Missed Questions Flashcards
Causes of diarrhea in HIV patient (4primary)
cryptosporidium (<180) - severe watery diarrhea
Microsporidium (<100), fever is rare
MAC (<50) - high fevers
CMV (<50) cause of colitis, bloody diarrhea, tx: ganciclovir, ocular exam for concurrent retinitis
Ehrlichiosis
suspect when pt from an endemic region (southeast/southcentral US) with a history of a tick bite, febrile illness w/systemic sx, AMS, leukopenia, and/or thrombocytopenia, elevated AST. Rash uncommon, TOC is doxycycline empirical while confirmatory test done
“rocky mountain spotted fever without spots”
Primary hyperthyroidism, causes and one way to distinguish
Causes:
- Overproduction of thyroid hormone: graves, toxic nodular goiter…
- release of preformed hormone: painless thyroiditis, subacute thyroiditis…
Etiologies can be distinguished using radioactive iodine uptake scintigraphy (RAIU)
when there is hormone overproduction, RAIU is increased!
When it is due to preformed hormone, RAIU is low/undetectable
Painless thyroiditis
associated with thyroid peroxidase autoantibodies, considered a variant of chronic lymphocytic/Hashimoto thyroiditis
Similar to postpartum thyroiditis but by def excludes pt within a year of preg
tx: self-limited thus doesn’t req meds, but can treat symptoms ie) adrenergic overstimulation with beta blockers
EKG changes that would point to pericardial effusion
most specifically sinus tachy, electrical alternans;
others: low voltage
EKG changes that would point to pericarditis
diffuse ST elevation with exception of AVR depression and/or PR depression
Amphetamine intox
commonly exhibit prominent psychi sx ie) agitation, irritability, psychosis (w/ or w/out delirium). Can also experience CP or palpitations, tachy, HTN, diaphoresis, MYDRASIS. other complications, cardiac arrhymthias, seizures, hyperthermia, intracerebral hemorrhage
*decongestant pseudoephedrine and antiD bupropion, and selegiline can cause false positive for amphematimes on urine tox
How do you distinguish Lichen Sclerosis from vuvlovaginal atroph due to low estrogen?
LS is distinguished dt the presence of white plaques and severe retractions/loss of normal anatomical landmarks of the vulva (eg clitoral hood, labia minor, introitus) and possibly perianal region but not the vagina
Patho of true exophthalmos in Graves:
due to T cell activation and stimulation of orbital fibroblast and adipocytes by thyrotropin R autoantibodies, resulting in orbital tissue expansion an d lymphatic infiltration
What medication could cause seizures if abruptly discontinued?
Alprazolam/xanax is a short acting benzo, likely to result in seziures following abrupt discontinuation.
bc of short half life, sx can appear as early as 24hrs after cessation and can include seizures tremors, anxiety, perceptual disturbances and psychosis
Describe cystic teratoma:
Dermoid ovarian cyst, common bengin germ cell tumor that occurs in premenopausal women. Cyst contents include sebaceous fluid, hair and teeth. adnexal fullness on routine physical exam in an otherwise asympto pt is common pres.
US findings: hyperechoic nodules and calcifications in dermoid cyst are typically diagnostic.
Tx: surgical removal
Risk for ovarian torsion, suspect if pt is having pelvic pain with known ovarian mass; higher likelihood than other massess; typically don’t rupture vs other.
Describe follicular cyst:
when do they typically occur?
describe US
small phsiologic cyst that occur in the first half of the menstrual cycle and are typically asx.
US: simple small, thin-walled cyst rather than a large adneal mass with calcifications
Describe a theca lutein cyst-
when do they typically occur?
describe the US
typically form due to ovarian stimulation by high bhCG levels (molar preg) and resolve after these decline.
US: multiseptated bilateral cystic masses and do not have calcifications or hyperechoic nodules.
