UWorld 2 Flashcards
Clinical presentation of a popliteal (Baker) cyst
- Asymptomatic bulge behind knee that diminishes with flexion
- Posterior knee pain, swelling, stiffness
Complications that can accompany a Popliteal (Baker) cyst
- Venous compression (leg/ankle swelling)
- Dissection into calf (erythema, edema, positive Homan sign)
- Cyst rupture (acute calf pain, warmth, erythema, ecchymosis)
A popliteal cyst is due to what
extrusion of synovial fluid from the knee joint into the gastrocnemius or semimembranosus bursa through a communication between the joint and the bursa
Risk factors for popliteal cyst
- Trauma (e.g. meniscal tear)
- Underlying joint dx (RA or OA)
What is the crescent sign in terms of popliteal cysts
-An arc of ecchymosis visible distal to the medial malleolus when popliteal cyst ruptures
This presents with subacute medial knee pain and exam shows a well-defined area of tenderness over the medial tibial plateau below the joint line
Pes anserinus pain syndrome (anserine bursitis)
patient with progressive dyspnea, decreased exercise tolerance, Afib with rvr and LV systolic dysfunction is consistent with what
tachycardia-mediated cardiomyopathy
Treatment of tachycardia-mediated cardiomyopathy
-Aggressive rate control or restoration of normal sinus rhythm
effect of albumin on calcium
- approximately 40-45% of total blood calcium is bound to albumin and other plasma proteins, the remainder is transported in the blood as ionized calcium or complexed with phosphate and other anions
- Patients with hypoalbuminemia may have significant deficit in total blood calcium . However, the ionized plasma calcium (physiologic active form) is hormonally regulated and remains stable
what is the corrected calcium equation
CC = (measured total calcium) + .8 (4.0 - serum albumin)
Untreated hyperthyroidism and bone health?
risk for rapid bone loss from increased osteoclastic activity in the bone cells
Lab findings in Hereditary spherocytosis
- Increased corpuscular hemoglobin concentration (due to membrane loss and RBC dehydration)
- Spherocytes on peripheral smear
- Negative Coombs test
- Increased osmotic fragility on acidified glycerol lysis test
- Abnormal eosin-5-maleimide binding test
Treatment of Hereditary spherocytosis
- Folic acid supplementation
- Blood transfusions
- Splenectomy
Complications of Hereditary Spherocytosis
- Pigment gallstones
- Aplastic crises from parvovirus B19 infection
Absent CD55 molecule causes hemolytic anemia induced by the complement system, which is the mechanism of what disorder
Paroxysmal nocturnal hemoglobinuria
A patient with end-stage Renal disease has severe HTN, headache, and retinal hemorrhages consistent with acute hypertensive crisis. This should raise suspicion for what
-erythropoietin-related hypertension
CSF findings in Herpes encephalitis
- Lymphocytic pleocytosis
- increase in erythrocytes (due to hemorrhagic destruction of temporal lobes)
- elevated proteins
- Low CSF glucose is NOT SEEN
imaging for herpes encephalitis
-MRI preferred over CT (which may be normal in up to 50% of patients)
This is a circadian rhythm disorder characterized by the inability to stay awake in the evening (usually after 7:00 p.m.), making social functioning difficult
Advanced sleep phase syndrome
This is a circadian rhythm disorder characterized by the inability to fall asleep at “normal” bedtimes, resulting in sleep-onset insomnia and excessive daytime sleepiness. Patients sleep normally if allowed to follow their internal circadian rhythm and sleep until late morning
Delayed sleep phase syndrome
what testing can help confirm a suspected ankylosing spondylitis
- Xrays of SI joints
