Medicine Flashcards
CD4+ count at which MMR/V vax contraindicated?
<200
Patients with HIV need what vaccines due to elevated risk of infxn?
- Hep B (unless immune);
- S. pneumo (PCV13 followed by PPSV23 8 weeks later then again 5 yrs later and at 65yrs);
- Varicella (if CD4+>200)
- Influenza
- Td q 10 yrs
A commercial sex worker with Hx of IV drug use, fever, joint pains, and skin pustules on the extensors/chest, but not on palms/soles without abnormal heart tones likely has?
Disseminated gonorrhea:
1. purulent monoarthritis OR triad (tenosynovitis, dermatitis [papules/pustules], migratory polyarthralgias
2. Inflammatory effusion with PMNs in synovial fluid
Rx: ceftriaxone IV, then cefixime oral once improved; Azithromycin/doxy for chlamydia; can drain joint
What pulse quality may help differentiate aortic regurgitation and aortic stenosis?
AR: bounding (water hammer effect due to high stroke volume)
AS: pulsus parvus et tardus (low amp, delayed)
A young, obese female with a headache has normal imaging, papilledema, and elevated CSF pressure. What is the most likely complication?
Blindness is the most common complication of pseudotumor cerebri (idiopathic CSF pressure elevation). Weight reduction, acetazolamide, or if all else fails, optic nerve fenestration may prevent blindness. If SZ presents, think brain tumor, not CSF pressure.
When might heterophile testing for Mono be falsely negative?
Early in illness - retest days later
Why is routine dipstick testing of urine not effective during early nephropathy stages?
They detect only excessive urinary protein (albumin) excretion (>300mg/24hr - e.g. macroalbuminuria), which is above the threshold for a microalbuminuria that may be seen in DM. 24hr collection is best to detect microalbuminuria (30-300mg/24hr).
What are the differences in appearance of leukoplakia and squamous cell cancer of the mouth?
Leuko: reactive precancerous lesion that demonstrates hyperplasia -white, granular lesions layered on top of oral mucosa
Ca: persistent nodular, erosive, ulcerative lesions with erythema/induration, maybe regional lymphadenopathy
Define the following terms: End diastolic volume End systolic volume Afterload Preload
EDV: volume in the heart after diastolic filling (max volume) - increased by increasing preload
ESV: volume in heart after sytole/before diastole (min volume) - decreased by elevated stroke volume/increased afterload
A: force against which heart pumps to deliver blood from the heart - elevation leads to decreased ejection fxn/elevated ESV
P: fluid filling the vents - increased by longer diastolic filling time which increases EDV and ESV
After subarachnoid hemmorrhage, what risks of complications occur within 24hrs? 3-10days? Any time?
24hrs: Rebleed
3-10days: Vasospasm (stroke-like Sx)- major cause morbidity/mortality
Others: elevated ICP, SZ, hyponatremia (SIADH)
Dx: CT>90% sensitive, LP reveals xanthochromia in CSF, angiography to ID source
What is the feared side effect of propylthiouracil and methimazole? How does this present?
PTU and MMI cause agranulocytosis in 0.3% taking the drug. If a fever and sore throat occur, the drug should be DCed promptly and WBCs measured. If <1000, then permanent DC of drug should occur.
How do erythrocyte sed rate and CK levels differentiate myopathies?
Glucocorticoids: normal ESR and CK
Polymyalgia rheumatica: elevated ESR, normal CK
***Important to diff. these two as temporal arteritis Rx with high dose steroids that are then tapered…
Others:
Inflammatory myopathy (polymyositis, dermatomyositis): CK and ESR elevated
Statins and hypothyroid myopathy: Normal ESR, elevated CK
Symptomatic hypercalcemia (fatigue, constipation, kidney stones) suggests primary hyperparathyroidism. A man complaining of inflammatory arthritis and the suggested history likely will have what in the joint space on aspiration?
Pseudogout: Rhomboid-shaped crystals made of calcium pyrophosphate dihydrate - usually associated with hypeparathyroidism and chronic hypercalcemia as well as hypothyroid and hemochromatosis.
What characteristics differentiate vitreous hemorrhage from retinal detachment?
VH: sudden loss of vision and onset of floaters/dark red glow in humor; hard to visualize fundus
RD: vision loss, photopsia (flashes of light) with showers of floaters
How should acute pain management be induced in a person with a substance abuse Hx?
The same as anyone else. Meaning opioids should be included regardless.
A patient with urethritis, conjunctivitis, or mouth ulcers as well as an asymmetric oligoarthritis (2-4 joints) including the back is suspicious for what?
Reactive arthritis. NSAIDs are the first line.
How can amebic liver abscess and hydatid cyst due to Echinococcus granulosus be differentiated on CT?
Ameba: form abscess causing RUQ pain, fever, etc.
Echinococcus: form classic eggshell calcification on CT; transferred from contact with dogs
The pathophysiology of Paget’s Disease involves disordered osteoclastic bone resorption. What is the treatment for this disease? Why?
Bisphosphonates (-dronates) - These drugs inhibit osteoclast fxn
A man with abd. distention, and flatulence as well as foul smelling stools, generalized lymphadenopathy, skin hyperpigmentation, and a diastolic murmur in the aortic area has a biopsy of his intestinal wall and is found to have what pathologic changes there?
PAS-positive materials in the lamina propria secondary to Whipple’s disease. GI symptoms predominate with migratory polyarthropathy, cough, and cardiac symptoms (valvular) lead to CHF later. CNS manifestations can occur.
What lung sound findings make CHF easily differentiated from COPD?
Crackles bilaterally at the lung bases. Wheezes may be present as cardiac asthma in CHF.
Name three classes of abortive and three preventive migraine medications.
A: triptans, NSAIDs, antiemetics (metoclopramide), Ergots (dihydroergotamine)
P: Topiramate, divalproex, TCAs, Beta blockers
40s female presents with pruritis has fatigue. PE reveals skin excoriations and mild hepatomegaly. She has xanthelasmas and a total bilirubin = 1.6. Antimitochondrial antibody is positive. What is she at risk for developing later?
