UW Pre-Reset Flashcards
FATRN: fever, anemia (microangiopathic hemolytic anemia), thrombocytopenia, renal insufficiency, neuro *HA confusion, dx? mgmt?
TTP! (small vessel thrombi that consume platelets, shear RBCs, and cause end organ damage; emergency tx w/ plasma exchange +/- steroids. TTP is caused by def in plasma protease ADAMTS13 (d/t formation of autoantibody); lots of vWF accumulate on endothelial wall trapping platelets and generate thrombi
TTP vs HUS
Very similar in that both cause MAHA and thrombocytopenia; except HUS a/w E. coli and is primarily a disorder of renal system - no neuro findings or fever
MAHA - microangiopathic hemolytic anemia on peripheral blood smear?
Schistocytes/RBC fragments
Pt w/ recent fever, chills, productive cough, and leukocytosis has 3rd episode of RLL pneumonia in past several months
Recurrent pneumonia occurring in the same anatomic location of lung raises suspicion for localized airway obstruction, which if present can lead to impaired bacterial clearance and predisposition to infection; get CT to r/o cancer
PFTs for chronic lung diseases: asthma, COPD, ILD/restrictive chest wall disease
Asthma and COPD: normal to inc TLC, dec FEV1/FVC, DLCO dec in COPD but normal in asthma
ILD/restrictive chest wall (restrictive pattern): dec TLC, normal FEV1/FVC, dec DLCO for ILD and normal for restrctive chest wall disease
Splenic abscess p/w fever, leukocytosis, LUQ pain; pts develop left sided pleuritic chest pain and left pleural effusion and splenomegaly, risk factors for splenic abscess?
Hematogenous spread ie infective endocarditis
Pure motor hemiparesis, lesion where?
Lacunar stroke (single modality defect) affecting posterior limb of internal capsule (commonly a/w chronic HTN which leads to arteriolar sclerosis)
47yo man, recurrent blisters on dorsum of his hand and forearm, fatigue and occasional joint pain, elevated transaminases, dx?
Porphyria cutanea tarda d/t chronic hepatitis C virus (other extra hepatic manifestations = mixed cyroglobuinemia syndrome *paplpable purpura, athralgias, glomerulonephritis, low
complement), lichen planus
Lady w/ transient (lasting just hours) of foot drop and sensory changes over dorsal foot and lateral shin; PE shows impaired ankle dorsiflexion and great toe extension w/ preserved plantar flexion and reflexes, dx?
Common fibular neuropathy aka common peroneal d/t peripheral nerve compression; common peroneal travels near fibular head and is susceptible to compressive injuries eg cast/bedrest/leg crossing. This is not MS since resolved in hours (MS episodes take days to weeks)
Edema in just the UE, venous congestion in anterior chest, dx?
Superior vena cava syndrome (60% of cases d/t cancer, get cxr)
Muffled voice, deviated uvula w/ unilateral lymphadenopathy, dx and mgmt?
Tonsilitis -> progressed to peritonsilar abscess; dx w/ needle peritonsilar aspiration and give IV abx
Dvlpt of clubbing and sudden onset joint arthropathy in a chronic smoker, dx?
Hypertrophic osteoarthropathy, this condition is a/w lung cancer, get cxr
vWF blood panel findings? DIC findings?
vWF deficiency = prolonged bleeding and aPPT, normal platelets
DIC = consumption of all coagulation cascade components - thrombocytopenia, microangiopathic hemolytic anemia, low clotting factors (fibrinogen, factors V and VIII), and prolonged PT and aPTT
Lady w/ fluctuating double vision, found to have antibodies against nicotinic receptors on the motor end plate, next steps?
She has myasthenia; get CT scan chest to look for thymoma that is operable since that can lead to long-term improvement; side note while ACH receptor antibodies are highly specific - other tests for MG include muscle specific tyrosine kinase antibodies -> EMG -> or edrophonium test (less specific though since it is just acetylcholinesterase inhibitor)
Complication of dermatomyositis that over 15% of adult pts will develop or have?
Malignancy commonly ovarian, lung, pancreatic, stomach, colorectal, non-Hodgkin
Anti-RNP, anti-Jo-1, dx?
Dermatomyositis
Persistence of nocturnal and early morning penile erections helps ddx psychogenic from organic causes of male ED
Normal nocturnal erections indicate vascular and nerve function
Old lady, focal neuro symptoms - drops spoon, right sided weakness - followed by vomiting, pressures of 180/105, dx?
