Medicine Flashcards

Question

Frailty Criteria, definition of skilled vs non-skilled care

Answer 1

1 or more of the following: 1. Used supportive device 2. ability to leave home only with assistance 3. Medial CI to leave home Non-skilled care: bathing, grooming, dressing Skilled care: PT/OT, mediation adherence assistance

Answer 2

Ischemic Stroke : RF: HTN (STRONGEST), Hypercholesterolemia, DM, Smokig Dx: Noncontrast CT is often normal in the early hours (<6hr) following ischemic events Tx: - tPA if within 4.5hrs - Within 24hrs, obtain CTA or MRI angiography of head and neck to determine if large vessel occulusion is present. ---If present --> Mechanical thrombectomy ---If not --> anti-platelet therapy then find source. 1. Head MRI which is more sensitive for ischemia 2. US of carotid (70-99%) 3. ECG or ambulatory monitoring for r/o arrhythmia 4. Echo to r/o thrombus (when >4mm, ulcerated) or structure abnormality If patient can not have tPA or mechanical thrombectomy, they should be treated with aspirin. Should undergo dyspagia screening beforehand. Patient can also be given ppx heparin to prevent DVT an PE tPA can cause complications like hemorrhage 1. Repeat imaging immediately 2. Tx with cryoprecipitate (has factor VIII, vWF adn fibrinogen) or antifibrinolytics (aminocaproic acid or transexamic acid) ________________________________________________ Lacunar Strokes: - RF: chronic HTN - Path: Hypertensive microangiopathy that occlude small, deep penetrating arteries. - Sx: Sensory only deficits ________________________________________________ Subarachnoid hemorrhage RF: HTN, smoking, alcohol use, fam hx, sympathomimetic drug use Cause: Ruptured saccular aneurysm (most common) Dx: Noncontrast CT (good for early), if nothing then LP (xanthochromia ~2hr after onset). Cerebral angiogram to identify source Tx: tPA (if on time), monitor neuro exam, maintain BP <180/105. Wait 24hrs after tPA to give antiplatelet or anticoagulation therapy d/t risk of beeding. Comp: - Cerebral vasospasms --> localize stroke - Communicating hydrocephalus (d/t impair absorption of CSF)

Answer 3

Thiamine deficiency seen in heavy alcohol drinking. 3 features: encephalopathy, oculomotor dysfunction, gait ataxia Tx: IV Thiamine Korsakoff syndrome: Late-stage complication of thiamine deficiency. Mammillary body atrophy

Answer 4

Sx: bulky, foul smelling stools d/t fat malabsorption Acute Pancreatitis: Causes: Gallstone, Alcohol, Hypertriglyceridemia 2 or 3 criteria: 1. Acute severe epigastric pain (received by sitting up or leaning forward) 2. Elevated lipase or amylase >3x upper limit of normal 3. Imaging (CT w/contrast - low sensitivity in first 72hrs of presentation, MRI) Predictors that correlate to severity: old age, obesity, hematocrit >44%, CRP, BUN >20 Comp: Pseudocysts _______________________________________________ Chronic pancreatitis Most common causes are alcohol, CF, ductal obstruction (cancer, stone), autoimmune Sx: - episodic or continuous abdominal pain - steatorrhea - weight loss - fat-soluble vitamin deficiency - diabetes mellitus Labs: - Does not regularly have laboratory abnormalities Dx: MRCP (abd CT is an alternative) showing pancreatic calcification. Can also see pancreatic enlargement, ductal dilation and pseudocyst Tx: - 1st line: alcohol and smoking cessation, eating small low fat meals, fat vitamin supplements - if severe: analgesics (TCA, NSAIDs, pregabalin) and pancreatic enzymes supplements - Refractory: opioids, procedures, surgery

Answer 5

6 P's: pain, pallor, paresthesia, pulselessness, poikilothermia (coolness), paralysis Tx: Anticoagulation (Heparin infusion) and based on severity, emergency revascularization. If mild case: tPA can be use

Answer 6

Neuro: Tremor, insomnia, irritable Cardio: HTN, Tachycardia Mucocutaneous: gingivitis, diaphoresis, desquamation of hands/feet Renal: tubular damage, proteinuria Inhibits catecholamine breakdown = mimics pheochromocytoma

Answer 7

MEN1 - Pituitary - Parathyroid - Pancreatic - Associated with angiofibromas, collagenomas, meningiomas MEN 2A - Thyroid ( Medullary - high calcitonin) - Parathyroid - Pheochromocytoma ---Dx: 1st - 24hrs fractionated urinary metanephrines and catecholamines levels. 2nd - Abdominal CT or MRI ---Tx: Tumor removal but first give alpha blocker For HTN: IV nitroprusside, phentolamine or nicardipine. For hypotension: NS volus and pressers Patient with Medullar thyroid cancer should be screened for pheochromocytoma (with plasma free metanephrines) before tumor resection MEN 2B - Thyroid ( Medullary) - Pheochromocytoma - Mucosal neuromas

Answer 8

Hypoxemia is mainly d/t V/Q mismatch, higher FiO2 compensates for low V/Q ratio alveoli. Exacerbation Tx: - Steroids - Abx if there is increased sputum purulence, sputum volume, increased dyspnea, or require mechanical ventilation. - Short course of steroids - continuous oxygen is shown to improve long-term survivial to maintain sat's between 88-92%

Answer 9

Dx: RUQ US Tx: ERCP can dx and tx if the following is present If none of these are present and dx is still suspected --> MRCP or HIDA Gallbladder inflammation Dx: RUQ US If US is negative or inconclusive: HIDA scan Gallstone in the cystic duct Dx: - RUQ US showing dilated CBD - ERCP (dx and tx): done if 1. Visualized stone in common bile duct 2. Dilated CBD and elevated bilirubin 3. Evidence of acute infection (fever, ruq pain, jaundice, hypotension, confusion) - MRCP if none of the above are present in the patient but choledocholithiasis is suspected Complication s/p cholecystectomy --> bile salt-induced diarrhea Tx: cholestyramine (bile salt binding resin)

Answer 10

All calcium stones tx: - Increase Fluids - Increase citrate: binds to Ca to inhibit stone formation - Increase K: increase citrate excretion - Decrease Na: Increase Ca reabsorption Calcium oxalate stones tx: - Adequate Ca intake: decrease oxalate absorption - Low oxalate: decrease urinary excretion Mediation: - Thiazides: Increase renal Ca reabsorption - Potassium citrate:

Answer 11

High CA, ESR and Alk Phos, - ACE levels are elevated in 75% but can not be used to confirm a diagnosis Dx: Biopsy revealing noncaseating granuloma. If palpable LN are not available, transbronchial biopsy can be performed.

Answer 12

Blunt trauma to lungs --> accumulation of edema and blood --> chest pain, SOB, hemoptysis, hypoxemia Dx: chest x-ray showing irregular localized opacification Tx: monitor for 24-48hrs, pain control, oxygen _________________________________________________ Blunt cardiac injury --> cardiac contusion --> depressed cardiac contractility and acute heart failure. Can also lead to arrhythmias or myocardial rupture leading to pericardial effusion, tamponade and shock. Dx: bedside US or FAST to r/o out injuries

Answer 13

1. Bradycardia 2. Hypertension 3. Respiratory depression Early: HA, V, blurry vision, papilledema Late: Altered level of consciousness dilation of the ipsilateral pupil, CNIII palsy, hemiparesis, decerebrate posturing, respiratory arrest

Answer 14

Osteochondroma - Most common benign - Boney spur of cartilaginous cap Ewing - 1 of 2 most common malignancies - Lytic lesion w/mulitlayer periosteal reaction Osteosarcoma - 1 of 2 most common malignancies - ill-defined with aggressive periosteal reaction (sunburst, codman triangle)

Answer 15

#1 Hemodynamic instability Other predictors: - >80y/o, AMS, Hx of cancer, Tachypnea, tachycardia, hypothermia, Sat <90%, high troponin and BNP. Dx to showing RV dysfunction - Stable Dx: CTA or V/Q scan - Unstable: TTE Tx: thrombolysis

Answer 16

Tx: Anticoagulation (factor Xa inhibitor) PPX - If secondary a hypercoagulable state: should be treated for at least 3 months but no longer than 6 months with warfarin Idiopathic: treat for minimum of 6 months with warfarin

Answer 17

IgE mediated/Type 1 hypersensitivity If there is a rapid symptom onset & any 1 of the following criteria: 1. Skin/mucosa involvement AND hypotension or respiratory distress 2. Involving >2 organ systems (Cardiovascular, Respiratory, Skin, GI) 3. Hypotension after exposure to allergen Immediate Tx: 1. Epinephrine (IM preferred, may be repeat x2). Even if initial sx are less severe, give IM epi ASAP. IV for severe/refractory sx 2. IV crystalloid & Trendelenburg positioniong for hypotension 3. Albuterol for bronchospams 4. Early intubation Others: 1. H1/H2 antihistamines 2. Glucocorticoids 3. Glucagon for patients on beta blockers 4. Hospital admission for observation

Answer 18

- IgG Ab against form against foreign components --> immune complex. - Clearance of these complexes occur without issue when there is minimal antigen because phagocytic system has a large capacity. - If multiple doses of foreign components are received --> more complexes --> overwhelm phagocytic system --> aggregation of complexes in the bloodstream --> deposit in tissue --> Type III Hypersensitivity reaction --> fever, rash, arthralgia typically 1-2 weeks after exposure. - Resolve spontaneously after days once complexes are cleared.

