Medicine Shelf Exam Flashcards
Goodpastures Disease
Young adult male, nephritic proteinuria, acute renal failure, urinary sediment w/ dysmorphic RBC.
Caused by Antibodies to alpha-3 chain of type IV collagen in alveolar and glomerular basement membranes. LUNG AND RENAL SXS, hemoptysis
Renal biopsy shoes linear IgG deposition along BM. Systemic sxs uncommon.
Pneumocystic pneumonia
PCP – HIV w/ CD4
Which electrolyte needs to be corrected in alcoholics in order to successfully fix hypokalemia?
Magnesium
Sxs of hypophosphatemia
weakness, rhabdo, paresthesias, respiratory failure
Common electrolyte abnormalities in alcoholics
low K low Mg, low hosphate. Hypomag causes refractory hypoK.
Complications of PEEP?
Alveolar damage, tension pneumo, hypotension when high pressure applied.
What is atelectasis?
all or part of a lung becomes airless/ collapes
Organisms implicated in epiglottitis?
H flu and Strep pyogenes (GAS)
What is a hazard ratio?
ratio of event rate occurring in treatment arm versus non treatment arm. Ratio less than one means tx arm had lower event rate.
What is factorial design study?
Two or more experimental interventions each w/ two or more variables studied independently.
Most common side effect of radioiodine therapy for graves?
Hypothyroidism. Like 80 percent get it.
Also worsening opthalmopathy is bad too. Can be prevented w/ corticosteroid tx before and after.
tx for stable chronic angina?
Beta blocker FIRST LINE - reduce myocardial oxygen demand
Ca blocker can combine w/ beta blocker if angina persists. Causes peripheral and coronary vasodilation.
Nitrates; ACUTE
Pr
Preventive tx w/ angina?
aspirin, statin, smoking cessation, BP and DM control, exercise weight loss
Conditions associated w/ Erythema Nodosum?
Recent strep infx, sarcoidosis, TB, histoplasmosis, IBD. Sarcoid most common in AA women.
What is erythema nodosum?
painful subQ nodule on anterior surface of lower legs
Things associated w/ sarcoidosis?
Cough arthritis, uveitis, hilar adenoathy, and erythema nodosum (shin lesions)
What is thyrotoxicosis?
increased thyroid hormone w/ suppressed TSH, radioactive iodine uptake in nodule. Toxic adenoma
What causes molluscum?
poxvirus. Usually skin colored papules w/ central pit
How do viral URI and influenza present differently?
Flu usually starts abruptly, URI is stepwise. Flu has myalgias, posssible fever, HA.
Nitroglycerin MOA?
Dilation of veins (capacitance vessels) this decreases preload and decrease heart size, decrease oxygen requirement of the heart. Can alsy dilate arteries but less significant for anginal pain.
sxs of zinc deficiency?
aloecia, abnormal taste, bullous, pustulous leasions surrounding body orifices or extremities, impaired wound healing
Celiac sxs?
diarrhea, weight loss, fatigue, can lead to malabsorption of vitamin D, K , B12, folate, calcium, zing
vitamin a deficiency?
blindness, dry skin, imaired immunity
sxs of selenium deficiency?
cardiomyopathy
Likely complication of GCA?
Aortic aneurysm
Sxs of GCA?
headache, jaw claudication, muscle fatigue / polymyalgia, visual disturbance. high ESR
Important causes of membranous glomerulonephritis?
hep B, C, syphilis, gold, penicillamine, SLE, rheumatoid arthritis
Management of acute COPD exacerbation?
Oxygen, albuterol/ipratropium, IV steroids, Abx if >1 cardinal symptom, NPPV for severe, intubation if necessary
Cardinal sxs of COPD exacerbation
Increased dyspnea, increased cough, increased sputum production (change in color/volume)
what’s cromolyn?
mast cell stabilizer (prevents histamine release and leukotrienes) used for asthma.
Salmeterol?
long acting beta two agonist used in maintenance therapy of COPD, not for acute exacerbation.
Tropical sprue?
chronic diarrheal illness, malabs of nutrients esp B12 and folate, metaloblastic anemia. Fatty diarrhea, cramps, gas, fatigue, weight loss. small intestine biopsy shows villus blunting and infiltration of chronic inflammatory cells, lymphocytes, plasma cells, eosinophils.
epidermal inclusion cyst?
benign nodule w/ normal epidermis that produces keratin. It’s hard. May develop inflammation w/ rupture and involvement or surrounding tissue.
Dx: cliically, dome shapped, firm, movable cyst/nodule w/ central unctum (pore like opening). Some can have discharge. Some can resolve spontaneously. `
dermatofibroma?
benign fibroblast proliferation, firm, hyperpigented nodule on lower extremities. Have “dimple” or “buttonhole sign” when pinched.
Management of STEMI?
nitrates (caution w/ hypotension, RV infarction, severe aortic stenosis)
antiplatelets
anticoag
beta blockers – contraindicated in overt heart failure
Prompt reperfusion with PCI
Statin ASAP
Imipramine / amytriptiline overdose? (TCA)
Has anticholinergic effects, can cause sinus brady/hypotension, prolonged intervals., anticicholinergic toxicity (hyperthermia, dilated pupils, cardiac toxicity.) risk of vtach 2/2 widening QRS.
Imipramine/amitryptiline overdose (TCA) treatment
Bicarb - given if QRS is widened >100 ms give sodium bicarbonate, increases serum pH and extracellular sodium. Increased pH decreases drug avidity for sodium channels
Salicylate / aspirin overdose tx:
urine alkalinization w/ sodium bicarb to increase asirin excretion
Isolated systolic HTN
usually in elderly, 2/2 decreased elasticity of artery wall. Tx: thiazide, ACE I, or long acting calcium channel blocker for initial tx.
