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Surgery > Medicine Part 2 > Flashcards

Medicine Part 2 Flashcards

1
Q

Most common causes of ESRD

A

Diabetes

HTN

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2
Q

How is ESRD defined?

A

Not by BUN or Cr

Loss of kidney function leading to clinical and lab findings of uremia

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3
Q

Calciphylaxis

A

Hyperphosphatemia –> calcium adn PO4 precipitate –> vascular calcifications –> skin lesions/necrosis!

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4
Q

Absolute indications for dialysis

A

AEIOU

Acidosis

Electrolytes - HYPERkalemia

Intoxications - methanol, eth glycol, lithium, aspirin

Overload - hypervolemia that can’t be solved

Uremia - based on clinical presentation, like pericarditis

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5
Q

Microscopic hematuria usually

A

glomerular in origin

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6
Q

Gross painless hematuria usually

A

Bladder or kidney cancer

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7
Q

Hematuria

A

> 3 erythrocytes / HPF on UA

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8
Q

Order to evaluate proteinuria

A

Urine dipstick - specific for albumin

UA

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9
Q

Dipstick + blood

UA no RBC

What is it?

A

Hemoglobinuria

Myoglobinuria

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10
Q

Proteinuria

A

> 150 mg protein/days

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11
Q

Glomerular d/o vs tubular d/o

A

In glomerular but not in tubular:

  • need biopsy usually
  • steroids and immunosuppressive meds for tx

In tubular but not in glomerular:

  • acute presentation,
  • caused by toxins
  • does not cause nephrotic syndrome
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12
Q

Acute Interstitial Nephritis

  • features
  • seen on labs
  • causes
A

Polyruia and sterile pyruria (maybe some WBC casts) are early manifestations

acute interstitial renal inflammation + pyuria + eosinophils (hypersensitivity) + azotemia

happens after drugs 
METHICILLIN #1
NSADs
captopril
penicillins
sulfonamides
rifampin
TMP
cephalosporins
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13
Q

AIN treatment

A

Remove offending agent

Steroids if still getting worse

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14
Q

Acute tubular necrosis

  • causes
  • stages
A

Toxic (#1 aminoglycosides) or Ischemic (more serious, prerenal azotemia usually (shock, sepsis) or crush injury w/ myoglobinuria) → granular casts (muddy brown)

o This is medullary necrosis and ATN is limited to outer medullar segments b/c renal medulla is susceptible to ischemic injury b/c low medullary blood flow → glomeruli look normal

o Stages: (1) inciting event → (2) Maintenance (oliguric, risk of hyperkalemia & met acidosis) → (3) Recovery (polyuric, risk of hypoK)

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15
Q

Nephrotic syndrome

- features

A

o Hyperlipidemia b/c increased hepatic lipoprotein synth – but only LDL; HDL will decrease!
o Hypoagammaglobinemia = increased risk infection
o Hypoalbuminemia = edema
o Hypercoagulable = loss antithrombin 3

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16
Q

Minimal change disease

A

-only lose albumin, not all globulins

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17
Q

Diffuse cortical necrosis

A

usually due to hypOperfusion of kidney (vasospasm, DIC, abruption placentae, septic shock), medulla spared

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18
Q

Renal papillary necrosis

  • what is it
  • causes
  • dx
A

necrosis of renal papillae (supplied by vasa recta) = hematuria, proteinuria

o “POSTCARDS” = Pyelonephritis, Obstruction, Sickle Cell, TB, Cirrhosis, Analgesic abuse (phenacetin, acetaminophen, aspirin), Renal transplant rejection, Diabetes (#1), Systemic vasculitis

o DACS = Diabetes Mellitus (#1), Acute pyelonephritis, Chronic phenacetin use (acetaminophen), Sickle Cell

Dx w/ ecretory urogram - note change in papilla or medulla

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19
Q

Acute renal failure

A

↓ renal function → ↓GFR → INCREASE BUN and Creatinine (azotemia)

will also have met acidosis!

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20
Q

Chronic renal failure

A 
Hyper K (#1 COD b/c arrhythmia)
Metabolic ACIDosis (increase H+, ↓ bicarb)
Uremia
Anemia
renal osteodystrophy
dyslipidemia
Na/H2O retention
growth retardation in children;

FREE Ca will be decreased b/c increase in PO4 will bind up the free Ca in blood

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21
Q

Renal tubular acidosis

A

D/o of renal tubules –> nonanion gap HYPER Cl metabolic acidosis

Glomerular function OK

decrease in acid excreted in urine

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22
Q

Type 1 RTA

- what is it?

A

Distal

Can’t secrete H+ at distal tubule –> new bicarb cannot be made

Urine pH does not go below 6

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23
Q

Type 1 RTA

- effects of it

A

Decrease ECF

Hypo K, HYPER Cl, met acidosis

Renal stones

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24
Q

Type 1 RTA

- causes

A

MM

Nephorcalcinosis

Amphotericin B

Lupus, Sjorgen’s

Medullary sponge kidney

Analgesics

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25
Q

Type 2 RTA

- waht is it?

A

Proximal

Can’t reabsorb HCO3 at PCT –> more bicarb excreted in urine

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26
Q

Type 2 RTA

- effects

A

Hypo K, HYPER Cl, met acid

NO KIDNEY STONES

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27
Q

Type 2 RTA

- causes

A 
Fanconi's syndrome
Wilson's
Lead toxicity
Amyloid
MM
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28
Q

Type 4 RTA

A

Hypoaldo or resistant to aldo

Decreased Na absorbtion + decreased H and K secretion in DCT

HYPERkalemia (not hypo) + acidic urine + met acidosis

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29
Q

Hartnup syndrome

A

AR

defective aa transporter

Tryptophan can’t be reabsorbed –> NAD deficiency

Dermatitis, diarrhea, ataxia, psych disturbances (all like pellagra)

Supplement w/ NAD if symptomatic

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30
Q

Fanconi’s syndrome

A

PCT dysfunction

can’t transport

  • glucose
  • aa
  • Na
  • K
  • PO4
  • uric acid
  • bicabr

Results in

  • rickets
  • osteomalacia, osteoporosis
  • polyuria,
  • dehydration
  • type 2 RTA
  • hypercalciuria
  • hypo K
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31
Q

Dx ADPKD

A

Ultrasound

Can use CT and MRI

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32
Q

Extrarenal involvement of ARPKD

A

Liver - protal HTN, cholangitis

Pulm insufficiency - pulm hypoplasia + enlarged kidneys - mostly because not enough amniotic fluid

Potter syndrome

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33
Q

Medullary sponge kidney

A

Cystic dilation of CD

can be assoc w/ hyper PTH and parathyroid adenoma

Benign; some stones and more UTI sometimes

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34
Q

Dx medullary sponge kidney

A

Intravenous pyelogram - inject contrast to see on xray

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35
Q

Renal artery stenosis

- causes

A

Atherosclerosis (31)

Fibromuscular dysplasia

  • usually in young fems
  • bilateral in 50% ppl
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36
Q

Dx renal artery stenosis

A

Renal arteriogram
- DO NOT USE FOR RENAL FAILURE. Contrast can be nephrtoxic

MRA - ok for renal failure

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37
Q

Renal vein thrombosis

- when is it seen?

A

RCC invasion

Nephrotic syndrome

Preggers/OCP

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38
Q

Dx renal vein thrombosis

A

renal venography

IVP

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39
Q

Where does sickling of sickle cell most commonly occur in kidney?

A

Renal papille

Can get papillary necrosis, renal fail, lots of UTIs

ACEI can help

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40
Q

Causes of hyperoxaluria

A

Steatorrhea

Small bowel disease

Crohns

Pyridoxine deficiency

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41
Q

Initial test to dx urinary tract obstruction

A

Renal ultrasound

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42
Q

Gold standard to dx urinary tract obstruction

A

Intravenous urogram (IVP)

NOT for preggers, allergies to contrast

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43
Q

PSA
DRE
Transrectal ultrasonography (TRUS)

  • what do you do with these results when screening for prostate cancer?
A

PSA > 10 —> Do TRUS w/ biopsy
DRE abnormal —> Do TRUS w/ biopsy

PSA < 4 + DRE (-) —–> annual f/u

4.1 < PSA < 10 + DRE (-) —–> biopsy

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44
Q

DRE of prostate cancer

A

Prostate hard, nodular, irregular

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45
Q

PSA of cancer vs PSA normal

A

PSA cancer usually bound by plasma proteins

PSA normal usual free in plasma

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46
Q

Risks for RCC

A 
Cigarettes
Phenacetin analgesics
ADPKD
Chronic dialysis
Mercury
Cadmium
HTN
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47
Q

Dx RCC

A

Renal US only detects mass

Abdominal CT (w/ and w/o contrast)
- for dx and staging
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48
Q

Tx RCC

A

Radical nephrectomy

Take out:
kidney
adrenal
Gerota’s fascia

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49
Q

Transitional cell caricinoma

A

Can be anywhere along kidneys –> ureter

Mostly in bladder

Frequently recurs

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50
Q

TCC risk factors

A

Pee SAC

Phenacetin
Smoking (#1)
Aniline dyes
Cyclophosphamide

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51
Q

Dx TCC

A

Cystoscopy + biopsy (definitive)

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52
Q

Staging of TCC

A

CXR

CT scan

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53
Q

Testicular cancers

- Germ cell tumors

A

Most common

Seminomas
- radiosensitive, slow growing

Embryonal
- very malignant, mets early

Choriocarcionma
- most aggressive, mets always

Teratoma
- usually no mets

Yolk sac
- rare, usually in kids

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54
Q

Testicular vs. scrotal cancers

A

Testicular cancers usually always malignant

Scrotal cancers usually benign

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55
Q

Testicular cancers

- Non germ cell tumors

A

Usually benign, less common

Leydig cells

  • benign, tx w/ surgery
  • secrete estrogens and androgens –> precocious puberty

Sertoli cells
- usually benign

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56
Q

Testicular cancer risk factors

A

Cryptochidism (risk still there w/ correction)

Kleingelter’s

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57
Q

Testicular ca tumor markers

A

B HCG
- increased in choriocarcinoma

AFP
- increased in embryonal tumors

US to try and localize tumor

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58
Q

DDx of testicular mass

A

Cancer

Varicocele

Torsion

Spermatocele

Hydrocele

Epididymitis

Lymphoma

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59
Q

Tx testicular cancer

A

Inguinal (not scrotal) excision of testicle

CT scan to stage

BHCG and AFP measurements

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60
Q

Penile cancer assoc

A

HSV

HPV 18

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61
Q

Testicular torsion

A

Surgical emergency

After 6 hrs, may have infarction and no longer save testicle

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62
Q

Epididymitis

A

Infection of epididymis

Usually E coli
Gonorrhea, Chlamydia in sex active

Fever
Less acute onset vs. torsion

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63
Q

Total body water

A

60-40-20

60% body wt = water

40% = ICF

20% = ECF
- 15% = interstitial
5% = plasma

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64
Q

What is impt to track to assess volume status?

A

Urine output

Normal kids = > 1 mL/kg/hr

Normal adults = 0.5-1 mL/kg/hr

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65
Q

Anascara

A

extreme generalized edema

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66
Q

Fluid replacement therapy options

A

NS

  • increase intravascular volume if dehydrated
  • not great for CHF

D51/2NS = 5% dextrose, 1/2 NS

  • standard maintenance fluid
  • dextrose to inhibit muscle breakdown

D5W

  • dilute powdered meds
  • only some stays intravascular b/c diffuses into TBW compartment; not great to replenish intravascular

Lactated ringer’s solution

  • good to replacing intravascular volume
  • NOT a maintenance fluid
  • common trauma resuscitation
  • DO NOT USE if hyperkalemia is concern b/c has K
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67
Q

Calculation of maintenance fluids

A

100.50.20 rule

For 70 kg man:

10 kg x 100
10kg x 50
50 kg x 20

Total: 2500

2500/24 = 104 mL/hr

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68
Q

Changes in Na concentration = ?