- HLA-B27 is not specific and is not necessary for diagnosis
Exam findings in Ankylosing Spondylitis
- Arthritis (sacroiliitis)
- Reduced chest expansion and spinal mobility
- Enthesitis (tenderness at tendon insertion sites)
- Dactylitis (swelling of fingers and toes)
- Uveitis
Most common extraarticular manifestation of ankylosing spondylitis
-Anterior uveitis
definition of excessive alcohol intake
- > 2 drinks a day
- or binge drinking (5 or more drinks in a row)
- both associated with increased incidence of HTN compared to nondrinkers
Describe the primary mechanism behind the anti ischemic effects of nitrates
- SYSTEMIC rather than coronary vasoldilation
- lowers preload and left ventricular end-diastolic volume and reduces myocardial oxygen demand by reducing wall stress
Describe the CURB-65 system to determine hospitalization in CAP
1 point for each
- Confusion
- Urea >20
- Respirations 30 or more
- BP <90/60
- Age 65 or more
- score 0: low mortality. Outpatient treatment
- Score 1-2: intermediate mortality. likely inpatient treatment
- Score 3-4: high mortality. Urgent inpatient admission possibly ICU if score >4
Describe the Outpatient empiric treatment of CAP
- Macrolide or doxy (healthy)
- Fluoroquinolone or beta-lactam + macrolide (comorbidities)
Describe Inpatient (non-ICU) empiric treatment of CAP
- Fluoroquinolone (IV)
- Beta-lactam + macrolide (IV)
Describe inpatient ICU empiric treatment of CAP
- Beta-lactam + macrolide (IV)
- Beta lactam + fluoroquinolone (IV)
describe pronator drift
- sign of upper motor neuron problem
- have patient hold arms outstretched with palms up
- one arm will begin to pronate involuntarily indicated UMN lesion on opposite side
Once Dx of MS is established, patients with an acute attack and disabling symptoms are typically treated with what
- High dose IV glucocorticoids (e.g. methylprednisolone)
- Plasma exchange is indicated in those who do not respond to glucocorticoids
- other immunomodulators (e.g. interferon beta, natalizumab, glatiramer) can be used for long term disease suppression
Lumbar puncture is typically performed in patients with suspected MS when the dx is not completely clear. what is typically found in the CSF
oligoclonal IgG bands
Common causes of nephrotic syndrome in adults are membranous glomerulopathy, focal segmental glomerulosclerosis, minimal change disease, and amyloidosis. What clues would lean towards amyloidosis
- Hx of RA (or other chronic inflammatory conditions like IBD)
- Enlarged kidneys
- Hepatomegaly
What are the typical findings on renal biopsy in amyloidosis
-Amyloid deposits that stain with Congo red and demonstrate a characteristic apple-green birefringence under polarized light
Crescent formation on light microscopy is the characteristic finding of what renal dx
-rapidly progressive glomerulonephritis
Hyalinosis that affects both afferent and efferent arterioles is pathognomonic of what
diabetic nephropathy
Linear deposits on immunofluorescence microscopy are typical for what renal dx
-Antiglomerular basement membrane disease (e.g. goodpasture’s syndrome)
Granular deposits are usually present in what renal dx
-immune complex glomerulonephritis (e.g. lupus nephritis, IgA nephropathy, postinfectious glomerulonephritis)
What is the most common cause of AL amyloidosis?
Multiply Myeloma
What is the most common cause of AA amyloidosis
Rheumatoid arthritis
Patient who receive solid organ transplantation require high-dose immunosuppressant medication to prevent organ rejection. This creates an immunocompromised state with a high risk for opportunistic infection, most notably what?
-What is the most effective and well tolerated medication for prophylaxis?
