Pretest Flashcards
1
Q
Acute epiglottis
1) Presentation
2) Most common bacteria
3) Classic sign on lateral neck x-ray
4) Differentiate presentation of acute epiglottis with strep and mono
5) Management
A
1) Hoarseness, stridor, difficulty breathing
2) H. Flue
3) Thumbprint sign
4) Strep: throat pain, no descendence to larynx or hypopharynx so no hoarseness, stridor, trouble breathing
Mono: exudative pharyngitis + cervical adenopathy
5) Intensive care to protect airway + ENT consult
2
Q
1) common causes of otitis media
2) external otitis in elderly diabetic
A
1) Hflue, M catarrhalis, strep pneumo
2) Pseudomonas- can cause meningitis and affect facial nerve or temporal bone
3
Q
condyloma lata vs condyloma acumninatum
A
lata: flat=> syphillis => also has hand and foot rash
acumninatum: HPV
4
Q
1) CSF profile of bacteria vs virus meningitis
2) Listeria meningtis suspected in…
3) ___ is the second most cause of bacterial meningitis but rarely causes penumonia
4) Pneumonia + meningitis w bacterial csf …..
5) Manage #4
A
1) Bacteria: PMN, elevated protein, low glucose
Virus: lymphocytes, normal glucose
2) alcoholic, immunocompromised, elderly; positive gram stain
3) Neisseria meningitidis-nasopharynx to brain
4) Strep pneumo
5) - Dexamnethasone: decreases adverse neurological sequelae of meningitis + lower mortality
- ceftriaxone
- vancomycin
5
Q
1) What is hemorragic fever
2) What organisms cause that
3) Pathophysiology
4) Management of #3
A
1) Fever + petechia or hemopytsis
2) yellow fever, dengue fever, lassa fever, marburg, hantavirus, ebola
3) vascular bed infection casuing microvascular adamage and changes in vasuclar permeability w subsequent organ dysfunction
4) observe close contacts for 21 days
6
Q
1) charcot’s triad
2) what is it for
3) most common bacteria
A
2) Cholangitis
1) : RUQ pain, jaundice, fever
3) enterobacteriaceae and anarobes
7
Q
1) Impetigo is…
2) Chicken pox produces..
3) Coxsackievirus description
A
1) cellulitis caused by group A strep
2) diffuse vesicles in various stages of development; more pruritus than pain
3) Morbilliform vesiculopustular rash + hemoragic componenet + throat, pain, soles
8
Q
Scenario of amebic liver abscess
A
1) 2-5 months after travel
2) Diarrhea occurs first but resolves
3) presents w RUQ pain
4) Diagnosis: Serology with enzyme immunoassay + US
5) Blood culture only if pyogenic liver abscess which this is not
6) Metroniadazole is tx if entamebea hystolytica
9
Q
most common source of vertebral osteomylitis
A
UTI bacteremia or pyelonephritis bacteremia; thus pt w such bacteremia in the past presenting with low back pain in suspicious for vertebral osteomylitis
tx: antibiotics
10
Q
Influenza A prevention in elderly nursing home
A
Vaccine unless allergic to eggs + oseltamavir for 2 weeks until antibodies against vaccine are formed
11
Q
1) stages of lyme disease
2) Distinguish that palsy from lacunar infarct
3) What else can cause facial nerve palsy
A
1) weeks: rash w erythema migran (stage 1)
weeks to months: secondary neurologic, cardiac, arthritic symptom, facial nerve palsy (stage 2)
Month to years: recurrent destructive oligoarticular arthiritis (stage 3)
2) Upper motor neuron involvement of lacunar infarct would spare upper forehead which is innervated by lower motor neuron. Upper forehead would be involved in lower motor neuron palsy like in Lymes
3) Sarcoidosis
12
Q
West nile vs HSV vs TB meningitis
A
West nile: epidemic in US during summer
HSV: temporal lobe + seizure
TB: aseptic meningitis + cranial nerve palsies
13
Q
UTI: Lactose fermenting gram neg vs non fermenting oxidase positive gram neg bacteria
A
Lactose fermenting gram neg: Enterobacteria, E.Coli
Non fermenting oxidase positive gram neg bacteria : Pseudomonas
14
Q
1) ab to treat UTI
2) Ab for pseudomonas
A
1) ceftriaxone, imipenem, trimethoprim-sulfamethoxazole
2) Pip/taz, cephaolosporin like cefepemine, carbapenem, fluroquinolones (cipro and levo), aminoglycoside (gentam, tobra, amikacin)
15
Q
chlamydia psittaci causes…
A
fever, dry cough, malaise after parrot exposure
16
Q
BP goals and managment
A
1) <60: 130/90; >60: 150/90
2) CKD: ACEI or ARB
non block: thiazide type, CCB, ACEI, or ARB
black: thiazide or CCD
17
Q
High intensity statin for
A
1) hx of CV event
2) LDL>190
3) diabetic 40-75
18
Q
moderate or high intensity statins for
A
1) 40-75 wo CV or diabetes who have >7.5 ASCVD risk
2) diabetics under 40 yo
19
Q
meds after MI
A
1) Statin high intensity
2) b blocker: lower risk of reinfarction
3) ace inhibitor
20
Q
how much drinking increases the risk of alcohol dependence
A
1) Men: >4 drinks/day or >14 drinks per week
women: >3 drinks/day or >7 drinks per week
2) Tx: Complete abstent (as controlling the amount is difficult) + group therapy + acomprosate or naltrexone
21
Q
GAD:
1) Men vs women
2) side effects of therapy
A
1) women>men
2) sexual impairment, worsening of anxiety shortly after initiating therapy with SSRI so starting doses are half of treatment dose
22
Q
1) bloated, diarrhea, severe after fatty meal, + diarrhea after travel
2) tx of bloody diarrhea
A
1) Giardia: metroniadazole
2) C. jejuni, enterotoxigenic E coli, salmonella, Shigella => fluoroquinolones or azithromycin
23
Q
1) someone had tetanus-diptheria 5 years ago. What do they need?
2) Penumococal vaccine recommendation
3) Zoster vaccine
4) Meningococcal vaccine
A
1) Tetanus-diptheria-pertusis (Tdap) - always give pertusis combined single dose vaccine if someone only has TD
2) 65 or older: if PV23 after 64 yo, PV 13 after 1year
if PV23 before 65, PV 13 after 65 then PV23 booster after 6 months of PV 13
-younger adults with COPD, DM, HIV, or asplenia
3) 60 or older
3) Anatomic or functional asplenia, complement deficineies, or first year college students in dorm
24
Q
USPFT recs for following:
1) Mamogram
2) Lung cancer
3) Aortic aneurysm
A
1) Q2 years at 50
2) Q1 year 55-80 for smoker within last 15 years
3) once between 65-75 in male smokers
25
any young adults w cv symptoms should be ___
tested for drugs- especially in the absence of dyspnea . Lack of dyspnea means cannot work up for asthma or DVT.
26
PVC's are treated with
B blocker
27
what is one way to see if pt has ketoacidosis
Ketoacidosis: body responds with respiraoty alkalosis aka body goes typhneic to exhale CO2 and increase ph
28
half life of nalaxone vs opiod
nalaxone : short half life so might have to give it multiple times to counter opiod over dose
29
abuse potential of opiods in which receptor
#1 abuse potential: mu receptor
Mu (morphine) receptor => sedation ,analgesia, euphoria, decreased resp drive and supressed appetitie
Delta: hormone changes and causes dopamine release
Kappa receptor: analgesia and decreases respirations and appetitie, dysphoria and psychosis
30
acute gout treatment
```
#1 NSAIDS unless GI bleeds or ulcer
Alternatives: colchicine or high dose prednisone (unless prediabetic which increases sugar level0
```
31
tx of hypertriglycerimia
<500: food low diet
>500: #1 is fibrate like fenofibrate or gemfibrozil
#2: statin
32
Contradictions to options for smoking cessation
1) Nicotine replacement: MI, angina, sever arrhythmias
2) Bupropion: preexisting seizures
3) Verenicline: depression and behavioral abnormalities
33
causes of hypo and hyperkalemia
Following shifts K+ into cell causing Hypokalemia:
1) alkalosis
2) Hyperthyroidism
3) insulin
4) Beta agonist
5) Alcohol withdrawl: high catecholamine state => beta agonist and shift K+ into the cell
6) Hypomagnesium
7) Renal loss with diuretic or renal tubular acidosis
8) poor oral intake
Hyperkalemia:
1) Pseudo: lysis of RBC due to difficult phlebotomy
2) acute alcohol ingestion=> accumulation of beta hydroxybutyrate and other Ketoacids
34
how to check for renal tubular acidosis
if low bicarb then RTA
35
1) diagnosis of metabolic syndrome
| 2) why is metabolic syndrome important
3 of following:
1) abd abesity (waist >35 inch in women and >40 in men)
2) Hypertriglycerdemia (>150)
3) Low HDL (<50 in women and <40 in men)
4) BP greater or equal to 130/85
5) fasting glucose >110
metabolic syndrome puts risk for diabetes and CAD
36
stage 1 HTn should be treated
130-140=> less than 2.4 g sodium, daily aerobic exercise, restriction of alcohol
>140=> meds
37
when are beta blocker the fist line therapy for HTN
ischemic heart disease or chf w reduced ef
38
prophalactic aspririn in
men at increased risk for CV and women with increased risk for stroke
39
HPV from ages
11 to 26
40
who should be tested for TB
1) congregant settin: prison, homeless shelters, **nursing homes**
2) Severly immmunocompromised
3) exporuse to active TB
4) healthcare professional
41
tx for latenet TB
6-9 months of isoniazid, 4 months of rifampin, or isoniazid plus rifapentine once weekly for 12 weeks
42
What are the inducers p450?
