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0

Normal ankle to brachial index

Ratio of systolic at ankle to arm

.9 to 1.3 is normal

Pts with increased ABI usually due to calcified vessels and false readings.

Claudication because of peripheral vascular disease has lower ABI

1

Leriches syndrome

Atheromatous occlusion of distal aorta just above bifurcation

Causes:
bilateral claudication, (low back, hip, buttock, thigh)
impotence,
and absent or diminished femoral pulses.
atrophy of lower extremities

2

Gold standard diagnosing peripheral vascular disease

Arteriography

3

Gold standard diagnosing acute arterial occlusion

Arteriogram

4

Homans sign

Calf pain on ankle dorsiflexion

Sign of DVT

5

Most accurate test to dx DVT

Venography

But invasive and not used a lot

6

Initial test for DVT

Doppler analysis and duplex US

7

Phlegmasia cerulea dolens

Extreme cases of DVT

Severe leg edema compromises arterial supply

8

Signs and symptoms common to all forms of shock

Hypotension
Oliguria
Tachy
Altered mental status

9

Address what for all pts in shock

ABC

Airway
Breathing
Circulation

10

Number one cause of bronchiectasis

Cystic fibrosis

11

Pleural effusion with elevated pleural fluid amylase

Esophageal rupture
Pancreatitis
Malignancy

12

Pleural effusion with elevated blood

Malignancy

13

Causes of liver failure

Hepatitis a-e

Drugs - acetaminophen, alcohol, phenytoin, valproate, carbamazepine, ecstasy, cocaine, rifampin, INH, HAART

Ischemia

Autoimmune

Wilson's, hemochromatosis, fatty liver in preg, HELLP sx

14

Pleural effusion with elevated mostly lymphocytes + adenosine deaminase marker

TB

15

Can you see cardiomegaly on AP CXR?

No

Heart is further from film so always looks bigger. Do PA to see

16

Difference on CXR between alveolar and interstitial pneumonia

Alveolar is fluffy and lumped together

Interstitial is linear streaking

17

What are the mediastinal masses and where are they?

Anterior mediastinum

Thyroid cancer
Teratoma
Lymphoma
Thymoma

18

Eggshell calcification a on CXR

Silicosis

19

Pleural plaques

Asbestosis

20

Pneumoconiosis with increase risk of TB

Silicosis

21

What looks like berylliosis and how do you tell the two apart?

Sarcoidosis

Good social history

22

Causative agent of hypersensitivity pneumonitis in:
Farmers lung
Air conditioners lung
Bagassosis
Mushroom workers lung

Sorcerers of thermophillic actinomycetes

23

CXR with ground glass appearance with bilateral alveolar infiltrates that resemble a bat shape

Pulmonary alveolar proteinosis

Accumulation of surfactant like protein and phospholipids in alveoli

DO NOT give steroids because patients at risk for infection

24

What is best imaging to detect radiation pneumonitis and what is treatment

CT scan

Corticosteroids

25

Effects of severe hypoxia

Irreversible organ damage (CNS, cardio)

26

Effects of severe hypercapnia

Dyspnea
Vasodilation of cerebral vessels causing increased ICP, papilledema, headache, impaired consciousness, coma

27

CPP =

MAP-ICP

28

What do you need to determine mechanism of hypoxemia?

PaCO2 level
Aa gradient
Response to supplemental O2

29

Normal aa gradient by hypoxia

Hypoventilation

Low inspired PO2

30

What is ventilation monitored by

PaCO2

Vs oxygenation monitored by PaO2

31

PaCO2 and Aa gradient increased

VQ mismatch or shunting

VQ mismatch improves with O2

Shunt (collapsed lung, ARDS) does not improve with more O2

32

EF in CAD

>50% is normal
Less than 50 has increase in mortality

33

Stress ECG diagnostic value in CAD

75% sensitive if pts can exercise to 85% of max HR for age

220-age = max HR

34

Is perfusion imaging useful for LBBB?

No

35

What tx increases mortality for CAD?

What is first line for CAD?

CCB increases HR so increases mortality

Use nitrates or beta blockers

36

Diagnostic tool for prinzmetals angina

Coronary angiography + ergonovine shows vaso spasm

Ergonovine is alpha Adernergic, dopaminergic, serotonergic, uterine and smooth muscle agonist

37

Chronology of acute appendicitis pain

Periumbilical to right lower quadrant

Visceral then somatic pain

38

When do you need screening for ovarian cancer. And what kind of screening is done?

When increased risk secondary to hereditary factors like BRCA

Don't do screening for pts of average risk

Screening is ab US or CA125

39

How do you manage exercise induced asthma?

Short acting beta Adernergic agonists 20mins before exercise

40

Treating trigeminal neuralgia

Carbamazepine

41

Tx for TTP HUS

Idiopathic, usually has Ab against ADAMTS13 which cleaves vWF so platelets will aggregate more

Plasmaporesis to get rid of antibody

DO NOT give platelets

42

Orthostatic hypotension

Decrease systolic by more than 20 when stand

Diastolic decreases by more than 10

43

Ramsay hunt

From of herpes zoster infection

Causes Bell's palsy

Vesicles seen on outer ear

44

Pseudo tumor cerebri symptoms, diagnosis, treatment

Headache, blurry vision or loss,papilledema, pulsatile tinnitus, abductees nerve palsy, nausea, vomiting

CT scan then LP if doesn't show a bleed

Acetazolamide to tx

45

Chest CT showing wedge shaped infarction is most likely what?

PE

46

Parvovirus in adults

CNN get anti-b19 antibody

Arthritis affecting MCP, PIP, wrists, ankle joints

Acute onset of symptoms, lack of redness and swelling (vs slow in RA)

47

What looks like an ST elevation but is not?

Left bundle branch block

48

If a pt has a suspected PE but kidney failure too, what do you use to detect PE?

VQ scan, NOT CT

49

Light's criteria

Lights criteria says a pleural effusion is likely to be exudative if one of the following exists

Pleural fluid protein to serum protein > 0.5
Pleural fluid LDH to serum LDH > 0.6
Pleural fluid LDH > 0.6 or 2/3 times the normal upper limit for serum.

50

Most common cause of thyroid nodules

Benign colloid nodules

Then follicular adenoma

51

What electrolyte abnormality do you worry about after surgery needing lots of transfusions?

Hypocalcemia

Hyperactive deep tendon reflexes

52

What mimics hypocalcemia?

Hypo magnesia that is severe becaus less PTH secreted

53

Diagnosis of diffuse esophageal spasm

Esophageal motility studies (manometric readings)

54

Beta 2 agonists can cause what side effect and why

Hypokalemia because drive potassium into cell

Muscle weakness arrhythmias, EKG changes

55

Porcelain gallbladder

Calcium deposits in gallbladder wall with bluish color and brittle consistency

Rim like calcification in area of gallbladder with central bile filled dark area on CT

At increased risk for gallbladder cancer

56

Most sensitive test to dx disseminated histoplasmosis

Antigen detection in serum or urine

57

First line DMARD for Rheumatoid arthritis

Methotrexate

58

Muddy brown cast

Acute tubular necrosis

59

RBC casts

Glomerulonephritis

60

WBC casts

Interstitial nephritis and pyelonephritis

61

Fatty casts

Nephrotic syndrome

62

Broad and waxy casts

Chronic renal failure

63

Gold standard for osteomyelitis diagnosis

Bone biopsy

64

What did the AFFIRM study show?

Management of afib with rhythm control offers no survival strategy over rate control

There are potential advantages such as lower risk of adverse drug effects with rate control strategy.

Better to rate control

65

Never give to Wolff Parkinson white patient

Beta blockers

Calcium channel blockers

66

Causes of afib

PIRATES

Pulm disease (COPD, PE)
Ischemia (ACS)
Rheumatic heart disease (mitral stenosis)
Anemia (high output failure, tachycardia), atrial myxoma
Thyrotoxicosis
Ethanol / endocarditis
Sepsis / sick sinus syndrome

67

How do you know you are hemodynamiclly unstable (eg for using cardioversion in afib)

Hypotension
Angina
Heart failure

68

What is the RE-LY trial?

Dabigatran vs warfarin

Dabigatran superior to warfarin to inhibit ischemic stroke and decreases risk of intracranial bleed.

However, dabigatran has increased risk of GI bleed

69

Diffuse bilateral pulmonary infiltrates in CXR

Hypoxemia refractory to oxygen therapy

ARDS

PaO2 / FiO2 ratio < 200

70

Necrotic migratory erythema

High blood glucose

Gucagonnoma

71

Checking if endotracheal tube is in correct place

CXR

Tip of ET should be 3-5cm above carina

Bilateral breath sounds

72

Minute ventilation =

RR x Tidal volume

73

What's the usual I:E ratio?

1:2

74

Cor pulmonale

Usually secondary to pulmonary disease and not LHF
Usually secondary to COPD

Polycythemia may be present if COPD is cause

75

Prospective investigation of pulmonary embolism diagnosis (PIOPED)

Guides tx if V/Q performed

76

Christopher study

Guides tx if spiral CT performed

77

1. What is mortality of PE in first 60 mins if diagnosed?

2. How many die of recurrent PE if left untreated?

3. Anticoag tx deceased mortality to....

1. 10%

2. 30%

3. 2-8%

78

Gold standard to diagnose PE

Pulmonary angiography

Is invasive

VQ scan only finds a ventilation but not perfusion in 50% of cases

79

Goals for aPTT, PT

1.5-2.5times normal aPTT

2-3 PT
2.5-3.5 PT for mech valve

80

How does Na bicarbonate help in wide QRS (like TCA OD)?

Narrows the qrs because it increases extra cellular Na for action potential.

TCAs act on Na channels and inhibit them

81

SAAG value saying it is peritonitis

> 1.1

82

Guillain barre csf findings

How do you assess lung function in GBS?

High protein
Normal cell count
(Albumino-cytologic dissociation)

Vital capacity serial measurements
GBS can lead to respiratory muscle weakness --> respiratory failure

83

Primary HIV infectious can look a lot like mono. How do you tell the difference?

Mono has LESS rash (unless you used an antibiotic) and diarrhea

EBV has more tonsilar exudates

84

Most common type of diabetic neuropathy

Symmetric distal sensorimotor polyneuropathy

85

Mono neuropathy most often due to

Vascular

86

When do you stop INH?

If patient gets symptoms that look like viral hepatitis so damage to liver


Cand get asymptomatic mild increases in AST and ALT. this is okay and continue drug. This is subclinical hepatic injury and self limited

87

Dyspnea, tachypneic, normal lung evaluation, right axis deviation

Pulmonary embolism

88

A pt has PCP. What do you give them? What is an alternative?

TMP SMX + steroids.

Steroids decreases mortality in severe PCP. This is switch PaO2< 70 or Aa > 35

Pentamidine works less well but used for severe cases that intolerant to TMP SMX

89

Pt has abrupt mental status changes and hallucinations. CSF has mildly deceased glucose and increase in lymphocytes and negative gram stain. What is the gold standard of testing? Start should you do?

CSF PCR. This is most likely viral encephalitis by HSV

You should give acyclovir STAT

90

What is DDx for high serum Ca and normal PTH? How do you tell the difference between DDx?

Primary hyperPTH
Hypocalciuric hypercalcemia

24 hr urinalysis calcium excretion and creatinine clearance

FHH has decreased urinary calcium excretion edges life increased serum calcium. Primary hyperPTH has increased 24 hr Ca excretion.

91

Selenium deficiency

Cardiomyopathy


92

Zinc deficiency

Alopeia
Weird taste in mouth
Bulbous pustule lesions surrounding body offices and/or extremities
Impaired wound healing

93

What do you use CT with contrast for?

Structural abnormalities
Mass lesions

Not ok for blood because blood already shows up as white and can't see it with contrast.

MRI is best for no emergency situations where you want to ID vascular malformations, epilepsy foci, etc

94

How do you diagnose myasthenia gravis?

Eectromyogram
Ach captor antibody test both confirm

Then do CT of chest to look for thymoma

95

Autosomal dominant
Diffuse telangectasias
Recurrent epistaxis
Widespread AVM

Osler weber rendu syndrome (hereditary telangectasias)

Usually in mucous membranes, skin, GI tract

If in lungs, can do right to left shunt and cause chronic hypoxemia and reactive polycythemia.

96

First step in managing case of pleural effusion. What is the exception?

What do you do if you suspect malignacy but cytology is negative?

Thoracentesis

See if exudative or transudative.

EXCEPT in cases of pts with clear cut evidence of CHF where you use diuretics and Echo


If cytology is negative, an then negative - you keep going 3 times until you totally rule out malignancy

97

Type of anemia associated with tea and toast diet

Folate

99

Leukocytes that h ave undergone partial breakdown during prep of stained smear or tissue section, because of their greater fragility.

Smudge cells of CLL

100

Most sensitive and specific test for colorectal cancer

Colonoscopy

Do this after have + FOBT

101

IS fecal occult blood testing sensitive or specific for CRC?

NO

Predictive vlue is only about 20%

102

Does UC or Crohns have greater risk for CRC?

UC

103

Familial adenomatous polyposis

AD disease
Colon always involved
90% have duodenum too

100% risk CRC by 30
Prophylactic colectomy

104

Gardner;s syndrome

Polyps + osteomas + detal abnormalities + benign soft tissue tumors

105

Turcot's sydnrome

AR
polyps + cerebellar medulloblastoma or glioblastoma multiforme

106

Hamartomas through GI tract, pigmented spots around lips, oral mucosa, face, genitalia, and palmar surfaces, inussusception risk

Peutz Jeghers

Hamartomas have low malignant potential

107

HNPCC

Lynch 1 - early onset CRC

Lynch 2 - Lynch 1 + increased number and eary occurence of other cancers (female GU, skin, stomach, pancreas)

108

Most common presenting sx of CRC

Ab pain

109

Most common cause of large bowel obstruct in adults

CRC

110

Common R sided CRC symptoms

Melena

obstruction is more rare b/c larger luminal diameter

Change in bowel habits uncommon

111

Triad of R sided CRC

Anemia
Weakness
RLQ mass

112

Common L sided CRC symptoms

Hematochezia

obstructino more comon b/c smaller luminal diameter

CHANGE in bowel habits - yes! Pencil stools

113

Most common sx of rectal cancer

Hematochezia

Rectal cancer has higher recurrent rate and lower 5 year survival rate than colon cancer

114

ACTH stimulation test

Cosyntropin test = During the test, a small amount of synthetic ACTH is injected, and the amount of cortisol, and sometimes aldosterone, the adrenals produce in response is measured

115

If pts are hypotensive due to adrenal sufficiency, can:

+ hydrocrotisol 100 mL TID
+ normal saline
if the above two don't work, add fludrocortisone

116

SIRS criteria

SIRS is a serious condition related to systemic inflammation, organ dysfunction, and organ failure. It is a subset of cytokine storm, in which there is abnormal regulation of various cytokines

Temp < 96.8 or > 100.4
HR > 90/min
RR > 20/min or PaCO2 < 32 mmHg
WBC 12x10^9/L (>12,000/mm³), or 10% bands

117

CHADS2 score

C = CHF
H = HTN
A = age >=75
D = Diabetes
S = previous TIA or stroke or thromboembolism

118

What is heparin induced thrombocytopenia?

In HIT, the immune system forms antibodies against heparin when it is bound to a protein called platelet factor 4 (PF4).
These antibodies are usually of the IgG class and their development usually takes about five days

119

4T score for HIT

Thrombocytopenia
+2 if > 50% fall in platelet count

Timing
+2 if fall is betwen 5-10 days after commencement of treatment

Thrombosis
+2 in new thrombosis, skin necrosis, or systemic reaction

alTernative cause possible (liver function, chemo)
+2 if no other cause possible

120

#1 cause of systolic CHF

MI

121

#1 cause of diastolic CHF

HTN

122

CHF treatment to decrease mortality

Beta blocker (carvedilol, bisproplol, metoprolol)

ACE --| / ARBs
- Candesartan is the only one for diastolic heart failure

Spironolactone (stage 3 or 4 CHF)

Hydralazine + nitrate
- If african american good for it
- use this also if can't use ACE --| or ARBs

AICD (EF < 35%)

Biventricular AICD
Wide QRS and EF < 35% can use this
wide QRS because ventricle desynhrony

123

CHF treatment for symptoms, not decreasing mortality

Digoxin
Diuretics
Millrinone
- For end stage heart failure

124

What's a bad prognostic factor in heart failure?

Hyponatremia

t give more Na!)

125

Cardiorenal syndrome

1) Can have primary heart failure or renal failure that cause failure of the other organ.
- if this is due to heart failure and decreased perfusion of kidney, look diuretics do not help the worsening kidney fuction

2) Can also have kidney congestion when you have too much volume to kidney and the kidney will get more blood
- this gets better wafter diuretics

126

Takotsubo cardiomyopathy

- ST elevation
- + troponins
- when look at with cath, there are no coronary blockages
- This is really due to increase in catecholamines
- can lead to cardiogenic shock and vfb

127

LE edema differential

- cirrhosis
- CHF
- DVT
- venous insufficiency (ACE wraps up to thigh, compression stockings)
- cardiac cirrhosis (bad RHF can cause liver cirrhosis)
- Nephrotic syndrome

128

VRE colonization

VRE, check for colonization via rectal swab

129

MRSA colonization

MRSA, check for colonization via nares swab

130

Third spacing

Third-spacing refers to a situation in which fluid shifts out of the blood into a body cavity or tissue where it is no longer available as circulating fluid.

131

Pathogenesis for normal pressure hydrocephalous

increase in ICP causing ventricular enlargement

Due to:
- diminished CSF absorption at arachnoid villi
- obstructive hydrocephalus

132

What meds do you hold before cardiac stress testing for:

48 hrs:

48 hrs before vasodilator stress test:

12 hrs before vasodilator stress test:

Continue taking:

48 hrs
- beta blockers
- CCB
- nitrates

48 hrs before
- Dipyridamole

12 hrs before:
- Caffeine

Continue:
- ACE ---|
- ARBs
- digoxin
- Statins
- Diuretics

133

What can cause a false + on stress test

Diuretics
- diuretic-induced hypoK can cause ST segment depression and false +

134

Photopsia + floaters + curtain coming down over eyes

Retinal detachment

135

Blurred vision + blunt trauma

Choroidal rupture

Reveals: central scotoma, retinal edema, hemorrhagic detachment of macula

136

Infectious mononucleosis

EBV

TRIAD: High fever + lymphadenopathy + pharyngitis

Also: fatigue + maculopapular rash + posterior cervical lymphadenopathy + splenomegaly

not as much anterior cervical lymphadenopathy

Leukocytosis + atypical lymphocytes

Heterophile antibodies are negative early in illness

Autimmune hemolytic anemia (IgM cold agglutinin)
Thrombocytopenia

137

Focal vertebral pain + no neuro sx

Compression fracture (vertebral body demineralization)

Happens in osteomalacia, osteoporosis

138

Back pain with movement + feel best in morning + perispinal pain

Ligamentous sprains

139

Low back pain + worse as day goes on + relieved with rest

Lumbar disk degeneration

hallmark of lumbar osteoarthritis

140

Pain and progressive limitation of back motion + young men + worse pain in AM

Apophyseal joint arthritis of ankylosing spondylitis

141

testicular fibrosis + azospermia + gynecomastia + increased LH and FSH

Kleinfelter's

142

small testes + normal testosterone + low LH

exogenous steroid use

143

Liver mets characteristics

Colon #1 site mets is to liver
Lung and breast also love to go here

RUQ pain
MILDLY elevated liver enzymes
Firm hepatomegaly

Confirm w/ CT

144

Hypercalcemia secondary to malignancy - how does this happen?

Osteolytic mets
PTrH secretion
increased Vit D formation
Increased IL6 levels

145

Most common COD of pts w/ acromegaly

Cardiovascular

Can get Coronary artery disease, cardiomyopathy, arrhythmias, LVH, diastolic dysfunction

146

Reversible causes of asystole/pulseless electrical activity

5H's and 5 T's

Hypovolemia
Hypoxia
H+ (acidosis)
Hypo/hyperkalemia
Hypothermia

Tension pneumo
Tamponade (cardiac)
Toxins (narcotics, benzos)
Thrombosis (pulm, coronary)
Trauma

147

Tx for pulseless electrical activity w/o palpable pulses

CPR
Epi

148

When do you use early defibrilation?

V fib
Pulseless V tach

149

When do you use synchronized electrical conversion?

Symptomatic / sustained V tach
hemodynamically unstable afib

150

Back pain initial diagnostic test

Plain film Xray

151

Acid fast staining organisms

Nocardia (partly)

TB

152

Tx for nocardia

TMP-SMX (can be used as prophylaxis too)

Minocycline (2nd line)

153

Tx for paget's disease

Bisphosphonates

154

Attributable risk percent

(RR - 1) / RR

155

Inpatient tx of community acquired pneumonia

Outpatient tx of community acquired pneumonia

Inpatient: NEW fluoroquinolones (levofloxacin, moxifloxacin)
Ceftriaxone + azithromycin

Outpatient: azithromycin, doxycycline

Outpt w/ comorbidities - fluoroquinolones

156

What is absolutely contraindicated to give first to pt w/ pheochromocytoma

Beta blocker - will get reflex HTN

Block alpha first, then beta

157

Best initial eval for gallstones

Abdominal ultrasound

ERCP after if US doesn't reveal anything but there is a high suspicion

158

Risk factors for gallstones

Native american
diabetes
obesity
rapid wt loss
oral contraceptive use

Fat, female, forty, fertile

159

Best to dx biliary obstruction

ERCP

160

Best to confirm suspected cholecystitis

HIDA scan

161

usual cause of renal artery stenosis in young adults? older?