*do not present outside of preg
Describe sx of trochanteric bursitis
Trochanteric bursitis is inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur’s greater trochanter. excessive frictional forces secondary to overuse, trauma, joint crystals or infection are responsible
superficial unilateral hip pain that is exacerbated by external pressure to the upper lateral thigh (ie-lying on the affected side), usually seen in middle-aged adults
Catatonia:
Syndrome (not specific disorder) of marked psychomotor disturbance that occurs in severely ill patients with mood disorders with psychotic features, psychotic disorders, autism spectrum and some medical conditions (infectious, metabolic, neurologic, rhematalogic)
Common features: dec motor activity, lack of responsiveness during interview, posturing. Can range from stupor to marked agitation (catatonic excitment).
tx: Benzodiazepines and/or ECT
Lorazepam challenge test (1-2 mgIV) resulting in partial, temporary relief within 5-10 min confirms diagnosis.
What are some complications of primary sclerosing cholangitis/cirrhosis? (3)
Malabsorption especially of fat-soluble vitamins (deficiencies), metabolic bone disease (osteoporosis, osteomalacia with NORMAL calcium and vit D levels, etiology is unclear), hepatocellular carcinoma
What are variable decelerations on fetal heart tracing and what can cause them?
Variable decels are ABRUBPT (<30sec to nadir) decelerations of fetal heart rate, followed by a rapid return to baseline, duration last from 15sec to 2min, occurance is variable in relation to contractions.
Causes:
Cord compression (sometimes occurs after AROM)
Oligohydraminos
cord prolapse (sometimes cord can be seen on exam)
What effect can TB have on the adrenal glands?
TB can disseminiate to the adrenal glands and cause primary adrenal insufficiency.
Pt can develop fatigue, weakness, borderline hypotension and electrolyte abnormalities.
this is due to the fact that adrenal glands typically secrete cortisol, adrenal sex hormones and aldosterone. Dec aldosterone causes the kidney to inappropriately lose sodium while retaining excessive potassium and hydrogen ions -> normal gap hyperkalemia, hyponatremic metabolic acidosis
Chronic prostatitis/chronic pelvic pain syndrome:
chronic pelvic pain (perineum, testes, radiation to back) for >3mo without identifiable cause
sx: voiding difficulties, irritative voiding sx, pain w/ejaculation or blood in the semen
can be inflammatory or noninflammatory based on presence of leukocytes in urine and prostatic secretions but this distinction has uncertain significance
thought to be dt chronic prostate inflammation
diagnosis of exclusion
tx: antibiotics are helpful; alpha-adrenergic inhibitors (tamsulosin) and 5-alpha reductase inhibitors (finasteride)
How can co-morbid GERD affect asthma?
GERD is common in pt with asthma and can exacerbate asthma sx through microaspiration of gastric contents -> increased vagal tone and bronchial reactivity.
hx suggesting comorbid GERD: sore throat, morning hoarseness, worsening cough only at night, increased need for albuterol following meals, dysphagia, CP/heartburn, sensation of regur; obesity increases ris k for developing GERD
PPI therapy has shown to improve both asthma and peak expiratory flow rate in asthma pt w/evidence of GERD
Which drug classes show use dependence? how do they affect the complex?
Anti-arrythmic drugs, most class IC displays use dependence. Act by blocking sodium channels and inhibiting the initial depolarization phrase. Class IC has the slowest rate of drug binding and dissociation from teh sodium channel receptor, thus in FASTER HEART RATES, drug has less time to dissociate -> lots of channels blocked -> progressive decrease in impulse conduction and WIDENING OF QRS.
Verapamil and diltiazem (CCB with anti-arrhythmic props_ also display use dependence, with an increase in calcium channel blockade with increasing ventricular activation. They cause a prolongation of the refractory period of the AV node -> increased PR interval, NO change in QRS
When can we typically see AIN vs crystal-induced AKI?
Crystal induced AKI occurs much sooner, usually 24-48 after med (can be seen 1-7 days). Drugs such as Acyclovir (IV>oral), sulfonamides, ethylene glycol, protease inhibitors
VS
AIN, due to drugs seen about5-10 days after use. Can see skin rash, eosinhophilia, eosinopiluria, pyuria
Friedreich ataxia:
autosomal recessive
excessive repeats of GAA
limb, gait ataxia, neuro findings, cardiac findings,
cardiac arrhythmia an dCHF significant #deaths, poor prognosis. most pt are wheelchair bound by 25, death occuring btwn 30-35
Differentiate btwn depersonalization/derealization disorder, dissociative amnesia, and dissociative identity disorder:
Depersonalization/derealization DO - persistent/recurrent experiences of feeling detached from/being outside looking in AND/OR derealization/experiencing surroundings as unreal. Pt have intact reality testing
Dissociative amnesia - inability to recall impt personal info, usually after stressful event; not explained by another DO
Dissociative ID disorder - marked discontinuity in indentity an dloss of personal agency w/fragmentation in >2 distinct personality states. asc with severe trauma/abuse
What renal/urinary changes do we see in pregnancy?
increase RBF, inc GFR, increase BM permeability ->
decrease serum BUN, dec serum Cr, increase protein excretion
Leydig tumors:
increase testosterone release, can also secondary lead to an increase in estrogen dt increase aromatase activity.