Intracranial hemorrhage 2/2 HTN occurring commonly in basal ganglia, thalamus, pons, cerebellum. Pts present w/ focal symptoms progressing to signs of elevated ICP (nausea, vomiting, HA)
Other bugs involved w/ GBS besides campy
Herpes viruses, mycoplasma, haemophilus influenzae; GBS occurs more frequently in pts w/ lymphoma, sarocoidosis, SLE
Hemolysis can occur intra or extra vascularly
Intravascular hemolysis is d/t significant RBC structural damage resulting in RBC destruction within intravascular space (eg paroxysmal nocturnal hemoglobinuria, or DIC) Extravascular hemolysis: RBCs predominantly destroyed by phagocytes in the reticuloendothelial system (eg lymph nodes, spleen). Less HgB release than intravascular hemolysis but still low haptoglobin, elevated LDH and elevated indirect bilirubin. Extravascular is d/t antibody mediated RBC destruction (AIHA), intrinsic RBC enzyme (G6PD def) or membrane defects (hereditary spherocytosis) *AIHA vs hereditary spherocytosis: same spherocytes, but AIHA is coombs positive while hereditary is family hx auto dom/negative Coombs/positive osmotic fragility test
Dramatic leukocytosis, absolute basophilia, shift towards very early neutrophil precursor cells (promyelocytes, myelocytes), dx? Use what score to ddx from leukemoid rxn?
Chronic myeloid leukemia. Leukocyte alkaline phosphatase score is low in CML while it is high in leukemoid reaction (which is caused by severe infection where as CML is d/t BCR-ABL fusion). More myelocytes in CML, more metamyelocytes in leukemoid rxn
Blood transfusion following liver injurt from MVA, now w/ numbness in fingertips/lips, forceful flexion of wrist w/ abduction of the thumb while nurse measures BP (trousseau signs), dx?
Acute hypocalcemia (chelation - blood citrate from transfusion binds free ionized calcium causing functional hypocalcemia)
RA vs Parvovirus B19 infection
RA presents w/ joint stiffness for at least an hr in the morning, joint swelling, and symptoms for > 6 weeks
B19: although similar joints affected as RA (MCP, PIP, wrist) symptoms are acute (10 days) and there was absence of joint swelling or prolonged joint stiffness in the morning; look for erythema infectiosum rash/diarrhea/fatigue/fever; look for anti-B19 IgM antibodies but self-resolving course
Bugs that can cause infective endocarditis?
Staph aureus, viridans, staph epidermidis, enterococci (nosocomial UTI question), strep bovis, fungi
SOB, productive cough (despite worse w/ exertion), evidence of destruction of lower lung lobes, look for panacinar emphysema causing destruction in lower lobes (vs smoking causing centrilobular emphysema of the upper lobes), dx?
Alpha-1 antitrypsin deficiency; dx confirm w/ serum AAT levels, tx w/ pooled human AAT
Complication of subarachnoid hemorrhage post coiling?
Vasospasm that can result in cerebral infarction; prevented w/ nimodipine
Substance abuse and incarcerated pt, p/w subacute/chronic fevers, weight loss, fatigue, and pulmonary symptoms, CXR shows diffuse reticulonodular pattern (millet seed), dx?
TB!
Jarisch-Herxheimer rxn
Acute, febrile rxn that occurs <12 hrs after initial tx of early syphilis. Symptoms = fever, HA, myalgias, rigor, sweating, hypotension, and worsening syphilitic rash. Manifestations self limited and resolves spontaneously 48hrs
Partial acid fast gram positive bacteria, on chest CT showing multiple cavitary nodules, dissemination to brain forming abscess, pt is immunocompromised, dx and tx?
Nocardia, tx w/ bactrim (add carbapenems for brain involvement); tx duration is 6mo-1yr
Cushing reflex?
Inc ICP response = HTN, bradycardia, respiratory depression (everything down except pressures)
Urate crystals deposited in skin resulting in formation of tumors w/ chalky white appearance
Chronic tophaceous gout
What virus causes mononucleosis like illnesss (fever, malaise, fatigue, absolute lymphocytosis w/ atypical lymphocytes), but these pts have mild to absent
pharyngitis/lymphadenopathy/splenomegaly? What tests to order? and tx?
CMV mononucleosis (~10% of pts seroconvert); look for negative heterophile antibody test (that is negative monospot) but positive CMV IgM serology. -cyclovir
Individuals w/ history of high risk sexual intercourse should be screened for HIV and HepB
Individuals who use IV drugs, have high risk needle stick exposure, or received blood transfusions before 1992 should be screened for HepC
Elevated alk phos and elevated TB + DB = obstructive pattern
Post hepatic: conjugated bilirubin will build up and over flow bucket = build up of TB and DB = obstruction. If TB > DB and indirect bili elevated = think pre hepatic or hemolysis picture
4th and 5th fingers w/ decreased sensation and weak grip, dx?
