Uworld questions #2 Flashcards
What are symptoms of someone OD on diphenhydramine? What’s the treatment?
Diphenhydramine is an anti-histamine with anticholinergic properties. OD presents with drowsiness and confusion 2/2 to anti-histamine effects and dry mouth, dilated pupils, blurred vision, bowel and urinary retention 2/2 to anti-cholinergic effects.
Treatment is physostigmine which is an achase inhibitor increasing concentrations of acetylcholine
Describe salicylate intoxication. What’s the treatment?
Salicylate intox: tinnitus, N/V, fever, AMS, metabolic acidosis with resp alkalosis
treatment: sodium bicarb to alkalinize urine
5-HT syndrome symptoms.
tachycardia diaphoresis dilated pupils HTN hyperthermia
What should you suspect in a sickle cell patient with macrocytic anemia?
SCD is usu a chronic normocytic hemolytic anemia with approp reticulocytosis. If pt has macrocytic anemia, suspect a folate deficiency due to increased RBC turnover and increased consumption of folate in the bone marrow. Hence, daily folic acid supplementation is recommended in all SCD pts.
What are the recommendations for colorectal carcinoma screening in someone with ulcerative colitis?
Begin colonoscopy surveillance 8 years after diagnosis. Then repeat every 1-2 years.
Common tetrad describing Parkinson’s
resting tremor (usu starts one-sided)
rigidity
postural instability
bradykinesia
What is hypertensive nephrosclerosis?
pts with chronic HTN and is assoc with retinopathy, LVH, progressive renal failure and mild proteinuria
Paraneoplastic syndromes of SIADH, ACTH and lambert eaton are most commonly assoc with which lung cancer? What about hypercalcemia?
SIADH, ACTH, Lambert –> small cell
hypercalcemia –> squamous
If you suspect adrenal insufficiency (hyponatremia, hyperkalemia, eosinophilia, fatigue, hypotension, hyperpigmentation), what’s the initial step?
-simultaneous basal early morning cortisol, ACTH, and cosyntropin test
low cortisol, high ACTH and minimal response to cosyntropin (ACTH synthetic analogue –> no to little rise in cortisol) –> primary
low cortisol, low ACTH and minimal response to consyntropin (minimal b/c low ACTH has caused adrenal gland atropy–> secondary adrenal insufficiency
lymphocytosis + smudge cells on peripheral blood smear
CLL
presence of thrombocytopenia indicates a poor prognosis
esophageal rupture either via vomiting or from endoscopic procedure can cause pneumomediastinum. Describe.
retrosternal pain
crepitus in suprasternal notch
b/c of esophageal rupture, amylase from saliva will leak into pleural fluid (mostly exudative and low pH)
A painless hard testicular mass + US result showing high likelihood of a testicular tumor, what’s the next step?
no need for biopsy or FNA; go straight to radical orchiectomy
in fact FNA and transcrotal biospy are contraindicated b/c of risk of spillage of cancer cells which can spread thru lymphatics and blood vessels
De Quervain tenosynovitis classically affects? Which 2 tendons are affected?
What’s the finkelstein test?
new mothers who hold their infants with the thumb outstretched (abducted/extended). The abductor pollicis longus and extensor pollicis brevis tendons are affected.
any passive stretch of these tendons elicits pain.
Finkelstein test: passively stretching the affected tendons by grasping the flexed thumb into the palm with fingers elicits pain
What should one suspect in someone with a chronic scar that develops into a nonhealing, painless, bleeding ulcer?
squamous cell carcinoma
Therefore, a punch biospy is warranted
COPD, interstitial lung disease, pulmonary vascular disease and OSA are common etiologies of cor pulmonale. What are some symptoms of cor pulmonale? What do you see on exam and imaging?
symptoms: exertional dyspnea, fatigue, lethargy, exertional syncope (due to decreased CO), exertional angina (due to increased myocardial demand)
PE: peripheral edema, increased JVP w/ a wave, loud S2, right-side heave, pulsatile liver, tricuspid regurg murmur
Imaging:
EKG -right axis deviation, RBBB, RVH
ECHO: pulm HTN, dilated right ventricle, tricuspid regurg
Right heart cath: GOLD STD can show RV dysfunction, pulm HTN without heart disease
someone with metastatic squamous cell carcinoma of the mucosa of the head and neck with a palpable cervical LN. What’s the best initial test?
panendoscopy (triple endoscopy: esophagoscopy, bronchoscopy, laryngoscopy) to detect primary tumor
Compare the coloring of someone who has CO, CN poisoning and methemoglobinia
CO -headache, N/V, vague abd discomfort, confusion, and pinkish-skin hue,
CN-same as CO + almond breath
methemoglobinemia -cyanosis and bluish discoloration
Define Cauda Equina Syndrome in terms of pain, anesthesia, motor weakness, and onset of bowel/bladder dysfunction and either hypo or hyperreflexia
cauda equina (lumbosacral nerves below L1-L2)
Requires emergent MRI, IV glucocorticoids and neurosurg consult
- compression of spinal nerve roots 2/2 to disc herniation or rupture, spinal stenosis, tumors, infection, hemorrhage, iatrogenic
- cauda equina provides sensory innervation to the saddle area
- provides motor to anal and urethral sphincters
- provides parasymp to bladder and lower bowel
sympoms: BILATERAL severe radicular pain, saddle hypo/anesthesia, asymmetric motor weakness, hyporeflexia/areflexia, late-onset bowel and bladder dysfunction
Define Conus Medullaris Syndrome in terms of pain, anesthesia, motor weakness, and onset of bowel/bladder dysfunction and either hypo or hyperreflexia
cauda equina (lumbosacral nerves below L1-L2)
Requires emergent MRI, IV glucocorticoids and neurosurg consult
Conus medullaris is part of the spinal cord so injury here will cause both UMN and LMN signs (vs cauda equina onlyLMN)
- sudden-onset of severe back pain
- perianal hypo/anesthesia
- symmetric motor weakness
- hyperreflexia
- early onset bowel and bladder dysfunction
When should you suspect proteus as the cause of someone’s UTI?
proteus secretes urease that hydrolyzes urea to ammonia and carbon dioxide. ammonia + H+ –> ammonium leading to urinary alkalinization (pH > 7) and promotes formation of struvite stones which will be the nidus for infection.
