Random UWorld Flashcards
treat HYPERNatremia
euvolemic
hypovolemic asymptomatic
hypovolemic symptomatic
how and why to limit rate of serum sodium correction
euvolemic - free water
hypovolemic asymptomatic - D5 (hypotonic)
hypovolemic symptomatic - .9% NS (isotonic) till euvolemic, then D5 (hypotonic)
Limit Na correction to .5mEq/dl/hr (12mEq/dl/24hr) – or Risk CEREBRAL EDEMA
mechanism of Li induced nephrogenic diabetes inspidus
symptoms
treatment
ADH Resistence by Impairing Water Resorption in collecting duct
nocturia, polyuria, polydipsia, CNS symptoms when severe
discontinue lithium, if cannot - salt restriction and amiloride (select diuretic)
water deprivation test differentiates between…
central diabetes insipidus (low ADH from pituitary)
nephrogenic diabetes insipidus (ADH resistance in kidney - impaired water resorption)
primary polydipsia
Manage hypercalcemia
severe
moderate
mild
^14 or symptomatic - IVNS and Calcitonin acutely, Bisphosphonate long term (Zoledronic Acid, Pamidronate)
12-14 - only treat as above if symptomatic
v12 asymptomatic - no immediate treatment…. avoid thiazide diuretics (can use loop diuretics to secret calcium Only if volume up) avoid lithium, volume depletion, prolongued bed rest
why might an old lung cancer guy with PTHrp secreting tumor get an AKI
volume depleted via hypercalcemia-induced nephrogenic diabetes (trying to pee out the calcium)
why will fiail chest patient have decreased lung sounds in bases bilaterally
shallow breaths to avoid pain
treat flail chest
pain control
supplemental O2
if respiratory failure eg from edema/blood/pulmonary contusion - PPV Positive Pressure Ventilation… maybe with prophylactic chest tube to minimize risk of mechanical PPV causing tension pneumo
how to follow an AAA
ultrasound is all that is needed, very sn and sp and can measure and see thrombi
TF
abruptio placenta can cause extreme maternal pain
T
at 36 weeks gestarion, sudden extreme pain, vaginal bleeding, firm distended uterus, low fetal heart rate
diagnosis
abruptio placenta
Pain?
placenta previa vs abruptio placenta
no pain placenta previa usually, just painless bleeding
PAIN Abruptio Placenta, severe
interstitial cystitis aka assoc with UA findings treatment
aka painful bladder syndrome
assoc with anxiety, fibromyalgia, psche and pain syndromes
UA normal
treat with Behavioral Modification and Trigger Avoidance, Amitripyline, Analgesics for exacerbations
Criteria for home oxygen
general
if right heart failure or polycythemia?
generally if SpO2v88% or PaO2v55mmhg
if RHF or PCV (HC^55%) then SaO2v89% PaO2v59mmhg
(supplement to SpO2^90%)
what kind of diuretic can treat calcium kidney stones
thiazide diuretic
-hypercalcemia, hypocalcuria
(all others, loops, potassium sparing, increase urinary calcium excretion)
longstanding smoking and chronic productive cough with recent hemoptysis
chronic cough with daily production of copious mucopurulent sputum in setting of recurrent respiratory tract infections
diagnoses?
Chronic Bronchitis - smoking, chronic small productive cough with recent hemoptysis
Bronchiectasis - irreversible dilation and destruction of bronchi, chronic cough and impaired mucus clearance, history of recurrent URIs and copious mucupurulent sputum… can also cause hemoptysis
3 most common causes of hemoptysis in adults
pulmonary airway disease
- chronic bronchitis
- bronchogenic carcinoma
- bronchiectasis
define chronic bronchitis
most common cause
Chronic Productive Cough ^3months in 2 successive years
smoking most common cause
how can ruptured AAA cause hematuria
can rupture into retroperitoneum, cause aorto-caval fistula (aorta-IVC) backup of venous system, bleeding of bladder veios, hematuria
potential ECG changes with ruptured AAA
ischemic changes
eg ST Depressions
TF
Drug Fever is a common cause of fever 1-2 hours postop
F
Drug Fever 1-2 WEEKS postop – more allergic picture with rash and eosinophilia
1-2 hour postop fever ddx is
- preop infection or trauma
- malignant hyperthermia
- medications side effect (eg to anesthesia… but this is NOT “Drug Fever”
- Febrile NonHemolytic Transfusion Reaction to Blood Products
Febrile NonHemolytic Transfusion Reaction
time to onset
cause
treat
1-6 Hours after transfusion
cytokine buildup in stored blood by residual leukocyte debris
stop transfusion, rule out other serious causes of fever (acute hemolytic ABO incompatability), antipyretics (avoid aspirin if thrombocytopenic)
appendicitis symptoms ^5 days with phlegmon with abscess that has walled off
manage
manage conservatively with abx and bowel rest, then Delayed Appendectomy weeks later
trauma to sphenoid bone will classically cause… epidural or subdural hematoma? how?
