UW Internal Medicine Flashcards

Question

Old guy with memory loss and muscle spasms when startled. He also has nystagmus, hypokinesia, and positive Babinski (plantar reflex). EEG shows periodic sharp-wave complexes. Diagnosis?

Answer 1

Creutzfeldt-Jakob disease (CJD) * prion disease (usually sporadic, but can be due to contaminated corneal transplants). * key findings: startle response and sharp waves on EEG * *as it progresses, patients may lose ability to move and speak (txt is supportive)

Answer 2

Drug-induced myopathy -glucocorticoids (used to treat giant cell arteritis) can cause myopathy (think of Cushing’s secondary to too much glucocorticoid use...skin thinning, fat redistribution, and muscle thinning!)

Answer 3

One 13-valent pneumococcal conjugate vaccine (PCV13) + One 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 6-12 months later *give add’l PCV13 and PPSV23 vaccines to high-risk patients (CSF leaks, sickle cell, cochlear implants, asplenia/ immunocompromised) **give one PPSV23 before age 65 too for some patients (smokers or chronic medical problems like heart/ lung/ liver dz or DM)

Answer 4

2-4 mm in light

Answer 5

Nystagmus, ataxia, confusion

Answer 6

Ulnar nerve At the elbow (medial epicondylar groove) *ulnar nerve syndrome can be caused by prolonged compression on the ulnar nerve from leaning on the elbows while working at your desk

Answer 7

Incidence= # new cases Prevalence= total cases

Answer 8

All low -the exogenous testosterone will feedback and inhibit GnRH, LH, and FSH production (-> low endogenous testosterone, small testes, possible infertility)

Answer 9

G6PD deficiency - in this condition, RBCs can’t make enough NADPH to protect against oxidative injury. Some meds (Dapsone, TMP/SMX, Primaquine), foods (Fava beans), and infections cause oxidative damage and bring on anemia attacks in patients with this * *hemolytic anemia-> blood in urine (dark urine)

Answer 10

Low-molecular weight heparin (LMWH)

Answer 11

This is heparin-induced thrombocytopenia (HIT) - bad reaction to heparin where heparin binds to platelet factor 4 (PF4) and antibodies form against the hep-PF4 complex. These antibodies attack platelets—> thrombocytopenia (low platelets) and stick them together—> clotting (opposite of what you’d expect when giving an anti-coagulant). * discontinue the hep immediately and pick another anticoagulant to treat with!

Answer 12

Lucency= shows up dark on x-ray -means it’s less dense (like air-filled lungs in emphysema)—> more X-rays pass through Basilar= bottom of lungs (opposite of apex, which is the pointy top of the lungs) So...”bilateral basilar lucency” means the bottom of both lungs appears darker (air-filled) on X-ray

Answer 13

Alpha-1 antitrypsin deficiency—> panacinar emphysema (destruction of lower lobes *vs. emphysema due to smoking alone would be centriacinar and cause destruction of upper lobes “smoke rises”)

Answer 14

Measure serum AAT levels (should get pulmonary function tests too)

Answer 15

Kidney stones

Answer 16

Rhabdomyolysis *seizures-> skeletal muscles overexertion-> release of myoglobin into the blood-> clogs up renal tubules and causes renal injury

Answer 17

Cr- 0.6-1.2 BUN- 7-25 BUN/CR- around 15

Answer 18

Small cell: 1. SIADH 2. Lambert-Eaton 3. ACTH (Cushing’s) 4. Anti-Hu antibodies Squamous cell: 1. PTHrP (-> hypercalcemia)

Answer 19

Calcium is high (normal would be 8.5-10ish...14 is very high) This is due to squamous cell carcinoma of the lung-> PTHrP (paraneoplastic syndrome)-> excess calcium reabsorption (and phosphorous wasting) -This is also known as “hypercalcemia of malignancy”

Answer 20

Short term: Give normal saline (and calcitonin) * why? Hypercalcemia-induced DI (high calcium interferes with renal channels that allow ADH to work to retain water)-> hypercalcemia patients pee a lot and are volume depleted, so you have to restore volume/ hydrate * may also give Calcitonin (directly blocks osteoC’s from breaking down bone and releasing calcium-> so, they lower calcium levels in the blood) * *don’t give loop diuretics (even though they can lower calcium levels) unless they have HF (not worth the side effect of worsening volume depletion) Long term: Give bisphosphonates *why? Bisphosphonates stimulate apoptosis of osteoClasts (they stop osteoC’s from breaking down bone and releasing calcium-> so, they lower calcium levels in the blood)

Answer 21

150,000- 400,000

Answer 22

Normal Hb in males= 13.5- 17.5 | Normal Hb in females= 12-16 a little lower due to bleeding once a month/ menstrual cycles

Answer 23

Horse-derived (equine) antitoxin therapy

Answer 24

Plasmaphoresis (therapeutic plasma exchange) *GB occurs when the immune system attacks nerves (can be after Campylobacter or a flu shot...)

Answer 25

The presence of antiphospholipid antibodies + you have blood clots (DVT, PE, stroke, or MI) or pregnancy problems (miscarriages or premature birth from placental insufficiency or preeclampsia) **Antiphospholipid antibodies are seen in SLE (lupus) (though not specific to it). They can cause 3 problems: (1) antiphospholipid antibody syndrome, (2) increased PTT, (3) false positive syphilis test (RPR/ VDRL)

Answer 26

A bacterial infection of the ascitic fluid of the peritoneum (So, it’s when a patient has ascites, usually secondary to cirrhosis, and that fluid gets infected)

Answer 27

Hepatorenal syndrome

Answer 28

Histoplasmosis *Blasto is also seen in the Mississippi region, but usually does not involve hilar lymphadenopathy

Answer 29

1. Histoplasmosis- Mississippi/ Ohio river valley (Midwest) 2. Blastomycoses- Great Lakes/ Ohio river valley (Midwest) 3. Coccidioides- Southern US (Cali, Arizona, northern Mexico) 3. Paracoccidioides- South America, Brazil

Answer 30

Chronic liver disease - IV drug use= high-risk for hep C w/ chronic liver dz (cirrhosis)—> ascites (the portal HTN causes fluid to accumulate in the peritoneum) * IV drug use also—> endocarditis with embolic stroke. Stasis (wheelchair-bound) following the stroke—> DVT. But DON’T be distracted by everything going on w/ this patient! The question is just asking why does he have ascites? 80% of ascites is due to liver failure and you can trace this to his IV drug abuse.

Answer 31

Ultrasound the abdomen (High serum alk phos suggests cholestasis/ reduced bile flow, possibly due to an obstruction/ stone. U/S will help you look for intrahepatic or extrahepatic causes of biliary obstruction.)

Answer 32

Systemic sclerosis (diffuse type) 1. anti-Scl-70 antibody (aka anti-DNA topoisomerase-1 antibody) 2. anti-RNA polymerase III *Systemic sclerosis= autoimmunity + non inflammatory vasculopathy + collagen deposition w/ fibrosis. 2 sub-types: (1) diffuse (involves the skin all over and early visceral involvement- interstitial lung dz), (2) limited aka CREST syndrome (face and fingers) **CREST= Calcinosis (calcium deposits) and anti-Centromere antibody Raynaud’ s phenomenon Esophageal dysmotility (GERD0 Sclerodactyly (thickened skin on hands and feet) Telangiectasia (dilated blood vessels)

Answer 33

Calcinosis (calcium deposits) and anti-Centromere antibody Raynaud’ s phenomenon Esophageal dysmotility (GERD0 Sclerodactyly (thickened skin on hands and feet) Telangiectasia (dilated blood vessels)

Answer 34

Severe Alzheimer’s disease - it blocks NMDA glutamate receptors - may improve cognitive symptoms

Answer 35

Pulmonary embolism (PE) * She was on a long flight, has SOB, and is coughing up blood. Red flags! * typical PE presentation= tachypnea (rapid breathing) and tachycardia in addition to SOB. This is because she has the pulm artery occluded-> dec oxygenation-> heart tries to compensate.

Answer 36

Marijuana (Conjunctival injection= bloodshot eyes) *increases appetite, HR, breathing, causes dry mouth, and bloodshot eyes. Also slows reaction time-> car accidents.

Answer 37

Non-nation gap metabolic acidosis -from retention of uremia and impaired acid excretion (if you can’t pee out the acid, it accumulates in the blood)

Answer 38

Breathing less= less oxygen being delivered to organs in the body to provide energy

Answer 39

Nephrogenic DI (not responding to ADH)-> not retaining water-> pee more-> [Na+] will go up-> HYPERNATREMIA (high Na+) Blood will be more concentrated (HIGHER OSMOLARITY) than the urine (urine is more dilute since you’re peeing more)

Answer 40

Nephrogenic DI (not responding to ADH)-> not retaining water-> pee more-> [Na+] will go up-> HYPERNATREMIA (high Na+) Psychogenic polydipsia (drinking water like a crazy person)-> you’re putting so much water into the body that it dilutes [Na+]-> HYPONATREMIA (low Na+)

Answer 41

DASH= Dietary Approaches to Stop Hypertension -this is the diet you put HTN patients on (Involves eating fruits, veggies, whole grains, low-fat, low salt, high potassium foods)

Answer 42

Urine protein over creatinine ratio | A way to estimate how much protein is being spilled in the urine per day

Answer 43

Ratio of BP at the ankle to BP in the upper arm (brachial) - If BP in the ankle is lower than in the arm, it suggests blocked arteries in the ankle due to peripheral vascular disease (PAD) * used to check when patient has claudication, dermal atrophy, and absent distal pulses

Answer 44

Sudden cardiac death (SCD) due to ventricular arrhythmia

Answer 45

Measuring carboxyhemoglobin level *this is likely carbon monoxide (CO) poisoning from an old heater. Hb binds CO instead of oxygen (CO has a greater affinity)—> carboxyhemoglobin. Less oxygen delivered to tissues (left shift).

Answer 46

A calculator to assess the probability a patient has a PE (pulmonary embolism) *if total score (based on clinical signs of DVT, previous DVT/ PE, tachycardia, recent surgery, hemoptysis/ cancer) is >4, a PE is likely

Answer 47

Check the D-dimer (make sure it’s less than 500) * D-dimer is sensitive, but not specific for PE. So, you get this to make sure you can rule out PE. * *If PE is likely (based on Wells criteria), don’t get a D-dimer...go straight to CT pulmonary angiogram (aka spiral CT) (or V/Q scan if you can’t do the pulmonary angiogram bc the patient has bad kidneys and can’t handle the contrast) to diagnose.

Answer 48

Get a CT pulmonary angiogram (aka spiral CT) to diagnose Unless your patient has kidney problems (in which case they can’t handle the IV contrast needed to do the pulmonary angiogram)—> then get a V/W scan to diagnose

Answer 49

Ciprofloxacin (short-course) *if symptoms fail to improve, test for something else (ex: may be parasitic like Giardia and require Metronidazole)

Answer 50

Pituitary adenoma * anterior pituitary—> FLAT PiG (FSH, LH, ACTH, TSH, Prolactin, GnRH) * mass effect—> headache and visual disturbance. Production of most hormones will be decreased due to compression of normal pituitary cells. But, prolactin is high due to anatomic disruption of the dopamine brake onto prolactin. * *NOT Hashimotos/ hypothyroidism bc T4 would be low, but TSH would be high due to negative feedback. * *NOT Risperidone side effect bc that’s an anti-dopamine drug-> takes brake off prolactin-> high prolactin, but does not affect these other hormones.

Answer 51

Aortic regurg *Ankylosing spondylitis= a seronegative spondyloarthritis (FA pg 461- lack of Rheumatoid factor, axial skeleton involvement, HLA-B27) with spinal fusion—> bamboo spine. Patients can also get uveitis and aortic regurg (aortic inflammation-> aortic aneurysm-> pulls on valve-> regurg). **These patients are at risk for vertebral fractures with minimal trauma! (Increased osteoclast activity in the setting of chronic inflammation)

Answer 52

Interventricular septum rupture (complication 3-5 days post-MI) -> cardiogenic shock (hypotension, pulm edema, confusion due to poor pumping and poor organ perfusion). Cold extremities due to shunting of blood to core vital organs.

Answer 53

Febrile neutropenia (fever + low neutrophils, specifically absolute neutrophil count <1500) Treat with an anti-pseudomonas beta-lactam agent (these bugs are often responsible)— Cefepime (4th gen cephalosporin), Meropenem (carbapenem), or Piperacillin-Tazobactam (extended-spectrum penicillin) *Chemo patients are at higher risk for this and you need to give emergent empiric antibiotics to prevent progression to sepsis!

Answer 54

HIV test *HIV is associated with flares of psoriasis. Other things that can worsen psoriasis— skin trauma, withdrawal from glucocorticoids, and certain meds (anti-malaria, indomethacin, propranolol)

Answer 55

CD4 < 50 | “Charity drive 50 cents”

Answer 56

Ganciclovir *Herpes Simplex esophagitis (well-circumscribed, round ulcers as opposed to linear ulcers in CMV) is treated with Acyclovir

Answer 57

Strep pneumo *Don’t assume it’s PCP pneumonia just bc she has HIV! That is seen in HIV patients with CD4 <200. Still, step pneumo is the no. 1 cause of lobular CAP!

Answer 58

Cytomegalovirus (CMV colitis) * common causes of diarrhea in HIV patients: 1) Cryptosporidium—CD4 <180 (severe watery diarrhea, low-grade fever) 2) Microsporidium—CD4 <100 (crampy watery diarrhea, usually no fever) 3) MAC—CD4 <100 (watery diarrhea and high fever) 4) CMV—CD4 <50 (bloody diarrhea, abdominal pain, low-grade fever)

Answer 59

Reactivation TB (affects upper lobes) * not likely to be aspiration pneumonia bc that is found in lower lobes (due to gravity) * you do not HAVE TO HAVE hemoptysis for it to be TB!!! Also, note this guy’s HIV status puts him at increased risk for TB

Answer 60

It’s in the family of Step Viridans *think of it when there is a patient with a heart problem who gets a dental procedure done!

Answer 61

Group A strep (Strep Pyogenes) This is Erysipelas (superficial skin infection of the upper dermis *like cellulitis but more superficial)

Answer 62

In HIV patients with CD4 <100

Answer 63

In some organ transplant recipients

Answer 64

Urine Histoplasma antigen (This sounds like disseminated histoplasmosis) *treat with Amp B

Answer 65

Vancomycin -it is broad spectrum and has MRSA coverage

Answer 66

Blastomycosis *seen in the Mississippi/ Ohio river valley (Wisconsin has the highest infection rate)

Answer 67

Wolff-Parkinson-White syndrome -going through an accessory “secret pathway” (bundle of Kent) that bypasses the rate-slowing AV node-> ventricles get depolarized before they should (shows up on EKG as delta waves).

Answer 68

When you have a long QT interval (QT= ventricular depolarization + depolarization, so the entire systole) * >450 mace in males or >470 mace in females * can be congenital or acquired * risk for sudden cardiac death (due to Torsades or polymorphic ventricular tachycardia)

Answer 69

ECG! (Same thing as EKG)

Answer 70

Order an echocardiogram This guy most likely has aortic stenosis (exertional syncope, systolic murmur, LV hypertrophy). Get an echo any time you suspect a structural/ valvular heart disease (aortic stenosis, HOCM, LV dysfunction, cardiac tamponade, etc.) *do NOT stress test symptomatic severe aortic stenosis

Answer 71

Mitral valve prolapse *Apex= mitral region Systolic murmur= MVP or mitral regurg Squatting= increased preload (kink veins in legs-> more ‘milking’ of blood to heart) Murmur is softer with squatting= MVP (more preload helps the valve to be more crisp as opposed to floppy where it doesn’t align well) **Do an echo to confirm the diagnosis. Symptoms are benign.

Answer 72

Chest compressions - The heart has an abnormal rhythm going on, but it is not effectively pumping blood out to the extremities, so you can’t feel a pulse (this is called pulseless electrical activity). - ACLS guidelines say do CPR and give epi (beta>alpha agonist, so helps improve contractility and is a vasopressor-> vasoconstricts to improve cerebral and coronary perfusion). *Although we should cardiovert new a-fib patients (had it <48 hrs) or a-fib patients who are unstable, if they are so unstable they go into a non-perfusing rhythm, you follow ACLS guidelines!

Answer 73

Asystole- Cardiac arrest No electrical activity Monitor is flat-lined Pulseless electrical activity (PEA)- A non-perfusing rhythm There is an abnormal heart rhythm (ex: a-fib), but the heart isn’t effectively pumping blood out, so there’s no palpable pulse (or measurable BP) Monitor shows the abnormal rhythm **NOTE: 3 rhythms cannot be PEA: (1) V-fib, (2) V-tach, (3) Asystole. Why? Bc we don’t expect a pulse with these rhythms. PEA is an organized electrical activity where we expect to see a pulse but we don’t have one.

Answer 74

ACLS= Advanced Cardiac Life Support (guidelines on what to do if a patient is in cardiac arrest) CPR= Cardiopulmonary Resuscitation

Answer 75

``` Hypovolemia Hypoxia Hydrogen ions (acidosis) HypOkalemia/ HyPERkalemia Hypothermia ``` ``` Tension pneumothorax Tamponade, cardiac Toxins (narcotics, benzos) Thrombosis (pulmonary or coronary) Trauma ```

Answer 76

NO Asystole= they are flat-lined. There is ZERO electrical activity in the heart, so shocking them will not work (shocks work by feeding off of electrical activity). Do chest compressions, give epi (every 3-5 min), and try to figure out why the patient went into asystole bc there may be a reversible cause.

Answer 77

SHOCK: 1. V-fib (ventricular fibrillation) 2. V-tach (ventricular tachycardia) * *note: Torsades is a subcategory of ventricular tachycardia- shock it. NON-SHOCKABLE: 1. Asystole 2. Pulseless electrical activity (PEA) Rap song: “Defib for V-fib and pulseless V-tach. Don’t defib asystole, you won’t get them back!”

Answer 78

Decrease in BP by 20 systolic or 10 diastolic when standing | *may be accompanied by an increase in HR

Answer 79

Aging-> some baroreceptor activity is lost *normally: you stand-> gravity is working against you so vessels have to constrict in the lower extremities to ‘milk’ blood up to the heart so it can pump enough to maintain BP. For the moment that BP is dropped right when you stand, baroreceptors (on carotid sinus) respond to decreased stretch-> decrease firing-> this increases sympathetic stimulation to raise the BP to baseline.

Answer 80

HOCM | Basically a functional aortic stenosis, since the intraventricular septum is in the way of aortic outflow

Answer 81

Perivalvular abscess *Be suspicious of perivalvular abscess anytime a patient has endocarditis + conduction abnormalities on EKG (the abscess can extend into the conduction pathway, messing it up). Endocarditis alone wouldn’t cause AV block or syncope.

Answer 82

Alcohol-> A-fib w/ RVR (rapid ventricular response)-> tachycardia-mediated cardiomyopathy (the prolonged arrhythmia and rapid ventricular rate is causing HF) *treat with aggressive rate and rhythm control **note: the mitral regurg in this patient is just due to the fact that the ventricles are overloaded

Answer 83

When you have a tachyarrhythmia (heart is beating super fast, out of rhythm for a while) that leads to HF (*can be due to a-fib, a-flutter, v-tach, etc.) Treat with aggressive rate or rhythm control (*AV nodal blocking agents, antiarrhtymic drugs, ablation of arrhythmia, etc.)

Answer 84

Rheumatic heart disease-> mitral stenosis-> a-fib-> stroke *remember that mitral stenosis (MS) over time-> increased LA pressure. This predisposes to a-fib. This also leads to pulmonary vascular congestion, explaining the hemoptysis.

Answer 85

Acute pulmonary edema secondary to increased cardiac filling pressures (such as after an MI)

Answer 86

ECG! (Same thing as EKG)

Answer 87

Order an echocardiogram This guy most likely has aortic stenosis (exertional syncope, systolic murmur, LV hypertrophy). Get an echo any time you suspect a structural/ valvular heart disease (aortic stenosis, HOCM, LV dysfunction, cardiac tamponade, etc.) *do NOT stress test symptomatic severe aortic stenosis

Answer 88

Mitral valve prolapse *Apex= mitral region Systolic murmur= MVP or mitral regurg Squatting= increased preload (kink veins in legs-> more ‘milking’ of blood to heart) Murmur is softer with squatting= MVP (more preload helps the valve to be more crisp as opposed to floppy where it doesn’t align well) **Do an echo to confirm the diagnosis. Symptoms are benign.

Answer 89

Chest compressions - The heart has an abnormal rhythm going on, but it is not effectively pumping blood out to the extremities, so you can’t feel a pulse (this is called pulseless electrical activity). - ACLS guidelines say do CPR and give epi (beta>alpha agonist, so helps improve contractility and is a vasopressor-> vasoconstricts to improve cerebral and coronary perfusion). *Although we should cardiovert new a-fib patients (had it <48 hrs) or a-fib patients who are unstable, if they are so unstable they go into a non-perfusing rhythm, you follow ACLS guidelines!

Answer 90

Asystole- Cardiac arrest No electrical activity Monitor is flat-lined Pulseless electrical activity (PEA)- A non-perfusing rhythm There is an abnormal heart rhythm (ex: a-fib), but the heart isn’t effectively pumping blood out, so there’s no palpable pulse (or measurable BP) Monitor shows the abnormal rhythm **NOTE: 3 rhythms cannot be PEA: (1) V-fib, (2) V-tach, (3) Asystole. Why? Bc we don’t expect a pulse with these rhythms. PEA is an organized electrical activity where we expect to see a pulse but we don’t have one.

Answer 91

ACLS= Advanced Cardiac Life Support (guidelines on what to do if a patient is in cardiac arrest) CPR= Cardiopulmonary Resuscitation

Answer 92

``` Hypovolemia Hypoxia Hydrogen ions (acidosis) HypOkalemia/ HyPERkalemia Hypothermia ``` ``` Tension pneumothorax Tamponade, cardiac Toxins (narcotics, benzos) Thrombosis (pulmonary or coronary) Trauma ```

Answer 93

NO Asystole= they are flat-lined. There is ZERO electrical activity in the heart, so shocking them will not work (shocks work by feeding off of electrical activity). Do chest compressions, give epi (every 3-5 min), and try to figure out why the patient went into asystole bc there may be a reversible cause.

Answer 94

SHOCK: 1. V-fib (ventricular fibrillation) 2. V-tach (ventricular tachycardia) * *note: Torsades is a subcategory of ventricular tachycardia- shock it. NON-SHOCKABLE: 1. Asystole 2. Pulseless electrical activity (PEA) Rap song: “Defib for V-fib and pulseless V-tach. Don’t defib asystole, you won’t get them back!”

Answer 95

Decrease in BP by 20 systolic or 10 diastolic when standing | *may be accompanied by an increase in HR

Answer 96

Aging-> some baroreceptor activity is lost *normally: you stand-> gravity is working against you so vessels have to constrict in the lower extremities to ‘milk’ blood up to the heart so it can pump enough to maintain BP. For the moment that BP is dropped right when you stand, baroreceptors (on carotid sinus) respond to decreased stretch-> decrease firing-> this increases sympathetic stimulation to raise the BP to baseline.

Answer 97

HOCM | Basically a functional aortic stenosis, since the intraventricular septum is in the way of aortic outflow

Answer 98

Perivalvular abscess *Be suspicious of perivalvular abscess anytime a patient has endocarditis + conduction abnormalities on EKG (the abscess can extend into the conduction pathway, messing it up). Endocarditis alone wouldn’t cause AV block or syncope.

Answer 99

Alcohol-> A-fib w/ RVR (rapid ventricular response)-> tachycardia-mediated cardiomyopathy (the prolonged arrhythmia and rapid ventricular rate is causing HF) *treat with aggressive rate and rhythm control **note: the mitral regurg in this patient is just due to the fact that the ventricles are overloaded

Answer 100

When you have a tachyarrhythmia (heart is beating super fast, out of rhythm for a while) that leads to HF (*can be due to a-fib, a-flutter, v-tach, etc.) Treat with aggressive rate or rhythm control (*AV nodal blocking agents, antiarrhtymic drugs, ablation of arrhythmia, etc.)

Answer 101

Rheumatic heart disease-> mitral stenosis-> a-fib-> stroke *remember that mitral stenosis (MS) over time-> increased LA pressure. This predisposes to a-fib. This also leads to pulmonary vascular congestion, explaining the hemoptysis.

Answer 102

Acute pulmonary edema secondary to increased cardiac filling pressures (such as after an MI)

Answer 103

Oral glucose tolerance test | It is more sensitive in PCOS patients than fasting glucose and A1c standard screenings tests

Answer 104

Inc LH (related to insulin resistance)—> theca cells in ovaries use this to make androgens, then granulosa cells of ovaries take the androgens and make estrogen (estradiol). With all the excess LH, there’s too many androgens for the granulosa cells to convert to estradiol, so excess androgens circulate in the blood and go into the peripheral fat—> fat cells make it into estrone and this feeds back onto the GnRH axis, inhibiting it. Excess androgens—> hirsutism Inhibition of GnRH—> anovulatory, infertile

Answer 105

Chronic prostatitis (Noninfectious chronic prostate inflammation) * this is a diagnosis of exclusion based on urinary symptoms + perineal or genital pain + pain or blood with ejaculation in the setting of a negative urine culture * antibiotics (fluoroquinolones) can help (even though a bacteria is not identified) * alpha-adrenergic inhibitors (Tamsulosin) and 5-alpha-reductase inhibitors (Finasteride) can also help

Answer 106

Urinary/ voiding symptoms + scrotum pain/ swelling + purulent (pus) urethral discharge

Answer 107

It can occur in the setting of an autoimmune or systemic disease (ex: CREST syndrome)

Answer 108

Dihydropyridine CCBs | Vasodilate, so help improve perfusion to the fingertips

Answer 109

Hepatitis C

Answer 110

It’s either post-renal (later stage) or intrinsic AKI | Normal FeNa= <1%. If FeNa is higher, you know the kidneys are not working to reabsorb Na+

Answer 111

An aminoglycoside -these drugs treat serious gram-negative infections (pyelonephritis is often due to E-coli—a bladder infection that ascends) and are nephrotoxic

Answer 112

``` Hemorrhoids (varicose veins in the rectum that can cause bleeding) OR Anal fissures (aka anal ulcer) (small tear in the lining of the anal wall) ```

Answer 113

They give you a contrast solution and then take an x-ray of the colon

Answer 114

Anoscopy (anal speculum) Why? This is minimally invasive and allows you to look in there for hemorrhoids (varicose veins) or rectal fissures (ulcer/ tear in anal wall). If you don’t find the cause with the anoscopy, then consider a sigmoidoscopy or colonoscopy. *If the patient were 40-49, you may consider a sigmoidoscopy. If the patient were 50+ and it’s been 2-3 years since the last colonoscopy, you’d want to do a colonoscopy.

Answer 115

>5 minutes *Status epilepticus used to be defined as a seizure <30 min, but recent studies show all it takes is 5+ minutes of seizing for there to be risk of permanent brain injury (from the excitatory cytotoxicity)

Answer 116

Mohs micrographic surgery (Sequential removal of thin layers of skin with microscopic inspection to confirm that the margins have been cleared of malignant tissue)

Answer 117

Seborrheic keratosis

Answer 118

Corticosteroids

Answer 119

Give them Adenosine (vasodilator) - to normal coronary arteries—> this causes a big increase in blood flow (dilates them a lot) - to stenotic coronary arteries—> this does not cause an increase in blood flow (the body’s mechanisms have already dilated these stenotic vessels to the max, so adding in a vasodilator doesn’t do a thing) - the difference in blood flow allows us to diagnose CAD

Answer 120

Furosemide -Diuretics are recommended for acute pulmonary edema (“flash pulmonary edema”) secondary to an MI. *Although beta-blockers are part of the therapy for MI (“MONA BASH”), do NOT give a beta-blocker to a patient with decompensated CHF (dilated cardiomyopathy) or bradycardia (This guy has this based on S3 and crackles—fluid overloaded). Why? Beta-blockers cause decreased contractility and HR...if you already got a pumping problem, this will worsen it!

Answer 121

Interstitial fibrosis and pulmonary HTN *if pulm HTN, would expect a RV heave (impulse palpated immediately left of the sternum that suggests RV enlargement) and/or a loud pulmonary component of the 2nd heart sound

Answer 122

TCA (tricyclic antidepressants) overdose Give sodium bicarbonate *Can cause QRS prolongation (or QT prolongation-> Torsades). Also causes anti-cholinergic effects.

Answer 123

Hyperkalemia (peaked T waves)

Answer 124

Opioid overdose Priority= airway protection—intubate and give Naloxone (mu-opioid antagonist to reverse acute opioid toxicity) - What gives it away is the respiratory depression (RR=5)! - Other findings also support this diagnosis (extremities cool to touch is due to hypothermia from impaired thermogenesis) *don’t rule out opioid use just cuz the pupils are normal sized (not pinpoint)! They can be normal (could even be dilated if the patient took amphetamines too, for example)

Answer 125

A sunken in stomach

Answer 126

Anorexia nervosa BMI <18.5 + distorted body image (thinks stomach is “puffed up” when it is not) * Constipation and cold intolerance are also consistent with hypOthyroidism. BUT, in hypOthyroidism you’d expect weight GAIN (everything is slowed down) and HTN (not low BP). * In Anorexia, electrolyte abnormalities—> slowed bowels and constipation. Malnutrition—> loss of muscle mass (which includes the heart)—> heart shrinks and beats slower to conserve energy (think of it as the heart is weakened bc it is starving)

Answer 127

Topical glucocorticoids (betamethasone, fluocinonide) or Vitamin D derivatives

Answer 128

Endoscopy | Tube that goes down the mouth-> esophagus-> stomach-> duodenum

Answer 129

Diabetes insipidus (DI) - glucose is normal, so rule out DM - Na+ is high, so rule out side effect of the Thiazide diuretic alone (this causes hypOnatremia) - the blood is more concentrated than the urine...in DI, you are not making/ responding to ADH, so you cannot retain water and just pee it all out, makes sense

Answer 130

Stop taking the over-the-counter headache meds! Using these too often—> medication overuse headaches (like a caffeine headache, these occur do to getting addicted to the meds)

Answer 131

Fever-> cytokines cause the hypothalamus to change the body’s setpoint to a higher level-> to reach this new setpoint, peripheral blood vessels vasoconstrict (to shunt blood to the core) and this can make a person feel cold *also, muscles may contract (shivering) during this process

Answer 132

Granulomatosis with polyantiitis (Wagner’s) - small-vessel vasculitis involving the nasopharynx, lungs (but not in this patient), and kidneys - systemic symptoms are common (anemia, fatigue, fever, joint pains) Next step= check for c-ANCA (autoantibodies against neutrophils) *tissue biopsy is the confirmatory test

Answer 133

Hydrogen breath test - Lactose intolerance= you lack lactase, a brush border enzyme that breaks down lactose in dairy products (decreases with age, esp in Asians). Since lactose doesn’t get broken down into simple carbs, its draws in water-> osmotic diarrhea. - Since it’s not broken down, more stomach acid will try to compensate to digest it—> positive H+ breath test.

Answer 134

Stress-induced (takotsubo) cardiomyopathy Aka “broken heart syndrome” * believed to be brought on by a catecholamine surge from a stressor-> microvascular spasm and impaired contraction of the heart (hypokinesis). * EKG usually shows evidence of ischemia (ST elevation, T wave inversion, etc.) in the anterior precordial leads (V1-V4) and troponin may be a little high. But, angiogram shows no CAD. * self-limiting in weeks

Answer 135

1. Panic attack—> no EKG abnormalities | 2. Broken heart syndrome—> ischemic EKG symptoms (ST elevation, T wave inversion, moderately elevated troponin, etc.)

Answer 136

1. Serum calcium- NORMAL 2. Serum phosphorus- NORMAL 3. Alkaline phosphatase- HIGH 4. Urgent hydroxyproline- HIGH (an elevated bone turnover marker) * Paget disease of the bone- imbalance between osteoclast and osteoblast function (osteoC’s go crazy breaking down bone w/o the regulation of osteoB’s-> osteoB’s rush to compensate and lay down bone, but do a poor job of it-> thick bone that fractures easily) * Symptoms: bone pain, increasing hat size, hearing loss, lion face, isolated elevated alk phos (due to activation of osteoB’s)

Answer 137

Reposition the endotracheal tube (When you intubate, the goal is to get the tube just before the carina, where the main bronchus bifurcates into the right and left bronchus. If only one lung is expanding after intubation, you advanced the tube too far into either the right bronchus or the left bronchus.)

Answer 138

Guillain-Barré syndrome -ascending paralysis from a URI or diarrheal illness (Campylobacter jejuni)

Answer 139

Protein- HIGH WBC’s- NORMAL RBC’s- NORMAL Glucose- NORMAL * CSF protein may be high due to increased permeability of the blood-nerve-barrier * treat with IV Ig or plasmapheresis * takes patients months to recover (can be chronic too- I saw a patient like this in the hospital)

Answer 140

When the gift directly benefits patient care and it is of low monetary value

Answer 141

1. PaO2 < 55 or oxygen sat SaO2 < 88% 2. In patients with cor pulmonale, right HF, or hematocrit >55%, PaO2 < 59 or oxygen sat SaO2 < 89% * *PaO2= Oxygen in blood, not bound to Hb * *SaO2= Percent of oxygen that is bound to Hb (saturated)

Answer 142

Emergent neurosurgery to get rid of the hematoma

Answer 143

Sarcoidosis -systemic granulomatous disease that can involve the nervous system (Bell’s palsy), lymphadenopathy, parotid gland swelling, hypercalcemia (1-alpha hydroxylase activity)

Answer 144

TCAs block fast sodium channels—> slower conduction speed= QRS prolongation (*can also lead to Torsades) *Treat with sodium bicarb bc it increases serum pH (more alkaline) and extracellular sodium. Both the increased pH and extra extracellular Na+ decrease the drug’s binding to cardiac Na+ channels.

Answer 145

8.4-10.2 | For simplicity, remember about 8.5-10

Answer 146

Hypercalcemia of malignancy Bisphosphonates *She has metastatic breast cancer to the bone—> more bone breakdown—> bone pain and higher levels of calcium in the blood (*you can also get hypercalcemia of malignancy if you have a tumor secreting PTHrP). Bisphosphonates cause osteoClast apoptosis so they can’t keep breaking down bone

Answer 147

Primary hyperaldosteronism due to adrenal adenoma *aldosterone-> Na+ reabsorption, K+ and H+ wasting, so hypokalemia makes sense **treat with an aldosterone antagonist (Spironolactone, Eplerenone) or surgery

Answer 148

Get an MRI of the cervical spine -He most likely has C5-6 nerve root impingement (cervical radiculopathy) from underlying cervical spondylitis (wear and tear of spinal disks in neck/ cervical spine degeneration)

Answer 149

Carcinoid syndrome - Serotonin-secreting tumor - Usually in the GI tract, but if Mets to the liver, it can’t be broken down and serotonin travels through the bloodstream causing systemic effects. Can affect right heart only (tricuspid regurg in this patient) bc lungs (like the liver) have the enzyme to break down serotonin. - Symptoms= diarrhea, flushing, tricuspid regurg, bronchospasm

Answer 150

``` Carcinoid= serotonin-secreting tumor Tryptophan gets used up to make serotonin Since tryptophan (and vit B6) are required to make niacin (vit B3), you’ll get a niacin deficiency as a result ```

Answer 151

Diabetic ophthalmoplegia- poorly controlled DM—> ischemic neuropathy (tiny blood vessels that supply CN 3 are damaged)—> CN 3 palsy

Answer 152

Tendon- muscle to bone Ligament (“Like”)- bone to bone

Answer 153

Inflammation and pain at sites where tendons (muscle to bone) and ligaments (bone to bone) attach to bone * most often at the Achilles’ tendon (but also can be at the costosternal junction, shoulders, elbows, hips, iliac crests, tibial tuberosities, etc.) * can be part of an isolated disorder (like plantar fasciitis) or in spondyloarthropathies (like ankylosing spondylitis)

Answer 154

IBD (Crohn’s or Ulcerative Colitis) *remember they are associated with arthritis, including spondylarthritis or sacroilitis

Answer 155

There is upper motor neuron (UMN) or pyramidal/ CST (corticospinal tract) disease *UMN lesions cause more weakness in supinator muscles compared to pronator muscles of the upper limb—> affected arm drifts down and the palm turns (pronates) toward the floor

Answer 156

Oxybutynin (anti-muscarinic for treatment of urinary incontinence)

Answer 157

Age-related hearing loss *due to cochlear hair cell loss (and cochlear neuron degeneration)

Answer 158

Cross legs, tense calf muscles, handgrip, and tense arm muscles with clenched fists...) -These maneuvers increase venous return to the heart (more ‘milking’ of blood to heart)—> more CO, which can stop the syncope from happening

Answer 159

Febrile nonhemolytic transfusion reaction (Due to cytokines in stored blood products) *prevention of this is by leukoreduction of blood products (filter out most the WBCs after blood collection, before storage to prevent cytokine production within the packed RBC product)

Answer 160

1. Nitrates | 2. Alpha blockers (ex: Doxazosin)

Answer 161

IV Penicillin G or IV Ceftriaxone - Fever + murmur suggests endocarditis - Initial emperic treatment with Vanco is appropriate to cover MRSA (just in case) - Now we got cultures back and know it is not MRSA (it is sensitive to penicillin), so switch to IV penicillin or Ceftriaxone (easier to administer due to once daily dosing vs. every 4-6 hrs) * Do not use oral Penicillin- should treat IV for endocarditis

Answer 162

YES You have a high A-a in any V/Q mismatch where there is impaired gas exchange! - in the case of PE, the problem is with Q (perfusion) - oxygen is getting from the alveoli fine, but the blood isn’t there to pick it up bc it is stuck (there’s a clot in major pulmonary vessels)

Answer 163

LOW PE—> hyperventilation (in effort to compensate)—> blowing off more CO2, so less CO2 stays behind in the blood

Answer 164

Topical Minoxidil | A vasodilator that increases blood flow to the scalp *side effects: irritation and itching

Answer 165

Vascular dementia (Stepwise/ gradual decline, often presents with motor, gait, urinary, and psych symptoms) *not likely to be Alzheimer’s bc that starts with memory problems and other stuff goes later

Answer 166

Common peroneal neuropathy (L5 radiculopathy-> back pain radiating to the foot and weakness on foot inversion and plantar flexion) *remember the common peroneal (fibular) nerve: PED= Peroneal Everts and Dorsiflexes If injured-> foot dropPED

Answer 167

BNP >400 (Remember BNP is released by the heart in response to stretch, which there is more of when you have CHF and are fluid overloaded) *BNP is a highly sensitive test for CHF. Clinical signs (JVD, crackles, lower extremity edema) are highly specific, but not sensitive.

