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
T/F: Brain death is a legally acceptable definition of death and does not require additional steps like permission from next of kin to take the patients off life support.
True
In non-bleeding esophageal varices, what is the initial treatment of choice?
beta blockers
**octreotide is used in acute bleeding cases; no role in ppx of non-bleeding varices
Central retinal artery occlusion 2/2 to embolism often presents as painless loss of monocular vision. It is commonly assoc with amaurosis fugax and worse visual acuity. Fundoscopy can show diffuse ischemic retinal whitening and cherry red spots. It is an opthalmologic emergency. What is the treatment of choice?
immediate intervention includes ocular massage to dislodge the embolus and high flow oxygen
What are risk factors, symptoms of pseudotumor cerebri? What can you find on PE? Dx? Treatment? What is likely to result if untreated?
Risk factors: overweight women of childbearing age, possible link to medications (growth hormone, tetracyclines, excessive vitamin A)
Symptoms: headache, transient vision loss, pulsatile tinnitus, diplopia
PE: papilledema, peripheral visual field defect, CN VI palsy
DX: MRI, LP will show CSF pressure > 250 mm H20)
Treatment: weight loss, acetazolamide, stop offending meds
If untreated, blindness is likely to result
If you suspect esophageal motility disorder, what is the recommended initial test, followed by what confirmatory test?
initial test: barium swallow
if barium swallow suggests a motility disorder, then confirm with manometry
upper endoscopy is not used b/c can cause perforation of esophagus
Treatment of actively bleeding esophageal varices
hemodynamic support
octreotide
endoscopic therapy
ppx abx
Causes of spinal cord compression include spinal injury (from MVA), malignancy, infection. What are some symptoms? How to manage?
symptoms:
- gradually worsening severe local back pain
- pain worse in the recumbent position/at night
- symmetric LE weakness, hypoactive/absent DTRs
- b/l babinski reflex, decreased rectal sphincter tone, paraparesis/paraplegia with increased DTRs, sensory loss
management:
- emergency MRI
- IV glucocorticoids
- radiation oncology & neurosurgery consultations
Blastomycosis is a fungal infection endemic to the central US. It usu causes mild pulmonary illness, but disseminated infection may occur. Describe cutaneous manifestations.
well-circumscribed verrucous nodules and plaques that progress to microabscesses
List the different groups of drugs that can cause pancreatitis
1) diuretics (furosemide, thiazides)
2) drugs for IBD (mesalamine)
3) immunosuppressive agents (azathioprine)
4) HIV-related meds (didanosine, pentamidine)
5) abx (metronidazole, tetracycline)
6) anti-seizure (valproic acid)
anemia + painless GI bleeding + murmur of aortic stenosis is most consistent with?
angiodysplasia
Heyde’s syndrome: aortic stenosis + angiodysplasia
Porphyria cutanea tarda is a skin finding consistent with hep c infection. describe
-fragile skin, photosensitivity, vesicles and erosions on the dorsum of the hands.
Nearly 90% of essential mixed cryoglobulinemia have hep c. What is it due to?
- IgM against anti-hep C virus IgG
- circulating immune complexes that deposit in small and medium vessels
- may be assoc with low complements, increased rheumatoid factor, increased liver transaminases, serum cryoglobulins
- palpable purpura, arthralgias, renal complications (membranoproliferative glomerulonephritis)
- kidney/skin biopsy can confirm dx
What’s a well-known side effect of the protease inhibitor indinavir for HIV?
crystal-induced nephropathy caused by precipitation of the drug in the urine and obstruction of urine flow
recommend periodic 3-4 month check up of UA and sCr
Any NRTIs has what side effect to worry about
lactic acidosis
Any NNRTIs has what side effect to worry about
stevens johnson syndrome
When should you expect myogloburia 2/2 to rhabdomyolsis?
when there’s large amount of blood on UA with relative absence of RBCs on urine microscopy
What is the most common cause of death in dialysis patients?
cardiovascular
What are characteristic eye findings in someone with herpes simplex keratitis?
corneal vesicles and dendritic ulcers
in VZV: dendriform corneal ulcers
How to diagnose acute pancreatitis?
Diagnosis requires 2 out of the 3 criteria:
1) acute onset of severe epigastric pain radiating to the back (***pt may get partial relief by sitting up and leaning forward)
2) increased amylase or lipase > 3 times the upper limit of normal
3) abdominal imaging findings (focal or diffuse pancreatic enlargement) usu CT (this is NOT done if the patient fulfills 1 & 2) **done in pts with unclear diagnosis
**US is done only to assess for gallstones as the cause of pancreatitis
A post-seizure anion gap metabolic acidosis is usu due to
lactic acidosis b/c seizures result in accelerated production of lactic acid in muscle and reduced hepatic lactate uptate.
this post-ictal lactic acidosis is transient and typically resolves withint 60-90 minutes
acute back pain + point tenderness after strenuous activity suggests?
vertebral compression fracture
risk factors: osteoporosis, trauma, infection, malignancy, metabolic abnorm
What’s the classic tetrad of multiple myeloma?
CRAB
- calcium (hypercalcemia: constipation, polyuria, polydipsia)
- renal impairment mediated by IgG abs or paraproteins
- anemia
- bones (bone pain, lytic lesions, fractures)
- **elevated ESR
- **normally a 3-4 g/dL difference btw serum total protein and albumin, but in multiple myeloma, the gap is bigger b/c the paraproteins add to the # of total proteins
- **total decrease in functional antibodies and leukopenia as bone marrow is filled with malignant plasma cells
- **hyperviscositysyndrome
- **stacked of RBCS = rouleaux appearance
Why should US be performed in all patients with acute pancreatitis?
to evaluate for cholethiasis or choledocholithiasis
Leprosy can present with insensate hypopigmented plaque with muscle atrophy. How to diagnose?
skin biospy to show acid-fast bacilli
What should you use in cases of lower GI bleeding where the source cannot be identified by colonoscopy?
technetium-99 labeled erythrocyte scintigraphy aka tagged RBC scan
What are the 2 most appropriate tests to diagnose acute infection with hep B?
- HBsAg
- IgM anti-HBc
Dermatomyositis presents with proximal symmetric weakness in UE and LE, gottron’s papules, heliotrope rash, interstitial lung disease, dysphagia, myocarditis. How to diagnose and manage?
Diagnosis: increase CPK, aldolase, LDH; Anti-RNP, anti-Jo-1 and anti-Mi2.
If still uncertain, do EMG or biopsy of skin/muscle
Management: high-dose glucocorticoids, and screen for malignancies b/c of increased risk (15% of pts)
Open angle glaucoma -symptoms and finding?
More common in African Americans
Generally asymptomatic at first followed by gradual loss of peripheral vision over years –> tunnel vision
may be cupping of optic disc
Variant angina aka Prinzmetal’s angina causes chest pain by coronary vasopasm that typically affects young females. What’s the greatest risk factor? When do these episodes typically occur? What are some associated EKG fingings, What’s the DOC?
Greatest risk factor: smoking Episodes typically occur at night EKG: transient ST elevations Calcium channel blockers and/or nitrates are DOC Avoid beta blockers, aspirin
How to best diagnose empyema?
CT
What’s is meant by salvage therapy?
When initial standard therapy fails, another therapy after is considered salvage
What’s the best test for diagnosing and evaluating acute episode of diverticulitis
CT
Reversible acetylcholinesterase inhibitors such as donepezil, rivastigmine, and galantamine are beneficial in…
slowing cognitive decline assoc with alzheimer’s disease
Right mainstem bronchus intubation is a common complication of endotracheal intubation. What are the symptoms?
- asymmetric chest expansion during inspiration
- absent breath sounds on the left side or markedly decreased
fix by repositioning ETT by pulling back slightly
What is delayed sleep phase syndrome? Advanced sleep phase syndrome?
Delayed sleep phase syndrome: circadian rhythm disorder due to inability to fall asleep at normal bedtimes (10 PM -midnight); sleep is normal if allowed to continue until late morning; pts have insomnia and excessive daytime sleepiness
Advanced sleep phase syndrome: circadian rhythm disorder due to inability to stay awake in the evening usually after 7pm, making social functioning difficulty.
What’s the preferred treatment of choice for hyperthyroidism in North America?
radioactive iodine ablative therapy with most pts achieving euthyroid after one dose. Takes about 6-8 weeks to see improvements.
Contraindications: pregnancy, severe opthalmopathy
Pancytopenia found in Lupus is due to?
peripheral immune-mediated destruction of all 3 lines
What are some indications for urgent dialysis?
AEIOU
A: intractable acidosis E: electrolyte imbalances I: intoxicants O: overload state U: uremia (encephalopathy, pericarditis, nausea, seizure)
In all patients with symptoms of stroke, what imaging should be obtained asap? Once this imaging rules out this condition, what medical therapy should be initiated?
head CT w/o contrast to rule out hemorrhagic stroke
if not hemorrhagic, use fibrinolytics (IV alteplase) within 3-4.5 hours of symptom onset.
