uworld 8 Flashcards
how does svr macrocytifc anemia px?
dyspnea, fatigue, generalized weakness, can occur w/ chronic hemolysis
How does splenic sequestriation px w/ sickle cell disease?
sudden and rapid fall in Hgb
How does BPH px?
incrsd fequency, hesitancy, dribbling, nocturia, enlarged smooth prostate
What is pathogen of HIT type 2?
heparin binding to platelet factor 4, IgG ab binds to complex leading to platelet activation and consumption + incrsd risk thrombosis
Si/sx of amyotrophic lateral sclerosis?
get upper and LMN lesions, get atrophy bulbar signs, muscle weakness (distal > prox), hyperreflexia, spsasticity, fasciculations
CV risk w/ marfan sydnrome?
incrsd risk of aortic dilation, regurg, dissection, MVP.
What is an orthostatic proteinuria test?
obtain daytime (upright) and nighttime (supine) urine collections for protein quantificiation
What drugs most notorious for tubulointerstitial nephritis?
beta lactam ABX
How w/u persistent isolated hematuria?
Needs cystoscopy to ID cause, will likely also require kidney U/S
What suggests nonglomerular hematuria?
if RBCs of nml morphology on UA w no RBC casts or proteinuria
Risk fx for GU cancers?
smoking, male, >50 y/o, exposure to benzene, radiation, cyclophosphamide
How does ETOH cause rhabdo?
causes hypophosphatemia leading to muscle wasting
How would bladder outlet obstrxn px?
type men w/ difficulties w/ flow, px w/ poor UOP, suprapubic pain, hydronephrosis on kidney U/S
Si/sx of prerenal azotemia?
hypotension, hypoNa, dcrsd Urinary Na, bland urinary sediment.
How does tumor lysis px? How manage?
hyperuricemia, hyperphosphatemia, hyperkalemia. Give allopurinol or rasburicase
What is critical management in pt w/ CKD?
most closely mange bp, target <125/75
When is dialysis indicated?
Uncontrolled hyperK, refract hypervolemia, or AMS, uremic pericarditis, bleeding due to uremic platelets.
Which is better kidney xplant or dialysis?
Best to attempt kidney transplant.
How long does it take to get DM nephropathy?
usually 5-10 yrs of uncontrolled DM, also commonly occurs w/ diabetic retinopathy
Result of CKD on calcium homeostasis?
get incrs in phosphorous and dcrs in 1,25 vit D — > dcrs in Ca and incrs in PTH
How calculate urine anion gap?
(Ur Na + Ur K) - Ur Cl. Nml is 30-50
If abnml UAG?
if lrge, neg UAG then likely metabolic acidosis of extrarenal origin w.out gap
What is expected relation btwn PCO2 and bicarb?
For each 1 meq incrs in bicarb, should have 0.7 mmHg incrs in PCO2. BIcarb will incrs by 1 meq for each 10 mmhg incrs in PCO2
What is eqtn for plasma osmolality?
2(Na) + (BUN/2.8) + (Gluc/18)
ECG signs of hyperK?
spiked T waves & widened QRS
What is affect of villous adenoma on lytes?
causes hypokalemia
What is acute pancreatitis affect on Ca?
Dcrsd serum Ca due to chelation w/ FFA released by panc enzymes that get into peritoneum due to panc necrosis
How tx hypercalcemia 2/2 sarcoidosis?
Incrs serum Ca due to incrsd prodxn of 1a hydroxylase by macroph. — Incrsd 1,25 vit D. tx w/ corticosteroids
What is cinacalcet and when used?
parathyroid Ca sensing receptor blocker. Used in secondary hyperPTH
What are nml phosphorous levels?
2.5-4.5 mg/dl
What is issue w/ phosphorous in chronic alcoholic?
once receive tx (insulin + gluc), phos shifts into cells exposing deficit in body stores
How does hypophosphatemia px?
If acute — confusion, rhabdo, hemolytic anemia, svr muscle weakness
How does trousseau’s syndrome present?
Migratory superficial thrombophletbitis — single or multiple tender, erythematous and palpable cord like veins.
If develop troussea’s?
Should begin work up to determine if visceral tumor present
Cause of Meniere’s disease?
Due to distention of endolymphatic compartment of inner ear. Triggered by ETOH, caffeine, nicotine, salt. Managed initially w/ salt restriction.
