Questions--March 2017 Flashcards
Disseminated gonococcal infection: Clinical presentation
Purulent monoarthritis and/or triad of (1) dermatitis, (2) assymetric migratory polyarthralgias, and (3) tenosynovitis
Disseminated gonococcal infection: diagnostic testing
Blood and pustule cultures may be negative.
NAAT of urethra, cervix, pharynx, or rectum usually will come back positive.
Two types of contact dermatitis
allergic vs irritant
Allergic contact dermatitis: pathophys, triggers, appearance
pathophys: type IV hypersensitivity
triggers: poison oak, poison ivy, nickel, rubber, meds
appearance: primarily on exposed skin and well demarcated, with erythema, papules/vesicles, and chronic lichenification
Irritant contact dermatitis: pathophys, triggers, appearance
pathophys: physical or chemical
triggers: soaps, detergents, chemicals
appearance: commonly on hands, with erythema and fissures
VIPoma: clinical presentation
watery diarrhea, hypo or achlorhydia due decreased gastric acid secretion, associated flushing, NN/V, muscle weakness, cranps
VIPoma: lab findings
hypokalemia, hyperclacemia, hyperglycemia, stool studies showing secretory diarrhea and increased sodium and osmolol gap less than 50
VIPoma: diagnostic criteria
watery diarrhea with VIP level greater than 75; abdominal CT or MRI to localize tumor in the pancreas (usually the pancreatc tail)
Acute interstitial nephritis: Clinical features and number of days until symptom onset
maculopapular rash, fever, new drug exposure (penicillins, TMP SMX, cephalosporins, NSAIDS), +/- arthralgias
NOTE: 5days to several weeks after use of offending agent
Acute interstitial nephritis: lab findings
AKI
Pyuria, hematuria, WBC casts
Eosinophilia, urinary eosinophils
Renal biopsy: inflammatory inflitrate, edema
stevens-johnson syndrome: triggers
Drugs: allopurinol, antibiotics, anticonvulsants, NSAIDs, sulfasalazine
Other: Mycoplasma pneumo, vaccination, graft-vs-host disease
steven-johnson syndrome: clinical features
4-28 days after exposure to trigger
Acute influenza-like prodrome
Rapid-onset erythematous macules, vesicles, bullae
Necrosis and sloughing of epidermis
Mucosal involvement (this is distinction with toxic epidermal necrolysis, which does not have mucosal involvement and involves >30% body surface area as opposed to <10%)
Systemic signs: AMS, fever, HDinstability
true positive vs flase positive rate
true positive (sensitivity) false positive (1-specificity) the higher the false positive rate the lower the specificity
Trichinellosis infection: clinical presentation
Intestinal stage (within one week of ingestion): asymptomatic or GI upset including abdominal pain, N/V/D
Muscle stage (up to 4 weeks after ingestion): myositis, fever, subungal splinter hemorrhages, periorbital edema, eosinophilia (usually >20%) with possible elevated CK and WBC
NOTE: severe disease can involve the heart, lungs, and CNS
Bacteria in viridans group streptococci
strept mutans/mitis/oralis/sanguinis
Major modified Duke criteria for infective endocarditis
Blood culture positive for typical organism (s. viridans, staph aureus, entercoccus), Echo showing valvular vegetation
NOTE: definite IE = 2 major OR1 major + 3 minor criteria
Minor modified Duke criteria for infective endocarditits
Predisposing cardiac lesion, IVDU, febrile, immunologic phenomena (glomerulonephritis), positive blood cx not meeting above criteria
6 clinical features of inectious mononucleosis
fever tonsillitis/pharyngitis +/- exudates Posterior or diffuse cervical lymphadenopathy Significant fatigue \+/- hepatosplenomegaly \+/- rash after amoxicillin
Equation for appropriate respiratory compensation for a metabolic acidosis
PaCo2 = 1.5 x bicarb + 8 +/- 2
Digoxin toxicity
N/V, decreased appetite, confusion, weakness, scotoma/blurry vision with changes in color/blindness
NOTE: Inciting events include anything that leads to volume depletion (viral illness or excessive diuretic use)
5 clinical features of primary hyperparathyroidism
nephrolithiasis, osteoporosis, nausea, constipation, and neuropsychiatric sxs (stones, bones, abdominal moans,and psychic groans)
Conditions associated with secondary amyloidosis
