PANCE Flashcards
Primary HTN is defined by ? readings
Ranges for Normal, Elevated, Stage 1 and Stage 2 HTN
What are the ACC/AHA HTN targets
What are the JNC-8 HTN targets
SBP ≥130/ ≥DBP 80
N: <120/80 and <80
E: 120-129 and <80
1: 130-39 or 80-89
2: ≥140/≥90
A: <130/80
J: <60y/o/CKDz/DM: <140/90
≥60y/o: <150/90
When does ACC/AHA suggest starting Rx management for HTN
How is OHOTN Tx
What is the earliest stage of an atherosclerotic plaque
All Stage 2
Stage 1 w/: DMT2
ASCVDz/≥10% CKDz
Inc Na/Fluids, Fludrocortisone, Midodrine
Inflammation induced foam cell (lipid laden macrophage) w/ fatty streak
Absolute c/is for fibrinolytic therapy for STEMI Tx
Suspect dissection Active bleed/diathesis Malignant intracranial neoplasm Ischemic stroke <3mon Cerebral vascular lesion Hemorrhage, cranial
? medication is used for chronic angina and safe for the above c/i but w/ ? s/e
? is the only drug class shown to be antianginal and prolong life in Pts w/ CADz
? medication is used during CHF to reduce morbidity and mortality
Ranolazine; QTc prolongation
BBs
ACEI
What are the 3 beta-1 selective used to reduce mortality from HF
Why do ventricles release BNP in response to inc volume
What can cause this to be artificially low
Bisprolol
Metoprolol succinate
Carvedilol
Dec RAAS, Inc Na excretion
Obesity, Constrictive pericardial dz
HF w/ EF of ? is a sign of increased mortality and need for ? next step
What are the 4 NYHA HF Classificaitons
? scoring system is used to estimate risk of major bleeding in Pts on anticoag meds
<35; defib placement
1: ASx, no limitations
2: Sx w/ mod activity
3: Sx w/ mild activity
4: Sx at rest
HAS-BLED:
HTN Abnormal Kid/Liv function Stroke
Bleeding Labile INR Elder >65y/o Drugs/ETOH
0-1: low 2: mod 3-6: high
AR
MS
PR
TS
AS
PS
HOCM
MVP
MR
TR
VSD
Sit, lean fwd; Diaphragm at Erbs
L lat-decubits; Bell at mitral
Sit, lean fwd: Diaphragm at Pulmonic
Supine; Bell at Tricuspid
Sit; Diaphragm at Aortic
Supine; Bell at Tricuspid
Supine; Diaphragm at Mitral
Supine, Diaphragm at Mitral
Supine, Diaphragm at Mitral apex
Supine, Diaphragm at Tricuspid
Supine; Diaphragm at Tricuspid LLSB
MCC of AR
What is a rare seronegative cause
What will be seen on PE in this condition
Aging process makes leaflets weak/floppy
Ankylosing
Wide pulse pressure, Water hammer/Corrigan pulse heard at LSB
What 5 other signs are seen when AR is present
What extra murmur can be present w/ AR
What is the indication after load reduction is needed and what class is preferred
Hill: leg > arm BP Musset- head bob Quinke- nail bed Duroziez- to-and-fro Traubes: pistol sound over femoral/radial pulses
Austin-Flint: diastolic murmur from blood hitting anterior mitral leaflet
SBP >140 w/ ARBs
MCC of MS
What is heard w/ this murmur
MC Sx of MS
Rheumatic fever
Opening snap after S2
Dyspnea
What will be heard on PE of MR
? maneuver intensifies MR murmur
MC murmur associated w/ Marfans
Soft S1, wide split S2 w/ loud P2
Hand grip
MVP
? part of the valve is MC involved in MVP
? unique presentation in females can indicate underlying MVP
How is MVP defined by Echo
Middle cusp of posterior leaflet (both= Barlow Syndr.)
POTS
Billowing leaflet 2mm/> above annular plane
When is medical Tx for MVP indicated and ? is used
In the USA, TS is MC d/t ? etiologies
TS is characterized by ? four PE findings
Palpitations= BBs
Rheumatic fever-MC
Prior regurge
Carcinoid syndrome
Hepatomegaly
Ascites
Right HF
Dependent edema
Tricuspid stenosis will cause ? type of JVP finding
Since this valvulopathy can mimic ?, it’s differentiated by ?
? is the mainstay of Tx, particularly ? one is considerable bowel ischemia is present
Giant a-wave
MS;
Increases w/ inhalation
Loop diuretics;
Tosemide, Bumetanide
How is TS Tx if liver is engorged/ascites is present
? congenital and iatrogenic etiology can cause TR
? JVP wave is altered w/ TR
Aldosterone inhibitors
Ebstein Anomaly: septal, posterior leaflets into the RV
Pacemaker lead injury
X-descent fades w/ inc regurg
Large V-wave w/ rapid descent
MCC of TR
PS is usually d/t ? and found in ? population
What type of PE finding is heard w/ PR
RVF and dilation d/t P-HTN or LVF
Congenital- Peds
Widely split S2 w/ pulmonic ejection sound
Right sided S4
What secondary murmur is also heard w/ PR
? is a common EKG finding in these Pts
What is the MC c/c of PR
Graham Steel- diastolic pulmonary murmur d/t dilated annulus; mis-Dx as AR
RBBB
Dyspnea w/ exertion
Define Ortner’s Syndrome
? leaflet is affected by age and calcification the most
? is the most important lab ordered for Afib work up and ? is the MC site for thrombus to develop
Hoarse voice d/t PR
Posterior
TSH (thyroxine)- inc cellular basal metabolic rate; LA
How is the Anticoagulation need for Tx of Afib/flutter determined
When is Warfarin used and w/ ? INR goal
CHF/LVEF <40% HTN Age >75 DM Stroke/TIA/Embolis Vasc Dz Age 65-74y/o Female
INR 2.5: Prosthetic valve EGFR <30 Rx: phenytoin, antiretroviral Mitral stenosis
Mnemonic for BBBs
What do these look like on EKG
What are the two types of PSVT
WiLLiaM MoRRoW:
V1- W and M in V6= LBBB
V1- M and W in V6- RBBB
LBBB: up bunny ears V4-6
RBBB: up bunny ears V1-3
AVNRT: arrhythmia from above BoHis
WPW: arrhythmia from BoKent
3 EKG characteristics of WPW
What two medications can be used to manage WPW
How are PSVTs definitively Dx
D-wave c/ slow ventricular activation
Narrow tachycardia
Short PR interval
Procainamide, Quinidine
Holter monitor
How are PSVTs Tx
What can not be used for Tx in WPW
What are the 3 types of premature beats
Carotid massage/valsalva
Adenosine for Sxs
BBs/CCBs if regular
Definitive: ablation
Adenosine or CCBs
PAC: abnormal P-wave
PJC: narrow QRS
PVC: wide QRS
Premature Atrial Contractions are common in ? population
Pts w/ heart Dz and frequent PACs may soon develop ?
? type of premature beats are common in healthy adults
COPD
PSVT, Afib/Flutter
PVCs
If PVCs are symptomatic, what is described
What causes PJCs
How are premature beats Dx
Palpitations in throat
Irritable site in AV node fires before SA node
EKG, Holter monitor
How are premature beats Tx
How is wide and regular V-tach Tx
PAC: reassure
PJC: only if >10/min or multifocal= lidocaine/antiarrhythmic
PVC: only if Sxs, BBs/ablation
Stable: amiodarone, procainamide
Unstable: cardiovert
Pulseless: defib
V-tach rhythm is a frequent complication of ? heart conditions
How is Stable V-Tach Tx
How is unstable Pts w/ monomorphic VTach Tx
MI, Dilated myopathy
In sequence:
Amiodarone Lidocaine Procainamide
Synchronized conversion
? valvulopathies can predispose Pts to VFib
SSS may also manifest and present as ?
What are the 4 possible presentations of SSS
AS/PS
Chronotropic Incompetence- inappropriate HR response to exercise/stress
Brady: sinus <60bpm
Pause: <3 seconds
Arrest: >3 seconds
Tachy-Brady syndrome
How is IE in native valves w/out IVDA Tx
How is prosthetic valve IE Tx
How is IVDA IE Tx
Genta Naficillin Ceftriaxone
Vanc Genta Rifampin
Cefepime and Vanc
Who needs Infective Endocarditis prophylaxis
What is used for IE prophylaxis
Heart valves w/ ? d/o are more likely to become infected w/ endocarditis
Prosthetic material
Previous Dx IE
Unrepaired cyanotic heart dz
Transplant w/ regurg
2g Amox/Clinda
Regurgitation
? microbe can cause culture-negative Endocarditis
How can endocarditis be prophylactic Tx while cultures are pending
Rheumatic fever MC affects ? valve and follows ? but is technically not a ?
Bartonella quintana
Vanc and Ceftriax
Mitral;
Strep throat infection;
Inflammatory reaction
How is Rheumatic Fever Tx
When is AB prophylaxis indicated for Peds
Acute pericarditis can often progress into developing ? issue
CCS ASA/NSAID Pen G Benzathine
PCN allergy: Erythromycin
W/out carditis: for 5yrs or until 21y/o
Carditis, no residual damage: 10yrs
Carditis and residual damage: >10yrs
Pericardial effusion
How does a pericardial effusion present
How is it Dx
How is it Tx
Low voltage QRS
Alternans
Distant sounds
EKG: low voltage w/ alternans
Echo: swinging heart
Centesis
Window if recurrent
? triad is seen in Cardiac Effusion w/ Tamponades
? is a classic finding for this condition
? is the gold standard for Dx
Becks: HOTN Inc JVD Muffled
Pulsus paradoxus- inhale dec SBP >20mm
Echo w/ RV collapse during diastole
When does USPSTF recommend screenings for AAA
How are Aortic Aneurysms screened for
? is the gold standard for screening
65-75y/o w/ +smoking Hx
Initial: US
CT- test of choice for thoracic aneurysms/eval of known AAA
Angiography
What medical therapy is used for AAAs until surgical correction
How do Aortic Dissections present to ED
What is the gold standard for Dx
BBs
Tearing chest pain radiating to scapuas and decreased pulses
MRI angiography
How are aortic dissections Tx
What are the 5 Ps of arterial occlusions
What are common causes of the thrombus formation
Ascending: surgery
Descending: LEP-olol, morphine/dilaudid
Pallor Pulselessness Paresthesia Paralysis Poikilothermia
Afib, MS
? is the gold standard for Dx or arterial occlusions
? is done for Tx until surgery is needed
AV malformations are more likely to be located ?, Dx by ? and Tx w/ ?
Angiography
IV heparin
Brain Lungs Spine;
Angiography;
Surgical excision
How does Peripheral Artery Dz present
If ulcers are present how do they appear on PE
How are these Dx
Intermittent claudication and ABI <0.9
Well circumscribed, lateral/distal
Angiography- gold standard
Doppler US
? is the definitive Tx of peripheral artery dz
? medical management is used
What PE finding suggests thrombo/phlebitis
Arterial bypass
Anti-platelet/lipid
Cilostazol
ASA
Clopidogrel
Palpable cord
How are thrombo/phlebitis Dx
How is phlebitis Tx
How is thrombophlebitis Tx
Venous duplex US- noncompressable vein indicates clot
NSAID Elevate Compress
Anticoagulation
How does Venous Insufficiency appear on PE
Where do ulcers appear in this condition
How does a Venous Thrombosis present
Hyperpigmentation
Atrophic skin
Stasis dermatitis
Superior to medial/lateral malleolus
Unilateral, asymmetrical swelling of lower extremity
? is first line imaging for DVTs
How are these Tx
Define Acute Bronchitis
Duplex US
Venography- gold standard
LMWH or, Fondaparinux or, Factor Xa inhibitors
Afebrile cough x 5 days (fever- think pneumonia)
MCC of acute bronchitis
What are other possible etiologies
How is this Tx
Viral
HFlu, M catarrhalis*, Strep pneumo
Support, Dextrmethorphan, Guaifenesin
When are ABX indicated for acute bronchitis
Define Sinusitis
Criteria for Acute, Chronic
ImmSupp/Elderly w/ CardioPulm Dz and cough x 7-10days
Sxs worsening over 5-7d or don’t improve >10d
A: <4wks, quick onset
C: >12wks
Gold standard method to Dx sinusitis
Indications to use ABX
What is used for adults
Sinus CT
Fever >102
Rapid worsening after improvement
Nasal d/c
Sxs >10d
Amox/Augmentin
Doxy/Clinda if allergic
When/Why are second line ABX used for sinusitis
What meds are used now
What meds are used for chronic sinusitis
Sxs don’t improve x 7d
2g BID Augmentin
Moxi/Levo-floxacin
3rd gen Cephalo
Augmentin, Clinda
What is used for Peds w/ sinusitis
When is f/u needed
How do Pts w/ bacterial pneumonia present
Augmentin
72hrs: no improvement, switch meds
Cough Dyspnea Tachy/Tachy Fever
How does Strep Pneumo pneumonia present
How does Staph A pneumonia present
How does Mycoplasma pneumonia present
Rust colored sputum, common in asplenics
Salmom sputum after influenza
Walking pneumo w/ bullous myringitis
How does Histoplasmosis pneumonia present
? is AKA Valley Fever
What are 3 common PE findings for Pts w/ pneumonia
Bat dropping contact mimicking sarcoidosis on CXR
Coccidioides- unremitting cough despite Txs
Tactile fremitus Egophony Dull percussion
How is bacterial pneumonia Tx
When are the admitted
What ABX are used
Doxy, Marcolides
> 50y/o w/ comorbidities
AMS
Dehydrated
Cefrtiax + Azith/Flqn
How is Coccidioides Pneumonia Dx
What Pts does Aspergillus infect and how is it Tx
How are both Tx
EIA for IgM/IgG
TB/COPD Pts w/ healthy immune system
Flu/Itra-conazole
Cryptococcus pneumonia can also cause ?
? form of pneumonia is apical and mimics TB
How are both Tx
Meningitis
Histoplasma from bird/bat droppings in Ohio River valley w/ hilar adenopathy
Amphotericin B
How is P Jirovici Dx
What is a common PE finding
How are they Tx and what is used if allergic to primary med
Bronchoalveolar lavage
Low O2 despite supplemental O2
TMP-SMX; Pentamidine
MCC of pneumonia in adults
MCC of pneumonia in Peds
How is viral pneumonia Dx
Influenza
RSV
Rapid Ag- flu; Nasal swab- RSV
? two meds can be used to Tx influenza A and B
What two can only treat Influenza A
How is RSV pneumonia Tx
Zanamivir, Oseltamivir
Amantadine, Rimantadine
Ribavirin
What are the classic findings of TB on PE
Define Drug Resistant TB
Define Multiple Drug Resistant TB
Fever Anorexia Weight loss Night sweats
Resistant to one: I/R
Resistant to I and R
How is TB Dx
What is seen on CXR
What is seen on biopsy results
Acid fast smears and Mycobacterium cultures
Apical Ghon complexes w/ cavitary lesions
Caseating granulomas
What are the two forms of miliary TB
How is TB Tx
What are the s/e of RIPE therapy
Potts Dz: spine
Scrofula: cervical lymph nodes
+ PPD= CXR
Neg CXR: latent, Tx w/ Isoniazid/B6 x 9mon
Active CXR:
Baseline LFTs- RIPE x 8wks; RI x 16wks
R: orange fluids
I: neuropathy
P: hyperuricemia
E: red-green blindness
What is used for prophylaxis for household members
When are Pts considered fully Tx
Isoniazid x 12mon
Two negative AFB smears and cultures
Why do Pts need to be tested prior to Tx w/ Etanercept for RA
What part of RIPE needs to be adjusted if CrCl is <30
? RIPE adjustment is needed if Pt is also on HIV meds
Activates latent TB
P/E- 3 x/wk
Raltegravir, double dose when w/ Rifampin
What are the 4 indications to test for TB w/ NAAT
? is the traditional test for latent TB
Define Ranke Complex
HIV
Endemic resident
MDR contact
Previously Tx for TB
TST via Mantoux method
Calcified hilar lymph node
How are pregnant Pts w/ TB Tx and w/ ? educational piece
How is asthma Dx
What type of improvement result helps w/ Dx
R/I/E x 4-8wks, R/I x 7months
Breast feeding not c/i
Peak expiratory flow: FEV1/FVC 75-80%
> 10% inc of FEV1
Define Intermittent Asthma
Define Mild
Define Moderate
Define Severe
Sx/SABA ≤2 days/wk
Awake ≤2 x/month
No activity interference
Sxs/SABA ≥3day/wk
Awake 3-4x/mon
Minor limitations
Daily Sxs/SABA w/ ≥1 awakening/wk
Some limitations
Daily Sxs
Nightly awakenings
SABA several x/day
Extreme limitations
Step 1 Asthma Tx
Step 2 Asthma Tx
Step 3 Asthma Tx
Step 4 Asthma Tx
Step 5 Asthma Tx
Step 6 Asthma Tx
1- Intermittent; SABA PRN
2- Mild; Low ICS daily
3- Moderate; Low ICS + LABA daily
4- Moderate; Med ICS + LABA daily
5- Persistent; High ICS + LABA daily
6- Persist; High ICS+LABA+PO CCS daily
What is used for acute Tx of asthma exacerbation
MC inhaled precipitant
Define Samter Syndrome and Atopic Triad
Nebulized SABA
O2
PO CCS
Ipratropium bromide
Cigarette smoke
Samter: Asthma ASA Polyps
Atopic: Asthma Rhinitis Eczema
What defines Chronic Bronchitis
What defines Emphysema
Most smokers will be Dx w/ ? and termed ?
Productive cough x 3mon/year x 2yrs
Structural changes
Chronic bronchitis, blue bloater
What is the single best variable for predicting which Pt will develop COPD
How is Chronic Bronchitis Dx
What is seen on CXR
Hx 40 pack/year smoker
Lung biopsy w/ inc Reid index (gland layer >50% of bronchial wall)
Inc interstitial markings and non-flat diaphragm
What will be seen on PFT in chronic bronchitis
What is the most effective therapy for Tx Pts w/ chronic bronchitis
When is supplemental O2 indicated
FEV/FVC ratio <0.7
Cessation
SaO2 <89% or,
Rest PaO2 <55mmH
How are COPD exacerbation Tx
If ABX are used, ? ones and w/ ? indication
What will probably develop in these Pts d/t chronic hypoxic vasoconstriction
O2 (goal 88-92%)
Nebulized albuteral and Ipratropium
PO Prednisone
Inc dyspnea, sputum/purlence;
Azith/Cefur/Doxy
Cor pulmonale
COPD Gold Categories
A: Less Sx, Low risk;
Breathless w/ hustle on flat ground, 0-1 exacerbation, 0 admission; SABA/SAMA
B: more Sx, low risk;
Breathless w/ walking slower than peers, 0-1 exacerbations, 0 admission; LAMA/LABA
C: less Sx, High risk
Breathless w/ hustle on flat ground, ≥2 exacerbations, ≥1 admissions; LAMA and SABA
D: more Sxs, High risk;
Breathless w/ walking slower than peers, ≥2 exacerbation, ≥1 hospitalizations
LAMA+LABA w/ SABA
What causes structural changes seen in emphysema
What type of breathing habit do these Pts develop
What term is used for these Pts
Destruction of alveolar septae d/t lost elastin
Purse lip, keeps airway from collapsing
Pink puffer- retained CO2
What is different between Blue Bloaters and Pink Puffers on CBC results
? is the MC of all interstitial lung dzs
How is this MC Dx
BB- Inc H/H
PP- normal Hct
Idiopathic pulmonary fibrosis
CXR w/ diffuse, patchy fibrosis and pleural base honeycomb
What type of PFT results are seen in Idiopathic Pulmonary Fibrosis
How is this Tx
Define Pneumoconiosis
Restrictive pattern- dec volume, normal/inc FEV1/FVC
CCS O2 Transplant
Pulmonay fibrosis w/ known cause;
Exposure to mining/dust causing dec lung volume/FVC (restrictive dz)
Asbestosis CXR findings
Coal Workers CXR findings
Sillicosis CXR findings
Linear pattern w/ basilar predominance, opacities and honeycomb
Nodular opacities in upper fields and less prominent hilar adenopathy
Egg shell classifications of hilar nodes
Berylliosis CXR findings
? restrictive lung dz makes Pts at increased risk for TB
? restrictive lung dz needs tobacco cessation more than others
Difuse infiltrates w/ hilar adenopathy
Sillicosis- need serial TST/CXRs
Asbestosis
? tissue finding indicates significant exposure to asbestos
? size lung mass is a nodule or a mass
How are incidental CXR findings of pulmonary nodules managed
Ferruginous body
<3cm- coin lesion, nodule (<30mm)
>3cm- mass
CT w/out contrast-
Ill defined, lobular, spiculated= biopsy
<1cm, calcified, smooth/defined border= f/u 3mon, 6mon, annual x 2yrs
What are the two categories of lung cancer
What are the 4 subtypes of one of these categories
Small cell
Non-Small cell:
Adeno: non-smoker w/ small peripheral lesion; MC bronchogenic Ca
SCC: central, solitary mass in smokers w/ hemoptysis
Large: fast growth that rarely responds to surgery
Carcinoid- lack differentiation
How does Small Cell Lung Ca present
What lab results would be seen
What syndrome can this Ca cause
Aggressive and almost always in smokers;
more likely to spread early
ACTH/ADH: HypoNa/HyperCa
Lamber Eaton- limb weakness
How are lung Ca Dx
Pancoast tumors are more likely to be ? types
What makes up the Pancoast Syndrome
Bronchoscopy w/ biopsy if central or,
Fine Needle Transthoracic aspiration (most useful)
Adeno/SCC
Shoulder pain Horners Bone destruction
How is Non-Small Cell lung Ca Tx
How is Small Cell Ca Tx
? measurement means PHTN
Stage 1-2: surgery
Stage 3: chemo then surgery
Stage 4: palliative
Chemo, no surgery option
> 25mmHg at rest
? is the MCC of PHTN
How is this Dx
How is this Tx depending on the origin
MS
Right sided catheterization
LVF: diuretic, digoxin, anticoagulate
Cardiogenic: prostanoids, PD5 inhibitors, endothlin antagonists
Pulm Artery HTN: endothelin antagonists, prostanoids
Lab result showing s/e of prolonged rescue inhaler B-2 agonist use
Preferred fluid used for aortic dissections
? artery supplies LV and if occluded will cause a loss of ejection fraction?