Answer 168

HIGH prolactin will feedback on GnRH, making it LOW (negative feedback)—> LOW testosterone production

Answer 169

Coarctation of the aorta - narrowing of descending aorta-> pressure overload in proximal part of aorta-> HTN in arms (where BP is normally measured), headaches (pressure goes back to carotids-> head) * murmur for coarctation is systolic (blood through constricted aorta like aortic stenosis) or continuous (if collateral vessels are present) * S4 may be heard due to LV hypertrophy (induced by HTN)

Answer 170

Notching of the ribs (erosions of inferior costal surfaces) -this finding is due to collateral vessel formation

Answer 171

VIPoma -rare tumor of pancreatic cells—> releases vasoactive intestinal peptide (VIP)

Answer 172

ARDS (Acute Respiratory Distress Syndrome) *acute inflammatory response w/ cytokines in the lungs-> epithelial damage/ necrosis of alveolar cells + endothelial damage/ inc capillary permeability leaking proteins-> hyaline membranes

Answer 173

Acute inflammatory response w/ cytokines in the lungs-> epithelial damage/ necrosis of alveolar cells + endothelial damage/ inc capillary permeability leaking proteins-> hyaline membranes (The release of cytokines/ overreactive inflammatory response to a stressor like sepsis, PNA, whatever is the problem...causes damage to lung tissue) **rarely can lead to irreversible pulmonary fibrosis (from too much collagen deposition as endothelial cells, pneumocytes, and fibroblasts proliferate to repair damaged lung)

Answer 174

1. Increase FiO2 (fraction of inspired oxygen) 2. Increase PEEP (positive end-expiratory pressure) * This is the best way to improve hypoxemia in a patient with ARDS bc it additionally prevents alveolar collapse

Answer 175

PEEP (positive end-expiratory pressure) * There are 2 ways to improve oxygenation of a ventilated patient: 1. Increase FiO2 (fraction of inspired oxygen) 2. Increase PEEP (positive end-expiratory pressure)

Answer 176

Nonallergic rhinitis (aka vasomotor rhinitis) Treat with an intranasal antihistamine and/or intranasal glucocorticoid

Answer 177

Splenic infarction (Acute occlusion of splenic artery, causing LUQ pain) * High retic count and UCB= Intravascular hemolysis * Could be due to sickle cell trait (usually asymptomatic, but can get Intravascular hemolysis and splenic infarction in stressors like a long flight- do Hb electrophoresis to diagnose

Answer 178

Treating a disease a different way when the standard treatment fails (Ex: guy gets radical prostatectomy for prostate adenocarcinoma and PSA is undetectable. Months later, PSA is high and he gets radiation= a salvage therapy)

Answer 179

Macular degeneration - often age-related, the macula (center of retina in back of eye responsible for visual acuity) wears down - early finding= straight lines look wavy - eventually they loose central vision *most common cause of blindness in industrialized nations

Answer 180

Diagnosis: light microscopy of skin scrapings Treatment: topical permethrin or oral ivermectin

Answer 181

Lupus (SLE) Diagnosis if 4+ of these criteria: 1. Butterfly rash 2. Photosensitivity 3. Oral/ nasopharyngeal ulcers 4. Discoid rash (coin-shaped, worse with sun exposure) 5. Arthritis 6. Pericarditis 7. Hematologic dz (anemia, leukopenia, thrombocytopenia) 8. Renal disease (proteinuria, casts) 9. CNS- seizures, psychosis 10. Immuno markers (false positive Syphilis, anti-dsDNA, anti-Smith Ab) 11. ANA *She has: (1) arthritis, (2) oral ulcer, (3) lymphadenopathy, (4) anemia and thrombocytopenia

Answer 182

Triad of: RA + splenomegaly + neutropenia (low neutrophils-> high-risk for bacterial infections) *"SANTA's suit is felty" Splenomegaly, Anemia, Neutropenia, Thrombocytopenia, Arthritis (Rheumatoid)

Answer 183

Bronchoalveolar lavage This is likely PCP (Pneumocystis) pneumonia *immunosuppressed/ organ transplant patients are at high risk for PCP and CMV pneumonia. Therefore, they should be on prophylactic Bactrim (for PCP) and Ganciclovir-Valganciclovir (for CMV in seropositive patients)

Answer 184

Lying down

Answer 185

Abdominal CT - Patient most likely has RCC (renal cell carcinoma) (*classic triad: flank pain, hematuria, palpable abdominal mass is in few patients) - smoking is a risk factor - varicocele is due to tumor pressing against left renal vein and left testicular vein, impairing venous drainage from testicle - fever is a nonspecific cancer finding (also weight loss, anorexia, fatigue, night sweats) - ectopic production of EPO by kidney tumor-> polycythemia

Answer 186

LV hypertrophy

Answer 187

Isolate ambulatory HTN (aka masked HTN) - even though BP is okay rn, it is probably high on average (avg over day of >135/85= HTN) - he has evidence of end-organ failure from HTN (retinal AV nicking aka hypertensive retinopathy and LV hypertrophy shown by peaked QRS’s)

Answer 188

Anti-phospholipid antibody syndrome Treat/ prophylaxis with aspirin and LMWH (low molecular weight heparin) to avoid clotting problems and pregnancy loss - the presence of antiphospholipid antibodies + you have blood clots (DVT, PE, stroke, MI) or pregnancy problems (miscarriages or premature birth from placental insufficiency or preeclampsia) - antiphospholipid antibodies are seen in SLE (but not specific to it). They can cause 3 problems: (1) antiphospholipid antibody syndrome, (2) increased PTT, (3) false positive syphilis test (RPR, VDRL)

Answer 189

Hodgkin lymphoma - B symptoms - painless lymphadenopathy - mediastinal mass - PET scan radiotracer is taken up by cancer cells w/ a high metabolic rate (supraclavicular and mediastinal LN’s) and healthy organs with high metabolic rates (brain, kidneys, bladder)

Answer 190

Gout - usually occurs in big toe, but can occur in ankle or knee too - triggers: alcohol, surgery/ trauma, dehydration, some meds (diuretics)

Answer 191

1. Liver releases AT 2. Kidney JGA cells release Renin, which converts AT-> AT I 3. Lungs release ACE (angiotensin converting enzyme), which converts AT I-> AT II * ACE also breaks down bradykinin 4. AT II has multiple effects on the body to raise BP: - vasoconstriction - constricts efferent arteriole (raise GFR) - aldosterone release from adrenal gland-> reabsorption of Na+ (wasting of K+, H+) - ADH (retains water) and thirst

Answer 192

Temporary loss of vision (in 1 or both eyes) -For example, due to emboli from severe carotid stenosis can cause ischemia to the optic nerve-> transient (on/off) vision loss

Answer 193

CT Angiogram of the abdomen (look at the renal arteries) Why? She has such a high BP that it is causing transient vision loss (amaurosis fugax- emboli from severe ipsilateral carotid stenosis can cause ischemia to the optic nerve), so you need to work it up. High Renin and Aldosterone means it’s secondary hyperaldosteronism. This is most likely due to FIBROMUSCULAR DYSPLASIA (developmental defect in blood vessel wall-> irregular thickening of renal, carotid, vertebral arteries)-> kidneys read low BP-> activate RAAS-> increased renin, aldosterone, and BP.

Answer 194

Paroxysmal supraventricular tachycardia (PSVT)

Answer 195

Reflex on immersion in cold water that slows HR and causes peripheral vasoconstriction to divert blood flow to central, vital organs (brain, heart, lungs) to conserve oxygen until breathing resumes and to delay potential brain damage (*the body knows it cannot breathe in oxygen while underwater, so it slows the HR down so that the body can survive longer with the blood/ oxygen it already has to pump) *colder water (drops core temp super fast)= stronger diving reflex response (and therefore better chance of survival if you drown in ice cold water vs. a pool) (*supraventicular means it is coming from the atria)

Answer 196

Vagal maneuver (cold water immersion/ diving reflex, carotid sinus massage, Valsalva, eyeball pressure)—> increased stretching and firing of baroreceptors—> more parasympathetic response—> lowered HR *diving reflex (immersion in cold water slows the heart to conserve energy/ so you could survive longer + vasoconstricts to shunt blood to central, vital organs)

Answer 197

1. PCWP (=LA pressure)- LOW (due to decreased preload) 2. CO- LOW (due to decreased preload) 3. BP- LOW (due to deceased CO) 4. SVR- HIGH (vasoconstriction in attempt to raise BP and maintain CO)

Answer 198

Inferior MI—> occluded RCA, which supplies the AV node—> since the AV node has cut off blood supply, it won’t be able to do a good job of delaying the signal from the atria to ventricles—> AV block (prolonged PR’s= impulse from atria to ventricles gets too delayed, dropped QRS’s= part of the AV node is blocked so failing to send the impulse from the atria to ventricles)

Answer 199

Inferior MI- occlusion of the RCA *His vitals tells you he’s in cardiogenic shock (really low HR and BP). This makes sense bc MI-> heart not getting fed enough blood to pump well

Answer 200

Diffuse ST-segment elevations

Answer 201

Acute pericarditis (aka fibrinous pericarditis aka peri-infarction pericarditis) *EKG would show diffuse ST-segment elevation

Answer 202

She has mitral stenosis (from rheumatic heart disease which causes mitral regurg, later mitral stenosis)—> increased pressure in LA causes the LA to dilate—> predisposes to a-fib—> worsening flow through the stenotic mitral valve—> more backing up of blood/ congestion to lungs, explaining the SOB *up to 70% of patients with mitral stenosis will develop a-fib from the significant LA dilation

Answer 203

Tongue biting (*95% specificity for epileptic seizure, esp if on the lateral tongue- bc rarely syncope can cause frontal tongue biting)

Answer 204

LV hypertrophy

Answer 205

Coarctation of the aorta - high-voltage QRS’s, ST-segment depression, and T-wave inversion= LV hypertrophy from long-standing HTN - prob not essential HTN bc that rarely causes end-organ damage in young patients <40 - coarctation of the aorta (narrowing at distal aorta) usually causes asymptomatic HTN, but can cause headache, nosebleeds, lower extremity claudication *check bilateral arm and leg BP measurements

Answer 206

ECG *You need to rule out acute coronary syndrome (STEMI, NSTEMI, unstable angina), which could have an atypical presentation like this! Once ruled out, then you can consider GI things like pancreatitis **women, elderly, and diabetes patients are more likely to have atypical heart symptoms

Answer 207

Vasospastic (Prinzmetal) angina- due to episodic vasospasm of pulmonary vessels Raynaud phenomenon- due to episodic vasospasm in fingers and toes

Answer 208

One-time abdominal ultrasound screen for men 65+ who have ever smoked

Answer 209

Unstable—> immediate cardioversion Stable—> IV procainamide or Ibutilide (rhythm control) *do NOT use AV node blockers like adenosine, beta blockers, CCBs, digoxin—they would promote conduction across the accessory ‘secret’ pathway, causing a-fib—> v-fib

Answer 210

1. Episodes of vertigo (20 min- 24 hrs, associated with nausea/ vomiting) 2. Sensorineural hearing loss (fluctuates) 3. Tinnitus (ringing of ear)

Answer 211

Meniere Disease (disorder of inner ear where you have too much volume/ pressure of endolymph fluid) Triad: 1. Episodes of vertigo 2. Sensorineural hearing loss 3. Tinnitus

Answer 212

1. Acute-onset epigastric pain radiating to the back 2. Increased amylase or lipase >3x the upper limit of normal (lipase more specific) 3. Abdominal imaging suggestive of pancreatitis- CT of abdomen (pancreatic enlargement) * NOTE: you do NOT need CT to make the diagnosis...epigastric pain radiating to back + lipase >3x upper limit of normal is sufficient! **U/S is not used (gas prevents visualization) and X-ray is not used (poor test for pancreatitis)

Answer 213

A P2y12 receptor blocker (like Clopidogrel aka Plavix) *normally, ADP binds this receptor on platelets to promote platelet aggregation (we block it to stop platelet aggregation) Dual Anti-Platelet Therapy (DAPT) (ASA + P2y12 receptor blocker) is given to patients with stents for 12 mo to reduce the risk of stent thrombosis. Also, it reduces risk of recurrent MI in NSTEMI compared to ASA alone!

Answer 214

At least 12 months | Significantly reduces risk of stent thrombosis and recurrent MI

Answer 215

IgA nephropathy - protein in urine= nephrotic syndrome - most common nephrotic syndrome in adults= IgA nephropathy, esp after a URI (“sore throat”)

Answer 216

Herpes zoster oticus aka Ramsay Hunt syndrome Varicella zoster (VZV) reactivates—> Herpes zoster. If the herpes occurs in the dermatome of the geniculate ganglion (collection of sensory nerves from the facial nerve in the facial canal of the head), you get this. It disrupts CN 7/ facial nerve motor fibers and spreads to CN 8/ vestibulocochlear nerve—> facial paralysis and ear pain there.

Answer 217

Influenza virus (Muscle aches + nonspecific flu symptoms after shopping in a germy mall) *pneumonia is the most common complication of the flu

Answer 218

Pneumonia! - This can be from secondary bacterial infection (ex: Strep pneumo, Staph a.) or from direct viral attack (influenza pneumonia) * give oxygen support and oseltamivir (Tamiflu) + treat the pneumonia with Abx

Answer 219

Autosomal Dominant Polycystic Kidney Disease (ADPKD)—> chronic kidney dz (CKD) - evidence of ADPKD: flank pain, HTN (would be due to excess renin release), large liver (cysts) - evidence of CKD: nausea, fatigue, high Cr (due to structural degeneration of the kidneys) * NOTE: BPH is a separate issue here

Answer 220

IV Morphine *INITIAL management for acute pain (including opioids) is about the same for all patients—regardless of addiction history (you will just need to monitor this guy closely to avoid relapse)

Answer 221

1. Diminished and delayed carotid pulse (“pulsus parvus et tarsus”)—> since you have a stenotic aortic valve, there’s less blood flow making it through 2. Systolic murmur (crescendo-decrescendo)—> aortic valve opens during systole so makes sense that aortic stenosis (problem opening) is heard during systole 3. Soft and single S2—> normally, you have physiologic split of S2 (inspiration-> more blood to right heart-> pulmonic valve takes slightly longer to close than aortic valve in S2)...with aortic stenosis, the stenotic aortic valve takes longer to close too so they close at the same time= single S2

Answer 222

Order TSH Fatigue, muscles aches, weight gain-> suspicious for hypothyroidism, which can cause lipid abnormalities! You need to confirm this diagnosis—if it is in fact hypothyroidism, you will need to treat the underlying cause with Levothyroxine (will improve lipid levels, but does take a few months). Don’t jump straight to a statin (can worsen myopathy) or another anti-lipid drug until you do the work-up.

Answer 223

Decreased LV wall stress (afterload) Nitrates-> venodilate-> decrease preload/ blood in heart-> decrease demand on the heart (heart has to pump less blood) to match decreased supply (heart fed less blood) from angina *they also vasodilate, resulting in less pressure (afterload) the heart has to pump against **nitrates-> decreased LV end diastolic volume and wall stress-> decreased myocardial oxygen demand

Answer 224

Surgical removal of the rectum and colon | Done in FAP and UC, for example

Answer 225

Frequent colonoscopic surveillance - screening sigmoidoscopies for kids starting at 10-12 yrs - once you detect adenoma (or if >50 yrs) do annual colonoscopies - do proctocolectomy (surgical removal of rectum + colon) if they initially present bad with high-grade dysplasia or adenomas or once they get into their 20’s (prophylactic since nearly 100% FAP patients will get colon cancer)

Answer 226

Antiphospholipid antibody syndrome (These antibodies are present in SLE/ lupus and we call it a syndrome if you also have blood clots or miscarriages/ placental problems) -sudden-onset left-sided weakness= stroke (Babinski= UMN signs) -fatigue and mitral regurg are lupus symptoms (antibodies can damage valves-> exposure of subendothelial collagen-> vegetations of platelets/ clotting factors form) -ANA is non-specific to autoimmune dz’s -false positive Syphilis (RPR/ VDRL) is a thing with antiphospholipid antibody syndrome (*as well as high PTT)

Answer 227

1. CMV (cytomegalovirus) | 2. PCP (pneumocystis)

Answer 228

Narrow QRS—> SVT (supraventricular tachycardia) or A-fib *In SVT, the fast rhythm is coming from the atria. QRS is narrow (shorter ventricular contraction) bc it the atria send a rapid signal to the ventricles-> ventricles contract faster, keeping up with incoming signals. Wide QRS—> V-tach (ventricular tachycardia) or Torsades *In V-tach, the fast rhythm is coming from a rapid-firing pacemaker in the ventricles. QRS is wide (takes longer for ventricular contraction) bc it takes longer for a signal to go from ventricular myocyte to myocyte over the normal conduction pathway. That said, since it’s not paying attention to atrial signals and the ventricle is just going crazy on its own, the overall pace is fast/ tachy.

Answer 229

Stable SVT—> Adenosine (x3, rate control) Unstable SVT—> shock * Sketchy: Adenosine (swing dancing) is the agent of choice of SVT * *Valsalva, carotid sinus massage, breath holding, and immersion in cold water may help temporarily by lowering HR

Answer 230

Stable V-tach—> Amiodarone Unstable V-tach—> shock

Answer 231

Sinus tachycardia | Normal P waves followed by QRS’s *do NOT cause narrow QRS= supraventricular tachy (PSVT) or wide QRS= V-tach

Answer 232

No, probably not You get narrow QRS complexes and can have “hidden P-waves”

Answer 233

Rupture of the interventricular septum * can happen 3-5 post-MI of the LAD or RCA * when the interventrciular septum ruptures you basically get a VSD with flow from the LV-> RV, which explains the holosystolic murmur and cardiogenic shock presentation (too much backward flow of blood, not enough forward flow)

Answer 234

The left sternal border (Not the usual right 2nd intercostal space where you hear many aortic murmurs echo best...aortic regurg is actually heard best directly over the aortic valve)

Answer 235

Retinal detachment

Answer 236

No! They have their own blood supply

Answer 237

The respiratory acidosis/ CO2 retention (hypercapnia)

Answer 238

The kidneys aren’t working to reabsorb bicarb-> less bicarb in the blood

Answer 239

MD Calc tool to determine whether a pneumonia patient should be admitted to the hospital ``` C- confusion (+1) U- urea >20 (+1) R- respirations >30/ min (+1) B- BP, hypotensive <90/60 (+1) Age >65 (+1) ``` If CURB-65 score is 3 or greater—> admit to hospital (*if 1-2 you might still admit) **basically you’re looking at their vitals (is this a sepsis-like picture, really sick patient?) to determine if they need inpatient vs outpatient care

Answer 240

Beta-lactam + macrolide (ex: Ceftriaxone + Azithromycin) OR Fluoroquinolone (ex: Moxifloxacin)

Answer 241

Oxygenation is a problem—> consider changing FiO2 or PEEP (the percent oxygen in the air you are giving to the person or the positive end expiratory pressure to keep the alveoli from collapsing) Ventilation is a problem—> consider changing Tv (tidal volume) (mL of air the patient is getting in/out) or the RR (respiratory rate) (how fast they are breathing/ blowing off CO2)