- Pneumocystis pneumonia and cytomegalovirus
- TMP-SMX (patients with sulfa allergy should undergo desensitization if possible)
- Many patients also require cytomegalovirus prophylaxis with ganciclovir or valganciclovir
What is used in HIV patients with CD4 counts <50 to prevent mycobacterium avium complex (MAC)
Azithromycin
What is the most critical factor determining overall patient survival in sudden cardiac arrest
- Elapsed time to effective resuscitation
- this includes effective bystander CPR, prompt rhythm analysis, and early defibrillation for pts found to be in ventricular fibrillation
Patients who have received the equivalent of more than one blood volume of blood transfusions or packed RBCs over 24 hours may develop elevated plasma levels of citrate (a substance added to stored blood). Describe what this does to electrolytes and the results
- Citrate chelates calcium and magnesium and may reduce their plasma levels
- Causing paresthesias
A drop in platelets by >50% or a new thrombus within 5-10 days of heparin initiation should raise suspicion for what
HIT, heparin induced thrombocytopenia
how is HIT dx confirmed
- functional assay (e.g. serotonin-release assay)
- high-titer immunoassay of the blood
in HIT what is patient at risk for
-highly thrombogenic . . . . arterial and venous clots
This should be suspected in patients presenting with sudden onset of severe epigastric pain that spreads over the entire abdomen. Upright chest and/or abdominal radiographs typically reveal free air under the diaphragm
Chemical peritonitis due to perforated peptic ulcer
difference in osmolar gap b/t osmotic and secretory diarrhea
- Osmotic: elevated
- Secretory: reduced
Stool osmotic gap (SOG) equation
SOG = plasma osmolality -2(stool sodium + stool potassium)
Lab findings that support a diagnosis of Acute tubular necrosis following hypovolemic shock
- Serum BUN and Cr ratio is less than 20:1
- Urine osmolality of 300-350 (but never <300)
- Urine Na of >20 mEq/L
- FENa >2%
Hallmark findings on UA of ATN following hypovolemic shock
Muddy brown granular casts consisting of renal tubular epithelial cells
What casts are seen on UA of patients with chronic renal failure
- Broad casts
- These arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to the reduced renal mass
- Waxy casts, which are shiny and translucent, are also generally seen in chronic renal disease
RBC casts
Glomerulonephritis
WBC casts
Interstitial nephritis and pyelonephritis
Fatty casts
Nephrotic syndrome
Describe the Post exposure prophylaxis of Rabies from a domesticated dog bite when the dog is available to be observed and is asymptomatic
- Observe for 10 days
- No Prophylaxis needed yet
Aortic regurgitation murmur with tearing chest and elevated creatinine
-Aortic dissection with proximal extension and possibly distal extension into the renal arteries
What is the preferred diagnostic study in suspected aortic dissection in a patient with renal insufficiency or hemodynamic instability
TEE
Laboratory evaluation of those with pancreatic cancer typically demonstrates what
increased serum bilirubin and alkaline phosphatase in conjunction with a mild anemia
In suspected pancreatic cancer, abdominal US is usually the initial imaging performed on pts with jaundice. When nondiagnostic, what is next step
CT scan
-ERCP is an excellent tool but is invasive so is reserved for those patients who have already undergone a nondiagnostic US and CT
Another name for pancoast tumor
Superior pulmonary sulcus tumor
Congestive Heart failure can cause transudative pleural effusions due to increased hydrostatic pressure. Describe the effusions generally
-often bilateral (or right sided)
Sudden onset dyspnea, chest pain, and tachycardia with no consolidation on chest imaging suggest a PE. this can cause what kind of effusions
-typically small, exudative, and bloody
Describe what raising the cute off point (increasing the inclusion criteria) of a screening test does to specificity and sensitivity
- Decrease sensitivity
- Increase specificity
Describe the acid base disturbance caused by aspirin toxicity
- Mixed Respiratory alkalosis and metabolic acidosis
- Directly stimulates the medullary respiratory center to cause tachypnea and respiratory alkalosis
- Also causes an anion gap metabolic acidosis due to increased production and decreased renal elimination of organic acids (e.g. lactic acid, ketoacids)
Myoneural junction dysfunction is another name for what
Myasthenia gravis
Hemolytic episodes in patients with G6PD deficiency are most commonly precipitated by infections or medications that increase oxidative stress, particularly what meds?
