Medicine 2 Flashcards
What is the best initial test for suspected dx of pneumothorax?
Bedside US is 90% sensitive and specific
upright AP view is good but only 50% sensitive
How do you calculate anion gap?
What is normal anion gap?
= Serum Na - (Serum Cl + Serum Bicarb)
normal = 12
Common causes elevated anion gap metabolic acidosis
MUDPILES Methanol Uremia DKA Popylene glycol/paraldehydre Isoniazid/Fe Lactic Acidosis Ethylene Glycol (antifreeze) Salicylates (ASA) *Metformin increases risk lactic acidosis (2.2 diarhrea)
Progressive neuro disease with symptoms in apraxia, language difficulties, executive dsyfunction. Over 60 years of age, pt become aggitated, irritable and frustrated.
Dx and Tx
Alzeihmers; irreversible and progressive. Pt pass away from infection/complications, malnutrition or dehydration
Tx Cholinesterase inhibitors to slow progression
Pt with stepwise decline and cognignition as well as possible focal neurological findings. Brain imaging shows multiple small cortical and subcortical infarcts.
Dx?
RF?
Vascular dementia
RF: hypertension, DM, elevated cholesterol
Newborn presents at 4 days of life with BL purulent conjuctival discharge, born at home. No routine labs done for mom during pregnancy.
Dx?
Tx?
Prevention?
Gonococcal conjuctivitis, dx with gram stain adn shows G - diplococci or + culture on Thayer martin
Tx is one dose of IM CTX of Cefotaxime
Prevention: erythromycin eye ointment
What are SE of Lithium toxicity?
What medications can precipitate this SE?
Confusion, ataxia, neuromuscular excitability
Be careful in co-administration with these drugs: NSAIDs, Thiazide diuretics (chlorthalidone), ACE inhibitors
Goal TI: 0.8 to 1.2 mEq/L
Acute onset and potentially fatal SE to medication; involves fever, extreme generalized lead pipe rigidity, autonomic instability, AMS
Neuroleptic malignant syndrome
What is the treatment for Lithium toxicity in patients with levels?
General Approach:
Levels >4
Levels >2.5 with signs or Sx of renal fail
General: q2-4 levels, aggressive IV hydration with NS, bowel irrigation if OD
Hemodialysis in pts >4 or 2.5 with renal fail or increasing levels despite aggressive IV hydration
Syndrome includes tremulousness, confusion, myoclonus, HYPERreflexia, hyperthermia, tachycardia, diaphoresis, HTN, V/D. From mult agents of same drug class
Serotonin syndrome From SSRIs MAOis: phenylzine SNRIs TCAs
What symptoms will women with prolactinoma present with? Men? Why?
Premenopausal, oligo/amenorrhea, infertility, galactorrhea, hot flashes, decreased bone density
Men: infertility, decreased libido, impotence, big boobs
High prolactin–> suppresses GNRH (gonadotropin releasing hormone), LH and FSH
How is prolactinoma dx and treated?
Prolactin level >200 + MRI
mild elevation may be 2/2 to other causes; meds as cause; antipsychotics, nipple stim, hypoT, stress/exercise)
Tx = Doapmine agonist (cabergoline, bromocriptine)
Pt with hx of well controlled T1DM presents with recurrent episodes of hypoglycemia, fatigue, wt loss, weakness and low BP with hyperpigmented skin.
Most likely dx?
What lab abnormalities would you expect to see?
Addisons, Adrenal insufficiency
HyperKalemia with mild metabolic acidosis ( can’t excrete either H+ or K+ bc of aldosterone loss)
HypoNa
May have hypoglylcemia and neutropenia
Pt presents with maroon stools and blood in rectum. Most likely location of bleed?
What would lead you to pursue EGD first?
Lower GI
Get EGD first in patient with hematochezia and hemodynamic instability… assume upper GI bleed until ruled out, resuscitate first
Most common adverse reaction occurring in 1-6 of receiving blood transfusion. Develop fever, chills, malaise /o hemolysis
Prevention?
Febrile nonhemolytic transfusion reaction
Due to small amt of residual plasma/leukocyte debris in red cell concentrate–> during storage these leukocytes release cytokines causing reaction
Prevent with Leukoreduction
Patients with BMT, acquired or congenital cellular immunodeficiency, Blood from 1st or 2nd degree relatives get what special tx for blood transfusions?
Irradiated
What patients get washed RBCs for transfusions?
IgA deficiency, Complement dependent autoimmune hemolytic anemia, Cont allergic rx despite antihistamines
What pts get leukoreduced RBC infusions
chronically transfused, CMV seroneg at risk, potential transplant, previous febrile non hemolytic transfusion patients
Home health aid services do NOT include..
medication or periodical health evaluation
What patients require eval with cystoscopy?
