UWorld Flashcards
What can you change on vent settings if in resp alkalosis?
- decrease RR if TV is appropriate (6ml/kg of ideal body weight)
What is initial the treatment for PAD?
risk factor modiciation –> smoking cessation, statin, ASA, DM treatment, exercise therapyif claudication
When do you use cilostazol for PAD?
when persistent sx despite risk factor mod and exercise therapy
alternative = can do percutaneous or surgical revascularization
Which meds have mortality benefit in CHF?
- ACE inhibitors
- B Blockers
- ARBs
- spironolactone
What is next step if you suspect post-cholecystectomy syndrome (ab pain/dyspepsia post-op after cholecystectomy)?
do US followed by ERCP/MRCP to establish diagnosis and guide therapy
What is presentation of zinc deficiency? who is at risk?
alopecia, abnormal taste, bullous, pustulous lesions surrounding body orifices, impaired wound healing
at risk: TPN
What is presentation of vit A deficiency?
blindness, dry skin, impaired immunity
What is significance of S3? When is it normal? What pathological states associated?
2/2 rapid turbulent filling of ventricles w/ increased volume
normal in young adults, pregnant
associations: heart failure, restrictive cardiomyopathy, high output states
What is significance of S4? What pathological states associated?
hear after atrial contraction as blood forced into stiff ventricle
associations: ventricular hypertrophy, acute MI, hypertension, AS, hypertrophic cardiomyopathy
What happens to S2 in MI?
paradoxical splitting 2/2 delayed myocardial relaxation
What is next step after you confirm pancreatitis by CT/lipase?
do RUQ US to look for gallstones = more sensitive than CT, gallstones are major cause of pancreatitis
What is treatment of biliary pancreatitis?
do ERCP for extraction of visible common bile duct stone and laparoscopic cholecystectomy prior to discharge to prevent recurrent pancreatitis
What are clinical features of chronic hep C?
- intermittent elevations of transaminases
- non-specific nausea, anorexia, myalgias/arthralgias
What are extra-hepatic manifestations of chronic hep C?
- essential mixed cryoglobulinemia
- membranous glomerulonephritis
- porphyria cutanea tarda, lichen planus
- increased risk of diabetes
What is presentation of porphyria cutanea tarda? associated with what underlying condition?
fragile skin, photosensitivity, vesicles and erosions on dorsum of hands
associated w/ HCV
What is essential mixed cryoglobulinemia? associated with what underlying condition?
circulating immune complexes deposit in small/medium vessls –> low serum complement, palpable purpura, arthralgias, renal complications (membranoproliferative glomerulonephritis)
associated w/ HCV
What is presentation of erythema nodosum? Associated w/ what underlying conditions?
painful nodules on anterior legs
associated w/ strep and TB infections, sarcoid
What is use of ACE inhibitors in MI?
start w/in 24 hrs of MI to prevent remodeling/dilation of ventricle
What are risk fractors for C Diff?
- advanced age
- recent abx (clinda, ceph, FQ)
- hospitaliation
- comorbidity (ESRD, dialyris)
- PPI or H2 antagonist
How do you dx C diff?
stool assay for toxin A/BW
What are complications of long term PPI use?
- cdiff
- impaired Ca absorption –> osteoporosis
- colonization pathogens of upper GI –> higher risk pna
When do you do empiric PPIs for GERD vs go straight to endoscopy?
endoscopy if:
- men > 50 w/ sx 5 yrs
- ca risk factors: tobacco
- alarm sx: dysphagia, odynophagia, wt loss, anemia, GI bleed, recurent vomiting
What underlying condition should you think if you see jejunal ulcer?
ZE
What is pathogenesis of ZE?
gastrin producing tumor – causes parietal cell hyperplasia, stomach acid production is significantly increased.
steatorrhea 2/2 increased stomach acid production inactivates pancreatic enzymes
What are some lab changes in IBD?
- anemia
- elevated ESR
- acute phase reactants
- reactive thrombocytosis
What is the most common primary cardiac tumor? where are they usually located?
myxoma
in L atrium
What are clinical feat of cardiac myxomas?
- constitutional: fever, wt loss, raynaud
- dv: mitral disease, HF, myocardial invasion leading to arrhythmia, heart block
- embolization
- lung invasion cuaseing resp sx
What is acute liver failure (fulminant hepatitis)?
onset of severe liver injury with enecphalopathy and impaired synthetic function (INFR > 1.5) in pt w/o cirrhosis
What do you see in lab on acute liver failure?
worsening PT/INR and bilirubin elevated transaminases (declining AST/ALT can indicated decrease in fucntional liver tissue)
PT = single most important prognostic indicator in ALF
What is next step if you see organized rhythm on cardiac monitor w/o measurable BP or palpable pulse?
start CPR and vasopressor (epinephrine)
What are the reversible causes of asystole/pulseless electrical activity “5Hs and 5Ts”?
- hypovolemia, hypoxia, hydrogen ions (acidosis), hypo/hyperkalemia, hypothermia
- tension pneumo, tamponade, toxins (narcotic, benzos), thrombosis (pulm, coronary), trauma
What is next step if suspect zencker diverticulum?
contrast esophagram
What are sx of zencker diverticulum?
- elderly, particularly men
- dysphagia, regurgitation
- foul smelling breath
- may have palpable diverticula in neck
- at risk for aspiration pna
What is the usual presentation of mitral stenosis?
gradual and progressive worsening dyspnea on exertion, orthopnea, hemoptysis 2/2 pulm edema
eventual backflow of bblood int LA leads to elevated LA and pulm pressures, LA enlargement, leading to lcough/hoarse voice, and displaing L mainstem bronchus
can develop A fib
What should you change about vent if pH 7.42 pO2 105 pCO2 37 with:
FiO2 80%, RR 14 TV 380 PEEP 7?
decrease FiO2 –> goal
How can you distinguish CHF from COPD exacerbation?
BNP = elevated in CHF
What are indications for oxygen therapy in COPD?
PaO2 55
evidence of cor pulmonale
What is clinical presentation of esophagel perforation?
chest and abdominal pain, systemic sx
subcutaneus emphysema in neck
hamman sign = crunching on chest auscultation
How do you dx esophageal performation?
CXR/CT: wide mediastinum, pnuemomediastinum, pneumothorax, air around paraspinal muscle
CT: esophageal wall thickening, mediastinal air fluid level
water soluble contrast esophagogram: leave at perforation site
What do you see on pleural fluid analysis in boerhaave syndrome?
exudate, low pH, very high amylase (>2500)
What clinical feat/hx should make you think GI bleed is 2/2 angiodysplasia?
- recurrent painless bleed in > 60yo
hx of aortic stenosis or ESRD
What are the 3 screening strategies for colon cancer?
routine for eeryone > 50
- FOBT annually
- flexible sigmoidoscopy q5 + FOBT q3
- colonoscopy q10
What patients should begin screening for colon cancer earlier than 50?
if affected first degree relative, start screening at age 40 or 10 yrs before the age of the relatives diagnosis
What dx should you think if episodes of dysphagia, regurgitation +/- chest pain precipitated by emotional stress? next dx step?
diffuse esophageal spasm
next: do manometry –> repetitive non-peristaltic high amplitude contractions
What is next step in pt with upper GI bleed w/ depressed level of consciousness and ongoing hematemesis?
- 2 large bore IVs
- fluid resuscitation
- type and screen
- intubation if neeeded
do endoscopy w/ band ligation after pt is stabilizaed and intubated
When should you suspect 2ndary hypertension like renal artery stenosis?
- systolic-diastolic abdominal bruit
- hx of atherosclerosis
What should you think if displaced apical impulse, holosystolic murmur, and 3rd heart sound? What is MC etiology?
chronic severe MR
MC = 2/2 MVP from myxomatous degeneration of mitral valve leaflets
When is carotid endarterecetomy recommended?
- symptomatic w/ stenosis 70-99%
- asymptomatic 60-99
What is definition of pulmonary htn?
PA pressure > 25 or > 30 w/ exercise
What meds increase survival in CHF?
ACEi, ARBs, BBlockers, spironolactone
How do you define orthostatic hypotension?
- postrual decrease in BP by 20 systolic or 10 diastolic
What should you do if pt with symptomatic 3rd degree (complete) AV block?
temporary pacemaker insertion while working up and correcting reversible causes
if no reversible cause, need permanent pacing
What are reversible causes of 3rd degree heart block?