```
ATWO => antiepilectics, theophylline, warfarin, OCPs
Inducer of P450=> low warfarin => low INR: Chronic alcholics steal phen Phen and never refuse greasy carbs
1) Chronic alcohol use
2) St John's wart
3) Phenytoin
4) Phenobarbital
5) Nevirapine
6) Rifampin
7) Griseofulvin
8) Carbamazepine
```
43
what are the inhibitors of p450?
Inhibitors of p450=> high warfarin=> high INR: AAA RACKS in GQ Magazine
1) Acute alcohol use
2) Ritonavir
3) Amiodarone
4) Cimetidine/Ciproflaxicin
5) Ketoconazole
6) Sulfonamides
7) Isoniazid (INH)
8) Grapefruit juice
9) Quinidine
10) macrolides (except azithromycin)
NSAIDS and GINKGO BILOBA
44
calculate NNT
NNT=1/absolute risk where absolute risk = different between prevelance in control vs experimental groups
45
when following vaccines are recommended?
1) Typhoid and hep A
2) Polio
3) Rabies
4) malaria prophalyxix
5) Meningococcal vaccine
6) Dengue
1) anywhere outside of europe or north america
2) few countries in africa, asia, southeast asia
3) animals in rural outdoors
4) most of africa, southeast asia, middle east, central and south america
- - if traveling outside of chloroquine-reistant malaria, mefloquine, atovaquone/proguanil or doxy are drugs of choice
5) Subsaharan africa and pilgrims to mecca
6) none
46
Case vs cohort
Case-control: a-o => one disease, other no disease => looks different so odds ratio => only look back
Cohort: o-o=> neither groups has disease => look the same so relative risk => look forward or backward
47
odds ratio vs relative risk
odds: one number / another
relative risk: one number/two numbers
** but for both of them since it is a ration, you have to calculate odd/RR for group A over odd/RR for group B
48
specificity vs sensitivity vs ppv vs npv
1) Sensitivy: LUQ=> LLQ
2) specificity: RLQ=> RUQ
3) PPV: left upper to right
4) NPV: right lower to left
49
Two bell curves of disease vs no disease. How to label
Left: True Negative
Right: True positive
Inside: they keep their last names: left: false negative right: false positive
50
how to calculate power of study?
power = 1-B
B = true H1, test Ho
Alpha: test H1, true Ho
51
1,2,3 SD's
1= 68%
2=95%
3 = 99.7%
52
What is the benefit of following studies?
1) Case control
2) Cohort
3) Cross sectional
4) Randomized control
1) only way to study rare disease
2) only way to study incidence and etiology
3) only way to study prevalence
4) only way to study cause and effect
53
when is odds ratio clinically important
Even if odds ratio itself is >1, but its 95% confidence intraval falls <1, then its not statistically significant, =1 means clincially insignificant
54
if the origin of urticaria is rarely found, why do we care about it?
very rarely can accompany illnesses such as chronic infection, myeloproliferative disease, collagen vascular disease, or hyperthyroidism
55
hx of infertility raises the issue of
immotile cilia syndrome or cystic fibrosis
56
tx for allergic rhinitis
1) oral antihistamine
2) nasal corticosteroid
3) Leukotrien antagonist montelukast and immunotherapy
intranasal cromolyn is less effective than nasal corticosteroid and can be tried in mild cases
57
What to do next time if someone has a history of anaphalaxis to radiocontrast media like in cath lab this time and you need to cath next time
worse w ionic contast and if asthma
1) premedicate w oral corticosteriod and use nonionic agent
Note: IV saline and oral N-acetylcysteine are used to prevent dye mediated aki
58
tx of anaphalaxis
0. 3mg epinephrine IM or IV
| - -- if IV: 0.3ml 1:1000 solution
59
one of cardiac arrest meds
1mg epinephrine
60
facts about immune therapy
1) specific antigens have to be identified through dermal or serum testing before immune therapy
2) requires 3-5 years of treatment that last for years
3) more beneficial for allergic rhinitis than asthma
61
Facts about food allergy
1% prevalent; soybean, seafood, peanut, soybean most allergen; GI and Skin most affected, avoiding is the only solution; RAST test most effective to diagnose
62
contraindication to epi pens in someone w known anaphalyxis reaction
ishemic heart disease
63
Live virus vaccine is contraindicated in which patients?
- HIV CD4 <200
- Prego
- congenital immune problems like SCID
- organ transplant
- prednisone >10mg daily
64
C1 inhibitor deficiency
1) high activated C1 and other proteins normally controlled by inhibitor => angioedema, GI attacks of colic due to angioedema of bowel
65
IgA def
severe allergic reaction to transfused blood; increased sinopulmonary infections and chronic diarrhea illness
------no tx, but can be accompanied with IgG subclass deficiency that make GI issues more susceptible. Can treat IgG subclass deficiency with immunoglobulin infusions
66
Ataxia telangiectasia
1) ataxia, facial and ocular telangiectasias
2) ATM gene abnormal=> impaired DNA repair mechanism => thus heterozygotes can acquire later in life after radiation exposure
67
Wiskott aldrich
Water: thrombocytopenia, exzema, recurrent infection including lymphoma
1) wASP mutation=> mut in protein involved in cytoskeleton => T cells affected more than B cells
68
Gigeorge syndrome
isolated T cell deficiency; thymic cells do not migrate normally from their origin int he pharyngeal pouches; 22q11 deletion
69
SCID
combined T and B cell dysfunction; adenosine deaminase deficiency more common where accumulation of purine metabolites leads to T and B cell apoptosis; X linked or autosomal recessive causing failure to thrive, chronic fungal, bacterial, viral infection; death in infancy wo stem cell transplant
70
1) Complement deficiency C5-C9
2) Post splenectomy
3) meds that cause drug induced agranulocytosis
4) IL 12 def
1) Neisseria infection
2) Spleen produces opsonins=> lack of opsonins=> high capsulated infection like pneumococcus and haemophilus influenza and salmonella
3) Antibiotics, antithryoids, antiepileptic
4) causes disseminated mycobacterial infection w nontuberculous species
71
Hyper-IgE syndrome
impaired neutrophil recruitment; causes staphlococcal abscess and pneumatoceles in lungs, Dermatologic problem, retained primary teeth (neutrophils important here)
72
hypersensitvity penumonitis
1) inflamatory reaction to inhaled organic dusts=> thermophilic acitnomycetes, fungi, and avian proteins
2) Acute: presents like pneumonia: cough, dyspnea, fever, chills, myalgia 4-8 hours after exposure => but hx of previous similar symtpoms on exposure suggest hypersentitivity pneumonitis
2) Subacute: no fever and chills but cough, anorexia, wieght loss, dyspnea
3) chronic: progressive dyspnea, weight loss, anorexia, ; pulmonary fibrosis
***bit igE mediated as reaction occurs hours, not minutes, after exposure
Tx: steriod + avoidance
73
1) indication for bronchoscopy
2) Pt w neutrophil disorders
3) Pt w T cell dysorder
1) recurrent pneumonias in the same lobe or segment
2) gram postivie cocci like staph, gram negative rods, invasive fungal like aspergillus or mucor
3) like in acquired T cell def like HIV: mucocutaneous candidiasis, pjneumocystis pneumonia, crytococcal meningtitis, disseminated fungal or mycobacterial infections
74
1) functional incontiennce is
| 2) causes of overflow incontinence
incontinence due to reasons other than urologic for example diabetic inspidius causes increased peeing.
overflow incontience can be caused by mechanical (BPH) or functional (Diabetes causing low tone to bladder) obstruction
75
side effects of bisphonates
reflux esophagitis; thus only take med upright and after food in stomach
76
why both pv13 and 23 to over 65?
