Medicine Flashcards
1
Q
Most common cause of odynophagia/dysphagia in HIV patient
A
candidal esophagitis (presents w/thrush)
2
Q
Tx of candidal esophagitis
A
1 - 2 week course of fluconazole + biopsy if refractory
3
Q
HIV patients with severe odynophagia without oral thrush
A
ulcerative esophagitis from CMV
4
Q
Tx of CMV ulcerative esophagitis
A
ganciclovir
5
Q
Presentation of CMV ulcerative esophagitis
A
focal substernal burning pain with odynophagia + large, shallow, superficial ulcerations (linear) + intranuclear and intracytoplasmic inclusions + distal esophagus
6
Q
Tx of apthous ulcers
A
prednisone
7
Q
Presentation of HSV esophagitis
A
multiple, small, well-circumscribed volcano-like ulcers + ballooning degeneration and eosinophilic intranuclear inclusions
8
Q
Tx of HSV esophagitis
A
acyclovir
9
Q
Malaria ppx for ovale and vivax (Korea)
A
primaquine
10
Q
Malaria ppx for p falciparum (Africa, S. Asia, Amazon)
A
mefloquine, atovaquone-proguanil, or doxycycline
11
Q
Malaria ppx during pregnancy
A
mefloquine
12
Q
Adverse Effect of mefloquine
A
neuropsychiatric
13
Q
Presentation of Crohn’s
A
esophagus to anus, skip lesions, c/b strictures, anal fissures, intestinal fistula
14
Q
Lab findings of every chronic inflammatory disease can include…
A
anemia and thrombocytosis
15
Q
_____ is associated w/diarrhea and weight loss but does not cause significant abdominal pain and leukocytosis.
A
Celiac disease
16
Q
Diverticulitis is associated w/ constipation or diarrhea?
A
constipation
17
Q
UC or Crohn’s is associated with bloody diarrhea?
A
UC
18
Q
Suspect ____ in a young patient with chronic diarrhea, abdominal pain, and weight loss
A
IBD
19
Q
Most commonly involved bones in Paget’s disease of bone/osteitis deformans
A
femur, axial skeleton, skull
20
Q
How does osteitis deformans lead to deafness?
A
hypertrophy of the skull compresses vestibulocochlear nerve
21
Q
Lab abnormalities in Paget’s disease/osteitis deformans
A
normal calcium/phosphate
elevated alk phos from bone degradation
elevated hydroxyproline, deoxypyridinoline, N/C telopeptide AKA bone degradation markers
22
Q
_______ is associated with hypercalcemia, hypophosphatemia, and increased alkphos
A
hyperparathyroidism
23
Q
Hypercalcemia in the setting of normal phosphate and alkphos my be observed in ______
A
milk-alkali sydnrome
24
Q
Serum _____ is decreased in immune complex-mediated kidney disease such as SLE and poststrep glomerulonephritis
A
C3 is reduced because immune complex deposition triggers complement cascade AKA consumptive deficiency
25
IgE mediated kidney disease occurs in _____
allergic interstitial nephritis (e.g. methicillin induced nephritis)
26
In what disease do cytotoxic antibodies cause kidney damage?
goodpasture's
27
In what disease does delayed hypersensitivity cause kidney damage?
non-specific chronic glomerulonephritis
28
RA affects ___ joints
MCP and PIP
29
Gout: poly vs monoarticular
80% monoarticular
30
Characteristic radiographic findings in hemochromatosis-associated arthropathy
squared off bone ends and hook like osteophytes in second and third MCP
31
OA affects ____ hand joints
DIP
32
Major radiographic findings of OA in hands
joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts
33
Clinical features of PSC
fatigue and pruritis + underlying IBD (UC)
34
Biopsy findings of PSC
fibrous obliteration of small bile ducts with onion skin concentric replacement w/ connective tissue
35
5 complications of PSC
intra/extrahepatic biliary stricture
cholangitis/cholelithiasis (cholesterol and pigment stones)
cholangiocarcinoma
cholestasis (reduced fat soluble vitamins and osteoporosis)
colon cancer
+/- portal hypertension and liver failure
36
Lab findings of PSC
```
elevated liver function tests but <300
severely elevated alkphos and bilirubin
hypergammaglobulinemia
increased serum IgM
atypical perinuclear antineutrophil cytoplasmic antibodies
```
37
Dx of PSC
cholangiogram (ERCP/MRCP) showing multifocal narrowing w/intra/extrahepatic duct dilation AKA beading or liver biospy
38
Presentation of acute bacterial cholangitis
severe jaundice, fever, RUQ pain, leukocytosis
39
Women get PBC/PSC
PBC
40
Association of PBC w/ IBD
none
41
Adverse effects of digoxin
GI (anorexia, n/v)
Bidirectional ventricular tachycardia
Accelerated junctional rhythms
*verapamil reduces renal clearance of digoxin and increases toxicity
42
Presentation of pancreatitis
abdominal pain radiating to back
| n/v
43
Presentation of mesenteric ischemia
severe abdominal pain out of proportion to exam w/ risk factor like afib
44
Clinical signs of AVF
```
widened pulse pressure
strong peripheral arterial pulsation (brisk carotid upstroke)
systolic flow murmur
tachycardia
flushed extremities
displaced PMI
LVH on EKG
```
45
Cardiac consequence of AVF
increased preload, decreased SVR --> increased CO
| increased HR to meet oxygen requirements of peripheral tissues
46
Causes of high-output heart failure
thyrotoxicosis, AVF, paget's disease, anemia, thiamine deficiency
47
Dx of AVF
doppler u/s
48
Risk factors for acute diverticulitis
constipation and low fiber intake
49
Tx of diverticulitis
IV antibiotics
| CT those who are refractory to abx in case of complication (abcess, fistula, perforation)
50
Tx of progressive pain in pt w/prostate cancer and bony mets?
1. orchiectomy/androgen ablation
| 2. radiation
51
How effective is cervical cordotomy in controlling axial pain/pain in UE?
not effective
52
Aspirin sensitivity syndrome is believed to be a _______ reaction
pseudo-allergic reaction --> results from prostaglandin/leukotriene misbalance
53
Tx of aspirin sensitivity syndrome
leukotriene receptor antagonist
54
Presentation of aspirin sensitivity syndrome
hx aspirin ingestion
persistent nasal blockage
episodes of bronchoconstriction w/ periodic breathing difficulty +wheezing
55
Transmission of HepB
sex, IV drugs
56
What is fulminant hepatic failure?
hepatic encephalopathy w/in 8 weeks of onset of acute liver failure
57
Tx of FHF
1. TRANSPLANT
| 2. fresh frozen plasma + Vit K to manage coagulopathy
58
Tx of acute HepB
interferon + lamivudine
59
Presentation of HP
cough, breathlessness, fever, malaise 4-6 hours after antigen exposure
60
Chronic findings in HP
ground glass opacities w/honeycombing fibrosis w/haziness of the lower lung fields
weight loss, clubbing
61
Tx of essential tremor
beta-blockers
| primidone AKA phenobarb
62
Adverse effect of primidone
acute intermittent porphyria presents as abdominal pain, neurologic, and psychiatric abnormalities
63
Dx of acute intermittent porphyria
urine porphobilinogen
64
How effective is diazepam in treating essential tremor?
not.
65
Mutation associated with primary polycythemia vera
JAK2 V617F
66
Are serum epo levels high or low in polycythemia vera?
low b/c primary PCV is epo-independent RBC production
67
Presentation of polycythemia vera
headache, dizziness, visual disturbances, pruritis (from mast cell dengranulation), peptic ulcer (histamine), hypertension from blood volume, facial plethora, splenomegaly, hepatomegaly
68
Lab findings in polycythemia vera
elevated hgb/hct/platelets/wbc, thrombosis, bleeding, normal o2 sat, hypercellular bone marrow, normal/low ESR, low iron
69
BCR-ABL is usually seen in
CML
70
Does CML cause elevated hgb/leukocytosis/thrombocytosis?