- myocardial ischemia
- increased vagal tone
- metabolic (hyper K)
- ddrugs (Bblocker, CCB)
What signs in post-op patient should make you think massive PE?
- hypotension
- JVD
- new onset R BBB (sx of acute R heat strain)
What is the etiology of isolated systolic hypertension in elderly? tx?
2/2 decreased elasticity of arterial wall
tx: monotherapy with low dose thiazie, ACEi, or long acting CCB
What are sx of chronic venous insufficiency?
B/L lower extremity pitting edema, varicose veins, venous ulcer
What is elevated JVD?
> 3
What are sx of chronic venous insufficiency?
leg discomfort, pain, swelling worse with prolonged standing, varicose veins, pitting edema, skin discoloration, ulcers
What is treatment for chronic venous insufficiency?
leg elevation, exercise, compression stockings
What should you think if palpable mass in epigastrum 4 wks after acute pancreatitis? Dx? Tx?
likely pancreatic pseudocyst
dx: US
tx: resolves spontaneoulsy, drainage if persists > 6 wks, >5cm diameter, or secondarily infected
What are the 3 categories of causes of hypertension and hypokalemia?
- secondary hyperaldosteronism
- primary hyperaldosteronism
- non-aldosterone causes
What is the mech of action of aldosterone?
- increases Na reabsorption, K secretion, H secretion
- Na reabsorption leads to H2O reabsorption
- hypokalemia increases renal HCo3 resorption –> metabolic alkalosis
What are sx of conn syndrome?
hypertension, mild hypernatremia, hypoK, metabolic alkalosis
What happens to plasma Ca when high pH (ex. resp alkalosis)?
H+ displaced from albumin so more Ca bound to albumin
- higher Ca bound albumin
- lower ionized free Ca
What happens to PaO2/PaCo2/pH in PE?
respiratory alkalosis –> low PaO2 and PaCO2, high pH, elevated A-a gradient
What is pathophys of diabetic nephropathy? best intervention to reduce progression?
hyperfiltration and microalbuminuria –> macroproteinuria and hypertension
intensive BP control = primary intervention to slow decline of GFR, goal BP 130/80 if DM w/ nephropathy
tx = ACEi and ARBs
How can you distinguish familial hypocalciuric hypercalcemia from primary hyperparathyroidism?
hypocalciuric hypercalcemia = low urine Ca
hyper PTH = high urine Ca
How do you dx primary hyperparathyroidism?
- hypercalcemia w/ high or normal PTH
- 24 hr urine Ca > 250
- urine Ca/cr > 0.02
Which pts with primary hyperparathyroidism should get surgical removal?
- serum ca > 1 mg/dl above ULN
- age
What is the effect of Mg on Ca?
low magnesium –> results in decrease PTH secretion –> low Ca
What are common causes of hypo-Ca with high PTH?
vit D deficiency
CKD
What is presentation of glucagonoma?
necrolytic migratory erythema [erythmatous papules on face, perineum, extremities] DM [mild, easily controlled] GI sx [diarrhea, anorexia] wt loss associated w/ venous thrombosis
What is presentation of gastrinoma?
upper GI pain [ulcers], diarrhea, anemia, wt loss
What is presentation of carcinoid syndrome?
diarrhea, wt loss, episodic flushing w/ hypotension
When should you work up hypogonadotropic hypogonadism for secondary cause?
- headaches
- testosterone
What type of CA most associated with ectopic ACTH? How are they different?
small cell lung cancer
= rapid high ACTH –> hypertension, hypokalemia, met alkalosis, hyperpigmentation
carcinoids (bronchial, pancreatic, thymus)
= slow growing –> more characteristic cushing syndrome
Why do ACTH secreting tumors cause effects of mineralcortioids?
in excess –> bypass enzyme 11 beta hydroxyl dehydrogenase and can have action on the minerlaocorticoid receptors
What are criteria for metabolic syndrome?
- ab obesity (M > 40in, W > 35 in)
- fasting gluc > 100-110
- BP > 130/80
- TG > 150
- HDL M
What are some complications of untreated hyperthyroid?
rapid bone loss from increased osteoclast activity cardiac arrhythmias (AFib)
What should you order next if hypercalcemia w/ hypoPTH?
- measure PTHrP
- measure 25OHD
- SPEP/UPEP
- 1,25 OHD
What should you think about if hypercalcemia > 13?
think malignancy
What metabolic abnormalities are associated w/ hypothyroid?
hyperlipidemia
hyponatremia
asx increase CK, AST/ALT
What is secondary hypothyroidism?
hypothyroidism 2/2 low TSH from pituitary
What should you think if sx of hypothyroid w/ high thyroid hromones and normal/elevated TSH?
generalized resistancen to thyroid hormones
How does thyrotoxic myopathy present?
proximal muscle atrophy/weakness, low amplitude tremor, normal/increased DTR
What should you think if patient’s urine turns dark and stains prussian blue after infection/med?
G6PD deficiency –> oxidative stress leading to hemolysis
What is the presentation of MEN1?
- primary hyperparathyroidism
- enteropancreatic tumor
- pituitary tumor
What is the presentation of MEN2A?
- medullary thryoid carcinoma
- pheo
- parathyroid hyperplasia
What is the presentation of MEN2B?
- medullary thryoid cancer
- pheo
- mucosal/intestinal neuroms
marfanoid habitus
Which MEN syndrome is associated w/ marfanoid habitus? which tumors?
MEN2B
- MTC
- pheo
- mucosal/intestinal neuromas
What are the adverse effects of methimazole?
agranulocytosis
1st trimester teratogen
cholestasis
What are the adverse effects of propylthiouracil?
agranulocytosis
hepatic failure
ANCA associated vasculitis
What should you think if decrease T3 with normal T4/TSH?
euthyroid sick syndrome = ocurs in pts with severe illness
will recover with recovery of illness, do not need to treat
What lab values do you see in osteomalacia?
- increased alk phos, PTH
- decreased serum Ca, phos, urine Ca, 25OHD
What do bilateral symmetric pseudofractures suggest?
osteomalacia
What antibodies associated w/ hashimoto?
anti-thyroid peroxidase and anti-thyroglobulin antibodies
What are the hemodynamic effects of thryotoxicosis leading to hypertension?
- systolic hypertension and increased pulse pressure
- increased contractility and cardiac output
- decreased systemic vascular resistance
- increased myocardial oxygen demand
What is the mech of thyrotoxicosis causing angina?
coronary vasospasm
What is the effect of diabetic autonomic neuropathy on GU?
decreased ability to sense full bladder –> incomplete emptying and decreased urination
eventually have recurrent UTI and overflow incontinence (dribbling, poor urinary stream)
What is the next best step if pt with asymptomatic hypercalcemia?
PTH level
– want to distinguish between PTH mediated vs non-PTH (malignancy, vit D, hyperthyroid)
What is likely etiology of thryotoxicosis w/ reduced thryoid uptake?
subactue lymphocytic (painless) thyroiditis
–> leakage of thryoid hormones into circulation 2/2 inflammatory damage of thyroid follicles
other causes:
- subacute granulomatous thryoiditis
- iodine-induced thryoid toxicosis
- levothyroixine OD
- struma ovarii
What is the etiology of ED 2/2 urethral injury?
nerve injury
What levels of prolactin, TSH, LH, FSH do you see in symptomatic prolactinoma?
prolactin > 200
normal TSH
low FSH/LH
What are effects of metformin? complicatoin?
weight netural, low risk hypoglycemia
lactic acidosis = complication
What are side effects of sulfonylureas?
weight gain and hypoglycemia
add when pts have failure w/ metformin
What are side effects of thiazolidinediones (pioglitazone)?
weight gain, edema, CHF, bone fracture, bladder cancer
Which DM meds can be used in renal insufficiency?
pioglitazone (thiazolidinediones)
sitagliptin (DPP-IV inhibitors)
Which DM meds good for wt loss?
GLP1 receptor agonists (exenatide, liraglutide)
add as 2nd agent for metformin failure
What are the first get H1 antihistamines? side effects?
diphenhydramine, chlorpheniramien, doxepin, hydroxyzine
lots of anticholinergic effects
What is the mech of diphenhydramine on bladder?
causes urinary retention and dysuria from detrusor inactivity
What is the presentation of menieres disease?
episodoes of vertigo lasting
What is therapy for menieres disease?
initially low salt diet, avoid triggers
What is the next step if have high T4, low TSH, no sx of graves (goiter, opthalmopathy) low iodine uptake?
measure serum thyroglobulin
low –> exogenous hormone
high –> thyroiditis, iodine exposure
What is the equation for number needed to treat?