Osteomalacia. This is classic example of Primary biliary cholangitis, an autoimmune disease that targets the intrahepatic bile ducts only (unlike sclerosing which attacks intra/extra and is assoc. w/ UC and colorectal cancer). Malabsorption in PBC leads to fat-soluble vitamin deficiencies and can cause hepatocellular carcinoma. Ursodeoxycholic acid delays progression. Liver Tx may be needed.
Individuals with a previous Hx of malignancy from chemo or radiation are more likely to develop what later in life?
Secondary malignancy.
What surgical procedure is the most effective cure for removing basal cell carcinoma?
Mohs procedure: a procedure involving taking layers of skin until the tumor is completely resected.
BCC presents as a persistent sore that oozes/crusts/bleeds and my be red or irritated and elevated. It may be pink, red, or white in color or be pale/scar-like.
Women taking OCs are at risk of developing what liver anomaly?
Hepatic adenoma.
What metabolic/electrolyte side effects may be expected in a Pt on chlorthalidone or another thiazide diuretic?
Hyponatremia, hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia, hypercholesterolemia
How can lab values and S/S differentiate infectious mono from AML?
Mono: aside form obvious Sx, mono may present with leukopenia (viral suppression), +monospot (heterophile Ig), atypical lymphocytes on smear - autoimmune hemolytic anemia and thrombocytopenia may occur due to crossrxn w/ RBCs and platelets of Ig
AML: generally present with pancytopenia, hepatosplenomegaly, and generalized lymphadenopathy, usually having leukocytosis rather than peukopenia as mono can
What qualities differentiate Hashimoto, painless, and subacute thyroiditis from one another? How is Grave’s differentiated from Painless thyroiditis?
H: hypothyroid with diffuse goiter, positive TPO antibidy, variable radioiodine uptake
P: Brief hyperthyroid phase (2-5 months) followed by hypothyroidism and recovery, small nontender goiter; TPO Ig+, low radioiodine uptake (differentiates from Grave’s during thyrotoxic phase)
SA: Postviral inflammation causes high fever and hyperthyroid with painful/tender goiter, TPO Ig -, low radioiodine uptake
What is the most probable form of glomerulopathy in an African/Hispanic individual with HIV?
Focal segmental glomerulosclerosis.
Any Pt found to have an enlarged thyroid should be evaluated how first?
- TSH, US of thyroid
- If TSH low, do thyroid scintigraphy w/ Iodine123
- Hot: low cancer risk–>Rx for hyperthyroid
Cold: high cancer risk –> Fine needle aspiration
A patient with chronic cough and mucopurulent discharge, but no smoking or CF Hx, dyspnea, hemoptysis, and recurrent infections may have what condition?
Bronchiectasis. Dx with CT initially. Recurrent inflammatory reaction due to CF (50% cases), or infxn (MCC if not CF), kartageners, autoimmune.
Recall the mnemonics for IE and for RH disease.
IE: FROM JANE:
Fever, Roth spots, Osler nodes (“Ouch” on fingertips), murmur, janeway lesions, anemia, nail hemorrhage, emboli
RH: JONES
Joints, O is heart shaped, Nodules, Erythema migrinatum, syndenham chorea
What does DEXA stand for? What levels become concerning? Who gets one?
Dual-energy X-ray absorptiometry.
Osteoporosis: ≥2.5 SDs below the mean for a young adult at peak bone density (T-score ≤-2.5)
Osteopenia: T-score ≤-1 to -2.4
Women with RFs like smoking or age≥65.
Define the following: Episcleritis Dacrocystitis Hordeolum Chalazion
E: Infxn of episcleral tissue b/t conjunctiva and sclera. Photophobia, watery discharge, PE shows bulbar conjunctival injxn
D: (dacro=tears) infxn of lacrimal sac -pain in medial canthal region
H: abscess over upper/lower eyelid (Usually S. aureus); sty
C: granulomatous inflammation of meibomian gland - hard painless lid nodule
What are the common associated neoplasms with each of the following:
Lynch syndrome
Familial adenomatous polyposis
von Hippel-Lindau
L: colorectal, endometrial, ovarian
FAP: colorectal, desmoids/osteomas, brain tumors
VHL: Hemangioblastomas, clear cell renal carcinoma, pheochromocytoma
What are the common associated neoplasms with each of the following: MEN1 MEN2a MEN2b (3) BRCA1 and 2
MEN1 (3P’s): Parathyroid, pituitary, pancreatic (ZES, insulinoma) adenomas
MEN2a (Sipple syndrome - MPH): parathyroid hyperplasia (hyperparathyroidism), medullary thyroid cancer, pheochromocytoma
MEN3 (MMMP): medullary thyroid carcinoma, mucosal neuromas, marfinoid habitus, pheochromocytoma,
What indicates it is time for CT scan of the abdomen/pelvis in a patient with pyelonephritis?
No clinical improvement in 48-72hrs
A confounder requires what two characteristics to be defined as such?
- It must be related to the exposure (those who drink are more likely to smoke)
- It must be related to the outcome of interest (smoking is associated with oral cancer as alcohol is)
In HOCM, what valve is observed in the ECHO and what is the problem with it?
Anterior cusp of the mitral valve touches the septum during systole. This is worsened when preload is decreased, because the size of the chamber is smaller leaving a smaller gap to be bridged by the leaflet. This causes a midsystolic crescendo/decrescendo murmur at the LLSB. An MVP is a click with a mid-to-late systolic murmur of MR. It is also accentuated (earlier) by decreasing preload or afterload.
