Ultimate Merge Flashcards
Conjunctivitis:
Viral vs Bacterial vs Allergic
a) UL vs BL
b) “stuck shut”
c) dcg
d) dcg reappear after wiping
e) other complaints
f) conj. appearance
tx and MoA for each
a) UL->BL vs UL——> vs BILATERAL
b) all
c) serous, thick/purulent, serous
d) no, YES, no
e) burning/gritty vs unremitting dcg vs itchy
f) bumpy vs non-bumpy vs bumpy/chemosis [bumpy=follicular] [edema=chemosis]
Viral: tx compresses +/- anti-hist/decongestant
Bacterial: tx topical abx (erythromycin, polymyxin-TMP, azithromycin); CONTACT lens (FLUOROQUINOLONE drops)
ALLERGIC: tx mast cell stabilizer (olopatadine, azelastine), antihistamine/decongestant drops
What dz’s do you see tau protein in but what types of aggregates?
Alzheimers-NFTs of tau
Pick’s-round aggregates of tau
Common complication in those with treated Hodgkin’s Lymphoma?
secondary malignancy (often in Lung but many others)
PROLACTINOMA (3) popluations and px and detection
Management of Prolactinoma?
1) premenopausal - detected early
- galactorrhea, infertility, oligo/amenorrhea, hot flash, bone loss
2) postmenopausal - detected late
- visual deficits/headache (2/2 mass effect)
3) men - detected late
- vLibido, gynecomastia, impotence, infertility (h/a, visual)
DOPAMINE AGONIST
surgery if refractory
1) dx. benign vs malig? potential? no mass, mass, or other?
a1) intermittent, UL bloody discharge in PREmenopausal woman? hist?
a2) bloody dcg in POSTmenopausal woman? hist?
b) BL cyclical (menstrual) breast pain
c1) painless, firm, mobile lump in young woman
c2) overgrowth of c1 (>5cm) and older pt than c1
d1) asymp/bloody discharge+lump
d2) eczematous changes of the nipple
e) smoker/vitA def. nipple retraction
1)
a1) benign intraductal papilloma; epithelial+MYOepithelial; no mass
a2) malig intraductal papillary carcinoma; ONLY epithelial
b) benign fibrocystic change; lumpiness; NO MALIG POTENTIAL unless sclerosing calc. adenosis (2x), ductal hyperplasia (2x), or atypical hyperplasia (5x) is present
c1) benign fibroadenoma [MC in premenopausal females]; mobile, well-circumscribed mass; NO MALIG POTENTIAL
{um, estrogen sensitive, but is it non-cyclical?}
c2) Cystosarcoma Phyllodes
d1) DCIS
d2) malig Paget’s Dz of Breast (underlying DCIS has spread to nipple)
e) PERIDUCTAL mastitis
Which type of breast cancer does Tamoxifen treat?
What is the most important prognostic factor in breast CA?
LOBULAR carcinoma in situ (which is a RF for invasive lobular carcinoma)
TNM staging (tumor burden)
Explain the benefits;risks of the following SERMs and think through each:a) Tamoxifen b) Raloxifene !
tx?
(2) risk modifications
(3,2) MoA
a)
- tx breast CA
- reduces osteoporosis risk; predisposes endometrial CA-
- estrogen receptor ANTagonist in breast (tx and ppx)
- estrogen receptor AGONIST at osteoclasts; inhibits bone turnover
- estrogen receptor (partial) AGONIST on endometrium
b)
- tx osteoporosis
- reduces breast CA risk; predisposes VTE
- estrogen receptor AGONIST on bone
- estrogen receptor ANTagonist in breast and vagina
nipple discharge* and breast mass in multiparous postmenopausal woman 2 ddx
- BENIGN plasma cell MAMMARY DUCT ECTASIA (*GREEN/BROWN dcg)
- malig Ductal CA in Situ (*bloody dcg)
Fat embolus vs Pulmonary Contusion
FE= AMS+petechiae following a 12-72 hour latency
PC= blunt chest trauma: dyspnea, tachypnea, chest pain, hypoxemia worsened with IVF
Natural infection immunity vs Vaccine immunity?
-- Levels during the following? a) early b) window c) recovery
sAg+anti-c
(elevated both during initial infx and window)
–
Vaccine - anti-S (IgM)
Nat. Imm- anti-S (IgM) + anti-C (IgG!)
a) E, S, anti-C (IgM)
b) anti-C (IgM) only!
c) anti-C (IgG), anti-E, anti-S
[DNA in all 3]
NBS in suspected gout or pseudogout?
What condition do you typically see pseudogout in and why?
What is a weird cause of CPPD/chondrocalcinosis/pseudogout? What else can this cause and is it reversible? What is chondrocalcinosis?
How treat gout? (2)
Arthrocentesis (joint aspirate, fluid analysis)
Hyperthyroidism predisposes pseudogout development.
Hemochromatosis;
lol restrictive cardiomyopathy that’s reversible (vs amyloidosis, sarcoidosis, scleroderma)
Chondrocalcinosis is calcified articular cartilage.
1) ACUTE:
a) NSAID
b) Colchicine
c) Corticosteroids
2) PREVENTION:
a) allopurinol, febuxostat (XOi; decreases uric acid production)
b) Probenecid (inhibits uric acid reabsorption)
c) Rasburicase (metabolizes uric acid) [tx TLS]
Ocular, Vascular, and Cardiac manifestations of opioid use? What are these mediated by?
MiOsis, hypOtension, BRADYcardia
histamine release
Compare/contrast the nodes:
a) Osteoarthritis
b) Gouty Arthritis
c) RA
a) H/B Nodes: bony nodules
b) TOPHI: can ulcerate and drain a chalky material (dist. calcinosis cutis)
c) Flesh-colored, nontender
c) “volcano” with central keratotic plug
d) another name for skin tag
c) keratoacanthoma
d) acrochordon
Initial treatment strats for RA.
What do you give if unresponsive for 6 months?
Classify this category of drugs. What do you need to test for prior to starting?
non-biologic DMARD (methotrexate!) + NSAID/celecoxib/glucocorticoids (relief while awaiting DMARD response)
Add biologic (anti-tnf alpha) or a second non-bio if refractory.
DMARD = non-biologic (methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, azathioprine) + biologic (etanercept, infliximab, adalimumab, toclizumab, rituximab)
[TEST FOR HEP B/C and TB!]
EM vs SJS vs TEN
targetoid s/p HSV infx vs
bullae/desquamation 2/2 “triggers”
v10% = SJS ^30% = TEN
triggers = sulfonamides, carbamazepine, lamotrigine, phenytoin, sulfasalazine, NSAIDs, allopurinol, mycoplasma
What is senile purpura? mech
Suppurative hidradenitis
““acute” SH-looking things
Explain why purulent vesicles can form in allergic contact dermatitis?
BENIGN ecchymoses in elderly patients (nasty hands) due to loss of perivascular CT
Chronic follicular occlusive disease; painful inflammatory nodules and draining sinus tracts. ODORUS (“rotten stretchmarks”)
Intertrigo. More erythematous.
Scratching can lead to 2ndary infxn
Tx frostbite?
Warm water rewarming. Only debride later
What are the two types of scaphoid fractures and how to tx each?
a) NON-displaced (fine radiolucent line or nL xray; v2mm displacement and no angulation) : wrist immobilization for 6-10 wks
b) DISPLACED: open reduction, internal fixation
What is osteonecrosis and what causes almost all of these cases? What are 4 synonyms?
gold standard dx?
Osteochondritis dessicans, aseptic necrosis, avascular necrosis, ischemic necrosis
Corticosteroid, alcohol
also SLE and sickle cell
MRI! (commonly hip. ttp + predinosone/SLE etc. )
What is scleroderma crisis? What does it present with (3)?
What GI issue are scleroderma ppl (as well as DM) at risk for?
Pulmonary manifestation of scleroderma?
Sudden RF (urinalysis can be nL)
MAHA (schistocytes!)
Malig HTN
Sm. Intestinal Bacterial Overgrowth (2/2 lack of proper motility); also angiodysplasia
INTERSTITIAL LUNG DZ! (FIBROSIS)
pulmonary arterial HTN
Burr Cells (echinocytes)
HJ bodies
Spur Cells (acanthocytes)
Target Cells
Spiculated/serrated; Liver dz / ESRD
Basophilic remnants; functional asplenia/splenectomy
Irregular projections; Liver dz
Bull’s eye; hemoglobinopathy (thallasemia); obstructive liver dz
ACLS
How are the (2) different forms of persistent tachyarrythmias treated based on the (2) broad category of symptoms?
What to avoid in WPW?