Answer 242

``` Analgesic nephropathy (too many NSAIDs damaged the kidneys) -most often—> Tubulointerstitial nephritis or Papillary necrosis ``` *Naproxen (Aleve)= NSAID Remember that NSAIDs block PG’s (PG’s dilate the afferent)—> constriction of afferent—> decreased GFR and RPF (decrease blood flow to kidneys/ put more pressure on the kidneys) **chronic NSAID use also can cause premature aging, atherosclerotic valvular disease, and urinary tract cancer

Answer 243

NO! Aspirin is an antiplatelet agent-> stops clotting, and therefore causes bleeding, which would worsen aortic dissection. In fact, aspirin can kill a patient with aortic dissection.

Answer 244

Blocks COX-1 (and COX-2)—> decreased production of TXA2 (thromboxane A2) (*and PGs) within platelets—> decreased platelet aggregation (It is an NSAID/ antiplatelet agent that stops platelets from sticking)

Answer 245

Aspirin | Blocks COX-1-> TXA2-> platelet aggregation

Answer 246

Membranoproliferative glomerulonephritis (nephrotic syndrome) *complement gets activated/ used up—> decreased C3 protein

Answer 247

Restrictive= problem getting air IN FEV1 low/ FVC low= NORMAL or HIGH (less air in means less air out) Obstructive= problem getting air OUT FEV1 lower/ FVC low= LOW *remember FEV1= max air you can blow out in 1 second; FVC= max air you can blow out after max inspiration

Answer 248

Sarcoidosis-associated lung disease (restrictive pattern, so problem breathing in) *Clues: he’s young, “mediastinal fullness and scattered reticular opacities”= hilar lymphadenopathy, hypercalcemia (vit D conversion by lung macrophages)

Answer 249

Restrictive= problem breathing in (less air in= less air out) FEV1 (max air you can breathe out in 1 sec)= normal to low TLC= low (problem breathing in, so lungs hold less air) DLCO= low (inflammation and scarring interfere with gas exchange)

Answer 250

Low tidal volume ventilation (LTVV) | -to prevent overdistention of alveoli

Answer 251

Herpes Zoster (Shingles) *The pain can come before the vesicular rash by several days!

Answer 252

Vitamin B12 deficiency - gastrectomy (surgical removal of part or all of the stomach)—> loss of intrinsic factor, which is needed to absorb vit B12–> vit B12 deficiency, which is a macrocytic anemia * why hemolysis (inc LDH)? Vit B12 is needed for DNA synthesis. If it is deficient, you get ineffective erythropoiesis (making of RBCs in the bone marrow)-> intramedullary hemolysis

Answer 253

Get antibodies to Ro/SSA and La/SSB - this sounds like Sjogren syndrome (autoimmune disorder of exocrine glands)—> dry mouth (leading to difficulty swallowing, thrush, and dental carries) - to diagnose you need (1) evidence of dry mouth/ eyes (positive Schirmer test for decreased lacrimation) and (2) histologic evidence of lymphocytic infiltration of the salivary glands OR serum antibodies against SSA (Ro) and/or SSB (La)

Answer 254

Cauda equina syndrome - compression of 2+ spinal nerve roots in the lumbar cistern (in his case, likely due to a tumor *other cases: large lumbar disc herniation or abscess in the region) - the urinary incontinence is due to damage to S3-S5 (can also get sexual dysfunction) * get an urgent MRI of the lumbosacral spine * emergency surgical decompression within 1-2 days is required to prevent irreversible neuro damage

Answer 255

Autoimmune adrenalitis (autoantibodies against the adrenal gland)

Answer 256

ANA (antinuclear antibody) -this is sensitive, so it is the best screening test. Anti-dsDNA and anti-Sm (smith) antibodies are specific, so they are confirmatory tests.

Answer 257

1. Anti-cyclic citrullinated peptide—> Rheumatoid arthritis 2. Anti-histone—> drug-induced lupus (from hydralazine, procainamide, etc.) 3. Anti-neutrophil cytoplasmic (ANCA)—> vasculitis 4. Anti-Ro/SSA—> Sjogren syndrome 5. Anti-Scl-70 (anti-topoisomerase)—> scleroderma (systemic sclerosis)

Answer 258

Inflammation of the serous membranes in the body (for example, the pleural lining of the lungs or the pericardium lining of the heart) * can cause positional chest pain and SOB * if this is part of the presentation along with fatigue, polyarthritis, etc. you would suspect lupus (SLE)

Answer 259

8 years after initial diagnosis and every 1-2 years thereafter

Answer 260

Rapid rewarding with warm water (37-39*C/ 98.6-102.2*F) *also give pain meds (rewarming tissue is painful) *frostbite= freezing of tissue-> disruption of cell membranes, ischemia, vascular thrombosis, inflammatory changes (usually involves face, ears, distal limbs) **do NOT do hot air rewarming (not good enough control over the temp) or rewarm by placing the limb near your abdomen in the field if there’s the possibility of refreezing before getting definitive care (freezing-> warm-> freezing can cause more damage than just freezing-> warm)

Answer 261

Complex regional pain syndrome - can happen 4-6 wks post-trauma due to inflammatory cytokine effects - causes burning/ tingling pain out of proportion to the injury - associated with erythema, edema, skin changes, X-ray may show patchy demineralization

Answer 262

Give off the OCPs! Women with migraines, esp with aura, are at increased risk for ischemic stroke. OCPs (and other estrogen-containing contraceptives) increase risk for stroke too. So you don’t want to have both these stroke risk factors at once! OCPs are contraindicated in migraine sufferers for this reason.

Answer 263

Dopamine agonist (Cabergoline, Bromocriptine) *remember that dopamine puts the break on prolactin, so by giving a dopamine agonist, you are stopping prolactin (helps normalize prolactin levels and reduce tumor size) **only do surgery (transsphenoidal resection) if the tumor is really large (>3 cm) or not responding to meds

Answer 264

Add fludrocortisone (a synthetic mineralcorticoid/ aldosterone) -she is already taking hydrocortisone (a synthetic glucocorticoid/ cortisol)...since this doesn’t do much for the mineralcorticoid/ aldosterone deficiency, she gets those symptoms (hypOnatremia/ salt cravings/ light-headedness, hyperkalmeia)

Answer 265

Contact lens associated keratitis -usually due to Pseudomonas and serratia (gram-neg) and require removal of contacts and antibiotics emergently! (Otherwise can-> corneal perforation, scarring, permanent vision loss)

Answer 266

Compare to a previous CXR Most likely it’s a solitary pulmonary nodule (SPN)= benign nodule * no further testing if it’s stable in size >2 yrs * if it’s changed, move on to a CT and continue to rule out or rule in cancer

Answer 267

Mixed cryoglobulinemia Vasculitis (from immune complexes) - palpable purpura on legs, joint pain, liver involvement, kidney disease/ glomerulonephritis - associated with hep C and hypocomplementemia (depleted complement levels)

Answer 268

AV fistulas connect the arteries to the veins directly Rather than the normal path: arteries-> arterioles-> capillaries-> venous system, AV fistulas directly connect arteries-> veins (blood can dump right into the venous system at the top of the arm where the fistula is placed for dialysis access). Now the lower arm isn’t getting good perfusion-> heart makes up for it by pumping harder. This constant increase in contractility (heart having to work harder)-> high-output cardiac failure.

Answer 269

Renal artery stenosis **A bruit does not usually indicate AAA (abdominal aortic aneurysm)- this would be a pulsatile mass (in <50% of patients) or picked up on screening Doppler U/S.

Answer 270

Vasodilation

Answer 271

Most are asymptomatic! (Trick Q)

Answer 272

A-fib Cardiovert (it is <48 hrs plus he is hemodynamically unstable)

Answer 273

Defibrillation= unsynchronized shock - “drops a bomb”/ shocks at a random point in the cardiac cycle - use for V-fib and V-tach (Rap: “defib for V-fib and pulseless V-tach. Don’t defib asystole you won’t bring em back”) Cardioversion= SYNCHRONIZED shock (press that sync button) - shock is given at the QRS complex (purpose is to minimize shock occurring during depolarization, which could throw the patient into V-fib) - example: use for a-fib if unstable, onset <48 hrs, or in a young person with a structurally normal heart after anti-coagulating with Warfarin for 3 weeks and do TEE right before to make sure there’s no clots (don’t want to throw a clot with the CV-> stroke)

Answer 274

Chronic venous insufficiency (CVI) (Incompetent venous valves-> backflow of blood and pooling in legs) *ankles often appear hyperpigmented, may have ulcers Leg elevation, compression stockings, exercise **patients who don’t respond to these conservative treatments should get venous duplex U/S to confirm the diagnosis (by retrograde venous blood flow)

Answer 275

1. ACE inhibitors 2. ARBs 3. Beta-blockers 4. Mineralcorticoid receptors antagonists (Spironolactone/ Eplerenone) *also hydralazine + nitrates in African American patients

Answer 276

Varying amplitude (height) of QRS complexes Suggests cardiac tamponade

Answer 277

Mitral regurg *clinical features: SOB on exertion (dec CO due to the regurg and inc LA pressure) and fatigue...can lead to a-fib (stretched LA) and HF

Answer 278

Medication non adherence He’s having stent thrombosis. To prevent this, patients should be on ASA + Clopidogrel (Plavix)= dual anti-platelet therapy (DAPT). Most common cause of stent thrombosis= not taking these meds as instructed. How do you know this is stent thrombosis, not a recurrent MI? LAD= leads V1-V4 where the stent was placed! So this is far more likely.

Answer 279

Hypertensive emergency—> next day Cyanide (CN) toxicity Really high BP + end-organ damage (CHF, renal failure, and eye signs/ symptoms) *cotton-wool spots= white patches on retina (high pressure damages blood supply to the nerve fibers) IV Nitroprusside is given in HTN emergency, but gives off nitric oxide and cyanide byproducts. CN toxicity= neurologic change (seizure, altered mental status, lactic acidosis, coma)

Answer 280

GLUCAGON -Bradycardia, AV block, hypotension and wheezing suggests beta-blocker overdose *Remember that beta-blockers dec HR (block beta-1 on heart), can cause AV block (AV node is slowing the signal from atria to ventricles too much), can cause hypotension (block beta-1, which causes renin release), and can cause wheezing (block beta-2, which bronchodilates-> bronchoconstriction) **extremities are cold due to peripheral vasoconstriction (inc BP, dec blood flow) to shunt blood to centrally located vital organs ***also, the fact he has CAD and HTN tells you he prob was prescribed a beta-blocker and has it available to overdose on in a suicide attempt

Answer 281

PPI (like Omeprazole) -this is GERD * GERD symptoms mimic angina, worse at night bc acid can reflux easier when laying down * cough and hoarseness from laryngeal irritation (from the acid) *Although the exercise EKG shows ST depression (subendocardial ischemia), evidence of ischemia when exercising at 90% of maximal HR is NOT unusual in patients with known CAD

Answer 282

Does not typically cause diffuse ST elevation (or PR depression) * this is bc the inflammation doesn’t affect the myocardium * *uremic pericarditis presents in patients with advanced renal failure requiring dialysis (they come in with pleuritic chest pain and pericardial friction rub)

Answer 283

CHADS-VASC score is used to determine whether an a-fib patient should be started on lifelong anticoagulation ``` C- CHF H- HTN A- Age >75 (*2 points) D- DM S- Stroke/ TIA (*2 points) V- Vascular dz (prior MI, PAD, aortic plaque) A- Age 65-74 Sc- Sex (female) *everything positive counts as 1 point except age >75 and stroke count as 2 points ``` 0–> no anticoagulation 1–> none, ASA, or oral anticoagulation 2+-> oral anticoagulation

Answer 284

NO His CHADSVASc score is 0 so it is not indicated. ``` C- CHF H- HTN A- Age >75 (*2 points) D- DM S- Stroke/ TIA (*2 points) V- Vascular dz (prior MI, PAD, aortic plaque) A- Age 65-74 Sc- Sex (female) *everything positive counts as 1 point except age >75 and stroke count as 2 points ``` 0–> no anticoagulation 1–> none, ASA, or oral anticoagulation 2+-> oral anticoagulation

Answer 285

Echocardiogram You need to check for peripartum cardiomyopathy (dilated cardiomyopathy that can occur during or up to 5 mo. after pregnancy). It is often associated with mitral regurg (holosystolic murmur at the apex).

Answer 286

Latex allergy (anaphylactic shock)

Answer 287

Petechial rash (also SOB and confusion) 12-24 hrs later! Not immediate

Answer 288

Increased LV compliance (The LV undergoes eccentric hypertrophy of myocardial fibers in series, meaning it stretches out/ dilates in response to the backflow of blood)

Answer 289

> 7.5-10% | Depends on the resource you’re looking at

Answer 290

Pericarditis (*typically presents as pleuritic chest pain, pericardial friction rub, and diffuse EKG changes w/ other SLE symptoms such as joint pain)

Answer 291

Tricuspid regurg

Answer 292

No -though liver biopsy is the gold standard for diagnosis of cirrhosis, if the history and physical is obvious for cirrhosis, do not put the patient through this *you also don’t need to do unnecessary work-up for rare causes of cirrhosis like alpha-1 antitrypsin deficiency or hemochromatosis. This guy is an alcoholic so you can say with confidence that the cirrhosis resulted from alcohol intake.

Answer 293

Endoscopy (EGD= EsophagoGastroDuodenoscopy) -you need to check for esophageal varices, determine their risk for variceal hemorrhage, and come up with strategies for prevention of variceal hemorrhage (these patients bleed so much it’s life threatening!)

Answer 294

Antibiotics- Ciprofloxacin + Metroniadazole (Flagyl) And bowel rest Follow up with colonoscopy (4-8 wks later) since colon cancer can mimic the presentation and CT findings of diverticulitis! *also advice patients to increase fiber intake and exercise and lose weight and stop eating red meats, smoking, and straining on the toilet **Cipro is a fluoroquinolone that is broad spectrum and good for gram neg GI bugs + Metronidazole is good for anaerobic coverage

Answer 295

Alcoholic dilated cardiomyopathy - he has evidence of systolic dysfunction in the setting of alcohol abuse. Know that dilated CM from alcohol is a dx of exclusion (he had no prior CAD or valvular heart dz and heavy alcoholism is evident) * abstinence from alcohol should improve or normalize LV function over time

Answer 296

Peripheral vascular dz- blood flow is reduced to a limb (same concept as angina) Acute arterial occlusion- blood flow is cut off to a limb (same concept as MI, emergency!)

Answer 297

Peripheral artery disease Treat with smoking cessation, graduated exercise program (walk until claudicaiton/ pain from ischemia, then rest, then do 1 more cycle), atherosclerotic risk factor reduction, avoid temperature extremes, aspirin + a stain, can also give Clopidogrel, cilostazol (surgery- angioplasty or bypass grafting- if severe) * this usually occurs with CAD/ is a manifestation of atherosclerotic cardiovascular dz (ASCVD) * *do not confuse with acute arterial occlusion- this is an emergency where blood flow through an artery to a limb is fully cut off! Presents with 6 P’s: pain, pallor, polar (cold), paralysis, paresthesias, and pulselessness (not just reduced pulse/ blood flow...none at all!)

Answer 298

Autoimmune gastritis—> pernicious anemia (Antibodies against parietal cells—> cannot absorb vit B12–> macrocytic anemia) *look for hypochlorhydria (decreased stomach acid- since parietal cells produce acid) and elevated gastrin (gastrin stimulates parietal cells to release acid, so it will get up-regulated in response to the low acid as feedback)

Answer 299

1. Synthetic (makes stuff) - clotting factors - cholesterol - proteins (ex: protein c and s, albumin) 2. Metabolic - metabolism of drugs and corticosteroids (P450 system) - detox - breaks down estrogen 3. Excretory - bile excretion

Answer 300

He is peeing out a LOW amount of D-xylose (monosaccharide), meaning he has a mucosal reabsorption problem like celiac dz or SIBO...but it’s not SIBO since that’s treated with Rifaximin and that did not help...so it’s celiac (problem with reabsorption due to flattened villi-> less of the monosaccharide pushed into the blood-> less filtered through the kidneys and peed out) *patients with malabsorption due to enzyme deficiencies would have normal absorption and urinary output of D-xylose (bc their problem is with enzymes breaking polysaccharides into monosaccharides and D-xylose is already a monosaccharide)

Answer 301

D-xylose is a monosaccharide and gets fully absorbed into the blood. Pancreatic insufficiency (not getting enough pancreatic enzymes into the duodenum to break down polysaccharides-> monosaccharides)—since D-xylose is already a monosaccharide it doesn’t need the help of pancreatic enzymes, so all the D-xylose gets appropriately absorbed into the blood and a normal amount is peed out Celiac dz (flattened villi/ problem at small intestine level with pushing nutrients into the blood/ reabsorption)—so some D-xylose does NOT get reabsorbed into the blood as it should and a low amount is peed out

Answer 302

Both due to hyperestrinism Liver not working to break down estrogen—> too much estrogen

Answer 303

Caput medusae= dilation of superficial veins on the abdominal wall DUE TO PORTAL HTN (Backs up portal vein-> periumbilical vein)

Answer 304

PE (pulmonary embolism) *presents with SOB, pleuritic chest pain, tachypnea, tachycardia (CXR may appear normal)

Answer 305

Aortic dissection -this guy has Marfan syndrome (mutation of fibrillin-1-> connective tissue integrity problems throughout the body, including aortic root dilation)

Answer 306

Wilson disease - rare AR disease in which copper transport is impaired—> copper accumulation in tissues - consider this when there is liver dysfunction + neuro psych symptoms!

Answer 307

DASH diet ``` *the following can decrease BP by this much: Weight loss—5-20 per 10kg loss DASH diet—8-14 Exercise—4-9 Dietary sodium reduction—2-8 Limiting alcohol—2-4 ``` **tell patients to do all of the above, but losing weight and eating a DASH diet (all-around healthy diet rich in fruits and veggies, low in saturated and total fats) is key to lowering BP, more so than limiting salt

Answer 308

Loop diuretics He has LV failure (backing up to lungs). Taking off fluid is the first step in providing symptomatic relief. *yes, drugs like beta-blockers are helpful in the long-term and reduce mortality, but this wouldn’t be the best initial therapy—wouldn’t take the excess fluid off to make the patient feel better

Answer 309

Restrictive cardiomyopathy | Amyloidosis= misfolded protein that deposits around the body

Answer 310

Spontaneous bacterial peritonitis -infection of the ascitic fluid * presents as abdominal discomfort in a cirrhosis patient, possibly mental status change * diagnose by PMN (neutrophil) count >250 + positive peritoneal fluid culture

Answer 311

PCP pneumonia *it’s associated with AIDS, but also immunosuppressed people (she’s taking glucocorticoids/ steroids, which block the immune system)

Answer 312

ST elevation in II, III, aVF= inferior STEMI (occlusion of the RCA). Inferior wall MI’s have a 50% chance of involving the RV. Since he has clear lungs (meaning left heart is good), it probably did involve the right heart. In a right sided MI, you don’t give nitrates bc the right heart is preload dependent and this will drop BP too much! Since you already gave nitros and his BP did drop too much, give a normal saline bolus (IV fluids) to get the preload back up (which will improve CO and BP).

Answer 313

>500 (*10^6/ L)

Answer 314

Yes! Alcoholic cirrhosis-> liver inflammation after drinking involving fibrosis and nodule formation. This fibrogenesis improves with abstinence from alcohol. Although advanced cirrhosis is irreversible, avoiding alcohol still carries a huge survival benefit.

Answer 315

Constitutional (fever, night sweats, fatigue, malaise, weight loss) and GI (diarrhea, abdominal pain) symptoms

Answer 316

8-40 is the normal range for both AST and ALT

Answer 317

Nonalcoholic fatty liver disease (NAFLD) * we see a mild elevation in liver enzymes in these patients (AST/ALT ratio <1) and mild hepatomegaly. Alk phos may also be on the high side. Albumin and bili are typically normal. * diagnose by labs and U/S showing hyperechoic texture of the liver (liver biopsy would confirm but we don’t do this for fatty liver) * treat with weight loss/ manage metabolic risk factors

Answer 318

Class I anti-arrhythmic drugs block Na+ channels in depolarization (phase 0) In patients with faster heart rates, the drug has less time to dissociate from the Na+ channels—> longer effect of the drug (more widening of the QRS interval/ ventricular contraction) **this is why class I anti arrhythmic drugs (esp class IC) are good at treating supraventricular tachyarrhythmias

Answer 319

SVR goes up (vasoconstriction) Afterload goes up *Here’s the cycle of hemodynamics in HF: Dec contractility-> dec CO-> poor perfusion to kidneys activates RAAS-> vasoconstriction (inc SVR)-> inc afterload (the vasoconstriction/ inc BP increases the pressure the heart now has to pump against)-> decreases the contractility even more since the extra afterload makes it harder to pump...so its a nasty cycle

Answer 320

LV dilation (due to decreased CO)/ remodeling—> functional mitral regurg

Answer 321

Basically the same as cardiac output, but takes into account the person’s body weight *Cardiac Index (CI)= CO/ body surface area

Answer 322

Distributive shock | “Warm shock” from vasodilation

Answer 323

Mitral valve prolapse (MVP) | Myxomatous degeneration of the mitral valve

Answer 324

Check serum electrolytes! If a patient is stable in V-tach, you need to find out why there are having this arrhythmia (if unstable defibrillate)! She likely has electrolyte imbalance due to the IV Lasix/ Fuorosemide, which is a loop diuretic and causes hypokalemia and hypomagnesemia. Low K+ and Mg can lad to V-tach. If this is the case, you need to correct her electrolytes.

Answer 325

Variant angina or Prinzmetal angina

Answer 326

Mechanism= the intima layer of the artery smooth muscle is hyperactive—> intermittent coronary artery vasospasm (ST elevation during chest pain episodes lasting <15 min) Treatment= CCB’s (Diltiazem, Amlodipine) - cause coronary artery vasodilation to prevent vasospasm * Nitrates given to stop chest pain during an episode

Answer 327

IV Benzo (like Diazepam) This guy is on cocaine (tachy, HTN, signs of MI specifically NSTEMI, dilated pupils, nose jacked up from snorting cocaine) having cocaine-induced MI. Benzos bind to GABA and enhance its inhibitory CNS activity-> less sympathetic activity so reduced agitation, improved HR and BP, improvement in cardiac symptoms. *also give ASA (antiplatelet to stop thrombus formation enhanced by cocaine), nitrates, and CCBs to vasodilate. Do NOT give beta-blockers due to unopposed alpha-1 constriction-> worsening vasoconstriction!! * *Remember cocaine blocks NET and DAT (NE and dopamine reuptake)-> inc NE and dopamine in the cleft. NE= alpha-1> beta-1 agonist, so causes vasoconstriction (including coronary vasoconstriction). * *Use alpha-blockers in cocaine toxicity where BP is super high

Answer 328

Advise quitting alcohol PACs are early beats from the atria firing on its own, you see early P waves (QRS is normal bc conduction below the atria is normal). Usually asymptomatic and does not require treatment, however advice to quit tobacco, alcohol, caffeine, stress bc these things can be what’s causing it! *if symptomatic (palpitations) a beta-blocker can be given

Answer 329

Acute Aortic Dissection *Diastolic murmur at sternal border= aortic regurg (dissection can pull apart at aortic valve)

Answer 330

Fasting blood glucose >125 Hb A1c of 6.5% or more

Answer 331

A statin! (Long-term)

Answer 332

Glucocorticoids (methylprednisolone) cause mobilization of marinated neutrophils-> inc WBCs (Medication effect)

Answer 333

1. Intermittent- symptoms 2 or less days/ week (treatment= SABA prn) 2. Mild persistent- symptoms >2 days/ week but not daily (SABA prn + low-dose ICS) 3. Moderate persistent- symptoms daily (SABA prn + low-dose ICS + LABA (or medium-dose ICS)) 4. Severe persistent- symptoms throughout the day (SABA prn + medium-dose ICS + LABA) * if worse: SABA prn + high-dose ICS + LABA + oral corticosteroid and/or Omalizumab (if allergies too)

Answer 334

Quitting smoking right now There is no evidence that drugs (such as Moxifloxacin) or anything else decreases PNA risk in the setting of surgery. There is, however, evidence that quitting smoking 1-2 months prior to surgery decreases post-op pulmonary risk by a lot!

Answer 335

Mitral stenosis (Mitral valve has a hard time opening-> blood backs up to LA and lungs-> pulmonary edema and that extra pressure in the lungs can burst capillaries-> cough up blood)

Answer 336

Lung cancer!

Answer 337

Pulmonary airway disease (Chronic bronchitis, bronchiectasis, lung CA) -Chronic bronchitis (the constant coughing and irritation from mucus plugs can cause bursting of blood vessels in the bronchus), Bronchiectasis (same reason- you also have chronic coughing and mucus trapping from the abnormal dilation of the bronchus), and Bronchogenic carcinoma/ Lung cancer (likely due to coughing and maybe related to the rich vascular supply of the tumor)

Answer 338

Most concerning= the fact that PaCO2 is normal-high - Why? The normal response to an asthma exacerbation is hyperventilation (compensation for not breathing well)—> blowing off more CO2–> low PaCO2 (<40). If you are not hyperventilating in an asthma attack, you are not blowing off as much CO2 and PaCO2 will be high >40–this suggests respiratory muscle fatigue or severe air trapping suggesting RESPIRATORY COLLAPSE. * CXR showing hyperinflation is expected in an asthma exacerbation (obstructive= hard to breathe out= air trapping)

Answer 339

Invasive aspergillosis (Fever, pleuritic chest pain, and hemoptysis in immunocompromised) Voriconazole + an echinocandin (Caspofungin)

Answer 340

COPD (accounts for 25% of cases) (Widespread vasoconstriction in pulmonary vasculature to shunt blood to areas where there’s better oxygen...but problem is all areas are diseased, so this just creates a greater pressure that the right heart has to pump against-> right-sided HF)

Answer 341

SIADH - He has PCP pneumonia (HIV, classic fever + cough + SOB symptoms, crackles, CXR infiltrates) - SIADH can happen from PNA= too much retention of water-> low sodium concentration - Giving normal saline will worsen this kind of hypOnatremia (although it’s salty and you’re giving back some Na+, it is FLUID and that fluid dilutes the [Na+] more)

Answer 342

CT of the chest

Answer 343

Bad liver—> not making albumin like it should—> low oncotic pressure holding fluid in vessels—> peripheral edema

Answer 344

An infection of the ascitic fluid *usually occurs in patients with underlying chronic liver disease and ascites. Spontaneous bacterial peritonitis (SBP) is often associated with fever and abdominal pain (can also present with hepatic encephalopathy alone)

Answer 345

Repeat For example, “serial troponin” means you are measuring troponin several time (usually q8 hrs). “Serial CT scan” for lung cancer screening means you are doing a CT annually.

Answer 346

Collection/ pocket of pus in the pleural space * empyema often results from untreated exudative pleural effusion (usually secondary to bacterial PNA) * give antibiotics and do aggressive draining of the pleura with thoracentesis. If that doesn’t do it, do throacotomy (surgical opening up of the chest to gain access to the pleural space/ open drainage)

Answer 347

GFR <30 mL/min

Answer 348

D) Unfractionated heparin A) Enoxaparin= low-molecular-weight heparin (LMWH) B) Fondaparinux= IV factor Xa inhibitor C) RivaroXaBAN= oral factor Xa inhibitor E) Warfarin Cannot use A, B, C, E^ because the patient has renal failure (GFR <30) and these anticoagulants are not recommended for patients with renal insufficiency (takes too long to clear them-> increased factor X activity and bleeding risk) *Remember that LMWH (IV) is the best choice for renal insufficient patients and bridge to Warfarin (PO)!

Answer 349

Fluid restriction SIADH-> too much ADH-> too much retention of fluid diluting [Na+] so that it is low Less fluid will help this concentration come back up *SIADH drugs (Vaptans and Demeclocycline) can be used to block V2 ADH receptors, but start with fluid restriction and see if that is enough

Answer 350

Most common side effect of inhaled corticosteroids (ICS) like Beclomethasone (in asthma, COPD)= OROPHARYNGEAL THRUSH (oral candidiasis)

Answer 351

Aspirin-exacerbated respiratory distress (AERD) *ASA and all NSAIDs block COX—> more shunting toward LOX in AA pathway—> more leukotriene synthesis, which causes bronchoconstriction and can bring on an asthma attack

Answer 352

A pleural effusion that arises as a result of a pneumonia *subtypes: uncomplicated, complicated, and empyema

Answer 353

P:S (pleural: serum ratios)— Protein >0.5 LDH >0.6 Pleural LDH > 2/3rds the upper limit of normal for serum LDH If any of these are true, it is exudative (“extra shit in it”) vs. transudative (fluid only)

Answer 354

1. Allergic Bronchopulmonary Aspergillosus (ABPA) - Pulm infiltrates, wheezing, IgE in an asthma or CF patient 2. Aspergilloma (fungal ball) - Gravity-dependent lung cavitation, fever, hemoptysis in a patient with prior TB 3. Invasive pulmonary Aspergliosis - Fever, hemoptysis, chest pain, SOB-> kidney failure, endocarditis, ring-enhancing lesions in brain, and sinus tissue necrosis in an immunocomprimised/ neutropenic patient

Answer 355

Will present as a lung cavitation in a patient with prior TB (seen on chest CT) and you get Aspergillus IgG serology to confirm

Answer 356

Decreased lung compliance -ARDS= inflammatory condition in the setting of infection (sepsis, PNA, etc.), trauma, or other conditions (pancreatitis, massive transfusion). Lung injury causes the release of proteins, inflammatory cytokines, and neutrophils into the alveolar space (hyaline membranes). This leads to leakage of bloody and proteinaceous fluid into the alveoli, alveolar collapse due to loss of surfactant, and DIFFUSE ALVEOLAR DAMAGE-> inability to expand/ stiff lungs/ dec compliance

Answer 357

It decreases ``` Arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio: PaO2/ FiO2 (also called P/F ratio) Decreases (<300) bc the lung injury/ hyaline membranes impair gas exchange-> decreases PaO2 and raises the FiO2 requirement (the oxygen that you have to give them through the ventilator) ```

Answer 358

HOCM * remember that HOCM is a SYSTOLIC murmur at the left sternal border (systolic bc the problem is when the blood is being pumped out through the aorta) * remember that squatting increases preload (compress leg veins= more ‘milking’ of blood to heart), which makes the problem better (more blood to push septal defect out of the way)

Answer 359

Autosomal dominant *caused by mutations in sarcomere genes (ex: cardiac myosin binding protein C and cardiac beta-myosin heavy chain gene) for the myocardial contractile proteins of the heart

Answer 360

TEE (trans esophageal echocardiogram) is preferred But you can also do a chest CT with contrast (if patient’s kidneys are ok/ can tolerate contrast) or an MRI (if non-emergency and patient can lie still) *do whichever of these is available at the time

Answer 361

Abdominal ultrasound once on men 65+ who EVER smoked

Answer 362

Mammogram every 2 years on women 50-74

Answer 363

Pap smear every 3 years on women 21-65 *women 30-65 may substitute w/ HPV testing every 5 yrs

Answer 364

Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year OR Colonoscopy every 10 years

Answer 365

Do HIV antibody screen once in adults 15-65

Answer 366

Low-dose CT scan every year in adults 55-80, 30+ pack-years of smoking, current smoker, or quit in last 15 years

Answer 367

DEXA scan in women 65+

Answer 368

CHF -CHF—> increased hydrostatic pressure pushing fluid out of vessels—> transudative pleural effusion ``` *you’d expect: Pleural protein: serum ratios to be... Protein <0.5 LDH <0.6 LDH < upper 2/3rds limit of normal serum ```

Answer 369

Complicated parapneumonic effusion (exudative pleural effusion in the setting of pneumonia)

Answer 370

1. pH > 7.25 2. Adequate oxygen on minimal support (FiO2 less than or equal to 40%, PEEP less then or equal to 5) 3. Intact inspiratory effort and sufficient mental alertness to protect the airway * if a patient is ready to be exubated based on the above criteria, do a spontaneous breathing trial (keep them intubated but turn off ventilator support to check that they breathe on their own and ABG remains normal throughout this effort)!

Answer 371

``` Cardiac amyloidosis (Amyloid, a misfolded protein, deposits in various tissues, including the heart-> restrictive CM and you pee out some excess protein) ```

Answer 372

Uremic pericarditis (Toxins accumulate and cause inflammation of the heart sac) Hemodialysis

Answer 373

Mono-like symptoms (fever, lymphadenopathy, sore throat, athralgias) 2-4 weeks post-exposure *Viral load is really high (>10,000 copies/mL) (but HIV antibody testing may be negative adn CD4 still normal)

Answer 374

Amyloidosis - Causes a restrictive CM + peeing out protein - Remember, it’s a misfolded protein that deposits in various places (systemic dz)

Answer 375

Seen in gastric bypass patients The stomach is now so small that food, esp simple carbs, gets dumped into the intestines really fast-> diarrhea (can also cause abdominal pain, nausea, hypotension, tachycardia, lightheadedness)

Answer 376

Severe dehydration, etc.-> dec preload to heart-> dec CO-> cardiopulmonary receptors recognize there’s less volume in the heart-> initially this causes inc sympathetic activity, so inc HR and contractility to raise CO to normal-> contortion/ weird twisting of the LV (bc it’s pumping normal but there’s not enough blood to pump out)-> messes up cardiopulmonary receptors so that they have the opposite effect (they think the heart is over full)-> dec sympathetic activity, so dec HR and contractility-> lack of blood to brain-> body faints to inc preload back again (gravity isn’t against you when you’re laying on the floor)

Answer 377

Mid-diastolic sound associated with constrictive pericarditis Remember, constrictive pericarditis= fibrotic, scarred pericarditis (from repeated inflammation/ recurrent pericarditis). This restricts diastolic filling of the heart-> “pericardial knock” during diastole.

Answer 378

EGD (endoscopy) to screen for esophageal varices

Answer 379

Non-selective beta blocker (Propranolol or Nadolol) -Block beta-2 (vasodilates)-> vasoconstricts-> reduces portal blood flow

Answer 380

PT- High (liver makes clotting factors. If the liver is bad, it’s not making as many clotting factors and PT goes up bc takes longer to clot) Albumin- Low (liver makes albumin. If the liver is bad, makes less of it)

Answer 381

Alcoholics

Answer 382

AV fistula= direct connection between artery and vein (blood goes in arteries away from heart and meets up right away with vein back to heart rather than having to journey through tiny vessels first) Way more blood in venous system to heart—> heart has to deal with more blood, so a preload overload—> high-output cardiac failure *these patients get a wide pulse pressure (ex: 160/90) bc in systole the heart pumps out a huge amount of blood (due to having more preload) and during diastole blood is shunting across the AV fistula to VEINS so the pressure drops a lot in the ARTERIES

Answer 383

“Spared eye injury” Damage to eye-> exposes antigens your body has never seen (‘hidden antigens’)-> immune system responds to them and attacks other eye

Answer 384

Granulomatosis with polyangiitis (Wegner’s) -systemic vasculitis that involves nasopharynx + lungs + kidneys

Answer 385

“Steppage gait” L5 radiculopahty adn compression peroneal neuropathy are common causes

Answer 386

Bacterial infection * most infections within the first month are bacterial causes, during months 1-6 opportunistic (in setting of immunosuppression) * hemodynamic instability (look at the vital signs) makes bacterial infection more likely than transplant rejection

Answer 387

Octreotide

Answer 388

Renal vein thrombosis Remember that nephrotic syndrome (esp membranous GN)-> peeing out protein, including antithrombin III-> hypercoagulable state

Answer 389

Ulcerative colitis (UC) *has a bimodal distribution- more common in young (15-40) and old (50-80) **NOT colon cancer...although low Hb in elderly is colon cancer until proven otherwise, the colonoscopy 4 years ago did prove otherwise (only need 1 every 10 years). Plus, the sigmoidoscopy showing involvement of just the distal colon is constituent with UC (bleeding-> low Hb from that)

Answer 390

Upper GI bleed *look for elevated BUN (due to increased GI digestion/ breakdown of Hb)

Answer 391

Iron deficiency anemia from NSAIDs (block GI protective prostaglandins-> gastritis and/or gastric ulcers leading to chronic GI blood loss and depletion of iron stores) *osteoarthritis does NOT cause anemia of chronic dz!

Answer 392

Obesity hypoventilation syndrome - BMI >30 (obese) - Lungs are clear - Distant heart sounds and low-voltage QRS= heart is further away due to excess fat in between (*think of this and pericardial effusion) - Reactive polycythemia (poor oxygenation due to shallow breaths-> kidneys inc EPO-> inc Hb to try to compensate by having more O2 binding sites) - Respiratory acidosis (retained CO2 from shallow breathing)

Answer 393

Reactive polycythemia Poor oxygenation-> kidneys pump out more EPO-> more Hb to try to compensate by providing more oxygen binding sites

Answer 394

1. Obesity with BMI >30 2. Daytime hypercapnia (PaCO2>45) 3. No alternate explanation of their hypoventilation * work it up by getting ABG (hypercapnia, normal A-a gradient), r/o pulm disease w/ CXR, restrictive pattern on PFTs (all the fat restricts them from expanding their lungs), normal TSH, polysomnography * treat with weight loss/ bariatric surgery, nocturnal positive-pressure ventilation * *most of these patients have coexisting OSA

Answer 395

Digoxin toxicity (causes GI symptoms) She was already taking Digoxin. You added Amiodarone (anti-arrhythmic) to her regime, which blocks the P450 system (broken chrome bumper in uno, does, tres sketchy)-> inc Digoxin in blood.

Answer 396

4,500-11,000 *just remember it as roughly <10,000

Answer 397

MG= antibodies against the nicotinic ACh receptors on the post-synaptic at the motor end plate (skeletal muscle NMJ)-> proximal muscle weakness worse w/ use, ptosis, diplopia Pyridostigmine= ACh-esterase inhibitor-> blocks the breakdown of ACh-> more ACh in the cleft to outcompete MG antibodies

Answer 398

Exacerbation of Myasthenia Gravis (antibodies going crazy against post-synaptic nicotinic ACh receptors-> muscle weakness) * can be brought on by infection, surgery, pregnancy/ childbirth, tapering off immunosuppressant drugs, some meds (aminoglycosides, beta blockers) * presents with oropharyngeal and general weakness, respiratory insufficiency * intubate, plasmapheresis or IVIG + corticosteroids

Answer 399

Myasthenia crisis Endotracheal intubation - This patient has PNA (SOB, productive cough, shallow breathing, crackles, WBC count). Resp acidosis (low pH, high CO2) explained by not breathing deep-> less air getting down into lungs for gas exchange. This was a trigger for MG crisis/ exacerbation. - Do elective intubation bc of evidence of impending respiratory failure (ill-appearing, tachypnea/ breathing rapid and shallow, muscle weakness, difficulty clearing secretions/ choking sensation, and respiratory acidosis).

Answer 400

Subjective: - they look really sick - tachypnea (breathing fast and shallow) - muscle weakness - can’t clear secretions/ choking Objective: - low vital capacity (after max inspiration, the max air you can exhale/ breathe out) *low means they have a weak ability to exhale - respiratory acidosis (retaining CO2 from poor gas exchange)

Answer 401

A problem with aldosterone! Remember, aldosterone-> Na+ absorption, K+ and H+ wasting. If aldosterone is low, you get dec Na+ in the blood and inc K+, H+ in the blood-> hypOnatremia, hypERkalemia, and metabolic acidosis.

Answer 402

Military TB-> infectious adrenalitis/ primary adrenal insufficiency (Addison’s disease) * Remember, no.1 cause of Addison’s in the US= autoimmune destruction of adrenal glands. But no.1 cause of Addison’s in developing countries= TB! The inflammation from military TB destroys adrenal glands so that they stop producing hormones. * Addison’s= adrenal glands aren’t making aldosterone and cortisol-> low Na+ in blood (low BP, weakness/ lightheadedness, hypOnatremia), high K+ in blood (hypERkalemia).

Answer 403

Check serum electrolyte panel Albuterol= beta-2 agonist-> hypokalemia (stimulates sodium potassium pumps, so brings K+ into cells). HypOkalmeia can cause muscle weakness and tremor. *Another side effect is palpitations (speed up the heart bc has some agonist effects on beta-1 too)

Answer 404

Septic shock * note: you can’t meet all the SIRS criteria based off this question, have to roll with just the info they give you. But the clinical picture is septic shock- possible PNA for infection source (crackles and SOB), hemodynamic instability (low BP, tachy), low SVR= widespread vasodilation in response to inflammatory cytokines. * high CI (which is CO taking into account body size) and no problems with the heart, so not a cardiogenic shock picture (inc CO is the heart trying to compensate for low BP). **do NOT get thrown off by the murmur (systolic at right upper sternal border). This is aortic stenosis- a lot of old people have it due to calcifications!

Answer 405

1. Cardiogenic shock (Heart is not pumping blood out well to extremities and vasoconstriction to divert blood to vital organs) 2. Hypovolemic shock (hemorrhagic shock) (Body vasoconstricts to divert blood away from extremities and toward vital organs)

Answer 406

No Just means the heart is working overtime (inc CO)

Answer 407

COPD exacerbation—> BiPAP Obstructive Sleep Apnea—> CPAP

Answer 408

88-92% *if higher, you will inhibit their respiratory drive (based on low oxygen, not high CO2 like normal people since they have chronic CO2 retention and are desensitized to it)-> hypoventilation (slows or stops their breathing)

Answer 409

Get an ABG (arterial blood gas analysis) to confirm acute hypercapnic respiratory failure - remember our O2 sat goal in COPD’ers is 88-92% due to their respiratory drive being controlled by low O2 (vs. high CO2)...giving too much O2 will stop their respiratory drive to breathe - also, too much O2 may encourage hypercapnia (CO2 retention) and worsened VQ mismatch (in COPD you have vasoconstriction in lungs to shunt blood to better oxygenated areas...if you flood in the oxygen, there will be areas that vasodilate thinking the oxygenation is good now, so blood will be sent to this damaged tissue but can’t gas exchange well so the CO2 just builds up more) - hypercapnia (CO2 retention)-> delirium, confusion, lethargy, eventually coma and seizures

Answer 410

Increased lung compliance (more stretchy lungs) *remember COPD is obstructive= hard to get air out. The lungs are filling well, but not pushing air out well.

Answer 411

CHF exacerbation - Given his hx of CAD and smoking, be thinking of COPD or CHF exacerbation - High pH, low O2, low CO2= respiratory alkalosis (hyperventilating/ blowing off more CO2) - NOT COPD exacerbation (that would have CO2 retention) - NOT PE (this may have a unilateral, not bilateral pleural effusion and would have more history like recent travel or surgery, tachycardia) - CHFe makes sense—bilateral pleural effusions (dec breath sounds), crackles from backing up of fluid from left heart to lungs. Pumping problem, so patient hyperventilates to compensate and get more oxygen in

Answer 412

Not expanding lungs well-> air not reaching as many alveoli for gas exchange-> low O2 into blood, high CO2 in blood bc cannot get out

Answer 413

Yes, sometimes Think of S4 as “stiff heart” Can be due to diastolic dysfunction/ filling problem/ hypertrophy/ thick LV wall OR scar tissue making the heart stiff

Answer 414

FiO2 <60% * for comparison, normal air has roughly 20% oxygen content in it * don’t go higher than FiO2 of 60% long-term or else you risk oxygen toxicity to the patient (pro inflammatory oxygen free radicals-> atelectasis/ collapsing of alveoli)

Answer 415

High PEEP (prevent alveolar collapse) Low Tv (Tv= the air going into the lungs. You don’t want to shove too much air into the lungs at once or you cause alveoli to pop open and slam shut. Goal is to have LOW trauma to alveoli)

Answer 416

6 mL per kg Ex: patient weighs 50kg. Make Tv 6*50= 300 mL **Tv= the air going into the lungs. The reason you don’t want it too high is to avoid trauma to alveoli. If you shove too much air into the lungs at once or you cause alveoli to pop open and slam shut.

Answer 417

No, not necessarily (RR can be within normal range) Obesity-> fat restricts lungs from expanding well-> not as much air reaches alveoli for gas exchange (more dead space)-> CO2 retention= respiratory acidosis due to ‘hypoventilation’

Answer 418

Chronic CO2 retainers (impaired gas exchange)-> high CO2 (respiratory acidosis)-> body compensates by increasing HCO3/ bicarb retention... So, INCREASED bicarb and DECREASED chloride (for every negatively charged bicarb you keep, you get rid of a negatively charged Chloride)

Answer 419

Bilateral Transudative= due to high hydrostatic pressure or low oncotic pressure driving fluid out (no other inflammatory cells in the effusion) - CHF, nephrotic syndrome, cirrhosis - these things don’t just target one side like a pneumonia does, so you’d expect if there’s a pleural effusion from it, it is bilateral

Answer 420

Right-sided pleural effusion in cirrhosis patient (ruled out other causes) * Pathophys is incompletely understood, but is thought to happen from ascites crossing the diaphragm (travels from the peritoneal cavity into the pleural cavity through small diaphragmatic defects) - increased permeability of right hemidiaphragm

Answer 421

Rheumatoid arthritis (RA can rarely lead to inflammation affecting the lungs= pleuritis/ pleurisy, and that inflammation can cause effusion) * StepUpToMed page 82, 2nd quick hit box * But when glucose is low, still consider other causes of pleural effusion (complicated parapneumonic effusion, empyema, malignant effusion, TB pleurisy, lupus pleuritis, esophageal rupture)! (Just put this in the differential)

Answer 422

Pneumonia (this is a parapneumonic effusion, or pleural effusion 2/2 PNA) -Specifically, it’s likely an empyema (low glucose due to high metabolic activity of WBCs and bacteria in the pleural fluid) - LDH of fluid= 250, which is >2/3rds upper limit of normal serum LDH (45-90), so EXUDATIVE - NOT a pleural effusion due to CHF (high hydrostatic pressure) or cirrhosis (low albumin= low oncotic pressure) bc these are transudative (plus would expect them to cause bilateral, not unilateral, pleural effusions—these disease processes don’t isolate to one side) *hepatic hydrothorax (right-sided pleural effusion in cirrhosis patients from ascites crossing diaphragm is also usually transudative)

Answer 423

Pleural effusion due to pancreatitis, esophageal rupture, or malignancy

Answer 424

Pleural membrane and capillary permeability

Answer 425

Cholecystectomy - This patient has acute pancreatitis from a gallstone (*ALT>150 is pretty specific for it—plus patient has high lipase, AST, alk phos) - Early cholecystectomy is recommended in stable patients who receiver from acute pancreatitis * ERCP would have been the answer (to remove obstructing stone) if we saw common bile duct dilation/ obstruction on U/S (gallstone pancreatitis), or if liver enzymes keep rising * *Note: My surgery patient had choledocolithiasis (stone lodge in common bile duct) so we did— 1. RUQ U/S 2. MRCP (MRI of the biliary tract to prove it) 3. ERCP (to remove the stone blocking the common bile duct) 4. Wait for the pancreas to cool down/ labs to downtrend (bc inflammation complicates surgery) 5. Cholecystectomy (take out the gallbladder to avoid this happening again)

Answer 426

Hepatorenal syndrome - Kidney function is declining in the setting of cirrhosis - You know it’s not just AKI because: no casts (not ATN/ intrinsic), no hydronephrosis/ obstruction (not post-renal), no improvement with fluids (not pre-renal) *treat with stopping alcohol, liver transplant if possible (if not, can try splanchnic vasoconstrictors like Octreotide, NE, Midodrine or albumin or dialysis, but may not help too much)

Answer 427

Hepatorenal syndrome

Answer 428

Celiac disease - IgA anti-tissue transglutaminase and IgA anti-endomysial antibodies are screening tests, but can be negative in a person with celiac dz + IgA deficiency (if negative but clinical suspicion is high, order total IgA to check for IgA def or do IgG-based serologic testing) - Biopsy showing villous atrophy is the confirmatory test * associated with iron def anemia (not absorbing enough iron from the food they eat)

Answer 429

Fe deficiency *Ferritin= Fe in storage site (this will be the first thing depleted in iron deficiency anemia)

Answer 430

Low-sodium diet (restricting Na+= less water will follow) and diuretics, specifically Furosemide (Lasix) + Spironolactone (loop and K+ sparing) *you always do diagnostic paracentesis, but only do regular therapeutic paracentesis if the patient is having symptoms from the ascites (SOB, tense, early satiety)

Answer 431

- yellow or straw-colored - low total protein in it (<2.5 g/dL) - high SAAG (serum-ascites albumin gradient) (>1.1) * if SAAG <1.1 ascites is likely due to another cause (CHF, CKD, massive fluid overload, TB peritonitis, malignancy, hypoalbuminemia, hepatorenal syndrome) * get cell count and differential—if neutrophils >250, spontaneous bacterial peritonitis (SBP)

Answer 432

SAAG >1.1 means portal HTN (due to cirrhosis) SAAG <1.1 means the ascites is due to another cause (CHF, CKD, massive fluid overload, TB peritonitis, malignancy, hypoalbuminemia, hepatorenal syndrome)

Answer 433

Recovered from a past Hep B infection ``` *remember “SpECiES” HBsAg: 1st marker of infection HBeAg: marker of infectivity Anti-HBc: core antibody Anti-HBe: e antibody Anti-HBs: surface antibody (indicates vaccination if alone, recovery if with anti-HBc) ```

Answer 434

Discontinue hydrochlorothiazide * Most common causes of pancreatitis= 1. Gallstones 2. Alcohol abuse 3. Triglycerides >1,000 - Once you rule out these 3 causes, consider less common causes including drug-induced pancreatitis. Loop and Thiazide diuretics can cause pancreatitis as a side effect.

