Combo with "Internal Medicine - Gastro" and 8 others Flashcards
(719 cards)
0
Q
Pt presents with jaundice and an elevated GGT and ALP. Total bilirubin is high as is direct bilirubin.
What is the most LIKELY etiology and dx?
What is the WORST CASE dx?
A
post-hepatic obstruction (b/c bilirubin is CONJUGATED)
most likely Dx - gallstones
worst case dx - pancreatic ca.
1
Q
A 54 yo woman is referred to a hepatologist because of her yellowing skin. Her ALT and AST are normal, but her ALP and GGT are elevated.
She is asymptomatic and has no complaints except for her yellow skin and eyes.
What dx must you rule out?
A
Painless jaundice is
Pancreatic cancer
UNTIL PROVEN OTHERWISE
2
Q
A jaundiced pt with ALP 3x normal and AST & ALT 5x normal is most suggestive of which etiology?
A
post-hepatic OBSTRUCTION = CHOLESTASIS
3
Q
List the etiologies that can push AST and ALT in the 1000s
A
DIVAS are in the 1000 club:
Drugs - tylenol and halothane Ischemia - shock liver or SMA embolus Viruses - HBV, HCV, HAV, HEV Autoimmune hepatitis Stones - gallstones
4
Q
List the liver FUNCTION tests
A
Albumin
Bilirubin
INR
ALT, AST- tell us about hepatocellular injury
ALP, GGT and bili – indicate cholestasis
(Toxin removal is also part of liver function)
5
Q
A patient presents with end-stage liver failure, what do you expect his ALT and AST levels to be:
a) in the 1000s
b) elevated x 5-10
c) normal
A
c)
At this stage the liver is cirrhosed and ALT and AST are normal.
6
Q
Name the type of viral hepatitis that most commonly is associated with the following hx:
a) IVDU
b) immigrant from Pakistan
c) recently travelled on a cruise with infectious contacts
d) had unprotected sex
e) had a blood transfusion
f) is an infant born to a + mom
A
a) HBV
b) HBV
c) HAV (HEV also fecal-oral, but rare in Canada)
d) HBV
e) HCV
f) HBV
7
Q
Which type of viral hepatitis is more likely to cause long-term morbidity in adults?
A
HCV
30% recover fully and 70-85% become chronic
8
Q
A patient’s serology shows the following:
\+HbSAg Ab \+antiHbcAg IgM -antiHbcAg IgG \+ SAg -eAg \+HBV DNA
What’s the diagnosis?
A
HBV - very recent current infection
9
Q
A patient’s serology shows the following:
+HbSAg Ab
- antiHbcAg IgM
- antiHbcAg IgG
- SAg
- eAg
- HBV DNA
What’s the diagnosis?
A
Pt is vaccinated for HBV
10
Q
A patient’s serology shows the following:
\+HbSAg Ab \+antiHbcAg IgM \+antiHbcAg IgG \+ SAg \+eAg \+HBV DNA
What’s the diagnosis?
A
Highly active infection
11
Q
What is a laboratory investigation that is warranted in suspected Wilson’s disease?
A
Ceruloplasmin
12
Q
What finding is suggestive of Primary biliary cirrhosis on ERCP?
A
Beading of the bile duct.
13
Q
List the main causes of cirrhosis
A
- Fatty liver - NASH and Alcoholic Liver disease
- Autoimmune - PBC and AI Hepatitis
- Infection - viral hepatitis
- Genetic - hemochromatosis/Wilson’s/alpha-1-anti-trypsin deficiency
- Degenerative=Congestive - Budd Chiari/RH failure
14
Q
A patient with known EtOH dependence presents to the hospital with excessive hematemesis. You diagnose esophageal varices.
How will you INITIALLY manage this patient?
When is surgery indicated?
A
- ABCs
- IVF
- Endoscopy if unstable/active bleeding w BANDING/GLUE
- Octreotide
- Beta blocker to reduce portal HTN
See if bleed stops.
Surgery is indicated if bleeding continues - bridge with BALLOON tamponade & then perform Transjugular Intrahepatic portosystemic shunt and fix varices
15
Q
What does TIPS stand for?
A
Transjugular Intrahepatic Portosystemic Shunt
16
Q
Which ABx should be given for spontaneous bacterial peritonitis
A
Cefotaxime 2g q8h
17
Q
A 46 year old female with alcohol dependence and IVDU presents to your ward with severe ascites. She came in because she’s no longer able to walk up to her apartment on the second floor due to SOBOE. She is HCV positive, but refused treatment and never had ascites until about 6 months ago.
You examine her and she has severe ascites, but is afebrile and otherwise well. She has crackles in the lung.
You decide to drain her with a paracentesis.
What are your next steps in management of her ascites?
A
Ascitic fluid analysis:
1. SAAG
2. protein
3. glucose
4. cell count & differential
Maybe also, depending on the presentation:
CULTURE & Gram stain/cytology/LDH/Lactate/TB/TG/Bili/glucose
18
Q
A 65 year old man presents with ascites. His PMHx is significant for acute pancreatitis. He smokes 1.5 packs a day and drinks 4 beers a night.
How do you determine whether or not this is a transudate or exudate?
A
Serum-Ascites Albumin Gradient to determine exudate vs. transudate
(SAAG= serum albumin - ascites albumin) >11 is transudative), but <11 is exudative (ie. ascites albumin is abnormally high)
19
Q
What is the criterion for SBP in ascitic fluid?
A
WBC > 500
or
PMN >250
20
Q
What is the main Tx for hepatic encephalopathy?
A
Lactulose - to acidify colon and trap ammonium ions in their insoluble form!
21
Q
What are the treatments for hepatorenal syndrome?
A
- Hemodialysis until transplant
- Gelofusine
- Octreotide
- Midrodine (alpha agonist)
- Albumin
22
Q
What laboratory marker should be ordered in suspected liver cancer?
Which imaging modality is definitive?
A
Alpha-feto protein
CT WITH CONTRAST!
23
Q
A patient’s SAAG results come back at 12.
What type of ascitic fluid does he have, and what is the possible ddx?
A
Transudative!
DDx:
CHF, portal HTN, congestion (Budd Chiari)
24
A patient's SAAG results come back at 4.
What type of ascitic fluid does he have, and what is the possible ddx?
Exudative!
DDx:
SBP, cancer, bleed, pancreatitis, TB, nephrotic syndrome, peritoneal carcinomatosis.
25
A patient presents with severe LUQ abdo pain.
What level of lipase would confirm a dx of pancreatitis?
Lipase >400
26
A patient presents with severe LUQ abdo pain starting 2 hours ago. You suspect pancreatitis.
If serum amylase is WNL can you rule out acute pancreatitis? Why/why not?
Is it a better or worse marker than lipase?
No. You're too early!
Amylase takes 6-12h to peak and 3-5 days to clear.
It is LESS SPECIFIC than lipase.
27
You're working rurally in a small hospital and a patient presents to the hospital with acute onset severe epigastric pain radiating to the back. You suspect pancreatitis.
If the lab isn't running bloodwork at this hour, what alternative investigation could help you rule it in?
Urine Tripsinogen
Has a sens and spec of >90% for ACUTE pancreatitis.
28
What is the #1, 2, and 3 cause of acute pancreatitis?
I GET SMASHED
1) IDIOPATHIC
2) Gall stones
3) EtOH
```
T - tumors
S - scorpion bites -- yup.
M - micro - bacteria/viral/parasites
A - autoimmune - SLE, Crohn's
S - surgery/trauma
H - hyperlipidemia, hyperCALcemia, hyperTHERMIA
E - Emboli/ischemia
D - drugs/toxins - tylenol, ASA, methanol, valproic acid, lasix, E2, etc.
```
29
What is the #1 cause of chronic pancreatitis
#1 - alcohol (90%)
30
True or False
Gall stones are both the #1 cause of acute pancreatitis which may or may not progress to chronic pancreatitis
False.
Gallstones are only associated with ACUTE pancreatitis.
31
List the laboratory investigations etc. in the workup of a diagnosis of celiac.
1. anti-TTG, anti-gliadin Ab, serum IgA
2. small bowel biopsy
3. small bowel follow-through to exclude lymphoma
4. Empiric improvement on a gluten free diet
32
A 28 year old female presents to your clinic with chronic abdo cramping. She endorses constipation and about a 10lb weight loss over 6 months. She has no travel history, and eats a regular diet.
You suspect she has_____?
Which dermatological manifestation should you look for?
Celiac disease.
Dermatitis herpetiformis!
Vesicular lesions on the anterior tibias.
33
When is URGENT endoscopy for a UGIB bleed warranted?
1. suspected variceal bleed or BRBPO
2. comorbid disease
3.
34
List the steps for stabilization of a pt with a brisk upper GI bleed, whose BP is now 90/50, HR 104, and SaO2 is 92% on RA.
1. ABCs - MOVIE
2. Make NPO
3. NG tube - decreases risk of aspiration???
4. IV Pantoloc
5. Octreotide
6. Erythromycin (to remove clots - weird)
7. Consult GI - urgent scope
8. Balloon tamponade if glue/banding fail.
35
What investigations are warranted in a pt with a UGIB?
CBC, lytes, BUN, Cr
Type and Cross
ALT, AST, Bili, INR, Albumin
36
What BUN: Cr ratio suggests UGIB and why?
High ratio.
Because...ummmm....if pt kidneys are hypoperfused, this is similar to a pre-renal AKI. Less blood filtered, more resporption of BUN relative to Cr = increased BUN:Cr ratio.
37
UC, Crohns or Pseudomembranous Colitis?
Granulomas on biopsy
Crohns
38
UC, Crohns or Pseudomembranous Colitis?
Associated with PBC
UC
39
UC, Crohns or Pseudomembranous Colitis?
Pus and blood in stool
Pseudomembranous Colitis
40
UC, Crohns or Pseudomembranous Colitis?
Flares up post-Abx
Pseudomembranous Colitis
41
UC, Crohns or Pseudomembranous Colitis?
+ arthritis
Crohns
42
UC, Crohns or Pseudomembranous Colitis?
Skip lesions
Crohns
43
UC, Crohns or Pseudomembranous Colitis?
obstruction w apple core on barium enema
Crohns
44
UC, Crohns or Pseudomembranous Colitis?
lead pipe colon
UC
45
UC, Crohns or Pseudomembranous Colitis?
only superficial mucosa inflamed on biopsy
UC
46
UC, Crohns or Pseudomembranous Colitis?
esophageal involvement
Crohns
47
UC, Crohns or Pseudomembranous Colitis?
anal fistulas
Crohns
48
A patient who received a Roux-en-Y gastric bypass is most likely to experience which of the following?
a) rise in PTT & INR
b) rise in INR only
c) B12 deficiency
d) rise in PTT only
a)
Due to malapsorption of lipid-soluble vitamins, ADEK, pts can experience coagulopathies related to Vitamin K deficiency post Roux-en-Y.
