VENI VIDI VICI Flashcards
1
Q
Diagnostic criteria- Lewy Dementia
A
Central: Progressive decline in cognition - dementia + >= 2 of the following: Core: 1. Fluctuation in cognition 2. Visual hallucinations 3. Spontaneous parkinsonism features 4. rREM sleep behavior disorder (Dream enactment). THYE HAYVE ANIPSYCHOTIC HYPERSENSITIVITY
2
Q
Most common causes of Dementia
A
1st is AD, 2nd Lewy Body ( survival time after diagnosis is 8 years)
3
Q
Tto for lewy dementia
A
Donepezil (Cognition), Carbidopa-levodopa (Parkinsonism), Melatonin(rEM disorder), Antispychotic( Hallucinations- BUT MAY WORSEN CONFUSION, PARKINSONISM AND AUTONOMIC DYSFUNCTION
4
Q
Patient with Lew Dementia treated with Donepezil, Carbidopa-Levodopa, and Risperidone, that comes with worsening confusion
A
They have antipsychotic hypersensitivity- may worsen the confusion, parkinsonism, orthostatic changes. IF ANTIPSYCHOTIC NEEDED TRY QUETIAPINE (risk is lower). In addition to worsening confusion, antipsychotics are associated with increased mortality in patients with dementia
5
Q
Brain death algorithm
A
say it
6
Q
why can brain death pts have some movements
A
because these originate for peripheral nerveso spinal cords
7
Q
Transverse myelitis
A
Progressive lower extremity weakness, urinary retention, loss of sensation in the setting of URI
8
Q
RF for Tunnel Syndrome
A
Obesity, Pregnancy, DM, Hypothyroidism, RA
9
Q
Dx Carpal Tunnel Syndrome
A
Nerve conduction studies
10
Q
Tto Carpal Tunnel syndrome
A
wrist splint, glucocorticoid injection,
11
Q
the striatal dopamine transporter scan
A
imaging that can be considered when Parkinson disease diagnosis in unequivocal
12
Q
TTO Parkinson
A
If < 60 and mild Pramipexole or Bromocriptine. For odler levodopa carbidopa.
13
Q
Traumatic LP
A
Often has > 6000 RBCs. iT may also elevate WBCs usually 1 per 750-1000. If WBC/RBC< 0.01 is less likely that is meningitis
14
Q
SAH vs traumatic LP
A
Xantochromia is seen with SAH
15
Q
Amaurosis fugax
A
Is a marker of carotid artery atherosclerosis - Carotid bruit indicates obstruction
16
Q
Triad of SAH
A
Sudden onset headache, nausea, nuchal rigidity- often due to aneurysm rupture ( can be posterior cerebral artery causing compressinon of third nerve -diplopia- can also have anisocoria, proptosis)
17
Q
Brainstem glioma
A
Has more brainstem involvement , multiple CN involvement , ataxia, motor and sensory involvement
18
Q
Patient with DVT that 2 days after develops hemiparesis and Facial paralysis
A
Paradoxical embolism- Transesophageal echocardiogram
19
Q
Meningovascular syphilis
A
low grade infection in the subarachnoid space can affect intracranial vessels and cause stroke
20
Q
Stroke in young- Cardiac causes
A
Patent foramen ovale, congenital heart disease, arrhythmia
21
Q
Stroke in young Heme causes
A
HIT, Sickle cell anemia, inherited hypercoagulable disorders
22
Q
Stroke in young- Infectious causes
A
Meningovascular syphilis, Endocarditis, TB meninigits, Bacterial meninigits, vzv
23
Q
Stroke in young- other causes
A
Cocaine, amphetamines, nflammatory arteritis, cerebral artery dissection
24
Q
TTO of meningovascular syphilis (stroke)
A
Penicillin
25
Red flags for headaches: SNOOP
Systemic signs(fever) or illnesses(Cancer), Neurologic signs/symptoms, Onset is new, Other associated conditions ( head trauma), Previous headaches with changes in frequency, quality.
26
NSAIDs induced headache
Patients who take analgesics (eg, acetaminophen) for headaches >10 days/month for >3 months can develop a secondary headache disorder due to medication overuse.
27
Prophylaxis Cluster
The first-line therapy for cluster headaches that typically last >2 months is verapamil. This medication is usually initiated at 240 mg and titrated up as needed.
28
Trigeminal Neuralgia tto
Carbamazepine
29
Ages of febrile seizure
6 months to 5 years
30
Prognosis of febrile seizure
Risk of epilepsy is 1-2%, if complex increases to 5-10%. In addition, abortive antiepileptic drugs do not alter the outcome of a child who has had a febrile seizure, even with an abnormal EEG.
31
Spina bifida complications
Neurogenic bladder/bowel, hydrocephalus, scoliosis, motor or sensory dysfunction.
32
Vertebrobasilar insufficiency
Eldery who presents with dizziness, unable to speak, nauseated, sensation of tingling in face, body, lasting 8-10 minutes. Common in patients with hypertension, DM, hypercholesterolemia. vertigo, dizziness, dysarthria, diplopia, and numbness.
33
Patient with NPH by clinic and then imaging, next step?
LP ALWAYS FIRST- TO CONFIRM THAT THIS IS NORMAL PRESSURE. MILLER FISCHER TAP- looks if patient improves after removal of 30-50 cc of CSF. THE TREATMENT IS THEN VP SHUNT
34
MS and pregnancy
lower MS activity during pregnancy, but at delivery higher likelihood of cesarea or instrumented delivery. If exacerbation during pregnancy-- short term steroids.- After delivery there is high MS activity.
35
Major risk factor for stroke
HTN! , THEN SMOKING, THEN DM. Maintain < 150/90 in > 60 years old
36
Subtypes of syncope
Cardiovascular: .1Arrhythmia 2. Aortic stenosis. NonCardiovascular: vasovagal, carotid sinus hypersensitivity, orthostasis, seizure TIA
37
Opoiod withdrawal medications and when to use one over the other
Opioid agonists ( Methadone and buprenorphine): require supervision program - so patient needs to be adherent. Clonidine and adjunctive medis( antidiarrheal, antiemetics)
38
Prior to giving aspirin in stroke what should you consider?
Swallowing study! Some patients may have dysphagia. quick swallowing screening evaluation (eg, water swallow test, Toronto Bedside Swallowing Screening Test)
39
Management of Hypertension in patients with stroke
In pastients who do not receive the tPA <220/120 is allowed to assure good perfusion to brain . In patients who receive tPA 180/105.
40
How do you monitor the respiratory function in Guillain Barre
vital capacity and negative inspiratory force. NOT THE PEAK EXPIRATORY PHASE
41
In whom do you give IVIG or plasmapheresis in Guillain Barre
Non ambulatory and within 4 weeks of onset. If ambulatory and doing well generally do not require treatment.
42
Botulism characteristics
symmetric descending paralysis, does not have sensory compromise.
43
Guillain Barre Progression
2 weeks of progressing weakness and can arrive to full paralysis , 2-4 weeks of full plateau, slow recovery over months
44
Diagnostic criteria for Narcolepsy
Recurrent lapses into sleep and multiple naps in the day, at least 3 times a week for 3 months. aT LEAST 1: Cataplexya, low hyporexin, REM< 15 min
45
MOA modafinil
Direct, non direct dopamine receptor agonist
46
tto of cataplexy
SSRIs
47
MOA methylphenidate
inhibits the reuptake of dopamine and norepinephrine, increased dopaminergic and noradrenergic activity in the prefrontal cortex may explain its efficacy in ADHD.
48
Childhood absence prognosis
CAE often spontaneously remits by early puberty with no major long-term sequelae. When the patient has been seizure-free for 2 years, the antiepileptic medications frequently can be tapered.
49
Neurofibromatosis I and II
Type I: Tumor suppression gene chromosome 17, neurofibromin. Cafe au lait, neuromas, lisch nodules, can have optic gliomas. Type II: Merlin, chrom 22, bilateral acoustic neuroma and cataracts.
50
Nerve injuries during endarterectomy
hypoglossal nerve ( ipsilateral deviation of tongue when is protruded), recurrent laryngeal nerve (unilateral vocal cord paralysis- is distal to lesion) facial nerve( damage the mandibular brnch innervates orbicularis oris muscle- asymmetric smile),vagus nerve, ansus hypoglossal nerve innervates neckm can be sacrificed.
51
Parinaud Syndrome
pineal gland. 4 things: vertical gaze paralysis, loss of pupillary reaction, loss of optokinetic nystagmus , ataxia
52
Cremasteric reflex - level, and causes
Diabetic neuropathy, L1, L2
53
gET UP AND gO TEST
To assess postural stability
54
Valproate SE
Dose-related Thrombocytopenia , hepatotoxicity,pancreatitis, teratogen
55
Psychogenic coma
normal reaction to caloric stimulation : transient, conjugate, slow deviation of gaze to the side of the stimulus (brainstem-mediated), followed by saccadic correction to the midline (cortical correction).
56
unilateral facial nerve palsy, hepatomegaly, and lymphadenopathy
Extrapulmonary manisfestations of sarcoidosis
57
Extrapulmonary manifestations of sarcoidosis
Skin: erythema nodosum,
58
If you suspect sarcoidosis, next step in management?
Chest X ray
59
Confirm diagnosis of sarcoidosis
Excicional lymph node biopsy - Biopsy reveals noncaseating granulomas
60
Contraindications tpa
Presence of active internal bleeding
Bleeding diathesis (eg, platelets <100,000/µL)
Hypodensity in >33% of an arterial territory on CT scan
Presence of intracranial hemorrhage on CT scan
Intracranial surgery in the last 3 months
Blood pressure >185/110 mm Hg
61
Alzheimer
Donepezil, rivastigmine, galantamine
62
Wernicke's Korsakoff triad
Encephalopathy, ophtalmoplegia, Gait ataxia
63
Wernicke's Korsakoff tTO
IV thyamine- Intravenous thiamine usually improves ocular abnormalities within hours, but confusion and gait ataxia may persist for days or weeks; many patients never fully recover. - DO NOT GIVE GLUCOSE PRIOR TO THIAMINE! WORSENS IT
64
Initial workup of Tuberous sclerosis
MRI for hamartomas, and EEG
65
MC cause of death in tuberous sclerosis
epilepsy, renal
66
ASTHMA IN BABY
maternal asthma may be associated with an increased risk of preterm birth, pre-eclampsia and caesarean delivery.
67
Scissors gait
spastic CP
68
Evaluation of CP
MRI-eg, periventricular leukomalacia, brain malformation, ischemia. MRI is superior to CT!
69
Gerstmann syndrome
Dominant parietal lobe: acalculia, agraphia, R/L
70
ataxia, weakness, and absent deep tendon reflexes after a camping trip to Washington State
tick paralysis - normal sensation
71
prolactinoma
bromocriptie and cabergoline- dopamine agonists
72
Prolactinoma presentation and definition
PRL>200. Rule out renal insuff or thyroid problems. Microadenoma (<10mm or 1 cm). Macroprolactinoma(>10mm, >1cm). If macroprolactinoma or micro but symptomatic try dopamine agonists- that decrease PRL (Bromocriptine, cabergoline). If > 3 cm surgery
73
Dx of Myasthenia gravis
acethylcholine receptor antibodies, if negative- muscle specific tyrosine kinase antibodies. CT chest
74
Myasthenia gravis
NM junction
75
Tto of myasthenia gravis
Pyridostigmine/neostigmine ( acethylcholinesterase inhibitor), if doesn’t work and patient < 60 thymectomy.
76
Triggers for myasthenia gravis
surgery, childbirth, pregnancy, surgery, infection. TTO is plasmapheresis
77
Definition of concussion
Transient neurological disturbance ( dizziness, amnesia, disorientation), and NO intracranial injury
78
Management of concussion, recs on returning to physical activity
suspend from same day play. Rest for 24 hours. If without ss start exercise ( light aerobic exercise, non contact sports, then contact sports) . For mental: decreased screen time, and school accomodations. Potentially returning to full contact sports in one week.
79
Unilateral headache and partial horner ( anisocoria, transient vision impairment)
Carotid artery dissection- so always do imaging
80
MCC of carotid dissection
Trauma, HTN, Smoking or connective tissue disease
81
Presentation of carotid artery dissection
unilateral head and neck pain, transient vision loss, ipsilateral horner disease ( ptosis and miosis without anhidrosis), signs of focal cerebral ischemia( focal weakness)
82
Dx of carotid artery dissection
CT angiography head and neck
83
TTO OF carotid artery dissection
Thrombolysis if < 4.5 hours ( dissection leads to thrombi formation), aspirin, anticoagulation
84
presentation of temporal arteritis
head ache, jaw claudication, fever, anemia, high ESR. No anisocoria.
85
Peripheral Facial palsy and hx of cold sores, tto
Steroids within the first 3 days of onset . Bell palsy. If there is a central facial nerve palsy it requires further imaging . Although HSV can be a cause, there is NO BENEFIT og given antiviral therapy
86
PECARN rule
say it
87
Blepharospasm presentation and treatment
type of dystonia, involuntary closeure of the eye, usually trigger by bright light, irritants ( like smoke). Older women are predisposed potentially due to dry eye. TTO: Botulin toxin
88
Wallenberg Syndrome, etiology
aka lateral medullary infarction - caused by intracranial vertebral artery occlusion- or PICA
89
Wallenberg Syndrome presentation
Vestibulocerebellar findings ( dizziness, ipsilateral limb ataxia), ipsilateral horner, contralateral loss of pain and T, Ipsilateral cerebellar ataxia, nausea, nystagmus, vertigo,
90
lateral pontine syndrome
anterior inferior cerebellar artery is occluded
91
lateral pontine syndrome
Afftect motor and sensory trigemin. Weakness of muscles of mastication, diminished jaw jerk reflex, impaired tactile sensation. In contrast dysphagia, hoarseness, and dimished gag reflex are more lateral medulla.
92
Patients with late life depression are more likely to develop alzheimer
true , this is in contrast with patients who develop depression at any age.
93
Medial Medullary Syndrome etiology
aka alternating hypoglossal hemiplegia, occlusion of vertebral or the anterior spinal artery
94
Medial medullary Syndrome presentation
Contralateral paralysis of the arm and leg. And tongue deviation towars the side of the injury.
95
Presentation of vit B12 deficiency
Dementia and subacute combined degeneration ( dorsal column: loss of vibration, impaired Romberg)( Lateral corticospinal tract: spastic paresis and hyperreflexia)
96
Cause for increase in indirect bilirrubin in patients with vit B12def
ineffective erythropoiesis - defective DNA and cell production-- intramedullary hemolysis.
97
Clinical suspicion of spinal/epidural abscess, next step
MRI with gadolinium (preferred) or CT with contrast
98
MCC bacteria in spinal epidural absces s
S.aureus
99
tto od epidural abscess
CT guided aspiration and culture for antibiotic, most pts require immediate surgical decompression.and drainage
100
fOR DEMENTIA TEST FOR
TSH,VITB12, AND DEPRESSION
101
Pt with forgetfulness, responses are very slow, gait is slow and cautious,
TSH- IS ASSOCIATED WITH HYPONATRMIA AND MICROCYTOSIS
102
Phenytoin toxicity
Horizontal nystagmus is the first sign! Blurred vision, diplopia, ataxia, slurred speech, drowsiness and decreased mentation . Oif this happen phenytoin should be decreased and look for resolution of nystagmus.
103
Never do an LP prior to MRI if suspecting tumor
TRUE
104
ss of postconcussive syndrome and prognosis
amnesia, headache, confusion,difficulty concentrating, vertigo, hypersensitivity to stimulus, mood alteration, sleep disturbances, and anxiety. Ss often resolve with symptomatic treatment within few weeks and months but some patients may have persistent ss lasting >=6 months.
105
Normal glucose, protein, cell count in CSF
glucose : 40-70, protein < 40, cell count 0-5
106
Bacterial meningitis glucose, protein, cell count in CSF
cell count >1000, glucose < 40, protein >250
107
Viral meningitis glucose, protein, cell count in CSF
cell count 100-1000, glucose normal, protein <100
108
TB meningitis
cell count 5-1000, glucose <10, protein >250
109
treatment of meningitis -empiric
vancomyicin, ceftriaxone, steroids + Ampi for Listeria
110
glucose less than 10 IN CSF, and lymphocytosis predominance
TB, cells 5-1000, glucose <10, protein >250, elevated adenosine deaminase
111
meninigits + yellow white nodules in bilateral optic discs, basilar enhancement
TB tuberculosis
112
TB meningitis dx
serial lumbar punctures with CSF examination for acid fast bacilli
113
In patients with altered mental status check
TSH , CMP,Urinalysis, infection. Thyrotoxicosis or hypothyroidism can present as confusion, altered mental status
114
Apathetic thyrotoxicosis is often misdiagnosed with dementia
TRUE
115
MVP
Non ejection click due to snapping of the mitral chordae as the valve cusps extend to the left atrium during systole, followed by a systolic murmur or mitral regurgitation. WORSE with low venous return( standing valsalva) and better with handgrip or squatting that increases left ventricular size.
116
Ejection murmur followed by crescendo-decrescendo
Aortic or pulmonic valve stenosis
117
Harsh holosystolic murmur with palpable thrill
VSD
118
Compartment syndrome presentation
pain out of proportion, increased pain with passive stretch, paresthesia " ants crawling", burning pain.
119
Dx of compartment syndrome
Compartment pressure > 30, or DBP-Compartment pressure < 20-30.
120
HF with preserved EF
Diastolic HF
121
Most common cause of Diastolic HF
htn --> concentric hypertrophy and impaired diastolic filling.
122
BNP in HF and obesity
BNP IN HEART FAILURE IS VERY SENSITIVE. HOWEVER, OBESITY LOWERS THE BNP, MAKING IT UNRELIABLE IN THIS PATIENTS.
123
Newborn with respiratory distress and murmur, son of diabetic mother
transient hypertrophic cardiomyopathy due to increase glycogen storage in the heart, and particularly interventricular. Flow can be obstructed and patient can have congestive heart failure,
124
Hypoplastic left heart syndrome
seen in children of prediabetic mothers.
125
Most common complication of Compartment syndrome
Renal failure due to myoglobin release --rhabdomyolysis
126
Left foot pain likely due to arterial thrombosis + diastolic murmur
left cardiac myxoma
127
Hypertension,who to treat?
If >=60 with >= 150 or 90. If<60, CKD, DM >=140/90
128
Tto of HTN
Black: thiazides or CCB, alone or in combination . Other ethnicities: thiazides, ACEi, ARB or CCB Other ethnicities with DM or CKD: ACEi and ARB
129
alpha blockers are not 1st line HTN meds but can be used in BPH
yes
130
Classification of pulmonary hypertension
WHO Classification 1.Pulmonary arterial Hypertension 2. Due to left heart disease 3. Due to chronic lung disease ( COPD, ILD), 4. Chronic thromboembolic disease 5. other causes(sarcoidosis)
131
progressive dyspnea with exertion, prominent S2, Chest X ray with prominent pulmonary arteries but no infiltrate, ECG right axis deviation Dx?
Pulmonary hypertension
132
If clinically you suspect pulmonary HTN, next step?
Transthoracic TTE -- mean arterial pressure >=25
133
TTO pulmonary HTN
1. Endothelin antagonists ( bosentan, Ambrisentan): vasodilation, and delay progression of disease
2. PD5 inhibitors (Sildenafil, tadalafil)
3. Prostacyclin pathway agonists ( epoprostenol, treprostenol)
134
Prgnosis of postural tremor
incidence increases with age, familiar cases may present younger, no disability and normal life expectancy
135
Tto of essential tremor
propanolo, primidone
136
Trastuzumab cardiotoxicity PROGNOSIS
is a monoclonal antibody that targets HER 2 , Causes decline in LVEF. Cardiotoxicity is REVERSIBLE , is due to loss of myocardial contractility. It should be withheld by 4 weeks if EF decreases > 16% from baseline, and if symptomatic heart failure discontinue.
137
Anthracycline(Doxorubicin) cardiotoxicity PROGNOSIS
IRREVERSIBLE, there is myocyte destruction. Toxicity is associated with accumulative dosing
138
Tto of post MI perdicarditis
high dose aspirin, is preferred over NSAIDs and if refractory may consider Colchicine. NSAIDs not ideal because they interfere with myocardial healing. Steroids should be avoided as well.
139
Tto of idiopathic or viral pericarditis
Naproxen and colchicine
140
Patient with blunt thoracic trauma, mildly hypotensive, next step?
Bedside US or Focused assessment with sonography in trauma. Bedside Chest X rays ( Anteroposteroir) are performed after and are preffered over the posterior anterior and lateral that require the patient to stand up.
141
Causes of prolonged QT
Reemember that Sinus bradycardia can also cause it!
142
Pulmonary edema -exacerbation CHF
Can present with hypoxia, tachypnea, sensation of choking.
143
tto of acute decompensation of HF
fUROSEMIDE, OXYGEN, NITROGLYCERIN IV, MEXT STEP? ECHO
144
After LMNOP in acute HF exacerbation , next step?
Echo, to assess for type of HF and any valvular abnormalities that may be contributing to it . If there is signficant left ventricular dysfunction -- then pt may require stress testing or coronary angiography
145
TIMI score
say it
146
Aortic dissection tto
IV B blocker, morphine, Sodium nitroprusside IV if SBP>120, emergent surgical repair.
147
TTO for chronic HF
NYHA classification
148
Tto for cocaine induced MI
BZD and nitrates. NO B BLOCKERS, CCbs if persistent chest pain , phentolamine if persistent hypertension, +/- PCI if MI
149
Chest pain cocaine induced and new neurologic symtpom, and negative CT head, diagnosis and next step?
acute dissection of ascending aorta-- Ctangiography-- that is a surgical emergency
150
Meds for redcuing TRG
Fibrates ( Gemfibrozil)
151
Niacin
Increased HDL, modest decrease of LDL
152
Bile acid sequestrants function
cholestyramine, colestipol, colesevelam-- decrease LDL levels but no impact on cardiac outcomes.
153
Interaction between warfarin and amiodarone
amiodarone (for Afib) increases warfarin level, so warfarin dose should be reduced by 25-50%.
154
SE of amlodipine
Peripheral edema - are arteriolar vasodilators . To reduce it you can add ACEis
155
difficulty breathing ECG with narrow QRS complex, different P wave morphology , not able to talk
Multifocal atrial tachycardia
156
Multifocal atrial tachycardia
Seen in patients with pulmonary disease, but can be triggered by exacerbation of pulmonary disease, electrolyte disturbance, or cathecolamine surge(sepsis)
157
ECG findings multifocal atrial tachycardia
R-R interval irregular, P waves of at least 3 different morphologies atrial rate of >100
158
tto of multifocal atrial tachycardia
underlying disease, can be electrolyte replacement, NIPPV or O2 supplementation
159
short apical low pitch diastolic rumbling murmur, notched p waves, opening snap
mitral stenosis
160
Mitral stenosis presentation
Dyspnea, orthopnea, hemoptysis, SOB, cough at night.