13 has better immune response but 23 has more serotypes
77
GFR and old age
1) after 60, GFR decreases by 1 point each year
2) But muscle mass decreases too so creatinine production and excretion also declines proportionately
3) causes accumulation of meds like digoxin which causes nausea and vomiting
4) Especially suspicious as pt is on a stable dose of meds for years without any changes, but pt presents with new symptoms. Exam is unremarkable. Then, think GFR decrease causing accumulation of meds
78
Post-parandial hypotension is common in
- frail elderly on nitrates
- due to splanchnic blood pooling
- avoid large meals
79
Venlafaxine is an----- ; contradincated in
low dose: ssri
high dose: SNRI
pt's with hypertension and sexual dysfunction
80
Meniere disease causes
unilateral hearing loss
81
acoustic neuroma is
unilateral hearing loss
82
delirum vs dementia
Dementia: alzhmiers
Delirium: more recewnt onse,t a fluctuating course and prominnet inattention on exam
83
BP treatment in elderly
```
Treat when systolic >160:
#1 Thiazide
#2 Ace inhibtor or long acting ccb
```
****avoid short acting ccb
84
Difference between medicaid and medicaire
```
1) Medicare: Federal
A: acute hospitalizations
B: doc's visist, transition services like skilled nursing facilities
D: some perscriptions
***does not pay for chronic nursing home
```
2) medicaid: state
pays for chronic nursing home of income requirement is met
85
thoughts on restraining adults
restrains including geri chair increases the risk of falling and complications thus avoided
86
Lewd body dimentia vs alzhiemers vs
| delirum
LBD: visual hallucinations more common, paranoa and delusions more common, antipsychotic drugs worsen things
delirium: acute
87
stages of pressure ulcers and management
1: erythema: change mattress, wound care
2: partial thickness epidermis and dermis loss: hydrocolloid gels, debridgement
3: full thickness skin loss with subq tissue: hydrocolloid gel, debrigement
4: stage 3 + bone and muscle involvement: debridgement
* timed voiding preferred over foley
* *change matress and wound care for all levels
* **IV ab for osteo, sepsis, or cellulitis otherwise topical is fine
88
Nsaids in adults
contrindicated due to gi bleeding risk; esp indomethacin causes CNS side effects and has long half life
***acetomenophen much more preferred
89
dignosing forgetfullness vs dimentail
Dimentail: abnormal mini mental state exam
Forgetfulness: normal MSE but only remembers 2/3 items after 3 minutes
Treat forgetfulness: avoid sedating and anticholinergic drugs, have safe structures at home
90
stages of acne treatment
comedone: topical bdonzoyl peroxide and topical antibiotcs
papules and postules: oral ab
moderate: azelaic acid
nodules and cyst: : long term oral ab
refractory: isoretinin: double contraception + iPLEDGE program
**ab = clindamycin and erythromycin
91
trichinosis
1) acquired from raw port ingestion
2) causes myalgias and maculopapular rash wo distal involvement (unlike rocky mountain spotted fever)
3) periorbital edema and eosinophilia
92
psioraisis tx
1) topical calcineurin antagonist
2) Psoralen with UVA phototherapy (PUVA)
3) Methortrexate, oral cyclosporine, immune resopnse modifiers liker etancercept
topical corticosteriod of mod or high potency
1) atopic dermatitis
2) Severe or moderate clases of psoriasis due to risk of SCC
3) extensive disease .10% body surface are or if joint involved
93
rocky mountain spotted fever
- tennesse
- maculopapular rash over distal extremities (wrists, palms, ankles, soles) with petecial rash
- febrile, nausea, myalgia
94
how to diagnose sarcoidosis
Erythema nodusum biopsy non specific
lung biopsy too invasive
Thus, biopsy the plaques on nares or back or neck often present in sarcoidisis => non caseating granulamatous
95
explain telogen effluvian vs male pattern baldness in women
Telogen effluvian: Stressful/illness => extra tons hair follicles enter death phase aka telogen phase => DIFFUSE loss => heals w time
Male pattern=> lose crown and frontal hair => measure androgen at this point
96
SCC of skin vs melanoma
SCC: ulcerated erythematous nodule or plaque; precursor is actinic keratosis
melanoma: hyperpigmentation
Basal cell: pearly nodule with telangectasis
97
google what erythema multiforme looks like; what is it associated with
target lesion with non blanching dusky violet or petiachial center; herpes (HSV or EBV)and drugs (phenytoin, sulfa, barbiturates, penicillin)
98
suspect melanoma; what type of biopsy?
full thinkness excisional so you can assess invasion depth; NOT shave biopsy as it does allow you to asses depth
99
difference between SJS vs TEN
SJS: <10% skin invloved
TEN: >10% skin invovled
Common meds: anticonvulsants, allopurinol, anitbiotics
Tx: admit to burn unit and care for electrolyte derangement and infection
100
1. Pityriasis rosea
2. tinea corporis
3. Psioriasis
4. Lichen planus
5. secondary Syphillis
1. Christmas tree pattern - trunk and proximal extremities
2. annular like pityrasis rosea but red around the circle than inside the circle like in PR
3. distal extensor surfaces
4. lichen is like psioriasis and pitryasis rosea but POLYGONAL plaque involves oral mucosa
5. oral plaque, macular hand and food lesion + lymphadenopathy
101
pattern of sobbreic keratosis and tx
- macular areas of erythema with greasy scale behind ears, scalp, eyebros, glabella, nasolabial fold, central chest
- worse in winter
tx: usual fungal so ketoconazole or 1% hydrocortisone cream
102
dd for yellow and thick nails
1) onchomycosis: if not all nails are invovled: needs 6 months of oral terbinafene or itraconazole until nail grows out
2) yellow nail syndrome due to cancer or pulmonary: affects all 20 nails so work up for those
103
basal cell vs scc met pattern
Basal: pearly papule with telangecctasia w central ulceration => LOCAL invasion
SCC: ulcerated on erythamatous base => METS invasion
104
suspect cutaneous anthrax in...
postal office (bioterrorism), infected animals or their wool;
105
Presentation of cutenous anthrax vs its dd
- cutaneous anthrax: begining as small papule, painless, progresses to black necrotic lesion over several days; no systemic signs; gram + rods
erythema gangrenosum: black necrotic skin s/p sepsis w pseudonomas W systemic sign
brown recluse spider bite: black necrotic ulcer; PAINFUL, rapidly systemic illness with nausea, vomitng, myalgias, fever
Nec fasc: systemic illness with fever
bubonic plague: lymphadenitis
106
chicken pox vs small pox
chicken pox: trunk concentration, superficial, different stages of development, fever at the time of rash
small pox: face, palm, soles, same stage, fever preceding the rash
No small pox anymore except for bioterrorism
107
how to assess what kind of bullae
biopsy edge of bulla with some surround intact skin
108
pruitic dermatitis associted with asthma
atopic dermatitis=> low dose corticosteriod, skin moisturize, topical calcineurin inhibtor (tacrolimus, pimercolimus)
109
nail signs
1) Linear hyperpigmentation (hutchinson sign): melanoma
2) Psioris or lichen planus: pitting or roughened
3) Beau lines ( horizontal white lines ): hypoalbuniemia and lead poisoning
110
Kaposi characterisistcs
1) HIV
2) HHV 8
3) proliferation of endothelial cells in blood./lymphatic microvasculature => violaceous pathches, plaques on skin, mucosa, or vicera
4) pulm infiltrates due to viceral invovlement
111
1) Rosacea
2) Carcinoid
3) Porphyria cutanea tarda
4) Lupus
All: flushing
1) rosacae: telangiectasias of cheecks, nose + red papules and pustules; conjunctivities w dilated scleral vessels; flushing and blushing with wine; low dose oral tetracycline, erythromycin, metronidazole control symptoms
2) carcinoid causes flushing but no papules or pustules and is GI symptoms
3) Porphyria cutanea tarda: telangiectasias, can be associated w alcohol, but facial hair growth and fragile skin in sun exposed area
4) Lupus: butterfly shaped macular rash do not cause pustules
112
scabies aka arthropod
intsense priutus + linear serpiginous burrow+ interweb, wrist, periumbilical
113
dermatitis herpetiformis
pruitic disease with IgA deposion in the dermis=> vesicular affecting elbow, knees, buttocks
NOT contagious
114
what is USPFT rec for alcohol use disorder?
do it in all: men >14 or >4 drink and women >7 or >3 drinks
115
risk for low bone mass that could cause someone under 65 to have bone mass of 65 yo => requiring early dexa?