1) Wide or narrow (qrs) complex
2) STABLE - MEDICINE (amiodarone); UNSTABLE-CARDIOVERT
a) narrow-complex (ex. paroxysmal SVT) tx vagal
b) wide-complex (ex. sust. monomorphic VT) tx (2)
in WPW avoid drugs that increase conduction thru the accessory pthwy (BB, CCB, digoxin, adenosine [av block]); instead tx with procainamide or ibutilide
PALPABLE KIDNEYS, hepatomegaly, nephrotic syndrome, LVH, recurrent pulmonary infection.
tx?
Secondary amyloidosis
tx colchicine
Unexplained elevation in CK and signs of myopathy?
Consider hypothyroidism
Most serious ADR of anti-thyroid drugs?
FIRST AND SECOND MC for Radioablation? [ppx/tx?]
Most serious ADR of hydroxychloroquine? What is this used for?
Agranulocytosis (methimazole)
1) !!!!HYPOTHYROIDISM (MC, unpreventable, but tx with T4) [destruction of folliciles]
2) Exace. of ophthalmopathy [ppx w/ corticosteriods before and after]
SLE w/ isolated skin and joint involvement. ADR: RETINOPATHY (eye exam q6months)
What is the “herald patch” and what does it signify?
1) erythematous papules w/ Sandpaper texture
2) rosy telangiectasia over cheeks, nose, chin
3) allergies + umbilicated vesicles on top of healing atopic dermatitis
4) Lichenification vs Lichen Planus, vs Lichen Simplex Chronicus vs Lichen Sclerosis
5) non-comedogenic erythematous pap/pustules in central face
6) another name for suppurative hydradenitis
7) STABLE SIZED pale/yellow papules on the central face
8) more common on LE, **centrally dimples when pinched; nontender and hyperpigmented [path?] tx?
9) more common on upper, **UNCHANGED when pinched; small central keratin plug (dot?) spontaneously resolves and recurs[path?] tx?
10) dry scaly patch, rough skin, horny plates, extensor surfaces, “lizard skin”
Brown/pink/scaly plaque with central clearing; first symptom of ‘pityriasis rosea’
1) actinic keratosis
2) rosacea [PRECIP. BY HEAT, HOT DRINKS, TEMP CHANGE]
3) Exczema Herpeticum tx acyclovir! esp in infants
4) thickening bc of scratching vs hyperkeratosis/HepC (pruritic, purple, polygonal, planar, papules & plaques) vs hyperplasia of vulvar squamous epi (itchy!) vs increased risk SSC vulva “parchment”
5) acne (papulopustular) rosacea
6) acne inversa (hydradenitis suppurativa)
7) sebaceous hyperplasia
8) dermatofibroma [path: fibroblast proliferation]; if symptomatic, bleeding, or evolving, tx cryosurg or shave exision
9) MC cutaneous cyst: epidermal inclusion cyst/epidermoid cyst/epidermal cyst wrong (benign nodule with normal epidermis that produces keratin [path: when epidermis is lodged into dermis due to trauma or comedones] may become inflammed; tx for cosmetic or infxn
10) icthyosis vulgaris
Rheumatology Pharm
moa and ADR
1) Methotrexate
2) Hydroxychloroquine
3) Sulfasalazine
4) Azathioprine
5) cyclosporine
6) Leflunomide
7) anti-TNF (adalimumab, certolizumab, etanercept, golimumab, infliximab)
1) DHFr-ase inhibitor (purine antimetabolite); macrocytic anemia MCV^100 Hg v12; stomatitis, hepatotoxicity
2) TNF and IL-1 suppressor; G6PD def. hemolysis, GI/visual disturbance!!! (retinitis)
3) TNF and IL-1 suppressor; stomatitis, hepatotoxicity, hemolytic anemia
4) bone marrow suppression; pancreatitis
5) predisposes viral infx and lymphoma; nephrotoxic
6) pyrimidine synthesis inhibitor; hepatotoxicity, cytopenia
7) infection, demyelination, CHF, malignancy
Preload: Hypovol vs cardiogenic (myoC cont.)
SVR: The above vs septic
MvO2: The above vs septic
decreased vs increased PRELOAD
increased (hypovol) vs decreased (septic) SVR
decreased (hypovol) vs increased (septic) MvO2
define RTA
RTA 4
RTA 2
RTA 1
Fanconi
a) hypophosphatemia sx
how to tx ATN 2/2 rhabdo
RTA = decreased urinary excretion of H+ leading to ACIDIFICATION of the TUBULES leading to
hypERchloremic NAGMAcidosis w/ ALKALINE URINE!
4) “aldosterone resistance” or deficiency
often seen in DM2!!!*****
2) “proximal” = lack of HCO3 reabsorption = hypERchloremic hypOkalemic NAGMA
(hypokalemia bc more Na delivered to DCT)
[contrast emesis: hypOchloremic hypOkalemic ma]
1) “distal” = hypOkalemia and **inability to generate HCO3 2/2 DCT’s inability to secrete H+
Fanconi: PCT defect. increased secretion of all AA’s phophate, bicarb etc.
a) weakness, rhabdo, paresthesia, resp failure
NS!
EKG changes and MoA :
Class IA, 1B, 1C
2
3
4
Class 1: Na blocker
a) quinidine, procainamide, disopyramide
b) Lidocaine, Mexilitine
c) Flecainide and Propafenone - prolonged QRS (ONLY DURING TOLERANCE)
Class 2: Beta block - increased PR
Class 3: Amiodarone, Ibutilide, Dofetilide, Sotalol - increased QT
Class 4: Calcium blocker - increased PR
Painful, red eye, opacification/ulceration of the cornea assoc. w/ contact use? Organism?
Painful, peripheral and central retinal necrosis on fundoscopy (2)
vs
Painless with fluffy granular lesions around the retinal vessels; not assoc w/ keratitis/conjunctivitis
Contact-lens-assoc. keratitis (medical emergency!)
Pseudomonas
HSV or VZV
CMV
Myocardial contusion vs aortic injury
Aortic inury WIDENED MEDIASTINUM
2 things that can cause a centripetal rash
RMSF, Secondary syphilis
Opportunistic Infections in HIV
(Ppx, Tx?) [risk factors]
CD4 count:
a) -200
b) -150
c) -100 (2) 1alg
d) -50
FC ppx summary
Overall general summary
a) Pneumocystis jirovecii ppx TMP-SMX (+steroids for pulm function IF PAO2 v70 or A-a>35) alternative to TMP: dapsone; [oropharyngeal candidiasis], IV pentamadine if refractory, PO atovaquone, [PO primaquine+clinda]
b) Histoplasma (ppx Itraconazole) [ohio/mississippi river valley]
c) Toxoplasma (ppx TMP-SMX) [pos. Toxo IgG Ab]
TREAT: sulfadiazine, pyrimethamine
candida esophagitis MC (alt HSV, CMV, apthous)
NBS: tx empiric fluconazole
a) if no improvement, do upper endoscopy +biopsy
b) Large ulcer, deep/distal/LINERAR, tx ganciclovir/foscarnet (for CMV)
c) if small, round/OVOID, tx acyclovir (for HSV)
d) MAC (ppx azithromycin, clarithromycin)
FC summary ppx:
At CD4 count
Progression of Alcholic Liver Disease and prognosis with cessation of EtOH
1) Fatty (completely reversible)
2) hepatitis (completely reversible)
3) cirrhosis/fibrosis (completely IRreversible)
Painless blisters, increased dorsal-hand skin fragility, facial hypertrichosis/hyperpigmentation.
What is this seen in (rmm hehe)
vague abdominal pain, neuropsychiatric issues
how do you dx this?
what drug commonly precipitates this? what type of drug is it?
Porphyria cutanea tarda
extrahepatic manif. of Hep C
acute intermittent porphyria
urine porphobilinogen
primidone (MoA: anticonvulsant that converts into phenobarbital and phenylethylmalonamide)
What two things can topical 5FU treat?
Superficial BCC, actinic keratoses
Hiv ppx
a) PPD>5mm
a) Isoniazid + B6 (Pyridoxine) 9 months
***(vs RIPE-2mo+RI-4mo for ACTIVE tb)
Lidocaine benefits/risks
a) asystole
b) Vfib
c) overall prog
d) VPBs
Increases the risk of asystole
Decreases the risk of VPBs, Vfib
Overall prognosis unaffected
a) Intense surgical wound pain, “dishwasher” dcg, paresthesia
b) fever, chest pain, leukocytosis, mediastinal widening, purulent dcg
c) fever, leuk, tachycardia, CP, few weeks s/p surg for congenital heart dz
Dx, NBS
a) Necrotizing surgical site infx; emergent surgical exploration
b) acute mediastinitis s/p cardiac surg; tx debridement + abx
c) autoimmune postpericardiotomy syndrome: tx NSAIDs or steroids
Ddx for pulmonary ID in HIV
a) cavitary lesions (4+1)
b) pneumonia
a)
TB!!!!