If pts cannot have fibrinolytics, use aspirin. But for those who do receive fibrinolytics, aspirin should be held for 24 hours.
How does hypovolemia cause hyponatremia?
hypovolemia will cause release of ADH from pituitary. The elevated ADH increases renal water reabsorption to cause hyponatremia
Carbamazepine is DOC for trigeminal neuralgia and can be used for atypical bipolar disorder. How come routine CBC should be done?
b/c with prolonged use, there’s risk of aplastic anemia
Torsades de pointes refers to polymorphic ventricular tachy that occurs in setting of congenital or acquired prolonged QT interval. What’s the treatment of choice?
hemodyn unstable –> immediate defib
hemodyn stable –> IV magnesium
systemic scleroderma in someone with HTN and AKI –> sceroderma renal crisis which can occur in up to 20% of scleroderma pts. Describe the mech of renal crisis
- increased vascular permability
- activation of coagulation cascade
- increased renin secretion –> increased chance of malignant HTN
Peripheral blood smear can show microscopic hemolytic anemia or DIC with schistocytes and thrombocytopenia
Someone with vit b12 deficiency, what happens if you give folic acid without correcting vit b12?
It corrects the megaloblastic anemia, but can precipitate neurological decline (lose proprioception and vibration of LE)
Pt with recurrent nosebleeds and oral lesions, one should at least suspect which AD disorder?
hereditary telangiectasia aka osler-weber-rendu syndrome characterized by diffuse telangiectasias, recurrent epistaxis, widespread AV malformations.
AVMs can occur in liver, brain, lung, mucous membranes, skin, GI. Pulm AVMs can cause chronic hypoxemia and a reactive polycythemia, can even cause fatal hemoptysis
CT scan of head showing numerous minute punctuate hemorrhages with blurring of gray-white matter interface What’s the most likely diagnosis
diffuse axonal injury is the most significant cause of morbidity in pts with TBIs
A nail puncture in an adult resulting in osteomyelitis is most likely due to which organism?
pseudomonas aeruginosa
What’s the DOC for diabetic neuropathy?
TCAs
gabapentin if pt has orthostatic hypotension or urinary symptoms
Can also use NSAIDs
Senile purpura usu presents with ecchymoses in elderly pts in areas exposed to repeated minor trauma. It is due to?
age-related loss of elastic fibers in perivascular CT.
What is hidradenitis suppurativa aka acne inversa?
chronic inflammatory occlusion of skin follicles which most commonly occurs in the intertriginous skin areas (axilla, inguinal, genital, perianal, and perineum). Risk factors include family history, smoking, obesity, and mechanical stress on the skin
Systemic arterial pressure normally falls 10 mmHg during inspiration. If it falls more than 10 mmHG
g, it is called pulsus paradoxus aka significant variation of SBP related to respiratory cycle What most commonly causes this? What about other conditions that can cause this as well?
Most commonly due to cardiac tamponade.
Other conditions: asthma, COPD, pericarditis
Infectious esophagitis is common in patients with advanced HIV. The most common cause (>60%) is due to candida. But in pts whose predominant symptom is severe odynophagia without dysphagia, one should suspect?
viral esophagitis
need upper gi endoscopy with biospy to confirm
HSV -circular or ovoid vesicular ulcerated lesions
CMV -large, linear distal esophgeal ulcers
why would you see steatorrhea in someone with zollinger-ellison syndrome?
gastrinoma leading to increased acid production, which will inactivate pancreatic enzymes needed for digestion leading to malabsorption
A dialysis pt with low-grade fever, acute watery diarrhea, abdominal pain and guaiac-positive stool in setting of prolonged PPI use, you should suspect?
c. diff b/c risk factors include advanced age, recent abx use, hospitalization and comorbid illnesses like ESRD, dialysis. Also, prolonged use of PPI and H2 blockers can increase risk of c. diff. Order stool assay for toxins A and B
Achalasia typically presents w/ dysphagia for solids and liquids, heartburn, regurg of food, and weight loss. What’s the initial and confirmatory studies? What must be done to exclude malignancy first since esophageal malig at GE junction can mimic achalasia? Treatment for achalasia?
initial: barium swallow will show “bird-beak” narrowing
confirmatory: manometry detecting increased LES tone
must do endoscopy to rule out cancer
treatment: pneumatic dilatation or surgical myomectomy as definitive treatment; can also try botulinum toxin, CCB or nitrates
Nontender firm hyperpigmented nodules
dermatofibroma
What test should be obtained in all pts with syncope due to suspected heart disease (aortic stenosis, hocm, cardiac tamponade)?
TTE
What are some clinical features of aortic stenosis?
systolic murmur
- exertional symptoms: chest pain, dyspnea, dizziness, syncope
- delayed and diminished carotid pulse (pulsus parvus et tardus)
- single and soft S2, audible S4
- Harsch ejection crescendo-decrescendo systolic murmur in second right intercostal space with radiation to carotids
Combination of recent onset confusion, fever, muscle rigidity (“lead pipe rigidity”) and diaphoresis are consistent with which condition if the pt was recently on neuroleptic agents like haloperidol? Treatment?
neuroleptic malignant syndrome can occur w/in 2 weeks of starting drug. The rigidity and hyperthermia can cause muscle necrosis leading to elevated CK. Can also see fever and leukocytosis
can treat with dantrolene, a muscle relaxant
What are 3 lab indications that suggest poor prognostic factors in systolic heart failure?
- hyponatremia parallels severity of heart failure and is independent predictor of adverse clinical outcomes due to increase renin, NE, and ADH
- elevated pro-BNP levels
- renal insufficiency
Type A vs Type B aortic dissection
Type A: involves ascending aorta and are treated with medical therapy and surgery
Type B: involves descending aorta and are treated with medical therapy
both types A and B if pt has HTN, treat acutely with IV labetalol
Ulnar nerve entrapment presents as decreased sensations over the 4th and 5th fingers and weak grip due to involvement of interosseous muscles of the hand. Where’s the most common site of ulnar nerve entrapment?
at the elbow where the ulnar nerve lies at the medial epicondylar groove
most common scenario is prolonged, inadvertant compression of the nerve by leaning on the elbows while working at a desk or table.
Rotator cuff tendonitis is caused by impingement 2/2 to repetitve arm movements above the head. It presents with pain when lifting the arm. How can lidocaine injection help differentiate this from frozen shoulder and rotator cuff tear?
lidocaine will improve the tendonitis but does nothing to improve tear and frozen shoulder
We use SAAG to evaluate ascites. SAAG >/- 1.1 g/dL indicates? SAAG - 1.1 g/dL indicates?
SAAG (serum albumin - ascitic albumin gradient)
if >/- 1.1 g/dL: portal hypertensive etiologies (cardiac ascites, cirrhosis)
if - 1.1 g/dL suggests non-portal hypertensive etiologies (malignancy, pancreatitis, nephrotic syndrome, TB)
Idiopathic thrombocytopenia when there’s isolated thrombocytopenia without anemia or leukopenia. All pts should be tested for?
HIV and hep C virus b/c a percentage of these pts end up having chronic HIV infection
Mallory hyaline on liver biopsy may suggest alcohol injury, but it can also suggest what other disease in conjunction iwth neuropsych symptoms?
Wilson’s disease
In PE, indicate whether these values will be lower, normal, or higher than normal range
- right atrial pressure
- pulmonary artery pressure
- pulmonary wedge pressure
- right atrial pressure is elevated
- pulmonary artery pressure is elevated
- pulmonary wedge pressure is normal
What are contrainidcations in starting antiviral therapy for hep C?
- ongoing alcohol or drug abuse
- major uncontrolled depression
Pts with toxic adenoma presents as symptoms suggestive of thyroid toxicosis. What will radioactive iodine show?
uptake in nodule, and suppression of uptake in the rest of the thyroid gland. These pts will not have infiltrative opthalmopathy
Which nerve is commonly damaged in midshaft humerus fracture?
radial nerve - wrist drop
When you suspect esophageal cancer, what imaging should you do?
barium swallow followed by endoscopy
Primary adrenal insufficiency (hypotension, hyperpigmentation, hyponatremia, hyperkalemia, high ACTH, low cortisol) in developed countries is most commonly due to?
autoimmune adrenalitis
Hypopituitarism is characterized by glucocorticoid deficiency, hypogonadism, hypothyroidism. What are some of the clinical symptoms?
cold intolerance, hypoglycemia, anorexia, hyponatremia, low libido, infertility
What is anterior cord syndrome commonly associated with?
anterior cord syndrome is assoc with burst fracture of the vertebra & is characterized by total loss of motor function below the level of lesion with loss of pain and temp on both sides below the lesion and with intact proprioception
What is central cord syndrome?
burning pain and paralysis in upper extrem with relative sparing of lower extrem commonly seen in elderly 2/2 to forced hyperextension type of injury to neck
How come patients with temporal arteritis be followed up with serial chest x-rays?
aortic aneurysms are well known complications of temporal arteritis.
