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)
Low back pain w/ neuro symptoms (sensory loss weakness in legs) worse w/ spinal extension (walking/standing) but improved leaning forward or lying down (shopping cart sign)
Lumbar spinal stenosis
Lumbosacral strain - pain in paraspinal area w/o significant tenderness over midline vertebra. Localized point tenderness over midline, normal neuro exam, old lady, recent lifting incident, dx?
Vertebral compression fracture
Mechanism of graft versus host disease:
Recognition of host major and minor HLA antigens by DONOR T cells and consequent cell mediated immune response; organs affected include skin (maculopapular rash involving palms, soles, and face), intestine (blood positive diarrhea), and liver (abnormal LFTs and jaundice)
CSF findings in GBS
ONLY elevated PROTEIN, totally normal cell count (normal whites, reds, and glucose)
CSF findings: bacterial meningitis, TB meningitis, viral meningitis, GBS
Bacterial: elevated whites, low glucose, high protein
TB meningitis: elevated whites, much lower glucose, elevated protein
Viral: elevated whites, normal glucose, high normal protein
GBS: just elevated protein
Adenocarcinoma = most common type of primary lung cancer in both smokers and nonsmokers; the predominant type in non smokers. CXR findings of adeno
Peripherally located solitary nodule; squamous is centrally located and often has necrosis/cavitation. Vs TB lesion = hilar adenopathy and/or cavitary patchy lung lesions *variable x-ray findings (though definitely not solitary nodules). Sarcoidosis = bilateral hilar adenopathy sometimes w/ scattered opacities
Hallmark of prolonged seizures (status epilepticus = sz >5mins OR cluster of sz w/ pt not recovering mental status in btw)
Cortical laminar necrosis
Side effects of trimethroprim sulfamethoxazole?
Hyperkalemia - blocks epithelial sodium channel in collecting tubule (similar to action of K sparing diuretic)
Elevated serum Cr - Bactrim competitively inhibits renal tubular Cr secretion causing artificial inc in serum Cr, however GFR is unchanged
Painless loss of monocular vision w/ cardiovascular risk factors, dx and tx?
CRAO; look for diffuse ischemic retinal whitening and cherry red spots; tx the opthalmologic emergency w/ ocular massage (dislodge the embolus) and high flow oxygen
When and how to screen for lung cancer in at-risk pts?
Low dose CT yearly for pts 55-80yo, w/ >30 pack year smoking hx, and currently smoking or quit within past 15 years
Colon cancer screening?
Avg risk starts at 50; if family hx of colon cancer, consider screening at 40 or 10 years before family member’s initial dx
S/s of ICP (nausea, vomiting, HA that worsens w/ changes in position, coughing or sneezing) = space occupying lesion. CT/MRI showing butterfly appearance w/ central necrosis, dx?
Gliobastoma multiforme = high grade astrocytoma (heterogenous and serpiginous contrast enhancement)
Definition of nephrotic syndrome
Heavy proteinuria (> 3.5g/24hs) w/ hypoalbuminemia and edema; other findings = hyperlipidemia and inc lipids in urine
Causes of nephrotic syndrome in adults = either primary glomerular (membranous nephropathy, FSGS, and minimal change) OR secondary glomerular (diabetes mellitus, amyloidosis)
Primary renal causes and their associations - (FSGS and membranous most common)
FSGS: African American or Hispanic, obesity/HIV/heroin Membranous nephropathy: adenocarcinoma (breast/lung), NSAIDs, HepB, SLE
Membranoproliferative glomerulonephritis: HepB and HepC, lipodystrophy
Minimal change: NSAIDs, lymphoma
IgA nephropathy: upper respiratory tract infxn
Sickle cell pt, progressive hip pain, limited internal rotation/abduction, no tenderness, normal x-rays and inflammatory markers, dx?
Osteonecrosis caused by occlusion of end arteries supplying femoral head leading to necrosis/collapse of periarticular bone and cartilage (common complication in SCD = disruption of microcirculation in bone by sickling as well as inc intraosseous pressure d/t
bone marrow hyperplasia)
Homeless person w/ lacerations over extremities, now fever, muscle stiffness, trismus/lockjaw, painful muscle spasms triggered by stimuli, dx?
Tetanus, MOA = toxin binds to peripheral nerve terminals and w/ retrograde axonal transport arrives at CNS where it blocks release of inhibitory neurotransmitters glycine/GABA. Tx = clean wound, start abx, human tetanus immunoglobulin and tetanus toxoid
HIV pt, blurred vision, floaters, photopsia, fundoscopy shows multiple yellow-white fluffy hemorrhagic lesions along vasculature (full thickness retinal inflammation that moves centripetally along vasculature), dx and tx?
HIV and eye issue = CMV retinitis (or HIV retinopathy but HIV is not hemorrhagic); tx w/ valganciclovir (if lesions near fovea or optic nerve then tx w/ intravitreal injections)
More eye diseases: herpes simplex keratitis, herpes zoster opthalmicus, HIV retinopathy
Herpes simplex keratitis: corneal lesions resulting in ocular pain, tearing, discharge
Herpes zoster opthalmicus: eye pain and vesicular eruption involving cornea/iris
HIV retinopathy: cotton wool retinal lesions that are not hemorrhagic, tend to resolve over
weeks to months *does not cause floaters or blurred vision as in CMV retinitis
Pt w/ past cholecystectomy now w/ recurring pain similar to pre-procedural pain, dx and mgmt?
Postcholecystectomy syndrome: persistent abdl pain/dyspepsia either months of even years after chole. Etiologies = biliary (retained stone in CBD or cystic duct) or extra biliary (pancreatitis, PUD). Abdl US then ERCP to dx and guide tx
Woman w/ giant cell arteritis (aka temporal arteritis) recently started on tx, now p/w proximal muscle weakness in LE (manifests as difficulty getting up from chair, climbing stairs, brushing hair), dx?
Drug induced (glucocorticoid) myopathy - no muscle inflammation or tenderness, CK and ESR are normal. DDx to polymyalgia rheumatica: seen in 50% pts w/ temporal arteritis, morning stiffness/aching w/ pain and dec ROM in shoulders/necks/hip girdle - but NORMAL muscle strength; elevated ESR *improves w/ glucocorticoids
Hypercalcemia, normocytic anemia, renal insufficiency, protein gap > 4 (seen in infection, connective tissue dz, excessive monoclonal protein), rouleaux formation (stacking of RBCs like coins)
Multiple myeloma; dx w/ SPEP to see if protein gap is monoclonal (M-spike) then bone marrow bx to show >10% clonal PLASMA cells
Dyspepsia (indigestion), intermittent epigastric, postprandial discomfort (fullness bloating) and nausea, pt from low income country, dx?
