UW Flashcards
liver enzyme levels typical of alcoholic liver disease?
AST:ALT ratio of atleast 1.5, AST rarely more than 300 units/L
complication of critical illness that arises 2ndary to gallbladder stasis and presents w Sxs of biliary obstruction? what will be more elevated than the AST and ALT?
Acalculous cholecystitis;
Alk phos and total bilirubin levels
the hallmark of this is a rapid and massive increase in AST and ALT with modest elevations in total bili and alk phos
ischemic hepatic injury following hypoTN ie from septic shock or HF
pts with WPW Sy who develop a fib w RVR should be treated with what is stable? if unstable?
antiarrhythmics such as procainamide;
immediate cardioversion
ventilation-perfusion scan is used to Dx? which typically presents with what Sxs?
PE;
dyspnea, tachypnea, pleuritic chest pain, S/Sxs of DVT
acute limb ischemia (cold, mottled, puseless) after MI suggests possible ____ from….? Management?
arterial embolus from LV thrombus;
immediate anticoagulation, vascular surg consult, echo (to screen for LV thrombus)
presents with hematuria, RBC casts, acute renal failure, HTN, and edema ?
glomerulonephritis
Pts present w. fever, rash, AKI, and eosinophiluria w. WBC casts? most commonly d/t?
Interstitial nephritis;
drug rxn
ARP represents the excess risk in an exposed pop. that can be attributed to the risk factor, how can it be derived from RR?
ARP = (RR-1)/RR
patient has severe hyperkalemia and ECG shows lack of p waves, QRS widening and bradycardia, next step in Mx? then?
IV Ca++ gluconate to stabalize cardiac membrane;
IV insulin w glucose, beta- agonists to transiently shift K into cells lowering serum levels
after transient measures what definitive measures can reduce total body K?
reversal of correctable etiology (ie IV fluids for pre-renal AKI), diuretics (dont use if dehydrated), exchange resins, hemodialysis
warfarin dose is typically adjusted to achieve a therapeutic INR value btwn?
2 and 3
(nml INR is 0.8-1.1
chronic pancreatitis is MC d/t alcohol use and can present with N/V and abd pain radiating to back, imaging typically reveals?
pancreatic calcifications
Tumors in the head of the pancreas can present w weight loss, painless jaundice, non-tender distended gallbladder on exam, characteristic imaging finding?
Intra- and extrahepatic biliary tract dilation
pancreatic tumors are MC where? and present with?
head of pancreas;
weight loss, jaundice (itching, pale stools, dark urine), non-
tender distended gallbladder
when would pancreatic cancer present with abdominal pain without jaundice?
cancers in the body or tail of pancreas
pt presents after episode of binge drinking w N/V, severe epigastric pain that radiates to the back but otherwise stable, next best step in Mx?
serum amylase and lipase
if levels are more than 3x nml then imaging would not be needed to Dx acute pancreatitis
type of dementia characterized by fluctuating cognition, bizarre visual hallucinations and parkinsonism
Dementia with Lewy bodies
chronic use of _____ can cause painless proximal muscle weakness esp in legs, ESR and CK will be nml, slowly improves after stopping offending med
glucocorticoids (ie glucocorticoid- induced myopathy)
presents w aching and morning stiffness w pain and decr ROM in shoulder, neck and hips, nml strength, can be seen in up to half of pts w temporal arteritis? ESR will be? Mx?
Polymyalgia rheumatica;
ESR usually more than 40;
Sxs improve rapidly with glucocorticoids
NF type 1 is c/b cafe-au-lait macules, freckling in skin folds, Lisch nodules, and neurofibromas, kids may also develop ____ which manifest w unilateral vision loss, proptosis, esotropia, and optic disc pallor
optic pathway gliomas
this type of heart block is due to delayed impulse transmission from A to V, leads to prolonged (but constant) PR interval (more than 0.20s), there is a QRS for every p wave
first degree AV block
Type of heart block w no impulse conduction from A to V, ECG shows p waves completely unrelated to QRS
third-degree ie complete AV block
Toxic megacolon is a med emergency that requires prompt..
IV steroids, NG decompression, ABXs and fluid management
imaging of choice if pt presents in ER w unprovoked first seizure and possible head trauma ?
brain CT withOUT contrast to exclude intracranial or subarachnoid bleed
most sensitive in identifying structural causes of epilepsy thus imaging modality of choice in nonemergency/elective situations?
MRI
causes HA, fever, focal neuro deficits and altered mental status in pts w advanced HIV (CD4 less than 100/mm3), MRI of brain reveals multiple ring-enhancing lesions? Tx?
Toxoplasmosis;
Sulfadiazine and pyrimethamine (plus leucovorin to prevent hematologic side effects)
fever and sore throat in any pt taking antithyroid drugs suggests? (the most feared ADR of PTU and methimazole) the most imp NEXT step?
agranulocytosis (caused by immune destruction of granulocytes); STOP the antithyroid drug and measure WBC count
Calcium level of 13.5, should be what until proven otherwise
malignancy
when is carotid endarterectomy indicated?
pts with symptomatic carotid artery stenosis of 70-99%, men with ASx stenosis of 60-99% may also benefit
this drug rapidly breaks down serum uric acid and can be used for Tx of hyperuricemia and tumor lysis syndrome?
Rasburicase
MC malignancy of the lower lip? Bx c/b?
SCC; invasive cords of squamous cells w keratin pearls
Hallmark triad of nml pressure hydrocephalus?
dementia, gait disturbance, urinary incontinence
(wacky, wobbly, and wet), the memory impairment is very slow and progressive
CT or MRI shows what in nml pressure hydrocephalus?
dilated ventricles
which Graves disease Tx option can worsen ophthalmopathy? what can be used to minimize this effect?
radioactive iodine;
glucocorticoids and antithyroid drugs can be given first
Pts present w weakness of contralateral face, arm and leg (pure motor hemiparesis), and a noncontrast CT shortly after event will look nml (no sensory loss, seizures or cortical signs)?