How meniere’s disease px?
vertigo x 20 min/ episode, hearing loss, tinnitus. May have postural instability/ vomiting w/ nystagmus
What is hypertrophic osteoarthropathy?
digital clubbing occurs w/ sudden onset arthropathy esp in wrist and hand joints. Can be assoc w/ lung cancer, TB, bronchiectasis, emphysema.
Who likely to get diarrhea due to shigella?
DAy care centers and other institutions.
Likely cause of yersinia enterocolitica?
eating undercooked pork
Most common cause of campylobacter infxn? How px?
eating undercooked poultry, px w/ watery/bloody diarrhea + svr ab pain.
Findings w/ OA?
involves DIP more than PIP, MCP — px w/ shortening joint space, osteophytes
CAuse and px of foot drop?
2/2 trauma to common peroneal n. or radiculopathy to nay of spinal roots (L4-S2), px w. steppage gate (high stepping w/ exaggerated flex of hip + knee since cannot dorsiflex foot)
What are indications for lipid lowering tx?
If hx of ACS/MI, angina, past revasc, PAD — do statin tx. If LDL>/= 190 — statin tx, if 40-75 y.o w/ dm then likely need statin.
How manage PAD?
- if intermittent claudication, start w/ graded exercise program. Reduce other CV risk fx (dm, htn).
- DO antiplatelet to dcrs risk of MI, stroke, etc.
What is common side effect w. Ca channel blockers?
can get peripheral edema — due to peripheral vasodilation.
How manage asx, mild hyperCa (<12)
avoid thiazides and lithium.
How manage moderate hyperCa (>14) or sx hyperCa
short tx w/ NS + calcitonin, avoid loops unless volume overloaded. Long term tx w. zolendronate
Mechanism of nitrates as tx for angina?
Vasodilate capacitance vessels (veins), dcrs preload leading to dcrs contraction of ventricles and dcrs myocardial ox demand.
CAuse of progressive multifocal leukoencephalopathy?
Due to reactivation of JC virus in AIDS pts
Px of PML in AIDS pts?
involvement of cortical white matter, gradual onset of sx w. hemiparesis, speech, vision, gout probs, non-enhancing demyelin lesions on MRI
CSF findings w/ GBS? How tx?
high protein w/ no other abnormalities. Tx w/ supportive care, IVIG, plasmapharesis
How does rotator cuff impingement px?
pain during reaching or lifting arm above head, usualyl due to repetitive movement. Confirm w/ Neers test
How does adhesive capsulitis px?
similar px as rotator cuff tendinitis except pain will not relent w/ lidocaine injxn.
When do CEA?
If asx, obstrxn >70%, good 5 year survivaal, and accessible stenosis site. Aspirin only prevents further wrosening, once significant blockage, aspirin has no benefit.
How remove tick?
with tweezers, grab as close to skin as possible and pull away
Px of dense membranoproliferative GMN?
dense depostis of C3 in GBM. nephrotic proteinuria, hematuria.
What is pathophys of MPGN?
IgG against C3 convertase leads to persistent activation of alt. complement pathway.
What disease due to anti-GBM ab?
goodpastures disease
How does seborrheic dermatitis px?
fine, loose, yellow greasy looking scales. May be due to pitryosporum.
What is seborrheic dermatitis suggestive of?
If multiple present, suggestive of GI tract cancer
How tx simple metastatic brain mass?
if possible, surgically resect then whole brain radiation.
What is differential for elevated serum protein?
multiple myeloma, MGUS, waldenstrom’s, amyloidosis
How w/u MGUS?
Do metastatic bone surgey (xray of long bones and skull) to r/o lytic lesions.
How dx amyloidosis?
abd fat pad biopsy
What is serious risk w/ PTU tx for hyperT?
can induce agranulocytosis, usually px w/ fvr and sore throat.
How manage prolactinoma?
if 10mm, tx w/ surgery.
How tx ethylene glycol or methanol poisoning?
Use inhibition of alcohol dehydrog w/ either ethanol or fomepizide
Signs of diabetic autonomic neuropathy?
Dcrsd appetite, nausea, ab pain, occ vomiting 2/2 delayed gastric emptying/ gastroparesis, can cause hypoglycemic episodes.
How manage gastroparesis in diabetics?
rec small freq meals and incrsd fiber intake. Give metoclopramide for incrsd gastric emptying.
How does ETOH hepatitis appear on biopsy?
mallory bodies, neutrophil infiltirate, liver cell necrosis and perivenular distrib of inflamm.
