Flashcards in IM Deck (417):
EPISODIC headache, palpitations, sweating (diaphoresis)
In HIV/AIDS --> solitary esophageal ulcer, retinitis (floaters in eye), colitis
Myeloproliferative disorder --> increased RBCs, WBCs, platelets
Predisposes to Budd-Chiari syndrome
Bicuspid aortic valve, coarctation of aorta
Short female, webbed neck (cystic hygromas), XO karyotype
Turner syndrome (heart defects)
Endocrine disorder w/ high correlation w/ pernicious anemia (megaloblastic anemia)
Cold-agglutinin hemolytic anemia
"Squeaks" on ausc.
Common in women shortly after childbirth from position of holding/lifting baby
Inflammation of abductor pollicus longus & extensor pollicus brevis
de Quervain's tenosynovitis
Inflammation and thrombosis in superficial veins (usually legs) that feel like palpable cords
Associated w/ pancreatic adenocarcinoma
Migratory thrombophlebitis (Trousseau syndrome)
Microcytic anemia w/ normal RBC count & normal RDW
MCV very low; hematocrit slightly reduced
Refractory epigastric pain despite PPI treatment
Diarrhea & epigastric pain
Solitary ulcer in duodenum
Onset of hypertension in females under 35 yo
Activates RAAS (hypokalemia)
Rhinorrhea, sneezing, allergic conjuctivitis
Intermittent (s/s 4 days/week or > 4 weeks)
Moderate-severe (1+ of following present):
Impaired school work/performance
Impaired daily/sport activities
Complications: sinusitis, asthma, nasal polyps
Causes of reversible agranulocytosis
Hyperthyroidism drugs --> propylthiouracil & methimazole
Inflammatory disorder of small/medium blood vessels & nerves of extremities.
Normal proximal pulses; decreased-absent distal pulses
Rest pain in distal extremities
Corkscrew pattern seen on angiogram (tortuous)
Thromboangiitis obliterans (Buerger disease)
RTA Type ____
Pathophys: No distal tubular acid secretion
Nephrocalcinosis & nephrolithiasis
U/A: alkalotic urine (high pH) w/ low serum H+ (low pH)
Dx: acid load test
Tx: oral HCO3
RTA Type 1
RTA Type ___
Pathophys: No proximal tubular HCO3 absorption
Osteomalacia & rickets
U/A: alkalotic urine w/ deceased urine output
Dx: HCO3 load test (levels stay low)
Tx: volume restriction first; may use HCO3/thiazides
RTA Type 2
RTA Type ___
Pathophys: Adrenal/aldosterone deficiency
U/A: Na excretion (high in urine) w/ K-H retention
Dx: Na restriction (high urinary sodium)
RTA Type 4
Adults w/ mild GI s/s and may have unexplained nutritional deficiencies
*Unresponsive Fe-deficiency anemia (repeated anemia refractory to tx)
Anti-endomysial Ab & Anti-tissue transglutaminase antibodies
Anatomical variation that predisposes to AAA & aortic dissection
Bicuspid aortic valve
Large stone impacted in cystic duct that externally compresses & obstructs the adjacent common hepatic duct. Results in intrahepatic bile duct dilation w/ obstructive cholestasis (jaundice)
Prone to arterial/venous thrombus formation b/c of hyper-coaguable state --> can manifest as flank pain & hematuria
Nephrotic syndrome (membranous nephropathy w/ decreased antithrombin III)
Bone marrow failure w/ TdT (+) cells; "meningeal leukemia" if relapsed
Tx w/ intrathecal methotrexate
Scleroderma is associated w/ esophageal dysfunction secondary to fibrosis. This defect in either 1) peristalsis or 2) LES function can lead to:
Chronic acid reflux
Drug that interrupts the interpretation of EKG during a presentation of ACS b/c it causes non-specific EKG changes
New onset ascites in elderly woman
Ovarian cancer (peritoneal carcinomatosis - ovarian mets to peritoneal cavity)
Fever, ALTERED MENTAL STATUS, microangiopathic hemolytic anemia, acute renal failure (not severe), thrombocytopenia, PURPURA
The drug Quinine associated w/ this
TTP (thrombotic thrombocytopenic purpura)
Seen mainly in children/teens after a GI infection w/ E.coli
UREMIA (elevated BUN/ammonia), post-infection, SEVERE RENAL FAILURE (high creatinine)
HUS (hemolytic uremic syndrome)
Dopamine INHIBITS what hormone?
High prolactin/low dopamine (usually drugs) causes decreased GnRH, LH, FSH
Autoimmune disease of cartilage-containing structures (ear, nose, laryngotracheal tree)
Laryngotracheal inflammation & destruction leads to tracheal luminal narrowing and peritracheal inflammation, destroying the supportive matrix around the trachea --> COLLAPSE of trachea on expiration is exaggerated (decreased expiratory volume)
Kaposi sarcoma associated with which virus and disease?
How does it appear and where?
Human Herpesvirus 8 (HHV-8)
AIDS defining disease
Multiple violaceous papules on LE, face, oral mucosa, and genitalia
Hypoglycemia that eventually causes nocturnal release of GH & cortisol --> causes nocturnal hyperglycemia that causes the increased morning glucose levels
Normal physiologic phenomenon
2 causes of acute renal failure (immediate)
IV contrast (direct toxicity to renal tubules)
IV Acyclovir (causes crystaluria)
*Make sure you pre-treat w/ IV fluids before and after these 2
Abs that causes delayed renal failure (3 days after starting)
Vancomycin (long volume of distribution if PO)
Common causes of pancreatitis
Gallstones (female, fat, forty, fertile)
Drugs (sulfas, HCTZ, HIV drugs - look if recently started)
Situations where MUST give IV fluids
Pancreatitis, sepsis, DKA
Causes of increased LFTs
TYLENOL OD (values in thousands)
Acute viral hepatitis (values in hundreds)
Shock liver (hypotension and decreased perfusion)
Contraindicated in ARF, EXCEPT in sclerodermal renal crisis (intra-renal B/L stenosis)
Heparin bridging to Coumadin protocol
INR needs to be b/w 2-3 for 2 consecutive days
Need at least 4 days of heparin before D/C it
Coumadin-like drugs (Dabigatran, Apixaban, Rivaroxaban) and their effects
Fewer major bleeds (joints, brain, eye cavity, spinal)
No INR monitoring
More GI bleeds
Disrupt folate pathway --> cause megaloblastic anemia
Cocaine-related MI --> contraindication for what drug tx
B-blocker (results in hypertensive crisis)
Polymyalgia rheumatica association
Transient monocular blindness from ischemia to retinal artery
Amaurosis fugax (associated w/ TIA)
Hollenhorst plaques: cholesterol emboli
2 common causes of painless, bright red rectal bleeding
Angiodysplasia (dilated, slow filling veins in colon wall)
6 P's of vascular assessment
Pain, Pallor, Pulseless, Paralysis, Paresthesias, Poikloithermia (cold)
Drug causing fibrotic changes in lungs that can mimic cancer nodules & can also cause hypersensitivity pneumonitis
Drugs that increase the QT interval
Anti-arrhythmics (Class I & III)
Quinolones, metronidazole, HIV drugs
Pneumonia w/ diarrhea & hyponatremia
Pneumonia w/ hepatitis
Asthma (allergic rhinitis), eosinophilia, vasculitis
Corrected Na = (Na) + [0.016 x (glucose - 100)]
Corrected Ca = measured Ca + [0.8 x (4 - Alb)]
Serum Osm = 2(Na) + [Glu/18] + [BUN/2.8]
Cockcroft-Gault (Cr clearance) = ([140-age] x wt) / (Cr x 72)
Classic Multiple Sclerosis onset of symptoms
Eye/visual problems (ophthalmoplegia) followed by foot/hand paralysis or numbness
Someone w/ WPW that presents w/ new onset AFib - DOC?
Anti-arrhythmic that interacts w/ Coumadin to increase INR?
Amiodarone - must decrease the Coumadin levels
3 signs with obstructive ascending CHOLANGITIS
2) jaundice (total bilirubin >3)
3) RUQ pain
Severe obstructive ascending cholangitis
Charcot's triad + hypotension (shock) & altered mental status (confusion)
Side effect of concern w/ nitroprusside?
Methemoglobinemia (b/c nitroprusside contains cyanide)
(sodium nitrite, thiosulfate, hydroxycobalamin)
What is Todd's paralysis?
Transient focal neurological deficits that occur immediately AFTER a seizure (convulsions w/ intra-oral lesions & in continence) in the post-ictal phase and resolve after this phase
NOT a stroke!
Why glucagon for B-blocker OD?
Glucagon stimulates the production of cAMP via a pathway that is separate from the pathway that B-receptor activation causes increased cAMP production
Excessive B-blockers = decreased cAMP (hypoglycemia, bradycardia, hypotension, hyperkalemia)
Type of eating disorder where patient is a "perfectionist"
"Young patient who is extremely competitive and high-achieving with a low BMI (< 18.5)
Only time to use benzo's for delirium?
Signs of lead poisoning?
*Purple lines on gingiva (gums)
Antidote for methemoglobinemia?
*Different than CYANIDE poisoning (also from nitroprusside). The methylene blue converts Fe+3 --> Fe+2 where cyanide you need amyl nitrite to convert the remaining RBC to methemoglobin to bind the CN then give thiosulfate to regenerate the reducing power of glutathione
Patient develops dyspnea 2 days after beginning course of antibiotics for pyelonephritis. What is the diagnosis and why?
Acute respiratory distress syndrome (ARDS) --> 1-2 days after Abx are given, if the organism is gram NEGATIVE, the lysis of the bacteria release the endotoxins --> these endotoxins cause pulmonary injury, leading to capillary leakage of fluid into pulmonary interstitial space ("capillary leakage")
What CMP component will be increased w/ a GI bleed and why?
BUN --> digested blood in the GI tract is a source of urea
Most common cause of testicular torsion?
Bell-Clapper deformity: the anterior portion of testicle is not anchored to the scrotum, allowing for testicle movement
Another common cause of torsion is during sleep when the cremaster muscle is active during REM
Support the base of testicles and elevate them - if this relieves the testicular pain --> think epididymitis
Helps to differentiate between testicular torsion (no pain relief) vs. epididymitis (relief of pain)
Highest risk for diabetic foot ulcers?
Diabetic Peripheral Neuropathy
MOA: multifactorial and is thought to result from vascular disease occluding the vasa nervorum; endothelial dysfunction; deficiency of myoinositol-altering myelin synthesis and diminishing sodium-potassium adenine triphosphatase (ATPase) activity; chronic hyperosmolarity, causing edema of nerve trunks; and effects of increased sorbitol and fructose. Other etiologies of diabetic ulceration include arterial disease, pressure, and foot deformity.
1) Irregular breathing/apnea
2) Increased MAP
Suggests marked increase in ICP and impending brain herniation.
Earliest indicator of hypovolemia?
Decreased renal output
The renal blood flow is decreased as a compensatory mechanism to make blood volume available to the body.
Timeline of changes in hypotension:
Lower urine output --> + tilt test --> tachycardia
What to worry about when treating G(-) infections?
Endotoxins released from lysis of bacteria can cause damage throughout the body
E.g. --> endotoxins cause endothelial damage & pulmonary injury --> capillary leakage --> fluid moves from intravascular space into alveolar spaces --> ARDS!
What 2 compounds affect iron absorption in duodenum?
Vitamin C = increases iron absorption
Calcium = decreases iron absorption (have to be careful with women taking supplements during pregnancy)
Seizures vs Pseudoseizures?