Lacunar stroke (microatheromas and lipohyalinosis lead to thrombotic small-vessel occlusion of penetrating arteries)
Tx of actively bleeding esophageal varices?
place 2 large-bore IVs, volume resuscitation, IV octreotide, ABX prophylaxis then urgent endoscopic therapy
this statistical method is used to compare the means of 3 or more variables?
Analysis of variance (ANOVA)
DOC for pregnant/lactating pts and kids less than 8yo w early localized Lyme disease (erythema migrans)?
Amoxicillin
since Doxy can cause permanent teeth discoloration and retard skeletal development
Should be suspected in pts with HTN, hypercalcemia, kidney stones, and depression?
Hyperparathyroidism
an uncommon cause of secondary HTN
poisoning with this causes hypocalcemia and Ca oxalate crystals.. pts develop flank pain, hematuria, oliguria, AKI, anion gap met. acidosis (low bicarb)?
Tx?
Ethylene glycol ingestion;
Fomepizole or ethanol, sodium bicarb for acidosis, hemodialysis may be needed in severe cases
Tx for moderate to severe COPD exacerbations?
O2 (target SpO2 of 88-92%), inhaled bronchodilators, systemic glucocorticoids, ABXs (may need NPPV or intubation)
EKG with diffuse ST elevation w the exception of reciprocal depression in aVR is classic for?
pericarditis
a couple weeks after an MI a pt has S/Sxs of pericarditis, elevated ESR, most likely? Tx?
Dressler’s Syndrome;
NSAIDs (corticosteroids used in refractory cases or if NSAIDs CI) (avoid anticoagulation)
In the absence of clear provoking factors (ie recent procedure, immobilization), pts w a first episode of VTE should be referred for?
chest x-ray and age appropriate cancer screening (ie colonoscopy, mammogram)
the Number needed to treat is ? how is it calculated?
the number of ppl that need to receive a Tx to prevent 1 additional adverse event; NNT=1/ARR
Causes of secondary gout due to increased urate production?
Myeloproliferative/ lymphoproliferative disorders, Tumor lysis syndrome, HGPRT deficiency (Dxed in childhood)
Causes of secondary gout d/t decreased urate clearance?
CKD, thiazide/loop diuretics
Pruritis triggered by hot water, hepatosplenomegaly, HAs, and gout together suggest? which is c/b?
Polycythemia vera;
incr cell turnover d/t clonal hyperproliferation in all 3 primary bone marrow lineages
can cause invasive infections in pts with weak immune systems who have dental infections/trauma (extraction) -nonpainful mandible mass that drains yellow granules ? Tx?
Actinomyces (filamentous G+ rods w branching);
PCN for 2-6mos, surgery if severe
_______-induced psychosis is c/b delusions, hallucinations, disorganized thoughts and aggression
corticosteroid
c/b severe hyperglycemia, high serum osmolality (320+), nml anion gap, bicarb greater than 18, neg or small serum ketones? clinical symptoms?
Hyperosmolar hyperglycemic state; altered mental status, gradual onset of hyperglycemic Sxs, hypovolemia and dehydration
the Altered mental status seen in pts with hyperosmolar hyperglycemic states is d/t?
high serum osmolality
Urine sample staining positive with Prussian blue indicates?
presence of hemosiderin, which is found in urine during hemolytic episodes
G6PD deficiency causes hemolytic anemia d/t? Hemolytic episodes can be precipitated by?
oxidative injury to RBCs;
infection or meds (esp Sulfa drugs, antimalarials and nitrofurantoin)
an older pt w long standing hypothyroidism presents w new onset hoarseness, dysphagia, mild fever, diffusely enlarged, firm, mildly tender thyroid, nml TSH and elevated anti-TPO Abs. Dx?
Thyroid lymphoma, which is much more common in pts w preexisting chronic lymphocytic (Hashimoto) thyroiditis as in this pt
Typical presentation of thyroid lymphoma?
rapidly enlarging firm goiter assoc w compressive Sxs ie hoarseness/dysphagia. As w other lymphomas- pts may have systemic B Sxs (fever, night sweats, weight loss)
c/b progressive fibrosis of the thyroid gland and surrounding tissues, Sxs are chronic and slowely progressive
Riedel thyroiditis
Typically follows an acute viral Sy and presents w fever, neck pain, and a tender diffuse goiter. Pts commonly thyrotoxic d/t release of preformed thyroid hormone
Subacute (de Quervain) thyroiditis
Infliximab ?
drug that blocks TNF-a, used to treat inflammatory conditions ie RA, crohns, psoriasis - it suppresses immune system
RUQ/epigastric pain that radiates to right scapula or shoulder think?
Acute Cholecystitis/biliary colic
Overproduction of calcitriol (active form of vit D) is seen in what kind of diseases?
granulomatous- such as sarcoidosis and TB
most pts w this are ASx but can get skeletal deformities, bone pain/fractures. Involvement of cranial bones may lead to HAs and hearing loss
Paget disease (c/b osteoclast dysfxn)
This is used primarily to treat infections w anaerobic organisms and is the ABX of choice in aspiration pneumonia
Clindamycin
Sxs seen in Legionnaires’ disease that distinguish it from other causes of CAP?
GI Sxs (D/V), high fever, neuro Sxs (confusion, ataxia). Hyponatremia and hepatic dysfxn are common
Tx of Legionella pneumonia?
fluoroquinolones or macrolides
Hypothyroidism can cause additional metabolic abnormalities such as?
hyperlipidemia, hyponatremia, and asymptomatic elevations of CK, AST and ALT
occurs as a response to severe infection and is c/b more than 50,000 WBCs, more metamyelocytes then myelocytes, and high leukocyte alkaline phosph?