sphenoid trauma - Epidural Hematoma - tearing of Middle Meningeal Artery
sphenoid trauma, bruise, ipsilateral pupillary dilation
diagnosis?
mechanism of pupillary dilation?
how to treat when focal neurological deficits?
epidural hematoma
increased intracranial pressure
uncal herniation - CN III Palsy and Hemiparesis
if FNDs treat with Craniotomy to decrease ICP
brief unconsciousness, lucid interval, then worsening state again… what kind of dural hematoma
epidural hematoma
most common location of urethral injury with pelvic fracture, why
next step if suspected
what to do with urine leading up to urethral repair
Posterior Membranous urethra at bulbomembranous Junction (between prostate and penis) – where less support and risk for tearing when bladder and prostate elevated in pelvic fracture
get Retrograde Urethrogram
temporary Suprapubic Catheter while awaiting Delayed repair when associated with pelvic fracture… don’t foley because may damage urethra more, don’t repair immediately unless anterior urethra without pelvic fracture… because must address pelvic fracture first…
acanthosis nigracans (thick velvety skin plaques) in PCOS indicates
insulin resistance (diabetes)
suggested by acanthosis nigracans thick velvety skin plaques
how does clomiphene citrate induce ovulation
Selectively Blocks Estrogen Receptors in Hypothalamus to Restore Pulsatile GnRH, normalize LH and FSH and LH SURGE
how could bromocriptine induce ovulation
Dopamine Agonist blocks HyperPROLACTINEMIA which was preventing ovulation
what is Cyclic Progesterone supplementation’s role in the the treatment of PCOS
endometrial protection from uncontrolled anovulatory estrogen fueled proliferation
when are pregnant women screened for diabetes
and how, fasting glucose?
screen at 24-28 Weeks for Gestational Diabetes
Earlier IF HIGH RISK
screen with 1 Hour OGTT, more sensitive than fasting blood glucose
TF
if pregnant woman not flu-vaccinated, and it is flu season, the next best step is always Vaccinate with Inactive Virus
TRUE
Vaccinate in ANY TRIMESTER and IF BREAST FEEDING, NO CONTRAINDICATION to INACTIVE virus
…active vaccine contraindicated in pregnancy
44yo F with night sweats, insomina, irregular periods 6 mos, otherwise healthy – no thyroid abnormality on exam
top 2 ddx?
next steps
still HyperThyrodism and Menopausal transition even with normal thyroid exam, a little early for Menopausal transition (usually ^45yo) but not very early…
so think TSH and FSH next… must rule out thyroid issue before concluding menopausal
pale enlarged turbinates, transverse nasal crease, and pharyngeal cobblestoning are suggestive of ___
treat with ___
less effective alternatives include…
pale enlarged turbinates, transverse nasal crease, and pharyngeal cobblestoning suggest ALLERGIC RHINITIS
treat with INTRANASAL CORTICOSTEROID
less effective alternatives include nonsedating oral antihistamines, cromolyn nasal sprays, leukotriene modifiers
TF
intranasal glucoccorticoids for allergic rhinitis cause rebound congestion (rhinitis medicamentosa)
FALSE
that’s nasal decongestant sprays (alpha antagonists?) that cause rebound congestion rhinitis medicamentosa
intranasal glucoccorticoids are first line for allergic rhinitis
genitopelvic pain / penetration disorder aka risks features, key absent feature treatment
aka vaginismus
risks - past trauma, abuse, lack of sexual knowledge
features - pain and anxiety re Penetration (not external genital tenderness) with no medical cause
treat - desensitization therapy, kegels
vulvodynia and pudendal neuralgia will produce pain/tenderness where
superficial vulva / external genitalia
watch out especially for concurrent use of these two drug classes when prescribing sildenafil
nitrates, alpha blockers
risk combined hypotension
manage suspected PE in 3 steps
1 - O2, IVMF
2 - assess for Contraindication to Anticoagulation - if CI, diagnostic testing
3 - if No CI, assess PE probability with Modified Wells Criteria
- 3points if DVT or PE most likely dx
- 1.5points if prior DVTPE, HR^100, or recent Surgery or Immobilization
- 1point if Hemoptysis or Cancer
- –^4 PE likely (and in distress), anticoagulate
- –v4 PE unlikely, get diangostic testing
Basically, if PE most likely and patient in distress and no CI, skip diagnostics and anticoagulate… because huge in reducing mortality
postop CABG guy intubated in SICU with fever WBC RUQ tenderness… most likely dx?
