Internal Medicine Shelf Flashcards
(338 cards)
0
Q
When are nitrates contraindicated (3)?
A
RV Infarction (preload dependent)
Aortic Stenosis
PDE-i use
1
Q
PFTs in Obstructive + Restrictive Disease
A
Obstructive
Low FEV1/High FVC (trapped air) <70%
Restrictive
Low FEV1/Low FVC >70%
2
Q
2 Tests to Differentiate Asthma vs. COPD?
A
Bronchodilator Test (Asthma =improves) DLCO (low in COPD)
3
Q
Acid Base Values for ASA Toxicity:
- pH, PaCO2, HCO3
- PaCO2 actual vs. expected?
- Mechanism of Metabolic Acidosis (3)
A
- pH nl, PaCO2 low (stimulates resp) and HCO3 low
- PaCO2 actual < expected (via Winters) b/c ASA will itself lower PaCO2 in addition to the metabolic requirement for compensation
- 3 Mechanisms: Inhibits renal function (retain acid), uncouples OxPhos (fever) and inhibits enzymes in CHO/lipid metabolism
4
Q
SBP
- Presentation
- Next step/diagnosis?
A
- Presentation: cirrhotic with AMS + fever
- Next step: diagnostic para looking for:
1. +Fluid Cx
2. >250 cells
5
Q
First step in any ACS is…
A
Give ASA (inhibits TXA2 = low risk for Adverse Event). EKG is first best test for any chest pain btw
6
Q
Heart Block
- Type 1
- Type 2
- Type 3
- All cause _____
- The MCC of ____ is Type 3
A
Type 1: >0.2 s of PR interval
Type 2:
- Mobitz 1: increase PR with dropped beat, low risk of bradycardia
- Mobitz: no PR change with dropped beat, high risk of bradycardia
Type 3:
- Complete loss of atria–ventricular conductivity, MCC bradycardia
All cause bradycardia
MCC = Type 3 Heart Block
7
Q
HIV Rx ADE: give class and name
- NRTIs in general
- NNRTIs in general
- Indinavir
- Didanosine
- Abacavir
- Nevirapine
- Efavirenz
- Zidovudine
A
NRTI = lactic acidosis NNRTI = SJS Indinavir = protease inhibitor = crystalline nephropathy Didanosine = pancreatitis (NRTI) Abacavir = hypersensitvity (NRTI) Nevirapine = NNRTI = liver failure - Efavirenz: sleepy confused - Zidovudine: leukopenia
8
Q
PEA
- Causes (5+5)
- Management
- Never used…
A
Causes
- 5 Hs: Hypovolemia, Hypothermia, HypoK/HyperK, H+ (Acidosis), Hypoxia
- 5 Ts: thromboembolism, trauma, tamponade, tension pneumo, toxin
Management: CPR + Epi (no role for DC/defib)
9
Q
Horny plates on extensor surfaces of limbs in a 20 y/o female who had normal skin at birth?
A
Ichthyosis
10
Q
Acetaminophen Ingestion Protocol
A
- Activated charcoal in 1st 4 hours
- First plot on Rumack-Matthew nomogram in 1st 4 hours
- After 1st plot +/- NAC
11
Q
Mediastinal Masses
A
Teratoma, Thyroid, Thymoma and Terrible Lymphoma
12
Q
Teratoma Includes what 5 Tumors
A
Germ Cell Tumors
- Seminoma (high hCG, nl AFP, all other have high AFP)
- Yolk Sac
- Embryonal
- Mixed Germ Cell Tumor
- Choriocarcinoma
13
Q
PPD Indurations
A
> 5mm + HIV/IC, Recent Contact with TB+, +CXR for TB
10mm + Immigrant, Jail Worker, <4 y/o, CKD/DM
15mm + Everyone else
14
Q
What happens in an HIV+ patient has a PPD of 6 mm and a negative CXR?
A
9 months of INH + Pyridxoine
- Remember INH also can cause liver toxicity, watch LFTs!
15
Q
MC Type of Stone and it’s shape?
A
CaOx = envelope
Cystine (“Sixstine”) = hexagonal (6 sides)
16
Q
Giardia
Entomoeba
Cryptosporidium
A
Giardia: trophozite in bad water adheres to bad wall and causes malabsorption foul/floating/fatty diarrhea
Entomoeba: flask shaped ulcers, liver anchovie paste, bloody diarrhea
Cryptosporidium: watery diarrhea in IC patients with AFP stools
17
Q
Ascending Cholangitis
- Triad/Pentad
- First line treatment
- If first line fails
A
- Charcot Triad: fever, RUQ pain, Jaundice
- Reynold’s Pentad: hypotension + AMS
- First Line: Fluids + Broad Spectrum IV Abx
- If fails, ERCP for biliary tree decompression
18
Q
Per ATP guidelines:
- CHD Equivalents
- Risk Factors
A
- Equivalents ABCD
AAA, Bad Peripheral Arteries, Carotid Artery DZ, DM - Risk Factors ABCDE
Age (45/55), BP >140/90, Cigarettes, hDl, familE h/x
19
Q
Disease where emergency plasma exchange is Tx?
Disease where emergency transfusion is Tx?
A
Goodpastures
Sickle Cell Disease
20
Q
MCC Outpatient HyperCa
MCC Inpatient HyperCa
A
HyperPTH = out Malignancy = in
21
Q
Patient with high Ca, low phosphate and low PTH with back pain
- Diagnosis
- Initial Treatment
- Long term of sarcoid mediated hyperCa
- Long term treatment of primary hyperparathyroidism
A
Dx: HyperCa of Malgiancny (PTHrP)
Initial Tx: Saline (if hypovolemic) +/- calcitonin
Long term treatment of sarcoid mediated: steroids
Long term of primary hyperPTH = bisphosphonate
22
Q
4 Lab Findings representing metabolic complications of hypothyroidism
A
- High lipids/cholesterol
- HypoNa
- Elevated CPK
- Elevated LFTs
23
Q
Solitary Pulmonary Nodule Definition and W/u
A
Definition: <3cm nodule surrounded by normal lung
-Low Risk (<40y/o nonsmoker): ask for old imaging. If no change in last 12 months –> serial CXR q3x12mo
-High Risk (>40y/o smoker): immediate CT +/- biopsy
24
4 Indications for home O2 in COPD
PaO2 <55
HCT >55
SaO2 <88%
Cor Pulmonale
25
Hemochromatosis patients increases risk of infection from...
1. Listeria
2. Yersinia
3. Vibrio
26
Alcoholic Liver Disease Pathology
- Stages
- Buzz words for 2nd stage
- How much damage can binge drinking do?
- Reversible vs. not
Stages
- Steatosis ---> Alcoholic Hepatitis ---> Fibrosis
- Alcoholic Hepatitis Buzz Words: PMNs, Mallory Bodies (like mallory weiss!) and perIVENULAR fibrosis
- Binging can cause steatosis
- Reversible even in early fibrosis; nodular fibrosing disease is irreversable
27
MCC Painless Hematuria?
Bladder Cancer
28
Hematuria Timing:
- Initial Hematuria
- Terminal Hematuria
- Total Hematuria
```
Initial = urethritis
Terminal = bladder cancer
Total = kidney/ureter disease
```
29
Rotator Cuff Damage
- Best Test
- DDx and how to tell them apart
- Best Test = MRI Shoulder
| - DDx: Tear vs. Tendinitis/Impingement. Inject lidocaine, which will make the latter better
30
Give Findings Associated with:
- Vitreous Hemorrhage
- Retinal Detachement
- CRVO
- CRAO
- Macular Degeneration
- Choroidal Rupture
- Vitreous Hemorrhage: sudden onset floaters with difficulty seeing fundus in patient with proliferative diabetic retinopathy (exudates)
- Retinal Detachement: sudden onset of flashes of light
- CRVO: venous congestion, dilated tortuous veins, swollen optic disks and cotton wool spots
- CRAO: pale optic disk, cherry red fovea, boxcar veins
- Macular Degeneration: loss of central vision and distortion of lines b/l in patient with
- Choroidal Rupture: trauma with crescent shape around optic nerve
31
Patient with CRAO is a MEDICAL EMERGENCY. Why and whats the management?
Why? Associated with ocular stroke
| Mgmt? Ocular massage + Hyperbaric O2
32
Dendritic Ulcers?