Changes in Na content =

A

Concentration –> reflection of water homeostaiss

Content –> reflection of Na homeostasis

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69
Q

Hyper/hyponatremia

vs

Hypo/hypervolemia

A

Hyper/hyponatremia caused by too little/too much WATER

Hyper/hypovolemia caused by too much/too little Na

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70
Q

Hypo Na symptoms

A

Usually neuro sx

Headache, delirium, irritability
Muscle twitching, weakness
Hyperactive deep tendon reflexes

Seizures, coma

N/V, watery diarrhea

HTN b/c increased ICP

Oliguria

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71
Q

Tx hyponatremia

- hypotonic hyponatremia

A

Mild (120-130)
- withhold free water

Moderate (110-120)
- loop diuretics + saline

Severe (< 110)
- hypertonic saline increasing serum Na by 1-2 mEq/L/hr

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72
Q

Risks of correcting hypoNa too fast

A

Central pontine demyelination

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73
Q

Risks of correcting hyper Na too fast

A

cerebral edema

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74
Q

Hyper Na symptoms

A

Neuro sx usually

AMS
restlessness
Weakness
Focal neuro deficits

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75
Q

What should be given to differentiate nephrogenic from central DI if DI suspected?

A

DesmopressiN

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76
Q

Hypoalbuminemia, Ca is low. But ionized Ca is normal.

How do you est ionized Ca

A

Total Ca - (serum albumin * 0.8)

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77
Q

What alters Ca binding to albumin?

A

pH changes

Increase pH –> increase binding of Ca

  • decrease ionized Ca
  • total Ca ok
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78
Q

Causes of decreased Ca

A 
Hypo PTH
Acute pancreatitis
Renal insufficiency
Hyper PO4
Pseuhypoparathyroidism
Hypo Mg
Vit D deficiency
Malabsorb
Blood transfusion w/ citrated blood
Osteoblastic mets
Hypoalbuminemia
DiGeorge
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79
Q

Features of decreased Ca

A 
Rickets, osteomalacia
Tetany
- Chovstek's, Trousseau's sign
Seizures
Basal ganglia calcifications
Arrhythmias

PROLONGED QT`

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80
Q

Causes of increased Ca

A

Hyper PTH
Renal failure (usually hypo Ca but can be hyper w/ high enough PTH)
Acromegaly
Addison’s

Metastatic ca
MM
PTH paraneoplastic

Vit D intox
Milk alkali syndrome
Thiazides,, lithium

Sarcoidosis
Familial hypocalciuric hypercalcemia

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81
Q

Features of increased Ca

A 
Stones
Bones
Groans
Psych overtones
---> All increased PTH signs

POlydipsia, polyuria
HTN
Wt loss
SHORT QT

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82
Q

1st step in management of hyper Ca

A

Increase urinary excretion via IV fluids

Diuretics (furosemide) to stop Ca reabsorb

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83
Q

What can you use to quickly tell why someone is hypokalemic?

A

Presence or absence of HTN

HTN - aldo increased - causes K wasting

No HTN - GI or renal loss of K

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84
Q

Hypo K EKG

A

Flattened T wave/ T wave inversion

U wave

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85
Q

Does dig cause hyper or hypo K?

What predisposes to dig toxicity

A

Causes HYPER K

Hypokalemia predisposes - allows Dig to bind more to Na/K pump

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86
Q

Features of hypo K

A 
Arrhythmias 
Muscle weakness, paralysis, cramps
Paralytic ileus
Polyuria adn polydipsia
N/V
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87
Q

How best to replete K?

A

KCl

10 mEq KCl increases K by 0.1 mEq/L

Add lidocaine so KCl doesn’t burn as much

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88
Q

How fast can you infuse K?

A

10 meq/hr in periph IV line

20 meq/hr in central line

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89
Q

When do you correct hypo Mg first?

A

In both hypo K and Ca

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90
Q

How does hyper K affect kidneys to worsen acidosis?

A

Inhibits renal ammonia synthesis and reabsorb

Net acid excretion is impaired!

Metabolic acidosis

Further makes K move out of cells

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91
Q

Hyper K EKG

A

Peaked T waves
Prolonged PR interval
Widen QRS

–> eventually get QRS merge w/ T wave producing sine pattern
–>
Vfib

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92
Q

Tx Hyper K

A

IV calcium

  • decreases membrane excitability
  • be careful giving this to pts on dig b/c can worsen toxicity

Shift K into cell

  • glucose + insulin (fastest)
  • sodium bicarb (for emergencies)

Remove K from body

  • Kayexalate (exchange resin)
  • hemodialysis
  • diuretics
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93
Q

Where is most of Mg in body?

A

Bones

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94
Q

Where is most of K in body?

A

Intracellular

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95
Q

Where is most of Na in body?

A

Extracellular

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96
Q

Causes hypo Mg

A

Malabsorb
Fasting
Fistulas
TPN

Alcoholism

SIADH
Diuretics
Bartter;s syndrome
Gentamicin, amphotericin B, cisplatin, PPIs
Renal transplant

DKA, burns, lactation

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97
Q

Hypo Mg features

A 
Muscle twitching
Weakness
Tremors
Hyperreflexes
Seizures
AMS

Hypo K and Ca

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98
Q

Hypo Mg EKG

A

Prolonged QT

T wave flattening

Torsades

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99
Q

Causes of hyper Mg

A

Renal failure

Burns, trauma, ECF volume deficit

Mg-laxatives, antacids

Adrenal insufficiency

Adnreal insufficiency

Rhabdomyolysis

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100
Q

Hyper Mg features

A 
Nausea
Facial paresthesias
Deep tendon reflex LOSS
Respiratory depression
Coma
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101
Q

Hyper Mg EKG

A

Like hyper K

Increased PR
Widened QRS
Elecated T

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102
Q

Tx hyper Mg

A

No Mg

IV calcium gluconate

Saline + furosemide

Dialysis

Intubation if respiratory depression

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103
Q

Where is most of PO4 in body?

A

Bones

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104
Q

Causes of decreased PO4

A

DKA

Alcohol abuse

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105
Q

Hypo PO4 clinical features

A

Encephalopathy
COnfusion
Seizures
Paresthesias

Weakness
Myalgias
Rickets

Hemolysis
RBC dysfunction

Cardiomyopathy b/c low ATP

Rhabdomyolysis

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106
Q

Hyper PO4 causes

A 
Renal insufficiency
Bisphosphoates
Hypo PTH
Vit D intoxication
Tumor calcinosis
Rhabdo
cell lysis
acidosis
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107
Q

Hyper PO4 features

A

Metastatic calcification + soft tissue calcifications

Neuro changes from decreased Ca

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108
Q

Tx hyper PO4

A

PO4 binding antacids (Al OH or carbonate)

Hemodialysis

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109
Q

Which bicarb value is more reliable?

- serum vs. ABG?

A

Serum (venous) CO2

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110
Q

Salicylate OD acid base status

A

Respiratory Alkalosis

Metabolic acidosis

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111
Q

Causes of renal loss of bicarb

A

Proximal tubular acidosis

  • MM
  • cystinosis
  • Wilsons

Distal tubular acidosis

  • can’t make HCO3
  • SLE, sjogren’s, amphotericin B

Acetazolamide

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112
Q

Causes of GI loss of bicarb

A

Diarrhea
Pancreatic fistulas
Small bowel fistulas
Ureterosigmoidostomy

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113
Q

Danger to tx acidosis w/ bicarb

A

Bicarb takes 24 hrs to get to brain

Hyperventilation is continuing though

PaCO2 low while HCO3 increases - dangerous

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114
Q

What can be used to clinically detect endogenous depression?

A

Dexamethasone suppression test

50% of pts w/ depression, DST will be abnormal

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115
Q

Hallmark of prolonged seizures

A

Cortical laminar necrosis

Can lead to persistent neuro deficits and recurrent seizures

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116
Q

Status epilepticus

A

Any 1 seizure > 5 mins

Cluster of seizures w/ pt not recovering normal mental stauts in between

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117
Q

Initial TB infection - what does it look like on CXR?

A

Peripheral pulmonary focus
- Gohn focus remains as calcified granuloma

Mediastinal or hilar lymphadenopathy on CXR

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118
Q

Hyposthenuria

A

Found in pts w/ sicklle cell + trait

Thought to result from RBC sickling in vasa rectae of inner medulla which impairs countercurrent exchange and free water reabsorb

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119
Q

Proximal muscle weakness
Spares muscles of mastication and facial expression
Dysphagia possible

What is this?

A

Polymyositis/Dermatomyositis

Muscle biopsy to dx

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120
Q

Large blunt hyphae

Thick walled budding spores

What is this?

A

Malassezia furfur

Causes tinea versicolor

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121
Q

Hypopogmented macules that do not tan

Do not appear scaly

Scale on scraping

What is this? How to tx?

A

Tinea versicolor

Topical selenium sulfide ltion
Ketoconazole shampoo

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122
Q

What do you expect in any pt w/ hx of cancer or fever who p/w back pain and neuro sx, particularly loss of bowel or bladder function?

How do you confirm dx?

What should you do 1st?

A

Compression of thecal sac

MRI to confirm

Glucocoritoicds (dexamethasone) to start asap so decrease risk of permanent neuro damage

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123
Q

Low leukocyte alk phos + leukocytosis

A

CML

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124
Q

Most impt modifiable factors for decreasing HTN

A

Wt control > physical activity > Na restrict > moderation of EtOH consumption

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125
Q

Waldenstroms macroglobulinemia

A

Plasma cell neoplasm

IgM spike –> hyperviscosity

Hepatosplenomegaly, lymphadenopathy
Anemia --> tiredness
Increased bleeding
Night sweats
headaches
Dizziness
Visual problems (retinal v engorgement)
Pain and numbess in extremities --> demyelinating sensorimotor neuropathy
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126
Q

MM vs. Waldernstroms

A

MM has

IgA or IgG

Doesn’t have hyperviscosity

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127
Q

Big danger of pancreatic necrosis

A

Locally released pancreatic enzymes can increase vascular permeability w/in and around pancreas

Large volume of plasma into retroperitoneum

Hypotension mainly due to increase in vascular permeatbility!!!

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128
Q

Valvular consequence of aortic dissection

Best way to dx AD

A

Aortic regurg

Transesophageal echo (more than MRI b/c MRI is long)

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129
Q

Contraindicaitons to liver transplant

A

Irreversible cardio-pulm dz causing prohibitive risk

incurable or recent malignancy outside of liver

Active EtOH or IVDU

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130
Q

During acute asthma, what is one indicator of severe attack

A

Normal PaCO2

Should be decreased b/c hyperventilate

Normal to increased = CO2 retention b/c severe obstruct and/or respiratory muscle fatigue

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131
Q

How do you improve ARDS oxygenation

A

Increase PEEP w/ low tidal volumes on ventilator setting

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132
Q

How does a person get infected w/ cystercosis

A

If eat larvae in undercooked pork, will get intestinal infection

If eat eggs from human feces, cystercercosis happens
- larvae will invade intestinal wall adn can go to muscle, brain, subQ tissue, eye

NOT GOTTEN BY EATING INFECTED PORK AS THE ONLY WAY - POOP OF HUMAN!

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133
Q

When is AS symptomatic?

A

Valve area < 1 cm2

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134
Q

Systemic effects of sarcoidosis

A

ACE increase

Increase vitamin D

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135
Q

Antiphospholipid syndrome features

A

Arterial and venous thromoboses

Thrombocytopenia
Prolonged PTT

Avoid preggers loss w/ LMWH

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136
Q

Signs of glucocorticoid deficiency

A

Weakness
Fatigue
Loss of appetite
Eosinophilia

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137
Q

Presentations of P vera

A 
HTN
Increased peptic ulceration
Gouty arthritis
Plethoric face
Splenomegaly
Hypercellular bone marrow
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138
Q

Earliest renal abnormality in pts w/ DM

A

Glomerular hyperfiltration

ACEi reduce intraglomerular HTN –> decrease glomerular damage

This can eventually cause thickening of glomerular BM –> nodular sclerosis

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139
Q

Pneumonia + GI sx + elevated LFTs

What is this? How do you tx?

A

Legionella pneumoniae

Quinolone or macrolide ot tx

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140
Q

What is infection w/ Moraxella catarrhalis commonly assoc w/

A

COPD

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141
Q

PFTs in IPF

A

Decreased TLC
normal FEV1/FVC

Diffusing capacity decreased
Increased Aa gradient

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142
Q

Diagnostic criteria for ARDS

A

Acute onset

PaO2/FiO2 < 200

Bilateral infiltrates on CXR

Swann Ganz P < 18 mm Hg

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143
Q

What should FiO2 be if person is adequately venetillated to prevent O2 toxicity to lungs?

