Uworld 1 Flashcards
Clinical associations with Large cell carcinoma of lung
- Gynecomastia
- Galactorrhea
Describe the use of ABIs in evaluation of risk for diabetic ulcers?
-primarily measures a large vessel PAD and does not accurately assess small vessel disease, which often contributes to ulcers in diabetic
What infections are particularly prevalent after puncture wounds through the sole of a shoe as the warm moist environment is quite hospitable to this organism
Pseudomonas
Dermatitis herpetiformis is associated with what conditions?
Celiac disease
Patients with pernicious anemia need to be monitored for the development of what long term complication?
Gastric cancer (periodic stool testing for the presence of blood)
Subacute (de Quervain, subacute granulomatous) thyroiditis is thought to be due to what?
-a post viral inflammatory process and is often preceded by an upper respiratory illness
which thyroid cancer has psammoma bodies
papillary
patient with CKD develops anemia and needs erythropoietin. Describe what then happens to iron?
- The production of new RBCs is associated with a surge of iron usage
- This can cause a rapid depletion in body’s iron stores, particularly in chronically ill pts whose iron stores may already be lower
- iron stores must be evaluation prior to starting supplemental erythropoietin
risk factors for Cervicofacial Actinomyces
- Dental infections and trauma (extractions)
- Immunosuppression, DM, malnutrition
what imaging is helpful for establishing a diagnosis of chronic pancreatitis
CT scan
Multiple skin tags is associated with what conditions?
- Insulin resistance
- Pregnancy
- Crohn disease (perianal)
Lab studies in HHS
- Glucose > 1000 mg/dL
- NORMAL pH and bicarb
- NORMAL anion gap
- negative or small serum ketones
- serum osmolality > 320 mOsm/kg
what does pulmonary histoplasmosis usually cause on x ray
focal or perihilar infiltrates
Describe the acid base disturbance found in adrenal insufficiency
- aldosterone deficient –> kidney loses sodium and retains potassium and hydrogen ion
- NORMAL ANION GAP and hyperkalemic and hyponatremic metabolic acidosis
Current guidelines recommend moderate intensity or high intensity statin therapy for patients age 40-75 with an estimated 10 year risk for cardiovascular disease of what %?
> /= 7.5%
What is chalazion
- eyelid discomfort
- chronic granulomatous inflammation of the meibomian gland
- it appears as a hard, painless lid nodule
What drugs are associated with thyroid dysfunction
- Amiodarone
- lithium
metabolic acidosis after a seizure
Postictal lactic acidosis
Describe the PaCO2 in a PE
most have decreased due to hyperventilation
Wernicke encephalopathy occurs in patients with long-term thiamine (vitamin B1) deficiency due to what?
- Poor dietary intake (e.g. anorexia, chronic alcohol use)
- impaired metabolism
- poor absorption
pupils in cocaine intox
dilated
This eye pathology typically presents with light flashes, floaters, or a curtain across the visual field that usually starts from the periphery and is generally NOT painful
Retinal detachment
This refers to slow, writhing movements that typically affects the hands and feet
Athetosis
What is the modality of choice for patients with suspected vertebral osteomyelitis
MRI
Treatment of Wernicke encephalopathy
-IV thiamine followed by glucose infusion
What is the most common presenting symptom of fibromuscular dysplasia
-Recurrent headache caused by carotid artery stenosis or aneurysm
what is the most common etiology of amaurosis fugax
- retinal ischemia due to atherosclerotic emboli originating from the ipsilateral carotid artery
- pts with vascular risk factors should be evaluated with a duplex US of the neck
A young male patient with 2 months of cough and has evidence of pulmonary nodules and retroperitoneal lymphadenopathy raises concern for a neoplastic process. Malignancies are rare in young men; most are what?
testicular, lymphoma, or leukemia
What is episcleritis and how does it present
- an infection of the episcleral tissue between the conjunctiva and sclera
- diffuse or localized bulbar conjunctival injection
how does mixed cryoglobulinemia syndrome commonly present
- fatigue
- nonblanching, palpable purpura
- arthralgias
- renal disease (hematuria, proteinuria, glomerulonephritis)
- and peripheral neuropathies
Describe the role of Octrotide in management of esophageal varices
- long acting somatostatin analogue that causes splanchnic vasoconstriction and reduced portal blood flow by inhibiting the release of glucagon
- Used in treatment of ACTIVE variceal bleeding and has no role in primary prophylaxis
eye symptoms in Sarcoidosis
Iritis or uveitis
Hepatorenal syndrome is an important complication of end stage liver disease. What is it characterized by
- significant decrease in Glomerular filtrations in absence of another clear cause of renal dysfunction
- minimal hematuria (<50 erythrocytes/hpf)
- lack of improvement with volume resuscitation
Patient with painless muscle weakness associated with weight gain, bone loss, HTN, and hirsutism is consistent with what?
Hypercortisolism (Cushing syndrome)
Acute interstitial nephritis is frequently caused by antibiotics (such as those administered for spontaneous bacterial peritonitis) or infection. what does urinalysis show
active sediment with white cells and white cell casts
Patients with Hepatitis C are at risk for a number of immune-mediated complications, including membranoproliferative glomerulonephritis, which commonly occurs in association with mixed cryoglobulinemia syndrome (an immune complex deposition disorder). What does urinalysis reveal?
dysmorphic red cells, red cell casts, and protein
As muscle cells break down, what is released into the blood stream
- potassium
- CPK
- Myoglobin
In the treatment of hyperthyroidism, what is the black box warning when using PTU
severe liver injury and acute liver failure
hematological manifestations of acute lead poisoning
microcytic anemia
Patients with cirrhosis and medium or large esophageal varices should receive primary prophylaxis to prevent bleeding. How can this be achieved?
- Endoscopic variceal ligation (EVL)
- or administration of a nonselective beta blocker (propranolol or nadolol)
Clinical manifestations of paroxysmal nocturnal hemoglobinuria
- Hemolysis –> fatigue
- Cytopenias (impaired hematopoiesis)
- Venous thrombosis (intraabdominal, cerebral veins)
ANCAs and biopsies in diagnosis of Granulomatosis with polyangiitis
- PR3 and MPO
- Skin: leukocytoclastic vasculitis
- Kidney (pauci-immune GN)
- Lung (granulomatous vasculitis)
Hepatorenal syndrome occurs as cirrhosis progresses and patient develop what?
- splanchnic arterial dilation and an overall decrease in vascular resistance
- this, in turn, activates the RAS and results in renal vasoconstriction with decreased perfusion and glomerular filtration.
Most appropriate next step in management of a patient with substernal chest pain, oral thrush, and CD4 count <100
- oral fluconazole
- Patients who do not have thrush or who fail to respond to empiric therapy warrant esophagoscopy with biopsy, cytology, and culture to determine the specific etiology
patient presents with anasarca, pulmonary and facial edema, HTN, and abnormal UA with proteinuria and microscopic hematuria suggests what
acute nephritic syndrome with fluid overload
Classic triad of polyarthralgia, tenosynovitis, and painless vesiculopustular skin lesions
disseminated gonococcal infection
This is a sensation of restlessness that causes the patient to move frequently
Akathisia
what pharmacological intervention is effective at increasing appetite, causing weight gain, and improving well being in patients with cancer-related anorexia/cachexia syndrome?
-Progesterone analogues (e.g. megestrol acetate) or corticosteroids
Hemi-neglect syndrome is characterized by ignoring the left side of space. What part of the brain is involved
-RIGHT (non-dominant) PARIETAL lobe
what metal in jewelry can cause an allergic type IV hypersensitivity reaction (contact dermatitis)
Nickel
Describe the organ involvement of diffuse cutaneous sclerosis
- Scleroderma renal crisis
- Myocardial ischemia and fibrosis
- Interstitial lung disease
Most sensitive imaging modality to visualize avascular necrosis of hip
MRI
Describe sarcoidosis with cardiac involvement
- recent uveitis
- mild dyspnea
- presyncope episodes likely due to conduction abnormalities
- marked bradycardia with AB block and LBBB
Brain abscesses can come from adjacent infections (sinusitis, otitis, or dental infection) or hematongenously from distant infection (e.g. endocarditis, osteomyelitis). What organisms are usually the culprits?
