True learn missed part 2 Flashcards
What are the common manifestations of Antiphospholipid syndrome? (5)
Thrombosis, Pregnancy loss, thrombocytopenia, and nonbacterial vegetative endocarditis. Livido reticularis
PELTT (pregnancy loss, endocarditis, livedo reticularis thrombosis, thrombocytopenia)
What are the antibodies associated with Antiphospholipid syndrome
Anticardiolipin
Anti beta 2 glycoprotein
Lupus anticoagulant
(can be associated with SLE)
What are the common central venous catheters sites
internal jugular vein
subclavian vein
femoral vein
complications with central venous catheter insertion
nosocomial blood stream infections (you can combat this with practicing proper insertion technique, maintain occlusive dressings, and removing any unnecessary lines)
hematoma, pneumothorax, infection
where is the internal jugular vein in comparison to the carotid artery
the IJV is in the carotid sheath lateral to the carotid artery
what are the contents of the carotid sheath (vascular compartment of the neck in the deep cervical space)
internal jugular vein
common carotid artery
vagus nerve
where is the vagus nerve in comparison to the carotid artery ?
posterior to the carotid artery
what is the normal distribution rule
68% - 1 standard deviation outside of the mean (34% on each side of the mean)
95% - 2 standard deviations outside the mean (47.5 on each side of the mean)
99.7 %- 3 standard deviations outside the mean (49.85 on each side of the mean)
MCC of LEMS myasthenic syndrome
paraneoplastic syndrome from Small cell lung cancer
Antibodies associated with LEMS syndrome
Antibodies associated with Myasthenia gravis
LEMAS: voltage gated calcium channels antibodies
MG: acetylcholin receptor antibodies
Does LEMS or MG have autonomic dysfunction like dry mouth, erectile dysfunction?
LEMS!
Muscle weakness in LEMS VS MG
MG: begins with eye weakness (diplopia) , worsens with excercise and worsens throughout the day , progresses to proximal muscle weakness and bulbar weakness (slurred speech, dysphagia)
LEMS: begins with procimal limb weakness (rising from chair, going up stairs), improves with excercise, and improves throughout the day
Reflexes in MG vs LEMS
MG: normal
LEMS: decreased or absent
Does MG or LEMS respond to cholinesterase inhibitors
MG
Treatment of MG vs LEMS
MG: cholinesterase inhibitors (pyridostigmine) , +/- immunosuppressants
LEMS: treatment of underlying lung malignancy if it is paraneoplastic syndrome
, if it is idiopathic treat with amifampridine
diseases associated with MG
thymoma, thymic hyperplasia
Antibodies in Miller-fisher syndrome
Anti- GQ1b antibodies
(this is a variant of Guillan Barre syndrome that presents with areflexia, opthalmoglegia and ataxia)
dermatomyositis and polymyositis are associated with what paraneoplastic syndrome
adenocarcinoma
symptoms of polymyositis/dermatomyositis
muscle fiber injury that causes symmetric proximal muscle weakness, polyarthritis, dysphagia, skin findings (gottron papules)
increased CK
antibodies for dermatomyositis/polymyositis
Anti- Jo1, Anti- Mi2
cushing syndrome is associated with paraneoplastic syndrome and what are the symptoms
small cell lung cancer (ectopic ACTH production)
proximal muscle weakness and atrophy, weight gain, HTN, striae, hyperglycemia
Most common location for osteosarcomas and most common site of metastasis
location: metaphysis of long bones
mets: lungs
Treatment of Osteosarcoma (most common primary tumor in teenagers)
chemotherapy and limb salvage surgery
(osteosarcomas are radioresistant)
Ewing sarcoma treatment
radiation and chemotherapy (onion skinning)
which bone tumor pain is relieved by NSAIDS
osteoid osteoma (tumor has high burden off prostaglandins)
Where should the urinary drainage bag be placed in order to avoid risk of UTI
at the foot of the bed
lung adenocarcinoma location, symptoms and cell presentation on histology
location: periphery of the lung (most common lung cancer, especially in non smokers and women)
symptoms: diminished breath sounds, hemoptysis, chronic cough
histo: glandular formation with mucin production
can you prescribe opiods to a friend who is also a patient
yes if there is a need for it and additional tests have been completed
if you cant come to an agreement you can refer them to another provider
if a patient does not want HIV testing even though it is clear that they have aids defining illnesses can they refuse testing?
Yes, just document in their records that they refused testing
when do you screen for HIV in pregnancy
once per pregnancy
what are the CDC guidlines for screening for HIV
onces between the ages of 13 and 64
what is the first line treatment of juvenile myoclonic epilepsy?