So suspect proteus in someone with UTI with alkaline urine +/- presence of struvite stones
Of all the therapies available to treat COPD, which has been proven to prolong survival the best?
long-term O2 therapy
use O2 therapy in pts with PaO2 - 55, SaO2 - 88%, and erythrocytosis (hct > 55%) or evid of cor pulmonale
What are some symptoms of acute angle closure glaucoma?
- u/l orbitofrontal headache
- N/V
- u/l severe eye pain with conjunctival injection
- dilated pupil w/ poor light response
w/o treatment can lead to permanent blindness w/in 2-5 hours
Recurrent pneumonia in the same anatomic location is a red flag for bronchial obstruction. If X-ray confirms consolidation, what is your next step in addition to giving abx for the pneumonia?
CT to rule out carcinoma
Bronchoscopy is more invasive and should be done after CT
The anserine bursa is located anteromedially over the tibial plateau just below the joint line of the knee. What are some symptoms of anserine bursitis? How to differentiate from medial collateral ligament damage?
sharply localized pain over the anteromedial part of the tibial plateau. Xrays are normal
not medial collateral ligament damage b/c when you apply valgus stress, it won’t create pain.
intensive axillary freckling + cafe au lait spots + optic glioma (h/o of slowly progressive u/l visual loss)
NF type 1
how to treat solitary vs multiple brain mets
solitary –> surgical resection
multiple –> whole brain radiation
What’s the initial treatment of choice for SIADH?
fluid restriction to less than 800 mL/day
if resistant hyponatremia –> hypertonic saline
demecyclocycline works at the renal collecting tubule and can be nephrotoxic so not DOC unless pt is not responding to fluid restriction
Pts taking antipsychotics like fluphenazine should be advised to avoid prolonged exposure to extreme temp. Why?
can occasionally cause hypothermia by disrupting thermoregulation and body’s shivering mech.
DOC for hypertrophic obstructive cardiomyopathy
beta blockers or cardio selective CCB like verapamil or dilitazem
Associate with the renal pathology muddy brown granular casts --> RBC casts --> WBC casts --> Fatty casts --> Broad and waxy casts -->
muddy brown granular casts –> ATN
RBC casts –> glomerulonephritis
WBC casts –> interstitial nephritis and pyelonephritis
Fatty casts –>nephrotic syndrome
Broad and waxy casts –> chronic renal failure
classic xray finding of someone with flail chest
multiple rib fractures overlying a lung contusion
development of a palpable mass in the epigastrium 4 weeks after onset of acute pancreatitis –>
pseudocyst
preferred imaging modality is US
usu resolves spontaneously, but if persists for greater than 6 wks, or becomes infected or greater than 5 cm in diameter –> drainage
An induration of greater than what in a healthy individual actually warrants TB treatment
> /- 15 mm
any healthy individual with no risk factors with any thing less than 15 mm does not have to be treated
Guillain barre syndrome presents as symmetric ascending muscle weakness and absent DTRs after recent infection that can have some sensory symptoms and autonomic dysregulation. How to diagnose? Treat?
Diagnosis
- clinically
- LP: elevated CSF fluid protein with normal white blood cell count aka albuminocytologic dissociation
Treatment
- IV immunoglobulins
- plasmapheresis Wha
What is euthyroid sick syndrome?
aka low T3 syndrome when there’s a fall in total and free T3 levels with normal T4 and TSH levels usu found in people with acute, severe illness
How to treat temporal arteritis? what about polymyalgia rheumatica that is pelvic girdle, shoulder pain (elevated ESR, normal CK)?
iv high-dose corticosteroid tapered slowly over a period of time
low-dose glucocorticoids can treat polymyalgia rheumatica as well
what is glucocorticoid-induced myopathy?
complication of chronic corticosteroid use, characterized by painless proximal muscle weakness more prominent in LE. There is no muscle tenderness or inflammation. NORMAL ESR and CK. This will slowly improve once offending medication is d/c
Describe clinical features of statin-induced myopathy and whether ESR and CK are elevated
prominent muscle pain/tenderness with or without weakness
normal ESR
elevated CK
Cocaine OD presents with sympathetic hyperactivity (tachy, HTN, dilated pupils), chest pain due to coronary vasoconstriction, seizures. How to treat?
IV benzos will improve psychomotor agitation, reduce myocardial oxygen demand, and alleviate cardiovascular symptoms.
other helpful meds: aspirin, nitroglycerin, CCB
what’s the moa of rivaroxaban? How long does it take to get into effect?
direct factor Xa inhibitor with effects within 2-4 hours that can also be used as a single agent (w/o bridging) for acute DVT treatment.
How does respiratory alkalosis lead to hypocalcemia?
respiratory alkalosis (pH is high) will cause dissociation of hydrogen ions from albumin so more binding sites for Ca2+, decreasing free Ca2+ leading to clinical manifestations of hypocalcemia.
ppx vs treatment for toxoplasmosis
ppx -TMP/SMX
treatment -sulfadiazine and pyrimethamine
Suspect bartonella henselae infection/Cat scratch disease in someone with localized cutaneous and lymph node disorder near the site of scratch. Can self-resolve, but what’s the general abx course
5-days of azithromycin
Triad of wernicke encephalopathy due to vitamin b1/thiamine deficiency
seen in malnourished chronic alcoholics
- encephalopathy
- ocular dysfunction
- gait ataxia
treat with thiamine + glucose
How to treat benzo OD
flumazenil -GABA antagonist
Neurocardiogenic/vasovagal syncope is preceded by prodrome of pallor, dizziness, nausea diaphoresis and is assoc with triggers (mictuirtion, cough, defecation, emotional stress, prolonged standing). How to diagnose?
- clinical diagnosis based on history
- upright tilt table testing in uncertain cases which involves patient being strapped on an exam table with continuous EKG and BP monitoring. the table is passilve moved from a supine to a head up position that the pt is in for 20-45 min. If there are signs of unconsciousness –> positive test
Pt with episodic dizziness triggered by positional changes is called? Due to? What’s the name of the maneuver that can diagnose this condition?