HypoK
Crystalloids
LAD
Why do Tet Spells lead to cyanosis
What does squatting help w/ Tet Spells
Tetrology of Fallot is associated w/ ? chromosomal abnormalities
22 deletions, DiGeorge Syndrome
Worsened pulmonary outflow obstruction
Increases systemic vascular resistance
What valves are MC affected by Rheumatic Fever in descending order
? is cardiotoxicity d/t BB/CCBs Tx
How is sinus bradycardia Tx if atropine is ineffective
M>A>T
Glucagon
Dopamine, Epi
Most PEs arise from where in the body
What are the 4 specific RFs
What triad would be seen if a fat emboli is the cause
Iliofemoral DVTs
Cancer
OCPs
Pregnancy
Surgery
Hypoxemia
Neuro abnormals
Petechial rash
How are PEs Tx
How long is medical therapy used for
What are the indications for embolectomy
Acute phase: Heparin
Then: ARE-aban and Dabigatran
3mon minimum
Unstable w/ c/i for thrombolytic therapy
What are the 5 RFs for OSA
For a Dx, ? sleep study or lab results are needed
How is mild/mod/sev OSA Tx
Obesity Anatomy FamHx
ETOH/Sedative Hypothyroid
≥5 events/hr w/ Sxs
≥15 events/hr
PCO2 > 45mmHg
Mild/Mod: CPAP, PO piece
Sev: CPAP Uvuloplasty
Tracheostomy
What is the hallmark CXR finding for almost all pulmonary sarcoidosis
What other 3 DDx need to be considered though if this hallmark is seen
How is pulmonary sarcoidosis Dx
How is this Tx
Mediastinal adenopathy
Young female: sarcoidosis
Kid from Ohio/zookeeper: histo
60y/o ceremics: berylliosis
HyperCa; Inc ACE 4x
CCS ACEI Methotrexate w/ serial PFTs
Define ARDS
What 3 events account for 75% of all ARDS cases
What 3 things can be seen on PE
Resp failure d/t fluid in lungs from inc alveolar capillary permeability
Sepsis syndrome- MC
Sev/mulitple trauma
Aspiration/inhalation
Tachypnea Pink sputum Crackle
What would be seen on CXR of ARDS
How is it Dx
How is ARDS Tx
Bronchogram, Bilat infiltrates
Bilateral infiltrates
Non-CHF Sxs
PaO2:FiO2 <300
Sxs developing <7d
Intubate w/ lowest level of PEEP to maintain PaO2 >60mm/SaO2 >90
How is the mortality of septic shock predicted
? is an indirect marker of tissue perfusion used in sepsis Tx
? is the MCC of sepsis and ? is the MC manifestation
qSOFA
Lactate
Pneumonia; Fever
A Dx of sepsis should be considered if Pt presents w/ two of ? three Sxs
What causes gram positive shock
What causes gram negative shock
Worsening mentation
RR ≥22/min
SBP ≤100mmHg
Exotoxins from staph/strep
Endotoxins from EColi Klebsiella Proteus or Pseudomonas
MCC of anaphylaxis
? type of reaction is the usually
What does this reaction cause to happen
Ingested foods
MC a Type 1 IgE mediated reaction
Mast cells/basophils cause HOTN, shock, angioedema from fluid shift from intravascular space
What is usually the first sign of anaphylaxis
Acronym for acute asthma exacerbation Tx
Cutaneous pruritus/urticaria/angioedema
BIOMES:
Bagonist Ipratropium O2 Mg sulfate Epi/Terbutaline Steroids
Mod/High suspicion for DVT needs ? next steps
Duplex US:
Pos= anticoagulate
Neg= repeat US in 5-7d
D-Dimer: Pos: Duplex US Pos US- anticoagulate Neg US- repeat in 5-7d Neg D-dimer: DVT excluded
Kawasakis mnemonic
GCA is associated w/ ? other Dx
Crash and Burn: Conjunctivitis Rash Adenopathy Strawberry tongue Hand/feet swelling Burning fever >5d
Polymyalgia rheumatica
? is the MC primary cardiac tumor
? genetic condition is this MC associated w/
When do ASx AAAs need to be refereed for elective repair
Atrial myxoma in LA
Carney syndrome
≥5.5cm or expands ≥0.6cm/6mon
Janeway lesions are more common w/ ? form of endocarditis
Ebstein’s Anomaly is associated w/ ? arrhythmia
? three defects make up this condition
Subacute
WPW
Small ASD/PFO
Dilated RA, small RV
TV insufficiency
? features are associated w/ an innocent murmur
Define Leriche Syndrome
? heart condition has a pericardial knock
≤2 intensity Minimal radiation Softer w/ sitting Musical/vibratory Short systolic duration
Claudication in thigh/butt d/t atherosclerosis in aortoiliac system
Constrictive pericarditis
MOA for Adenosine
This is the first line drug used to Tx ?
Preferred anticoagulant for pregnancy
Inhibits AV node conduction
PSVT
LMWH
What two anticoagulants can be used during breast feeding
What labs are ordered for Secondary HTN work up
What is the next step in work up after a suspected Dx of infectious endocarditis is suspected
LMWH< Warfarin
CBC/CMP Lipid UA ECH
Blood culture x 3, then empiric ABX
How are hemodynamically unstable Pts w/ WPW Tx
What is the first step in Tx of orthodromic AVRT in stable Pts
What is the definitive Tx for these Pts
Conversion
Vagal then adenosine then BB/CCBs
Ablation
What are the Hs and Ts for PEA
Hypovolemia
Hypoxia
Hypothermia
HyperK
Tension pneumo
Thrombus
Toxicologic
Tamponade
What is the most specific finding on stress test for myocardial ischemia
What drugs need to be avoided in 2* Type 2 and 3 AV blocks
What causes the PDA to close after birth
2mm down sloping ST depressions
Adenosine BBs CCBs Digoxin
Pulm vasculature resistance dec= bradykinin release
PDA defects are associated w/ ? two conditions
When would Pts benefit from Palivizumab administration
What type of murmur exists w/ AS
Downs, Maternal rubella
Cyanotic heart defect
Mod/Sev P-HTN
Congenital HF w/ meds
Paradoxically split S2 w/ narrow pulse pressures
What are the 5 cyanotic congenital heart Dzs
Why do Pts w/ Brugadas have inc risk for sudden death
Define Brugadas and how is this acquired and Tx
Truncus arteriosus Transposition of great vessels Tricuspid atresia Tetrology Total anomalous pulm vascu
Inc risk for Vfib
Pseudo-RBBB w/ ST elevation in V1-2; Autosomal dominant; ICD
How are stable Pts w/ monomorphic V-tach Tx
What are the s/e of the first line med
MCC of V-tach
Procainamide or Amiodarone then Sotalol
Pro: HOTN, prolonged QTc
Structural heart Dz
How are unstable Pts in V-tach Tx
Mnemonic for s/e of loop diuretics
What are the loop diuretics
Synch’d conversion
Ototoxicity HypoK/Mg Dehydrate Allergy to sulfa Alkalosis, metabolic Nephritis Gout
Furosem/Torem/Bumetan-ide
What adverse outcome of MI appears 2-7d after w/ mid-systolic murmur and rapid onset of pulm edema
How does a Klebsiella induced lung abscess appear on CXR
Although Klebsiella and alcohol is common, ? microbe is more common cause of pneumonia
Acute MR w/ sinus tachy
R sided infiltrate in upper love w/ bulging fissure
Strep pneumonia
CXR w/ decreased vascularity d/t suspected PE is called ?
What causes Croup
What is heard on PE and what is seen on CXR
Westermark’s sign
Parainfluenza virus
Inspiratory stridor, Steeple sign
Two MCC of Ventilator Associated Pneumonia
What causes Pertussis
What are the three stages of this condition
Staph A, Pseudomonas
Bordatella
Catarrhal: lacrimation
Paroxysmal: whoop
Convalescent: resolution
How is Whooping Cough Tx
Pancreatitis induced pleural effusion would have ? inc lab result
What does surfactant expression begin during development
Pertussis: Azithromycin or TMP/SMX
Amylase
20wks; gradual increase until 36wks
What is the MC presenting S/Sx and finding of a PE
Define Esophageal Ring
What syndrome can this develop
S: tachypnea
Sx: dyspnea at rest/exertion
F: normal CXR
Schatzki- distal stricture at B-ring junction; almost always w/ hiatal hernias
Steakhouse: progressive dysphagia to solids
Define Esophageal Web
? syndrome can develop w/ esophageal webs
Pts that develop the above syndrome are at increased risk for developing ?
Membrane across mid/upper esophagus MC d/t GERD
Plummer Vinson:
iron deficient anemia Dysphagia Cervical-web Glossitis Cheilosis
SCC
How are esophageal strictures Dx
How are these Tx
When do umbilical hernias need surgical referral
Initial: barium swallow, upper endoscopy
H2 antagonist, Omeprazole, Endoscopy w/ dilation; PPI dec recurrence
Persists >2yrs of life
Define Strangulated hernia
Define Obstructed Hernia
Define Incarcerated
Blood supply has been impaired
Irreducible hernia w/ intact blood supply
Occluded and irreducible, can progress to strangulated
? is the main RF for esophagitis
Endoscopy for esophagitis work up shows multiple, shallow ulcers meaning ? etiology
Two MC meds that cause medication induced esophagitis
ImmComp
HSV
NSAIDs, Bisophosphonates
When is Eosinophilic Esophagitis a considered Dx
What would be seen on barium swallow and how is it definitively dx
Radiation exposure exceeding ? much puts these Pts at risk for ?
Asthma and GERD non-responsive to antacids
Ribbed esophagus w/ multiple corrugated rings; Biopsy
5000 cGy; Stricture
What is the hallmark sign of infectious esophagitis
Since esophagitis primarily occurs in ImmComp Pts, what are the MC microbes
What would be seen on exam if etiology was fungal
Odynophagia- pain w/ swallow
C albicans HSV CMV
Linear yellow/white plaques w/ odynophagia
What would be seen on PE if etiology of esophagitis was viral and how they’re Tx
How is esophagitis Dx
How is esophagitis Tx depending on cause
HSV- shallow punched out lesions; Acyclovir
CMV- large, solitary ulcer; Ganciclovir
Biopsy Culture Endoscopy
Double contract esophogram
Candida: Fluconazole
HSV: acyclovir
CMV: ganciclovir
Corrosive: steroid
Chronic GERD puts Pts at risk for ? Dz
What are Pts at risk for if the above issue develops
What is the gold standard and test of choice for Dx
Barretts; f/u screening q3-5yrs
Adenocarcinoma
Gold: 24hr pH monior w/ manometry confirmation
TxoC: endoscopy w/ cytologic washing
? meds lower LES pressure and worsen GERD Sxs
Pts w/ GERD Sxs and ? RFs are considered high risk and need endoscopy
Progesterone Anticholinergic/histamines Nitrates TCAs CCBs
Hematemesis Age >50 Weight loss Anemia/melena Recurrent vomiting Dysphagia
How is GERD Tx
H2 antagonist class ending
PPI class ending
H2 antagonist, Qd then BID
Sxs persist- switch to PPI
Continue x 8wk after Sx control
- tidine
- prazole
Define Achalasia
What will be seen on swallow studies
What is the best study for Dx
How is achalasia Tx
Motility d/o in distal esophagus d/t loss of auerbach plexus- no peristalsis and weight loss
Bird beak/Rat tail
Manometry
EGD dilation or mytomy
CCBs, Nitro, PPIs prevent stricture return
Define Diffuse Esophageal Spasm
What would be seen on a barium swallow
What is the best method to confirm a Dx of esophageal spasm after a barium swallow and how is this Tx
Non-peristaltic, painful contractions after ingesting hot/cold food
Corkscrew appearance
Manometry; w/ Nitrates/CCB/Botox
How does esophageal cancer present
What is the MC type of esophageal Ca
What part of the esophagus is MC affected and by ? RFs
Dysphagia to solids progressing to liquids w/ adenopathy
World: SCC
USA: Adeno d/t GERD/Barretts
Distal; men who smoke
How is esophageal Ca Dx
How is this Tx
How often are Pt w/ Barretts f/u and screened
Endoscopy w/ biopsy- test of choice; CT for staging
Resection, Radiation, Chemo w/ 5-FU
q3-5hrs
Rosh Pulm- #19
Rosh Cards- #70
GI- Gastritis
What happens if achalasia is left untreated
? infectious Dz can cause Achalsia Sxs
Candidiasis esophagitis not responding to itraconazole needs ? Tx adjustment
Sigmoid esophagus
Chagas
Itraconazole suspension of Voriconazole
Refractory candidiasis esophagitis infections are Tx w/ ?
How is CMV esophagitis Tx but is limited d/t ? s/e
Pts intolerant or unresponsive to the above Tx are then Tx w/ ?
IV Caspofungin
Ganciclovir; neutropenia
IV Foscarnet
How is herpetic esophagitis Tx
Pts that are intolerant/unresponsive to the above Tx are then Tx w/ ?
Normal LES pressure ranges
A/F/V-cyclovir
IV Foscarnet
10-35mmHg
Most GERD reflux is induced by ?
What two autoimmune Dzs can have worse GERD Sxs
? Dx study needs to be avoided during a GERD work up
Gastric distension by vasovagal reflex
Sjogrens, Scleroderma
Barium study
When Tx GERD w/ H2 antagonists (-tidine), Pt education for pill use
? medication is the preferred initial med for Tx of GERD
What two Sxs are common indicators of gastritis
Take prior to eating
PPIs: -prazole
Inflammation of stomach lining- Dyspepsia, Abdominal pain
Acute Gastritis usually develops in ? part of stomach
What are the two types of Chronic Gastritis
Antrum
Type A- in fundus d/t anti-parietal Abs, associated w/ Pernicious Anemia; risk for AdenoCa
Type B- in antrum d/t NSAIDs, Pylori and often ASx; risk to develop PUD
How is Gastritis Dx
What are 3 methods to detect H Pylori if a suspected DDx
How is this Tx
Endoscopy w/ 4 biopsies
Fecal Ag, Serology, Urea breath test
Mild: Famot/Cime-tidine
Sev: Omeprazole taper, d/c when ASx x 8wks
What is the next step for gastritis if Sxs return ≤3mon of d/c acid suppression meds
What are the s/e of PPI use
What RF increases incidence of gastric ulcers and dec healing time
Upper endoscopy
HypoCl/B12/Mg
Dec Ca absorption
Pneumonia
C D-ff
Cigarette smoke
What type of PUD ulcer are MC
The MC is MCC by ?
How do Pts present
Duodenal > Gastric
H pylori
Dec pain w/ food
Duodenal ulcers are MC located ?
If located elsewhere, ? is the increased risk
PUD can rarely be caused by ? syndrome
Anterior duodenum
Posterior= bleeding from gastroduodenal artery/acute pancreatitis
Zollinger Ellison- gastrinoma of pancrease releasing excess gastrin; >200=Dx
Gastric ulcers are MC found located ?
? is the MCC of non-hemorrhagic GI bleed
This MC typically presents as ?
Lesser curvature of antrum
PUD
Melena
What is the most accurate Dx test for PUD
All Pts undergoing this test need ? additional test
What would be seen on labs/rads if an ulcer ruptured
Upper endoscopy
H pylori biopsy
Inc serum amylase, Pneumo-diaphragm
How is PUD Tx
When is Pylori eradication testing performed
How are Pts w/ NSAID induced PUD Tx
All Pts- PPI
H Pylori: Metro/Clarithromycin Amox PPI
≥4 weeks after completing therapy
PPI for minimum of 8wks
Define Functional Dyspepsia
Functional dyspepsia is the MCC of ?
How can this be managed
Dyspepsia w/out etiology on scope/studies
Chronic dyspepsia
Desipramine, Nortriptyline
Buspirone- dec bloat/fullness
What are the 4 RFs for gastric Ca
How does this form present
How is this Dx
FamHx
Anemia, pernicious
Gastric ulcers
H pylori**- most important
Vague fullness/early w/ meal
Anorexia
N/V w/ weight loss
EGD w/ biopsy; Pos guiac
What lab results may be seen in Pts w/ gastric Ca
How is this Tx
What mnemonic is used for gastric Ca suspicion
Microcytic/Hypochromic
Gastrectomy w/ rad/chemo
WEAPON:
Weight loss Emesis Anorexia Pain Obstruction Nausea
What is the MC early Sx of gastric Ca
Overall, what is the MC Sx
What lymph nodes will be involved
Epigastric discomfort/indigestion
Weight loss
L-side virchows node (r-side= HL)
Sister Mary, Joseph- umbilical
What is the MC type of gastric cancer worldwide
What EGD finding suggests gastric Ca presence
Define Celiac Dz
Adeno
Linitis Plastica- diffuse thickening of stomach wall
Immune response to gluten causing injury to proximal end mucosa
What blood test is used to Dx Celiac Dz
How is the Dx confirmed after ? positive test
Celiac Pts may need correction of ? deficiencies
IgA endomysial and transglutaminase Ab
+ endymysial Ab: mucosal biopsy from duodenal bulb
B12 Ca D, Vit Fe Folate
What lab test has a higher spec but lower sense for Celiac testing
What causes lactose intolerance
Pts may need ? supplementation
EMA-IgA
No lactase= dec conversion of lactose in glucose/galactose
Ca
How is a presumptive Dx of lactose intolerance made
How is the Dx confirmed
Fecal pH test can also be performed w/ ? being normal
Mild Sxs w/ lactose ingestion that resolve 5-67d after eliminating from diet
Lactose breath H test
+= 20ppm over baseline
Normally alkaline;
Abnormal- intolerance, Rotavirus/EColi infection
How is lactose intolerance Tx
Crohns involvement
Appearance on colonoscopy
Lactase supplements;
Lactose avoidance
Global GI tract, spares rectum
Skip lesions, cobble stone
? type of diarrhea does Crohns have
Risk for fistula development
Appearance on x-ray
Non-bloody w/ frequent abdominal pain
Yes
Terminal ileum string sign
Crohns histological findings
Effect of smoking on condition
What serology marker is used for this
Transmural, non-caseating granuloma
Worsens Dz
ASCA and Perinuclear antineutrophil cytoplasmic Ab
UC area of involvement
Appearance on colonoscopy
? type of diarrhea do Pts have
Colon, usually w/ rectum
Continuous lesions
Non-painful, bloody
UC risk for fistula development
Appearance on x-rays
Histological findings
No
Erythematous, friable ulcers w/ lead pipe appearance d/t loss of haustral folds
Mucosa only crypts abscess
Effect of smoking w/ UC
? serology marker is used
How is this Dx
Protective
p-ANCA
Barium enema- lead pipe
Flex sigmoid- dec risk for perf
? complications can arise from UC
Pts need ? nutritional screening q1-2yrs
How are UC and Crohns Tx
Toxic megacolon, Ca
Vit D, B12
Sulfasalazine/Mesalamine- block prostaglandin release; UC > Crohns
What is the next step in Tx if Pts w/ UC/Crohns don’t respond to 5-ASA Tx
What med is used during exacerbation
What meds can be used in conjunction w/ the above if no response is achieved
Metronidazole
Systemic CCS
Azathioprine, 6-Mercaptopurine
What bile acid sequestrants are used during UC/Crohns Tx
Which one can be Tx w/ surgery
What do asthma exacerbations get upon d/c
Cholestyramine, Colestipol
UC w/ total colectomy
Beta agonist, CCS
? antihypertensive med can cause prolonged HOTN when used w/ Sildenafil
? P2Y12 inhibitor is c/i in Pts w/ MEdHx of TIA <12mon
What criteria is used for Dx IBS
A-blockers
Prasugrelor
Rome:
Pain x 3d/mon x 3 mon w/ ≥2 of:
Improved w/ BM
Changed freq/consistency
Pts w/ IBS report w/ ? c/c and ? relieving fact
What red flags make the Rome Criteria for Dx invalid
What is the next step if red flags are present
N/V, bloat relieved w/ defecation
Hematochezia Weight loss
Fever
Imaging or colonoscopy; no labs- normal during IBS
How is IBS Tx
Toxic megacolon is a complication of ?