Nocardia (gram+, acid fast, filamentous/branching rod)
Gram neg. rods
Anearobes
Coccidiodomycosis (SW US)
invasive Aspergillosis (halo sign on CT!)
b) pneumocystis (PCP)
What is the pathogenic mech. for osteomyelitis in DM foot ulcer
CONTIGUOUS SPREAD
vs direct inoculation in trauma
vs hematogenous in adults
a) Pt 3+ months s/p TKA px with joint infx.
b) px 3- months, acutely?
c) asymmetric polyarthralgias, tenosynovitis, rash
d) asymmetric oligoarthritis, oral ulcers, urethritis, enthesitis (achilles pain), conjunctivitis tx?
MC org in each?
a) 3+ months s/p arthroplasty:
- coag negative staph (epidermidis)
b) v3 months s/p arthroplasty
- staph aureus
c) gonococcal arthritis
d) Reactive Arthritis (2/2 chlamydia, campylobacter, etc.);
NSAIDs
What are the two ways disseminated gonococcal septic arthritis could present?
Tx?
vs RF, px and dx tx for septic arthritis (non-gonoccocal)
a) migratory asymmetric polyarthralgias
tenosynovitis (wrist, ankle fingers, knees)
skin rash/dermatitis/pustules
OR
b) isolated purulent mono/oligoarthritis without derm
[purulent arthritis in sex active = gonococcal UPO]
Tx IV ceftriaxone 1-2wk; switch to PO cefixime when improved
underlying joint dz (RA, OA, prostetic, gout), DM, IA gluc injections, IVDA, +80y
px - acute monoarthritis, hot/edema/vROM, ^ESR/CRP
tx - based on gram stain/blood cultures
a) gram + = vanc
b) gram - = 3rd gen cephalo
c) negative gram stain =
i) immunocompetent = vanc
ii) immonoCOMPROMISD = VANC + 3RD CEPH
THEN: arthroscopic washout (closed drainage) or
arthrotomy (open drainage)
CSF findings and tx in the following:
a) HSV encephalitis
b) Bacterial meningitis
c) Cryptococcal meningitis
d) RMSF
a) LYMPHOCYTIC predominance, elevated protein, nL glucose; tx IV acyclovir
b) NEUTROPHILIC predominance, elevated protein, LOW glucose; tx IV dexamethasone + ceftriaxone + vancomycin (ampicillin in >50y)
c) ELEVATED OPENING PRESSURE, low glucose, elevated protein; tx IV amphotericin (+flucytosine), maintenance w/ fluconazole
d) mimics VIRAL
OSA vs Pickwickian Syndrome (Obesity hypoventilation syndrome)
What are 3 systemic weird px of Pvera
OHS has daytime ABNORMAL BLOOD GASES (aka hypercapnea and hypoxemia during the day)
(persistent underventilation of the lungs… chronically high PaCO2, low PaO2……)
(LATER, BOTH can have polycythemia, pHTN, RVfail)
[therefore OHS often have concomitant OSA]
1) gouty arthritis (^cell turnover) 2) PUD (^histamine from basophils) 3) HTN (hypervolemia)
Fungus
- risk/location
- path
- px
- imaging
- dx
- tx
a) Histoplasmosis
- SE/mid-atlantic/central US
- acute pneumonia
- cough fever malaise
- hilar LAD
- histoplasma serum or urine Ab
- ITRACONAZOLE
b) Aspergillosis
- IC, chemo, glucocorticoids
- invasive pulmonary dz
- fever, cough, dyspnea,
- CXR - cavitary
- CT- halo/moon sign (air crescent)
c) Coccidiomycosis
- SW US/ valley (california/AZ)
- primary pulm + secondary cutaneous/arthralgia
- norm. pleuritic CP
- …
d) Sporotrichosis
- dimorphic mold (hyphae)
- SQ infx, reddish nodule/papule, ulceration. lymphatic
e) BLAgStomycoses (“bone, lung, and genitals/skin”)
- south, MIss/OH riv. valleys, midwest/great lakes
- pneumonia
- wartlike violaceous nodules
- osteomyelitis
- prostatitis, ortchitis
- dx culture/microscopy, antigen
- tx oral itraconazole; IV ompho if severe/i/c
Two etiologies of Primary Hyperaldosteronism (MC cause of secondary HTN)
tx?
a) UL adenoma - surgery
b) BL hyperplasia - aldosterone antagonists (spironolactone)
What medication to avoid in Restrictive Lung Disease? What other side effects does this drug have
Obstructive?
Amiodarone (sinus brady, heart block, HEPATITIS, corneal deposits, blue gray skin discoloration, peripheral neuropathy)
Beta-blockers
Elderly patient with bone ANEMIA, bone pain, RF, and hypercalcemia.
NBS in mgus to exclude MM?
Multiple Myeloma UPO
Metastatic skeletal bone survey
Coverage:
1) Amoxicillin
1) gram neg. “HELPS” H. Flu, E. Coli, Listeria, Proteus, Salmonella
Widended pulse pressure, strong peripheral arterial pulsation (brisk carotid upstroke), systolic flow murmur, tachycardia, flushed extremities (one warmer than the other).
Phys?
AV-fistula (high output CF)
Increased preload, increased CO, decreased SVR
Symmetric small inflammatory arthritis resolving within 2 months (+/- ANA, RF)
Viral ARthritis, (parvoB19, hepB/C, HIV, rubella)
tx nsaids
anorexia, weakness, Diarrhea, nausea, fatigue + (arrhythmia MC to digitalis)
Hypoglycemia, wheezing, hypotension, bradycardia, shock/seizures/delirium
txs to lower serum potassium (besides kayaxelate and “CaGluconate”. What weird abx
Status asthmaticus, receives inhaled beta-agonists, what side effects to worry about?
Think Digoxin tox. [color alterations lol]; tx Dig Fab
ATRIAL TACHYCARDIA W/ AV BLOCK
mech: increased ectopy and vagal tone
Beta blocker overdose; tx 1) IVF + atropine 2) GLUCAGON
Beta agonist (albuterol), insulin+glucose, Moderate w/out EKG changes- loop+IVF Symptomatic or K^ 6.5 - hemodialysis
hyPOkalemia (muscle weakness, cramps, arrhythmia, tremor, palp/headache) vs hypER (muscle weakness, flacid paralysis, asystole)
3 Ddx for immediate postop fever
What is postoperative cholestasis? 3pathophys?
Prior infx, FEBRILE HEMOLYTIC TXFUSION RXN, malig hyperthermia
Benign condition ~2-3 days s/p a PROCEDURE W/ HYPOTENSION AND MASSIVE TRANSFUSION in which cholestasis occurs by
a) hypotension leading to decreased hepatic fxn
b) increased bilirubin load from transfusion
c) decreased bilirubin clearance by kidneys 2/2 tubular necrosis
Prolonged tachyarrythmia/RVR + LVSD . Tx?
dist?
Tachycardia-mediated cardiomyopathy (reversible)
tx agressive rate control (restoration of NSR?)
vs CHF which is more irreversible
What vaccines do you give to splenectomy patient and when (4)?
Pathophys of why?
How long does the sepsis risk last s/p splenectomy?
***EITHER 2 WEEKS BEFORE OR 2 WEEKS AFTER
1) PCV13 + meningococcal + Hib
2) PPSV23 [8 WEEKS LATER]
impaired PHAGOCYTOSIS against encapsulated organisms. Ab won’t really work till 2 weeks later
30+ y to life
Leukemia/Lymphoma
a) Lymphocytes with fine, irregular cytoplasmic projections that yield a strong acid phosphatase rxn upon stain with tartaric acid (TRAP+). another name for this? TREATMENT?!
b) MC leukemia in west dx? What indicates the worst prognosis?
c) splenomegaly, neutrophilic leukocytosis (left shift), BASOPHILIA, and low leukocyte alk-phos, no LAD
d) Non-Hodgkin’s Lymphoma tx
e) increased blasts, young patient
f) Which is treated by ATRA
g) Which is tx by imatinib
a) Leukemic Reticuloendotheliosis [Hairy Cell Leukemia] (CD11c)
tx - purine analogs {aka adenosine deaminase} inhibiors [cladribine (2-chlorodeoxyadenosine), pentostatin}
b) Chronic Lymphocytic Leukemia (CLL); smudge cells, mature small lymphocytes predominant; thrombocytopenia=poorest prog; “leukemia of old age”
c) Chromic Myeloid Leukemia (CML); [9,22] [bcr, abl] [philly]
abnL tyrosine kinase activity
d) CHOP
e) ALL
f) APromyelocyticL (a subtype of AMyeloidL)
g) CML (tyrosine kinase inhibitor)
Path of MM and consequence.