Answer 435

DO A PLASMA METANEPHRINE ASSAY (may also do RET mutation testing) Thyroid nodule w/ malignant cells and high calcitonin= Medullary Carcinoma of the thyroid. This is associated with MEN II (2a and 2b have Medullary Carcinoma + Pheochromocytoma. 2a also has parathyroid cancer. 2b also has acoustic neuromas/ marfanoid habitus). So you need to screen for Pheochromocytoma! *this is important bc a pheochromocytoma can be asymptomatic at the time of diagnosis, but cause life-threatening HTN crisis during surgical procedures (thyroidectomy) if not caught and respected!

Answer 436

Guillain-Barre syndrome Specifically, the sub-type Miller Fisher syndrome (abnormal muscle coordination, absent tendon reflexes, and paralysis of eye muscles)

Answer 437

HIV screening Tinea corporis with extensive skin involvement raises the question of whether the patient is immunocompromised

Answer 438

Ventricular aneurysm * Months post-MI there are 3 complications to remember: 1. Aneurysm (scar tissue outpouches bc it is weaker than the myocardium) 2. Mural thrombus (clotting within the wall-> blood clot thrown elsewhere) 3. Dressler syndrome (autoantibodies against the pericardium)

Answer 439

Concentric: - LV hypertrophy (thickened LV) - myocardial contractile fibers are in parallel (stacked up) Eccentric: - LV dilation/ dilated cardiomyopathy (stretched out LV) - myocardial contractile fibers are in series (stacked out)

Answer 440

1. Substernal 2. Provoked by exercise or emotional stress 3. Relieved by rest or nitroglycerin * 3/3= typical/ classic angina * 2/3= atypical * <2= non-anginal

Answer 441

Coronary artery disease (CAD) - he has typical angina symptoms (substernal, with exercise, better with rest) * Although he also has aortic stenosis and this too can be a cause of angina, it’s unlikely to be the cause unless it’s severe aortic stenosis (valve area <1 cm^2). Since his aortic valve is 1.3 cm^2 and the angina is mild-moderate, its most likely CAD causing it.

Answer 442

Wilson disease AR mutation in copper transporting channel-> accumulation of copper in liver, eyes (Kayser-Flesher corneal deposits), and brain (psychosis, Parkinson’s and behavior symptoms) *diagnose with decreased serum ceruloplasmin (copper transporter) and increased urinary copper

Answer 443

AKI secondary to rhabdomyolysis -binge drinking and cocaine-> acute alcohol myopathy esp in lower extremities= drug-induced rhabdo-> myoglobin gets released into blood-> can block renal tubules-> AKI

Answer 444

- uric acid: INCREASED (nucleic acids are released and metabolized to uric acid) - potassium (K+): INCREASED (released from lysed cells) - phosphate (P): INCREASED (released from lysed cells) - calcium (Ca2+): DECREASED (the extra phosphate binds it up-> decreased free calcium levels in the blood)

Answer 445

A bad reaction to heparin where the heparin binds to PF4 (platelet factor 4) and then antibodies get made against that complex (hep-PF4). The antibodies attack platelets-> thrombocytopenia and cause platelets to stick/ aggregate (leading to paradoxical blood clots/ thrombosis). *usually happens in 5-10 days post-heparin administration, stop heparin and give another anticoagulant (Argatroban, Fondaparinux)! **type 1 HIT is milder (nonimmuned-mediated platelet aggregation) and doesn’t require treatment

Answer 446

Sarcoidosis | Chronic non-caseating granulomatous inflammation

Answer 447

``` Creatinine phospholipase (CPK) (Marker of skeletal muscle damage) ``` - Sounds like Rhabdo! Statin + Colchicine-> drug-induced rhabdomyolysis (both are myotoxins and muscle breakdown is more likely in combination) - Dark Urine, blood on U/A w/o RBCs on urine microscopy (myoglobinuira), high BUN and Cr all point to AKI 2/2 rhabdo

Answer 448

Topical terbinafine or azoles (like Miconazole)

Answer 449

Renal infarction due to embolization of valvular vegetation (Fever, mitral regurg point to infective endocarditis. A vegetation embolized/ got thrown to infarct the kidney- an ‘MI’ of the kidney causing sudden pain and wedge on CT)

Answer 450

Pneumothorax -This is a complication of PEEP *Remember, in ARDS inflammation and edema-> alveolar collapse. PEEP maintains airway pressure at the end of expiration to prevent alveolar collapse. But, since the lung tissue is already weak and predisposed to barotrauma, PEEP can rupture alveoli-> leakage of air to pleural space-> pneumothorax (sudden-onset SOB, hypotension, tachy, tracheal deviation, unilateral absence of breath sounds).

Answer 451

FeNa <1% (normal- the kidneys reabsorb most Na+) BUN/Cr >20:1 (high- blood flow to the kidneys is slowed, so there is more time for Na+ to get reabsorbed at the PCT)

Answer 452

Hospitalize and isolate the patient against his wishes You cannot let a patient leave AMA when the patient is a risk to public health! This is highly contagious and serious.

Answer 453

Endotracheal intubation This patient has signs of impending respiratory failure (need to intubate to maintain adequate oxygenation and ventilation) - Diminished breath sounds/ wheezing - Respiratory acidosis (low pH, high CO2) * Note that a normal response to an asthma exacerbation is hyperventilation (blow off more CO2)-> decreased CO2. So, CO2 retention is a bad sign that they’re not maintaining their airway well! - Low PaO2/ hypoxia

Answer 454

Increase in cell count, so more lymphocytes/ WBCs (lymphocytosis)

Answer 455

Bacterial- neutrophils + decreased CSF glucose Viral- lymphocytes + normal CSF glucose (elevated protein) Fungal- lymphocytes + decreased CSF glucose

Answer 456

IV Acyclovir-> Crystalline Nnephropathy (type of intrinsic AKI where crystals obstruct renal tubules) *note: this is NOT the same as acute interstitial nephritis—drug (NSAID, Penicillin, diuretic)—> fever, rash, and dec urine output

Answer 457

Ethylene glycol poisoning - low pH, low bicarb, low PaCO2 means metabolic acidosis - calculate anion gap: AG= Na-Cl-HCO3= 140-100-10= 30. This is >12, so anion-gap met acidosis - keep in mind “MUDPILES”: Methanol, Uremia, DKA, Porpylene glycol, Iron tablets or INH, Lactic acidosis, Ethylene glycol, Salicylates - Ethylene glycol blocks alcohol dehydrogenase (competitive inhibitor)-> build up of toxic metabolites-> Ca2+ oxalate kidney stones (envelope-shaped) an AG met acidosis

Answer 458

``` Methanol Uremia DKA Porpylene glycol Iron tablets or INH Lactic acidosis Ethylene glycol Salicylates ```

Answer 459

AG= Na-Cl-HCO3 | Sodium minus chloride minus bicarb

Answer 460

Dopamine agonists (Pramipexole) * Also check for iron deficiency anemia and treat that with Fe supplementation * Alpha-2-delta calcium channel ligand (gapapentin) may also help

Answer 461

Diphenhydramine (1st gen anti-histamine)-> anticholinergic side effects, including urinary retention from detrusor hypOcontractility *BPH wouldn’t cause urination to go downhill more so in just one day

Answer 462

Crohn’s disease - Inflammatory markers are suggestive of inflammatory bowel dz rather than celiac or IBS - Crohn’s inflames anywhere along GI tract from mouth (mouth ulcers) to anus (*vs UC affects only distal GI tract-> LLQ pain, bloody diarrhea) - IBD associated with iron def anemia (malabsorption of iron)

Answer 463

Trigeminal neuralgia most likely due to MS (multiple sclerosis), one of the few conditions that causes BILATERAL trigeminal neuralgia (due to demyelinating of the trigeminal nerve axon/ root) *hand numbness was probably her first MS symptom

Answer 464

NONCONTRAST CT | No contrast bc contrast appears white and so does blood

Answer 465

Do NONCONTRAST CT head CT of brain w/o contrast is the initial imaging choice to r/o acute neuro problems (intracranial or subarachnoid bleeds). Note that MRI is more sensitive than CT is identifying structural causes of epilepsy but takes longer, so this is the choice if non-emergent. *EEG is a good test for helping to decide course of antiepileptic agents, but ruling out brain bleeds is the 1st imaging step!

Answer 466

Diabetes mellitus! *don’t jump straight to rare junk like Charcot-Marie-Tooth disease

Answer 467

Large fiber neuropathy secondary to DM * small fiber neuropathy-> positive symptoms such as pain, paresthesias, allodynia (pain out of proportion like light touching of the skin makes you scream out in pain) - pain and temp - burning and stabbing pain * large fiber neuropathy-> negative symptoms such as numbness, loss of proprioception/ vibration, diminished reflexes (this guys’ symptoms fit this picture) - pressure/ proprioception/ balance - numbness and poor balance

Answer 468

Multiple myeloma malignancy of plasma cells - cytokines activate osteoClasts-> lytic lesions - inc serum protein (M spike) - inc infection risk (monoclonal antibody lacks antigenic diversity) - Rouleaux formation of RBCs - primary amyloidosis from light chains depositing in tissue - proteinuria (Bence Jones proteins)-> kidney failure - normocytic anemia (bone marrow replaced by plasma cells + renal failure so dec EPO to drive production of RBCs)

Answer 469

Oxygen facemask or Sumatriptan

Answer 470

Short-acting opioid (morphine, hydromorphone) *If the pain is still bad, you can add a long-acting opioid (morphine, fentanyl) for help with sleep, but he’s never been on opiods before so do not start him right away on long-acting due to risk of respiratory depression! Start with short-acting to determine appropriate dosing for the patient.

Answer 471

Get a urinalysis (U/A) - Seems he has BPH, but all patients with urinary symptoms (frequency, nocturia, hesitancy) should get a U/A to check for hematuria and infection. * Also get a PSA as prostate cancer screening unless predicted life expectancy is <10 yrs.

Answer 472

Bone loss/ weakened bones

Answer 473

Osteomalacia (vit D deficiency) -Crohn’s disease-> inflammation esp at terminal ileum-> impaired reabsorption of bile acids-> malabsorption of fats and fat-soluble vitamins, including vit D-> DECREASED calcium + P, INCREASED PTH (to try to compensate)

Answer 474

This is opioid withdrawal (she is off her heroin and has symptoms within ~12 hrs of last use) -N/V, cramps, diarrhea (opposite of constipation from opioids), restlessness, rhinorrhea, lacrimation, myalgia, arthralgia, HTN, tachy, mydriasis (dilated pupils), hyperactive bowel sounds Give OPIOID WITHDRAWAL MEDS: Methadone (done timer) or Buprenorphine (blueprint) *long half-life

Answer 475

Opioid toxicity—> Naloxone (no lax zone) *short-acting Opioid withdrawal—> Methadone (done timer) or Buprenorphine (blueprint) *long half-life

Answer 476

Bactrim (TMP-SMX, trimethoprim-sulfamethoxazole) *Bactrim reduces the risk of toxo in CD4<100 so that getting toxoplasmosis is only 0-2%! Bactrim also reduces the risk of PCP PNA in CD4 <200.

Answer 477

PPI + Amoxicillin (Metronidazole if allergic) + Clarithromycin

Answer 478

Acute severe pancreatitis - premature release of pancreatic enzymes-> inflammation and increased vascular permeability around the pancreas-> widespread vasodilation-> septic shock with multisystem organ dysfunction (respiratory and renal failure) * old people >75, alcoholics, obese, CRP>150 at 48 hrs, and inc BUN/CR in 48 hrs at higher risk for this (most other patients with acute pancreatitis have mild dz and recover in 3-5 days with fluids/ conservative treatment)

Answer 479

Pyelonephritis (kidney infection) - presents as cystitis (bladder infection/ UTI symptoms) + flank pain, costovertabral angle tenderness, fever, and/or nausea/ vomiting * get urine culture and treat empirically with antibiotics that cover gram-neg organisms (ex: Fluoroquinolones)

Answer 480

- Patient does not clinically improve within 72 hours (3 days) - Has history of nephrolithiasis (kidney stones) - Has complicated pyelonephritis (progression to renal abscess, emphysematous pyelonephritis where there’s gas accumulation in the tissues, papillary necrosis, or sepsis) - Has unusual urinary findings (gross hematuria, suspicion for urinary obstruction)

Answer 481

Give Ondansatron (serotonin 5HT receptor antagonist/ anti-emetic) *mild anemia and thrombocytopenia is normal for a patient with a lymphoproliferative disorder on chemo—she’s just having N/V from chemo

Answer 482

Retinal artery occlusion (from embolism) Treat with high-flow oxygen and ocular massage * he has all the risk factors for retinal artery occlusion * note: episode of vision loss for 5 min is “amaurosis fugax” (like TIA of retinal artery) and then persisting loss of vision is retinal artery occlusion (like stroke of retinal artery)

Answer 483

Antibiotics This is septic arthritis Do synovial fluid analysis to confirm diagnosis (and blood cultures) Gram (+)—> Vanco Gram (-)—> 3rd gen cephalosporin

Answer 484

Hypomagnesemia ``` Low Mg (common in alcoholics)—> decreases PTH secretion and decreases responsiveness to it—> Low calcium (bc PTH increases calcium and you don’t have as much of it) (**PTH also dumps Phosphorus, so you’d think with less PTH you’d get higher Phosphorus levels, but oddly Phosphorus levels are normal-low, possibly due to intracellular P depletion) ```

Answer 485

Get an MRI of the hip - This sounds like avascular necrosis (risk is increased with SLE and glucocorticoid use) - MRI is more specific than X-ray (can visualize the boundary between normal and ischemic bone) * note that in the first few months of having this, range of motion and x-rays may be normal but this will decline later on

Answer 486

Trimethorpim—> hyperkalemia (by blocking Na+ channel in CD) and artificial increase in Cr (w/o affecting GFR)

Answer 487

A vascular surgical procedure done to reduce the risk of stroke by correcting stenosis in the internal carotid artery -indicated in patients with TIA/ stroke with high-grade carotid stenosis (>70%)

Answer 488

Adhesive capsulitis aka “Frozen shoulder” Thickened, tight shoulder (glenohumeral joint) capsule -due to chronic inflammation, fibrosis, and contracture - pain with aBduction, external rotation - decreased passive and active range of motion

Answer 489

A statin Give statins to any patient >40 years old with DM regardless of LDL level! *Although a fibrate (like gemfibrozil) seems reasonable to reduce the elevated TAGs, statins are 1st line in ASCVD prevention (you would give a fibrate just to reduce TAGs in someone with TAGs>1000 at risk for acute pancreatitis)

Answer 490

Exertional- when heat stroke happens to patients who have over exerted themselves Non-exertional- when heat stroke happens to patients with chronic medical conditions (have underlying impaired thermoregulation) * HEAT STROKE: Too hot-> blood is shunted away from central organs and to skin to sweat and cool down body-> distributive shock, where organs lack adequate perfusion-> organs suffer and die - SIGNS/ SYMPTOMS: temp >105, altered mental status, hypotension, tachycardia, tachypnea

Answer 491

Give the blood transfusion In the absence of an advance directive, a life-saving blood transfusion can be given to a Jehovah’s Witness who lacks decision-making capacity

Answer 492

Check anti-mitochondrial antibodies For Primary Biliary Cholangitis (autoimmune destruction of intrahepatic bile ducts) *classically in middle-aged women and associated with other autoimmune conditions (hypothyroidism)

Answer 493

Give thiamine before glucose! Do NOT give glucose, then thiamine. (Pixorize: don’t eat sugar before you work out your thighs)

Answer 494

Chronic myeloid leukemia (CML) t(9,22), BCR-ABL *too many granulocytes in myeloid path, esp basophils Treatment target= tyrosine kinase inhibitor (imatinib)

Answer 495

Acute epididymitis (swelling of the epididymis around the testicle), most likely due to E.coli (from bladder outlet obstruction) *In age <35 it would be most likely due to chlamydia, gonorrhea from STD

Answer 496

Lateral epicondylitis= tennis elbow= swollen extensor tendon (where extensor muscles insert into lateral epicondyle of the humerus) *remember from anatomy: Medial-> flexors. Lateral-> extensors.

Answer 497

Pancreatitis - he has chronic pancreatitis (recurrent episodes) - pancreatic ascites is a rare complication of pancreatitis! (Repeated inflammation damages pancreatic duct-> leakage of pancreatic juice into peritoneal space-> ascites) - serosanguinous fluid= straw-colored ascites fluid (yellow w/ blood streaks)—pancreatic ascites is usually this color - pancreatic ascites has high amylase (>1000), high total protein (>2.5), and low SAAG (<1.1 means NOT due to portal HTN from cirrhosis)

Answer 498

Entamoeba histolytica (A parasite, protozoan that causes liver abscess) - RUQ pain, fever, hepatomegaly, transaminases (*but note that ALT, AST are not SUPER high in the hundreds or thousands as in viral hepatitis) - recent travel and sex - hypoechoic lesion= dark on U/S (less dense, fluid-filled, consistent with liver abscess) *But why decreased right lung breath sounds?? Don’t get hung up in this—possibly due to a small right-sided pleural effusion due to the inflammation in the nearby liver

Answer 499

No Remember the most common causes of hyperthyroid are: 1. Graves dz (TSI autoantibodies that stimulate TSH receptors) 2. Toxic adenoma 3. Toxic multi-nodular goiter (Toxic adenoma and goiter caused by activating mutation in TSH receptor) She has a single “hot nodule” (radioactive iodine uptake) suggestive of toxic adenoma. Baby won’t get this. *If Graves were the reason she had hyperthyroidism, then the autoantibodies would cross the placenta and baby would be affected.

Answer 500

Bone loss -excess thyroid hormone increases osteoclast activity-> more bone resorption (breakdown) (-> hypercalcemia-> dec PTH-> more urinating/ wasting of calcium)

Answer 501

Atelectasis= deflated/ collapsed alveoli—> allows for formation of mucus plugs—> inc risk of infection (always a higher risk of infection when any tube is blocked- from Pathoma) *spirometers help patients breathe deeper to avoid shallow breathing-> atelectasis-> possible PNA as a complication. So, spirometers are used in the hospital for prevention of atelectasis and indirect prevention of PNA.

Answer 502

Rib fracture-> pain-> hypoventilation (hurts to take deep breaths, so patient takes shallow breaths)-> atelectasis (alveolar collapse)-> allows for formation of mucus plugs (and any time you block a tube you inc infection risk)-> pneumonia

Answer 503

Autoimmune hepatitis - more common in women than men (esp consider if they have another autoimmune disorder) - initial presentation varies—can involve abdominal pain, pruritus (itching), possibly cirrhosis (jaundice, ascites), but 25% are asymptomatic! * positive serology (anti-smooth muscle antibody, anti-liver/ kidney microsomal type 1, antinuclear antibodies) * may have high gamma gap (serum protein-serum albumin of >4) prob due to bad liver producing less albumin

Answer 504

Chronic pancreatitis (Progressive inflammatory disease of the pancreas) - epigastric pain (worse w/ meals and intermittent, but may become constant later on) - steatorrhea (loose, fatty stools) (pancreas isn’t functioning well to release enzymes that will help break down fat) - weight loss - history of pancreatitis episode(s) *treatment involves pancreatic enzyme replacement

Answer 505

Low fecal ELASTASE - this is an inactive enzyme (zymogen) that is released by the pancreas and normally activated by trypsin in the duodenum - low levels= exocrine insufficiency

Answer 506

1. In mouth, vit B12 is bound to amylase (salivary protein) 2. In stomach, the acid (pepsin) breaks up vit B12—amylase and vit B12 binds to R-binder 3. In duodenum, pancreatic proteases break up vit B12—R-binder and vit B12 binds to IF (intrinsic factor), which is made by parietal cells in the stomach 4. vit B12—IF gets absorbed in the ileum

Answer 507

Eosinophilic esophagitis-> food impaction (food stuck in the esophagus due to underlying problem) *history of asthma and refractory heartburn makes eosinophilic esophagitis the most likely thing predisposing to food getting stuck

Answer 508

Primary sclerosing cholangitis (Inflammation and fibrosis of intrahepatic and extrahepatic bile ducts) *highly associated with UC (ulcerative colitis), which this guy has Get a MRCP (magnetic resonance cholangiopancreatography, MRI of bile ducts) -will show you the “bead on a string” appearance of bile ducts from “onion-skinning” fibrosis

Answer 509

Acute (ascending) cholangitis Charcot triad: (1) RUQ pain, (2) fever, (3) jaundice Reynolds pentad: (4) hypotension/ shock, (5) altered mental status *this patient has it all except jaundice is not noted (but bili is high and it jaundice may develop as this worsens) *anion gap metabolic acidosis due to lactic acidosis from severe sepsis **no ketones so no DKA. Her hyperglycemia is likely due to infection Life-threatening emergency! Sepsis-> death happens fast. Give broad-spectrum antibiotics, aggressive IV fluids, and relief of common bile duct obstruction with ERCP or percutaneous drainage

Answer 510

RUQ pain, nausea/ vomiting, elevated bilirubin, maybe anion gap metabolic acidosis, and SUPER high liver enzymes (AST, ALT in the thousands)

Answer 511

Peptic ulcer disease (most likely due to H. Pylori) - epigastric abd pain + melena (black stool from digested blood) - food makes it better and worse at night when not eating, which suggests a duodenal ulcer (acid-neutralizing enzymes are released there) *peptic ulcer dz is one of the most common causes of GI bleeds! Think of it and diagnose it with upper GI endoscopy **he has a carotid bruit, suggesting atherosclerosis. This is a throw-off here

Answer 512

Crohn’s (affects anywhere in GI tract, skip lesions)- MELENA (Upper GI tract bleeding-> digested blood= black stool) UC (affects distal colon/ rectum)- HEMATOCHEZIA (lower GI tract bleeding-> bright red blood per rectum)

Answer 513

Hematochezia (bright red blood per rectum)

Answer 514

Toxic adenoma of the thyroid *not Graves, even though that’s the most common cause of hyperthyroidism—Graves affects the thyroid in a diffuse manner (TSI thyroid-stimulating antibodies stimulate the entire thyroid), so wouldn’t just be a single hot nodule

Answer 515

UTI’s | It is a bactericidal antibiotic

Answer 516

No PPD test can be false negative in an immunocompromised patient! (Their immune system sucks, so does not mount the appropriate response to the injected antigen)

Answer 517

Thyrotoxicosis/ hyperthyroidism *lid retraction likely is referring to the protruding eyes seen in Graves dz, the most common cause of hyperthyroidism

Answer 518

Due to increased myocardial contractility Thyroid hormone (T3) acts on cardiac myocytes-> increased cardiac output (more blood is getting pumped out, so more blood is in circulation= hyperdynamic circulation)-> so inc BP!

Answer 519

Milk-alkali syndrome (Excessive intake of calcium/ inflammation absorbable alkali like calcium carbonate) *she has osteoporosis, so makes sense she’d take calcium as the vitamin - symptoms of hypercalcemia: abdominal pain, constipation, polydipsia (urinary frequency) (*too much calcium-> kidneys have to work harder to filter it. Causes renal vasoconstriction and dec GFR) - Milk-alkali syndrome often presents as symptomatic hypercalcemia + metabolic alkalosis + AKI

Answer 520

If the nodule is >2 cm or >1 cm with high-risk U/S features | microcalcifications, irregular margins, internal vascularity

Answer 521

Cervical radiculopathy (of C6 nerve root) -caused by disc herniation-> compression of nerve root (*could also be caused by spondylosis/ osteoarthritis of neck-> compression of nerve root, but this would be chronic not acute) - acute right shoulder/ arm pain, biceps weakness, diminished biceps reflex with cervical muscle spasm * shoulder aBduction w/ hand on head provides relief bc it takes tension off the impinged nerve root (diagnostic and therapeutic!)

Answer 522

Hepatitis secondary to Isoniazid (causes liver injury that presents similarly to viral hep)

Answer 523

Serum vitamin B12 level (test for vitamin B12 deficiency) **Methylmalonic acid and homocysteine if inconclusive * Remember that vit B12 is reabsorbed at the terminal ileum (“iron fist bro”- iron at duodenum, folate/ B9 at jejunum, B12 at ileum) and Crohn’s disease affects the terminal ileum (and his surgery was likely removal of the ileum, which means no B12 reabsorption). * Vit B12 is needed for DNA synthesis and myelin formation, so B12 deficiency-> macrocytic anemia + neuro demyelination (causing paresthesias). **Why is his anemia normocytic? He prob has iron deficiency too (due to GI bleeding from Crohn’s). Vit B12 def (macrocytic) + Fe def (microcytic)= normocytic.

Answer 524

Subacute combined degeneration- demyelination of dorsal column (DC-ML)-> dec vibration and proprioception AND lateral corticospinal tracts (CST)-> spastic paresis, enhanced reflexes. *Peripheral nerves often affected first-> lower extremity paresthesias.

Answer 525

Euthyroid sick syndrome (“low T3 syndrome”) - Any patient with acute, severe illness may have abnormal thyroid function tests w/ low T3 (less conversion of T4-> T3 due to caloric deprivation, inflammation, and FFA’s/ meds that inhibit 5’-deiodinase) * It is not recommended to test thyroid function in sick patients for this reason.

Answer 526

Broca’s—> frontal lobe Wernicke’s—> temporal lobe *both on dominant side of brain (if right-handed, on right brain)

Answer 527

Broca’s is in the frontal lobe. Nonfluent aphasia (can’t talk well, but can understand)

Answer 528

Wernicke’s is in the temporal lobe. Fluent aphasia (can talk, but can’t understand—“Wernicke word salad,” words you say don’t make sense)

Answer 529

Normal pressure hydrocephalus “Wet, wobbly, and wacky” - Urinary incontinence (urinating on self) - Gait dysfunction (falls) - Dementia (forgetful) *It is a type of communicating hydrocephalus (decreased CSF absorption) in elderly-> more CSF in ventricles-> stretching of corona radiata (nerve fibers running along edge of ventricles)-> motor neurons are disrupted (Normal pressure means the CSF opening pressure is normal)

Answer 530

Large ventricles (ventriculomegaly) with normal sulci *It is a type of communicating hydrocephalus (decreased CSF absorption) in elderly-> too much CSF in ventricles (elevated central pressure, improvement with LP)-> stretching of corona radiata (nerve fibers running along edge of ventricles)-> motor neurons are disrupted (Normal pressure means the CSF opening pressure is normal)

Answer 531

1. Intubate to protect airway 2. Hold AChE inhibitors (Pyridostigmine) to reduce excess airway secretions and reduce aspiration risk 3. Give IV plasmapheresis (or IVIG) + corticosteroids

Answer 532

Secretory diarrhea *causes: chronic infection, microscopic colitis, bile salt diarrhea, hormone secreting tumor (gastrinoma, VIPoma)

Answer 533

This patient has alarm symptoms, specifically nocturnal diarrhea (this suggests secretory diarrhea, as it occurs during the night when fasting) *IBS is a clinical diagnosis and involves limited work-up (CBC, serological for celiac dz, inflammatory markers) and reassurance. However, you need to do further testing on patients with alarm features: older age of onset (>50), GI bleeding, nocturnal diarrhea, worsening pain, unintended weight loss, concerning labs (Fe def anemia, elevated CRP), or family hx of IBD or colon CA.

Answer 534

Adrenal mass with hirsutism (androgen excess)—> HIGH testosterone, LOW LH (due to negative feedback)

Answer 535

Order a glucagon level - She likely has glucagonoma (DM, weight loss, watery diarrhea, rash) - The rash is “necrolytic migratory erythema” (red blistering rash that spreads across the skin), seen in 70% of glucagonoma patients * normocytic anemia likely due to anemia of chronic disease * *glucagon >500 confirms the diagnosis + CT abdomen will localize the tumor and check for metastasis

Answer 536

Lead poisoning - Microcytic anemia with basophilic stippling (lead toxicity blocks ALAD, an enzyme needed for heme synthesis) - Hyperuricemia (due to impaired purine metabolism) - Neuropsych manifestations (memory loss, sensorimotor neuropathy, headaches, ataxia) - GI manifestations (abdominal pain, constipation) - HTN and possible nephrotoxicity (elevated creatinine) * remember that it causes anemia, GI and kidney disease + Kids (lead paint)-> mental deterioration. Adults (batteries, environmental exposure)-> headache, memory loss, demyelination.

Answer 537

Gross, painless hematuria= BLADDER CANCER or KIDNEY CANCER (RCC) until proven otherwise!

Answer 538

Surgical resection of brain mass * Metastatic brain tumors= most common brain tumors, often seen at the grey-white matter junction (grey matter= neuron cell bodies, white matter= axons) * Single brain metastasis-> surgery is the best choice if possible! * *Multiple brain metastasis-> whole brain radiation therapy (or supportive care, but then expectation is that the person will live <2 mo.)

Answer 539

EXUDATIVE * Remember Light’s criteria based on Pleural: Serum ratios. Exudative if: 1. LDH >0.6 2. Protein >0.5 3. LDH > 2/3rds the upper limit of normal P:S LDH is 300/100= 3 >0.5, so exudative (by the 2nd criteria) Pleural LDH is 300, which is more than 2/3rds the upper limit of normal Serum LDH (upper limit of the normal serum LDH is 90...2/3rds of 90 is 60...300 >60), so exudative (by the 3rd criteria)

Answer 540

Decrease the RR (18 is too high) -His pH is 7.5 and CO2 is low= respiratory alkalosis (due to hyperventilation-> blowing off too much CO2) **GUIDELINES: Ventilation settings (CO2): -Tidal Volume of 4-8 mL/kg is appropriate (may go lower for COPD or ARDS) -RR of 10-12 breaths/ min is appropriate Oxygenation settings (O2): - Start with FiO2 of 100% and titrate down to <60% (you want the lowest FiO2 to maintain PaO2 of 50-60 or O2 sat of >90%) - PEEP around 5 cm H2O is appropriate

Answer 541

Ventilation settings (CO2): - Tidal Volume of 4-8 mL/kg is appropriate (may go lower for COPD or ARDS) - RR of 10-12 breaths/ min is appropriate Oxygenation settings (O2): - Start with FiO2 of 100% and titrate down to <60% (you want the lowest FiO2 to maintain PaO2 of 50-60 or O2 sat of >90%) - PEEP around 5 cm H2O is appropriate

Answer 542

4-8 mL/kg is appropriate (may go lower for COPD or ARDS)

Answer 543

10-12 breaths/ min is appropriate

Answer 544

Start with FiO2 of 100% and titrate down to <60% (you want the lowest FiO2 to maintain PaO2 of 50-60 or O2 sat of >90%)

Answer 545

Around 5 cm H2O is appropriate *PEEP keeps alveoli propped open, but too high of PEEP increases risk of barotrauma (injury to alveoli) and can lead to pneumothorax and decreased CO (inc intrathoracic pressure-> dec venous return)

Answer 546

Idiopathic Intracranial Hypertension (IIH) aka Psuedotumor Cerebri Give Acetazolamide - High ICP (papilledema is a sign), high CSF opening pressure, otherwise normal neuro exam (may have CN6 palsy), CT, and CSF analysis - Often seen in young, obese females * We don’t use Mannitol- that’s used in inpatient setting for increased ICP due to cerebral edema (given IV and requires close monitoring for renal function and electrolytes)

Answer 547

MEN 1: “pans of pitted pears” 1. Pancreatic tumors 2. Pituitary tumors 3. Parathyroid tumors MEN 2a: 1. Medullary thyroid CA 2. Pheochromocytoma 3. Parathyroid tumors MEN 2b: 1. Medullary thyroid CA 2. Pheochromocytoma 3. Mucosal neuromas/ marfanoid habitus

Answer 548

Have the receptionist instruct the patient to schedule an appointment (Stay professional, she has to make an appointment like everyone else, but don’t blow her off either...obviously you’ll have to tell her a chaperone is required at her appointment if a private exam is indicated)

Answer 549

Von Hippel-Lindau Disease

Answer 550

Continue current care with observation IV antibiotics significantly reduce risk of septic cardioembolism (thrown vegetation-> stroke). Aspirin would only be indicated in ischemic stroke due to atherosclerotic thrombosis or embolism. Heparin is NEVER indicated in stroke due to risk of hemorrhagic stroke (and no proof it helps in the acute setting)/

Answer 551

K+ sparing diuretic | “Almonds” in Sketchy

Answer 552

If there is significant valvular dysfunction-> Heart Failure (or if infection persists/ septic embolization is recurrent)

Answer 553

Gastritis (stomach inflammation) aka Acute erosive gastropathy (or gastric mucosal erosion) - alcohol-> stomach mucosal injury - cocaine-> vasoconstriction-> dec gastric blood flow to sweep away acid-> stomach mucosal injury - aspirin blocks protective prostaglandins-> gastric mucosal injury * NOT pancreatitis (this is usually associated with chronic alcohol abuse- not one binge drinking party and doesn’t include hematemesis) * NOT esophageal varices (he is young, no signs of cirrhosis) * NOT Mallory-Weiss esophageal tear (he hasn’t had multiple vomiting/ retching episodes)

Answer 554

NAFLD is associated with insulin resistance! Insulin resistance (body not responding to insulin)-> increased lipolysis (break down of fats for energy, since glucose is not getting into cells), more triglyceride synthesis, and hepatic uptake of fatty acids

Answer 555

Give intramuscular epi- this is anaphylaxis! - likely caused by the antibiotic she started in the morning for sinusitis * epi is a beta > alpha agonist, so causes bronchodilation (beta-2) and vasoconstriction to inc BP (alpha-1). The perfect drug for anaphylactic shock!