leukocytosis and thrombocytosis but not hgb elevation
71
Extreme fatigue, malaise, sore throat, fever, maculopapular rash +/- posterior cervical lymphadenopathy and palatal petichiae and splenomegaly
mono
72
Lab findings in mono
leukocytosis w/variant/atypical lymphocytes + heterophile antibodies (may be negative early in illness)
73
Peripheral smear finding in ALL
blasts (easy to remember: young cells in young people)
74
Peripheral smear findings in CLL
mature small lymphocytes (remember: little old cells in little old people) --> leukemia of old age
75
Findings in CML
leukocytosis, basophilia, thrombocytosis, splenomegaly (no lymphadenopathy)
76
Peripheral smear findings in hodgkin's
normal blood smear, reed-sternberg cells in lymph node biospy
77
Cutaneous tumor with dome-shaped nodule and central keratinous plug
Keratoacanthoma
78
Cutaneous golf-ball size lesion
lipoma
79
Inflammatory ring-like skin lesions with peripheral scaling
fungal infection like tinea
80
Stuck on skin lesion, well circumscribed, scaley, hyperpigmented on trunk, face and UE
seborrheic keratosis
81
Clinical presentation of GBS
symmetric, ascending weakness w/ absent DTR after recent infectious illness
can have bulbar symptoms like dysphasia and respiratory compromise
mild sensory paresthesias and ataxia possible
82
Dx of GBS
LP: elevated CSF protein w/normal WBC AKA albuminocytologic dissociation
electromyogram
83
elevated CSF protein w/normal WBC
albuminocytologic dissociation feature of GBS
84
Tx of GBS
supportive care
| IVIG or plasmapheresis
85
Tx of myasthenia gravis
cyclosporine
| pyridostigmine
86
Clinical presentation of myasthenia gravis
often ocular symptoms (ptosis/diplopia) and fluctuating muscle weakness worse late in the day w/normal DTR
87
Findings in HSV encephalitis
AMS ,focal deficits, seizures, fever, lymphocytic pleocytosis on LP
88
Tx of HSV encephalitis
iv acylcovir
89
Tx of AML
riluzole
90
Which bug is classically associated with GBS?
c. jejuni
91
Serum findings in Vitamin D deficiency
low calcium and phosphate --> secondary hyperparathyroidism which brings calcium back up closer to normal and leads to further phosphate dumping to worsen hypophosphatemia
also low vitamin d and elevated alkphos
92
X ray findings in vitamin D deficiency
osteomalacia: decreased bone density w/ cortical thinning, codfish vertebral bodies and pseudofractures
93
Serum findings in primary hyperparathyroidism
elevated pth, elevated calcium, decreased phosphate
94
Serum findings in hypoparathyroidism
low calcium, low pth, high phosphate
95
Difference in presentation of osteoporosis and osteomalacia
osteomalcia: complaints of bone pain and muscle weakness w/xray findings of decreased bone density and pseudofractures
96
Presentation of respiratory TB
fever, night sweats, weight loss, cough +/- blood, CXR w/apical cavitary lesions +/- AFB stain
97
Most likely cause of ascites
cirrhosis from alcohol liver dz and hepC
98
Signs and symptoms of cirrhosis
asterixis, milkmaid sign, jaundice, terry's nails, palmar erythema, caput medusae, pruritis, confusion, spider angiomas, fluid wave/ascites, pleural effusion (low breath sounds), splenomegaly, decreased leukocytes (get stuck in spleen)
99
Most common cause of SAH
ruptured berry aneurysm
100
Clinical features of SAH
severe thunderclap headache @ onset of neurologic symptoms (focal deficits uncommon)
meningeal irritation w/neck stiffness
101
Complications of SAH
```
rebleeding (24h)
vasospasm (after 3 days)
hydrocephalus/increased intracranial pressure
seizure
hyponatremia from SIADH
```
102
Dx of SAH
noncontrast head CT w/ lp (xanthochromia after 6 hours onset) +/-cerebral angiography
103
Tx of SAH
coil w/ stent
| nimodipine and hyperdynamic tx to reduce vasospasm
104
When does Todd's palsy typically occur?
after focal motor seizure
105
_____ is the major cause of delayed morbidity and mortality in SAH and can result in cerebral infarct
vasospasm
give nimodipine
106
Presentation of subacute hydrocephalus post SAH
headache w/ progressive mental decline and multiple neurologic deficits from compression--> usually not unilateral
107
What kind of reaction is anaphylaxis?
Type 1 hypersensitivity w/ preformed IgE from previous exposure
108
Tx of anaphylaxis
epi (bronchodilation and vasoconstriction)
w/adjunct bronchodilator, anithistamine, steroid, more vasoconstrictors (dopamine)
109
Effect of increased pH on calcium
increase in albumin bound calcium (decrease in io calcium) --> features of hypocalcemia like crampy pain, paresthesias, carpopedal spasm)
110
Can you have signs of hypocalcemia w/a normal total calcium?
yes--> e.g. if you increase pH and reduce io calcium b/c it gets bound up w/albumin
111
Major causes of secondary bacterial PNA
strep pneumo, staph aureus, hflu
112
Which cause of secondary bacterial PNA can cause post-viral URI necrotizing pulmonary bronchopneumonia w/ nodular infiltrates and cavitary abscesses?
Staph aureus
113
What's a positive ppd?
>5 in HIV+, recent contact w/TB+ person, signs of TB on CXR, organ transplant/immunocompromised
>10 in recent immigrants, IV drugs, high-risk settings, diabetes, CKD, malignancy, fibrotic lung disease, kids
>15 healthy people
114
Tx of +PPD w/normal CXR
tx for latent tb: daily INH for six months or INH +pyridoxine for 9 months
115
Tx for active TB
INH + rifampin + pyrazinamide for 8 weeks followed by 5 months of INH and rifampin
116
Can cocaine cause ST elevations
yes via coronary vasospasm--> tx for STEMI
117
Can cocaine cause dissection
yes
118
What causes grave's opthalmopathy
autoimmune attack on EOM w/ lymphocytic infiltrate and causing edema, proliferation of fibroblasts, deposition of gag's which pushes out the eye--> associated with sandy/gritty eyes b/c of corneal exposure
119
Do thyroid hormone levels cause protopsis?
no --> graves causes lymphocytic infiltrate in EOMs that causes exopthalmos
120
Hypernatremia w/ urine osmolality < serum osmolality suggests
diabetes insipidus (dilute urine aka dumping water even w/hypernatremia)
central: usually higher [Na] b/c no thirst mechanism
- ->differentiate central and nephrogenic w/ desmopressin --> nephrogenic won't respond
121
How do we differentiate DI from primary polydipsia
water deprivation test- -> if urine osmolality increases, it's primary polydipsia
122
Tx of SIADH
demeclocylcine --> inserts aquaporins in cortical collecting tubule --> dilutes urine
can also use tolvaptan but has lots of adverse effects
123
Tx of nephrogenic DI
HCTZ
124
Tx of central DI
desmopressin
125
RUQ pain + n/v + fever + abdominal crepitus w/o peritonitis + air fluid levels in gallbladder + curvilinear gas shadowing in gallbladder
emphysematous cholecystitis --> gas forming bacteria (clostridium ,ecoli, staph, strep, psuedo, klebsiella) in older men
126
Risk factors for emphysematous cholecystitis
vascular compromise of cystic artery, immunosuppression, gallstones, infection w/gas forming bugs
127
Tx of emphysematous cholecystitis
fluid/electrolytes, chole, pip tazo or quinolone + flagyl
128
u/s findings in pt w/acute calculous cholecystitis
gallstones w/o air fluid levels or gas shadowing
129
radiographic finding in peptic ulcer perf
free air under diaphragm
130
Charcot's triad
jaundice, fever, RUQ pain = acute cholangitis due to biliary tract obstruction and post-obstructive infection
can be due to choledocholithiasis, biliary stenting, malignancy --> alk phos and wbc elevated
131
Hypercalcemia + lung malignancy = what cancer?
squamous cell AKA sCa++mous cell --> from pthrp which causes increased bone resorption and increased renal resorption in distal tubule
132
Paraneoplastic phenomena common in small cell lung cancer
siadh and acth production
133
Lung cancer associated w/hypertrophic pulmonary osteoarthropathy
adenocarcinoma
134
Tx of stroke w/ presentation 3-4 hours after symptom onset and no contraindictations
IV alteplase
135
Tx of stroke w/o prior antiplatelet tx
aspirin
136
Tx of stroke on aspirin tx
apsirin + dipyridamole or clopidogrel
137
Tx of stroke on aspirin tx w/ large intracranial atherosclerosis
aspirin + clopidogrel
138
Tx of stroke w/ afib
long term warfarin or dabigatran or rivaroxaban
139
Does early anticoagulation reduce risk of recurrent stroke?
nope (even in those w/afib) ...don't give heparin
140
What is the only tx that is effective in reducing risk of early recurrent stroke?
aspirin --> give w/in 24 hours in ischemic stroke
141
What should we think if a pt w/ COPD has clubbing
probs has cancer --> COPD doesn't usually have clubbing on its own
142
Skin findings in acute meningococcemia
petechial rash that progressis to ecchymosis, bullae, vesciles, and gangrenous necrosis + fever, n/v, myalgias, meningeal signs
143
Clinical findings in TSS
fever, hypotension, diffuse macular erythroderma, skin desquamation (1-2 weeks after), multi organ system failure
144
What toxin causes TSS
staph TSS toxin 1--> T cell activation and cytokine megahurricane
145
Why does Sjogren's cause firmness and enlargement of salivary glands?
lymphocytic infiltration
146
Which disease? Ro/SSA and La/SSB abs
sjogrens
147
Which disease? ama abs
PBC
148
Clinical findings in sjogren's
dry mouth/eyes AKA keratoconjunctivitis sicca and xerostomia
149
Tx of nephrolithiasis in pt's w/normal renal function
NSAIDs + fluid...narcotics cause n/v
150
Tx of hyperkalemia
1. calcium gluconate for arrhythmia
2. insulin/beta agonist for cellular shift
3. kayexalate aka sodium polystyrene sulfonate to poop it out
4. low k diet
151
What common medications cause sinus brady?
