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Flashcards in Medicine Part 2 Deck (584):
1

Most common causes of ESRD

Diabetes
HTN

2

How is ESRD defined?

Not by BUN or Cr

Loss of kidney function leading to clinical and lab findings of uremia

3

Calciphylaxis

Hyperphosphatemia --> calcium adn PO4 precipitate --> vascular calcifications --> skin lesions/necrosis!

4

Absolute indications for dialysis

AEIOU

Acidosis

Electrolytes - HYPERkalemia

Intoxications - methanol, eth glycol, lithium, aspirin

Overload - hypervolemia that can't be solved

Uremia - based on clinical presentation, like pericarditis

5

Microscopic hematuria usually

glomerular in origin

6

Gross painless hematuria usually

Bladder or kidney cancer

7

Hematuria

>3 erythrocytes / HPF on UA

8

Order to evaluate proteinuria

Urine dipstick - specific for albumin

UA

9

Dipstick + blood

UA no RBC

What is it?

Hemoglobinuria

Myoglobinuria

10

Proteinuria

>150 mg protein/days

11

Glomerular d/o vs tubular d/o

In glomerular but not in tubular:
- need biopsy usually
- steroids and immunosuppressive meds for tx

In tubular but not in glomerular:
- acute presentation,
- caused by toxins
- does not cause nephrotic syndrome

12

Acute Interstitial Nephritis
- features
- seen on labs
- causes

Polyruia and sterile pyruria (maybe some WBC casts) are early manifestations

acute interstitial renal inflammation + pyuria + eosinophils (hypersensitivity) + azotemia

happens after drugs
METHICILLIN #1
NSADs
captopril
penicillins
sulfonamides
rifampin
TMP
cephalosporins

13

AIN treatment

Remove offending agent

Steroids if still getting worse

14

Acute tubular necrosis
- causes
- stages

Toxic (#1 aminoglycosides) or Ischemic (more serious, prerenal azotemia usually (shock, sepsis) or crush injury w/ myoglobinuria) → granular casts (muddy brown)

o This is medullary necrosis and ATN is limited to outer medullar segments b/c renal medulla is susceptible to ischemic injury b/c low medullary blood flow → glomeruli look normal

o Stages: (1) inciting event → (2) Maintenance (oliguric, risk of hyperkalemia & met acidosis) → (3) Recovery (polyuric, risk of hypoK)

15

Nephrotic syndrome
- features

o Hyperlipidemia b/c increased hepatic lipoprotein synth – but only LDL; HDL will decrease!
o Hypoagammaglobinemia = increased risk infection
o Hypoalbuminemia = edema
o Hypercoagulable = loss antithrombin 3

16

Minimal change disease

-only lose albumin, not all globulins

17

Diffuse cortical necrosis

usually due to hypOperfusion of kidney (vasospasm, DIC, abruption placentae, septic shock), medulla spared

18

Renal papillary necrosis
- what is it
- causes
- dx

necrosis of renal papillae (supplied by vasa recta) = hematuria, proteinuria


o “POSTCARDS” = Pyelonephritis, Obstruction, Sickle Cell, TB, Cirrhosis, Analgesic abuse (phenacetin, acetaminophen, aspirin), Renal transplant rejection, Diabetes (#1), Systemic vasculitis

o DACS = Diabetes Mellitus (#1), Acute pyelonephritis, Chronic phenacetin use (acetaminophen), Sickle Cell

Dx w/ ecretory urogram - note change in papilla or medulla

19

Acute renal failure

↓ renal function → ↓GFR → INCREASE BUN and Creatinine (azotemia)

will also have met acidosis!

20

Chronic renal failure

Hyper K (#1 COD b/c arrhythmia)
Metabolic ACIDosis (increase H+, ↓ bicarb)
Uremia
Anemia
renal osteodystrophy
dyslipidemia
Na/H2O retention
growth retardation in children;

FREE Ca will be decreased b/c increase in PO4 will bind up the free Ca in blood

21

Renal tubular acidosis

D/o of renal tubules --> nonanion gap HYPER Cl metabolic acidosis

Glomerular function OK

decrease in acid excreted in urine

22

Type 1 RTA
- what is it?

Distal

Can't secrete H+ at distal tubule --> new bicarb cannot be made

Urine pH does not go below 6

23

Type 1 RTA
- effects of it

Decrease ECF

Hypo K, HYPER Cl, met acidosis

Renal stones

24

Type 1 RTA
- causes

MM

Nephorcalcinosis

Amphotericin B

Lupus, Sjorgen's

Medullary sponge kidney

Analgesics

25

Type 2 RTA
- waht is it?

Proximal

Can't reabsorb HCO3 at PCT --> more bicarb excreted in urine

26

Type 2 RTA
- effects

Hypo K, HYPER Cl, met acid

NO KIDNEY STONES

27

Type 2 RTA
- causes

Fanconi's syndrome
Wilson's
Lead toxicity
Amyloid
MM

28

Type 4 RTA

Hypoaldo or resistant to aldo

Decreased Na absorbtion + decreased H and K secretion in DCT

HYPERkalemia (not hypo) + acidic urine + met acidosis

29

Hartnup syndrome

AR

defective aa transporter

Tryptophan can't be reabsorbed --> NAD deficiency

Dermatitis, diarrhea, ataxia, psych disturbances (all like pellagra)

Supplement w/ NAD if symptomatic

30

Fanconi's syndrome

PCT dysfunction

can't transport
- glucose
- aa
- Na
- K
- PO4
- uric acid
- bicabr

Results in
- rickets
- osteomalacia, osteoporosis
- polyuria,
- dehydration
- type 2 RTA
- hypercalciuria
- hypo K

31

Dx ADPKD

Ultrasound

Can use CT and MRI

32

Extrarenal involvement of ARPKD

Liver - protal HTN, cholangitis

Pulm insufficiency - pulm hypoplasia + enlarged kidneys - mostly because not enough amniotic fluid

Potter syndrome

33

Medullary sponge kidney

Cystic dilation of CD

can be assoc w/ hyper PTH and parathyroid adenoma

Benign; some stones and more UTI sometimes

34

Dx medullary sponge kidney

Intravenous pyelogram - inject contrast to see on xray

35

Renal artery stenosis
- causes

Atherosclerosis (31)

Fibromuscular dysplasia
- usually in young fems
- bilateral in 50% ppl

36

Dx renal artery stenosis

Renal arteriogram
- DO NOT USE FOR RENAL FAILURE. Contrast can be nephrtoxic

MRA - ok for renal failure

37

Renal vein thrombosis
- when is it seen?

RCC invasion

Nephrotic syndrome

Preggers/OCP

38

Dx renal vein thrombosis

renal venography

IVP

39

Where does sickling of sickle cell most commonly occur in kidney?

Renal papille

Can get papillary necrosis, renal fail, lots of UTIs

ACEI can help

40

Causes of hyperoxaluria

Steatorrhea

Small bowel disease

Crohns

Pyridoxine deficiency

41

Initial test to dx urinary tract obstruction

Renal ultrasound

42

Gold standard to dx urinary tract obstruction

Intravenous urogram (IVP)

NOT for preggers, allergies to contrast

43

PSA
DRE
Transrectal ultrasonography (TRUS)

- what do you do with these results when screening for prostate cancer?

PSA > 10 ---> Do TRUS w/ biopsy
DRE abnormal ---> Do TRUS w/ biopsy

PSA < 4 + DRE (-) -----> annual f/u

4.1 < PSA < 10 + DRE (-) -----> biopsy

44

DRE of prostate cancer

Prostate hard, nodular, irregular

45

PSA of cancer vs PSA normal

PSA cancer usually bound by plasma proteins

PSA normal usual free in plasma

46

Risks for RCC

Cigarettes
Phenacetin analgesics
ADPKD
Chronic dialysis
Mercury
Cadmium
HTN

47

Dx RCC

Renal US only detects mass

Abdominal CT (w/ and w/o contrast)
- for dx and staging

48

Tx RCC

Radical nephrectomy

Take out:
kidney
adrenal
Gerota's fascia

49

Transitional cell caricinoma

Can be anywhere along kidneys --> ureter

Mostly in bladder

Frequently recurs

50

TCC risk factors

Pee SAC

Phenacetin
Smoking (#1)
Aniline dyes
Cyclophosphamide

51

Dx TCC

Cystoscopy + biopsy (definitive)

52

Staging of TCC

CXR

CT scan

53

Testicular cancers
- Germ cell tumors

Most common

Seminomas
- radiosensitive, slow growing

Embryonal
- very malignant, mets early

Choriocarcionma
- most aggressive, mets always

Teratoma
- usually no mets

Yolk sac
- rare, usually in kids

54

Testicular vs. scrotal cancers

Testicular cancers usually always malignant

Scrotal cancers usually benign

55

Testicular cancers
- Non germ cell tumors

Usually benign, less common

Leydig cells
- benign, tx w/ surgery
- secrete estrogens and androgens --> precocious puberty

Sertoli cells
- usually benign

56

Testicular cancer risk factors

Cryptochidism (risk still there w/ correction)

Kleingelter's

57

Testicular ca tumor markers

B HCG
- increased in choriocarcinoma

AFP
- increased in embryonal tumors

US to try and localize tumor

58

DDx of testicular mass

Cancer

Varicocele

Torsion

Spermatocele

Hydrocele

Epididymitis

Lymphoma

59

Tx testicular cancer

Inguinal (not scrotal) excision of testicle

CT scan to stage

BHCG and AFP measurements

60

Penile cancer assoc

HSV

HPV 18

61

Testicular torsion

Surgical emergency

After 6 hrs, may have infarction and no longer save testicle

62

Epididymitis

Infection of epididymis

Usually E coli
Gonorrhea, Chlamydia in sex active

Fever
Less acute onset vs. torsion

63

Total body water

60-40-20

60% body wt = water

40% = ICF

20% = ECF
- 15% = interstitial
5% = plasma

64

What is impt to track to assess volume status?

Urine output

Normal kids = > 1 mL/kg/hr

Normal adults = 0.5-1 mL/kg/hr

65

Anascara

extreme generalized edema

66

Fluid replacement therapy options

NS
- increase intravascular volume if dehydrated
- not great for CHF

D51/2NS = 5% dextrose, 1/2 NS
- standard maintenance fluid
- dextrose to inhibit muscle breakdown

D5W
- dilute powdered meds
- only some stays intravascular b/c diffuses into TBW compartment; not great to replenish intravascular

Lactated ringer's solution
- good to replacing intravascular volume
- NOT a maintenance fluid
- common trauma resuscitation
- DO NOT USE if hyperkalemia is concern b/c has K

67

Calculation of maintenance fluids

100.50.20 rule

For 70 kg man:

10 kg x 100
10kg x 50
50 kg x 20

Total: 2500

2500/24 = 104 mL/hr

68

Changes in Na concentration = ?