Answer 19

- Deficiency or dysfunction of C1 inhibitor --> elevated bradykinin (a peptide that causes vasodilation and increased vascular permeability) --> edema - Episodes precipitated by minor trauma or emotional stress - No pruritis or urticaria Dx: - Low C4 because C1 inhibitor is not present --> C1 activated --> uncheck cleavage of C4. - Decrease in functional C1 inhibitor level

Answer 20

Age 15-35 RF: family hx, cryptorchidism Sx: Usual firm/hard testicle with or without painless nodules. Dull lower abd pain, metastatic sx Dx: Scrotal US then radical orchiectomy to dx, tumor markers, staging with CT scan/chest xray Tx: Radical orchiectomy, Chemo, cure rate ~95%. Biopsy increases risk of lymphatic spread ____________________________________________ Hydrocele - Results when the processes vaginalis remains patent and allows peritoneal fluid to accumulate within the tunica vaginalis. - Painless, scrotal swelling that transilluminates - Most cases resolved spontaneously in 2 years

Answer 21

CO poisoning Cause: smoke inhalation, gas motors in poorly ventilated areas, car exhaust Path: binds to HgH with a high affinity and reduced oxygen delivery to the tissues. Sx: ---Mild: HA, Confusion, cherry red skin, malaise, dizziness, nausea ---Chronic exposure can lead to polycythemia d/t increased EPO ---Severe: Sz, Syncope, coma, MI, arrhythmia Dx: ABG for carboxyhemoglobin level. Pulse oxy cannot differentiate between O2 and CO Tx: Mild: High flow 100% oxygen If severe: intubation, hyperbaric oxygen CI: sodium thiosulfate _____________________________________________ Cyanide poisoning Causes: fires, occupation exposure, cyanide-containing meds (sodium nitroprusside) Path: inhibits oxidative phosphorylation --> forces anaerobic metabolism Sx: --- HTN, cardiac instability --> death --- HA, confusion, anxiety --> sz, coma --- Cherry red skin --- vomiting ---can quickly progress to hypotension and bradycardia Labs: Elevated anion gap metabolic acidosis due to increased lactic acid Tx: Decontamination, 100% oxygen, IVF, vasopressors, empiric tx with hydroxocobalamin + sodium thiosulfate Hydroxocobalamin binds to cyanide and forms cyanocobalamin which can be renally excreted. ___________________________________________ Inhalation injury: - Upper airway thermal injury +/- lower airway chemical injury. Strong indicators: - Oropharyngeal blistering or edema - Retractions, respiratory distress, hypoxia. TX: - 100% oxygen to displace CO2. - Stable patient with concerning features but no strong indicators: bedside fiberoptic laryngoscope. - Unstable patient or patient with strong indicators: endotracheal intubation

Answer 22

Elevated HgG (16.5 women, 18.5 men)and Hct Most likely due to chronic hypoxia 2/2 cardiac or pulmonary disease Dx: 1. Repeat testing 2. Erythropoietin level ----if 2/2 hypoxia: high EPO level --> pulse ox --- RCC can also secrete EPO (RF: smoking, obesity, HTN) --> CT scan of abdomen ----If low: possibly polycythemia vera (myeloproliferative disorder) - JAK2 mutation

Answer 23

RF: smoking, obesity , HTN Sx: flank pain, hematuria, palpable abdominal mass Labs: EPO production Dx: CT scan of abdomen showing enhancing mass of the kidney with thickened, irregular septa Tx: Nephrectomy

Answer 24

Pneumothorax RF: PPV --> barotrauma --> alveolar rupture --> Pneumothroax Dx: Bedside US or chest x-ray Tx: - Chest tube if tension had not yet developed. - Needle decompression is appropriate for emergency tension pneumothorax. Always followed by chest tube placement. _________________________________________________ Pleural effusion Dx: - Acute setting: Bedside US is the test of choice - Nonacute setting: Uprigith PA chest xray Tx: Needle decompression or chest tube placement An also be secondary to liver cirrhosis Thoracentesis can drain but effusion will recurs. Tx: Na restriction, loop and K sparing diuretics (furosemide and spironolactone)

Answer 25

RF: Non-coronary athletic disease, diabetes, CKD, age > 50, Male, family history of first-degree relative, hypertension, dyslipidemia, cigarette smoking > 1 pack daily Can resume sexual activity within 1-4 weeks if low risk Dx: - EKG: STEMI - Troponon - Exercise EKG when possible or Adenosine myocardial perfusion imaging/Dobutamine echo Time frame of complications 0-24hrs: Ventricular arrhythmia, HF, cardiogenic shock 1-3 days: postinfarction fibrinous pericarditis (Tx high dose aspirin) 3-14 days: Free wall rupture --> tamponade. Primary muscle rupture --> mitral regurg. Intraventricular septal rupture. LV pseudoaneurysm. 2 weeks to several months: Dressler syndrome, HF, arrhythmias, ventricular aneurysm Stress test significant - High-risk feature: clinically significant CAD and a high short-term risk of cardiovascular event. Should undergo angiography and possible re-vasularization. - Low-risk features: have a <1% chance of cardiovascular events within the next year. Inferior wall MI STEMI of leads II, III and aVF - Commonly cause sinus bradycardia and AV block Tx: - IV atropine is 1st line to increase CO. - Transcutaneous followed by transvenous cardiac pacing --> PCI - If accidentally treated with NO --> give NS bolus

Answer 26

- Caused from atherosclerotic narrowing - Representation of atherosclerotic cardiovascular disease and increase risk of cardiovascular events. TX: aspirin (decrease risk of stroke), statin (regardless of baseline cholesterol levels) Sx: Intermittent claudication Dx: reduced ankle-brachial index TX: Stage 1A: - Smoking cessation - BP and DM control - Aspirin (decrease risk of stroke) - Statin (regardless of baseline cholesterol levels) Step 1B: - Supervised exercise therapy Step 2: Cilostazole (blood thinner) Step 3: Revascularization with stent/graft

Answer 27

Follicular lymphoma: most common indolent growing non-Hodgkin lymphoma in adults, B cell, present with painless waxing/waning lymphadenopathy Burkitt: highly aggressive and rapidly growing non-Hodgkin lymphoma, B cell, associated with EBV

Answer 28

- Single carbon donors for formation of purine and pyrimidine bases. Deficiency impairs DNA replication. Makes RBC more susceptible to hemolysis --> anemia and low retic count because RBC are not made properly Sx: - Dementia and subacute combined degeneration, impaired vibration. - Hyperbilirubinemia, elevated LDH Tx: supplemental B12. Look out for hypokalemia d/t uptake of K by newly forming RBC. Can pre-transfuse with pRBC to prevent adverse effect ____________________________________________ Pernicious Anemia Cause: Autoimmune destruction of parietal cells Dx: causes autoimmune metaplastic atrophic gastritis --> glandular atrophy (many gastric body and fundus), intestinal metaplasia and inflammation

Answer 29

Tx: --> beta blockers (metoprolol), non-dihydropyridine CCB (verapamil) and Na channel blocker (disopyramide) High risk of SCD --> Implantable cardiac defibrillator Significant LVOT obstruction --> septal ablation or surgical myectomy

Answer 30

Path: Th2 response to food antigens Association: Atopic disease (asthma, eczema, food allergy, allergic rhinitis) Sx: dysphagia, heartburn/epigastric pain refractory to PPI, regurgitation, food impaction Dx: Endoscopy w/biopsy (concentric rings, strictures, and linear furrows) Tx: Elimination diet, PPI, Topical steroids (spray)