personal history of fracture, secondary cause of low bone mass (celiac, hyperparathyroidism, liver disease, long term use of systemic steroids or anti-epileptic drugs,), cigarette smoking, alcohol abuse, low BMI, first deep memeber w hip fracture
116
diagnosis of osteoporosis
occurence of fragiligy fracture aka fall from walking weight or T score less than -2.5
117
Therapies for osteoporosis related
1) Bisophosphonate: reduce recurrent fractures
2) Raloxifene: non appropriate for thromboembolism
3) Estrogen: same as #2 => used more for prevention than treatment
4) Hydrochlorothiazide: decreases urine calcium loss and maintains bone density => decreases 1st fracture , not recurrent
118
men vs women in
1) cornary disase
2) MI
Women: develop symptoms 10 years later in life than mne, atycpical symptoms, less degree of coronary obstruction leading to hypothesis that vasospasm and endothelial dysfunction more important than plaque instabliity and obstruction in women => women less stenting than men
119
tx of vaginal candidiasis
Uncomplicated: responds to topical imidazoles or one dose of roal flucanozole
complicated: requires prolonged course of topical antifungals or at least two doses of oral flucanozole
complicated when: diabetes, prego, immunocpuressed, revered recurrent disease
120
tx for BV; trich; GC/chlym
BV and trich: ph>4.5
BV: 1 week metroniadazole - clue cells aka squamous cells plastered w coccibacilli
trich: yellow green discharge: also metroniadazole
121
hirsuitism vs virilization; management
hirsuitism: abnormal hair growth in androgen dependent area
virisliation: fontal balding, deepening voice, cliteromegaly, => worrisome for androgen producing tumor of adrenal gland or ovary
mod hisrsuitism and any virilization should undergo: Dhea-S (to rule out andrenal androgen overproduction)_, testosterone (to rule out ovarian endrogen overproduction), TSH, prolactin, and follicular phase 17 hydroxy progesterone (to rule out late manifestation of congenital adrenal hyperplasia)
122
PCOS diagnosis:
| tx for non prego interested:
two of: oligomenhorea (anovulatory bleeding), clinical or biochemical evidence of hyperandgrogenism (excluding other causes of hyperandrogenism), and PCOS by US
tx: ocps to improve hirsuitism or metformin improves insulin resistance and restores ovulatory periods
123
____ treats idiopathic hirsuitism (normal menses and normal androgen level)
spiralactone
124
nullparity___ breast cancer risks
increases
125
recs for aspirin in men and women
men: CV: 45-79
women: stroke: 55-79
126
ecg pattern of pe
S wave in lead 1; Q wave in lead 3; inverted T in lead 3
127
worrisome characterisitcs of breast mass
management of a mass
irregular borders, size larger than 1 cm, and location in upper outer quadrant
even w negative mamogram or MRI, non cystic mass on US should be biopsied: don't fixate on needle or core biopsy
128
the only FDA approved contrapective for PMDD is
Premenstrual dysphoric disorder => OCP as IUD's still ovulate
129
HT aka estrogen for menopausal causes
increases breast cancer; decreases osteoportic fracture
only perscribe for <5 years for vasomotor symptoms
130
managment of acute fatty liver of prego
EMERGENCY
1) IV gluconate
2) immediate induciton of labor and delivery
3) third trimester
4) associated with preeclampsia
131
presentation of acute fatty liver of prego
initial: nausea and RUQ pain but evidence of liver failure (prolonged PT due to synthetic failure, hypoglycemia as lack of gluconeogenesis, asterixis, somnelence) occurs rapidly
biopsy: microvesicular fat deposition
132
dd of acute fatty liver prego
1) acute alcohol hep: modest rarely above 300 of transaminitis; acute liver failure rarely occurs
2) Intrahepatic cholestasis of prego: high alk phos and bili elevation but not liver synthetic failure
3) hepatitis: transaminitis above 1000
133
mammorgram in Braca mutation
annual MRI + mamo @30yo
134
Breast cancer prevention
1) Raloxifene: prevention in postmenopausal women;
2) Tamoxifen: prevention in premenopausal women: associated with uterine cancer in women >50 yo
3) oophorectomy: decreases risk of breast cancer
Both meds => increased thrmboembolic event
135
braca mutation in men
pancreas, prostate, breast
136
dd for dyspnea in hospitalized pt
1) anxious: high bp=> give benzo
2) PE: cancer, prego, long hospitalization, fracture
- if risk factor, therapeutic heparin before definite diagosis
- diagnose w CT PE in someone with lung cancer as VQ scans may be abnormal given abnormal chest x ray
137
what causes pulseless electrical activity? How to manage?
Normal lung breathing and heart rater, but no pulse
PEA occurs due to loss of cardiac output from decreased ventricular filling (hypovoolemia, pE< cardiac tamponade, tension penumothroax) or electomecchanical dissociation (hypoxia, hyperkalemia, or severe acidosis)
Manage: Vascular access, airway stabilitzation, adminster IV fluids
138
pre-op evaluation of post op cardiovascular risk factor after non cardiac surgery
Goldman Cardiac Risk index or RCRI
1) hx of ishemic heart disease
2) history of heart failure
3) serum creatinine >2
4) insulin dependent diabetes mellitus
5) history of stroke
139
contraindication to thromboembolytic therapy for stroke
1) unkonwn onset of symptoms
| 2) bleeding on ct non con
140
how to manage acute dilirium
1) keep pain meds on but at low dose
2) dc denzodiazapine
3) dc fluoroquinolones as worsens mental status
4) dc noxious stimuli like urinary catherter, oxygen delivery if unnecessary, telemetry or restrains
5) haloperidol if severe agitation
141
when to give ACEi/ ARB and spiralactone
ACEi/ARB: <40
| Spiralactone: Class 3 and 4
142
classes of HF
1. minimal symtoms during activity
2. mild symtpom during activvty
3. marked symtpoms during activity. Only asymptomatic at rest
4. Symtoms even at rest.
143
how to managment hypovolemic shock in sepsis
1) Switch from normal saline of 100cc/hr to a saline bolus of 2L over 20 minutes
2) If refractory to volume resuscitation, hydrocortisone and IV NE
**don't switch from normal saline to NE
144
Empiric therapy for CAP; microbes you are protecting
Fluoroquinole or third geneation cephalosporin+macrolide for atypical coverage like mycoplasma or chlamydia
* **avoid fluorquinoles in old people as causes deliroium
* ****use low dose as often have decreased GFR with age
145
bleeding in diverticulosis vs malignancy
diverticulosis: active bleeding, non stop
malignancy: blood laced with stool
146
confusion, agitaiton, tremor, tachy, high bp, fever, "something crwaling on skin"
alcohol withdrwal; tx w lorazepam
147
how should errors be handled
inform patient, apologize, and report to patient safety network
148
ways to minimize VAP
- orotrachial instead of nasophryngeal
- interuption of sedation to check for extubation readiness
- subglotting secretion suction
- elevation of bed rather than flat bed
149
signs of RA; xray; worse sign of prognosis; tx
BILATERAL, MCP/wrist, morning stiffness, rheumatoid factor, cutaneous nodules. xray shows joint space narrowing and erosion but only apparent later in the course; anti-CP antiboides and subq nodules are worst prognostic factors.
tx: DMARDS like metothrexate, hydroxychloroquine, sulfasalazine, leflunomide, anti-TNF
150
scratch onknee then septic arthiris from; white count range for gout
staph; 2-50 thousand
151
pathophysiology of Sjgrogen sydnrom
t cells infiltrate exocrine glands and B cels become hyperactive; autoantibodies including anti-Ro/SSa and anti-La/SSb: both pro and anti apoptotic messages are sent to ductal and acinar epithelial cells
152
pathophysiology of sclerosis
activated T cells and monocytes accumlate in the skin => induration for unknown reason=> causes structural abnormalities in various tissues and organs => reduction in normal functioning.j Anti-topoisomerase 1 and anti-centromere autoantibodies are commonly present
153
pathophysiology of vasculitits
immune comoplexes form and deposit in vessel walls; vasoactive amines including histamines, bradykinin, and leukotrienes are released, vesseled permeability is increased. Complement acitvation occurs and monoculear cells are attracted causing infltration and decreased gland function
154
pathophysiology of wegner's vasculitis
necrotizing vasculitis of small arteries and veins leads to granuloma formation and decreased exocrine function of salivary and lacrimal glands
155
diagnosis of schrojen's
biopsy the lip for lymphocytes; check autoantibodies anti-Ro/SSA and anti-La/SSB in serum
156
RA family and gender prevalence
women>>>men; family RA means 4x chance in kids; 10% of the people have first degree member have RA
157
SLE epi
women of child bearing age; african american
158
polymyalgia rheumatica
occurs after 50 yo and women>>>men; white
159
Diagnosis of: insidious back pain occuring in young male and improving w exercise
likely spondyalarthropathies: ankylosing spodylitis, reative arthritis aka reiter syndrome, psoriatic arthritis, enteropathic arthritis
RA not on back
If no signs to suggest one of them, then lab test showing following supports ankylosing spondylitis:
- mild anemia,
- positive HLA-B27
- elevated sedimentation rate
- symmetrical sacrolitis on xray
160
cause of death of ankylosing spondylitis
cervical fracture, heart block, amyloidosis
161
tx for SLE; pregnancy
high dose glucocrticoid therapy if glomerulonephritis, severe thrombcytopenia, or hemolytic anemia
SLE don't cause join deformities; can be prego as long as pred is <10mg
162
what things point towards scleroderma
Raynaud's phenomenon, arthralgia, dysphagia
163
two variant of scleroderma
```
Limited type (CREST syndrome): anticentromere
Severe diffuse type:
Antinuclear antibodies = universal
Anti-topoisomerase-1 aka Anti-Scl-70= specific
```
164
myositis like polymyositis antibodies
elevated CK and anti-Jo-1
165
Reactive arthiritis cahracterisitcs
1) occurs several weeks after non-gonococcal urethritis and GI infections and symptoms such as Yersinia enterolitica, C. jujuni, Salmonella, shigella
2) triad of urethritis, oligoarthritis, conjunctivitis
3) only spondyloarthritis without sacrolitis
4) Circinate blanitis and Keratoderma blennorhagicum
166
What to do if pt presents with Lyme disease
1) Emperic doxy while antibody titer for Lyme pends
| * *** Use Western blott to confirm initial diagnosis after ELISA shows Lyme
167
tx for PMR w and wo temporal arteritis
If headache aka sign of temporal arteritis: high steriod then biopsy
If no headache aka no sign of temporal arteritis: low steriod
***high dose steriod: around 80
low dose steroid: around 10-20 ******
168
Psoriasis classic and timeline; tx:
"pencil in cup" deformity of the DIP joints. Usually psoriasis and then joint involvement;
tx: immunesupression with metotrexate or TNF alpha antagonist based therapy
169
linear calcification of cartilage of knee
aka chondrocalcinosis
---- pseudogout=>calcium =>positively birefringement
tx: nsaids, colchicine, steriods if symptoms
170
tx fibromylagia
graded aerobic exercise, then TCAD then cyclobenzaprine
171
ACL tear normally has what movement
twisted; usually in atheletes
172
characteristics of dermatomyotis
1) gradual weakness of proximal muscles: can't get out of tub or stairs
2) helitrope rash present in 50%
3) Gatron's papule = pathoneumonic
- ----CK always high
4) biopsy is diagnostic
5) tx: high dose corticosteroid
173
causes of drug induced lupus
minocycline, procainamide, hydralazine, propylthiouracil, carbamazepine, phenytoin, isoniazid``
174
common maifestation of drug induced lupus
- CNS and renal involvemnt rare,
- skin and joint involvmenet most common
- imune mediated hemolysis of RBC = anemia w hyper bili
- anti-histone antibodies are common in drug induced lupus
- all kinds of lupus have high clot formation + anti-phospholipid syndrome
175
Behcet disease presentation
- asian
- recurrent oral apthous and genital ulcers
- 25% develop venous thromboophlebiutis
- Iritis, uveitis, and non deforming arthritis are common
- blindness, aspetic meningitis, and CNS vasculitis may occur
- Rare complications: pulmonary artery aneurysms and GI inflammation which may lead to perforation
- tx w topical corticostroids unless threatened blindness treat with immunosuppressive thrapy
176
carpal tunnel is associated with
thickening of connective tissue, acromegaly or with deposition of amyloid
- occurs in hypothyroidism, RA and DM
177
Granulomatosis with polyangitis aka wegener granulomatosis presentation
- vasculitis of small and medium size3d arteries and veins
- lungs, sinuses, nasopharynx and kidneys affected
- -------focal and segmental glomerulonephritis
- -------cavitary lung nodules caused by ishemic necrosis from arterial occlusion
- ------ others: skin, eyes, nervous system
178
antibodies in wedner granulomatosis
C-ANCA with antibodies to proteinase 3 or less common P-anca with antibodies to myeloperoxidase
179
large vessel vasculitides
Temporal (giant cell): older pt
Takayasu: aorta and its main branches in young woman; local vascular occlusion and arm or leg claudication. Following may precede vascular symptoms: arthralgia, fatigue, malaise, anorexia, weight loss
180
medium sized vasculitides
polyarthritis nodosa: necrotizing with signs of vascular insufficiency in involved organs => abd most common
-------30% pt have Hep B virus with immune complexes containing virus are pathogenic
181
small vessel vasculitides
1) granulomatosis iwth poyangiitis: necrotizing and granulomatous sinus lungs kidneys
2) microscopic polyangitis: necrotizing vasculitis causing glomerulonephritis, pulm hemmorrhage, fever. Mononeuritis multiplex, palpatble purpura with lung biopsy showing inflammation of capillaries
3) Churg-Strauss syndrome; wheezing, fever, eosinophilia, systmic vasculitis involving peripheral nerves, cns, heart, kidneysk, or GI tracts
4) Henoch Schonlein purpura; children: palpable purpura, arthritis, glomerulonephritis
5) Cryoglobulinemic vaculitis : HepC, palpable purpura, arthritis, glomerulonephritis
182
whipple disease presentation
arthritis (migratoy, intermittent, short duriation of hours to days) precedes Gi symptoms by years. GI symtoms occur due to malabsoroption.
