Uworld CK Flashcards
What does the femoral nerve innervate?
The anterior thigh for knee extension and hip flexion
Sensation to the anterior thigh and medial leg – via the saphenous branch.
How should hemodynamically stable pts w/suspected splenic injury be managed?
They should first undergo a FAST.
- If normal FAST, but they have high risk features (anemia or guarding)then they should undergo abdominal CT scan w/contrast.
- If equivocal FAST and stable = CT w/contrast
- If equivocal FAST and unstable = DPL
- if DPL positive = laparotomy
How should pts w/massive hemoptysis be managed?
Bronchoscopy is the procedure of choice to identify the site of bleeding and attempt intervention.
This is done after establishing a patent airway, maintaining ventilation/gas exchange, and ensuring hemodynamic stability.
Thoracotomy should only be done if bronchoscopy fails.
What are hard signs of vascular injury and how are they managed?
Observed pulsatile bleeding
Presence of bruit/thrill over injury
Expanding hematoma
Signs of distal ischemia (absent pulses, cool extremity)
Pts w/any of these signs should undergo urgent surgical repair.
What is the management for SBO?
Nasogastric tube, IV fluids, bowel rest, analgesics and surgical exploration (esp. if they aren’t stable or show signs of ischemia and necrosis – metab. acidosis)
Most common complications of cardiac catheterization?
Bleeding, hematoma (local or w/retroperitoneal extension), arterial dissection, actue thrombosis, pseudoaneurysm, or AV fistula formation.
Hemorrhage/hematoma normally occur w/in 12 hrs.
Causes, sxs, and dx of a retroperitoneal hematoma:
Causes: Recent cardiac cath., anticoagulation.
Sxs: sudden onset HoTN, tachycardia, flat neck veins, and back pain.
This is diagnosed w/a NON-contrast CT of the abdomen/pelvis.
Management of pancreatic pseudocyst:
Expectant mgmt. - (NPO,symptomatic therapy) for those without sxs or cxs
Endoscopic drainage - pts w/significant sxs (N/V/abd pain), infected cysts, or evidence of a pseudoaneurysm.
Mgmt of a clavicular fracture:
Careful neurovascular exam to r/o injury to the brachial plexus or subclavian artery. Often involves an angiogram – esp. if a bruit is heard.
Ankle-brachial index:
Non-invasive test that is sensitive and specific for PAD in symptomatic pts. (intermittent claudication). Usually the first step taken to confirm the diagnosis.
Done by dividing the higher ankle systolic pressure by the higher brachial artery systolic pressure.
What happens to the Left ventricle in states of hypovolemic shock?
It will decrease in size d/t low filling volume, and compensate by increasing the ejection fraction (~75%).
Most common causes of massive hemothorax:
Traumatic laceration of the lung parenchyma, or damage to an intercostal or internal mammary artery.
Likely post-op complication that would lead to cardiogenic shock?
Perioperative MI
What are the interventions for lowering ICP? (5)
1- Head elevation: increases venous outflow from brain
2- Sedation: decreases metabolic demand and controls HTN
3- IV Mannitol: Free H2O clearance from brain tissue –> osmotic diuresis
4- Hyperventilation: CO2 washout –> cerebral vasoconstriction
5- CSF drainage: Decreases Vol/P
What anticoagulants are contraindicated in ESRD?
LMWH and Xa inhibitors like Rivaroxaban
What is the tx for DVT in patients w/ ESRD?
Unfractionated heparin and warfarin. Must start on both and then stop heparin bc warfarin initially causes prothrombotic state.
Who is likely to get bacterial parotitis, how does it present, how can you prevent, most common cause?
Post-op patients and the elderly are most likely to get it.
Presents with fever, leukocytosis and parotid inflammation.
Can prevent with adequate fluid intake and oral hygiene.
S. aureus is most common cause
Indications of urgent exploratory laparotomy:
Hemodynamic Instability
Peritonitis (rebound tenderness and guarding)
Evisceration (exposed organs)
Blood from NGT or on rectal exam
Also to remove any foreign material such as knives
Signs/Sxs suggestive of meniscal injury:
Acute knee pain a/w catching/popping or reduced ROM.
PE may be normal and should be followed by MRI if suspected.
Earliest sign of burn wound infection:
Change in appearance – partial thickness injury turns into full-thickness- of the wound, or loss of a skin graft.
Difference in bacteria of burn wound infection:
G+ are common directly after injury
G- and fungi are more common >5 days after injury.
What should happen immediately after placing a CVC?
Obtain portable CXR to confirm the catheter is in the correct place before catheter use. Catheter should be visualized just proximal to the angle b/w the trachea and R mainstem bronchus.
What is torus palatinus?
Fleshy immobile mass on the midline hard palate. It is a congenital growth, and doesn’t require intervention unless it casues sxs or interferes w/speech or eating.
Leriche syndrome:
A triad syndrome from aortoiliac occlusion
Bilat. Hip, thigh, and buttock claudication
Absent/diminished femoral pulses – often w/symmetric atrophy of the bilat. LEs from chronic ischemia
Impotence.
What is Extraperitoneal bladder injury? When should this be considered?
Contusion/rupture of the neck, ant. wall, or anterolateral wall of the bladder. Often from pelvic fractures.
Get localized pain and gross hematuria. Signs of peritonitis shouldn’t be present (seen in IPBI).
Signs and symptoms of necrotizing surgical site infection:
Pain, edema, erythema spreading beyond the surgical site
Systemic signs: Fever, HoTN, tachy
Par/anesthesia at the wound edges
Purulent, cloudy-grey “dishwater drainage”
SubQ gas or crepitus
Treatment of necrotizing surgical site infections:
Urgent surgical exploration and debridement + parenteral abx
What causes the hyperpigmentation/discoloration in stasis dermatitis?
RBC extravasation from the capillaries cause hemosiderin deposition in the tissues.
What can be seen on AXR in paralytic ileus?
Gas filled loops in the stomach, SI and LI with no transition point.
Common causes of paralytic ileus:
Abdominal surgery is #1
Others: Retroperitoneal/abd hemorrhage or inflammation, intestinal ischemia, and electrolyte abnormalities.
What causes flail chest?
3+ rib fractures in 2+ locations
What nerve is most commonly injured in shoulder dislocation, what will it cause?
Axillary nerve is most commonly injured
It innervates teres minor and deltoid –> weakened shoulder abduction
Provides sensation to lateral shoulder
What imaging is indicated for suspected penile fracture? Other indications for this imaging?
Retrograde urethrogram.
Indications for urethrogram: Blood at the meatus, hematuria, dysuria, urinary retention.
Shin splints v. Stress fracture:
Stress fractures – have localized point tenderness and activity-related pain, swelling. Often in underweight female athletes
Shin splints – diffuse area of tenderness (not point), and is more common in overweight casual runners.
What kind of effusion would be expected with a low pleural glucose?
An exudative effusion – typically has glucose <60 mg/dL.
What is the light criteria to define an exudative pleural effusion?
Must have at least one of the following (pleural/serum):
Pleural fluid protein/serum protein ratio >0.5
Pleural fluid LDH/serum LDH >0.6
Pleural fluid LDH >2/3 of the upper limit of normal for serum LDH.
What are empyemas?
Exudative effusions w/low glucose concentration d/t high metabolic activity of leukocytes and bacteria w/in the pleural fluid.
What are the different biopsy techniques for central v. peripheral tumors?
Central are done by EBUS (endobronchial US) directed biopsy.
Peripheral are hard to reach via EBUS and are normally done by VATS (Video-Assisted Thoracoscopic Surgery).
What lung ca is most likely to cause SVC syndrome?
SCLC
Most common locations of lung mets:
Brain, Bone, Adrenals, Liver
When is surgical resection indicated for lung ca.?
If the predicted post-op FEV1 is 800mL+
What type of skin cancer is more common in males v females?
Basal cell more common in males
Squamous more common in females
What are the vaccine recommendations for a patient post-splenectomy? When are they given post-splenectomy?
Give pneumococcal, meningococcal, and H. influenzae vaccines on 14th post-op day
Most common surgical txs of Subclavian steal syndrome:
Carotid-subclavian bypass
Carotid transposition
Percutaneous angioplasty w/ stenting
Surgical intervention should only be done in symptomatic patients
What is the next best step in mgmt. of a new solitary pulmonary nodule w/out previous images to compare it to?
Obtain chest CT
If CT shows intermediate to high chances of malignancy then a PET should be ordered.
If PET suggests malignancy then do a biopsy.
Common findings a/w Peutz-Jegher:
Polyps in both the small bowel and colon, perioral melanosis, breast malignancy
Treatment for anal fissures:
High fiber diet + adequate fluid intake
Stool Softeners
Sitz baths
Topical anesthetics + Vasodilators – Nifedipine, nitroglycerin, etc.
Management of spontaneous pneumothorax:
Small (< 2cm) can be managed w/observation and O2
Large + Stable need needle aspiration or chest tube.
Unstable – tube thoracostomy
Management of tension pneumothorax:
(variant w/ one-way valve causes expansion of pneumothorax during inspiration)
Urgent needle decompression or chest tube placement
Why is Supplemental O2 used in tx of pneumothorax?
It increases the rate of resorption.
Where should a needle be placed to decompress a pneumothorax? What size needle should be used?
A large bore 14-18 gauge needle is inserted in the 2nd or 3rd ICS in midclavicular line, or the 5th ICS in the mid/anterior axillary.
Visualization of a dilated common bile duct in the absence of stones is commonly seen in what disorder?
Sphincter of Oddi dysfunction – dyskinesia and stenosis of the sphincter can cause obstruction of flow through the sphincter which mimics a structural lesion.
Gold standard for dx: Sphincter of Oddi manometry.
Characteristics/Causes of Bile reflux gastritis:
d/t incompetent pyloric sphincter, often following gastric surgery.
Allows retrograde flow of bile-rich duodenal fluid into the stomach and esophagus
Sxs: Vomiting, frequent heartburn, abdominal pain.
Presentation of ruptured ovarian cyst:
Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous (exercising) or sexual activity.
Will see fluid in pelvis on US
Hemodynamically unstable pts require immediate surgery.
In a patient post-MVA what should an elevated PCWP be suspicious of? What is the next best step?
(What does PCWP measure, and what’s a normal value?)
Myocardial dysfxn d/t cardiac contusion. These pts need an urgent echo.
(PCWP = pulmonary artery occlusion pressure = left atrial pressure. Normal value is 4-12mm)
What is the typical course leading to an appendiceal abscess? Sx and Dx tests?
Acute appendicitis with delayed presentation and >5 days of sxs. This often leads to appendiceal rupture with a contained abscess.
These pts often have fever and leukocytosis but palpation of the abdomen may be normal. Need to use psoas and other tests to assess for the deep abdominal spaces.
CT can be used to confirm
Post-op cxs in these pts is extremely high, they should wait 6-8 weeks before removal.
Management for duodenal hematomas:
Gastric decompression via NGT and parenteral nutrition.
Surgery or percutaneous drainage only if non-surgical mgmt. fails.
Presentation , dx, labs of Emphysematous cholecystitis:
Fever, RUQ pain, N/V, crepitus in abd wall.
See air-fluid levels in GB and gas in GB wall.
Cultures w/gas-forming Clostridium, or E. coli
Labs: UC hyperBRemia (from clostridium-induced hemolysis), slight elevation in aminotransferases
Risk factors of emphysematous cholecystitis:
DM, vascular compromise, IMCP
Tx of Emphysematous cholecystitis:
Emergent cholecystectomy
Broad-spectrum abx w/clostridium coverage (pip-tazo, ertapenem, amp-sulbactam)
Bile cultures
Immediate (0-2hr) Post-op fever causes:
Prior trauma or infection
Blood products
Malignant Hyperthermia
What is the most likely acid-base disturbance to occur in atelectasis?
Respiratory Alkalosis – pts become hypoxic and hyperventilate to compensate. This decreases the arterial PaCO2, and PaO2. pH will increase.
Factors that decrease risk of post-op atelectasis:
Adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry.
How does post-op atelectasis occur? What is the result of these mechanisms?
Post-op changes in lung complicance can lead to shallow inhalations which limit the recruitment of alveoli at the lung bases, and then impaired cough can predispose to small-airway mucus plugging.
These both result in hypoxia –> increased RR and low pCO2.
Common cause of poor wound healing in alcoholic:
Vit. C deficiency
Most common organisms of prosthetic joint infection:
Early <3 months – S. aureus, G- rods, anaerobes (Pseudomonas)
Delayed 3-12 months – Coag-neg staph (S. epidermidis), Propionibacterium, Enterococci
Late >12 months – S. aureus, G- rods, B-hemolytic strep.
What is a cx of eschar formation from a circumferential, full-thickness burn?
It may lead to constriction of venous and lymphatic drainage, fluid accumulation and result in distal acute compartment syndrome.
What is abdominal succussion splash, and when is it seen?
It is elicited by placing the stethoscope over the upper abdomen and rocking the pt. back and forth.
Seen in gastric outlet obstruction – malignancy, PUD, strictures, etc.
What are some cxs of infection w/in the retropharyngeal space?
The retropharyngeal space drains inferiorly to the superior mediastinum. Infection can spread to the carotid sheath –> thrombosis of the IJV and deficits in CNs IX, X, XI, and XII.
