UW mix 1 Flashcards
Pathobiology of Goodpasture’s dz
antibodies to alpha 3 chain of type IV collagen (glomerular and alveolar BM) - kidney bx see linear IgG deposition
Sx in Invasive Aspergillosis
hemoptysis, pleuritic chest pain, and fever
Imaging of invasive aspergillosis
nodules with halo sign surrounding ground glass opacities
Incidental finding of 1.5 cm lung nodule/opacity on CXR - what to do next?
Look up old films! Then get CT.
Low prob - serial CT
Intermed prob - PET
High prob - excise
Presentation of amniotic fluid embolism? Tx?
Cardiogenic shock, hypoxemic respiratory failure, DIC, coma or seizure. Tx: respiratory and hemodynamic support +/- transfusion.
Risks: advanced maternal age, G>5, C section, preeclampsia, placenta previa or abruption
Presentation and tx of eclamptic seizures
Seizures w/ hypertension. Give Magnesium sulfate.
Patient has weakness after asthma attack - why?
Treated with b2 agonists - drives K+ into cells, get hypokalemia - weakness, arrhythmia, and EKG changes. B2 agonists also get tremor, palpitations, headache.
What happens in asthma w/ GERD
Commonly comorbid. GERD causes microaspiration and can increase vagal tone and bronchial reactivity.
Tx of PE in patient with CKD? What can’t you use?
Unfractionated heparin - monitor with aPTT. Dont use enoxaparin, fondaparinux, or rivaroxaban (Xa levels would build up)
What is the step up tx pattern for asthma?
Rescue SABA, low dose ICS, low dose ICS + LABA, up doses of ICS + LABA, maybe adjuncts, last is oral corticosteroid
Do you use ipratropium in asthma?
Not typically; used in COPD
What is contraindicated as a monotherapy in asthma?
LABA. Only use in combination with an ICS.
How to treat anaphylaxis? Mode of delivery?
IM epinephrine (IV only if failed IM, has more SEs); adjuncts like antihistamines (help skin sx) and glucocorticoids (act slowly but can prevent relapse); airway support
pH of pleural effusion - transudative? exudative?
Trans - 7.44-7.55 (nml 7.6)
Exudate - 7.30-7.45
Causes of low pleural fluid glucose?
complicated parapneumonic effusion, malignancy, tb, RA
Main findings in granulomatosis with polyangiitis
Wegener’s - 30-50yo white
- upper and lower respiratory tract granulomatous inflammation (chronic sinusitis, otitis, lung nodules, tracheal narrowing with ulcers) and glomerulonephritis
what symptom might acetylcysteine treat?
it’s a mucolytic - but may increase risk bronchospasm in COPD exacerbation
When would you use inhaled corticosteroid (like fluticasone)?
long-term management of persistent asthma. don’t help in COPD exacerbation. Maybe helpful in reducing exacerbation frequency.
What inhaler to give in a COPD exacerbation?
inhaled bronchodilators - B2 agonist and anticholinergic
In malnutrition causing macrocytic anemia, which vitamin deficiency usually comes first? And why?
Folate deficiency - folate has much smaller stores. Lots of B12 stores - takes years to develop deficiency, usually.
- That’s why we give FOLATE to pregnant women, because the stores are that much smaller!
Cushing syndrome, way to remember, and causes
high urine cortisol 24hr. cushing like cushion (Face, central adiposity); adrenocortical adenoma, hyperplasia
Why are NSAIDs bad in kidney disease?
constrict afferent arteriole
What to do with patient with tachycardia to 240, young, BP 65/37?
Cardiovert! Any arrhythmia with hemodynamic instability.
signs someone is unstable during arrhythmia and needs cardioversion
hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure
when would you defibrillate?
v fib or pulseless v tach
- this is unsynchronized, high energy
arrhythmia seen in digitalis toxicity?
atrial tachycardia with AV block (one of the few times to see ectopy at same time as AV block)
megacolon (or megaesophagus) + heart disease is?
Chagas. Chronic protozoal disease caused by Trypanosoma cruzi. Common in Latin America.
Focal GI dilation from destruction of nerves
Most common cause of a liver mass?
Metastatic disease.
Common presentation of cholangiocarcinoma? And usually had this disease previously?
Sx of biliary obstruction - jaundice, pruritus, light stools, dark urine. Had primary sclerosing cholangitis.
What is PCWP a measure of?
LA pressure - and LV end diastolic pressure
In septic shock, what happens to cardiac index? SVR? MvO2?