A

below 60%

Increase PEEP as needed to maintain adequate O2 after FiO2 lowered

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144
Q

Bilateral trigeminal neuralgia

Transient muscle weakness

What is this most likely?

A

MS!

MS is one of few conditions presenting w/ bilatearl trigminal neuraligia

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145
Q

Systemic issue w/ L sided endocarditis

A

Can send septic emboli to regions rich in blood supply (brain, kidney, livre, spleen)

R sided endocarditis more likely to cause septic pulm emboli

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146
Q

Lab values for portal HTN causing splenomegaly

A

Anemia

Thrombocytopenia

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147
Q

Expansile adn eccentric lytic area (soap bubble) in epiphysis

Pain, swelling, decreased ROM

Most get pathologic fractures

A

Giant cell tumor

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148
Q

How do you diagnose a pheochromocytoma?

A

CT scan

MRI better for extra adrenal catecholamine secretion

Mibg scan if cr shows nothing

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149
Q

Any wide complex tachyarrhythmia is what until proven otherwise?

A

Ventricular tachycardia

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150
Q

In an MI, what is your long term prognosis most influenced by?

What do you do to achieve this?
How quickly?

A

Duration of time that lapses before coronary blood flow restored

Use Percutaneous transluminal coronary angioplasty and fibrinolysis

  • PCTA better
  • should be done w/in 90 mins

Fibrinolytics should be done w/in 30 mints

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151
Q

Erythematous rash and maculopapular

Starts on face –> trunk and extremities

Lymphadenopathy (occipital and posterior cervical)

Arthritis in adult women

Maybe some conjunctivitis

What is this?

A

Rubella

Measles does not have arthritis

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152
Q

What are cholesterol emboli usually preceded by?

A

Angiography

Plaque is disrupted by catheter or guidewire

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153
Q 
Blue toe syndrome
Livedo reticularis (reddish-cyanotic reticular discoloration of skin)
Acute renal failure
Ab pain
Sometime pancreatitis
Eosinophils in blood
DECREASED COMPLEMENT LEVELS
A

Cholesterol emboli

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154
Q

Infarction of

  • medial vermis of cerebellum
  • lateral cerebellum
A

Medial

  • severe vertigo
  • nystagmus

Lateral

  • dizziness
  • ataxia
  • weakness
  • tendedncy to sway towards side of lesion
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155
Q

Dizziness
Hearing loss
Tinnitus

A

Meniere’s disease

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156
Q

Pathophys of benign positional vertigo

A

Ca crystals in inner ear shift position

Nystagmus
Nausea
Vomitting

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157
Q

4 cardinal symptoms of rest less syndrome

A

Uncomfortable sensation/urge to move legs
Discomfort worse at night/sleep
Discomfort worse at rest
Discomfort helped by mvmt of affected limbs

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158
Q

Pathophys of RLS

A

Abnormalities of dopaminergic transmission in CNS

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159
Q

What vaccines should pts w/ chronic liver disease get?

A 
Tdap (every 10)
Influenza
Pneumococcal vaccine (every 5)
Hep A
Hep B
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160
Q

Major causes of vit K deficiency

A

Inadequate diet intake

Intestinal malabsorb

Loss of storage sites due to hepatocellular disease

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161
Q

How long does vit K storage last?

A

30 day

acutely sick - 7-10 days

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162
Q

Hemolytic uremic syndrome

A

Often follows diarrhea

Thrombocytopenia
MAHA
Fever
Renal failure (rather than neuro sx of TTP)

Shiga-toxin binds to the globotriaosylceramide (Gb3) receptor on the surface of the glomerular endothelium
This action includes a cascade of signaling events leading to apoptosis and binding of leukocytes to endothelial cells.
The Shiga-toxin-activated endothelial cells then become thrombogenic (clot-producing)
Additionally, the binding action of Shiga-toxin inactivates a metalloproteinase called ADAMTS13

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163
Q

What should all pts w/ significant bladder outlet obstruction get?

A

Foley catheter

Prolonged obstruction > 2 weeks can results in permanent kidney damage

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164
Q

How do you best view an acoustic neuroma?

A

MRI w/ contrast

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165
Q

DO NOT miss this as reason for hyperkalemia in an asymptomatic pt

A

Pseudohyperkalemia

- venipuncture can hemolyze RBC –> cause K to be released

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166
Q

When do you tx hyperkalemia?

How do you do it?

A

If cardiac toxicity (EKG shows), muscular paralysis, K > 6,5

+ Ca gluconate to stabilize myocardial membrane

  • push K into cells w/ insulin and/or B-agonists
  • can also use Na Bicarb to shift into cells
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167
Q

Nonhealing ulcer
Scaling plaque w/ central ulceration
Biopsy shows polygonal cells w/ atypical nuclei at all levels of epi w/ zones of keritnization

What is this?

A

Squamous cell carcinoma of skin

Sunlight is risk factor

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168
Q 
Personality changes
Compulsive behaviors
Impaired memory
Visuospatial functions intact
\+ family hx in some

What is this?

A

Frontotemporal dementia (Pick’s disease)

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169
Q

Fluctuating cognitive impairment
Bizarre, visual hallucinations
Some parkinsonism but poor response to D agonist therapy

What is this?

A

Lewy body dementia

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170
Q

Eczematous lesion on breast
Biopsy = large cells that appear to be surrounded by clear halos

What is this?

A

Paget’s disease of breast

Usually represents underlying adenocarcinoma

Halo cells b/c cancer cells become retracted from adjacent keratinocytes

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171
Q

Corneal sensation is via which nerve?

A

CN 5 - Trigeminal

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172
Q

3 most common causes of chronic cough (> 8 weeks)

A

Post nasal drip
Asthma
GERD

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173
Q

Steps to tx ascites

A

Na and water restriction

Spironolactone

Loop diuretic (not more than 1 L/day of diuresis)

Frequent abdominal paracentesis (2-4L/day if renal function ok)

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174
Q

When are vascular shunts for liver cirrhosis indicated?

A

Symptomatic varices

Side to side porto caval shunt to help ascites but worsens encephalopathy

Peritoneo jugular shunt tx ascites

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175
Q

Indications for hemodialysis

A

Refractory hyper K

Volume overload/pulm edema NOT responding to diuretics

Refractory met acidosis (pH < 7.2)

Uremic pericarditis

Uremic encephalopathy or neuropathy

Coagulopathy due to renal failure

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176
Q

Best to tx frostbite

A

Rapid re-warming w/ warm water (40-44)

Result in less tissue damage than slow rewarming

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177
Q

Osgood Schlatter disease

A

Overuse injury caused by repetitive strain

Young kids w/ rapid growth spurt

Avulsion of apophysis of tibial tubercle

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178
Q

1 COD in dialysis pts

A

Cardiovascular disease

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179
Q

GERD hx

- progressive dysphagia to solids w/o anorexia or wt loss

A

Benign strictures

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180
Q

GERD hx

  • progressive dysphagia to solids w/ anorexia or wt loss
  • GERD for > 20 years
A

Adenocarcionma of esophagus

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181
Q

Charcot’s joint

A

Neurogenic arthropathy

Usually in diabetic neuropathy

Complication of neuropathy and repeated joint trauma
Affects wt bearing joints –> functional limitation, deformity, degenerative joint disease

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182
Q

Persistent ST segment elevation after recent MI and deep Q waves in same leads

A

Ventricular aneurysm

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183
Q

Causes of pulsus paradoxus

A

Cardiac tampanode
ASthma
COPD

–> in pulm conditions b/c extra negative pressure gets more blood into lungs, further decreasing LV preload

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184
Q

What prevents development of pulsus paradoxus even in presence of pericardial effusion and cardiac tamponade?

A

Signficiant arotic regurg – causes large increase in LVEDP preventing septum shift

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185
Q

Pts w/ hyper PTH increased risk of developing what arthropathy?

A

Pseudogout - CPPD deposition

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186
Q

Dx lactose intolerance

A

Lactose hydrogen breath test

Increase H level after eat lactose –> indicates bacterial carb metabolism (as lactose no absorbed by gut so bacteria get to it)

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187
Q

Waddling gait

A

Muscular dystrophy

- weakness of gluteal muscles

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188
Q

Spastic gait

A

Lesions of UMN

Slow, stiff, effortful movements

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189
Q

Wide based high stepping gait

A

Loss of proprioception

Dorsal roots or posterior column damage

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190
Q

Pathology of angioedema

A

C1 inhibitor deficiency, dysfunction or destruction

Leads to increased C2b and bradykinin = edema producing factors

C4 levels are depressed

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191
Q

erythema nodosum - what is it?

A

Infection of fat cells

It is a panniculitis

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192
Q

When are you at risk for hypocalcemia due to citrate chelation

A

If transfuse > 1 unit/5 min

Live failure b/c liver processes citrate

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193
Q

Definition of HTN

  • in gen pop
  • in diabetics and renal disease
A

Gen pop > 140/90

Diabetes and renal disease > 130/80

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194
Q

Emergency eval of headache

A

Noncontrast CT to rule of ICH

Small bleeds may not show up - LP can be done if high suspicion and no bleed shown

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195
Q

Which headache is most responsive to ppx?

A

Cluster headaches

– use verapamil

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196
Q

Pt w/ migraines but do not respond to drugs for tx migraines. What are they?

A

Rebound analgesic headaches

Try and wean from analgesics!

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197
Q

Do you need antibiotics for bronchitis?

A

NO! Usually viral

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198
Q

Causes of laryngitis

A

Usually viral

Moraxella catarrhalis, H influenzae

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199
Q

Sore throat Ddx

A

Viral infection
Tonsilitis
Strep throat
Mononucleosis

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200
Q

When should a pt w/ GERD be screened for Barrett’s

A

Symptomatic for at least 5 yrs

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201
Q

What Pulm finding are you at risk for w/ GERD?

A

REcurrent aspirationi pneumonia

you can find lipid laden macrophages in cytology

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202
Q

Need ppx for dental procedures for these groups

A
  • Prosthetic cardiac valves
  • History of prior infective endocarditis
  • Unrepaired cyanotic congenital heart disease
  • Completely repaired congenital heart disease for 6 months following repair
  • Repaired congenital heart disease with residual defects or abnormalities
  • Cardiac transplantation recipients with cardiac valvulopathy
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203
Q

How to tx small focal breast cancer

A

Lumpectomy w/ sentinel lymph node biopsy

Irradiation

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204
Q

1st degree family hx colorectal cancer - what’s the screening procedure?

A

Age 40

OR

10 yrs younger than 1st diagnosis

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205
Q

1st degree heart block

A

First-degree atrioventricular block is diagnosed when the PR interval is greater than 0.20 sec

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206
Q

EKG of WPW

A

PR interval (<0.11 sec), prolonged QRS duration, and slurred onset of the QRS (delta wave) complex.

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207
Q

Chronic alcoholism pts have risk of what electrolyte abnormality if they get admitted?

A

Hypo phosphate

Can be normal on admissions and decrease over first 12 to 24 hrs. Possibly because of IV glucose admin

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208
Q

Manifestation of rapid decrease in phosphate

A

Confusion
Rhabdomyolysis
Hemolytic anemia
Muscle weakness

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209
Q

Tx gallstone pancreatitis

A

ERCP with sphincterotomy and stone extraction

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210
Q

Orthostatic prteinuria

A

Increase in urinary protein excretion only in uprivht psiion

Most common in yong adults or children

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211
Q

Urine aniongap formula

Normal value

A

= (U sodium + U potassium) - U chloride

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212
Q

How do you tell if metabolic acidosis is of renal or extrarenal origin just by labs?

A

Extrarenal causes of metabolic acidosis are associated with an appropriate increase in net acid excretion primarily reflected by high levels of urine ammonium excretion, whereas kidney causes of this condition are associated with low net acid excretion and decreased urine ammonium levels.

Can get Urine ammoium w/ urine anion gap

Metabolic acidosis of extrarenal origin is suggested by a large, negative UAG caused by significantly increased urine ammonium excretion. Conversely, metabolic acidosis of kidney origin is suggested by a positive UAG related to minimal urine ammonium excretion.

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213
Q

If pt w/ polymyagia rheumatica has a prednisone taper 2x but keeps getting flares, what should be done?

A

Add steroid sparing agent and incease prednisone

Example ismethoteate.

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214
Q

When do you need a TTE for a murmur?