Extension through alar fascia can cause acute necrotizing mediastinitis.
What should be suspected of an extra-axial dural-based brain mass? Tx?
Meningioma. These are treated via surgical resection.
What is likely in a pt. w/persistent pneumothorax, and persistent air leak post-chest tube placement? Cause?
Tracheobronchial rupture. This is rare and often follows blunt chest trauma.
Other sxs: pneumomediastinum, subcutaneous emphysema.
What likely causes esophageal rupture and what will be the findings?
Often iatrogenic (w/endoscopy) or esophagitis-related. Findings: pneumomediastinum and pleural effusions.
Postpericardiotomy Syndrome presentation + Tx?
Presents w/fever, leukocytosis, tachy, and chest pain.
Often AI and occurs few weeks after a procedure w/ a pericardium incision.
Tx: NSAIDs or steroids, and pericardial puncture if tamponade occurs.
Acute Mediastinitis findings and tx:
Often follows cardiac surgery.
Sxs: fever, chest pain, leukocytosis, mediastinal widening on CXR
Tx: Drainage, surgical debridement, and prolonged abx.
Which rotator cuff tendon is most commonly injured?
Supraspinatus – d/t degeneration of the tendon w/age and repeated ischemia induced by impingement b/w the humerus and acromion during abduction.
What abx should be given in GB disease?
Ones that cover G- rods and anaerobes
Ciprofloxacin + Metronidazole
Ampicillin-Gentamycin + Metroniadazole
DO NOT pick pip-tazo on tests
When should diastolic and continuous murmurs be evaluated?
ALWAYS
these are almost always pathological.
Midsystolic murmurs in young healthy people don’t need further evaluation.
What needs to occur pre-op in pts. on Warfarin?
Rapid reversal of anticoagulation, done by infusion of FFP.
What should be done to manage acute cholecystitis?
Cholecystectomy within 72 hours
What is normal urine output?
800-2000 mL per 24hrs.
Oliguria is <500 mL per 24 hrs.
What can post-op pneumonia lead to and how is it managed?
Septic shock – fever, tachy, HoTN, oliguria.
Treat w/IVF (0.9% saline) and abx for the underlying infection.
If the patient fails to respond or has signs of V-overload w/out improvement in BP then vasopressors (Dopamine) should be started to improve perfusion.
Anterior Cord Syndrome presentation? Cause?
Loss of movement, pain and temp
Vibration, touch and proprioception still intact.
May be a cx of thoracic AA repair, bc there’s decreased blood flow through the radicular aa.
What is one of the most common postgastrectomy cxs, and how is it managed?
Dumping syndrome – N/D/V, palpitations, diaphoresis, HoTN
Loss of normal pyloric sphincter axn –> rapid emptying of gastric contents
Tx: Dietary modification – frequent, small meals, eat slowly, avoid sugars, increase fiber and protein, drink fluids b/w and not during meals.
Causes of initial hematuria:
Reflects Urethral damage
Urethritis, Trauma to urethra (caths)
Causes of terminal hematuria:
Reflects bladder or prostate damage
Urothelial ca., Cystitis, Urolithiasis, BPH, Prostate ca.
Causes of continuous hematuria (7):
Reflects Kidney or ureter damage
Renal mass, Glomerulonephritis, Urolithiasis, PCKD, Pyelonephritis, Urothelial ca., Trauma to kidney
Marjolin Ulcer:
SCC arising within a burn wound.
SCC may arise in chronically wounded, scarred or inflamed skin.
SCC in chronic wounds tends to be more aggressive.
Steps in management of complicated diverticulitis:
Fluid collections <3cm – IV abx and observation
>3cm – CT-guided percutaneous drainage
If sxs are still uncontrolled by 5th day – surgical drainage and debridement
Sigmoid resection for pts w/ fistulas, perforation w/peritonitis, obstruction or recurrent attacks.
What is a cx of PP mechanical ventilation in a pt w/hypovolemic shock?
Pts in hypovolemic shock have decreased CVP, and the initiation of mechanical ventilation can cause acute loss of RV preload –> loss of CO and cardiac arrest.
What are the criteria for initiating long-term O2 therapy in pts. w/COPD?
- Resting PaO2 <55mmHg or SaO2 <88% on room air
2. PaO2 <59mmHg or SaO2<89% in pts. w/cor pulmonale, evidence of RHF or Hct >55%.
What causes the constitutional symptoms in cardiac myxomas?
Overproduction of IL-6 –> fever, weight loss, or Raynaud phenomenon.
Most common causes of hyperkalemia:
Acute or Chronic kidney disease
Medications or disorders that impair the RAAS.
Clinical and ECG findings of hyperkalemia:
Chronic may be asx until K+ > 7mEq/L
Acute causes sxs at lower levels –> ascending m. weakness, flaccid paralysis
ECG changes = peaked Twaves, short QT interval, QRS widening, sine wave w/vFIb
Therapy for hyperkalemia and when it should be instituted:
Acute tx: Calcium gluconate or chloride, insulin w/glucose
Should be given to pts. w/ ECG changes, K+ > 7 w/out ECG changes, or rapid K+ d/t tissue breakdown.
What is the most common cause of acute limb ischemia post-MI? Mgmt?
Arterial embolus from LV thrombus.
Mgmt: immediate anticoag., vascular surgery consult, and transthoracic echo to screen for thrombus.
Classic murmur in Aortic Regurg:
Decrescendo, blowing, diastolic murmur best heard at the L 4th ICS at the sternal border.
Murmur in Aortic stenosis:
Systolic, crescendo-decrescendo radiating to the carotids. Best heard in R 2nd ICS at sternal border.
Murmur in Mitral regurg:
HoloSystolic, best heard at apex, radiates to axilla.
Murmur in mitral stenosis:
Rumbling diastolic with opening snap (closer snap is to S2 worse the stenosis).
Best heard at apex.
Diagnosis and management of AAA:
Use US for screening/diagnosis NOT arteriogram
Anything >3.5cm is considered AAA
TX:
>3.5cm – re-screen every 12 mos
>4.5cm – re-screen every 6 mos
>5.5cm or growing >0.5cm/6mos – surgery
How to diagnose aortic dissection
Hemodynamically stable pts: CT Angiogram (but can’t do in renal failure/elevated Cr)
Unstable pts and renal failure: TEE
MRA can be used but is not preferred and should also be avoided in pts w/severe kidney disease
How to diagnose PVD:
How to identify the lesion location:
ABI: >1.4 = calcified vessel, need to do TBI instead 1.0-1.4 = normal 0.9-1 = equivocal, do exercise ABI 0.8-0.9 = Mild 0.4-0.8 = Moderate <0.4 = Severe Can use Doppler US and CTA to find where lesion is
How to treat PVD:
Use Angioplasty/Stent if the lesion is above the knee or small
Use Bypass if lesion is below the knee or large
All should f/u with medical tx (Cilostazol, Pentoxyphylline)
How to differentiate b/w neonatal conjunctivitis, and treatment:
Onset:
<24 hr – Chemical/Silver Nitrate, tx w/topical erythromycin
2-7d – Gonorrhea: PURULENT. Tx: Ceftriaxone
5-14d – Chlamydia: MUCO-Purulent. Tx: Oral Erythromycin
How to differentiate between RAS and Primary Hyperaldosteronism:
Both will have HTN and Hypokalemia.
Conns: Aldosterone:Renin >20
RAS: Aldosterone:Renin <10
How to diagnose esophageal rupture?
Water-soluble contrast upper GI study.
How to calculate amount of fluid needed for resuscitation in burn victims:
Parkland formula:
4 x Weight in Kg x % Area Burned
Treatment of hypocalcemia:
IV calcium gluconate
Common presentation of atrial myxoma:
Fever, fatigue, night sweats, weight loss.
Low-pitched rumbling diastolic murmur heard at the apex that disappears when pt. rolls onto R side (d/t tm obstructing mitral valve).
May also have decreased Hb.
Where does brain cancer metastasize?
Trick question bitch!!!
It doesnt. It stays in the brain.
Diagnostic test for brain tm?
MRI w/contrast is best, then MRI w/o contrast, then CT w/contrast.
Once located bx.
Brain ca tx?
Resection, radiation, chemo, steroids, seizure ppx.
Presentation and Dx of epididymitis:
Spontaneous pain in testicle with relief on elevation.
Vertically lying testicle (opposed to horizontal in torsion)
Dx w/Doppler US
Difference in Epididymitis etiology and tx based on age:
<35 yrs most likely an STD – tx w/Ceftriaxone + Azithromycin
>55 yrs most likely E. coli – tx w/a fluoroquinolone.
Best diagnostic test for kidney stones:
Non-con CT
cant do CT? do US
Presentation, Dx, and Tx of Transient synovitis:
Can occur at any age
Presents as hip pain following a viral illness. May be so severe that the pt is non-weight bearing.
Dx= clinical; Tx= supportive
Treatment of a fracture that involves the growth plate in a kid?
Surgery always
Ant. v. Post. dislocations of the shoulder:
Both will be adducted.
Anterior- from any trauma, even minor, will have external rotation (shows palm of hand)
Posterior- from massive trauma, a/w seizures and lightning strikes. Will have internal rotation (shows back of hand).
Hard signs of neck injury:
Airway: gurgling, stridor, loss of airway
Vasculature: Expanding hematoma, pulsatile bleeding, stroke, shock, flat neck veins
Soft signs of neck injury:
Dysphonia
Dysphagia
SubQ air/emphysema
Mild hard signs (hematoma not expanding, bleeding but not pulsatile etc.)
Treatment of Spinal Cord syndromes:
Steroids– dexamethasone
Then diagnose w/MRI
Mgmt of pelvic fractures:
Typically external fixation and stabilization w/blood transfusions is enough.
Only go to surgery if they are bleeding into the peritoneum. If just bleeding into pelvis don’t go.
What complication should be investigated for in electrical burns?
Burnt muscle will lead to Rhabdomyolysis so check CK and Creatinine.
Rxs that cause hyperkalemia:
TMP-SMX – blocks eNac channel
BBs – interfere w/B2 mediated K+ uptake
ACEIs, ARBs, Ksparing diuretics – block eNac
Digoxin – Inhibits NaK-ATPase
Cyclosporine – Blocks aldosterone
Heparin – Blocks aldosterone
NSAIDs – decrease renal perfusion and K+ delivery to CDs
Succinylcholine – extracell leakage of K+ through Ach Rs.
Renal effects of TMP-SMX:
Blocks ENac channels –> hyperkalemia.
Also competitively inhibits renal tubular creatinine secretion –> artificial increase in serum Cr.
GFR does NOT change.
Pts should have serial monitoring of K+ to avoid complications.
Mgmt of Hypercalcemia:
Only severe (>14 mg/dL) or symptomatic pts require treatment. Short term: Normal saline + Calcitonin; Avoid loop diuretics Long term: Bisphosphonate (Zoledronic acid)
What is the mgmt. and contraindications for chest pain in cocaine use?
Managed with benzos for BP and anxiety
Aspirin, Nitroglycerin, and CCBs for pain
BBs are contraindicated and Fibrinolytics should be avoided d/t risk of ICH.
Cardiac catheterization w/reperfusion done when indicated.
What are the different aspiration sites in recumbent v. upright pts?
Recumbent – posterior segment of the upper lobes
Upright – lower lobes or right middle lobe
Obesity Hypoventilation Syndrome definition, and other features:
Daytime hypercapnia (PaCO2 >45mmHg) in an obese patient (BMI >30), without another explanation for the hypercapnia. Other features: dyspnea, polycythemia, RESP. ACIDOSIS w/renal compensation, pHTN, and cor pulmonale.
Enoxaparin:
LMWH
Factor Xa inhibitors:
Fondaparinux (injection), Rivaroxaban (oral)
What defines severe renal insufficiency?
Estimated GFR <30 mL/min/1.73 m2.
Expected changes in hyponatremic hypovolemia for:
Serum electrolytes
Urine electrolytes
Enzymes
Decreased serum and urine Na+, Increased renin, aldosterone, and ADH.
How do nitrates exert their effect?
Nitrates like nitroglycerin cause venodilation which increases peripheral venous capacitance.
They cause systemic vasodilation and decrease cardiac preload –> reduce LV wall stress.
What is the first line tx for HTN d/t renal artery stenosis (RAS)?
ACEIs or ARBs. If pts are refractory to therapy then revascularization or stenting may be considered.
How will pleural pH change based on the type of effusion?
Normal pleural pH: 7.6
Transudative pH: 7.4-7.55
Exudative pH: 7.3-7.45
pH <7.3 norm. d/t Empyema, pleuritis, tm., pr pleural fibrosis
What are the common respiratory findings in Granulomatosis w/Polyangitis?
(aka. Wegener’s)
URT: chronic rhinosinusitis, otitis, saddle-nose deformity
LRT: tracheal narrowing w/ulceration and CXR w/multiple lung nodules w/cavitation and alveolar opacities.
Tx of Uric Acid stones:
Alkalinization of the urine w/oral Potassium Citrate, hydration, and a low-purine diet.
How are diuretics related to renal stones?
Furosemide and loop diuretics increase urinary calcium excretion and can cause calcium stones.
Thiazides decrease Ca2+ excretion and is used in the tx of calcium stones.
What patients have a higher association of angiodysplasia?