Answer 556

Severe, life-threatening allergic reaction. IgE-> mast cell degranulation-> MASSIVE histamine release-> systemic vasodilation-> hypotension-> poor organ perfusion. Also, causes edema (due to histamine + complement), which compromises the airway. * Give epi (beta > alpha agonist) to cause bronchodilation (beta-2) and vasoconstriction to inc BP (alpha-1) * Order: give IM epi (if airway compromise)-> antihistamines-> steroids

Answer 557

MRI of the spine - He is presenting with signs and symptoms of spinal cord compression (bilateral in just lower extremities means you can localize to spinal cord. No UMNs below compression-> UMN signs). - Since he’s an IV drug user, an epidural abscess (even w/o fever) is a concern. **if you were thinking Guillain-Barre, you’d do an LP. But that wouldn’t cause UMN signs or sensory deficit. Bad idea to do LP when abscess is in the differential bc that can introduce more bacteria.

Answer 558

Hereditary spherocytosis -Classic triad is: (1) hemolytic anemia, (2) jaundice, (3) splenomegaly * RBC protein (Ankrin, band 3) deficiency-> RBCs are spherical instead of donut-shaped-> spleen kills them-> hemolytic anemia, splenomegaly, and jaundice is due to too much bilirubin (UCB) for the liver to conjugate. * *inc MCHC (mean corpuscular Hb concentration) is due to membrane loss and RBC dehydration *Patient is presenting with RUQ pain worse with deep inspiration (positive Murphy’s sign) wi nausea/ vomiting. This is due to bilirubin (pigmented) gallstones, which he has increased risk for due to his underlying disease (hemolysis).

Answer 559

Viral myocarditis - presents with CHF symptoms (usually a few weeks after a viral prodrome of fever, malaise, myalgias) - EKG shows nonspecific ST changes, echo shows 4 chamber dilation - common cause of dilated cardiomyopathy in young adults * can be caused by parvovirus B19, HHV 6, coxsackievirus, adenovirus, influenza, HIV * thought to happen due to an initially inadequate immune response to viral infection-> virus invades cardiac myocytes-> cytotoxicity (toxic to cells) and impaired contractile function * gold standard to diagnose is endomyocardial biopsy with PCR (but cardiac MRI is noninvasive and can help)

Answer 560

Endomyocardial biopsy with PCR (but cardiac MRI is noninvasive and can help)

Answer 561

AKI due to acute calcineurin inhibitor (CNI) renal toxicity (*calcineurin= protein that activates T-cells and is targeted by immunosuppressant agents like Tacrolimus) She was recently diagnosed with a-fib, so recently started Diltiazem (CCB), which blocks P450-> allows other drugs like Tacrolimus to stay in the system longer-> increased Tacrolimus levels-> vasoconstriction and AKI

Answer 562

AA amyloidosis nephrotic syndrome (peeing out protein, pitting edema) - rheumatoid arthritis (deformed hands, joint pains, fatigue)-> chronic inflammation-> release of the acute phase protein serum amyloid associated protein-> AA amyloidos is (that protein misfolds and deposits in tissue) * diagnose with renal biopsy showing Congo-red glomerular deposits

Answer 563

Renal biopsy showing Congo-red glomerular deposits *suspect this is patients with nephrotic syndrome (peeing out protein, pitting edema) with history of rheumatoid arthritis (or other chronic inflammatory disease)

Answer 564

1. Minimal change dz 2. Focal segmental GN 3. Membranous GN 4. Membranoproliferative GN 5. DM nephrotic syndrome 6. Amyloidosis (AL in multiple myeloma, AA in chronic inflammation like RA)

Answer 565

1. Post-strep GN 2. Rapidly progressive GN - Goodpastrues, post-strep GN, diffuse proliferative GN, Wegner’s, microscopic polyangiits, or Churg Strauss 3. IgA nephropathy (Bergers) 4. Alport syndrome

Answer 566

SLE (lupus) * also called DIFFUSE proliferative GN (most common nephritic syndrome in lupus with “wire-looping”) * *renal biopsy would show glomerular immune deposits on histo

Answer 567

Gonococcal septic arthritis (from Disseminated Gonococcal Infection) - asymmetric polyarthralgias (hers is migratory), fever, high neutrophil count in synovial fluid * confirm diagnosis with gram stain of synovial fluid, blood cultures, and genital NAAT (PCR) for Neisseria Gonorrhea

Answer 568

Ankylosing spondylitis | Joint disorder that affects the sacroiliac joints-> fusion “bamboo spine”

Answer 569

Inflammation of entheses, the sites where tendons (attaching bone to muscle) or ligaments (attaching bone to bone) insert into bone -this is seen in ankylosing spondylitis!

Answer 570

Compression of a spinal nerve root/ “pinched nerve”

Answer 571

``` Topical Metronidazole (gel form) (Other options: Azelaic acid or Ivermectin) ``` *2nd line: oral tetracyclines

Answer 572

Vestibular neuritis (Inflammation of vestibular nerve/ CN8-> vertigo) - it is a self-limited disorder that follows a viral URI * vestibular neuritis + unilateral hearing loss= labyrinthitis

Answer 573

Stress-induced ulcer - common in ICU patients w/ severe physiologic stress (risk factors: shock, sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/ brain injury, burns, high-dose corticosteroids) - multifactorial: due to poor blood flow to abdomen (splanchnic hypoperfusion) and kidneys-> uremic toxins accumulate and impair formation of the protective mucosal layer of the stomach-> mucosal injury and bleeding * this is the very reason we give GI prophylaxis (PPIs) to patients at high-risk! (*but don’t just throw them at everybody either, as PPIs inc risk for C diff)

Answer 574

STEMI 2/2 cocaine abuse

Answer 575

Tonometry (measure that IOP) -This is acute angle-closure glaucoma, possibly triggered by decongestant use (alpha-1 agonists like Phenylephrine-> pupillary dilation, which can completely close the anterior chamber angle in a person who’s predisposed bc of their anatomy/ already has a narrower angle) **don’t confuse alpha-1 and alpha-2. Alpha-1-> pupillary dilation. Alpha-2-> decreases aqueous humor production. When we treat open angle glaucoma with alpha agonists (“activate alpha, block beta”), that’s alpha-2 agonists**

Answer 576

Oligoclonal bands (this is MS) - He has neurologic deficits separated by time and space (trigeminal neuralgia, lower limb motor loss, upper limb sensory loss) * For diagnosis, do an MRI (expect to see demyelinating lesions affecting white matter). If not classic, follow-up with LP (expect to see oligoclonal bands of Ig).

Answer 577

Elevated CSF protein w/ normal cell count (on LP CSF analysis) Characteristic of Guillain-Barré syndrome

Answer 578

Increased cell count

Answer 579

Prison disease (Creutzfeldt-Jakob disease) *these patients have rapid, profound deterioration of mental status (dementia, behavioral changes) with startle myoclonus

Answer 580

Right-sided pleural effusion *given her history of breast cancer, this raises concern for a malignant effusion due to breast cancer recurrence

Answer 581

1. Breath sounds- DECREASED 2. Tactile fremitus- DECREASED 3. Percussion (dull, resonant, or hyperresonant)- DULL - There’s fluid between you and the lungs, so lung sounds are more distant - There’s fluid between you and the lungs, os vibrations from the lung will be felt less - Fluid causes dullness to percussion (vs air creates a hollow, hyperresonant sound)

Answer 582

None This is Polymyalgia rehumatica (pain and stiffness in shoulders/ hips/ neck, fatigue, weight loss, low-grade fever) -classic symptoms, elevated inflammatory markers, and response to glucocorticoids-> no further testing needed *a small number of cases are associated with giant cell (temporal) arteritis (headache, temporal tenderness, jaw claudication, visual disturbance)

Answer 583

Diverticulosis (diverticulum hemorrhage) - the most common cause of large-volume rectal bleed in adults (painless, but can be associated with lightheadedness or hemodynamic instability) * usually resolves on its own, but occasionally requires endoscopic or surgical evaluation **diverticulosis is most common in the sigmoid colon, but diverticular bleeding is more common in the right colon

Answer 584

Diverticulosis (diverticular hemorrhage) * painless, but can be associated with lightheadedness or hemodynamic instability * usually goes away on its own, but may require endoscopic or surgical intervention

Answer 585

Psoriatic arthritis - psoriasis + arthritis - characteristic “sausage digits” (also called dactylitits, meaning inflammation of the fingers and toes) w/ nail pitting may be present

Answer 586

``` Decreased DLCO (diffusion problem) Normal FEV1/FVC ratio (restrictive lung dz= problem getting air in, so less air in= less air out, so FEV1 and FVC are both lower, but ratio is maintained) ```

Answer 587

centriacinar

Answer 588

Chronic bronchitis- DLCO is normal Emphysema- DLCO is low (alveolar destruction impairs diffusion capacity)

Answer 589

1. Coal workers pneumoconiosis (coal miners) 2. Silicosis (sandblasters and silica miners) 3. Asbestosis (construction workers, plumbers, and shipyard workers) 4. Berylliosis (beryllium miners and aerospace workers like in NASA)

Answer 590

Requirement for Levothyroxine would increase (you’d have to up her dose) *if hypothyroid patient is pregnant or on estrogen therapy, you need to up the thyroid dose. Why? Pregnancy/ estrogen increases TBG (thyroid-binding globulin)-> more TH will bind it-> less free TH (will require more to be at normal levels).

Answer 591

Metcolopramide | Remember the D2 rings in Sketchy

Answer 592

Benign paroxysmal positional vertigo (BPPV) - vertigo episodes triggered by head positional changes - caused by calcium debris in the semicircular canal-> disruption of normal fluid flow through the vestibular system - diagnose with Dix-Hallpike maneuver (quickly lie patient down with head rotated 45 degrees)-> will reproduce vertigo and nystagmus - treat with Epley/ canalith repositioning maneuvers *murmur is unrelated! Ejection murmur at left sternal border= still murmur aka functional murmur (an innocent murmur)

Answer 593

Dementia with Lewy bodies -dementia with Parkinsonism and visual hallucinations (the dementia may come first or at the same time as the other symptoms) * treat with carbidopa-levodopa for Parkinsonism and anticholinergics for cognitive impairment * on autopsy: Lewy bodies (eosinophilic inclusion bodies of alpha-synuclein protein) in brain

Answer 594

Acute bacterial prostatitis (Most likely due to E. Coli) -presents as a flu-like illness w/ lower urinary tract symptoms

Answer 595

AG= sodium- bicarb- chloride

Answer 596

MI-> cardiogenic shock - He’s in shock - cold skin= vasoconstriction diverts blood away from extremities to vital organs + lack of perfusion - CO is low, so heart isn’t pumping well - PCWP is high, so LA is extra full since heart isn’t pumping forward well

Answer 597

Bicuspid aortic valve (causing aortic regurg) * bicuspid aortic valve is often associated with aortic STENOSIS, but can also be a cause of aortic regurg (from aortic root dilation)! * remember the 3 murmurs best heard at the left sternal border: (1) aortic regurg, (2) pulmonary regurg, (3) HOCM

Answer 598

1. aortic regurg 2. pulmonary regurg 3. HOCM

Answer 599

Smokers age 55-80 * start earlier if 30+ pack year history comes before age 55 * stop earlier if 15+ years w/o smoking comes before age 80

Answer 600

Slowly taper her off Phenytoin and discontinue it - she’s been seizure free >2 yrs, so discontinuation of anti-seizure medication is reasonable (wein her off bc rapid withdrawal could cause seizure reoccurrence) - Phenytoin is a teratogen! Causes fetal hydantoin syndrome (group of defects due to Phenytoin): cleft palate, microcephaly, nail/ digit hypoplasia, cardiac defects, facial feature abnormalities

Answer 601

Nephrogenic DI 2/2 Lithium use - Lithium accumulation in renal collecting ducts-> ADH resistance (kidneys not responding to ADH, so not retaining water-> pee out the water too much) * will have concentrated blood, dilute urine (since you’re peeing out the water)

Answer 602

Give Atropine This is organophosphate poisoning (cholinergic toxicity). * remember DUMBBELS (Diarrhea, Urination, Miosis/ constricted pupils, Bronchospasm and Bradycardia, Emesis, Lacrimation, Salivation) - PNS symptoms *Manage A,B,Cs (airway, breathing, circulation), give Atropine (anti-muscurinic), also give Pralidoxime if neuromuscular dysfunction is present

Answer 603

Diffuse axonal injury -traumatic brain injury that results in unconsciousness-> vegetative state-> death

Answer 604

Hyperosmolar hyperglycemic state -state of severe hyperglycemia (>600), hyperosmolarity, and dehydration in T2DM patients * they have such high blood sugar (body not responding to insulin to pull glc into cells)-> hyperosmolarity and glc is spilling out into urine, water follows-> dehydration. * hyperkalemia is an issue (lack of insulin to pull K+ into cells and hyperosmolarity also pushes K+ out of cells). Giving insulin to treat can then rapidly shift K+ back into cells-> hypokalemia, so watch it.

Answer 605

The caudate nucleus and putamen

Answer 606

ACE inhibitors dilate the efferent arteriole (Angiotensin II constricts the efferent and ACE i’s block that-> dilation of efferent-> dec GFR, inc RPF) *since they decrease GFR (reduce glomerular hydrostatic pressure, while still preserving renal perfusion flow), they take pressure off the kidneys and are important in preventing nephrotic syndrome (DM nephropathy) in diabetics

Answer 607

Start her on an ACE inhibitor - She has systemic sclerosis (diffuse scleroderma) - Widespread fibrosis of multiple organ systems (autoimmune vasculopathy involving collagen deposition)-> thick skin, telangiectasias, HTN emergency and acute renal failure from renal vascular injury (scleroderma renal crisis) - ACE inhibitors are used to prevent and treat renal HTN crisis (StepUp2Med pg 249), they reduce RAAS activation (*the high Cr is not a contraindication for ACEi’s in this population)

Answer 608

Cardiac tamponade (likely 2/2 viral pericarditis) Beck’s triad: (1) hypotension, (2) distended neck veins, (3) muffled heart sounds *pulsus paradoxus (>10 drop in BP during inspiration) is another common finding *normal JVP= 6-8 cm (11 is elevated!)

Answer 609

Due to decreased LV preload Fluid filling the pericardial sac RESTRICTS FILLING-> decreased preload-> decreased stroke volume-> decreased CO

Answer 610

Inhaled bronchodilator - This is likely ACUTE BRONCHITIS (90% viral) * cough can be dry or productive * self-limited (lasts 3-4 wks), but treat with supportive therapy (throat lozenges, over-the-counter cough suppressants, albuterol in patients with underlying asthma)—NO antibiotics * fever is not typical (if fever is present, think PNA) * no need to get a CXR here to r/o PNA—do this for patients with high fever, tachypnea, crackles/ dullness on lung exam, or underlying COPD

Answer 611

PRIMARY ADRENAL INSUFFICIENCY (lack of aldosterone and cortisol production by the adrenal glands) -likely 2/2 metastatic breast cancer (adrenal glands are a common site of metastasis, and when they are destroyed by cancer, they stop working like they should) - > low BP, low Na+ (not reabsorbing it), high K+ (not peeing it out) * confirm the diagnosis by cosyntropin (synthetic ACTH) stimulation testing (after giving ACTH to stimulate the adrenal glands, her adrenals would still fail to produce cortisol)

Answer 612

Do a Cosyntropin (synthetic ACTH) stimulations test (after giving ACTH to stimulate the adrenal glands, adrenals will still fail to produce cortisol if adrenal insufficiency is present) * this test is usually done in the morning when cortisol levels are normally most pronounced (body gets ready for the day of stress) * remember adrenal insufficiency= lack of aldosterone and cortisol by the adrenals

Answer 613

Anterior cord syndrome (Motor + pain/ temp are broken on both sides, since the anterior part of the spinal cord is where CST and STT fibers cross) *from injury to anterior spinal artery in trauma

Answer 614

Motor + pain/ temp are broken on both sides | since the anterior part of the spinal cord is where CST and STT fibers cross

Answer 615

Pain/ temp broken on both sides (affects STT crossing) - paralysis and burning pain in upper extremities - usually in old patients after forced hyperextension of the neck (whiplash) * can be assoc with bladder dysfunction

Answer 616

Papilledema (swollen optic nerve due to elevated ICP) - causes transient vision loss with change in head position - headaches due to inc ICP are usually worse in the morning *she may have idiopathic intracranial HTN (pseudotumor cerebri), given her young age, obesity, and lack of other comorbidities...next step would be neuroimaging (CT or MRI brain)

Answer 617

Plasmapheresis (plasma exchange) - This patient has TTP (Thrombotic Thrombocytopenic Purpura) - Presents with thrombocytopenia, microangiopathic hemolytic anemia, renal insufficiency, neuro changes (headache, confusion, coma, stroke), fever * autoantibody against ADAM 13, an enzyme that normally degrades vWF-> vWF stays there, clumping up platelets-> dec platelets/ thrombocytopenia (since they are getting used up forming microthrombi) + CNS abnormalities (tends to involve CNS vessels) * fragmented RBCs= shistocytes/ helmet cells * PT, PTT are normal (unlike in DIC)

Answer 618

Organophosphate poisoning RBC acetylcholinesterase activity test *you can also just give Atropine and if it works in resolving the symptoms, you know your diagnosis was correct - organophosphates block AChE in muscarinic and nicotinic synapses-> ACh can’t be broken down-> too much ACh-> overstimulation at the NMJ to where muscles stop responding - PNS symptoms: DUMBBELS (Diarrhea/ Diaphoresis, Urination, Miosis, Bronchospasm/ Bradycardia, Emesis, Lacrimation, Salivation) * think of this in an agricultural worker (pesticides) or in a group of people with similar symtpoms (nerve agent—these chemical weapons are used in terrorist attacks and the gas is colorless, tasteless, but has a slight fruity odor)

Answer 619

Multiple system atrophy (Shy-Drager syndrome) -degenerative disease w/ Parkinson’s symptoms + autonomic insufficiency - this patient has Parkinson’s symptoms—resting tremor, rigidity, bradykinesia - and autonomic dysfunction (postural hypotension, erectile dysfunction, dry skin, dry mouth) * other autonomic symptoms may include: loss of bowel or bladder control, abnormal salivation or lacrimation, gastroparesis...

Answer 620

Central retinal vein occlusion (Blood not draining from the eye) *this is describing a “blood and thunder” appearance (optic disk swelling, retinal hemorrhages, dilated and tortuous veins, cotton wool spots)

Answer 621

*He has microcytic anemia= iron deficiency, anemia of chronic dz, sideroblastic anemia, or thalassemia. Most likely IRON DEFICIENCY (usually due to GI blood loss in men)- this is most common + he has no inflammatory disorders that point to anemia of chronic dz (osteoarthritis is wear and tear—it’s not autoimmune like rheumatoid) Serum iron- LOW Serum ferritin (iron in storage)- LOW TIBC (total iron binding capacity) (Tf)- HIGH Transferrin (Tf) saturation- LOW

Answer 622

NSAID | Trade name= Aleve

Answer 623

Alcoholic peripheral neuropathy (a toxic neuropathy) - alcohol is neurotoxic-> symmetric distal polyneuropathy in a “stocking and glove pattern” - loss of deep tendon reflexes begins with loss of ankle reflexes * treat with stopping alcohol (improves symptoms), give thiamine supplements, and may give gabapentin or TCAs for refractory neuropathic pain

Answer 624

Charcot-Marie-Tooth disease

Answer 625

Guillain-Barré syndrome - rapidly progressive, ascending - usually follows a GI infection or URI

Answer 626

Yes—hypOnatremia in patients with CHF parallels the severity of HF and is a predictor of clinical outcomes -it is caused by increased ADH (more water retention-> dilutes [Na+]) and increased renin and NE (increase Na+ and water reabsorption in the distal tubules)

Answer 627

Toxoplasma encephalitis | Sulfadiazine + Pyrimethamine Sulfa dyed eggs + pyramid shape on dyed eggs

Answer 628

Give Aspirin * This is likely ischemic stroke and patient is not a TPA candidate (last normal was >4.5 hrs ago) * ASA is the only antiplatelet agent hat is effective in reducing the risk of early ischemic stroke recurrence- give within 24 hrs!

Answer 629

1. Increase fluid intake 2. Decrease sodium intake 3. Normal calcium intake * hydration always helps prevent kidney stones * low sodium in the diet promotes sodium and calcium reabsorption (by pushing more calcium in the blood, you pee out less= less calcium kidney stones) * calcium intake has no effect

Answer 630

Brain tumor - morning headaches + focal neuro deficits * diagnose with MRI brain

Answer 631

Consolidation of the lung - dullness= trapped fluid - increased breath sounds (bronchial, crackles)= fluid in lungs (**vs pleural effusion breath sounds are decreased bc the fluid is in the pleura b/w you and the lungs)

Answer 632

Beta blocker (Propranolol) This is hyperthyroidism - a-fib with RVR, tachycardia - anxiety - weight loss - tremor * beta-blockers are used for initial treatment of a-fib 2/2 hyperthyroidism to control HR and sympathetic symptoms (they also block peripheral conversion of T4-> to active T3) - continue beta-blockers until patient becomes euthyroid + treat hyperthyroidism with medication, radioactive ablation, and/or surgery

Answer 633

Lumbar puncture (LP) This sounds like subarachnoid hemorrhage (*from ruptured berry aneurysms) - thunderclap headache (reaches max intensity in few minutes) “worst headache of my life” - associated with N/V, photophobia - neck stiffness= meningeal irritation (from the blood) You would expect a non-con CT to show bleeding, but if it comes back negative and you are highly suspicious of subarachnoid hemorrhage, do a LP to check! Xanthochromia (yellow/ bloody CSF)= SAH *NOT a migraine (migraine headaches don’t irritate the meninges)

Answer 634

Communication failures between providers

Answer 635

Implementing a signout checklist *face-to-face handoffs w/o interruptions are also ideal, but not proven to be AS good as checklists in the signout procedure for improving medical outcomes

Answer 636

HBsAg- NEGATIVE HBsAb- POSITIVE HBcAb- POSITIVE * remember “SpECiES” (HBsAg, HBeAg, HBcAb, HBeAb, HBsAb) - serum antigen, e antigen (infectivity), core antibody, e antibody, and serum antibody This patient had the serum antigen at the time he presented with infection, but not the e antigen and no antibodies (hadn’t been produced yet)...so now he will have the core antibody (1st one that gets made- in “window period”) and serum antibody (may or may not have the e antibody) (No antigens anymore bc the infection is resolved)

Answer 637

95% of hep B infections are self-limited (resolve on their own) **vs. babies who get it from vertical transmission are likely to get the chronic form and children age 1-5 have a 30-50% chance of getting the chronic form

Answer 638

Get a FLOW CYTOMETRY of the peripheral blood (To diagnose CLL—will show too many naive B-cells) - Fever + cough + R lung infiltrate= PNA - Note that most bacterial infections, including PNA, cause leukocytosis with neutrophil predominance—this guy has dramatic lymphocyte predominance - Old patient + lymphocytosis (too many lymphocytes) + anemia + thrombocytopenia + hepatosplenomegaly= CLL (chronic lymphocytic leukemia) *the most common leukemia * *anemia and thrombocytopenia due to the B-cells crowding out other cell lines * *note that a peripheral blood smear could also aid in the diagnosis (would show smudge cells)

Answer 639

“Rales in the tails, rhonchi in the bronchi” Rales= Crackles -from the alveoli Rhonchi= low-pitched wheezing -from the bronchus

Answer 640

Essential tremor Propranolol - this is an action tremor (vs. the resting tremor you get in Parkinson’s) * Propranolol is first-line, but other options are Primidone and Topiramate

Answer 641

Ask him why he doesn’t want to have treatment -before you respect his decision to not have treatment, you need to explore why he feels this way...there’s a chance he’s just in denial or afraid and needs more clarification on treatment options or depressed... Always discuss reasons for a patient’s decision to withhold treatment before honoring it!

Answer 642

Chronic CO poisoning (Exposure to car exhaust in an enclosed space + has intermittent headaches, dizziness, nausea + polycythemia) *CO has a greater affinity for Hb than oxygen-> carboxyhemoglobinemia. Less oxygen is able to bind to Hb to be delivered to tissues (left shift on Hb curve)-> hypoxia-> reactive polycythemia (kidneys release more EPO so more RBCs are made) to try to compensate. * *normal pulse ox bc pulse oximetry cannot differentiate between Hb bound to CO vs. oxygen * *diagnose with ABG (arterial blood gas)!

Answer 643

Emergency neurosurgical evaluation! This patient has acute spinal cord compression, likely due to vertebral metastasis (progressive back pain and activity brought on the onset of concerning symptoms) * some causes of spinal cord compression are: fracture, trauma, disk herniation, malignancy, epidural abscess * urinary retention occurs with lesion above S2 (autonomic tract involvement) * regardless of the cause, when the spinal cord is compressed, you need to get a surgery consult for decompression 1st, do neuroimaging, and IV glucocorticoids may be given

Answer 644

Cryptosporidium - profuse watery diarrhea in AIDS (seen w/ CD4 count <180) - get it from drinking contaminated water, animal contact (horse breeding), or person-to-person contact * stool exam w/ modified acid-fast stain shows cryptosporidium oocytes

Answer 645

Cryptosporidium

Answer 646

Microsporidium

Answer 647

Mycobacterium avium complex (MAC)

Answer 648

Cytomegalovirus (CMV colitis)

Answer 649

Give Vitamin B6 (Pyridoxine) (*the bees w/ pyramid sticks in Pixorize) - Isoniazid depletes Vit B6 stores. Since Vit B6 is needed to make protoporphyrin (and to make heme, since heme= Fe + protoporphyrin), this causes sideroblastic anemia (type of microcytic anemia, though it starts off normocytic). - increased serum Fe (there is lack of protoporphyrin to combine with Fe, so excess free iron-> ringed sideroblasts) - decreased TIBC (Tf)

Answer 650

Thalassemia minor No treatment needed -mild microcytic anemia, target cells, high RBC count * microcytic anemia means choices are: iron deficiency, anemia of chronic dz, sideroblastic anemia, or thalassemia (alpha or beta, minor or major) * alpha thal is due to a gene mutation-> dec synthesis of beta globin chain * target cells due to dec Hb (RBC “blebs up” like a deflated B-ball you can indent) * inc RBC count (to compensate for having less functional Hb)

Answer 651

SSRI (like Fluoxetine) This is somatic symptom disorder (when a patient has a minor symptom like a headache and is convinced they got brain cancer for sure). Manage with regular appointments and avoid unnecessary referrals and tests. SSRIs and cognitive-behavioral therapy may help too.

Answer 652

Echocardiogram -Look for evidence of Prosthetic Valve Thrombosis (PVT), a complication of artificial valve repair (patients can have a new murmur, HF due to stenosis/ valvular obstruction or regurg from valve not aligned perfectly, or a thromboembolic event like a TIA)

Answer 653

IV hydration He has CDK and you gave him IV contrast—stupid idea! -> contrast-induced nephropathy. If you have to give contrast for imaging, dilute the contrast with hydration to prevent injury to the kidneys.

Answer 654

All normal to low *HypOkalemia is common particularly in the binge-purge type (vomit out K+-> low K+ in blood)

Answer 655

In acute renal failure, liver failure, or sepsis—as these conditions increase risk of LACTIC ACIDOSIS

Answer 656

Infective endocarditis | *need 2 major + 1 minor or 3 minor criteria

Answer 657

Strep viridans (includes strep mutants, mitis, oralis, and sanguinis) -infective endocarditis following a dental procedure (previously affected heart valve)

Answer 658

It is a strep viridans *In the strep viridans family: strep mutants, mitis, oralis, and sanguinis

Answer 659

Rheumatoid Arthritis (RA) Pleural effusions due to RA have a low glc, high LDH * if pleural glucose level is low (<60), consider RA as the cause of the pleural effusion! (StepUp2Med pg 82) * exudative= due to inflammation * fine crackles + increased interstitial lung markings= interstitial lung disease (ILD), a pulmonary manifestation of RA

Answer 660

Exertional heat stroke -heavy exercise (bootcamp) presenting with hyperthermia (>104 F), confusion, and multi-organ dysfunction * way too hot-> vasodilation happens to shunt blood toward skin to sweat (though sweating is inadequate to cool the body at this temp)-> distributive shock (blood is not where it needs to be feeding the central organs)-> organs die and become ischemic-> tissue factor is released-> pathologic activation of coag cascade= DIC * may also cause CNS dysfunction (confusion, seizures), ARDS (his lung crackles), hepatic failure, renal failure...end-organ damage from the distributive shock * may present with anhidrosis (lack of sweating from dehydration) or sweating * leukocytosis is from the severe stress * this patient was taking an antihistamine, which has anti-cholinergic activity and can further impair heat dissipation (“hot as a hare”)

Answer 661

Exertional heat stroke—> rapid cooling with ice-water immersion Regular heat stroke—> evaporative cooling with spraying lukewarm water as fans blow on the patient’s skin *why? Studies have shown these treatments are based in each case in reducing mortality

Answer 662

Primary adrenal insufficiency (Addison’s disease) - the adrenal glands are the problem (usually due to autoimmune adrenalitis, but can also be due to TB or metastatic infiltration)-> deficiency of aldosterone, cortisol (hypOnatremia, hypERkalemia, hypotension) - high ACTH (neg feedback) (you get hyperpigmentation from this! Since it binds Melanocyte-Stimulating Hormone) -initial symptoms are nonspecific: fatigue, weakness, weight loss + GI symptoms: nausea, abdominal pain, diarrhea

Answer 663

Herpes simplex keratitis (Keratitis= inflammation of the cornea) *common cause of corneal blindness in the US

Answer 664

- contact lens wearers - patients w/ corneal trauma - patients w/ foreign body in eye (Keratitis= inflammation of the cornea) *In bacterial keratitis, the cornea appears HAZY with central ulcer and adjacent stromal abscess

Answer 665

Beta-blocker or CCB - This is a-fib with RVR - Do not cardiovert bc he is hemodynamically stable and has had this 2+ weeks (not <48 hrs) - Use medications to rhythm control (*other options that may be considered are anticoaugaiton for 3 wks-> CV or medications to rhythm control)

Answer 666

CHADS-VASc score ``` *C- CHF H- HTN A- Age >75 (2 points) D- DM S- Stroke/ TIA (2 points) V- Vascular dz (prior MI, PAD) Sc- Sex category (female) ``` (Max points= 9) 0 points-> no anticoagulation indicated 1 point-> moderate risk, consider anticoagulation (none, ASA, or oral anticoagulant) 2+ points-> anticoagulation for sure

Answer 667

YES- CHADS-VASc score is 2 (one point for HTN + one point for DM) ``` *C- CHF H- HTN A- Age >75 (2 points) D- DM S- Stroke/ TIA (2 points) V- Vascular dz (prior MI, PAD) Sc- Sex category (female) ``` (Max points= 9) 0 points-> no anticoagulation indicated 1 point-> moderate risk, consider anticoagulation (none, ASA, or oral anticoagulant) 2+ points-> anticoagulation for sure

Answer 668

Laxative abuse - young (more likely to be concerned about appearance), healthcare worker (has access to laxatives) - watery diarrhea, abdominal cramping - low BP and near-syncope (from dehydration 2/2 diarrhea) - hypokalemia (you lose bicarb and K+ in diarrhea) - metabolic alkalosis (you lose bicarb in diarrhea, so you’d expect met acidosis, but met ALKALOSIS is a common finding in laxative abuse *may also have hypermagnesemia if Mg-containing laxative is used) - the give-away is the dark pigmentation on colonoscopy= MELANOSIS COLI (*remember the guy tanning in Sketchy: chronic use of Senna-> melanosis coli/ brown pigmentation of colon)

Answer 669

ACTH- Low Cortisol- Low Why? On corticosteroids-> cortisol is high (by the exogenous supply), so ACTH is low (neg feedback) Abruptly stop steroids-> cortisol is low. You’d expect ACTH to go high (neg feedback), but it hasn’t had time to adjust so it remains low (this is why it’s important to wean patients off steroids!) * primary adrenal insufficiency affects all layers of the adrenal gland (bc the adrenal gland is the source of the problem), but secondary adrenal insufficiency (as in this Q) does not affect all layers- depends on the cause. Here, aldosterone levels are normal, but cortisol is low. * why the mild hypOnatremia? Cortisol-> vasoconstriction and inc BP. Lack of cortisol-> vasodilation and dec BP. Body responds by activating RAAS-> aldosterone + ADH. The increase in ADH > Aldo-> excess water retention-> mildly low Na+.

Answer 670

Hodgkin lymphoma - old w/ fatigue and mediastinal mass - Hodgkin lymphoma is a common cause of mediastinal mass. Presents with cough, SOB, retrosternal chest pain (due to compression of adjacent structures), lymphadenopathy, B symptoms, worsening pain w/ alcohol. - labs show elevated LDH and eosinophilia * MILD leukocytosis bc cancer cells are confirmed to lymph nodes, not circulating (it’s lymphoma, not leukemia!) * Remember eosinophils mainly w/ parasites + allergies, but also in Hodgkin lymphoma (related to cytokines activating them) * High LDH due to increased cell turnover in cancer (not always hemolysis)

Answer 671

No—high LDH is a result of cell rupture. Also consider cancer (ex: Hodgkin lymphoma), where there is increased cell turnover.

Answer 672

The cancer cells in lymphoma are confined to the lymph nodes, not circulating around much as in leukemia! So the PERIPHERAL blood sample won’t show a crazy number of WBCs.