YOUNG: fibromuscular dysplasia

OLD: atherosclerosis

162

Contraindications of ACE ---|

Hyperkalemia
bilateral renal A stenosis

163

Tx of choice for fibromuscular dysplasia

Percutaneous angioplasty + stent placement

164

Classic heart sound in MI

S4

Ischemic damage of heart --> diastolic dysfunction --> stiff LV --> atrial gallops (S4)

165

Behcet syndrome

Recurrent oral ulcers + 2 of the following:

- recurrent genital ulcers
- eye lesions (anterior uveitis, etc)
- skin lesions (erythema nodosum, etc)
- + pathergy test

166

#1 cause of hypercalcemia in ambulatory pts
#1 cause of hyperCa in hospitalized pts

Ambulatory: primary hyperPTH

Hospitalized: malignancy

167

Milk alkali syndrome

Risk of this w/ taking in too much Ca or using old absorbable alkali for tx peptic ulcer disease

TRIAD: hyperCa, metabolic alkalosis, renal insufficiency

168

Pathogenic factors involved in developing hepatic encephalopathy

What is hepatic encephalopathy characterized by?

1. Accumulate NH3 in blood
2. Produce false neurotransmitters
3. Zinc deficiency
4. Increased sensitivity of CNS to inhibitor neurotransmitters (eg GABA)

reversal of sleep cycle
asterixis
progressive coma
characteristic delta waves on EEG

169

Malignant potential of polyps

Size (larger --> malignant)
Histo type (villous --> malignant)
Atypia of cells
Shape (sessile = flat --> malignant)

170

Complications of
- diverticulosis
- diverticulitis

Diverticulosis
- painless rectal bleeding
- diverticulitis

Diverticulitis
- bowel obstruction
- abscess
- fistula
- free colonic perforation

171

Dx
- Diverticulosis
- Divertiulitis

OSIS - Barium enema

ITIS - CT w/ contrast (NOT scope or enema)

172

Angiodysplasia of colon
- What is it?
- What are its associations?

Dilated, ectatic thin-walled vessels
Lined by endothelium
Prone to recurrent and chronic PAINLESS bleeding

Assoc w/ aortic stenosis, ESRD
- aortic stenosis --> turbulent blood flow through valve --> disrupt vWB multimers --> increased risk of bleeding --> angiodysplasia
- Uremic platelet dysfunction from ESRD --> increase bleeding risk --> angiodysplasia

173

Acute mesenteric ischemia types

1) Embolic
- usually from heart emboli
- sx SUDDEN + painful

2) Arterial thrombosis
- usually happens w/ CAD
- sx gradual + less severe than embolic

3) Nonocclusive
- due to low CO
- usually in critically ill pts

4) Venous thrombosis
- sx present for many days + gradual worsening

174

Acute Intestinal infarction signs

HypoTN
Tachypnea
Lactic acidosis
Fever
Altered mental status

Can lead to shock

CHECK LACTATE LEVELS IF SUSPECT MESENTERIC ISCHEMIA!!!!

Mesenteric ischemia has > 50% mortality rate!?!?!

175

Dx acute mesenteric ischemia

Mesenteric angiography

176

Chronic mesenteric ischemia

usually due to atherosclerosis

abdominal angina, usually postprandial

Wt loss b/c of fear of eating

177

Ogilvie's syndrome

signs, sx, radiograph shows large bowel obstruction but there is no mechanical obstruct

Causes: recent surgery, trauma, malignancy, anticholinergics, etc

Decomrpress!

178

Most frequent cause of pseudomembranous colitis

Clindamycin
Ampicillin
Cephalosporins

179

Dx pseudomembranous colitis

C diff toxins is stool is diagnostic (need 24 hrs)

180

Dx sigmoid volvulus

sigmoidoscopy

sigmoid colon #1 site for volvulus

181

Dx cecal volvulus

Barium enema???

182

Which volvulus needs surgery?

When do you NOT give barium enema in volvulus

--> cecal volvulus

--> don't give BE if suspect stranulation

183

Most common causes of cirhosis

EtOH liver disease

Chronic viral infection (esp Hep C)

Others:
- drugs - acetaminophen, methotrexiate
- PBC
- autoimmune hepatitis
- R heart failure congestion, constrictive pericarditis
- a1-antitrypsin deficiency
- NASH

184

What do you useto classify severity of liver disease?

Child's Classification

A is mild, C is severe

Factors
- Ascites
- Bilirubin (higher is worse)
- Encephalopathy
- Ntritioalstatus
- Albumin (lowe is worse)

185

Gold standard to Dx liver cirrohsis

Liver biopsy

186

Classic sgns of chronic liver disease

Ascites
Varices
Gynecomastia, testicular atrophy
Pamar erythema, spider angiomas
Hemorrhoids
Caput medusae

187

Tx for esophageal/gastric varices

1) Hemodynamic stabilization
-give fluids to maintain BP

2) Variceal ligation/banding
- endoscopy when stabilized

or

2) Enoscopic sclerothrapy
- inject sclerosingitem into varices
- more risk of rebleed than ligation

3) IV octreotide + prophylactic antibiotics
- cause splanchnic vasocontrit and lower portal P

or

3) IV vasopressin
- not as good as octreotide --> lots of complicatons

188

Long term tx for esophageal/gastric varices

Beta blockers to prevent releed

189

Ascites from liver cirrhosis - what causes it?

- too much fluid b/c of portal HTN so increased hydrostatic P

- hypoalbuminemia (reduced oncotic P)

ONLY get ascites w/ portal HTN

190

Serum ascites albumin gradient (SAAG)

> 1.1 = portal HTN ver likely

<1.1 = portal HTN less likely

191

Tx ascites

Bed rest

Low Na diet

Diuretics (furosemide, spironolactone)

192

Monitoring pts w/ cirrhosis

- LABS: CBC, renal fnt tests, electrolytes, LFTs
- Endoscopy to see if esophageal varices
- CT guided biopsy to see if HCC

193

Tx hepatic encephalopathy

1) Lactulose
- Gut bacteria met of lactulose causes acifification of colonic contents, causing NH3 ---> NH4 (not absorbable --> ammonia trap)

2) Neomycin
- kills gut bacteria so dec ammonia production

3) Diet limiting protein

194

Features of hepatic encephalopathy

- dec mental function, confusion, stupor, coma
- asterixis
- rigidity, hyperreflexia
- fetor hepaticus = musty odor of breath

195

Complications of Liver failure

AC, 9H

Ascites*
Coagulopathy

Hypalbuminemia
portal HTN*
Hyper NH3
Hepatic encephalopathy*
Hepatorenal sx
HYPOglycemia (b/c liver stores glycogen)
HYPERbilirubinemia/jaundice
HyperESTROGEN
HCC

* = most serious complications

196

Causes of spontaneous bacteral peritonitis.

SIgns?

E. coli
Klebsiella
Strep pneumo

SIGNS:
- fever
- change in mental stauts
- ab pain
- rebound tenderness
- all happens in pt w/ known ascites

197

Spider angiomas - what are they?

Dilated cutaneous arterioles w/ central red spot

198

How long abstain from EtOH before get liver transplant (eligibility)?

6 months

199

Wilson's disease

Liver can't excrete copper b/c deficiency of ceruloplasmin

Ceruloplasmin is Cu-binding and needed for excetion

200

Do Kayser fleischer rings interfere w/ vision?

No

201

Tx Wilson's disease

- D- penacillamine

- Zinc (prevents Cu uptake from diet)

- Liver transplant

202

Dx hemochromatosis

ALT and AST

Iron studies

Liver biopsy --> needed for Dx

203

Complicatons of Hemochromatosis

1) Cirrhosis
- increase risk of HCC

2) Cardiomyopathy
- CHF, arrhythmias

3) DM
- iron deposits in pancreas

4) Arthritis
- usually in 2nd and 3rd MCP, hips, knees

5) Hypogonadism

6) Hypothyroidism

7) Bronze like skin

"CHAD CHuB"

204

Complications of hepatocellular adenoma

Usually asymptomatic

Rupture --> hemoperitoneum and hemorrhage is major risk

Resect tumors > 5cm that don't regress after stopping OCP

205

#1 benign liver tumor

#1 malignant liver tumor

Cavernous hemangioma

Malignant
- HCC
Cholangiocarcionmas

206

Dx cavernous hemangioma

US
CT w/ contrast

NOT biopsy b/c risk rupture and hemorrhage

207

Hepatic tumors assoic w/ OCP

Hepatocellular adenoma

NOT focal nodular hyperplasia - but this is in women usually

208

Types of HCC

1) Nonfbrolamellar
- more common
- assoc w/ Hepb B and C
- usually not resectable, short time

2) Fibrolamella
- no Hep assoc
- often resectable, longer survival time

209

HCC risk factors

Cirrhosis
Aflatoxin
Vinyl chloride
Thorotrast
AAT deficiency
Hemochromatosis, Wilson's
Schistosomiasis
Hepatic adenoma
Cigs
Glycogen storage disease type 1 (Von Gierke's)

210

Paraneoplastic sx of HCC

Erythrocytosis
Thrombocytosis
HYPER Ca
Carcionid
Hypertrophic pulmonary osteodrystrophy
HYPO glycemia
High cholesterol

211

HCC tumor marker

AFP

212

Heyde's syndrome

Syndrome of aortic valve stenosis associated with gastrointestinal bleeding from colonic angiodysplasia.

213

Hemobilia

Blood drains into duodenum via common bile duct

Bleed starts anywhere in Hepatobilliary system.

Diagnose with arteriogram

213

GIST marker

c-kit

214

Causes of hemobilia

Clinical features

Trauma, tumors, infection
Papillary thyroid carcinoma
Surgery like cholecystectomy

GI bleed so melons or hematemesis, jaundice, RUQ pain

215

Budd chiari

Block hepatic vein outflow getting hepatic congestion and micro vascular ischemia

Hepatomegaly, RUQ pain, jaundice

Dx via hepatic venography, SAAG

Tx usually needs surgery because thrombocytes may not work. Liver transplant if cirrhosis

216

3 major causes of jaundice

Hemolysis
Liver disease
Biliary obstruction

217

Bilirubin metabolism

Hbg to bilirubin in spleen

Unconjugated bilirubin in plasma bound to albumin and not water soluble so NOT excreted in urine

Conjugated in liver

Excreted into intestine and made into urobilinogen and urobili by gut bacteria

218

Dark urine and pale stools means what?

Conjugated bilirubinemia

Conjugated is soluble so it is the only one to get into the urine.

219

Where are ALTs and ASTs

ALT - liver

ALT is more specific for liver damage

AST - in many tissues like brain, kidney, heart, skeletal muscle

Alcoholic hepatitis usually has higher increase in AST (a scotch and tonic)

220

If AST and alt are mildly elevated....

Moderate....

Severe...

Mild = Think chronic viral hepatitis or acute alcoholic hepatitis

Moderate = acute viral hepatitis

Severe = extensive hepatic necrosis due to ischemia, shock, Tylenol, severe viral hepatitis

221

LFT pearls

Increase in ALP and GGT, small ALT and AST increase = cholestatitic disease

Normal or increase in ALP, very big increase in ALT and AST = hepatocellular necrosis or inflammation

222

ABCDEFGHI of AST or ALT increase

Autoimmune hepatitis
Hepatitis B
Hepatitis C
Drugs or toxins
Ethanol
Fatty liver
Growths (tumors)
Hemodynamic disorders (CHF)
Iron (hemochromatosis), copper (Wilson's), or aat deficiency

223

Cholesterol stone associations

Obesity, diabetes, hyperlipemia

Multiple preggers, OCP

Crohns, illegal resection

Old age

Native American

Cirrhosis

Cystic fibrosis

224

Pigment stone associations

Black
- hemolysis, alcoholic cirrhosis

Brown
- biliary tract infection

225

Boas sig

Cholelithiasis

Referred right Subcapsular pain of biliary colic

226

Pain from

Acute cholecystitis

Biliary colic

Is secondary to what?

Acute cholecystitis
- gallbladder wall inflammation
- several days

Biliary colic
- contraction of gallbladder against obstructed duct
- only a few hrs

227

High sensitivity and specificity test for cholelithiasis

RUQ ultrasound

228

Best for dx acute cholecystitis. What do you see?

RUq ultrasound

Thickened gallbladder wall
Pericholecystic fluid
Distended gallbladder
Presence of stones

CT good for ID complications of acute cholecystitis

HIDA if US inconclusive. Sensitivity and specificity are about the same.

229

Choledocholithiasis

Stones an originate in common bile duct and in gallbladder. Most come from gallbladder

Use ERCP (vs US for cholelithiasis) to dx

Can be asymptomatic for years but if there are symptoms, it is much more threatening than when you get symptoms from cholelithiasis.

230

Charcots triad

Reynolds Pentad

Sign of cholangitis

RUQ pain
Jaundice
Fever

Only in 50-70% cases


Charcots triad + septic shock + altered mental status

231

To do for pts with cholangitis

Blood culture
IV fluids
IV antibiotics after blood cultures obtained
Decompress CBD when patient stable

233

Primary biliary cirrhosis

Features
Clinical presentation
Dx
Tx

Intrahepatic duct destruction leading to portal inflammation and cirrhosis
Vanishing ducts!

Antimitochondrial antibodies

Usually in middle aged women

Can get xanthomas or xanthelasmata, osteoporosis , hepatosplenomegaly, jaundice, statorrhea, portal HTN, osteopenia

Test for AMAs, liver biopsy to confirm disease

Tx with liver transplant. Ursdeoxycholic acid can slow progression of disease

Cholestyramine for pruitus relief

233

Where are most of cholangiocarcinoma tumors?

Proximal third of CBD

Bad prognosis.

Associated with clonorchis sinensis infection in Asia, choledochol cysts

234

Primary biliary cirrhosis

Features
Clinical presentation
Dx
Tx

Intrahepatic duct destruction leading to portal inflammation and cirrhosis
Vanishing ducts!

Antimitochondrial antibodies
Increased IgM
Increased ALP, cholesterol

Usually in middle aged women

Can get xanthomas or xanthelasmata, osteoporosis , hepatosplenomegaly, jaundice, statorrhea, portal HTN, osteopenia

Test for AMAs, liver biopsy to confirm disease

Tx with liver transplant. Ursdeoxycholic acid can slow progression of disease

Cholestyramine for pruitus relief

236

Carcinoid tumors originate from

Neuroendocrine cells usually in appendix

Secrete serotonin

237

Drugs to increase RBC count. How do you tell which one a person took?

Steroids
-- will have gynecomastia, HTN

EPO
--will NOT have gynecomastria, but will have HTN

238

What alcohol poisonings can you do hemodialysis for?

Methanol

Ethylene glycol

239

[Na] in normal saline

154

240

Tx nephrogenic diabetes insipidus

amiloride
HCTZ

Amiloride causes excretion of lithium if that is the cause

241

Amount of fluid restriction to correct hypoNa

800-1000cc

242

Coccidiodomycosis clinical features

SW US
Central and S America

Fever
Fatigue
Dry cough
Weight loss
Pleuritic chest pain
Erythema multiforme
Erythema nodosum
arthralgias

243

Histoplasmosis clinical features

SE, mid atlantic, and central US

Acute pneumonia
- cough
- fever
- malaise

244

Blastomycosis clinical features

South-centrl and north-central US

Lungs
Skin
Bones
Joints
Prostate

245

What is the Well's score most useful for?

people with low probabiliyt of PE

246

Hemochromatosis iron panel

Increased
- Fe
- Ferritin
- Transferrin saturation

Decreased TIBC

247

Cephalization on CXR

= redistribution of blood into the upper lobe vessels.

If hydrostatic P > 10 mHg, fluid begins to leak into interstitum of lung --> excess fluid compresses the lower lobe vessels, perhaps as a result of gravity.

As a result, upper lobe vessels are recruited to distribute a greater volume of blood. In order to carry a greater volume of blood, the upper lobe vessels increase in size

248

Cause of pancreatiis

EtOH
Gallstones
post-ERCP
Viral(mumps, coxsackie)
Drugs (Sulfas, thiazides, furosemide, estrogens, HAART)
Pancreas divism
HYPER TGs
Uremia

249

Ranson's Criteria

To assess prognosis of acute pancreatitis

Admission Criteria (GA LAW)
Glucose > 200 mg/dL
Age > 55yo
LDH > 350
AST > 250
WBC >16,000

Initial 48 hrs (C HOBBS)
Ca < 8 mg/dL
Hct decrease > 10%
PaO2 < 60 mm Hg
BUN increas > 8 mg/dL
Base deficit > 4mg/dL
Sequestration of fluid > 6L

5-6 criteria has 40% mortality

250

How does hypo Ca of pancreatitis happen?

Fat saponification

Fat necrosis binds calcium

251

How do you dx acute pancreatitis

clniical presentation

lab studies are supportive
- Serum amylase and lipase are most sensitive and specific tests for dx acute pancreatitis

CT is confirmatory (most accurate)

252

Acute pancreatitis ab radiograph findings

Sentiel loop - air filled bowel in LUQ - sign of localized ileus

Colon cut off sign - air filled segent of tarnsverse colon cutoff at region of pancreatic inflammation

253

Pancreatic pseudocyst

encapsulated fluid collection appearing 2-3 weeks after acute attack

Has no epithelial lining

Can rupture, get infection, hemorrhage

Dx w/ CT and drain if > 5cm

Can be present at sites distant from pancreas

254

Tx for acute pancreatitis

Most only need supportive pain control, bowel rest, IV fluids, electrolyte corrections

Most don't need more therapy

ERCP if it is severe biliary pancreatitis -- can remove stone. NOT for EtOH pancreatitis

255

Pain control in acute pancreatitis

Fentanyl and meperidine

Not morphine b/c itcauses increase in sphincter of Oddi pressure

256

When give antibiotics for acute pancreatitis

If > 30% of pancreas is necrosed

imipenem

257

#1 cause of chronic pancreatitis

Chronic alcoholism

Methanol can also cause!

258

Classic signs of chronic pancreatitis

steatorrhea
diabetes
pancreatic calcification on CT scan is diagnostic

usually have constant pain radiating to back

ERCP is gold standard to dx

NO elevation of amylase or lipase

NOT pancreatic cancer if this has been ongoing for > 1 year

259

What vitamin deficency can you get with chronic pancreatitis?

Vit B12

260

Classic chronic pancreatitis picture on ERCP

Chain of lakes

areas of strictre and duct dilatation throughout pancreatic duct

261

Tx chronic pancratitis

INsulin

Pancreatic enzymes ( ---| CCK release to decrease secretions from bad pancreas)

H2 blockers (prevents gastric acid made so it doesn't degrade pancreatic enzyme supplements)

262

Pancreatic cancer - risk factors

#1 - SMOKING

Male sex
Black race
Obesity
FH of pancreatic cancer
chronic pancreatitis
CHRONIC diabetes
benzidine, b-naphthylamine

NOT ALCOHOL

263

Painles or painful jaundice in pancreatic cancer?

PAINFUL jaundice

264

Courvoisier's sign

palpable gallbladder

indicates cancer of head of pancreas

265

Dx pancreatic cancer

CT preferred for diagnosis and assessment of spread

ERCP most sensitive but invasive

266

Pancreatic cancer tumor marker

CA 199
CEA (less sensitive and specific)

267

Aortoenteric fistula

Hx of aortic graft surgery who has small bleed of the duodenum

Quickly turns massive and fatal hemorrhage

268

Dieulafoy's vascular malformation

Submucosal dilated arterial lesions causing massive GI bleed

Upper GI bleed

269

Melena

black, tarry liquid foul-smelling stool

due to degradation of Hb by bacteria in colon - further bleed is from rectum, more likely melena happens - usually upper GI bleed

270

Hematochezia

Usually a lower GI bleed

Can be upper GI if it is massive and bleeding is so fast it does not stay in GI tract for long

271

BUN/Cr in GI bleed

BUN/Cr usually increased w/ upper GI bleed, esp if pt has no renal insufficiency

272

When do you use arteriogrpahy for GI bleed?

For pts w/ lower GI bleeding

Perform during active bleeding

273

GI bleed indicatons for surger

- hemodynamicallnstable pts not responding to IV fluid, transfusion, endoscopy intervenions, coagulopathy correctins

- severe inital bleed or recurrence of bleed after endoscope

- continued bleed > 24 hrs

- visible vessel at base of ulcer

- ongoing transfusion requirement

274

Staging esophageal cancer

1 - invades lamina propria or submucosa. nodes -

2a - invades muscularis propria or adventitia; nodes -

---> surgery up to here

--> palliative below

2b - invades up to muscularis propria; nodes +

3 - invades adventita or tumor invades adjacent structions

4- distant mets

275

Achalasia causes

US:
#1 - idiopathic
#2 - adenocarcinoma of proximal stomach

World:
#1 - Chagas

276

Esophageal squamous cll cancer causes

EtOH
Tobacco
Nitrosamines, hot food ingestions
HPV
Achalasia
Plummer Vinson sx

277

Types of esophageal hiatal hernias

Type 1 - Sliding

Type 2 - Paraesophageal

Type 3 - Sliding + Paraesophageal; tx like it is paraesophageal (surgical)

278

Where is Mallory weiss tear?

at Gastroesophageal junction

tear is only mucosal

279

Plummer vinson syndrome

Upper esophageal web --> dysphagia
Iron deficiency anemia
Koilonychia (spoon nails)
Atrophic oral mucosa

280

Schatzki's ring usualy accompaniedby

sliding hiatal hernia

281

Platypnea

Dyspnea relived by laying down, exacerbated by sitting up

Platypnea is due to either hepatopulmonary syndrome or an anatomical cardiovascular defect increasing positional right-to-left shunting (bloodflow from the right to the left part of the circulatory system).