- Eyes are OPEN
- Post-ictal period: confusion & altered mental status
- "Floppy" appearance during event
- Not true seizures, but they are real!
- Eyes are CLOSED
- No confusion or altered mental status
- Immediately after, coherent and alert
- During event, "tight" and rigid appearance
Low vs High doses of Epinephrine?
Low doses: B+ effects (increased HR/force; vasodilate & decreased TPR or diastolic pressure)
High doses: a+ effects (vasoconstrict & increase TPR or diastolic pressure)
CO monoxide poisoning - what do you see?
- Suspect more in winter time
- Pt has POOR O2 SATURATION, but physical exam is normal (clear airway, no increased breathing effort, no abnormal breath sounds, no discoloration of skin)
Tx: 100% O2 continuously
Recurrent thromboembolic events (DVT/PE) & recurrent miscarriages?
Antiphospholipid syndrome (APS)
- Recurrent small PE's can result in pulmonary HTN --> progressive dyspnea
- Anti-phospholipid antibodies present (test w/ Lupus anticoagulant or anticardiolipin ELISA)
1) thrombosis in any organ/tissue or pregnancy (miscarriage)
2) persistently positive aPL levels (> 12 weeks apart in testing)
- Dermatologic effects: digital cyanosis, livedo reticularis, digital gangrene, leg ulcers
- Aspirin (inhibit platelet aggregation)
- Warfarin (inhibit clotting cascade)
- LMWH/aspirin used in pregnancy b/c of teratogenic effects of warfarin
- Maintain INR b/w 2-3 FOR LIFE
3 types of holosystolic murmurs?
Tricuspid regurgitation (radiate to back)
Mitral regurgitation (radiate to axilla)
Cellulitis vs Stasis Dermatitis vs DVT?
Cellulitis: commonly asymmetrical (one leg)
- hot to touch, pattern of redness is uniform (same height on leg)
- increased WBC
- Tx: Abx (Keflex - cefalexin)
Stasis Dermatitis: result of venous insufficiency (blood pools in lower leg veins & fluid/RBC leak out into surrounding tissues)
- Skin looks like cobblestone (bumpy), dry/cracked
- Skin sores can appear
- Tx: topical steroid cream & ointment
*ALWAYS r/o in U/L leg swelling and pain!
- Tx: Lovenox and Ultrasound of leg
Why is blood ammonia increased during GI bleed?
RBC digestion in the GI tract results in excess hemoglobin breakdown to basic proteins --> this increased nitrogen load is absorbed into bloodstream --> can lead to encephalopathy (confusion, altered mental status, etc)
Person presents w/ facial palsy (Bell's palsy) & hearing loss on the same side along with vesicular-like lesions in/around the ear?
- VZV residing in geniculate ganglion (of CN7 & runs next to CN8 in internal acoustic meatus)
*Look for vesicles on the outer ear looking like zoster
*CN 7-8 involved (facial deficits + hearing loss all on one side)
Atypical presentation of MI?
U/L neck pain, nausea, vomiting --> esp in women/diabetics
U/L headache that is daily & continuous w/ pain-free periods w/ at least 1 of the following:
- conjunctival injection
- nasal congestion
PAINFUL goiter following a URI (viral illness)?
Subacute thryoidits (De Quervain's)
Progression: hyperthyroid --> hypothyroid --> euthyroid
Characteristics of Papillary thyroid cancer?
Characteristics of Medullary thyroid cancer?
- Psammoma bodies (concentric calcifications)
- Orphan Annie bodies (cells appear empty)
- Produce Calcitonin (marker for monitoring)
Person with tachycardia, high BP, sweating, anxiety and recently got over an infection or a stressor in their life?
*Usually follows a precipitating factor --> infection, stress, DKA
*Tx: aggressive fluids
Purpura is the hallmark of what process?
Leukocytoclastic vasculitis (small vessel vasculitis)
Caused by inflammation of small cutaneous vessels --> wall damage and extravasation of RBC into surrounding tissue --> seen as purpura
Palpable purpura is hallmark of what 2 infectious processes?
Neisseria meningitis & Rocky Mountain Spotted Fever
Why do you get alkalosis w/ taking loop diuretics?
Loops cause excretion of Na (& H2O), K, and Cl in the urine and lower the blood levels --> decreased K+ levels cause the K/H cellular pumps to transport H+ INTO cells and K+ OUT of cells to normalize blood K levels --> the drop in blood H+ levels causes alkalosis
What happens to cerebral blood flow with hypercapnia (increased blood CO2) and acidosis?
INCREASED cerebral blood flow
Effect on cerebral blood flow w/ hypocapnia (decreased blood CO2) and alkalosis?
DECREASED cerebral blood flow
**This is why you hyperventilate to reduce ICP via decreased intracranial blood volume
Disease where you have aneurysms (from loss of vaso vasorum) and either oral, ocular, or genital ulcers?
2 main causes of gout and what test can differentiate the 2 causes?
Overproducer of uric acid
Underexcreter of uric acid
24hr urine collection for uric acid levels:
If high = overproducer
If low = underexcreter
What is treatment of choice for acute gout attack?
NSAIDs (indomethacin) or colchicine
What is treatment for overproducers of uric acid?
What is treatment for underexcreters of uric acid?
Probenecid (blocks kidney organic anion transporter in PCT --> decreases uric acid reabsorption and increases excretion)
What is a concern for probenecid?
Blocks tubular secretion of penicillins, cephalosporins, sulfonamides, indomethacin --> levels will remain increased over longer period of time
Painless jaundice w/ non-painful palpable gallbladder. What is it until proven otherwise?
Pancreatic cancer (Courvoisier's sign)
Red & tender spots (cords) in superficial veins that come and go in different areas of the body? What association?
Migratory thrombophlebitis (Trousseau syndrome)
What antibiotics are NEVER to be used with Coumadin? Why?
Sulfa drugs (Bactrim), Macrolides (except azithromycin)
They (-) CYP450 protein and cause an increase in drug levels in the blood
What conventional treatment helps eliminate restless leg syndrome?
Tonic water (quinine) --> quinine in it will (-) Mg & Ca flux across the sarcoplasmic reticulum in muscles
Autoimmune condition that attacks the skin?
CREST syndrome manifestation of what disease?
Calcinosis (hard calcium deposits in fingers)
Esophageal dysmotility (will see air-filled esophagus on CT scan)
Sclerodactyly (hardening of digits)
Telangectasias (capillaries near skin surface causing discoloration)
Explain graft vs host disease?
Immunologically-driven reaction from transplant of one person's immunologically-active (immune cells are present in that tissue) tissue (bone marrow) into someone who is immunosuppressed b/c of treatment to prevent host from rejecting the graft. However, the graft's immune cells proliferate and attack host cells. Mortality around 20%
Sclerosing cholangitis has higher incidence of what cancer?
What is Klatskin tumor?
Cholangiocarcinoma (bile duct cancer)
Klatskin: subtype of cholangiocarcinoma that forms at confluence of R & L hepatic bile ducts and causes obstruction of bile outflow, leading to contracted gallbladder
Before Rx-ing erectile dysfunction meds (Sildenafil, etc), what other drug must you ask about and is a contraindication?
Nitrates!! (blood pressure or angina)
*Cause large drop in blood pressures!
Progressive neurological disease involving upper and lower motor neurons - usually gradual onset of asymmetric weakness of distal limb?
Amyotrophic Lateral Sclerosis (ALS)
Middle age woman on several medications for blood pressure control presents to ER w/ gradually increasing blood pressure readings. Her normal pressures are around 115/75. Current BP is 210/115. CT shows narrowing of renal arteries. What is the cause?
Causes of new-onset atrial fibrillation?
EtOH (chronic EtOH or acute EtOH intoxication)
Mitral stenosis (rheumatic fever)
CAD, CHF, MI, pneumothorax
Pearly pink nodules/papules related to sun exposure often seen on hands, face, neck?
Basal cell carcinoma
- spreads laterally then vertically
- rarely spreads beyond primary site
Precursor lesion for squamous cell carcinoma?
5 characteristics of melanoma?
What iatrogenic condition can result in locked-in syndrome?
Central pontine myelinolysis from rapid correction of hyponatremia --> want around 10 mEq/24hrs
Compete paralysis of voluntary muscles in all parts of the body EXCEPT for those that control eye movement
Male patient has increasing weakness of his urine stream and in last 24 hrs has not urinated at all. He is very uncomfortable and when a catheter is attempted, it meets resistance w/ no urine discharge. Blood starts oozing from the catheter. What do you do next?
Suprapubic tube placement --> percutaneous bedside technique under ultrasound guidance
Used to relieve urinary retention w/ bladder outlet obstruction & possible hydronephrosis
What test should always be done to male w/ acute onset testicular pain? Why?
Doppler ultrasound to r/o testicular torsion
45 yo male w/ low back pain radiating to scrotum, dysuria, and pain of defecation. Tried several courses of Abx, w/ symptoms recurring 1 week after stopping each therapy. On rectal exam, prostate is enlarged w/ areas of tenderness and fluctuance. What is it?
*Suspect when a man develops repeated UTI's w/ improve w/ Abx, but recur after therapy ends.
***Presence of fluctuant mass in prostate = prostatic abscess
What is Morton neuroma?
Enlarged nerve located in foot's 3rd interspace b/w 3rd & 4th toes --> diagnosis made by eliciting extreme pain on palpation in that area.
Look for woman w/ high-heeled shoes, standing in them all day
88 yo male w/ findings consistent w/ localized prostate cancer, but has multiple overlying comordibities. What is next best step in mgmt?
NO intervention --> no PSA, no biopsy, nothing
Disease-specific survival rates for localized prostate cancer at 10 years was 83% for those who did NOT receive therapy --> with his multiple other comorbidities, he may die from those instead of prostate cancer
Vague RUQ discomfort w/ recent wt loss in a 60 yo alcoholic woman w/ cirrhosis from Hep C. What are you thinking? What blood marker is most helpful?
Hepatocellular carcinoma --> increased aFP (correlates w/ tumor size)
*Solitary tumor in liver w/ RUQ discomfort + wt loss
In someone with bladder cancer, what is a feared complication?
*Think bladder cancer in pts w/ hx of smoking, urinary obstruction (leading to hydronephrosis), and/or hematuria
Treatment for temporal arteritis? What is a common association?
Why does serum Na drop during prolonged vomiting or diarrhea?
GI tract fluids have Na concentration similar to plasma; as these fluids are lost (vomiting or diarrhea), the Na levels will drop due to lack of absorption from GI tract --> these fluids should be replaced w/ isotonic, Na-containing fluids. However, most people drink water (hypotonic) --> the body retains this water b/c of its volume depletion --> results in dilutional hyponatremia
Dilutional hyponatremia --> when isotonic fluids are lost (vomiting/diarrhea) and replaced by hypotonic (water) fluids.
81 yo found on living room floor. Last seen 3 days ago. Obtunded but breathing spontaneously and hemodynamically stable. Temp 100.7 w/ tender, tense R calf. K 5.9, BUN 88, Cr 3.5, lactic acid 2.6, CK 7,200, WBC 17,000. What does he have? What is appropriate mgmt?
Rhabdomyolysis (immobilized position, elevated CK): from pressure injury & can cause ARF
*CK and hyperkalemia --> from crush injury leading to leakage of K, CK, & myoglobin out of cells into blood --> myoglobin precipitated in kidney tubules & changes into acid hematin leading to renal failure
Indications for urgent hemodialysis?
A: acidosis (severe)
E: electrolytes (hyperkalemia)
I: intoxication w/ nephrotoxic substances (ethylene glycol)
O: overload (fluid in renal/CHF patients)
U: uremia (mental status changes or pericardial effusion)
How do you prevent rhabdomyolysis-induced renal failure?