How do Pts present
Hyoscyamine before meals for antispasmotic effect
IBS: UC > Crohns
Shock Abdominal distension Fever Enlarge colon >6cm Peritonitis
Criteria used w/ radiology to Dx Toxic Megacolon
How is this Tx
Three of:
Fever Leukocytosis >10.5K Anemia Tachy >120bpm
One of:
HOTN E+ imbalance AMS Dehydration
Ceftriax+Metro, Decompression, Resection
? is the MC vessel blocked during intestinal ischemia
What would be seen on x-rays
How is it Dx by gold standards and how is it Tx
Superior Mesenteric artery
Thumb printing
Angiography; Revascularization
How does chronic mesenteric ischemia present
What MedHx do Pts usually have
? two meds can help prevent formation of new polyps
Post-prandial pain w/in 60min of eating, resolves <3hrs
PVDz Smoker DM
ASA, Cox-2 inhibitors
Polyp growths are the MCC of ? in Peds
These tend to be more malignant w/ ? association
Define Familial Adenomatous Polyposis
Painless rectal bleeding
More superior in intestine they are
Thousands of polyps by 15y/o, Ca by 40y/o
When do first degree relatives need screening w/ FamHx for Familial Adenomatous Polyposis
? types of polyps are common in the distal colon/rectum
What types of plyps have a higher risk for Ca transformation
Genetic screening after 10y/o
Adenomatous: MC tubular type, least risk
Villous adenomas
When do Pts start routine screening colonoscopies
How can this form of Ca be screened for
How often are scopes performed
45y/o, ending at 75y/o
Guiac q12mon
Fecal q12mon
FIT DNA q 1-3yrs
Flex Sigmoid: q5yrs or,
q10yrs w/ FIT every year
Colonoscopy: q10yrs
CT colonography q5yrs
What is seen on barium study if colon cancer is present
How is this Tx
? is the MCC of lower GI bleeds and how does this MC present
Apple core lesion
Resection w/ 5-FU chemo
Diverticulosis- painless rectal bleeding in Pt w/ LLQ pain
Where are diverticuli MC found
How does diverticulitis w/ macroperforation present
? triad is considered a pos Dx
Descending colon;
Western society- sigmoid
Constipation LLQ pain
Inc WBC/CRP Fever
No vomit, CRP >5mg, LLQ tenderness
How is diverticulosis Dx
What ABX are used for Tx
When is admission indicated
Noncontrast CT: fat stranding w/ thick wall
X-ray r/o free air
Avoid colonoscopy
Cipro or Augmentin w/ Metronidazol
Complicated
Uncomplicated w/ fever >102.5, Septic, ImmSupp, NPO
What are the bulk-forming laxative
What are the osmotic laxatives
What are the suppositories used for constipation Tx
Psyllium Ca polycarbophil Methylcellulose Dextrin
Lactulose Mg Polyethylene glycol Sorbitol
Glycerin Bisacodyl Senna
? Pt presentation w/ constipation needs to have colon Ca r/o
Constipation lasting more than ? and refractory to Tx needs further work up
What causes Traveler’s Diarrhea
> 50y/o w/ new onset constipation
> 2wks
E Coli
Diarrhea after picnic/egg salad
Diarrhea after shellfish
Diarrhea after pork/poultry
Staph A
Vibrio cholerae
Salmonella
Diarrhea after poorly preserved canned foods
? lab result indicates inflammatory diarrhea
How can the frequency of diarrhea be decreased
C perfringens
WBCs in stool
Loperamide Diphenoxylate Codeine Paregoric
Hep A virus type and mode of transmission
Where are epidemics seen
What vectors can also carry this virus
RNA virus transmitted via ATM
Daycare/Barracks
Water, Milk, Shellfish
What labs are seen during Hep A during early/late phase
How is this Tx
When are vaccinations given
Acute: anti-HAV IgM
Later: anti-HAV IgG
Immune globulin IgG <2wks since exposure
12-23mon
Hep B virus type and mode of transmission
What lab result is seen first and is the first sign of infection
What lab result is seen w/ viral replication and indicates infectiousness
Where is the Ag core going to be found
DNA virus w/ Dane particle from sex/blood products
HBsAg
HBeAg
HBcAg- intracellular, liver- Pt now ‘has’ Hep B
What is the first response seen to Hep B infections
How is acute Hep B Dx
What is the second response seen in response to Hep B
What is the last response seen to Hep B infections
HBcAb IgM; x3mon- IgG
HBcAb
HBeAb IgM; x3mon- IgG
HBsAb IgM; x3mon- IgG
What lab result suggests Pt is immune to Hep B
How do you differ active from passive Hep B immunity
How do you Dx Chronic Hep B
anti-HBs IgM/IgG
ABcAg; anti-HBc Ab
HBsAg is always Pos
Hep C virus type and mode of transmission
What is different between Hep C and B
How is Hep C Dx
Single RNA strand in transfusion recipients and IVDA
Hep C more likely to be chronic
Anti-HCV Abs
How is Chronic Hep C managed
Hep D virus type and mode of transmission
Hep D will cause >50% of all ? cases
Interferon
RNA virus transmitted w/ HBsAG
Fulminate hepatitis
Hep E infection resembles ? and is transmitted by ?
MC infectious cause of dilated cardiomyopathy
What are the 3 phases of acute heptatitis
Hep A; via ATM
Enterovirus: Coxsackie B
Prodromal: dec smoking, spiking fever- Hep A
Icteric: jaundice after fever
Fulminant: encephalopathy, coagulopathy
What lab results are seen w/ acute hepatitis
Only ? etiologies of hepatitis can become chronic
Define Fulminant Hepatitis
Inc ALT/AST:
Acute >500, Chronic <500
B, C, D
Acute liver failure in Pts w/ hepatitis
What are 3 etiologies for Fulminant hepatitis
How does this form of hepatitis appear on PE
Tylenol OD- MC in USA
Viral infection
Reye syndrome- kids w/ ASA use after viral infection
Encephalopathy w/ astrix
Coagulopathy- INR ≥1.5
Reye syndrome- uncontrollable N/V w/ hand/foot rash
How is Fulminant Hepatitis managed
What is definitive Tx
What lab result suggest alcoholic liver dz
IV fluid/E+
Mannitol- inc ICP
PPI- stress ulcer prophylaxis
Liver transplant
AST>ALT x 2
AST- normally in mitochondria, ETOH induces injury/release
What are the etiologies for non-alcoholic fatty liver dz
What are the two types
HyperLipid Obese GCCS DM
NAFL: benign, no fibrosis or malignant potential
NA Steatohepatitis- inflammation and fibrosis w/ premalignant potential
How is NAFL Dz Dx
Define Cirrhosis
What is the MCC
Biopsy- fatty deposits w/out alcoholic Hx
Irreversible fibrosis w/ nodular regeneration 2/2 chronic liver dz
Chronic Hep C > alcohol
What may be seen on PE of cirrhosis
How is this Dx and managed definitively
What type of f/u surveillance do these Pts need
Telangiectasis Ascites Gynecomastia Confusion Lethargy Asterixis Medusa Spider angioma
Liver biopsy; Transplant
RUQ US q6mon
How is cirrhosis encephalopathy managed
How is cirrhosis ascites managed
How is cirrhosis pruritus managed
1st: Lactulose/Rifampin
2nd: Neomycin
Na restriction
Spironolactone Furosemide
Cholestyramine
How is cirrhosis staging done
? autoimmune d/o can cause cirrhosis
? lab/rads are ordered at Dx
Child-Pugh: Serum albumin Encephalopathy Ascites Total bili PT INR A: 5-6pts B: 7-9pts C: 10-15pts
Wilson’s Dz- inc copper, dec ceruloplasmin w/ +FamHx
A-fetoprotein- high= MRI
EGD
Pt w/ cirrhosis presenting w/ ? two Sxs suggest spontaneous peritonitis
What marker is used to see if Pts convert to cancer
? vascular issue can develop and present in a triad
Fever, Abd pain
A-fetoprotein
Budd Chiari- hepatic vein thrombosis: Pain Ascites Megaly- lver
? is the MCC of portal HTN in peds
What are the two types
How is this Dx
Budd Chiari
1: hepatic vein thrombisis (MC)
2: hepatic/IVC occlusion
RUQ Us- screening
Venography- test of choice
Define ‘Nutmeg Liver’
How is Budd Chiari Tx
How is autoimmune hepatitis Tx
Congestive hepatopathy, DDx for Budd Chiari Dx
Shunt decompression
Diuretics for ascites
CCS
How is Wilson’s Dz induced cirrhosis Tx
What is used for prophylaxis against variceal hemorrhage/esophageal bleeds
Define Hepatocellular Carcinoma
Penicillamine- chelation therapy
Nadolol, Propranolol
Tumor developing d/t chronic liver dz and cirrhosis
Hepatocellular Carcinomas work up once lesion <1cm is found
What sizes have a good prognosis w/ transplant Tx
Define Cholelithiasis
Contrast MRI;
Neg- f/u US q3mon
No rad findings- biopsy
Single tumor <5cm
≤3 tumors all ≤3cm
Gallstones (cholesterol > pigment) w/out inflammation
What are the RFs for cholelithiasis
? is the cardinal Sx of cholelithiasis
How is this Dx
5 Fs: Fat Fertile Female Flatulent Forty
Biliary colic
RUQ US after 8hrs of fasting
What lab result is elevated when there is obstructed bile flow in cholelithiasis
What lab result is decreased
What clotting factors are made in the liver and how are they assessed
ALK-P, confirmed w/ GGT
Albumin
1 2 5 7 9 10 12 13 w/ PT
How is cholelithiasis Tx
Black gallstones mean ?
Brown gallstones mean ?
Ursodeoxycholic- dissolves stones over 6-9mon;
Cholecystectomy
Hemolysis, ETOH related cirrhosis
Asian, parasite/bacterial infection
Define cholecystitis
What PE finding aids w/ Dx
What ABX are used for cholecystitis prior to ? surgical procedures
Cystic duct obstruction leading to EColi infection/inflammation
Murphy- pain w/ inspiration Boas- pain to R shoulder;
US then HIDA- most specific
Ceftriax and Metronidazole;
Cholecystostomy- percutaneous drainage
? pre-malignant condition can develop from chronic cholecystitis
Define Choledocholithiasis and what this can lead to
What PE finding is more suggestive of choledocholithiasis
and what is the Dx test of choice
Porcelain GB
Gallstone in common bile duct; cholestasis- inc ALP w/ GGT
Jaundice; ERCP
Define Cholangitis
What triad presents w/ ascending cholangitis and what additional Sxs makes this into a pentad
How is this Dx
Biliary tract infection 2/2 obstructed common bile duct and EColi/Klebsiella
Charcot: F/C, RUQ pain and jaundice;
HOTN/shock and AMS
US then cholangiography via E/MRCP
How is pulmonary wedge pressure measured
HyperK EKG changes
S1/S2 sounds
Swan Ganz cath
Peaked T, Dropped P, Wide QRS, Sine wave
S1: MT S2: AP
What is the classic presentation for pancreatic cancer
What is the imaging study of choice for this
What PE sign may be seen
Painless jaundice and pruritus w/ mass compressing bile duct w/ jaundice
Abdominal CT:
Neg: endoscopic US w/ biopsy
Pos: resection w/ biopsy
Courvoisier sign- palpable gallbladder
What is the worst type of pancreatic cancer w/ the lowest prognosis
What is the MC s/e after PUD surgery
What is the MCC of pediatric intestinal obstruction
Ductal adenocarcinoma
Weight loss d/t early satiety
Intussusception- colicky pain, vomit and bloody stool
How is intussusception Dx
MCC of small bowel obstruction
MCC of large bowel obstructions
US or pneumatic enema- Dx and therapeutic
Adhesions
Neoplasms
? is the MC location for primary anal fissures to develop and what would be seen on PE of chronic fissures
How are these Tx in order
What part of the cardiac system has the slowed electrical conduction
Posterior to midline; skin tags
WASH, Topical nifedipine/Nitro, Botox, Lateral internal sphincterotomy
AV node
What causes Primary Anal fissures posterior to midline
What causes Secondary anal fissures lateral to midline
What type of cells make surfactant
Trauma Constipation Vaginal delivery
Crohns Malignancy Communicable/Granulomatous Dzs
Type 2 pneumocytes
What criteria allows for Tetrology Pts to play in sports after surgical correction
What mnemonic is used for DDxs for pancreatitis
R ventricular pressure <50mmHg
GET SMASHED
Gallstone Ethanol Trauma Steroid Mumps Autoimmune Scorpions HyperCa Hyperlipid ERCP Drug
How is chronic pancreatitis’ presentation different from acute
What is the classic triad for chronic pancreatitis
What anatomical variant may be seen w/ chronic cases
Steatorrhea, Fat malabsorbed
Pancreatic calcification Steatorrhea DM
Pancreatic pseudocyst
? lab result is more specific for pancreatitis
What is the Dx test of choice
How is this x if biliary sepsis is present
Serum lipase 3x higher
Initial: CT or MRCP
Dx: CT** or
Xray: sentinel loop w/ dec bowel sounds; colon cut off sign
ERCP
What lab result is highly suspicious for gallstone induced pancreatitis
What lab result will be seen on BMP
Once admitted, how are Pts managed
ALT 3x higher than normal
HypoCa- necrotic fat binds to Ca via soponification
LR w/ Meperidine and Imipenem
What is the most sensitive and specific test for pancreatic function w/ chronic pancreatitis
What tumor marker is used to track PTs after pancreatic cancer Tx
Name of surgical procedure
Fecal elastase
CA 19-9
Pancreaticoduodenectomy- whipple
How is pancreatic cancer managed if Pt is inoperable
MC Sx of anorectal Ca
What is the MC type
ERCP w/ stent
Hemaochezia w/ tenesmus
Adenocarcinoma
What studies are ordered for hemorrhoids
How are hemorrhoids classified
Anoscopy- benign PE
Colon/Sigmoidoscopy- >40y/o w/ RFs for cancer
Degree of prolapse:
1: none below dentate line
2: spot reduction
3: manual reduction
4: irreducible, may strangulate
How are internal hemorrhoids Tx
Hemorrhoidectomy is used for Tx of ? stages
What is the MC microbe and location for anal fistula/abscess
Docusate/Psylliumw/ sitz baths
Lidocaine/witch hazel
Rubber band ligation
+bleeding= sclerotherapy
Stage 4 and medical failures
Staph A; posterior wall
How are anorectal abscess and fistulas Tx
Define anal fissure
InD then WASH:
Warm water cleanse Analgesic Sitz bath High fiber
Painful linear tear/crack along distal canal
How are anal fissures Tx
Define Vit C deficiency
What condition develops d/t the deficiency
First: Sitz bath, inc water/fiber
2nd; Nitro, Nifedipine
3rd: botox to internal sphincter
4th: internal sphincterotomy
Ascorbic acid
Scurvy: tooth loss w/ 3 Hs-
Hyperkeratosis: hyper hair follicles w/ curled hair
Hemorrhage: gun/skin/joint bleeding and dec healing
Heme: anemia w/ glossitis
How is Vit C deficiency Dx
How does Vit D deficiency appear on PE
What would be seen on x-rays
Leukocyte ascorbic levels > serum levels
Bone pain
Prox muscle weakness
Bowing of long bones
Looser lines- pseudo Fxs
How is Vit D deficiency Tx
What is the other name for Vit D and it’s role in the body
Viatmin A deficiency/toxicity
Ergocalciferol
1,25 Dihydroxycalciferol- needed to absorb Ca from intestine
Inc: idiopathic intracranial HTN
Dec: night blindness
What is seen on PE if Vit A deficiency is present
B2 deficiency syndrome name
B1 Deficeincy
Bitot’s spots: white spot in conjunctiva
Riboflavin-
Oral: magenta colored tongue
Ocular: photophobia
Genital: scrotal dermatitis
Thiamine: d/t alcoholism
What are the two forms of B1 Thiamine Deficiency
What form of encephalopathy can form
Why is this such a concern
Dry Beriberi: symmetric peripheral neuropathy
Wet Beriberi: high output HF w/ dilated myopathy
Wernicke: ataxia, confusion, ophthalmoplegia
Neuro emergency commonly seen in alcoholics
? form of dementia can form w/ B1 Thiamine deficiency
What are the etiologies of B3 Deficiency
What condition does this present as
Korsakoff: short term loss w/ confabulation d/t Wernickes
Untreated corn lacking tryptophan
Carcinoid syndrome: inc tryptophan metabolism w/ serotonin production
Hartnup dz: dec tryptophan absorption
Pellagra: Dermatitis (sun exposed) Diarrhea Dementia
How does B6 deficiency present
How is B12 absorbed into the gut
What is the MCC of this deficiency
Peripheral neuropahty and anemia
W/ intrinsic factor in distal ileum
Pernicious anemia- dec IF d/t parietal cell Abs
How does B12 deficiency appear on PE
How is this Dx
Since this presents similarly to folate deficiency, what lab results are used to differ the two
Initial Sx: symmetric paresthesia in legs
Lat/Post spinal cord demyelination: loss of vibratory/proprioception, dec DTRs
CBC w/ peripheral smear: macrocytic w/ hypersegmented neutrophils and macro ovalocytes
Inc LDH, homocysteine, methylmalonic acid
Define RA
How does this present on exam
What two syndromes can be seen w/ this Dz
Chronic autoimmune inflammatory dz w/ persistent symmetric polyarthritis
AM stiffness improving through day, affects DIP and PIP
Felty: RA + splenomegaly + dec WBC
Caplan: coal worker lung and RA
What are the two hand deformities seen w/ rheumatoid arthritis
How is RA Dx
How is RA Tx w/ DMARDs
Boutonniere: PIP flexion, hyperextend DIP
Swan neck: DIP flexion, hyperextend PIP
Rheum factor: sens, not spec
Anti citrullinated peptide Abs: most spec
NSAIDs w/ CCS
Hydroxychloroquine Methotrexate* Sulfasalazine
How is RA Tx w/ Biologics
Lab results seen w/ OA
What DDx can occur w/ OA in the knee
IL-1 antagonist: Anakinra
Anti-TNF: Etanercept Infliximab Adalimumab
Normal ESR/CRP
Bakers Cyst
What are four meds that can induce lupus
Define SLE
What lab result is usually pos in these Pts
Procainamide Isoniazid Quinidine Hydralazine
Autoimmune dz w/ rash (maculopapular butterfly), joint pain, fever
ANA and anti-histone Abs, normal complement
What are the three types of SLE
How is this Dx
What lab result means Pt is at increased risk for thrombosis
Fixed erythematous: rash on cheeks/nose bridge
Discoid: annular, erythematous patches
Systemic: Renal Alopecia CNS Eye CV
Initial: ANA
Anti-double DNA/AntiSmith- 100% spec
Antiphospholipid Ab syndrome
What lab result can indicated females w/ SLE will have frequent miscarriage/livedo reticularis
What complement levels are dec during flares
? lab results suggest increased risk for neonatal lupus erythematosus during pregnancy
B-2 glycoprotein 1 Ab
C3,4 CH50
Anti Ro/La
? lab result has high sensitivity for an etiology for drug induced lupus
How is SLE managed
Define Scleroderma
Antihistone Ab
Hydroxychloroquine
NSAID/Acetaminophen
Sun protection
CT d/o w/ thickened skin (sclerodactyly)
Limited Cutaneous Systemic Sclerosis is AKA ? syndrome
How is the vascular phenomenon Tx
How is Scleroderma Dx
CREST: Carlcinosis Raynauds gErd, Sclerodactyly Telangiectasis
Raynauds- CCB and prostcyclin
Anti-centromere Ab- limited crest, better
Anti-SCL 70 Ab- diffuse Dz w/ multiple organ involvement
How is Scleroderma Tx to prevent progression/if pulm system is involved
What meds are used if P-HTN develops
What is the drug of choice for renal crisis
Methotrexate
Mycophenolate
Cyclophosphamide
Ambrisentan and Tadalafil
Captopril
Define Ankylosing Spondylitis
This Dx is also associated w/ ? other four Dx
How is this condition Dx
Seronegative arthropathy affecting sacroiliac joints
Psoriasis IBDz Anterior uveitis AR
CRP/ESR, HLA-B27
X-ray: gold standard
How is Ankylosing Spondylitis managed
What meds can be used for relieving joint Sxs
What lab result will be Pos in >80% of Reitters Pts
PT w/ NSAIDs
Refractory: a-TNF Etanercept/Infliximab
Sulfasalazine, Methotrexate
HLA-B27
Define Reitters Syndrome
What GI infections can cause this
Other than + HLA-B27, what other lab result aids w/ Dx
Autoimmune response to infection, MC G > C
Salmonella/Shigella
Campylobacter
Yersinia
Aseptic synovial fluid
How is Reitters Tx
Define Gout
How is this Dx if the attack is in great toe
NSAIDs/ABX
No response: methotrexate, a-TNF, CCS
Uric acid accumulation in joints/tissue
Podagra
How does acute gouty arthritis present
How does chronic gout present
Define Pseudogout
Podagra, monoarthropathy
Tophi deposition
Ca pyrophosphate crystal in tissues, MC knee, wrist
What will be seen on x-rays of pseudogout
How is gout Dx
How is pseudogout Dx
Chondrocalcinosis- linear radiodensities
Neg birefringent needles
Rat bite/punched out erosion on x-ray
Inc serum uric acid/ESR/WBCs
Pos birefringent, rhomboid crystals
How is acute gout Tx/managed
What is avoided
When/How is chronic gout considered for managed
1st: Indomethacin, Naprosyn
2nd: colchicine, steroid
ASA- inc serum uric acid
Tophi or ≥2 attacks/year:
Allopurinol: red uric acid production
Probenecid: inc uric acid secretion
NSAID or Colchicine
How is Pseudogout Tx
What is used for prophylaxis
Define Polymyositis
CCS then NSAID
Colchine
Chronic, idiopathic inflammation causing symmetric, proximal weakness/pain
What would be seen on PE in Pts w/ Polymyositis
What parts of the body are MC affected
