NBME/ General Things to remember for shelf Flashcards
paroxysmal v tach may present as
syncope
clubbing should always raise red flag for?
lung cancer, order CXR
High pitched bowel sounds+ air fluid levels=
obstruction of bowel
direct current countershock =
SCD
U/A finding specific for rhabdo….
+ for blood, - for RBCs
Pre-renal azotemia definition
BUN:Cr greater than 20
FeNa less than 1
FeNa & BUN: Cr for intrarenal azotemia
BUNCr lower than 20
FeNa higher than 5
isolated systolic hypertension cause
decreased compliance
Phases of ATN
oliguric –> diuretic –> recovery
Four stages pressure ulcers
1- skin intact
2- skin gone
3- crater like
4- involves bone/muscle/tendons
Management pressure ulcer by stage
1- prevent
2- wet to dry dressing
3 & 4- debridement
Location mycoplasma PNA on CXR
can be segmental or nonsegmental
Treatment of HyperPTH in squamous cell
bisphosphonates (–dronate)
Prevention of anemia in CKD
EPO
Cold/nonfunctioning nodule thyroid management
FNA
Knee pain and swelling that self resolves?
gout
Common predisposing feature to gout
alcoholism
Most sensitive test for osteo
MRI
Lung hyperressonance=
pneumothorax
Increased tactile fremitus on lung exam=
consolidation
lung conditions that cause mediastinal shift
Peff (away), TPTX (away), lobar collapse (towards)
Best osteoarthritis prevention
weight loss
Pain over delt with abduction
supraspinatus tendon tear
(noncardiac) Cancer causing heart murmur
gastric carcinoma
carcinoid tumor
Cause of AMS in respiratory failure
Hypercarbia
methimazole serious ADR
neutropenia
Sudden onset severe hypertension, normal labs
renal artery stenosis
Imaging for unexplained pancreatitis
ERCP
Adult with recurrent pna/ diarrhea/ sinusitis….screen for?
CVID
Urgent Dialysis indications
AEIOU acidosis electrolye change ingestion toxin overload uremia
K^ drugs
ACE/ARBs
spiro/amiloride
BBer
Acute UTI empiric treatment
Bactrim
nitrofurantoin
fosfomycin
Met alkalosis –> next step
Cl measurement
low= vomiting/prior diuretic
high= endo (aldo/ACTH/cushings); diuretic or barter/gitleman
Metabolic alkalosis with low Cl is _____ _____
saline responsive
Three steps in evaluating Hyponatremia?
Serum osm above 290?
Urine osm below 100?
Urine Na greater/less than 25?
Hyponatremia 2/2 CHF/Cirrhosis presents how?
serum osm below 290; urine osm above 100; urine sodium LES THAN 25
How does SIADH present?
serum osm below 290; urine osm above 100; urine sodium ABOVE 25 (not peeing out any water)
Causes of hyponatremia that present similar to SIADH
hypothyroid
adrenal def
Causes of hyponatremia with high serum osm
very high hyperglycemia
advance renal failure
Cause of hyponatremia with low urine osm
primary polydipsia/beer potomania
Drug preventing calcium stones? Uric acid stones?
Calcium- thiazides (avoid loops)
Uric acid- give K+
Hexagonal stones are?
Envelope stones are?
hexagonal- uric acid
envelope- Ca Ox
AGAP equation
sodium -cl - bicarb
winters formula
paco2= 1.5xbicarb + 8 +/- 2
Bicarb changes in respiratory alkalosis/acidosis?
acidosis ^10 CO2= ^1 bicarb
alkalosis ^10 CO2= ^2 bicarb
CO2 change assc with met alkalosis
^bicarb 1= ^CO2 0.75
What is the add back method?
Calculate actual AGAP - calculated. Add difference back to bicarb.
FeNa/FeUrea in pre renal disease
FeNA is LESS THAN 1
Fe Urea is less than 35
Intra/post renal AKI test of choice
noncontrast CT/US
GFR and staging of CKD
I- above 90 II- 60-89 III- 30-59 IV-15-29 V- under 15
**HD at stage 5, start preparing at stage IV
DM goals in CKD
A1C under 7; glucs 80-120
Cinacalcet- role in CKD?
Give to prevent ^^PTH due to low Ca
Hb goal in CKD
above 10
Causes of low K
vomiting/diarrhea
high aldo, loops, thiazides, barters, gittlemans
K+ EKG changes
classic= T waves but can be anything!
Hypernatremia treatment
mild- oral water
moderate- D5
severe- NS
How are Na and gluc related in low Na/hyperosmolarity
for every ^100 glucose= ^1.6 Na
(ie 500 gluc= 400^ gluc= ^4.6 Na)
measured Na= 130; actual = 136
just give insulin
UNa ~
Uosm ~
UNa~aldo
Uosm~ADH
Treatment of hypercalcemia
FLUIDS –> calcitonin –> bispohs
Cause of ^^ vitamin D?
granulomas- sarcoid, TB
=^^Ca and PO4; low PTH
How to evaluate low Ca?
check albumin, check ionized Ca
Contrast hyperCa in mets vs Squamous Cell
Squamous Cell- ^^Ca; low PO4
Mets to Bone- ^^ Ca & PO4
Order vitamin D to r/o granulomatous disease
Which kidney stones are radiolucent
uric acid and cysteine
When do stones require surg?
greater than 1.5 cm
RCC produces
EPO
MUDPILES
methanol uremia dka propylene glycol iron/inh lactic acidosis ethylene glycol salicylates
Causes of respiratory acidosis
hypoventilations- opiates, asthma, copd, OSA, poor muscle strength
When to use stress echo?
baseline EKG changes
Wide complex tachy –> next step
SCD
MMSE suggestive of dementia
25 or less
Subchondral cysts=
OA, first line = NSAIDs
Acute MI blood gas finding
lactic acidosis= MI
Management of esophageal perforation=
Surgery
Gram stain -; papules on palms; arthritis=
gonorrhea
STE =
MI
**Tamponade = alternans
Midshaft fracture of the humerus=
radial nerve damage
High platelets + pain in finger tips: dx and tx?