IV fluids + Alkalization of urine w/ NaHCO3 (sodium bicarb) --> facilitates excretion of myoglobin, preventing tubular injury
24 yo suffered subarachnoid bleed from ruptured aneurysm 4 days ago and is now recovering. He Na level is gradually decreasing despite being on fluid restriction. He is clinically euvolemic, but has high urine osmolality & specific gravity w/ salt wasting, elevated fractional excreted Na and total urinary sodium level. What is the cause? What is appropriate tx?
Syndrome of inappropriate ADH release (SIADH)
- Occur in patients w/ recent head trauma or major CNS procedure
- Assn w/ small-cell carcinoma of lung (ectopic ADH production)
- Clinical euvolemic
- High urine osmolality (concentrated)
- Fractional excretion of Na is high (water w/o salt is retained)
Tx: ADH (-) --> demeclocycline, lithium
58 yo woman found to have elevated serum Ca and parathyroid hormone. She is asymptomatic and does NOT want elective surgery but rather close medical f/u. What therapy should she start?
Most likely parathyroid adenoma --> only cure is surgery
Tx: Estrogen-progestin tx helps in post-menopausal women w/ primary hyperparathyroidism
- Estrogen-progestin helps reduce bone resorption & thus increase bone density and possibly decrease serum Ca levels
Painless sore on glans of penis --> rough surface that began to enlarge to develop into painless ulcer. 2 new sexual partners in past year w/ no protection. Small, palpable lymph nodes felt in his inguinal area B/L. VDRL (-). What is it?
Squamous cell carcinoma of penis
*First symptom of penile cancer = painless, exophytic growth --> ulcerated nodule or a flat ulcer that does not heal but enlarges progressively.
If not response to conservative tx, need to confirm w/ biopsy.
Describe Menetrier's disease. What 4 side effects are often seen?
Excess mucus production in the stomach
1) Protein-losing enteropathy (low albumin, edema)
2) Hypertrophy of gastric rugae
3) No gastric acid production
Patient presents w/ watery diarrhea of sudden onset. Colonoscopy is normal and histopathology of colon biopsy reveals significant lymphocytes. What is the diagnosis?
Microscopic colitis --> normal appearance but inflammatory cells on histology
Assn w/ autoimmune diseases, drugs (PPI, H2(-), NSAIDs)
What is Marjolin's ulcer?
Aggressive ulcerating SCC that results from long-term, continuous mitotic activity as epidermal cells attempt to resurface the open deficit --> becomes a malignant transformation of a chronic wound
Slow growing, painless, and no lymphatic spread due to destruction of local lymphatics
**Seen in BURNS, osteomyelitis ulcer, venous stasis ulcer, chronic inflammation, scarred skin
Describe characteristics of seborrheic keratosis
Yellow/brown and greasy in appearance
What medication can help reduce the systemic response of hyper metabolism and increased catecholamine release due to SIRS/sepsis?
Propranolol --> B-adrenoreceptors responsible for increased catabolism and reaction to stress
Which laboratory sign is an indicator of severe sepsis?
What is a ganglion cyst?
What is treatment?
If removing it, what part is crucial to removal or it will reappear?
Non-neoplastic soft tissue lump most often on/near joints and tendons of hands or feet. Formed from sheaths of collagen from joint space and communicates w/ joint space via pedicle
Tx: 50% resolve spontaneously
If surgically removing it, need to remove the pedicle!
What is a carcinoma?
What are its 2 subtypes?
Malignant neoplasm of epithelial origin or internal/external lining of body
1) Adenocarcinoma --> glandular origin
2) Squamous cell --> squamous epithelium
What is sarcoma?
Treatment of choice?
Cancer originating from mesoderm (bones, tendons, cartilage, muscle, fat - the supportive & connective tissue)
Tx: Wide-margined excisions w/ keeping patients functional reserve in mind (using that area after removal)
Diagnostic of choice for any soft tissue mass?
MRI --> analyze surrounding tissue
What are most common EKG findings for PE?
Non-specific ST-segment & T-wave changes
What EKG finding is pathognomonic for R-heart failure, usually from large PE?
S waves in Lead 1
Q waves in Lead 3
Inverted T waves in Lead 3
Common side effect of steroids that are often overlooked?
Why are chronic steroids such an issue, especially during surgery?
Chronic steroid use causes (-) of HPA axis by (-) CRH & ACTH secretion --> (-) cortisol made by adrenals --> adrenals shrink due to low production --> during times of stress (surgery), they can't produce the high quantity of steroids needed
Results in shock (low BP, tachycardia)
Pt presents w/ chronic history of intermittent episodes of severe, crushing chest pain radiating to back and jaw lasting from seconds to minutes. Pain accompanied w/ dysphagia triggered by ingestion of certain foods. Cardiac workups have been negative. What 2 diagnoses are clinically indistinguishable and what further test will differentiate them?
Diffuse esophageal spasm & Nutcracker esophagus
DES: high-intensity disorganized contractions w/ NORMAL resting LES pressure
Nutcracker: INCREASED resting LES pressure
Young female (20-30's) smoker is wanting protection from getting pregnant. She receives a course of oral contraceptive pills from her OBGYN. Several days/months later, she develops one-sided leg pain and swelling. It hurts to touch her leg & when she lifts her foot up towards the sky. What is it?
*This presentation is pathognomonic for USMLE*
*One-sided calf pain, tenderness, (+) Homans sign
(+/- leg edema)
What pathogen causes infection in lymphatics leading to chronic fibrosis w/ non-pitting lymphedema?
Wuchereria bancrofti --> filariasis
Bruit heard near groin (one side) & patient has a high resting HR. Progressive one-sided leg swelling has occurred over several months. What is it? What medical history component is a common preceding incident?
Femoral arteriovenous malformation
*Hx of penetrating trauma --> leads to AV malformation
*Groin bruit + high resting HR = femoral AVM
What is overflow/stress incontinence?
What is best initial treatment?
Why not 5a-reductase (-)?
Large prostate causes outlet obstruction and traps a large amount of urine in the bladder. The involuntary urine loss (during cough, sneeze) occurs when bladder pressure > urethral pressure.
Tx: alpha-blocker (doxazosin, terazosin, tamsulosin) --> these RELAX the sphincter, allowing easier voiding
5a-reductase (-) --> takes a LONG TIME to act (up to FULL YEAR) so not appropriate for immediate relief
What is urge incontinence?
Appropriate initial tx?
Bladder hyperactivity causing frequent bladder emptying --> NO warning w/ sudden urge to urinate & can't hold it
Tx: anti-spasmodics (oxybutynin & tolterodine) --> help relax the detrusor muscle
Same day after surgery, a smoker develops fever. What is most likely cause? What is treatment?
Day 1 Post-Op Fever = Atelectasis!
Incentive spirometry to improve ventilation via deep breathing, coughing
Man presents to ER after being struck by a car. He has a subarachnoid hemorrhage and has to be intubated. The next day develops bradycardia, BP of 130/80, and is not over breathing the ventilator. What is next appropriate step in mgmt?
*Reduce intracranial pressure
Least invasive first:
- Raise head of the bed
- Sedation w/ propofol
- Hyperventilation (PaCO2 30-35)
- Mannitol (osmotic diuretic)
*Cushing triad: bradycardia, hypertension, irregular respiratory pattern
What is Cushing's triad & when is it seen?
2) Hypertension (relative)
3) Irregular breathing pattern
*Seen w/ increased ICP
Progressive dysphagia to both solids and liquids w/ a massively dilated proximal esophagus & narrowed, tapered distal esophagus on barium swallow. What is it? What is pathophys? What are 3 other associations w/ it?
Achalasia: failure of LES to relax due to loss of inhibitory neurons (nitrous oxide releasing neurons) in LES
Most idiopathic, but other associations:
- Chagas disease (reduviid bug)
- Gastric carcinoma
*NO progression pattern to solids then liquids (seen in esophageal carcinoma)
*Barium swallow --> "bird's beak" (proximal dilation of esophagus w/ narrowed lower esophagus)
What 3 tests are performed for workup of a prostate nodule?
2) PSA levels
3) Biopsy (want histologic diagnosis & Gleason score)
Do biopsy when:
- Can't distinguish b/w a cyst
- Can't distinguish b/w benign or cancerous condition
*Gleason score - grading system determined by cellular features of prostate cancer cells that correlates w/ clinical behavior)
- Higher score = greater likelihood of spread outside of prostate
What is initial drug choice for treatment of BPH? What is next step in therapy if the first choice drug fails?
1st choice: a-adrenergic (-)
- tamsulosin, doxazosin
2nd choice: 5a-reductase (-)
- finasteride, dutasteride
- blocks intracellular conversion of testosterone to DHT and shrinks hyperplastic prostate tissue & helps reduce progression of BPH
Unmonitored use of blood thinners can cause coagulopathy & worsen a GI bleed. What is the first & second steps in management?
1st step: hemodynamic stability --> transfusing blood pdts
2nd step: reversal of elevated INR
*Acute setting = FFP
*Prolonged effects on clotting cascade = Vitamin K
Patient presents w/ blood in the stool, high ALP, high total bilirubin, and anemia. What should you consider? Next best step(s)?
Duodenal tumor obstructing common bile duct (Ampulla of Vater)
1) Upper abd ultrasound --> shows dilated intra & extra hepatic ducts
2) Upper endoscopy to confirm suspicion
3) Biopsy tissue
Pt with protracted diarrhea recently develops jaundice and has high ALP and total/direct bilirubin levels. RUQ ultrasound shows strictures and dilations of intrahepatic & extra hepatic ducts. What is it? What 2 types of cancer is this patient most at risk for?
Primary sclerosing cholangitis (PSC)
*Seen w/ Inflammatory Bowel Disease (Ulcerative Colitis)
- Look for intermittent cramping & bloody diarrhea
Cholangiocarcinoma & colon cancer
66 yo woman who underwent laparotomy 1 week ago recently develops chest pain, shortness of breath, & has head and neck vein distention. Her vitals show tachycardia, tachypnea, and a loud S2. His ABGs find hypoxemia and hypocapnia and EKG is normal. What is next best test?
Spiral CT scan
- Heparin is better option before CT scan
Massive PE causes cor pulmonale --> seen by hypotension & neck vein distension.
*Risk factors for PE:
- Orthopedic surgeries
- Hypercoagulable states (OCPs, Factor V Leiden mutation, antithrombin III deficiency)
- Prolonged immobilization
What is most appropriate step of someone w/ longstanding GERD?
Endoscopy w/ biopsies
*Anyone w/ epigastric pain, older than 45 yo, (+) stool guaiac, wt loss, or dysphagia/odynophagia --> needs endoscopy and biopsies
- Mucosal biopsies in stomach for H. pylori
Man w/ chronic pancreatitis has LUQ pain & has no jaundice or spider angiomata. Abdomen is NT, ND, no caput medusa. The spleen tip is palpable. Upper endoscopy shows profound gastric varices but no esophageal varies. What is diagnosis?
Splenic vein thrombosis
Well described complication of chronic pancreatitis --> splenic vein runs along posterior surface of pancreas & adjacent inflammation can eventually induce thrombosis
Gastric varices seen b/c gastric mucosa vessels drain into an obstructed splenic vein
NO esophageal varices
Woman presents w/ fever & chills, RUQ pain and jaundice. She had a laparoscopic cholecystectomy 3 months ago. Her ALP and direct bilirubin are very high. Ultrasound shows extremely dilated intrahepatic ducts but common bile duct can't be visualized. What is most likely diagnosis?