HSV Keratitis = MCC CORNEAL Blindness in USA
33
Classic Presentation with Open Angle Glaucoma
- Underlying Pathophys
- Treatment
AA initially ASx with progressive loss of peripheral vision ---> progresses to tunnel vision
Pathopys: increased IOP ---> cupping of optic disk ---> loss of peripheral vision
Treatment: Tinolol (Block Beta = no dilation so no drainage occlusion; also loss of beta stimulation = decreased production of trabecular fluid)
34
ARDS = acute respiratory distress with what 3 criteria:
1. PaO2/FiO2 <200
2. B/l Fluffy CXR
3. PCWP <18
35
Mechanism of Acute GvHD
DONOR T cells attack against pre-formed antigens on skin, GI and biliary tree (vs. hyperacute = preformed ab)
36
(T/F) Crypt Abscesses are common to both UC + CD
True
37
Serous Otitis Media
- Who gets it?
- What part of the ear?
- Presenation?
Who: HIV
Middle ear infection
Presentation: HIV+ Patient with hypomobile TM and conductive hearing loss 2/2 HIV induced lymphadenopathy
38
Patient p/w waxing and waning LFTs. Diagnosis?
Chronic Hepatitis C
39
DM management that slows down MACROVASCULAR disease.
LDL<100
| BP< 130/80
40
Formula for Aa Gradient?
PAO2 = .21(760-47) - PaCO2/0.8
41
Dipyramidole
Can use in non-exercise stress test with Adenosine, as both dialte the healthy coronary arteries and steal blood from bad coronaries
42
Observer Bias
Occurs when INVESTIGATOR is made aware of the EXPOSURE
43
Rx for Smoking Cessation
Buproprion = xNE/DA reuptake
| Varenicline: nicotinic AcH partial agonist (little hit!)
44
MC inherited hypercoag disorder?
Factor V leiden
45
CAP Treatment
- Outpatient
- Patient
- Out: Doxy vs. Azitrho
- In: Moxy > Levo
* Goal is to cover Strep Pneumo and the Atypicals
46
Herpes Zoster
- Cause
- 2 Most important risk factors
- Treatment accomplishes what 2 things
- Cause = reactivation of VZV from zensory ganglion in dermatomes
- Risk Factors = AGE vs. IC Status
- Treatment: lowers duration of symptoms and risk of post-herpetic neuralgia
47
Best management for patient with ST-elevation MI?
- Time limit
- Even better than thrombolytic?
- What if not available to cath?
PCI = percutaneous Angioplasty
- Time Limit = 12 hours
- YES better than thrombolytic = lower 30 day mortality in STEMI
- If no cath is available, give the thrombolytic therapy
In summary, management of MI = PCI or thrombolytic with PCI>Thrombolytic
48
Contraindications to thrombolytics?
H/o Intracranial Bleed
H/o Ischemic Stroke
Active Bleed
Aortic Dissection
49
Pt p/w acute hypotension, clear lung fields and elevated CVP. What is the best next step in management?
IV NS
| Triad is classic for acute RHF. These patients are preload dependent!
50
Management of patient with chronic stable angina requires... (2)
Anti-Anginal Agent
- Beta blocker > CCB > Nitro
Vasoprotective Agent
- ASA, ACE-I, statin
51
Worsening chronic stable angina in a patient with high BP and high HR?
increase metoprolol
52
When do you cath a patient with chronic stable angina?
When maxed on medical management
53
Adenosine stress test is CI in what patients?
Asthmatics = causes bronchoconstriction
54
Murmur in 1st week after MI DDx?
Papillary Rupture
| VSD
55
Man with alzheimer's dementia comes in with bradycardia. Mechanism?
Donepezil is an AcH-ase inhibitor = AV block 2/2 increase AcH/vagal tone.
56
Approach to treating Afibb (2)
1. Control Rate vs. Rhythm
- Rate: control the RVR to Afibb = beta blocker
- Rhythm: control the Afibb
2. CHADS2 to add ASA +/- Warfarin
57
EF criteria for implantable cardioverter defbirillator?
EF <35%
58
Best next step for new onset heart failure?
Cardiac Angio
*NOTE: this isn't he same question for new onset chest pain
59
3 Types of Hypopigmentation
1. Albinism = defective enzyme, nl #melanocytes
2. Vitiligo = AI destruction, low #melanocytes
3. Piebaldism = Inherited absence of melanocytes, low #
60
Low PTH + High Ca, what 3 labs are important?
- PTHrP = malignancy
- 1,25 OH2 VItD3 = Sarcoid/Lymphoma
- VitD = VitD Toxicity
61
HTN:
+HyperCa
+Brachiofemoral Delay
+HypoK
MEN Syndrome
Coarctation
Hyperaldosteronism (Primary)
62
Define Persistent HTN
≥3 anti-HTN medications do not resolve the HTN
63
Features of Renovascular HTN
*Note although this causes 2nd Persistent HTN like RAS, this is not the same thing as renal artery stenosis (which can be congenital)
- Diffuse atherosclerosis = PAD/CAD
- Recurrent Flash Pulm Edema
- Increase in SCr when started on ACE-I
64
HBV Titers
```
HBsAg = infected
AntiHbsAg = immune (vaccinated/h/o infection)
```
```
HbEAG = infective
Anti-HbEAG = low infectivity
```
AntiHbcAg - IgM = acute infection
AntiHbcAg - IgG = chronic
65
Which is the only one present in window period?
Anti-HbcAg IgM
66
Serology for Patient with:
```
Acute HBV
Window Period
Chronic HBV with high Infectivity
Recovered
Immunized
```
Acute HBV: HBsAg, HBeAg, IgM AntiHbCAg
Window: IgM Anti-HBcAg
Chronic HBV, high ifnectivity: HbSAg, HBeAg, IgGAntiHBcAG
Recovery: Anti-HBSAg, Anti-HbE, Anti-HBcAG IgG
Immunized: Anti-HBsAg
67
Nephrotic Syndromes
Nephritic Syndromes
Both Syndromes
Nephrotic: MCH, MGN, FSGS, DM
Nephritic: APSGN, Alports, IgA, RPGN
Both: DPGN, MPGN (1+2)
68
Describe:
- Dermatitis Herpetiformis
- Erythema Multiforme (General vs. Major vs. Minor)
- Acanotholytic Dermatosis
- Dermatitis Herpetiformis = extensor surfaces vesicular rash in Celiac's disease = +Endomysial Antibody; icnreased risk for gastric lymphoma
- Erythema Multiforme = central clearing in symmetric TARGET lesions
* *EM Major = SJS if <10%, TEN>30% but have to have 2+ mucosa sites
* *EM Minor = no mucosa
- Acantholytic Dermatotiss = Grover's Disease = hyperkeratotic papules on chest/back/upper rib cage
69
Zenker's
- Pathophys
- Diagnosis
- Treatment
Pathophys = incoordiation of UES/LES leads to pulsion herniation of esophageal mucosa
- Diagnosis = barium swallow
- Treatment: excision/myomectomy
70
Ankylosing Spondylitis
- Under what class of diseases?
- Presentation (time of day, location of pain)
- 2 MC Extraarticular Finding
- Diagnosis*
- Seronegative= -FANA/-RF
- Presentation = AM stiffness, lower back limited ROM and sacroilitis
- 2MC Extraaritcular = Anterior Uveitis, Enthesitis (tendons attach to ligament inflammation)
- Diagnosis: requires plain film evidence of joint dysfunction = fusion of sacroiliac joint vs. bamboo spine (apophyseal joint arhtiriis)
B27 does not make diagnosis!
71
First and 2nd management step in SIADH
Fluid Restriction ---> Hypertonic Saline (or salt tablets with loop diuretics)
72
Drug that causes the following:
- Hemorrhagic Cystitis/Bladder Cancer
- Cochlear Dysfunction (3)
- Optic Neuritis
- Raynaud (2)
- Gout
- Hemorrhagic Cystitis/Bladder Cancer: cyclophos
- Cochlear Dysfunction (3): loops, aminoglycosides, cisplatin
- Optic Neuritis: ethambutol
- Raynaud (2): beta blocker (increase alpha) , ergots
- Gout: cyclosporin
73
What drug is a moitolin receptor agonist?
Erythromycin
74
Management of:
- Single brain met
- Multiple brain mets
- Single: Surgery + whole brain radiation
| - Multiple: Palliative + whole brain radiation
75
22 y/o with FEV1 <80% and FVC > 80% will have what + in liver biopsy?