- Sulfa drugs
- Antimalarials
- Nitrofurantoin
Positive Pressian blue stain on urine indicates what
presence of hemosiderin, which is found in the urine during hemolytic episodes
what is found on smear in G6PD deficiency
Heinz bodies
Autoimmune hemolysis occurs when IgG autoantibodies bind to the RBC membrane and promote removal from circulation in the spleen’s RES. The direct Coombs test will be positive. What meds can cause this type of reaction
- Alpha methyldopa
- penicillin
Renal Vein Thrombosis is an important complication of nephrotic syndrome due to loss of antithrombin III in the urine. This can be acute and present with abdominal pain, fever, and hematuria. This is most commonly seen with what pathology
Membranous glomerulopathy
Clinical features of CHRONIC mesenteric ischemia
- Crampy, postprandial, epigastric pain
- Food aversion
- Weight loss
Dx of chronic mesenteric ischemia
- Signs of mallnutrition
- Abdominal Bruit
- CT angiography (preferred)
- Doppler US
Presentation of ACUTE mesenteric ischemia
-Abrupt with severe abdominal pain out of proportion to exam
- Acute, diffuse, NONinflammatory hair loss
- Scalp and hair fibers appear normal
- Hair shafts easily pulled out (hair pull test)
Telogen effluvium
Triggers of Telogen effluvium
- Severe illness, fever, surgery
- Pregnancy, childbirth
- Emotional distress
- Endocrine and nutritional disorders
This is an autoimmune disorder characterized by circumscribed patches of hair loss. Hair shafts show narrowing close to the surface and may be broken off
Alopecia areata
This causes uneven hair loss in a characteristic pattern. Men have thinning at the fromtotemporal hairline and vertex. Women predominantly have thinning at the vertex and sides with preservation of the hairline
Androgenetic alopecia
This causes erythema and scaling at the ears, eyebrows, nasolabial folds, and scalp
Seborrheic dermatitis
This is a superficial dermatophyte infection characterized by pruritic, scaly, erythematous patches with hair loss. Proximal hair shafts may be visualized as small dots in the area of hair loss
Tinea Capitis
This is characterized by fragility of hair with breaking of strands. IT can be congenital or acquired (e.g. excessive heat, hair dyes, salt water). Close inspection shows fractured strands with splitting of fibers
Trichorrhexis nodosa
This is a behavioral disorder characterized by compulsive pulling of hair. It presents with irregular patches of hair loss and broken fibers, and typically affects the front and sides of the scalp, eyebrows, and eyelashes
Trichotillomania
Patient who recently emigrated from Mexico has abdominal pain, fever, Leukocytosis, and a liver abscess on imaging. If young age, absence of animal contact, and history of dysentery a few months ago, what is most likely etiology
Amebic abscess caused by intestinal protozoan Entamoeba histolytica
-DDx includes pyogenic (bacterial) abscess (usually in older patients with underlying medical condition like DM or hepatobiliary dx) and hydatid cyst caused by echinococcus (No fever and require contact with animals like dogs)
Treatment of amebic liver abscess
- Metronidazole
- A luminal agent (ie, paromomycin) is also required to eradicate intestinal colonization
Why is drainage of amebic liver abscess NOT recommended
- due to high response rate to appropriate antiamebic therapy
- risk of rupture into peritoneum
Large hydatid cysts due to echinococcus can be treated how
Aspiration in combination with albendazole
Recommended treatment for pyogenic abscess
IV antibx (ceftriaxone) and drainage
What is the most common cause of spontaneous deep intracerebral hemorrhage
Hypertensive vasculopathy involving the small penetrating branches of the major cerebral arteries
Chronic HTN leads to the formation of Charcot-Bouchard aneurysms, which may rupture and bleed within the deep brain structures. The most frequently affected locations include what
- Basal Ganglia (putamen)
- Cerebellar nuclei
- Thalamus
- Pons
What is the most common cause of spontaneous lobar-cortical hemmorhage (e.g. occipital, parietal) in the elderly >60
cerebral amyloid angiopathy
What is the most common cause of intraparenchymal brain hemorrhage in CHILDREN
Arteriovenous malformation
A history of a recent URI followed by sudden onset of cardiac failure in an otherwise healthy patient is suggestive of what?
dilated cardiomyopathy, most likely secondary to acute viral myocarditis
Dx of dilated cardiomyopathy is made by echo, which typically shows what
dilated ventricles with diffuse hypokenesia resulting in a low ejection fraction
Asymmetric septal hypertrophy is present in what
hypertrophic cardiomyopathy
-Dullness to percussion with increased breath sounds
Lobar pneumonia causing focal lung condolidation
-resonant to percussion and auscultation at the periphery demonstrates vesicular breath sounds that consist of a quiet inspiratory phase and an almost inaudible expiratory phase
normal lung
Bilateral hyperresonant to percussion and intensity of breath sounds is decreased.