Leukemoid reaction
This drug can treat cholesterol gallstones in pts w mild Sxs who cant get cholecystectomy, also Tx for PBS and PSC
Ursodeoxycholic acid
Pts typically have pruritis, fatigue, jaundice, abd pain, and Antimitochondrial Abs
Primary biliary cirrhosis
Recommended vaccines for pts with chronic liver disease?
Tdap once then Td every 10yrs, Flu, PPSV23 once then PCV13 and PPSV23 at age 65, if sero negative need Hep A and B
Pt attempts suicide and ODs on acetaminophen, in hospital pt develops scleral icterus and asterixis, PT goes up to 120s, total bili, AST and ALT get very high, next best step?
Refer to liver transplant center (ALF defined as elevated AST/ALT often 1,000+, hepatic encephalopathy and synthetic liver dysfxn- prolonged PT w INR more than 1.5)
most common cause of death following acute liver failure?
cerebral edema that leads to coma and brain stem herniation
in ALF due to acetaminophen toxicity, liver transplant is firmly indaicated in pts with?
grade 3-4 hepatic encephalopathy, PT more than 100s and serum Cr more than 3.4mg/dL
the most common cause of hypernatremia is hypovolemia, mild cases can be treated with? and severe cases with?
mild: 5% dextrose (or 0.45% saline);
0. 9% saline until vol deficit restored then switch to hypotonic fluid (5% dextrose in water prefferred)
Goal rate of plasma sodium correction is no more than?
1mEq/L/hr
This infection usually causes subacute meningitis in pts w/ HIV, esp CD4 counts less than 100, can also cause severe pneumonia in these pts
Cryptococcal
typically presents w subacute fever, dyspnea, and cough in pts w CD4 counts less than 200, CXR is often nml or shows diffuse alveolar infiltrates
Pneumocystis pneumonia
Pts typically present w subacute or chronic Sxs- fever, fatigue, cough, weight loss, night sweats; upper lobe cavitary lesions are common on CXR
TB
4 MCCs of cirrhosis in the US?
Viral hep (C more than B), chronic alcohol abuse, NAFLD, and hemochromatosis
X-rays of pts w long-standing, poorly controlled RA will reveal?
periarticular osteoporosis, joint erosions and joint space narrowing
Avascular necrosis of bone is MC in pts with?
systemic corticosteroid use, heavy alcohol use, SLE, or sickle cell disease
2 weeks following knee surgery pt presents w sudden onset dyspnea, nonprod cough, tachycardia, mild hypoxia, highly suggestive of? test of choice?
PE; CT angiography (TOC in stable pts with likely acute PE, and empiric anticoagulation is often appropriate)
which metal in jewelry is most likely to cause allergic contact dermatitis? most pts respond well to?
Nickel;
topical corticosteroids and elimination of exposure
modified CHADS-VASc score is used for stroke risk assessment, it stands for?
CHF HTN Age (75+) (2) DM Stroke/TE/TIA (2) Vascular disease Age 65-74 Sex category (ie female)
Most imp pre-disposing factor assoc w developing aortic dissection?
HTN
condition responsible for almost 50% of aortic dissections in pts less than 40yo? (but an uncommon cause in pts 60+)
Marfan Sy
Most appropriate tests to Dx acute hep B infection?
test serum for HBsAg and anti-HBc
Urinalysis in contrast induced nephropathy (CIN) typically shows? CIN usually begins to resolve within?
muddy-brown granular cell casts;
3-5days
should be suspected in pts w multisystem involvement with renal failure, eosinophilia, cerebral or intestinal ischemia, hollenhorst plaques, and livedo reticularis/blue toe Sy after recent arteriography or cardiac cath
Cholesterol crystal embolization (atheroembolism)
what findings on CXR suggest thoracic aortic aneurysm?
widened mediastinum, incr aortic knob, tracheal deviation
Ascending aortic aneurysms are MC d/t?
Descending ones are MS d/t?
cystic medial necrosis or CT disorders;
atherosclerosis
holosystolic murmur that increases in intensity with inspiration?
tricuspid regurg (augmentation of intensity with inspiration means it is a right sided systolic murmur)
what is the preferred HIV screening test?
HIV p24 antigen and HIV Ab testing
plasma HIV RNA if pt has neg serologic tests but high clinical suspicion of acute HIV
who should be screened for Hep C?
those who use injection drugs, have a high-risk needle stick exposure, or received blood transfusions before 1992
chest CT showing a wedge-shaped infarction is virtually pathognomonic for?
PE
3 MCCs of chronic cough (more than 8wks)?
upper-airway cough Sy (post-nasal drip- improves with antihistamines), asthma and GERD
this marine bacterium primarily causes infection via raw oyster consumption or wound infections which can be mild or rapidly severe- nec fasc w hemorrhagic bullous lesions and septic shock? Tx?
Vibrio vulnificus;
IV ceftriaxone and doxy
pts w what conditions are at incr risk of vibrio vulnificus infection?
those w liver disease (cirrhosis, hepatitis) or Hereditary hemochromatosis (iron acts as growth catalyst)
In a fib w/ RVR, rate control should be attempted initially with?
if pt with rapid a fib is unstable what is indicated?
beta-blockers or Ca-channel blockers
seen primarily in pts w HIV (CD4 less than 100), vascular skin lesions- red/purple papules to friable pedunculated or nodular lesions, constitutional Sxs, +/- organ (CNS, liver, bone) involvement? Tx?
Bacillary angiomatosis ;
Doxy or erythromycin (plus need antiretrovirals)
seen in HIV pts w CD4 less than 50:
1) causes constitutional Sxs and GI sxs (D, abd pain)
2) causes retinitis, colitis, pneumonitis, encephalitis and other organ involvement
1) disseminated MAC;
2) CMV
sudden-onset dyspnea, tachycardia, chest pain with pleural effusion but no consolidation on CXR suggests? confirmatory test?