Most common head/neck cancer?
Squamous cell carcinoma. Hard unilateral LN. Biopsy stat.
lymph nodes most often affected in EBV?
posterior cervical chain
EKG of afib?
Absent P wave, replaced by tiny fibrillatory waves, irregularly irregular R-R interval, and narrow QRS. The pulmonary veins are most frequent location of ectopic foci that cause AF. Can ablate the tissue around PV
WPW syndrome causes?
accessory atrioventricular bypass tract can cause reentrant loop pattern and AVRT. Will see delta waves on WPW.
AVnRT caused by?
reentrant circuit formed by two separate conducting pathways (one fast and one slow) in the AV node. Characterized by sudden onset/stop, 10-250 /min, regular, no p waves to be discerned.
Most common cause of A flutter?
reentrant circuit around tricuspid annulus, “cavotricuspid isthmus”. Rapid sawtooth waves on EKG.
bad things w/ Lyme disease
Carditis (AV block) Neuro: cranial nerve palsy, esp VII Muscles: arhtralgia conjunctivitis Skin Adenopathy Long term: Encephalomyelitis, peripheral nueropathy
disseminated gonorrhea sxs
vesculopustular dermatitis, reactive arhtiritis, migratory asymmetric polyarhtralgia. Rash rarely involves face
recommended vaccines for chronic liver dz
Td q 10 years (give one Tdap?), flu annual, pneumo PPSV23 once then follow w/ PCV13 and PPSV23 at age 65, Hep A, and Hep B
risk factors for avascular necrosis
steroids, alcohol, lupus, APA, hemoglobinopathies, infx, renal transplant.
Groin pain w/ weight bearing, worse on hip abduction and internal rotation. Normal ESR/CRP. MRI most sensiive
Babesiosis?
caused by tick bite w/ babesia. Northeast US. Enters RBC and causes hemolysis. Leads to jaundice, hemoglobinuria, renal failure, etc. No rash. Giemsa stain can dx. Use: quinine clinda and atovaquone-azithro.
Ehrlichiosis?
Spotless rocky mountain spotted fever, tick borne. Leukopenia and thrombocytopenia, fever/malaise, HA, N/V.
Q fever?
zoonosis, caused by coxiella burnetii. Infected by cattle/goat/sheep usually in meat workers and fets. flu, hepatitis, pneumo
Lynch syndrome?
Hereditary non-polyposisi colorectal cancer (HNPCC). Risk for colon cancer and endometrial carcinoma
Diffuse esophageal spasms / motility disorders, sxs & tx
spontaneous pain, odynophagia for cold and hot food. Nitroglycerin helps. Nitrates relax the esophagus! Dx w/ esophageal manometry showing non-peristaltic high amplitude contractions.
amlodipine
calcium channel blocker (norvasc) used for tx of HTN
Secondary adrenal insufficiency, cause & sxs
Usually chronic steroid therapy. Cortisol is down, ACTH is down, aldo is normal. No hyperpigmentation or hyperkalemia. Possible hypontatremia
Primary adrenal insufficiency
Autoimmune, causes low cortisol and aldo, elevated ACTH. Causes severe sxs, hyperpigmentation, hyperkalemia, hyponatremia, hypotension.
Aldo deficiency can cause sodium wasting and lead to hyponatremia.
Coccidiomycosis?
Southwest US (think Arizona, California), central/south america. Primay pulmonary infection. Cutaneous findings of erythema multiforme and erythema nodosum, arthralgias.
Blastomycosis
south and north central US. Lungs, skin, bone, joint, and prostate involvement. Rare in immunocompetent
Invasive aspergillosis
happens in immunocompromised(on immune modulating therapies, AIDS), invasive pulmonary disease p/w fever, cough, dyspnea, hemoptysis. Cavitary lesions on chest x ray. CT shows pul mondules w/ halo sign or air crescent
Sporotrichosis
Subcutaneous skin infection
Cryptococcus
Meningoencephalitis in HIV patients w/ CD4 pulmonary phase –> meningoencephalitis.
Diabetes insipidus
Central: decreased ADH from pituitary, or
nephrogenic (normal ADH w/ renal ADH resistance.) Central DI patients have problem w/ thirst and have high serum sodium >150. Nephrogenic DI can have intact thirst w/ lower sodium. ~145
Desmopressin to distinguish between nephrogenic vs. central. Central will cause ADH release and urine will concentrate. If nephrogenic won’t help. . Tx w/ intranasal desmopressin.
Primary polydipsia
Person just wants to drink a tons of water for no good reason. Intact ADH, ability to concentrate urine but just drinks too much.
Treatment for SIADH?
Demeclocycline –> inhibits ADH mediated aquaporin insertion in collecting tubule to help dilute urine.
Treatment for nephrogenic DI?
hydrochlorothiazide. Increases proximal water and sodium resorption
Ulcerative colitis features (colonic + extracolonic)
20’s/30’s, bloody diarrhea, lower abd pain, tenesmus. Skin findings like erythema nodosum, pyoderma gangrenosum, arthritis, cholangitis. P-ANCA is positive. Arthritis is similar to ankylosing spondylitis (low back)
assAnkylosing spondy and IBD both associated with HLA-B27. +p-ANCA even though no vasculitis.