Emphysema
-wheezing may be present due to commonly accompanying chronic bronchitis
- resonant to percussion
- breath sounds normal or decreased intensity
- fine crackles are heard at the end of inspiration
interstitial lung disease
Mucus plugging decreases airflow in the affected part of the bronchial tree resulting in collapse of the downstream lung parenchyma (atelectasis). Describe the breath sounds
absent in affected area
- decreased breath sounds
- decreased tactile fremitus
- dullness to percussion
Pleural effusions as the fluid in the thoracic cavity acts to insulate sound and vibration originating from the lung
- Decreased breath sounds
- decreased tactile fremitus
- Hyperresonance to percussion
pneumothorax
Treatment of porphyria cutanea tarda
-either serial phlebotomy or hydroxychoroquine with management of underlying causes (e.g. HCV)
Alpha-1-antitrypsin deficiency is associated with emphysematous lung disease, chronic hepatitis, cirrhosis, and what skin manifestation
Panniculitis (painful, erythematous nodules and plaques on the thighs or buttocks)
Wilson disease is associated with what skin disorders
- blue lunulae (blue deposits at base of fingernails)
- Acanthosis nigricans
Points to remember for Sulfonylureas
- Generally added in patients with metformin failure
- Weight gain and hypoglycemia are main side effects
Points to remember for Pioglitazone (TZDs)
- Used if unable to tolerate metformin or sulfonylureas
- Side effects: weight gain, edema, CHF, bone fracture, bladder cancer
- Low risk of hypoglycemia when used alone or with metformin
- Can be used in renal insufficiency
Points to remember for DPP-4 inhibitors (gliptins)
- Low risk of hypoglycemia
- weight neutral
- Can be used in renal insufficiency
Points to remember for GLP-1 agonists (tides)
- Possible second agent for metformin failure, especially if weight loss is desired
- Low hypoglycemic risk when used alone or with metformin
- associated with acute pancreatitis
Most guidelines recommend adding insulin to metformin in pts with HBA1c greater than what?
8.5%
Presentation of pancreatic cancer
- varies depending on location (most occur in head)
- as they expand, they compress the pancreatic duct and common bile duct (leading to PAINLESS) jaundice, sometimes seen on imaging as the double duct sign
- Subsequent backup of bile leads to intra and extrahepatic biliary duct dilation and a nontender, distended gallbladder at the right costal margin (Courvoiseier sign)
- The jaundice can also lead to pruritius, PALE stools, and DARK urine
Describe presentation of cancers in the body or tail of pancreas
abdominal pain WITHOUT jaundice
Pancreatic calcifications
Chronic pancreatitis . . . not pancreatic cancer
This is a hypercoagulable disorder that usually presents with unexplained superficial venous thrombosis at unusual sites (e.g. arm, chest area). The syndrome is usually diagnosed prior to (sometimes months to years before) or at the same time as on occult visceral malignancy
Trousseau’s syndrome . . . get a CT of abdomen
most common malignancy associated with Trousseau’s syndrome
pancreatic
CSF findings in viral (Herpes simplex virus) encephalitis
- Increased WBCs (lymphocyte predominant)
- Normal glucose
- normal to slightly Increased protein
- elevated RBC count
Treatment of viral (herpes) encephalitis
IV acyclovir: start immediately after obtaining CSF fluid
Exam and clinical signs in pure encephalitis
- Neurologic abnormalities, including hemiparesis, cranial nerve palsies, and exaggerated DTRs
- Meningeal irritation (e.g. photophobia and nuchal rigidity) are usually ABSENT
Normal CSF
- WBC count?
- Glucose?
- Protein?
- 0-5
- 40-70
- <40
How is diagnosis of viral encephalitis confirmed?
