UW Week 1 & 2 Flashcards
What does succusion splash help dx?
Gastric outlet obstruction; retained gastric material >3 hrs after a meal will generate a splash indicating presence of viscus filled w/ fluid and gas -> definitive eval w/ endoscopy
57yoM episodes of blood in urine, fatigue, and fever for 4 weeks, 50 pack year smoking, father died of blood disorder (meh) but pt unsure of name, left sided varicocele that fails to empty when pt is recumbent. Hgb = 18, WBCs 7400, PLTs = 580000, U/A > 10 RBCs/hpf, dx and imaging?
Renal cell carcinoma (classic triad of hematuria, back pain, and palpable mass not always present), note LEFT SIDED varicocele that does not empty while recumbent is pretty good indicator for mass - left gonadal vein drains into left renal vein; note ectopic production of EPO by tumor can produce polycythemia. Get CT abdomen
Management of pulseless electrical activity or asystole?
Uninterrupted CPR along w/ vasopressor therapy to maintain adequate cerebral and coronary perfusion; potentially reversible causes of PEA = the 5H’s and 5T’s; there is no role for defib or cardioversion in PEA pts
Polycythemia vera vs carbon monoxide poisoning question (47yoM, daytime HA, dizziness, nausea, works as a traffic controller in underground parking garage - cars in an enclosed space)
Polycythemia vera: clonal myeloproliferative disorder that causes inc in all 3 cell lines (PLTs, white count, hematocrit) pts often asymptomatic w/ occasional transient neuro symptoms or thrombosis
Carbon monoxide poisoning: can see secondary polycythemia d/t tissue hypoxia prompting kidneys to produce more EPO, pulse ox dose not differentiate btw carboxyhemoglobin and oxyhemoglobin so can not be used to dx CO poisoning; dx made on ABG w/ co-oximetry; tx w/ oxygen or hyperbaric/intubation if severe
31yoF, nephrotic syndrome, renal bx performed, pt started on diuretics and salt and protein intake is restricted, edema improves but pts suddenly develops right sided abdominal pain, fever, and gross hematuria, dx and what will renal biopsy show?
Renal vein thrombosis! RVT is an important complication of nephrotic syndrome d/t loss of antithrombin III in the urine *inc risk of venous/arterial thrombosis. RVT can occur in any etiology of nephrotic syndrome but commonly seen w/ MEMBRANOUS!
Gross or microscopic hematuria w/ MINIMAL proteinuria after upper respiratory
IgA nephropathy - rarely will develop into glomerulonephritis or nephrotic syndrome
Fhx of colonic polyps and osteomas and alteration in tumor suppresor gene adenomatous polyposis coli, dx and mgmt?
Familial adenomatous polyposis (FAP), pts w/ classic FAP develop >1000 polyps and universally develop colorectal cancer -> inc screening and elective proctocolectomy are standard of care (start w/ annual sigmoidoscopies for children starting at 10-12 followed by annual colonoscopies - start screening 8 years after initial dx for adults). Also look out for upper GI tumors. CEA monitoring is used for pts w/ established colorectal cancer
Hard unilateral non-tender lymph nodes are always suspicious for cancer; in pts w/ hx of smoking w/ lymph nodes in submandibular or cervical region, c/f what?
Head and neck cancer d/t squamous cell carcinoma
Pts w/ severe bladder outlet obstruction d/t BPH will have inc in Cr and develop AKI, next steps
Get renal U/S to assess for hydronephrosis
Ototoxic medications?
Aminoglycoside antibiotics, chemotherapeutic agents, aspirin, and LOOP DIURETICS. This pt had renal failure and was on aspirin (baby dose) and furosemide (normal dose but d/t renal failure = higher risk of ototoxicity leading to hearing loss)
HIV screening in asymptomatic man preparing to “take the next step”
HIV screening recommended for all pts age 15-65 regardless of risk factors at least once
Pts develops well-circumscribed and raised erythematous plaques w/ central pallor; pts have intense pruritus that can persist at night, individual lesions appear and enlarge over minutes to hours before disappearing within 24hrs, dx?
Acute urticaria (<6wks) can be d/t infections, NSAIDs, IgE mediated (abx, insects, latex, food), direct mast cell activation (narcotics, radiocontrast) or idiopathic (50% pts have this)
Random Facts
1) Contact dermatitis - erythematous papules/vesicles and last several days
2) Atopic dermatitis - flexural areas lasting days/weeks
3) Erythema multiforme - target lesion w/ iris shaped macule +/- vesicle or bullae, extensor surfaces
4) Pts w/ malnutrition, pregnancy, or certain comorbid conditions (diabetes mellitus) should be started on pyridoxine supplementation (B6) when tx for latent or active TB w/ isoniazid to prevent INH induced peripheral neuropathy
5) Fluoroquinolone is a/w tedinopathy and tendon rupture (commonly Achilles); stop drug at onset and avoid exercise/use, change abx
IVDU w/ fevers/chills for a week and holosystolic murmur at cardiac apex last used heroin yesterday, now w/ right arm weakness/lower facial droop/broad-based gait/difficult heel to shin (cerebellar lesion), dx?
Cerebral septic emboli; next steps include draw cultures, initiate broad spec abx, and obtain echo for vegetations
Neck pain, syncope, hx of HTN, mediastinal widening on cxr, and pericardial effusion, but NO pulse differential blood pressure in UE, dx and next steps?
Aortic dissection (BP differential is present in only 20-30% pts); next steps get CT angio if kidneys working and HDS - TEE if hemodynamically unstable or renal insufficiency
Painless, rapid, transient monocular vision loss, dx and imaging?
Amaurosis fugax - curtain descending over visual field - retinal ischemia d/t atherosclerotic emboli originating from ipsilateral INTERNAL carotid artery - get duplex US neck
Dx and mgmt of esophageal rupture (pt had recent EGD)?
Contrast esophagram! Start w/ water soluble contrast since less inflammatory but if that is nondiagnostic get barium study; if perf confirmed = primary closure of esophagus and drainage of mediastinum
Constipation, polyuria, and possibly abdl pain in the setting of Ca lvl of 11.4, and low phosphorus
Symptomatic hypercalcemia d/t primary hyperparathyroidism
Hyperparathyroidism, recurrent PUD/ulcers/burning upper abdl pain, pituitary adenomas, dx?
MEN1 - the GI/pancreatic endocrine tumors including gastrinomas aka Zollinger Ellison
Hypothyroid myopathy has myalgias, proximal muscle weakness, and elvated serum creatine kinase levels; pts often have features of hypothyroid (fatigue, delayed reflexes)
Vs polymyositis: SYMMETRIC proximal muscle weakness (lady just had LE), also myalgias is typically absent and DTR are normal (get bx to confirm polymyositis)
Mechanism or etiology of Mallory-Weiss?
Sudden increase in abdl pressure (forceful retching or blunt abdl trauma) causes mucosal tear in esophagus (submucosal arterial or venous plexus bleeding); risk factors include hiatal hernia or alcohol, dx w/ endoscopy, most heal spontaneously
Types of hearing loss:
Prescbycusis: old age hearing loss, high frequency first
Otosclerosis: chronic conducting hearing loss a/w bony overgrowth of the stapes, low frequency first (middle age pts)
Meniere’s: episodes of tinnitus, vertigo, and sensorineural hearing loss
Acoustic neuroma: most common tumor causing hearing loss - a/w unilateral hearing loss
AIDS pts on HAART, 32yo, complains of 1 mo left sided difficulty hearing, no HA/fever/chills/weight loss/ or ear discharge, exam shows dull tympanic membrane that is hypomobile on pneumatic otoscopy, dx?
Serous otitis media (non infectious effusion)
Mediterranean (this question was Greek), hemoglobin 10.2 w/ MCV 70, unresponsive to iron, dx?
Beta-thalassemia (minor)
Note on oxygen management in COPD exacerbation pt:
Goal of SaO2 of 90-93% or PaO2 60-70 in chronic COPD pts since increase in oxyhemoglobin reduces the uptake of CO2 from tissues by the Haldane effect (CO2 remains in tissues). Uptake in CO2 leads to acidosis (this inc GABA and glutamine/decreases glutamate and aspartate causing changes in consciousness. Also hypercapnia causes reflex cerebral vasoDILATION and may induce seizures
Celiac sprue and bone loss, mechanism?
Malabsorption -> severe Vit D deficiency -> osteomalacia (defective mineralization of organic bone matrix). Vit D def leads to dec intestinal calcium and phosphorus absorption resulting in hypocalcemia and hypophosphatemia -> which in turn leads to secondary hyperparathyroidism bringing Ca lvl to normal or near normal by inc Ca reabsorption in bone and kidney *this also leads to elevated alk phos. Osteomalacia - look for x-rays showing thinning of cortex w/ reduced bone density
How bone formation and remodeling works?
Osteoclasts create cavity at bone surface that osteoblasts fill w/ organic matrix (osteoid). Calcium and phosphorus then deposit in the matrix to provide adequate mineralization
Lights criteria?
At least one of the following:
Pleural fluid protein/serum protein ratio > .5
Pleural fluid LDH/serum LDH > .6
Pleural fluid LDH >2/3 ULN ( so greater than 60)
If pleural glu < 60 = d/t rheumatoid pleurisy, complicated parapneumonic effusion/empyema, malignant effusion, TB pleurisy, lupus pleurisy, esophageal rupture
If pleural glu < 30 = empyema d/t high metabolic activity of leukocytes or bacteria
Pt w/ plantar puncture wound through footwear are at risk for what osteomyelitis infxn?
Pseudomonas; beta hemolytic streptococci and coag neg staph (staph epi) rarely cause osteomyelitis in the absence of predisposing factors like T2DM
Small cell lung cancer paraneoplastic and associations
Lambert-Eaton (pre-synaptic NMJ dysfunction), ACTH/ADH
Wide split fixed S2
ASD
Fever and sore throat in pts just started on antithyroid drug, dx and mgmt?
Agranulocytosis - stop drug and check WBC
Celiac sprue and bone loss, mechanism?
Malabsorption -> severe Vit D defiency -> osteomalacia (defective mineralization of organic bone matrix). Vit D def leads to dec intestinal calcium and phosphorus absorption resulting in hypoCa and hypophosphatemia -> which in turn leads to secondary hyperparathyroidism bringing Ca lvl to normal but STILL LOW by inc Ca reabsorption (not elevated like in primary PTH) in bone and kidney *this also leads to elevated alk phos. Osteomalacia - look for x-rays showing thinning of cortex w/ reduced bone density
How does bone formation and remodeling works?
Osteoclasts create cavity at bone surface that osteoblasts fill w/ organic matrix (osteoid). Calcium and phosphorus then deposit in the matrix to provide adequate mineralization
Management options for acute pain (including opioids) even in pts w/ prior substance abuse hx?
Pain management will be similar for all pts regardless of substance abuse (given documented need for analgesic); although those w/ hx of opioid addiction who are given opioids may need close f/u to avoid relapse
22yoM recently returned from Honduras p/w 2 weeks fever, malaise, exudative pharyngitis, hepatosplenomegaly, generalized lymphadenopathy (he had posterior cervical), he also developed autoimmune hemolytic annemia and thrombocytopenia, dx?
Infectious mononucleosis; this is not malaria since that presents w/ cyclic fevers and dose not have leukopenia, lymphadenopathy, or exudative pharyngitis (although it does p/w fever, malaise, HSM, and anemia)
Rare complication of infectious mononucleosis?
Splenic rupture, airway compromise, and autoimmune hemolytic anemia and thrombocytopenia (d/t cross reactivity of EBV induced antibodies against RBCs and platelets - antibodies are IgM cold agglutinin antibodies that cause complement mediated destruction)
Old lady on chronic NSAID and aspirin, here for fatigue p/w conjunctival pallor, renal function normal, dx and concern for?
Iron deficiency anemia likely d/t gastritis and or gastric ulcers leading to chronic GI blood loss and depletion of iron
Type 4 renal tubular acidosis (hyperkalemic renal tubular acidosis) is characterized by a non-anion gap metabolic acidosis, persistent hyperK, and mild to moderate renal insufficiency; commonly occurs in pts w/ poorly controlled diabetes
Primary hyperaldosteronism causes inc H+ and K+ excretion leading to hypoK and metabolic alkalosis! Renal artery stenosis causes secondary hyperaldo d/t low perfusion to kidney; look for similar hpoK, metabolic alkalosis, and HTN. Vomiting causes hypochloremic metabolic alkalosis d/t loss of gastric HCL. Loop diuretics are potassium wasting and cause metabolic alkalosis
Causes of non-anion gap metabolic acidosis:
Good mneumonic but for the most part remember diarrhea (GI loss) or RTA; where is bicarb being loss (HARDUP)
Hyperalimentation (starting TPN)
Acetazolamide
Renal tubular acidosis (Type 1 = distal, 2 = proximal, 4 = hyporeninemic hypoaldosteronism)
Diarrhea
Uretosigmoid fistula
Pancreatic fistula
PaO2 is influenced mainly by what vent settings? PaCO2 is therefore a measure of what?