161
Sudden cardiac death in young patients-- think of 2 things
HCM, and Anormalous Aortic Origin of Coronary Artery
162
Types of Aortic Origin of Coronary Artery
1. LAD originating from the right aortic sinus 2. RCA originating from the Left aortic sinus
163
Why is AAOCA dangerous
it creates a curvature that is less amenable for high flow, and in situatins of high flow like exercise when pulmonary and aortic vessels are dilated these may cause external compresion as the anomalous coronary is in the middle.
164
AAOCA DX
ECG resting is normal, Echo sometimes can show it, but the best is CT coronary angiography.
165
Medications that should be withheld prior to any surgery
ACEi/ARBs unless heart failure( they have peri and postoperative risk of hypotension), Diuretics, Metformin, Raloxifen.
166
Ortner syndrome
Hoarseness due to recurrent laryngeal nerve compression due to left atrial enlargement- seen in mitral stenosis
167
Brugada Syndrome ECG characteristics
Right bundle branch block and ST elevation on V1-V3,can cause SCD but not in exertion
168
Define long QT syndrome
> 450 in men, > 470 in females
169
Raloxifen SE
Venous thromboembolism, should be discontinued 4 weeks prior to any surgery
170
Treatment of Afib
say it
171
Algiruthm arrythmias, PE/Asystole, and Vfib/pulseless Vtach
say I t
172
Chronic heart failure tto
1) ACEi/ARBs + B blockers 2. Same 1 + Furosemide 3. Same as 2 + spironolactone , hydralazine+nitrate
173
Indications for hydralazine+nitrate in CHF
African americans and if ACEi/ARBs are not tolerated
174
Patient with sudden onset of SOB, diaphoresis, hypotension, hyperdynamic pre-cordium and early decrescendo holosystolic murmur
Acute mitral regurgitation - can be seen in patients with ehler Danlos, Marfan, or in patients with papillary muscle rupture in the setting of MI. THE MURMUR IS OFTEN ABSENT!!! ( due to severity, and equalizationof LA and LV pressures
175
Tto of acute Mitral regurgitation
Echo at beside, emergent surgical eval
176
What do Ehler and Marfan share in common and what is different
Common things: JPSM: Joint hypermobility, Pectus excavatum, Scoliosis, MVP. Ehler danlos: Easy bruising, velvety skin, atrophic scars, uterine prolapse, inguinal and abdominal hernias, high arched palate. Marfan: tall stature, aortic root dilation, lens and retinal detachmen, spontaneous pneumothorax.
177
Definition of peripartum cardiomyopathy
occurs between 36 weeks and 5 months postpartum, signs of left heart failure, and LVEF =<45
178
RF for peripartum cardiomyopathy
MATERNAL AGE>30, PRE-ECLAMPSIA,MULTIPLE PREGNANCIES
179
Prognosis of peripartum cardiomyopathy
Some may resolve spontaneously and completed. If at time of diagnosis LVEF<20 the risk of recurrence is higher. Patients need to be followed with Echo for years. If persistent or recurrent, may be adviced not to pursue another pregnancy
180
3 Complications of cardiac catheterization
1. Hematoma: +/- mass, no bruit 2. Pseudoaneurysm: bulging, pulsatile mass, systolic bruit 3. AV fistula: continuous bruit, no mass.
181
Patient post catheterization, leg pain, pulsatile mass, next step
US leg
182
Main RF for pseudoaneurysm after catheterization
inadequate post-procedural manual compression
183
tto of pseudoaneurysm post catheter
Small can be treated with US guided compression or intraluminal thrombin injection, larger or rapidly expanding can rupture so surgery.
184
Criteria for biventricular pacing in HF
1. LVEF < 35% 2. NYHA II,III,IV with ss despite tto 3. LBBB with QRS > 150. These patients also meet criteria for cardioverter defibrillator implant.
185
wHAT DOES Deep Q waves indicate
prior infarct
186
MC location of abdominal aneurysm
infrarenal > 3cm
187
What intervention will more likely decrease the expansion risk of aortic aneurysm
stop smoking
188
aortic aneurysm screening
Abdominal US, 65-75 yo who have ever smoked
189
Indications for aortic aneurysm repair
large > 5.5 cm, rapidly progressive > 0.5 in 6 months, AAA associated with PAD or aneurysm
190
Management of AAA
Smoking cessation, ASA, statin, and evaluate If candidate for surgery
191
Follow-up of aortic aneurysms
Medium : 4-5.4 (US every 6-12 months), Small( every 2 -3 years)
192
Patient with hypertensive emergency who received IV labetalol and IV nitroprusside , 2 days after presents with confusion and seizures
Cyanide toxicity
193
Cyanide toxicity presentation
Cherry red color first, then cyanosis, altered mental status to seizures, arrythmias, respiratory depression and then tachypnea, pulmonary edema, METABOLIC ACIDOSIS
194
Cyanide toxicity treatment
sodium thiosulfate
195
Beck's triad for cardiac tamponade:
hypotension, muffled heart sounds, JVP
196
The most specific finding of cardiac tamponade indicating that emergent treatment is needed
early diastolic collapse of the right ventricle and right atrium. Other signs pulsus paradoxus . LOW VOLTAGE QRS IS NOT SPECIFIC OF CARDIAC TAMPONADE, THAT CAN BE FOUND IN OTHER CAUSES. THIS IS DIFFERENT FROM ELECTRICAL ALTERANS
197
Most significant predictor of cardiovascular risk ?
Diabetes Mellitus , other CHD equivalents are: CKD, and noncoronary atherosclerotic isease
198
Strict glycemic control improves microvascular complications but not macro
Micro include retinopathy, nephropathy, neuropathy. Macro: CHD, stroke
199
Criteria for Aortic valve replaement
Severe AS (JET>0.4, GRADIENT>40,) PLUS >=1: onset of symptoms, LVEF< 50%, undergoing other cardiac surgery (CABG)
200
men died steering wheel , motor vehicle accident. Cause of sudden death?
Aortic rupture. NOT CARDIAC CONTUSSION! IT CAN CAUSE BUT WHEN THERE IS INVOLVEMENT OF VESSELS AND CHAMBERS.
201
Management of statin myopathy or rhabdomyolysis
Symptomatic patients-discontinue statin. Asymptomatic patients with CK increased >10 times stop. BECAREFUL because statin can also potentiate myopathy in the setting of exercise so if pt did a marathon presents with high CK, discontinue statin, and then recheck CK, and if levels have normalized re-start statin as it was initially tolerated.
202
Patient developing cardiogenic sshock in the setting of inferior MI and bradyarrhythmia. Not responsive to atropine, hemodynamically stable, next step
temporary pacing, and then PCI
203
Patient diagnosed with bicuspid aortic valve, next step?
First degree relative screen with echocardiography. Patients are followed with echo every 1-2 years. And can require valvuloplasty.
204
Complications or risks of having bicuspid valve
Endocarditis, Severe aortic stenosis or regurgitation, aortic root dilation, dissection.
205
Treatment of Wolff Parkinson white Afib
unstable: cardioversion. Stable: procainamide or ibutilide
206
Meds CI in Wolff Parkinson White
Digoxin, CCBs, b blockers, verapamil, adenosine
207
INR target with aortic and mitral mechanic valve
Warfarin 2-3: aortic valve replacement with no risk factors(
208
Patients with bicuspid valve should be assessed for
thoracic aortic aneurysm, or dissection.
209
Afib but pulseless
Pulseless electrical activity- any type of arrythmia. Start compressions and then give Epinephrine
210
Syncope in patient with prior mI
think that cause can be ventricular tachyarrhythmia due to scarring tissue.
211
Causes of cardiogenic syncope
Aortic stenosis/HCM, Ventricular tachyarrhythmia, Sick sinus syndrome, Torsades de pointes, advanced AV blocl
212
Athlete asymptomatic with low heart rate, next step
reassure, and routine care
213
Patients with suspected marfan syndrome require an echo prior to initiation of physical activity
if there is root dilation, they are advised not to do strenous activity.
214
Patient with cardiogenic shock secondary to MI, presenting with sinus bradycardia and infarct on II, III, Avf, next step
Intravenous atropine. Inferior infarcts can be associated with sinus bradycardia because the the SA node is irrigated by the RCA. In RV infarcts its true that they can be preload dependent and may require IV fluids, but its not the case for patients who have cardiogenic shock, where fluids can worsen it
215
Perioperative stratification for cardiac risk, High risk and low risk procedures.
High risk procedures: aortic surgery , or peripheral vascular. Low risk : ABCE: Ambulatory or superficial, Breast, Cataract, Endoscopy. Low risk no further testing unless decompensated HF, or unstable angina. For high and intermediate risk based on RCRI risk, and if they are able to do brisk walking or climb 2 flight of stairs no further testing.
216
Lateral wall of the heart Is irrigated by
LCA
217
LAD irrigation
anterior interventricular groove and irrigates the anterior wall of the left ventricle
218
RCA irrigation
right ventricle and inferoposterior wall of left ventricle
219
TCA overdose
CARDIAC ARRHYTHMIA, ALTERED MENTAL STATUS, Hyperthermia, confusion, flushing, blurred vision, urinary retention, mydriasis
220
TCA antidote
sodium bicarbonate for stabilization of the heart. , if not resolve give Mg, or lidocaine.
221
Management of TCA OVERDOSE
O2,intubation as needed, IV fluids. Activated charcoal if within 2 hours of ingested( unless ileus is present) and sodium bicarbonate for WIDE QRS arrhythmias
222
patients with CAD that are elderly > 80 may present more often with anginal ss ( shortness of breath) rather than chest pain in CAD!!!
TRUE
223
Patient with MI leading to acute decompensated HF, what medication should NOT BE GIVEN
B blockers, as it may worsen pulmonary edema
224
Resume sex after MI
If they are asymptomatic they can resume ot. Guidelines say within 3-4 weeks after MI, and as early as 1 week.
225
ECG findings in constrictive pericarditis
nonspecific, Afib, low voltage QRS complex. Imaging shows calcifications
226
Causes of constrictive pericarditis
Idiopathic or viral, cardiac surgery or radiation, TB
227
T wave abnormalities in ECG may raise suspicion for CAD
always do troponin (at least 2 in 3 hours apart) and serial EKG every 30 minutes.
228
indications of implantable cardioverter-defibrilator in HCM
1. Prior history of cardiac arrest or sustained Vtach 2. family history of SCD 3. Recurrent or exertional syncope 4. Nonsustained SVT, 5. Hypotension with exercise 6. Extreme left ventricular hypertrophy
229
PCI timing
ideally 90 minutes from when patient is seen by physician (independent of when the ss started) and 120 if will be transfer
230
Epigastric pain associated with exercise, think of CAD!
WARRANTS ECG
231
Management of Afib
b blocker or CCBs!and assess need for cardioversion and CHA2DS2VASc
232
PAD management
Aspirin + High dose statin , then supervised exercise progrma > 3 x/week for 3 months. If despite this persist cilostazole, if persists revascularization
233
Antiarrhythmics for Afib indication and what to use
Indications: 1. inability to maintain adequate HR control with rate drugs 2. Symptomatic despite rate control agents. For LVH AND HF: Amiodarone. Nothing: flecainamide, propafenone, CAD:Sotalol.
234
What has the major impact inHTN
Weight loss ( < 25%), BASH diet, and exercise.
235
Digoxin toxicity
nausea/emesis, anorexia, fatigue, confusion, visual disturbances, cardiac abnormalities
236
What drugs cannot be given with Digoxin, otherwise there is Digoxin toxicity?
VASQ--Verapamil, Amiodarone, Spironolactone, Quinidine.
237
Patients in TPN should be closely monitored for which electrolyte and why?
Phosphorous. It is possible that they develop silent hypophosphatemia ( in the setting of IV dextrose in TPN- Dextrose--insulin production--insulin drives serum phosphate into the cell for ATP generation-- and there is hypohosphatemia. It is also seen in refeeding syndrome
238
Complications of refeeding syndrome
seizures, rhabdomyolysis, arrhythmias, CHF
239
First line tto for DVT/PE in cancer and non cancer patients
in non cancer: oral X inhibitors (Rivaroxaban) for at least 3 months. In cancer LMWH (this is non oral)
240
Alternative for horomone replacement therapy for hot flashes due to risk of DVT
SSRIs OR NSRIS
241
Risks of hormone replaceent therapy
Increase risk of breast Ca, stroke, and DVT
242
Down is associated wiith which conditions
Endocardial cushion defect, duodenal atresia, hirschprungs, atlanto axial instability, hypothyroidism
243
Patients with Down syndrome are at risk of developing
ALL, Alzheimers, autism, ADHD, depression and seizures
244
characteristics of AS murmur,
single S2 ( delay in aortic equalizing pulmonic), pulsus parvus et tardus ( diminished and delayed carotid pulse), soft S2 in severe, and loud S2 in mild and severe.
245
in vasovagal syncope prodromal symptoms may persist briefly AFTER the syncope
true.
246
HCM treatment
B blocker, if not work verapamil, and disopyramide. Implantable cardioverter defibrillator.
247
Single most important RF for CAD
DM
248
Is stress a RF for CAD
NO
249
RF fo0r CAD (8)
DM- IS THE MOST IMPORTANT. Others: HTN, smoking, Obesity, sedentarism, hyperlipidemia, PAD, family history (female < 65, men <55)
250
Chest pain in CAD
Dull chest pain, lasts 15-30 mint, occurs in exertion, substernal location, and radiates to the jaw or left arm.
251
The most common cause of pain that is not cardio related
GERD
252
NSTEMI tto
DNA BSG. Dual anticoagulation( Aspirin, clopidogrel), nitroglycerin, anticoagulation( heparin) , b blickers, statin
253
EKG changes in CAD
ST depression, elevation, and T wave inversions
254
Types of troponins and function
T- tropomyosin C- binds calcium to activate actin-myosin interaction, and Troponin I blocks or inhibits actin-myosin interaction.
255
When do CKMB levels go down and and then up
go down at day 2-3 and then elevate after if re-infarct. While troponins will remain elevated
256
Best initial treatment for CAD
Aspirin
257
Aspirin lowers mortality?
Aspirin alone reduces mortality by 25% for acute MI, reduces mortality by 50% in unstable angina.
258
MOA clopidrogrel, prasugrel, ticagrelor
P2Y12 antagonists- block aggregation of platelets to each other by INHIBIYING ADP-induced activation of the P2Y12 receptor.
259
Angioplasty and thrombolytics both lower mortality in STEMI
true , IBUT IN STABLE ANGINA it does not decrease mortality more than medical therapy
260
Stable angina tto
ABNS - Aspirin, B blocker, Nitrate, Statin
261
Timing for angioplasty and thrombolytics
angioplasty > thrombolytics. Angioplasty 90 min of arrival to ED. If not able to PCI then thrombolytics within 30 minutes of arrival to the ED, BUT CAN BE GIVEN UP TO 12 HOURS FI THERE IS ST ELEVATION >=2 leads.
262
ACEis lower mortality in STEMI?
ONLY IF there is LV dysfunction or systolic dysfunction
263
When to add prasugrel inSTEMI
If they go to Angioplasty
264
Mechanism of thrombolytics and why time matters
thrombolytics convert plasminogen to plasmin. Plasmin cleaves fibrin clot into D dimer. Normally, once fibrin clot is formed after a couple of hours it is stabilized by factor XIII, Once is stabilized plasmin will not cleave fibrin.
265
Mechanism of B blockers in STEMI
Slow heart rate-- increases coronary artery perfusion, and ncreased left ventricular time increases both stroke volume and cardiac output.
266
Meds in ACS that lower mortality
Aspirin, thrombolytics, primary angioplasty, metoprolol, statins, clopidogrel, prasugrel ticagrelol.
267
Heparin lowers mortality in MI?
only if ST DEPRESSION- NSTEMI
268
When do you give prasugrel, clopidogrel,?
aspirin allergy, they go to PCI, or MI.
269
SE of ticlopidine
neutropenia
270
When to give CCBs in MI
intolerance to b-blockers: asthma patients, cocaine induced chest pain, or Prinzmetal angina
271
When do you give lidocaine or amiodarone in MI
When is Vtach or Vfib. NEVER prophylaxis.
272
In which patients prasugrel cannot be given
>75years and in stroke. It increases bleeding.
273
When is a pacemaker needed in MI
Symptomatic bradycardia, Mobitz II, 3rd degree block, bifascicular block, New LBBB.
274
All complications of MI lead to hypotension
TRUE
275
Dx and tto of cardiogenic shock post MI
Echo, swan-Ganz catheter. ACEI, and urgent revascularization
276
Dx and tto of valve rupture post MI
Echo, ACE, nitroprusside, intraortic ballon bump to bridge into surgery
277
Dx and tto ofseptal rupture post MI
Echo, right heart will show step up in Oxygen. ACE, nitroprusside, and urgent surgery.
278
Dx and tto of Myocardial wall rupture inMI
Echo, pericardiocentesis, urgent cardiac repair.
279
Dx and tto of sinus bradycardia in MI
ekg, and give ATROPINE , followed by pacemaker if ss persist.
280
Dx anf tto of 3rd degree AV block
EKG showing canon a waves(high amplitude), and give atropine and pacemaker.
281
All patients POST-MI should go home on
Aspirin, clopidogrel( or prasugrel), b blocker, statin, ACEi.
282
How is NSTEMI management different from STEMI
NO thrombolytic use, We use heparin ( lMWH>unfractionated), Glycoprotein Iia/IIIb INHIBITORS(ABCIXIMAB) LOWER MORTALITY
283
Abciximab lowers mortality in NSTEMI
yes, particularly in those going for angioplasty
284
ACE and ARBs SE
both cause hyperK, but cough is only caused by ACE
285
In chronic CAD and pain persists despute all treatment
ranolazine- antianginaal- blocks inward sodium currents
286
LDL goal of statins in coronary artery disease and DM
<70
287
Proprotein convertase subtilisin/kexin type 9 (PCSK9). Moa and use
binds (LDL-R) on the surface of hepatocytes, leading to the degradation of the LDL-R and higher plasma LDL-cholesterol (LDL-C) levels. if patients on ACS already on statins and they cannot control severe hyperlipidemia. Injected meds that block clearance of LDL BY THE LIVER FROM THE BLOOD. NO impact on mortality.
288
Alirocumab and evolocumab
Proprotein convertase subtilisin/kexin type 9 (PCSK9). Inhibitors
289
Erectile dysfunction causes post MI
MC is anxiety, but can be due to B blockers.
290
mechanism of rales in CHF
increased hydrostatic pressure develops in the pulmonary capillaries from the left heart pressure overload. It transudates into alveoli. In inhalation the alveoli open with a popping sound referred as rales.
291
Management of Pulmonary edema as manifestation of CHF
LMNOP -I first prior to imaging!
292
Labs to order when patient is with pulmonary edema as complication of CHF
Chest X ray ( pulmonary vascular congestion, cephalization of flow, effusion, cardiomegaly). EKG, Oximeter, Echo
293
MOA dobutamine, inamrinone, milrinone
Phosphodiesterase inhibitors. Increase contractility and decrease afterload.
294
If after LMNO in pulmonary edema patient continues symptomatic
positive inotrope.- dobutamine 30-60 min
295
neVER USE DIGOXIN IN ACUTE TREATMENT OF CHF AND PULMONARY EDEMA
Digoxin can be used in chronic treatment.
296
Treatment of systolic dysfunction chf
ACE/ARBs, b blockers, furosemide, sspironolactone, digoxin if persistent, if still persistent jhydralazine+ nitrates, sacubitril with valsartan
297
Side effects of Mineralocorticoids receptor antogonists (Spironolactone, eplerenolne)
hyperK. Spironolactone can cause gynecomastia and erectile dysfunction. Eplerenone has no andorgenic. IF HYPERK and needed to decrease mortality then five Patiromer.
298
Spironolactone decreases mortality in SYSTOLIC CHF
TRUE
299
Treatment of diastolic CHF
Spironolactone, or eplerenone.
300
Patient with pulmonary edema that has Vtach, next step
Synchronized cardioversion , pulmonary edema is not considered hemodynamically stable.
301
when to do synchronized cardioversion in pulmonary edema
if Vtach, a fib, flutter or SVT- These are considered hemodynamically UNSTABLE!
302
Escalation in treatment of acute pulmonary edema
LMNOP --Inotropes ( Dobuitamine,iunamrinone, milrinone)--> nesitiride (SYNTHETIC FORM OF ATRIAL NATRIURETIC PEPTIDE)
303
What is wedge pressure
Left atrial pressure
304
When to order echo inpulmonary edema secondary to CHF
Once the patient has been stabilized.
305
In systolic CHF what to do if ACE/ARBs cannot be given
hydralazine+nitrates in addition to other meds.
306
Digoxin and diuretics in CHF do not reduce mortality
TRUE
307
what CHF med causes transient excess brightness or vision
ibravidine (Sa nodal inhibitor of funny channels that slow heart rate.
308
Pacemaker in CHF
LVEF <35%, and QRS >120msec
309
All valvular heart disease can be expected to have murmurs and rales on lung exam.
True, can also have peripheral edema, carotid pulse findings, gallop.
310
Tto of most of the murmurs
ACE/ARBS or diuretics.
311
Tto of MVP
B blocker if ss
312
tto of Mitral Stenosis
Furosemide and Na restriction, Balloon valvuloplasty, warfarin and rate control for Afib.
313
Early diastolic decresecendo best heard in the lower left sternal border
Aortic regurgitation.
314
Intensity of murmurs
I/VI only heard with special manuevers ( handgrip, valsalva) , II/VI AND III/VI majority, no obkective difference between these. IV/VI: palpable thrill. V/VI: can be heard with the stethoscope partially off the chest VI: stetoscope no needed to hear it.
315
Best initial test for Valvular lesions, and most accurate
BIT: Echo, MAT: Left heart catheterization.
316
Prognosis of AS
coronary disease: 3-5 year survival, syncope 2-3 year survival, CHF 1.5-2 year survival.
317
AS treatment
Diuretic and TRANSCATHTER valve replacement.
318
Management of bio vs. mechanical valve in AS
Boioprostethic valve will last 10 years but requires no anticoagulation with warfarin. Mechanical valve will last longer but requires warfarin goal INR 2-3.
319
Antithrombotic therapy in mechanical valve
Warfarin with INR 2-3 in Aortic valve replacement without risk factors. Warfarin 2.5-3.5 for mitral valve replacement, and for aortic valve replacement with risk factors: Afin, LV dysfunction, thromboembolism, hypercoagulable state. Always ADD ASPIRIN FOR MECHANICAL VALVES
320
how long mechanical valves last
10-15 years.
321
Causes of AR
HTN, endocarditis, rheumatic heart disease, Marfan, AS, cystic medial necrosis, Syphilis, reactive arthritis.
