies for a diagnosis of infertility?
Women < 35: 12 months of unprotected and appropriately timed intercourse has not resulted in conception
Women > 35: 6 months without conception
What labs are typically seen in pts with oligoarticular juvenile rheumatoid arthritis (oligoarticular juvenile idiopathic arthritis (JIA))?
Neg RF and positive ANA
What is the most common complication of oligoarticular juvenile idiopathic arthritis (JIA)?
Uveitis
What are the signs/symptoms of HELLP syndrome in pregnant women?
H: hemolysis (LDH > 600)
E: elevated
L: liver enzymes (AST/ALT > 2x ULN)
L: low
P: platelet count (<100,000)
Do pregnant women have to have HTN and/or proteinuria to be diagnosed with HELLP syndrome?
No
What disorder is most common in children (boys > girls) between the ages of 4 and 8 and is characterized by loss of abduction, painless limp, and radiographic findings consistent with avascular necrosis?
Legg-Calvé-Perthes disease
What is the most concerning complication of a scaphoid fracture?
Avascular necrosis
What condition can show a right axis deviation on an EKG?
Pulmonary hypertension
What is the most common electrocardiographic finding in the setting of a pulmonary embolism?
Sinus tachycardia
What test is highly specific in the clinical setting of suspected Guillain-Barré syndrome (GBS)?
Elevated protein with only a mild pleocytosis on cerebrospinal fluid analysis (albuminocytologic dissociation)
What are the signs/symptoms of Guillain-Barré syndrome (GBS)
Symmetric lower extremity weakness
Decreased or absent deep tendon reflexes
Little or no sensory involvement
Follows a respiratory or GI infection by weeks to days
If a patient presents with a nosebleed that has continued for longer than 10 mins, what is the next step in treatment?
Apply oxymetazoline with a gauze pledget
What is duodenal atresia?
A congenital abdominal obstruction due to failure of the duodenum to recanalize in early fetal development
How does duodenal atresia classically present on ultrasound/x-ray?
Double bubble appearance
Patients with multiple myeloma are at an increased risk for what electrolyte disturbance?
Hypercalcemia secondary to increased breakdown of bone
How does essential tremor differ from the tremor of Parkinson disease?
Essential tremor: symmetric and exacerbated by action
Parkinson disease: asymmetric and occurs at rest
What is described as “continuous PVCs”, or more specifically, consecutive, fast, large and wide QRS complexes on EKG?
Ventricular tachycardia
What is recommended for long-term secondary stroke prevention for noncardioembolic transient ischemic attack and ischemic stroke?
Aspirin
What is seen on x-ray of an infant with tetralogy of Fallot (TOF)?
“Boot-shaped” heart with an upturned apex and a concave main pulmonary artery segment and a lack of vascular congestion (no engorgement of pulmonary vessels)
What is the preferred study to diagnose cauda equina syndrome?
Lumbar spine MRI scan
What are the signs/symptoms of acute myeloid leukemia (AML)?
More common in adults in 60s
Fever, fatigue, anemia, bleeding, hx infections, bone and joint pain
Petechiae, bruising, hepatosplenomegaly
Labs: leukocytosis; normocytic, normochromic anemia; thrombocytopenia; myeloblasts; Auer rods
What is considered to be a positive TB skin test (Mantoux test) in otherwise healthy, immunocompetent adults?
≥ 15 mm induration
What is first-line therapy for tinea corporis (ring worm)?
Topical azoles such as topical clotrimazole
What tumor marker is elevated in testicular cancer?
Serum alpha-fetoprotein
What type of hemorrhage results in a rapid progression of hemiplegia, nausea, vomiting and headache over 30 minutes, which is quickly followed by ipsilateral deviation of the eyes, stupor, coma and mydriatic pupils (“blown-pupil”, associated with brainstem compression and oculomotor nerve palsy)?
Putamen
When should tetanus immune globulin (TIG) be given?
If unclear or unknown previous vaccination: Tdap (low-risk wounds), Tdap and TIG (high-risk wounds)
Lab readings for Hep B
HBsAg: active infection
Anti-HBs: recovered or immunized
Anti-HBc IgM: early marker of infection, positive in window period
Anti-HBc IgG: best marker for prior HBV
HBeAg: high infectivity
Anti-HBeAb: low infectivity
What is the treatment for migraines?
Abortive: triptans, DHE, antiemetics, NSAIDs
Triptans, DHE: avoid in those with uncontrolled HTN or CV disease
Prophylaxis: TCAs, beta-blockers, anticonvulsants (valproic acid, topiramate), CCBs
What medications are used to treat vertigo due to labyrinthitis?
Corticosteroids
What are the signs/symptoms of myasthenia gravis?
Ocular or generalized muscle weakness, bulbar weakness (dysarthria, dysphagia), ptosis and diplopia that is worse at the end of the day or following exertion
PE: applying ice pack to eyelid improves diplopia, normal deep tendon reflexes
What is the most common cause of acute pancreatitis worldwide?
Gallstones
Salter-Harris Fractures
SALTER
I: slipped epiphysis
II: fracture above physis, most common
III: fracture below physis
IV: fracture through physis
V: erasure of the growth plate
What is dacryocystitis?
Pain, swelling, warmth, and erythema of the lacrimal sac area
Purulent drainage can be expressed from the lacrimal duct
Usually secondary to obstruction of the nasolacrimal system
What is the most common cause of dacryocystitis?
Staphylococcus aureus
What is the concentration and dose of intravenous epinephrine in an infant with cardiac arrest?
0.1 mL/kg of 1:10,000 concentration
What is the most common cause of verruca vulgaris (warts)?
HPV
Common warts commonly caused by HPV 2 & 4
What is the treatment for dacryocystitis?
