Medicine Flashcards
What is the treatment for anemia of chronic disease? (decreased TIBC and increased ferritin)
Address the underlying disorder (if RA then give methotrexate, ect).
What are headaches, nausea/vomiting, an abducens nerve palsy, and umbilicated skin lesions in a patient with HIV suggestive of? (patient also has enlarged ventricles on head CT)
Cryptococcus meningioencephalitis. Next step is to perform LP with India ink stain. Head imaging may show enlarged ventricles from increased ICP (fungal components clogging arachnoid villi).
What are the signs of acute closed angle glaucoma?
Sudden onset of decreased vision, visual halos/photophobia, unilateral headache, sever eye pain, and nausea/vomiting. Is a medical emergency.
What is the medical management of closed angle glaucoma?
Agents that decrease IOP such as mannitol, acetazolamide, pilocarpine, or timolol. Avoid mydriatic agents (such as atropine, ect.) as pupillary dilation worsens the glaucoma.
What agent is given for acute cocaine intoxication?
Benzodiazepines (if ACS present also give aspirin, nitroglycerin, and calcium channel blockers).
What is a solid organ transplant patient who presents with dyspnea/dry cough, GI symptoms (abdominal pain, hematochezia, ect) suggestive of?
Tissue invasive CMV (causing pnemonitis, hepatitis, gastroenteritis, ect).
What is a patient with brownish skin pigmentation, elevated fasting blood glucose, elevated LFT’s, and erectile dysfunction suggestive of?
Hereditary hemochromatosis (“bronze diabetes” and ED from hypogonadism). Increased risk of HCC and infections such as Listeria, Vibrio vulnificus, ect.
In addition to IV benzos, what should be administered for status epilepticus?
A non-benzo anti-epileptic such as fosphenytoin to prevents seizures. Then head imaging can be performed.
What defines aplastic anemia?
An acquired deficiency of pluripotent stem cells (pancytopenia with no splenomegaly or abnormal cells on peripheral smear).
What cardiac dysfunction is seen with acromegaly?
Concentric myocardial hypertrophy. (asymmetric IV septum hypertrophy would be seen in hypertrophic cardiomyopathy but not myocardial hypertrophy due to other causes).
What is the most likely cause of esophagitis in an HIV patient with odynophagia (pain with swallowing)?
Viral esophagitis. Candida esophagitis would have dysphagia but would not be painful (additionally there would be the presence of oral thrush which the patient did not have).
What are the signs of high output heart failure?
Widened pulse pressure, strong peripheral arterial pulsation (e.g. brisk carotid upstroke), and a systolic flow murmur. LV hypertrophy is usually present with the point of maximal impulse displaced to the left.
What should be suspected in a patient with signs of heart failure and a history of prior trauma (stab wound) to the thigh?
An AV fistula causing high-output heart failure.
What is the management of severe Grave’s disease? (mild would be with anti-thyroid drugs)
A beta-blocker plus an anti-thyroid drug (propylthiouracil, methimazole) is given to stabilize the patient before definitive treatment (radioactive iodine or thyroidectomy).
What would hyponatremia, hyperkalemia, and hypoglycemia in a patient with an upper lobe cavitary lesion on CXR suggest?
Addison’s/primary adrenal insufficiency secondary to disseminated TB. Would have a normal anion-gap metabolic acidosis.
What are the signs and fundoscopic findings of a vitreous hemorrhage?
Sudden loss of vision and onset of floaters. Most commonly occurs in those with diabetic retinopathy. Fundoscopy shows loss of fundus details (difficulty visualizing the fundus) with floating debris and a dark red glow.
What is proximal muscle weakness in the setting of hand and/or eyelid rash, normal DTR’s, and a lung mass indicative of?
Dermatomyositis.
What does a right sided pleural effusion in a patient with ascites suggest?
Hepatic hydrothorax (transudative fluid movement through diaphragmatic defects).
What is the empiric antibiotic regimen for patients with acute bacterial meningitis who are immunosuppressed? (i.e. organ transplant, ect).
Cefepime, vancomycin, and ampicillin (to cover for Listeria).
What drug class can cause SIADH in the elderly?
SSRIs.
Which Grave’s disease treatment can worsen the Grave’s ophthalmopathy?
Radioiodine ablation.
What is the first line maintenance medication for stable angina and how dies it address stable angina?
Beta-blockers, their main effect is to decrease myocardial oxygen demand by reducing myocardial contractility and heart rate.