In 20-30s, can see endocrine sx (gynecomastia)
In younger individuals, can lead to precocious puberty
Causes of aortic regurg:
AR: early decrescendo diastolic murmur, best heard with the diaphgram of the stethoscope along the left sternal border at the third and fourth intercostal spaces, while the patient is sitting up, leaning forward, hold a breath in full expiration
Congenital bicuspid aortic valve is the most common cause of isolated aortic regur in young adults in developed countries. Other causes: aortic root dilation (marfan, syphilis), post-inflammatory (rheumatic heart disease, endocarditis)
Increased LVEDV…initially SV and CO maintained with myocardial hypertrophy and ventricular enlargement. excessive LV strech later leads to dec SV, and systolic HF, with increase lVED pressure -> pulm congestion
Guillain-Barre Syndrome: CSF findings
GBS is an immune-mediated polyneuropathy dt cross-reacting antibodies
sx: symmetric muscle weakness, absent/dec DTRs, parethesias, autonomic dysfxn (arrhythmia, ileus), respiratory compromise*
GBS characterized by ascending weakness, bulbar sx (dysarthria), respiratory compromise after antecedent illness (respiratory or GI esp campy)
Largely clinical dx, supported by CSF, electrodiagnostic fidnings
CSF: albuminocytologic dissociation, increase protein and normal leukocyte count
tx:IVIG or plasmapheresis. monitor autonomic and respiratory function
Light criteria:
Criteria to classify an exudative effusion.
A least one of the following classifies as being exudative:
*pleural fluid protein/serum protein ratio > 0.5
*pleural fluid LDH/serum LDH > 0.6
*pleural fluid LDH>2/3 UNL of serum LDH (above 60)
Empyemas are exudative effusions with a low glucose concentration dt the high metabolic activity of leukocytes and bacteria within the pleural fluid
Trastuzumab AE + prophylaxis:
Cardiotoxicity is a know AE of trastuzumab and usually manifests as asx decline in LV ejection fraction, but overt HF can occur. Risk increased if used with other meds that are also cardiotoxic (doxorubicin)
*baseline assessment of cardiac function by echo, and reassesed echo at reg intervals during therapy.
DC tx if symptomatic HF or significant decline in EF (>16 from baseline).
Typically REVERSIBLE (unlinke doxirubacin) with pt experiencing complete recovery of cardiac function following DC
How can you augment a tricuspid regur murmur?
Tricupsid regur (holosystolic murmur) increases with inspiration!
Increasing with inspiration helps distinguish right sided murmurs from all others
ACL injury
sx
findings
dx
ACL injury dt rapid deceleration or direct change; pivoting on lower extremity w/foot planted
sx: pain rapid onset
POPPING sensation at time of injury
significant swelling-> effusion/hemarthrosis!
Joint instability
anterior laxity of tibia rel to femur (ant drawer test, lachman test)
dx: MRI
ECG findings of left ventricular hypertrophy
high-voltage QRS complexes (lateral leads), lateral ST segment depression, lateral T wave inversion
Where is the location of a pure sensory stroke?
What is a complication?
Lacunar stroke of the posterolateral THALAMUS, typically dt atherothormbotic occlusion of small, penetrating (thalamogeniculate) branches of PCA
(VPL and VPM nuclei of thalamus transmit sensory info from the contralateral side of body and face, respectively)
sx can be accompanied by transient hemiparesis, athetosis, ballistic movements dt disruption of neighboring basal ganglia structures and CST fibers of post limb in internal capsule
Complication: thalamic pain syndrome / Dejerine-Roussy Syndrome - wks to mos following, pt can experience severe paroxysmal burning pain over teh affected area and clasically exacerbated by light touch (allodynia)