Oral abx
What is a physical examination finding specific for an L5-S1 herniated nucleus pulposus?
Weak plantar flexion of the foot
What is the clinical presentation of Niacin (B3) deficiency?
Pellagra: dermatitis, diarrhea, and dementia
What is the treatment for aortic dissection?
Reduce BP and HR (beta-blockers)
Pain control
Emergency surgery (type A dissection)
What are the signs/symptoms of ALL?
Sx: fatigue, fever, hx infections, bleeding, bone pain
PE: lymphadenopathy, hepatosplenomegaly, bruising, petechiae
Labs: anemia, thrombocytopenia, lymphoblasts, Philadelphia chromosome [t(9:22)] (in some B-cell subtypes)
What is the change that occurs in a patient diagnosed with Barrett’s esophagus?
From stratified squamous epithelium to columnar-lined epithelium with goblet cells
What is the gold standard in the diagnosis of acute angle closure glaucoma?
Gonioscopy
What is the treatment of choice in asymptomatic patients with chronic hyperphosphatemia?
Phosphate binder (sevelamer)
Passive flexion of a patient’s neck that causes a reflexive flexion of his hips and knees is called what?
Brudzinski sign (meningitis)
A patient who overdoses on aspirin would be expected to have what acid/base changes?
Respiratory alkalosis (due to tachypnea) with a metabolic acidosis
Cardiac arrhythmias with premature beats
PVC: Early wide bizarre QRS, no p wave seen
PAC: abnormally shaped P wave
PJC: Narrow QRS complex, no p wave or inverted p wave
What is the difference between A. fib and A. flutter?
A. fib: Irregularly irregular rhythm with disorganized and irregular atrial activations and an absence of P waves
A. flutter: Regular, sawtooth pattern and narrow QRS complex
How is V. fib described?
Erratic rhythm with no discernable waves (P, QRS, or T waves)
What are the treatment options for CHF?
Systolic: ACEI +BB + loop diuretic + spironolactone
Diastolic: ACEI + BB or CCB
What are the classic signs of endocarditis?
Osler’s nodes
Janeway lesions
Roth Spots on retina
Splinter hemorrhages on nail beds
Clubbing
What is the treatment for endocarditis?
Empiric treatment: IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
Prosthetic valve: Add rifampin
High-Risk pts prophylaxis for procedures: Amoxicillin - 2 g 30-60 minutes before the procedure
Systolic heart murmurs
Mitral regurgitation -
Increased atrial pressure/dilation
Most common cause: MVP
Manifestations: dyspnea, HTN, A fib
PE: holosystolic murmur @ apex that radiates to axilla
TX: surgery
Tricuspid regurgitation -
Only severe causes issues
Pretty common
Causes: Ebstein anomaly, infective endocarditis
Manifestations: usually asymptomatic
PE: holosystolic murmur @ LLB
TX: surgery: diuretics for fluid overload
Aortic stenosis -
Can lead to LV hypertrophy & HF
Most common valvular disease
Manifestations: angina, syncope, HF (these are late stage)
** Dyspnea on exertion *
PE: crescendo-decrescendo @ RUSB, radiates to carotids, pulsus parvus et Tardus (weak, late pulses)
TX: valve replacement definitive
Pulmonary stenosis -
Commonly assoc w. Tetralogy of Fallot, Congenital Rubella Syndrome, & Noonan syndrome
Manifestations: usually asymptomatic, mild exertional dyspnea/ other sx of R sided HF
PE: crescendo-decrescendo @ LUSB → can radiate to neck, increases w/ inspiration
TX: mild -mod: observe, mod-severe: surgery
Mitral valve prolapse -
Most common cause of mitral regurg
** Marfans, Ehlers-Danos
Manifestations: usually asymptomatic
MVP syndrome: anxiety, palpitations, dizziness
PE: mid-late systolic ejection click
Raises legs → decrease in murmur w/ late click
TX: asymptomatic → reassurance; severe → surgery
Diastolic heart murmurs
Mitral stenosis -
* most common cause: rheumatic heart dz
Manifestations: A fib, hoarseness, mitral facies (if severe)
PE: rumbling @ apex opening snap
TX: balloon valvuloplasty
Tricuspid stenosis -
Usually d/t some underlying condition
Manifestations: fatigue, dyspnea
PE: diastolic @ LLB opening snap
TX: surgery
Aortic regurg -
Chronic: rheumatic heart dz
Acute: endocarditis, aortic dissection, acute MI
Manifestations: angina, dyspnea, HF sx
PE: high pitched decrescendo @ LUSB, bounding pulses, Quinke’s pulses (fingertips & nailbeds)
TX: surgery
Pulmonary regurg -
Can lead to R sided HF
Manifestations: usually asymptomatic
PE: decrescendo @ LUSB
Increases w/ inspiration, Graham Steell murmur
TX: observe & tx underlying cause
Hypertension is defined as what?
BP > 130/80
What is the treatment for HTN?
Lifestyle modifications (heart healthy diet, smoking cessation, exercise, stress reduction)
Pharm tx:
→ start for pts 18-60 yo w/ BP ≥ 140/90 or pts >60 w/ BP ≥150/90
Specific populations:
→ DM & nonblack population: thiazides, CCBs &/or ACEi or ARB
→ black population: thiazide &/or CCB
→ CKD: ACEi/ARB
Stage 1: start w/ single medication
Stage 2: start w/ 2 medications
Uncontrolled: titrate pre-existing medication to max dose before adding another med
What is Dressler’s syndrome?
Pericarditis 2-5 days after an acute MI
What is the step-wise treatment for asthma?