even with no jaundice and normal LFTs?
diagnose
treat
ACALCULOUS CHOLECYSTITIS (F WBC RUQ pain with risk factors… yes jaundice and lft abnorms are less common… if Alk Phos elevated think more Cholangitis)
risk factors are severe trauma or recent surgery, critical ICU illness, prolonged fasting or TPN
RUQ US…. HIDA or CT if needed
antibiotics, cholecystostomy till clinically stable for cholecystectomy
Acute Acalculous Cholecystitis is acute inflammation of the gallbladder in the absense of gallstones most commonly seen in
acute acalculous cholecystitis most commonly seen in Hospitalize and Critically ill Patients
MVA guy with blow to lower abdomen and pelvis with chemical peritonitis… what part of GU system probably injured? Why? Mechanism?
Dome of bladder
adjacent to peritoneal cavity
sudden blow and increase in bladder pressure while full can cause rupture upward into peritoneal cavity and chemical peritonitis… lower pelvic bladder injuries urethral injuries and retroperitoneal structures etc not going to cause intraperitoneal leaks and peritonitis… more lower abdominal pain or back/flank pain
1st and 2nd line therapy for BPH
alpha blockers (terazosin, tamsulosin) -1st line, fast onset, rapid relaxation of bladder neck and prostate smooth muscle
5-alpha reductase inhibitors (finasteride)
-2nd line, delayed effect,… take months to shrink prostate
normal post void residual in nonoperative patient
v12ml
TF
low PSA means less suspicion for BPH
Fish not really
PSA suggests prostate cancer… also BPH a little bit… but less…
when to get Urodynamic studies in general
when to get in setting of BPH
urodynamics to assess for Overactive Bladder, Neurogenic Bladder
get in BPH if FAILED Medical treatment or Atypically present v50yo
15yo 2 years post-manarche with irregular cycles, family history of PCOS but she has no ovarian cysts no hirsutism no obesity etc… positive bleed with progesterone challenge…
cause of irregular menstrual cycles probably PCOS or or just developing HPA axis? cause of each? Typical time to HPA normalization in newly menstruating female?
prob HPA immaturity (low GnRH secretion… so estrogen but not regular ovulation or progesterone so uterine buildup and positive bleed with progesterone challenge)…. can take 1-4 YEARS TO NORMALIZE
anovulation in pcos from elevated androgens and LH… without other signs hpa immaturity is more likely
first 5 steps for suspected variceal hemorrhage in cirrhotic with hematemesis
f/u management
2 large bore IV catheters
Fluids
IV Octreotide
Abx
Endoscopic eval/therapy Urgently
f/u BB, band ligation, TIPS depending on control
megacolon/megaesophagus with cardiac disease in Latin American think…
CHAGAS disase
chronic protozoal disease cause by
TRYPANOSOMA CRUZI
2 primary manifestations of Chagas disease
demographic
bug
pathophys
Megacolon/Megaesophagus
Cardiac disease
Latin America
Trypanosoma Cruzi
destruction of Nerves to GI smooth muscle
Myocarditis from protozoal infection
general Diptheria symptoms
Upper Respiratory Tract symptoms with Diptheria
treat frostbite
rapid rewarming with Warm Water ~body temp
analgesia and wound care
Thrombolysis if severe/limb-threatening/amputation probable
(not for limited distal frostbite)
when is debridement indicated for frostbite
after rewarming and accurate survey of devitalized structures
for what diagnosis are CCBs nifedipine amlodipine indicated for cold fingers
Raynaud’s
most common causes of Cirrhosis in the USA
viral Hepatitis B more than C
Alcoholism
NAFLD
Hemochromatosis
what are you looking for in family history of cirrhotic
hemochromatosis (bronze diabetes, cardiomyopathy, arthropathy)
pt with heart failure diagnosed 2 mos ago and treatment started now has chronic dry cough 1 month but no signs of heart failure, seems well controlled… likely cause of cough?
ACEI - angioedema, cough
prob started as 1st line for CHF
produces cough in 20% of patients
what CHF drug class should always be considered on the differential for chronic cough?