Increase CI
Decreased SVR
INCREASED MvO2 due to hyperdynamic circulation (can’t use it fast enough!)
alcoholic cirrhosis - describe typical liver size and enzymes?
shrunken, not palpable. AST:ALT > 2:1
hemochromatosis - mild or significant transaminitis?
significant
Key to good outcomes in out of hospital sudden cardiac arrest?
Time to Effective CPR, and time to rhythm analysis and defibrillation. Usually from sustained v tach or v fib, probably from MI.
(Studies show better effectiveness of compression only CPR for bystanders)
When do you use epinephrine in ACLS?
Asystole, PEA (pulseless electrical activity), or refractory ventricular arrhythmias unresponsive to defibrillation
When do you see pulsus paradoxus and why?
Fall in SBP by more than 10 mmhg during inspiration. See in cardiac tamponade or restrictive pericarditis. Or asthma or COPD (drops in intrathoracic pressure a lot more, blood pools in pulmonary vasculature)
Sudden onset chest and neck pain in Marfan’s?
Aortic dissection - worry about regurgitation and associated murmur, too
Toxicity of high doses (or long tx with) nitroprusside?
Cyanide toxicity (when high doses given for hypertensive emergency). Particularly in renal insufficiency. See AMS, lactic acidosis, seizure, and coma. - Nitroprusside as parenteral vasodilator, quick onset and offset. Metabolism releases NO and CN- ions. The NO causes arteriolar and venous dilation
Causes of unconjugated hyperbilirubinemia - including genetic
Hemolysis, overproduction, reduced uptake (TIPS), and Gilbert’s (low UDP glucuronyltransferase)
Causes of conjugated hyperbilirubinemia - including genetic
problems in liver (high AST and ALT - think hemochromatosis or hepatitis)
- problems in biliary tract (high alk phos - think cholestasis, malignant biliary obstruction maybe from pancreas, cholangiocarcinoma) - primary biliary sclerosis, primary sclerosing cholangitis, or choledocholithiasis
- Normal transaminases: Rotor’s (the motor rotor to push out the bili is broken) or Dubin Johnson
Physiology and symptoms of Wilson’s disease
Mutation in ATP7B - hepatic copper accumulation - leaks and goes to basal ganglia, cornea, etc
Get liver failure, neuro (parkinsonism, gait, dysarthria), and psych (depression, personality change)
Dx and tx for wilson’s disease
Dx: low ceruloplasmin, KF rings, more copper on liver biopsy
Tx: Chelators like d-penicillamine and trientine; or zinc (interfers w/ copper absorption)
transient monocular vision loss in 30yo?
Amaurosis fugax - disorders anterior to the optic chiasm
Fibromuscular dysplasia
Noninflammatory, nonatheroscloerotic - cause involvement in carotid artery, renal artery, and vertebrals.
Renin and aldosterone levels in primary hyperaldosteroneism
High aldosterone - this suppresses renin, so have aldosterone/renin ratio >20
What is dexamethasone suppression for?
Cushing’s (central obesity and moon facies like a cushion, purple striae, proximal mm wasting, glucose intolerance and hypertension
drugs to hold before a cardiac stress test
b blocker, CCB, nitrate; day of don’t use caffeine
Name an ultra short acting b blocker
esmolol
Classic triad in renal cell carcinoma
hematuria, abdominal mass, flank pain (contrast enhancing lesion on CT)
How to diagnose Boerhaave’s
Transmural esophageal rupture - get CT or contrast esophagography with gastrographin. CXR may show wide mediastinum with pleural effusion (L) - effusion with low pH and high amylase
Most common cause of sudden cardiac arrest post acute MI?
Reentrant ventricular arrhythmia! ( v fib) - also common are PVCs and sustained or nonsustained v tach. And re-entry is the most common mechanism for these arrhythmias.
What is orthodeoxia
decreased o2 sats while upright- often seen with platyptnea - increased dyspnea while upright. See in setting of hepatopulmonary syndrome - intrapulmonary vascular dilations in setting of chronic liver dz. Essentially shunts through areas with poor oxygen perfusion.
Extrahepatic issues in chronic hepatitic C?
derm: porphyria cutanea tarda (fragile, photosensitive skin that develops vesicles and bullae with trauma or sun - eg dorsum of hand).
Renal: membranoproliferative glomerulonephropathies
Heme: mixed cryoglobulinemia syndrome (palpable purpura, arthralgias, glomerulonephritis, low complement)
Systemic: fatigue, arthralgia
Sx in a1 antitrypsin:
emphysema, chronic hepatitis, cirrhosis, panniculitis (painful pannus w/ erythematous nodules, plaques on thighs or buttocks)
Heart failure in otherwise healthy young(ish) person
Dilated cardiomyopathy from viral myocarditis - parvovirus B19, coxsackievirus, adenovirus, influenza and HIV.