Tx: antimicrobial
183
hemophilia and arthritis
recurrent bleeding into joint can cause joints to bome chronically inflamed and swollen; flexion deformities causes limitation of function
184
hemochromatosis presentation
- small joints of hands has pain w activity: often bilateral second and thrid MCP joints
- hyperpigmentation of skin
- liver or pancreatic dysfunction: cirhosis or diabetes
185
what makes anaerobic lung iinfection likely
Aspiration
1) air fluid level abcess in right lower lobe
2) loss of consciousness or poor oral hygiene tx w clinda for 4-6 weeks
186
presentation of hypertrophic osteoarthropathy; its management
Clubbing of digits, periosteal new bone formation, arthritis
Associated with intrathroacici malignancy, suppurative lung disease, and congenitalheart problems
Thus, Next: chest x ray looking for lung infection and carcinoma
187
lites criteria
exudative if:
1) pleural/serum proten greater than 0.5
2) pleural to serum LDH greater than 0.6
3) pleural LDH greater than 2/3 of upper limit of normal serum
188
transudative associated with
increased hydrostatic pressure like CHF or decreased oncotic pressure like nephrotic syndrome
189
explain parapneumonic effusion
if pt has pneumonia and if pt has exudative process per lites criteria,
parapneumonic effusion means increased capillary permeability of fluids to exit from vicera to inststitial.
1) Simple effusion: no bacterial invasion
2) Complicated effusion: bacteria seeped out causing neutrophil attraction => glucose less than 60 and ph <7.2
190
hemorrage into pleural space occurs with
trauma, cancer, pulm embolism. NOT with penumonia
191
if someone with COPD is hypoxic at low O2 but has hypercapnia and toxicity at high O2, how to manage
intubate to protect airway
COPD are chronically hypoxic and that is what causes an increase inrespiratory drive. With high O2 sat, COPD are not hypoxic thus respiratory drive decreases causing hypercapnea
192
black woman with dyspnea and hilar lymphadenopahty
biopsy to diagnose sarcoidosis; can present with subsequent hepatosplenomagal as well
193
causes of chylothorax
trauma, surgery or lymphoma
194
what to do if cystic fibrosis suspecte
sweat chloride measurement; if sweat CL .70, CFTR mutation analysis should be ordered
195
what causes interstitial lung disease
nitrofurantoin and cancer chemotherapy
196
isocyanates in automobile paints are the cause of
occupational asthma
197
which presentation of patients makes hospitalization likely for CAP
Depends on Curb 65 criteria: confusion, BUN >19, RR>30, Age>65, systolic <90 or diastolic below 60.
198
How does DVT turn into PE and when to do what tests:
1) Most common DVT in calves but rarely cause dislodge
2) most common dislogement is from above knee
- ---tachy and tachypnea are two signs
- --- chest pain less likely unless infarct
- --- low PCO2 with wide O2 gradiant
- --- EKG findings: tachy, a fib or S1Q3T3 (inverted T)
3) while 80% of PE come from DVT, normal lower extremity dopplar does not rule out PE
4) Normal D-dimer can be used to rule out PE in LOW risk case
5) However, in high risk case, CT PE is the only method to rule out PE
6) Give heparin in high risk situation while waiting for confirmation
199
Next step after echo confirms pulm htn and secondary causes are ruled out
1) Right heart catherization and dilation with endoethelin 1 receptor antagonist (bosanten), phosphodiesterase 5 inhibitor (sildenafil) or infused prostanoids
200
High risk surgery for DVT prophalyxis; what do we do?
major orthopedic surgery aka knee or hip; need unfranctionated, low mw heparin, fondaparenux, warfarin, apixaban, riveraxaban; SCD's are not sufficient in high risk
201
reason for htn in osa
hyperandrogenism
202
ACTH, ADH, PTHrp, SIADH
ACTH and ADH: Small cell
PTHrp: Squamous
SIADH: benigh process
203
Think ARDS when
Diagnosis:
Percippitated by:
Can you diuresis the lungs?
pathogensis:
tx:
1) acute onset hypozemia refractory to oxygen
2) poor lung compliance
3) pulmonary edema that is non cardiogenis
Diagnosis confirmed by: Po2/FIo2 ration less than 100, diffuse alveolar infiltrates on x ray and exclusion of cardiogenic pulmonary edema
percipitated by sepsis, aspiration, or severe truama
Cardiopulmonary wedge pressure normal and diuretics are ineffective
pathogenesis: diffuse endothelial injury related to underlying event
tx: low tidal volume and PEEP
204
what kills patients in scleroderma
used to be kindey but it can be slved with ace inhibitors, but now ILD= most common cause of death
205
ILD is complication of:
| Diagnosing ILD:
scleroderma, polymyositis/dermatomyositis, RA, SLE
diagnose: DLCO measurement with spirometry or High resolution CT
tx: not good; cyclophosphamide will slow progression
206
appetite suppresant is associated with
PAH=> fenfluramine type appetite supressant
207
asthma classification and treatment
Mild intermittent: <2 a week; <2 nights a month => SABA
Mild persistent: 2 a week to daily; >2 night a month => low dose inhaled corticosteroids + SABA
Moderate persistent: daily; >1 a week => low-medium ICS + LABA + SABA
Severe persistent: continous => High dose ICS + LABA
---- at this point: leukotriene inhibitors, cromolyn, or oral steroids
208
features of bronchiectasis on CT
dilated bronchi + signet right sign of dilated bronchus adjacent to pulmonary artery
209
methyloxyglobinemia vs carboxyglobeniemia
meth. .: cyanosis
| carboxy: no cyanosis=> CO posisoning. O2 after carboxy measurement
210
restrictive, obstructive vs mixed
what is bronchodilator response
restrictive: normal FEV/FVC + low FVC
obstructive: low (<75%) FEV/FVC
mixed: low (<75%) FEV/FVC + low FVC
if FEV increases by 9% or more than 200 ml with bronchodilators
211
anti-trypsin deficiency vs smoker lung
smoker: upper lungs; antitrypsin deficinecy = affects lowers lungs
212
most common cause of chronic cause and tx
1) acid reflux: cough worst at night, hx of reflux => trial PPI
2) Postnasal drip syndrome: trial of nasal steriods/decongestants
3) coungh variant asthma: trial bronchodilators
4) ACEI=> switch to arb
213
When does acetazolamide help vs not help with probelms with high elevation?