Iatrogenic stricture of common bile duct
Look for biliary colic & obstructive jaundice (high ALP & direct bilirubin)
CBD strictures get infected and cause cholangitis --> look for Charcot triad (fever/chills, RUQ pain, jaundice)
72 yo Norwegian w/ contracted hand that can't be extended or placed flat on a table. It has developed gradually over many years. Palpable fascial nodules are present. What is it?
Dupuytren contracture: palmar fascial disease resulting in shortening & thickening of fibrous bands in hands/fingers
Seen in older men of Scandinavian descent
Best treatment for acute prostatitis? What bugs cause it?
E. coli, Chlamydia
*Fluoroquinolone (ofloxacin) covers both E. coli & Chlamydia --> need for 4-6 weeks to ensure adequate levels of drug in prostate
Risk factors for gallstones? Best test to confirm/look for gallstones?
5 F's --> Fat, Fertile (kids), Forty, Female, Fair
Ultrasound of RUQ
Best initial treatment for hemorrhoids?
Conservative: sitz baths, local anesthetics, high-fiber diet, lots of fluids
For herniated spinal disc, what is initial imaging study and treatment? Always assess what with disc herniation?
Imaging --> MRI
Tx: pain control w/ resolution overtime
**Always assess bowel/bladder function for emergency cauda equina syndrome
(+) fecal occult blood in adult >40 yo?
Cancer until proven otherwise
How does L-sided colon cancer present?
Obstructive symptoms --> changes in stool caliber, constipation overtime, bright red blood covering stools, wt loss
First treatment option for BPH? Second treatment option?
1st: a1 blocker (tamsulosin) --> acts on bladder trigone & urinary sphincter
- S/e: orthostatic hypotension
2nd: 5a-recductase (-) (finasteride) --> blocks conversion of testosterone to dihydrotestosterone in the prostate --> DHT responsible for hormone-dependent enlargement of the prostate
Does Hgb or Hct change during acute blood loss?
NO --> Hct or RBC count only decreases as fluid from other body sources (ECF) enters intravascular space in response to a decreased intracapillary blood pressure. This takes about 4-6 hours for normalization to occur
If IV fluids are given, this causes a dilutional effect and Hct may decrease
Man w/ intermittent abdominal cramps and bloody diarrhea over past 8 years has a relapse of diarrhea and takes loperamide to control diarrhea. He develops severe abdominal pain in epigastric area over past 12 hours. Xray shows massively distended transverse colon w/ gas in the colon wall w/ no air under the diaphragm. What is the diagnosis?
Toxic megacolon --> acute distended colon w/ wall ischemia and pneumatosis intestinal (coli)
- hx of intermittent abdominal cramps w/ bloody diarrhea = ulcerative colitis
*Fever, leukocytosis, and abd distension on imaging
**Toxic megacolon is complication of UC
5 triggers that can induce toxic megacolon?
Solitary, painless testicular mass in 20 yo man on histology shows small cells w/ crowded nuclei, high mitotic rate, & necrosis. Enlarged retroperitoneal nodes are seen. aFP is elevated. What type of cancer is it?
What marker is elevated in choriocarcinoma?
What marker is elevated in seminoma?
- cytotrophoblastic & syncytiotrophoblastic cells resembling chorionic villi
*Placental alkaline phoshpatase (PLAP)
- centrally-placed nuclei & nucleoli resembling primary spermatocytes
- papillary structures resembling glomeruli (Schiller-Duval bodies)
Intense burning pain that occurs after an injury that is not relived w/ analgesics - what is probable diagnosis? If so, what is diagnostic test to confirm?
CRPS or reflex sympathetic dystrophy (RSD)
*Do sympathetic block --> if it relieves the symptoms, RSD is confirmed
*Surgical sympathectomy will cure RSD
Smoking & drinking history are very important for what type of cancer?
Squamous cell carcinoma
Progressively growing, painless lymph node mass in the absence of systemic symptoms must be evaluated for what type of cancer in person w/ smoking and drinking history & poor dental hygiene?
Next best step in diagnosis?
Metastatic squamous cell carcinoma --> arising from somewhere in respiratory or digestive tract
Next step: triple endoscopy (laryngoscopy, endoscopy, bronchoscopy) w/ mucosal biopsies to determine primary site of cancer
*Painless neck masses in older patients are considered cancer until proven otherwise!
28 yo woman w/ vague RUQ pain suddenly gets much worse and she becomes hypotensive, tachycardic and vomits. Her abdomen is mildly distended and diffusely tender. Hgb is 8.1 and abd x-ray shows no evidence of pneumoperitoneum. She denies pregnancy b/c she takes her OCPs daily and last menstrual period was normal. What is the cause of her acute illness?
Ruptured hepatic adenoma
*OCPs huge risk for hepatic adenoma in women b/w 20-40 yo
- Risk = dosage & duration of estrogen use
- Will spontaneously regress when stop taking OCPs
*Sudden RUQ pain + hypotension with OCP use
CT scan is diagnostic
Cold spots on sulfer colloid liver scan
Risks for hepatic adenomas?
Glycogen storage disease type 1
Anabolic steroids (body builder)
Sudden onset erectile dysfunction w/ presence of nocturnal erections?
Psychogenic cause of problem
Flank pain that radiates to inner thigh and scrotum w/ hematuria. What is diagnosis until proven otherwise? Best initial test?
Nephrolithiasis (kidney stone)
1) plain x-ray (calcified stones will be visible)
2) If not, CT scan w/o contrast
Besides strictures and fistulas, what is another complication of Crohn's disease? What is mechanism behind this?
Nephrolithiasis (kidney stones)
Calcium normally binds oxalate from diet in the intestine --> in Crohn's, fat malabsorption (disease of terminal ileum - site of fat reabsorption) results in increased intra-luminal fat that binds all the Calcium in the intestine --> oxalate (normally bound by calcium & excreted) is now absorbed by body and precipitates in higher concentrations in the kidneys --> stones
Elderly and alcoholics are at risk for what cerebral complication? Why?
Brain volume decreases over time in both elderly & alcoholics --> minimal trauma causes brain to "rattle around" & tear bridging veins
*Sudden "senility" in previously health person w/ hx of trauma --> suspect subdural hematoma
Name complications of Neurofibromatosis Type 1 (von Recklinghauen disease)?
Pigmented iris hamartomas
Person w/ history of neurofibromatosis type 1 presents w/ LLQ abdominal mass. He is found to have metabolites of epinephrine & norepinephrine in 24-hour urinary collection. What do you suspect? Next best test?
MRI scan of his adrenal glands to confirm pheo
How to differentiate b/w extra-adrenal or adrenal focus of pheochromocytoma?
If Epinephrine metabolites are present in urine --> adrenal origin
Epi not made outside the adrenal glands
Most common cause of double vision in adults over 40 yo?
Which is more of an emergency - periorbital or orbital cellulitis and why? What are signs to watch for?
Orbital cellulitis (post-septal) --> infection behind orbital septum (posterior boundary of eyelids that are directly in front of the corneas)
Which is more of an emergency - periorbital or orbital cellulitis and why? What are signs to watch for?
Orbital cellulitis (post-septal) --> infection behind orbital septum (posterior boundary of eyelids that are directly in front of the corneas)
*Proptosis, eye pain on movement, vision loss, visual acuity changes, fever
Look for hx of recent sinusitis or tooth infection
When using TMP-SMX (Bactrim), aside from Coumadin, what other drug should you NOT use? What side effect do you worry about?
*Increased risk of HYPERKALEMIA when used together
What 3 conditions (2 genetic 1 renal) must you consider when dealing w/ subarachnoid hemorrhage?
Describe Paget's disease of the bone (osteitis deformans)?
What symptoms might you see as initial s/s?
Common lab findings?
Initial osteoclast overactivity (bone breaks down) --> accelerated osteoblast activity in effort to rebuilt drastically reduced bone matrix --> results in structurally inferior woven bone --> bone starts to bow & fracture easily
- Pain (from bowing/fracture of long bones secondary from arthritis)
*Headaches --> see below
*CN palsies --> see below
*Hearing loss --> damage of cochlear nerve from enlargement of temporal bone & narrowing of internal auditory meatus
*High ALP, normal Ca, normal Phos
Describe respiratory quotient (RQ) & normal values for different sources of fuel?
Steady-state ratio of CO2 produced to O2 consumed per unit time
*Used to make assessments of metabolism
*Normal RQ = 0.8 (mix of carbs, fats, proteins)
Carbohydrate diet only = 1.0
Proteins only = 0.8
Oxidation of fatty acids only = 0.7
Acute pain & swelling over coccyx that never happened before?
Pilonidal cyst --> infection of midline sacrococcygeal skin & sub-Q tissues
*Dermal sinus tract originating over the coccyx
Describe important features of epidural hematoma?
- Rupture of middle meningeal artery as it exits from foramen spinosum
- Blood in the potential space b/w cranium & dura mater
- Presents as unconsciousness followed by lucid interval; followed by gradual deterioration of consciousness w/ symptoms of elevated ICP (headaches, N/V)
- May have dilation of pupil on same side (CN3 compression)
- May have contralateral hemiparesis
- Biconvex hematoma that does NOT cross the suture lines
What are some common associations with undifferentiated nasopharyngeal carcinoma?
How do patients present?
Viral infections (EBV)
Middle East/Far East descent
Nitrosamine consumption (salted fish)
Man w/ constant & gnawing epigastric pain that is worse at night, anorexia w/ wt loss, & painless jaundice. What do you suspect? What are other signs you may see?
*Smoking big risk factor
- Jaundice (common bile duct blockage)
- Steatorrhea (inability to secrete fat-digesting enzymes or blockage from main pancreatic duct)
- Epigastric pain (insidious, gnawing, worse at night)
- Painless jaundice
- Wt loss & fatigue
- Migratory thrombophlebitis (Trousseau sign)
32 yo woman w/ intermittent blood staining her bra from L breast. No breast masses or axillary lymphadeonpathy noted and ultrasound is normal. What is it?
*Most common form of intermittent bloody discharge from one nipple in PERImenopausal women
In a person w/ a joint replacement, a subacute (months after) presentation of joint pain w/ increased WBC most likely points to what bug?
What are 4 T's of anterior mediastinal masses?
Teratoma (other germ cell tumors)
Triad for mononucleosis?
These patients will develop rash w/ what type of Abx?
Best initial tests to confirm?
Fever, sore throat, lymphadenopathy
B-lactams (-cillins, cephalosporins)
Heterophile antibody test & CBC
Drug side effects on respiratory system. What naturally causes bronchodilation?
Beta stimulation/anti-ACh = bronchodilation
Propranolol --> non-specific B-blocker that causes bronchoconstriction --> WHEEZES
Enalapril --> ACEi causes dry COUGH
Patient w/ HIV presents w/ fever and bleeding from site of recent IV drug use. She has confusion and tingling sensation her her arms and legs for past 2 hours. She has scleral icterus and non palpable purport on her chest and arms. Labs showed anemia, low WBC, low platelets, increased bleeding time, proteinuria, hematuria, and fragmented RBC on peripheral smear. What is it?
Thrombotic Thrombocytopenic Purpura (TTP)
2) Thrombocytopenia (low platelets, petechiae, excessive bleeding from punctured site)
3) Microangiopathic hemolytic anemia
4) Neurologic symptoms (confusion, paresthesias)
5) Renal failure (proteinuria, hematuria)
How to differentiate TTP from DIC?
TTP --> NO changes in PT or PTT
DIC --> coagulation factors consumed (INCREASED PT/PTT)
Best therapy for chemotherapy-induced N/V?