PAS+ cells representing undersecreted alpha1 antitrypsin (recall this is acute phase reactant)
76
Effect Modification vs. Confounding
Effect Modification = has effects on JUST the OUTCOME
Confounding = has effects on the EXPOSURE AND OUTCOME
Ex: Smoking ---> PO Cancer; alcohol is confounder b/c smokers drink and b/c drinkers get PO cancer
Ex: Estrogen ---> DVT; smoking is effect modifier b/c smokers don't have different estrogen levels, while they do get DVTs
77
Asthma Classes + Definitions + Treatments
DRAW
78
Celiac Sprue MC Presentation
Fe Deficiency Anemia 2/2 inability to absorb Fe in the duodenum
79
ITP Treatment
>30 K = Observe
| <30K or Bleeding = Steroids
80
Vanishing Duct Syndrome
- Definition
- MCC
Definition: loss of intrahpeatic bile ducts
MCC: primary biliary cirrhosis
81
MCC Skin Cancer in USA and MC Location
Basal Cell Carcinoma, MC location is eyelid
82
Chalazion
Hordeolum
Acrochordon
Chalazion: painful swelling ---> rubbery nodule = chronic granulomatous disease 2/2 obstructed meibomian (tarsal) glands; all require biopsy b/c risk of meibomian gland carcinoma
Hordeolum: style 2/2 infection of eyelid glands
Acrochordon: skin tag "added on"
83
UTI symptoms in male with boggy prostate. Next best step?
Mid-catch urine for culture to determine source of PROSTATITIS
84
4 Ways to Dx Type 2 DM
1. Fasting plasma Glu >126 x2
2. Random >200 with signs/symptoms of DM
3. 2hr OGTT >200
4. A1C in VENOUS blood >6.5
85
Non-proliferative vs. Proliferative Diabetic Eye Optho Findings
Non-Proliferative = Hard Exudates/hemorrhages
Proliferative = vessels + cotton-wool
86
Types of Insulin from Short ---> Long Acting
```
Shortest = GAL = Glulisine, Aspart, Lispro
Then = Regular Insulin
Then = NPH
Then = Levemir/Glargine
```
87
What insulin management type reduces risk of hypoglycemia?
Basal Long Acting + HS Short Acting
88
4 Tests to Dx DKA
ABG, SERUM Ketones, Serum Glucose and Electrolytes
89
Pt p/w signs/symptoms of Hashimoto's. What is the next best step?
Start Levothyroxine; anti-TPO Ab are NOT needed to make the diagnosis
90
FNA all thyroid nodules >____
1cm
91
When is thyroglobulin a good test to order?
Thyroglobulin = presence of follicular cells. Great test for RESIDUAL thyroid after THYROIDECTOMY or I-131 treatment.
92
Hypothyroid patient on Levo becomes pregnant. What's the next best step?
Check thyroid studies; recall that Estrogen = increases TBG. TBG binds free T4; total t4 won't change, free will. May need to increase levothyroxine 30-50%!
93
51-year-old woman is evaluated in the office following an emergency department visit for abdominal pain. The pain spontaneously resolved. A CT scan in the emergency department revealed an incidentally discovered 1.4-cm left adrenal nodule with smooth borders and low attenuation and vascularity. Next best step.
Plasma free metanephrines + overnight dexamethasone suppression test
94
3 Components to treating someone with t = -2.6 on DEXA?
Vit D, Ca and Bisphosphonate
95
MoA and benefit of bisphosphonate
MoA = pyrophsophate that inhibits osteoclastic bone remodeling
Reduces fracture risk in osteoporotic patients
96
What if patient cannot handle PO (ADE, CI?)
Give once yearly IV zolendronate which can last for the entire year
97
Most aggressive Skin Cancer?
Squamous Cell = quickly metastasizes
98
DEXA Age Recs by USPTF and T Values
65+ for all, >60 for +risk factors
```
-1.5-2.4 = osteopenia
<-2.5 = osteoporosis
```
99
4 Recs for Patient with Kidney Stones
1. Hydrate
2. Decrease protein/oxalate
3. Decrease Na
4. Increase Ca
100
Use for:
| K-Citrate vs. K-HCO3
Citrate = binds Ca (think about citrate in blood = hypoCa), rec for citrate def only
HCO3 = increase urinary pH good for uric acid stones
101
MCC Back Pain in USA
Lumbosacral Strain
102
For Lumbosacral Strain, Lumbar Spinal Stenosis, Compression Fracture, and Herniated Disk:
- Cause
- Presentation
- Next Step
Lumbosacral Strain: post-exertional pain caused by paraspinous contraction
Compression Fracture: acute pain in osteopenic/porotic with focal point tenderness
LSS: presents 2/2 DJD formation of osteophyte compression when EXTENDING (walking downhill), relieved when FLEXING (walking uphill) --- MRI
Herniated Disk: +straight leg ---> early immbolization + NSAIDs ---> +/- MRI if development of neurologic symptoms. Surgery if presents with significant neuro loss initially
103
Subacromial Bursitis
| - How to diagnose + Describe
NEER SigN: passive internal rotation + forward flexion = PAIN
Definition of this disease is inflammation between acromion + supraspinatus tendon
104
Again, EM Major vs. Minor
```
Major = 2 mucocutaneous sites
Minor = cutaneous only
```
105
Patient has chest pain and >20 mmHg SBP difference in 2 arms.
Aortic Dissection
106
Two Types of Aortic Dissection
- Describe
- Ideal treatment
Stanford A = proximal
Stanford B = distal
```
A = Beta Blocker (Labetalol) --> Surgery
B = Beta Blocker (Labetalol)
```
107
Screening for Cirrhotic Patients
1x Endoscopy for Varices
| q6mo HCC Screening
108
Presbyopia
- Definition
- Presentation
- Tx
Definition = loss of lens elasticity with old age
Presentation = difficulty reading nearby structures
Tx = reading glasses
109
Cutaneous Larva Migrans
- Location in World
- Type/name of bug
- Host
- Located mainly in SE USA
- Caused by HELMINTH Ancylostoma
- Host = Dog/Cat
110
65 y/o man p/w LLQ pain, fever and leukocytosis.
- best initial test
- best treatment
- Abdominal CT b/c ddx = diverticulitis, colon cancer, pyelonephritis or complication of these 3
- Treatment = IV ABx
111
S/p cardiac catheter patient develops blue toe. What 2 lab findings are assocaited with this?
Low Eosinophils
| Low Complement
112
Best imaging for kidney stone?
Noncontrast helical CT (used to be IV pyelography) b/c detects stones as small as 1 mm as well as R/O other causes of hematuria
113
Next best step for acute abdomen?
Supine + upright abdominal plain films to evaluate for AIR FLUID LEVELS (obstruction) or FREE AIR (viscus). CT will be best eventual diagnostic step, but need a powerful screening test first.
114
Elderly patient with BRBPR has crampy pain and diarrhea. CT shows SEGMENTAL THICKENING of SIGMOID COLON. Dx? How would this change if 45 y/o?
Dx = ischemic oclitis
| Would be Crohns in younger patinet
115
LLQ + Fever + Leukocytosis. Next best step?
Diverticulitis ---> Contrast CT
*Colonoscopy / Barium increase risk for perforation and would miss the extraluminal complications (perf, obstruction, fistula, abscess)
116
Radiation Proctitis
- Timeline
- Diagnosis
Timeline: usually <6weeks of radiation therapy
Diagnosis: must visualize the mucosa. Endoscopic of submucosal fibrosis
117
(T/F) Rec Abx for treating salmonella gastroenteritis
False. ABx make shigella better, make salmonella worse
118
- Hepatocellular Injury
| - Cholestatic Injury
- Hepatocellular = AST + ALT AND CB
- Cholestatic = Big ALK PHOS jump
*Mixed = HCV/HBV
119
First step in a person with cholestatic pattern of labs?
ABD USG to evaluate if intra/extra hepatic
120
When to use ERCP +/- sphincterectomy?
Biliary obstruction 2/2 choledocholithiasis
*NOT IN CHOLECYSTITIS (how's that thing going to remove stones from the gallbladder)
121
Acute Cholangitis
- Definition/pathophys
- Presentation
- Treatment
Definition: infection of biliary tree associated with obstruction of CBD
Presents with fever, jaundice and RUQ Pain (+/- Hypotension/AMS)
Treatment: Immediate IV ABx against aerobic/anaerobic bugs --> ERCP with sphincetrectomy to remove impacted stones
122
2 MCC PUD?
NSAID + H. Pylori = always stop the NSAID
123
Patient with vague recurrent GI bleeding and a normal endoscopy 3 months. Next step?