322
When do you repair Bicuspid aortic valve
>5 cm
323
Complications of bicuspid aortic valve
aneurysm, and endocarditis
324
AR treatment
ACEi/ARBs, NIFEDIPINE.- but these are not proven to decrease velocity of disease. Surgery if LVEF < 55%
325
Murmur in MS
opening snap followed by diastolic rumble, loud S1, as it gets worse the opening snap moves towars S2
326
BIT and MAT in Mitral Stensois
Best initial therapy diuretics, MAT: ballon valvuloplasty
327
Pregnancy is NOT A Contraindication for Ballon valvuloplasty
TRUE
328
Operative criteria for AR and MR
AR: EF<55% AND LV end systolic volume > 55. MR LEVF<60% and LVESD >40
329
Mechanism of fixed splitting of S2 in ASD
LA/RA pressure no change in respiratrion = no change in splitting
330
When is percutaneous repair indicated in ASD
SHUNT RADIO EXCEEDS 1.5:1
331
Causes for Wide splitting of S2, delayed P2
RBBB, Pulmonic stenosis, RVH, Pulmonary HTN
332
Causes for PARASOXICAL splitting of S2, delayed A2
LBBB, AS, LVH, HTN
333
TTO of dilated cardiomyopathy
same as systolic HF- ACE/ARBs, b blockers, furosemide, spironolactone
334
Tto of hypertrophic cardiomyopathy
distolic HF- Spironolactone, or eplerenone.
335
Most accurate diagnositic test in Restrictive cardiomyopathy
endomyocardial biopsy, but usually we do first echo and EKG
336
Amyloid cardiomyopahty ECG and Echo findings
Low voltage ECG and spleckled pattern on echo
337
Treatment of Tako Tsubo Cardiomyopathy
ACEi, diuretics, b blockers.
338
pleuritic vs ischemic pain
pleuritic is sharp, positional. Ischemic is dull and sore.
339
Best initial test in pericarditis
EKG- ST elevation everywhere, and PR segment depression in lead II but this last one is always present.
340
Electrical alternans is seen in which condition
cardiac tamponade
341
earliest finding in cardiac tamponade in echo
diastolic collapse of the right atrium and right ventricle, later findings include equalization of all pressures in the heart during diastole.
342
tto of cardiac tamponade
pericardiocentesis, DO NOT USE DIURETICS
343
Best initial treatment in constrictive pericarditis
diuretic, the most effective treatment is removal of pericardium (pericardial stripping)
344
BIT and MAT in aortic dissection
cHEST X RAY, AND THE MAT is CT.
345
Aortic dissection in CSS
Give b blocker, order EKG and Chest X ray. Then order CT angiography and start nitroprusside to control BP. ICU AND SURGERY CONSUTL,
346
Normal ankle brachial index
>=0.9
347
BIT and MAT in PAD
Ankle brachial test, angiogram
348
Treatment in PAD
Aspirin + High dose statin , then supervised exercise progrma > 3 x/week for 3 months. If despite this persist cilostazole, if persists revascularization
349
CCS, Patient with Afib
Echocardiogram ,TSH,T4, CMP,
350
if severe bleeding occur with warfarin, next step
Prothrombin complex concentrate (II, VII,IX, X)or FPP
351
If bleeding occurs with Xa inhibitors
give andenaxet
352
if bleeding occurs with dabigatran
gice idarucizumab
353
Factor X inhibitos and dabigatran( inhibitoer thrombin) decrease more mortality in Afib than warfarin
TRUE
354
When is obligatory to use Warfarin in Afib
metallic valves or MS
355
Atrial flutter is managed the same as Afib
true
356
Treatment for multifocal atrial tachycardia
If PO2< 55 give O2 first, then diltiazem. NO B BLOCKERS
357
SVT tto
unstable: cardioversion. Stable: first vagal manuevers, IV adenosine, if doesn’t work b blocker, CCBs, or digoxin
358
Best long term tto for SVT
radiofreq catheter ablation
359
CCS syncope
EKG, CMP, CBC, Cardiac enzymes, oxymetry, echo if murmur if present, head CT is neuro exam focal.
360
What class of antihypertensive agent is best known for severe, first dose orhtostatic hypotension
terasozin ( alpha 1antagonist)
361
List 4 primary categories of shock
Hypovolemic, cardiogenic, distributive( septic, anaphylactic shock, neurogenic shock), and obstructive shock ( tension pneumothorax, impeding venous return)
362
Fluids in shock
generally 10-20 cc/kg, but in distrubutive shock be more aggressive 30cc/kg
363
If fluid challenge fail to raise BP in shock patient, next step
Norepinephrine is first line tto for SEPTIC AND CARDIOGENIC SHOCK. Epinephrine for anaphylactic
364
Types of shock and parameters CO, PCWP, SVR, SVO2
Septic: high CO, low PCWP, Low SVR, High SVO2. Hypovolemic: low CO, low PCWP, high SVR,low SVO2. Cardiogenic : low CO, high PCWP, high SVR, Low SVO2. Anaphyactic: high CO, low PCWP, SVR, and SVO2
365
Pulmonary embolism can cause shock
TRUE
366
aortic dissection can cause cardiac tamponade
true
367
What clues suggest Addison disease as a cause of shock
history of steroid, traima, hypotension, eosinophilia, hyperK, and hyponatremia. Treat with steroids and high volumes of fluids
368
Norepinephrine MOA and when to use in shock
alpha1 and beta 1 agonist effects. For hypotension to increase peripheral resistance. 1st line in septic shock and cardiogenic shock
369
Dobutamine MOA and when to use in shock
B agonist to increase cardiac contractility
370
Dopamine
at low doses: affects dopamine receptors--> vasodilation. At higher doses its beta 1 agonist effect increases contractility. At even higher doses has alpha 1 agonist effects and causes vasoconstriction. The b1 agonist activity makes it first line symtpomatic bradycardia.
371
Stages of hypertension
normal <120/<80. PreHTN 120-139/80-89, HTN stage 1 140/90 , stage II >=160/100
372
HTN tto
black: thiazides or CCB, alone or in combination . Other ethnicities: thiazides, ACEi, ARB or CCB Other ethnicities with DM or CKD: ACEi and ARB
373
HTN in pregnancy
Labetalol, hydralazine and alpha methyldopa are safe.
374
Define Hypertensive urgency
>200/120 without ss, if ss is called emergency
375
What tests should be ordered in HTN
ECG, CMP, Urinalysis, CBC, Lipid panel
376
ST changes in leads V5 and 6 are often seen with left ventricular hypertrophy from systolic overload and are termed a "strain pattern."
TRUE
377
Hyperthyroidism algorithm
say it
378
Hypothyroidism algorythm
say it
379
Thyroid nodule algorithm
say it
380
Types of Ca in thyroid
say it
381
Indications for treating in subclinical hyperthyroidism
TSH < 0.1 , or TSH 0.1- 0.5 IF >=65, hear problems, osteoporosis, and nodular disease . TTO is indicated due to the risk of developing overt hyperthyroidism
382
Precocious puberty algorithm
say it
383
Patient with acne, no testes enlargement, and advanced age. No CNS ss, cause?
Peripheral precocious puberty - CAH. There is significant acne, may exhibit hypotension, hypoNa, hyperK.
384
Dx of Congenital adrenal hyperplasia, classic
Elevated 17 hydroxyprogesterone on ACTH stimulation test.
385
Dx of glucagonoma
pancreatic alpha cell tumor. Glucagon > 500. Necrolytic erythema migrans, new diagnosis of DM, weigh loss, GI ss ( diarrhea, constipation), venous thrombosis , neuro ss(ataxia, dementia, proximal weakness)
386
Treatment of glucagonoma
octeotride or surgery
387
Treatment of hyperthyroidism
Anthythyroid drugs ( Methimazole prefered over PTU, unless is 1st trimester pregnancy), radioactive iodine, and thyroidectomy. IN ACTIVE SYMPTOMS ADD B BLOCKER
388
Patients candidate for Antithyroid medications
Mild hypothyroidism, older with limited life expectancy, preparation for radioactvie iodine, pregnancy
389
Patients candidate for radioactive iodine
Moderate to severe hyperTSH with or without ophtalmopathy, patient preference in mild hyperTSH
390
Patients candidate for thyroidectomy
large goiter, suspect cancer, concurrent hyperparaTSH, Pregnant who cannot tolerate antithyroid meds, severe ophtalmopathy, retrosternal goiter with obstructive ss
391
When do you check labs in thyroid disease once starting antithyroid meds?
4-6 weeks after initiating meds, and then every 2-3 months. TSH levels remain suppressed for a while so check with T3 and T4
392
iF YOU WANT TO MONITOR FOR EFFICACY OF antithyroid medications what are the labs you check
TSH levels remain suppressed for a while so check with T3 and T4
393
SE of anithyroid
agranulocytosis and hepatotoxicity
394
Patient with hypertension and hyperK, what do you think of?, next step in management
Hyperaldosteronism - plasma aldosterone to renin ratio
395
Causes of primary hyperaldosteronism and labs
Primary hyperaldosteronism (Conn Syndrome), bilateral adrenal hyperplasia. Low renin and high aldosterone (PAC/PR>20) -- Do CT scan
396
Causes of secondary hyperaldosteronism and labs
High renin, high aldosterone. Renovascular HTN, Malignant HTN, Renin producing tumor, diuretic use, coartaction, cirrhosis (PAC/PR~10)
397
causes of decreased renin and decreased aldosterone, hypertension, and hypoK
Non aldosterone causes: CAH, Cushings, Exogenous mineralocorticoids
398
treatment of bilateral vs unilateral adrenal hyperplasia
unilateral may benefit from surgery, bilateral just medical therapy ( spironolactone, eplerenone)
399
Aldosterone escape mechanism
sodium and water retention volume expansion → secretion of atrial natriuretic peptide (ANP) and pressure natriuresis (other mechanisms may be responsible, although how these operate remains unclear)→ compensatory diuresis → “escape” from edema and formation and frank hypernatremia
400
Why patients with hyperaldosteronism have polyuria
hypokalemia → desensitization of renal tubules to antidiuretic hormone (ADH) → increased water excretion (polyuria) and excessive thirst (polydipsia)
401
The best way to assess diabetic neuropathy
tuning fork
402
First line treatment for diabetic neuropathy
glycemic control + First line meds: duloxetine (SNRI), pregabalin- alter neuronal transmission and decrease pain. TCA decrease pain but not alter transmision. Other meds are gabapentin, lamotrigine, or carbamazepine.
403
what is the advantage of using Glargine or other long acting insulin over NPH
Less risk of hypoglycemia
404
Short acting insulins
Analogs (Lispro, aspart, glulisine), and Regular
405
Peak and duration of short acting insulin
analogs (Peak 0.5-1.5, Duration 3-5hours), Regular ( Peak 2-4h, duration 5-8hrs)
406
Intermediate acting insulin
NPH
407
Peak and duration of NPH Insulin
Peak 4-12 and duration 14+
408
Long acting insulins
Detemir, Glargine, and Degludec
409
Duration of detemir, glargine, and degludec
12-24, 20-24, 42+
410
hypertension, hyperglycemia, osteoporosis, mood swings, and hypoK with metabolic alkalosis
Cushing syndrome
411
Clinical presentation of cushing
central obesity, bone fractures/osteopenia, mood swings, skin atrophy, proximal muscle weakness, glucose intolerance, skin pigmentation
412
Dx of cushing syndrome
24 hour urine cortisol, late evening salivary cortisol, low dose dexamethasone test
413
high cortisol, high/normal ACTH, next step
MRI. If >6mm --> dexamethasone suppression test and CRH suppresion test. If suppressed cortisol but elevated ACTH- cushing disease. If < 6mm or no mass: inferior petrosal venous sampling: high cushing
414
Dexamethasone supression test for Cushing
dexamethasone administration woul decrease cortisol levels
415
Presentation of pseudoparathyroidism
Seizures, muscle cramping, hyperreflexia, basal ganglia calcifications and cataracts- are sign of hypocalcemia.
416
Vit D deficiency related changes in Ca and pphos
Ca and phos are decreased
417
Scuvadiving an epistaxis
barotrauma, generally decongestants and pain control
418
Macrocytosis (MCV >110 fL), diarrhea and neurologic symptoms
Vit B12 def - Diarrhea from celiac sprue, bacterial overgrowth or pancreatic insufficiency can be seen with vitamin B12 deficiency because these are malabsorptive syndromes. Also pernicious anemia
419
folate deficiency does not cause neurologic deficits
develops faster than B12 def, but is often asymptomatic. Causes include nutritional deficiency, alcoholism, malabsorption, pregnancy, chronic hemolytic states and the administration of drugs that interfere with folate metabolism (for example, trimethoprim and methotrexate).
420
MCC of travelers diarrhea
E.coli
421
gas gangrene in a diabetic foot, pathogen?
C. perfringens
422
Carcinoid tumor presentation with and without metastasis
cutaneous flushing, abdominal cramps, bronchospasm and diarrhea, Gastrointestinal carcinoids that have not yet metastasized are much less likely to produce carcinoid syndrome, because the liver metabolizes and clears the portal blood of the vasoactive substances.
423
Carcinoid tumor cardiac complications
Right-sided endocardial fibrosis, with pulmonary stenosis and tricuspid regurgitation
424
Hypersensitivity types
Describe all and examples.
425
extrahepatic manifestations of hep B
polyarteritis nodosa, and glomerulonephritis.
426
Elderly, smoker, Recurrent pneumonia in same place, and imaging also shows some scarring
Bronchogenic carcinoma , in young patients and non-smokers may think of carcinoid tumor.
427
Indications for screening for lung cancer
55-80 years with Hx of 30 packs/year AND currently smoking or stopped within the last 15 years. Diagnosis is with CT and done yearly.
428
SIADH management
1st water restriction, and if still asymptomatic demeocycline
429
The best diagnostic test for diagnosing endobronchial obstruction
Is flexible bronchoscopy is the best first initial tool to assess persistent or nonresolving pneumonia, if they ask about the next step in management would have been CT chest.
430
Well's score
3 Signs of DVT, alternate diagnosis less likely. 2.5 Previous PE, DVT, HR>100, Recent surgery or immobilization. 1 hemoptysis and cancer. > 4 PE likely
431
PE presentation
sudden onset pleuritic chest pain ( hurts with inspiration and movement), loud S2, friction rub, hypoxia, tachypnea and tachycardia, can have small pleural effusion ( in the setting of pulmonary infarction due to inflammation)
432
V/Q scan pretest results
If normal rules out PE, if abnormal ( saying low , medium probability) then it DOES NOT RULE IT, AND IF HIGHLY SUSPECTED BASED ON WELLS START ANTICOAGULATION. High probability on V/Q scan confirms PE
433
Test of choice for diagnosis pneumothorax in the acute setting
Bedside US ( in the ED, ICU). In non acute setting is the UPRIGHT POSTEROANTERIOR CHEST X RAY
434
Patients with OSA are at higher risk for residual anesthesia effect and decreased respiratory drive
True because there is decrease in pharyngeal muscle dilator tone, and they have prior propensity for obstructive apneic or hypoapneic events.
435
patients with respiratory failure due to residual anesthesia effect
respiratory acidosis with normal anion gap, and hypoxemia typically correct with supplementary oxygen.
436
Atelectasis when do they occur?
2-5 days POP, hypoxemia fails to correct with O2 and it is elevated anion gap.
437
cough variant asthma presentation
nonproductive cough triggered by exercise(particularly cold weather), allergens, and forced expiration. Occurs also at night and can present chest tightness. Wheezing and rhonchi are often absent
438
cough variant asthma tto
same as asthma, but If cough is resistant to bronchodilators or inhaled corticosteroids then leukotriene receptor agonists (montelukast) can be used
439
upper airway cough syndrome
sam is postnasal drip
440
Indications of palivizumab in bronchiolitis
Preterm birth <29 weeks, chronic lung disease of prematurity, hemodynamically significant congenital heart disease.
441
Complications of RSV
Apnea ( those premature, chronic lung disease and congenital heart failure are more likely to develop), and respiratory failure
442
Labs in pertussis
lymphocyte predominant lymphocytosis: > 20,000 with >50% lymphocytes.
443
Why does tachycardia in asthma exacerbation occurs, is it contraindication for albuterol?
hypoxia-- activates carotid chemoreceptors that release catecholamines drom adrenal gland, not a contraindication to give albuterol.
444
Weight loss in COPD
Pulmonary cachexia syndrome: =<20 BMI or weight loss > 5%. Caused by: 1. Increased WOB, caloric use, energy imbalance- 2. Inflammation 3. skeletal muscle hypoxia and sometimes glucocorticosteroids.
445
tto of pulmonary cachexia syndrome
optimization of lung function, nutrition supplementation, and exercise.
446
asthma exacerbation+fever, malaise, brownish sputum, eosinophilia, patches in upper lobes
bronchopulmonary aspergillosis -- do either allergy skin testing for Aspergillus or IgE.
447
tto of bronchopulmonary aspergillosis
MAINSTAY IS ORAL STEROIDS , and also voriconazole or itraconazole.
448
How to differentiate pulmonary contusion from pulmonary embolism
pulmonary contusion often occurs in the setting if blunt trauma, has SOB, chest pain, tachycardia, hypoxia BUT respiratory ss can present even 24 hours after insult, and the XRAY SHOWS IRREGULAT , LOCALIZED OPACIFICATION.
449
tto of pulmonary contusion
supportive- pulmonary hygiene, supplemental oxygen, pain management. Most resolve by 3-5 days.
450
patients with pulmonary contusion are at higher risk of pneumonia
true but prophylaxis antibiotics are not indicated
451
Why is the hypoxemia in COPD
low V/Q mismatch. Poor ventilation leads to hypoxic vasoconstriction.
452
Why do COPD patients that are hypoxic improve with supplemental oxygen
despite low V/Q mismatch, supplemental oxygen is able to reach alveoli, decrease the vasoconstriction increasing Q, and overal V/Q.
453
Croup presentation
Inspiratory stridor, cough, hoarseness
454
Croup tto
mild(no stridor at rest): humidified air +/- corticosteroids. Mod/severe (stridor at rest): corticosteroid + racemic epinephrine.
455
Suspects croup, next step?
TREAT! CORTICOSTEROIDS. NO NEED FOR IMAGING, DX is clinical.
456
STOPBANG Questionnaire for OSA
Snoring, Tiredness during day, Observed apnea or chocking/gasping, Pressure high, BMI>35, aGE>50, Neck size M>17 and women >16, Gender Male.
457
Elimination of bedtime alcohol and smoking are preferred strategies for isolated snoring- no OSA
TRUE
458
Factors increasing the malignancy of solitary nodule
Large size (>2cm), Female, advanced age, smoker(previous or active), personal or familiar hx of Ca, spiculated, upper lobe
459
Algorithm of solitary nodule.
say It
460
hypotension and hypoxemia in the absence of infiltrates, requiring intubation
massive pulmonary embolism- patients can have massive RH strain causing RBBB, dilation of the RV and tricuspid regurgitation
461
suspect massive PE, next step
bedside Echo, but first stabilize the patient like with intubation
462
postextubation stridor and hypoxemia, what is it and tto?
laryngeal edema, re-intubate if impending respiratory failure
463
Signs of impending respiratory failure
pH<7.35 AND PCO2>45. clinical signs of respiratory failure, , RR > 25 X 2 HRS, Hypoxemia
464
RF for extubation failure
weak cough, frequent suctionin, poor mental status, positive fluid balance, pneumonia as initial cause of respiratory failure, Age > 65, Comorbid conditions
465
Administration of multiple doses of corticosteroids prior to intubation can prevent laryngeal edema and extubation failure
TRUE
466
Acute respiratory failure due to OSA postop causes
hypoventilation (evidenced by bibasilar atelectasis in the chest X ray) and hypercapnic and hypoxic respiratory failure. With respiratory acidosis.
467
definition of acute bronchitis
persistent cough> 5 days up to 3 weeks, cough can present with purulent yellow or green discharge and this is associated with epitelial sloughing. 90% have a previous URI
468
Presentation of acute bronchitis
persistent cough > 5 days up to 3 weeks, can have purulent sputum, rhinchi at auscultation that clear when coughing. , wheezin, chest wall tenderness an mild dyspnea.
469
tto of acute bronchitis
symptomatic( NSAIDs and bronchodilators), no antibiotics! If pt has fever, suspect bacterial pneumonia or bronchitis with influenza
470
Spirometry in symptomatic and asymptomatic asthma
asthma overall has decreased FEV1/FVC and normal or high DLCO. In symptomatics if we give albuterol there is increase of FEV1 > 15%, and in asymptoamtic and we give metacholine there is a reduction of FEV >=20%
471
Elderly with confusion, hypothermia, tachypnea, hypoxia and hypotension, not responsive to fluids. Next step
Fluids + empiric antibiotics== qSOFA ( RR>22/MIN, AMS, SBP=<100)
472
qSOFA
( RR>22/MIN, AMS, SBP=<100) IF>=2
473
Inhaled bronchodilators in RSV, are they recommended?
Can be used but they do not show evidence that they reduce illness, admission rates, r length of hospital stay.
474
Patients with RSV are at risk of?
Apnea ( those premature, chronic lung disease and congenital heart failure are more likely to develop), and respiratory failure, AND RECURRENT WHEEZING 30%.
475
Low dose chest CT in lung cancer, if positive what is the probability of having cancer?
<10%, has a false positive rate of 96%.So any postiive finding may need confirmation. Screening reduces 20% mortality.
476
Pulmonary embolism and fever
15%, likely due to pulmonary necrosis in the setting of infarction.
477
risk factors for TTN
cESAREA, PREMATURE, MATERNAL DM.
478
Chest X ray finding in TTN
Hyperinflatio (flattened diaphgram), mild cardiomegaly, prominent vascular markings, fluid in the interlobal fissures, and pleural,.
479
prognopsis of TTN
usually resolve by 72 hrs and no long term complicatiosn
480
Management of tension pneumothorax
Needle decompression ins appropriate in the acute setting where cardiac arrest is imminent. However, needle decompression must ALWAYS be followed by chest tube placement. In patients that you identify pneumothorax but there is not yet a big compromise chest tube is the answer!
481
Patient 6 yo who had rhinorrhea 6 weeks ago and since then has only has cough, day and night, next step?
spirometry, think this can be cough variant of asthma. And also a chest X ray.
482
two most important predictors of surivival en COPD
1. FEV 2. AGE. BUT THE SINGLE MOST IMPORTANT IS FEV!!!!!!
483
LYMPHOCYTE PREDOMINANT PLEURAL EFFUSION
Malignancy and TB
484
Tb in pleural effusion
lymohaocyte predominant and elevated adenosine deaminase leve.
485
Suspect TB due to pleural effusion, and imaging on chest X ray, next step
pleural effusion biopsy
486
acute bronchitis can cause hemptysis
true, so do a chest X ray not a CT scan, to rule out other causes malignancy, focal infection, or cardiac disease.
487
first line tto for OSA in children
tonsillectomy and adenoidectomy,
488
Varicose vein tto
elevation and compression stocking, if not helpful after 3-6 months, can try sclerotherapy. Surgical ligation is done for ulcers , bleeding, or recurrent thrombophlebitis.
489
Impact of decreasing smoking in COPD
Will decrease exacerbations, and the risk of developing cancer.
490
Management of chocking
<1 year: back blows >=1 year: abdominal thrust and old alternate between abdominal thrust and back blows.
491
whixh is the most reliabke marker to confirm endotracheal intubation?
persistent capnographic waveform
492
What decreases mortality in sepsis
aggressive fluid administration and broad spectrum antibiotics- should be given within 1 hour of presentation to the hospital- after cultures have been drawn.