Intermittent (step 1): daytime sx up to 2d/wk, nocturnal awakenings up to 2x/mo., normal FEV1, ≤1 exacerbation/yr
PRN SABA (albuterol, levalbuterol)
If identifiable triggers, can pretreat w/ SABA or budesonide-formoterol inhaler ~5-20 min before exposure
Mild persistent (step 2): daytime sx 2-6d/wk, 3-4 nocturnal awakening/mo., minor interference w/ activities, FEV1 normal, 2+ exacerbations per year
Daily low dose inhaled ICS, PRN SABA
Moderate persistent (step 3): daily sx, >1 nocturnal awakenings per wk, daily need for SABA, FEV1 60-80%, 2+ exacerbations per year
1st line: combo low dose ICS + LABA (Budesonide-formoterol) that can be used up to 12x/day or add a PRN SABA
Severe persistent (step 4 or 5): sx all day, nightly awakenings, SABA needed several times/day, extreme activity limitation, FEV1 ≤60%, 2+ exacerbations per year
Step 4: combo medium dose ICS-formoterol daily w/ use up to 12x/day
Step 5: high dose steroid-LABA combo OR med to high dose ICS-LABA plus LAMA daily & SABA as needed (preferred)
What is Samter’s triad?
Aspirin induced asthma
samter’s triad: pt w/ hx of asthma, inflamm of sinuses, & recurrent nasal polyps
What are the GOLD grades for COPD?
1: FEV1 ≥ 80% pred.
2: FEV1 50-80% pred
3: FEV1 30-50% pred
4: FEV1 ≤30% pred
What is the treatment for COPD?
Exacerbation tx:
Continue SABA q4-6hrs PRN
Start abx (augmentin, doxy, or bactrim)
Start steroid burst (40-60mg prednisone x 5days)
Chronic tx :
SMOKING CESSATION most effective
O2 is the only therapy that impacts natural history (indicated w/ O2 sat ≤88%)
GOLD 1 or 2 w/ 0-1 exacerbations: SABA or LABA
GOLD 3 or 4 w/ 2+ exacerbations: LABA/ICS &/or LAMA
What disease process is often described as reticular honey- combing and focal ground glass opacification on CT scan?
Pulmonary fibrosis
What shows bilateral hilar lymphadenopathy on CXR and noncaseating granulomas on tissue biopsy and is commonly seen in African American women 20-40 yo?
Sarcoidosis
What is used to determine prognosis of pancreatitis?
Ranson criteria
What is the most common colorectal cancer?
Adenocarcinoma
When do you start screening patients for colorectal cancer?
45 yo OR 10yrs prior to onset of fam member’s cancer
What is Charcot’s triad and Reynold’s pentad?
Charcot’s triad: fever, RUQ pain, & jaundice
Reynold’s pentad: charcot’s + shock & AMS
Seen in cholangitis
What are the signs/symptoms of cirrhosis?
General sx: weakness/ fatigue, wt loss, anorexia, muscle cramps,
abd pain
Upper GI tract bleeding (varices, ulcers, etc)
PE: ascites, gynecomastia, hepatosplenomegaly, spider angiomas, caput medusa, muscle wasting
What is the treatment for esophageal varices?
Management of acute variceal bleed:
Stabilize pt: 2 large bore IVs, fluids
Endoscopic interventions: variceal ligation initial TOC
Pharm: octreotide 1st line
Best if octreotide + ligation
Abx prophylaxis: FQ or ceftriaxone given to prevent infectious complications
Prevention of rebleed: nonselective BBs (propranolol)
What is the 1st line treatment for eosinophilic esophagitis?
PPI
What is the triple therapy treatment for gastritis?
PPI, amoxicillin, & clarithromycin BID for 7-10 days
What is the treatment for gastroenteritis?
Fluid & electrolyte replacement
BRAT diet (bananas, rice, applesauce, toast)
Antiemetic: phenergan, zofran
Antidiarrheal: don’t use imodium in c diff → increased risk of toxic megacolon
Traveller’s diarrhea: empiric w/ ciprofloxacin 500mg/day x 3days
C diff: fidaxomicin $$$ or vanc as alternative
Recurrent infxn: fidaxomicin standard/pulsed regimen
multiple recurrences vanco regimen, vanc followed by rifaximin, FECAL MICROBIOTA TRANSPLANT
What is the most common cause of upper GI bleeding?
Peptic ulcer disease
What is the treatment for ulcerative colitis?
Mild: Mesalamine, avoid NSAIDs
Moderate-severe: IV methylprednisolone or oral prednisone in flares
What medication can be given to help increase the elimination of aspirin from the body in pt’s who have attempted to OD?
Sodium bicarbonate
What are the characteristics of Gilbert syndrome?
Patient presents with intermittent yellowing of the eyes
Labs will show a transient rise in unconjugated bilirubin
Most commonly caused by an inherited deficiency in uridine diphospho-glucuronosyltransferase
Treatment is supportive care and reassurance
When testing pleural effusion fluid, what does a pleural fluid:serum protein ratio > 0.5 indicate?
An exudative effusion consistent with an infectious cause
What is cervical spondylotic myelopathy?
A clinical syndrome of spinal cord dysfunction caused by narrowing of the cervical spinal canal from degenerative changes to the vertebral bodies and intervertebral disks, which result in compression of the cervical spinal cord
What are the signs/symptoms of cervical spondylotic myelopathy?
Pain
Sensory dysfunction (numbness or paresthesias)
Motor weakness
Abnormal deep tendon reflexes
Gait impairment
Bladder dysfunction
Symptoms usually have an insidious onset
What are the 2 major groups of local anesthetics?
Amides and benzoic acid esters
How can you tell the difference between an amide and an ester local anesthetics?
