Medicine 2 Flashcards
Vesicular ear rash and facial droop or facial pain with vesicular eruption. Dx?
Herpes zoster oticus (Ramsay Hunt syndrome).
Isolated damage (often penetrating) to one eye that is followed by a delayed (often weeks) reaction of blurred vision and other visual symptoms (floating spots, perilimbal flush, etc.) in the other eye. Dx?
Sympathetic ophthalmia. Damage to opposing eye leads to uncovering of hidden antigens that result in immunologic rxn in other eye, often anterior uveitis.
Erysipelas and cellulitis differ in what way physically?
Cellulitis is deep in dermis and subQ fat, thus it appears flat with indistinct borders. Erysipelas appears raised, highly demarcated and erthematous as it involves the epidermis and superficial dermis.
Define Number Needed to Treat.
NNT = 1/ARR; The number of people receiving a medicine that need to receive an Rx to prevent 1 additional adverse event. e.g. The population taking ASA vs those not have 1 less per 100 people taking the drug, then the NNT is 100.
When can Relative risk and odds ratio be a good approximation of one another?
In a population with a low incidence of the disease in question.
Progressive cellulitis of the submandibular space arising from a dental infxn. Dx?
Ludwig angina. Patients may develop local compression with systemic sx also. Infxn often anaerobic with gas-producing bacteria sometimes leaving crepitus. Rx: IV clinda or ampicillin/sulbactam
MEN 1, 2, and 3 (2B) associated conditions?
- PPP: primary hyperparathyroidism, pituitary tumors, pancreatic tumors (esp. gastrinomas)
- PPM: parathyroid hyperplasia, pheochromocytoma, medullary thyroid cancer
- PMMM: Pheochromocytoma, medullary thyroid cancer, mucosal neuromas, marfanoid
What are the leading causes of euvolemic hypernatremia and euvolemic hyponatremia?
DI and SIADH respectively.
What lab values are expected in a female with recurrent miscarriage and VDRL+ and FTA-ABS negative testing?
Antiphospholipid antibody syndrome commonly presents with recurrent abortus and VDRL positivity in the absence of syphilitic disease (confirmed by FTA-ABS). Thrombocytopenia and prolonged PTT are common findings.
Rx for antiphospholipid syndrome while currently pregnant to avoid loss?
ASA and LMWH. Not warfarin.
What are ABCDE criteria for melanoma?
Asymmetric Borders jagged Color variability Diameter ≥6mm Evolution Also look for "ugly duckling" sign
What is an empyema and what is the management?
Exudative pleural effusion that go untreated lead to bacteria in the pleural space (pus in pleural space). Rx: drain pleura (thoracentesis) and antibiotics. Often repeated draining is required.
How are empyema and lung abscess different?
Empyema is in pleura space. Absvess is a cavity with air fluid level on Xray. Abscess is often caused by aspiration.
Define pH, glucose, and WBCs in parapneumonic effusions (empyema) that are complicated or uncomplicated. Rx for each?
pH U≥7.2; C<7.2
Glucose U≥60; C<60
WBC U≤50,000; C>50,000
Rx: U = antibiotics; C = antibiotics and drainage (aka empyema)
Colon Ca screening for ulcerative colitis?
8 years after Dx begin screening and q 1-2 yrs after that colonoscopy.
Pt has recurrent kidney stones from childhood and positive family Hx also. Stones are radioopaque and hexagonal on urinalysis. Cyanide nitroprusside test screen is positive. Dx?
Cystinuria. Impaired AA transport especially cystine, lysine, arginine, and ornithine by brush borders of renal tubular/intestinal epithelium. Cystine is poorly soluble.
Pearly flesh or pink-colored nodule with telangiectatic vessels on head or neck. Dx?
Basal cell carcinoma. Most common in population unless Pt is immunosuppressed, then SCC. BCC commonly causes neural invasion leading to neurological symptoms.
Enlarging nodule in sun-exposed areas that appears thick and roughened. Ulceration with crusting and bleeding also present. Dx?
Squamous cell carcinoma. Most common in immunosuppressed, but less common in general pop. Tends to invade neurological tissue causing paresthesia, etc.
Small cell cancer of lung commonly assoc. with which paraneoplastic syndromes?
ACTH (cushing) and SIADH
Squamous cell cancer of lung commonly assc. with which paraneoplastic syndrome?