Answer 673

Fournier gangrene (Necrotizing fasciitis of the scrotum) Emergency surgery! (To do debridement of dead tissues. This quickly progresses to sepsis and death!) * metabolic acidosis is due to lactic acidosis from sepsis-> end-organ damage * his diabetes is a risk factor

Answer 674

``` Tubulointersitial nephritis (*Remember interstitial nephritis is a type of intrinsic AKI) ``` * This isn’t the classic presentation: long-term drug use (NSAIDs, Penicillin, diuretic)-> fever, rash, eosinophilia * But, he is taking NSAIDs for back pain and the give-away is AKI (high BUN, Cr) w/ WBC casts **glomerulonephritis (nephritic syndrome) is less likely—although there’s trace protein and blood, you would expect RBC (not WBC) casts in GN!

Answer 675

Infectious mononucleosis -young adult, fever, tonsillitis, lymphadenopathy, splenomegaly, high WBCs (infection) * don’t be thrown off by the murmur—likely a flow murmur (innocent and unrelated) * don’t be thrown off by the recent travel—malaria, for example, wouldn’t cause tonsil exudates * don’t be thrown off by the elevated liver enzymes—remember that mono can cause inflammation of the liver too (Sketchy cow) * hemolytic anemia and thrombocytopenia are rare complications of mono due to EBV antibodies cross-reacting with RBCs and platelets, destroying them

Answer 676

Cardiac arrhythmia (from high K+) - Succinylcholine is a depolarizing neuromuscular blocking agent - depolarization of neuron-> ACh release-> Succinylcholine blocks ACh esterase from breaking down ACh-> too much ACh in cleft paralyzes the muscle - with increased depolarization of neuron, you get more Na+ going into cells, more K+ going out-> hypERkalemia-> life-threatening cardiac arrhythmia *patients with crush injury who are intubated with succinylcholine are at higher risk for this adverse effect! (They already have inc K+ in blood due to muscle cell lysis)

Answer 677

An innocent murmur from blood moving faster across the valves *for example, can be heard in anemia. Blood is less viscous/ thinner, so it moves faster across valves (higher velocity), so you hear the blood flow louder

Answer 678

HTN *the extra pressure on the vessels speeds up plaque formation and increases bleeding risk **HTN increases stroke risk more than any other risk factor, including high cholesterol, DM, smoking, and sedentary lifestyle.

Answer 679

1. Alpha-1 blockers (ex: Terazosin) - relax smooth muscle of the prostate - side effects: orthostatic hypotension (dec BP), reflex tachy 2. 5-alpha reductase inhibitors (ex: Finasteride) - block conversion of testosterone-> DHT, which is responsible for prostate growth (so addresses the underlying cause, not just the symptoms) - side effects: ED, decreased libido * takes 6-12 mo to work Alpha-1 blockers are 1st line. Use 5-alpha reductase inhibitors if alpha-blockers are not tolerated (hypotension) or refractory (need a 2nd med).

Answer 680

Hemochromatosis (Problem with HFE iron-sensing receptor on hepatocytes-> lack of hepcidin release/ inhibition on ferroportin channel, so you get excess reabsorption of iron from enterocytes) - excess iron deposits in organs like the liver (elevated liver enzymes) and skin (dark pigmentation) - notice that fasting glucose is high (>110)= “bronze diabetes” *can progress to cirrhosis and increases risk for hepatocellular carcinoma (HCC)

Answer 681

About 8.5-10

Answer 682

Osteomalacia -softening of the bones due to Vitamin D deficiency (2/2 celiac malabsorption of fat-soluble vitamins A, D, E, K in this patient) (**you can also get osteomalacia from inadequate calcium/ phosphorus in the diet) *normally Vit D increases calcium and P in the blood. If deficient-> dec calcium and/ or P-> impaired bone mineralization

Answer 683

Putaminal hemorrhage (on left side of brain) - The basal ganglia (putamen) is a common site of brain hemorrhage due to HTN (involves the same small vessels responsible for lucunar stroke). The internal capsule, which is right next to the putamen, is almost always involved-> controlateral hemiparesis (loss of movement), contralateral sensory loss, and conjugate gaze deviation toward the side of the lesion. * severe headache + worsening neuro deficits are more in line with hemorrhagic stroke (vs. ischemic stroke)

Answer 684

Bicuspid aortic valve -younger guy with aortic stenosis (systolic murmur at aortic area) (<70 so senile calcifications are not likely to be the cause) *S4 is due to hypertrophy of the LV-> left atrial kick—the ventricle has to thicken to push blood through the stenotic aortic valve

Answer 685

1. Senile calcifications (>70) 2. Bicuspid aortic valve (<70) 3. Rheumatic heart dz

Answer 686

Give activated charcoal and order acetaminophen levels * charcoal can be given (to absorb Tylenol in the setting of acute toxicity) if Tylenol was ingested <4 hrs ago * patients can be asymptomatic during the first 24 hrs, then develop severe liver injury

Answer 687

First give activated charcoal (to absorb the Tylenol in the setting of acute toxicity) if ingestion was <4 hrs ago + order an acetaminophen level Next, use the Rumack-Matthew nomogram on MDCalc to calculate the likelihood of hepatotoxic effects based on plasma acetaminophen level and hrs since ingestion...this is to guide you on whether or not to give N-acetylcysteine If not a dangerous level, repeat acetaminophen level 2 hrs later. If dangerous acetaminophen level, give N-acetylcysteine now (restores hepatic glutathione stores) **note that patients can be asymptomatic for 24 hrs, then suffer severe liver injury

Answer 688

Oral doxycycline *In early Syphilis, try alternate treatment with Doxy (or similar agents) before resorting to Penicillin desensitization

Answer 689

Aortic aneurysm | Remember, it is a vasculitis meaning there is inflammation affecting large branches off the aorta

Answer 690

Hypercalcemia of malignancy Smoker-> squamous cell carcinoma of the lung-> PTHrP production (paraneoplastic syndrome)-> hypercalcemia (*actual PTH will be low by neg feedback) * *other causes of PTH-independent hypercalcemia: - other malignancy (squamous cell cancer of head/ neck, renal, bladder, breast, ovarian CA) - vit D toxicity or milk-alkali syndrome - granulomatous dz (sarcoidosis) - drug-induced (thiazides) - thyrotoxicosis - vit A toxicity - immobilization

Answer 691

Interstitial lung dz (ILD) 2/2 systemic sclerosis (*remember scleroderma is a disease of collagen deposition and fibrosis. ILD is a group of diseases characterized by fibrosis/ scarring of the lungs.)

Answer 692

Vasovagal (neurocardiogenic) - often involves a prodrome before passing out (dizziness, nausea, diaphoresis, vision changes, abdominal pain, generalized feeling of warmth) - can be triggered by prolonged standing (or emotional distress/ pain)-> excessive vagal tone (drop in HR, BP)

Answer 693

Pneumonia (parapneumonic effusion) -fever, SOB, R middle lobe infiltrate, R pleural effusion *pleural effusions occur in 40% of PNA patients, but usually resolve with antibiotics (**if bacteria cross into pleural space, a complicated pleural effusion or empyema w/ pus can develop requiring drainage w/ a chest tube in addition to Abx)

Answer 694

Swelling of breast tissue in males (“man boobs”)

Answer 695

Liver cirrhosis - alcohol - decreased libido, small testes, and gynecomastia (due to increased estrogen, since liver isn’t working well to break it down) - decreased TOTAL T4, T3 (liver isn’t working to make thyroid binding hormones as it normally does, so total TH goes down but free TH and TSH are unchanged)

Answer 696

At age 40 Rule is start at age 50 and do colonoscopy every 10 yrs (or sigmoidoscopy every 5 yrs or fecal occult blood testing every year). Unless there’s a family history...then start colonoscopies 10 years prior to when family member got colon cancer.

Answer 697

- neutrophils: around 55-60% - eosinophils: 1-3% - lymphocytes: 25-33% - monocytes: 3-7%

Answer 698

Drug-induced lung injury This is nitrofurantoin-induced pulmonary injury. A side effect of the drug is hypersensitivity pneumonitis-> cough, SOB, crackles, bilateral opacities, eosinophilia. *treat by stopping the drug—should improve in 1-2 days

Answer 699

Alcoholic hepatitis -AST, ALT, GGT, and Ferritin all HIGH * alcoholic with anorexia, jaundice, tender hepatomegaly * expect AST <500, ALT <300, AST:ALT ratio >2 * GGT is in liver cells and ferritin is an acute phase protein (inflammation), so both would likely be high in hepatitis

Answer 700

Transverse myelitis (Segmental inflammation of the spinal cord) * This is a rare condition that affects tracts across the horizontal aspect of the spinal cord at a given level. Cause is unknown but can occur after viral infections. (StepUp2Med pg 229) - Treat w/ high-dose IV steroids (often w/ plasmapheresis) *Less likely to be cauda equina syndorme. Why? This presents with severe back pain and sensory loss of the saddle area (thighs, buttocks). This patient has sensory loss below the umbilicus (T10).

Answer 701

Tetanus - can’t open mouth completely= trismus/ lockjaw - painful muscle spasms (Clostridium tetani enters puncture wound-> toxin travels retrograde from PNS-> CNS and blocks release of the inhibitors neurotransmitters GABA-> over-contraction of muscles) * almost always occurs in those with poor access to health care (not vaccinated) * treat with debridement of infected wound, antibiotics, tetanus Ig, and tetanus toxoid

Answer 702

Give normal saline (To promote urinary excretion of bicarb) *She has bulimia. Fine hair, dental erosions (from vomiting), and enlarged cheeks (parotid gland hypertrophy) are findings. Vomiting-> loss of HCl, K+ -> metabolic alkalosis and hypokalemia. *Urinary chloride is helpful is distinguishing between saline-sensitive vs. saline-resistant met alkalosis (StepUp2Med pg 323). Saline-sensitive-> low urinary Cl- (<20) Saline-resistant-> high urinary Cl- -Volume down-> activates RAAS-> aldosterone relaxes-> Na+ reabsorption and Na+ brings Cl- with it-> more Cl- retention, so decreased urinary Cl- So, low urinary Cl- means the patient is salt sensitive/ volume responsive (giving fluids will help!)

Answer 703

Urinary chloride is helpful is distinguishing between saline-sensitive (giving fluids will help) vs. saline-resistant met alkalosis (StepUp2Med pg 323). Saline-sensitive-> low urinary Cl- (<20) Saline-resistant-> high urinary Cl- -Volume down-> activates RAAS-> aldosterone relaxes-> Na+ reabsorption and Na+ brings Cl- with it-> more Cl- retention, so decreased urinary Cl- So, low urinary Cl- means the patient is salt sensitive/ volume responsive (giving fluids will help!)

Answer 704

Drug-induced lupus (from hydralazine use) *Hydralazine + nitrates can be used in place of an ACEi for treatment of HF in ACEi intolerant patients... But unfortunately, hydralazine can cause drug-induced SLE. *Treat by stopping the hydralazine and give NSAIDs for SLE-like symptoms.

Answer 705

Overnight low-dose dexamethasone suppression test OR late-night salivary cortisol assay OR 24-hr urine free cortisol measure - This sounds like Cushing’s syndrome (excess cortisol-> central obesity, proximal muscle weakness, glucose intolerance, depression/ anxiety) - FIRST step is to figure out if it actually is Cushing’s syndrome (THEN you’d measure ACTH to find out if it’s ACTH-dependent or independent)

Answer 706

Single dose of Tdap vaccine * This is what we do: - KIDS: primary 3-dose vaccine series at 2, 4, and 6 months old (add’l doses recommended at 15-18 mo and 4-6 years) - ADULTS: single Tdap (tetanus-diphtheria-acellular pertussis) + booster for tetanus/ diphtheria (Td) every 10 yrs *Patients with puncture wounds who haven’t gotten a booster within 5 yrs, get vaccinated. Plus, we give tetanus Ig if the patient never got the 3-dose tetanus vaccines or if their wound is large and dirty.

Answer 707

Adverse effect of medication | -Aspirin and beta-blockers can trigger bronchoconstriction in asthma patients!

Answer 708

``` Hepatic hydrothorax (Right-sided pleural effusion in a cirrhosis patient due to ascites fluid passage through a diaphragmatic defect) ``` * rule out all other cases of pleural effusion before making this diagnosis in a cirrhosis patient * treat with salt restriction and diuretics (to get off fluid) * therapeutic thoracentesis may be done if symptoms are bad enough, but avoid chest tube placement (can result in large-volume protein, fluid, and electrolyte losses)

Answer 709

Less than or equal to 7%

Answer 710

Urine albumin/ Cr ratio <30 is normal If >30, this means micro-albuminuria is present. Start on ACE inhibitor to prevent diabetic nephropathy.

Answer 711

Give IV Potassium - This is Hyperosmolar Hyperglycemic State (HHS) (similar to DKA, but occurs in type 2 diabetics and the little insulin present prevents ketosis and metabolic acidosis) - These patients have a total body K+ deficit + giving insulin stimulates the Na/K pump and shifts K+ into cells-> hypokalemia, so have to replete K+. * In both HHS and DKA, monitor K+ closely (replete IV K+ when drops below 5.3)

Answer 712

Aging-> Impaired baroreceptors sensitivity (autonomic failure)

Answer 713

Deceased urinary sodium -hypovolemia-> activation of RAAS-> more Na+ is reabsorbed/ pushed into blood-> less sodium is peed out

Answer 714

Propranolol (beta-blocker) *High T4, low TSH seems like hyperthyroidism. But, anti-TPO antibodies is seen in Hashimoto’s thyroiditis= hypothyroidism! Remember, Hashimoto’s can start off with high TH due to lysis of thyroid cells that already produced TH.

Answer 715

Angiodysplasia - most common vascular abnormality of the GI tract due to tortuous dilation of vessels (usually in the R colon)-> hematochezia - presents as episodes of painless GI bleeding in an old person >60 * systolic murmur in R 2nd intercostal space= aortic stenosis (common in old people due to senile calcifications of the valve) * Angiodysplasia is more commonly seen in patients with aortic stenosis, von Willebrand dz, and renal dz

Answer 716

Give Methotrexate For treatment of RA (will also improve the anemia of chronic dz) *low iron, low TIBC, high ferritin in anemia of chronic dz bc iron is trapped in storage sites (hepcidin, an acute-phase protein, blocks the ferroportin channel that reabsorbs/ pushes iron into the blood)

Answer 717

Get a Rheumatoid factor assay * tapping on flexor surface of wrist-> pain is Tinnel sign - This is Carpal Tunnel syndrome (compression of medial nerve) - BUT, she also has joint stiffness in the morning, suspicious for RA and RA can cause swelling in the wrist-> compression of the median nerve Initial evaluation of RA should include all the following: inflammatory markers (ESR, CRP), serologic studies (Rhuamatoid factor, cyclic citrullinated peptide antibodies), and x-rays of symptomatic joints

Answer 718

Central DI Desmopressin (synthetic ADH) ``` Water deprivation-> would expect urine to concentrate more (holds back more water in response to the dehydration). It doesn’t really change here, so we’ve ruled out psychogenic polydipsia and we know it’s DI. Give vasopressin (ADH)-> urine osm goes up, meaning urine gets more concentrated as it should in response to dehydration. So we know the problem was lack of ADH= central DI. ``` *DI (central and nephrogenic) cause hypernatremia (lack of ADH retaining water-> higher [Na+])

Answer 719

Acute angle-closure glaucoma - headache, eye pain, decreased visual acuity from narrowing of the anterior angle chamber-> decreased aqueous humor outflow * anticholinergic medication use (Tolterodine) is a risk factor

Answer 720

Hypomagnesemia *remember low Mg-> low Ca, P, K

Answer 721

Plasma renin and aldosterone concentration | Hyperaldosteronism would cause high Na+, low K+ and this is the screening test you do

Answer 722

Bell palsy Prednisone (steroid) -a peripheral neuropathy involving CN 7 (the facial nerve) * stroke (UMN lesion)-> spares the forehead bc the upper face receives dual innervation (can’t smile on affected side, but can raise eyebrows *FA pg 520) * Bell palsy (LMN lesion)-> involves the forehead (can’t smile or raise eyebrows on affected side) like in this patient

Answer 723

Esophageal (peptic) stricture (Abnormal narrowing of esophageal lumen) * chronic GERD predisposes to Barrett’s esophagus and esophageal strictures (other causes of strictures include radiation, systemic sclerosis, and caustic ingestions) * esophageal stricture-> dysphagia to solids and the stricture can actually block acid reflex, improving heartburn symptoms * must do endoscopy w/ biopsy to r/o adenocarcinoma * if no malignancy, you do a dilation to treat

Answer 724

Illness anxiety disorder (vs. somatic symptom disorder—where you actually have a symptom, but just think it’s something more serious than it is like tummy ache= must have stomach cancer)

Answer 725

Methimazole- 1st trimester teratogen, cholestasis PTU- hepatic failure, ANCA-associated vasculitis BOTH- agranulocytosis (*if patient develops sore throat and fever, discontinue the drug and check WBC count) **note: while both of these meds are treatments for hyperthyroidism, the preferred treatment is radioactive ablation

Answer 726

Cervical myelopathy= compression of the cervical spinal cord Cervical radiculopathy= compression of a cervical spinal nerve root/ “pinched nerve” Cervical spondylosis= osteoarthritis of the cervical spine (marked by osteophyte formation)

Answer 727

Recommend supportive/ symptomatic treatment This is influenza. Patients with the flu often develop systemic (fever, myalgia, headache) and respiratory (rhinorrhea, sore throat, nonproductive cough) symptoms. *no tonsillar exudate, so unlikely to be strep pharyngitis

Answer 728

Systemic sclerosis | Esophageal dysmotility, fibrotic lung dz, arthralgias

Answer 729

Smooth muscle atrophy and fibrosis in the lower esophagus | Remember that systemic sclerosis is a disease of fibrosis

Answer 730

Increased blood vessels

Answer 731

Cushing’s syndrome - painless muscle weakness - bone loss - HTN - hirsutism *she needs further work-up to determine the cause: exogenous steroids, ACTH-producing pituitary adenoma (Cushing disease), ectopic ACTH production (small cell lung CA), or primary adrenal cancer

Answer 732

1. Pulses parvus (slow-rising) and tardus (and weak carotid pulse) - less blood gets through the aortic valve, so carotid pulse is slow and weak 2. Single and soft S2 - the stenotic aortic valve takes longer to close, so it doesn’t close faster than the pulm valve, but closes at a the same time. Soft bc the calcifications on the aortic valve makes its closure softer. 3. Mid to late systolic murmur (w/ max intensity at the 2nd right intercostal space radiating to the carotids) - aortic stenosis= problem opening the aortic valve during systole

Answer 733

Exertional syncope due to aortic stenosis (outflow obstruction)

Answer 734

Paget disease of the bone

Answer 735

1. Cephalexin (flex) aka Keflex | 2. Cafazolin (Fez hat)

Answer 736

1. Cefuroxime (furious) 2. Cefotetan (tea cup) 3. Cefoxitin (fox)

Answer 737

1. Ceftazidime (Taz) 2. Ceftriaxone (3 axes) aka Rocephin 3. Cefotaximine (3 axes)

Answer 738

Cefepime (prime)

Answer 739

Ceftaroline (Tara)

Answer 740

NO Give empiric antibiotics first

Answer 741

``` Focal neuro deficit Altered mental status Immunocompromised Lesion (previous CNS disease) Seizure ``` *also papilledema (a sign of increased ICP)

Answer 742

Cefepime + Vanco + Ampcillin *This is an immunocompromised patient with suspected bacterial meningitis. We need to cover for strep pneumo, Neisseria meningitidis, Listeria, and gram neg rods. Cefepime is a 4th gen cephalosporin with broad-spectrum coverage, esp covers gram negatives. Vanco will get cover cephalosporin-resistant pneumococci. Ampcillin will cover Listeria.

Answer 743

Transformation of ischemic stroke to hemorrhagic stroke Repeat CT brain (non-con so blood will show up) *transformation to hemorrhagic stroke is a complication of ischemic stroke, most often seen when the patient is treated with TPA or when the patients suffered a major large area stroke (this guy). With any change in mental status, get a repeat CT to evaluate bc urgent surgical decompression will likely be needed!

Answer 744

Means very lethargic/ “out of it”—a state where the patient is less interested in the environment, has slowed responses to stimulation, and tends to sleep more than usual w/ drowsiness during the day

Answer 745

Methotrexate (for rheumatoid arthritis) * periarticular osteopenia (swelling and weakening of bones around the joint) and bony erosions (chronic inflammation of the joint-> formation of pannus-> erodes the cartilage and bone) are signs of RA * anemia of chronic dz

Answer 746

Side effects of Methotrexate (Medication-induced inhibition of DNA synthesis) * Remember, Methotrexate blocks dihydrofolate reductase in the thymidine (DNA building block) pathway-> impaired DNA synthesis, esp in rapidly dividing cells-> oral ulcers, bone marrow suppression. Also can cause hepatotoxicity (Sketchy: meat chef w/ liver spot on apron). * It also suppresses the immune system, which is why it’s 1st line for RA.

Answer 747

Rheumatic heart disease * can cause mitral regurg-> mitral stenosis (and aortic stenosis) * he likely has mitral stenosis (hard to get blood into the LV)-> dilated LA-> a-fib and backing up of blood to lungs-> pulm congestion **pericarditis (effusion) can present with SOB, orthopnea, enlarged heart on CXR...but this guy didn’t have a recent infection suggestive of this. He is from Asia= red flag for Rheumatic heart dz.

Answer 748

Subdural hematoma -elderly patient with history of falls-> tearing of bridging veins due to trauma (*cerebral atrophy from aging can also stretch these veins)-> gradual onset (veins are low-pressure vessels) neuro symptoms (headache, tiredness, confusion, focal neuro deficits)

Answer 749

Viral esophagitis (due to HSV or CMV) *Candida esophagitis is most common in HIV patients, but viral esophagitis is more likely in her case due to: severe odynophagia (pain w/ swallowing) is main symptom, no dysphagia (difficulty swallowing), no thrush. Not eosinophilic esophagitis (despite her asthma)—this is uncommon and presents with difficulty swallowing + GERD symptoms. *Confirm diagnosis with upper GI endoscopy. **There are 3 major causes of esophagitis in HIV patients: 1. Candida—oral thrush, white plaques in esophagus, pseudohyphae on biopsy 2. HSV—orolabial lesions (cold sores above lip), vesicular or ulcerative lesions, multinucleated giant cells on biopsy 3. CMV—large linear ulcers in distal esophagus, intranuclear inclusions on biopsy

Answer 750

``` Vitreous hemorrhage (Bleeding into the vitreous humor of the eye) ``` * most common cause is diabetic retinopathy (damage to blood vessels at the back of the eye) * presents as sudden loss of vision and onset of floaters * fundus is hard to visualize on exam

Answer 751

Anaphylactic reaction - occurs seconds to minutes after transfusion due to massive histamine release - more common in IgA deficient patients (their anti-IgA antibodies react w/ donor blood IgA) - presents with hypoxia w/ wheezing (but severe bronchospasm can prevent air entry-> decreased lung sounds), angioedema, hypotension * stop the transfusion and give epi and respiratory support!

Answer 752

RF (rheumatoid factor) and anti-CCP

Answer 753

The joint at the upper neck between the first two cervical vertebrae *Rheumatoid arthritis can affect this joint, leading to spinal cord compression

Answer 754

Small peripheral joints—MCP (metacarpophalangeal) joints of the hands, PIP (proximal interphalangeal) joints of the hands, the wrists, MTP (metatarsophalangeal) joints of the toes—and the cervical spine (Atlantoaxial joint)

Answer 755

Vertebral osteomyelitis Get an MRI - Back pain + FOCAL spinal tenderness, plus or minus fever (*often misdiagnosed as degenerative spine dz) - most likely due to hematogenous spread of his recent UTI (Staph aureus is the most common cause of vertebral osteomyelitis, but gram negative bugs can cause it too) *MRI is the best test (X-ray can be falsely negative for the first 2-3 wks of infection)

Answer 756

Subarachnoid hemorrhage (SAH) - “worst headache of my life”/ thunderclap (max intensity reached in a couple minutes) due to rupture of berry aneurysm (may occur spontaneously or triggered by physical exertion/ rise in BP) - If CT is negative and suspicion is high, you do an LP expecting to see xanthochromia (yellow CSF from bilirubin)—elevated opening pressure, increased RBCs, and slightly elevated protein are consistent with SAH

Answer 757

1. Colorectal cancer 2. Endometrial cancer 3. Ovarian cancer * do genetic testing for patients with a strong family hx of colon cancer (>3 relatives, multiple generations) * once diagnosis is established, the patient needs to undergo regular colonoscopies and annual endometrial biopsies to screen. After age 40 (or earlier if childbearing is complete), a prophylactic hysterectomy and bilateral oophorectomy is recommended

Answer 758

An acute confusion also state (fluctuating level of consciousness), often associated with infection

Answer 759

Baroreceptor hypersensitivity (In elderly the baroreceptors can become overly sensitive) *when carotid sinus baroreceptors detect increased pressure (carotid massage or tie around neck)-> increases firing of afferent baroreceptors-> increases PNS response-> vasodilation (to lower BP) and decreased HR-> less blood flow to brain-> syncope (In response to high pressure, baroreceptors trigger a PNS response of vasodilation/ lower BP + slowed HR)

Answer 760

Vitamin D deficiency 2/2 malabsorption - steatorrhea (fatty stool) and bone pain - malabsorption problem-> lack of vitamin D (and A, K, E, the fat-soluble vitamins)-> low calcium (also low phosphate, high PTH)

Answer 761

Waldenstrom macroglobulinemia - plasma cell malignancy that results in excessive IgM production-> hyperviscosity (explains his vision problems, headache, and ringing of ears) * neuropathy (end-organ damage) and general infiltrative symptoms (hepatosplenomegaly, anemia, thrombocytopenia) can also occur

Answer 762

Legionella * penumonia + diarrhea + hypOnatremia * test with a urinary Legionella antigen

Answer 763

``` Acute bronchitis Supportive care (symptomatic treatment only) ``` * 90% of cases are viral—avoid antibiotics because they don’t provide much benefit (even in bronchitis due to Mycoplasma bacteria) * cough >5 days is characteristic of acute bronchitis * yellow sputum may occur due to epithelial sloughing and blood in sputum can occur due to inflammation and epithelial damage

Answer 764

``` Giant cell (temporal) arteritis High-dose systemic glucocorticoids (steroids) ``` - large vessel vasculitis in elderly that can present with flu-like symptoms (fever, fatigue, malaise, weight loss), headaches, jaw claudication, and vision changes/ loss (amaurosis fugax temporary loss-> permanent loss) * tenderness on palpation of lateral scalp was a key (temporal area) + she is old with malaise and headaches, now visual changes/ loss

Answer 765

Lacunar stroke Chronic HTN-> Lenticulostriate arteries off the MCA stroked out-> posterior limb of the internal capsule infarcted-> “pure motor stroke” **can cause controlateral motor and sensory loss (but can be just a “pure motor stroke” or “pure sensory stroke” if only part is affected)

Answer 766

Parvovirus B19 (virus arthritis)

Answer 767

Immune thrombocytopenia *normal platelet count= 140,000-500,000

Answer 768

Elderly patients and those with underlying dementia or past stroke (likely due to reduced cognitive reserves) *you can help their recovery by treating underlying cause and infection, avoiding unnecessary medication, encouraging regular activity during the day, and minimizing disturbance during the night

Answer 769

Secretory diarrhea * secretory diarrhea (toxins, hormones, etc.)-> low stool osmotic gap - You get large volume diarrhea that continues during the night! - As in this patient, can occur after bowel resection of cholecystectomy) *osmotic diarrhea (malabsorption problem)-> high stool osmotic gap

Answer 770

Primary biliary cholangitis -autoimmune destruction of intrahepatic bile ducts

Answer 771

Cytomegalovirus (CMV) * since she is immunosuppressed due to meds for organ transplant, she is on prophylaxis for PCP (Bactrim) and CMV (Valganciclovir). She had to go off these meds, so she has increased risk for both at this time. * pulm symptoms (SOB, dry cough), GI symptoms (abdominal pain, diarrhea, hematochezia)

Answer 772

1. On a nitrate 2. On an alpha-blocker *Sildenafil is a PDE-5 inhibitor. Taking with nitrates (venodilate) or alpha-blockers (block constriction, so dilates) can cause severe hypotension!

Answer 773

1. Serum anion gap (the gap normalizes) | 2. Serum beta-hydroxybutyrate levels (disappear)

Answer 774

Thoracic spinal cord ischemia - this is a rare (2-3%) complication of aortic dissection due to interruption of blood flow (to intercostal and/or lumbar arteries) that feeds the anterior spinal cord (doesn’t affect dorsal/ posterior cord—this has a different blood supply) * the aorta gives off branches that supply the spinal cord * thoracic region makes sense-> affects lower extremities -neuro findings (bilateral weakness in legs, loss of motor, loss of pain, intact vibration tell you there’s an anterior cord problem...everything but the DC-ML tract in the dorsal/ posterior column is affected)

Answer 775

Ventricular tachycardia * wide-complex tachy= ventricular problem (like v tach or torsades) * high-amplitude JVP (Cannon A waves) are due to RA contraction against a closed tricuspid valve (there’s no valve between the superior vena cava and the RA, so JVP tells you about the right heart. There’s high pressure there bc the atria and ventricles are both contracting but not coordinated) * you get atrioventricular dissociation= atria and ventricles not coordinating (happens in V tach and complete AV block)

Answer 776

Hemobilia (bloody bile/ bleeding into the biliary tract) - complication of liver biopsy (sticking a needle into the liver) - RUQ pain, upper GI bleed (hematemesis, melena), jaundice and anemia from bile duct obstruction

Answer 777

Supravalvular aortic stenosis * this is the 2nd most common type of AS (congenital LV outflow obstruction due to narrowing of the ascending aorta—the aortic valve is fine, it’s the aorta above the valve that’s stenotic) * chest pain during exercise due to increased myocardial oxygen demand

Answer 778

Osteoarthritis

Answer 779

Osteoarthritis of the neck (cervical spondylosis)-> osteophytes (bony outgrowths) that grow around/ compress the nerve roots (cervical radiculopathy)

Answer 780

AAA CT abdomen - old smoker (has risk factors), hypertensive - back pain from expanding abdominal aortic aneurysm (not ruptured bc his BP is stable) - pre-vertebral calcifications means the structure in front of the vertebrae (the aorta) is calcified (the atherosclerosis is so extensive it shows up on x-ray) *CT is the best test for diagnosis of abdominal aortic aneurysm

Answer 781

Advise lifestyle modification and give lipase supplementation - this is chronic pancreatitis * In acute pancreatitis, you get inflammation causing premature activation of pancreatic enzyme and auto-digestion. Lipase is elevated from pancreatic cells. * In chronic pancreatitis the pancreas is scarred/ non-functional tissue, so not a lot of lipase to be released (usually not elevated). The pancreas isn’t working well to make pancreatic enzymes so you need to give supplementation. Plus, giving lipase will block CCK to stop pancreatic stimulation of enzymes (tells the pancreas it doesn’t have to work anymore) to relieve pain from pancreatic hyperstimuation.

Answer 782

1. PaO2 <55 or SaO2 <88% 2. If right HF or hematocrit >55%: PaO2 <59 or SaO2 <89%

Answer 783

Long-term supplemental oxygen at home (when indicated)

Answer 784

Calcium chelation by citrate in the transfused blood *patients who get more than 1 blood volume of blood transfusions or packed RBCs over 24 hrs may develop elevated plasma levels of citrate (a substance added to stored blood)-> binds up calcium and magnesium-> paresthesias

Answer 785

Anterior uveitis - painful, red eye associated w/ photophobia, tearing, and diminished visual acuity - exam findings: hypopyon (layering of WBCs in the anterior chamber) + ciliary flush (hyperemia/ excess blood vessels at the junction of the sclera and cornea) - he has Crohn’s (uveitis can be associated with IBD)

Answer 786

Inflammatory diseases (certain infections, sarcoidosis, spondyloarthritis, IBD)

Answer 787

Paget disease of the bone - osteoClast dysfunction: 1) osteoC’s go crazy and break down bone w/o the regulation of osteoB’s 2) bones weaken and osteoB’s realize they need to start laying down more bone so they rush to compensate 3) osteoC’s burn out and osteoB’s are still rushing to lay down as much bone as possible, but do a bad job of it -bone pain, headaches (enlarging cranial bones-> inc hat size), unilateral hearing loss (entrapment of CN8), and femoral bowing are typical symptoms

Answer 788

Hepatitis A vaccine (*note: this became part of the childhood vaccine series in 2006, as a 42 y.o. it is unlikely he got this vaccine) - recommended in travelers to countries where hep A is prevalent (contaminated water, oysters), for men who have sex with men, and for adults with chronic liver dz * positive anti-HBS means he’s already immune to hep B (vaccinated), so a vaccine for hep B is not needed

Answer 789

Strep pneumo! Don’t be fooled...the most common is always strep penumo. Yes, AIDS patients are at risk for additional bugs like PCP, but strep pneumo is still more common.

Answer 790

Microvascular complications (nephropathy, retinopathy) *studies have shown tight glucose control in diabetics reduces microvascular complications, but unfortunately doesn’t reduce macrovascular complications or mortality (*in fact, getting the glucose too low-> hypoglycemia can increase mortality so we aim for an A1c goal of 7% in diabetics)

Answer 791

7% | *too tight of regulation, like A1c of 6-6.5% can actually increase mortality risk due to hypoglycemia

Answer 792

Renal U/S (looking for hydronephrosis) - severe BPH compressing the urethra-> urine backs up to kidneys-> bilateral hydronephrosis-> AKI * serum Cr test is not required in routine evaluation of uncomplicated BPH, but it is recommended for some patients with more significant symptoms or add’l risk factors (HTN, DM, CKD)

Answer 793

Lichen planus *although this skin condition is usually seen on the extremities and trunk, lesions may also appear on the genitals or oral mucosa

Answer 794

Mixed connective tissue disease | Autoimmune disorder with variable features of: SLE, systemic sclerosis, and polymyositis

Answer 795

1. SLE 2. Systemic sclerosis 3. Polymyositis

Answer 796

Pseudogout (Acute calcium pyrophosphage crystal arthritis) * associated with meniscal calcification (calcifications in the cartilage are released into the joint space) * often occurs in the setting of surgery or medical illness

Answer 797

Actinic keratosis

Answer 798

Start him on antiplatelet (aspirin) and statin therapy *carotid endarterectomy (CEA) is recommended for SYMPTOMATIC patients with high-grade carotid stenosis (>70% stenosis) (may consider in asymptomatic patients with >80% stenosis) (**also note CEA is preferred over carotid artery stenting)

Answer 799

In symptomatic patients with carotid artery stenosis >70% (May also do it in asymptomatic patients with stenosis >80%) *if stenosis is less than this, medical management with aspirin + statin is appropriate

Answer 800

Thiazides | They pull calcium out of the pee, into the blood

Answer 801

V1 branch of CN5 (abducens nerve)

Answer 802

Subtype of communicating hydrocephalus, meaning decreased CSF absorption (vs. noncommunicating, which is due to structural blockage of CSF) -dec absorption of CSF into arachnoid granulations (outpouchings) episodically-> inc CSF-> dilated ventricles-> stretching of corona radiata (nerve fibers running along edge of ventricles)-> the disruption of motor neurons causes a triad of urinary incontinence, gait instability, and cognitive dysfunction (“wet, wobbly, and wacky”_

Answer 803

Osteopenia (weakened bones), osteoporosis, and bone fractures *inflammatory cytokines promote bone loss *osteoporosis risk is twice as high, so encourage exercise, vitamin D, calcium, avoid glucocorticoids if possible, and bisphosphonate therapy (**Vit D bc it promotes absorption of calcium + P, which are needed for bone mineralization)

Answer 804

- higher glucose levels (often >1,000 vs 300-500 in DKA) - normal anion gap and pH - absent ketosis * some baseline insulin (type 2 diabetes) prevents ketoacid formation and anion gap

Answer 805

Normal saline - This guy has hyperosmolar hyperglycemic state (HHS) - Although you will give insulin (and monitor K+), aggressive IV fluids is the best immediate step! (Replenishes extracellular volume, lowers plasma osmolality, and increases tissue perfusion and responsiveness to insulin). Use normal saline initially regardless of Na+ levels. **remember that the high glucose spillage into urine (water follows)-> severe dehydration. High BUN is due to severe dehydration (prerenal AKI). High K+ bc no response to insulin means K+ isn’t being pushed into cells, so hangs out in the blood.

