Uworld Misc. Flashcards
Arrhythmia ️Assoc. With digitalis toxicity
A-tach with av block
Usually it is rare for both of these to occur at the same time so this is pretty diagnostic
Initial Tx for Hypovolemic Hypernatremia and correction rate
Isotonic saline
Can use hypotonic saline once the patient is hemodynamically stable and euvolemic
Correction rate: .5meq/dl/hr without exceeding 12 in 24 hrs
This is done to prevent cerebral edema
Hairy cell leukemia
B cell neoplasm associated with BRAF mutations
Clinical: Pancytopenia (infections, anemia, ️Bleeding)
Splenomegaly
Dx: BM biopsy
Tx: chemo
Isolated increased ALK phos in a patient with an enlarging cap size
Paget’s disease
Vasospastic angina
Hyperreactivity of ️coronary smooth muscle leading to transient myocardial ischemia
Presents in young patients (<50) who are smokers but lack other RFs for heart disease; have recurrent chest discomfort
️Occurs at rest and during sleep; resolves spontaneously
Diagnosis: ST elevations with exertion however, ️coronary angiography shows no CAD
Tx: CCB (preventative), nitroglycerin (acute)
Earliest renal abnormality in diabetes patients
Glomerular hyper filtration
ACEIs help prevent this and therefore reduce chances of developing diabetic nephropathy
Warm agglutinin AIHA
Caused by drugs (usually penicillins), viral infxns, AI disorders (lupus), and immunodeficiency or Lymphoproliferative states
Ss: Normocytic Anemia with hemolysis
DAT (+) with anti-IgG or anti-C3
Tx: corticosteroids, splenectomy if necessary
Serum osmolality calculatio
[2 X (Na)] + [(glucose)/18] + [(BUN)/2.8]
Hemodynamic measurements in hypovolemic shock
RA pressure (preload) (pulmonary capillary wedge) ⬇️
Cardiac index (output) ⬇️
SVR (Afterload) ⬆️
MvO2 ⬇️
Cavernous sinus thrombosis
Can occur following infections of the facial skin, sinuses, and orbit ➡️ life-threatening CST and intracranial hypertension
Develop low grade fever, headache, and periorbital edema alongside CN II, IV, V, and VI pansies
Tx: Broad spectrum antibiotics and reversal of cerebral herniation if necessary
IgA nephropath
Gross ️hematuria following a URI that happens within 5 days of the infxn
⭐️ Common in young adult men ages 20-30
Ss: Recurrent gross ️hematuria
Extrarenal manifestations of ADKPD
Cerebral aneurysm
Hepatic or pancreatic cysts
Mitral valve prolapse
Aortic regurgitation
Colonic Diverticulation
Ventral or inguinal hernia
Dx: Abdominal US
Cauda equina syndrome
Bilateral and severe radicular pain
Saddle anesthesia
Asymmetric motor weakness
Hyporeflexia
Late onset bowel and bladder dysfunction
Conus medullaris syndrome
Sudden onset of severe back pain
Perianal anesthesia
Symmetric motor weakness
Hyperreflexia
Early onset bowel and bladder dysfnxn
Tx for tachyarrhythmia with hemodynamic instability
Synchronized cardio aversion
Disseminated histoplasmosis
Found in Midwestern US in soil contaminated by bird or bat droppings
S/s: Systemic (fevers, malaise, chills)
Weight loss/ cachexia
Cough, dyspnea
Mucocuatenous ulcers and papules
Lymphadenopathy, hepatosplenomegaly
Dx: Pancytopenia, increased LDH and ferritin
***Urine/serum Histoplasma antigen
CXR: Reticulonodular opacities
Tx: Ampho B in hospital
After improvement, oral itraconazole is continued for 1 year for maintenance therapy
Earliest finding in macular degeneration
Distortion of straight lines to where they start to appear wavy in the affected eye
ADKPD extrarenal complications
Hepatic cysts (most common)
Valvular heart disease (mitral valve prolapse or aortic regurg.)
Colonic diverticula
Abdominal/inguinal hernia
***INTRACRANIAL BERRY ANEURYSM
HIV patient with painful swallowing and substernal burning
HIV esophagitis
Occurs when CD4 <100
Etiologies: Candida, HSV, CMV
Tx: Empiric treatment with oral fluconazole; if they do not respond, THEN GET ENDOSCOPY
Pseudotumor cerebri
Idiopathic Intracranial HTN
Patients present with a headache that is pulsatile and awakens the patient at night, transient vision loss, pulsatile tinnitus (whooshing sound in the ears) and diplopia
S/S: Papilledema, peripheral visual field defects, CN VI palsy
RFs: Overweight
Isotretinoin, tetracyclines, hypervitaminosis A
Tx: Stop medications
Weight loss
Acetazolamide for idiopathic cases
Hidradenitis suppurativa
Also known as acne inversa
Occurs in intertrigous areas and is due to a chronic inflammatory occlusion of folliculopilosebaceous units preventing keratinocytes from shedding epithelium
RFs: DM, smoking, obesity, skin friction
S/s: Painful, solitary, and inflamed nodules that can progress to abscesses that open with purulent or serosanguineous drainage
Can lead to sinus tracts, comedones, and scarring with lymphedema
Test for lactose intolerance
Lactose hydrogen breath test
-Increased breath hydrogen level after ingesting lactose =» POSITIVE
Test to always include in Hep B testing
Anti-HepBc
This is the one that is positive during the window period
Patient with sudden visual loss and S/s suspicious for GCA
Give High dose steroids
Wait for the temporal artery biopsy
Toxic Shock Syndromew
Patient who has had a tampon in OR had a recent nasal packing
Followed by:
Rash Fever Hypotension Diarrhea Thrombocytopenia Skin desquamation including palms and soles
And 3 of the following systems: GI involvement (vomiting/diarrhea) Muscular (myalgia, elevated CK) Renal (Elevated BUN/Creatinine) Heme (Thrombocytopenia) Liver (Elevated transaminases) CNS (altered mentation without focal signs)
Tx: Fluids, broad-spectrum anti-Staphylococcal abs
Trichinellosis
Patient eats undercooked meat (usually pork) and develops acute GI illness; corresponds to larvae invading SI and developing into worms
2-4 weeks later:
Larvae encyst into muscle and cause myositis, subungual hemorrhages, periorbital edema, and eosinophilia
Classic triad: Periorbital edema + myositis + eosinophilia
Prevention of calcium kidney stones
Decreased sodium intake
=» Will enhance calcium excretion
NMS tentrad
MSC
Rigidity
Fever
Autonomic dysregulation (tachycardia, hypertension, tachypnea)
Tx of uric acid stones
Hydration
Alkalinization of the urine (Potassium citrate usually)
Low-purine diet
If absolutely necessary: Allopurinol (but only helps if there’s hyperuricemia)
Initial therapy for aortic dissection
IV BBs (labetalol, propanolol, esmolol)
Decrease the HR, contractility, and SBP
Wedge shaped infarct on chest CT scan
Think PE
Periinfarction ventricular arrhythmias
Phase 1a - Acute ischemia causing heterogeneity of conduction with areas showing marked slowing and delayed activation
Phase 1b - Occur 10-60 minutes following infarction and represent abnormal automaticity
Primary polydipsia
Patients present with hyponatremia, decreased serum osmolality, and decreased urine osmolality and a normal BP
Common in pts. with psychiatric conditions
Giant cell tumor
Eccentric and lytic area of epiphyseal bone (soap bubble)
Benigh and locally aggressive skeletal neoplasm seen in YOUNG ADULTS
S/s: Pain, swelling, decreased ROM, pathologic fracture
Tx: Surgery
Arsenic poisoning
Binds to sulfhydryl groups and interferes with enzyme activity regulating cellular respiration
RFs: Pesticides, contaminated well water, pressure-treated wood (antiquing)
S/s: Stocking-glove neuropathy
Hyporeflexia
Distal weakness
Hyperpigmentation of the skin
Hyperkeratosis of the soles and palms
Horizontal striation of the fingernails (DIAGNOSTIC)
Pancytopenia
Tx: Dimercaprol
Patient with an increased T4 but normal TSH
Suggestive of a euthyroid state; look for possible causes of increased TBG such as estrogens, hepatic dysfnxn, or tamoxifen
Isolated systolic hypertension
Systolic pressure >140 with a diastolic of <90
Path: Increased stiffness of the aorta and arterial walls in elderly patients reduces the abilities of the arteries to dampen systolic pressure
Tx: Lifestyle modifications and same pharmacologic therapy
Thyroid lymphoma
Presents as a rapidly enlarging, firm goiter assoc. with upper airway compressive symptoms; can have systemic B-sx.
- **Arises w/ preexisting Hashimoto’s thyroidits
- Suspect if patient has a positve TPO-antibody test
*When patients raise their arms, the mass will compress the subclavian and right internal jugular veins between the clavicle causing JVD
Dx: Core biopsy
Pemberton sign
Patient raises their arms up and get JVD due to compression of a lymphoma against the left subclavian and right internal jugular veins
Shy-Drager Syndrome
“Multiple System Atrophy”
- Parkinsonism
- Autonomic dysfnxn (postural hypotension, abnormal sweating, loss of bowel and bladder control, impotence, decreased salivation)
- Widespread neurologic signs (cerebellar, LMN)
**Consider when a Parkinsonian patient has signs of autonomic dysfnxn
Tx: Salt supplementation, fludrocortisone, a-agonists
Painless thyroiditis
Patient has increased T4 and decreased TSH
May have positive anti-TPO
Tx: BB (just to control symptoms of hyperthyroid phase)
Clubbing pathology
Megakaryocytes become entrapped in distal fingertips after bypassing the lungs (due to some pathology) and released PDGF and VEGF
=»CT hypertrophy and capillary growth
Scleroderma renal crisis
Increased vascular permeability, activation of the coag cascade, and increased renin secretion
=» Malignant HTN, RF (increased labs), and microangiopathic hemolytic anemia/DIC
Typically happens within 5 years of diagnosis
Paroxysmal nocturnal hemoglobinuria
AI hemolytic disorder characterized by intravascular and extravascular hemolysis and hemoglobinuria
Path: Lack of glycosylphophatidylinositol anchor that connects proteins CD55 and CD59 to RBC surface which normally inhibit complement activation
Clinical: Hemolysis, cytopenias, hypercoagulability
Dx: Flow cytometry to detect CD55 and CD59
*Sx. usually appear in pts. 40s
Malignant (necrotizing) otitis externa
Severe infxn of the external auditory canal and base of the skull usually caused by Pseud.