282

Sitophobia

food fear

283

Screening for lung cancer

National Lung Screening Trial
- > 30 pack year smoking history
- low dose chest CT yearly for those who are still smoking or smoked in the past 15 years
- shows to have decreased motality but no long term data

284

Transudative pleural effusion causes

Due to increased hydrostatic or decreased oncotic P

CHF
Cirrhosis
PE
Nephrotic syndrome
Peritoneal dialysis
Hypoalbuminemia
Atelectasis

285

Exudative pleural effusion causes

Caused by increased capillary permeability

Bacterial pneumonia, TB
Malignancy, mets
Sarcoidosis
Rheumatoid arthritis
Viral infection
PE

286

Paraneoplastic syndrome of Small cell lung cancer

SIADH
ACTH
Lambert Eaton
Hypertrophic osteoarthropathy - It is characterized by new bone formation on the outside of the diaphyses of long bones of the limbs, without destruction of cortical bone

287

Chylothorax pleural effusion - what is in the fluid?

Common causes of it

Triglycerides >110mg/dL

Cancer
Trauma

TB
Chronic mediastinal infections
Sarcoidosis
Lypmhangioleiomyomatosis
Radiation fibrosis

288

Absolute neutrophil count

(% neutrophils + % bands) * WBC / 100

289

Chemtherapy transfusion reaction - what do you do?

Shortness of breath, rash are red flags

Give
- all things to inhibit all histamines (benadryl, pepcid)
- epinephrine
- steroids

Evaluate

Call oncologist

290

Traction diverticula

true

At midpoit of esophagus near tracheal bifurcation

Due to traction from contiguous mediastina inflamation and adenopathy (pulmonary TB)
--> TB causes hilar node scarring causing retraction of esophaus

291

Epiphreic diverticula

- lower 1/3 of esophagus
- usually assoc w/ spastic esophageal dysmotility or achalasia

292

Associated blood type of duodenal ulcer? Gastric ulcer?

Duodenal - O

Gastric - A

293

Risk factors of duodenal ulcer? Gastric ulcer?

Duodenal - NSAIDs

Gastric - Smoking

294

#1 nephrotic syndrome associated w/ Hodgkin's lymphoma

Minimal change disease

295

#1 nephropathy associated w/ carcionma

Membranous glomerulonephritis

296

Conn's syndrome lab values

HTN
Mild hyper Na
HYPO K
Metabolic alkalosis (decreased bicarb)

297

Reason for oxalate stones in Crohn's, small bowel resection

Happens in IBD, small bowel resection, other malabsorption syndromes

Increased intestinal fat binds dietary calcium --> can't bind oxalate in gut --> oxalate gets reabsorbed adn precipitates in kidney

298

Define the following therapies:
- Salvage
- Adjuvant
- Consolidation
- Induction
- Maintenance
- Neoadjuvant

Salvage = form of tx for disease when standard tx fails

Adjuvant = therapy given in addition to standard tx

Consolidation = given after induction therapy to really wipe out tumor cells

Induction = initial tx to kill tumor cells to send pt into remission

Maintenance = given after induction and consolidation to ensure remission

Neoadjuvant = tx given before standard tx

299

Reddish nodule --> ulcerates --> spreads forming subQ nodules and ulcers

No adenopathy or systemic signs

What is the offending agent?

Sporothrix schenckii

299

Reddish nodule --> ulcerates --> spreads forming subQ nodules and ulcers

No adenopathy or systemic signs

What is the offending agent?

Sporothrix schenckii

300

Elderly + dementia + severe depression + very concerned about memory loss

Tx?

Pseudodementia

SSRIs

301

HTN Hx + unilateral weakness + no changes on CT

Lacunar infarct

microatheroma and lipohyalinosis

Most commonly in internal capsule

302

HTN Hx + unilateral weakness + no changes on CT

Lacunar infarct

microatheroma and lipohyalinosis

Most commonly in internal capsule

304

Severe symptomatic hyper Ca
- What happens?
- How do you tx?

Hypercalcemia --> induces salt wasting --> significant volume depletion

Volume depletion causes more reabsoption of solutes, hence more reabsorb of Ca

Tx w/ normal saline (200 mL/hr) + calcitonin + bisphosphanates to reduce serum Ca levels and restore back volume

305

Sudden loss of vision
Onset of floaters
Fundus is difficult to visualize

Vitreous hemorrhage

#1 cause of vitreous hemorrhage is diabetic retinopathy

306

Sudden painless, unilateral loss of vision
HTN hx perhaps
Disk swelling, venous dilation, cotton wool spots, retinal hemorrhages

Central retinal vein occlusion

307

Pellagra

- what is it
- causes of it
- symptoms

It is niacin deficiency

Corn based diet
Alcoholics
Carcinoid sx patients
Hartnup's disease

Diarrhea + Dermatitis + Dementia
- skin rash in sun exposed areas (can look malar rash!)

REMEMBER PELLAGRA when you see malar rash + diarrhea. SLE doesn't have diarrhea

308

Fever in neutropenic patient

> 100.9 F
> 100.4 F for more than 1 hr

309

Febrile neutropenia

Happens when neutrophil count is low
Neutropenia = absolute neutrophil count < 1500/microL

310

What should tx of febrile neutropenia cover?

Monotherapy?

Combo therapy

Pseudomonas

Monotherapy: ceftazadine, imipenem, cefepime, meropenem

Combo: aminoglycoside + anti-pseudomonal beta lactam

311

#1, #2 muscles involved for myasthenia gravis

1 - extraocular muscles

2 - muscles of jaw (bulbar muscles)

CPK usually normal in myasthenia gravis

312

Myasthenia gravis vs. primary muscle problem - what lab value is helpful to distinguish?

CPK normal in MG

313

Myasthenia gravis vs. ALS

normal reflexes in MG

314

Toxoplasmosis
- Tx
- Prophylaxis

Tx = Sulfadiazine + pyrimethamine

Prophylaxis = TMP-SMX

315

Rapid plasma reagin test

Screens for syphillis

316

anti-thyroperoxidase antibodies + enlarged rubbery goiter

- What am I at risk for?

Hashimoto's

Lymphoma of thyroid (60x)

Dx via core biopsy as FNA may miss diagnosis

317

Normocytic anemia +
Hyper Ca +
Renal failure +
Elevated total serum protein w/ normal albumin

Multiple Myeloma

Mnemonic: CRAB
- Calcium
- Renal impairment
- Anemia
- Bones (pain, lytic lesions)

HyperCa because of bone lysis from plasmocyte-released humoral factors and expanding plasma cell mass

Hyper Ca can present as CONSTPATION!

318

Can you see MM lesions on bone scan?

No

There is no associated new bone formation

Use skeletal survey (xray)

319

Thrombocytopenia +
Hemolytic anemia (increase in indirect Bili, decrease Hg, increase retic count) +
Altered mental status +
Renal failure

TTP-HUS

Peripheral blood smear to tell if there are schistocytes

320

Colloid solutions used to..

in burns or conditions w/ hypoproteinemia

321

Classic signs of dehydration

Dry mucosa
Marginally high Hct, electrolytes
BUN/Cr > 20

Tx w/ intravenous crystalline solution (normal saline)

322

How does respiratory alkalosis happen in preggers?

Progesterone stimulates medulla respiratory centers

This leads to tachypnea --> resp alkalosis

323

Digital Rectal Exam signs for
- BPH
- Prostate cancer

BPH - smooth, firm enlargement of prostate

PC - palpable nodule at periph of prostate

324

If get ROS and PE suggestive symptoms of BPH, what is the first thing to do?

Ab ultrasound to look for hydronephrosis
- put in catheter if needed

325

What test do you use to evaluate spinal stenosis?

MRI

326

Alterations in consciousness + disorganized speech + visual hallucinations + Extrapyramidal symptoms

Lewy Body Dementia

327

Pickwickian syndrome (obesity hypoventillation syndrome)

Obesity impedes expansion of chest and ab wall during breathing

Underventillation of lungs and chronically elevated PaCO2, decreased PaO2

Abnormal ABG

328

Causes of blood diarrhea - bacterial

CSS YE

Campylobacter
Shigella
Salmonella
Yersinia
E. coli

329

HIV pt + bloody diarrhea + normal stool exam

Highly suspicious for CMV

330

Electrolyte risk with immobilization (eg paralysis)

Hypercalcemia

-possibly due to increased osteoclastic bone resorption
- tx w/ hydration + bisphosphonates

331

Rhabdomyolysis electolyte imbalance

HYPO Ca
Ca preceipitates w/ PO4 b/c it is released from damaged muscles

332

Prinzmetal's angina
- Risk factors
- Tx

Smoking is risk factor

Tx
- CCB
- nitrates

333

Prior sensitization is needed for phototoxic or photoallergic drug?

Photoallergic

Phototoxic does not need prior sensitization for drug eruption - an example is tetracyclines

334

Prior sensitization is needed for phototoxic or photoallergic drug?

Photoallergic

Phototoxic does not need prior sensitization for drug eruption - an example is tetracyclines

335

Strk + no hemorrhage on CT w/o contrast + within 4.5 hrs after onset, what is best med to give to improve neuro outcomes?

tPA

(NOT STREPTOKINASE)

336

Endotracheal intubation common common complication

Right mainstem bronchus intubation causng asymmetric chest expansion during inspiration and markedly decreased or absent reath sounds on the L side

337

Endotracheal intubation common common complication

Right mainstem bronchus intubation causng asymmetric chest expansion during inspiration and markedly decreased or absent reath sounds on the L side

338

Manifestatons of Sarcoidosis

Pulm - Bilateral hilar adenopathy

Eye - uveitis

Heme - Lymphadenopathy, Hepatomegaly, splenomegaly

MS - polyarthriis

CNS/Endo - Central DI, Hypercalcemia (makes a1-hydroxylase), increased ACE

Lofgren's syndrome - erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever

339

Lofgren's sydnrome

erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever

340

Lofgren's sydnrome

erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever

341

NF-2 genetics

Autosomal dominant
Severe disease casued by frameshift or NONSENSE mutations

Less severe are missense

342

Bradycardia +
AV block +
HypoTN +
Diffuse wheezing

Beta blocker toxicity

Tx w/ glucagon

Wheezing indicative of bb toxicity
Can also get cold and clammy due to cardiogenic shock from bradycardia and hypoTN

343

Most common origin of ectopic foci for afib

Pulmonary vein

344

#1 cause of atrial flutter

reentrant circuit rotating around tricuspid annulus

345

Analgesic abuse nephropathy

Tubulointerstitial disease
Characterized by focal glomerulosclerosis

346

Hyperglycemic nonketotic state is not symptomatic until what glucose level

600 mg/dL of glucose in blood

get altered mental state

347

Cardiac cath complications

Arthroembolism (cholesterol) --> dislodges anywhere

Common sequelae of embolism:
- Blue toes
- Increase Cr

348

Optic neuritis sx

- Pain with eye mvmt
- Change in color perception
- Afferent pupilary defect and field loss
- papilledema

- more in fems, multiple sclerosis

349

Tx Bacillary angiomatosis

Oral Erythromycin

350

How long does heart transplant last?

~10 years

Nerves severed so be careful of atypical MI
- palps, diaphoresis, but no chest pain

351

When do you admit a pyelonephrtis patient?

Usually if they can't meds PO b/c vomitting too much

352

Emphesematous cholecystitis
- what is it?
- how does it happen?
- clinical manifestaitons

Acute choecystitis arising b/c of infection w/ gas forming bacteria (Clostridium, Escherichia, Staph, Strep, Pseudomonas, Klebs)

- Due to vascular compromise (stenosing of cystic A), immunosuppression (DM2), gallstones

- Crepitus in ab wall adjacent to gallbladder is occasionally detectable - NO peritoneal signs though

Dx w/ ab radiograph

only a small increase in bilirubin or AST/ALTs

353

underlying path of lateral epicondylitis

Degeneration of extensor carpi radialis brevis tendon near the lateral epicondyle

354

What restrictive lung disease doesn't respond to steoids?

Idiopathic Pulmonary FIbrosis

355

#1 finding in interstitial lung disease on PFTs

Decreased diffusion capacity to CO

356

What kind of age distribution for diagnosis does Crohns have?

Bimodal

357

How much blood do you ave to lose to become tachycardic? Orthostatic?

Tachy - 15%
Ortho -30%

358

#1 cause of septic arthritis

Staph aureus

359

Beck's triad

Cardiac tampanode

- hypotension
- distended neck veins
- muffled heart sounds

- pulsus paradoxus

360

Young black male + painless hematuria. What do you expect? How does it happen?

Sickle cell trait

Episodes of painless hematuria are classic

Papillary ischemia is possible cause

361

Tx of stroke in sickle cell patient

Exchange transfusion
- decreases % of sickle cells in blood and another stroke of happening

Continue hydroxyurea

362

EKG finding of supraventricular tachycardia

Narrow QRS complex

363

Renal artery stenosis occurs most commonly w/ which nephrotic syndrome?

Membranous glomerulonephritis

Sudden onset
- ab pain
- fever
- hematuria

364

Most specific arrhythmia for digoxin toxicity

Atrial tachycardia w/ AV block

Digoxin increases vagal tone thus decreasing conduction through AV node
Digoxin also increases ectopy in the atria and venticles

Rare for atachy + AV block together so pretty specific for dig toxicity

365

Secondary AA amyloidosis

Results from deposition of acute phase reactants (serum amyloid A) in setting of chronic inflammatory disease (psoriasis IBD, rheumatoid arthritis)

Nephrotic syndrome common, hepatomegaly

366

Elevated BUN + no increase in Cr

OR

Increased BUN/Cr

Pts receiving steroid treatments

Prerenal renal fail

GI bleed

367

Most common feature of hemophillia

Hemarthroses

368

Acute monocytic leukemia features

Bleeding gums
Leukocytosis + lots of blast forms
Staining - + alpha-naphthyl esterase
peroxidase (-) b/c lack auer rods

369

How do you tell the difference between peripheral vascular disease (arterial stenosis) and venous insufficiency?

Artery - shiny, hairless skin

Vein - skin discoloration (purple/pink), hair is ok, edema

370

Normal skin at birth --> dry skin w/ horny plates over extensor surfaces of limbs

Ichthyosis vulgaris

371

Blood transfusions received before
1992
1986
1980s
Should be screened for...?

1992 - Hep C
1986 - Hep B
1980s - HIV

372

Essential tremor

Stable at rest

Usually noticeable when pt attempts to do something requiring fine movement

Tx w/ beta blocker - propanolol
anticonvulsants - primidone
topiramate
benzos - clonazepam

373

Parkinson's tremor

Worse at rest (4-6 Hz)

Better when try to do something

Asymmetric, assoc w/ rigidity

374

Dx acute MI

Dx reoccurence of MI

Acute - Troponin T (takes longer to return to normal)

Reoccurence - CK-MB

375

What do you give for all that have high risk of developing aplastic crisis

Folic acid

376

If someone says they got something in their eye

High velocity...

- don't see anything with penlight
- use fluorescein exam (slit lamp, etc)

- never use MRI because it will risk dislodging the item
- use CT or Ultrasound

377

Dyspnea + fever + cough (nonproductive)
Tachypnea + cyanosis + minimal chest findings
Bilateral diffuse interstitial infiltrates beginning in perihilar region

P. jirovecei

378

Most common places for perihilar involvement of P. jiroveci

lymph nodes
spleen
liver
bone marrow

379

HIV pt with CD4 count < 50 / mm3 should receive what prophylaxis against what?

Mycobacterium avium complex
-->Azithromycin

CMV (but also if serum CMV IgG is +)
--> Ganciclovir

380

Metabolic syndrome diagnosis

3/5 present:

1. Ab obesity (> 40 inc men, > 35 inc women)
2. Fasting glucose > 100 -110 mg.dL
3. BP > 130/80 mm Hg
4. Triglycerides > 150 mg/dL
5. HDL (Men < 40 mg/dL; women < 50 mg/dL)

381

Bloody diarrhea bacterial causes

Campylobacter
Shigella
Salmonella
Yersinia
E coli

E coli doesn't have a fever sometimes (vs the other) and has more ab pain than the others - that's how you tell the difference

382

Pts w/ cirrhosis - what do you do for them first?

Endoscopy ASAP - esophageal varicies are a big bleed risk. Use beta blockers to prophylactically decrease risk of bleeding.

383

SLE + anti-ds DNA antibodies

First step in tx?

Kidney biopsy

- informs different nephritis treatments
- is baseline to compare other biopsies to monitor disease progression

384

Equation for anion gap

AG = Na - (HCO3 + Cl)

385

What is cor pulmonale most commonly caused by?

COPD

Less frequent:
- Pneumoconiosis
- Pulmonary fibrosis
- Kyphosis
- Primary pulmonary HTN
- repeated episodes of PE

386

Cause of S3

Reasons for S3

Tx for symptoms for abnormal S3
Tx for long term for abnormal S3

Inflow from L atrium strikes blood already in LV causing an extra sound

Normal in younger athletes and preggers

Abnormal - usuall sign of left ventricular failure

Tx symptoms - diuretics
Tx long term - beta blockers

387

Atypical lymphocytes Ddx

VACTER RM

Viral hepatitis
Acute HIV infection
CMV
Toxoplasmosis
EBV (mono)
Rubella

Roseola
Mumps

388

What diabetes medication do you hold on hospital admission? Why?

Metformin

Metformin gets processed by liver and excreted by kidney. If kidney excretion is bad, will build up metformin and get lactic acidosis.

If pt needs CT w/ contrast, can possibly get renal damage and will decrease ability to excrete metformin.

389

When do you stop colonoscopy screenings?

85 yo

390

Best test to evaluate pt w/ epigastric pain

Upper GI endoscopy
Can diagnose:
- PUD
- gastritis
- esophagits
- rule out cancers of esophagus and stomach
- H. pylori infection w/ biopsy

391

Mets of gastric carcinoma

Krukenberg - mets to ovary

Blumer's shelf - mets to rectum (can feel on rectal)

Sister mary joseph's node - mets to periumbilical lymph node

Virchow's node - mets to supraclavircular ofssa nodes

Irish's node - mets to left axillary adenopathy

392

Risk factors for gastric carcionma

atrophic gastritis
gastric polyps
H. pylori
Pernicious anemia
Nitrates diet
Blood type A

393

Most common malignancy in asbestosis patients

Bronchogenic carcionma

394

Causes of renal transplant dysfunction in early post-op period

Tx?

Ureteral obstruct
acute rejection
cyclosporine toxicity
vascular obstruct
ATN

IV steroids best tx

395

Effects of an AV fistula

Decreases systemic vascular R

Increases cardiac preload

INcrease cardiac output

Widens pulse pressure
Strong arterial pulsation (brisk carotid upstroke)
Systolic flow murmur
Tachy
Flushed extremities

LV hypertrophy
PMI displaced to left

396

How can you have heart failure in AV fistula pts?

Heart still pumps lots of CO but circulation is unable to meet O2 demand of peripheral tissues

397

High output cardiac failure causes

Thyrotoxicosis
AV fistula
Paget disease
Anemia
Thiamine deficiency

398

Congenital AV fistula causes

PDA
Angiomas
Pulmonary AVF
CNS AVF

399

Acquired AV fistula causes

Trauma
Femoral cath
Aortocaval fistula (eg atherosclerosis)
Cancer

400

Tx Meniere's disease

Decreasing triggers that increase endolymphatic retention

Avoid:
- EtOH
- Caffeine
- Nicotine
- Foods high in salt

401

Do you need to bridge heparin and warfarin in pts w/ afib? DVT?