Changes in Na content =

Concentration --> reflection of water homeostaiss

Content --> reflection of Na homeostasis

69

Hyper/hyponatremia

vs

Hypo/hypervolemia

Hyper/hyponatremia caused by too little/too much WATER

Hyper/hypovolemia caused by too much/too little Na

70

Hypo Na symptoms

Usually neuro sx

Headache, delirium, irritability
Muscle twitching, weakness
Hyperactive deep tendon reflexes

Seizures, coma

N/V, watery diarrhea

HTN b/c increased ICP

Oliguria

71

Tx hyponatremia
- hypotonic hyponatremia

Mild (120-130)
- withhold free water

Moderate (110-120)
- loop diuretics + saline

Severe (< 110)
- hypertonic saline increasing serum Na by 1-2 mEq/L/hr

72

Risks of correcting hypoNa too fast

Central pontine demyelination

73

Risks of correcting hyper Na too fast

cerebral edema

74

Hyper Na symptoms

Neuro sx usually

AMS
restlessness
Weakness
Focal neuro deficits

75

What should be given to differentiate nephrogenic from central DI if DI suspected?

DesmopressiN

76

Hypoalbuminemia, Ca is low. But ionized Ca is normal.

How do you est ionized Ca

Total Ca - (serum albumin * 0.8)

77

What alters Ca binding to albumin?

pH changes

Increase pH --> increase binding of Ca
- decrease ionized Ca
- total Ca ok

78

Causes of decreased Ca

Hypo PTH
Acute pancreatitis
Renal insufficiency
Hyper PO4
Pseuhypoparathyroidism
Hypo Mg
Vit D deficiency
Malabsorb
Blood transfusion w/ citrated blood
Osteoblastic mets
Hypoalbuminemia
DiGeorge

79

Features of decreased Ca

Rickets, osteomalacia
Tetany
- Chovstek's, Trousseau's sign
Seizures
Basal ganglia calcifications
Arrhythmias

PROLONGED QT`

80

Causes of increased Ca

Hyper PTH
Renal failure (usually hypo Ca but can be hyper w/ high enough PTH)
Acromegaly
Addison's

Metastatic ca
MM
PTH paraneoplastic

Vit D intox
Milk alkali syndrome
Thiazides,, lithium

Sarcoidosis
Familial hypocalciuric hypercalcemia

81

Features of increased Ca

Stones
Bones
Groans
Psych overtones
---> All increased PTH signs

POlydipsia, polyuria
HTN
Wt loss
SHORT QT

82

1st step in management of hyper Ca

Increase urinary excretion via IV fluids

Diuretics (furosemide) to stop Ca reabsorb

83

What can you use to quickly tell why someone is hypokalemic?

Presence or absence of HTN

HTN - aldo increased - causes K wasting

No HTN - GI or renal loss of K

84

Hypo K EKG

Flattened T wave/ T wave inversion

U wave

85

Does dig cause hyper or hypo K?

What predisposes to dig toxicity

Causes HYPER K

Hypokalemia predisposes - allows Dig to bind more to Na/K pump

86

Features of hypo K

Arrhythmias
Muscle weakness, paralysis, cramps
Paralytic ileus
Polyuria adn polydipsia
N/V

87

How best to replete K?

KCl

10 mEq KCl increases K by 0.1 mEq/L

Add lidocaine so KCl doesn't burn as much

88

How fast can you infuse K?

10 meq/hr in periph IV line
20 meq/hr in central line

89

When do you correct hypo Mg first?

In both hypo K and Ca

90

How does hyper K affect kidneys to worsen acidosis?

Inhibits renal ammonia synthesis and reabsorb

Net acid excretion is impaired!

Metabolic acidosis

Further makes K move out of cells

91

Hyper K EKG

Peaked T waves
Prolonged PR interval
Widen QRS


--> eventually get QRS merge w/ T wave producing sine pattern
-->
Vfib

92

Tx Hyper K

IV calcium
- decreases membrane excitability
- be careful giving this to pts on dig b/c can worsen toxicity

Shift K into cell
- glucose + insulin (fastest)
- sodium bicarb (for emergencies)

Remove K from body
- Kayexalate (exchange resin)
- hemodialysis
- diuretics

93

Where is most of Mg in body?

Bones

94

Where is most of K in body?

Intracellular

95

Where is most of Na in body?

Extracellular

96

Causes hypo Mg

Malabsorb
Fasting
Fistulas
TPN

Alcoholism

SIADH
Diuretics
Bartter;s syndrome
Gentamicin, amphotericin B, cisplatin, PPIs
Renal transplant

DKA, burns, lactation

97

Hypo Mg features

Muscle twitching
Weakness
Tremors
Hyperreflexes
Seizures
AMS

Hypo K and Ca

98

Hypo Mg EKG

Prolonged QT

T wave flattening

Torsades

99

Causes of hyper Mg

Renal failure

Burns, trauma, ECF volume deficit

Mg-laxatives, antacids

Adrenal insufficiency

Adnreal insufficiency

Rhabdomyolysis

100

Hyper Mg features

Nausea
Facial paresthesias
Deep tendon reflex LOSS
Respiratory depression
Coma

101

Hyper Mg EKG

Like hyper K

Increased PR
Widened QRS
Elecated T

102

Tx hyper Mg

No Mg

IV calcium gluconate

Saline + furosemide

Dialysis

Intubation if respiratory depression

103

Where is most of PO4 in body?

Bones

104

Causes of decreased PO4

DKA
Alcohol abuse

105

Hypo PO4 clinical features

Encephalopathy
COnfusion
Seizures
Paresthesias

Weakness
Myalgias
Rickets

Hemolysis
RBC dysfunction

Cardiomyopathy b/c low ATP

Rhabdomyolysis

106

Hyper PO4 causes

Renal insufficiency
Bisphosphoates
Hypo PTH
Vit D intoxication
Tumor calcinosis
Rhabdo
cell lysis
acidosis

107

Hyper PO4 features

Metastatic calcification + soft tissue calcifications

Neuro changes from decreased Ca

108

Tx hyper PO4

PO4 binding antacids (Al OH or carbonate)

Hemodialysis

109

Which bicarb value is more reliable?
- serum vs. ABG?

Serum (venous) CO2

110

Salicylate OD acid base status

Respiratory Alkalosis
Metabolic acidosis

111

Causes of renal loss of bicarb

Proximal tubular acidosis
- MM
- cystinosis
- Wilsons

Distal tubular acidosis
- can't make HCO3
- SLE, sjogren's, amphotericin B

Acetazolamide

112

Causes of GI loss of bicarb

Diarrhea
Pancreatic fistulas
Small bowel fistulas
Ureterosigmoidostomy

113

Danger to tx acidosis w/ bicarb

Bicarb takes 24 hrs to get to brain

Hyperventilation is continuing though

PaCO2 low while HCO3 increases - dangerous

114

What can be used to clinically detect endogenous depression?

Dexamethasone suppression test

50% of pts w/ depression, DST will be abnormal

115

Hallmark of prolonged seizures

Cortical laminar necrosis

Can lead to persistent neuro deficits and recurrent seizures

116

Status epilepticus

Any 1 seizure > 5 mins

Cluster of seizures w/ pt not recovering normal mental stauts in between

117

Initial TB infection - what does it look like on CXR?

Peripheral pulmonary focus
- Gohn focus remains as calcified granuloma

Mediastinal or hilar lymphadenopathy on CXR

118

Hyposthenuria

Found in pts w/ sicklle cell + trait

Thought to result from RBC sickling in vasa rectae of inner medulla which impairs countercurrent exchange and free water reabsorb

119

Proximal muscle weakness
Spares muscles of mastication and facial expression
Dysphagia possible

What is this?

Polymyositis/Dermatomyositis

Muscle biopsy to dx

120

Large blunt hyphae

Thick walled budding spores

What is this?

Malassezia furfur

Causes tinea versicolor

121

Hypopogmented macules that do not tan

Do not appear scaly

Scale on scraping

What is this? How to tx?

Tinea versicolor

Topical selenium sulfide ltion
Ketoconazole shampoo

122

What do you expect in any pt w/ hx of cancer or fever who p/w back pain and neuro sx, particularly loss of bowel or bladder function?

How do you confirm dx?

What should you do 1st?

Compression of thecal sac

MRI to confirm

Glucocoritoicds (dexamethasone) to start asap so decrease risk of permanent neuro damage

123

Low leukocyte alk phos + leukocytosis

CML

124

Most impt modifiable factors for decreasing HTN

Wt control > physical activity > Na restrict > moderation of EtOH consumption

125

Waldenstroms macroglobulinemia

Plasma cell neoplasm

IgM spike --> hyperviscosity

Hepatosplenomegaly, lymphadenopathy
Anemia --> tiredness
Increased bleeding
Night sweats
headaches
Dizziness
Visual problems (retinal v engorgement)
Pain and numbess in extremities --> demyelinating sensorimotor neuropathy

126

MM vs. Waldernstroms

MM has

IgA or IgG

Doesn't have hyperviscosity

127

Big danger of pancreatic necrosis

Locally released pancreatic enzymes can increase vascular permeability w/in and around pancreas

Large volume of plasma into retroperitoneum

Hypotension mainly due to increase in vascular permeatbility!!!

128

Valvular consequence of aortic dissection

Best way to dx AD

Aortic regurg

Transesophageal echo (more than MRI b/c MRI is long)

129

Contraindicaitons to liver transplant

Irreversible cardio-pulm dz causing prohibitive risk

incurable or recent malignancy outside of liver

Active EtOH or IVDU

130

During acute asthma, what is one indicator of severe attack

Normal PaCO2

Should be decreased b/c hyperventilate

Normal to increased = CO2 retention b/c severe obstruct and/or respiratory muscle fatigue

131

How do you improve ARDS oxygenation

Increase PEEP w/ low tidal volumes on ventilator setting

132

How does a person get infected w/ cystercosis

If eat larvae in undercooked pork, will get intestinal infection

If eat eggs from human feces, cystercercosis happens
- larvae will invade intestinal wall adn can go to muscle, brain, subQ tissue, eye

NOT GOTTEN BY EATING INFECTED PORK AS THE ONLY WAY - POOP OF HUMAN!

133

When is AS symptomatic?

Valve area < 1 cm2

134

Systemic effects of sarcoidosis

ACE increase
Increase vitamin D

135

Antiphospholipid syndrome features

Arterial and venous thromoboses

Thrombocytopenia
Prolonged PTT

Avoid preggers loss w/ LMWH

136

Signs of glucocorticoid deficiency

Weakness
Fatigue
Loss of appetite
Eosinophilia

137

Presentations of P vera

HTN
Increased peptic ulceration
Gouty arthritis
Plethoric face
Splenomegaly
Hypercellular bone marrow

138

Earliest renal abnormality in pts w/ DM

Glomerular hyperfiltration

ACEi reduce intraglomerular HTN --> decrease glomerular damage

This can eventually cause thickening of glomerular BM --> nodular sclerosis

139

Pneumonia + GI sx + elevated LFTs

What is this? How do you tx?