What’s the strongest influence on long-term prognosis following an ST elevation MI?
duration of time that passes before coronary flow is restored via PTCA or fibrinolysis therefore impt to restore coronary flow
What is Shy-Drager sydrome aka multiple system atrophy?
degenerative disease characterized by:
- parkinsonism
- autonomic dysfunction (postural hypotension, abnormal sweating, disturbance of bowel or bladder control, abnormal salivation or lacrimation, impotence, gastroparesis)
- widespread neurological signs (cerebellar, pyramidal or LMN signs)
Treatment aimed at volume expansion with fludrocortisone, salt supplementation, alpha agonists, constrictive garments to lower body
What is Riley-Day syndrome?
familial dysautonomia AR disorder in children of ashkenazi jewish ancestry characterized by gross dysfunction of the autonomic nervous system with severe orthostatic hypotension.
Where’s the most common anatomic site of ectopic foci that causes atrial fibrillation?
The pulmonary veins
What’s the most common cause of atrial flutter (sawtooth flutter waves on EKG)?
a reentrant circuit around the tricuspid annulus with slowing of the impulse thru a region known as the cavotricuspid isthmus.
What’s the most common type of diabetic neuropathy?
symmetric distal sensorimotor polyneuropathy characterized by classic “stocking glove” pattern of sensory loss.
What’s the first-line therapy for treatment of meniere’s disease?
environmental and dietary modifications, including maintenance of a low-salt diet.
What’s the murmur typically assoc with tetralogy of fallot?
harsh crescendo-decrescendo systolic murmur over left upper sternal border
Milk- or soy-protein-induced colitis is a condition exclusive to infants. What is it? clinical symptoms?
a non-IgE mediated immunologic response to dairy and/or soy proteins in formula or breast milk causing rectal and colonic inflammation
symptoms: severe reflux or vomiting, and/or painless bloody stools, possible eczema
bleeding stops within 2 weeks of eliminating dietary diary and soy; condition spontaenously resolves by age 1
Acquired torticollis aka wryneck is most commonly due to upper resp infections, minor trauma, and cervical lymphadenitis. Relatively common in children. What imaging should be obtained?
cervical spine radiographs to ensure there is no cervical spine fracture or dislocation.
Methotrexate is the initial DMARD of choice in pts with RA. What are some common side effects? Folic acid supplementation has shown to reduce incidence of adverse effects.
- GI symptoms
- oral ulcers
- stomatits
- rash
- alopecia
- hepatotoxicity
- pulmonary toxicity
- bone marrow suppression
- macrocytic anemia
What are the 3 pathophys assoc with ARDS
- impaired gas exchange
- decreased lung compliance
- pulmonary HTN
What is used to assess severity of ARDS?
severity of hypoxemia as defined by PaO2/FiO2 ratio (PF) - 300 mmHg
mild ARDS: 200-300 mmHg
mod ARDS: 100-200 mmHg
severe ARDS: - 100 mmHg
What is the first step in managing severe hypercalcemia (> 12mg/dL).
hydration with iv normal saline
longterm management includes bisphosphonates and if due to primary hyperparathyroidism, treatment of choice is parathyroidectomy
Pts who present with acute onset of back pain, syncope and profound hypotension should be evaluated for a presumptive dx of?
ruptured abdominal aortic aneurysm and emergently taken to operating room
Syringomyelia is a fluid-filled cavity in the spinal cord that may represent dilation of the central canal or a separate cavity within the spinal parenchyma. It is most commonly assoc with?
arnold chiari malformation type 1 but can also be due to inflammation, infection, tumor or trauma involving the spine
-loss of pain/temp in cape distribution
Some etiologies of constrictive pericarditis includes idiopathic, viral, TB, or 2/2 to cardiac therapy or radiation therapy. Symptoms include fatigue, exertional dyspnea, increased JVP, pericardial knock, pulsus paradoxus, kussmaul’s sign. What are some diagnostic findings on EKG, imaging, and jugular venous pulse?
EKG: nonspecific or show atrial fib or low voltage QRS complex
Imaging: pericardial thickening & calcification
Jugular venous pulse tracing: prominent x and y descents
what’s the classic triad assoc with disseminated gonoccoal infection?
polyarthralgia
tenosynovitis (pain elicited along tendon sheaths)
painless vesiculopustular skin lesions
also assoc with high fevers
Which nephritic/nephrotic syndrome is most usually seen in someone with Hodgkin lymphoma?
minimal change disease (nephrotic)
Drug-induced liver disease can be catergorized by morpholoy into 5 different groups. List groups and some causative drugs
1) cholestasis: chlorpromazine, nitrofurantoin, erythromycin, anabolic steroids
2) fatty liver: tetracycline, valproate, anti-retrovirals
3) heptatits: halothane, phenytoin, isoniazid, alpha methyl dopa
4) toxic or fulminant liver failure: carbon tetrachloride and acetaminophen
5) granulomatous: allopurinol and phenylbutazone
Hyposthenuria is found in patients with sickle cell disease and in trait, which is an inability to concentrate urine. What is thought to cause hyposthenuria?
RBC sicling in vasa rectae of te inner medulla impairing countercurrent exchange and free water reabsorption.
acute interstitial nephritis is usu assoc with exposure to medications. What’s the general timeframe can this happen?
usu 7-10d days after drug exposure
What is sympathetic opthalmia?
damage of one eye (the sympathetic eye) after a penetrating injury to the other eye. It is due to an immunologic mech involving the recog of hidden antigens
What is subconjunctival hemorrhage?
red eye, completely benign
may be due to simple trauma from rubbing the eyes vigorously, violent coughing spells, hypertesnive episodes or coagulopathy
usu disppears in 24-48 hours
simple observation is best treatment
Babesiosis is caused by a paraiste babesia that is trasmitted by the ixodes tick endemic in NE. What are some clinical features
parasite enters RBCs and causes hemolysis
can be asymp to hemolytic anemia assoc with jaudnice, hemoglobinuria, renal failure, death
RASH is not common
definitive dx: giemsa-stained thick and thin blood smear
treatment: quinine-clindamycin and atovaquone-azithro
Ehrlichiosis causes spotless rocky mountain spotted fever is another tick-borne illness. How to differentiate from babesiosis?
ehrlichiosis can cause fever, malaise, headache, nausea, vomiting, leukoepenia, thrombocytopenia
babesiosis causes hemolytic anemias bc parasite enters RBCs. there’s no hemolysis assoc in ehrlichiosis
Q fever is a zoonosis caused by coxiella burnetti mainly in infected cattle, goat and sheep. Pt at risk include meat processing workers and vets. What are some symp
flu-like syndrome
hepatitis
pneumonia
Fibromyalgia most commonly presents in young to middle-aged women w/ widespread pain, fatigue, and cog/mood disturbances with point muscle tenderness in areas like mid trapezius, lateral epicondyle, costochondrol junction in chest. How to manage?
- regular aerobic exercise
- good sleep hygiene
- pt education
medications (TCAs, SNRIs) reserved for pts who fail initial measures
What’s the triad of DKA? What characterizes hyperosmolar hyperglycemic state?
DKA: hyperglycemia, ketonemia, anion gap acidosis
HHS: severe hyperglycemia, increased serum osmolality (>320 mosm/kg)
Both DKA and HHS have decreased total K+ although serum K+ appears normal b/c K+ is being mobilized out of cell into serum
How to diagnose and confirm fibromuscular dysplasia, a noninflam and nonatherosclerotic condition that most commonly affects women btw 15-50?
CT angiography of abdomen or duplex US
What ratio increases with severity of hypovolemia and is a sensitive but not specific indicator of hypovolemia?
BUN/cre ratio
chorea and athetosis often occur together. Both are common in someone with huntingtons. what is athetosis?
slow, writhing movements that typically affect the hands and feet
Hemiballismus is u/l, violent arm flinging caused by damage to the?
contralateral subthalamic nucleus
What’s the treatment of choice for agitation in the elderly?
low dose haloperidol
Acute pancreatitis complicated by hypotension is thought to arise from?
intravascular volume loss 2/2 to local and systemic vascular endothelial injury, causing vasodilation, increased vascular permeability, plasma leak into retroperitoneum
Someone with uremic pericarditis (renal failure + friction rub + chest pain) will have BUN > 60. What will resolve chest pain and assoc pericardial effusion?
hemodiaylsis
What are some lab values you look at to assess if parapneumonic effusions are indications for tube thoracostomy?
pH of pleural fluid
What are some indicators of severe asthma attack?