Classic tetrad of of MM
What are the symptoms of hypOOOOOOOcalcemia. Causes?
Mg and reflex relative to calcemia?
Malignant monoclonal prolif of plasma cells
Increased risk for infxn 2/2 decrease in fnxnL Ab’s
CRAB (hyperCalcemia, renal impairment, anemia, bone lysis)
bone lysis = back pain!?
HypERRRreflexia, CRAMPS, convulsions rarely, periooral tingling?
Caused by increased albumin-binding and BLOOD TRANSFUSION (citrate)
vs “immobilization hypercalcemia”
Follows Ca++
Acute occipital headache, gait ataxia/vertigo, repeated vomiting in hypertensive patient. Dx? Tx?
Cerebellar hemorrhage, evacuative craniotomy
[can present with blepharospasm, 6th nerve palsy, conjugate deviation, and coma in severe cases]
(FEVER IS COMMON IN ANY BRAIN HEMORRHAGE!)
What structures are commonly affected in the following injuries?
a) Anterior shoulder dislocation nerve injury?
b) Radial head fracture/dislocation?
c) Surgical Neck of the humerus?
d) Midshaft humeral fracture?
e) Medial epicondyle of humerus fracture?
f) Saturday Night Palsy? Crutch injury?
g) Dorsal wrist laceration/compression?
h) Supracondylar humeral fracture?
a) Axillary
b) Radial (preserved triceps, but) only weakened extension of digits
c) Axillary
d) Radial (but triceps preservation! wrist drop tho)
e) Ulnar
f) Radial
g) Radial (but no motor deficits since radial n. doesn’t innervate any muscles in the hand. Only sensory loss here)
h) BRACHIAL ARTERY and Median n.
explain the following [a,c,e are the dopamine antagonistic effects of antipyschotics]:
a) decreased dopamine activity in MESOLIMBIC pathway
b) increased dopamine activity in MESOLIMBIC pathway
c) decreased dopamine activity in NIGROSTRIATAL pathway
d) increased dopamine activity in NIGROSTRIATAL pathway
e) decreased dopamine activity in TUBEROINFUNDIBULAR pathway
f) increased dopamine activity in TUBEROINFUNDIBULAR pathway
What regulatory mechanism can happen when taking fluphenazine, for instance.
a) this is what makes antipsychotics efficacious
b) delusions/hallucinations in schizophrenia; euphoria from drug use
c) extrapyramidal side effects from antipsychotics: acute dystonia, akathisia, parkinsonism
d) chorea, tics
e) hyperprolactinemia: amenorrhea, galactorrhea, sexual dysfunction, gynecomastia
f) hypOprolactinemia
Shivering 2/2 hypothermia (thermoregulatory dysruption)
Meningeal signs, Sudden vasomotor crash, flank petechiae, death. Dx?
Waterhouse-Frederichson in the setting of meningococcemia, leading to adrenal hemorrhage which leads to death
HSP px, 2 most common complications, tx
Typically abdominal pain, palpable purpura (with normal coag panels), hematuria, arthralgia, scrotal pain/edema
Intussusseption (due to bowel wall edema and localized hemorrhage, typically small bowel ileo-ileal vs usually ileo-colic, therefore may not be seen on enema) and GI bleed
Tx pain control, corticosteroids if severe
Contraindications to rotavirus vaccine? What is a known small complication of rotavirus vaccine?
What are the live vaccines and when are they contraindicated?
Risk of intussusseption, therefore if patient has hx of intussuseption then don’t administer vaccine. Other regular contra. are allergies to ingredients, SCID, etc.
MMR, varicella, zoster, live-attenuated influenza, c/i when
CD4v200
Manifestations of lyme disease
1) early localized: erythema migrans (targetoid rash), malaise
2) early disseminated:
a) carditis: AV block, cardiomyopathy
b) neuro: facial nerve palsy, meningitis, encephalopathy, conjunctivitis
c) MSK: migratory polyarthralgia
d) skin: multiple erythema migrans, generalized LAD
3) Late/chronic: arthritis, encephalomyelitis, peripheral neuropathy
Reactive arthritis vs Lyme Arthritis
Reactive: acute, asymmetric oligoarthritis, 1-4 weeks following urethritis or diarrhea
Lyme: happens in the setting of untreated localized disease; history of recent travel to the northeastern/upper midwestern states; monoarticular/oligoarticular arthritis (knee) following several months of migratory polyarthralgia;
NBS: ELISA and Western Blot, tx. Amoxicillin if there’s no other Lyme stuff going on. Otherwise Ceftriaxone?
Painless antepartum hemorrhage with fetal decline (sinusoidal tracing or bradycardia) shortly after rupture of membranes; materal vitals preserved.
Dx?
Ddx of antepartum bleeding
Vasa previa (maternal vitals preserved bc it’s fetal bleeding)
a) Normal labor - bloody show, small amount of bleeding
b) Placental abruption - abdominal pain, HYPERTONIC/tender uterus; YOU DON’T NEED BLEEDING TO MAKE THIS DIAGNOSIS!
c) Uterine rupture - abdominal pain, palpable fetal parts, CESSATION OF UTERINE CONTRACTIONS
d) Placenta previa - painless, low lying placenta
e) Vasa previa - PAINLESS; if ruptured, baby dies
previas=painless
ption/pture=painful
Gestational HTN vs Chronic HTN
Severe Preeclampsia. Tx?
Gestational: new onset >20 weeks 140+/90+
Cr of 1.1 or doubling of Cr, bp 160/110 or more, transaminitis, thrombocytopenia, cerebral/visual signs, pulmonary edema
STABILIZE, then DELIVER!
With labs; treatment, distinguish:
HELLP
Intrahepatic Cholestasis of Pregnancy
Acute Fatty Liver of Pregnancy
HELLP - hemolysis, proteinuria, increased LDH; delivery w/mag to prevent convulsions
ICoP - NORMAL PT/PTT; ursodeoxycholic acid
AFLP - increased PT/PTT, increased creatinine/uric acid, hypoglycemia; delivery
Patient with Grave’s Disease has a baby and the baby is low birth weight, tachycardic, irritable.
Dx?
Path?
Tx?
- Neonatal thyrotoxicosis
- anti-TSH receptor antibodies cross placenta and trigger hyperthyroid symptoms
- methimazole and beta-blockade (atenolol?)
Px of RUPTURED ectopic pregnancy?
Px of of Molar preg
Distinguish ectopic pregnancy from molar pregnancy
Cervical/adnexal tenderness, orthostasis/hemodynamic instability, diffuse abdominal pain
vs
high hcg, hyperemesis gravidarum, theca leutein cysts, MASS/ENLARGED UTERUS
ECTOPIC DOESN’T HAVE A MASS
Postpartum woman, pulmonary symptoms, multiple nodules on CXR.
Dx?
Best confirmatory test?
Choriocarcinoma
b-HCG
What is the triad of gestational trophoblastic disease in general. Examples of GTD?
vaginal bleeding, enlarged uterus, pelvic pain
choriocarcinoma
Ddx of vaginitis (3)
a) causative agent
b) discharge
c) inflammation?
d) labs, pH, etc.
e) treatment
1) Trichomoniasis
2) Bacterial Vaginosis
3) Candida Vulvovaginitis
1) [can also cause strawberry cervix]
a) trichomonas vaginalis
b) THIN, yellow-green, frothy, malodorous
c) motile trichomonads, pH>4.5
d) inflammation
e) metronidazole, treat partner
2)
a) gardnerella vaginalis
b) THIN, whitish, fishy, malodorous
c) clue cells, + whiff test (amine odor on KOH), pH>4.5
d) NO inflammation
e) metronidazole
3)
a) candida albicans
b) THICK “cottage cheese”
c) pseudohyphae, normal pH (3.8-4.2)
d) inflammation
e) fluconazole
a) 3 Emergency contraception and MOA
b) Medical abortifacient regimen
c) preferred contraception for lactating mothers. why?
PO Ulipristal (anti progestin, delay ovulation) PO Levonorgestrel (progestin, delay ovulation) copper IUD (inflammatory rxn hostile to ova and sperm)
Mifepristone + misoprostol
progestin-only pills. no VTE risk and no estrogen to pass into milk or affect milk quality.
What is the only absolute contraindication to breastfeeding?
What are other contraindications to breastfeeding?