tx: polycythemia, therapeutic phlebotomy
Options for pyelo treatment
Oral FQs, IV ceftriaxone, amp + aminoglycoside
7-14 days
Labrynthitis findings
dull TMs
distorted light reflex
dizziness
**tx= antihistamines
+ Fecal Occult… Next step
colonoscopy
alopecia + rash= what mineral deficiency
Zinc
PPD considered positive in HIV
5+ mm
Scleroderma pathogenesis & MC antibody & population
excess collagen
MC antibody = ANA
middle aged women
Two most common complications of scleroderma
pulm fibrosis
esophageal dysmotiliy
CREST syndrome findings
C-calcinosis of digits R- raynauds E- esophageal dysmotility S- sclerodactyly T- telangiectasias
Cheilosis and corneal vascularization = deficiency of what mineral/ vitamin
B2/ riboflavin
“the 2 C’s of B2”
Describe “dermatitis” assc with B3/niacin deficiency
broad collar rash
dermatitis, alopecia, adrenal insufficiency cause
B5/ pantothenic acid deficiency
B6/ pyridoxine anemia type
siderblastic anemia + neuro findings
Folate is vitamin B \_\_\_\_\_\_ Niacin is vitamin B \_\_\_\_\_\_\_\_\_ Pyridoxine is vitamin B \_\_\_\_\_\_\_ Pantothenic acid is vitamin B \_\_\_\_\_ Riboflavin?
Folate= 9 niacin = 3 pyridoxine= 6 pantothenic acid = 5 riboflavin = 2
Scurvy findings
corkscrew hair
swollen gums
bleeding
Vitamin E deficiency findings?
How different from vitamin B6?
E= hemolytic anemia, acanthocytosis, neuro findings B6= sideroblastic anemia
Cause of vitamin K deficiency in adults
prolonged use abx
Delayed wound healing Alopecia Rash Dysgeusia Cause
Zn def (assc with IBD)
Hypervolemic hypenatremia cause
cushings hyperaldo bicarb TPN saltwater drowning
Euvolemic hypernatremia causes
DI
insensible respiratory
Hypovolemic hypernatremia causes
diuretics, glycosuria, renal failure
sweating, diarrhea, respiratory sensible
In true hyponatremia serum osmolality is
low; under 280
Cause of “pseudohyponatremia” (serum osmolality above 280)
mannitol
glycerol
high protein
high triglycerides
Causes of hyponatremia with urine sodium under 25
CHF
cirrhosis
depleted volume
Causes of hyponatremia with urine sodium above 25
SIADH
adrenal
hypothyroid
Hep B antibody assc with vaccination
Hep B surface; core = true infection
How to screen for CKD in HTN
creatinine
Pilonidal cyst first approach to treatment
surgical drainage
Typical blood product given in GI bleed
packed RBCs
diuretic induced hypernatremia pattern
hypovolemic
normal response to water deprivation
Cause of respiratory distress in sepsis
increased vascular permeability
New onset PKD inheritance pattern
still assume AD
Treatment SIADH
fluid restriction
Cause of hypotension in MI
decreased contractility
harsh systolic ejection murmur, peaking in late systole, with slow rising carotid pulse =
aortic sten- bicuspid esp if young
Calcium levels in pancreatitis
low
Murmur assc with bicuspid aortic valve
can be AR or AS
AR murmur
decrescendo diastolic
Subauricular bruit is a clue for
FMD
Cause of differential BP in upper extremities
supravalvular aortic stenosis
V1-2 STE =
LAD infarct- anteroseptal
V3-4 STE=
distal LAD infarct- anteroapical
V5-6 STE =
anterolateral infarct- LAD or LCX
I, AVL STE=
lateral infarct - LCX
II, III, aVF STE=
inferior infarct- RCA
V7-9 STE + V1-3 depression=
Posterior MI - PDA (usually originates from RCS)
How does myocardial infarction lead to pulmonary edema?
acute mitral regurg = increased LA/LV filling pressures
Treatment of afib in wolff Parkinson white syndrome
SCD
procainamide
Drugs that are contraindicated in WPW
CCB adenosine dig
Severe AS =
soft s2
delayed carotid pulse
AAA rupture risks
large diameter
rapid expansion
cigarette smoking
Afib origin
Aflutter origin
fib= pulm veins flutter= tricuspid annulus
ISH cause
thickened arteries
For purposes of boards… latent TB therapy?
isoniazid + B6
+ CXR, - AFB=
latent TB
Interpretation of PPD
+ if induration greater than:
5mm in immunocompromised
10 with risk factors
15 for anyone
Pyrazinimide ADRs
gout
SIRS criteria
temp above 38, below 36
WBC above 12, below 4
HR above 90
RR above 20
2/4 = +
Therapy sepsis
2-3 L fluid
empiric abx
pressors if pressure doesn’t stay above 90 with IVF
fever, headache, focal deficit=
abscess or cancer
Criteria for safety of LP
FAILS focal neurologic deficit AMS immunosuppressed lesion seizures
If LP is not safe, what is next best step?
