Week 3 Flashcards
Next step in massive >600mL/24hr or >100/hr hemoptysis?
Secure airway (intubate), breathing, circulation, lay them so bleeding lung is in the dependent position (lateral position), then BRONCHOSCOPY, bcus it can localize bleeding, provide suctioning, and can be therapeutic (balloon tamponade, electrocautery).
How to nitrates exert their effect?
Direct vascular smooth muscle relaxation causing venous dilation and increase in peripheral venous capacitance. Anti ischemic effect –> venodilation and decrease in cardiac preload, decrease in LVED and ES volume. This leads to a reduction in left ventricular systolic wall stress which reflects afterload (pressure *Radius/Thickness) and decrease in myocardial oxygen demand.
Most common cause of MR in develped countries?
MVP which initially has mid systolic click and mid to late systolic murmur, but eventually has severe leaflet dysfunction and MR with holosystolic murmur. Though to be due to myxomatous degeneration of the mitral valve leaflets and chordae.
3-4 month old with hypoglycemia, seizures, lactic acidosis, hyperuricemia, hyperlipidemia, doll like face with round cheecks, short, proteuberant abdoment with hepatomegaly?
Glucose 6 phosphatase deficiency, type 1 glycogen storage disease, VOn Gierke
PEA or asystole manage with ..
CPR and vasopressors
No Defibrillation of synchronized CV
When to do defibrillation?
Vfib or pulseless VT
Thrombocytopenia, what to look for?
Chronic HIV infection, EBV, HCV
Cardiac tamponade causes?
Decreased left ventricular preload
Pathophys of high output HF?
2/2 trauma, iatrogenic, atherosclerosis, cancer, PDA, angiomas, pulm AVF, CNS AVF
Shunt a large amount of blood through the fistula decreases SVR, increases cardiac preload, and increases CO. See widened pulse pressure, strong peripheral arterial pulsation, systolic flow murmur,t tachy, flushed extremities.
Common drugs associated with photosensitivity
Tetracyclines (doxy), chlorpromazine, prochlorperazine, furosemide, HCTZ, amiodarone, promethazine, prioxicam
If left untreated hyperthyroidism can cause
Bone loss, osteoporosis 2/2 increased thyroid hormone increase osteoclastic bone resorption. Also high Ca++
Contraindication to raloxifene?
Hx Venous thrombosis
E Antagonist breast and endometrium, E agonist on bone
Adverse effects: Hot flashes, VTE, endometrial hyperplasia and carcinoma with tamoxifen
2 year old with 2 months of chronic oligoarthritis (more in the AM), daily fever for over 2 weeks, and rash, increased WBC/platelet, decreased RBC, increased ESR.. what is dx?
systemic Onset Juvenile idiopathic arthritis
Reyes syndrome what does liver look like?
Mircovesiculr fatty infiltration 2.2 ASA during flu or varicella
HTN IP brain hemorrhage that shows contralateral hemiparesis and sensory loss, and conjugate gaze TOWARD side of lesion, where is lesion?
Basal Ganglia, Putamen (involves internal capsule too)
HTN IP brain hemorrhage that shows contralateral hemiparesis and sensory loss, non reactive miotic pupils, upgase palsy, and gaze away from lesion, toward hemiparesis?
Thalamus
HTN IP brain hemorrhage with deep coma and total paralysis, pinpoint reactive pupils
Pons
Treatment BPD in patients with renal dysfunction?
Valproate bcus lithium nephrotoxic
What is ludwig angina?
Cellulitis of submandibular space, from dental infections that spread to root of the submylohyoid and then sublingual space.polymicrobial usually. Fever, chills, drooling, dysphagia, muffled boice. Crepitus. Tx IV abx.(amp-sulbactam, or clinda) and remove tooth.
What DM2 med can have losing weight as a side effect?
GLP1 receptor antagonist. Exenatide.
Flank pain, hematuria, palpable abdominal mass, scrotal varicoele (left sided)
RCC, abdominal CT
Treatment of asx prolactinoma <10mm?
No treatment
Treatment of prolactinoma <10mm and symptomatic OR >10mm
- Dopamine agonist cabergoline or bromocriptin
- Resect if very large >3cm or it increases in size while on tx
Labs in Vit D deficiency
Low to normal Ca and Phos
Low 25-OH Vitamin D
High high Alk phos, High PTH
How do you manage Renal artery stenosis with HTN?