Whipple disease
multisystemic disease, caused by tropheryma whippelii, malabsorptive diarrhea, weight loss, skin hyperpigmentation, migratory arthritis, lymphadenopathy, fever. PAS+ small bowel biopsy
Celiac antibody findings
anti-endomysial and anti-transglutaminase. Characteristic cutaneous findings is dermatitis herpetiformis
primary aldosteronism sxs
hypokalemia, slight hypernatremia, hypertension w/ adrenal incidentaloma
pheochromocytoma sxs
elevated BP w/ tachy, pounding A, plapitation, diaphoresis, HTN w/ adrenal incidentaloma
high plasma aldo/renin ratio >20:1?
primary aldosteronism. Resistant HTN, hypokalemia.
urinary excretion of vanillylmandelic acid?
pheochromocytoma.
rib notching on x ray?
coarctation of aorta 2/2 enlarged collateral intercostal vessels
renovascular htn tip off:
diffuse athero, asymmetric kidney, recurrent flash pulm edema, elevation in Cr 30% from BL after ACE I or ARB. Abd bruit.
causes of esophagitis in HIV (painful swallowing, substernal burning)
candida, HSV (ovoid ulcers, vesicles), CMV (deep, linear ulcers), idiopathic
CMV mononucleosis
looks like mono, smells like mono, but heterophile AB negative and atypical lymphocytes w/ vacuolated appearance. Usually no pharyngitis or lymphadenopathy.
CLL pathology?
smudge cells and mature appearing small lymphocytes
Light’s criteria for exudative pleural effusion
protein/serum protein ratio >0.5
Pleural fluid LDH/serum LDH ratio >0.6
Pleural LDH > 2/3 of upper limit of normal for serum LDh
Causes of exudative effusion
infection, malignancy, PE, connective tissue disease, iatrogenic. Occurs 2/2 inflammation and increased capillary and pleural membrane pemeability or impaired lymph drainage of pleural space
Transudative pleural effusion
hypoalbuminemia and CHF, typically bilaterall/symmetrical and w/ few red or WBC.
acid base disturbance in PE?
respiratory alkalosis – hyperventilation as patient tries to overcome hypoxia and V/Q mismatch.
inflammatory, symmetric arthritis, quick resolution
viral arthritis, 2/2 parvo, hep, HIV, Mmumps and rubella etc. Can get positive RF and ANA.
Septic and crystalline arthritis sxs
monoarticular, usually the knee. use joint aspiration to differentiate
Rheumatoid arthritis
symmetric, inflammatory. Chronic, doesn’t resolve quickly
SLE arthritis
symmetric, inflammatory
Osteoarthritis
noninflammatory, no fever.
Sarcoid arthritis
polyarthritis, usually ankles/knees
Rubella sxs
Fever, conjunctivitis, coryza, cervical lymphadenopathy, FAST cephalocaudal spread of blanching erythematous maculopapular rash that spares hands/feet. Young women get arthralgias too. Dx w/ PCR and rubella seriology IgM IgG. Tx is supportive
rash of secondary syphilis
involves trunk and extremities, including palms and soles (not like rubella)
treatment of acne (comedonal, inflammatory, and nodular)
comedonal: topical retinoids, salicylic acid
inflammatory: topical retinoids, benzoyl perox, abx like erythro and clinda, severe oral abx
nodular: topical retinoid, benzoyl, oral abx if severe. if unresponsive severe, oral isotertinoin
gout prevention
lower alcohol is a big one, lower BMI, low fat diet, decrease seafood/red meat intake, vegie protein is good, avoid organ rich foods like liver, avoid beer and diuretics if possible. quit smoking
only use urate lowering meds for those w/ recurrence.
Causes of ILD
sarcoid, amyloid, alveolar proteinosis, vasculitis (eg wegeners), infx, occupational (silicon), connective tissue dz (SLE, scleroderma), idiopathic
PFT findings in ILD
Normal or increased FEV1/FVC ratio, decreased CO diffusion, decreased lung capacity, decreased residual volume. V/Q mismatch (restrictive lung pattern)
A-a gradient
difference between alveolar concentration of oxygen and arterial concentration. AA mismtch can happen in pulmonary fibrosis, but resting arterial blood gas may be normal or only mildly hypoxic
ILD pathophys
excessive collagen deposition in peri-alveolar tissue leading to decreased lung volume w/ preserved or increased FEV1/FVC ratio.
Calcium phosphate kidney stone
primary hyperparathyroid and RTA
Uric acid stone
dehydration, acidic urine
Cysteine stones
due to IEMs 2/2 increased cysteine excretion
struvite
proteus/klebs high ph urine w/ recurrent UTI
features and tx of 2ndary raynauds
2/2 connective tissue disease/occlusive vascular condition, hyperviscosity. Usually men >40, tissue injury/digital ulcers. Treat with CCB (nifedipine and amlodipine) and aspirin and treat underlying disorder.
send ANA and RF, ESR and complement levels
primary raynauds
no underlying cause, usually young women, negative ANA and ESR. CB for persisting sxs
antibodies in systemic sclerosis
ANA and antitopoisomerase-1
Buerger’s disease
aka thromboangitis obliterans, vasculitis that affects small and medium sized arteries of young smokers. P/w distal extremity ischemia, ulcers, gangrene. Usually diagnosed as exclusion after systemic dz have been ruled out.
type of cancer in distal esophagus?
adenocarcinoma, arises from Barrett. Risk factors include reflux, obesity. Sxs are CP, weight loss, dysphagia
Type of cancer anywhere in esophagus?
squamous cell carcinoma. RF include smoking alcohol and caustic injury.
ABG in COPD exacerbation?
resiratory acidosis and hypoxia. You’d be holding on to C2.