Parathyroid hormone-related protein release and hypercalcemia. Remember: sCa++mous cell cancer
Antibody attachment in bullous vs vulgaris pemphigoid diseases?
B: Basement membrane
PV: Between epidermal keratinocytes (desmosomes - aka desmoglein 1 and 3)
Under what level is Mycobacterium avium complex prophylaxis needed? What is prophylaxis?
CD4<50 and prophylaxis is Azithromycin
Shingles pain onset time scale?
Pain may precede rash by several days during which physical exam would not reveal typical vesicular rash. However, pain would be in typical dermatomal distribution. .
Abnormal ankle-brachial index?
Under 1. Suggestive of PAD. PAD and claudication have estimated 20% 5 year risk of nonfatal MI and stroke and 15-30% 5-year risk of death due to CV causes.
Rx for hepatic encephalopathy?
Lactulose or rifaximin
A 20-30s male with sudden onset thrombocytopenia and no other obvious Sx should be tested for what?
HIV and HepC. Thrombocytopenia may be initial presentation of HIV infxn.
What is cardiac index?
CI = CO/BSA; it is a measure of cardiac fxn and is reduced in CHF
How is Ca++ found the blood?
40-45% on albumin, 40-55% as free ions, and 5-15% bound to phosphate or other anions.
How does low albumin in the blood affect Ca++?
Hypoalbuminemia can reduce total blood calcium as albumin binds Ca++.
Corrected Ca++ based on serum albumin?
Corrected Ca++ = (measured Ca++) + 0.8*(4 - serum albumin); in other words, if albumin is higher or lower than 4, the corrected Ca++ is either lower or higher respectively.
Evaluation of hypercortisolism (Cushing syndrome) steps?
Two of following must be abnormal to establish Dx: Late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone suppression test. If hypercortisolism confirmed, ACTH levels measured to differentiate ACTH-dependent (Cushing disease, ectopic ACTH) from ACTH-independent (adrenal adenoma) causes.
What test differentiates CML from leukemoid rxn?
Leukocyte alkaline phosphatase score. In CML, the neutrophils are cytochemically and fxnly abnormal, so LAP score is low.
Most sensitive test for avascular necrosis of hip?
MRI, not Xray, though crescent sign on Xray is helpful in advanced disease.
Indications for primary and secondary preventive statin Rx?
Primary: Estimated 10-year risk of atherosclerotic CV disease (ASCVD) ≥7.5%
Secondary: Known ASCVD and LDL≥190 (suggestive of familial hypercholesterolemia)
Aside from antibiotics, what RFs are associated with C diff infxn?
Gastric acid suppression (omeprazole, etc.) alter microbiome.
Hospitalization.
Old age.
What is the null value of relative risk?
1.0. The outcome occurs with equal frequency in both groups studied and there is no association between the exposure and the outcome. If RR>1, then the outcome occurs more frequently in the exposed group. If RR<1, then the outcome occurs less in the exposed group. If a study has a 95% CI, then the RR must NOT be 1; it must not contain the null value. This means the p is under 0.05.
An obese Pt without COPD or any other pulmonary disease and chronic hypercapnia (>45) likely suffers from?
Obesity hypoventilation syndrome (aka Pickwickian Sx). BMI ≥30 and awake daytime hypercapnia (PaCO2>45) with no other possible cause likely has this.
Proper Rx for delerium un the elderly?
Haldol or atypical antipsychotics (quetiapine or risperidone). Benzos not typically used as they are not recommended.
Sclerotic, cortical lesion on Xray of bone with central nidus of lucency. Painful at night and unrelated to activity. NSAIDs relieve pain. Dx?
Osteoid osteoma.
Painful, swollen knee with decreased ROM. Osteolytic lesion present on Xray of distal epiphyseal region of long bone. Dx?
Giant cell tumor. Presents with painful Sx and soap-bubble appearance on Xray. Eipphyseal in appearance of long bones especially distal femur or proximal tibia at knee joint. Osteoclast giant cells appear as round-to-oval mononuclear cells on pathology. Surgery is Rx.
HA, confusion, amnesia, difficulty concentrating/multitasking, vertigo, mood issues, sleep problems, and anxiety after a brain injury are signs of?
Postconcussive syndrome. Usually resolve in weeks after TBI, but can last ≥6 months.