ACEI
bradykinin, agioedema, cough
old guy gross hematuria or microscopic hematuria with cancer risks with no evidence of glomerular disease or infection… next step
cystoscopy
bladder cancer… think when painless hematuria
TF
BPH can cause hematuria
T
BPH can cause hematuria
but must rule out bladder cancer before settle on BPH
management of inevitable abortion depends on __ and __
options include __ __ and __
patient preference and vital stability
options- Expectant, Misoprostol induction, Suction Curettage (indicated above others if infection or hemodynamic instability)
TF
Oxyctocin for medical abortion
F
few oxytocin receptors in fist/second trimesters
Misoprostol for medical abortion
hallmark LFTs of Ischemic Hepatic Injury (Shock Liver)
timecourse of abnormalities
Massively Elevated AST ALT
modest tbili and alk phos
spike within a day of insult
1-2 weeks to recovery after treated
TF
prostate cancer commonly mets to liver
FALSE
prostate mets to Pelvic Lymph Nodes and Bones
To Liver: Colon Cancer #1, also Lung and Breast
most common mets to liver
Colon #1
Lung and Breast
Mets to liver on CT
next diagnostic test
Colonoscopy
most common Mets to Liver: Colon #1, Lung and Breast
old guy with mets to liver, slightly enlarged prostate, most probable source of mets? Next test?
Colon Cancer #1 Mets to Liver
also Lung and Breast
get COLONOSCOPY
Prostate mets to Pelvic Lymph Nodes and Bones not liver
how does NSAID cause AKI
constricts afferent arteriole
cause of AKI in HepatoRenal Syndrome
treat
does it improve with volume resuscitation?
Cirrhosis, Portal HTN, SBP and GI Bleeding, SPLANCHNIC ARTERIAL DILATION and DECREASE IN OVERALL VASCULAR RESISTANCE….. RAAS Activation, Renal Vasoconstriction
treat - recover hepatic function by ABSTAINING from Alcohol, or TRANSPLANT… temporize to transplant with splanchnic vasoconstrictors - Midodrine, Octreotide, Norepiniephrine… Albumin…. maybe Dialysis
does not improve with volume resuscitation… not from hypovolemia
3 most common causes of ATN
and UA findings
Aminoglycosides
Iodinated Contrast Dye
Hypotension
Muddy Brown Granular Casts on UA
HepatoRenal Syndrome
does it improve with volume resuscitation?
why/why not?
No, HRS does not improve with volume resuscitation
because not due to hypovolemia… due to Splanchnic Arterial Dilation and Decrease in Overall Vascular Resistance
(Cirrhosis, Portal HTN, SBP and GI Bleeding, SPLANCHNIC ARTERIAL DILATION and DECREASE IN OVERALL VASCULAR RESISTANCE….. RAAS Activation, Renal Vasoconstriction)
2 causes of AIN
and UA findings
Infection and some Antibiotics both cause AIN
White Cells and White Cell Casts on UA
causes of ATN vs AIN an UA differences
ATN - Aminoglycosides, Iodinated Contrast Dye, Hypotension…Muddy Brown Casts
AIN - Infections and certain Antibiotics… WBCs and WBC Casts
hearing loss with dull hypomobile tympanic membrane in AIDS patient
diagnosis
pathophys
Serous Otitis Media
HIV LYMPHADENOPATHY or OBSTRUCTING Lymphoma leads to NON-INFECTIOUS Middle Ear Effusion
___ is a demyelinating disease that can occur in patients with HIV/AIDS with CD4 count v___
PML Progressive Multifocal Leukoencephalopathy
is a demyelinating disease that can occur in HIV/AIDS pts with CD4 count v200
when to bronch a chronic cough
RARELY
only if foreign body suspected really
TF
asthma may present with chronic cough that is predominantly nocturnal
how does this knowledge inform your workup
T so if already failed a 1st gen H1 blocker (not upper airway cough syndrome / postnasal drip, already on a PPI (not GERD) not on an ACEI low suspicion of infection or cancer
consider PFTs
2, TWO major toxic products of combustion (fire) in closed spaces
treat one empirically
why
do they cause methemoglobinemia?
Cyanide - combustion of foam cotton paint silk Nitrogen Containing Polymers
- HydroxoCobalamin or Sodium ThioSulfate Antidotes (bind cyanide)
- Nitrites to Induce Methemoglobinemia (Fe3 which binds cyanide) IF NO ANTIDOTE AVAILABLE
- Respiratory support, Fluid support
- —treat to avoid eg CARDIORESPIRATORY ARREST and PERMANENT NEUROLOGIC DISABILITY, no way to measure exposure so treat empirically
CO Carbon Monoxide #2
-Methemoglobinemia (oxidation of ferrous Fe2 to Ferric Fe3 in Hb which cannot bind oxygen causing a functional anemia) occurs after exposure to Oxidizing agents DAPSONE NITRATES topical/local ANESTHETICS…. NOT FIRE, NOT CO POISONING… that is carboxyhemoglobin… i think…
how does Cyanid toxicity, e.g. inhaled in house fire /combustion of nitrogen containing household polymers, cause Lactic Acidosis?