Benign paroxysmal positional vertigo due to crystalline deposits (canaliths) in the semicircular canals that disrupt the normal flow of fluid in the vestibular system.
Dix-Hallpike maneuver which is when you trigger verigo and nystagmus when pt quickly lies back into a supine position with the head rotated 45 degrees
Relieve symptom with Epley maneuver
suspect which condition when presented with someone with elevated JVP, hepatojugularreflux, kussmauls sign (increase of JVP on inspiration), pericardial knock (middiastolic sound), and pericardial calcifications on CXR
constrictive pericarditis
What’s the gold std in diagnosing someone with acute angle closure glaucoma (sudden severe u/l pain with dilated midline pupil)? What could be helpful if urgent opthalmological consultation is unavailable?
- Gonioscopy is the gold std
- ocular tonometry can be helpful
What’s the treatment of choice for mild cellulitis vs cellulitis with systemic symptoms?
mild cellulitis: oral dicloxacillin
severe: IV nafcillin or cefazolin
What is ludwig angina?
rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces classically arising from the teeth 2/2 to strep and anaerobic infection.
presents with fever, dysphagia, odynophagia, drooling
may have crepitus in submandibular area 2/2 to anaerobes
asphyxiation is the most common cause of death
VIPoma is a rare tumor affecting the pancreas causing excess production of VIP. VIP binds to intestinal epithelial cells to increase fluid and electrolyte secretion. Clinical symptoms? lab findings? dx?
Clinical symptoms: watery diarrhea, hypo- or achlorhydria due to decreased gastric acid secretion, flushing, lethargy, N/V, muscle weakness/cramps
Lab: hypokalemia, hypercalcemia, hyperglycemia, stool studies will show secretory diarrhea
Dx: watery diarrhea with VIP level > 75 pg/mL; abd CT or MRI to localize tumor, usu in pancreatic tail
What is systemic mastocytosis?
involves GI tract –> steatorrhea, hepatomegaly, peptic ulcer disease. Usually with skin symptoms like pruritus, facial flushing and urticaria.
Doxy is the DOC for lyme disease in non-pregnant, older than 8 patients. What’s the treatment of choice for pregnant and lactating pts and pts
amoxicillin
Chalazion presents as swelling on the eyelid as a nodular, painless, rubbery lesion is a chronic granulomatous condition that develops when a meibomian gland becomes obstructed. What kind of work up should you do if there’s recurrent chalazion?
histopathologic examination b/c there is a risk for an underlying sebaceous (meibomian gland) carcinoma. Also, be wary of basal cell carcinoma which can manifest in lid margin and look similar to chalazion
How can immobilization result in hypercalcemia?
unclear underlying mech but is likely due to increased osteoclastic bone resorption. Therefore, prolonged immobilization can result in significant bone loss which can be prevented by administering bisphosphonates
Sudden onset dyspnea, chest pain, and tachy with a hemorrhagic, exudative pleural effusion and absence of consolidation on CXR –> ?
Pulmonary embolism-hypoxemia, resp alkalosis, A-a o2 gradient
CHF vs COPD
Hypoxia, hypocapnia, resp alkalosis –>
hypoxia, resp acidosis –>
Hypoxia, hypocapnia, resp alkalosis –> CHF
hypoxia, resp acidosis –> COPD
dermatitis herpetiformis that can occur b/l, symmetrically and in a grouped herpetiform arrangement on extensor surfaces, elbows, knees, upper back and buttocks, commonly assoc with celiac disease. how to treat?
a gluten free diet
Dapsone -can see improvement within hours
Always suspect lacunar stroke if a patient presents with a limited neurologic deficit. Principal cause is HTN which induces lipohyalinotic thickening of the small vessels. List and describe the 4 classical lacunar strokes
1) pure motor hemiparesis due to lacunar infarction in posterior limb of internal capsule –> u/l motor deficit
2) pure sensory hemiparesis due to stroke in VPL nucleus of thalamus –> u/l sensory deficit involving face, arm, trunk and leg
3) ataxic-hemiparesis due to infarct in anterior limb of internal capsule –> weakness that is more prominent in LE, along with ipsilateral arm and leg incoordination
4) dysarthria-clumsy hand syndrome due to stroke at basis pontis –> hand weakness, mild motor aphasia, NO sensory abnorm
Small intestinal bacterial overgrowth can be caused by anatomical abnormalities (strictures, surgery), motility disorders (diabetes, scleroderma), advanced age, AIDS, ESRD, cirrhosis, etc. What are some clinical symptoms? Dx? treatment?
Clinical symp: abd pain, diarrhea, bloating, excess flatulence, malabsorption, weight loss, anemia, nutritional deficiencies
dx: endoscopy with jejunal asprate showing > 10^5 organisms/mL = GOLD STD; glucose breath hydrogen testing
treatment: abx, dietary changes, trial of promotililty agents
suspect what if a patient is presenting with ipsilateral ataxia, falling towards the side of the lesion, nystagmus, intention tremor, ipsilateral muscular hypotonia, dysdiadokinesia
cerebellar tumor
Tabes dorsalis/neurosyphilus affects
posterior columns –> loss of proprioception
pt walks with legs wide apart
In Brown sequard syndrome, damage to the lateral spinothalamic tracts causes contralateral loss of pain and temp sensation beginning where in comparison to lesion
two levels above lesion therefore if someone has left-sided loss of pain and temp at T12 then the lesion is right-sided at T10
What are some clinical symptoms of retinal detachment? What will opthalmoscopic exam reveal?