Ulnar nerve entrapment; most common site is at elbow where ulnar nerve lies at medial epicondylar groove (leaning on elbow at computer)
Tumor lysis syndrome: risk, manifestations, tx, prophylaxis
Risk: initiation of cytotoxic chemotherapy
Manifestations: severe electrolyte abnormalities - cellular contents (K and phosphorus and uric acid from nucleic acids are released -> phosphorus binds up calcium causing hypocalcemia and precipitating calcium phosphate stones -> so now CaPO4 and uric acid stones can cause AKI -> oh and cardiac arrhythmias w/ electrolytes
Tx: telemetry, manage lytes
Proph: IV fluids, allopurinol to control uric acid metabolism
Chronic large artery vasculitis affecting Asian women <40; involves aorta, symptoms include fever/athralgias/weight loss, arterio-occlusive manifestations (claudication, distal ulcers) particularly in UE. BP discrepancies in either arms (like aortic dissection), pulse deficits and bruits. Cxr shows aortic dilation and widened mediastinum (thickening of large artery walls and lumenal narrowing); tx w/ systemic glucocorticoids
Takyasu arteritis
*Aortic coarctation can cause BP discrepancies more in lower rather than upper extremities
Drugs of choice for stabilizing bony metastatic lesions to prevent hypercalcemia of malignancy and pathologic fractures?
Bisphosphonates (zoldrenoic acid, pamidronate), normal Ca = 8.4 - 10.2
Acute erosive gastropathy
Dvlpt of hemorrhagic lesions after ischemia or exposure of gastric mucosa to various injurious agents (alcohol, aspirin, cocaine)
Old man p/w fatigue, forget fullness, abdl pain/constipation/anorexia, PERIPHERAL neuropathy, lab findings w/ microcytic anemia and basophilic stippling on peripheral smear
Lead poisoning
Caustic ingestion w/ sodium or KOH causes immediate esophageal injury w/ liquefaction necrosis and potential perforation
Endoscopy is recommended within the 1st 12-24hrs to assess severity of dmg and guide further therapy. Activated charcoal, corticosteroids,
emetics and acid neutralization are not recommended
HTN pt w/ acute severe thunderclap HA (maximal intensity reached in <1 minute) and symptoms of meningeal irritation (nausea/vomiting/photophobia), dx and imaging findings?
Nontraumatic subarachnoid hemorrhage d/t ruptured saccular berry aneurysm; CT w/o contrast (good for blood) will show high density signal around brain stem and basal cisterns (middle of brain); tx = cerebral angiography to confirm and craniotomy w/ aneurysm clipping or endovascular methods (coiling/stenting aneurysm)
Acute pyelonephritis: uncomplicated vs complicated
Uncomplicated: otherwise healthy, nonpregnant, primarily E. coli, tx w/ oral fluoroquinolone or bactrim, IV abx if vomiting/septic/elderly
Complicated: DIABETES, urinary obstruction/instrumentation, renal failure, immunosuppression, hospital acquired, inc risk of abx resistance and tx failure consider IV
fluoroquinolone, aminoglycoside
Abnormal copper deposition in liver, basal ganglia, cornea, autosomal recessive in younger individuals, how to dx?
Wilson's disease, presence of low serum cerulopasmin in conjunction w/ inc urinary copper excretion or Kayser-Fleischer rings. Clinical findings can include asymptomatic aminotransferase elevations to fulminant hepatic failure while young peeps get neuropsychiatric disease (tremor, rigidity, depression, paranoia, catatonia)
OA vs RA x-ray findings?
OA: narrowing of joint space and osteophytes
RA: periarticular osteopenia and joint margin erosions
Pseudogout findings? Gout findings?
Pseudogout: CPPD deposition, rhomboid and positively birefringent crystals
Gout: Inflammatory effusion, needle shaped and negatively birefringent crystals; x-rays w/
punched out erosions w/ rim of cortical bone
Mechanism of G6PD?
G6PD enzyme deficient erythrocytes cannot bind oxidative metabolites - this causes membrane instability and leads to acute episodic hemolysis in the spleen *bite cells. Lab findings suggestive of hemolysis include low HgB, inc indirect bilirubin, inc LDH, dec haptoglobin. G6PD activity assay may be negative during acute hemolytic episode
G6PD all you need to know:
Epi: hemolytic anemia (indirect bili inc, hapto negative, hemoglobin dec, inc LDH), following oxidative stress (infection, sulfa drugs like bactrim, fava beans), Asian/Black x-linked!