How is Polymyositis different from Dermatomyositis and Polymyalgia Rheumatica
Early fatigue
Inability to rise from seated
Shoulders, Hips
Derm: skin changes
PR: lack of joint pain
Polymyositis:` inc muscle enzymes/CrK
Define Dermatomyositis
What differentiators may be seen on exam
Autoimmune myopathy w/ symmetric proximal weakness AND cutaneous findings
Gottrons: raised purple, scaling plaques on bone prominences
Shawl/V-sign: pink rash on neck/trunk
Heliotrope rash: purple/red rash around eyes/on lids
What would be seen on muscle biopsy results in Dermatomyositis Pts
What serology result is specific for Dermatomyositis
What marker is specific for interstitial lung fibrosis
Endomysial inflammation
Anti-Mi-2 Ab
Anti-Jo 1 Ab
How is Polymyositis/Dermatomyositis Tx
What two presenting factors are unique for fibromyalgia
How is this Dx
Suppress w/ CCS
Long term management- Methotrexate
Sleep disturbances, Sxs worse w/ stress
Pain w/ 4kgs of force in 11 of 18 sites
How is fibromyalgia managed
What is the only FDA approved med for Tx
What is the preferred method of PT
TCAS
Pregabalin
Swimming
What part of the body is attacked during Sjogrens
How is it Dx
What test can be done in office for Dx
How is Sjogrens Tx
Exocrine glands: Xerostomia, Keratoconjunctivitis sicca
ANA, Anti-SS A/B (anti-RO/La)
Schirmers: pos if <5mm lacrimation in 5min
Pilocarpine- cholinergic for xerostomia Cevimeline
What is the Rule of 50 for GCA
What causes this to occur
What branches of the carotid artery are affected by GCA
Steroids ESR Age >50
Viral infection causing monocyte activation and cytokine production
Post-Ciliary Occipital Ophthalmic Temporal
GCA prevalence is closely linked w/ ? other Dx
What type of vision loss can occur
Polymylagia Rheumatica- inflammatory condition causing synovitis, bursitis and tenosynovitis
Amaurosis fugax- temporal monocular d/t ischemic optic neuritis
What do Pts present w/ as c/c w/ polymyalgia rheumatica
How are Pts w/ this condition managed
Define Polyarteritis Nodosa and w/ co-Dx may exist w/ this
AM stiffness/joint swelling w/ normal strength
CCS, Methotrexate
Vasculitis of med/small arteries; Hep B/C
Two abnormal c/c making Polyarteritis Nodosa a possible dx
What PE finding supports this
How is a Dx confirmed
New foot/wrist drop
Rapidly inc HTN
Tender lumps on thigh/lower legs
Biopsy- necrotizing arteries
Ateriography- arterial aneurysms
What rheum factor is usually negative in Pts w/ Polyarteritis Nodosa
How is this Tx
? is the MCC of hyperthyroidism
ANCA neg
Steroids w/ cyclophosphamide
Hep B: plasmapheresis
Graves dz
What will lab results show in hyperthyroidism
How is this Dx
How is this Tx
Low TSH, high T3 and FT4 (graves- only T3 is elevated)
Anti-thyrotropin Abs via TSI/TBII
Methimazole- mild cases
PTU- pregnancy
Cards Sx: Atenolol
? is the MCC of hypothyroidism
What will be seen on lab results
How is this form of thyroid d/o Dx
Autoimmune Hashimoto
High TSH, low FT4
Anti-thyroid peroxidase (TPO) Abs
Lab results for Primary Hypothyroidism
Lab results for Secondary Hypothyroidism
How is this Tx
Inc TSH, low T4 w/ high cholesterol
Low TSH and low T4 w/ low cholesterol
Thyroxine/Synthroid- synthetic free T4
What presentation shift DDx from Hashimotos thyroiditis to subacute thyroiditis
? is the MCC of thyroid pain
What path does this follow and w/ ? lab result
Neck tenderness/goiter w/ recent viral illness
Subacute thyroiditis (Quervains)
Hyper to hypo-thyroid;
Inc ESR
Two meds that cause thyroiditis
Infectious thyroiditis are usually d/t ? microbes
How is Subacute/Postpartum thyroiditis Tx
Lithium Amiodarone
Staph/Strep
BBs, ASA
? is the MC RF for thyroid Ca
? is the MC type
? is the MC benign thyroid nodule
Radiation
Papillary in females 40-60y/o
Thyroid adenoma
Thyroid nodules must be bigger than ? size to be palpable
What are the RFs for thyroid Ca
How are thyroid Ca Dx
> 1cm diameter
FamHx
Age >65/<20
Radiation
US
>1cm- biopsy
How to tell if thyroid nodules are malignant or not
How is thryoid Ca Tx
What Tx step is different for ? type of Ca
Thyroid uptake:
Ca- cold, no uptake; next step= FNA
Benign- hot (uptake)
Thyroidectomy w/ chemo
External beam radiation- anaplastic Ca
First line Tx for tinea corporis
How does this appear on PE
What other DDx appears similarly
Topical clotrimazole
Red, itching scaly patch w/ scaly edges and central clearing
Granuloma annulare- benign inflammatory condition w/out scaling
? is the MC overlooked DDx when assessing isolated pleural effusions
What is the MCC of isolated effusions
Define Lymphogranuloma venereum
PE
HF
STD from Chlamydia trachomatis in MSM- painless genital ulcers resolving <3days
What PE finding may be seen w/ Lymphogranuloma venereum
How is this Tx
How are scabies Tx in adults/infants or in nursing home populations
Groove sign- adneopathy above and below inguinal ligament
Doxy
Permethrin 5%; PO Ivermectin
Common s/e to IV delivered chemo Txs
What two atypicals have the least amount of weight gain associated w/ use
Define DI and what lab results are seen
`Irritative voiding Sxs
Aripiprazole, Ziprasidone
Dec ADH secretion= Inc serum Na/Osm, dec urine Osm
Medical management for chronic barotrauma/pain w/ flying
How does Primary Immune Thrombocytopenia present
How are Pts managed
Pseudophedrine (decongestants)
Petechiae, gingival bleeding after viral illness
Platelets <10K: IVIG, steroids transfuse
Platelets >20K: observe
How is life threatening HypoMg Tx
Histology results of psoriasis biopsy
S/e of lidocaine toxicity
IV CaCl or Ca gluconate w/ dialysis
hyerpkeratosis, parakeratosis, acanthosis
Bradycardia, heart blocks
Max doses of lidocaine w/ or w/out epi
Pts w/ open skull Fxs need ? ABX prophylaxis
When do hyperCa Sxs begin in pts w/ hyperparathyroidism
3-5mg/kg w/out; 5-7mg/kg w/
Vanc w/ Ceftriax
> 12
What causes Primary and Secondary Hyperparathyroidism
What saying goes w/ the presentation of hyperparathyroidism
How is this Tx
P: parathyroid adenoma
S: CKDz induce hypoCa/D
Bone pain
Stone, kidney
Groan, ab cramps
Psychic depression, irritability, psychosis
Parathyroidectomy
How is hyperparathyroidism induced hypreCa Tx
How is osteoprorosis induced by hyperparathyroidism Tx
How does hypoparathyroidism present
Furosemide/Calcitonin
Bisphosphonates
Dec PTH= dec Ca levels
What are the two MCC of hypoparathyroidism
What two PE findings suggest this Dx
How is hypoparathyroidism Tx immediately
Damaged parathyroid
Autoimmune destruction
Trousseaus: carpal
Inc DTRs
Chvosteks: facial
Vit D, Ca
Tetany: IV Ca gluconate
How is hypoparathyroidism managed long term
What triad is Dx for hypoparathyroidism
? bone Ca is most associated w/ Paget’s Dz
Recombinant PTH replacement
Dec Ca/PTH, Inc phosphate
Osterosarcoma (Paget’s Sarcoma)
Define Paget’s Dz
? infection can cause this dz
What parts of the body are MC involved w/ Paget’s Dz
Bone remodeling d/o leading to less compact/weaker bones
Measles
Femur Lumbar Pelvis Skull
What PE finding can be seen in Paget’s Dz Pts
How is Paget’s Dz Dx
How is this condition Tx
Excessive skin warmth, Deafness
Inc ALP
CXR- lytic lesion, thick cortex
Bisphosphonates, Calcitonin
What are the two MC types of dyslipidemias
What are normal fasting triglyceride levels
Combined, 2b: elevated total, LDL and Tgl
HyperTrigly- 4; normal total/LDL, inc Trigly
Norm: <150
Mod: 150-499
Mod/Sev: 500-999
Sev: ≥1000
What risks present w/ mod/sev hypertriglyceridemia >500
What risks present when levels exceed >2000mg
What can be seen on PE in Pts w/ Type 3 hyperlipidemia
Pancreatitis, Eruptive xanthomas, Lipidemia retinalis
Chylomicronemia syndrome: recurrent abd pain, N/V, pancreatitis
Palmar xanthomas- yellow palmar creases
What are fasting lipid panel screening started
If results are found to be over ? what is the next step
What meds are used to reduce levels and prevent pancreatitis
20y/o, repeat q5yrs; +RFs= q12mon
> 150mg, 12-16hrs later after fasting
1000- B-quant
Niacin/Fish oil
Fenofibrate*/gemfibrozil
Lipitor
How often is Pt f/u needed when Tx hypertriglyceridemia
Define Dawn Phenomenon
Define Somogyi effect
Sev: q3d
Mod/Mod-Sev: q6-8wks
Down Insulin:
Early AM increase d/t insulin sensitivity/nightly surge of regulatory hormones; Inc bedtime NPH dose/dec snak
So much insulin:
Hyperglycemia rebound d/t GH surge; dec bedtime dose/inc snack
? type of fluid should be used in the Tx of DKA
What lab results Dx DMT1
All DMT1 are Tx w/ ? and ? f/u sequence
NS
Fasting ≥126
A1c ≥6.5%
Random ≥200 w/ Sxs
Insulin w/ Basal/pre-meal
A1c rechecks q3mon
What test is used to differ Type 1 or 2 DM
When does ASA become part of DMT1 Tx
What 2 diuretics and ? CCB are used in Tx
C-peptide test:- T1: low, T2: inc
Men >50y/o or Women >60y/o w/ CVD, HTN, HyperLipid/Albumin
Thzd: Chlorthiazide, Indapamide; Amlodipine
All DM of ? age need additional meds added
What is the MCC of gynecomastia in infants/boys
What is the MCC of gynecomastia in men
40-75= statin
Physiologic gynecomastia
Drug: spironolactone, anabolics, antiandrogens
Idiopathic
Pubertal gynecomastia
Onset, Peak and Duration of insulin
Novolog/Apidra/Humalog:
10-15m 60-90m 4-5hrs
Regular:
30-60m 2-4hr 5-8hrs
NPH
1-3h 5-8hrs 12-18hrs
Levemir
90min no peak 12-24hrs
Lantus
90min no peak 24hrs
How is Osteoporosis Dx
What are the T-scores
This is Tx w/ but w/ ? s/e
DEXA at ≥65y/o or Confirmed fragility Fx
Penia: -1 - 2.4
Porosis: ≤2.5
Sev: ≤-2.5 w/ Fx
Bisphos (Alen/Rise-dronate), jaw osteonecrosis
Sev/continue Fxs: Teriparatide
When do DEXA screenings begin younger than 65y/o
Primary, Secondary, Tertiary adrenal d/o
Define Primary Adrenal Insufficiency
FamHx osteroporosis
Weight <127lbs
Tobacco
CCS
P: adrenal gland destruction, low cortisol, aldosterone)
S: pituitary fails to secrete ACTH, low ACTH/cortisol
T: hypothalamus fails to release CRH
Dec aldosterone/cortisol, inc ACTH
Define Secondary Adrenal Insufficiency
What can cause this form
How is Primary/Secondary Adrenal Insufficiency Dx
Dec ACTH/cortisol, normal aldosterone
MCC: d/c steroid w/out taper, Pituitary adenoma
1: Inc ACTH, Low cortisol
2: low ACTH and Cortisol
What will lab results look like in Primary Insufficiency
How is Primary/Secondary adrenal insufficiency Tx
How are these Pts managed during surgery
HyperK, HpoNa, HypoGlyc, non-gap metabolic acidosis d/t dec aldosterone
1: Hydro/Fludro-cortisone (only ad Fludro in Primary)
2*: resection
Normal response= 3x inc cortisol: IV GCSS and Isotonic fluids
How are Addisonian Crisis Tx
Define Pheos
What other Dxs are these associated w/?
NS/D5 w/ Hydrocortisone- Dx Addisons or,
NS/D5 w/ Dexameth- unknown Dx
Fludro: reverses E+ d/o
Catecholamine secreting adrenal tumor releasing Epi/NorEpi/Dopa (MC adrenal adult tumor)
NF-1, MEN 2A/2b, Von Hippel Dz
What are the 5 Ps of Pheo Sxs
How are Pheos Dx
How are these Tx
Pressure, HTN Pain, HA
Perspiration Palpitations Pallor
24hr catecholamine UA for metanephrine/vanillylmandelic acid
Adrenalectomy w/ phenoxybenzamine or phentolamine then BB/CCB
Define Cushings Syndrome
What two Cas can produce Cushings Syndrome
Why do Cushing’s Dz Pts gain weight
Inc cortisol/BP w/ dec K d/t excess aldosteronism
Carcinoid tumor, Small cell Ca
Cortisol stims fat/carb metabolism= Insulin release=
Increased appetite
How is Cushings Syndrome Dx
How do ACTH levels indicated etiology of Cushings w/ high dose DexaMeth suppression test
24hr urine cortisol: most spec
11pm salivary cortisol
Low_dexa suppression test- inc cortisol/no suppression= Cushings syndrome
Inc ACTH, Dec cortisol- pituitary tumor (CDz only etiology suppressed w/ DexaMeth)
Inc ACTH, no supp: ectopic
Dec ACTH, no supp: adrenal
How is Cushings Dz Tx
How is Cushings Synd Tx
What is the difference between gigantism and acromegaly
Transsphenoid surgery;
Radiation or Pasireotide, Mifepristone
Tumor resection or,
Ketoconazole, Metyrapone
Ketoconazole,
Giant: inc GH in childhood, epiphyses open
Acro: inc GF secretion in adulthood
How is Acromegaly Dx
If surgery is not a Tx option, how are Pts Tx
Define Diabetes Insipidus and the two types
Serum IG-F1 d/t dec fluctuation compared to GH
Oct/Lan-reotide
Deficient/resistant to vasopressin:
Central: MC; no production
Nephrogenic: insensitivity
What drugs can cause Nephrogenic Diabetes Insipidus
What electrolyte abnormalities can cause DI
How is Diabetes Insipidus Dx w/ lab results
Lithium, Amphoterrible
HyperCa, HypoK
High serum osmolality
Low urine osmolality
How is DI Dx
How is a Dx differentiated from Central and Nephrogenic
How is Central Diabetes Insipidus Tx
How is Nephrogenic Diabetes Insipidus Tx
Water deprivation test: DI continues to produce diluted urine
Desmopressin stim test:
Central: dec (no production)
Nephro: continued ( resistant)
Desmopressin/DDAVP
Hydrochlorothiazide, Amiloride
What are the four types of stones seen in Nephrolithiasis
Which ones are radiolucent and radiopaque
Ca Oxalate- MC; grapefruit inc production
Struvite: MC infected d/e chronic UTIs w/ Klebsiella, Proteus
Uric acid- acidic urine
Cystine- genetic difficiency;
Paque: oxalate, struvite
Lucent: cystine, uric acid
How is Nephro/Urolithiasis Dx
What are the indications to admit
How are these Tx based on size
CT w/out contrast
Uncontrolled pain
Anuria
Renal Colic and UTI/Fever
<5mm: spont passage
>5-10mm: elective lithotripsy
>10mm: nephrostomy/stent
Extracorporeal lithotripsy is good for Tx stones ? size
Percutaneous nephrolitotomy is indicated for stones ? size
MC microbe causing pyelonephritis
> 5mm - <2cm
> 2cm diameter
E Coli
What UA result is pathognomonic for pyelonephritis
What other Dx is this pathognemonic for
How is this Tx
WBC casts
Interstitial nephritis
Cipro/Levo/Cephalexin
Preg= admit w/ Ceftriax
What is the most important RF for ED
Priapism is associated w/ ? 3 etiologies
How is ED Tx
Artherosclerosis of cavernous arteries d/ smoking/DM
Trazodone Coaine Sickle cell
Phosphodiesterase inhibitor- Inc cGMP to increase NO release
What ED Txs need to be taken w/ or w/out food
Which one has the longest effect of 24-36hrs
How are med induced priapisms Tx
Sildenafil- w/
Vardenafil- w/out
Tadalafil
Stair climber, Sudafed
What are the 5 types of incontinence
Mixed- MC; stress and urge
Urge- detrusor over activity; MC elderly/nursing homes
Dx: urodynamic study
Functional- physical/mental disabled
Overflow- dec contraction- high post-void volume; common in DM/neuro d/os
Stress- weak pelvic floor; post-pregnancy
How is urinary incontinence Dx
? is the only mandatory lab needed for Peds w/ enuresis
Post-void residual;
Overflow: high
Stress/Urge: norm/low
Urodynamic study:
Stress: normal
Urge: inc during filling
UA
How is incontinence Tx depending on etiology
Mixed- lifestyle mod and floor exercises
Urge- training, Oxybutynin, Imipramine- TCA
Functional- schedule
Overflow- self-cath, Bethanechol, -zosin)
Stress- kegels, vaginal estrogen, pessary, mid-urethral sling surgery
Epididymitis is characterized by ? triad
How is the microbe etiology differed by age
What PE finding is classic for this Dx
Dysuria
Unilateral pain, posterior testis
Swelling
<35: G/C
>35: EColi
Prehns- relief w/ elevation
How is Epididymitis Tx
How is this Tx in Pts that practice insertive anal sex
Define Orchitis
<35y/o: Ceftriax and Doxy
≥35y/o: Levoflox or TMP-SMX
Ceftriaxone and Levoflox
Ascending bacterial infection from urinary tract to testes
How is Orchitis Dx
How is this Tx
What is the MC form of prostatitis
UA w/ culture: Py/Bacter-uria
<35y/o:
Ceftriax + Doxy or
Azithromycin + Doxy
≥35 Levofloxacin (x21 days if w/ prostatitis)
Chronic: enlarged, nontender on DRE
How does acute bacterial prostatitis present on DRE
What needs to be avoided on exam
How are acute/chronic prostatitis Dx
Boggy, warm and tender w/ F/C/malaise and urine Sxs
Prostate massage
Acute:
UA w/ WBC, +cultures
Chronic- negative cultures
How is prostatitis Tx
Pts w/ BPH need to avoid ? three classes of drugs
How does BPH present on DRE
<35y/o: Ceftriax and Doxy
>35y/o: Flqnln or Bactrim
Anticholinergic Sympathomimetic
Opioid
Uniformly large, firm/rubbery
How is BPH Tx
How is this Tx if Pt is refractory to meds
How does prostate Ca present on DRE
Tamsulosin
5-a reductase- dec size: Finasteride/Dutasteride
TURP; transurethral resection of prostate
Hard, nodular and asymmetric
What PSA levels indicate suspected prostate Ca
What are the two RFs for prostate Ca
When is screening done
PSA >4: US w/ needle biopsy
PSA >10: bone scan
Age, FamHx
> 50y/o
40y/o w/ 1* FamHx/AfAm
Prostate Ca Tx is accomplished w/ ? and w/ ? s/e
How is this Tx if mets is present
How is this Tx if no mets are present
Prostatectomy- ED
Ieuprolide- androgen deprivation therapy
Castration
? is the MC type of bladder Ca
What is the ‘classic’ presentation
How is this definitively Dx
Transitional cell Ca
Painless hematuria in smoker
Cystoscopy w/ biopsy
How is bladder Ca Tx
What is the classic triad for renal cell carcinoma
What are the MC type of renal cell carcinoma and w/ ? RF
Endoscopic resection w/ cystoscopy q3mon
Flank pain w/ mass
Hematuria
Clear cell; smoking > transitional
What are the first tests for Dx renal cell carcinoma
How is this Tx
How does testicular cancer present
Abdominal CT/US
Radical Nephrectomy
Firm, painless mass in 15-40y/o
? is the MC type of testicular Ca
What are the two types of this MC
What is the RF for this type of Ca
Germ cell tumor
Seminoma- classic/spermatocytic
Non-seminomatous
Cryptorchidism
How is testicular Ca Dx
What are the 3 most likely locations for mets
What tumor markers are used
US
Lung Abdomen Brain
AFP- NSGCT only
HCH- both
What lab result indicates a higher tumor burden during testicular Ca
How is testicular Ca Tx
? is the most convenient marker for assessing acute RF
LDH
Orchiectomy
Seminoma- radiosensitive
NSGCT- radioresistant
Creatinine
What do UA results look like in pre-renal acute RF
What do UA results look like in renal acute RF
Spec Grav: >1.030
BUN/Cr >20
Osmolality >500
FENA <1
Spec Grav <1.010
BUN/CR <10
Osmolality <300
FENA >1
During renal failure work ups, what doe the following mean
RBC casts
WBC casts
Muddy casts
Hyaline casts
Waxy casts
Inc osmolality FENA >2%
RBC: glomerulonephritis
WBC: pyelonephritis
Muddy: tubular necrosis
Hyaline: normal
Waxy: chronic renal dz
O-FENA: tubular necrosis
What are the 3 MC causes of acute renal failure in order
What causes acute tubular necrosis
What is the MCC
Tubular necrosis
Interstitial nephriti
Glomerulonephritis
Kidney ischemia
Toxins
Pre-renal fialure
What causes Interstitial Nephritis
What will be seen on UA results
How is it Tx
Immune mediated response
WBC casts,
Hematuria
Eosinophils
D/c offender
CCS
Dialysis
What are the 3 etiologies of Glomerulonephritis
What will be seen on UA results
What criteria is needed for Dx of CKDz
IGA nephropathy (bergers dz)
Post-infectious
Membranoproliferative
Hematuria
RBC casts
eGFR <60mL x 3mon or, Albuminuria >30mg/day Proteinuria/Cr >0.2 Hematuria Structural abnormals
? is the MCC of CKDz
How is CKDz staged
What stag is considered “symptomatic stage”
DM
1: normal GFR w/ persistent albuminuria/structural dz
2: GFR 60-89
3: GFR 30-59
4: GFR 15-29
5: GFR <15
Stage 4: HyperK/Ph, HypoCa
Criteria needed to Dx CKDz
Pts w/ CKDz need to avoid ? compound
? UA result is a specific finding to CKDz
eGFR <60mL x 3mon or: Albuminuria >30mg/day Proteinuria/Cr ratio >0.2 hematuira Structural abnormalities
Mg
Broad waxy casts
? is CKDz Dx
What marker is used to find damage w/ ? appearing first
Other than E+ abnormalities, ? other lab result will be low
GFR
Proteinuria, microalbuminuria
Epo
How is CKDz Tx
What is the JNC-8 BP and A1c goal range
What vaccine do Pts need
ACEI/ARB
<140/90, 11-12g
Pneumococcal
Define Glomerulonephritis
There are two types and are based on ?