dig, beta blockers, ca channel blockers
152
1st and 2nd step in tx of sinus brady
IV atropine --> immediate increase in hr by reducing vagal input
transcutaneous pacing
only give epi if hemodynamically unstable
153
What is the role of adenosine in tx of arrhythmias?
helps identify supraventricular tachycardia by causing temporary av block
154
Tx of sinus brady in hemodynamically compromised
epi
155
Role of amiodarone in tx of arrhythmias?
supraventricular and ventricular tachycardias --> slows SA and AV node
156
De Quervain tenosynovitis
inflammation of pollicus tendons in mothers who hold their babies with thumb outstretched --> can elicit tenderness at radial side of wrist at base of hand
157
Pain w/ radial flexion of wrist and point tenderness over trapezium
flexor carpii radialis tenosynovitis
158
Multiple rib fractures + respiratory distress = consider ____
flail chest (esp if there is a visible lung contusion + fractures on CXR)
159
CXR appearance of esophageal rupture
subq crepitus in chest w/ pneumomediastinum
160
Classical feature of stage 1 hepatic encephalopathy
altered sleep pattern --> progress to stage 4 (stupor and coma) w/ addition of typical symptoms of HE
161
What can trigger hepatic encephalopathy?
anything that puts a load on the liver: hypoxia, toxins (like opiates), hypoglycemia, excess nitrogen load, gi bleeding, hypovolemia, infection, surgical shunting
162
Symptoms that help distinguish Legionella from other causes of CAP
high fever, GI symptoms, neurologic
163
Gram stain of legionella typically shows:
neutrophils w/no organisms (hard to stain)
164
Definitive dx of legionella CAP
growth on charcoal agar, urinary antigen testing
165
Tx of legionella CAP
azithromycin or levoflox
166
Ab of choice in aspiration pneumonia
clindamycin
167
Tx of pulmonary cryptococcal infection
fluconazole
168
Earliest renal abnormality in diabetic
hyperfiltration
169
Why do ACE-I help in diabetic nephropathy?
reduce glomerular hypertension --> reduce renal damage
170
Progression of diabetic nephropathy
glomerular hyperfiltration --> GBM thickening --> mesangial expansion --> nodular sclerosis
171
First quantifiable change in diabetic nephropathy
GBM thickening
172
Describe the pathogenesis of HIT
heparin + IgG + PF4 + platelet --> early activation of splenic macrophages to clear platelets + activation of platelets
== thrombocytopenia + arterial/venous thrombosis
173
Spontaneous hemarthrosis =
hemophilia
174
Most common cause of hemarthrosis
trauma > vascular damage > hemophilia
175
________ is characterized by fluctuating cognitive impairment and bizarre visual hallucinations +/-motor features of parkinson's
lewy body dementia
176
_____ is a progressive dementia with initial memory loss, language difficulty, apraxia, followed by impaired judgement and personality changes.
Alzheimer's
177
Associations with alzheimer's
age, female, family hx, head trauma, downs
178
______ dementia is characterized by motor and sensory dysfunction.
multi infarct
179
Association's with multi infarct dementia
age, male, black, smoking, htn, diabetes, vasculitis
180
_____ is associated with general cortical involvement + decrease in concentration + memory loss + dysarthria, tremors, irritability, mild headaches + personality changes (irresponsibility, confusion, psychosis)
neurosyphilis
181
______ dementia is associated with personality changes, compulsions, hyperorality, and impaired memory.
frontotemporal/pick's
182
Dx of DKA
glucose > 250, ph < 7.3/bicarb < 15-20, detection of plasma ketones
183
Tx of DKA
normal saline + insulin, K --> D5/.45 saline once hemodynamically stable
184
Indications for bicarb
sever acidosis < 5, or severe hypokalemia
185
Risk of giving bicarb
cerebral edema and left shift of oxygen curve causing poor tissue oxygenation
186
Tx of stye
warm compress --> I/D if refractory 48 hours
187
Tx of chalazion
(granulomatous inflammation of meibomian gland) --> incision and curettage
188
Weight loss + diabetes + diarrhea + anemia + necrolytic migratory erythema (coalescing plaques/papules that form large painful inflammatory blisters w/crusting and central clearing in perineum, extremities, and face)
glucagonoma
189
Dx of glucagonoma
glucagon levels > 500 pg/mL
190
Why is FNA of testicular masses contraindicated
spillage of cancer cells into lymphatics and blood vessels
191
Symptoms of theophylline toxicity
headache, insomnia, seizures, GI (n/v), arrhythmia in context of drugs affecting cytochrome oxidase (cipro, erythro, clarithro, verapamil, cimetidine) or illness (cirrhosis, resp + fever)
192
What marker is elevated w/pheo?
plasma fractionated metanephrines
193
Clinical presentation of pheo
headache, sweating, tachycardia, paroxysmal hypertension
194
LFT abnormality w/o evidence of necrosis or fatty changes in a woman
ocp
195
Dx of Type 1 autoimmune hepatitis
ANA +/- SMA
196
2 hematologic complications of mono
1. AIHA
2. thrombocytopenia
--> cross reactivity of EBV antibodies --> IgM cold agglutinin (coombs test positive) mediated destruction of rbcs/platelets 2-3 weeks after symptoms
*splenic rupture is another complication
197
Sore throat w/ pseudomembrane formation
Cornyebacterium infection --> c/b dilated cardiomyopathy
198
Fatigue + hyperpigmentation + hypotension + eosinophilia + hyponatremia +hyperkalemia
How do we dx this?
primary adrenal insufficiency (Addison's, infections, surgical, hemorrhage, mets)
1. basal morning cortisol
2. ACTH
3. cosyntropin (ACTH analogue --> measure cortisol response --> low in primary AI)
199
Dx of cushing's
24 hour urinary cortisol + low-dose dexamethasone suppression test
200
Which vaccines are live and contraindicated in HIV patients?
BCG, anthrax, oral typhoid, intranasal influenza, oral polio
*MMR, varicella, yellow fever and zostercan be given if CD4>200 and no history of AIDS defining illness
201
Single or multiple rounded dome shaped papules w/central umbilication on face, lower abdomen, genitals
molluscum contagiosum
202
Pruritis, papules, and vesicles over elbows, knees, buttocks, posterior neck, and scalp
dermatitis herpetiformis
203
Genetic associations with dermatitis herpetiformis
HLA B88, Dr3 and DQw2
204
Superficial aggregated small vesicles, papules, pustules over trunk with itching and burning in hot/moist climate
milaria
205
Bright red, friable, exophytic nodules in HIV infected patient
bacillary angiomatosis
206
Tx of bacillary angiomatosis
oral erythromycin
207
What kind of disorders are associated with gout due to increased catabolism/turnover of purines?
myeloproliferative
208
Gout crystals are ____ birefringent
-
209
Bloody diarrhea + flask shaped colonic ulcers + trophozoites on stool exam
E. histolytica
210
Charcot's joint
neurogenic arthropathy usually due to diabetic neuropathy
211
Rat bit lesion on xray
gout --> punch out erosion w/overhanging rim of cortical bone
212
Common causes of avascular necrosis
steroids, trauma, lupus, sickle cell
213
Optho manifestations of sarcoid
anterior uveitis, posterior uveitis
214
Lofgren's syndrome
```
manifestation of sarcoid:
erythema nodosum
hilar adenopathy
migratory polyarthralgias
fever
```
215
Cardiac analog to Raynaud's
Printzmetal's angina: coronary artery vasospasm triggered by cold, exercise, stress --> usually presents in middle of night w/transient ST elevation
216
Tx of Printzmetal's angina
calcium channel blockers and nitrates
217
Tx of sickle cell stroke
exchange transfusion + hdyroxurea (reduces HgbF)
218
Microcytic/hypochromic anemia w/elevated serum iron and decreased TIBC.
sideroblastic --> dimorphic RBCs (normo and hypochromic)
*ringed sideroblasts on bone marrow biospy
219
Tx of sideroblastic anemia
B6/pyridoxine
220
Common drug cause of sideroblastic anemia
isoniazid
221
Intermittent but chhronic abdominal pain + weight loss + alcohol use + diarrhea
chronic pancreatitis
222
Preferred screening test for HIV infection
ELISA
223
What marker is + in UC?