Manifestations: dark urine (d/t hemolysis), jaundice, abdl back pain (w/ severe hemolysis)
Labs: bite cells w/ Heinz bodies, G6PD activity assay level may be low during attack
Mgmt: remove or tx agent/condition, supportive care
Mild pulmonary illness,cutaneous manifestations include circumscribed verrucous nodules and plaques that progress to microabscesses (warty heaped up skin lesions w/ violaceous hue and sharply demarcated border; some crusted lesion w/ peripheral ulcer), dx?
Blastomycosis (endemic to south/south central states, Mississippi and Ohio River Valleys); other organ involvements include lung, skin (wartlike lesions, violaceous nodules, skin ulcers), osteomyelitis, GU - prostatitis or epididymo-orchitis)
Antibodies found in systemic sclerosis
ANA, anti-topoisomerase, anti-centromere (anti-scl-70 and anti-RNA pol III a/w diffuse cutaneous systemic sclerosis)
Complications a/w systemic sclerosis
Lung: ILD, pulmonary arterial HTN
Kidney: HTN, scleroderma renal crisis (oliguria, thrombocytopenia, MAHA)
Heart: myocardial fibrosis, pericarditis, pericardial effusion
Antibodies and associated disorders
RF: many autoimmmune but predominantly RA
Anti-dsDNA: SLE
Anti-CCP: more specific for RA
Anti-mitochondrial: primary biliary cholangitis
ANCA: GPA (Wegner), microscopic polyangitis, other vasculitidies
Anti-scl-70: systemic sclerosis (anti-RNA pol III)
Anti-Jo1: dermatomyositis
HLA-B27: ankylosing spondylitis
Anti-smooth muscle antibodies: autoimmune hepatitis
Syringomyelia is a fluid filled cavity located within cervical and thoracic spinal cord that is most commonly a/w Arnold Chiari malformation type 1
Pts p/w areflexic weakness in the UE and dissociated sensory loss following cape distribution (neck, shoulders, upper arms)
HIV pt w/ subacute onset low grade fever, HA and signs of inc ICP (papilledema, vomiting), evaluate for what?
Cryptococcal meningitis using cryptococcal antigen or isolation of organism in CSF
JC virus causes what in HIV pts?
Multifocal leukoencephalopathy - MRI shows patchy areas of white matter c/w demyelination
Any patient w/ acute, severe illness may have abnormal thyroid function tests, syndrome?
Euthyroid sick syndrome “low T3 syndrome” is characterized by a fall in total and free T3 levels w/ normal T4 and TSH levels; self-resolving
Hereditary spherocytosis info?
Epidemiology: autosomal dominant, northern european Clinical: hemolytic anemia, jaundice, splenomegaly
Lab findings: elevated MCHC, spherocytes (spheres on peripheal smear), negative coombs, can confirm w/ osmotic fragility test or eosin-5-maleimide binding test Tx: folid acid supplementation, blood transfusions, splenectomy
Complication: pigment gall stones, aplastic crises from parvovirus B19 infection
Spherocytes also found in G6PD and autoimmune hemolytic but these have other lab findings
Vitreous hemorrhage vs retinal tear?
Vitreous hemorrhage: sudden vision loss, floaters, fundus is hard to visualize!
Retinal detachment: sudden vision loss, floaters, photopsia (flashing lights), fundoscopy will show elevated retina w/ folds and or a tear
CRAO: sudden painless vision loss, opthalmoscopic signs show disk swelling venous dilation/tortuosity, retinal hemorrhages and cotton wool spots
Young female w/ MS and prolonged immobilization p/w sudden onset CP, dyspnea, tachycardia, small pleural effusion, dx?
PE! Pleural effusion d/t hemorrhage or inflammation (generally exudative, grossly bloody, can be a/w pain d/t irritation); where as aspiration pneumonia presents as lobar infiltrate
Large RBCs and hypersegmented neutrophils?
Megaloblastic anemia d/t either folate or cobalamin (B12) def, either def will result in elevated homocysteine
Which lab can ddx btw folate and cobalamin def?
Measure MMA concentration (if inc = cobalamin deficiency since cobalamin is also involved in conversion of methymalonyl-CoA to succinyl-Coa *unlike folate)
Definition of solitary pulmonary nodule:
Rounded opacity, <3cm, completely surrounded by pulmonary parenchyma, no associated lymph node enlargement. Lesions w/ high malignancy risk require surgical excision. If .8cm but w/ no suspicion for malignancy consider PET for further eval or f/u w/ serial CT
Young man, sharp localized pain and tenderness over anteromedial part of tibial plateau just below joint line of knee, recent fall, valgus stress test negative (not MCL involvement), x-rays
normal, dx?
