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