Gross hematuria w/o evidence of glomerular disease or infection
Microscopic hematuria w/o evidence of glomerular disease but risk of malignancy
recurrent UTI
Obstructive symptoms c/f stone or stricture
Irritative symptoms w/o UTI
abnormal bladder imaging
Seen in patients with preexisting asthma or CF; recurrent and quickly resolving asthma exacerbations, infiltrates on CXR and CT that quickly come and go, central bronchiectasis and coughing brownish mucus plugs
ABPA: Allergic bronchoplmonary aspergillosis = exaggerated IgE/IgG immune response
hypersensitivity dx associated w/ noninvasive aspergillosis colonization
Dx skin test for aspergillus, eosinophilia >500, IgE >417, Speficic IgG and E for A. fumigatus
Pt has ABPA, what is treatment
Steroids and itraconazole or voriconazole (NOT fluconazole)
Central bronchiectasis/brown mucus/fleeting infiltrates in hx of asthma or CF
Pt with difficult to control asthma, allergic rhinitis, nasal polyps, chronic sinusitis, skin stuff (granulomas, purpurua)
Dx
Churg Strauss or eosinophils granulmatosis with polyangitis; uncommon auto-immune vasculitis
_____ presents as linear papules, clear and fluid filled vesicles, painful and itchy and spread via contaminated clothes and resin
Tx?
Poison ivy dermatitis
remove clothes, cool compresses, topical steroids and oral if severe
Type IV hypersensitivity
Knee injury due to valgus (abductor stress) stress to partially flexed knee. Pt with pain, pop sound.
Or blow to the lateral knee with foot flexed or event twisting activities
Tender of medial knee and laxity when foot is aBducted and knee stationary (valgus stress test)
Medial cruciate lig injury
Uncommon to have effusion
Occurs with rapid pivots, deceleration or direction chnage or blow to knee with twisting force. Rapid onset hemarthrosis common. + laxity on anterior drawer or Lachman maneuver
ACL injury
Hyperextension to knee, tender along lateral joint line, often from dramatic varus or adductor stress
LCL injury
MC organisms in eye injuries?
What about contact wearers?
Staph (also strep, Haemophilus,)
PSA in contacts
Patient with insect bites, summertime. Has AMS consistent with encephalopathy, nucchal rigidity as well as fever, HA, vomiting
West nile (summer/fall); viral encephalopathy Lymes more meningitis over encephalopathy
How do old people with thyrotoxicosis present?
Apathy, confusion, tremor, proximal msl weakness.
decreased appetite, can have A fib, tachycardia and heart fail
Thyromegaly often absent
Dreaded side effect of amiodarone?
Pulmonary toxicity: chronic interstitial pneumonitis, organizing PNA or ARDS; non productive cough, fever, pleuritic chest pain and weight loss with DOE
its an antiarrythmic
normal coags, isolated thrombocytopenia, purpura with isolated thormbocytopenia on smear
Why?
Immune thrombocytopenic purpura
platelet destruction by antiplatelet autoantiB against platelet membrane
What is tx for ITP
kids with PLT <100,00: glucocortidoids, IVIV, anti-D if bleeding
Adults: >30,00 plt + cutaneous observe
<10,000: glucocortidoids, IVIG, antiD if bleeding and plateltes
Treatment of choice for TTP with HUS
plasma exchange
Blood transfusion reaction: Flank pain, dark urine, fever, hemolysis, oliguric renal fail and DIC
Acute hemolytic transfusion reaction; often mismatched blood (ABO or chronic transfusion Rh or Khell)
Tx: STOP infusion and aggressively hydrate with NS to prevent renal fail
Blood transfusion: patient gets uticaria everywhere, rection and tx
Uticarial, Recipient IgE vs blood compoment, occurs in 2-3 hrs
Pt blood transfusion, develops resp distress and has noncardiogenic pumonary edema, see pulmonary infiltrates BL
Transfusion related acute lung injury
From donor anti-leukocyte antB
Pt with heart fail gets blood transfusion; dyspnea, tachycardia, hypertension and hypoxemia. PT has hypervolemia with increased central venous pressures, pulmonary edema, elevated BNP
Dx
Tx
TACO: transusion associated circulatory overload
Tx: diuretics, oxygen, may need Non invasive PPV`
SE of
Carbamazepine
Lamictal
Valproic acid
Carbamazepine: Bone marrow suppression (watch for neutropenia, thrombocytopenia, anemia), SIADH and hypoNa
Lamictal: SJS and severe skin reactions
Valproic acid: limb deformities in preggo
When is a HC growing TOO fast?
What do we do?
> 97% = macrocephaly (may be familial)
worry if >2cm/month in infant <6mo
neurologic issues or DD
Get head US if ant font are open
What meds and electrolyte disturbances cause long QT (long QT–> polymorphic V tac then torsades de pointes)
Meds: diuretics, zofran, haloperidol/quetiapine/risperidone, TCA adn SSRI, antiarrhythmics (amiodarone, sotolol, flecainide), antianginal, anti-infective (macrolids, FQ, antifungal)
HypoK, HypoMg, HypoCa
What arrythmias cause long qT
sinus node dysfunction, AV block (2nd or 3rd degree)
First line therapy for tx and prevention of recurent torsades?