If unresponsive to promethazine, try triple therapy:
1) Serotonin blocker --> ondansetron, "-setron"
3) Substance P/neurokinin 1 receptor blocker --> Fosaprepitant
Which ulcer IMPROVES with eating?
Which ulcer WORSENS with eating?
IMPROVES = duodenal (HCO3 secreted helps ulcers)
WORSENS = gastric (acid secreted w/ meals irritates ulcers)
Testicular tumor causing erectile dysfunction and gynecomastia. Cells show eosinophilic cytoplasm, bland nuclei, and small crystalline cytoplasmic inclusions. What is the type of cancer. What are the crystals called?
Leydig cell tumor
- Produce excess androgens (may be converted to estrogens by peripheral aromatization)
- This is what causes erectile dysfunction/gynecomastia
In adrenal mass found on imaging, what are 2 most important steps?
1) Benign vs malignant --> radiologic features
2) Functional (secreting hormones) vs nonfunctional
- 24hr urine catecholamine/metanephrine screen
- Serum aldosterone-to-renin ratio
- Low dose dexamethasone suppression test
Sources for brain abscess?
20 yo w/ persistent headaches & fever for 1 wk who just had a seizure. He is obtunded. Imaging shows ring-enhancing lesion in R frontal lobe and an air-fluid level in the R frontal sinus. What is most likely organism(s)? What is it?
a-hemolytic Streptococcus + mixed anaerobes
Brain abscess in frontal lobe --> associated w/ sinusitis
22 yo African American male receives vaccinations and travel meds for trip to India. He became fatigued and has mild jaundice now. Developed severe abd pain after starting prophylactic meds. Urine is darker, jaundiced, new heart murmur, and palpable spleen tip. What is the cause? What is the inheritance pattern?
*Chloroquine (malaria prophylaxis)
Certain drugs (Sulfa drugs, antimalarials), foods (fava beans)
X-linked RECESSIVE (also Hemophilia A + B)
Someone develops sudden onset LE weakness after recovering from GI infection 5 days ago. Has paresthesias in hands and feet. Becomes obtunded and needs intubation. Why?
Guillian-Barre syndrome causes ASCENDING paralysis that can affect muscles of respiration!
26 yo man has back pain that is worse at night and began near his sacrum. Pain starting to creep up his back and gets a little better with activity. What must you consider? What is treatment?
Ankylosing Spondylitis --> "bamboo spine" on imaging
Tx: anti-TNFa agents (etanercept, infliximab)
Can use NSAIDs for some relief
Only treatment options for COPD that decrease morbidity and mortality?
What drug should be given to someone w/ a history of recent MI?
B-blocker (decreases myocardial O2 demand by decreasing HR - this increases diastole and coronary artery perfusion time)
What are you thinking in a person w/ EKG changes showing ST-segment elevation in leads II, III, aVF? Symptoms?
Inferior wall infarct/R ventricular infarct --> R coronary artery
Symptoms: hypotension, tachycardia, lungs clear, ABSENCE of pulses paradoxus
How to distinguish R ventricular infarct vs cardiac tamponade?
Tamponade: both ventricles already compressed -> during inspiration, venous return increases to R ventricle --> excess filling and expansion of R ventricle that further compresses and displaces the L ventricle --> LV ejection fraction and contraction very low and causes low systolic BP during inspiration
R vent infarct: heart not being compressed and any increase in RV volume is accommodated by pericardial sac
Treatment for R ventricle infarction?
IV fluids --> volume loading of R ventricle causes it to contract more forcefully (Sterling's law - more in, more out)
How to differentiate b/w central vs nephrogenic diabetes insipidus?
Dilute urine w/ frequent urination
Central: no ADH release from pituitary --> kidney is fine & will respond to exogenous ADH/vasopressin by increasing H2O reabsorption and concentrating the urine (increased urine osmolality)
Nephrogenic: ADH secreted from pituitary -> kidney INSENSITIVE to its effect --> exogenous ADH/vasopressin does NOT cause significant rise in urinary osmolality (urine remains dilute!)
What medication is indicated in mgmt of acute asthma attacks?
Steroids (oral or IV)
Vomiting w/ upper GI bleeding - suspect what?
Best mgmt for 2nd degree Moritz Type II or 3rd degree heart block?
Permanent transvenous pacemaker
Why is anticholinergic overdose so deadly?
Any drug w/ anticholinergic effects (e.g. diphenhydramine) can cause multiple effects including tachycardia & seizures
*In high doses, block Na channels --> lead to a prolonged QRS interval, prolonged QT interval, and lethal arrhythmias
Anticholinergic s/e --> cutaneous vasodilation, anhidrosis, hyperthemia, mydriasis, delirium, hallucinations, urinary retention
Acute mononucleosis from EBV - what 4 signs do you look for?
What lab finding is key?
What is tx?
Most likely potential FATAL complication?
Lymphocytosis w/ ATYPICAL lymphocytes
Tx: symptomatic control --> acetaminophen/NSAIDs
Deadly complication = Splenic rupture (no sports for at least 4 weeks)
Pt w/ multiple myeloma has B/L leg weakness. Why is bone pain the first sign?
Osteoclastic bone lesions result from stimulation of osteoclasts & inhibition of osteoblasts by humoral factors elaborated by malignant plasma cells
Multiple myeloma --> known to compress the spinal cord --> focal neurological deficits
What is the caution in using metronidazole?
Get a disulfiram-like reaction --> FLUSHING
Nail pitting and distal destructive asymmetric arthritis w/ elevated ESR?
What type of drugs to you need to avoid in this condition?
*Commonly nail bed deformities
AVOID anti-malarials if disease-modifying therapy has started b/c they can exacerbate psoriasis
Person younger than 45 yo w/ asymptomatic scant hematochezia (blood in stool) should receive what test?
Anoscopy & flexible sigmoidoscopy
Majority of lesions are in distal colon, rectum or anus
First line for symptomatic bradycardia?
What bug characterized by granulomatous-suppurative lesions that become widely disseminated in host is immunocompromised. Lesions may be seen in the brain. Stains weakly acid-fast but is bacteria?
Symptoms & Signs of Cavernous Sinus Thrombosis?
HA, CN palsies, fever, diplopia, altered mental status
*Proptosis, EOM impairment, *papilledema, ptosis, blurry vision
Contrast CT / MRI scan
Tx: parenteral Abx (adjuvant w/ LMWH & steroids)
Why do you see pulsus paradoxus is severe asthmatics?
During severe asthma attack --> hyper-inflated lungs compress against the heart, decreasing heart's ability to fill with blood
Needs intubation & mechanical ventilation
What is mechanism of action of best initial treatment for Parkinson disease?
MOA: dopamine precursor that CAN cross BBB where it's converted to dopamine
- Combined w/ carbidopa, which blocks peripheral conversion of levodopa to dopamine
Best initial test to evaluate suspected lung cancer that is centrally located?
Best test to evaluate CT scan finding of a solitary lung mass?
Bronchoscopy w/ biopsy
First line therapy for diabetic patients w/ HTN?
ACEi --> prevent progression of diabetic nephropathy
Mgmt for post-chemotherapy neutropenia?
Afebrile = observation
Febrile = Abx therapy
Symptomatic mitral regurgitation from ischemic cardiomyopathy treatment?
Decrease Preload (loop diuretics) & Afterload (ACEi or B-blocker)
33 yo with fever, chills, productive cough. Hx of past cellulitis and tricuspid valve endocarditis. Recent HIV test is pending. Has rhonchi in R mid-posterior lung field. CXR shows lobar consolidation w/ air-fluid level. What bug is responsible? What is best initial treatment?
S. aureus (see past hx of cellulitis & tricuspid valve endo)
Very dangerous - necrotizing or cavitary pneumonia
IV vancomycin or linezolid
New-onset ascites in 50+ yo woman?
What syndrome is this disease associated?
Ovarian malignancy w/ peritoneal metastasis
Do pelvic ultrasound & paracentesis to determine SAAG (1.1 = transudative/portal HTN)
*Meigs syndrome: ovarian tumor, ascites, pleural effusion
2 causes of acute torticollis/dystonia?
Drug s/e (antipsychotics)
Tx: dopamine agonists, anti-ACh/H1, muscle relaxants, benzos
Man w/ end stage renal failure found to have potassium level of 8.8. What is best initial therapy?
IV calcium gluconate
- Works VERY rapidly to counteract the effect of high potassium on the heart and muscle by stabilizing cardiac membranes
- Does NOT actually decrease level of potassium
What 2 electrolyte abnormalities cause nephrogenic DI?
In pancreatic insufficiency, what vitamins will be deficient?
Vit A, D, E, K + Vit B12
*Need pancreatic enzymes to cleave B12 from R-binder (released in saliva) in order to have B12 bind to Intrinsic Factor!
Side effect of hydralazine and test to confirm?
What must you consider in a YOUNG person with a stroke or MI?
Most specific findings of multiple myeloma?
Increased monoclonal proteins (IgG, IgA) in urine/serum
Clonal plasma cells from bone marrow biopsy
38 yo found to have at least 200 polyps on colonoscopy. What is most appropriate initial colon cancer screening strategy for his 2 children?
FAP --> autosomal dominant disease w/ mutations in APC gene
1st degree family members --> genetic testing for APC gene mutations
If unavailable --> ANNUAL sigmoidoscopy/colonoscopy starting at 12 yo
What are the 2 key findings in septic shock?
HIGH cardiac output
LOW peripheral resistance
Look for infection, peritoneal bacterial contamination (gut perforation)
28 yo woman experiences episodes of passing reddish-brown urine in the morning after getting out of bed. The diagnosis can be confirmed by what finding?
*Flow cytometry showing deficient CD55 or CD59 on RBCs (anchor needed for cell membrane proteins to repel complement)
Characteristics of multi-infarct (vascular) dementia?
SUDDEN, STEP-WISE deterioration of mental function
*Look for some improvement of symptoms followed by sudden deterioration of mental function after period of time
Prominent gait, motor, or visual abnormalities
MRI: cortical and subcortical infarctions and subcortical ischemic changes
65 yo male has 3 yr history of progressive weakness. He has difficulty getting up from chairs, mild muscle cramps in his thighs, and difficulty swallowing. He has elevated CRP and CK. What is it? What is most accurate diagnostic test?
Inclusion body myositis
Diagnostic test --> muscle biopsy
Hallmark symptom of vertebrobasilar insufficiency (TIA)?
Other S/S: diplopia, dysphagia, dyarthria, facial numbness/paresthesia, syncope
These TIAs much shorter than internal carotid TIAs
Response of normal bone marrow to either infection OR trauma w/ exceedingly high WBC count (>50,000) and HIGH leukocyte alkaline phosphatase?
Management of antiphospholipid syndrome?
Warfarin w/ INR b/w 2.0-3.0 FOR LIFE
Man presents w/ vomiting bright red blood. No heartburn, dyspepsia, or EtOH consumption. No signs of cirrhosis, portal HTN. Nasogastric lavage returns bright red blood and endoscopy reveals blood in gastric lumen. No evidence of ulcers, gastric wall erosion, or esophageal/gastric varices. What is it?
1) Nasogastric lavage
2) Volume resuscitation
*Dieulafoy's lesion --> dilated submucosal vessel that failed to branch into capillaries, penetrating overlying epithelium and bleeds.
- Usually located along lesser curvature of stomach near GE junction
This herb prolongs the INR in a patient on warfarin?
Common findings in multiple myeloma?
- Pathologic fractures (doing everyday ordinary movements)
- Elevated Calcium
- Elevated total serum protein (hypergammaglobulins)
Person with Type1 DM and low B12, what must you investigate as cause of anemia?