inflammatory arthritis (RA) Chronic infections (Tb) IBD Malignancy Vasculitis
Clinical presentation and treatment of secondary amyloidosis
Clinical presentation: multi-organ dysfunction–asymptomatic proteinuria or nephrotic syndrome, cardiomyopathy with heart failure, hepatomegaly, mized sensory and motor peripheral neuropathy and/or autonomic neuropathy, visible organ enlargement (macroglossia), bleeding diathesis, waxy thickening/easy bruisability of skin
Treatment and ppx: colchine
Infective endocarditis: vascular phenomena
systemic emboli, mycotic aneurysm, janeway lesions (macular, erythematous, nontender lesions on the palms and soles)
Infective endocarditis: immunologic phenomena
Osler nodes (painful, violacious nodules seen on the fingers and toes) Roth spots (edematous and hemorrhagic lesions of the retina)
hepatitis A virus vaccine: indications
chronic liver disease (including HBV and HCV)
Risk factors for HIV (men who have sex with men, IVDU) or HIV itself
Chronic pancreatitis: clinical presentation
chronic epigastic pain with intermittent pain free periods, malabsorption (steatorrhea, weight loss), DM, partial relief when leaning forward
Chronic pancreatitis: appropriate labs and imaging
CT scan or MRCP (can show calcifications, dilated ducts, and an enlarged pancreas)
NOTE: Amylase/lipase in CPcan be nl or nondiagnostic, while they will be elevated 3xnl in AP
Adult Still Disease
An uncommon inflammatory d/o characterized by recurrent high fevers, arthritis/arthralgias, and a salmon-colored macular/maculopapular rash. ESR may be markedly elevated
NOTE: distinguished from infective endocarditis by absence of active urine sediment, painful fingertips, and pulmonary symptoms
MEN1
Primary hyperparathyroidism (hypercalcemia)
Pituitary tumors (prolactin, visual defects)
Pancreatic tumors (especially gastrinomas)
MEN2A
Medullary thyroid cancer (calcitonin)
pheo
parathyoid hyperplasia
MEN2B
Medullary thyroid cancer (calcitonin)
Pheo
Mucosal neuromas/marfanoid habitus
Porphyris cutanea Tarda: clinical features and associations
Clinical: blisters, bullae, scarring on sun-exposed skin
Scarring and calcification can look similar to scleroderma
Progressive buildup of porphorin lends itself to more severe presentations over time
Association: HCV, HIV, ecessive alcohol consumption, smoking, estrogen use
Scleroderma renal crisis
Occurs in 20% of those with systemic scleroderma (for most within first 5 years)
Presents with acute renal failure (w/ out previous kidney disease) and malignant HTN (HA, blurry vision, and nausea). UA may show mild proteinuria. PBScan show microangiopathic hemolytic anemia with schistocytes and thrombocytopenia
3 prokinetic agents used in diabetic gastroparesis
metoclopramide, erythromycin, and cisapride
Treatment of primary biliary cholangitis
ursodeoxycholic acid
relative risk vs exposure odds ratio
Relative risk: risk of one group having a certain outcome vs another group (cohort study where people tracked over time )
Exposure odds ratio: used in case-control (retrospective) studies where expousre of people already known to have the disease is compared to the exposure of those without the disease
ABG findings: COPD vs decompensated CHF
COPD: respiratory acidosis and hypoxia
CHF: respiratory alkalosis and hypocapnia as well as hypoxia
3 criteria in COPD exacerbation
Increased dyspnea
Increased cough (more frequent or severe)
Change in sputum production (color or volume)
Use antibiotics if fits 2 or more criteria, especially with increased sputum purulence
antibiotic tx of moderate-severe COPD exacerbation
macrolides (azithro)
fluoroquinolones (levofloxacin, moxifloxacin)
penicillin/beta-lactamase inhibitors (amoxicillin-clavulante)
Etiologies of interstitial lung disease
chronic inhalation of organic/inorganic dust (asbestos berylium, silicon dioxide)
Drug toxicity (amiodarone, bleomycin, nitrofurantoin)
radiation
systermic connective tissue disease (RA, scleroderma)
Adverse effects of ACE inhibbitors
Acquired angiodema
cough
hyperkalemia
acute renal failure in pts with bilateral renal artery stenosis
pulmonary capillary wedge pressure =
left atrial pressure and left-sided heart function