Repeat the endoscopy
124
Ischemic Colitis vs. AMI
- Pain location
- Blood vs. no blood in rectum
- Unique symptoms
- Location = LLQ (ischemic colitis) vs. diffuse
- Blood vs. No Blood: IC will have blood/maroon stool. AMI will have heme+ stool
- Unique Symptoms; IC has urge to defecate, AMI has pain greater than the proportion
125
Treatment of ischemic colitis?
Worried about dead bowel = FLUIDS + ABx
126
Patient p/w bright red emesis. Shock. Next step?
IV Fluids ---> UPPER GI SCOPE to diagnose/endoscopic guided therapy
127
Lower GI Bleeding:
- MCC PAINLESS
- 2 Additional MCC
MCC Painless = Diverticulosis (not itis or else it would hurt) and Angioectasia (=Angiodysplasia = Vascular Ectasia)
2 Other MCC = CRC + Colitis (IBD)
128
Hepatocellular Carcinoma
- MCC
- Best Screening Tool
MCC = Cirrhosis; MCC cirrhosis = chronic HCV/HBV. Note Chronic HBV may skip cirrhosis for HCC
Screening = Ultrasound! (not AFP)
129
2 MC Risk Factors for Hep B?
IV Drug Use
| Multiple Sexual Partners
130
MC Risk Factor for Hep C?
IV Drug Use/Transfusion
131
Patient with PMH Type 2 DM, HLD and BMI 32 develops jaundice, weight gain and elevated LFTs. Dx?
NASH
132
MKSAP Gen Medicine q3: if given the prevalence of disease and sensitivity/specificty - how to find the PPV?
Sensitivity xActual +#Pts = TP Rate
Ex: 1/10,000 = 10/100K have HIV and ELISA is 98% sensitivity = 9.8 is TN rate
Specificity xActual -#Pts = TN Rate
Ex: 99,990 actual -s x 98% = TN Rate
Actual- - True- = False Positive
133
+Likelihood Rations of 2, 5 and 10 increase the pretest probability by...
15, 30 and 45% respectively
134
What is an ROC curve?
When is it used?
What two visual features will tell you which is the best/most accurate test?
ROC - Receiver Operating Characteristics Curve
Used for continuous test results that have cutoff points (AFP, LFTs) and you can compare them by plotting Sensitivity as a function of 1-Specificity
Curves that crowd LUQ (high sensitivity / low 1-specificty = high specificity) and curves with largest AUC
135
AAA Screening
All men 65-75 y/o ever smokers
136
Influenza Vaccine
- Frequency
- Route
Frequency = qYr for all >6mos
Main route is trivalent killed vaccine. Intranasal live attenuated is avaialable for non-pregnant/IC pts 5-49 y/o
137
What is the best endpoint for a cancer screening test?
Cancer-specific mortality
138
Zoster Vaccine Indications
(T/F) Previous zoster/herpes infection is a CI to zoster vaccine.
All >60 non-IC patients
FALSE
139
Tetanus Vaccine Series
Tetanus Booster
Give 2 Doses 4x weeks apart ---> 3rd dose 6-12 months later
Booster is given q5 years, but may be omitted if series occurred in last 10 years
140
3 Screening Tests for Colon Cancer
1. Colonoscopy q10yr
2. Annual Home FOBT
3. Flexible Sigmoidoscopy q5 combined with annual FOBT q3
141
How to evaluate infrequent syncope?
Implantable Loop Recorder
142
Who can get Rx s/p spouse death?
Patients who show MD symptoms for 2 consecutive weeks if it has been ≥8 weeks since spouse's death
143
First step in patient with violent cocaine intoxication?
Lorazepam = decrease cardiac work. Don't give haldol b/c lowers seizure threshold.
144
Best pharm intervention to decrease the frequency of alcohol abuse relapse?
Naltrexone = decrease craving = decrease relapse attempts.
I put disulfram which has not been shown to increase abstinence (b/c it doesn't decrease the craving)
145
IVDU has high fever, ESR and focal back pain. Next steps (3 in a row).
MRI Back
Blood Cx
Antibiotics
Notice how this is same as in meningitis and acute abdomens. Image ---> Cx --> treat
146
3 MCC Cough?
Asthma, Post nasal drip syndrome and GERD
147
2 MCC Hemoptysis in Ambulatory Setting
Next Step?
MCC = Infection (bronchitis/pneumonia) vs. malignancy
All patients get a CXR. High risk get CT vs. bronch
148
How to manage patient with acute bronchitis?
Symptomatically
149
Most important lifestyle intervention to lower BP vs. CVD riskS?
Low BP = weight loss
| Low CVD risks = stop smoking
150
Indications for bariatric surgery?
BMI >35 with multiple comorbids
| BMI >40 without multiple comorbids
151
BMI 32 for patient who can't lose weight. Next STEP?
Give orlistat inhibits gasric/pancreatic lipases so cannot break down and absorb FA
152
Best treatment for patient with structural cause of heavy bleeding (other than remove the structure?)
Medroxyprogesterone acetate = quiets the endometrium
153
Cellulitis vs. Venous Stasis
Cellulitis is DERMIS rapidly spreading infection caused by SA/GAS; think fever, chills, leukocytosis
Venous stasis is often b/l near the malleoli, with no fever/leuks
154
Patient has acute herpes zoster. Best treatment?
ORAL (not IV) valacyclovir/famcyclovir > acyclovir b/c better bioavailability
155
Stages of Acne + Treatment
Non-Inflammatory = Topical Isotretinoin
Mild Inflammatory = Topical Benzylperoxide +/- Topical Abx
Moderate Inflammatory = PO Abx (Clinda, Erythro, Doxy); think of this when you see/hear "pustules" b/c topical won't work
Severe Nodulocystic = PO Isotretinoin; think of this when you see/hear "refractory to ABx"
156
Best way to test for hearing impairment?
Whisper voice test
157
Gait and balance problems in elderly. Best test?
Get up and go (should be <20 sec)
158
DDx High RV/TLC ratio? How to tell them apart?
Obstructive lung disease and NM disease
Tell them apart with the FEV1/FVC ratio which is normal in NMD
159
Young patient with 3 weeks of resp symptoms has lymphocytic and bloody pleural effusion. NExt step?
Biopsy the pleura b/c this is TB
160
Patient with stable asthma (moderate intermittent) has respiratory infection that causes persistent worsening of symptoms. What is the next best step?
Short course of low dose PO steroids have been shown to let people establish their baseline function back in the setting of exacerbation 2/2 respiratory infections
161
2 Keys for Trochanteric Bursitis and Treatment
1. Patients can point with 1 finger
2. Pain with abduction
Treatment = INjected Steroid in Joint
162
Anserine Bursitis
| - Pain location
Location: upper inner tibia 5cm distal to articular area of knee
163
Pt with shoulder pain has a completely normal musculoskeletal exam of the shoulder. Next step?
Chest X Ray for referred pain
164
Patient has septic joint of gram+ cocci. Rx?
Vanc, assume MRSA
165
Acute gout treatment options
NSAIDs (INDOMETHACIN) > Colichine/STeoids
166
When do you start uric lowering therapy in gout?
2 attacks or signs of tophacious gout
167
Goal uric acid?
What do you use?
<6
Allopurinol, but before starting bridge with Colcohine/NSAIDs to not mobilie uci acid
168
Pt with osteoarthritis, not responding to Acetaminophen. NExt step?
NSAIDs. If not good enough, THEN go to the injected steroid
169
VTAC Treatment
Stable - IV Amiodarone; vagal techniques don't do it b/c electricle impulse is not originating at/above the AV node
Untable = Cardiovert
170
Fever + Focal Spine Pain + Neurologic Deficits
- Diagnosis
- Pathophys
- Next step
- Diagnosis: vertebral osteo
- Pathophys: heme spread (vs. most other osteo is cont spread)
- Next step: MRI Spine
171
Ethylene Glycol Metabolism and treatment
EtGlycol ---Alcohol Dehydrogenase--> Oxalic Acid (binds Ca = stones/hypoCa) and glycolic acid (directly damages renal tubules + Metabolic Acidosis).