GALASCTOSEMIA
active substance/alcohol abuse, active TB, HIV
Hep B and C NOT considered contraindications, neither is mastitis
Causes of elevated maternal AFP?
Decreased?
a) elevated:
- multiple gestation (look for improper fundal height for age)
- congenital nephrosis/obstructive uropathy
- ventral wall defects (gastroschisis, omphalocele)
- open NTDs (open spina bifida, anencephaly)
b) decreased:
- aneuploides (trisomy 18, 21)
MENORRHAGIA
Heavy feeling in the abdomen, chronic constipation, urinary frequency, pelvic mass
dx?
ddx? and define and tx?
Fibroid (uterine leiomyoma)
[mass can compress colon and bladder leading to those symptoms]
- enlarged uterus
- clots
adenomyosis - dysmenorrhea/menorrhagia, but wouldn’t have bowel and urinary symptoms, wouldn’t have a mass. boggy on exam
- typically >40 years, MULTIPAROUS
- enlarged, globular, boggy uterus (glandular hyperplasia)
vs
endometriosis - dysmenorrhea/menorrhagia, but wouldn’t have bowel and urinary symptoms, wouldn’t have a mass. laparoscopy for dx
- typically younger, NULLIPAROUS
- normal sized uterus (no glands, it’s outside the uterus)
- dyschezia, dyspareiunia, infertility! (inflamm/adhesion, etc.)
-RF: early menarchy, outflow obstruction
Tx -
1) nsaids +/- combined OCP
2) laparoscopy to confirm (dx and tx)
endometritis
-foul smelling s/p instrumetnation/abortion, FEVER
TX - clinda + gent [POLYMICROBIAL]
vs
endometrial CA/hyperplasia
- hx of obesity, nulliparity
- small uterus, NON-tender
- irregular bleeding
1) Complications of cryptorchidism and how to avoid this?
2) Indications for surgery in hydrocoele?
Hydrocele (dx + NBS)
Varicocele (dx + NBS)
1)
(prevented by bilateral orchiopexy)
Testicular torsion (affixed to wall in orchiopexy), subfertility (better w/pexy), and malignancy (lower risk w/ pexy)
2) persitent beyond 1 yr
3)
Cryptorchid testes, [absent uterus], absent upper vagina, breasts (androgens converted to estrogens),
vs
normal ovaries, [absent uterus], absent upper vagina, external genitalia normal
transillumination? yes; resolves spontaneously by 1 year, surgery if unresolved by that time
transillumination? no; resolves spontaneously, surgery if a) bilateral, decreased sperm count, or painful
NBS in isolated thrombocytopenia!
PREDNISONE FIRST!
Unable to relax grip, balding
Myotonic Dystrophy
CSF analysis
Neutrophil HAS to be bacterial
Viral usually NO ^protein
Lymphocytes could be viral, TB, cryptococcal, lyme, or ricketts
Cryptococcal in IVDA/AIDS
Antibodies:
1) anti-mitochondrial
2) anti-smooth muscle, anti LKM
3) anti-Jo 1 (antisynthetase), andti-Mi-2 (antihelicase)
4) ANA, dsDNA
5) ASO
6) Ro/SSA; La/SSB
7) topoisomerase-I
1) PBC
2) AUTOIMMUNE hepatitis
3) dermatomyositis
4) SLE (sens; specific)
5) acute rheumatic fever/recent strep infxn (migratory polyarthritis, pancarditis, syndenham, erythema marginatum, SQ nodules); usually LE, migratory arthritis
- affects Mitral Valve (can be stenosis or regurg, ^CRP and prolonged PR. ppx PCN for GAS)
6) Sjogren
7) Scleroderma
Endocarditis causative agents:
a) nosocomial UTI
b) Prosthetic/pacemakers/vasc. cath; IVDA
c) IBD/colon CA
d) Immunocompromised, prolonged abx, indwelling cath
e) dental, respiratory biopsy/I and D…
sentence
tx
a) Enterococcus faecalis
b) Staph (MC) epidermidis (coag neg); aureus
c) Strep bovis (gallolyticus)
d) fungi
e)
i) viridans (STREP sanguinis, mitis, oralis, MUTANS, sobrinus, milleri) [ tx IV penicillin G -or- ceftriaxone ]
Staph - MC HAIE
Strep - MC CAIE
a)
b) empiric IV vanc; can switch to oxacillin if clx show MSSA
c)
d)
e) Penicillin G (aqueous)
- (amp-sulbactam for Hacek?)
Two possible causes for macrocytic anemia in Sickle Cell?
Others?
1) Folate def. (increased RBC turnover)
2) Hydroxyurea use
hypothyroidism, liver dz, myelodysplastic, AML, zidovudine, chemotherapy
alcohol, B12
Shoulder Pain ddx:
Adhesive Capsulitis (“frozen shoulder”) vs Biceps Tendinopathy vs Rotator Cuff Tendinopathy (tests?) vs Glenohumeral OA vs subacromial bursitis
a) ROM
b) pain
c) weakness
decreased PASSIVE AND active ROM; stiffness>pain
vs
ANTERIOR shoulder pain (lifting, carrying, overhead reach); weakness uncommon
vs
NORMAL ROM; pain w/ abduction, ext rotation, subacromial tenderness; Neer/Hawkins test
vs
Decreased passive AND act. ROM and ext. rotation; trauma
vs
PAIN with active ROM and passive I-rot and forward-flex; caused by repetitive overhead motions
What do the following EKG changes signify
a) prolonged PR interval
b) F waves
c) electrical alternans
d) delta waves
e) new onset RBBB
f) 2 P’s before each QRS
g) increasing PR, decreasing RR, constant PP; dropped QRS
a) FIRST degree heart block, benign
b) a-flutter
c) QRS varies from beat to beat - pericardial effusion (+JVP, muffled heart sounds, and hypotension)
d) WPW
e) acute right heart strain (PE)
f) SECOND degree AV block 2:1 Mobitz 2
g) SECOND degree mobitz 1
Anemia of Chronic KIDNEY!!!!!! DISEASE
2) regular anemia of chronic dz
a) morphology
b) Tx
c) important complication and strat to avoid
a) microcytic hypochromic
b) EPO
c) iron def. bc of rapidly depleted stores
2) tx underlying (ex. methotrexate if RA)
Kid has low CD19 cell count but normal CD3. Dx? Tx for maintenance therapy?
Bruton’s X linked (bc low B cells and normal T cells).
Tx. IVIg
Prodrome of measles
Measles vs Roseola px
Measles vs Rubella
vs RMSF
Cough, Coryza, Conjunctivitis, Koplik spots
Tx - Vit A!!!
In measles the rash appears when the fever peaks, in roseola (HHV-6) the rash appears as the fever resolves
Similar but Rubella is milder and sorter, no oral koplik spots in Rubella. . Both cephalocaudal. Measles “darkens” but rubella doesn’t.
RMSF = centripetal spread (hands to in)
Vitamin Def.:
Zinc A B1 B2 B3 B5 B6 B9 B12 C D E K
Zinc - RF: TPN; alopecia, skin lesions, abN taste, impaired wound healing
Selenium - RF: TPN; CARDIOMYOPATHY
A - poor night vision, hypoparathyroidism, dry skin, impaired immunity
B1 (thiamine) - beriberi, wernicke’s
B2 (riboflavin) - angular chelosis, stomatitis, glossitis
B3 (niacin) - diarrhea, dermatitis, dementia, death
B5 (pantothenoate) - burning feet
B6 (pyridoxine) - peripheral neuropathy
B9 (FOLATE) - megaloblastic anemia/HSMneutrophils
B12 (cyanocobalamin) - “folate” + dorsal column signs
C - SCURVY (ecchymoses, bleeding gums, petechiae)
D - rickets, osteomalacia
E - peripheral neuropathy, hemolytic anemia (without MMA)
K - INCREASED PT/INR; “giving warfarin”
Carpal Tunnel Findings
Proximal vs Distal lesions of the median nerve?
THENAR ATROPHY
PARESTHESIA IN FIRST 3.5 DIGITS
THENAR and MIDPALM SENSATION INTACT
distal lesions (carpal tunnel, lunate dislocation)
vs proximal lesions (aka supracondylar humeral fracture) where thenar and midpalm sensation compromised (branch given off beforehand)
ACLS (no pulse aka cardiac arrest)
Vfib or pulseless Vtach tx? (3)
a) PEA/Asystole
- definition
1) DEFIB (shock) first
2) 1mg Epi q3min + CPR q2min
3) repeat defib + amiodarone
a) NO SHOCK but same-ish algorithm as above. def of PEA: organized rhythm on monitor but no pulse
Approach to Acute Lower Back Pain.