- Viridans strep
- Staph. aureus
- Gram-neg organisms
Patients with early syphilis who have a penicillin allergy receive alternate treatment with what?
oral doxy
antidote for cyanide poisoning
- hydroxocobalamin or
- sodium thiosulfate
- or treat with nitrites to induce methemoglobinemia
What is the recommendation from USPSTF for screening for bladder cancer
AGAINST due to it relatively low incidence and poor positive predictive value
- Recent URI
- dyspnea
- elevated jugular venous pressure
- clear lung fields
- increased cardiac silhouette on chest x-ray
- suggestive of what
early cardiac tamponade due to a large pericardial effusion
Describe malignant acanthosis nigricans
- associated with underlying neoplasms, esp. GI and GU
- The sudden appearance of such skin changes in middle aged or elderly patients is suggestive of underlying malignancy
- patients are not obese (but instead may have lost weight)
- lesions occur in uncommon areas: mucous membranes, palms, soles
associated complications with UC?
Which is the ONLY one that needs regular surveillance **
- Toxic megacolon
- Primary sclerosing cholangitis
- colorectal cancer**
- Erythema nodosum, pyoderma gangrenosum
- spondyloarthritis
patient with PAINLESS gross hematuria with large smoking history
bladder cancer
A patient has a chronic cough that worsens overnight and did not improve with antihistamine therapy. What should be suspected and what should be done
- asthma suspected
- should be evaluated with spirometry to assess bronchodilator response
- Methocholine challenge test can be performed if no bronchodilator response seen
- Alternate approach is to treat empirically with 2-4 weeks of inhaled glucocorticoids, If cough improves, a Dx of asthma can be made
What are the physical counterpressure maneuvers that can be done during the prodromal phase of vasovagal syncope that can improve venous return and cardiac output, sometimes aborting syncopal episodes
- leg crossing with tensing of muscles
- handgrip and tensing of arm muscles with clenched fists
What should be suspected if AST and ALT are markedly elevated like >25x the upper limit?
- toxin induced (acetaminophen)
- ischemic
- viral hepatitis
Both IgA nephropathy and Postinfectious glomerulonephritis can occur following a URI. Describe the differences
- IgA nephropathy: within 5 days of URI, adult men age 20-30, Normal complement levels
- Post infectious: usually 10-21 days after URI, more common in children, Low complement
Hypertrophic pulmonary osteoarthropathy is a subset of hypertrophic osteoarthropathy where the clubbing and arthropathy are attributable to what?
-underlying lung disease like lung cancer, Tb, bronchiectasis, or emphysema
Describe the Acid base disturbance that can occur with loop diuretics
- inhibits Na-K-2Cl carrier in loop of Henle
- This leads to increased loss of sodium in urine which increases delivery to distal tubule which subsequently leads to elevated Hydrogen and K+ in urine.
- Also results in volume contraction and increased aldosterone levels, further promoting the secretion of hydrogen ions in urine
- mild acute kidney injury could occur due to volume contaction
- METABOLIC ALKALOSIS
vital signs in marijuana intoxication
-other signs
- tachycardia
- tachypnea
- HTN
- dry mouth
What should be obtained in all patients with syncope due to suspected structural heart disease
A TTE
What is the treatment for beta thalassemia minor
None required
What is the most sensitive test to screen for diabetic nephropathy
random urine for microalbumin/creatinine ratio
What position should a patient with recurrent vasovagal syncope get into at the onset of symptoms
-supine position with leg raising
initial step in confirming a diagnosis of hypercortisolism
- Late night salivary cortisol assay
- 24 hour urine free cortisol measurement
- and/or overnight low dose dexamethasone suppression test
hyponatremia due to SIADH is a common complication of small cell lung cancer. What is the initial treatment of choice in asymptomatic or mildly symptomatic patients?
fluid restriction
Acute Dacryocystitis is characterized by what
the sudden onset of pain and redness in the medial canthal region
What electrolyte abnormality in CHF usually parallels the severity of heart failure and is an independent predictor of adverse clinical outcomes
hyponatremia
UTI with urinary alkalization (pH >8) raises suspicion for what organism
urease-producing bacterium such as Proteus mirabilis (most common) or Klebsiella pneumoniae
In a patient with atrial premature beats, also called premature atrial complexes (PACs), even if asymptomatic, precipitating factors such as what should be identified and avoided.
- tobacco
- alcohol
- caffeine
- stress
What metabolite of cyclophosphamide is responsible for causing hemorrhagic cystitis and bladder cancer?
acrolein
This heart valve dysfunction leads to an early decrescendo diastolic murmur, best heard with the diaphragm of the stethoscope along the left sternal border at the third and fourth intercostal spaces while the patient is sitting up, leaning forward, and holding a breath in full expiration
Aortic regurgitation
another name for skin tags
acrochordons
Desribe how urine alkalinization from a urease producing organism increases the risk for stones
decreases the solubility of phosphate
Clinical manifestations of avascular necrosis of the hip?
Lab finding?
- Groin pain on weight bearing
- Pain on hip abduction and internal rotation
- No erythema, swelling, or point tenderness
- Normal WBC, ESR, and CRP
This is defined as daytime hypercapnia (PaCO2> 45 mm Hg) in an obese patient (BMI >30) without another explanation for the hypercapnia
Obesity hypoventilation syndrome
When should transfusion cells be washed first
- if pt is IgA deficient
- Complement-dependent autoimmune hemolytic anemia
- continued allergic reactions (e.g. hives) with red cell transfusion despite antihistamine treatment
In a non African patient coming for preconception counseling with a family history of thalassemia anemia, what is the most appropriate initial test to determine appropriate Hb identification
CBC . . . if African descent then Hb electrophoresis is usually obtained along with the initial CBC
-Test of the patients partner is offered if an abnormal Hb level is diagnosed
What does a chest x-ray of a thoracic aortic aneurysm show
- widened mediastinal silhouette
- increased aortic knob
- tracheal deviation
Acute tubular necrosis is one of the main differential diagnoses of HRS, and patients with cirrhosis are especially susceptible. Aminoglycosides, iodinated contrast dye, and hypotension are the most common causes. What does urinalysis show?
muddy brown granular casts
UC or Crohn: crypt abscesses
UC
Cyclophosphamide is an alkylating agent frequently used as an immunosuppressant in SLE, vasculitis, and certain cancers. Regarding SLE, it is reserved for patients with significant renal or CNS problems. What are the serious side effects?
- acute hemorrhagic cystitis
- Bladder carcinoma
- sterility
- myelosuppression
What is the skin manifestation of acute pancreatitis from cholesterol emboli
- Livedo reticularis (reticulated, mottled, discolored skin)
- Blue toe syndrome
Ascending aortic aneurysms are most often due to what?
cystic medial necrosis or connective tissue disorders
What skin conditions are associated with Hepatitis C
- Porphyria cutanea tarda
- Cutaneous Leukocytoclastic vasculitis (Palpable purpura) secondary to cryoglobulinemia
What drugs can cause peripheral neuropathy
- phenytoin
- isoniazid
- vincristine
- heavy metals
- chronic alcoholism
What are the classic chest x ray findings with a PE
- Hamptom hump: dome-shaped, pleural-based opacification in the lung
- Westermark sign: sign that represents a focus of oligemia (hypovolemia) (leading to collapse of vessel) seen distal to a pulmonary embolism (PE)
What are frequent abnormalities in patients with advanced dementia what can cause aspiration pneumonia?
impaired swallowing and cough reflex
Describe the symptoms that are a consequence of the retrosternal extension that can occur in a thyroid lymphoma
- can result in venous compression with distended neck veins and facial plethora
- raising the arms causes compression of the subclavian (and right internal jugular) vein beween the clavicles and the enlarged thyroid, leading to more prominent venous distension and facial redness (pemberton sign)
Describe the treatment of Lyme disease
- Skin/mild disease: oral antibiotics (e.g. doxy)
- Neurologic/cardiac dx: IV antibx (ceftriaxone)
Describe the possible glycemic state that can occur with Primary aldosterone insufficiency
-Hypoglycemia . . can be triggered by fasting, infection, or alcohol consumption
Thyroid lymphoma is uncommon, but the incidence is approximately 60 times greater in patients with preexisting what?
chronic lymphocytic (Hashimoto) thyroiditis (positive antithyroid peroxidase antibody)
What is the first line treatment for Idiopathic intracranial hypertension
Acetazolamide
What is the most common valvular abnormality detected in patients with infective endocarditis?