A

3/6 or greater systolic murmur
Diastolic murmur
Continuous murmur
New murmur if last PE was healthy

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215
Q

PR interval length

A

120 to 200ms

No more than 1 large box

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216
Q

QRS length

A

80 to 120ms

3 small boxes

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217
Q

QT interval

A

< 1/2 of R-R interval

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218
Q

How to tell the earliest if someone has rheumatoid arthritis?

A

A radiograph showing marginal joint erosions would most likely support a diagnosis of rheumatoid arthritis (RA).

Erosions of cartilage and bone are cardinal features of RA. Erosions and joint-space narrowing may develop as early as 2 to 3 mos

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219
Q

Where do you find rheumatoid factor?

A

RA

Hep C

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220
Q

Histo of Acute promyelocytic anemia

A

predominant cell is a large immature granulocyte with multiple granules overlying the cytoplasm and nucleus.

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221
Q

AML diagnosis

A

The diagnosis of AML is confirmed by a bone marrow aspirate showing hypercellular marrow containing greater than 20% to 30% myeloblasts.

Once the diagnosis of acute leukemia is established, the classification is based on the morphology of the immature cells.

The presence of Auer rods confirms the myeloid nature of the leukemia.

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222
Q

ALL features

A

lymphocytosis, neutropenia, anemia, thrombocytopenia, lymphadenopathy, and hepatosplenomegaly at presentation.

An increased number of lymphoblasts found on bone marrow examination are suspicious for the diagnosis.

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223
Q

When to screen for asymptomatic bacteruria

A

pregnant women

before urologic surgery

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224
Q

Pt w/ TB - suggestive pleural effusion. How do you best evaluate next?

A

Pleural biopsy

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225
Q

Is a duodenal ulcer cancerous?

A

No

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226
Q

Most common causes of gastric ulcers

A

NSAIDs

H pylori

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227
Q

Diabetic retinopathy classifications

A

nonproliferative (with hard exudates, microaneurysms, and minor hemorrhages), which is not associated with visual decline

proliferative (with “cotton-wool spots” and neovascularization), which is associated with loss of vision.

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228
Q

The presence of hypotension, hyponatremia, and a decreased urine sodium excretion accompanied by a bland urine sediment raises suspicion for…..

A

Prerenal azotemia

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229
Q

Tumor lysis syndrome may manifest as what electrolyte abnormalities?

A

hyperkalemia
hyperphosphatemia
hyperuricemia.

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230
Q

Meniscal tear vs. ligament injuries (ACL)

A

Swelling faster in ligament injuries

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231
Q

Click/knock of joint w/ loose cartilage

Pain on walking

What could have happened? what tests do you do to figure this out?

A

Meniscal tear

Pain along the joint line is 76% sensitive for a meniscal tear

an audible pop or snap on the McMurray test is 97% specific for a meniscal tear.

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232
Q

McMurray test

A

Maximally flexing the hip and knee and applying abduction (valgus) force to the knee while externally rotating the foot and passively extending the knee

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233
Q

Suspect common bile duct stone for sx of pancreatitis and jaundice. But none seen on US. What do you think it is?

A

Abdominal ultrasonography has a sensitivity of only 50% to 75% for choledocholithiasis, and a common duct stone should be suspected in the correct clinical situation even when ultrasonography does not show a stone

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234
Q

Suspected osteomyelitis - you cultured the ulcer ontop of the wound and it shows X bacteria. What do you do next?

A

Cx from sinus tract or ulcer base don’t reflect bacterial etiology of underlying osteo

DO A BONE BIOPSY! Then do antibiotic therapy

The one exception is Staphylococcus aureus, which, if found in superficial cultures, correlates well with findings on deep cultures

235
Q

Cardiac events in pts w/ long QT syndrome

A

Cardiac events in patients with LQTS include syncope and cardiac arrest due to torsade de pointes ventricular tachycardia.

236
Q

Risk factors Long QT

A 
female sex
hypokalemia
hypomagnesemia
structural heart disease
previous QT-interval prolongation
history of drug-induced arrhythmia
237
Q

Familial syncope…causes?

A

Long QT syndrome

238
Q

When do you consider HIT?

A

HIT/T should be considered in any patient with an otherwise unexplained decrease in the platelet count and/or a new thrombotic event 5 to 10 days after initiation of heparin therapy.

239
Q

Gold std diagnose HIT

A

14C-serotonin release assay (SRA)

240
Q

Abnormal uterine bleeding - what types

A

infrequent menses, excessive flow, prolonged duration of menses, intermenstrual bleeding, and postmenopausal bleeding.

241
Q

Asthma exacerbation - signs of respiratory failure

A

Slightly elevated or even normal Paco2 levels often indicate impending respiratory failure rather than recovery,

pulse oximetry less than 95%, respiration rate greater than 30/min, and heart rate greater than 120/min

242
Q

Dx ankylosing spoindyliis

A

MRI of sacroiliac joints

243
Q

If pt w/ CRF is without fluid overload, hyperkalemia, metabolic acidosis, or uremic symptoms, what do you do for them?

A

Keep them on meds

Hemodialysis or Kidney replacement therapy can be delayed

. Transplantation in patients who have not yet been treated with hemodialysis is associated with better patient and allograft outcomes.

244
Q

Whaty is the most appropriate option patient with continued anginal symptoms despite optimal medical therapy.

A

Coronary angiograph

245
Q

Coronary revascularization is beneficial in patients with chronic stable angina and the following conditions

A

angina pectoris refractory to medical therapy; a large area of ischemic myocardium and high-risk criteria on stress testing; high-risk coronary anatomy, including left main coronary artery stenosis or three-vessel disease; and significant coronary artery disease with reduced left ventricular systolic function

246
Q

Risk factors for legionnaires disease include

A

smoking, diabetes mellitus, hematologic malignancy, other types of cancer, chronic kidney disease, and HIV infection.

247
Q

Test for legionella?

A

Leginoella urinary antigen test

248
Q

The patient is having a moderate to severe exacerbation of chronic obstructive pulmonary disease (COPD)…what do you do?

A

should be placed on noninvasive positive-pressure ventilation (NPPV).

A landmark study found that NPPV reduced the need for intubation, the length of hospital stay, and the mortality rate in such patients.

249
Q

Contraindications to NPPV include

A

impending respiratory arrest, cardiovascular instability, altered mental status, high aspiration risk, production of copious secretions, and extreme obesity, as well as surgery, trauma, or deformity of the face or upper airway.

250
Q

What do you suspect in patients with explosive onset, widespread psoriasis and the occurrence of dactylitis; marked distal interphalangeal (DIP) joint involvement; asymmetric joint involvement; symptoms of enthesitis; or joint ankylosis.

A

HIV-related psoriatic arthritis

251
Q

Diarrhea + N/V

Cause?

A

VIral gastroenteritis

Food poisoning

252
Q

Diarrhea + fever + blood in stool

A

Shigella
Campylobacter
Salmonella
E. coli

253
Q

Diarrhea + no fever + no blood

A

VIruses (rotavirus)
Entertoxic E coli
Food poisoning (Staph aureus, C. perfringens)

254
Q

Fecal leukocytes in

A 
C diff
Camylobacter
Salmonella
Shigella
EIEcoli
255
Q

Endocrine causes of conspitation

A

hypo TH

Hyper Ca

Hypo K

Uremia

Dehydration

256
Q

1 way decrease SBP

A

Reduce BMI

257
Q

Severe diarrhea electolyte disturbancce

A

Metabolic acidosis

Hypo K

258
Q

Vomiting electrolyte disturbance

A

Metabolic alkalosis

Hypo K

259
Q

Positive straight leg test means…

A

Nerve root compression

260
Q

If low back pain in the absence of progressive neuro deficits, osteoporosis, steoird use, constitutional sx, hx of malignancy, recent trauma, IV drug use, is refractory to conservative tx for at least how many months, what should you do next?

A

3 months

MRI

261
Q

Osteochondritis dissecans

A

Area of necrotic bone and degenerative changes in overlying cartalage

Bone and cartilage can separate and become loose –> pain, catching and popping

262
Q

Plica syndrome

A

Dx of exclusion

Usually in atheletes w/ overuse injuries

263
Q

Most common ankle ligament injured

A

Anterior talofibular ligament

264
Q

Trochanteric bursitis

A

Common cause of lateral hip pain

Very painful on palpation

Tx w/ NSAIDs

265
Q

Tests for carpal tunnel syndrome

A

Tinel’s sign
- tap over median N @ wrist –> paresthesias

Phalen’s test
- palmar flexion of wrist for 1 min –> paresthesias

266
Q

Definitive dx of carpal tunnel

A

Electomyography and nerve conduction velocity study

267
Q

Cartilage vs. bone –> which one has nerve endings?

A

Bone!

That’s why in arthritis, wear down cartilage and don’t notice but will notice once bone starts rubbing against each other!

268
Q

Where is pain of osteoarthritis of hip?

A

In groin

Can radiate to anterior thigh

269
Q

Where do you hold the cane for L knee pain?

A

R hand

270
Q

Is there a correlation b/n x ray osteoarthritis and severeity of disease?

A

No

271
Q

Type 1 vs type 2 osteoporosis

A

Type 1 - more trabecular bone loss

Type 2 - = trabecular and cortical bone loss

272
Q

Calcitonin effects

A

No help w/ hip

Helps w/ spine (lumbar)

273
Q

Which osteoporotic fracture has highest morbidity and mortality?

A

Hip

274
Q

SENSORINEURAL HEARING LOSS PATHOPHYS

A

DEGENERATION OF SENSORY CELLS AND NERVE FIBERS AT BASE OF COCHLEA

275
Q

Screening for ab aortic aneurysm

A

w/ US at age 65 in all men w/ smoking hx - only 1 test needed, no repeat if normal

276
Q

Osteoporosis screening

A

DEXA scan starting at 65

277
Q

RBBB

A

Wide QRS
rSr in chest leads
Wide S in lead I

278
Q

LBBB

A

Wide QRS
No Q in I, V5, V6
Notched R in I, V5, V6

279
Q

Q waves pathologic if

A

> 0.04 s wide

> 25% height of QRS

280
Q

T wave inversions in

A 
MI
Pericarditis
Cardiomyopathy
INtracranial bleed
Acidosis
LBB
LVH
281
Q

Peaked T waves in

A

early MI
Hyper K
Hyper Mg

282
Q

To do ASAP after putting in central venous line

A

CXR to check for pneumothorax

283
Q

Causes of rales

A

fluid in lungs

atelectasis

pneumonia, CHF, ILD

284
Q

Causes of wheezes

A

Asthma

285
Q

Causes of rhonchi

A

Chronic bronchitis

Snoring quality, low pitch, due to lots of mucus

286
Q

Type 1 error

A

Null hypothesis rejected even though it is true

FALSE +

287
Q

Type 2 error

A

Null hypothesis not rejected even though it is false

False -

288
Q

Effects of increase mineralocorticoid secretion

A

Increased tubular reabsorb of Na and HCO3
Loss of Cl in urine

Metabolic alkalosis and expansion of ECF

289
Q

PaCO2 mainly determined by

A

Respiratory rate

Tidal volume

290
Q

How much does 1 unit of packed RBC increase Hb level?

A

Hb increase by 1
Hct increased by 3

Hb x 3 = Hct

291
Q

FFP

A

All clotting factors

NO RBCs, WBCs, platelets

292
Q

Cryoprecipitate

A

Factor 8
Fibriongen

For hemophili A, DIC, vWD

293
Q

Dx beta thalassemia

A

Hemoglobin electrophoresis
- increase HbF and HbA2

Periph blood smear

  • microcytic
  • hypochromic
  • target cells maybe
294
Q

Tx thalassemias

A

frequent PRBC transfusions

295
Q

Clinical features of b-thalassemia

A

Anemia
Hepatosplenomegaly
Expansion of marrow space
Crew cut skull

296
Q

Sideroblastic anemia

  • what is it?
  • causes?
  • tx?
A

Abnormality in RBC iron metabolism

Hereditary or acquired

Chloamphenicol
INH
Alcohol

Lead

Collagen vascular disease

Myelodysplasia

Tx w/ removing offending agent, B6

297
Q

Consequence of aplastic anemia

A

Transform into leukemia

Increased infections

298
Q

Causes of B12 deficiency

A

Pernicious anemia

Gastrectomy

Vegans
Alcoholism

Crohn’s disease

Diphyllobothrium latum
SIBO

299
Q

Causes of folate deficiency

A

Tea and toast diet
Alcoholism

Long term antibiotic use

Increased Demand

Preggers

Hemolysis

MTX, phenytoin

Hemodialysis

300
Q

Signs of intravascular hemolytic anemia

A

Dark urine color (hemoglobinuria)
Schistocytes
Low haptoglobin
Increased LDH

301
Q

Signs of extravascular hemolytic anemia

A

Spherocytes or helmet cells
Increased LDH
Increased unconjugated bilirubin –> jaundice

302
Q

What does sickle cell survival correlate with?