What are the major side effects of the following DMARDs: Methotrexate Lefluonomide Hydroxychloroquine Sulfasalazine Anti-TNF agents (Infliximab)
M, L, S all cause hepatotox; M, L cause cytopenias (marrow suppression)
S: Hemolytic anemia
H: Retinopathy
AntiTNF: TB reactivation, infxn
What findings will help differentiate Blastomycoses from Histoplasmosis?
B: characteristic heaped-up verrucous/nodular lesions with violacious hue that can turn into microabscesses; skin involvement; can disseminate in immunocompetant as well as compromised
H: rarely disseminates in immunocompetant; mild/asymptomatic pulm. infxn; immunocompromised may get disseminated disease with papular/crusting lesions on skin
What are the qualities that differentiate delayed sleep phase syndrome from advanced sleep phase syndrome?
D: sleep-onset insomnia (can’t fall asleep easily due to changes in schedule to earlier time frame that doesn’t coincide with circadian rhythm), excessive sleepiness, often feel rested on weekends when they can sleep in to a time that coincides better w/ rhythm
A: Inability to stay awake in evening –> fall asleep early –> early morning insomnia (wake up early often)
What is the presentation of a ventricular aneurysm?
Scar tissue deposits after transmural MI leads to heart failure/angina months later. Arrythmia/embolization can occur due to hypokinesis of myocardial wall. ECG: persistent ST elevation/deep Q waves; Echo: thin/dyskinetic myocardial wall
What is the first-line Rx for aborting cluster headaches?
100% O2.
In a Pt. with suspected MS, what is the first test done to support Dx?
MRI of brain and spine (T2-weighted). An LP to check CSF for oligocloncal IgG bands may help also. MRI is 1st. Nerve conduction studies Dx peripheral nerve disorders.
What qualities differentiate Waldenstrom macroglobulinemia, multiple myeloma, and monoclonal gammopathy of undetermined significance?
W: excessive monoclonal IgM, end-organ damage (hyperviscosity syndrome - diplopia, tinnitis, HA, fundoscopic changes), neuropathy, and infiltrative disease (anemia, hepatosplenomegaly)
MM: IgG, IgA, or light chain spikes; osteolytic lesions/fractures (bone pain instead of hyperviscosity, neuropathy, infiltration)
MG: IgM spike (but smaller, <3g/dL), no end organ damage or obvious systemic effects like the others
Where is DHEAS produced and what is the significance of this in adrenal tumors vs virilizing ovarian tumors?
DHEAS is only made in the adrenals, whereas DHEA and testosterone are produced by both the adrenals and ovaries. Thus, DHEAS will only be elevated in a virilized female with an adrenal tumor and it will be normal in a virilized woman with an ovarian tumor.
Thyrotoxicosis leads to what effects on myocardium and peripheral vasculature, respectively?
Myo: increased contractility and rate
Vasc: oddly enough elevated thyroid leads to decreased systemic vascular resistance, the opposite is true of hypothyroidism (HTN)
Common causes of anion gap metabolic acidosis?
MUDPILES: Methanol Uremia DKA Propylene glycol Isoniazid/Iron Lactic acidosis Ethylene glycol Salicylates
Normal anion gap value?
6-12mEq/L
Calculation for corrected calcium
corrected calcium = measured Ca++ + 0.8 x (4 - albumin)
Best screens for multiple myeloma
serum protein electrophoresis (M-spike), urine protein electrophoresis, and free light chain analysis, confirm with bone marrow biopsy
Ischemic vs hemorrhagic stroke progression
I: abrupt onset, may progress/fluctuate some; atherosclerotic RFs
H: HTN/coagulopathy Hx; symptoms progress over minutes/hours; early neuro Sx with later ICP Sx (vomiting, HA, bradycardia)
Management of acute bronchitis
Symptomatic Rx (NSAIDs, etc.)
Acute bronchitis Dx
Clinical Dx: (no CXR)
Cough>5days - 3 wks +/- purulent sputum; absent systemic findings (fever/chills); wheeing/rhonchi
What nephrotic syndrome is Hodgkins lymphoma associated with?
Minimal change disease
First-line Rx in rheumatoid arthritis?
DMARDS (e.g. methotrexate - 1st line, hydroxychloroquine, sulfasalazine, leflunomide, azathioprine, and the anti-INF agents: infliximab, etc.)
3 most common etiologies of acute pancreatitis?
Chronic EtOH
Gallstones
HyperTG
Dx criteria for pancreatitis?
2+ of following:
1. Acute epigastric pain rad to back
2. Elevated amylase or lipase >3x Normal limit
3. Abnormalities on imaging
Note: ALT>150 suggests biliary pancreatitis
Meds that must be held prior to cardiac stress testing?
Hold 48hrs prior: Beta blockers, calcium channel blockers, nitrates
Continue others: ACEI, digoxin, statins, diuretics
Features that differentiate R. sided CHF from ascites due to cirrhosis
Ascites due to liver failure will have shifting dullness and fluid waves. R. sided CHF will not have this, but will have JVD and hepatojugular reflex.
Isolated systolic HTN definition and path?
ISH: >140/<90 (elevated sys, normal dias)
In elderly, usually due to aortic stiffness/decreased elasticity of the arterial wall
Warfarin-induced skin necrosis path?
Reduced Vit K-dependent clotting factors II, VII, IX, X, Protein C and S results in Protein C deficiency within first day while others decline more slowly, resulting in a transient hypercoagulable state.
Presence of erythema nodosum requires what imaging?