CT scan to rule out mass lesion
if +… check for toxo/biopsy
LP appearance in encephalitis
mostly leukocytes
check for HSV
bacterial meningitis appearance on LP + empiric abx
lots of polys (more than 1000) ceftriaxone vanc steroids \+amp only if immunosuppressed
Treatment of cryptococcal meningitis
amphotericin
Treatment of Lyme/ RMSF meningitis
ceftriaxone
Treatment of neurosyphillis
IV penicillin q4 x 10-14 days
Crytpococcal meningitis LP findings
high opening pressure
++Cryptococcal antigen
Toxo: management
TMP-SMX; rescan in 6 weeks
Cellulitis
layer
most common bugs
clue
subQ
well demarcated
staph strep
Treatment for cellulitis if toxic
strep: zosyn/ ampclauv
staph: vanc/ linezolid/ clinda
Treatment for cellulitis if nontoxic
strep: 1st gen ceph
staph: TMP-SMX/Bactrim
Osteo presentation
refractory cellulitis
osteo treatment
debridement; 4-6 weeks IV antibiotics
Gas gangrene
presentation
bug
treatment
infected wound
c perfiringes
PCN + clinda
Nec Fac
presentation
bugs
xray
weird cellulitis (blue and black, rapid, crepitus)
staph, strep
xray
Treatment Nec Fac
1st gen ceph
clinda
amp
& debride
THREE
Diabetic foot treatment
vanc and zosyn
Oster + cirrhosis + osteo=
vibrio
PrEP drugs
emcitbrabine
tenofovir
PEP drugs
emcitrabine
tenofovir
+/- raltegravir
Highest risk method of HIV transmission
vertical
Opportunistic bugs at 200, 100, 50 CD4 count
200- PCP
100- Toxo
50- MAC
What are the NRTIS to remember? (5)
ziDOVEudine ABBAcavir DIDanOsine LAMBivudine Tenofovir
Protease inhibitors suffix
-cavir except ABBAcavir= NRTI
NNRTI drugs (2)
- Nevirapine
- Efavirenz
HIV testing in anti-retroviral syndrome
PCR load
CAP empiric therapy
1) FQ (sickly)
2) 3rd gen ceph + macrolide (hosp)
3) macrolide alone
HCAP empiric therapy
vanc and zosyn
Meningitis empiric therapy
vanc
ceftriaxone
steroids
+/- amp if immunocompromised
UTI in pregnant pt empiric therapy
amoxicillin
TMP-SMX should be avoided as empiric therapy for UTI in what patients?
renal failure
warfarin
Treatment for pyelo
inpatient: IV ceftriaxone
outpt: oral Cipro
pseudomonas coverage
zosyn
carbapenems
cefepime
anaerobe coverage
clinda most places
metro if vaginal/abdomen
FQ for gram-; gram +?
gram- Cipro
gram+ moxi
Treatment for lung abscess
3rd gen ceph + clinda
When is asx bacteruria treated?
pregnancy, procedure
amoxicillin –> repeat screen
duration of treatment for simple cystitis complex cystitis pyelo perinephric abscess
3,7,10,14 respectively
What makes cystitis complicated?
pregnant penis plastic procedure pyelo
Empiric treatment options for cystitis
Bactrim
nitro
fosfomycin
Empiric treatment options for prostatitis
Bactrim
FQ
doxy
Perinephric abscess treatment
I&D
14 days IV ceftriaxone
When to get CT scan in pyelo
no improvement x72 hours
Best diagnosis method for primary, secondary, tertiary syphilis
1- dark field
2- RPR –> TP abs
3- LP PRP and TP abs
Treatment of primary syphilis, early latent, late latent, tertiary.
primary- 1x IM pen
early latent- 1x IM pen
late latent- weekly x 3 weeks
tertiary- IV q4 x 10-14 days
Interpretation RPR results…
:
not a fraction
second # should drop with treatment
Treatment LGV, how distinguished from primary syphilis?
syphilis: chancre and LN are Nontender
LGV: chancre Nontender, LN tender +/- drainage
Treatment LGV
doxy
Chancroid dx and tx
gram stain and cx
azithro or Cipro
dx HSV
PCR
OM vs OE on exam
OM- pain relieved with tugging of pinna
OE- painful if pinna moved
OM treatment
amox or cefdininr
OE treatment
supportive or cipo + steroid drops
Mastoiditis signs
bulging behind ear
anteriorly rotated ear
tx is surgical
Sinusitis treatment
augmentin
Phayngitis scoring of symptoms
CENTOR c-cough +1 e- exudate +1 n- nodes +1 temp above 38 + 1 OR under 14 +1 (-1 if over 44)
1- do nothing
2-3 do rapid strep
4 empiric treatment
Treatment of strep pharyngitis
augmentin
Treatment anterior/ posterior epistaxis
cauterization with silver nitrate
posterior = packing + px abx
Treatment of acute endocarditis with a native valve?
vanc
Treatment of acute endocarditis with a prosthetic valve
young (less than 65 days) = vanc, gent, cefepime
old (greater than 65) = vanc, gent, ceftriaxone
subacute endocarditis treatment
gent and ceftriaxone
Alternative to vanc in treatment of endocarditis
dapto
Acute endocarditis culture guidelines
culture until negative
treat with abx until cx is negative
Subacute endocarditis culture guidelines
culture until +
don’t treat until +
Who gets surgery for endocarditis?
vegetation above 15 mm above 10 + emboli florid CHF abscess fungus
What are the three major criteria for endocarditis
bacteremia
new murmur
+echo
Two pansystolic murmurs
VSD
MR
systolic murmur- early ejection
AS
Drugs that decrease morality in [CHF] ? 3
ACEi
BBer
Spiro
+/- hydral with nitro (AA, FMT)
Location of VSD? MR?
VSD- everywhere
MR- axilla, apex
Maneuvers that increase MVP and HCOM
standing
valsalva
Post prandial pain- ddx
mesenteric ischemia
DPU
S4 cause
atrial contraction against stiff ventricle
Becks Triad
distant heart sounds
low BP
JVD/ Hypotension
= Tamponade
Cardiac conditions that require fluid (3)
RHF
shock
tamponade
When to give IV metoprolol
severe HTN
afib
Dobutamine use
pressor
MI type that causes hypotension
posterior/inferior= RHF
BP that is absolute/ relative CI to thrombolytics
220= absolute 180= relative
Time window for thrombolytics in MI
12 hours
MI type that most commonly causes arrhythmias
RCA; supplies SA node
Aside from congenital VSD, what may cause VSD?
post MI ventricular free wall rupture
Persistent STE post MI=
aneurysm
Head nodding/ fingernail pulsations is a clue for
AR (hyperdynamic)
AS= hypodynamic
When to give px before oral procedures
- prosthetic
- congenital cyanotic disease
- history of IE
- cardiac transplant
Which murmurs need echo?
diastolic
3/6
thrill
symptomatic
How does valsalva cause increased HCOM murmur
decreased blood= increased contact of leaflets
Exhalation increases what murmurs?
exhalation- L sided
inspiration- R sided
Bicuspid aortic valve management?
annual echo
screen first degree relative
Which valve is normally bicuspid?
mitral
Bicuspid aortic valve causes what complications?