PE;
CT pulm angiography
CXR findings of TB ?
hilar adenopathy and/or cavitary/patchy lung lesions (solitary nodules are not typical)
MC type of lung ca in both smokers and nonsmokers? nonsmokers usually only get this kind of primary lung ca.
presents with?
Adenocarcinoma;
peripherally located solitary lung nodule, w/ or w/o Sxs
what is considered resistant HTN? all pts with it should be evaluated for?
persistent HTN despite using atleast 3 diff classes of antihypertensive (one being a diuretic); secondary causes
continuous abd bruit is up to 99% specific (but not sensitive) for?
Renal artery stenosis
Urinary vanillymandelic acid is incr in what cause of secondary HTN? pts present with episodic…
pheochromocytoma;
HAs, palpitations, and/or diaphoreis assoc w paraxoysmal elevation in BP
usually presents w fever, back pain, and focal spinal tenderness, markedly elevated ESR and CRP? imaging modality of choice for Dx?
Osteomyelitis
MRI
how is Dx of fibromuscular dysplasia confirmed?
CT angiography of the abd or duplex U/S
pt presenting w STEMI plus holosystolic murmur at the apex and bibasilar crackles of lungs is consistent with?
acute MI with papillary m. displacement leading to acute mitral regurg and pulm edema
all pts w acute cocaine toxicity and MI should be txed initially with?
supplemental O2 and IV benzos (aspirin, nitroglycerin and Ca-channel blockers also used for initial Mx of the chest pain)
How is Dx of asthma confirmed on PFTs reguardless of age
reversible airway obstruction (more than 12% incr in FEV1) after bronchodilator with nml diffusion capacity for CO
pleural effusions are common in pts w pneumonia, they are exudative so pleural fluid protein/serum protein ration will be:
greater than 0.5
when should pts with COPD initiate long term home oxygen?
those w signs of right HF or hematocrit more than 55 should be started if?
resting PaO2 of 55mmHg or less or O2 sat 88% or less;
PaO2 59mmHg or less or O2 sat 89% or less
a brain that has seized for more than 5 mins (status epilepticus) is at incr risk of developing?
cortical laminar necrosis, which can lead to persistent neuro deficits and recurrent seizures
TCA OD can present w CNS, cardia and anticholinergic findings, what is used for Tx of cardiac toxicity (c/b prolonged QRS to 100+ msec, and ventricular arrhythmias)? mechanism?
Sodium bicarbonate- increases serum pH and extracellular Na thus alleviating the cardio-depressant action TCAs have on Na channels
“eggshell” calcification of a hepatic cyst on CT scan is highly suggestive of ? d/t?
Hydatid cyst, d/t Echinococcus granulosus- a tapeworm humans contract from dogs
SJS vs TEN ?
less than 10% of BSA is SJS, some overlap but if more than 30% BSA = TEN
delta wave is? assoc with?
upsloping just before QRS cmplx, occurs in pts w accessory conduction pway like WPW
what 2 organisms are responsible for most deep infections such as osteomyelitis following puncture wounds?
Staph aureus and pseudomonas aeruginosa (esp after puncture through a shoe d/t moist environment)
Tx of pituitary prolactinoma?
if symptomatic or 1+cm: dopaminergic agonists (ie Cabergoline, bromocriptine) to normalize prolactin levels and reduce tumor size; if pt fails to respond or tumor 3+cm- transphenoidal resection
Ring sideroblasts are seen in sideroblastic anemias which typically are what type of anemia? Hgb will be?
microcytic;
less than 7
Should be suspected in elderly pts w/ weight loss, fatigue, hypercalcemia, normocytic anemia, renal insuff and a protein gap (may have bone pain), peripheral blood smear shows rouleaux formation?
Multiple Myeloma
In multiple myeloma, serum protein electrophoresis shows? Dx is then confirmed by bone marrow biopsy which will show?
monoclonal M-spike;
more than 10% clonal plasma cells
the critical distinction btwn case control and retrospective studies?
is the order in which outcomes and RFs are assessed. Case control: determine outcome first then look back for assoc RFs; retrospective cohort- RF exposure is determined then outcome is determined, to calc RR
Pts w febrile neutropenia need immediate Cxs and emperic IV monotherapy w an anti-pseudomonal such as?
Pip-tazo, cefepime, or meropenem
TCA OD is c/b ? it can also cause what EKG changes?
CNS depression, hypoTN, anticholinergic effects ie dilated pupils, hyperthermia, intestinal ileus; QRS prolongation (pts susceptible to ventricular arrhythmias)
1st steps in Mx of Pts suspected of TCA OD ?
ABCs, give sodium bicarbonate to improve BP, shorten the QRS interval and prevent arrhythmia
disorder c/b recurrent episodes of vertigo, unilateral sensorineural hearing loss and tinnitus, feeling of ear fullness? it is due to?
Meniere disease;
increased vol and pressure of endolymph (endolymphatic hydrops) which damages inner ear
what is USPSTF’s recommendation for osteoporosis screening? which is defined as T score of?
osteopenia if T score is?
one time DEXA for all women 65+ yo (or younger w equivalent risk of fracture) ;
- porosis if less than -2.5;
- penia if btwn -1 and -2.4
high Sen vs spec: which is better as a screening test?
as a confirmatory test?
sensitivity;
specificity
presents as unilateral testicular pain and tender palpable mass in scrotum? in pts 35+ it’s usually d/t?
in pts less than 35? Tx for both?
Acute epididymitis;
bladder outlet obstruction (BPH)-coliform B. such as e coli, thus UTI Sxs are common in these older men Tx- Levofloxacin;
STI- chlamydia or N gonorrhoeae Tx- Ceftriaxone/ doxy
this benzo receptor antagonist can be used for benzo intox- ?(which typically presents as depressed mental status and slurred speech)
Flumazenil
progressive dyspnea on exertion, fatigue, decreased exercise tolerance and exertional syncope is suggestive of?
fixed cardiac outflow obstruction (ie severe AS)
delayed (slow-rising) and diminished carotid pulse (“pulsus parvus and tardus”), single/soft S2, and systolic murmur w max int at 2nd R intercostal space and radiation to carotids are all PE findings of?
