Step studying 10 Flashcards
What causes elevated AFP in pregnancy
NTD, ventral wall deficits, multiple gestations
What causes low AFP in pregnancy
Aneuploidies
What will you see in the following in Down Syndrome
- AFP
- bHCG
- Estriol
- Inhibin A
Decreased alpha-fetoprotein Increased b-hCG Decreased estriol Increased Inhibin A • THINK: low boy (alpha) and girl (estriol)
What will you see in the following in Edwards syndrome (Trisomy 18)
- AFP
- bHCG
- Estriol
- Inhibin A
Decreased alpha-fetoprotein
Decreased b-hCG
Decreased estriol
Normal Inhibin A
What part of the brain is affected in Parkinson’s
Basal ganglia (this is where dopamine works)
What type of anemia will you see in liver disease
Macrocytic (non-megaloblastic) anemia
Causes of B12 deficiency
- Strict vegan
- Pernicious anemia
- Crohn’s disease
- Gastric bypass
How can you distinguish between B12 deficiency caused by nutritional deficiency vs impaired absorption
Schilling’s Test
o Give pt IM injection of B12 to saturate liver
o Then give pt oral B12 and check urine
o Because body is saturated, all oral B12 will be absorbed and then excreted in the urine, so pt will have positive B12 in urine IF they were able to absorb it
♣ = deficiency due to poor nutrition
o If urine is negative for B12, that means there was poor absorption
♣ = deficiency due to malabsorption
How should you think about total iron binding capacity (TIBC) in determining anemia cause
Think: opposite of Ferritin
• High TIBC (Total iron-binding capacity = # of transferrin molecules in the blood – will be elevated because the liver is pumping out more in a state of low iron in order to replenish iron
Does sickle cell have micro or normocytic anemia
Normocytic
What lab value can you use to distinguish leukemoid reaction from leukemia
♣ Leukocyte alkaline phosphatase (LAP) will be elevated
♣ Will have more mature neutrophils (metamyelocytes > myelocytes)
What will you see in AML (histology, chromosomes, tx, tumor marker)
o When you think AML, think “All My Life” = musicals
o Auer sounds like Fuer (Hitler) – Sound of music - Auer rods
o I am 16 going on 17 (15;17)
o Poke Hitler in the eye with a carrot – treat with retinoic acid
Myleoperoxidase (MPO) +
Which leukemia is primarily a disease of children
ALL
What positive tumor marker is in ALL
TdT+
Tx of ALL
Chemotherapy with CNS prophylaxis (ALL tends to infect the CNS)
Treatment of CML
Imatinib (bcr-abl tyrosine kinase inhibitor)
Which chronic leukemia has risk for blast crisis (transforming into acute leukemia)
CML
Tx of CLL
Usually occurs in older people
- If old and asymptomatic = no tx
- If old and symptomatic = chemo
- If young = stem cell transplant
What lymphoma do you see Reed Sternberg cells
Hodgkin
What are alcohol lymph nodes
Nontender lymph nodes of Hodgkns lymphoma turns painful with consumptions of alcohol
What type of lymphoma is Burkitt’s
Non-hodgkins
What population does lichen sclerosis occur in
Prepubertal girls and perimenopausal/postmenopausal women
o These are all hypoestrogenic populations
Tx of multiple myeloma
- <70 y/o with donor = stem cell transplant
* >70 or without donor = chemo
Diagnosis of multiple myeloma
- +Serum protein electrophoresis (SPEP)
- +Urine protein electrophoresis
- Skeletal bone survery shows lytic lesions
- Bone marrow biopsy >10% plasma cells
Diagnosis of monoclonal gammopathy of undetermined significance
- +Serum protein electrophoresis
- (-)Urine protein electrophoresis
- (-) Skeletal survery
- Bone marrow biopsy <10% plasma cells
Diagnosis of Waldenstrom
- +Serum protein electrophoresis
- (-) Urine protein electrophoresis
- (-) skeletal bone
- Bone marrow biopsy >10% lymphoma
Tx of Waldenstrom
- Rituximab (treat it like a lymphoma)
* Plasmapharesis for hyperviscosity
Cause of TTP
o Due to decreased ADAMTS13, enzyme that normally cleaves vWF for degradation ♣ No vWF degradation = abnormal platelet adhesion = microthrombi
Clinical presentation of TTP
o Findings (Pentad) – THINK: FAT RN ♣ F = Fever ♣ A = anemia (Microangiopathic hemolytic anemia = RBCs sheared by microthrombi) ♣ T = thrombocytopenia (platelets being used up) ♣ R = renal insufficiency (thrombi involve vessels of kidney) ♣ N = neurological symptoms – confusion, HA, seizures, coma (thrombi involve vessels of CNS)
Tx of TTP
Plasma exchange transfusion
Describe following lab findings in TTP:
- Platelets
- PT/PTT
- Fibrinogen
- D-dimer
- Low platelets
- PT/PTT = normal
- Fibrinogen = normal
- D-dimer = normal
Describe following lab findings in DIC
- Platelets
- PT/PTT
- Fibrinogen
- D-dimer
♣ Increased bleeding time – low platelets
♣ Increased PT and PTT
♣ Low fibrinogen – being used up
♣ High D-dimer (fibrin split products)
Describe cause of immune thrombocytopenic purpura (ITP)
o IgG autoantibodies to GP2b3a (which allow platelets to connect to each other)
o Antibodies produced by plasma cells of spleen and antibody-bound platelets consumed by macrophages of spleen
o Often associated with HIV
Tx of ITP