Mitral PROLAPSE with coexisted REGURG
What is the most common trigger of COPD exacerbation
URI
What is typically used in patients with multiple brain metastases?
whole brain radiation therapy
typical features of a patient with cerebellar dysfunction in the setting of likely alcoholic cerebellar degeneration
- progressive gait dysfunction
- Truncal ataxia
- nystagmus
- intention tremor or dysmetria (limb-kinetic tremor when attempting to touch a target)
- impaired alternating movement (dysdiadochokinesia)
- Muscle hypotonia can also be present: pendular swinging movement of limp after eliciting the deep tendon reflex
primary therapy for moderate hypothermia
active external rewarming, which includes use of warmed blankets, warm baths, and warmed IV fluids
Describe Lumbar puncture results in idiopathic intracranial HTN
-opening pressure > 250 mm H2O
Skin infection: involvement of the external ear is particularly suggestive of what as this skin lacks a lower dermis level (making cellulitis, a deeper skin infection, unlikely)
Erysipelas
What drugs may cause digital vasospasm (Raynaud’s)
- beta blockers
- ergotamine
Gout is a side effect of what drug
cyclosporine
Describe when a TIPS procedure is performed and what is its associated with hepatic encephalopathy
- performed when a patient has ascites that does not respond to medical therapy (e.g. diuretics) or has ongoing active or recurrent variceal bleeding even after appropriate treatment with upper endoscopy
- TIPS is associated with HE in up to 35% of patients due to (NH3-rich) bypassing the liver.
infective endocarditis due to eikenella corrodes is usually seen in what setting
poor dentition and/or periodontal infections
What are some physical exam finding suggestive of severe Aortic stenosis?
- Diminished and delayed carotid pulse (“pulsus parvus and tardus) due to blood flow obstruction
- Mid- to late-peaking systolic murmur from turbulence due to the stenosis
- Presence of soft and single second heart sound (S2)
How do large pericardial effusions typically appear on chest x-ray
- enlarged and globular cardiac silhouette
- “water bottle” shape
Circulating immune complexes account for the group of glomerulonephritis called immune complex mediated glomerulopathies. These include what?
- SLE
- Post-strep glomerulonephritis
How is diagnosis of carboxyhemoglobinemia made?
- pulse ox does NOT differentiate b/t carboxyhemoglobin and oxyhemoglobin
- Diagnosis made by arterial blood gas with cooximetry
What are the causes of pulsus paradoxus
- most common, cardiac tamponade
- Also COPD and asthma
history consistent with upper airway cough syndrome (postnasal drip). liquid dripping into back of throat. frequent throat clearing. After a URI. without expectorant. what is best diagnostic approach?
- treat empirically with an oral first gen antihistamine (e.g. chlorpheniramine) or
- combined antihistamine-decongestant (e.g. brompheniramine and pseudoephedrine)
What patients should be started on pyridoxine supplementation when treated for latent or active Tb with isoniazid (INH) because it helps prevent INH-induced peripheral neuropathy, which is due to INH-mediated pyridoxine deficiency
- malnutrition
- pregnancy
- certain comorbid conditions (e.g. DM)
What is the most appropriate therapy for the management of progressive pain in a patient with prostate cancer and bony metastases after androgen ablation (orchiectomy)
Radiation therapy
Describe the MOA of how lead causes anemia
-it is 99% bound to erythrocytes and can disrupt heme synthesis to cause microcytic anemia
what treatment of Graves disease can worsen ophthalmopathy
Radioiodine ablation
clinical associations with adenocarcinoma of lung
- clubbing
- hypertrophic osteoarthropathy
Cardiac sarcoidosis should be suspected in who?
-any young patient (<55) with unexplained second or third degree heart block or when ECG changes occur in a patient with known or suspected systemic sarcoidosis
etiologies of primary adrenal insufficiency
- Autoimmune
- Infections (TB, HIV, disseminated fungal)
- Hemorrhagic infarction (e.g. meningococcemia, anticoagulants)
- Metastatic cancer (e.g. lung)
recent nasal packing followed by rapid onset of rash, fever, hypotension, diarrhea, and thrombocytopenia
Toxic shock syndrome
Treatment for HIV patient who develops progressive disseminated histoplasmosis?
IV amphotericin B
-after 1-2 weeks of clinical improvement, most patients are switched to oral itraconazole for 1 year or more for maintenance therapy
What cardiac arrhythmia is associated with a PE
A fib: irregular RR intervals, absent P waves, narrow QUS complexes
Explain Glucocorticoids (e.g. methylprednisone) role in treatment of hypercalcemia
- inhibit 1,25-dihydroxyvitamin D by activated mononuclear cells in the lungs and lymph nodes
- They can be used to treat hypercalcemia due to excessive vitamin D intake, Granulomatous diseases (e.g. sarcoidosis) and certain lymphomas
- take 2-5 days to occur
mixed cryoglobulinemia syndrome is most commonly associated with what chronic inflammatory conditions
- Hep C
- SLE
All patient with RA should be started on what ASAP as joint damage begins early in its course
- DMARDS (methotrexate is initial DMARD of choice)
- NSAIDS and COX-2 inhibitors are adjunctive therapies for symptomatic relief but do not reduce disease progression
Penicillin desensitization is costly and time consuming. When should it be used?
-should be reserved primarily for situation in which alternative treatments are either ineffective (e.g. CNS syphilis, multiple treatment failures) or contraindicated (e.g. pregnancy)
describe the relationship b/t Aortic dissection, cardiac tampanode, and a syncope episode
- Cardiac tamponade can occur as a complication of aortic dissection
- An abrupt accumulation of even small amounts of blood can significantly raise the pressure inside pericardial cavity
- Increased pericardial pressure causes compression of cardiac chambers and limits diastolic filling of the right-sided chambers
- This causes a decrease in preload and reduces cardiac output, resulting in hypotension and syncope
what deficits are usually caused by lacunar infarcts
pure motor hemiparesis
Elevated serum Alkaline phosphatase levels are indicative of cholestasis. These patients (with or without hyperbilirubinemia) should be evaluated with what?
right upper-quadrant ultrasound to assess for intrahepatic or extrahepatic causes of biliary obstruction
The risk of myoglobin-induced renal failure is significant when the CPK concentration is what
greater than 20,000 units/L
- microcytic anemia
- target cells
- mediterranean
Beta thalassemia minor
lab findings in paroxysmal nocturnal hemoglobinuria
- anemia
- low haptoglobin
- elevated bilirubin
- elevated LDH
Despite the potential benefits, what are the numerous complications that can occur from positive pressure mechanical ventilation
- alveolar damage
- pneumothorax
- hypotension
A patient with SLE, who is on prednisone, has atraumatic hip pain with normal x-ray most likely has what
osteonecrosis (avascular necrosis) of the femoral head
Adenosine deaminase (ADA) is found in what cause of pleural effusion
Tb
What is the first line treatment for Pneumocystis jiroveci
TMP-SMX
-corticosteroids are used concomitatnly in patients with impaired oxygenation
In the case of any chemical contact with the eye, the first priority is to immediately do what
begin flushing the affected eye with copious amounts of running water
In a patient with a RV MI that goes into cardiogenic shock when given a nitrate, what should be the next steop in management
-Bolus with isotonic saline to increase RV preload and improve cardiac output
What can be used during an SVT to identify the type
- vagal maneuvers (carotid sinus massage, Valsalva, eyeball pressure)
- IV adenosine
this is defined as sustained muscle contraction resulting in twisting, repetitive movement, or abnormal postures
Dystonia
Describe the Uhthoff phenomenon in MS
symptoms may worsen during exposure to high temperatures such as moving to Arizone in June
further evaluation of simple renal cyst?