Inflamed glomeruli causing protein/RBC leakage into urine d/t immune response
24hr protein:
Nephritis <3.5g/day
Nephrotic >3.5g/day
What is the classic presentation of Nephritic Syndrome
? infection can cause this syndrome
How is this post-infectious etiology Dx
HTN
Edema
RBC casts
Proteinuria <3.5g/day
Group A strep
+ASO titer w/ low complement
? is the MCC of anute glomerulonephritis worldwide
How do Pts present
How is this Dx
IgA Nephropathy- Berger Dz
Gross hematuria and flank pain after URI/GI infection
IgA deposits in mesangium
Define Alports Syndrome
What non-renal exam needs to be done
How is this Dx
Ped w/ isolated, persistent hematuria and hearing loss
Ophth exam: anterior lenticonus
C3/4 levels
What causes Membranoproliferative Glomerulonephritis
How is this form Dx
What lab result is Dx of Rapidly Progressing Glomerulonephritis
SLE, Hep C
Low C4, C4
Crescent formation of biopsy d/t fibrin/plasma proteins
Rapidly Progressing Glomerulonephritis is AKA ?
? type of Abs are found
How is it Tx
Goodpastures
Anti-GBM
Steroids Plasmapheresis
Cyclophosphamide
What type of Abs are seen in Rapidly Progressing Glomerulonephritis induced vasculitis
Glomerulonephritis as a group usually has ? decreased lab result and needs / for Dx
How is Glomerulonephritis Tx
ANCA Abs:
Micro polyangitis: P-ANCA
Granulomatosis w/ polyangitis: C-ANCA (Wegners)
Dec C3,
Renal biopsy- gold standard
Enalapril/Losartan
Post-Strep: Nifedipine
Nephropathy- GCCS
How does Nephrotic Syndrome present on PE
What would be seen on lab results
What are the two classifications of nephrotic syndrome by etiology
Edema Ascites Effusion HTN
Proteinuria >3.5g
HypoAlbumin, Hyperlipid
Primary: kidney biopsy
Secondary: SLE DM Pre-E
What UA results suggest a Dx of nephrotic syndrome w/ protein >3.5g/day
What are the 3 MCC primary causes of this syndrome
Fatty cast w/ maltese cross
Oval fat body
Membrane nephropathy- MC in non-DM w/ Ca and Hep B
Minimal Change: MCC in kids; Tx w/ CCS
Focal Segment: obese heroin users w/ HIV/Sickle
How is Minimal Change Dz and Focal Segmental Glomerulosclerosis Tx
How is Membranous Nephropathy Tx based of risk
how is Focal Segmental Glomerulosclerosis Tx if resistant to primary Tx
Pred w/ ACEI
Low: ACEI
Mod/Sev: GCCS w/ Cyclophosphamide
Cyclosporine
What makes the cysts in PCKDz
? MC stat does this Dx own
What cardiac abnormalities can these Pts have
Epithelial cells from renal tubules
MC autosomal dom d/o
MCP, LVH
How is PCKDz Dx
What genetic studies are needed
How are these Pts managed until transplant is possible
US
PKD-1 and 2
ACE/ARB
? is the MC E+ d/o
? level is Dx
What is the MCC
HypoNa
<135
Hypotonic fluids
What are the 4 types of HypoNa
HypoVol HypoNa: volume contraction
HyperVol HypoNa: volume expanded
SIADH: volume expansion w/out edema
HypoNa w/ Euvol: GCSS, hypothyroid
How is HypoNa Tx
How fast is Tx limited to
If severely hypoNa, don’t Tx faster than ?
0.9% NS w/ Loop diuretics
<0.5mEq/L/hr
3% NS; <10mEq q24hrs to avoid demyelination syndrome
What lab result suggest HyperNa
How is this Tx
What happens if Tx is too fast
BUN/CR >20:1 w/ Na >145
D5W
Cerebral edema
Pontine herniation
HyperK level
What can cause this
What does this look like on EKG
> 5 mEq
KF stage 5
ACEI/Spironolactone
Peaked T
Prolonged QRS
Muscle fatigue
How is HyperK Tx
When is HypoK seen
What does HypoK look like on EKG
Na bicarb Insulin Glucose
Diuretics, Cushing Syndrome
Flat/Invert T wave
U-waves
What is avoided while replacing K
MCC of hypo/hyperCa
How are these Tx
Destrose- stimulates insulin and will cause K shift into cells
Hypo: Hypoparathyroidism
Hyper: hyperparathyroidism
Hypo: Ca gluconate/chloride
Hyper: NS w/ Furosemide
How does HypoMg present
How is this Tx
How is HyperMg Tx
Weak, Hyper-reflex, Widened EKG
Acute: IV Mg
Chronic: PO Mg
Isotonic saline
Loop diuretics
What are the two rules to calculate maintenance of fluids
100/50/20: 100mL/kd first 10kg 50mL for next 10kg 20mL for every 1kg over 20 Divide by 24 for hourly rate
4/2/1 Rule:
4mL first 10kg
2mL for next 10kg
1ml/kg for every kg over 20
What is the average value rule for Acid-Base d/os
What is the 3 step approach to assessing acid/base d/ox
Metabolic Acidosis w/ low anion gap suggests ?
24/7 40/40
Bicarb: 24 pH 7.40 Co2- 40
pH PCO2 Bicarb
Diarrhea
Pancreatic/biliary drainage
Renal tubular acidosis
DDx for metabolic acidosis
Anion gap: Na - (Cl+BiCarb)= 10-16 >16: MUDPILES Methanol Uremia DKA Paraldehyde Infection Lactic acidosis Ethylene glycol Salicylates
What is the first sign of Fe Deficient Anemia
What are later findings
This owns ? MC stat
Low ferritin
Indices change: micro/hypo
MCC of anemia
Anemia d/t lead poisoning presents w/ ? lab result
How is this Tx
How is Fe Deficient Anemia Tx
Basophilic stippling
EDTA
Ferrous sulfate w/ juice:
6wks corrects anemia
6mon repletes stores
F/u q3mon x 12mon
What are the two MCC of Anemia of Chronic Dz
How are the two differed
How is this form Tx
Chronic RF, CT d/os
Dec epo w/ RF
EPO and Fe supplements
How does B12 deficiency anemia present
This is laboratory similar to ? other deficiency
How are the two differed
Macrocytic w/ hypersegmented neutrophils
Loss of proprioception
Dec vibratory sense
Folate, only other macrocytic anemias
Folate- no neuro Sxs
What lab results suggest Hemolytic anemia
What test is positive if hemolytic anemia is d/t autoimmune etiology
How is this form of anemia Tx based on etiology
Inc LDH, Dec Haptoglobin
+ Direct Coombs
Autoimm: steroids, splenectomy
Hereditary Spherocytosis: splenectomy
What does Aplastic Anemia look like
What is unique about this types lab results
How is this Dx
Loss of blood cell precursors= anemia w/out reticulocytosis
All 3 cell lines dec’d RBC WBC Platelet
Marrow biopsy: hypocellular w/ fatty infiltrates
? medication may be used in Aplastic Anemia to reduce incidence of infections
Sickle Cell Dz and Trait lab results
How is Sickle Dx
G-CSF: Filgrastim
HbSS: Dz
HbSA: Trait
HgbS on electrophoresis
? buzz work is used w/ Sickle Cell lab findings
These Pts are at risk for ? microbe of osteomyelitis
How is Thalassemia anemia differed from Fe Deficient Anemia
Howell Jolly Bodies: non-phagocytosed nuclear remnants
Salmonella
Fe: low RBCs
Thal: normal/high RBCs
How does peripheral vertigo present
How does central vertigo present
Vertigo w/ syncope= ? DDx
Sudden onset N/V w/ tinniuts and HL w/ horizontal nystagmus w/ rotation
Sudden onset w/ vertical nystagmus and w/out auditory changes
Vertebrobasilar insufficency
BPPV Sx, Tx and Dx
Vestibular neuritis Sx and Tx
Labrynthitis Sxs, Dx and Tx
Sx; positional vertigo w/out auditory manifestations
Dx: Dix-Hallspike
Tx: Epley and Meclizine
Sx: Vertigo despite position, no auditory, MedHx URI
Tx: Meclizine
Vertigo w/ HL, tinnitus and URI
MRI, Meclizine w/ steroids
Meniere’s Dz Sx, and Tx
Acoustic neuroma Sx, Dx and Tx
Define Delerium
Episodic vertigo w/ HL and NO recent URI
Diuretics, Na restriction, CN8 ablation
Vertigo, Unilateral HL, tinnitus and ataxia
MRI, surgery
Acute, short and reversible alteration in mental status
How are Cluster HAs Tx
What meds can be used for propylaxis
What are the two types of migraines
100% O2 at 12-15mL/min x 15-20min via NRB w/ Sumatriptann
Verapamil then Lithium
Common: no aura > Classic: aura
What criteria provide a 93% probability of migraine dx
MC type of aura
How miraines Tx
Last 3mon has Pt had 2/3:
Photophobia Impairment Nausea
Visual
Mild/Mod: NSAIDs, Excedrin
2nd line: Sumatriptan Ergomar Metoclopramide w/ Benadryl
When is prophylaxis indicated for migraines
What is used for first, second and third line meds
Define TIA
≥4 HA/mon or ≥HA days/mon
Divalproex Topiramate PMT-olol
Amitriptyline Venlafaxine AN-olol
Botox, CGRP Abs
Transient neuro dysfunction d/t ischemia w/ infarct
What presentation can indicate Pt has TIA
What are the two types
What scoring system is used to estimate a stroke after a TIA
Wrinkling of forehead
Large artery low flow d/t stenosis
Embolic d/t Afib
ABCD2: Age BP Clinical Duration DM
How are TIAs Tx
Lab result seen in amyloidosis induced restrictive myopathy
What other two conditions can present w/ myocarditis
ASA w/ Clopidogrel x 21days
Apple green birefringence w/ Congo-red stain
Megacolon, Pericarditis
How Pts w/ myocarditis managed for Tx
How is a sinus rhythm determined on EKG
How is atrial enlargement determined
Support w/ Loops ACEI BBs
Pos P-wave in lead 1, 2 aVF
Neg P-wave in aVR
L: m-shaped p-wave in lead 2; biphasic P-wave in V1 w/ larger terminal component
R: P-wave in lead 3 ≥3mm; biphasic P-wave in V1 w/ larger initial component
EKG criteria for right ventricular hypertrophy
What are the two methods for EKG criteria for left ventricular hypertrophy
EKG vector movement in relation to hypertrophy or ischemia
V1 R > S or R>7mm
Soklow lyone: V1 S + V5/6 R= >35mm (men) or >30mm (fem)
Cornell: aVL R + V3 S >28mm (men) or >20mm (fem)
Towards hypertrophy, away from ischemia
What is the quadrant method for determining axis deviation on EKGs
Inferior or Lateral MIs causes ? deviation
LAD based on Lead 1 and aVF, check Lead 2, neg QRS= deviation
Inf: left, Lat: right
Brady cardia Tx algorithm
What is the exception to this rule
How is SSS Tx if unstable
Unstable w/ Sxs, HOTN, AMS, refractory chest pain or acute HF:
Atropine then: Epi or Dopamine the transcutaneous pace
Atropine then Dopamine, Epi and TransCu pacing
Tachycardia Tx algorithm
Unstable: sync’d conversion
Unstable w/ regular narrow QRS: Adenosine
Not unstable: QRS ≥12sec wide:
Yes, wide QRS complex: Amiodarone Lidocaine Procainamide
Yes, monomorphic: Adenosine
No wide QRS:
Vagal Adenosine BB CCB
How are the 3 different stable, narrow complex tachycardias Tx
How is sinus tachycardia Tx during acute MIs
What is the most important/helpful aspect of determining if AV blocks are present
Afib/flutter: BB or CCBs
WPW: procainamide or Amiodarone, avoid ABCDs
SVT: vagal, Adenosine
Metoprolol
PR intervals
Mobitz Type 2-2 is commonly located where
Stable Aflutter Tx
Unstable Aflutter Tx
BoHis
Vagal
Rate: MAE-olol or Diltia/Verapa
Definitive: ablation
Synch’d conversion
What phenomenon may be seen on EKG during Afib
How are stable Pts managed
How are unstable Pts managed
Ashmans: aberrant conduction w/ wide QRS after short R-R cylcles
Rate: MAE-olol or Diltia/Verapa (Digoxin if BB/CCB c/i)
Synch’d conversion
Saying to help ID SVT rhythms
how are stable w/ regular, narrow complexes Tx
What is the definitive Tx
Cant tell if bump is T or P, must be SVT
Vagal then Adenosine then BB/CCB/Digoxin
Ablation
How is WAP vs MAT differed
MAT is associated w/ ? Dz and managed w/ ? meds
Define Orthodromic and Antidrome PSVTs
WAP: <100bpm w/ 3 different P-wave morphologies
MAT: >100bpm w/ 3 different P-wave morphologies
COPD: Verapamil or BBs
Ortho: regular, narrow complex w/out P-waves
Anti: regular, wide tachy mimicking Vtach
How do PVCs appear on EKG
Torsades can be caused by ? med if all E+ are normal
? anti-arrhythmic can enhance the above meds toxicity
Wide, bizarre QRS w/ T wave in opposite direction of QRS w/ compensatory pause beat
Digoxin
Quinidine
Class 1 Anti-arrythmic drugs
Na channel blockers: dec Na conduction and AV node automaticity leading to membrane stabilization
1A: Procainamide Quinidine Disopyramide;
Prolong repolarization and action potential
1b: Lidocaine, Tocainide;
Dec conduction velocity and shortens repolarization;
C/i: narrow SVT
1c: Flecainide Propafenone Ecainide;
Inc QRS prolongation and dec conduction velocity w/ affecting action potential
Class 2 Anti-arrhythmic drugs
Cardio sel: AME-olol
Non-Sel B1, B2: PS-olol
Non-sel A, B1,2: LC-olol
Dec SA/AV node conduction
Non-sels can cause bronchospasms in asthma/COPD
Toxicity Tx w/ glucagon
Class 3 anti-arrhythmics
Sotalol Amiodarone Ibutilide Dofetilide
Prolongs action potential
Amiodarone: characteristics of Class 1-4 meds w/ s/e of pulm fibrosis and thyroid d/o
Class 4 anti-arrhythmics
Class 5 anti-arrhythmics
Verapamil, Diltiazem
Slows SA/AV conduction to inc PR interval and refractory period
Digoxin- cardiac glycoside, dec ATP-ase
Class 1 and 3 antiarrhythmics are used for while Class 2 and 4 are used for
Intracranial hemorrhage can cause Pts to present w/ ?
How are the categorized by size
1/3: rhythm
2/4: rate
Subarachnoid hemorrhage
Small: <15mm Large: 15-25mm Giant: 25-50mm Super: >50mm
? is the MC type of brain aneurym and is the MCC of ?
Cerebral aneurysms are associated w/ Coarctation and ?
What are the key features of these on presentation
Saccular/Berry- MCC of atraumatic SAH
PCKDz
Sudden, unilateral HA w/ N/V/AMS
How are brain aneurysms screened for
What would be seen on LP results
How are these Tx
Non-contrast CT
Inc opening pressure w/ gross blood
Xanthorchromia- blood in CSF >2hrs
Surgical clipping, Endovascular coiling
What defines a seizure as general or partial
What are the two types of partial seizures
Partial seizures originate from ? and are the MC ?
Gen: LoC
Part: partial preservation of consciousness
Simple: consciousness maintained
Complex: impaired consciousness
Temporal lobe; MC seizure of elderly PTs
Define Todd’s Paralysis
Define Generalized Seizure
What would be seen on EEGs during absence seizures and how are these managed
Hemiparalysis last <24hrs after simple partial seizure
Seizure start midbrain and spread to both cortices
Symmetric 3Hz spikes; Ethosuximide
What would be seen on EEG during Tonic Clonic seizures
how are these managed
What characterizes tonic clonic seizures
High amplitude, rapid spiking
Phenytoin
Facial/truncal spasms
Flex/Extension of extremities
Impaired consciousness
Febrile seizure lasting longer than ? need to be Tx w/ ?
Define Status Epilepticus
What are the two types
> 5min w/ Diazepam/Lorazepam
Single seizure >5min or ≥2 seizures w/ 5min w/out returning to baseline
Non/Convulsive
Withdrawal from anticonvulsant meds can lead to ? type of seizures
Brain damage can occur if these last longer than ?
How are these Tx
Generalized convulsive status epilepticus
> 60min
Lorazepam then Phenytoin
Define Essential Tremor
How can these be acquired
What can help reduce the tremor
Bilateral tremor during purposeful/voluntary movements w/out a resting component
Autosomal dominant
Alcohol
Resting tremors indicates ? and not ?
Intention tremor suggest ? issues
Postural tremor suggests ? issue
Parkinsons, essential tremor
Cerebral d/o or MS/Wilson’s Dz
Toxic/Metabolic d/o
How are essential Tremors Tx
What is done for drug resistant cases
What are the 3 cardinal features of Parkinsons
Propranolol, Primidone
Deep brain stimulation
Resting tremor, Cogwheel, Bradykinesia
What is the most specific clinical sign for Parkinsons
What causes this Dz
What are the TRAP Sxs commonly associated with this
Pill rolling tremor that disappears w/ voluntary movement
Degeneration of basal ganglia in substantia nigra
Tremor: asymmetric resting tremor, disappears w/ movement
Rigidity: cogwheel/lead pipe
Akinesia: slow/less movement
Postural instability: late feature
Define Myerson sign
What reflex is this called
What Dx is this sign/reflex associated w/
Reflexive eye blinking d/t repetitive tapping above nasal bridge
Glabellar
Parkinsons
What is the gold standard to Dx Parkinsons
How is this Tx in younger Pts
What is used for Pts >65y/o
Neuropathologic exam
Dopamine agonist: Pramipexole Bromocriptine Ropinirole
Sinemet: levodopa/carbidopa
What are the classic signs of Huntingtons
What is the Dx test for Huntingtons
What would be seen on MRI results
Chorea Rigidity Dementia w/ seizures
CAG repeats
Atrophy of caudate nucleus
How is Huntingtons Tx
How are peripheral neuropathies Tx
Define Myasthenia Gravis
Chorea: Tertrabenazine Risperidone Haloperidol
Gaba Amytriptyline SNRI Topiramate
Autoimmune attack of Acth receptors at neuromuscular junctions causing hallmark Sx: fatigability
What Pt presentation indicates Myasthenia Gravis
How to Sxs spread
What is the MC and gold standard Dx method
Weakness w/ everyday activities
Prox to Dist:
Ptosis Weak chewing Limb fatigue
MC: Tensilon test; prevents Acth breakdown, +MG when Pt becomes stronger w/ injection
GS: single fiber electromyography
How is Myasthenia Gravis Tx
Define Myasthenic Crisis
How are these PTs Tx
Pyridostigmine/Neostigmine- prevents Acth breakdown
Pred- dec production of autoAbs
Thymectomy <60y/o: curative
Neuromuscular resp failure from dysphagia/aspiration
IVIG, plasma exchange
Define Polycythemia Vera
What is a classic Sx of this condition
What causes Secondary Polycythemia Vera
Marrow malignancy leading to over production of cells
Pruritus after hot baths, Gout
Artificial increased cell production d/t inc Epo (high altitude living)
What are the 4 ‘H’s’ of Polycythemia Vera
What cell mutation do these Pts have
How is this Dx
Hypervoemia, Hyperhistonemia, Hyperviscosity, Hyperuricemia
Jak 2 tyrosine kinase mutation
Marrow biopsy
How is Polycythemia Vera Tx
Pts >60y/o and Pts w/ prior thrombosis can be Tx w/ ? meyelosuppressive agent
What med is used to decrease platelet count specifically
Phlebotomy to keep Hct ≤42%
Hydoxyurea w/ ASA
Anagrelide
Define Primary Thrombocytosis
What Sx/presentation can this have
What would be seen on smear results
Platelets <600K
Erythromelalgia- burning/erythema d/t micro occlusions
Hypogranular, abnormally shaped platelets
How is Essential Thrombocytosis managed
Define TRALI
Define TACO
Anagrelide, Hydroxyurea
Transfusion Related Acute Lung Injury- donor Abs attack PTs WBCs leading to resp distress/pulm edema <6hrs
Transfusion Associated Circulatory Overload- fluid overload in Pts w/ CHF/CKD; differed by TRALI by inc pulm wedge pressure
How is TRALI Tx
How is TACO Tx
Define Von Willebrand Dz and the two types
Mechanical ventilation
Diuretics
Missing protein for platelet function;
A: dec Factor 8; B: dec Factor 9
? is the MC genetic bleeding d/o
How does this MC present
How is it Tx
VWB Dz- Autosonal dominant
No hemarthrosis, Petechiae, Bleed w/ minor injury
DDAVp
Define Hemophilia
What are the two types
How does this present
X-linked recessive (almost always affects males)
A: Factor 8; B: Factor 9 (Xmas Dz)
Hemarthrosis, Bruises, Bleeds
How is Hemophilia A/B Dx
What is the most specific method to Dx
How are these d/os Tx
Inc PTT w/ normal platelets and correct w/ mixing (uncorrected= lupus, factor inhibition)
Functional factor assay
Factor replacement
How does ALL present
? MC stat does ALL own
How are most cases Tx
Child w/ adenopathy, bone pain, bleeding and fever
MC childhood malignancy
Chemo; stem cell transplant if relapse
How does CLL present
What MC stat does this own
How is this Dx
How is this MC Tx
Middle age Pt w/ fatigue, adenopathy and splenomegaly
MC leukemia in adults
Smudge cells, mature lymphocytes
Lymphocytes >100K or Sxs= chemo
How is ALL Dx
How is CLL Dx
How does AMl present
Bone marrow w/ >20% blast cells
Peripheral smear w/ fragile B cells that smudge during prep
Blast cells w/ Auer rods in adult w/ dec blood levels
How is AML Tx
How does CML present
Most CML Pts will be ASx until ?