Treatment = omepizole (inhibit ADH) or Ethanol
172
MC Thyroid Cancers
Papillary > Follicular > Anaplastic > Medullary > Lymphoma
173
Dubin Johnson
Rotor's
Craiglar Najjar
All causes hyperCB
- DJ: asymptomatic until OCP, pregnancy, illness with increase CB/normal LFTs. Dark pigment in liver
- Rotors: asx without dark pigmented liver
- CN: conjugated hyperbili of children that are symptomatic
174
Patient with pain on knee extension and when patella is pushed into knee.
Basketball player with pain and tenderness at inferior patella.
Patient with pain on palpation over anterior medial tibia just adjacent to tibial plateau.
Pain and swelling right over the patella with cystic swelling in someone who fell on knees.
Patellofemoral Syndrome
Patellar Tendonitis
Arsenine Knee
Pre-patellar Tendonitis
175
Lynch Syndrome alternate name.
Hereditary Non-polyposis CRC. Recall Type 2 is known as familial cancer syndrome, MC = endometrial cancer
176
Patient has sinus bradycardia. What is the next best step?
IV Atropine ---> Transcutaneous Pacing
177
What do you do if someone has ingested lye?
lye = basic = aLkaline = liquefactive necrosis risk. Next step = endoscopy
178
NNT Definition?
| NNH Definition?
1/Absolute Risk Reduction
| 1/Attributable Risk
179
What mosquito bite will cause malaria?
Anophales Mosquito
180
HCV Rx Treatment
| HBV Rx Treatment
```
HCV = IFN + Ribiviarin
HBV = LITE = Lamuvidine, IFN, Tenofovir, Entecavir
```
181
Acromegaly W/u
IGF1 ---> OGTT for GH Suppression ---> MRI Brain
182
Cervical Cancer Screening
q3 21-29 y/o
then
q3 30+ or q5 if combo with HPV test
183
SBO Pathophysiology
Increased secretion proximal with decreased absorption distal = hypoK/hypoCl metabolic alkalosis
Can be closed/open.
Can be complete (operative management) or incomplete (Bowel Rest, Fluids, NG Tube)
184
Patient with dermatitis herpetiformis has macrocytic anemia. How?
Damage to terminal ileum = poor B12 absortpion
185
Unique about follicular thyroid carcinoma pathology
SPREADS HEMATOGENOUSLY, which is unique for the thyroid cacner world. So biopsy is usually reuired for this diagnosis. The only exception is that the Hurthle cell variant spreads lymphatically
186
Pleural effusion WBC value?
GLu<60
187
Testing for DeQuervain Tenosynovitis?
Finklestein Test
188
Mammography Screening
q2y ages 50-74
189
Patient with known duodenal PUD has early satiety and intractable vomiting, p/w early satiety. DDx?
Gastric outlet obstruction
190
Psoriatic Arthritis associations?
Sausage fingers
191
PSVT vs. Afibb?
```
PSVT = REGULAR narrow complex tachy
Afibb = irregular
```
192
5 Indications for Px Doxy in patient with tick bite?
```
Bite from Ixodes Deer Tick AND
Bite >36 hours ago AND
Bite was in endemic area (NE) AND
Doxy can be provided within 72 hours AND
No CI To doxy (pregnant/lactating)
```
193
Presentation for:
- Primary/Secondary Syphilis
- RMSF
- Erhlichiosis
- Primary/Secondary: painless chancre ---> 2-6weeks gone ---> 2/2 with rash on palms/soles, condyloma lata and GENERALIZED LYMPHADENOPATHY
- RMSF: tick bite ---> HA, fever, RASH on wrists/ankles ---> spreading outward
- Erhlichiosis: HA, fever (no rash) and THRMOBOCYTOENIA/LFTs
194
Older patient as 2nd ICS RSB murmur + painless lower GI bleeding?
Heyde's Syndrome = angiodysplasia in setting of aortic stenosis
195
Presbycusis?
Loss of high frequency sound occurring normally with old age
196
Why is urine dipstick not good at screening for diabetic nephropathy? What is the better screening tool?
Dipstick: only sensitive for 300 mg/24 hours of urine protein = MACROALBUMINURIA
Microalbumin/Creatine Ratio = best for microalbuminuria
197
What lab value will be different in patient on lovenox vs. heparin?
PTT; lovenox does not prolong the PTT
198
MC Arrhythmia in Digitalis Toxicity?
Atrial / Ventricular Tachycardia + AV Block = increases ectopic beats = tachycardia. AV Block = slowing conduction through AV node.
199
p<0.01 correlates with what confidence interval?
99% that does not contain the null value
200
Patient with malabsorption has vesicular rash on butt cheeks and dorsum of ankles. 2 aspects to treatment?
Avoid gluten ---> Dapsone
201
Tinea Corporis
- Definition/Microbiology
- Presentation
- Diagnosis
- Treatment
- Definition/Microbiology: fungal skin infection caused by dermatophyte trichpohyton rubrum
- Presentation: ITCHY ring shaped scaly lesion
- Diagnosis: scrape + KOH = hyphae
- Treatment: Topical Terbinafine > PO Griseofulvin
202
Why would a patient with h/o temporal arteritis get serial CXRs?
Increased risk for aortic aneursym as inflammation can spread to the aorta.
203
Patient with cancer has normal TSH, T4 and low T3.
Sick Euthyroid. T4 is getting shunted to rT3 so there is low T3
204
In DKA/HHNKS when do you add back glucose?
Recall start with Fluids ---> insulin drip ---> dextrose when GLUC < 250. The reason is you don't want to make them hypoglycemic and you also don't want to dilute the itravascular compartment so much that fluid shifts to interstitial space
205
UA in a patient with dysuria shows lots of WBC and pH = 8. DDx?
Urease producing bug (proteus, ureaplasma, nocardia, crytpo, h. pylori). urease takes ammonia to urea and H+. This H+ binds NH3 to make NH4+. The low H makes the urine less acidic = high pH
206
4 Drugs used in SIADH/DI
SIADH: fluid restriction ---> hypetonic saline
- Demeclocycline: can induce NDI
- Vaptans: used in severe cases of SIADH
DI
- DDAVP for central
- HCTZ for nephrogenic
207
3 Big Fungal Infections
- Locations / Exposure Risks
- Key Presentation
1. Histoplasmosis
- Location: ohio river valley/caves and bat droppings
- Key Presentation: histo hides in macrophages/RES so p/w RES findings = pancytopneia, splenomegaly and palate ulcers
2. Blastomycosis
- Location: great lakes, east of MS river and central america
- Key Presentation: p/w nodular lung issues and lytic bone lesions (b/c spread hematogenously)
3. Coccidiomycosis: SW USA
208
PE/DVT Protocols
DRAW
209
Definition of Chronic Hepatitis
Best way to assess liver damage in acute vs. chronic hepatitis
Chronic = ≥6 months of liver injury
Acute Hepatitis = LFTs + Viral Serology
Chronic = Biopsy
210
24 y/o AAM has recurrent nocturia.
Hyposthenuria 2/2 SCD = sickling of vasa recta mean that you can't concentrate the urine
211
Pt with protal HTN and cirrhosis has terrible ascites. What is the stepwise treatment?
Na/H2O restriction --> Spironolactone --> Lasix --> Small taps
212
You perform the protocol above and patient ends up having decreased UOP. WHy?
Frequent taps in ascites patients = hepatorenal syndrome
213
Necrotizing Fascitis
- Definition
- Etiology
- Presentation
- Treatment
- Definition: spreading infection of the deep muscle fascia
- Etiology: trauma > surgery infection with GAS/SA/Anaerobes
- Presentation: purplish/gangrenous skin rash/crepitus
- Treatment: debridgement + Amp/Sulbactam/Clinda for coveratge
214
Patient steps on nail in construction site when wearing a boot in summer time 4 days ago.
- Bug?
- What will xray for osteo show?
- Bug = pseudomonas foot
| - Xray = nothing b/c takes 2 weeks for osteo to show up on xray
215
Organophosphate Poisoning
- Mechanism
- Presentation
- Treatment
- Mech: inhibits AcH-ase = increase AcH
- P/w: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Salivation, AMS
- Treatment: Atropine + remove all the clothes
216
Pregnant woman was bit by ixodes deer tick. She meets 5 criteria for px doxy. What will you give her?