1/Absolute risk reduction
What is the tx of primary raynaud phenomenon?
CCB (amlodipine) for persistent symptoms
What is the tx of secondary raynauds?
CCB for persistent sx, ASA for at risk for digital ulceration
What are features of primary raynaud?
F
How do you distinguish asthma vs copd?
positive bronchodilator response (>12% increase in FEV1) with normal DLco
What should you suspect if chronic scar develops into nonhealing painless bleeding ulcer?
squamous cell carcinoma
What are side effects of TMP-SMX?
rash, neutropenia, hyperkalemia, high transaminases
What are alternative regimens for PCP others than TMP-SMX?
- pentamidine (IV)
- atovaquone (PO)
- trimethoprim + dapsone (PO)
- clinda (IV/PO) + primaquind (PO)
What are side effects of primaquine?
methemoglobinemia hemolytic anemia (check for g6pd deficiency)
What are indications for adjunctive steroid use for PCP?
- PaO2 35
What are guidelines for ventialtion in ARDS?
- low TV [6-8 ml/kg]
- inspiratory plateau airway p
What is the pathophysiology of ARDS?
- imparied gas exchange
- decreased lung compliance
- increased pulm artery pressure
PaO2/FiO2 indicates degree of severity,
usually
When does ventricular aneurysm occur after MI? presentation?
5 days to 3 mo after MI
presents with:
- persistent ST elevation after recent MI
- deep Q waves in sam leads
- progressive LV enlargement –> HF, mitral regurg
How/when does acute pericarditis present after MI?
- acute pericarditis presents firs several days
- sx: pleuritic/positional CP, pericardial friciton rub, diffuse ST elevation
How/when does papillary muscle rupture present after MI?
- 2-7 days after MI
- life threatening, severe mitral regurg leading to hypotension and pulm edema, does not typically cause persistent ST elevation on EKG
What is presentation of pericardial effusion?
low voltage QRS and electircal alternanas on EKG
sx of tamponade (dyspnea, hypotension, pulsus paradoxus, elevated JP)
What are the recommended vaccines for chronic liver disease?
- Tdap then Td every 10 yrs
- influenza annualy
- PPSV23 1x then at 65 yo revaccinate with PCV13 then PPSV23
- hep A
- hep B
What arrhythmia associated w/ digitalis tox?
atrial tachycardia w/ AV block
[increases ectopy in atria/ventricles leading to atrial tach]
- HR 150-250
- p present but different from normal
What is the treatment for fibromuscular dysplasia?
percutaneous angioplasty with stent placement
What is treatment of scabies?
topical permethrin 5% or oral ivermectin
What is next step if pt with hematochezia and no actie upper GI bleed, colonoscopy no source identified?
labeled erytherocyte scintigraphy (tagged RBC)
if pos –> do repeat colonoscopy or angiography
if negative –> do upper endoscopy with push enteroscopy to evaluate small bowel
What are the mos common causes of acute lower GI bleed > 50?
diverticulosis, angiodysplasia, ischemia, infectious, neoplasm
In order what should you give to a patient presenting wtih non-ketotic hyperglycemic coma?
- NS, then replace w/ .45% saline
What are two major products of house fire? tx?
- cyanide –> hydroxyocobalamin or Na thiosulfate
- CO
What is methemoglobinemia?
formed by exposure to dapsone/nitrates/anesthetics which xoide Fe2+ to Fe3_ in hgb, unable to bind O2
What happens in anaphylactic blood transfusion reaction?
- rapid onset shock, angioedema/urticaria, resp distress/wheezing
- w/in seconds to min of transfusion
- due to recipient anti-IgA antibodies [in IgA deficient pt]
What happens in tranfusion related acute lung injury?
- resp distress, signs of noncardiogenic pulm edema
- w/in 6 hrs of transfusion
- due to donor anti-leukocyte antibodies
What happens in primary hypotension reaction of transfusion?
- transient hypotension in pts taking ACEis
- occurs w/in minutes of transfusion
- due to bradykinin in blood products (normally degraded by ACE)
What is etiology/presentation of cutaneous larva migrans?
due to infective stage larva of ancyclostoma braziliense
sx: initially multiple pruritic erythematous papules at site of larval entry, then severely pruritic, elevated, serpiginous red brown lesions on skin creeping up l=extremity
What should you do if dog/cat bite from animal with no rabies vaccine?
if available for quarantine: observe for 10 days and no PEP if animal healthy
if can’t quarantine: test animal if possible, start PEP and discontinue if rabies test negative
What is complication of temporal arteritis?
aortic aneurysm
pt should have serial CXR
What is presentation/ tx for hepatorenal syndrome?
hepatorenal: cirrhosis w/ renal failure that does not respond to volume resuscitation
tx: liver transplantation
What is presentation of peptic strictures? risk factors?
present: symmetric/circumferential narrowing of esophagus w/ dysphagia for solids but no wt loss
etiolgoy: chronic GERD, radiation, systemic sclerosis, caustic ingesionts
What is the etiology of parasthesia after getting blood transfusions?
citrate in stored blood chelastes Ca and Meg –> reduces their levels –> parasthesias
What bug is filamentous, aerobic, gram positive branching rod that is partially acid fast? tx?
nocardia
tx: TMP-SMX
What bug is filamentous, gram positive, non-aerobic, not acid fast? tx?
actinomyces
tx: penicillin G
Where does nocardia infect?
immunoompromised –> systemic sx, lung nodules, brain abscess causing seizures
What bug should you think if immune compromised pt presents with: cutaneous exophytic papules and visceral angioma-like blood vessel growths that are prone to hemorrhage?
bartonella
What are some forms of selection biases?
- sampling bias (study pop different from target pop)
- nonresponse bias (high nonresponse rate to survey)
- berkson bias (disease studied using only hospital-based pts)
- prevalence bias (exposure happens long before disease assessment, miss pts that die early or recover)
- attrition bias
What are some forms of observation bias?
- recall bias (subjects w/ neg outcome more likely to report certain exposures than control)
- observer bias (misclassify data 2/2 differences in interpretation)
- reporting bias (over/under report exposure hx due to perceived social stigma)
- surveillance/detection bias (risk causes increased monitoring in exposed vs unexposed group, higher prob of identifying diease
Who is at risk for warfarin skin necrosis?
pts w/ underlying protein C deficiency
What type of BM cancer w WBCs w/ strong acid phosphatase rxn not inhibited by tartrate and CD11c?
hairy cell leukemia
What to cytochemical features of hairy cell leukemia?
- tartrate-resistant acid phosphatase stain
- CD11c marker
What type of ulcer pain gets better w/ food?
duodenal ulcer –> better w/ food b/c buffered, worse 2-5 hrs after meals, on empty stomach, or at night
What should you do next if find a solitary pulm nodule (
if previous CXR shows stability ver 2-3 yrs –> no further testing necessary = likely benign hamartoma
if no previous CXR or CXR w/ no nodule –> do CT
What are characteristics of pulm nodule that make you think cancer?
larger size, low density, spiculated borders, eccentric calcification
What are some meds that can cause drug induced esophagitis?
- tetracyclines
- ASA/NSAIDs
- alendronate
- KCL
- quinidine
- Fe
What type of vasculitis presents with glomerulonephritis + upper and lower resp tract disease? How dx?
wegeners (granulomatosis w/ polyangiitis)
dx: c-ANCA + tissue bx
tx: high dose steroids
What should you think if pt has microcytic anemia not responsive to Fe supplmenetation?
thalassemia
- if mediteranea –> B thal minor
What are typical presentations of sarcoid?
- pulm: dyspnea + dry cough
- skin: erythema nodosum
- eyes: uveitis
What are likely etiologies if syncope w/ exertion or during exercise?
aortic stenosis, hypertrophic cardiomyopathy, anomalous coronary arteries
What is likely etiology of syncope w/ hx of CAD/MI/cardiomyopathy or reduced EF?
ventricular arrhythmia
What is likely etiology of syncope w/ sinus pauses on monitor, prolonged PR or long WRS?
sick sinus syndrome, bradyarrhythmia, or AV block
What metabolic alteration typically w/ vomiting?
hypochloremic metabolic alkalosis w/ hypokalemia 2/2 GI loss of H/Cl/K
What is significance of ankle-brachial index?
ratio of SBP at ankle to SBP at arm
normal = 0.9-1.3
ABI > 1.3 = noncompressible vessel = severe disease
ABI
What is biggest risk factor for peripheral vascular disease?
stop smoking
What does BUN/Cr ratio > 20 suggest?
prerenal cause of azotemia
When should you stop metformin in a diabetic?