Chemo w/ marrow transplant
WBC >100K w/ hyperuricemia and elevated blood levels
Blastic crisis- acute leukemia
How is CML Dx
How is this form Tx and turned into a chronic condition
What is an adverse s/e of AML Tx
Philadelphia chromosmoe: translocation of chrom 9, 22
Gleevec (Imtanib)
Tumor Lysis Syndrome: release of K, Ph; Tx w/ Allopurinl and manage RF
How does HL present
What MC stat does this own
What PE finding is indicative
Painless adenopathy, Reed-Sternberg cells in bimodal age distribution
MC type of lymphoma
Painless cervical nodule w/out change x 30d
Half of HL cases are implicated w/ ? MedHx infection
How is HL Tx
How does N-HL present
Epstein barr
Chemo and Rad
HIV Pt w/ GI Sxs and painless adenopathy
HL affects ? nodes MC while NHL affects ? nodes MC
How is NHL Tx
? form of lymphoma has a geographical aspect to it’s prevalence
HL: upper body; NHL: peripheal nodes
Rituximab and chemo
Burkitt- Central Africa w/ association w/ EBV and AIDS
? is the name of chemo regiment HL Pts receive
Define Multiple Myeloma
What MC stat does this form own
ABVD: Adriamycin Bleomycin Vinblastine Dacarbazine
Monoclonal plasma cell Ca producing IgG > IgA
MC primary tumor of bone/marrow
How does MM present
How is this Dx
Marrow biopsy results would show ?
Bone pain (low back/ribs) Anemia Infection
Serum protein electrophoresis- M-protein spike
UA: Bence Jones proteins (IgG light chain)
Peripheral smear: Rouleaux formation
Xray: pumched out lytic lesion
Fried egg appearance- proliferation of monoclonal plasma cells
How is MM Tx
What meds can be used during Tx
Define Meningitis
Marrow transplant
Melphalan: nitrogen mustard alkylating
Tha/Lena-lidomide: immune modulator
Bortezomib: proteasome inhibitor
Chemokine induced inflammation of leptomeninges, membranes around brain and spinal cord
How is Meningitis and Encephalitis differed on PE
When does Crypto become an opportunistic infection and cause of meningitis
? parasite can cause meningitis
Enc: altered brain function, petechiae (N meningitis)
CD4 <100
P Falciparum
MCC of meningitis in newborns
MCC of meningitis in children/teens
MCC of meningitis in adults/elderly
GBS, EColi, LIsteria
N meningitidis, Strep pneumo
Strep pneumo, Listeria
Bacterial meningitis LP results
Viral meningitis LP results
How is meningitis Tx based on etiology
Inc Protein/Opening pressure, dec glucose
Norm pressure, Inc WBCs
Aseptic: Acyclovir
Bacterial: Dexameth w/ Cephalosporin/Vanc
Bacterial >50: Vanc Rocephin Ampicillin
Contact: Rifampin
MCC of Encephalitis
Define Reye Syndrome
What would be seen on PE during Reye’s
HSV; ImmCOmp= CMV
Rapid encephalopathy w/ hepatic dysfunction
Pos Babinski, HyperReflexia
What would be seen on LP results of encephalitis
How is Encephalitis Tx
Define MS
Inc WBCs predominantly lymphocytes
Norm glucose, proteins
Support and Acyclovir
Autoinflammatory Dz w/ demyelination, neuron loss and scarring of white matter
What are the MC Sxs seen w/ MS
What PE sign is seen early in this Dz
What is the MC form of MS
Paresthesia Optic neuritis Weakness Sensory loss
Lhermittte- electric shock in limb/torso from neck flexion
Relapsing Remitting MS: episodic flare ups
Secondary Progressive: progressive deterioration
Primary progressive: declining neuro function w/out flares
Progressive Relapse: declining neuro function w/ flares
What is the next Dx step for MS if MRI is inconclusive
MS targets ? cells particularly resulting in demyelination
What MRI criteria is used for Dx
Oligocloncal bands
Oligodendrocytes
McDonald dx criteria
How is MS Tx
How is MS incontinence Tx
AIDS is defined as ?
CCS for attacks, Interferon betas
Oxybutynin: incontinence
CD4 <200
How is HIV Dx
When is medical HAART therapy indicated
ELISA w/ confirmation by Western blot
CD4 <350 or Viral load PCR >55K
? opportunistic infection is present regardless of CD4 levels
? opportunistic infection is present w/ CD4 count of ≤250
? opportunistic infection is present w/ CD4 count of ≤200
? opportunistic infection is present w/ CD4 count of <150
? opportunistic infection is present w/ CD4 count of <100
? opportunistic infection is present w/ CD4 count of <50
All: TB
250: Coccidio
200: Pneumocystis
150: Histo
100: Toxoplasmosis/Crypto
<50: mycobacterium ovium complex
Post-HIV exposure prophylaxis should be started w/in ? time frame
When are retestings done
How is neonatal acne Tx
<72hrs
6wks, 3mon, 6mon
Topical Ketoconazole 2%
What are the 4 stages of acne
What are the 4 DDxs and how could each be r/o
1: comedonal
2: papular, little scarring
3: pustular; >25 lesions w/ mod scarring
4: nodulocystic, severe scars
CCS acne: no comedone, pustules all in same stage
Rosacea: no comedones
Perioral: distribution
Acneiform drug eruption
How are each grade of acne Tx
1: topical retinoid
2: topical retinoid and benzoyl peroxide; add Clascoterone/Minocycline if no response
3: systemic ABX (Doxy, Mino, Sare) + grade 2 regiment
4: Isotretinoin
Any case of acne that is more than mild is Tx w/ ? first line Tx regiment
What birth control options are available for Tx
What type of reaction is Erythema Multiform and is usually associated w/ ?
Topical retinoid
Topical antimicrobial
Ethinyl estradiol norgestimate
Estrostep
Yaz
Type 4; HSV, Sulfa drugs
How does Erythema Multiforme present on PE
What are the two types of EM
How is EM differed from SJS
Target lesion w/ dusky center on palms, soles, and extensors that blanch, but don’t itch or Nikolsky
Major: two mucus sites and widespread skin
Minor: limited skin, one mucosal
EM: extremity/mouth
SJS: trunk
How is EM Tx
Define SJS
What is this commonly caused by
PO antihistamine
Acyclovir if +HSV
Topical CCS
Milder TEN, ≤10% BSA w/ +Nikolsky’s
Gout meds
Anticonvulsants
Sulfa drugs
How is SJS and TEN Dx
How is this Tx
Define TEN
Biopsy- necrotic epithelium
D/c offender
IVIG
Consult derm/ophth
≥30% BSA affected
TEN can present in Peds mimicking SSS, how is it differed on exam
How is TEN Tx
Define Urticaria
Sparing of mucous membranes
Admit Consult Cyclosporine
Blanchable papules/wheals that disappear <24hrs
What sign is associated w/ urticaria
What is a painless, deeper form or urticaria
What type of hypersensitivity reaction is this
Darier’s Sign- localized urticaria occurring where skin is rubbed d/t histamine release
Angioedema
Type 1, IgE: mast cell degranulation releases inflammatory reactants
General measure for Tx urticaria
What two factors can exacerbate Sxs
How is urticaria Tx
Calamine or 1% menthol
NSAIDs, ETOH
2ng Gen AntiHist:
Fexofenadine
Des/Loratadine
Cetirizine
How is Urticaria Tx in Pts w/ disrupted sleep d/t itching
What TCA can be used too
What med is safe for chronic, unresponsive cases
First Gen:
Hydroxyzine
Diphenhydramine
Doxepin
Leukotriene antagonists
Define Acanthosis Nigricans
The presence of this indicated ? two issues
What are these Pts at risk for developing
Velvety, hyperpigmented plqaues
Hyperinsulinemia
Insulin resistance
Metabolic Syndrome
How is Acanthosis Nigricans Tx
What can be done for cosmetic Tx
How does BCC present
Weight loss
Metformin
Vit D analogs
Topical retinoids
Pearly rolled border, telangiectasis w/ central ulcer
How is BCC Dx
How is this Tx
What is Kaposi Sarcoma associated w/ and is a ? defining Ca
Shave/Punch biopsy
Surgical; Fluorouracil, Imiquimod
HHV-8; AIDS
What is the hallmark of Kaposi Sarcoma used for Dx
What lab result will be seen in these Pts
How is it Tx
Biopsy- vascular proliferation d/t angiogenic inflammation
CD4 <100
Chemo/Radiation
HAART for all Pts w/ AIDS related cases
What are the ABCDEs of moles
Define Melanoma
What is the MC site of this in wo/men
Asymmetry Borders Color
Diameter Evolving
Tumor growth d/t malignant transformations in melanocytic system
M: back W: calves
Malignant melanoma is the MC tumor responsible for mets to ?
What acronym is for the most important independent factors for increased likelihood of melanoma
How is this Dx
Heart
HARMM: Prior Hx of melanoma Age >50 Absent regular Derm evals Changing mole Male
Biopsy
How is malignant melanomas staged
Prognosis is associated w/ ?
How are these Tx
Clark Classification:
1: epidermis
2: papillary dermis
3: papilary reticular
4: reticular dermis
5: penetrates SQ fat
Lesion depth
1-3: excision, 4: chemo
Define SCC
What do they look like on PE
These usually arise within preexisting ?
Malignant epithelial tumor from epidermal keratinocytes
Enlarged hyperkeratonic macule w/ scales/crusted lumps
Actinic keratosis
Intraepidermal carcinoma
How are BCC and SCC differed on exam
How is SCC Dx
How are they Tx
BCC: telangiectasia, central ulcer, rolled border
SCC: scaly papules
Biopsy
Excision w/ Mohs
Two areas MC affected by pressure ulcers and how can they be avoided
What are the 4 stages
How are pressure ulcers Tx
Sacrum, Hip; Reposition q2hrs
1- Non-blanching
2- pink ulcer, lost dermal layer
3- dermal loss, SQ/fat visible
4: exposed bone/tendon
1: prevention, thin dressing
2: occlusive dressing
3-4: necrotic debridment
? is a common inflammatory dermatosis of the lower extremities
Where are these MC seen
How is this MC Tx
Stasis dermatitis: chronic venous insufficiency w/ varicose veins
Medial ankle
Compress, CCS, ABX if cellulitis present
Define AKs, which are synonyms for ?
These are precursors for ? Ca
How are they Tx
Solar Keratosis- pink/yellow lesions w/ sand paper texture
SCC
Cryo Imiquimod 5-Fu
Define SKs
What are these commonly referred to as?
How are they Tx if desired
MC benign skin tumor; dark plaques w/ stuck on appearance
Barnacles of old age
Cryo, Electrodissection, Curettage
What MCC cellulitis in adults
What MCC cellulitis in kids
How are these Dx and w/ ? education
Staph, Strep pyogenes
HFlu, Strep pneumo
Cultures; F/u <48hrs
How is cellulitis Tx
Mild:
Cephalexin
Cefuroxime
PCN allergy: Clinda
Purulent/MRSA: TMP-SMX Clinda Doxy IV Vanc or Linezolid
Erysipelas is always caused by ? microbe
How is this type of infection defined
How is it Dx
GAS: Strep pyogenes
Superficial cellulitis w/ dermal lymphatic involvement
Culture
Antistreptolysin titer
How is Erysipelas Tx
Mild: Pen G
PCN-All: Erythro/Clinda
Mod:
TMP-MSX and Pen VK
Cephalexin
Severe:
Vanc and Daptomycin
How does dermal candidiasis present on PE
What is seen on KOH preps
How is vaginal candidiasis Tx
Diffuse, beefy red erythema w/ sharp margins and satellite lesions
Budding yeast, hyphae and pseudohyphae
Micon/Clotrim/Flucaon-azole
How is oropharyngeal dandidiasis Tx
How is esophageal candidiasis Tx
How is diaper cadidiasis Tx
Clotrimazole, Nystatin
Flucon/Itracon-azole
Nystatin
Clotrim/Micon/Ketocon-azole
How is symptomatic candidiasis induced vulvovaginitis during pregnancy Tx
What type of herpes is Varicella Zoster
How is Shingles Dx
Topical Clotrim/Micon-azole
HHV-3
PCR/Tzanck prep: multi-nucleated giant cells
What PE finding w/ shingles is an Ophtho referral
How is Zoster Tx
How is this Tx during pregnancy
Hutchinson
Antivirals, Sxs <72hrs
FAV-ciclovir
Acyclovir
How is chicken pos (varicella) Tx
What needs to be avoided in Peds and why
When can Peds be vaccinated from chicken pox
<12y/o: none, >13: acyclovir
Salicylates; Reyes syndrome
12-15mon and 4-6yrs
When should Pts get Shingles vaccine
Warts are AKA ? and all caused by ?
50y/o x two 2-6mon apart
Verrucae; HPV
Verruca Vulgaris
Verruca Plana
Verruca Plantaris
Common warts from
HPV 1 2 4 7; grow on areas of trauma
Flat warts from HPV 3 10 26 29 41; grow on face, scratch marks
Plantar warts D/t HPV 2 4 on weight bearing surfaces of feet
Condyloma Acuminatum
Filiform Wart
Epidermodysplasia verruciformis
Veneral warts d/t HPV 6 11
Frond-like narrow growths on face; variant of common wart
Hereditary d/o of chronic HPV infections
Cardinal sign of warts is ? on PE
How are these Tx
How are anogenital warts x
Absent skin lines
Pin-point black dots
Bleeds when shaved
Cryo Salicylic acid Interferon- refractory
Trichloroacetic acid, Podophylin
HPV vaccine is effective against ? strains
Define GAD/o
What meds can be used for Tx
6 11 16 18
Excessive worry about multiple things x 6mon
SSRI: Paroxetine Escitalopra
Buspirone
SNRI: Venlafaxine
Kava herb: liver damage
Define Panic D/o
How is this Tx
Define OCD
Intense fear/discomfort w/ Sxs peaking <10min causing altered behavior x 1mon
Benzo if SSRI too slow
SSRI: Paroxetine Sertraline Fluoxetine
CBT
Repetitive, disabling thoughts (obsession) or behaviors (compulsion)
What is the primary goal of OCD’s actions
This d/o is labeled as ?
What other Dx is associated w/ OCD
Not lose control
Ego-dystonic: behavior is inconsistent w/ beliefs/attitudes
Tourettes
How is OCD Tx
Define Body Dysmorphic D/o
What other Dxs commonly co-exist in these Ptx
Psychotherapy
SSRI/Clomipramine
Imagined defect in physical appearance d/t stereotype of beauty
Psychotic and OCD
How is BDD/o Tx
Define Hoarding D/o
How is this d/o Tx
SSRIs w/ CBT
Difficulty discarding items regardless of value
Paroxetine w/ CBT
Define Trichotillomania
What is used first in Tx and what can be used as adjuncts
Define Excoriation D/o and how is this Tx
Intentional hair pulling w/ pleasure/relief after completing task
CBT- 1st then SSRI/TCA
Picking of skin causing distress; CBT w/ Fluoxetine
Define PTSD
How can this be Tx
Criteria for Adjustment D/o
Traumatic exposure leaving Sxs >1mon
SSRI w/ CBT
Prazosin for nightmares
Benzos x first 2wks
Sxs emerge <3mon of stressor and end <6mon after stressor is resolved
Define Major Depressive D/o and what is first line Tx
What is a major cause of depression
How is the severity of depression measured
5 or more SIGECAPS ≥2wks; SSRIs
Unemployment
Beck depression inventory
Define Dysthymia
How is this Tx
How does BP1 present
Depressive Sxs >2yrs w/out being Sx free for >2mon at a time
SSRI w/ therapy and PT
Destroys relationships
Neglects work
Spending life savings
What class of medication needs to be avoided in BP1
How does BP2 present
How can these PTs be managed
SSRIs
Sadness, distracted and dec need for sleep
SSRIs
Quetiapine
Olanzapine w/ Fluoxetine
Define Cyclothymic D/o
How are these Pts managed and Tx
Criteria for ADHD
Hypomaniac episodes w/ low mood state x 2yrs
Lithium Valproate Carbamazepine w/ therapy
Hyper, impulsive and inattentive <12y/o and in more than 1 environment
? is one of the most inheritable psych d/os
Who is more likely to have this
Define Autism
ADHD
First born son
Dec social communication/ interactions w/ restricted, repetitive movements and adherence to routines
What meds can be used for Autism
Define Narcolepsy
What can be presenting c/c
2G: Risperidone, Aripiprazole
SSRI: sterotype/repetitive behavior
Recurrent sleeping/napping w/ intense urge to sleep 3x/wk x 3mon
Cateplexy: bilateral loss of muscle tone w/ retained consciousness
What causes narcolepsy
How are PTs managed
Define Insomnia
Hypocretin deficiency in CSF
Modanafil, Methyphenidate
Insufficient quality/quantity of sleep 3x/wk x 3mon
What would be seen on PE during alcohol withdrawal
What needs to be given during withdrawals along w/ benzos
What med is used for ingestion aversion
Anxiety Hyper autonomic- tachy, sweating Insomnia N/V Tremor
Dextrose Mg Thiamine
Disulfiram- inhibits acetaldehyde dehydrogenase
What med is used for alcoholics to change brain chemistry and decrease restlessness during sobriety
What drug is used w/ equal efficacy as the above drug and naltrexone
? presentation suggests PCP ingestion
Acamprosate, 666mg TID
Topiramate
Aggressive w/ enraged response to loud noises/sudden movements, horizontal nystagmus
What is the MOA of PCP
How is this form of ingestion Tx
What is the MOA of LSD
NMDA antagonist
Haloperidol, Benzos
5-HT action
How is LSD ingestion Tx
MOA of opium
What does ingestion cause to occur
Haloperidol, Benzos
Mu receptor agonist
Constipation Resp-depression Pin-point pupils
How are opioid withdrawals Tx
What is the MOA of Benzos
What is seen during withdrawals
Clonidine, Methadone, Buprenorphine w/ Naloxone
Inc frequency by opening GABA receptors
Anxiety Seizure Tremor- MC if short acting abuse
How are Benzo ODs Tx
MOA of barbituates
Why are barbituate ODs more dangerous than benzos
Flumazenil- competetive GABA antagonist
Clonazepam- long acting w/ taper
Inc open duration of GABA channels
No depression ceiling
MOA of cocaine
What is seen w/ ingestion
What is used during intoxication
Prevent amine (Dopamine NorEpi Serotonin) reuptake
Sympathetic activation: Anorexia Tachycardic Dilated pupils HTN
Haloperidol Vit C: promotes excretion
What needs to be avoided when Tx cocaine intoxication
What meds can be used for withdrawal
MOA of amphetamines
BBs, restraints- risk developing rhabdo
Buproprion, Bromocriptine, SSRIs
Promotes DNS release w/ dec reuptake
How are amphetamine ingestion Tx
MOA of ectasy
What is seen during use
Haloperidol Benzos Vit C
5HT > dopamine effects
Hyperthermia, hyponatremia
When are smokers screened for lung cancer
How are screenings completed
What meds are used during cessation
50-80y/o w/ 20ppy Hx w/ current use/quit <15yrs
Annual low dose CT
Buproprion Varenicline
Define Conversion D/o
These PTs can present w/ ? odd factor
How is this Tx
Neuro Sxs that can’t be Dx/explained
La belle indifference
Therapy w/ anxiolytics
Define Somatic Sx d/o
How are these Pts best managed
Define Hypochondriasis
Pre-occupation w/ serious illness ≥6mon
Single clinician for monthly visits/therapy
Illness Anxiety D/o: obsession w/ idea but no Dx’d illness x 6mon
How is Illness Anxiety D/o managed
What are the two types of Anorexia Nervosa
How is Anorexia Nervosa differed from Bulemia nervosa
Therapy w/ SSRIs
Restricted, Bing/purge
BMI <17, weight <85% of ideal
When does Anorexia Nervosa need to be admitted
How are these Pts Tx
What metabolic disequalibrium is caused by bulimia nervosa
Weight <75% expected body weight
Therapy w/ SSRIs
Met alkalosis
How is Bulimia Nervosa Tx
Define Binge Eating D/o
How is this managed for Tx
Fluoxetine w/ therapy
Lack of control over eating despite being full/not hungry
Therapy, behavioral Tx
What causes Pityriasis Rosea
How is this Tx
Define Blepharitis
HSV 7
Steroids w/ antihistamines
Painless inflammation of eyelid d/t dysfunctional meibomian gland or staph infection
Blepharitis is associated w/ what two conditions
What will Pts complain of
How is this Dx and Tx
Seborrhea, Rosacea
Crusty eyelids in AM
Slip lamp; Compress, massage, ABX
Define Chalazion
How are these Tx
Define Hordeolum
Painless infected meibomian gland in middle section of eye lid
Warm compress, CCS, Incision w/ curettage
Painful, warm lump on eye lid w/ photophobia/foreign body sensation d/t Staph A
How are Hordeolums Tx
How are corneal abrasions Dx
How are these Pts Tx
Warm compress w/ topical ABX; Non-response: InD
Fluorescein stain
Bacitracin/Polymyxin B or Cipro
Contacts= Ciproflox
How does Cauda Equina present
How is this Dx
How is this Tx
Compressed lumbrosacral nerve roots below conus medularis
MRI of L4-5
Surgical emergency
How is spinal stenosis differed from lumbar rediculopathy
What sign may be seen in these Pts
What PE test is negative
Stenosis: worse w/ walking/exercise, relieved w/ hip flexion/leaning forward
Kemp: unilateral radicular pain from stenosis made worse w/ extension
Straight leg raise
How is spinal stenosis Dx
Criteria for this Dx
Define Secondary Amenorrhea and the MCC
CT myelogram if MRI c/i
No menses or secondary features at 13yrs
No menses at 15yrs w/ secondary features
No menses x3mon or 6mon w/ Hx of irregular cycles; pregnancy
? syndrome can cause Secondary Amenorrhea
How is Amenorrhea Dx
How is this Tx
Ashermans: endometrial atrophy d/t scarring/radiation
Sheehan: dysfunctional pituitary d/t posterior stalk bleed
Quant hCG
OCP: cyclic progesterone 10mg x 10days
What are the three MCC of hearing loss
Define CHL
Define SNHL
Presbycusis Impaction ET dysfunction
Lesion on EAC, TM or middle ear preventing conduction
Lesion in inner ear or on CN8
SNHL d/t brain tumor will be MC located ?