FiO2 and PEEP. PaCO2 is a measure of pulmonary minute ventilation = affected mainly by RR and TV. Think of it like this: look at PaO2 and PaCO2 to determine what settings you need to change: FiO2/PEEP for PaO2 while RR/TV for PaCO2
Finasteride mechanism of action?
5-alpha reductase inhibitor: second line for BPH since not as fast as alpha 1, prevents conversion of testosterone to potent DHT (anti-androgen) so good for hair loss and transgender women
Skin lesion that does not meet ABCDE characteristics for melanoma but has these features; ugly duckling sign (different from others, dark brown instead of light, or nodular) has sensitivity up to 90% for melanoma, any mole that itches or bleed since benign lesions are
generally asymptomatic, next steps is melanoma suspected?
Excional biopsy w/ initial margins of 1-3mm of normal tissue
Pt w/ severe bladder outlet obstruction d/t BPH will have inc in Cr and develop AKI, next steps?
Get renal U/S to assess for hydronephrosis
Painless, rapid, transient monocular vision loss, dx and imaging?
Amaurosis fugax - curtain descending over visual field - retinal ischemia d/t atherosclerotic emboli originating from ipsilateral INTERNAL carotid artery - get duplex US neck
Proximal muscle weakness (inc difficulty up stairs,) pain is mild/absent, elevated muscle enzyme (CK, aldolase, AST), autoantibodies (ANA and anti-Jo-1), bx will show endomysial infiltrate, patchy necrosis, dx?
Polymyositis (anti-Jo-1 like dermatomyositis but w/o skin findings like Gottron papules or the butterfly rash)
Progressive pain in pts w/ prostate cancer and bony metastases even after androgen ablation, radionuclide bone scan now showing inc uptake in these pain areas next step?
Radiation therapy
Recent diverticulitis (or a Crohn disease, malignancy), p/w air in urine, stool in urine, recurrent UTI, dx and use what to dx?
Colovesical fistula - dx w/ abdl CT w/ (oral or rectal) contrast
Pernicious anemia MOA?
VitB12 deficiency d/t presence of autoantibodies against gastric intrinsic factor (which is required for B12 absorption); confirm w/ anti-intrinsic factor antibodies
Megaloblastic anemia in whites of Northern European ancestry shiny tongue (atrophic glossitis), vitiligo, thyroid disease, and neuro abnormalities (autoimmune and megaloblastic anemia), dx?
Pernicious anemia - antibodies against intrinsic factor = B12 def
Elevated alk phos, normal hepatic transamniase, normal RUQ U/S, positive AMA antibody, dx?
Early primary biliary cholangitis (chronic progressive liver dz w/ cholestasis and autoimmune destruction of intrahepatic bile ducts); very common in middle-aged women look for pruritus and fatigue first symptom onset; tx ursodeoxycholic acid as soon as dx made regardless of symptoms (liver transplant if severe)
Murmur? Delayed and diminished carotid pulse, soft second heart sound, mid to late peaking systolic murmur w/ maximal intensity at 2nd right intercostal, radiation to carotids
Aortic stenosis!
Chronic epigastric pain suddenly worsens, acute abdomen w/ rebound tenderness and guarding, x-ray showing radiolucency under diaphragm, dx?
Perforated peptic ulcer - air under the diaphragm
66yoF agitation, restlessness, and poor sleep; past 3 mo HA and weight gain, no meds, smokes 50 yrs. BP 160/110 and pulse 90; skin findings show facial plethora and scattered bruises on extremities. Lab findings NOT RAS but Cushing syndrome, why?
Likely paraneoplastic w/ ACTH. Cushing syndrome: HTN, hyperglycemia, weight gain, easy bruising (causes look for excess glucocorticoid intake, ACTH producing pituitary adenoma, and ectopic ACTH - eg small cell lung cancer)
NOT RAS because: RAS is severe HTN a/w flash pulmonary edema, resistant HF, chronic kidney disease (elevated Cr), abdl bruit, look for other features of atherosclerosis
Work up of hypercortisol?
Start w/ low dose dexamethasone or 24 hr urine free cortisol or late night salivary cortisol measurement -> if these are positive get ACTH lvl next to determine whether ACTH dependent (Cushing disease or ectopic ACTH) or ACTH independent (adrenal disease or
exogenous glucocorticoid)
20yoM w/ 4-6 watery bowel movements w/ intermittent bright red blood per rectum; sigmoidoscopy demonstrates mild erythema involving the rectum and distal sigmoid colon and rectal biopsy confirms mucosal inflammation and crypt abscesses, dx and future required screening?
CRYPT ABSCESSES = UC (Crohn has abscesses but not crypt). Ulcerative colitis; inc risk for colorectal carcinoma. Other complications of UC = toxic megacolon, PSC, erythema nodosum/pyoderma gangrenosum, spondyloarthritis
Arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts are the most common renal vascular lesions seen, dx? Vs increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis, dx?
HTN (arteriosclerotic) vs Diabetes (mesangial expansion)
Lady w/ hx of migraines but develops new type of headache w/ signs of INC pressure (frequent nausea, vomiting, blurry vision), next steps?
MRI - need to r/o mass
Toxic shock rash vs meningococcemia rash?
TSS: staph aureus exotoxin will cause erythroderma (macular rash similar to sunburn)
Meningococemia: petechial rash
Skin infection caused by poxvirus presents as small pruritic skin colored papules w/ umbilicated centers, dx? And which pts have prolonged course as opposed to self-limiting 6months?
Molloscum contagiosum; pts w/ impaired cellular immunity ie HIV disease, have prolonged course w/ widely distributed papules, facial involvement, and lesion counts in the hundreds *test for HIV in aduts w/ large or numerous lesions
Primary vs central AI
Primary: most common cause autoimmune, dec cortisol (same in central), elevated ACTH, DEC ALDO, look for hyperpigmentation/hyperK/hypoNa/hypotension
Central: most commonly d/t glucocorticoid therapy, dec cortisol, DEC ACTH, normal aldo, less severe symptoms/no hyperpigmentation/no hyperK
Bones, stones, abdominal moans, psychic groans (muscle weakness, recurrent nephrolithiasis, neuropsychiatric symptoms, hyperCa), dx?
Primary hyperparathyroidism - majority of cases d/t parathyroid adenoma; HTN w/ primary hyperparathyroidism is suspicious for MEN2A (parathyroid hyerplasia) w/ pheochromocytoma requiring w/u
MEN1; MEN2A and MEN2B
MEN1: primary hyperparathyroidism, enteropancreatic tumors (gastrinoma), pituitary tumor
MEN2A: medullary thyroid carcinoma, pheochromocytoma, parathyroid hyperplasia
MEN2B: MTC, pheo, other (mucosal/intestinal neuromas, marfanoid habitus)
Low frequency tinnitus w/ feeling of fullness, episodic vertigo, sensorineural hearing loss, dx?
Meniere disease
Common causes of vertigo: meniere, BPPV, vestibular neuritis, migraine, brainstem/cerebellar stroke
Meniere: recurrent eps lasting 20 mins to hrs, sensorineural hearing loss, tinnitus w/ feeling of fullness (mechanical humming causing distortion of speech) BPPV: brief eps triggered by head movement, dix-hallpike causes nystagmus
Vestibular neuritis: acute single ep last days, follows viral syndrome, abnormal head-thrust test
Migraine: vertigo a/w HA or other migrainous phenomenon (visual aura), symptoms resolve in btw eps
Brainstem cerebellar stroke: sudden onset persistent vertigo, w/ other neuro symptoms
Lesion at spinal cord affecting bladder?
Thoracic or sacral
Diabetes insipidous - central vs nephrogenic?
Cental = decreased ADH secretion from pituitary Nephrogenic = normal ADH but kidneys resistant to ADH . Cutoff for dilute urine = 100mOsm/kg
Polyuria in nonhospitalized pt can be d/t diabetes mellitus, primary polydypsia, and diabetes insipidus
Primary polydipsia (HypoNa) = inc water intake that surpasses kidney’s ability to excrete it; look for hyponatremia (Na <137), very dilute urine (osmolality <100mOsm) and urine osmo < serum osmo
Polyuria in nonhospitalized pt can be d/t diabetes mellitus, primary polydypsia, and diabetes insipidus
DI = central vs nephrogenic (both HyperNa). Ddx the two w/ water deprivation test (also distinguishes if there was true polydipsia). The pt must abstain from water for 2-3hr; urine osmo >600 suggest primary polydipsia d/t INTACT ADH and ability to concentrate urine in the absence of water intake. Pts w/ continued dilute urine likely have DI. These pts then receive desmopressin to distinguish btw central and nephrogenic. Central DI = >50% inc in urine osmolality w/ demopressin (ADH analogue replacing the nonexistent ADH)
Nephrogenic DI will not see inc in urine osmo since kidneys do not respond to ADH. Tx for central DI is desmopressin (ADH analogue)
Demeclocycline is for SIADH; where you see hyponatremia w/ concentrated urine
Cystic hepatic lesion w/ egg shell classification, dx?
Will also see hydatid cysts d/t echinococcus, tx w/ surgical resection under the cover of albendazole (aspiration can be performed but there is risk of anaphylactic shock d/t cyst content spillage)
High fever, chills, tenosynovitis, polyarthralgias, pustular/papular lesions on trunk and extremities, commercial sex worker, dx?
Disseminated gonococcal infection; blood cx may be negative so get NAAT. IV ceftriaxone (switch to oral cefixime when improving) and empiric azithro/doxy chlamydial co-infection coverage
Classic TSS rash by Staph aureus?
Diffuse erythematous desquamating rash throughout the body including palms and soles; also look for hypotension and fever
When to start colonoscopy screenings in pts w/ UC
8 years after initial diagnosis and repeat 1-2 years after for CRC
4 indications when to start statin
1) any atherosclerotic disease (ACS, MI, stable angina, stroke, TIA, PAD)
2) LDL > 190
3) Age 40-75 w/ diabetes
4) 10 year ASCVD risk > 7.5
Antiplatelet therapy vs anticoagulation therapy (recommended in A-fib pts w/ appropriate CHADS-VASC scoring)
Antiplatelet = aspirin and clopidogrel Anticoagulation = Warfarin or non-Vit K antagonist orals like apixaban, dabigatran, rivaroxaban
Contraindications to anticoagulation?
Active bleeding or failed therapy = consider IVC filter
Ankylosing spondylitis buzz words?
Reduced forward flexion of lumbar spine and tenderness over lumbosacral area. Chronic progressive back pain and stiffness; pain relief w/ activity; lumbosacral tenderness *SI; and reduced spinal range of motion *bamboo sign d/t fusion of vertebral bodies w/ ossification of discs. Prevalent in young and males
Best dx for ankylosing spondylitis?
X-ray of SI joints more specific than HLA-B27; not everyone w/ HLA-B27 has AS
6mo intermittent upper abdl pain w/ nausea, dull epigastric pain worse after meals, relieved leaning forward, occasional diarrhea *steatorrhea, lost 15lbs over 12 months; five years ago w/ similar event. Alcohol daily. Dx and use what to test?
Chronic pancreatitis; best modality is CT to look for pancreatic calcifications *lipase in chronic panc may only be slightly elevated or even normal
Presbyopia and poor near vision, d/t loss of what mechanic?
Loss of lens elasticity; cornea shape change = astigmatism
Skin lesion presents as macules, vesicles, and bullae w/ honey colored crusts (common in children); dx and what bug?
Bullous impetigo caused by Staph aureus (coagulase negative staphylococci that threw you off on the poison ivy question - common skin contaminant in cultures)
Armpit lesion w/ painful nodules and abscesses *chronic and relapsing, dx?
Hidraneitis suppurativa
22yoM yellow eyes, otherwise feels well no symptoms, has noticed occassional darkening of urine in past; no other medical problems, immigrated from Turkey. Fasting for past 2 days for religious reasons, normal vitals, scleral icterus present. PE - heart lungs abdomen normal, no HSM or masses. Labs - elevated INDIRECT total bili and direct bili, normal alk phos, dx and mgmt?