What are the Red Flags (~12)?
Red Flags: > 1 month, night, >50y, constant/dull/unremitting/unrelieved by rest/NOT exacerbated by movement, constitutional signs, hx of malig, IVDA, infx risk, trauma
1) If no red flags, conservative 4-6 wk
2) If RED flags, ESR+plain films
a) if abN, MRI (vertebral osteomyelitis will px w/ nL xray and ^ESR)
3) If cord compression signs, MRI
HIV (immunocompromised) neurology:
a) papilledema, fever, headache
b) CD4
c)
d) NON-RING-ENHANCING
e) RING-enhancing
a) cryptococcal meningoencephalitis
b) CMV
c) HSV-1 encephalitis
d) PML (JC polyoma virus)
e)
1) toxoplasma gondii (Toxo serology not necessarily specific in the US)
2) Primary CNS Lymphoma (esp. with + EBV DNA in CSF)
a) egg shell calcifications of hepatic cyst on CT
-cause!?
tx!?
b) cysts in the brain or liver
-cause!?
c) bloody diarrhea + liver signs (fever + RUQ pain)
-cause, tx?
a) HYDATID cyst 2/2 echinococcus granulosus
- SHEEP/dogs
- albendazole+aspiration
b) cysticercosis 2/2 taenia solium
- PIGS
c) amoebic liver abscess
- entamoeba histolytica; tx METRONIDAZOLE! (+paromycin for intraluminal coverage)
Leprosy
px
epid
dx
insensate, hypopigmented patch of skin
asian
acid-fast bacilli (mycobacterium leprae) on skin BIOPSY
Mixed Essential Cryoglobulinemia vs HSP
both have palpable purpura!
Cryo - assoc/ hep C and LOW complement
HSP - normal complement
Immunologic Blood Transfusion rxns
a) timing
b) path
c) sx
1) Febrile Nonhemolytic (MC)
2) acute hemolytic
3) delayed hemolytic
4) anaphylactic
5) urticarial/allergic
6) acute lung injury
1)
a) 1-6 hrs
b) cytokine accumulation during blood storage
c) fever, chills
2)
a) within 1 hr
b) ABO incompatibility ; + direct coomb’s
c) fever, flank pain, RF/DIC
3) 2-10 days; anamnestic Ab response/+D-coomb’s; fever
4) seconds; anti-IgA; shock, angioedema, resp distress
5) 2-3 hrs; angi-IgE + mast; flushing, pruitis
6) 6 hours; donor anti-leukocyte Ab; resp distress
Polymyalgia Rheumatica vs Fibromyalgia
sx
lab
tx
STIFFNESS, vROM in shoulders/neck/hips
VS
point tenderness and NORMAL physical exam
+/- decreased hematocrit; ESR!^ VS NORMAL
glucocorticoid taper
VS
exercise, sleep hygiene, stress reduction + TCAs, levomilnacipran/duloxetine [SNRI], pregabalin
EKG
a) inferior wall infarct, (vessels?)
b) STEMI affecting right-heart
c) pathophys of above phenomenon
d) POSTERIOR wall MI (B)
e) anterior
a) inferior leads (2, 3, avF) ST-elevation (RCA, LCX)
b) left-most leads (1, avL) ST-depression RCA (or elevation if LCX)
- right sided EKG to confirm RV infarct
c) RV involvement is common in inferior infarcts, leading to RVF (JVD, kussmauls increase of JVD with inspiration, and clear lung fields) leading to marked hypotension
d) V1-V3 ST- DEPRESSION
1 & avL ST-ELEVATION if (LCX)
1 & avL ST-DEPRESSION if (RCA)
e) V1-V6 (LAD)
What 4 other things do you need to screen for if you’re tx gonorrhea/chlamydia PID
1) syphilis (RPR)
2) cervical cancer (PAP)
3) Hepatitis B (HBsAg)
4) HIV
+HepC if IVDU
management of PNH?
1) Folate + Iron supp
2) ECULIZUMAB + N. MENINGITIDIS (bc eculizumab inhibits MAC formation)
Orthopedic Injuries
a) cause?
b) complications
1) Supracondylar Humeral Fracture
- “3” complications
1)
a) FOOSH
b)
i) brachial artery + median nerve (MC!)
ii) cubitus varus deformity (NOT limb length discrepancy!)
ii) compartment syndrome + volkmann contracture
Limb length discrepancy more common in more proximal humeral fractures
What is bacillary angiomatosis?
RF?
Dx
Cat Scratch nbs?
Immunosuppresed; caused by bartonella henselae/quintana
angioma-like blood vessel growths; large pedunculated exophytic papules with collarette of scale; resembles pyogenic GRANULOMA (benign vascular red papular tumor, pedunculated, bleeds) or cherry angioma. [resembles Kaposi!]
dx biopsy; tx abx
cat scratch tx azithromycin (Ab test or +warthin starry-stain to confirm)
High alk phos, constitutional, splenomegaly?
dx tx, mAT
Disseminated MAC w/ hepatosplenic involvement
CD4
azithromycin ppx
azithromycin or clarithromycin tx
most accurate test = NAA (nucleic acid amplification)
Microcytic/Hypochromic anemia simulating iron-def but iron studies show ^serum iron and -TIBC
dx
tx
Sideroblastic Anemia
pyridoxine
What are the recommended vaccines for adults (age 19+)? (3)
HIV?
Chronic Liver Disease
1) Influenza yearly
2) one Tdap then Td (booster) q10y
3) Pneumococcus
a) +65y: PCV13 + PPSV23 6-12 months after
b) -65y w/ high-risk: PCV13 +PPSV23 8 wks after, then q5y
c) -65y w/ med-risk: PPSV23 only
“medium risk” = smoker, EtOH, DM, chronic heart/lung/liver disease, nursing home
“high risk” = Sickle cell, asplenic, immunocompromised, cochlear implant, CSF leak
If HIV+:
1, 2, 3b
+ HepA Vaccine (gay sex, HepB+, HepC+, IVDU)
+ HepB Vaccine
+ HPV (9-26y)
+ meningococcus (11-18y, closed quarters, asplenic/complement deficiency)
LIVE (attenuated?) VACCINES CONTRAINDICATED IF CD4 v200
MMR, rotavirus, varicella, zoster, nasal flu, yellow fever,
If Chronic Liver Dz:
1, 2, 3b
+ HepA Vaccine
+ HepB Vaccine
What are the STD screening recommendations.
Confirmatory tests?
1) HIV
a) Age 15-65 (v65): one time *HIV p24 + antibody testing* if +, HIV-1/2 Ab immunoassay the "d-dimer" (if - but ^ios) HIV RNA (additionally pregnancy, MSM, unprotected sex, co-STD)
b) IVDU, MSM, homeless shelter, jail, partner of HIV+:
annual
2) Syphilis
a) No routine screening for syphilis. Only pregnant 1st prenatal visit, co-STD, MSM, whore, jail.
3) Gonorrhea
a) No routine screening gonorrhea in men (it’ll be symptomatic and obvious).
b) Screen sexually active women who are v25y, no condoms, multiple partners, co-STD, pregnancy
c) MSM at extra-genital sites
4) HepB! if high risk (unprotected or MSM)
5) HepC! (if transfusions before 1992 or baby boom?)
Cor Pulmonale vs Constrictive pericarditis
a) causes
b) clinical signs
c) imaging
a) COPD, PE [hypoxic vacoconstriction in lung-> PULMNONARY ARTERY HTN> 25 -> right ventricular hyperrophy]
vs TB (asia/africa), viral, RADIATION!, cardiac surg
AKA Hodgkin’s!
b) Loud, split P2; pulmonary HTN
vs (kussmaul [paradox INCLINE in CVP w/ insp], ascites/pedal edema), pericardial knock (early diastolic heart sound after S2), sharp x and y descents
constrictive = CALCIF RING AROUND HEART (pericardium)!
c) you see calcifications! confirm dx
Febrile/chills, w/ sudden onset of SHARPLY demarcated, erythematous, edematous, tender skin lesions with RAISED borders. FIREY RED
(What if it’s POORLY demarcated)
Dx?
Cause?
MC location?
purulent cellulitis subtypes (3) and def. and mc causative agent
Erysipelas [type of cellulitis that involves the superficial dermis]
vs (cellulitis, not raised)
Group A beta-hemolytic strep pyogenes
vs (beta-hemolytic strep, Staph Aureus)
Legs. (…)
Purulent Cellulitis (staph aureus!):
a) folliculitis
b) furuncles (boils) - folliculitis into dermis leading to abscess
c) carbuncles - multiple furunlces aggregated
Survival/prognosis/mortality
a) STEMI long-term prognosis
- strongest influence?