- normal to increased PCO2 values
- speech difficulty
- diaphoresis
- altered sensorium
- cyanosis
- silent lungs
If marked elevations >25x upper limit of AST and ALT, suspect…
toxin-induced
ischemic
viral hepatitis
Symptoms of spontaenous pain, odynophagia for cold and hot food are suggestive of diffuse esophageal spasm. Chest pain can resolve after nitroglycerin as well. What are other meds that can help? What establishes diagnosis?
nitrates or CCBs help
manometry should show repetitive, non-peristaltic, high-amp contractions either spontaneously or after ergonovine stimulation
Mallory weiz tears cause bleeding from?
ruptured submucosal arteries of the distal esophagus and proximal stomach
Pts with cirrhosis should undergo screening endoscopy for?
esophageal varices
DIP joints involved, dactylitis “sausage fingers” indicate which arthritis?
psoriatic arthritis
Assoc with giant cell arteritis + stiffness and pain of the shoulders and pelvic girdle?
polymyalgia rheumatica
Which organism is assoc with causing post-viral URI necrotizing pulmonary bronchopneumonia with multiple nodular infiltrates that can cavitate to cause small abscesses?
staph aureus
What is the preferred initial screening for primary hyperaldosteronism (HTN + hypokalemia + metabolic alkalosis)?
ratio of plasma aldosterone to plasma renin (> 20)
*adrenal suppression test after oral saline load can confirm dx
What’s the most sensitive test for differentiating adrenal adenoma and bilateral adrenal hyperplasia in pts without discrete u/l adrenal mass on imaging?
adrenal venous sampling
If u/l adrenal adenoma –> surgery preferred but if surgery is unlikely, then aldosterone antagonists like spironolactone or eplenerone
If b/l adrenal hyperplasia –> aldosterone antagonists
What are the current recommendations in all pts with probable BPH based on history and rectal exam?
UA to assess for urinary infection and hematuria (for stones and bladder cancer and infection)
What is the most common cause of non-traumatic subarachnoid hemorrhage? What will imaging show?
more than 2/3rds of the cases due to ruptured saccular/berry aneurysms.
CT w/o contrast is initial imaging to rule out SAH, which will show acute bleeding in cisterns along major proximal cerebral blood vessels from circle of willis.
If imaging is negatve but still suspect SAH, do LP to check for xanthochromia and elevated opening pressure
Addison’s disease causes what type of acid-base disturbance?
aldosterone deficiency
non-anion gap metabolic acidosis
In asymptomatic hypercalcemic pts discovered on routine labs, a single elevated Ca2+ must be confirmed by a second serum Ca2+. After confimration, what’s the next step?
To distinguish btw PTH-mediated vs non-PTH-mediated hypercalcemia so get PTH level
Rapidly developing hyperandrogenism with virilization is highly suggestive of an androgen-secreting neoplasm of ovary or adrenal. HOw to distinguish?
Get serum testosterone and DHEAS
- if elevated testosterone –> ovarian source
- if elevated DHEAS –> adrenal source
What to suspect if pt presents after surgery, with extensive atheroscloertic vascular disease, with abdominal pain followed by bloody diarrhea and have minimal abdominal exam findings?
ischemic colitis
most commonly affected area = splenic flexure
If someone with a PMH of infective endocarditis develops a new conduction abnormalities (i.e.AV block), one should suspect?
perivalvular abscess extending into the adj cardiac conduction pathway. This is seen in about 30-40% of pts with infective endocarditis at the time of surgery or autopsy
Aortic coarctation is assoc with bicuspid aortic valve, turner syndrome, VSD. Most commonly presents as asymptomatic hypertension. Other symp: chest pain, claudication, headache, epistaxis, heart failure, aortic dissection. What will you see on physical exam? What will you see on EKG, CXR? What’s the diagnositc confirmatory test? Treatment?
PE: brachial-femoral delay, UE hypertension, LE hypotension, continuous cardiac murmur
EKG: LVH
CXR: notching of 3rd-8th ribs from enlarged intercostic arteries; “3 sign” from aortic indetation
ECHO is confirmatory
Treatment: balloon angioplasty +/- stent
Trichinellosis is caused by the parasite trichinella prevalent worldwide but more common in MExico, China, Thailand, Argentina and parts of Europe 2/2 to ingestion of undercooked meat. It typically presents with GI complaints. What’s the characteristic triad? list some other findings
Triad: periorbital edema, myositis, eosinophilia
other findings: fever, subungal splinter hemorrhages, conjunctival or retinal hemorrhages
Malignant (necrotizing) otitis externa is a serious ear infection in elderly esp with uncontrolled diabetes, most commonly caused by pseudomona aeruginosa. What’s the characteristic presentation? Treat with?
ear pain
ear discharge/drainage
granulation tissue
if not treated, can lead to osteomyelitis of the skull base and destruction of facial nerve
Treat with IV cipro
Splenic abscess can be caused by infection with hematogenous spread (slamonella, staph, and strep are most common), trauma, hemoglobinapathies, immunosuppression, IV drug use. What’s the classic triad? What are other symptoms? Treatment? What’s most commonly associated with it?
Triad: fever, leukocytosis, left upper quadrant abdominal pain
other symptoms: left-sided pleuritic chest pain, left pleural effusion, splenomegaly
diagnosed by CT
treatment: abx but still high mortality, so splenectomy is best
infective endocarditis is most commonly associated with it
what is endocardial fibroelastosis
idiopathic diffuse fibroelastic thickening of LV endocardium, usu occurs in first 2 years of life and is a cause of restrictive cardiomyopathy
What 4 basic testing should be done in someone initially diagnosed with HTN?
1) UA for occult hematuria and urine protein/creatinine ratio
2) chemistry panel
3) lipid panel
4) baseline EKG
A reliable test should? What about an accurate test?
a reliable/precise test give similar results on repeat measurements.
an accurate/valid test gives a result similar to gold std test
Mucormycosis commonly assoc with uncontrolled diabetes presents with fever, dull facial pain, bloody nasal d/c, necrotic nasal turbinates or eye proptosis should best be treated with
surgical debridement and IV amphotericin
In assessing malignancy for solitary pulmonary nodule, separate the low, intermediate and high risk according to size, age, smoking status, nodule margin
low risk: 15 yr of cessation, smooth margins
intermediate: 0.8-2cm, age 40-60, current smoker or 5-15 years of cessation, scalloped margins
high risk: >/- 2 cm, > 60 y.o, current smoker or corona radiata or spiculated margins
If high risk –> surgical excision
If low or intermeidate risk, depending on size:
either serial CT, FDG-PET biopsy, or no follow up
Cocaine use can cause elevated CPK why?
assoc with rhabdo b/c cocaine causes vasoconstriction leading to ischemia of myocytes as well as acts a direct toxin to myocytes. excessive myoglobin is filtered leading to ATN
What’s the treatment of choice to abort an acute attack of cluster headaches? What about long-term ppx?
100% oxygen
long-term ppx: verapamil, prednisone, ergotamine, cyproheptadine, indomethacine, methysgeride
Sudden loss of vision + onset of floaters (floating debris and a dark red glow) + dark red glow?
vitreous hemorrhage
**typically occurs in pts with diabetic retinopathy
Cutaneous larva migrans aka creeping eruption is a helminth disease caused by ancylostoma braziliense (the dog and cat hookworm). Infection occurs after skin contact. What are some symptoms? Who is at risk?
- symptoms: pruritic, elevated, serpiginous lesions on skin more commonly LE but UE are affected as well
- infection is often acquired thru contact with SAND so people involved in sandy activities are at risk
Idiopathic pulmonary fibrosis is due to excessive deposition in peri-alveolar tissues. Explain some lab/imaging findings
CXR: reticular or nodular opacities
CT: fibrosis, honeycombing or traction bronchiectasis
PFT: normal or high FEV1/FVC, decreased DLCO, decreased TLC, decreased RV
ABG: normal or mild hypoxemia
V/Q mismatch (increased A-a gradient
Most impt risk factor in causing strokes
HTN
Corticosteroid induced avascular necrosis of the femoral head usu presents as progressive hip or groin pain without restriction of motion range. What’s the gold std for dx of avascular necrosis of hip?
MRI
Calcium oxalate crystals are rectangular, enveloped shaped seen in pts with what type of poisoning?
ethylene glycol
DOC for primary biliary cirrhosis (antimitochondrial abs, xantelesmas, pruitis, intrahep duct dilation, cholestasis)
ursodeoxycholic acid can relieve symptoms and lengthen transplant free survival time
What should you suspect in pts with unexplained CHF (predom diastolic dysfunction), low voltage on EKG, and ECHO shows increased ventricular wall thickness with normal left ventricular cavity dimensions esp in absence of HTN?
cardiac amyloidosis
watch out for symptoms like waxy thickening, easy bruising of skin, bleeding diathesis, visible organ enlargement (macroglossia), peripheral neuropathy and/or autonomic neuropathy, hepatomegy, asymp proteinuria or nephrotic syndrome
How can someone who is hyperthyroid in thyrotoxicosis get systolic hypertension?
T3 works directly on cardiac myocytes to increase contractility as well as indirectly by causing them to be more sensitive to catecholamines. Therefore, increased contractility and HR will cause a hyperdynaic circulation leading to higher SBP.