PUD w/ H. pylori
Systemic sclerosis subtypes and their s/s: limited cutaneous vs diffuse cutaneous
Limited cutaneous: scleroderma on head and distal UE, prominent vascular manifestations
Raynaud/cutaneous telangiectasia/PA HTN, CREST syndrome, anticentromere antibodies, better prognosis
Diffuse cutaneous: scleroderma on trunk and UE, internal organ involvement (scleroderma renal crisis, myocardial ischemia/fibrosis, INTERSTITIAL LUNG DISEASE, anti-scl-70 antibodies, anti-RNA pol III ab, worse prognosis
Patients w/ SIADH who are asymptomatic or have mild symptoms or Na 120-130 usually respond to fluid restriction
Pts w/ severe symptoms, neuro symptoms, or Na < 120 = need hypertonic saline (care, less than 8 correction in 24hrs or .5-1 over an hr)
More skin stuff: pyogenic granuloma, dermatofibromas, BCC, SCC
Dermatofibromas: fibroblast proliferation causing, lesions on LE, nontender, hyperpigmented <1cm, fibrous component causing dimpling in center when area is pinched “dimple or buttonhole sign”
Pyogenic granuloma: benign vascular skin tumor that presents as small red papule that grows rapidly over weeks, to pedunculated or sessile shiny mass, common on lip/oral mucosa
Basal cell: pearly nodule w/ small telangiectasias in sun exposed (upper lip)
Squamous cell carcinoma: firm scaly papules, plaques or nodules (lower lip)
Acute epididymitis epidemiolopgy, symptoms, dx, tx
Age <35: usually sexually transmitted (chalmydia/gonorrhea); asymptomatic urethritis
Age >35: bladder outlet obstruction coliform bacteria ie E.coli
Symptoms: unilateral testicular pain, epididymal edema, dysuria/frequency only w/ coliform infection not stds
Dx: UA and culture, NAAT for chalmydia and gonorrhea
Tx: ceftriaxone/doxy if STI, levo for coliform bacteria
Alz dementia, CT w/ hyperdensity in entire lobe (ie parietal lobe hemorrhage), dx?
Parietal lobe hemorrhage d/t cerebral amyloid angiopathy - amyloid deposition in arteries results in vessel wall weakening and predisposition to rupture. Hemorrhage occurs during routine activity, and commonly involves occipital/parietal lobes
What prophylaxis is considered in HIV pts w/ CD4 <200, <100, <50?
Bactrim for <200 (PCP - remember a/w oral candidiasis), bactrim for <100 (toxo), and azithromycin for coverage against mycobacterium avium complex (MAC - c/f disseminated MAC causing systemic symptoms and splenomegaly) for <50. Acyclovir and fluconazole not needed for proph but only for acute infections
Acute urinary incontinence in elderly pts, consider reversible etiologies first especially if new onset - think DIAPPERs
D: delirium I: infection UTI very common, routine U/A is not bad A: atrophic urethritis/vaginitis P: pharmaceuticals (alpha blockers, diuretics, anticholinergics) Psychological: depression E: excessive urine output: T2DM, CHF R: restricted mobility: post sx S: stool impacton
Leukocyte esterase vs nitrites in urine signify?
Leukocyte esterase = significant pyuria
Nitrite = presence of enterobacteriaceae which convert nitrates to nitrites
Pt w/ CAP takes metformin, lisinopril, atorvastatin at home, presents w/ s/s pre-renal azotemia, next steps?
Discontinue metformin (can cause lactic acidosis in AKI and sepsis - must withhold until renal fxn improves) and start fluids
Thyroid nodule pathway -> clinical evaluation (for cancer risk factors = family hx, radiation exposure, cervical lymphadenopathy, compressive symptoms like hoarseness/difficulty swallowing, and current thyroid status hyper or hypo) -> TSH and US
If suspicious for cancer via clinical or US findings go to FNA. If no cancer risk factors of suspicious US findings and low TSH = Iodoine 123 scintigraphy -> if hot then tx hyperthyroidism if cold then FNA c/f cancer
Manifestations of SLE: clinical vs lab
Clinical: constitutional, arthritis, butterfly rash and photosensitivity, serositis (pleurisy, pericarditis, peritonitis), thromboembolic events d/t vasculitis and antiphospholipid antibodies, cognitive dysfn and seizures
Lab: hemolytic anemia, thrombocytopenia, leukopenia (all three cell lines d/t peripheral destruction!), hypocomplementemia (C3 and 4), antibodies = ANA (sensitive), anti-dsDNA and anti-Sm (specific). If pancytopenia = d/t peripheral immune mediated destruction of all 3 cell lines; however can w/u by doing bone marrow biopsy to r/o drugs/leukemia/myelodysplasia/malignant invasion
1st line tx for MS exacerbation
Glucocorticoids (IV methylpred); plasmapharesis if pt is refractory to corticosteroid therapy. No evidence for cyclophosphamide or IVIG during flare
Complications of heat stroke (epistaxis mechanism)
Rhabdo, renal failure, ARDs, and DIC - DIC can lead to coagulopathic bleeding which explains persistent epistaxis
What disorders are associated w/ vitiligo?
Autoimmune disorder (since vitiligo is an autoimmune destruction of melanocytes) pernicious anemia, definitely autoimmune thyroid disease, T1DM, primary adrenal insufficiency, hypopituitarism, alopecia areata
MEN1 associated conditions
Hyperparathyroidisms, Zollinger Ellison syndrome, pituitary tumors
When to tx pts w/ metabolic acidosis w/ sodium bicarb
Only if severe acidosis w/ pH < 7.1
Median age 60, inc in production of all three blood cell lines and splenomegaly, dx?
Polycythemia vera
Diffuse telangiectasias (ruby colored papules on lips that blanch w/ pressure), digital clubbing, recurrent epistaxis, wide spread AV malformations, dx?
Hereditary telangiectasia (Osler-Weber-Rendu syndrome); auto dominant disorder. AVMs in lungs can shunt blood from right to left side of heart causing chronic hypoxemia and reactive polycythemia
Pulmonary symptoms, IVDU, cavitary lesions on imaging, dx?
Septic embolism from infective endocarditis of tricuspid valve most commonly w/ staph aureus
Causes of high anion gap metabolic acidosis: CAT MUDPILES
C: carbon monoxide, cyanide A: aminoglycosides T: theophylline, toulene (glue sniffing) M: methanol U: uremia D: DKA, alcoholic ketoacidosis, starvation ketoacidosis P: paraldehyde, phenformin, paracetamol/acetaminophen I: iron, isoniazid, inborn erros metabolism L: lactic acidosis E: ethylene glycol, ethanol S: salicylates
Victims of house fire, concern for what toxicities?
Cyanide and carbon monoxide; tx cyanide w/ hydroxocobalamin or sodium thiosulfate OR w/ nitrates to induce methemoglobinemia
Intermittent diarrhea and lower abdl pain now w/ low back pain/stiffness for two months; pain helps w/ NSAIDs but makes diarrhea worse. Labs show anemia and thrombocytosis and SI joint inflammation, dx?
IBD complicated by spondylarthritis - extraintestinal manifestations of IBD (including both) = arthritis, eye, skin (pyoderma gangrenosum), hepatobiliary dz (primary sclerosing cholangitis). Arthritis common in IBD and can involve axial or peripheral joints; tx the IBD to treat arthritis (DMARDs)
Pt w/ T2DM on metformin and glargine (long acting basal) but still elevated A1c but good fasting blood glu, likely cause
Postprandial hyperglycemia -consider combined long acting basal (to control baseline and fasting glucose) and add rapid acting meal time insulin to control postprandial glu
When to do barium enema or sigmoidoscopy or colonoscopy?
Left sided pathology
What type of infection and tx for pt w/ fever and cough productive of foul smelling sputum after instrumentation of upper airway (other risk factors = poor dentition, impaired consciousness)
Aspiration pneumoniae d/t anaerobes - tx w/ clindamycin for anaerobic coverage
What diagnostic tool/score to determine placement and guide tx for community acquired pneumonia
CURB65 C - confusion U - BUN >30 R - respirations > 30 B - pressures < 90 sys or < 60 dia 65yo Score 0-1 outpatient, 2-3 likely inpatient, >3 inpatient +/- ICU
Tx for CAP and types of bugs?