Gilbert syndrome , reassurance/supportive care. Intermittent jaundice d/t mild unconjugated hyperbilirubinemia w/o evidence of hemolysis; triggered by fasting or consumption of fat-free diet, physical exertion, illness, stress
RANDOM FACTS
1) Elevated unconjugated bilirubin (aka INDIRECT) = think hemolysis or reduced conjugation process like Gilbert. Elevated conjugated bili (DIRECT) = think hepatobiliary disease obstructive nature (cirrhosis, hepatitis, Dubin-Johnson and Rotor)
2) Unconjugated bili disease = Gilbert -> Crigler Najjar (bad for babies) *GC
3) Conjugated bili disease = Dubin Johnson and Rotor *DR
4) Aortic coarctation vs dissection (the dissection is before the aortic split - pressure difference btw arms will be present) (the coarctation is after the split - difference in UE vs LE BPs *unless the coarctation occurs proximal to the left subclavian artery)
5) Plantar warts are d/t HPV infection and most commonly occur in young adults and immunocompromised individuals; lesions appear as hyperatotic papules on sole of foot that can be painful when walking or standing
1st line tx for chemotherapy induced nausea
Serotonin (5HT) receptor antagonist, like ondansetron, that target 5HT3 receptors; second line if refractory is dopamine antagonist (metoclopramide, prochloperazine, promethazine)
HyperK management: 3 goals in this order
Stabilize cardiac membrane w/ calcium gluconate -> shift K intracellularly (fastest is insulin/glucose) -> reduce total K ie Kaexelate (sodium polystyrene sulfonate)
Cough, chest pain, hemoptysis, numerous round alveolar infiltrates on chest imaging, murmur best heard systolic murmur inc on inspiration, prior IVDU, dx?
Infective endocarditis affecting tricuspid valve leading to pulmonary septic emboli (most commonly staph aureus)
Note on paradoxical aka reversed splitting of second heart sound: normally A2 closes then P2 (A before P - makes sense longer breath)
In paradoxical: A2 comes AFTER P2; best heard during expiration - commonly d/t fixed LVOT obstruction (aortic valve or subaortic stenosis, LBB)
Most reliable indicator for opioid intoxication?
DEC respiratory rate! Dec bowel sounds and hypotension are good indicators too; absence of miosis does not exclude diagnosis
Pt w/ organ transplant on high dose immunosuppressive suddenly stopped bactrim and valganciclovir, now p/w pneumonitis (diffuse bilateral interstitial infiltrates), gastroenteritis (bloody diarrhea), and hepatitis (elevated transaminases), dx?
CMV; dx w/ CMV PCR; tx w/ either IV ganciclovir if severe or oral valganciclovir (not acyclovir)! Legionella - hyponatremia, diarrhea, pulmonary symptoms (NO bloody diarrhea)
Concern for what bone complication in pts w/ rheumatoid arthritis?
Osteoporosis (soft tissue swelling, joint space narrowing and bony erosions)! Osteitis deformans = aka Paget disease of bone
BP 180/120 *high, they’ve mentioned it being this threshold on multiple questions, HA, upper abdominal systolic-diastolic bruit, dx?
Renal artery stenosis (look for resistant multi drug HTN, malignant HTN, pressures 180/120, abdl bruit, unexplained atrophic kidney, or unexplained rise in Cr after starting ACE). Vs AAA = abdl bruits typnically NOT present, most pts are asymptomatic, if anything look for pulsatile mass
42yoM 4 weeks fatigue, weakness, fleeting joint pains/low grade fever/dark cloudy urine/pain in fingertips (Osler) and SOB; exam shows swelling and tenderness in several finger pads. Normocytic anemia, elevated leukocytosis, SUPER elevated ESR and elevated RF, UA 2+ blood and 1+ protein, dx?
Infective endocarditis! The giveaway was the Osler nodes and abnormal urine sediment
Another bone pain w/ hx of Crohn’s and small bowel resection, what are the calcium phosphate and PTH levels
LOW Ca, LOW phos, HIGH PTH. Malabsorption causing Vit D def causing low calcium and phosphate absorption -> high PTH = concern for osteomalacia. Note high PTH also causes inc urinary phosphate excretion as serum calcium levels try to go up (Ca and Phos go in opposite direction unless this is a malabsorption problem)
Polycythemia management
Myeloproliferative disorder characterized by erythrocytosis - HTN, transient vision disturbances, facial plethora, and splenomegaly are common! Tx w/ serial phlebotomy; bone marrow suppressive drugs like hydroxyurea may be added if there is high risk of thrombosis
HACEK organisms account for 3% of organisms that can cause infective endocarditis
Eikenella a/w normal human oral flora - dental procedure or peridontal infection
1st line mgmt of carpal tunnel syndrome
Start w/ nocturnal wrist splinting -> if significant weakness or refractory symptoms consider surgical decompression
Nephrotic range proteinuria and hematuria w/ electron microscopy showing dense deposits within glomerualr basement membrane; immunofluorescence microscopy is positive for C3 not immunoglobulins, most likely pathophysiologic mechanism?
COMPLEMENT activation antibodies against C3 convertase - MPGN. Persistent activation of the alternative complement pathway = membranoproliferative glomerulonephritis (unique nephropathy because IgG antibodies against C3 convertase of the alternative complement cause persistent complement activation). VS immune complex mediated glomerulopathies is d/t circulating immune complexes (SLE, post strep glomerulonephritis)
Raw oyster consumption or wound contamination during sailing/boating or raw seafood handling; usually causes mild cellulitis but those w/ liver disease or hemochromatosis are at risk of nec fascitis w/ hemorrhagic bullous lesions and septic shock, dx?
Vibrio vulnificus: dx w/ blood and wound cultures and tx w/ IV ceftriaxone + doxycycline
Organ transplant prophylaxis?
Bactrim for PCP proph and ganciclovir or valganciclovir for CMV coverage
Scabies? Bed Bugs?
Scabies = intense pruritus that is worse at night, pustules, finger web involvement, and excoriations (mites dig burrow into skin causing delayed type IV hypersensitivity); focus on flexor surface of wrist, lateral surface of fingers, and FINGER WEBS. Tx w/ permethrin topical or oral ivermectin
Bed bugs: breakfast/lunch/dinner bites sparing palms and soles, worse at night
55yo white male, many falls for the past weeks, dizzy, dry mouth, dry skin, erectile dysfunction over this period, past hx of resting tremors, orthostatic hypotension, dx?
Multiple system atrophy (Shy-Drager syndrome): degenerative disease w/ 1) parkinsonoism, 2) autonomic dysfunction (postural hypotension, sweating, bladder/sexual problems), 3) widespread neurological signs (cerebellar, pyramidal, or LMN)
Always consider what syndrome when a Parkinson pt experiences orthostatic hypotension, impotence, incontinence, and other autonomic symptoms?
Shy-Drager: concern for laryngeal stridor/bulbar dysfxn; tx is aimed at intravascular volume expansion w/ fludrocortisone, salt supplementation, alpha adrenergic agonists
BIOSTATS:
Loss to f/u in prospective studies create potential for attrition bias a subtype of selection bias
Timeline of renal changes in pts w/ diabetes?
Glomerular hyperfiltration (as early as several days after diabetes dx is made) -> this leads to intraglomerualr HTN leading to progressive glomerular dmg and renal fxn loss -> thickening of GBM -> mesangial expansion -> nodular sclerosis (specific to diabetic nephropathy) *ACEi help diabetes by reducing intraglomerular HTN
Schilling test
How well stomach can absorb B12 (intrinsic factor problem vs absorption vs dietary)
34yoF diarrhea, weight loss and fatigue for a year; diarrhea 2-3x daily w/ abdl pain; no tenesmus or bloody diarrhea but stool is very foul smelling and floating; also complains of diffuse bone pain; lab shows Hgb 9.8 w/ MCV 72, dx? and expected calcium, phosphate, pth
levels
Steatorrhea and malabsorption (from some chronic GI disease) resulting in poor absorption of Vit D thereby causing poor absorption of calcium and phosphorus -> pts with low calcium and phosphorus d/t poor absorption will develop secondary hyperparathyroid (low Ca and low phos high PTH). Low Vit D can
lead to osteomalacia (bone pain
Tylenol toxicity management; toxic ingestion = > 7.5g
Initial mgmt = focus on gastric decontamination w/ activated charcoal if pts presents within 4 hrs of ingestion; also obtain acetaminophen level at that time. Next use nomogram to determine change of hepatotoxic effects given acetaminophen level at hr since ingestion - tool will guide whether NAC is required
Spontaneous bacterial peritonitis, dx criteria? Tx?
Paracentesis - PMNs > 250, positive culture (often gram neg like E. coli or Kleb), protein < 1 and SAAG > 1.1. Tx = 3rd gen cephalosporin; fluoroquinolones for SBP proph
Corneal vesicles, opacification, dendritic ulcers, dx and tx?
Viral keratitis d/t herpes simplex or VZV tx w/ ganciclovir or trifluridine
Localized swelling along margin of lower eyelid w/ erythema and tenderness, no conjunctival injection or ocular discharge, dx and tx?
External hordeolum (stye!) - acute inflammatory d/o of eyelash follicle or tear gland often d/t staph aureus but sterile in many cases; start w/ warm compresses first (pustule may form -> then rupture w/ pus/relief of pain -> chalazion may take its place and regress over months)
Mgmt of pts w/ vasovagal syncope?
Reassurance and education about benign nature of condition, advised to avoid triggers and use physical counterpressure maneuvers during prodromal phase in order to abort episode; BB don’t help - no sig benefits in trial
Autoimmune hepatitis vs hemochromatosis:
Hereditary hemochromatsis a/w calcium pyrophosphate dihydrate crystal deposition (pseudogout) in joints leading to chondrocalcinosis, pseudogout, and chronic arthropathy. Not autoimmune hepatitis since that affects symmetric small joints while the pt w/ hemochromatosis (both him and dad w/ diabetes and aminotransferases) had a single bad knee
Cardiac (aortic dissection, MVP), skeletal (disproportionately long extremities and inc arm-span-to-height ratio), pulmonary (spontaneous pneumo), and ocular (ecoptia lentis), abnormalities, dx? All of these pts w/ acute chest pain require eval for what?
Marfan syndrome; aortic dissection! Pts w/ dissection and or progressive aortic root dilation can develop AR. Look for early descrendo diastolic murmur best heard along left sternal border at 3rd and 4th intercostal space w/ pt sitting up, leaning forward, and holding breath after full expiration
All about Marfan: tall w/ long arms, flexible joints, pectus carinatum
Skeletal: arachnodactyly, upper to lower body segment ratio is dec while arm to height is inc, pectus deformity/scoliosis/lyphosis, and joint hypermobility Ocular: ectopia lentis CV: aortic dilation, regurgitation or dissection (the trifecta of aortic valve!), and MVP
Pulmonary: spontaneous pneumo from apical blebs
Tachyarrhythmia (narrow or wide doesn’t matter), a/w clinical or hemodynamic instability (hypotension, cardiogenic shock, signs of ischemia, acute HF), first line tx?
Immediate synchronized cardioversion (amiodarone is for maintence of sinus rhythm - duh antiarrhythmic)
Hypothyroidism can cause what additional metabolic abnormalities?
HYPERLIPIDEMIA, hyponatremia and asymptomatic elevations of creatinine kinase and serum transamniases
Common side effect of CKD pts started on EPO (after ruling put iron def anemia)?
Hypertensive crisis (pts who receive large dose or exp rapid rise in HgB)
40yo w/ SLE on prednisone has atraumatic hip pain w/ normal x-ray findings, dx and best imaging modality?
Osteonecrosis (aka avascular necrosis) of the femoral head (d/t disruption of circulation of bone through micro-occlusion); common complication of SLE/pts on glucocorticoids. X-ray normal in first few months; MRI more sensitive
Absent of identifiable bacteria on culture or gram stain, mucopurulent discharge in a pt who is sexually active suggests what dx?
Chlamydial urethritis; get NAAT
What to check before initiating these therapies: TNF-alpha inhibitor vs Trastuzumab
TNF-alpha inhib - tx of rheumatologic disease, can cause reactivation of latent TB prior to initiating agent get PPD
Trastuzumab - used for HER-2 positive breast carcinoma. Risk of cardiotoxicity get baseline echo and ctm
MOA of nitrates?
Primary anti-ischemic effect = systemic vasodilation and dec in cardiac preload resulting in a dec in left ventricular end-diastolic and end-systolic volume -> this in turn leads to 1) reduction in left ventricular systolic wall stress (which reflects afterload and is proportional to pressure*radius/thickness) AND 2) dec in myocardial oxygen demand
Antiischemic effect of nitrates?
Mediated by systemic vasodilation w/ a dec in left ventricular end diastolic volume and wall stress resulting in dec myocardial oxygen demand
Multiple myeloma pts are at increased risk for recurrent infections d/t what abnormality?