Most pts. are old, have poorly controlled DM, or immunosuppressed
S/s: Unrelenting ear pain worse at night, purulent drainage, sense of fullness, conductive hearing loss, granulation tissue and edematous external canal on otoscopy
Tx: IV ciprofloxacin
Middle mediastinal mass
Suspect bronchogenic cysts
Anterior mediastinal mass
Suspect thymoma
Patient with pain, itching, red streaks on their left arm that are palpable
Suspect Trousseau’s Syndrome
Hypercoagulable disorder associated with occult malignancy (usually pancreatic; can also be lung, prostate, stomach, colon)
Path: Tumor releases mucins that react with platelets to form microthrombi
***Patient’s with this should get a CT to find malignancy
Patient who received topical anesthetic and becomes hypoxic
Suspect methemoglobinemia; topic anesthetics cause the iron component of Hgb to be oxidized
Patients will have O2 sats that appear normal BUT this is because the O2 sat only measures the PaO2
S/s: Headache, lethargy, AMS, seizure, respiratory depression
Tx: Methylene blue
RFs for acute urinary retention
Male
> 80
Hx of BPH
Hx of neurologic disease
Recent surgery
Anticholinergics, opioids
Tx: Foley cath, urinalysis
Toxic megacolon
Caused by UC or C.diff infxn
S/s: Fever, tachycardia, hypotension, BLOODY diarrhea, abdominal distension,
Radio: Lead pipe
Tx: Supportive, Steroids if UC, surgery if unresponsive
Management of suspected esophageal perforation
Water soluble contrast esophogram
Suspect if recent endoscopy, esophagitis, ulcer, or heavy retching
Histoplasma capsulatum
Found in the Ohio and Mississippi river valleys in contaminated BAT DROPPINGS
***SUSPECT IN PTS WHO CAVE DIVE OR HAVE CHICKENS
S/s: Fever, chills, myalgias, DRY COUGH, HILAR LYMPHADENOPATHY
Dx: Histoplasma antigen urine testing; tissue diagnosis will reveal granulomas with budding yeasts
Botulism
Can be obtained from canned foods OR aged seafood (“cured”)
S/s: Blurred vision, diplopia, facial weakness, dysarthria, dysphagia, progresses to =»> Descending muscle weakness with possible diaphragmatic failure
Dx: Toxin in blood
Tx: Equine serum antitoxin (horse antitoxin)
First-time seizure in an adult
Run:
BMP, CBC, glucose, Ca2+, Mg2+, Renal and hepatic fnxn tests
AND DRUG SCREEN
-Possibly even consider an EKG
Patient with history of treated Hodgkin’s Lymphoma presenting with cough, hemoptysis, chest pain, and dyspnea
Likely a secondary malignancy developed after chemo or radiation therapy tx
BB OD
Bradycardia, AV block, hypotension, diffuse wheezing***
Tx: Secure airway, IV fluid boluses, IV atropine, IV glucagon
Consider IV calcium, EPI
K+ sparing diuretics
Spironolactone, amiloride, triamterene
Associated neoplasms with Lynch Syndrome
Colorectal cancer
Endometrial cancer (prophylactic hysterectomy after childbearing is complete is recommendation)
Ovarian cancer
Associated cancers with FAP
Colorectal cancer
Desmoids and osteomas
Brain tumors
Associated cancers with vHL Syndrome
Hemangioblastomas
Clear cell renal carcinoma
Pheochromocytoma
Vertebral osteomyelitis
Usually chronic and insidious
Will have tenderness to percussion over affected vertebrae
***Leukocytes can be normal as well as temp
***Usually will still have increased Platelets and ESR
Tx: Long term IV abs
Lead toxicity (3 manifestations)
- GI- abdominal pain, constipation
- Neuropsych- Forgetfulness, neuropathy, weakness in a stocking-glove distribution
- Hematologic- Microcytic anemia with basophilic stipling
* Also see HYPERURICEMIA
Drugs to start on RA patients
NSAIDS and MTX (or sulfasalazine, hydroxychloroquine, azathioprine)
***PTS NEED MTX to prevent progression of diseae
-Test them for Hep B, C, TB, and pregnancy
Dermatofibroma
Firm, small, hyperpigmented nodules that have a “dimple” when pinched
Typically follow a bug bite or minor trauma
Tx not required
MCC of pneumonia in IV drug abusers
Staph aureus
Septic embolism
Occur in pts with tricuspid endocarditis (think IV drug abusers)
Imaging may show pulmonary septic emboli seen as abscesses, infarction, or cavities typically in the lung periphery
Extraglandular features of Sjogrens
Raynaud phenomenon
Arthralgia
Interstitial lung disease
Idiopathic Intracranial HTN
Classic pt is an overweight woman of childbearing age possibly on OCPs, tetracyclines, or Vitamin A
-Pts. may have an empty sella, although, this is not diagnostic
Pts have an elevated opening pressure on spinal tap
Tx: Stop offending meds; weight loss and acetazolamide for idiopathic cases
Ichthyosis vulgaris
Chronic, inherited skin disorder characterized by diffuse dermal scaling caused by mutations in the filaggrin gene
Skin appears as “plated” much like reptile scales
*Symptoms often worse in the winter
Tx: Lotion, coal tar, topical retinoids
Work up for suspected Zenker’s
Contrast esophagram
Chronic prostatitis
Often a diagnosis of exclusion; presents as pain the perineum, pelvis, or genitalia with irritative voiding symptoms
-Urine is sterile; may have increased WBCs
Tx: Tamsulosin (a-blocker), antibiotics, finasteride
Tx for cutaneous larva migrans
Ivermectin (antihelminthic)
Patient who is vomiting up blood and you think is a risk for aspiration
INTUBATE; this will block off her airway and not allow her to aspirate while you get an upper endoscopy
Ludwig angina
Cellulitis of the submandibular space arising from a dental infxn; infxn is usually polymicrobial and spreads deep into the teeth roots
S/s: Fever, chills, malaise, local compressive symptoms such as drooling, mouth pain, muffled voice, and potential airway compromise
Tx: IV abxx (Bactrim, clindamycin); possible removal of tooth
Panendoscopy
Esophagoscopy + bronchoscopy + laryngoscopy
Also called a triple endoscopy
Amiodarone ADRs
Cardiac: Bradycardia, heart block, QT PROLONGATION
Pulm: Interstitial pneumonitis (infiltrates on CXR)
GI: Elevated transaminases
Ocular: Corneal microdeposits that are blue-gray; optic neuropathy
Derm: Blue-gray skin discoloration
Neuro: Peripheral neuropathy
Pt with signs of inferior MI and symptoms get worse with sublingual nitrogylcerin
Suspect RV MI
Give pt. IV bolus and avoid venodilation; otherwise, treat like normal MI
Patients who cannot produce sputum for a sample should undergo what
BAL
Patient who is presenting with signs of heart failure after placement of a pacemaker
Suspect tricuspid regurg. (or some other right heart problem)
-Pacemakers pass thru the SVC into the RA
Pneumococcal vaccines and their differences
PPSV23: capsular materials from 23 serotypes that induces a T-cell INDEPENDENT B-cell response
-Recommended to adults >65 and people <65 with predisposing conditions (IC, lung disease, cirrhosis, DM)
PCV13: Capsular polysaccharides that induces a T-cell dependent B-cell response
-Recommended for infants and children
EEG in cVJD
Sharp, triphasic, and synchronous discharges
Pts. present with myoclonus and rapidly progressive dementia
Carcinoid syndrome
Neuroendocrine tumors found in the distal SI, colon, and lung with metastasis to the liver; only become symptomatic with metastasis because histamine, serotonin, and VIP are inactivated by the liver
S/s: Flushing, cyanosis
Diarrhea, cramping
RIGHT SIDED HEART LESIONS (insufficient tricuspid)
Bronchospasm
Niacin deficiency (dermatitis, diarrhea, dementia)
Dx: Elevated 24 hour urine 5-HIAA; CT: echo
Tx: Octreotide and then surgery
Baker’s Cyst
Occurs due to extrusion of synovial fluid from the knee into the gastrocnemius or semimembranosus bursa thru a communication typically from chronic inflammation (osteoarthritis)
***CAN RUPTURE; following strenuous exercise, pt. will present with tenderness and swelling of the calf resembling a DVT and will show ecchymosis distal to the medial malleolus
US will r/o DVT
Psoriatic arthritis
Presents as morning stiffness and swelling of the DIP joints; may also have dactylitis (SAUSAGE DIGITS) and nail involvement
Nails may be pitting showing onycholysis (Separation of the nail bed)
Low risk cardiac chest pain patients
Men <40
Women <50 with atypical chest pain and no RFs
If patient is low-risk and has a normal EKG, do not do further work up on chest pain
Hypokalemia
S/s: Weakness, fatigue, muscle cramps, flaccid paralysis, hyporeflexia, rhabdomyolysis, arrhthmias
EKG =» Broad T-waves, U waves, ST depression, and PVCs
Putamen hemorrhage
Sudden contralateral hemiparesis and hemianesthesia with conjugate gaze deviation towards the side of the lesion
*Internal capsule containing the corticospinal and somatosensory fibers in the PLIC is damaged
Noninvasive Positive Pressure Ventilation
Ventilator support delivered via facemask allowing for CPAP or BiPAP
Decreases the work of breathing, improves alveolar ventilation
Indications: COPD exacerbation not responding to normal tx., cardiogenic pulmonary edema, Acute respiratory failure
CIs: ARDS, severe acidosis, cardiac arrest, encephalopathy, GI bleed, agitated, high aspiration risk
MC missed lesion on colonoscopy
Angiodysplasia
Think this if a patient has painless GI bleed with a recent negative colonoscopy
Lambert-Eaton Syndrome
S/s: Proximal muscle weakness, autonomic dysfnxn (Dry mouth), CN involvement (ptosis), diminished DTRs
PE Management
Step 1: Supportive care with O2 and fluids
Step 2: Assess CIs for anticoagulation (bleeding, hemorrhagic stroke)
Step 3: Wells Criteria
Wells Criteria for PE
+3 = Signs of DVT, alternate diagnosis less likely than PE
+1.5 = Previous PE or DVT, HR >100, Recent surgery or immobilization
+1 = Hemoptysis, cancer
> 4= PE likely; Heparin BEFORE further testing
Causes of constrictive pericarditis
Tuberculosis (in endemic areas)
Cardiac surgery
Radiation therapy
Viral
Idiopathic
Constrictive pericarditis
S/s: Fatigue
Dyspnea
Peripheral edema, ascites
Increased JVP
Pulsus paradoxus, Kussmaul's sign
Dx: EKG shows low-voltage QRS
Imaging shows pericardial thickening with possible calcification
JVP tracing shows prominent x and y descents
Sensorimotor polyneuropathy and differences in symptoms
Small fiber injury =» Pain, paresthesias, allodynia (“Positive sx.”)
Large fiber injury =» Numbness, loss of proprioception and vibration sense, decreased DTRs (“Negative sx.)
Tx for testicular tumor
Radical orchiectomy FOLLOWED by platinum based chemo if necessary
Mitral stenosis
Presents as dyspnea, orthopnea, and hemoptysis
May see afib, thromboembolisms, and voice hoarseness from recurrent laryngeal nerve compression after LAE
PE: Mitral facies (pink-purple patches on cheeks), LOUD S1, opening snap, mid-diastolic rumble
Dx: CXR shows pulmonary blood flow redistribution to upper lobes
EKG shos “p mitrale” (notched p wabes), RVH
Echo shows MV thickening with possible calcification, decreased mobility
Patient presenting with acute limb ischemia following an MI
Perform an echo; need to identify if there is a thrombus along with immediate anticoagulation
Pts. with candida esophagitis will also have what
Oral thrush
Criteria for LTOT
Pulse ox <88% on RA
Resting PaO2 <55
PaO2 <59 or SaO2<89% in patients with cor pulmonale, RHF, or Hcrt >55%
-O2 will greatly enhance these patients’ survival
Cerebellar degeneration
Gait probs
Truncal ataxia
Nystagmus
Intention tremor
Dysmetria
Dysdiadochokinesia
First tx of PACs
Stop smoking, caffeine, alcohol, and stress
Acute interstitial nephritis
Maculopapular rash, fever, arthralgia following an acute drug exposure
Labs: AKI, pyuria, hematuria, eosinophilia, urinary eosinophils
Tx: Discontinue drug, steroids if unstable
Diseases leading to secondary pseudogout
Hyperparathyroidism
Hemochromatosis
Hypothyroidism
Renal tubular acidosis
Patients present with non-anion gap metabolic acidosis in t he presence of preserved kidney fnxn; patients may be hyperkalemic if the problem is in the collecting tubule
Seen in patients with poorly controlled diabetes due to hyporeninemic hypoaldosteronism from longterm damage to the juxtaglomerular apparatus
Causes of normal anion gap metabolic acidosis
Diarrhea
Fistulas
Carbonic anhydrase inhibitors
RTA
Iatrogenic
Patient’s with a likely PE
GET A CTA; FUCK THE DDIMER
Bronchogenic carcinoma
Common with asbestos exposure; may see pleural plaques alongside other typical lung cancer signs
Intracranial HTN
Patients present with a headache worse at night, N/V, and AMS changes
Can also have focal neurologic symptoms such as vision change, unsteady gait, and seizure
Symptoms worsen with maneuvers that increase intracranial pressure such as leaning forward, Valsalva
Myasthenic crisis
Patient presents as a 30-40 year old woman with generalized and oropharyngeal weakness alongside respiratory insufficiency
Can be brought on by infxn, surgery, pregnancy, childbirth, aminoglycosides, FQNs, BBs
Monitor in ICU; intubate if necessary
Bath salts intoxication
Amphetamines
S/s: Severe agitation, combativeness, psychosis, delirium, myoclonus, increased BP and HR
***HAS A VERY LONG DURATION; can last from days to weeks
Pt who presents as an MI with a new onset of a holosystolic murmur at the apex
MI with papillary muscle displacement =» acute mitral regurg.
Pramiprexole
Dopamine agonist used for Restless Leg Syndrome
If patients have comorbid insomnia, chronic pain, or anxiety, can try Gabapentin insetead (Ca2+ channel ligand)
Interstitial cystitis
“Painful bladder syndrome”
Patients present with bladder pain when it is full and relief with voiding; patient’s have increased urinary frequency and urgency along with dyspareunia and pain on pelvic exam
Dx: Normal urinalysis, pelvic pain with other causes ruled out
Tx: Avoiding triggers, amitriptyline, NSAIDs
Differentiating ALF from acute hepatitis
Presence of hepatic encephalopathy
Uncommon complication of mono
AI hemolytic anemia along with thrombocytopenia
Hydroxychloroquine ADRs
Retinopathy
Pts. should have annual eye exam while on this drug
Prerenal AKI
Causes: Volume depletion, displace intravascular fluid (sepsis, pancreatitis), renal artery stenosis, afferent arteriole vasoconstriction (NSAIDs),
S/s: Increased serum creatinine, decreased UOP, BUN >20:1, FeNa <1
Tx: Fluid replacement
Tx of afib in stable pts.