- ideal
b) COPD mortality reduction
c) CHF mortality reduction
d) Sudden Cardiac Arrest
a) “time to restoration of coronary perfusion” via
i) PTCA (-90 min ideal)
ii) fibrinolysis (-30 min ideal)
b) smoking cessation, oxygen
c) spironolactone, ACEi …
d) time to effective resuscitation
- bystander CPR
- rhythm analysis
- defibrillation
What is a complication that may arise in dehydrated post op patients? Path? Px? Tx?
Acute Bacterial Parotitis
staph aureus MC
painful chewing, erythematous parotid gland expulsing purulent saliva
adequate hydration and oral hygiene both pre and post op
EPIDEMIOLOGY
a) adrenal insufficiency?
a) DEVELOPING COUNTRIES: TB (look for CALCIFICATION)
DEVELOPED: autoimmune
Approach to Meningitis (bacterial for now)
- Algorithm
- Empiric Regimen
1) ^ICP? (immunosuppressed, FND, papilledema, AMS)
a) YES
b) NO
2)
a) BLOOD CULTURES, empiric, CT-head, LP
b) BLOOD CLX+LP, empiric
3) alter therapy based on LP if appropriate
dexamethasone + (3rd ceph + vanc) 1 month - 50y
dexamethasone + (3rd ceph + vanc + Amp) 50+y
–
(4th ceph + vanc) skull penetration/NS/shunt
(4th ceph + vanc+ Amp) im/comp
(amp+cefotaxime/AMG) v1 month
Notes:
amp covers listeria (alt: TMP-SMX)
steroids for when there’s pneumo, d/c if no pneumo
meropenem or ceftazidime can replace cefepime
Indications for Carotid Endarterectomy (2)
Statins?
Aspirin 81
1) ALL symptomatic 70+% stenosis
2) MEN asymptomatic 60+% stenosis
1) Clinically significant atherosclerotic dz (CAD, CVD, PAD)
2) LDL>190 (high intensity)
3) ANYONE age 40-75 w/ DM
- note, you don’t always give ACEi; pressure has to be 140/90 or higher
4) ASCVD>9%
1) >50y
Foot Injuries
a) Stress Fracture tx?
b) Plantar Fasciitis
c) Achilles Tendinopathy
d) Morton Neuroma
e) Tarsal Tunnel Syndrome
a) Insidious; focal pain in navicular or metatarsals; RF: abrupt increase in training, poor running mechanics, female with eating dz;
- tx rest and analgesia
b) Worse when initiating running or first steps of the day
c) Burning pain/stiffness
d) Common digital nervitis: Numbness/pain between 3rd/4th toes; **clicking sensation when palpating space between 3rd/4th toe while squeezing metatarsal joints. (wearing heels?)
e) Compression of tibial n. at ankle; burning/numbness/aching of distal plantar surface of foot/toes
Diarrhea
a) MC febrile, bloody; what caution!?
b) ddx for LONG TERM (+2wk) traveller’s diarrhea
c) ddx for SHORT term (-2wk) traveller’s diarrhea
d) asia, africa, centra/south america, ab pain bloody diarrhea
a) E Coli; avoid empiric abx bc precip HUS
b) (nonbloody, watery)
1) cryptosporidium parvum
2) cystisospora
3) microsporidia
4) cyclospora
5) GIARDIA
c)
1) rotavirus/norovirus (brief, vomiting)
2) ETEC, EPEC (contaminated food/water)
3) Campylobacter (abdominal pain PSEUDOAPPY, bloody)
4) Salmonella (fever)
5) Shigella (bloody, ab pain)
d) entamoeba histolytica
Diuretics
[prostaglandins normally vasodilate]
1) loop diuretics potentiate PGs! Therefore NSAIDs can cancel this therapeutic effect!
2)
a) ATP-dep K+ channel opening, which leads to vasodilation
b) thiazides are ATP-dependent K+ channel OPENING (like diazoxide/minoxidil), which decreases insulin release from the pancreas [contrast sulfonylureas which BLOCK K+ channels] (c/i in diabetes?)
c) LOOPs and thiazides decrease urate excretion by increasing net urate reabsorption (by either increased reabsorption directly, or decreased secretion back into the lumen)
1) Natriuresis! (except with osmotic diuretics)
2) Look for Kaliuresis (if you don’t see this, it’s an Aldosterone antagonist)
3) Look for Bicarbonaturesis (if you see this, it’s CAi/acetazolamide)
4) Look for Calciuresis (if you see this, it’s Loop)
1) Acetazolamide (but paradoxical hypOkalemia) and Aldosterone Blockers cause ACIDOSIS
LOOPs and Thiazides cause ALKALOSIS
dx, TREATMENT!?!?!?
Slowly growing, nontender mandibular indurated mass with yellow granular pus s/p dental, poor oral hygeine, malnutrition, DM, or i/s
Purulent crusting lesions/ulcers s/p traumatic inoculation (“puncture wound while gardening”)
Cervicofacial Actinomycosis (yellow “sulfur granules)
actiNo aNaerobe, gram + an
tx Penicillin
Nocardiosis
noCAERdiosis, AERobic, gram+ (*partially acid fast)
tx TMP-SMX
px - TB-like, pulm nodules, pneumonia-like; CNS!
1 ) PERIorbital edema, myositis, eosinophilia/CPK; w/ fever, subungual splinter hemorrhages, and conjunctival/retinal hemorrhages?
2) Nonproductive cough then intestinal signs
3) RETRO-orbital pain, fever/h-a, rash, myalgia/arthralgia
4) POLYARTHRALGIA, LYMPHO/THROMBOCYTOPENIA fever/h-a, myalgia, conjunctivitis
5) tropical, Skin, Pulm, GI (NO DIARRHEA)
what do 3 and 4 share in common
1) Trichinellosis - roundworm/pork
a) intestinal stage (sp 1 week of ingestion)
b) muscle stage (sp 4 weeks of ingestion) - eosinophilia, CK
2) Ascaris Lumbricoides
a) pulm phase
b) intestinal phase
3) dengue fever
4) chikungunya
5) strongyloides stercoralis
both caused by AEDES mosquito
Shift work vs Delayed sleep-phase
!!!
?
“not your fault”
vs “YOUR fault”
desire/work schedule incongruent w/ internal clock
vs
internal clock incongruent w/ desire/work schedule
sleep problems after beginning night shift
vs
night-shift worker rollin’ along just fine (which isn’t normal, societally) until all of a sudden required to work day shift and gets fucked, BUT CAN SLEEP IN ON THE WEEKENDS
*** delayed sleep-phase = “night owl” common in teenagers
TOXICITY and POISONING
NBS in the following overdoses? MoA?
1) TCA.
- Overall tox?
- What EKG changes do you see and what electrolyte abN does this resemble; what NOT to give
2) Aspirin - what acid base disturbance
3) Acetaminophen
- what else is this antidote used for
4) Organophosphates
5) Hyperkalemia
6) Torsadde’s w/ prolonged QT
7) Caustic (oven cleaner, draino, KOH, lye)
8) isopropyl vs ethanol vs methanol vs elthylene glycol
1) general: NaHCO3, IVF, charcoal, supp 02/intubation
- CNS (coma, convulsion, sedation), anticholinergic (hot, mydriasis/cycloplegia?, ileus, urinary retention, dry mouth), cardiac (MC cause of death)
“cgACh” [anti-cardiac fast Na, anti-GABA-a, anti-Alpha1, anti-Cholinergic, anti-H1]
TCAs inhibit fast Na channels in the his purkinje system and myocardium, decreasing conduction velocity and increases repolarization, prolongs absolute refractory periods, leading to hypotension, ^QRS, and vtach/vfib
do NOT give physostigmine (even thought there’s anti-cholinergia). it worsens heart conditions.