- loss of vision in affected eye, painless
- photopsia (flashes of light)
- floaters (spots in the visual field)
- classic description: “a curtain coming down over eyes”
- eye exam: grey, elevated retina
Giant cell tumor of the bone is a benign locally aggressive skeletal neoplasm that presents with pain, swelling, and decreased ROM. What is its typical xray appearance?
osteolytic lesions with a “soap-bubble” aka expansile and eccentrically placed lytic area in the epiphysis of long bones most commonly affecting distal femur and proximal tibia
Osgood schlatter disease affects young children and adolescents who have recently undergone a rapid growth spurt. Xray typically shows?
avulsion of the apophysis of the tibial tubercle
Osteitis fibrosa cystica aka von Recklinghausen disease of bone is a rare condition commonly due to?
hyperparathyroidism leading to osteoclastic resoprtion of bone –> replacement with fibrous tissue –> brown tumors that are painful
imaging: subperiosteal bone resorption, “salt and pepper appearance” of skull, bone cysts and brown tumors
Cardiac tamponade (beck’s triad: hypotension, muffled heart sounds, and jvp elevation): what happens to preload, SV and CO, HR, and cardiac contractility?
fluid accumulates in pericardial cavity that restricts venous return to the heart and lowers right and left ventricular filling. Therefore, preload, SV and CO decrease.
There will be compensatory symp stimulation in response to hypotension, decreased CO, SV via increasing HR and contractility
Pt treated for Hodgkins lymphoma years ago with chemo and radiation presents with pleuritic chest pain, nonproductive cough and xray of a solitary lesion, suspect?
malignancy recurrence b/c there’s an 18.5x increase risk of developing a second cancer in HL pts
Someone with unclear vaccination history with fever, occipital or posterior cervical LAD followed by a maculopapular rash that spreads from top to bottom sparring the palms and soles + arthritis –>
Rubella
vaccination: live rubella vaccine
Lateral epicondylitis (tennis elbow) presents as pain while
supination or extension of the wrist with point tenderness just distal to lateral epicondyle
External hordeolum aka stye is? How to treat?
a common staph abscess of the eyelid treated with warm compresses. Incision and drainage only when resolution does not begin in the next 48 hrs.
How to treat acute rejection of kidney as demonstrated by biospy of transplant showing heavy lymphocyte infiltration and vascular involvement with swelling of the intima within 3-5 days of transplant?
iv steroids!
Precipitating factors of avascular necrosiis/osteonecrosis/aseptic necrosis/ischemic necrosis/osteochondritis dissicans include long term corticosteroid use, excessive ingestion of alcohol, sickle cell anemia, trauma, antiphospholipid syndrome.
What are symptoms? What’s the best modality to diagnose?
symptoms: slowly progressive anterior hip pain with limitation of motion
MRI is best modality to use
When should you start looking at lipid panel in average women and men? What’s the interval of screening?
women - start at age 45
men -start at age 35
then every 5 years if normal
High fever with bradycardia, headache and confusion. Watery diarrhea. Hyponatremia. What is it? How to diagnose and treat?
Diagnose using legionella urine antigen test
Treat with respiratory fluoroquinolones or newer macrolides
How to manage someone with pulseless electrical activity when there’s no palpable pulse over arteries but EKG still shows activity?
uninterrupted CPR + vasopressor therapy to maintain adequate cerebral and coronary perfusion.
While urinating, hematuria in the beginning of the stream vs at the end suggests what types of pathology
beginning –> urethral damage
terminal –> bladder or prostatic damage
through out –> kidney or ureters
A pt with hematuria at the end of the stream + passing clots should get cystoscopy to evaluate for possible
bladder cancer
Untreated hyperthyroidism are at risks for
rapid bone loss from increased osteoclastic activity
cardiac tacyharryhtmias like AF, HTN,
What is the initial screening test for acromegaly? What’s performed after this initial test b/c it’s considered a sensitive dynamic test.
initial screening -IGF-1
if not elevated then no acromegaly
if elevated –> oral glucose suppression test (give glucose, should negative feedback and suppress GH)
If inadequate GH suppression –> MRI of brain to assess pituitary
List the strongest predictors of AAA expansion and rupture
large anerysm diameter
rapid rate of expansion
current cigarette smoke
Current recs on operative or endovascular repair of AAA
- size > 5.5 cm
- rapid rate of expansion (>0.5 cm in 6 months or >1cm per year)
- presence of symptoms (abdominal, back or flank pain, limb ischemia)
prolonged vs shortened QT intervals in related to calcium state
prolonged QT - hypocalcemia
shortened QT -hypercalcemia
Sudden onset of a sharply demarcated, erythematous, edematous, tender skin lesion with raised borders in a febrile patient suggests? Most commonly due to which organism?
erysipelas -group A strep
Which lab value is the single most important prognostic indicator in acute liver failure (acute onset of severe liver injury with encephalopathy)?
PT -worsening PT/INR suggests worsening synthetic function
ALT most commonly due to drugs or virus
What is aspirin-exacerbated respiratory disease (AERD)? How to manage?
pseudoallergic rxn to NSAIDs occuring in pts with comorbid asthma, chronic rhinosinusitis with nasal polyposis. Asthmatic symptoms (cough, wheezing, chest tightness), nasal and ocular sym and facial flushing w/in 3o min-3 hrs after NSAID use.
avoid NSAIDs, use leukotriene receptor antagonist (montelukast)
Describe how a pericardial effusion will look like on CXR. What will you find on PE
- water-bottle shaped cardiac silhouette
- PE: dimished heart sounds on auscultation and a maximal apical impulse that is difficult to palpate in huge pericardial effusions
Which vitamin has been assoc with reduction of morbidity and mortality in patients with measles?
Vitamin A
Decreased serum T4, elevated TSH, positive anti-thyroperoxidase abs –> ?. Increased risk of which cancer?
hashimoto’s -increased risk for thyroid lymphoma
Macular degeneration is the leading cause of blindness in industrialized countries leading to central vision loss. What are some earlier signs of mac degeneration?
- distortion of straight lines such that they appear wavy
- grid test can be used to screen for mac degeneration in which you ask the pt to cover one eye and ask him/her to look at a small spot on a grid made of parallel vertical and horizontal lines.
Where’s the most common site of hypertensive hemorrhage? Symptoms?