Amoxicillin
217
Zn Deficiency
- Pathophysiology
- Presentation
- R/o Vit A deficiency
- R/o Selenium Deficiency
- Pathophysiology: absorbed in jejunum so gone in IBD/malaborption syndromes
- Presentation: ABC = alopecia/abnormal taste, bullous lesions skin/mouth, cuts that don't heal
- R/o Vit A deficiency: vision change+ skin change
- R/o Selenium Deficiency: cardiomypathy
218
DDx for Recurrent Pneumonia:
- Same Location
- Different Location
Same Location = Structural Lung Change (mass/obstruction) vs. Aspiration
Different Location = Sinopulmonary DZ (CF), IC State (HIV) and Vasculitis
219
Chronic fungal foot infections predispose patients to...
recurrent cellulitis
220
MGUS - how can it be diagnosed?
Can only diagnose MGUS after ruling out MM = CRAB = hyperCa, Renal, anemia and lytic bone lesions. This patient had normal CRA, so the next step before saying MGUS is to do a bone scan for lytic bone lesions
221
Fulminant Hepatic Failure
- Definition
- Management
Definition = development of encephalopathy within 8 weeks of acute liver injury
Management = immediate placement on transplant list
222
Definition of Orthostatic Hypotension
MC Mechanisms in Elderly (2)
Positional change yield change in SBP by 20 or DBP by 10
Mech = Decreased baroreceptor sensitivity + decreased myocardial sensitivity
223
Saline Responsive vs. Resistant Metabolic Alkalosis
- Test to determine
- Examples of saline resistent
Urinary Chloride = if low this tells you that loss of fluid is the cause b/c the body is reabsorbing Na so Cl will also be reabsorbed
Saline resistent will have high UCl, consider barters/gittlmen/licorice (NOT Diuretics0
224
Patient presents with S3 on cardio exam, proteinuria and easy bruising. Dx.
Amyloidosis
- Dilated cardiomyopathy
- Proteinuria = neprhotic syndrome
- Bruising = Amyloid lIver
225
Indications for FFP (2)
Chronic Liver Failure = cannot snythesise 27910
Warfarin Toxicity = inhibit synthesis of 27910
preferred over whole blood because of higher concentration of clotting facotrs
226
Effusions in PE?
Exudative and Hemorrhagic
227
Attributable Risk Percent =
(Risk in Exposed - Risk in Unexposed)/(risk in exposed) = (RR-1)/RR.
Recall that NNH = 1/Attributable Risk
228
22 y/o healthy female p/w diastolic murmur. Next step?
Echo, all diastolilc murmurs require echo
229
What lab value is a poor prognostic sign in CHF?
Hyponatremia; indicates that hypoperfusion of the kidneys is severe that the RAAS/ADH response is super kicked in
230
How does melanoma present?
Recall:
- MCC Skin Caner
- Most Likely to Met
- Which associated with dysplasti nevus
Mole that has become symptomatic (itchy, changed size and shape)
Recall ABCDE of the melanoma
Assym, Borders, color, DIMATER >6mm, enlargement
MCC Skin Cancer = BCC, occuring on the eye
MC Mets = Squamous cell
Dysplastic Nevus = melanoma
231
3 Steps in Diagnosis of Primary Adrenal Insufficiency
AM Cortisol (low), ACTH (high) and confirm with Cosyntropin Test. This is an IV infusion of ACTH, if cortisol rises you R/O AI. If no rise, you R/I AI.
Recall primary = hyperK, pigmentation and eosinophilia
232
Before starting ABx in suspected endocarditis, what do you need?
Bacteremia + Lab/Imaging/PE evidence of leaflet vegetation (= +BCx and ECHO)
233
Patient has cavitary lung lesion that shows different movement with positional change. DDx?
What is the halo sign?
DDx = Aspergillosis + Abscess. The difference will be that the abscess will have an air fluid level. The aspergilloma will have the "Halo Sign" which is a pulmonary nodule and air crescent
234
Consolidation vs. Effusion
- Auscultation
- Fremitus
- Percussion
Consolidation
- Auscultation: egophany pectriloquy bronchial sounds b/c sound travels fast through solid
- Fremitus: increased vibration
- Percussion: dull
Effusion
- Auscultation: decreased b/c fluid is in the way
- Fremitus: decreased
- Percussion: decreased
235
DDx for HIV Esophagitis and Treatment. Associated CD4 count?
CD4 COunt <50
MCC = Candida (PO Fluconazole)
If no improvement, endoscopy with biopsy for the next MC:
HSV (PO Acyclovir) = clusters of ulers
CMV (PO Ganciclovir) = linear ulcers
236
Patient has dilute urine. Easy lab test to tell between Polydypsia vs. DI?
Serum Osmolarity. Polydypsia has dilute urine AND dilute serum. DI has dilute urine and CONCENTRATED serum.
237
Patient has Lithium toxicity induced NDI. What is the best treatment?
Amiloride; inhibits further lithium accumulation in the kidney
238
Patient has foul smelling breath, palpable neck mass and no cavitation on CXR, though there is an aspiration pneumonia. What is the next best step?
Barium esophagram for Zenkers ---> Surgery for correction
The lack of cavitation and neck mass makes pure aspiration pneumonia unlikely
239
ZES
- Presentation
- 2 Endoscopic Findings
- 3 Steps in W/u
Presentation: steatorrhea/malabsorption 2/2 acid's inhibition of pancreatic enzymes (like orlistat!)
2 Endoscopic Findings = prominent gastric folds as well as ulcers BEYOND duodenal bulb
3 W/u: Serum Gastrin (>1000) ----> Secretin Stimulation (should lower gastrin, but will be high in gastrinoma) ---> IV Ca Infusion (raises Gastrin in +Gastrinoma patients)
240
Why are patients with nephrotic syndrome at risk for accerelated atherosclerosis?
Recall this causes increased LDL/low HDL because of abnormalities in lipid metabolism
241
Management of Rabies Bite from Dog
1. Acquire the Dog
- If Acquired: observe for 10 days. If no signs develop, no intervention is needed. If rabies signs develop = ACTIVE + PASSIVE IMMUNIZATION
- If not acquired: assume ACTIVE + PASSIVE IMMUNIZATION
2. If bite is in head/neck: ACTIVE + PASSIVE IMMUNIZATION regardless
Recall this is all known as post-exposure prophylaixs
242
Acute Cystitis
- Presentation
- Uncompliated vs. Complicated Definition
- Uncomplicated vs. Complicated w/u treatment
Presentation = UTI si/sy + suprapubic discomfort
"Un/Complicated": uncomplicated are non pregnant otherwise health, complicated are pregnant/old/recurrent
W/u Treatment
- Uncomplicated = NO Cx = bactrim/macrobid
- Complicated = Cx = fluorquinolone
243
In order, what steps can be taken in lifestyle modificaiton to have teh greatest impcat on bp?
Weight Loss > Dash diet > exercise/low Na intake > low EtOH intake
Recall smoking is not in hear (can actual decrease BP), but it is the single most important lifestyle modification that can be made to decrease cardiovascular diseas
244
After metformin, what drugs coud you add (2) to allow further weight loss and improve glycmeic contro/
1. Exenatide: GLP-1 agonist that decrease intestinal absorption of CHO. Decreases hypoglcyemic events and weight like metformin
2. Gliptins (end with IN = increase incretin); improve glycmiec control
245
Two ways to differentiate polymyostis vs. hypothyroidism?
DTRs = nl in poly low in hypothyroid
ESR = high in poly, nl in hypothyoid
246
Baseball pitcher has pain with abduction over head. DDx?
Subacromial bursitis = repetitive overhead movements
247
Diabetic patient with granulation tissue and pain/drainaige from one year. Treatment?
Treatment for malignant external otitis = ciprofloxacin
248
Latency Bias
- What is latency?
- Ex of short latency vs. long latency?
- Explain bias
- Latency: time from exposure to change in health
- Short = infections; exposure to bug and feeling ill is short. Long = cancer
- Bias questions usually have a drug that is started with more people dying early on then later. It takes time (latency) for drug to get into effect, therefore the study is subject to latency bias
249
Lead Time Bias
- Classic Script
- Explain bias
- Classic Script = new screening test for fatal disease seems to improve survival
- Bias: survival is unchanged, the new screening test just picks it up earlier so it makes the time from diagnosis to death seem longer
250
MC Renal Stones (In order)
CaOx (envelope) > Ca PO4 > Uric Acid (lucent) > Struvite (Coffin) > Cystine
251
Why would a person with exogenous glucocorticoid use become hyponatremic?