493
Patient who you suspect PE and impaired renal function, next step
V/Q scan
494
TB in HIV patients
Those with CD4 count high mount response and cause typical apical, cavitary lesion. In those whom CD4 is very low, causes lobar, pleural or disseminated infection. As pleural effusion are generally a hypersenstitivity reaction to M. tuberculosis, pelural fluid smear is generally aseptic. so pleural biopsy is needed. IF hHIV is newly diagnosed, ARTis often delayed 1-2 weeks after initiating TB tto
495
best initial test for studying hemoptysis
Chest X ray
496
When to give antibiotics in COPD exacerbation
increased sputum purulence, increased sputum quantity, or increased dyspnea. Also need for mechanical ventilation.
497
mcc of hemoptysis
acute bronchitis-- a trial of antibiotics needed if increased sputum quantity or purulence, dyspnea.
498
Choking and then turns unconcious, next step
CPR once unconcious.
499
medical conditionst greatest risk for POP Pulmonary complications
COPD, Cigarrette smoking, Sleep apnea, CHF,
500
iNCENTIVE SPIROMETRY AND Deep breathing exercised to decreas POP lung complications have little to no benefit.
true,and we still do it.
501
ST depression in V1-V2, where is the infarct
posterior wall
502
Aspirin decreases mortality in infarct by ___
25%
503
Anterior MI - artery and ECG leads
LAD V1-V6
504
Inferior MI artery and ECG leads
RCA/LCX II, III, AVF - associated with
505
Which type of infarct is associated with SINUS BRADYCARDIA and AV blocks due to increased vagal tone?
Inferior MI
506
Lateral MI
LCX , elevation of I, AVL V5 and V6
507
Right ventricle MI
RCA ST elevation V4-V6R + INFERIOR LEADS
508
How do you recognize ventricular aneurysm in ECG?
Persistent ST elevation after recent MI, and deep Q waves in same leads.
509
Prognostic indicators in CAD
1. LV function > 50% ( if less, poor prognosis)
2. Vessels involved
3. Left main coronary artery --poor prognosis
4. 2-3 vessels CAD
510
MC cause of sudden cardiac arrest post MI
Vfib
511
Types of arrhythmias after infarct
<10 min: phase 1a ventricular arrythmia- is reentrant
| 10-60 min: phase 1b- abnormal automaticity
512
tto of cardiogenic shock
Dx Echo, swan Ganz
| tto ACEi and urgen revascularization
513
Valve rupture tto
ACEi, Nitroprusside, intraaortic balloon pump as bridge to surgery
514
Nitroglycerin vs Nitroprusside
NG: smooth vessel relaxation, acts in both arteries and venins but more in veins. cleared via liver
NG--> 1,2 glyceroldinitrate + nitrate --> NO
Nitroprusside - same mechanism but nO SELECTIVITY FOR VEINS.
- decreases BP very fast
- cleared via RBC- produce cyanide
- Administration warrants BPmonitoring.
515
SE ACEis and ARBs
CATCHH
| Cough, angioedema, teratogen , increased creatinin, hyperK, hypotension.
516
The most common cause of death from CHF
Arrhythmia/Sudden death
517
BIG FIB Cortisol
```
High blood pressure - increase sensitivity to alpha 1 receptors in arterioles- so epinephrine and norepi can join. in excess acts at mineralocorticoid receptor (aldosterone)
Insulin resistance (DM)
increased gluconeogenesis, proteolysis, lipolysis
```
Decreases fibroblasts (Striar)
Decreases immune and inflammatory response ( causes demarginzalization, inhibit production of leukotrienes and PGs, reduces eosinophils).
decreases bone formation
518
Sources of hypercortisolism and low dose dexamethasone test
- Adrenal - no suppression with dexamethasone
- Pituitary- suppression with dexamethasone
- Ectopic ACTH production ( lung tumor) no suppression
519
Difference between Cushing Syndrome and Cushing disease
Syndrome is MCC exogenous
| Disease: pituitary overproduction of ACTH (70%) or ectopic (small lung)
520
If suspecting cushing next step
24 hour urine cortisol, midnight salivary cortisol, low dose dexamethasone ( would only suppress cortisol if ACTH produced by pituitary)
Then measure ACTH
Then can do MRI , petrosal vein sampling or chest CT
521
How does hypercortisolism causes metabolic alkalosis
Cortisol has both mineralocortioic effects in the kidney. increase hydrogen ion excretion at the distal collecting duct
Also causes hypoK
522
BIT and MAT of hypercortisolism
BIT : 1 mg low dexamethasone ( normally suppresses morning peak)
MAT: 24 hour urine cortisol
late night salivary cortisol( normally should be low)
523
If hypercortisolism and ACTH high, next step?
high dose dexamethasone- if pituitary origin will suppress ACTH
If ectopic, will not suppress
524
If there is a pituitary lesion causing Cushings and it cannot be removed, or there is residual hyperfunctioning, what meds are helpful?
Pasireotide (somatostatin analog)
| Mifepristone ( helps with hyperglycemia)
525
Causes of PTH independent hyperCa
```
Malignancy
Granulomatosis
High vit A and D
Milk Alkali Syndrome
excess Ca intake
thyrotoxicosis
thiazides
immobilization
```
526
Causes of primary hyperPTH
Adenoma, hyperplasia , Cancer
Osteitis fibrosa cystica
familial hypocalciuric hyperCa
lithium
(high ALP,cAMP)
527
Causes of secondary hyperPTH
```
CKD
Vit Deficiency
TUmor lysis syndrome
pacnreatitis
sepsis
PseudohypoPTH
```
528
Causes of primary hypoPTH
Resection ( QZ)
Polyglandular autoimmune syndrome
Infiltrate ( metastasis, wilson, hemochromatosis)
DiGeorge)
529
Presentation of hypoCalcemia
```
seizures
tetany
Chvostek sign
ipsilateral facial muscle contraction caused by tapping the facial nerve
Trousseau sign
carpopedal spasms by inflating the sphygmomanometer above systolic blood pressure
QTc prolongation
laryngospasm
```
CHRONIC BASAL GANGLIA CALCIFICATION AND CATARACTS
530
Tto of hypoCa
1. asymptomatic or patients with chronic hypocalcemia
oral calcium replacement therapy such as (calcium
citrate, calcium carbonate)
vitamin D supplementation
thiazides for patients with hypoparathyroidism
2. symptomatic patients
IV calcium gluconate is the first-line
3. chronic renal failure
phosphate binders
oral calcium replacement
calcitriol
531
tto hyperCa
Mild 11-12: Nothing, or NS
Moderate 12-14: only is ss: NS or calcitonin
Severe > 14:
Always treat
NS (Calcium dehydrates)-acute tto
Calcitonin ( inhibit resorption)-acute tto
Biphosphonates (Zolendronic acid)-- mostly long term
If the cause is sarcoidosis+ granulomatosis+ lymphoma: add steroids
Avoid thiazide and loop diuretics-- they increase Ca.
532
Tto of hypoparathyroidism
1. high doses of VitD ( vit D preferred over 1,25 hydroxivitD because cheaper and effective)- high doses because there is defective 25 hydroxy vitD conversion to 1,25 due to low pTH
2. Calcium
3. Thiazides
533
Patient with hypoparathyroidism treated with Ca and Vit D has increased Urinary calcium excretion, why and next step
because there is low PTH who usually causes resorption of Ca in the kidney)
Add a thiazide - decreases urinary Ca excretion and increases Ca in blood
534
Patient who had sex with woman and condom broke, asymptomatic and wants to be tested for infection. which test
HIV p24 and antibody screening.
Chlamydia only if high risk patient ( men-men, or with urethral discharge)
535
Patient with hypercalcemia , next step?
PTH
536
HyperCalcemia related to Malignancy - causes
PTHrP ( Small cell cancer, renal and bladder, breast, ovarian) PTH activity.
Bone metastasis ( Breast, MM)- increased osteolysis
1,25 hydroxyvit D ( Lymphoma)- increase Ca reabsorption
537
Patient with central hypothyroidism, low cortisol. next step
ACTH level and ACTH stimulation test
538
Treatment of hypoaldosteronism
1. measure cortisol, give IV fluids plus hydrocortisone (provides both mineralocorticoid and glucocorticoid)
2. Prednisone for stable patients(nonhypotensive)
3. Fludrocortisone (steroid highest in mineralocorticoid content) for adrenal insufficiency with continued hypotnesion after prednsione.
539
hypertension + low renin+ low potassium
hyperaldosteronism
540
BIT hyperaldosteronism
plasma aldosterone/plasma renin-- has low renin
541
Most common causes of meningoencephalitis in children
enterovirus (coxsackie, echovirus)
HSV
West nile
542
Can lyme cause encephalitis
no
543
Parathyroidectomy indications
> 50
symptomatic hypercalciuria (> 1 g/dl above normal)
end organ involvement ( osteoporosis, CKD, nephrolithiasis)
urinary Ca >400mg/day
T score < 2.5
544
MEN 1 Pancreatic manifestations
pancreas or gastrointestinal neuroendocrine tumors:
Gastrinoma (recurrent peptic ulcer)
Insulinoma
VIPoma (diarrhea, hypoK,hypoCl)
Glucagonoma
545
organisms in non gonococcal urethritis
Gram stain with leukocytes no organism
Chlamydia
ureaplasma urealyticum
Mycoplasma genitalium (moxifloxacin)
Trichomona Vaginalis
546
Patient who had urethritis treated with azithromycin, comes 2 weeks later due to persistent ss, next steps?
reswab and gram stain.
| NAAT
547
Most cases of unsuccessfully treated Non gonococcal urethritis with azithro are caused by ____ and treated with ______
Mycoplasma genitalium and moxifloxacin
548
Reservoir of human rabies
USA: bats (most common) racoons, skunks, foxes
| developing countries: dogs
549
Presentation of rabies
Encephalitis: hydrophobia and aerophobia ( due to laryngeal spasm), autonomic instability (fever, tachycardia), spasticity, agitation and altered mental status
Paralytic: ascending paralysis
550
postexposure prophylaxis for rabies
Ig and vaccine if not able to test animal or observe
551
pROGNOSIS OF RABIES
Coma, respiratory failure and death within weeks.
There is no treatment, mainly palliative. RABIES IS A VIRAL INFECTION
552
rabies is a viral infection
YES
553
Milwaukee protocol for rabies
experimental, therapeutic coma and antiviral. Currently it is not recommended.
554
Treatment of gestational diabetes once pt has delivered
stop insulin
do a fasting glucose within 24-72 hours after delivery
then at 6-12 weeks postpartum do a glucose tolerance test
They should be screened every 3 years because they have higher risk of developing DM2
if patient had diabetes prior to gestation, usually keep half of the insulin dose required for pregnancy
555
treatment of congenital adrenal hyperplasia
hydrocortisone
556
Patient with parkinson on carbidopa/levodopa and depressive ss, tto?
sertraline. 50% of Parkinson patients have depression
557
treatment of trichomoniasus
single dose of MTZ 2 g. If patient. isbreastfeeding, milk should be expressed and discarded for 24 hours.
558
Papillary carcinoma of the thyroid
```
most common
excellent prognosis
lymph node spread
orphan annie nuclei
psammoma bodies
hx of head and neck radiation
braf and ret mutations
associated with gardner syndrome and cowden
```
559
Patient with papillary carcinoma, next step?
US of the neck and lymph nodes, to asses extension. and determine treatment
560
Treatment of papillary carcinoma
Simple lobectomy: <1 cm and no lymph node involvement
Total thyroidectomy: large papillary, extrathyroid extension, distant metastasis, in pts with head radiation
Neck dissection: involvement of neck structures and lymph node.
561
Follicular carcinoma of the thyroid
```
Solitary cold nodule
Hematogenous spread
good prognosis
hx of head and neck radiation
uniform follicles that invade the capsule of the thyroid
```
562
Medullary thyroid cancer presentation
Sporadic type: elderly
Familial: MEN, RET
Parafollicular cells: calcitonin-- so hypoCa
Can produce ACTH
Dx sheets of cells with amyloidosis
563
Management of DKA
sAY IT
564
Hx of abdominal surgery (14-17 days ago), fever, leukocytosis, pain. in the shoulder
right subphrenic abscess
565
Hx of abdominal surgery (14-17 days ago), fever, leukocytosis, pain in the shoulder. next step?
Abdominal US
566
Patient with bipolar disorder on lithium experiencing depressive ss, and subclinical hypothyroidism. Why and next step
Lithium interferes with synthesis and release of thyroid hormone. Goiter in 50% and 20-30% present hypothyroidism.
Lithium induced hypothyroidism- treat with levothyroxin
567
Vit D deficiency cutoff values for diagnosis
Deficiency < 20 ng/ml
| Insuffienciey 20-30
568
Treatment of Vit D
Cholecalciferol(Vit D3)50,000IU/weekle for 8 weeks until to achieve >30.
Maintenance: 1500-2000IU/day
Malabsorption:3000-6000IU/day
569
Presentation and management of nonfunctioning pituitary adenomas
hypogonadism and low gonadotropins levels
SERUM ALPHA LEVELS INCREASED
Can have compressive ss like headache blurred vision if big.
transphenoidal surgery. - radiation just as adjunctive if there is something left from the surgery.
FSH has both alpha and beta subunits, dysfunctional pituitary adenoma cells just secrete alpha.
570
patient with ataxia, loss of propioception and vibration, tingling + anemia, next step?
vit B12-subacute combined degeneration
THink of pernicious anemia if there is other autoimmune disorder such as hypothyroidism.
571
POEMS SYNDROME
ENDOCRINOPATHY WITH POLYNEUROPATHY
Polyneuropathy.
Organomegaly. Enlarged spleen, liver or lymph nodes.
Endocrinopathy/edema. Abnormal hormone levels that can result in an underactive thyroid (hypothyroidism), diabetes, sexual problems, fatigue, swelling in your limbs, and problems with metabolism and other essential functions.
Monoclonal-protein.
Skin changes. More color than normal on your skin, red spots, possibly thicker skin, and increased facial or leg hair.
572
When correcting for moderate TO severe VitB12 deficiency, which electrolye you have to monitor?
K
Hypokalemia results from uptake of newly form RBCs
So monitor for 24 hours
Some physicians transfuse a package of RBC before treatment with Vit B12
aLSO FOLIC ACID AND IRON GO DOWN
573
What causes molluscum contagiosum
DNA pox virus
574
TTO OF molluscum contagiosum
1.cryotherapy
indications:well tolerated in adolescents and adults
can be too painful for young children, especially with multiple lesions
2.topical podophyllotoxin 0.5% cream
indication:ideal for genital lesions
3. cantharidin
indication: treatment is applied topically in the office and blistering occurs hours later
ideal for children with multiple lesions
575
lesions that resemble molluscum contagiosum in HIV patients
Cryptococcal
576
CSF fluids characteristics of cryptococcal meningoencephalitis
Extremely high opening pressure >250-300 ( yeast and capsule clog the arachnoid villi, prevents csf outflow and ICP)
low leukocyte count < 50 , but lymphocyte predominance
577
tto of cryptococcal meningoencephalitis
3 stages:
Induction: amphotericin B and flucytosine >=2 weeks ( until ss abate)
Consolidation: high dose oral fluconazole for 8 weeks
Maintenance: low dose oral fluconazole for >= 1 year ( in HIV pts can be discontinued after a year if CD4 >100 or if viral load undetectable for 3 months)
578
Difference between primary, secondary and tertiary syphilis
Primary: painless chancre
Secondary: Rash, LAD, Condyloma lata, oral lesions, hepatitis
Tertiary: CNS(Tabes dorsalis, Argyll Robertson)
Cardiac(aortic aneurysm, aortic insufficiency)
Gummas
579
What is Tabes Dorsalis
```
Degeneration of dorsal column
orthopedic pain (charcot joints)
Reflexes decreased
Shooting pain
Argyl Robertson pupil
Locomotor ataxia
Impaired propioception
```
580
Treatment of primary, secondary and early latent (< 1 year)
Benzathine penicillin G 2.4 million U IM SINGLE DOSE
581
Treatment of late latent (> 1 year), unknown duration, gummas, or CV syphilis
Benzathine penicillin G 2.4 million U IM weekly for 3 weeks
582
Treatment of neurosyphilis
Aqueus penicillin 3-4 million units IV Q4H for 10-14 days
583
Treatment of congenital syphilis
Aqueus penicillin 50,000 units/kg/dose IV Q8H for 10 days-
584
Alternative for penicillin in syphilis tto
Doxy, and for neurosyphilis ceftriaxone.
| Pregnant need desensitization
585
Patient with cryptococcus meningoencephalitis who is being treated but has headache, emesis, and signs of ICP. next step?
serial lumbar punctures until ss resolve
yeast and capsule clog the arachnoid villi, prevents csf outflow, and causes increased ICP.
Occasionally some pts may require VP shunt
586
Patient with newly diagnosed HIV who has cryptococacal meningoencephalitis, when do you start antiretroviral therapy
2-10 weeks after initiating treatment for meningitis
587
Antiretrovirals should be started independent of the CD4 count
true
588
Antiretrovirals decrease the risk of transmission to sexual partners
true
589
What type of drug is Canagliflozin, Dapagliflozin
SGLT2 inhibitors- Sodium glucose co-transporter. increase renal glucose excretion by decreasing reabsorption
590
MOA SGLT2 inhibitors (Canagliflozin, Dapagliflozin)
Sodium glucose co-transporter. increase renal glucose excretion by decreasing reabsorption
591
SE SGLT2 inhibitors (Canagliflozin, Dapagliflozin)
```
Euglycemic DKA ( IF fasting, major illness, intense exercise, excessive alcool) - glucose is < 250
UTI/Vulvoganial candidiasis
Hypotension,
AKI
HyperK
Hyperlipidemia
```
592
MOA Thiazoladinediones
Activate PPAR gamma (Peroxisome proliferator activated receptor gamma) and decreases insulin resistance
593
SE Thiazoladinediones
weight gain
Fluid retention -- so CI in HF or pulmonary edema
Myalgia
URI
Increased risk for hepatitis, bladder cancer, osteoporosis
594
What drug class is exenatide?
GLP-1 agonist
| incretin mimetic - activate GLP-1 receptors
595
MOA GLP-1 agonist (Exenatide)
incretin mimetic - activate GLP-1 receptors - delayed gastric emptying, stimulate release of insulin, suppresses appetite.
596
SE GLP-1 agonist (Exenatide)
pancreatitis,
decreased weight
Nausea,Vomit, diarrhea
Black box warning for Thyroid Cancer ( Liraglutide)
597
DPP4 inhibitors and MOA
Sitagliptin, saxagliptin
inhibit degradation of incretins (GLP1,GIP) increasing insulin release
598
SE DPP4 inhibitors
Nasopharyngitis
Pancreatitis
Steven Johnson
599
Sulfunylureas names and MOA
Glipizide, glyburide
Block K channels in B cells causing depolarization- Ca enters and releases insulin
600
Sulfunylureas relation with B blockers
Avoidbecause B blockers can masl sympathetic response of hypoglycemia
They also decease the release of insulin
601
SE of sulfunylureas (Glipizide, glyburide)
hypoglycemia, Weight gain, SIADH
602
MOA metformin
Stimulates AMK
decreases gluconeogenesis
increases insulin sensitivity
603
SE metformin
Lactic acidosis
GI distress
Weight loss
Vit B12/Folate def
CI in renal falures (creat >=1.5) or in contraststudies.
604
Thyroiditis de Quervain tto
NSAIDs and B blocker
605
Difference in presentation between hypoaldosteronisn and addison disease
Hypoaldosteronism: usually asymptomatic, hyponatremia not that evident if cortisol normal. NO FRECKLES , RENIN, NOT ACTH stimulates Aldosterone
Addisson: weight loss, fatigue, myalgias, ACTH causes hyperpigmentation,
606
Dx of Addison disease
low morning cortisol and increased ACTH
607
Patient with monucleosis like ss, oral painful ulcer, rash in the body involving palms and soles. Hx of unprotected sex 2-4 weeks
Acute HIV infection
```
2-4 weeks post exposure
Mononucleosis like ss ( fever, LAD, sore throat)
Generalized rash
GI ss
Painful mucocutaneous ulcer ) mouth)
```
Leukopenia, thrombocytopenia
608
Dx of HIV
HIV antigen
HIV1/HIV2 antibody
HIV viral load
609
Recommendations when taking levothyroxine
take 30-60 minutes prior to breakfast on an empty stomach
Calcium, iron, PPIs, sucralfate decrease the absorption, so calculate to administer these 3-4 hours apart.
610
Drugs that increase metabolism of thyroid hormone
CPR
Carbamazepine,
phenytoin, rifampin
611
Parents asking if HIV kid can go to school and if there are any restrictions? Do they need to disclose with school?
Can go to school without restrictions
Can play all sports, and standard precautions should be taken if there is blood
They do NOT need to disclose with school, is voluntary
may be beneficial for school to monitor for infections though
612
primary amenorrhea, good breast development , no pubic hair/axilla, Dx?
Androgen insensitivity Syndrme - X linked mutation in androgen receptor
613
Diabeitc with foot ulcer, how do you rule out osteomyelitis?
initial screen at bedside is probe to bone testing
If negative do MRI.
MRI will have changes even < 5 days from onset.
614
Diagnosis of Hepatitis C
requires positive HCV antibody and HCV NAT (which measures HCV RNA)
615
What are the diabetic medications that an cause hypoglycemia the most? and particularly in renal failure
Sulfunylrueas (Glipizide, glyburide)
| Meglitinide(Nateflinide, repaglinide)
616
Pregnant women at 26 weeks 50 g oral glucose challenge 145, next step?
If 50 g oral glucose challenge >=140 the do glucose tolerance test (100g)and check each hour after 3 hours. cutoff fasting, 1,2,3 hr:95, 180,155, 140 ( if equal or above in >=2 Dx of gestational)
617
Target glucose levels in GDM
Fasting =< 95
| 1 hour postprandial =<140 or 2 hour postprandial =<120
618
Insulin in GDM decreases the risk of shoulder dystocia
yes, reduces risk of macrosmia and shoulder dystocia.
619
Diabetic meds ok to use during pregnancy
Insulin, metformin, glyburide
620
Nelson's syndrome
enlargement of an adrenocorticotropic hormone-producing tumour in the pituitary gland, following surgical removal of both adrenal glands in a patient with Cushing's disease.
can manifest with compressive ss - hemianopia, and hyperpigmentatiion due to increase ACTH
pituitary enlargement due to the loss of feedback
now the tto for cushing is transphenoid surgery rather than bilateral adrenelctomy
621
impact of improved glucose level on peripheral arterial disease?
NONE, this is considered macrovascular (MI, stroke)
The only things that can be improved: nephropathy, retinopathy.
622
Patient with nodule in thyroid that is confirmed to be medullary cancer, next step?
measure plasma free metanephrines
623
What should you order in every patient with medullary thyroid cancer
```
calcitonin
CEA antibody
Neck US
Abdominal US
Plasma free metanephrines
```
If no metastasis- thyroidectomy
624
Difference between bacterial joint infection vs. Lyme arthritis
```
Lyme:
Arthritis tend to present weeks or months after the insult.