The putamen (basal ganglia) (internal capsule is adj so almost always involved)
- c/l hemiparesis & hemisensory loss
- homonymous hemianopsia
- gaze palsy
List symptoms assoc with a cerebellar hemorrhage
- usually no hemiparesis
- facial weakness
- ataxia & nystagmus
- occipital headache and neck stiffness
List symptoms assoc with hemorrhage of the thalamus
- c/l hemiparesis & hemisensory loss
- NONREACTIVE miotic pupils
- upgaze palsy
- eyes deviate towards hemiparesis
Hemorrhage in frontal lobe –>
Hemorrhage in parietal lobe –>
Hemorrhage in occipital lobe –>
Hemorrhage in frontal lobe –> contralateral hemiparesis
Hemorrhage in parietal lobe –> contralateral hemisensory
Hemorrhage in occipital lobe –> homonynmous hemianopsia
Hemorrage in Pons
- deep coma & total paralysis w/in minutes
- pinpoint reactive pupils
Nephritic glomerulonephritis usu presents with urinary sediment containing RBCs, occasional WBCs, and red cell or mixed cellular casts. Edema in these pts is due to?
decreased GFR and retention of sodium and water by the kidneys
Suspect what in someone with these symptoms: acute severe retroorbital pain that wakes the pt up from sleep, may be accompanied by redness of ipsilateral eye, lacrimation, stuffed or runny nose and ipsilateral horners
Cluster headaches
ppx: verapamil, lithium, ergotamine
acute: O2 and subcut sumatriptan
Clinical findings suggestive of exogenous androgen use
- gynecomastia
- testicular atrophy
- acne
- mood disturbances
- hepatotoxicity
- erythrocytosis, polycythemia,
- LVH
Pt can develop tendon pain within 24 hours with a median of 8 days starting which abx? How to manage?
fluoroquinolone -can even lead to achilles tendon rupture. Pts should stop drug, avoid exercise and/or use of the area, seek medical care for symptom
Categorize the 4 severities of asthma and the appropriate treatment
- intermittent: daytime symp - 2x/week, nighttime awakenings -2x/month–> b agonist like albuterol prn
- mild persistent: symptoms > 2days/week, nighttime awakenings 3-4x/month –> albuterol + inhaled corticosterids
- mod persistent: daily symp, weekly nighttime awakenings, mod limited activities, FEV1 60-80% of predicted –> b agonist + inhaled corticosteroids + long-acting b agonist (salmeterol)
- severe: symp throughout the day, FEV1 all of the above + oral corticosteroids
How to differentiate btw myasthenia crisis due to decrease ach from myasthenia cholinergic excess?
give edrophonium (an achase inhibitor –> increased ach)
- if symptoms improve, then crisis
- if symptoms deterioate, then cholinergic excess
Myasthenia crisis is a life-threatening emergency,usu caused by infection. What are some symptoms, and how to manage
MG -autoab against achR on NMJ
crisis –> diplopia, ptosis, weakness of the proximal muscles, weakness of bulbar muscles and diaphragm –> respiratory distress
management: intubated for airway protection, followed by iv immunoglobulins or plasmapheresis (preferred) and corticosteroids
CXR showing free air under the diaphragm (pneumomediastinum) + chronic epigastric pain that suddenly worsens and becomes diffuse, suspect?
chemical peritonitis due to perforated peptic ulcer should be suspected in pts presenting with sudden onset of severe epigastric pain that spreads over the entire abdomen + CXR of free air
What are some metabolic abnormalities assoc with hypothyroidism?
- hyperlipidemia
- hyponatremia
- elevated CK
- elevated AST and ALT
Which class of abx is used for complicated pyelonephritis?
aminoglycosides -watch out for nephrotoxicity
what are some side effects of high dose b2 agonist?
hypokalemia (muscle weakness, arryhtmias, EKG abnormalities), tremor, palpitations, headache
Zenker’s diverticulum presents as dysphagia and regurgitation, hallitosis 2/2 to pooling of material in the diverticulum located in the posterior lower cervical esophageus near cricopharyngeus muscle. Pts are at risk for aspiration pneumonia. What’s the diagnostic test of choice for ZD?
contrast esophagogram
treatment is surgical
Initial treatment in all patients with peripheral artery disease/intermittent claudication
supervised exercise program reserving cilostazol and/or surgical intervention after failed exercise program
What are the primary anti-ischemic and anti-anginal effects of nitrates?
systemic vasodilation –> lowers preload and LVEDV, reducing wall stress and myocardial O2 demand
What is wrong with platelets in someone with uremia?
abnormal hemostasis is a common manifestation seen in pts with chronic renal failure. Abnormal bleeding and bruising are characteristic of uremic coagulopathy. Defect involves platelet-vessel wall and plt-plt interaction. The uremic toxin guanidinosuccinic acid is implicated in platelet dysfunction.
PT, PTT, and plt count are normal
DDAVP causes release of factor VIII:vwF multimers is the treatment of choice
U/l foot drop is characterized by a “steppage gait”: exaggerated hip and knee fllexion while walking. Come causes include?
L5 radiculopathy and compression of peroneal neuropathy.
L5 radiculopathy will also have weak foot inversion and plantar flexion which are normal in peroneal neuropathy
What are some metabolic abnormalities found in someone who takes thiazide diuretics?
- hyperglycemia
- increased LDL cholesterol, and plasma trigylcerides
- hyponatremia
- hypokalemia
- hypercalcemia
Chest CT showing wedge-shaped infarction is pathognomonic for?
PE -sudden onset pleuritic chest pain, cough, dyspnea, and hemoptysis
What are the current recs regarding meningococcal vaccination?
- age 11-12 (or age 13-18 if not prev vaccinated)
- booster vaccine from age 16-21 if prev vaccinated before 16
- vaccine > 21 if considered high risk (military recruits, college students living in dorms, and travelers to sub-Saharan Africa)
What is the histopathology of nephrosclerosis
due to HTN
hypertrophy and intimal medial fibrosis of renal arterioles
What is the first and second leading causes of ESRD in US?
1 -diabetic nephropathy
2 -HTN
Characterize diabetic nephropathy
-increased ECM, BM thickening, mesangial expanion, firbosis
What is Todd’s palsy?
transient paralysis that occurs during the postictal state
2 medications that commonly cause priaprism
trazodone and prazosin
If someone’s DVT is 2/2 to increased homocysteine levels, what can you give in addition to heparin and warfarin?