A

Frequency of vaso occlusive crises

More = shorter lifespan

303
Q

Aplastic crisis in sickle cell

  • precipitants
  • tx
A

Caused by virus (eg parvo B19)

Tx blood transfusion

304
Q

Splenic sequestration crisis

A

Sudden pooling of blood into spleen –> splenomegaly + hypovolemic shock

Happens in sickle cell adn beta thal

More common in kids b/c they ahve intact spleens

305
Q

Consequences of sickle cells

A 
Painful bone crises
Dactylitis
Acute chest syndrome (repeated episodes of pulmonary infarctions)
Splenic infarctions
Avascular necrosis of joints (hip, shoulder)
Priapism
Renal papillary necrosis w/ hematuria
Chronic leg culcers b/c vaso occlusion
Ab crises
Infections w/ H influenzae, strep pneumo
Salmonella osteo
306
Q

Manage painful crises

A

Hydration
Morphine for pain
Keep pt warm
Supplemental O2 if hypoxic

307
Q

When do you do blood transfusion for sickle cell?

A

Acute chest syndrome
Stroke
Unresponsive priapism
Cardiac decomp

308
Q

Paroxysmal noctual hemoglobinuria

A

Deficiency of anchor proteins linking complement-inactivating proteins to blood cell membranes

Intravascular hemolysis

Pancytopenia

309
Q

Dx PNH

A

Ham’s test
- pt cell incubated in acidified serum –> triggers alternative complement –> lysis of PNH cells

Sugar water test
- mix pt’s serum in sucrose –> hemolysis if PNH

Flow cytometry to detect CD55 or 59

310
Q

Tx PNH

A

Glucocorticoids (prednisone)

- most don’t respond

311
Q

Platelet disorders

A 
ITP
TTP
HIT
Bernard Soulier
Glanzmann's
312
Q

Idiopathic thromocytopenic purpura

  • what is it
  • clinical features
  • dx
  • tx
A

IgG antibodies on platelets –> removed by spleen

Minimal bleeding
NO splenomegaly

Dx

  • plt count < 20,000
  • low periph platelets
  • increased megakaryocytes

Tx

  • steroids
  • IV immunoglobulin
  • splenomgaly
  • plt transfusions
  • romiplastim, eltrombopag
313
Q

Thrombotic thrombocytopenic purpura

  • what is it
  • clinical features
  • tx
A

Plt consumption disorder
Plt count decreased
PT, PTT normal

TTP = HUS + fever + AMS

Features

  • hemolytic anemia
  • thrombocytopenia
  • renal failure
  • fever
  • neuro signs

Tx

  • plasmapheresis
  • steroids, splenectomy
  • NO plt transfusions
314
Q

Bernard Soulier

A

AR

Deficiency in GpIb

Plts large, plt count low

315
Q

Glanzman’s thrombathenia

A

AR

Deficiency in GpIIb-IIIa

Plt count NORMAL

316
Q

Thrombin time

A

Measure of fibrinogen concentration

317
Q

Bleeding time

A

Reflects plt function

318
Q

Of clotting factors, which has shortest 1/2 life? How does this affect PT or PTT

A

Factor 7

PT increases 1st with clotting factor deficiency

319
Q

Inherited hypercoagulable states

A

AT 3 deficiency (AD)

Antiphospholipid antibody syndrome (acquired)

Protein C deficiency (AD)

Proetin S deficiency

Factor 5 leiden (protein C can’t activate factor 5)

Prothrombin gene mutation

Hyperhomocysteinemia

320
Q

How long are you hypercoagulable for preggers?

A

All of preggers

2 months postpartum

321
Q

Highest incidence of cancers in men

A

Prostate > lung > colon

322
Q

Higher mortality cancers in men

A

Lung > prostate > colon

323
Q

Highest incidence of cancers in women

A

Breast > lung > colon

324
Q

Highest death cancers in women

A

Lung > breast > colon

325
Q

Oncologic emergies needing immediate tx

A

Hyper Ca
- fluids, diuretics, bisphosphanates

Spinal cord compression
- steroids, MRI

Pericardial tamponade
- pericardiocentesis

Tumor lysis syndrome

  • IV fluids
  • tx electrolyte abnormalities
326
Q

DCIS vs LCIS - which is palpable?

A

DCIS

327
Q

1st step for breast mass in woman > 30

A

Biopsy

328
Q

When do you need chemo after removing breast lump?

A

Don’t need it for small lesions (< 1cm) w/o lymph node involvement

329
Q

Indicates poor prognosis staging in CLL

A

Thrombocyotpenia

330
Q

Dx MM

A

> 10% abnormal plasma cells in bone marrow + 1 of the following:

M protein in serum
M protein in urine
Lytic bone lesions

331
Q

Waldenstrom’s macroglobulinemia

A

Malignant prolif of plasmocytoid lymphocytes

IgM

No bone lesions

NO cure

332
Q

Dx Hodgkin’s lymphoma

A

Biopsy of lymph node shows Reed Sternberg cells

333
Q

Clinical features of Hodgkin’s lymphoma

A

Painless lymphadenopathy
Constitutional symptoms (poorer prognosis)
Spread continuity from 1 lymph node to adjacent lymph node

Pruritus
Cough

334
Q

Myelodysplastic syndrome

A

Acquired clonal blood d/o

Ineffective hematopoiesis
Apoptosis of myloid precursors

Results in pancytopenia despite normal or hypercelllular bone marrow

335
Q

Abnormalities of myelodysplastic syndromes

A

Low retic count
Howell Jolly bodies
Basophilic stippling
Ringed sideroblasts

336
Q

Tx myelodysplastic syndrome

A

RBC and plt transfusions

EPO
GCSF

Vit B6, 12 folate for cell turnover

337
Q

Essential thrombocythemia

A

Plt > 600,000

Dx of exclusion

Splenomegaly
Pseudohyper K
Elevated bleeding time

Increased megakaryocytes in bone marrow

338
Q

Normal pulse in setting of high fever is suggestive of…

A

atypical CAP

339
Q

Approach to CAP

A

Lower vs. upper?
- nasal discharge, sore throat –> usually upper

If lower, is it PNA vs. bronchitis?
- CXR to tell

340
Q

If CXR not suggestive of PNA, what do you do

A

DO NOT tx w/ antibiotics

341
Q

False negative CXR for PNA in…

A

Neutropenia
Dehydration
PCP
Early disease

342
Q

PNA hints

  • alcoholics
  • immigrants
  • nursing home
  • HIV +
  • transplant recipients
A

Alcoholics - Klebs

Immigrants - TB

Nursing home - Pseudomonas

HIV - PCP, M TB

Transplant - Legionella

343
Q

If suspect PNA is the following, how do you test?

TB
PCP
Legionella

A

TB - acid fast

PCP - silver stain

Legionella - urinary antigen

344
Q

When do you admit for PNA?

A

If pt is hypoxic or hypotensive

345
Q

Parts of lungs most affected by aspiration lung abscess

A

Posterior segments of upper lobes

Superior segments of lower lobes

Right lung more affected

346
Q

CXR of lung abscess

A

Thick walled cavitation w/ air fluid levels

347
Q

Who is contagious w/ TB

A

Active TB

Primary TB NOT contagious

348
Q

Radiologic findings in primary TB

A

Ghon’s complex
- calcified primary focus w/ assoc lymph node

Ranke’s complex
- Ghon complex –> fibrosis and calcification

349
Q

Primary Tb

A

usually asymptomatic

May have pleural effusion

350
Q

Secondary (active) TB

A

Constitutional sx
Dry cough –> purulent sputum
Apical rales

351
Q

Definitive dx of TB

A

Sputum culture

PCR

352
Q

PPD

A

DO NOT use to dx active TB - only for latent TB

If pt is symptomatic or has abnormal CXR, order sputum acid-fast test, not PPD

Positive PPD:
No risk factors: >= 15

High risK> 10 mm

HIV, acitve TB close contacts : 5 mm

353
Q

If person had BCG vaccine and positive PPD, what do you do?

A

INH for 9 months no matter what!

354
Q

When do you stop TB tx as a result of adverse effects?

A

If liver transaminases rise to 3-5x upper limit of normal

355
Q

Kerning’s sign

A

Can’t fully extend knees when supine

Irritate meninges

356
Q

Brudzinski’s sign

A

Flex legs adn thighs that is brough on by passive flexion of neck

Irritate meninges

357
Q

Dx meningitis

A

LP

Do a CT scan 1st

Get blood cx before start abx

358
Q

Best way to Dx viral encephalitis

A

CSF PCR

359
Q

Best way to Dx encephalitis

A

MRI of brain

360
Q

Transmission

  • Hep A
  • Hep B
  • Hep C
  • Hep D
  • Hep E
A

A, E - fecal oral

B - sex, parenteral

C - parenteral

D - w/ hep B

361
Q

If transaminases are really elevated, what do you think of?

A

Viral hepatitis
Shock liver
Drug induced hepatitis

362
Q

Symmetric descending flaccid paralysis

A

Botulism

363
Q

Dx botulism

A

ID toxin in serum, stool, or gastric contents

364
Q

How does a UTI happen?

A

Colonization of vaginal area by pathogens from fecal flora

E. coli
Staph saprophyticus
Enterococcus
Klebs
Proteus
365
Q

You suspect HUS in someone. What do you do next? How do you tx?

A

Peripheral blood smear to diagnose

Tx is supportive

Do not use abx

May need dialysis if ARF, PRBC for anemia

Only do platelet transfusion if bad. Otherwise can make worse

366
Q

Do we recommened screening for early stage lung cancer even if pt smokes?

A

NO

367
Q

How to dx acute parvovirusB19 infection?

A

IgM Abs

368
Q

Transient aplastic crisis in pts w/ chronic hemolytic anemia - what do you think happened?

A

Parvo B19 infection

369
Q

Pink pearly nodules w/ telangiectasias + flecksof melanin pigment

What is this?
How to tx?

A

Basal cell carcinoma

Superficial lesions tx w/ curettage, imiquimod, cryotherapy, or excision

370
Q

How do ou improve survival in severe sepsis?

A

Agggressive fluid rescussitation

If lactic acid resolves in 6 hrs, good for survival

5-6L fluids/6hrs.

371
Q

Causes of prostatitis

A

Usually gm -

E coli
Klebs
Proteus
Pseudomonas
Enterobacter
Serratia
372
Q

Which is worse - acute vs chronic prostattis?

- how do you tell what it is?

A

Acute

Acute
- prostate tender
- fever
- pt looks ill
DO NOT MASSAGE THE PROSTATE as can cuse bacteremia
WBC in UA, U cx always + for bacteria

Chronic

  • prostate may not be tender
  • pt doesn’t look ill
  • WBC in UA, U Cx may or may not be +
373
Q

Most common STD? Most cmmon bacterial STD?

A

STD - HPV

Bacterial STD - chlamydia

374
Q

Leading cause of infertility in women

A

Chlamydia b/c of tubal scarring

375
Q

Complication of gonorrhea and chlamydia

A

Infertility

Fitz-hugh curtis syndrome

376
Q

When do you do csection for hIV + mom?

A

Viral load > 1000 copies

377
Q

Best indicator of status of immune system ad risk for opportunistic infections and disease progressio

A

CD4 count

> 500, immune system normal

378
Q

Best indicator of adequacy and response to antiretrovirals?

A

Viral load (HIV-1 RNA levels)

379
Q

Leading cause of death in pts w/ AIDS

A

PCP

380
Q

When at increased risk for CMV or MAC w/ HIV?

A

CD4 < 50

381
Q

Dx cryptococcal meningitis

A

CSF ID

tain w/ india ink

382
Q

When do you see esophageal candidiasis in HIV?

A

CD 4 < 100

383
Q

How long to seroconvert to HIV +

A

3-7 weeks

384
Q

When does ELISA become + for HIV?

A

1-12 weeks after infection

If negative, usually doesn’t have HIV

385
Q

When do you say someon has AIDS?