49
What are triggers for hepatic encephalopathy
1. bleed/hypovolemia
2. infection (SBP)
3. hypoK
4. hypoglycemia
5. drugs
etc.
50
List the grades of hepatic encephalopathy
1. confused/altered sleep-wake cycle
2. asterixis
3. somnolent
4. coma
51
SSx of hemochromatosis
- Bronze diabetes
| - what else???
52
Write a prescription for H.pylori treatment
H-PAC
Pantoprazole 40mg bid
Amoxicillin 1g po BID
Clarithromycin 500mg po BID
Mitte - 14 days
53
A 68 year old man presents with severe sudden hematemesis.
You're unable to take a hx.
What's on the top of your DDx?
What should your initial management NOT include?
a) NG tube
b) NPO
c) Pantoprazole 80mg PO
d) Ocretotide IV
e) IvNS
DDx - mallory-weiss, varices, peptic ulcer, (aortoenteric fistula - if hx of aortic aneurism repair).
Should NOT include c)!!! DO NOT GIVE ANYTHING BY MOUTH!!!
54
what is the most prevalent extraintestinal complication of inflammatory bowel disease?
Anemia
55
bp is low what kind of ABG wil you see
lactic acidosis - PH - 7.2 anion gap etaboic acidosis
56
fluffy bilateral interstitial infiltrates
ARDS - Alveolar arteriolar mismatch
| intra cardiac shunt, PE, Pulmonary edema, R-> L shunt also causes A-a mismatch
57
treatment for acute prostatitis
Both ciprofloxacin and ofloxacin have been shown to be highly effective as empirical oral therapy for acute prostatitis.
58
2 dys afetr undergoing surgical repair for a town ACL, pt develops jaundicen
Gilberts
59
25 yr old has fatigue, nausea and vomiting and decreased appetite. todl she has a viral infectino but comes back. bili is 4.2 with direct 3.6 AST - 350, ALT - 280 LDH - 410 , alk phos norm
acute hepatitis
60
pt with vesicular painful rash on left and right low quadrant on abdomen. Pt is IC and has fever. TX?
IV acyclovir
61
dullness to what is the most accurate test for TB?
pleural biopsy and culture of lung mass
62
HIV pt with cough and wheezing. taking prednisone. dullness to percussion over the left upper post thorax. Eosinophils 10% in labs
pcp pneumonia mostly. biopsy and staining may show pneumocyxtic jiroveci cysts
63
primary mineralcorticoid
aldosterone
64
hypogonadotrophic hypogonadism
kallmans
65
pt has ASD what happens to RV
ASD and thus chronic volume overload in right ventricle
66
when do you see a paradoxical pulse?
```
cardiac tamponade,
pericarditis,
chronic sleep apnea,
croup,
obstructive lung disease (e.g. asthma, COPD)
```
67
wife has hb A and father has not been screened, what is the risk of baby having sickle cell disease?
0% - AR
68
77 yr old women with hx of HTN. has afib intermittently. No hx of cerebral infarct or TIA. bp is 170/90. Which med should she be taking to prevent cerebral infarct in this pt?
Warfarin.
69
hep B surface ag (-)
anti hep B core ag (+)
anti hep B surface ag (-)
next step --> give hep B vaccine because ANTI hep B surface is (-)
70
Labs for klein felters
testosterone
FSH
LH
(primary) hypogonadism,
low serum testosterone
high (FSH) and (LH) levels
71
what can be used to treat anaerobes?
clindamycin
72
left lower lobe infiltrate and a pleural effeusion. Thoracocentesis yields yellow fluid. pH 6.8 . segmented neutrphil gram stain - 90% - gram positive dipplococci
Empeyema
73
myelocutes 10%
metamyelocyts 5%
37 yr old
cml
74
42 yr oldl man with 1 mo history progressive shortness of breath. younger bro had single lung transplant for COPD 1 yr ago. breath sounds decreased bilaterally, bilateral basilar crackles heard. Xray shows hyperlucent lung fields and flattened diaphragm.
Alpha 1 antitripsin def- abnormality of antiprotease resulting in destruction of alveolar supporting structures
75
Another name for variant angina pectoris
prinzmetal angina
76
osteonecrosis is a known cause of what drug?
prednisone
77
py pm dialysis develops left hip pain and fracture of the femoral neck. Why?
the kidney cant keep calcium in blance in bone. --> osteoporosis.
All dialysis pts should be on supplemental Ca
78
rash on the face neck and hands when she was in the backyard wear sleevless cloothing. red papules vesicles and bullae, some in linear pattern, on her forearms, neck and face. oozing vesicles over the wrists
contact dermatitis
79
73 yr old man has syncopal episodes without warning. what is the next step in dx
ambulatory ECG monitoring
80
pesticide poisoining mechansim
decreased synaptic activity of cholinesterase
81
iron def
decreased MCV - mean red cell volume
low retic
Low ferritin
82
pt has firmness and distention with shifting dullness.. leukocytes 17500. next step
abdominal paracentesis - i think you do that next casue you dont want it to get to spontanoeous bacterial peritonitis.... maybe it already is?
83
pt has been taking alot of ibuprofen and is throwing up blood but his liver labs are normal and he has occult blood, next step
packed RBC's. (no FFP cause liver is fine )
84
pitting edema, heavy menses, 5 pound weight gain, periorbital edema, low bp. next step?
TSH measurement
85
What is the strongest predisposing factor for perioperative MI
mi with in past 6 mo ( in this question)
86
Sympathetic ophthalmia?
Characterized by immune medicated damage (uveitis) against one eye after a penetrating injury to the OTHER eye.
It is due to an immunologic mechanism involving the recognition of "hidden" antigens.
87
Signs/Symptoms of Cor pulmonale
Most common cause of cor pulmonale?
```
JVD
Increased intensity of P2
Right ventricular heave
Hepatomegaly/ascites
Dependent pitting edema
```
COPD
88
Young patient who develop CHF randomly...diagnosis?
viral myocarditis
89
Most common cause of viral myocarditis?
Coxsackie B virus
90
Causes of respiratory acidosis?
```
narcotic overdose (opioids)
Neuromuscular weakness (ALS, myasthenia gravis)
COPD
```
91
Causes of metabolic alkalosis?
Vomiting
Hyperaldosteronism
Volume contraction
92
Respiratory alkalosis?
Salicylate intoxication --> Hyperventilation
| High altitude --> hyperventilation
93
Treatment for exercise induced asthma?
Beta agonists 20 minutes before exercise
94
Initial management of acne?
MOderate acne?
Severe acne?
Mild acne --> Topical retinoids, Benzoyl peroxide
Moderate acne --> addition of topical antibiotics (erythromycin)
Severe acne --> Oral isoretinoin
95
Hyatid cyst?
Characteristic CT scan finding?
Treatment?
Liver cyst caused by infection with Echnococcus granulosius (close contact with dogs)
**Eggshell calcification of a hepatic cyst**
DO NOT aspirate due to risk of anaphylactic shock secondary to spilling of cyst contents
Treatment by surgical resection + ALBENDAZOLE
96
Chagas disease?
Protozoal infection associated with dilated cardiomyopathy and Toxic megacolon/mega esophagus
Organism: Trypanosoma cruzi (protozoa)
97
Most sensitive test for diabetic nephropathy?
Random urine for microalbumin/creatinine ratio
Microalbumin = 30 - 300 mg/24 hr
98
Creatinine clearance in diabetic nephropathy?
Remember, there is glomerular hyperfiltration and an INCREASE in creatinine clearance in the early stages of diabetic nephropathy.
99
Anti-phospholipid syndrome?
Occurs in Lupus (SLE)
*Promotes coagulation in vivo, but in vitro, prolongs the PTT*
PTT does NOT correct with addition of 1:1 dilution with normal plasma (Russel viper venom test)
100
Treatment of PTLD?
Cause of PTLD?
Reduction of immunosuppression + Acyclovir
Primary or reactivation of Epstein Barr virus
101
Tumor lysis syndrome?
Treatment?
Hypocalcemia
Hyperuricemia
Hyperkalemia
Hyperphosphatemia
Uric acid elevations can cause urate-induced kidney failure
**Allopurinol reduces acute urate nephropathy**
**Treatment includes IV fluids + allopurinol (xanthine oxidase inhibitor).
102
Absolute contraindication to transplant?
Cancer
103
Hereditary angioneurotic edema?
C1 esterase inhibitor deficiency
Autosomal dominant
104
Chediak Higashi?
Light skinned
**Increased susceptibility to infection that results from defective neutrophil granulation**
Patients are at increased risk of hemophagocytic syndrome following viral infection
105
Treatment for a solitary brain metastasis with stable extracranial disease?
Multiple brain metastases?
Surgical resection of the mass
Whole brain radiation
106
Pernicious anemia is associated with increased risk of what cancer?
Chronic atrophic gastritis --> Double the risk of gastric cancer
107
What is a risk for native valve endocarditis?
MVP (particularly as a complication of rheumatic heart disease) is a risk factor for native valve infective endocarditis
108
Most common causative organisms of native valve infective endocarditis?
Subacute endocarditis?
Prosthetic valve endocarditis?
Acute = Staph aureus
Subacute = Strep viridans
Prosthetic valve = staph epidermidis (coagulase negative)
109
Immunosuppressed pt. with sinus symptoms...diagnosis?
Always think fungal sinusitis in an immunosuppressed pt
Amphotericin B is treatment
110
Asplenic patients at risk for what?
What is empriric abx therapy?
Infection with encapsulated organisms
(Strep pneumoniae, Haemophilus influenzae, Neisseria meningitidis)
Vancomycin + Ceftriaxone
111
Abx. Treatment for diabetic foot ulcer?
Always think Pseudomonas in a diabetic patient
Treatment for pseudomonas is Zosyn + Vancomycin
112
Cardiac symptoms of Lyme disease?
2nd or 3rd degree heart AV block
Myocarditis
113
3 most common organisms in bacterial sinusitis (most are viral)?
Strep. pneumoniae
Haemophilus influenzae
Moraxella Catarrhalis
(same as otitis media)
114
Trigeminal neuralgia most often affects what nerve distribution?
Sharp, burning pain lasting a few seconds
V2 distribution
115
Treatment for:
Syphilis
HSV-2
Chancroid (Haemophilus ducreyi)
Syphilis - penicillin (doxycycline if allergic)
HSV-2 - acyclovir
Chancroid (Haemophilus ducreyi) - Ceftriaxone (broad spectrum against gram -)
116
What does CMV cause in AIDS patients?
Not pneumonia!
Retinitis
Esophagitis
Treatment is gancyclovir or FOSCARNET
117
Diagnosis and treatment of Nocardia?
Diagnosis - filamentous gram positive branching rods ...buffered charcoal yeast extract
Treatment - TMP - SMX
118
1st line treatment of lyme disease?