BBs, diltiazem, digoxin to control rate
Acute erosive gastropathy
Development of severe hemorrhagic lesions after the exposure of the gastric mucosa to agents that reduce blood flow; decreased blood flow and mucosal injury allow acids and proteases to injure the stomach and vasculature
***Think this if a patient develops hematemesis and epigastric pain after ingesting Aspirin and Cocaine
Acetaminophen intoxication protocol
<4 hours since administration? =» Administer activated charcoal while obtaining acetaminophen levels
N-acetylcysteine administered based on the nomogram
Hyperthyroidism
S/s: Anxiety, insomnia, palpitations, heat intolerance, increased perspiration, weight loss, goiter
PE: HTN, tremors, hyperreflexia, PROXIMAL MUSCLE WEAKNESS, lid lag, A-fib
Chronic findings can include muscle atrophy
Patient with bone lesion and recurrent infxn
MM
Alcoholic hepatitis
S/s: Jaundice, anorexia, fever
RUQ pain
Abdominal distension
Proximal muscle weakness (due to muscle wasting)
Possible hepatic encephalopathy
Labs: AST:ALT >2
Increased GGT, Br, and INR
Leukocytosis
Fatty liver
Increased ferritin
Ferritin as an APR
Increased
Membranoproliferative glomerulonephritis, Type 2
Caused by IgG abs against C3 convertase causing persistent complement activation and kidney damage
Antibodies are called “C3 convertase”
EM: Dense deposits with the glomerular basement membrane
Mixed cryoglobulinemia
Presents as palpable purpura, proteinuria, and hematuria
Other nonspecific symptoms: Arthralgia, hepatosplenomegaly, hypocomplementemia
Confirm with test for circulating cryoglobulins
***F/U: Test for HCV as these two usually COEXIST
Wallenburg Syndrome
Lateral medullary infarction possibly due to intracranial vertebral artery occlusion
Vestibulocerebellar: Vertigo, falling to side of lesion, diplopia, nystagmus, ipsilateral limb ataxia
Sensory: Loss of pain and temp. in ipsilateral face and contralateral body
Autonomic: Ipsilateral Horner’s, hiccups, lack of autonomic respiration
Ipsilateral bulbar muscle weakness (dysphagia, hoarseness, aspiration)
First step in managing liver cirrhosis
Screening endoscopy to identify varices and determine risk
Management of cirrhosis
Variceal hemorrhage: BB or ligation (ligation preferred if varices are large)
Ascites: Na restriction, diuretics, abstinence
Encephalopathy: ID underlying cause, lactulose
Deficiency associated with carcinoid syndrome
Niacin
Increased tryptophan =» serotonin conversion; less niacin and tryptophan
Disseminated MAC
Presents with fever, cough, abdominal pain, diarrhea, night sweats, weight loss, and SPLENOMEGALY AND ELEVATED AP
-indicates hepatosplenic involvement)
Tx: Azithromycin
TTP
ADAMTS13 deficiency leads to formation of small vessel thrombi due to long chains of vWF accumulating on the endothelial wall
Dx: Hemolytic anemia, thrombocytopenia, possible renal failure, neurologic change, and fever
Tx: Plasma exchange
Sporotrichosis
Infections occur in gardeners via direct inoculation; a papuler forms at the site that ulcerates and drains an odorless and nonpurulent fluid
=»Later, several proximal lesions develop along the line of lymphatic drainage
Tx: Oral itraconazole
Management of stones <1cm
Hydration
Analgesics
a-blockers (Tamsulosin)
MCCo acute epididymitis in pts. >35 years
E. coli
ADRs of cyclosporine
Nephrotoxicity- azotemia, hyperuricemia, hyperkalemia
HTN- can tx w/ CCBs
Neurotoxicity- Headache, tremors, visual probs
Glucose intolerance
Infxn
Malignancy- SCC
*****Gingival hypertrophy
*****Hirsutism
GI probs
Autoimmune adrenalitis
Presents with symptoms of primary adrenal insufficiency (hyperpigmentation, hyponatremia, hyperkalemia, fatigue, weakness, GI probs)
Can occur as an isolated disorder or in association with other AI syndromes
S3 sound
ken-tuc-KY
Typically a sign of Left Ventricular failure
Senile purpura
Ecchymosis, skin fragility, and consistent bruising due to loss of elastic fibers in the perivascular CT
Minor abrasions can rupture superficial vessels and lead to large ecchymoses
-Labs normally appear normal
Best test to diagnose brain tumors
MRI with gadolinium
Double duct sign
CT finding with a carcinoma of the head of the pancreas in which we see compression of the pancreatic and common bile duct
=»Intra and extrahepatic biliary duct dilatation with a nontender, distended gallbladder
Complications of primary biliary cholangitis
Xanthelasmas (due to hyperlipidemia)
Malabsorption (fat-soluble deficiencies)
Hepatocellular carcinoma
Osteoporosis, osteomalacia (not due to deficiencies; Ca and Vit D can be normal so pathophysiology is unknown)
Tx of bacterial endocoarditis w/ acute stroke
Just IV fluids and antibiotics; do not anticoagulate
Leukomoid Reaction
Reactive process to acute infxn
LAP score: High (>20)
PMN precursors: Late phases
Basophilia: Not present
Exam for suspected chronic pancreatitis
Abdominal CT
Raynaud’s Phenomenon workup
CBC
Metabolic panel
Urinalysis
ANA, RF
-If positive for ANA, get antitopoisomerase-1 abs for systemic sclerosis
ESR and C3, C4 levels
Zinc deficiency
Alopecia
Pustular skin rash (perioral region and extremities)
Hypogonadism
Impaired wound healing
Impaired taste
Immune dysfnxn
Causes: Malabsorption, bowel resection, poor intake, paraenteral nutrition
Patient who has just gotten out of ophthalmic surgery and presents with a fever, swollen eyelid, edematous conjunctiva, and exudates in the anterior chamber
Postoperative endophthalmitis
Occurs within six weeks of surgery and is due to an infection of the eye; viterous humor can be sent for gram stain and culture
Tx: Intravitreal antibiotics
MCC of gross painless lower intestinal bleeding in adults
Diverticulosis
Hyponatremic patients who are presenting with severe neurologic manifestations
Treat with hypertonic saline; still correct at <8meq/L for first 24 hours to prevent osmotic demyelination syndrome
Hallmark of prolonged and recurrent seizures
Cortical laminar necrosis; MRI shows cortical hyperintensity suggestive of infarction
Tumor lysis Syndrome
Patients present with N/V, diarrhea, muscle cramps, seizures, tetany, CARDIAC ARRHYTHMIA, and AKI
HAllmarks: Hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia
Tx: IV fluids (flush kidneys), allopurinol
Mechanism of ACEI dry cough
Inhibits the metabolism of kinins and substance P
=» Kinins irritate bronchi with increased prostaglandin production
Also, inhibition of ACE activates the arachidonic acid pathway
=»Increased thromboxane =» Bronchoconstriction
Clinical features of multiple sclerosis
Optic neuritis
Internuclear opthalmoplegia
Fatigue
Heat sensitivity
Numbness, parasthesia
Paraparesis, spasticity
Bowel, bladder dysfnxn
MRI: Lesions disseminated in space and time (usually found in periventricular, juxtacortical, intratentorial, or spinal cord areas)
CSF: Oligoclonal IgG bands
CSF in MS pts
Oligoclonal bands
S4 Sound
TEN-nes-see
Indicates a stiff, left ventricle which occurs in the standing of longstanding hypertension or restrictive cardiomyopathy
Sound is made by blood striking a stiffened left ventricle
Mechanical Complication of acute MI timeline
Acute: RV failure (Kussmaul’s sign)
3-5 days: Papillary muscle rupture (severe pulmonary edema, new holosystolic murmur)
3-5 days: Interventricular septum rupture (shock, chest pain, new holosystolic murmur, biventricular failure)
5 days-2 weeks: Free wall rupture (shock, chest pain, JVD, distant heart sounds)
Disseminated gonoccocal infxn
Presents as a purulent monoarthritis OR
Triad: Tenosynovitis, dermatitis (erythematous papules/pustules), and asymmetric MIGRATORY POLYARTHRALGIAS
Dx: Blood cultures can be negative, synovial fluids show PMNs
Tx: IV ceftriaxone, empiric azithromycin/doxy, joint drainage for purulent arthritis
Reactive arthritis
Cant’ see, can’t pee, can’t climb a tree
Look for STD history
Tx: NSAIDs
Patient who has arthritis of the hands, wrists, and knees with joint effusion BUT also has kids
THINK ABOUT PARVOVIRUS B19
MCC of primary adrenal insufficiency
Autoimmune adrenalitis
Pulmonary empyema
Patients have frank pus or bacteria in a cavitary space; usually an IC pt.
Pleural fluid: ph<7.2, decreased glucose, WBC >50,000
Tx: Abs and drainage
Anserine burisitis
“Pes anserinus”
Localized pain and tenderness over the anteromedial tibia distal to the joint line
Patients are usually fat and obese diabetic females
Tx: NSAIDs, symptoms usually go away in a few weeks
Amyloidosis
Can be primary or secondary to chronic inflammation (RA, TB, osteomyelitis, IBD, malignancy, vasculitis)
S/s: Proteinuria, nephrotic syndrome
Restrictive cardiomyopathy (heart is concentrically thickened)
Hepatomegaly
Peripheral neuropathy/Autonomic neuropathy
Organ enlargement (macroglossia)
Waxy, thickened skin that easily bruises**
Extrahepatic manifestations of chronic HCV
Mixed cryoglobulinemia syndrome
Membranoproliferative glomerulonephritis
Porphyria Cutanea Tarda (photosensitive vesicles and bullae erupt on skin with sun exposure, lesions scar forming hyperpigmented areas)
**Always order HCV testing if a pt. has this
Lichen planus
Highest RF for stroke
HTN
Patients with steatorrhea may present with what deficiencies
Fat soluble vitamin deficiencies
Vit D= Low Ca2+, Low PO4, and increased PTH
Best tests for Cushing Syndrome
Low-dose dexamethasone suppression test
RBC transfusion thresholds
<7 = always
<8= Cardiac sx., oncology patients in treatment, heart failure
8-10= Symptomatic anemia, ongoing bleeding, ACS, noncardiac surgery
Complication of aortic dissection
Cardiac tamponade
Acromegaly effects
Local tumor effect: Visual field defects, headache, cranial nerve defects
MSK: Gigantism, protruding jaw, arthralgia, myopathy, skin tags, carpal tunnel syndrome
Cardiac: Concentric hypertrophy, HTN, mitral/aortic regurg,
Pulm/GI: OSA, colon polyps, diverticulosis
Enlarge organs = Tongue, salivary glands, liver, spleen
Endocrine: Galactorrhea, decreased libido, DM, hyperparathyroidism, hypertriglyceridemia
**Effects are due to increased IGF-1
Patient with periodic headaches and HTN who presents with severe HTN after anesthetic admin.
Suspect pheochromocytoma
BBs can also cause these exacerbations
Epidermal Inclusion Cyst
Dome-shaped, firm, freely movable cyst or nodule with a central punctum (pore-like opening)
Represents epidermis lodging in the dermis; can intermittently produce discharge; only needs tx. if signs of infxn develop
Characteristics of uncomplicated parapneumonic effusion
Caused by movement of fluid from pneumonia into visceral pleura
Fluid analysis: ph>7.2
Decreased-normal glucose
WBC <50,000
Gram stain (-)
EXUDATIVE
-Differs from empyema because no bacteria are present
Tx for acute sciatica
- Trial of NSAIDs
- Muscle relaxant/short-term opioid
* Don’t need MRI unless patient has progressive deficits, cauda equina, or signs of epidural abscess (IV drug use, fever)
Aspirin allergy
ALSO GOES FOR NSAIDs
Globus sensation
Sensation of foreign body in the throat; occurs when swallowing saliva and is assoc. w/ anxiety
Patients do not have pain, dysphagia, or dysphonia; just the sensation of something in their throat
Crescendo-decrescendo murmur along the left sternal border with no radiation
HCOM; indicates the presence of interventricular septal hypertrophy
S/s: Syncope, dyspnea, chest pain
Spinal cord compression management
Immediate IV glucocorticoids (decreased vasogenic edema caused by an obstructed epidural venous plexus)
Emergency MRI
Neurosx. consult
Patients with steatorrhea may present with what deficiencies
Fat soluble vitamin deficiencies
Vit D= Low Ca2+, Low PO4, and increased PTH
Best tests for Cushing Syndrome
Low-dose dexamethasone suppression test
RBC transfusion thresholds
<7 = always
<8= Cardiac sx., oncology patients in treatment, heart failure
8-10= Symptomatic anemia, ongoing bleeding, ACS, noncardiac surgery
Complication of aortic dissection
Cardiac tamponade
Acromegaly effects
Local tumor effect: Visual field defects, headache, cranial nerve defects
MSK: Gigantism, protruding jaw, arthralgia, myopathy, skin tags, carpal tunnel syndrome
Cardiac: Concentric hypertrophy, HTN, mitral/aortic regurg,
Pulm/GI: OSA, colon polyps, diverticulosis
Enlarge organs = Tongue, salivary glands, liver, spleen
Endocrine: Galactorrhea, decreased libido, DM, hyperparathyroidism, hypertriglyceridemia
**Effects are due to increased IGF-1
Patient with periodic headaches and HTN who presents with severe HTN after anesthetic admin.
Suspect pheochromocytoma
BBs can also cause these exacerbations
Epidermal Inclusion Cyst
Dome-shaped, firm, freely movable cyst or nodule with a central punctum (pore-like opening)
Represents epidermis lodging in the dermis; can intermittently produce discharge; only needs tx. if signs of infxn develop
Characteristics of uncomplicated parapneumonic effusion
Caused by movement of fluid from pneumonia into visceral pleura
Fluid analysis: ph>7.2
Decreased-normal glucose
WBC <50,000
Gram stain (-)
EXUDATIVE
-Differs from empyema because no bacteria are present
Tx for acute sciatica
- Trial of NSAIDs
- Muscle relaxant/short-term opioid
* Don’t need MRI unless patient has progressive deficits, cauda equina, or signs of epidural abscess (IV drug use, fever)
Aspirin allergy
ALSO GOES FOR NSAIDs
Globus sensation
Sensation of foreign body in the throat; occurs when swallowing saliva and is assoc. w/ anxiety
Patients do not have pain, dysphagia, or dysphonia; just the sensation of something in their throat
Crescendo-decrescendo murmur along the left sternal border with no radiation
HCOM; indicates the presence of interventricular septal hypertrophy
S/s: Syncope, dyspnea, chest pain
Spinal cord compression management
Immediate IV glucocorticoids (decreased vasogenic edema caused by an obstructed epidural venous plexus)
Emergency MRI
Neurosx. consult
Patients with steatorrhea may present with what deficiencies
Fat soluble vitamin deficiencies
Vit D= Low Ca2+, Low PO4, and increased PTH
Best tests for Cushing Syndrome
Low-dose dexamethasone suppression test
RBC transfusion thresholds
<7 = always
<8= Cardiac sx., oncology patients in treatment, heart failure
8-10= Symptomatic anemia, ongoing bleeding, ACS, noncardiac surgery
Complication of aortic dissection
Cardiac tamponade
Acromegaly effects
Local tumor effect: Visual field defects, headache, cranial nerve defects
MSK: Gigantism, protruding jaw, arthralgia, myopathy, skin tags, carpal tunnel syndrome
Cardiac: Concentric hypertrophy, HTN, mitral/aortic regurg,
Pulm/GI: OSA, colon polyps, diverticulosis
Enlarge organs = Tongue, salivary glands, liver, spleen
Endocrine: Galactorrhea, decreased libido, DM, hyperparathyroidism, hypertriglyceridemia
**Effects are due to increased IGF-1
Patient with periodic headaches and HTN who presents with severe HTN after anesthetic admin.
Suspect pheochromocytoma
BBs can also cause these exacerbations
Epidermal Inclusion Cyst
Dome-shaped, firm, freely movable cyst or nodule with a central punctum (pore-like opening)
Represents epidermis lodging in the dermis; can intermittently produce discharge; only needs tx. if signs of infxn develop
Characteristics of uncomplicated parapneumonic effusion
Caused by movement of fluid from pneumonia into visceral pleura
Fluid analysis: ph>7.2
Decreased-normal glucose
WBC <50,000
Gram stain (-)
EXUDATIVE
-Differs from empyema because no bacteria are present
Tx for acute sciatica
- Trial of NSAIDs
- Muscle relaxant/short-term opioid
* Don’t need MRI unless patient has progressive deficits, cauda equina, or signs of epidural abscess (IV drug use, fever)
Aspirin allergy
ALSO GOES FOR NSAIDs
Globus sensation
Sensation of foreign body in the throat; occurs when swallowing saliva and is assoc. w/ anxiety
Patients do not have pain, dysphagia, or dysphonia; just the sensation of something in their throat
Crescendo-decrescendo murmur along the left sternal border with no radiation
HCOM; indicates the presence of interventricular septal hypertrophy
S/s: Syncope, dyspnea, chest pain
Spinal cord compression management
Immediate IV glucocorticoids (decreased vasogenic edema caused by an obstructed epidural venous plexus)
Emergency MRI
Neurosx. consult
Effect modification
External variable positively or negatively impacts the effect of a risk factor on a disease of interest
*However, if you remove the variable, there is still risk in the group with one factor
Confounding
Exposure-disease relationship is obscured by an extraneous factor associated with exposure and disease
*If you remove the RF, there is no difference between two groups
Lacunar stroke
Occlusion of the deep penetrating arteries of the brain; particularly susceptible to HTN, DM, hyperlipidemia, and smoking
Path: Microatheroma formation and lipohyalinosis leading to small vessel occlusion
Erlichiosis
S/s: Flu-like illness, neurologic symptoms (confusion)
“RMSF without the spots”
Labs: Leukopenia, thrombocytopenia, elevated LFTs, elevated LDH
Dx: Intracytoplasmic morulae in monocytes
Tx: Doxycycline
First line tx. of chemotherapy-induced nausea
SSRI
Caustic ingestion
S/s: Hoarseness, stridor (laryngeal), dysphagia, odynophagia (esophageal), epigastric pain, bleeding (gastric)
Tx: Secure airway, remove contaminated clothing, CXR if respiratory probs, EGD
Systolic anterior motion of the mitral valve
Associated with HCOM; contacts the thickened interventricular septum causing LVOT obstruction
Patient who recently had a drug eluting stent placed and has an MRI
Think medication noncompliance
Cardiac myxoma
S/s: Constitutional (fever, weight loss, Raynaud’s),Heart failue, arrhythmia, embolization
Dx: Echo
Tx: Surgery soon (decrease risk of embolus)
Tubulointerstitial nephritis
Usually due to analgesic use
Patients may have poluria and steril pyuria
Glucocorticoid-induced myopathy
Patients have proximal muscle weakness and atrophy but no pain due to inflammation caused by catabolic breakdown
Will also see signs of glucocorticoid excess
Felty Syndrome
Advance RA with splenomegaly and neutropenia
Pleural effusion exam findings
Decreased breath sounds
Decreased tactile fremitus
Dullness to percussion
May be a mediastinal shift away from effusion
Pt with an acute STEMI and pulmonary edema
Make sure to give Lasix
Tophaceous gout
Tumors in the soft tissues that can ulcerate and drain a chalky material
Patients don’t even need microscopic examination for gout crystals; this is pathagnomic
Most common glomerulopathy with HIV
Focal segmental glomerulosclerosis
Bilateral trigeminal neuralgia
Think MS as this is usually a unilateral condition
Bethanechol
Cholinergic agonist used to treat urinary retention
Hyposthenuria
Found in patients with SCD OR Sickle Cell Trait; presents as a patient who cannot concentrate urine or reabsorb water; usually will be young in the question stem
-RBCs get caught in the vasa recta impairing countercurrent exchange
Tx for syphilis patients who have SEVERE penicillin allergies
Doxycycline
Supravalvular aortic stenosis
Congenital LVOT obstruction causing a systolic murmur; usually heard in the first intercostal space
**Patients have differential blood pressures in the two arms
Hypertensive nephropathy
2nd leading cause of ESRD
Decrease in renal blood flow and GFR =» hypertrophy and intimal medial fibrosis of the renal arterioles
Can see microscopic hematuria and proteinuria
Patient with renal issues who suddenly develops severe retroperitoneal pain, fever, and gross hematuria
Think RVT due to antithrombin III loss
HIV screening indications
Once between the ages 15-65
Treatment for TB
Treatment for another STD
Annual: IVDU, MSM, prostitutes, partners of HIV positive, homeless, prison
Additional: Pregnancy, exposure
Solitary brain mass in HIV patient
CNS lymphoma; is usually ring-enhancing
Multiple ring enhancing lesions in HIV pt.