Bath salts
synthetic cathinones that are amphetamine analogs. Can cause people to go cray cray via inhibition of reuptake of NE dop and 5HT. Severe tgitation, combative, psychosis, delirium, myoclonus, seizures. Long duration. Do not show up on routine toxicology
severe MDMA intox
significant hyperthermia
PCP intox
psychomotor agitation, combative, low pain perception, hallucination, HTN tachy and nystagmus. Included in utox.
What’s a VIPoma?
rare tumor of pancreas, produces vasoacive intestinal peptide. Binds to intestinal epithelial cells to increase fluid/electrolyte secretion
Sxs of VIPoma
water diarrhea, low acid secretion, flushing, N/V, muscle cramps/weakness, hypokalemia!!!! hypercalcemia, hyperglycemia, abd CT shows pancreatic tail tumor. Lots of water loss = volume depletion
Can have hyperparathyroidism concurrently as part of multiple endcorine neoplasia (MEN)
VIPoma tx
IV volume repletion, octreotide to decrease diarrhea, possible hepatic resection in pts w/ mets
Carcinoid syndrome?
causes flushing, diarrhea, bronchospasm. Nearly 80% of carcinoid tumors occur in small intestine
Gastrinoma?
Can occur in a few places including pancreas. Cause increased gastrin release w/ multiple gastric ulcers and dyspepsia (Zollinger-Ellison syndrome).
med tx for diabetic neuropathy?
amytriptyline, gabapentin, NSAIDS (if kidney fnx in tact)
TCAs can worsen urinary sxs and cause orthostasis
Autosomal Dominant Polycystic Kidney Disease
hypertension, palpable masses, microhematturia. Intracranial berry aneurysms are common complications. Other complications include hepatic cysts, valvular heart disease, diverticula, hernias.
Cervical spondylosis
General term for degenerative changes in the neck. Causes chronic neck pain, limited rotation due to osteoarthritis and musce spasm. From osteophytes. Can cause hypertrophic vertebral bodies.
meds implicated in crystal induced kidney injury (tubular obstruction)
acyclovir, sulfonadmides, methotrexate, ethylene glycol, protease inhibitors (ex: HIV meds like ritonavir).
clinical fts of acute interstitial nephritis (AIN) and some associated meds that cause it
beta lactams, PPIs. Usually 7-10 days after exposure. Causes skin rash, eosinophilia, eosinophiliuria, pyrua
Addison’s disease
autoimmune destruction of adrenals. Low mineralcorticoids, leading to low aldo–> low Na2+ and thus retention of potassium leading to hyperK. Weight loss, N/V, abd pain, diarrhea, hyperpigmentation, low BP, vitiligo. In most cases hyperk is accompanied by mild hyperchloremic acidosis.
Etiology of primary adrenal insufficiency
autoimmune, infx like TB, HIV, fungal, hemorrhagic infarction, mets
clinical presentation of acute adrenal insufficiency
shock, abd tenderness, unexplained fever, N/V, weight loss, anorexia, hypoNa, hyperK, hyperCa, eosinophilia
clinical presentation of chronic adrenal insufficiency
fatigue, weakness, anorexia, GI, weight loss, hyperpigmentation or vitiligo, hypotension, hypona, hyperk, hyperca, anemia, eosinophilia.
low cortisol, high ACTH
primary adrenal insufficiency
extrapulmonary sites for TB
liver, spleen, kidney, bone, adrenal gland
causes of elevated anion gap metabolic acidosis
ketoacidosis (etoh, dm, starv), intox (methanol, salicylate, eth glycol, isoniazid, metformin) tissue hypoxia, renal failure
in hypoaldo, why do you get metabolic acidosis?
sodium losses while simultaneous retention of potassium/H+
Jarisch-Herxheimer rxn
can develop in tx of syphilis. When tx w/ penicillin, spirochetees die rapidly leading to release of antigen/ab complex in blood and consequent immunologic rxn which seems ike accute syphillis flar.
Two major side effects of isoniazid
peripheral neuropathy and hepatitis
diagnostic step in signs/sxs of adrenal insufficiency?
cosyntropin stimulation test w/ cortisol and ACTH levels. Can tell you primary vs secondary or tertiary.
what is cosyntropin?
ACTH synthetic analogue for pdiagnostic purposes in adrenal insufficiency
most important risk factor for bladder cancer?
psmoking
Positive predictive value:
proportion of subjects w/ positive test who actually have the disease.
PPV = TP/TP+FP
NPV= TN/TN+FN
Sxs of hyperthyroid
proximal muscle weakness, can cause myopathy. Fatigue, anxiety, tremor, weight loss, tachycardia.
medication for raising HDL and lowering triglycerides
niacin (nicotinic acid)
Echinococcosis
parasitic dz caused by tapeworm. Can cause liver cysts w/ daughter cysts. Majority associated w sheeps.
cause of Kaposi sarcoma
HHV8, . Brown macules found in HIV+ pts
dermatofibroma
dimple sign
cause of pyogenic spinal osteomyelitis
usually s. aureus, can also be G- bacilli. Can spread from UTI.
anion gap formula
sodium - bicarb - chloride
on mech ventilation, pO2 and pCO2 mostly affected by?
pO2: FiO2 and PEEP.
pCO2: RR and TV
Goal is maintain PO2 > 60. Early goals of ventilation are to decrease FiO2 to nontoxic levels
tx of echinococcus liver cyst
unlike E histolytica, these can be aspirated + albendazole.
E histolytica is metronidazole only.