Pes anserinus pain syndrome
Sjorgen syndrome is an autoimmune disorder characterized by a lymphocytic inflammatory infiltrate in the exocrine glands and can present w/ dry eyes and dry mouth
It may occur independently or a manifestation of another autoimmune disorder (systemic sclerosis). However, onset is typically in middle age, and initial presentation after 65 is unusual. Also pts
have ANA positive and those with systemic sclerosis have associated systemic manifestations
Traveler’s diarrhea that is prolonged, profuse, and watery, dx?
Cryptosporidium parvum (transiently severe but self-limited in healthy individuals; AIDS pts are at risk for chronic infection)
What bacteria causes IE in pts w/ colon cancer or IBD
Strep bovis aka strep gallolyticus
Most common cause of IE in structurally normal heart valves, IVDU, prosthetic valve or implanated device pts
Staph aureus - look for acute high fever and rapid progressive cardiac dysfunction; whereas strep viridans (or mutans) is typically subacute w/ several weeks of fatigue and low grade fever
> 40yo indolent pain worse by activity relieved by rest; joint is not tender and systemic symptoms are absent, dx?
Osteoarthritis (affects knees, hips, DIP joints)
Delayed sleep wake phase disorder vs shift work disorder
DSWPD: long history of sleep difficulties that occur when work or school schedule requires and early rise time (sleep onset insomnia and excessive morning sleepiness); basically’s internal clock for sleeping does not align with her social/professional schedule; consider light or behavioral therapy
Shift work disorder: person has normal circadian rhythm who is now required to work night
shift
Ear pain and ear drainage w/ granulation tissue, dx and bug? Progression of infection can lead to osteomyelitis of skull base and cranial nerve damage (facial drooping)
Malignant otitis externa, pseudomonas, pts w/ diabetes and are old are at risk
MOS of bacillus cereus?
Preformed enterotoxin, hence why expect to see quick onset vomiting predominant
RANDOM FACTS
Brain death is a clinical dx, characteristic findings are absent cortical and brain stem functions; spinal cord may still be functioning hence DTR can be present still
Innocent flow murmur d/t hyper dynamic circulation from fever - HIV pt w/ lobar pneumoniae and midsystolic upper left sternal border murmur
Individuals w/ resolved HepB infection are positive for anti-HBs and anti-HBc but negative for HBsAg. Individuals who are immunized w/ HepB vaccine are positive for anti-HBs but negative for HBsAg and anti-HBc. Recovery phase of HepB = presence of anti-HBs, anti-HBc (now IgG) and anti-HBe. Chronic HepB still has HbsAg. The HBe antigen and antibody usually indicates either active infection or very recent infection that is nearing cessation or low infectivity
A normal D dimer result is useful in excluding pulmonary venous thromboembolism (VTE) in patients w/ unlikely pretest probability. However, a normal D-dimer (as in negative D- dimer) result is not useful in pts w/ likely pretest probability (f/u w/ V/Q scan or CTA). An elevated
D dimer result in any pt is not diagnostic of VTE, and must be followed up
AVM malformation common in intracranial hemorrhage in kids. Cardioembolic stroke multiple ischemic infarctions at grey-white matter junction. Ischemic stroke = hypodense (bleeding is hyper dense on CT). Subarachnoid hemorrhage - severe thunderclap HA and
hyperattenuation of sulci and basal cisterns on CT
Aminoglycoside can cause ototoxicity by damaging cochlear cells and some aminoglycosides like gentamicin can also damage motion sensitive hair cells in inner ear causing vestibulopathy
Mgmt of frostbite?
Rapid rewarming in water bath
Telogen effluvium vs alopecia areata
Telogen: acute diffuse noninflammatory hair loss triggered by STRESS; hair pull test shows extraction of >10% fibers - scalp and hair shaft appear normal. Reassurance!
Alopecia areata: autoimmune disorder w/ circumscribed patches of hair loss; hair shafts show
narrowing close to surface and may be broken off
Pneumovax 23 vs prevnar 13, who gets what and mechanism for each
Prevnar 13 for all infants and young children; Pneumovax 23 for adults <65 w/ predisposing comorbidities (chronic heart or lung disease, diabetes mellitus, cirrhosis). For adults >65 and immunocompromised = both vaccines Pneumovax - less robust immune response since just polysaccharides (capsular material)
Prevnar - more robust since capsular polysaccharides attached to inactivated diptheria toxin protein inducing T cell dependent B cell response
Atropine and pralidoxime as antidote?