Characterize the skin condition ichthyosis
normal skin at birth with graduatl progression to dry scaly skin. The skin is usu dry and rough with horny plates over the extensor surfaces of the limbs, worsening in the winter time. “lizard skin”
Mech of loop diuretics and its effects
inhibit Na/K/2Cl carrier in loop of henle leading to increased loss of sodium in urine. The increased Na+ delivered to distal tubule stimulates aldosterone release causing Na+ reabsorption and K+/H+ secretion –> contraction alkalosis. and potential hypokalemia
What does hypoalbuminemia do to total calcium vs free calcium levels?
can lead to decreased total calcium b/c albumin binds Ca2+ so less albumin = less Ca2+ bound, however no change to free Ca2+ b/c that is hormally regulated & remains stable
What’s the initial DOC for pts with mild to mod pain from OA?
acetaminophen
Lidocaine a class Ib anti-arrhythmic is widely used to control ventricular arryhtmias in pts with ACS. But it is not used ppx in pts with ACS mainly b/c of which side effect?
increase in risk of asystole
If you suspect infective endocarditis, what to order first: imaging or blood cultures?
3 serial blood cultures prior to abx therapy should be collected first, then imaging with TTE/TEE
A urine osmolality
primary polydipsia
malnutrition
Hydration is cornerstone therapy for kidney stoles. What’s the relative size of the stone that can typically pass with hydration? Do you need detailed metabolic eval in assessing kidney stones in someone for the first time?
What are typical EKG manifestations of pericarditis?
EKG: diffuse ST elevations, esp with PR depressions
amiodarone vs beta blockers -which one is absolutely contraindicated and the other is relatively contraindicated in someone with pre-existing lung disease?
amiodarone can cause pulm fibrosis as well as organizing pneumonia, ARDS so this is absolutely contraindicated
EKG showing prolonged PR interval and prolonged QRS (indicating intraventricular conduction delay) is suggestive of in a pt with syncope.
bradyarrhytmia or AV block
name this murmur: holosystolic heard best at apex with radiation to axilla
MR
Which bacterial infection is the most frequent precipitant of guillain-barre syndrome characterized by ascending symmetric weakness with intact sensation
campylobacter jejuni
What to do if you suspect necrotizing surgical site infection?
signs of necrotizing surgical site infection: pain, edema or erythema spreading beyond surgical site, systemic signs (fever, tachy, hypotension), paresthesia or anesthesia at edges of wound, purulent cloudy-gray discharge, subcutaneous gas
early surgical exploration is essential + abx
What are 3 primary uses of n-acetylcysteine
1) dissolution of mucus
2) protection against contrast induced renal failure
3) therapy for acetaminophen overdose
LV free wall rupture is one complication that can occur after an anterior wall MI within the first 5 days to 2 weeks. usu due to early reperfusion therapy and medical managament.
What are some signs?
- sudden onset of left-sided chest pain
- can lead to hemopericardium and eventual cardiac tamponade (hypotension, muffled heart sounds and JVD) characterized by pulsesless electrical activity showing low voltage complexes.
*rapidly diagnose with ECHO, supportive care, pericardiocenteses and possible surgical repair to save life
Interventricular wall rupturecan also happen within a couple of days after an anterior MI. What can result from this rutpure?
ventricular septal defect –> loud holosystolic murmur at the apex
-hypotension,CHF predominantly right-sided
management of idiopathic pulmonary hypertension vs secondary pulmonary hypertension
idiopathic –> endothelin receptor antagonists (bosentan) PDE5I (sildenafil), and/or prostanoids (epoprostenol)
secondary –> ACEI/diuretics
What are 2 commonly used medications that can triger bronchoconstriction in pts with asthma?
aspirin (esp in pts with chronic rhinitis and nasal polyps)
beta blockers
How to fix hyperkalemia
1) calcium gluconate to stabilize membrane
2) insulin and dextrose to drive K+ in cells
3) albuterol (b2 agonists) to drive K+ in cells
4) Kayexlate aka sodium polystyrene
5) NaHCO3 to drive K+ in cells
How does someone taking oral estrogen preparations (raloxifene, tamoxifen) or have increased estrogen with hypothyroidism be managed?
- estrogen –> increases TBG concentration
- therefore may need higher levothyroxine to saturate the increased # of TBG sites
steroids can precipitate acne. Describe steroid-induced acne.
monomorphous pink papules and absence of comedones
DOC for reactive arthritis (conjunctivitis, urethritis, arthritis)
NSAIDS
What’s the most common cause of papillary necrosis
analgesic overuse
Paroxysmal supraventricular tachycardia is the most common paroxysmal tachy in ppl without structural heart disease. Attacks begin abruptly andare characterized by HRs btw 160-220 bpm. What’s the most common mech underlying PSVT? What are therapies?
- AV node re-entry
- therapies: vagal maneuvers (valsalva, carotid sinus massage, immersion in cold water to increase vagal tone and decrease conduction thru AV node); adenosine (short acting AV nodal blocker)
Most effective way to differentiate btw asthma and COPD
spirometry before and after administration of bronchodilator (albuterol)
Long term analgesic use can cause what types of problems in the kidneys
CKD due to tubulointerstitial nephritis and hematuria due to papillary necrosis
What’s the gold std for diagnosis of suspected pneumonia
CXR showing infiltrates
TBI of any severitiy can lead to (a few hrs or days later) post-concussive syndrome. Symptoms?
headache confusion amnesia difficulty concentrating or with multitasking vertigo mood alteration sleep disturbance anxiety
How to treat cardiac toxicity assoc with TCA overdosse (sinus tachy, hypotension, prolonged PR/QRS/QT, arrhyhtmias)?
sodium bicarb by alleivating the inhibitory effects of TCA on Na+ channels on cardiac myocytes
QRS duration estimates severity of TCA OD
About 10% of patients with pulmonary embolism develops pulmonary infarction when there’s occlusion of peripheral pulmonary artery by thrombus. These small thrombi cause what clinical pciture
pleuritic chest pain and hemoptysis due to inflammation and irritation of the lung parencyhma and adj vsiceral and parietal pleura
Severe vomiting can cause hypokalemic, hypochloremic metabolic alkalosis. What’s the most approp treatment for alkalosis
IV normal saline and potassium
rupture of berry aneurysm –>
hypertensive hemorrhage –>
middle meningeal artery injury –>
bridging veins injury –>
rupture of berry aneurysm –> subarachnoid hemorrhage
hypertensive hemorrhage –> intracerebral hemorrhage most likely affecting putamen and thalamus
middle meningeal artery injury –> epdiural hematoma (biconvex hematoma on CT)
bridging veins injury –> subdural hematoma (semi-lenticular/crescentWhat is considered hematoma
progressive multifocal leukoencephalopathy
- opportunistic infection in immunocompromised
- JC virus
- focal neurological defects
- multiple non-enhancing lesions with no mass effect on CT
- no treatment; mean survival 6 months
Cerebral toxoplasmosis is most common ring-enhancing mass lesions in HIV-infected pts. Primary CNS lymphoma is 2nd most common cause of ring-enhancing mass lesion that is usually solitary, weakly enhancing and periventricular. The presence of what in CSF is quite diagnostic of primary CNS lymphoma
EBV
CCK is released in the presence of proteins and fatty acids in the duodenum, which will cause gallbladder contraction. What happens if pts are fasting or on TPN?
no normal stimulus for CCK –> no gallbladder contraction –> gallbladder stasis –> increased risk of gallstone formation and bile sludge
What’s the classic triad of spinal epidural abscess? management?
fever, severe focal back pain & neurologic deficits
management: CBC, ESR
D-xylose is a monosaccharide absorbed by passive diffusion and active Na+ transporter in proximal small intestine followed by urine excretion.
Normal or anormal in celiac vs pancreatic insufficiency vs lactose intolerance vs chronhns
- celiac: abnormal with decreased urinary exretion b/c can’t absorb the xylose instead xylose is excreted in feces
- pancreatic insuff: normal bc pancreatic enzymes are not needed to absorb xylose
- lactose intolerance: normal b/c xylose has no effect
- chronhns: IBD with transmural inflam affecting terminal ileum not needed in xylose reabsrption so normal
RCC triad: flank pain, hematuria, palpable abdominal renal mass
often assoc with left-sided scrotal varococles. What are some paraneoplastic symptoms/? What’s the most sensitive and specific test for diagnosing RCC?
- anemia or erythrocytosis
- thrombocytosis
- fever
- hypercalcemia
- cachexia
CT scan of abdomen is most sensitive and specific test for diagnosing RCC
How to differenitate btw a simple cst and a malignant cyst based on xrays?
simple cysts are thin smooth, unilocular, homogenous content, usu asymptomatic that requires no follow up
maligannt cysts have thich irregular wall, multilocular with heterogeneous content
Blood glucose of 1000 –> pt is in non-ketotic hyperglycemic coma, what is the most approp initial infusion you should give the patient?