IV Mg, may need temp transvenous pacing if they do not respond. Don’t do anything to further slow the heart rate! Bradycardia/arrythmias can make worse
Patient with VZV outbreak failed o/p treatment and now has non-adjacent spread of shingles, needs admitted for IV acyclovir. What precautions should they be on?
Contact + airborne
just contact if in only one area
What is the screening for HIV and when should you test after exposure?
HIV antigen (p24) and HIV1 and 2 antibodies titers may be too low in first 1-4 weeks after exposure, repeat it
What should be tested before starting someone on HARRt therapy bc it also treats that?
Hep B
Pt with CV catheter (on hemodialysis) has fever. What antiB are started?
When do you remove the catheter?
MC organisms?
Start Vanc/Cefipime (or gent)
Remove if hemodynamically unstable, severe sepsis, c/f metastatic infection (endocarditis) pus at cath site, symptoms despite tx
Cause: CONs, Staphylococcus, Gram (-) bacilli
Trastazumab is used for HER2 positive tumors, can cause what complication?
Cardiotoxicity: decreased LVEF that may or may not cause symptoms and is REVERSIBLE once therapy is stopped
chemo medication that causes dose related cardiotoxicity
anthracyclines
patient has excessive daytime sleepiness, falls asleep suddenly at work and in classes, states he hears strange noises right before he falls asleep and frequent wakenigns at night.
dx and cause
narcolepsy, dx with sleep study
has hypocretin 1 deficiency in CSF,latent REM sleep <15 mins
What is first line therapy for narcolepsy?
What about cataplexy (fainting goat in emotional stress)
Modenifil: is a novel stimulant with more favorable SE profile
Can use other stimulants but more addicting
Cataplexy: can do SSRI/SNRI
Patient has decreased BS on the right side. Currently intubated on high support. Vitals are otherwise stable, no tracheal deviation noted, BP appropriate. What do you do for management?
Place chest tube
If patient has tension pneumo physiology (hypoT, abscent of JVD, tracheal deviation) then you do not need to do needle decompression first, just provide definitive tx of CT (if it does exist… needle then CT)
Pt presents with PE consistent with acute pancreatitis.
What is needed to establish diagnosis?
2 of 3 criteria
- Characteristic epigastric pain
- A or L 3x normal
- Imaging consistent w/ pancreatitis
Imaging: US is good first line bc helps look for etiology; gall stones or cholecystitis as well as being rapid, safe and cheap.
CT and MRI are more sensitive for more pricey. Use for suspected complications
Most common etiologies of acute pancreatitis?
EtOH, gallstones, hypertriglyceridemia (test lipids if you don’t know the cause), recent retrograde cholangiopancreatography (ERCP), medications, infections, trauma
Pt is now day 3 of tx for acute pancreatitis, was getting better. Now have fever, recurrence of pain, elevated white count. What is next best step for management? what are you concerned may have occured?
CT of abdomen w/ contrast
Necrosis of pancreas: tx with antibiotics + debridement when >30% is infected/nectrotic.
What is the mechanism of parathyroid hormone?
What affect does it have on Calcium?
PTH: reabsorbs Ca in distal tubule, excretes phosphate at proximal tubule
Activates Vt D from 25–> 1,25 dihroxy
Resorbs Ca and phosphate from the bone
40 yo Patient comes in with confusion, constipation and abdominal pain, bone pain with new occult hip fracture and signs of osteoporisis on imaging. What lab do you want to get?
Ca and PTH; concern for hypercalcemia 80% from solitary adenoma 19% have 4 gland hyperplasia 1% cancer Dont forget about MEN
In what situations do we remove the parathyroid gland?
Symptomatic disease (stones, bones, groans, pysch overtoans)
renal insufficiency, or nephrogenic DI (thirsty/pee)
Ca >12.5
Age <50
Osteoporosis
What is medical management for hyperparathydoirdism with hyperCa
Hydration with NS
Bisphosphonate (these are slow acting but effective)
Lasix AFTER rehydration (will increase Ca excretion)
Calcitonin if hydration and lasix don’t control Ca level
Patient presents with elevated PTH, low Ca and elevated Phosphorus levels. On imaging there are bilateral cataracts adn basal ganlia calcifications.
What is most likely diagnosis?
Pseudohypoparathyroidism
end organ resistance to PTH; results in chronic hypoCa (causes cataracts and calcification in basal ganglia)
Pt with hypocalcemia (tetany, seizure, cramping, hyperreflexia) with low phosphorus and high PTH, cause?
Vit D deficiency
Pt with HYPOcalcemia, elevated phosphorus and low PTH, cause?
Hypoparathyroidism
PTH increases Ca absorbtion, increase Phos excreation
Pt with hypoCa, high phosphate and high PTH? Cause?