Aortic stenosis
c/b small, pruritic, firm, fleshy-colored umbilicated papules? kids are MC affected, in teens/adults it is MC assoc with what condition?
Molluscum contagiosum from poxvirus; cellular immunodeficiency (ie HIV)
Pts w obesity hypoventilation Sy (OHS) have chronic hypoxia and hypercapnia, in an effort to maintain nml pH the kidneys..
incr bicarb retention and decr Cl reabsorption to create a compensatory metabolic alkalosis
this type of syncope can be triggered by emotional or painful stimuli and is frequently assoc w prodromal Sxs ie dizziness, N, pallor, diaphoresis, abd pain, sense of warmth
Neurocardiogenic/Vasovagal
Mx of pts w recurrent vasovagal syncope includes?
reassurance and education about its benign nature and use of counterpressure maneuvers suring prodromal phase, also should avoid triggers
pulseless electrical activity is when there is an organized rhythm on cardiac monitor w/o measurable BP or palpable pulse in a cardiac arrest pt, Mx?
immediate CPR, IV access, Api every 3-5mins, attempt to identify/treat reversible causes
(possible airway)
S4 is heard just before S1 and is MC assoc w?
LV hypertrophy from prolonged HTN (DH D for dialated ventricle, H for hypertrophic one, S4 sounds like TEN-ne-see)
Pts with profound cardiogenic shock following acute MI are most likely to have what finding on ABG?
primary metabolic acidosis - respiratory compensation
Pts had retinoblastoma as a child, presents in teens with distal femur lytic bone lesion and elevated alk phos suspect?
Osteosarcoma- which is MC in distal femur, causes elevated alk phos and pts with RB have a much higher risk
more common in women, esp over 40yo, pts develop rapid onset severe eye pain, may see halos around lights, affected eye will be injected and pupil dilated/poorly responsive to light. plus tearing, HA then N/V? can lead to..
acute angle closure glaucoma;
vision loss w/in 2-5hrs of Sx onset
Optic neuritis presents as? MC in ?
acute vision loss, pain, afferent pupillary defect; women less than 50yo often initial pres of MS
Surreptitious vomiting and Diuretic abuse both can present w hypokalemia, alkalosis (high bicarb), and nml BP, what in the urine can distinguish them?
Surreptitious vomiting may cause hypochloremia which can lead to low urine [Cl];
Diuretic abuse causes high urine [Cl]
Lower urinary tract Sxs (LUTS) include? initial eval of pts with LUTS?
urinary urgency, hesitancy, nocturia, weak urinary stream..; urinalysis and PSA, serum Cr.. if Cr is acutely incr need renal U/S
presents w Sxs of anorexia, N/V, early satiety, postprandial fullness and impaired glycemic control in diabetic pts? what can be tried first to manage Sxs?
Diabetic gastroparesis (delayed emptying); Prokinetic agents (ie Metoclopramide, erythromycin) plus dietary mod (incr fiber, small frequent meals)
CML is driven by the BCR-ABL fusion, this gene leads to constitutive activation of? what type of drugs are key in therapy?
Tyrosine kinase;
TK inhibitors such as imatinib
Pseudogout presents as acute pain, swelling, redness and limited motion of joint(s) and often occurs in setting of surgery/illness, synovial fluid analysis will show? x-ray?
inflamm effussion (15,000-30,000 cells), rhomboid- shaped positively birefringent crystals of CPPD; chondrocalcinosis
Pseudogout MC affects what joint? Tx?
knee; intra-articular glucocorticoids, NSAIDs, Colchicine
initial diagnostic study of choice in hemodynamically stable pts with suspected aortic dissection?
unstable pts?
CT angiography;
TEE
pt with a new sexual partner presents with a single, nonpainful ulcer on shaft of penis, mild nontender bilateral lymphadenopathy, serum VDRL and HIV testing are neg, what test will likely yield Dx?
Treponemal Syphilis test (fluorescent treponemal Ab Abs or TP-enzyme immunoassay) these have greater sensitivity in early infection than Non-treponemal tests (RPR, VDRL)
Hypercalcemia of malignancy is usually d/t secretion of?
Ca level will typically be..?
PTH level will be?
PTH-related protein ;
more than 14md/dL;
suppressed
all pts w newly Dxed HIV need screened for latent TB w a PPD or interferon-gamma release assay (not both), what is considered a positive PPD test in pts with HIV? if positive next step is..
induration of 5mm or more at 48-72hrs; rule out active TB with a CXR and Sx review (ask about night sweats, fever, cough).. then treat either active or latent TB based on findings
Most likely Dx in older pt. w sudden severe chest pain radiating to back, significant HTN, decrescendo diastolic murmur of aortic regurg, and elevated Cr?
Acute ascending (type A) aortic dissection
Best diagnostic study If acute Aortic dissection is suspected in pt with hemodynamic instability or renal insuff?
TEE
Best diagnostic study if Aortic dissection is suspected in a hemodynamically stable pt with no renal insuff?
chest CT (or MR) angiography
elevated pleural amylase concentrations are found in pleural effusions d/t either? (2)
esophageal rupture or pancreatitis
Why is glucose conc low in exudative effusions d/t empyemas?
d/t the high metabolic activity of leukocytes and bacteria w/in the pleural fluid
this potent inotropic agent is an adrenergic agonist w predominant activity on beta-1 receptors, it stimulates incr myocardial contractility thus improved EF, reduced LVESV, and symptomatic improvement of decompensated HF
Dobutamine
preffered Tx of vasospastic angina?
smoking cessation and Ca channel blockers (ie Diltiazem, amlodipine), sublingual nitroglycerin for abortive relief
recurrent chest discomfort in pts less than 50yo that occurs at rest or during sleep and resolves on its own w/in 15mins is most likely?