High altitude pulmonary edema (HAPE) (non cardiogenic)=> susceptible people have increased pulmonary vasoconstriction in responde to hypoxia => damages capillary endothelium and exudateion of fluids into alveoli
- ------- recurrent possible
- ------- tx: oxygen + descent to lower altitude => first line
- ------- acetozolamide not helpful
- -------- nefedepine decreased vasoconstriction => not first line tx but has prophalactic value
214
someone with COPD that is uncontrolled what is the most important thing for his health
oxygen is the only mortality benefit if O2 sat less than 88 w the goal of keeping sat greater than 90; at that point, all the meds that are needed for symptom control only
215
stages of copd
stage 1: FEV1=>80
stage 2: FEV1=>50-80
stage 3: FEV1=>30-50
Stage 4: FEV1=> less than 30
216
staph penumonia characterisitcs on x ray
1) cavitary pneumonia on x ray
217
signs of congestive HF on x ray vs long standing hypertension
CHF: bilateral lung infiltrates, cephalization, kerly B lines, cardiomegaly >50%
HTN means LV hypertrophy: boot shaped heart that is >50% of xray
218
Moa of:
1) Corticosteroids
2) Theophylline and methylxanthines
3) Cromolyn
4) Montelukast and zafirlukast
1) inhibits cytokine synthesis
2) inhibition of phosphodiesterase thus increased cAMP thus bronchodilation
3) inhibits degranulation of mast cells
4) leukotriene inhibitor
219
silicosis vs asbestos
silicosis: upper lungs, lymphadenopathy, egg shell cavitary 15 years post exposure
asbestos: lower lungs, pleural
220
Lymphangioleimyomatosis
rare progressive cystic lung disease that occurs excclusively in young women; spontaneous pneumothrax common
221
Eosinophilic pneumonia
causes reverse pulmonary edema pattern with peripheral infiltrates; responds to corticosteriods
222
mets to lungs vs primary lung tumor
mets: multiple lesions
primary: one lung lesion
223
1) tram track pattern
2) dry velco rales, clubbing, insteritial thickening
3) resembles TB exposure history of mississippi or ohio valley
1) bronchiectasis
2) idiopathic lung disease
3) histoplasmosis
224
lung cancer tx
Stage I and II: surgical resection is cure unless medical contraindications or severe COPD
Stage 1: <5cm =>surgery
2: >5cm or associated with ipsilateral peribronchial or hilar lymph node invovlement => adjuvant + surgery
Curative surgery not available to: mediastinal lymph node involvement, pleural effusion, or distant mets
Thus chemo and/or radiotherapy for these people
225
what medication causes acute hypersensitivity pneumonitis; what happens, diagnosis, tx
1) Nitrofurantoin
2) presents as fever, chills, cough, and bronchospasm, arthralgia, myalgias, erythematous rash => can progress to chronic alveolitis with pulm fibrosis
3) alveolar or interstitial infiltrate on xray
4) EOSINOPHILIA
5) tx: dc meds, corticosteriods
226
hyperosmolar ketotic state vs diabetic keto acidosis
DKA: anion gap = na-bicarb-cl = greater than 10 with low bicarb
HKS: Diabetics who become volume depleted and develop renal insufficiency=> glucose not excreted => high glucose=> pulls water out of extracellular fluid out of Intracellular space => dehydration in brain and CNS changes. Normal anion gap and bicarb
227
course of postpartum thyroiditis
1) painless Hyperthyroidism due to inflamamtion and release of preformed thyroid hormone from inflammed follicle-2-4 weeks; different from graves because of absence of infiltrative opthalmopathy and supressed radioiodine uptake
2) Transient hypothyroidism 1-3 months
3) Resolution and eythyroidism; in Hashimoto there is permanent autoimmune hypothyroidism
228
course of subacute thyroidism
1) Painful hyperthyroidsim
229
meds for T2DM
1st: Medical nutrition therapy aka calorie intake, weight loss, and exercise to achieve goal of less than 7 A1c
If MNT not successful, 1st medication is metformin
Thiazolidinediones (glitazones), DPP4 inhbitior, GLP1 agonists, sulfonureas, insulin are second line or add on therapy for most pt
230
Men 1
Pituatory, Parathyroid, Pancreatic
231
Men 2A
Parathyroid, Medullary thyroid, Pheochromocytoma
232
Men 2B
Medullary thyroid, Pheochromocytoma, Mucosal Neuroma, Marfanoid body habitus
233
when is osteoporosis due to celiac disease
Low calcium and low vit D; GI symptoms and anemia suggests low vit D is due to intestinal malabsorption
234
labs for osteoporosis due to hypoparathyroidism
causes low calcium but no hypo-vitamin D
235
labs for osteoporosis due to low estrogen
normal calcium, vit D, hgb
236
what antibody does graves produce and what other signs?
Anti-TPO antibodies: cytokines active fibroblasts => produces glycosaminosglycans=> trap water in muscles, swelling of ocular muscles and thus opthalmopathy
237
when check plasma aldo to plasma renin activity
when check urinary metaneprine
when check 24 hour urine cortisol
when htn + hypokalemia: note htn can be diastolic only as well such as >90
pheochromocytoma
cushings syndrome
238
what to do with adrenal incidentaloma in asymtomatic patient
1) determine if it is a functioning or nonfunctioning tumor via measurement of serum metanephrines (pheochromocytoma) and dexamethasone suppresed cortisol (Cushing syndrome) levels
2) Once functioning tumor is excluded, repeat ct in 6 months and 1 year to ensure stability of adrenal masss
239
Distinguish following for thyroid storm vs mild hyperthyroidism
1) Characteristics
2) Management/Contraindicated
3) Meds to use
1) Thyroid storm: fever, severe tachy, CHF, CNS changes, Afb, abd symptoms, jaundice
2) Thyroid storm: ICU; avoid propanol in CHF though it prevents conversion of inactive T4 to active T3; corticosteriod is routinely adminstered because relative adrenal insufficiency
3) Propylthiouracil: blocks uptake and organification of iodide by thyroid gland
Oral iodides: prevent release of preformed T4 and T3 from thyroid gland
*** in step before thyroid storm outpatient, diffuse goiture can be sent for radioiodine uptake to distingusih between Graves and painless thyroiditis (low RAI uptake), but do not do this is thyroid storm and treat immediately
*********Methimazole is often used in mild to moderate hyperthyroidism because of ease of dosing; Propulthiouracil blocks T4 to T3 conversion and should be used in thyroid storms
240
palpable thyroid nodules management
1st: TSH
- --- low TSH means hot nodule => benigh
- -----------confirm this diagnosis by RAI uptake and scan
- ---- euthyoid
- -----------thyroid US
- -----------------pure thyroid cysts => aspirated and followed
- ----------------- benign charafcteristics (less than 1cm, hyperechogenicity, "comet tail" on US), no previous radiation to neck, no family history => followed sonographically
- ------------------ all other: FNA => if malignant, total thyroidectomy
241
what to do in amiodarone induced hypo vs hyperthyroidism
DO NOT STOP amiodarone unless suggested by cardiology as this was for paxorysomal a fib
- ---hypo: start levo and recheck=> some people resolve within weeks, some needs levo due to presence of anti-TPO antibodies
- --- hyper: prednisone
242
workup for erectile dysfunction
1) decreased testes => test hypogonadism => test morning testerone level
-------->350: normal
--------200-350: equivocal: repeat or follow with free testosterone (more expensive)
----------<350: test gonadotropi=> low test, low gonad means central hypogonadism=> test for prolactin to exclude harmonally active pituatory tumor
=> low tst, high gonad means peripheral problems
2) can be due to peripheral arterial disease and peripheral neurophaty as well
3) Once hypogonadism and other causes ruled out, then the reason is psychological
4) Once all ruled out, then phosphodiesterase 5 inhibtors for ED
243
how to manage DM in ICU pt
- test fingerstick glucose often to find the insulin where glucose is between 140-180.
- IV insulin infusion with goal of 140-180
****avoid sliding scale because it is reactive instead of proactive and leads to wide fluctuations
244
someone presents with hypercalcemia. what is next?
measure intact pth; most common cause is due to malignancy or high pth
245
Indication for following
1) High dose bisphosphonate
2) Melphalan and prednisone
3) Ursodeoxycholic aicd (UDCA)
1) Paget Disease: alk phos + bony deformity with sclerotic changes + bone pain, hearing loss, CHF, hypercalcemia, repeated fractures; osteoporosis requires low dose bisphonates.
- -----subq injectable calcitonin to if GI symptoms of bisphonates not tolerated
2) mulitple myeloma which as lytic bone lesion wo alk phos elevation
3) elevated alk phos with elevated GGT in Primary biliary cirrhosis
246
differentiate followin
1) Subacute thyroiditis:
2) Graves
4) Struma ovarii
5) Multinodular goiter
6) Thyroid nodule
7) Iodide deficinecy
8) TSH secreting pituitary adenoma
1) tender, elevated ESR
2) high T4, lowww TSH
4) ectopic thyroid tissue in ovarian teratoma causes struma ovarii => hyperthyroidism wo thyroid enlargement => diagnosed via whole body radioiodide scanning
5) Area of iodine insufficiency, normal labs, risk of malignancy same as solitary nodule=> biopsy
6) fucntional thyroid adenoma: single nodule, hyperthyroidism, hot nodule
7) iodide deficinecy=> goiter and hypothyroidism
8) high T4, high or normal TSH
247
explain following
1) Acromegaly
2) Exogenous human growth hormone use
3) Empty sella syndrome
4) Cushing disease
5) Chronic oral glucocorticoid use
6) Prolactin secreting adenoma
1) Acromegaly: pituitary macroadenoma: physical changes devleop slowly
2) Exogenous human growth hormone use: does not cause acromegoid changes
3) Empty sella => enlargement of the sella turcicia from CSF pressure compressing the pituitary gland
- ---common in obese, hypertensive
- ---- normal pituitary function as rim of pituitary tisue is fully functional
4) Cushing: produces hypercortisolism secondary to excessive secretion of pituitary ACTH=> chronic hypercortisolism results in diabetes mellitus
5) presentation same as cushing except no mineralocaorticoid and adrogenic effect: hlypokalemia and hirsutism are rare
6) Prolactinoma cause amenorrhea and galactorrhea in women and hypogonadism in men
248
contraindications to harmonal therapy
endometrial cancer, history of venous thromboembolism, breast cancer, or gall bladder disease
249
effect of estrogen in lipid panel
decreases LDL, increases HDL, increases triglyceride level
250
differentiate neuropathy between diabetic foot, alcoholic withdrawl, B12 neuropathy, restrictive footwear
diabetic foot: stocking and glove, lose pin prick sensation first, metabolic sydrome or diabetic risks
alcohol withdrwal: need to drink a ton
B12: propioception and vibratory sensation first
restrictive: foot pain but no peripheral neuropathy
251
in septic patient, what should be given in addition to epi in hypotensive shock
corticosteriod because they can have adrenal insufficiency too. This can decrease mortality.