May also see chest pain mimicking MI
Usually have viral prodrome
Coccidiodomycosis typical presentation
Looks like community acquired PNA - see in Southwestern USA
Main treatment of chronic Hep C
Strategies to prevent further liver damage. Quit drinking, vaccinage Hep A and B. Evaluate for cirrhosis / varices.
Treatment for severe alcoholic hepatitis
Prednisolone
-see fever, abd pain, jaundice, nausea, vomiting
Leriche syndrome (triad of sx with aortoiliac artery occlusion)
bilateral hip/buttock/thigh claudication, impotence, and symmetric atrophy of bilateral lower extremities. Chronic ischemia.
List 4 causes of ankle swelling
Venous insufficiency, renal insufficiency, right heart failiure, or liver disease
how long after MI would you expect papillary MM rupture? free wall or septal wall rupture? reinfarct? pericarditis or LV aneurysm?
papillary mm rupture - 2-7 days wall rupture - hours - 2 weeks pericarditis - 1 day - 3 months LV aneurysm - 5 days - 3 months reinfarct - hours - 2 days
1 month after MI, still have ST elevations and deep q waves, what is this?
ventricular aneurysms
EKG findings for acute inferior MI - and what artery? what ventricle?
RCA - see STEMI in II, III, avF. (Right ventricle)
Can happen after aortic dissection!
Symptoms of right ventricular MI - and what artery?
hypotension, JVD, and clear lung fields - RCA
Symptoms of digoxin toxicity
anorexia, n/v, fatigue; abd pain, confusion, color vision alteration
What is the risk of gadolinium? why is it used?
It’s used for MRI contrast
Risk: nephrogenic systemic fibrosis - long term complication, not good for kidney problem pts
Chest pain in CKD patient, relieved by sitting forward?
Uremic pericarditis. Particularly when BUN >60. Needs dialysis.
Name 2 cardioselective beta blockers
carvedilol and metoprolol ER (don’t use in acute CHF!)
Labs to get after initial dx of HTN
UA for occult hematuria, UPC ratio, BMP, lipids, baseline ECG
Biggest risk factors for AAA expansion and rupture
1 - pre-existing large diameter 2 - rate of expansion 3 - current cigarette smoking (uncontrolled HTN is small risk factor!) -- repair if >5.5cm or >1 cm/yr, or symptomatic
Side effects of amiodarone: cardiac, GI, endocrine, pulm, derm
cardiac: QT prolong / torsades, sinus brady/heartblock
GI: transaminases,
Endo: hypo/hyperthyroid
Pulm: chronic interstitial pneumonitis **
Derm: blue gray skin
Ocular: corneal microdeposit, optic neuropathy
How might a pt abort a vasovagal episode?
Stop neurocardiogenic syncope by counterpressure measures. Cross legs tensely, handgrip - to improve venous return and cardiac output.
symptoms of CHF in otherwise healthy, younger patient?
Think viral myocarditis - like coxsackie virus
Concentric vs eccentric ventricular hypertrophy?
Concentric: from chronic pressure overload
Eccentric: from chronic volume overload, like in valvular regurgitation
Nondihydropyridines: name two - name primary mechanism
verapamil, diltiazem - reduce rate (AV nodal slowing - ‘north of the av node) and contractility - potent vasodilator to increase
Dihydropyridines:
amlodipine, nifedpine - coronary artery vasodilation (increase myocardial supply) and systemic arterial vasodilation to reduce afterload
- can cause reflex tachycardia 2/2 decreased afterload - good to use with BB in angina
Other name for ventricular preexcitation?
Wolff Parksinson White - short PR with wide QRS and delta
What do you need to have after a drug-eluting stent (for CAD) is placed?
dual anti platelet therapy - aspirin + P2y12 inhibitor (clopidogrel etc). Watch for subacute thrombosis - particularly med noncompliance as risk predictor in first 12 months
Signs of most common cardiac tumor
Myxoma - usually left atrium - mimicks atrial valve disease, early diastolic rumble/plop
Indications for Statins:
1 - clinically significant atherosclerotic disease (CAD, PVD, Carotid stenosis)
2 - LDL >190
3- age 40-75 w/ diabetes
4- ascvd >7.5
What does electrical alternans signify?