What diabetic medication class is best for weight loss?
GLP-1 agonists (exenatide, liraglutide).
How does thyrotoxicosis cause HTN?
Increases myocardial contractility, leading to an increase in systolic BP with a widened pulse pressure (can lead to high out-put heart failure).
What typically precedes vasovagal syncope?
A prodrome of nausea, diaphoresis, pallor, and light headedness. EKG immediately before syncope would show sinus bradycardia and sinus arrest.
What is typically seen in Alzheimer’s patient’s on MRI?
Temporal lobe atrophy.
What is seen with Grave’s opthalmopathy?
Proptosis and impaired extraocular motion (impaired convergence and diplopia).
What compensatory mechanism allows for LV volume overload states (aortic regurgitation, ect) to initially be asymptomatic?
An increase in LV compliance (increased LV stretch leading to increased SV via Frank-Starling). Leads to eccentric hypertrophy.
What causes bloody diarrhea in an AIDS patient?
CMV (cryptosporidium would be watery diarrhea).
What is the management outline for hypernatremia?
First assess volume status. If euvolemic then oral water, if hypovolemic then assess if they are symptomatic or not. If not then use hypotonic fluid (5% dextrose) and if symptomatic then rehydrate with NS (0.9%) followed by hypotonic.
What are the best markers for assessing resolution of ketonemia in DKA?
The serum anion gap and direct assay of beta-hydroxybutyrate.
What does lower extremity pitting edema with a medial malleolus ulcer, a history of being worse at night, and no signs of CHF suggest?
Chronic venous insufficiency. Manage initially with leg elevation and compression stockings.
What are the exam findings for open angle glaucoma?
Cupping of the optic disc (from increased intraocular pressure) and loss of peripheral vision.
What is the initial empiric antibiotic for febrile neutropenia?
An anti-pseudomonal agent such as piperacillin-tazobactam, cefepime, ect. (Gram negative and gram positive coverage).
What is the most significant complication of untreated benign intracranial hypertension/pseudotumor cerebri?
Blindness (may need to perform an optic nerve sheath fenestration).
What does the development of hypotention and an urticarial rash after the insertion of a foley catheter suggest?
Anaphylaxis due to latex allergy (many foley catheters still contain latex).
What is the difference between a case control study and a retrospective cohort study?
Case control studies determine the outcome and look for associated risk factor, while a cohort study ascertain risk factor exposure and then determine the outcome.
What is the PCWP in PE?
Normal to low (since blocking the PA means less blood return to the LA). If PCWP is elevated then it is most likely MI.
What can be seen on examination with pulmonary hypertension (as can be caused by scleroderma)?
Right ventricular heave (impulse palpated immediately to the left of the sternum that suggests RV enlargement).
What is the initial presentation of cyanide toxicity? (i.e. patient with HTN emergency on nitroprusside drip)
AMS/confusion and seizures followed by coma.
What is the only anti-platelet that is effective in reducing the risk of early occurrence of ischemic stroke/TIA?
Aspirin. It should be given w/i 24 hours for all patient swith ischemic stroke. If patient is already on aspirin then add clopidegrel or dipyradamole.
Are heparins indicated in the management of ischemic stroke?
No, due to the risk of intracranial bleed (no enoxaparin and stroke). Use anti-platelet (aspirin).
What can be seen on imaging of pseudogout (CPPD crystal disease)?
Chondrocalcinosis (calcification of articular cartilage).
On EM what does dense deposits of C3 in the GBM in a patient with nephrotic range proteinuria and hematuria suggestive of?
Type 2 membranoproliferative glomerulonephritis (dense deposit disease). Due to persistent activation of the alternative complement pathyway caused by C3 nephritic factor.
What is the management of a myasthenic crisis? (i.e. patient with myasthenia gravis who develops respiratory failure,ect).
Secure the airway/intubate and hold their acetylcholinesterase inhibitor (as agents such as pyridostigmine can increase bronchial secretions). Once stabilized perform plasmapharesis and give corticosteroids.
Is the PPV-23 a conjugate vaccine?
No, so it will induce a T-cell independent B cell response (as opposed to the PPV-13 which is conjugated and thus will induce a T cell dependent B cell response).
What are some signs of co-morbid GERD in an asthma patient?
Sore throat, morning hoarseness, cough worse only at night, and an increased need for rescue inhaler following meals. Justifies adding a PPI.