Normal saline then 0.45% saline
once, glucose level is around 250 mg/dl by insulin therapy, add 5% dextrose
Hypovolemic shock (hemorrhage) presents as loss of intravascular volume… What happens to right atrial pressure (preload), pulmonary cap wedge pressre (LA pressure/preload), cardiac index (pump function), systemic vascular resistance (afterload), mixed venous O2 saturation.
loss of intravascular volume –> decrease left ventricular preload –> decreased CO –> decreased SBP
this will cause reflex SNS stimulation –> increased HR, and peripheral vasoconstriction (SVIR) to maintain CO and perfusion to vital organs.
- decreased right atrial press
- decreased pulmon wedge pressure
- decreased cardiac index
- increased SVR/afterload
- decreased mixed venous O2 sat
Cardiogenic shock (heart failure) presents as cardiac pump failure. Severe heart failure leads to decreased CO and blood pressure. What happens to right atrial pressure (preload), pulmonary cap wedge pressre (LA pressure/preload), cardiac index (pump function), systemic vascular resistance (afterload), mixed venous O2 saturation.
decreased CO –> reflex HR, and SVR
increased PCWP and right atrial pressure b/c less is being pumped out
- increased right atrial press
- increased pulmonary wedge pressure
- decreased cardiac index
- increased systemic vascular resistance
- decreased mixed venous O2 saturation
Septic/vasodilatory/distributive shock can be seen in sepsis, anaphylaxis, SIRS, or CNS injury. There’s a hyperdynamic state that when it progresses to hypodynamic, it signifies a grave deterioation. What happens to right atrial pressure (preload), pulmonary cap wedge pressre (LA pressure/preload), cardiac index (pump function), systemic vascular resistance (afterload), mixed venous O2 saturation.
-Significant decrease in SVR, reduced BP and a compensatory rise in HR and CO.
in hypodynamic state, may be vasoconstriction w/ a rise in SVR and a significant decline in CO
- normal to slight decrease in right atrial press
- normal to slight decrease in pulm cap wedge
- decrease in cardiac index
- decrease in SVR
- increase in mixed venous O2 sat
What is normal pH of pleural fluid? Transudative fluid pH?
normal - 7.6
transdutive - 7.4-7.55
What can be used to confirm the diagnosis of myasthenia gravis (autoantibodies against achR in NMJ)? What imaging should be done after confirmation of disease?
- electromyogram and achr ab test can be used to confirm the diagnosis
- after establishing diagnosis, screen for thymoma using CT, esp if pt is younger than 60
What’st the treatment for micro r macro prolactinomas (serum prolactin often > 200 ng/mL)
The primary treatment regardless of size is with dopaminergic agents like bromocriptine and cabergoline. It can normalize prolactin levels as well as lead to tumor size decrease.
Cabergoline is a newer drug with less side effects than bromocriptine. Surgery only if medical therapy is not tolerated
. What accounts for the polycythemia seen in OSA?
hypoxemia induced stimulation of EPO
Cyclosporine is a commonly used immunosuppressant that inhibits the transcription of Il-2. List the 8 most common side effects
1) nephrotoxicity (hyperkalemia)
2) HTN (if cyclosporine induced -CCB is good choice)
3) neurotoxicity (headache, visual disturb, seizure)
4) hyperglycemia
5) infection
6) malignancy (increased risk of sq cell carcinoma of the skin and lymphoproliferative diseases)
7) gingival hypertrophy and hirsutism
8) GI manifestations
Azathioprine is a purine analog that is enzym converted to 6-mercaptopurine that acts primarily by inhibiting purine syntheisis. Major 3 toxicities assoc are
1) dose-related diarrhea
2) leukopenia
3) hepatotoxcity
Mycophenolate is a reversible inhibitor of inosine monophosphate dehydrogenase which is the rate limiting enzyme in de novo purine syn. What’s the major side effect
bone marrow depression
Tacrolimus is a calcineurin inhibitor like cyclosporine and has many of the same side effects like nephrotoxicity, hyperglyceia, diarrhea and neurotoxicity. What side effects doesn’t tacrolimus have that cyclosporine does
hirsutism
gingival hyperpaslia
Liver cirrhosis can lead to higher estrogen levels bc liver cannot metabolize the estrogens. What are the manifestations of this higher estrogen state?
gynecomastia palmar erythema spider angiomas testicular atrophy decreased body hair in males
Tropical sprue should be suspected in pts with chronic diarrhea living in endemic areas formore than one month. It’s characterized by malabsorption of nutrients, esp of? How to confirm
- malabsorption of Vit B12 and folic acid –> megaloblastic anemia
- confirm with small intestinal mucosal biospy will show blunting of villi and infiltration of chronic inflam cells like lymphocytes, plasma cells and eosinophils
Purulent arthritis in sexually active individual is what until proven otherwise
gonococcal arthritis
What is the abx of choice for ppx/treatment of infections caused by a human bite? This is also the abx of choice for dog bites
amoxicilinn-clavulanate
A lung consolidation like a lobar pneumoniais considered increased dead space ventilation or increased physiologic shunting?
increased physiologic shunting b/c consolidated regions act as a physiologic shunt
Explain all types of selection biases:
1) ascertainment/sampling bias
2) nonresponsive bias
3) berkson bias
4) prevalence (neyman) bias
5) attrition bias
1) ascertainment/sampling bias: study pop differs from target pop
2) nonresponsive bias: high nonresponse rates
3) berkson bias: using only hospital based pts not applicable to target pop
4) prevalence (neyman) bias: exposures that happen long before disease assessment can cause study to mis miss diseased pts that die early or recover
5) attrition bias: significant loss of study participatns
After MI, the only 2 complications that can occur about 2-3 months later are pericarditis and left ventricular aneurysm. Explain the pathogenesis of LV aneurysm. What can LV anerysm lead to? How to confirm diagnosis?
LV anerysms can occur 5days to 3 months after MI when the affected MI area can heal and remodel to form a true ventricular aneurysm componsed of thin, scarred or fibrotic myocardium.
EKG: persistent ST elevations and deep Q waves in samle leags
Large VAs –> LV enlargemnt –> heart failure, refractory angina, ventricular arryhtmias, mural thrombus, mitral annular dilataion with mitral regurg (new murmur)
Dx is usu confirmed by ECHO showing dyskinetic wall motion of a portion of the LV.
Pts with CHF have decreased CO. How will the kidneys respond?
decreased CO leads to neurohumoral adaptations: 1) increased sympathetic nervous system tone and 2) activation of renin-angiotensin-aldosterone system and 3) increased ADH to maintain CO and systemic pressure
The kidneys are responsible for the RAAS system:
leading to elevations of angiotensin levels:
1) vasoconstrict both afferent and efferent glomerular arerioles –> increase in renal vascular resistance and a net decrease i RBF
2) preferential vasoconstriction of efferent renal arterioles, increasing intraglomerular pressure to maintain GFR
3) Direct stim of sodium resportion in PCT and increased aldosterone from adrenal glands –> furter Na+ resoprtion in cortical collecting tubule –> increase in extracellular fluid volume
Benzo overdose is characterized by? How is it different from opioid overdose? How is it different from alcohol OD?
slurred speech, unsteady gait, drowsiness
- opioid OD: will also have decreased RR, and pinpoint pupils that benzo OD does not have
- alcohol OD: will have nystagmus that benzo OD doesn’t have
lithium toxicity?
tremor
hyperreflexa
ataxia
seizures
What role does antiemetics have in treating acute migraine attacks?
IV antiemetics (chlorpromazine, prochlorperazine, metoclopramide) can be used as monotherapy or as adjuvant therapy in combo with NSAIDs or triptans for treatment for acute migraines
Electrical alternans seen on EKG is when the amplitudes of QRS complexes vary from beat to beat. It is fairly sepcific for?
pericardial effusion (often 2/2 to viral pericarditis) can lead to electrical alternans b/c the heart’s swinging back and forth within an increased quantitiy of pericardial fluid.
someone with pericardial effusion + jugular venous distenstion + muffled heart sounds + borderline hypotension –> cardiac tamponade
ECHO can confirm pericardial effusion
NF type 2 is an AD d/o caused by mutation in tumor suppressor gene located on chromo 22. List some clinical features
subcutaneous neurofibromas
hyperpigmented cafe-au-lait spots
deafness due to acoustic neuromas (typ b/l) **MRI with gadolinium is the best method to diagnose acoustic neuromas
Radiolucent uric acid stones (not seen on xrays, but on CT and US) are most commonly seen in pts with unusally low urine pH. How to treat?
hydration, and alkalinization of urine to pH 6–6.5 using oral potassium citrate.