Pericardial effusion - often 2/2 viral URI
- QRS amplitude varying beat to beat
Name one thing that RBBB may signify if new onset?
pulmonary embolism
bradycardia, AV block, hypotension and diffuse wheezing suggests? tx?
beta blocker overdose. Causes cardiogenic shock, hypoglycemia, bronchospasm from beta 2 blockade, and neurologic dysfunction
-give glucagon. increases intracellular cAMP. Good for BB and CCB toxicity. Can also give IV calcium, vasopressors, insulin and glucose, and IV lipids
Digoxin toxicity and treatment?
Tox: fatigue, anorexia, nausea, blurred vision, changed color perception, and arrhythmia
Tx: dig specific antibody
Cocaine intoxication toxicity tx if you think they also have myocardial ischemia?
Chest pain - give benzo. beta blocker is contraindicated
Also aspirin because predisposes to thrombus formation. And nitroglycerin and CCB if needed
common heart sound during acute MI?
S4
two main causes of galactorrhea outside of pregnancy?
pituitary adenoma, dopamine antagonists like antipsychotics - which causes hyperprolactinemia
Visual cortex damage (occluded posterior cerebral artery) vs optic tract or optic radiation damage?
Optic tract: contralateral hemianopia (left side of world is blind)
Cortex / PCA: contralateral hemianopia BUT macular sparing due to collateral flow from MCA
acute painful vision loss with abnormal pupillary response to light?
optic neuritis - think about MS
what is pseudotumor cerebri? age/sex most common?
idiopathic intracranial hypertension.
MC in obese women >45
Presents with headache, transient visual sx, and pulsatile tinnitis.
Exam: papilledema, 6th nerve palsy, visual field loss
Cause of episode of painless hematuria in 17yo AA boy?
Possibly renal papillary necrosis 2/2 sickle cell trait. Also can have UTIs, painless hematuria, renal medullary cancer. Inability to concentrate urine.
Name several categories of syncope
Vasovagal / neurocardiogenic - prodrome Situational (cough, micturition, BM) Orthostatic LVOT obstruction (AS, HCM) Ventricular arrhythmia Sick sinus, bradyarrhythmia, AV block Long QT - Congenital or Torsades (hypokalemia, hypomag, long QT)
isolated systolic hypertension
2/2 increased arteriolar wall stiffness and decreased elasticity
McCune Albright sx
ovarian cyst (may cause precocious puberty), polyostotic fibrous dysplasia of bone, and café au lait spots
DiGeorge syndrome
absent thymus, congenital absence of parathyroid glands = hypoparathyroid = cause hypocalcemia (tetany, long QT), tetany in first 48 hrs of life, immunodeficiency, cardiac anomalies, and midline facial defects
Hypertension, hypokalemia, hypernatremia, and edema
Hyperaldosteronism! See weakness and edema
Low renin if primary dz (uncommon)
Causes of central DI? Nephrogenic DI?
Main sx and cause of DI?
Sx: tons of dilute urine 2/2 no ADH effect
Central DI: lack of ADH from posterior pituitary - idiopathic, trauma, neoplasm, sarcoid, granuloma
Nephrogenic: meds (lithium, demeclocycline)
Name a bunch of causes of SIADH:
stroke, hemorrhage, infection, trauma. Oxytocin (in pregnant patients), narcotics, PAIN, PNA, small cell cancer
Weakness, dizziness, sweating, n/v after eating -
hint - especially after some sort of surgery
Dumping syndrome. Anything with small stomach or missing pylorus.
Symptoms of pernicious anemia…. other than just vitamin B12 deficiency anemia
Achlorhydria! Destroyed acid secreting parietal cells.
Causes of secretory diarrhea
bacterial toxin (e coli, cholera), VIPoma (pancreatic islet cell tumor), or bile acids after ileal resection
Is toxic megacolon more likely with UC or Crohns?
UC
TTP pentad
thrombocytopenia, microangiopathic hemolytic anemia, renal insufficiency, neurologic changes (AMS), fever.
- Live threatening small vessel thrombotic dz! Normal coags!
hot thyroid nodule is high or low risk for canceR?
LOW. if low TSH with hot nodule, just tx for hyperthyroid without FNA>
Name an antibiotic used to treat MSSA, but can cause AIN version of AKI
nafcillin
Name a drug/class commonly used for serious gram negative infections, but can be nephrotoxic
aminoglycosides - like amikacin
Sudden and severe headache, brief LOC, n/v, and meningismus?
subarachnoid hemorrhage
Suspected acute stroke first step?
CT head w/o contrast
acute focal neurologic deficits gradually worsening over minutes to hours - first concern?
stroke! probable intracerebral hemorrhage
vincristine and vinca alkaloids / platinum based chemo neuropathy sx
symmetrical paresthesias, stocking-glove pattern. early loss of ankle jerk reflexes, and loss of pain and temperature sensation.