When necessary to send aspirated fluid of breast cyst for cytology?
If fluid is bloody or foul.
How does fibrocystic disease of breast px?
firm, movable, rubbey mass w/ clear fluid w/ aspiration, cyst disappears following aspiration.
Common side effects of aminoglycosides
Ototoxicity px w/ vertigo, gait imbalance, hearing loss, esp w/ gentamicin, due to damage to inner ear hair cells, nephrotoxicity.
How screen for MEN syndrome? Prophylactic if positive?
do DNA test of pt and family. If MEN2A or B, do total thyroidectomy.
How does babesiosis px?
endemic in NE US, px w/ hemolysis, haundice, hemoglobinuria, renal failure, death. fvr, drenching sweats, malaise
How dx and tx babesiosis?
Do giemsa stain of periph smear, tx w/ quinine-clinda or atovaquone + azithromycin
What is px of erhlichiosis?
rockey mounted spotted fever
Si/sx of hyperthyroidism?
anxiety, insomnia, palpitations, heat intol, incrsd sweating, weight loss, goiter, htn, tremors, hyperreflex, prox muscle weakness
What are criteria for CHAD score?
Age>/=75, htn, DM, CHF each 1 pnt. Prior stroke = 2 pts,
What do diff levels of scores on CHAD score mean?
if 0 pts, just do aspirin, if >2 need warfarin or dabigatran, if 1-2 then consider clinical situation in choosing anticoag tx.
Common s/e of amiodarone?
CV - brady/ heart block, pulm - chronic interstitial pneumonitis, hypo/hyperthyroid, incrsd LFTs, hepatitis, optic neuropathy, blue-gray skin, periph neurop
How does digoxin toxicity px?
N/V/D anorexia, confusion, arrhythm, vision probs
How manage RA?
begin w/ DMARDS (methotrexate), can do cox 2 inhibt for sx tx, if sx persists add 2nd non-biologic (hydroxychloro or sulfasalazine), if persists do etanercept.
How w/u 1st episode of unprovoked seizure?
if self limited no post-seizure benzo/phenytoin ppx needed. Do CT or MRI to determine any underlying probs.
How does giardiasis px?
fatty, foul smelling stools, bloating, flatulence, N, malaise, ab cramps
How dx histoplasmosis quickly?
Urine or serum ANTIGEN, not antibody
How tx histo dissem infxn in HIV pts?
Use IV ampho x 2 wks, then itraconazole if svr, or just itracon if mild-mod
What does presence of PAD indicate?
significant risk fx for MI in 5 years
If bilirubin is in urine what does that indicate?
means signif amt of conjugated bili (unconj not water soluble)
What is rotor syndrome?
benign disease w/ defect in hepatic storage— incr in conj bilirubin w/ jaundice, nml LFTs
What is effect of DM on kidneys?
first get glomerular hyperperfusion, renal hypertrophy, incrs in GFR. Then get GBM thickening, glomerular hypertrophy, mesangial volume expansion next.
What is effect of htn on kidneys?
hypertrophy, intimal fibrosis of arterioles, glomerular and peritubular fibrosis
If lasting diarrheal illness after travel, think what?
More likely parasatic if > 1 week, bacterial infxns usually short and self limiting.
How does cryptosporidium px?
lasting high volume watery diarrhea, w/out blood.
How does enteamoeba GI infxn px?
following travel to SE Asia, Africa, L.A., get abd pain and bloody diarrhea
How tx signif pain in recovered opioid abuser?
still need IV morphine like anyone else. Undertreatment equally signif risk fx for relapse.
How prevent gout attacks in leukemic tx?
allopurinol or other xanthine oxidase inhibitors
How manage symptomatic bradycardia?
1st attempt to correct w/ atropine. IF fails do xcutaneous pacing.
DDX of restrictive lung disease?
- interstitial lung diseae. 2. neuromusc dx. 3. alveolar edema. 4. pleural fibrosis 5. chest wall abnormalities.
Young patient w/ low back pain and restrictive lung disease?
think ankylosing spondylitis, have incrsd FRC due to chest wall motion restriction.
What can cause a dcrsd DLCO?
interstitial edema, interstitial infiltrate, tissue fibrosis, COPD/emphysema.
Best test to dx asthma?
can do methacholine challenge which induces bronchoconstrxn
How use methacholine challenge?
get provacative concentration leading to dcrs of 20% of FEV1. If dose less than 4 mg/ml then positive test for asthma.