Treats cholinergic toxicity (bradycardia, miosis, bronchospasm, vomting, diarrhea), caused by organophosphate poisoning. Atropine blocks peripheral effects of acetylcholine at muscarinic receptors whereas pralidoxime aids in reactivation of acetylcholinesterase
Symptoms begin w/ bilateral cranial neuropathies (blurred vision, diplopia, facial weakness, dysarthria, dysphagia), then descending muscle weakness (hands then feet) or diaphragmatic weakness w/ respiratory failure, dx and tx?
Foodborne botulism; tx w/ equine serum heptavalent antitoxin (passive immunoglobulins)
Painless maroon colored rectal bleeding, hx of CKD or aortic stenosis or vWF deficiency, dx?
Angiodysplasia - dilated submucosal veins and AVM
Ankylosing spondylitis: inflammatory back pain, exam findings, complications, lab findings, imaging?
INFLAMMATORY back pain: relieved w/ exercise worse in morning, not relieved by rest
Exam findings: AREDU (arthritis, reduced chest expansion/spinal mobility), enthesitis (tenderness at tendon), dactylitis (swelling of finger toes), uveitis Complications: osteo/vertebral fractures, aortic regurg, cauda equina. Most common extraarticular manifestation of AS = anterior uveitis (inflammation of uveal tract - iris, ciliary body, choroid)
Lab: HLA B27, ESR CRP
Imaging: x-ray of SI joints
CT w/ contrast vs CT w/o contrast
W/ contrast = good for indentifying structural abnormality or mass lesions
W/o contrast = good for investigating bleeds (intracranial bleeds)
Elevated ALP and the use of GGT
ALP is found in liver and bones; however GGT is only in liver -> so if ALP is elevated but GGT is normal than the elevated ALP is d/t bone issue
Focal bone pain, elevated ALP but normal GGT, dx and mechanism?
Paget disease of bone - d/t abnormal osteoclast activity leading to inc bone turnover and bad remodeling
X-ray findings for Paget’s disease and other complications
Cortical thickening and osteolytic or mixed lytic/sclerotic lesions on x-ray and focally inc radiotracer uptake on bone scan. Complications include involvement of cranial bones w/ frontal bossing, inc hat size, hearing loss (enlargement of temporal bone and encroachment on cochlea)
Hypocalcemia (seen w/ hyperventilation and blood transfusions) = carpopedal spasms vs hypercalcemia (seen w/ = abdl pain, constipation, polydipsia
Hypercalcemia causes renal vasoconstriction and dec glomerular blood flow -> loss of sodium and free water
Milk alkali syndrome?
Excessive intake of Ca and absorbable alkali - pts taking calcium bicarb for osteoporosis; look for symptomatic hypercalcemia (abdl pain, constipation, polydipsia), metabolic alkalosis and AKI
What drugs to be cautioned about when given sildenafil?
Alpha blockers, nitrates or any hypotensives
Erysipelas vs cellulitis
Erysipelas: typicall streptococci infection, limited to epidermis and superficial dermis = which gives it characteristic RAISED, sharp borders and intense erythema
Cellulitis: deep dermal and subcutaneous fat infection typically caused by either beta hemolytic streptococcus (nonpurulent) or staph aureus (purulent); look for warm tender erythematous FLAT indistinct borders
Long standing joint pain (RA), severe erosive joint disease and deformity, neutropenia (ANC <1500), splenomegaly, recurrent ulcerative skin lesions, dx?
Felty syndrome d/t long standing RA; dx w/ anti-CCP and RF, markedly elevated ESR
Aspergillosis vs PCP cxr and clinical findings
Aspergillosis: pulmonary nodules or segmental infiltrates (like that TB cavitary lesion w/ aspergillosis ball); fever/pleuritic CP/hemoptysis; tx w/ voriconazole and enchinocandin. THIS has ground glass opacities
PCP: bilateral diffuse interstitial infiltrates; fever/nonproductive cough (hemoptysis not common)
Arsenic vs lead poisoning:
Arsenic: painful sensorimotor polyneuropathy, SKIN LESIONS (hypo and hyper pigmentation, hyperkeratotic), pancytopenia, mild transaminase; dx w/ urine arsenic levels, tx w/ chelation
Lead poisoning: can lead to sensorimotor neuropathy in stocking glove distribution w/ microcytic anemia, GI complaints common!