reassurance and no further evaluation
Describe how there can be a Large amount of blood on UA but under urine sediment microscopy there are only 0-1 RBCs
A large amount of myoglobin
-A standard UA is not able to distinguish between hemoglobin and myoglobin due to chemical similarities
Descending aortic aneurysms are usually due to what
atherosclerosis
What Dx? -uncontrolled infection of skin, sinuses, and orbit
- intracranial HTN
- Headache is most common symptom and can become intolerable
- low grade fever and periorbital edema usually occur several days later secondary to impaired venous flow
- Vomiting possible
- fundoscopy may reveal papilledema
Infectious cavernous sinus thrombosis
physical exam findings in a patient with pericardial effusion without cardiac tamponade
- diminished heart sounds
- maximal apical impulse that is difficult to palpate
Describe Endophthalmitis
- usually postoperative
- infection within the eye, particularly the vitreous
- usually present with pain and decreased visual acuity
- swollen eyelids and conjunctiva
- hypopyon (inflammatory anterior chamber of the eye)
- corneal edema
Patient with DVT and elevated plasma homocysteine levels. Along with heparin and warfarin, what should be given to try to correct the homocysteine
-Independent of the underlying cause, homocysteine levels can usually be normalized by administration of pyridoxine (B6) and folate
Clinical associations with squamous cell carcinoma of lung
Hypercalcemia
What is the most important initial step in management of HHS
- fluid replacement . . aggressive hydration will improve tissue perfusion and responsiveness to insulin therapy
- NS is recommended in first few hours (regardless of sodium levels), with a subsequent change to .45% NS if corrected sodium is normal
What skin conditions are associated with HIV infection
- Sudden onset severe psoriasis
- Recurrent herpes zoster
- disseminated molluscum contagiosum
- Severe seborrheic dermatitis
A patient with a family history of colonic polyps and osteomas and an alteration in the tumor suppressor gene adenomatous polyposis coli has familial adenomatous polyposis (FAP). What is the standard of care?
- increased screening by colonoscopy and ELECTIVE proctocolectomy
- annual screening sigmoidoscopies for children starting at age 10-12, followed by annual colonoscopies once colorectal adenomas are detected or if the patient is 50 or more
Thyroid storm is a life threatening thyrotoxicosis usually triggered by what specific events?
- Surgery
- Trauma
- Infection
- childbirth
- IODINE CONTRAST
PE causes V/Q mismatch, resulting in an increase from the expected in what
A-a oxygen gradient
a patient with 2 recent episodes of pneumonia that has splenomegaly, anemia, thrombocytopenia, mild leukocytosis, and an abnormal blood smear (leukocyte with hairy projections)
Hairy cell leukemia
management of delirium other than treating the underlying cause
- introducing NONpharmacological measures such as:
- reduction of nighttime noise and disturbances
- frequent verbal orientation
- reassurance
- interactions with family
all patients with presume idiopathic thrombocytopenia purpura should be tested for what viruses as platelet counts can be affected by treating the underlying disease
HIV and hepatitis C
What is recommended as an initial stress test for diagnosis and risk stratification of most patients with suspected stable ischemic heart disease (like atypical angina)
Exercise ECG
When taking cyclophosphamide, what things are helpful in preventing serious complications?
- drinking plenty of fluids
- voiding frequently
- taking MESNA
How does crystal induced AKI cause injury
Renal tubular obstruction
What are the HACEK organisms responsible for infective endocarditis
- Haemophilus aphrophilus
- Aggregatibacter actinomycetemcomitans
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella kingae
What meds have been implicated in causing optic neuritis?
- Ethambutol
- Hydroxychloroquine
Describe what C. diff patient receive empiric oral metronidazole while awaiting stool studies
- Mild to moderate
- WBC <15,000
This thyroid cancer is characterized by slow spread into local tissues and regional lymph nodes
papillary
What are the indications for a hepatitis A vaccine in adults with HIV?
- Chronic liver disease (including HBV and HCV)
- Men who have sex with men
- IV drug users
what is the most appropriate management of a patient with postictal lactic acidosis
- observation and a repeat chemistry panel after approximately 2 hours
- typically transient and self limited
Viral arthritis due to parvovirus B19 is characterized by acute, symmetric, small joint arthralgias, mild joint swelling and a benign, self limited course. How is this differentiated from SLE and RA?
SLE and RA usually correlated with inflammatory markers like ESR
Clinical features of Wernicke Encephalopathy
- Encephalopathy
- Oculomotor dysfunction (e.g. horizontal nystagmus, bilateral abducens palsy)
- Postural and gait ataxia
Lab findings in polymyalgia rheumatica
- ESR >40, sometimes > 100
- Elevated CRP
- Normocytic anemia possible
uric acid levels in lead poisoning
High due to impaired purine metabolism
Besides HIV, severe seborrheic dermatitis is associated with what other condition?
Parkinson disease
antibodies for Limited cutaneous sclerosis (CREST)
anticentromere
When is an upright tilt table test used
occasionally to establish the diagnosis of vasovagal syncope in patients with recurrent UNEXPLAINED syncope in the absence of organic heart disease
What is the preferred method to diagnose fibromuscular dysplasia
-CT angiography or duplex US
Describe the treatment in subacute thyroiditis
-symptomatic with beta blockers to control thyrotoxic symptoms and NSAIDS for pain relief
after a penetration injury, how long does it take for osteomyelitis to form?
2 or more weeks
Acanthosis nigricans is associated with what conditions?
- Insulin resistance
- GI malignancy
Exudative pleural effusions generally have 1 of the following characteristics
- Pleural fluid protein/serum protein ratio >.5
- Pleural fluid LDH/serum LDH ratio > .6
- Pleural fluid LDH > 2/3 upper limit of normal serum LDH
What are the clinical features of drug induced interstitial nephritis?
- Fever, rash, arthralgias
- Also, peripheral eosinophilia, hematuria, sterile pyuria, and eosinophiluria
- WBC casts may be present in the urine, but red cell casts are rare
difference between ulcers from DM and those for PAD
- DM usually on plantar surface under bony prominences
- Arterial usually located at the tips of toes
What time of day is the typical onset of cluster headache
during sleep
Describe the difference between bleeding from angiodysplasia and diverticuli
- Angiodysplasia: usually causes low volume venous bleeding
- Diverticuli: can cause large volume arterial hemorrhage
In a stable patient with a likely PE what should be used to confirm the diagnosis
CT angiogram
What is the most important prognostic consideration in the treatment of patients with breast cancer
TMN staging
what vitamin is cobalamin
B12
Describe the levels of PTH, Ca, and phosphate in a patient presenting with a year of foul smelling diarrhea, weight loss, and fatigue . . likely steatorrhea and malabsorption
- vitamin D deficiency (fat soluble)
- because vitamin D mediates intestinal calcium and phosphorus absorption, patients develop hypocalcemia and decreased phosphorus levels
- leads to secondary HYPERparathyroidism
What lymph nodes are often initially affected in testicular cancer
retroperitoneal
Describe the pathogenesis of lacunar strokes
due to microatheroma formation and lipohyalinosis in the small penetrating arteries of the brain
Idiopathic intracranial HTN is usually seen in who
- Young obese women
- or certain meds (isotretinoin, Tetracyclines, growth hormone, excessive vitamin A)
What is the treatment of choice for opioid withdrawal
low dose methadone with adjunctive meds
Uric acid levels characteristic of SIADH
low
Suspect what 4 conditions whenever a patient presents with hypokalemia, alkalosis, and normotension?
- Surreptitious vomiting
- Diuretic abuse
- Bartter syndrome
- Gitelman’s syndrome
who to screen for fibromuscular dysplasia
- Women age <50 with 1 of the following:
- Severe or resistant HTN
- Onset of HTN before age 35
- Sudden increase in BP from baseline
- Increase in creatinine (>.5-1 mg/dL) after starting ACEI or ARB and without significant effect on BP
- systolic-diastolic epigastric bruit
What should be suspected in any hypertensive patient presenting with hypokalemia
Primary hyperaldosteronism
causes of Pulmonary HTN
- idiopathic
- secondary to left heart dx
- secondary to chronic lung disease
- secondary to chronic thromboembolism
Describe Alprostadil in the treatment of ED
- prostaglandin E1 that induces vasodilation of the cavernosal arteries
- Second-line
What medications can cause SIADH
- SSRIs
- Carbamazepine
- NSAIDs
urine chloride concentration in Diuretic abuse and Bartter/Gitelman’s syndrome?
high
Describe the symptoms of Diabetic retinopathy
- usually asymptomatic, even though changes in fundoscopy are seen
- Once a diabetic patient presents with a sudden onset of visual loss with numerous floaters, a vitreous hemorrhage is most likely to have occurred
Patients with severe hypercalcemia (>14 mg/dL) require what
- Aggressive saline hydration to restore intravascular volume and promote urinary calcium excretion
- Calcitonin, by inhibiting osteoclast-mediated bone resorption, quickly reduces serum calcium concentration and can be administered concurrently with saline
- Bisphosphonates (e.g. pamidronate, zoledronic acid) also inhibit bone resorption and provied a sustained reduction in calcium levels. However, the calcium-lowering effect of bisphophonated is delayed, usually occurring over 2-4 days and they are typically given after initial administration of saline and calcitonin
When a patient is ventilated, what is an appropriate tidal volume
6 ml/Kg
Bronchiectasis refers to irreversible dilation and destruction of bronchi, resulting in chronic cough and inadequate mucus clearance. Compared with chronic bronchitis, bronchiectasis is more likely associated with a history of what?
