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medicine Clerkship > Step Up Quick Hits > Flashcards

Step Up Quick Hits Flashcards

1
Q

What is standard of care for stable angina?

A

ASA + B Blocker for mortality

Nitrates for CP

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2
Q

What type of infarct will present w/ clear lungs?

A

RV infarct

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3
Q

What EKG changes in anterior, posterior, lateral, and inferior MI?

A

anterior: ST elevate in V1 - V4, Q in V1-V4
posterior: R in V1, V2, ST depression in V1 V2
lateral: Q in I, aVL
inferior: Q in II, III, aVF

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4
Q

What agents decrease mortality in MI?

A

ASA, B lockers, ACEi

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5
Q

What tx are indicated in MI?

A 
O2
nitroglycerin
B Blocker
ASA
morphine
ACEi
IV heparin
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6
Q

What is MCC death in first few days after MI?

A

ventricular arrhythmia (VT or VFib)

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7
Q

What is tx for VT after MI?

A

if unstable – cardioversion

if stable –> IV amiodarone

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8
Q

What should you think if pt w/ MR after MI?

A

papillary muscle rupture

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9
Q

What are indications for using dig?

A

EF

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10
Q

What are side effects of dig tox?

A

N/v/anorexia
ectopic ventricular beats, AV block, AFib
visual disturbances, disorientation

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11
Q

What are indications for cardioversion vs defibrillaton?

A 
cardioverson = AFib, A flutter, VT w/ pulse, SVT
defibrillation = VFib, VT w/ a pulse
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12
Q

WHat are steps before cardioversion in AFib?

A
  • if can cardiovert
    if > 48 hrs or unknown:
  • do TEE if no thrombus can cardiovert, if yes thrombus anticoagulate for 3 wks then cardiovert
  • or just skip TEE and anticoagulate 3 wks then cardioert
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13
Q

What is dz for paroxysmal SVT?

A

valsalva, carotid massage

if doesnt work –> IV adenosine

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14
Q

What are side effects of adenosine?

A

AH, flushing, SOB, chest pressure, nausea

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15
Q

What drug treatments for WPW?

A

procainamide or quinidine

avoid digoxin, verapamil b/c may increase accessory path conduction

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16
Q

What is tx if pt w/ non-sustained VT and underlying heart dz?

A

implantable defibrillator

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17
Q

What should you do if pt in asystole?

A

defibrillation does not work –> do transcutaneous pacing instead

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18
Q

What is pulseless electrical activity? next step?

A

electrical activity on monitor w/o pulse

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19
Q

What are indications for cardiac pacemaker?

A
  • sinus node dysfunction = sick sinus syndrome
  • symptomatic heart block: mobitz 2 second degree or complete
  • symptomatic brady arrhythmias
  • tachyarrhythmias to interrupt rapid rhythm disturbances
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20
Q

Which murmurs increase/decrease w/ squatting?

A

squatting increases all except MVP and HOCM

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21
Q

What are cardinal manifestations of acute pericarditis?

A

CP, pericardial friction ru, EKG changes, pericardial effusion (+/- tamponade)

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22
Q

What happens in early and late diastole in constrictive pericarditis?

A 
early = rapid filling
late = halted filling

(vs in cardiac tamponade have filling impeded throughout diastole)

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23
Q

What cardiac process should you r/o if pt w/ sx of cirrhosis (ascites, hepatomegaly) and distended neck veins?

A

r/o constrictive pericarditis

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24
Q

What dx test for pericardial effusion and cardiac tamponade?

A

echo

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25
Q

What is beck’s triad for cardiac tamponade?

A

hypotension, muffled heart sounds, JVD

venous waveforms = prominent x descent and absent y descent

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26
Q

What is tx for AS?

A 
asx = none
sx = surgery (aortic valve replacement
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27
Q

What are some specific physical findigns in aortic regurg?

A
  • de mussets = head bobbing
    mullers = uvula bob
    duroziez = pistol shot sound heard over femoral arteries
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28
Q

What is tx for acute AR post MI?

A

medical emergency –> perform emergent aortic valve replacement

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29
Q

What are key features of MVP murmur?

A

mid systolic click

systolic rumbling murmur increases w/ standing and valsalva and decreases w/ squatting

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30
Q

What are duke’s criteria for endocaditis?

A

need 2 majoror 2 major and 3 minor or 5 minor

major:
- sustained bacteremia
- endocardial involvemeed (new regurg)

minor:

  • predisposing
  • fever
  • vascular phenom: janeway, emboli
    immune: glomerulonephritis, osler, roth
  • postiive b cx
  • positive echo
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31
Q

What is murmur of VSD?

A

harsh blowing holosystolic murmur w/ thrill at 4th left intercostal space
decreases w/ vlasalva and handgrip

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32
Q

What is tx in hypertensive emergency?

A

IV –> hydralazine

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33
Q

What are preferred tests for dx acute aortic dissection?

A

TEE and CT

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34
Q

What type of aortic dissection involves ascending vs just descending?

A

ascending = A

just descending = B

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35
Q

What is lerische’s syndrome?

A

atheromatous occlusion of distal aorta just above bifurcation causes B/L claudication, impotence, absent/diminished femoral pulses

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36
Q

Which vessels lead to calf claudication? vs buttock/hip claudication?

A 
calf = femoral or popliteal
buttock/hip = aorto-iliac occlusive disease
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37
Q

What are sx of acute arterial occlusion?

A

pallor, pain, pulselessness, paresthesias, paralysis, polar (cold)

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38
Q

What is cholesterol embolization syndroem?

A

showers of cholesterol crystals from proximal source

  • small discrete areas of tissue ischemia: blue toes, renal insufficiency, ab pain or bleeding
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39
Q

What is mycotic aneurysm?

