Medicine 3 Flashcards
Individuals who have received a blood transfusion before 1992 are at risk for what?
Hep C. They should be tested.
In a patient with signs of infective aortic valve endocarditis and associated AV conduction block/syncope, suspicion of what is critical?
Perivalvular abscess. The infected valve can extend into adjacent tissues and compress the nodal tissues leading to block. 30-40% of IE patients have perivalvular abscess.
A man presents with fatigue, dyspnea on exertion with edema and ascites. Liver border is 8cm and he has JVD>9cm. Xray shows scattered calcification on the left side of the heart. Echo shows enlarged atria with normal ventricle thickness and vent size, and EF of 65%. Dx?
Constrictive pericarditis. Thickened or calcified pericardium limits diastolic filling. Prior cardiac surgery is often the cause, but can be idiopathic. Radiation, TB, malignancy, or uremia also. Kussmaul sign (lack of JVP decrease on inspiration) or pericardial knock (middiastolic sound) are classic signs.
Under what conditions are antithyroid drugs (PTU or methimazole) indicated?
Mild hyperthyroidism
Older age with limited life expectancy
Preparation for radioactive iodine/thyroidectomy (often accompanied by ß-blocker)
Pregnancy (PTU 1st line)
Renal vein thrombosis (RVT) is commonly associated with nephrotic or nephritic syndrome? Why? Which condition within the syndrome?
RVT is most commonly associated with nephrotic syndrome as the loss of antithrombin III predisposes to thrombosis. However, within nephrotic syndrome, RVT is most commonly associated with membranous glomerulonephropathy, though RVT can happen in any of the nephrotic conditions.
Aspirin intoxication leads to what acid/base derangement?
Mixed respiratory alkalosis and metabolic acidosis. The respiratory alkalosis is due to increased respiratory drive and the metabolic acidosis due to increased prodxn and decreased renal elimination of organic acids (lactic acid, ketoacids) leading to an increased anion gap.
In a patient with normal pH, but PaCO2 of 25 and PaO2 of 100 and HCO3- of 14, what is the derangement? Use Winter’s formula to help decide.
PaCO2 = 1.5 (HCO3-) + 8+/-2
PaCO2 = 29 +/-2
The formula gives us what the PaCO2 should be if we had a purely metabolic acidosis. The PaCO2 is lower than that, thus, this is mixed metabolic acidosis and respiratory alkalosis. ASA toxicity is the most common cause of this kind of metabolic derangement.
Classic signs of digoxin toxicity are?
NVD, decreased appetite, confusion, and weakness. Scotomata, blurry vision and xanthochromia are common too. Hypokalemia, caused by loop diuretics, often predispose patients on digoxin to toxicity.
Central retinal artery occlusion Rx?
Emergently treated with an ocular massage and high flow O2.
In a patient with mild weakness in whom a pronator drift is found, where is the likely lesion?
Pyramidal/corticospinal tract. An UMN lesion in these areas causes more weakness in supinators compared to the pronators of the upper limb and when the eyes are closed leaves proprioception to do the sensing. This leads to affected arm drifting downward and palms turning toward the floor.
Patients with resting tremor, rigidity, bradykinesia, or choreiform movements typically have a lesion where?
Basal ganglia.
Patients with ataxia, intention tremor, impaired dysdiadochokinesia (impaired alternating movements) have a lesion where?
Cerebellar dysfxn.
Classic triad of Wernicke’s encephalopathy?
Encephalopathy
Ocular dysfxn (e.g. pupillary rxn delay)
Gait ataxia
*Due to thiamine deficiency.
CML gene abnormality and Rx?
Abnormal BCR-ABL gene fusion t(9;22) leads to constitutively active tyrosine kinase. First line Rx is tyrosine kinase inhibitors (imatinib). Dramatic leukocytosis >100K with absolute basophilia and shift toward very early neutrophil precursors is typical.
APML Rx?
APML is a subtype of AML and is typically treated with all-trans retinoic acid.
A man with weakness, weight loss, hyponatremia, and hyperkalemia, with a low-normal cortisol level presents. Next steps?
ACTH stimulation test (cosyntropin - synthetic ACTH) given first to test if adrenals respond to ACTH. Then do 8am cortisol and plasma ACTH. Low cortisol level with high ACTH confirms primary adrenal insufficiency. High/high-normal cortisol rules out PAI.
Best strategy for prevention of further liver damage in HCV positive patient?