♣ Steroids and IVIG (autoimmune treatment)
♣ Splenectomy
Tx of leprosy
Dapsone + Rifampin
Add Clofazimine if severe
What is laryngomalacia
♣ Caused by “floppy” supraglottic structures that collapse during inspiration
♣ Inspiratory stridor worsens when supine
♣ Peaks at age 4-8 months
Diagnosis of laryngomalacia
♣ Usually clinical
♣ Confirmation by flexible laryngoscopy for moderate/severe cases
Tx of laryngomalacia
♣ Reassurance for most cases
♣ Supraglottoplasty for severe symptoms
Empiric tx for community acquired pneumonia
- Moxifloxacin
- CTX + Azithro
- Azithro
Empiric tx for hospital acquired pneumonia
Want to include coverage of MRSA and Pseudomonas
- Vanc + Pip/Tazo
Empiric tx for meningitis
CTX
+ Vancomycin
+/- steroids
+/- Ampicillin (if immunocompromised)
Tx for UTI in pregnancy
Amoxicillin
Empiric tx for UTI
- Nitrofurantoin (if woman)
- TMP-SMX aka Bactrim (do not use with renal failure)
Empiric tx for pyelo
inpatient vs outpatient
Inpatient = CTX Outpatient = Cipro
Empiric tx of cellulitis
♣ Vancomycin
♣ Clindamycin
♣ Bactrim
What test is used to diagnose anti-retroviral syndrome
This is the acute flu-like illness that occurs with initial onset of disease
Too early to have antibodies so ELISA will be negative
Need to get PCR (viral load) for diagnosis
Diagnosis of chronic HIV
ELISA first, and if positive must confirm with Western Blot
Then check viral load and CD4 count to see where you start and to follow how medications work
What’s the bug you are worried about at CD4 <200
PCP
Toxo is <100
MAC is <50
What do you do if pt had a positive PPD skin test
Get a CXR
What do you do if pt has +PPD and -CXR
This is latent TB - treat with Isoniazid + B6
What do you do if pt has +PPD and +CXR
Get an AFB smear (3 separate) to determine if they are infectious
What do you do if pt has +PPD, +CXR, and -AFB
This is latent TB - treat with Isonizid + B6
What do you do if pt has +PPD, +CXR, and +AFB
This is active TB - RIPE therapy
What are the contraindications to LP
FAILS
- FND
- AMS
- Immunosuppression
- Lesion over site where LP would happen
- Seizures
Tx of asymptomatic Bartholin duct cyst
Observation
Can I&D if it is symptomatic or infected (abscess)
Describe imaging in meconium ileus
• Contrast enema will show a narrow, undeveloped colon
Describe imaging in Hirschprung
o Level of obstruction usually at the rectosigmoid junction, with proximal dilated colon
Describe the MOA behind cyanide poisoning
Cyanide poisoning occurs because cyanide binds to Fe3+, inhibiting its reduction to Fe2+ and blocking production of ATP from oxidative phosphorylation
Describe MOA of methemoglobinemia
Caused by nitrates/nitrites, antimalarial drugs, dapsone, sulfonamides
It causes an oxidation of hemoglobin to methemoglobin (Fe2+ to Fe3+) - oxidized form has reduced affinity for O2 and thus reduced O2 delivery to tissues
Tx of cyanide toxicity
o You can induce methemoglobinemia with nitrites (will oxidize Fe2+ to Fe3+) in order to treat cyanide poisoning
Cyanide will get bound up by Fe3+
Tx of methemoglobinemia
- Methylene blue
* Vitamin C
Tx of elevated homocysteine
Folate + B6
- Can also add B12 if it is deficient
Next step in management of solitary pulmonary nodule
- Check old imaging (if stable for 2-3 years, can just observe)
- CT scan to look for malignant features
- Biopsy or surgical excision if malignant features
What is the pathophys of Fanconi Anemia
♣ Inherited DNA repair defect
♣ Bone marrow failure
Clinical findings of Fanconi anemia
♣ Short stature ♣ Hypo/hyperpigmented macules ♣ Abnormal thumbs ♣ Genitourinary malformations \+ Pancytopenia
Tx of Fanconi anemia
Stem cell transplant
Tx of hospital acquired pneumonia
♣ Vanc + Pip/Tazo
Want to cover for MRSA and pseudomonas
How do you diagnose syphilis
Primary disease (chancre) o Darkfield microscopy
Secondary disease (fever and rash) o RPR antibody
Tertiary (tabes dorsalis and Argyll Robertson pupil)
o Get an LP and check RPR of the CSF
Tx of native valve endocarditis
Vancomycin
Causes of Cushing syndrome (x4)
♣ Exogenous corticosteroids (most common cause)
♣ ACTH-secreting pituitary adenoma (Cushing disease)
♣ Paraneoplastic ACTH secretion (e.g. small cell lung cancer)
♣ Primary adrenal adenoma
First step in suspected Cushings
♣ First give low-dose dexamethasone (synthetic glucocorticoid) + 24 hour urine cortisol or late night salivary cortisol
• If there is a failure to suppress cortisol, this is cushing syndrome
Next step if low dose dex test is positive
♣ Measure ACTH:
What does +low dose dex test + low ACTH mean
Adrenal tumor or exogenous glucocorticoids
What dose +low dose dex test + high ACTH mean
Also what is next step
• If high, suspect Cushing disease (ACTH-pituitary adenoma) or ectopic ACTH secreting tumor
o Give high dose Dexamethasone:
What dose +low dose dex + high ACTH + lack of suppression with high dose dex mean
Ectopic tumor (e.g. small cell lung)
What does +low dose dex + high ACTH + suppression with high dose dex man
Cushing disease (pituitary adenoma)