Does ILD have impaired gas exchange? High or low FEV1/FVC? Normal or high A-a gradient?
Impaired gas exchange / DLCO
NML or even elevated FEV1/FVC ratio (both both are low)
Big A-a gradient
New DM2 diagnosis - what do start with for glucose control? What not to use for lipid help in this patient?
Always lifestyle modification, but probably add on metformin right away. Goal <7.5 A1c.
Don’t use niacin in diabetes - can worsen BS control
Tx for recent lyme disease? What if severe/meningitis with lyme? What about <8yo or pregnant?
Doxycycline for most. IV ceftriaxone for severe. Amoxicillin for kids b/c doxy stains teeth.
severe hypercalcemia with pancytopenia suggests? how to treat first? then diagnose what second?
First IV fluids for hypercalcemia. Then bone marrow biopsy to look for suspected multiple myeloma!
what causes warfarin-induced skin necrosis? what factors does warfarin inhibit?
necrosis: protein C deficiency - usually early in therapy. C gets blocked first - turns into transient hypercoagulability.
inhibits: II, VII, IX, X, C and S
subdural hematoma vs epidural. Which is biconvex? which crosses suture lines?
subdural: rupture of bridging veins, concave; 1-2 days after injury. Crosses suture lines.
epidural: miningeal arteries, bigger trauma; convex
what commonly causes lacunar strokes?
HTN causing hyalinosis of penetrating branches of major cerebral arteries. Lacunes are small, often missed on early CT; deep = BG, thal, internal capsule
sudden clap of headache, brief LOC, then meningismus - what happened?
subarachnoid hemorrhage
risks of being small for gestational age?
Long term hypoxia can lead to polycythemia, hypocalcemia, hypoglycemia, hypothermia 2/2 low SC fat, meconium aspiration
Suspect pyoderma gangrenosum in patient with a large painful ulcer and what underlying health condition?
Violaceous border to the ulcer
Hx of a systemic disease, like IBD, UC, arthropathies, RA, or heme stuff (AML)
Risk factors for RCC?
smoking, HTN, diabetes= the basics
Patient has ischemic stroke. also hemineglect - where was stroke?
Most likely R (or non-dominant) parietal lobe. MCA or PCA. May also have anosognosia - inability to learn self-awareness.
anion gap metabolic acidosis, abdominal pain, n/v, hematemesis. Radioopaque pills on CXR. Hypotensive shock.
Iron poisoning! Can have acute onset, 30 min to 4 days. Give: whole bowel irrigation, deferroxamine.
It’s corrosive to the GI mucosa! Also potent vasodilator, cellular toxin
dry eyes, dry mouth, dysphagia to solids - likely diagnosis? first test?
Sjogren syndrom - most common in middle age women. Text with anti Ro and anti-La (SSA and SSB, respectively) antibodies first.
Dry mouth causes caries.
Can biopsy salivary (submandibular glands) if others are nondiagnostic
Suspecting acromegaly - first test? Main sx?
Get IGF-1 level. Always elevated in acromegaly. Then oral glucose suppression test, doesn’t suppress growth hormone in acromegaly!
Sx: coarse facial features, arthralgias, HTN, enlarging digits, carpal tunnel.
Acid base disturbance in DKA? Expected Na? Glucose? K?
low nml Na (also low phos)
Glucose HIGH
K high due to intracellular shifts 2/2 plasma hypertonicity and loss of insulin dependent shifts (but total body K is down due to loss in urine!)
Metabolic acidosis, low bicarb
workup of male hypogonadism -
testosterone, LH, FSH. Primary hypogonadism = low T, high FSH/LH. Fine, can give T? Secondary = low or nml FSH/LH also. Check for prolactin level. If high, check other pituitary hormones. If more problems, consider imaging. Pituitary adenoma (tx with dopamine agonists!) mass effects, visual field defect
Diabetic nephropathy - what level becomes macroproteinopathy?
> 300 mg/24hrs
What causes Graves ophthalmopathy? What is it?
Cause: T cell activation and stimulation by orbital fibroblasts by TSH receptor autoantibodies, leading to expansion of orbital tissues
Sx: ocular irritation, impaired extraocular movtion, and proptosis
Relevance of urine staining positive with prussian blue?
Stains hemosiderin. Found in urine during hemolytic episodes (e.g. in G6PD flare after sulfa drug, infection, antimalarial drug, or nitrofurantoin)
Patient on antithyroid drugs (like propylthiouracil) + new sore throat and fever - indicates?
Concern for agranulocytosis. Check WBC count (for ANC <1000 is concerning)