Human monocyte ehrlichiosis
south east US, flu like illness w/ confusion
“RMSF w/out spots”
leukopenia and thrombocytopenia, elevated LFTs. dx w/ intracytoplasmic morulae in monocytes. give DOXYCYCLINE
medication that treats neurologic and cardiac Lyme
ceftriaxone
osteomalacia causes
malabsorption, intestinal bypass, celiac, liver and kidney disease
dx of osteomalacia
high alk phos and pth
slow calcium and phos, low urinary calcium
low vitamind D
paget’s disease
accelerated focal bone remodeling. normal ca/phos/pth, but markers of bone resorption high like c and n telopeptide, alk phos.
prolactinoma therapy
cabergoline or bromocriptine (dopamine agonist)
tx for hyperthyroid afib
beta blocker until you can control the hyperthyroidism
Trousseau’s syndrome
“migratory superficial thrombophlebitis”. Hypercoagulable disorder w/ unexplained superficial venous thrombi at unsual sites (arm, chest). Often accompanies an occult visceral malignancy. Often associated w/ pancreas cancer.
phenytoin deficiency*
folate. megaloblastic anemia!!
pancoast tumor?
usually non small cell lung cancer in superior pulmonary sulcus, can cause horners and compress the brachial plexu.
ring shaped lesions w/ scaly patches
tinea corporis, often trichophyton rubrun
salmon colored patches, silvery scale, peeling on extensor surfaces
psoriasis
secondary syphilis skin lesions?
maculopapulor, usually palms and soles
TCA overdose seizure tx
GABA agonist like benzo
tx for delerium 2/2 anticholinergics (ie atropine, diphenhydramine)?
physostigmine.
why are people hypercoagulable w/ nephrotic syndrome?
possible loss of antithrombin III in urine. Usually affects renal veins.
MI causes what kind of “immediate” arrhythmia most frequently? What kind of delayed?
immediate: ventricular reentry
delayed: abnormal automaticity
asystole?
complete absense of electrical or cardiac activity
pancreatic cancer sxs
painless jaundice, double duct sign on imaging. Causes back up of bile. Most pancreatic cancers in the head of the pancreas. Cancers in the body or tail present w/ pain but no jaundice.
causes of acute pancreatitis
I GET SMASHED Idiopathic, gall stones, ethanol, tumors, scorpion, microbiological, autoimmine (sle, polyarteritis nodosa, crohns) surgery or trauma hypertriglyceridemia emboli or ischemia drugs (azathioprine, abx, valproate, others)
tx w/ lots of fluids!!!
cardiac cath complications
livedo reticularis, AKI, pancreatitis, mesenteric ischemia
muddy brown casts
ATN
broad and waxy casts in urine
chronic renal failure 2/2 dilated tubules of enlarged nephrons
RBC casts
glomerularnephritis orr vasculitis
WBC casts
interstitial nephritis and pyelo
fatty casts in urine
nephrotic syndrome.
hyaline casts in urine
protein passing unchanged along UT, may be in in asymptomatic people w/ prerenal azotemia.
sxs of ASA overdose
respiratory alkalosis, then anion gap met acidosis. GI pain, tinnitus, fever, tachypnea, GI irritation
Winter’s formula
tells you if you have appropriate acid/base compesation, helps determine if there’s one process going on or multiple processes.
tx for tylenol overdose
ore than 7.5 grams, less than four hours, give charcoal and check levels. Any evidence of liver injury give N-acetylcystein and monitor for liver injury.
G6P dehydrogenase deficiency causes
bite cells w/ heinz bodies, hemolysis, sxs include pallor, jaundice or dark urine, abd pain
Holt Oram syndrome
upper limb defects (radius, carpal bones) and atrial septal defect. Means “hand-heart). Often w/ atrial septal defect can hear wide, fixed splitting of S2.
clinical findings of aortic dissection
can cause aortic regurge and diastolic murmur.
tx for graves
radioactive iodine therapy. contraindications are pregnancy and severe opthalmopathy
ulcerated pearly nodule w/ rolled border
basal cell carcinoma. most common in US.
four causes of diarrhea in AIDS patients
Lambert Eaton
paraneoplastic syndrome: proximal muscle weakness, autonomic dysfunction, CN involvement and diminished DTRs 2/2 cancer, usually lung cancer
dermatomyositis
can be a paraneoplastic syndrome, causes muscle fiber injury. Skin findings, esophageal dysmotility, symmetrical/proximal muscle weakness, ILD
3 paraneoplastic syndromes associated w/ lung cancer
dermatomyositis/polymyositis (muscle fiber)
Lambert eaton (presynaptic membrane calcium channels)
Myasthenia (acetylcholine receptor in postsynaptic membrane)
w/out a spleen, what’s impaired in the immune system?
phagocytosis (dendritic cells in the white pulp of spleen)
what’s impaired in chronic granulomatous disease?
x linked recessive, defect in NADPH oxidase
impairment in SCID?
number of circulating lymphocytes, usually AR defect in adenosine deaminase
BPH tx and their MOA
finasteride - five alpha reductase
tamulosin - alpha 1 blocker
COPD features
increased pulmonary complailnce due to loss of elastic tissue
airflow limitation w/ reduced inspiratory and expir. flow rates
hyperinflation leads to increased thoracic wall recoil and diaphragm flattening.
flat diaphragm causes increased WOB
narcolepsy treatment
methylphenidate
diverticulosis highly associated with?
constipation! Give them fiber.
what is prevalence?
incidence x time. You can have stable incidence w/ rising prevalence.