recurrent respiratory tract infections and chronic cough with daily production of copious mucopurulent sputum
treatment for uncorrectable causes of acute pancreatitis (e.g. hypotension, ischemia, viruses, atheroembolism)
- Supportive care (e.g. pain control, IV fluids, Bowel rest)
- Most are self limiting and improve in 4-7 days with conservative management
- NPO except essential meds
Cell mediated injury may be important in what glomerulopathy
idiopathic crescentic glomerulonephritis
This presents with chronic epigastric abdominal pain that can radiate to the back and is partially relieved by sitting upright or LEANING FORWARD
Chronic pancreatitis
What should you suspect in a patient who presents with palpable purpura, proteinuria, and hematuria and also low complement and an HCV infection?
mixed cryoglobulinemia
Explosive onset of multiple itchy seborrheic keratosis is associated with what condition
GI malignancy
Treatment of paroxysmal nocturnal hemoglobinuria
- Iron and folate supplementation
- ECULIZUMAB (monoclonal antibody that inhibits complement activation)
Describe thyrotoxic myopathy from hyperthyroidism
- can present with severe distal or proximal muscle weakness, usually without bulbar or respiratory muscle involvement
- Chronic hyperthyroid myopathy presents with proximal muscle weakness weeks to months after the onset of hyperthyroidism
- Objective findings may include muscle atrophy
What is the most sensitive and specific test for diagnosing RCC
CT scan of abdomen
What does CMV esophagitis show on endoscopy and what is used to treat?
- Large linear ulcers
- ganciclovir
What is an appropriate initial study for identifying the cause of suspected hypertrophic pulmonary osteoarthropathy
chest x ray
AST and ALT levels in alcoholic hepatitis?
What else is elevated?
- elevated but LESS THAN 300 usually
- GGT and ferritin
What is the most important contributing factor found in 80% of patients with diabetic ulcers
Diabetic neuropathy
What is the source of most PEs?
- > 90% are PROXIMAL DVTs. (iliac, femoral, popliteal) probably due to their large caliber and proximity to the lungs
- Distal/calf are less likely to embolize and more likely to spontaneously resolve
Common physical exam findings with Aortic Regurg
-Bounding or “water hammer” pulse
After the diagnosis of a solid testicular mass has been made (a painless hard mass in testicle + suggestive US), what is the initial management?
removal or the testis and its associated cord, orchiectomy
Describe a febrile nonlhemolytic transfusion reaction
- most common adverse reaction that occurs within 1-6 hours of transfusion
- When red cells and plasma are separated from whole blood, small amounts of residual plasma and/or leukocyte debris may remain in the red cell concentrate
- During blood storage, these leukocytes release cytokines, which when transfused can cause transient fevers, chills, and malaise, without hemolysis
A patient with chronic hep C and cirrhosis is found to have medium sized, nonbleeding esophageal varices. What medication should he be started on
Nonselective beta blocker
-This will decrease progression to large varices and risk of hemorrhage
treatment of polymyalgia rheumatica
response to glucocorticoids
Antibodies for diffuse Sclerosis
- Anti-Scl-70 (topoisomerase-1)
- Anti-RNA polymerase III
Porphyria cutanea tarda is frequently associated with hepatitis C and can be triggered by ingestion of what
- ethanol
- estrogens
What is the most common cause of vitreous hemorrhage
diabetic retinopathy
What is the treatment of drug induced interstitial nephritis
discontinuing offending agent
Diagnostic testing for Porphyria cutanea tarda
- Mildly elevated liver enzymes and iron overload
- Elevated plasma or urine porphyrin levels
In a patient with HIV, what level of CD4 count should the varicella Live attenuated vaccine NOT be given to
<200
- same goes for all live attenuated vaccines
- All HIV pts should receive appropriate inactivated vaccines
What C. diff patients receive oral Vanc with or without IV metronidazole or a possible switch to intracolonic vancomycin
- Severe
- WBC > 15,000
Pyoderma gangrenosum is associated with what condition
Inflammatory bowel disease
Conjunctival pallor suggestive of anemia in a patient taking NSAIDs and aspirin is likely due to what
iron deficiency anemia . . ulcers leading to bleeding
What is the most common lyme disease carditis
AV conduction block
Any patient with an acute, severe illness may have abnormal thyroid function tests. The most common pattern is a fall is TOTAL and FREE T3 LEVELS, with normal levels of T4 and TSH. This condition is often referred to as what
-Euthyroid sick syndrome or “Low T3 syndrome”
what is anasarca
extreme generalized edema
Treatment of cyanide poisoning from sodium nitroprusside
sodium thiosulfate
Dense intramembranous deposits that stain for C3 is a characteristic microscopic finding for what nephrotic disease?
- Membranoproliferative glomerulonephritis (also called dense deposit disease)
- leads to persistent complement activation and kidney damage
What is the most sensitive test for differentiating adrenal adenoma and bilateral adrenal hyperplasia in patients without discrete unilateral adrenal mass on imaging?
Adrenal venous sampling
When MS is suspected, what should be performed to support the diagnosis
MRI
imaging of herpes encephalitis
- hypodense lesions in the temporal lobe
- ring enhancement is uncommon
Erysipelas is most commonly caused by what organism
-Strep pyogenes (group A)
Management of PH due to hypoxemia from chronic lung disease
-Oxygen and/or bronchodilator therapy
What organism are a common cause of endocarditis associated with nosocomial UTIs
Enterococci
What heart defect produces a fixed splitting of S2 and may also be associated with a midsystolic pulmonary flow murmur
Atrial septal defects
For Adenocarcinoma of the stomach, what is commonly employed for disease staging and is sensitive for revealing metastases (especially in the liver(
CT scan of the abdomen and pelvis
Pulmonary HTN is defined as what?
Mean pulmonary arterial pressure >/= 25 mm Hg at rest (normal is less than or equal to 20)
Management of granulomatosis with polyangiitis
- Corticosteroids and immunomodulators
- MTX, cyclophosphamide or rituximab
treatment of carboxyhemoglobinemia?
- High flow 100% oxygen
- Intubation/hyperbaric oxygen therapy (severe)
What is the preliminary investigation of choice in the management of pleural effusion
Diagnostic thoracentesis except in patients with classic signs and symptoms of congestive heart failure, where a trial of a diuretic is warranted
What area of brain do lacunar infarcts often affect
internal capsule
What is Dacryocystitis
infection of the lacrimal sac
Sodium nitroprusside is a potent arterial and venous vasodilator often used for hypertensive emergencies. Describe its link to cyanide poisoning
- The drug contains 5 cyanide groups and undergoes rapid conversion to cyanide and eventually thiocyanate, which is eliminated by the kidneys
- Prolonged infusion at high rates can lead to cyanide toxicity, especially in patients with chronic kidney disease
- Low rates, short term use, and close monitoring are recommended
Describe the relationship between a Crohn Dx pt with a scar, Oxalate, and a symptoms consistent with nephrolithiasis
- Patients with Crohn disease, or any other small intestinal disorder resulting in fat malabsorption are predisposed to hyperoxaluria.
- Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption
- In patients with fat malabsorption, the calcium is preferentially bound by fat leaving oxalate unbound and free to be absorbed into the bloodstream
A patient with COPD and acute onset shortness of breath, hypoxia, and unilaterally decreased breath sounds likely has what?
secondary spontaneous pneumothorax (rupture of an apical alveolar bleb)
What are the 2 major products of combustion from a fire in closed spaces that cause poisoning
- Hydrogen cyanide
- carbon monoxide
Describe the mechanism of how cyanide poisoning causes lactic acidosis
- Cyanide binds to ferric iron in cytochrome oxidase a3 in the mitochondrial electron transport chain
- this activity blocks oxidative phosphorylation and promotes anaerobic metabolism, causing lactic acidosis
Describe the hterophile antibody (monospot) test in infectious mononucleosis
positive (but 25% false negative rate during 1st week of illness)
Myopathy in Cushing syndrome is characterized by weakness predominantly involving the proximal muscles and may be severe enough to interfere with daily activities. It is due to what?
the direct catabolic effects of cortisol on skeletal muscle, which leads to muscle atrophy
What heart defect can be due to an adverse effect of a permanentpacemaker
-tricuspid regurg
what medications are indicated for symptomatic relief of idiopathic PH
- Endothelin receptor antagonists (Bosentan)
- PDE-5 inhibitors (Sildenafil)
- and/or prostanoids (epoprostenol)
what imaging modalities are used to evaluate uric acid kidney stones?