Toxoplasma
Patient who becomes alkalotic after being treated for fluid overload
Think loop diuretics
The increased Na+ delivery to the DCT causes K+ and H+ to be secreted
Pt with AKI due to postrenal causes
Catheterization
Do bladder scan first to see but if it’s inconclusive, jump to this
Medications associated with SIADH
Carbamazepine
SSRIs
NSAIDs
Pt. with COPD exacerbation and has a seizure
Due to acute cerebral vasodilation
Use O2 with a goal of 90-93%
NaHCO3 mechanism in TCA OD
Na+ increases the serum pH and extracellular sodium =» decreased avidity of TCA for cardiac sodium channels
-This helps to prevent QRS widening
Charcot joint
“Neurogenic arthropathy”
Presents as patients with large, deformed joints that lack sensation and have lost neurologic input; patients can have DJD and loose bodies on joint imaging
-Patients only have mild pain tho due to the loss of neurologic input
Causes: Diabetes, syringomyelia, spinal cord injury, B12 deficiency, tabes dorsalis
=»Patients damage feet unknowingly
Tx: Manage underlying conditions; weight bearing assistance
Secondary amyloidosis
Seen with chronic inflammation, chronic infections, IBD, malignancy, and vasculitis
S/s: Proteinuria w/ nephrotic syndrome possible
Cardiomyopathy
Hepatomegaly
Peripheral neuropathy
Macroglossia
Waxy thickening and easy bruising of skin
Management of frostbite
Rapid rewarming in 37-39 degree water
Analgesia and wound care
Thrombolysis in severe, limb-threatening cases
“Water hammer pulse”
Aortic regurgitation
Vasovagal syncope
“Neurocardiogenic syncope”
Triggered by emotional or painful stimuli and is associated with prodromal sx. (dizziness, nausea, pallor, diaphoresis); pts. rapidly regain consciousness
Tx: Reassurance, avoidance of triggers, ***Counterpressure maneuvers (leg crossing, tensing arm muscles) that involve raising the SVR
CT imaging on pyelonephritis
Persistent clinical symptoms after 48-72 hours of therapy, history of kidneys tones, or unusual findings (gross hematuria, obstruction)
Pressure ulcers
Suspect over any bony prominences (sacrum, ischia tuberosities, malleoli, heels, 1st or 5th metatarsal heads)
Serous otitis media
Conductive hearing loss that presents with a dull tympanic membrane that is hypomobile
Aspirin Toxicity
RESPIRATORY ALKALOSIS
THEN
ANION GAP METABOLIC ACIDOSIS
pH is relatively normal, however, the pCO2 and HCO3 will both be decreased
Vessel that supplys the inferior wall of the heart
RCA
Protein C resistance
Factor V Leiden
Splenic abscess
Patients present with fever, leukocytosis, and LUQ pain; possibly can have left-sided pleuritic chest pain with a left sided effusion
RFs: Infxn, hemoglobinopathy, IC, IV drug use, trauma
Tx: Abs and splenectomy
**HIGHLY ASSOC. W/ LEFT-SIDED ENDOCARDITIS
Meniere Disease
Increased volume and pressure of endolymph in the inner ear due to defective resorption
Triad: Low frequency tinnitus w/ a feeling of fullness
Episodic vertigo (may have N/V, lightheadedness)
Sensorineural hearing loss (usually worsens with time)
Tx: Restrict Na+, caffeine, nicotine, alcohol
Benzos or antiemetics for acute sx.
Diuretics for long term management
Management of hypercalcemia
- Normal saline
- Calcitonin
- (Long term) bisphosphonates
Hepatic hydrothorax
Pleural effusion due to small defects in the diaphragm that occurs when PERITONEAL FLUID passes thru
***MORE COMMON ON THE RIGHT
S/s: Dyspnea, cough, pleuritic chest pain, hypoxemia
Tx: Na+ restriction, diuretics
Prevalence studies are what kind of study?
Cross-sectional
Pneumonia breath sounds
Represents consolidation of a lung
Increased crackles
Increased tactile fremitus
Dullness to percussion
No mediastinal shift
Cyanide toxicity
Causes: Combustion of carbon and nitrogen material (wool, silk), industrial exposure (mining metals), or sodium nitroprusside
S/s: Skin- Flushing, cyanosis CNS- Headache, AMS, seizure, coma CV- Arrhythmia Respiratory- Tachypnea followed by respiratory depression, pulmonary edema GI- Pain, N/V Renal- Metabolic acidosis (LA), RF
Type of cardiomyopathy assoc. w/ amyloidosis
Restrictive cardiomyopathy
Antiparkinsonian drug that is dangerous in pts. w/ glaucoma
Anticholinergics (trihexyphenidyl)
These can ppt. ACG
Granulomatosis with polyangiitis Diagnostic findings
anti-PR3, anti-MPO
Biopsy:
Skin-leukocytoclastic vasculitis
Kidney- Pauci-immune GN
Lung- granulomatous vasculitis
Tx: Corticosteroids and immune modulators (MTX, cyclophosphamide)
Pancoast tumor
S/s: Shoulder pain
Horner cyndrome
C8-T2 neurologic involvement (weakness of intrinsic hand muscles)
Weight loss
Enlarged supraclavicular lymph nodes
SVC syndrome
MS
S/s: Fatigue
Episodes of numbness, paresthesia, bowel/bladder dysfnxn, heat sensitivity, optic neuritis
Symptoms may worsen when a patient moves to a hotter area
Uhthoff phenomenon
MS patients experiencing increased frequency of episodes after they move to a hotter region
Adhesive capsulitis
“Frozen shoulder”
Patients have decreased passive and active ROM in the shoulder joint with a gradual increase in severity but NOT a lot of pain
-Can be due to chronic inflammation, fibrosis, or contracture of the capsule
Felty Syndrome
triad
RA
-including vasculitis with necrotizing skin lesions
Neutropenia
Splenomegaly
*Also have anti-CCP, elevated ESR
Mechanism of cyanide poisoning
Inhibits cytochrome oxidase a3 in the mitochondrial electron transport chain blocking the production of ATP
=»Increase in anaerobic metabolism and metabolic acidosis
Follow-up of a CXR with a new mass
Chest CT
Hypertrophic Osteoarthropathy
Digital clubbing accompanied by sudden-onset arthropathy affecting the wrist and hand joints
-Can be due to underlying lung disease (cancer, TB, bronchiectasis, COPD)
Initial study: CXR (rule out cancer)
Things to rule out in patients presenting with pseudogout
- Hyperparathyroidism
- Hypothyroidism
- Hemochromatosis (get iron studies)
Progressive Multifocal Leukoencephalopathy
JC virus reactivation typically in an IC host
S/s: Slowly progressive confusion, paresis, ataxia, and seizure
Dx: MRI of brain shows multiple white matter lesions with NO enhancement or edema
-Virus lies dormant in kidneys and lymphoid but reactivated w/ CD4 <200; moves to CNS and lyses oligodendrocytes
Medications to hold prior to cardiac stress test
48 hrs: BBs, CCBs, Nitrates
-If vasodilator, dipyramidole as well
12 hrs: Caffeine
Chikungunya fever
Patient who is from Central or South America (or recently traveled) and presents with high fever, SEVERE ARTHRALGIA, lymphopenia, thrombocytopenia, and increased LFTs
Other S/s: Headache, myaglia, conjunctivits, maculopapular rash
Tx: Supportive
Anemia that develops with antiepileptics
Folic acid; due to impaired absorption
Tx for hepatic encephalopathy
Lactulose
Tx for Lyme Disease in kids and pregnant women
Amoxicillin
Treatment of cachexia
Progesterone analogues (megestrol acetate)
Corticosteroids
- These increase appetite, cause weight gain, and improve well being
- Megestrol acetate preferred due to decreased side effects
Takayasu Arteritis
Asian female who presents with constitutional signs of fever and weight loss as well as with arterio-occlusive sx. (Claudication, ulcers in the upper extremities)
PE: Blood pressure discrepancies
Pulse deficits
Arterial Bruits, especially in the upper extremities
Dx: elevated ESR, CRP
CXR: widened mediastinum, aortic dilatation
Ct/MRI: thickening of aortic walls and narrowing of vessel lumen
Tx: Glucocorticoids
Invasive aspergillosis
Triad of fever, chest pain, and hemoptysis in an IC pt.
⭐️CXR: Pulmonary nodules with halo sign
Can also have cell wall bio marks (Galactomannan, beta-D-glucan)
Tx: Voriconazole plus caspofungin
Post-streptococcal AGN
Preiorbital edema, hematuria, and oliguria
Patient will have ️Decreased c3
Systemic sclerosis subtypes
Limited cutaneous:
Scleroderma on the head and distal upper esophagus
Vascular manifestation (Raynauds, cutaneous Telangiectasia, pulmonary hypertension)
CReSt
Anti-centromere abs
DIFFUSE CUTANEOUS:
More internal organ involvement as well as the skin (renal crisis, myocardial ischemia and ️fibrosis, interstitial lung disease)
Anti-Scl-70 (anti-topoisomerase-1) and anti-RNA polymerase III
Tx for variceal hemorrhages
Volume resuscitation
IV octreotide
Antibiotics
Urgent endoscopy to evaluate for balloon tamponade
First thing to do with hyperkalemia
STABILIZE THE MYOCARDIUM
Give calcium gluconate
Patient who has had a gastrectomy years ago and is now presenting with signs of anemia
IF deficiency; suspect Vitamin b12 deficiency
Most common vaccination to give to people traveling abroad
Hepatitis A vaccine
Patient who still has a tick attached and it just happened recently
Remove tick; follow-up closely
Evaluation of hyperthyroidism
- Measure TSH, T3, and T4
- If primary, evaluate for signs of Graves (goiter, ophthalmopathy)
- If none, do a radioactive iodine uptake scan
- If it is low, evaluate serum TBG
High? =» Thyroiditis, iodide exposure
Low? =» Exogenous
Cervicofacial actinomyces
Patient with dental infxn or facial trauma who is IC, DM, or malnourished
S/s: Nonpainful, indurate mass; sinus tracts with SULFUR-LIKE GRANULES
-typically affects the mandible
Dx: FNA; culture shows GPR that are slightly branching
Tx: Penicillin; surgery if invasive
Management of cancer pain
Mild= NSAIDs
Moderate= Weak opioids and NSAIDs
-Codeine, hydrocodone, tramadol
Severe = Strong, short-acting opioids
- morphine, hydromorphone
- consider adding long acting if this does not provide relief
pH effects on Ca2+
Increased= dissociation of H+ from albumin =» increased calcium binding to albumin =» decreased serum level
Decreased ph= association of h+ to albumin =» decreased calcium binding to albumin =» increased serum level
Ice pack test
Ice pack applied over eyelid that is droopy =» relief in ptosis CONFIRMS MG
*Cold temperature inhibits the breakdown of Ach in the NMJ
Ventilation goals with ARDS
Low-tidal volume ventilation to decrease the likelihood of overdistending the alveoli
-decreases the work on the lungs
Provide oxygenation by increasing the FiO2 and PEEP
-prevent SpO2 <88%
Patient who presents with widespread molluscum contagiosum
Test for HIV or other immunodeficiency
Tx for variceal hemorrhages
Volume resuscitation
IV octreotide
Antibiotics
Urgent endoscopy to evaluate for balloon tamponade
First thing to do with hyperkalemia
STABILIZE THE MYOCARDIUM
Give calcium gluconate
Patient who has had a gastrectomy years ago and is now presenting with signs of anemia
IF deficiency; suspect Vitamin b12 deficiency
Most common vaccination to give to people traveling abroad
Hepatitis A vaccine
Patient who still has a tick attached and it just happened recently
Remove tick; follow-up closely
Evaluation of hyperthyroidism
- Measure TSH, T3, and T4
- If primary, evaluate for signs of Graves (goiter, ophthalmopathy)
- If none, do a radioactive iodine uptake scan
- If it is low, evaluate serum TBG
High? =» Thyroiditis, iodide exposure
Low? =» Exogenous
Cervicofacial actinomyces
Patient with dental infxn or facial trauma who is IC, DM, or malnourished
S/s: Nonpainful, indurate mass; sinus tracts with SULFUR-LIKE GRANULES
-typically affects the mandible
Dx: FNA; culture shows GPR that are slightly branching
Tx: Penicillin; surgery if invasive
Management of cancer pain
Mild= NSAIDs
Moderate= Weak opioids and NSAIDs
-Codeine, hydrocodone, tramadol
Severe = Strong, short-acting opioids
- morphine, hydromorphone
- consider adding long acting if this does not provide relief
pH effects on Ca2+
Increased= dissociation of H+ from albumin =» increased calcium binding to albumin =» decreased serum level
Decreased ph= association of h+ to albumin =» decreased calcium binding to albumin =» increased serum level
Ice pack test
Ice pack applied over eyelid that is droopy =» relief in ptosis CONFIRMS MG
*Cold temperature inhibits the breakdown of Ach in the NMJ
Ventilation goals with ARDS
Low-tidal volume ventilation to decrease the likelihood of overdistending the alveoli
-decreases the work on the lungs
Provide oxygenation by increasing the FiO2 and PEEP
-prevent SpO2 <88%
Patient who presents with widespread molluscum contagiosum
Test for HIV or other immunodeficiency
Renovascular HTN S/s
Severe HTN after the age of 55
Recurrent flash pulmonary edema or resistant HF
Unexplained rise in serum Cr
Abdominal bruits (can be periumbilical)
ADRs of EPO therapy
Worsening of HTN
Headaches
Flu like syndrome
Red cell aplasia (rare)
CYP 450 inhibitors
ACETAMINOPHEN, NSAIDs
Metronidazole, antifungals
Amiodarone
Cimetidine
Cranberry juice, Ginkgo bilboa, Vitamin E
Omeprazole
SSRIs
2 most common orgs that can cause direct extension to the brain from sinusitis
Strep viridans and Staph aureus
Organisms associated with contact lens keratitis
Psuedomonas and Serratia
MC source of pulmonary embolus
Femoral vein
Empiric tx for meningitis
Cefepime/Ceftazidine \+ Vancomycin \+ Ampicillin (covers Listeria monocytogenes)
-Pts. should also receive dexamethasone to prevent complications of S. pneumoniae meningitis (deafness, focal probs) until it is ruled out
Small intestinal bacteria overgrowth
Causes: Anatomic abnormalities (surgery, strictures)
Motility disorders (DM, scleroderma)
ESRD, AIDS, cirrhosis
S/s: Abdominal pain, diarrhea, bloating, malabsorption, weight loss, anemia, nutritional deficiencies
Dx: Endoscopy (shows >10^5 organisms), glucose breath hydrogen testing (shows rapid increase in lactulose)
Common orgs: Strep, bacteroides, E. coli, lactobacillus
Tx: 7-10 day course of rifaximin or Augmentin, avoid antimotility agents, high fat diet, metoclopramide (promotes motility)
Normal protection comes from gastric acidity, peristalsis, intact ileocecal valve preventing retrograde travel of bacteria from the colon
Tx for vitiligo
Topical or systemic corticosteroids
Can try topical calcineurin inhibitors but the answer is probably steroids
Characteristics of benign renal cysts
Thin, smooth, regular wall
Unilocular
No septae
Homogenous content
Absence of contrast enhancement on CT/MRI
Asymptomatic
*Do not need follow-up unless there are changes
Tetanus prophylaxis
ALWAYS JUST GIVE TDaP UNLESS THEY ARE IC
=»THEN ALSO GIVE TIG
Patient with TB who is presenting with fatigue, weakness, borderline hypotension, and electrolyte abnormalities
Suspect chronic primary adrenal insufficiency due to TB
FAP screening guidelines
Annual sigmoidoscopies starting at age 10-12
Annual colonoscopies once colorectal adenomas are detect or at the age of 50
Proctocolectomy if the patient presents with carcinoma or adenomas with high-grade dysplasia
Less known RFs for Toxic Shock Syndrome
Recent surgery
Sinusitis
Nasal surgery
Skin lesions/burns
Primidone
Used as a treatment for essential tremor alongside BB