Covering strep pneumo, haemophilus influenzae, legionella, mycoplasma pneumoniae SO need beta-lactam coverage and atypicals = 1) for inpatient coverage: fluoroquinolone (eg moxi) or beta-lactam plus macrolide (ie ceftriaxone plus azithro), 2) outpatient consider just macrolide or doxy
Toxin drug not shown on usual drug screen (cocaine, PCP, THC, alcohol, and meth show up), long duration of effect (agitation, combativeness, delirium, psychosis), effects of intoxication take up to a week to subside, drug?
Bath salts
Painless genital ulcer (chancre) in setting of high risk sexual behavior, dx and types of tests?
Primary syphilis, nontreponemal vs treponemal; non treponemal (VDRL serum) lower sensitivity w/ false negative early on in dz, treponemal like florescent treponemal antibody absorption has higher sensitivity
Single most important prognostic consideration in tx of pts w/ breast cancer?
TNM staging; other stuff like ER/PR status, HER-2/neu oncogene, and histological grading are important but less so
OSA pathophys, s/s, sequelae
Relaxation of pharyngeal muscle causes airway closure w/ loud snoring w/ periods of apnea, daytime somnolence/morning HA/affective cognitive symptoms, look for systemic HTN and pulmonary HTN and right heart failure, also hypoxemia causes kidneys to respond by increasing EPO -> erythrocytosis elevated hematocrit/HgB (polycythemia)
Men 40-60, weight loss, steatorrhea, fever, abdl pain, athralgia, chronic cough, valvular regurgitation, pigmentation, PAS positive material in lamina propria of small intestine, foamy macrophages dx?
Whipple’s disease = rare multi systemic illness caused by bacillus Tropheryma whippelii
Winter’s Formula for determining respiratory compensation during metabolic acidosis
PaCO2 = 1.5(HCO3) + 8 (+/- 2)
D-xylose for proximal small intestinal malabsorption
Normally D-xylose absorbed w/o need for degradation by pancreatic or brush border enzymes; subsequently excreted in urine if absorption unimpaired. Low urinary D-xylose indicates poor absorption d/t mechanical likely atrophy of intestinal villi as in Celiac disease. If D-xylose excretion is normal indicates good absorption and likely enzymatic issue like chronic pancreatitis
Evaluate ascites as portal htn vs non portal htn with what?
SAAG serum albumin to ascites gradient >1.1 = portal HTN (cardiac ascites or cirrhosis). SAAG <1.1 = non portal HTN (malignancy, pancreatitis, nephrotic, TB). Calculating SAAG = serum albumin - ascites albumin
Erythema nodosum (painful subcutaneous nodules common on anterior lower legs), athralgias, cough/dyspnea/CP, anterior posterior uveitis, black woman, path showing noncaseating granulomas (negative for acid-fast or fungi), dx and what on cxr?
Sarcoidosis, cxr shows bilateral hilar lympphadenopathy w/ reticular opacities. Non-caseating = non-necrotic not infectious
MS, new plaque at thoracic spinal cord, expected deficits
Leg weakness (lateral corticospinal tract), dec pinprick sensation (lateral spinothalamic tract), dec proprioception (dorsal columns), urinary continence (descending motor and parasympathetic autonomic fibers)
Lesion at cerebellar hemisphere expected symptoms
Dysdiadochokinesia, dysmetria, limb ataxia, intention tremor
Brain stem lesion expecting s/s
Ipsilateral cranial nerve dysfunction, contralateral motor and sensory deficits
1st line tx for trigeminal neuralgia, side effects of said drug?
CBZ - care for nausea, vomiting, aplastic anemia (well technically leukopenia)
OA vs RA
OA: idiopathic aging or chronic wear and tear causing chronic pain, stiffness, bony enlargement of large weight bearing joints on LE or small peripheral joints in hands/cervical/lumbar spine; look for Bouchard noges (PIP) and Herbeden nodes (DIP)
RA: most frequently involves metacarpophalangeal joints/PIP/wrist, and improvement throughout day
African American, cough, hilar adenopathy, erythema nodosum, non caseating granulomas, dx?
Sarcoidosis! This pt was tx w/ high dose glucocorticoids but rapidly decompensated, hx of farmer in Mississippi, found to eventually have histoplasmosis (appropriate epidemiologic setting Mississippi Ohio River, mediastinal or hilar lymph nodes, athralgias, and erythema nodosum)
Chronic hypoventilation d/t COPD, obesity hypovent, neuromuscular causes have chronic hypercapnia w/ respiratory acidosis, compensation how?
Kidneys inc bicarb retention creating secondary metabolic alkalosis
Cancers a/w paraneoplastic syndrome (tumor producing hormones and or cytokines)
Lung, breast, ovaries, lymphomas
Pt w/ lung cancer and muscle weakness/purple violaceous papules involving dorsum of fingers, dx?
Paraneopalstic syndrome w/ dermatomyositis (other syndromes affecting peripheral nerve and or muscle = myasthenia or lambert); symmetrical proximal muscle weakness and erythematous rash on finger (Gottron’s sign) and or upper eyelids (heliotrope eruption), dx w/
muscle bx
Myasthenia vs Lambert
Myasthenia: antibodies against ACH receptor in postsynaptic membrane; fluctuating weakness worsens w/ use
Lambert: presynaptic membrane voltage gated Ca channels; gets better w/ use
PE -> hyperventilation -> respiratory alkalosis -> crampy pain/paresthesias/carpopedal spasm -> what happened to Ca?
Calcium exists as 3 forms = ionized (45%), albumin bound (40%), calcium bound to inorganic/organic ions (just 15%); the alkalosis shifted pH to basic = H+ ions dissociate from albumin freeing up albumin to bind w/ calcium inc total albumin bound calcium and lowering ionized ca (this is what matters) = causing dec in free calcium while total calcium unchanged. Alkalosis -> H+ dissociate from ablumin -> albumin binds Ca -> hypocalcemia = carpopedal spasms etc
Episodic flushing (pounding sensation), chronic diarrhea, weight loss, valvular heart dz w/ tricuspid regurg, miscellaneous includes niacin deficiency w/ dermatitis/diarrhea/dementia (pellagra), dx and mgmt?
Carcinoid syndrome, dx w/ elevated 24hr urinary excretion of 5-HIAA, CT/MRI of abdomen/pelvis to localize tumor, tx w/ octreotide for symptomatic patients and prior to sx/anesthesia, sx for liver mets
What is carcinoid syndrome?
Neuroendocrine tumor common in distal small intestine, proximal colon and lung, strong mets to liver = secrets histamine, serotonin, and VIP that are metabolized in liver; in pts w/ liver mets these hormones are released directly into systemic circ leading to carcinoid syndrome
Cherry angiomas = senile hemangiomas (common benign vascular tumors in adults) vs the kid version?
Strawberry hemangiomas = infantile, rapidly grow but regress by age 5-8
A single brain abscess results from direct extension of adjacent infection (otitis, sinusitis, dental); most common bugs = viridans strep, staph aureus; look for HA/fever/focal deficits/seizure w/ brain imaging showing SINGLE ring enhancing lesion w/ central necrosis,
other ddx?