Amoxicillin
| Doxycycline
119
Lymphogranuloma venerieum (LGV)?
Caused by Chlamydia
3 stages:
1 - painLESS herpetiform ulceratoin
2 - painFUL unilateral inguinal lymphadenitis, presents at fluctuant buboes
3 - Elephantiasis
120
Causative agent of keratoconjunctivitis?
Symptoms?
HSV
Photophobia, constricted pupil, foreign body sensation)
Dendrites visible on fluorescein staining
121
Treatment of viral vs. bacterial conjunctivitis?
Viral - topical acyclovir (or eye drops)
Bacterial - Erythromycin or Sulfa eye drops
**Can distinguish by the presence of purulent discharge in bacterial conjunctivitis)
122
Rash that starts on wrists and ankles and spreads to trunk?
Treatment?
Rickettsia rickettssi
Doxycycline (even in children)
123
Staining for TB?
Red, acid fast Ziehl Neelsen staining (
124
Cause of Bacilliary angiomatosis?
Treatment?
Bartonella Henseleae
Erythromycin / doxycycline
125
What vaccines are contraindicated in immunocompromised individuals?
Live vaccines
LIVE! one night only...come see small yellow chickens get vaccinated with MMR and Sabin's polio
```
Small pox
Yellow fever
Varicella
MMR (can be given to HIV pts. with no signs of immunodeficiency)******
Oral poliovirus (sabin
```
126
Appearance of the following brain lesions in HIV patients:
PML
CMV
Cryptococcal
Toxoplasmosis
Neurocysticercosis
PML - NONENHANCING WHITE MATTER LESIONS
CMV - asymmetric lesions with meningeal enhancement after contrast
Cryptococcal - Clustered hyperintesne lesions
Toxoplasmosis - Ring enhancing lesions
Neurocysticercosis - Scattered cystic lesions with edema
127
Leukoplakia vs. Candida scraping off?
...
128
Preferred treatment for mucocutaneous and pseudomembranous candidiasis?
(affects the immunocompromised population)
Clotrimazole
129
Mycoplasma pneumoniae on gram stain?
Negative gram stain b/c no bacterial cell wall! also, lack of growth on bacterial agar
"Walking pneumonia"
**Check serum cold agglutinins*
130
How to diagnose legionella pneumoniae?
Urine antigen test
Direct fluorescent antibody (DFA) staining of sputum
131
How to diagnose PML?
JC virus --> PCR of CSF
132
Before you perform a lumbar puncture, what do you have to do?
Imaging (CT or MRI) to assess for increased ICP
133
Chemotherapy combination for Hodgkin's lymphoma?
CHOP
Cyclophosphamide
Doxorubicin
Oncovin (Vincristine)
Prednisone
134
Progression of HIV infection?
When to treat HIV?
Initially acute seroconversion, the viral load will peak and the CD4+ count will plummet, until a set point is reached.
Then the CD4+ count will rise back up , and the viral load will decrease
Treat HIV when CD4+ count <350 or the presence of symptoms
135
Round pneumonic lesion in a *PREEXISTANT* lung cavity...diagnosis?
Aspergilloma
136
Histoplasmosis?
Coccidoides?
Blastomycoses?
Histoplasmosis - Mississippi river valley; spelunking (bats), pigeon droppings; can cause erythema nodosum
Coccidoides - Southwestern United states, San Joaquin Valley fever - rash erythema nodosum,
Blastomycoses?
137
Treatment of otitis externa?
Ear cleaning, debridement, and acidifying drops
138
Side effects of TB drugs?
Rifampin - Cyp450 inducer, orange body fluids (tears, sweat, urine)
Isoniazid - hepatotoxicity, neuropathy
Pyrazinamide - hepatotoxicity
Ethambutol - optic neuritis
139
Most common side effects of Fluoroquinolones?
GI upset most common
Tendon rupture - very rare
140
Treatment for Coccidoides in immunocompetent pt.
Same concept in other Fungal infection (Histo, Blasto)
None necessary...
Fluconazole if not immunosuppressed
Amphotericin B if immunosuppressed or an extrapulmonary infection
141
Chronic urinary tract infections as a child...diagnosis?
How to diagnose?
Vesicoureteral reflux
Voiding cystouregrogram
142
Treatment for Cryptococcus neoformans (india ink stain)?
Amphotericin B
143
In diabetic patients, what is the cause of otitis externa?
Pseudomonas
144
PPD test in a patient with HIV?
You may get a false negative if CD4 < 500 b/c of anergy, so not a good test
145
Diagnosis of lyme disease?
1. ELISA (lots of false positives from other spirochetal diseases)
2. Western Blot confirmation
(same as HIV)
146
Treatment of a human bite?
Augmentin (Amoxicillin/Clavulanate
147
What lab value is elevated in PCP pneumonia infections?
LDH
148
what is the most prevalent extraintestinal complication of inflammatory bowel disease?
Anemia
149
bp is low what kind of ABG wil you see
lactic acidosis - PH - 7.2 anion gap etaboic acidosis
150
fluffy bilateral interstitial infiltrates
ARDS - Alveolar arteriolar mismatch
| intra cardiac shunt, PE, Pulmonary edema, R-> L shunt also causes A-a mismatch
151
treatment for acute prostatitis
Both ciprofloxacin and ofloxacin have been shown to be highly effective as empirical oral therapy for acute prostatitis.
152
2 dys afetr undergoing surgical repair for a town ACL, pt develops jaundicen
Gilberts
153
25 yr old has fatigue, nausea and vomiting and decreased appetite. todl she has a viral infectino but comes back. bili is 4.2 with direct 3.6 AST - 350, ALT - 280 LDH - 410 , alk phos norm
acute hepatitis
154
pt with vesicular painful rash on left and right low quadrant on abdomen. Pt is IC and has fever. TX?
IV acyclovir
155
dullness to what is the most accurate test for TB?
pleural biopsy and culture of lung mass
156
HIV pt with cough and wheezing. taking prednisone. dullness to percussion over the left upper post thorax. Eosinophils 10% in labs
pcp pneumonia mostly. biopsy and staining may show pneumocyxtic jiroveci cysts
157
primary mineralcorticoid
aldosterone
158
hypogonadotrophic hypogonadism
kallmans
159
pt has ASD what happens to RV
ASD and thus chronic volume overload in right ventricle
160
when do you see a paradoxical pulse?
```
cardiac tamponade,
pericarditis,
chronic sleep apnea,
croup,
obstructive lung disease (e.g. asthma, COPD)
```
161
wife has hb A and father has not been screened, what is the risk of baby having sickle cell disease?
0% - AR
162
77 yr old women with hx of HTN. has afib intermittently. No hx of cerebral infarct or TIA. bp is 170/90. Which med should she be taking to prevent cerebral infarct in this pt?
Warfarin.
163
hep B surface ag (-)
anti hep B core ag (+)
anti hep B surface ag (-)
next step --> give hep B vaccine because ANTI hep B surface is (-)
164
Labs for klein felters
testosterone
FSH
LH
(primary) hypogonadism,
low serum testosterone
high (FSH) and (LH) levels
165
what can be used to treat anaerobes?
clindamycin
166
left lower lobe infiltrate and a pleural effeusion. Thoracocentesis yields yellow fluid. pH 6.8 . segmented neutrphil gram stain - 90% - gram positive dipplococci
Empeyema
167
myelocutes 10%
metamyelocyts 5%
37 yr old
cml
168
42 yr oldl man with 1 mo history progressive shortness of breath. younger bro had single lung transplant for COPD 1 yr ago. breath sounds decreased bilaterally, bilateral basilar crackles heard. Xray shows hyperlucent lung fields and flattened diaphragm.
Alpha 1 antitripsin def- abnormality of antiprotease resulting in destruction of alveolar supporting structures
169
Another name for variant angina pectoris
prinzmetal angina
170
osteonecrosis is a known cause of what drug?
prednisone
171
py pm dialysis develops left hip pain and fracture of the femoral neck. Why?
the kidney cant keep calcium in blance in bone. --> osteoporosis.
All dialysis pts should be on supplemental Ca
172
rash on the face neck and hands when she was in the backyard wear sleevless cloothing. red papules vesicles and bullae, some in linear pattern, on her forearms, neck and face. oozing vesicles over the wrists
contact dermatitis
173
73 yr old man has syncopal episodes without warning. what is the next step in dx
ambulatory ECG monitoring
174
pesticide poisoining mechansim
decreased synaptic activity of cholinesterase
175
iron def
decreased MCV - mean red cell volume
low retic
Low ferritin
176
pt has firmness and distention with shifting dullness.. leukocytes 17500. next step
abdominal paracentesis - i think you do that next casue you dont want it to get to spontanoeous bacterial peritonitis.... maybe it already is?
177
pt has been taking alot of ibuprofen and is throwing up blood but his liver labs are normal and he has occult blood, next step
packed RBC's. (no FFP cause liver is fine )
178
pitting edema, heavy menses, 5 pound weight gain, periorbital edema, low bp. next step?
TSH measurement
179
What is the strongest predisposing factor for perioperative MI
mi with in past 6 mo ( in this question)
180
other names for the celiac antibody
endomysial IgA antibody; anti tissue transglutaminase
181
Dark skin, fatigue/increased urination, with s3 and embiggened liver with elevated liver enzymes
Hemochromatosis; triad is skin pigmentation crap, bronze diabetes, liver cirrhosis
182
AIN can also be called
TUBULOinterstitial nephritis; think of the damn tubule
183
1. SOB
- cardiac or pulmonary?
184
h/o Ca, sx, immobility
suspect PE Rx. heparin, supplemental O2 if <90%.
185
sxs pna
- get CXR
186
murmur or h/o CHF
- get echo/check EF.
187
acute pulm edema
- gives nitrates, lasix and morphine.
188
young +sxs of CHF + prior viral infxn
- consider myocarditis (Coxsackkie B)
189
young and no cardiomegaly on CXR
consider primary pHTN. Right heart cath can tell CHF from pulmonary HTN
190
2. CHF:
Rx: ACE-I improve survival- prevent remodeling by aldo, B-blocker (metoprolol and carveldilol) improve survivalprevent remodeling by epi/norepi. Spironolactone- improves survival in NYHA class III and IV. Furosemide- improves sxs (SOB, crackles, edema). Digoxin- decreases sxs and hospitalizations
191
Systolic
- decreased EF (<55%). Ischemic, dilated (Viral, ETOH, cocaine, Chagas, Idiopathic). Alcoholic dilated cardiomyopathy is reversible if you stop
192
Diastolic
- normal EF, heart can't fill. HTN, amyloidosis, hemachromatosis. Hemachromatosis restrictive cardiomyopathy is reversible w/
phlebotomy
193
CP
1. stemi 2. nstemi 3. unstable angina ??