Those with advanced renal disease, Von Willebrand, and Aortic stenosis (d/t acquired vWF deficiency).
How does Angiodysplasia often present?
Episodic painless GI bleeding – often seen as dark colored stools w/normal bowel movements in between episodes.
Will often have signs of anemia as well
How is angiodysplasia diagnosed?
Via endoscopy – Upper GI or colonoscopy.
However it is often missed d/t poor bowel prep or location behind a haustral fold.
EKG findings in pericarditis:
Diffuse ST elevation with the exception of depression in aVR.
First line therapy for Dressler’s syndrome:
NSAIDs
Common AEs of inhaled B2-agonists:
Hypokalemia – they drive K+ into cells, causes muscle weakness and can be confirmed w/a BMP.
Headache, tremors, and palpitations.
Hepatic Hydrothorax – Cause and presentation:
Seen in some pts w cirrhosis and portal HTN.
Results from small defects in the diaphragm that allow peritoneal fluid to pass into the pleural space. Occurs more commonly on the right.
Causes dyspnea, cough, pleuritic chest pain, and hypoxemia.
Hematologic effects of glucocorticoids:
Causes leukocytosis with NP predominance.
Mobilizes marginated NPs into the blood, where they are non-fxnl.
Decreases LPs and eosinophils.
Oliguria:
<250 mL of urine in 12 hrs.
Post-op Oligura definition + management?
<0.5 mL/kg/hr – needs immediate assessment w/bladder scan, if urinary retention is present they need a catheter.
Scleroderma renal crisis:
Sudden onset of renal failure (w/o previous kidney disease), malignant HTN (HA, blurry vision, N).
UA may show mild proteinuria
PBS may show microangiopathic hemolytic anemia or DIC w/schistocytes and thrombocytopenia.
What is the common finding of a hepatic mass with central scarring on CT scan?
Focal nodular hyperplasia.
Doesn’t require tx unless symptomatic – then resection.
What hematologic abnormalities may be seen in Meckel Diverticulum?
Ongoing bleeding from the diverticulum may cause Iron Deficiency anemia
CXR shows: pleural effusion w/extensive soft tissue density. Dx? Thoracentesis findings?
Mesothelioma – extensive soft tissue density = pleural plaques.
Thoracentesis will show bloody, exudative effusion.
What will be seen on XR of toxic megacolon?
Loss of haustra and dilated bowel.
Use sigmoidoscopy-guided placement of rectal tube to manage.
What lab values will be seen with decreased excretion of BR?
Hyperbilirubinemia with predominately conjugated BR.
If it is 50-50 Direct-Indirect or predominately indirect then look for another cause of the hyperbilirubinemia (overproduction of BR after transfusion, etc.)
Why might alcoholics develop Hypocalcemia?
They are at increased risk for Hypomagnesemia d/t renal tubular loss.
W/o magensium PTH cannot be released and therefore Ca2+ levels fall.
When is it safe to give anticoagulants post-op?
They can be given 6-12 hrs post-op
Tx of hyperaldosteronism:
Spironolactone or other Aldosterone receptor blockers
What are ARBs?
ANGIOTENSIN RECEPTOR BLOCKERS!!!!!
Management of anal mass:
When thought to be cancer first biopsy to prove cancer, and then use Nigro chemoradiation protocol.
If this is not successful in eliminating it completely (90% success rate) then surgery can be used as a last resort in rare cases to remove residual tumor.
Causes of fistulas:
Foreign body Epithelization Tumors Irradiation Inflammation/IBD Distal obstruction
What abx should be given in pancreatitis w/proven infection?
Carbapenem
When should a pancreatic pseudocyst be drained?
Needs draining if >6cm or if its been present >6 weeks.
This indicates complication and high risk of infection.
<6cm or 6 weeks you can observe.
Colonoscopy schedule:
q10 if clean or hyperplastic
q5 if polyp is seen
q3 if polyp is CIS or villous
q1 if polyp has dysplasia
Treatment of urethral injuries:
Anterior- immediate surgical repair
Posterior- suprapubic cystostomy tube and wait for repair
What does the cyanide-nitroprusside test detect?
Elevated levels of cystine. Can help confirm the dx of Cystinuria.
What metabolic disorder can develop in carcinoid syndrome?
Pellagra (Niacin deficiency).
This is d/t the depletion of tryptophan for the preference of conversion to serotonin and 5-HIAA.
Tryptophan is needed for both 5-HT and Niacin synth.
What metabolic disorder can Isoniazid therapy lead to?
B6/pyridoxine deficiency –> peripheral neuropathy
Pellagra/Niacin deficiency –> Diarrhea, Dementia and Dermatitis. D/t interference of tryptophan metabolism (less common, seen in prolonged tx).
ABG findings in CHF:
hypoxic, hypercapnic, respiratory alkalosis.
What drug therapy is started in pts w/Coronary heart disease to reduce morbidity and mortality?
Dual-antiplatelet therapy: Aspirin + P2y12R blocker (clopidogrel, prasugrel, ticagrelor)
BBs
ACEIs or ARBs
Statins
Aldosterone Antagonists (spironolactone, eplerenone)
Complications of PEEP:
Alveolar damage, pneumothorax, and HoTN.
Pts. w/underlying lung disease (ARDS, pneumonia, COPD) are especially susceptible.
Clinical features of Pneumothorax:
Hyperresonance to percussion Diminished breath sounds Decreased tactile fremitus HoTN from decreased VR (collapsed lung compresses the IVC) Tachycardia from impaired RV filling Increased CVP
Features of obstructive ureterolithiasis:
Severe L lower AbdP radiating to the groin, vomiting, and unremarkable findings on PE.
Dx w/US or noncon CT
Renal vein thrombosis:
Complication of any nephrotic syndrome, but most commonly a/w membranous glomerulopathy.
D/t the loss of antithrombin III in the urine.
Presents acutely w/AbdP, fever, hematuria
Or more commonly progressive as a gradual worsening of renal fxn, and proteinuria in an asx pt.
Clinical presentation of spontaneous bacterial peritonitis:
T > 37.8/100
Abdominal Pain/tenderness
Altered mental status
HoTN, Hypothermia, paralytic ileus w/severe infection
What is spontaneous bacterial peritonitis?
Ascitic fluid infection w/out an obvious intraabdominal surgical etiology. Seen in pts w/cirrhosis.
Metabolic AEs of thiazides:
Hyperglycemia Increased LDL and TGs Hyperuricemia Hypokalemia Hyponatremia Hypomagnesemia Hypercalcemia
Tx to rapidly lower K+:
Insulin w/glucose
B2-agonists
Sodium bicarb in acidotic patients
Ca2+ gluconate will stabilize the cardiac membrane, but will not reduce K+
Tx to slowly remove K+ from the body:
Diuretics
Cation exchange resins
Hemodialysis
What cardiac issues are associated with malignancies?
Malignancy causes a hypercoagulable state which can lead to massive PE –> RV dysfxn: hemodynamic collapse, syncope, decreased VR, decreased CO.
Elevated CVP/JVP
What arrhythmia is most specific for Digoxin toxicity?
Atrial tachycardia w/AV block
What test is advised for all pts w/suspected gallstone pancreatitis?
RUQ US
Then managed w/ERCP to remove the stone
Biliary causes of pancreatitis typically present w/ALT > 150
How to differentiate b/w osmotic and secretory diarrhea:
Osmotic will have an elevated stool osmotic gap (>125mOsm/kg)
Secretory will have a reduced SOG (<50mOsm/kg)
Difference between stress and urgency incontinence treatments:
Stress- Lifestyle mods, pelvic floor exercises, pessary, pelvic floor surgery
Surgery for stress incontinence can cause urge incontinence later.
Urge- Lifestyle mods, bladder training, then antimuscarinics (oxybutynin)
Overflow incontinence tx:
Cholinergic agonists, intermittent self-catheterization.
If urine osmolality is <100mOsm what should be considered?
Primary polydipsia and malnutrition (beer drinker’s potomania)
Difference b/w thrombus and emboli:
Emboli is a fragment that travels and blocks. Thrombus is a blockage that develops in the site it blocks.
What ECG findings are consistent with LVH?
High-voltage QRS complexes, lateral ST depression and lateral T wave inversion.
Persistent HTN, headaches and nosebleeds in a young pt is concerning of what?
Coarctation of the Aorta—should asses w/ bilateral arm and leg BP readings and pulse checks for brachial-femoral delay.
Diagnostic test of choice for PE:
CT angio
Most common source of liver mets?
Colorectal cancer—blood from the colon travels through the portal circulation directly to the liver.
Lung and breast also commonly met to the liver.
What is likely in a young woman with a subauricular systolic bruit?
Fibromuscular dysplasia – causes internal carotid a. stenosis and presents w/recurrent HA, pulsatile tinnitus, TIA and stroke.
May also have an abdominal bruit from the RAS –> secondary HTN (leads to hyperaldosteronism) and flank pain.
Most common CoD in dialysis pts:
CVD. Also the most common CoD in renal transplant pts.
Varying amplitude of QRS complexes suggests what?
Electrical alternans which is highly specific for pericardial effusion.
Tx would be emergency pericardiocentesis.
Treatment of variant/vasospastic angina:
Prevention w/diltiazem (CCB = potent coronary dilator, but weak systemic dilator) and sublingual nitroglycerin for abortion of an episode.
BBs and aspirin are contraindicated in variant angina.
What drugs are likely used to tx MDR pyelonephritis?
Aminoglycosides (like Amikacin) bc they treat serious G- organisms which commonly cause pyelonephritis.
These may cause ARF in the setting of CKD though. Renal function should be monitored closely.
What complication is often secondary to viral pericarditis?
Pericardial effusions – causes electrical alternans on EKG, enlarged cardiac silhouette, distended neck veins and distant heart sounds.
PE can vary, but almost all patients have an impalpable PMI
What should be done first in mgmt. of suspected cardiac tamponade?
Urgent echo to confirm diagnosis.
Most likely will present with signs of cardiogenic shock
What will be seen on pulmonary artery catheterization in the setting of cardiac tamponade?
Elevation and equalization of intracardiac diastolic pressures
RA, RV, and PCWP will all resemble LA pressure.
What is a positive Kussmaul’s sign and what does it suggest?
Increase in JVD with inspiration
Often positive in RV failure.
What are signs of RV MI?
Often in patients w/acute inferior wall MI d/t occlusion of the RCA proximal to the RV brs.
Signs/Sxs: chest pain, HoTN, autonomic signs (diaphoresis, V), and EKG findings of ST elevation in leads II, III, and aVF.
May also have JVD, +Kussmaul’s sign, and clear lung fields suggestive of RVF
Possible bradycardia or AV block bc enhanced AV tone.
What special mgmt. is implemented in RVF in addition to standard MI therapy?
Boluses of IVF to improve RV preload and increase LV filling.
These pts are preload dependent and anything that reduces preload (nitrates, diuretics) should be avoided.
What coronary a. is involved in papillary muscle rupture?
RCA
What complications are associated with the LAD coronary?
Free wall rupture
LV aneurysm
Interventricular septum rupture
What coronary vessels can be involved in a IV septum rupture?
LAD (apical septal)
RCA (basal septal)
Most common signs/sxs of PE:
Dyspnea, pleuritic chest pain, tachypnea, tachycardia
Often CXR is abnormal, but many cases may have normal CXR
Mgmt of BB overdose:
Initially secure airway, IVF, IV atropine.
Pts w/refractory or profound HoTN may then require IV glucagon as the next step.
This may also treat CCB overdose.
Other therapies include: IV Ca2+, vasopressors (E/NE), high dose insulin and glucose, and IV lipid emulsion.
Most common cause of constrictive pericarditis in developing countries:
TB
Beck’s triad:
HoTN, Distended neck veins, muffled heart sounds – a/w cardiac tamponade
Pulsus paradoxus and +hepatojugular reflux are other common signs of tamponade
What is responsible for the sxs of cardiac tamponade?
Fluid accumulation in the pericardial cavity increases intrapericardial P above the diastolic ventricular P. The sxs (Beck’s triad) are d/t an exaggerated shift of the IV septum toward the LV cavity, this reduces LV preload, SV, and CO.
Most common cause of sudden cardiac arrest immediately post-MI:
Reentrant ventricular arrhythmias (vFib)
How does a ventricular aneurysm present on EKG?
With persistent ST-elevation after a recent MI (5d-3m), and deep Q waves in the same leads.
What is a systolic-diastolic abdominal bruit most suggestive of?
Renal artery stenosis.
What should be suspected in pts w/diffuse atherosclerosis and resistant HTN?
Renovascular HTN (RAS)
Why are IMCPd more likely to develop nocardia infections?
Bc the branching, filamentous growth prevents phagocytosis making host defense dependent on cell-mediated immunity which is often lacking in IMCPd.
Tx for nocardiosis:
TMP-SMX txs pulmonary Nocardiosis, may require additional abx like amikacin in severe disease.
Carbapenems are added when the brain is involved
Who should receive the HAV vaccine?
Pts w/chronic liver disease (HBV, HCV etc)
MSM
IVDU
Travelers to endemic countries
Presentation of vitreous hemorrhage:
Sudden loss of vision and onset of floaters.
Reduced visual acuity to light perception, loss of fundus details, floating debris and a dark red glow.
Diabetic retinopathy is #1 cause
What is the best way to monitor a pts response to treatment in DKA and HHS?