*BB is still first line
TX FOR PARKINSON’S
Trihexiphenidyl (anticholinergic)
Enthesitis
Pain at sites where tendons and ligaments attach
Common in AS, psoriatic arthritis, and reactive arthritis
Patient with meningococcal meningitis
ISOLATE THEM; even if it’s against their wishes
Riluzole
Glutamate inhibitor used in patients with ALS
Prolongs survival time and the time towards necessary tracheostomy
Alveolar infiltrates with several thin-walled cavities
Can be a finding in normal, uncomplicated pnemonia
Patient who presents with skeletal deformities, bone and joint pain, and fractures
-May possibly also have headache or hearing loss
Paget’s Disease
First order test for suspected SLE
ANA
Babesiosis
S/s: Flu-like sx.,
Severe (CHF, DIC, splenic rupture)
Dx: Anemia, thrombocytopenia, increased bilirubin, LDH, and LFTs
-Findings due to intravascular hemolysis
**Intraerythrocytic rings on peripheral smear
Tx: Atovaquone + Azithromycine
Quinine + clindamycin (if severe)
Occupational HIV postexposure prophylaxis
Tenofovir + emtricitabine (two NRTIs) + Raltegravir (integrase inhibitor), protease inhibitor, or NNRTI
Cocaine toxicity tx
IV Benzos and O2
-Also consider CCBs, nitrates, and aspirin if their is CA vasoconstriction
Rotor’s Syndrome
Defect in the hepatic secretion of bilirubin; consider this when the patient has normal LFTs and AP but has hyperbilirubinemia
Patient who has a negative IgA anti-tissue transglutaminase deficiency but the biopsy still shows villi blunting
This is still Celiac’s!
Many patients have selective IgA deficiency; if your assay is negative, measure total IgA
Juvenile Idiopathic Arthritis
Symmetric arthritis for at least six weeks
Lab findings:
Increased ESR, CRP
Hyperferritinemia
Hypergammaglobulinemia
Thrombocytosis
Anemia
Patients who have been longtime vegans and are alcoholics
Likely BOTH folic acid and B12 deficiencies
On administration of folic acid, megaloblastosis will resolve, however, the pt. will still have neurologic sx.
Vertebral compression fracture
Clinical:
Chronic: Progress kyphosis and loss of statue; can even be painless
Acute: Low back pain with decreased spinal mobility, pain increasing with standing, walking, and lying on the back; tenderness at the affected level
**Patients CAN have neuro sx. BUT if they have shooting pains down their spine, THEN you should think maybe a herniation
-Pts are at increased risk for future fractures and development of hyperkyphosis =» protuberant abdomen, early satiety, weight loss, and decreased respiratory capacity
Cryoglobuinemia Type 1 (not mixed)
Pts. may have hyperviscosity (blurry vision), thrombosis, livedo reticularis, purpura
-Pts. have normal complement levels (unlike in mixeD)
Assoc. w/ lymphoproliferative conditions or hematologic probs
Suppurative thyroiditis
High grade fever and pain at the thyroid due to infxn; can be enlarged due to abscess formation
*Pts. are EUTHYROID
de Quervain thyroiditis
“Subacute thyroiditis”
Pts. present with prominent fever and hyperthyroid sx. as well as a painful, tender goiter
***Likely a postviral etiology
Dx: Elevated ESR and CRP, low radioiodine uptake
“Ostetitis deformans”
Paget’s
Symptomatic sarcoidosis tx
Glucorticoids
Milk-alkali syndrome
Pts. have excessive intake of calcium and absorbable alkali (usually calcium carbonate in pts. w/ osteoporosis)
=»Renal vasoconstriction and decreased glomerular blood flow
=»Renal loss of Na+ and H2O, increased resorption of HCO3-
-due to inhibition of the Na-K-2Cl transporter and impaired ADH
Sx: N/V, constipation, polyuria, polydipsia, neuropsychiatric sx.
-“Hypercalcemia + extra pee
-Increased risk w/ ACEIs, Thiazides, and NSAIDs
Lab: Hypercalcemia, hypophosphatemia, hypomagnesemia
Metabolic alkalosis
AKI
Decreased PTH
Tx: Discontinue causative agents, IV saline + furosemide
SCD pt. with decreased internal rotation and abduction of the hip with normal x-rays and inflammatory markers
Think aseptic necrosis; occlusion of end artery by sickle cell
Warfarin skin necrosis
Warfarin administration causes immediate DECREASE in Protein C and S
=»Transient hypercoagulable state
Tx: Protein C concentrate and cessation of warfarin
TSH in prolactinoma
To assess whether you think it might be low or normal, look at the patient’s sx. cause it could be either
Lab findings in VIPoma
Hypokalemia (increased intestinal secretion)
Hypercalcemia (increased bone resorption)
Hyperglycemia (increased glycogenolysis)
Stool osmolality studies show decreased gap and increased Na
Methods to control confounding
Design: Matching, restriction, and RANDOMIZATION
Analysis: Stratified; statistical monitoring
Saline-resistant and saline-responsive Metabolic alkalosis
Saline-responsive: Due to vomiting, diuretics, laxative, decreased oral fluids
Saline-resistant: Primary hyperaldosteronism, Cushing’s, severe hypokalemia
Urine chloride can differentiate if the history does not (it is <20 in saline-responsive)
Nocardia
Partially acid-fast branching, GPR
Presents in IC pts. with systemic symptoms, possible lung nodules, and possible lung abscesses
Tx: Bactrim
Phosphorus levels in tertiary hyperparathyroidism
High; kidney is not able to excrete it
Factorial design
Study that is designed to have 2 or more interventions with 2 or more variable endpoints
-Like studying BP endpoints on different antihypertensives
Morton neuroma
Numbness or pain between the 3rd and 4th toes
**Clicking sensation when palpating space between 3rd and 4th toes while squeezing the metatarsals
**Common in runners
Path: Mechanically induced neuropathic degeneration of the interdigital nerves
Sx. can be worse when walking in high heeled shoes
Tx: Metatarsal support with inserts
Leprosy
S/s: Anesthetic, macular skin lesions with raised borders
-Nerves nearby can be painful or also have a loss of sensory
-Patients present as immigrants or long travel history
Dx: Full-thickness biopsy of the skin lesion
Tx: Dapsone; rifampin; possible clofazimine if there are extensive lesions
MC nephrotic syndrome in pts. with Hodgkins
Minimal change disease
-Resolves with successful treatment of the lymphoma
Type of reaction that aspirin-exacerbated respiratory disease is
Pseudoallergic rxn
Production of leukotrienes via lipooxygenase and decreased anti-inflammatory prostaglandins due to COX inhibition
Tx: Leukotriene inhibitors (zileuton) or antagonists (montelukast) for acute sx.
Patient presenting with chest pain not related to exertion and has a chronic history
This shit dont sound like cardiac CP
Reason alcohol is bad for acetaminophen related liver failure
Depletes glutathione levels preventing the liver from glucuronidating NAPQI, the toxic metabolite of acetaminophen
Patient who has a syncopal episode and starts jerking
Do not rule out other causes; any case of cerebral hypoxia can cause jerks
Asymptomatic range of carotid artery blockage that indicates surgery
> 60%
Symptomatic? >50%
Total body K+ in DKA or HHS
Decreased; elevated plasma levels but osmotic diuresis causes excessive loss
NF1
CFs: Cafe-au-lait spots
Neurofibromas
Lisch nodules
Optic gliomas (lead to decreased visual acuity, optic nerve atrophy, and proptosis)
-Defect in NF1 TSG neurofibromin on Cr. 17
D-xylose test
D-xylose is absorbed in the proximal SI; patients will absorb this after administration and increased levels are detected in the urine
ABNORMAL TEST: No increase in D-xylose in the urine
=»SUSPECT CELIAC
False positives can be seen with impaired glomerular filtration or delayed gastric emptying
Thalamic pain syndrome
Weeks after suffering a stroke of the penetrating branches of the PCA (supplies the ventral posterolateral and ventral posteromedial nuclei of the brain); patients will have paroxysmal burning over the affected areas of their body and allodynia (pain with light touch)
-These nuclei transmit sensory info from the contralateral side of the body in all modalities
Pulmonary physiology with pneumonia
Inflammation =» impaired alveolar ventilation =» RIGHT-TO-LEFT SHUNT
-Also described as a V/Q mismatch (decreased)
Hepatorenal syndrome
Significant decrease in renal fnxn in the absence of any causes of renal dysfnxn
***As cirrhosis progresses, patients get splanchnic vasodilation and renal vasoconstriction
Precipitating factors: GI bleed, vomiting, sepsis, spontaneous bacterial perotonitis, NSAID use
Dx: Renal hypoperfusion
FeNa <1%
Absence of signs of tubular injury
No casts in the urine
No improvement in renal fnxn with fluids
Tx: Stabilize; give splachnic vasoconstrictors (octreotide, midodrine, norepinephrine); transplant
Significant complication of pseudotumor cerebri (idiopathic intracranial HTN)
Blindness
IF necessary, can perform shunting or optic nerve sheath fenestration to prevent
Young Patient with chronic low back pain that improves with activity and has an elevated ESR
AS
Pain may also be worse at night; sacroiliitis on radiographs
Tx for acute pericarditis
NSAIDs
Sick sinus syndrome
Symptomatic bradycardia without signs of heartblock
Tx of torsades du pointes
MgSo4 if hemodynamically stable
If not =» Defibrillation
Postpartum endometritis tx
Clindamycin + gentamicin
Odds ratio
Measures the odds of exposure among individuals with the disease to the odds of exposure among individuals without the disease
Rare disease assumption
A rare disease that has a low incidence and allows for the OR to be approximately equal to the RR
Atropine
Dilates the eye; avoid in AACG
Pilocarpine
Topical agent that rapidly reduces intraocular pressure by opening the canals of Schlemm and drain aqueous humor
Lymphocytes with vacuolated cytoplasm
Atypical lymphs; probably Mono
Heterophile antibody test
Negative during first week of mono; may want to repeat after a while
TL:DR = NEGATIVE TEST DOES NOT RULE OUT MONO
Pts who have a CN III palsy but preserved pupillary dilation (control of the iris and ciliary muscles)
Acute ischemia of the fiber (outer fibers control pupillary dilation; inner fibers control EOMs)
-IF they have both, it is likely a lacunar stroke
CMV-related HIV
Frequent, small volume diarrhea
Hematochezia
Abdominal pain
Low-grade fever
Weight loss
Dx: Colonoscopy with biopsy; shows eosiniophilic intranuclear and basophilic intracytoplasmic inclusions
Tx: Ganciclovir; eye exam to rule out retinitis
Central retinal artery occlusion
Painless monocular vision loss that persists for serveral hours
Fundoscopy reveals a whitened retinal and a cherry red macula
Patients may have a defect in the afferent pupillary reflex
Tx: Attempt at revascularization; follow-up with carotid imaging and atherosclerosis tx
Gonococcal pharyngitis
Inoculation of the pharynx with pharyngeal erythema and NONTENDER cervical lymphadenopathy
Treatment with radioactive iodine for Grave’s disease
Give glucocorticoids with treatment; otherwise pt. can get worsening of ophthalmopathy
This is because titers of anti-TSH antibodies typically increase after therapy
Bicuspid valve
Actually causes aortic regurgitation in young patients
Pt with bright red blood on the toilet paper and is under the age of 40
Get an anoscopy; colonoscopy if they are older than age 50 or have risks for colorectal cancer
ACTH levels in pts. with secondary adrenal insufficiency
Decreased; the HPA is what gets suppressed with chronic steroid use
Delayed sleep phase syndrome
Circadian rhythm sleep-wake disorder characterized by sleep-onset insomnia and excessive morning sleepiness
Occurs when internal clock is misaligned with a persons desired sleep time
- Pts. describe themselves as “night owls”
- Sleep normally when allowed to set their own schedule
Treatment for febrile neutropenia
Monotherapy Pip-tazo, cefepime, meropenem
Just make sure there is Pseudomonas coverage
Cryptosporidium
Possible in healthy adults, however, it should resolve in 10-14 days
Coccidiodes
PT DOES NOT HAVE THIS IF THEY DO NOT LIVE IN THE SOUTHWESTERN US
Thiazide diuretic effect on glucose
Increases blood levels
-Impairs insulin release and glucose utilization in the peripheral tissues
Pt with heat stroke and red urine
Rhabdomyolysis can occur when body temp is >105
Trimethoprim effects on kidney
Increases serum K+ by blocking the epithelial sodium channels in the CT (like amiloride)
Increases creatinine by competitively inhibiting its secretion (although GFR is unchanged)
Patient who has a high fever, VS instability, agitation/delirium, lid lag, tremor, warm skin
Thyroid storm
Give propanolol, PTU, and glucocorticoids (decreases peripheral T4=>T3)
-This can be triggered by surgery, trauma, infxn
Testing to do on all ITP pts
HIV, Hep C
Bone marrow bx. if you still dont have an answer
Metabolic syndrome triad
HTN
Dyslipidemia
Impaired glucose tolerance
Metabolic syndrome diagnostic criteria
Abdominal obesity (Men: >40; Women: >35)
Fasting glucose >100-110
BP >130/80
TGL >150
HDL (Men: <40; Women: <50)
Must have 3/5 of these
Hemodynamic measures in septic shock
RA pressure (preload): Normal or decreased
PCWP (preload): Normal or decreased
CI (pump fnxn): Increased
SVR (afterload): Decreased
MvO2: Increased
Differentiating HG from normal N/V during pregnancy
Urinary ketones are (+) in HG
FiO2 in ARDS
Start off high; however, it should be decreased to <60% to keep PaO2 in the 50-80 range
Flow-volume loop in fixed upper airway obstruction
Looks pretty egg shaped
Recurrent pneumonia in the same location of the lung
Can be due to localized airway obstruction =»impaired bacterial clearance
Causes: External bronchial compression (neoplasm, lymphadenopathy, vascular irregularity)
Intrinsic obstruction (bronchiectasis, foreign body)
-Get a CT to eval
Complication of GCA
Aortic aneurysm
treatment for refractory c dif
Fidaxonycin
If all else fails, fecal transplant
Toxins that can cause ATN
IV contrast
Myoglobin
It’s also caused by ischemia
Tx of prerenal AKI
IVF
Or
Diuretics if they are in a volume overload state
Indications for hemodialysis
Acidosis
Electrolytes ( particularly potassium and calcium)
Intoxication
Overload
Uremia
Common confections with gonorrhea
Chlamydia, hiv, hep b, and syphilis
Test for all of these
Rivaroxaban
Direct Xa inhibitor used for DVT prevention and has no increased risk for ️Bleeding
Can additionally be used for acute DVT as long as the patient is hemodynamically stable
Ekg finding in PE
New onset bundle branch block
Hypercalcemia of immobilization
Increased osteoclastic resorption after increased periods of time being nonambulatory
Worse with renal insufficiency
Polymyositis
Patients have symmetrical proximal muscle weakness with possible Mild muscle tenderness
Dx: AAs (anti-Jo-1)
Elevated CK
Muscle biopsy shows endomysial mononuclear infiltrate
Can be associated with Cancer, myocarditis, and lung disease
Tx: Systemic glucocorticoids
What should you do at stage IV CKD?