Pseudogout
An acute inflammatory arthritis caused by calcium pyrophosphate crystals
Occurs in the setting of recent surgery or medical illness
Diagnosed with synovial fluid showing rhomboid-shaped positively birefringent crystals and radiographic evidence of chondrocalcinosis ( caalcified articular cartilage)
Theophylline toxicity: 2 main manifestations
central nervous system stimulation (HA, insomnia, seuzures) and cardiac toxicity (arrythmia) in the setting of medication changes
Bronchiectasis
A disease of bronchial wall damage and airway dilation due to a recurrent cycle of infection, inflammation, and tissue damage in combinatio with impaired bacterial clearance (d/t impaired immmune defenses, structural airway defect, etc)
Modified Wells criteria for pretest probability of PE
+3 points–clinical signs of DVT, alternate diagnosis less likely
+1.5 points–previous PE or DVT, hr greater than 100, recent surgery or immobilization
+1 point–hemoptysis, cancer
Greater than 4 points = PElikely
DKA: Lab findings
metabolic acidosis (shownn by low bicarb) with an elevated anion gap Hyperkalemia (d/t extracellular shift and loss of insulin dependent cellular uptake. however, osmotic diuresis is actually promoting total body depletion of potassium)
Anion gap calculation
sodium - (chloride + bicarb)
nl is 10-14
Treatment of DKA: 3 must-haves +/- 2
IVfluids + potassium (when K<5.2 as nearly all pts K depleted even when hyperkalemic)
Insulin
Bicarb for pH < 6.9
Phosphate if cardiac dsyfunction
PIKIB
Polymyalgia rheumatica: symptoms and treatment
Age > 50
BL pain and morning stiffness > 1 month
Involvement of 2 of the following: Neck or torso, shoulders or proximal arms, proximal thigh or hip, constitutional
TX: glucocorticoids
Time frame for reinfarction after acute MI
hours-2 days
Time frame for ventricular septal rupture after acute MI
hours-1 week
Time frame for free wall rupture after acute MI
hours-2 weeks
Time frame for post-infarction angina after acute MI
hours-1 month
Time frame for papillary muscle rupture after acute MI
2days-1week
Time frame for pericarditis after acute MI
1day-3months
Time frame for left ventricular aneursym after acute MI
5days-3months
NOTE: presents with ECGfindings of persistent ST-segment elevation after a recent MI and deep Q waves in the same leads
Anti-pseudomonal agents
cefepime (4th) or ceftazidime (3rd)
piperacillin/ticarcillin-tazobactam
Aminoglycosides (amikacin, gentamicin)
Fluoros (cipro, levofloxacin)
Monobactams (aztreonam)
carbapenems (imipenam, meropenam)
Most commonly seen infections in MM (2)
respiratory (streptococcal pneumonia)and UTIs
Mitral stenosis: PEfindings
mitral facies (pink/purple patches on cheeks)
Loud S1
Loud P2 if pulmonary HTN
diastolic sounds
Opening snap
mid-diastolic rumble
Diabetic neuropathy affecting the large nerve fibers
negative sxs: numbness, loss of proprioception and vibration sense, diminished ankle reflexes
Diabetic neuropathy affecting the small nerve fibers
positive sxs: pain, paresthesias, allodynia
CD4 count where reactivation of toxo becomes high
<100
30% reactivation
Cyanide toxicity
Presents with confusion, seizures
Often seen with prolonged nitroprusside drip (as you could see in treatment of HTNemergency), higher doses of nitrop, or baseline CKD
Most sensitive indicator of hypovolemia in labwork
Decreased urine sodium (FeNa <1%)
Acute urinary retention: 6 major risk factors
Male sex Advanced age BPH Neurologi disease Recent surgery Anticholinergics UTI
For diagnosis in someone unable to void, bladder US demonstrates >300mL urine
Diagnosis of CAP
CXR showing a lobar, interstitial, or cavitary infiltrate
NOTE: clinical and physical findings have a <50% sensitivity at predicting presence of pna
A person with a 44pack year smoking ho coming in with wt loss, constipation, increased thirst, fatigue, and a calcium level of 14.5 likelt has ________
humoral hypercalcemia of malignancy due to secretion of PTH related protein
volume depletion from hypercalcemia-induced nephrogenic DI and decreased PO
Use ___ and ___ immediately and ____ long-term to treat severe hypercalcemia, defined as a calcium over ___