NaHCO3 - tx cardiotox (>100 msec QRS, v-arrythmia)
moa: sod-bicarb ALKALINIZES everything and increases extracellular SODIUM. The alkalinity keeps the TCA neutral (nonionized) and away from the sodium channels. The extracellular sodium increases the electrochemical gradient across cardiomyocytes, which helps keep the heart going (negates cardiodepression)
Resembles hyperkalemia (except hyperkalemia has peaked T and depressed ST and no ^QT) in its prolonged PR/QRS/QT
2) MIXED resp alk (stim resp center) and AGMA (acid buildup from uncoupling of oxPhos
tx- NaHCO3 -
3) NAC
- nephroprotection for radiocontrast induced nephropathy
- mesna is used to prevent hemorrhagic cystitis in the setting of cyclophosphamide use
4) (organophosphate = anticholinesterase = procholinergic = bradycardia, miosis, salivation)
tx - atropine + pralidoxime
5) calcium gluconate; kayaxelate; SABA; insulin+glucose; loop+IV fluids
6) Mg++ SO42-
7)
a) ABCs
b) decontaminate
c) barium esophogram w/in 24h
d) strictures at 2-3 wks can form
8) iso isn’t AGMA (mudpiles) and has absent ciliary reflex and dysconjugate gaze
vs methanol has blindness, APD, central scotoma
vs ethylene glycol has flank pain and Ca oxalate
Ddx for hair loss in all ages
What is Pediculosis Capitis
a) Tinea Capitis
- Trichophyton tonsurans (black dot tinea capitis) [MC in blacks]
- Microsporum Canis, Microsporum audouinii
- transferred thru fomites (ie combs)
- scaly erythematous patch, may progress to alopecia leaving a black dot
- dx KOH, tx ORAL GRISEOFULVIN (contacts tx selenium sulfide or ketoconazole shampoo)
b) Autoimmune
- Alopecia areata (smooth areas of hair loss w/out scaling)
- Discoid Lupus Erythematosus (plaques, cutaneous lesions, inflammation of hair follicle, photosensitivity, pruitits
c) pressure-induced (postoperative) alopecia
- prolonged pressure on the scalp after surgery under general anesthesia
d) trichotillomania
- irregular pattern and length
- Pediculus humanus capitis (head louse)
- pruritis but NO ALOPECIA
MC CAUSE of steatorrhea?
Steatorrhea + villous atrophy on biopsy + NEGATIVE IgA anti-tissue transglutaminase . Explain
1) What is the utility of the D-Xylose test?
2) Explain “abnormal” vs “normal” result
3) Etiologies for each result
Chronic Pancreatitis 2/2 EtOH
Still CELIAC! it was confirmed on biopsy. they probs have IgA deficiency
1)
Xylose is already fully digested; all it needs is intact sm. intestinal mucosa for absorption
Pancreatic Enzymes are NOT required for carbohydrate digestion!
Therefore, the utility of the D-xylose test is to determine the etiology of suspected malabsorption (steatorrhea, etc.)
2)
Abnormal = DECREASED D-xylose absorption, DECREASED D-xylose in urine, INCREASED D-xylose in feces
Normal = INCRESED D-xylose absorption, INCREASED D-xylose in urine, DECREASED D-xylose in feces
3)
Abnormal suggests proximal small intestinal disease (celiac, etc.)
Normal suggests pancreatic etiology (because the brush border is intact, the steatorrhea must be due to fat malabsorption)
Performance enhancement ADRs
a) Androgen abuse (4)
b) autologous transfusion (1)
c) EPO (MC to LC ADR) 1 (3)
a) GYNECOMASTIA!!!!!!!!!!!!!!!, POLYCYTHEMIA, LVH, (decrease HDL ^LDL)
b) only increased hematocrit
c) increased hematocrit, (HTN!, headaches, flu-like)
What is erythema nodosum and how should you work it up?
Painfus erythematous/violaceous SQ nodules on anterior LL
Can be benign, but also can signify serious dz such as
a) recent strep MC (ASO aka anti-streptolysin O)
b) sarcoidosis (CXR) [uveitis too]
c) TB (PPD)
d) Histoplasmosis, Coccidiomycosis
e) IBD exacerbation (stool, colon studies)
HIV and co. PHarm
What are the ADR of the following: (reverse)
a) pancreatitis
b) HSR
c) Lactic Acidosis
d) SJS
e) Hepato failure
f) Crystal-induced AKI
g) AIN
a) didanosine
b) abacavir
c) any NRTIs
d) any NNRTIs
e) nevirapine
f) ACYCLOVIR, sulfonamides, methotrexate, ethylene glycol, protease inhibitors
g) penicillins, PPIs…e tc?
Thyroid
a) increased thyroid, suppressed TSH + RAIU uptake only in 1 lobe (suppression in the rest of the gland)
b) RAIU patchy
c) RAIU markedly reduced
c) Hashimoto
a) thyrotoxicosis 2/2 toxic adenoma
b) toxic multinodular goiter
c) painless thyroiditis
d) hypO or euthyroid
Extrahepatic Hepatitis Manifestations
b)
c)
B) PAN (immune complex deposition in BV walls)
C)
- porphyria Cutanea tarda (photosensitivity; vessicles/erosion on hands)
- membranoproliferative GN
- mixed essential CRYOglobulinemia (immune complex deposition in BV walls, low complement)
4/5: leukocytoclastic vasculitis (HSP?), lichen planus
Patient receiving abx and TPN develops bleeding at the IV site. Explain both causes
Vit K def (abx destroy gut flora, no enteral nutrition)
RVMI (RVentr. MI)
a) EKG
b) px (3)
c) goal and justification of tx. and what to avoid.
1) initial (expound)
2,3) “unique”
4) avoid
a) ST-elevations in (2, 3, avF), since RVMI is usually caused by inferior wall infarcts
b) MI signs, HYPOTENSION (decreased left heart filling), JUGULAR VENOUS DISTENTION (due to RV dysfunction)
c) RH is failing so they need HIGH preload to maintain CO;
1) initially tx like normal MI*
2) in patients with hypotension and low/normal JVP, give HIGH-FLOW IVF to increase preload
3) if JVP is elevated, IVF less helpful
4) AVOID NITRATES, OPIATES, DIURETICS (since these can precipitate hypotension)
Reperfusion therapy + *MONABScH (! caution in RVMI)
PCI/tPA Morphine (!) Oxygen Nitrates (!) [give for CHF, CP, HTN; C/i!!! in RVMI, sildenafil] [Aspirin + P2Y12* r-block] = "dual antiplatelet" Beta-block (~) Statin Heparin/Enoxaparin/Fondaparinux
P2Y12 is the Gc ADP receptor (clopidogrel, prasugrel, ticlopidine, ticagrelor) aka THIENOPYRIDINES aka ADP antagonist
Bone Tumors
1) What is Giant Cell Tumor of Bone? Alternate name? Benign/malignant? trick Location?!
2) Osteoid Osteoma vs Osteoblastoma: (both benign tumors of osteoblasts) (4)
3) Chondroma vs Chondrosarcoma locations
1)
Giant Cell Tumor (OsteoCLASToma) is a benign, aggressive, bone tumor.
-epiphysis of the distal femur and proximal tibia.
-Unlike most bone tumors which occur most commonly in males, giant cell tumors of bone most commonly occur in females in early to mid-adulthood (20-40 years of age).
-Radiologic imaging of giant cell tumors of bone show destructive lytic lesions near joints, with a characteristic “double bubble” or “soap bubble” appearance.
less
-Giant Cell/Osteoclastoma is the ONLY bone tumor in the EPIphysis!
2)
An osteoblastoma is a benign, bone-producing tumor similar to osteoid osteoma, but unlike an osteoid osteoma, is not self-limited (with a nidus usually greater than 2 cm in diameter).
- Osteoblastoma pain not relieved by aspirin (vs osteoid osteoma, nocturnal and relived by aspirin)
- Osteoblastomas most commonly occur in the (metaphysis?) of vertebrae vs osteoid osteoma usually the cortex of the diaphysis of the long bones.
- Osteoblastomas are most commonly seen in young patients (10-30 years of age).
- Histology of osteoblastomas, similarly to osteoid osteomas, show a NIDUS of vascular osteoblastic tissue (interlacing trabeculae of immature woven bone lined by regularly arranged osteoblasts) surrounded by normal reactive bone. but blastoma nidus >2 cm in diameter.
3) medulla/fingers vs medulla/pelvis
always medulla for chondros!
Biostat Definitions
1) Hazard Ratio
1) Ratio of event occurring in tx arm vs non-tx arm
a) less than 1 = tx arm had lower event rate
2)
Study Design
1) Factorial Design
2) Parallel-group
3) Crossover
4) Cluster
1) randomization to different interventions w/ additional study of 2 or more variables
ex. BB, CCB, ACEi and each has two different bp endpoint groups
2) Randomizes one tx to one group and a different tx to another group. No other variables
ex. Drug vs placebo
3) group of participants is randomized to one tx for some time, and the other group is given an alternate tx for the same period of time. Then switch.
4) Grouping of different data point into similar categories; randomization at the level of groups
Indications for Lymph Node Biopsy
Indications for sputum culture
Often normal in children, young adults. s/p infx, rubbery
Bad signs:
Painless, firm, immobile
Biopsy if >2 cm. Observe otherwise
- MRSA
- bioterrorism
- Legionella (+urine Ag/ab?)
- TB
- fungal