Legionella pneumoniae

Quinolone or macrolide ot tx

140

What is infection w/ Moraxella catarrhalis commonly assoc w/

COPD

141

PFTs in IPF

Decreased TLC
normal FEV1/FVC

Diffusing capacity decreased
Increased Aa gradient

142

Diagnostic criteria for ARDS

Acute onset

PaO2/FiO2 < 200

Bilateral infiltrates on CXR

Swann Ganz P < 18 mm Hg

143

What should FiO2 be if person is adequately venetillated to prevent O2 toxicity to lungs?

below 60%

Increase PEEP as needed to maintain adequate O2 after FiO2 lowered

144

Bilateral trigeminal neuralgia

Transient muscle weakness

What is this most likely?

MS!

MS is one of few conditions presenting w/ bilatearl trigminal neuraligia

145

Systemic issue w/ L sided endocarditis

Can send septic emboli to regions rich in blood supply (brain, kidney, livre, spleen)

R sided endocarditis more likely to cause septic pulm emboli

146

Lab values for portal HTN causing splenomegaly

Anemia
Thrombocytopenia

147

Expansile adn eccentric lytic area (soap bubble) in epiphysis

Pain, swelling, decreased ROM

Most get pathologic fractures

Giant cell tumor

148

How do you diagnose a pheochromocytoma?

CT scan

MRI better for extra adrenal catecholamine secretion

Mibg scan if cr shows nothing

149

Any wide complex tachyarrhythmia is what until proven otherwise?

Ventricular tachycardia

150

In an MI, what is your long term prognosis most influenced by?

What do you do to achieve this?
How quickly?

Duration of time that lapses before coronary blood flow restored

Use Percutaneous transluminal coronary angioplasty and fibrinolysis
- PCTA better
- should be done w/in 90 mins

Fibrinolytics should be done w/in 30 mints

151

Erythematous rash and maculopapular

Starts on face --> trunk and extremities

Lymphadenopathy (occipital and posterior cervical)

Arthritis in adult women

Maybe some conjunctivitis

What is this?

Rubella

Measles does not have arthritis

152

What are cholesterol emboli usually preceded by?

Angiography

Plaque is disrupted by catheter or guidewire

153

Blue toe syndrome
Livedo reticularis (reddish-cyanotic reticular discoloration of skin)
Acute renal failure
Ab pain
Sometime pancreatitis
Eosinophils in blood
DECREASED COMPLEMENT LEVELS

Cholesterol emboli

154

Infarction of
- medial vermis of cerebellum
- lateral cerebellum

Medial
- severe vertigo
- nystagmus

Lateral
- dizziness
- ataxia
- weakness
- tendedncy to sway towards side of lesion

155

Dizziness
Hearing loss
Tinnitus

Meniere's disease

156

Pathophys of benign positional vertigo

Ca crystals in inner ear shift position

Nystagmus
Nausea
Vomitting

157

4 cardinal symptoms of rest less syndrome

Uncomfortable sensation/urge to move legs
Discomfort worse at night/sleep
Discomfort worse at rest
Discomfort helped by mvmt of affected limbs

158

Pathophys of RLS

Abnormalities of dopaminergic transmission in CNS

159

What vaccines should pts w/ chronic liver disease get?

Tdap (every 10)
Influenza
Pneumococcal vaccine (every 5)
Hep A
Hep B

160

Major causes of vit K deficiency

Inadequate diet intake

Intestinal malabsorb

Loss of storage sites due to hepatocellular disease

161

How long does vit K storage last?

30 day

acutely sick - 7-10 days

162

Hemolytic uremic syndrome

Often follows diarrhea

Thrombocytopenia
MAHA
Fever
Renal failure (rather than neuro sx of TTP)


Shiga-toxin binds to the globotriaosylceramide (Gb3) receptor on the surface of the glomerular endothelium
This action includes a cascade of signaling events leading to apoptosis and binding of leukocytes to endothelial cells.
The Shiga-toxin-activated endothelial cells then become thrombogenic (clot-producing)
Additionally, the binding action of Shiga-toxin inactivates a metalloproteinase called ADAMTS13

163

What should all pts w/ significant bladder outlet obstruction get?

Foley catheter

Prolonged obstruction > 2 weeks can results in permanent kidney damage

164

How do you best view an acoustic neuroma?

MRI w/ contrast

165

DO NOT miss this as reason for hyperkalemia in an asymptomatic pt

Pseudohyperkalemia
- venipuncture can hemolyze RBC --> cause K to be released

166

When do you tx hyperkalemia?

How do you do it?

If cardiac toxicity (EKG shows), muscular paralysis, K > 6,5

+ Ca gluconate to stabilize myocardial membrane
- push K into cells w/ insulin and/or B-agonists
- can also use Na Bicarb to shift into cells

167

Nonhealing ulcer
Scaling plaque w/ central ulceration
Biopsy shows polygonal cells w/ atypical nuclei at all levels of epi w/ zones of keritnization

What is this?

Squamous cell carcinoma of skin

Sunlight is risk factor

168

Personality changes
Compulsive behaviors
Impaired memory
Visuospatial functions intact
+ family hx in some

What is this?

Frontotemporal dementia (Pick's disease)

169

Fluctuating cognitive impairment
Bizarre, visual hallucinations
Some parkinsonism but poor response to D agonist therapy

What is this?

Lewy body dementia

170

Eczematous lesion on breast
Biopsy = large cells that appear to be surrounded by clear halos

What is this?

Paget's disease of breast

Usually represents underlying adenocarcinoma

Halo cells b/c cancer cells become retracted from adjacent keratinocytes

171

Corneal sensation is via which nerve?

CN 5 - Trigeminal

172

3 most common causes of chronic cough (> 8 weeks)

Post nasal drip
Asthma
GERD

173

Steps to tx ascites

Na and water restriction

Spironolactone

Loop diuretic (not more than 1 L/day of diuresis)

Frequent abdominal paracentesis (2-4L/day if renal function ok)

174

When are vascular shunts for liver cirrhosis indicated?

Symptomatic varices

Side to side porto caval shunt to help ascites but worsens encephalopathy

Peritoneo jugular shunt tx ascites

175

Indications for hemodialysis

Refractory hyper K

Volume overload/pulm edema NOT responding to diuretics

Refractory met acidosis (pH < 7.2)

Uremic pericarditis

Uremic encephalopathy or neuropathy

Coagulopathy due to renal failure

176

Best to tx frostbite

Rapid re-warming w/ warm water (40-44)

Result in less tissue damage than slow rewarming

177

Osgood Schlatter disease

Overuse injury caused by repetitive strain

Young kids w/ rapid growth spurt

Avulsion of apophysis of tibial tubercle

178

#1 COD in dialysis pts

Cardiovascular disease

179

GERD hx
- progressive dysphagia to solids w/o anorexia or wt loss

Benign strictures

180

GERD hx
- progressive dysphagia to solids w/ anorexia or wt loss
- GERD for > 20 years

Adenocarcionma of esophagus

181

Charcot's joint

Neurogenic arthropathy

Usually in diabetic neuropathy

Complication of neuropathy and repeated joint trauma
Affects wt bearing joints --> functional limitation, deformity, degenerative joint disease

182

Persistent ST segment elevation after recent MI and deep Q waves in same leads

Ventricular aneurysm

183

Causes of pulsus paradoxus

Cardiac tampanode
ASthma
COPD

--> in pulm conditions b/c extra negative pressure gets more blood into lungs, further decreasing LV preload

184

What prevents development of pulsus paradoxus even in presence of pericardial effusion and cardiac tamponade?

Signficiant arotic regurg -- causes large increase in LVEDP preventing septum shift

185

Pts w/ hyper PTH increased risk of developing what arthropathy?

Pseudogout - CPPD deposition

186

Dx lactose intolerance

Lactose hydrogen breath test

Increase H level after eat lactose --> indicates bacterial carb metabolism (as lactose no absorbed by gut so bacteria get to it)

187

Waddling gait

Muscular dystrophy
- weakness of gluteal muscles

188

Spastic gait

Lesions of UMN

Slow, stiff, effortful movements

189

Wide based high stepping gait

Loss of proprioception

Dorsal roots or posterior column damage

190

Pathology of angioedema

C1 inhibitor deficiency, dysfunction or destruction

Leads to increased C2b and bradykinin = edema producing factors

C4 levels are depressed

191

erythema nodosum - what is it?

Infection of fat cells

It is a panniculitis

192

When are you at risk for hypocalcemia due to citrate chelation

If transfuse > 1 unit/5 min

Live failure b/c liver processes citrate

193

Definition of HTN
- in gen pop
- in diabetics and renal disease

Gen pop > 140/90

Diabetes and renal disease > 130/80

194

Emergency eval of headache

Noncontrast CT to rule of ICH

Small bleeds may not show up - LP can be done if high suspicion and no bleed shown

195

Which headache is most responsive to ppx?

Cluster headaches

-- use verapamil

196

Pt w/ migraines but do not respond to drugs for tx migraines. What are they?

Rebound analgesic headaches

Try and wean from analgesics!

197

Do you need antibiotics for bronchitis?

NO! Usually viral

198

Causes of laryngitis

Usually viral

Moraxella catarrhalis, H influenzae

199

Sore throat Ddx

Viral infection
Tonsilitis
Strep throat
Mononucleosis

200

When should a pt w/ GERD be screened for Barrett's

Symptomatic for at least 5 yrs

201

What Pulm finding are you at risk for w/ GERD?

REcurrent aspirationi pneumonia

you can find lipid laden macrophages in cytology

202

Need ppx for dental procedures for these groups

• Prosthetic cardiac valves

• History of prior infective endocarditis

• Unrepaired cyanotic congenital heart disease

• Completely repaired congenital heart disease for 6 months following repair

• Repaired congenital heart disease with residual defects or abnormalities

• Cardiac transplantation recipients with cardiac valvulopathy

203

How to tx small focal breast cancer

Lumpectomy w/ sentinel lymph node biopsy

Irradiation

204

1st degree family hx colorectal cancer - what's the screening procedure?

Age 40

OR

10 yrs younger than 1st diagnosis

205

1st degree heart block

First-degree atrioventricular block is diagnosed when the PR interval is greater than 0.20 sec

206

EKG of WPW

PR interval (<0.11 sec), prolonged QRS duration, and slurred onset of the QRS (delta wave) complex.

207

Chronic alcoholism pts have risk of what electrolyte abnormality if they get admitted?