pANCA
224
Extracolonic manifestations of UC
episcleritis, ankylosing spondylitis, cholangitis, erythema nodosum, pyoderma gangrenosum
225
Serologic finding in celiac disease
anti-endomysial and anti-transglutaminase
226
Characteristic cutaneous finding celiac disease
dermatitis herpetiformis
227
Protean disease with chronic malabsorptive diarrhea + weight loss + migratory non-deforming arthritis + lymphadenopathy + fever
Whipple's disease : tropheryma whippelii
228
HLA association with IBD
HLA B27
229
hyponatremia + serum osmolality > 290
hyperglycemia or renal failure
230
hyponatremia + low serum osmolality < 100 + urine osmolality < 100
primary polydipsia, malnutrition
231
hyponatremia + normal serum osmolality + high [sodium]>25
siadh, adrenal insufficiency, hypothyroidism
232
hyponatremia + normal serum osmolality + low urinary [sodium ]
volume depletion, chf, cirrhosis
233
Tx of SIADH
mild: fluid restriction, oral salt tablets, loop
moderate: hypertonic saline
severe: hypertonic saline +/- vasopressin antagonists (conivaptan)
234
Key difference in GBS and tickborne paralysis
GBS has autonomic involvement
235
Descending paralysis w/early cranial nerve involvement
botulism
236
Rapidly ascending paralysis w/o fever/sensory abnormality, normal CSF exam
tickborne
237
anion gap metabolic acidosis + n/v + epigastric pain + hyperemic optic disk
methanol poisoning
238
anion gap metabolic acidosis + n/v + episgastric pain + renal dysfunction
ethylene glycol poisoning
239
anion gap metabolic acidosis + tinnitus + fever + hyperventilation (+/- respiratory alkalosis)
aspirin overdose
240
Consequences of methanol poisoning
vision loss and coma
241
Ocular manifestation of Marfan's
ectopia lentis
242
Murmur associated with Marfan's
early decrecendo diastolic: aortic regurg in context of aortic root dilation
243
Holt-Oram syndrome is associated with what heart sound?
wide and fixed splitting of S2 --> heart hand syndrome associated with upper limb defects and asd
244
PE finding associated with severe aortic stenosis
pulsus parvus et tardus
| systolic murmur
245
MOA of digoxin
increases AV nodal refractoriness and slows ventricular rate in fib and flutter
246
What is the role of digoxin in management of premature atrial beats
none
247
What kind of arrhythmias are treated with lidocaine?
ventricular
248
Impaired swallowing among patients with advanced dementia is often due to what abnormality?
impaired epiglottic reflex
249
What kind of UTI leads to urinary alkalinization?
proteus mirabilis
250
What kind of stones form in alkaline urine?
struvite --> bacteria + protein + leukocytes --> staghorn
251
How does opioid intoxication present?
miosis, depressed mental status, decrased respiratory rate, decreased bowel sounds, hypotension, and bradycardia
252
What is the best predictor of intoxication in opioid intoxication?
decreased respiratory rate
253
____ is a common cause of lactic acidosis in patients with atherosclerotic disease, atrial fibrillation.
bowel ischemia
254
When do acute appendicitis and peptic ulcer formation lead to severe acidosis?
when the patient becomes hypotensive
255
What is a cheap and effective test for determining level of activity of Paget's disease in managed patients?
alk phos
256
What is the preferred therapy for those with metabolically active Paget's disease?
bisophosphonates --> inhibit osteoclasts
257
How do patients w/paget's respond to bisphosphonates?
clinical reduction in bone pain before reduction in alkphos
258
At what point in clinical course is it recommended we treat pagets disease?
once symptomatic
259
When do we treat paget's with calcitonin?
if refractory to bisphosphonates
260
______ is an anti-TNF effective in treating RA, psoriasis, AS, and Crohn's.
infliximab
261
Most common non-neoplastic polyps of the colon
hyperplastic (from mucosal proliferation)
262
What are 2 kinds of hamartomatous colonic polyps?
both non-malignant: juvenile, peutz-jegher
263
Most common polyp found in the colon
adenoma (premalignant) --> <1% become malignant
264
What factors affect the probability of adenomatous colon polyp progressing to cancer?
gross appearance, histology, and size
1. sessile polyps are worse
2. villous are 3x more likely than tubular to become malignant: villous> tubulovillous > tubular
3. larger is worse (e.g. >2.5 cm)
265
What kind of colonic polyps should be removed?
adenomas (pre-malignant) and juvenile polyps (bleeding risk)
266
Most common cause of non-traumatic SAH
ruptured saccular/berry aneurysms
267
Patients with suspected SAH and negative CT should undergo ______
LP
268
What kind of CT is used to evaluate SAH?
non-contrast
269
What lp findings are highly suggestive of SAH?
elevated opening pressure and xanthochromia
270
This arterial cause of intracerebral hemorrhage is typically lobar in location.
amyloid angiopathy --> pts >75 w/ amyloid mediated arteriopathy
271
What kind of cerebral hemorrhages are associated with hypertension?
intraparenchymal or intracerebral (basal ganglia, thalamus) are most common though it is a risk factor for aneurysm formation/rupture
272
_____ presents with thunderclap headache (worsened with lying flat) associated with vision changes and nausea w/ slit-like lateral ventricles on CT and elevated opening pressure on LP.
idiopathic intracranial hypertension
273
This venous cause of intracerebral hemorrhage is typically lobar in location.
venous sinus thrombosis causes lobar intracerebral/intraparenchymal hemorrhages along path of major cerebral draining veins due to backup pressure
274
Patients presenting with worsening headache over several days are likely to have this kind of intraparenchymal hemorrhage.
venous sinus thrombosis
275
Impairment in kidney's ability to concentrate urine presenting with nocturia.
hyposthenuria --> found in apteints with sickle cell --> impaires countercurrent exchange and free water resorption
276
Recurrent childhood UTIs suggest
vesicouteral reflux
277
Sediment findings in FSGS
red blood cell casts
278
Diffuse telangiectasias, recurrent epistaxis, and widespread AVMs aka nosebleeds and oral lesions
hereditary telangiectasia/osler-weber-rendu
AVMs present in mucous membranes, skin, gi, liver, brain, lung --> pulmonary avms can cause right left shunt causing hypoxemia and reactive polycythemia and sometimes fatal hemoptysis
279
Median age for patients with polycythemia vera
60
280
Are telangiectasias and digital clubbing seen in polycythemia vera?
no
281
Most likely cause of macrocytic anemia in patient with sickle cell disease.
folate deficiency
hemolysis of reds causes bone marrow proliferation of red that leads to consumptive folate deficiency
282
Name a few drugs that cause macrocytic anemia
hydroxyurea, phenytoin, methotrexate, trimethoprim
283
What is hyperhemolytic crisis?
acute severe anemia with marked reticulocytosis in sickle cell
usually SCD is chronic and has a normal reticulocytosis
284
Basic pathophys of GVHD
recognition of host HLA antigens by donor t cells and consequent cell-mediated response
285
Target organs of GVHD
skin (maculopapular rash on palms.soles/face), intestine (bloody diarrhea), hepatitis
286
Basic pathophys of graft rejection
activation of host t lymphocytes --> causes depression in myelopoiesis leading neutropenia and infection risk
287
__________ is the mechanism responsible for the development of immunoblastic lymphoma in patients who underwent bone marrow transplant.
EBV induced lymphocyte proliferation
288
_____ is an effective migraine treatment but must be started early in the course before symptoms become severe to be of benefit.
triptans
289
_____ is an effective migraine treatment (IV) that helps with vomiting tendency especially.
prochlorperazine or metoclopramide --> IV antiemetics
290
_____ is effective for migraine prophylaxis but is not helpful in the acute setting.
amitryptyline or propanolol
291
Acute presentation of CO poisoning
headache, nausea, vomiting, abdominal discomfort, confusion, coma, w/pinkish-red skin hue
292
Dx of CO poisoning
carboxyhemoglobin levels
293
Tx of CO poisoning
hyperbaric oxygen administration
294
Burning of _____ can cause cyanide inhalation.
rubber or plastic (not wood)
295
_____ is characteristic of cyanide inhalation.
bitter almond breath
296
3 imaging modalities to confirm Crohn's disease
1. abdominal CT
2. small bowel fluroscopy
3. endoscopy
297
____ can be seen histologically in up to 30% of Crohn's patients.
granulomas in oral apthous ulcers
298
Folic acid deficiency can cause: oral ulcers or abdominal pain?
oral ulcers
299
CSF findings in viral encephalitis
elevated whites (lymphocyte predominant), normal glucose, elevated protein -->dx w/presence of viral DNA in CSF
300
MRI findings in viral encephalitis
temporal lobe abnormalities
301
_____ viruses most commonly cause encephalitis in immunocompetent adults
herpes (simplex, varicella, EBV)
302
Physical exam findings in viral encephalitis
hemiparesis, cranial nerve palsy, exaggerated DTRs
303
_____ is used for induction therapy in patients with cryptococcal meningitis
IV amphotericin + flucytosine
304
What kind of patients typically get cryptococcal meningitis?