- stop in acutely ill pt w/ acute renal failure, liver failure, orsepsis –> increases risk of lactic acidosis
What is mech of HIT?
heparin-platelet-PF4 antibody complex removed by splenic mcrophages –> activated adjacent platelets to release procoagulants
= get thrombocytopenia but higher risk of thrombus
What is preferred anticoagulation for pt w/ DVT and severe renal insufficiency (GFR
unfractionated heparin preferred over LMWH (enoxaparin), direct factor X inhibitors (fondaparinux IM, rivaroxaban PO)
What should you think if adult presents w/ fever, conjuncitivitis, coryza, cervical lymphadenopathy, blanching erythematous maculopapular rash that spreads from head down body, polyarthralgias? dx? tx?
rubella = german measles
dx: PCR, acute/convalescent serology for anti-rubella IgM/IgG
tx: supportive
How does presentation of measles differ from rubella?
measles: fever higher (>40), more gradual spread of rash over days, no arthritis, less posterior cervical lymphadenopathy
What is porcelain gallbladder? Tx? associated risks?
calcium laden gallbladder 2/2 chronic cholecystitis
associated w/ increased risk gallbladder carcinoma
tx: requires surgical resection
What are signs of restrictive cardiomyopathy?
- primarily diastolic dysfunction –> HF w/ only mild systolic dysfunction on echo
- normal LV volume
- normal or symmetrically thickened walls
What is likely dx if pt w/ decreased passive and active ROM of shoulder, more stiffness than pain?
adhesive capsulitis = frozen shoulder
What is likely dx if pt w/ anterior should pain, pain w/ lifting/carrying/overhead reach, less commonly weakness?
biceps tendinopathy/ rupture
What is likely dx if pain w/ abduction, external rotation, subacromial tenderness, normal ROM w/ positive impingement tests?
rotator cuff impingement or tendinopathy
if weakness w/ external rotation –> think rotator cuff tera
What should you do if pt on INH develops AST/ALT elevation w/o any sx of hepatitis?
nothing –> usualy yoccurs inf irst few weeks of treatment, self-limited and will resolved on its own
what antihypertensive is associated w/ peripheral edema side effect? how do you reduce the effect?
dihydropyridine CCBs [amlodipine/nifedipine]
reduces if add ACEI or ARB
What should you make sure to work up in young person w/ systemic hyeprtension?
- coarctation of aorta
- -> do B/L PBs to assess for differences in presure
- -> check for brachial-femoral delay
What dx studies in aortic coarctation?
EKG w/ LV hypertrophy
CXR w/ notching 3rd-8th ribs, 3 sign from aortic indentation
echo = dx confirmation
How does aortic coarctation present?
asx htn = most common
also can have CP, claudication, HA, epistaxis, HF, aortic dissection
What is tx for aortic coarctation?
balloon angioplasty +/- stent
What does it mean if dark urine with high bilirubin but not urobilinogen?
conjugated hyperbilirubinemia
[unconjugated is insoluble, would have urobilinogen in urine]
What is the best test for polymyositis dx?
muscle biopsy
How does polymyositis present?
- slowly progressive proximal weakness of lower extremities
- diffuclty going up/down stairs or rising from seated position
When do you treat lyme disease w/ PO doxycycline vs IV ceftriaxone?
doxy: early localized [days - 1mo after bite]: erythema migrans, fatigue/malaise/mild HA/myalgias
ceftriaxone: eraly disseminated or late/chronic [wks - mos to yrs after bite] – carditis, neuro sx, migratory arthralgias, conjunctivitis
What lab findings in antiphosphlipid syndrome?
- long PTT
What is medical tx for prolactinoma?
dopamine agonist [bromocriptine or cabergoline]
if does not respond –> consider surgery –> radiotherapy
What is the effect of hyperinflation in COPD?
increases work of breathing b/c increases elastic recoil pressure
What is next step if pt on cocaine presents w/ CP?
benzos for BP + anxiety, ASA, nitro/CCB for pain
Why are Bblockers contrainidicated in cocaine induced MI?
can cause unopposed alpha stimulation and worsen coronary vasoconstriction
What is interstitial cystitis?
painful bladder syndrome = chronic painful bladder/pelvic pain exacerbated by bladder filling and relieved by voiding
sx: iurinary urgency/frequency, chronic pelvic pain exacerbated by exercise, sex, alcohol
How do you dx interstitial cystitis?
bladder pain w/ no other attributatble cause for > 6 wks w/ normal urinalysis
What is likely underlying etiology if pt w/ nephrotic syndrome w/ palpable kidneys, hepatomegaly, ventricular hypertrophy in setting of chronic inflammation?
secondary amyloidosis
tx: treat underlying, also give colchicine
What does S4 suggest?
ventricular hypertrophy
What is presentation of central retinal artery occlusion?
painless loss of monocular vision w/ diffuse ischemic retinal whitening and cherry red spots
What is tx for central retinal artery occlusion?
immediate: ocular massage to dislodge embolus plus high flow O2 or carbogen therapy
What is the most common source of PE?
embolic in proximal deep veins [iliofemoral]
What is presentation of ADPKD?
multiple renal cysts, intermittent flank pain, hematuria, UTIs, nephrolithiasis, hypertension –> renal failure
What is meniere’s disease? presentation?
accumulation of endolymph in inner ear
sx: vertigo, ear fullness, hearing loss
What is goal INR in anticoagulation w/ warfarin?
INR goal 2.5 w/ range 2.0-3.0 okay
What is next step if suspect hepatic encephalopathy?
get serum NH3 –> nonspecific but helps support dx
What are the 4 stages of hepatic encephalopathy?
stage 1: hypersomnia/insomnia, impaired cognition, confusion, tremor, asterixis
stage 2: lethargy, confusion, difficutly writing, slurred speech
stage 3: marked confusion, sleeping but arousable
stage 4: stupor or coma
How do you distinguish insulinoma vs excess sulfonylurea or insulin use?
insulinoma: high insulin, high c peptide and proinsulin
sulfonylurea: high insulin ad C peptide but often prosinsulin
What is tx of caustic ingestion?
- secure airway, breathing, circulation
- removed contaminated clothing and visible chemicals
- CXR if resp sx
- endoscopy w/in 24 hrs
do not use charcoal, steroids, emetics, or acid neutralization
What can you do to prevent contrast induced nephropathy in pt w/ renal insufficiency?
use non-ionic contrast agen, IV hydration, acetylcysteine
What is the treatment for febrile neutropenia?
start empiric broad spectrum abx as soon as blood culutres
empirically start monotherapy w/ anti-psueodmonal [cefepime, meropenem, piperacillin tazobactam]
What is likely dx if pt w/ HIV presents with proteinuria, rapid renal failure, and normal size kidneys?
focal and segmental glomerulosclerosis = HIV related nephropathy
What is the presentation of allergic conjunctivitis?
aucte hypersentivity rxn –> episodic itching, hyperemia, watery tearing, edema of conjunctiva and eyelids, gritty sensation
hx of atopic d/o, usually subsided in 24 hr
What is presentation of anterior uveitis?
significant pain, miosis, photophobia, +/- visual loss, unlikely to have gritty sensation/itching
What is presentation of endophthalmitis?
invasive infection of globe 2/2 disruption of external surface –> conjunctival irritation, purulent haziness of ocular contents, layerign-out of pus in anterior chamber
What is presentation of orbital cellulitis?
erythema, edem,a tenderness of eyelids, w/ impaired EOM
What do you see on kidney biopsy in hypertensive nephorpathy?
arteriosclerotic lesions of afferent/efferent renal arterioles and glomerular capillary tufts
What do you see on kidney biopsy in DM nephropathy?
increased extracellular matrix, BM thickening, mesangial expansion, fibrosis
What is presentation of malignant otitis externa?
ear discharge and severe ear pain, granulation tissue in ear canal, hx DM
What types of Ca associated w/ PTHrP production?
- squamous cell Ca of lung/ehad/neck/esophagus
- renal/bladder
- ovarian/endometrial
- breast
What is mech of bone metastasis causing hypercalcemia?
tumor cells induce cytokine release that activate osteoclasts
What are the major side effects of cyclosporine?