CXR for sarcoidosis (sarcoid may be present in almost 30% of EN cases)
Two most commonly isolated organisms in single brain abscess
S. aureus, Strep viridans both due to direct extension from adjacent infxn (sinuses, otitis media, etc.)
Most common Rx for essential tremor
Propanolol (ß-blocker)
Most common thalassemia in Mediterraneans
ß-thalassemia (anemia, microcytosis, target cells on smear, normal RDW)
Most common thalassemia in Southeast Asians
alpha-thalassemia (anemia, microcytosis, target cells on smear, normal RDW)
Light criteria for pleural effusion (transudate has absence of all of these values)
- Protein-p/Protein-s>0.5
- LDH-p/LDH-s >0.6
- LDH-p >2/3 upper limit of normal for serum LDH (45-90 normally)
* s = serum
* p = pleural fluid
* *Transudative pleural fluid pH is 7.4-7.55
3 main causes of unconjugated hyperbilirubinemia
- Overprodxn (e.g. hemolysis)
- Reduced liver uptake
- Conjugation defect (e.g. Gilbert’s)
Evaluating liver enzyme pattern in conjugated hyperbilirubinemia (3 possibilities) - UWQ 2975
- Elevated AST and ALT (viral, autoimmune, toxin, ischmemic, alcohol hepatitis or hemochromatosis)
- Normal AST, ALT, alk phos (Dubin-Johnson, Rotors)
- Predominantly elevated alk phos (Malignancy (pancreas, ampulla), cholangiocarcinoma, PBC, PSC, choledocolithiasis) –> do US/CT or Antimitochondrial antibody
Elevated alkaline phosphatase levels indicate
Cholestasis
EBV DNA positive CSF in HIV Pt with solitary weakly ring-enhancing lesion in brain
Primary CNS lymphoma
Brain damage in heavy alcohol use
Cerebellar vermis - truncal coordination (wide gait, postural issues, falls, etc.)
Presentation: Alzhemier’s
Early, insidious short-term memory loss
Presentation: Vascular dementia
Stepwise decline in executive fxn, forgetful, neuro deficits (hemiparesis, etc.)
Presentation Frontotemporal dementia
Early personality changes (apathy, disinhibition, compulsive)
Presentation Lewy body dementia
Visual hallucinations, parkinsonianism
Presentation normal-pressure hydrocephalus
Ataxia early, urinary incontinence, dementia, dilated vents on imaging (wet, wobbly, wacky)
Presentation Prion disease
Rapid behavioral changes w/ myoclonus/seizures
Classic allergic conjunctivitis presentation
red, watery, ITCHY, granular conjunctiva
Acute kidney transplant rejection first-line
IV steroids
Treatment for trigeminal neuralgia
Carbamazepine
Imaging for suspected stroke
CT scan without contrast (hemorrhage appears as white hyperdense regions in parenchyma; ischemic strokes are hypodense until >24 hrs after event)
Rx for anorexia in cancer; HIV?
C: progesterone (megestrol, medroxyprogesterone), corticosteroids
H: cannabinoid
Low haptoglobin indicates?
Hemolysis
Elevated LDH indicates?
Hemolysis
Low haptoglobin with elevated bilirubin and LDH indicate?
Intravascular hemolysis
If hemolytic anemia, cytopenias, and hypercoagulable state (presence of thrombus) suspicious of?
Paroxysmal nocturnal hemoglobinuria
Zinc deficiency Sx?
- Alopecia
- pustular skin rash (perioral)
- impaired wound healing
- impaired taste
- immune dysfxn
Anion gap metabolic acidosis after Sz Rx?
Repeat tests after 2 hrs in post-ictal lactic acidosis - usually resolves in 90 mins.
High stepping (steppage gait) due to right foot drop secondary to?
L5 radiculopathy or common peroneal nerve neuropathy
Porcelein gallbladder (calcium rim on CT) at risk for?
Gallbladder adenocarcinoma
1st line for MS attacks?
Glucocorticoids
Refractory MS attack Rx to steroids?
Plasmapheresis
Allergic/irritant contact dermatitis Sx?
Erythema
Papules/vesicles
Lichenification
Fissures
Initial screening in suspected thalassemia?
CBC, if abnormal and MCV is low (iron, TIBC, and ferritin normal in thalassemia vs iron def.), then Hgb electrophoresis.
Mitral regurgitation sound?
Holosystolic @apex w/ radiation to axilla
Isoniazid leads to neuropathy due to what deficiency?
Pyridoxine (B6)
Hazard ratio definition? (as in a study outcome)
Ratio of an event rate occurring in Rx arm versus non-treatment arm. Ratio>1 indicate Rx arm has higher rate of events, <1 ratio means lower rate.
Adrenal adenoma or bilateral adrenal hyperplasia Rx?
Aldosterone antagonist (spirinolactone/eplerenone) or surgery for adenoma (unless poor candidate)
Pernicious anemia is the most common cause of what?
B12 deficiency
Pernicious anemia is associated with what cancer?
Double risk of gastric cancer
Hypovolemic hypernatremia Rx?
IV 0.9% saline
Desmopressin admin for what?
Differentiate Central DI (No ADH) from Nephrogenic DI (No response)
Most common causes of hyperkalemia are?
Acute/chronic kidney disease, meds (ß-blockers, K+-sparing drugs, ACEI/ATII blocker, NSAIDs, trimethoprim), disorders of RAA
Tricuspid regurgitation and right sided HF are caused by what syndrome?
Carcinoid syndrome - plaque-like fibrous deposits on endocardium in R>L heart
24-hour test for what in carcinoid syndrome?
5-hydroxyindoleacetic acid (5-HIAA)
Dx: Decreased FEV1/FVC ratio, decreased FEV1, normal FVC, normal DLCO
Chronic bronchitis
Dx: Decreased FEV1/FVC ratio, decreased FEV1, normal FVC, decreased DLCO
Emphysema (low DLCO from destroyed alveoli)
Dx: Decreased FEV1/FVC ratio, decreased FEV1, normal FVC, elevated DLCO
Asthma
Obstructive pattern PFTs
- Decreased FEV1/FVC
- Decreased FEV1
- Normal FVC
Restrictive pattern PFTs
- Normal/elevated FEV1/FVC
- Normal/somewhat low FEV1
- Low FVC
- DLCO is either normal or low (unless morbidly obese then high)
Precision measures?
Random error in a study (The smaller the confidence interval is, the more precise.)
Carcinoid syndrome causes what vitamin deficiency?