Monitor the serum anion gap, or direct assay of beta-hydroxybutyrate
What condition classically causes bilateral internuclear ophthalmoplegia?
MS – bilateral lesions in the MLF, bilateral adduction difficulties and nystagmus in the abducted eye.
Why do some pts w/celiac disease have negative results on IgA testing?
Many patients have an associated selective IgA deficiency as well.
This causes the anti-tissue transglutaminase and anti-endomysial tests to be negative.
What MRI changes are associated with alzheimers disease?
Temporal lobe atrophy, mostly in the medial temporal lobes and hippocampi.
Parietal may be seen but is much less likely - more likely to be seen in Primary Progressive aphasia Dementia syndrome
What will an EKG show in moderate hypokalemia?
Broad, flattened T-waves, U-waves, ST-depression and PVCs
May have some or all
When does workup need to be done for a murmur?
Grade III and above systolic murmurs, and all diastolic murmurs.
Start w/ echo
Why are pts w/Multiple Myeloma at increased risk of infection?
Bc the neoplastic cells infiltrate the bone marrow and impair normal lymphocyte proliferation – ineffective Ab production and hypogammaglobulinemia.
What will CSF analysis of Guillain-Barre look like?
Normal except for increased protein.
Most commonly isolated organisms to cause brain abscess:
S. aureus and S. viridans
What should be used to reduce thromboembolic events in pts w/aFib?
Warfarin or non-VitK antagonist anticoagulants.
These are much more effective than the antiplatelet agents (aspirin, clopidogrel)
What is a factorial design?
A study that involves the randomization to different interventions w/additional study of 2+ variables.
What is likely to cause chondrocalcinosis?
Pseudogout, which is typically caused by:
- hyperPTHism
- HypOthyroidism
- Hemochromatosis
Chrondrocalcinosis = irregular opaque structures in articular cartilage (looks like white stuff IN BETWEEN joint lines)
What is Adhesive capsulitis?
When the glenohumeral joint loses its normal distensibility d/t chronic inflammation, fibrosis, and contracture of the joint capsule.
Have shoulder stiffnes»_space; pain, and ROM is markedly reduced both actively and passively.
How to distinguish Grave’s from painless (silent) thyroiditis:
Radioiodine uptake.
Painless/silent will have decreased uptake
Graves will have increased uptake
What metabolic/lab abnormalities can hypothyroidism cause?
Hyperlipidemia (decreased LDL-Rs or decreased LDL-R activity)
Hyponatremia (d/t decreased free H2O clearance)
Asx elevation in creatinine kinase
Elevated serum transaminases
Macrocytic anemia
What can and cannot be calculated in a case-control study?
Odds ratio can- it measures the association between exposed individuals and the controls.
Relative risk cannot- it can be calculated in cohort studies that follow individuals over time.
The OR generally approximates the RR in case-controls if the disease is rare (low disease prevelance), or the disease incidence (# of new cases) is low –> “rare disease assumption”
When do Relative Risk and Odds Ratio approximately equal each other?
In rare disease states.
What type of skin cancer is most common in IMCPd?
SCC is common especially in post-transplant patients or those on immunosuppressants. It is also more aggressive in these pts. with increased risk of local recurrence and mets.
What complication is a/w neurologic deterioration w/in 2 days after an ischemic stroke?
Hemorrhagic transformation – often when the stroke affects large areas, is d/t an embolic cause or the pt. has been treated with thrombolytics.
Often need urgent surgical decompression to treat.
When will you see the Jarisch-Herxheimer reaction?
W/in 6-48 hrs of treating a spirochetal disease – mostly syphilis but could be lyme etc.
What complications can be prevented by lowering HbA1c/achieving glycemic control in DM?
The microvascular complications – nephropathy and retinopathy – will be reduced.
It will have no change on the macrovascular complications – MI, stroke.
How to differentiate bed bug rash from scabies:
Scabies are often on the palms, flexor wrist, lateral surface of the fingers and finger webs. It is v pruritic and worse at night.
Bed bugs often cause small, punctate lesions in a linear track of clusters. Not commonly on the palms or soles bc of the thickness of the skin.
Tx of scabies:
Topical permethrin or oral ivermectin.
When is abx prophylaxis indicated for patients w/rheumatic fever valvular defects?
ONLY if they have a history of IE.
If no hx of IE then the risk of developing it following a dental procedure is v low and abx aren’t indicated.
How does PCV affect EPO levels?
It causes them to be low bc the constitutively active JAK2 is what causes the overproduction of RBCs and high Hb, not hypoxia.
What is Riluzole?
A glutamate inhibitor for ALS. Doesn’t stop progression, but may prolong time to tracheostomy.
Most common location of ectopic foci to cause aFib?
Pulmonary veins
Best treatment for acute for cluster headaches? And prophylaxis?
Tx: 100% O2 by facemask – most rapid-acting and effective w/out any major AEs.
- SubQ sumatriptan can be used if there are no contraindications.
Pphx: Verapamil or lithium and should be started asap after the onset of an acute attack.
What causes of Hyperthyroidism cause ophthalmopathy?
ONLY graves. If a patient has elevated thyroid hormones and ophthalmopathy then it has to be graves.
How to differentiate between Subacute granulomatous (De Quervian) vs. Subacute lymphocytic thyroiditis:
BOTH:
- Progress from hyper to hypothyroidism w/ a diffusely enlarged thyroid.
- Screen: T3/T4, thyroglobulin (increased), and TSH
- Confirm: Increased ESR, decreased iodine uptake
- Tx: BB + NSAIDS (MTZ is contraindicated!) for thyrotoxic, levothyroxine for hypothyroid phase
Subacute granulomatous = due to infection + painful thyroid +/- jaw pain.
Subacute lymphocytic = due to drugs/autoimmune/post-pregnancy + not painful
What auto-Abs may be seen in PBC?
Anti-mitochondrial are the most commonly associated. Anti-smooth muscle may also be present but these are more commonly seen in Autoimmune hepatitis.
What is goat’s milk deficient in?
Folate
What test should be done in a patient with a low Wells score meaning PE is unlikely?
D-dimer – it has high negative predictive value and can exclude the diagnosis of PE.
Patients with a high wells score should undergo a CTA, or a V/Q scan if they have contraindications to a CTA.
What chromosome is linked to CF?
Chromosome 7 at position F508 is most common.
What drug is often a/w an increased risk of PML?
Natalizumab an alpha-4-integrin inhibitor.
Often used to treat MS and Crohn’s.
It interferes w/LCs, MCs and vascular adhesion of inflammatory cells.
Rituximab a CD20 antagonist.
Used to treat B-cell NH lymphoma, CLL, RA, and ITP.
Most common cranial nerve palsy a/w idiopathic intracranial HTN?
CN VI
Medications that can cause idiopathic intracranial HTN:
Growth Hormone
Tetracyclines (minocycline, doxy)
xs Vit. A and its derivatives: Isotretinoin, ATRA.
What FiO2 levels can cause O2 toxicity?
Anything >60%.
When pts are first put on ventilators these levels are often exceeded but should be reduced asap to prevent toxicity.
What bone complication can be caused by Celiac and what would the lab findings be?
Osteomalacia – impaired osteoid matrix mineralization.
Have increased AlkPhos and PTH, decreased serum and urinary Ca2+, and 25 OH-D levels.
Characteristic radiologic finding of osteomalacia:
Decreased bone density w/thinning of the cortex
Bilateral and symmetric pseudofractures (looser zones)
Eventually will cause “codfish” vertebral bodies w/a concave shape.
Management of tachyarrhythmia causing hemodynamic instability:
Immediate synchronized direct current cardioversion.
Initial management for patients with hypertriglyceridemia:
Statin therapy
Weight loss
Decreased EtOH intake
Increased exercise
** Although fibrates decrease TGs these are rarely needed in addition to statins.
Treatment of Shingles:
Acyclovir, Famciclovir, Valacyclovir
What is Hepatorenal syndrome?
Complication of end-stage liver disease.
Characterized by decrease in glomerular filtration w/out another clear cause of renal dysfxn., minimal hematuria (<50 RBCs) and lack of improvement w/volume resuscitation.
Pts. develop splanchnic arterial dilation and decrease in vascular resistance, get renal HoPerfusion.
Treatment of Painless/Silent thyroiditis:
It is normally self-limiting and doesn’t require therapy, but a BB (propranolol) may be prescribed to control the hyperthyroid sxs.
Complications of Metoclopramide and Prochlorperazine:
Both are dopamine antagonists and used as antiemetics. They can cause EPS like acute dystonias, akathisia, and parkinsonism.
What is telogen effluvium?
One of the most common causes of hair loss in adults. Follicles undergo widespread shedding and cease growing.
Often follows a stressful event – weight loss, pregnancy, major illness/surgery, or psychiatric trauma.
In the hair pull test, extraction of >10-15% of fibers suggests TE.
Self-limiting but may take up to a year to resolve.
Characteristics and treatment of Ehrlichiosis:
Transmitted by tick, causes flu-like illness w/ fever, HA, myalgias, chills, neuro sxs
Leukopenia and thrombocytopenia w/elevated liver enzymes and LDH
Tx: doxycycline.
Rxs that contribute to increased LDL-C levels:
Thiazides
Cyclosporine
Glucocorticoids
Amiodarone
Treatment of central retinal a. occlusion:
Emergently treated w/ocular massage and high-flow O2.
Can give thrombolytics if w/in 4-6hrs but must be admin’d intra-ARTERIALLY cannot be given systemically via IV.
Presentation of Multiple Myeloma:
Often presents w/anemia and hypercalcemia in a patient with bone pain (chest or back). Classically progresses to renal insufficiency w/bland urinalysis and evidence of granular casts.
Treatment of Bacillary angiomatosis:
Oral erythromycin
Cause of bilateral trigeminal neuralgia:
MS is one of the only conditions that causes b/l trigeminal neuralgia – d/t demyelination of the nucleus of the CN V nerve or nerve root.
Management of Infectious Mononucleosis:
Supportive, and avoidance of sports for >3 weeks (4 if its contact sports) d/t risk of splenic rupture.
What test can identify patients w/ Primary adrenal insufficiency (Addison’s)?
ACTH stimulation (cosyntropin test). Should also include 8AM serum cortisol measurement.
What has the strongest association with both ischemic and hemorrhagic strokes?
HTN – d/t the shearing force on the intracerebral vascular endothelium, it accelerates AS and promotes thrombi formation.
What test is commonly used to compare two means?
The two-sample t test.
In contrast to the chi-squared test which compares categorical data and proportions between two groups.
Best initial test to perform on acute stroke patients?
CT w/out contrast – this will rule out hemorrhage the quickest.
How to differentiate b/w CML and Leukemoid rxn:
CML:
- LAP low
- Immature NP precursors = myelocytes > Metamyleocytes
- Absolute basophilia
Leukmoid:
- LAP high
- Mature NP precursors = Metamyelocytes > myleocytes
- No basophilia
EKG leads involved in anterior MI:
LAD blocked
Some or all of V1-V6
EKG leads involved in inferior MI:
RCA or LCX blocked
ST elevation in leads II, III, and aVF
Inferior MIs are a/w HoTN, bradycardia and AV block.
EKG leads involved in posterior MI:
LCX or RCA blocked
ST depression in V1-V3
ST elevation in I and aVL (LCX)
ST depression in I and aVL (RCA)
EKG leads involves in lateral MI:
LCX, diagonal vessel blocked
ST elevation in I, aVL, V5 and V6
ST depression in II, III, and aVF
EKG leads involved in RV MI:
Blocked RCA
ST elevation in V4-V6
Occurs in 1/2 of Inferior MIs
What is used to confirm the diagnosis of ankylosing spondylitis?
Lumbar XR.
HLA-B27 is not needed – only seen in 5% of patients.
Common causes of secondary amyloidosis (AA):
Inflammatory arthritis (RA) Chronic infections (bronchiectasis, TB, osteomyelitis) IBD (crohn’s) Malignancy (lymphoma) Vasculitis
Diagnosis of secondary amyloidosis (AA):
Abdominal fat pad aspiration biopsy
Tx of secondary amyloidosis (AA):
Tx underlying condition
Colchicine for prevention and treatment
Management of iatrogenic Hyponatremia:
Hypertonic (3%) saline
Serial measurement of electrolytes
Increase serum sodium
What makes a patient automatically not a candidate for lung cancer surgery?
If they have positive LNs from a mediastinal sampling.
What is the initial workup for pts. w/HTN?
Basic lab analysis w/urinalysis, chemistry panel, lipid profile, and baseline EKG.
In addition a detailed history and physical should be performed
Management of torsades de pointes:
In hemodynamically stable pts. first line is Magnesium sulfate.
In hemodynamically unstable patients immediate defibrillation needs to be done.
DoC for treating Lyme disease:
Doxycycline for most patients – will also treat/prevent coexisting anaplasmosis.
In pregnant/lactating women and young children DoC is amoxicillin or cefuroxime
Causes of metabolic alkalosis that are responsive to saline:
Vomiting Gastric suctioning Diuretics Laxative abuse Volume depletion Urine Chloride <20 mEq/L
Saline-resistant causes of metabolic alkalosis:
Primary hyperaldosteronism Cushing’s Severe hypokalemia (<2mEq/L) Urine chloride >20 mEq/L May see increased Na+ as there is xs mineralocorticoid in these types of metabolic alkalosis and Na+ retention.