Hypo phosphate

Can be normal on admissions and decrease over first 12 to 24 hrs. Possibly because of IV glucose admin

208

Manifestation of rapid decrease in phosphate

Confusion
Rhabdomyolysis
Hemolytic anemia
Muscle weakness

209

Tx gallstone pancreatitis

ERCP with sphincterotomy and stone extraction

210

Orthostatic prteinuria

Increase in urinary protein excretion only in uprivht psiion

Most common in yong adults or children

211

Urine aniongap formula

Normal value

= (U sodium + U potassium) - U chloride

212

How do you tell if metabolic acidosis is of renal or extrarenal origin just by labs?

Extrarenal causes of metabolic acidosis are associated with an appropriate increase in net acid excretion primarily reflected by high levels of urine ammonium excretion, whereas kidney causes of this condition are associated with low net acid excretion and decreased urine ammonium levels.

Can get Urine ammoium w/ urine anion gap

Metabolic acidosis of extrarenal origin is suggested by a large, negative UAG caused by significantly increased urine ammonium excretion. Conversely, metabolic acidosis of kidney origin is suggested by a positive UAG related to minimal urine ammonium excretion.

213

If pt w/ polymyagia rheumatica has a prednisone taper 2x but keeps getting flares, what should be done?

Add steroid sparing agent and incease prednisone

Example ismethoteate.

214

When do you need a TTE for a murmur?

3/6 or greater systolic murmur
Diastolic murmur
Continuous murmur
New murmur if last PE was healthy

215

PR interval length

120 to 200ms

No more than 1 large box

216

QRS length

80 to 120ms

3 small boxes

217

QT interval

< 1/2 of R-R interval

218

How to tell the earliest if someone has rheumatoid arthritis?

A radiograph showing marginal joint erosions would most likely support a diagnosis of rheumatoid arthritis (RA).

Erosions of cartilage and bone are cardinal features of RA. Erosions and joint-space narrowing may develop as early as 2 to 3 mos

219

Where do you find rheumatoid factor?

RA

Hep C

220

Histo of Acute promyelocytic anemia

predominant cell is a large immature granulocyte with multiple granules overlying the cytoplasm and nucleus.

221

AML diagnosis

The diagnosis of AML is confirmed by a bone marrow aspirate showing hypercellular marrow containing greater than 20% to 30% myeloblasts.

Once the diagnosis of acute leukemia is established, the classification is based on the morphology of the immature cells.

The presence of Auer rods confirms the myeloid nature of the leukemia.

222

ALL features

lymphocytosis, neutropenia, anemia, thrombocytopenia, lymphadenopathy, and hepatosplenomegaly at presentation.

An increased number of lymphoblasts found on bone marrow examination are suspicious for the diagnosis.

223

When to screen for asymptomatic bacteruria

pregnant women

before urologic surgery

224

Pt w/ TB - suggestive pleural effusion. How do you best evaluate next?

Pleural biopsy

225

Is a duodenal ulcer cancerous?

No

226

Most common causes of gastric ulcers

NSAIDs

H pylori

227

Diabetic retinopathy classifications

nonproliferative (with hard exudates, microaneurysms, and minor hemorrhages), which is not associated with visual decline

proliferative (with “cotton-wool spots” and neovascularization), which is associated with loss of vision.

228

The presence of hypotension, hyponatremia, and a decreased urine sodium excretion accompanied by a bland urine sediment raises suspicion for.....

Prerenal azotemia

229

Tumor lysis syndrome may manifest as what electrolyte abnormalities?

hyperkalemia
hyperphosphatemia
hyperuricemia.

230

Meniscal tear vs. ligament injuries (ACL)

Swelling faster in ligament injuries

231

Click/knock of joint w/ loose cartilage

Pain on walking

What could have happened? what tests do you do to figure this out?

Meniscal tear

Pain along the joint line is 76% sensitive for a meniscal tear

an audible pop or snap on the McMurray test is 97% specific for a meniscal tear.

232

McMurray test

Maximally flexing the hip and knee and applying abduction (valgus) force to the knee while externally rotating the foot and passively extending the knee

233

Suspect common bile duct stone for sx of pancreatitis and jaundice. But none seen on US. What do you think it is?

Abdominal ultrasonography has a sensitivity of only 50% to 75% for choledocholithiasis, and a common duct stone should be suspected in the correct clinical situation even when ultrasonography does not show a stone

234

Suspected osteomyelitis - you cultured the ulcer ontop of the wound and it shows X bacteria. What do you do next?

Cx from sinus tract or ulcer base don't reflect bacterial etiology of underlying osteo

DO A BONE BIOPSY! Then do antibiotic therapy

The one exception is Staphylococcus aureus, which, if found in superficial cultures, correlates well with findings on deep cultures

235

Cardiac events in pts w/ long QT syndrome

Cardiac events in patients with LQTS include syncope and cardiac arrest due to torsade de pointes ventricular tachycardia.

236

Risk factors Long QT

female sex
hypokalemia
hypomagnesemia
structural heart disease
previous QT-interval prolongation
history of drug-induced arrhythmia

237

Familial syncope...causes?

Long QT syndrome

238

When do you consider HIT?

HIT/T should be considered in any patient with an otherwise unexplained decrease in the platelet count and/or a new thrombotic event 5 to 10 days after initiation of heparin therapy.

239

Gold std diagnose HIT

14C-serotonin release assay (SRA)

240

Abnormal uterine bleeding - what types

infrequent menses, excessive flow, prolonged duration of menses, intermenstrual bleeding, and postmenopausal bleeding.

241

Asthma exacerbation - signs of respiratory failure

Slightly elevated or even normal Paco2 levels often indicate impending respiratory failure rather than recovery,

pulse oximetry less than 95%, respiration rate greater than 30/min, and heart rate greater than 120/min

242

Dx ankylosing spoindyliis

MRI of sacroiliac joints

243

If pt w/ CRF is without fluid overload, hyperkalemia, metabolic acidosis, or uremic symptoms, what do you do for them?

Keep them on meds

Hemodialysis or Kidney replacement therapy can be delayed

. Transplantation in patients who have not yet been treated with hemodialysis is associated with better patient and allograft outcomes.

244

Whaty is the most appropriate option patient with continued anginal symptoms despite optimal medical therapy.

Coronary angiograph

245

Coronary revascularization is beneficial in patients with chronic stable angina and the following conditions

angina pectoris refractory to medical therapy; a large area of ischemic myocardium and high-risk criteria on stress testing; high-risk coronary anatomy, including left main coronary artery stenosis or three-vessel disease; and significant coronary artery disease with reduced left ventricular systolic function

246

Risk factors for legionnaires disease include

smoking, diabetes mellitus, hematologic malignancy, other types of cancer, chronic kidney disease, and HIV infection.

247

Test for legionella?

Leginoella urinary antigen test

248

The patient is having a moderate to severe exacerbation of chronic obstructive pulmonary disease (COPD)...what do you do?

should be placed on noninvasive positive-pressure ventilation (NPPV).

A landmark study found that NPPV reduced the need for intubation, the length of hospital stay, and the mortality rate in such patients.

249

Contraindications to NPPV include

impending respiratory arrest, cardiovascular instability, altered mental status, high aspiration risk, production of copious secretions, and extreme obesity, as well as surgery, trauma, or deformity of the face or upper airway.

250

What do you suspect in patients with explosive onset, widespread psoriasis and the occurrence of dactylitis; marked distal interphalangeal (DIP) joint involvement; asymmetric joint involvement; symptoms of enthesitis; or joint ankylosis.

HIV-related psoriatic arthritis

251

Diarrhea + N/V

Cause?

VIral gastroenteritis

Food poisoning

252

Diarrhea + fever + blood in stool

Shigella
Campylobacter
Salmonella
E. coli

253

Diarrhea + no fever + no blood

VIruses (rotavirus)
Entertoxic E coli
Food poisoning (Staph aureus, C. perfringens)

254

Fecal leukocytes in

C diff
Camylobacter
Salmonella
Shigella
EIEcoli

255

Endocrine causes of conspitation

hypo TH

Hyper Ca

Hypo K

Uremia

Dehydration

256

#1 way decrease SBP

Reduce BMI

257

Severe diarrhea electolyte disturbancce

Metabolic acidosis

Hypo K

258

Vomiting electrolyte disturbance

Metabolic alkalosis

Hypo K

259

Positive straight leg test means...

Nerve root compression

260

If low back pain in the absence of progressive neuro deficits, osteoporosis, steoird use, constitutional sx, hx of malignancy, recent trauma, IV drug use, is refractory to conservative tx for at least how many months, what should you do next?

3 months

MRI

261

Osteochondritis dissecans

Area of necrotic bone and degenerative changes in overlying cartalage

Bone and cartilage can separate and become loose --> pain, catching and popping

262

Plica syndrome

Dx of exclusion

Usually in atheletes w/ overuse injuries

263

Most common ankle ligament injured

Anterior talofibular ligament

264

Trochanteric bursitis

Common cause of lateral hip pain

Very painful on palpation

Tx w/ NSAIDs

265

Tests for carpal tunnel syndrome

Tinel's sign
- tap over median N @ wrist --> paresthesias

Phalen's test
- palmar flexion of wrist for 1 min --> paresthesias

266

Definitive dx of carpal tunnel

Electomyography and nerve conduction velocity study

267

Cartilage vs. bone --> which one has nerve endings?

Bone!

That's why in arthritis, wear down cartilage and don't notice but will notice once bone starts rubbing against each other!

268

Where is pain of osteoarthritis of hip?

In groin

Can radiate to anterior thigh

269

Where do you hold the cane for L knee pain?

R hand

270

Is there a correlation b/n x ray osteoarthritis and severeity of disease?

No

271

Type 1 vs type 2 osteoporosis

Type 1 - more trabecular bone loss

Type 2 - = trabecular and cortical bone loss

272

Calcitonin effects

No help w/ hip

Helps w/ spine (lumbar)

273

Which osteoporotic fracture has highest morbidity and mortality?

Hip

274

SENSORINEURAL HEARING LOSS PATHOPHYS

DEGENERATION OF SENSORY CELLS AND NERVE FIBERS AT BASE OF COCHLEA

275

Screening for ab aortic aneurysm

w/ US at age 65 in all men w/ smoking hx - only 1 test needed, no repeat if normal

276

Osteoporosis screening

DEXA scan starting at 65

277

RBBB

Wide QRS
rSr in chest leads
Wide S in lead I

278

LBBB

Wide QRS
No Q in I, V5, V6
Notched R in I, V5, V6

279

Q waves pathologic if

> 0.04 s wide

> 25% height of QRS

280

T wave inversions in

MI
Pericarditis
Cardiomyopathy
INtracranial bleed
Acidosis
LBB
LVH

281

Peaked T waves in

early MI
Hyper K
Hyper Mg

282

To do ASAP after putting in central venous line

CXR to check for pneumothorax

283

Causes of rales

fluid in lungs

atelectasis

pneumonia, CHF, ILD

284

Causes of wheezes

Asthma

285

Causes of rhonchi

Chronic bronchitis

Snoring quality, low pitch, due to lots of mucus

286

Type 1 error

Null hypothesis rejected even though it is true

FALSE +

287

Type 2 error

Null hypothesis not rejected even though it is false

False -

288

Effects of increase mineralocorticoid secretion

Increased tubular reabsorb of Na and HCO3
Loss of Cl in urine

Metabolic alkalosis and expansion of ECF

289

PaCO2 mainly determined by

Respiratory rate

Tidal volume

290

How much does 1 unit of packed RBC increase Hb level?