Niacin (Niacin and serotonin made from tryptophan. Serotonin overprodxn = deficient niacin = pellagra).
In HIV, PPD resulting in induration ≥5mm requires?
Isoniazid and pyridoxine Rx for latent TB
What size PPD requires treatment in nonimmunocompromised person?
≥15mm
Attributable risk measures?
Measure of impact attributed to a risk factor (i.e. impact of diet on colon cancer risk)
Calculate attributable risk
Calculation: (RR - 1)/RR
Words: (risk in exposed - risk in unexposed)/risk in exposed
BSA in Stephen Johnson vs Toxic-epidermal necrosis
10% = SJS 10-30% = SJS/TEN overlap 30+ = TEN
Classic SJS/TEN Sx
Skin and mucosal (oral) macules, vesicles, bullae (mucocutaneous)
Nonosmotic stimuli (i.e. hypovolemia) results in ADH secretion leading to what?
Hypovolemic hyponatremia (more H2O uptake than Na+ reuptake) - once hypovolemia corrected (euvolemia), ADH shuts off, and body corrects hyponatremia via RAAS
Most common porphyria?
Porphyria cutanea tarda (uroporphyrinogen decarboxylase deficiency) - blisters w/ skin fragility are classic - commonly an extrahepatic manifestation of HepC
Most common cause AR in young adults in developed world?
Congenital bicuspid aortic valve
Scleroderma renal crisis typical presentation?
Acute renal failure with no previous renal disease and malignant HTN (HA, blurry vision, nausea)
First step in hypercalcemia management?
Normal saline and calcitonin
High levels of estrogen (e.g. pregnancy, OCs, HRT) can lead to what changes in total vs free T4?
Total T4 elevated due thyroid binding globulin via reduced catabolism/increased synth in the liver. Free T4 (unbound by TBG/albumin) is normal (euthyroid).
Treatment for hyperthyroidism/storm?
ß-blocker, PTU
AR murmur sound?
Blowing diastolic/decrescendo after A2
AR murmur best heard?
LLSB w/ Pt sitting up and leaning forward with full expiration
Labs/Hx in nonalcoholic fatty liver disease?
Labs: Steatohepatitis (AST/ALT ratio<1)
Hx: No alcohol Hx
*NAFLD resembles alcohol induced liver disease, but without EtOH Hx
Path of nonalcoholic fatty liver disease?
Insulin resistance (elevated FFA Tx from adipose to liver due to peripheral lipolysis/TG synth/hepatic FFA uptake)
Mycoplasma pneumonia onset vs S. pneumoniae?
Indolent (vague) vs abrupt in S. pneumoniae
Mycoplasma pneumonia CXR vs S. pneumoniae?
Interstitial infiltrate vs lobar in S. pneumoniae
Mycoplasma pneumonia skin signs vs S. pneumoniae?
Myco: Maculovesicular rash
SP: Rash very rare
Common medications causing priapism?
Trazadone, prazosin
Common diseases causing priapism?
Sickle cell, leukemia
Isoniazid therapy can cause what vitamin deficiencies?
Most commonly B6 (pyridoxine), but also B3 (niacin)
2 groups at risk for subdural hematoma?
Elderly and alcoholics (both have cerebral atrophy and increased fall risk)
Common causes of ill esophagitis?
PAINT-B: Tetracyclines NSAIDs ASA Bisphosphonates Potassium chloride Iron
2 common locations for stenosis in fibromuscular dysplasia?
Internal carotid artery stenosis = HA
Renal artery stenosis = HTN
Most common organism causing IE after UTI?
Enterococci
Most common organism causing IE after dentist visit or respiratory tract incision?
Viridans stretococci
Most common organism causing IE after pacemaker/prosthesis/catheter placement?
S. aureus (also IV drug use)
S. epidermidis
Most common organism causing IE in colon carcinoma or IBD?
Streptococcus gallolyticus (S. bovis)
Hypokalemia, alkalosis and normotension may indicate what causes?
Surreptitious vomiting
Diuretic abuse
Bartter syndrome
Gitelman’s syndrome
Urine Ca++ and serum Mg++ in Bartter vs Gitelman’s syndrome?
B: UCa++ excretion high, normal serum Mg++
G: UCa++ excretion low, low serum Mg++
Most appropriate tests for acute Hep B infxn?
HBsAg
anti-HBc IgM
Liver enzymes in acute Hep B infxn?
ALT>AST spike around 3 months or after 4-8wks (about same time IgM anti-HBc appears)
MCC of polyuria in nonhospitalized Pts?
DM. primary polydipsia, DI
Polyuria, increased water intake with dilute urine (<1/2 plasma Osm), and hyponatremia classic for?
Primary polydipsia
Polyuria, increased water intake with dilute urine (<1/2 plasma Osm), and Na+>145 indicates?
DI
- Central: impaired thirst mechanism leads to severe hypernatremia (>150)
- Neph: Intact thirst mech, adequate water intake, maybe normal Na+
Absence of polyuria, concentrated urine (Uosm>100), hypotonic serum osmolality (<275), hyponatremia, low Serum uric acid level indicates?
SIADH
Postvoid residual bladder volume over what value is diagnostic for urinary retention?
> 50mL
Appearance of pyoderma gangrenosum?
Inflamed pustule that expands to ulcer with purulent base/violaceous borders
Pyoderma gangrenosum assoc. with what disease?
Systemic inflamm. disease: IBD, RA, hematologic issues (AML)
Initial imaging modality for gastric adenocarcinoma?
CT scan - determine stage (usually detected late; stage 3-4)
Management of Pt w/ claudication due to PAD?
- Smoking cessation
- ASA, statins
- Exercise program (most useful for Sx reduction)
- Surgery/stenting reserved only for failure to improve w/ exercise
Red-flag symptoms for cavernous sinus thrombosis?
Severe HA
Bilat. periorbital edema
CN 3, 4, 5, 6 deficits
Lead poisoning Sx?