Ramsay Hunt syndrome
form of herpes zoster infx that causes bells palsy, vesicles seen on outer ear
do what if patient has likely DVT?
compression ultrasonography. If not, then do d dimer.
5 common viruses implicated in viral myocarditis?
coxsackie B, parvo, HHV6, adeno, entero
concentric cardiac hypertrophy caused by?
chronic pressure overload, like aortic stenosis or untreated HTN
eccentric cardiac hypertrophy due to?
chronic volume overload like valvular regurgitation.
cor pulmonale?
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signs/sxs of mixed essential cryoglobulinemia?
palpable purura, proteinuria, hematuria, arthralgias, hepatosplenomegaly, low complement. Related to HCV
SLE antibodies:
ANA, anti-DNA and Anti-Sm
microscopic polyangitis:
abd pain, hematuria, urinary sedient, purpura. Serology usually negative except ANCA, comlement normal
restrictive lung disease
low FEV1 but preserved ratio. This includes obesity and COPD. FVC is decreased below 80%
obstructive lung disease
asthma. Shows reversibility w/ broncho dilators (COPD does not show complete reversibility) DLCO in asthma is usually normal but increased in COPD. decreased FEV1/FVC ratio
colonoscopy frequency?
10 years unless polyps, then 3-5
DEXA screening?
women over sixty five, maybe younger if other risk factors for osteoporosis
Sjogren syndrome
autoimmune, women in their 5th/6th decade. Clinical findings include dry eyes and dry mouth, dental caries, dysphagia (lack normal amounts of saliva).
milk-alkali syndrome
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symptoms of hypercalcemia
polyuria, polydipsia, nausea, vomiting, constipation.
2ndar and Tertiary hyperparathyroid
pts w/ CKD have decreased renal Vitamin D production leading to low calcium, hyperphos, and compensatory PTH rise (secondary HPTH). Some will develop parathyroid hyperplasia w/ autonomus PTH production and resulting hypercalciemia (tertiary).
how can sarcoid cause hypercalcemia?
increases conversation of 25 vitamin D to 1, 25 in granulomatous tissue. Lymphoma can do this too. You’d see higher levels of 1,25 dihydroxy vitamin D
lupus nephritis sxs/signs
photosensitive skin, thrombocytopenia, glomerulonephritis w/ erythrocyte casts, proteinuria, HTN with low complement. Can also affect CNS, cause strokes/seizures, headaches.
positive ANA, anti-dsDNA, anti-sm. Immune inflammatory reaction activates complement system causing them to decrease.
Can also get nephrotic syndrome w/ out low complement.
signs of drug induced interstitial nephritis
WBC casts and eosinophiliuria. Fever, rash eosinophilia.
Granulomatosis w/ angiitis
commonly involves ear, nose, throag, pulm, can present sometimes w/ renal involvement and nephritic syndrome. Normal complement
hemolytic uremic syndrome
usually after infection w/ shigella or e coli. Present w/ schistocytes, low platelets, frenal failure, usually from thrombotic angiopathy. R
poststrep glomerulonephritis
HTN, acute renal failure, RBC casts in urine, low C3.
which hormone prevents endometrial hyperplasia
progestin
first line tx for PCOS
OCPs
first line tx for ovulation induction in PCOS
clomiphene citrate
when do we use spirinolactone in PCOS?
since it can cause low androgens in developing fetus, it shouldn’t be used in women of chilbearing age unless they have an OC contraindication.
how can you tell between exogenous vs endogenous insulin?
endogenous requires cleavage of peptide, so if someone is giving themselves insulin you won’t see any c peptide in the blood
clinical features of amyloidosis
Epidemiology: arhthritis (ex: RA), chronic infx like TB, osteo, bronciectasis), IBD (crohns), malignancy, vasculitis.
Clinical: nephrotic syndrome, cardiomyopathy, hepatomegaly, peripheral neurop, organ enlargement, bleeding diathesis, waxy thickening of skin. Dx w/ fat pad bx
treatment of amyloidosis (AA)
colchicine ( and underlying condition)
polycystic kidney disease present w/:
flank pain, hematuria, renal failure, HTN, large kidneys
MI vs PE can cause what on ekg?
MI: left BBB
PE: RBBB
what kinds of cancer do you see pericardial effusion?
mostly lung and lymphoma. Can cause tamponade
baker cyst
develop as a result of excessive fluid production by inflamed synovium, seen in RA, osteoarthritis, and cartilage tears. can be seen in popliteal bursa
digitalis toxicity causes what arrhythmia?
atrial tachycardia w/ AV block. Will also see inverted T waves.
first enzyme activated in aute pancreatitis
trypsin
most common cause of acute pancreatitis
alcohol and gallstones!`
periumbilical and flank hemorrhage?
think acute pancreatitis
reason for amylase to stay elevated after pancreatitis?
pancreatic pseudocyst
pancreatic adenocarcinoma risk factors
smoking, chronic pancreatitis. disease of the elderly.
can cause secondary diabetes if in tail/body.
also migratory thrombophlebitis
ca-19 9 is marker in blood
side effect of cholestyromine
cholesterol stones in GB - radiolucent
cholecystitis radiates where?
right scapula
what is porcelain gallbladder
appears on Xray as chronic cholescystitis
imaging of chronic pancreatitis
dystrophic calcification
increased risk for pancreatic carcinoma
ascending cholangitis usually caused by?
gram negative enteric bacteria
increased incidence w/ choledocholithiasis
gallbladder carcinoma
p/w cholecystitis in ELDERLY woman – poor prognosis. They usually get cholecystitis when younger so if they’re super old suspect cancer
extravascular hemolysis increases risk of what stones?