Answer 31

Mild: well appearing, hemodynamically stable --> Tx: oral rehydration. Severe: ill-appearing, hemodynamically unstable --> Tx: IVF and Abx DO NOT TREAT SHIGA-TOXIN, which is produced by E.Coli (EHEC 0157:H7) or Shigella due to risk of hemolytic uremic syndrome NONINFLAMMATORY: Viruses: - Norovuris: most common - Rotavirus: most common in unvaccinated age <2, N/V/F Bacteria: - Staph Aureus (1-6hrs) - Bacillus cereus (1-6hrs) - Clostridium perfringens (>1day) - ETEC (>1day) - Vibrio cholerae (>1day) - Listeria Parasites: - Giardia: Malaise, abd cramps, foul-smelling fatty diarrhea >1 week after exposure - Cryptosporidium - Cyclospora INFLAMMATORY: Bloody diarrhea Pathogens : Bacteria: - Nontyphoidal salmonella - Campylobacter --> rare but can lead to GBS - Shigella - Shiga toxin-producing E.Coli - Yersinia - Vibrio parahaemolyticus Parasites - Entamoeba Avoid: fructose (fruit juice). transient lactase deficiency can occur

Answer 32

Chronic abd pain associated with defecation and changed in stool consistency (diarrhea, constipation or alternating). Can be precipitated by infectious gastroenteritis Dx: no mucosal abnormalities on histology Tx: dietary modification (lactose-free diet) Loperamide

Answer 33

Recent heparin exposure Type 1: non-immune mediated caused by heparin-induced plt clumping arising within 2 days of exposure. Tx: Resolves spontaneously w/o intervention. Type 2: life-threatening. Antibodies form against heparin-platelet factor 4 complexes --> thrombocytopenia and AV thrombosis Tx: Stop heparin, start direct thrombin inhibitor (argatroban, bivalirudin) and fondaparinux Avoid heparin for life and obtain confirmatory testings (serotonin release assay). Start direct thrombin inhibitor (argatroban) or fondaparinux to prevent thrombosis Transition to warfarin after plt are >150,000

Answer 34

Heparin - Immediate therapy - Enhances antithrombin which inhibits thrombin and factor X - CAN BE USED IN PREGNANCY: For high-risk patient 1. LMWH during 1st trimester 2. Warfarin for 2-3 trimester 3. Unfractionated heparin before delivery Discontinue all at onset of labor. - Overdose? ---Protamine for LMWH and unfractionated ---Prothrombin complex concentrate for synthetic heparin Warfarin: - Takes time to work - Interfere with gamma-carboxylation of Vit K-dependent coagulation factors - NOT USED IN PREGNANCY - Overdose? Prothrombin complex concentrate (has vit k dependent clotting factors) and Vit K

Answer 35

Prohibits cardiopulmonary resuscitation 1. Basic life support: chest compressions 2. Advance cardiac life support: defibrillation, cardiac resuscitation medication (epi) ONLY IN THE EVENT OF CARDIOPULMONARY ARREST ________________________________________________ CPR: CPR, given oxygen, start defibrillator 1. VF/pulseless VT --> defibrillation 2. Pulseless electrical activity (PEA)/asystole ---> CRP, Epi

Answer 36

Acute compartment syndrome Cause: crush injury, long bone fracture, rhabdomyolysis, reperfusion after prolonged ischemia, massive fluid resuscitation. Path: increased pressure within enclosed fascial space, decreased blood and tissue perfusion Sx: - Early: Worsening severe pain, rapid increase in swelling, increase pain with passive stretching, paresthesia - Late: Decrease sensation, weakness, paralysis, loss of pulses Dx: diastolic pressure - compartment pressure. <30mmHg is positive. Tx: fasciotomy Comp: fixed muscle contracture due to irreversible skeletal muscle fibrosis and shortening. Develop over weeks to months. ________________________________________________ Chronic exertional compartment syndrome: - nonemergent. self-limiting - recurrent pain that occurs at the same time, distance, and intensity of exercise. - pain resolved <10min with rest and exam is normal ________________________________________________ Abdominal Compartment - Systemic inflammatory response, increased capillary permeability, and rapid third spacing of fluid —> increased intra-abdominal pressure --> decreased perfusion to intraabdominal organs --> dysfunction. - compress renal vein, diaphragm elevation, IVC Tx: - Avoid over resuscitation with IVF, decrease intra-abdominal volume with NG tube, increase abdominal wall compliance with sedation. - Definitive management is surgical decompression.

Answer 37

Sx: - Recurrent sinopulmonary infections - Meconium ileus: intestinal obstruction of the distal Ileum. Can be associated with bilious emesis and abdominal distention, with a right-sided “ ground-glass mass” (d/t the mixture of air bubbles and meconium in the ileum) - Pancreatic failure d/t ductal obstruction and buildup --> pancreatic DM Can cause the loss of alpha (glucagon) and beta (Insulin) cells. - Male infertility Dx: - Elevated sweat chloride test - CFTR mutation on genetic testing - Abnormal nasal potential difference Tx: - Nutritional support Airway clearance - Abx coverage for Staph aureus and Pseudomonas ---Vanco for MRSA coverage ---2 drug coverage for Pseudomonas: Cefepime & ceftazidime (cephalosporins), amikacin & tobramycin (aminoglycosides)

Answer 38

Normal fasting glucose level 70-100 Impaired fasting plasma glucose if 100-126 DM is diagnosed if fasting blood sugar >126 Anyone >100 are at increased risk of coronary artery disease Tx: diet, activity modification, weight loss and metformin monotherapy. However, for patients with Hgb A1C >9% should be started on insulin _________________________________________________ DKA Definition: 1. Acidosis 2. Hyperglycemia 3. Ketonuria Management: 1. IVF - Normal Saline - 0.9% 2. Insulin infusion 3. K (if < 5.3) 4. Consider bicarb if pH < 6.9 - Insulin infusion is required until acidosis is corrected (check anion gap) - Once glucose is 200-250: decrease infusion rate of insulin and add dextrose to IV fluids to maintain glucose >200 due to the risk of hypoglycemia - If K gets below 3.3, insulin should be held - Switch to subcutaneous insulin once out of DKA. A sliding scale can be given if bolus insulin is insufficient. ________________________________________________ Dupuytren contracture - Associated with DM (40%), Tobacco and alcohol use - Tx: - Modification of hand tools - Needle aponeurotomy, collagenase injection, - Intralesional glucocorticoid injection - Surgery for contractures or advanced disease. ________________________________________________ Delayed gastric emptying Dx: - 1st: EGD to exclude mechanical obstruction - Nuclear diagnostic emptying study - Gastroduodenal manometry Tx: 1. Eating frequent small-volume meals. 2. Food high in fat, insoluble fiber, and carbonated drinks should be avoided. - Glycemic control can also reduce symptoms. 3. Metoclopramide (risk for EPS), domperidone, erythromycin ________________________________________________ Primary prevention - Age >40 with DM: start statin _______________________________________________ Neuropathic (Charcot) arthropathy Cause: repetitive bone and tissue trauma d/t impaired sensation and joint proprioception Sx: erythema, warmth, edema Dx: only soft tissue swelling without bone involvement --> inflammation-induced bone resorption showing osseous destruction (phalangeal osteolysis, partial disappearance of metatarsal heads resembling "sucked candy" ) Tx: Acute & subacute: foot cast Chronic: orthotic footwear, infection control, surgical realignment

Answer 39

Effects lacrimal and salivary glands Anti-Ro/SSA and Anti-La/SSB Associated with B-cell non-hodgkin lymphoma History: intense periductal lymphocytic infiltrates (focal lymphocytic sialadenitis), often with germinal centers; the glandular tissue is typically atrophic and fibrotic

Answer 40

Men - Gradual decline of sex hormones with aging: lower testosterone (total and free), compensatory rise in LH, increased hepatic synthesis of sex hormone-binding globulin Women: - Drop in sex hormones at menopause Both: - Reduce renal mass (atrophy and fibrotic replacement) and functional glomeruli --> Decrease in GFR and increased creatinine - Reduced ability to concentrate urine - Reduced renal blood flow - Reduce secretion of renin and reduced hydroxylation of vit d

Answer 41

Open globe laceration: small high-velocity particle --> teardrop pupil Tx: Abx, eye shielding, CT scan or orbits and emergency ophthalmology Open glove rupture: blunt injury

Answer 42

RF: Advanced age and underlying brain disorder (dementia, parkinson, stroke) Precipitate: polypharmacy, infection, fluid and electrolyte disturbances, malnutrition, immobility, etc. Dx: 1st- Vital signs 2nd - UA and CMP 3rd- reassurance, orient to environment, constant supervision 4th- low dose haloperidol