194
EKG
2mm ST elevation or new LBBB (wide/flat QRS) -->STEMI
195
timing: ST elevation, Twave inversion, Qwave
ST elevation immediately, Twave inversion 6hours to year, Qwave is forever
196
STEMI
Rx: cath or thrombolytics
197
RV infarct sxs
hypotension, tachycardia, clear lungs, JVD, no pulses paradoxus. Do NOT give nitro. Admin IVF to inc preload
198
CE elevation without ST elevation
NSTEMI: get CE q8h x3.
199
NSTEMI Rx
Morphine, O2, nitrates, asa/plavix, BBL, coronary angiography w/in 48h, PCI with stenting is standard, CABG if: 1. L main dz, 2. 3 vessels dz, 3. 2 vessels dz +DM, 4. pain despite aggressive meds, post infarct angina
200
NSTEMI d/c meds
asa, +plavix 6-12month if stent, BBL, ACEI (if CHF or LV dysfxn), statin, short acting nitrates
201
If no ST elevation and normal CE
unstable angina
202
unstable angina work up
1. exercise EKG (avoid BBL, CCB before) 2. exercise echo if: old LBBB or baseline ST elevation or on digoxin 3. chemical stress test with dobutamine or adenosine if can't exercise 4. MUGA to tests perfusion of areas of heart. unstable angina is positive if during stress: ST depression or hypotension --> coronary angiography
203
Post MI complications
depends on time of presentation
204
MC cause death
arrythmia, afib
205
5-7d, new systolic murmur
papillary muscle rupture
206
acute severe hypotension
ventricular free wall rupture
207
step up [O2] from RA-->RV
ventricular septal rupture
208
1 mo, persistent ST elevation
ventricular wall aneurysm
209
cannon A waves
AV dissociation. either Vfib or 3rd degree heart block
210
5-10 week, pleuritic CP low grade temp
Dressler's (?) autoimmune pericarditis (Rx: NSAIDS, asa).
211
Naco3 mechanism tca
Na fast channels
212
Trousseau syndrome
Migratory phlebitis. Suggests pancreatic or lung adenocarcinoma
213
M2
Myeloblast
214
ALL
PAS-positive lymphoblasts
215
Monoblasts
Esterase positive
216
Cushing's syndrome acid/base status
hypokalemic alkalosis
217
BCR-ABL
CML
218
prussian blue stain
hemosiderin
219
Vitamin K deficiency
PT prolonged, then PTT prolonged. 30 days if not sick, 7-10 days if sick (surgery, etc). NPO, antibiotics can predispose you. tx: FFP
220
vWF disease
increase bleeding time and increased PTT.
221
glucagonoma
hyperglycemia, dermatitis, weight loss, anemia
222
haptoglobin in hemolytic anemia
decreased (too much hgb binds, leads to excretion.
223
Malt lymphoma
w/o spread to lymph node: triple therapy (PPI, clarithromycin, amoxicillin)
224
Malt lymphoma
w/ spread: chemotherapy (CHOP)
225
Warfarin + ___ = bleeding
alcohol, vitamin E, garlic, ginkgo, ginseng, St. John's wort, antibiotics.
226
Lymphadenopathy + normocytic anemia
warm hemolytic anemia
227
pleural effusion Physical exam
decreased tactile fremitus, dull to percussion, decreased breath sounds.
228
increased fremitus
pneumonia
229
pancoast tumor
Ulnar distribution of pain.
230
aspergilloma
hemoptysis, fever, weight loss, chronic cough. mobile mass
231
legionella
GI + pneumonia. hyponatremia
232
legionella tx
quinolone or macrolide.
233
H flu infects whom
COPD-ers
234
moraxella infects whome
COPD
235
Staph aureus pneumonia affects whom
recent influenza infection.
236
Tube in one bronchus
No hypotension
237
Tension pneumothorax
Hypotension
238
mitral stenosis predisposes to
atrial fibrillation and pulmonary edema.
239
graft rejection
neutropenia
240
GBHD
rash, and bad LFTs
241
ichthyosis vulgaris
skin normal at birth, scaly throughout as you age.
242
lichen planus
purple pruritic, flat, papules, white streaks.
243
miliaria
heat rash. small vesicles and papules / pustules on trunk. burn, itch. hot/moist climates
244
rosacea
taelangiectasia. redder with hot drinks, heat, emotion. leads to permanently flushed skin. 30-60. topical flagyl
245
tinea versicolor
pale, pink or white. don't tan. scale on scraping. tx: selenium and ketoconazole. mlassezia furfur. microscope: spaghetti and meatballs.
246
vitiligo
peri-oral or fingers.
247
Pityriasis rosea
oval, fawn-colored plaques. 2cm. Christmas tree. herald patch, then eruption.
248
ringworm
ring-shaped lesion. advancing caly border, central clearing.
249
seborrheic keratosis
waxy, suck-on, warty, well-circumscribed, flat. any shade of grade. \
250
achrochordon
skin tag. flech-colored.
251
actinic keratosis
flat papules w/ erythematous base.
252
basal cell
pearl, rollwed border. telangectasia. ulcer.
253
bullous pemphigoid
lasix, nsaids, captopril, penicillamine, antibiotics. TENSE bullae and urticaria. no mucous membrane involvement. IgG target hemidesmosomes. direct immunofluorescence. subepidermal. IgG, C3
254
pemphigus
intraepidermal. DIF: keratinocyte IgG. flaccid and fragile blisters
255
linear IgA bullous dermatosis
dermal-epidermal JCN. childhood bullae.
256
acne + scars
oral isotretinoin
257
erythromycin S/E
GI upset, jaundice
258
doxycycline S/E
sunburn
259
secondary syphilis
palms and soles included!
260
rubella
posterior auricular lymphaenopathy, polyarthralgia, rash.
261
canker sore
aphthous ulcers. fibrin-coated ulcers. mononuclear infiltrates.
262
basal cell not found
on the lips.
263
Atopic dermatitis tx
Corticosteroids
264
Dermatitis herpetiformism (celiac) tx
Dapsone
265
Actinic keratosis
Sandpaper texture
266
Seborrhea keratosis
Stuck-on appearance
267
Atopic dermatitis microscooic
Spongiosus
268
Porphyria cutanea tarda
Painless blisters, hand skin fragility, facial hypertrichosis. hep C. Uro-decarbox def.
269
Porphyria cutanea tarda tx
Hydroxychloroquine, or phlebotomy
270
IgA def
Chronic giardia and respiratory infections
271
C3 def
Respiratory and sinus
272
C5-c8
Neisseria
273
Plavix
Causes TTP
274
Hepatitis C
Porphyria cutanea tarda and leukocytoclastic vasculitis (cryoglobulinemia), membranoproliferative nephritis
275
Severe seborrheic dermatitis
HIV
276
New-onset psoriasis
HIV
277
Severe serborrheic keratosis, itchy
Gi malignancy
278
Pyoderma gangrenosum
Ibd
279
Addison's
Hyperpigmentation
280
Mupirocin
MRSA skin infections
281
non-healing ulcer
squamous cell carcinoma. sunlight.
282
pemphigus vulgaris
flaccid bullae. desmoglein. tx steroids.
283
bullous pemphigoid
tense bullae. IgG and C3 deposits in the dermal epideraml jcn.
284
cutaneous larva migrants
pruritic, elevated, serpiginous lesions. contact w/ sand. Ancylostoma braziliense.
285
brown recluse bite
papule w/ erythema, then severe ulceration
286
ivdu endocarditis
staph. use vanc.
287
Babesiosus
tick in NE. no rash. Symptomatic if asplenicGiemsa stain. tx: quinine-clindamycin or atovaquone-azithromycin
288
Erlichiosis
"spotless RMSF" leukopenia, thrombocytopenia, elevated LFTs. Doxycycline.
289
Q fever
Coxiella burnetii. cattle, goat, sheep. flu, hepatitis, pneumonia
290
RMSF in pregnancy
chloraphenicol
291
Legionnaire's disease Tx
erythromycin.
292
prosthetic valve endocarditis
staph epidermidis.
293
trichinella
GI complaints. Then periorbital edema. myositis, eosinophilia, subungual splinter hemorrhages. undercooked pork.
294
Ascariasis
GI and eosinophilia. 1. lung phase. non-productive cough. 2. asymptomatic phase. 3. SBO or biliary obstruction from bug.
295
botulism
constipation, descending paralysis, respiratory failure. inhibits ACh
296
HIV pneumonia
think staph aureus if CD4>200 and especially if IVDU.
297
pulmonary TB
more indolent than 3 days.
298
rubella
fever, rash, occipital or posterior cervical lymphadenopathy, arthritis.
299
New HIV
CBC, CMP, 2 RNA levels, CD4, VDRL, PPD, anti-toxoplasma Ab, MMSE, Pneumococcal vaccine (unless CD4<200), Hep A&B serology, then vaccine if seronegative
300
postherpetic neuralgia
TCA tx
301
bacillary angiomatosis
bright red firm, friable, exophytic nodules. in HIv infected patients. tx: erythromycin.
302
CD4<50
Zithromax (for MAC) and ganciclovir (for CMV)
303
dapsone
if you cannot use TMP-SMX
304
INH for HIV
induration >5mm
305
Tx for MAC
clarithomycin + Ethambutal
306
Ganciclovir
if CD4<50, CMV IgG is positive, or (+) biopsy
307
HIV vaccine
if CD4 > 200, pneumococcal vaccine + annual flu vaccine. meningococcal vaccine doesn't work well.
308
needle stick HIV
draw serolog, start HAART (3 drugs). repeat in 6wks, 3 mos, 6 mos,
309
toxoplasmosis prevention
TMP-SMX
310
Pneumocystis prevention
TMP-SMX
311
fluconazole
Crypto and coccidiodes prophylaxis if HIV+ w/ hx of these diseases and for those w/ frequent candida infections.
312
CMV retinitis
usually causes encephalitis, not lesion. painless.
313
toxoplasmosis brain
causes ring-enhancing lesion. most likel.
314
nocardia
gram + weak acid-fast, filamentous branching rod. lung infection of any sort. Tx: TMP-SMX
315
EHEC
abd tenderness w/o fever. + Bloody diarrhea.
316
Nail puncture wound
if in an adult through a rubber shoe, think pseudomonas causing osteomyelitis. tx: quinolones and surgery.
317
mono complication
autoimmune hemolytic anemia
318
corynebacterium
sore throat with pseudomembrane formation. Cx: dilated cardiomyopathy.
319
analgesic nephropathy
papillary necrosis. chronic interstitial nephrititis. polyuria, sterile pyuria, chronic renal failure.
320
myotonnic dystrophy
testicular atrophy, widespread muscular atrophy, weakness, lower than normal T, high FSH & LH
321
IgA nephropathy
glomerular hematuria after URI. normal serum complement. RBC cast. looks like AIN otherwise.