Place an av fistula in to prep for dialysis need
GFR= 15-29
Treatment of severe hypernatremia
D5W
Hyponatremia workup
- Serum osmols
2xNa+gluc/18+BUN/2.8= approx. 280
Normal? =» isotonic (pseudohyponatremia)
Abnml =» Hypertonic hyponatremia
-Hyperglycemia (For every 100g starting at 200= +1.6)
Hypotonic hyponatremia
-Diuresis
-SIADH (euvolemic)
Renal tubular acidosis
Addison's
Thyroid Disease
First thing to check on a sample with hyperkalemia
Evidence of hemolysis in the tube
Barrter’s disease
Looks like Loop diuretics
hypoglycemia, hypocalcemia
Gittelman’s Syndrome
Looks like thiazide diuretics
hyperglycemia, hypercalcemia
IV K+ replacement
IV replacement can not go faster than 10meQ/hr
10meQ =» Change of 0.1
Initial eval of adrenocortical insufficiency
8AM serum cortisol and ACTH stimulation test
Crystal-induced AKI
Causes: Acyclovir (especially if IV)
Sulfonamides
Methotrexate
Ethylene glycol
Protease inhibitors
S/s: Elevated Creatinine, possible hematuria, pyuria, crystals
Tx: Discontinue drug; IV fluids
**IF YOU GIVE PLENTY OF FLUIDS WITH ADMINISTRATION OF DRUG; YOU CAN PREVENT IT FROM EVER HAPPENING
Patient who has a popping sensation in their kneww and has a rapid onset of hemarthrosis
Probably ACL tear
Pt. with thrush and signs of pneumonia
Probably still PCP
Pt. who has decreased proprioception and a pupil that does not constrict with light
Probably tabes dorsalis
Tx: IV penicillin
Complications with SAH
Rebleeding (think this if in 24 hrs)
Vasospasm (think this if in 3 days)
Hydrocephalus/Increased ICP
Seizure
Hyponatremia due to SIADH
Familial hypocalciuric hypercalcemia
Mutation of the Calcium-sensing receptor that leads to increased reabsorption of calcium in the tubules
Causes of Wernicke’s encephalopathy
Chronic alcoholism
Malnutrition (anorexia)
Hyperemesis gravidarum
Pneumonia vaccine everyone should get
PPSV23
MCC of resistant HTN
Renal artery stenosis
These pts. will be on 3 or more antihypertensives with consistently high readings
PE: Can hear abdominal bruits, asymmetric renal size, rise in serum Cr after starting ACEIs
Patient with a nonpalpable point of maximal impulse and dyspnea
Consider pericardial tamponade
Reason pts. with Crohn’s get kidney stones
Hyperoxaluria
Bacillary angiomatosis
Arises w/ CD4 <100
S/s: Vascular cutaneous lesions resembling Kaposi’s sarcoma
-Papular, nodular, peduncular
B-sx.
Dx: Lesional biopsy
Tx: Doxycycline or erythromycin
Pts. with malabsorption issues and now have bone pain
Osteomalacia
May also see muscle cramps or a waddling gait
Dx: Increased AP, increased PTH, decreased Ca2+ and PO43-, decreased urinary Ca2+
X-ray shows thinning of the cortex and reduced BMD
Bilateral and symmetric pseudofractures can be found
Intraocular inflammation in HIV patients
Actually caused by HSV or VZV; called bilateral necrotizing retinitis
-keratitis, conjunctivitis, eye pain, rapid vision loss
*CMV retinitis is painless and has hemorrhages and retinal lesions
MRI of metastatic brain lesions
Multiple-well circumscribed lesions with vasogenic edema at the gray and white matter jnxn
Lung cancer and melanoma most commonly have multiple brain mets
Tx for Eikenella corrodens
Augmentin
Pt treated with antiarrhythmic and later develops pulmonary sx.
Probably amiodarone toxicity; develops months after treatment
Pt. with abdominal pain right after eating that is not localized
Suspect chronic mesenteric ischemia
Most effective way of improving communication of relevant patient transfers
Implementing a signout checklist
Volume responsive metabolic alkalosis
Diuretics, dehydration, enuresis
Pts will have a urinary Cl of less than 10
RTA urine anion gap
Increased
CT in acute pancreatitis
Swelling with peripancreatic fluid and fat stranding
Fluid does NOT appear enhanced
Tx of acute MS exacerbation
Corticosteroids
If no improvement =» Plasmapheresis
Tx of bony mets in prostate cancer
Radiation
Salvage therapy
Therapy when standard treatment for a disease fails
Ex: Radical prostatectomy performed but months later the pts. PSA begins to rise again
Adjuvant therapy
Tx given in addition to standard therapy
Consolidation therapy
Given after induction therapy with multidrug regimens to further reduce tumor burder
Induction therapy
Initial dose of tx. to rapidly kill tumor cells and send a patient into remission
Maintenance therapy
Given after induction and consolidation therapies to kill any residual tumor cells and keep the pt. in remission
Neoadjuvant therapy
Tx give before the standard therapy for a particular disease usually used to decreased the size of a tumor before a resection or some shit like that
G6PD activity test during an acute hemolytic episode
Useless
Signs of severe aortic stenosis
Diminished and delayed carotid pulse
“pulsus parvus and tardus”
Mid-to-late peaking systolic murmur
Present of a single and SOFT S2
Tx for Central Retinal Artery Occlusion
Hyperbaric O2 and ocular massage
Tx of elevated homocysteine levels and hypercoagulability
Pyridoxine
-This will help to active cystathionine B-synthase to eventually convert homocysteine to cysteine
Initial work-up of HTN
BMP, CBC, urinalysis, lipid profile, and EKG
-These are done to evaluate for any high risk comorbidities made worse by HTN
Tx for HIT
Stop heparin; start argatroban (diretct thrombin inhibitor) or fondaparinux
Assist control mode of respirator
Delivers a preset tidal volume that the patient can initiate with a breath but if they fail to breathe, then the respirator maintains a minimum breathing rate
If the respirator is on this setting, consider adjusting the respirator rate with undesirable CO2 and O2 levels
Most frequent location of ectopic foci that cause a-fib
Pulmonary veins
PPD treatment protocols
> 5: HIV, recent TB contact, nodules or fibrotic changes on CXR, organ transplant, immunosuppresion
> 10: Recent immigrant, injection drug users, high risk settings (homeless, prison, hospital), prolonged corticosteroids, diabetes, ESRD, children 15: Everybody
HHV-8
Kaposi’s Sarcoma
Charcot-Bouchard aneurysms
HTN causing small ruptures and bleeds into the deep brain structures
Locations: Basal ganglia (putamen), cerebellar nuclei, thalamus, pons
MCCo lobar or cortical hemorrhage
Cerebral amyloid angiopathy
MCCo nephrotic syndrome in adults
FSGS
-Assoc. w/ being black, using heroin, having HIV, and being fat
Patient who presents with signs of B12 deficiency but doesn’t have classic RFs for nutritional deficiencies
Pernicious anemia
***Monitor these pts. for gastric cancer because they typically have atrophic gastritis from the anti-IF abs
HIV pt with diarrhea
Non-bloody? =» Stool exam for ova/parasites, C. dif ag, and acid-fast stain for Cryptosporidium
Nloody? =» CMV colitis or other typical infectious cause
Hyperextensive injury in pt. with degenerative changes in the cervical spine
High RF for central cord syndrome
S/s: Weakness in upper extremities w/ possible loss of pain and temp up here too
Primary intervention to control GFR decline once azotemia is present
Intensive BP control
Target= 130/80
Patient with an autoimmune condition and it asks what other disease they might have
PICK THE AUTOIMMUNE CONDITION
Lab findings in Paget’s
Calcium- Normal
PO43- Normal
AP- Increased
Urine hydroxyproline- Increased
Urine Calcium- Increased
Ulnar nerve syndrome
Entrapment of the ulnar nerve in the medial epicondylar groove
Commonly caused by prolonged, inadvertant compression of the nerve by leaning elbows on a desk or table
S/s: Numbness in 4th and 5th digits; weakened grip
MTX ADRs
Hepatotoxicity
Stomatitis
Cytopenias
-Try to prevent by giving the pt. folic acid supplementation
Sulfasalazine ADRs
TNF and IL-1 suppressor
ADRs are hepatotoxicity, stomatitis, and hemolytic anemia
Pt who receives blood and shows signs of tetany and carpopedal spasm
Hypocalcemia
Prevention of recurrent nephrolithiasis
Increase fluids
Reduce sodium and protein
Thiazide diuretics
Test used to compare two means
Two sample t-test
Test used to compare 3 or more means
ANOVA
Best survival chance for renal failure pts.
Renal transplantation from a living related donor
Hawthorne effect
Subjects are aware they are being studied and then they alter their behavior
Isoniazid toxicity
Peripheral neuropathy and hepatotoxicity
Post-ictal pt. who is acidotic
Just wait; this is temporary lactic acidosis caused by skeletal muscle hypoxia
Lupus nephritis abs
anti-dsDNA
Drug induced lupus abs
anti-histone ab
PBC antibodies
anti-mitochondrial abs
Pseudogout flare tx
Colcichine, NSAIDs
Steroids if absolutely necessary
Colcichine can cause diarrhea so be careful
Causes of gout
Increased production:
Tumor lysis syndrome
Chemotherapy for leukemia
Renal Failure
Decreased excretion:
Probenecid
CKD
EtOH
HCTZ
“Periarticular osteopenia”
RA
DMARDS for RA
MTX
Leflunoamide
Sulfasalazine
Hydroxychloroquine
CREST syndrome
Calcinosis Raynauds (tx. w/ CCB) Esophageal dysmotility (tx. w/ PPI) Sclerodactyl (tight and no wrinkles) (tx. w/ penicillamine) Telangectasia
Tx for renal failure in sclerotic crisis
ACEI
Usually you give steroids w/ ARF but not in this case
Lymphoplasmacytic infiltration of the exocrine glands
Sjogren’s Syndrome
Stasis dermatitis
Patients have peripheral edema that leads to chronic stretching presenting as erythematous and dark skin
Tx: Diuretics; compression stalkings; leg elevation
Can progress to ulcers on the medial malleolus (stasis ulcer)
Hand dermatitis
Chronic hand-washing =» dermatitis
Found in health care workers and food preparers
Tx: Conservative
Tinea versicolor
Malasezzia sp.
Fungal infxn presenting as scaly macules of varying color
**There are areas of the body that DO NOT TAN
Dx: KOH prep =» Spaghetti and meatballs
Tx: Selenium shampoo; ketoconazole
Diagnosing and treating vitiligo
Dx: Wood’s lamp; biopsy shows lack of melanocytes
Tx: High potency topical steroids; extensive UV light
Tyrosinase deficiency
Albinism
Ash Leaf spot
Found in TS
***LOOK FOR SHARGREN PATCHES (elevated patches of fleshy blood vessels)
F/u: CT scan to ID brain lesions
“eggshell calcification”
Hyatid cyst
Ototoxic drugs
AGCs, chemo, LOOP DIURETICS, and aspirin in high doses
Things you can still see after brain death
Spinal reflexes (anything that doesn’t require input to the brain)
MCCo elevated AP in an asymptomatic elderly pt.
