Uworld questions Flashcards
Symptoms of digoxin toxicity
cardiac: life-threatening arrhythmias
GI: anorexia, N/V, abdominal pain
neurologic: fatigue, confusion, weakness, color vision alterations
acute toxicity: more GI symptoms
chronic toxicity: more neuro symptoms
Describe the pain found in mesenteric ischemia
severe periumbilical abdominal pain out of proportion to findings on abdominal exam
Risk factors for mesenteric ischemia: AF, severe cardiomyopthy
Parkinson’s tremor (resting tremor that is asymmetric and associated with rigidity) is often the first presenting sign of disease. Which drug is typically used in young parkinsons patients where tremor is the predominant symptom.
trihexyphenidyl (anti-cholinergic agent)
List some clinical features of drug-induced interstitial nephritis (penicillins, cephalosporins and sulfonamides)
- fever, rash, arthralgias, peripheral eosinophilia, hematuria, sterile pyuria, eosinophiluria
- WBC casts may be in urine
- treatment: d/c drug
70% of cases with interstitial nephritis are caused by which drugs
- cephalosporins
- penicillins
- sulfonamides
- sulfonamide containing diuretics
- NSAIDs
- rifampin
- NSAIDs
- phenytoin
- allopurinol
Acute limb ischemia (leg pain, leg is cold with a mottled appearance, minimal swelling w/ absence of distal pulses) from arterial occlusion is typically caused by?
cardiac emboli, thrombosis
Major cardiac sources: LV thrombus, thrombus (usu. left atrial) formation due to AF, aortic atherosclerosis
Management for someone with acute limb ischemia 2/2 to arterial occlusion most likely from cardiac source (symptoms: affected leg is painful, and cold with mottled appearance with little edema)
- immediate anticoagulation
- vascular surgery consultation
- transthoracic ECHO to screen for LV thrombus and evaluate V function
What are clinical symptoms of Vit D toxicity
symptoms are mainly due to hypercalcemia: constipation, abdominal pain, polyuria and polydipsia
State Light’s criteria used in evaluating if effusions are exudative
- pleural fluid protein/serum protein ration > 0.5
- pleural fluid LDH/serum LDH > 0.6
- pleural fluid LDH is > 2/3 the upper limits of normal serum LDH
What conditions cause exudative effusions vs transudative effusions?
-exudative due to increased capillary permeability
infection, autoimmune disease, neoplasm, pulmonary embolism
**if there are lymphocytes in fluid, ddx includes TB, sarcoidosis, lymphoma, RA
-transudative due to decreased plasma oncotic pressure or increased hydrostatic pressure
CHF, liver failure, PE
What’s pathognomonic for Chrohn’s as compared to ulcerative colitis?
non-caseating granulomas but still only present in 60% of the cases
Someone with intention tremors without other neurologic signs that is occasionally relieved by alcohol
essential tremors
- treatment of choice is propranolol
- alternate meds include primidone (can cause acute intermitten porphyia: abd pain, neuro and psych abnormal) and topiramate
Describe the type of population in which IVC filters can be an option for
pts with DVT with contraindications to anticoagulation (recent surgery, hemorrhagic stroke, bleeding diathesis or active bleeding) or recurrent DVTs after treatment with anticoagulation
Describe clinical symptoms and biospy of someone with laxative abuse (aka factitious diarrhea)
- frequent, watery, nocturnal diarrhea
- biopsy will show dark brown discoloration of the colon with lymph follicles shining thru as pale patches (melanosis coli)
acyclovir can cause crystalline nephropathy b/c it is excreted in the urine via glomerular filtration and tubular secretion. How to prevent this?
adequate hydration and dosage adjustment (e.g. slowing rate of IV infusion)
Patellofemoral syndrome typically affects young female athletes who present with subacute to chronic pain that increases with squatting, running, prolonged sitting, climbing stairs.
Explain the patellofemoral compression test and management
pain elicited by extending the knee while compressing the patella
tests such as xray of the knee and MRI are usu normal
management includes exercises to stretch and strengthen the thigh muscles
Which cancer is Eaton-Lambert syndrome associated with? What is it aresult from?
Small cell carcinoma of the lung and results from autoantibodies against voltage-gated calcium channels in presynaptic motor nerve terminal.
Proximal muscle weakness and symptoms improve with muscle use as confirmed by electrophysiological studies (muscle response to motor nerve stimulation should increase with repetitive stimulatiom). Treatment is plasmapheresis and immunosuppressive therapy.
What are some symptoms of hypocalcemia (can occur during or immediately after surgery esp if it requires extensive transfusions since citrate in packed RBCs can bind ionized calcium)?
hyperactive deep tendon reflexes, muscle cramps, convulsions
**symptoms of hypomagesemia can mimic hypocalcemia since Mg2+ is needed for PTH to work
What are signs of mild and severe hypermagnesemia
mild: decreased DTRs
severe: loss of DTRs, muscle paralysis, apnea, cardiac arrest
What is the name of the exam used to assess the eyes after high velocity injuries to look for intraocular foreign bodies and abrasians
fluorescein examination
What’s the agent of choice for malaria ppx in pregnant people and in ppl in areas of chloroquine-resistant p. falciparum
mefloquine
Hemophilia A (Factor VIII def) and B (Factor IX def) both are x-linked presenting with hemarthrosis, hemophilic arthropathy, intramuscular hematomas, GI or GU tract bleeding. Describe lab findings and treatment.