Knee swelling and mild pain
ABLE TO BEAR weight
well-appearing
no fever, no leukocytosis
```
Synovial fluid 20,000-60,000 with neutrophil predominance.
In bacterial: fever, ill-appearing, no bear weight, synovial fluid with cell > 50,000
625
Dx of lyme arthritis
ELISA (enzyme-linked immunosorbent assay) and Western blot
626
Prognosis of Lyme arthritis
Patients are at risk of persistent or recurrent joint damage.
So they need antibiotic 28 days with doxy or amoxi.
Prognosis: most patients are disease free after antibiotic therapy
Rest and avoid impact sports until all symptoms resolve due to risk of further joint damage.
627
Can a patient with lyme arthritis go back to play sports?
Rest and avoid impact sports until all symptoms resolve due to risk of further joint damage.
Patient will likely be cured after antibiotic tto
628
Lyme arthritis tto in children
SAME,DOxy. has been approved even for < 8 years. Due to good CNS penetrance and excellent efficacy with coinfections (Anaplasma)
21 days instead of 28 for children
629
tto of Lyme arthritis
28 days with doxy or amoxi.
630
Synovial fluid in JIA
2,000-20,000 WITH 50-75% neutrophils
631
CENTOR CRITERIA
```
CAFE
Cough absent
Adenopathy
Fever
Exudates tonsillar
```
3 or more: rapid antigen detection test for strep
632
tto for strep pharyngitis
10 days of penicillin V or amoxi
if penicillin allergy:10 days cephalexin or 5 days azythro
633
tto for acute bacterial sinusitis
1st line: amoxi-clavulanate 5-7 days
| Alternative doxy or fluoroquinolone
634
Diagnosis of acute bacterial rhinosinusitis
Any of the following:
>=10 days of ss
>=3 days of severe ss, high fever, purulent discharge, face pain,
Worsening of ss >=5 days after initially improving upper respiratory illness
635
Patient who had intercourse with HIV man, was tested and was negative a month ago. next step?
repeat HIV antibody (p24) and HIV1/HIV2 antibody.
| Window period: first 4 weeks after exposure the titles may be very low causing a false negative.
636
Before starting antiviral therapy in HIV patient, test for ____
Hep B , some antivirals have dual activity against hep B and HIV
HIV patients also screened for TB, HCV, and STIs
637
Definition of failure to thrive
weight below 5th percentile , or downtrending weight crossin 2 or more major percentiles.
```
Inadequate calorie intake
Calorie malabsorption (Celiac, CF)
Increased Calorie use ( Congenital heart disease, hyperTSH)
```
638
TTO OF ACUTE CYSTITIS IN PREGNANT WOMEN
Nitro, Cephalexin, amoxi-clavulanate, fosfomycin for 3-7 days
639
Fluoroquinolones should be avoided in pregnancy
toxic to fetal cartilage development
640
TMP -SMX effects in PREGNANCY
1ST TRIME:neural tube defects due to folate antagonist
| 3rd trim: neonatal kernicterus
641
tto pyelonephritis in pregnant women
IV Ceftriaxone, once afebrile for 48 hours can place on oral antibiotic for 10-14 days.
642
RF for acute pyelonephritis in pregnancy
```
<20
nulliparity
pregestational DM
sickle cell disease or trait
tobacco use
```
643
Complications of pyelonephritis in pregnant
pulmonary edema
respiratory distress syndrome
preterm labor
low birth weight
644
Treatment of acute HepB
Most cases of acute Hep B will RESOLVE SPONTANEOUSLY (even if elevated transaminases) - outpatient and serial follow-up would be tto.
Hospitalization if severe symptoms, fever, hemodynamically unstable, encephalopathy, > 50 years, impaired hepatic synthetic function.
645
When do you consider antiretroviral therapy for hep B
Most cases of acute Hep B will RESOLVE SPONTANEOUSLY (so just supportive tto is needed)
But antiretrovirals for: immunocompromised, Hep C, severe hepatitis, fulminant hepatitis
entecavir (Baraclude), tenofovir (Viread), lamivudine (Epivir), adefovir (Hepsera) and telbivudine (Tyzeka)
646
3 criteria for acute liver failure
1. Hepatic injury (elevated transaminases)
2. encephalopathy
3. INR >=1.5
647
after initial Hep B infection, when. do transaminases normalize as well as HBV DNA levels
transaminases 2-8 weeks
HBV DNA at 6 m
If patient persist with HBV DNA levels after 6 months this is consider chronic hep B
648
Why identification of viral genotype is helpful in chronic Hep B infection
genotype A has better response to interferon therapy
649
Percent of patients with Hep B that evolve to chronic?
Depends on age:
1. perinatally: 90%
2. 1-5 years 20-25%
3. Adults 5%
650
In which patients is metformin contraindicated
renal failure, hepatic dysfunction, alcohol abuse, sepsis and congestive heart failure
651
Patient on metformin undergoing cardiac catheterization, should it be held?
Yes, because of contrast. Should be held the day of the procedure and restart 48 hours after the procedure.
652
pregnant women with hypothyroidism asking about dosing of levothyroxin
increase by 30% at the time of a positive pregnancy test and check every 4 weeks.
653
Thyroif changes. inpregnancy
1st trim: BHCG joins the TSH receptors producing T4 AND T3 that given negative feedback and decreases production of TSH
Estrogen --increases TBG -increasing total T4 and T3
2nd trim
654
High dose dexamethasone test in Cushing interpretation
If suppresses ACTH then is pituitary, if it does not suppress it can be adrenal or ectopic.
655
non supressive high dose dexamethasone and low ACTH , indicates origin is in?
Adrenal gland
656
Patient with meningococcal meningitis, who needs postexposure prophylaxis?
- Family-household member
- Roomates or intimate contacts
- Childcare center workers
- patients directly exposed to respiratory or oral secretions ( kissing, mouth to mouthesucitation, intubation)
- person seated for more than >=8 hours to infected person ( airline traveler)
**coworkers, classmates or teachers do not need
657
what is the postexposure prophylaxis for meningococcal meninigits
1. 4 doses oral of Rifampin ( inhibits bacterial DNA-dependent RNA synthesis by inhibiting bacterial DNA-dependent RNA polymerase)
OR
2. 1 dose of IM Ceftriaxone (safe in pregnancy)
OR
3. 1dose oral of ciprofloxacin
658
Inactivated (killed vaccines)
Polio
| Hep A
659
Toxoid vaccines (inactivated toxin)
Diphteria, tetanus
660
Live attenuated vaccines
MMR + Varicela + Rotavirus
661
Subunit conjugate vaccines
Hep B , HIB, Pneumococcus, meningococcus, pertussis, influenza(injection), HPV
662
CHILDREN OF PREGNANT women can be vaccinated with live vaccines?
YES!
- If children develops rash from varicella vaccine, then isolate mom. but otherwise ok/
663
popcorn calcification in pulmonary nodule indicates
benign finding, pulmonary hamartoma
664
Benign signs of solitary pulmonary nodule
smooth, popcorn calcification, concentric, laminated CENTRAL, or diffuse homogeneous calcification
665
Malignant characteristics of pulmonary nodule
Corona radiata or spiculated
| Eccentric, reticulare, or punctuate calcification
666
Presentation of prolactinoma
PRL decreases GNrh
In premenopausal women: oligo/amenorrhea, infertility, galactorrhea, hot flashs, osteoporosis
In postmenopausal: more compressive ss (headache, vision problems)
667
Complications prolactinoma
osteoporosis
668
Dx of prolactinoma
PRL >200
Rule out renal insuff and thyroid
MRI brain
669
Tto prolactinoma
```
dopamine agonists (cabergoline, bromocriptine)
Trans sphenoidal surgery
```
670
Familial hypocalciuric hypercalcemia mechanism
AD, mutation on calcium sensing receptor (CaSR)
Ca levels are not high enough to cause negative feedback for PTH.
Also because of the mutation there is increased Ca reabsorption
671
Presentation of chagas besides cardiomegaly
Biventricular heart failure R>L
Ventricular apical aneurysm
mural thrombosis and embolic complications
Fibrosis leading to conduction abnormalities - arrhythmias
672
Chagas is a protozoan
true
673
Patient with acute limb ischemia/arterial thrombosis, next step in management?
Heparin followed by emergency surgical revascularization
IV heparin bolus followed by continuous infusion
*** Heparin followed by imaging CT angiography would be reasonable if there is viable limb-- capillary refill intact, color, mild pain.
674
acute limb ischemia-- when does irreversiblemyonecrosis occurs
4-6 hours
675
Factitious vs Malignering disorder
BOTH ARE CONSCIOUS
Factious: consciously creates physical and/or psych ss yo assume sick role and to get medical attention (PRIMARY GAIN)
on self- Munchahausen Sx
on others- Munchhausen by proxy
think of healthcare workers
Malingering: consciously fakes, profoundly exaggerates or claims to have a disorder in other to attain specific 2dary GAIN.
-Different to factitious, complaints cease after obtainin gain)
676
organisms in intraabdominal abscess
bacteroides fragilis, e.coli
677
patient with fever, pain in knee, wrists, hand joints, and pustules in hands.
- history of inconsistent condom use
- dx and next step?
Disseminated gonoccocal infection
| - NAAT urogenital specimen
678
Disseminated gonococcal infection presentation
inconsistent condom use
present with oligo or polyarthritis
or the triad of:
1. Dermatitis - 2-10 pustules in the distal extremities
2.Tenosynovitis- swelling and pain with passive extension of multiple tendons
3. Polyarthralgia
679
presentation of parvovirus in adults
often asymptomatic
| may present with fever, arthritis/arthralgia, and reticulated or lacelike rash
680
Gonoccal infection treatment
DUAL THERAPY:
single dose of IM Ceftriaxone
single dose of azythromycin, regardless of the Chlamydia status, to limit antibiotic resistance
** Doxycycline 7 days can be used instead of azytrho if allergy
681
mutiple cutaneous papules with central umbilication in HIV patients, which is the organism
Cryptococcus
head and neck preferred location
682
Mycobacterium avium skin lesions
polymorphous , rash, papules, nodule or ulcer
683
Pyoderma gangrenosum is associated with
IBD
684
Patient with HIV with cryptococcus skin lesions (resemble molluscum), what would yield the diagnosis
Biopsy of the lesion (will show encapsulated yeasts)
685
treatment of cutaneous cryptococcocis
2 weeks of amphotericin B + Flucytosine
| Followed by 8 weeks of fluconazole
686
Presentation of diphteria
```
Corynebacterium diphteria (toxin)
<15 yo, unvaccinated
```
fever, malaise, sore throat
pharyngitis (grey patches, pseudomembranous ) scrapping causes bleeding
COMPLICATIONS: toxin mediated myocarditis, neuritis renal disease
687
Complicatios of diphteria infection
toxin mediated myocarditis(complete heart block, heart failure)
, neuritis (peripheral neuropathies) - NO MENINGOENCEPHALITIS
renal disease
688
Treatment of diphteria
Erythromycin or penicillin G
| For severe Diphteria anti-toxin
689
Guillain Barre caused by either URI or GI infection, examples of organisms involved
Mycoplasma pneumoniae
| Campylobacter
690
Healthcare provider that was exposed to HIV through pts needle, next step?
start prophylaxis within 1-2 hours, and continue for 4 weeks
| Then do HIV testing agan at 6 weeks and 4th months
691
Human bites most common organisms
MC: Eikenella(gram negative anaerobe)
others: viridians, s.aureus, fusoacterium
692
Management of human bites
irrigated, debridates,
LEAVE OPEN (UNLESS THE FACE) FOR SECONDARY INTENTION CLOSEURE
+Antibiotic (Amoxi-clavulanate)
693
Tetanus prophylaxis
clean + immunized ( 3doses): give vaccine only if last booster >=10 years
clean +(unimmunized, unknown, <3 doses): vaccine
dirty + immunized : give vaccine if last >=5 years
dirty + unimunzed: Vaccine + Ig
694
patient with HIV bites another person, risk of HIV transmission?
VERY LOW! if patient has undetectable viral count
695
Antibiotic used for human bites
Amoxi-clavulanate
696
Acute rheumatic fever cause and presentation
Untreated Strep A pharyngitis - murmur
```
JONES FEAP
Joint( migratory arthritis)
Ocarditis
Nodules (subcutaenous)
Erythema marginatum
Syndeham chora
```
```
Minor cirteria:
Fever
Elevated CRP, EST
Arthralgias
Prolonged PR interval
```
697
Kid with emotional liability, decline in school performance distal hand movements that progress to facial grimacing and jerking, hypotonia global, pronator positive, relaxation of patellar reflex is delayed and MURMUR. dX
Sydenham chorea due to ARF
698
Sydenham chorea due to ARF
Kid with emotional liability, decline in school performance distal hand movements that progress to facial grimacing and jerking, hypotonia global, pronator positive, relaxation of patellar reflex, ballisumus is delayed and MURMUR.
699
When do carditis and Sydenham chorea develop after strep A pharyngitis untreated?
carditis : 3 weeks
| syndenham chorea: 1-8 months
700
Kid with emotional liability, decline in school performance distal hand movements that progress to facial grimacing and jerking, hypotonia global, pronator positive, relaxation of patellar reflex is delayed and MURMUR. next step?
echo! carditis
ARF
ALSO IS Syndenham chorea
701
treatment of Acute Rheumatic Fever and complications
Penicillin continued until adulthood to prevent recurrence of ARF
Corticosteroids can be given but only in the severe cases, they can decrease the duration
702
Why is aspirin avoided in children
Reye syndrome: acute non-inflammatory hepatic encephalopathy resulting in fatty liver as a result of viral infection treated with aspirin
```
nausea and sudden-onset vomiting
diarrhea
lethargy
irritability
restlessness
delirium
seizures
coma
```
increased LFTs, ammonia,
CT with cerebral edema
703
Teenager with 3cm firm mass subareolar, cervical LAD, next step?
Observation and reassurance
Pubertal gynecomastia
- normal to have a < 4 cm firm, mass, subareolar can be bilateral or unilateral
- No pathologic signs: galactorrhea, axillary LAD, systemic illness
704
prognosis of Pubertal gynecomastia
resolves in 1 year
705
Iodine induced thyrotoxicosis presentation
patient who had nodulat thyroid disease, in the setting of dietary iodine deficiency , develop areas of autonomous functioning thyroid tissue.
When exposed to radiocontrast (i.e., cardiac cath), amiodarone, topical antiseptics this triggers thyrotoxicosis due to increase iodine available
706
treatment of Iodine induced thyrotoxicosis
b blockers initially
but consider thionamides for persistent hyperthyroidism ( 4-6 weeks), severe ss, or older pts with underlying cardiac condition
707
treatment of toxic megacolon by C. diff
IV metronidazole and high dose oral vanco
708
Patient with acute prostatitis on Cipro who develops C.diff infection. Next step?
Stop cipro, initiate vanco andTMP-SMX
709
High risk antibiotics - associated with C. diff
clindamycin, fluoroquinolones, 3-4th generation cephalosporin, carbapenems, monobactams
710
Low risk antibiotics - associated with C. diff
```
MATT
Macrolides
aminoglyceosides
tetracyclines
TMP/SMX
```
711
Treatment of C.diff recurrence
oral vancomycin 2-8 weeks OR
| 10 days of fidaxomicin
712
tto of C.diff in patients wi have ileus
rectal vanco + IV metronidazole
713
How long do pts with infectious mononucleosis have to avoid sports?
avoid sports for >=3 weeks (>=4 weeks contact sports)
714
rash from EBV often erupts after inappropriate administration of amoxi or ampi
likely immune mediated to derivatives of penicillin
| THIS IS NOT CONSIDERED A TRUE ANTIBIOTIC REACTION
715
tto of Kawasaki
IVIG
716
prognosis of mononucleosis infecciosa
ss will improve but fatigue can last even for >6 months
| - pts with preexistent mood disorders are at higher risk of chronic fatigue
717
Classification of C.diff infection
non severe CDI
severe CDI (Leukos >=15,000, and or serum creat >=1.5)
Fulminant (hypotensin, ileus, megacolon)
718
Complications of untreateated chlamydia or gonorrhea
```
PID
Ectopic pregnancy
pharyngitis
Infertility
Disseminated gonococcemia
```
719
Complications of untreated chlamydia in pregnant women
preterm premature rupture of membranes
preterm labor
postpartum endometritis
720
Fetal Complications of untreated chlamydia
neonatal conjunctivitis
| neonatal pneumonia
721
RF for abruptio de placenta
HTN , cocaine use
722
RF for pyelonephritis in pregnancy
untreated bacterirua, DM, smoker
723
tto of cardiovascular manifestations (i.e Afib, atrial flutter) in hyperthyroidism
b blokers, block sympathetic activity
724
Treatment of pediatric pneumonia
preschool age or focal findings (can be even air bronchograms) --likely S. pneumonia --> high dose amoxi
older age, diffuse finding-- azythromycin
725
Organisms causing OMA
S.pneumonaie
NON TYPABLE Hemophilus influenza
Moraxella catarrhalis
726
Treatment of Acute otitis media
1st Line: Amoxi
2nd line Amoxi-Calvulanate
If allergy to penicillin:azithromycin or clinda
727
Complications of Acute otitis media
TM rupture
hearing loss
Mastoiditis
MENINGITIS
728
Otitis media + purulent conjunctivitis (otitis-conjunctivitis syndrome), which organism
non-typeable HiB
729
Dx of OMA
Bulging TM
| Effusion ( limited motility to insufflation) + TM inflammation
730
When is myringotomy and tympanostomy tubes placement indicated in OMA
persistent effusion for more than 3 months
OR >=3 episodes in 6 months
OR >=4 episodes in 1 year
731
timeframe and characteristics of postpartum thyroiditis
up to 1 year after pregnancy
hyperthyroid ss + thyroid peroxidase antibody, low RAIU
High thyroglobulin
have a hypothyroid state prior to returning to euthyroid state
732
Management of influenza
healthy patients >48 hrs of ss onset:sympttomatic care with acetaminophen
Patients with< 48 hrs should be treated with Oseltamivir, as well as ptswith high risk of complications regardless of duration:
Age >65
Woman who are pregnant and women up to 2w postpartum
Underlying medical condition
Immunosuppression
morbid obesity
Nursing home and chronic care facility residents
733
Oseltamivir MOA
ihibiting the activity of the viral neuraminidase enzyme found on the surface of the virus, which prevents budding from the host cell, viral replication, and infectivity.
734
Who should receive Oseltamivir for influenza?and why?
reduce duration of illness, and complications ( pneumonia)
Patients with< 48 hrs should be treated with Oseltamivir,
as well as pts with high risk of complications regardless of duration:
Age >65
Woman who are pregnant and women up to 2w postpartum
Underlying medical condition
Immunosuppression
morbid obesity
Nursing home and chronic care facility residents
735
HIV associated lypodystrophy is associated with 3 things, and how does it presents
insulin resistance,dyslipidemia, cardiovascular complications
1. Lipoatrophy: loss of subcutaneous fat - skeleton appearance
2. Fat accumulation: dorsocervical fat "buffalo hump" and visceral abdominal fat - increase abdominal girth (Despite loss of subcut fat)
can have either one or both.
736
Treatment of antiretroviral therapy associated displipidemia, hepatoesteatosis
statins - rosuvastatin, atorvastatin, pravastatin
737
pregnant women with HIV, indications to do vaginal vs. cesarea delivery
Avoid artificial ROM, fetal scalp electrodes, operative vaginal delivery
If Viral load <= 1,000:ART +vaginal delivery
If viral load >1,000: ART +Zidovudine +cesarean delivery
738
postpartum management of both mom and infant HIV
mom: ART
infant: if maternall viral load =<1,000: Zidovudine for >=6 weeks
If maternal load > 1,000: ART
739
Can mom with HIV breastfeed baby? even if both receiving treatment?
NO, give formula
740
CI of breastfeeding (7)
```
active untreated TB
HIV infection
Varicella
Herpetic lesions
Chemo/radiation
substance use
Galactosemia
```
741
Pre exposure prophylaxis of rabies
vaccine at 0,7,&21 or 28 days
742
Postexposure prophylaxis for rabies in unvaccinated
rabies vaccine 0,3,7,and 14 days
Rabies Ig on day 0
If vaccinated: vaccine on days 0& 3
743
Postexposure prophylaxis for rabies in vaccinated
vaccine on days 0& 3
if unvaccinated :rabies vaccine 0,3,7,and 14 days
Rabies Ig on day 0
744
Benefits of hormone replacement therapy
remember estrogen/progesterone for those with uterus
estrogen alone for hysterectomy
Benefits: decrease menopausal ss, decrease all cause mortality (< 60 years), decrease risk of colon cancer, DM2, bone mass/fractures
NO EFFECT ON ALL CAUSE MORTALITY >=60
745
Detrimental effects of hormone replacement therapy
```
increased risk of
DVT
breast cancer
coronary heart disease
ischemic STROKE
Gall bladder
```
746
Most common organism causing Erysipelas
Group A Strep (S.pyogenes)
747
Eryipelas presentation
superficial, red, edema, well demarcated
abrupt onset
systemic ss (fever)
often involves lower extremities but 5-20% can be in the face
748
Indications of parathyroidectomy
Age < 50
Systemic hypercalcemia
Complications: osteoporosis, nephrolithiasis/calcinosis, CKD (GFR<60)
Elevated risk for complications: elevated Ca > 1 above normal, urine Ca 400mg/day
749
CLABSI stands for
Central line associated blood stream infection
- usually associated to skin organisms: coagulase negative staph, s.aureus, candida, gram -.
750
Duration of ___ with a central line increases the risk of CLABSI
6 days
751
Organism that causes Herpangina
Coxsackie A
752
Presentation of Herpangina
summer
3-10 yo kids
fever, malaise,drooling, sore throat, decreased appetite
vesicles in palate
753
tto of herpangina
saline gargles
antipyretics
analgesics
cold popsicles
* ss resolve in a week
754
prevention of herpangina transmission
hand washing
755
how to differentiate herpangina from herpes
herpangina has vesicles mostly in back of the palate and tonsills, while herpes is most anterior mucosa, gingiva, and perioral skin. They look sicker.
756
triad of mono
fever, diffuse bilateral cervical LAD, exudative pharyngitis
757
although less common in acute HIV, patients with HIV experience seborrheic dermatitis
TRUE! may complain of dandruff and scaly rash
758
Pregnancy complications of subclinical hypothyroidism
```
recurrent miscarriages
severe pre-eclampsia
pre-term birth
low birth weight
placental abruption
```
759
Chest Xray findings in TB
apical cavitation 70%, bilateral hiliar LAD, pleural effusion
760
Patient with respiratory ss and X ray concerning for TB, next step for dx?
sputum sampling and culture
3 sputum samples in a 8-24 hr period, one of them early morning. And send sputums for acid fast bacillus smear, mycobacterial culture and NAAT
ALTHOUGH tuberculin and IFgamma are also for screen these do not differentiate for latent vs. active.