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1) pituatory tumor tx
| 2) tx for growth hormone producing tumors
1) dopamine agonist therapy: cabergoline long acting prefered; bromociptine not used as its short acting; surgery is last resort
2) somatostatin analogue
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1) pituatory tumor tx
| 2) tx for growth hormone producing tumors
1) dopamine agonist therapy: cabergoline long acting prefered; bromociptine not used as its short acting; surgery is last resort
2) somatostatin analogue
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normal DHEA with high testosterone and symptoms of masculinization (cliteromegaly, frontal balding) indicates what?
most common is
ovarian rather than adrenal cause; most common andorogen producing ovarian tumor is arrhenoblastomas
255
granulosa theca cells tumors produce;
ovarian teratoma produce;
feminization;
dermatoidal cyst in the ovaries increasing risk for torsion and hyperthyroidism (stroma ovarii tissue in teratoma) but no sex hormones produced
256
1) pt with high calcitonin and thyroid nodules is suspicious for
2) if pt has fh of medullary and pth cancer, what should he be tested for prior to surgery
1) medullary carcinoma
2) Men 2A
- pheo: metanephrines to avoid hypertensive crisis during surgery
- pth: not needed if normal calcium
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radioactive iodine in thyroid cancer
only in follicular thyroid cancer
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hemochromatosis should be considered in someone w
hepatomegaly, weakness, hyperpigmentation, atypcal arthritis, diabetes, erectyle dysfunction, chronic abd pain, cardiomyopathy
259
infertility, gynecomastia, tall stature with arms and legs longer than expected for truncal size is .......; its harmone ....
consistent with klienfelter: XXY; low testoerstone but high gonadotropin, no sperm, are infertile
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Hypertension, truncal obesity, abdomninal striae, DM, amnehorrea, easy brusiability are due to which of following?
1) pituitary tumor
2) adrenal tumor
3) Ectopic adrenocorticoproic hormone (ACTH) prodcution
4) Hypothalamic tumor
how to diagnose endogenous cortisol overproduction
these cushing syndrome are due to excess cortisol production by adrenal gland; occurs due to:
1) Most often: acth producing pituary microadenoma
2) Next most: adrenal adenoma
3) ectopic ACTH producing noeplasma: aka lung cancer progress too rapidly for full cushing sy;dnrome to develop; usually present with myalgia due to profound hypokalemia
4) Hypothalamic tumors can affect ADH production and eating behavior but do not produce cortisol or ACTH
diagnosis of endogenous cortisol overproduction:
1) 24 hr urine collection fo rfree cortisol or overnight dexamethasone supression test ( in normal patients, the am cortisol should supress to <2ug./dl after a midnight dose of 1mg dexamethasone)
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1) SIADH diagnosis
| 2) tx
1) Hyponatremia; uosm high normal concentrated urine aka euvolemia
2) 1st: fluid restriction; tetracycline derivative demeclocycline decreases renal response to adh and can be used if fluit restriction not helpful; try hypertonic saline only if pt has CNS symptoms with confusion, obtundation, seizures.
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1) what causes bitemporal hemianopsia
1) most common: prolactinomas
| second most common: growth hormone secreting tumors
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how to diagnose growth harmone deficiency
growth harmone stimulation test like insulin induced hypoglycemia, arginine plus GHRH
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acromegaly is due to.... and can be diagnosed with...
growth harmone secreting tumor
- ---- diagnose with serum insulin like growth factor IGF-1 elevation
- -------------prolactin also measured as 40% produces prolactin
- -----------------single GH level not helpful as GH secretion is pulsatile => GH must be supressed mwith glucose to diagnose gutonous overproduction
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When should pheochromocytomas be considered and what are the differential diagnosis
1) Hypertensive crisis in young woman + palpitation, aphrension and hyperglycemia (catecholinmine supresseses insulin and stimulates hepatic glucose output, hypercalcemia (decreased plasma volume and ectopic pthrp)
- -- dd but wo systemic effect are panic attack, renal stenosis, essential htn, diabetes doesnt cause htn crisis
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how does osa affect glucose level
causes insulin resistance
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myxedema coma aka .....
presents as....
treat with....
1) hypothyroidism coma
2) hypothermia, diffuse thyroid enlargement, hypothyroidism, hyponatremia, elevated PCO2`
3) obtain t4 and tsh but 1) emperically treat with levo IV bolus with maintenence 2) watch for cardiac arrythmias as a result of bolus levo 3) parenteral hydrocortisone as can be accompained with impaired adrenal reserve 4) IV fluids though less important than levo and hydrocortisone 5) rewarming accomplished slowly otherwise can cause cardiac arrythmias
268
definition of subclinical hypothyroidism; tx
tsh above normal but below 10; no symptoms of hypothyroidism;
- check free thyroxine level (should be normal)
- repeat TSH in 3-6 months to monitor for progression toward overt hypothyroidism
- thyroxine therapy is not recommended for most asymptomatic pt with tsh below 10
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thyroxine therapy is not recommended for asymptomatic pt with tsh below 10. one exception is..
women completaing prego; their TSH should be lowered with 1 thyroxine to less than 2.5 mU/L before conception
270
describe features of LADA vs MODY
1) Late onset autoimmune diabetes of adults (LADA) =>
- occurs in older, non obese adults, wo FH
- slower in onset and less keotsis prone than type 1
- anti-GAD ab part of LADA and T1DM; features similar to T1DM
- Early use of insulin necessary to control glucose level
2) Maturity onset diabetes of young
- associated with <20 yo, obesity, w FH of T2DM
- features similar to T2DM
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glucagonoma present as
islet cell tumor that causes weight loss, malabsorption, and severe skin rash
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hyponatremia, volume depletion causing orthostatic hypotnesion, hyperkalemia, moderate eosinophilia, hypergimentation due to...
addison's disease=> adrenal insufficiency
1) low aldo => hyponatremia, water follows, hypotension, orthostatics, hyperkalemia
2) pro-opiomelanocortin by pituatory which has melanocyte sitmulating activity causing hyperpigmentation
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- causes of adrenal insufficiency
| - diagnosis
TB can involve adrenal gland
- diagnose with serum cortisol baseline and then stimulation with cosntrophin (a synthetic acth analogue)
- ---------cortisol above 18 after stimulation excludes adrenal insuffieincy
- ACTH level before cosynthrophin level can assess if problem is primary or secodnary
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what to do if someone is hypoglyemic in the morning?
| Best type of insulin format
1) that means the long acting at night time is too high.
lower long acting and keep short acting the same.
2) long acting like glargine before bedtime and short acting like lispro, aspart, glulisine before each meal
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longest to shortest acting insulin
look up on google
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dd for diverticulitis
ischemis colitis: abd pain, rectal bleeding +diarrhea, atherosclerosis or CAD
- ----colonoscopy
diverticulitis: NO ab pain, rectal bleeding
- ----ct
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common causes of duodenal ulcer
in US: NSAIDS then H pylori
abroad: H pylori then NSAIDS
* ***cancer is rare
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evaluation of hyper bili
DIrect: urine shows bili, conjugated bili=> cholestatic or hepatocellular in pattern
Indirect: no bili in urine because indirect is bound to albumin which is too large to be filtered by kidney=> hemolysis, ineffective erythropoiesis, enzyme deficiency
----- get ret count if hemolysis suspected
***ferritin if transaminases and hepatomegaly => hemochromotosis
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why is only furosemide insufficient to diurese a cirrhotic patient?
furosemide increases sodium in the distal nephron; cirrhotic have high level of aldo for unknown reason; thus causing increased sodium absorption.