A

aneurysm from damage to aortic wall 2/2 infection

tx = IV abx and surgical excision

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40
Q

What is luetic heart?

A

complication of syphilitc aortitis, aneurysm of aortic arch —> arotic regurg

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41
Q

What are characteristics of centrilobular emphysema?

A

MC type, smokers

  • respiratory bronchioles destroyed
  • upper lungs
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42
Q

What are characteristics of panolbular emphysema?

A
  • a1 antitrypsin deficinecy
  • proximal and distal acini
  • lung bases
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43
Q

What happens to lung volumes in COPD?

A
  • FEV1/FVC ratio
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44
Q

What are characteristics of pts w/ predominant emphysema?

A
  • thin 2/2 increased energy expenditure w/ breathing
  • lean fwd
  • barrel chest
  • tachypnea w/ prolonged exp. through pursed lips
  • pt distressed and uses accessory muscles (esp strap muscles in neck)
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45
Q

What acid/base disturbanced in COPD?

A

chronic resp acidosis w/ met alklaosis as compensation

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46
Q

What is most important intervention for improving outcome in COPD?

A

smoking cessation

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47
Q

What are criteria for using O2 therapy in COPD?

A

PaO2

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48
Q

What is initial tx for mild-mod disease?

A

bronchidilator in metered dose inhaler –> anticholinergic or B agonist or combo

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49
Q

What are next steps if pt w/ COPD exacerbation?

A 
- B agonist and anticholingeric
systemic steroid
abx (azithromycin or levo)
O2 to keep about 90
NPPV (BIPAP or CPAP) if neded
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50
Q

What are signs of impending resp failure in pt w/ asthma attack?

A
  • paradoxic movement of ab and diaphragm on inspiration
  • normalizing/increasing CO2
  • decreases breath sounds/movement
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51
Q

What happens to PFTs in asthma?

A
  • decreased FEV1, FVC, ratio
  • increase in FEV1 > 12% w/ albuterol
  • decrease in FEV1 > 20% w/ methacholine challenge
  • increase in diffusion cpacaity CO
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52
Q

Which types of lung CA require surgery vs chemo vs radiation?

A

surgery for non small cell lung CA + adjunct radiation
for small cell
- chemo + radiation for limited dz
- chemo alone for extensive dz

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53
Q

What kind of mediastinal masses in

  • anterior
  • middle
  • posterior
A

anterior: thyroid, teratogenic, thymoma, lymphoma
middle: lung CA, lymphoma, aneurysm, cyst
posterior: neurogenic tumor, esophageal mass, enteric cyst, aneurysm

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54
Q

What physical exam findings in pleural effusion?

A

dull to percussion
decreased breath sounds
decreased tactile fremitus

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55
Q

What 3 dx likely if pt w/ pleural effusion w/ high amylase?

A

esophageal rupture
pancreatitis
malignancy

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56
Q

What dx likely if blood pleural effusion?

A

malignancy

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57
Q

What dx likely if pleural effusion pH

A

parapneumonic effusion

empyema

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58
Q

What should oyu r/o if pleural fluid w/ glucose

A

r/o RA

also could be: TB, esophagela rupture, malignancy, lupus

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59
Q

What physical exam findings in pt w/ pneumothorax?

A

decreased breath sounds
hyperresonance
decreased/absent tactile fremitus
mediastinal shift toward side of pneumothorax

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60
Q

What is first tx for spontaneous pneumothorax?

A

give supplemental O2 = helps quicken resporption of air in pleural space

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61
Q

What meds associated w/ ILD?

A 
bleomycin
gold
amiodarone
penicillamine
nitrofurantoin
phenytoin
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62
Q

What is MCC death in pt w/ sarcoid?

A

cardiac disease

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63
Q

What type of ILD w/ p-ANCA? c-ANCA?

A

p-ANCA: churg strauss (asthma + pulm infiltrates, eos), goodpasture (hemorrhagic pneumoinitis + glomerulonephritis)

c-ANCA: wegeners (necrotizing granuloma vasculitis of lung kidney upper-airway)

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64
Q

What ILD w/ pleural plaques?

A

asebestosis

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65
Q

What ILD w/ eggshell calcifications

A

silicosis

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66
Q

What are features of asbestosis?

A

lower lobe fibrosis

CXR w/ hazy infilarates and b/l linear opacities

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67
Q

What are features of siloicosis?

A

localized and nodular peribronchial fibrosis, more common upper lobes
2/2 mining, stone cutting, glass manufacturing
increased risk for TB

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68
Q

What are features of berylliosis?

A

hypercalcemia, granulomas, skin lesions

tx - steroids

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69
Q

What is tx for goodpasture?

A

IgG antibodies against glomerular and alveolar bBM
renal failure
hemoptysis + dyspnea

tx = plasmapheresis, cyclophosphamide, steroids

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70
Q

What is pulm alveolar proteinosis?

A

bat shape B/L alveolar infiltrates w/ ground glass on CXR

accumulation surfactant like protein and phospholipids in alveoli

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71
Q

What is hypoxemic resp failure? etiologies?

A

low PaO2 w/ PaCO2 low or normal

2/2 lung process –> ARDS severe pna, pulm edema

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72
Q

What is hypercarbic resp failure?

A

failure of ventilation –> decrease minute ventilation or increase in dead space
2/2 underlying lung dz (COPD, asthma, CF, severe bronchitis) OR 2/2 impaired ventilation due to neuromuscular dz, CNS depression, mechanic restriction of lung inflation, resp fatigue

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73
Q

What is tx for primary pulm htn?

A

IV prostacyclins, CCBs

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74
Q

What are 7 wells criteria for PE?