Impaired effective antibody production (bone marrow infiltration by neoplastic cells alters normal leukocyte population thereby causing hypogammaglobulinemia)
New mom holding infant w/ thumb outstretched (abducted and extended); inflammation of abductor pollicis longus and extensor pollicis brevis tendons passing through fibrous sheath at radial styloid process; pain elicited w/ direct palpation of radial site of wrist at base of hand (also positive Finkelstein test = passive stretching of tendons) dx?
De Quervain tenosynovitis
Pain over palmar aspect of first MCP joint and locking of the thumb in flexion?
Trigger thumb
Wells score < or equal to 4 = PE unlikely -> get diagnostic study before starting IV heparin
Wells score > 4 = PE likely -> consider symptoms and contraindications then start IV heparin
Wells score takes into account what factors?
3+ for signs of DVT or no alt diagnosis 1.5+ for previous PE/DVT, HR >100, or recent sx/immobilization 1+ for hemoptysis or cancer
Mgmt of C diff? Suspect in what pts?
Any pt on abx and has diarrhea and or abdl pain; send stool studies for C diff TOXIN; tx initial ep w/ oral vancomycin or oral fidaxomicin; pts w/ fulminant dz (like hypotension, ileus, megacolon) should be tx w/ high dose oral vanc and IV metro
The lupus anticoagulant, an anti-phospholipid antibody, is a prothrombotic immunoglobulin that causes artifact error w/ prolonged aPPT in vitro; with this prolongation and clinical findings = still anti-phospholipid syndrome
Specific tests like diluted Russel viper venom test exist
Thickened white patch inside mouth after recently started chewing tobacco? Granular texture on buccal mucosa, not indurated, not removed by scraping w/ tongue depressor
Leukoplakia. Canker sore = aphthous stomatitis
You can scrape of thrust (oral candidiasis) but you can not scrape off leukoplakia
Fever, leukocytosis, prostate tenderness, more pronounced than UTI symptoms w/ systemic symptoms like fever, chills, ill appearance, associated REGIONAL pain, dx and what to get next?
Acute bacterial prostatitis - get mid stream urine sample to direct abx therapy (start empiric w/ bactrim or fluoroquinolone while waiting cultures)
Amiloride side effects?
Potassium sparing diuretic - hyperK. Other potassium diuretics = spironolactone, eplerenone (both aldosterone antagonist), triamterene (sodium channel blocker like amiloride)
Tx categories for Parkinsonism?
Levidopa plus carbidopa (dopamine precursor), benztropine (anticholinergic), amantadine *unclear MOA, bromocriptine/pramipexole (dopamine agonist), selegiline (MAO B inhibitor)
Most common initial side effect of levidopa plus carbidopa? long term side effects?
Hallucinations! Dyskinesia/dystonia appear after 5-10 years after therapy
Cerebellar dysfunction causes what, vs pyramidal tract disease?
Ataxia, intention tremor, impaired rapid alternating movements; pyramidal signs = look for pronator drift, focal weakness, spasticity, hyperreflexia and Babinski sign. Basal ganglia dysfunction causes EPS signs (resting tremor, rigidity, choreiform)
10-20 days after strep throat or skin infection, now w/ hematuria, HTN, red cell casts, and mild proteinuria, dx?
Acute post-streptococcal glomerulonephritis
How to ddx ACL tear from MCL/meniscus?
ACL injuries usually present w/ rapid onset of pain/swelling w/ hemarthrosis
Renal transplant dysfunction in the early post op period manifests as oliguria, hypertension, and inc Cr/BUN; what causes are there and what’s the immediate tx in acute rejection?
Ureteral obstruction (expect dilation of calyces on US), cyclosporine toxicity (supratherapeutic levels), vascular obstruction, ATN, acute rejection (heavy lymphocytic infiltration and vascular invlvmt w/ swelling of intima = IV steroids!)
Reversal for Heparin? Warfarin?
Heparin - protamine
Warfarin - FFP/Vit Kand prothrombin complex concentrate
Most common cause of death in dialysis patients?
Cardiovascular disease - 20% MI, 60% sudden cardiac death
This question you missed because most likely main contributor to GI bleed/COPD lady’s lethargy was hypoventilation (she had mixed respiratory acidosis and non-anion gap metabolic
acidsosi); but what is type 2 RTA (very common type of non-anion gap metabolic acidosis)
Defective tubular bicarb resabsorption in the proximal tubules = type 2 RTA (aka proximal RTA
YOUNG LADY, transient monocular vision loss, family hx of stroke, HTN (160/110s) carotid bruit, dx?
Fibromuscular dysplasia: commonly women age 15-50; non inflammatory and nonatherosclerotic condition caused by abnormal cell dvlpt in arterial wall that leads to vessel stenosis, aneurysm, or dissection (most commonly affects renal, carotid, and vertebral
arteries); dx w/ CT angio abdomen or duplex US.
How does fibromuscular dysplasia affect the kidneys?
FMD decreases perfusion to kidneys causing inc in both renin and aldosterone levels and resistant HTN (secondary hyperaldosteronism); note since both aldo/renin inc the aldo to renin ratio is <20. Cerebrovascular symptoms of brain ischemia = amaurosis fugax, Horner’s, TIA, HA, tinnitus, dizziness
BRBPR in man <40, first steps?
Anoscopy first if likely hemorrhoids and no risk of cancer; if pt >50 or w/ clinical features suggesting malignancy get colonoscopy
Clinical features of IBS:
Recurrent abdl pain/discomfort for >3 days per month for at least 3 months AND: symptoms improve w/ BMs, change in freq of stool, change in form of stool. S/s suggesting other etiologies = rectal bleeding, nocturnal abdl pain, weight loss, abnormal lab findings
Recent UTI, now w/ 10 days of malaise, low back pain, and fever and focal spinal tenderness, dx and next steps?
Vertebral osteomyelitis; note white count and fever not always present but ESR and CRP are usually markedly elevated; get MRI if you suspect vertebral osteo followed by CT guided needle aspiration/biopsy (low back pain, focal spinal tenderness, recent infection)
Patients w/ cardiac tamponade usually have Beck’s triad of hypotension, distended neck veins, and muffled heart beats
Symptoms are d/t exaggerated shift of the interventricular septum toward the left ventricular cavity which reduces left ventricular preload, stroke
volume, and CO
Recurrent bacterial infections (pneumonia, sinusitis, oitits and GI bugs like salmonella/campy; also w/ chronic diarrea or IBD like conditions) in an adult raises suspicion for what?
Common variable immunodeficiency; get quantitative measurement of serum immunoglobulin levels
Wheezing following ingestion of naproxen as well as rhinitis and post nasal drainage = what dx and what is it commonly a/w?
Aspirin exacerbated respiratory disease; commonly a/w nasal polyps
Malignancies that commonly mets to spine = lung, renal, prostate and multiple myeloma (thoracic most frequent followed by lumbar)
Gradually worsening, severe local back pain, pain worse in recumbent position (pain from degenerative joint disease is better laying down). EARLY signs: symmetric LE weakness and hypoactive DTRs. LATE signs: Babinski, dec rectal sphincter, paraplegia w/ hyperactive DTRs and sensory loss, diagnosis?
Malignancies that commonly mets to spine = lung, renal, prostate and multiple myeloma (thoracic most frequent followed by lumbar)
Spinal cord compression; look for spinal injury, malignancy, infection; get MRI, IV glucocorticoids, rad-onc/neurosx consult
Pts w/ asplenia (gunshot pt that had abdl sx in the past now w/ strep pneumo) are at risk for fulminant infection w/ encapsulated bacteria like what? this is d/t deficits in what response?
Strep pneumo, H influenzae, Neisseria meningitidis; no spleen = no antibody response and antibody-mediated phagocytosis/complement activation
Recurrent bacterial infections primarily of the skin and mucosa is d/t what impaired mechanism?
Chemotaxis is impaired in pts w/ leuykocyte adhesion deficiency (can’t move to the SKIN)
Pts w/ recurrent bacterial or fungal infxns d/t catalase producing organisms like Aspergillus and Staph aureus is d/t what deficiency/disease?
Pts w/ chronic granulomatous disease have impaired oxidative burst (catalase - chronic granulomatous dz - oxidative burst)
Cancer related anorexia/cachexia mgmt? Vs HIV cachexia
Progesterone analogues (megestrol acetate and medroxyprogesterone acetate) Synthetic cannaboids for HIV cachexia
This pt has symptomatic hypotonic hyponatremia d/t SIADH (serum osmo <275 = hypotonic). Normally kidneys excrete free water at rate to prevent blood hypotonicity. However in SIADH, inappropriately HIGH levels of ADH prevent kidneys from excreting dilute urine (leading to urine osmo > 100), and hypotonicity and hyponatremia develop. Pts w/ SIADH are typically euvolemic; therefore, urine sodium concentration is typically elevated (>40 mEq/L), unlike in pts w/ hypovolemia. In addition, in SIADH, serum uric acid levels are characteristically low, serum K is normal, acid base status is normal
Etiologies: CNS disturbance, medications (CBZ, SSRIs, NSAIDs), lung disease (pneumonia), ectopic ADH (small cell), pain and nausea
Labs: hyponatremia, serum osmo <275 (hypotonic), urine osmo >100 (concentrated), urine Na >40
Mgmt: fluid restriction + salt tablets, hypertonic saline for severe s/s
RANDOM FACTS
1) Lactose intolerance characterized by positive hydrogen breath test, positive stool test for reducing substances, low stool pH and inc stool osmotic gap; no steatorrhea
2) Noninvasive evaluation w/ compression US is recommended as an initial test in pts w/ moderate or high probability of DVT
3) P2y12 = clopidogrel
4) Ejection murmurs think AR or PR
5) Aspirin and beta blockers can trigger bronchoconstriction in pts w/ asthma. ACE too but by inc bradykinin (can occur at any time), not affected by asthma
CPPD vs urate crystal gout
STONES: calcium vs uric acid
CPPD: smaller rhomboid shaped weakly positively birefringent
Urate cyrstal gout: needle shaped and negatively birefringent
Calcium oxalate - enveloped shaped *most common
Uric acid - low pH, RHOMBOID shaped, tx w/ potassium citrate
Cysteine - hexagonal *familial cystinuria impaired transport of cystine, urinary cyanide nitroprusside test +
Struvite - coffin lid shape
HMG-CoA reductase MOA
Inhibition of INTRACELLULAR synthesis pathway
A number of features are helpful in ddx Crohn from UC.
Crohn: multiple portions of GI, rectal sparring, noncaseating granulomas (noninfectious), fistula formation, transmural inflammation, crypts but NO abscesses
UC: CRYPT abscesses
55yoF pain itching red streaks on left arm (similar in past that resolved), also w/ heart burn and milkd upper abdl pain for months. Lots of smoking. Epigastric tenderness to palpation; tender erythematous palpable cord like veins on left arm and upper chest, dx and next steps?
Migratory superficial thrombophlebitis - aka TROUSSEAU’“S syndrome. Typically a/w pancreatic (or lung, prostate, stomach, colon), cancer. Tumor releases mucins that react w/ platelets to form platelet rich microthrombi. Get CT to r/o cancer
Three types of infections w/ Bartonella
Bartonella henslae - local cutaneous dermal infection
Bartonella angiomatosis - lymphatic penetration leading to vascular cutaneous lesions (red/purple papules that become friable/pedunculated nodular)
Endovascular infection - endocarditis
Tx doxy or erythromycin, start HAART in HIV (esp CD4 < 100)
Use/rate dependent anti-arrhythmic
Flecainide. Class 1C and Class IV CCB antiarrhythmics
No pain w/ palpation for osteoarthritis! Also no redness, warmth, tenderness. X-ray shows loss of joint space, ostephyte formation and subchondral sclerosis. Vs aortoiliac atherosclerosis
LE pain w/ activity; pain typically in entire leg (butt, thigh, calf) and pedal pulses diminished!
Pulmonary emboli classically p/w sudden onset pleuritic CP, cough, and dyspnea; hemoptysis can occur as a result of pulmonary infarction. Chest CT shows?
Wedge shaped infarction is virtually pathognomonic for PE
Asthma vs COPD PFT findings
Asthma will improve post bronchodilators; COPD will not. Also, remember that DLCO is normal in asthma while it is dec in COPD
HoCM mechanism of inheritance?
Autosomal dominant
Metals that can trigger allergic contact dermatitis:
Cobalt, chromium, beryllium, nickel, zinc; the good shit like gold/silver/platinum/titanium don’t do it
Hypovolemia’s affect on kidney?