- nephrotoxicity –> high K
- hypertension
- neurotoxicity/tremor
- glucose intolerance
- gingival hypertrophy
- hirsuitism
What is mech of action cyclopsorine?
calcineurin inhibitor = inhibits transcription of IL-2
Which immunosuppressive causes hirsuitism and gum hypertrophy?
cyclosporine
What are the main side effects of tacrolimus?
nephrotoxicity, hyperkalemia
What is mech of action azathrioprine?
purine analog, converted to 6-mercaptopurine
What are toxicities of azathioprine?
dose related diarrhea, leukopenia, hepatotoxicity
What is major side effect of mycophenolate?
BM suppression
What is presentation of BBlocker overdose?
bradycardia AV block hypotension diffuse wheezing hypoglycemia delirium seizures leading to cardiogenic shock
What is treatment for B Blocker overdose?
- 1st give IVF, atropine
- if refractory, give glucagon
What should you suspect if pt w/ nephropathy presents w/ sudden onset flank pain and gross hematuria?
renal vein thrombosis = higher risk of thrombosis 2/2 loss of antithrombin III
Which type of nephropathy is most associated w/ renal vein thrombosis?
membranous glomerulopathy
What are CSF characteristics of cryptococcal meningitis?
- elevated opening pressure
- low WBC (
What CD4 count puts you at risk for cryptococcal meningitis?
CD4
What is tx for cryptococcal meningitis?
amphotericine B and flucytosine VI for 2 wks then fluconazole x 8 wks
+/- serial lumbar punctures to reduce ICP
hold ARVs for 2 wks after start antifungal
What should you think if pt presents w/ polyarthralgia, tenosynovitis (pain along tendon sheeth w/ movement), and painful vesiculopustular skin lesions?
disseminated gonococcal infection
What is next step if pt presents w/ back pain + positive straight-leg raise w/o neurological deficit?
likely disk herniation –> next step = early mobilization + NSAIDs
if pain persists 4-6 wks or progressive neuro deficit –> do MRI or CT /- contrast myelography
What should you suspect if pt presents w/ hypercalcemia, anemia, bone pain/lytic leiosn, and high Cr? Why would they be at increased risk of infection?
suspet multiple myeloma
at increased risk infection b/c total decrease in functional abs and leukopenia as BM filled w/ malignant plasma cells
What should you think if more than 3-4 g/dl difference between total protein and albumin conc?
paraprotein gap = suggestive of MM
What should you think if young healthy man w/ chronic low back pain, worse at night, improved w/ activity and high ESR?
ankylosing spondylitis = progressive stiffness of spine, sacroiliitis, HLA-B27+
What are extra-articular causes of ankylosing spondylitis?
- anterior uveitis
- IBD
- aortic regurg
- restrictive lung dz 2/2 diminished chest wall expansion
What PFT findings in ankylosing spondylitis?
- decreased VC
- decreased TLC
- normal FEV1/FVC
What is tx for giant cell arteritis?
high dose IV steroids
reduces progression of visual complications in affected and unaffected eye, start while awating confirmation of dx
What two pathologies commonly seen w/ analgesic nephropathy?
- papillary necrosis
- chronic tubulointerstitial nephritis
What are UA findings of glomerular damage?
blood + portine
RBC casts, dysmorphic RBC
What is likely dx if proteinuria and hematuria a few days after pharyngitis?
IgA nephropathy
What type of testicular tumor presents w/ hyperestrogenism?
leydig cell tumors –> produce testosterone –>have increased estrogen from aromatase
What is definition of orthostatic hypertension?
drop in SBP > 20 when standW
What is definition of fulminant hepatic failure? tx?
hepatic encephalopathy w/in 8 wks of onset of acute liver failure
tx = only treatment is orthotopic liver transplant
What are etiologies of fulminant hepatic failure?
- acetaminophen
- alcohol
- methamphetamines
- coinfection hep B/D
What should you think if pt w/ hx of smoking presents w/ clubbing and sudden onset join arthropathy?
next step?
hypetrophic osteoarthropathy
often associated w/ lung CA
next: do CXR to r/o malignancy
What is next step of pt w/ sx of polymyalgia rheumatica?
low dose steroids –> do temporal artery biopsy if symptoms – HA, jaw claudication, vision loss
What percent of values w/in 1 SD from mean? 2 SD? 3 SD?
1 SD = 68%
2 SD = 95%
3 SD = 99.7%
What things increase and decrease the murmur of HOCM?
increase: w/ decreased preload –> valsalva, absrupt standing, nictroglycerin
decrease: w/ increase afterload/preload: sustained hand grip, squatting, passive leg raise
What is the murmur of HOCM?
harsh crescendo-descrescendo systolic murmur heard best at apex and L lower sternal border
What is MCC death in pts w/ acromegaly?
cardiovascular –> corohnary heart disease, MI, etc
What is emphysematous cholecystitis?
common form of cholecystitis in elderly DM males
2/2 infection of gallblader wall w/ gas-forming bacteria
What should you think if air fluid levels in gallbladder on XR or US w/ curvilinear gas shadowing in gallbladder?
emphysematous cholecystitis
What is tx for staph abscess of eyelid (stye)?
apply warm compresses
incision and drainage if not resolved in 48 hrs
What should you think if pt w/ AV block and infectious endocarditis?
perivalvular abscess extending into cardiac conduction tissue
What are risk factors for periannular extension of endocarditis?
- IVDU
- aortic valve endocarditis
What are auscultation, tactile fremitus, and percussion findings in consolidation?
- crackles/bronchial breath sounds
- increased tactile fremitus
- dull to percussion
What are auscultation, tactile fremitus, and percussion findings in pleural effusion?
- decreased breath sounds
- decreased tactile fremitus
- dull to percussion
What are acuscultation, tactile fremitus, and percussion findings in COPD?
- decreased breath sounds
- decreased fremitus
- hyperresonant to percussion
What are auscultation, tactile fremitus, and percussion findings in pneumothorax?
- decreased breath sounds
- decreased fremitus
- hyperresonant to percussion
What meds have mortality benefit as secondary prevention in MI?
- ASA
- B blocker
- ACEi
- statin
When do you give clopidogrel in pt w/ MI?
give for 12 mo to all pts w/ unstable angina/NSTEMI
or for 1 mo post-PCI w/ bare metal, 1 yr w/ drug eluding
What is the nature of appendicitis peri-umbilical vs RLQ pain?
peri-umbilical = referred, visceral RLQ = somatic
What is tx if pt w/ acute hep B?
- if unvaccinated: give vaccine and IG
What are AST/ALT changes in acute alcoholic hepatitis?
AST > ALT, usually in 2-300s, rarely exceed 500
What are 3 MCC acute liver failure?
acute viral hepatitis (acetaminophen), acetaminophen tox, ischemic hepatopathy
What is presentation of acute liver failure?
- RUQ pain, pruritis, jaundice, hepatic encephalopathy
high PT, INR > 1.5, AST/ALT > 10x normal, worsening PT/INR
What is pathophysiology of SLE nephritis?
immune complex mediated (thats why you get decreased C3)
Can alpha blocker (doxazosin) and phosphodiesterase inhibitor (sildenafil) be given together?
yes but w/ 4 hours interval to reduce risk of hypotension
When is sildenafil CI?
pts w/ nitrates
What are clinical markers of severe pancreatitis?
age > 75 alcoholism obesity CRP > 150 at 48 hrs increased BUN/cr in first 48 hrs
What is cullen sign?
periumbilical bluish coloration indicating hemoperitoneum in pancreatitis
What is grey-turner sign?
reddish brown coloration around flanks indicating retroperitoneal bleed in pancreatitis
What are wells criteria for pretest probability of PE?
score +3:
- clinical sx DVT
- alternative dx less likely
score + 1.5:
- previous PE/DVT
- HR > 100
- recent surgery or immobilization
score +1:
- hemoptysis
- cancer
do d-dimer
>4 = likely –> do CTA
What are sx of TCA overdose?
CNS depression
hypotension
anticholinergic –> dilated pupils, hyperthermia, intestinal ileus, QRS prolongation
What is tx for TCA overdose?
ABCs and Na bicarb to improve BP, shorten QRS, and prevent arrhythmia
What are manifestations of carcinoid sx?