Vit B6 acts as a cofactor for cystathinine b synthase making cystathionine from homocysteine
Post-BMT pts who present with lung (pneumonitis on Xray showing as multifocal diffuse patchy infiltrates) and colitis -suspect?
CMV
Most effective therapy against Parkinson’s is levodopa/carbidopa. What are some early side effects? Late side effects?
Early: hallucinations, dizziness, headache, agitation
Later/several years: involuntary movements
Ventricular remodeling in the weeks to months after an MI can lead to ventricle dilatation. This process is lessened by which med?
ACEI
What’s the treatment of choice for fibromuscular dysplasia/renal artery stenosis (young woman with hypertension resistant to meds, renal bruits, headaches)
percutaneous angioplasty with stent placement
Acetaminophen toxicity can be asymptomatic for the first 24 hours. How to manage?
- charcoal if within 4 hours of presentation and get acetamiophen levels
- acetaminophen levels can guide treatment with n-acetylcysteine
Symptoms of beta blocker OD and treatment
- bradycardia
- hypotension
- WHEEZING (b2 blockade)
- hypoglycemia
- delirium
- seizures
- cardiogenic shock
treat with IV glucagon
All pts with chronic renal failure and HCT
- worsening HTN (treat with fluid removal via dialysis and/or anti-hypertensives like b blockers and vasodilators)
- headaches
- flu-like syndromes
- red cell aplasia
What is the hepatojugular reflux aka abdominojugular reflux? List the 3 conditions most assoc with positive hepatojugular reflux.
elicited by applying firm and sustained pressure for 10-15 seconds over the upper abdomen. A positive response is defined by a sustained elevation of JVP > 3 c. during continued abdominal compression.
This reflux is not specific for a disorder but shows a failing RV that cannot accomodate an increase in venous return with abdominal compression.
3 conditions most assoc with positive hepatojugular reflux: constrictive pericarditis, RV infarction, restrictive cardiomyopathy
How to differentiate edema from cardiac failure vs liver failure?
cardiac -increased JVP, positive hepatojugular reflux when firm and sustained pressure on upper abdomen for 10-15 sec will cause elevation of JVP > 3 cm
liver -normal JVP, negative hepatojugular reflux
list 3 conditions assoc with higher BUN/cre ratio?
- prerenal failure due to hypovolemia
- GI bleed –> bacterial breakdown of Hb in GI –> urea reabsoprtion
- steroid administration
Aortic dissection is the most dangerous complication of marfan syndrome. Which murmur is a complication of aortic dissection?
aortic regurgitation - early decrescendo diastolic murmur
Some causes of osteomalacia are malabsorption, intestinal bypass surgery, celiac, chronic liver and kidney disease. Pt may be asymptomatic or with bone pain, muscle weakness and cramps with difficulty walking. What are some of the lab vales. While will xrays show?
- elevated alk phos
- elevated PTH
- decreased serum Ca2+ and marked hypophosphorous
- decreased Vit D
- Xrays: thinning of cortex with reduced bone density; b/l and symmetric pseudofractures (looser zones)
*impaired osteoid matrix mineralization
How to work up someone with metabolic alkalosis?
metabolic alkalosis (pH > 7.45; serum HCO3 > 24 mEq/L)
1) is it low urine chloride (20 mEq/L)
* *low urine chloride will be saline responsive
* *high urine chloride will not be saline response
a) IF low urine chloride –> vomiting/nasogastric aspiration, prior diuretic use
b) IF high urine chloride, will have to assess if hypovolemic/euvolemic or hypervolemic
* *if hypovolemic/euvolemic –> current diuretic use, bartter & gittelman syndromes
* **if hypervolemic –> primary aldosteronism, Cushing, ectopic ACTH production
List the 7 diagnostic criteria for SIADH, which will not correct with normal saline infusion
1- Sosm Sosm
3- UNa > 20 mEq/L
4- absence of hypovolemia
5- normal renal, adrenal and thyroid function
6 - no obvious surgical, traumatic or painful stimulus known to activate the neuroendocrine stress response, includin ADH release
7 -absence of other known causes of hyponatremia
Metabolic syndrome is diagnosed if 3 of these 5 criteria are met. They are…
- abdominal obesity (waist circum > 40 in men; greater than 35 in women)
- fasting glucose >100-110
- blood pressure > 130/80
- triglycerides > 150
- HDL cholesterol (men
How to treat someone with pheochromocytoma?
pheochromocytoma has increased circulating catecholamines. DO NOT give beta blockers first b/c then these catecholamines can do unopposed stimulation of alpha-receptors leading to severe HTN.
To treat, alpha blockers first, then a beta blocker. Or you can use agents with both beta and alpha blocking characteristics like labetalol
Sinusitis + brain abscess in immunocompetent individual –> ?
viridans strep and anaerobes causing sinusitis spread to brain causing brain abscess
Hypoxia in patients with pneumonia occurs 2/2 to alveolar and interstitial inflammation, which causes areas of?
V/Q mismatch –> increased A-a oxygen gradient
equation for urine anion gap
Na+K-Cl
Type 1 renal tubular acidosis a cause of non-anion gap metabolic acidosis affecting the distal tubule's ability to secrete H+. urine pH: urine anion gap: consequences: causes: How to correct acidosis and hypokalemia?
urine pH: > 5.5
urine anion gap: positive
consequences: nephrolithiasis, hypokalemia
causes: autoimmune, drug toxicity
How to correct acidosis and hypokalemia? sodium bicarbonate
Type 2 renal tubular acidosis is due to inability to reabsorb HCO3 in PCT
causes:
urine pH:
How to differentite from type I and type IV
causes: fanconi’s syndrome, multiple myeloma, medications like carbonic anhydrase inhibitors, NRTIs,
urine pH: variable
FEHCO3 > 15% can differentiate
treat underlying problem
Type 4 renal tubular acidosis is due to reduced production of aldosterone leading to hyperkalemia.
Causes?