Avoid EtOh, give HAV, HBV vaccines.
A patient presenting with a mild type 1 rxn after taking a new medication (itchy, urticaria, but no wheezing) is managed how?
Antihistamines and discontinue drug
Best analysis of HSV encephalitis?
PCR is gold std.
In anaphylaxis, when are IM and IV epi indicated?
IM Epi is given initially. IV Epi is only given if the Pt has not responded to IM Epi.
Pt with an MI undergoing revascularization via PCI who gets a drug-eluting stent requires what 6 drug therapy afterwards?
Dual antiplatelet Rx: ASA and P2y12 receptor blocker ("grel" drug e.g. clopedogrel). These are taken for 12 months.
Beta blocker
ACEI
Statin
Aldosterone antag.In a man newly diagnosed with liver cirrhosis, what potential life threats must be ruled out first?
Esophageal varices. M&M are 30-60% in cirrhotic patients, thus, a screening endoscope is required.
In a known cirrhotic patient, how often must surveillance for HCC with AFP be done?
q 6 months alongside EGD for varices.
Management of ascites prevention in cirrhosis?
Sodium restriction
Diuretics
Paracentesis
EtOH abstention
Pt presents with abd. pain, constipation, and forgetfullness. His sensation is decreased in the lower legs and he has a microcytic anemia. Wife reports he has been drinking moonshine distilled at home. Dx?
Acute lead toxicity due to soldered metal joints with lead. Classic symptoms here. Lead causes porphyria due to heme synth disruption. Basophilic stippling of RBCs can present on smear.
If alk phos elevation is isolated do what test to check origin?
GGT. GGT positivity means biliary origin.
Medical management of PBC?
Ursodeoxycholic acid. This drug prevents damage from hydrophobic bile acids and improves bile movement. It may improve survival in these patients.
Path of Heparin-induced thrombocytopenia?
Conformational change in platelet factor 4 surface protein acts as neoantigen. Antibodies form to this antigen and bind to platelets leading to aggregation, thrombocytopenia, and prothombotic state.
Classic signs of Heparin induced thrombocytopenia?
Skin necrosis at the abdominal injection site. Must stop all heparin products and start direct thrombin inhibitor (argatroban) or fondaparinux.
Black woman presenting with focal proliferative glomerulonephritis has low platelets. Why?
SLE causes an autoimmune-mediated destruction of WBCs, RBCs, and platelets that occurs peripherally.
Calcium oxalate crystals found in the urine with a high osmolar gap in a patient with hematuria, oliguria, flank pain, and a cranial nerve palsy ingested what?
Ethylene glycol. Fomepizole is Rx of choice to inhibit alcohol dehy.
Ethylene glycol is metabolized to oxalic acid (which leads to calcium binding and hypocalcemia as well as crystal formation) and glycolic acid (which causes renal tubulear injury.
Why are elderly more susceptible to orthostatic changes?
Senescence of baroreceptor response and defects in myocardial responsiveness to this reflex.
Intubated patient in the ICU presents with fever 5 days after surgery. He grimaces to RUQ palpation. He has leukocytosis. US reveals pericholecystic fluid and enlarged GB wall. Dx?
Acalculus cholecystitis. Surgical patients or Pts on prolonged NPO status or TPN are susceptible. Unexplained fever with RUQ mass and leukocytosis or abnormal LFTs may present.
A patient on TPN develops gallstones. Why?
Bile stasis predisposes to gallstones and bile sludging that lead to cholecystitis.
CLL and CML are different in the leukocyte count in that?
CLL has lymphocytosis. CML has elevated neutrophils.
Hairy cell leukemia presents with?
Splenomegaly and pancytopenia.
Hodgkin lymphoma often presents with what symptoms?
Painless lymphadenopathy, B symptoms, with a normal blood smear and CBC. Massive lymphocytosis is unlikely.
Shistocytosis is expected in what 3 medical conditions?
Microangiopathic hemolytic anemias: DIC HUS TTP Prosthetic valves do it also. They all present with low haptoglobin, high LDH and bilirubin.
Impaired memory and attention, personality changes and ataxia with other motor symptoms in a person with longstanding HIV who is over 50 and poor compliance with their HAART likely has?
HIV-associated neurocognitive disorder (HAND) or progressive multifocal leukoencephalopathy (due to JC virus). Both occur in chronic HIV patients and have similar symptoms. An MRI would show diffuse intensity changes of the white matter in HAND, but PML would show spotty, focal and asymmetric lesions.