Dec renal perfusion leads to activation of renin-angiotensin-aldosterone system -> aldosterone stimulates aggressive sodium reabsorption in collecting tubules of kidney in an effort to sustain blood volume *answer was dec urine sodium
Lady who recently started weight loss supplement p/w clear signs of hyperthyroidism; work up showed elevated T4 and low TSH (primary hyperthyroidism), no signs of Graves (goiter or proptosis), and RAIU was low (so again not Graves or toxic adenoma or multinodular goiter), next steps to confirm that this is exogenous administration of thyroid
Measure serum thyroglobulin: 1) if it is high then the thyroid is endogenous coming from either thyroiditis condition or iodide exposure, 2) if the thyroglobulin is low = confirmed exogenous hormone
Brief morning stiffness, normal ESR, exposure to small children, dx?
Viral arthritis d/t parvovirus B19 (anti-parvovirus IgM levels will be elevated; unnecessary for dx purposes); tx symptomatically w/ NSAIDs
Fibromyalgia 1st line tx?
Amitryptyline is effective initial therapy; pregablin/duloxetine/milnacipran are alternate therapies
Sinusitis/otitis, saddle nose deformity, lung nodules/cavitation, RAPIDLY PROGRESSIVE GN, livedo reticularis, nonhealing ulcers, ANCA+, dx? labs? mgmt?
GPA (Wegner), bx of skin = leukocytoclastic vasculitis, kidney = pauci immune GN, lung = granulomatous vasculitis, tx w/ steroids and immunomodulators (MTX, cyclophosphamide). C-ANCA = GPA. P-ANCA = microscopic polyangiitis, eosinophilic granulomatosis w/ polyangiitis
Pt > 50, new onset HA localized to the temples and frequently a/w fever, weight loss, vision changes, jaw claudication (fatigue and pain when chewing), dx and complication?
Giant cell arteritis (aka temporal arteritis); biggest complication is aortic aneurysm/dissection
Info on UC
Bloody diarrhea, weight loss, fever
Endoscopic findings show: erythema friable mucosa, pseudopolyps, invlmt of rectosigmoid, continuous colonic involvement (no skip)
Bx shows: submucosal inflammation, crypt abscesses
Complication: colorectal cancer, toxic megacolon, PSC, spondyloarthritis!, erythema nodosum
Rib notching on cxr is a/w what?
Coarctation of the aorta
19yoF recurrent HAs for years, hx of HTN, BP on exam 175/100 and 170/102 on left and right arm; pulses in all extremities full and symmetric (this obvs incluide LE). Systolic bruit heard under right ear; abdl exam w/o tenderness or mass, dx?
Fibromuscular dysplasia (typically affects internal carotid and renal arteries - leading to arterial stenosis, aneurysm or dissection, 90% women): subauricular systolic bruit and abdl bruit are common. Dx w/ duplex US, CTa, MRA, catheter based arteriograph based arteriography. Tx w/ anti-HTN, PTA (percutaneous transluminal angioplasty), sx
Flank or abdl pain radiating to the perineum often w/ nausesa and vomiting, dx and imaging?
Ureterolithiasis; get US or NONCONTRAST spiral CT (contrast not needed)
Flank or abdl pain radiating to the perineum often w/ nausesa and vomiting, dx and imaging?
Ureterolithiasis; get US or NONCONTRAST spiral CT (contrast not needed)
Characteristic pattern of referred pain:
Cholecystitis - right shoulder Angina - substernal Pancreatitis - radiates to the back Appendicitis - periumbilical Nephrolithiasis -flank/abdl pain down to groin
45yoF months of watery diarrhea; cramps in leg muscles and feels dehydrated, abdl discomfort and stool is tea colored; episodic flushing in her face, no fever or weight loss, nontender abdomen w/ normoactive bowel sounds. Low K, low HCO3, elevated Cr, 3 cm mass in pancreatic tail, dx?
VIPoma - rare tumor affecting pancreatic cells that produce VIP (vasoactive intestinal peptide) - causes inc fluid and electrolyte secretion in intestinal lumen. Look for watery diarrhea, a/w flushing/lethargy/muscle cramp and weakness, hypoK, stool studies show secretory diarrhea w/ inc sodium and osmolal gap <50
VIPoma dx and tx?
Dx = watery diarrhea w/ VIP lvl > 75; abdl CT or MRI to localized tumor in pancreas (tail usually, mets to liver possible). Tx = IV volume repletion, octreotide to dec diarrhea, hepatic resections if mets
Most common cause of primary hyperparathyroidism (pt usually mild asymptomatic hypercalcemia) is d/t? Vs PTH independent hypercalcemia
Primary HPT: parathyroid adenomas or parathyroid hyperplasia - stones/bones/abdl moans/psychic groans but usually asymptomatic
PTH independent hyperparathyroidism: malignancy (that’s why need to measure PTH first to determine dependent/independent aka low or high PTH). These pts have crazy high Ca > 14 and are symptomatic
Painless thyroiditis *silent thyroiditis
Acute thyrotoxicosis w/ mild thyroid enlargement and suppressed TSH; thyroid scintigraphy shows decreased RAIU (released of PREFORMED thyroid hormone - unlike Graves which is d/t inc synthesis of thyroid hormone - antibodies to receptor). Mild brief hyperthyroid phase w/ spontaneous recovery. Not struma ovarii = would present in women >40yo w/ pelvic mass, ascities or abdl pain
Tetanus mgmt for adult pt who completed childhood series but has not had a booster in years, stepped on nail, mgmt?
Single dose of Tdap vaccine (if last dose > 5 years ago, NOT 10) is sufficient; give immune globulin if never had 3 shot series or vaccine status unknown
Major side effect = nephrotoxicity, hyperK, HTN, gum hypertrophy, hirsutism, and tremor, drug?
Cyclosporine. Tacrolimus has similar effects since similar MOA but no hirsutism or hypertrophy (both calcineurin inhibitors)
Major toxicity of azathioprine (inhibits purine synthesis) =
Dose related diarrhea, leukopenia, hepatotoxicity
Major side effect of mycophenolate =
Bone marrow suppression (M for M)
Recently started on Parkinson drug, develops acute angle glaucoma, drug?
Trihexyphenidyl an anticholinergic leading to eye dilation precipitating ACG
Normal pupilary constriction w/ accomodation but not w/ light, sensory ataxia/lancinating pains/reduced or absent DTR, dx and tx?
Late neurosyphilis manifesting as tabes dorsalis and Argyl Robertson pupils; IV PCN
Murmurs that get softer w/ squatting?
HCM and MVP (inc in preload causes inc in LV size and volume leading to delay in valve prolapse w/ a later click and shorter murmur)!
Chronic glucocorticoid followed by abrupt termination causes what, what lab values (ACTH, cortisol, aldo)
Central adrenal insufficiency w/ suppression of hypothalamic-pituitary-axis; look for low morning cortisol and ACTH (if this was primary adrenal insufficiency you would see high ACTH, low cortisol, and low aldo) AND also normal aldosterone as that is regulated by the renin-angiotensin-aldo system
Urease producing bacteria causing UTI w/ pH > 8
Proteus mirabilis: alkaline urine dec solubility of phosphate inc risk of urinary calculi w/ struvite stones
What increases risk of stroke more than any other factor?
HTN!
Coalescing erythematous macules, bullae, desquamation, MUCOSITIS, recently started on Bactrim (5 days ago)
Stevens-Johnson syndrome: <10% is SJS but >30% toxic epidermal necrolysis. Usually occurs 4-28 days after exposure to trigger (mycoplasma pneumoniae can do it too)
What antiemetics can cause EPS and why?
Metoclopramide, prochloperazine, promethazine (phenergan); anti-psychotics that are dopamine antagonists
GGT an enzyme present in liver and ferritin (acute phase reactant) would likely be seen in what dz?
Alcoholic liver disease - will also see 2:1 AST/ALT though that NBME exam had alcohol at just elevated GGT w/ normal AST/ALT
Molar extraction, mass over angle of right mandible w/ erythematous skin, serosanguineous fluid w/ yellow granules, cx shows gram positive rods w/ rudimentary branching dx and tx?
Actinomyces tx penicillin
Pt w/ hypertension and hypokalemia; w/ dec renin and inc aldosterone?
Primary hyperaldosteronism: d/t either aldosterone producing tumor or bilateral adrenal hyperplasia
*If RENIN and ALDO is elevated = secondary hyperaldosteronism d/t renovascular HTN, malignant HTN, renin secreting tumor, diuretic use (thiazide); if secondary hyperaldo then Aldo:Renin ratio <20 as in that fibromuscular dysplasia or RAS card
Spiculated appearing RBCs w/ serrated edges seen in liver disease and ESRD?
Burr cells aka echinocytes (E for Edges)
RBCs w/ irregularly sized and spaced projections most commonly seen in liver disease
Spurr cells (S for Spaced)
Graves opthalmopathy is d/t what mechanism?
Activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes
What complication occurs following radioactive iodine tx for Graves pt?
Worsening opthalmopathy if that was present before tx (TRAB titers inc following RAI therapy); administer steroisd prior to prevent complication
Cardiovascular effects of thyrotoxicosis: rhythm? hemodynamic effects? HF? angina symptoms?
Rhythm: sinus tach, premature atrial/ventricular complexes, A-fib/flutter
Hemodynamic effects: systolic HTN and inc pulse pressure, inc contractility and CO, dec systemic vascular resistance, inc myocardial oxygen demand
HF: high output failure, exacerbation of pre existing low output failure
Angina symptoms: coronary vasospasm, pre-existing coronary atherosclerosis
When is a vaginal pessary indicated in urinary incontinence?
Symptomatic pelvic organ prolapse and stress incontinence when surgical correction (midurethral sling surgery) fails (do not use in urge incontinence since that can exacerbate issue)
Inflammation and pain at sites of tendon/ligament attachment to bone (tenderness over shoulder/AC junction, heels, iliac crests, tibial tuberosities), a/w what what condition?
Ankylosing spondylitis - limited spine mobility, low back pain that improves w/ activity, and peripheral arthritis
Ice pack test is for what disease?
Myasthenia gravis - get antibodies against ACH receptors after (ice pack similar to Edrophonium - increases ACH in junction); again tx of myasthenia = acetylcholinesterase inhibitors
Pt in this question had surgery recently then developed lid lag post op (likely exposed to NMJ blocking agent like rocuronium - anticholinergic)
Acute limb ischemia after MI suggests what and requires what?
Possible arterial embolus from left ventricular thrombus -> requires anti-coagulation, vascular sx consultation, and TTE to screen for the thrombus and evaluate LV function
32yoM, 5 days high fever, chills, drenching sweats, malaise/fatigue/dark urine. Likes to explore the woods; recently camped in New England and found 2 ticks on legs, current temp 103 and mild sclera icterus, liver edge palpable 3 cm below margin, 4.3 total bili 10% retic, AST/ALT 60/70s, LDH 300, dx?
Babesiosis dx w/ blood smear. Protozoal illness endemic to NE US via Ixodes Scapularis (also transmits lyme and human granulocytic anaplasmosis); ticks multiply in RBCs so pts develop anemia w/ signs of intravascular hemolysis (jaundice, dark urine, indirect hyperbili, reticulocytosis, elevated aminotransferases and LDH) - MALTESE CROSS tx w/ atovaquone + azithro
Early diastolic murmur, hyperdynamic pulse, bounding pulses aka water hammer pulses, dx?
Pulsus parvus (dec pulse amplitude) and pulsus tardus (delayed upstroke), dx?
Fixed split S2?
Aortic regurgitation
Aortic stenosis
Atrial septal defect
1st line tx in pregnant or lactating pts w/ Lyme disease
Amoxicillin; avoid Doxycycline (though normally excellent since can treat coexisting human granulocytic anaplasmosis a conditions also caused by the same tixk I. scapularis) since it can cause permanent discoloration of teeth/retardation of skeletal dvlpt
Southeast Asian pt w/ chronic anesthetic hypopigmented lesions w/ peripheral nerve involvement (nodular painful nerve deformations w/ diminished sensory/motor activity), dx?
Leprosy, dx w/ biopsy. Tx w/ Dapsone + rifampin
Subarachnoid hemorrhage/embolic stroke vs intraparenchymal brain hemorrhage vs ischemic stroke, symptom severity?