HIV/immunocompromised
305
CSF abnormality in cryptococcal meningitis
markedly elevated opening pressure --> symptoms mostly due to pressure from capsular swelling
306
Empiric tx for bacterial meningitis
IV CTX and vanc (and ampicillin in adults >50)
307
CSF findings in bacterial meningitis
elevated whites with neutrophils, low glucose, elevated protein (>250)
308
Suspected viral encephalitis. Empiric tx or MRI first?
empiric tx first then MRI
309
Chlordiazepoxide
tx for alcohol withdrawal in hospitalized patients
310
EtOH withdrawal symptoms
tremulousness, anxiety, headache, palpitations --> fever, hypertension, delirium tremens
311
The first step in ventilator management of ventilated ARDS patients is to decrease _____
FiO2 to non-toxic values --> can increase PEEP to compensate if necessary
312
Spherocytes without central pallor are seen in what conditions?
AIHA and hereditary spherocytosis
313
How do we distinguish between AIHA and hereditary spherocytosis?
AIHA: - fam history, + coombs test
HS: + fam history, - coombs test, + osmotic fragility
314
If Coombs test - and still suspect AIHA what do you do?
microcoombs test
315
Tx of warm agglutin vs cold agglutin AIHA
warm: steroids, rituximab, splenectomy
cold: warming the body, supportive care, RBC transfusions
warm is usually autoimmune, cold is more likely infectious
316
______ is caused by a defect in cell membrane anchor that leads to complement-mediated hemolysis w/- coombs but evidence of venous thrombosis and sometimes episodic intravascular hemolysis.
paroxysmal nocturnal hemoglobinuria
317
Heinz bodies
G6PD deficiency --> X linked hemolytic anemia often triggered by drug ingestion
318
Anemia + splenomegaly + chills and shiveing followed by highgrade fever followed by diaphoresis and resolution of fever
falciparum malaria
*other kinds of malaria have cyclical fever
319
____ malaria causes fever every 72 hours
p malariae
vs. 48 hours for vivax and ovale and just once for falciparum
320
Top 3 risk factors for NASH
1. obesity
2. diabetes
3. hypertriglyceridemia
321
Meds that increase risk of NASH
steroids, amiodarone, diltiazem, tamoxifen, HAART, TPN
322
Pathophys progression of NASH
insulin resistance --> accumulation of fat in liver --> steatohepatitis/fibrosis due to lipid peroxidation and oxidative stress
323
Tx of NASH
primarily controlling underlying conditions, ursodeoxycholic acid to lower transaminase levels
324
Lab findings in NASH
AST:ALT <1, mild elevation in liver enzymes
325
Portal tract infiltration by lymphocytes, macrophages, plasma cells, eosinophils w/ noncaseating granulomas and progressive destruction leading to clinical presentation of jaundice and pruritis
PBC --> AMA+
*ultimately with portral tract scarring and bridging fibrosis leading to cirrhosis
326
hepatitis w/ lymphocytes and plasma cells + ASMA/ANA
autoimmune hepatitis
327
Dx of acute pancreatitis
2/3
1. acute onset of severe epigastric pain w/ radiation to back
2. amylase or lipase >3x upper limit of normal
3. focal or diffuse pancreatic enlargement on imaging
328
Increasing sample size increases _____ which is signified by a tighter confidence interval.
precision
329
Most common pancreatic cancer
adeno
330
Hereditary risk factors for pancreatic adenocarcinoma
1st degree relatives with pancreatic cancer, hereditary pancreatitis, germline mutations (BRCA1/2, Peutz-Jegher syndrome)
331
Most consistent reversible risk factor for pancreatic cancer
cigarette smoking
332
Most common cause of acquired angioedema
ACE I
333
1st step in management of angioedema
stop ACE I immediately, check airway compromise and vasomotor instability, consider subQ epi admin if vasomotor instability, if obstruction refractory to epi, emergency tracheostomy
334
megaloblastic macrocytic anemia with glossitis and neurologic changes
B12 deficiency
335
Common causes of B12 deficiency
total/partial gastrectomy, pernicious anemia, gastritis, elderly age w/poor absorption
336
RBC membrane instability is mechanism behind anemia seen in ______
hereditary spherocytosis
337
Impaired hemoglobin synthesis is mechanism behind _____ anemia
iron deficiency
also thalassemia and sickle cell
338
Impaired glutathione synthesis is mechanism behind _____
G6PD
339
After ____% loss of pancreatic function, patients develop fat and protein malabsorption
90
340
Diff dx of steatorrhea
1. most common = chronic pancreatitis due to alcohol
2. pancreatic insufficiency
3. bile salt dysfunction (as in crohn's, ileal resection)
4. celiac
341
___ stain on spot stool specimen can confirm steatorrhea
sudan
342
Thrombosis of ______ can occur after TPN lines
subclavian or SVC
343
Management of TPN line thrombosis
1. remove line
2. duplex ultrasound to document thrombus
3. short-term anticoagulation
4. elevation of arm and heat application
344
White granular patch or plaque over buccal mucosa in patient with history of alcohol and tobacco use
leuokplakia --> reactive precancerous lesion that represents hyperplasia of squamous epithelium
345
T/F leukoplakias tend to resolve within a few weeks of ceasing tobacco use
T
346
_____ is the most common cause of oral ulcers
recurrent apthous stomatitis
347
How can you distinguish between thrush and leukoplakia?
plaque of candidiasis can be scraped off with tongue depressor
348
multiple vesicular lesions with erythematous and inflammatory base and erythematous border within the oral cavity and perioral area caused by HSV1
gingivostomatitis
349
Clinical findings in brain death
1. absent corneal reflex
2. absent gag reflex
3. absent oculovestibular reflex
4. fixed and dilated pupils
5. patient won't breath spontaneously when ventilator is turned off for 10 minutes
350
What must happen in brain death before patient is taken off ventilator?
confirmation with another physician
351
Lab findings in Paget's disease of bone
normal calcium and phosphate
| elevated alk phos + urinary bone markers like hydroxyproline
352
bone resorption/sclerosis + recent hearing loss
paget's disease of bone
353
Immediate management of GCA
empiric IV prednisone
354
stiffness/pain of shoulder + pelvic girdle
polymyalgia rheumatica --> increased risk of GCA
355
Tx of polymylalgia rheumatica
low dose steroids + screening for GCA
356
Acetazolamide is used to tx:
open-angle glaucoma and benign intracranial hypertension
357
Symptoms of opioid withdrawal
nausea, vomiting, cramps, diarrhea, dysphoria, restlessness, rhinorrhea, lacrimation, myalgias, arthralgias
mydriasis, piloerection, hyperactive bowel sounds
358
Tx of choice for opioid withdrawal
oral/im methadone
359
Lab findings of anemia of chronic disease
normal/decreased MCV + decreased serum iron + decreased TIBC + mildly decreased transferrin w/ normal - high ferritin
* iron trapping in macrophages leads to reduced serum iron and poor iron availability + poor epo response
360
First line tx of RA
hydroxychloroquine, methrotrexate, TNF inhibitors (infliximab, etandercept)
361
Definitive treatment for hereditary spherocytosis
splenectomy
362
Drug of choice in treating PBC
ursodeoxycholic acid --> slows disease progression and relieves symptoms
* methotrexate and colchicine have moderate benefit
* cholestyramine is second line but is only symptomatic tx
363
Tx of advanced PBC
liver transplant
364
____ typically cause slowly progressive dysphagia to solid foods w/o anorexia or weight loss and can eventually block reflux leading to improvement of heartburn symptoms
peptic esophageal strictures --> symmetric circumferential narrowings on endoscopy
365
Causes of peptic strictures
1. gerd
2. radiation
3. scleroderma
4. caustic ingestions
366
Best test for diagnosing and evaluating abdomen of patients in acute episode of diverticulitis
CT
367
_____ stroke is usually accompanied by a sudden dramatic onset of severe headache.
SAH
368
___ stroke usually is accompanied by previous TIAs
ischemic
369
____ stroke is characterized by focal neurologic signs over minutes or hours
hemorrhagic stroke
370
Most important risk factor for hemorrhagic stroke
hypertension
371
+ PPD in HIV patient
5mm or more induration w/in 48-72 hours of intradermal injection of 5 tuberculin units
372
ppx of tb in hiv patients
9 months of isoniazid
+w/pyridoxine to prevent neuropathy from isoniazid
+ regular liver function tests to check for isoniazid hepatitis
* can also use pyrazinamide w/rifampin or rifabutin for 2 months or rifampin alone for 4 months
373
defective mineralization of bone matrix is called
osteomalacia
374
hypocalcemia + hypophosphatemia + elevated alk phos + elevated PTH
osteomalacia
*also low 25 vitamin d and low urinary calcium w/ bilateral and symmetric pseudofractures (looser zones)
375
Characteristic radiologic finding in osteomalacia
looser zones - bilateral and symmetric pseudofractures
also codfish vertebral bodies and bone density decreased with thinning of cortex
376
Causes of osteomalacia
severe vitamin d deficiency, malabsorption, intestinal bypass, celiac sprue, chronic liver/kidney disease, RTA proximal type 2, inadequate calcium intake
377
____ is a dopamine receptor antagonist used to treat nausea, vomiting, and gastroparesis.
metoclopromide
378
Side effects of metoclopromide
agitation, loose stool, tardive dyskinesia, dystonic reaction, parkinsonism, neuroleptic malignant syndrome
379
Tx of dystonic reaction
discontinue med, administer benztropine or diphenhydramine
380
pulmonary cavitation + acid fast, filamentous, branching rods
nocardia
381
tx of nocardia
bactrim
382
3 most common causes of constrictive pericarditis
cardiac sx, radiation, viral pericarditis
383
Thoracic duct obstruction leads to what kind of edema?