How differentiate neuromuscular cause of lung disease?
NM disease causes restrictive pattern on PFTs w/ incrsd RV/TLC ratio. Incrsd RV/TLC ratio typically seen in obstructive pattern.
What is hepatopulmonary syndrome?
dyspnea @ rest, platypnea, hypoxemia in setting of chronic liver diseae. Also have clubbing, cyanosis, hypoxemia.
What is platypnea?
Worsening dyspnea when sitting up.
WHat is pathophys in hepatopulm syndrome?
get pulm vascular dilatation w/ intrapulmonary shunting & VQ mismathc.
How does vocal cord dysfxn present?
throat and neck discomfort, wheezing, stridor, not corrected w/ beta agonist. Dx w/ laryngoscopy - see adduction of cords.
Possible pulmonary manifestations of Systemic sclerosis (CREST)
can get pulmonary artery htn or interstitial lung disease.
Px of PAH in pt w/ CREST?
worsening fatigue + dyspnea on exertion w/ clear lung fields and nml cxr.
Indications for chest tube placement?
effusion w/ ph1000, + gram stain, cx or presence of pus
How differentiate effusion or lobar pneumonia?
effusion px w/ dcrsd breath sounds, dcrsd fremitus, dullness. Lobar pneumo px w/ bronchial breath sounds, icnrsd fremitus,
How dx chylothorax?
pleural fluid TG> 110 typically.
Cause of acute resp failure in setting of asthma?
incrsd airway resistance leading to dynamic hyperinflation that reduces chest wall complaince.
If poor responding acute asthma exacerbation, how manage if on albuteral, inhaled steroids?
D o short 5-7 day course of PO roids, if steroids not possible, do leukotriene.
How manage persistent asthma w. steroid/ albuterol?
If not respond to inhaled steroid/ albuterol, do long term beta agonist next, if this fails add leukotriene modifier
How manage major COPD exacerbation?
if nml COPD meds fail, do course of ABX like levofloxacin
When is long term O2 therapy indicated?
PaO2<88% on RA
If acute exacerbation of COPD not resp to suplpm O2?
Do noninv + pressure vent, use when pts have mod/svr resp distress, use of accessory muscles, resp >25/min, pH45
What is pulm findings w/ a1 antitrypsin deficiency?
leads to panacinar emphysema, leads to early onset in COPD in smkoers + nonsmokers.
What is cryptogenic organizing pneumonia?
aka bronchiolitis obliterans w/ organizing pneumo — small airways and alveoli become inflammed w/ connective tissue.
What Ab present in systemic sclerosis?
anti-topo1 ab (anti-SCL-70)
When is CTA contraindicated for dx of PE?
when have elevated Cr due to need for lrg amount of contrast?
How does olecranon bursitis px?
get tenderness to palpation over elbow but no dcrs in ROM.
Joints typically spared by OA?
MCP, wrist, elbow, shoulder, ankle
How does anserine bursitis px?
focal tnederness on upper medial tibia, usually in middle age pts or older, pain releif occurs w/ steroid injxn @ bursa
What is rotator cuff tendenitis?
inflamm of supraspinatus +/- infraspinatus tendon w/ possible involvement of subacrom.
If nml shoulder exam w/ shoulder pain?
consider causes of referred pain, do cxr and other studies.
how does prosthetic joint infxn px?
usually have joint pain w/out fvr, incrsd wbc, must do arthrocentesis to dx, xray may have no findings
Approp 1st line therapy for OA?
NSAIDS for sx management & PT, if NSAIDS fail or are contraindicated, can do intraarticular steroids
When is methotrexate contraindicated?
if person regularly consumed ETOH. combined etoh+metho = incrsd risk of hepatotox
Best method to establish dx of ankylosing spondyl?
must do MRI of sacroilliac joints
How tx drug induced lupus? What drug rx?
infliximab in tx of RA can actually induce drug-induced lupus. Tx by stopping offending agent and starting steroids.
How manage lupus GMN renal disease?
start high dose steroids.
How tx Raynauds in CREST?
tx/ w. amlodipine (CCB), also can use a1 blockers, phosphodiesterase, endothelin receptor antagonist. 2nd line is topical nitrates on fingers
how does fibromyalgia px?
diffuse pain and tenderness bilaterally & above and below waist
How does polyarteritis nodosa px?
necrotizing inflammation of medium sized vessels w/out GMN or vasculitis of arterioles, smaller vessels