Manage?
causes: diabetic nephropathy, primary adrenal insufficiency, ACEI, heparin
give fludrocortisone (but becareful in pts with HTN b/c can worsen)
post-cardiac cath thru femoral artery, pt presents with a pulsatile mass, femoral bruit, and compromised distal pulses –> ?
femoral pseudoanerysm -an impt vascular comp of cardiac cath
hepatopulmonary syndrome occurs as a complication of cirrhosis presumedly 2/2 to failure of liver to clear pulmonary vasodilators. What are some findings?
- liver cirrhosis
- platypnea: dyspnea with an upright posture and relief while lying down
- orthodeoxia: worsening hypoxia in upright position
Initial treatment for anklyosing spondylitis
- NSAIDs like indomethacin, physical therapy and exercise
- other treatments are disease modifying agents like sulfasalazine
- anti-TNF agents (infliximab and entanercep) *most effective
aplastic anemia -predominance of fat and stroma with cellular hypoplasia in bone marrow biospy can be caused by which chemicals, drugs and viral infections?
- arsenic
- benzene
- chloramphenicol
- viral infections like parvovirus
TTP -symptoms and initial management?
FAT RN
- fever
- anemia
- thrombocytopenia
- renal failure
- neuro symptoms
initial management: large-volume plasmapheresis to remove plasma and replace with FFP daily until pt is in remission
How to manage acute pulmonary edema 2/2 to heart failure?
- supportive: O2, sit pt upright
- loop diuretics
- morphine -decrease preload via venodilation, reduce anxiety
- nitrates -decrease preload via venodilation and improve coronary flow
List the 3 criteria for the dx of multiple myeloma (CRAB)?
1- presence of monoclonal protein in serum/urine
2-presence of tissue damage (renal insuff, anemia, bone lytic lesions)
3-presence of clonal marrow plasma cells (plasmacytomas)
definitive dx: bone marrow biopsy showing > 30% of plasma cells
If you suspect pancreatic cancer, which should be initial imaging of choice?
CT > US
Pt with ST segment elevations in II, III, avF received coronary angiography and PCI. The next day gets hypotensive, tachycardic with clear lungs and absence of pulsus paradoxus. Suspect? Treatment
RV infarction
Treat with IV fluids
What’s the most initial test in diagnosis of meningitis?
CSF cell count and differential
CSF leukocyte count > 1000 cells/mm3 that are predom neutrophils –> bacterial
CSF luekocyte count 10-100 –> viral
What is the most common cause of meningitis overall?
strep pneumo
If you suspect gastroparesis, what should be done first? What’s the gold std for diagnosis?
should do endoscopy to rule out similar diseases.
scintigraphic measurement of gastric emptying is the gold std for diagnosis
treat with metoclopramide or erythromycin
Compare and contrast Dubin Johnson vs Rotor syndrome
Both are problems with secreting bilirubin into bile canaliculi and characterized by conjugated hyperbilirubinemia without hemolysis.
Dubin -has darkly pigmented liver and NO elevations of coproporphyrins
Rotor -NO darkly pigmented liver, YES elevations in coproporphyrins
Which infection can cause diarrhea and RLQ findings similar to appendicitis (“pseudoappendicitis)
yersinia
First line treatment for paget disease (could be asymp and incidentally found on lab work due to elevated alk phosp or have symptoms like decreased hearing due to enlarging calvarium, fractures, high output heart failure, bowed leg and CN deficits. What’s first line therapy
bisphosphonates
How does Cushing cause DVT
it’s a hypercoaguable state due to increased factor VIII and vWF and decreased fibrinolytic activity
What is hungry bone syndrome?
severe hypocalcemica following partial parathyroidectomy due to rapid remineralizing of bones 2/2 to severe decrease in PTH. When remineralization is complete, blood calcium level normalizes
What is the goal INR therapeutic range from someone on warfarin for AF, idiopathic DVT, w/ prosthetic heart vavles.
- idiopathic DVT: 2-3
- AF: 2-3
- prosthetic valves: 2.5-3.5
List the 4 dietary recommendations for pts with renal calculi
1 -decreased dietary protein and oxalate
2 -decreased sodium
3 -increased fluid intake
4 -increased dietary calcium
Someone got a blood tx. Then developed fever, flank pain, hemoglobinuria, renal failure and DIC within 1 hour of tx. What type of transfusion rxn does he have? How to manage?
acute hemolytic 2/2 to ABO incompatibility, will have positive direct Coombs test, pink plasma
Manage by cessation of transfusion while maintaining IV access for fluids and supportive care
Someone got a blood tx. Developed mild fever and hemolytic anemia within 2-10 days after transfusion with positive coombs and positive new ab screen. What type of tx does he have?
delayed hemolytic caused by amanestic antibody response to a RBC Ag to which the pt was prev sensitized. Requires no treatment
Pt with anorexia, weight loss, fatigue, mild cog impairment and history of drug abuse –> test for
HIV and Hep C
How to best treat inflammatory myopathies like dermatomyosiitis and polymyositis (elevated ESR, CK)?
high dose corticosteroids
diagnosing idiopathic intracranial HTN involves ocular exam, MRI, MRV and LP. What will LP show? Which ocular condition is most commonly assoc with increased intracranial pressure?
CSF is normal with exception of elevated opening pressure > 250 mmHg
this elevated opening pressure + clinical symptoms = diagnostic of idiopathic intracranial HTN
Papilledema is assoc with increased intracranial pressure which can make blind spots even bigger.
What are the best markers to assess resolution of DKA?
serum anion gap
beta-hydroxybutyrate levels
What’s the most common type of gallstones? Are they radioopaque or radiolucent?
- cholesterol and mixed stones make up 80% of stones
- they are radiolucent so cannot be seen on xray
- hence, US is the method to use to detect gallstones
Pronator drift is a finding that is relatively sensitive and specific for? What does the positive romberg sign indicate?
Pronator drift –> UMN disease that can cause a weakness in supination that results in the pronator muscles becoming dominant
Romberg –> ask pt to close eyes and put feet together, if they lose balance, can indicate problems with propioception
ST elevations in leads II, III, avF, hypotension, elevated JVP, clear lung fields, dx? treat?