Lab findings: normal platelet count, normal bleeding time, normal prothrombin time, prolonged activated PTT, decreased or absent factor VIII or IX activity
treatment: administer factor VIII or IX
What’s the most reliable and predictive sign in opioid intoxication?
decreased RR
other symptoms: pinpoint pupils although normal pupils can be seen esp in coingestions, hypotension, hypothermia, decreased bowel sounds
Most common cause of Cushing’s? Signs of symptoms of Cushing’s syndrome
iatrogenic steroid administration is the most common cause
signs and symptoms: fatigue, weight gain, easy bruising, central adiposity, proximal muscle weakness, hyperglycemia, osteopenia and osteoporosis, hypertension, acne, cataracts and susceptibility to infections
What are some electrolyte abnormalities found in Cushing’s? Why?
hypokalemia and hypernatremia
b/c cortisol has mineralocorticoid activity and can bind to aldosterone receptors in kidneys. Aldosterone causes retention of Na+ and secretion of K+
*spironolactone can treat severe hypokalemia caused by excessive cortisol by binding and inhibiting aldosterone receptors
Explain pathogenesis of renal vein thrombosis in nephrotic syndrome and symptoms
nephrotic syndrome -proteinuria, hypercoagulable state b/c of loss of antithrombin III in urine increases risk of arterial and venous thrombosis.
acute RVT –> abdominal pain, fever, hematuria
RVT is commonly progressive –> gradual worsening of renal function and proteinuria
RVT can happen in any nephrotic syndrome but most commonly in membranous glomerulopathy.
List 4 features of chest pain that may make CAD the top of your differential
- substernal
- radiation to arm, shoulder, or jaw
- precipitated by exertion
- relieved by rest or nitroglycerin
Sharp/stabbing chest pain that is worse with inspiration should put what on top of your differentials? How to differentiate them?
Pulmonary/pleuritic causes (pleurisy, pneumonia, pericarditis, PE)
Pericarditis -worse when lying flat
PE, Pneumothorax -respiratory distress, hypoxia
What are features of chest pain that will make aortic dissection the top of the differential?
- sudden, severe “tearing” pain
- radiates to back
- elderly men
- hypertension & risk factors for atherosclerosis
What are some features of chest pain that makes GI/esophageal causes the top of your differential?
- nonexertional, relieved by antacids
- upper abdominal & substernal
- assoc with regurgition, nausea, dysphagia
- NOCTURNAL PAIN
- post-prandial symptoms
What are some features of chest pain that make chest wall/MSK pathologies top of your differential?
- persistent and/or prolonged pain
- worse with movement or change in position
- often follows repetitive activity
Intravascular hemolysis has lower haptoglobin levels while haptogloblin levels in extravascular hemolysis are normal. Why?
Intravascular hemolysis is due to RBC structural damage leading to destruction in intravascular space. The hemolyzed RBCs release Hb that will bind to haptoglobin. The hb-haptoglobin complexes are then cleared by the liver, leading to almost undetectable levels of haptoglobin in the blood. LDH level is raised b/c it’s released by the RBCs.
Extravascular hemolysis is when RBCs are destroyed by phagocytes in reticuloendothelial system
Autoimmine hemolytic anemia and hereditary spherocytosis (increased MCHC and RBCDW)can both cause extravascular hemolytic anemia. Both peripheral blood smear will show spherocytes without central pallor. how to differentiate them?
AIHA - negative family h/o and positive Coombs test (most are IgG/warm-agglutinin AIHA)
HS - positive family h/o and negative Coombs test, increase osmotic frgaility on acidified glycerol lysis test or abnormal eosin-5-malimide binding test
Define fulminant liver failure. How to treat?
hepatic encephalopathy that develops within 8 weeks of the onset of acute liver failure. Treatment is liver transplant.
List the classification of MEN
MEN type 1 - pan, pit, para
MEN type 2a - medullary carcinoma of thyroid (calcitonin), pheochromocytoma, para
MEN type 2b -medullary carcinoma of thyroid (calcitonin), pheochromocytoma, marfanoid habitus and mucosal and intestinal neuromas
Zollinger-Ellison Syndrome
a gastrinoma associated with MEN type 1 that causes high levels of gastrin which can lead to multiple ulcers distal to duodenum and jejunum. These ulcers are refractory to PPI and antacids
what are the 2 meds that can be used to stimulate appetite in someone with cancer-related anorexia/cachexia syndrome?
- progesterone analogs (megestrol acetate and medroxyprogesterone acetate)
- corticosteroids
What are the 2 steps that can be taken to manage respiration in someone on ventilation?
MV does 2 things: 1) FiO2 -normally its 21%, usu patients on MV get >80%, goal is to maintain paO2 >/- 60) to increase fraction of inspired oxygen; 2) PEEP to prevent alveolar collapse
PaO2 is influenced by FiO2 and PEEP
-IMPT to decrease FiO2 to below 60% to prevent O2 toxicity to lungs
PaCO2 is influenced by minute ventilation (RR x TV)
Varicocele presents as a soft scrotal mass like a bag of worms that decreases in supine position and increases with standing/valsalva maneuvers, can lead to subfertility and testicular atrophy. List US findings. and treatment
US: retrograde venous flow, tortuous dilation of pampiniform plexus
Treatment: gonadal vein ligation (in younger men) or scrotal support & NSAIDs in older men who do not desire children
*DOES NOT TRANSILLUMINATE
What is required to rule out subarachnoid hemorrhage?
lumbar puncture
if there’s xanthochromia in CSF then SAH is confirmed
What are some complications to worry about in someone with subarachnoid hemorrhage?
1) rebleeding within first 24 hours is the major cause of death, esp within first 6 hours of presentation
2) vasospasm can occur 3-10 days after and is a major cause of delayed morbidity and death ***CT angiography is preferred for diagnosing vasospasm and can be prevented by nimodipine
Other complications: seizures, hyponatremia (2/2 to SIADH), hydrocephalus
When will you need imaging of the kidneys in someone with acute pyelonephritis
persistent clinical symptoms despite 2-3 days of abx therapy, h/o of nephrolithiasis, complicated pyelo or usual urinary findings (gross hematuriia)
In gastric adenocarcinoma, tumor stage at time of diagnosis determines prognosis and treatment options. what’s the initial staging modality?