A
  • sx of DVT: 3
  • alternative diagnosis less likely: 3
  • HR > 100: 1.5
  • immobilization > 3 days or surgery in previous 4 wks: 1.5
  • previous DVT/PE: 1.5
  • hemoptysis: 1.0
  • malignancy: 1.0

if total score > 4 –> high likelihood of PE skip D-dimer

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75
Q

What should happen to PH w/ every increased/decrease in PaCO2?

A

by 0.08

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76
Q

What are 3 sx specific to graves disease?

A
  • exophthalmos
    pretibial myxedema
    thyroid bruit
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77
Q

What is effect of TBG on thyroid?

A

TBG increases w/ pregnancy, liver dz, OCP, asa

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78
Q

What does radioactive T3 uptake tell you?

A

radioactive T3 can bind to TBG or to resin

if increased radioactive T3 uptake to resin –> tells you true hyperthyroidism as T4 bound to TBG

if not –> just high TBG

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79
Q

What is likely cause of transient painful enlarged thyroid?

A

subacute granulomatous viral thyroiditis

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80
Q

What type of thyroid cancer cannot be dx w/ FNA?

A

follicular

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81
Q

What is hurthle’s cell tumor?

A

variant of follicular thyroid ca
spread by lymphatics, does not take up iodine
tx = total thyroidectomy

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82
Q

What is biggest risk factor for papillary thyroid CA?

A

radiation head/neck

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83
Q

What type of thyroid CA produces calcitonin?

A

medullary CA from para-follicular C cells

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84
Q

What is MCC death in acromegaly?

A

cardiovascular disease

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85
Q

What lab abnormalities in pt w/ acromegaly?

A
  • hyperprolactinemia
  • high glucose, TG, phosphate
  • high IGF1 (somatomedin C)
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86
Q

How do you dx acromegaly?

A
  • high IGF1

- oral glucose suppression test – > glucose fails to suppress GH (as it should in healthy individual)

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87
Q

What does calcification of suprasellar region suggest?

A

craniopharyngioma

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88
Q

What is tx for central DI?

A

desmopressin

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89
Q

What is tx for nephrogenic DI?

A

Na restriction and thiazide diuretics

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90
Q

What are major characteristics of SIADH?

A
  • hyponatremia
  • volume expansion w/o edema
  • natriuresis
  • hypouricemia
  • low BUN
  • normal or reduced cr
  • normal thyroid and adrenal
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91
Q

What is tx w/ SIADH?

A

for asx: water restriction, NS w/ loop diuretic or lithium

for sx: restrict water intake, give isotonic saline

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92
Q

What are lab findings in pseudohypoparathyroidism?

A

hypoa
hyperPhos
high PTH
low urinary cAMP

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93
Q

what EKG changes in hypoparathyroid?

A

long QT from hypocalcemia

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94
Q

What are relative indications for surgery in primary hyperparathyroid?

A

age 400mg in 24 hr

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95
Q

What is tx for 2ndary hyperparathyroid 2/2 renal failure?

A

calcitriol and oral Ca + dietary phos restriction

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96
Q

What is initial screening test for cushing?

A

low dose dexamethasone suppression test
- give dexamethasone
- if serum cortisol not scushing
if > 5 –> cushing dz

OR 24 hr urinary free cortisol

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97
Q

What does a high dose dexamethasone suppression test tell you?

A

if positive –> cushings disease
if negative:
- + low ACTH: adrenal tumor
- + high ACTH: ectopic ACTH produceing turmo

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98
Q

What does CRH stim test tell you?

A

if ACTH/cortisol increases = a response = cushing disease

if ACTH/cortisol do not increase = no response = ectopic ACTH or adrenal tumor

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99
Q

What are rules of 10 for pheos?

A
  • 10% familial
  • 10% bilateraol
  • 10% malignant
  • 10% multiple
  • 10% in kids
  • 10% extra-adrenal
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100
Q

What is most common site of non-adrenal pheo?

A

organ of zuckerkandl = aortic bifurcation

will have high epi (vs adrenal cant methylate the norepi)

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101
Q

What should you give pt w/ pheo before/after surgery?

A

alpha block (phenoxybenzamine) for 10-14 d before surgery and B block (propanolol) for 2-3 days

alpha = for BP
B = for tachycardia
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102
Q

What are the findings in MEN1?

A

3 Ps

  • parathryoid hyperplasia
  • pancreatic islet
  • pitutiary tumor
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103
Q

What are the findings in MEN2A?

A
  • medullary thyroid ca
  • pheo
  • hyperparathryoidism
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104
Q

What are the findings in MEN2B?

A
  • mucosal neuropa
  • nedullary thyroid
  • marfinoid body
  • pheo
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105
Q

What is next step for adrenal incidentaloma?

A

r/o functioning tumor

then resect any tumor > 6cm

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106
Q

how do you dx primary hyperaldosteronism?

A

aldo:renin ratio > 30

saline infusion –> if primary aldo, aldo levels will not decrease after saline

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107
Q

What isMCC addisons worldwide? in US?

A

in world = TB

in US = autoimmune

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108
Q

What are clinical findings in adrenal insufficiency?

A 
wt loss
weakness
pigmentation
anorexia
nausea
postural hypotension
ab pain
hypoglycemia
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109
Q

if adrenal insufficinecy w/ hyperK and hyperpigmentation what should you think?

A

primary (not secondary) etiology

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110
Q

How do you dx diabetes?

A
  • two fasting gluc > 126 or >200 2hr postprandial
  • single gluc > 200 w/ sx
  • increased glucose on oral glucose tolerance test
  • hemoglobin a1c > 6.5%
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111
Q

What is mech of sulfonylureas (glyburide, glipizide, glimepiride)? side effects?

A

stimulate pancreas to produce more insulin

can cause hypoglycemia, wt gain

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112
Q

What is mech of metformin? side effects?