Low serum B12 --> if low need to determine etiology:
- Pernicious anemia = dyspepsia, autoimmune conditions --> anti-IF & anti-parietal cell antibodies
Dental extraction bleeding w/ petechiae and ecchymoses. Platelet count normal. PT & PTT normal. Bleeding time prolonged. Platelet aggregation studies showed:
ADP (no response)
Epi (no response)
What is the cause?
Deficient platelet glycoprotein IIb/IIIa complex
Primary platelet aggregation response to platelet agonists (ADP, epi, collagen) are DECREASED but ristocetin response is normal.
Ptosis & mitosis of a single eye in a person with long smoking history. What must you consider?
Pancoast tumor --> lung cancer in long time smoker at APEX (superior sulcus) of one lung
- Compresses cervical sympathetic plexus
- May also complain of scapular pain and radiculopathy in ULNAR distribution
What physical exam findings are seen with traumatic diaphragmatic rupture?
L sided elevation of diaphragm --> abdominal viscera protrude into chest cavity on L side
NG tube may also curl up into the chest
Hemothorax may be only finding
CXR shows bowel in L chest
Treatment of herpes zoster (shingles) WITH neuropathic pain?
Acyclovir (famciclovir) + TCA (despiramine - neuropathic pain)
What s/s suggest sarcoidosis?
What is secreted by the granulomas?
What lab finding is common?
NON-caseating (no necrosis) granulomas
1,25-dihydroxycholecalciferol (ACTIVE Vit D)
Hypercalcemia seen from increased Vit D
Person with anemia (normal MCV) and no reticulocytes or erythroid precursors in the bone marrow. What organ must you investigate as cause?
What condition has high incidence of co-existing?
Thymoma (thymus) --> PURE RBC APLASIA seen
Signs of anticholinergic overdose?
Red as a beet = cutaneous vasodilation
Dry as a bone = no sweating (anhidrosis)
Hot as a hare = hyperthermia
Blind as a bat = NONreactive mydriasis (dilated pupil)
Mad as a hatter = delirium
Full as a flask = urinary retention
Type of lung cancer seen in nonsmokers, arises in periphery of the lung?
What screening test should be done in men aged 65-75 who currently or have previously smoked?
Abdominal ultrasound (AAA)
Patient is increasingly anxious and jittery. She is disoriented and easily distracted, however she dozes off when talking to you and has to be repeatedly awakened. Her complaints are abdominal pain and constipation. She has dry mucus membranes and orthostatic changes are present. What electrolyte abnormality do you suspect? What EKG changes would be present?
- Stuporous mental status changes
- Intravascular volume depletion from osmotic diuresis
**Decreases renal sensitivity to ADH (nephrogenic DI) = osmotic diuresis
**Hypercalcemia = BONES, STONES, GROANS, and PSYCHIATRIC OVERTONES
EKG = QT segment shortening
What are risk factors for stress gastric ulcers?
How to differentiate between stress ulcer and ischemic colitis?
- Complicated hospital course
- Prolonged intubation
- Taking medications that cause coagulopathy (aspirin, heparin, warfarin)
- Cranial trauma
Look for upper GI bleed (black tarry stools)
*DAYS after surgery (vs ischemic colitis where usual 1 day post-op)
ALL patients should be given prophylactic H2 receptor or PPI
Cholangiocarcinoma risk factors?
Presentation and imaging findings?
Recurrent pyogenic cholangitis (RPC)
Chronic liver disease
S/S: jaundice, itching, elevated LFTs & bilirubin
Ultrasound: dilation of R & L hepatic biliary ducts (NO gallbladder or common bile duct involvement)
AIDS patient with painful swallowing. What is initial treatment?
What if symptoms persist?
Initial prophylactic Candida treatment
CMV: deep large ulcers
HSV: multiple small shallow ulcers
S/S, imaging findings, and treatment of neurocysticercosis?
Caused by pork tapeworm (Taenia solium)
S/S: SEIZURES, HA, increased intracranial pressure
Imaging: cystic lesions and calcified lesions
What 2 serum markers are elevated in acute Hep B infection?
HbsAg (surface antigen)
anti-HBc IgM (core antigen)
Complication of pancreatitis where person develops fever, chills, leukocytosis around 4 weeks after acute pancreatitis episode?
What is treatment?
Infected pancreatic pseudocyst
*Look for fluid-filled cyst in pancreas off of pancreatic duct on CT
What is classic story for corneal abrasion? What is initial treatment?
Foreign body sensation + painful, red eye
Tx: topical anesthetic (tetracaine) to allow adequate physical, fundoscopy and fluorescein slit-lamp exam
Person with abnormal behavior and confusion with abdominal pain resents with high calcium and low PTH. What are you thinking? What is next best test?
HYPERcalcemia --> bones, stones, groans, psychiatric overtones
If calcium high and PTH is low --> think exogenous production of PTH-rp
- Small cell carcinoma of lung
Most appropriate treatment for acute spinal cord injury
IV steroids after neurologic exam
Compression from metastatic cancer (prostate, breast, lung)
3 common causes of B12 deficiency?
8 signs of B12 deficiency?
What is the name of severe B12 deficiency
Small bowel disease
Pallor, Weakness, Paresthesia, Ataxic gait, Loss of vibratory sensation, increased DTRs, extensor plantar reflex, dementia
*Subacute Combined Degeneration --> neurologic s/s of B12 deficiency
Asymptomatic jaundice with conjugated hyperbilirubinemia w/o any LFT abnormalities. Also has elevated urine coproporphyrins. What 2 disorders could this be? How to differentiate the 2?
Dubin-Johnson syndrome OR Rotor syndrome
Black liver = Dubin-Johnson syndrome
Confirmatory test for MG?
EMG (progressive decrease in amplitude of muscle)
Infections, inflammatory autoimmune disorders (RA), and cancers all can cause what blood disorder? What other blood test results are seen?
Anemia of chronic disease
LOW iron levels
Treatment of recurrent calcium oxalate kidney stones?
Thiazide diuretics --> cause increased reabsorption of calcium from urine to decrease urinary calcium
UTI treatment duration in men vs women?
Tx of choice? Secondary option?
7 days for MEN; 3 days for WOMEN
Acute brain stem infarction (adult or child) best evaluated with what test?
Angiography of neck vessels --> determine sources of bleeding, thrombus, or stenosis.
Differentiate between Gilbert syndrome, Criggler Najjar 1 & 2?
NO anemia with these!
Gilbert: mild icterus from unconjugated hyperbilirubinemia
*Triggered by certain events (fasting, physical exertion, illness, stress, fatigue)
CN 1: severe jaundice and neurologic impairment due to kernicteris in infants
- Indirect bili very high
- Tx: phototherapy and plasmapheresis
CN 2: lower serum bill levels and survival into adulthood with NO kernicteris/neuro impairment
2 common side effects of isoniazid treatment?
B6 deficiency (replace w/ pyroxidine)
INH hepatits (if mild, no worries)
What types of nerve fibers are affected by Guillian Barre syndrome?
Demyelination of PERIPHERAL motor nerves (sensory and autonomic nerves also)
*Ascending weakness w/ feet tingling
Signs of pellagra?
Deficiency of what?
Diarrhea (long term)
Dementia (depressed mood, can't recall things)
Dermatitis (sun-exposed areas w/ rash)
Most common cause of loss of bile ducts in the liver in adults?
Primary biliary cirrhosis
What are some side effects of celiac disease?
What 2 antibodies are specific for celiac?
Fe deficiency anemia --> from malabsorption
Rash = dermatitis herpetiformis
anti-tissue transglutaminase IgA
1st line tx for animal bites?
Persistent rhinorrhea, congestion, asthma, and B/L nasal polyps all side effects of what drug?
Management kg suspected scaphoid fracture?
Initial X-ray --> wrist immobilization for 6-10 weeks
Person with MCV 75 and nucleated erythroblasts with red dots around the nuclei on peripheral smear. Also has fatigue and abdominal pain with headache. What is cause of anemia?
*Sideroblasts: nucleated erythroblasts
*Basophilic stippling: red dots (ribosomes) on periphery of erythrocytes
*S/S: abd pain, neuro (HA, memory loss, foot drop)
What is the cutoff value?
Serum-to-ascities albumin gradient
> 1.1 = portal HTN (cirrhosis, cardiac, budd-chiari)
Headaches, dizziness, pruritus (especially after showering), and splenomegaly are indicative of what hematologic disorder?
Look for increased RBC (Hb & Hct), WBC, and platelets
HA and dizziness from increased blood viscosity
What are the below parameters in septic shock:
CO: increased (due to extreme vasodilation - try to maintain BP)
PVR: decreased (due to endotoxin causing vasodilation)
PCWP: decreased (no preload do to third spacing of intravascular fluid)
RBCs with single, round, blue inclusions on Wright stain. What are they? What do they indicate?
Howell-Jolly bodies (normally removed by the spleen)
Indicate either physical absence of spleen or functional hyposplenism
Person with alcoholic cirrhosis - what is the most import at screening test?
If found, what is best prophylactic treatment?
Endoscopy - assess presence of varices
If present and NON-bleeding = b-blocker
What medications will exacerbate G6PD?
In someone with hypertensive emergency, what is one of the best treatments? If given, what is a potential side effect? What are the signs?
Altered mental status, lactic acidosis, seizures, coma
What are complications of Chagas disease?
What vitamin deficiency is seen with cracking of the corners of the lips, swollen tongue and mucus membranes, and red scaly patches on his eyebrows, cheeks, and nose. What is it?
Riboflavin (vit B2) deficiency
Patient with dysphagia, coughing, halitosis, and a neck mass that varies in size with gurgling or swallowing foods/liquids. What is it? What is the cause behind it?
Esophageal sphincter dysfunction and esophageal dysmotility
Effects of thyrotoxicosis are caused by what physiologic change?
T3 causing increased sensitivity to circulating catecholamines --> (+) chronotropic and inotropic effects --> myocardial contractility increases
Thrombocytopenia (low platelets) are a finding in what chronic infection?
Person with celiac sprue has normal Ca levels, low phosphate, elevated PTH and elevated Alk Phos. What is the cause?
Osteomalacia --> HIGH Alk Phos, low Ca, low Phos
*Celiac sprue causes malabsorption of Vit D --> inadequate Ca and Phos reabsorption from the gut --> this triggers PTH release --> bone resorption increases Ca levels and Phos remains decreases
Female with frequent headaches, fatigue and recent wt loss has should muscle stiffness in the mornings. A tender cord is palpated in the R temporal area. What is the most likely complication of this?
Giant cell (Temporal) Arteritis
Association w/ Polymyalgia Rheumatica
2 week hx of weakness, low-grade fevers, and exertion dyspnea. Also has fingertip pain and his urine has been dark & cloudy recently. Several of his PIP and DIP joints are swollen. What is the cause?
Painful fingertips = Osler nodes
Red non-tender lesions on palms and soles = Janeway lesions
Red and bleeding lesions of retina = Roth spots
Person has pain that is worsened after eating and leads to weight loss from no eating foods because of fear of the pain that will follow. What is the most likely cause?
Atherosclerosis of mesenteric arteries
What describes a severe anemia with low or absent reticulocytes?
Most effective initial treatment for hypertension?
Lifestyle modification --> DASH diet, low Na intake, regular exercise
Treatment for hepatic encephalopathy?
Lactulose --> helps draw ammonia out of blood into the gut
Person with anemia, elevated BUN and creatinine, and high blood calcium - what is it? Next best test?
Multiple Myeloma (CRABBI)
Serum immunoelectrophoresis --> M spike (IgG)
How to differentiate between B-thalassemia trait and Fe deficiency anemia?
what is seen on peripheral smear with B-thal?