lymphedema: firm, nonpitting that does nto cause skin changes like ulceration and dermatitis as in venous stasis
384
Why are people with CKD more likely to bleed?
uremic coagulopathy --> defect in platelet-vessel/platelet interaction
*normal aptt, pt, tt, platelet count w/prolonged bleeding time
385
Tx of uremic coagulopathy
ddavp (tx of choice), cryo, conjugated estrogen
*can't use platelet transfusion because they will be inactivated
386
How does ddavp work when treating uremic coagulopathy?
increases factor 8/vwf multimers from storage
387
4 features of nephrotic syndrome
1. proteinuria (>3-3.5 g/day)
2. hypoalbuminemia
3. edema
4. hyperlipidemia and lipiduria
388
Which renal disease cause nephrotic syndrome?
1. minimal change
2. membranous
3. mesangial
4. membranoproliferative
5. fsgs
389
Etiology of hypercoagulation in nephrotic syndrome
increased urinary loss of AT3, altered levels of protein C/S, increased platelet aggregation, hyperfibrinogenemia from hepatic synthesis, and impaired fibrinolysis
390
Most common manifestation of nephrotic coagulopathy
renal vein thrombosis
391
Why can nephrotic syndrome present with iron-resistent microcytic hypochromic anemia?
transferrin loss
392
What life-threatening extrarenal manifestation occurs in adult polycystic kidney disease
rupture of brain aneurysm (and also AAA)
393
Pulmonary hemorrhage occurs in the context of which renal syndromes?
good pasture's and GPA (wegener)
394
Currant jelly sputum + cavitation + empyema + GNR (encapsulated)
klebsiella
395
GNR pneumonia with CF and bronchiectasis
pseudomonas
396
-gram stain + cold agglutinins w/ interstitial pneumonia
mycoplasma pneumoniae
397
Why don't we use haloperidol in alcohol withdrawal?
doe snot have cross tolerance with alcohol and reduces seizure threshold
398
Side effects of vancomycin
nephro and ototoxicity + red man syndrome
399
Spinal levels associated with RA
cervical spine --> neck pain, stiffness, radicular pain due to subluxation and in bad cases, cord compression (can present with hyperreflexia or + babinski)
400
Where do rheumatoid nodules occur
firm, nontender subQ nodules close to pressure points like elbows
401
Polyarthralgia + tenosynovitis (pain in tendon sheaths) + painless veisculopustular skin lesions
disseminated gonococcal infection
402
Petechial rash + high fever+ headache + n/v + photophobia
meningococcemia
403
Arthralgias + fever+ sore throat + lymphadenopathy +mucocutaneous lesions + diarrhea + weight loss
acute HIV
404
Migratory arthritis of large joints + erythema marginatum (raised and ring shaped lesions on trunk and extremities) + subQ nodules + cardities + syndenham chorea
acute rheumatic fever
405
Most common organism for IE in IVDU
s. aureus
406
Empiric tx of IE in IVDU
vancomycin
407
red as a beet, dry as a bone, hot as a hare, blind as a bat, mad as a hatter, and full as a flask
flushing, dry mouth, hyperthermia, vision changes/mydriasis, delerium/confusion, urinary retention/constipation --> anticholinergic excess
+ headache, dizziness, tachycardia
408
trihexyphenidyl
tx of parkinson's --> can cause drug-induced/anticholinergic extrapyramidal symptoms
409
What symptoms occur if levodopa is delivered without carbidopa?
nausea and vomiting
410
Selegiline
MAOB inhibitor for tx of parkinson's
* can cause serotonin syndrome if used with SSRI or TCA
411
Serotonin syndrome
agitation, confusion, tachycardia, muscle rigidity, seizures
412
Bromocriptine
dopamine agonist for tx of parkinson's
*can cause hypotension, nausea, constipation, headaches, dizziness
413
Tx of benign essential tremor
propanolol
414
Propanolol side effects
bradycardia, hypotension, somnolence, impotence
415
high spiking quotidien fevers, salmon colored maculopapular rash, arthritis
adult still's disease
416
Tx of adult still's disease
IL-1 blockers
417
Which maneuvers worsen the murmur of hypertrophic cardiomyopathy?
valsalva and abrupt standing decrease preload --> increase intensity
418
Which maneuvers decrease the murmur of hypertrophic cardiomyopathy?
isometric handgrip, squatting, leg elevation increase venous return/preload --> decreased intensity
419
Location: ASD murmur
left second intercostal space
420
Location: murmur of hypertrophic cardiomyopathy
apex and lower left sternal border
421
Location: AR murmur
left sternal border 3/4 intercostal space
422
Most common cause of AR in young adults in developed countries
bicuspid valve
423
Most common cause of AR in young adults in developing countries
rheumatic heart disease
424
Which HIV patients need ppx for MAC and what should they get?
cd4 azithromycin or clarithromycin
*rifabutin if allergies
425
Which HIV patients need ppx for histo and what should they get?
cd4 itraconazole
426
PPx for PCP in HIV patients
bactrim or pentamidine
427
Acute vertigo is often due to dysfunction of the _____
labyrinth
428
Patients with BPPV have vertigo related to ____
head positioning
429
Nightime chest pain in youngfemales who smoke
printzmetal's angina --> coronary vasospasm
430
Tx of Printzmetal's angina
ccbs (like diltiazem) or nitrates + stop smoking
431
Why should aspirin be avoided in Printzmetal's angina
can promote coronary vasospasm
432
Why should nonselective beta blockers be avoided in Printzmetal's angina
can promote coronary vasospasm
433
Which fungus can present as cavitary lung lesions + cytopenia + lymphadenoopathy + HSM + fever/fatigue/weight loss
disseminated histo (central/southern US)
434
Dx of histo in immunocompromised patients
histoplasma antigen assay of serum/urine --> fungal cultures take time and have lower sensitivity
435
Tx of mild to moderate histo
itraconazole
436
Tx of severe histo
IV liposomal amphotericin B 2 weeks followed by itraconazole for a year
437
How do diuretics precipitate HHNK?
reduction of intravascular volume --> reduced GFR --> reduced glucose excretion
438
Why does HHNK not present with ketones?
T2D have enough insulin to prevent ketone formation but not enough to regulate excess glucose surges in times of infection/drug-induced dysregulation
439
Screening for colon cancer in UC
1. should begin once disease has been present for 8 years
2. maybe a longer interval if it's only left colon
3. repeat colonoscopy every 1-2 years
440
Symptoms of hypokalemia
mild: weakness, fatigue, muscle cramps
severe: flaccid paralysis, hyporeflexia, tetany, rhabdo, arrhythmias
441
ECG changes in hypokalemia
broad, flat T waves, u waves, ST depression, PVCs
442
Most prevalent antibody in hashimoto's thyroiditis
anti TPO and anti-thyroglobulin
443
muddy brown granular casts
ATN
444
broad and waxy casts
chronic renal failure --> tubules undergo hypertrophy b/c of reduced renal mass
445
rbc casts
glomerular disease or vasculitis (e.g. glomerulonephritis)
446
wbc casts
interstitial nephritis, pyelonephritis
447
fatty casts
nephrotic syndrome
448
hyaline casts
asymptomatic individuals, pre-renal azotemia
449
Most sensitive and specific test for MI
troponin T
450
Best test for recurrent MI within 10 days
CKMB --> troponin levels take up to 10 days to come down vs ckmb which takes 1-2 days
451
Hydatid disease is due to infection w/_____
ecchinococcus (think dogs and sheep)
452
eggshell calcification of hepatic cyst on CT
hydatid cyst
453
Why do we not aspirate hydatid cysts?
risk of anaphylactic shock with spillage of cyst contents
454
Tx of hydatid cysts
sx resection under cover of albendazole
455
Hypertension in patients with thyrotoxicosis is predominantly systolic/diastolic and is caused by ______.
systolic and caused by hyperdynamic circulation
456
____ causes isolated systolic hypertension and increased pulse pressure in elderly patients
decreased vascular compliance
457
Hypertension in patients with hypothyroidism is predominantly systolic/diastolic and is caused by ______.
diastolic and caused by increased SVR
458
reduced iron, increased TIBC, decreased ferritin
iron deficiency anemia
459
general mechanism of lead poisoning and sideroblastic anemia
reduced heme synthesis
460
general mechanism of thalassemias and hemoglobinopathy
reduced globin production
461
general mechanism of anemia of chronic disease
defective utilization of storage iron
462
general mechanism of iron deficiency anemia
decreased intake or increased blood loss
463
Workup of megaloblastic anemia
folate level and schilling test
464
Tx of COPD flare
albuterol, ipratropium, broad spectrum abs, 2 week cortisol taper, supplemental O2
465
Danger of administering o2 to chronically hypoxic patients like those with COPD
suppresses hypoxia fueled respiratory drive
1. increase in oxygenated hemoglobin has lower CO2 affinity (haldane effect) so more CO2 is released into tissues
2. reversal of hypoxic vasoconstriction increases dead space ventilation and worsens V/Q mismatch
--> CO2 narcosis
466
4 stages of chronic hepatitis b
1. immune tolerance
2. immune clearance
3. inactive carrier
4. HBeAg - chronic hepatitis
467
Followup test for patients with active HepB in immune clearance to see how well they are doing?