-Viral DNA by PCR of CSF
Describe the acid base disturbance in salicylate (Aspirin) toxicity
- respiratory alkalosis by stimulating the respiratory center in the medulla and causing tachypnea
- It then causes an anion gap metabolic acidosis by uncoupling of oxidative phosphorylation in the mitochondria leading to anaerobic metabolism
- Mixed respiratory alkalosis and anion gap acidosis . . normal pH
What intoxication should be suspected in a patient with fever, tinnitus, and tachypnea
Aspirin
Diagnostic findings in constrictive pericarditis
- ECG may be nonspecific or show atrial fibrillation or low voltage QRS complex
- Imaging shows pericardial thickening and calcification
- Jugular venous pulse tracing shows prominent x and y descents
Etiology of constrictive pericarditis
- Idiopathic or viral pericarditis
- Cardiac surgery or radiation therapy
- Tuberculous pericarditis (in endemic areas)
- Endemic in south america and may cause megacolon, megaesophagus, and cardiac disease
- causes both systolic and diastolic heart failure
- may also cause arrhythmias and mitral/tricuspid regurg
Chagas disease caused by Trypanosoma cruzi
What is the most common cause of an isolated, ASYMPTOMATIC elevation of alkaline phosphatase in an elderly patient
Paget disease of bone (osteitis deformans)
-levels can be strikingly elevated, often > 10 times the upper limit of normal
Besides alkaline phosphatase, what other markers are increased in Paget disease of bone
- Procollagen type I N propeptide (PINP)
- urine hydroxyproline
What is useful to fully stage Paget disease of the bone
Radionuclide bone scan
what type of transfusion is recommended in acute GI bleeding for patients with hemoglobin <7
Packed RBCs
Metabolic acidosis with an anion gap and osmolal gap and envelope shaped, rectangular crystals on UA
Ethylene glycol poisoning
episodic painless GI bleeding suggests what
angiodysplasia
most common location for angiodysplasia
right colon
Angiodysplasia is more frequently diagnosed in patients with what ?
- Advanced renal disease
- vW disease
- Aortic stenosis, possbily due to acquired vW factor deficiency
Diagnosis of angiodysplasia is usually made on endoscopic eval. However, it is not uncommon to be missed on colonoscopy due to what
- Poor bowel preparation or
- location behind a haustral fold
Angiodysplasia patients with anemia or bleeding can be treated how
cautery
A patient with worsening epigastric pain and weight loss in the setting of idiopathic chronic pancreatitis suggests what
pancreatic cancer
Describe imaging preferrence for pancreatic cancer
- if at head (jaundiced) then abdominal US preferred
- If in body or tail (non jaundiced) then abdominal CT preferred
what are the drugs of choice for stabilizing bony metastatic lesions to prevent hypercalcemia of malignancy and pathologic fractures
Bisphosphonates
most common histologic lesion in diabetic nephropathy
- diffuse glomeruloscerosis
- Nodular glomerulosclerosis (eith kemmelsteil-Wilson nodules) is pathognomonic
Parenchymal atrophy due to calyceal dilation occurs in what renal pathology
obstructive nephropathy
What is Dressler syndrome
this is post myocardial pericarditis usually 1-6 weeks after MI
Describe uremic induced pericarditis
-Serum BUN usually >60 but degree of pericarditis does not always correlate with decree of elevation
describe EKG findings of uremic pericarditis
-does NOT usually present with the classic ECG finding of pericarditis (e.g. diffuse ST-segment elevation) as the inflammatory cells do not penetrate the myocardium
what are generally used as first line agents for most patients with idiopathic or acute viral pericarditis
- NSAIDS
- and/or colchicine
treatment of uremic pericarditis
hemodialysis leads to rapid resolution of chest pain and reduces the size of any associated pericardial effusion
In a patient with facial nerve palsy, it is very important to assess for symmetry by raising their eyebrows due to bilateral upper-motor-neuron innervation to the forehead. Forehead muscle sparing is suggestive of what
an intracranial lesion and would warrant brain imaging to evaluate for ischemia or tumors
In a patient with suspected Acute urinary retention who is unable to void, the diagnosis is confirmed by bladder US demonstrating how much urine
> 300 ml
patient with jaundice and icterus with a positive urine bilirubin assay, consistent with a buildup of conjugated bilirubin. also normal transaminases and normal alkaline phosphatase.
Rotor’s syndrome . . defect in hepatic secretion of conjugated bilirubin into biliary system
A positive urine bilirubin assay is typically indicative of what
buildup of CONJUGATED bilirubin
What is the cause of erectile dysfunction in a patient who still gets normal nonsexual nocturnal erections
Psychogenic
-Normal nocturnal erections indicate intact vascular and nerve function in the penis and are usually absent in patients with organic causes
CT/MRI findings of a butterfly appearance with central necrosis of brain is classic for what
Glioblastoma multiforme
Patients with low grade astrocytoma usually present with what
seizures
What is meant by albuminocytologic dissociation found on LP
- elevated CSF protein with a normal cell count
- characteristic of Guillain-Barre
presence of 14-3-3 protein in the CSF indicates what?