Cerebral toxo = HIV w/ CD4 <100, look for multiple ring enhancing lesions
Rhizopus causing mucormycosis = necrotic and highly destruction multiple lesions, most infxn in pts w/ bad T2DM or immunocompromised
Primary brain neoplasm = lymphoma or gliobastoma or mets could cause sz and single ring enhancing lesion too HOWEVER this pt w/ fever and weeks of sinusitis = brain abscess more likely
Young man, two months cough w/ pulmonary nodules and retroperitoneal lymphadenopathy - think metastatic - so what common malignancies are in young men and what is this dx?
Common malignancies (obviously rare) = testicular, lymphoma, leukemia. Testicular - unilateral painless testicular nodules, dull abdominal ache, metastatic symptoms (dyspnea, low back pain d/t retroperitoneal lymph node compression); dx w/ tumor markers AFP and beta-hCG, scrotal US, staging imaging w/ CT/CXR, tx w/ radical orchiectomy/chemo
Mammogram guidelines? Colon cancer guidelines? HIV guidelines? Hyperlipidemia guidelines Osteoporosis screen guideliens
Every two years starting at 50; routine mammo not necessary after 75
Age 50-75; every ten years or yearly fecal occult blood (40 or 10 year before family member’s dx)
15-65yo HIV antibody screen once
Men 35+ every 5 years, women starting 45 every 5, uncertain when to quit
Women 65+ DEXA, interval unknown
Old lady, recent sx for femoral fracture 4 months ago following a fall, now w/ progressive confusion/weakness/unsteadiness for days, dx and MOA?
Subdural hematoma - tearing of bridging veins leads to slow bleeding in subdural space common in pts w/ cerebral atrophy (old/alcoholics) since bridging veins must traverse longer distance. Noncon CT shows crescent shaped hyperdensity that crosses suture lines; if small hematomas manage conservatively where as larger ones w/ neuro deficits = sx evacuation
Stroke lesions and their s/s: *first off important note - anterior vasculature is compromised of the ICA and its branches (paired anterior and middle cerebral arteries) while the posterior circ is comprised of the paired vertebrals which combine to form basilar which then divides into paired posterior cerebral
Anterior cerebral artery: contralateral motor and or sensory more pronounced in lower limb; also urinary incontinence d/t damage to micturition center of mesial frontal lobe
Lacunar infarcts: small vessel infarcts affecting deep subcortical structures, look for pure motor hemiparesis, pure sensory stroke
MCA: contralateral, somatosensory deficits *more pronounced in face/upper limb than lower limb AND homonoymous hemianopia/quadrantanopia (if dom left = aphasia; if nondom right = hemineglect)
ICA occlusion: affects both MCA and ACA - dense symptoms
Posterior cerebral artery: eye stuff!
RA mgmt?
Start DMARDs soon as possible -> methotrexate first -> if s/s >6 months consider step up w/ TNF inhibitor or parallel therapy w/ a nonbiologic eg sulfasalazine/hydroxychloroquine. Save NSAIDs or glucocorticoids for initial temporary symptomatic relief while awaiting response to DMARD
Middle aged women 30-50, fatigue/pruritus, progressive jaundice/hepatomegaly/cirrhosis, cutaneous xanthomas (fat under eyelids) and xanthelasmas, dx and complications and mgmt?
Primary biliary cholangitis (bitches are coy so no UC/IBD), look for AMA antibody, cholestatic pattern of livery injury (elevated alk phos and aminotransferases), complications include malabsorption/osteo/hepatocellular carcinoma, tx w/ ursodeoxycholic acid and liver transplant
Which vitamin deficiency a/w each condition: chronic alcohol use, vegetarians/vegans
Chronic alcohol = folate d/t limited dietary intake Vegetarians/vegans = Vit B12 def
Both folate and B12 cause megaloblastic anemia; however B12 has neuro deficits
(proprioception and vibration deficit, memory, irritability and dementia)
MOA of senile purpura (old people bruising)
Loss of elastic fibers in perivascular connective tissues: minor abrasions that merely stretch skin of younger pt can rupture superficial blood vessel in elderly
Asymptomatic hypercalcemia and normal renal function with high-normal PTH and low urinary calcium excretion, dx? Compared to what other dx?
Familial hypocalciuric hypercalcemia; benign autosomal dominant w/ mutation in calcium sensing receptor - normally high Ca suppresses PTH secretion but in FHH higher calcium concentrations are required to suppress PTH. Compared to primary hyperparathyroidism: pts w/ primary hyperPTH have inc urinary calcium excretion while FHH pts have low urinary
calcium. Urine calcium/Cr ratio UCCR is .02 in primary hyperPTH
Fire in building, HA w/ altered mentation and dizziness and bright cherry lips, dx and mgmt?
CO poisoning (CO higher binding affinity than O2 -> CO forms carboxyhemoglobin which impairs oxygen delivery to tissue since carboxy heme shifts dissociation curve to left), tx w/ 100% oxygen via nonrebreather to compete w/ CO binding and dec half life of CO; hyperbaric if severe
Progression of Alz disease?
Early memory loss!, then language difficulties, apraxia, followed late in course by impaired judgment and personality changes
DDx of dementia subtypes: alz, vascular, ftd, dementia w/ lewy, NPH, prion
Alz: early memory loss, language difficulties, and apraxia followed late by impaired judgement and personality changes
FTD: early personality changes, compulsive behaviors, and impaired memory
Lewy: visual hallucinations, spontaneous parkinsonism (w/ inc sensitivity to antipsychotics), fluctuating cognition NPH: ataxia early, urinary incontinence, dilated ventricles
Prion: behavioral change, RAPID progression, MYOCLONUS
Types of HA: migraine, cluster, tension
Migraine: female, family hx, variable onset, unilateral, pulsatile throbbing, a/w auras/photophobia/phonophobia/nausea
Cluster: male, no family hx, onset during sleep, behind one eye, excruciating/sharp/steady, a/w sweating/facial flushing/nasal congestion/lacrimation/pupillary changes Tension: female, no family hx, onset w/ stress, band-like pattern around head bilateral, dull
tight persistent, a/w muscle tenderness in head/neck/or shoulders
Three types of acne vulgaris presentation and tx option progression?
Comedonal acne -> inflammatory acne -> nodular cystic acne. Start with topical retinoids +/- organic acid preps like salicylic -> add topical benzoyl peroxide -> add topical antibiotics
(erythromycin/clindamycin) -> add oral antibiotics -> finally take oral isotretinoin
Pt w/ previous TB tx, now w/ >3 months of weight loss, cough, hemoptysis, and fatigue; imaging shows >1 apical cavitary lesions w/ collecting “ball inside”, dx?
Chronic pulmonary aspergillosis; dx w/ aspergillus IgG serology
4 types of blood transfusion reaction a/w hypotension:
Anaphylactic: seconds to minutes, rapid shock/angioedema/urticaria/wheeze/respiratory distress, d/t anti IgA antibodies
Primary hypotension rxn: minutes, transient hypotension in pts taking ACEi, d/t bradykinin in blood products (normally degraded by ACE)
Bacterial sepsis: minutes to hrs, fever/chills/septic shock and DIC
Transfusion related acute lung injury: within 6 hrs, resp distress and signs of noncardiogenic pulmonary edema, d/t donor anti-leukocyte antibodies
Side note on ABO mismatching: within an hour, clerical errors mostly, will cause acute hemolytic transfusion reaction w/ fever, chills, flank pain, hemoglobinuria, can progress to renal failure and DIC
19yoM, recent influenza viral infection, gets better than worsens, now has high fever, productive cough often hemoptysis, and multilobar cavitary infiltrates, dx?