A fib - NO!
- Your protein C and S levels are normal so if start warfarin without bridging, will have a slight depletion of C and S but not enough to cause necrosis
- heparin use if want to cardiovert someone

DVT - yes!
- Body is actively depleting protein C and S to try and break up clots
- if add warfarin without heparin, you're going to decrease C and S even more and will definitely have necrosis

402

Hypertension in pts w/ thyrotoxicosis

Predominantly SYSTOLIC HTN, w/ increase in pulse pressure

Caused by hyperdynamic circulation due to hyperTH. Possibly due to increased expression of myocardial SR Ca-dependent ATP

403

Managing Nephrolithiasis

Imaging
- helical CT highest sensitivity and specificity

Pain
- Narcotics and NSAIDs if have normal renal function
- NSAIDS better because narcotics can worsen N/V

Size of stone
- < 5 mm = pass spontaneously, drink lots of fluids

Urology consult
- if anuria, urosepsis, acute renal fail

404

Multiple sclerosis CSF findings

Oligoclonal bands (mostly IgG)

405

Most important contributor to CHF edema

Increased renal sodium retention

Results from RAAS due to renal hypoperfusion secondary to decreased CO

406

Pathophysiology of non-EtOH fatty liver disease

Insulin resistance --> fat accumulation in hepatocytes by increasing rate of lipolysis and elevating circulating insulin levels --> intrahepatic fatty acid oxidation --> increase in oxidative stress --> local increase in proinflammatory cytokines TNF-a --> liver inflammation, fibrosis, cirrhosis

407

Immediate goal of managing pt w/ confusion if hx is limited

Tx potentially reversible causes of confusion

Thiamine --> Wernicke's encephalopathy
Dextrose --> hypoglycemia
Supplemental O2 --> hypoxia
Naloxone --> Opiate OD

408

Major cause of morbidity and mortality in SAH pts

Vasospasm of arteries at base of brain

Signs of ischemia happen about 7 days after SAH

Use CCB to prevent!

409

Warm agglutinin disease
- what is it
- causes
- tx

IgG

Extravascular hemolysis --> splenomegaly

May have spherocytes

Causes
- lymphoma, leukemia (CLL)
- SLE
- a-methyldopa

tx w/
- steroids
- rituximab
- splenectomy
- immunosuppressive drugs

410

Cold agglutinin antibody disease
- what is it
- causes
- tx

IgM

Intravascular (activates complement --> hemolysis)

Causes:
- Mycoplasma pneumoniae
- EBV

tx w/
- supportive care
- RBC transfusions
- NOT steroids

411

Common causes of priapism

Sickle cell
Leukemia
Perineal or genital trauma (laceration of cavernous artery)
Neurogenic lesions (spinal cord, cauda equina compression)
Meds - trazodone, prazosin (#1)

412

What spinal process are diabetics prone to develop?
- How do you dx?

Epidural abscesses

Do an MRI to eval cord compression

413

Spontaneous bacterial peritonitis
- Ascitic fluid Dx
- When do paracentesis?
- Most commonly cultured organisms
- Empiric therapy?

Dx: + ascitic culture, PMN > 250 / mm3

When: Before antibiotics

Org: E coli, Klebsiella

Empiric tx: 3rd gen cephalosporin

414

Acute aortic dissection presentation

HTN (not HYPO)
Tearing chest pain
Unequal pulses

Early diastolic murmur - dissection causes aortic regurg

415

Presentation of influenza

When does tx need to start?

Leukopenia
Acute onset fever, chills, cough, malaise, myalgias, coryza

Antiviral therapy (ostltamivir) must be started w/in 48 hrs to significantly decrease duration and severity

416

SLE hemotologic abnormalities

Anemia (warm agglutinin hemolysis)

Thrombocytopenia (like ITP in Ab formed against platelets)

Neutropenia (Ab-destruction of WBC)

417

Medial medullary syndrome

Occlusion of vertebral artery/branch

Contralateral paralysis of arm and leg
Contralateral loss of tactile, vibratory adn position sense

DEviation of tongue to injured side

418

Wallenberg syndrome

Lateral medulla injury

Ipsilateral Horner
Contralateral loss of pain and temperature sensation on body

Loss of pain and temp of face
weakness of palate, pharynx, vocal cords

cerebellar ataxia

419

Acute pericarditis EKG

Diffuse ST elevations

PR depressions

420

Breath sounds over consolidated lung retions

LOUDER + more prominent expiratory component if airways are patent
- egophony also present
- crackles

- decreased if airways are blocked

421

Acalculous cholecysititis commonly seen in pts...

1. Extensive burns
2. Severe trauma
3. Prolonged TPN
4. Prolonged fasting
5. Mechanical ventillation

422

Zenker's diverticulum
- Where?
- Why?
- Dx?
- Tx?

Happens right above UES by herniating POSTERIORLY between fibers of crcopharyngeal muscle

Motor dysfunction and incoordination responsible for problem
Can sometimes see the outpouching in the neck!

Dx - contrast esophogram to clearly show diverticulum

Surgical tx = excision and cricopharyngeal myotomy

423

When do you do a carotid endarterectomy?

"Symptomatic" carotid stenosis of 70-99%
Asymotompatic stenosis of 60-99%
Low surgery risk
Good 5 year predicted survival
Accessible lesin

<50% - just aspirin

424

When do a carotid angioplasty w/ stenting?

High surgical risk
Poor 5 year survival

NOT for asymptomatic pts

425

DVT anticoagulation contraindications

How do you tx?

Recent surgery
Hemorrhagic stroke
Bleeding diathesis
Actve bleeding

IVC filter

426

Cluster headache features

Intense unilateral retroorbital pain, usually waking pt up from sleep
Starts suddenly, peaks rapidly, lasts 2 hrs
More in men

Redness of ipsilateral eye, Horner's, runny nose, tearing

427

Causes of macrocytic anemia

Folate deficiency
B12 deficiency
Orotic aciduria

Myelodysplastic syndrome
Acute myeloid leukemias

Drugs

Liver disease
EtOH abuse
HYPO thyroid

428

Pernicious anemia

#1 cause of B12 deficiency

Usuall have other autoimmune d/o (thyroid, vitiligo)

Shiny tongue (atrophic glositis)
Ataxia (shuffling, broad based)
DCMLS deficit

429

How long do you have to be on a pure vegan diet to replete your B12 stores?

Folate stores?

B12 - 4-5 years

Folate - 4-5 months

430

Extraintestinal manifestations of UC

Sclerosing cholangitis
Uveitis
Erythema Nodosum
Spondyloarthropathy

Toxic megacolon
Colon cancer

431

#1 valvular abnormality in infective endocarditis (not IV drug use related)

Mitral regurgitation

432

Urinalysis:
Gluc - negative
Ketones - trace
LE - negative
Blood - Large
RBC - 0-1
WBC - 5-10

What do you suspect?

Rhabdomyolysis --> myoglobinuria

ALWAYS suspect this if test results have large amt of blood on UA but absence of RBCs on microscopy

433

Altered mental status causes

Decreased glucose
Decreased Na
HYPO thyroid

Increased Ca
Uremia
NH3
Increased CO2

434

Can you gain wt with cancer?

YES!

Hyper ACTH of small cell --> Cushings --> fat redistribution

435

Ectopic ACTH causes

Lung cancer
Carcinoid
Pancreatic cancer
Neuoendocrine tumors

436

Important electrolyte disturbance w/ SAH

Hyponatremia --> Cerebral salt wasting syndrome

1) Inappropriate secretion of vasopressin --> water retention

2) Increased secretion of ANP/BNP --> cerebral salt wasting

3) SIADH also commonly seen

437

What lab values are best representations of acid base status?

pH
PaCO2

438

Pronator drift

Sensitive an specific for UMN lesion

UE supinators naturallyw eaker than pronators - exaggerated in pts w/ UMN lesion

Extend arms wti palms up, affected arm will tend to pronate ad drift down

439

Most common site of hypertensive hemorrhage (intracerebral)
- features on PE

Putamen (35%) - BASAL GANGLIA!
Internal capsule lying adjacent almost always involved--> hemiparesis

Cerebellum (16%), thalamus, and pons also common

Motor deficits opposite site of lesion
Gaze deviation TOWARDS side of lesion

440

What's the best way to improve LV function in pt with tachysystolic afib?

Control rhythm or rate

441

Uremic coagulopathy

Abnormal hemostasis seen in pts w/ CRF

Abnormal bleeding and bruising are characteristic

Guanidinosuccinic acid is #1 uremic toxin implicated in pathogenesis of platelet dysfunction seen in CRF

PTT and PT and TT usually normal

Bleeding time usually prolonged
Platelet count normal, platelet dysfunction present

442

Extrarenal complicatins of ADPKD

Hepatic cysts (#1)

Berry aneurysm

MV prolpse
Aortic regurg

Colonic diverticula

Ab wall and inguinal hernia

443

Extrahepatic sequelae of chronic hep C

Chronc arthralgia (false + RF or ANA)
Cryoglobulinemia
Porphyria cutanea tarda
Membranoproliferative glomerulonephritis
B cell lymphomas
Plasmacytomas
Sjogren's, thyroiditis
Lichen Planus
Idipathic thrombocytopenic purpura (ITP)

444

FeUrea

< 35% = pre-renal azotemia

> 35% = intrinsic renal failure

445

FeNa

< 1%
- prerenal
- the physiologic response to a decrease in renal perfusion is an increase in sodium reabsorption to control hyponatremia, often caused by volume depletion or decrease in effective circulating volume (e.g. low output heart failure).

> 2-3%
- ATN or kidney damage
- either excess sodium is lost due to tubular damage, or the damaged glomeruli result in hypervolemia resulting in the normal response of sodium wasting.

446

Risks for contrast induced nephropathy

FeNa < 1
Diabetes
Decreased GFR

447

Black currant jelly stools

Intusuception

448

How do you decide how and where to tx a patient with pneumonia?

CURB-6
C = Confusion
U = Urea (BUN > 20)
R = RR > 30
B = systolic BP = 65

0-1 = outpt, 2 = admission

449

Facticious thyrotoxicosis - labs

Hyperthyroidism signs (no goiter or exophthalmos though)

LOW TSH
HIGH T3 and T4

Dx w/ 24 hr radioiodine uptake test --> diffusely decreased iodine uptake by thryoid

Biopsy = follicular atrophy

450

Reasons for pain postcholecystectomy

1) Sphincter of oddi dysfunciton
- abnormal ALP
- dilatation of biliary tree
- high pressure of sphincter on manometry

2) common bile duct stone
- abrnomal ALP
- dilatation of biliary tree

3) functional pain
- normalLFTs
- no dilatation of biliary tree
- diagnosis of exclusion

451

When do a cholecystectomy?

Indicated for all pts w/ symptomatic gallstones (eg pancreatitis) who are medically stable enough for surgery

452

Mass in anterior mediastinum

Thymoma
Retrosternal thyroid
Teratoma
Lymphoma

Dx w/ CT scan

453

Mass in middle mediastinum

Bronchogenic cysts
Tracheal tumors
Lymph node enlargement
Aortic aneurysms of arch
Pericardial cysts

454

Mass in posterior mediastinum

Neurogenic tumors
- meningocele
lymphoma
diaphragmatic hernias
esophageal tumors
aortic aneurysms

Dx w/ MRI

455

How do you decrease risk of contrast-induced nephropathy?

Use non-ionic contrast agents

456

Tricuspid valve endocarditis + pleuritic pain + cavitating lung nodules on xray

Staph aureus

septic embolism to lungs from staph IV use

457

Dilated cardiomyopathy causes

Alcohol
Adenovirus
Beri beri
Coxackie
Chagas
Cocaine
Doxorubicin/Danorubicin
Enterovirus

Hemochromatosis
HHV 6
Parvovirus B19
Peripartum cardiomyopathy

458

Tx after diagnose solid testicular mass suggestive of cancer (via US)

Radial orchiectomy
- remove testis and associated cord

459

Diabetes insipidus features

Polyuria
Polydipsia
DILUTE urine w/ increased serum osmolality

Pts prefer cold water

460

Primary polydipsia features

Excessive water drinking

Both plasma and urine are diluted

461

SIADH features

Hyponatremia
Low serum osmolality
Inappropriate high urine osmolality
Hypouricemia and low BUN
Normal or reduced Cr b/c of dilution
Euvolemia

462

Osmotic diuresis features

Happens w/ hyperglycemia, glucosuria, mannitol admin

Urine and serum osmolality elevated
Urine > serum

463

Pap smear screening guidelines

Start at 21 no matter if sex active

21-30:
- screen every 2 years

> 30 w/ 3 consecutive (-) paps, screen every 3 years

If have CIN II/III, screen w/ pap smear every 6 months until 3 negatives obtained
- then resume standard (annual) screening

464

What should all chronic hep C people get?

Vaccinations to Hep A and B if not already immune

465

Heat stroke
- characteristics
- consequences

Body temp > 105

Dehydration common --> hot, dry skin and hypotension, tachycardia, tachypnea, hemoconcentration

Seizures
ARDS (scattered rales on exam)
DIC (low platelets, increased PT/PTT) - eg epistaxis
Hepatic/renal failure

466

Electrical alternans

Pathognomonic for pericardial effusion

Due to swining motion of heart in pericardial cavity causing beat to beat variation in QRS axia adn amplitude

EA + sinus tachy very specific for pericardial effusion

467

Mixed cryoglobulinemia

Palpable purpura
Proteinuria
Hematuria (RBC casts)

Arthralgias
Hepatospelnomegaly
Low complement

HCV infection usually

468

Colon cancer screening

Start age 50 or 10 years before 1st diagnosis in family member

Do every 10 years for average risk

469

Mammogram screenings

age 50 - 75
- every 2 years

>75
- NONE!

470

Common complication of CABG

Afib

Rate of afib increases w/ CABG + aortic valve replacement

471

Pickwickian syndrome (Obesity Hypoventilation syndrome)

Severe obesity + alveolar HYPOventilation during wakefullness + thick neck

Low voltage QRS on EKG
Polycythemia secondary to hypoventilation

472

Smoking cessation cardiovascular benefits

LITTLE effect on BP reduction

Significantly reduce risk of cardiovascular disease

473

Risk factors for osteosarcoma

Radiation
Chemo
Paget's

474

Osteitis fibrosis cystica

Due to HYPER PTH
Osteoclastic resorption --> replace bone w/ fibrous tissue (brown tumors)

475

Wernicke's encephalopathy

Triad
Altered mental status
Ataxia
Nystagmus, conjugate faze palsy

DOES NOT cause asterixis

476

Chalazion

Painful swelling --> nodular rubbery lesion

Is a chronic granulomatous condition happening when meibomian gland becomes obstructed - chronically can be due to sebaceous carcinoma

Need to do biopsy-histo to see what it is so make sure it's not basal cell carcinoma

477

Hordeolum

Stye
Acute infection of gland of eyelid

Use antistaph meds

478

Indicators for severity in pancreatitis

Hgb
Cr

479

Clubbing

Chronic hypoxia
NOT in COPD though

If COPD has clubbing, there is another hypoxic event happening on top of the COPD

480

UA vs. NSTEMI vs. STEMI features on EKG and Labs

UA - (-) trop, nonspecific EKG

NSTEMI - (+) trop, ST depressions, T wave inversions

STEMI - (+) trop, Q waves

481

Electrolyte abnormalities of chronic alcoholism

Hypomagnessemia
Hypokalemia
Hypophosphatemia

482

Hypomagnesia
- consequences
- importance of Mg
- how to correct
- causes of it

Can cause refractory hypokalemia

Mg is important cofactor for K uptake and maintenance of intracellular K levels

NEED TO GIVE Mg first for hypoK

Get hypo Mg also with
- diuretics
- poor nutritoin
- malabsorb
- alcohol

483

Hypophosphatemia effects

Weakness
Rhabdomyolysis
Paresthesias
Respiratory failure

484

Hypoalbuminemia effects

Decreased oncotic pressure --> edema

Hypocalcemia (b/c Ca bound by albumin)

485

INTRAVASCULAR hemolytic anemia
- panel of lab results

Increased
- indirect bilirubin
- urinary urobilinogen
- hemoglobinemia
- hemoglobinuria
- LDH

Decreased
- Haptoglobin (binds up the free Hg)

486

Tumors almost NEVER mets to brain

Non-melanomatous skin cancer
Oropharyngeal cancer
Esophageal carcinoma
Prostate cancer

487

Do you screen for bladder cancer?

Never

Even w/ smoking history or family history

488

Common cause of lactic acidosis in pts w/ atherosclerotic disease and afib

Bowel ischemia

Lactic acidosis b/c lactate is end product of anaerobic metabolism in ischemic tissue

489

Common infectious cause of adrenal insufficiency

TB

Histoplasmosis
Coccidiodomycosis
Cryptococcosis
Sarcoidosis

490

What should all pts complaining of asthma like sx be questioned about as well?

Reflux!

GERD in 75% of asthma pts

491

Dystonia

sustained muscle contraction resulting in twisting, repetitive mvmts or abnormal postures

Torticolis is a focal dystonia

492

Akathisia

Sensation of restlessness causing pt to move frequently

493

Athetosis

Slow writing mvmts affecting hands and feet

Characteristic of Huntingtons and goes wtih chorea

494

Myoclonus

involuntary jerking of muscle or muscle group

495

Sore throat
Odynophagia
Drooling
Progressive airway obstruction
Stridor
Fever

Epiglottitis!

Common pathogens:
- Hib
- Strep pyogenes

496

BNP diagnosing CHF

> 100 pg/mL diagnoses CHF w/ high sensitivity

497

Common causes of thyrotoxicosis

You get increased TH but decreased radioactive iodine uptake

- Subacute lymphocytic thyroiditis (painless) - postpartum relation usually
- Subacute granulomatous thyroiditis (De Quervain's)
- Levothyroxine OD
- Iodine-induced thyrotoxicosis
- Struma ovarii (teratoma in ovary producing thyroid hormones)

498

When do you think pancreatic pseudocyst?

A few weeks (~4) post acute or chronic pancreatitis

Dx via US

Resolves spontaneously; only drain if persists for more than 6 weeks, infected, or > 5cm

499

Best way to dx disc herniation/abscess

MRI of spine

500

Bacterial overgrowth in small bowel has what manifestations?

Assoc w/ hx of ab surgery

Tetany (b/c vit D deficiency so dec Ca)
Night blindness (vit A def)
Neuropathy (vit B12 def)
Dermatitis
Arthritis
Hepatic injury

501

Subclavian atherosclerosis prefers which artery?

Left artery subclavian

502

Myasthenia crisis

Life-threatening
Weakness of resp and pharyngeal muscles
Usually caused by intercurrent infection
Can be caused by anticholinesterase overdose

Need to do:
- endotracheal intubation
- w/d anticholinesterases for several days

503

Osteomyelitis - most common cause

Staph aureus

504

Osteomyelitis - sexually active

N. gonorrhae
Septic arthritis more common

505

Osteomyelitis - Diabetics and IV drug users, stepping on a nail

Pseudomonas aeruginosa
Serratia

For IV drug users, spine is usual place for osteomyelitis
Will have tenderness to gentle percussion over spinous processes of involved vertebrae

506

Osteomyelitis - Sickle cell

Salmonella

507

Osteomyelitis - prosthetic replacement

Staph aureus
Staph epi

508

Osteomyelitis - vertebral disease

M. tuberculosis (pott's)

509

Osteomyelitis - cat and dog bites or scratches

Pasteurella multocida

510

Flank pain
Poor urine outflow w/ intermittent episodes of high volume urination
UA - occasional RBCs, WBCs, NO CASTS

Obstructive uropathy due to renal calculi

511

Anterior blood supply to brain

Internal carotid --> branches --> ACA, MCA

512

Posterior blood supply to brain

Paired vertebral arteries --> basilar artery --> paired PCA

513

ACA stroke

Contralateral motor and/or sensory deficits more in the lower limb
Urinary incontinence
Gait apraxia
Primitive reflexes
Abulia (lack of will/initiative)
Paratonic rigidity

514

MCA stroke

Contralateral motor and/or sensory deficits more in the upper limb
Homonymous hemianopia

IF dominant lobe (left) --> aphasia
IF nondominant lobe (right) --> neglect and/or anosognosia

515

PCA stroke

Homonymous hemianopia
Alexia w/o agraphia (dominant hemi)
Visual hallucinations (Calcarine cortex)
Sensory sx (thalamus)
3rd nerve palsy w/ paresis of vertical eye mvmt
Motor deficits *cerebral peduncle, midbrain)

516

Internal carotid stroke

MCA stroke + amaurosis fugax

517

Lacunar infarcts

Pure motor hemiparesis
Pure sensory stroke
Dysarthria-clumsy hand
Ataxic hemiparesis

518

Difference in PFTs b/n Ankylosing spondylitis and restrictive lung diseases

Both have decreased
- FEV1
- FVC
- FEV1 / FVC

AS has increased FRC b/c fixation of chest wall in inspiratory position
Restrictive lung disease has decreased FRC

519

Lupus anticoagulant features

PTT normal or increased

vWF, bleeding time, platelet count normal

D-dimer normal or high

520

Pain with neck extension
Trismus (inability to open mouth normally)
Fever
Sore throat
Dysphagia
Odynophagia

Retropharyngeal abscess

Do CT of neck

521

Best initial test for squamous cell carcionma of mucosa of head and neck

Panendoscopy
- esophagoscopy
- bronchoscopy
- laryngoscopy

to detect primary tumor

522

Signs of cerebellar dysfunction

Ataxia
Broad based gait
Dysmetria
Intention tremor
Difficulty with rapid alternating movements
Nystagmus
Muscle hypotonia

523

Causes of atypical pneumonia

M. pneumo
C. pneumoniae
Legionella
Coxiella
Influenza

524

Erysipelas

Specific type of cellulitis
Inflammation of superficial dermis --> prominent swelling

- sharply demarcated, erythematous, edematous, tender

Usually caused by S. pyogenes

525

Cellulitis after a puncture wound- what org do you suspect?