Answer 806

Onychomycosis (a tinea fungi/ dermatophyte of the toenails)

Answer 807

Sodium minus chloride minus bicarb | Na- Cl- HCO3

Answer 808

Stress fracture - often occurs in athletes (or non-athletes who suddenly increase their activity) - presents as pain in the forefoot over the metatarsal bones *more common in female runners with the “female athlete triad”: (1) amenorrhea (no periods)/ oligomenorrhea (infrequent periods), (2) decreased calorie intake, (3) osteoporosis (This lady has a BMI of 15 and period 8 wks ago, so this is likely)

Answer 809

ALS (amyotrophic lateral sclerosis) -neurodegenerative disorder-> both UMN and LMN signs (UMN signs- spasticity and exaggerated reflexes, LMN signs- weakness, atrophy, and fasciculations (movements of face and tongue in him))

Answer 810

Immersion in ice water -This is exertional heat stroke * Problem is the body is too hot to cool itself by sweating alone (cooling mechanism is overwhelmed). Blood gets shunted to the periphery so that the body can sweat (heat dissipation by evaporation), resulting in a distributive shock (organs now deprived of blood). * Body temp >104 and CNS dysfunction (confusion, irritability, seizures)...may also get hypotension, tachycardia, hyperventilation, diarrhea, cramps, ataxia * Mortality is 20%! Cool the patient rapidly!

Answer 811

Both will involve body temp >104 Heat stroke additionally involves CNS dysfunction (confusion, irritability, seizures)

Answer 812

Exertional—> athletes (due to overexertion in the heat), rapid immersion in ice water Classic—> old people with comorbidities (due to limited ability to cope with excessive heat), evaporative cooling (fans)

Answer 813

De Quervain (“De Quervain causes pain”- you get pain in the thyroid, thought to be due to a post-viral inflammatory process after a URI. There is a self-limited thyrotoxic phase followed by hyperthyroidism and then recovery.)

Answer 814

Intensive BP control (with ACE inhibitor or ARB) **NOT tighter glycemic control bc he’s already around our goal for diabetics of 7% (this reduces microvascular complications like nephropathy and retinopathy). If we get A1c even lower, we’d be putting him at risk for hypoglycemia and earlier mortality.

Answer 815

Get an MRI of the brain/ spine - This is likely MS (multiple sclerosis) * autoimmune inflammatory demyelinating disorder of the CNS (esp the white mater where there’s axons w/ myelin sheaths) that presents with neuro deficits separated by time and space (sensory loss/ paresthesias, dizziness, optic neuritis, uhthoff phenomenon where symptoms worsen during heat exposure *like moving to Arizona!) * MRI (T2 weighted) will show white mater lesions

Answer 816

MS symptoms worsen during exposure to hot temperatures/ heat

Answer 817

Reduce alcohol intake! *Statins are 1st line for mild hypertriglyceridemia (150-500, where normal TAGS= 35-160) bc they reduce cardiovascular events. In addition, do lifestyle modification (heavy alcohol consumption increases TAGs). **Although fibrates are the best anti-lipid meds for lowering TAGs, we rarely use them bc they don’t have proof of providing cardiovascular benefit. We only use them in severe hypertriglyceridemia (500-1000).

Answer 818

Two drinks/ day for men One drink/ day for women

Answer 819

Order a IGF-1 (insulin-like growth factor 1) level (*ordering Growth Hormone directly isn’t as accurate bc these levels fluctuate often) - This is acromegaly (too much GH) * work-up: IGF-1 level-> oral glucose suppression-> MRI brain looking for pituitary mass (somatotroph adenoma) **GH increases insulin, so acromegaly is associated with insulin resistance, which may also induce HTN**

Answer 820

Africa (sub-Saharan) and South American countries

Answer 821

Hep A | Give to those traveling to developing countries. It is the most preventable disease among travelers.

Answer 822

Infective endocarditis * clinical features: - fever (bacteremia) - other non-specific/ systemic symptoms (including arthralgia) - murmur (vegetations disrupt blood flow across valve) and cardiac effects (including SOB) - septic emboli of bacteria pieces (vegetations get shot off into circulation)—> Janeway lesions (palms), Osler nodes (fingers, painful), Splinter hemorrhages (nail beds), Roth spots (eye) (*septic emboli can reach the brain, spleen, LUNG) - anemia of chronic disease (from inflammation) - immune response-> elevated ESR, positive RF (possibly due to antibody production), IC-mediated GN (hematuria)

Answer 823

Alzheimer’s disease -progressive dementia- first you loose memory of recent events and have language difficulty (followed by impaired judgment and personality change)

Answer 824

Long-standing HTN (S3: blood into an already overfilled ventricle/ dilated CM/ systolic dysfunction S4: blood into a stiff ventricle/ hypertrophic CM/ diastolic dysfunction)

Answer 825

Orthostatic hypotension (Drop in systolic >20 when moving from lying to standing) * he’s an older person experiencing syncope upon standing after a period of bed rest * usually patient will feel lightheaded or presyncope prodrome before passing out

Answer 826

PCP (“angel dust”)

Answer 827

Acute dystonia Benztropine (anti-muscarinic, improves tremor/ rigidity) OR diphenhydramine (anti-histamine) * He was given Haloperidol (1st gen antipsychotic) and now has a stiff neck + forced upward gaze deviation. Remember the extrapyramidal side effects: “ADAPT” - Acute Dystonia (sudden muscle stiffness) - Anesthesia (restlessness) - Parkinsonism (cogwheel rigidity, slow movement) - Tardive dyskinesia (involuntary jerky, repetitive movements like striking out the tongue) **see FA pg 561 for extrapyramidal side effect treatments

Answer 828

Noninvasive positive pressure ventilation (BiPAP or CPAP, *though it seems BiPAP is preferred in acute respiratory distress) **why the respiratory acidosis (low pH, high CO2)? It is a obstructive disease/ problem breathing out-> air trapping and CO2 retention

Answer 829

Ventilatory support delivered by face mask rather than endotracheal tube - can be delivered continuous (CPAP) or bi-level (BiPAP) * *only resort to invasive intubation and mechanical ventilation when this fails** *CPAP= continuous positive airway pressure □ Administers equal inspiratory & expiratory pressure support □ Used in sleep apnea when people just need help propping their airway open at night *BiPAP= bi-level positive airway pressure □ Administers inspiratory pressure > expiratory pressure □ Often used in acute respiratory distress patients

Answer 830

Porphyria Cutanea Tarda * due to defective uroporphyrinogen decarboxylase enzyme-> impaired heme synthesis * associated with hep C * can present with tea-colored urine and cutaneous findings (photosensitivity, hyperpigmentation, painless blistering)

Answer 831

Autosomal dominant polycystic kidney disease (ADPKD) Abdominal ultrasound (looking for enlarged kidneys with multiple cysts) * father’s sudden death is likely due to a cerebral aneurysm in the setting of ADPKD * HTN is an early disease manifestation (due to excess renin release) * renal cysts are often palpable

Answer 832

Hypokalemia - symptoms: weakness, muscle cramps, decreased deep tendon reflexes, flattening of T waves (U waves if severe) w/ PVC’s... - when severe: paralysis, rhabdo, arrhythmias

Answer 833

Colonoscopy *there is a strong association between strep bovis (aka strep gallolyticus) and colon cancer

Answer 834

Strep bovis

Answer 835

TNM staging | Stage 4 is the worst

Answer 836

Babesiosis Blood smear - tick-borne illness (Ixodes tick from the northeastern US) *same tick that causes Borrelia/ Lyme dz - the splenectomy (immunocompromised) makes this patient at higher risk - causes hemolytic anemia (explains jaundice, dark urine, indirect hyperbilirubinemia, reticulocytosis, high liver enzymes and LDH) - “Maltese crosses” on blood smear is diagnostic

Answer 837

Atovaquone + Azithromycin

Answer 838

Polymyositis (inflammatory disorder of skeletal muscle) Prednisone (steroids) (*most patients also get a glucocorticoid-sparing agent like Methotrexate or Azathioprine to minimize adverse effects) - proximal muscle weakness (otherwise normal neuro exam), elevated CK * involvement of upper esophageal muscles can cause dysphagia (difficulty swallowing) *to diagnose: elevated muscle enzymes (CK), autoantibodies (ANA, anti-Jo-1), biopsy (endomysial infiltrate, patchy necrosis)

Answer 839

Fibromyalgia Exercise program with aerobic conditioning (*although patients will complain exercise makes it worse short-term, explain it will improve symptoms in the long-term) * you can use a “widespread pain index” and “symptom severity scale” for diagnosis—more accurate than trigger points * treatment with meds (SNRI Dulexetine, TCAs) is reserved for patients who fail initial measures

Answer 840

1. Initially, try exercise (worsens short-term, but improves long-term symptoms!) 2. If still struggling, try meds (SNRI Duloexetine, TCAs)

Answer 841

EPO therapy She is in hypertensive crisis- this is an adverse effect of EPO treatment

Answer 842

The patient is severely depressed/ suicidal

Answer 843

Focal segmental glomerulosclerosis (FSGS) * nephrotic syndrome * more often seen in: Hispanics, African Americans, HIV, heroin, sickle cell

Answer 844

Give IV Acyclovir This is Herpes (HSV) encephalitis (inflammation of the brain due to infection *herpes viruses are most likely to cause encephalitis in immunoCOMPETENT adults) - confusion, seizures, exaggerated reflexes (can also see other neuro abnormalities) - absence of neck stiffness (not meningitis) - CSF: high protein, lymphocytes, no bacteria= viral * PCR of CSF showing viral DNA confirms diagnosis

Answer 845

Herpes viruses (HSV, EBV)

Answer 846

Screening: LP with CSF showing normal-high protein, lymphocyte predominance, no bacteria (viral) Confirmatory: PCR of the CSF showing viral DNA

Answer 847

Echocardiogram - this is acute limb ischemia - although it’s often due to thrombosis (plaque), it can be caused by embolism (thrown clot) - post-MI complication (especially in big heart attacks like the LAD) is LV aneurysm - LV aneurysm-> heart doesn’t contract well-> low ejection fraction-> stasis of remaining blood in there, which promotes clot formation-> clot gets thrown to periphery (can lead to stroke, or acute limb ischemia like in this patient)

Answer 848

Acute cholangitis - stone is lodged in the common bile duct and infected-> sepsis - Charcot triad: fever, jaundice, and RUQ pain - Reynold’s pentad: +shock (low BP), altered mental status * treat with supportive care, broad-spectrum antibiotics, and biliary drainage (preferably by ERCP)

Answer 849

Dilation of the intrahepatic and common bile ducts *remember, acute cholangitis is when a stone is lodged in the common bile duct, causing infection.

Answer 850

SUPER high (like >3,000)

Answer 851

Thickening of the gallbladder wall and pericholecystic fluid *remember, acute cholecystitis is when a stone is lodged in the cystic duct

Answer 852

1. Rate or rhythm control? | 2. Long-term anticoagulation needed to prevent stroke? (Use CHADS-VASC score)

Answer 853

1. Beta-blocker | 2. Non-dihydropyridine CCB (Verapamil or Diltiazem—the “non-dairy” ones that act on the heart)

Answer 854

Esophageal motility studies (manometry recordings) - episodes of dysphagia (difficulty swallowing), regurgitation, and/or chest pain brought on by stress should raise suspicious for an esophageal motility disorder like DIFFUSE ESOPHAGEAL SPASM - Nitrates (and CCBs) relax coronary vessels, but also smooth muscle cells of the esophagus, alleviating pain

Answer 855

Painful swallowing

Answer 856

Testosterone and DHEAS levels * most women with hirsutism have PCOS * BUT, rapid-onset (<1yr) hirsutism with virilization suggests very high androgen levels, possibly due to an androgen-secreting tumor of the ovaries or adrenal glands If high testosterone + DHEAS—> ovarian source If just high DHEAS—> adrenal source

Answer 857

Decompensated HF most likely 2/2 Viral myocarditis (from coxsackievirus, adenovirus, parvovirus B19, etc.) * would expect to see dilated ventricles and diffuse hypokinesis of the ventricle walls (not pumping well) on echo * treat supportively and with meds for HFrEF (diuretics, beta-blocker, ACEi)

Answer 858

dilated ventricles and diffuse hypokinesis of the ventricle walls (not pumping well) *dilated cardiomyopathy picture

Answer 859

Vascular air embolus from decompression sickness (“the bends”) -results from transfer of nitrogen gas from tissues into venous bloodstream when a diver ascends too rapidly from high pressure/ deep waters -these small air bubbles in the venous bloodstream can lodge into skin capillaries, causing mottled skin. Into pulmonary capillaries, causing respiratory distress and pulm edema. Into the RV outflow tract, causing obstructive shock. Can also pass into arterial circulation and travel to the brain, causing confusion and stroke or MI. * *from PATHOMA: scuba diving/ spearfishing-> pressure increases the lower you go-> that pressure forces nitrogen to dissolve in the blood (inc pressure= inc gas that gets dissolved int he body)-> when the diver rapidly ascends back up, nitrogen can precipitate out of the blood as little gas bubbles that lodge in various tissues - > joint and muscle pain (“the bends”) - > respiratory symptoms (“the chokes”)

Answer 860

Calculate SAAG (serum albumin ascites gradient)= serum albumin- ascites fluid albumin If >1.1–> cause of ascites is portal HTN (liver cirrhosis or cardiac ascites) If <1.1–> other cause (cancer, pancreatitis, nephrotic syndrome, TB, etc.)

Answer 861

1. Thrombocytopenia 2. Thrombosis (arterial or venous) 3. >50% drop in the platelet count from baseline Within 5-10 days after initiation of heparin treatment

Answer 862

Progressive multifocal leukoencephalopathy (PML) * caused by the JC virus * seen in AIDS patients with CD4 <200 * virus affects the CNS-> white mater demyelination * no specific treatment, but antiretroviral therapy prevents it (most patients with this end up with long-term neuro damage)

Answer 863

IV fluids (Normal saline) - to promote urinary calcium excretion * calcitonin (directly blocks ostoC’s-> less bone breakdown-> less calcium into blood) and bisphosphonates (ostoC apoptosis-> less bone breakdown-> less calcium into blood *takes 2-4 days to work) usually given also, but aggressive hydration is the first step in management

Answer 864

1. RA 2. Sarcoidosis 3. Hypothyroidism 4. Amyloidosis

Answer 865

1. ANA 2. Anti-Jo-1 (anti-histidyl-tRNA-synthase) 3. Antisignal recognition particle (anti-SRP) * worse prognosis 4. Anti-Mi-2 antibodies * better prognosis

Answer 866

Increased risk of malignancy | Lung, breast, ovary, GI, and myeloproliferative disorders

Answer 867

Massive PE * cancer (pro-thrombotic state) is a risk factor * acute presentation of SOB/ hypoxia, chest pain, tachycardia, clear lungs * may hear loud S2, have elevated JVP * massive PE-> syncope (PE is impairing ability to breathe, so there’s insufficient oxygen getting to the brain) and hemodynamic collapse (RV has to pump against extra pressure-> dilation and impaired pumping) **can be difficult to distinguish massive PE from RV MI (both cause RV dysfunction)—but, RV MI is less likely to cause SOB, tachycardia, syncope. More likely to cause bradycardia or arrhythmia

Answer 868

Poor sleep hygiene - caffeine (should avoid caffeine after lunch) and nicotine (stimulants) - takes evening nap - works late hours - eats late dinner *recommend for her to have a regular sleep schedule, quiet/ dark/ comfortable sleeping environment, avoid late afternoon naps, electronic devices before bedtime, nicotine/ caffeine, and heavy evening meals **although she is questioning her purpose and irritable, this is likely a consequence of sleep deprivation, not an underlying psych disorder

Answer 869

1. ACE inhibitors (Enalapril, Lisinopril, etc.) 2. Cardioselective beta-blockers (Metoprolol) 3. Aldosterone antagonists (Spironolactone)

Answer 870

Parvovirus B19 - self-limited viral arthritis (“slapped cheek” rash in kids, joint swelling and tenderness in adults) * can present similar to RA or SLE, but is acute and goes away (also more common than RA and SLE)

Answer 871

``` Viral conjunctivitis (most likely due to adenovirus) Cool, moist compresses/ symptomatic relief (can give antihistamine/ decongestant eyedrops) ``` - mild injection= redness (pink eye) - granular appearance of tarsal conjunctiva (lining of the eyelids when you pull them down look granular, secretory) - profuse watery discharge= viral (vs. purulent/ pus discharge in bacterial conjunctivitis)

Answer 872

Muddy brown casts (ATN) -pre-renal AKI (hypovolemic shock)-> intrinsic AKI (ATN is the most common) -BUN/Cr= 30/2= 15 (Remember in intrinsic: BUN/Cr is low <20:1, FeNa is high >2%, and urine osm is high >300 bc it is a kidney problem) (*vs. pre-renal where BUN/Cr is high >20:1 due to slow blood flow-> extra time for BUN to get reabsorbed at PCT) -muddy brown casts= necrosis of renal tubular epithelial cells (very sensitive for ATN)

Answer 873

ATN (acute tubular necrosis)

Answer 874

Glomerulonephritis

Answer 875

1. Acute Interstitial nephritis (type of intrinsic AKI from drug like NSAID, Penicillin, diuretic) 2. Pyelonephritis

Answer 876

Nephrotic syndrome

Answer 877

Chronic renal failure

Answer 878

Gabapentin - this is Distal Symmetric Polyneuropathy 2/2 long-standing HIV infection (thought to occur due to accumulation of HIV antigens on distal sensory nerve fibers-> inflammation and nerve damage) * r/o other causes of polyneuropathy: diabetic (normal glc), uremic (normal renal function), Vit B12 def (normal RBC count/ no anemia)

Answer 879

Sporotrcihosis (from sporothrix schenckii fungus in decaying plant matter/ soil) - causes skin papules-> ulceration along lymphatic chain - lymphadenopathy is rare (only with deeper spread) *vs. cat scratch disease where tender lymphadenopathy is a hallmark feature

Answer 880

1st degree: prolonged PR interval (>5 small boxes) 2nd degree: -Mobitz type I (Wenckebach): progressive lengthening of PR until QRS beat is dropped (“longer, longer, longer, drop- this is how you Wenckebach”) -Mobitz type II: random dropped QRS beats (not preceded by a change in length of PR) 3rd degree/ complete AV block: P and QRS’s not in sync *what is AV block? Remember the AV node works to delay the signal from the atria to the ventricles so the heart beats at an appropriate rate. 1st degree is when it’s delaying too much (prolonged PR). 2nd degree is when it’s partially blocked and the missed QRS is when it fails to relay the impulse. 3rd degree is when there’s no communication btwn the atria and ventricles.

Answer 881

Search for a tick on his body - most likely diagnosis is tick-borne paralysis (from neurotoxin release...the tick has to feed for 4-7 days to release this toxin so find the tick an remove it and the patient usually improves in an hour with full recovery after several days!!) - progressive ascending paralysis over hours to days - absent fever, no autonomic dysfunction (as in Guillain Barre), normal CSF exam

Answer 882

Atelectasis -most likely due to asthma exacerbation-> mucus plugging in the airways-> blocks air from entering and the air molecules diffuse into the bloodstream and create a vacuum that leads to alveolar collapse -decreased breath sounds (collapsed alveoli, so that part of the lung is not getting air) (Also dullness to percussion due to lack of air and decreased fremitus due to lack of air to create vibrations) -collapsed alveoli pull the trachea over to same side

Answer 883

Pyridoxine (Vitamin B6) *Remember that Vitamins B6 (pyridoxine), B9 (folate), and B12 (cobalamin) are involved in the homocysteine pathway...giving B6, B9, and/or B12 can restore homocysteine levels in homocystinuria

Answer 884

Chest x-ray - he is presenting with signs and symptoms of COPD (heavy smoker, clubbing, decreased breath sounds/ prolonged expiration since it’s hard to get air out, “sick” often probably due to URI’s/ COPD exacerbation * *convex nails (going outward like a lens)= digital clubbing (sign of poor oxygenation) -his presentation is suspicious for HYPERTROPHIC OSTEOARTHROPATHY (abnormal proliferation of skin and bone at distal extremities-> clubbing, arthralgia/ joint pain). This is a sign of ADENOCARCINOMA OF THE LUNG, so start with a CXR to assess for cancer.

Answer 885

Retinal detachment - separation of the layers of the retina (retina peels away from the underlying choroid layer) - myopia (nearsightedness where far objects are blurry) or trauma (like her recent cataract surgery) can cause breaks in the retina-> fluid seeps in and eventually pulls apart the retina layer - presents as photopsia (flashes of light in vision), floaters, dark “curtain coming down over eyes”

Answer 886

Cardiovascular disease *cardiovascular dz is the most common cause of death in patients with ESRD (50%). Due to risk factors they have (HTN, advanced age, etc.) and ESRD-related risks (anemia of chronic dz, oxidative stress related to dialysis)

Answer 887

Leuk esterase-> means there are WBCs in the urine Nitrites-> means there is gram (-) bacteria in the urine (most likely E. Coli) *convert urinary nitrates to nitrites

Answer 888

She had a concussion She can gradually increased activity over 1 week if she no longer has symptoms * recent head injury + vomiting + transient amnesia= concussion, even though she did not lose consciousness! Definition is a temporary neuro disturbance (includes disorientation, amnesia) resulting from a mild traumatic brain injury * further imaging usually not required, but advice to rest at least one day and gradually return to exercise (full return no sooner than 1 week) to reduce complication (chronic traumatic encephalopathy, second impact syndrome)

Answer 889

Renal vein thrombosis (RVT) - this is a complication of nephrotic syndrome - membranous nephropathy (nephrotic syndrome)-> RVT - proteinuria (>3.5 g/day), hypoalbuminemia (<3 g/dL), edema (decreased oncotic pressure), hypercholesterolemia (liver pushed cholesterol into “thinned out” blood), hypercoagulable state (due to loss of anticoagulant proteins) - men can get edema in the scrotum and the RVT causes blockage preventing the left testicle from draining blood

Answer 890

Vitamin B12 deficiency -suspect this in hard-core vegetarians/ vegans with anemia and neuro complications (loss of proprioception/ vibration, memory deficit, irritability) * he most likely has a combined folate (from veggies, risk from having a poor diet/ alcoholic) and B12 deficiency (from meat, risk from being a vegetarian many years) * replenishing the folate only will partially correct hematologic abnormalities, but will not help (may worsen) neuro issues! **if you give a vit B12 deficient patient folate, you pull their limited B12 stores to making more RBCs (not myelin)—this can worsen neuro problems!

Answer 891

Pancoast tumor

Answer 892

1. Elevated aminotransferases (high ALT, AST) 2. Signs of hepatic encephalopathy (confusion, somnolence, flapping tremor) 3. Synthetic liver dysfunction (INR >1.5) **acetaminophen (Tylenol) toxicity is the no. 1 cause of ALF

Answer 893

Chronic alcohol use accelerates Tylenol’s toxicity Why? Alcohol depletes glutathione levels (glutathione protects the liver from oxidative damage). Tylenol also does this by the NAPQI enzyme. So this combination can lead to hepatic necrosis and acute liver failure!

Answer 894

Priapism (persistent, painful erections) * atypical antidepressant (serotonin-modulating) * this happens in <1% of cases, but is a medical emergency (can lead to permanent tissue damage)

Answer 895

Skin biopsy (from edge of lesion)

Answer 896

Take potassium citrate *uric acid kidney stones are seen in low pH acidic urine, so we can prevent them through alkalization of the urine and a low-purine diet. Citrate helps to alkalize the urine.

Answer 897

Rectovaginal fistula (Connection between rectum and vagina) *seen in patients with ob/ pelvic trauma/ surgery or in patients with underlying Crohn’s disease (transmural inflammation of the GI tract)

Answer 898

Temporal lobe

Answer 899

GI cancer (likely colon cancer) that metastasized to the liver (Abdominal pain, microcytic anemia, positive fecal occult blood, hepatomegaly with hard liver edge) * liver= most common site for colon CA metastasis * pleural effusion likely due to malignancy (NOT hepatic hydrothorax—this would be right-sided) * get a CT abdomen

Answer 900

Treat with antihistamine - this is a type I hypersensitivity reaction (immediate onset, IgE mediated) * In patients with mono (EBV), amoxicillin can cause rash after 24 hrs. Mono is not really a concern here since her rash came on shortly after taking amoxicillin (not after a day) and she doesn’t have other mono-like symptoms (fever, fatigue, posterior cervical lymphadenopathy)

Answer 901

Bell palsy * upper face involvement distinguishes Bell palsy from UMN disorders (stroke), which spare the upper face * it is a peripheral neuropathy of the facial nerve (CN 7) characterized by facial weakness that involves the upper + lower face * thought to be caused by reactivation of neurotrophic viruses (like HSV)-> inflammation, edema, and degeneration of the myelin sheath * treat with glucocorticoids

Answer 902

Pellegra (Niacin/ Vitamin B3 deficiency) 3 D’s: “Diarrhea, Dermatitis, and Dementia”

Answer 903

Drug-induced interstitial nephritis (type of intrinsic AKI) D/C the cephalexin - drug (NSAID, Penicillin, diuretic, etc.)-> fever, rash, dec urine output, eosinophils - WBC casts-> think interstitial nephritis or pyelonephritis

Answer 904

Endotracheal intubation - she needs airway protection bc she has depressed level of consciousness + ongoing hematemesis (she is unstable!) - THEN, promptly stop the bleeding with endoscopy ligation or sclerotherapy (solution injected into veins to cause them to constrict)

Answer 905

HTN (hypertensive nephrosclerosis) * renal dz with high BUN, Cr, bilateral small kidneys, trace proteinuria, S4 (blood into thick ventricle/ hypertrophic CM) * long-standing HTN-> hyaline arteriOlosclerosis (renal arterioles undergo medial hypertrophy and intimal fibrosis and this endothelial damage leads to protein and BM deposition into arteriolar walls)-> decreased blood flow to glomerulus (glomerulosclerosis) **no casts is a clue it’s not ATN (muddy brown casts), interstitial nephritis (WBC casts), glomerulonephritis (RBC casts), etc.

Answer 906

Replace Warfarin with an oral factor Xa inhibitor (RivaroXaBAN, ApiXaBAN) *oral direct factor 10 inhibitors work similar to warfarin in treating acute venous thromboembolism and do not increase risk of bleeding complications (in fact, they are not preferred since they don’t require INR monitoring or dietary restrictions) **he got a clot in the setting of sub-therapeutic INR (normal INR= 1, but for patients on Warfarin we aim for 2-3 bc higher INR= less clotting)

Answer 907

Hereditary Hemorrhagic Telangiectasia (HHT) aka Osler-Weber-Rendu syndrome - Autosomal dominant disorder - Diffuse telangiectasias (ruby-colored papules that blanch with pressure) - Recurrent epistaxis (nosebleeds) - AV malformations (shunts blood from arterial to venous system)-> hypoxemia (explains the clubbing and elevated Hct to compensate)

Answer 908

Methotrexate (a disease-modifying agent) *If persistent symptoms for >6 months, add another agent (ex: TNF-alpha inhibitor, sulfasalazine, hydroxycloroquine)

Answer 909

``` Candida esophagitis Oral fluconazole (start empiric treatment) ``` * HIV patients w/ CD4 <100 and esophagitis-> most likely to be Candida, HSV, or CMV * oral thrush is the big hint here that it’s Candida * if doesn’t respond to the anti-fungal meds, then you’d proceed to upper endoscopy and biopsy

Answer 910

Hyperparathyroidism Usually from a parathyroid adenoma-> too much PTH-> too much calcium into the blood This is associated with HTN. Why? Thought to be due to increased renin release, sympathetic activation, and/or peripheral artery vasoconstriction

Answer 911

MRI brain *got to assess for a brain tumor

Answer 912

Herpes simplex encephalitis * most common fatal sporadic encephalitis (swelling of the brain) (due to HSV-1) * presents with acute focal neurological findings and usually fever * CSF shows lymphocyte pleocytosis, increased number of erythrocytes (due to hemorrhagic destruction of temporal lobe), and elevated protein * MRI shows temporal lobe involvement/ lesions * PCR showing HSV DNA in CSF is diagnostic * treat with IV Acyclovir

Answer 913

This is pyelonephritis complicated by septic shock You gave NE (vasopressor, alpha-1 > beta agonist)-> vasoconstriction to raise MAP -shunts blood to central organs, but away from periphery -decreased perfusion to the digits-> NECROSIS of tissue (dry gangrene) if prolonged

Answer 914

Pneumonia (SOB, productive cough, fever) * IV drug user + candida esophagitis= he’s got AIDS * midsystolic murmur at R upper sternal border (aortic valve)= sounds like aortic stenosis, but it’s actually a flow murmur from fever causing hyperdynamic state, so you hear the blood flow across the valve louder (IV drug use, fever, and murmur are suspicious for endocarditis, but the patient lacks other signs of HF—JVP and edema) * V/Q mismatch is the mechanism for his hypoxemia

Answer 915

Obstructive lung dz, like COPD or severe asthma attack Hard to get air out-> air trapping (air stacking)-> when you inhale the lungs expand more, compressing the heart-> heart fills less-> drop in CO and BP

Answer 916

1. Anti-smooth muscle antibody—> autoimmune hepatitis 2. Anti-mitochondrial antibody—> primary biliary cholangitis/ cirrhosis (autoimmune destruction of intrahepatic bile ducts)

Answer 917

Admit the patient to the hospital to cath lab (stable angina has progressed to unstable angina) *definitely want to cath females >50 with typical chest pain

Answer 918

An ingested foreign body (hard mass in the stomach)

Answer 919

Gastric bezoar (foreign body/ mass in stomach) -he is swallowing his hair

Answer 920

Mild cognitive impairment

Answer 921

Osteosarcoma *patients with familial retinoblastoma are at increased risk for osteosarcoma (Pathoma fact)

Answer 922

PH <7.2 Glucose <60 (If pH >7.2 and glucose >60, it’s uncomplicated)

Answer 923

Labyrinthitis - inflammation of the vestibular nerves in the inner ear, usually triggered by an infection (self-limited) - acute onset with vertigo, N/V, gait disturbance - distortion of light reflex off tympanic membrane is due to ear fullness

Answer 924

(Primary) Sclerosing cholangitis (PSC) - associated with Ulcerative Colitis - inflammation and fibrosis of intrahepatic and extrahepatic bile ducts (“string on pearl” appearance) - direct hyperbilirubinemia

Answer 925

Asthma *don’t be stupid and put sarcoidosis just cuz she’s African American!!

Answer 926

ETEC (Enterotoxigenic E. Coli) *aka traveler’s diarrhea

Answer 927

Aortic stenosis

Answer 928

Infection of the joint from Disseminated Gonorrhea -TRAID: polyarthralgias (pain in multiple joints) + tenosynovitis (inflammation of flexor tendon sheath in wrist) + vesiculopustular skin rash

Answer 929

Sandblasters—> Silicosis Aerospace workers (NASA)—> Berylliosis Construction/ plumbers/ shipyard workers—> Asbestosis

Answer 930

Primary biliary cholangitis/ cirrhosis | Autoimmune destruction of intrahepatic bile ducts

Answer 931

Metabolic bone disease, including osteoporosis and osteomalacia (decreased bone mineralization) *etiology of this is unknown, but there is an association

Answer 932

> 1 big box (or >5 small boxes)

Answer 933

Noninvasive ventilation (BiPAP) * she is having acute decompensated HF (dilated cardiomyopathy/ systolic dysfunction from chemo and heart hasn’t had time to appropriately compensate for the changes)-> CHF symptoms (distended neck veins, crackles from pulm edema) * the stretching of the heart-> a fib (irregularly irregular) **although Dobutamine may be helpful to help the heart pump, her HF-> is causing respiratory failure that is severe and needs to be addressed 1st (aggressive diuresis, oxygen, assisted ventilation)

Answer 934

Uremic encephalopathy Urgent hemodialysis -car crash with contusions (suggests trauma/ crush injury)-> rhabdo-> intrinsic AKI from myoglobin clogging up tubules (explains high BUN)-> the high BUN/ inability to clear urea (uremia) is an indication for dialysis (“AEIOU”)-> uremic encephalopathy-> flapping tremor

Answer 935

Drug toxicity (aminoglycosides, like gentamicin, are ototoxic to both the cochlea-> sensorineural hearing loss and vestibular system-> imbalance) *nystagmus with rapid head movement away from a fixed target= head thrust test (vs. Dix-Hallpike maneuver used to dx Benign Paroxysmal Positional Vertigo—this would also have <1 min episodes of vertigo)

Answer 936

Cerebral vasospasm and infarction *vasospasm (the bleed causes irritation to the surrounding vessels) is the major cause of death within 24 hrs of SAH. Prevent with Nimodipine (CCB).

Answer 937

Adenocarcinoma of the lung *most common lung ca in non-smokers

Answer 938

TMJ (Temporomandibular joint) disorder - ear pain in the setting of a normal ear exam is likely to be referred pain - often associated with teeth grinding (brutish) at night - clinical diagnosis (TMJ test where palpation of TMJ with mouth opening/ closing-> pain and clicking is not super sensitive) - give bite guard + NSAIDs

Answer 939

Multiple sclerosis (MS) - autoimmune inflammatory demyelinating disorder of the CNS (the fact that she has T1DM, another autoimmune disorder, makes this even more likely) - young woman with neuro symptoms separated by time and space—optic neuritis (monocular blindness, painful eye movements) and transverse myelitis (motor and sensory loss below level of lesion, incontinence)

Answer 940

Hashimoto thyroiditis anti-TPO antibodies - thyroid disease increases risk for miscarriages - she has subclincial hypothyroidism (normal free T4, but high TSH as you’d expect with hypothyroidism) - treatment with Levothyroxine is recommended for subclinical hypothyroidism for patients with high anti-TPO levels even if they don’t have symptoms (this will reduce risk of future miscarriage)

Answer 941

1. Super high aminotransferases (>1000) 2. Signs of hepatic encephalopathy 3. Impaired hepatic synthetic function (INR >1.5) In a patient w/o cirrhosis or underlying liver dz!!