A

enhances insuline sensitivity

CI w/ cr > 1.5 b/c of lactic acidosis
GI upset (D/N, ab pain)
metallic taste
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113
Q

What is mech of acarbose? side effects?

A

reduces glucose absorption from gut, reduces calorie intake

SE = GI upset

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114
Q

What is mech of thiazolidinediones (rosiglitazone, pioglitazone)? side effects?

A

reduces insulin resistance

hepatotoxic = need to monitor LFTs

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115
Q

What is difference between different types of insulin?

A 
lispro = onset in 15 min, last 4 hr
regular = onset 30-60 min, last 4-6 hr
NPH = onset 2-4 hr, last 10-18 hr

glargine (lantus) = 3-4 hr onset, lasts 24 hr

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116
Q

What is definition of microalbuminuria?

A

30-300 mg/day

albumin-cr ratio 0.02 to 0.20

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117
Q

What is diabetic retinopathy?

A

hemorrhage, exudate, microaneurysms

can be proliferative –> new vessel formation, scarring, vitreal hemorrhage

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118
Q

What is presentation of DM CN3 palsy?

A

eye pain, diplopia, ptosis, inability to adduct eye

pupils are spared

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119
Q

What are two complications of treatment of DKA?

A

cerebral edema: if glucose levels rise too fast

hyperchloremic nongap met acidosis: 2/2 rapid infusion of large amt of saline

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120
Q

What is the body’s first line defense against severe hypoglycemia?

A

glucagon

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121
Q

What lab abnormalities in VIPoma?

A

watery diarrhea –> dehydration, acidosis, hypoK
achlorhydria
hyperglycemia
hypercalcemia

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122
Q

When should colon cancer screening begin in pt w/ family hx?

A

begin at 40 or 10 yrs before age of onset of family member

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123
Q

What are risk factors for CRC?

A 
age > 50
adenomatous polyps
personal hx of CRC
IBD (UC?Crohns)
first degee relative dz
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124
Q

What is gardner syndrome?

A

FAP + osteomas, dnetal abnormalities, benign soft tissue tumors, desmoid tumors, sebaceous cysts

125
Q

What is turcot syndrome?

A

ar polyps + cerebellar medulloblastoma or GM

126
Q

What side of GI tract presents w/ melena vs hematochezia?

A 
melena = R side
hematochezia = L side
127
Q

How do R side vs L side colon cancer tumors usually present?

A

R = rare to obstruct, usually anemia, weak, RLQ weka, occult blood in stool

L side: obstruction, change in bowel habit, pencil stools

128
Q

What is tx for colon cancer?

A

surgery

radiation not indicated

129
Q

What is MC location of diverticulosis?

A

sigmoid colon

130
Q

What are complications of diverticulosis?

A

painless rectal bleeding

diverticulitis

131
Q

What are complications of diverticulitis?

A

absecess formation
fistulas
bowel obstruction
free colonic perforation

132
Q

What is dx test of choice for diverticulosis? tx?

A

barium enema

tx = high fiber, psyllium

133
Q

What is dx test of choice for diverticulitis?

A

CT scan w/ oral and IV contrast

contraindicated colonoscopy and barium enema 2/2 risk sof performation

134
Q

What other disease process associated w/ bleeding AVM malformations in GI tract?

A

aortic stenosis

135
Q

What is presentation of acute mesenteric ischemia? types?

A

compromised blood supply

  • arteriol embolism: 2/2 a fib –> sudden painful
  • arterial thrombosis: in pt w/ CAD/PVD, acute occlusion may be 22 plaque rupture or acute MI, more gradual sx
  • nonocclusive: splanchnic vasoconstriction 2/2 low cardiac output in ill elderly
  • venous thrombosis: in hypercoagulable states, portal HTN, malignancy
136
Q

What are sx of acute mesenteric ischemia?

A

severe ab pain disproportionate to physical findings
pain 2/2 ischemia = like mI in CAD
anorexia, vomiting, tachypnea, hypotension, lactic acidosis, fever, mild GI bleed, AMS –> shock

137
Q

What is dx test for acute mesenteric ischemia?

A

mesenteric angiography

get ab xr to exclude other causes

138
Q

What is tx for acute mesenteric ischemia?

A

IVF, broad spectrum abx
arterial causes –> direct infusion papaverine = vasodilator
avoid vasopressors

139
Q

What is presentation of chronic mesenteric ischemia?

A

abdominal angina = postprandial pain, wt loss

dx by mesenteric arteriography
tx = surgical revascularization

140
Q

What is ogilvie’s syndrome?

A

sx of large bowel obstruction but no mechanical obstruction

decompress w gentle enemas of NG suction

141
Q

What is next step if colonic distention w/ dm > 10cm?

A

decompress immediately –> bowel is at risk of impending rupture –> causing peritonitis and death

142
Q

What is ppx tx for varices?

143
Q

What is tx for variceal hemorhage?

A

IV abx
IV octreotide
emergent endoscopy once stabilize

144
Q

What are features of ascites that suggest portal HTN is the cause?

A

serum ascites albumin gradient > 1.1

= serum albumin - ascites albumin

145
Q

What is hepatorenal?

A

azotemia, oliguira, hypoN, hypotension, low urine Na

146
Q

What is tx for hepatorenal syndrome?

A

liver transplant

147
Q

What is hepatocellular adenoma?

A

benign liver tumor in young women

risks = OCP use, F, anabolic steroid use

148
Q

What is MC benign liver tumor?

A

cavernous hemangioma

149
Q

What type of bili high in filbert?

A

unconjugated

150
Q

What is presentation of hydatid liver cysts?

A

2/2 echiinococcus granulosis
usually in R lobe

tx = surgical, give mebendaozle after surgery

151
Q

What is presentation of amebic liver abscess?

A

M>F, fecal oral
entamoeba histolytica
fever, RUQ pain, N/V, hepatomegaly, diarrhea

tx = IV metronidazole

152
Q

What kind of bilirubin can cause dark urine?