Stocking glove neuropathy
Microcytic anemia
Arsenic poisoning Sx?
- Stocking glove neuropathy w/ burning/pain, weakness, hyporeflexia
- Skin hypo/hyperpigmentation and hyperkeratosis
- Pancytopenia
- Hepatitis
Arsenic OD Rx?
Dimercaprol, Succimer (dimercaptosuccinic acid)
Primary sclerosing cholangitis labs/imaging?
Labs: Elevated alk phos; usualy ATs <300
I: ERCP confirms Dx showing “beads on a string” intra/extrahepatic duct dilation
Priary sclerosing cholangitis comorbid disease?
Ulcerative colitis (unlike PBC)
Primary biliary cholangitis (or cirrhosis) antibody?
Antimitochondrial antibody
Primary biliary cholangitis (or cirrhosis) affected duct?
Intrahepatic only
Trimethoprim lab abnormalities?
Blocks Na+ channel in CT like amiloride diuretic
- Hyperkalemia (must do serial check in AIDS on high doses)
- Creatinine elevation
Pulsus paradoxus occurs with what conditions?
- Cardiac tamponade
- Severe asthma/COPD (high pressure elevation intrathorax during inspiration = blood pooling = low left vent. preload)
Imaging for uric acid stones?
CT as they are radiolucent, US or IV pylogram
Findings on PE coarctation?
Brachial-femoral delayed pulse, upper/lower BP differential, continuous murmur
Sx in coarctation?
Epistaxis, HA, claudication
Oliguria definition?
≤250mL urine output in 12 hours
Atypical pneumonia after travel w/ high fever, GI Sx, confusion, and hyponatremia are signs of?
Legionnaires’ disease (gram neg. rod, intracellular = poor staining - often shows up as PMNs w/o organism)
Legionnaires’ disease Rx?
Macrolides, flouroquinolones
Postcholecystectomy syndrome presentation?
Persistent abd pain/dyspepsia occurring months/years after cholecystectomy
Best Rx for primary hyperparathyroidism?
Parathyroidectomy or bisphosphonates in those who decline surgery and have osteopenia/osteoporosis
Primary hyperparathyroidism labs?
Asymptomatic hypercalcemia, hypophosphatemia, and elevated PTH
Familial hypocalciuric hypercalcemia labs?
Hypercalcemia, elevated PTH, but low urinary calcium excretion (<100mg/24hrs)
Median definition?
To the right or left of the mode (peak) of curve if data skewed positively/negatively. Value in the middle of a dataset (divides right from left - e.g. 18, 20, 21, 22, 22 - median is 21; If there are even number of values, add middle two and divide by 2).
Mode definition?
The peak of the curve. Most frequent dataset - e.g. 9, 10, 9, 15, 12 - then 9 is mode; can have more than one mode in a dataset if the several values have the same frequency.
Mean definition?
Always the most right or left on a curve if the curve is skewed positively or negatively. Sum of all observations divided by the number of observations; the average
Rx in exercise induced asthma?
Antileukotrienes (mast cell stabilization) and albuterol taken 10-20 minutes prior to exercise
Bright red, firm, friable, exophytic nodules on skin of HIV+?
Bacillary angiomatosis (Bartonella)
Rx for bacillary angiomatosis (Bartonella)?
Oral erythromycin
Papular lesions (trunk/face/extremities) that become plaques/nodules starting as light brown to pink to dark violet in HIV+?
Kaposi Sarcoma (HSV 8)
Broca’s area location?
Dominant (left hemisphere in right hander and most left handers) frontal lobe
Wernicke’s area location?
Dominant (left hemisphere in right hander and most left handers) posterior temporal lobe
Classic psoriatic arthritis pattern?
DIP joints effected
Morning stiffness
Dactylitis (sausage fingers)
Nail involvement (pitting, onycholysis - separation of nail bed)
Age range for HPV vax?
Women recommended 11-12yrs (9-26 at latest)
Men up to 21yrs
Tdap vax recommendation?
Single dose at 11yrs and Td q 10 yrs after
Pap smear recommendations?
21-29 q 3 yrs
30-65 q 5 yrs
Duodenal ulcer pain improved by?
Eating
Gastric ulcer pain worsened by?
Eating
Suppurative (infective) thyroiditis labs/Sx?
Euthyroid
High fever
Pain at thyroid gland
Palpable enlargement of thyroid
Subacute (de Quervain) thyroiditis Labs/Sx?
Elevated free T4/low TSH (early) Hypothyroidism (late) followed by recovery Recent infxn Fever Tender goiter ESR elevated
Chronic lymphocytic (Hashimoto) thyroiditis labs/Sx?
Hypothyroidism (low free T4/high TSH)
Nontender goiter
Absence of fever
Non-anion gap metabolic acidosis and hyperkalemia out of proportion to renal dysfxn indicate?
Renal tubular disorder
Renal tubular acidosis is a group of disorders characterized by?
Non-anion gap metabolic acidosis in the presence of preserved kidney fxn
Path/labs in Type 1 RTA?
Type 1 “Classic” distal RTA:
Defective H+ secretion in distal tubule–> defective pH gradient –> hyperchloremia and poor bicarb. reuptake
Hypokalemia
Metabolic acidosis
High urine pH (>6)
Nephrolithiasis common (up to 70% have stones)
Path/labs Type II Proximal RTA?
Type II proximal RTA:
Similar to type 1 in that: Defective bicarbonate reuptake in proximal tubule causes metabolic acidosis –> hyperchloremia and hypokalemia, but may be due to Fanconi syndrome w/ loss of glucose, AAs, PO4, Ca++, K+ or multiple myeloma; no nephrolithiasis as in Type 1 RTA
Path/labs Type IV RTA?
Type IV RTA:
Aldosterone deficiency or antagonism causes reduced hyperchloremia, hyperkalemia, non-anion gap metabolic acidosis, salt wasting
Hemiparesis w/ motor aphasia location lesion?