Answer 942

Anabolic (androgens) steroid abuse - In men-> testicular atrophy, reduced spermatogenesis, gynecomastia, mood disturbance, aggressive behavior, hepatotoxicity - In women-> acne, hirsutism, deepening of the voice, menstrual irregularities, hepatotoxicity *causes erythrocytosis (inc Hct and Hb) for unknown reasons but this is a clue they’re abusing

Answer 943

Myasthenic crisis * life-threatening complication of MG characterized by severe respiratory muscle weakness-> respiratory failure * triggers include: infection, surgery, certain meds (fluoroquinolones)

Answer 944

Decompensated HF (HF exacerbation) - HF (pumping problem)-> activation of RAAS + sympathetic NS (try to compensate for poor perfusion)...eventually, these systems are maladaptive, as Na+ retention leads to increased preload and vasoconstriction leads to increased afterload. This makes the pumping problem worse!! (It’s a vicious cycle of decompensated HF) * His HF is in the setting of recent MI

Answer 945

Constricts the efferent arterioles *this increases GFR (and decreases RPF)

Answer 946

A Diphenhydramine -have anticholinergic properties: “dry as a bone, blind as a bat, hot as a hare, full as a flask”

Answer 947

Sepsis 2/2 PNA * fever/ chills, SOB, productive cough, leukocytosis * met alkalosis due to hyperventilation (blow off more CO2-> dec CO2) **SIRS criteria: 1. Temp >38 (100.4) or <36 (96.8) 2. WBC >12 or <4 3. HR >90 4. RR >20 SIRS= 2/4, sepsis= SIRS (+) w/ infection source

Answer 948

Lucunar stroke of the Thalamus (Pure sensory stroke) *Internal capsule is often a pure motor stroke

Answer 949

Inability to feel sensation on one side

Answer 950

Abnormal muscle contractions

Answer 951

Increased sensitivity (ex: light touch is painful)

Answer 952

Severe burning pain over an area exacerbated by light touch

Answer 953

Paget disease of the bone - most patients are asymptomatic! You get an isolated increase in alk phos - osteoclasts go crazy breaking down bone-> osteoblasts rush to catch up and do a poor job of laying down bone-> thick bone that fractures easily - treatment: bisphosphonates

Answer 954

Gram positives (staph, strep)

Answer 955

Bisphosphonates *note: treatment w/ bisphosphonates is usually stopped after 5 yrs, as prolonged use can cause atypical fracture

Answer 956

Whipple’s disease - infection with T. Whippelii (how you get it is not fully understood) - causes a variety of symptoms, including malabsorptive diarrhea, weight loss, arthritis, lymphadenopathy, and low-grade fever

Answer 957

Albuterol (beta-2 agonist)-> shift of K+ into the cells (hypokalemia) *this is a COPD exacerbation

Answer 958

Pulmonary Embolism (PE) - Acute-onset pleuritic chest pain, tachycardia - EKG w/ irregular RR intervals, no definite P waves, and narrow QRS’s= a-fib (associated with PE) *Acute-onset pleuritic chest pain occurs in 70% of PE patients. Hemoptysis in <20%. DVT symptoms in <30.

Answer 959

Euthyroid sick syndrome (“Low T3 syndrome”) -less peripheral conversion of T4-> T3 in the setting of acute illness * factors in acute illness that block peripheral deiodination of T4-> T3 include high endogenous cortisol levels, inflammatory cytokines (TNF-alpha), and starvation * also, he’s on glucocorticoids which we know blocks conversion of T4-> T3 * no treatment needed

Answer 960

Open-angle glaucoma (High intraocular pressure-> atrophy of the optic nerve head—thins out w/ increased cup-to-disc ratio/ “cupping”) Prescribe a med to lower IOP (by decreasing aqueous humor production or increasing its outflow)—1st line is a PG eye drop (Latanoprost, Bimatoprost) *2nd line= beta-blockers (Timolol) (*would have to use w/ caution in this guy with asthma!) **Don’t give Acetazolamide—this is used for closed-angle glaucoma

Answer 961

Chlamydial urethritis * not Gonorrhea, or you’d get a gram negative staining * confirm dx with NAAT or first-catch urine sample (w/o pre-cleaning of genital area) * treat with Azithromycin or Doxy

Answer 962

Radioactive iodine (RAI) - Graves ophthalmopathy is due to effects of activated T-cells and thyrotropin receptor antibodies on TSH receptors on retro-orbital fibroblasts and adipocytes - RAI can raise titers of these antibodies-> worsening ophthalmopathy * give glucocorticoids to prevent this complication of RAI **Sketchy: Radioactive iodine initially worsens Graves hyperthyroidism and ophthalmopathy due to inflam-> release of TH into the blood

Answer 963

pH and PaCO2 *HCO3- can be calculated from these 2 values using the Henderson-Hasselbalch equation

Answer 964

Glucocorticoids -this is an acute MS exacerbation (we treat exacerbations with steroids, plasmapheresis if refractory)

Answer 965

Refer to liver transplant center - this is acute liver failure (ALF) 2/2 acetaminophen toxicity - severe acute liver injury w/o underlying liver disease + LFT’s >1,000, hepatic encephalopathy, and synthetic liver dysfunction (prolonged PT) * only 1/2 patients with ALF will survive w/o transplant * there are ethical issues with transplants in suicide attempts, but it is usually pursued in patients with reactive depression (no psych hx)

Answer 966

Autoimmune adrenalitis-> primary adrenal insufficiency (lack of aldosterone, cortisol) - postural hypotension, lightheadedness, low Na+, high K+ (lack of aldo) - primary adrenal insuff-> neg fdbk-> high ACTH-> hyperpigmentation (due to subsequent inc of melanocyte-stimulating hormone)

Answer 967

The same thing as hypercapnia! Retained CO2 (as in COPD patients).

Answer 968

ACTH stimulation test (aka cosyntropin test) - weakness, weight loss, low Na+, high K+ -> primary adrenal insufficiency (PAI) aka Addison’s disease (lack of aldosterone + cortisol) * initial presentation: nonspecific symptoms, GI symptoms, hypotension - start by getting an 8am cortisol level and plasma ACTH (ACTH stimulation test) - normal-high cortisol r/o adrenal insuff - low cortisol + high ACTH= primary - low cortisol + low ACTH= secondary (get pituitary MRI) *this Q is tricky bc his K+ is not technically high and cortisol is not technically low. But be aware, each patients baseline differs.

Answer 969

Primary—> Prednisone + Fludrocortisone (Cortisol + Aldo replacement) Secondary—> Prednisone only (Cortisol replacement) **Remember: Primary-> problem at the level of the adrenal glands-> lack of aldosterone + cortisol Secondary-> problem at the level of the pituitary-> lack of cortisol (aldo is normal bc it is NOT controlled by the ACTH axis from the pituitary gland)

Answer 970

- combination short-acting bronchodilators (beta-2 agonist + anticholinergic drugs—this is your muscurinic antagonist) - systemic glucocorticoids (IV methylprednisolone) - broad-spectrum antibiotics (Azithro, Doxy) * Tamiflu (Oseltamivir) if flu is suspected as the cause - supplemental oxygen (goal SpO2 88-92%) * noninvasive positive-pressure ventilation (BiPAP) (tracheal intubation if fails)

Answer 971

Upper GI endoscopy (To assess severity of esophageal damage and guide further management) *Activated charcoal can help get poisons out of the body, but will not help the damage already done to the esophagus. Plus, you want to do the GI endoscopy 1st bc charcoal would otherwise obstruct the view during endoscopy. **NEVER induce vomiting (re-exposes the esophagus to the toxins) or give a neutralizing agent (will cause a chemical rxn that worsens the damage)!!

Answer 972

Cancer screening - it is either inherited (factor 5 Leiden, prothrombin gene mutation, protein C/S deficiency) OR acquired (immobilization, surgery, malignancy, medications) - since this is unprovoked (no recent travel or surgeries), cancer screening (colonoscopy) is appropriate. Remember cancer-> hypercoagulable state-> inc DVT risk **you do NOT need to test for inherited causes (like factor 5 Leiden)—we do this in patients with clots 45 years old or family hx or recurrent clots

Answer 973

Patients age 55-80 w/ 30+ pack-year smoking hx And patient is a current smoker or quit less than 15 yrs ago *do annual low-dose CT scan

Answer 974

Patient is less than 45 y.o. OR Patient has a family hx of these OR Patient has had recurrent DVTs

Answer 975

Cytomegalovirus (CMV) infection (CMV mononucleosis) - asymptomatic in 90% of cases, but causes mono-like illness in 10% (same symptoms, negative mono-spot test/ Heterophile antibody testing) * gay men at higher risk * confirm with CMV IgM serology * treatment is supportive only (though, sometimes Valganciclovir is given—may speed up recovery but data is weak)

Answer 976

Negative mono-spot test/ heterophile antibody testing (r/o EBV) Confirm with CMV IgM serology

Answer 977

Monitor while treating the COPD exacerbation - SOB, productive cough, wheezing in a COPDer= COPD exacerbation * *distant heart sounds due to air trapping in COPD making it harder to hear the heart beats - irregular rhythm, rapid rate, 3+ P-wave morphologies= multifocal atrial tachycardia (MAT) - seen in elderly pts w/ COPD - treat the underlying COPD * *most likely due to a disturbance (RA enlargement, catecholamine surge from sepsis, or electrolyte imbalance)-> triggers atrial conduction abnormalities-> you get this supraventricular tachyarrhythmia

Answer 978

Multifocal atrial tachycardia Treat the underlying COPD *most likely due to a disturbance (RA enlargement, catecholamine surge from sepsis, or electrolyte imbalance)-> triggers atrial conduction abnormalities-> you get this supraventricular tachyarrhythmia

Answer 979

Respiratory insufficiency in the setting of ALS Noninvasive positive-pressure ventilation (CPAP, BiPAP) (Helps prop open airways for support) - She has ALS—a neurodegenerative disease-> UMN + LMN signs - Most ALS patients die of respiratory failure (inspiratory muscle/ diaphragm weakness-> poor inspiratory strength, expiratory muscle weakness-> ineffective cough, bulbar muscle weakness-> chronic aspiration)

Answer 980

Patient meets these 2 criteria: 1. Has antiphospholipid antibodies—lupus anticoagulant, anticardiolipin antibody, or anti-beta-2 glycoprotein antibody 2. Has clotting problems (DVT, PE, stroke, MI) or pregnancy problems (3+ miscarriages before wk 10, 1+ miscarriage after wk 10, preeclampsia/ eclampsia/ placental insufficiency) **antiphospholipid antibodies are seen in SLE (lupus), though not specific for it. They can cause 3 problems: (1) antiphospholipid antibody syndrome, (2) increased PTT, (3) false positive Syphilis test (RPR/ VDRL)

Answer 981

1. antiphospholipid antibody syndrome (presence of antiphospholipid antibodies + clots or pregnancy problems like miscarriages) 2. increased PTT 3. false positive Syphilis test (RPR/ VDRL)

Answer 982

1. lupus anticoagulant 2. anticardiolipin antibody 3. anti-beta-2 glycoprotein antibody

Answer 983

Dobutamine (“Just do bugling” beta-1 > beta-2 agonist) *increases heart contractility and CO Meth use-> cardiomyopathy-> decompensated HF (progressive SOB, diffuse pulmonary crackles, S3, hypotension, cool extremities, diminished pulses, and high BUN and Cr= evidence of poor organ perfusion)

Answer 984

Decreases LV end-systolic volume - Dobutamine (“Just do bugling” beta-1 > beta-2 agonist) increases heart contractility and CO - increased contractility-> improved ejection fraction-> reduced LV end-systolic volume (more blood got pumped out, so less blood stays behind at end of systole)-> improvement in decompensated HF

Answer 985

- maintain moderate physical activity - NSAIDs or Tylenol - consider: muscle relaxants, spinal manipulation

Answer 986

- intermittent use of NSAIDs or Tylenol - exercise therapy! (Stretching/ strengthening, aerobic) - consider: TCAs, Duloxetine

Answer 987

Add topical antibiotic (topical erythromycin) -mild-mod inflammatory acne vulgaris that failed initially therapy (topical retinoids + benzoyl peroxide) —> go to topical antibiotics (erythromycin, clinamycin) —> if that also fails, go to oral antibiotics (tetracyclines) (*only start here if the acne is severe, nodular, or widespread)

Answer 988

UC (ulcerative colitis) *vs. Crohn’s: skip lesions, transmural inflammation, non-caseating granulomas

Answer 989

Cyanide toxicity - he was given a Nitroprusside drip to lower his BP, which can cause CN toxicity as an adverse effect! (*CN poisoning is caused by Nitroprusside or smoke inhalation) - CN inhibits complex 4 of the ETC so that the oxygen delivered to tissues cannot be utilized - symptoms: neurological (headache, confusion, hyperreflexia), respiratory (tachypnea-> resp depression), GI (vomiting), skin (flushing) - low bicarb-> metabolic acidosis (lactic acidosis!) * treat with Thiosulfate

Answer 990

Prescribe OCPs *too much LH (related to insulin resistance)-> theca cells in ovaries use this to make androgens-> overwhelms the granulosa cells—they cant convert all the extra androgens to estrogen (estradiol)-> so excess androgens circulate the blood-> hirsutism. Also, fat cells use the androgens to make estrone which feeds bk and inhibits GnRH-> anovulatory, infertility. -Anovulatory cycles-> irregular menses, dec progesterone, and unopposed estrogen which causes uncontrolled endometrial proliferation (when they do get a period its really heavy and can cause anemia) OCPs will make cycles regular and block adrenal androgen production to reduce hirsutism

Answer 991

Brain abscess (*most likely due to staph a. OR strep viridans) - sinusitis-> brain abscess - may cause seizures or focal neuro deficits - single ring-enhancing lesion on CT

Answer 992

1. Staph a. | 2. Strep viridans

Answer 993

Serum protein electrophoresis (looking for monoclonal IgM spike) - this is likely Waldenstrom macroglobulinemia (B-cell lymphoma where tumor cells differentiate into plasma cells and produce too much IgM-> hyperviscosity symptoms since IgM is large) - headache, vision changes, vertigo/ dizziness/ ataxia, rarely stroke or coma, peripheral neuropathy (as in this pt) * treat with plasmapheresis to remove IgM from serum

Answer 994

Recommend a diet (and exercise) diary | Track food intake and changes in weight

Answer 995

Upright x-ray of the chest/ abdomen - this is peptic ulcer disease complicated by perforation-> peritonitis (acute onset worsening of symptoms, fever and guarding) * *remember that rebound tenderness + guarding are signs of an acute abdomen (consult surgery!) -look for free air under the diaphragm (*if the x-ray is negative, you may follow-up with CT w/ contrast to detect smaller amounts of free fluid, but don’t get the CT if it will delay surgery)

Answer 996

Aplastic anemia (Pancytopenia—dec RBCs, WBCs, and platelets) Dec RBCs-> anemia (fatigue, pallor) Dec WBCs-> infection (pneumonia) Dec platelets-> bleeding (ecchymoses) * acquired deficiency/ absence of pluripotent stem cells from exposures (drugs, toxins, radiation), viral infections (parvovirus B19, HIV, EBV), and autoimmune conditions (SLE, eosinophilic fasciitis) * definitive diagnosis made w/ bone marrow biopsy showing hypocellular marrow (few normal hematopoietic stem cells, no myeloid infiltration/ fibrosis, and mainly stroma and adipocytes/ fat cells)

Answer 997

Myelofibrosis

Answer 998

1. Lymphocytes with hairy projections—> Hairy Cell Leukemia 2. Smudge cells—> Chronic Lymphocytic Leukemia (CLL)

Answer 999

Nothing A PPD skin test (TB screening) is considered positive if... >15 mm in a healthy person >10 mm in a healthcare worker, prison worker, recent immigrant in TB area, kid less than 4 years or adult with a comorbidity >5 mm in an immunocompromised person (*we are more conservative with the cut-offs in high-risk individuals to avoid missing cases of TB!)

Answer 1000

IGRA (interferon-gamma blood test)

Answer 1001

Acute transplant rejection - Think of this w/ elevated Cr + proteinuria in a patient with a transplant less than 6 months ago - Confirm w/ renal biopsy showing lymphocytic infiltration + intimal arteritis * T-cell mediated immune response to antigens from the donor kidney within 6 mo of transplant * Patients are often asymptomatic (but may have fever, decreased urine output, graft tenderness)

Answer 1002

1. Renal biopsy is unremarkable—> ACUTE TOXICITY OT CALCINEURIN INHIBITORS (TACROLIMUS) CAUSING AKI 2. Renal biopsy shows intranuclear inclusions and mixed lymphocytic + neutrophilic infiltrate—> BK VIRUS 3. Renal biopsy shows heavy lymphocytic infiltration w/ vascular involvement of the intima—> ACUTE TRANSPLANT REJECTION (*T-cell mediated)

Answer 1003

ATN (Acute Tubular Necrosis) - hypotension-> pre-renal AKI-> progression to ATN - the fact that fluids did not improve the AKI (BUN, Cr still high—in fact, worse than on admission) means it is not pre-renal - “granular casts” is the give-away (remember, ATN-> brown muddy granular casts—but here they dont mention the brown muddy color)

Answer 1004

Airway compromise - due to swelling * other complications of peritonsillar abscess: aspiration pneumonitis, lung abscess, hemorrhage due to septic necrosis of the carotid sheath, extension of infection into deep neck tissue or posterior mediastinum, and post-strep sequelae like rheumatic fever or GN (does NOT lead to necrosis of the tonsils)

Answer 1005

Group A strep

Answer 1006

Ulnar nerve compression *remember the hypothenar muscles are on the opposite side as the thumb and the ulnar nerve innervates this area (medial side of hand)

Answer 1007

No further testing needed -blunt trauma to flank w/o hematuria on U/A means chances of renal trauma are LOW (*would get a CT abdomen if trauma to flank + hematuria)

Answer 1008

Swallowing study -recurrent PNA in a dementia patient-> think aspiration PNA

Answer 1009

Constipation | *remember the toilet plunger in the CCB sketchy

Answer 1010

PNA-> consolidation (alveoli filled with mucous)-> V/Q mismatch (perfusion w/o ventilation in those alveoli) Right to Left shunt bc the shunt is in the normal direction of right heart-> lungs-> left heart. Deoxygenated blood is not getting oxygenated-> hypoxemia (R->L shunts are cyanosic vs. L->R shunts just push already oxygenated blood to the right heart as in early ASD or VSD)

Answer 1011

Systemic Sclerodermia Renal Crisis - Malignant HTN and AKI (high BUN, Cr) in the setting of Systemic Scleroderma - The damage to the kidneys can cause microangiopathic hemolytic anemia (low Hb, platelets- getting used up) like an HUS-type clinical picture

Answer 1012

Schistocytes (helmet cells) -the renal involvement-> microangiopathic hemolytic anemia

Answer 1013

Osteoarthritis of the spine (spondylosis) - osteoarthritis-> bone spurs (osteophytes)-> lumbar spinal stenosis (narrowing of spinal canal w/ compression on lumbar nerve roots)-> pseudoclaudication - “shopping cart sign”-leaning forward relieves pressure on the spinal cord * NOT vascular claudication bc ankle-brachial index is normal

Answer 1014

Pelvic fracture -blood can hide in the retroperitoneum (negative FAST exam) * NOT intracranial hemorrhage (Cushing’s reflex is hypertension-> bradycardia, which is opposite of his vitals) * most common shock in trauma= hemorrhagic (hypovolemic)

Answer 1015

No—that would be premature. She is on no BP meds yet...only do secondary HTN work-up if atypical presentation 30 y.o., resistant HTN (requiring >3 meds), or signs/ symptoms suggestive of a specific etiology (ex: high Na+ and low K+ on labs, raising a flag for hyperaldo)

Answer 1016

Lipid panel- to evaluate their risk factors U/A- to evaluate if they are peeing out protein or blood *primary HTN is far more common than secondary HTN, so get routine lab work done and start on BP meds. Only do work-up for secondary causes if BP is refractory (fails >3 meds) or if specific signs/ symptoms are present.

Answer 1017

Autoimmune adrenalitis - her presentation is consistent with Addison’s disease/ low cortisol (lightheaded, hyperpigmented from high ACTH from neg fdbk) (*so primary/ at the level of the adrenal glands, NOT at the level of the pituitary so NOT Sheehans) - labs (low Na+, high K+) show aldosterone is also low—not just cortisol, so primary adrenal insufficiency * the fact she has Hashimotos (an autoimmune dz) makes another autoimmune dz more likely

Answer 1018

Shock liver (ischemic hepatic injury) PNA-> septic shock-> liver is deprived of blood-> shock liver (diffuse liver injury) **liver enzymes usually return to normal within 1-2 wks

Answer 1019

Non-contrast CT head To evaluate for cerebellar hemorrhage/ stroke - she is having CENTRAL vertigo (peripheral vertical is horizontal only, central can vary and hers is rotatory= going in circles) - vertigo from a central cause may also affect stability (cerebellum-> coordination) * central vertigo may also present w/ headache **NOT BPPV, Meniere dz, or vestibular neuritis, as these are causes of peripheral vertigo

Answer 1020

Infection in the floor of the mouth (Rapidly progressive cellulitis of the submandibular and sublingual spaces, usually from an infected molar) *symptoms: fever, dysphagia (difficulty swallowing), odynophagia (pain w/ swallowing), and drooling

Answer 1021

Propranolol (beta-blocker) - this sounds like hyperthyroidism (Graves)... - but in Graves you’d expect high radioactive uptake (“hot thyroid”) and TSI (thyroid stimulating immunoglobulin) antibodies... - low uptake + anti-TPO antibodies are consistent with Hashimotos (hypothyroid, but can start out with hyperthyroidism due to lysis of thyroid cells that already made TH) * this is a variant of chronic lymphocytic (Hashimotos) thyroiditis - give a beta-blocker to control the current hyperthyroid symptoms * Methimazole would NOT work, as this blocks TH production (the problem here is not too much TH being produced, but too much that was already made being released)

Answer 1022

Lead poisoning (-> impaired heme synthesis) - he prob mixed/ poured his whiskey through things with lead when homemaking it - lead blocks ALAD in heme synthesis pathway-> anemia w/ basophilic stippling, Lead lines on long bone x-ray, Encephalopathy, Abdominal sxs, and Drops-foot and wrist drop (“LEAD”) *this is NOT methanol poisoning (seen in ppl who make their own moonshine), as that would present with eye problems

Answer 1023

Diabetes Glycosylation= adding sugar to stuff

Answer 1024

Bronchial rupture - he had a right-sided tension pneumothorax from trauma (chest tube placed-> air gushed out) - now, the air came back and filled the right pleural space - bronchial rupture makes sense bc you intubated him-> pumping more air in to the pleural space (would successfully go into the lungs if the esophagus or something else was ruptured, not the bronchus) “Persistent pneumothorax + large air leak despite thoracostomy in the setting of blunt trauma suggests tracheobronchial rupture” * confirm with bronchoscopy * repair with surgery

Answer 1025

Removal of the pleural lining *rarely done, but can be done for things like recurrent pleural effusions

Answer 1026

Oxygen supplementation -This is spontaneous pneumo (rupture of bleb) -Management depends on the size: Small and patient is stable-> supp O2 (regardless of O2 sat, since it speeds recovery) Large and patient is stable-> needle decompression and/ or chest tube

Answer 1027

Small-> supplemental oxygen (*regardless of O2 sat, since it speeds recovery) Large-> needle decompression and/ or chest tube

Answer 1028

Cervical spondylosis/ osteoarthritis -> cervical radiculopathy (compression on spinal nerve root)

Answer 1029

Osteoarthritis *Remember the O and O for Osteoarthritis and Osteophytes

Answer 1030

1. Hypoxemia correct with oxygen? NO 2. Lung compliance? LOW (fluid collection restricts expansion of the lungs) 3. A-a gradient? HIGH (hyaline membranes get in the way of gas exchange)

Answer 1031

Non-seminoma germ cell tumor * seminomas also have inc beta-hCG, but NOT AFP (you see inc AFP-> think a non-seminoma type) * germ cell tumors are NOT only found in the testicles! They can occur in other places too

Answer 1032

Rheumatoid arthritis Atlantoxial joint= between C1, C2 Sublaxation= one moves in relation to another-> can compress the spinal cord *this is the risk of intubating RA patients—don’t do it

Answer 1033

Infective endocarditis-> mitral valve affected-> mitral regurg-> acute CHF symptoms (from the mitral regurg and backing up of blood) LA size- normal LV size- normal LV EF- normal-increased (heart working harder to pump in this illness/ acute condition) *you would think LA and LV dilated and LV EF low (CHF picture). But this is so acute (3 days) that the heart hasn’t had time to dilate and fail at pumping yet.

Answer 1034

Decrease respiratory rate (RR) -pCO2 is low, so he’s blowing off lots of CO2= hyperventilation (also pH shows alkalosis, as it is a respiratory alkalosis) - there are 2 things you can do to mess with the ventilation (CO2): change Tv or RR (vs. O2: FiO2 or PEEP) -appropriate tidal volume= ~6mL/kg =6*70 kg= 420 mL (his is 450 mL, so appropriate) -since Tv is appropriate, lower RR!!

Answer 1035

4-8 mL/kg *just remember ~6 mL/kg...so multiply 6 times the patient’s weight in kg to get the appropriate tidal volume in mL

Answer 1036

Alcohol withdrawal Long-acting benzo (chlordiazepoxide) - alcohol is a CNS depressant (more GABA inhibitory signals, less NMDA/ glutamate excitatory signals) - alcoholics adapt to a new homeostasis...extra excitatory signaling develops to balance out the extra inhibitory signaling from the alcohol - take the alcohol away (lost job, moved in parents)-> CNS overexcitation: - anxiety, agitation, tremor, diaphoresis, nausea - hallucinations - delirium tremens (DT): rapid-onset delirium and autonomic stability (fever, tachy, HTN, diaphoresis) - seizures

Answer 1037

Common! About 14% of the US population has it! (It is often masked, but if these people abruptly stop drinking alcohol, they will develop withdrawal symptoms)

Answer 1038

Endoscopic evaluation (colonoscopy and/or EGD/endoscopy) - Microcytic anemia + low ferritin (iron in storage sites) is consistent with iron def anemia - iron def anemia in old folks is colon cancer until proven otherwise!

Answer 1039

1. Alpha blockers (Terazosin, Tamsulosin) | 2. 5-alpha reductase inhibitors (Finasteride)

Answer 1040

Toxic adenoma -hyperthyroidism with nodular uptake-> toxic adenoma (1 nodule of uptake) or multinodular goiter (multiple nodules of uptake) (*vs. hyperthyroidism with diffuse uptake-> Graves’ disease)

Answer 1041

Toxic adenoma and multinodular goiter (inc radioactive uptake at nodule(s))-> autonomous TH production (the hyperplastic cells in the nodules produce TH w/o TSH stimulation) Graves’ disease (inc radioactive uptake diffusely)-> extra TH production is from the TSI (thyroid stimulating immunoglobulin) antibodies

Answer 1042

Gabapentin *TCAs should be avoided in elderly due to anticholinergic side effects

Answer 1043

Amp B + Flucytosine (2 wks) Followed by Fluconazole (8 wks)

Answer 1044

DKA (indicating a new diagnosis of T1DM *often how it first presents) - acute stress (including calorie restriction)-> cortisol-> triggers worsening of hyperglycemia (no insulin to bring glucose into cells) - severe hyperglycemia (375) (*normal non-fasting glucose is less than 120, *glucose in DKA is 300-500) - anion gap metabolic acidosis: Na-bicarb-Cl= 132-12-96= 24= high anion gap (>12 +/- 2) from ketones formed from FA breakdown - glucose spills into urine with water and Na+ (glc-Na co-transporter)-> dehydration (dry oral mucosa) and hypoNa+ - hyperK+ due to low pH (high H+ goes into cells-> K+ shifts out of cells into blood) and lack of insulin (to stimulate Na/K pump and bring K+ into cells, so more K+ stays in blood)

Answer 1045

Dementia with Lewy bodies (Lewy Body Dementia) -fluctuating cognitive impairment, recurrent visual hallucinations, Parkinsonism **called Lewy body dementia if cognitive and motor (tremors) symptoms are less than 1 yr apart (vs. dementia 2/2 Parkinson’s disease)

Answer 1046

TTP (Thrombotic Thrombocytopenic Purpura) Get a peripheral blood smear (looking for shistocytes) - dec ADAM13 level-> vWF does not get degraded-> too much sticking of platelets - thrombocytopenia (low platelet count), microangiopathic hemolytic anemia (RBCs get sheared when going past the microthrombi) - “FAT RN” Fever, Anemia (microangiopathic), Thrombocytopenia, Renal failure, Neuro manifestations

Answer 1047

“my Extra Value Meal costs $4.56” Eye response- up to 4 points Verbal response- up to 5 points Motor response- up to 6 points

Answer 1048

Prescribe a bisphosphonate (like Alendronate) - this is Paget disease of the bone - osteoCs go crazy breaking down bone-> osteoBs lay down bone quickly and do a sucky job of it rushing-> thick brittle bone - clinical features: - bone pain (microfractures) - increasing hat size (skull affected) - hearing loss (impingement on CNs) - lion-like faces (craniofacial bones involved) - isolated high alk phos - bisphosphonates to treat (cause osteoC apoptosis to stop this madness)

Answer 1049

GI fluid loss Vomiting-> loss of HCl (acid) and K+ (so loss of chloride!) **metabolic alkalosis is the consequence, not the cause, of vomiting!

Answer 1050

Surreptitious vomiting - she is making herself vomit (scares on hands, dental caries) - metabolic alkalosis-> low urinary chloride-> means diuretics or vomiting

Answer 1051

Sarcoidosis (w/ cardiac involvement) * cardiac noncaseating granulomas are in 25% of sarcoidosis patients, but only 5% develop cardiac symptoms * cardiac sarcoidosis is a disease of non-caseating granuloma infiltration of the myocardium-> arrhythmia, cardiomyopathy, HF, and sudden cardiac death

Answer 1052

Diabetic nephropathy * microvascular process * NOT BPH—this explains his urinary symptoms (urinary outflow obstruction), but a postvoid residual less than 50 mL means the obstruction is not significant (and you’d need complete obstruction to lead to a spike in Cr). Also BPH wouldn’t cause proteinuria.

Answer 1053

1. GLP-1 agonists (EsenaTIDE) 2. SGLT-2 (sodium-glucose co-transporter 2) inhibitors (CanagliFLOZIN) - both are good for add-on therapy in patients with cardiovascular disease, as they are associated with weight loss and reduce cardiovascular mortality and morbidity (*insulin, sulfonylureas, and TZDs are NOT associated with weight loss)

Answer 1054

He probably had a splenectomy during his operation for multiple gunshot wounds to the abdomen (at increased risk for encapsulated bacterial infections—strep pneumo, H flu, Neisseria meningitidis) Now has strep pneumo (PNA)-> septic shock

Answer 1055

These pathogens are eliminated by humoral response with antibody-mediated phagocytosis (opsonization) and complement activation *much of this is dependent on splenic macrophages and splenic opsonizing antibodies (so patients without a spleen are at higher risk for encapsulated bacterial infections and need vaccination)

Answer 1056

Constipation due to hypercalcemia Likely has multiple myeloma - back pain (lytic lesions), anemia (too many plasma cells, not enough of other blood cells), renal damage (from Ig light chains stuck in tubules), hypercalcemia * fatigue, constipation, and depression are common symptoms of mild hypercalcemia

Answer 1057

Lead poisoning -GI symptoms (constipation), neuropsych symptoms (sensorimotor neuropathy, memory loss), hematologic symptoms (microcytic anemia w/ basophilic stippling, hyperuricemia due to impaired purine metabolism)

Answer 1058

Chelation therapy with an agent like Calcium disodium EDTA

Answer 1059

``` Granular or muddy brown—> ATN RBC casts—> GN (glomerulonephritis) WBC casts—> pyelonephritis or interstitial nephritis Fatty casts—> nephrotic syndrome Broad, waxy casts—> CKD ```

Answer 1060

BUN/Cr >20 (high, bc the slow blood flow to kidneys gives the PCT more time to reabsorb urea) FeNa less than 1% (normal, bc kidneys are working to reabsorb Na+) Urine osm >500 (normal, bc kidneys are working to concentrate urine)

Answer 1061

BUN/Cr less than 20 (low, bc kidneys are NOT working to reabsorb sufficient urea) FeNa > 1% (high, bc kidneys are NOT working to reabsorb Na+) Urine osm less than 500 (low, bc kidneys are NOT working to concentrate urine)

Answer 1062

``` “HARD ASS” Hyperchloremia Addisons (primary adrenal insuff) RTA (renal tubular acidosis) Diarrhea Acetazolamide Spironolactone Saline infusion ``` **the big ones are: RTA, diarrhea, Addisons

Answer 1063

Ischemic colitis- cut off blood supply to watershed areas of colon (due to hypovolemia) Acute mesenteric ischemia- “MI of the colon” (due to thrombotic event) Chronic mesenteric ischemia- “angina of the colon”

Answer 1064

Antibiotics (Azithro, Doxy) Bronchodilators w/ anticholinergics (albuterol + ipratropium) Corticosteroids (IV methylprednisolone) Oxygen (keep O2 sat 89-92%) * also BiPAP * do not use tiotropium in place of ipratropium, as this is long-acting/ too slow in an exacerbation

Answer 1065

1. SABA (if intermittent- symptoms less than 2 days/ wk) 2. ICS (add if mild persistent- symptoms >2 days/ wk) 3. LABA (add if moderate persistent- symptoms daily) 4. Oral corticosteroid and Omalizumab (if allergies) (add if severe persistent- symptoms many times daily)

Answer 1066

1. Painless ulcer (chancre) + painless lymphadenopathy—> primary Syphilis (*give Penicillin G or Doxy) 2. Painful ulcer (chancroid) + painful lymphadenopathy—> H. Ducreyi (*give Azithro) 3. Painless single ulcer + painful lymphadenopathy—> LMV (*due to Chlamydia so give Doxy)

Answer 1067

Low Ca2+, low P, and low K+ *so check those mag levels!

Answer 1068

1. Low-dose CT checking for lung cancer—> smokers 55+ (who smoked more than 30 years or quit less than 15 years ago), annually/ every year 2. DEXA scan checking for osteoporosis—> women 65+, once 3. Abdominal U/S checking for AAA—> men 65+ who smoked ever, once 4. Mammogram checking for breast cancer—> women 50+ every 2 years OR 40+ every year (conflicting recommendations are out) 5. Colonoscopy checking for colon cancer—> everyone 50+ every 10 years (or do fecal occult blood check every year) *test more if got a genetic disease or ulcerative colitis that puts at higher risk

Answer 1069

Esophageal rupture, pancreatitis, or malignancy

Answer 1070

RA, TB, SLE, esophageal rupture, or malignancy