Esters: a single letter I in their generic names (e.g., benzocaine, novocaine), Amides: two I’s in their name (e.g., lidocaine, bupivacaine, mepivacaine, and prilocaine)
What medication is recommended by the New York Heart Association (NYHA) for class III-IV heart failure and an ejection fraction less than 35%?
Spironolactone
What changes are seen on EKG in patients with pericarditis?
Diffuse ST segment elevation (except for aVR and V1 which will show reciprocal ST depression and PR elevation)
What condition can alter the appearance of the arterial blood and make it appear chocolate colored?
Methemoglobinemia
What is the treatment for methemoglobinemia, aside from respiratory support?
Methylene blue
What is the gold standard test used to diagnose gout, and what will it show?
Synovial fluid analysis: needle shaped crystals & (-) birefringent
What will be seen on synovial fluid analysis in a patient who has pseudo-gout?
Rhomboid shaped crystals & (+) birefringence
What is the 1st line treatment for reactive arthritis?
NSAIDs
What diagnosis should you suspect if a patient presents with arthritis and recent urethritis or diarrheal illness?
Reactive arthritis
If a pt requires abx for an underlying infection in reactive arthritis, how long is the treatment?
3-6 months
What is a gene that is commonly associated with RA?
HLA-DRB1
What are the signs/symptoms of RA?
Symmetrical joint pain/swelling starting insidiously over wks to months
→ initially in small joints of the hands/ feet w/ progression to larger joints
→ joint stiffness worse in the MORNING & lasts >30 min
Does not involved lumbar spine
What lab tests are indicative of RA?
RF: present in >90%
Anti-CCP: ↑ is highly predictive of dx
What are the treatment options for RA?
DMARDs
→ conventional/synthetic:
Methotrexate
Hydroxychloroquine
Sulfasalazine
→ biologic
Etanercept
Infliximab
Rituximab
All pts starting DMARD/ anti-TNF alpha inhibitors should be screened for what?
Hep B/C & TB
What are the signs/symptoms of Sjogren syndrome?
Sensation of foreign body in the eyes
Dry eyes
Dry mouth
Polyarthritis
LE purpura
Peripheral neuropathy
What is pathognomonic for Sjogren syndrome?
Keratoconjunctivitis sicca (KCS)
What are signs/symptoms of SLE?
Most common sx (in >90%):
→ fatigue
→ wt loss
→ fever w/o focal infxn
→ arthralgia
→ myalgia
Less common:
→ malar rash
→ photosensitivity
→ pleuritic chest pain
→ new onset Raynaud
→ oral sores
If you suspect a patient has SLE and they have a positive _____, then you should draw these labs
ANA
anti-double-stranded DNA (anti-dsDNA) & anti-smith antibody
What is the cornerstone of treatment of SLE?
Hydroxychloroquine
What classically presents as young/middle age female w/ a hx of raynaud phenomenon w/ skin induration & internal organ dysfunction?
Systemic sclerosis (scleroderma)
What is the treatment for scleroderma?
Dependent on organ system involved w/ the following examples:
Topical steroids for derm manifestations
PPIs/prokinetic agents w/ esophageal manifestations
Systemic steroids for joint/ muscular manifestations
DHP CCBs for Raynaud
Immunosuppressive drugs have not shown significant effectiveness
What things cause metabolic acidosis (↓pH & ↓HCO3)?
MUDPILERS
Methanol
Uremia
DKA
Propylene glycol
Isoniazid, Infection
Lactic acidosis
Ethylene glycol
Rhabdo/Renal Failure
Salicylates
What things cause a non-anion gap metabolic acidosis?
HARDUPS
Hyperalimentation
Acetazolamide
Renal tubular acidosis
Diarrhea
Ureto-pelvic shunt
Post-hypocapnia
Spironolactone
What things cause metabolic alkalosis (↑ HCO3 w/ ↑ pH)?
CLEVER PD
Contraction
Licorice
Endo (Conn’s, Cushings)
Vomiting
Exogenous Alkali
Refeeding Alkalosis
Post-hypercapnia
Diuretics
What things cause respiratory acidosis?
“CHAMPP” (anything that causes hypoventilation)
CNS depression (drugs/CVA)
Hemo/pneumothorax
Airway obstruction
Myopathy
Pneumonia
Pulmonary edema
What things cause respiratory alkalosis?
“CHAMPS” (anything that causes hyperventilation)
CNS disease
Hypoxia
Anxiety
Mech. ventilators
Progesterone
Salicylates/sepsis
What are the levels of renal failure?
Stage 1: normal - GFR (>90)
Stage 2: Early - GFR (60-89)
Stage 3: Moderate - GFR (3a 45-59) ( 3b 30-44)
Stage 4: Severe - GFR (15-29)
Stage 5: Kidney failure (GFR < 15=dialysis)
Characteristics of AKI due to prerenal cause
Perfusion (50%) – kidney working fine but the things that perfuse it aren’t
Ex: volume loss, heart failure, loss of peripheral vascular resistance (sepsis/anesthesia)
d/t ↓ blood flow to the kidneys, the nephrons are intact
S/Sxs: Weak, decreased urine output, dizziness, sunken eyes, tachy, orthostatic
Fractional excretion of sodium is normal
Labs: Urine specific gravity > 1.030, Bun/Cr > 20, urine osm > 500
Causes: Hypovolemia (most common)
NSAIDs, IV Contrast ACEI, ARBS (renal artery stenosis)
Tx: fluids, cardiac support, treat shock
Characteristics of AKI due to intrinsic cause
Glomerular, tubular, interstitial
Renal (intrinsic) direct damage to the kidneys
Causes: Nephrotoxic drugs= aminoglycosides (gentamicin), cyclosporine
Tumor lysis syndrome
Vasculitis (SLE, Sarcoidosis)
Crystals from gout
Myoglobin from rhabdomyolysis
Labs: Urine specific gravity <1.010, BUN/Cr <10, urine osm <300
TX: IV Fluids remove drugs if present & sometimes Lasix to get the kidneys moving
What are the cell casts seen in renal disorders?