Biostatistics:
NNT formula: 1/ARR
Statistical method to compare means: two sample T
Sensitivity = proportion of positive test results among subjects w/ the disease (will incorporate false negatives)
Specificity = proportion of negative test results among subjects without the disease (the total will incorporate false positives)
Prevalence affects PPV and NPV only, does not affect sensitivity/specificity (high prevalence = PPV is high, NPV is low)
Pts in a study no they are part of control/experimental group, alter their activities because of said info = Hawthorne effect
Gradual painless PERIPHERAL vision loss; optic disc enlargement w/ inc cup:disc ratio
Open angle glaucoma (central vision loss in macular degen)
Progressive CENTRAL vision loss, pt has vascular risk factors, both eyes affected, funduscopic shows drusen yellow deposits
Macular degeneration (peripheral vision loss in glaucoma)
Elderly pt, acute, painless monocular vision loss, cherry red spots and cotton wool spots on funduscopy
CRAO
Painful red eye, blurry vision, photphobia
Anterior uveitis
Acute onset monocular vision loss w/ central scotoma, afferent pupillary defect, changes in color perception, pain w/ eye movement, dx and association
Optic neuritis and MS
Inc homocysteine levels predispose to venous thrombosis as well as atherosclerosis (d/t vascular dmg, clotting mechanism activation, inhibition of antithrombosis), it is usually metabolized to either cysteine or methylated to form methionine, what factors are involved in these pathways?
B6 (pyridoxine) - cysteine pathway; folate and cobalmin (B12) - methionine pathway. Can normalize homocysteine levels w/ either B6 or folate; B12 if B12 def is documented
NO B SYMPTOMS, pancytopenia (granulocytopenia causing infections, anemia causing fatigue, thrombocytopenia causing bleeding), splenomegaly (early satiety), peripheral smear w/ B cells showing cytoplasmic projections (many finger like extensions), dx? dx technique? tx?
Hairy cell leukemia, bone marrow bx w/ flow cytometry, tx is chemo (life expectancy great); hair cell leukemia = clonal B cell neoplasm affecting middle age older adults d/t BRAF mutation
Chronic B cell neoplasm that infiltrates bone marrow, spleen, and peripheral blood resulting in cytopenia, splenomegaly, peripheral smear w/ evidence of hairy cytoplasmic projections, no B symptoms, dx?
Hair cell leukemia (low cell lines and hair projection, no b symptoms!)
Significant leukocytosis, lymphadenopathy, B symptoms, peripheral smear shows smudge cells (blobs)
CLL chronic lymphocytic leukemia
Occupations a/w asbestosis, and what type of cancer?
Plumbers, electricians, carpenters, pipefitters, insulation workers; bronchogenic carcinoma (look at card comparing cxr/CT findings for carcinoma vs mesothelioma)
Cxr and CT findings for bronchogenic carcinoma 2/2 asbestosis
CXR: atelectasis and bilateral PLEURAL PLAQUES over the diaphragm
CT: reticular opacities of lung fields, multiple PLEURAL PLAQUES and round single cavitary mass
Compared to pleural mesothelioma (another risk factor of asbestosis) but presents as unilateral pleural abnormality w/ large pleural effusion
Diabetes meds and important points to remember: metformin, sulfonylureas, pioglitazone, DPP-IV inhibitors, GLP-1
Metformin initial therapy for T2DM, weight neutral, low risk hypoglycemia, CARE for lactic acidosis Sulfonylureas: added if failed metformin, weight gain and hypoylgycemia are main side effects
Pioglitazone: used if can’t tolerate metformin/sulfonylureas, side effects include everything (weight gain, edema, CHF, bones, bladder CA), can use in renal insufficiency
DPP-IV inhibitors: low hypoglycemia risk, weight neutral, can be used in renal insufficiency
GLP-1: GOOD FOR WEIGHT loss, low hypoglycemia risk
New anticoagulation, 5-10 days later, >50% drop in platelets, new clot, dx?
Heparin induced thrombocytopenia (Type 2 - immune mediated via antibodies against platelets, days after tx vs Type 1 = immediate non-immune mediated drop in plts that resolves)
Periorbital cellulitis vs cavernous sinus involvement:
Opthalmoplegia = sign of orbital muscle and nerve damage; the presence of HA and bilateral face and eye symptoms reflects involvement of the cavernous sinus
Cheek insect bite, now severe HA, bilateral periorbital edema, restricted extraocular movements, forehead/mid-face tender to palpation, dx?
Infectious cavernous sinus thrombosis
Skin findings in meningococcemia
Petechial rash that progresses to ecchymosis, bullae, vesicles, and gangrenous necrosis; pts have fever, nausea, vomiting, severe myalgias, meningeal signs, and shock
Rocky mountain spotted fever rash?