Pseudomonas

526

MPGN type 2 - pathophysiology

Unique among glomerulopathies

Caused by IgG antibodies (C3 nephritic factor) against C3 convertase of alternative complement path
- antibodies reacting w/ C3 convertase --> persistent complement activation --> kidney damage

527

Common causes of UTIs in ppl w/ catheters
- which ones produce alkaline urine?

Alkaline:
- Proteus

Candida
Pseudomonas
Klebs

528

Pleural fluid glucose:
< 30 mg/dL
30-50 mg/dL

< 30 mg/dL
- empyema or rheumatic effusion
- decreased glucose b/c high met activity of WBC in fluid

30-50 mg/dL
- malignancy
- lupus
- esophageal rupture
- TB

529

Pica causes

Iron deficiency (blood loss)
Psych disease

530

Vit D toxicity

Constipation
Ab pain
Polyuria
Polydipsia

531

Pneumococcal (PPSV) vaccine indications

Given once all adults >=65

Give to all adults < 65 w/ chronic diseases:
- Cardio
- pulm
- hepatic
- renal
- metabolic (eg diabetes)
- immunosuppression

Need booster 5 years later if vaccinated before age 65

HIV pts whose CD4 > 200 need pneumovax

532

Granulomatosis w/ polyangitis
- Features
- Tx

Triad
- systemic vasculitis (subQ nodules, palpable purpura, pyoderma grangenosum)
- upper and lower airway inflammation (saddle nose deformity, epistaxis, otitis, sinusitus)
- glomerulonephritis (RBC casts, proteinuria, sterile pyruia)

+c-ANCA (vs proteinase-3)

Tx w/ cyclophosphamide

533

Proximal weakness of lambert eaton vs. polymyositis

Both have proximal weakness

CPK high in polymyositis
CPK normal in LE

Polymyositis - anti Jo1 and ANA
Lambert eaton - anti voltage gated Ca channels

534

Cocaine use
- Clinical features
- Complications

Features
- tachy, HTN, dilated pupils
- chest pain b/c coronary vasoconstrict
- psychomotor agitation, seizures

Complications:
- MI
- Dissection
- Intracranial hemorrhage

535

Temporal arteritis pt - tx w/ steroids - now comes in with myopathy - what does pt have?

If no tx w/ steroids for TA and came in with morning stiffness and pain in shoulders, hip girdle and neck, what does pt have?

Myopathy - steroid-induced myopathy
- ESR normal

Pain/stiffness - polymyalgia rheumatica
- in 50% of TA
- ESR elevated

536

Choriocarcinoma loves to spread to

Lungs

537

RCC triad

Hematuria
Abdominal Mass
Flank Pain

Also can have left sided scrotal varicocele

538

Abnormal labs in Paget's

Increased ALP

Urinary n telopeptide

539

Dermatomyositis
- Findings
- Autoantibody
- Associations

Findings
- proximal extensor muscle inflammatory myopathy
- periorbital edema = hemiotrope sign
- violaceous poikloderma on chest and lateral neck = shawl sign
- poikloderma on knuckles, elbows, knees = Gottron's sign
- Gottron's papules = lichenoid papules over joints = pathognomonic
- more in females

Autoanitbody
- anti-Mi-2 (against helicase)

Associations
- Malignancies (ovarian, breast, lung, urogenetal female)

540

Inflammatory diseases assoc w/ aoritc aneurysms

Behcet
Takayasu arteritis
GCA
Ankylosing spondylitis
RA
Psoriatic arthritis
Relapsing polychondritis
Reactive arthritis

541

Inflammatory disease assoc w/ carpal tunnel

RA
Sarcoidosis
Amyloidosis

542

Criteria for starting long term O2 therapy in COPD

PaO2 < 55 mmHg
OR
SaO2 < 88% on room air

Pt w/ cor pulmonale
OR
Hct > 55%

If become hypoxic during exercise or sleep

543

Grave's disease
- specific signs

Exophthalmos
Pretibial myxedema
Thyroid bruit

544

HYPERthyroidism features

Nervousness, insomnia, irritability

Hand tremor, hyperactivity, tremulousness

Excessive sweating, heat intolerance

Weight loss, increased appetite

Diarrhea, frequent defecation

Palps

Muscle weakness

545

Graves Proptosis pathophys

Autoimmune attack on extraocular muscles

Lymphocytes infiltrate EOM and orbita fat --> edema, proliferaion of local interstitial fibroblasts, and deposition of glycosaminoglycans --> fibrosis and increased edema w/ EOM enlargement

546

Thyroid storm

Med emergency

usually precipitating factor like infection, DKA or stress

high mortality rate

Fever
Tachy
Agitation or psychosis
Confusion
N/V, diarrhea

Tx
- supportive (IV fluids, cooling blankets, glucose)
- + antithyroid agents
- b-blockers

547

Myxedema coma

Depressed state of consciousness + HYPOthermia + respiratory depression

Can develop after years of severe untreated hypoTh

Med emergency

Tx
- supportive to maintain BP and respiration
- IV thyroxine and hydrocortisone

548

HYPOthyroidism features

Fatigue, weakness, lethargy

Menorrhagia, wt gain

Cold intolerance

Constipation

Slow mentation, inability to concentrate

Muscle weakness

Depression

Diminished hearing

Dry skin, coarse hair, hoarseness, nonpitting edema, Bradycartia

Goiter

549

Hashimoto's thyroiditis

Rubbery, nontender goiter

Antimicrosomal antibodies

Can also have increased LDL, decreased HDL, normocytic anemia

550

Papillary carcinoma of thyroid
- Features
- Tx

MOST COMMON
Least aggressive
RIsk factor: hx radiation to head/neck
Spreads via lymphatics in neck - distant mets are rare

Tx
- lobectomy w/ isthmusectomy
- total thyroidectomy if tumor > 3 cm, bilateral, advanced, or distant mets
- TSH suppression theapy, radioiodine therapy

551

Follicular carcinoma of the thyroid
- Features
- Tx

Loves to absorb I
Prognosis worse than follicular
spread HEMATOGENOUS
Distant mets common
Tumor extension past capsule distinguishes it from benign adenoma

Tx
- Total thyroidectomy
- Postop I ablation

552

Medullary carcinoma of the thyroid
- Features
- Tx

1/3 assoc w/ MEN II
Arises from parafollicular C cells - makes calcitonin
Stains w/ congo red

More malignant than follicular cancer!

Tx
- Total thyroidectomy

553

Anaplastic carcinoma of the thyroid
- Features
- Tx

Mostly in elderly
Highly malignant
CAn arise from longstanding follicular or papillary thryoid carcinoma
Death usually in months

Tx
- chemo and radiation
- palliative surgery for airway

554

Hurthle cell tumor

Variant of follicular cancer but more aggressive
Spread by lypmhatics
Tx - total thyroidectomy

555

Felty syndrome

Form of RA w/ splenomegaly and granulocytoenia

Usually happens if A present fore more than 10 years

556

Lab values w/ glucocorticid use

Decrese:
- Eosinophil
- Lymphopenic

Increase bone marrow release and mobilize marginated neutrophil pool (neutrophilia)

557

What makes a Q wave pathologial?

If it is greater than 1/3 of the R wave

558

Albumin charge change
- Example w/ Ca

Increase pH of blood
- more negative charge on albumin
- increase affinity to Ca
- increase albumin-bound ca
- decreases levels of ionized calcium

559

Hypocalcemia signs

Crampy pain
Paresthesias
Perioral tingling
Tetany
Carpopedal spasm
Seizures
Prolongation of QT interval on EKG

560

Hypo K + alkalosis + normotension

- what do you suspect?

Surreptitious vomitting (urine Cl low)
Diuretic abuse (Cl urine high)
Bartter syndrome (Urine Cl high)
Gitelman syndrome (Urine Cl high)

561

Presbycusis

Sensorineural hearing loss w/ age

symmetrical high freq hearing impairment

562

Otosclerosis

Chronic conductive hearing loss w/ bony overgrowth of stapes

Usually starts as low freq hearing loss

563

Pancoast tumor

Shoulder pan radiating into armin ulnar distribution

Caused by tumor ivasion of 8th cervical - 1st thoracic nerves

564

What can an apical pulmonary tumor cause in terms of symptoms?

Horner's - sympathetic trunk compression
Pancoast - brachial plexus compression
Hoarse voice - R recurrent laryngeal N compression
SVC syndrome - compress SVC ad decrease blood return from head

565

Normal distribution of statistical values

Mean = median = ode

566

Positive skew (tail on right) distribution

Mean > median > mode

567

Negative skew (tail on left) distribution

Mean < median < mode

568

Rapidly developing hirsutism
- Best test to dx
- how to interpret the results?

Suggestive of androgen-sereting neoplasm of adrenal or ovary

Serum testosterone and DHEAS (sulfated form of DHEA)

Increased testosterone, normal DHEAS = ovarian source

Increased DHEAS, normal testosterone = adrenal source

DHEA is secreted from both ovaries and adrenals
DHEAS is made only in adrenals

569

Hairy cell leukemia
- What is it?
- Markers?

Type of B lymphocytic derived chronic leukemia

Tartrate-resistant acid phosphatase stain

CD11c marker

570

Hypo K+ effects
- physio effects
- EKG

Weakness
Fatigue
Muscle cramps
Flaccid paralysis
Hyporeflexia
Tetany
Rhabdomyolysis
Arrhythmias (afib, torsades)

Broad flat T waves, U waves, ST depression

571

Cystinuria

Impaired amino acid transport of dibasic amino acids (csteine, lysine, argiine, ornithine)

Cysteine is poorly soluble in water --> get renal stones

+ urinary cyanide nitroprusid test

572

Cysteine kidney stones

Usually due to cystinuria

Hard and radioopague stones

UA shows hexagonal crystals

+ urinary cyanide nitroprusside test

573

Pt presentation:
- lower ab pain, bloody diarrhea, tenesmus over several weeks
- acute fever, leukocytosis, hypoTN, tachy

What are you worried about?

Probably has undiagnosed IBD

Now has toxic megacolon

Can be lethal

574

Dx toxic megacolon

Radiographic evidence of colonic distension +
3 of the below:

- Fever > 38C
- HR > 120
- Neutrophilic leukocytosis > 10,500
- Anemia

Plus at least one of the below:
- vol depletion
- altered sensorium
- electrolyte disturbance
- hypoTN

Dx w. abdominal Xray to confirm dilated colon > 6cm

575

SIADH tx

Hypertonic (3% saline) SLOWLY

Rate of correction not more than 0.5-1 mEq/L/hr

576

Normal pressure hydrocephalous

Abnormal gait
Incontinence
Dementia (memory loss w/o focal neurologic changes)

577

Toxoplasmosis CNS

Mass lesions
Usually multiple
In basal ganglia and at cortical grey[white matter interface
Ring-enhancing

578

Common causes of brain abscesses

Anaerobic Strep
Bacteroides

579

On CT:
- isolated, round smooth bordered ring enhancing intracranial lesion on contrast CT
- immunocomp pt
- known extracranial bacterial infection

this is a brain abscess

580

Chlamydia trachomatis screening

Screen all sexually active women age 24 and younger

Screen other asymptomatic women at increased risk for STIs

581

Sources for PE clots

LE DVT most common
- proximal deep veins (iliac, femoral, popliteal) = > 90%
- calf vein is less than proximal

582

Cavernous sinus thrombosis
- symptoms
- how do you tell the difference w/ orbital cellulitus?

CST happens b/c facial/ophthalmic venous sys is valveless

Headache
Binocular palsies
Periorbital edema
Hypoesthesia or hyperesthesia in V1/V2 distribution
CAN BECOME BILATERAL

Dx w/ magnetic resonance venography

Orbital cellulitus DOES NOT have headache, bilateral cranial nerve findings, or bilateral periorobital edema

583

VIPoma

Diarrhea
Hypo K --> leg cramps
Decreased H+ in stomach
Dehydration
Ab pain
Wt loss
Facial flushing
Redness

Tx - ocretotide to help w/ diarrhea

584

Glucagonoma

Necrotizing dermatitis
Wt loss
Anemia
Persistent hyperglycemia

585

Role of spleen in immune system

Blood borne antigens enter spleen via splenic A --> phagocytosed by dendritic cells in WHITE PULP

Dendritic cells present antigens on MHC 2 --> TH cells --> activated TH cells go to marginal zone of spleen --> contact B cells in primary follicles

B cell activation --> secondary follicles --> germinal centers w/ lots of plasma cells form --> make antibodies --> bind antigen --> facilitate phagocytosis by opsoniziation

586

Leukocyte adhesion defect

Chemotaxis impaired

Autosomal recessive

Defect in integrin B2

587

Osteonecrosis
= aseptic necrosis
= avascular necrosis
= ischemic necrosis
= osteochondritis dessicans

Vasculature of bone disrupted --> bone and bone marrow infaction

Bone can't remodel --> trabecular thinning --> collapse of affected bone

Use MRI to dx (most sensitive)

Precipitating factors:
- steroid use
- chronic EtOH
- hemoglobinopathies
- trauma
- antiphospholipid syndrome

588

Liver main functions

Synthetic
- make clotting factor, cholesterol, proteins

Metabolic
- met drugs and steroids
- detoxify

Excretory
- bile excretion

589

Isolated systolic HTN

Caused by decreased elasticity of arterial wall
- increase in SBP but not DBP
- get widened pulse pressure

Always treated b/c assoc w/ increased risk for CV events

Tx: thiazide, ACE-I or CCB

590

What abnormal labs are indications for thyroid function tests?

Hyperlipidemia (increased LDL)

Unexplained hypo Na

Elevated serum muscle enzymes

Anemia (normocytic, normochromic)

591

How do you tell between NPH and atrophy of brain?

Sulci - enlarged in atrophy, not enlarged in NPH

Both have increased ventricle size

Clinical symptoms different though

592

MMSE < what is suggestive of dementia

24

593

Pt w/ PID - what else should you test them for?

HIV
Syphilis
Hep B
Pap smear

Hep C if IVDU

594

Liver main functions

Synthetic
- make clotting factor, cholesterol, proteins

Metabolic
- met drugs and steroids
- detoxify

Excretory
- bile excretion

595

Tx calcium stones

Hydrocholorthiazide (NOT FUROSEMIDE)

Hydration

596

Typical renal colic but no stone on flat film of abdomen and pelvis
- what do you consider?

1. radiolucent stone (uric acid)
2. calcium stones < 1-3 mm in diameter
3. Non stone causes (obstruction via blood clot, tumor)

597

Tx uric acid stones

Hydration

Alkalnize urine
- oral KHCO3 or potassium citrate

Low purine diet w/w/o allopurinol

598

Secretin stimulation test

Done if suspected Z-E but gastrin values not diagnostic

Secretin stimulates release of gastrin from GASTRINOMA cells

Normally, secretin ----| g cell and gastrin release

599

Indications for parathyroidectomy in hyperparathyroidism

Symptomatic

OR

Asymptomatic + 1 of features below:
- serum calcium `> 1 mg/dL above upper limit of normal
- < 50 yo
- Bone mineral density < 1-2.5 at any site
- reduced renal function

600

Small bowel obstruction:
Proximal vs. distal obstruction

Proximal - frequent vomiting, severe pain, minimal ab distention

Distal - less frequent vomitting, LOTS Of ab distention

601

Tx hypo PTH

Calcium gluconate in severe cases

Oral Ca

Vit D supplementation

602

What is diagnostic of hyper PTH?

Chloride/phosphorus ratio of > 33

Cl high secondary to renal bicarb wasting

603

Causes of Cushing's syndrome

- Iatrogenic (prednisone)

- ACTH secreting adenoma of pituitary --> bilateral adrenal HYPERPLASIA

- Adrenal adenoma

- Ectopic ACTH from tumor

604

ACTH secreting adenoma of pituitary--> changes in adrenals?

Bilateral adrenal hyperplasia

605

Helpful signs for increased cortisol in a pt

Impaired collagen production
- easy bruising
- striae

Myopathy

Virilization

Anti-insulin effects (glucose intolerance)

Protein catabolism
- periph muscle wasting

Impaired immunity

Enhance catecholamine activity
- HTN

606

Whcih cushings syndromes do you see masculinization?

ACTH secreting adenoma
Ectopic ACTH

607

Pheochromocytoma
- features
- labs

Features
- HTN
- headache
- sweating
- tachy, palps
- anxiety

Labs
- HYPER glycemia, lipidemia
- HYPO K

608

Rule of 10s for pheochromocytomas

FaCEBk Me

10% are...
Familial
Children
Extraadrenal
Bilateral
Malignant

609

Are plasma or serum emtanephrines better for pheo dx?

Plasma

610

What does it mean if epi levels are high in suspected pheochromocytoma?

Tumor is in adrenal or near adrenal (organ of zuckerandl at aortic bifurcation)

Nonadreanal tumors can't methylate norepi --> epi

611

MEN I

Parathyroid hyperplasia
Pancreatic islet cell tumor - ZE, insulinoma
Pituitary tumors

612

MEN IIa

Medullary thyroid carcionma
Pheochromocytoma
Parathyroid

613

MEN IIb

Mucosal neuromas + Marfanoid habitus
Medullary thryoid carcinoma
Pheochromocytoma

614

Causes of primary hyper ALDO

- Conn syndrome = adrenal adenoma making aldo

- Adrenal hyperplasia

- Adrenal carcinoma

615

Dx primary hyper ALDO

screen w/ early AM plasma aldosterone to plasma renin activity ratio
--- > 30 --> hyperaldo

Saline infusion test
- should dec aldo but won't in primary aldo

Oral sodium loading
- high NaCl diet for 3 days
- High urine aldo + high urine Na = primary aldo

616

Why is it impt to differentiate adrenal adenoma from hyperplasa?

How do you tell the difference?

HTN assoc w/ hyerplasia NOT benefited by bilateral adrenalectomy

HTN assoc w/ adenoma is usually cured by removal of adenoma

Adrenal venous sampling for aldo levels
- high aldo on one side indicates adenoma
- high level on both sides = bilateral hyperplasia

617

#1 cause of Addison's disease worldwide?

#1 cause of adrenal insufficiency?

Addison - TB

Insufficiency - exogenous glucocorticoids, abrupt stop in usage

618

Clinical findings of adrenal insufficiency

Wt loss
Weakness
Pigmentation
Anorexia
Nausea
Postural HYPO TN
Ab pain
Hypo glycemia

619

What appears in primary but not secondary adrenal insufficiency?

Hyperpigmentation
Hyperkalemia

620

Alcoholic liver cirrhosis
- Labs

Labs
- AST > ALT by 2x BUT usually less than 500 IU/L. If more, some other hepatic injury happened
- modest hepatic transaminitis
- modest inc GGT

621

Why does AST increase more than ALT in alcoholic hepatitis?

Hepatic deficiency of pyridoxal-6-P, a cofactor for ALT enzymatic activity

622

Pleural fluid studies in pleural effusion
- what studies tell you when you need a chest tube?

pH
- low pH usually means empyema
- need thoracostomy w/ low pH

Glucose
- need thoracostomy w/ low glucose
- low in RA, TB, empyema, malignancy, esophageal rupture

Protein

Gm stain

Cell count

Cytology

623

Empyema

collection of pus within a naturally existing anatomical cavity, such as the lung pleura

Usually in context of pneumonia

+ empyema if:
- has pus
- has + gm stain
- has pH < 7.2 but serum pH is normal

624

Blood in urine
- at beginning of stream
- at end of stream
- throughout stream

Beg:
- injury in urethra (urethriti, for ex)

End:
- disease in prostate or bladder

All throughout:
- Ureter or kidney disease

625

Polyarthralgia
Tenosynovitis
Painless vesiclopustural skin lesions

Dissemnated gonococcal infection

626

What side of the heart is most restrictive cardiomyopathy on?

Right

627

When is it best to use bronchoalveolar lavage?

Eval suspected malignancy and opportunistic infection (eg PCP)

628

Bilateral sacroilitis
LImited spine mobilit > 3 mo duration
20-30 yo

Ankylosing spondylitis

629

Modified acid-fast stin showing oocysts in stool suggestive of...

Cryptosporidium parvum

Isosporal belli (not as common in US)

630

Presence of spores in stool
Severe malabsorption and persistent diarrhea in HIV pts

Microsporidia
Enterocytozoon bieneusi
Encephalitozoon intestinalis

631

Symptoms of intracranial hypertension (> 20 mm Hg)

Headaches worse in AM
N/V early in day
Vision changes
Papilledema
Cranial nerve deficits
Somnolence
Confusion
Unsteadiness
Cushing's reflex (hypertension and bradycardia)

632

New onset RBBB can suggest....

PE

633

Dietary recommendation for pts w/ renal calculi

1. Decreased dietary protein and oxalate
2. Decreased sodium intake
3. Increased fluid intake
4. Increased dietary calcium

Vit C will increase oxalate stone formation -- don't take too much! Esp if have renal failure

634

Herpetic whitlow

Common viral infection of hand

Caused by HSV1 or 2

Self limiing

Health care workers coming in direct contact w/ infected orotracheal secretions are at high risk of developing whitlow

635

Most important cause of torsades de pointes

Hypo Mg

636

Prolonged QRS suggests...

Prolonged QT suggests...

QRS:bradyarrhythmia (eg BBB)

QT: tachyarrhythmia

637

Older pt with new diagnosed achalasia + wt loss - what do you do next for the pt?