SAH/embolic stroke = symptoms severity is maximal at onset
Ischemic stroke = symptoms progress in stuttering fashion
Intraparenchymal brain hemorrhage = symptoms get even worse over time (hemorrhage expands leading to ICP symptoms like HA/vomiting/seizures)
Most common lesions for HTN hemorrhage leading to lacunar strokes (stand out features for each lesion)
Basal ganglia (putamen) - homonymous hemianopsia
Cerebellar nuclei - NO hemiparesis, ataxia/nystagmus
Thalamus - eyes deviate t for TOWARD hemiparesis
Pons - p for pinpoint reactive pupils, deep coma/total paralysis within minutes
Pt w/ syphillis but severe penicillin allergy, next step?
Doxycycline - be strict on getting pre and post tx titers to ensure clearance. Only do penicillin w/ desensitization if severe like neurosyphillis, multiple tx failures or contraindicated conditions to doxy like pregnancy. Desensitization is costly/time consuming
IF UNSTABLE SHOCK - IF NOT consider adenosine or vagal maneuvers (bearing down, squatting, breath holding) in pts w/ persistent tachyarrhythmia (like regular narrow complex supraventricular tachycardia)
Defib shockable rhythms?
V-fib, PEA ventricular tachycardia
Bright red firm friable exophytic nodules in HIV infected patient, dx?
Bacillary angiomatosis caused by Bartonella (gram negative bacillus) - erythromycin tx
Pt w/ prostate cancer w/ subacute back pain (months) now w/ LE motor weakness, hyperreflexia, bladder dysfunction (late finding), dx and immediate tx?
Epidural spinal cord compression (common mets come from lung, breast, prostate, MM). Tx w/ glucocorticoids (dec vasogenic edema - reduce pain restore neuro fxn) then get MRI
Yellow fever is for what countries only?
Sub-Saharan Africa (not Egypt question) and South America. HepA is the most COMMON vaccine preventable disease among travelers; vacc should be considered for travels to developing countries
Ugh common bugs in IE
Staph - HEALTHCARE *indwelling catheters, prosthetic valves or devices and IVDU
Strep - community acquired
Viridans - includes sanguinis/mitis/oralis/mutans/sobrinus think dental
Enterococci - UTI
Strep gallolyticus (bovis) - IBD/colon cancer
H. pylori is a/w what what cancers?
Mucosa associated lymphoid tissue (MALT lymphoma) - eradication of H. pylori will help reduce relapsing of this cancer. Eradication of H. pylori is not curative for adenocarcinoma - get staging
PCP vs aspergillosis again?
Aspergillosis is worse - fever, CP, HEMOPTYSIS; CXR shows pulmonary nodules or segmental infiltrates
PCP - fever, DRY COUGH, no hemoptysis; bilateral diffuse interstitial infiltrates
Anterior uveitis is seen in what inflammatory diseases?
Sarcoidosis, spondyloarthritis (ankylosing spondylitis, reactive arthritis), and IBD
45yoM 2 month PAINLESS nonpruritic purple lesions on legs, progressive fatigue/weakness/fleeting joint pains. Exam shows multiple purpuric palpable lesions on both LE that do not blanch w/ pressure. Labs show elevated AST/ALT, Cr, thrombocytopenia, low C3/C4 complement, RF positive, UA 3+ blood and proptein, dysmorphic RBCs, dx?
Mixed cyroglobulinemia syndrome (MCS) - nonblanching palpable purpura (painless, while erythema nodosum is painful), athralgias, renal disease and peripheral neuropathies. Most commonly a/w hepatitis virus and SLE (must test for hepatitis)
Erythema nodosum is a/w (painful nodules on LE)
Sarcoidosis, IBD
Mixed cyroglobulinemia, dx, associations, mgmt?
Dx - confirm serologically w/ serum cyroglobulins and low complement or w/ skin/renal bx
A/w - viral hepatitis or SLE
Tx - address underlying dz (hepatitis/SLE), including plasmaphresis and immunosuppression
Advanced RA associated w/ splenomegaly and neutropenia, dx?
Felty syndrome (SANTA is felty: splenomegaly, anemia, neutropenia, thrombocytopenia, ARTHRITIS)
What study is this: selecting pts w/ particular disease and pts w/o disease then determining their previous exposure status
Case control (selecting the cases of disease and cases of controls comparing exposures)
More biostats: different types of studies and their end goal -> clinical trial, prospective cohort, retrospective cohort, case control, cross sectional
Clinical - tx group control group, compare outcome of interest
Prospective - risk factor +/-, compare disease INCIDENCE
Retrospective - risk factor +/-, compare disease INCIDENCE in the past
Case control - disease cases vs non diseased cases, compare risk factor frequency
Cross sectional - risk factor +/- compare disease PREVALENCE
Xa inhibitors are as effective as Warfarin in tx of DVT or PE and do not inc risk of bleeding complications; also have rapid onset and do not require lab monitoring or dietary restrictions. Restrictions?
Renally cleared so do not give to renal pts or those w/ DVT/PE 2/2 malignancy. Diet - pt should avoid too much greens in order to have consistent vitK.
Thrombolytic therapy is reserved for hemodynamically unstable pts w/ PE. IVC placement?
Anticoagulation failure (sub-therapeutic INR despite Warfarin compliance; tried the direct inhibitors too) OR active bleeding = IVC filter
Dihydropyridine Ca-channel antagonist vs non-dihydro
Dihydro = -dipines. Amlodipine a/w peripheral edema (vasodilation) Non-dihydro = diltiazem, verapamil. Acts on heart
USPTF recommendations for osteoporosis screening (osteoporosis =
Women > 65 at least one DEXA (if normal unsure when to repeat)
Women <65 screen if equivalent risk of osteoporotic fracture (using FRAX tool)
Top 3 nonmodifiable and modifiable risk factors for osteoporosis?
Nonmodifiable = age, postmenopausal, low body weight Modifiable = smoking, alcohol, sedentary lifestyle
Oliguria definition (number)
68yoM recent knee replacement, on post op day 5 new onset abdl discomfort. Over past 12 hrs voided 200mL urine; recorded infrequent fluid input/output over previous 4 days. Large body habitus; portable bladder scan inconclusive. Labs show BUN:Cr = 70/3.5. Dx and next steps
Post renal obstruction get bladder cath (inefficient detrusor muscle activity)
DDX systemic scleroderma vs ankylosing spondylitis (pulmonary fibrosis and pulmonary arterial HTN = scleroderma)
AS is a chronic inflammatory disease of the axial skeleton characterized by stiffness of the spine, sacroiliitis on radiographs, and positive HLA-B27 serology. Extraarticular features = anterior uveitis, IBD, and aortic regurgitation. Chest wall motion restriction *diminished chest wall/spinal mobility - restrictive pattern
Massive PE is defined as what?
PE complicated by hypotension and/or acute right heart strain (RBBB on EKG and JVD); confirm w/ CTa and fibrinolysis!
Ugh you put vitiligo but that is complete depigmentation most commonly on face/hands; the actual dx was
Tinea versicolor = salmon colored hyper/hypo pigmented macules. Confirm w/ KOH prep of skin scrapings; tx w/ antifungals
C. diff testing?
Get stool toxin testing *PCR toxin (not stool cultures)
3 possibilities when pt has symptoms c/w typical renal colic but no stones on x-rays
1) Radiolucent stones (uric acid stones, xanthine stones)
2) Ca stones <1-3 mm in diamater
3) Non-stone ureteral obstruction (blood clot, tumor)
Uric acid stone - pt has low urine pH d/t possible defect in renal ammonia excretion, and hyperuricosuria, imaging and tx?
Radiolucent on x-ray but can be seen on US or CT *hexagonal on UA - tx w/ hydration, alkalinization of urine w/ potassium citrate
Diabetic pt w/ symptoms of anorexia, nausea, vomiting, early satiety, postprandial fullness and poor glycemic control, what drug w/ both prokinetic and anti-emetic properties?
Metoclopramide!
Rapid onset of unilateral upper and lower facial weakness (dx = focus on just the face) =
Bell’s palsy *acute peripheral neuropathy of cranial nerve VII (lesion BELOW the pons); also would be unable to raise eyebrow or close eye, and drooping of mouth corner and disappearance of nasolabial fold. MUST ASSESS for preservation of forehead and brow
movements (if forehead/eyebrow spared = intracranial lesion warranting imaging)
Carcinoid is a/w what nutritional deficiency?
Niacin (carcinoid tumor cells inc production of serotonin using up tryptophan which is required for niacin synthesis); look for pellagra w/ dermatitis/diarrhea/dementia
Hereditary spherocytosis is inherited disorder that increases RBC fragility; look for hemolytic anemia, jaundice, splenomegaly in person of Northern European ancestry, common complications?
Acute cholecystitis from pigmented gallstones
Pulmonary airway diseases responsible for hemoptysis (3)?
Chronic bronchitis, bronchogenic carcinoma, bronchiectasis
Chronic bronchitis - chronic productive cough for >3mo in 2 successive years *smoking, clear mucus
Bronchiectasis - irreversible dilation/destruction of bronchi *cystic fibrosis, recurrent respiratory infxns, chronic cough w/ mucopurulent sputum
Prolactinoma mgmt?
If incidental and w/o symptoms = observe w/ serial MRIs
If MACRO or symptomatic - start w/ dopaminergic agents (negative feedback on prolactin) like carbegoline, bromocriptine
IF meds don’t work or tumor > 3cm = transsphenoidal resection
Nongonococcal urethritis, asymmetric oligoarthritis and conjunctivitis, mucocutaneous lesions and enthesitis (tendon pain), dx and first line given that pt is afebrile (not gonococcal septic arthritis)
Reactive arthritis - NSAIDs
Oxalate absorption is increased in Crohn and all other intestinal diseases causing malabsorption, inc risk of what?
Nephrolithiasis d/t inc absorption of oxalate leading to hyperoxaluria and oxalate stone formation
Hyperextension injury (car accident will do), w/ weakness that is more pronounced in the upper extremities than the lower extremities, lesion where?
Central cord syndrome - generally seen in old folks w/ underlying cervical spondylotic myelopathy after fall/whiplash
24yoF lump in neck, palpable 2 cm nodule in right thyroid lobe, serum TSH and calcium levels are normal, but calcitonin is elevated. Family hx of thyroid malignancy. US guided aspiration bx reveals malignant cells, what test should you get next?
Plasma fractionated metanephrine assay - this pt likely has medullary thyroid cancer (1/3 of MTC are part of MEN2A or 2B -> must r/o pheo prior to thyroidectomy or HTN crisis will occur during sx). MTC = calcitonin producing tumor of the thyroid parafollicular cells
HIIT - heparin induced (meaning LMWH like enoxaparin/dalteparin subcutaneous OR unfractionated heparin)
NOAC = dabigatran, rivaroxaban, apixaban, argatroban, fondaparinux
What GU tumors are a/w inc in AFP or beta-hCG
First off Leydig cell tumor = testosterone +/- estrogen, will see secondary inhibition of LH/FSH
Choriocarcinoma = beta-hCG
Yolk sac tumor (endodermal sinus tumor) = inc in serum AFP
HIV pt, eye problem - acute retinal necrosis a/w PAIN, keratitis, uveitis, funduscopic findings of peripheral pale lesions and central retinal necrosis, dx? versus?
HSV or VZV keratitis! In contrast to CMV = which is PAINLESS and is not a/w keratitis or conjunctivitis, imaging shows hemorrhages and fluffy/granular lesions around retinal vessels
Pulmonary toxicity = serious adverse effect of long term amiodarone use that can occur months to several years after initiation, what tests should be obtained prior to initiation?
Baseline CXR and PFTs
TEN vs Stevens-Johnson
Toxic epidermal necrolysis = >30%. SJS = <10%
17yoM intense left flank pain radiating to groin (duh u know this), refers to symptoms as stone passage, which he has experienced many times in childhood; uncle has same problem. UA shows HEXAGONAL crystals. Urinary cyanide nitroprusside test is positive, dx and
cause?
Cystinuria - amino acid transport abnormality -> impaired transport of cystine and the dibasic amino acids (orthine, lysine, arginine) -> dec reabsorption of cystine which is poorly soluble leading to stone formation (cyanide-nitrprusside test can detect cystine levels)
You drive CaRS using your PALMS and SOLES
Coxackie A virus, rocky mountain spotted fever rickettsia, syphillis rash starts on extremities. Though note the other rickettsia starts trunk and moves outward (R. prowazekii). Syphilis and the two handed sailor shake checking for elbow lymphadenopathy *epitrochlear
Erythema infectiosum - Fifth disease Parvo B19 slapped cheek
Erythema multiforme - target lesion a/w herpes simplex
Painful flaccid bullae that usually ruptures leaving raw ulcers, Nikolsky sign (separation of epidermis w/ light traction), antibodies against DESMOGLEINS 1 and 3, dx?