Cyanide Reduces Oxygen Utilization by Tissues
inhibits cytochrome oxidase a3 in mitochondrial electron transport chain by binding Ferric Fe3 preventing reduction to Ferrous Fe2 so NO ATP from Oxydative Phosphorylation so ANAEROBIC METABOLISM and LACTIC ACIDOSIS
TF
unilateral pleural effusion rules out CHF as the cause
F
usually bilateral in CHF but 10-30% unilateral
pH of
normal pleural fluid
transudative pleural effusion
exudative pleural effusion
normal - 7.6 (higher than serum)
transudate - 7.4-7.55 (serum plus)
exudate - 7.30-7.45 (serum minus)
what to think of high amylase in pleural fluid
think pancreatitis-associated effusion or esophageal rupture (saliva)
sympathetic ophthalmia
aka
is characterized by
aka “spared eye injury”
characterized by immune recognition (antibody or cell-mediated) of “hidden” antigens in one eye (the sympathetic eye) after a penetrating injury to the other eye
inflammation and breast inflammation/dimpling/pitting without fever is trying to point you to
peau d’orange INFLAMMATORY BREAST CANCER
(DIMPLING NOT typically seen with MASTITIS or INFECTION… THINK CANCER… ABSENCE OF FEVER should also make you think LESS MASTITIS/INFECTION and MORE CANCER)
workup is mammography, ultrasound, tissue biopsy
morbidly obese woman stopped breast feeding 2 mos ago now with 1 month of unilateral breast pain and inflamed dimpling/pitting no fever…
top diagnosis is
workup is
peau d’orange INFLAMMATORY BREAST CANCER
(DIMPLING NOT typically seen with MASTITIS or INFECTION… THINK CANCER… ABSENCE OF FEVER should also make you think LESS MASTITIS/INFECTION and MORE CANCER)
workup is mammography, ultrasound, tissue biopsy
what helps you differentiate between Mastitis, Infection, and Inflammatory Breast Cancer on patient presentation with painful breast
Mastitis/Infection - fever
Inflammatory Breast Cancer - peau d’orange dimpling/pitting
___ is a benign palpable breast mass most commonly found in young women – estrogen-sensitive tumor typically firm and mobile with regular borders and spherical shape
Fibroadenoma
is a benign palpable breast mass most commonly found in young women – estrogen-sensitive tumor typically firm and mobile with regular borders and spherical shape
___ is a benign condition that typically presents with unilateral bloody nipple discharge and no other symptoms or skin changes
Intraductal Papilloma
is a benign condition that typically presents with unilateral bloody nipple discharge and no other symptoms or skin changes
treat laryngeal edema from food allergy eg sob in restaurant
epinephrine
systemic corticosteroids
antihistamines
empty gestational sac with yolk sac but no fetal pole and b-hCG 25,000 dropped to 24,000 with no change to ultrasound suggests…
missed abortion or molar pregnancy?
missed abortion - sac no fetus or fetus no heart rate with closed cervix, declining b-hCG
mole would be snowstorm appearance and b-hCG SUPER high like 100,000
adult single toxic dose of acetaminophen
peds toxic dose
first step in management
7.5g adult, 150mg peds
Activated Charcoal if v4 hours since ingestion,
measure Acetaminophen level
^3 mos fever weight loss fatigue cough hemoptysis or dyspnea
cavitary lung lesion with debris/fluid on CT with history of cavitary TB
think
pathophys
diagnose
treat
chronic pulmonary aspergillosis
aspergillus many of us are exposed to every day can get traction in underlying lung disease / prior cavitary TB especially or immunocompromise
diagnose with aspergillus IgG
treat with VoraconAZOLE and maybe CaspoFUNGIN
Actinomyces israelii is an anaerobic bacterium that usually causes infections where…
CervicoFacial infections from Actinomyces
fever fatigue weight loss
pulmonary disease with cavitary nodules
nasal/sinus/ear symptoms
renal insufficiency and active urine sediment
think
GPA Granulomatosis with Polyangiitis
ENT Pulm Renal stuff…
Amikacin belongs to this class of drugs that may be used to treat multi-drug resistant pyelo and can cause acute failure of this organ
Amikacin
Aminoglycoside
can cause ARF Acute Renal Failure (ATN not AIN)
what kind of renal failure does Nafcillin cause, is it used in MDR pyelo
Nafcillin, AIN
MSSA not MDR organisms
use Vanc to treat MDR pyelo?
