Shelf Review Flashcards
Pituitary adenoma
- treat with: bromocriptine or cabergoline
Tricuspid stenosis
- Opening snap with diastolic rumble at the left 4th interspace
- jugular venous A wave tall, due to atrial contraction (against increase resistance)
- increase intensity of murmur ( make it worse) with increase preload via inspiration, infusion, raise leg
- decrease intensity of murmur (make it better) via increase afterload
Pyrphoria cutania tarda
- elevated ALT/AST, blisters in the dorsum of the hand, hirsutism
- deficiency in urooo…
- treated with phlebotomy (others are hematochromatosis)
Whipple triad
- hypoglycemia + hypoglycemia symptoms + improve with glucose administration
- increase insulin & low C-peptide —> exogenous insulin
- increase insulin & C-peptide —> inslunoma
- increase insulin & C-peptide —> sulfanylurea
—> use sulfalnylurea screen—> detect sulfanylurea in blood
—> treat hypoglycemia with —> glycogen or glucose drip
—> glucagonoma associated with necrotizing migratory erythema
Diarrhea & organism
- Pork consumption —> yersenia
- Shelffesh —> vibrio
- Severe rice-water stool in developing country —> vibro cholera
- Bloody diarrhea with a super small inoculum —> shigella
- Bloody diarrhea after consuming egg/poultry —> salmonella
- Watery diarrhea 2 hours after consuming potato -> staph aureus
- Bloody diarrhea with a low platelet + low unconjugated hyperbilirubinemia + elevated creatinine —> E.coli (EHEC) —> CAN lead to hemolytic uremic syndrome (HUS) (thrombocytopenia + hemolytic anemia + AKI) IF antibiotic is given
** most diarrhea treated with:
1. Fluoroquinolone
2. Macrolide (azithromycin)
Continue diarrhea
- Diarrhea upon return to the US from Mexico —> (ETEC)
- Foul-smelling watery Diarrhea, after recent treatment for anaerobic bacteria pneumonia with antibiotics —> C.difficile (prevent with hand water, treat with: metronidazole, oral vancomycin, fedaxomycin, fecal transplant)
- Crampy abdominal pain after consumption of home canned veggies —> botulism (+ flaccid paralysis)
- Bloody diarrhea with ascending paralysis in a puppy owner —> campylobacter jenjuni ( the ascending paralysis is Gullain-Barre syndrome)
- Watery diarrhea after eating fried rice at a Chinese restaurant —> B. Cerus ( rice-heated) —> toxin causes N/V
Prussian blue staining of a bone marrow smear reveals basophillic inclusion around the nucleus in a 75 year old male that lives in a home built in the 1930s.
What are the associated iron lab value? How is this disease treated? ( + potential helpful vitamin supplement)
- Sideroblastic anemia (caused by lead toxicity) —> heme synthesis pathway is damaged —-> microcytic anemia with ( low hemoglobin, low MCV, high iron, high ferritin, low TIBC)
- Treated with: DMSA ..or succymere ..or EDTA
Accompanied by vitamin B 6 (pyroxine) + thiamine + folic acid
Chest x-ray showing diffused, bilateral, ground glass infiltrates in a febrile patient taking immunosuppressant.
What is the bug? Relevant stain ? Prophylaxis ? Treatment? Who should get concomitant steroid ? Diagnostic studies? Classically elevated marker from pulmonary fluid?
- pneumocystis Jirovecii pneumonia (PCP) = (fungus)
- Silver stain positive organism
- Prophylaxis with: TMX-SMZ, pentamidine, dapsone
- Begin prophylaxis when CD4 is 200
- Treat with: TMX-SMX
- Who should get steroid: SaO2 is less than 92% & PO2 is 70% & A-a gradient > 35
- Diagnose PC pneumonia via: bronchioalveolar lavage
- Elevated LDH in pulmonary fluid
Flank pain with gross hematuria. Envelop shaped? Coffin shaped ? Radiolucent? Shape like hexagon?
What is the best diagnosis testing modality? How is this presentation treated ?
—> causes urinary tract infection:
- Kidney stone (nephrolithiasis)
- Envelop shaped = calcium oxalate (seen with chron’s disease) (common type)
- Coffin shaped= struvite stone (magnesium-ammonium-phosphate stone) ( Proteus bug is urease positive = make urine alkaline) (avoid acetazolamide becuase it enhances urine alkalinization) (huge stooone)
- Radiolucent = uric acid stone
- Shaped like hexagon = cysteine stone (transporter defect that don’t absorb cysteine at proximal tubule) ( they are acidic stone —> give them acetazolamide ) ( type 2 RTA at proximal tubule )
- Helical CT scan for diagnosis of kidney stone ( ultrasound for pregnant women)
- Treat with:
- Iv fluid + pain control + tamsulosin (alpha 1 antagonist) + Nifedipine (CCB) + struvite stone (surgery)
24 year old male present with painless, palpable bony mass on the left knee.