- CT of abdomen
- US
- IV pyelography
This is characterized by painless, rapid, and transient (<10 minutes) monocular vision loss
Amaurosis fugax
chronic, intermittent pain and postprandial discomfort is typical of what
dyspepsia
What is a Hordeolum?
abscess located over the upper or lower eyelid
Describe the management of chronic back pain
- should include an exercise program emphasizing stretching and strengthening of the back muscles and aerobic conditioning
- Acetaminophen or NSAIDs can be used intermittently
- Some patients may benefit from TCAs or duloxetine, but opioids, benzos, and muscle relaxants are not advised
What description is highly suggestive of amaurosis fugax
curtain descending over the visual feld
What is the empiric treatment of bacterial meningitis in an immunocompromised pt
-cefepime plus vancomycin plus ampicillin
what are the common drugs associated with photosensitivity reactions?
- Tetracyclines (doxy)
- Chlorpromazine, prochlorperazine
- Furosemide and HCTZ
- Amiodarone
- promethazine
- piroxicam
what is the most common presenting sign of Parkinson disease
asymmetric resting tremor in distal part of upper extremity
Significant HTN with primary hyperparathyroidism suggests possible what disorder?
MEN type 2 with pheo and requires further eval
Describe the use of Neomycin in the treatment of hepatic encephalopathy
-nonabsorbable antibiotic used to treat hepatic encephalopathy in patients unresponsive to lactulose and those unable to tolerate rifaximin
in non small cell lung cancer sensitive to chemo?
no
Patients with ulcerative lesions of the colon due to colonic neoplasia or inflammatory bowel disease have increased predilection to develop Infective endocarditis due to what organism?
-Streptococcus gallolyticus (S. Bovis biotype I)
Treatment of vasovagal syncope
- Reassurance
- Avoidance of triggers
- COUNTERPRESSURE techniques
IV naltrexone is a potent opioid antagonist used for what
patients with opioid INTOX. it can induce rapid withdrawal and should not be used in those who have withdrawal symptoms as it may cause acute worsening
The effectiveness of ACEI’s in diabetics nephropathy is related to their ability to do what
reduce intraglomerular HTN and, thereby, decrease glomerular damage
Patients with Hepatic encephalopathy and hypokalemia require what kind of prompt treatment
-Potassium repletion in addition to intravascular volume repletion
in a patient with postoperative oliguria and an inconclusive portable bladder scan, what is the next appropriate step
bladder catheterization
Describe a dermatofibroma
- due to fibroblast proliferation causing isolated or multiple lesions, most commonly on the lower extremities
- nontender and appear as discrete, firm, hyperpigmented nodules that are usually < 1 cm in diameter
- The lesions have a fibrous component that may cause dimpling in the center when the area is pinched (“dimple” or “buttonhole” sign)
What is the best therapeutic option for patients with a single brain metastasis in a surgically accessible location and good performance status?
Surgical resection
ERCP is usually performed in patients when?
when initial US or CT suggests the presence of obstruction due to cholelithiasis or malignancy
recommendation for back braces for prevention or treatment of low back pain?
Not effective
Synthetic cannabinoids like dronabinol are useful in treating cachexia due to what
advanced HIV
CSF finding in Guillain-Barre syndrome
- Increased protein
- normal leukocyte count
Non-immunologic kidney damage is believed to operate in what disorders
- diabetic nephropathy
- Hypertensive nephropathy
What is an important tool to prevent undesired medical outcomes that result from physician communication failures during the patient handoff process
checklists
What does HSVesophagitis show on endoscopy and what is used to treat?
- vesicles and round/ovoid ulcers
- Acyclovir
Progressive shortness of breath, tricuspid regurg (systolic murmur at the sternal border, increased with inspiration), peripheral edema, and Echocardiogram showing dilated left ventricle with EF 30% and mildly dilated right ventricle is indicative of what?
Pulmonary HTN
Serum amylase and lipase levels in CHRONIC pancreatitis
-only slightly elevated or normal
imaging shows what in pseudogout?
CHONDROCALCIFICATION
This type of GI bleed is typically painless, but large volume bleeding may be associated with lightheadedness and hemodynamic instability
Diverticular
What confirms the diagnosis of primary hyperaldosteronism
- Adrenal suppression test
- then if Positive adrenal imaging
Treatment of Primary Raynaud’s phenomenon
Calcium channel blocker like nifedipine or amlodipine
Patients with this typically present with holocranial headache, vision changes (blurry and diplopia) and pulsatile tinnitus (“whooshing” sound in the ears)
-idiopathic intracranial HTN (pseudotumor cerebri)
Describe the typical presentation of thyroid lymphoma
- rapidly enlarging firm goiter
- associated with compressive symptoms (e.g. dysphagia, hoarseness)
- As with other lymphomas, patients may have systemic B symptoms (e.g. fever, night sweats, weight loss)
- MILD PAIN and tenderness may be present
- gland is often fixed to the surrounding structures and does not move up when swallowing
Physical exam findings in young women with fibromuscular dysplasia
- Subauricular systolic bruit
- Abdominal bruit
The abdominal succussion splash is elicited by placing the stethoscope over the upper abdomen and rocking the patient back and forth at the hips. This is useful in diagnosing what disorder
Gastric outlet obstruction
This eye pathology typically presents as a sudden loss of vision and onset of floaters
Vitreous hemorrhage
What finding on imaging is present in about 70% of patients with idiopathic intracranial HTN
empty sella
primary treatment for papillary thyroid cancer
surgical resection
Clinical associations with Small cell carcinoma of lung
- Cushing syndrome
- SIADH
- Lambert-Eaton syndrome
what is believed to be the earliest renal abnormality present in patients with DM
Glomerular hyperfiltration
Although amitriptyline is effective for reducing neuropathic pain, it should be used with caution in who
patients >65 due to its anticholinergic effects, and it is not recommended in patients with pre-existing cardiac disease due to the risk of precipitating conduction abnormalities
What are the lab findings in disseminated histoplasmosis
- Pancytopenia
- transaminitis
- Increased LDH and ferritin
Describe the EKG findings in a post MI ventricular aneurysm
persistent ST-segment elevation after a recent MI and deep Q waves in the same leads
Pulsus parvus (i.e. decreased pulse amplitude) and pulsus tardus (i.e. delayed pulse upstroke) are associated with what heart defect
Aortic stenosis
what therapy is indicated for patients with PH due to chronic thromboembolic occlusion of pulmonary vasculature
long term anticoagulation
what thyroid pathology will show invasion of the tumor capsule and/or blood vessels when excised and can metastasize via hematogenous spread to distant tissues?
Follicular thyroid cancer
management of PH due to LV systolic dysfunction
- loop diuretics and ACEI’s (or ARBs)
- often with beta blockers
What is first line treatment for most patients with ED, including those with cardiovascular disease?
a phosphodiesterase-5 inhibitor (PDE-5) like sildenafil
- safe and effective in treating ED in low risk patients with cardiovascular dx
- contraindicated in patients taking nitrates as concomitant use can cause a precipitous drop in BP
Lab findings in SIADH
- Hyponatremia
- Serum Osm <275
- Urine Osm > 100
- Urine sodium >40
What test confirms a diagnosis of paroxysmal nocturnal hemoglobinuria
-Flow cytometry tests by assessing for absence of CD55 and CD59
What vitamin or mineral deficiency can be seen with carcinoid syndrome?
What is the mechanism?
- Niacin deficiency: dermatitis, diarrhea, dementia (Pellagra)
- Serotonin made from tryptophan which is also used in the production of niacin
Alpha-1 antitrypsin deficiency should be considered in what situations?