Vasospastic (ie Prinzmetal) angina
pts who receive a solid organ transplant are at risk for opportunistic infections, most notably what 2? what are the Px meds for these?
PCP (bactrim) and
CMV (valganciclovir)
Pts who receive solid organ transplant are at particularly high risk for PCP and tissue-invasive CMV disease, how would their presentation differ?
PCP presents w pulmonary Sxs but not GI or hepatic issues; CMV can cause pulm and GI sxs, pancytopenia, mild hepatitis, interstitial infiltrates on CXR
how can acute hypercarbia be differentiated from chronic CO2 retention in pts w COPD?
chronic retainers have nml pH and high serum bicarb but acute hypercarbia is assoc w acidosis
Peripheral blood smear shows spherocytes w/o central pallor, could be? differentiate btwn them
Hereditary spherocytosis (usually has a strong fam history, positive osmotic fragility test and Neg Coombs test) OR AIHA (usually has neg FH and POSITIVE Coombs test)
first line Tx for ED? CI with what?
PDE-5 inhibitors ie Sildenafil (viagra) CI with Nitrates/alpha blockers, can cause severe hypoTN
2 Hallmarks of secretory diarrhea? how can you differentiate it for Osmotic diarrhea?
large daily stool volumes (more than 1 L/day) and occurs even during fasting or sleep; it has a reduced stool osmotic gap, Osmotic diarrhea (such as in lactose intolerance) has an elevated SOG
differentiate between saline-responsive and saline-resistant metabolic alkalosis?
saline-resistant MA will have high urine chloride; saline responsive will have urine Cl less than 20 so give nml saline to these pts
older pt presents w sudden onset pain/redness in L eye, photophobia, N, and severe HA, recent use of OTC decongestant, exam shows nonreactive mid-dilated L pupil.. suspect? next step?
Acute angle closure glaucoma, possibly precipitated by decongestant use. Urgent Ophtho consult, they use Gonioscopy. Tonometry measures IOP can be helpful
Pt presents w SOB and dullness to percussion and CXR suggests pleural effusion, next step?!
Diagnostic thoracentesis to determine transudative or exudative, UNLESS pt has classic S/Sx of CHF where a trial of diuretics is warranted
who needs one-time screening for AAA
men active or former smokers aged 65-75 w abdominal U/S
Impaired mucociliary clearance in CF typically leads to bronchiectasis where? which is characteristic to CF and helps differentiate from other causes of bronchiectasis
upper lung lobe
Mx of Pt w acute aortic dissection?
If Ascending- needs urgent surgical repair, control pain w IV morphine, give IV BB (esmolol, propanolol, labetalol) to reduce SBP to goal of 100-120 and decr LV contractility
what is Hyposthenuria? what is it commonly assoc with?
impairment in kidney’s ability to concentrate urine; SCD and sickle cell trait
Cor Pulmonale? right heart cath will show pulm systolic P that is?
impaired fxn of RV d/t pulmonary HTN, that usually occurs d/t chronic lung disease; elevated (greater than 25mmHg)
Mx if triglyceride level is greater than 1,000?
fibrates, fish oil, abstinence from alcohol until levels less than 500 to reduce risk of pancreatitis, evaluate for 2ndary causes
fluid of choice for initial bolus resuscitation in severe hypovolemia hypernatremia?
isotonic solutions such as nml saline (ie 0.9 saline)
uric acid stones are radiolucent but may be seen on U/S or CT scan, along w incr hydration what is TOC to prevent recurrent stones?
oral potassium citrate (to alkalinize the urine since these stones are highly soluble in alkaline urine)
chronic, inherited skin disorder c/b diffuse dermal scaling?
ichthyosis vulgaris (ikythys is Greek for fish, skin looks like fish scales)
Primary polydipsia is d/t increased water intake that leads to dilute urine (ie ?) and hyponatremia
dilute urine if urine osmolality is less than 1/2 plasma osmolality
MC site of ulnar n. entrapment?!
the elbow where the ulnar n lies at the medial epicondylar groove
a h/o recent URI and sudden onset CHF symptoms in an otherwise healthy pt is suggestive of? Dx made by?
Dilated cardiomyopathy, most likely 2ndary to acute viral myocarditis; echo- dilated ventricles w diffuse hypokinesia resulting in low EF
name 5 2nd gen antipsychotics
Risperidone, Ziprasidone, Olanzapine, Quetiapine, Aripiprazole
90% of Congenital adrenal hyperplasia cases are d/t deficiency of what enzyme? leads to what hormone abnormalities (4)?
21-hydroxylase;
increased 17-hydroxyprogesterone and Testosterone,
decr cortisol and aldo
cafe au lait spots, macrocephaly, feeding probs, short stature, and learning disabilities are characteristic features of?
Neurofibromatosis 1
first line Tx for chemo-induced nausea? MOA?
Ondansetron, serotonin receptor antagonist
Trastuzumab is used w chemo in pts w HER2-positive breast ca., prior to initiating pts need what test?
Echo d/t risk of cardiotoxicity
earliest renal abnormality in pts with DM?
Glomerular hyperfiltration, this is the major mech of injury in these pts creating intraglomerular HTN, prog glomerular damage and renal fxn loss, ACEI help by reducing intraglomerular HTN
2 MCCs of nephotic Sy in adults in the absence of a systemic disease like DM or amyloidosis?
FSGS and membranous nephropathy
This common cause of membranous nephropathy in adults is assoc w African american and hispanics, obesity, HIV, and heroin use?
FSGS
c/b fever, malaise, sore throat, HA, lymphadenopathy, grey mucous patches, raised grey genital papules (condylomata lata) and a diffuse maculopapular rash- bengins on trunk extends to extremities, palms and soles?