probably not
Vanc for MRSA… MDR pyelo probably GNR
TF
Vanc can cause nephrotoxicity
T at HIGH DOSES
TF
Levofloxacin can cause renal toxicity
F
fluoroquinolones must be renally dosed but do not cause renal toxicity
Doxycycline 4 common uses
CAP
Lyme…other zoonotic infections…
Chlamydia
Acne
Azithromycin 4 common uses
CAP
Sinus Infections
Strep Pharyngitis
Chlamydia
Aminoglycosides are used to treat ___
monitor for __toxicity
Serious Gram Negative Infections
monitor for Nephrotoxicity (ATN)
TF
impaired lung expansion from pleural calcifications cause respiratory compromise in asbestosis patients
False
there are pleural calcifications but it is Pulmonary Fibrosis (Interstitial Lung Disease) that causes respiratory compromise
TF
xanthelasma and hyperlipidemia are consistent with PBC
T
don’t ask me why
TF
PBC can cause hepatomegaly with high Alk Phos but normal ast alt
T
3 adverse effects of oxytocin
do they include uterine rupture
HypONatremia (oxytocin similar to ADHvasopressin)
HypOtenison
Uterine TachySystole - abnormally frequent contractions
(NOT uterine rupture really unless uterine abdnormalities, scars, multiple gestation, abnormal placentation)
what is Vasa Previa
how can it affect mom and fetus
Vasa Previa - fetal blood vessels (yes, the cord) cross the fetal membranes between teh fetus and the inernal cervical os… then loop back in a longer path outside the membranes to the placenta…. instead of normally taking a more direct route not near the cervix
PAINLESS antepartum hemorrhage for mom
but RAPID DETERIORATION of FETAL HEART TRACING… because hemorrhage is of fetal origin
placenta previa vs vasa previa – painful or painless – fetal heart tracing affected?
placenta previa - painless, no FHT effect
vasa previa - painless, FHT distressed (big fetal blood loss)
pain with placental abruption?
umm YES distended and TENDER UTERUS with abruption
diagnose vaginal lesion suspicious for vaginal cancer
biopsy that shit
SCC vs Clear Cell Adenocarcinoma of the Vagina
age
risk factor
location
diagnose
SCC ^60yo Smoking HPV upper Posterior vagina
Clear Cell Adenocarcinoma in utero Diethylstilbesterol v20yo upper Anterior vagina
biopsy both
why is vaginal breech delivery bad
what do you recommend instead
vaginal breech bad because higher fetal Asphyxia and Trauma
prefer External Cephalic Version or breech C-section
what is internal podalic version of fetus
breech eg butt first.. reach in and deliver feet first
presentation of Benign Intraductal Papilloma vs Infiltrating Ductal Carcinoma
unilateral Bloody nipple discharge Without mass or lymphadenopathy
- benign intraductal papilloma
pathologic nipple discharge but Mass and Lymphadenopathy
- infinltrating ductal carcinoma
other symptoms to look for when trying to attribute seizure to hypoglycemia
Hanger - anxiety, tremor, cognitive impairment, diaphoresis
why can S3 be normal in young folk and athletes
from splash into large left ventricle…. fast depol and relaxation causes suck-splash?
otherwise think chf…
TF
Lupus flare during pregnancy is a thing
T
Increased Risk of Lupus Flare in Pregnancy and Postpartum
causes obstetrical complications such as preeclampsia, premature birth, c-section, growth restriction, fetal demise
signs of Lupus Flare as cause of pregnancy proteinuria rather than preeclampsia
lupus stuff: associated joint pain, malar rash, bloody casts in urine, decreased complement levels, incraesed ANA titers
Hemolytic Uremic Syndrome presents with ___ ___ and ___ most often due to ___
Hemolytic Uremic Syndrome presents with Renal Injury, Thrombocytopenia and MAHA Microangiopathic Hemolytic Anemia most often due to Shiga Toxin producing E.Coli
TF
hepatitis and panlobular mononuclear infiltration with hepatic cell necrosis on biopsy is consistnent with Isoniazid side effect eg in the treatment of pulmonary TB
what other drugs also do this
T
this is what Isoniazid-Induced Hepatic Cell Injury looks like….