Answer 43

Sx: agitation, aggression, wandering, delusion, hallucination, paranoia Non-pharm tx: - Stable environment - Structured routine, scheduled activity - Calm reassurance - Regular exercise, sleep hygiene Med Tx: - Cholinesterase inhibitors - SSRI - Antipsychotics - Avoid benzodiazepines

Answer 44

Cherry aka Senile: - Filled with capillaries and post-capillary venules. - Usually asx and require no treatment. - Electrocauterization for small lesions. Add shave excision for larger lesions. ____________________________________________ Photoaging - Intrinsic aging: fine wrinkles on otherwise smooth surface - Photodamage: course deep wrinkles on rough skin surface with keratosis, telangiectasias and brown liver spots - Smoking can make wrinkles worst - Tx: Tretinoin __________________________________________ Bullous pemphigoid Cause: Ab against hemidesmosomes (dermal-epidermal junction) Sx: pruritic, tense bullae, rare mucosal involvement, prodrome of eczematous/urticaria-like rash Histo: subepidermal cleavage Dx: skin biopsy Tx: topical vs systemic steroids, doxycycline _____________________________________________ Seborrheic dermatitis aka cradle cap aka dandruff Cause: Malessezia Tx: - Topical anti-fungal (selenium sulfide, ketoconazole) - Topics steroids (low potency) - Oral antifungal for severe cases (itraconazole, ketoconazole) - Maintenance/intermitted re-treatment may be required to prevent recurrence every 1-2 weeks ______________________________________________ Atopic dermatitis aka eczema Moisture barrier + steroids if severe _______________________________________________ Tinea capitus Tx: Griseofulvin ________________________________________________Pseudofolliculitis barbae - Small, painful papules - Penetration of the hair shaft into interfollicular skin , either through the lateral wall of the follicle or by curving back into the skin after exiting the follicle. - Most prevalent in black men who have tightly coiled facial hair - Shaving with a multi-blade razor increases the risk. Complications: hyperpigmentation, secondary bacterial infection, and occasionally keloid formation TX: discontinuation of shaving, adjusting shaving routine to single blades proceeded by warm compresses _______________________________________________ Cellulitis Most common bug: Strep pyogenes (GAS) or Staph aureus Poorly demarcated, involved deep dermis and subcutaneous fat, +/- fevers ________________________________________________ Necrotizing fasciitis: Infection of the subcutaneous tissue that spread rapidly along the facial planes and lead to extensive tissue necrosis and shock Micro - Type 2 occur in patients with no medial illness: Strep pyogenes (GAS) - Type 1 occur in patients with underlying DM or peripheral vascular disease: Staph aureus, clostridium perfringes (causes crepitus), polymicrobial Path: Bacterial spread rapidly through subcutaneous tissue and deep fascia, undermining the skin. Mostly involves the extremities and perineal region. Sx: - Often minor trauma - erythema of overlying skin - swelling, pain out of proportion to exam - systemic sx: fever, hypotension Tx: surgical debridement and abx - Piperacilli/tazobactam or carbapenem: GAS and anaerobes - Vancomycin: MSSA and MRSA - Clindamycin: inhibits toxin formation of Strep and staph _______________________________________________ Plaque psoriasis - Erythematous plaques with silvery scales - Asx or pruritic - Can also cause arthritis, nail changes, and ocular inflammation - Koebner phenomenon: worsening symptoms from skin trauma _______________________________________________ Urticaria 80-90% are idiopathic Can be associated with atopic & rheumatologic diseases Sx: Symptoms >6 weeks without apparent trigger. Pruritic, round/serpiginous erythematous plaques, individual lesions lasting <24hrs, +/- angioedema Evaluation: - CBC, CRP, ESR, LFT, UA - Skin biopsy to exclude urticarial vasculitis or mastocytosis Tx: - Initial: 2nd generation H1 antihistamines (loratadine, cetirizine) - avoid aggravating conditions (head, NSAIDs) - If persistent, progress to 1st generation (hydroxyzine), leukotriene receptor antagonist (montelukast), oral steroids Prog: usually self limiting that resolve in 2-5 years

Answer 45

Rectal Prolapse: - Medical tx used for non-full thickness prolapse - Fiber and fluid intake, pelvic floor muscle exercise - Possible biofeedback therapy for fecal incontinence - Surgery for full thickness or debilitating sx (fecal incontinence, constipation, sensation of mass) _______________________________________________ Pelvic floor: RF: - Obesity, multiparty, hysterectomy, postmenopausal age Sx: - pelvic pressure - obstructed voiding - urinary incontinence - constipation - fecal urgency, incontinence - sexual dysfunction - vaginal bleeding Tx: - Weight loss - Pelvic floor exercises - Vaginal pressary - Surgical repair (if patient is a good candidate)

Answer 46

Stress - Leaking with COUGH, sneezing, laughing, lifting - cause: intrinsic sphincter deficiency or urethral hypermobility - Tx: pelvic floor exercise, pessary, urethral sling Urge: - SUDDEN overwhelming frequent urge d/t overactive or spastic bladder - Tx: bladder training, antimuscarinic Overflow: - Constant DRIBBLING, incomplete bladder emptying - Tx: intermittent catheterization, correct underlying etiology. Vesicovaginal fistula Abnormal track between vagina and bladder RF: Surgery, irradiation, prolonged labor/childbirth trauma, GI malignancy Sx: painless, continuous urine leakage from vagina --> malodorous Dx: PE, dye testing, cystourethroscopy

Answer 47

Cardiac death: - Irreversible electrical or mechanical asystole. - Apnea - Confirmed by observation period (~5min) Brain death Prerequisites: 1. Clinical or brain image of devastating cause 2. Absence of confounding factor (sedatives, metabolic 3. No evidence of ongoing drug intoxication or poisoning. 4. No hypothermia or hypotension Neuro exam: - Irreversible coma without confounding factors - Absent brain originating motor responses (posturing) - IRREVERSIBLE ABSENCE OF CEREBRAL AND BRAINSTEM REFLEXES (pupillary light or corneal, oculovestibular, cough, gag, suck, swallow, extensor reflex). Biceps reflex would still be intact **can still see spontaneous limb movements** NEXT STEP - Apnea formal test must be performed : no spontaneous breaths for 8-10min If still highly suspicious, Other test: - EEG: absence of brainstem-invoked potentials - Absence of intracranial blood flow on imaging A 2nd independent examination, generally performed after a 12hr observation period, is required in children ________________________________________________ - Organs do not need to be in pristine condition for donation, some degree of preexisting dysfunction is common. CI of organ donation - Patients <18y/o - Lack of mental ability to make an informed decision - Uncontrolled hypertension, HIV, DM - Active or partially treated cancer - Acute infection - High suspicion of donor coercion - High suspicion of illegal financial exchange from recipient to donor - Uncontrolled/untreated psychiatric illness - Active substance abuse For organ donations from a live patient, risk are as followed: ----Short term: deep vein thrombosis, and hospital acquired infection. Risk is low. ---Long-term risk: immediate decrease in net GFR following removal of one kidney, however, remaining kidney compensates by hypertrophy, leading to no increased risk of end-stage renal disease. ----In female donors, there is an increased risk of gestational complications: fetal loss, preeclampsia, gestational, diabetes, gestational hypertension. _________________________________________________ Decorticate (flexor) posturing—lesion above red nucleus, presents with flexion of upper extremities and extension of lower extremities. Decerebrate (extensor) posturing—lesion at or below red nucleus, presents with extension of upper and lower extremities. WORSE PROGNOSIS Caloric stimulation: performed by irrigation of the external auditory canal with cold water Normal: transient, conjugate, slow deviation of gaze to the side of the stimulus followed by saccadic correction midline. A caloric response cannot be voluntarily suppressed, therefore, the normal reaction = nothing is wrong

Answer 48

RF: Prematurity Lead exposure - GI blood loss Age<1 (delay introduction of solids/primarily breastfeeding after 6 months, consumption of cow, soy or goat milk before 1y/o) Age >1 (consumption of >24oz cows milk per day, <3 servings of iron-rich foods) Labs: - Mentzer index (MCV/RBC) >13 - 1st decease in Ferritin --> decrease in serum iron and transferrin saturation --> decrease reticulocyte count as bone marrow is unable to produce prerequisites for RBC --> decrease MCV (microcytic) and MCHC (hypochromatia) Tx: iron supplement with vitamin C - retic count increases in 1-2 weeks - Hgb and hematocrit increase ~1month ________________________________________________ Absolute iron deficiency - Depleted iron stores, low ferritin, high iron responsiveness Functional from erythropoiesis-stimulating agent: - insufficient iron to accomodate accelerated erythropoiesis, Normal to high ferritin, High iron responsiveness. Functional from anemia of chronic disease: - iron sequestered in macrophages and cannot be mobilized. normal to high ferritin, low iron responsiveness

Answer 49

Plantarflexes the food Complete rupture - Dx with calf squeeze test aka Thompson test --> absence of PASSIVE plantar flexion ACTIVE plantar flexion can still be present with complete rupture because action fo accessory muscles

Answer 50

Dx: - Superficial wounds cx are inaccurate and should not guide therapy - Bone biopsy with culture are gold standard!