322
AIN
WBC casts
323
Cholesterol embolization
causes ARF, bluish discoloration (livedo reticularis), GI complaints, eosinophilia in blood or urine, decreased complement. If patient has an angiography, they're at risk "blue toes syndrome"
324
diabetic nephropathy
microangiopathy. mild to moderate proteinuria with increased Cr.
325
mixed cryoglominemia
palpable purpura, proteinuria, hematuria. arthralgia, hepatosplenomegaly, low complement. underlying HCV.
326
Henoch-schonlein purpura
childhood. palpable buttocks purpura, abd pain, arthralgia, proteinuria ,hematuria w/ RBC casts on urinalysis.
327
Microscopic polyangitis
constitutional symptoms, fever, malaise. abd pain, hematuria. ANCA.
328
acyclovir S/E
crystalluria w/ renal tubular obstruction during high-dose parenteral therapy in inadequately hydrated patients.
329
unilateral varicocele
if it fails to empty when recumbent, think RCC.
330
broad cast
chronic renal failure. (compensatory hypertrophy)
331
waxy casts
chronic renal failure. (compensatory hypertrophy)
332
RBC cast
glomerular disease or vasculitis
333
WBC cast
interstitial nephritis, pyelonephritis.
334
Fatty casts
nephrotic syndrome
335
hyaline casts
pre-renal azothemia.
336
RBC cast
glomerulonephritis.
337
Recurrent Idiopathic hypercalciuria
1) increase fluid. 2) Na restriction 3) thiazide. Do not restrict calcium.
338
hyperuricosuria
purine-restriction, allopurinol.
339
CKD contrast choice
non-ionic superior.
340
CKD + Bleeding
platelet dysfcn is the most common cause of abnl hemostasis. Bleeding time is only thing prolonged. Tx: DDAVP, which increases multimers of vWF and VIII.
341
non-inflammatory chronic prostatitis
afebrile, irritative voiding symptoms.
342
chronic bacterial prostatitis
afebrile, freq, urgency, suprapubic perineal discomfort. Normal urinalysis. expressed secretion WBC >10. Positive culture
343
inflammatory chronic prostatitis
afebrile, freq, urgency, suprapubic perineal discomfort. Normal urinalysis. expressed secretion > 10WBC/hpf. negative culture
344
premature ejaculation
fluoxetine
345
trazodone
painful erejctions.
346
cyclosporine S/E
nephrotoxicit, hyperkalemia, HTN, gum hypertrophy, hirsutism, tremor.
347
tacrolimus S/E
same as cyclosporine (-) gum hypertrophy and hirsutism.
348
azathioprine
diarrhea, leukopenia, hepatotoxicity.
349
mycophenolate S/E
bone marrow suppression
350
Na polystyrene sulfonate
removes K from GI tract. takes hours to have an effect.
351
Insulin's effect on K
takes 30 minutes to take effect.
352
Bone pain, renal failure, hypercalcemia
multiple myeloma. laminated casts (paraproteins). normocytic anemia
353
primary hyperparathyroidism
decreased Phosphorus level.
354
secondary hyperparathroidismm
hypocalcemia and hyperphosphatemia.
355
nephrotic syndrome repercussions
hypercoagulable (MI, stroke, renal vein thrombosis), accelerated atherosclerosis (higher LDL, lower HDL), Tx: aggressive statins.
356
Goodpasture's tx
emergency plasmapheresis
357
Wegener's tx
cyclophosphamide & steroids.
358
Good pasture's
bilateral
359
Wegener's
has UPPER respiratory symptoms
360
Goodpasture's
has LOWER respiratory symptoms
361
teenager painless hematuria
thicnk sickle cell trait!!!
362
carcinoma + nephropathy
membranous
363
hodgkin's + nephropathy
minimal change disease.
364
detrusor-sphincter dyssynergia
neurologic disease. difficulty initiating, inadvertent interruption of the urinary stream.
365
pyelonephritis that does not respond to a susceptible drug within 72 hrs
renal US.
366
Intermittent low and high urinary flow
renal stone. RBC and WBCs onl
367
gonorrhea
purulent discharge
368
chlamydia
mucopurulent discharge. less likely to have urethritis. positive grram stain.
369
membranoproliferative type 2
persistent activation of complement pathway.
370
FSGS
AA, obesity, IVDU
371
rhabdomyolysis tx
aggressive hydration, mannitol, urine alkalinization
372
uric acid stone
acidic pH. Tx: potassium citrate or potassium bicarb.
373
hepatorenal syndrome
ESLD. decreased GRF w/o shock, proteinuria, or other causes of renal failure.
374
HRS1
rapid progressive. 10 wks w/o tx. Liver transplant
375
HRS2
slower. 3-6 months w/o tx liver transplant.
376
Amikacin
aminoglycoside.
377
aminoglycosides
multi-drug resistant gram (-) rods (UTI).
378
Nafcillin kidney damage
AIN
379
doxycycline uses
CAPneumonia, zoonotic infections (lme), chlamydia, acne
380
zithromax
CAP, sinus infections, strep, chlamydia
381
primary hyperparathyroidism
hypercalcemia in ambulatory patients asymptomatic.
382
Hypercalcemia in hospitalized patients
malignancy.
383
Familial hypocalciuric hypercal
very low urine calcium.
384
if dexamethasone suppression test does not work
think ectopic b/c it won't have normal receptors.
385
Corrected calcium
Calcium + (0.8*(4-albumin)
386
CKD hypocalcemia
1-alpha-hydroxylation of vitamin D.
387
Primary hyperaldo
young patient w/ HTN, muscle weakness, numbness. high aldo/renin ration. autonomic aldo secretion.
388
hashimoto's Cx
thyroid lymphoma.
389
seizure labs
repeat after 2 hrs. metabolic acidosis should resolve by then if it was only due to the seizure.
390
lactic acidosis and ketoacidosis
only give bicarb if pH is <7.2. Only give enough to correct pH to 7.2
391
Unexplained high CPK and myopathy
Get a TSH. proximal muscle weakness, myalgias, sluggish reflexes (reflexes makes polymyositis less likely)
392
Nephrogenic DI as a drug S/E
Lithium, demeclocycline, foscarnet, cidofovir, amphoeteriicn
393
chronic pancreatitis
causes vitamin D malabsorption. Low Ca and low PO4
394
Tumor lysis syndrome
causes hyperkalemia. Calcium gluconate first, then insulin w/ glucose.
395
Succinylcholine S/E
hyperkalemia. never use if patient is already hyperkalemic (burn, crush injuries)
396
diuretic abuse
orthostasis, hypokalemia, hyponatremia.
397
Cor pulmonale (COPD)
Diuretics used, but be gentle b/c you can become prerenal.
398
persistent diarrhea
non-anion gap metabolic acidosis.
399
Chloride-resistant metabolic alkalosis
primary hyper aldo, bartter's, Gitelman's, black licorice.
400
RTA
non-anion gap metabolic acidosis.
401
Addison's
anorexia, fatigue, GI complaints, weight loss, hypotension, hyponatremia, hyperkalemia.
402
Acromegaly cause of death
CHF
403
Lithium induced DI tx
Amiloride
404
Demeclocycline
Siadh
405
DI
Intranasal AVP
406
Exopthalmos pathophysiology
periorbital lymphocytic infiltration
407
hyperthyroid nodule, untreated risks
rapid bone loss (osteoclasts). (aka toxic adenoma)
408
autoimmune adrenalitis
80% of adrenal insufficiency.
409
Adrenal insufficiencey infections
CMV, fungal, TB
410
hypokalemic alkalosis and normotension
Vomiting, diuretic, Bartter's, Gitelma's (You don't get BiG if you're trying to get skinny). Urine Cl is high in all except vomiting.
411
hypokalemia acidosis
chronic diarrhea. (bicarb in stool)
412
hyperaldosteronism
HTN, hypokalemic alkalosis, low renin, elevated aldo.
413
renal artery stenosis
hypokalemic HTN with high renin.
414
secondary high aldo
liver cirrhosis and CHF.
415
eosinophilia
can be a sign of glucocorticoid deficiency.
416
Screening for MEN IIa
DNA test. if positive, total thyroidectomy. (RET)
417
alkalosis's effect on Ca
increases affinity to albumin, decreasing ionized Ca.
418
acromegaly dx
GH levels after oral glucose. (unable to suppress GH w/ glucose) (IGF-1 can be used as a screening test, but this confirms it)
419
sick euthyroid syndrome
fall in T3 w/ nl TSH & T4.
420
pheochromocytoma + Propranolol
Don't do! They need an alpha blocker! Phenoxybenzamine is a good choice. Could also be started on Labetalol another mixed blocker)
421
Antithyroid drug therapy (prophylthiouracil and methimazole))
Agranulocytosis S/E
422
HHNK
if bicarb >20, think this.
423
Doxazosin + Sildenafil
do not take within a 4 hour interval (BP)
424
microalbumin:Cr
most sensitive test for nephropathy in diabetic
425
DM screening age
45. get an A1C w/o any risk factors.
426
hypoparathyroidism
low Ca, high P, normal renal fcn.
427
addison's
high K. Cosyntropin stimulation test.
428
Hyperthyroid causing HTN
Hyperdynamic circulation. increased myocardial sarcoplasmic reticulum Ca-dependent ATP-ase.
429
low Ca, high PO4
think 2ndary hyperparathyroidism. (CKD). phosphate retention causes parathyroid hormone to decrease Ca.
430
MEN 2a
parathyroid
431
MEN 2b
mucosal neuromas & marfans. B for brain stuff
432
MCC Thyroid nodule
colloid nodule (benign), then follicular adenoma.
433
hypoglycemia due to IGF II
non-beta cell tumor. suppressed insulin and c-peptide levels.
434
glucagonoma
skin rash (necrotic migratory erythema) and hyperglycemia
435
bartter's
thick ascending limb. High Urine Cl.
436
Gitelman's
DCT. High urine Cl
437
primary hyper aldo and renin tumors
all have HTN>
438
cold nodules
perform FNA on them.
439
orphan annie nuclei
papillary thyroid cancer. nuclear "clearing"
440
Diffuse follicular hyperplasia
grave's
441
dense lymphocytic infiltrate
hashimoto's.
442
Vit D deficiency
low calcium, low P, increased PTH.
443
Emergent varices
IV fluids, then sclerotherapy if it's really bad
444
Planned varices fix
band ligation.
445
Wilson's
Mallory hyaline, young person
446
Pancreatitis in non-alcoholic
At discharge, schedule cholecystectomy.
447
Varices
Beta blockers and then nitrates
448
Hepatorenal syndrome
Octreotide
449
Crigglar najjar type 1
Phototherapy and liver transplant
450
Crigglar najjar type 2
Phenobarbital periodically
451
Pancreatic cancer risk
Smoking.