potassium not only alkalinizes the urine but citrate is also a stone inhibitor and reduces crystallizations
Myeloproliferative disorders like polycythemia vera is often assoc with gout. Explain why and symptoms of polycythemia vera
polycythemia vera causes splenomegaly and pruitis with hot baths due t histamine release from an increased # of circulating basophils. Up to 40% will suffer from goutb/c of uric acid overproduction 2/2 to increased catabolism and turnover of purines
Conductive vs sensorineural hearing loss
Conductive (obstruction of external sound to inner ear)
Rinne test: BC > AC in affected ear while normal air is AC > BC
Weber test: lateralizes to affected ear
Sensorineural (involving inner ear, cochlea, or auditory nerve
Rinne test: AC > BC in both ears
Weber test: lateralizes to unaffected ear, away from affected ear
Causes of of conductive hearing loss
Rinne test: affected ear BC > AC
Weber test: laterlizes to affected ear
- cerumen impaction
- middle ear fluid or infection
- decreased movement of the bones in ears
- bony tumors of middle ear
- otosclerosis: common cause in 20s, 30s due to abnormal remodeling of otic capsule (bony overygrowth of stapes) thought to be autoimmune related
Causes of sensorineural hearing loss
Rinne test: AC > BC both ears b/c conduction is normal
Weber: lateralizes to unaffected ear, away from affected
- acoustic neuroma
- ototoxic abx such as aminoglycosides
- meniere’s disease
- presbycusis
How to describe xanthomas?
crops of yellow-red papules -a sign of eruptive xanthomas
xanthomas generally occur 2/2 to abnormal depositions of fat in subcut tissues or tendons –> order fasting lipid profile
Autoimmune hemolytic anemia is a hematologic complication of EBV infection. Explaing
cross reactivity of EBV-induced antibodies against red blood cells and platelets leading to hemolytic anemia and thrombocytopenia
-EBV-induced antibodies are IgM cold-agglutinin abs aka anti-i antibodies will be Coombs test positive.
Pt’s h/o of CAD with sudden dyspnea after IV fluids makes V/Q mismatch due to what likely?
What can usu correct hypoxemia, V/Q mismatch, and A-a gradient
pulmonary edema (low lung compliance, high A-a gradient) and hypoxemia can be fixed with oxygen
What’s the most reliable physical exam sign of vertebral osteomyelitis. What’s the most sensitive imaging diagnostic study? Treatment?
Tenderness to gentle percussion over the spinous process of involved vertebra is themost reliable sign for spinal osteomyelitis. Pain is not relieved with rest. MRI is the most sensitive diagnostic study. Treat with abx and CT-guided bone biospy
Suspect in pts who are injection drug users, sickle cell anemia, and immunocompromised or recent infections
CURB-65 in assessing whether to admit pts with pneumonia
Confusion
Uremia (BUN 20 mg/dl)
Tachynea (RR > 30/min)
Blood pressure 65
1 pt each for total of 5 pts
2+ pts will benefit from inpatient treatment
>/- 4 pts require ICU
Abx treatment for community acquired pneumonia whether outpatinet vs inpatient non-ICU vs inpatient ICU
outpatient: healthy pts -macrolide or doxy
w/ comorbid conditions (diabetes, malignancy) -fluoroquinolone or beta lactam + macrolide
inpatient non iCU: Fluoroquinolone or beta lactam + macrolide
inpatient ICU: betalactam + macrolide IV or beta-lactam + fluoroquinolone
Peripheral edema is a common side effect of amlodipine b/c it’s a arteriolar dilator. An addition of which other BP med can decrease CCB-assoc peripheral edema?
ACEI
Cushing reflex (HTN, bradycardia, respiratroy depression) is a worrisome finding suggestive of?
brainstem compression
What are some symptoms of intracranian HTN.
headache (worse at night) N/V mental status changes papilledema focal neurologic deficits
symptoms can worsen with maneuvers that furter increase intracranial pressure like leaning forward, valsalva, cough)
Pemphigus vulgaris is a blistering disease characterized by flaccid bullae that appear spontaneously and are tender and painful when they rupture. They first appear in oral mucous membrane. What will immunofluorsence microscopy reveal? Autoabs are formed against?
immuno microscopy: IgG deposits intercellularly in the epdiermis
autoabs against desmoglein, an adhesion molecule
treatment with steroids and immunosuppressive agents
Trosseau syndrome is a hypercoagulability disorder presenting with recurrent and migratory superficial thrombophlebitis at unusal sites (arm, chest). Describe these lesions. What should one worry about
- tender, erythematous, palpable cord-like veins on arm and chest
- order CT scan of abdomen b/c usu assoc with pancreatic cancer (other cancers as well)
Metoclopramide is a prokinetic agent used to treat N/V, gastroparesis. Pts on this med should be monitored for?
drug-induced EPS symptoms like dystonia,tardive dyskinesia
How come nephrotic syndrome can lead to accelerated atherosclerosis?
b/c decreased synthesis of proteins will cause compensatory increase snythesis of cholesterol and lipids –> hyperlipidemia
so hyperlipidemia + hypercoagulable state (due to decreased ATIII and protein C and S) –> increased risk of MI, stroke
Hereditary spherocytosis is an AD d/o assoc with northern european descent in which the RBC membrane is defective (ankyrin gene) causing RBCS that are more prone to splenic sequestration –> hemolytic anemia. Clinical presentation, lab findings, tratment and complications
Clinical presentations: hemolytic anemia, jaundice, splenomegaly
Lab: increased MCHC, spherocytes, negative coombs, increased osmotic fragility, abnormal eosin-5-maleimide binding test
treatment: folic acid supplements, blood tx, splenectomy
complciations: pigment gallstones, aplastic crises from parvo
What should one order after central line placement (Central venous cath thru IJ)
CXR to confirm proper placement of catheter tip (ideally in SVC) and absence of complications before administering drugs or other agents thru catheter
Goodpasture’s syndrome is caused by circulating anti-glomerular BM abs. What’s imperative treatment? What’s diagnostic?
Emergency plasmaphereisis is required to minimize the extent of kidney damage
Diagnostic: renal biospy demonstrating LINEAR IgG deposition along GBM on immunofluorsence
B lymphoctes with fine, irregular cytoplasmic projections, strong tartrate-resistant acid phosphatase (TRAP) stain, and CD11c marker —>?
hairy cell leukemia
Someone on TB drug regimen presenting with red urine, saliva, sweat and tears –> which drug? Also this can cause discoloration of soft contact lenses.
rifampin
You suspect gastrinoma, what are the next steps?
1) endoscopy (will show stomach ulcers, thickend gastric folds)
2) check serum gastrin level off PPI therapy for one week
If low gastrim –> no gastrinoma
If high > 1000 –> check gastric pH off PPI therapy for 1 week
If intermediate 110-1000 –> secretin stimulation test
Paraneoplastic syndromes presenting as muscle weakness include which 3 syndromes
1) myasthenia gravis involves acthr in postsynaptic membrane: ptosis, diplopia, dysphagia, dysarthria, facial, neck and limb muscle weakness
2) lambert eaton involves presynatpic voltage-gated Ca2 channels: proximal muscle weakness, autonomic dysfucntion (dry mouth), CN inovlvement (ptosis), DIMINISHED or ABSENT DTRs
3) Dematomyositis/polymyositis involves muscle fiber injury: symmetrical and more proximal muscule weakness, interstitial lung disease, esophgeal dysmotility polyarthritis, skin findings (gottron’s papules, heliptrope rash)
Seborrheic dermatitis is a common inflam disease that affects areas with sebaceous glands characterized by
fine loose waxy scales with underlying erythema on scalp, central face, presternal region, interscapular areas, umbilicus, and body folds.
may be assoc with parkinsonism or HIV
Caustic ingection with sodium or potassium hydroxide causes immediate esophgeal injury with liquefaction necrosis and potential perf. What is recommended to do?
endocscopy within first 12-24 hrs to assess severity of damage and guide further therapy
DO NOT do activated charcoal, corticosteroids, emetics and acid neutralization
Clinical manifestations of hemochromatosis: skin MSK GI Endocrine Cardiac infections
*intial test is serum iron studies, confirmatory is genetic testing for HFE , biospy is useful for staging
skin: hyperpigmentation “bronze diabetes”
MSK: arthralgia, arthropathy, chondrocalcinosis (pseudogout)-rhomboidshaped crystals
GI: elevated ALT, AST with hepatomegaly, cirrhosis, HCC
Endocrine: diabetes, hypogonadism 2/2 cirrhosis, hypothyroid
Cardiac: restrictive or dilated cardiomyopathy, conduction abnormalities
infections: increased susceptibilities to listeria, vibrio vulnificus, yersinia
Familial hypocalciuric hypercalcemia is a AD and benign disorder caused by?
- abnormal Ca2+ sensing receptors on PTH cells and renal tubules
- mild asymp hypercalcemia
- high normal PTH
- very low urinary calcium lelves (
Drug-induced esophagitis (retrosternal chest pain + eigpastric burning, chest discomfort upon swallowing). List the main drugs involved in abx, antiinflammatory and bisphosphonate groups
abx - tetracyclines
antiinflam -aspirin and many NSAIDS
bisphosp -alendronate
others -potassium chloride, quinidine, irone
Most cases of hypercalcemia assoc with cancers is due to?