Hb increase by 1
Hct increased by 3

Hb x 3 = Hct

291

FFP

All clotting factors

NO RBCs, WBCs, platelets

292

Cryoprecipitate

Factor 8
Fibriongen

For hemophili A, DIC, vWD

293

Dx beta thalassemia

Hemoglobin electrophoresis
- increase HbF and HbA2

Periph blood smear
- microcytic
- hypochromic
- target cells maybe

294

Tx thalassemias

frequent PRBC transfusions

295

Clinical features of b-thalassemia

Anemia
Hepatosplenomegaly
Expansion of marrow space
Crew cut skull

296

Sideroblastic anemia
- what is it?
- causes?
- tx?

Abnormality in RBC iron metabolism

Hereditary or acquired

Chloamphenicol
INH
Alcohol

Lead

Collagen vascular disease

Myelodysplasia

Tx w/ removing offending agent, B6

297

Consequence of aplastic anemia

Transform into leukemia

Increased infections

298

Causes of B12 deficiency

Pernicious anemia

Gastrectomy

Vegans
Alcoholism

Crohn's disease

Diphyllobothrium latum
SIBO

299

Causes of folate deficiency

Tea and toast diet
Alcoholism

Long term antibiotic use

Increased Demand

Preggers

Hemolysis

MTX, phenytoin

Hemodialysis

300

Signs of intravascular hemolytic anemia

Dark urine color (hemoglobinuria)
Schistocytes
Low haptoglobin
Increased LDH

301

Signs of extravascular hemolytic anemia

Spherocytes or helmet cells
Increased LDH
Increased unconjugated bilirubin --> jaundice

302

What does sickle cell survival correlate with?

Frequency of vaso occlusive crises

More = shorter lifespan

303

Aplastic crisis in sickle cell
- precipitants
- tx

Caused by virus (eg parvo B19)

Tx blood transfusion

304

Splenic sequestration crisis

Sudden pooling of blood into spleen --> splenomegaly + hypovolemic shock

Happens in sickle cell adn beta thal

More common in kids b/c they ahve intact spleens

305

Consequences of sickle cells

Painful bone crises
Dactylitis
Acute chest syndrome (repeated episodes of pulmonary infarctions)
Splenic infarctions
Avascular necrosis of joints (hip, shoulder)
Priapism
Renal papillary necrosis w/ hematuria
Chronic leg culcers b/c vaso occlusion
Ab crises
Infections w/ H influenzae, strep pneumo
Salmonella osteo

306

Manage painful crises

Hydration
Morphine for pain
Keep pt warm
Supplemental O2 if hypoxic

307

When do you do blood transfusion for sickle cell?

Acute chest syndrome
Stroke
Unresponsive priapism
Cardiac decomp

308

Paroxysmal noctual hemoglobinuria

Deficiency of anchor proteins linking complement-inactivating proteins to blood cell membranes

Intravascular hemolysis

Pancytopenia

309

Dx PNH

Ham's test
- pt cell incubated in acidified serum --> triggers alternative complement --> lysis of PNH cells

Sugar water test
- mix pt's serum in sucrose --> hemolysis if PNH

Flow cytometry to detect CD55 or 59

310

Tx PNH

Glucocorticoids (prednisone)
- most don't respond

311

Platelet disorders

ITP
TTP
HIT
Bernard Soulier
Glanzmann's

312

Idiopathic thromocytopenic purpura
- what is it
- clinical features
- dx
- tx

IgG antibodies on platelets --> removed by spleen

Minimal bleeding
NO splenomegaly

Dx
- plt count < 20,000
- low periph platelets
- increased megakaryocytes

Tx
- steroids
- IV immunoglobulin
- splenomgaly
- plt transfusions
- romiplastim, eltrombopag

313

Thrombotic thrombocytopenic purpura
- what is it
- clinical features
- tx

Plt consumption disorder
Plt count decreased
PT, PTT normal

TTP = HUS + fever + AMS

Features
- hemolytic anemia
- thrombocytopenia
- renal failure
- fever
- neuro signs

Tx
- plasmapheresis
- steroids, splenectomy
- NO plt transfusions

314

Bernard Soulier

AR

Deficiency in GpIb

Plts large, plt count low

315

Glanzman's thrombathenia

AR

Deficiency in GpIIb-IIIa

Plt count NORMAL

316

Thrombin time

Measure of fibrinogen concentration

317

Bleeding time

Reflects plt function

318

Of clotting factors, which has shortest 1/2 life? How does this affect PT or PTT

Factor 7

PT increases 1st with clotting factor deficiency

319

Inherited hypercoagulable states

AT 3 deficiency (AD)

Antiphospholipid antibody syndrome (acquired)

Protein C deficiency (AD)

Proetin S deficiency

Factor 5 leiden (protein C can't activate factor 5)

Prothrombin gene mutation

Hyperhomocysteinemia

320

How long are you hypercoagulable for preggers?

All of preggers

2 months postpartum

321

Highest incidence of cancers in men

Prostate > lung > colon

322

Higher mortality cancers in men

Lung > prostate > colon

323

Highest incidence of cancers in women

Breast > lung > colon

324

Highest death cancers in women

Lung > breast > colon

325

Oncologic emergies needing immediate tx

Hyper Ca
- fluids, diuretics, bisphosphanates

Spinal cord compression
- steroids, MRI

Pericardial tamponade
- pericardiocentesis

Tumor lysis syndrome
- IV fluids
- tx electrolyte abnormalities

326

DCIS vs LCIS - which is palpable?

DCIS

327

1st step for breast mass in woman > 30

Biopsy

328

When do you need chemo after removing breast lump?

Don't need it for small lesions (< 1cm) w/o lymph node involvement

329

Indicates poor prognosis staging in CLL

Thrombocyotpenia

330

Dx MM

> 10% abnormal plasma cells in bone marrow + 1 of the following:

M protein in serum
M protein in urine
Lytic bone lesions

331

Waldenstrom's macroglobulinemia

Malignant prolif of plasmocytoid lymphocytes

IgM

No bone lesions

NO cure

332

Dx Hodgkin's lymphoma

Biopsy of lymph node shows Reed Sternberg cells

333

Clinical features of Hodgkin's lymphoma

Painless lymphadenopathy
Constitutional symptoms (poorer prognosis)
Spread continuity from 1 lymph node to adjacent lymph node

Pruritus
Cough

334

Myelodysplastic syndrome

Acquired clonal blood d/o

Ineffective hematopoiesis
Apoptosis of myloid precursors

Results in pancytopenia despite normal or hypercelllular bone marrow

335

Abnormalities of myelodysplastic syndromes

Low retic count
Howell Jolly bodies
Basophilic stippling
Ringed sideroblasts

336

Tx myelodysplastic syndrome

RBC and plt transfusions

EPO
GCSF

Vit B6, 12 folate for cell turnover

337

Essential thrombocythemia

Plt > 600,000

Dx of exclusion

Splenomegaly
Pseudohyper K
Elevated bleeding time

Increased megakaryocytes in bone marrow

338

Normal pulse in setting of high fever is suggestive of...

atypical CAP

339

Approach to CAP

Lower vs. upper?
- nasal discharge, sore throat --> usually upper

If lower, is it PNA vs. bronchitis?
- CXR to tell

340

If CXR not suggestive of PNA, what do you do

DO NOT tx w/ antibiotics

341

False negative CXR for PNA in...

Neutropenia
Dehydration
PCP
Early disease

342

PNA hints
- alcoholics
- immigrants
- nursing home
- HIV +
- transplant recipients

Alcoholics - Klebs

Immigrants - TB

Nursing home - Pseudomonas

HIV - PCP, M TB

Transplant - Legionella

343

If suspect PNA is the following, how do you test?

TB
PCP
Legionella

TB - acid fast

PCP - silver stain

Legionella - urinary antigen

344

When do you admit for PNA?

If pt is hypoxic or hypotensive

345

Parts of lungs most affected by aspiration lung abscess

Posterior segments of upper lobes

Superior segments of lower lobes

Right lung more affected

346

CXR of lung abscess

Thick walled cavitation w/ air fluid levels

347

Who is contagious w/ TB

Active TB

Primary TB NOT contagious

348

Radiologic findings in primary TB

Ghon's complex
- calcified primary focus w/ assoc lymph node

Ranke's complex
- Ghon complex --> fibrosis and calcification

349

Primary Tb

usually asymptomatic
May have pleural effusion

350

Secondary (active) TB

Constitutional sx
Dry cough --> purulent sputum
Apical rales

351

Definitive dx of TB

Sputum culture

PCR

352

PPD

DO NOT use to dx active TB - only for latent TB

If pt is symptomatic or has abnormal CXR, order sputum acid-fast test, not PPD

Positive PPD:
No risk factors: >= 15

High risK> 10 mm

HIV, acitve TB close contacts : 5 mm

353

If person had BCG vaccine and positive PPD, what do you do?

INH for 9 months no matter what!

354

When do you stop TB tx as a result of adverse effects?

If liver transaminases rise to 3-5x upper limit of normal

355

Kerning's sign

Can't fully extend knees when supine

Irritate meninges

356

Brudzinski's sign

Flex legs adn thighs that is brough on by passive flexion of neck

Irritate meninges

357

Dx meningitis

LP

Do a CT scan 1st

Get blood cx before start abx

358

Best way to Dx viral encephalitis

CSF PCR

359

Best way to Dx encephalitis

MRI of brain

360

Transmission
- Hep A
- Hep B
- Hep C
- Hep D
- Hep E

A, E - fecal oral

B - sex, parenteral

C - parenteral

D - w/ hep B

361

If transaminases are really elevated, what do you think of?

Viral hepatitis
Shock liver
Drug induced hepatitis

362

Symmetric descending flaccid paralysis

Botulism

363

Dx botulism

ID toxin in serum, stool, or gastric contents

364

How does a UTI happen?

Colonization of vaginal area by pathogens from fecal flora

E. coli
Staph saprophyticus
Enterococcus
Klebs
Proteus

365

You suspect HUS in someone. What do you do next? How do you tx?