Answer 51

Occurs with the initiation of chemotherapy Labs - HyperPhos + CaPhos stones --> AKI and Hypocalcemia - Hyperkalemia --> arrhythmia - Hyperuricemia --> Uric acid stones --> AKI Tx: IVF + Rasburicase (metabolizes uric acid that is already made). Allopurinol and febuxostat: prevent production of uric acid

Answer 52

Cricothyrotomy is faster, easier and lower risk of hemorrhage. Does not need full anesthesia Tracheostomy needs full anesthesia therefore not used emergently. Signs of failed extubation - post-extubation stridor with no improvement with conservative measures - RR >25 - hypoxemia

Answer 53

Sx: - C - Hypercalcemia d/t bone demineralization with osteoLYTIC lesions --> Tx: hydration and dexamethasone, bisphosphonate - R - Renal insufficiency d/t congestion of glomerulus with light-chain --> Tx plasmapheresis or dialysis - A - Anemia - B - Back pain --> Bisphosphonate helps prevent Dx: - Serum or urine protein electrophoresis (Urine dipstick usually detects albumin) - Cross-secional imaging with whole-body CT, MRI or positron emission tomography scan. - Some cases also have cryoglobulins (type 1) and precipitate intravascularly, causing symptomatic occlusion. Comp: Hyperviscosite syndrome d/t excessive monoclonal IgM --> Tx with plasmapheresis

Answer 54

Technetium-99m pertechnetate scan --> Meckel's Technetium-99m bone scintigraphy scan --> detects bone remodeling, osteoblastic bone lesions Plan xray and positron emission tomography (PET) are better for osteolytic lesions

Answer 55

Remove contaminated apparel Cool compress Topical corticosteroids - Antihistamines are not effective

Answer 56

Boerhaave: - Transmural esophageal rupture --> mediastinitis --> fever. Mediastinitis has a high mortality rate if not treated within 24hrs. Can also cause a pleural effusion, pneumomediastinium, pneumothorax - Dx: Chest xray, Esophography or CT with water-soluble contrast - Tx: acid suppression, Abx, NPO, Emergency surgical consult ______________________________________________ Mallory: - Partial tear of mucosa --> hematemesis - Dx: Upper GI endoscopy - Tx acid suppression but will heal spontaneously. _______________________________________________ Eosinophilic Esophagitis Path: Th2 response to food antigens Association: Atopic disease (asthma, eczema, food allergy, allergic rhinitis) Sx: dysphagia, heartburn/epigastric pain refractory to PPI, regurgitation, food impaction Dx: Endoscopy w/biopsy (concentric rings, strictures, and linear furrows) Tx: Elimination diet, PPI, Topical steroids _______________________________________________ Diffuse esophageal spasm Path: Uncoordinated simultaneous contractions of the esophageal body Sx: intermittent CP, dysphasia of solids & liquids DX: - Manometry: intermittent paralysis, multiple simultaneous contractions - Esophagram: corkscrew pattern TX: CCB, Alternates – nitrites and tricyclics ______________________________________________ Barrett esophagus - Intestinal metaplasia in distal esophagus (replacement of squamous with columnar thats red and velvety) - Premalignant condition for adenoma RF: Chronic GERD, white, race, family sx, age >50, obesity, smoking Management: PPI. If dysplasia --> scope

Answer 57

Prerenal: - decrease renal perfusion - BUN/Cr >20 - FeNa <1% Acute tubular necrosis: - Tubular injury - BUN/Cr normally (10-20) - FeNa >2% - Muddy brown cast Postrenal: - Urinary obstruction - BUN/Cr variable - FeNa variable - AKI is rarely caused by unilateral urethral obstruction because thAme renal functional reserve of the contralateral kidney allows filtration of the entire blood supply, creatinine remains normal. Diabetic kidney disease - Hyperfiltration--> increased hydrostatis pressure --> glomerular capillary sclerosis and the gradual progression. - Tx: ACE and ARB inhibitors decrease GFR --> reduce hydrostatic pressure --> slowing progression of DKD

Answer 58

- Wrap in sterile gauze, moistened with saline and placed in a sealed, sterile plastic bag. - The bag should then be placed in a chill container with ice and saline or sterile water.

Answer 59

Sx: - back pain with morning stiffness which improves with exercise. Reduce range of forward flexion and chest expansion. Dx: - Plan x-ray of sacroiliac joint to see spondylitis. If negative and there is high clinical suspicion, CT or MRI can be used. - Repeat x-ray used to check disease progression (lumbar, cervical and sacroiliac joint and hip) in addition to ESR. Comp: - Restrictive lung disease - Cauda equina syndrome - Regular aerobic exercise (swimming, walking, bicycling) can improve joint stability, strength and overall function. - No change in life expectancy

Answer 60

Preceded by a GI illness (campylobacter) or respiratory infection --> cross-reacting antibodies to peripheral nerve components. Must trend vital capacity and negative inspiratory force to monitor respiratory status. Tx: - Plasma exchange or IVFIG if nonambulatory and within 4 weeks of sx onset. - Those who are ambulating and recovering do not require treatment. The weakness may improve spontaneously, but tx shortens the time required for recovery. Campylobacter tends to worsen presentation and course of illness.

Answer 61

Myxoma - Most common - “ball valve” obstruction in the left atrium (associated with multiple syncopal episodes) - Histo: mucopolysaccharides stroma/gelatinous material and blood vessels- - Comp: Can embolism --> strokes Rhabdomyomas: - Most frequent 1° cardiac tumor in children (associated with tuberous sclerosis). - Histology: hamartomatous growths.

Answer 62

ITP - Viral illness --> platelet autoantibodies - Sx: petechiae, ecchymosis, mucosal bleeding (epistaxis, hematuria) - Labs: isolated thrombocytopenia <100,000, few plts on peripheral smear - Tx: ---Children: acute and self-limiting, observe if cutaneous sxs only. IF ACTIVELY BLEEDING: glucocorticoids, IVIG, or anti-D ---Adults: chronic, observe if cutaneous AND plt >30,000. If bleeding OR plt <30,000: Glucocorticoids, IVIG, or anti-D - Rituximab if failed above therapy. - Splenectomy is last resort. TTP: - Acquired or hereditary autoantibodies --> decrease ADAMTS13 activity -->uncleaved vWF mulitmers --> plt trapping and activation --> disseminated microvascular thrombosis - Sx: Always (abd pain/nausea, petechial rash). Sometimes (kidney failure, neurological manifestations, fever) - Labs: MAHA, thrombocytopenia, schistocytes, high LDH - Tx: plasma exchange, steroids, rutuximab. - Caplacizumab: prevent plt from binding to vWF and forming new clots

Answer 63

Anterior uveitis (iritis) Sx: Pain, redness, visual loss, constricted and irregular pupils. Dx: slit lamp exam showing leukocytes. Tx: antibiotics or topical steroids ________________________________________________ Infectious keratitis (infection of cornea): Sx: severe photophobia with difficulty keeping eyes open. Dx: Penlight exam shows corneal opacity or infiltrate. Comp: permanent visual impairment or blindness 1. Baterial: most commonly Staph aureus and Pseudomonoas. RF: improper contact lens use, corneal trauma, foreign body. Dx: ulcer, stromal abscess, purulent discharge. Tx: topic antibiotic 2. HSV: common in immunocompromised or HIV patients. Dx: branched dendritic ulcers, decreased corneal sensation, watery discharge. Tx: topical or oral antiviral 3. Fungi: most commonly Candida. common in immunocompromised with corneal injury with contaminated soil. Dx: ulceration with feathery margins & satellite lesion, purulent discharge. Tx: topic or oral antifungal ______________________________________________ Endophthalmitis - infection of the structures and fluid chamber of the eye - RF: hospitalized patients with indwelling catheters, GI preformation, immunocompromised, total parenteral nutrition. - Sx: Begin with floaters --> loss of visual acuity --> eye pain - Dx: Blood culture, vitreous fluid sampling and culture - Tx: fluconazole or voriconazole , vitreous injection with amphotericin B or voriconazole, and vitrectomy (eliminated fungal microabscesses)