Most effective non-pharmacological intervention to reduce BP:
Weight loss in overweight patients.
DASH diet in others.
What should be suspected in a pt w/painless blisters that heal with scarring, and increased skin fragility?
Porphyria cutanea tarda – especially in a patient with HCV.
May also see facial hypertrichosis, and hyperpigmentation.
Effect of cirrhosis on thyroid function:
The liver produces thyroid-binding proteins (thyroxine-binding globulin, transthyretin, albumin etc).
When the liver fails, total T3 and T4 levels will decrease (because of decreased transport proteins), but free T3 and T4 remain unchanged. So, TSH will be normal looking like the pt. is euthyroid.
Common precipitating factors of thyroid storm:
Thyroid surgery NON-thyroid surgery!! Acute illness Childbirth Acute iodine load (iodine contrast)
In diabetic neuropathy what is responsible for the positive v. negative symptoms?
Axonopathy of large nerve fibers causes the negative sxs (numbness, loss of proprioception and vibration sense, diminished ankle reflexes)
Axonopathy of small nerve fibers causes the positive sxs (pain, paresthesias, allodynia)
NNT equation:
NNT = 1/ARR ARR = Risk in control group – Risk in treatment group
Main complication of prolonged seizures:
Cortical laminar necrosis – can lead to persistent neuro deficits and recurrent seizures.
Treatment of Nocardia:
TMP-SMX for pulmonary
Add Carbapenems if brain is involved
Rxs that commonly cause folic acid deficiency:
Phenytoin (plus other anti-epileptics), primidone, phenobarbital, TMP, MTX
Presentation of pulmonic valve stenosis:
Severe cases present w/RHF in childhood
Mild cases have sxs like dyspnea in early adulthood w/ a crescendo-decrescendo murmur that increases on inspiration with a systolic ejection click and widened split S2.
What should be given to patients with hypercalcemia d/t bony metastatic lesions?
Bisphosphonate therapy – will stabilize the destructive tumors, reduce risk of pathologic fractures and malignant hypercalcemia.
ABG in salicylate toxicity:
Low PaCO2, Low HCO3, and near-normal pH
Bc there is respiratory alkalosis followed by an anion gap metabolic acidosis.
Benign paroxysmal positional vertigo:
Episodic dizziness triggered by positional changes d/t crystalline deposits (canaliths) in the semicircular canals that disrupt the flow of vestibular fluid.
This is the most common cause of vertigo
Dix-hallpike maneuver:
Vertigo and nystagmus triggered by quickly lying back into a supine position with the head rotated 45 degrees.
Used to diagnose benign paroxysmal positional vertigo.
Tx of Malignant otitis externa:
IV anti-pseudomonal antibiotics, like ciprofloxacin
+/- surgical debridement
Gait in Parkinsonism:
Slow, Shuffling, HYPOKINETIC gait. Typically narrow-based.
CYP450 Inhibitors:
Increase drug effects. Acetaminophen, NSAIDs Abx/Antifungals (metronidazole) Amiodarone Cimetidine Cranberry juice, Ginko, Vitamin E Omeprazole/ PPIs Thyroid Hormone SSRIs (fluoxetine)
CYP450 Inducers:
Decrease drug effects Carbamazepine, phenytoin Ginseng, St. John’s wort Oral contraceptives Phenobarbital Rifampin
What foods may have an effect on Warfarin?
Brussel sprouts, spinach, or anything else with a good source of Vitamin K.
These decrease warfarin’s effect
Treatment of Polymyalgia rheumatica:
Glucocorticoids
Lab findings in Antiphospholipid antibody syndrome:
paradoxical aPTT prolongation not reversed on plasma mixing studies – d/t the lupus anticoagulation effect.
Anticardiolipin Ab
Anti-B2-Glycoprotein-I Ab
Treatment of Rhino-Orbital-Cerebral mucormycosis:
Surgical debridement + Amphotericin B
What complication is seen with Voriconazole use in pts w/Heme malignancies?
Independent risk factor for Mucormycosis
Early side effects of levodopa/carbidopa:
Hallucinations Confusion Agitation Dizziness Somnolence Nausea
How would a patient with metastatic testicular cancer likely present?
Testicular tms often met to the retroperitoneal LNs causing low back pain, and the lungs causing dyspnea/cough and pulmonary nodules on CXR.
Should be suspected when a young patient presents w/these sxs.
Tx of aFib in pts with WPW:
Cardioversion or antiarrhythmics like Procainamide AVN blockers (BBs, CCBs, Digoxin, Adenosine) are contra’d bc they can increase conduction through the accessory pathway.
What levels of pro-insulin are expected to be seen in patients with insulinomas?
Increased levels >5 pmol/L
What are some complications of heat stroke?
Rhabdomyolysis
Renal failure
ARDS
DIC – which leads to coagulopathic bleeding and persistent epistaxis
Ocular AEs a/w PDE-5 inhibitors:
Blue discoloration of vision
Nonarteritic anterior ischemic optic neuropathy
Rx interactions w/PDE-5 inhibitors:
Antihypertensives along with these Rxs can cause severe HoTN, but especially a-blockers like Doxazosin and Nitrates. Both these classes should be avoided.
Tx of E. histolytica:
Metronidazole + an intraluminal abx (Paromomycin- an aminoglycoside)
When are smudge cells seen?
In cases of CLL – these are pathognomonic.
Presentation of CLL:
Often asx, but can have extreme fatigue, B sxs, infection or weight loss.
PE shows lymphadenopathy and splenomegaly.
What suggests impending respiratory collapse in an asthma exacerbation?
A near normal pH and PaCO2 on ABG – indicates that the ongoing increased work of breathing is unable to maintain adequate ventilation.
Resp. mm. fatigue and/or severe air trapping prevent meeting the demands of increased respiratory drive and suggest impending resp. collapse.
What valvular pathology can occur 2/2 pacemaker placement?
Tricuspid regurge.
The RV lead passes through the SVC and RA through the tricuspid valve and can damage the valve leaflets.
What causes Age-related macular degeneration?
Degeneration and atrophy of the central retina (macula), retinal pigment epithelium, Bruch’s membrane, and choriocapillaries.
How will AMD present?
Age-related macular degeneration.
Presents w/ progressive loss of central vision with peripheral fields and navigational vision maintained.
May develop cataracts after a while.
Presentation of Chronic Prostatitis/Chronic pelvic pain syndrome:
Pain in pelvis, perineum, and genitalia. Pain can radiate to the back.
Irritative voiding sxs (urgency, hesitancy)
Hematospermia, pain w/ejaculation
Normal urinalysis and negative culture results
Typically NO prostate tenderness.
What causes Chronic Prostatitis/CPPS?
Unclear etiology – thought to be noninfectious chronic prostate inflammation.
Tx for chronic prostatitis/CPPS:
Abx (quinolones) even though bacteria aren’t thought to cause it.
a-blockers (tamsulosin)
5-a-reductase inhibitors (finasteride)
How long does it take for Coccidioides to present?
Typically get sxs 7-14 days after inoculation w/ the fungus (mold).
Incubation time for Blastomyces?
3-6 weeks!
When do you begin tx for HoThyroidism?
When TSH >5
Hetrophile antibody test:
Aka monospot – positive in infectious mononucleosis, but there is a 25% false-negative rate during the 1st week of illness.
Manifestations of PCV:
HTN Erythromelalgia (burning cyanosis in hands/feet) Transient Visual distrubances Aquagenic pruritis Gouty arthritis Bleeding Facial plethora Splenomegaly
Tx of PCV:
Phlebotomy or Hydroxyurea if increased risk of thrombus
What should be given in cases of COPD exacerbation?
Inhaled bronchodilators (B2 agonists and anticholinergics), and systemic glucocorticoids. Supplemental O2, Abx, and ventilator support may also be needed.
How to diagnose Leprosy:
Full-thickness biopsy of skin lesion from an active edge.
It is not culturable.
Tx of Leprosy:
Dapsone + Rifampin
Add clofazime if severe/multibacillary
What arthritis is non-erosive?
SLE arthritis. It is an inflammatory. All others destroy the bone.
What is familial Mediterranean fever?
Genetic disorder causing recurrent episodes of fever often accompanied by pain in abdomen, chest and joints.
Febrile Neutropenia common causes and treatment:
G-negs (P. aeruginosa especially) are most common infection in febrile neutropenia.
Once blood cultures are taken monotherapy w/an anti-pseudomonal B-lactam should be started – cefepime, meropenem, pip-tazo.
How do alcoholics get hypocalcemia?
Often they develop hypomagnesemia which then creates resistance to PTH and decreases PTH secretion leading to hypocalcemia and hypophosphatemia.
What Rx is used to diagnose and manage narrow-QRS-complex tachycardia?
Adenosine.
It slows the sinus rate, increases AVN conduction delay or can cause transient AVN block.
What should be expected/tested for in unexplained cytopenias?
Chronic HIV infection.
What should all patients with presumed ITP be tested for?
HIV and HCV
Features of Lewy Body Dementia:
Fluctuating cognition, bizarre, visual hallucinations, and Parkonsonism (giving DA antagonists, 1st-gen antipsychs and risperidone will exacerbate the condition).
Most common cause of community-acquired bacterial meningitis:
S. pneumoniae
Can occur w/ or w/o concurrent pneumococcal pneumonia.
What is one of the earliest signs of macular degeneration?
Distortion of straight lines so that they look wavy.
Lab results of AML:
Cytopenias, elevated LDH, myeloblasts w/auer rods on peripheral smear.
What should be thought of in a HIV patient with pulmonary, mucocutaneous and reticuloendothelial findings?
Progressive disseminated Histoplasmosis.
Get systemic sxs (fevers, chills, malaise)
Weight loss/cachexia
Pulmonary – cough, dyspnea
Mucocutaneous lesions (papules, nodules)
Reticuloendothelial (Hepatosplenomegaly, Lymphadenopathy)
Labs in disseminated histoplasmosis:
Pancytopenia
Transaminitis
Increased LDH + Ferritin
Tx of Disseminated Histoplasmosis:
Amphotericin B (mod-severe disease) Itraconazole (mild disease/maintenance)
Most common cause of spontaneous lobar hemorrhage:
Amyloid Angiopathy – most often involves the occipital and parietal lobes.
What should pts w/chest pain and suspected ACS be given first in the ED?
Aspirin – as long as the risk of aortic dissection is low.
Common AEs of Cyclosporine:
Nephrotoxicity – most common
HTN from renal vasoconstriction and Na+ retention
Neurotoxicity – HA, visual disturbances, seizure, tremors
Glucose intolerance
Infection
Malignancy – SCC of skin and lymphoproliferative
Gingival hypertrophy and hirsutism
GI – anorexia, N/V/D
Preferred initial test in patients with suspected DVT:
Compression ultrasonography
What sites are affected in spondyloarthropathies?
The ligamentous insertion points (enthesitis).
Pain is worse at night and with rest.
Causes of chemotx-induced peripheral neuropathy (CIPN):
Vinca alkaloids (Vincristine, Vinblastine)
Pb-based analogs (Cisplatin, Carbaplatin)
Taxanes (Paclitaxel)
What is seen on autopsy of LBD?
Eosinophilic intracytoplasmic inclusions – accumulations of a-synuclein protein.
Seen in neurons of the substantia nigra, locus coeruleus, dorsal raphe nucleus, and sustantia innominata.
Tx of LBD:
Carbidopa-levodopa for Parkinsonism
Cholinesterase inhibitor for cognitive impairement
SECOND-gen anti-psychs for psychotic sxs. 1st gens create severe neuroleptic sensitivity in these pts.
Euthyroid Sick Syndrome:
Abnormal thyroid fxn tests in any pt. w/an acute, severe illness (post-MI etc)
Most common pattern is low free and total T3 with normal TSH and T4.
Esophagus ulcers in HIV pts:
Large linear = CMV
Vesicles and round/ovoid ulcers = HSV
White plaques = Candida
What will cause Hyperchylomicronemia?
Aka Type I familial dyslipidemia
D/t a defective LPL or apoC-II
Often presents with acute pancreatitis
Phosphate levels in secondary hyperPTHism:
Normally caused by renal failure – leads to phosphate retention and improper clearing, so increased serum PO4 with decreased Vit D, and Ca2+ and increased PTH.
25-hydroxycholecalciferol (inactive Vit. D storage form) will increase.
How should B12 be administered in Pernicious anemia pts?
IM injection – this bypasses enteral absorption which is impaired in these patients.
Tx of PE:
Heparin or LMWH (Enoxaparin) then bridge to warfarin
Can give tpa in some cases, but is contraindicated in post-op patients.
IVC filters can be placed in pts if PE recurs or anticoagulation is strictly contra’d
Major risk factors for HBV infection:
Multiple sexual partners and IVDU.
HBV is much more likely to present with sxs than HCV.
HBV is also much more commonly contracted through sexual contact than HCV.
Molluscum contagiosum:
Skin infection from Poxvirus.
Characterized by small, pruritic, skin-colored papules w/umbilicated centers.
Imaired cell-immunity may lead to a prolonged course w/widely spread papules involving the face.
HIV testing should be considered for patients w/MC.
Severe cx of Nitroprusside therapy:
Cyanide toxicity – get AMS, lactic acidosis, seizures and coma.