A

cnojugated bilirubin only

153
Q

What are sx of cholestasis?

A 
- jaundice, gray stool, dark urine
pruritis
high Alk Phos
high cholesterol
skin xanthomas
malabsorption fats and fat soluble vitamines
154
Q

Who gets pigmented gallbladder stones?

A

hemolsis (sickle, thalassemia, spherocytosis) or alc cirrhosis

155
Q

What is dx test of choice for gallbladder stones?

156
Q

How can you differentiate cholecystitis vs biliary cholic pain?

A

cholecystitis pain = 2/2 gallbladder wall inflammation, persists for daysbiliary colic pain = 2/2 contraction of gallbladder against obstructed cystic duct, lasts onyl a few hrs

157
Q

What is presentation of cholescytitis?

A

RUQ pain, fever, leukocytosis 2/2 gallblader inflammation

158
Q

What is acalculous cholecytitis?

A

cholecystitis w/o stones obstrcuting cystic duct
usually idiopathic
tx = emergent cholecystectomy

159
Q

How do sx differ in cholelithiasis vs choledocholithiasis?

A 
cholelithiasis = stone in gallbladder, biliary cholic
choledocholithiasis = stone in common bile duct --> have jaundice
160
Q

How do you dx choledocolithiasis?

A

US = initial study, ERCP is gold standard

161
Q

What is charcot’s triad of cholangitis?

A

RUQ pain, jaundice, fever

pentad = triad + septic shock and AMS

162
Q

WHat is most serious complication of cholangitis?

A

hepatic abscess

163
Q

What is porcelain gallbladder?

A

intramural calcification of gallbladder wall –> 50% will go on to develop carcinoma, recommend cholecystectomy

164
Q

What are complications of primary sclerosing cholangitis?

A

cholangiocarcinoma
recurrent cholangitis
progression to 2ndary biliary cirrhosis, portal HTN
liver failure

165
Q

What is PSC?

A

jaundice + pruritis

ERCP to dx –> beeds on a string, stricturing and dialtiongs of intrahepatic and extrahepatic ducts

166
Q

What is PBC?

A

cholestatic liver dz w/ destruction of intrahepatic bile ducts w/ inflammation and scarring
autoimmune
positive antimitochondrial antibodies, high chol, HDL, high IgM

167
Q

What is tx for primary biliary cirrhosis?

A

cholestyramine for pruritis, Ca/vitd for osteoporosis

ursodeoxycholic acid to slow progression of dz

168
Q

What is tx for primary sclerosing cholangitits?

A

stent placement for symptoms 2/2 stricture

169
Q

What are klatskins tumors?

A

cholangiocarcinoma tumors in proximal 1/3 of common bile duct, involve jucntion of R and L hepatic ducts
poor prognosis b/c unresectable

170
Q

What are risk factors for cholangiocarcinoma?

A

PSC = major risk factor

171
Q

What is biliary dyskinesia?

A

motor dysrunction of sphincter of Oddi –> recurrent biliary colic w/o evidence of gallstones
dx by HIDA scan –> give CCK and see low EF of gallbladder

172
Q

What is presentation of carcinoid syndrome?

A

cutaneous flushing, diarrhea, sweating , wheezing, ab pain, heart valve dysfcuntion

173
Q

What should you think if pt w/ chronic epigastric pain and calcifications on plain xr?

A

chronic pancreatitis

174
Q

What is classic traid of chronic pancreatitis/

A

steatorrhea, DM, pancreatic calcification

175
Q

What type of esophageal Ca associated w/ barretts?

A

adenocarcinoma

176
Q

What are risk factors for squamous esophageal cancer?

A

smoking
alcohol
nitrosamines
achalasia

177
Q

What are risk factors for adenocarcinoma of esophagus?

A

distal 1/3
GERD
barretts

178
Q

What is presntation of diffuse esophageal spasm?

A

hard to differentiate from cardiac cause of CP –> do a cardiac workup

mims angina, radittes to jaw, arms, back, dysphagia

dx: manometry
tx = nitrates, CCPs

179
Q

WHat is pathogenesis of mallory weiss syndrome?

A

forceful vomiting –> increasd intra-ab pressure transmitted to esophagus

tear in mucosa at GE junction

180
Q

What is boerhaaves? presentation?

A

esophageal tear transluminal –> perforation

can be 2/2 forceful vomiting

present: pain (retrosternal/chest/shoulder), tachycardia, hypotension, tachypnea, dyspnea, fever, hammans sign = mediastinal crunch, pleural effusion

181
Q

What are features of plummer vinson syndrome?

A

upper esophageal web (dysphagia), iron eficiency anemia, koilonychia, atrophic oral mucosa

182
Q

What is difference in presentation between duodenal and gastric ulcers?

A

duodenal = increase in asid secretion, eating relieves pain, nocturnal pan more common, risks = NSAIDs, low malignancy potential, up to 90% H pyloir

gastric = decrease defensive factors, higher malignancy potential, older pts, smoking is risk factor, eating does not relieve pain

183
Q

Is smoking or alcohol more associated w/ PUD?

184
Q

What are locations of gastric Ca met?

A 
krukenberg = ovary
blumer = rectum
sister mary joseph = periumbilical lymph node
 virchow = supraclavicular 
Irish = L axillary
185
Q

What are sx of proximal vs distal bowel obstruction?

A 
proximal = frequent vomiting, severe pain, minimal ab distention
distal = less freq vomiting, significant ab distention
186
Q

What are lab findings in small bowel obstruction?

A

dehydration

low Cl, K, met alkalosis

187
Q

What are extraintestinal manifestations of IBD?