- flushing, tenalngiectasia
diarrhea, cramping - valve lesions (R>L)
- bronchospasm
How do you dx carcinoid syndrome?
elevated 24hr urine 5HIAA
CT/MRI of abdomen/pelvis to localize
What is tx for carcinoid?
octreotide for sx prior to surgery if liver met
What vitamin needs to be supplemented in carcinoid?
niacin –> get pellagra w/ dermatitis, diarrhea, dementia b/c uses up tryptophan that is required for niacin synthesis
By how much should FEV1 improve after bronchodilator in pt w/ asthma?
by > 12%
How does injection of joint w/ lidocaine differentiate rotator cutt tendonitis from tear/frozen shoulder?
tendonitis – pain/ROM resolved w/ injection
vs others do not
What are the 3 cardinal symptoms of COPD exacerbation?
- increased dyspnea
- increased cough
- increased sputum production
What is the tx for acute COPD exacerbation?
supplemental O2
bronchodilators (albuterol, ipratropium)
systemic steroids
abx IF 2 of 3 cardinal sx [cough, dyspnea, sputum] OR severe exacerbation OR ventilation required
What type of abx for acute COPD exacerbation?
macrolide, FQ, or penicillin/beta lactamase inhibitor
for 3-7 days
What are the 3 tumors associated w/ type 1 MEN?
- parathryoid adenoma
- enteropancreatic tumor
- pituitary tumor
What are the 3 tumors of type 2A MEN?
- meduallry thryoid cancer
- pheo
- parathyroid hyperplasia
What is the mech of nitrates having an anti-angina effect?
systemic vasodilation –> lowers preload and LVEDV –> less wall stress and oxygen demand
What is the pathology in DM nephropathy?
nodular glomerulosclerosis (kimmelstiel wilson nodules)
What genetic condition is associated w/ hyposthenuria?
hyposthenuria = impaired ability to concentrate urine –> have nocturia
seen in sickle cell disease and trait –> 2/2 RBC sickling in vasa rectae of inner medulla
What does S4 suggest?
stiff LV 2/2 restrictive cardiomyopathy or LV hypertrophy from prolonged hypertension
What is likely dx if pt presents w/ muffled voice, deviation of uvula, and unilateral lymphadenopathy in setting of fever/sore throat? tx?
likely peritonsillar abscess complicating tonsillitis
tx: aspiration of abscess and IV abx
How can you distinguish epiglottitis from peritonsillar abscess?
epiglottitis = more distal in airway, would require emergency lrayngoscopy
both present w/ muffed voice and difficulty swalloing
absecess = w/ uniltareal lymphadenopathy and deviation of uvula
What is presentation of behcet’s syndrome?
recurrent oral and genital ulcers, anterior uveitis, skin lesions (erythema nodosum = painful and nodules 2/ areas of hyperpigmentation)
What is the most frequent location of the ectopic foci that cause atrial fibrillation?
pulmonary veins
What is usually the source of foci in atrial flutter?
reentrant circuit around the tricuspid annulus
What is the source of foci in AVNRT?
reentrant circuit formed by 2 separate conducting paths within the AV node,
What is the source of foci in AVRT?
reentrant circuit involing accessory AV bypass tract
What clinical associations w/ FSGS nephrotic syndrome?
- AA, hispanic
- obesity
- HIV
- heroin use
What clinical assocaitions w/ membranous nephropathy?
- adenoCA (breast/lung)
- NSAIDs
- hep B
- SLE
What clinical associations w/ membranoproliferative glomerulonephritis?
- hep B/C
- lipodystrophy
What clinical associations w/ minimal change disease?
- NSAIDs
- lymphoma
What are the 4 main substrates of gluconeogenesis?
alanine
glutamine
lactate
glycerol 3-phosphate
lactate/alanine get turned into pyruvate
What is MCC AR in young adult?
congenital bicuspid aortic valve in developed country
rheumatic heart disease of aortic valve in developing
What is the murmur of HOCM?
harsh crescendo-decrescendo systolic murmur best at apex and LLSB
increases w/ valsalva, standing
When is AR murmur heard loudest?
apply firm pressure w/ diaphragm of stethoscope, pt sit up, lean forward, hold breath in full expiration
What are clinical feat of nocardia infection? tx?
- gram positive partially acid fast, aerobic, filamentous
- present: PNA [similar to TB], CNS, or cutaneous
- tx: TMP-SMX
What is recommended colon cancer screening in UC patients?
yearly colonoscopy beginning 8-10 yrs after dx
How do you distinguish MGUS from MM?
MGUS: absence of anemia, hypercalcemia, lytic lesions, arenal insufficiency
serum monocloncal protein
When do you do abdominal fat bad biopsy?
if concern for amyloidosis
What type of angioma is small, red, cutaneous, common in aging adult?
cherry angioma
What medication for AFib should be avoided in pt w/ underlying restrictive lung disease?
amiodarone –> can cause lung fibrosis
What is tx of SIADH?
fluid restriction
if sx or resistant hyponatremia –> hypertonic saline
What underlying dz associated w/ acanthosis nigricans?
- insulin resistance [DM, PCOS]
- GI malignancy
What underlying dz associated w/ multiple skin tags?
- insulin resistance,
- pregnancy
- crohn [perianal]
What underlying dz associated w/ dermatitis herpetiformis?
celiac
What underlying dz associated w/ severe seborrheic dermatitis?
- HIV
- parkinson
What dz asscoaited w/ prophyria cutanea tarda?
hepatitis C
What is benefit of Na bicarb in TCA toxicity?
use in pts w/ QRS >100msec
increases serum pH –> decreases drug avididity for Na channels
alleviates effect on myocardial Na channels
What is presentation of TCA overdose?
- mental status change seizure resp depression - sinus tach, long PR/QRS/QT arrhythmia anticholinergic
What are presenting sx of addisons dz?
anorexia, fatigue, GI sx, wt loss, hyperpigmentation, decreased BP, vitiligo
hyponatremia 22 volume contraction, hyperkalemia
What are two most common electrolyte abnormalities in primary adrenal insufficiency?
- hyponatremia
- hyperkalemia
What is tx for NMS [fever, muscle rigidity, ANS instability]?
- dantrolene [muscle relaxant]
- bromocriptine [dopamine agonist]
- amantadine [antirial]
What are sx of worsening prognsos in CLL?
- lymphocytosis only = good \+ adenopathy = fair \+ splenomegaly = fair \+ anemia = intermediate \+ thrombocytopenia = poor
What lab findings in alcoholic hepatitis?
- AST/ALT 2
- high GGT, bilirubin, or INR
- leukocytosis, PMNs
- decreased albumin
- elevated ferritin
What defines obesity hypoventilation syndrome?
BMI > 30
daytime hypercapnia (PaCO2 > 45)
- alveolar hypoventilation –> hypoxemia
will have resp acidosis
What is tx for obesity hypoventilation syndrome?
- wt loss
- noninvasive Positive pressure ventilation
What is pathophys of giardia?
adhesive disks and malabsorption
What levels of Ca, phos, Alk phos, urinary hydroxyproline in paget
- normal Ca, phos
- high alk phos
- high urine hydroxyproline and other markers of bone degradation
What bone disease w/ recent hearing loss, bone resorption and sclerosis?
paget disease
What is tx for HIV infected pt w/ positive PPD (>5mm) and negative CXR?
- ppx w/ INH and pyridoxine for 9 months
What is reason for adding pyridoxine to INH treatment/ what should you still monitor?
decrease neuropathy
still monitor LFTs for inh induced hepatitis
What should you think if pt on high dose albuterol develops muscle weakness?
hypokalemia –> check serum electrolytes and do EKG
What are indications for urgen dialysis?
Acidosis: pH 6.5 refractory to medical therapy
Ingestion:
- toxic alcohols
- salicylate
- lithium
- valproate/carbamazepine
Overload:
- volume overload refractory to diuretics
Uremia
- symptomatic encephalopathy, pericarditis, bleeding
What is likely bug if pt w/ secondary bacterial PNA complicating viral infection w/ blood spreaked sputum and midfield lung cavities on CXR?
staph aureus = suggests necrotizing PNA w/ secondary pneumatoceles
What is the pathogenesis of ASA-exacerbated respiratory disease?
pseudoallergic rxn to NSAIds
broncospasm or nasal congestion following ASA ingestion, usually in pts w/ asthma w/ nasal polyps
What is presentation of acute angle closure glaucoma?
acute onset severe eye pain and blurred vision w/ N/V, red eye w/ steamy cornea and moderatley dilated pupil that is non-reactive to light
What is next step if pt w/ fever, back pain, focal spinal tenderness?
- blood culture
- ESR/CRP
- spinal xray
if high ESR/CRP but normal CRAY –> do MRI, then CT guided bone bx
What is presentation of dig toxicity?