AS
AR
aneurysm
Drugs that decrease mortality in [MI]? (3)
ASA
BBer
statin
most common risk factor for IHD
HLP
Family history of MI at what age is worrisome?
women earlier than 55
men earlier than 45
Time limit for PCI
must be able to transfer within 2 hours otherwise do thrombolytics
Best troponin for ACS
troponin I
When can adenosine not be used for chemical stress test?
COPD/ asthma
When can CABG be done?
left main
3 vessels
2 vessels + DM
1 vessel that FMT
Stenting always gets what medical therapy?
double antiplatelet (ASA, plavix)
Who gets statins (4)
risk above 7.5
LDL above 190
ACS/stroke
diabetics age 45-75
Who gets aspirin? (2)
older than 50
risk above 10
no contraindications
Drugs for everyone with MI
MONA ACE BBer clopidogrel statin
Paracentesis: Polys under 250 + SAAG above 1.1 causes (2)
cirrhosis
CHF
Paracentesis: Polys under 250 SAAG below 1.1 causes (1)
nephrotic
Paracentesis: High white count- more than half polys: ddx? (3 things)
SBP (above 1.1)
secondary infection (SAAG varies)
pancreatitis (high amylase, above 100, SAAG under 1.1)
Paracentesis: High white count- mostly lymphocytes- ddx? (two things)
malignancy
TB
Normal FEV1 FVC ratio
0.7
Normal DLCO
0.8
PFT clue to NMJ d/o
low max inspiratory/expiratory pressures
Platypnea is a clue to?
hepatopulmonary syndrome
Lights criteria
Pp/Sp above 0.5
Pldh/Sldh above 0.6
LDH more than 2/3 ULN
Criteria for draining
below 7.2
below 60 gluc
Treatment for effusion with loculation
VATS (surgery)
loud P2
fixed split S2
TR
=
Pulmonary hypertension
PAH PFT pattern
restrictive
TB effusion clue
risk factors for TB
bloody effusion
What causes increased fremitus?
consolidation
effusion decreases
How to confirm TB effusion
pleural biopsy
Chylothorax dx
high triglycerides in effusion fluid
When does anemia lead to MI/CVA etc?
Hgb 4-5
DcO2=
CO x Hgb x %sat
Retic levels in destructive anemia
More than 2%
Macro, micro, normocytic anemia are destructive or productive, most commonly?
Macro/ Micro = production failure
Normocytic= destruction
Microcytic anemia –> next step in narrowing diagnosis?
Iron panel (TIBC, Fe, ferritin, %sat)
Normocytic anemia –> next step in dx
LDH, billi, haptoglobin
Causes of normocytic anemia
Hemolytic
Bleeding
Ca
CKD
Causes of microcytic anemia
IDA
Thal
Sideroblastic
ACID
B12, folate def are what kind of microcytic anemia?
Megalocytic (hypersegmented neutrophils)
Aside from B12/ folate def, what causes macrocytic anemia?
Liver
Alcohol
Drugs
Metabolism
B12/folate:
Which has high MMA? Homocysteine?
MMA = B12 Homocysteine = both
Test that narrows causes of B12 def?
Schillings rules out pernicious anemia
Give IM/oral B12 —> check urine for B12, none = PA
Drugs that cause megaloblastic anemia (3)?
5FU
AZT
Ara-C
2 metabolic disorders that cause megaloblastic anemia
Leach nyhan
Hereditary orotic aciduria
How does chrons cause B12 def?
Terminal ileum destruction = site of IF+B12 absorption
How long must B12 be deficient from diet before becoming symptomatic?
Years!
Neuro symptoms assc with B12 def? How treated?
DCML destruction
Tabes dorsalis
Loss of propioception etc
Irreversible
Who is generally folate deficient
Alcoholics
Depressed widows not eating
Iron studies suggestive of IDA
Fe Ferritin TIBC
Low Fe
Low ferritin
High TIBC
Two common causes IDA
Colon Cx
Menorrhagia
Iron studies suggestive of anemia of chronic disease
Low Fe
High Ferritin
Low TIBC
Give causes sideroblastic anemia
Drugs Alcohol Lead B6 def MDS
HgF is elevated in which Thal type?
Beta
Treatment of major Thal
Transfuse
Deferoxamine in case of iron overload
Normocytic anemia that is not hemolytic- causes
CKD
Ca
MDS
Leukemia
PNH cause
PIG-A def
Lack of CD55 cells
Increased complement/attack complex formation
Treatment of PNH
Eculizumab
Two diseases with spherocytes on smear
HP
AIHA
Bite Cells + Heinz Bodies =
G6PD def
Three Meds that cause crisis in G6PD Def
Bactrim nitrofurantoin dapsone
How to dx G6PD def
Check level 6-8 weeks after attack
Hereditary sphrocytosis
Dx
Tx
Osmotic fragility
Splenectomy
AIHA
Cold/IgM are assc with what infections
Mono
Mycoplasma
Warm AIHA/IgG is assc with what disease, Dx? tx?
AI, cancer
Dx Coombs +++
Tx steroids –> rituxumab –> splenectomy
Sickle cell stroke treatment
Exchange transfusion
Appearance of chronic vs acute leukemia cells
chronic= large nucleus acute= small nucleus
WBC count suggestive of leukemia? acute?
greater than 60
acute if more than 20% blasts
Acute leukemia, next steps in diagnosis
analyze smear –> BMBx
Treatment AML? Treatment ALL?