Pemphigus vulgaris (this is worse). As opposed to bullous pemphigoid (bullae are not as weak they are tense and less mucosal lesions) w/ antibodies against the hemidesmosomes (bullous is better than pemphigus - tense bullae and affects just the hemidesmosomes)
Epigastric pain and intermittent melena that improves w/ eating, vs pain that worsens w/ eating, dx?
Duodenal ulcer vs gastric ulcer. Most duodenal ulcers are d/t H. pylori or NSAIDs
Triple therapy H. pylori
Clarithromycin, amoxicillin, metronidazole, and PPI
Brown-Sequard syndrome? *side note dorsal columns (proprioception, vibration, light touch), lateral corticospinal tract (motor), spinothalamic tract (pain and temp)
Ipsilateral hemiparesis and diminished proprioception/vibratory sensation/light touch at the level of the spinal cord injury and below
Diminished pain and temp (spinothalamic) CONTRALATERALLY, usually 1-2 levels BELOW the cord injury *so if stabbing occured causing right hemisection at T8 then 1) loss of motor/sensation right side at T8 and below, and 2) loss of pain/temp left side at T10 (belly button)
More organisms to be worried about in HIV pt CD4 < 100
Toxo Cryptococcal meningoencephalitis (this question pt has oral thrush w/ meningeal signs indicates likely immunocompromised)
Clinical manifestations of long term alcohol use (x3)
Alcoholic cerebellar degeneration - damage to Purkinje cells of cerebellar vermis leading to ambulation difficulty (wide based gait, truncal ataxia, postural instability). Limb coordination intact and everything else is too
Wernicke (COAT) - ataxia present but also confusion/opthalmoplegia - nystagmus/thiamine
Vit B12 def - spinal cord degeneration resulting in ataxia/paresthesia/loss of vibration and proprioception sensation
Fever, rash, AKI, eosinophiluria w/ WBC casts
Acute interstitial nephritis most commonly d/t drug reaction
One kidney pt w/ flank pain, low volume voids w/ occasional high volume voids, dx?
Urinary outflow obstruction; excessive diuresis can lead to potassium wasting, dehydration, weakness
Hematuria, RBC casts, AKI, HTN, edema, dx?
Glomerulonephritis
Hypocalcemia dx w/u?
HypoCa -> check PTH -> if elevated think Vit D def or CKD (oh yeah, secondary hyperparathyroidism card said despite elevated PTH, Ca still playing catch up)
If low PTH think parathyroid surgery previously, or polyglandular autoimmune
Elevated conjugated (direct) hyperbilirubinemia along w/ elevated alk phos = cholestasis pattern in the setting of either extrahepatic or intrahepatic biliary obstruction, next step?
Get US to assess hepatic parenchyma (intrahepatic cholestasis) vs biliary ducts (extrahepatic) or both
51yoM admitted for renal failure; pmhx recurrent eps of bilateral flank pain over the past several years as well as nocturia 2-3 times per night for the past 10 years. BP 164/100, mass felt at right flank, dx?
Polycystic kidney disease (autosomal dominant); multiple renal cysts causing intermittent flank pain, hematuria, UTI, nephrolithiasis
Anterior cord (again) - anterior spinal artery from trauma resulting in?
Bilateral motor function loss at and below level of injury w/ diminished pain/temperature that begins 1-2 levels below cord injury. Proprioception, vibratory sensation, light touch (aka dorsal column aka posterior cord) are unaffected. Versus central cord = dec sensation AND motor in just the arms; seen in old folks w/ underlying cervical spondylotic myelopathy after fall/whiplash
56yoF weight loss over 6mo, recent dx of diabetes controlled w/ sitagliptin, watery stools (no palpitations, abdl pain, vomting, or flushing), skin exam shows erythematous plaques w/ CENTRAL clearing and eroded borders on right thigh and mouth, next steps and dx?
Skin findings = necrolytic migratory erythema aka NME. Get glucagon levels for glucagonoma (rare pancreatic neuroendocrine tumor that usually p/w diabetes, weight loss, diarrhea, anemia and skin findings)
HTN, elevated sodium, hypoK, and metabolic alkalosis (seen in the hepatic encephalopathy pt on K wasting diuretic)
Conn’s syndrome - primary hyperaldosteronism (mass on CT) you missed this because metabolic alkalosis w/ elevated bicarb goes along with hypokalemia (think vomit = hypoK aka hypochloremic hypokalemic metabolic alkalosis)
Zollinger Ellison syndrome should be suspected in pts w/ multiple duodenal ulcers (or jejunal) that is refractory to tx OR a/w chronic diarrhea. Lots of fatty stools why?
Excess gastric acid inactivates pancreatic enzymes leading to malabsorption - intermittent abdl pain, weight loss, chronic diarrhea, possible other MEN1 manifestations, think Zollinger
ALS is characterized by upper and lower motor symptoms, what are they?
Upper = spasticity, bulbar symptoms, hyperreflexia Lower = fasciculations
Urine sample stain positive for Prussian blue, African American man recently tx for UTI now has dark urine, dx?
G6PD deficiency - oxidative stress precipitated this event
35yoF, office for oral ulcers started a few days ago, similar lesions 3 months ago, in addition was recently diagnosed w/ anterior uveitis. Recurrent genital lesions over the last YEAR. Exam shows oral ulcerations and hyperpigmentation skin lesions and tender indurated areas on her legs, dx?
Bechet syndrome: recurrent painful oral apthous ulcers (canker sores), genital ulcers, eye lesions, skin lesions (erythema nodosum), high risk for THROMBOSIS, clinical dx but can get bx for nonspecific vasculitis. *This was not reactive arthritis despite so many similar
symptoms but no evidence of acute GI or GU infection; also multiple episodes of ulcers in the past
36yoM weeks of lower abdl pain, bloody diarrhea, fecal urgency. Exam shows fever, DISTENTION, leukocytosis, hypotension, tachycardia, dx and next steps?
IBD likely UC complicated by toxic megacolon (d/t severe colitis w/ massive colonic distention = >6 cm dilation of right colon). Get abdl x-ray! This pt is acute do not get barium enema or CT - risk perforation
Calcium, phosphorus, alk phos, urine hydroxyproline (collagen breakdown) findings in: 1) primary hyperparathyroidism, 2) Paget dz, 3) osteoarthritis, 4) hypoparathyroidism (following neck sx usually)
1) elevated Ca, dec PO4, elevated alk phos, elevated urine hydroxyproline (hyperparathyroidism)
2) normal Ca, normal PO4, elevated alk phos, elevated urine hydroxyproline (Paget)
3) normal EVERYTHING, just MSK pain and x-ray findings confined to joints and periarticular bone (not skull, or ears affected) (osteo)
4) low Ca, low PO4, normal alk phos, suggest hypoparathyroidism
Painless hard mass in testicle + US suggesting testicular tumor, initial mgmt?
This is the kill first look at later type of cancer - prevent risk of seeding by avoiding fine needle or bx. High cure rate!
Joint w/ chronic calcification (chondrocalcinosis), warmth/erythema/swelling/tenderness, dx?
CPPD arthritis - rhomboid shape, positive birefringence
Hyperestrinism in cirrhosis can lead to what?
Gynecomastia, testicular atrophy, dec body hair, spider angiomas, palmar erythema. Caput medusae arises from dilation of superficial veins on abdl wall d/t portal HTN (also esophageal varices)
Alteplase vs heparin for acute ischemic stroke = heparin sucks in the early acute phase and risk bleeding. Pathway for suspected acute ischemic attack
Get CT non con to r/o bleed -> if stroke and <4.5 hrs since symptom onset -> tPA w/ altepase
Hodgkin lymphoma
Common cause of mediastinal mass w/ weight loss in young pts, involves cervical, supraclavicular and axillary nodes. Remember from this question: teratoma have all 3 germ layers but do not produce AFP or b-HCG
Mechanisms involved in ARDS?
Gas exchange impaired d/t V/Q mismatch Lung compliance (ability to expand) is decreased (stiff lungs) d/t loss of surfactant and inc elastic recoil of edematous lungs Pulmonary arterial pressure is increased d/t destruction of lung parenchyma and compression of vascular structures PaO2/FiO2 is dec as you need more FiO2 to maintain that PaO2
What to give and what to avoid in right ventricular MI?
Pt is pre-load dependent (will have hypotension, JVD, clear lung fields) - so give IV fluids and avoid preload reducing meds like nitrates/diuretics
DIP joints affected, morning stiffness, deformity, swollen fingers (dactylitis - sausage digit), nail involvement, AND well demarcated red plaques w/ silvery scaling, dx?
Psoriatic arthritis - tx NSAIDs, methotrexate, TNF-alpha
Only requirement for hospica care?
Pt has prognosis < 6 months
Aspiration pneumonia vs aspiration pneumonitis
Pneumonia: symptoms of fever/cough/sputum presents days after event, CXR shows infiltrate classically in RLL. Need abx - clindamycin or beta-lactam w/ inhibitor
Pneumonitis: just aspiration of gastric acid *pt was being intubated, presents HOURS after event, CXR infiltrates can be unilateral but mostly bilateral, supportive care
*ddx w/ time of symptom onset
Initial tx for pts w/ cocaine toxicity?
Benzodiazepine for symptomatic control of BP and anxiety, aspirin, nitro/CCB for pain, NO beta blockers d/t unopposed alpha adrenergic stimulation worsening vasoconstriction induced by cocaine
1st line tx regimen for BPH (central symmetric prostate enlargement - where as peripheral and asymmetric think prostate cancer) -> 3 treatments
1) Alpha adrenergic anatagonists (tamsulosin, terazosin): relax smooth muscle in bladder neck. prostate. 1st line therapy since faster onset! Side effects - orthostatic
2) 5 alpha reductase inhibitors (finasteride): inhibit conversion of testosterone to dihydrotestosterone, reduces prostate gland size but takes 6-12mo to take effect. Side effects = dec libido, ED
3) Antimuscarinics (tolterodine, oxybutynin): used to tx overactive bladder, side effects of retention/dry mouth
Erectile dysfunction 1st line after ruling out psych and lifestyle modification for (CAD, diabetes, etc) is what and MOA?
SILDENAFIL. PDE-5 inhibitors prevent degradation of cGMP by PDE-5 thereby increasing blood flow to corpus cavernosum
Rapidly progressive ascending paralysis (can be asymmetrical, w/o fever or sensory abnormalities - so not GBS), CSF is NORMAL, dx?
Tick borne paralysis! Note ascending paralysis w/o CSF findings or autonomic dysfunction like seen in GBS. Tick releases neurotoxin - if you remove tick = cure
1) Loss of pain temp in ipsilateral face and contralateral trunk and limbs, 2) ipsilateral Horner’s syndrome, 3) dysphagia, dysarthria, HOARSENESS (ipsilateral vocal cord paralysis), lesion where?
This is Wallenberg syndrome - lateral medullary infarction (occluded intracranial vertebral artery). L for waLLenberg
Contralateral paralysis of arm/leg and tongue deviation toward lesion; contralateral loss of tactile position sense can also occur
Medial medullary syndrome (alternating hypoglossal hemiplegia)
DDX cobalamin (b12) vs folate deficiency? Both cause inc homocysteine
Measure methylmalonic acid concentrations (if elevated = B12 deficiency)
Smoker, seizures, MRI showing well-circumscribed lesions with edema at GREY and WHITE MATTER JUNCTION, dx?
Lung cancer METS to brain!
Polyathralgia, tenosynovitis, painless vesiculopustular skin lesions (no signs of meningeal affects - stiff neck, petechial rash), dx?
Disseminated gonococcal infection
Fever, athralgias, sore throat, lymphadenopathy, mucocutaneous lesions, diarrhea, weight loss, dx?
Acute HIV infection
Squamous cell carcinoma - sCamous = calcium
Small cell - paraneoplastic w/ ACTH and SIADH. Other paraneoplastic syndromes - dont forget myasthenia gravis and lambert eaton
Pt w/ WPW develops a-fib w/ RVR, he is HDS, next steps? And what to avoid
Anti-arrhythmic like procainamide. WPW = accessory pathway bypassing AV node leading to very rapid ventricular response rates that if untreated can lead to v-fib. Since this is an avoiding the AV node problem - do not give AV nodal blocking agents (adding to the
problem). Avoid adenosine, BB, CBB, digoxin
Herpes simplex keratiits vs herpes zoster opthalmicus
HSK - adults, corneal vesicles/dendritic ulcers
HZO - caused by varicella ZOSTER, mostly elderly, vesicular rash in division of trigeminal nerve, conjunctivitis and dendriform corneal ulcer!