Idiosyncratic Liver Injury with Histological Features Similar to Viral Hepatitis
Isoniazid, Halothane, phenytoin, alpha methyl dopa….
just watch out for hepatic stuff after starting drugs…
how often to screen healthy 70yo lady with
mammogram
lipid panel
blood pressure
DEXA scan
in old lady
mammo q2 age 50-74
lipid panel… no just q5 for men over 35 and women at high risk over 45
BP q2
DEXA for osteoporosis at least once over 65
treat VTach
IV Amio of stable
Cardioversion if unstable or severely syptomatic
carotid sinus massage useful for what arrhythmia
PSVT
paroxysmal supraventricular tachycardia
(narrow complex)
digoxin for what arrhythmia
afib aflut atach
pt diagnosed previously with chronic bronchitis but seeming more like bronchiectasis now (less smoking with little production and viral exacerbations, more difficulty clearing tons of mucus with bacterial infections and sinus congestion…)
workup?
high resolution chest CT #1 best test for bronchiectasis
Immunoglobulin quantification
CF testing, sputum culture
PFTs
chronic bonchitis vs bronchiectasis
smoking
sputum production
viral vs bacterial
antibiotics
chronic bronchitis - smoking, small sputum, viral exacerbations
bronchiectasis - copious sputum production, bacterial exacerbations, antibiotics
“linear atelectasis” on cxr suggests…
bronchiectasis
cxr linear atelectasis, dilated and thickened airways, irregular peripheral opacities
hrct bronchial dilation, lack of airway tapering, bronchial wall thickening
diagnosis?
pathogenesis
obstructive?
bronchiectasis
airway/bronchial dilation from recurrent infection, inflamation, tissue damage from bacterial infections with impaired clearance
yes, obstructive
most common cause of Massive lower GI bleed
hemorrhiods?
diagnose
treat
Diverticulosis
(hemorrhoid bleeds rarely massive)
diagnose diverticular bleed with colonoscopy
most diverticular bleeds spontaneously resolve, if not, endoscopic or surgical therapy
diverticulosis most common in the ___ colon but diverticular bleed most common in the ___ colon
diverticulosis left colon
but diverticular bleeds more common right colon
so may get a little darker, maroon
___ causes sudden onset abdominal pain and tenderness followed by rectal bleeding…. due to inadequate perfusion of watershed area of colon (splenic flexure) in setting of nonocclusive ischemia or surgical intervention
ischemic colitis
indoor barbecue, headaches nausea vomiting abdominal pain confusion coma pinkish-red skin hue
think
get
treat
CO poisoning
Carboxyhemoglobin level
Hyperbaric oxygen
bitter almond breath is characteristic of inhaled ___
bitter almond breath is characteristic of inhaled Cyanide
drug or environmental exposure, headache nausea vomiting abdominal pain confsion coma bluish discoloration of skin and mucous membranes
think
methemoglobinemia
CO poisoning vs Methemoglobinemia
skin color?
CO Pinkish-red skin
Methemoglobinemia Bluish cyanosis
plaque-like reddish-brown velvety lesions at intertriginous areas without cyst formation think
condylomata lata
secondary syphilis
young guy with agitation, dilated pupils, atrophic nasal mucosa, htn, MI
think
pathophys
treat with 4
avoid 2
cocaine
block norepinephrine reuptake by sympathetics, increased sympathetic alpha and beta adrenergic stim, hr bp cardiac oxygen demand, coronary vasoconstiction, platelet activation
Supplemental O2 and IV BENZODIAZEPINE… reduces sympathetic outflow
ASPIRIN
NITRATES and CCBs
avoid bb’s… can unappose alpha and worsen coronary vasoconstriction
avoid thrombolytics unless STE like always
all patients with acute cocaine toxicity and myocardial ischemia should be treated initially with supplemental oxygen and ___
IV Benzodiazepines for cocaine toxicity.
…reduces sympathetic outflow and symptoms
empiric treatment of CAP
outpatient healthy
outpatient comorbidities
inpatient
ICU
Macrolide or Doxy if healthy outpatient
respiratory fluroquinolone (Levofloxacin or Moxifloxacin) or Beta Lactam and Macrolide (Ceftriazone and Azythromycin) if comorbidities outpatient or inpatient (IV if inpatient)
Beta Lactam and Macrolide (Ceftriaxone Azythromycin) or
Beta Lactam and Fluoroquinolone (Ceftriaxone and Levo or Moxi)
IV if ICU
to admit for CAP?