Pearls = Cellular cast is the hallmark (RBC casts)
RBC casts = glomerulonephritis
WBC casts = pyelonephritis
Muddy casts = ATN
Waxy casts = chronic renal disease
Hyaline casts = normal
Characteristics of AKI due to post renal cause
Obstructive – most likely prostate
Some type of obstruction in the ureters such as kidney stones, BPH, or tumors
S/Sxs: Usually low/no urine output
Dx: Place foley cath to find the source of obstruction; renal US to look for tumor/hydronephrosis
Tx: Remove the obstruction or fix the structural abnormality
Characteristics of AKI due to acute tubular necrosis (ATN)
From kidney ischemia/toxins
Dx: UA shows muddy brown casts
Damaged tubules means can’t concentrate urine = high FENa
Cause: Prerenal failure is MC
Drugs: amp B, cisplatin, aminoglycosides, NSAIDs, ACE
Ischemic: dehydration, shock, sepsis
Labs: FENa >2% + muddy, pigmented granular casts + high urine osm
Characteristics of AKI due to interstitial nephritis
Immune-mediated response
Drugs: PCN, sulfa, NSAIDs, phenytoin
US: WBC casts + eos + hematuria
Dx: renal biopsy
Tx: discontinue offending drug, steroids, dialysis if needed, usually self-limiting
Characteristics of AKI due to glomerulonephritis
IGA nephropathy, postinfectious, membranoproliferative
UA: oliguria, hematuria, RBC casts
Causes: group A strep, IGA, anti-GBM, ANCA
Post-strep glomerulonephritis = MC infectious cause of acute glomerulonephritis: either from strep pharyngitis or strep skin infection (impetigo) ⇒ hematuria, HTN, periorbital edema
Dx: proteinuria + RBC in urine; usually caused by group A beta-hemolytic strep
What is the classic triad of symptoms of acute interstitial nephritis?
Fever
Transient maculopapular rash
Arthralgias
What are the treatment options for BPH?
Observation: if no or mild sx
Lifestyle changes (avoid fluids before bed, ↓ consumption of diuretics)
Alpha-1 blockers: best initial therapy to rapidly relieve sx - don’t change prostate size
5-alpha reductase inhibitors: to reduce prostate size
Persistent/refractory → Transurethral Resection of the Prostate (TURP)
What is the most common type of bladder cancer?
Urothelial (transitional cell) carcinoma
What is Prehn’s sign?
Test to determine cause of testicular pain
Elevate affected hemiscrotum (may relieve pain in epididymitis but exacerbates in torsion)
What is the 1st line treatment of epididymitis?
250mg IM Rocephin + doxy 100mg BID x 10 days
Men ≤35 & sexually active (presumptive GC/Chlamydia)
No quinolones
What is the treatment for prostatitis?
Acute >35 yrs: FQs or bactrim x 4-6wks
Acute <35 yrs or STI likely: cover for G/C - ceftriaxone plus doxy
Chronic: FQs or bactrim x 6-12wks
Alpha blockers can help w/ chronic pain syndrome
Refractory chronic: transurethral resection of prostate
What is the most common formation of kidney stones?
Calcium oxalate
When should you refer a patient with kidney stones to urology?
Stone >6mm
Fail to pass stone within a month
What is the gold standard test for diagnosing renal artery stenosis?
Renal arteriography
What is the treatment for renal artery stenosis?
Percutaneous transluminal angioplasty (PTA) + stent placement or with a surgical bypass of the stenotic segment
What is the 1st line abx for treatment of pyelonephritis in a patient who is pregnant?
IV ceftriaxone
What is the abx treatment of choice for treating pyelo for an outpatient?
Fluoroquinolones
ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), and ofloxacin (Floxin)
What is the treatment for UTI?
Uncomplicated:
1st line = nitrofurantoin, bactrim, or fosfomycin
2nd line = FQs, cephalosporins
Complicated:
PO or IV FQs, aminoglycosides x 7-10 or 14 days
Pregnancy:
Amoxicillin, augmentin, keflex, nitrofurantoin, & fosfomycin are safe
Avoid bactrim in 1st trimester; aminoglycosides, FQs, doxy not safe
What pts require treatment for asymptomatic bacteriuria?
Pregnancy & pts undergoing urologic intervention & hip arthroplasty
What disorder is commonly described as feeling like a bag of worms?
Varicocele
What is the most appropriate first-line therapy for myasthenia gravis?
Pyridostigmine
What lab tests do pts with von Willebrand disease commonly show?
Normal platelet count, normal prothrombin time (PT), and normal activated partial thromboplastin time (aPTT)
What are the signs/symptoms of acute angle closure glaucoma?
Injected conjunctiva
Steamy cornea
Fixed dilated pupil
Painful eye/loss of vision
Tearing
N/V
Diaphoresis
IOP acutely elevated
What is the treatment for acute angle closure glaucoma?
Ophthalmic emergency!
Immediately refer to ophthalmology
Start IV carbonic anhydrase inhibitor (acetazolamide)
Topical BB (timolol)
Osmotic diuresis
Laser/surgical iridotomy
What is Beck’s triad and when do you see it?
Hypotension, JVD, muffled heart sounds seen in cardiac tamponade
What can be seen on EKG in pts with cardiac tamponade?
Electrical alternans: beat to beat change in QRS
What is the treatment for a pt who presents in DKA?