Valproic Acid
what conditions is valproid acid frequently used to treat?
absence seizures, bipolar disorder, juvenile myoclonic epilpsy, tonic clonic seiszures, migraine prophylaxis
side effects of valproic acid
hepatotoxicity, pancreatitis, NTD (teratogenic), tremor and weight gain
Uses for topiramate and side effects
migraine prophylaxis, partial seizures, tonic clonic seizures
SE: glaucoma, nephrolithiasis , weightloss
phenytoin uses and side effects
uses: partial seizures, tonic clonic seizures
SE: CYP P450 inducer, enlarged gums, folate deficiency, hirsutism, skin discoloration, teratogenesis (fetal hydantoin syndrome)
phenobarbital is used in what types of seizures
seizures in neonates
side effects: cardiorespiratory depression, CYP450 induction
Levetiracetam use and side effects
juvenile myoclonic epilepsy, partial seizures, tonic clonic seizures
SE: behavioral changes, suidical thought, corrdiation problems
Lamotrigene uses and SE
uses: absence sizures, juvenile myoclonic epilepsy, partial seziures, tonic clonic seizures
SE: steven johnson syndrome, hemaphagocytic lymphohistocytosis
ethosuximide uses and SE
first line treatment of absence seizures
SE: pruiritis, and gi upset
carbamezapine uses and SE
first line for trigeminal neuralgia and partial seizures
SE: agranulocytosis, aplastic anemia, cyp 450 inducer, hepatotoxicity, SIADH, teratogenesis
What drugs are commonly known to cause pulmonary fibrosis (6)
amiodarone, bleomycin, bulsulfan, carmustine, methotrexate, nitrofurantoin
BAB CMN
drugs that commonly cause pancreatitis
Azathioprine, corticosteroids, didanosine, diuretics, valproic acid
“DAD’s CV’
actions of the hamstrings
knee flexion and hip extension
tight hamstring muscles lead to what type of innominate rotation
posterior innominate rotation
parts of the hamstring muscle (3)
biceps femoris
semimembranosus
semindinosus
single blinded studies
double blinded studies
triple blinded studies
single blinded studies: patient OR clinican is unware of intervention recieved
double blinded studies: patient AND clinican is unware of intervention being received
triple blinded studies: patient, clinicians and individual assessing the outcomes are all blinded to the intervention being received
AFIB is stable is treated with CCB or Beta blocker but if unstable treated with cardioversion what is considered unstable
systolic blood pressure <90, chest pain, SOB, confusion
treatment of chanchroid (papule–pustule–ulcer)
oral azithromycin (preferred)
OR
ceftriaxone, erythromycin or ciprofloxacin
risk factors for hypomagnesemia
chronic PPI use, alcoholism, DM, chronic diarrhea and malnutrition
what electrolyte disturbances are often seen with hypomagnesemia?
hypokalemia (most important)
hypocalcemia
hypoparathyroidism (low magnesium impairs PTH release from the parathyroid glands in response to low calcium)
(low potassium, low calcium)
symptoms of low magnesium
weakness, muscle twitching, muscle cramps
Central hypothyroidism vs Primary hypothyroidism
Central: low T4 and Low or low normal TSH, due to a lesion in the pituitary (2) or hypothalamus (4)
Primary: Low T4 and high TSH due to a lesion in the thyroid the most common cause is autoimmune destruction of the thyroid gland (hashimotos)
what is a helpful way to decrease burnout and improve physician well being and the ability to cope with fried and emotional distresses caused by caring for ill and/or dying patients
interdisciplinary debriefing sessions that discuss psychosocial aspects of patients care
mindfulness training
wellness campaigns
sjogren syndrome is associated with increased risk of developing what?
non-Hodgkins lymphoma (5-10% increase)!!!!
vasculitis, cytopenias
sjogren syndrome antibodies
anti-Ro, anti- La , ANA and RF
what is the most effective way to decrease medication errors during transitions of care
involving pharmacists in the discharge med rec process
having more than 1 person do a med reconcilliation review
squamous cell carcinoma of the lungs can secrete what leading to hypercalcemia, what are the lab values
parathryoid hormone related peptide which will decrease parathyroid levels (hypoparathyroidism)
which hepatitis is partly double stranded DNA that encodes a reverse transcriptase (uses reverse transcriptase to replicate)
Hep B
which hepatitis is a flavivirus with a positive sense RNA genome
hepatitis C
ST segment elevation in V1-V3 with ST depression in II, III, aVF are indicative of
acute anteroseptal infarction with reciprocal changes
old infarcts are seen as?