Endoscopy

Achalasia could be secondary to systemic diseases (Chagas, amyloidosis, sarcoid) or due to mass at GE junction
Use endo to rule out mass!

638

Dawn phenomenon vs. Somogyi effect

Both cause morning hyperglycemia

Dawn - due to inc in nocturnal secretion of GH

Somogyi - rebound response to nocturnal hypoglycemia --> morning hyperglycemia

639

Diagnosis of diabetes

1 of the following:

- 2 fasting glucose > 125 mg/dL
- 1 gluc level = 200 mg/dL w/ symptomes
- Inc gluc level on oral gluc tolerance testing
- HbA1c > 6.5%

640

Optimal tx for DM type 2 pts

Glycemic control

BP < 130/85

LDL < 100, HDL > 40

Smoking cessation

Daily aspirin (if not contraindicated)

641

#1 COD in diabetic patients

Coronary artery disease

642

Autonomic neuropathy of DM

Impotence in men

Neurogenic bladder - retention, incontinence

Gastroparesis - chronic N/V, early satiety

Constipation and diarrhea

Postural hypoTN

643

Defense against HYPOglycemia

Insulin decreases
Glucagon increases
Epinephrine increases next
Cortisol also helps

Glucose < 50 --> symptoms

644

Main organ at risk w/ hypoglycemia

Brain

Brain can't use free fatty acids as energy source

645

Hypoglycemic unawareness

Diabetics w/ severe neuropathy --> autonomic response (epi) to decreased glucose is not activated
- these reactions are supposed to be sweating, tremors, increased BP and pulse, anxiety, palps

Can lead to neuroglycopenic symptoms
- headache, visual distrubances, confusion , seizures, coma

Therefore, if hypoglycemic, can go into seizure or coma

646

Whipple's triad

Used to dx Insulinoma

Hypoglycemic sx broung on by fasting
Blood glucose < 50 during symptomatic attack
Glucose admin brings relief of sx

647

Where are most gastrinomas?

Gastrinoma triangle
- cystic duct (superior)
- junction of 2nd and 3rd duodenum portions (inferior)
- neck of pancreas (medially)

648

Dx Zollinger Ellison syndrome

Secretin injection test
- usually prevents gastrin secretion
- ZES, gastrin will increase a lot after secretin

649

Glucagonoma manifestations

Necrotizing migratory erythema (below waist)
Glossitis
Stomatitis
BM
Hyperglycemia

650

Somatostatinoma features

Malignant, poor prognosis

Gallstones
Diabetes
Steatorrhea

651

VIPoma features

Watery diarrhea --> dehydration, hypo K, acidosis
Achlorhydria (VIP ---| gastric secretion)
Hyperglycemia
Hypercalcemia

652

Bartonella henselae
- features
- treatment

Localized cutaneous and lymph node d/o near site of inoculum

Vesicular, erythematous and papular phases - can be pustular or nodular

Dx w/ clinical or + B henselae antibody test or tissue w/ + Warthin-Starry stain

Tx azithromycin

653

Toxic epidermal necrolysis
- features
- vs. Stevens Johnson?
- drug causing

Erythematous mobilliform eruption ----> exfoliation of skin (+ Nikolsky's sign)

> 30% of body skin involved

10% involved only in SJS

Oral mucosa has blisters

Common drug causes:
sulfa
barbs
phenytoin
NSAIDs

654

Best imaging for vertebral osteo

MRI

can also see if there is abscess or cord compression

655

Most common site of ulnar nerve entrapment

Elbow, medial to epicondylar groove

656

Gene mutation for hemochromatosis

AR disease

C282Y on chromosome 6

657

Complications of GCA

Aortic aneurysms (do serial CXR)
Blindness

658

Causes of membranous glomerulonephritis

Hep B, C
Syphilis
Gold
Penicillamine
SLE
Rheumatoid

659

What bacteria can cause food poisoning in short time?

How do you tell the difference between what bacteria it is?

Bacteria w/ PREFORMED toxins
- Staph aureus
- B. cereus

Tell by what food the person ate

Staph:
- poultry and eggs
- meats
- mayos
- pastries
- milk and daily

B. cereus:
- starchy foods (rice)

660

Generalized myxedema of hypothyroidism
- where can it go?

Deposition of mucopolysaccharides (matrix substances, mucin)

- perineurium of median nerve and tendons passing through carpal tunnel
- skin
- heart
- nerves

661

Carpal tunnel due to deposition of substances. What do you see this in?

Hypothyroidism

Dialysis (beta-2-microglobulin)

662

Accumulation of fluid in carpal tunnel can cause carpal tunnel syndrome. When does this happen?

Preggers

3rd trimester

663

Carpal tunnel syndrome due to:
- tenosynovial inflammation
- synovial tendon hyperplasia

When do each happen?

Tenosynovial - RA

Hyperplasia - acromegaly

664

Essential measures in managemetn of DKA

Restore intravascular volume
- NS

Correct hyperglycemia
- Regular insulin IV

Correct electrolyte abnormalities
- K correction crucial

Tx precipitating factors
- use antibiotics for infections

665

Baker cyst

Assoc w/ RA

Tender mass in popliteal fossa

Happen b/c excessive fluid production by inflamed synovium

Can burst and look like a thrombophlebitis (DVT)

666

Heart burn, wt loss, chest pain unrelated to eating, dysphagia, regurg of food

What is this?

Esophageal cancer, most likely

Use barium swallow, EGD and biopsy, and PET scan to evaluate

667

Common etiologies of constrictive pericarditis

Idiopathic
Viral
Cardiac surgery and radiation therapy
TB pericarditis

668

Clinical presentation of constrictive pericarditis

Fatigue and dypsnea on exertion
Periph edema and ascites
Increased JVP
Pericardial knock

669

Diagnostic findings of contrictive pericarditis

Increased pericardial thickening and calcification

Prominent x and y descents on JVP

670

How do you first evaluate pts w/ probably prostatic hyperplasia?

Hx

Rectal exam

Urinalysis

Serum Cr measurement ----> if increased, US of kidneys or CT of abdomen for reason for obstruction, hydronephrosis or underlying renal disease

671

#1 middle ear pathology in pts w/ acquired immunodeficiency

serous otitis media

conductive hearing loss

dull tympanic membrane that is hypomobile

672

How best do you alter course of diabetic NEPHROpathy once azotemia occurs?

Intensive BP control

< 130/80

ACE inhibitors preferred tx

You would want to control glucose once proteinuria/albuminuria happens

673

Suddenet onse vertigo, vomiting, occipital headache in HTN pt

Cerebellar hemorrhage (strong suspicion)

Can also see:
6th nerve paralysis
conjugate deviation
Blepharospasm
Coma

674

If a young pt presents w/ stroke, look for...

Order...

Vasculitis
Hypercoag state
Thrombophilia

Order
Protein C, Protein S, antiphospholipid antibodies
Factor 5 leiden mutation
ANA
ESR
Rheumatoid factor
VDRL/RPR
Lyme
TEE

675

PUpillary findings in intracerebral hemorrhage and corresponding level of involvement

Pinpoint pupils = pons

Poorly reactive pupils = thalamus

Dilated pupils = putamen

676

Top causes for COPD exacerbation

Smoking

Environmental pollutants/exacerbators

Pneumonia
- S. pneumo
- H. influenza
- M. catarrhalis

677

How do you dx renal artery stenosis?

Captopril renal scan

678

Parkinson's disease
- pathophys
- how this is logical for treatment

Dopaminergic path of basal ganglia is compromised
Cholinergic system operate unoppossed

Lewy bodies (hyalin inclusion bodies) are key neuronal finding in brains

Tx will enhance dopamine's influence or inhibit Ach influence

679

When do you not do a LP on a suspected SAH?

If slit lamp exam reveals papilledema

May cause herniation - repeat CT scan before LP

680

Parkinson's clinical features

Pill rolling tremor @ rest - worse w/ emotional stress - gone w/ doing tasks

Bradykinesia

Cogwheel rigidity

Shuffling gait

Expressionless facies

Dementia in advanced disease

Personality changes early on - withdrawn, apathetic, dependent, depression

681

Complicated GERD
- Manifestations
- Diagosis

Manifestations
- dyphagia
- odynophagia
- wt loss
- bleeding
- Fe deficiency anemia
- typical sx: heartburn, regurg, bitter/sour taste

Diagnosis
- Endoscopy (esophagoscopy)
----also do endo if complicated GERD or antacids/meds don't control the codition

682

Contraction alkalosis

Intracellular volume contraction

Increased aldo functions to restore intravascular volume but also causes increased H+ and K+ loss --> alkalosis!

683

Thyroid myopathy

- predminant PROXIMAL symptoms
- can have a tremor (action)
- can happen in hyper or hypo thyroid

684

Central vs 7th nerve palsy of face

Central - forehead wrinkling is ok b/c LMN is bilaterally innervated by both UMN; one is knocked out, the other still works

7th nerve - LMN knocked out, doesn't matter that it is bilateral, the signal will not go through. So forehead and lower face both out.

685

Irreversible causes of dementia

Alzheimer's
Parkinson's
Huntington;s
Multi infarct dementia
Dementia w/ lewy bodies, Pick's disease
Unresectable brain mass
HIV dementia
Korsakoff's
PML
CJD

686

Broca's aphasia

Comprehension ok, can't speak or write

Posterior part of dominant frontal lobe infarct

687

WBC count in synovium of
- crystal induced arthritis
- septic arthritis

Crystal: 10-50,000

Septic: 50-150,000

688

#1 cause of prosthetic joint septic arthritis

#2?

1 -Staph aureus

2 - Strep

Salmonella can cause in elderlyand immunocompromised

689

#1 cause of septic arthritis in young sex active ppl

Neisseria gonorrhea

690

Syringomyelia
- Characteristics
- Pathophys
- Acquired causes

Areflexic wakness in upper extremities
Loss of pain and temp w/ preserved position and vibration in cape ditribution

Presence of cord cavity that communicates w/ central canal of spinal cord
Usually in lower cervical or upper thoracic region

Acquired causes:
- trauma
- inflammaory spinal cord d/o
- spinal cord tumors

691

Monoclonal gammopathy of undetermined significance

- NO anemia, hyper Ca, lytic lesions, and renal insufficiency
- serum monoclonal protein < 3 g / dL
- < 10% plasma cells in bone marrow

Dx w/ metastatic skeletal bone x rays to exclude MM
1% risk of progression to MM

692

Multiple Myeloma

- Presence of anemia, hyper Ca, lytic lesions, and renal insufficency
- Serum monoclonal protein > 3 g/dL
- > 10% plasma cells in the bone marrow
- Elevated beta-2 microglobulin

693

Dx amyloidosis

Serum Immunoelectrophoresis (SIEP)

Biopsy ab fat pad, rectum, organ involved

694

Diagnostic test to dx MS

MRI
- sensitive in ID demyelinating lesions in CNS
- # lesions on MRI NOT necessarily proportional to disease severity or speed of progression

695

Gm - bacteria causing pneumonia

E coli
klebs
Pseudomonas
Enterobacter
Proteus
Serratia
Acinetobacter

Rare in healthy individuals

696

What space in the neck carries the highest risk of spreading an infection to the mediastinum?

Retropharyngeal space

- between alar and prevetebral fascia

697

Complication of infection in paapharngeal space

Involvement of the carotid sheath --> erosion of carotid artery and jugular thrombohlebitis

698

What does it mean when it says toe webs are fissured and macerated?

Tinea pedis!

699

Complication of infection in paapharngeal space

Involvement of the carotid sheath --> erosion of carotid artery and jugular thrombohlebitis

700

What does it mean when it says toe webs are fissuredand macerated?

Tinea pedis!

701

Top causes for COPD exacerbation

Smoking
Environmental pollutants/exacerbators

702

Gold std for dx SAH

Xanthochromia
- results from RBC lysis and implies blood has been in CSF for hours and not due to traumatic tab

703

Parkinson's disease
- pathophys
- how this is logical for treatment

Dopaminergic path of basal ganglia is compromised
Cholinergic system operate unoppossed

Tx will enhance dopamine's influence or inhibit Ach influence

704

When do you not do a LP on a suspected SAH?

If slit lamp exam reveals papilledema

May cause herniation - repeat CT scan before LP

705

Parkinson's clinical features

Pill rolling tremor @ rest - worse w/ emotional stress - gone w/ doing tasks

Bradykinesia

Cogwheel rigidity

Shuffling gait

Expressionless facies

Dementia in advanced disease

Personality changes early on - withdrawn, apathetic, dependent, depression

706

Progressive supranuclear palsy

Degenerative condition of
- brainstem
- basal ganglia
- cerebellum

Like parkinson's:
- bradykinesia
- limb rigidity
- cognitive decline

NOT like parkinson's
- no tremor
- ophthalmoplegia

707

Huntington's
- pathyophys

Autosomal dominant, chromosome 4 trinucleotide repeat

Loss of GABA producing neurons in striatum

708

Huntington's
- clinical features
- diagnosis w/....

Chorea
Altered behavior - irritable, personality changes, psychosis, OCD

Dx w/ MRI - atroph of head of caudate
- DNA testing confirms diagnosis

709

Seizure causes

4M's, 4I's

Metabolic / electolyte disturbances - hypo Na, water intox, hypo glycemia, hyperglycemia, HYPO Ca, uremia, thyroid storm, hyperthermia

Mass lesions - brain mets, tumors

Missing drugs
- noncompliance w/ antiseizures
- w/d from EtOH, benzos, barbs

Misc
- Eclampsia
- HTN encephalopathy

Intoxications - cocaine, lithium, lidocaine, theophylline, Mercury, lead, CO

Infections - septic shock, meningitis, brain abscess

Ischemia - stroke, TIA

Increased ICP - trauma

710

Alzheimer's pathophys

Decreased Ach synth --> impaired cortical cholinergic function

Diffuse cortical atrophy on CT or MRI

711

Features of Cushings

Central obesity
Hirsutisum
Moon facies
Buffalo hump
Purple striae on abdomen
Lanugo hair
Acne
Easy bruising

HTN
Diabetes
Hypogonadism
Masculinization in fems
Proximal muscle wasting and weakness
Osteoporosis
Aseptic necrosis of femoral head

Depression
Mania

Decreased immunity

712

What is arousal dependent on? Cognition?

Arousal - Intact brainstem
- reticular activating system in brainstem

Cognition - cerebral cortex

713

Causes of delirium

SMASHED (Coma) + P DIMM WIT

Postop state

Dehydration and malnutrition

Infection

Meds - TCAs, steroids, anticholinergics, hallucinogens, cocaine

Metals

W/D states

Inflammation, fever

Trauma, burns

714

DDx of coma or stupor

SMASHED

Structural brain pathology (stroke, bleed, tumor)

Meningitis, mental illness

Alcohol, acidosis

Seizures, substrate deficiency (thiamine)

Endocrine (Addisonian crisis, thyrotoxicosis, hypoTH), encephalitis, extreme disturbances in Ca, Mg, PO4

Drugs (opiates, barbs, benzos, sedatives), dangerous compounds (CO, CN, MeOH)

715

Unilateral fixed dilated pupil

Herniation w/ CN III compression

This is anisocoria

716

Spinal lesion - how can you tell it is in the spinal cord?

Decrease in sensation below a sharp band in the abdomen/trunk

Pinprick felt above level but not below it

Pathognomonic for spinal cord disease

Level of lesion = sensory level

717

Intranuclear ophthalmoplegia

Strongly assoc w/ MS

Lesion in MLF -->
= ipsilateral medial rectus palsy on attempted lateral gaze (can't adduct)
= horizontal nystagmus of abducting eye (contralateral to size of lesion)

718

Diagnostic test to dx MS

MRI
- sensitive in ID demyelinating lesions in CNS
- # lesions on MRI NOT necessarily proportional to disease severity or speed of progression

719

Guillain Barre
- characteristics
- treatment

Inflammatory demyelinating polyneuropathy - ascending paralysis/weakness

Usually follows infection: C. jejuni, Herpes, Mycoplasma, H. influenzae, HIV

Tx:
- NOT steroids b/c can be harmful
- monitor pulmonary function
- IV IgG if pt has significant weakness
- plasmaphoresis

720

Principles of using Ultrasound

Images muscle, soft tissue, bone surfaces very well - can delineate interfaces b/n solid and fluid filled spaces
- shos structures of organs

Has trouble penetrating bone
- has difficulty if there is gas b/n transducer and organ of interest (eg seeing pancreas under the bowel is hard)

721

Clinical features of neonatal lupus

Skin lesions

Cardiac abnormalities (AV block, transposition of great vessels)

Valvular and septal defects

Increased risk for neonatal SLE if have anti-Ro (SSA) antibodies

722

Duchenne's Muscular Dystrophy
- pathophys
- lab values

X linked recessive - mutation on gene coding for dystrophin protein --> muscle cells die then
No inflammation

Labs:
- Serum CPK HIGH

723

Tuberous sclerosis

AD

Cognitive impairment
Epilepsy
Facial angiofibromas, adenoma sebaceum

Retinal hamartomas
Renal angiomyolipomas
Rhabdoomyomas of heart

724

Sruge Weber

Acquired disease
Presence of capillary angiomatoses of pia mater
Facial vascular nevi (port wine stain)
Epilepsy and mental retardation
- tx epilepsy mainly

725

+ Ro (SS-A) and La (SS-B)

Sjogren's
Subacute cutaneous
Neonatal lupus
Complement deficiency
ANA negative lupus

726

Horner's syndrome

Ipsilateral -
ptosis
miosis
anhidrosis

Causes:
- pancoast
- internal carotid dissection
- brainstem stroke
- cervical spine injury

727

Poliomyelitis

- Anterior horn cells and motor neurons of spinal cord and brainstem involved
- LMN involvement

Asymmetrical muscle weakness
Normal sensation

728

Peripheral vs central vertigo

Periph
- hearing loss and tinnitus only occur here

Central
- focal neuro problems only occur here

729

Seronegative spondyloarthropathies HLA

HLA B27

730

Difference between lupus and drug-induced lupus

NO Renal or CNS involvement in drug induced lupus
- also no butterfly rash, alopecia, and ulcers

731

Pathophys of scleroderm

Cytokines stimulate fibroblasts --> abnormal amt of collagen deposition

It is quantity of collagen that causes the problems assoc w/ this disease (composition of collagen is normal)

732

Most important thing to do in syncope workup

Differentiate b/n cardiac and noncardiac causes

Always get an EKG

733

Seizure causes

4M's, 4I's

Metabolic / electolyte disturbances - hypo Na, water intox, hypo glycemia, hyperglycemia, HYPO Ca, uremia, thyroid storm, hyperthermia

Mass lesions - brain mets, tumors

Missing drugs
- noncompliance w/ antiseizures
- w/d from EtOH, benzos, barbs

Misc
- Eclampsia
- HTN encephalopathy

Intoxications - cocaine, lithium, lidocaine, theophylline, Mercury, lead, CO

Infections - septic shock, meningitis, brain abscess

Ischemia - stroke, TIA

Increased ICP - trauma

734

When do you tx a person who has 1st seizure

DO NOT Tx

Tx w/ antieplipetics if
EEG abnormal
brain MRI abnormal
Patient is in status epilepticus

735

Amyotrophic lateral sclerosis - features

D/o of anterior horn cells and corticospinal tracts

UMN and LMN signs

Progressive muscle weakness noticed 1st in legs or arms
Fasiculations
Impaired speech and swallowing
Respiratory muscle weakness
Wt loss, fatigue

OK throughout:
bladder, bowel
sensation
cognition
EOM
sex functions

736

Features of Cushings

Central obesity
Hirsutisum
Moon facies
Buffalo hump
Purple striae on abdomen
Lanugo hair
Acne
Easy bruising

HTN
Diabetes
Hypogonadism
Masculinization in fems
Proximal muscle wasting and weakness
Osteoporosis
Aseptic necrosis of femoral head

Depression
Mania

Decreased immunity

737

Sjogren's classic triad

Can't see, can't spit, can't climb a tree

Xerophthalmia
Xerostomia
Arthritis

738

Broca's aphasia

Expressive, nonfluent aphasia
Speech is slow and needs effort
Good comprehension of language

739

COnduction aphasia

Can't repeat
Pathology involves connections b/n Wernicke's and Broca's areas

740

Global aphasia

Disturbance in all areas of language function
Often assoc w/ R hemiparesis (damage of L hemisphere)

741

Spinal lesion - how can you tell it is in the spinal cord?