Secondary bacterial pneumonia (common influenza complication - improves than gets worse) d/t MRSA in young <65 following recent influenza
Dry skin with rough horny plates resembling fish or repitle scales, dx and mgmt?
Ichthyosis vulgaris - mutation in filaggrin gene - ikthys is Greek for fish; tx w/ emollients but if worse consider keratolytics (coal tar, salicylic acid) and topical retinoids. Psoriasis = silvery scales over extensor surfaces of elbows, knees, scalp, and trunk
Acromegaly, initial work up?
Get Insulin-like GF1 first since that mediates most effects of GH and GH not as sensitive d/t wide fluctuations. If IGF-1 elevated -> get oral glucose suppression test since that should suppress GH. If no sppression = MRI brain for pituitary mass vs extrapituitary cause of
acromegaly ie ectopic GH tumor
Mechanisms of hypokalemia *4 possibilities
Insulin, beta-adrenergic agents (given during COPD exacerbation question), GI losses, and renal wasting (hyperaldo or diuretics)
Mgmt and cutoff ranges in carotid artery stenosis?
Initial interventions should include intensive medical mgmt (ASA, statin, BP control, lifestyle); symptomatic patients (ie TIA or stroke in distribution of the affected vessel) w/ high grade stenosis (>70%) = CONSIDER CAROTID ENDARTERECTOMY
Chronic HepC infection, mgmt?
Tx of underlying cause and strategies to prevent further liver dmg (alcohol avoidance, HepA and HepB vaccination); sofosbuvir-velpatasvir have improved ability to achieve virologic cure!
(side not: lamivudine - reverse transcriptase inhibitor used for HIV and chronic HBV co-infection)
Diabetic patients w/ alteration in sensation including loss of propiroception, however w/ motor findings including weakness, positive Babinski and hyperreflexia, dx and mgmt?
Upper motor neuron process (Babinski and hyperreflexia; diabetic neuropathy is purely lower motor neuron); get spine MRI to r/o mass or epidural abscess
Pt w/ stroke found down on floor for hours, hx of CKD, EKG abnormalities, dx and mechanism and tx?
Acute on chronic renal failure (d/t on floor for hours = dehydration/rhabdo) w/ hyperK; tx w/ IV calcium gluconate first followed by definitive measures to reduce total K
Intravascular and extravascular hemolysis and hemoglobinuria, cytopenias, venous thrombosis, dx/MOA/tx?
Paroxysmal nocturnal hemoglobinuria (PNH); genetic defect causing lack of CD55 and CD59 (needed to prevent membrane attack complexes from forming on RBCs); LOOK for intravascular hemolysis (elevated bili/LDH/low hapto) and thrombosis; flow cytometry for
dx; tx w/ iron and folate supplementation and eculizumab to inhibit complement
Secondary causes of restless leg syndrome and tx options?
Iron deficiency anemia, uremia, T2DM, MS/Parkinson, pregnancy, drugs
Tx: supplement w/ iron when serum ferritin low, supportive measures/avoid aggravating factors if symptoms mild/intermittent. For persistent/moderate 1st line meds = dopamine agonists (pramipexole) or alpha 2 delta calcium channel ligands (gabapentin)
Spontaneous red eye in 34yoM, no itching/pain/or discharge, vitals stable, dx and mgmt?
Spontaneous subconjunctival hemorrhage, no tx required
Pure sensory stroke, location of lesion
Lacunar stroke of the posterolateral thalamus p/w sudden onset contralateral sensory loss involving all sensory modalities; weeks to months later pts develop thalamic pain syndrome = severe paroxysmal burning pain exacerbated by light touch
Pt w/ PE and CKD (estimated GFR <30) mgmt?
Anticoagulation w/ unfractionated heparin d/t severe renal insufficiency; can consider enoxaparin (LMWH), fondaparinux (factor Xa inhibitor), or rivaroxaban (factor Xa inhibitor) if pts not renally impaired
Monitor Heparin w/ what? Warfarin?
aPTT for Heparin. PT or INR for Warfarin
Criteria for metabolic syndrome:
At least 3/5 criteria:
1) Large waist circumference (>40 men or >35 women)
2) Fasting glu >100-110
3) BP >130/80
4) Triglycerides >155
5) HDL <40 men, <50 women
Old man dysphagia, halitosis, aspiration, regurgitation, large neck mass, dx? Dx tests? Mgmt?
Zenker diverticulum; dx w/ barium esophagram or esophageal manometry; open/endoscopic sx or cricopharyngeal myotomy
LIver maintains glucose via glycogenolysis and gluconeogenesis. How does gluconeogenesis work?
Main 3 substrates are gluconeogenic amino acids (breakdown of muscle protein), lactate (anaerobic glycolysis), and G3P (triacylglycerol in adipose). Amino acids that can be used in gluconeogenesis = alanine and glutamine. Alanine converted to pyruvate during this process
Fluctuating and fatigable proximal muscle wekaness worse later in day, dx? And s/s for different organs, dx, and tx?
Myasthenia gravis (typically middle age women, old men); ocular (diplopia, ptosis), bulbar (dysphagia, dysarthria), respiratory muscles (myasthenic crisis). Dx via Edrophonium (Tensilon) test, ice pack test, ACH receptor antibodies! If already confirmed myasthenia -> CT chest to eval thymoma (since that can tx). Tx w/ acetylcholinesterase inhibitors (eg pyridostigmine), immunotherapy w/ corticosteroids/azathioprine, thymectomy
Causes of exacerbations to myasthenia gravis:
Meds: fluoroquinolones, aminoglycosides, anesthetic blocking agents, BB
Pregnancy/childbirth
Sx especially thymectomy
Ddx for neuromuscular weakness: upper motor neurons, anterior horn cells, peripheral nerves, NMJ, muscle fibers
Upper motor neurons: leukodystrophies, vasculitis, brain mass, Vit B12 def
Anterior horn cells: spinal muscular atrophy, ALS, paraneoplastic syndromes, poliomyelitis
Peripheral nerves: hereditary primary motor sensory neuropathy, GBS, diabetic neuropathy, amyloid neuropathy (myeloma), lead poisoning
NMJ: myasthenia gravis, Lambert-Eaton syndrome, organophosphate poisoning, Botulism
Muscle fibers: muscular dystrophies, polymyositis and dermatomyositis, hypothyroidism, corticosteroids, HIV myopathy
UMN and LMN signs (spastic paralysis and muscle atrophy/fasciculations), dx?
ALS
Complication of AR where pt develop sudden onset of worsening CP, hypotension, PE, and early decrescendo diastolic murmur
Dissection can propagate proximally from site of intimal tear to involve aortic valve and cause acute AR. The dissection can propagate into pericardial space and lead to hemopericardium/tamponade; these pts have pulsus paradoxus, elevated JVD, and cardiogenic shock but w/ CLEAR lung fields
Recurrent episodes of prolonged CP over several months not a/w activity or other accompanying symptoms; EKG, exercise stress test, PE are unremarkable, dx?