pigmented gallstones.
you’ll see lots of urobilinogen in DARK URINE
dubin johnson syndrome
conjugated bilirubin builds up in cell, deficiency of bilirubin canalicular trasnport. LIVER IS VERY DARK.
rotor syndrome similar, but liver not dark
obstructive jaundice sxs
dark urine (bilirubinuria), pale stool, pruritis (from bile acids building up), will also see hypercholesterolemia and xanthomas, steatorrhea w/ malabsorption of fat soluble vitamins.
viral hepatitis
inflammation of hepatocytes, increase in both direct and indirect bilirubin. Dark urin due to conjucated bilirubinemia. Urine urobilinogen will actually be normal or decreased.
viral hepatitis causes
Hep, EBV, CMV
acute hepatitis
jaundice (mixed CB and UCB) w/ dark urine (too much CB), fever, malaise, anusea.
Elevated ALT>AST,
chronic hepatitis
> 6 months
inflammation involves portal tracts. not much in the lobules.
Hep E/A
fecal oral, both acute, not chronic.
IgM - active. HEV in pregnant woman is associated w/ fmulminant hepatitis and liver failure. HEV commonly from water/seafood undercooked.
HBV
only 20% go on to be chronic
HbsAG key marker of infection. First marker to rise. If present for >6 months, defines chronic. IgM against core is high during acute phase. During window face, only IgM. Then IgG picks up. IgG surface antibody - protective. Envelope antigen –> can trasmit to other peol
Hep C
hep c RNA is marker of infection
hep D
requires HBV for infection.
Cirrhosis caused by what process
fibrosis mediated by stellate cell secreting TGF beta. Lie beneath endothelial cells that line sinusoids.
portal HTN causes
ascites, congestive splenomegaly/hypersplenism (can consume red cells and platelets), portosystemic shunts (caput medusae, for example), hepatorenal syndrome
decreased detox in hepatitis
AMS, asterixis, coma,
gynecomastia, spider angiomata and palmar erythema due to excess esttrogen
jaundice
Use which to follow coagulopathy
PT shows effect of cirrhosis
Alcohol related liver disease
damage of hepatic parenchuyma:
1) fatty liver (reversible!)
2) alcoholic hepatitis, chemical injury to hepatocytes seen w/ binge drinking (acetaldehyde). MALLORY BODIES. damaged IF in the hepatocytes.
Presentation of alcoholic hep
AST>ALT. Painful hepatomegaly, mitochondria causes AST elevation.
NAFLD
obesity, ALT>AST. Diagnosis of exclusion to make sure alcohol not involved.
Hemochromatosis
excess iron deposition in organs, hemosiderosis –> damage is called hemochromatosis. Damage mediated by generation of free radicals. Primary or secondary, mutations in HFE gene, C282Y.
In secondary - transfusion
presentation of hemochromatosis
cirrhosis, DM, bronze skin, cardiac arrhtyhmia, gonadal dysfunction
high ferritin, low TBC, high iron, high percent saturation
biopsy: brown pigment in hepatocytes. Use prussian blue stain, turns iron blue but won’t touch lipofuchsin
tx: phlebotomy
Wilson disease
can’t put copper into ceruloplasmin. Copper builds out in hepatocytes – leaks and goes into tissues. Presents in kids w/ cirrhosis, neurological manifestations like chorea, KF rings, tx w/ D penicillamine
labs of wilson disease
high urine copper
low serum ceruloplasmin
PBC
autoimmune. granulomatous destruction of intrahepatic bile duct, avg age forty
mostly in women
antimitochondrial antibody
obstrctive jaundice, cirrhosis
PSC
inflammation and fibrosis of intranepatic and extrahepatic bile ducts
periductal fibrosis/onion skin
p-ANCA positive, associated with ulcerative colitis.
presentation of PSC
obsrucive jaundice
cirrhosis, increased risk for cholangiocarcionma
Reye syndrome
fulminant liver failure and encephalopathy in kids w/ viral illness who take aspirin, causes mitochondrial damage of hepatocytes
hypoglycemia high liver enzymes, NV, may progress to coma/death.
HOWEVER you SHOULD give aspirin in Kawasaki’s!
Hepatic adenoma
Benign hepatocyte, associated w/ OCP use, resolves if you stop. Risk of rupture and intraperitoneal hemmorage expecially during pregnancy
risk factors for HCC
chronic hep, cirrhosis, aflatoxins derived from aspergillus. induce p53 mutation.
increased risk for budd-chiari syndrome. Thrombosis of hepatic vein, leads to necrotic damage of the liver
serum tumor marker: alpha fetoprotein
mets to liver
colon, pancreas, lung, breast. Multiple nodules in liver, hepatomegaly w nodular free edge.
Pituitary adenoma
functional if produces hormones,
bitemporal hemianopsia, hypopituitarism if nonfunctional bcaus it presses on it, headache.
functional: most common is
prolactinoma
prolactinoma. low libido, HA, milk, inhibits GNRH so you don’t get LH/FSH so you get amenorrhea in women. Bros don’t get milk but they get gynecomastia.
treat w/ dopamin agonist. like bromocriptine.or surgery
GH adenoma
giganitism in kids, acromegaly in adults. secondary diabetes is often present . Growth of tongue and heart. can die from cardiac problems.
Dx: elevated GH and IGF-1. Oral glucose does not suppress GH release
Tx: octreotide. somatostatin analog, blocks response of AP to GHRH
cause of hypopituitary
apoplexy - bleeding into pituitary.
crangiopharyngioma in kids.
sheehan -
sheehan
pregnancy ; gland doubles and is susceptible to infarction if lose too much blood.
poor lactation and loss of pubic hair - sheehan
empty sella
leakage of CSF into the sella is one mechanism, causing pressure on the pituitary sitting in there and damages it.