B-thal trait: mild anemia, very high RBC count, Hgb > 10
Fe def anemia: LOW RBC count, microcytic when Hgb
Person presents with shock from infection and has BP 70/40. Next day has LFT's in the thousands. Why?
LFTs in thousands with slightly elevated total bilirubin and ALP
Why is Graves disease at risk for developing HYPOthyroidism if treated with radioactive iodine?
In Graves, the ENTIRE gland is hyper-functional --> radio-iodine is taken up the the entire thyroid gland resulting in complete thyroid ablation
What is the source of bleeding in Mallory-Weiss tear?
What can help determine between artery or vein tear?
Ruptured submucosal ARTERIES of distal esophagus/proximal stomach
*Prior upper endoscopy will show dilated veins if present (varices)
What is a common side effect of dihydropyridine Ca-channel blockers (e.g. amlodipine)?
Peripheral edema --> these drugs cause dilation of peripheral blood vessels and leakage of fluid into interstitial space
Person has periodic abdominal pain. Endoscopy shows multiple duodenal ulcers and a single jejunal ulcer. What is the cause of his impaired fat absorption? What is this?
*Jejunal ulcer pathognomonic
Excess gastric acid produced --> inactivates pancreatic enzymes
What 2 conditions present with difficulty swallowing solids and liquids, heartburn, and wt loss?
Best initial test?
Achalasia and GE cancer
Barium swallow --> shows dilation of upper esophagus with smooth narrowing of distal esophagus in ACHALASIA
Before starting achalasia tx --> do endoscopy to r/o cancer
What is the initial finding in Pancoast tumor? What are other s/s?
Best initial test?
*Horner syndrome (same side as shoulder pain)
Ptosis, miosis, anhydrosis
*Weakness/atrophy of hand muscles
Complication of prolonged immobilization (aside from rhabdo)? What is the mechanism and treatment?
Increased osteoclastic bone resorption --> starts occurring in week 4 after immobilization
Bisphosphantes prevent bone loss
77 yo male recently treated 3 months ago for pyelonephritis. Had cystoscopy done few days ago for persistent dysuria. Now he has new-onset heart murmur with painful red lesions on his fingertips. What bug is responsible for what he has?
**Recurrent UTIs and pyelo = ENTEROCOCCUS
Difficulty hearing in a crowded or noisy environment - classic for what?
Presbycusis --> sensorineural hearing loss occurring with aging
- Begins with symmetrical, high-frequency hearing impairment
All patients with cirrhosis should have what screening test done?
Esophageal endoscopy --> r/o varices
Also liver biopsy for hepatocellular carcinoma
Man has attack of gout in R great toe. Also describes occasional headaches and pruritus that can be "unbearable" after a hot bath. What is the cause of his gout flares?
Polycythemia vera (myeloproliferative disorder)
*Look for splenomegaly and pruritus after baths (histamine release from basophils)
- Causes overproduction of purines from catabolism of cells
Associated symptoms with chronic inflammatory diarrhea?
Reactive thrombocytosis (increased platelets)
*Positive stool blood test
Most common cause of sepsis in sickle cell patients?
What is important prophylaxis?
Prophylaxis with Penicillin
Patient has facial swelling upon waking up as well as b/l LE edema. 4+ proteinuria found as well as palpable kidneys and liver. S4 heard on auscultation. History of recurrent pulmonary infections from bronchiectasis and psoriasis. What is the cause of all this?
Secondary Amyloidosis (AA)
*Nephrotic syndrome, palpable kidneys, hepatomegaly, ventricular hypertrophy (S4) w/ chronic inflammatory disease (recurrent pulm infections, bronchiectasis)
Describe an acute hemolytic transfusion reaction?
*Develops WITHIN AN HOUR after blood transfusion has begun
*Caused by ABO incompatibility
*S/S: FLANK PAIN, fever, chills, hemoglobinuria
May progress to DIC
(+) Direct Coombs test
How does cirrhosis affect transport protein levels of various hormones?
Signs of cirrhosis?
DECREASES the transport proteins
**TOTAL level of hormones are decreased, but FREE levels are unchanged (most bound to their plasma proteins)
Jaundice, hepatosplenomegaly, ascites
Telangectasias, Palmar erythema, testicular atrophy, gynecomastia
What is the pathogenesis behind gynecomastia in cirrhosis?
Damaged liver can't metabolize circulating estrogen --> causes excess estrogen in bloodstream and causes:
- Palmar erythema
- Spider angiomas
- Testicular atrophy & decreased body hair
In a person with (+) HBeAg must be monitored with what tests?
*ALT (specific for hepatitis)
Every 3-6 months until they achieve viral clearance
What are biliary cysts?
What are the findings on exam?
Congenital/acquired dilations of the biliary tree
1) Abdominal pain
3) Palpable mass in RUQ
In Sickle Cell disease, what is a common finding on peripheral smear?
*Howell-Jolly bodies (nuclear remnants of RBC normally removed by functional spleen) --> due to recurrent splenic damage and decreased function, can't remove these from RBCs
What is Metoclopramide used to treat?
Prokinetic agent used for nausea, vomiting, gastroparesis
Dopamine receptor blocker (antagonist - like antipsychotics)
**EPS --> dystonia
What is Metoclopramide used to treat?
Prokinetic agent used for nausea, vomiting, gastroparesis
Dopamine receptor blocker (antagonist - like antipsychotics)
**EPS --> dystonia
Besides Barrett's, what is another complication of GERD?
Esophageal strictures --> progressive dysphasia to solids without wt loss
Circumferential narrowing of distal esophagus
Person has itching all over her body and when pooping takes forever to flush. Also has jaundice, enlarged liver and spleen. There is also elevated ALP, bilirubin, and (+) anti-mitochondrial antibodies. What is it and what other eye finding can be present?
Primary biliary cirrhosis (PBC)
*Xanthelasma (eye cholesterol deposits) and xanthomas
Person has itching all over her body and when pooping takes forever to flush. Also has jaundice, enlarged liver and spleen. There is also elevated ALP, bilirubin, and (+) anti-mitochondrial antibodies. What is it and what other eye finding can be present?
Primary biliary cirrhosis (PBC)
*Xanthelasma (eye cholesterol deposits) and xanthomas
How to distinguish Fe-def anemia from Thalassemia?
Thalassemia: NORMAL RDW, low RBC count
**Peripheral smear: Target cells, Teardrop cells
Fe-def anemia: HIGH RDW, low RBC count
What electrolyte deficiency causes weakness, fatigue, muscle cramps in addition to broad flat T waves on EKG?
Painless jaundice with elevated conjugated bilirubin is what until proven otherwise?
Pancreatic cancer or biliary tract cancer
Person has TB and is taking isoniazid, rifampin, and pyrazinamide. He develops red urine. What is the cause?
Rifampin --> causes Red coloration of body fluids
What is the test of choice to diagnose lactose intolerance?
Hydrogen breath test
38 yo man has 6 mo history of persistent and progressively worsening knee and shoulder pain. He was recently diagnosed with diabetes. He has mild hepatomegaly on exam and knee joints are swollen and tender. LFTs are normal. Knee and shoulder X-rays show chondrocalcinosis. What do you suspect? Next best step?
**Pseudogout associated w/ hemochromatosis
**Recent onset of diabetes
Also can have hyper pigmentation, dilated cardiomyopathy
Next best step --> serum iron studies (increased Fe and transferrin, ferritin)
Person found to have MALT lymphoma without any evidence of metastasis. What is the association with this? What is treatment?
H. pylori associated with MALT lymphoma
*If you treat the H. pylori --> the MALT lymphoma will usually resolve!
Tx: PPI, clarithromycin, amoxicillin
After a bout of pancreatitis, a person develops an epigastric mass that radiates pain to the back. Vitals are stable. Serum amylase is up to 308. What is the likely diagnosis? Tx?
*Fibrous capsule containing inflammatory enzymes, including amylase, and when it ruptures it releases these into the bloodstream
Tx: most resolve spontaneously
What are signs suggestive of Zenker's diverticulum?
What is a potential complication?
Test of choice?
Dysphagia, REGURGITATION of food, HALITOSIS, occasional palpable neck mass
*Aspiration pneumonia (R lower lobe)
Test of choice: contrast esophagram (barium swallow)
Man presents with unremitting nose bleeding. He had similar bleeding episodes in the past. He has several ruby-colored papillose on his lips that blanch partially with pressure. Digital clubbing is present. His Hct is elevated and platelet count is normal. What is causing his bleeding?
AVM in lungs --> shunt blood from R --> L heart in lungs without oxygenation --> causes chronic hypoxemia and a reactive polycythemia
**Osler-Weber-Rendu syndrome (hereditary telangiectasia)
1) Diffuse telangiectasias
2) Recurrent epistaxis
3) Widespread AV malformations
What deficiency is manifested by hair loss, bullous and pustular lesions around the mouth and eyes, and a strange taste when eating foods?
What other systemic diseases can precipitate this deficiency?
*Any malabsorption conditions (Crohns) --> zinc is absorbed in the jejunum
What common findings are seen in people with anorexia?
**Osteoporosis (decreased estrogen from HPA abnormalities)
Elevated cholesterol and carotene levels
Prolonged QT interval (arrhythmias)
Euthyroid sick syndrome
HPA dysfunction --> anovulation, amenorrhea, estrogen deficiency
Hyponatremia from excess water drinking
Person in hospital is being treated for DVT. On the 6th day, they develop a cold R upper extremity with no pulse in that arm. The platelets have dropped significantly from admission and aPTT is elevated. What is the cause?
Heparin-induced thrombocytopenia --> from unfractionated heparin use
**Elevated aPTT and thrombosis
Antibodies to platelet factor 4 + heparin --> IgG binds to this complex --> causes platelet aggregation, thrombocytopenia, THROMBOSIS usually 5-10 days after staring heparin
What physical manifestation is seen in malignant hypertension?
What disease is characterized by recurrent oral ulcers, recurrent genital ulcers, anterior uveitis and skin lesions?
Common cause of B12 deficiency associated with autoimmune diseases such as thyroid disease and vitiligo, shiny tongue, and shuffling gait?
What signs are seen in Addison disease?
Dark brown discoloration of the colon with lymph follicles shining through as pale patches - what is this?
*Look for healthcare worker
What condition is characterized by PAINLESS blisters (hands), increased skin fragility on the hands, facial hypertrichosis, and hyper pigmentation?
What meds is it associated with?
What medical condition is it associated with?
Porphyria cutanea tarda
Ethanol, OCP --> trigger it
What vitamin deficiency is commonly seen in alcoholics?
What signs are seen with Vit D overdose?
Hypercalcemia --> abdominal pain, constipation, polydipsia, polyuria
Vit D increases Ca gut absorption
What condition can give you Marfan-like body habitus?
How do you differentiate it from Marfans?
*Fair skin & eyes
Risk factors for osteoporosis?
*Alcohol consumption (excessive)
54 yo woman presents with dizziness and palpitations with exertion. Her feet feel "numb" and are less sensitive to cold. She has pale conjunctiva and a shiny tongue. Ankle reflex is decreased b/l. Labs show megaloblastic anemia. What is it? What should be monitored for long-term complications?
Pernicious anemia (Vit B12 def)
**Glossitis (Shiny tongue)
Person has fragmented RBCs on peripheral smear with low Hb. They also have low platelets and elevated BUN & creatinine. Headaches and confusion are present. PT is normal. What is it? What is treatment?
1) Hemolytic anemia
2) Low platelets
3) Renal failure
4) Neuro symptoms
Deficincy in ADAMTS-13 (normally cleaves vWF units) or autoantibodies --> have large vWF multimers that cause platelet aggregation
*Tx: Plasmapheresis (removes the autoantibodies)
In a person with transient monocular vision loss (amaurosis fugax), what 3 conditions must you assume?