Ostetitis deformans
Tx for renovascular HTN
ACEIs
Renal stenting indications
Pts who cant tolerate medical therapy, develop recurrent flash pulmonary edema and/or refractory CHF, and pts. who fail to reach adequate BP control after a long time of medical therapy
Best preventative measure for pressure ulcers
Pressure redistribution
Tx for SVT
Adenosine; lowers automaticity of the SA node
ADRs: Headache, flushing, SOB, chest pressure, nausea
Prevention of SVT
Digoxin
BB or Verapamil are 2nd line
WPW drug tx
Type 1A or 1c antiarrhythmics
Although definitive tx is radioablation
Torsades de pointes tx
IV magnesium
Tx of Vtach
Stable =» IV amiodarone or sotalol
Unstable =» Cardioversion followed by amiodarone
Patient who has sharp chest pain and it is the worst of their life with a widened mediastinum
Aortic dissection
Probably caused by systemic HTN
Tx of hyperthyroidism
Mild =» Antithyroid med alone
Moderate to severe =» Antithyroid med, BBs, radioactive iodine
Tinea corporis
Scaly, erythematous, pruritic patch with centrifugal spread and central clearing with a raised, annular border
Skin scraping w/ KOH would show segmented hyphae and arthrospores
Tx: Topical clotrimazole or terbinafine
Second line: Oral griseofulvin or terbinafine
Cyclophosphamide ADRs
Acute hemorrhagic cystitis, bladder cancer, sterility, and myelosuppression
Prevent by drinking plenty of fluids or taking MESNA****
Follow-up of positive stress test
Coronary angiography on pts. with high risk findings
OR
Have a high pre-test probability (typical angina in men >40 or women >60)
Bronchiectasis
Pts have repeated pulmonary infxn plus defective bacterial clearance; could also be caused by airway obstruction (cancers) immunodeficiencies, CR, a1-antitrypins deficiency
PE: Crackles, wheezing, fever, dyspnea, increased sputum
Dx: CT scan of the chest (shows bronchial dilation and wall thickening)
-May also consider IG quantification, CF testing, and PFTs
Tx of diabetic gastroparesis
Increased fiber, small and frequent meals
Metoclopromide
Erythromycin is second line
Anemia that pyridoxine deficiency produces
Acquired sideroblastic anemia
Increased serum iron and decreased TIBC
Euthyroid sick syndrome
Normal TSH And T4 but decreased T3 caused by decreased deiodination to T4
Typically occurs in pts. w/ exacerbation of illnesses and thyroid hormone supplementation is NOT recommended
Severely ill pts. who on CXR have pneumonia
Still get a sputum culture before empiric antibiotics because the antibiotics can produce a false negative
Extramuscular findings of dermatomyositis
Interstitial lung disease
Dysphagia
Myocarditis
MALIGNANCY (must screen pts.)
Follicular thyroid cancer
Biopsy shows follicular cells clustered together and INVADE THE TUMOR CAPSULE and possibly a blood vessel
***Spreads hematogenously
Drug that acts on B1-receptors
Dobutamine
Used for severe left ventricular systolic dysfnxn and cardiogenic shock
=»Decreased LVESV
First thing to do in someone SUSPICIOUS for pneumonia
CXR YOU DUMB FUCK
Postviral thyroiditis
Likely subacute thyroiditis; hyperthyroid sx. and fever alongside elevated ESR and CRP
RA leads to an increased risk of what bone conditions?
Osteoporosis and bone fractures
Extension of the knee while compressing the patella
Patellofemoral compression test
Dermatitis herpetiformis
Intensely pruritic papules, vesicles, and bullae that occure symmetrically in clusters on the elbows, knees, back, and butt
AI rxn to gluten; ASSOC. W/ CELIAC
Skin biopsy: Microabscesses at the tips of the dermal papilla and anti-epidermal transglutamase IgA
Tx: Dapsone; long-term is gluten free diet
Recurrent cataracts
NOT A THING
Pt recovering from a viral uri who is having episodic dizziness and hearing loss
Vestibular neuritis
Tx: Steroids
MAO-b inhibitor
Selegline
COMT inhibitor
Entacapone
Major interactions of levothyroxine
Decreased absorption: Bile acid binders, iron, calcium, AlOH, PPIs, sucralfate
Increased TBG conc: Estrogen, tamoxifen, raloxifene, heroin, methadone
Decreased TBG conc: Androgens, glucocorticoids, anabolic steroids
Increased thyroid hormone metabolism: Rifampin, phenytoin, carbamazepin (CYP-inducers)
Drug-induced acne
Monomorphic papules without comedones
Lesions are found in the same stage of development; does not respon to typical tx.
Causes: Steroids, androgens, azathioprine, anticonvulsant, antipsychotics, isoniazid
pH disorder with adrenal insufficiency
Normal anion gap metabolic acidosis
Due to decreased aldosterone
Tx for cervicofacial Actinomyces
Penicillin
DOC for primary biliary cholangitis
Ursodeoxycholic acid
Measurement bias
Results from poor data collection with inaccurate results
STI that cannot be seen on gram stain
Chlamydia
Imaging for obstructive urolithiasis
Abdominal US or noncontrast spiral CT
IE from streptococcus sp.
IV penicillin or ceftriaxone
Biopsy in Histoplasmosis
Granulomas with narrow-based budding yesasts
Confirming a diagnosis of primary sclerosing cholangitis
Can be done with an ERCP
Bx would show intrahepatic ductular obliteration with lymphocytic infiltration and periductular “onion-skin” fibrosis
CHADS-VASc score
Congestive heart failure HTN Age >75 (+2) DM Stroke/TIA/Thromboembolism hx. (+2) Age 65-74 Sex category (female)
Naloxone OD in homeless person
AMS, hypothermia, bradypnea, and hypoxia
Tx for hypertensive emergency
IV nitrates, CCBs, and BBs
Drop the BP by 25% in 2-6 hrs; get it to normal in 24
Tx for hypertensive emergency
IV nitrates, CCBs, and BBs
Drop the BP by 25% in 2-6 hrs; get it to normal in 24
Acute, monocular vision loss, “washed-out” colors, afferent pupillary defect, and pain with eye movement in a woman
Optic neuritis
Immune-mediated inflammatory demyelination of the optic nerbve
Chronic cirrhosis effects on thyroid hormone
Lowers total T3 and T4
Free T3 and T4 are normal as well as TSH
Blastomycosis
Found in the Mississippi and Ohio River valleys as well as the Great Lakes region
S/s: Pneumonia, wartlike lesions, skin ulcers, violaceous skin lesions, possible osteomyelitis and prostatits
Amitriptyline in old people
Dont do this, you’ll trigger urinary retention and then have to cath them
Patient who receives nitroprusside for a long time
Look for signs of cyanide toxicity
Signs of secondary syphilis
Diffuse rash
Lymphadenopathy epitrochlear
Condyloma lata
Grey mucous patches
Hepatitis
Repaglinide, nateglinide
Glinides
Weight gain; mostly targets postprandial glucose
Binds to sulfonylurea receptor and stimulates insulin release
Pioglitazone, rosiglitazone
Thiazolidinediones
PPARy activators that increase peripheral tissue sensitivity to insulin
ADRs: HF, weight gain, minor infarction risk
Exenatide, liraglutide
Incretins
Activates GLP-1 receptors increasing glucose-dependent insulin secretion and decreasing glucagon secretion
**ALSO DELAYS GASTRIC EMPTYING AND INCREASES EARLY SATIETY
ADRs: N/V; rare pancreatitis
Sitagliptin, saxagliptin
DDP-4 inhibitors
Inhibit degradation of GLP-1
ADRs: Urticaria
Dapagliflozin, canagliflozin
SGLT2 inhibitors in the proximal renal tubules to reduce renal reabsorption of filtered glucose
ADRs: Genital yeast infxns and UTIs
Elderly pt. with history of chronic falls and progressive dementia
Think chronic subdural hematoma before vascular dementia
RVMI leads
V4r-V6r
Pneumomediastinum
Esophageal perforation related to Boerhaave syndrome, instrumentation, esophagitis, or ulcer rupture
CRVO tx
No macular edema? =» Conservative
Macular edema? =» Intravitreal injxn of anti-VEGF
Indications to treat subclinical hypothyroidism
Symptomatic
Pregnancy
TSH >10
Anti-TPO abs
Acute cystitis tx options
Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or CKD)
Bactrim for 3 days
Single fosfomycin dose
FQNs if primary tx. fails; also get a urine culture
Pt. who is on a ventilator and develops signs of pneumonia
VAP; typically caused by Psed. E. coli, or K. pneumoniae (gram negs) or gram pos bacteria
Management:
- Get CXR
- Sputum culture
- Abs
Pts. who are on EPO but remain anemia
Give iron supplementation due to rapid depletion
First thing to do in suspected stroke
Non-contrast CT
Coverage for HCAP
Vance and zosyn
F/u on pulmonary cavitary lesion on CXR
CT
Improvers of mortality in copd
O2
Smoking cessation
Treatment of hypernatremia
Dextrose in water
Confounding factors
Things that partially explain an association
I.e. - People who smoke are also more likely to drink
Tx for severe hypovolemic hypernatremia
Normal saline
Patients with mild hypovolemic hypernatremia
Dextrose in saline
Patients with hypervolemic hypernatremia
Dextrose in 1/2NS
Patient who has a viral illness but then a cough productive of sputum that sticks around for a while
Acute bronchitis
Initial step in confirming hypercortisolism
EITHER A 24 HOUR URINE FREE CORTISOL MEASUREMENT AND/OR OVERNIGHT LOW-DOSE DEXAMETHASONE SUPPRESSION TEST
YA DUMB FUCK
Comps of acute pancreatitis
ARDS
ARF
GI bleed
Necrotizing pancreatitis
Peripancreatic fluid collection
Pseudocyst
Pathophys: Release of inflammatory mediators cause widespread vasodilation, capillary leak, shock, and end organ damage
Miliary TB x ray
Diffuse reticulonodular patter (millet seed)
Make sure to be on the look out for predisposing factors
Tx for single brain mets
SURGERY
Tx for multiple brain mets
Whole Brain Radiation or supportive care
Wernicke Encephalopathy features
Encephalopathy (confusion)
Oculomotor dysfnxn (horizontal nystagmus, bilateral abducens palsy)
Postural and gait ataxia
Pt with aortic stenosis and under the age of 70
Bicuspid valve
S4 associated conditions
Young adults/children
Ventricular hypertrophy
MYOCARDIAL INFARCTION (EARLY)
Acute GVHD
Donor T-lymphocytes react with host minor HLA-antigens and produce a cell-mediated response
=»Maculopapular, pruritic rash, bloody diarrhea, and abnormal LFTs with jaundice are common manifestations
HIT antibodies
Heparin produces a change in platelet surface protein 4 causing the formation of AAs
=»Platelet aggregation, thrombocytopenia, skin necrosis at abdominal injection site
Papillary muscle displacement but not rupture of the mitral valve
Increased left ventricular pressure due to the regurgitation
Patients to screen for fibromuscular dysplasia
Women <50 with one of the following:
Severe or resistant HTN
Onset of HTN before 35
Increase in Cr after starting an ACEI or ARB
Epigastric bruit
Screen with CT scan or US
EKG showing LVH
High voltage QRS complexes, lateral lead ST segment depression, lateral lead T wave inversion
Renal vascular lesions with chronic HTN
Arteriosclerosis of the afferent and efferent arterioles and glomerular capillary tufts
Eventually hypertrophy and intimal fibrosis of the arterioles
Pronator drift
Patient whose hand drifts downward when they hold their arms straight out with their palms up and eyes close
**SIGN OF PYRAMIDAL OR CORTICOSPINAL TRACT LESION
-UMNs cause more weakness in supinator muscles
Patient with a stone 5mm or less
DRINK LOTS OF FLUIDS YOU DUMB FUCK
Flank pain, RCC, palpable renal mass
RCC triad; pt. needs a CT scan
***Scrotal varicies can be seen on the the left side due to tumor obstruction of the gonadal vein entering the renal vein
Pt with bone mets from prostate cancer
TX WITH RADIATION YA DUMB FUCK
Chronic pancreatitis
Can occur with prolonged consumption of socially acceptable amounts of alcohol; pain can radiate to the back and be relieved by sitting up or leaning forward
Pts typically also have steatorrhea, weight loss, glucose intolerance
Does prostate cancer go to the liver?
No, colon cancer does ya dingus
New onset of urinary incontinence in an elderly patient
UTI= MCC
Could also include meds, CHF, DM, alcohol, stool impaction
Initial workup of any blood disorder q
CBC
ya dingus
What should be done after a diagnosis of cancer?
CT scan
Stage disease and look for mets
New lung mass found on CXR, what do you do next?
CT scan
Patient with back pain that improves with movement who is >50
Probably spinal stenosis
AS presents in pts. from 15-30
Confirmatory test for spinal stenosis
MRI
Young patient presenting with restrictive lung disease signs but also improves with exertion
Probably AS
Restrictive signs are due to chest wall motion restriction
PT with acutely elevated serum creatinine
Get a renal US
Want to rule out hydronephrosis
Causes of increased peak pressure on a ventilator
Normal plateau pressure: Bronchospasm, mucus plug, biting ET tub
Increased plateau pressure: PTX, edema, pneumonia, atelectasis
Seborrheic keratosis locations
Face, trunk, upper extremities
Initial test for a positive cervical lymph node for cancer
Panendoscopy
Contact dermatitis
Encompasses both allergic and irritant (acids, soaps)
Tx of uric acid stones
Hydration, alkalinization, and low-purine diet
Prevention: Potassium citrate (citrate reduces crystallization)
Allopurinol if this fail
Follow up test for a positive Hep C antibody
HCV viral load (confirmatory)
Pt who is started on a BB and develops SOB a couple days later and wheezing
Guess what happened?
Pt probably has a history of rhinitis and eczema meaning undiagnosed asthma
Pt with amoxicillin and develops anemia later
Warm AIHA
Positive urine urobilinogen
Sign of INTRAVASCULAR hemolysis
Unconjugated hemoglobin is converted to this and excreted in the urine and feces
Megacolon in someone who is from SA
Still consider chagas
Pt with alcohol abuse who develops mouth swelling from the floor of the mouth
Ludwigs angina
TTP
Hemolytic anemia with possible renal failure, neurologic manifestations, and fever
Tx: Plasma exchange
Most effective nonpharmacologic measure to decrease BP in overweight individuals
Weight loss
Asking about hypertensive emergency criteria
Pick end organ damage over BP
Cauda equina syndrome is primarily an issue with what?