A

eye: anterior uveitis, episcleritis
skin: erythema nodosum (crohn), pyoderma gangrenosum (UC)
arthritis: migratory monoarticular, ankylosing spondylitis (UC)
thromboembolic hyper coagulable
ITP
osteoporosis
gallstones in crohns
PSC in UC

188
Q

What is tx for crohns?

A

sulfasalazine if colon involved

systemic steroids for actue exacerbation

189
Q

what are pathology findings in crohns vs UC?

A

crohns: transmural inflammation, non-caseating granulomas, mesenteric creeping fat

UC: crypt abscesses, mucosa/submucosa inflammation

190
Q

What level of urine Na suggests prerenal vs intrinsic renal cause of AKI?

A

urine Na 40 = intrinsic renal

191
Q

What are lab findings in rhabdo?

A

high CPK, K, uric acid

low Ca

192
Q

What is tx for rhabdo?

A

IVF, mannitol, HCo3

193
Q

What are 2 MC deadly complications of AKI?

A

hyperkalemic cardiac arrest

pulmonary edema

194
Q

What lab abnormalities in AKI?

A 
met acidosis
high K
low Ca
high Phos
high uric acid
195
Q

What is mech of contrast causing ATN?

A

spasm of afferent arteriole

196
Q

What should you worry about if pt w/ painless gross hematuria?

A

bladder CA or renal cell CA

197
Q

What is next dx step if suspect bladder ca?

198
Q

What is rapid progressive glomerulonephritis?

A

clinical syndrome w/ any type of glomerulonephritis and rapid deterioration of renal function ove wks - mos

199
Q

What underlying conditions associated w/ membranous glomerulonephritis?

A

infection (hep B, C, syphilis, malaria), drugs (captopril, penicillamine), neoplasm, lupus

200
Q

What is usual underlying dz w/ membrano-proliferative glomerulonephritis?

A

usually w/ hep C, can also be hep B, syphilis, lupus

associated w/ cryoglobulinemia

201
Q

What is goodpasture? tx?

A

rapid progressive renal failure, hemoptysis, cough, dyspnea, igG anti glomerular abs

tx = plasmapharesis

202
Q

What is analgesic nephropathy?

A

toxic injury to counter 2/2 over counter analgesic use (phenacetin, acetaminophen, nsaids, asa)
manifest as interstitial nephritis or renal papillary necrosis

203
Q

What is mech of type 1 RTA? lab values?

A

distal = can’t secrete H+
hypokalemia
renal stones / nephrocalcinosis 2/2 increased Ca and phos excretion

204
Q

What is mech type 2 RTA? lab values?

A

proximal = can’t reabsorb HCO3
hypokalemia
can be 2/2 multiple myeloma

205
Q

What type of RTA w/ hyperkalemia?

206
Q

What kind of RTA responds to HCO3?

A

type 1 = distal

207
Q

What is hartnup syndrome?

A

AR, defect AA transporter, decreased reabsorption tryptophan –> nicotinamide deficiency
sx: dermatitis, diarrhea, ataxia, psych

208
Q

What is fanconi syndrome?

A

prox tubul defect trasnport –> glucosuria, phophaturia, proteinuria, RTA type 2, hypercalciuria, hypkalemia

209
Q

How do you dx RAS?

A

renal arteriogram

210
Q

What are some causes of hypercalciuria leading to kideny stones?

A
  • increased intestinal absorption
  • decreaed renal reasborption
  • increased bone reabsorption of Ca
  • primary hyperparathyroid
  • sarcoid
  • malignancy
  • vit D excess
211
Q

What are some causes of hyperoxaluria leading to calcium stones?

A
  • severe steatorrhea
  • small bowel disease
  • crohns
    B6 deficiency
212
Q

Are Ca stones radio-opaque or radiolucent?

A

radio-opaque = visible on xr

213
Q

What are etiologies of uric acid stones? appearance?

A

flat square, radiolucent

seen w/ acidic urine pH

214
Q

What are etiologies of struvite stones? appearance?

A

radiodense, rectangular prisms

in pts w/ recurrent UTIs from proteus, klebsiela, serratia, enterobacter

215
Q

What is best test for diagnosing kidney stones?

A

noncontrast CT ? radiograph

216
Q

What is next step for ongoing stone obstruction and pain not controlled by narcotics?

A

shock wave lithotripsy

if fails –> percutaneous nephrolithotomy

217
Q

What is next step if abnormal digital rectal exam?

A

trans-rectal ultrasound w/ bx

218
Q

How can you distinguish metabolic alkalosis 2/2 volume contraction vs expansion?

A

2/2 contraction = urine Cl 20, ECF expansion, hypertension

219
Q

How much does 1 unit of RBCs raise hct?

A

by 3-4 points

220
Q

When do you give FFP?

A

for high PT/PTT and deficiency of clotting factors, if liver failure, or waiting for vit K to take efffect

221
Q

When do you give cryoprecipitate?

A

for hemophilia A, decreased fibrinogen (DIC) and vWD

222
Q

What are intravascular hemolytic transfusion rxns?

A 
acute hemolytic reactions
- serious/life threatening
2/2 ABO mismatch
fever, chills, N, V, flank/bak pain, CP, dyspnea
tx: stop transfusion, give fluids
223
Q

What are extravascular hemolytic transfusion rxns?

A

less severe, w/in 3-4 wks of transfusion
2/2 minor RBC antigens (kell)
sx = fever, jaundice, anemia

224
Q

What does schilling test tell you?

A
  • give IM dose unlabeled B12
  • give oral dose radioactive B12
  • measure B12 in urine and plasma to determine how much absorbed
  • repeat w/ addition of intrinsic factor

if malabsorption –> IF will not help
if pernicious anemia –> IF will correct

225
Q

What types of anemia present w/ schistocytes and helmet cells?