CT scan
What are some complications of PEEP?
barotrauma and tension pneumo
What is the hallmark on imaging (MRI) of prolonged seizures that can lead to persistent deficits and recurrent seizures?
cortical laminar necrosis
What’s the preferred modality to diagnose bronchiectesis (cough, mucopurulent sputum and hemoptysis)?
high-resolution chest CT can show bronchial dilation, lack of airway tapering and bronchial wall thickening
after diagnosis, then you can do sputum analysis or bronchoscopy
acute exacerbations of MS is treated with?
corticosteroids
Explain the succussion splash physical exam and what does it indicate?
the abdominal succussion splash is elicited by placing stethoscope over upper abdomen and rocking pt back & forth at the hips. Retained gastric material > 3 hours after a meal will make a splash sound signifying possible gastric outlet obstruction
what can chronic mesenteric ischemia cause? And triggered by?
cause intermittent abdominal pain usu triggered by eating aka “intestinal angina.”
aortic regurgitation is a diastolic murmur. Explain some physical findings assoc with aortic regurgitation
-bounding pulse aka “water hammer” pulse: due to increased SV producing an abrupt rise in SBP and rapid distension of peripheral arteries then during diastole, there is a regurg of blood back to LV leading ot low diastolic pressure and collapse of peripheral arteries = hyperdynamic pulse
Whats the imaging of choice to diagnose MS?
MRI
In WPW syndrome, an accessory pathway conducts depolarization directly from atria to ventricles w/o passing thru AV node. AF occurs in 10-30% of these pts and is potentially life-threatening. How to treat ppl with WPW in AF with RVR?
- if hemodynamically unstable –> electrical cardioversion
- stable –> iv Ibutilide or procainamide
**avoid AV nodal blockers like b blockers, calcium channel blockers, digoxin, and adenosine since they can icnrease conduction thru accessory pathway
What’s the best treatment for frostbite injuries?
rapid re-warming with warm water
What is rilozole and what is it used for?
Riluzole is a glutamate inhibitor that is approved for ALS
Opthalmologic problems occur in 1/2 of patients with HIV infection. Describe the retinitis caused by CMV vs HSV and VSV
- HSV, VZV can cause severe acute retinal necrosis associated with PAIN, KERATITIS, UVEITIS, and funduscopic findings of peripheral pale lesions and central retinal necrosis
- CMV retinitis is PAINLESS, not usually assoc with keratitis or conjunctivities, and characterized by funduscopic findings of hemorrhages, and fluffy or granular lesions around the retinal vessels. (yellow-white patches of retinal opac and hemorrhages)
How to confirm aortic dissection?
transesophageal echocardiogram (TEE)
if TEE is not available, use CT and MRI
Eggshell calcification of a hepatic cyst on CT scan is highly suggestive of which hepatic cyst?
hydatid cyst due to echinococcus granulosus (a tapeworm found in dogs). It is most commonly seen in areas where sheeps are raised b/c sheep are intermediate hosts.
treatment is surgical resection under the cover of albendazole.
What is bronchoalveolar lavage good at evaluating?
bronchoscopy with bronchoalveolar lavage is used to sample lung cells during bronchoscopy, greatest diagnostic utility in evaluation of suspected malignancy and opportunistic infection.
Paget disease of the bone 3 phases characterized by osteclastic, mixed and osteoblastic phases. Only abnormal lab value is increased alk phosphatase. What are some urinary markers of bone degradation
hydroxyproline
deoxypyridinoline
N-telopeptide
C-telopeptide
List side effects of aminoglycosides (gentamicin, neomycin, amikacin, tobramycin)
- ototoxicity (hearing loss) by damaging the cochlear cells
- vestibulopathy by damaging motion-sensitive hair cells in the inner ear
- oscillopsia -a sensation of objects moving around in the visual field when looking in any direction
Benign paroxysmal positional vertigo (BPPV) -typical clinical presentation?
- brief and recurrent episodes described as a feeling of the room spinning when turning the head to one direction or looking up, nystagmus, nausea without ear pain, tinnitus or hearing loss
- is due to calcium crystals within the semicircular canals
the patient with back and leg pain that is aggravated by spinal extension and relieved with flexion has features of which condition? There’s back pain that radiates to the buttocks and thights. What is neurogenic claudication?
lumbar spinal stenosis due to narrowing of the spinal canal –> compression of lumbar nerve roots. Most comonly due to 1) enlarging osteophytes and 2) hypertrophy of ligamentum flavum
Neurogenic claudication is when pt feels pain when walking upright but relief when walking while leaning forward when the spine is flexed (“shopping cart sign”)
Diagnosis is done via MRI of the spine
In diabetic pts, what is the mechanism of osteomyelitis?
contiguous spread
Succinylcholine is a depolarizing neuromuscular blocker often used during rapid-sequence intubation b/c it has a rapid onset (45-60 sec) and offset (6-10 min). Who cannot be given succinylcholine?
succinylcholine can cause significant K+ release and life-threatening arrhythmias so should not be used in pts with or at high risk for hyperkalemia.
Pts in crush or burn injuries more than 8 hours long, with demyelinating syndromes like Guillain-Barre, and tumor lysis syndrome.
Use vecuronium or rocuronium in these patients
Chikungunya fever -suspect in pts who recently traveled to the carribean and are now presenting with?
fever, malaise, rash, lymphadenopathy, polyarthralgias, lymphopenia, thrombocytopenia
What’s considered a positive PPD test in someone with HIV?
skin induration greater than 5 mm and will require ppx with isonazid and pyridoxine for 9 months
What’s the preferred modality to diagnose a kidney stone?
US or noncontrast spiral CT scan of abdomen and pelvis
What does a high BNP correlate with? What’s a clinical sign that best correlates with a high BNP?
high BNP - correlates with severity of LV filling pressure elevation as well as mortality
It can rule in dyspnea 2/2 to CHF
audible S3 is a sign of increased cardiac filling pressure
A post-operative patient with hypotension, jugular venous distension and a new onset RBBB -suspect?
pulmonary embolism
RBBB and jugular venous distension signify right heart strain
How to treat candida esophagitis?
oral fluconazole
Bladder tumors are the most common malignancy assoc with painless hematuria in adults. Pts age > 35 with gross hematuria should be evaluated for urological neoplasms with which 2 modalities?