Emboli from carotid atherosclerosis (older people)
Emboli from heart (AFib)
Fibromuscular dysplasia (younger women)
Anyone, even pregnant women, with a seizure and problems moving an arm?
Posterior shoulder dislocation
27 yo female presents with very dark yellow urine and her boyfriend believes she is "more moody than usual." She has yellow sclera, spider nevi, rigidity, and tremor at rest. Slit-lamp shows greenish brown deposits around both corneas. Liver is enlarged with irregular edge. What is it?
Hepatolenticular degneration (Wilson disease)
*Copper leaks from injured hepatocytes into the blood to be deposited in various tissues (basal ganglia/hepatolenticular and cornea)
66 yo has 4 wk hx of increasing back pain and severe constipation. He has also been urinating excessively. He has no weakness or sensory loss. Only meds are Tylenol and metoprolol. Occult blood is (-). Hb is 9.5, BUN 28, Cr 1.9, and ESR is elevated. What is the cause for his constipation?
*Causes polyuria, constipation, confusion, anorexia, weakness
**Multiple myeloma --> remember CRABBI
Back pain, anemia, renal dysfxn, elevated ESR
Bone lytic lesions
Infections (less Ig)
Person has signs of intravascular hemolysis (low haptoglobin, low Hb, elevated bilirubin) and low platelets and WBCs. They have evidence of enlarged liver from hepatic vein thrombosis. What is the cause?
Paroxysmal nocturnal hemoglobinuria (PNH)
**Increased risk of thrombosis (cerebral or abdominal)
Flow cytometry for ABSENCE of CD55/CD59
62 yo male has increasing fatigue and weakness for past 4 months. Has a dull pain in back and arms that is worse with walking, but no paresthesias or numbness. There is lumbar spine tenderness. His labs show normal WBC count, low Hb and Hct, and low/normal platelets. What must you consider?
What would you see on peripheral smear?
What would you see in urine?
What about bone marrow exam?
Rouleux formation (stacked RBCs)
Bence-Jones proteins (Ig light chains)
Plasma cell over proliferation
**Lytic bone lesions (back pain)
**Bence-Jones proteins in urine (light chains)
How does aspirin affect acid-base relationships?
Mixed acid-base disturbance
Resp alkalosis --> aspirin (+) medullary resp center to INCREASE ventilation = decrease pCO2
Metabolic acidosis --> uncouples oxida phos and causes buildup of organic acids
What is classic triad for splenic abscess?
What other s/s can be present?
What cardiac pathology is associated with this?
Fever, high WBC count, LUQ abd pain
L-sided pleuritic chest pain, L pleural effusion, splenomegaly
What medications are associated with increased risk of pancreatitis?
56 yo develops oliguria 3 days after having a kidney transplant. BP is 160/100 and his serum Na 145, K 5.5, Cr 3.2, BUN 30. Cyclosporine levels are normal. Biopsy of the transplant shows heavy lymphocyte infiltration and vascular involvement with swelling of the intima. What is the best treatment?
*Oliguria, HTN, and increased Cr/BUN
Most common cause of painless GI bleeding in elderly patients?
What is a risk factor?
Best treatment for hemodynamically stable pancreatitis?
IV fluids, analgesics, NPO
What blood condition results in normocytic anemia, high reticulocyte count, and *high MCHC* with jaundice and splenomegaly?
Test to confirm?
Eosin-5-maleimide binding + acidified glycerol lysis test
What vitamin deficiency is characterized by diarrhea, nausea, large tongue, hyper pigmented rash and poor concentration, irritability, or dementia?
Person with heparin-induced thrombocytopenia, what is the appropriate course of action?
Stop ALL heparin products
Switch to alternative agent (agatroban)
What is the step-wise approach for treatment of ascites?
1) Fluid/Na restriction
3) Loop diuretics (not more than 1L/day of diuresis)
4) Frequent abdominal paracentesis (2-4 L/day if renal fxn is ok)
What other GI disease is associated with UC?
Primary sclerosing cholangitis
Deficiency in hereditary angioedema?
C1 inhibitor deficiency
Person on chemotherapy develops peaked T waves on EKG. Ca gluconate is given. What additional tx will help immediately lower his K?
Insulin + glucose --> drives K intracellularly
Man has R-sided varicocele that does NOT empty when recumbent. What must you consider? What lab findings would be seen?
Renal cell carcinoma
Polycythemia --> increased Hb/Hct, platelets
What triad of symptoms is multiple myeloma until proven otherwise?
Bone pain (back/chest pain)
Renal failure (elevated BUN/Cr)
Also have anemia
What disorder is characterized by bite cells and RBC inclusions?
No G6PD = no creation of NADPH --> no glutathione which normally prevents oxidation of hemoglobin --> Hb denatures as it's oxidized into Heinz bodies
Common findings in primary biliary cirrhosis?
Lab finding diagnostic for PBC?
S/S: Pruritus, large liver, xanthomas (eye/skin/tendons), xanthelasmas
*Tx: Ursodeoxycholic acid (slows disease progression and relieves symptoms)
Man found to have elevated serum protein with normal albumin levels. Further workup showed monoclonal paraprotein band on serum protein electrophoresis. Several days later, repeat urine protein electrophoresis shows NO monoclonal protein. What is the best next step in mgmt?
MGUS --> NO anemia, hypercalcemia, or renal insufficiency
18 yo African American man has 3 day hx worsening fatigue and exertional dyspnea. He had mononucleosis 2 weeks ago. Spleen is enlarged and mild scleral icterus is present. Labs show anemia with normal MCV and high reticulocytes. What else is likely to be seen on testing?
What other conditions would have this same finding?
(+) Direct Coombs test --> COLD agglutinin AIHA
*CLL, EBV mononucleosis, SLE, Mycoplasma (walking pneumonia), penicillin
In person with chronic kidney disease, what treatment is needed for anemia?
What else must be given to also prevent anemia?
Erythropoietin --> stimulates progenitor cells in the bone marrow to create more RBCs --> surge in iron usage --> can cause rapid depletion in body's iron stores
Person has chronic diarrhea and fecal fat content that is increased. D-xylose test shows decreased urinary excretion before and after Abx treatment. What is the cause?
Celiac disease --> D-xylose is monosaccharide that requires intact mucosa for absorption
What is commonly found in the MIDDLE mediastinum?
MIDDLE --> bronchogenic cysts
ANTERIOR --> thymoma
POSTERIOR --> neurogenic tumors
43 yo man with hx of allergic rhinitis and childhood eczema has chest pain with ST depression in lateral leads. Treated with aspirin, clopidogrel, LMWH, metoprolol, and lisinopril. On day 2 of hospitalization, has SOB w/ prolonged expiration and b/l wheezes. What is most likely cause of respiratory s/s?
Medication side effect from either aspirin or B-blocker
*Aspirin --> causes bronchoconstriction (asthma) in people with chronic rhinitis and nasal polyps
*B-blocker --> non-selective can trigger bronchoconstriction (B2 blockade)
12 yo girl with L sided ear drainage that has persisted for 3 weeks despite antibiotics. She also has L sided hearing loss. There is peripheral granulation and some skin debris on otoscopic exam. What should be considered?
*Continued ear drainage for several weeks despite Abx therapy + hearing loss*
Chronic middle ear disease leads to formation of retraction pocket in the TM which can fill with granulation tissue and skin debris.
Most common cause of death in general population AND dialysis patients?
22 yo male develops resting tremor, muscular rigidity, and clumsy gait in addition to slurred speech. He has mild liver enlargement. He anemia and elevated LFTs. Liver biopsy shows inflammation and portal fibrosis with hepatocellular necrosis. What are you suspecting? How do you verify?
Wilson's disease --> liver, neuropsych (basal ganglia)
*Ceruloplasmin (low) + slit-lamp for Kayser-Fleischer rings
Person has episodic abdominal pain that wakes him at night and is relieved with glass of water and piece of bread. He experienced an occasional "dark stool." Vitals are stable. What is best option for long-term symptoms relief?
H. Pylori gastritis
Antibiotics + omeprazole
*(Amoxicillin + clarithromycin) + PPI
Other extracolonic findings in UC?
*Erythema nodosum (painful, red nodules over extensor surfaces)
*Arthritis --> similar to ankylosing spondylitis
*Cholangitis --> elevated ALP
What findings are classic in TTP?
Hemolytic anemia --> indirect hyperbilirubinemia, normocytic anemia, high reticulocytes
Renal failure --> elevated BUN + Creatinine
Altered mental status
Man has easy fatiguability for several months. He is a vegetarian and drinks alcohol daily. Hb is 10.8 and is given thiamine and folic acid daily. After several months, he reports recurrent falls and increasing forgetfulness. What is the most likely finding at this point?
Loss of proprioception in LE
*B12 deficiency --> giving folic acid will correct the megaloblastosis but NOT the neurologic effects
What should be suspected in any person with malabsorption and Fe-def anemia?
Why will anti-tissue transglutaminase antibodies or anti-endomysial antibodies be absent in some cases?
*May be concurrent IgA deficiency --> these specific antibodies will be ABSENT
*If the intestinal biopsy shows villous atrophy = celiac
What feature is most characteristic of Crohn's vs UC?
Non-caseating granulomas in Crohn's
Most common causes of folic acid deficiency?
Medication-induced causes of folic acid deficiency?
Poor diet OR alcoholism
Phenytoin (impaired absorption of folic acid)
Methotrexate, TMP-SMX (both block folic acid physiologic effects - blocking dihydrofolate reductase)
Why is hematuria the most common renal finding in sickle cell patients?
Isosthenuria --> sickling of RBCs block the vasa recta to renal papilla, causing impairment of countercurrent exchange mechanism in kidney --> painless hematuria
What is common complication of upper endoscopy?
How to verify?
*Water-soluble contrast esophagram --> does NOT irritate the pleura (contrast does)
25 yo African male has nocturnia over past several months despite increasing fluid intake. Had recurrent OM as a child. Urinalysis shows no proteinuria or sediment abnormalities. What is the nocturnia from?
Sickle cell disease --> hyposthenuria (RBC sickling in the vasa rectae from the inner medulla --> impairs countercurrent exchange and free water absorption)
47 yo man with several months of lethargy and decreased libido. Has OA and DM diagnosed 1 yr ago. Exam shows mild hepatomegaly and testicular atrophy. What cardiac abnormality is most likely to be present?
Conduction abnormalities, restrictive/dilated CM
*Hypogonadism (testicular atrophy, decreased sexual drive)
Best tx for sickle cell disease in the acute setting?
Exchange transfusion (decrease % of sickled cells in circulation)
Best step in hypothermia?
What treatment is given to people who do NOT want elective cholecystectomy?
Ursodeoxycholic acid --> decreases cholesterol content of bile by reducing hepatic secretion and intestinal reabsorption of cholesterol
25 yo female comes for preconception counseling. Her grandparents are from Greece and her husband's family is Mediterranean descent. Her mother and sister have been diagnosed with anemia. Thalassemia anemia is suspected. What is the most appropriate initial screening test?
CBC --> determine hemoglobin concentration
*If anemia is present + reduced MCV = further testing
Mechanism behind hemophilia causing joint damage?
Iron/hemosiderin deposition in joint space leading to synovitis and fibrosis within the joint
Why would a person with RA receiving treatment have a macrocytic anemia?
Methotrexate --> folate antimetabolite (blocks utilization of folate in cells)
Metformin should NEVER be given in what situations?
Acute renal failure, liver failure, sepsis --> risk of lactic acidosis