How is HL Dx
ETD is the primary cause of ? two Dxs
Cerebellopontine angle
Weber: sound to affected ear= CHL unaffected= SNHL
Rinne: BC > AC= CHL, AC > BC= SNHL
AOM, OME
All children under 7y/o have ? ENT issue
How is this issue Dx
How are these Pts managed
ETD
Tympanogram
Ibuprofen Steroids Pseudophedrine
Tympanostomy tubes
How is barotrauma Tx prophylactically
Barotrauma can present w/ SNHL and vertigo if ? develops
AOM is AKA ?
Afrin- risk for medicamentosa
Perilymph fistula: torn membrane separating middle and inner ear
Suppurative OM
MC microbe for AOM
Criteria for Acute, Chronic and Recurrent AOM
What would be seen on PE during AOM
Strep pneumo then Hflu, Moraxella
Acute: <3wks
Chronic: >3wks
Recurernt: 3x in 6mon, 4 in 12mon
Bulging TM w/ loss of landmarks and limited mobility w/ pneumatoscopy
How is AOM in children and adults Tx
What is used for kids w/ immediate hypersensitivity to first line Txs
How is Chronic Otitis Media Tx
Peds: Amox Adult: Augmentin or Doxy/Azith/Clarithromycin
Azith/Clarith-romycin
Myringotomy
How does Otitis Externa present on exam
What is the MC microbe
What variant is seen in the DM population
Itching canal w/ pain during movement, Weber lateralizes to blocked canal
Pseudomonas
Malignant OE:
Fungal Otitis is d/t ? microbes
How is OE Tx if TM can’t be visualized
How is fungal otitis externa Tx
Aspergillus niger or Candida
Cipro and Dexamethason, Ofloxacin, Cortisporin suspension
Acetic acid, Clotrimazole, Itraconazole PO
What is the MCC of CHL
How is this MC Tx
What three PE findings suggest Allergic Rhinitis
Cerumen impaction: Weber to clogged side, abnormal Rinnie (BC>AC)
Cabamide peroxide or Triethanolamine
Boggy turbinates Allergic shiner/salutes
How is non-allergic rhinitis Tx
How is cold air induced rhinitis best Tx
MC site for anterior and posterior nose bleeds
Intranasal steroids, antihistamines, Ipratropium
Ipratropium
A: Kiesselbach plexus/Little’s area
P: Woodruff d/t sphenopalatine artery
How are persistent epistaxis Tx
MCC of Acute Sinusitis
MCC of Chronic Sinusitis
Pressure x 10min while leaning fwd
Oxymetazoline/Cocaine
Anterior packing w/ cephalosporin
Petroleum jelly/ABX ointment
Strep pneumo Hflu Moraxella
Staph A, Anaerobes, Gram-neg
What are the indications to prescribe ABX for sinusitis
How are these Pts Tx
What is used if Pt fails to improve in 7d
Duration >10d w/out improvement
Fever >102
Purulent d/c
Improvement then rapid worsening
Amox the Augmentin
Allergy: Clinda/Doxy/Cephalosporin
Augmentin 2g Levo/Moxi-floxacin
How is Chronic Rhinosinusitis Tx
Define Leukoplakia
What are the two RFs that put these Pts at risk to develop ?
Augmentin, Clinda if allergic
White pre-cancerous patches on mucosa that can’t be wiped off
Tobacco use, HPV; SCC
What PE finding of leukoplakia makes the risk for dysplasia or Ca higher
This mouth condition presents mimicking ? other Dz
How are Pts Tx for leukoplakia
Erythematous appearance- erythroplakia
Hairy luekoplakia: EBV associated lesion in HIV Pts w/out pre-malignancy risk
Surgical excision, d/c tobacco
How is Hairy leukoplakia Tx
When does an aphtous ulcer need to be considered for biopsy
Zidovudine A/G-clovir Foscarnet Podophyllin Isotretinoin
Lasts >3wks
How are aphthous ulcers Tx
How is Strep Throat Tx in Pts w/ PCN allergy
MCC of viral pharyngitis
Diphenhydramine hydrochloride
Mg hydroxide
Viscous lidocaine
Erythromycin, 1st gen cephalosporin
Adenovirus
How is Mono Dx
How is fungal pharyngitis Tx in HIV Pts
How many Centor criteria for rapid testing
Heterophile agglutination test: Monospot
PO Fluconazole
3 of 4; neg= culture is Gold Standard
How long are athletes benched after having Mono
How is Ghonorrhea pharyngitis Tx
Peritonsillar abscess AKA ? and MC d/t ?
3wks from Sx onset
Ceftriaxone
Quincy’s abscess; Strep/Staph or Bacteroides
What ABX are used for PTAs
MCC of epiglottitis
How do Pts present on PE
Amox Amp-Sulbactam Clinda
HIB
Drooling Dysphagia Distress while sitting w/ neck hyperextended/chin protruding
What ABX are used to Tx epiglottitis
When is laryngitis cancer a considered Dx
How is laryngitis Dx
Ceftriax w/ Clinda and CCS
SCC if persists >2wks w/ ETOH/smoking Hx
Laryngoscopy
How are vocal performers w/ pharyngitis Tx
What is the MC thyroid neoplastic dz
MC type of PO Cancer
CCS
Papillary
SCC
Define Brachial Cleft Cyst
These Cysts own ? MC stat
Define Thyroglossal cyst
Cyst appearing after URI anterior to SCM
MC lateral neck mass
Soft mass rising w/ tongue protrusion; MC midline mass
AV node blocking drugs
How long after conversion are Afib Pts anticoagulated
What two med classes can have first dose HOTN
Digoxin
4wks
ACEI, A-blockers**
MCCC of sudden cardiac death/arrest
? med dec mortality in CHF the most
? med does not increase mortality after MI
Ischemic heart dz
ACEI
Nitro
Most modifiable RF for CADz
? med decreases mortality from acute MI
LVH criteria
Smoking
ASA
On EKG?
? atypical beat causes inverted P-waves on EKG
? PE finding suggests CHF as the most likely cause of a Pts dyspnea
High output cardiac failure
Junctional beats
Third heart sound
PE: warm skin, bulging eyes, wide pulse pressures
Post-CHF exacerbation d/c education to prevent readmissions
BNP can be artificially low d/t ? two things
TIMI RFs
Daily weights
Obesity, Pericardial constriction
Criteria/indications
MOA of statins
Two possible adverse outcomes
Pt education for taking these meds
Inhibit HMG-CoA reductase, inc LDL clearance
Rhabdo, Myositis
Take at night (Atorva/Rosuva- anytime of day)
MOA of Niacin
Adverse effect of use
C/i to use
Inc HDL levels by decreasing clearance
Inc prostaglandins= flushing/warm skin; Pre-Tx w/ NSAID/ASA 30min prior
PUD, Liver Dz
MOA of Fibrates
Adverse effects of use
C/i to use
Dec triglyceride synthesis w/ inc lipoprotein catabolism
Increased gallstones
Hepatobiliary Dz, Breastfeeding
What is the only Fibrate approved for co-use w/ a Statin
Genfibrozil can’t be used w/ ? meglitinide
How is the pruritus associated w/ biliary obstruction Tx
Fenofibric acid
Repaglinide
Cholestyramine
MOA of Bile Acid Sequestrants
Adverse effects of use
C/i to use
Binds to bile acids preventing absorption and dec LDL
Inc triglycerides
Impairs medication/fat soluble vitamin absorption
Sev hypertriglycerides, Complete biliary obstruction
MOA of Ezetimibe
What are the indications for use
What are the adverse effects of use
Inhibits intestinal cholesterol absorption
Combo use w/ statin to dec LDLs
Inc LFTs, HA/D
? are the two MCC of end stage renal dz in USA
? is the only ARB that doesn’t cause hyperuricemia
MOA of Thiazide diuretics (including Metolazone)
S/e of use
DM then HTN
Losartan
Dec reabsorption and Ca excretion at distal tubule
HypoNa/K, HyperUr/Ca/Glucose
MOA of Loop Diuretics
Adverse effects of use
C/i in ? population
Inhibit water transport across LoH
HypoK/Na/Ca
Sulfa allergy
MOA of K-sparing diuretics
S/e of use
C/i to use
Inhibit Na/water absorption, most useful combo use w/ Loops
HyperK, metabolic acidosis
Renal failure, HypoNa
MOA of ACEI
Adverse effects of use
C/i to use
Dec pre/after load, inc vasodilation and insulin action
1st dose HOTN, HyperK Cough Angioedema
Pregnancy
MOA of ARBS
Adverse effect of use
C/i to use
Binds/blocks angiotensin two receptors w/out increasing bradykinin levels
HyperK
Pregnancy
MOA of Non-Dihydro CCBs
MOA of Dihydro CCBs
S/e of use
C/i to use
Vasodilators w/out cardiac effect
Affect contractility/conduction along w/ vasodilation
HA Edema Consitpaion- Verapamil
CHF, 2/3 blocks
How are Coarctations repaired
What do Pts need prior to surgery
MC cyanotic congential heart Dz
Surgery/Transcatheter
Prostaglandin E1- Alprostadil
Tetrology: PROV
Tetrology is associated w/ ? genetic defect
What is the MC presentation
How is this Dx
Chrom 22 deletion
Blue Baby Syndrome; tet spell relieved w/ squatting
Echo
What are the two revascularization techniques for Tx angina and what determines the method
What two meds are used for a chemical stress test for Pts unable to exercise
Pts need to d/c ? two meds prior to test
PCI: 1 or 2 vessel Dz in non-DM w/out LAD involvement and normal EF
CABG: L-main or 3 vessel Dz, or two vessel Dz in diabetics, or Pts w/ EF <40%
Adenosine: dec AV conduction
Dipyridamole: dec platelet aggregation, coronary artery dilation
Theophylline: adenosine receptor antagonist
Caffeine
What can trigger Rest Angina
What medication may be used during angiography to aid w/ Dx
How are these Pts managed and what is avoided
rinzmetal: cocaine, pseudophedrine
Ergonovine
CCBs, then Nitro;
No BBs
Check ? leads for P-wave morphology
How is a sinus rhythm determined
Normal PR interval
2, V1
Upright 1, 2, aVF;
Neg in aVR
.12-.2 (3-5 boxes)
How is L atria enlargement assessed
How is R atria enlargement assessed
Normal QRS length is ? but if shortened ? step is
M-shaped in lead 2
Biphasic in V1 w/ larger terminal component
Tall in lead two ≥3mm
Biphasic in V1 w/ larger initial component
What iis the typical outpatient medical regiment for angina
What are the two procedures done for Tx and what determined each one
MCC of HF
BB ASA Nitro Statin
PCI: 1-2 vessel dz w/out L-main involvement and normal EF
CABG: L-main stenosis or 3 vessel dz (2 vessel if diabetic) of LVEF <40%
CADz
Define Sinus Arrhythmia
If Sx, how are these Pts Tx
Beat to beat variation: inc w/ inspiration, dec w/ expiration
Brady w/ Atropine first, then:
Trans-pace, Epi, Dopamine
Criteria for Sinus Tach
What med is used for persistent sinus tach during ACS
Criteria for Sinus Brady and how are Pts w/ Sxs Tx
> 100bpm w/ P-waves
Metoprolol
<60bpm w/ P-waves;
Atropine then Epi/Trans-pacing
How does A-flutter appear on EKG
How are stable Pts managed
How are unstable Pts managed
Identical saw-tooth waves at 250-350 bpms
Vagal, Rate: BB/CCBs
Sync’d conversion
Definitive Tx for A-flutter
? class anti-arrhythmics can be used
What are the four types of Afib
Ablation
1A, 1C or 3
Paroxysmal: <7days
Persistent: >7days
Permanent: >12mon, refractory to conversion or no attempts
Lone: no heart Dz
? syndrome can occur during Afib
How are stable Pts Tx
How are unstable Pts Tx
Ashman: aberrant conduction beats w/ wide QRS after short R-R cycles
Rate: BB or Non-Di CCBs, Digoxin if BB/CCB c/i
Synch’d conversion
What class medication is avoided during systolic HF
Harsh rumbling murmur means ? and lead to ?
Rumbling murmurs mean ? and lead to ?
CCBs
Stenosis- pressure overload
Regurgitation- volume overload
What are the two different EKG presentations of PSVTs
How are the two Tx
Orthodromic: narrow complex tachycardia
Antidromic: regular, wide complex tachycardia
Stable, narrow: vagal, Adenosine, BB CCB Digoxin
Stable, Wide:
Amiodarone, Procainamide
Unstable: Synch’d conversion
What is the difference between WAP and MAT
MAT frequently co-exists w/ ? other d/o
How is MAT Tx in this population
WAP: <100bpm
MAP: >100bpm
COPD
Verapamil;
BB if LV function preserved
WPW is a AVRT variant w/ accessory pathway located ?
What are the 3 EKG findings
How is this wide complex Tx
Bundle of Kent
Short PR
Wide QRS
D-wave
Procainamide/Amiodarone
Synch’d conversion
Ablation
What EKG finding suggest AV junctional rhythms
What EKG finding suggest PVCs
MCC of Vtach
Inverted P-wave 1, 2, aVF
Post P-wave aVR
T-wave opposite direction of QRS w/ compensatory pause
Ischemic heart dz
Along w/ low E+, what medication toxicity can cause V-tach
How is stable, sustained Vtach Tx
MCC of Vfib
Digoxin
Amiodarone Lidocaine Procainamide
ischemic heart Dz
MCC of syncope
Harsh/Rumbling murmur indicates ?
Blowing murmur indicates ?
Vasovagal: prodrome of dizzy, light headed, tunnel vision
Stenosis
Regurg
Increasing venous return to the heart increases the intensity of ALL murmurs except ? two
What two murmurs radiate
What positions accentuate aortic and mitral murmurs
HOCM, MVP
MR: axilla AS: carotid
Aortic: sit, lean forward
Mitral: lay on side
What does hand grip do for heart murmurs
This murmur increases ? murmurs
What effect does Amyl nitrate have on murmurs
Inc after load, dec LV emptying
Outflow: AS, HOCM, MVP
Dec afterload, inc LV emptying; inc AR/MR murmurs; this is why after load reducers (ACEI) are used
? is the MC valvular Dz
What are the two MCC by age
What would be seen on PE indicating this murmur
AS- preload depended
> 70: age degeneration <70: bicuspid valve
Pulsus parvus et tardus: weak, delayed carotid pulse w/ narrow pulse pressure
How are Pts w/ AS managed until surgical correction
What additional murmur can be heard w/ AR
What two additional PE findings aid w/ Dx AR
Avoid exertion and neg inotropes: BBs, CCBs
Austin Flint: Mid-late diastolic rumble at apex d/t regurg from LA into LV
Bounding pulses, Wide pulse pressure
What are the 8 types of wide pulse pressures seen w/ AR
Water Hammer: rapid up/down of radial pulse
Corrigan: water hammer in carotid artery
Hill’s: SBP popliteal > brachial, most sensitive
Duroziez: femoral artery pressure= bruit
Traubes: double sound at femoral w/ compression
De Musset: head bob w/ pulse
Muller’s: pulsations seen in uvula
Quincke’s: finger nail pulsations
How is AR Dx
How are Pts managed until surgery
MCC of MS
Echo w/ cath
Dec afterload: ACEI/ARB
Rheumatic heart dz
What facial changes are seen on PE in Pts w/ MS
What ENT syndrome can this cause
What will be heard on exam
Mitral facies: flushed cheeks w/ facial pallor d/t hypoxia
Ortners- recurrent nerve plasy d/t LA dilation
Loud S1 (MV closure) w/ opening snap
MCC of MVP
What does this sound like on PE
What makes this click occur sooner/later
USA: MVP
Developing: rheumatic heart dz
Widely split S2 w/ displaced PMI
Soon: dec preload, Late: inc preload
What med is used during MVP w/ Sxs
Do Pts need endocarditis prophylaxis
What causes PS
BBs
No
Congenital Rubella Syndrome
What additional murmur is heard w/ PR
Define Carvallos Sign
? lab result makes a Dx of CHF more likely
Graham Steel: early diastolic decrescendo at LUSB, accentuated w/ inc venous return/dec w/ dec return
Inc murmur w/ inspiration w/ pulsatile liver= TR
BNP >100; LMOP:
Fuorsemide Morphine Nitrates O2 Position- sit and dangle legs over bed to dec preload/venous return
What are the two MCC of pericarditis
How is pericarditis Dx
How is this Tx based on etiology
Infection: Coxsackie, Echovirus
Dresslers
EKG: diffuse, precordial ST elevation/PR depression, opposite in aVR
NSAID/ASA; Dressler: ASA/Colchicine (avoid NSAID)
? size of abdominal aorta is considered an aneurysm
What is the MC location
How do un/ruptured aneurysms present
> 3cm
Infrarenal
Un: Flank pain, abdominal bruit, pulsatile mass
Rup: Flank pain w/ echymosis, HOTN, mass
How are AAA Dx
When are screenings performed
What sizes are indicative of repair/referral
Stable: CT w/ contrast Unstable: bedside US
All men 65-75y/o w/ smoking Hx
> 5.4 or expands >0.5cm/6mon
4.5cm: refer
4-4.5cm: US q6mon
3-4cm: US q12mon
What is the MC Sx of PADz
How can the location of Sxs determine the side of occlusion
What type of ulcers does this condition develop
LE claudication
Aortic bifurcation/Common iliac: butt, hip, groin
Femoral artery/branch: thigh/upper calf
Popliteal: lower calf, ankle/foot
Lateral malleolus
Define the triad for Leriche Syndrome
How is PADz pain at rest relieved
How is PADz Dx
Claudication Impotence Dec femoral pulses
Foot dependency (hanging off of bed)
ABI <0.9, pain at rest suggests ABI <0.4
How is PADz Tx
What is the name of the first line revascularization procedure
Acute Arterial Occlusion is most likely to occur where
Exercise w/ smoking cessation
Clostazol > ASA/Clopidogrel
Percutaneous transluminal angioplasty
Superficial Fermolr/Popliteal artery d/t thrombotic occlusion
What is an early and late sign for Arterial Occlusion
Define Thromboangitis Obliterans
How is this condition Dx
Paresthesia, Paralysis
Buerger’s Dz: non-atherosclerotic vasculitis
Abnormal Allens test, Corkscrew arterioles on aortography
How is Thromboangitis Obliterans Tx
Where is the MC primary cardiac tumor found
This MC can present mimicking ? valvulopathy
Cessation w/ Iloprost (prostaglandin analog) and CCB
LA near fossa ovalis
MVP
How are Atrial Myxomas Dx
How is GCA Tx if steroid-sparing/refractory agents are needed
What PE sign can be seen w/ superficial thrombophlebitis
TEE: ball-valve obstruction on MV
Methotrexate, Azathioprine
Trousseaus: migratory thrombophlebitis w/ malignancy
Most specific sign for DVT
3 indication for IVC filter w/ DVTs
How long are Pts anticoagulated for
Swelling/edema >3cm
Recurrent despite anticoagulation
C/i to anticoagulation
RV dysfunction/enlargement
x3mon
PVDz stats
PADz stats
Pain worse w/ leg dependency/rest
Pain improves w/ activity/elevation
Cyanosis w/ dependency
Medial ulcers
Better w/ dependency/rest
Lateral ulcers
Worse w/ activity/elevation
Redness w/ dependency
What does Chronic Vein Insufficiency have hyperpigmented skin changed
How are ulcers dressed
What medication can be used to improve healing time
Hemosiderin deposition
Zinc gauze w/ MC site on medial malleolus
ASA
Define Wheeze
Define Rhochi
Define Crackle/Rales
Define Stridor
Louder expiration d/t narrow/obstructed airway
Low pitch rumble/rattle cleared w/ coughing
High pitched noises w/ inspiration NOT cleared by cough
Narrowing in larynx/trachea hear throughout cycles
MC type of cardiomyopathy
What are the two MCCs
What is the hallmark PE finding
Dilated: systolic dysfunction
Idiopathic, Coxsackie/Echovirus
S3 gallop
How is Dilated Cardiomyopathy Dx
How are these Pts Tx
When is an ICD warranted
Echo w/ dec EF and LV dilation/thin walls
Loops ACEI BB Spironolactone
EF <35%
Define Restrictive Cardiomyopathy
What is the MCC
What sign may be seen on PE
Diastolic dysfunction d/t dec filling compliance
Amyloidosis
Kussmaul: inc JVP w/ inspiration
How is Restrictive Cardiomyopathy Dx
How are Pts Tx
Define HOCM
Definitive: biopsy
Echo: non-dilated ventricles w/ normal wall thickness and diastolic dysfunction
Chelation: hemochromatosis
GCCS: sarcoidosis
Autosomal dominant d/o causing hypertrophy w/ diastolic dysfunction
What causes the obstruction during HOCM
What makes the murmur worse
How is this Dx
Septal hypertrophy w/ anterior MV motion during systole
Inc contraction: B-agonist Exerise Digoxin
Dec LV volume: Valsalva, dehydration
Echo: 15mm wall thickness w/ LVH
How is HOCM Tx
MC type of ASD
What is the other type and the valvulopathy associated w/ it
BB then CCBs/Disopyramide
Young and refractory: myomectomy or alcohol ablation
Ostium Secundum, mid-septum
Ostium premium: MV abnormalities
What does ASD sound like on PE
How is this Dx and what EKG sign may be present
These can be Tx w/ observation but surgery is indicated when
Wide, Fixed Split S2 w/out vary w/ inspiration
Def: Cath
Echo; Crochetage: R-wave notching in inferior leads
> 1cm or Sxs via percutaneous transcatheter
Define PDA
What population is more likely for this defect
What allows this defect to continue after birth
Continuous connection between descending aorta and pulm arteries
Premature female
Continued prostaglandin E1 production and low O2
What syndrome can develop out of PDAs
What does this sound like on PE
How is this condition Dx
Eisenmenger: P-HTN w/ cyanosis and feet clubbing
Continuous ‘to-and-fro” machinery murmur w/ wide, bounding peripheral pulses
Initial: Echo, Def: Cath
How are PDAs Tx
What is the MC congenital heart Dz of childhood
What EKG phenomenon may be seen w/ this MC
Indomethacin; Surgical if non-responsive by 1-3y/o
VSDs, MC type: Perimembranous
Katz-Watchel: LVH + RVH
When are VSDs Tx w/ surgery
Why is surgical intervention done prior to 2y/o
Where are aortic coarctations MC located
Symptomatic infant
Uncontrolled CHF
Delayed growth
Recurrent resp infections
Prevent P-HTN
Insertion of ductus arteriosus distal to L subclavian origin
How does aortic coarctations present
What are the two types
What is the Gold Standard and Confirmatory Dx test
Arm BP > Leg BP (bilateral claudication)
Post-ductal: adults, narrowing distal to ductus
Pre-ductal: infantile, narrowing prox to ductus
Confirm: Echo, Gold: Angiography
How are Coarctations repaired
What do Pts need prior to surgery
Surgery/Transcatheter
Prostaglandin E1- Alprostadil
Tetrology is associated w/ ? genetic defect
What is the MC presentation
How is this Dx
Chrom 22 deletion
Blue Baby Syndrome; tet spell relieved w/ squatting
Echo
Ranges for Normal, Elevated, Stage 1 and Stage 2 HTN
What is the MCC of Primary and Secondary
What are the two MCC of end stage renal dz
N: <120/80 and <80
E: 120-129 and <80
1: 130-39 or 80-89
2: ≥140/≥90
P: idiopathic, S: renovascular dz
DM then HTN
? is the only type of shock where large amounts of fluid are avoided
What drugs are used instead
What is the first line medical therapy for O-HTON
Cardiogenic- capillary wedge pressure >15mmHg
Dobutamine Epi Amrinone- PPD-3 inhibitor
Fludrocortisone then Midodrine- A-1 agonist or Droxidopa- pressore
What is the worst RF for CADz
What is the most important modifiable RF
How long does angina pectoris last
DM
Smoking
<30min or <5min w/ rest/Nitro
Initial test of choice for Angina and classic finding
What is the most important non-invasive test
What is the definitive test
EKG: ST-depression
Stress test
Angiography
What iis the typical outpatient medical regiment for angina
What are the two procedures done for Tx and what determined each one
BB ASA Nitro Statin
PCI: 1-2 vessel dz w/out L-main involvement and normal EF
CABG: L-main stenosis or 3 vessel dz (2 vessel if diabetic) of LVEF <40%
MCC of L-sided HF
MCC of R-sided HF
MC form of HF
CADz and HTn
L-sided HF (Pulm Dz, MS)
Systolic: Dec EF w/ S3
What causes High Output HF
What are the 3 parts leading to HF
Wet BeriBeri Anemia Pagets Thyrotoxicosis Shunts, AV
Sympathetic activation
Hypertrophy/remodel
RAAS activation w/ ventricular remodel
What is the most important prognostic factor of HF
What are the two initial tests ordered for suspected CHF
What medication class is the single most effective med for mortality benefit in HF w/ reduced EF
EF: <35% inc morality and ICD indication
CXR w/ BNP >100
ACEI
Indications to use Ivabradine for HF
? med has decreased hospitalizations but offers no benefit for mortality
Chronic, stable HF w/ LVEF ≤35% and HR ≥70bpm and already maxed out/unable to take BBs
Digoxin
What are the LMOPs of CHF Tx
What CXR finding suggests CWP of 18-25mmHg
What CXR findings suggest CWP of >25mmHg
Lasix (Furosemide) Nitrate O2 Poistion- sit and dangle legs
Kerley Bs
Butterfly/Batwing
What class medication is avoided during systolic HF
Define Acute Bacterial Endocarditis
Define Subacute Bacterial Endocarditis
Prosthetic valve endocarditis is MC d/t ?