Answer 64

Hypermetabolic response - Within first 5 days of event Path: Release of inflammatory mediators from damaged tissue —> increase catecholamines, glucocorticoids & glucagon. Sx: - Increased basal body temperature - Hyperdynamic circulatory response: HTN, tachycardia - Increase gluconeogenesis and insulin resistance --> persistent hyperglycemia. - Increase protein and lipid metabolism --> lean muscle wasting Tx: nutritional support, anabolic steroid therapy ie.Oxandrolone which is a synthetic testosterone analog that enhances protein synthesis and decreases protein catabolism. For electrical burns: Evaluation includes EKG, urine myoglobin (to evaluate for excessive muscle tissue breakdown) For high-voltage: serum electrolyte, creatinine phosphokinase, kidney function, and troponin

Answer 65

Oropharyngeal damage --> hoarseness, unable to control secretions, edema, necrosis with grey pseudomembrane, respiratory distress. LARYNGOSCOPY should be used to assess impending airway compromise. Then undergo endoscopy within 24hrs to determine severity.

Answer 66

- Dihydropyridine calcium channel blockers (act on smooth muscles): Amlodipine, clevidipine, nicardipine, nifedipine, nimodipine. - Diltiazem also proven to help - If resistant, obtain further work up with ANA, RF, CBC, CMP, UA and complement levels.

Answer 67

Cause: Abnormal spasm or diminished relaxation of the cricopharyngeal muscles during swallowing (cricopharyngeal motor dysfunction). This increases intraluminal pressure --> herniation of pharyngeal mucosa through a zone of muscle weakness (false diverticulum) in the posterior hypopharynx (Killian triangle).

Answer 68

CBT is preferred initial therapy, esp in the elderly.

Answer 69

Significant risk of development of premature coronary atherosclerosis and CAD d/t HTN, hyperlipidemia, chronic inflammation and glucocorticoid use. Lupus Nephritis - Labs: proteinuria, hematuria, dysmorphic RBC and casts - Dx: renal biopsy - Tx: steroids and cyclophosphamide - Monitor renal disease activity: Complement and Anti-dsDNA

Answer 70

Tx: 1st. Wrist splinting 2. glucocorticoids injection 3. Surgery Can be used preoperatively or to diagnose if unsure: Nerve conduction studies or Electromyography

Answer 71

Consequence of chronically elevated inflammatory cytokines, most importantly hepcidin.

Answer 72

Onset usually 24-72hrs following inciting events Sx: - Respiratory distress - Neurological dysfunction - Petechial rash Prevention & Treatment - Early fracture immobilization & fixation - Supportive care

Answer 73

Path: decrease hepatic conjugation of bilirubin Sx: recurrent episodes of mild jaundice provoked by stress (febrile illness, fasting, dehydration, vigorous exercise, menstruation, surgery) Tx: benign, no tx

Answer 74

Cognitive test: MMSE, Montreal Cognitive Assessment, Mini-COG Lab test: CBC, Vit B12, TSH, CMP. Possibly folate, syphilis, vit D levels. Rarely CSF Imaging: CT scan or MRI or brain. Rarely EEG Path: amyloid build up --> neuronal stress --> excitotoxicity (glutamatergic NMDA overactivity ) --> neuronal degeneration --> diffuse cortical atrophy - Loss of cholinergic neurons --> impairs memory and cognition Tx: - Acetylcholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine - NMDA receptor antagonist: memantine, serves as a neuroprotective role No medication is disease-modifying but for symptomatic treatment - Respite care an help with home services, adult day centers, and overnight are

Answer 75

Path: - Progressive tissue fibrosis - Vascular dysfunction - Abnormal deposition of collagen in multiple organ systems - Pulmonary arterial HTN d/t abnormal inflammatory and fibroproliferative signaling --> thickening and luminal narrowing. - Fibrotic interstitial lung disease d/t lung parenchymal inflammation and collagen deposition: This would lead to a restrictive lung disease. Sx: Skin : telangiectasia, sclerodactyly, digital ulcer, calcinosis cutis - Extremities: arthralgia, myalgia, contractures - GI: esophageal dysmotility, dysphagia, reflex - Lungs: dyspnea, dry cough - Vascular: Raynauds Labs: - ANA - Anti-topoisomerase Tyle 1 (Anti-Scl 70) (diffused SSc) - Anticentromere (limited SSc) Tx: - ACE (esp captopril): renal crisis - Nitroprusside for a short duration): lower BP - Calcium channel blocks for Raynaud's Comp: - Lung: interstitial lung disease, pulmonary arterial HTN - Kidney: HTN, Scleroderma renal crisis (severe HTN, AKI, MAHA) - Heart: myocardial fibrosis, pericarditis, pericardial effusion

Answer 76

Sx: changed in temp, abd pain/tenderness, paralytic ileus , AMS, Hypotension Ascitic fluid - Neutrophils >250 - Positive culture - < Proteins - Serym ascities albumin gradient >1.1 Tx: 3rd gen Cephlosporine and albumin , Fluoroquinolones for ppx Predictor of mortality: bili, INR, creatinine, Na

Answer 77

Sx: - Hypertension and tachycardia - Coronary vasoconstriction - Increase platelet activity and thrombus formation - Myocardial ischemia and infarction - Aortic dissection - Neurologic ischemia or stroke Tx: - 1st line: Benzodiazepine and nitroglycerin - 2nd line: CCB for persistent CP - Another 2nd line: Phentolamine (alpha-blocker) - Beta-blockers should be avoided - Percutaneous coronary intervention for myocardial infection

Answer 78

RF: - #1: Chronic HTN - Underlying aortopathy (Marfan syndrome) - Cocaine use Sx: - sever, tearing cast pain or back pain - Variation of SBP between arms by >20mmHg - Hypertension usually present Dx: - ECG: normal or nonspecific ST & T-wave changes - Chest x-ray: mediastinal widening - CT angiography and TEE for definitive diagnosis Tx: - Pain control (morphine) - IV beta blockers (esmolol) - Sodium nitroprusside (if SBP >120 after beta blocker) - Emergency surgery repair for ascending dissection

Answer 79

- Locally aggressive benign tumor arising from fibroblastic elements within the muscle or fascial planes (connective tissue). - They are characterized by their locally invasive behavior and high recurrence rates, but they do not metastasize. - Associat3d with familial adenomatosis polyposis (Gardner syndrome) - Can be located in trunk /extremity, intraabdominal bowel and mesentery, and abdominal wall. - Can cause intestinal obstruction and bowel ischemia - Dx: CT or MRI w/histology - Tx: surgery

Answer 80

Pineal gland Parinaud syndrome: - limitation of upward gaze - light-near dissociation (pupils reactive to accommodation but not light) - Convergence retraction nystagmus and bilateral eyelid retractions - Ataxia - obstructive hydrocephalus _________________________________________________ Pituitary adenoma: - Gonadotrophs secrete LH and FSH which have an alpha and beta subunit. Dysfunctional gonadotrophs adenomas secrete only alpha subunit. - Thyrotrophs secrete TSH --> elevated TSH, T3 and T4 --> hyperthyroid sx - Radioiodine uptake diffusely increased Dx: MRI Tx: transsphenoidal surgery _______________________________________________ Prolactinoma: - Prolactin >200 - Tx: Cabergoline ________________________________________________ Craniopharyngioma and pituitary tumor: Suprasellar and compress optic chiasm

Answer 81

Aka pseudotumor cerebri Risk factors - Female gender - Tetracyclines - Obesity - Vitamin A excess - Danazol Path: Increased ICP d/t impaired CSF resorption and intracranial venous hypertension Sx: - HA (worse when lying flat), N/V - Vision changes - CN VI palsy (impaired abduction) - Pulsatile tinnitus (rhythmic whooshing sound) - Retrobulbar pain/neck pain/back pain Dx: - Papilledema and enlarged blind spot - 1st image:CT or MRI to r/o mass, hydrocephalus - MRV to rule out venous thrombus - If negative, the perform LP - Opening pressure >250mmH2O is diagnostic Tx: - Weigh loss, including bariatric surgery - Carbonic anhydrase inhibitor (acetazolamide, topiramate)