Decrease in sensation below a sharp band in the abdomen/trunk

Pinprick felt above level but not below it

Pathognomonic for spinal cord disease

Level of lesion = sensory level

742

Principle of imaging of MRI

Good for tissues w/ many H nuclei and little density contrast

Good to detect differences between 2 similar but not identical tissues

Brain
Muscle
Connective tissue
Most tumors

743

Principles of imaging of CT scans

CT of the head
- detects infarction, tumors, calcifications, hemorrhage, bone trauma
- dark structure = infarction and edema
- bright structure = calcifications and blood

744

Causes of
- dematomyositis
- polymyositis
- inclusion body myositis

derm - humoral immune response

poly - cell mediated process

inclusion body - cell mediated process

745

Fibromyalgia

Multiple trigger points (tender to palpation)
11/18 to diagnose

Stiffness, body aches, fatigue, sleep disrupted, anxiety, depression

746

Clinical features of neonatal lupus

Skin lesions

Cardiac abnormalities (AV block, transposition of great vessels)

Valvular and septal defects

747

Positive ANA conditions

SLE
RA
Scleroderm
Sjogren's syndrome
Mixed connective tissue disease
Polymyositis and dermatomyositis
Drug-induced lupus

748

Risks for skin cancer

Recent changed mole - 10x
Family hx melanoma - 8x
Sun sensitivity - 2x
Previous sunburns - 2x

749

Graft vs host disease

Common after bone marrow transplatntation

T cell mediated immune response by donor

Targets
- skin
- intestine
- liver

750

+ Ro (SS-A) and La (SS-B)

Sjogren's
Subacute cutaneous
Neonatal lupus

751

SLE HLA

HLA DR2, 3

752

Sjogren's HLA

HLA DR3

753

RA HLA

HLA DR4

754

Facticious diarrhea (laxative abuse)

Watery
Increase in freq and vol of stool
10-20 bowel mvmts / day

Characteristic biopsy finding:
- dark brown discoloration of colon w/ lymph follicles shining through as pale patches (melanosis coli)
- can return to normal after laxative

755

Difference between lupus and drug-induced lupus

NO Renal or CNS involvement in drug induced lupus
- also no butterfly rash, alopecia, and ulcers

756

Pathophys of scleroderm

Cytokines stimulate fibroblasts --> abnormal amt of collagen deposition

It is quantity of collagen that causes the problems assoc w/ this disease (composition of collagen is normal)

757

Ways to Dx sjogren's

ANA, Anti-Ro, Anti-La

Schirmer test - filter paper to measure lacrimal gland output

Salivary gland biopsy (lip or parotid)

758

If someone has dysphagia to solids only, what test do you do to eval?

Barium esophagram w/ tablet

Liquid barium may not see obstruction

759

Rheumatoid arthritis clinical features

Inflammatory polyarthritis
- NO DIP joints
- PIP, MCP, wrists, knees, ankles, elbows
- ulnar deviation of MCP
- Boutonniere deformities of PIP joints
- Swan neck deformities of MCP

Morning stiffness
Constitutional symptoms

Cervical spine involvement - life threatening

Pericarditis, conduction abnormalities, valvular incompetence

Pleural effusions (low glucose)

Episcleritis, scleritis

760

Poor prognostic indicators in RA

High RF titers
SubQ nodules
Erosive arthritis
Autoantibodies to RF

761

Antibodies in RA

Radiologic findings

rheumatoid factor

Anti citrullinated protein antibody

Erosions + periarticular osteoporosis

762

Sjogren's classic triad

Can't see, can't spit, can't climb a tree

Xerophthalmia
Xerostomia
Arthritis

763

Pathogenesis of gout

Increased prod of uric acid
- HGPRT deficiency
- PRPP synthetase overactivity
- chemo, hemolysis, heme malignancies

Decreased excretion of uric acid
- renal disease
- NSAIDs, diuretics
- Acidosis

764

Pathophys of gout

ECF saturated with uric acid -->
uric acid crystals collect in synovial fluid -->
IgGs coat monosodium urate crystals -- >
phagocytosed by PMNs -->
release inflammatory mediators and protelytic enzymes from PMNs -->
Inflammation

765

Tophi

Happens w/ uncontrolled gout for > 10 years

Aggregations of urate crystals surrounded by giant cells in an inflammatory reaction

Common locations:
- forearms
- elbows
- knees
- achilles tendons
- pinna of external ear

766

Diagnosis of gout

Joint aspiration + synovial fluid analysis
- needle shaped and negatively birefringent urate crystals

Radiographs
- punched out erosions w/ overhanging rim of cortical bone

767

Pseudogout vs. gout

Different crystals

Pseudogout usually in larger joints (knee)

Pseudogout classically monoarticular

768

Pseudogout Dx

Joint aspirate
- weakly + biregringent rhomboid crystals (calcium pyrophosphate)

Radiograph
- chondrocalcinosis (cartilage calcification)

769

Causes of
- dematomyositis
- polymyositis
- inclusion body myositis

derm - humoral immune response

poly - cell mediated process

inclusion body - cell mediated process

770

Fibromyalgia

Multiple trigger points (tender to palpation)
11/18 to diagnose

Stiffness, body aches, fatigue, sleep disrupted, anxiety, depression

771

Test to confirm prostatitis

Mid-stream urine sample

Give antibiotics

Prostate is tender and boggy

772

Treatment for acute mechanical back pain

Without significant neuro deficit
- mobilization + NSAIDs (not bedrest)

W/ lots of neuro deficit
- early surgical decompression

773

Risks for skin cancer

Recent changed mole - 10x
Family hx melanoma - 8x
Sun sensitivity - 2x
Previous sunburns - 2x

774

Graft vs host disease

Common after bone marrow transplatntation

T cell mediated immune response by donor

Targets
- skin
- intestine
- liver

775

Methanol vs ethylene glycol poisoning

Methanol damages vision

Ethylene glycol damages kidneys
- oxalic acid binds ca --> hypoCa and Ca-oxylate crystal deposits
- Glycolic acid injures the renal tubules

776

Pancreatic cancer clinical features
- tumor in body/tail
- tumor in head

Body/tail - pain adn wt loss

Head - stetorrhea, wt loss, jaundice

777

Most sensitive screen for diabetic nephropathy

Random urine for microalbumin/creatinine ratio

24 hr collection best but inconvenient

778

Dx rotator cuff tear

MRI

779

Facticious diarrhea (laxative abuse)

Watery
Increase in freq and vol of stool
10-20 bowel mvmts / day

Characteristic biopsy finding:
- dark brown discoloration of colon w/ lymph follicles shining through as pale patches (melanosis coli)
- can return to normal after laxative

780

Dx acute aortic dissection

TEE
CT w/ contrast

781

Rotator cuff tear vs .tendonitis

Happens usually w/ fall out on outstretched hand

Shoulder pain and weakness

Tendonitis is helped by lidocaine injection - tear is not

782

Which pleura has nerve endings that give you pleuritic pain?

Parietal pleura

783

If someone has dysphagia to solids only, what test do you do to eval?

Barium esophagram w/ tablet

Liquid barium may not see obstruction

784

Fulminant liver failure

no previous liver disease +
Jaundice +
hepatic encephalopathy

785

When monitoring DKA, and response to treatment, what is most reliable index to monitor response to tx?

Serum anion gap
pH

Fall in serum and urinary ketones lags behind changes in arterial pH or anion gap

786

#1 macrocytic d/o in sickle cell disease

Folate deficiency

787

Causes of toxic megacolon

ulcerative colitis
CMV colitis in HIV pts

788

Korsakoff's syndrome

Irreversible amnesia
Confabulation
Apathy

789

Indicators for surgery in pts w/ aortic stnosis

SAD -
Syncope
Angina
Dyspnea (from CHF)

Pts w/ severe AS going for CABG

Asymptomatic pts w/ severe AS + poor LV sys function, LV hypertrophy ? 15 mm, valve area < 0.6 cm2 or abnormal response to exercise

790

When should DM screening start?

age 45 w/ no risk factors

earlier if have risk factors

791

Managing dysphagia/odynophagia in HIV pts

#1 cause of this is candida
- 1-2 wk course empiric oral fluconazole

If doesn't work...endoscopy to investigate other etiologies

#1 cause of ulcerative esophagitis = CMV

792

CMV esophatitis

Evidence of large, shallow superficial ulcerations

Focal substernal burning pain w/ odynophagia

Presence of intranuclear and intracytoplasmic inclusions

Tx = ganciclovir

793

HSV esophagitis

Multiple, small, well circumscribed w/ small and deep appearance of ulcers

Cells show ballooning degeneration + eosinophilic intranuclear inclusions

Tx = acyclovir

794

Cancer assoc w/ pernicious anemia

Gastric intestinal-type cancer

Gastric carcinoid tumors

795

Pathophys of senile purpura

These are ecchymotic lesions in areas susceptible to trauma in elderly

Happens b/c perivascular CT atrophies as ppl age

No tx needed

796

Lupus anticoagulant

IgM or IgG that PROLONGS activated PTT
- binds phospholipids used in assay
- it is NOT an anticoagulant though and increases risk of thrombosis and spontaneous abortion

797

How do you change the urine pH to prevent gouty attacks?

Urine alkalinization

798

Spinal stenosis

Pain is posture-dependent

Flexion of spine = widening of canal
Extension - narrowing of canal

Pain exacerbated by standing still, walking
Pain improved by sitting, lying down

Normal arterial pulses
Straight leg test negative

Dx w/ MRI

Tx laminectomy

799

Herniated disc

Low back pain sciatica presentation
- radiates to thighs adn below knee

Pain worsens w/ sitting

+ straight leg test

800

PFTs of COPD

Decreased
- VC
- FEV1 / FVC

Increased
- functional residual capacity
- total lung capacity

801

Nephrotic syndrome - etiology of hypercoagulation

Loss of antithrombin 3 in urine
altered levels of protein C and S
Increased platelet aggregation
Hyperfibrinogenemia b/c increased hepatic synth
Impaired fibrinolysis

RENAL VEIN thrombosis most common manifestation of coagulopathy

802

Complications of nephrotic sydnrome

Protein malnutrition
Fe-resistant microcytic hypochromic anemia b/c lose transferrin
Vit D deficiency b/c lose cholechalciferol-binding protein
Decreased thyroixin levels b/c loss of TBG
Increased susceptibility to infection

803

Solitary nodule that is....on CXR:
- popcorn calcification
- bulls eye

Popcorn - hamartoma

Bulls eye - granuloma

804

How can TIA produce syncope?

This is rare

Needs to affect posterior circulation and brain stem in order for syncope to occur

805

Pt receives transfusion - then in 1 hr, gets fever, chills, flank pain, hemoglobinuria. What happeend?

Acute hemolytic transusion reaction

ABO mismatching from clinical error or blood mistyping

hemoglobinuria present!!

Can get DIC, acute renal fail, shock
Tx - supportive

806

Pt receives transfusion - fevers, chills, malaise. What happened?

Reaction to cytokines in transfused blood products
OR
Antibodies in pt's plasma reacting w/ donor's leukocytes

Febrile nonhemolytic reaction

Prevent using leukoreduced blood prods (wash RBCs)

807

Pt receives tranfusion - within seconds - minutes, gets anaphylactic reaction. What happened?

IgA deficiency

808

CMV vs. EBV mononucleosis

Both
- atypical lymphocytes (large, basophilic w/ vacuolated appearance)

CMV only:
- no pharyngitis
- no cervical lymphadenopathy
- negative monospot test

809

Bartter syndrome

Polyuria, polydipsia, growth and mental retardation
- usually presents early but can present late

Defective Na and Cl reabsorb in TAL
Causes hypovolemia --> activates RAAS
Increased urine Cl level

810

Gitelman syndrome

Defect in DCT in reabsorb Na and Cl
Causes hypovolemia --> activates RAAS
Increased urine Cl level

811

#1 complication of PUD

Hemorrhage - upper GI bleed

812

Shifts K+ out of cell (causing hyperkalemia)

DO Insulin LAB

Digitalis
HyperOsmolarity
Insulin deficiency
Lysis of cells
Acidosis
B-adrenergic antagonist

813

Shifts K+ into cell (causing hypokalemia)

Hypoosmolarity
Insulin (increases Na/K ATPase)
Alkalosis
B-adrenergic agonist

INsulin shifts K INto cells

814

Renal Cell carcionma (RCC) paraneoplastic conditions

Anemia / erythrocytosis
Thrombocytosis
Fever
Hyper Ca
Cachexia

815

Dx RCC

CT scan of abdomen

816

Progressive multifocal leukoencephalopathy
- cause
- pathophys
- symptoms
- dx

JC virus (polyomavirus)

Loves cortical white matter

Onset of symptoms gradual
- hemiparesis, distrubances in speech, vision, gait

MRI confirms diagnosis
- multiple demyelinating, nonenhancing lesions w/ no mass effects

No tx available

817

Most common mass lesion in HIV pts

Cerebral toxo

#2 = primary CNS lymphoma

Both are ring enhancing lesions
Toxo loves basal ganglia
Lymphoma loves periventricular

818

Dizziness vs vertigo

Dizziness - imbalance and unsteadiness
Vertigo - illusion of head mvmt, head spinning
- actute vertigo usually due to dysfunction of labyrinth

819

Leukomoid reaction
- what is it?
- whcat can it look like?
- how do you tell the difference?

Marked increase in leukocytes due to severe infection or inflammation

Key is increased leukocyte ALP (LAP)

It can look like CML
- LAP is decreased in CML though

820

Nontender gallbladder + biliary obstruction evident on US + direct bilirubin elevation + disproportionate elevation of ALP

What is this? How do I eval it?

Pancreatic cancer

CT of the abdomen

821

Basal cell carcinoma

Slow growing papule w/ pearly, rolled borders and overlying telangiectasia

#1 malignant tumor of eyelid (lower margin)

Tx w/ surgical excision using microscopically-controlled margins (Mohs technique)

822

Squamous cell carcinoma

Less common than basal
Faster growing

Often arises from precursor (eg actinic keratosis)

Usually has overlying hyperkeratosis

823

Keratoacanthoma

Rapidly growing volcano-like nodule w/ central keratotic plug

Usually self limited but treated like SCC

824

Secondary bacterial pneumonia most commonly due to

Strep pneumo
Staph aureus
H. influenzae

825

Which is the pathogen to cause post-viral URI necrotizing pulmonary bronchopneumonia w/ multiple nodular infiltrates --> can cavitate to small abscesses?

Staph aureus

blood streaked sputum

826

Legionnaire's disease

Can cause intersitial infiltrates on CXR

827

How do you see amyloidosis deposits in nephrotic syndrome?

Deposits are revealed under polarized light

Apple green birefringence under polarized light after staining w/ congo red

828

Psammoma bodies?

PSMM

Papillary carcinoma of the thyroid
Serous cystadenoma of the ovary
Meningioma
Mesothelioma

829

Which thyroid carcionma has hematogenous spread?

Follicular thyroid cancer

830

Carcinomas spread via....

Lymphatics

831

Sarcomas spread via....

Hematogenous

832

Carcinomas that love to spread hematogenously

RCC
HCC
Follicular thyroid carcinoma
Choriocarcionma
Prostate adenocarcionma

833

Hypertrophic osteoarthropathy

Digital clubbing accompanied by sudden-onset arthropathy, commonly affecting wrist and hands

Can be attributed to pulm etiologies like:
lung cancer
TB
Bronchiectasis
Emphysema

834

HNPCC Amsterdam Criteria I

At least 3 relatives w/ colorectal cancer (1 is 1t degree relative of the other 1)

Involvement of >=2 generations

At least one case diagnosed before 50 yo

Family adenomatous polyposis excluded

835

Which lynch syndrome is associated w/ high risk of extracolonic tumors? What is the most common extracolonic tumor?

Lynch syndrome II

Endometrial carcinoma

836

1st line tx of anal fissure

Local anesthetic + stool softner + dietary modification (high fiber diet and fluids)

837

Pt w/ prostate cancer who underwent orchiectomy has bone pain - mets! What do you d to manage bone pain?

Radiation therapy

838

Caudia equina syndrome

Surgical emergency

Absent rectal tone
Urinary incontinence
Motor and sensory loss in extremities

839

S/E of PEEP in person w/ ARDS

Alveolar damage
Tension pneumo
Hypotension

This happens if pressures are too high! Can rupture fragile lung parenchyma --> air leakage into pleural space

840

Risk factors:
HTN
Smoking
Elevated cholesterol
Alcohol
DM

Which has highest risk for
- CVA?
- CAD

CVA --> HTN (4x risk)

CAD ---> hypercholesterolemia

841

Immune thrombocytopenic purpura

DECREASE platelet count
INCREASE bleeding time

Decrease platelet survival b/c anti GpIIb/IIIa antibodies
Increased megakaryocytes on labs

842

Thrombotic thrombocytopenic purpura

DECREASE platelet count
INCREASE bleeding time

Decrease platelet survival
Deficiency of ADAMTS 13 ---> decrease degradation of vWF multimers --> increase platelet aggregation and thrombosis

Labs: Schistocytes, increased LDH

Sx
- neuro symptoms
- renal symptoms (more in HUS)
- fever
- thrombocytopenia
- microangiopathic hemolytic anemia

843

What MI is most commonly assoc w/ sinus bradycardia?

Why?

Inferior MI

Increased vagal tone in 1st 24 hrs after infarction
Decreased RCA blood supply to SA node

844

How does afib happen in grave's? How do tx?

Increased sensitivity of beta-adrenoreceptors to sympathetic stimuli

Beta blocker (propanolol) to tx

845

If kidneys want to icnrease bicarb retention (perhaps to fight alkalosis), what will reabsorb less?

Chloride

846

Common fungal meningitis is AIDS pts

Cryptococcus

847

Situational syncope

Middle age man
Lose consciousness after urination
Lose consciousness during coughing fits

848

Grover disease

Acantholytic dermatosis

Pruiritus
Erythematous to brown keratotic papules over the anterior chest, upper back, and lower rib cage

Etiology unknown

849

Most common electolyte abnormality in adrenal insufficiency?
How does it happen?

Hyponatremia

Volume contraction b/c mineralocorticoid deficiency
Increased vaspressin (ADH) b/c lack of cortisol suppression

850

Features of primary hyperaldo

HYPER TN

HYPO K

Metabolic alkalosis

Decreased renin

Elevated aldo

851

Diastolic decrescendo murmur @ L 3rd intercostal space that increases with handgril

Aortic regurgitation

852

Corrected Ca value
- when do you use it?
- how does it get calculated?

Corrected Ca = 0.8 (normal albumin - measured albumin) + measured Ca

853

Impetigo #1 cause

Staph aureus + Strep pyogenes

Bullous impetigo has bullae and usually Staph aureus

Nonbullous impetigo more common

854

Hyperkalemia causes

Tumor lysis syndrome
Renal insufficiency
ACE inhibitor

855

What is quickest way to decrease serum K concentration?

Insulin/glucose administration

856

#1 cause of primary adrenal insufficiency

TB

Autoimmune in developed countires

857

Vision abnormality assoc w/ NF 1

Optic glioma

858

Risk factors assoc w/ ab aorta aneurysm expansion and rupture

Large diameter

Rate of expansion

Current cigarette smoking

859

Indications for surgery on AAA

aneurysm > 5.5 cm
Rapid rate of aneurysm expansion (> 0.5 cm in 5 mo or > 1 cm / yr)
Presence of sx (ab, back, flank pain; limb ischemia)

860

PaCO2 needed to compensate for pt's metabolic acidosis

PaCO2 = 1.5 (HCO3-) + 8

If CO2 lower, cannot be due to physio compensation alone - mixed acid base present

861

Why is there malabsorption in ZE syndrome?

Inactivation of pancreatic enzymes b increased stomach acid

862

Goal oxyhemoglobin saturation in COPD pts?

90-94%

863

Glucagonoma sx

Hyperglycemia
Necrotizing dermatitis (erythematous plaques on skin)
Wt loss

Often mets to liver, is malignant
DOES NOT respond to chemo - need surgery

864

How to tell the difference between cardiac or liver related LE edema?

Hepato jugular reflex
- positive in ppl w/ heart disease

865

Pt presentation:
- drank unknown bottle of lye
- retrosternal/epigastric pain, hypersalivation, and odynophagia/dysphagia

What do you worry about?
What should you give?
How do you manage?

Worry a/b liquefactive necrosis of esophageal wall --> perforation and mediastinitis

Give IV hydration and get serial ab and chest XRAYS

Endoscopy to see extent of esophageal damage --> determines if need more tx

If perforation, Gastrografin study performed

DO NOT neutralize alkali w/ acid as can exacerbate injury by releasing heat

866

When do you do a urine culture for a suspected cystitis?

When complicated.
- infections in women who are preggers, young, old, diabetic, immunocompromised, abnormal anatomy

No need for uncomplicated.

867

Serum ascites albumin gradienet (SAAG)

Serum albumin - ascites albumin

>= 1.1 g/dl = transudative = portal HTN

868

Persistent muscle pain
Gets worse w/ exercise
Joints not swollen
Palpation over affected muscles--> tenderness

ESR WNL

What does she have?

Fibromyalgia

Radiograph and labs have no abnormalties

869

Infection that begins to drain fluid (yellow)
Gm + branching bacteria

What is it?
What do you tx with?

Actinomyces israelii
- sulfur granules draining

Tx w/ high dose IV penicillin for 6-12 wks

870

Scrofula

Draining infection caused by TB

871

Conditions needing hyperbaric O2 tx

The bends (deep sea diving)
CO poisoing
Slow healing ulcers

872

Causes of primary hypo parathyroidism

Post surgical
- during thyroidectomy

Congenital absence of parathyroid glands
- Digeorge

Autoimmune
- In APECED syndrome = mucocutaneous candidiasis in polyglandular autoimmune endocrinopathy type 1

Defective CaSR on parathyroid glands
- pseudohypoparathyroidism

873

Common causes of steppage gait/foot drop

Most commonly due to peripheral neuropathy

Trauma to common peroneal nerve or spinal roots contributing to peroneal nerve (L4 - S2)

Charcot Marie Tooth (congenital)

874

Postoperative cholestasis
- How does it happen?
- How does the jaundice happen?
- lab abnormalities

Benign condition happening after major surgery w/ hypoTN, lots of blood loss into tissues, massive blood replacement

Jaundice happens b/c
1) Increased pigment load (b/c of transfusion)
2) decreased liver functioning (b/c hypoTN)
3) Decreased renal bilirubin excretion (b/c tubular necrosis)

ALP very high
AST, ALT usually normal/slightly elevated

875

In spinal cord injury, you need to cath a pt. What can you do to decrease UTI?