AML- vitamin A for M3/ auer rods; other= chemo
ALL- chemo, +++CNS px
CML, CLL, ALL, AML:
Which is seen in kids?
Which is seen in middle age people?
(other= old)
CML= middle age ALL= kids
Chronic leukemia, next steps in dx?
Diff —> BMBx
Treatment CML? CLL?
CML- imantinib
CLL- HSCT is young, chemo if old with sx, nothing if old and asx
AML cell markers?
ALL cell markers?
AML- myeloperoxidase
ALL- tdt, cALLa
AML assc exposures
benzene, radiation
CML- genetic assc?
t(9,22)..philidelphia chromosome; BCR-ABL; treat with TKi (imantinib)
Nontender lymphadenopathy- next step in dx?
excisional biopsy
How to stage lymphoma
CXR, CT CAP/Pet, BMBx
How to stage hodgkins
1-1 node
2- 2+ nodes, same side of diaphragm
3- 2+ nodes, opposite sides
4- mets
Cyclophosphamide ADR
Cisplatin ADRs (2)
Vincristine/blastine ADR
cyclophosphamide hemorrhagic cystitis
cisplastin- ear and kidney toxic
vin- neuropathy
Which is more severe- Hodgkins or nonhodgkins?
non
Two types of non hodgkins
Burkitts
Extranodal
ETOH LNs /Pel Epstein are assc with?
Hodgkins
Hodgkins chemo regimen
ABVD
Non-Hodgkins chemo regimen
R-CHOP
Multiple Myeloma three serum/urine findings
high Ig
osteoclast stim factor
Bence Jones Proteins
How do MM patients become immunocompromised
^^Ig but its dysfxnal
Four tests to evaluate plasma cell d/o
spep
upep
skeletal survey (not nuc med)
BMBx
Treatment waldenstroms
(lymph predominates)
rituximab
+/- plasmapheresis
spep upep skeletal survey BMBx results in MM
MM-
+spep, upep
+/- skeletal survey
BMBx more than 10% plasmas
spep upep skeletal survey BMBx results in MGUS
spep+ protein gap + upep ---- skeletal survery ---- BMBx les than 10% plasmas
spep upep skeletal survey BMBx results in Waldenstroms
+spep
-upep, skeletal survey
BMBx more than 10% lymphocytes
Contrast platelet vs factor bleeding
platelet- gingiva, skin, vagina
factor- hemarthrosis, hematoma
Test of choice for platelet bleeding
platelet count
Test of choice for factor bleeding
PT/PTT and mixing studies
Three general causes of thrombocytopenia
1) sequestration
2) destruction
3) poor production
Four diseases that cause platelet destruction
ITP TTP HIT DIC (alphabet soup)
Two processes that cause sequestration
splenic crisis
cirrhosis
Platelet bleeding, platelets within normal limits…
what are causes of platelet dysfunction?
drugs (ASA, NSAIDs)
uremia
VWD (which causes VIII instability), BS, Glanzmans
VWD
dx
tx
platelet bleeding –> normal counts –> vwf assay
tx: DDAVP, VIII supplementation in case of bleeding
Bernard Souiler deficiency
GP1B
Glanzmanns deficiency
GP2b3A
How to diagnose inhibitors as a cause of factor bleeding
PT/PTT increases –> mixing study negative= inhibitor
Factor I is? II is?
II prothrombin
I fibrin
Four causes of thrombophilia directly related to factors
prothrombin 20210A mutation
factor 5 leiden mutation
protein C,S def
antithrombin def
Antiphospholipid syndrome:
path
dx
lupus anticoag
Russell viper venom assay
When to anticoagulate in thrombophilias
most- after second clot
APl- after first clot
Clot types in TTP vs DIC
TTP- hyaline
DIC- fibrin
TTP- cause & sx
ADAMST 13 def FAT RN fever anemia thrombocytopenia
renal failure
neuro sx
lab findings in TTP
low platelets + shistocytes
normal PT/PTT/fibrinogen/ddimer
Treatment TTP
exchange transfusion
DIC lab findings (platelets, smear, PT/PTT, finbrinogen, d-dimer)
low platelets
schistocytes
high PT/PTT, d-dimer
low fibrinogen
Timeline HIT
heparin –> 7-14 days –> low platetlets
Management HIT
stop heparin
start argatroban
bridge to heparin
ITP:
cause
dx
ab to platelets
diagnosis of exclusion, low platelets, AI d/o pt
Treatment ITP
steroids
IVIG
splenectomy/rituximab if FMT
Cause of pigmented gallstones
hemolysis
IV abx for gallbladder disease
amp&gent + metro
cipro + metro
Cholelithiasis- 2 tx options
chole
ursodeoxycholic acid if not candidate
Define cholelithiasis, cholecystitis, cholangitis, choledocolithiasis
cholelithiasis- stones in gall bladder, colicky
cholecystitis- stones at cystic duct + inflammation, constant
cholangitis- ascending infection, dilated ducts
choledocolithiasis- obstruction at common duct by stone, “painful jaundice”
Cholecystitis findings on US
pericholecystic fluid
thickened gallbladder wall
Workup for
- cholelithiasis
- cholecystitis
- choledocolithiasis
- cholangitis
- cholelithiasis: U/S
- cholecystitis: U/S then HIDA
- choledocolithiasis: U/S then MRCP then urgent ERCP
- cholangitis: U/S then EMERGENT ERCP
chole always an option later, only emergent ERCP= cholangitis
Medical therapy for all gallbladder disease
IVF
IV abx (metro +ampgent or cipro)
NPO
Triad/Pentad of cholangitis
- RUQ pain
- jaundice
- fever
- +AMS/ hypotension
- (see dilated ducts on US)
-note choledocolithiasis also = painful jaundice but not SAS
Common bugs in cholangitis
gram - anaerobes
Workup for dysphagia
barium swallow –> EGD +Bx –> manometry if mechanical
Achalasia-
absence of ____ plexus
best treatment
myenteric
myotomy
Treatment of diffuse esophageal spasm
CCB; NG PRN
Esophageal webs are assc with?