Knee x-ray shows a contiguous mushroom shaped mass. What is the diagnosis ?
- Osteochondroma
66 year old female found unconscious at home by her daughter in December (fire places). PE is notable for cherry red appearance of skin
- Carbon-monoxide poisoning
- Diagnose with: Carboxy-hemoglobin level
- Treat with: Hyperbaric oxygen (decrease half life of CO bind to hemoglubin)
- Left-shift ( tissue hypoxia)
- Symptoms of CO poisoning: Headache + altered mental status + cherry red lips + winter space heater + garage suicide
- Hyper-intense lesion in Glubus Palidus region in MRI of brain
Elevated creatinine 24 hours after getting CT scan.
- Contrast- induced nephropathy
- Prevented with: fluid + oral N-acetylcysteine (Nac)
- Skin fibrosis after getting MRI —> nephrogenic system fibrosis (NSF)—> caused by exposure to Gadolinium-based contrast agent
- If person has diabetes —> hold metformin before getting CT scan—> can lead to lactic acidosis
- Nac —> in addition to contrast-induced nephropathy, can be used for acetaminophen overdose or cystic fibrosis or hemorrhagic cystitis
- Hemorrhagic cystitis (damage to bladder) caused by:
- adenovirus
- schistosomiasis ( +person from egypt)
A common lower extremity side effect associated with hydralazine & CCB (causes vasodilation)
- peripheral edema
- Caused increase hydrostatic pressure in capillaries
B 12 deficiency
- Pernicious anemia is associated with autoimmune disease ( adrenal insufficiency, Addison disease, Hashimoto thyroiditis)
- Cystic disease
- Chronic
- Extreme vegan
CD4 cutoff & prophylaxis in HIV
(200, 100, 50)
(250, 150)
- Pneumocystis Jirocercii (PCP) pneumonia
- CD4 = 200
- via TMP-SMX, dapsone, pentamidine - Toxoplasmosis: (ring enhance lesion in MRI)
- CD4 = 100
- TMP-SMX (bactrim) - MAC:
- CD4 = 50
- azithromycin (macrolide) - Coccidiodes Immitis
- CD4 = 250
- Arizona, Texas, California, los angles
- Itraconazole - Histoplasmosis
- CD4 = 150
- Ohio, kentaki, Missouri
- itraconazole
Hyperosmolar serum + hypoosmolar urine + hypernatremia + hypokalemia
Central DI:
- damage of supraoptic nucleus in hypothalamus (no ADH produced) in posterior pituitary
Nephrogenic DI:
- kidney not responding to ADH
—> water deprivation test then + desmopressin
1. Central DI: diluted urine then urine osmolarity go up
2. Nephrogenic DI: diluted urine than stays diluted
Treatment:
1. Nephrogenic DI:
- HCZT
- amiloride or triamterene: treat lithium-induced nephrogenic DI
- Central DI:
- desmopressin (ADH) - Normovolemic hypernatremia:
- normal saline - Hypovolemic hypernatremia:
- normal saline first (to become normovolemic) then 5% dextrose - Fix hypernatremia quickly lead to cerebral edema
- Fix hyponatremia quickly lead to osmotic demyelination
Osteoarthritis
- Joint space narrowing + osteophyte + subchnodro sclerosis/cyst
- In older people
- Pain gets worse throughout the day
- Less than 2000 WBC (during taping)
- First line medication: acetaminophen (not NSAIDs), then proceed to NSAIDs
- If medication don’t work send them to ortho to replace the whole joint
- Obesity increases risk for OA
- Obesity decreases risk for osteoporosis (constant weight bearing ) -> mostly seen with anorexic patients
Business conference 1 week ago + fever+ abdominal pain + nonproductive cough + hyponatremia
- Legionella —> test via: urinary antigen—> treat via: fluoroquinolone, macrolide (azithromycin)
- Common cause of atypical pneumonia: mycoplasma —> chlamydia —> legionella ….typical chest x-ray finding: interstitial infiltrate
- C. Psittaci —> associated with birds/turtles
- also turtle associated with salmonella - C. Burnetii —> associated with cow, cattle, goat
- Mycoplasma —> associated with walking pneumonia —> teenager or 20-40 year old (variety of age) + not super high fever + not productive cough + interstitial infiltrate
Macrolide
- Mycoplasma
- chlamydia
- legionella,
Midsystolic click heard best at apex
- Mitral valve prolapse (MVP) —> risk factor: marfan, ehler danlos, autosomal dominant polycystic kidney disease/ADPKD (bilateral kidney mass)
- Female + history of psychiatric problem + pregnancy + connective tissue diseases (lupus..)