Intermitten cath rather than indwelling cath

Indwelling can form biofilm along catheter wall

876

Type 2 diabetes w/ increasingly blurred vision over 1 week - what is happening?

Nonketotic hyperosmolar syndrome

Acute hyperglycemia --> cause myopic increase in lens thickness and intraocular hypoTN secondary to hyperosmolarity --> blurred vision!

877

De Quervain's tenosynovitis

Classically affects new moms holding infants w/ thumb abducted + extended

Inflamm of abductor pollicis longus adn extensor pollicis bevis as pass through fibrous sheath at radial STYLOID process

Tenderness on direct palpation

+ Finkelstein test

878

A pt has suspected bacterial pneumonia. What do you do 1st? After that?

CXR

Antibiotics ASAP w/o waiting for sputum Gm stain or cx

879

Best way to eval liver damage in
- acute hepatitis
- chronic hepatitis

Acute - LFT, viral serology

Chronic - liver biopsy

880

Types of neuropathies in diabetes mellitus

Symmetrical:

peripheral neuropathy

mononeuropathy
- cranial (CN 3 most often - ischemic neuropathy, usually only motor, not PSNS b/c have diff blood supplies)
- somatic

autonomic neuropathy

881

Paroxysmal supraventricular tachycardia
- What is it?
- How to alleviatae?

#1 paroacetxysmal tachy in ppl w/o structural heart disease

Usually due to re-entry into AV node

To dec conduction through AV node:
- valsalva
- carotid sinus massage
- immersion in cold water
---> these all are vagal manuevers

882

Liver cysts w/ daughter eggs
- What is this due to
- What occupation do you worry about this?

Echinococcus granulosus

Sheep farmers!

Loves to go to lungs too

883

Simple renal cyst
- what should it NOT look like
- what is it?

Benign, only observation needed.

Make sure mass does not have:
- multilocular mass
- thickened irregular walls
- thickened septae within mass
- contrast enhancement

884

What is Wilson's disease assoc w/?

Fanconi syndrome
Hemolytic anemia
neuropathy

885

How do you dx Wilson's?

Liver biopsy --> hepatic cover level > 250 mg /gm dry wt
Low serum ceruloplasmin w/ high urinary Cu excretion

886

Trousseau's syndrome

migratory thrombophlebitis

usually due to adenocarcinoma
- most in pancreas
- lung
- prostate
- stomach
- acute leukemia
- colon cancer

Thrombophlebitis of atypical sites like arms and chest is impt clue to underlying carcinoma

887

Smudge cells

CLL

888

Paravertebral tenderness = ?

Spinal tenderness = ?

Para - lumbosacral strain

Spinal - compression fracture, etc

889

Acute, afebrile, blood tinged sputum. Young pt. no smoking hx
PE revealed b/l wheezes
No findings on CXR

What is the dx?
What is the cause?

Acute bronchitis

Usually viral in etiology

890

How to histoplasma cause cytopenias, lymphadenopathy, adn hepatospenomegaly?

B/c it targets histiocytes and reticuloendothelial system

891

Dx herpes encephalitis

PCR of HSV DNA in spinal fluid is gold standard

892

PPD testing

Inducation > 5 mm is + in...

HIV
Recent TB contact
Signs of Tb on CXR
Organ transplants, pts on immunosuppression

893

PPD testing

Induration > 10 mm is + in...

Recent immigration from TB endemic area
IVDU
Residents/employees of high risk settings (prisons, homeless shelters)
Diabetes
CKD
Heme malignancies
Fibrotic lung disease
Kids < 4 yo, teens exposed to high risk adults

894

PPD testing

Inducation > 15 mm is + in...

Healthy ppl w/ no TB infection risk factors

895

Pts w/ hemochromatosis and cirrhosis are at increased risk of infection with...

Listeria monocytogenes
Yersinia enterocolitica
Vibrio vulnificus

Possibly b/c impaired phagocytosis due to iron overload in reticuloendothelial cells

896

Romberg test

Proprioception test

Ataxia, (+) romberg = ataxia is sensory in nature
- DCMLS damaged

Ataxia, (-) romberg = cerebllar dysfunction

Romberg is NOT a test of cerebellar function

897

Pronator drift

+ pronator = spasticity

Can happen w/ UMN lesion

If pronates, person have pronator drift on that side - tehrefore CONTRALATERAL pyramidal tract lesion

A lesion in the cerebellum = upward drift

898

If history and physical suggestive of ankylosing spondylitis, how do you confirm the dx?

Plain film X ray demonstrating fused sacroiliac joints and/or bamboo spine

899

How do you explain sx of P vera?
- dizziness/headache
- pruritus
- PUD

Dizziness/headache - hyperviscosity

Pruirtus - increased histamine (mast cell degranulation) and prostaglandins (stimuli from RBC0

PUD - increased histmine, activates more acid prod by stomach

900

TImeline to tx acute acetaminophen OD

If eaten within 4 hrs, can give activated charcoal

Obtain acetaminophen level @ 4 hrs (1st timepoint where hepatotoxicity evident)

Then decide to give N acetylcysteine based on result - ok if given wtihin 8 hrs of ingestion

901

How does syphillis rash spread?

Secondary syphilis

Start on trunk --> palms and soles

902

#1 cause of glomerulonephritis in adults

IgA nephropathy

serum complement levels normal

LOW in post-strep

903

If you have chronic UTI w/ Klebs, what kidney stone are you more prone to?

Struvite stones

904

How does aspirin cause an anion gap metabolic acidosis?

1) Uncouples ox phos --> increase rate of O2 consumption in periph tissues --> hyperpyrexia

2) Inhibits enzymes for carb and lipid metabolism --> accumulate pyruvate, lactic, and acetoacetic acid

3) Impair renal fx --> accumulate organic acids like sulfuric and phosphoric acid

905

Fever, tinnitus, and tachypnea - what do you suspect?

Aspirin intoxication

906

How does preggers or oral contraceptive increase gallstone formation?

Estrogen --> increase cholesterol secretion

Progesterone --> reduce bile acid secretion, slows gallbladder emptying (stasis)

907

#1 site of mets

#2?

1 - Lymph nodes

2 - Liver
--> GI, lung, breast, melanoma loves to go here

908

Aspirin exacerbated respiratory disease

All 3 features:

ASthma
Chronic rhinosinusitis w/ nasal polyps
Bronchospasm/nasal congestion after Aspirin/NSAID use

Can also have anosmia b/c nose messed up

909

What shown to prolong survival in pts w/ COPD and hypoxemia?

Long term supplemental O2 therapy

910

What serum omsmolality does neuro manifestations happen?

> 310

U osm = 2 (Na) + glucose / 18 + BUN / 2.8

911

Bone marrow transplant pt ~45 days s/p transplant who has lung adn intestinal pathology. What microbe is this?

CMV
- pneumonitis
- lower GI ulcers --> ab pain and diarrhea

912

Suspected melanoma - what do you do to tx?

Excisional biopsy

After confirm dx of melanoma, excise w/ wide margins

913

Melanoma - what are the work ups for diff size lesions?

Depth < 1 mm
- excise w/ 1 cm tumor free margin

Depth > 1 mm
- sentinel lymph node study

914

Cerebellar tumor

Ipsilateral ataxia
Fall toward side of lesion

Nystagmus
intention tremor
ipsilateral muscular hypotonia

915

Festinating, shuffling gait

Parkinson's

916

Broad based gait
Feet lifter higher than usual and make slapping sound w/ floor

Tabes dorsalis

917

During walking, keep affected arm adducted adn affected leg extended
Will swing leg in semicircle

Hemiparetic patient from stroke

918

Waddling gait

Muscular dystrophy
- b/c weakness of glut muscles

919

Metabolic abnormalities of tumor lysis syndrome

Hyper PO4
Hyper K
Hyper uricemia
--> high PO4 and K b/c both intracelluar and released w/ lysis

Hypo Ca
--> decreased b/c freed PO4 binds Ca taking down the [ ]

920

Age distribution of craniopharyngioma

Biomodal

kids
- stunted growth

age 55-65 yo
- sex dysfunction

921

Presenting symptoms of craniopharyngiomas

Suprasellar tumors

Hypopituitarism
Headaches
Bitemporal blindness

922

Mediastinal widening

Often in aortic dissection

923

Folate vs. B12 deficiency - how do tell the difference?

Both have increase homocysteine

ONLY Cobalmin has elevated methylmalonic acid (folate does not convert methylmalonyl coa --> succinyl Coa)

924

Type A lactic acidosis

Lactic acidosis from poor O2 delivery to tissues

CO poisoning
Shock

925

HIV needle stick
- what do you do?
- how do you test?

Test for HIV ASAP
- repeat after 6wks, 3 mos, 6 mos

Ppx of 2-3 drugs
- 2 NRTIs + Protease inhibitor

926

Difference between drug induced liver injury and isoniazid induced liver injury

Both have liver injury like viral hepatitis

BUT INH doesn't have rash, arthralgias, fever, leukocytosis, eosinophilia

927

Vanishing duct (ductopenia) in liver causes

Primary biliary cirrhosis
Failing liver transplant
Hodgkin's
GVHD
Sarcoid
CMV
HIV
Medication tox

928

Characteristic LP finding of SAH

Xanthrochromia

Happens b/c RBC go into CSF and have time to be lysed and digested into bilirubin, thus making a yellow color

If blood in LP b/c damaged BV while doing it, would be red rather than yellow b/c not enough time to digest

929

Only ilicit drug to cause vertical nystagmus

Phencyclidine

Use benzos to tx severe psychomotor agitation

930

Seborrheic dermatitis

Assoc w/ parkinsonism or HIV

Fine, loose, waxy scales w/ underlying erythema on scalp, central face, presternal region, interscapular areas, umbilicus, body folds

931

Type 4 RTA

Can happen in diabetic nephropathy

Aldo deficiency or renal tubular insensitivity to aldo

Retain K
Waste Bicarb
Nonanion gap metabolic acidosis

932

How do you tell b/n cardiac and noncardiac pulmonary edema

PCWP

> 18 --> impaired LV function

< 18 --> noncardiac etiology (eg ARDS)

933

Correcting hypernatremia

Usually water deficit in relation to sodium --> hypotonic fluid loss and decreased access to free water

Isotonic 0.9% saline

Once normal volume, switch to 0.45% saline

Don't correct more than 1 mEq/L/h or cerebral edema

934

What's a quick and easy way to tell b/n COPD and asthma?

Bronchodilator response test
- measure FEV1 before and after bronchodilator
- significant FEV1 improvement --> reversible etiology --> asthma

935

HIV ppx for CD4 count less than:
50
100

50
- Azithromycin, clarithromycin or Rifabutin for ppx against mycobacterium avium complex

100
- Itraconazole for histoplasmosis (if live in endemic area)

936

What do you do for solitary brain met w/ stable extracranial disease? Multiple mets?

Single - surgical resection, brain radiation

Multiple - palliative whole brain radiation

937

How big is a pituitary microadenoma?

< 10 mm in diameter

938

Rabies post exposure prophylaxis

1. If dog NOT captured, assume rabid
++++give post-exposure ppx

2. If dog captured and NO features of rabies, keep to observe for 10 days.
+++++see signs in dog, give post-exposure ppx immediately

3. Post exposure ppx for bites on head and neck

939

Recommendation for screening for AAA

65-75 yo M w/ PMH smoking benefit most from screening

Should do 1x abdominal US in pts

940

What's the logic behind the timeline for A1c showing you glucose values?

tells you glucose levels over past 100-120 days

This correlates w/ RBC survival time

941

Person comes in w/ stroke...first thing you do?

CT noncontrast of the head

942

Winter's formula for PaCO2 compensation of metabolic acidosis

PaCO2 = 1.5 (HCO3-) + 8

943

Chronic epigastric pain suddenly worsens and becomes diffuse
Pneumoperitoneum

What is it?

Gastric ulcer perforation

944

If a pt has an UGIB w/ depressed level of consciousness, + hematemesis, what do you do?

Intubation!

Stabilize first with ABCs

Then endocscopy w/ band ligation or sclerotherapy to stop bleeding

945

What kind of effusion is CHF?

Transudative

pH = 7.35 for transudative

946

What is the pH for pleural effusion in
- empyema
- normal
- inflammation
- transudative

empyema - 7.2

normal - 7.64

inflammation - 7.3

transudative - 7.35

947

Always include in workup of acute delirium in elderly?

UA

Serum electolytes

948

When do you start colonoscopy screening for UC?

Once disease present for at least 8 years regardless of age of pt

Do exam every 1-2 years

Need prophylactic colectomy if evidence of dysplasia

949

Dejerine Roussy syndrome

Thalamic stroke

Usually of VPL nucleus

Contralateral hemianesthesia w/ transient hemiparesis, athetosis or ballistic mvmt

Thalamic pain phenomenon

950

W/ diabetic peripheral neuropathy, how do you get the paresthesias pain? How about the numbness?

Small fiber neuropathy --> pain, allodynia, paresthesias; sensory OK

Pure large fiber --> more numbness, ankle reflex lost

951

Psoriatic arthritis
- signs adn symptom

DIP usually involved

Morning stiffness
Deformity of involved joints
Dactylitis
Onycholysis (Separation of nail bed)

952

Eggshell calcification of liver cyst

Hydatid cyst!

Echinoccoccus granulosus

953

Well's criteria (Modified)

3 pts
PE as likely or more likely than alternate dx
clin s/s of DVT

1.5 pts
HR > 100 bpm
prior DVT or PE
Immobilization (>3d) or surgery w/in 4 wk

1 pt
Hemoptysis
malignancy

6 = High prob for PE

954

Previous hx of rheumatic fever
Dental cleaning procedure
Then get infective endocarditis

What order do you do your tx?

What if it is a person who was IVDU who get IE?

Blood cx 1st

Then empiric antiboiotics

Then Transesophageal echo to see valvular vegetations

Transthoracic Echo if tricuspid endocarditis - IVDU

955

Dukes major criteria

For IE diagnosis

+ Blood Cx

Evidence of endocardial involvement on echo

956

Dyspepsia

1 or more of sx:

- epigastric pain
- postprandial fullness
- early satiety

w/ ab burning, nausea, bloating

NOT HEARTBURN b/c that is GERD

- usual etiology is GERD, meds, etc

957

Pt > 55 yo w/ dyspepsia
- what are the alarm sx?
- what do you do for this pt?
- what do you do for pt w/ alarm sx?

Alarm sx:
unexplained wt loss
vomiting
dysphagia
GI blood loss
odynophagia
FH GI cancer

No alarm sx - test for H pylori or empiric H pylori tx (PPI)

Alarm sx - upper endo

958

Alcohol w/d timeline

6-24 hrs
- reflex hyperactivity in brain --> anxiety, insomnia, tremors, diaphoresis

48 hrs
- hallucinations
- w/d seizures

48-96 hrs
DTs
HTN, agitation, tachy, hallucinations, fever

959

What's the best marker for opioid intoxication w/ suggestive clinical feature?

Bradypnea

NOT miosis - sometimes don't have miosis

960

Hepatorenal syndrome

Complication of ES liver disease

Decreased GFR in absence of shock, proteinuria, or clear cause of renal dysfunction
- als no response to 1.5 NS bolus

Type 1 - rapidly progressive, pts die w/in 10 wks w/o tx

Type 2- slower; survive 3-6 mos

Usually die of infection and hemorrhage

Need to get liver transplant to survive

961

Pruritic elevated serpiginous lesions on skin - what caused this? how did you get it?

Ancylostoma braziliense
- hookworm!

Sandy beaches, sandboxes

962

Can you get mild elevations in transaminases, bilirubin, and amylase in cholecystitis?

Yes!

Even w/o obvious common bile duct or pancreatic disease
- sludge or pus into CBD causes these elevations

BUT ALP is not increased unless cholangitis or choledocholithiasis

963

Tx acute cholecystitis

NPO

IV antibiotics

analgesics

Laparoscopic cholecystectomy soon after hospitalization

964

Sx hypercalcemia

Confusion
Lethargy
Fatigue
ANorexia
Polyuria
Constipation

965

What type of pericarditis does not present w/ classic EKG diffuse ST segment elevations?

Uremic pericarditis

Inflammatory cells don't penetrate myocardium

Tx uremic pericarditis w/ dialysis

966

What's a normal decreased reflex finding in elderly?

Decreased achilles tendon

967

What sx are typical for asbestosis? Uncommon?

Typical - progressive dyspnea

Uncommon - cough, sputum prod, wheezing

968

Large exophytic papule w/ collarette scale
- what is this?
- how do you dx?
- what do you have to be careful of?
- Tx?

Bartonella henselae!

Tissue bx + microscope ID of org

Biopsy can cause hemorrhage - be careful!

Abx to regress lesion

969

Pt works in daycare
- acute onset of polyarticular (MCP, PIP, wrist) and symmetric arthritis
- resolves in 2 months

What is it?

Parvovirus

970

How long do you have arthritis before diagnosed as RA?

at least 6 wks

971

pANCA positivity

Anti-MPO

Microscopic polyangitis
Churgg strauss
Ulcerative colitis

972

Factorial design study

Randomization to diff interventions w/ additional study of 2 or more variables

973

Diarrhea in HIV pt - what do you do 1st?

ID causal organism

Then do antibiotic

974

Tx pts w/ diabetic gastroparesis

Diabetes control + dietary mod

Small frequent meals

Metoclopramide - improve gastric emptying
Erythromycin
Cisapride (not used in US)

975

Anorexia
N/V
Early satiety
Postprandial fullness
bad glucose control

What is this?

DIabetic gastroparesis

976

Macrocytic anemia
- causes
- what does it look like?

Vit B12 deficiency
Folic acid deficiency
Hypothyroidism
Liver disease
Antimetabolites

Macroovalocyte RBCs, hypersegmented neutrophils, anisocytosis, poiklocytosis, basophilic stipling
Retic count decreased
Bone marrow hypercellular

977

P vera can be associated with what? And why?

Gout! 40% w/ pvera have gou

Myeloprolif d/o are common causes of uric acid overproduction
- increased catabolism and turnover of purines

978

Delayed sleep phase syndrome

Circadian rhythm d/o

Can't fall asleep at normal bedtimes (10 or midnight)

979

Advanced sleep phase disorder

Circadian rhythm disorder

Can't stay awake in evening (usuallya fter 7 pm) so social functioning difficult

pts complain of early AM insomnia

980

What is a sensitive marker of dehydration?

BUN/Cr ratio

981

What do you risk giving bicarb in tx lactic acidosis or ketoacidosis?

Bicarb may paradoxically depress cardiac performance and worsen acidosis by enhancing lactate production

982

What do you suspect w/:
- decreased haptoglobin
- increased LDH
- decreased Hg
- venous thrombosis

Paroxysmal nocturnal hemoglobinuria

- abnormal anchor protein GP1 which usually binds CD55 adn CD58 which stop complement from destroying RBC

- intravascular hemolytic anemia

- PNH have tendency towards venous thrombosis, particularly hepatic veins

- mild thrombocytopenia too

Use flow cytometry tests to dx - find if cells have CD 55 and 59 on surface

983

When do you do a DEXA scan for women for osteopororsis?

65 yo - one time

Osteopenia = T score -1.5 to - 2.5
Osteoporosis = T score less than - 2.5

984

Monoarticular or asymmetric arthropathies

Seronegative spondyloarthropathies

Septic arthritis

Crystalline arthritis

985

Symmetrical polyarthritis

Viral arthritis (mumps, rubella, parvovirus)

Rheumatoid arthritis
SLE

--> tell the difference b/c viral will resolve but RA and SLE do not resolve in less than 4 weeks

986

Live vaccines are NOT recommended in HIV pts. But which is the only one that is?

MMR

- measles is life threatening in HIV pts
- usually ok for counts > 200 (CD4)

987

Causes of aortic aneurysm
- ascending
- descending

CXR findings

ascending
- cystic medial necrosis or CT d/p

descending
- atherosclerosis

CXR
- widended mediastinal silhouette
- increased aortic knob
- tracheal deviation

988

Tx acute cholangitis

CBD blockage --> infection up the bile duct w/ increased ALP

Supportive
Broad spectrum antibiotics

No response,
Biliary drainage w/ ERCP

989

Types of polyps in colon

Hyperplastic - nonneoplastic, no further work up needed

Hamartomatous - juvenile, peutz jeghers - usually not malignant

Adenoma - most common, can be premalignant

990

Probability of adenoma progressing into cancer

Sessile vs/ stalked (pedunculated)
- sessile more cancerous

Tubular, tubulovillous, villous
- villous more malignant

Size
- bigger size, more liekly malignant (>2.5cm)

991

Intraepidermal blisters + erosions w/ multinucleated giant cells w/ molded stell gray nuclei

HSV
VZV

vessicles

992

Extensor weakness
Chronic interstitial nephritis
Anemia w/ low-normal MCV

What is happening?