CURB-65 Confusion Urea (BUN) ^20 Respiratory rate ^30 BP v90/60 ^65yo
outpatient if 0
admit if 1-3
prob ICU if 4-5
because mortality
define excess alcohol
define binge drinking
excess ^2 drinks per day
binge ^5 drinks at a time
what does FeNa v1% tell you about AKI
likely prerenal
kidneys retaining most sodium and fluid, not excreting in urine
TF
prerenal AKI can lead to ATN
T
lactational mastitis
pathophys
bug
how do myalgia chills malaise change management? erythema and tenderness in one quadrant but no fluctuance?
treatment?
sin fluora or infant oral fluora multiplying in stagnant milk ducts
Staph Aureus most common
myalgia chills malaise common, do not change management, neither does tenderness localized to one quadrant without fluctuance
- still Keep Breastfeeding (for infant nutrition and to treat mastitis, better than pumping)
- Analgesia
- anti-MSSA abx Dicloxacillin or Cephalexin… if MRSA Clindamycin TMPSMX or Vancomycin
2 keys to differentiating between cholecystitis and cholangitis
total / direct bili? transaminases?
cholangitis will have additional Jaundice and Higher Alk Phos
not bili so much… cholecystitis can cause mild transaminase elevations and bili elevation up to 4 mg/dl
treat PBC
if elevatged Alk Phos and anti-mitochondrial antibody but asymptomatic?
if PBC advanced?
early, even asymptomatic PBC - URSODEOXYCHOLIC ACID… limits bile injury to bile duct and antiinflammatory and immunomodulatory
if advanced PBC with cirrhosis - LIVER TRANSPLANT
TF treat PBC with steroids
F
treat PBC with Ursodeoxycholic acid
(treat AI Hepatitis with Steroids)
___ should be initiated as soon as diagnosis of PBC is made
Ursodeoxycholic acid
should be initiated as soon as PBC diagnosed, even if asymptomatic… limits bile duct injury and has antiinflammatory and immunomodulatory effects
best test to diagnose acute Hep B infection
HBsAg and anti-HBc IgM
HBsAg is the Ag that occurs early with other Ags in infection but lasts the longest
anti-HBc IgM because covers window period in which HBsAg vanishes but anti-HBs is yet to arise
- HBcAg is not detectible in serum
- HBeAg demonstrates INFECTIVITY but levels fall early so HBsAg a better marker of infection
HBV DNA used in chronic HepB to indicate antiviral treatment and monitor response
TF
esophageal rupture possible with vomiting
T
it’s called Boerhaave syndrome
in smoker with chronic cough and small sputum production exacerbated by URTIs, also with dyspnea, decreased vital capacity on PFT, which of the following is true?
alveolar-capillary membrane thickening
decreased FRC
air trapping with expiration
decreased lung distensibility
This patient has cOpd - bronchitis (chronic cough smoker some sputum urti viral exacerbations) and emphysema (dyspnea)
OBSTRUCTIVE
so Air Trapping
not alveolar thickening - destruction
not decreased frc - increased frc.. cannot get air out
not decreased distensibility - increased lung distensibility
hypercalcemia associated with which lung cancer
SCC
sCa++mous cell carcinoma
PTHrp
TF
suspect TB in USA non-immigrant with unilateral hilar mass and hypercalcemia
F
not so much, TB rare in USA unless immunosuppressed
think more SCC squamous cell carcinoma of the lung
TF
small cell lung cancer causes hypercalcemia via PTHrp
F
SCLC - SIADH and ACTH
Squamous cell carcinoma SCC - PTHrp
sCa++mous cell carcinoma
TF
suspect sarcoidosis in unilateral hilar mass and hypercalcemia
F
think more SCC squamous cell carcinoma of the lung PTHrp
think sarcoid if Bilateral hilar masses and erythema nodosum
treat / prevent uric acid ureteral stone
hydration
Alkalinize Urine to pH 6-6.5 with Potassium Citrate
Allopurinol if recurrent despite above
thiazide diruetic, loop diuretic, or potassium citrate to treat uric acid kidney stone?
Potassium Citrate to treat Uric Acid stone – K Alkalinizes urine to pH 6-6.5, Citrate inhibits stone formation
thiazides decrease Calcium stone formation
loops increase calcium stone formation… bad…
most common cause of aortic regurge
developing countries
developed countries
developing country AR - rheumatic heart disease
developed country AR - bicuspid aortic valve, aortic root dilation
most common electrolyte abnormality in alcoholism and how does it cause refractory hypokalemia
hypomagnesemia most common in alcoholic
normally inhibits K+ secretion by kidney, so low magnesium makes hard to replete K+ because kidney just excretes it
low albumin causes __ total calcium, because…
low albumin LOW total calcium… because lots of calcium is protein bound
adult patient with nephrotic proteinuria and anasarca gets acute flank pain and hematuria
caused by
why
renal biopsy most likely shows
caused by Renal Vein Thrombosis
nephrotic proteinuria loses Antithrombin III
possible with any nephrotic syndrome but most common with MG Membranous Glomerulonephropathy
RVT MG