Peripheral blood smear to diagnose

Tx is supportive

Do not use abx

May need dialysis if ARF, PRBC for anemia

Only do platelet transfusion if bad. Otherwise can make worse

366

Do we recommened screening for early stage lung cancer even if pt smokes?

NO

367

How to dx acute parvovirusB19 infection?

IgM Abs

368

Transient aplastic crisis in pts w/ chronic hemolytic anemia - what do you think happened?

Parvo B19 infection

369

Pink pearly nodules w/ telangiectasias + flecksof melanin pigment

What is this?
How to tx?

Basal cell carcinoma

Superficial lesions tx w/ curettage, imiquimod, cryotherapy, or excision

370

How do ou improve survival in severe sepsis?

Agggressive fluid rescussitation

If lactic acid resolves in 6 hrs, good for survival

5-6L fluids/6hrs.

371

Causes of prostatitis

Usually gm -

E coli
Klebs
Proteus
Pseudomonas
Enterobacter
Serratia

372

Which is worse - acute vs chronic prostattis?
- how do you tell what it is?

Acute

Acute
- prostate tender
- fever
- pt looks ill
DO NOT MASSAGE THE PROSTATE as can cuse bacteremia
WBC in UA, U cx always + for bacteria

Chronic
- prostate may not be tender
- pt doesn't look ill
- WBC in UA, U Cx may or may not be +

373

Most common STD? Most cmmon bacterial STD?

STD - HPV

Bacterial STD - chlamydia

374

Leading cause of infertility in women

Chlamydia b/c of tubal scarring

375

Complication of gonorrhea and chlamydia

Infertility

Fitz-hugh curtis syndrome

376

When do you do csection for hIV + mom?

Viral load > 1000 copies

377

Best indicator of status of immune system ad risk for opportunistic infections and disease progressio

CD4 count

>500, immune system normal

378

Best indicator of adequacy and response to antiretrovirals?

Viral load (HIV-1 RNA levels)

379

Leading cause of death in pts w/ AIDS

PCP

380

When at increased risk for CMV or MAC w/ HIV?

CD4 < 50

381

Dx cryptococcal meningitis

CSF ID

tain w/ india ink

382

When do you see esophageal candidiasis in HIV?

CD 4 < 100

383

How long to seroconvert to HIV +

3-7 weeks

384

When does ELISA become + for HIV?

1-12 weeks after infection

If negative, usually doesn't have HIV

385

When do you say someon has AIDS?

CD4 < 200

386

PCP signs

Dyspnea, dry cough, fever

CD4 < 200

CXR = bilateral interstitial infiltrates

Increased LDL
Hypoxia

Bronch to dx fully

387

When do start px for MAC in HIV?

CD4 < 100

388

Where does HSV stay latent?

dorsal root ganglia

389

Reactivaton of HSV assoc w/

stress
fever
infection
sun exposure

390

How to tx herpetic whitlow?

Acyclovir

DO NOT incise and drain

391

Dx herpes

Tzanck smear - quickest - shwes multinucleated giant cells

Cultur of HSV is gold standard (2-3 days)

ELISA

392

Most common presentations of syphillis

Chancre

Inguinal lymphadenopathy

Maculopapular rash of 2ndary syphilis

393

Dx syphilis

NOntreponemal test - RPR, VDRL
- very sensitive
- if +, confirm w/ specific treponemal test
- can be + w/ SLE

Treponemal test - FTA-abs, MHA-tp
- more specific
- not for screening, just to confirm

394

Lymphogranuloma venereum

STD by C. trachomatis

Painless ucer at site of inoculation --> tender inguinal lymphadenopathy few wks later --> constitutional sx

395

How to dx cellulitis?

Clinical!

It is inflammation of skin adn subQ tissue

396

When is cellulitis med emergency?

Orbital involvement

397

Likely cause of cellulitis if caused by break in skin

Group A srep

398

Likely cause of cellulitis if caused by wounds, abscesses

Staph aureus

399

Likely cause of cellulitis if caused by immersion in water

Pseudomonas
Aeromonas
Vibrio vulnificus

400

Likely cause of cellulitis if caused by acute insusitis

H. influenzae

401

Erysipelas
- what is it
- tx

Celluitis confined to dermis and lymphatics

Usually caused by group A strep

Tx IM penicllin or erythromycin

402

Necrotizing fascitis
- what is it
- common causes
- clinical features

Infectio of deep soft tissues rapidly tracking along fascial planes

Strep pyogenes
Clostridium perfringens

Fever and pain out of proportion to appearance of skin
Tissue necrosis
Crepitus

403

Lymphadenitis

Inflammation of lymph node usually due to local skin or soft tissue bcterial infection

Tender lymph nodes, red streaking of skin from wund or area of cellulitis

404

Dx of tetanus

Clinical

405

Tx tetanus

Neutralize unbound toxin w/ passive immunization

Give 1 dose IM tetanus immune globulin

+ active immunizaton w/ Tdap

406

When do you give tetanus immunoglobulin?

If suspect pt is not immunzed for tetanus and has a bad woud. Don't need it in minor wounds for these ppl

407

When do you give tetanus/diptheria toxoid

If suspect pt is not immunized for tetanus and has clean, minor wound or worse

408

Common osteo bugs in catheter septicemia

Staph aureus

409

Common osteo bugs in prosthetic joint

Coag-negative staph

410

Common osteo bugs in diabetic foot ulcer

polymicrobial

411

Common osteo bugs in nosocomial

pseudomonas

412

Common osteo bugs in IV drug use, neutropenia

Fungal

Pseudomonas

413

Common osteo bugs in sickle cell

Salmonella

414

Common osteo bugs in vertebrae

M. TB

Pott's disease

415

How do you use ESR for osteo?

Monitor response to therapy

416

Best way to dx osteo

Needle aspiration of infected bone

MRI

417

Most common joint affected in septic arthritis

Knee

418

What do you do for septic arthritis?

Joint aspiration + analyze synovial fluid

Tx immediately if suspect - do not delay starting abx

419

Most impt tests to confirm clinical suspicion of Lyme disease

ELISA

Western blott to confirm

420

Pathophys of RMSF

Rickettsia rickettsii multiply in vascular endothelium adn spred to diff layers of vasculature

Damage endothelium --> increased vascular perm --> activate complement, microhemorrhages, microinfarcts
Dx is clinical

421

Fever patterns of
P falciparum
P ovale
P vivax
P malariae

P falciparum --> constant

P ovale, vivax --> every 48 hr spike

P malariae --> every 72 hrs spike

422

How do you screen for HCC? How can you dx w/o Bx?

Ultrasound

Patients with a compatible ultrasound imaging study and a subsequent serum α-fetoprotein level greater than 500 ng/mL (500 µg/L) can be diagnosed with hepatocellular carcinoma without a biopsy.

423

Corrected [HCO3]

= measured [HCO3] + (measured anion gap – 12)

424

Dx diffuse parenchymal lung disease

High-resolution CT (HRCT) is more sensitive than chest x-ray for DPLD and reveals ground-glass and reticular linear opacities, subpleural cysts, and honeycombing in patients with advanced disease.

425

Mycobacterium avium intracellulare

causes fevers, diarrhea, malabsorption and anorexia, and can disseminate to the bone marrow

Always consider in HIV pts w/ diarrhea

426

Bronchial breath sounds - meaning

when bronchial breath sounds are heard in a location other than the trachea, it is suggestive of pulmonary consolidation

427

V/Q mismatch examples

pneumonia, pulmonary edema, and COPD/asthma

428

Pulmonary shunt
- what is it
- examples

extreme form of V/Q mismatch where there is no ventilation.
This is clinically recognized when a patient who is hypoxic fails to respond to oxygen.

right-to-left intracardiac shunt
acute respiratory distress syndrome (ARDS)

429

PTT and BT affected. What does this person have?

von Willebrand disease is one of the few hemostatic disorders characterized by both a platelet and coagulation defect due to a reduction or defect in von Willebrand factor (vWF), which supports platelet adhesion and also serves as a carrier protein for factor VIII.

The diagnosis is confirmed by measuring the vWF antigen level and activity.

430

The three classic findings in chronic pancreatitis are

abdominal pain that is usually mid-epigastric,

postprandial diarrhea,

diabetes mellitus secondary to pancreatic endocrine insufficiency.

Dx w/ CT
The presence of pancreatic calcifications on radiographs confirms the diagnosis.

431

A patient with a breast mass requires

triple assessment:

palpation,

mammography

ultrasonography (if BI-RADS 1-3, skip to biopsy if 4,5)
---> distinguishes cystic from solid mass

biopsy (FNA) or aspiration

432

5 major cardiovascular risk factors

cigarette smoking,
hypertension,
older age (men ≥45 years; women ≥55 years),
low HDL-cholesterol level (<65 years).

433

Goal LDL in pts w/ 0-1 cardio risk factors

below 160 mg/dL (4.1 mmol/L).

434

Allergic bronchopulmonary aspergillosis

typ 1 HS rxn

Asthma
Eosinophilia

435

Pulmonary aspergilloma

Inhale spores into lung

Chronic cough, hemoptysis

Can resolve spontaneously; may need lung lobectomy

436

invasive aspergillosis

hyphae invade lung vasculature --> thrombosis and infarction

Immunocomp at risk

Diffuse bilateral pulm infiltrates

437

Dx aspergillosis

Fungus ball on CXR

Sputum has aspergillosis

Blood cx not helpful

438

What is characteristic of tissue biopsy of cryptococcus?

Lack of inflammatory response

439

What should you be suspicious of for persistent fever in ICU?

Fungal infection

Antimicrobial resistance

Needing surgery (abscess)

Drug fever

440

Top causes fever of unknown oritin

Infection - TB, endocarditis, HIV

Neoplasms - lymphoma, leukemia

441

How many organs must be involved to be TSS?

3

Renal
GI
Heme
MS
CNS

442

Before starting oral retinoids, what do you ABSOLUTELY need to do for fems?

Get 2 negative pregnancy tests

Use 2 forms of BC for 1 month before starting med through 1 month after stopping med

443

How do you tell between SCC and keratoacanthoma

Keratoacantoma grows SUPER FAST

444

Hypersensitivity of allergic contact dermatitis

Type 4

Eg poison ivy

445

Is pityriasis rosea contagious?

NO

446

Multiple round/oval patches appear than generalized rash w/ multiple oval shaped lesions. What is this?

Pityriasis rosea

Usually not on face

447

Common infectious cause of erythema multiforme

HSV

Acyclovir can help prevent HSV assoc EM

448

What should you always rule out when child presents w/ molluscum contagiosum?

Child abuse

It is highly contagious, may have sex abse

449

Marjolin's ulcer

SCC arising from chronic wound such as previous burn scar

Usually very aggressive

450

Who has better prognosis for malignant melanoma - men or women?