761
3 sputum tests for acid fast bacilli are negative but tuberculin test is positive, how to interpret?
patient may have active TB still, await for the rest of the results. -- from mycobacterium culture and NAAT
If those are negative then latent infection.
762
3 related thyroid syndromes related to amiodarone
1. Decreased peripheral conversion of T4 to T3. Patients are clinically euthyroid---- no tto needed
2. Increased iodine from amiodarone inhibits thyroid hormone synthesis leading to primary hypothyroidism --> levothyroxine
3. Amiodarone induced thyrotoxicosis (AIT):
AIT 1: increased thyroid hormone synthesis
AIT2: destructive thyroiditis --steroids
In both TSH is low.
763
Aspirin in high doses (>2g/day) displace displaces thyroid hormone from TIBG leading to hyperthyroid ss
true
764
propanolol decreases peripheral conversion of T4 to T3
true
765
MCC of Traveler's diarrhea
E.coli
766
Diarrhea +prominent abdominal pain+ pseudoappendicitis +bloody diarrhea. ORGANISM?
Campylobacter
767
Organisms to think about > 2 weeks diarrhea
Cryptosporidium/Isospora/Microsporidia
Cyclospora
Giardia
768
Patient in whom you suspect herpes zoster, next step?
Dx can be just clinical
Oral VALACYCLOVIR - reduce the risk of transmission, formation of new lesions, and postherpetic neuralgia
769
Precautions for localized and disseminated herpes zoster infection
localized: standard precautions and lesion cover
disseminated: contact and airborne precautions
only healthcare providers immunized should be allowed to come in.
770
Cause of acromegaly
Overproduction of GH- Leading to soft tissue overgrowth
MCC Pituitary adenoma
771
Presentation of acromegaly
```
increased hat, ring, show
Carpal tunnel syndrome, OSA
Body odor ( sweat gland hypertrophy)
Coarsening facial features, teeth widening from jaw growth
Deepening, voice
Colonic polyps and skin tags
```
HTN
CARDIOMEGALY, HTN, DIASTOLIC DYSFUNCTION
ERECTYle dysfunction due to increased prolactin cosecreted from pituitary
INSULIN RESISTANCE
772
Best initial test for acromegaly
IGF1
| Most accurate: glucose suppression test ( glucose should suppress GH normally)
773
tto of acromegaly
1. Transphenoidal resection of pituitary
2. Cabergolin: (dopamine inhibit GH release)
Octeotride (somatostatin inhibit GH release)
Pegvisomant (GH antagonist)
3. Radiotherapy
774
If patient with acromegaly is not treated is at risk of dying from?
cardiovascular disease!!
They also have increased risk of colon cancer
775
Pediatric sepsis tto if =< 28 days and > 28 days.
MC organisms and tto
=< 28 days: E.coli and Group B strep(agalactiae)
Ampicillin + Gentamicin or Cefotaxime ( Cefotaxime preferred due to high risks of gent resistance and better CNS penetration)
> 28 days: S. pneumoniae, N. meningitidis
Ceftriaxone or Cefotaxime
+/- Vancomycin(when meningeal involvement is suspected)
776
workup for neonatal fever
```
CBC
Blood culture
Urinalysis
urine culture
CSF cell count
CSF culture
```
777
Abcs that should be avoided in neonates due to risk of hyperbilirubinemia
Cefriaxone and sulfas
778
Patient with HIV and TB who was initiated on appropriate management, and comes back after 6 weeks with worsening of TB ss. What is happening
Immune reconstitution inflammatory syndrome (IRIS)
779
Immune reconstitution inflammatory syndrome (IRIS) in HIV , how does it happen
Patients with HIV who start ART experience a potent immune recovery, CD4 improve and viral load undetectable. This renewed activity to fight to infection then causes a rebundant reaction if there is an ongoing infection--> paradoxical worsening and often occurs after weeks of initiating antiviral.
IRIS is transient, and no need for further changes in therapy or management is needed. --just symptomatic
780
Patient with recent onset of amiodarone, now complaining of fatigue and weight gain think of?
hypothyroidism, in patients with chronic amiodarone therapy check TSH every 3-4 months.
781
Dx of pheochromocytoma
24 hour urine fractionated metanephrines and catecholamines
or plasma free metanephrine
** sometimes can be falsely elevated if TCA or decongestants, so stop 2 weeks prior to test
782
patient in whom suspect pheochromocytoma, positive 24 hour urine metanephrines and catecholamines, next step?
CT abdomen
If positive: surgical eval, genetic testing, alpha (phenoxybenzamine) and b blocker for BP control before surgery (usually 10-14 days) and if tumor > 5 cm and suspicion of extraadrenal disease do MIBG (METAIODOBENZYLGUANIDINE)
IF negative: MIBG, octeotride scan, whole body MRI or PET
783
Patient with pheochromocytome undergoinf tumor resection, than becomes hypotensive. Next step?
IV fluid bolus, followed by infusion
Pressors if unresponsive
784
Mechanism and tto of hypotension during pheocromocytoma removal
decrease in catecholamines after tumor removal
and persistent alpha blockage (phenoxybenzamine) prior to surgery
tto IV fluids and pressors if unresponsive
785
Mechanism and tto of hypertensive crisis during pheocromocytoma removal
increase of catecholamine release due to endotracheal intubation and manipulation of the adrenal gland.
increase of NE with large tumors (> 4 cm)
tto: IV nitroprusside, phentolamine, nicardipine
786
Mechanism and tto of hypoglycemia during pheocromocytoma removal
increase insulin following removal of tumor (catecholamines suppress insulin secretion)
IV dextrose infusion
787
Mechanism and tto of cardiac arrhythmias during pheocromocytoma removal
increase cathecholamines due to adrenal handling
IV lidocaine or esmolol
788
Patient complaining of erectile dysfunction, low testicular volume, bronze skin, high AST/ALT, , dX?
Hereditary Hemochromatosis AR
789
tto Hereditary Hemochromatosis
therapeutic phlebotomoy--- 1 united of blood every week (removes 250 mg iron) until iron levels normalize
790
tto Wilson disease
penicillamine
791
fever, drooling, tripod positioning, respiratory distress, stridor Dx and tto
Epiglotittis--- bag valveask ventilation while preparing for INTUBATION
and then antibiotics: CEFTRIAXONE OR CEFOTAXIME PLUS VANCOMYCIN
792
TTO of epiglottitis
INTUBATION
| and then antibiotics: CEFTRIAXONE OR CEFOTAXIME PLUS VANCOMYCIN
793
tto croup
racemic epi and corticosteroids
794
Patient with HIV, not yet on ART with thrombocytopenia. Cause?
HIV associated thrombocytopenia- can occur at any time of disease
due to immune dysfunction or viral destruction of megakaryocytes.
rarely associated with bleeding
Just start ART as this may help. No need of corticosteroids unless bleeding.
795
Virologic failure in HIV definition
failure to achieve < 200 copies/mL in 6 months of ART ( due to resistance or nonadherence)
796
Goals of viral load with ART
<5,000 by a month of ART
<500 by 2-4 months of ART
< 50 BY 4-6 months of ART
797
Patients with hemochromatosis are susceptible of which infections
listeria
vibrio vulnificus
yersinia enterocolitis
798
RF for rhino-orbital-cerebral mucormycosis
DM
Hematologic malignancy
Solid organ transplant
799
tto rhino-orbital-cerebral mucormycosis
surgical debridement and amphotericin B . once treated for a couple of weeks with amphotericin B it can be step down to other antifungal e.g.,posaconazole.
800
Dx rhino-orbital-cerebral mucormycosis
sinus endoscopy with biopsy and culture
801
tto of actinomycosis
high dose penicillin
802
tto aspergillosis
voriconazole
803
tto nocardia
TMP-SMX -- pulmonary or CNS (abscess) disease
804
MCC of meningoencephalitis
enterovirus (coxsackie)
herpes
arbovirus ( West Nile)
805
MCC of cellulitis vs. abscess
cellulitis: S.pyogenes ( poorly demarcated, flat and tender to palpation)
Abscess: S. aureus
806
cellulitis presentation
poorly demarcated, flat and tender to palpation
| +/- fever
807
Exercise induced amenorrhea effect on bone, TRG
Osteopenia, osteoporosis
mild hyperTRG
infertility
breast and vaginal atrophy
808
Patient with recent nasal septum surgery with nasal packs, that developed fever, hypotension, rash in palms and soles, vomiting, diarrhea. What does he have, and underlying mechanism
Toxic Shock Syndrome
bacterial exotoxin production!
809
tto for toxic shock syndrome
Extensive fluid replacement ( can be 20L day) + Clindamycin (prevent toxin synthesis)+ Vanco(erradicate organism)
NOT CORTICOSTEROIDS
810
Presentation of POP atelectasis
2-5 days after surgery ( likely thoracoabdominal)
increased WOB and hypoxemia
Chest X ray with LINEAR OPACIFICATIONS
811
Management of POP atelectasis
if no significant secretions : CPAP
| if significant secretions: pulmonary hygiene, chest physiotherapy and frequent suctioning.
812
Treatment of active TB
RIPE (Rifampin, Isoniazid, pyrazinamide, ethambutol) x 2 months
RI x 4 months
813
Treatment for latent TB (4 options)
1. Isoniazid +Rifapentine weekly for 3 months under strict supervision ( not recommended in hIV)
2. Isoniazid x 6-9 months
3. Rifampin x 4 months
4. Rifampin + isoniazid x 4 months
814
patient with clinically high suspicion of bacterial meningitis and Gram stain negative, how to interpret?
check if the patient has been treated with antibiotics before
also pretreatment causes higher CSF glucose levels and less protein
815
Vomiting predominant food born disease causes
S.aureus, B.cereus, Norovirus
816
Patients with impaired fastign glucose levels are at risk of
coronary artery disease (even with normal lipid profile) and progression to overt DM
817
impaired fasting glucose leves
100-126
Dx of DM: ABOVE 126
818
When do you normally give Varicella vaccine
2 doses
12-15 months
4-6 years
819
Absolute contraindications for varicella vaccine
```
anaphylaxis to neomycin
anaphylaxis to gelatin
pregnancy
immunossupressed state:
congenital immunodeficiency
long term immunosuppressive therapy
hematologic or solid tumors
severe HIV infection
```
820
is it ok to vaccinate kid if there is a pregnant women or immunosuppressed family member at home?
YES, but careful watch for rash
if that happens isolate until the lesions have crusted over
- if it happens immunosuppressed family member should receive Ig. ( within 10 days of initial exposure)
821
reproductive effects of anabolic steroid use
decreased testosterone, LH, FSH
Testicular atrophy
decreased spermatogenesis
normal libido and erectile function (during use)
decrease libido and erectile dysfunction (during withdrawal)
gynecomastia/acne
822
Heme and endocrine effects of anabolic steroid use
increased LDL, decreased HDL
| Erythrocytosis
823
acute cystitis can cause hematuria
true
824
patient with recurrent UTIs, sexually active and has used spermicides
treat with antibiotics, and start postcoital antibiotic prophylaxis - TMP-SMX, nitro,cephalexin.
If these do not work may consider doing a renal US, but it is not the first choice.
825
healthcare worker that was exposed to urinein his eyes of patient with HIV, next step?
follow-up counceling.
urine, feces, tears, and vomitus are considered NONINFECTIOUS IF there is no visible blood in it.
826
high risk and possible risk fluids in HIV patients for transmission
high risk: blood, semen, vaginal secretions
possible risk:cerebrospinal synovial, pericardial, amniotic fluid
827
duration of Postexposure prophylaxis for HIV
generally 4 weeks
828
Patient with CNS infection and hyperglycemia, why is it caused?
stress hyperglycemia -- seen in severe illnessess, due to increased release of catecholamines cortisol)
829
RF for stress hyperglycemia
```
severe illness
temperature > 39C
sepsis
meningitis
admission to the ICU
```
830
Stress hyperglycemia is associated with
increased morbidity
there is no relationship with subsequent development of DM,or altered glucose metabolism
831
treatment of stress hyperglycemia
in adults avoid dextrose containing fluids, and insulin can be given to maintain glucose levels betwen 140-180.
In children there is no data
832
Dx of DM
Random >=200
OR fasting >=120
OR hBa1c >=6.5
OR 2hr glucose >=200 tolerance test
833
Treatment of TSH pituitary adenoma
Somatostatin analgo
Transphenoidal sx
** these tumors secrete biologically inactive alpha subunit and other pituitary hormones
834
kid with cat bite in hand, clean. next step
prophylaxis with amoxi clavulanate, do not close, irrigate , and tentanus prophylaxis as appropriate
835
wounds/bites with high risk of infection
```
crush injurie
cat and human bites
bites on hands and feet
wounds on bodys > 12 hrs, or on face > 24 hrs
bite wounds in immunocompromised
```
836
cat bite organism
pastereulla
837
Should you treat asymptomatic bacteriuria? >100,000cfu/ml with a single organism
NO, usually resolves within 2 weeks. no need of additional testing either.
Only treat in pregnant women, undergoing urologic procedures, or within 3 months of kidney transplant.
NOT EVEN IN ELDERLY!
838
diagnostic test for EBV
heterophile antibody test aka monospot test-- which screens for IgM antibodie
839
Patient with mono who hasdifficulty breathing, tonsills are huge almost to midline. Next step
admit and steroids
840
steroid indications in EBV infection
airway obstruction
overwhelming infection
aplastic anemia
thrombocytopenia
841
modification of short acting insulin during exercise
decrease the dose of short acting insulin within 1-3 hours prior to exercise, with the reduction proportionate to the intensity of the workout
If the exercise is prolonged > 60 minutes and will occur in the morning, the dose of basal (long acting) should be decresed too.
intake of additional carbs is recommended.
842
Med of choice for hyperTSH in 1st trimester of pregnancy
PTU, metimazole should be used in the second and third trimester due to the risk of liver failure with PTU
843
METhIMAZOLE teratogen effects in 1st trim
aplasia cutis, tracheoesophageal fistula, choanal atresia.
844
egg allergy is nOT a contraindication for influenza!
true
845
side effects of isoniazid
liver damage, can range from hepatitis to liver failure within the first 2 months.
- should be discontinued with LFTs > 5 x UNL or > 3UNL with ss
if alcoholic is taking is very likely to have
846
tto of TB in pregnancy
3 DRUG -- RIE x2 , RI x7 months
give pyridoxine
monitor closely, these meds cross placenta but have not been assocaited with teratogen effects.
847
Patient with HIV, CD4 count < 200, presenting with fever, peluritic chest pain, dry cough. At exam with murmur and chest X ray with nodular opacities. Dx?
Septic emboli secondary to infectious endocarditis
848
Septic emboli secondary to infectious endocarditis, can look as nodular opacities in chest X ray
TRUE
849
PCP in chest x ray
interstitial infilitrates/ground glass opacities
850
urinary ss, terminal hematuria, peripheral eosinophilia. Dx?
urinary schistosomiasis (parasito) - SubSaharan Africa
851
Dx of urinary schistosomiasis
urine sediment microscopy
852
tto of urinary schistosomiasis
praziquantel
853
effects of syphilis during pregnancy
IUGR, fetal demise, congenital syphilis
854
transmission of malaria
bite from Anopheles mosquito
855
prevention of malaria
there are antimalarial regimens prior to travel-- depend on the typ eof malaria and resistance- atovoquone/proguanil, mefloquine, doxy
856
presentation of malaria
periodic fever, headache, chills myalgia, THROMBOCYTOPENIA
857
Dx of malaria
peripheral smear
858
Differential dx of fever for returning traveler
incubation < 10 days: typhoid, dengue, chikunguya, influenza, legionella
incubation 1-3 weeks: malaria, typhoid, leptospirosis, schistosomiasis, rickettsial disease
> 3 weeks:TB, leishmania, parasites
859
typhoid fever presentation
stepwise fever, non bloody diarrhea, relative bradycardia, rose spots
860
tto typhoid fever
ciprofloxacin
861
when do you receive tetanus vaccines
2,4,6m and 4 yo
862
hookworm (Ancylostoma, necantor) presentation
abdominal pain, bloody diarrhea, poor growth, weight loss
microcytic anemia
eosinophilia
863
hookworm (Ancylostoma, necantor) tto
albendazole, nitazoxanide
864
Complications of hyperthyroidism
arrythmia, cardiomyopathy
| osteoporosis (T4 stimulate Ca and phosphorus release from bone)
865
treatment pneumocystis jiroveci
TMP-SMX
866
TTO Rickettsia
Doxy, including for children and pregnant
867
presentation rocky mountain fever
north carolina
triad: fever, headache, rash
malaise, fever, lethargy
macular and petequial rash on wrists and ankles (around days 3-5 )- can spread to the trunk
labs: hyponatremia, thrombocytopenia, high ALT/AST
868
complications of rocky mountain fever
encephalitis, pulmonary edema, bleeding shock
869
Dx of Rickettsia
Ricktessia serology
| Skin biopsy
870
mode of transmission for rickettsia
tick
871
treatment of chronic bacterial prostatitis
6 weeks of ciprofloxacin or TMP-SMX
872
chronic bacterial prostatitis presentation
> 3 months with urinary ss, pain with ejaculation, genital discomfort.
exam can have mil hypertrophy, tenderness or edema
Dx with urinalysis before and after prostatic massage, ( or examination of expressed prostatic fluid)
873
First line for Benign prostetic hyperplasia
Tamsulosin- alpha 1 agonist that relaxes the smooth muscle of the bladder neck.
874
tto of Lyme for pregnant women
14-21 days of amoxi or cefuroxime
no risk for fetus!
875
in which patients with DM do you start statin?
>=40 yo with DM type I or type 2
876
Treatment cat scratch disease
Azithromycin
When it is not very clear can cover with clindamycin for Staph, and strep
877
cat scratch disease can also cause meningoencephalitis in rare cases, tto?
doxi + rifampin
878
who should be screened for osteoporosis with DEXA?
>=65
and postmenopausal < 65 with risk factors: low body weight, smoker, steroids, family hx of hip fracture
879
When are biphosphonates indicated (3)
1. osteoporosis
2. osteopenia (-1 to -2.5) + history of fragility fx
3. osteopenia (-1 to -2.5) + 10 year risk of osteoporotic fracture >=20% or hip fracture>=3% based on Frax
880
Excessive drinking (3x/day) is associated with increased fracture risk
true
881
estrogen and hepatitis increased TBG, need increase of levothyroxine dose
true
882
Things that decrease the Thyroid binding protein
anabolic steroids
chronic hepatitis
hypoproteinemia (nephrotic sx)
glucocorticoids
883
In type DM1 strict glycemic control can decrease the incidence of new neuropathyand slow the progression of already existing one! but this is NOT TRUE FOR DM 2!
In DM2 strict glycemic control will only help nephropathy and retinopathy.
884
why do you whan HCV RNA PCR instead of antibodies
1. Antibodies cannot say if it was past or active infection.
2. Usually antibodies develop too late! 2-6 months after exposure, while RNA PCR within days up to 8 weeks.
885
Hepatitis C presentation
Usually asymptomatic
nausea, jaundice, right upper quadrant pain
transaminases 10 to 20 times higher, high ALP, high bilirubin
886
Resolved Hep C infection markers
Hep C antibodies positive, Hep C RNA PCR negative
887
Treatment Giardia
Tinidazole, MTZ
888
Who should be treated with Giardia
SYmptomatic and positive stool cultures. They should attain from water venues for 2 weeks.
No need to treat asymptomatic patients with positive stools.
889
painless red macules that rapidly evolve to pustules/bullae, then quickly evolve to necrosis ulcer. +fever in immunosuppressed. Dx?
Ecthyma gangrenosum- pseudomonas
890
how to differentiate Ecthyma gangrenosum vs clostridium myonecrosis
clostridium myonecrosis is painful, severe muscle pain, purple colored bullae
891
tto ecthyma gangrenosum
piptazo+ gentamicin
892
neurosyphilis can occur at any time, even during secondary syphilis.
it presents with meninigitis , posterior uveitis ( floaters), otosyphilis (hearing loss), can have Facial nerve compromis
eye: can have posterior uveitis, retinitis, optic neuritis
893
SE of thyazoladinediones(pioglitazone)
```
HEART FAILURE, PULMONARY EDEMA - in patients with underlying cardiac condition
weight gain
myalgia
hepatitis
osteoporosis
high risk of bladder Ca
```
PPAR gamma receptors in kidney increase sodium reabsorption. These drugs are PPAR gamma agonists
894
presentation Rubeola
cough, coriza, conjunctivitis, fever, koplik spots
cervical LAD
maculopapular rash cephalocaudal
895
tto rubeola
supportive, vit A for those hospitalized
896
presentation Roseola
high fever for 3 days, maculopapular rash develops once fever stops, nagayama spots ( erythematous papules found on the soft palate and uvula)
897
Whipple's triad
ss of hypoglycemia
documented hypoglycemia
resolution of hypoglycemia when glucose is given
898
Hypoglycemia + Elevated insulin, C-peptide, proinsulin. next step?
serum assay for oral hypoglycemic agents
that setting can be either insulinoma or oral hypoglycemic agents (sulfonylureas)
if insulinoma the next step is Abdominal CT
899
patient recently treated for Acute otitis media, now asymptomatic and at exam has retracted tympanic membrane with yellow fluid and decrease mobility. next step?
Watchful waiting.
He has serous otitis media or otitis media with effusion which can last up to 3 months.
If patient is asymptomatic no further tto
If symptomatic may consider antibiotic
900
antihistamines and decongestants are not recommended in < 6 years due to SE.
true
901
Definition of delayed puberty in males
lack of testicular enlargement (>=4ml) by 14 yo
902
Causes of delayed puberty in males
due to inadequate secretion of testosterone
Primary hypogonadism: Klinefelter disease
```
Secondary hypogonadism
Constitutional growth delay
Chronic illness
malnutrition
HypoTSH
Hyper PRL
Kallman syndrome
Cranyopharyngioma
```
903
Workup for delayed puberty
LH, FSH, testosterone, PRL, TSH,
904
Dx of Klinefelter
Karyotype 47 XXY
905
Adenovirus presentation
conjunctivitis, cervical LAD, pharyngitis, fever
| ss last < 1 week
906
children with 2 cervical LAD, painful. and conjunctivitis. All > 2 weeks, kittens at home
Oculoglandular Syndrome ( Parinaud Syndrome) can present in cat scratch fever
often when scratch occurs near the face. Unilateral LAD, conjunctivitis. Tends to be more chronic
907
How to differentiate adenovirus presentation from oculoglandular syndrome from cat scratch fever.
Adenovirus: conjunctivitis, cervical LAD, pharyngitis, fever
ss last < 1 week
Oculoglandular sx:often when scratch occurs near the face. Unilateral LAD, conjunctivitis. Tends to be more chronic > 2 weeks.