ARBs or ACEis
Euvolemic hyponatremia in HIV pt?
2/2 SIADH
Workup bilious vomiting in neonate:
1st Abdomina X ray
2nd Water soluble contrast enema
Labs in euthyorid sick syndrome:
Low T3, normal T4 and TSH
Chronic nonbloody diarrhea and weight loss after multiple abdominal surgeries, what type of diarrhea?
Secretory
Risks of succinylcholine in rapid sequence intubation?
Cardiac arrhythmia 2/2 efflux of K ions, causing hyperkalemia!
This is more likely with crush injury, burns, muscle atrophy, denervation. In these cases give non depolarizing NM blockers like vecuronium, rocuronim.
Contraindications to breastfeeding?
Active untreated TB Maternal HIV Herpetic breast lesion Active varicella Chemo/Rad tx Active substance abuse
What initial study of choice in hemodynamically stable people with suspected aortic dissection?
CT angiography
What initial study of choice in hemodynamically UNstable people with suspected aortic dissection? (also renal insuff)
TEE
What are the main substrates of gluconeogenesis?
Alanine –> pyruvate
Lactace –> pyruvate
Glutamine –> citric acid cycle
Glycerol 3 phosphate –> from adipose, to glucose
Tx of euvolemic hyponateremia?
Hyponatremia Serum osm <275 Urine osm >100 Urine Na >40 TX. Fluid restriction + salt tables 3% Saline for severe hyponatremia
Guy with hyperCa++ (11) and acute painful monoarthritis, sxs like fatigue, constipation, nephrolithiasis?
Pseudogout 2/2 hyperparathyroidsm (pseudogout also associated with hemochromatosis)
Guy with HIV and CD4 <50, Mycobacterium avium vs CMV?
MA: Watery diarrhea, HIGH FEVER >102.2, weight loss
CMV: Frequent small volume diarrhea, hematochezia, abpain, low fever, weight loss
Dx colonoscopy
Fanconi anemia
AR or XLR, predispo for cancer, 2/2 DNA repair
See: Aplastic anemia and progressive bone marrow failure, short stature, microcephaly, abnormal thumbs, hypogonadism, hypo/hyperpigmented areas, cafe au lait spots, large freckle, stravismus, low set ears, middle ear abnormalities.
Most common coag d/o in Caucasians
Factor V leiden d/o, activated protein C resistance
Measles vs rubella
Measles has higher fever 104F, cephalocaudal spread of rash over DAYS, and cervical adenopathy, no arthritis
Northern european guy with megaloblastic anemia and atrophic glossitis, vitiligo, thyroid disease, neuro abnormalities
Pernicious anemia
Prefered anticoagulation for those with pulm embolism and renal insufficiency? GFR<30
unfractioned heparin
Fetal complications of preeclampsia
oligohydramnios and fetal growth restriction/small of GA due to chronic uteroplacental insuffiency
Suspect meniscal injury? >3-4 weeks sxs and younger
MRI
Tx polymyositis?
Steroids (prednisone) and methotrexate, azathrioprine.
HIV + guy with floaters, blurred vision in right eye, photopsia, may cause blindness, increases risk of retinal detachement
CMV retinitis
Tach Sachs
B hexosaminidase A deficiency AR Jewish 2-6month onset cherry red macula NO HSM hyperreflexia
Niemann Pick
Sphingomyelinase deficiency AR Jewish 2-6month onset cherry red macula HSM areflexia
Gaucher
glucocerebrosidase deficiency anermia thrombocytopenia HSM no loss of milestones
Tx of acute cystitis in non pregos
Uncomplicated: Nitrofurantoin for 5 days (not if pyelon or Cr Cl <60), TMP/SULF 3 days, single dose Fosfomycin, FQ if above can’t be used. Urine culture if initial tx fails.