Women

451

Most impt indicator of melanoma prognosis

Depth of invasion

452

Angioedema vs. urticaria

Angioedema is deeper in skin (deep skin/subQ)

Angioedema is more tender and burning vs. pruritic b/c fewer mast cells/sensory N endings in deeper tissues

453

Hypersensitivity rxns 1-4

1 - IgE

2 - IgG (Goodpastures, pemphigus vulgaris)

3 - Antigen-Ab complex (SLE, serum sickness)

4 - T cell mediated (poison ivy, TB)

454

How long dos it take for a drug allergy to appear?

1 month

Usually not less than 1 week

455

Diagnose cobalamin deficiency in a patient with a low-normal vitamin B12 level with...

methylmalonic acid and homocysteine measurements.

Levels of methylmalonic acid and homocysteine become elevated in patients with vitamin B12 deficiency before serum vitamin B12 levels decrease below the normal range

456

How do you get hypo Ca in acute pancreatitis?

Acute pancreatitis can generate free fatty acids that chelate insoluble Ca salts --> hypo Ca

This is saponification

457

All pts w/ acute monoarthritis should be suspected to have....

Septic arthritis

Arthrocentesis to dx

usually manifests as acute monoarthritis and is characterized by pain on passive range of motion in the absence of known trauma.

458

MRI of joints is useful when?

detecting avascular necrosis
soft-tissue masses
collections of fluid not visualized by other imaging modalities

459

peripheral blood smear showing few, but large, platelets supports the presence of

a young population of platelets, consistent with increased turnover.

ITP!

460

For parapneumonic effusion, what situations/characteristics are abx not enough? How else do you tx?

the presence of loculated pleural fluid,
pleural fluid with a pH less than 7.20,
pleural fluid with a glucose < 60 mg/dL
lactate dehydrogenase > 1000 U/L,
positive pleural fluid Gram stain or culture,
presence of gross pus in the pleural space

Chest tube or catheter drainage to tx too

461

Drug induced lung toxicity

hypersensitivity-type reaction,
with presenting symptoms of
fatigue,
low-grade fever,
cough.

Peripheral blood eosinophilia may be present.

AMIODARONE is a common cause

Acute eosinophilic pneumophilia is MUCH FASTER progressing than this so can r/o if disease has been around for awhile

462

How does handgrip help HOCM murmur?

increasing afterload and decreasing the relative pressure gradient across the left ventricular outflow tract.

463

Aortic stenosis vs. HOCM - differences

HOCM is associated with rapid upstrokes of the carotid arteries,
aortic stenosis, is associated with a carotid artery pulsation that has a slow up-rise and is diminished in volume.

murmur of aortic stenosis decreases with the Valsalva maneuver.

464

decreased anion gap in the presence of anemia, proteinuria, hypercalcemia, and renal failure suggests

Multiple myeloma

465

How does low anion gap happen in MM?

Most unmeasured anions consist of albumin. Therefore, the presence of either a low albumin level or an unmeasured cationic light chain, which occurs in multiple myeloma, results in a low anion gap.

466

Milk alkali

characterized by hypercalcemia caused by repeated ingestion of calcium and absorbable alkali

Often w/ excess milk and antacids for dyspepsia

467

Glomerular vs. nonglomerular hematuria

RBC casts in glomerular

Normal RBC in nonglomerular

468

Evaluate persistent hematuria with

cystoscopy

469

The best way to screen for hearing loss is the

whispered voice test.

470

dyspnea at rest or on exertion, platypnea, and hypoxemia in the setting of chronic liver disease.

hepatopulmonary syndrome


The hypoxemia results from pulmonary vascular dilatation with intrapulmonary shunt and ventilation-perfusion mismatch, which may worsen when the individual is in an upright position.

CXR is nl

471

Cells of sickle cell

Sickle cell

Target RBC

472

Criteria for Type 2 DM

fasting plasma glucose level of at least 126 mg/dL

a random plasma glucose level of at least 200 mg/dL

and symptoms of hyperglycemia (for example, polyuria, polydipsia, or blurred vision),
or a 2-hour oral glucose tolerance test (OGTT) result of at least 200 mg/dL

473

Impaired fasting glucose is diagnosed when

the fasting plasma glucose level is in the range of 100 to 125 mg/dL

474

impaired glucose tolerance

plasma glucose level at the 2-hour mark of an OGTT is 140 to 199 mg/dL

475

Imaging results of ischemic colitis

What is a definitive diagnosis?

Thickened bowel wall on CT

The finding of patchy segmental ulcerations on colonoscopy in a patient with a compatible history establishes the diagnosis.

476

Management of hyperglycemic hyperosmolar syndrome mainly involves

identifying the underlying precipitating illness and restoring a markedly contracted plasma volume.

Insulin reduces glucose levels but should be administered only after expansion of the intravascular space has begun.

Potassium should not be administered until urine output is verified, because these patients are prone to acute kidney injury.

477

Incidental asymptomatic adrenal mass - what do you do next?

Plasma-free metanephrine levels (for pheo)

overnight dexamethasone suppression test (Cushing's)

Adrenal incidentalomas unlikely to secrete aldo and screen if have HTN or hypo K

478

Acute chest syndrome in patients with sickle cell anemia should be managed by

exchange transfusion.

Red blood cell exchange transfusions are performed to increase the hemoglobin A level to at least 50% and thereby decrease the percentage of abnormal sickle cells and prevent hemoglobin S polymerization and sickling.

Will see pulm infiltrate on CXR for acute chest syndrome

479

Dark blue or black berry like lesions that are symmetric, elevated, and one color

Nodular melanoma

Usually in older
Tend to expand vertically rather than horiz

480

Goal LDL of pts with previous stroke or TIA

Less than 100

481

Who should get HPV vaccine?

All girls between 9 and 26 regardless of sex activity

482

Genital herpes lesions

Vesicles that ulcerated and are painful.
Can have crusted roof

483

Chancroid lesions

Deep ragged ulcers

Purulent

May have tender lymph nodes

484

Prosthetic joint infection

Pain is main sx

Usually no fever or leukocytosis

Arthrocentesis is gold std to dx

485

Zinc excess can cause...

Copper deficiency

Copper def can look like b12 def and have demyelination

486

Patients with new-onset heart failure and angina should be evaluated with

cardiac catheterization and angiography if they are possible candidates for revascularization.

487

Patients with new-onset heart failure and angina should be evaluated with

cardiac catheterization and angiography if they are possible candidates for revascularization.

488

Sequelae of infective endocartitis

Fever
Roth's spots (white spots on retina)
Osler nodes (tender nodes on fingers or toes)
Murmur
Janeway lesions (painless erythematous lesions on palm)
Anemia
Nailbed Hemorrhage
Emboli

489

HUS commonly manifests as

acute kidney injury (AKI) accompanied by thrombocytopenia and microangiopathic hemolytic anemia (schistocytes on peripheral blood smear).

490

When is prostate cancer screening beneficial?

Under 75 years old

491

how to reduce the risk of ventilator-associated pneumonia (VAP).

Semi-erect position

Oral placement of endotracheal tubes better than nasal placement

492

Osteoporosis screening guidelines

Guidelines recommend that screening for osteoporosis begin at age 65 years for women. Women aged 60 to 64 years should be screened if they are at higher than average risk for osteoporosis.

The most predictive risk factor for osteoporosis is weight below 70 kg (154 lb), as with this patient.

493

Pneumococcal vaccine is indicated for

persons age 65 years and older or for those younger than 65 years who live in long-term care facilities, or who have chronic illnesses, or who are Alaskan natives or American Indians.

494

Which acute hepatitis rarely causes symptoms?

C

495

cosyntropin stimulation test

is used to determine the adrenal reserve by measuring the response to a standard dose of synthetic adrenocorticotropic hormone.

The test does not detect Cushing syndrome but, rather, adrenal insufficiency

496

the most common causes of cirrhosis in the United States

Alcohol and chronic hepatitis C infection are

497

# drinks to cause alcoholic cirrhosis

6 alcoholic drinks per day for men

3 alcoholic drinks per day for women for 10 years

498

Bowen disease

SCC in situ

Gradually enlarging
Well demarcated
erythematous scaly plaques

can look like psoriasis, BCC, eczema

499

Cryptogenic organizing pneumonia

Alveolar filling opacities on CXR

The tempo of the disease process is the key to differentiating COP from other interstitial lung diseases.

COP is often acute or subacute, with symptom onset occurring within 2 months of presentation in the majority of patients.

The presentation is so suggestive of an acute or subacute lower respiratory tract infection that patients have almost always been treated with and failed to respond to one or more courses of antibiotics before diagnosis.

500

How does a mixing study help w/ diagnosing disorders in coagulation?

The results of the mixing study will normalize in a patient with a factor deficiency but will remain abnormal if an inhibitor is present.

501

classic ekg finding for pe

s1q3t3

502

For what women is there no proven benefit to routine Pap testing to detect cancer.

In asymptomatic women who have had a complete vaginal hysterectomy for benign disease

Still need it if did a complete vaginal hysterectomy but for a malignant disease reason

Also need to screen if have cervix in still

503

1st step for tx hyper K

intravenous calcium gluconate


THEN:
Sodium bicarbonate and β-antagonists such as albuterol and glucose (with or without insulin) would facilitate intracellular potassium shift.

504

How do you tell DIC from HUS and TTP?

Neither TTP nor HUS is associated with elevations of the prothrombin or partial thromboplastin time or the D-dimer or depression of the fibrinogen level.

505

Do you tx salmonella diarrhea w/ abx?

No, only some cases (severly ill, young, immunocompromised)

May prolong disease duration!

506

When do you do tests for lymphadenopathy?

patients with systemic symptoms,

progressively enlarging lymph nodes,

or persistently enlarged nodes for more than 2 weeks


If lymph node < 2 cm, don't need to do tests!

507

How do you 1st manage prostate cancer screening?

physicians discuss potential, but uncertain, benefits and possible harms (complications of future diagnostic testing and therapies, including incontinence; erectile dysfunction; and bowel dysfunction) before ordering PSA testing

508

Osteoporosis is diagnosed by

the presence of fragility fractures (fracture secondary to minor trauma, such as falling from a standing position),

or by a bone mineral density (BMD) T-score less than −2.5 in patients who have not experienced a fragility fracture.

509

AST vs ALT - which is more specific to liver tissue?

ALT

510

Cholestatic injury (cholestasis),

which consists of a lack of or an abnormality in the flow of bile,

is indicated primarily by an elevation of serum alkaline phosphatase and relatively minimal elevations of AST and ALT.

511

only calcium channel blockers with demonstrated neutral effects on mortality in patients with heart failure.

Amlodipine and felodipine


First-generation calcium channel blockers (such as nifedipine) have been shown to increase the risk of heart failure decompensation and hospitalization.