N/V, decreased appetite, confusion, weakness
visial sx
renal injury
precipitated by loop diuretic use causing hypokalemia
What is tx of chocie for human bite?
amoxicillin clavulanate –> covers gram positive, negatives, and anaerobes
What is tx for nephrogenic DI 2/2 lithium?
salt restriction and discontinue lithium
What is mech of edema on glomerulonephritis?
decreased GFR and retention of Na and H2O by kidneys
What is the prognosis of alcoholic liver disease if stop drinking?
reversible unless have true cirrhosis w/ regenerative nodules
What does it suggest if pt has mallory bodies in liver?
alcoholic hepatitis
What is MC malignancy in asbestos?
bronchogenic carcinoma
What is presentation of alcoholic ketoacidosis? lab reults?
- slurred speech, unsteady gait, eltered mentation
- high osmolar gap, increased anion gap
What is presentation of methanol ingestion? labs?
visual blurring, central scotomata, afferent pupillary defect
- high osmolar gap, increased AG met acidosis
What is presentation of ehtylene glycol? labs?
flank pain, hematuria, oliguria, CN palsies, tetany
- high osmolar gap, increased AG met acidosis, Ca oxalate crystals in urine
What is presentaiton of isopropyl alcohol ingestion? labs?
CNS depression, disconjugate gaze, absent ciliar reflex
- high osmolar gap, no increased AG, no met acidosis
What is tx for ethylene glycol tox?
fomepizole or ethanol to inhibit alcohol dehydrogenase
What should you think if hemolytic anemia and thrombocytopenia in pt w/ renal failure and neuro sx?
TTP-HUS
tx = plasma exhange
What are clinical sx of atheroembolism (cholesterol embolism) 2/2 cardiac catheterization?
- cutaneous: livdeo reticularis
- cerebral or intestinal ischemia
- AKI
- hollenhorst plaques
What is the pathophysiology of cardiac tamponade?
exagerrated shift of IV septum toward LV –> reduced LV preload, stroke volume, and cardiac output
What are some medications that cause hyperkalemia?
non-selective B blockers ACEi/ARB/k sparing diuretics digitalis cyclosporine heparin NSAID succinylcholine
What is next step if pt on methotrexate for RA has persistent sx for > 6 mo?
- add another nonbiologic [sulfasalazine, hydroxychloroquine]
OR - add biologic [TNF inhibitor]
What is best tx for prinzmetal angina?
eliminate risk factors {smoking]
- CCBs or nitrates
What do you see on CSF w/ HSV encephalitits?
- high WBC (lymphocytes)
- normal glucose
- high protein
What is next best test if suspect diverticulitis?
abdominal CT
What should you think if pt w/ LLQ pain, nausea, vomiting, constipation?
diverticulitis
What should you think if HIV pt w/ severe odynophagia w/o dysphagia and no thrush?
viral esophagitis
- HSV = round ovoid ulcers
- CMV = deep linera ulcers
What is MCC PNA in nursing home pt?
strep pneumo
unless advanced dementia –> worry about aspiration by anaerobes
When is primary percutanesou coronary intervention recommendied in STEMi?
if w/in 12 hrs x onset AND 90 min from first medcal contact to device time
OR 120 min from first medical contact at non-PCI facilitiy (allows transprot time)
When is fibrinolysis used in STEMI?
if w/in 12 hrs of STEMI sx onset and can’t do PCI
What stabilization measures do you do immediately in pt w/ STEMI?
- O2
- full dose ASA
- platelet P2Y12 receptor blocker
- nitroglycerin for pain (don’t use if hypotension, RV infarct)
- BB (CI in HF, bradycardia)
- anticoagulation (heparin)
What is tx of choice to assess glucose tolerance/DM in pt w/ PCOS?
2 hr oral glucose tolerance test
What are 4 dx tests for DM2?
fasting BG >=126
A1C >= 6.5
1 hr OGTT >=200
random plasma gluc >=200 + sx
What are 3 dx tests of prediabetes?
fasting BG 100-125
2 hr OGTT 140-199
A1C 5.7-6.4
What is dx test of choice for pt w/o jaundice to assess if pancreatic Ca? what if they are jaundiced?
contrast enhanced CT of abdomen
ab US = preferred 1st test if jaundice to assess for obstruction
What does S3 suggest?
increased cardiac filling pressure –> seen in CHF
What does high BNP mean?
secreted in response to ventricular stretch and wall tension when cardiac filling pressures are high
What is tx for symptomatic AS?
aortic valve replacement
What are indications for aortic valve replacement?
- symptomatic AS
- severe AS undergoing CABG or other valve surgery
- asx w/ severe AS and either poor LV systolic function, LV hypertrophy > 15, valve area
What is the screening test for syphilis?diagnostic?
screening = VDRL and FTA-ABS = test ofr syphilis exposure
- dx = darkfield microscopy, visualize of spiorchtes
What physical exam findings of lymph node make it more likely to be benign?
less than 1cm, small, ruberry
vs Ca = firm and immobie, >2cm
What medical conditions associated w/ AL amyloidosis?
- multiple myeloma
- waldenstrom macroglobulinemia
What medical conditions associated w/ AA amyloidosis?
chronic inflammatory: RA, IBD
chronic infections: osteomyelitis, TB
What is composition of AL amyloid?
light chains (usually lambda)
What is composition of AA amyloid?
abnormally folded proteins
beta 2 microglobulin, apolipoprotein, or transthyretin
What should you think if pt w/ suddent onset CHF after URI?
likely dilated cardiomyopathy 2/2 vial myocarditis
mC = coxsackie B virus
What screening tests shouly ou do in pt w/ PID?
screen for HIV, syphilis, hep B, cervical Ca, and hep C if hx of IVDU
What neuro sx w/ B12 deficiecny?
loss of proprioception and virbaton sense mostly in lower extremities
What is tx for fibromyalgia?
regular areobic exercise, good sleep hygiene
if need drugs: TCAs (amitriptyline)
What is MC valvular abnormality detected in infective endocarditis?
mitral valve disease (usually MVP w/ coexisting MR)
What is management of compensated cirrhosis? [those who are asx or w/ vague complaints]
- US surveilance for HCC +/- AFP q6mo
- EGD varicies surveilance
What are indications for statin?
- clinically significnat atherosclerotic dz (ACS, MI, angina, etc)
- LDL > 190
- age 40-75 w/ DM
- estimated 10 yr ASCVD risk > 7.5%
What type of statin should you give w/ pt w/ clinically significant atherosclerotic dz?
if 75 - moderate
What type of statin should you give pt w/ LDL > 190?
high intensity statin
What type of statin should you give pt w/ DM age 40-75?
10 yr risk > 7.5 = high
10 yr risk
What markers of para-pneumonic pleural fluid tell you it needs to be drained?
if pH
What can you do in pt w/ neurogenic bladder to reduce risk of recurrent UTI?
intermittent catheterization {vs indwelling = greater risk infection]
What is tx for pt w/ coagulopathy in liver fialure?
FFP [b/c missing all vit K dependent factors]
What is the mech of albuterol?
beta 2 agonist
What sx distinguish between primary HIV and mono?
rash and diarrhea suggest HIV
tonsillar exudate suggests mono
What are side effects of TMP-SMX?
rash, neutropenia, hyperkalemia, elevated LFTs
What is presentation of acute hypersensitivity pneumonitis?
cough, breathelessness, fever, malaise 2/in 4-6 hrs of antigenic exposure
chronically –> wt loss, clubbing, honeycombing
What does urine chloride tell you in metabolic alkalosis?
UCl 20 = volume non-responsive
What is presentation of thyroid storm?
- fever up to 104-106
- tachycardia, hypertension, CHF, cardiac arrhythmia
agistation, delirium, sezirue coma
goiter, lid lag, trmemor
N/V, diarrhea, jaundice
What is tx for thyroid storm?
- Bblocker (propanolol) for drenergic manifestioant
- PTU then iodine solution
- glucocorticoirds to decreased peripheral conversion T4 –> T
What characteristics of low back pain suggest disk dz?
- postive straight leg
- radiculopathy
- neuro deficits
What characterisitcs of low pain pain suggest spinal stenosis?
- pseudoclaudication
- better w/ spine flexion
- worse w/ extension
- older age
What characteristics of low back pain suggest compression fracture?