CCBs
Normal valve infected w/ Staph A
Abnormal valve infected w/ Strep V
Staph Epidermis
What organisms cause endocarditis w/ negative blooc cultures
What are two microbes that cause endocarditis in Pts w/ colon Ca/UC
What is the MC Sx of infective endocarditis
Haeomophilus aphrophilus Actinobacillus Cardiobacterium hominis Eikenella corrodens Kingella kingae
Strep bovis
Fever
What are the clinical manifestations of Infective Endocarditis
How long is Fungal Endocarditis Tx
What valve is most likely to be affected by infective endocarditis
FROM Jane:
Fever Roth Osler Megaly, speen Janeway lesions
Amphotericin x 6-8wks
M>A>T>P
What are the major criteria
What are the minor criteria for Rheumatic Fever
Rheumatic valvular dz is most likely to affect ? valves
Joint polyarthritis Oh no, carditis Nodules, SQ Erythema marginatum: macular, non-pruritic annualr rash w/ sharp demarcation borders on trunk/extremity Sydenhams chorea
Arthralgia Fever Inc ESR/CRP Prolonged PR
M>A>T>P
Gold standard for Dx myocarditis
How are these Pts Tx
MCC of pericardial effusions
Biopsy
Systolic failure: Loops ACEI BBs
Lung Ca then Breast Ca
Most important RF for aortic dissection
How can the location of pain predict the type of dissection
What two meds are used for Type B dissections
HTN
Ascending: anterior pain, type A
Arch: neck/jaw
Descending: interscapular pain, type B
Non-Sel: labetalol w/ Na nitroprusside
How quickly is BP lowered during aortic dissections
Define COPD and what is the MC RF
What is the only genetic dz linked to COPD
100-120 <20min
Smoking
Alpha-1 antitrypsin deficiency
Define Emphysema
What are the 3 types of emphysema
What is the hallmark of emphysema
Enlarged terminal airspace (distal to terminal bronchioles)
Centrilobar: smoking
Panacinar: a-1 antitrypsin
Paraseptal: Spot Pneumos
Dyspnea
How is emphysema Dz
Define Chronic Bronchitis
What is the MC etiology
PFT: irreversible restrictive pattern w/ FEV1/FVC <70%
Productive cough x 3mon x 2yrs
Smoking
What are the 3 cardinal Sxs of chronic bronchitis
How is Chronic Bronchitis Dx
? arrhythmia is seen in these Pts
Chronic cough, Sputum, Dyspnea
PFT: FEV1/FVC <70% w/ dec FVC
MAT: >100bpm w/ 3 different P-wave morphologies; Tx- Verapamil
What lab result differs Chronic Bronchitis from Emphysema
Most important step in Pt management along w/ ? vaccines
When is O2 supplementation needed
Inc H/H w/ resp acidosis
Cessation, Pneumococcal/Influenza
PaO2 >55,
SpO2 88% or less
Cor Pulmonale
Emphysema
Chronic bronchitis
Dyspnea- MC Sx Hyperinflated lunged/flat diaphragm Hyperresonance Matched V/Q defect Hypoxic
Productive cough- hallmark Rales, Rhonchi, Wheeze Resp acidosis w/ inc H/H V/Q mistmatch Hypercapnea
What ABX classes are used during COPD exacerbations
How are Pts Tx by GOLD Class
Macrolide: Azith/Clarith-romycin
Cephalosporin
Augmentin
Fluroquinolones
A: SABA (Albuterol) or SAMA (Ipratropium)
B: LAMA>BA (Tiotropium>Sal/For-meterol)
C: LAMA (Tiotropium)
D: LAMA+LABA or LABA+inhaled GCSS
Why doe COPD Pts develop P-HTN and Cor Pulmonale
Define Bronchiectassis
What is the MCC and what infections are Pts vulnerable to
Hypoxic constriction inc R-sided atrial pressures
Permanent dilation of bronchials
CF w/ Pseudomonas infections;
Non-CF: HFlu
How is CF Dx and w/ ? two findings
What are the three components of Asthma
What is the strongest RF
CT: tram-track and signet ring sign
Airway hyperactivity
Bronchoconstriction
Inflammation
Atopy
Define Samter’s Triad
Define Atopic Triad
How is Asthma Dx
ASA, Rhinosinusitis, Polyps
Asthma Dermatitis Rhinitis
PFT: reversed obstruction w/ dec FEV1/FVC
How is Asthma Dx via bronchoprovocation test
How is an exacerbation best assessed
What criteria are needed for discharge after exacerbation
Methacholine challenge: 20% or more dec of FEV1 followed by bronchodilator challenge w/ FEV1 inc 12% or more
Peak expiratory flow rate
PEFR >70% or >15% improvement
Define Sarcoidosis
What do Pts present w/
What lab results would be seen
Idiopathic, multi-system inflammatory granulomatous dz
Lupus pernia- most specific
Erythema Nadosum (classic)
Dry cough
Hyper ACE, Ca, Vit D
Define Lofgren Syndrome seen w/ Sarcoidosis
What is the best initial test and what would be seen
Polyarthralgias w/ fever
Erythema Nadosum
Bilateral hilar adenopathy
CXR:
1: BHL w/out pulm Sxs
2: BHL w/ ILDz
3: ILDz only
4: fibrosis w/ restrictive dz
What is the most accurate Dx method for sarcoidosis
How are these Pts Tx
What meds can be used for cutaneous manifestations
Tissue biopsy: non-caseating granulomas
PO CCS
Methotrexate, Hydroxychloroquine
What are two poor prognostic factors for Sarcoidosis
MCC of typical pneumonia and CAP
What would be seen on PE for this MC
Lupus pernio, Interstitial lung Dz
Strep pneumo
Tactile fremitus
Egophony
Dull w/ percussion
How does pneumonia d/t Strep Pneumo appear
What would be seen on lab results
What is the 2nd MCC of CAP
Chills/Rigors w/ rusty (blood-tinged) sputum
Gram-pos diplococci
H-Influ: Gram-neg rod in ImmComp or Pts w/ Pulm Dzs
Pneumonia d/t Staph A is commonly seen after ? and causes ?
What stain pattern does this have
? microbe causes pneumonia in alcoholics
Influenza, HAP
Clustered gram-pos cocci
Klebsiella: purple (currant jelly) sputum w/ cavitary lesions on CXR;
Gram-neg rods
? is the MCC of Atypical pneumonia
What two non-pulm manifestations can this cause
How is this MC Dx
Mycoplasma pneu.
Bullous myringitis
Cold Autoimmune Hemolytic Anemia
CXR:
Reticulonodular pattern, PCR (test of choice)- cold agglutinins
What ABX are used for pneumonia Tx
What class of ABX is this naturally resistant to
How is Legionella Dx and Tx
Azith/Clarith-romycin, Doxy
Lacks cell wall= B-lactams
PCR > Urine Ag;
Azith/Clarith-romycin or Levofloxacin
How is aspiration induced pneumonia Tx
How is the need to admit pneumonia Pt determined
? additional PE finding suggests aspiration pneumonia
IV Amp-Sulbactam, PO Augmentin
CURB65:
Confusion Uremia >30 Resp >29 BP <90/<60, Age >65
Foul smelling sputum d/t accumulation in R-lower lobe
How is Histoplasmosis transmitted
This can also be an AIDS defining illness if CD4 is below ?
How is this Dx
Bird/bat droppings in Mississippi/Ohio River Valley
150/<
Sputum culture > PCR
Inc ALK-P, LDH w/ pancytopenia
How is Histoplasmosis Tx
? is the MC opportunistic infection of HIV
How do Pts present w/ this MC
Mild/Mod: Itraconazole
Sev: Amphotericin
P jirovecii
Dyspnea/dec O2 sat w/ exertion
How is P jirovecii pneumonia Dx
How is the normal course of TMP-SMX adjusted w/ add on meds
What IV med is used for severe cases
Diffuse bilateral interstitial infiltrates w/ LDH >200
Broncho lavage for fluorescent Ab stain
Definitive: biopsy
HIV w/ Hypoxia: add Prednisone
Pentamidine
How is P jirovecii Tx in Pts w/ G6PD
? forms of TB are infectious
Two forms of extrapulm TB
Atovaquone or Pentamidine (avoid Dapsone, Primaquine)
Primary, Secondary (reactivated)
Scrofulla: cervical nodes
Pott’s: vertebral
What are the two granuloma complexes seen w/ TB
How is TB Dx and when is a Pt considered Tx
How is this Dx if primary Dx methods are c/i
Ghons: calcified lymph node
Rankes: healed, calcified Ghons complex
One pos acid fast= pos
NAAT: more sensitive than sputum
3 consecutive neg acid fast= neg
Gastric specimen
MOA/adverse of Rifampin
MOA/adverse Isoniazid
MOA/adverse of Pyrazinamide
MOA/adverse of Ethambutol
MOA/adverse of Streptomycin
RNA synthesis inhibitor; orange secretion
Inhibits myclonic acid synthesis; peripheral neuropathy
Gout/liver Dz
Color vision changes
Aminoglycoside, CN8 toxicity
Pos PPD criteria >5mm
Pos PPD criteria >10mm
Pos PPD criteria >15mm
Close contact w/ ATB
HIV/ImmSupp
15mg/day x 1mon or equivalent of Pred
Pox CXR w/ calcified granuloma
High risk, dense populus, Immigrant
IVDA
GI surgery
Induration inc x 10mm x 2yrs
No RFs
Define Silicosis
This condition puts Pts at risk for ?
What is seen on CXR for Dx
How are Pts Tx
Pulm Dz d/t inhaled silicone dioxide from quarrys/sand blasting
TB/mycobacterium infection
Nodular opacities in upper lobes w/ eggshell calcifications
CCS w/ O2
Coal Worker’s Lung CXR resembles ? and has ? PFT pattern
How is Berryllium exposure made
How is this Dx made
Emphysema, Obstructive
Nickel, Copper, Aluminum in aerospace/electronics
Lymphocyte proliferation test- assess thymidine uptake
How is Berylliosis Dx
How are PTs Tx
This lung condition puts Pts at increased risk for ?
Restrictive lung patter and non-caseating nodule biopsy
CCS w/ O2 then Methotrexate
Colon Lung Stomach Ca
Name of lung Dz from cotton exposure
What occupational hazard puts Pts at risk
What c/c do Pts present w/
Byssinosis
Textile: flax/hemp seed exposure
Sxs better at end of work week, restart when work resumes
MC complication from Asbestosis
Most specific complication from Asbestosis
Define Silo Filler Dz
Bronchogenic Carcinoma
Mesothelioma of pleura
Hypersensitivity pneumonitis from nitrogen dioxide release; N95 mask helps
Pertussis is most contagious during ? phase
When is the whoop/emesis seen
How are Pts Tx
Catarrhal
Paroxysmal
Azithromycin or TMP-SMX
What med is used for prophylaxis Tx of close contacts w/ epiglottitis
What meds are used for Pt Tx after intubation is established
How is Croup d/t parainfluenza Tx
Rifampin
Ceftriax/Cefotax or -cillin
Dexamethasone w/ nebulized Epi
MCC of Solitary Pulm Nodules
What characteristics make these increased risk for malignancy
What characteristics make these more likely to be benign
Infectiours Granulomas
Lobulated Age >40 Irregular Diameter Size >2cm
Circumscribed Smooth <1cm <30y/o
What are the two MC sites for carcinoid tumors
What do these look like on bronchoscopy
How can the location of the tumor be identified
GI > Lungs
Pink/Purple centrally located tumor w/ vascularization
CT or Octreotide scintigraphy
Bronchial carcinoid tumors are made of ? type of cells
What do these tumors secrete
What is the strongest association for SCLC
Enterochromaffin
Serotonin ACTH ADH MSH
Smoking
? is the MC solid tumor to present w/ paraneoplastic syndromes
Mesothelioma tumors arise MC from ? and 2nd MC from ?
Criteria for Pulm-HTN and ? genetic association
Small cell carcinoma (oat cell)
Pleura, Peritoneum
Pulm arterial pressure ≥20mmHg;
BMPR2 defect
What are the four classifications of P-HTN
If vasoreactive condition, ? class med is first line Tx
? combo findings on PE are suspicious for PEs
1: idiopathic
2: d/t left heart dz
3: hypoxemia/chronic lung dz
4: thromboembolic dz
CCBs
Normal CXR w/ hypoxia
What is the MC abnormal CXR finding of PEs
What are two classic but rare findings
How are Pts Tx if un/stable
Atelectasis
Westermark: avascular marking distal to PE
Hampton: wedge shape infiltrate d/t infarct
Stable: Heparin w/ Warfarin bridge
Un: SBP <90/RV dysfunction: thrombolysis w/ LMWH
Well’s Criteria for PE
What is done if the above stratification method shows a score of 0-1
3pts: Clinical S/Sxs of DVT or PE likely 1.5pts: HR >100, Immobile x 3d/surgery <4wks, Prev PE/DVT Dx 1pts: hemoptysis, malignancy w/ Tx <6mon
PERC Rule: Hormone Age >50 DVT/PE Hx Coughing blood Leg swelling O2 <95% Tachy >100bpm Surgery/Trauma <28days
What steps are used for PE prophylaxis in low, mod, and high risk Pts
MCC of ARDS and w/ ? presentation
Mimicks CHF on CXR, how are they differed
<40y/o/low risk early ambulation
Mod: stockings, pneumatics
Sev: LMWH (Ortho/Neuro surgery)
Gram-neg sepsis: hypoxemia w/out hypercarb
ARDS spares CV angles
Define Central Sleep Apnea
Define Cheyne Stokes breathing pattern
Define Biots Breathing pattern
Dec CNS drive causes dec respiratory effort
Response to hypercapnia d/t dec brain blood flow
Quick, shallow breaths of equal depth w/ irregular apnic periods (medulla damage, opioid use)
Define Kussmauls Respirations
What are the two types of pleural effusion and their etiologies
Hyperpnea; deep, rapid breaths d/t metabolic acidosis (body tries to blow off excess Co2) w/out pauses
Transudate: CHF** Cirrhosis Hypoalbumin Atelectasis Nephrotic (inc hydrostatic, dec oncotic press)
Exudate: infection/inflammation-
Pneumonia Emboli TB Ca
What is the initial test of choice for pleural effusions
What is the best type of image
What is the Dx Gold Standard
CXR: blunting of angles (meniscus sign)
Lateral decubitus films
Thoracentesis for Light’s Criteria;
Protein:Serum >0.5
LDH:serum >0.6
LDH >2/3 upper limit of normal
Max amount to be removed by throacentesis during therapeutic procedure
What lab results suggest fluid is empyema
How are effusions Tx if recurrent, chronic or d/t malignancy
1.5L
pH <7.2, glucose <40, +Gram stain
Pleurodesis w/ Talc or Doxy/Mino-cycline
Define Anaphylactic Shock
How are Pts Tx
How long is observation mandated
IgE mediated hypersensitivity
Epi, Airway, Antihistamines
4-6hrs d/t biphasic phenomenon
MCC of infectious esophagitis
Hallmark of GERD
What are the 4 red flags of GERD
Candidis: empiric Tx w/ Fluconazole
Pyrosis
Bleeding Odynophagia Weight-loss Dysphagia
What are the two MCCs of gastritis
H Pylori quad therapy
Concomitant therapy
1: H pylori 2: NSAID/ASA
Bismuth subsalicylate Tetracycline Metronidazole w/ PPIs
Clarithromycin Amox Metro PPI
? medication is good for preventing NSAID induced gastric ulcers
What is the MC site for extranodal N-HL
MCC of acute/chronic pancreatitis
Misoprostol
Stomach
A: Gallstones, C: ETOH
What two lab results suggest cholestasis is present
MCC upper GI bleeds
MCC lower GI bleeds
Inc ALP w/ GGT
PUD
Diverticulosis Dx by colonoscopy
? ABX are used for Diverticulitis Tx
What anti-Ab indicated Crohns
MCC acute mesenteric ischemia
OutPt/Uncomp: Metro and Cipro/Levo or TMP
Anti-Saccharomyces cerevisiae
Afib emoblus
What two ‘water shed’ locations are MC affected by ischemic colitis
MC non-neoplastic polyp in colon
MC tumor marker screened during colon Ca
Splenic flexure, Rectosignmoid junction
Hyperplastic
CEA
TCA over dose antidote
Amphetamine over dose antidote
Benzos antidote
Na bicarb
Ammonium chloride
Flumazenil
Theophylline antidote
Digoxin antidote
Methemoglobin antidote
BBs
Digibind w/ Mg
Methylene blue w/ Vit C
Ethylene glycol antidote
What is used to Tx fecal impaction after manual removal
When is diverticulitis considered to be complicated
Ethanol infusion, Fomepizole
Polyethylene glycol
Fistual, Obstruction, Perforation, Abscess