A

CD4 < 200

386
Q

PCP signs

A

Dyspnea, dry cough, fever

CD4 < 200

CXR = bilateral interstitial infiltrates

Increased LDL
Hypoxia

Bronch to dx fully

387
Q

When do start px for MAC in HIV?

A

CD4 < 100

388
Q

Where does HSV stay latent?

A

dorsal root ganglia

389
Q

Reactivaton of HSV assoc w/

A

stress
fever
infection
sun exposure

390
Q

How to tx herpetic whitlow?

A

Acyclovir

DO NOT incise and drain

391
Q

Dx herpes

A

Tzanck smear - quickest - shwes multinucleated giant cells

Cultur of HSV is gold standard (2-3 days)

ELISA

392
Q

Most common presentations of syphillis

A

Chancre

Inguinal lymphadenopathy

Maculopapular rash of 2ndary syphilis

393
Q

Dx syphilis

A

NOntreponemal test - RPR, VDRL

  • very sensitive
  • if +, confirm w/ specific treponemal test
  • can be + w/ SLE

Treponemal test - FTA-abs, MHA-tp

  • more specific
  • not for screening, just to confirm
394
Q

Lymphogranuloma venereum

A

STD by C. trachomatis

Painless ucer at site of inoculation –> tender inguinal lymphadenopathy few wks later –> constitutional sx

395
Q

How to dx cellulitis?

A

Clinical!

It is inflammation of skin adn subQ tissue

396
Q

When is cellulitis med emergency?

A

Orbital involvement

397
Q

Likely cause of cellulitis if caused by break in skin

A

Group A srep

398
Q

Likely cause of cellulitis if caused by wounds, abscesses

A

Staph aureus

399
Q

Likely cause of cellulitis if caused by immersion in water

A

Pseudomonas
Aeromonas
Vibrio vulnificus

400
Q

Likely cause of cellulitis if caused by acute insusitis

A

H. influenzae

401
Q

Erysipelas

  • what is it
  • tx
A

Celluitis confined to dermis and lymphatics

Usually caused by group A strep

Tx IM penicllin or erythromycin

402
Q

Necrotizing fascitis

  • what is it
  • common causes
  • clinical features
A

Infectio of deep soft tissues rapidly tracking along fascial planes

Strep pyogenes
Clostridium perfringens

Fever and pain out of proportion to appearance of skin
Tissue necrosis
Crepitus

403
Q

Lymphadenitis

A

Inflammation of lymph node usually due to local skin or soft tissue bcterial infection

Tender lymph nodes, red streaking of skin from wund or area of cellulitis

404
Q

Dx of tetanus

A

Clinical

405
Q

Tx tetanus

A

Neutralize unbound toxin w/ passive immunization

Give 1 dose IM tetanus immune globulin

+ active immunizaton w/ Tdap

406
Q

When do you give tetanus immunoglobulin?

A

If suspect pt is not immunzed for tetanus and has a bad woud. Don’t need it in minor wounds for these ppl

407
Q

When do you give tetanus/diptheria toxoid

A

If suspect pt is not immunized for tetanus and has clean, minor wound or worse

408
Q

Common osteo bugs in catheter septicemia

A

Staph aureus

409
Q

Common osteo bugs in prosthetic joint

A

Coag-negative staph

410
Q

Common osteo bugs in diabetic foot ulcer

A

polymicrobial

411
Q

Common osteo bugs in nosocomial

A

pseudomonas

412
Q

Common osteo bugs in IV drug use, neutropenia

A

Fungal

Pseudomonas

413
Q

Common osteo bugs in sickle cell

A

Salmonella

414
Q

Common osteo bugs in vertebrae

A

M. TB

Pott’s disease

415
Q

How do you use ESR for osteo?

A

Monitor response to therapy

416
Q

Best way to dx osteo

A

Needle aspiration of infected bone

MRI

417
Q

Most common joint affected in septic arthritis

A

Knee

418
Q

What do you do for septic arthritis?

A

Joint aspiration + analyze synovial fluid

Tx immediately if suspect - do not delay starting abx

419
Q

Most impt tests to confirm clinical suspicion of Lyme disease

A

ELISA

Western blott to confirm

420
Q

Pathophys of RMSF

A

Rickettsia rickettsii multiply in vascular endothelium adn spred to diff layers of vasculature

Damage endothelium –> increased vascular perm –> activate complement, microhemorrhages, microinfarcts
Dx is clinical

421
Q 
Fever patterns of 
P falciparum
P ovale
P vivax
P malariae
A

P falciparum –> constant

P ovale, vivax –> every 48 hr spike

P malariae –> every 72 hrs spike

422
Q

How do you screen for HCC? How can you dx w/o Bx?

A

Ultrasound

Patients with a compatible ultrasound imaging study and a subsequent serum α-fetoprotein level greater than 500 ng/mL (500 µg/L) can be diagnosed with hepatocellular carcinoma without a biopsy.

423
Q

Corrected [HCO3]

A

= measured [HCO3] + (measured anion gap – 12)

424
Q

Dx diffuse parenchymal lung disease

A

High-resolution CT (HRCT) is more sensitive than chest x-ray for DPLD and reveals ground-glass and reticular linear opacities, subpleural cysts, and honeycombing in patients with advanced disease.

425
Q

Mycobacterium avium intracellulare

A

causes fevers, diarrhea, malabsorption and anorexia, and can disseminate to the bone marrow

Always consider in HIV pts w/ diarrhea

426
Q

Bronchial breath sounds - meaning

A

when bronchial breath sounds are heard in a location other than the trachea, it is suggestive of pulmonary consolidation

427
Q

V/Q mismatch examples

A

pneumonia, pulmonary edema, and COPD/asthma

428
Q

Pulmonary shunt

  • what is it
  • examples
A

extreme form of V/Q mismatch where there is no ventilation.
This is clinically recognized when a patient who is hypoxic fails to respond to oxygen.

right-to-left intracardiac shunt
acute respiratory distress syndrome (ARDS)

429
Q

PTT and BT affected. What does this person have?

A

von Willebrand disease is one of the few hemostatic disorders characterized by both a platelet and coagulation defect due to a reduction or defect in von Willebrand factor (vWF), which supports platelet adhesion and also serves as a carrier protein for factor VIII.

The diagnosis is confirmed by measuring the vWF antigen level and activity.

430
Q

The three classic findings in chronic pancreatitis are

A

abdominal pain that is usually mid-epigastric,

postprandial diarrhea,

diabetes mellitus secondary to pancreatic endocrine insufficiency.

Dx w/ CT
The presence of pancreatic calcifications on radiographs confirms the diagnosis.

431
Q

A patient with a breast mass requires

A

triple assessment:

palpation,

mammography

ultrasonography (if BI-RADS 1-3, skip to biopsy if 4,5)
—> distinguishes cystic from solid mass

biopsy (FNA) or aspiration

432
Q

5 major cardiovascular risk factors

A

cigarette smoking,
hypertension,
older age (men ≥45 years; women ≥55 years),
low HDL-cholesterol level (<65 years).

433
Q

Goal LDL in pts w/ 0-1 cardio risk factors

A

below 160 mg/dL (4.1 mmol/L).

434
Q

Allergic bronchopulmonary aspergillosis

A

typ 1 HS rxn

Asthma
Eosinophilia

435
Q

Pulmonary aspergilloma

A

Inhale spores into lung

Chronic cough, hemoptysis

Can resolve spontaneously; may need lung lobectomy

436
Q

invasive aspergillosis

A

hyphae invade lung vasculature –> thrombosis and infarction

Immunocomp at risk

Diffuse bilateral pulm infiltrates

437
Q

Dx aspergillosis

A

Fungus ball on CXR

Sputum has aspergillosis

Blood cx not helpful

438
Q

What is characteristic of tissue biopsy of cryptococcus?

A

Lack of inflammatory response

439
Q

What should you be suspicious of for persistent fever in ICU?

A

Fungal infection

Antimicrobial resistance

Needing surgery (abscess)

Drug fever

440
Q

Top causes fever of unknown oritin

A

Infection - TB, endocarditis, HIV

Neoplasms - lymphoma, leukemia

441
Q

How many organs must be involved to be TSS?

A

3

Renal
GI
Heme
MS
CNS
442
Q

Before starting oral retinoids, what do you ABSOLUTELY need to do for fems?

A

Get 2 negative pregnancy tests

Use 2 forms of BC for 1 month before starting med through 1 month after stopping med

443
Q

How do you tell between SCC and keratoacanthoma

A

Keratoacantoma grows SUPER FAST

444
Q

Hypersensitivity of allergic contact dermatitis

A

Type 4

Eg poison ivy

445
Q

Is pityriasis rosea contagious?

A

NO

446
Q

Multiple round/oval patches appear than generalized rash w/ multiple oval shaped lesions. What is this?

A

Pityriasis rosea

Usually not on face

447
Q

Common infectious cause of erythema multiforme

A

HSV

Acyclovir can help prevent HSV assoc EM

448
Q

What should you always rule out when child presents w/ molluscum contagiosum?

A

Child abuse

It is highly contagious, may have sex abse

449
Q

Marjolin’s ulcer

A

SCC arising from chronic wound such as previous burn scar

Usually very aggressive

450
Q

Who has better prognosis for malignant melanoma - men or women?

A

Women

451
Q

Most impt indicator of melanoma prognosis

A

Depth of invasion

452
Q

Angioedema vs. urticaria

A

Angioedema is deeper in skin (deep skin/subQ)

Angioedema is more tender and burning vs. pruritic b/c fewer mast cells/sensory N endings in deeper tissues

453
Q

Hypersensitivity rxns 1-4

A

1 - IgE

2 - IgG (Goodpastures, pemphigus vulgaris)

3 - Antigen-Ab complex (SLE, serum sickness)

4 - T cell mediated (poison ivy, TB)

454
Q

How long dos it take for a drug allergy to appear?

A

1 month

Usually not less than 1 week

455
Q

Diagnose cobalamin deficiency in a patient with a low-normal vitamin B12 level with…

A

methylmalonic acid and homocysteine measurements.

Levels of methylmalonic acid and homocysteine become elevated in patients with vitamin B12 deficiency before serum vitamin B12 levels decrease below the normal range

456
Q

How do you get hypo Ca in acute pancreatitis?

A

Acute pancreatitis can generate free fatty acids that chelate insoluble Ca salts –> hypo Ca

This is saponification

457
Q

All pts w/ acute monoarthritis should be suspected to have….

A

Septic arthritis

Arthrocentesis to dx

usually manifests as acute monoarthritis and is characterized by pain on passive range of motion in the absence of known trauma.

458
Q

MRI of joints is useful when?

A

detecting avascular necrosis
soft-tissue masses
collections of fluid not visualized by other imaging modalities

459
Q

peripheral blood smear showing few, but large, platelets supports the presence of

A

a young population of platelets, consistent with increased turnover.

ITP!

460
Q

For parapneumonic effusion, what situations/characteristics are abx not enough? How else do you tx?

A

the presence of loculated pleural fluid,
pleural fluid with a pH less than 7.20,
pleural fluid with a glucose < 60 mg/dL
lactate dehydrogenase > 1000 U/L,
positive pleural fluid Gram stain or culture,
presence of gross pus in the pleural space

Chest tube or catheter drainage to tx too

461
Q

Drug induced lung toxicity

A 
hypersensitivity-type reaction, 
with presenting symptoms of 
fatigue, 
low-grade fever, 
cough.

Peripheral blood eosinophilia may be present.

AMIODARONE is a common cause

Acute eosinophilic pneumophilia is MUCH FASTER progressing than this so can r/o if disease has been around for awhile

462
Q

How does handgrip help HOCM murmur?

A

increasing afterload and decreasing the relative pressure gradient across the left ventricular outflow tract.

463
Q

Aortic stenosis vs. HOCM - differences

A

HOCM is associated with rapid upstrokes of the carotid arteries,
aortic stenosis, is associated with a carotid artery pulsation that has a slow up-rise and is diminished in volume.

murmur of aortic stenosis decreases with the Valsalva maneuver.

464
Q

decreased anion gap in the presence of anemia, proteinuria, hypercalcemia, and renal failure suggests

A

Multiple myeloma

465
Q

How does low anion gap happen in MM?

A

Most unmeasured anions consist of albumin. Therefore, the presence of either a low albumin level or an unmeasured cationic light chain, which occurs in multiple myeloma, results in a low anion gap.