PTHrp production (80%)
Hypercalcemia due to mutliple myeloma is due to which mech
release of local factors that stimulate bone resorption
Alcohol withdrawal leads to reflex hyperactivity
first 6-24 hrs: anxiety, insomnia, tremors, diarphoresis
first 48 hrs: hallucinations and seizures
after 48-96 hrs: delirium tremens: HTN, agitation, tachy, hallucinations, fever
What’s a common choice of treatment for alcohol withdrawal
benzos particularly chlordiazepoxide
Pernicious anemia ist the most common cause of Vit B12 def (macrocytic anemia, glossitis, and neuro changes). There’a a double risk of what?
gastric cancer
so pts should have periodic stool testing for presence of blood
What is enthesitis?
condition in which inflammation and pain occur at the site of tendon and ligament attachment to bone and is a common finding in ankylosing spondylitis (limited spinal mobilitiy). tpyical sites include heels, tibial tuberositis and iliac crests
AS –> apophyseal (facet) joints of axial skeleton are affected, enthesitis, anterior uveitis, HLA-B27, sacroillitis (xray)
COPDs effect on alveolar capillary membrane, FRC, air trapping, lung distensibility
- alveolar cap membrane site of resp gas exchange is destroyed leading to increased lung distensibility and compliance
- due to air trapping, COPD pts have increased FRC and TLC
What should be performed in all pts with oliguria and AKI due to suspected bladder outlet obstruction in post-op period. Post op urinary retention is common complication of surgery and anesthesia
urgetn bladder scan
catheterization
Acute on CHF presents with acute dyspnea, orthopnea nad paryxysmal nocturnal dyspnea with accessory muscule use, tachycardia and tachypnea. How to treat?
- supplemental O2 if needed
- aggressive IV diuresis (furosemide)
- possible vasodilator therapy (nitroglycerine, nitroprusside)
Cervical spondylosis affects about 10% of people above 50 with a PMH of chronic neck pain. What are some clinical symptoms. What’s the most common finding on cervical xray?
limited neck rotation and lateral bending is due to osteoarthritis and 2/2 muscle spasm. Sensory deficit is due to osteophyte-induced radiculopathy
XRAY: bony spurs and sclerotic facet joints aka osteoarthritic changes
Toxic megacolon if suspected should be confirmed with an abdominal xray. What’s the most widely used critera to clinically diagnose toxic megalon?
-radiographic evidence of colonic distension (> 6cm)
+
-3 of the following
fever > 38C, HR >120, neutrophilic leukocytosis > 10500/mL, anemia
+
-at least one of the following
volume depletion, altered sensorium, electrolyte disturbances, hypotension
How to manage toxic megacolon
conservative medical management: bowel rest/NPO, NG tube placement, either steroids (IV prednisone preferred)for cases caused by IBD or abx for cases 2/2 to infection
if not responding –> emergent surgery with subtotal colectomy and end-ileostomy
Preventive Services Task Force recommends routine one0time HIV testing in individuals btw 15-65. What’s the preferred screening test? confirmatory test?
Which test is recommended in pts with negative serologic tests and high clinical suspicion of acute HIV
screening: 4th generation assay that detects both the HIV p24 antigen and HIV antibodies
confirmatory: HIV-1/HIV-2 antibody differentiation immunoassay
plasma HIV RNA testing is recommended in pts with negative serologic tests and high clinical suspicion of acute HIV
Zinc deficiency
Where can you find zinc. What are clinical presentations of zinc def?
zinc is found in animal protein, whole grains, beans and nuts. Digested in jejunum
zinc def –> alopecia, abnormal taste, bullous, pustulous lesions surrounding body orifices and or the extremities, and impaired wound healing
Selenium deficiency
cardiomyopathy
What’s the gold std for diagnosis of herpes encephalitis
Polymerase chain reaction analysis of HSV DNA in CSF
replaced brain biopsy
Contact lens associated keratitis: painful, red eye and opacification and ulceration of the cornea. Most cases are due to? How to manage
most cases are due to pseduomonas
medical emergency bc can lead ot permanent vision loss , require topical brad spectrum abx.
What are the electrolyte abnroml assoc with tumor lysis syndrome
hyperkalemia
hyperphosphataemia
hypocalcemia
hyperuricemia
treat with hydration, allopurinal, rasburicase
What’s the study of choice for diagnosing rotator cuff tear
MRI
What 4 things to remember when prescribing a phosphodiesterase inhibitor like sildenfail for erectile dysfunction
- contraindicated in pts being treated with nitrates (b/c severe hypotension)
- used with precaution in conditions predisposing to priaprism
- concurrent use of drugs which interfere with metabolosim of sildenafil like erythromycin and cimetidine by prolonging its hlaf life
- while combining with an alpha blocker like tamsulosin, impt to give the drugs with at least a 4-hour interval to reduce the risk of hypotension
CSF finding in someone with multiple sclerosis
CSF pressure, protein and cell count are grossly normal
oligoclonal bands are present (IGG)
What kind of a heart failure does AV fistulas cause?
high output by shunting the blood from the arterial to venous side thereby increasing cardiac preload. Pt can develop heart failure despite maintaing a normal or high CO
Explain Mohs micrographic surgery
sequential removal of thin skin layers with micrscopic inspection to confirm that the margins have been cleared. Highest cure rate for BCC and provides the least disruption to surrounding tissues
Cholesterol crystal embolism (atheroembolism) can occur after vascular procedure esp in ppl with comorbiid conditions. What are some clinical features?
dermatologic: livedo reticularis, ulcers, gangrene, blue toe syndrome renal injury CNS (stroke, amarosis fugax) ocular (hollenhorst plaques) GI
LAB
-elev scre, eosinophilia, hypocomplementemia
Skin or rneal biospy
-perivascular inflamm with eosinophils
Describe theophylline toxicity
CNS stimulation (headache, insomnia, seziures) GI (nausea/vomiting cardiac tox (arrhythmia)
Regardless of patient’s addiction history, the best option ofr relief of acute, severe pain is?
IV morphine
HOw to define irritable bowel syndrome?
recurrent abdominal pain/discomfort >/- 3 days/month for the past 3 months and >/- 2 of the following:
- symptom improvement with bowel movement
- change in freq of stool
- change in form of stool
Define serous otitis media
presence of middle ear effusion without signs of an active infection. Exam shows dull tympanic membrane that is hypomobile on pneumatic otoscopy
What should always be considered in pts with unexplained elevation of serum CK and myopathy
hypothyroidism
Acute bactieral prostatitis presents similar to UTIs but for what other symptoms? What should be done initially?
symptoms like perineal pain, tender, boggy prostate
do urine culture to helt direct abx therapy
Victims of smoke inhalation injury should be treated empirically for? How come there’s a metabolic acidosis
CO monoxide poisoning as well as CN posioning because both are found in smoke
Treat CN with hydroxocobalamin or sodium thiosulfate or nitrites to induce methemoglobin
CN binds cyto oxid a3 blocking oxid phosp –> more anaerobic respiration – lactic acidosis
What’s the name of a study that is aka prevalence study and looks at simultaneously measurement of exposure and outcome
crosssectional study
If someone presents with pain, pulselessness, paresthesias, poikilothermia (coldness) and pallor in a limb, what should you suspect? HOw to manage
Acute limb ischemia (e.g. acute popliteal artery occlusion)
Angiography can show abrupt cutoff of arterial blood flow. IV heparin should be started immediately upon suspicin. Definitely treatment is surgical embolectomy or IR embolectomy
How can acute pancreatitis lead to ARDS
enzymes (phospholipase a2) leaked during an acute pancratitis episode can leak across the pulm capillaries and damage surfactant in the alveoli. The increased inflam leads to breakdown of endothelial barrier, recruitment of inflam cytokines and diffuse alveolar damage –> impaired gas exchange, decreased lung compliance. and pulm HTN
ADPKD -HTN and palpable bilateral abdominal masses and microhematuria. List the extrarenal complications
- intracranial berry aneurysm
- hepatic cysts
- valvular heart disease (MVP, aortic regurg)
- abdominal wall and inguinal hernia
Bloody diarrhea + normal stool in HIV-infected patients –> suspect? Should do what to confirm dx?
CMV colitis: chronic bloody diarrhea, abdominal pain, CD4 count
What is considered diagnostic of chronic pancreatitis?
pancreas calcification on CT scan or Xray
ECHO can confirm dilated cardiomyopathy. What will it show?
dilated ventricles with diffuse hypokinesia –> low ejection fraction
Radioiodine therapy is more likely to cause permanent hypothyroidism in pts with which form of hyperthyroidism (graves, multinodular goiter, or toxic adenoma).
Graves
be careful b/c radioidine therapy can also worsen eye symptoms aossoc wiht graves
Suspect what in someone with COPD and catastrophic worsening respiratory symptoms?
secondary pneumothorax due to dilated alveolar blebs that rupture into pleural space