Glucocorticoids inhibit CRH/ACTH and therefore there is low cortisol secretion and low androgen secretion. The endogenous glucocorticoids normally inhibit ADH secretion, leading to more excretion of free water. Without this endogenous cortisol (in the case of exogenous use), there is no tonic inhibition on ADH, so you have increased ADH = increased water reabsorption = dilutional hypotnatremia
252
Immuno mechanism of PCV vaccine
T cell INDEPENDENT B cell immunity. Recall this is a polysaccharide (vs. peptide) vaccine so cannot Stimulate T cells
253
2 Indications for BAL
Suspected Malignancy
| Opportunistic Infections
254
Best Agents to Give with Cardiogenic Plumonary Edema (3)
Preload reducing agents
- Lasix
- Nitroglycerin
- Morphine
255
Diabetic patient with black eschar in nostril. Best treatment? (2)
Surgical Debridgement
| IV Amphotercin B
256
Ursodeoxycholic Acid
- MoA
- 3 Uses
MoA: bile salt so decreased EHC = decreased bile reabsorption/secretion into gallbladder = low stone formation
Uses:
1. Patients with symptomatic gallstones who cannot go surgery
2. PSC
3. PBC
257
Leukoplakia
- Definition/Pathophysiology
- Presentation
Definition: pre-cancerous lesions (therefore WON"T WIPE AWAY) representing squamous epithelium hyperplasia 2/2 etoh/smoking insult
Presentation: white patch that cannot wipe away
258
OCP + HTN Mechanism and Mangaement
OCP stimulates angiotensinogen synthesis in liver = increase RAAS effects
Management = dc OCP
259
Acute Epididymitis
- Presentation
- Etiology (Young v.s Old)
Presentation: U/L Painful testicular enlargement + voiding symptoms.
Young Patients = GC + CT
Old = ECOLI 2/2 TUI
260
Presentation/Key Points Differentiating:
1. Flu
2. Viral URI
3. GAS Pharyngitis
1. Flu
* SUDDEN ONSET of SYSTEMIC SYMPTOMS
* Three serotypes; Neuraminidase inhibitors (Oseltamavir/Znamavir) can decrease duration if given in 1st 48 hours, otherwise symptomatic
2. Viral URI
* Slow progression of nasopharynx disease, no systemic symptoms
3. GAS Pharyngitis: triad of erythema in nasopharynx, exudative pharyngitis, cervical lymphatdenopathy
261
(T/F) Tenderness to palpation exists with osteoarthritis.
FALSE
262
Patient has sudden onset of sharply demarcated skin rash with palpatble raised borders. Dx and what are the potential sequele?
Erysipleas 2/2 GAS
---> cellulitis ---> osteomyelitis
263
Dx:
- Constipation + Back Pain
- Cough + Constipation
- Nontender lymphadenopathy + Constipation
- Myeloma
- Sarcoid
- Cancer
264
Treatment for B. Henslae?
Think cat scrath + axillary lymph node = Azithyromycin x 5 days
265
Reactive Arthritis
- Presentation
- Associated skin findings / extraintesetinal manifestations
- Treatment
- Presentations: urethritis, conjunctivitis, arthritis
- Skin: keratoderma blenorrhagic/balannitis/enthesitis
- Treatmetn: NSAIDs
*Recall this is caused by intesintal infection with yersinia, salmonella, shigella, campylobacter, cdif
266
Patient has a murmur. Uncomfortable to lay down on their back or on their left side.
Aortic Regurge
267
(T/F) The larger the CI range the better.
False the tighter the range the more precise
268
UC Patient has suddenly worsening health, he is in SIRS. First step in diagnosis?
First step in management?
Diagnosis = abdominal plain film for Colon diameter >6cm = Toxic Megacolon
Management = NPO, NG Suction and Steroids (or ABx if non UC etiology of Toxic Megacolon)
269
Patient is 20 y/o and finds out that he has UC. What is he at increased risk for and when should screening begin?
Increased risk for CRC and therefore should get annual colonoscopies 8-10 years after receiving the diagnosis (28-30)
270
Carbon Monoxide
- Pathophysiology of hypoxemia
- Key exposure risk factors
- Key physical exam findings
- Diagnosis
- Treatment
- HCT level
- Pathophysiology: 250x affinity for hemoglobin so less O2 binds. Also alters Hb shape so less Ox that does bind can leave to tissue
- Exposure: Automobiles, furnace charcoal grill
- Physical Exam: cherry red skin hue
- Diagnosis: Carboxyhemoglobin levels
- Treatment: Hyperbaric O2 (compete back with the CO for hemoblobin)
- HCT: high b/c reactive polycythemia
271
Patient 10 weeks post MI has an EKG. What will it show?
Persistent ST elevations and deep Q weeks = old infarct
272
Patient has painless jaundice. NExt step?
Abdominal CT for pancreatic cancer
273
MCC Pancreatic Cancer
Smoking > Chronic Pancreatitis
274
MCC Chronic Pancreatitis
Alcoholism
275
HIT Syndrome
- Pathophys
- Diagnostic Criteria
- Diagnostic Test
- Management
- Pathophy: Ab to PF4 cross reactions and prematurely activates platelets ---> thrombosis + thrombocytopenia
- Diagnostic Criteria: Heparin Exposure >5 days AND
1. 50% reduction in platelets
2. Arterial + Venous thrombosis
3. Skin Necrosis
- Test: 5HT release assay
- Management: cease all heparin products + swtich to direct Xa inhibitor (argobatran/Fondaparinaux)
276
Patient presents with hematuria, flank pain and palpable abdominal mass. Dx and next step/
Dx = Renal cell carcinoma
| Next STep = abdominal ct
277
What are the live vaccines?
LIVE Big/Tiny Yellow Chickens Say MMR
| - BCG, Typhoid, Yellow, Chicen/Small pox, Sabin PO Plio, MMR
278
What vaccines can be given to HIV patients?
CD4 > 200 = MMR, Varicella/Zoster
All HIV Patients Should Get Max 8 = Tdap (all adults q10), Pneumococcal, Killed Flu, HAV/HBV (if high risk/exposure), Meningococcal, HPV, and Flu B
279
Pregnant woman with hep C is being evaluated. What vaccines does she need?
HAV/HBV. Safe in pregnancy
280
HTN Emergency vs. Urgency
HTN Emergency and Urgency both have SBP >200 or DBP >120. If there is evidence of end organ dysfunction = Emergency. NO evidence = urgency.
End organ dysfunction = AMS, exudates/papilledema
Treatment = lower BP by 25% over 1-2 hours with PO meds
281
Patient comes back from camping trip with periorbital edema, muscle aches. CBC shows eosinopholia.
Trichienellosis = eat undercooked pork ---> GI ---> migrates to muscle
282
Long term management of prostate mets?
Orchiectomy = remove source of androgens
or
Flutamide = antiadnrogen paired with Leupron
283
What about patient who already has undergone orchiectomy?
Radiation
284
HSV vs. CMV Retinits
- Presentation
- Optho Exm
Presentation: HSV painful, CMV painless
Exam: Dendritic ulcers in HSV with Fluffy glandular pattern/yellow-white plaques in CMV
285
5 Vaccines in CLD
HAV, HBV, Tdap, PCV and Flu
286
Bronchiectasis vs. Bronchitis. Next best step?
Bronchiectasis has more more more more sputum and it is FOUL smelling. The next best step is Chest CT
287
HIV patient with PCP. Treatment and depends on ...
Bactrim, if PaO2 <70 or Aa >35 = add steroids
288
Leads/Arteries for:
- Anterior
- Lateral
- Inferior
- R Ventricular
- Anterior: LAD = V1-V4
- Lateral: Circ = I, avL, V5-V6
- Inferior: II, III aVF (RCA)
- R. Ventricular: R sided EKG
289
Cardiac Enzymes:
- List in order they rise
- Provide time to rise, time to peak and time to resolution
1. Myoglobin
- Time to Rise: 1 hour
- Time to Peak: 2 hours
- Time to Resolution: 24 hours
2. CKMB
- Time to Rise: 4
- Time to Peak: 24 hours
- Time to Resolution: 72 hours
3. Troponin
- Time to Rise: 4 hours
- Time to Peak: 24-48 hours
- Time to Resolution: 14 days
290
Patient presents with chest pain. Summary for protocol:
First do an EKG. If STEMI = Cath + MONAS HepB
Next best step is Cardiac Enzymes, if + = MONAC/S HepB
If - Cardiac Enzymes = NSTEMI ---> Stress Test; if + ---> Cath
291
Persistent ST elevation + MR murmur 1 mo s/p MI?