CT urogram
cystoscopy
What is Pickwickian syndrome aka obesity hypoventilation syndrome?
obesity impedes the expansion of the chest and abdominal wall during breathing leading to increased respiratory work and decreased respiratory drive
chronically elevated PaCO2 (retention of CO2) and reduced PaO2, can eventually develop OSA, polycythemia, pulmonary HTN, RV failure
List some signs of marijuana toxicity
increased appetite tachycardia tacyhpnea HTN dry mouth conjunctival injection decreases rxn time impairs attn, concentration
What’s the relationship btw ankylosing spondylitis and osteoporosis?
Ppl with ankylosing spondylitis for more than 20+ years are at increased risk of vertebral fracture due to rigidity and decreased bone mineral density. Osteopenia/osteoporosis in this population is caused by inflammation (mediated by TNF-alpha and Il-6) that results in increased osteoclast activity. Annual incidence of vertebral fracture may reach 1%.
Pt with ureteric colic 2/2 to ureteral stone if uncomplicated can be managed conservatively with hydration, analgesics and alpha blockers. How do alpha blockers like tamsulosin help with kidney stones?
they act on distal ureter, lowering muscle tone and reducing reflex ureteral spasm 2/2 to stone impaction. therefore, alpha blockers can facilitate stone passage and reduce the need for analgesics.
What is the ppx DOC for m. avium in HIV pts with CD4 cell count
azithromycin
Graft vs host disease occurs after BMT when there’s activation of donor T lymphocytes against HLA antigens. Up to 50% of patients with BMT from matched siblings develop the disease. What are the target organs involved?
- skin (maculopapular rash involving palms, soles, face)
- intestine (blood positive diarrhea)
- liver (abnormal liver function tests, jaundice)
Clinical symptoms of someone with Whipple disease (caused by tropheryma whippelil). How to diagnose?
Whipple disease: chronic malabsorptive diarrhea (steatorrhea, flatulence, abdominal distension), protein losing enteropathy, weight loss, migratory non-deforming arthritis, LAD and a low-grade fever, can damage EYES, CNS, and MYOCARDIUM.
diagnosis: small intestinal biopsy showing PAS-positive macrophages in lamina propria containing non-acid-fast gram-positive bacilli
If blood culture reveals strep bovis, what should one suspect and do?
s. bovis is a normal inhabitant of the GI tract and S. bovis bacteremia is assoc with colon cancer.
Do colonoscopy
Differentiate btw hypertensive urgency and emergency.
hypertensive urgency: BP usually above 180/120 mmHg with no symptoms or acute end organ damage
hypertensive emergency: BP is high + signs of life-threatening, end-organ complications
- Malignant HTN: severe HTN + retinal hemorrhages, exudates or papilledema
- Hypertensive encephalopathy: severe HTN + cerebral edema & non-localizing neuro symptoms and signs
Nonalcoholic fatty liver disease resembles alcohol-induced liver injury on histology but occurs in patients with minimal or no alcohol history. The most likely mech is?
insulin resistance leading to increased peripheral lipolysis, triglyceride synthesis and hepatic uptake of fatty acids
Needle shaped crystals on urinalysis indicate????
uric acid stones
they are radiolucent so have to be evaluated by CT of the abdomen or IV pyelography, or US. Plain xrays will not be able to see them.
How does ischemic hepatic injury in the setting of shock presents as??
acute, massive increases in the AST and ALT with milder associated increases in total bilirubin, alk phosp. Liver enzymes will return to normal within a few weeks
All patients with smoke inhalation should be suspected to have acute CO poisoning and treated with?
100% oxygen via a nonrebreather facemask
symptoms of CO poisoning: agitation, confusion, somnolence, headache, nausea, dyspnea. Severe CO poisoning: seizure, coma, syncope, heart failure or arrhythmias
What can be used to differentiate CML from polycythemia vera and other causes of myeloproliferation (i.e. leukemoid reaction)?
CML has low levels of leukocyte alkaline phosphate activity b/c the WBCs are defective while other myeloproliferative disorders have normal leukocyte alkaline phosphate activity.
Someone with chronic liver disease should get which vaccinations?
- Tdap/Td: Tdap once as substitute for Td booster, then Td every 10 yrs
- Influenza: annually
- Hep A: 2 doses 6 months apart with initial negative serologies
- Hep B: 3 doses at 0 months, 1 month and at least 4 months
- Pneumococcal vaccines: PPSV23 once, then revaccinate with sequential PCV13 and PPSV23 at age 65
What causes lateral medullary syndrome aka Wallenberg syndrome? What are some symptoms?
- due to occulsion of PICA or vertebral artery
- loss of pain and temperature over ipsilateral face & contralateral body
- ipsilateral bulbar muscle weakness
- vestibulocerebellar impairment (vertigo, nystagmus)
- Horner’s syndrome
- motor function of the face and body is typically spared
When will you choose endotracheal intubation vs noninvasive positive-pressure ventilation?
when they fail a 2-hour trial of NPPV
Cardiac myxoma
clinical features
diagnosis and management
clinical features:
- constitutional symptoms: fever, weight loss, raynaud phenomenon
- cardiovascular complications: valvular abnormalities (e.g. mitral disease), heart failure due to anatomic obstruction, myocardial invasion causing arrhythmias, heart block, pericardial effusion
- embolization
- lung invasion causing resp symptoms mimicking bronchogenic carcinoma
Diagnosis: ECHO
Management: Prompt surgical resection
Sinus bradycardia in adults
1) identify and treat underlying causes, IV access, cardiac monitoring to identify rhythm, pulse oximetry with O2 for hypoxemia, 12-lead EKG
2) if persistent bradyarrhythmia & either hypotension/signs of shock/AMS/chest discomfort/acute heart failuire –> IV atropine, repeat every 3-5 min up to 3 mg maximum
3) if no response to atropine –> transcutataneous pacing or IV dopamine or epinephrine
CT findings in someone with alzheimer’s disease
diffuse cortical and subcortical atrophy which is disproportionately greater in the temporal and parietal lobes
What are some red signs assoc with cavernous sinus thrombosis? What’s the imaging modality of choice?