Frontal cortex of dominant lobe
Hemiparesis without motor aphasia location lesion?
Frontal cortex of nondominant lobe
Receptive aphasia location lesion?
Left temporal lobe
Visual disturbances brain lesion location?
Occipital lobe
Hemi-neglect syndrome lesion location?
Ignoring entire side (e.g. shaving only one side of face); involves right (non-dominant) parietal lobe (even in most left handers ~70%).
Bleeding in diverticulosis is commonly what color?
Arterial bleeding, thus, frank red bloody stool
Pathology of angiodysplasia of colon?
Tortuous, dilated veins in submucosa in colon wall; common cause of painless GI bleeding frequently missed on colonoscopy; usually low volume bleeding
Suspect what with recurrent, painless, maroon colored GI bleeding without definitive Dx after colonoscopy?
Angiodysplasia of the colon (Diverticulosis would be frank red blood and larger-volume hemorrhage)
Rare, AR disease characterized by abnormal copper deposition in liver, basal ganglia, and cornea?
Wilson’s disease
Test for Wilson’s disease?
Low serum ceruloplasmin w/ elevated urinary copper and Kayser-Fleischer rings
Steatorrhea w/ an Hx of longstanding alcohol abuse suspicious for?
Pancreatic insufficiency/cancer
Acute reversal of warfarin-associated bleeding?
Prothrombin complex concentrate (PCC; contains clotting factors; onset minutes) or fresh frozen plasma (if PCC not available) and vitamin K admin (12-24hr onset)
Long-term reversal of warfarin-associated bleeding?
IV Vitamin K (12-24 hours onset)
Protamine sulfate indication?
Heparin reversal, not warfarin
Prothrombin complex concentrate indication?
Acute warfarin reversal; contains clotting factors
Relative risk <1 interpretation?
Exposed are less likely to have condition than unexposed (e.g. pericarditis trials: those w/ colchicine less likely to get recurrent pericarditis than those on placebo)
Relative risk >1 interpretation?
Exposed have higher incidence of disease than unexposed (e.g. smoking and lung cancer incidence)
Nephritic syndrome casts?
RBC or mixed
Localized nonpitting thickening and induration of the skin over the lower legs/pretibial area/dorsum of feet Dx?
Graves disease
Severe abd. pain after meal that presents with w/ vomiting and elevated lipase Dx?
Acute gallstone pancreatitis
Dx of IE criteria?
Modified Duke criteria:
2 major, 1 major + 3 minor
Major criteria -
1. Blood culture + (S. viridians, S. auereus, Enterococcus)
2. Echo shows valvular vegetation
Minor:
IV drug use, fever >100.4, embolic signs, etc.
Reduced vital capacity and total lung capacity but normal FEV1/FVC in a young male with back pain/high ESR suspect?
Ankylosing spondylitis
Caustic ingestion managment?
Endoscopy w/in 12-24hrs to assess for severity. Charcoal or acid neutralization are not recommended.
Amaurosis fugax presentation?
Rapid, painless, transient (<10 minutes) monocular vision loss
Amaurosis fugax imaging?
Duplex US of neck
Most common cause of spontaneous lobar (e.g. parietal, occipital) hemorrhage in the elderly?
Cerebral amyloid angiopathy
Cerebral amyloid angiopathy associated disease?
Alzheimer’s disease (ß-amyloid deposition in walls of small-medium vessels.
Osler-Weber-Rendu syndrome is associated with hemoptysis and shunting in the lungs due to?
Pulmonary AVM
It’s also called hereditary telangiectasia.
Ingested enterotoxin bugs?
S. aureus
Bacillus cereus
(Quick onset - hours; Vomiting)
Enterotoxin made in intestine bugs?
C. perfringens
ETEC
Vibrio cholerae
(Delayed onset >1day; watery/bloody diarrhea)
Bacterial epithelial invasion bugs?
Campylobacter jejuni
Nontyphoidal salmonella
Listeria
(Watery/bloody diarrhea; fever)
Acute angle closure glaucoma Sx?
Severe eye pain
Blurred vision
Nausea/vomiting
Open angle glaucoma Sx?
Insidious onset w/ gradual vision loss peripherally due to cupping of optic disk
Management of mild hypercalcemia (<12) of malignancy to bone?
Bisphosphonates
Ankylosing spondylitis PE presentation?
UDARE: Uveitis Dactylitis (sausage finger) Arthritis (sacroiliitis) Reduced chest expansion/spinal mobility Enthesitis (tenderness at tendon insertion)
Ankylosing spondylitis relieved by?
Exercise, worsened by rest
Common complications of ankylosing spondylitis?
Osteoporosis/Fx
Aortic regurg
Cauda equina
Solitary, hard, nontender lymph nodes in the head and neck are characteristic of?
Squamous cell carcinoma
A/a ratio oxygen gradient def?
The A/a ratio indicates the percentage of alveolar PO2 located in the arteriolar PO2.
When V/Q elevated (as in PE), what happens to A/a oxygen gradient?
A/a increases on ABG (alveolar PO2 increases vs arteriolar)
Rx for viral/idiopathic pericarditis?
NSAIDs and colchicine
Young man (<40) with insidious onset arthritic pain with pain at the insertion sites of tendons Dx?
Ankylosing spondylitis (Enthesis - pain at tendon insertion sites)
Sudden onset pulm edema with a new holosystolic murmur w/in 3-5 days of an MI Dx?
Papillary muscle rupture (severe mitral regurg)
Sudden onset CP, pulm edema w/ new holosystolic murmur, biventricular failure and shock after 3-5 days of an MI Dx?
Interventricular septum rupture
Free wall rupture time period?
5 days - 2 wks
Free wall rupture presentation?
Cardiac tamponade
Blastomycosis may resemble histoplasmosis and tuberculosis, but what differentiates it from the others?