Strictures are assc with?
Webs- Plummer Vinson
Strictures- severe longstanding GERD
Appearance of stricture vs cancer on barium swallow
stricture= SYMMETRIC loss cancer= assymetric
Describe plummer vinson syndrome
IDA
dysphagia
webs
female
Dx of esophagitis
EGD with biopsy
If infectious screen for HIV
Drugs that cause esophagitis
tetracyclines
NSAIDs
bisphosphonates
HAART
Clues to eosinophilic esophagitis
atopy
asthma
allergies
(trial of PPi–> FMT may do aerosolized steroids)
What treatments should never be done for caustic esophagitis
neutralization of ph
induced emesis
Alarm symptoms that warrant immediate EGD in GERD
anemia
weight loss
Treatment of GERD metaplasia dysplasia cancer
GERD- PPI
metaplasia- high dose PPI BID, surveillance
dysplasia- location ablation + surveillance
cancer- stage and resect
PUD which location is worse with food? better with food?
worse- stomach
better- duodenum
Cause of cushings ulcers
^^ICP
steroids
ventilators
Endoscopy findings below suggest what ulcer types:
- many and shallow
- heaped margin, necrotic center
- single
- many = NSAIDs
- heaped margins w/ necrotic centers
- single= H pyolori
Triple therapy for h pylori
clarithromycin
amoxicillin
PPI
Dx for Zollinger Ellison
If ^^^ gastrin (normal 25)… check secretin stim test
decreased pH should decrease gastrin
ZE- benign or malignant
benign but induces malignancy
Gastric adenocarcinoma bx findings
signet rink cells
assc = asia and nitrites
Treatment for gastroparesis
metaclopromide PO daily
erythromycin IV for acute
BG level- Clue to gastroparesis
low glucs after meals
give insulin but no food gets absorbed
What is considered a +++ emptying study in gastroparesis
more than 60% of contents at 2 hrs or 10% at 4 hrs
Diabetics with gastroparesis will also have?
neuropathy!!
5 types of invasive (bloody diarrhea, +WBCs, + lactoferrin):
1) Salmonella
2) Shigella
3) EHec
4) E Histolytica
5) campy
6 types of enterotoxic (watery) diarrhea
1) c diff
2) vibrio
3) ETEC
4) SA
5) B cereus
6) giardia
When can loperamide be used in gastroenteritis
viral
Triad HUS
bloody diarrhea
ARF
anemia
(supportive or plasma exchange therapy)
Secretory diarrhea: clue + labs
occurs at day + night
no gap, WBC, RBC, mucous, fat etc in stool
Infalammatory diarrhea lab findings
+WBC, RBC, mucous
Osmotic/malabsorption diarrhea lab findings
high osm gap in both
fecal fat + if malabsorption
Stool osm gap equation
measured osms - calculated osms (2xNa+K)
Stool osm gap interpretation
below 50 = secretory
above 100= osmotic/malabsorption
Secretory diarrhea types
1) hormone secreting tumor
2) celiac sprue
3) c diff
Three tumors that cause diarrhea
VIPoma
Zollinger Ellison
Carcinoid
ZE dx
high gastrin above 250; secretin stim fails to decrease gastrin; SRS to localize
Carcinoid causes symptoms when?
lung/ mets; not intestinal
What is absorbed from terminal ileum
B12, fats, bile salts
How to dx malabsorption
100g fat diet–> more than 14 g fat in stool –> give pre-digested xylose –> absorbed = pancreas; unabsorbed = intestinal border
tropical Sprue- clue
carribean farmer
Whipples disease:
- bx clue
- meds
PAS+ organism
Bactrim or doxy
Presentation of:
Diverticular spasm
D hemorrhage
Diverticulitis/perforation
spasm: post prandial LLQ pain relieved with BM
hemorrhage: large volume painless BRBPR
perforation/ diverticulitis: “left sided appendicitis”
Abx for diverticulitis
cipro+metro
or ampgent + metro
same as gallbladder path
Cirrhosis causes
VW HAPPENS Very Weird (stuff) Happens Viral Wilsons Hemochromatosis A1AT PSC PBC Ethanol NASH/ NAFLD Something else
Treatment Hep C
INF + ribavirin
Wilsons treatment
penicillamine
Hemochromatosis tx
phlebotomy
deferoxamine
A1At treatment
transfer
PSC/PBC treatment
transplant
NASH/NAFLD/alcoholic liver treatment
transplant
Treatment of hepatic encephalopathy
lactulose
rifamixin
SAAG in portal HTN/ CHF
above 1.1
Marker for HCC
AFP; triple phase CT washout
Treatment SBP
rocephin
Management GIB
stabilize (fluids, PPI, type and cross, call GI..octreotide if cirrhotic)
endoscopy
Four causes of LGIB
- Hemorrhoids
- Diverticular Hemorrhage
- Mesenteric Ischemia
- Ischemic Colitis
Mesenteric ischemia vs ischemic colitis
mesenteric ischemia- s/sx of vasculopathy
CAD of gut
ischemic colitis- death at watershed, heavy painful bleeding
Diagnosis pancreatitis
CT with fluid around pancreas
Medical mangagement of pancreatitis
IVF
NPO
pain control
ERCP if gallstones
Complications of early pancreatitis
ARDS (leaky caps)
low Ca (saponification)
pleural effusion/ ascites
Prognosis measurement for pancreatitis
BUN
When to drain pancreatic cyst
greater than 6 wks old
p-ANCA is assc with what IBD?