Q qaves in V1-V3
inferior infarct shows ST elevation in?
leads II, II and AVF
with ST depression in leads 1 and aVL
**avoid nitroglycerin
pericarditis on ECG
diffsue ST segment elevation, low voltage and PR depression in leads II, and PR elevation in aVR
**treat with NSAIDS, aspirin or cholchicine
pulmonary embolism symptoms
acute onset dyspnea, pleuritis chest pain
exam of pulmonary embolism
hypoxia, tachypnea, tachycardia, can have a pleural EFFUSION with decreased breath sounds and dullness to percussion
+/- signs of DVT,
ECG pattern of pulmonary embolism
sinus tachycardia, S1Q3T3
a person with ALS has respiratory dysfunction what should you do
- noninvasive positive pressure ventilation first- has been shown to improve survivial and quality of life
- intubate and mechanically ventilate
Idiopathic thrombocytic pupura
this is an isolated thrombocytopenia that can be caused by a recent URI or medications patients are well appearing and may have petechiae or brusing thats IT!!!!
treatment is with : steroids or IVIG
if platelet count is < 30,000 then you treat, if there is bleeding you can give platelet transfusion as well
refractory cases: splenectomy
Spontaneous pneumomediastinum
crepitus from coughing paroxysms (asthma, respiratory infection) usually in a thin boy
chest pain, SOB and cough, palpation of crepitus along the neck and chest wall can have hmman sign on crunching sound over the heart and chest on ausculation
DX: CXR
TX: supportive care if there is no evidence of a pneumothorax
normal TSH, normal T3, increased T4, increased TBG
euthyroid hyperthryoxinemia
(no symptoms)
low TSH, normal T4, normal T3
subclinical hyperthyroidism
(asymptomatic)
what two tendons are inflamed in de quervain tenosynovitis
abductor pollicus longus and extensor pollicis brevis
Eye response grades in the glascow glaucoma scale
- no eye opening (1 point)
- eyes open to pain (2 points)
- eye open to voice (3 points)
- eyes open spontaenously (4 points)
verbal response glascow score
- no verbal response (1 point)
- incomprehensible sounds (2 points)
- inappropriate words (3 points)
- confused (4 points)
- Oriented (5 points)
motor response scores in glascow coma scale
- no motor response (1 point)
- extension to pain (2 points)
- abdominal flexion to pain (3 points)
- flexion/withdrawal (4 points)
- can tell you where his pain is (5 points)
- obeys commands (6 points)
anything lower than 8 on the glascow coma scale means you need to intubate
methemglobenemia what is it and how is it treated
an oxidized form of hemoglobin that causes iron to be in the ferric Fe3+ state and decreases oxygen delivery to tissues leading to cyanosis, dyspnea, confusion, chocolate colored blood , but a normal PaO2
can be caused by a cytochrome b5 reductase deficiency or drugs like nitroprusside, nitroglycerin, anesthetics (benzocaine)
tx: methyelene blue which is a synthetic blue dye (gives electron to methylated hemoglobin)
methylene blue should be avoided in patients with what deficiency
G6PD
- it can precipitate hemolysis in these patients
antibodies for autoimmune hepatitis that is most specific
anti-smooth muscle antibodies
what antibodies in primary biliary cholangitis
anti-mitochondrial antibodies
Acute mesenteric ischmia from arterial embolism presents in the setting of?
atrial fibrillation
(can be from athersclerosis, embolic sourfce, hypercoaguable states, vasculitis)
diagnosis of Acute mesenteric ischemia
CT angiography is preferred
alternativesL MRF angiography, color doppler, ultrasound
cryptococcous infections are treated with?
amphotericin B
management of spontaneous bacterial peritonitis
DIAGNOSTIC PARACENTESIS THEN ANTIBIOTICS
SAAG> 1.1, >250 PMNs
treatment of status epilepticus
IV lorazepam, if given 2 doses and patients is in respiratory distress (30 breaths per minute) preform rapid sequence intubation before administering another does of lorazepam
CHECK ABCs (address these before anything else)
refractory cases put in a phenobarbital coma
lead poisoning interferes with?
erythrocyte cell membrane integrity
irritability, wrist drop, anemia, trouble concentrating, lead lines, basophilic stippling
Acute intermittent porphyria
presents in adolescents with a deficiency in the enzyme porphobilinogen deaminase
symptoms: abdominal pain, constipation, and extremity weakness, neurovisceral symptoms
alternative options for PCP other than TMP-SMX
dapsone
atovaquone
dapsone + pyrimethamine + leucovorin
aerosolized pentamidine
**discontinue TMP-SMX if there is development of steven johnson syndrome, toxic epidermal necrolysis, neutropenia, renal failure
le fort II fractures involve what
maxilla, nasal bones and medial aspects of the orbits
nasal bone and maxilla mobility
(incorrect teeth placement)
+/- rhinorrhea
le fort I fracutre involves what
maxilla at the nasal fossa
only movement of the maxilla
le fort fracture III involves
maxilla, nasal bones, and zygoma
unstable entire midface “floating of the face from the head
CSF, rhinorrhea, maloclusion, trismus (lock jaw)
herpes zoster ophthalmicus initial and late complications (v1 distribution)
acute keratitis initially showing a psuedodendritic pattern
uveitis (irregular shaped pupil) and cataracts or glaucoma
blindness later on
tx: oral antivirals are the mainstay of treatment, but topical antivirals can be used as well