Petechial, starts in extremities and migrates inward, starts a few days after fever onset
Toxic shock syndrome associations, skin findings, clinical findings?
A/w menstruation (tampons), nasal packing (epistaxis), post sx infections; pts develop fever, myalgias, marked hypotension, diffuse erythematous macular rash; thrombocytopenia more common than leukocytosis!; immature neutrophils (bands) present as well; mainly staph aureus
Bilateral nontender enlargement of submandibular glands, dx and cause?
Sialadenosis - found in pts w/ liver disease (alcoholic and nonalcoholic cirrhosis). Benign noninflammatory swelling of salivary glands; reassurance. DDx includes salivary gland stones (swelling pain w/ meals) and sialadenitis (focal tenderness erythema fever)
Mechanism of ARDS
Lung injury and inflammation and edema leading to alveolar collapse and poor oxygenation
Complications of positive pressure ventilation?
Alveolar damage, pneumothorax, and hypotension
Calcium oxalate crystals, hypocalcemia, flank pain, hematuria, oliguria, AKI, anion gap metabolic acidosis, dx and tx?
Ethylene glycol posioning (ethylene glycol and methanol found in antifreeze, ingested as substitute for ethanol); tx w/ fomepizole (competitive inhibitor of alcohol dehydrogenase prevents further breakdown of ethylene glycol into toxins oxalic acid and glycolic acid);
consider hemodialysis for end organ dmg or sodium bicarb to help metabolic acidosis (only if pH < 7)
Intracranial HTN or pseudotumor cerebri mgmt?
Tx goals are prevention of BLINDNESS, reduction of ICP, and symptomatic relief of HA; 1st line meds is acetazolamide which inhibits choroid plexus carbonic anhydrase thereby decreasing CSF production, furosemide can be added if symptoms persist. Refractory to med pts w/ vision loss = sx intervention w/ optic nerve sheath decompression or lumboperitoneal shunting
Causes of acute liver failure (which = ALT and AST >1000, encephalopathy, and synthetic liver dysfunction INR >1.5)
Viral hepatitis (everything but C, also HSV and CMV), drug toxicity, ischemia (shock liver or Budd-Chiari look for RUQ pain), autoimmune hepatitis, Wilson disease, malignant infiltration
Rapid onset of severe eye pain seeing halos around lights, DILATED pupil w/ poor response to light, can have tearing and HA w/ nausea and vomiting, dx?
Acute angle closure glaucoma (dilated eyes, neuro symptoms, severe eye pain); can be precipitated as a response to pupilary dilation from meds (anticholinergics, sympathomimetics)
Wells score >4, next steps for dx?
Get that CT angiogram or V/Q scan, skip the D-dimer
RA sites of involvement?
Progressive and symmetrical involvement of peripheral joints: MCPS and PIP of fingers, metatarsophalangeal joint of toes; RA most commonly affects cervical spine joints in axial skeleton and can cause spinal subluxation and spinal cord compression - radicular pain, neck
pain/stiffness, hyperreflexia or babinski w/ spinal cord
Tx of uric acid stones (not seen on x-ray d/t radiolucency but seen on US or CT)
Occurs in low urine pH -> therefore tx by alkalinzation of urine to pH 6.0 w/ oral potassium citrate.
Tx hypercalciuric renal stones w/ HCTZ since that dec urinary calcium excretion (this is also tx for osteo)
Kidney stones info:
Recurrent calcium stone formation d/t hyperoxaluria - restrict dietary oxalate
Potassium citrate tx for pt presenting w/ stone d/t citrate deficiency
Complete urinary evaluation for stones include Ca, citrate, uric acid, oxalate, pH and sodium levels
*For stones less than 5mm in diameter = can pass spontaneously w/ conservative mgmt
(including fluid intake >2L to inc urinary flow rate and lower urinary solute concentration)
PaCO2 in asthma exacerbation
Generally expect dec PaCO2 d/t hyperventilation; so if PaCO2 is normal or high or w/ no wheezes = ominous signs -> if unresponsibe to duonebs (SABA/SAMA and systemic corticosteroid) then consider intubation!
Dull HA a/w nausea and vomiting (d/t inc ICP), focal neurologic manifestations *unilateral weakness d/t invasion or compression, symptoms worse during the night or w/ positioning *early morning HA d/t laying in bed, dx?
Brain mass, dx w/ MRI
Sensory ataxia and lancinating pain, syphilis, dx?
Tabes dorsalis (affects dorsal column - proprioception, discriminative touch, vibration)