A

TTP, DIC, hemolytic anemia 2/2 prosthetic heart valve

226
Q

What is splenic sequestration syndrome?

A

suddne pooling blood in spleen –> rapid splenomegaly and hypovolemic shock

227
Q

What is presentation of acute chest syndrome?

A

CP, resp distress, pulm infiltrates, hypoxia

228
Q

What are the causes of spherocytosis?

A 
- hereditary spherocytosis
G6PD deficiency
ABO incompatibility
hyperthermia
autoimmune hemolytic anemia
229
Q

What is presentation of G6PD deficiency?

A

heinz bodies in RBC from denatured RBCs
bite cells after removal of heinz bodies by spleen
deficiency NADPH formation on G6PD assay

230
Q

What kind of hemolysis, Abs, etiology in warm AIHA?

A

IgG
extravascular hemolysis
splenomegaly
idiopathic or 2/2 lymphoma, CLL, SLE, a-methyldopa

231
Q

What kind of hemolysis, Abs, etiology in cold AIHA?

A

IgM
intravascaular hemolysis –> in liver
2/2 idiopathic, mono, or mycoplasma

232
Q

How can you tell difference between warm and col hemolytic anemia on coombs/smear?

A

direct coombs:

  • if coated w/ IgG = positive direct coombs = warm AIHA
  • ir RBCs coatd w/ complement alone = cold AIHA

if spherocytes may be warm AIHA

233
Q

What are HIT type 1 and 2?

A

type 1: heparin directly causes platelet aggregation,

234
Q

What test for vWD?

A

ristocetin assay

235
Q

What happens to PT, PTT, thrombin time, fibrinogen, platelets in liver disease?

A

high PT, PTT

normal TT, fibrinogen, platelets

236
Q

What happens to PT, PTT, TT, fibrinogen, PC in vit k deficiency?

A

long PT

normal PTTT, TT

237
Q

What is tx for DIC?

A

FFP

platelet transfusions

238
Q

What factors synthesized by vit K?

A

II, VII, IX

239
Q

What clotting factor has shortest half life?

240
Q

What drug is not succsesful in pt w/ ATIIII?

241
Q

What are actions for DVT ppx?

A

LMWH
low dose unfractionated heparin
pneumatic compression boots

242
Q

What is mech of action of clopidogrel?

A

blocks binding of ADP to specific platelet ADP receptor P2Y12

243
Q

WHen is clopidogreal indicated?

A

for ACS –> unstable angina, MI, NSTEMI
pretrement for PCI
receive for 1 yr after PCI

244
Q

What are risk factors for breast cancer?

A

age
fam hx
anything that increases number of menstrual cycles –> early menarche, late menopause, nulliparity

245
Q

What is tx of lobular carcinoma in situ?

A

removal of lesion does not reduce risk of progression to invasive CA
can tx w/ SERM, prophylactic B/L mastectomy

246
Q

What should you do for small vs large breast CA lesions?

A

for small do systemic chemo

247
Q

What is MCC death in MM?

A

recurrent infections

248
Q

What is mech of bony lesions in M?

A

osteolytic lesions are secondary to release of osteoclast-activating factor by neoplastic plasma cells

249
Q

What are sequela of waldenstrom macroglobulinemia?

A

IgM
–> hyperviscosity
no bony lesions
have fatigue, wt loss, neuro sx, lymphadenopathy, splenomegaly, anemia, abnormal bleeding, hypervsiscosity —> can lead to retinal vessel dilation and hemorrhage –> blindness

250
Q

What locations associated w/ adult T cell lymphoma?

A

japan and caribbean

251
Q

What is rituximab? use?

A

monoclonal CD20 antibody

use to treat NHL

252
Q

What are key features of SLL?

A

closesly realted to CLL

indolent course

253
Q

What are key features of follicular lymphoma?

A

painless peripheral lymphadenopathy

MC form of NHL

254
Q

What are key features of diffuse large cell lymphoma?

A

locally invasive

large extranodal mass

255
Q

What are key features of burkitt?

A

AA –> facial bone and jaw, associated w/ EBV
american –> ab organs
t8;14 translocation

256
Q

When should you bx lymph node?

A

any node > 1cm present for more than 4 wks not attributed to infection

257
Q

What is CHOP therapy for NHL?

A
  • cyclophosphamide
  • hydroxydaunomycin (doxorubicin)
  • oncovin (vincristine)
  • prednisone
258
Q

What translocation in Acute promyelocytic leukemia?

A

t15;17
foten have pancytopnea
tx w/ all trans retinoic acid

259
Q

What age ranges for ALL, AML, CLL, CML?

A

ALL 65

AML/CML 40-60yo

260
Q

What type of leukemia can present w/ AIHA?

261
Q

How do you differentiate from leukemoid reaction and CML?

A

leukemoid:

  • no splenomegaly
  • increased leukocyte alk phosphatase
  • hx of infection

CML = opposite

262
Q

What translocation in CML?

A

t(9;22) –> philadelphia

BCR-ABL -> activates tyrosine kinase protein

263
Q

What type of leukemia do you tx w/ imatinib?

A

CML = tyrosine kinase inhibitor

264
Q

What is presentation of polycythemia vera?

A

pruritis and hot batch or shower

265
Q

What is presentation of polycythemia vera?

A

hyperviscosity
thrombotic phenomena
bleeding
splenomegaly, hepatomegaly, htn

266
Q

What levels of EPO, B12, uric acid in PV?

A

high B12 and uric acid

low EPO

267
Q

What is presentation of carotid TIA?

A

loss of speech, paralysis/parasthesias

amaurosis fugax

268
Q

What is subclavian steal syndrome?

A

stenosis of subclavian artery proximal to origin of vertebral artery to fill subclavian artery distal to stenosis b/c cannot supply adeqaute blood to L arm

269
Q

What is location of dysarthria and clumsy hand stroke?