Esophageal disorder
DDX for chest pain?
CAD: substernal, radiation to arm, shoulder, jaw, exertion, relieved by rest/nitro
Pulmonary/pleuritic: sharp stabbing, worse w/ inspiration, pericarditis (worse when flat better leaning forward), PE, pneumothorax (respiratory distress, hypoxia)
Aortic: sudden severe tearing pain, radiates to back, elderly men, HTN and risk factors for atherosclerosis GI/esophageal: non-exertional, relieved by antacids, upper abdl and substernal, a/w regurgitation/nausea/dysphagia, nocturnal pain
Chest wall/MSK: persistent, prolonged, worse w/ mvmt or change in position, repetitive activity
24yo syncope while shoveling snow, SOB, CP recently related to exercise; crescendo decrescendo systolic murmur along left sternal border WITHOUT carotid radiation, dx?
HoCM
Tx of hypertriglyceridemia pathway:
Elevate for secondary causes -> 150-500 = lifestyle modifications (weight loss, moderate alcohol, inc exercise) + statin if known cardiovascular disease
If >1000: initial goal is pancreatitis prevention w/ fibrates, fish oil, or abstinence from alcohol
Wide pulse pressure! (sys»_space; dia), water hammer pulse, pounding heart sensation, dx?
Chronic aortic regurgitation: LV output leaks back into the left ventricle causing inc in LV end diastolic volume, myocardial hypertrophy, and chamber enlargement -> this brings LV apex close to chest wall causing pounding sensation esp in left lateral decubitus. Most common cause of chronic AR in developing countries = rheumatic; in developed = aortic root dilation/bicuspid
More on ventricular aneurysm as a late complication following transmural MI, EKG, and US findings?
Persistent ST elevation and deep Q waves in the same leads as initial MI; look for progressive left ventricular enlargement and dyskinetic wall motion leading to HF
What is the most effective lifestyle intervention in controlling BP?
Weight control! (other effective methods but in descending order = DASH diet, exercise, dietary sodium, alcohol intake)
Progressive dyspnea, decreased exercised tolerance, A-fib w/ RVR and left
Tachycardia-mediated cardiomyopathy, tx w/ aggressive rate control/restore normal sinus rhythm as this can reverse the tachycardia mediated cardiomyopathy and normalization of LV systolic fxn
Two weeks post MI, currently ECG unchanged w/ persistent ST segment elevation along w/ deep Q waves p/w exertional dyspnea and fatigue, faint systolic murmur over apex, dx?
Left ventricular aneurysm; look at question 2731 for good post MI pic
Two types of HTN complications
Urgency: 180/120 no s/s or end organ dmg
Emergency: malignancy - retinal hemorrgage, exudates, papilledema. Encephalopathy - cerebral edema, non focal s/s
MOA of stress testing w/ adenosine?
Pharmacologic vasodilator stress testing that causes inc in blood flow in coronaries; expect to see much larger inc in blood flow in normal coronaries vs occluded vessels
Types of stress testing, mechanism, best for, not for
Exercise EKG: inc HR and BP, best for patients able to reach tHR, not for LBBB/pacemaker/pts unable to reach tHR Pharmacologic w/ adenosine or dipyridamole: nonselective adenosine agonist that dilates coronary arteries w/o affecting HR or BP, best for LBBB/pacemaker/pts unable to reach tHR, NOT for reactive airway disease or pts on dipyridamole/theophylline Dobutamine stress: B-1 agonist, inc HR and BP much like exercise, best for reactive airway dz and pts unable to reach tHR, not for tachyarrhythmias
Most common cause of MR in developed countries?
MVP *rheumatic heart can cause MS, MR, and AR too but is less common than MVP. MVP: look for mid-systolic click and mid to late systolic murmur -> this can progress to holosystolic murmur if the leaflet dysfunction and prolapse is severe enough. Also look for left atrial dilation w/ severe MR leading to a-fib
Acute renal failure, malignant HTN (HA, blurry, nausea), UA w/ mild proteinuria, peripheral blood smear w/ schistocytes, dx?
Scleroderma renal crisis; microangiopathic hemolytic anemia (look for hemolysis w/ elevated bili, dec platelets, schistocytes)
RCA occlusion can cause infarctions where, EKG findings?
Inferior and posterior wall MI. Inferior wall MI = ST elevations in inferior leads II, III, aVF; posterior wall MI = ST depression in V1 and V2. Look for hypotension, bradycardia, and AV block (RCA supplies AV node) during inferior MI
Risk factors and clinical features a/w aortic dissection:
HTN (most common - think >50 yo), Marfan syndrome (think<40), cocaine use. S/s severe sharp tearing chest or back pain, >20mmHg variation in systolic BP btw arms
Complications involved in aortic dissection
Stroke (carotid arteries), acute aortic regurgitation, Horner syndrome, acute MI, pericardial effusion/tamponade, hemothorax
Biggest concern in giant cell arteritis (aka temporal arteritis)
Involvement of large vessels - aorta and proximal branches - look for aortic aneurysm and inc risk of dissection (also common symptoms of GCA = fever, weight loss, HA, claudication, visual symptoms)
Medication for secondary prevention of coronary heart disease?
DAPT (w/ aspirin and P2y12 receptor blockers like clopidogrel); DAPT for at least a year if drug eluding stent BB ACEi/ARB HMG-CoA
Aldosterone antagonist *if left ventricular EF <40% w/ HF symptoms or T2DM
Note on use dependence and antiarrhythmic agents
Use dependence = enhanced effects of a durg during faster heart rates (seen in class IC *flecainide and class IV CCBs); class IC agents cause progressive decrease in impulse conduction w/ faster heart rates leading to inc in QRS duration (man w/ a-fib, started on antiarrhythmic, exercise test cause widened QRS)
Symmetric duskiness and coolness of ALL symmetric fingertips, currently required pressors for hypovolemic shock, dx?
Norepinephrine induced vasospasm (pt has dec blood flow, vasoconstriction from pressure resulted in ischemia/necrosis). This is not cholesterol emboli w/ blue toe syndrome - since that has no symmetrical
involvement
Beck’s triad?
Cardiac tamponade - fluid in pericardial space (that increases the intrapericardial pressure above the diastolic ventricular pressure) causing hypotension, distended neck veins, muffled heart sounds. This is d/t shift of interventricular septum toward left ventricular cavity causing reduced preload, stroke volume, and cardiac output
Ejection click followed by crescendo-decrescendo systolic murmur over left 2nd intercostal space w/ widened splitting of S2 worse during inspiration, defect?
Pulmonic stenosis; ddx to aortic stenosis since murmur diminishes during inspiration (blood flow through lung instead of aorta)
Comorbid conditions (hypercholesterolemia, HTN, T2DM), recent cardiac catherization, s/s of erythematous/purple discoloration of skin that blanches (livedo reticularis) and blue toe syndrome, renal injury, ocular involvement (Hollenhorst plaques), GI involvement (intestinal ischemia - nausea/abdl pain), lab findings (elevated Cr, eosinophilia, hypocoplementemia, UA w/ little to none casts/cells), dx??
Systemic atheroembolism from disruption of atherosclerotic aortic plaques (cholesterol crystal embolism). Confirm w/ skin or renal bx: biconvex needle shaped clefts within vessels, perivascular inflammation w/ eosinophils
Multisystem involvent w/ renal failure, skin manifestations (livedo reticularis, blue toe), cerebral or intestinal ischemia (abdl pain, nausea), and Hollenhorst plaques after recent arteriography.