UC
Direct jaundice- painless causes
cancer
stricture
PBC
PSC
Two enzymatic causes of indirect jaundice
Crigler Najar
Gilbert (mild)
Two enzymatic causes of direct jaundice
Dubin Johnson (black liver) Rotors
Urine is dark in what type of jaundice
direct
HBSAB IgG vs IGM
IGM = early infection IGG= immune, vaccine
Two markers for active Hep B infection
HSBAG
HBEAG
Sand blasting, rock quarries=
silicosis
aeronautics, electrical work=
berylliosis
Hypersensitivity Pneumonitis tx
remove source
no steroids
DPLD CXR and CT findings
reticulonodular infiltrates ground glass (CT)
Best test for DPLD
bx
Treatment DPLD
steroids –> biologics
Two drugs that cause DPLD
bleo
amio
Define acute interstitial pneumonitis vs IPF
IPF = longer than 6 mo's acute= under 6 weeks
Rheum diseases that cause fibrosis
SLE
RA
SS
Three extra pulm clues to sarcoidosis
heart block
bells palsy
EN
Tx sarcoid
steroids
Asbestosis:
Ca effect
CXR findings
bx findings
high Ca
pleural plaques, mesothelioma
barbell bodies
O2 is _________limited
CO2 is ______
O2= diffusion CO2= perfusion
Result of ARDS leaky caps on O2/CO2 movement
CO2 moves but O2 does not so low CO2= alkalosis
Three causes ARDS
drowning
transfusion injury
septic shock
PCWP and LVF in ARDS
low PCWP
normal LV filling
PCWP and LVF in CHF
high PCWP
low LV filling
Ventilator settings in ARDS
low TV
high RR
high PEEP
COPD treatment order
- SABA
- LAMA
- LABA
(what dingess is on)
if above does not work:
- ICS
- PDE4i
- OCS
Goal O2 sat in COPD
88-92
COPDE antibiotics
doxy
azithro
PE ABG findings are same as
ARDS low CO2 (perfusion limited)-- moves out O2 low (cant get in--diffusion limited)
Treatment PE
heparin then bridge to wardarin
Massive PE is accompanied by _____ and need ____
hypotension
TPA
Wells Criteria
DDTTT2CC Don't Die Tell The Team 2 Calculate Criteria (3) -DVT symptoms -Dx most likely (1.5) -Tachy -TE in past -Three days immobile (1) -Cancer -Coughing up blood
Wells score 2 and under –> F/U
Score above 4?
Score above 6?
2: D-Dimer –> CTA
4+: CTA
6+: VQ
How to bx mass in periphery, middle lung, small airways, large airways
periphery: perc biopsy w/ CT guiding
middle: surg
small airways: EBUS (endobronchial w/ US)
large: bronchoscopy
When to bx lung mass
more than 2 cm + risks
age above 70, smoking, spiculations
When to get serial CTs for lung mass
under 2 cm
low risk
First thing to do in case of lung mass
get old films
Two paraneoplastic syndromes assc with small cell
Cushings
SIADH
Exudative effusion causes
malignancy
pneumonia
TB
Transudative effusion causes
1 CHF
2 nephrosis
3 cirrhosis
4 gastrosis
When LABA is given in Asthma what must also be given?
ICS or ^ mortality
Stage 1-4 asthma daily symptoms
I- 2x/week
II less than 1x/daily
III daily
IV all day
Stage 1-4 asthma nightly symptoms
I less than 2x/mo
II less than 1x/ week
III more than 1x/ week
IV nightly
CCP ab is + in what rheum disease
RA
Smooth muscle AB is + in what rheum disease
AI hepatitis
Ro, la are + in what rheum disease
sjogrens
jo is + in what rheum disease
PM
DM
AMA is + in what rheum disease?
PBC
Non inflammatory chronic joint pain =
OA
no fever, ESR, CRP
Seropositive rheum diseases causing joint pain? negative?
sero+: lupus, RA
sero-: CT d/o
WBC in joint that is normal OA inflammatory septic
normal under 200
OA under 2k
inflammatory 2k-50k
septic more than 50k
Spetic arthritis gram stain negative =
gonorrhea
Drugs that cause SLE (3)
hydral
procainamide
methyl dopa
Lupus nephritis tx
cyclophosphamide
General lupus tx
RA tx
lupus: HF
RA: MTX
steroids for flare, cyclophosphamide/myco for nephritis
Lupus nephritis ab
dsDNA
Complement changes in lupus
low C3,4
Cause of miscarriage in lupus
APL disease
1st line RA tx is
MTX
Xray finding specific to lupus
C1-2 spine disease/ periarticular osteopenia
RA spares what joint
DIP spared
Scleroderma: sclerodactyly tx raynauds tx GERD tx renal crisis tx
scleor- penicillamine
raynauds- CCB
GERD- PPI
renal- ACEi, no steroids
Clue for nephrogenic systemic sclerosis
gadolinium/ MRI
Sjogrens ab + 3 findings
dry shit (eyes, mouth, parotid swells) ro, la
Tests for IIM
mi, jo abs
high CK
best is bx
can do EMG to r/o neuropathic cause
Gout vs pseudogot
gout- negative birefringent, needles
pseudo- positive birefringent, rhomboid
Diuretic that causes gout
thiazide
but protects from osteoporosis
gonorrhea arthritis tx method
IV
4 seronegative arthritis types
MC sex?
tx?
PAIR psoriatic ank spon IBD assc reactive
males
NSAID and local steroids
Takayasu & GCA: age, dx, tx
GCA-elderly, bx, steroids
Takayasu- aortic, young adult, CTA, steroids
Clue to takayasu
pulselessness
PAN- medium vasculitis assc with what infection 3 symptom clues dx tx
Hep B
mesenteric ischemia, purpura, sensory loss
angiogram
steroids + cyclo
Small vasculitis:
c-ANCA?
p-ANCA?