908
Complications of cat scratch fever
lymph node suppuration
909
complication of adenovirus infection
keratitis
910
complications of severe DKA
cerebral edema
911
Dx of bacterial pharyngitis
throat culture or rapid strep test
if rapid strep test + : treat
if rapid strep test. -: then do throat culture
912
tto of strep pharyngitis
penicillin or amoxicillin for 10 days
penicillin allergic: cephalosporin ( mild reaction) or azithro ( if anaphylaxis)
913
when do you treat subclinical hyperthyroidism
```
TSH <0.1 OR
TSH between 0.1-0.5 PLUS:
Age >=65
Cardiac disease
Osteoporosis
Nodular disease
```
914
patient with minor trauma in foot now with erythema and edema on the calf, fever, hypotension, pain out of proportion. Dx? Organism?
Necrotizing fascitis
S.pyogenes
915
Types of necrotizing fascitis
I: in patients with DM or PAD (often polymycrobial)
II: in healthy people, precipitating factor: minor trauma, laceration ( S. pyogenes)
916
tto of necrotizing fascitis
can be either polymicrobial (type I) or by GAS (Type 2)
so when not clear:
- Pip tazo or carbapenem to cover S. pyogenes
- Vancomycin S. aureus
- Clinda - inhibit toxin formation from strep/staph
917
After thyroid cancer resection how should you treat the patient?
levothyroxine.
Goal of TSH is normally low in normal range to avoid stimulation of resting Ca thyroid cells.
small risk tumor: Target TSH 0.1-0.5 for 6-12 months, then low normal range
intermediat: Target TSH 0.1-0.5
high risk tumor : target TSH <0.1
918
PATIENT WITH DM who has elevated anion gap metabolic acidosis , think of ?
metformin related lactic acidosis
| particularly in patients with renal disease, heart failure, liver disease and hypovolemia
919
why do we give 10 days of amoxi or penicillin for strep pharyngitis
to prevent acute rheumatic fever
to prevent suppurative complications(peritonsillar abscess, cervical al lymphadenitis)
to decrease duration and severity
prevent spread to close contact
IT DOES NOT PREVENT GLOMERULONEPHRITIS
920
Complications of strep pharyngitis
peritonsillar abscess
cervical lymphadenitis
acute glomerulonephritis
acute rheumatic fever
921
When does post strep GMN develops
1-3 weeks after eithr cutaenous or pharyngitis
922
mom infected with Hep B in third trimester. Management for baby
At birth: Vaccine and Ig
complete series of Hep B 0,2,6
At 9 months do serology HBsAg- if not detected not infected
There is no point of checkin transaminases before even if infected they remain asymptomatic and there is minimal elevation of enzymes.
923
presentation of erysipelas
fever, nd acute rapdily progressive erythema well demarcated raised borders. S. pyogenes
can involve LAD-- which. isdifferent from cellulitis and abscess
924
tto of erysipelas
ampi, amoxi
925
management of incidentalomas
adrenal incidentalomas: always study further even if patient asymptomatic:
24 hour urine catecholamines, metanephrines, VMA,
Surgical excision if: 1. functional, 2. malignant features 3. > 4 cm
rest can be observed
926
Patient who needs CABG, and in workup found subclinical hypothyroidism.next step
best to do surgery right now (life threatening surgery)
if levothyroxine is started in MI can further worsen myocardial ischemia, or cause arrhythmia
Is ok to pursue surgery if there is. no myxedema or severe ss
927
Definition of hypoglycemia
< 60
in newborns <45
928
treatment of sporothricosis
3-6 months of oral itraconazole
929
presentation of sporothricosis
papule-ulcer--odorless drain
proximal lesions along the lymphatic chain
LAD OR Systemic ss are rare
930
difference in presentation between cat scratch fever and sporothricosis
cat scratch- prolonged fever, scratch, regional adenopathy ( can also have oculoglandular sx presenting with conjunctivitis )
sporotrichosis: starts with a papule that ulcerates, drain odorless. lesions are proximal to lymphatic chain. BUT IS RARE TO HAVE LAD OR SYSTEMIC SS
931
When do you use reverse T3
low TSH to identify if it is central hypothyroidism (low t4 leads to low rt3) from euthyroid sick syndrome
932
euthyroid sick syndrome why is it caused? tto?
aka low t3 syndrome
Peripheral conversion from T4 to T3 inhibited by increased cortisol, inflammatory cytokines, starvation, amiodarone, glucocorticoids.
No need to treat unless it persists when patient is back to his baseline.
933
tratment of CAP
OUTPATIENT:
healthy: Macrolide or doxy
comorbidities Fluoroquinolone or B lactam +macrolide
FLOOR:
Levofloxacin
B lactam + macrolide
ICU
B lactam+ macrolide
B lactam + fluoroquinolone
934
When do we use CURB 65 and what is it
to determine hospitalization and mortality in pts with pneumonia
```
Confusion
Uremia > 20
RR>=30
BP <90/<60
65 aGE >=65
```
1-2: LIKELY inpatient
3-4: urgen admission , icu
935
Healthy male, with difficulty swallowing solid foods, sometimes chest pain below sternum, no weight loss. Dx?
Esophageal stricture--secondary to GERD that was untreated.
Presents with obstructive dysphagia difficulty swallowing solid food, prolonged and careful chewing, swallowing small proportion of foods.
936
RF for rectal prolapse
prior pelvic surgery
women > 40 with multiple deliveries
increased intra abdominal pressure ( constipation, straining, BPH)
Stroke, dementia
pelvic floor dysfunction or anatomic defects
937
Rectal prolapse presentation
different to hemorrhoids
mass extending through the anus with CONCENTRIC RINGS of mucosa.
- difficulty defecation
- pelvic discomfort BUT NOT PAIN
- Diarrhea/fecal incontinence
Can be partial: only mucosa, or complete: full thickness
938
tto of rectal prolapse
medical: if partial, sometimes able to reduce manually. recommend fluid intake fiber, pelvic floor exercises.
surgical: complete/full thickness, high risk. ofstrangulation!
939
acute vs chronic radiation proctitis
acute: diarrhea, mucus discharge, tenesmus within 6 weeks of radiation. - treat symptomatic- antidiarrhea
chronic: similar ss + associated with stricture, fistula formation, rectal bleeding >9 weeks, -- tto sucralfate corticosteroids
colonocospy in both can show pallor, friability, telangiectasis
940
Carboxyhemoglobin effect on cardiac enzymes
can increase them and cause MI
It also causes lactic acidosis
941
Complex regional pain syndrome cause and stages
injury causes increased sensitivity to sympathetic nerves, abnormal response to and sensation of pain (pain out of proportion), increased neuropeptide release causing allodynia
Stage 1. Burning pain, edema, vasomotor changes
Stage 2 worsening edema, skin thickening, muscle wasting
Stage 3. limited ROM and bone demineralization on X ray
942
Dx of CRPS
autonomic testing to see high resting sweat output
| or MRI
943
tto of CRPS
sympathetic nerve block, regional anesthesia
944
Complications of Sicca syndrome
dental caries, candidiasis, chronic esophagitis
945
patient with dysphagia to solids and occasionally to fluids, weight loss, ear pain, next step
nasopharyngeal laryngoscopy
946
2 main histopathologic types of esophageal cancer and location
Upper esophagus: squamous cell carcinoma ( alcohol, tobacco)
mid to lower esophagus: Adenocarcinoma (Esophago de Barret in GERD)
947
Patient with oligoarthritis, uveitis, urethritis, recently with diarrhea. Dx?
Reactive arthritis - elevated WBCs with negative bacterial culture in synovial flui
948
What is Reactive arthritis and why is it caused
spondyloarthropathy
Caused by genitourinary (Chlamydia) or GI (Salmonella, shigella, campylobacter, yersinia)
Causes peripheral asymmetric oligoarthritis +
uveitis, urethritis, achiles enthesitis, dactilitis, keratoderma blennorrhagica.
949
tto reactive arthritis
NSAIDs, and antibiotic if urinary infection.
950
complication of reactive arthritis
aortitis
951
what percent of patients with rheumatoid arthritis have HLA-B27
30-50%
952
Who are at risk of developing reactive arthritis
HLA-B27 and Chlamydia infection
953
improvement of epigastric pain with meals
duodenal ulcer, they have worseing of ss at night because there is no meals.
Associated with H.pylori
954
exacerbation of epigastric pain with meals
gastric ulcer
955
H.pylori is associated with duodenal ulcers
true
956
triple therapy for H. pylori
omeprazole, clarithro, amoxi
957
How do you confirm eradication of H.pylori after tto
fecal antigen test or urea breath test 4 weeks after completion of therapy
H.pylori serology should not be used since is continues positive 1 year or more after eradication
958
most sensitive examination finding for scoliosis
thoracic or lumbar prominence on forward bend test
scoliometer: if >=7 degrees (>=5 in obese): clinically significant scoliosis.
959
if >=7 degrees (>=5 in obese): clinically significant scoliosis. , next step?
PA and lateral spine X rays.
960
patient with suspicion of scoliosis, X ray shows Cobbs angle. What angle is diagnostic of scoliosis and how is subsequent management?
Scoliosis: >=10 degrees Cobbs angle
Mild: <20 - observation is ok
moderate 20-40: brace
severe >=40: surgery consult, probable spinal fussion
961
complications of scoliosis
chronic back pain, pulmonary compromise
962
management of sulfunylurea overdose
octeotride -somatostatin analogue that decreases insulin
963
patient with DM on sulfunylurea with hypoglycemia event, not responsie to IV dextrose x. 3. next step?
octeotride
964
Bone tumors associated with Paget Disease
osteosarcoma, giant cell tumor
965
Presentation of Paget Disease
usually asymptomatic
Skull: deformity with enlargement, hearing loss, dizziness
Spine and pelvis: bone pain, spinal stenosis, nerve compression
Long Bones: BOWING deformities with an increase risk of fracture
CAN BE ASSOCIATED TO CHF
966
suspect paget disease, next step
Ca and ALP
Phosphorus is normal
Radionuclide bone scan
967
tto of Paget disease
biphosphonates
968
prognosis of hearing loss in paget?
37% of patients have it
| Calcitonin and biphosphonate may slow the progression but does not reverse the loss that has already occurred.
969
2 conditions with high stool osmotic gap
lactose intolerance and celiac disease
970
4 malabsorptive syndromes
1. Lactose intolerance
2. Chronic pancreatitis
3. Celiac disease
4. SIBO
971
SIBO presentation
malabsorption
Macrocytic anemia
B12 def
+ lactuLOSE breath test
972
Calculation of stool osmotic gap and interpretation
290mOsm - 2 (Na stool+ stool K)
< 50 secretory
>125 osmotic diarrhea
in between is indeterminate
973
histologic findings celiac disease
villous atrophy, intraepithelial lymphocytic infiltrate and crypt hyprplasia
974
treatment of dermatitis herpetiform in celiac
dapsone in addition to gluten-free diet
975
patient diagnosed with celiac, what other things need to be done
check iron, folate, calcium, ABED
DXA at diagnosis ( repeat in one year if osteopenia)
Pneumococcal vaccine -- due to associated hyposplenism
976
patient being rescued from burning apartment , singeing of facial hair. What is she at risk?
supraglottic edema - inhalation injury
977
Treatment of lead poisoning
mild ( 5-44) no medication and repeat labs 1 months
moderate (45-69) DSMA,succimer
severe (>=70) Dimercaprol PLUS EDTA
978
Suspect Sjogren syndrome, next step
Anti Ro and Anti La antibodies
Schirmer test for tear production
979
Patients with Sjogren syndrome are at risk of developing which type of tumor
B CELL LYMPHOMA - b cell activation in the setting of chronic inflammation
980
Alternative for biphosphonates in Paget?
calcitonin
981
76 yo man with pain and restriction of hip, X ray with thickening of outer cortex of his left proximal femur with mild bowing. Sclerotic lesions seen. Technetium with increased uptake from frontal bone, and other bones. Dx and tto
Paget, biphosphonates
982
underlying mechanism of Paget disease
osteoclast abnormality leading to increased bone turnover and impaired bone remodeling.
983
Initial and MAT for dx of acute cholecystitis
Initial test is Abdominal US
Most accurate test: HIDA scan (hepatobiliary iminodiacetic acid scan)
984
tto for biliary colic and cholecystitis
cholecystectomy
985
tto for choledocolitiasis
ERCP +/- Cholecystectomy
986
tto for cholangitis and gallstone pancreatitis
IV fluids, ERCP + CHOLECYSTECTOMY
For cholangitis antibiotics, and ERCP is to drain the bile needs to be done within 24-48 hrs.
987
Dx and tto of cholangitis
ERCP
If contraindications for ERCP ( hemodynamic instability, altered mental status) drainage via percutanous cholecystectomy is acceptable
988
Charcot triad for cholangitis and Reynold's pentad
Fever, jaundice, RUQpain
| + hypotension and altered mental status (SHOCK!)
989
Polymyalgia rheumatic presentation
Age > 50
bilateral pain and morning stiffness > 1 month, > 1 hr
involve neck, shoulders, proximal thighs
Can have constitutional ss
990
Polymyalgia rheumatica dx and tto
ESR > 40, elevated CRP, normocytic anemia
CK is normal
tto: low dosee prednisone- there is signficant improvement
991
Complication of polymyalgia rheumatica and treatment for complication
Giant cell arteritis
biopsy first followed by high dose prednisone
992
the primary treatment for all hernia types
surgical repair!
the risk of strangulation is higher with femoral hernias
993
biliary colic can present as epigastric pain, radiating to the back, and to the right shoulder
true
994
for biliary colic , next step
transabdominal US
995
If gallstones on imaging, but no ss. next step?
No need of treatment
996
If gallstones and ss, next step
cholecystectomy elective
| If poor surgical candidate ursodexocolic acid UDCA
997
If biliary colic ss but no gallstones on imaging
cholecytokinin stimulated cholescintigraphy
if there is low ejection bladder-- cholecystectomy.
998
abdominal pain, jaundice, and dilated duct but no fever. Dx?
choledocolithiasis
999
exertional dyspnea, cough, hypercalcemia, elevated ESR DX?
Sarcoidosis
1000
Pulmonary test in sarcoidosis
mix of restrictive( reduced diffusion capacity) and obstructive ( FEV< 80%, FEV/FVC 80%)
1001
Tto sarcoidosis
corticosteroids
1002
Lofgren syndrome
from sarcoidosis
| triad: fever, erythema nodosum, bilateral hilar adenopathy
1003
presentation of sarcoidosis
```
young, african american
constitutional ss
cough, dyspnea with exertion, chest pain
skin lesions
anterior/posterior uveitis
lofgren syndrome (fever, erythema nodosum, bilateral hilar adenopathy)
HEPATIC SARCOIDOSIS- high ALP, GGT
```
1004
alcoholic found in the street unresponsive, with large hematemesis likely due to mallory weiss tear. next step
endotracheal intubation, once stable upper endoscopy would be appropriate for diagnosis and tto
1005
treatment of variceal hemorrhage
octeotride ( decreases pressure reducing splachnic blood flow)
1006
when do you use fresh frozen plasma
It decreases the risk of bleeding due to coagulation factor deficiencies
INR>=2
Excess of warfarin
Vit K def
deficit coagulation factors (DIC, liver disease)
1007
when do you use cryoprecipitate
to give fibrinogen
contains fibrinogen, fibronectin, vWF, VIII, XIII
use with: fibrinogen <80-100 in massive hemorrhage
or replacement of VIII or Vwf
1008
Alcoholic patient who underwent band ligation and received octeotride, now going home. On which medication should he be going with
non selective b blocker- nadolol and propanolol.
reduce the pressure in the portal system
1009
management of splenic rupture in the setting of EBV
Volume resuscitation until patient stable and then pursue CT scan with contrast--assess severity and if extravasation.
Ideally should be managed NON-OPERATIVELY (serial Hb check, embolization) to preserve splenic function
If pt persists unstable he may require surgery
1010
faint erythematous RETICULAR rash + arthritis
Parvovirus
1011
Difference in presentation of parvovirus in children vs. adolescents and adults
children: slapped cheek, rarely arhtralgias
adolescent/adult: acute onset symmentric joint pain, swelling, stiffness after flu like ss
1012
prognosis of parvovirus infection/arthralgias
self resolving, no long term sequelae
1013
organism in hand foot mouth disease
coxsackievirus
1014
treatment and prognosis of hand foot mouth disease
supportive, hydration
lesions improve in a week
handwashing important because can be contagious even after weeks of rash disappearing.
1015
what causes isolated gastric varices
splenic vein thrombosis
- likely accompanied with GI bleeding and hx of pancreatitis or pancreatic cancer
- splenic vein runs posterior to pancreas and if inflammation it can damage or be compressed causing thrombosis
1016
left sided portal hypertension presentation and cause
cause: chronic splenic vein thrombosis
ascites, congestive splenomegaly, signs of hypersplenism ( anemia, thrombocytopenia)
1017
Dx and tto of splenic vein thrombosis
Dx: multiple modalities: CT scan, MRI, doppler
tto: splenectomy
1018
Budd chiari cause and presentation
thrombosis of hepatic veins or intra/suprahepatic inferior vena cava.
RUQ, hepatomegaly, jaundice, rapidly developing ascitis
1019
Angiodysplasias bleeding is common in the following conditions
End stage renal disease
Aortic stenosis
VonWillebrand Disease
1020
tricuspid valve is assocaited with carcinoid sx
true
1021
angiodisplasias present as flat, cherry red lesions in the right colon
true
1022
organisms in pediatric septic arthritis
<3 months: S. aureus, GBS, gram negative bacilli
| >=3 months: S.aureus, S. pyogenes
1023
septic arthritis in neonates or infants can present without fever, and likely has poor feeding, pseudoparalysis of involved extremity in addition to inflammatory markers
true,
| US shows effusion
1024
US would not show effusion in developmental hip dysplasia.
ture
1025
legg calve perthes presentation
3-12 years
acute onset, not wanting to bear weight
deformity in femoral head
inflammatory markers are normal
1026
Kawasaki Criteria
CRASH
```
Fever > 5 days
Conjunctivitis
Rash in perineum, inguinal folds, trunk- morbiliform with DESQUAMATION
Adenopathy >1.5 cm
Strawberry tongue
Hand and feet erythema and edema
```
1027
partial kawasaki treatment
if patient has >=3 criteria, the next step is to order CRP, ESR and follow-up daily to assess for appearance of new symptoms
1028
scarlet fever presentation
sand like paper rash- small papules
pharyngitis
strawberry tongue
circumoral pallor
1029
scarlet fever tto
amoxi
1030
kawasaki tto
IVIG ( reduces risk of sequelae- unknown mechanism) +aspirin
1031
when do coronary artery aneurysm presents in kawasaki?
10th day of fever
obtain echo at diagnosis, then at 2 and 6 weeks after treatment
1032
when do an echo should be obtained in Kawasaki
at diagnosis, then at 2 and 6 weeks after treatment
1033
Kawasaki being discharged from hsopital after treatment, recommendations?
defer live vaccines for 11 months after IVIG
1034
How do you diagnose spinal stenosis? X ray or MRI?
MRI
1035
patient with acute onset of periumbilical pain, and Afib. Dx?
acute mesenteric ischemia
pain out of proportion, no peritoneal signs, nausea and emesis
1036
causes of acute mesenteric ischemia
1. Occlusive (MC): embolic phenomena (Afib), segmental intestinal strangulation and volvulus
2. Non occlusive: hypoperfusion from splanchnic (low cardiac output)
1037
dx acute mesenteric ischemia
CT angiogram
1038
difference between acute mesenteric ischemia and acute colonic ischemia
acute mesenteric ischemia
embolic(Afib), splanchnic hypoperfusion
pain out of proportion, no peritoneal signs, nausea and emesis
acute colonic ischemia: hypoperfusion (hypotension)- splenic flexure, rectosigmoid areas. mild pain, BLOODY DIARRHEA
1039
Management of Barret esophagus
No dysplasia on endoscopy: PPI + repeat endoscopy in 3-5 years
Low grade dysplasi: PPI + surveillance endoscopy 6-12 months , and can consider endoscopic eradication
high grade: endoscopic eradication
1040
Salicylate toxicity aspirin
```
tachypnea
tachycardia
hepatitis
fever
N/V
pulmonary edema
arrhythmias
cerebral edema- seizures
```
1041
Anticholinergic toxicity
fever, tachycardia, mydriasis, flushing, urinary retention
1042
organosphosphates presetnation and tto
irreversibly inhibit ACHE
DUMBBELSS-diarrhea, urination,myosis, bronchospasm, bradycardia, excitation skeletal muscle, lacrimation, sweating, salivation
atropine ( competitive inhibition) +pralidoxime ( regenerates AcHE)
1043
Atropine/antimuscarinic tox presentation and tto
fever, dry mouth, flushed skin, cyclopefia, disorientation
tto:physostigmine
1044
salicilate toxicity treatment
alkalinization of urine and plasma with IV sodium bicarb
other ttos include glucose (add dextrose to bicarb fluids to avoid neuroglycopenia), activated charcoal if within 2 hours, dialysis.
1045
tto of scaphoid fracture
wrist splint and repeated X ray in 7-14 days, or an immediate MRI
Non displaced fractures can be treated with short arm thumb pica cast, but displaced may require surgery eval
1046
Complication of scaphoid fracture
non union if avascular necrosis occur if they are not treated appropriately
1047
CREST is a subtype of scleroderma
```
Calcinosis/antiCentromere antibodies
Raynaud's
Esophageal dysmotility
Sclerodactily
Telangiectasis
```
P- PULMONARY HYPERTENSION
ANTI CENTROMERE > ANTI SCL-70
1048
Manifestations and treatment of scleroderma (ANA 95%. Antitopoisomerase Anti Scl 70 in 30%)
Lung: fibrosis and pulmonary HTN
Bosentan, epoprostennol, sildenafil
lung fibrosis: Cyclophosphamide
Heart: restrictive cardiomyopathy and premature coronary disease
GI: wide mouthed colonic diverticula, esophageal dysmotility (leading to gerd and Barret) , primary biliary cirrhosis - PPI
Renal: AKI, Renal crisis -malignant hypertension leading to papiledema, SAH. -ACEis.
Raynauds- CCBs
Skin thickening: methotrexate or mycophenolate
1049
leading cause of death in scleroderma
pulmonary HTN
1050
Interstitial lung disease in scleroderma tto
cyclophosphamide
1051
Tto of scleroderma renal crisis + CNS involvement/papilledema
ACEis + IV nitroprusside
1052
a patient treated for esophageal varices is admitted. He is at greater risk of developing ___ during hospitalization
Spontanous bacterial peritonitis
treat prophylactically with fluoroquinolone 7-10 days
1053
management of adenocarcinoma polyps
generally they are resected.
```
however if:
adenocarcinoma in the head of polyp
margins are uninvolved
lesion well differentiated
no lymphovascular invasion
```
just colonoscopy every 2-3 months
1054
types of colon polyps and malignant characteristics
3 types:
1. Hyperplastic: benign, no treatment needed
2. Hamartomatous: benign, juvenile (often resected due to bleeding risk), Peutz Jeghers (benign)
3. ADENOMATOUS: Pre-malignant ( most resected!)
malignant features for adenomatous:
sessile, villous, > 2.5 cm
1055
projectile vomiting immediately after feed in infant
hypertrophic pyloric stenosis
1056
RF for hypertrophic pyloric stenosis
```
3-6 weeks of age
first born
preterm
bottle fed
erythromycin or azythromycin
```
1057
Dx of hypertrophic pyloric stenosis
abdominal US
1058
tto of hypertrophic pyloric stenosis
correct electrolytic disturbances
hydrate
then pyloromyotomy
1059
management of bordetella pertussis
azithromycin or erythromycin
also for prophylaxis
1060
Dumping syndrome
complication of gastrectomy
caused by the destruction or bypass of the pyloric sphincter.
rapid emptying of hyperosmolar chyme (particularly carbohydrates) into the small bowel [8].