452
Pancreatic pseudocyst
4 wks after pancreatitis. Amylase fibrous ball. Palpable. Fix if > 5cm, lasts more than 6wks, or invading blood vessel
453
Retro peritoneal hemorrhage
Greg turner's sign (bluish flanks) Cullen's sign (blue peri umbilical region)
454
Cirrhosis+ bleeding
Give FFP
455
Hydatid cyst
Dog contact. Ill-defined liver cyst. Egg-shell calcification.
456
Cysticercosis
Cyst in brain or muscle
457
lamivudine
can be used for chronic Hep B.
458
Hep B Tx
lamivudine or alpha-IFN if the ALT is twice normal or more.
459
Amebic abscess
mexican. oral metronidazole
460
Hep C Tx
alpha-IFN and ribavirn
461
PT higher and aminases lower
indication of progression to fulminant hepatitis
462
SAAG score
Albumin (-) ascites albumin. if >1.1, then it's transudative portal HTN.
463
postop cholestasis
prolonged surgery w/ hypotension & massive blood replacement. Jaundice. benign.
464
nonalcoholic pancreatitis step 1
RUQ US for gall stones. abd CT to confirm diagnosis.
465
Febrile nonhemolytic reaction (transfusion
reacion to cytokines. prevented by reducing WBCs and washing.
466
ABO mismatching
fever within 1 hour, hemolysis, shock, DIC.
467
IgA def transfusion
anaphylaxis within seconds to minutes.
468
paroxysmal nocturnal hemoglobinuria
acquired hemolytic anemia. complement mediated. unconjungated hyperbilirubinemia, thrombosis, pancytopenia.
469
conjugated bilirubin
in urine
470
pancreatitis + hypotension
pancreatic necrosis. increased vascular permeability
471
ascites + AMS + Abd discomfort
spontaneous bacterial peritonitis
472
alpha 1 antitrysin def.
PAS+, diastase (-)
473
hypothyroid + gynecomastia
think chronic liver disease.
474
spider angiomata
estrogen-related
475
palmar erythema
estrogen-related
476
primary biliary cirrhosis
anti-mitochondrial. Tx: Ursodeoxycholic acid
477
hep C related illnesses
cryoglobulinemia (and glomerulonephritis), B-cell lymphoma, plasmacytoma, autoimmune, lichen planus, porphyria cutanea tarda, ITP
478
emphysematous cholecystitis
clostridium, E. coli, staph, strep, pseudomonas, klebsiella. 50-70 yo Men. aur fluid levels in gallbladder and curvilinear gas shadowing. tx: fluids, cholecystectomy, IV antibiotics (amp-sulbactam, pip-tazo, aminoglycoside OR quinolone + clinda or metro
479
pancreatitis
IV fluids, NPO, no antibiotics.
480
Dubin Johnson and Rotor's labs
alk phos will not be elevated!
481
Case control
retrospective with outcome known.
482
retrospective cohort
exposed and not exposed. Then follows years later for the outcome.
483
Factorial design
groups with subgroups (high and low BP goals w/ different tx regimens)
484
cluster analysis
grouping different data points into similar categories. randomizes group. Crimes occur a lot in this particular area as opposed to another. What's the difference?
485
incidence
can't be calculated by case control
486
cohort
can calculate incidence.
487
selection bias
occurs if lost to follow-up
488
relative risk and relative rate
cohort, not case control.
489
case control
exposure odds ratio.
490
attributable risk percent
(RR-1) / RR
491
False Positive ratio
1-specificity
492
False negative ratio
1-sensitivity
493
effect modification
effect of the main exposure on the outcome is modified by the level of another variable.
494
When should screening for hypertension be done?
Start at 3 years old
| Every 2 years thereafter
495
How is hypertension diagnosed?
>140 sys or >90 dia
| x3 separate measurements
496
What is Stage 2 hypertension?
>160 sys or >100 dia
| Add 2nd agent
497
What is severe hypertension?
>210 sys or >120 dia or end-organ effects
| Immediate Rx
498
What is first line pharmaceutical treatment for hypertension?
Thiazides
499
What is prehypertension?
>120 sys or >80 dia
500
What are the compelling indications for treatment of prehypertension?
Diabetes
| Chronic Kidney Disease
501
What is the goal BP in the treatment of prehypertension?
<130/80
502
What is the workup for hypertension?
Urinalysis
BMP
EKG
H&H
503
What is the first line treatment of hypertension?
Weight reduction
Exercise
Alcohol & Smoking cessation
- attempt for 3 to 4 months before medication
504
What are the five first-line agents in the treatment of hypertension?
```
Thiazides
ACE inhibitors
Beta-blockers
ARBs
Ca-Channel blockers
```
505
What are the three antihypertensive agents used during pregnancy?
Hydralazine
Labetolol
Alpha-methyldopa
506
What lowers the blood pressure in pre-eclampsia?
Magnesium-sulfate
507
What is hypertensive emergency vs. urgency?
```
Both >200/120
Emergency occurs with end-organ damage:
Acute left ventricular failure
Unstable angina / Myocardial Infarction
Encephalopathy
```
508
What are the signs and symptoms of encephalopathy?
```
Headache
Altered mental status
Vomiting
Blurred vision
Dizziness
Papilledema
```
509
What is the treatment of hypertensive emergency?
Nitroprusside
Nitroglycerin
Beta-blocker (Labatelol)
510
What are the cariovascular effects of...
Nitroprusside
Nitroglycerin
Hydralazine, A1-antagonist, Ca-chnl blkrs
```
Dilates arteries and veins (both)
Dilates veins (reduces preload)
Dilates arteries (reduces afterload)
```
511
What risks are lowered in lowering blood pressure?
```
Stroke (HTN most important risk factor)
Heart disease
Myocardial infarction
Renal Failure
Atherosclerosis
Dissecting Aortic Aneurysm
```
512
What is the most common cause of death in the untreated hypertensive patient?
Coronary disease
513
Indications for use of ACE inhibitors
Heart failure
Diabetes
Acute coronary syndrome or unstable angina
Acute or prior myocardial infarction
High risk of coronary artery disease or stroke
Chronic kidney disease
514
Contraindications for ACE inhibitors
```
Pregnancy (fetal cardiac defects)
Renovascular hypertension (renal failure)
```
515
Indications for use of Aldosterone receptor blockers (eg spironolactone, eplerenone)
Heart failure
| Prior myocardial infarction
516
Contraindications for use of Aldosterone receptor blockers
Hypoerkalemia
| Pregnancy
517
Indications for use of ARBs (eg losartan, irbesartan)
Heart failure
Diabetes
Chronic kidney disease
518
Contraindications for use of ARBs
```
Pregnancy
Renovascular Hypertension (renal failure)
```
519
Indications for use of Beta-blockers
Stable angina
Acute coronary syndrome or unsatble angina
Acute or prior myocardial infarction
High risk of coronary artery disease
Atrial tachycardia or fibrillation
Thyrotoxicosis, Essential tremor, Migraines
520
Contraindications for use of Beta-blockers
```
Asthma
Chronic obstructive pulmonary disease
heart block
Sick sinus syndrome
*blocks signs of hypoglycemia
*causes hypercholesterolemia
```
521
Indications for use of Calcium channel blockers
Raynaud's syndrome
| Atrial tachyarrhythmias
522
Contraindications for use of Calcium channel blockers
Heart block
Sick sinus syndrome
Congestive heart failure
Pregnancy
523
Indications for use of Thiazides
Heart failure
Diabetes
High risk of coronary artery disease or stroke
Osteoporosis
524
Contraindications for use of Thiazides
Gout
Electrolyte disturbances (eg hyponatremia)
Pregnancy
525
What are the clues to possibilty of secondary hypertension?
Onset before 30 yrs old or after age 55
526
What are the possible causes of secondary hypertension in a woman?
In a young woman, most common cause is OCP
Next, renovascular HTN from fibrous dysplasia
Look for renal bruit
527
What are the possible causes of secondary hypertension in a man?
```
Excessive alcohol intake
Pheochromocytoma
Cushing's syndrome
Conn's Syndrome
Polycystic Kidney Disease
```
528
What are the possible causes of secondary hypertension in the elderly?
Renovascular HTN due to atherosclerosis
| ACE inhibs precipitate renal failure
529
Signs and symptoms of pheochromocytoma?
```
Urinary catecholamines
(vanillylmandelic acid, metanephrine)
Intermittent severe HTN
Dizziness
Diaphoresis
```
530
Signs and symptoms of Polycystic Kidney Disease?
Flank mass
Family history
Elevated BUN and creatinine
531
Signs and symptoms of Cushing's syndrome?
Dexamethasone suppression test
| 24-hr urine cortisol level
532
Signs and symptoms of renovascular hypertension?
MR/CT angiogram
Ultrasound
ACE inhib nuclear scan
Bruit on exam - angioplasty and stenting
533
Signs and symptoms of Conn's syndrome?
High aldosterone
| Low renin
534
Signs and symptoms of coarctation of the aorta?
```
Upper extremity HTN only
Unequal pulses
Radiofemoral delay
Associated with Turner's syndrome
Rib notching on xray
```
535
Diabetes screening
Generally not recommended, except
Obesity
Family History
Black, American indian, Latin American
536
Signs and symptoms of diabetes
Polyuria
Polydypsia
Polyphagia
Weight loss
537
Diagnosis of diabetes
Fasting (overnight) plasma glucose of 126 mg/dL
| Random glucose of 200 mg/dL
538
Differences between DM1 and DM2
- age at onset
- body habitus
- DKA
- hyperosmolar state
- endogenous insulin
```
<30yo - >30yo
Thin - Obese
Yes - No
No - Yes
Low - High
```
539
Differences between DM1 and DM2
- twin concurrence
- HLA association
- response to oral hypoglycemics
- antibodies to insulin
- Islet cell pathology
```
<50% - >50%
Yes - No
No - Yes
Yes - No
Yes - No
Insulitis (loss of beta cells) - Normal # (+amyloid)
```
540
Treatment of DKA
```
Fluids
iv Insulin
Potassium
Phosphorous
Do not use bicarb unless pH <7
Find cause - often infection
```
541
Treatment of Nonketotic Hyperglycemic Hyperosmolar state
Fluids
iv Insulin
Electrolytes
mortality is high
542
Complications of diabetes
Atherosclerosis (CAD, PVD, MI, Stroke)
Retinopathy (Screen annually, rx-lasr photocoag)
Nephropathy - ACE inhibs prevent, 30% of ESRD
Neuropathy, Infections, Foot disease
543
Sequellae of peripheral neuropathy in diabetes
```
Gastroparesis (early satiety, nausea)
rx-metoclopromide
Charcot's joints
Impotence
Cranial nerve palsies (esp III, IV, VI - ocular)
Orthostatic hypotension
Silent myocardial infarctions
```
544
Treatment of T2DM
Diet, exercise, wgt loss - cures 90%!!!