Most common in patients w/renal insufficiency.
Post-ictal lactic acidosis:
Often follows seizures (esp. tonic-clonic). Raises serum lactic acid d/t skeletal mm. hypoxia.
Typically transient/self-limited and resolves w/in 90 min.
Mgmt is observation and repeat chemistry panel//ABG after ~2hrs.
When should NaHCO3 be given for metabolic acidosis?
When pH < 7.1.
Anything higher may cause myocardial depression and increased lactic acid production.
Features of Chronic arsenic poisoning:
Polyneuropathy, pancytopenia, mild transaminase elevation, hypo/hyperpigmentation and hyperkeratosis.
Mees lines - horizontal striations of the finger nails is characteristic
Tx of acute MS exacerbation:
Glucocorticoids (IV Methylprednisolone)
Plasmapheresis can be considered in pts refractory to steroids.
Chronic maintenance tx of MS:
IFN-B or Glatiramer acetate.
Both are disease modifying agents and used for chronic tx in pts. w/relapsing-remitting or secondary, progressive forms of MS.
Auto-Abs in Scleroderma:
Antinuclear-Ab (most sensitive, but not specific)
Anti-topoisomerase I (anti-Scl-70) Ab and anti-RNA pol III (most specific)
Anticentromere-Ab (mostly in limited disease/CREST)
What does skin infection involving the external ear most likely suggest?
Erysipelas – bc the external ear lacks a lower dermis level which makes cellulitis a v. unlikely diagnosis.
Cause and presentation of erysipelas:
S. pyogenes (aka GBS)
Warm, tender, erythematous rash w/raised, sharply demarcated borders.
May have systemic sxs fever, chills, regional lymphadenopathy.
Most common AE w/in 1-6hrs of transfusion:
Febrile nonhemolytic transfusion rxn. – can be prevented with leukoreduction.
When should cells be washed prior to transfusion?
If the pt. has IgA deficiency or had a prior allergic transfusion rxn.
What should be given to transplant pts. to prevent opportunistic infections?
TMP-SMX.
This prevents PCP, some Listeria and toxoplasma infections.
Can be discontinued 6-12 months post-transplant.
Some pts. may also receive Ganciclovir for pphx against CMV
What is use dependence and what Rxs is it seen with?
It is enhanced pharmacologic effects of a drug during faster heart rates
Seen with class I (esp. IC, less so IA) and class IV (CCBs) anti-arrhythmic agents.
Class IC cause progressive decrease in impulse conduction w/faster HR – leads to increase in QRS duration.
Class IV (CCBs) will see an increase in the PR interval, but no change in the QRS complex.
First step in evaluation of Cushing syndrome:
Confirm hypercortisolism w/late-night salivary cortisol assay, 24-hr urine free cortisol, and/or low-dose dexamethasone test.
- 2/3 of these tests needs to be + to dx
If confirmed, then measure ACTH.
Tx of Diffuse esophageal spasm:
CCBs.
Alternatives: Nitrates or TCAs
Diagnostic requirements of acute liver failure:
Severe injury with elevated aminotransferases (often >1000)
Signs of hepatic encephalopathy
Impaired hepatic synthetic fxn (INR > 1.5)
Cirrhosis or underlying liver disease should not be present
Tx of Optic neuritis:
IV corticosteroids.
Diagnostic study for suspected aortic dissection:
TEE or CTA – but can’t use CTA in renal disease.
Presentation and diagnosis of oropharyngeal dysphagia:
History of difficulty initiating swallowing with cough, choking, or nasal regurgitation.
Diagnose with Videofluoroscopic modified barium swallow.
Mgmt of caustic ingestion:
Ingestion of alkali substances like sodium hydroxide (lye), can cause immediate chemical burn or liquefactive necrosis.
Managed with decontamination and IV hydration.
Upper GI endoscopy should be performed w/in first 12-24 hrs to determine extent of damage.
Mild injury = supportive measures
More severe = tube feedings and possible surgery.
What is tonometry and when is it used?
It measures intra-ocular pressure and is used to asses acute ACG.
Tx of Trigeminal Neuralgia:
Carbamezapine
Preferred tx for hypovolemic hypernatremia:
IV 0.9% saline.
The fluid can be switched to 5% dextrose once the patient is euvolemic.
DoC for Osteoporosis:
Alendronate
Can’t give to pts. w/GERD so give Zolendronic acid bc its given IV and doesn’t cause reflux esophagitis like Alendronate.
What cancers are likely to cause primarily solitary brain mets?
Breast
Colon
RCCa
Lung and melanoma likely to cause multiple mets.
Most common ca to met to the Brain?
Lung.
Neoplastic cells travel through vasculature and lodge in small-caliber vessels at the gray/white matter jxn.
Often cause vasogenic edema as well.
MS v. Brain mets on MRI:
MS often has inflammatory white matter lesions.
Brain mets often well-circumscribed lesions at the gray/white matter jxns w/ vasogenic edema.
What causes the cyclical fevers in malaria?
Plasmodium-induced RBC lysis.
What are Heinz bodies and when are they seen?
Heinz bodies are oxidized/denatured Hb that occurs when there’s a G6PD deficiency (XL-recessive dx).
Most frequent source of PEs:
Deep veins of the lower extremities.
>90% PEs come from iliac, femoral or popliteal vv.
**Exception is patients w/nephrotic syndrome – renal vv. are most common source of PE in these pts.
Recommendations for Bladder cancer screening:
Currently there is recommendation against screening d/t its low incidence and poor PPV of current screening tests.
Management of Hyperosmolar hyperglycemic state:
Aggressive hydration w/NS
IV Insulin (NOT subQ)
K+ supplementation.
Sxs of ACL injury:
Pain, rapid onset
Popping sensation at time of injury
Significant swelling w/effusion or hemarthrosis (gross blood on aspiration of joint fluid)
Joint instability
Common cardiac finding in chronic ankylosing spondylitis:
Aortic Regurgitation.
When do HCMP murmurs increase in intensity?
With Valsalva (straining phase), abrupt standing, nitroglycerin administration – all d/t decreased preload. They decrease with sustained hand grip, squatting, and passive leg raise.
Pathogenesis and common causes of phototoxic drug rxns:
D/t production of ROS that then directly damage cell membranes and DNA.
Sxs can be seen in both sun-exposed areas as well as non-exposed areas.
Common causes: Abx (tetracyclines), Antipsychs (chlorpromazine), Diuretics (furosemide, thiazides), Amiodarone, promethazine, piroxicam.
Most common cause of B12 deficiency and possible long-term complication:
Pernicious anemia.
Causes atrophic gastritis which increases risk of gastric cancer and gastric carcinoid tms.
Mgmt of frostbite:
Rapid rewarming in 37-39C water bath.
Analgesia and wound care
Thrombolysis in severe, limb-threatening cases.
What medication can help with stone passage?
Tamsulosin or a1-antagonists.
They relax ureteral muscles and decrease intraureteral pressure – facilitate stone passage and reduce need for analgesics.
Tx of PCT:
Serial phlebotomy or hydroxychloroquine along w/mgmt. of underlying causes (HCV).
Tx plan for patients with RA:
All pts should be started on DMARDs as soon as possible to prevent further joint damage.
Started on non-bio DMARDs first (MTX is DoC) and then if no improvement, step-up to a biologic DMARD after 6 mo.
Then NSAIDs and glucocorticoids can be added for symptom relief.
DMARDs:
Nonbiologic: MTX (Initial DoC), Hydroxychloroquine, sulfasalazine, leflunomide, azathioprine
Biologics: Etanercept, infliximab, adalimumab, tocilizumab, rituximab.
What can ingestion of home distilled liquor cause?
Lead poisoning. Often distill alcohol through parts w/lead soldering.
Best tx of Anaphylaxis:
IM epinephrine
What is likely to be the cause of NPH?
Decreased CSF absorption
What is pathognomonic for rhabdomyolysis on urine analysis?
3+ blood with no RBCs on microscopy. Bc the myoglobin is making it positive for blood.
What causes Graves ophthalmopathy?
T cell activation and stimulation of orbital fibroblasts by TSH-R auto-Abs leading to expansion of orbital tissues.
What is a complication of supplemental O2 in advanced COPD patients?
CO2 retention and worsened hypercapnia d/t
1- Increased dead space perfusion – V/Q mismatch
2- decreased affinity of oxy-Hb for CO2
3- reduced alveolar ventilation.
Can cause increased lethargy and confusion and lead to seizure.
What should the goal O2 saturation be in pts. w/advanced COPD?
SaO2 90-93% or PaO2 60-70mmHg
Will decrease chance of CO2 retention.
Heme abnormalities in Chronic renal failure:
Platelet dysfxn is the most common cause of abnormal hemostasis in pts. w/CRF.
Get abnormal bleeding and bruising in uremic coagulopathy
PT, aPTT, and platelet count will be normal, but BT is prolonged.
DDAVP is DoC.
**DON’T give platelet transfusion bc the new platelets will quickly become inactive
What comorbidities are a/w PCOS?
Metabolic syndrome (diabetes, HTN) Obstructive sleep apnea Nonalcoholic steatohepatitis Endometrial hyperplasia/cancer **Scren for DM w/oral glucose tolerance tes
Most common cause of Acute Liver Failure:
Acetaminophen toxicity
What is the preferred tx for Diabetic gastroparesis?
Metoclopramide – it is a prokinetic and antiemetic.
Tetrad that characterizes Neuroleptic malignant syndrome:
Mental status change
Rigidity
Fever
Autonomic dysregulation
How to differentiate b/w NMS and Rx-Induced Parkinsonism:
Only NMS will have autonomic instability and fever. Also more likely to see mental status changes.
Both will have tremors, rigidity, and gait abnormalities.
Pathophys of Cyanide toxicity:
Cyanide binds cytochrome oxidase and inhibits mitochondrial oxidative phosphorylation.
Cells shift to anaerobic metab w/decreased ATP production – lactic acidosis.
Thiocyanate accumulation causes the neuro sxs.
Treatment of Cyanide toxicity:
Sodium Thiosulfate
What would cause refractory hypokalemia?
Hypomagnesemia is one of the most common causes.
Intracellular Mg inhibits K+ secretion by renal outer medullary K+ channels in the CT of the kidney; So when Mg is low K is secreted in xs.
What lab values will be seen in hyperthyroidism d/t exogenous intake?
Low TSH
High fT3 and T4
Low radioactive iodine uptake
Low serum Thyroglobulin
What thyroid condition will give you an elevated ESR?
Subacute (DeQuervain’s) thyroiditis.
Most likely cause of Culture negative urethritis?
Chlamydia
Effects of UGI bleeding on BUN/Cr:
Pts. w/upper GI bleeding, but not lower, may have increased BUN:Cr d/t increased urea production (from intestinal Hb breakdown) and increased urea reabsorption (d/t hypovolemia).
No changes are seen with creatinine.
Meningococcal vax schedule:
Regular – Primary vaccine age 11-12, then booster at age 16-21
High-risk patients – Vaccinate/booster even if age >18 for pts w/complement deficiency/asplenics, college students in residential housing (<21yo), military recruits, travelers to endemic areas, exposure to community outbreaks.
When should epidural glucocorticoid injections be used for low back pain?
In patients with lumbosacral radiculopathy who haven’t responded to initial tx.
NOT helpful for nonradicular pain.
Heme effects of ParvoB19:
Transient pure red cell aplasia
Aplastic crises in pts w/underlying heme disease.
Arthritis of ParvoB19:
Non-destructive (like SLE)
Acute, symmetric – affects hands (MCP, PIP, and wrists), knees, and ankles.
Most common behavioral risk for TB:
Substance abuse
Common findings in invasive aspergillosis:
Triad of fever, chest pain and hemoptysis
Pulmonary nodules (yes plural) with halo sign (surrounding ground-glass opacities)
Positive cell wall biomarkers (galactomannan, beta-D-glucan)
Mgmt of DKA:
NORMAL (0.9%) saline and regular insulin infusion.
Can add dextrose 5% once glucose is <200 mg/dL
Add K+ if serum K+ is < 5.2 mEq/L
AE of EPO therapy:
HTN – may lead to HTN crises esp. in pts who receive large doses or experience a rapid rise in Hb concentration.
Dialysis disequilibrium syndrome:
D/t osmotic shifts during hemodialysis – causes changes in neuro status d/t cerebral edema. May cause HA and N.
What is salvage therapy?
A form of treatment for a disease when a standard tx fails.
Ex: Radiation for prostate ca. recurrence after radical prostatectomy fails.
Lab values in steroid abuse:
Erythrocytosis/increased erythropoiesis – elevated Hb
Cholestasis
Hepatic failure
Dyslipidemia
Slight elevation in Creatinine (d/t increased mm. mass)
Lab values in Klinefelter syndrome:
Low/no testosterone
High FSH and LH
Azoospermia
What risk is increased in pts w/plantar puncture wounds through footwear?
Osteomyelitis d/t Pseudomonas.
What adjunctive therapy can be used to tx PCP?
In addition to TMP-SMX corticosteroids may be used and have been shown to reduce mortality in severe cases.
Indications: PaO2 <70 or A-a gradient >35 on room air.
What is an external hordeolum, what causes it, what is used to tx?
Hordeolum = stye.
Its an acute inflamm. disorder of the eyelash follicle or tear gland.