What effect does a CYP450 inhibitor have on Warfarin? Inducer?
Inhibitor: increases warfarin effect leading to bleeding
INducer: reduces warfarin effect leading to reduced efficacy (clotting)
A young Pt (20-30s) taking HCTZ for HTN develops hypokalemia on just a low dose of the drug requires what testing?
Plasma renin and aldosterone concentrations. Suspicion of hyperaldosteronism (and other 2° causes) should be raised when young age and hypertensive. The Pt here with hyperaldosteronism may not have spontaneous hypokalemia, but may develop it on a new diuretic for the first time.
Use of oral contraceptives in a female with breast cancer has a strong association with breast cancer, but not in those without a family Hx. What phenomenon is occurring here?
Effect modification. Only in a person with a family Hx of breast cancer do OCs increase breast cancer risk, yet in those without family Hx, the breast cancer risk would not be altered by OCs. This differs from a confounder in that the confounder, when removed, would show no change to the outcome of the disease.
Supplementation of what will reduce SE in methotrexate Rx?
Folic acid. MTX is an folate antimetabolite and the preferred initial DMARD in moderate to severe RA.
Best way by which Rx efficacy for DKA is monitored?
Serum anion gap and ß-hydroxybutyrate levels. Anion gap returns to normal with disappearance of ketoacid anions.
What test is used to evaluate proximal small intestinal absorption in Celiac’s disease?
D-xylose test. Testing absorption of sugar at proximal small intestine by evaluating for high content in urine. If poor absorption in intestines, then poor output in urine. Malabsorption due to enzyme deficiencies (pancreatitis, etc.) will have normal D-xylose absorption.
Invasive fungal infxn most commonly seen in poorly controlled DM (esp. DKA)? Rx?
Mucormycosis. Rx: surgical debridement, antifungal meds (amphotericin B), treat DKA.
Tumor in pancreas leading to facial flushing, watery, often tea colored stool, and muscle weakness/cramping, with low chloride levels?
VIPoma. Similar Sx to carcinoid syndrome, but located in pancreas. VIPoma syndrome is characterized by the symptoms described due to a secretory diarrhea. Most Carcinoid tumors are located in the small intestine and do not involve the pancreas.
Management of diffuse esophageal spasm?
Calcium channel blockers, nitrates, or TCAs. Presents with “corkscrew” pattern on esophagram.
Dx tool in suspected DVT?
Compression US should be done in moderate or high probability DVT. Low Wells score requires D-dimer
Sx of dementia with falls and incontinence, but neurological deficits on one side (e.g. hemiparesis or weakness) are less likely due to normal-pressure hydrocephalus and more likely due to what?
Vascular dementia. Also presents as stepwise with events that are correlated with decreases in fxn.
HIV Pt with CD4<100 complains of difficulty swallowing and substernal burning. Dx?
Esophagitis. Candida (MCC), HSV, CMV, and aphthous (noninfectious esophagitis) are common. in HIV Pts with CD4<100.
MCC of contact lens-associated keratitis?
Pseudomonas and Serratua or other gram-negatives are the most common. Some Gram + organisms can cause issues also.
Small or low risk skin lesions suspicious of cancer require what? High risk/cosmetically sensitive?
Skin biopsy for low risk. High risk requires Mohs micrographic surgery.
What type of complications are prevented with intensive glycemic control of DM2?
Microvascular complications (e.g. nephropathy, retinopathy, neuropathy, etc.). Studies have not shown that macrovascular complications (e.g. MI, stroke, etc.) were prevented by glycemic control management.
What medication class can be given in significant anticholinergic overdose?
Cholinesterase inhibitors (-stigmine). Dry as a bone, blind as a bat, hot as a hare, full as a flask (urinary retention), red as a beet, mad as a hatter.
What microscopic qualities differentiate Crohn’s from UC?
Crohn’s has noncaseating granulomas, UC does not.
Initial management of IBDs?
5-aminosalicylic acids and steroids. Maintenance therapy may involve azathioprine or antitumor necrosis factors.
What is the cutoff CD4+ count for receiving live vaccines in HIV?
- If CD4 is under 200, then start antiretroviral therapy and give vax after CD4 count rises above 200.
What is the mechanism behind reduction of angina from nitrates?