Two causes:
- Pseudohypoparathyroidism (look for signs of chronic hypoCa in this situation as there is end organ resistance to PTH… cataracts and basal ganglia calcifications)
- Hyperphosphatemia
Patient with weight loss, fatigue, microcytic anemia and heme + stool, must rule out?
colon cancer
Get colonoscopy, if that is negative then EGD.
What area of heart do the following coronary arteries supply? LAD Left circumflex Right coronary Left main
LAD: Anterior wall of the LV
Left circumflex: lateral + posterolateral wall of LV
Right coronary: RV and inferoposterior wall of LV
Left main: branches to Left circumflex and LAD
3yoM comes to office, only able to run and play for up to 10 mins, used to play for hours with increased calf circumference. On PE you note mild scoliosis
What test do you order initially?
What are your next steps?
Patholophys?
CK, Duchenne muscular dystrophy; weakness of proximal LE
Elevated CK, genetic testing shows dystrophin deletion
muscle biopsy shows fibrosis, fat and muscle degeneration
Inheritance pattern of Duchenne?
What cardiac complications can be seen?
Tx?
X- linked
Dilated cardiomyopathy
Glucocorticoids
Wheelchair by adolescent, death 20-30 from resp or heart fail
Post menopausal woman now doesn’t leave home bc she is frequently soaking pads with urine. Been getting worse, will have sudden urge to go and won’t make it to bathroom. PE shows pale vagina, but no hypermobile urethra and no leakage of urine with cough.
Dx and tx?
Urgency incontinence
Tx bladder training and timed voids, wt loss, stop smoking avoid caffeine and EtOH
2.2 to detrusor muscle overactivity
Pt presents with frequently soaked pad with urine getting worse. Occurs with coughing or laughing.
On exam asked to cough, saw leaking urine.
Dx and Tx
Stress incontinence with + bladder stress test
Can do Pessary, pelvic floor exercises, urethral sling or possibly duloxetine (SNRI)
Option for pharmacotherapy in pt with urgency incontinence?
Anti-muscarinics: Tolterodine, solifenacin, oxybutynin
improve bladder capacity, inhibit detrusor muscle contraction during bladder filling; can get dry mouth,constipation and drowsiness
Pt with constant dribble of urine and post void emptying >100 cc.
Dx and Tx
Overflow
Tx intermittent cath and correct underlying cause
Man comes in with feeling like he still has to pee after he goes. Prostate full, non-glandular and dx with BPH. What can you prescribe?
Alpha 1 antagonist; terazosin for urgency incontinence
What affect does estrogen (pregnancy) and OCP have on patients with hypothyroidism?
Elevates TBG: throxine-binding globulin which binds circulating thyroid hormone (T3, T4).
Estrogen increases TBG, pt with hypothyroidism on levothyroxine need to increase their dose
______ reduced blood flow in base of brain, often 2/2 emboli, thrombi or arterial dissection. Pt have vertigo, dizzy, dsyarthria, diplopia, numbness
Hx of CAD, hypercholesterolemia, DM, smoking
Verebrobasilar insufficiency
abnormal feeling of motion triggered by certain positions 2/2 to calcium debris in posterior semicircular canal, often see nystagmus
BPPV
______ causing a red, painful rash that is edematous and elevated with sharp demarcation. Can be present in butterfly distribution of face and can be present with feveer and malaise
Erysipelas; specific form of cellulitis
Caused most commonly by Group A Strep
What are contraindications to varicella vaccine?
What about healthy kid due for vaccine and lives with immunocompromised sib?
Contraindications: anaphylaxsis to neomycin, gelatin, if pregnant, if immunodeficient (congenital, on longterm immunosuppresives, cancer, HIV severe)
Give vaccine, monitor for rash then avoid contact if that occurs
Pneumocystis jirovecci PNA occurs when CD4 is < _____
Present with these symptoms.
Diagnosis?
<200
Dry cough, fever, wt loss, hypoxia, interstitial infliltrates on CXR
identified in induced sputum samples 50-90% but if negative need to do further testing especially if suspected
Pt with HIV and PCP may need corticosteroids in addition to IV antibiotics for tx. What determines this?
ABG showing Alveolar-arterial oxygen gradient >35 and or arterial oxygen tension <70 on RA
Presents with lower motor neuron involvement; usually asymmetric weakness. Pt may c/o cramping in early morning then progressive weakness and atrophy. Bulbar msl involvement is common; difficult chewing, swallowing
Bowel, bladder, ocular motility, sensory and congnition are preserved
ALS: amytrophic lateral sclerosis
progressive motor neuro disease of upper and lower motor neurons
Vascular dementia involving white matter infarcts, present with apathy, agitation, bilateral corticospinal or bulbar signs
Biswangers disease
Pt with tumors here have weakness, fasciculations in upper limbs, spasticity in legs and change in sensory/blowerl and bladder function
brain stem tumor
Only medication shown to be beneficial for ALS
Riluzole; glutamate inhibitor
Pt presents with recurring episodes of headache, diaphoresis, and elevated HR. Noted to have HTN during episode. Not on medications.
Most likely dx?
Initial eval?