- severe headache
- bilateral periorbital edema
- cranial nerve III, IV, V, VI deficits
*MRI with magnetic resonance venography is imaging of choice
How to identify bronchiectesis?
CT by the presence of dilated bronchi with thickened walls
clinical signs: chronic productive cough with repeated courses of abx, hemoptysis (sometimes massive to require bronchial artery embolization)
How to diagnose barrett’s esophagus?
esophageal endoscopy with biopsy
How to diagnose someone with sjogren’s syndrome?
-subjective & objective evidence of dry mouth and eyes in the presence of either histologic evidence of lymphocytic infiltration of the salivary glands
OR
-serum autoantibodies against SSA (Ro) and/or SSB (La)
Pyruvate kinase deficiency
chronic hemolysis with hepatosplenomegaly, skin ulcers, pigmented gallstones
Cavernous sinus thrombosis can result from uncontrolled infection of the skin bc the facial venous system is valveless. What are the red flags? What’s the imaging of choice to diagnose It?
Red flag symptoms: severe headache, bilateral periorbital edema, cranial nerve 3, 4, 5 and 6 deficits
Magnetic resonance imaging with magnetic resonance venography is the imaging modality of choice.
Patient with heparin induced thrombocytopenia can have what DVT ppx?
Argatroban is a direct thrombin inhibitor that reversible binds to the active thrombin site of free and clot-associated thrombin.
What’s the timeframe in which you can give clot busters in acute ischemic strokes?
3-4.5 hours
Pneumococcal polysaccharide vs pneumococcal conjugate vaccine
Pneumococcal polysaccharide vaccine (PPSV23)
-induces a T cell independent B cell response that is less effective in children and elderly
Pneumococcal conjugate vaccine (PCV13)
- covalently attached to inactivated diphtheria toxin protein
- t cell dependent B cell response
- improved immunogenicity due to formation of higher affinity antibodies and memory cells
What are the cardiac, pulmonary, endocrine, GI, ocular, dermatological, and neurologic side effects of amiodarone (anti-arrhythmic)
Cardiac: sinus bradycardia, heart block, QT prolongation
Pulmonary: chronic interstitial fibrosis
Endocrine: hypothyroidism/hyperthyroidism
GI: hepatitis
Ocular: optic neuropathy, corneal micro deposits
Dermatological: blue gray skin discoloration
Neurologic: peripheral neuropathy
What is Ramsay hunt syndrome?
Form of herpes zoster infection that causes Bell’s palsy. Can see vesicles on outer ear
TMJ dysfunction can result in referred pain to the ear that is worsened with chewing. Typically reports a history of?
Nocturnal teeth grinding
Hydroxychloroquine is an excellent choice for patients with lupus with isolated skin and joint involvement. It’s typically safe, but what should one worry about?
Damage to eyes therefore IMPT to do eye exams every 6 months.
Which arrhythmia is most specific for digitalis toxicity?
Atrial tachycardia with AV block
Organophosphate poisoning inhibits acetylcholinesterase leading to cholinergic excess. Atropine can reverse effects. What is of equal importance?
Removal of any clothes and washing of the skin to prevent further transcutaneous absorption
What are supportive measures for upper gastrointestinal bleeding?
NPO
IV fluids thru large-bore catheters
Monitoring blood counts and vital signs
Packed red blood cells if Hb is less than 7 or less than 9 in patients with symptoms of anemia, ACS with active ischemia
Cryoprecipitate contains many insoluble products (factor VIII, fibrinogen, Von wilebrand factor, factor XIII) from cold fresh frozen plasma. This is used as replacement for?
Patients with fibrinogen, Von wilebrand factor, factor VIII deficiency
Characterize tick borne paralysis
Rapidly progressive ascending paralysis, absence of fever and sensory abnormalities, normal CSF exam. Removal of ticks can result in spontaneous improvement
Baker cysts develop why?
Excessive fluid production by an inflamed synovium as occurs in rheumatoid arthritis, osteoarthritis and cartilage tears. Baker cysts can burst and look like DVT
A child has isolated thrombocytopenia and petechiae after a viral infection. What is top of your ddx?
Immune thrombocytopenia which usu resolves spontaneously within 6 months and require only observation. If bleeding then give IV immunoglobulin or glucocorticoids
Six criteria that can be used to establish osteoarthritis in setting of osteoarthritis
Age > 50 Crepitus Bony enlargement Bony tenderness Lack of warmth Morning stiffness
Diuretics -Yay or nay for the following conditions:
- restrictive cardiomyopathy (causes: hemochromatosis, sarcoidosis, amyloidosis, scleroderma, endomyocardial fibrosis)
- dilated cardiomyopathy (alcohol, viral, radiation, chagas, doxorubicin, recent MI and ischemia)
- hypertrophic cardiomyopathy
- hypertrophic obstructive cardiomyopathy
- mitral valve prolapse
- pericarditis (most common idiopathic most likely due to cox B)
- pericardial tamponade
- constrictive pericarditis
- restrictive, dilated and hypertrophic cardiomyopathy can have symptoms improved with diuretics
- HOCM and MVP will worsen with diuretics b/c there will be less blood in the heart which will make HOCM obstruction worse and the floppy valve in MVP worse
- pericarditis: USE NSAIDS, and colchicine can prevent recurrences
- pericardial tamponade: NO DIURETICS b/c less filling of heart and worsen right heart collapse
- constrictive pericarditis: Diuretics can help relieve symptoms and then surgical removal of pericardium
Pts with suspected acute stroke should initially receive?
a head Ct without contrast to rule out hemorrhage first before giving medications
Hyperkalemia is most often due to decreased urinary potassium excretion. Most common causes are acute or chronic kidney disease and medications or disorders that impair the RAAS. List the 8 groups of medications that can cause hyperkalemia.