Cholesterol embolization! If contrast induced nephropathy = muddy brown casts and not multisystem involvement
Drugs used in cardiac cases
Adenosine: (A for affecting AV node) identify/termination of paroxysmal supraventricular tachycardia
Atropine: symptomatic sinus bradycardia or AV nodal block
Amiodarone: atrial and ventricular tachycardia,
IV magnesium: first line for stable pts w/ torsades
S3 vs S4 features, when normal, and abnormal associated conditions
S3: ventricular gallop sound after S2, heard during rapid filling of ventricles in diastole, turbulent blood flow to ventricles d/t increased volume; normal in children/young adults/pregnancy; a/w age >40, restrictive cardiomyopathy, high output states
S4: atrial gallop sound before S1, heard immediately after atrial contraction phase as blood is forced into stiff ventricle; normal in healthy old folks; abnormal in younger adults/children, a/w ventricular hypertrophy, and ACUTE MI d/t ventricular stiffening and dysfunction
induced by ischemia
Mechanism of action of statins and why statin induced myopathy?
Statins inhibit intracellular HMG-CoA reductase enzyme - thereby prevents conversion of HMG CoA to mevalonic acid, increases number of cell membrane LDL receptors. Statins dec coenzyme Q10 which is involved in muscle cell energy production possibly contributing to myopathy
Mgmt of HCM?
Avoidance of volume depletion, BB/CCB, sx if persistent; goal is to reduce LVOT *slow HR to prolong diastole and dec myocardial contractility
Mechanical complications of acute MI: right ventricular failure, papillary muscle rupture, interventricular septum rupture, free wall rupture, left ventricular aneurysm (time course, involved coronary, s/s, echo findings)
1) Rt ventricular failure: acute, RCA, hypotension/clear lungs/kussmaul sign, hypokinetic RV
2) Papillary muscle rupture: acute (3-5 days), RCA, severe pulmonary edema/holosystolic murmur, severe mitral regurg w/ fail leaflet
3) Interventricular septum rupture: acute (3-5 days), LAD or RCA, CP/holosystolic murmur/biventricular failure/SHOCK, left to right shunt w/ inc in O2 from RA to RV
4) Free wall rupture: 5 days - 2 weeks, LAD, CP/shock/distant heart sounds, pericardial effusion w/ tamponade
5) Left ventricular aneurysm: months, LAD, subacute HF/stable angina, thin and dsykinetic myocardial wall
Hemodynamics in heart failure
Dec contractility -> dec cardiac output -> compensatory neurohormonal activation -> inc systemic vascular resistance -> inc afterload
Pulsus paradoxus is commonly associated with what conditions?
Cardiac tamponade, severe asthma or COPD (inspiration decreases BP - think less left ventricular output d/t either mechanical constriction (effusion or lung expansion *COPD/asthma) or blood stays in pulmonary vasculature longer d/t inc intrathoracic pressure w/ COPD/asthma)
What drugs confer survival benefit in CHF vs drugs that reduce symptoms/hospitalizations but not overall survival?
ACEi, ARBs, BB, sprinolactone confer survival benefit; digoxin/furosemide reduce symptoms/hospitalizations
Mobitz type I vs type II
I = progressive prolongation of PR interval; benign, transient, tx involves observation and hold meds that affect AV node II = constant PR interval but QRS will drop suddenly; this can progress to complete block, tx requires pacemaker
Meds that affect AV node =
BB, CCB, digoxin
Elevated systolic, normal diastolic (<90) = what dx and MOA
Isolated systolic HTN (elderly); d/t inc stiffness of arterial wall, manage w/ lifestyle modifications and meds
Dihydropyridine CCBs and MOA
The -dipines; coronary artery vasodilation increases myocardial oxygen supply; also invokes systemic arterial vasodilation which causes a reduction in afterload causing reduction in myocardial oxygen demand (basically inc supply and dec demand through vasodilation)
Signs of digoxin toxicity?
GI symptoms (anorexia, nausea, abdl pain), and neurological visual symptoms (color vision, scotomas, blindness); beware amiodarone can inc dig lvls -> it is recommended to halve the dig when starting amiodarone
Most common cause of sudden cardiac arrest in the immediate post infarction period in pts with acute MI?
Re-entrant ventricular arrhythmias (v-fib, ventricular premature beats, or v-tach)
Infective endocarditis (IV drug user), dvlpt of AV block, suspicious for what dx?
Perivalvular abscess extending into adjacent cardiac conjunction tissues
Maneuvers to change murmurs and their physiologic effect: valsalva, standing, nitro, hand grip, squatting, leg raise
Valsava: dec preload Abrupt standing: dec preload Nitroglycern: dec preload aka dec diastolic pressure Sustained hand grip: inc afterload Squatting: inc afterload and inc preload Passive leg raise: inc preload
Primary valve abnormality in pts with HOCM
Asymmetric septal hypertrophy with LVH leads to systolic anterior motion of the mitral valve (valve makes contact with septum - obstructs blood flow out of LV during systole = LVOT)
Tachyarrhythmia (narrow or wide) w/ clinical hemodynamic instability, initial tx?
Cardioversion; cardioversion if QRS complex present (minimize chance of energy delivery during repolarization phase *which can precipitate v-fib). Vs defibrillation -> high energy at random point in cycle indicated in v-fib or pulseless v-tach
Prior cardiac sx (coronary artery bypass, valve sx, TB, malignancy, uremia), s/s of right hear failure (peripheral edema, ascites, elevated JVP, pericardial knock, pericardial calcifications), dx?
Constrictive pericarditis
How does hyponatremia parallel the severity of heart failure in pts w/ CHF (Na lvl is good predictor of adverse outcomes)
CHF -> low cardiac output and dec perfusion pressure at baroreceptors/renal afferent arterioles causes release of renin and norepinephrine and ADH -> ADH promotes water reabsorption dec Na
What is S3; and given the classical dx a/w with S3, immediate mgmt?
Low freq diastolic sound after S2 associated with left ventricular failure (ken-tuc-KY; blood from LA strikes blood that is already still in LV causing reverb). Tx w/ IV diuretics for symptomatic relief
Ddx for secondary causes of HTN?
Renal parenchymal disease: elevated serum Cr, abnormal UA w/ proteinuria and RBC casts
Renovascular disease: severe HTN >180 and resistant to multiple HTN meds, possible recurrent flash pulmonary edema, unexplained rise in Cr after starting ACEi, abdominal bruit (very specific)
Primary aldosteronism: hypoK, slight hypernatremia, HTN w/ adrenal incidentaloma (no effects on HR)
Pheochromocytoma: paroxysmal elevated BP w/ tachy, HA/palpitations/diaphoresis, inc urinary excretion of vanillylmandelic acid
Cushing: central obesity, facial plethora, muscle weakness, abdominal striae, ecchymosis, inc 24hr urinary free cortisol excretion
Coarctation of the aorta: difference in UE vs LE pressures
Hemodynamic measurements in shock: hypovolemic vs cardiogenic vs septic (RA pressure = preload, PCWP aka left atrial pressure = preload, cardiac index = pump function, SVR = afterload, MvO2)
Hypovolemic shock: decreased everything except elevated afterload
Cardiogenic shock = significantly decreased CI (pump dysfunction duh), elevated preloads and afterload to compensate
Septic shock = *main issue is major dilation and capillary permeability causing dec SVR, dec preload; CI and MvO2 increased to compensate
Hx of left ventricular systolic dysfunction and persistent a-fib (or rhythm problem), p/w s/s of hypo or hyperthyroidism, hepatotoxicity, bradycardia, heart block, pneumonitis, neurologic symptoms, and visual disturbances, what drug toxicity?