Pheochromocytoma
Get Urinary metanephrines and catecholamine levels OR plasma free metanephrine level ideally during episode
What med should we not Rx in pheochormocytoma
B-adrenergic receptor blockers (if given before alpha adrenergic receptor blockade can worsen hypertension)
Urinary metanephrines confirm pheo in patient (HA, tachy, diaphoresis). what is the next step?
Get MRI or CT
If >5cm get MIBG to check for extension
Remove that shit (give alpha and B blockade prior to surgery)
Pt is 34 wks pregnant, has RLQ pain, fever and tachycardic. Elevated leukocycte count, neg uterine tenderness, no flank pain and baby’s HR is normal with variability. No LOF or vaginal bleeding. No RUQ pain.
What are you concerned for and what do you do next?
Graded compression abdominal US to assess for atypical presentation of appendicitis
Complication: pylephlebitis (infective suppurative portal vein thrombus)
MOm is GBS +, planned for intrapartum antiBx, but ruptured and delivered within 3 hours. She was 38 weeks. Infant is 1 hour, normal vitals, well appearing… management?
Mom was 36 3/7, infant is well appearing and normal vitals, management?
Obs x48 hours
BCx, CBC w/ diff, obs x48 hrs
What is considered adequate prophylaxsis in mom who is GBS +?
Amp/PCN or Cefazolin given >4 hrs prior to delivery
Tx for atopic dermatitis?
1st line: emolients, cotton clothes, avoid hot/dry environments
May need topical steroids (hyrdocort) or even higher potency topical steroids (triamcinalone, betmethasone)
Tx used for acne, rosacea, hidradentitis suppurative
Doxycycline
Tx for superficial fungal infections like tinea
clotrimazole
30yoM comes to PCP, new onset SOB with exercise but otherwise feels fine. On exam hear a 2/6 systolic murmur over LUSB, exaggerated on valsalva.
Worse case scenario what would you see on echo?
Cause?
Tx?
Concern for Hypertrophic cardiomyopathy
See systolic anterior motion of the mitral leaflets with increased LVOT gradient.
Autosomal dominant dx of cardiac sarcomere
IF heart fail symptoms; negative inotropes (B-blockers, verapamil or disopyramide)
Alcohol septal ablation; causes localized MI in the basal septum for pt w/ symptoms refractory to medical management
What patients are candidates for implantable cardio-defibrilatory?
Primary prevention: prior MI with LVEF <30% or heart fail II or III + symptoms and LVEF <35%
Secondary prevention: Prior VF or unstable VT w/o reversible cause or prior sustained VT with underlying cardiomyopathy
Pt comes to ED with hx of COPD and c/o palpitations and SOB. Tachy and hypoxic with elevated BP.
ECG notable for narrow complex QRS, variable PR and RR intervals and irregular heart sounds. No signs of HF, but PaCO2 50 and PaO2 is 65.
Dx?
Cause?
Tx?
Dx: MAT; multifocal atrial tachycardia
Seen in pt with exacerbations in underlying pulm dx (COPD), those with hypoK or cathecholamine surge (sepsis)
Tx: Correct underlying cause; manage COPD and then can do verapamil if persistant (over B Blocker not great for bronchocx)
Pt presents with unstable SVT.. tx?
synchronized cardioversion
Pt presents in DKA:
Keys for IV fluid management including glucose
Keys for K and bicarb management
Rapid NS, add dextrose once glucose <200
K in all fluids <5.3 d/t intracellular K depletion
Bicarb if pH <6.9
Pt in DKA, keys for insulin management?
What do we start with?
When do we switch to subQ?
Cont IV insulin infusion
to SQ once: pt can eat, glucose <200, anion gap <12 AN serum bicarb >15
**overlap subQ and insulin GGT by 2 hrs
Diuretics, alpha blockers (tamsulosin, prazosin, terazosin) and nitrates often cause this SE in patients
dizziness; orthostatic hypoT (drop DB by 10, SB by 20, increase HR by 30)
PT present in asthma exacerbation. hypoxic with BL wheeze.
Tx if PEF is <40% of baseline
Tx if PEF is 40-70% of baseline
severe exacerbation: Start SABA + ipratorpium + IV steroid
mild to mod exacerbation: start SABA B2 agonist + IV or oral steroid
Give IV Mg if PEF is still <40 after 1 hr of cont inhaled albterol
Tx for RCC that is extending through renal capsule but not beyond Gerota’s fascia?
Tx for RCC that is confined to renal capsule?
Radical nephrectomy (stage II) Partial nephrectomy (Stage I) -get chemo and immunotherapy in metastatic dx w/ minimal effectiveness
Tx for ADHD in child 4-6 yo?
What medication is first line?
When would you stop or switch meds?
This age is CBT
Medication is methylphenidate (wt loss, moody, HA are intolerable SE).
Switch to dif stimulant, atomoxetine or alpha 2 adrenergic if having SE
What is the highest risk of having PID?
mult sexual partners
Also, age 15-25, inconsistent barrier contraception use, prior PID infection
What affect does poor glycemic control have on eye complications?