1) nonselective beta-adrenergic blockers: interfere with b2-mediated intracellular potassium uptake
2) ACEI: decreases aldosterone release
3) ARBs: also decreases aldosterone release
4) K+sparing diuretics: block the epithelial sodium channel (amiloride, triamterene) or aldosterone receptors (spironolactone, eplenerone)
5) Cardiac glycosides (digoxin/digitalis): inhibition of the NaK ATPase pump
6) NSAIDs: impaired local prostaglandin synthesis reduces renin and aldosterone secretion
7) cyclosporine: blocks aldosterone activity
8) heparin: blocks aldosterone production
9) TMP/SMX: similar amiloride/triamterene, causes hyperkalemia due to blockade of epithelial soidum channel in collecting tubule
Some EKG changes assoc with hyperkalemia
peaked T waves
short QT interval
QRS widening
sine wave with ventricular fibrillation
in hyperkalemia with EKG changes, treat first with calcium gluconate
Pts with severe BPH can lead to urinary obstruction and renal failure. how to assess?
use renal ultrasound to assess for hydronephrosis
What is the first-line treatment for central diabetes insipdus? How to diagnose central diabetes insipus?
First line treatment is intranasal desmopressin.
Diagnosis: water deprivation test –> + when despite depriving the person of water, s/he is still making dilute urine –> give ADH, if responsive, then central DI
Initial treatment for severe hypovolemic hypernatremia is?
isotonic 0.9% saline, which acts to gradually correct the hyperosmolality while normalizing volume status
Cirrhosis due to which 2 causes is most commonly associated with hypogonadism.
alcohol
hemochromatosis
Initial evaluation of urinary incontinence in elderly
UA and urine culture
What are typical features of zenker diverticulum?
dysphagia, coughing, regurgitation, halitosis and a neck mass usu affecting ppl > 60 y.o. due to outpouching immediately above UES occurring 2/2 to posterior herniation btw fibers of cricopharyngeal muscles
preferred imaging to confirm: barium esophagram
management: surgical
Clinical symptoms of glucagonoma
hyperglycemia
necrolytic migratory erythema
weight loss
anemia
How to diagnose? Hyperglycemia with elevated glucagon > 500 pg/mL or CT or MRI to localize tumor
Classic triad of milk alkali syndrome due to increased intake of calcium and alkali
hypercalcemia (constipation, polyuria, polydipsia)
renal insufficiency
metabolic alkalosis
What’s the only illicit drug that causes vertical nystagmus?
PCP -hallucinations, dissociative feelings, agitation, confusion, pupillary dilation, tachy, nystagmus, HTN, aggression, violence
How to treat Raynaud’s phenomenon when under cold or emotional stress, the arteries vasoconstrict causing affected fingers to turn white blue and then red.
smoking cessation
avoid cold temp or emotional stress
CCB like amlodipine or nifedipine
Evaluate diarrhea in HIV-infected patients should include?
- stool culture
- examination for ova and parasites
- test for c. diff toxin
What’s the most common cause of pneumonia is HIV patients?
encapsulated bacteria, especially strep pneumo
treatment of acute vs chronic MS
- acute attacks of MS: high-dose corticosteroids
- chronic MS can be treated with interferon-beta proven to decrease the frequency of relapse and reduce disability in patients with the relapsing-remitting form
Herpetic whitlow is a common viral infection of the hand caused by?
HSV 1 or 2 and is self-limiting
health care workers like dentists are at increased risk
Treatment of acute exacerbation of COPD includes:
supplemental oxygen (target O2 sat 88-92%) inhaled bronchodilators (b2 agonists and anticholinergics) abx systemic glucocorticoides (methylprednisolone)
CHADSVAS score greater than 4, pt should be on antithrombotic therapy for AF to reduce risk of embolization
CHF -1 pt HTH -1 pt Age > 75 - 2pts Diabetes -1 pt Stroke/TIA/thromboembolism -2 pt Vascular disease (MI, PAD) -1 pt Age > 65 -1 pt Sex F -1 pt
Chronic inflammatory conditions like RA and IBD can cause AA Amyloidosis which can lead to nephrotic syndrome. What’s the typical finding on kidney biopsy of someone wtih amyloidosis?
amyloid deposits that stain Congo red and have apple-green birefringence under polarized light
if kidney biospy reveals hyalinosis that affects both afferent and efferent arterioles (kimmelstiel’s nodules), it is pathognomonic for which condition
diabetes
What is Amaurosis fugax
transient visual loss and usually monocular, sometimes described as “a curtain falling down” most commonly caused by retinal emboli from the ipsilateral carotid artery generally due to atherosclerosis. Once the clot is displaced or breaksup, blood flow is restored and vision returns.
Workup includes noninvasive eval of the carotids
Acute glaucoma can present as severe u/l headache, nausea and eye pain. It is a medical emergency. How to treat?
pain should be controlled by narcotics
the increasedin intraocular pressure is reduced with mannitol, acetazolamide, timolol or pilocarpine
atropine is contraindicated b/c it can dilate pupil and worsen glaucoma
hydroxychloroqine should do routine eye exams bc side effect is ocular damage. What is hydroxycholorine used for?
- malaria ppx
- acute malaria
- RA
- SLE
For symptomatic sarcoidosis (SOB, chest pain, cough, malaise, b/l hilar adenopathy, increased ACE, noncaseating granulomas), treat with?
systemic glucocorticoids
Vit K deficiency is usu due to inadequate dietary intake, intestinal malabsorption or hepatocellular disease. The liver can normally store a 30-day supply of Vit K, but an acutely ill person with underlying liver disease can become vit K deficient in how many days? Explain lab findings
- vit k deficient as little as 7-10 days
- Vit K is needed to activate clotting factors II, VI, VII, IX, X, proteins C and S –> lower levels –> higher PT and PTT
- administer Vit K can replenish stores in 8-10 hours
Lupus anticoagulant is an antiphospholipid antbody that prolongs ___ during diagnostic testing.
It prolongs PTT (which should indicate increase bleeding), however antiphospholipid syndrome is assoc with hypercoagualability
How to diagnose peptic ulcer disease -most common cause of UGI bleed?
upper GI endoscopy
What are some classic chest x-ray findings in patients with pulmonary embolism?