Isotonic fluids
IV insulin: bolus + drip
Potassium first if <3.3 (K in fluid)
Monitor
Transition to SQ basal/bolus
What condition can show S1Q3T3 on EKG?
Pulmonary embolism
What are the signs/symptoms of thyroid storm?
Tachycardia, hypotension, arrhythmias
Hyperpyrexia 104-106ºF
Low TSH & High T3/T4
What is the treatment for thyroid storm?
BB: propranolol
PTU or methimazole
Iodine
Glucocorticoids
Characteristics of ALL
CHILD + Lymphadenopathy + bone pain + bleeding + fever in a CHILD, bone marrow > 20% blasts
S/SX: fever & infxn ( ↓WBCs), bleeding (thrombocytopenia), anemia (↓ RBC), hepato- or splenomegaly MC PE findings
Population: Children: MC childhood malignancy peak age 3-7
Highly responsive to chemotherapy (remission > 90%)
Characteristics of CLL
Middle age pt, often asymptomatic (seen on blood tests), fatigue, lymphadenopathy, splenomegaly
Population: Adults: MC form of leukemia in adults -increases w/ age
DX studies: SMUDGE CELLS on peripheral smear, mature lymphocytes
TX: observation, if lymphocytes are > 100,000 or symptomatic, treat with chemotherapy
Characteristics of AML
BLASTS + AUER RODS in ADULT PATIENT
Population: Adults (80%) majority of patients > 50 y/o
Anemia, thrombocytopenia, neutropenia. Splenomegaly, gingival hyperplasia and Leukostasis (WBC > 100,000)
Auer Rods and > 20% blasts seen in bone marrow
Characteristics of CML
Strikingly Increased WBC count > 100,000 + hyperuricemia + Adult patient (usually > 50 years old)
70% asymptomatic until the pt has a blastic crisis (acute leukemia)
S/SX: pruritus after hot shower, TTP over lower sternum
DX studies: Philadelphia chromosome (translocation of chromosome 9 and 22), splenomegaly
What condition has normal or ↓ MCV, ↓ TIBC, and ↑ Ferritin (high iron stores)?
Anemia of chronic disease
What are the most common causes of anemia of chronic disease?
Chronic renal failure and anemia from connective tissue disorder: RA, SLE, HIV, CA, cirrhosis, chronic infection
What is the difference between hemophilia A &B?
Hem A: most common, ↓ factor VIII, ↑ PTT, normal PT & platelets,
Hem B: AKA Christmas disease, ↓ factor IX, ↑ PTT, normal PT & platelets
What diagnosis should be considered in a patient who presents with 2-4 days of fatigue, pallor, jaundice, dark urine, and back or abd pain?
G6PD deficiency anemia
What is the virchow triad?
Things that predispose a pt to thrombosis
Blood stasis, hypercoagulable state, and vascular injury
What is an autoimmune reaction to platelets usually after a viral illness?
Idiopathic thrombocytopenic purpura (ITP)
What labs will be seen in a pt with ITP?
CBC normal except low platelets
Normal PT, PTT, INR
What is the treatment for ITP?
ADULTS:
Minor bleeding (platelets <50,000): steroids 1st line (IVIG 2nd line); refractory → rituximab, TPO receptor agonist, or splenectomy
Severe bleeding (<30,000): transfusion + IVIG + high dose steroids
KIDS:
No bleeding: observe
IVIG if rapid rise in platelets
Steroids if risk of bleeding
What are the signs/symptoms of iron deficiency anemia?
↓ MCV (microcytic)
↓ MCH (hypochromic)
↑ TIBC
↓ Ferritin (best test, low iron stores)
Target cells, pica, & nail spooning
What ferritin level is diagnostic for IDA?
<15
In what disease is Reed-Sternberg Cells (owl’s eye) pathognomonic?
Hodgkin’s lymphoma
Is Hodgkin’s or Non-Hodgkin’s lymphoa associated with a better prognosis?
Hodgkin’s
What are the signs/symptoms of multiple myeloma?
Bones BREAK in Multiple myeloma
Bone pain (MC), Recurrent infxns, Elevated calcium, Anemia, Kidney injury
What disease is seen in pts with a family hx of blood cell disorder, Microcytic hypochromic, Elevated iron?
Thalassemia
What presents with fever, anemia, thrombocytopenia, tenal failure, neurological symptoms ↓ Platelets + anemia + schistocytes (RBC fragments) on smear?
Thrombotic thrombocytopenic purpura (TTP)
What are the causes of TTP?
After drugs: Quinidine, cyclosporine & pregnancy
Inhibition of ADAMTS13
What is the mainstay for treatment of TTP?
Plasmapheresis
What population commonly has a folate deficiency?
Alcoholics
What are the signs/symptoms of B12 deficiency?
Glossitis: Smooth beefy, sore tongue
Neuro symptoms (poor balance, low proprioception)
Megaloblastic anemia (MCV > 100) Hypersegmented neutrophils
What is the first-line treatment for a patient with mild syndrome of inappropriate secretion of ADH (SIADH)?
Free fluid restriction
Abduction against resistance tests which muscle of the shoulder girdle?
Supraspinatus
Lateral rotation against resistance tests which muscle of the shoulder girdle?
Infraspinatus and teres minor
Medial rotation against resistance tests which muscle of the shoulder girdle?
Subscapularis
What medications are contraindicated in pts who test positive for cocaine?
Pure Beta-blockers, such as propranolol
The source of pain experienced during a migraine headache is a result of activation of which nerve?
Trigeminal
Ethanol, along with hemodialysis and supportive measures, is indicated for metabolic acidosis caused by what?
Methanol ingestion
What causes late decelerations of fetal HR during labor?
Uteroplacental insufficiency
What causes severe “rice water” diarrhea with extreme fluid and electrolyte depletion?