Amiodarone
Viral prodrome, heart failure symptoms (dyspnea, orthopnea, edema), chest pain, echo shows dilation (bx w/ lymphocyctic infiltration), dx and tx?
Viral myocarditis; tx w/ meds (diuretics, ACE, BB), temporary ventricular assist device, heart transplant if no recovery
Well known side effects of high dose niacin used to tx lipid abnormalities? Mechanism? Tx?
Cutaneous flushing and intensive generalized pruritus. D/t release of histamine and postaglandins resulting in niacin induced peripheral vasodilation. We know its prostaglandin so give aspirin beforehand to reduce symptoms
Recent stent placement in LAD, now p/w typical CP/diaphoresis/SOB w/ EKG showing 2mm ST elevations in I, aVL, and V1-V4, dx?
STEMI 2/2 stent thrombosis d/t medication non-compliance (question stem said recently unemployed); pts w/ stent should be counseled on 12mo dAPT w/ ASA and clopidogrel (platelet receptor blocker)
Patients w/ cardiac arrhythmias usually have underlying cardiac disorders like
Coronary heart dz, cardiomyopathy, valvular heart dz; pts may not have any prodromal symptoms prior to the syncopal episode (unlike vasovagal or neurocardiogenic syncope pts)
Digoxin (used for heart failure/A-fib) toxicity, s/s?
Nausea, vomiting, diarrhea, vision changes, and arrhythmias
What does ASCVD risk calculator take into account? Statin at what %?
Race, age, sex, total cholesterol, HDL, diabetes status, smoking status, systolic BP; initiate statin if 10 yr risk of ASCBD >7.5% for PRIMARY prevention. If hx of known ASCVD event or LDL >190 then initiate statin regardless
Syncope, prolonged PR interval and prolonged QRS (intraventricular conduction delay), cause of syncope?
Bradyarrhythmia or high-grade AV block
Question 4456 for chart of syncopal etiologies and clinical findings
Immigrant, acute dyspnea, hx of rheumatic heart dz, irregularly irregular HR, heart sound findings?
Loud S1 w/ mid diastolic rumble d/t mitral steonsis -> can lead to left atrial dilation and subsequent A-fib
Prolonged PR interval (>200), dx? Mgmt if normal QRS vs prolonged QRS
1st deg AV block. Most cases of 1st deg blocks w/ normal QRS = delayed AV nodal conduction (no further eval required if asymptomatic). If AV block w/ prolonged QRS = delay likely below AV node = need EP testing to determine site of delay
Pleuritic chest pain (improves when sitting up worse laying down, low grade fever, diastolic sound w/ squeaking quality at left sternal border, non-specific EKG, bun > 60, dx?
Uremic pericarditis (inflammation of visceral and parietal layers of pericardium): note unlike other etiologies of pericarditis - no diffuse ST elevation or PR depression as the myocardium is not affected. Squeaky sound at left sternal = friction rub. MUST rule our pericardial effusion/cardiac tamponade prior to tx w/ dialysis
Acute pericarditis ddx and mgmt?
Viral or idiopathic, autoimmune (SLE), uremia (acute or chronic renal failure), post MI (early = peri-infarction pericarditis, late = Dressler syndrome). Tx w/ NSAIDs and colchicine for viral or idiopathic; variable for other etiologies. Look for pleuritic CP worse laying down better sitting up, low grade fever, friction rub, diffuse ST and PR depression, pericardial effusion on echo
EKG findings for left anterior descending artery occlusion (anterolateral MI)?
ST elevation in I, aVL, V2-V6 and reciprocral ST depression in II, III, aVF
Mgmt of STEMI:
Rabid stabilization and immediate coronary reperfusion: oxygen, full dose aspirin (chewed = faster), platelet receptor blocker (clopidodgrel, ticagrelor), nitroglycerin for pain w/ morphine, beta blocker, and anticoagulation (heparin)
Time frame for STEMI and PCI
Within 12 hours of symptom onset AND within 90 minutes from first medical contact (if facility capable); 120 minutes alloted for non PCI capable facility *room for transport time. PCI > fibrinolysis but can opt for fibrinolysis if PCI not available within 120 mins
Excessive vs moderate alcohol intake?
Excessive = >2 drinks a day or binge drinking >5 drinks in a row (a/w w/ inc incidence of HTN)
Moderate intake = 1 or 2 for men a day, and 1 a day for women (moderate is a/w dec incidence of coronary heart dz and mortality and dec in blood pressure)
Sinus bradycardia (<60HR), mgmt?
IV atropine: anticholinergic, intial tx for bradycardia and hypotension
Cardiac drug and their effects: adenosine, amiodarone, IV glucagon, norepi/dobutamine
Adenosine: transient block of conduction at AV node - useful in identifying/terminating supraventricular tachycardia
Amiodarone: antiarrhythmic: used for supraventricular/ventricular tachyarrhythmias
Glucagon: inc cAMP - tx beta blocker or CCB toxicity
Norepi: tx of severe hypotension and shock
Tingling, burning of hand a/w localized vesicular rash, not bilateral or symmetric (innoculation by a virus)
Herpetic whitlow
Small erythematous papules and irregular burrows predominantly at finger webs, flexural surfaces, belt line, buttocks
Scabies
Pruritic, hyperkeratotic patches or annular erythematous lesions on palms, dx?
Tinea manuum
Two types of contact dermatitis: allergic vs irritant, ddx?
Allergic: type IV hypersensitiity, poison oak/ivy/nickel/rubber/leather dyes/medications, look for ACUTE erythema, papules/vesicles, primarily on exposed skin well demarcated Irritant: physical of chemical irritation (non-immune), soaps/detergents/chemicals/acid,
commonly on hands look for erythema fissure (chronic)
Types of hypersensitivity reactions - mneumonic?
ACID = I - IV
A - allergic: IgE mediated, quick onset after exposure, bee stings/latex/meds
C - cytotoxic: cytotoxic/antibody-mediated, hemolytic rxns/Goodpasture/hyperacute graft rejection
I - immune: immune complex/IgG/IgM mediated, hypersensitivity pneumonitis/SLE/polyarteritis nodosa/serum sickness
D - delayed: delayed or cell mediated, chronic graft rejections, PPD test, allergic dermatitis
Chronic lung disease -> pulmonary HTN -> impaired right ventricular functions. Signs of right ventricular failure = ?
Elevated JVD (w/ prominent a waves), S3, tricuspid regurgitation murmur, hepatomegaly w/ pulsatile liver (from congestion), LE edema/ascites/and or pleural effusions, look for elevated pulmonary artery systolic pressure in cor pulmonale
What is an estimation of left ventricular end-diastolic pressure, and is elevated in pts w/ left ventricular systolic/diastolic dysfunction?
PCWP - if elevated look for pulmonary edema on auscultation
Methemoglobinemia s/s?
Cyanosis/bluish discoloration. CO poisoning = pinkish-red skin hue; confirm w/ carboxyhemoglobin level