Dx RV MI, treat with IV fluids
-decreasing preload (nitrates, diuretics, opioids) can make symptoms worse! avoid!
Ehrlichiosis -seen in southeeastern and south central US, tick bite, febrile illness, AMS, leukopenia and thyrombocytopenia with elevated liver enzymes and LDH. Generally NO RASH, (“rocky mountain w/o spots) DX? Treatment?
dx: intracytoplasmic MORULAE in MONOCYTES; PCR testing
treatment: empiric doxycycline
Papillary necrosis with sloughing of the renal papilla is a rare cause of non-glomerular hematuria (blood BUT NO PROTEIN on UA, normal appearing RBCs without RBC casts). What’s the mnemonic used to assess causes of papillary necrosis?
NSAID
Non-steroidal anti-inflam drugs Sickle cell disease Analgesic abuse Infection (pyelo) Diabetes
Compare and contrast monoclonal gammopathy of undetermined significance vs multiple myeloma. What is recommended in MGUS pts to exclude lytic lesions of MM?
MGUS
- absence of anemia, hypercalcemia, lytic lesions, and renal insuff
- serum monoclonal protein /- 3 g/dL
- > /- 10% plasma cells in bone marrow
- elevated b2-microglobulin
*metastatic skeletal bone survey is done to exclude lytic lesions suggesting MM
What kind of a metabolic disturbance does vomiting cause?
hypochloremic, hypokalemic metabolic alkalosis
What’s the treatment for scabies caused by sarcoptes scabiei mite that presents with intensely pruitic rash in flexor surfaces of wrist, lateral surfaces of fingers and finger webs?
topical permethrin 5% cream or oral ivermectin
development of clubbing and sudden-onset joint arthropathy in a chronic smoker –> ?
hypertrophic osteoarthropathy assoc with lung cancer therefore impt to do CXR to rule out malignancy and/other conditions. More assoc with adenocarcinoma
Hypokinetic/shuffing gait —>
waddling gait –>
spastic gait –>
wide-based, high stepping gait –>
Hypokinetic gait —> parkinsons
waddling gait –> muscular dystrphy due to weakness of gluteus muscles
spastic gait –> UMN lesions like spinal cord injury or cerebral palsy leadng to slow, stiff, and effortful movements
wide-based, high stepping gait –> loss of proprioception
acute u/l PAINLESS loss of vision –> ?
central retinal vein occlusion
-“blood and thunder appearance”, optic disk swelling, retinal hemorrhages, dilated veins and cotton wool spots
Erythema nodosum is a condition of painful, subcutaneous, pretibial nodules. List conditions assoc with EN
- sarcoidosis
- TB
- histoplasmosis
- recent strep infection
- IBD
How to characterize thyrotoxicosis due to exogenous thyroid hormone?
low serum thyroglobulin levels
In pts in which PE is very high on the differential, should you give anti-coagulation (IV hep infusion) or do CT-A first?
IV hep infusion before imaging
When will you choose V/Q over CT-A to assess for PE?
when pt has significant renal allergy or contrast allergy
Tinea capitis is a superficial dermatophytosis that most commonly occurs in children, particularly African Americans. What are the symptoms and how to diagnose and treat?
symp: scaly erythematous patch that can progress to alopecia, sometimes with inflammation, LAD, and scarring.
Dx: KOH preparation
Treatment: Oral griseofulvin
What are the 4 steps in treatment of ascites?
- Sodium and water restriction
- Spironolactone
- Loop diuretic (not more than 1L/day of diruesis)
- Frequent abdominal paracentesis (2-4 L/day, as long as renal function is ok)
Neutrophilic cryptitis is a feature of?
both Chrohns and UC
What’s the most common electrolyte abnormality in adrenal insufficiency?
hyponatremia is the most common, followed by hyperkalemia
When does ventilator-assoc pneumonia usually occurs? Symptoms? Management?
Usually occurs within >/- 48 hours after intubation
symp: fever, purulent secretions, abnormal xray
management: gram stain and culture lower resp tract and give empiric abx
What is emphysematous cholecystitis (common in elderly diabetic men)?
acute cholecystitis that arises due to 2/2 infection of the gallbladder wall with gas-forming bacteria (clostridium, escheria, staph, strep, pseudomonas, klebsiella).
Symp include RUQ pain, N/V, low-grade fever, crepitus in abd wall adj to gallbladder may be heard
Dx: CXR showing air fluid levels in the gallbladder or an US showing curvilinear gas shadowing in gallbladder.
Hypothermia is broken down to mild, moderate, and severe. Rewarming techniques differ depending on severity. Outline.
Mild (32-35C: 90-95F) -tacy, tachypneic, ataxic, dysarthric, increased shivering ***passive external warming, remove wet clothing, cover with blankets
Mod (28-32 C: 82-90F) -brady, lethargic, hypoventilating, decreased shivering, atrial arrhythmias ***active external warming, warm blankets, heating pads, warm baths
Severe (
List symp assoc with alcohol cerebellar degeneration
- progressive gait dysfunction
- truncal ataxia
- nystagmus
- intention tremor
- dysmetria
- dysdiadochokinesia
- muscle hypotonia –> pendular knee reflex (more than 4 swings of limb after eliciting DTR)
Blastomycosis is a pulm fungal infection endemic to the great lakes and mississippi and ohio river basins. Blasto has characteristic skin and lytic bone lesions. How to confirm dx? Treat?
broad based budding yeast grown from sputum
treat with itraconazole or ampho B
Pts with HIT 2 (more than 50% decrease in PLTs after unfractionated heparin or LMWH use in 4-5 days after initial) should be monitored for?
thrombosis despite significant thrombocytopenia so watch out for arterial and venous clots
How to differentiate pituitary vs medication side effect as cause of hypogonadotropic hypogonadism in men?
- in medication side-effect causing hyperprolactinoma (being on dopamine antagonist like risperidone), there will not be abnormal TSH levels
- pituitary cause will have low LH and testost and low TSH and thyroxine
Aortic dissection on CT will show widened mediastinum. What’s the modality that can confirm aortic dissection and should be done urgently at bedside?
TEE