Skin lesions and lytic bone lesions
Acute asthma exacerbation PaCO2?
Resp alkalosis (low PaCO2, high pH) 2° to hyperventilation
Normal or elevated PaCO2/normal pH in acute asthma exacerbation suggests?
Impending respiratory failure (due to severe muscle fatigue or severe air trapping)
Corneal vesicles an dendritic ulcers on eye Dx?
Herpes simplex keratitis
Path of Factor V Leiden?
Hypercoagulable state caused by protein C resistance
Lupus anticoagulant Path?
Antiphospholipid antibody prolongs the PTT in diagnostic testing, but results in hypercoagulability and venous clots
von Willebrand disease path?
MCC bleeding time and PTT increase. PT is normal.
Vit K labs?
Acquired bleeding disorder causing prolonged PTT and PT.
DIC path?
Depletion of clotting factors and secondary fibrinolysis results in bleeding.
DIC labs?
Hemodynamic compromise (hypotension/tachycardia) assoc. with: Thrombocytopenia Prolonged PT/PTT Decreased fibrinogen Schistocytes on smear
Bulbar symptoms area damage?
Dysphagia, dysarthria, etc. caused by brainstem (bulbar) damage and cranial nerve problems
Classic symptoms of glucagonoma?
Mild DM/hyperglycemia (easily controlled by meds)
Necrotic migratory erythema (pustular rash)
Diarrhea
Anemia
Weight loss
Glucagonoma lab Dx?
Glucagon>500pg/mL
Smoked with vital capacity that is 65% of predicted likely Dx?
COPD (decreased FVC and increased total lung capacity): FEV1 disproportionately decreased vs FVC, thus, FEV1/FVC is low.
Define adjuvant therapy
Rx given in addition to standard Rx
Consolidation therapy definition
Given after induction Rx with multidrug regimens to further reduce tumor burden
Induction therapy define
Initial dose of Rx to rapidly kill tumor cells and send Pt into remission (<5% tumor burden)
Define maintenance therapy
Given after induction and consolidation therapies (or initial standard Rx) to kill residual tumor and keep Pt in remission
Define neoadjuvant therapy
Treatment given before the standard therapy for a disease (e.g. radiation given prior to radical prostatectomy)
Salvage therapy definition
Treatment for a disease when standard therapy fails (e.g. radiation for PSA recurrence after radical prostatectomy)
Screening test assessing risk for future diabetic foot ulcers?
Monofilament test
Most common underlying cause of diabetic foot ulcers?
Diabetic neuropathy (reduces pain/pressure perception leading to microcirculation/skin integrity impairment)
Rx for bullous pemphigoid?
Topical clobetasol
Path of lacunar strokes?
Microatheroma (plaque) formation and lipohyalinosis (vessel wall thickening in brain) lead to thrombotic small-vessel occlusion
Lacunar stroke Sx?
Often internal capsule infarction leads to pure motor hemiparesis on contralateral side. Absence of “cortical” signs (aphasia, agnosia, neglect, apraxia, hemianopia), Sz, and AMS supports Dx. Basal ganglia and pons also possible.
Carotid artery dissxn Sx?
Head or neck pain followed by partial ipsilateral Horner (ptosis/miosis w/o anhidrosis) due to postganglionic sympathetic fiber damage often after trauma
Cerebral vasospasm cause/Sx?
Often w/ amphetamine/cocaine leading to stroke
Cerebral sinus thrombosis cause/Sx?
Often in hypercoag. state (contraceptives/malig) leads to HA, AMS, SZ, focal deficits
Path of Zollinger Ellison syndrome?
Gastrinoma leads to hyperplasia of parietal cells and acid overprodxn. Deactivation of pancreatic enzymes can lead to injury of the mucosa and ulcers in the duodenum/jejunum.
Management of asymptomatic gallstones?
No treatment
Erythema multiforme presentation?
Target lesion with red iris shaped macules that may contain vesicles. Painful/pruritic on extensors.
Mutation responsible for polycythemia vera?
JAK2 mutation in myeloid precursor
Mainfestations of polycythemia vera?
HTN, erythromelalgia (burning cyanosis in hands/feet), Aquagenic pruritis, transient visual changes, thrombosis, facial plethora
Polycythemia vera labs?
Elevated Hgb/Hct
Leukocytosis/thrombocytosis
Low EPO
Acute Rx in AAA?
Beta blocker
Polycythemia vera Rx?
Serial phlebotomy
Radioiodine ablation of thyroid in Graves can lead to?
Hypothyroid Worsened ophthalmopathy (proptosis, periorbital puffiness)
PaO2/FiO2 ratio Dx for ARDS?
≤300mmHg
Management of frostbitten skin?
Rapid rewarming of affected area in warm bath (37-39°C). Debridement if needed afterwards and after assessment.
Common condition leading to dead space ventilation?
PE. Pneumonia does not cause significant alterations in dead space ventilation.
SpO2 in a patient with pneumonia changes depending on which side they are laying on due to what?
Right-to-left intrapulmonary shunting and V/Q mismatch. Alveolar consolidation results in impaired ventilation. If a L. sided PNA, then laying on L. side results in elevated blood flow to that area, poor V/Q and then hypoxemia.
Panacinar (panlobular) emphysema cause/location?
Alpha-1 antitrypsin deficiency; bases (bilateral basilar lucency)
Cantriacinar (Centrilobular) emphysema cause/location?
Smoking; apex
Consider what Dx if Hx of unexplained liver disease in young patient?
Alpha-1 antitrypsin deficiency
Alpha-1 antitrypsin (AAT) deficiency Rx?
IV supplementation of pooled human AAT
Exertional dyspnea and S4 likely indicates what?
Diastolic heart failure
S4 path?
S4 corresponds w/ atrial contraction and is believed to result from blood striking stiff L. vent
Best tool to address medical errors by physician communication failure?
Signout checklists reduce medical errors secondary to communication failures