NS hydration, calcitonin, bisphosphonate, 14
splenic abscess presents with triad of _____
fever, leukocytosis, and LUQpain
_____ is most commonly associated with splenic asbcess
infective endocarditis
5 features of pancoast tumors
pancoast tumors = superior sulcus tumor
Squamous cell lung carcinoma and adenocarcinoma most common types
(1) shoulder pain
(2) Horner syndrome (PMAVE)
(3) C8-T2 neurological involvement (weakness and paresthesias in hands)
(4) supraclavicular lymph node involvement
(5) weight loss
otosclerosis VS presbycusis
otosclerosis = chronic conductive hearing loss associated with bony overgrowth of the stapes, often beginning in middle-age and affects low-frequencies
presbycusis = sensorineural hearing loss that occurs with aging, most commonly starting in the 6th decade. High-frequency hearing loss
______ is the causative organism ofg bacillary angiomatosis
Bartonella (gram negative bacillus)
____ is the antibiotic of choice for bacillary angiomatosis
oral erythromycin
3 must-haves in acuteliver failure
markeeldly elevated transaminases (>1000)
hepatic encephalopathy
hepatic synthetic dysfxn (INR >1.5)
3 cancers in Lynch syndrome
colorectal
endometrial
ovarian
3 cancers in familial adenomatous polyposis
colorectal
desmoids/osteomas
brain
3 most common causes of cough
Postnasal drip
GER
asthma
Indications for an x-ray of back (3) =
osteoporotic fracture
ankylosing spondylitis
suspected malignancy
Indications for an MRI of back =
epidural abscess/infection
sensory/motor deficits
cauda equina syndrome
Causes of macrocytic anemia
meds (chemotherapy, DMARDs, hydroxyurea)
hypothyroidism nutritional deficiencies (b12, folate)
liver disease
alcoholism
Myelodysplastic syndromes
acute leukoblastic leukemia
People ages __ to ___ should receive statin regardless of baseline lipid panels
40-75
Clinical manifestation of chromium deficiency
Impaired glucose control in diabetics
Clinical manifestations of zinc deficiency
alopecia
perioral and extremity pustular skin rash
impaired taste, wound healing, and immune system
hypogonadism
Clinical manifestations of selenium deficiency
thyroid dysfunction
cardiomegaly
immune dsfxn
Clinical manifestations of copper deficiency
Ataxia (and peripheral neuropathy)
Brittle hair
Sideroblastic anemia
Depigmentation (skin)
Osteoporosis
(ABCD-O)
Risk factors for trace mineral deficiency
iron, copper, selenium, zinc, chromium
TPN
poor nutritional intake
malabsorption
bowel resection
Supravalvular aortic stenosis
Second most common cause of AS
Can present with CP 2/2 LVH
Can lead to coronary aortery stenosis
Signs: suprasternal thrill
midsystolic murmur at right second intercostal space
Kussmaul sign
Increase or lack of decrease of JVP on deep inspiration in constrictive pericarditis
Normal JVP
8
2 agents used for lowering serum ammonia
in hepatic encephalopathy
lactulose and lactilol (nonabsorbable dissaccharides)
Transudative causes of pleural effusions
CHF (most commonly bl)
liver cirrhosis
peritoneal dialysis
nephrotic syndrome
ph > 7.4
Exudative causes of pleural effusion
malignancy infection Connective tissue disorders inflammatory disorders PE
fluid LDH/serum LDH > .5
Fluid protein/serum protein >.6
LDH fluid is 2/3 uln of serum LDH
AL amyloidisis
Associated with MM and waldenstrom macroglobulinemia (IgM)
Light chains (usually lambda)
AA amyloidosis
Associated with inflammatory conditions (RA, IBD) and chronic infections (osteomyelitis, tb)
abnormally folded proteins (beta 2 microglobulin, apolipoprotein, or transthyretin)
initial tx for renovascular stenosis or HTN
ACE-is/ARBs
NOTE: renal artery stenting of surgical revascularization reserved for pts with resistant hypertension or ruecurrent flask pulmonary edema
3 causes of vitamin K deficiency
inadequate dietary intake
intestinal malabsorption
hepatocellular disease
Indications for acute hemo dialysis
Acidosis Elecrolytes (K or Ca) Intoxication Overload Uremia (encephalopathy, pericarditis)
Casts seen in different intrarenal conditions
golmerulonephritis–RBCcasts (nephrotic syndromes)
AIN–WBCcasts (infection or antibx)
ATN–muddy casts (ischemia or contrast)
Treatment of mild, mod, severe hypernatremia
mild: PO h20