Often d/t S. aureus, but can be sterile.
Tx: warm compresses.
If it persists or is v. large may consider I+D.
Typical features of cerebellar hemorrhage:
Occipital HA (may radiate to neck/shoulders)
Neck stiffness (d/t extension of blood into 4th ventricle)
N/V
Nystagmus
Ipsilateral hemiataxia
First-line tx of Reactive arthritis:
NSAIDs.
Abx are not used.
Pulse in severe aortic stenosis:
Pulsus parvus et tardus
Delyaed/Slow-rising and diminished/weak carotid pulse.
Winter’s Formula:
PaCO2 = 1.5 (HCO3-) + 8 +/- 2
What are conduction abnormalities in pts. w/IE suspicious of?
Perivalvular abscess – most commonly seen with aortic valve involvement.
These are seen in almost 30-40% of patients with IE.
Postconcussive syndrome:
Follows TBI (hrs to days)
Sxs: HA, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep disturbance, and anxiety.
Typically resolves w/in weeks to few months w/symptomatic tx.
What Rx increase risk of Exertional heat stroke?
Anticholinergics, antihistamines, phenothiazines, and TCAs.
Mgmt of exertional heat stroke:
Rapid cooling – ice water immersion preferred
Fluid resuscitation
Electrolyte correction
No role for antipyretics
Anticholinergic toxicity presentation:
Hyperthermia, tachycardia, dry skin, nonreactive mydriasis (Dilation w/ineffective accommodation), and decreased bowel sounds.
MOF/dysfxn is uncommon
What anti-DM medication is most likely to result in weight loss?
GLP-1 Receptor agonists (Exenatide, Liraglutide).
Pioglitazones (TZDs) and Sulfonylureas are likely to cause weight gain.
How to differentiate diarrhea in AIDS pts:
All can cause weight loss
Cyrptosporidium (CD4<180) – severe watery diarrhea, low fever
Micro/Isosporidium (CD4<100) – watery diarrhea, crampy AbdP fever RARE
MAC (CD4<50) – watery diarrhea HIGH FEVER (> 39/102)
CMV (CD4<50) – small volume diarrhea, only one that can be bloody/hematochezia, AbdP, low fever
When is asterixis seen?
Hepatic encephalopathy
Uremic encephalopathy
CO2 retention
Indications for Urgent Dialysis:
AEIOU
Acidosis – metabolic acidosis (pH < 7.1 and refractory to tx)
Electrolyte abnorms – symptomatic/severe hyperkalemia (EKG changes, arrhythmias, K>6.5)
Ingestion – toxic alcohols (MeOH, ethylene glycol), salicylate, Lithium, Na-valproate, carbamazepine
Overload – V overload refractory to diuretics
Uremia – symptomatic, encephalopathy, pericarditis, bleeding
What is hemi-neglect syndrome?
Caused by a lesion to the R/non-dominant parietal lobe, responsible for spatial organization.
Characterized by ignoring the L side of a space, and possible anosognosia
What are common BRAF inhibitors?
Vemurafenib and Dabrafenib
Adalimumab MoA and conditions it treats:
TNF-a inhibitor.
Txs IBD, RA, ankylosing spondylitis and psoriasis
What dx procedure should be done for pts. w/painless, gross hematuria?
Cystoscopy – to evaluate for bladder cancer.
Acid-Base abnormalities a/w salicylate toxicity:
Combined Respiratory alkalosis and an anion-gap metabolic acidosis
Clinical associations with FSGS:
AfAm + Hispanic ethnicity, obesity, HIV, heroin use
What post-MI cx is likely to cause biventricular failure?
Interventricular septum rupture aka VSD.
Aminoglycoside toxicity:
Can damage the cochlear cells – ototoxicity
Gentamicin especially can also damage the motion-sensitive hair cells in the inner ear to cause selective vestibular injury (vestibulopathy) w/or w/o ototoxicity.
What should be done before initiating trastuzumab therapy?
Trastuzumab = HER2 inhibitor
Baseline assessment of cardiac fxn by echo.
It is cardiotoxic.
2 Primary manifetations of Chagas disease:
Megacolon/megaesophagus and cardiac disease.
What patients should metformin be avoided in?
Acutely ill pts w/ARF
Pts predisposed for hypoxia (CVD, CKD, COPD)
Liver failure
Sepsis
All these conditions increase risk of lactic acidosis
Lab findings in PSGN:
UA: Protein+, Blood+, RBC casts +/-
Serum: decreased C3 and C4, increased Anti-DNase B, anti-AHase (antihyaluronidase), ASO, and anti-NAD
First line therapy for Raynaud?
Dihydropyridine CCBs (Nifedipine, Amlodipine) – just like vasospastic angina
What criteria must be met to receive pphx for Lyme dx?
Must meet all 5!
1- Tick is adult or nymphal Ixodes scapularis
2- Tick attached for >36hrs or engorged
3- Pphx started w/in 72hrs of removal
4- Local B. burgdorferi infection rate >20%
5- No contra’d to doxycycline
Effects of hypopituitarism on aldosterone:
There are no significant effects.
Adrenal aldosterone is mainly regulated by the RAAS and is not affected by low ACTH.
Tx of toxic megacolon:
IVF, BS Abx, and bowel rest.
IBD-induced should be treated w/IV corticosteroids
AEs of MTX:
Pancytopenia, folic acid deficiency, nausea, stomatitis, rash, hepatotoxicity, ILD, alopecia and fever.
Difference b/w case control and retrospective cohort:
Case control compares a group w/disease v w/o and tries to find risk factors
Retrospective cohort finds a group w/ a risk factor v a group w/o the risk and sees if the disease developed in each group.
Most appropriate diagnostic tests for acute HBV infection:
HBsAg and anti-HBc bc they’re both elevated during initial infection, and anti-HBc will remain elevated during the window period.
What is the most common tx of homocysteinemia?
Folate and B6.
Need B6 as cofactor for cystathionine B-synthase which catalyzes homocysteine to cystathionine.
If documented B12 deficiency then cobalamin is addcled.
Diagnosis of Dermatomyositis:
Increased CPK, aldolase, LDH
Anti-RNP, anti-Jo1 and anti-Mi2(anti-helicase) Abs
Can do EMG or mm./skin bx if uncertain
Should screen for malignancy once diagnosed.
Typical features of CJD:
Rapidly progressive dementia, myoclonus, and sharp, triphasic, synchronous discharges in EEG.
What are Hollenhorst plaques and when are they seen?
Bright, yellow, refractile plaques in the retinal a. seen on fundoscopy. These are seen in atheroembolism/cholesterol embolism and indicate a more proximal source (Internal carotid).
What is a mediastinal mass w/elevated AFP and B-hCG diagnostic of?
A nonseminomatous germ cell tumor.
If found a testicular US should be performed to exclude a sm. primary tm there.
What could pulsatile tinnitus in a young woman be concerning of?
Fibromuscular dysplasia with involvement of the carotid or vertebral aa.
Or Idiopathic Intracranial HTN
Treatment of Paget disease:
Bisphosphonates
What conditions are a/w Pseudogout?
Hemochromatosis
Hyperparathyroidism
Trauma/Overuse/Surgery
What is the main measure of association in case controls?
Exposure odds ratio
When is prevalence odds ratio calculated?
In cross-sectional studies
Tx for severe hypovolemic hypernatremia:
Isotonic 0.9% saline.
Once the volume deficit has been restored pts can be switched to half-normal 0.45% saline to better replace the free water deficit.
Goal rate of plasma Na+ correction is no more than 1mEg/L/hr to prevent cerebral edema.
Less severe cases can be treated w/5% dextrose in 0.45% saline
Most common cause of hypernatremia?
Hypovolemia
What is Ichthyosis vulgaris?
Chronic, inherited skin disorder characterized by diffuse dermal scaling. Caused by mutations in flaggrin gene.
Situational syncope:
Form of reflex/neurally mediated syncope a/w triggers – micturition, cough, defecation.
Triggers cause alteration in ANS response and lead to cardioinhibitory, vasodepressor or mixed response.
Increased PSNS and decreased SNS
Aspirin-exacerbated respiratory disease:
Non-IgE mediated, psuedoallergic Rx reaction.
Seen in pts. w/hx of asthma, chronic rhinosinusitis w/nasal polyposis.
Characterized by bronchospasm and nasal congestion following aspirin ingestion.
Post-exposure pphx in HBV unvax’d pts:
Immediate HB vaccine and HB immune globulin with follow up serology.
HSV retinitits in an IMCP’d pt:
Rapidly progressing b/l necrotizing retinitis – “acute retinal necrosis syndrome.”
Initial sxs: keratitis, conjunctivitis w/eye pain, followed by rapid vision loss.
Fundoscopy: widespread, pale, peripheral lesions and central necrosis of the retina.
VZV may also cause this same type of retinal necrosis.
Most common cause of corneal blindness in the US:
HSV infection.
CMV retinitis:
Most common ocular cx in HIV pts.
Typically painless (unlike HSV)
Fundoscopy: fluffy or granular retinal lesions near the retinal vessels and assoc. hemorrhages.
No conjunctivitis or keratitis like in HSV.
What is sympathetic ophthalmia?
“Spared eye injury”
Immune-mediated inflammation of one eye after a penetrating injury to the other eye.
Typically see anterior uveitis, but panuveitis, papillary edema, and blindness may develop.
Pathophys is thought to be the uncovering of “hidden antigens.”
Cxs of Subarachnoid hermorrhage:
Re-bleed (first 24hrs) Vasospasm (>3days – use nimodipine to prevent) Hydrocephalus/increased ICP Seizures Hyponatremia (from SIADH)
Serum measurement of what has a high sensitivity of diagnosing CHF?
BNP.
Elevated levels of BNP correlate w/the severity of LV dysfunction and help differentiate dyspnea 2/2 CHF from other causes.
What conditions are a/w Nephrotic syndrome 2/2 AA amyloidosis?
Chronic inflammatory conditions: RA, IBD
Chronic Infections: Osteomyelitis, TB
Risk factors for Fluoroquinolone associated tendinopathy:
Age >60, normal BMI, female, concurrent oral corticosteroid use, recent transplant.
Anti-mitochondrial Abs:
Seen in PBC – high sensitivity and specificity
Typical presentation of Idiopathic Intracranial HTN:
Holocranial HA
Vision changes (blurry/diplopia)
Pulsatile Tinnitus
When is Papilledema a contraindication to LP?
Only when the pt has evidence of obstructive/non-communicating hydrocephalus +/- a space-occupying lesion, or midline shift.
What does the pronator drift test assess?
UMN or pyramidal/corticospinal tract disease.
What are signs of pyramidal tract injury?
Pronator drift, focal weakness, spasticity, hyperreflexia, and Babinski sign.
What is most likely a/w pts describing a “curtain drawn down” over the eye?
Retinal detachment.
May also be seen in amaurosis fugax/central retinal a. occlusion.
Lung cancer screening:
Can be done w/annual low-dose CT for patients 55-80 with >30 pack year smoking history.
CXR has not been shown to reduce mortality as a screening method.
Murmur heard in HCMP:
Harsh crescendo-decrescendo systolic murmur heard best at the apex and lower left sternal border.
Valvular abnormalities a/w bicuspid aortic valve:
In younger patients: Aortic regurg
In older: aortic stenosis
How to calculate the corrected Ca2+ level:
Corrected Ca2 = Measured Ca2 + 0.8 (4-Albumin)
Tx for Syphillis in a Pen-Allergic patient:
Oral Doxycycline for 14 days
Pen desensitization should be avoided if possible.
What abx therapy should be started in prostatitis while awaiting urine cultures?
TMP-SMX or Fluoroquinolone for acute
Fluoroquinolone for chronic.
Role of PEEP in respiratory distress:
PEEP prevents alveolar collapse and may also reopen some alveoli that have already collapsed, reducing shunting.
High PEEP will improve oxygenation and directly counteract a mechanism by which ARDS causes hypoxemia.
High PEEP may improve mortality in pts. w/severe ARDS.
When should hypercoagulability testing be done?
In pts <45 with a 1st time unprovoked DVT/PE
Pts w/recurrent DVT/PE
Pts w/unusual sites of thrombi (cerebral, mesentery, portal vv.)
Manifestations of HITT:
Thrombocytopenia – normally with platelets <60K. d/t RES removal of ab-coated platelets.
Thrombus – HIT Abs activate platelets and cause aggregation w/ release of procoagulant factors.
What is required for dx of malignant HTN?
Severe HTN w/retinal hemorrhages, exudates, or papilledema.
Malignant nephrosclerosis is often seen, but not always present and not required for diagnosis.
What differentials present with low DLCO?
Obstructive spirometry – Emphysema
Restrictive – ILD, Sarcoidosis, asbestosis, heart failure
Normal – Anemia, PE, pHTN
What differentials present with Normal DLCO?
Obstructive – Chronic bronchitis, asthma
Restrictive – MSK deformity, Neuromuscular disease.
What differentials present w/Increased DLCO?
Obstructive – asthma
Restrictive – morbid obesity
Normal – pulm hemorrhage, polycythemia
What is the management for pts w/Epidural spinal cord compression?
Emergent MRI, IV glucocorticoids (given 1st before confirmation w/MRI), and Neurosurgery consult.
Common presentation of pancreatic cancer:
Most occur in the head and compress the pancreatic duct and common bile duct –> painless jaundice.