Wegners/GPA= c-anca eosinophilis/MPA= p-anca
Two small vessel vasculitis caused by immune complexes
cryoglobulinemia
HSP
Cryoglobulinemia
assc
clue
tx
Hep C
purpura
plasmapheresis
AKI, not pre-renal…. next best step
CT non con or US
Pre-renal AKI types
leak (nephrosis, gastrosis, cirrhosis)
pump failure
hole (bleed, diarrhea)
clog (RAS, FMD)
Goals for: BP a1c BG in CKD patients
130/80
less than 7
80-120
How to prevent PTH ^^ in CKD
cincalcet
How to stabilize in ^^K
Ca for EKG
how to temporize in ^^K
insulin & D50
bicarb
b agonists
How to decrease total body K
loop
kayexelate
dialysis
Diruetics that lower K
loops
thiazides
Refractory low K =
low mag!
When to give hypertonic saline in low Na?
seizures (3%)
UNa ~
Uosm ~
aldo= Na osm= ADH
Euvolemic hyponatremia causes
RATS Thyroid low Addisions RTA SIADH
Serum Osm calculation n
2xNa +gluc/1.8 + BUN/2.8
normal ~280
How are ca and albumin related
change 1 in albumin = change 0.8 Ca opposite direction
Simple renal cyst treatment
no treatment if asx
ADPKD = screen for
aneurysm, MRI
How to diagnose exogenous insulin use
low C-peptide
or + secretalogue score
C-peptide in insulinoma
high
How to monitor DKA severity
gap
DM dx
a1c
Fasting
GTT
a1c- 5.7, 6.5
fasting- 100, 125
GTT- 140, 200
When is a1c not helpful?
early DM
gestational DM
Ab type in DM1
GAD
IA2
Oral hypoglycemic that cause weight gain?
weight loss?
gain = TZD, --glitazone loss= GLP1i, --glutides
Three rapid acting insulins
- lispro
- aspart
- glulisine
Two long acting insulisn
- glargine
- detemir
MEN1 tumors
hard P’s
- pituitary
- pancreatic
- parathyroid
MEN2a tumors
parathyroid
pheo
medullary thyroid
MEN2b tumors
pheo
medullary
neuronal
Pancreatic tumors
ZE
insulinoma
Gene assc with MEN2a,b
RET
How does thyroid hormone affect prolactin?
TRH —-I prolactin
T4 —–I TRH
How does dopamine effect prolactin?
inhibits
so dopa antagonists increase
How are GH and BG related?
GH increases glucose
glucose should decrease growth hormone
insulin shoud increase GH
Dx for high growth hormone
IGF1
glucose suppression test
How to dx hypopituitarism
insulin/ vasopressin stim test (should ^ GH in healthy pt)
LH FSH also low
SIADH treatment
fluid restriction
demeclocycline
Treatment thyroid storm
BB
methimazole
steroids
Tx for follicular thyroid cancer
radioactive iodine
Which thyroid cancer has highest mortality rate
anaplastic
Cushing dx
low then high
low dose dexa suppression
ACTH levels
high dose dexa suppression
(responds to low dose, normal ACTH= adrenal tumor// no response to low dose, high ACTH, no response to high dose= ectopic// no response to low dose, high ACTH, response to high dose = pituitary tumor)
Addisons lab values + dx
low cushings AND aldo
early AM cortisol –> cosyntropin test
Medical treatment pheo
a blocker –> b blocker –> resect
Incidentaloma management
R/O conns pheo cushings
if above 4 cm resect, or if functioning resect
SVT drug
adenosine
brady drug
atropine, only sinus, first degree, 2nd degree
Old person no disease BP goal
150/90
Person under 60 or with disease BP goal
140/90
3 first line drugs BP control
CCB Thiazide ACE
Who doesn’t get ACE
Above 75
black
no CKD
Stage 1 HTN drug
1 drug (CCB Thiaizde ACE)
Stage 2 HTN drug
2 drugs (CCB, Thiazide, ACE)
Old (more than 48 hours) afib needs….
echo
Vtach appearance
monomorphic
Normal PR length
one big box
Shockable rhythms
pulseless vtach
vfib
Shockable rhythm drugs
epi amio
Pulseless person drugs
epi absent epi absent
Who can get aspirin in afib
no CHADSS 2 risks CHF HTN age above 75 DM stroke stroke
How to count rate on EKG
300 150 100 75 60 50 43 37
What type of heart failure cannot get nitro
RHF
Three symptoms for determining chest pain type
substernal or l
increased with exercise
decreased with NG
3= typical 2= atypical 1= noncardiac
CHF treatment cascade
ACE and BBer all classes diuretic class 2 spiro/iso class 3 ionotrope class 4
Opening snap=
mitral stenosis
MVP murmur is same as ____ except ___
MR except increased with Valsalva
HCOM is caused by what mutation
sarcomere
4 murmurs that decrease with Valsalva
MS
MR
AS
AR
What murmur gets balloon valvulopasty
MS
Treatment HCOM and MVP
BBer
Three diseases causing restrictive heart failure
amyloid
sarcoid
hemochromatosis
Amyloid dx
fat pad bx
Clues to sarcoid amyloid hemo restrictive CHF
amyloid- neuropathy
sarcoid- lung disease
hemo- cirrhosis
Sarcoid restrictive heart disease dx
endomyocardial bx
Two common causes of pericarditis
viral
uremia
NSAIDs treat pericarditis except when?
PUD
low platelets
CKD
Pericardial knock=
constrictive pericarditis –> need pericardectomy
1st line tx pericarditis
NSAIDs and colchicine
3 causes of + orthostatics
elderly
parkinsons
DM
MAP=
CO x SVR
CO=
HR x SV
SV=
contractility x preload
Neurogenic syncope clue
FND
+ orthostatics
20 change SBP
10 change DBP
pulse change 15
What are high dose statins
atorva 40-80
rosuva 20-40
ezetimibe causes
diarrhea
niacin causes
flushing, give aspirin