What does the rapid onset of hypotension and a harsh systolic murmur along the left sternal border in a patient with a recent MI suggest?
IV septum rupture.
What are the indications for home oxygen therapy in those with COPD?
PaO2 < 55 or pulse ox < 88% on room air.
What are the findings with supravalvular aortic stenosis? (Congenital LVOT obstruction from ascending aorta stenosis)
A systolic murmur in the right first intercostal space, a paplable thrill in the suprasternal notch, and a blood pressure difference between arms.
What is often associated with supravalvular aortic stenosis?
LV hypertrophy and coronary artery stenosis leading to exertional angina from increased myocardial O2 demand.
What are patients with a prior MI and an EF <30% at increased risk for?
Sudden cardiac death due to ventricular arrhythmia. Following a trial with optimal medical therapy (beta-blocker, ACEI, spironolactone), these patients should have primary prevention with an ICD (implantable cardioverter-defibrillator).
What types of vaccines should be avoided in those on TNF-alpha inhibitors (adalimumab, ect)?
Live attenuated.
What is the serum to ascites albumin gradient (SAAG) and what is it’s significance?
SAAG (i.e. serum albumin - ascites albumin) determines if ascites is from portal hypertension (cirrhosis, CHF) or another cause. SAAG > 1.1 mean portal hypertension, while a SAAG of <1.1 suggests another cause.
What is the cutoff for neutrophil count in ascites fluid to determine peritonitis/infection?
250 (less then 250 neutrophils means no peritonitis).
What does a painful, red eye with corneal opacification and ulceration in a contact lens user suggest?
Contact-lens associated keratitis, which is most commonly caused by Pseudomonas.
What is the treatment for central retinal artery occlusion? (painless mono-ocular vision loss with diffuse ischemic retinal whitening and cherry red spots on fundoscopy)
Ocular massage and high flow O2. Intra-arterial thrombolytics may be used but not intravenous.
What effects can trimethorprim have on lab values?
TMP can cause hyperkalemia and an artificial increase in serum creatinine (through blockade of ENaC in the collecting tubule and glomerular reabsorbtion of creatinine respectively).
In addition to trimethorprim what other medications can cause hyperkalemia?
Non-selective beta-blockers, ACEI/ARBS/K+ sparing diuretics, digoxin, cyclosporine, heparin, NSAIDS, succinylcholine.
What is a potentially life-threatening complication of influenza in a young adult?
Secondary bacterial pneumonia with community acquired MRSA (causes a necrotizing pneumonia with hemoptysis and multilobular cavitary lesions).
What is the next best step for a patient with chronic headaches who develops a new type of headache? (ex unilateral headaches for years and now a new-onset severe bilateral headache).
Brain MRI. Remember that a new type of headache in a patient with chronic headaches is one of the red flags that warrants head imaging.
What is pain/redness in the medial canthal region suggestive of?
Dacrocystitis (inflammation of the lacrimal sac). Usually caused by S. aureus and responds to systemic antibiotic therapy.
Can cyclophosphamide cause bladder carcinoma?
Yes, in addition to hemorrhagic cyctitis due to accumulation of acrolein.
What does tight glycemic control reduce the risk of?
Microvascular complications (retinopathy, nephropathy, ect.) but not macrovascular complications (MI, stroke).
What is the next best step for a patient with chronic epigastric pain that is relieved by leaning forward, weight loss, and alcohol use?
CT of the abdomen to look for chronic pancreatitis (weight loss indicated malabsorption). Plus the pain with chronic pancreatitis usually relieves with leaning forward.
What is the initial work-up for a first time seizure in an adult?
Basic blood tests and a toxicology screen (drug test, ect). If those are normal then follow-up with neuroimaging and EEG.
What should a splenic infarct (LUQ pain and wedge shaped hypodensity on ultrasound) prompt evaluation for?
Sickle cell disease or trait, hypercoagulable states, and embolic states (patient had normal Hgb but elevated reticulocytes and indirect bilirubin suggesting mild hemolysis secondary to sickle cell trait thus the answer was perform hemoglobin electrophoresis).
What is the next best step for confirmed myasthenia gravis?
Chest CT to look for a thymoma.
What is the cutoff for the PPD skin test?
15 mm
What is telogen effluvium?
An acute, diffuse, and non-inflammatory hair loss triggered by stressful events. Patients have widespread hair thinning but normal scalp and hair shafts and a hair pull test with >10% fibers. It is self-limiting.