Answer 82

Path: reduced PiO2 Physiologic response: - Hyperventilation: increases PaO2 but decreases PaCO2 - Erythrocytes: more O2 unloading in tissues - Kidney: increase EPO production and increase HCO3 excretion Comp - Acute mountain sickness: HA, fatigue, N - Cerebral edema: increased cerebral blood flow --> lethargy, confusion, gait disturbances - Pulm edema: hypoxic pulmonary vasoconstriction --> increase pulmonary arterial pressure --> alveolar-capillary membrane disruption --> dyspnea, cough, +/- hemoptysis, respiratory distress Tx: supplemental oxygen, descent to lower altitudes

Answer 83

Benign epithelial liver tumor Primarily young women on oral contraception Sx: - Often asymptomatic - Episodic abdominal pain - LFT wnl DX: - CT scan with contrast showing a well-demarcated lesion w/peripheral enhancement TX: - Asx and < 5 cm: stop oral contraception - Sx or > 5 cm: surgical resection Comp: - 10% malignant transformation - Rupture and hemorrhage

Answer 84

Small Cell * Cushing's Syndrome: ACTH , bilateral adrenal hyperplasia & diluted hypernatremia * Syndrome of Inappropriate ADH secretion (SIADH) * Myasthenic like syndrome/Lambert Eaton Syndrome * Gastrin releasing peptide --> ulcers * Calcitonin * Growth Hormone secretion Squamous Cell * Hypercalcemia: PTH related peptide * Dermatomyositis Dx: CT or PET scan and radionuclide bone scan to determine nodal involvement and distant metastases to determine treatment approach Screening Age 50-80: Low dose CT scan of chest YEARLY if 1. >20 pack year history AND 2. Currently smoking or quit smoking within the past 15years - If you stop smoking >15 years ago if you have medical condition that limits life expectancy, you can stop screening. Smoking cessation reduced the risk of COPD exacerbation (decreases progression of pulmonary function decline), and lung cancer

Answer 85

Describes a large area of cells within a field that are “primed” to develop cancer because of widespread exposure to mutagens (ex tobacco). Even with adequate treatment of the initial malignancy, the area affected by field cancerization remains at high risk for the development of multiple primary malignancies. Common for HNSCC, basal cell carcinoma, colorectal carcinoma

Answer 86

Transverse: - segmental spinal cord inflammation --> extreme weakness - Clear sensory level - No focal vertebral tenderness Dx: MRI to rule out masses vs abscess, but can also show enhancement of affected spinal cord Tx: 3-5 days of high dose steroids Spinal epidural abscess - Fever, focal/severe back pain, neurologic changes, Increase ESR

Answer 87

If patient has AMS, silent chest, high WOB with normal or high PaCO2, or sever hypoxemia --> ICU,trial noninvasive, intubate if needed If none of the above sx are present: SABA + SAMA, IV mag, steroids

Answer 88

Usually familial with AD inheritance Most common congenital heart disease in adults Can be isolated or associated with other cardiac abnormalities - Bicuspid aortic valve is also a risk factor for aortic dilation and can lead to aortic aneurysm and dissection _________________________________________________ Mechanical value All patients must be on lifelong anticoagulation after valve implantation. Warfarin (Vit K antagonist) is the only acceptable oral anticoagulation agent. Aspirin is only added if patient also has a separate, strong indication. Want to keep INR 2-3 Mitral valve has increase risk so INR should be 2.5-3.5

Answer 89

Tx: - Hormone therapy - Chemo - If refractory to hormone therapy: Focal external beam radiation therapy Surveillance: Radionucleotide whole body scan is preferred in this case

Answer 90

1: Insulin: drives K into the cell 2. Glucose: counter insulin hypoglycemia 3. Calcium gluconate: stabilize cardiac membrane Comp: Iatrogenic hypoglycemia Most monitor glucose closely.

Answer 91

Loss of cremaster reflex, diminished testicular sensation, bladder dysfunction, inability to masturbate

Answer 92

Td/Tdap: >19y.o then every 10 years Influenza: Annually Zoster: >50 y.o, 2 dose series 2-6 months apart Pneumococcus: - 19-65 y/o with increase risk with DM, heart, lung, liver or kidney disease, current smoking or alcohol disorder, impaired immune function: 1 dose of PCV20 OR sequential PCV15 + PPSV23 (8 weeks apart) - >65 y/o: 1 dose of PCV20 OR sequential PCV15 + PPSV23 (>1 year apart) CONJUGATE JUST BE GIVEN FIRST, THEN POLYSACCHARIDE

Answer 93

Hypertensive emergencies typically occur in patients with pre-existing essential hypertension and may be induced by medication non-compliance, resulting in rapid increase in systemic blood pressure. These are acute changes Kidney: malignant nephrosclerosis 1. Fibrinoid necrosis: cell death and excessive fibrin deposition within the arterial walls --> circumferential, amorphous, pink material with sludge, necrotic endothelial cells that lack cytologic detail 2. Hyperplastic arteriolosclerosis: activated, platelets and injured endothelial cells released growth factors —> concentric hyperplasia and layering of smooth muscle cells and collagen —> intimal thickening and an onion skin appearance. Eyes: papilledema, retinal hemorrhages Lungs: pulmonary edema Heart: acute coronary syndrome Brain: encephalopathy, stroke

Answer 94

- Abscess formation with purulent or serosanguineous drainage - Multiple recurrent nodules with sinus tracts, comedones and scarring. Tx: - weight loss, smoking message - Daily skin cleaning Mild stage: - Topical clindamycin - Intralesional steroids or oral antibiotics for flare-ups Moderate stage: - Oral Tetracycline - Oral clindamycin + rifampin in refractory cases Severe stages: - Biologic TNF alpha inhibitors (infliximab) - Oral retinoids - Surgical excision ***Try to avoid I & D because it does not provide long-term improvements.

Answer 95

Juvenile - Adolscents - Absence seizures - Morning myoclonus - Generalized tonic-clonic seizures Dx: Bilateraly polyspike & slow wave activity Tx: - Valproic acid - Avoid triggers (alcohol, sleep deprivation) ____________________________________________ Temporal lobe Focal seizures occurring in a small part of the cortex (temporal is most common) Sx: - Automatism (fumbling, picking, lip smacking) - Sensory aura (smell, taste, fear, deja vu) - Short postictal confusion (<1hr) - Impaired awareness - Secondary generalization of tonic-clonic seizures Dx: EEG or MRI

Answer 96

Sx: - Most patients are asx - Bone deformities with enlargement, hearing loss, dizziness - Bone, pain, spinal stenosis, nerve compression - Bowing deformities of long bones with increasing risk for fracture. - Bone tumor: osteosarcoma, giant cell tumor. Labs: - Calcium and phosphorus are normal - Alkaline phosphate is elevated DX: radionuclide bone scan. TX: #1 - bisphosphonates to reduce bone turnover. Calcitonin can also be used

Answer 97

With pulmonary edema, alveoli become flooded and unable to fill with gas. There is still perfusion but no ventilation, leading to V/Q ratio reaching zero. Shunting: Because blood passing through the lungs return to the left atrium without being oxygenated, this situation is analogous to right to left anatomical shunting and is termed intrapulmonary shunt effect. This situation is not corrected by 100% supplemental oxygen, however, PEEP reduces the shunt by propping the alveoli open and increasing the surface area. Anatomical death space Refers to the volume of air that never reaches the alveoli. Increase in anatomical space causes less air to reach the alveoli leading to worsening hypoxia.