- COPD at a young age (<45)
- COPD with minimal or no smoking history
- Basilar predominant COPD
- Hx of unexplained liver disease
An inferior Wall STEMI (II, III, and AvF) has a 50% chance of involving the right ventricle. Clear lungs on auscultation further suggest right Ventricular MI. This leads to impaired RV filling. Describe the relationship of nitrate (or other things that decrease BP such as diuretics and opiates) and Hypotension
- Administration of nitrates should be avoided as venous dilation causes an abrupt decrease in RV preload and can lead to profound hypotension
- In patients with suspected RVMI, hypotension and low or normal jugular venous distension (<3 cm H2O above the sternal angle at 30-45 degrees recumbency strongly suggest cardiogenic shock due to inadequate RV preload
Suspect what in an alcoholic smoker who presents with a palpable cervical lymph node?
What is the best initial test?
- Squamous cell carcinoma of the mucosa of the head and neck
- Panendoscopy
symptoms of polymyalgia rheumatica
- age >50
- Bilateral pain and morning stiffness > 1 month
- involvement of 2 of following: neck or torso, shoulders or proximal arms, proximal thigh or hip, constitutional (fever, malaise, weight loss)
treatment of cervicofacial actinomyces?
- Penicillin 2-6 months
- surgery in severe disease
Definition of pulsus paradoxus
-an exaggerated drop in blood pressure of > 10 mm Hg during inspiration
Describe the liver enzymes in nonalcoholic fatty liver disease
-mild elevation is AST and ALT with an AST/ALT ratio <1
What is the best tool to confirm a dx of Parkinson disease
physical exam
What is a key distinguishing feature of pseudodementia (often from severe depression) from true dementia?
- patients with pseudodementia are frequently distressed by their memory impairment
- those with Alzheimer are often relatively unconcerned and confabulate
how do you calculate corrected sodium
measured sodium in mEq/L + (2 mEq/L for each 100 mg/dL that glucose is above 100)
What is the Schilling test used for
to determine whether a patient had vitamin B12 deficiency due to pernicious anemia or a malabsorption syndrome
Alpha-1 antitrypsin deficiency is frequently associated with disease of what other organ?
Liver
What type of hearing loss is caused by ototoxic antibiotics
sensorineural
Serum calcitonin levels are used in the diagnosis of what thyroid cancer
medullary carcinoma
Brain imaging of brain abscess
ring enhancing lesion with central necrosis
A patient receiving treatment for chronic Afib and presents with diarrhea, nausea, and fatigue is consistent with possible toxicity from what
digoxin
What lifestyle change improves long term outcomes in all patients with PH, with or without LV systolic dysfunction?
-Graded exercise training
Treatment of Guillain-Barre
-IVIG or plasmapheresis
what type of hearing loss does otosclerosis cause
conductive
What are the classic findings consistent with PE on ECG?
- prominent S in lead I
- Q in lead III
- inverted T in lead III
- SIQ3T3
A patient with diffusely nodular (e.g. cordlike thickening) breasts and bilateral, nonfocal premenstrual tenderness are consistent with what
fibrocystic changes of the breast
What are the common etiologies of crystal induced acute kidney injury
- Acyclovir
- Sulfonamides
- Methotrexate
- Ethylene glycol
- Protease inhibitors
- Uric acid (tumor lysis syndrome)
What meds can cause cochlear dysfunction
- Cisplatin and carboplatin: used for testicular, ovarian, and bladder cancer
- Aminoglycosides
Describe the link between pseudogout and calcium?
-Pseudogout is caused by calcium pyrophosphate dihydrate (CPPD) crystals in the joint space and is a common complication of hyperparathyroidism with chronic hypercalcemia
What is the foundation of management of Nonalcoholic fatty liver disease
-Weight loss and control of metabolic risk factors
What is the best screening test for primary hyperaldosteronism
-Plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio
In HHS neurologic symptoms ranging from confusion to coma are common and are primarily due to what?
-high serum osmolality (usually > 320 mOsm/kg)
What C. diff patients receive Fidaxomicin, a bactericidal antibiotic
usually reserved for recurrent colitis or as initial therapy for patients with severe colitis who cannot tolerate oral vanc
Patients with coarctation of the aorta typically present in adulthood with what
- typically asymptomatic HTN (of the upper extremities)
- less often with accompanying epistaxis and headaches
Chest x ray findings in coarctation of the aorta
- Notching of the posterior third of the 3rd to 8th ribs that represents bony erosion due to enlarged intercostal arteries
- A classic “3” sign created by indentation of the aorta with pre-and poststenotic dilation may also be present
Acalculous cholecystitis, an acute inflammation of the gallbladder in the absence of gallstones, is most often seen in who?
- hospitalized patients who are critically ill
- Common predisposing condition include recent surgery (particularly cardiopulmonary, aortic, or abdominal), severe trauma, extensive burns, sepsis or shock, prolonged fasting or tatal parenteral nutrition, or critical illness requiring mechanical intubation
What is the preferred confirmatory test for giardiasis
stool antigen assay
What is the empiric treatment for traveler’s diarrhea
A short course of ciprofloxacin
What is the first line treatment during the acute phase of reactive arthritis
NSAIDS
-if this were gonococcal septic arthritis then antibiotic
Describe how to differentiate between reactive arthritis and gonococcal septic arthritis
-Reactive: nongonococcal urethritis, asymmetric oligoarthritis, and conjunctivitis. Common also are mucocutaneous lesions and enthesitis (Achilles tendon pain)
What is responsible for >90% of cases of primary adrenal insufficiency
Autoimmune adrenalitis
What are key differentiating features of primary adrenal insufficiency from central adrenal insufficiency
- Hyperpigmentation
- Hyperkalemia
In a case control study, if the outcome is uncommon in the population, what is a close approximation of the relative risk (“rare disease assumption”)
odds ratio
Describe the Arthritis in Psoriatic arthritis
- DIPs
- Asymmetric oligoarthritis
- Symmetric polyarthritis, similar to rheumatoid arthritis
- Arthritis mutilans (deforming and destructive arthritis)
- Spondylarthritides (sacroiliitis and spondylitis)
Describe the soft tissue and nail involvement in psoriatic arthritis
- Enthesitis (inflammation at site of tendon insertion into bone)
- Dactylitis (“sausage digits”) of toe or finger
- Nail pitting and onycholysis
- swelling of the hands or feet with pitting edema
Describe Gottron’s papules found in dermatomyositis
-Violaceous plaques, slightly scaly overlying the MCP joints, which at times can look simila to psoriasis, however no dactylitis or nail changes
Hand joints in OA
DIP
hand joints in RA
MCP and PIP
Sarcoidosis causes protean cutaneous manifestations, the most common of which is what?
erythema nodosum
current treatment options for psoriatic arthritis
- NSAIDs
- methotrexate
- anti-TNF
TBI of any severity can lead to (a few hours or days later) postconcussive syndrome, which is clinically described by what symptoms
- HA
- confusion
- amnesia
- difficulty concentrating or with multitasking
- vertigo
- mood alteration
- sleep disturbance
- anxiety
Secondary bacterial pneumonia is the most common complication of influenza and should be suspected in any patient who develops worsening fever and pulmonary symptoms after initial symptomatic improvement. patients >65 and with certain comorbid conditions (e.g. immunosuppression, lung disease) are at greatest risk. What are the 2 most common etiologic organisms
- Strep pneumo
- S. aureus
Describe the clinical presentation of a patient S. Aureus pneumonia
- severe, necrotizing, and rapidly progressive
- high fever
- hypotension
- dyspnea
- hemoptysis
- confusion
clinical presentation of legionella pneumonia
- high fever
- prominent GI symptoms (vomiting, diarrhea)
- symptoms of CAP evolving slowly
IV fluid management of DKA and HHS
- High flow .9% NS initially recommended
- Add dextrose 5% when serum glucose is <200 mg/dL
Insulin management of DKA and HHS
- Initial continuous IV insulin infusion
- Switch to SQ (basal bolus) insulin for: able to eat, glucose <200, anion gap ,12, serum HCO3 15 or more
- overlap SQ and IV insulin by 1-2 hours
Potassium management of DKA and HHS
- Add IV potassium if serum K <5.2
- Hold insulin for serum K <3.3
- Nearly all patients are K depleted, even with hyperkalemia
Bicarb management of DKA and HHS
Consider for patients with pH <6.9
Phosphate management of DKA and HHS
- Consider for serum phosphate <1.0, cardiac dysfunction or respiratory depression
- Monitor serum calcium frequently
In DKA, measured serum potassium levels are often initially high due to what
- Extracellular shift of potassium driven by increased plasma tonicity
- Loss of insulin dependent potassium uptake across cell membranes
Moderate anemia from anemia of chronic disease due to RA shows what iron studies levels?