- older age
- more common in F
- trauma/fall
What charactersitics of low back pain suggest inflammatory?
better w/ activity or exercise
- HLA B27
What characteristics of low back pain suggest met?
hx malignancy, > 50
- worse at night
- wt losss
- cauda equina
What is tx for basal cell carcinoma?
- low risk on trunk or extremities = do electrodessiation and curretage (ED&C)
- higher risk or on face –> do mohs micrographic surgery
What is tx for rosacea?
topical abx such as metronidazole
What are ferritin, TIBC, transferrin sat findings in iron deficiency anemia?
- low ferritin
- high TIBC
- low transferrin sat
What are ferritin, TIBC
- normal/high ferritin
- low TIBC
- normal/low transferrin sat
What is tx for cat scrtch disease?
azithromycin
What does it suggest if pts SBP falls > 10 during inspiration?
pulsus paradoxus = seen in pts w/ cardiac tamponade, asthma, COPD
What is tx for tinea versicolor?
topical ketoconazole, terbinafine, or selenium sulfide
What should you suspect if pt w/ idiopathic thrombocytopenia purpura?
test for hep C and HIV
What tests for dx lactose intolerance?
- positive hydrogen breath test,
- positive stool test for reducing substance
- low stool pH
- increased stool ostmotic gap
What is the common mech of thrombocytopenia in SLE?
immune mediated destruction
What are rome diagnostic criteria for IBS?
- recurrent ab pain/discomfort > 3day/mo for last 3 mo w/ at east 2 of:
- sx improves w/ BM
- change in stool frequency
- change in stool form
What are sx of theophyllnine tox?
CNS stimulation (HA, insomnia, seizrue), GI (N/V), cardiac (arrhythmia)
Which murmurs get softer w/ squatting?
HOCM
MVP
Which murmurs get softer w/ handgrip?
HOCM
AS
How can you use maneuvers to distinguish AS vs HOCM vs MVP?
AS = softer w/ handgrip, valsalva, standing
HOCM = louder w/ valsalva, standing, softer w/ squatting, handgrip
MVP = louder w/ valsalva, standing, not softer w/ handgrip
What are guidelines for hypoNa correction to prevent osmotic demyelination?
increase in Na conc w/ 3% or hypertonic Na at rate no more than 0.5 mEq/L/hr
What shold you suspect in pt w/ hx of mediastinal irradiaton and edema, JVP, hepatomegay?
HF 2/2 constrictive pericarditis
What are 3 clinical findings in constrictive pericarditis?
- hepatojugular reflux
- kussmaul [lack of decrease or increase in JVP on inspiratoin]
- pericardial knowck [mid-diastolic sound]
What do ca oxalate stones look like on radiograph?
envelope shaped
radio-opaque
What is MC type of renal stone? what are some risk factors?
ca oxalate
risks: small bowel dz, surgical reection, chronic diarrhea
Who should get just PPSV23 (not PPSV13) before 65 yo?
chronic heart, lung, liver disease
DM, current smoker, alcoholic
Who should get both PCV13 and PPSV23 before 65?
pt w/ csf leak, sickle cell, asplenia
HIV, malignancy
SKD
What are lab findings in SIADH?
- hypotonic hyponatremia w/ euvolemia
- low plasma osmo (100-150)
- low uric acid
What are lab findings in mineralocorticoid deficiency?
- hypotonic hyponatremia
- hypovolemia
- high K
What is tx for pt w/ AFib who is hemodynamically unstable? stable?
unstable: do immediate cardioversion
stable: rate control – B Blocker
What is tx for pt w/ suspected variceal hemorrhage?
- vol resusctiation
- IV octreotide
- abx
- then urgent endo tehrapy [sclerotherapy or band ligation]
if no further bleeding –> do B Blocker + endoscopic band ligation 1-2 wks later
- if continued bleed –> balloon tamponade –> then TIPS or shunt
What kind of back pain is worse w/ lumbar extension, relieved by flexion?
spinal stenosis
What are some revesrible risk factors for premature atrial contraction?
- tobaca, alcohol, caffiene, stress
What is tx for PAC?
bblocker if sx
if asx dont treat
What is dx test for aotic dissection?
TEE
What heme cancer associated w/ abnormal ch 22? tx?
CML = t(9;22) = BCR-ABL = philadeplphia chromosome
tx = tyrosine kinase inhibitors [imatinib]
What type of nephritic syndrome presents w/ intramembranous deposits of C3 w/o immunoglobulins?
membranoproliferative glomerulonephritis
mech: iGG antibodies (C3 nephritic factor) against C3 convertase of alternative complement path, leads to persistnet complement activation and kidney damage
What do needle shaped crystals on urinalysis indicate? what is next dx step?
uric acid stones. do CT abdomen or IV pyelography or US b/c radiolucent
What is likely dx if bright red firm friable exophytic nodules in HIV pt? tx?
bacillary angiomatosis 2/2 bartonella
tx = oral erythromycin
What is next step if pt presents 7.5 g acetaminophen?
administer activated charcoal
check acetaminophen levels
if timing of ingestion unclear, > 10ug/ml, any evidence of liver injury –> administer NAC and monitor for liver injury
What are clinical feat of trichinellosis?
2/2 undercooked meet w/in 1 wk ingestion: - asx or ab pain, N, V , diarrhea p to 4 wks later - myositis, fever, subungual splinter hemorrhage, periorbital edema, eosinophilia, high CK + leukocytosis
What should you suspect if pt w/ periorbital edema, myositis, and eosinophlia?
trichinellosis
What is presentation of dengue fever?
HA, retro-orbital pain, rash, significant myalgia, arthralgia
can also have hemorrhage in skin/nose
What is tx for antiphosphoipid syndrome?
prophylax w/ ASA and LMWH in pregnancy to avoid loss
What is next step if pt w/ persistent tachycardia causing hypotension, AMS
synchronized cardiovert and sedation
What is tx for pt hemodynaically stable but w/ persistent tachycardia?
if narrow (GRS
What disease is characterized by autoimmune destruction of intrahepatic bile ducts and cholestasis? tx?
primary biliary cirrhosis
tx = ursodeoxycholic acid
What are lab findings in PBC?
- high alk phos, cholesterol, IgM
- anti-mitochondrial antibodies
What happens if you give BBlocker to pt w/ pheochromocytoma?
will cuase unopposed alpha stimulation –> rapid increased in BP
*you should always give alpha blocker first before B blocker
What blood d/o presents w/ bite cells and heinz bodies on peripheral smear?
G6PD deficifiency
What is likely dx if pt ? 40 presents w/ knee pain worse w/ activity, relieved w/ rest, and crepitus?
OA
drug of choice = acetaminophen
What should you think if pt w/ CHF, thrombocytopenia, macrocytosis, and elevated LFTs?
alcohol induced dilated cardiomyopathy
What are findings of ATN?
BUN:cr 20
FeNa > 2%
What do WBC casts suggest?
interstitial nephritis and pyelonephritis
What do broad and waxy casts suggest?
chronic renal failue
What is pt lackign post-splenectomy?
risk of encapsulated organisims 2/2 impaired antibody-ediated opsonization in phagocytosis
What electrolyte abnormlaities in recurrent vomiting?
hypoK, hypoCL, met alklaosis
What are best meds for increasing appetite in cachexia?
progesterone analgos (megestrole, medroxyprogesterone) > steroids
What is difference bewtween steven johnson and toxic epidermal necrloysis?
TEN = > 30% body surface
SJS =
What is next step after dx adenocarcinoma of stomach?
CT ab/pelvis to look for mets, stage
depending on findings may do laparoscopy, US, CT, PET etc
What type of lung cancer is peripheral and presents w/ clubbing, hypertrophic osteoarthropathy?
adenocarcinoma
xanthelasma is associated w/ what GI condition?
PBC
What shoul you think if pt w/ popping sensation in knee injury w/ significnat sweeling and hemarthrosis and joint intstabliity?
ACL tear
What is the stepwise approach for ascites?
- Na and H2O restric
- spironolacton
- loop diuretic (no more than 1L/day diuresis)
- frequent abdominal paracentesis
What is drug of choice for chemo induced N/V?
5HT3 receptor antagonists
What antibodies in sjgoren?
SSA (Ro) or SSB (La)
What is etiology of zenker diverticulum?
upper esophageal sphincter dysfunction and esophageal dysmotitligy
What is presentation of cyanide yox in nitroprusside?
AMS, lactic acidosis, seizure, coma
What is next step if suspcet lupus nephritis?
do renal biospy to classify degree of nephritis –> start immunosuppresive therapy after it is classified