ALT increases (but fluctuates) due to immune-mediated lysis of infected hepatocytes until HBeAg levels start decreasing --> monitor both until inactive carrier (3 normal ALT and 2-3 normal HBV DNA over 12 month period)
468
Which phase of HepB infection is typically longer in those with perinatal infection?
immune tolerance phase --> high level of replication (+HBsAg and HBeAg) but minimal heaptocyte destruction (normal biopsy, transaminase levels)
469
What is blue toe syndrome?
cholesterol emboli (typically post stent or in atherosclerotic dz) lead to small vessel occlusion
also can present with livedo reticularis (red/cyanotic reticular discoloration of skin), acute renal failure (from emboli to renal arteries), GI symptoms, pancreatitis
470
Suggestive lab dx of cholesterol emboli
eosinophila in blood and urin with decreased complement levels
471
Suspect ______ in a young obese female with a headache that is suggestive of brain tumor but with normal imaging and elevated CSF pressure + papilledema, visual field defects and/or VI palsy
benign intracranial hypertension/pseudotumor cerebri
* can be preceded with glucocorticoid, vitamin A, OCP use
* due to impaired absorption of CSF by arachnoid villi
472
Tx of psuedotumor cerebri
weight loss and acetazolamide
*if refractory, shunting or optic nerve sheath fenestration to prevent blindness
473
Recurrent respiratory tract infections + chronic cough + mucopurulent sputum +/- crackles/rhonchi/wheezes +/- hemoptysis
bronchiectasis
474
Management: Rubbery, firm, mobile, painful breast mass in young woman
1. aspiration
2. if bloody or foul smelling --> cytology
3. if clear --> watch and wait for 4-6 weeks
*likely fibrocystic and associated with menses
475
Diarrhea due to ____ is typically four hours to four days after ingestion of seafood and can be watery or bloody.
vibrio parahaemolyticus
476
Symptomatic relief of hyperthyroidism
proanolol --> best initial treatment for hyperthyroidism
477
When is propylthiouracil used to tx hyperthyroidism?
when pregnant and can't receive radioactive iodine --> however high risk of recurrence
478
Cancer risk associated with pernicious anemia
chronic atrophic gastritis leading to inetstinal type gastric cancer and gastric carcinoid tumors
479
Screening for gastric cancer among patients with pernicious anemia
periodic stool testing for blood
480
Physical finding in AR
waterhammer pulse (bounding pulse) --> rapid increase in systolic pressure due to increased stroke volume + rapid decrease of diastolic pressure because of regurgitation into LV
481
Pulsus paradoxus occurs in ___
tamponade --> fall in systemic arterial pressure by more than 10 mmHg during inspiration
482
Pulsus parvus and pulsus tardus are associated with ____
AS
483
Most common benign vascular tumors in adults
cherry hemangiomas --> always cutaneous
484
Dilated vascular spaces with thin-walled endothelial cells presenting as soft blue compressible masses on skin, mucosa, deep tissues, and viscera
cavernous hemangioma
485
Cavernous hemangiomas of thebrain and viscera are associated with ___ dz
von hippel lindau
486
lymphatic cysts lined by thin endothelium presenting at birth on the neck and lateral chest wall
cystic hygromas
487
cystic hygromas are associated with ____ syndrome
turner
488
elevation of ____ leads to spider angiomas
estrogen
489
_____ appear during the first weeks of life, grow rapidly, frequently regress by age 5-8 and are bright red near the epidermis and more purple when deeper
infantile/strawberry hemangiomas
490
Acute hypercapnia causes cerebral vaso constriction/dilation
dilation to increase blood flow
491
Goal oxyhemoglobin sat in patients w/acute on chronic respiratory failure
90 to 94 not >95 b/c of risk of worsening hypercapnia and CO2 narcosis
492
EBV DNA in CSF is specific for ____
primary CNS lymphoma
493
Imaging finding in AIDS dementia
cortical/subcortical atrophy and secondary ventricular enlargement
494
Imaging of PML lesions
non-enhancing and without mass effect
495
Suspect ______ in a HIV patient with AMS, EBV DNA in CSF, and a solitary, weakly ring enhancing periventricular mass on MRI.
primary CNS lymphoma
496
Multiple Myeloma is caused by the proliferation of a single transformed plasma cell usually producing ____
IgG
497
Classic findings in Multiple Myeloma
```
CRAB
hypercalcemia
renal failure
anemia
back pain and bone lesions
```
498
In what disease is increased marrow cellularity with megakaryocytic hyperplasia seen?
essential thrombocytosis
499
What are the bone marrow findings of aplastic anemia?
hypoplastic fat filled marrow with no abnormal cells
500
Hypocellular and fibrotic bone marrow is seen in ____ disorders
myelofibrotic
501
Failure to achieve a spontaneous erection during the night and/or early morning is pathognomic of ____ ED
organic
502
Venogenic ED may occur after disruption of the ______
tunica albuginea
503
2 endocrine causes of ED
1. hyperprolactinemia
2. testosterone deficiency
diabetes mediates ED via systemic/vascular changes so it doesn't count
504
Microcytic anemia w/basophilic stippling associated with abdominal pain, constipation, fatigue, irritability, insomnia, hypertension, neuropathy, neuropscyhiatric disturbances, nephropathy.
lead poisoning
505
Dx of lead poisoning
blood lead levels, cbc w/smear, x ray fluorescence to measure bone lead
506
Tx of lead poisoning
chelation
507
Woman with chronic headaches presenting with painless hematuria with normal rbcs & no casts on UA
papillary necrosis from analgesic nephropathy ...i.e. chronic tubulointerestitial damage from analgesic-mediated vasoconstriction of vasa recta
508
Renal colic + hematuria
nephrolithiasis
509
Pathogens that cause >2weeks of secretory diarrhea after travel
crypto, cyclospora, giardia
510
Which bug? nausea/vomiting/abdominal pain w/skin lesions after travel to subtropical/tropical areas
strongyloides stercoralis
511
Most stones are _____
calcium oxalate/phosphate
512
Most common cause of calcium stones
idiopathic hypercalciuria
513
Tx algorithm for calcium stones
1. increase fluid intake >3L/day
2. normal or increased calcium diet
3. dietary sodium restriction
4. oxalate restriction (dark greens, chocolate, vit C)
5. decreased dietary protein
*can add thiazide diuretics (decrease urinary calcium excretion vs. loops)
514
Nephrotic syndrome predisposes patients to accelerated _____
atherosclerosis
515
Is nephrotic syndrome associated with cobalamin deficiency?
no
516
What is the mechanism of hypoparathyroidism in nephrotic syndrome?
there is none. vitamin d losses lead to increase in PTH to stabilize vitamin D levels
517
How does nephrotic syndrome lead to monoclonal gammopathy?
it doesn't. monoclonal gammopathy can lead to amyloidosis which can cause nephrotic syndrome
518
How can we distinguish between cardiogenic/noncardiogenic pulmonary edema?
PCWP >18 suggests cardiogenic vs non cardiogenic
519
What is the pathogenesis of ARDS?
systemic or major illness leads to cytokine storm which leads to increased alveolar capillary permeability and subsequent pulmonary edema
520
gradual onset of cough/dyspnea/crackles/clubbing with decreased lung volume and basal interstitial prominence
IPF
521
Tx of STEMI
MONAB: morphine, oxygen, nitrates, antiplatelet tx, beta blocker
522
Contraindication for nitrate use in STEMI
aortic stenosis, recent PDEI use, RV infarct (reduction of preload prevents any CO in this case vs in LV infarct where cost/benefit favors unloading the LV because there is already loss of CO)
523
What is the difference in how big left vs big right V infarcts present?
RV infarcts have clear lung sounds
| Large LV infarcts will lead to pulmonary edema
524
First step in tx of RV MI? What do you do if this doesn't work?