Answer 98

- Caused by ingestion of poorly stored seafood - Histidine can undergo decarboxylation and form histamine Sx: - flushing, - throbbing HA - Palpitation - abdominal cramps - Diarrhea - Oral burning - Skin erythema, wheezing, tachycardia, hypotension Self limiting

Answer 99

MRI of brain CSF with oligoclonal bands CSF IgG elevated Impaired adduction with contralateral nystagmus Sx of transverse myelitis

Answer 100

- cough >5 days but <3 weeks - purulent yellow/green sputum is common and not a sign of bacterial infection - absent systemic findings( fever, chills) - wheezing or rhonchi, chest wall tenderness Dx: - Clinical - Chest x-ray only if PNA suspected - Symptomatic treatment - Abx NOT recommended

Answer 101

Epigastric pain/burning Postprandial fullness, early satiety, bloating Dx: Low malignancy risk ( <60 & no alarm sx) - Test and treat for H. Pylori High malignancy risk (>60 or alarm sx) - Upper endoscopy **Alarm sx*** Bleeding, weight loss, IDA, lymphadenopathy, dysphagia, odynophagia, persistent vomiting, palpable mass, family history of upper GI cancer Tx: - Treat underlying cause - Trail PPI if no cause found

Answer 102

Lactose intolerant: - Diarrhea after lactose-containing meals - Increase stool osmotic gap - Decrease stool pH - Positive lactose hydrogen breath test Celiac disease - Increased stool osmatic gap - Microcytic anemia, iron deficiency anemia - Villous atrophy with lymphocytes

Answer 103

SCC: - Nest and sheets of polygonal cells with abundant eosinophilic cytoplasm that invade the submucosa and surrounding structures - intercellular bridges and keratin pearls. Squamous papilloma: - fibrovascular core surrounded by squamous epithelium Adenocarcinoma - glandular structures with drops of mucin

Answer 104

1st step: UA and urine cx Infection ? --> Abx Proteinuria or cast? --> glomerular dx --> renal US, urine studies, possibly biopsy Other cause suspected? --> CT, cystoscopy, or urine cytology Proteinuria Management urine protein creatinine ratio _____________________________________________ Orthostatic proteinuria - Higher protein excretion when upright vs laying down - Can collect urine protein creatinine ratio when both supine and standing. - Can compare protein excretion in a split 24hr urine collection divided into daytime and nighttime. - Benign condition that resolved spontaneously

Answer 105

Comp: septic embolism --> mycotic aneurysm --> hemorrhage

Answer 106

Ocular, sensory, bowel, bladder and cognitive function is preserved Tx: Riluzole (glutamine inhibitor) which can help prolong survival and delay need foe tracheostomy

Answer 107

Migraine Acute: NSAIDs, Triptan, Dihydroergotamine PPX: Lifestyle changes, Amitriptyline (TCA), Beta blockers, topiramate, valproate Tension: Acute: NSAIDs, Acetaminophen Chronic: Amitriptyline (TCA) Cluster Acute: Sumatriptan (Triptan- 5HT agonist), 100%O2 for 15min PPX: Verapamil, lithium, topiramate Can also perform MRI to r/o structural causes

Answer 108

Interstitial nephritis Causes: - Meds: Abx, NSAIDS, PPI - Rheumatologic disease: SLE, Sjogren, Sarcoidosis - Infection: Legionella, TB, CMV Sx: - New medication exposure - AKI - Arthralgias, malaise - Classic triad: Fever, skin rash, eosinophilia Dx: - UA: ***WBC*** and WBC cast +/- mild RBC & proteinuria - Peripheral eosinophilia - Renal biopsy: tubulointerstitial inflammation & edema Tx: - Discontinue offending drug or treat underlying condition - Systemic steroids - Supportive hemodialysis if needed ________________________________________________ Renal papillary necrosis - sloughing of necrotic medullary cells caused by prolonged renal ischemia (sickle cell disease) or oxidative damage (analgesic nephropathy) Sx: hematuria, flank pain

Answer 109

Stage 1: nonblanchable erythema of intact skin Stage 2: superficial causing partial thickness loss of epidermis, dermis or both Stage 3: deeper causing full thickness loss with damage to subcutaneous tissue but may extend to but not through underlying fascia. Stage 4: very deep causing full thickness with extensive tissue destruction that can damage adjacent muscle, bone and supporting structures. Tx: - Partial thickness require occlusive or semipermeable dressing. - Full thickness require debridement of necrotic tissue - All: repositioning , pain control, nutritional support

Answer 110

S - Snoring T - Tiredness (day time) O - Observed apnea or choking/gasping P - Pressure (high) B - BMI >35 A - Age >50 N - Neck size. Men (>17in). Women (>16in) G - Gender (male) Can have chronic respiratory acidosis , which is a clue for comorbid obesity hyperventilation syndrome

Answer 111

Legally mandates if: - Suspect a crime, suicide, medical malpractice - Unexplained death in otherwise healthy person - Infectious disease or other public health concerns - Inmate death ***Medical examiner is most likely the designated person to determine if autopsy is mandated. If determined, it is not optional and does not require consent from family.

Answer 112

Sx: - severe sore throat - Fever - "Hot potato" voice - Dysphagia Tx: Alarming signs - Tripod position - Inability to lie flat - Severe respiratory distress Tx: Secure airway, ENT consult, drain in OR, Abx Signs of deep neck space infection - Neck pain or stiffness on extension - Neck tenderness or swelling - Bulging of posterior pharyngeal mucosa - Chest pain Tx: CT neck w/contrast Clinical dx of peritonsillar abscess: - Trismus (cant open mouth) *** - Unilateral swelling - Uvular deviation - Fluctuant bulging of soft palate Tx: Need aspiration or I&D, Abx

Answer 113

Central retinal artery occlusion - Severe vision loss w/temporal sparing - Pale fundus with "cherry red spot" Central retinal vein occlusion - Acute onset, monocular - Blurred vision to severe vision loss - Fundus with retinal hemorrhages & optic disc edema Retinal detachment - Floaters, photopsia "flashing lights", progressive field defect Vitreous hemorrhage - Hazy vision +/- red hue or vision loss - Floaters/shadows

Answer 114

RF: - Advanced age and other osteoporosis RF - Weeks to months of pain in groin, hip, or back - Atraumatic or following minor trauma PE: - Leg length discrepancy - Local tenderness - Inability to raise leg or pain with active flexion Dx: - Plan x ray - MRI if xray is negative Tx: - Medication for pain relief - Early mobilization (nondisplaced fracture) or surgical intervention, depending on fracture type

Answer 115

A PFO (patent foramen ovale) does not directly cause DVT (deep vein thrombosis) or pulmonary embolism, but it can significantly increase the risk of paradoxical embolism, where a blood clot from a DVT travels through the PFO to the systemic circulation, potentially leading to a pulmonary embolism if the clot lodges in a lung artery; therefore, a PFO is considered a risk factor for developing a pulmonary embolism if a DVT is present.

Answer 116

Elevated ammonia d/ precipitating events Precipitating factors: - Drugs (sedation, narcotics) - Hypovolemia (diarrhea) - Electrolyte changes (hypokalemia) - Increased nitrogen load (GI bleeding) - Infection (PNA, UTI, spontaneous bacterial peritonitis) - Portosystemic shunting Sx: - Sleep pattern changes - Altered mental status - Ataxia and Asterixis Tx: - Correct precipitating causes (IVF, Abx) - Correct electrolytes - Decrease blood ammonia concentration (lactulose, 2nd line is rifaximin), to a goal of 2-3 bowel movements per day

Answer 117

2/2 chemotherapy and radiation Radiation causes diffused fibrosis in the interstitium of the myocardium, along with progressive fibrosis of the pericardial layers, cells in the conduction system, and the cusps and/or leaflets of the valves. it also causes injury to the interim layers, with arterial narrowing typically involving the postal parts of the coronary vessels. Leads to 1. myocardial ischemia and infarction d/t effect of cardiac arteries 2. restrictive cardiomyopathy and diastolic dysfunction 3. Constrictive pericarditis 4. Valvular abnormalities (mitral or aortic stenosis/regurg) 5. Conduction defects (sick sinus syndrome or variable degrees of heart block). _______________________________________________ Anthracycline class drugs use dilated cardiomyopathy

Answer 118

Sx: abd pain, N/V, altered bowel movements, fever, possible sterile pyre Dx: CT scan of abdomen Tx: bowel rest, abx (ciprofloxacin, metronidazole), liquid diet, Colonoscopy in 6-8 weeks after resolution. Comp: abscess, obstruction, fistula, perforation Most abscesses require percutaneous drainage, IV abx followed by possible colectomy every weeks later

Answer 119

Post concussion syndrome Any form of traumatic brain injury can lead to postconcussive syndrome, which includes the following constellation of symptoms: headache, confusion, amnesia, difficulty to concentrate or with multitasking, vertigo, hypersensitivity to various stimuli, mood alterations, sleep disturbances, and anxiety. Can take weeks to months to resolve and can be persistent for >6 months.

Answer 120

Some helpful preventions - Muscle strength and balance training - Withdrawal of psychotropic medications - Home hazard evaluation and modifications by a trained professional

Answer 121

critically ill patient typically develop intracellular phosphate deficiency TPN has dextrose --> increased insulin --> more phosphate into cells for oxidative phosphorylation --> hypophospatemia Patients on TPN should be monitored for Mg, Phosphate and triglycerides

Answer 122

Sx: - CP, lightheaded, syncope - Death Dx: EKG: wnl - TTE can sometimes make the diagnosis - CT coronary angiography pr coronary MRI is the best test HOCM Murmur increase in intensity with standing = decreased VR

Medicine Flashcards

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