Risk of macular edema (increased vascular permeability or retinal blood vessels–> blurred vision)
Long term; diabetic retinopathy leads to vitreous bleeds, retinal detachment; need laser photocoagulation.
GLYCEMIC CONTROL!
Pt presents with tremulousness, tachycardia, ext are warm with mild lid lag and missed periods. No wt change, neg preg test and thyroid is normal on exam.
Elevted T3 and T4, elevated TSH, Elevated alpha subunit.
Likely dx?
next steps?
TSH secreting pit adenoma (bc of high alpha subunit another tip off) = central hyperthryoidism
Get MRI; likely show mass
Tx is somatostain analogue or transsphenoidal surgery
Most common cardiac tumor, have signs of mitral valve obstruction (diastolic murmur) with worsening HF signs and new onset atrial fib. Frequently embolize leading to acute arterial occlusion
Left atrial myxomas
Pt is >50 presents with dysphagia to solids, then liquids with coughing fits. Has smoking history.
What is best diagnostic initial test?
Dx?
Tx?
Concern for esophageal cancer (RF >50, smoker, check for heme + blood)
Get Endoscopy! Manometry not helpful
Could get barium swallow if endoscopy not opiton
Tx: resection if no local or distant mets + chemo with 5-fluorouracil
Pt with dysphagia and weight loss, you are uncertain why.. what is best initial test?
When is endoscopy the best initial test?
Get Barium swallow or consider CXR if uncertain why
If its cancer or Barretts esophagus then need scope for dx (need to Bx)
What is the best initial test for achalasia?
Most accurate test for achalasia?
INitial: Barium swallow or CXR
Most accurate: Manometry
What is MC type of esophageal cancer?
Squamos cell carcinoma! ~95%, located more proximally or in upper esophageal lesions and in pt with EtOH and tobacco use
Adeno <5% mid esophagus, seen with Barretts and chronic GERD
25yoF presents with severe abdominal pain. LMP was 5 weeks ago,has vaginal spotting now. Not sure if pregnant. Hypotenisive and tachycardic with B-hCG 1200 with normal cardiac exam (except tachy). Has cervical motion tenderness and diffuse uterine tenderness.
Dx?
Next step?
Ruptured Ectopic pregnancy
Tx: emergent laparotomy wiht salpingectomy
RF: prior ectopic, PID, pelvic surgery
PT presents with suspected ectopic pregnancy but is hemodynamically stable. Next steps?
Transvaginal US
Adnexal mass–> tx the ectopic pregnancy with Methotrexate or laparoscopy, give Rhogam if indicated and follow up with B-hCG
Non-diagnostic–> repeat B-hCG levels until >1500 then repeat TVUS in 2 days
Pt presentig with leg weakness and now B/B dysfunction. Two weeks after URI symptoms.
DDx?
Next step
Myelopathy
Guillane Barre; however the bowel/bladder dsynfx more concerning for
Transverse myelitis
Given B/B dysfnx; get MRI of spine, for GBS can get LP
Pt with rosacea (flushing with emotion, spicy food, EtOH) with telangiectasias.
Tx:
above symptoms + papules/erythematous plaques
Tx:
What other organ can be involved?
Tx: Brimonide and avoid triggers
Tx with papules: topical metronidazole or azelaic acid
Ocular manifestations; burning or FOB sensations, blepharitis, keratitis, conjunctivitis
Pt confirmed dx of infectious mononucleosis after monospot test went home on supportive cares, comes back two days later, difficultly swallowing and uncomfortable. tonsils are touching, pooled secreations but breathing comfortably. Next step
Admit, IV steroids for inflammation
Pt has suspected achilles tendon rupture. What can be done in office to confirm this diagnosis?
Thompson test, squeeze calf msl of affected side while pt is prone, monitor for involuntary plantar flexion. If not present, diagnostic and >90% sensitive
if highly suspicious and its negative, then MRI
13yoF comes in for routine health exam, parent noticed sits to one side. On PE pt has rt thoracic prominence and that measures 9 degrees of trunk rotation.
Concerning for?
Next step?
idiopathic scoliosis
forward bend test with scoliometer measuring >7 degrees is significant
Get Xray of spine
Pt gets imaging for scoliosis. Cobb angle is 8, Dx and Next step?
Cobb angle is 12, dx and next step?
Cobb angle 45, dx and next step?
Not scoliosis.. variant of normal; must be Cobb >10
Scoliosis with low risk; monitor +/- brace
Severe Scoliosis with high risk for curve progression (if still growing)… Surgical correction
Pregnant woman dx with active TB. Treatment?
Multidrug therapy + Pyridoxine
Isoniazid + Rifampin + ethambutol x2 months
Rifampin + isoniazid x7 months
Pt with latent non-active TB, tx?