- pleural-based densities representing lung infarction (Hampton’s hump)
- prominent central pulmonary artery with local oligemia (Westermark’s sign)
- not abnormal to have perfectly normal chest x-rays
What is the value of ECHO in PE?
in large PE, ECHO can show pulmonary HTN, and/or evidence of right heart strain
This phrase “bones, stones, abdominal moans, and psychic groans” are clinical symptoms of what condition?
hypercalcemia from primary hyperparathyroidism which the treatment of choice is parathyroidectomy
What’s the first step in assessing thyroid nodules?
- get TSH measurement and ultrasound
- if pt has cancer risk factors or if US is suspicious showing hypoechoic, microcalcifications, internal vascularity) –> FNA
- no cancer risk factors or suspicious US findings –> normal or high TSH –> FNA or low TSH –> iodine 123 scintigraphy –> hot nodule –> treat hyperthyroidism; cold nodule –> FNA
Reasons for FNA in someone with thyroid nodules
- cancer risk factors (childhood radiation, family history, etc)
- suspicious US findings (hypoechoic, microcalcifications, internal vascularity)
- normal or high TSH
- low TSH + cold nodule
Cystinuria is a genetic condition caused by a defect in absorption of COAL (cystine, ornithine, arginine, lysine) by the brush borders of renal tubular and intestintial epithelial cells. Cystine is poorly soluble in water leading to formation of hard opaque stones. What kind of crystals can you find on UA? What can confirm diagnosis
- UA -hexagonal crystals
- positive urinary cyanide nitroprusside test can detect cystine levels that is widely used as a qual screening procedure
Lewy bodys are?
eosinophilic intracytoplasmic inclusions of alpha-synuclein protein found in neurons found in lewy body dementia (early onset dementia) and in parkinsons (motor symptoms first)
What is post-cholecystectomy syndrome? Diagnosis?
PCS refers to persistent abdominal pain or dyspepsia that occurs days, months to years after a cholecystectomy. Pts usually notice the same pain they had prior to surgery, new pain just after surgery or the same pain that never went away.
Do US first, then ERCP, MRCP to evaluate
What is the treatment of choice for TTP-HUS?
plasmapheresis to remove offending autoantibodies and replete the deficient enzyme
Warfarin-induced skin necrosis: what are the commonly involved sites?
- commonly involved sites: breasts, buttocks, thighs and abdomen
- initial complaint: pain
- bullae formation and skin necrosis
- occurs within weeks after therapy
- replace Vitamin K
If you see bright red, firm, friable exophytic nodules (resembles cherry angioma, large pyogenic granuloma) in an HIV infected patient, you should suspect…. Other symptoms: fever, weight loss, malaise, characteristic lesions of skin and vsicera
suspect bartonella causing bacillary angiomatosis
treat with oral erythromycin
How to reduce UTIs in patients with neurogenic bladder?
intermittent catheterization is effective. PPx abx have not been proven to be better.
Chronic venous insufficiency (b/l LE pitting edema, varicose veins, venous ulcer) should be treated initially with?
leg elevation, exercise and compression stockings
if it doesn’t improve, do venous duplex US and if documented reflux –> endovenous ablation
When do patients with GERD symptoms require upper GI endoscopy?
-alarm symptoms like dysphagia, odynophagia, weight loss, anemia, GI bleeding, or recurrent vomiting)
or
-men age > 50 with chronic (>5 yrs of symptoms) and cancer risk factors (tobacco use)
Nocardiosis most commonly presents as pneumonia in an immunocompromised host diagnosed by presence of branching, beaded, gram positive partially acid-fast filaments in gram stain and culture. Treatment of choice?
TMP-SMX
Of all the causes of restrictive cardiomyopathy (sarcoidosis, scleroderma, hemachromotosis, amyloidosis), which is the only one that is reversible?
hemachromatosis
In hypertrophic obstructive cardiomyopathy (AD disorder), mutations in which 2 genes account of most of the identificable mutations?
- cardiac myosin binding protein C
- cardiac beta-myosin heavy chain gene
Morton neuroma
pain btw 3rd and 4th toes on the plantar surface with a clicking sensation (Mulder sign) that occurs when simultaneously palpating this space and squeezing the metatarsal joints
Tarsal tunnel syndrome
due to compression of the tibial nerve as it passes thru the ankle, usu caused by a fracture of the ankle bones
burning, numbness and aching of the distal plantar surface of the foot/toes that sometimes radiates up to the calf.
Stress fractures are common in pts who suddenly increase their physical activity, esp in female runners with female athlete triad (?). Typical symptoms include localized pain to palpation and possible swelling
-triad: oligomenorrhea, osteoporosis, decreased caloric intake
How to manage acute pancreatitis?
analgesics
IV fluids
NPO
Pts with febrile neutropenia should be started on which empiric broad spectrum abx.
piperacillin-tazobactam
Atypical pneumonia has a more indolent course than pyogenic pneumonia. it also has more extrapulm manifestations. Which is the characteristic extrapulm manifestation of mycoplasma, the most common cause of atypical pneumonia?
erythema multiforme: dusky red, target shaped skin lesions
Septic arthritis: risk factors include abnormal joint 2/2 to OA, RA, prosthetic joint, and gout, diabetes, IV drug use, alcoholism, intra-articular glucocorticoid injections. What are some clinical features? How to diagnose? and treatment?