- Myxomatous degeneration of the valve common for MVP
- Diagnosis any murmur with: echocardiogram
- Increase murmur (worse) with decrease preload ( valsalva/standing) & decrease afterload (amyl nitrate)
- Decrease murmur (better) with increase preload (leg raise/ squatting) & increase afterload ( handgrip)
Aortic dissection
Associated risk factors: HTN + cystic medial necrosis (Marfan)
Maneuvers & murmurs
Increase venous return/ preload ( leg raise, inspiration, infusion, squat)
- Increase murmur (worse) in: MS, AS, MR, AR, VSD (better with decrease preload: valsalva/standing)
- Decrease murmur (better) in: HOCM, MVP (worse with decrease preload: valsalva/standing)
Increase afterload (handgrip)
1. Decrease murmur (better) in: AS, HCOM, MVP ( increase murmur with decrease after load: amyl nitrate)
- Increase murmur (worse) in: MR, AR, VSD (decrease murmur with decrease afterload: amyl nitrate)
Drugs with murmur
Diuretic:
1. Better
2. Replace AS + Balloon MS
3. Use in AR, MR, VSD
4. Don’t use for HOCM, MVP
ACE-i
1. Not used in AS/MS
2. Used in AR, MR, VSD
3. Don’t use for HOCM, MVP
Scaly, itching skin, with yellow crust in the winter
- sehborriec dermatitis
- treat with: topical antifungal
Pheochromocytoma
(over-expression of catecholamine)
- catecholamine-secreting tumor
- located in adrenal tumor & posterior mediastinum
- episodic HTN + Headache + palpitation
- associated with with MEN 2A & 2B
- Associated with NF type 1
- associated with VHL ( hemangioma in the brain )
** diagnosis with: elevated urine metanephrine + CT scan (if CT is negative, do MIBG scan)
** treat with: alpha-blocker (phenoxibenzamine or phentolamine) + then, beta-blocker (propranolol)
Low GI bleed in elderly
- common cause : diverticulosis —> diagnosed with barium enema or colonoscopy (note that diverticulitis is diagnosed with CT scan)
- prevent diverticulosis with eating high-fiber diet
Macrocytic or megaloblastic anemia
( MCV > 100)
- Blood smear finding: hyper-segmented neutrophils + big RBC cell
- Folate deficiency seen with: alcoholic, malnutrition (elderly women on tea & toast diet)
- Folate synthesis inhibitors:
- molar pregnancy (methotrexate)
- ring enhance lesion + HIV (pyrimethamine + sulfadiazem)
- HIV + CD < 200 ( TMP-SMX) - Methotrexate can lead to pulmonary fibrosis —> lead to toxicity in lung, liver, kidney
- Leucovorin is used rescue bone marrow with methotrexate toxicity
Classic CMV present with —>
esophagitis, colitis, retinitis + periventricular calcification + owl-eye inclusion
- CMV esophagitis shows in endoscopy as linear ulcer with punched out lesion
-post-transplant patient tend to get CMV colitis
- HIV patient tend to get CMV retinitis ( Usually when CD4 count below 50)
- if a kid gets congenital CMV —> Calcification in periventricular of the brain
** diffused calcification (everywhere in brain) + infection —> associated with congenital toxoplasmosis ( chorioretinitis + hydrocephalus + intracranial calcification)
- histology of CMV shows —> owls eye inclusion
- treat CMV via intiviral drugs:
1. ganciclovir —> foscarnet
CD4 < 200 + severe peripheral edema + frothy urine
- focal segmental glumerulosclerosis (FSGS)
- In HIV patient shows colapsin variant of FSGS
- Treat FSGS with: ACE- inhibitor (protect kidney) (+ steroid + cyclophosphamide)
- HIV drugs side effect on kidney:
1. Indinavir: causes nephrolithiasis - triad of:
1. fever + rash + eosinophil in urine/blood —> seen with acute interstitial nephritis (AIN) —> mainly caused by drugs—> Classic drug causing AIN is penicillin —> treat AIN with: 1. Stop drug, if severe AIN add steroid
Vitamin D metabolism
- vitamin D in stomach —> go to liver & converts it into 25- hydroxyvitamin D (calcidial) —> go to kidney & converts it into 1-25-hydroxyvitamin D ( calcitriol)
- osteomalacia: shows in adult
- rickets: shows in kids
Causes of vitamin D deficiency:
1. CKD —> 1-alpha-hydroxylase deficiency
2. Liver disease —> 25-hydroxyvitamin D deficiency
3. Cystic fibrosis/chron’s disease —> malabsorption (CF: no pancreatic enzyme/ADEK vitamins are not absorbed, CD: no terminal ileum)
- treat vitamin D deficiency with: vitamin D & Ca supplement
Laboratory:
1. Vitamin D deficiency:
- low vitamin D + low Ca + low/high phosphate + high PTH
(Secondary hyperparathyroidism) ( if vitamin D deficiency is caused by liver disease: low phosphate) ( if vitamin D deficiency is caused by CKD: high phosphate)
2.