Isoniazid (+ pyridoxine)
Pt with hx of non-hodkins lymphoma. Manifestations of _____ include coronary disease with MI, restrictive cardiomyopathy with diastolic dysfunction, valvular abnormalities (mitral or aortic stenosis/regurg) and conduction defects
Radiation induced cardiotoxicity
Diastolic dysfnx!
This type of chemo causes dose dependent decline in EF and lead to DILATED cardiomyopathy
Anthracyclines
Most common travelers diarrhea from contaminated food, short term
E. Coli
Travelers diarrhea, very brief; vomitting
Rota and Noro
Travelers diarrhea, prominent abdominal pain, ‘pseudoappendicitis’ with bloody diarrhea
campylobacter
Patient with SLE, SSD, renal transplant, antiphospholipid antB syndrome, HIV or Gauchers at increased risk.
Come in with contrast left groin/hip pain.
Likely dx?
What imaging is most SENSITIVE for diagnosis?
osteonecrosis of femoral head
Pt has osteonecrosis of femoral head.
tx for stage 1-2?
stage 3-4 with significant impairment?
Stage 1-2: Try core decompression; goal to preserve the joint as long as possible.
Stage 3-4: hip replacement
Early stages with some symptoms
What medications can be used to tx BPH as well as offer some BP management?
alpha adrenergic blockers: tamsulosin, doxazosin, terazosin
–relax sm muscles in bladder neck and prostate and some lowering of BP as added benefit.
SE: orthostasis/dizzy
Women breast feeding, comes in with fever, red swollen breast c/w mastitis. Vitals otherwise stable. No allergies, no RF.
1st line tx:
2nd line tx:
1st line: dicloxacillin or cephalexin; safe for BF 2nd Bacrtrim (be careful; transmitted in breast milk and cause jaundice)
What are more concerning findings on pulmonary nodule imaging?
More concern for malignancy?
Benign = popcorn calcification (hamartoma), concentric, central or diffuse homegenous calcification, smooth borders BAD = spiculated, eccentric or reticular or punctate calcificaiton
20yoM comes in to clinic with mild BL flank pain and red colored urine. Had a URI three days ago, otherwise feels fine. No edema, UA + blood and protein. MIcroscopy notable for dysmorphc RBC and occasional cell casts. CT was negative. normal complement levels
Dx?
Most accurate way to dx?
Tx?
IgA Nephropathy
painless recurrent hematurial more in Asian pts and right after URI. +/- protineuria and can see rec cell casts
Most accurate dx: renal Bx
Tx: Steroids for proteinuria, ACE inhibitors for all pt with protineuria and Fish oil
Pt comes in with tea colored urine and swelling around eyes. UA with hematuria, complement is LOW, BP elevated on vitals Recently had sore throat. most likely Dx: Best initial test: Most accurate test:
Dx: Post strep GN
Best initial: Antistreptolysin O, antiDNase, antihyadluronidase with LOW complement
Most accurate: Bx
Tx with PCN and maybe steroids
Pt comes in with cough and pink tinged sputum. Screening labs concerning for UA with hematuria and red cell casts on microscopy.
Renal Bx done and found linear deposits.
What is best initial test for this Dx?
Tx?
Dx: Goodpastures: cough/hemoptysis/ SOB and nephropathy
Most accurate: renal Bx with linear deposits
Best initial: anti-basement membrane antiB
Tx: Plasmapheresis and steroids
Pt has symptoms of stroke, currently can talk without focal weakness. When asked to draw, she is unable to do so. Likely location of lesion?
Construction apraxia
common in nondominant parietal lobe (often right lobe)
Can also have difficulty dressing or confusion
Pt with onset of clumsiness, and slurred speech better now, no focal deficits but when asked to do simple addition is unable. Also cannot name individual fingers or write and cannot tell left or right side of body apart.
Location of lesion
Gerstmann syndrome = dominant parietal lobe
Patient is having trouble seeing certain visual fields (upper qudrant of both eyes) as well as having a hard time interpreting complex sounds.
Location of lesion of stroke
Non dominant temporal lobe
Pt with recent kidney transplant comes to office 6 mo after for checkup. BP elevated to 160/90, hx of HTN and DM, already on anti-rejection meds + B blocker. His initial labs with normal electrolytes, Cr 1.1. STarted on ACE inhibitor and comes back next month with much better BP, but Cr of 2.4
What may be cause of elevated Cr?
Renal artery stenosis; highly suspicious if Cr bumps after initiation with ACE in pt in renal transplant.
ACE lowers angiotensin II thus GFR decreases by significant amount leading to AKI.
Pt with bicuspid aortic valve are at risk for what other complications?
infective endocarditis Aortic root dissection or ascending aortic dilation Severe regurg/stenosis *Get f/u echo every 1-2 yeras May need balloon valvuloplasty
What is alopecia ariata and its treatment
Hair loss; usually smooth, circular pattern over scalp, no inflammation. May be autoimmue mediated. Can treat but likely to recur.
Tx is intralesional steroids
Pt comes in with dizziness and back pain. Recent fall showing thickend skull with cotton wool appearance but not hematoma.
What lab do you want?