What is the fundamental difference between a cohort study and a case control study?
Cohorts start with a risk factor and try to link it to a disease. Case controls start with a disease and try to link it to a risk factor.
SE of levodopa plus carbidopa?
Hallucinations early Dyskinesia late (5-10 yrs)
SE of trihexyphenidyl or benztropine?
Anticholinergics for Alzheimer’s cause dry mouth, blurry vision, constipation, nausea, urinary retention.
Entacapone or tolcapone are used with what drugs? Why?
Used in combination with levodopa and carbidopa, these drugs inhibit COMT (which breaks down dopamine). They can cause dyskinesia, hallucinations, orthostatic hypotension, etc.
What percent FEV1 increase in asthma testing indicates reversibility?
> 12% increase in FEV1 indicates asthma as it is reversible. COPD is not.
Female patient experiences pain with filling of her bladder that relieves with voiding. She has increased frequency/urgency and notes pain with sex. Dx?
Interstitial cystitis. Often PE reveals tenderness to anterior vaginal wall. Cervical motion tenderness is not elicited on exam as in PID. This condition is often associated with fibromyalgia or other psychiatric diseases.
Man who had tooth abscess has been taking extra tylenol for the pain. He drinks two shots of whiskey daily and has Hx of HTN and DM. LFTs are elevated (thousands), INR>1.5, and he has a flapping of his hands when outstretched. Dx?
Acute liver failure. For a Dx of ALF, one needs elevated LFTs, INR≥1.5, and hepatic encephalopathy.
Focal segmental glomerulosclerosis is associated with what disease?
HIV
Membranous nephropathy is associated with what diseases?
Adenocarcinoma of lung/breast, Hep B, SLE
Membranoproliferative glomerulonephritis is associated with what diseases?
Hep B and C
Minimal change disease can be associated with what disease?
Lymphoma
Pts with IgA nephropathy typically have what prior to presenting with Sx?
Upper resp infxn
Patient presents with abdominal pain, constipation, and polyuria/polydipsia. She started over-the-counter supplementation for osteoporosis about 3 months ago. She has dry mucous membranes. Dx?
Milk-alkali syndrome. Excessive intake of calcium (hypercalcemia) and absorbable alkalis leads to renal vasoconstriction and decreased GFR, renal loss of sodium, water, and resultant bicarbonate reabsorption causes metabolic abnormalities. Thiazides, ACEIs, and NSAIDs can increase the risk. AKI, metabolic acidosis, low mag and phosphate can occur.
What factors affect PPV and NPV?
Pre-test probability (i.e. RFs [age, family hx, etc])
Risk group (e.g. condom use, many partners, etc.)
Prevalence is directly related to pre-test probability, which affects PPV/NPV.
3 MCC of PTH-independent hypercalcemia?
Malignancy
Vitamin D tox
Extrarenal activation of vitamin D (sarcoid)
What psych drug can lead to hypercalcemia?
Lithium.
Pleural effusions presents with what kind of breath sounds?
Decreased due to insulation around the lung. Poor transfer of sound to fluid from air. Tactile fremitus is also decreased.
Consolidation presents with what breath sounds?
Increased breath sounds with crackles or egophony. Tactile fremitus is increased.
Pt experiences respiratory distress and cardiogenic pulmonary edema within 6 hours after transfusion. Dx?
Transfusion related acute lung injury. Due to anti-leukocyte antibodies.
Shock, urticaria, and wheezing minutes after a transfusion. Dx?
Anaphylaxis. Due to anti-IgA antibodies in transfused blood.
What test is used for lactose intolerance?
Lactose hydrogen breath test. A rise in the measured breath hydrogen level after lactose ingestion indicates increased bacterial carbohydrate metabolism.
First line drug for fibromyalgia?
TCAs, but only after they fail to improve after aerobic exercise and sleep hygiene management.
18yo black man presents with splenomegaly and mild scleral icterus. Hgb is 8, MCV 90, MCHC normal, reticulocytes 10%, platelets and leukocytes WNL. He had a URI recently and took amoxicillin. No prior Hx. Dx?
Autoimmune hemolytic anemia (AIHA). Fatigue/dyspnea following respiratory infxn treated with amoxicillin has splenomegaly and anemia with reticulocytosis suggests warm agglutinin AIHA, possibly due to antibiotics. A positive direct Coombs test is typical as the test identifies autoantibodies or complement bound to RBC surfaces. Typical Rx: steroids.