In order to properly diurese, cirrhotics often need spiralactone, an aldo antagonist in addition to furosemide
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- Rectal bleeding in diverticulosis
| - managing diverticulosis
- may or may not be present but always have LLQ pain
- cipro and metronidazole agaisnt coliforms and anarobes; if abscess >4cm then percutaneous drainage; if abscess refractory to PCI and antibiotics, then surgery
281
most causes reasons of malabsorption in US
- pancreatic insufficiency or celiac
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1) villous atrophy and increased lymphocyres in lamina propia of small bowel
1) celiac- IgA antiendomysial antibodies and antibodies against tissue transglutaminase
283
signet rings
gastric cancer- anorexia, early satiety
284
colonic mucosal inflammation and crypt abscesses
UC; small bowel not affected
285
curved gram negatie rod on gastric biopsy
H pylori
286
periportal hepatitis seen in
chronic hepatitis
287
When is egd indicated in pt w gerd
1) alarm (dysphagia, weight loss, gi bleeding, odophyagia)
2) Pt has been having gerd symptoms for 5 years, check for barret's esophagus
otherwise, theraputic trial of ranitidine or omeprazole
288
SBP facts
1) diagnosis
2) bacteria
3) standard tx
4) recurrence
4) what improves survivial
1) diagnose w pnm >250 even if culture is negative
2) single bacterial; poly means perforation of bowel
3) levo or 3rd gen cephalosporin for 7-10 days
4) high recurrence rate => long term prophylactic therapy w fluoroquinolone recommended
5) Albumin in addition to antibiotics
289
differenciated the following:
1) small bowel ileus
2) small bowel obstruction
3) large bowel obstruciton
4) pseudo osbtruction of colon
5) fecal impaction
1) absent or decreased bowel sounds with air filled disteded loops of small and large bowel
2) abd distension + HIGH pitched+ copious vominting+ xray shows MULTIPLE air fluid levels in small intestine and no gas in large intestine
3) INCREASED bowel sound; dilated large colon w abrupt cttoff w bird beak pattern
4) mimic large bowel obstruction with dilation of colon on xray but DECREASED bowel sound and no abrupt cutoff of large bowel
5) x ray shows large feces
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pt with new gi (chronic diarrhea) should undergo
colonoscopy
291
tx of IBS
1) dietary changes with high fiber diet
2) Antispasmodis helps abdominal cramps
3) if dietary changes ineffective, add psyllium or polyethylene glycol
4) refractory => rifaximin
292
triad of chronic pancreatitis
abdomninal pain, malabsorption of B12, and diabetic mellitus
* ****amylase is normal in chronic
* ****absorption of ADEK is done in small intestine wo lipase thus not affected by pancreatic insufficiency. CHornic pancreatitis affects B12 absorption
293
courvoiseir sign
palpable nontender gallbladder in jaundiced patient => suggests malignnacy usually pancreatic cancer
294
1) Can hep C resolve spontaenously?
2) Risk of progression to cirhosis
3) vaccination
1) Hep C rarely spontaneously resolves
2) 15% progresses to cirhosis especially untreated pt with alcohol use, gentype 3, or coinfection w HIV or hep B more rapidly progress to fibrosis
3) Vaccinate agianst hep A and B, which can cause fulminnagt hepatic failure in pt w preexisting hep C
295
labs of gilbert vs crigler najjar syndrome
Gilbert: mild deficiency in glyconryl transferase; isolated indirect bili elevation
Crigler najjar: severe deficiency or absence of glucoronyl transferase=> bili greater than 5
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1) achalasia on manometry
| 2) tx of achalasia
1) low amplitude prolonged contracations
2) nitrates, calcium channel blockers, botox injections into LES or physical procedures (balloon dilatiation or surgical myotomy) tha decrease LES pressure
297
1) mutation in wilson
2) PBC
3) Hep B vs Hep C infection
1) ATP7B gene : copper accumulation in liver, brain causing tremor and psychiatirc symtoms
2) women, priutis, positive antimitochondiral antibody
3) Hep C: RNA Hep B: DNA
298
what hapens in G6pd deficiency
pt unable to maintain an adequat3e level of reduced glutathione in their red blood cells when an antibiotic or other toxin causes oxidatie stress to red cells: sulfonamide or trimethoprim sulfamethoxazole
299
Hereditary hemorrhagic tengiectasia or soler weber rendu syndorme is
a cuase of nose bleeds, mild GI bleed, and cutaneous or mucosal telangiectasias; asosciated with AV malformation in brain, lungs, liver, intestine
300
dieulafoy lesion is a
tortuous arteriole in stomach that can erode and bleed; difficult to find on endoscopy
301
segmental inflammation on watershed areas of colon
ischemic colitis
302
diverticulosis
no symtpoms: no bleeding or obstruction or pain
303
salmonella associated w
contaminated poultry or eggs but also turtles, lizards, and other reptiles
304
food borne illness due to staph
acute GI: short incubation period (inidicated preformed toxin rather than bacterial proliferation in GI tract) +prominent upper GI (less diarrhea and more vomit) => staph
305
labs of rhadbomyolis induced AKI vs NSAIDS vs hypovolemia
| *********study this**********
rhabdo: hyperkalemia, hyperphosphatemia causing hypocalcemia, hyperuricemia, BUN:Cr ratio <10:1, RBC, hemoglobin, myoglobin
NSAIDS: BUN:cr <20:1, >1% FEENA, urine sodium >40, brown cast, uosm >350
volume depletion: orthostatic hypotension, BUN:Cr elevated to >20:1, <1% FEENA, urine sodium <20, scant cast, Usom >500
306
what is combined high anion gap metabolic acidosis and respiratory alkalosis
1) High anion gap metabolic acidosis
+
2) compensated Pco2 is lower than expected = resp alkalosis
compensated Pco2 is higher than expected = resp acidosis
if within range, then just metabolic acidosis
307
compensation for metabolic acidosis
PCO2 = 1.5[HCO3] +8
PCO2= 12-14 mmHg
308
Metabolic alkalosis compensation
increased PCO2 = 0.6 mm Hg for each 1 mEq/L increased HCO3
| PCO2 = 55mg
309
Respiratory Acidosis compensation
increased HCO3 = 1(acute) - 4(chronic) mEq/L for each 10mmHg increased PCO2
310
Respiratory alkalosis compensation
decreased HCO3 = 2(acute) - 5(chronic) mEq/L for each 10mmHg decreased PCO2
HCO3 = 12-15 mEq/L
311
young female w resistant HTN and renal bruit suggestive of
fibromuscular dysplasia; diagnose with renal angiography
312
tx and contraindications for acute gout
1) NSAIDS: ckd, myelodysplasia
2) Colchicine: elderly, myelodysplasia
3) Prednisone
313
why is uric acid level in acute gout low`
cytokines in acute gout are uricosuric so serum uric acid is low during acute gout ; more accurate several days after the attack
314
how do contrast agents harm kidney?
who is at risk?
how to provide contrast to those individuals?
1) oxygen radicals cause vasoconstriction causing AKI
2) pt w kidney disease, diabetes, CHF, multiple myeloma, dehyration at risk
3) Pretreat: IV normal saline or sodium bicarb decreases nephropathy. N-acetylcysteine is also used by some.
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tx for life threatening hyperkalemia
IV calcium to combat hyperkalemia + insulin to shift K+ in cell
****dialysis, furosemide, kayexalate are slow to promote potassium loss from body
316
what happens to. creatinine after obstructive uropathy
after cather: creatinine goes back to baseline
couple days = complete reversal
if uropathy for 1-2 = partial recovery; several week= damage may be iireversible
317
online med ed:
| indications for dialysis
AEIOU: Acidosis, electrolytes (K+ and Na), Intoxication, Overload, Uremia
318
Online med ed:
| causes of pre renal
1) Prerenal:
- pump: MI or chf
- leaky: osis - cirhosis, gastrosis, nephrosis all cause albumin to leave
- hole: diuresis, diarrhea, dehydration, hemorrhage
- clog: fibromuscular dysplasia vs renal artery stenosis
319
causes of intra renal
3) Intrarenal:
- Glomerulonephritis: RBC casts after ruling out nephrotic syndrome (>3.5g/day protein, increased cholesterol, edema)
- AIN: WBC casts, eosinophils => look for infection, antibiotics (cephalosporins, penceillin, tMX-sulfa)
- ATN: muddy brown or granular mcasts (not sensitive or specific), ischemia, exposure to toxin (IV contrast and myoglobin from rhabdo => give vigorious IV fluid)
320
causes of post renal
2) Post renal:
- cancer or stone in ureter, bladder, or urethra
- neurogenic bladder w meds
- foley, BPH at the level of urethra in addition to the first point
321
phases of ATN
prodrome: creatine rises
oliguric: low urine output (dialyze fluid out because pt fluid overloaded w low UOP)
polyuric: increased urine (give fluids to keep up with fluid loss)
322
diagnostics steps of elevated creatine
1) Rule out prerenal => treat w IV fluids if volume low or diuresis if one of the "osis and volume up)
- BUN:Cr greater than 20
- FENA less than 1
- Urine sodium less than 10
- FrUrea (use if pt has diuretics) less than 35
2) rule out post renal w obstuction
- CT => better for stone
- US=> better for hydronephrosis
- Foley catheter/nephrostomy to treat
3) Intrarenal:
- UA
- diabetic w glucose and protein => diabetic nephropathy
- HTN + cr=> htn nephropahty
- diagnose w Biopsy
323
iron studies in chronic renal insufficiency
normal though pt has anemia due to epo def
324
1) hemolysis in mycoplasma pneumonia
2) size of RBC in hemolysis
3) paroxysmal noc=tunal hemoglobinuria is
IgM against that bacteria cross reacts with I/i surface molecule of RBC=> hemolysis
2) increases RET => normally larger diameter than mature cells => macrocytosis
3) surface proteins CD55, CD59 on granulocytes and RBC causes hemolysis => use flow cytometry to detect those surface proteins
325
Hyper vs hyponatremia online med ed
- folder
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pathology of posterior pituatory online meded
- folder