466
Q

Milk alkali

A

characterized by hypercalcemia caused by repeated ingestion of calcium and absorbable alkali

Often w/ excess milk and antacids for dyspepsia

467
Q

Glomerular vs. nonglomerular hematuria

A

RBC casts in glomerular

Normal RBC in nonglomerular

468
Q

Evaluate persistent hematuria with

A

cystoscopy

469
Q

The best way to screen for hearing loss is the

A

whispered voice test.

470
Q

dyspnea at rest or on exertion, platypnea, and hypoxemia in the setting of chronic liver disease.

A

hepatopulmonary syndrome

The hypoxemia results from pulmonary vascular dilatation with intrapulmonary shunt and ventilation-perfusion mismatch, which may worsen when the individual is in an upright position.

CXR is nl

471
Q

Cells of sickle cell

A

Sickle cell

Target RBC

472
Q

Criteria for Type 2 DM

A

fasting plasma glucose level of at least 126 mg/dL

a random plasma glucose level of at least 200 mg/dL

and symptoms of hyperglycemia (for example, polyuria, polydipsia, or blurred vision),
or a 2-hour oral glucose tolerance test (OGTT) result of at least 200 mg/dL

473
Q

Impaired fasting glucose is diagnosed when

A

the fasting plasma glucose level is in the range of 100 to 125 mg/dL

474
Q

impaired glucose tolerance

A

plasma glucose level at the 2-hour mark of an OGTT is 140 to 199 mg/dL

475
Q

Imaging results of ischemic colitis

What is a definitive diagnosis?

A

Thickened bowel wall on CT

The finding of patchy segmental ulcerations on colonoscopy in a patient with a compatible history establishes the diagnosis.

476
Q

Management of hyperglycemic hyperosmolar syndrome mainly involves

A

identifying the underlying precipitating illness and restoring a markedly contracted plasma volume.

Insulin reduces glucose levels but should be administered only after expansion of the intravascular space has begun.

Potassium should not be administered until urine output is verified, because these patients are prone to acute kidney injury.

477
Q

Incidental asymptomatic adrenal mass - what do you do next?

A

Plasma-free metanephrine levels (for pheo)

overnight dexamethasone suppression test (Cushing’s)

Adrenal incidentalomas unlikely to secrete aldo and screen if have HTN or hypo K

478
Q

Acute chest syndrome in patients with sickle cell anemia should be managed by

A

exchange transfusion.

Red blood cell exchange transfusions are performed to increase the hemoglobin A level to at least 50% and thereby decrease the percentage of abnormal sickle cells and prevent hemoglobin S polymerization and sickling.

Will see pulm infiltrate on CXR for acute chest syndrome

479
Q

Dark blue or black berry like lesions that are symmetric, elevated, and one color

A

Nodular melanoma

Usually in older
Tend to expand vertically rather than horiz

480
Q

Goal LDL of pts with previous stroke or TIA

A

Less than 100

481
Q

Who should get HPV vaccine?

A

All girls between 9 and 26 regardless of sex activity

482
Q

Genital herpes lesions

A

Vesicles that ulcerated and are painful.

Can have crusted roof

483
Q

Chancroid lesions

A

Deep ragged ulcers

Purulent

May have tender lymph nodes

484
Q

Prosthetic joint infection

A

Pain is main sx

Usually no fever or leukocytosis

Arthrocentesis is gold std to dx

485
Q

Zinc excess can cause…

A

Copper deficiency

Copper def can look like b12 def and have demyelination

486
Q

Patients with new-onset heart failure and angina should be evaluated with

A

cardiac catheterization and angiography if they are possible candidates for revascularization.

487
Q

Patients with new-onset heart failure and angina should be evaluated with

A

cardiac catheterization and angiography if they are possible candidates for revascularization.

488
Q

Sequelae of infective endocartitis

A 
Fever
Roth's spots (white spots on retina)
Osler nodes (tender nodes on fingers or toes)
Murmur 
Janeway lesions (painless erythematous lesions on palm)
Anemia
Nailbed Hemorrhage
Emboli
489
Q

HUS commonly manifests as

A

acute kidney injury (AKI) accompanied by thrombocytopenia and microangiopathic hemolytic anemia (schistocytes on peripheral blood smear).

490
Q

When is prostate cancer screening beneficial?

A

Under 75 years old

491
Q

how to reduce the risk of ventilator-associated pneumonia (VAP).

A

Semi-erect position

Oral placement of endotracheal tubes better than nasal placement

492
Q

Osteoporosis screening guidelines

A

Guidelines recommend that screening for osteoporosis begin at age 65 years for women. Women aged 60 to 64 years should be screened if they are at higher than average risk for osteoporosis.

The most predictive risk factor for osteoporosis is weight below 70 kg (154 lb), as with this patient.

493
Q

Pneumococcal vaccine is indicated for

A

persons age 65 years and older or for those younger than 65 years who live in long-term care facilities, or who have chronic illnesses, or who are Alaskan natives or American Indians.

494
Q

Which acute hepatitis rarely causes symptoms?

A

C

495
Q

cosyntropin stimulation test

A

is used to determine the adrenal reserve by measuring the response to a standard dose of synthetic adrenocorticotropic hormone.

The test does not detect Cushing syndrome but, rather, adrenal insufficiency

496
Q

the most common causes of cirrhosis in the United States

A

Alcohol and chronic hepatitis C infection are

497
Q

drinks to cause alcoholic cirrhosis

A

6 alcoholic drinks per day for men

3 alcoholic drinks per day for women for 10 years

498
Q

Bowen disease

A

SCC in situ

Gradually enlarging
Well demarcated
erythematous scaly plaques

can look like psoriasis, BCC, eczema

499
Q

Cryptogenic organizing pneumonia

A

Alveolar filling opacities on CXR

The tempo of the disease process is the key to differentiating COP from other interstitial lung diseases.

COP is often acute or subacute, with symptom onset occurring within 2 months of presentation in the majority of patients.

The presentation is so suggestive of an acute or subacute lower respiratory tract infection that patients have almost always been treated with and failed to respond to one or more courses of antibiotics before diagnosis.

500
Q

How does a mixing study help w/ diagnosing disorders in coagulation?

A

The results of the mixing study will normalize in a patient with a factor deficiency but will remain abnormal if an inhibitor is present.

501
Q

classic ekg finding for pe

A

s1q3t3

502
Q

For what women is there no proven benefit to routine Pap testing to detect cancer.

A

In asymptomatic women who have had a complete vaginal hysterectomy for benign disease

Still need it if did a complete vaginal hysterectomy but for a malignant disease reason

Also need to screen if have cervix in still

503
Q

1st step for tx hyper K

A

intravenous calcium gluconate

THEN:
Sodium bicarbonate and β-antagonists such as albuterol and glucose (with or without insulin) would facilitate intracellular potassium shift.

504
Q

How do you tell DIC from HUS and TTP?

A

Neither TTP nor HUS is associated with elevations of the prothrombin or partial thromboplastin time or the D-dimer or depression of the fibrinogen level.

505
Q

Do you tx salmonella diarrhea w/ abx?

A

No, only some cases (severly ill, young, immunocompromised)

May prolong disease duration!

506
Q

When do you do tests for lymphadenopathy?

A

patients with systemic symptoms,

progressively enlarging lymph nodes,

or persistently enlarged nodes for more than 2 weeks

If lymph node < 2 cm, don’t need to do tests!

507
Q

How do you 1st manage prostate cancer screening?

A

physicians discuss potential, but uncertain, benefits and possible harms (complications of future diagnostic testing and therapies, including incontinence; erectile dysfunction; and bowel dysfunction) before ordering PSA testing

508
Q

Osteoporosis is diagnosed by

A

the presence of fragility fractures (fracture secondary to minor trauma, such as falling from a standing position),

or by a bone mineral density (BMD) T-score less than −2.5 in patients who have not experienced a fragility fracture.

509
Q

AST vs ALT - which is more specific to liver tissue?

A

ALT

510
Q

Cholestatic injury (cholestasis),

A

which consists of a lack of or an abnormality in the flow of bile,

is indicated primarily by an elevation of serum alkaline phosphatase and relatively minimal elevations of AST and ALT.

511
Q

only calcium channel blockers with demonstrated neutral effects on mortality in patients with heart failure.

A

Amlodipine and felodipine

First-generation calcium channel blockers (such as nifedipine) have been shown to increase the risk of heart failure decompensation and hospitalization.

512
Q

Pt with severe, rapidly progressive pneumonia, especially during influenza season…waht do you suspect? What should you give to tx?

A

Methicillin-resistant Staphylococcus aureus (MRSA) should be suspected

cefotaxime, levofloxacin, and vancomycin.

513
Q

Peptic ulcer in gastric antrum - what do you do?

A

Biopsies of all gastric ulcers should be performed, because even small, benign-appearing gastric ulcers may harbor malignancy

Treatment for peptic ulcer disease is guided by the biopsy and presence of H. pylori infection.

514
Q

How do you screen for bleeding d/o prior to surgery?

A

Clinical hx!

In the absence of a personal or family history of abnormal bleeding, liver disease, significant alcohol use, malabsorption, or anticoagulation therapy, the likelihood of a bleeding disorder is low, and no further preoperative testing is required.

Patients with any of these risk factors should be screened further by obtaining a prothrombin time (PT/INR), an activated partial thromboplastin time, and a platelet count.

515
Q

The treatment for an acute STEMI is

A

either revascularization or thrombolytic therapy.

516
Q

Thrombolytic agents are an alternative to primary PCI in suitable candidates with STEMI. How long before you give it?

A

Thrombolytics should be administered within 12 hours after the onset of chest pain; the earlier the administration, the better the outcome.

517
Q

Progestin withdrawal challenge for secondary amenorrhea

A

If get menstural flow,

indicates relatively normal estrogen
no anatomical blockage

Then this person has chronic anovulation

518
Q

Patients with an elevated or rising serum PSA level noted during routine screening should…

A

undergo prostate biopsy, even if they are asymptomatic.

Any rise greater than 0.75 ng/mL/year (0.75 µg/L/year) is considered abnormal and should be evaluated

519
Q

Patients with new-onset urinary incontinence should first be evaluated for

A

transient, reversible causes, for which the mnemonic DIAPERS may be useful:

Drugs,
Infection,
Atrophic vaginitis,
Psychological (depression, delirium, dementia),
Endocrine (hyperglycemia, hypercalcemia),
Restricted mobility,
Stool impaction.

520
Q

anserine bursitis,

A

the diagnosis rests on the finding of focal tenderness on the upper, inner tibia, about 5 cm distal to the medial articular line of the knee

521
Q

one of the leading causes of death in patients with polymyositis and dermatomyositis

A

ILD with progressive pulmonary fibrosis and secondary pulmonary arterial hypertension

522
Q

When do you have an inferolateral MI

A

Left dominant circulation if your PDA comes off LCX.

Will see st elevation in I avL V VI and II III aVF

523
Q

What do you use for UTI in person with long QT?

A

Not fluoroquinolone, tmp smx, or nitrofurantoin.

Use amoxicillin

524
Q

If you have high suspicion that a person has lung cancer, what do you do next?

A

Sample lymph node to determine stage

525
Q

Pt has neisseria meningitis meningitis. Best next step for infection control management?

A

Face mask because droplet precautions

526
Q

Acute abdomen pain. What do you do first ?

A

Supine and upright ab radiographs to look for air fluid levels (bowel obstruct) or free peritoneal air (perforated viscus)

527
Q

GI bleed of unknown origin, what can help you ID the source?

A

Upper endoscopy

1/3-2/3 soured of bleeds of obscure etiology are found in reach of upper endo

528
Q

When can you not use adenosine nuclear perfusion stress test?

A

Pts with asthma , bronchospastic dz

529
Q

When do you do ppx for cirrhotic pts for SBP? Med?

A

When hospitalized for gi bleed like varicies

Give IV ceftriaxone

530
Q

CRC screening methods

A

Annual home high-sensitivity FOBT, sampling two to three consecutive specimens, is a method recommended by the U.S. Preventive Services Task Force (USPSTF) for screening if the patient is willing to undergo colonoscopy if results are positive.

colonoscopy every 10 years

flexible sigmoidoscopy every 5 years combined with annual high-sensitivity FOBT every 3 years.