Decreased left ventricular wall stress 2° to reduced systemic preload from peripheral vasodilation and then reduced wall stress and reduced myocardial oxygen demand. This is all from the Law of LaPlace where wall stress is proportional to pressure*radius/thickness.
Young active female with numbness and pain between 3rd/4th toes with a clicking sensation when palpating or squeezing the foot joints. Dx?
Morton neuroma. Common in runners. Is not a true neuroma, but a neuropathic degeneration of the interdigital nerves that causes numbness, aching, and burnign in the distal forefoot.
A patient with good fasting glycemic control (good numbers in the morning before eating), but poor A1C likely have what?
Postprandial hyperglycemia. Rx focused on controlling glucose without causing fasting hypoglycemia. Long-acting basal insulin and rapid -acting mealtime insulin may be needed to control postprandial glucose elevations.
MC extraskeletal complication of ankylosing spondylitis?
Anterior uveitis.
Three forms of calcium in serum?
Ionized (45%)
Albumin bound (40%)
Anion bound (15%)
These fluctuate based on pH. Extracellular pH rise causes H+ to leave albumin and Ca++ to bind. to it resulting in low ionized Ca++ and symptoms thereof.
A patient with an absolute neutrophil count below 1500/uL and a fever must be worked up for?
Neutropenic fever. This is a sign of an underlying infection without the ability to fight it off due to neutropenia. Initial Rx should include Zosyn (piper and tazo) to cover pseudomonas.
Young female athlete with pain with activity particularly using the stairs with more severe pain on compression of the patella on the femur. Dx?
Patellofemoral syndrome. Often due to overuse or trauma, the patellofemoral compression test elicits pain in the knee. Xray and MRI are usually normal and are unnecessary, unless all other tests are equivocal or fails to improve.
A rash with occult + bloody diarrhea and liver dysfxn (LFTs elevated) after bone marrow (or any organ) transplant is due to?
Gravft-versus-host disease. Caused by donor T-cells recognizing HLA-antigens on the host that results in cell-mediated immune rxn. Skin, liver, and intestines are the most classically affected organ systems.
Prophylaxis for varices in newly discovered cirrhosis?
Nonselective beta blocker. Propanolol or nadalol are recommended to decrease progression of medium to large sized carices and reduce RF for hemorrhage. They decrease adrenergic tone in mesenteric arterioles which cause unopposed alpha vasoconstriction and decreased portal venous flow.
What is the metric for a “reversible” airway obstruction in Asthma?
> 12% increase in FEV1. In COPD, there may be a partially reversible obstruction, but >12% change in FEV1 is only found in asthma and is evidence of fully reversible cause (aka Asthma). Diffusion capacity is unaffected or high in asthma and is either normal or low in COPD.
What common side effect appears due to Ca++ channel blockers that may mimic CHF or liver disease?
Edema. This occurs due to the inability to dilate peripheral blood vessels. If PE/labs/imaging are all normal and the patient has edema, consider this effect.
What is the most reliable and predictive sign of opioid intoxication?
Decreased respiratory rate in the presence of AMS, hypothermia, and miosis (can be misleading if coingestions…).
Classic presentation of AML?
Fatigue and >1 cytopenia of the myeloid cells (anything but T, B, NK, Plasma cells).
Imaging for diagnostic differentiation of acute diverticulitis from other abdominal causes of pain?
CT scan with oral or IV contrast.
An elderly patient with anemia and a negative guiac test requires what despite the negative test?
Colonoscopy and endoscopy. MCC of anemia in elderly is GI bleed.
What complications can result from heat stroke (AMS, hyperthermia >105°, tachycardia)?
Rhabdo
Renal failure
ARDS
Coagulopathic bleeding (nose bleed, bruising, etc.)
What Rx prolongs survival in COPDers with chronic hypoxemia (plethoric face, elevated Hct, clubbing, etc.)?
Long-term supplemental O2 therapy.
Lewy body dementia Sx?
Cognitive fluctuations
Visual hallucinations
Parkinsonianism (late)
What qualities differentiate Parkinson disease from Lewy body dementia (DLB)?
Early cognitive fluctuation and hallucinations in DLB, whereas dementia occurs very late in Parkinson disease.
First-line Rx for idiopathic intracranial HTN (pseudotumor cerebri)?
Acetazolamide +/- furosemide. If this fails, optic nerve sheath decompression (prevents MC complication - blindness) or lumboperitoneal shunting is recommended.