Secondary syphilis
Presence of epitrochlear LAD is particularly pathognomonic for?
Syphilis ( 2 handed sailor shake)
what is diclofenac?
an NSAID
painless progressive blurring of central vision bilaterally
macular degeneration
pt presents w vision loss in one eye, photopsia, and fundoscopy shows elevated retina w folds and or a tear
retinal detachment
ophthalmoscopic signs are disc swelling, venous dilation and tortuosity, retinal hemorrhages, and cotton wool spots
central retinal v. occlusion
Increased levels of homocysteine predispose to venous thrombosis and atherosclerosis and levels should be lowered by giving?
Pyridoxine (B6) and folate, add Vit B12 if pt is deficient
in a nml distribution, 95% of all values lie within____ from the mean
2 SDs
in a nml distribution, 68% of all values are within ____ from the mean
1 SD
which anti-diabetic medication class can reduce weight and help control blood sugars?
GLP-1 agonists (exenatide, liraglutide)
what test is done to confirm suspected leukemia?
bone marrow Bx
to prevent cardioresp arrest and permanent neuro disability, victims of smoke inhalation injury should be treated empirically for what? with what?
Cyanide toxicity with hydroxocobalamin or sodium thiosulfate
most common malignancy of the liver?
mets from another source
the major cause of anemia in pts w ESRD is? TOC? when is it started?
deficiency of erythropoietin;
recombinant erythropoietin; if Hb is less than 10g/dL
MC side effects of recombinant erythropoietin?
worsening of HTN, HAs, and then flu-like Sxs (Very rare ADR is red cell aplasia)
child gets recurrent episodes of lip and tongue swelling, several family members do too, likely has hereditary deficiency of? condition?
C1 esterase inhibitor; acquired angioedema
Pt has small vesicles and erosions on dorsa of both hands, prior lesions appear healed w scarring and hyper-pigmentation, elevated AST, ALT.. likely has?
chronic hep C which is assoc w porphyria cutanea tarda
pt rescued from a house fire presents confused, mildly agitated, had a brief tonic clonic seizure….?? Tx?
CO poisoning; high-flow 100% oxygen if severe intubate/hyperbaric O2 therapy
MCC of glomerulonephritis in adults?
IgA nephropathy
Pts have recurrent episodes of gross hematuria, usually w/in 5 days after a URI, usually in young men, RBCs and RBC casts
IgA nephropathy
auto-inflammatory disease in kids c/b long-standing daily fever, arthritis in at least 1 joint (pain worse in AM), pink macular rash, leukocytosis, thrombocytosis, incr inflamm markers and anemia
systemic onset Juvenile idiopathic arthritis
3 1st line Txs for smoking cessation
NRT, varenicline, buproprion
Pt presents w fever, leukocytosis, abd pain, U/S shows complx multiloculated adnexal mass w thick walls and internal debris
Tubo-Ovarian abscess, a complication of PID
first line pharmacotherapy for restless leg sy?
dopamin agonists (ie pramipexole)
pt getting IV acyclovir gets acute elevation of Cr likely secondary to acyclovir nephrotoxicity which can usually be prevented and treated with?
adequate hydration
untreated hyperthyroidism can have what effect on bones?
incr OC activity causes incr bone resorption, decr bone density and incr fracture risk (this is what causes the hypercalcemia in these pts)
meds that commonly cause hyperkalemia
non-selective BBs, K-sparing diuretics (triamterene, amiloride), ACEIs, ARBs, NSAIDs
bright red, firm, exophytic nodule on HIV pt is most likely? Tx?
bacillary angiomatosis dt bartonella (GNB);
oral erythromycin
light brown to pink, dark violet plaques or nodules on HIV pt?
Kaposi sarcoma
Dx of carpal tunnel Sy is usually clinical but can be confirmed with?
nerve conduction studies
have been shown to increase appetite and weight gain in pts w cancer related anorexia/cachexia
progesterone analogues and corticosteroids (prog would be preferred for longer term)
what test best assess a diabetics risk of foot ulcers?
monofilament test
All kids w a first febrile UTI at age 2-24mos should undergo ? those with recurrent UTIs after that need?
renal U/S to eval for any anatomic abnormalities; voiding cystourethrogram to evaluate for VUR
used in cases of TCA and aspirin OD?
Sodium bicarb
give to pts suffering from torsades induced by a long QT interval?
Mag sulfate
lead chelators: used for mild to mod lead poisoning? mod to severe?
oral succimer;
calcium EDTA
MC predisposing factor for orbital cellulitis?
bacterial sinusitis
Aortic aneurysms are a well-known complication of temporal arteritis d/t involvement of branches of aorta so pts should be followed with?
serial CXRs
acute interstitial nephritis usually occurs how long after drug exposure (ie beta lactams or PPIs)?
7-10 days
3 indications for operative/endovascular repair of a AAA?
size more than 5.5cm, rapid rate of aneurysm expansion (.5cm in 6mo or 1cm/yr), current Sxs reguardless of sz (abd, back or flank pain, limb ischemia)
Pts w tourette have a high rate psychiatric comorbid conditions esp what 2?
ADHD and OCD
Pt presets w Ca level of 11 and Sxs of hypercalcemia- fatigue, constipation, nephrolithiasis over last couple months now has acute inflammatory arthritis of the knee most likely d/t?
Psuedogout- caused by calcium PPD crystals, common complication of hyperparathyroidism (also assoc w hypothyroidism and hemochromatosis)
Unilateral varicoceles that fail to empty when pt is recumbent should raise suspicion of? Best test to Dx this?
underlying mass pathology such as renal cell carcinoma that obstructs venous flow (esp when on L); CT of abdomen
Renal vein thrombosis is an imp complication of all causes of nephrotic Sy however it is MC assoc w?
membranous glomerulopathy
Blood at urethral meatus, inability to void, perineal or scrotal hematoma and a high-riding prostate on DRE are consistent with? when this is suspected, what diagnostic test should be performed?