The osmotic gradient is believed to draw fluid into the intestine, and this may release one or more vasoactive hormones, such as serotonin and vasoactive intestinal polypeptide.
1061
tto for dumping syndrome
high protein food, high fiber , low carbs
frequent meals
Octeotride in severe cases
1062
SAAG >=1.1
Portal HTN
1. CHF
2. Cirrhosis
3. Alcoholic hepatitis
4. SBP
5. Budd Chiaria
1063
SAAG <1
Abscence of portal HTN
```
TB
Peritoneal carcinomatosis (ovarian cancer)
Nephrotic Syndrome
Pancreatic ascitis
Serositis
```
1064
Spontaneous Bacterial Peritonitis presentation and labs
Fever, abdominal pain/tenderness, AMS ( abnormal connect the number test)
Hypotension, hypothermia, paralytic ileus if severe
PMN> 250/MM3
ascitic culture + for gram - (E.coli, klebsiella)
Protein < 1
SAAG >=1.1
1065
Complication of SBP
renal failure ( IV albumin has demonstrated to decrease renal failure and mortality in this patients)
1066
tto for SBP
Ceftriaxone + IV albumin (prevent renal failure and decrease mortality)
Prophylaxis: Ciprofloxacin
1067
Transjugular intrahepatic portosystemic shunt (TIPS)indication
refractory ascitis and uncontrolled variceal bleeding
1068
most useful indicator of 90 day mortality in SBP?
SBP-- ScIBS
serum creatinine
INR
bilirubin
Sodium
1069
tto for hypothermia patients
warmed 42Ccrystalloid for hypotension
Endotracheal intubation in comatose patients
**no need to give atropine for bradycardia in moderate hypothermia- it will improve with rewarming
1070
risk with hypothermia
vfib
cardiac arrhythmias may be triggered by central line placement. So these patients need to be handled carefully
1071
patient with hypothermia already placed on IV warm fluids,intubated. Labs with hyperK, azotemia, respiratory alkalosis, hyperglycemia, coagulopathy. Next step?
Continue with IV warm fluids.
There will be increase in T by 1-2 degrees each hour
As the T improve that will correct
1072
Woman with PE and DVT treated with enoxa and warfarin, had complication of stomach bleedin due to undiagnosedulcers. next step
stop anticoagulants and place IVC filter.
1073
treatment of salmonellosis ( N/V, diarrhea, abdominal pain)
nothing, supportive in immunocompetent and >1 year old
1074
regular exercise can prevent back pain
true
1075
biliary atresia presentation
conjugated hyperbili (direct > 20% total)
1076
tto and prognosis. ofbreast milk jaundice
nothing, continue breastfeeding
spontaneous resolution by 3 months
1077
Patient with fatigue, xanthelasma, and inflammatory arthritis found to have elevated ALP, mildly LFTs. Dx?
Primary biliary cholangitis (same as cirrhosis)
| Anti mitochondrial antibodies
1078
tto Primary biliary cholangitis (same as cirrhosis)
ursodexocholic acid - slows the progression of disease
*Ca and Vit D
if cirrhosis liver transplant.
**corticosteroids or immunosuppresionis not useful.
1079
patients with primary biliary cholangitis are at high risk of
osteopenia and osteoporosis - cause is unknown
| warrant a dexa
1080
what improves and worsen pain in carpal tunnel syndrome
worsen at night
improves with shaking hands (Flick sing) and with running warm water.
1081
patient with carpa tunnel syndrome that comes after 6 months (had wrist spint) and no improvement. Next step
nerve conduction studies /EMG to diagnose and assess severity
they are used in preparation for surgery
1082
mechanism of infantile botulism
neurotoxin inhibits presynaptic ACHE release
1083
tto of infantile botulism
botulism immune globulin IV
as early as possible to reduce severity and duration of ss
1084
dx infantile botulism
stool sample C. botulinum spores or toxin
1085
management of ingested button battery
if in esophagus- endoscopy removal
| past esophagus- monitor closely.
1086
management of suspected foreign body ingestion -algorithm
say it
1087
Stool freqency in babies
< 1 month- stool with every feed
>1 month : 1 every 1-2 days or less, with some having 1-2 bowel mov per week
**adding water to breastmilk or formula not recommended due to risk of hyponatremia or electrolyte imbalance
1088
newborn bilious emesis, abdominal distension, not eating well, hypoactive abdominal sound, x ray with dilated bowel loops, ground glass mass. dx
meconium ileus
1089
neonate with cataracts , 2 potential diseases
rubella
| galactosemia- galactose 1 phosphate uridyltransferase (
1090
presentation galactosemia
galactose 1 phosphate uridyltransferase
Accumulation of G1P in the liver, kidney, brain
```
upon being fed milk, will develop
jaundice
vomiting
lethargy
irritability
convulsions
```
Continued feeding of milk products to the infant leads to
cataract formation
hepatosplenomegaly
mental retardation
1091
maternal use of macrolides is a risk factor for pyloric stenosis
true
1092
Indications for stress ulcer prophylaxis
any 1 factor:
- Coagulopathy: platelets < 50,000, INR>1.5, PTT> 2x normal
- mechanical ventilation > 48 hours
- GI bleeding or ulceration in the last 12 hours
- Head trauma, spinal cord injury, major burn
any 2 factors:
- corticosteroid therapy
- > 1 week ICU stay
- Occult bleeding > 6 days
- Sepsis
1093
extraesophageal manifestations of GERD
cough, wheezing, hoarseness, chest pain
1094
complications of GERD (esophageal and extraesophageal)
esophageal: erosive esophagitis, Barret, stricture
extraesophageal: asthma, laryngitis
1095
patient with DM with poor control with insulin, already with retinopathy, nephropathy. Complaining of early satiety, bloating, weight loss, sweating during meals. Dx and test to confirm it?
Gastroparesis
nuclear gastric emptying study
** always rule out a mechanical obstruction
1096
treatment of gastroparesis in DM
Diet modification: small, high fiber meals, low fat
If doesnt work, promotility agents: erythromycin, and metoclopramide
If persist: Gastric stimulation or jejunum tube feeding
1097
Causes of gastroparesis
```
DM
Meds (opioids, anticholinergic)
Trauma/postsurgical (Vagal nerve stimulation)
nEURO (MS, spinal cord injury)
Idiopathic- post viral
```
1098
Pattern of inheritance hemophilia
X linked recessive
1099
dysphagia for both solids and liquids, manometry with intermittent peristalsis and multiple simultaneous contractions
diffuse esophageal spasm
1100
tto of diffuse esophageal spasm
CCBs (Diltiazem)
| Alternative: nitrates or tricyclics.
1101
presentation of eosinophilic esophagitis
men> women
20-30s
associated to atopic dermatitis, seasonal allergies, asthma
dysphagia to solids
retrosternal pain
N/V
Weight loss
1102
tto eosinophilic esophagitis
dietary modifications - 6 month diet with serial endoscopy
PPIs
Steroids
1103
patient with headache that is remodeling old house, dx and tto
carbon monoxide posioning- seen with smoke inhalation, defective heating systems, gas motor with poor ventilated areas.
carboxyhemoglobin
high flow 100% oxygen
1104
patient with polyps concerning for malignant features in flexible sigmoidoscopy, next step?
colonoscopy now.
flexible sigmoidoscopy does not visualize all the colon, so he needs that
1105
Effects of brain death
hypotension
Endocrinpathies (Central DI, adrenal insuff, hypothyroidism)
Volume depletion
Systemic infections
1106
things to do to preserve organ function in brain death patients
```
give fluids and vasopressors as needed
keep in mechanic ventilation
for endocrinopathies (Central DI-desmopressin, Adrenal insuf-steroids, hypothyroidism- levothyroxin)
```
1107
What does DEXA stands for
dual energy x ray absorptimetrt
1108
Clinical characteristics and Management of GERD in babies
immature low esophageal sphincter
spit up
normal weight check
no back arching
upright position during feeds
burping
frequent small volume feeds
1109
prognosis of GERD IN BABIES
peaks by 4 months, resolve by 12-18 months
1110
When is H2 RECEPTOR THERAPY (rANITIDINE)indicated for GERD in babies
if poor weight,
| marked irritability despite lifestyle modifications and a trial. of a cow's milk free diet.
1111
patient with fatigue, night sweats, arthralgias, chest pain, pleural effusion, and has a history of cardiac disease on multiple drugs. next step in management?
if patient has hydralazine think of hydralazine induced lupus!
5-10% develops
anti-histone antibodies and ANA
1112
drugs that cause lupus
hydralazine
procainamide
minocycline
TNFFA inhibitors: etanercept, infliximab
**removal of agent improves lupus
1113
suspect ankylosing spondylitis, next step
X ray of sacroiliac joint--sacroilitis and erosions of the ischial tuberosity and iliac crest
1114
Criteria for diagnosis of ankylosing spondylitis
1. morning back pain, improves with exercise for more than 3 months
2. reduced range of flexion of lumbar spine on Schober test
3. Limited chest expansion relative to normal values
1115
how do you monitor the disease activity in ankylosing spondylitis
3 X rays:
1. AP and lateral of lumbar spine
2. Lateral of cervical spine
3. Pelvic radiograph including the sacroiliac joints and hips
* ESR can also be ordered
Every 3 months
1116
complication of ankylosing spondylitis
restrictive lung disease - limited costovertebral joint movement and apical fibrosis
*recommend smoking cessation
1117
extraarticular manifestations of ankylosing spondylitis
```
restrictive lung disease
IgA nephropathy
anterior uveitis
aortic regurgitation
apical pulmonary fibrosis
```
1118
life expectancy in ankylosing spondylitis
not reduced. normal, most do well.
1119
until when is ok that babies are still not walking
walking is normally acquired by 12, but the range is between 9 -16 months.
1120
Patient with Raynauds managed with nifedipine, now complaining of arthritis. Next step
ANA , RF, complement, CBC, BMP, urinalysis
1121
Most sensitive modality for dx of avascular necrosis
MRI
1122
conditions associated with osteonecrosis or avascular necrosis
+ Glucocorticoid therapy, alcohol.
```
SLE
Sickle cell disease
Antiphospholipid sx
CKD
trauma
Gaucher
Caisson's disease (Decompression sickness)
```
1123
management of avascular necrosis
conservative
core decompression(grade1-2: xray without femoral head collapse)
osteotomy
joint replacement ( for grade 4 )
1124
Management of dyspepsia (epigastric pain, fullness, heartburn)
>=60: endoscopy
<60:
Test and treat H.pylori
upper endoscopy in high risk patients(GI bleeding, more red flag ss)
If H.pylori negative: then PPI trial
1125
patient with fat malabsorption , chronic abdominal pain, alcoholic.
think of chronic pancreatitis- pancreatic insufficiency
best test: is MRCP preferred over CT
iT WOULD SHOW CALCIFICATIONS AND DUCTAL DILATION
1126
What is fecal elastase
a marker of pancreatic function
1127
lower extremity alignment in children
6 months: genu varum
2 years: straight legs
4 years :genu valgum
>7 years: straight
1128
shin splints- medial tibial stress syndrome can evolve to
stress fractures, initial X rays are negative. low sensitivity.
Only appear after 4 weeks
1129
management of stress fractures in lower legs
pneumatic splint
and reduced weightbearing activities
crutches fro the first 1-2 weeks to reduce weight bearing
followed by rehab program
1130
patients with HCV tto
antivirals
vaccine agains hep A and B
* no need of barrier protection for sex, this is usually treansmitted via parenteral
*safe to use acetaminophen < 2 g/day
1131
Child with viral gastroenteritis drinking apple juice. next step
Recommend stopping juice-- high fructose or sorbitol increases the osmotic load and leads to fructose malabsorption worsening diarrhea
recommend hypoosmolar oral hydration
1132
management of sharp body ingestion- fish chicken bones, toothpicks, pin
urgent FLEXIBLE endoscopy for removal.
1133
how to assess Achilles tendon ruputure
Thompson test- squeeze calf would normally cause plantar flexion
is negative in these patients
1134
elbow pain after falling in outstretched hand
| X ray with posterior fat pad Dx and management
supracondylar fracture
if nondisplaced:long arm splint and sling
if displaced: surgical reduction and pinning
1135
Dx of pancreatitis
Biochemical exam is enough, no need for imaging if pain is classic
1136
patient with pancreatitis, not alcoholic, and no evidence of gallstones in the US. Next step?
lipid panel, hypertryglicerides
1137
patient with acute pancreatitis that was improveing but at the third day develops pain again, fever, leukocytosis. Next step? What do you think is happening?
CT abdomen
Early complications of pancreatitis: pancreatic necrosis, acute peripjancreatic fluid collection, nectrotic infection.
1138
presentation and chest X ray findings of esophageal rupture
hx of vomiting, retching
back, chest, epigastric pain
shortness of breath, crepitus
odynophagia, FEVER, SEPSIS
Xray: pleural effusion, pneumothorax, pneumomediastinum
1139
Dx of esophageal rupture
Esophagogram or CT scan with water soluble contrast
**endoscopy is not done as it can worsen pneumomediastinum
1140
risk of gout increases in CKD and patients taking cyclosporine
cyclosporine decreases uric acid excretion
1141
uric acid crystals vs calcium pyrophosphate
uric acid: negative, needle shape
| calcium: positive, rhomboid
1142
next step when pt presents with gout
synovial fluid analysis
1143
acute vs chronic tto of uric acid gout
acute: indomethacine, colchicine, steroids
IN PATIENTS WITH RENAL FAILURE OR WHO HAD RENAL TRANSPLANT: INTRA-ARTICULAR STEROIDS OR INCREASE THE DOSE OF GLUCOCORTIOSTEROIDS
chronic:
1st line: Xanthine oxidase inhibitors- febustat, allopurinol
2nd line: uric acid agents: probenecid
1144
Complication of untreated celiac disease
enteropathy associated T cell lymphoma in JEJUNUM
presents with abdominal pain, weight loss, fatigue, bloody stools
they are at risk of bowel obstruction and perforation
1145
Gastrinoma
weight loss, abdominal pain, fatigue, bloody stools
1146
Patient who underwent radioiodine therapy for graves, currently receiving levothyroxine but have persistent elevated TSH despite escalating doses of levothyroxine. What is happening?
levothyroxine malabsorption - check for celiac disease
| autoimmune condition that can be present in these patients
1147
which antibodies correlate with disease activity in lupus
Anti ds DNA antibodies
and are associated with development of lupus nephritis
1148
management of lupus
prednisone and hydroxychloroquine
hydroxychloroquine is an antimalarial that helps with arthtralgias, serositis and cutaneous symptoms. May also help in prevention of kidney damage andCNS
1149
prior to start TNF inhibitors always test for
TB
-IFgamma assay
or skin test
1150
next step if you suspect septic arthritis
arhtrocentesis
*not MRI
1151
Ethylene glycol toxicity
```
rapid and deep breathing (Kussmaul)
N/V
slurred speech
ataxia
nystagmus
lethargy
```
later ss: renal failure, coma
1152
antidote for ethyleneglycol toxicity and moa
fomepizole- competitive inhibitor of alcohol dehydrogenasee ( which metabolizes the non toxic ethyleneglycol into toxic metabolites)
1153
uses of fomepizole
ethyleneglycol and metanol toxicity
1154
patient in whom you suspect thyroid cancer and has very high titers of anti peroxide antibodies. What type of Ca
Thyroid Lymphoma
1155
Diagnostic criteria for Giant Cell arteritis (5)
1. Age >=50 (greatest RF)
2. New onset headache with fever and visual disturbances
3. ESR >50
4. Tenderness or decreased pulse in temporal area
5. temporal artery biopsy show necrotizing arteritis with mainly mononuclear cells
3/5 very specific
1156
Alcoholic patients with chronic pancreatitis can develop DM! insulin islets destroyed. tto?
mild hyperglycemia: metformin
| severe hyperglycemia: INSULIN
1157
patient with fecal incontinence in the setting of constipation and hard stools at rectal exam. next step
manual disimpactation followed by enema
high fiber and increase fluids is not an immediate treatment as it needs to be treated aggressively. But is the recommendation following enema.
1158
diagnosis of dermatomyositis
high CPK, aldolase, LDH
ANA, Anti RNP, anti Jo1, anti Mi2
if still diagnostic uncertaintly : EMG or muscle biopsy.
1159
management of dermatomyositis
high dose glucocorticosteroid PLUS glucocorticosteroid sparing agent (methotrexate, mycophenolate, azathioprine)
Look for underlying manlignancy
1160
difference between aspiration pneumonia and aspiration pneumonitis
aspiration pneumonitis: inflammationof the lung parenchyma, in pts with decreased level of consciousness. 2-5 HOURS after generally witnessed event.Range from no symptoms to nonprodutive cough, respiratory distress. Chest X ray: infiltrates. Resolves without antibiotics
aspiration pneumonia: infection. 1-5 days after event, fever, cough, increased sputum, chest x ray infiltrate (generally right lower lobe)
requires antibiotic
1161
tto for aspiration pneumonia
clindamycin
1162
low back pain that increases at night, next step?
Xray first!
-
* MRI is done if sensory/motor deficit, cauda equina, suspected epidural abscess or infection
1163
which patients with osteopenia may benefit from biphosphonates
FRAX SCORE with hip fracure risk >=3% and combined osteoporotic risk fracture >=20%.
1164
should a woman postmenopausal with osteopenia receive hormone replacement therapy?
No, it is only useful if vasomotor ss. Not for osteopenia
1165
side effects of biphosphonates
pill esophagitis, jaw osteonecrosis
1166
50 hour baby boy with bilious emesis, not able. totolerate feeds, has not passed meconium. Next steps?
NG tube for decompression
IV fluids
Abdominal X ray
1167
Abdominal X ray concerning for Hirshprung's , next step for diagnosis
rectal suction biopsy
1168
Meds that cause orthostatic hypotension
alpha blockers
diuretics
nitrates
1169
Where is the lesion in Colles fracture? Mechanism of injury
distal radius
FOOSH( Fall on an outstretched hand)
1170
FOOSH( Fall on an outstretched hand) injuries
```
scaphoid fracture
wrist sprain
Colles fracture
Ulnar styloid fracture
supracondylar fracture
radial head fracture
olecranon fracutre
posterior glenohumeral dislocation
ACUTE CARPAL TUNNEL SYNDROME
```
1171
Colles and Smith fracture
Colles: outstretched hand
Smith: fall in hyperflexion of wrist
1172
More common lesion in boxer punch
4th and 5th metacarpals
1173
mitochondrial inheritance
only mom pass it to children
| MELAS- Stroke and epilepsy
1174
MELAS presentation
Mitochondrial Encephalopathy with lactic acidosis and stroke like episodes
- Seizures
- Stroke like ss
- lactic acidosis due to mitochondrial dysfunction
- muscle weakness
- hearing loss
1175
classic dashboard injury in motor vehicle crash
disruption of the posterior cruciate ligament
1176
mechanism and presentation of ACL injury
hyperextension of the knee
popping sensation
knee effusion and instability
Lachman positive
1177
patient with SLE on steroids should be on vit D and Ca
true
Based on the duration of therapy DEXA is indicated every year
1178
Conditions associated with Restless leg syndrome
```
Iron deficiency anemia
uremia
DM
pregnancy
parkinson, MS
Drugs (antidepressants, metoclopramide)
```
1179
treatment of Restless leg syndrome
Mild/intermittent:
iron if ferritin =<75ug/L
measures like heating pads, exercise
avoid triggers: sleep deprivation and some meds
Moderate to severe:
1st line: pramipexole(dopamine agonist)
2nd line:gabapentin
1180
Frozen shoulder mechanism and presentation
contracture of the joint capsule (Adhesive capsulitis)
Pain and stiffness
Decreased passive and active range of motion
X ray: osteoarthritis in glenohumeral junction
1181
How to differentiate rotator cuff tendinopathy vs tear
tendinopathy: pain with abduction, and external rotation. normal ROM. POsitive impigement tests (Neer, Hawkins)
rupture: Weakness with abduction and external rotation. + all of the above.
1182
treatment of frozen shoulder (adhesive capsulitis)
1st range of motion exercises
If no improvement after 2-3 months: intraarticular glucocorticosteroids
if not recovery after months or years: surgery
1183
septic arthritis vs transient synovitis
```
Kosher criteria:
non bearing weight
fever
leukocytosis
elevated CRP
```
3 criteria , > 93% likelihood of septic arthritis
1184
Organisms in septic arthritis
< 3 months: S.aureus, GBS, gram negative bacilli
| >=3 months: S.aureus, S.pyogenes
1185
tto septic arthritis
< 3 months: S.aureus, GBS, gram negative bacilli
Vancomycin +Cefotaxime
>=3 months:S.aureus, S.pyogenes
Vancomycin
1186
Definition of macrocephaly and when do you recommend imaging
macrocephaly is > 97th percentile
Imaging: Head US
Rapidly expanding: > 2cm/month in. < 6 months
Neuro abnormalities (Seizures)
Developmental delay
1187
digit amputation technique to save part
wrap it in gauze
moisten with normal saline
place on sterile bag
bag should be placed in container with ICE MIXED WITH SALINE
1188
hcg bind TSH receptors causing increased production of thyroid hormone
true
1189
MVA- breathing fast and shallow, multiple bruises in chest. Dx
Flail chest
1190
flail chest management
supplemental oxygen
PPV
Pain control
Surgical stabilization
1191
capillary blood lead level needs confirmation with venous lead level
true
1192
What would peripheral smear show in lead poisoning
basophilic stipping
Xray: increased opacities in the metaphyseal plates
1193
complication of lead poisoning
cognitive impairment/behavioral (ADHD)
| acute encephalopathy only occur if levels are > 100
1194
standard caloric intake for enteral feeds
30kcal/kg/day
a 1g/kg of protein is adequate
1195
b12 deficiency in addition to ataxia, dementia can present with delirum and hallucinations. There is pancytopenia too
folic acid does not give neuro ss
1196
most predominant feature of chikunguya infection
high fever and polyarthralgias-- they also tend to be chronic
bilateral and involve distal joints.
They can also have headache, myalgias, maculopapular rash, thrombocytopenia, lymphopenia, transmanitis
1197
Dx Chikunguya
PCR
1198
intussusseption cause bloody stools (currant jelly stools), dx and tto
abdominal US -target sign
however X rays are obtained to rule out perforation
air or saline enema
1199
patient with intussuspetion underwent water/air enema. After some hours again severe pain, next step
plain X rays to assess for perforation
1200
Patient with lupus who develops chest pain, enters in cardiac arrest due to Vfib and dies. Mechanism behind this?
premature coronary atherosclerosis is associated with SLE
Patients with SLE have 50x risk of CAD