Acute monoarthritis: hot, swollen, decreased ROM
Fever
Elevated ESR & CRP
Dx: blood cxs, synovial fluid analysis showing leukocytosis (>50,000/mm3), gram stain, culture
treatment:
gram + –> vancomycin
gram - –> 3rd gen cephalosporin like ceftriaxone
negative microscopy –> vancomycin + 3rd gen if immunocompromised
RA presents as progressive and symmetrical involvement of the peripheral joints. Common sites include MCP and PIPs of the jingers, MTP joints of toes and wrist joints. Which part of the axial skeleton does it more commonly affect?
cervical spine joints and can cause spinal subluxation and spinal cord compression
What is the most likely diagnosis of an asymptomatic, immunocompetent adult with a non-healing, isolated ulcer in the vermilion zone of the lower lip with significant sun exposure?
squamous cell carcinoma -“invasive cords of squamous cells with keratin pearls”
What’s the most common adverse rxn that occurs within 1-6 hours of transfusion?
febrile nonhemolytic transfusion reaction when left-over leukocytes remain in the blood and release cytokines which cause transiet fevers, chills and malaise without hemolysis!
indications for irradiated blood vs leukoreduced vs washed
irradiated: BMT recipients, acquired or congenital cellular immunodef
leukoreduced: chronically tx pts, CMV seroneg at rish patients, previous febrile nonhemolytic tx rxn, potential transplant recipients
washed: IgA deficiency, complement-dependent autoimmune hemolytic anemia, continued allergic rxns w/ red cell tx despite antihistamine treatment
Someone in septic shock is in overall peripheral vasodilation. What would hemodynamic monitoring show?
- low pulmonary capillary wedge pressure
- low systemic vascular resistance
- increased cardiac output
- high mixed venous oxygen saturation
Boerhaave syndrome, instrumentation (endoscopy), esophagitis, and esophageal ulcer are potential causes of eosphageal perforation What are some clinical presentation? How to diagnose? How to manage?
Clinical presentation: chest & abdominal pain, subcutaneous emphysema in the neck, Hamman sign (crunching sound on chest auscultation)
Dx: CXR or CT will show wide mediastinum, pneumomediastinum, pneumothorax, air around paraspinal muscles, pleural effusion
CT: esophageal wall thickening, mediastinal air fluid level
Water soluble contrast esophagogram (CONFIRMS DIAGNOSIS): leak at perforation site
Management: abx and supportive care and surgical repair for significant leakage
What’s the typical test to detect hemi-neglect syndrome? What’s the syndrome caused by?
Typical test is to ask a patient to fill in the #s of a clock. The clock will on be half-filled. Hemi-neglect syndrome is characterized by ignoring the left side of a space and involves the right (non-dominant) parietal lobe.
What is Dejerine-Roussy syndrome? What is dysestheisa?
a thalamic stroke involving VPL nucleus which transmits sensory info from the contralateral side of the body.
Classic presentation involves contralateral hemianesthesia that can be accompanied by transient hemiparesis, athetosis, or ballistic movements.
Dysesthesia (dysesthesia occurs when the act of touching a part of the body causes some unpleasant sensation, such as pain, burning, or tingling. In some cases these sensations may occur with no touch at all.) of the area affected by the sensory loss is characteristic called thalamic pain phenomenon.
What’s the most sensitive and rapid test to detect disseminated histoplasmosis (cytopenias, LAD, HSM, pulmonary involvement can cause cavitary lesions)?
What’s the preferred treatment of choice?
histoplasma antigen immunoassay of the serum or urine
Itraconazole is the preferred antifungal treatment for histoplasmosis
Interstitial cystitis aka painful bladder syndrome is a chronic, painful condition of uncertain epidemiology that is more common in women an assoc with psych disorders and pain syndromes. What are clinical presentations? dx? Treatment?
Clinical symp: bladder pain w/ filling, relief with voiding, increase freq & urgency, dyspareunia
Dx: bladder pain with no other cause for greater than 6 weeks duration, normal UA
Treatment: amitryptyline, analgesics, behavioral mods & trigger avoidance
Microbiology of infective endocarditis with staph aureus. List the 4 clinical assoc/predisposing conditions.
- prosthetic valves
- intravascular catheters
- implanted devices (pacemakers, defibrillators)
- injection drug users
Microbiology of infective endocarditis with viridiands group strep. List the 2 clinical assoc/predisposing conditions.
- dental procedures
- procedures involving incision and biospy of resp tract
Microbiology of infective endocarditis with coagulase-negative staph. List the 3 clinical assoc/predisposing conditions.
- intravascular catheters
- prosthetic valves
- pacemakers or defibrillators
Microbiology of infective endocarditis with enterococci. List the 1 clinical assoc/predisposing conditions.
-nosocomial UTIs
Microbiology of infective endocarditis with strep bovis (s. galloyticus). List the 2 clinical assoc/predisposing conditions.
- colon carcinoma
- IBD
Microbiology of infective endocarditis with fungi. List the 3 clinical assoc/predisposing conditions.
- immunocompromised
- chronic indwelling catheters
- prolonged abx therapy
What is the criteria to diagnose obesity hypoventilation syndrome?
BMI >/- 30 kg/m2
PaCO2 > 45 mmHg
alveolar hypoventilation
(hypercapnia, hypoxemia, resp acidosis)
1st line therapies: weight loss and noninvasive PPV
Symptoms of diabetic gastroparesis and treatment
symptoms: anorexia, nausea, vomiting, early satiety, postprandial fullness, impaired glycemia control
use prokinetic agents like metoclopramide, erthyromycin or cisapride
CJD disease should be suspected in older adult patients with rapidly progressive dementia, myoclonus. What can you find on EEG and CSF?
EEG: sharp wave complexes
CSF: elevated 14-3-3 proteins
gold std: brain biopsy
What’s the pathophys behind immune thrombocytopenia
autoimmune disorder with increased platelet destruction and inhibition of megakaryocyte platelet production due to IgG autoantibodies against the plt membrane glycoproteins. Treatment usu involves systemic glucocorticoids for severe thrombocytopenia (
Paget’s disease is characterized by increased bone remodeling and abnormal and abnormal osteoid formation-what’s the preferred treatment?
bisphosphonates
PCP infection presents as nonproductive cough, exertional dyspnea, fever, severe hypoxia, bilateral intersitital infiltrates on cxr. What’s the the drug of choice? and when do you add corticosteroids?
Drug of choice: TMP-SMX
Add corticosteroids if PaO2 - 70 mmHg or A-a gradient >/- 35 mmHg bc it has shown to decrease mortality in severe infections
Minimal bright red blood per rectum (BRBPR) aka “scant hematochezia” is assoc with pts complaints of small amounts of bright red blood on toilet paper. In ppl less than 50, what’s the initial test?
office-based anoscopy/proctoscopy in pts less than 50