mod: NS (N/V, headaches)
severe: d5w or 1/2NS (seizures, coma)
Treatment of mild, mod, severe hyponatremia
mild: disease-specific
mod: NS
severe: 3% NS
serum osmoles =
2 x Na + glucose/18+ BUN/2.8
NLis 280
Hypertonic hyponatremia
low Na, but high serum osmoles
Happens in DM, with high glucose and or BUN
Remember: serum osm = 2 x NA + glucose/18 + BUN/2.8
Sodium correction with hyperglycemia
(glucose-100) x 4 +Na
Categories of hypotonic hyponatremia
hypervolemic (ESRD, CHF)
euvolemic
hypovolemia (V,D, decreased PO, sepsis, burns)
Euvolemic hyponatremia
Rta
Addisons
Thyroid
SIADH (tx with volume restriction, diuresis, demecycline)
treatment of symptomatic hypercalcemia
ALWAYS DILUTE Ca (IVF)
Immediate phase and super symptomatic: calcitonin
ALWAYStreat with long term: bisphosponate
Consider diuretics
Assessment of hyperparathyroidism
high Ca
high PTH
low phosphorous
sestamibi scan:
multiple areas of uptake (tertiary) or one area (primary –> resection
NOTE: secondary hyperPTH is from CKD
Hyperparathyroidism from cancer (2 types of findings)
Metastatic cancer affecting bone: high Ca, high phosphorous, LOWPTH
Cancer that secretes PTH-rp: high ca, low phosphrous, low PTH, PTH-rp (PTH-rp acts on kidneys just like PTH)
2 types of granulomatous diseases causing increased vit D
TB and sarcoid
Secrete 1-25 vit D
high calcium, high phosphorous, low PTH (gut affected to absorb ca and P)
3 signs of severe aortic stenosis
pulsus pardus and tardus
soft or absent S2
late peaking SEM in 2nd right ics
CHADSVASC score for risk of thromboembolic event in a person with nonvalvular AF
Congstive heart failure Hypertension Age > 75 (2) DM Stroke/TIA/thromboembolism (2) Vascular disease (prior MI, PAD, or aortic plaque) Age between 65-74 Sex (F-->1)
Max score is 9
Proximal vs distal SBO presentations
Proximal: early vomiting, abdominal discomfort, and abnl contrast filling on XR
Mid/Distal: colicky abdominal pain, delayed vomiting, prominent abdominal distension, constipation/obstipation, hyperactive bowel sounds, and dilated loops of bowel on XR
Note: both of these can have the complication hypokalemia (from K loss in emesis and through contraction alkylosis) and of strangulation, which would additionally present with peritoneal signs and shock with feverm tachycardiam and leukocytosis being late findings.
Rotator cuff impingement/tendinopathy vs rotator cuff tear
impingement /tendinopathy–pain with abduction, external rotation but normal range of motion
tear–weakness with abduction and external rotation; age >40
MRI scan will confirm diagnosis
Differential diagnosis of anterior medistinal mass
The 4 Ts!
Thymoma
Teratoma
Thyroid neoplasm
Terrible lymphoma
Concerned for ____ in a pt s/p cardiac cath who is hypotensive and complaining of flank/back pain
retroperitoneal hematoma
Scaphoid fxs diagnosis options
Xray at time of injury not sensitive for fx –> either get CT or MRI ORimmobilize in thumb sicca splint and repeat XR i 7-10 days
Presentation of acute mediastinitus
Complication of cardiothoracic surgery, often within 14 days post-op
fever, tachycardia, CP, leukocytosis
XR showing mediatinal widening
sternal wound cloudy/prurulent drainage
2 most common peripheral artery aneurysms associated with AAAs
popliteal and femoral artery aneurysms
Lab values seen in alcoholic hepatitis
AST/ALT > 2
AST and ALT under 500
elevated ggt
elevated ferritin
Invasive aspergillosis: risk factor, clinical findings, and management
RF: immunocompromise
Clinical: Triad of fever, CP, and hemoptysis
pulmonary nodules with halo sign
Tx: voriconazole +/- caspofungin
Chronic pulmonary aspergillosis: risk factors, clinical findings, and Tx
RF: lung disease/damage (cavitary tb)
Clinical: >3 months wt loss (seen in 90% of pts), cough, hemoptysis, fatigue, cavitary lesion +/- fungus ball, positive aspergillus IgG
Tx: resect aspergilloma, voriconazole, embolization(if severe hemoptysis)
3 most common malignancies responsible for pleural effusion
lung, breastm lymphoma
Acute post-streptococcal glomerulonephritis
occurs 10-20days after streptococcal throat or skin infections
Presents with hematuria, HTN, RBCcasts, and mild proteinuria –> periorbital edema