Complicated cystitis: FQ 5-14 days, amp/gentamicin for severe cases, obtain sample for urine culture prior to abx and adjust as needed
Tx of pyelon in non pregos
Outpt: FQ Cipro,levo
Inpt: IV FQ, amiglycoside+amp obtain sample for urine culture prior to abx and adjust as needed
Abx for UTI in pregnancy
Cefpodoxime, cephalexin, amox-clav, fosfomycin
HTN, palpable abdominal masses, microhematuria
ADPKD
Berry aneurysm is a complication 5-10%
Can also have hepatic cysts, valvular heart disease, colonic diverticula, abdominal wall and inguinal hernia
Tx CRAO
Ocular massage and high flow oxygen
3 meds indicated in stable angina
BBlocker
Nitrates
ASA
Meds that cause HyperKalemia
BBlocker, ACEi, ARB, Sprinolactone, Digitalis, Cyclosporine, Heparin, NSAIDs, Succinylcholine, Trimethoprine
When to add prednisone to TMP-SMX for PCP?
If PaO2 <70, A-a >35 on room air, pulse ox <92%
Asymptomatic proteinuria or nephrotic syndrome, cardiomyopathy with heart failure, hepatomegaly, mixed sensory and motor peripheral neuropathy or autonomic, visible organ elargement (macroglossia), bleeding diathesis, waxy thickening easy bruiseing
2nd Amyloidosis
Dx wtih abdominal fat pad aspiration Bx
Tx underlying condition, colchicine for prevention and treatment
Respiratory distress, neurological dysfunction, petechial rash 24-72 hours following inciting event (femur fracture, orhto surgery, pancreatitis)
Fat embolism
IE w/hx of pyelonephritis and recent cystoscopy
Think Enterococci
Osteomalacia causes
Malabsorption (celiac sprue), bypass, chronic liver or kidney disease. 2/2 Calcium or phosphorus deficiency –> leads to defective mineralization of organic bone matrix. 2/2 severe vitamin D deficiency or renal tubular acidosis (proximal type 2). See elevated alk phos, PTH, low serum Ca, Phos, decreased 25OH
Dullness to percussion and increased breath sounds increased tacticle fremitus think ..
Consolidation / PNA
PPSV23
Polysaccharide vaccine, can not be presented to T cells, vaccine induces a relatively T cell independent B cell response that is less effective in young children and the elderly
CHARGE syndrome
Coloboma Heart Defects Atresia choanae Retardation/growth/dev GU anomalies Ear abnormalties/deafness
Someone with Primary biliary cholangitis is at risk for developing what?
Osteomalacia 2/2 vit D malabsorption and HCC
How do you define arrest of active phase of labor? How do you manage?
No cervical change >4 hours with adequate contractions OR
no cervical change for >6hours with inadequate contractions
C section delivery
What are considered adequate contractions?
> 200MVUs in 10 minutes
What are MVU?
#uterine contractions in 10 minutes x contraction strength (contraction strength = peak mmHG-baseline mmHG using Internal pressure catheter)
Things that can cause methemoglobinemia
Exposure to oxidizing substances dapsone, nitrites, local/topical anesthetic
See Cyanosis, pulse ox sat 85% dark choco colored blood
Lab:>5% difference between ox sat pulse ox and ABG
normal PaO2
Tx methylene blue
Pronator drift sign shows lesion where?
upper motor neuron or pyramidal tract disease affecting upper extremities
Allergic rhinitis
Always bilateral
can last <30 min to perennial
Watery discharge
Ocular pruritis
suspected DVT vs PE management
DVT - dx with compression US
PE - anticoagulate
What is a positive bronchodilator response?
> 12% increase in FEV1 after bronchodilator
<4 hours from ingestion of acetaminophen
Administer charcoal & check acetaminophen levels
Type 4 RTA
Hyperkalemia non anion gap met acidosis commong with poorly controlled DM
15 year old no menstruation, stage 4 breast dev and pubic hair, normal external female genetalia and axillary hair, vagina feels short no cervix or uterus, but does have ovraries…
Mullerian agenesis
What cardiac conduction abnormality is common with dig tox?
Atrial tachycardia with AV block
Spontaneous lobar hemorrhage in elderly 2/2
Amyloid angiopathy
Fever, chest pain, hemoptysis, pulm nodules with halo sign, positive cultures, positive galactomannan beta D glucan, immunocomp or neutropenia
Invasive aspergillosis
tx vori +/- capsofungin