Spinal nerve roots
Causes: Disc herniation, spinal mets, spinal stenosis, infxn, hemorrhage
***Spinal cord ends at L1-L2 and cauda equina begins below this
***Only causes LMN signs as opposed to conus medullaris
Classic clinical criteria for ARDS
Hypoxemia refractory to O2 therapy
Bilateral diffuse pulmonary infiltrates on CXR
No evidence of CHF
Tx of ARDS
Mechanical ventilation w/ PEEP; increases lung volume by opening collapsed alveoli
Avoid volume overload
Synchronous intermittent mandatory ventilation
Like assist control BUT the tidal volume is not precontrolled by the ventilator
***AC is much more commonly used
-This mode is good for weaning patients off the ventilator tho BUT I WOULD STILL USE CPAP
Ventilator to adjust to achieve baseline PaCO@
Minute ventilation
I:E ration on a vent
Usually uses 1:2
If you increase one, the other goes down
ADRs of high levels of PEEP
Barotrauma with possible PTX
Low CO due to decreased VR
Comps on ventilators
Sedation with benzos as anxiety and agitation are common
Suction trachea
Nosocomial pneumonia if >72 hrs
Accidental extubation
Barotrauma
Tracheomalacia (you know who)
-If she would have gotten a tracheostomy after 2 weeks on the vent; none of that would have happened
Tx for primary pulmonary HTN
Prostacyclin; CCBs (pulmonary vasodilators)
Anticoagulation
Lung transplantation if possible after evaluation
Peaked p waves
P pulmonale
Manifestations of Grave’s Disease
Gen: Heat intolerance, weight loss, sweating
Eyes: Lid lag, proptosis, DIPLOPIA, DECREASED CONVERGENCE
Skin: Hair loss, infiltrate dermopathy
CV: Tachycardia, HTN, a-fib
Nails- Onycholysis, clubbing
Endo: Hyperglycemia, hypercalcemia, bone loss, menstrual irregularities
GI: Diarrhea
Neuro: Tremors, hyporreflexia, proximal muscle weakness
Ventricular aneurysm
Commonly occurs 5 days-2 weeks after an MI
EKG: persistent ST-segment elevation after a recent MI and deep Q waves in the same leads
-HF, refractory angina, arrhythmia, mural thrombus with possible embolization, mitral annular dilatation with regurgitation
Dx: Echo shows dyskinetic LV portion in same area of previous MI
Indications for testing for someone for an inheritable hypercoagulopathy
Age <45
Recurrent DVT
Multiple or unusual sites of thrombosis
FH of VTE
Where is Broca’s area located?
Frontal lobe
Where is Wernicke’s area located
Temporal lobe
Thyrotoxicosis with normal or decreased iodine uptake
Painless (Silent) thyroiditis; assoc. w/ anti-TPO and is a variant of chronic lymphocytic (Hashimoto’s) thyroiditis
Subacute thyroiditis
Amiodarone-induced thyroiditis
Excessive intake
Struma ovarii
Iodine-induced
Cancer met s
Study of choice for Aortic Dissection of unstable pt.
Transthoracic echocardiography
CT if stable (Don’t do with kidney disease)
Tx for acute back pain
NSAIDs; moderate activity
NOT PT YOU IDIOT
Therapy for chronic back pain
PT
Pts loss to follow-up in a prospective study is what type of bias?
Selection bias
-Study winds up with inaccurate estimate of disease exposures and relevance
Pt who is given amoxicillin for sore throat and develops a rash 24 HOURS after administration
Probably has mono
***If the rash immediately develops, it is hypersensitivity
Riley-Day Syndrome
“Familial dysautonomia”
Jewish kid with gross dysfnxn of the autonomic nervous system with severe orthostatic hypotension
Attributable risk percent
Represents the excess risk in a population due to exposure to an RF
ARD= (risk in exposed-risk in unexposed)/risk in exposed
Factors found in Cushing Syndrome but not in PCOS
Skin atrophy
Muscle weakness
Bruisability
Patient who develops an infxn after being treated for hyperthyroidism
THINK ABOUT AGRANULOCYTOSIS
STOP PTU
Chronic bronchitis
Can progress to hemoptysis
Don’t automatically think of cancer or bronchiectasis
Polymositis vs/ hyperthyroidism
Does not present with any other sx. than muscle weakness
IF patients have tachcardia, weight loss; think hyperthyroidism
Patient who is on an antipsychotic and has elevated prolactin
Check other pituitary hormones; they should not be suppressed
If they are =» suspect adenoma
Hypothyroid myopathy
Muscle weakness; elevated CK; fatigued woman with decreased DTRs
Pt in the hospital for 2 days with hallucinations, HTN, hyperthermia, tremors, and diaphoresis
Delirium tremens
Give benzos because they act as GABA agonists like alcohol
Differences between strokes caused by amyloidopathy and HTN
Amyloidopathy =» Lobar and CORTICAL
HTN=» Charcot-Bouchard aneurysms and deep structures
Lab findings in anemia of chronic disease
Iron: Decreased
TIBC: Decreased
Ferritin: Normal-increased
Transferrin saturation: Decreased-normal
MCV: Decreased-normal
Patient with signs of RA and splenomegaly
Felty Syndrome
Bullous pemphigoid tx
Topical clobetasol
“Carboxyhemoglobinemia”
Refers to CO poisoning
NOT CO2 you dipshit
Other sign of a STEMI
New onset of LBBB
Psoriasis treatment
Calcipotriol
Steroids
Combo is best
Where is the fluid in Angioedema?
The subcutaneous layer, unlike with urticaria
Can also be found in the hands, feet and genitalia
Pleural effusion lung sounds
Percussion: Dull
Tactile fremitus: Decreased
Breath sounds: Decreased
Lung consolidation sounds
Percussion: Dull
Tactile fremitus: Increased
Breath sounds: Decreased
Mechanical obstruction abdominal x-ray appearance
Air through the entire GI tract with dilated and scattered loops stacked on top of each other
“Bag of sausages”
Ileus abdominal x-ray appearance
Dilated loops that are scattered and lack organization
“Bag of popcorn”
Patient who has a central line placed and then has sudden onset of dyspnea
Consder PTX or venous air embolism
Patient who was given an antibiotic for let’s say endocarditis and develops a diffuse, red rash
Probably vancomycin
“Red Man Syndrome”
S/s: Fever, nephrotoxicity, ototoxicity
Tx: Slow the infusion; give antihistamines
Drug you should always give with imipinem
Cilastatin; prevents renal toxicity
Drug used for GNR sepsis
CArbapenem
Tx of chlamydia in a pregnant woman
Erythromycin
Only FQN with anaerobic coverage
Moxifloxacin
TB therapy
4 drug therapy for two months
Rifampin and INH for 4 months
Prophylactic for pts. with contact for menigococcal meningitis
Rifampin
Pt treated for vaginal discharge and has vomiting after going out one night
Disulfarim rxn due to metronidazole
Pt who is in a car accident and has weakness that is more pronounced in the upper extremities than the lower
Central cord syndrome
- This is because the motor fibers serving the arms are closer to the central part of the corticospinal tract
- Pt. does not necessarily have to have loss of pain and temp
Patient who has signs of a heart attack and then has a syncopal episode shortly after to the ER
PRobably due to a reentrant arrhythmia
If it happens 10-60 minutes later, it is due to abnormal automaticity
Pt who has a chronically progressive cough and comes to the ER with upper lobe consolidation with possible cavitation
Mycobacteria
Remember, aspiration pneumonia typically affects the lower lobes
PT. who has malaria-like sx. but lives in New York
Babesiosis
Hypovolemic shock hemodynamic parameters
RA pressure: Decreased
PCWP: Decreased
CI: Decreased
SVR: Increased
MvO2: Decreased
Study in which population is randomly selected and then determined if they have the disease and marker or not
Probably a cross-sectional study
ANY STUDY THAT LOOKS AT PREVALENCE, GUESS THIS*
Tx for patients with symptomatic hypercalcemia
Parathyroidectomy
Causes of 1st time seizure
Vitamins Infxn Trauma Autoimmune Metabolic Ingestion/Withdrawal (benzos and alcohol) Neoplasm pSych
Tx for myoclonic seizures
Valproic acid
No loss of tone
Tx for atonic seizure
Valproic Acid
Loss of tone
Paradoxical splitting of S2
Narrowing of normal S2 split
Occurs due to LBBB, aortic stenosis, and HTN
Rales
Same thing as crackles!
Due to excessive fluid in the lungs
Positive babinski
EXTENSION
Observational studies
Case-control studies
Study that observes subjects at a specific point in time
Cross-sectional
“Snapshot of a population”
Patients are selected because they have a certain outcome and their history is reviewed for any exposures
Case-control
ALWAYS RETROSPECTIVE
*Good for rare diseases and diseases with long latent periods
Studies are selected according to exposure and are followed over time to determine the development of disease
Cohort study
Type I error
alpha error
Same thing as a p-value
Null hypothesis is rejected even though it’s true
Type II error
Null hypothesis is accepted even though it is not true
*Determines the statistical power of a study
Usually, 20% is accepted
Factors that affect it: Sample size, p-value, variability of data, effect size chosen by researcher
PErformance bias
Subjects in comparison groups are given different care other than the intervention being studied
Example: One group receives interventional counseling in addition to the treatments that both groups get
Attrition bias
Drop-outs from a study
Intent-to-treat analysis
Analyzes drop outs from a study in groups to which they were initially assigned
Helps prevent attrition bias
Studies that suffer from bias lack what type of validity?
Internal
Studies that cannot be generalized to a larger and more complex population lack?
External validity
Pt presenting with upper abdominal pain with nausea and vomiting and a history of diabetes
Still get EKG first; need to rule out ACS
Pt who has HIV and CXR suggestive of pneumoniae but CD4>200
NOT PCP; PROBABLY ONE OF THE NORMAL BUGS
COPD respiratory findings
Bilateral wheezing
ABG shows respiratory acidosis and hypoxia
Pt who has either liver disease or nephropathy and presents with hypocalcemia
Consider hypoalbuminemia as the cause
Should you give someone bitten by a pet rabies prophylaxis
Nah just observe the pet for 10 days
Tx for cocaine OD even if it is presenting with coronary vasospasm
IV benzodiazepines
Does thyroid hormone increase production of catecholamines?
No; it increases sensitivity to them
Best medication reconciliation to reduce adverse drug events in patients
Pharmacist-directed interventions
Ventilation-perfusion scans that show perfusion defects
SUSPECT SOME SORT OF EMBOLI
- Could be recurrent if the pt is not currently symptomatic
- Pt will probably have evidence of venous disease
Bone scan showing multiple dark areas that are well circumscribed and not diffuse
Think mets
Fluffy bilateral interstitial and alveolar infiltrates
Think pulmonary edema
=»Pts. will have alveolar-arteriolar mismatch
Severe umremitting chest pain radiating to the arm and back
Aortic dissection
Pt can have small left pleural effusion
Type I diabetic who collapses while exercising. What is your immediate treatment?
Dextrose
Probably a hypoglycemic episode
Pt with epigastric tenderness, itching, increased bilirubin, and a history of having her gallbladder removed
CT to r/o pancreatic cancer
You know it cant be gallstones
Healthcare proxy who insists that you do something that is medically contraindicated for a patient
Nah don’t do it what does he know
Cause of dehydration in HNNC
Osmotic diuresis
Most effective therapy to prevent an asthma exacerbation following an illness
Oral corticosteroids
Indications for a court order
Patient has no capacity to make a decision, there is no living will or proxy, and the family cannot decide
Drug to use when statins can’t be used
Fibrates
Can cause same ADRs tho
Ezetemibe ADR
Diarrhea; consider this if pt. just started
Drug to give w/ niacin
Aspirin
Will prevent the flushing
Vasovagal syncope causes
Visceral organ stimulation (excessive coughing, urination)
Carotid bodies (increased sensitivity to pressure =»vagal response)
Test: Tilt-table if you want but DX IS USUALLY DETERMINED BY HISTORY
**USUALY A PRODROME
Tx: BB
Dx of orthostatic hypotension
Systolic change of 20
Diastolic change of 10
HR change of 15
Tx: Give fluids or treat any loss of fluids or neuropathic disease
Test done for pain sensation
Pinprick yah dingus
Remember that the nerves come from 1-2 levels higher
Causes of pulsus paradoxus
Cardiac tamponade
Severe asthma
COPD
definition: drop in systolic bp >10 on inspiration
Indications for splenectomy
Hereditary spheroctosis
Warm AIHA if severe
Massive splenomegaly w/ B-thalassemia major or Hgb H disease
ANYTIME IT TELLS YOU ABOUT A PACEMAKER AND HEART FAILURE OR MURMUR
DO NOT RULE OUT RIGHT SIDED CAUSES
Pt who has a nighttime dry cough with a history of seasonal allergy; what is probably causing it?
Post-nasal drip yah dingus
Pt who has aortic stenosis at age 70 or greater
Age-related change
Pt with IV drug abuse and they also have TB but have rapid signs of decompensation
I would look more towards a problem with the IV drug use
INITIAL TREATMENT FOR FEBRILE NEUTROPENIA
Pip-tazo
-This is going to cover gram negs (including pseud) and many gram positives as well
Pt with hypernatremia with neurologic manifestations
Normal saline
then switch to D5W later
Initial treatment for Chronic Venous Insufficiency
Leg Elevation
Followed by compression stockings
Hyperkalemia EKG
Tall peaked T-waves
PR prolongated
QRS widened
Disappearance of p wave
Conduction blocks, sine wave pattern
Meningococcal meningitis
Sudden onset of fever, headache, myalgia, and vomiting alongside nuchal rigidity, AMS, and petechial rash
Differentiate this from RMSF because RMSF has CSF findings similar to VIRAL MENINGITIS
Old patient on NSAIDs and/or aspirin who is anemic
IDE most likely cause
Can osteoarthritis cause anemia of chronic disease?
No; but lupus and RA can
Treatment for CML
Imatinib; A TK INHIBITOR
RApid reversal of warfarin bleed
Prothrombin complex concentrate
or
FPP
along with
Vitamin K
Degenerative changes in Alzheimer’s
Diffuse cortical and subcortical atrophy mostly in the temporal and parietal lobes
Persistent Vegetative State
Similar to coma but there is NO ACTIVITY ON EEG
Both still have brainstem activity; therefore there is reflexes, they may swallow, have that cold water eye reflex, corneal reflex, and other shit ya feel
Virchow’s triad
- Venous stasis
- Endothelial injury
- Hypercoagulable state
Likely ABG on PE
Decreased pO2
-Due to decreased perfusion and it is DIFFUSION limited
Decreased pCO2
-Due to increased CO secondary to hypoxemia
Overall will show respiratory alkalosis
Test to get in pt with possible PE but history of CKD
V/Q scan
Massive PE tx
tPA
Do this if the pt. has PE with pulmonary hTN and overall hypotension