531
Q

SLE vs rosacea or seborrheic dermatitis

A

SLE - The nasolabial folds are relatively protected from the sun, and the absence of the rash in this area helps to distinguish it from other common rashes of the face, including rosacea and seborrheic dermatitis.

532
Q

In patients with trifascicular block, permanent pacer implantation is recommended for

A

intermittent third-degree atrioventricular block, type II second-degree atrioventricular block, and alternating bundle branch block.

A pacer is not indicated for asymptomatic trifascicular block.

533
Q

The “get up and go” test

A

Persons are timed in their ability to rise from a chair, walk 10 feet, turn, and then return to the chair.

Most adults can complete this task in 10 seconds,

most frail elderly persons, in 11 to 20 seconds.

Those requiring more than 20 seconds should undergo a fall evaluation.

534
Q

The most effective treatment for hepatorenal syndrome is

A

liver transplantation.

535
Q

secondary amenorrhea - 1st lab tests to do

A

Laboratory evaluation is first directed toward ovarian failure, hyperprolactinemia, and thyroid disease.

FSH (>20 = ovarian failure)
prolactin, thyroid-stimulating hormone, and free thyroxine (T4) levels are generally measured.

536
Q

Septic arthritis usually has leukocyte counts

A

greater than 50,000/µL (50 × 109/L) and a predominance of polymorphonuclear cells.

537
Q

Venous stasis vs cellulitis

A

Bilateral involvement, absence of fever or leukocytosis, hyperpigmentation due to hemosiderin deposition, and minimal pain help distinguish venous stasis dermatitis from cellulitis.

538
Q

What is the peak expiratory flow rate for

  • mild
  • mod
  • severe
  • life threatening

Athsma attack? When do you admit?

A

Mild > 70% –> home

Mod 40-69% –> ER

Severe < 40% –> inpt

Life threatening < 25% –> inpt

539
Q

acute cholangitis vs acute cholecystitis

A

Patients with acute cholecystitis may have right upper quadrant pain and gallstones, but the bilirubin level is usually not greater than 2 mg/dL (34.2 µmol/L), and aminotransferase levels are normal.

540
Q

The four-point Centor criteria

A

\fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough

often used as a prediction rule in patients with suspected GABHS infection.

Patients with two Centor criteria have an intermediate probability for GABHS infection, and rapid streptococcal antigen testing (sensitivity of 88% and specificity of 94%) is a reasonable strategy for these patients.

Patients with 0 or 1 criterion have a low (<3%) probability of GABHS, and neither testing nor antibiotic treatment is recommended.

Antibiotics are not indicated for this patient before rapid streptococcal antigen testing is done to determine whether they are needed. If treatment is indicated, the antibiotic of choice is penicillin. Macrolide antibiotics and first- and second-generation cephalosporins are alternative choices for penicillin-allergic patients.

541
Q

Best test to evaluate infrequent syncope

A

implantable loop recorder

542
Q

The initial treatment in acute cocaine intoxicatino should include

A

sedation with lorazepam, administered intravenously or intramuscularly.

Intravenous fluids should be administered to establish adequate urine output for possible rhabdomyolysis, and an electrocardiogram should be obtained to assess for myocardial ischemia.

543
Q

When to start tx for gout?

A

Uric acid–lowering therapy typically is not initiated until a patient experiences two documented acute attacks.

544
Q

What tx help to prevent disease flares in gout associated with changes in uric acid levels and may need to be continued until therapeutic serum uric acid levels have been achieved.

A

Prophylactic colchicine, low-dose corticosteroids (10 mg/d or less), or nonsteroidal anti-inflammatory drugs (NSAIDs) initiated at least 1 week before beginning or adjusting the dose of uric acid–lowering therapy

545
Q

Polymyositis and dermatomyositis vs inclusion body myositis

A

IBM didn’t respond to steroids

Anti Jo1 in all

546
Q

What do you use to treat scleroderma renal crisis?

A

Acei

547
Q

Which thyroid cancers should use radioablation on?

A

Follicular

Papillary

548
Q

The primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of sudden cardiac death in the setting of heart failure is

A

left ventricular ejection fraction less than 35%

549
Q

Hemachromatosis susceptible to these organisms

A

VYL

Vibrio vulnificus
Yersinia
Listeria

550
Q

The primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of sudden cardiac death in the setting of heart failure is

A

left ventricular ejection fraction less than 35%

551
Q

Hemachromatosis susceptible to these organisms

A

VYL

Vibrio vulnificus
Yersinia
Listeria

552
Q

What kind of tachy is WPW?

A

Atrioventricular reentrant tachy

553
Q

Zoster vaccine is indicated in

A

all patients age 60 years and older without contraindications, regardless of history of prior varicella infection.

The vaccine is more efficacious in preventing herpes zoster among adults 60 to 69 years of age than among those 70 years or older. On the other hand, the vaccine prevents postherpetic neuralgia to a greater extent among adults aged 70 years or more.

A reported history of possible herpes zoster is not a contraindication to vaccination.

554
Q

Septic shock

A

A subset of severe sepsis, defined as sepsis-induced hypotension despite adequate fluid resuscitation plus the presence of perfusion abnormalities. Patients receiving inotropic or vasopressor agents may no longer be hypotensive by the time they develop hypoperfusion abnormalities or organ dysfunction; however, they would still be considered to have septic shock

555
Q

Severe sepsis

A

Sepsis associated with organ dysfunction, hypoperfusion, or hypotension.

556
Q

Most patients with vertebral osteomyelitis have

A

back or neck pain that gradually worsens over weeks or months;

fever is present in only 50% of patients

leukocytosis is typically absent,

the erythrocyte sedimentation rate is often greater that 100 mm/h.

Always get blood cx and MRI imaging first.
Blood cultures are positive in 75% of patients with vertebral osteomyelitis

Then can start abx if infected and know organism

557
Q

Sinoatrial node dysfunction .

A

comprises a collection of pathologic findings that result in bradycardia.

These include sinus arrest, sinus exit block, and sinus bradycardia.

Approximately 50% of patients with sinoatrial node dysfunction also have associated supraventricular tachycardia, most often atrial fibrillation or atrial flutter

558
Q

Most patients with vertebral osteomyelitis have

A

back or neck pain that gradually worsens over weeks or months;

fever is present in only 50% of patients

leukocytosis is typically absent,

the erythrocyte sedimentation rate is often greater that 100 mm/h.

Always get blood cx and MRI imaging first.

Then can start abx if infected and know organism

559
Q

Coronary calcium testing may be considered in

A

asymptomatic persons with a 10% to 20% Framingham 10-year risk category (intermediate risk) and in young persons with a strong family history of premature cardiovascular disease.

560
Q

Pheochromocytoma classic sx

A

classic triad of sudden severe headaches, diaphoresis, and palpitations carries a high degree of specificity (94%) and sensitivity (91%) for pheochromocytoma in hypertensive patients

561
Q

Coarctation of teh aorta can ave murmurs in theback - how?

A

The systolic and diastolic murmurs noted over the back are related to collateral vessels, which also cause the sign of rib notching, seen on this patient’s chest radiograph on the inferior surface of the posterior upper thoracic ribs bilaterally.

562
Q

Pheochromocytoma classic sx

A

classic triad of sudden severe headaches, diaphoresis, and palpitations carries a high degree of specificity (94%) and sensitivity (91%) for pheochromocytoma in hypertensive patients

563
Q

In considering surgical treatment for patients with back pain from radiculopathy or spinal stenosis, guidelines recommend referring patients after

A

a minimum of 3 months to 2 years of failed nonsurgical interventions.

Failure is defined as progressive neurologic deficits and severe pain that is not responsive to conservative treatment

564
Q

GERD diagnosis

A

Endoscopy if GERD sx + alarm sx (dysphagia)

Response to empiric treatment with a proton pump inhibitor such as omeprazole would be sufficiently sensitive and specific to diagnose GERD

Testing for H. pylori is not indicated for patients with GERD, because the presence or absence of H. pylori does not correlate with the presence or absence of GERD or guide therapy.

Ambulatory esophageal pH monitoring is the gold standard for diagnosing GERD and is typically used in patients in whom the diagnosis is uncertain or who are unresponsive to empiric therapy.

565
Q

The diagnosis of diabetic ketoacidosis is based on

A

a blood glucose level greater than 250 mg/dL (13.9 mmol/L),

anion gap metabolic acidosis (arterial pH <7.30),

a serum carbon dioxide level less than 15 meq/L (15 mmol/L),

positive serum or urine ketone concentrations.

566
Q

GERD diagnosis

A

Endoscopy if GERD sx + alarm sx (dysphagia)

Response to empiric treatment with a proton pump inhibitor such as omeprazole would be sufficiently sensitive and specific to diagnose GERD

Testing for H. pylori is not indicated for patients with GERD, because the presence or absence of H. pylori does not correlate with the presence or absence of GERD or guide therapy.

Ambulatory esophageal pH monitoring is the gold standard for diagnosing GERD and is typically used in patients in whom the diagnosis is uncertain or who are unresponsive to empiric therapy.

567
Q

Diagnose spinal cord compression due to bone metastases with

A

MRI scan.

Radionuclide bone scanning is very sensitive for detecting bone metastases and has the advantage of visualizing the entire skeleton, but it has a high false-positive rate and provides no information about thecal sac compression.

568
Q

the primary cause of morbidity in patients with systemic sclerosis;

A

Pulmonary disease

PAH is among the most common manifestations of lung involvement in these patients
Pulmonary function studies in patients with PAH usually reveal an isolated decreased DLCO in the setting of normal airflow and lung volumes

569
Q

Cervicitis

A

is the presence of a mucopurulent cervical discharge or endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Cervicitis is commonly caused by either gonorrhea or chlamydial infection,

570
Q

the primary cause of morbidity in patients with systemic sclerosis;

A

Pulmonary disease

PAH is among the most common manifestations of lung involvement in these patients

571
Q

Routinely screen sexually active women under the age of 25 years for

A

chlamydia, gonorrhea, and HIV

572
Q

Treat acute sinusitis with

A

symptomatic measures
Most cases of acute sinusitis are caused by a virus

NO abx unless:
symptoms lasting longer than 7 days,
facial pain,
purulent nasal discharge.

The data as a whole suggest that if antibiotics are to be used, amoxicillin or doxycycline are adequate first-line agents.

573
Q

Routinely screen sexually active women under the age of 25 years for

A

chlamydia, gonorrhea, and HIV

574
Q

Which is worse, ingesting alkali or acidic solutions on your esophagus?

A

Alkali

  • causes liquefactive necrosis TRANSMURALLY

acidic is only on the surface

575
Q

Smoking cessation is associated with

A

a decreased rate of decline in lung function.

Improved lung function

576
Q

What do you measure on ppd?

A

The induration—not the erythema—resulting within 48 to 72 hours is then measured.

577
Q

stage 2 hypertension

A

systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg

recommend initiating treatment with two medications in patients with stage 2 hypertension or those whose blood pressure is greater than 20 mm Hg systolic or 10 mm Hg diastolic above target. Low-dose hydrochlorothiazide and an angiotensin-converting enzyme (ACE) inhibitor

578
Q

What do you measure on ppd?

A

The induration—not the erythema—resulting within 48 to 72 hours is then measured.

579
Q

Ischemic colitis

A

older than 60 years and usually present with left lower quadrant pain, urgent defecation, and red or maroon rectal bleeding that does not require transfusion

Colonoscopic findings are generally segmental and include hemorrhagic nodules, linear and circumferential ulceration, and gangrene

vs mesenteric ischemia - in SI!
- Severe abdominal pain is almost invariably present, but early physical examination findings are minimal, illustrating the classic teaching of “pain out of proportion to examination.”

580
Q

Acute small bowel (mesenteric) ischemia

A

should be suspected in patients who have risk factors for embolism or thrombosis and who present with sudden-onset, severe abdominal pain that, in the early stage, is out of proportion to the physical examination findings

581
Q

Ischemic colitis is

A

due to a temporary interruption in mesenteric blood flow and typically occurs in older individuals with significant cardiac and peripheral vascular disease; patients present with abdominal pain.

582
Q

Fitz Hugh Curtis syndrome

A

RUQ pain and pelvic adenexal tenderness

Gonococcal perihepatitis

583
Q

To confirm that an elevated ALP is of liver origin,

A

measure other bile duct enzymes (γ-glutamyl transpeptidase, 5’-nucleotidase)

584
Q

ALP indicates

A

cholestatic disease

Surgery (12 decks)

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