IV fluids to increase RV stroke volume and enhance LV filling
*if fluids don't work, give dobutamine for inotropy. may add dopamine if hypotensive because dobutamine can worsen hypotension if given alone
525
When do you pace in the context of MI?
if you have atropine-refractory bradycardia
526
Single most common cause of asymptomatic isolated elevation of alkphos in an elderly patient
Paget's disease of bone
527
First line therapy for chemo-induced nausea
serotonin (5HT3) antagonists like ondansetron
528
Primary anticholinergic agent used to treat vomiting is _____
scopalamine
529
Are lacunar strokes embolic?
No --> combo of microatheroma and lipohyalinosis (AKA small vessel hyalinosis)
530
Most common site and presentation of lacunar stroke
posterior internal capsule producing pure motor stroke
*can have ataxic hemiparesis, pure sensory stroke, or combined sensory motor stroke w/o aphasia
531
What do patients who have embolic stroke often experience before the stroke?
amaurosis fugax
532
Lacunar strokes compromise ____% of ischemic strokes
25
533
2 major risk factors for lacunar strokes
hypertension and diabetes
534
Initial imagining study of choice in symptomatic patient being worked up for pancreatic cancer.
multiphase thincut spiral CT of abdomen
535
Markers of response to tx for pancreatic cancer
CEA and CA 19-9
536
What does the presence of hyponatremia in a pt with heart failure suggest?
severe hf.
high RAAS activation leads to water retention causing hyponatremia --> associated with lower survival --> water restriction
*low serum sodium associated with high: renin, aldo, ADH, norepi
537
very high blood pressure, palpitations, abdominal pain, tremor, excessive sweating
pheochromocytoma (or general sympathetic hyperactivity)
538
What is the danger of using beta blocker in tx of paroxysm of a pheochromocytoma?
blocking beta receptors leads to unopposed stimulation of vascular alpha receptors which causes catastrophic/rapid increase in BP --> block alpha first in pheochromocytoma paroxysm and then add beta blocker --> or use labetalol (1st line) which does both
539
throbbing pain in pulp of finger with non-purulent vesicles and multinucleated giant cells on Tzanck smear
herpetic whitlow --> dentists/healthcare workers or people who already have genital or oral herpes
540
Light criteria
defines exudate vs transudative effusion...at least one of:
1. fluid protein/serum protein > .5
2. fluid LDH/serum LDH >.6
3. fluid LDH >2/3 upper limit of normal serum LDH
541
Likely ABG finding in PE
widened AA gradient and respiratory alkalosis
542
What kind of effusions are more common in PE?
exudative
543
Gold standard for dx PE and diagnostic test of choice for dx PE
pulmonary angiography and helical CT
544
Differential for exudative effusions
pneumonia, TB, malignancy, PE, connective tissue dz, iatrogenic
545
Describe the pleural effusions of heart failure
bilateral, symmetrical, transudative w/ few RBCs and WBCs
546
Describe the pleural effusions of heart failure
bilateral, symmetrical, transudative w/ few RBCs and WBCs
547
What kind of hypersensitivity rxn is contact dermatitis?
4 e.g. poison ivy, nickel
548
Chronic follicular occlusive disease most commonly affecting the intertriginous skin including axilla, groin, and inframammary regions appearing as painful inflammatory nodules and draining sinus tracts
suppurative hidradenitis
549
Craniopharyngiomas are benign/malignant tumors arising from _____ and are more common in children/adults.
benign, rathke's pouch, children
*bimodal distribution: children and 55-65
550
Presentation of craniopharyngioma
grows above sella turcica and consists of multiple cysts with oily fluid
--> hypopituitarism (retarded growth in children and sexual dysfunction/amenorrhea in adults), with bitemporal blindness, headaches (from pressure)
551
What is the distribution of alcohol and diabetic neuropathies?
glove and stocking (distal and symmetric)
552
Loss of central vision (scotoma) with afferent pupillary defect suggests what pathology?
optic neuritis
553
Dx of chlamydial urethritis
presence of mucopurulent urethral discharge + multiple sexual partners
*UA shows no bacteriuria, culture less than 100 colonies/mL
554
vaginal discharge + pruritis + dyspareunia w/o dysuria
vaginitis
555
dysuria + urinary frequency + suprapubic discomfort + urinary findings of bacteriuria
acute bacterial cystitis
556
weakness + fatigue + loss of appetite + eosinophilia + cold intolerance + constipation + bradycardia
panhypopituitarism = glucocorticoid and thyroid deficiencies
low TSH, low T4, low cortisol, normal aldosterone (ACTH independent)
557
Why does secondary (central) adrenal insufficiency not cause hyperpigmentation, hyperkalemia or salt wasting?
Aldosterone secretion from zona glomerulosa is ACTH independent
558
Typical findings in cerebellar degeneration
1. gait ataxia
2. truncal ataxia
3. nystagmus
4. intention tremor/dysmetria
5. dysdiadokinesia
6. muscle hypotonia w/ pendular knee reflex
* normal babinski b/c not UMN
559
_____ phenomenon is seen in patients with hypertonia due to pyramidal tract disease and is velocity-dependent.
clasp knife --> velocity-dependent resistance to passive movement
560
Differential: Fatigue + myalgias+ proximal muscle weakness + sluggish ankle reflexes + normal sed rate + elevated CK
1. hypothyroid myopathy (unexplained elevation of CK)
2. could be polymyositis but less likely than hypothyroid b/c pm is associated with raynauds, interstitial lung disease and presents with difficulty walkup stairs/getting out of chair, and with normal DTRs -->ANA won't help until after TSH b/c ANA is elevated in hashimotos as well
561
Meniere's dz triad
episodes of vertigo, low-pitched tinnitus, and hearing loss
--> abnormal accumulation of endolymph w/in inner ear
562
____ is the likely cause of vertigo if a patient also has the sensation of ear fullness.
Meniere's disease
563
Presentation of wallenberg syndrome
lateral medullary infarct
| vertigo + gaze abnormalities + limb ataxia + sensory loss + horner's
564
Most common cause of SVC syndrome
malignancy (lung, NHL)
565
Dx of malignancy in SVC syndrome
chest xray
566
Beck's triad in tamponade
jvd, distant heart sounds, hypotension
567
increased iron, reduced TIBC, increased ferritin, but low MCV
thalassemia
568
Most common histologic lesion in diabetic nephropathy? What is the histologic hallmark of diabetic nephropathy?
diffuse glomerulosclerosis
kimmelstiel-wilson nodules are pathognomic
569
3 ways to slow progression of diabetic nephropathy
1. strict glycemic control
2. ACEI
3. tx of htn
570
Which nerve is lesioned if there is absence of corneal sensation?
V1
571
Abnormal RInne test suggests _____ hearing loss
conductive (patient hears vibration longer on the mastoid than in the air)
572
The weber test lateralizes to which side?
patients with conductive hearing loss lateralize to the affected ear because inner ear hears the sound better than the external ear whereas patients with sensorineural hearing loss lateralize to unaffected ear since inner ear cannot sense the vibration
573
where is the lesion and what is it? + rinne with R Weber
left sensorineural loss
574
where is the lesion and what is it? - L rinne with R Weber
left mixed hearing loss
575
where is the lesion and what is it? - L rinne with L Weber
left conductive loss
576
where is the lesion and what is it? - R rinne with R Weber
right conductive loss
577
where is the lesion and what is it? - R rinne with R Weber
right mixed hearing loss
578
Otosclerosis is a common cause of ____ hearing loss in adults, especially patients 20-30 w/ slight F predominance
conductive --> abnormal remodeling of otic capsule (autoimmune)
579
What kind of hearing loss is caused by antibiotics and which one is notorious?
aminoglycosides--> sensorineural
580
Acoustic neuroma/vestibular schwannoma causes ___hearing loss
sensorineural
581
____ is sensorineural hearing loss that occurs w adults with advanced age
presbycusis
582
hyponatremia with high serum osms >290
hyperglycemia or advanced renal failure
583
hyponatremia with normal serum osm and low urine osms <100
primary polydipsia, malnutrition (beer drinkers potomania)
584
hyponatremia with normal serum/urine osms but low urine sodium <25
volume depletion, chf, cirrhosis
585
hyponatremia with normalish serum osms/urine osms but urine sodium>25
SIADH (urine osms>serum osms), adrenal insufficiency, hypothyroidism --> basically concentrated urine even with hyponatremia
586
What's the story on using beta blockers in patients with mild to moderate asthma?
use cardioselective beta blockers for a short term only and at lower doses (beta1)
587
mononucleosis like syndrome + lack of pharyngitis + cervical lymphadenopathy + atypical lymohocytes and negative monospot has____
CMV mono
presents w/o pharyngitis or cervical lymphadenopathy
588
How long must symptoms be present to dx chronic fatigue syndrome
6 months or longer
589
characteristic cell in CLL
smudge cell (and mature appearing small lymphocytes)
590
Presentation of scurvy
perifollicular hemorrhage, swollen gums, poor wound healing
591
Findings in Vit E deficiency
RBC fragility, hyporeflexia, muscle weakness, blindness
592
Tea and toast diet is associated with ____ deficency
folic acid