Posterior urethral injury (assoc w pelvic fractures) ; retrograde URETHROgram
why are pts w Multiple myeloma at incr risk for infection?
bone marrow infiltration by neoplastic cells causes hypogammaglobulinemia and ineffective Ab probuction
arrhythmia most specific for digitalis toxicity?
atrial tach w AV block
Acrochordon?
skin tag
these lesions vary from macule to wart-like, can be pinkish/white, brown or black. Velvety or greasy surface, look “stuck-on”, usually don’t but can itch
seborrheic keratoses
Hemochromatosis assoc w sign incr risk for what type of cancer? increased susceptibility to what 3 organisms?
Hepatocellular carcinoma;
listeria, vibrio vulnificans and Yersinia enterocolitica
This can initially present w nonspecific Sxs such as fatigue, malaise, weakness, weight loss, N/D, abd pain, vol depletion, hypoTN, postural dizziness or syncope. Skin signs inc vitiligo or patchy hyperpigmentation (palmar creases)
Primary adrenal insufficiency
Primary causes Pigmentation d/t cosecretion of melanocyte-stimulating hormone w ACTH
Folate and Cobalamin deficiencies can be distinguished by measuring what?
methylmalonic acid conc., incr in cobalamin deficiency but nml in folic acid deficiency
(both result in elevated homocysteine levels)
the source of embolus in over 90% of acute PEs?
deep veins of proximal leg ie iliac v., femoral v., or popliteal v.
Active hep B infection is an imp RF for what type of nephropathy?
membranous
affected boys and girls have nml genotype and nml internal repro organs but congenital absence of GnRH secretion results in short stature, hypogonadism, delayed or absent puberty (no breasts, no body hair, small phallus/testicles) and anosmia
Kallman syndrome (FSH and LH levels are low consistent w GnRH deficiency)
child presents w recurrent severe skin infections and lymphadenitis, cultures have grown staph aureus, Serratia, Burkholderia..Labs show nml leukocyte, platelet, B and T cell concs, most likely Dx?
Chronic granulomatous disease (majority X-linked recessive, recurrent skin and pulm infections w catalase positive organisms like those plus fungi like Aspergillus, Nocardia)
65yo man has new onset ptosis and slurred speech after knee surgery, an ice pack placed over eye for 2 mins leads to improvement of ptosis, likely cause of Sxs?
MG, usually presents in 6th-8th decade in men, m. weakness may be precipitated by surgery, infection, meds (aminoglycosides, BBs), ice pack test supports diagnosis
MG Tx?
Acetylcholinesterase inhibitors (eg pyridostigmine), +/- immunotherapy (corticosteroids, azathioprine), thymectomy
nml ESR values?
male: 0-15
female: 0-20
Positive leukocyte esterase signifies? positive nitrites?
pyuria; presence of Enterobacteriaceae (converts urinary nitrates to nitrites)
most likely Dx of HIV-infected pt w AMS, on Bactrim, positive toxoplasma serology, EBV DNA in CSF, solitary weakly ring enhancing periventricular mass on MRI? why?
primary CNS lymphoma
(toxoplasmosis less likely since on bactrim, it would show multiple ring-enhancing lesions.. positive serology is common in US but EBV DNA in CSF is specific for CNS lymphoma)
classic hemi-neglect, stroke where?
right (non-dominant) parietal
MC anatomic origin of the ectopic foci that cause atrial fibrillation?
pulmonary veins (can be ablated)
most significant RF for intraventricular hemorrhage in newborns?
prematurity/ low birth weight
what type of med is used to help facilitate passage of ureteral stones less than 1cm?
alpha receptor blockers such as tamsulosin
Mx of Torsades de points :
in a hemodynamically unstable pt?
in a stable pt?
defribillation; IV magnesium (mag sulfate)
the MC adverse rxn to blood transfusions that occurs w/in 1-6hrs of transfusion? what can be done to prevent it?
febrile nonhemolytic rxn;
Leukoreduction- ie reducing the number of transfused leukocytes by filtering, saline washing, freezing and deglycerolizing or buffy coat removal this also decreases transmission of CMV
differentiate between vulvovaginal atrophy from estrogen deficiency and Vulvar Lichen Sclerosus which can both cause pruritis, dyspareunia..
menopausal atrophy does not affect the perianal skin, lichen sclerosus may extend over perineum/anus causing painful defecation
main reason for the increased incidence of orthostatic hypoTN in the elderly?
progr. decreasing baroreceptor sensitivity and defects in the myocardial response to this reflex
Woman presents to ED complaining of confusion, polyuria, incr thirst.. labs show hypernatremia, urine osmolality 250, plasma osmolality 325
she has a history of bipolar d/o suspect?
Diabetes insipidus secondry to lithium
this is not psychogenic polydipsia which would cause HYPOnatremia
Fever, severe HAs (nocturnal or AM) and focal neuro changes make up classic triad for?
1/4 pts may have what other presenting Sx?
Brain abscess;
seizure
Disease w neuro (ataxia, dysarthria), skeletal (scoliosis, feet deformities) and cardiac( concentric hypertrophic cardiomyopathy) manif.. ? MCCs of death?
Friedreich ataxia (AR) cardiomyopathy (then resp) complications
highly malignant tumor that usually presents in 1st or 2nd decade of life w pain/swelling for wks/months, leukocyosis, anemia and incr ESR MC distal femur, tibia or humerus
Ewing’s sarcoma, can extend into the soft tissue and metastasizes early to lungs and LNs
infant w/ failure to thrive, bilateral cateracts, jaundice, and hypoglycemia think?
galactosemia d/t galactose-1- phosphate-uridyl transferase deficiency