- Low serum iron
- Low TIBC
- Normal or elevated ferritin
- Normal or low Transferrin saturation
iron studies in iron deficiency anemia
- low serum iron
- high TIBC
- low ferritin
- Low transferrin sat
iron studies in Thalassemia anemia
- high serum iron
- low TIBC
- High Ferritin
- very high Transferrin sat
Describe the pathophysiology of anemia of chronic disease
-thought to involve iron trapping within macrophages, leading to reduced serum iron concentrations and poor iron availability for hemoglobin synthesis
Commmon agents used in RA treatment
- Methotrexate
- Hydroxychloroquine
- TNF inhibitors (infliximab, etanercept
Clinical presentation of exertional dyspnea, orthopnea (choking sensation/dyspnea when lying flat), bibasilar rales, lower extremity edema, and normal ejection fraction on echo is consistent with what?
-heart failure with preserved ejection fraction (HFpEF) or diastolic dysfunction
What are the guidelines to accepting gifts from pharm companies
-Accepting nonmonetary gifts from interested parties only if the gifts directly benefits patient care and are of small monetary values (e.g. unbiased educational material, drug samples)
What is the only class of diuretics with a demonastrated survival benefit in patients with heart failure
-aldosterone antagonists like spironolactone and eplerenone
Pressure (decubitus) ulcers are most common over bony prominences, such as where?
- sacrum
- ischial tuberosities
- malleoli
- heels
- 1st and 5th metatarsal head
Arterial ulcrs are due to insufficient blood supply that leads to tissue necrosis and usually occur where?
most distal parts of the body where blood flow is lowest, such as the tips of the toes
Diabetic foot ulcers often occu rin association with Charcot deformity and are most common where
on the soles of the feet under the metatarsal heads and at the tops of the toes
Venous stasis ulcer usually occur in the setting of chronic lower extremity edema and stasis dermatitis. They are most common where?
at the pretibial area or above the medial malleolus
low Back pain
- Normal neurologic exam
- Negative straight leg raise
- possible paraspinal tenderness
Mechanical (muscle strain, spasm, degenerative arthritis
low Back pain
- Radiculopathy (usually L4-L5)
- Possible positive straight leg raise
- Possible neurologic deficits
-Herniated nucleus pulposus/disk disease
low Back pain
- Pseudoclaudication
- Better with spine flexion
- Worse with extension
- older age
Spinal stenosis
Low back pain
- Older age
- more common in women
- Trauma/fall (may be minor)
-Compression fracture
Low back pain
- Better with activity or exercise
- No improvement with rest
- gradual onset
- HLA-B27 present
- Ankylosing spondylitis
- Reactive arthritis
- Psoriatic arthritis
- IBD
Low back pain
- Hx of malignancy
- Age> 50
- Worse at NIGHT
- Unintentional weight loss
- Cauda equina syndrome (weakness, urine retention/incontinence, saddle anesthesia)
Metastatic cancer to bone
Low back pain
- Recent infection
- IV drug abuse
- DM
- Fever, exquisite point tendernes
Osteomyelitis, discitis, abscess
Genitourinary causes of urinary incontinence in the elderly
- Decrease Detrusor contractility, detrusor overactivity
- Bladder or urethral obstruction (e.g. tumor, BPH)
- Urethral sphincter or pelvic floor weakness
- Urogenital fistula
Neurologic causes of urinary incontinence in the elderly
- MS
- Dementia
- Spinal cord injury, disc herniation
Potentially reversible causes of urinary incontinence in the elderly
“DIAPPERS)
- Delirium
- Infection (e.g. UTI)
- Atrophic urethritis/vaginitis
- Pharm (e.g. alpha blockers, diuretics)
- Psychological (e.g. depression)
- Excessive urine output (e.g. DM, CHF)
- Restricted mobility (e.g. postsurgery)
- Stool impaction
What should be obtained routinely in an elderly patient with urinary incontinenct
-UA with culture as older adults often lack typical signs or symptoms of UTI
This is useful for diagnosing Behcet syndrome and involves obliquely inserting a 20-gauge needle into the skin and checking the site 24-48 hours later for the development of a >2mm papule
A pathergy test
Describe anemia and RIPE therapy
- Acquired sideroblastic anemia
- defective heme synthesis, most commonly due to pyridoxine-dependent impairment in early steps of protoporphyrin synthesis
- Isoniazid is a well-known pyridoxine antagonist that can be resonsible for this condition
- Give pyridoxine (B6)
pathophys of Non-Alcoholic fatty liver disease
- can be due to increased transport of free fatty acids from adipose tissue to the liver, decreased oxidation of FFA in the liver, or decreased clearance of FFA from the liver (due to decreased VLDL production)
- It is frequently related to peripheral insulin resistance leading to incrased peripheral lipolysis, triglyceride synthesis, and hepatic uptake of fatty acids
What medications have been shown to improve long-term survival in patients with left ventricular systolic dysfunction
- ACEI
- ARB
- Beta-Blocker
- Mineralocorticoid receptor antagonists (Spironolactone and eplerenone)
- in African americans, a combo of hydralazine and nitrates
What should be obtained first in a patient with a thyroid nodule
- TSH
- US
- Then patients with suspicious US finding (e.g. hypoechoic, microcalcifications, internal vascularity) or cancer risk factors should undergo fine needle aspiration
What is indicated in a patient with a thyroid nodule found to have low TSH
Radionuclide scan
-Hot nodules are almost always benign and can be treated for hyperthyroidism
what is next step in severe asthma exacerbation not responding to medical treatment
endotracheal intubation and mechanical ventilation
Describe the management of a patient with Upper GI bleeding who has depressed level of consciousness and ongoing hematemesis
- Should be intubated to protect the airway as a part of initial stabilization and resuscitation
- Prompt endoscopic treatment with ligation or sclerotherapy should THEN be performed to stop the bleeding
Carpal tunnel syndrome is caused by compression of the median nerve where it passes under the transverse carpal ligament in the wrist. Most patients respond to what?
Nocturnal wrist splinting, but those with significant weakness or refractory symptoms may require surgical decompression
Right sided endocarditis should be considered in pts with presumed history of IV use. Empiric antibiotic treatment of native valve endocarditis should be geared toward what?
What is the most appropriate empiric antibiotic?
- MRSA, strep, and enterococci
- Vancomycin
Describe the clinical picture of ethylene glycol poisoning
- The initial symptoms can mimic ethanol inebriation
- However, as alcohol dehydrogenase metabolized ethylene glycol to oxalic acid and glycolic acid, these metabolites cause profound clinical consequences
- Glycolic acid injures the renal tubules, and ocalic acid binds calcium, causing hypocalcemia and calcium oxalate crystal deposition in the kidneys
- They then develop flank pain, hematuria, oliguria, AKI, and anion gap metabolic acidosis
Describe the treatment of ethylene glycol poisoning
- Administration of fomepizole (a competitive inhibitor of alcohol dehydrogenase) or ethanol prevents furtehr breakdown of ethylene glycol into its toxic metabolites and is an integral part of treatment
- Sodium bicarb may help alleviate the acidosis, and hemodialysis may be required `
Treatment for methemoglobinemia, seen in the setting of ingestion of certain drugs (e.g. dapsone) or anesthetic agents, and manifests as cyanosis and respiratory depression as a results of impaired oxygen delivery to the tissues
Methylene blue
Describe acetaminophen overdose
- most often with nonspecific symptoms such as N/V or malaise, and can progress to liver damage and failure (e.g. encephalopathy, jaundice, elevated prothrombin time)
- AKI and metabolic acidosis can occasionally occur
antidote for acetaminohen OD
N-acetylcysteine
symptoms of cyanide poisoning
- generally seen in the setting of fires or occupational exposure (e.g. mining, pesticides)
- Markedly elevated lactate levels (typically >10)
antidote for cyanide poisoning
-sodium thiosulfate
Describe the treatment options for PCOS
- Weight loss (first line)
- OCPs for menstrual regulation
- Clomiphene citrate for ovulation induction