Backup of bile leads to intra- and extrahepatic biliary duct dilation and nontender distended GB.
Jaundice can lead to pruritus, pale stools, and dark urine.
What is Felty syndrome?
RA – erosive jt disease/deformity, rheumatoid nodules, vasculitis (mononeuritis multiplex, necrotizing skin lesions)
Neutropenia
Splenomegaly.
Often are anti-CCP and RF +, have v. high ESR.
What causes the myopathy a/w Cushing syndrome?
Direct catabolic effects of cortisol on sk.mm. which leads to muscle atrophy.
NOT d/t an electrolyte imbalance.
How to diagnose CO poisoning:
ABG – check carboxyHb levels, EKG and cardiac enzymes is Ischemia or CAD.
How to diagnose acromegaly:
First test IGF-1, if elevated confirm w/ glucose suppression test – normal pts. glucose will rapidly suppress GH secretion. In acromegaly it will not decrease and may even have a paradoxical increase.
Treatment of Neurosyphillis:
IV penicillin for 10-14d (Not IM PenG like primary)
1st line tx for Chemo-Induced N/V:
5HT3R antagonists – odansetron
Common precipitating factors for HHS:
Hyperosmolar hyperglycemic state
Infection (most common)
Meds (Steroids, thiazides, pentamidine, atypical antipsychs.)
Injury/Acute Illness
Interruption of insulin tx
HHS typically develops over days – weeks.
What causes the neurologic sxs in HHS?
Confusion to coma can occur and are primarily d/t the high serum osmolality (norm. >320 mOsm)
HHS pts typically have pseudohyponatremia and therefore this is not a cause of neuro sxs
Nephropathy with dense intramembranous deposits that stain for C3 but not Igs:
Membranoproliferative glomerulonephritis type 2 aka Dense deposit disease. IgG Abs (C3 nephritic factor) directed against C3 convertase of the alt. complement pathway lead to persistent complement activation and kidney damage.
What type of ulcers are typically seen on plantar surface of foot/toes?
Diabetic foot ulcers – tested for w/monofilament test.
In contrast arterial ulcers are often at v tip of toes but not plantar surface.
Causes and risk factors of GBS:
Most common cause is C. jejuni. Others – HHVs, Mycoplasma, H. influenzae.
Pts. at higher risk: Lymphoma, Sarcoidosis, SLE, recent HIV infection, and recent immunization.
Preferred tx for Pen-susceptible IE:
IV aqueous penicillin G or IV ceftriaxone for 4 wks.
PO abx aren’t recommended.
Tx of Ethylene glycol poisoning:
Fomepizole (competitive inhibitor of Alcohol DH) or EtOH. These prevent further breakdown into toxic metabs.
Bicarb can help alleviate acidosis
Hemodialysis may be required.
What does methylene blue tx:
Methemoglobinemia
Osteitis deformans:
Paget disease
Effect of serum albumin on Ca2+:
Decreases in albumin will cause a decrease in total serum Ca2+ bc about half of total blood Ca2+ is bound to it.
Ionized Ca2+ is hormonally regulated though and remains stable, so Ca2+ levels must be corrected based on albumin levels.
What Meds should always be considered in the differential dx of peripheral edema?
Dihydropyridine CCBs (Amlodipine and Nifedipine)
How to differentiate embolic v. thrombotic ischemic strokes:
Thrombotic are a/w AS risk factors, and sxs may alternate w/periods of improvement.
Emboli are a/w hx of cardiac disease and the onset is abrupt and normally maximal at the start. Will see multiple infarcts in different vascular territories.
pH effects on serum Ca2+:
Increased extracellular pH (alkalosis) causes H+ to dissociate from albumin, freeing up space for more ionized Ca2+ to bind. This leads to a decrease in ionized Ca2+, though total Ca2+ levels remain unchanged.
Causes signs/sxs of hypocalcemia – crampy pain, paresthesias, carpopedal spasm etc.
Seen in pts w/PE for example who get resp. alkalosis from hyperventilation.
What are the potential causes of hypocalcemia w/elevated PTH?
Endo: Vit.D def., CKD
Inflammatory: Pancreatitis, Sepsis
Oncology: Tumor lysis syndrome
Rxs that cause hypocalcemia:
Ca-chelators, Bisphosphonates, phenytoin
Features of Pyruvate Kinase deficiency:
Chronic hemolysis, hepatosplenomegaly, skin ulcers and pigmented gallstones.
Not triggered by stress/drugs like G6PD.
Seen as hemolytic anemia in a newborn.
Attributable risk percent calculation:
The risk percentage that can be explained by a particular exposure or risk factor
ARP = (Risk in exposed – risk in unexposed)/ Risk in exposed
ARP = (RR-1)/RR
(If a group has 4x risk w/an exposure the ARP=4-1/4=75%)
Tx for Exercise Induced Bronchoconstriction:
SABA 10-20min before exercise
Those who exercise daily can try ICS or antileukotriene agents.
What is Polymyalgia Rheumatica?
Seen commonly in pts w/temporal arteritis
Presents w/morning stiffness, pain and decreased RoM in the shoulders, neck and hip girdle.
Stiffness > Pain
Have normal muscle strength
Increase in ESR, normal CRP and creatinine kinase.
Tx w/glucocorticoids.
What are tophi?
Tumors formed in soft tissues by urate crystal deposition.
White in appearance and can ulcerate and drain a chalky material.
Mgmt of Diabetic foot infections:
Wound debridement and empiric IV abx (pip-tazo + vancomycin) to cover the polymicrobial nature of these infections.
Features of Interstitial cystitis:
Aka Bladder pain syndrome
A/w psychiatric and pain disorder (fibromyalgia)
Presents as bladder pain w/filling, relief w/voiding, increased freq, urgency and dyspareunia.
Pain can be exacerbated by exercise, EtOH and sex
Normal UA
Tx: not curative, can give Amytiptyline, pentosane polysulfate sodium, and analgesics for acute exacerbations.
Tx of Toxoplasmosis:
Sulfadiazine and Pyrimethamine + Leucovorin
PPhx w/TMP-SMX
Endocrine causes of recurrent pregnancy loss:
Thyroid disease PCOS DM Hyperprolactinemia **Celiac (not an endocrine dx) can also cause it
CA-MRSA Pneumonia:
A common cause of secondary bacterial pneumonia that complicates the flu. Often seen in young people.
Get severe, necrotizing pneumonia that’s rapidly progressive and often fatal.
Sxs: high fever, productive cough w/hemoptysis, leukopenia, and multilobar cavitary infiltrates.
CXR: multilobar (often midlung) infiltrates b/l and thin-walled cavities.
Behcet disease:
Seen in young adults of Turkish, middle east or Asian descent.
Get recurrent painful oral aphthous ulcers, genital ulcers, eye lesions (uveitis), skin lesions (erythema nodosum, acneiform lesions) and thrombosis.
May also get pathergy – exaggerated skin ulceration w/ minor trauma (needlestick)
What Rx-Combo is likely to reduce the risk of CCB-assoc. peripheral edema?
CCB + ACEI
Features of PCP:
Elevated LDH! With diffuse reticular infiltrates on imaging.
Normally indolent in HIV but can cause acute respiratory failure in IMCP’d
Presents w/fever, dry cough and decreased O2 levels.
CVS manifestations of Primary HyperPTHism:
HTN, arrhythmias, ventricular hypertrophy and vascular/valvular calcification.
Significant HTN a/w HyperPTHism should be worked up for MEN2 and pheochromocytoma.
What should victims of smoke inhalation be treated for?
CN toxicity and CO toxicity.
What is the likely mechanism of lactic acidosis in smoke inhalation victims?
CN toxicity – it binds Ferric iron in Cytochrome oxidase a3 of electron transport chain which blocks oxidative phosphorylation and promotes anaerobic metab – lactic acidosis.
Features of Sideroblastic anemia:
Microcytic anemia w/dimorphic RBC population (both normo- and hypochromic RBCs)
Will have normal Fe levels and decreased TIBC to differentiate from Fe-def anemia.
Caused by B6/pyridoxine deficiency.
Derm associated cx of M. penumoniae infection:
SJS
What infection is a/w aged seafood?
Aka cured fish – get foodborne Botulism
Tx of Botulism:
Equine serum heptavalent botulinum antitoxin
Findings suggestive of severe AS:
Sxs of fatigue, exertional lightheadedness, syncope
Diminished/delayed carotid pulse – parvus et tardus
Mid to Late-peaking systolic murmur
Presence of soft and single S2.
Early peaking of the murmur suggests mild-mod AS – these pts are typically asx.
Cxs of PBC:
Malabsorption, fat-soluble vitamin deficiencies
Severe hyperlipidemia w/xanthelasmas
Metabolic bone disease – osteoporosis, osteomalacia (w/normal levels of Ca and Vit. D - bone dx isn’t from malabsorption)
HCCa.
Hyperlipidemia a/w PBC:
HDL elevation out of proportion to LDL.
Does not increase the risk of AS.
Where is bile absorbed?
In the ileum.
Pts w/ileal disease (Crohn’s) can get bile salt malabsorption/bile salt diarrhea
Effects of HoVolemia on Na+ values:
HoVolemia can cause hyponatremia as well, but many patients have normal serum Na+ levels, and some may even have hypernatremia.
However all patients w/V depletion will have decreased urine Na+ d/t RAAS activation and aggressive Na+ reabsorption in the kidney.
Most common causes of bloody diarrhea:
E. coli (esp. if fever is absent)
Shigella (a/w fever)
Campylobacter
What types of shock will see an increase in SVR (afterload)?
Hypovolemic and Cardiogenic.
Septic shock the SVR decreases
Differentiate Cardio v. Hypovolemic based on increase in preload (RA pressure, and PCWP) in cardiogenic and decreased preload in hypovolemic.
Mgmt of acetaminophen toxicity:
For pts who present early (<4hrs from ingestion) gastric decontamination (activated charcoal) and measurement of acetaminophen levels should be obtained.
Then based on levels and time since ingestion it can be determined if N-acetylcysteine should be admin’d
Pts can be asx during first 24hrs post-ingestion.
Tx recommendations in pregnant women w/suspected APS:
PPhx w/Aspirin and LMWH to prevent arterial and venous thromboses and pregnancy loss.
Tachycardia-mediated cardiomyopathy:
Presents w/progressive dyspnea, decreased exercise tolerance, aFib w/RVR, and LV systolic dysfxn.
Dx: EKG, Echo, and exclusion of other causes of LV dysfxn.
Tx: Aggressive rate or rhythm control
Tx of Latent TB:
9 mo of Isoniazid + Pyridoxine
Latent TB is dx’d w/positive PPD and negative CXR/no sxs.
What is Melanosis coli characteristic of?
Laxative abuse – seen on colonoscopy
Dark brown discoloration of the colon w/pale patches of lymph follicles “alligator skin”
Can disappear if laxatives are stopped.
Histo will show pigment in the MPs of the lamina propria
Tx for Giardia:
Metronidazole
Features of Putaminal (BG) hemorrhage:
Putaminal hemorrhages almost always involve adjacent internal capsule – contralateral hemiparesis and hemianesthesia + conjugate gaze deviation toward side of the lesion (from damage to frontal eye field efferents in ant. limb)
Common site of HTN intraparenchymal brain hemorrhage.
Pontine hemorrhage features:
Deep coma and total paralysis w/in mins. Pinpoint reactive pupils.
Primary Pphx of esophageal variceal hemorrhage:
Nonselective BBs (Propranolol/nadolol), or endoscopal ligation.
Best investigation for pleural effusion:
Thoracocentesis, except in pts w/clear evidence of CHF – they undergo trial of diuretic therapy first.
Characteristics of Acute Interstitial Nephritis:
Maculopapular rash, fever, new Rx exposure, +/- arthralgias.
Mostly caused by Rxs – Pens (Naficilin common), TMP-SMX, cephalosporins, NSAIDs, omeprazole
Labs: AKI, pyuria, hematuria, WBC casts, eosinophilia
Renal bx: inflammatory infiltrates and edema
Infectious causes of Acute Interstitial Nephritis:
Legionella, TB, Streptococcus
These are uncommon causes. Rxs are most common cause of AIN.
Cxs of Paget disease:
Giant cell tm and osteosarcoma
What can Beta-D-glucan be useful in diagnosing?
Fungal infections – esp. candida and aspergillus
Cxs of Giant Cell arteritis:
Permanent vision loss d/t anterior ischemic optic neuropathy from arteritis and aortic aneurysm.
How does prevalence affect PPV and NPV?
Increased prevalence increased PPV and decreases NPV
Decreased prevalence increases NPV and decreases PPV
What are the contributing factors to orthostatic HoTN in the elderly?
Decreased baroreceptor sensitivity, arterial stiffness, decreased NE content of SNS nerve endings, and reduced sensitivity of the myocardium to SNS stimulation.
Characteristics of Myasthenic crisis:
Increased generalized and oropharyngeal weakness, resp insufficiency/dyspnea
Risk factors: Infection, surgery, pregnancy/birth, tapering immunosuppressants, Rxs – aminoglycosides, BBs.
Tx: Intubation, Plasmapheresis, IVIG and corticosteroids.
Daily AchEIs used in MG mgmt. should be held to prevent xs airway secretions and risk of aspiration.