Cholera
What is the classic triad for EBV (mono)?
Fever + lymphadenopathy + pharyngitis + atypical lymphocytes
What is the treatment for chlamydia and gonorrhea?
Chlamydia: Azithromycin 1g PO x 1 OR doxycycline 100 mg PO two times per day for 7 days
Gonorrhea: Ceftriaxone 500mg IM x 1 dose
Add metronidazole for PID
What CD4 count is associated with AIDS?
< 200
What is the treatment for pertussis?
Macrolide (azithromycin); supportive care with steroids / beta2 agonists
What is the treatment for PJP?
Bactrim x 21 days and steroids
What presents with abruptl diarrhea, lower abd cramps, & tenesmus accompanied by fever, chills, anorexia, HA, & malaise, and stools that are loose & mixed with blood & mucus?
Shigellosis
What is the treatment for shigellosis?
Oral rehydration mainstay of tx & electrolyte replacement (generally self - limited lasting <7 days)
Avoid anti-motility drugs
ABX: if severe (high fever, + culture in infants & young kids), ciprofloxacin (1st line in adults), azithromycin (1st line in kids)
Positive PPD based on population
> 5 mm: those w. CXR evidence of past TB, who are immunosuppressed d/t HIV or drugs, or close contacts of pts w/ infectious TB
10 mm: some RFs, (IVDU, recent immigrants from high prevalence areas, residents of high-risk settings (eg, prisons, shelters), pts w/ certain disorders (silicosis, renal insufficiency, DM, head/neck cancer), & hx of gastrectomy or jejunoileal bypass surgery
15 mm: no risk factors
What is used as 1st line prophylactic treatment for migraines?
Beta blockers (propranolol)
After starting a patient on levothyroxine (Synthroid) for hypothyroidism, when should you recheck their levels?
No sooner than 3-4 weeks
What INR should be maintained in pts with mitral valve replacements?
Mechanical MV prostheses: 2.5-3.5
Aortic mechanical valves: 2.0-3.0
What disorder will have a positive osmotic fragility test secondary to a defective red blood cell membrane?
Hereditary spherocytosis
Patients with primary adrenal insufficiency will have what electrolyte and hormone abnormalities?
Electrolytes: hyponatremia, hyperkalemia
Hormones: low cortisol, aldosterone, and sex hormones
A palpable thrill or left ventricular heave with associated murmur suggests what disorder?
Severe aortic stenosis
What clinical intervention is most successful in preserving vision in pts with diabetic retinopathy?
Panretinal laser photocoagulation
Thiazide diuretics, such as hydrochlorothiazide, are associated with an increased risk of what?
Hyperuricemia and gout
The most common pathogens in children with acute otitis media are what?
Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes
What does pulmonary capillary wedge pressure indirectly measure?
Left atrial filling pressure
What diagnosis is suspected in an infant who presents with a 4/6 holosystolic murmur heard at the left lower sternal border in the 3rd ICS, shows left and right ventricular hypertrophy on EKG?
Ventricular septal defect
What are the signs/symptoms of a pt suspected of Klinefelter syndrome?
Male with gynecomastia, diminished secondary sex characteristics, and small and firm testicles
What laboratory test would be elevated in a patient with symptomatic heart failure?
BNP
How/what is a dexamethasone suppression test performed?
Used to test for Cushing’s disease
Dexamethasone suppression test (given at 11-12pm & serum cortisol measured at 8-9am) → (+) if cortisol is elevated or no suppression
How does a patient with diabetes insipidus present?
With polyuria and polydipsia
Labs will show ↑ in plasma osmolality & ↓ in urine osmolality
What is the difference between central DI and nephrogenic DI?
Central DI: most commonly caused by a decrease in ADH production
DX: vasopressin challenge test: > 50% increase in urine osmolality and decreased urine volume
TX: intranasal DDAVP to reduce nocturia
Nephrogenic: history of taking lithium
Most commonly caused by kidney unresponsiveness to ADH
DX water deprivation test: no change in urine osmolality
TX: HCTZ, amiloride, indomethacin
What test is used to diagnose diabetes insipidus?
Water deprivation test: (+) if maximal osmolality of urine is low (<300) after 3-6hrs of water deprivation (confirms dx)
What is the treatment for DI?
Adequate free water intake
Thiazide diuretics
NSAIDs
Low salt, low protein diet
What are the glucose/A1C levels that qualify for a diagnosis of diabetes?
Random glucose >200
Fasting glucose >126 &/or
A1c >6.5%
Majority of cases of hypercalcemia are caused by what?
Primary hyperparathyroidism or malignancy
Others: thiazide diuretics, Vit A or D toxicity, hyperthyroid
What things can cause hypernatremia?
→ GI water loss: V/D
→ renal water loss: DI, osmotic diuretics, glycosuria in uncontrolled DM
→ unreplaced water losses: hypodipsia, sweating, burns, fever, insensible loss
→ hypertonic Na gain: massive salt ingestion, hypertonic fluids
What can occur if there is rapid correction of a pt’s sodium level?
> 0.5meq/L/hr can lead to cerebral edema
What is the classic triad of signs/symptoms of hyperparathyroidism?
Hypercalcemia + increased intact PTH + decreased phosphate
What thyroid hormone levels are seen in a pt with hyperthyroid disorders?
Decreased TSH
Increased free T3/T4
What are the treatment options for hyperthyroidism?
Radioactive iodine
Methimazole or PTU
BBs
Thyroidectomy
What are the signs/symptoms of hypocalcemia?