Ventricular wall aneurysm
292
Cannon A Waves after MI?
Represents A-V Dissocoation; think 3rd degree heart block
293
Patient comes in with mild fever, luekocytosis and pleuritic chest pain 5-10 weeks post MI?
Dresslers = give NSAIDs + ASA
294
Patient has transient ST elevations worse at night. Diagnostic test and treatment?
Prinzmetal; diagnostic test = ergonovine stimulation. Tx with CCB/nitrates
295
Mid systolic click?
Mitral prolapse
296
What causes of diastolic and restrictive cardiomyopathy are reversible?
```
Dilated = Alcoholic
Restrictive = Hemochromatosis
```
297
3 Buzz Word findings in patients with CXR and CHF?
1. >50% heart width
2. Kerly b lines
3. Cephalezation of flow
298
Pleural Effusions
- First step
- You tap: diagnosis if low glucose vs. high lymphocytes vs. bloody
- Light's Criteria
- Criteria for Complicated
- Treatment for Complicated
- First step: lateral decubitus CXR. if >1cm = tap! Will also show if solid component
Low glucose = RA
High Lymp = TB
Bloody = Malignancy vs. PE
Light Criterai: Protein Ratio >0.5, LDH Ratio >0.6, LDH >200
Criteria fro Complicated: pH 7.2, +Cx, Glucose <60
Treatment for Complicated = Chest tube for drainage; +loculations = surgery
299
Treatment of ARDS
Ventilation with PEEp
300
Do phrenic nerve injuries, MS/musculoskeletal/obesity have obstructive or restrictive PFTs?
Restrictive
301
COPD
- Clinical Criteria
- Treatment (1st, 2nd 3rd line)
- Best prognostic indicator
- Important Vaccinations
- Clinical Criteria = >3mo productive cough for 2 consec years
- Treatment
1. Ipra/tiotropium
2. Beta gonists
3. Theophylline
- Prognostic indicator = FEV1 (recall smoking/home o2 decreases the rate of decline and improves lung function)
- Important vaccines = yearly flu and pneumococcal with 5 year booster
302
New Clubbing in COPD Patient
- Diagnosis
- Next step
Diagnosis = hypertrophic osteodystrophy
| Next STep = CXR for malignancy
303
Patient has sings of lung cancer. CXR shows peripheral cavitation and CT shows distant lung mets. Dx?
large cell lung cancer
304
Which IBD is cured by colectomy?
UC
305
Treatment of IBD:
- First line for all patients
- For exacerbations
- For CD if any ulcer or abscess
- For severe cases of either
- ASA = sulfasalazine/mesalamine
- Exacerbations = steroids
- For CX ifany ulcer = metro
- Severe caes = 6MP, azothioprine, MTX
306
Craiglar Najja causes direct or indirect?
Indirect
307
Post-surgery/hemorrhage, AST and ALT are in the 1000s
Shock liver
308
Anti-Smooth Muscle Ab
AI Hepatitis
309
Patient has pneumonia.
- Dx if recent hospitaliation (<3 months or duration >5-7 days)
- Dx if HA, diarrhea/abdominal pain
- HCAP = Pseudo/Kelb/GNR = vanc/zosyn
| - Pneumonia + Diarrhea = Legionella; tx with fluoro
310
ADE of TB rx pyrazinamide
AZID = ACID = high uric aicd
311
Screening for TB protocol
ppd --- cxr ---sputum
312
Endocarditis
- MC Bug in Native Valvue (Acute vs. Subacute)
- Diagnosis of either
- Compications
- Who needs prophylaxs?
MC Bug = staph aureus in acute, viridans in subacute
- Diagnosis = BC+ and TTE/TEE
- Complications = CHF >>> septic emboli
- PPx: UNCORRECTED congenital heart, h/o EC and prosthetic valve
313
Treatment for acute vs. subacute?
```
Acute = nafcillin (anti-staph)
Subacute = PCN
```
314
Give two unique presentations of HIV in a young patient?
New onset bilateral bell's palsy
| New onset unexplained thrombocytopenia
315
Acute Retroviral Syndrome?
Nonspeecific prodromal phase of HIV exposure for 2-3 weeks before seroconversion (ELISA-)
316
When to start HAAART for hIV?
CD4<350
| Copies of HIV >55K (except pregnant >1000)
317
When to give Bactrim ppx?
CD4<200
318
HIV Neuro: give Dx + Treatment
- Multple ring enhancing lesions
- ONe ring enhancing lesion
- SEizure
- Hemisensory loss / visual impairment/ babinksi
- Memory/gait problems
- Meningits
Multiple REL = toxo, give pyramethamine + sulfa
One REL = Primary CNS Lymphoma = EBV+, HAART
SEizure = HSV, acyclovir
White matter change = PML, brain biopsy
Memory problems = HIV Dementia
Meningitis = Crypto, India ink, latex, Fluconazole/flucytosine
319
Febrile Neutropenia
- Definition
- Nevere do...
- MC Bugs
- Management (2)
Definition: single sustained temp >101.3 in ANC <500
Never do DRE
MC Pseudomonoas/MRSA
Management = Cx ---> 4th Gen CefVanc
320
How do you treat rhabdo kidney injury? and Oxalate renal injury and CIN?
Bicarb = alkalize urine
321
Indications for Dialysis
```
Acidosis
Electrolyte imbalance
Ingestion
Overload of Volume
Uremia
```
322
How to tell TTP vs. DIC on labs?
Pt and Ptt normal in TTP
323
cANCA lung + kidney involvement
| pANCA + ELK Syndrome
Wegener's
| Churg Strauss
324
What is the best diagnostic step in any of hte vasculitis and waht is best treatmetn?
Biopsy ---> Cyclophosphomide
325
Treatment of Stones
- <5mm
- 5mm-2cm
- >2cm
```
<5mm = let it pass, just hydrate
5-2cm = lithotrypsy
>3cm = surgery
```
326
Best first test for someone with proteinuria?
repeat in 2 weeks
327
How to treat DIC?
Underlying Cause
Replenish Platelets
FFP for clotting facotrs
328
Dx:
- VDRL + with elevated PTT
- Skin necrosis after warfarin
- Lupus anticoagulant
| - Protein C deficiency
329
Treatment for "frequent traveler" with knee pain. Tap showed >50K WBC but -Cx/
Dx = GC arthritis, IV Ceftriaxone
330
Antibodies:
- Drug Induced Lupus
- Crest
- Systemic Sclerosis
- MCTD
- Drug induced = anti-Histone
- Crest = Anticentromer
- Scleroderm = anti-topoisomerase 2
- MCTD = anti-RNP
331
List 3 Skin Cancers
- Next step
- Treatment
BCC
- Next Step: shave/punch biopsy
- Mohs excision
SCC
- Next Step: excision biopsy
- Wide excision
Melanoma
- Full thickness biopsy (depth is number 1 prognostic factor)
- Excision with margins determined by biopsy
332
Melanoma with best prognosis and worst?
```
Superficial Spreading (MC = best)
Nodular (worst)
```
Depth is most important!!
333
W/u for Incidental Adrenal Nodule
1. Check functional status (symptoms? - cortisol/urine meta)
2. Size Dependent
- <5cm AND non functional = CT q6 months
- >5cm OR functional = surgery
334
S/p MVC with whiplash patient has loss of pain/temp on neck and arms, but intact epicritic?
Syringomyelia ---> MRI then surgery
335
Stroke
- Best 1st step (vs. most accurate)
- Treatment (time dependnet)
- vs. Subarachnoid treatment?
1st = HEad CT (most accurate = DWI MRI)
Treatment = <3.5 = tPA (ischemic) vs. ASA if >3.5 h
Subarachnoid Hemorrhage treatment = nimodipine for vasospasm prevention
336
When to do endarterectomy?
>70% occlusion AND symptomatic
| >60% if less than 60 y/o and symptomatic
337
W/u for Dysphagia
Barium Swallow ---> endoscopy
+/- Manomatery for DES (CCB/nitrates) or Achalasia
+/- 24 hour pH most senstivie for GERD