The worse acute complication from myocardial infarction - acute onset CP and profound shock no murmur, rapid progression to PEA and death
Ventricular free wall rupture (LAD) - no murmurs so not VSD
*if it was interventricular septum rupture aka VSD - look for paradoxical change in O2 from atria to ventricle
43yoM, confusion and left sided weakness, shelter for month, 10 year history HIV, normal vitals, + oral thrush, expressive aphasia, CD4 = 30 and toxo positive, upper motor neuron signs, CT shows several asymmetric, hypodense/nonenhancing white matter lesions w/ no
edema, dx?
Progressive multifocal leukoencephalopathy (JC virus) - tx the HIV w/ HAART. So AIDS pts - progressive neuro symptoms and imaging of nonenhancing white matter lesions = PML
Approximately 40% of pneumonias are a/w what?
Pleural effusions! Most are free flowing, sterile, resolve w/ abx (ie uncomplicated parapneumonic effusion). However if bacteria cross from infected pulmonary parenchyma into pleural space = complicated parapneumonic effusion w/ large loculated effusions and typical thoracentesis abnormalities. Unlike complicated parapneumonic effusions, empyemas = frank pus or bacteria! This was not an abscess since that = cavity w/ air fluid level (think aspiration, dvlpt takes days)
Calcified rim in gallbladder wall w/ central bile-filled dark area, dx and a/w?
Porcelain gallbladder a/w GB adenocarcinoma
Berry aneurysms vs HTN vasculopathy
Berry - subarachnoid hemorrhage (thunderclap headache - hyperattenuation of sulci/basal cisterns)
HTN - DEEP intracerebral hemorrhage commonly basal ganglia/cerebellar nuclei/thalamus/pons
Prolonged infusion of sodium nitroprusside in the setting of renal failure can lead to AMS, arrhythmias, respiratory issues, GI complaints, and diffuse hyperreflexia, dx?
Cyanide poisoning tx sodium thiosulfate
> 35yoM, unilateral testicular pain, epididymal edema, dysuria/frequency, dx?
Acute epididymitis - likely E. coli in older men; STD like neisseria chlamydia in younger men. Tx either levofloxacin or ceftriaxone/doxycycline
CXR w/ ring of calcification around heart, JVP tracings show prominent x and y descents, signs of HF, dx in developed country vs developing?
Constrictive pericarditis - pericardial fibrosis and obliteration of pericardial space leading to impaired ventricular filling during diastole
Developing - TB!
Developed - idiopathic or viral pericarditis, radiation therapy, cardiac sx, connective tissue disorders
Facial swelling, bilateral LE edema, massive proteinuria = nephrotic syndrome, pt has palpable kidneys, hepatomegaly, ventricular hypertrophy (4th heard sound) in the setting of chronic inflammatory disease (recurrent pulmonary infxns, bronchiectasis), dx?
Secondary amyloidosis - tx and proph w/ colchicine
What is a complication of chronic inflammatory conditions (chronic infections, IBD, RA) resulting in extracellular tissue deposition of fibrils into tissues/organs?
Secondary amyloidosis - multi-organ dysfunction (heart, kidneys, liver, GI tract) = tx underlying inflammatory disease +/- colchicine
1st line tx CML (splenomegaly, neutrophil predominance - low leuk alkaline phosphatase score d/t poorly functional leukocytes)
BCR-ABL translocation btw chr 9 and 22 causing constitutively active tyrosine kinase = imatinib is a tyrosine kinase inhibitor
Pts w/ dementia w/ Lewy bodies are extremely sensitive to antipsychotics (problem was low dopamine so giving anti-psychotic can worsen symptom - caution when treating psychosis *use SGA but not Risperidone)
Dementia w/ Lewy bodies vs Parkinson Disease dementia
DLB = dementia before parkinson (or at the same time) PDD = Parkinson symptoms for a year first, then cognitive impairment
Mydriasis, piloerection (hair standing up), yawning, abdl cramps/diarrhea, dx?
Opioid withdrawal - occurs within a day.
VS alcohol = tremulousness, significant BP elevations, diaphoresis and possible seizures - NO EYES involved
Adjustment disorder, finally
Onset within 3 months of identifiable stressor w/ marked distress and/or functional impairment (does not meet criteria elsewhere); tx w/ psychotherapy
Severe back pain, syncope, hypotension, hematuria, dx?
AAA rupture - hematuria can occur if AAA ruptures into retroperitoneum and create aortocaval fistula w/ IVC leading to venous congestion in retroperitoneal structures like bladder
Blunt abdominal, blunt thoracic, blunt genitourinary trauma. This pt was able to urinate normally w/ clear urine but UA showed 50-100 erythrocytes/hpf, dx
Concern for renal contusion/lac/renovascular injuries. Did not get retrograde cystourethrograms (unless had gross hematuria, difficulty urinating and blood at meatus
*urethral injury or suprapubic pain *bladder rupture)
How does PaCO2 affect cerebral blood flow?
As cerebral PaCO2 rise so does blood flow (to compensate for inc CO2?). Lowering cerebral arterial PaCO2 through hyperventilation results in rapid vasoconstriction thereby decreasing ICP
Severe burn, extensive scar formation, chronic non healing wound, enlarging nodule at lesion site a/w persistent pain and inc drainage, dx?
Squamous cell carcinoma (SCC arising within burn = Marjolin ulcer)
Cutaneous T cell lymphoma aka? findings?
Mycosis fungoides - scaly, pruritic patches or plaques
Repleting blood/platelets info
Platelets > 50,000 provides adequate hemostasis for most invasive procedures
VitK is good in the long run for warfarin reversal but not emergently
Transfuse packed red blood cells if hemoglobin <7
FFP for Wafarin
Protamine for Heparin
Initial hematuria vs terminal hematuria vs total hematuria indicates what?
Initial (blood at initiation but then normal) - urethral damage (urethritis or urethral injury)
Terminal (normal pee followed by bloody pee) - bladder or prostate damage
Total hematuria - damage to kidneys or ureters
Abdl or flank pain w/ microscopic or gross TOTAL hematuria (blood throughout entire pee stream), and occasionally bulky mass on abdl exam, dx?
Polycystic kidney disease
Pt stands on 1 leg w/ knee flexed 20 deg, pt then internally and externally rotates on flexed knee - this will elicit locking sensation/sharp pain, dx?
Meniscal injury! For MCL - do valgus test - if laxity = MCL injury
Acute cardiac tamponade occurs d/t sudden rise intrapericardial pressure and should be suspected in all adults pts w/ blunt chest trauma who p/w persistent JVD, tachycardia, hypotension despite aggressive fluids
CXR findings typically reveal normal cardiac silhouette (small amount of fluid can cause tamponade in the acute setting) w/o tension pneumothorax
Complication of rapid sequence intubation w/ succinycholine?
Cardiac arrhythmia d/t severe hyperkalemia (especially in pts w/ muscle crush injury - cellular release of K through rhabdo); stick to nondepolarizing neuromuscular blocking agents (vecuronium, rocuronium)
59yo office for postop f/u 3 weeks ago, now w/ intermittent abdl cramps and diarrhea occuring 25-30 minutes after eating a/w palpitations/light lightheadedness/diaphoresis, what surgery did he have and this diagnosis?
Gastrectomy - dumping syndrome (rapid emptying of hypertonic gastric contents leading to GI and vasomotor symptoms - rec dietary modification (small meals, replace simple sugars, high fiber)
Small bowel obstruction clinical presentation
Clinical presentation: colicky abdl pain, vomiting, inability to pass flatus or stool if complete (partial = stome stool), hyperactive progresses to absent bowel sounds depends on peristalsis, distended and tympanic abdomen
Small bowel obstruction dx, complications, mgmt?
Dx: dilated loops w/ air fluid levels on plain film or CT, partial = air in colon, complete = transition pt *abrupt cut off w/ no air in colon
Complications: ischemia necrosis, strangulation, bowel perforation
Mgmt: bowel rest, NG tube suction, IV fluids; surgery if hemodynamically unstable/signs of complication
SBO is categorized by anatomic location (proximal versus mid/distal) or simple vs strangulated
Complete proximal: early vomiting, abdl discomfort, abnrml contrast filling
Mid/distal: colicky abdl pain, delayed vomiting, prominent abdl distention, constipation/obstipation, hyperactive bowel sounds
Simple obstruction: luminal occlusion
Soft scrotal mass bag of worms, dec in supine position inc w/ standing/valsalva, US shows?
Dilation of papmpiniform plexus - most often on left side d/t “nutcracker effect” where left gonadal vein drains into left renal which can be compressed by SMA. Tx w/ gonadal vein ligation for young males to prevent testicular atrophy
Penile fracture mgmt (blood at meatus, hematuria, dysuria, urinary retention)?
Retrograde urethrogram and surgical mgmt
Spinal cord injury from car accident in the past, now w/ dec strength and diminished pain and temperature sensation affecting arms/hands (OR having cape like distribution) w/ preservation of dorsal column fxn (light touch, vibration, position sense), dx?
Syringomyelia
Complete small bowel obstruction vs paralytic ileus question
SBO - no distended bowel after point of obstruction, also hyperactive TINKLING bowel sound typically present Paralytic ileus - hypoactive bowel sounds, distended small and large bowel dilated gas filled loops w/ no transition point (r/o volvulus); ileus common after abdl surgery/abdl hemorrhage inflammation, intestinal ischemia, eletrolyte abnormalities (bowel rest and tx cause)
37yoM hospitalized evaluated for acute onset of INTENSE periumbilical abdl pain, currently tx for infective endocarditis w/ vegetations on MV, abdl shows mild diffuse tenderness, no rigidity/rebound, abdl x-rays no free air or obstruction, dx?
Acute mesenteric ischemia
Presentation - rapid onset preiumbilical pain, POOP to exam, hematochezia, bowel sounds decreased Risk - atherosclerosis, embolic source (thrombus/vegetations)
Labs - leukocytosis, elevated amylase, metabolic acidosis (lactate)
Dx - CT or MR angiography
*not opioid withdrawal - bowel sounds typically increased
Femoral nerve innervation and function?
Femoral nerve innervates muscle of anterior compartment of the thigh, and is therefore responsible for knee extension and hip flexion; femoral nerve provides sensation to anterior thigh and medial leg via saphenous branch
Tibial nerve innervation and fxn?
Tibial nerve: supplies muscles of posterior compartment of the thigh, posterior compartment of the leg, and planatar muscles of the foot (so femoral is front while tibial is back).
Tibial controls flexion of knee and digits and plantar flexion of the foot; sensation to leg except medial side and plantar foot (common peroneal provide sensation to anterolateral lag and dorsum)
Acute diverticulitis vs ischemic colitis vs mesenteric ischemia
Acute diverticulitis: L sided appendicitis (d/t abscess, perforation, inflammation)
Ischemic colitis: painful BRBPR - vatershed areas recent sx
Mesenteric ischemia: POOP, not MI but gut attack
Prosthetic joint infection timeline w/ what bugs?
Early onset (<3mo): staph aureus, gram negative, anaerobes *the bad stuff Delayed (3-12mo): coagulase negative staphylococci (staph epi), enterococci THE E's Late onset (>12mo): similar to early onset + beta-hemolytic strep
Hemothorax is indistinguishable from pleural effusion on cxr; blunting of costophrenic angle or even partial to complete opacification of one hemithorax might be expected from a significant hemothorax
Pulmonary contusion = most common finding after blunt chest injury; cxr reveals opacities caused by hemorrhage
Acute onset severe abdl pain followed by peritoneal signs and abdominal distension; abdl x-ray demonstrates free air under the diaphragm
Peptic ulcer perforation
Fever and RUQ pain w/ ileus (dec or absent bowel sounds), infection d/t gas producing organism, dx?
Emphysematous cholecystitis
82yoF severe abdl pain and vomiting, intermittent nausesa and vomiting and abdl cramps/bloating. Hx of gallstones. Abdl is distended w/ HYPERACTIVE bowel sounds, mild elevation of liver transaminases, abdl x-ray shows dilated loops of small bowel and air in the
intrahepatic bile ducts, dx?
Mechanical bowel obstruction: intermittent N/V, pneumobilia (air in biliary tree), hyperactive bowel sounds, dilated loops bowel = gallstone ileus (gall stone passes through biliary enteric fistula in small bowel and lodging in ileum). Tx is sx removal +/- cholecystectomy
Subclavian central venous catheter placement, rapid onset severe SOB, tachycardia, tachypnea, hypotension, and distention of the neck veins d/t superior vena cava compression, dx?
Tension pneumothorax
Recent cardiac surgery (CABG) p/w fever, CP, leukocytosis, mediastinal widening on CXR (a touch of pericardial fluid), dx and mgmt?
Acute mediastinitis - drainage, surgical debridement and prolonged abx therapy