270
Q

When do you give hypertensives in acute stroke?

A

BP > 220/120 or acute MI, aortic dissection, severe HF

271
Q

When do you do carotid endarterectomy?

A

in symptomatic pt w/ stenosis > 70%

272
Q

What are pupil findings in CH 2/2 pons? thalamus? putamen?

A 
pons = pinpoint
thalamus = poorly reactive pupils
putamen = dilated pupils
273
Q

What is shy drager?

A

parkinson + autonomic insufficiency

274
Q

What is progressive supranuclear palsy?

A

degernative brainstem, basal ganglia, cerbellum

have bradykinesia, limb rigidiy, cog decline

but no tremor
also have opthalmoplegia

275
Q

What is mech of pramipexole?

A

dopamine agonist

276
Q

What are characteristics of essential tremor?

A

w/ certain postures or tasks
fine
head tremor, vocal tremulousness
improved by alcohol

277
Q

What is tx for tourettes?

A

clonidine, pimozide, haloperidol

278
Q

What is tx for guillan barre?

A

IVIG, avoid steroids

279
Q

What is etiology of MG?

A

postsynaptic receptor antibodies to Ach

280
Q

What is mcardles?

A

AR, muscle cramping after exercise 2/2 glycogen phosphorylase deficiency

281
Q

What is presentation of NF1 (von recklinghausen dz)?

A 
AD
cafe au lait
neurofibromas
CNS tumors
axillary freckling
iris hamartomas (lisch nodules)
bony lesions
cutaneous neurofibromas
282
Q

What is presentation of NF2?

A 
AD
b/l acoustic neuromas
multiple meningiomas
cafe au lait spots
neurofibromas
cataracts
283
Q

What is tuberous sclerosis?

A

AD
cognitive impairment, epilepsy, skin leasions (facial angiofibromas, adenoma sebaceum)
retinal hamartomas, renal angiomyolipomas, rhabdomyomas of heart

284
Q

What is presentation of polio?

A

LMN involvement, asymmetric muscle weakness, absent DTR, flaccid, atrophic muscles, normal sensation

285
Q

How do you distinguish between central and peripheral vertigo?

A

central: gradual, mild, N/V, neuro findings, mild nystagmus, mild effect w/ position change, multidirectional nystagmus
peripheral: sudden onset, severe intensity, intense N/V, no associated neuro findings, intense nystagmus, intense effect w/ position, unilat/vertical nystagmus

286
Q

What is tx for uncomplicated cap in pt w/o significant comorbidities? if older or w/ comorbidities?

A

azithromycin or clarithromycin or doxy

if older/comorbidities –> fluoroquinolone

287
Q

WHat is tx for ventilator associated pna?

A 
cefepime or pip/tazo or carbapenem
AND
aminoglycoside or FQ
AND
vanc or linezolide
288
Q

What is empiric tx for meningitis in HIV?

A

ceftazidiem + amp + vanc

289
Q

What is in pt hospital treatment for pyelo?

A

cipro or amp + gent

290
Q

At what CD4 count is pt at risk for CMV or MAC?

291
Q

What is presentation, tx for CMV?

A

present = disseminated GI or pulm sx, retinitis, colitis, esophagitis

tx = ganciclovir, foscarnet

292
Q

What is presentation of chancroid?

A

haemophilus ducreyi
painful genital ulcer(s) w/ ragged borders, purulent base
unilateral tender inguinal lymphadenopathy that appear 1-2 weeks after ulcer

tx = azithromycin or ceftriazone

293
Q

WHat is presentation of lymphogranuloma venereum?

A

chlamydia trachomatis
painless ulcer, a few weeks later have tender inguinal lymphadenopathy (unilateral)
and constitutional symptoms

294
Q

What is presentation of rocky mountain spotted fever?

A

rickettsia rickettsii

papular rash starts peripherally and spreads centrally

295
Q

What is tx for rocky mountain spotted fever?

296
Q

What is tx for malaria ppx?

A

mefloquine if chloroquinolone resistant area

297
Q

What is licehn planus?

A

pruritic, polygonal, purple, flat topped papules
on wrists, shins, oral mucosa, genitalia
tx: steroids

298
Q

What is bullous pemphigoid vs pemphigus vulgaris?

A

bullous pemphigoid: elderly, easily rupture, autoimmune

pemphigus vulgarus: loss of normal adhesion between cells, can involved oral mucosa, IgG against desmoglein, assocaited w/ lymphoma, CLL

299
Q

What is marjolins ulcer?

A

scc from chronic wound such as previous burn scar

300
Q

What is spitz nevi?

A

well circumscribed raised lesion often confused w/ melanoma

tx = complete resection

301
Q

What do you need to check yearly in pt on hydroxychloroquine?

A

annual eye exam

302
Q

What are sx of drug induced lupus?

A

SLE but not renal or CNS involvement

usually 2/2 hydralazine, procainamide, INH, chlorpromazine, methyldopa, quinidine

303
Q

What type of ab in diffuse vs limited scleroderma?

A 
diffuse = antitopoisomerase (antiscleroderma 70)
limited = anticentromere
304
Q

What are poor prognostic indicators in RA?

A

high RF titer
subcutaneous nodules
erosive arthritis
autoantibodies to RF

305
Q

What thigns can precipiate acute gouty attack?

A 
decrase temp
dehydration
stress
excess alcohol
starvation
306
Q

What are complications of gout?

A

nephrolithiasis

degenerative arthritis

307
Q

What meds should you avoid in acute gout?

A 
asa and acetaminophen
also allopurinol (mayybe)
308
Q

When should you suspect takayasu arteritis?

A

decreased absent peripheral pulses
discrepancies of bp arm vs leg
arterial bruits
young woman

medicine Clerkship (4 decks)

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