What is chlorpheniramine MOA?
H1 blocker.
Chronic cough (>8 wks) most commonly caused by what 3 conditions?
Upper-airway cough syndrome (postnasal drip) - Dx confirmed via improvement with histamine blockers
Asthma
GERD
What dietary recommendations are in place to prevent renal calculi?
Increase fluid intake
Decreased sodium intake (increased sodium intake enhances Ca++ excretion into tubules due to Na/Ca coupling mechanisms in thick ascending loop)
Normal dietary calcium intake
MCC of osteomalacia (maybe asymptomatic, or present with bone pain, weakness/cramping, trouble walking/waddling)?
Vitamin D deficiency. Often PTH increases as a result leading to normal Ca++ and often low phosphate lvls. Pseudofractures and concave appearing (codfish) vertebral bodies occur.
Common causes of Vitamin D deficiency?
Malabsorption (Crohn’s), intestinal bypass, celiac sprue, liver and kidney disease
Molluscum contagiosum appears widespread in a patient. What must be considered as a potential cause?
Impaired cellular immunity (HIV). Prolonged courses of the virus or very large lesions/widespread lesions suggest the patient cannot defend against it, which is normally not an issue in the healthy Pt.
If pneumocystic pneumonia is suspected (immunocompromised with bilateral, diffuse interstitial infiltrates), then what must be done to Dx?
Culture from secretions, or if this does not reveal a source, do broncheolar lavage.
In a study, what does latency period mean when gathering data on an exposure?
While infectious diseases have a short latency period usually, some diseases (cancer, heart disease) have longer ones before manifestation occur. In studies, time must pass on a drug or with an exposure before a significant result is seen. Statins require a long period of time (~1yr) before a significant protective advantage takes place.
Female patient with muscle weakness lately has diplopia on two occasions and ptosis of the right eye. On occasion she has trouble speaking (bulbar muscle weakness) and weakness in her neck muscles. She notes trouble brushing her hair. Dx? Where is the pathology?
Myasthenia gravis, thus, autoantibodies against ACh receptors on the motor end plate are present. Muscle weakness presenting as extraocular (diplopia/ptosis) or bulbar (dysarthria) in nature and fluctuating fatigability are classic. Also symmetric proximal neck weakness is typical of MG.
Young female presents with orthostatic hypotension has hypovolemia, hypokalemia, hyponatremia, and hypochloremia. Her urine sodium and potassium are elevated. Likely Dx?
Diuretic abuse. Woman has salt wasting (determined by urine electrolyte content) despite being dehydrated.
Young female presents with orthostatic hypotension has hypovolemia, hypokalemia, hyponatremia, and hypochloremia. Her urine sodium and potassium are very low. Likely Dx?
Self-induced vomiting. Woman has salt-retention (determined by urine electrolytes) as would be appropriate.
If K+ is hard to correct despite multiple K+ administrations, what is the issue most likely?
Hypomagnesemia. It can lead to refractory hypokalemia due to removal of inhibition of renal K+ excretion.
The serum-to-ascites albumin gradient helps to determine what?
The origin of the ascites in question. If ≥1.1g/dL then it indicates portal HTN (cirrhosis, or CHF), if below 1.1g/dL, then likely not (malignancy, pancreatitis, nephrotic syndrome, TB).
What is Stemmer sign?
A positive Stemmer sign is an inability to lift the skin on the dorsum of the second toe and is highly specific for lymphedema.
Unilateral edema of the lower extremity is more likely to be lymphedema or venous insufficiency?
Unilateral edema is typical of lymphedema whereas bilateral edema would be more typical of venous insufficiency.
Eosinophilia with SOB, cough, fever, diffuse lung opacities on Xray and an Hx of nitrofurantoin may indicate?
Hypersensitivity pneumonitis in short-term use, or interstitial lung disease in long-term use.
Proper management shown to reduce decline in GFR in diabetic nephropathy?
Intensive BP control (targeting 140/90). The diabetic that moves from micro to macroproteinuria (>300mg/hr) and an accompanied progressive decline in GFR is typical of DM nephropathy.
Nonseminomatous germ cell tumor markers?
AFP and ß-hCG. Seminomatous and nonseminotamous germ cell tumors have ß-hCG elevations.