a neurodegenerative prion disease (e.g. Creutzfeldt-Jakob disease)
Secondary amyloidosis can be secondary to chronic inflammatory conditions like what
- RA
- Chronic infections (e.g. bronchiectasis. Tb, osteomyelitis)
- IBD
- Malignancy
- Vasculitis
Clinical presentation of Secondary amyloidosis
- Asymptomatic Proteinuria or nephrotic syndrome
- Cardiomyopathy with heart failure
- Hepatomegaly
- Mixed sensory and motor peripheral neuropathy and/or autonomic neuropathy
- Visible organ enlargement (e.g. macroglossia)
- Bleeding diathesis
- Waxy thickening, easy bruising of skin
how is diagnosis of secondary amyloidosis made
Abdominal fat pad aspiration biopsy
what is approved for both treatment and prophylaxis of Amyloidosis
Colchicine
presence of nephrotic syndrome with palpable kidneys, hepatomegaly and ventricular hypertrophy (suggested by an audible fourth heart sound) in the setting of chronic inflammatory disease is suggestive of what
secondary amyoidosis (AA)
What medication do you hold prior to cardiac stress testing?
- Hold for 48 hours: beta blockers, CCB, nitrates
- HOld for 48 hours prior to vasodilator stress test: Dipyridmole
- Hold for 12 hours prior to vasodilator stress: caffeine
- CONTINUE: ACEI’s, ARBs, digoxin, statins, diuretics
possible effect of diuretics on stress test
- Diuretics do not directly affect the accuracy of stress testing
- However, diuretic-induced hypokalemia (potassium <3) can cause ST-segment depression and false positive results on exercise stress testing
mechanism causing edema from CCB
-preferential dilation of precapillary vessels (arteriolar dilation)
Combining a CCB with what medication can significantly lower the risk of CCB associated peripheral edema compared with CCB monotherapy
ACEI’s
Electrical Alternans is when the amplitudes of the QRS complexes vary from beat to beat. It is fairly specific for what
pericardial effusion
Clinical features of Stevens Johnson/Toxic epidermal necrolysis
- 4-28 days after exposure to trigger (2 days after repeat exposure)
- Acute influenza-like prodrome
- Rapid onset erythematous macules, vesicles, bullae
- Necrosis and sloughing of epidermis
- MUCOSAL involvement
Drugs that can cause SJS/TEN
- Allopurinol
- Antibiotics (e.g. sulfonamides)
- Anticonvulsants
- NSAIDS (e.g. piroxicam)
- Sulfasalazine
What are some common triggers of SJS/TEN that are NOT drugs
- Mycoplasma pneumoniae
- Vaccination
- Graft-vs-host dx
Describe difference b/t SJS and TEN
- Continuum of severity
- <10% of body is SJS
- > 30% is TEN
Describe the presentation of Staphylococcal scalded skin syndrome
- Acute exfoliation of skin
- skin is tender and warm, with a sandpaper-like difuse erythematous rash
- bullae, positive Nikolsky’s sign, facial edema, perioral crusting, dehydration
- usually seen in children less than 6
Why is MRI a poor imaging choice for patients with renal insufficiency
-association of nephrogenic dermatopathy with gadolinium administration
Adverse effects of carbamazepine
- N/V
- Leukopenia and aplastic anemia
Aminoglycosides (amikacin) are antibiotics used to treat serious gram-negative infection (e.g. pyelonephritis). . . renal implications?
-They are potentially nephrotoxic and drugs levels and renal function must be monitored closely
What is the primary intervention proven to slow the decline in GFR once azotemia develops . . . reduce progression of diabetic nephropathy
Intensive BP control
Patients with diabetic nephropathy should be treated toward a target blood pressure of what
130/80
Attributable risk percent represents the excess risk in the exposed population that can be attributed to the risk factor. What is the equation
ARP=(RR-1)/RR
How to differentiate b/t pemphigus vulgaris and Bullous pemphigoid
- Mucosal erosions
- antibodies to desmosomes (desmogleins 1 and 3)
- acantholysis
- IgG and C3 deposits in a netlike or “chicken wire” pattern
- Flaccid rather than tense
Use dependence refers to enhanced pharmacologic effects of a drug during faster heart rates and is seen with what antiarrythmics?
- Class I (especially class IC like Fecainide and propafenone)
- Class IV (calcium channel blockers)