Nephrotic syndrome in lymphoma?
Minimal change disease
Nephrotic syndrome in most malignancies?
Membranous nephropathy
Also NSAIDs SLE and hep b
Crescentic glomerular disease
AlKI hematuria hypertension
Associated with autoimmune disease
A few Causes of hypoK
Increased aldosterone activity
Beta agonists
Low blood pH
Insulin
pH of normal pleural fluid vs transudative vs exudative
normal: 7.6
trans: 7.4-7.55
exud: 7.3-7.45
signs of massive PE
JVD, hhypotension, RBBB
Leukocyte alkaline phosphate score
Differentiates between CML and leukemoid reaction. Will be low in CML because neutrophils are abnormal
Obstructive lung disease characteristics
low FEV1/FVC
if increased FEV1 after bronchodilators, it’s asthma. If no change it’s COPD
will also see elevated residual volume in COPD
Elevated in thalassemia?
HbA2
signs of marijuana intox
dry mouth, red eyes, increased appetite, tachy
signs of massive PE
JVD, hhypotension, RBBB
clinical features of scleroderma
fatigue, joint pain/stiffness
skin: telangiectasia, digital ulcers, raynaud
GI: dysphagia, gi bleed, dyspepsia, loss of smooth muscle to fibrosis
Pulm: Pulm fibrosis, arterial hypertension
renal crisis
thrombocytopenia
cardiac: myocarditis, pericarditis
Obstructive lung disease characteristics
low FEV1/FVC
if increased FEV1 after bronchodilators, it’s asthma. If no change it’s COPD
GI probs in HIV patients
cryptosporidium, MAC (in CD4
signs of cocaine intox
dilated pupils, tachy, euophoria, alertness, vigilance. Cocaine w/drawal associated w/ increased appetite
clinical features of scleroderma
fatigue, joint pain/stiffness
skin: telangiectasia, digital ulcers, raynaud
GI: dysphagia, gi bleed, dyspepsia, loss of smooth muscle to fibrosis
Pulm: Pulm fibrosis, arterial hypertension
renal crisis
thrombocytopenia
cardiac: myocarditis, pericarditis
achalasia:
dysphagia and regurtitation of undigested food due to aperistalsis in the distal esophagus.
GI probs in HIV patients
cryptosporidium, MAC (in CD4
sxs of primary adrenal insufficiency
pigmented skin, low BP, hyponatremia, hyperkalemia.
hyperchloremic acidosis
- elevated ACTH stimulates melanocytes causing hyperpigmentation
staph aureus food poisoning?
dairy, salad, meat, eggs. N/V, diarrhea,abd pain. Due to preformed toxin so it’s quick after ingestion
sleep disorder characterized by inability to stay awake in the evening (after like 7 pm)
advanced sleep phase disorder
de quervain tenosynovitis
classically affects no meothers holding their infants with the thumb outstretched, causes inflammation to APL and EPB tendons as they pass through radial styloid process
sxs of primary adrenal insufficiency
pigmented skin, low BP, hyponatremia, hyperkalemia.
hyperchloremic acidosis
- elevated ACTH stimulates melanocytes causing hyperpigmentation
four complications of acute pancreatitis
pleural effusion
ileus
ARDS
pancreatic pseudocyst/abscess
they get some relief when they lean forwards
formula for anion gap
sodium - bicarb - chloride
presbycusis
sensorineural hearing loss of old age
signs of tmponade
JVD, low voltage QRS, enlarged cardiac silhouette, hypotension
otosclerosis
chronic conducive hearing loss associated w/ bony overgrowth of the stapes
cause of leukemoid rxn
severe infection. Causes leuks>50K, metamyelocytes>myelocytes (more mature), no absolute basophiolia.
CML has way higher leuks, low LAP score, and more metamyelocytes than myelocytes (less mature). Also has absolute basophilia, whereas leukemoid does not.
signs of tmponade
JVD, low voltage QRS, enlarged cardiac silhouette, hypotension
LH/FSH levels in prolactinoma?
low! They get suppressed, so then you get low too.
cause of leukemoid rxn
severe infection. Causes leuks>50K, metamyelocytes>myelocytes (more mature), no absolute basophiolia.
CML has way higher leuks, low LAP score, and more metamyelocytes than myelocytes (less mature). Also has absolute basophilia, whereas leukemoid does not.
what are LATE neutrophil precursors?
bands, metamyelocytes.
Myelocytes and promyelocytes are younger/less mature.
cells involved in severe drug rxn?
often basophils and mast cells
main substrates for gluconeogenesis?
amino acids, lactate, glycerol 3-phosphate (from fat). Alanine is major gluconeogenic aa in the liver and is converted to pyruvate.
hemobilia
bleeding in the biliary tree, uncommon cause of GI hemorrhage. Usually after abd trauma or surgery
holosystolic murmur at apex w/ radiation to axilla?
mitral regurge
common clinical features include exertional dyspnea, fatigue, a fib, and heart failure signs
main substrates for gluconeogenesis?
amino acids, lactate, glycerol 3-phosphate (from fat). Alanine is major gluconeogenic aa in the liver and is converted to pyruvate.
treatment for anorexia in cancer
progesterone analogues like megestrol acetate.
holosystolic murmur at apex w/ radiation to axilla?
mitral regurge
common clinical features include exertional dyspnea, fatigue, a fib, and heart failure signs