Sulfonylurea (glimepiride, glipizide, glyburide)
Metformin
Thiazolidinedione
545
Insulin preparations
| - onset, peak, duration
```
Aspart <.25 1-3 3-5 before meals
Lispro <.5 .5-2.5 3-5 before meals
Regular .5-1 2-4 5-8 inpatient
NPH 2-3 4-12 12-24 standard regimen
Lente 2-3 4-12 12-24 standard regimen
Ultralente 6-10 8-16 18-26 basal
Glargine 1.5-4 none 24+ basal
```
546
Insulin dosing
0.5 to 1.0 U/kg per day
Initial requirements are less because of redisual endogenous insulin
Type 2 inpatients require more b/c of resistance
547
Somogyi Effect vs Dawn Phenomenon
High night-time insulin leads to low overnight glucose. Then stress hormone release increases morning glucose. Decrease insulin.
High morning glucose from GH secretion without overnight hypoglycemia. Increase insulin.
548
Monitoring of diabetes compliance
Hemoglobin A1c - 3 month avg, target 7%
| C peptide is present with endogenous insulin
549
Insulin for patients undergoing surgery
1/3 to 1/2 usual dose because of NPO status
| monitor intraoperatively - use D5 & regular insulin
550
Side effect of Chlorpropamide
SIADH
551
Treatment of diabetes and heart disease
Beta-blockers prevent physical manifestations of hypoglycemia (tachycardia, diaphoresis)
Benefits outweigh risks however
552
Cholesterol screening
Fasting lipid profile
Start at age 20 years
Every 5 years
More aggressive for family history and obesity
553
Lipoprotein analyis
Total - HDL - Trigly/5 = LDL
554
Secondary causes of hypercholesterolemia
```
Diabetes
Hypothyroid
Uremia
Obstructive liver disease
Alcohol (incrs trigly)
```
555
Medications that cause hypercholesterolemia
OCPs
Glucocorticoids
Thiazides
Beta-blockers
556
LDL levels and intervention
| - no risk factors
<160 none, goal
160-190 diet, +/- medication
>190 medication, +diet
557
LDL levels and intervention
| - 2 or more CHD risk factors
<100 none, goal
100-129 diet, +/- medication
>130 medication, +diet
Age, FH, Smoking, HTN, Low HDL
558
Coronary Heart Disease risk factors
Age - men=45yrs, women=55yrs (premat menop)
FH - first degree premat CHD, men55/women65
Current smoker >10 per day
HTN - 140/90 or on anti-HTN meds
Low HDL - <40mg/dL
HDL > 60 is protective and negates one risk fac
DM is risk factor, not included b/c also CADequiv
559
LDL levels and intervention
| - known CAD or equivalent
<100 none, goal
>100 medication, +diet
DM, PAD, CAD, AAA
560
LDL levels and intervention
| - very high risk
<70 none, goal
70-100 diet, +/- medication
>100 medication, +diet
CAD with MI or poorly controlled risks
561
LDL levels and medical intervention summary
No risk factors >190 (160)
2 risk factors >130 (100)
CAD (DM,PAD,AAA) >100
High risk >100 (70)
562
Epidemiology of Atherosclerosis
Involved in...
Half of all deaths in U.S.
Third of all deaths ages 35-65
Most important cause of disability&hospitalization
563
Other factors related to Coronary Heart disease
NOT independent risk factors:
Obesity, stress, physical activity, type a personality
Hypertriglyceridemia alone is not a risk but when associated with hyperXOL causes more CHD than hyperXOL alone.
564
Treatment of Hypercholesterolemia
Exercise and diet
| - decrease calories,cholesterol,fats, alcohol and smoking
565
Modifying factors of HDL
Increased by exercise, estrogens, mod alcohol
| Decreased by smoking, androgens, progesterone, hypertriglycerides
566
First line medications fo Hypercholesterolemia
Niacin - poorly tolerated but effective, raises HDL
Bile acid-binding agents
(cholesteramine, colesevelam)
HMG CoA-reductase inhibitors - Statins
- effective, expensive, liver & muscle damage
Block cholesterol absorption (ezetimibe)
567
What cancers have an increased risk in smokers?
```
Lung
Oral cavity, Esophagus, Larynx, Pharynx
Bladder, Kidney
Stomach, Pancreas
Cervix, vulva, penis, anus
```
568
Wernicke's Syndrome
```
Acute and reversible Thiamine (B1) Def
Opthalmoplegia
Nystagmus
Ataxia
Confusion
```
569
Korsakoff Syndrome
Chronic and irreversible Thiamine (B1) Def
Amnesia (anterograde)
Confabulation
570
Pathophysiology of Thiamine deficiency
Damage to mamillary bodies and thalamic nuclei
571
Specific dysmorphisms of Fetal Alcohol Syndrome
```
Epicanthal folds
Short palpebral fissures
Flattened filtrum
thin upper lip
"Railroadtrack" ears
Upturned nose
Flat nasal bridge
```
572
General recognition of Fetal Alcohol Syndrome
```
Mental retardation
Microcephaly
Micropthalmia
Short papebral fissure
Midfacial hypoplasia
Cardiac defects
```
573
Fetal Alcohol Syndrome
Most common preventable cause of mental retardation
574
Bacteria of aspiration pneumonia in alcoholics
```
Klebsiella (currant-jelly sputum)
Anaerobes
E. coli
Strep
Staph
```
575
Treatments for alcoholism
AA
Disulfiram
Naltrexone
576
Stigmata of chronic liver disease in alcoholics
varices, hemorrhoids, caput medusae, jaundice, ascites, palmar erythema, spider angiomas, gynecomastia, testicular atrophy, encephalopathy, asterixis, prolonged PT, hyperbilirubinemia, spontaneous bacterial peritonitis, hypoalbuminemia, anemia
577
Most common vitamin deficiencies in alcoholics
Folate
Magnesium
Thiamine
578
Important component in treatment of alcoholic
Alcohol precipitates hypoglycemia. But administer Thiamine before glucose othoerwise may precipitate Wernicke's
579
Treatment of esophageal varices
Bleeding - iv fluids, blood, endoscopy - sclerotherapy, cauterization, banding, vasopressin
TIPS (transjugular intrahepatic portosystemic shunt)
Portacaval shunting is now rare
580
Acid-Base disorders on ABG
```
pH CO2 HCO3
Met Acid low low low
Resp Acid low high high
Met Alk high high high
Met Acid high low low
```
581
Causes of respiratory acidosis
COPD, asthma, chest wall problems (paralysis, pain), sleep apnea, drugs (opioids, benzos, barbs, alcohol, resp depress)
582
Causes of respiratory alkalosis
Anxiety or hyperventilation, aspirin or salicylate od
583
Causes of metabolic alkalosis
diuretics (except CAI), vomiting, volume contraction, antacid abuse or milk-alkali syndrome, hyperaldosterone
584
Causes of metabolic acidosis
Ethanol, DKA, uremia, lactic acidosis (sepsis, shock) methanol or ethylene glycol, aspirin or salicylate, diarrhea, CAI
585
Signs and symptoms of Hyponatremia
```
Lethargy
Mental status changes
Anorexia
Seizures
Cramps
```
586
Causes of Hyponatremia in hypovolemia
```
Dehydration
Diuretics
DKA
Addison's disease
Hypoaldosteronism
```
587
Causes of Hyponatremia in euvolemia
SIADH
Psychogenic polydipsia
Oxytocin use
588
Causes of Hyponatremia in hypervolemia
```
CHF
Nephrotic syndrome
Cirrhosis
Toxemia
Renal failure
```
589
Causes and treatment of SIADH
Head trauma, surgery, meningitis, small-cell cancer, painful states, pulmonary infections, opioids, chlorpropramide
Water restriction
Demeclocycline (causes renal DI) if refractory
590
Classic finding with Addison's and Hypoaldosteronism in Hyponatremia
Elevated potassium
591
Na correction in hyperglycemia
Na decreases 1.6 per 100 glucose above 200
592
Signs and symptoms of Hypernatremia
Hyperreflexia
Altered mental status
Seizures
Coma
593
Causes of Hypernatremia
```
Dehydration
Diuretics
DI
Diarrhea
Renal disease (isothenuria from SC trait)
Iatragenic
```
594
Mimics DI by impairing renal concentrating mechanism
Hypokalemia and Hypercalcemia
595
Treatment of Hypernatremia
Normal saline - pts typically dehydrated
1/2 normal - once hemodynamically stable
D5W - should NOT be used
596
Pituitary vs. Nephrogenic DI
Pit - responds to Vassopressin
Nephrogenic - Thiazides (paradoxical)
Nephro - caused by lithium, demeclocycline, methoflurane, amphotericin
597
Signs and symptoms of Hypokalemia
```
Muscle weakness (smooth-ileus,hypotension)
EKG -
loss of T waves
presence of U waves
PVCs, PACs
tachyarrhythmias
```
598
Causes of Hypokalemia
| Treatment
Changes in pH alter K distriution
Alkolosis causes hypokalemia
H leaves cells to correct H, K enters
Do not replace potassium too quickly, <20/h
Hypomagnesemia makes correction difficult, treat hypomag first
599
Signs and symptoms of Hyperkalemia
```
Weakness, paralysis
EKG - with increasing K
tall, peaked T waves
widened QRS
prolonged PR interval
loss of P waves
sine waves
Vfib, asystole
```
600
General cause of Hyperkalemia
| Treatment
Changes in pH alter K distriution
Acidosis causes hyperkalemia
Give bicarbonate for severe Hyperkalemia
601
Specific causes of hyperkalemia
Renal failure
Severe tissue destruction
Hypoaldosteronism (hyporenin/aldoster in DM)
Adrenal Insufficiency
Medications - K-sparing diuretics, B-blockers, NSAIDS, ACE inhibs
602
Treatment of Hyperkalemia
```
Decreased intake
Kaxolate (Na-polysterene resin)
Calcium gluconate is cardioprotective
NaBicarb
Glucose with insulin (forces K inside cells)
Dialysis for renal failure
```
603
Signs and symptoms of Hypocalcemia
```
Neurologic
tetany (chvostek's-face, trousseau-carpopedal)
depression, encephalopathy, dementia
seizures
laryngospasm
EKG - QT prolongation
```
604
Specific causes of Hypocalcemia
DiGeorge's - tetany after birth, athymic
Renal failure - altered vitamin D metab
Hypoparathyroid - watch post thyroidectomy
Vitamin D deficiency
Psuedohypoparathyroid - short fingers and stature, MR, nml PTH, end-organ unresp to PTH
Acute pancreatitis
605
General treatment of hypocalcemia
Hypomagnesemia makes correction difficult, treat hypomag first
Alkalosis can cause hypocalcemic symptoms. treat pH
Phosphorous and calcium levels change in opposite direction
606
Signs and symptoms of Hypercalcemia
...