What do you expect to see on other xray imagin?
Pagets disease; skull deformities, hearing loss, dizzy, long bone w/ bowing deformity and increase fracture risk, spine and pelvic bone pain and spinal stenosis/nerve compression.
Labs: elevated serum and bone specific ALP
Calcium and Phos usually normal
plain films show osteolytic or mixed lytic/sclerotic lesions.
How is Pagets diagnosed?
Tx?
Radiographic findings and elevated ALP
Bone scan is more sensitive than xray
Tx: Bisphosphonates
Patient with shoulder pain getting worse over past three months, is a painter. Difficulty with ROM but no focal tenderness or swelling. Can’t lay on the shoulder. No trauma. Difficulty with active and passive ROM on exam.
Dx?
Adhesive capsulitis; frozen shoulder or contracture of joint capsule.
Don’t need imaging to dx
Pt with anterior shoulder pain, pain when lifting, carryong or overhead reaching
Biceps tendinopathy or rupture
Pt with pain at shoulder with abduction and external rotation. + for Subacromial tenderness. Normal ROM with + impingement test
Rotat cuff injury
if weak with abduction/ext rotation more likely a tear
Pt who is 60yo comes in with pain in left lower leg. The leg is shiny, w/o hair and no ulcers. the ABI is 0.76 on that leg and is 1.1 on the other.
What meds should they be on?
Peripheral arterial disease ASA STATIN BP control with ACE inhibitor Vorapaxar for antiplatlet as option Ca channel blockers NOT helpful
Management for peripheral arterial disease
Start ASA, statin and BP control
Start supervised exercise program, heart healthy lifestyle
If not helpful start Cilostazol
If not working may need revascularizations
What medication is indicated for acute psychosis in pregnant woman?
What about maintenance of bipolar?
Haloperidol Lamotrigine NOT lithium (Ebsteins), carbamazepine or valproate(NT defect)
How do you calculate a SAAG?
What does it mean to have SAAG >1.1
SAAG <1.1
Serum ascites albumin gradient
Serum albumin - ascites albumin
>1.1 = portal hypertension
<1.1 = or low is peritoneal carcinoma, peritoneal TB, nephrotic syndrome, pancreatitis, serositis.
The stupid fucking parts of Medicare A B C D
A = inpatient B= outpatient C = advantage; private health insurance w/ mediare benefits D= prescriptions
Patient presents with acute chest pain, what are the first steps
Rule out ACS
Get ECG to r/o STEMI
Serial troponin levels to r/o non-stemi
check for signs of chronic aschemia (T wave inversions)
Pt comes in with acute c/p that has now resoved, normal troponins and EKG. You suspect stable angina. What is the most appropriate initial diagnostic test?
What if patient has difficulty walking?
Initial: Exercise ECG or stress test
Can’t walk: pharmacologic stress test
Pt comes in with breast mass, as what age cut off do you use to determine getting an US vs mammogram?
<30, get US; if simple cyst–> FNA
<30 , get US if complex/mass–> core Bx
IF
>30 get Mammogram–> get core Bx if c/f malignancy
30yoM comes in with rt sided enlarged testis, left is normal, no fever, no pain. Exam shows firm, painless enlarged testis, neg transillumination, no penile discharge or signficant sexual hx.
MC diagnosis?
Best initial test?
Further w/u if screen is positive?
Testicular cancer; MC solid tumor men 15-35
BL scrotal US
If shows solid lesion.. need serum tumor markers: Alpha-fetoprotein, B-hCG) and likely screening CT
Tx inguinal orchiectomy + chemo
DONT bx, increases risk for spread
Pt comes in with tight feeling in her fingers, in the cold, she has sensation of fingers becoming white, then blue then red and painful and recently started on PPI for reflux. C/o BL joint pain.
Dx?
Scleroderma: tight skin + heartburn + raynauds = scleroderma
NO specific testing, but antitopoisomerase (anti-Scl 70) present in 30% pts while ANA is in 95% but not specific
Pt diagnosed with systemic scleroderma Tx for renal involvement: pulmnary HTN Raynauds GERD Lung fibrosis
renal: ACE inhibitors (can see malignant HTN)
Pulm HTN: Bosentan (endothelin antagonist), prostacyclin analogs or sildenafil
Raynauds: Ca channel blocker
GERD: PPI
Lung fibrosis: Cylcophosphamide
First line tx for sulfonurea poisoning?
What about refractory hypoglycemia?
IV dextrose (1-2mg/kg D50) Octreotide; somatostatin analog to decrease insulin secreation
Pt with renal stone, measures 9 mm, no hydronephrosis evident or evidence of renal failure and moderate pain. Plan?
Give alpha blocker and sent home
<10mm w/o evideicne of urosepsis, acute renal failure or complete obstruction then manage pain, hydrate and give alpha blockers
Pt with renal stone of 12 mm requires?
URology consult if >10 mm or less 10 mm but signs of complete obstruction, renal failure or urosepsis or if not responding to pain management