Muscle contractions: hallmark of acute hypocalcemia is tetany (NM irritability)
CV: prolonged QT, arrhythmias, CHF, ↓ HR
Derm: dry, rough, puffy skin if chronic
GI: diarrhea, abd pain, cramps
MSK: teeth issues, osteomalacia/dystrophy
Resp: broncho/ laryngo- spasm can cause stridor
Neuropsych sx
Chvostek sign
Trousseau’s sign
Hyperactive reflexes
What is a Chvostek and Trousseau’s sign?
Seen in hypocalcemia
Chvostek: facial spasm, twitching, & contraction of ipsilateral facial mm. when tapping facial n. in front of tragus
Trousseau’s: inflation of BP cuff > systolic BP for 3 mins causes painful carpal spasms
What are the levels of hyponatremia?
Mild: 130-134
Moderate: 120-129
Severe: <120
How do you treat hyponatremia?
Free fluid restriction
3% saline
Rapidly in first 6hrs 4-6mEq/L to alleviate sx
Slow correction to avoid ODS → avoid correcting >8meq/l over 24hrs
What are the thyroid hormone levels of a pt with hypothyroidism?
Increased TSH
Decreased free T4
Decreased or normal free T3
What is pheochromocytoma?
Catecholamine secreting tumor arising from the adrenal medulla
What are the signs/symptoms of pheochromocytoma?
Palpitations
Headache (most common)
Excessive sweating
What is the treatment for pheochromocytoma?
In order:
1. Nonselective alpha blockade
2. Beta blockade
3. Surgery (definitive)
When working up a pt for thyroid cancer and performing a thyroid uptake scan, what do the results mean?
Cancerous does not take up iodine (cold)
Non-cancerous will take up iodine (hot)
What are the signs/symptoms of Bell’s palsy?
Unilateral facial weakness or paralysis (forehead included): unable to lift affected eyebrow & fully close eyelid; weakness/ paralysis ONLY affects the face
Taste disturbances on anterior ⅔ of the tongue
Signs/symptoms of stroke based on location
Acute onset of focal neurologic deficits resulting from - diminished blood flow or hemorrhage
Contralateral paralysis, motor function. Right-sided symptoms = left side stroke, Left-sided symptoms = right-side stroke
Carotid/Ophthalmic: Amaurosis fugax (monocular blind)
MCA: Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia
ACA: Leg paresis, hemiplegia, urinary incontinence
PCA: homonymous hemianopsia
Basilar Artery: Coma, cranial nerve palsies, apnea, drop attach, vertigo
Lacunar infarcts occur in areas supplied by small perforating vessels and result from atherosclerosis, HTN, & DM
If a pt is discovered to have an ischemic stroke, when can tPA be given?
If within 3-4.5 hours of symptom onset
What presents with symptoms such as unilateral, excruciating, sharp, searing, or piercing pain (often at night), lacrimation, and nasal congestion, and how do you treat it?
Cluster HAs
Tx: 100% O2
What symptoms are seen in encephalitis that are NOT seen in meningitis?
AMS
Seizures
Personality changes
Exanthema
What type of tremor is worsened w/ action & intentional movement and
improved w/ alcohol?
Essential tremor
What is the 1st line medication for essential tremor?
Propranolol
What presents with symmetric, ascending, progressive, flaccid muscle weakness & sensory changes (distal LEs first), and is commonly caused by campylobacter jejuni?
Guillain-Barre syndrome
What is the treatment for Guillain-Barre syndrome?
Plasmapheresis or IVIG
What presents with the classic triad of headache, fever and a stiff neck (nuchal rigidity)?
Meningitis
What are the Kernig and Brudzinski signs?
Physical exam tests for meningitis
Kernig: knee extension causes pain in the neck
Brudzinski: leg raise when bend neck
What are common bacterial causes of meningitis?
Neonate: E. coli (gram-negative rods) and S. agalactiae (Group B Streptococcus)
Most people: S. pneumoniae (gram-positive diplococci), N. meningitidis (gram-negative diplococci)
Immunocompromised: Cryptococcus neoformans (DX: India ink stain)
What are CSF findings from an LP on a pt who has meningitis?
Bacterial: ↑ Protein ↓ Glucose (bacteria love to eat glucose)
Viral: No specific characteristics but may have lymphocytes
What are the abortive and prophylactic treatments of migraines?
Abortive: Triptans (do not use in ischemic heart disease), ergotamine (do not use in pregnant women)
Prophylaxis: Atenolol, propranolol, verapamil or TCAs
What commonly presents with sensory disturbances (paresthesias) followed by weakness & visual disturbance (diplopia)?
MS
What is the treatment for MS?
Acute exacerbation: IV high dose steroids
Prevention of relapse/progression: Beta interferon or glatiramer
What is seen on an MRI in a pt with MS?
Hyperintense white matter plaques (hallmark)
What classically presents with skeletal muscle weakness that is worse w/ repeated use & throughout the day?
Myasthenia gravis
What is the treatment for Myasthenia gravis?
Myasthenic crisis or severe: plasmapheresis or IVIG
Long term: acetylcholinesterase inhibitors (Pyridostigmine or Neostigmine)
Thymectomy
What presents with a resting tremor, bradykinesia, flat facies, & muscle rigidity?
Parkinson’s
How is a Parkinsonian tremor different from an essential tremor?
Worse at rest
Improves with voluntary activity and intentional movement
What type of HA presents as bilateral, “band-like” nonpulsatile, steady aching that is usually mild to moderate intensity and can last 30 mins to 7 days?
Tension HA
What is the mainstay treatment for tension HAs?
NSAIDs
What presents with neuro deficits similar to that of a CVA that last < 24hrs (typically for a few mins) w/ complete resolution within 1hr?
TIA
Common tumor markers
Alpha fetoprotein: hepatocellular carcinoma
CA-125: ovarian
CA 19-9: pancreatic
CEA: colorectal