607
1 small box = __ seconds
.04 s
608
1 large box = __ seconds
.20 s
609
__ small boxes = 1 large box
5 small boxes
610
What is the amplitude of each small box?
1 mm or .1 mV
611
The normal height of EKG standardization is __ mV or __ mm.
1 mV
| 10 mm
612
What formula can be used to calculate heart rate given the R-R interval? (assume regular rhythm)
300 / # large boxes in R-R interval
| 1500 / # small boxes in R-R interval
613
If there are 3 large boxes in the R-R interval, the heart rate = __ . (assume regular rhythm)
100 bpm
614
How do you determine HR given an irregular rhythm?
Measure out 6 seconds (6 second rule). Count the # of complexes in 6 sec and multiply by 10.
615
List 3 criteria for normal sinus rhythm.
1) Rate between 60-100
2) Every normal P wave followed by QRS
3) P wave upright in leads I and II, inverted in aVR.
616
Length of normal PR interval =
.12 - .20 s (3 to 5 small boxes)
617
Define PR interval
from ONSET of P wave to ONSET of QRS
618
Length of normal QRS =
<0.10 s
619
Define QRS interval
from ONSET of QRS to END of QRS
620
Define QT interval
from ONSET of QRS to END of T wave = systole
621
List the FRONTAL leads
I, II, III, aVR, aVL, aVF
622
List the HORIZONTAL leads
V1-6
623
Lead I runs from the __ to the __.
Right arm to left arm.
624
Lead II runs from the __ to the __.
Right arm to the left leg.
625
Lead III runs from the __ to the __.
Left arm to the left leg.
626
State where the positive lead is in lead I.
Left arm
627
State where the positive lead is in lead II.
Left leg
628
State where the positive lead is in lead III.
Left leg
629
____ leads record potentials between one extremity and the sum of the other two.
Unipolar
630
List three unipolar leads.
aVR, aVL, aVF
631
State where the lead is in aVR.
Right shoulder
632
State where the lead is in aVL.
Left shoulder
633
State where the lead is in aVF.
Left foot
634
Which lead is at 0 degrees?
+I
635
Which lead is at 30 degrees?
-aVR
636
Which lead is at 60 degrees?
+II
637
Which lead is at 90 degrees?
+aVF
638
Which lead is at 120 degrees?
+III
639
Which lead is at -30 degrees?
+aVL
640
Which lead is at -150 degrees?
+aVR
641
What part of the heart do leads V1-2 "see" best?
atrial, septal leads
642
What part of the heart do leads V2-4 "see" best?
anterior LV leads
643
What part of the heart do leads V5-6 "see" best?
lateral LV, precordial leads
644
What is the normal range of the axis of the heart?
-30 to +90
645
Related to age <30, normal heart range = __
0 to +90 (even +105)
646
As we age, the heart axis changes to __
-30 to +90
647
Overweight people have an axis that is shifted __.
leftward
648
A "Left Axis" heart is from __ to __
-30 to -90
649
A "Right Axis" heart is from __ to __
+90 to 180
650
An "Extreme Axis" heart is from __ to __
+180 to -90
651
Which three leads do you check to determine axis?
I, II, aVF
652
Describe the QRS axes for a "normal" heart.
+ in I and II, either in aVF
653
Describe the QRS axes for a "left" heart.
+ in I, - in II, - in aVF
654
Describe the QRS axes for a "right" heart.
- in I, either in II, + in aVF
655
Define "normal" P wave morphology.
I and II positive; aVR negative
656
Which leads are best to see P wave?
II and V1
657
Transition Zone: There is a progression of precordial R waves. Before V2, they should be (+/-) and (+/-) by V5.
Negative before V2
| Positive at V5
658
The ST segment is defined from the __ to the __.
J point to the beginning of the T wave.
659
List 2 EKG findings that can progress to infarction.
- ST depression
| - symmetric T wave inversion
660
A positive EKG stress test will show __.
ST depression > 1 mm
661
What does the EKG show in the HYPERACTURE period following an MI?
Tall T wave
662
What does the EKG show in the injury/acute period in the few hours following an MI?
ST elevation with tall T (tombstone)
663
In the later stages following an MI, an EKG will show what changes?
Pathological Q waves. T returns upright and ST becomes normal.
664
Which coronary artery feeds the inferior and posterior wall of the LV, and the RV?
Right coronary
665
Which coronary artery feeds the IV septum and anterior wall of the LV?
LAD
666
Which coronary artery feeds the lateral wall of the LV?
Circumflex
667
LVH should show ___ voltage.
Increased left voltage, due to increased mass
668
Which segment represents systole?
QT
669
The corrected QTc should be ___ s
< .44 s
670
An ST elevation with a concave upwards slope suggests...
Early repolarization
671
Describe the common case of early repolarization
A usually healthy male>female, athlete, with no symptoms
672
What is the difference between an ST elevation in MI and pericarditis?
STEMIs are more regional whereas pericarditis is seen in all leads except aVR and isoelectric leads
673
Describe the criteria for RBBB
- QRS elongation, >.12s
- R' in right precordial leads (V1)... R' is wider and taller than R wave
- Wide S in lateral leads
- Secondary ST-T changes (opposite direction)
674
Describe the criteria for LBBB
- QRS elongation, >.12s
- absent Q waves in lateral leads (I, V5-6)
- broad R wave (I, V5-6)
- Secondary ST-T changes (opposite direction)
- LAD common
675
Describe the criteria for LVH
- !!Increased QRS voltage
- ST-T "strain" changes in left sided leads
- Slight QRS elongation
- Abnormal Left axis deviation
676
An R in Lead I > 15 mm = __
An R>S in V1 = __
LVH
RVH
677
What is the usual axis of RVH?
>110 degrees
678
What EKG findings are associated with HYPERKALEMIA?
- peaked T waves
- QRS prolongation (widenen T)
- P waves with long duration, low amplitude
- Increased PR interval
- P wave disappears
- QRS sine wave
679
What is characteristic about the A fib EKG?
- No definite P shape can be determined
- Irregularly irregular P waves at 400-700 bpm
- Normal QRS at 100-180 bpm
680
What is characteristic about the A flutter EKG?
- Saw tooth shape
| - Normal QRS
681
What is characteristic about PVCs: Premature Ventricular Complexes?
- Wider and different from sinus QRS
- Not preceded by premature P wave
- Significance depends on the clinical setting
682
Define Ventricular tachycardia
- 3 or more PVCs
- abrupt onset and termination
- rate 140 - 200
- QRS >.14
- not preceded by P waves
683
Describe Type I Second Degree AV Block
- Progressively lengthening PR interval, then a non-conducted P
684
Describe Type II Second Degree AV Block
- PR interval is constant, followed by a non-conducted P
| - bi/trifascicular block
685
Describe Third Degree AV Block
- Regular PP and RR intervals, VARIABLE PR INTERVAL!
| - Atrial rate > ventricular rate
686
"25 y.o. senior medical student presents to the ER the night before Match Day, complaining of sharp chest pain and tenderness."
Normal EKG
687
"45 y.o supervisor with chest tightness and arm heaviness after foot surgery."
Subendocardial ischemia / ischemic ST depression
688
What is necessary about Q waves to show necrosis?
There must be Q waves in 2 separate leads
689
"75 y.o. Miami physician retired to N Dakota. He presents with chest pain while shoveling snow."
Ischemic T wave
690
"35 y.o. man presents with indigestion and chest fullness brought on by chili peppers and relieved by antacids."
Early repol - more common in young
691
The __on lead V5 is common in early repol
"J notch"
692
"24 year old student, recently recovered from upper respiratory infection, presents w fever and chest pain."
Pericarditis
693
What EKG changes should make you think pericarditis?
Diffuse ST elevations across multiple leads
694
"45 y.o. pilot in office for a routine physical."
RBBB - see RSR'
695
"85 year old female undergoing preop evaluation prior to hip surgery. Anesthiologist is asking if a pacemaker is needed."
LBBB - remember mneumonic "WiLLiaM MaRRoW"
| looks like rabbit ears
696
How do you tell a RBBB from a LBBB?
R - M in v1 and W in v6
| L - W in v1 and M in v6
697
"55 year old postman presents with severe chest pain after being chased by a pit bull."
acute STEMI
698
"85 year old retiree with hypotension and chest ache for 10 hours"
...
699
Finasteride, used to assist patients with benign prostatic hyperplasia , acts on which enzyme to inhibit conversion of testosterone to dihydrotestosterone?
5 alpha reductase
700
Muddy brown casts in a urinalysis is a clue towards which renal process?
Acute tubular necrosis (ATN)
701
Which form of nephrotic syndrome is most associated with heroin use?
Focal segmental glomerulosclerosis
702
What type of kidney stones are often implicated in recurrent UTIs?
Struvite (Magnesium ammonium phosphate) stones
703
What are the organisms that may lead to struvite stones?
Urea-splitting bacteria (Proteus, Klebsiella, or Pseudomonas)
704
What is the gold standard imaging modality for diagnosing kidney stones?
Noncontrast spiral CT
705
What kidney stones are most commonly missed on plain xrays?
Uric acid stones
706
Which type of renal tubular acidosis is associated with defect in proximal bicarbonate absorption?
Renal tubular acidosis type II
707
Which renal disorder can present both as nephritic and nephrotic syndrome?
Membranoproliferative glomerulonephritis (MPGN)
708
What is the goal hemoglobin level in patients with end stage renal disease?
11-12 g/dl (higher than this can increase risk of embolism or strokes)
709
Which subtype of nephrotic syndrome is most commonly associated with hepatitis B infections?
Membranous nephropathy
710
Besides rhabdomyolysis, what three major conditions will produce blood in the urine without seeing RBCs in urine?
Contamination with povidine, vitamin C excess, Paroxsysmal nocturnal hemoglobinuria (PNH)
711
What is the most likely diagnosis in a patient on hemodialysis with skin ulcerations and an elevated calcium-phosphate product?
Calciphylaxis
712
Which form of nephrotic syndrome is often associated with lithium use?
Minimal change disease
713
Proxmimal bicarbonate reabsorption is seen in which renal tubular acidosis type?
Renal tubular acidosis type 2
714
Excessive ingestion of licorice can lead to which electrolyte abnormality?
Hypokalemia
715
NSAIDS are known to cause allergic interstitial nephritis without eosinophils. What other class of medication is known to cause allergic interstitial nephritis without eosinophils about 33% of the time?
Proton pump inhibitors (PPI)
716
How many days after aminoglycoside use can acute tubular necrosis arise?
4-5 days
717
What would you expect the C3 complement levels to be (increased/decreased/same) in a patient with post-infectious glomerulonephritis?
Decreased
718
What is the most common type of glomerulonephritis throughout the world?
IgA Nephropathy