512

Pt with severe, rapidly progressive pneumonia, especially during influenza season...waht do you suspect? What should you give to tx?

Methicillin-resistant Staphylococcus aureus (MRSA) should be suspected

cefotaxime, levofloxacin, and vancomycin.

513

Peptic ulcer in gastric antrum - what do you do?

Biopsies of all gastric ulcers should be performed, because even small, benign-appearing gastric ulcers may harbor malignancy

Treatment for peptic ulcer disease is guided by the biopsy and presence of H. pylori infection.

514

How do you screen for bleeding d/o prior to surgery?

Clinical hx!

In the absence of a personal or family history of abnormal bleeding, liver disease, significant alcohol use, malabsorption, or anticoagulation therapy, the likelihood of a bleeding disorder is low, and no further preoperative testing is required.

Patients with any of these risk factors should be screened further by obtaining a prothrombin time (PT/INR), an activated partial thromboplastin time, and a platelet count.

515

The treatment for an acute STEMI is

either revascularization or thrombolytic therapy.

516

Thrombolytic agents are an alternative to primary PCI in suitable candidates with STEMI. How long before you give it?

Thrombolytics should be administered within 12 hours after the onset of chest pain; the earlier the administration, the better the outcome.

517

Progestin withdrawal challenge for secondary amenorrhea

If get menstural flow,

indicates relatively normal estrogen
no anatomical blockage

Then this person has chronic anovulation

518

Patients with an elevated or rising serum PSA level noted during routine screening should...

undergo prostate biopsy, even if they are asymptomatic.

Any rise greater than 0.75 ng/mL/year (0.75 µg/L/year) is considered abnormal and should be evaluated

519

Patients with new-onset urinary incontinence should first be evaluated for

transient, reversible causes, for which the mnemonic DIAPERS may be useful:

Drugs,
Infection,
Atrophic vaginitis,
Psychological (depression, delirium, dementia),
Endocrine (hyperglycemia, hypercalcemia),
Restricted mobility,
Stool impaction.

520

anserine bursitis,

the diagnosis rests on the finding of focal tenderness on the upper, inner tibia, about 5 cm distal to the medial articular line of the knee

521

one of the leading causes of death in patients with polymyositis and dermatomyositis

ILD with progressive pulmonary fibrosis and secondary pulmonary arterial hypertension

522

When do you have an inferolateral MI

Left dominant circulation if your PDA comes off LCX.

Will see st elevation in I avL V VI and II III aVF

523

What do you use for UTI in person with long QT?

Not fluoroquinolone, tmp smx, or nitrofurantoin.

Use amoxicillin

524

If you have high suspicion that a person has lung cancer, what do you do next?

Sample lymph node to determine stage

525

Pt has neisseria meningitis meningitis. Best next step for infection control management?

Face mask because droplet precautions

526

Acute abdomen pain. What do you do first ?

Supine and upright ab radiographs to look for air fluid levels (bowel obstruct) or free peritoneal air (perforated viscus)

527

GI bleed of unknown origin, what can help you ID the source?

Upper endoscopy

1/3-2/3 soured of bleeds of obscure etiology are found in reach of upper endo

528

When can you not use adenosine nuclear perfusion stress test?

Pts with asthma , bronchospastic dz

529

When do you do ppx for cirrhotic pts for SBP? Med?

When hospitalized for gi bleed like varicies

Give IV ceftriaxone

530

CRC screening methods

Annual home high-sensitivity FOBT, sampling two to three consecutive specimens, is a method recommended by the U.S. Preventive Services Task Force (USPSTF) for screening if the patient is willing to undergo colonoscopy if results are positive.

colonoscopy every 10 years

flexible sigmoidoscopy every 5 years combined with annual high-sensitivity FOBT every 3 years.

531

SLE vs rosacea or seborrheic dermatitis

SLE - The nasolabial folds are relatively protected from the sun, and the absence of the rash in this area helps to distinguish it from other common rashes of the face, including rosacea and seborrheic dermatitis.

532

In patients with trifascicular block, permanent pacer implantation is recommended for

intermittent third-degree atrioventricular block, type II second-degree atrioventricular block, and alternating bundle branch block.

A pacer is not indicated for asymptomatic trifascicular block.

533

The “get up and go” test

Persons are timed in their ability to rise from a chair, walk 10 feet, turn, and then return to the chair.

Most adults can complete this task in 10 seconds,

most frail elderly persons, in 11 to 20 seconds.

Those requiring more than 20 seconds should undergo a fall evaluation.

534

The most effective treatment for hepatorenal syndrome is

liver transplantation.

535

secondary amenorrhea - 1st lab tests to do

Laboratory evaluation is first directed toward ovarian failure, hyperprolactinemia, and thyroid disease.

FSH (>20 = ovarian failure)
prolactin, thyroid-stimulating hormone, and free thyroxine (T4) levels are generally measured.

536

Septic arthritis usually has leukocyte counts

greater than 50,000/µL (50 × 109/L) and a predominance of polymorphonuclear cells.

537

Venous stasis vs cellulitis

Bilateral involvement, absence of fever or leukocytosis, hyperpigmentation due to hemosiderin deposition, and minimal pain help distinguish venous stasis dermatitis from cellulitis.

538

What is the peak expiratory flow rate for
- mild
- mod
- severe
- life threatening

Athsma attack? When do you admit?

Mild > 70% --> home

Mod 40-69% --> ER

Severe < 40% --> inpt

Life threatening < 25% --> inpt

539

acute cholangitis vs acute cholecystitis

Patients with acute cholecystitis may have right upper quadrant pain and gallstones, but the bilirubin level is usually not greater than 2 mg/dL (34.2 µmol/L), and aminotransferase levels are normal.

540

The four-point Centor criteria

\fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough

often used as a prediction rule in patients with suspected GABHS infection.

Patients with two Centor criteria have an intermediate probability for GABHS infection, and rapid streptococcal antigen testing (sensitivity of 88% and specificity of 94%) is a reasonable strategy for these patients.

Patients with 0 or 1 criterion have a low (<3%) probability of GABHS, and neither testing nor antibiotic treatment is recommended.

Antibiotics are not indicated for this patient before rapid streptococcal antigen testing is done to determine whether they are needed. If treatment is indicated, the antibiotic of choice is penicillin. Macrolide antibiotics and first- and second-generation cephalosporins are alternative choices for penicillin-allergic patients.

541

Best test to evaluate infrequent syncope

implantable loop recorder

542

The initial treatment in acute cocaine intoxicatino should include

sedation with lorazepam, administered intravenously or intramuscularly.

Intravenous fluids should be administered to establish adequate urine output for possible rhabdomyolysis, and an electrocardiogram should be obtained to assess for myocardial ischemia.

543

When to start tx for gout?

Uric acid–lowering therapy typically is not initiated until a patient experiences two documented acute attacks.

544

What tx help to prevent disease flares in gout associated with changes in uric acid levels and may need to be continued until therapeutic serum uric acid levels have been achieved.

Prophylactic colchicine, low-dose corticosteroids (10 mg/d or less), or nonsteroidal anti-inflammatory drugs (NSAIDs) initiated at least 1 week before beginning or adjusting the dose of uric acid–lowering therapy

545

Polymyositis and dermatomyositis vs inclusion body myositis

IBM didn't respond to steroids

Anti Jo1 in all

546

What do you use to treat scleroderma renal crisis?

Acei

547

Which thyroid cancers should use radioablation on?

Follicular
Papillary

548

The primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of sudden cardiac death in the setting of heart failure is

left ventricular ejection fraction less than 35%

549

Hemachromatosis susceptible to these organisms

VYL

Vibrio vulnificus
Yersinia
Listeria

550

The primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of sudden cardiac death in the setting of heart failure is

left ventricular ejection fraction less than 35%

551

Hemachromatosis susceptible to these organisms

VYL

Vibrio vulnificus
Yersinia
Listeria

552

What kind of tachy is WPW?

Atrioventricular reentrant tachy

553

Zoster vaccine is indicated in

all patients age 60 years and older without contraindications, regardless of history of prior varicella infection.

The vaccine is more efficacious in preventing herpes zoster among adults 60 to 69 years of age than among those 70 years or older. On the other hand, the vaccine prevents postherpetic neuralgia to a greater extent among adults aged 70 years or more.

A reported history of possible herpes zoster is not a contraindication to vaccination.

554

Septic shock

A subset of severe sepsis, defined as sepsis-induced hypotension despite adequate fluid resuscitation plus the presence of perfusion abnormalities. Patients receiving inotropic or vasopressor agents may no longer be hypotensive by the time they develop hypoperfusion abnormalities or organ dysfunction; however, they would still be considered to have septic shock

555

Severe sepsis

Sepsis associated with organ dysfunction, hypoperfusion, or hypotension.

556

Most patients with vertebral osteomyelitis have

back or neck pain that gradually worsens over weeks or months;

fever is present in only 50% of patients

leukocytosis is typically absent,

the erythrocyte sedimentation rate is often greater that 100 mm/h.

Always get blood cx and MRI imaging first.
Blood cultures are positive in 75% of patients with vertebral osteomyelitis

Then can start abx if infected and know organism

557

Sinoatrial node dysfunction .

comprises a collection of pathologic findings that result in bradycardia.

These include sinus arrest, sinus exit block, and sinus bradycardia.

Approximately 50% of patients with sinoatrial node dysfunction also have associated supraventricular tachycardia, most often atrial fibrillation or atrial flutter

558

Most patients with vertebral osteomyelitis have

back or neck pain that gradually worsens over weeks or months;

fever is present in only 50% of patients

leukocytosis is typically absent,

the erythrocyte sedimentation rate is often greater that 100 mm/h.

Always get blood cx and MRI imaging first.

Then can start abx if infected and know organism

559

Coronary calcium testing may be considered in

asymptomatic persons with a 10% to 20% Framingham 10-year risk category (intermediate risk) and in young persons with a strong family history of premature cardiovascular disease.

560

Pheochromocytoma classic sx

classic triad of sudden severe headaches, diaphoresis, and palpitations carries a high degree of specificity (94%) and sensitivity (91%) for pheochromocytoma in hypertensive patients

561

Coarctation of teh aorta can ave murmurs in theback - how?

The systolic and diastolic murmurs noted over the back are related to collateral vessels, which also cause the sign of rib notching, seen on this patient's chest radiograph on the inferior surface of the posterior upper thoracic ribs bilaterally.

562

Pheochromocytoma classic sx

classic triad of sudden severe headaches, diaphoresis, and palpitations carries a high degree of specificity (94%) and sensitivity (91%) for pheochromocytoma in hypertensive patients

563

In considering surgical treatment for patients with back pain from radiculopathy or spinal stenosis, guidelines recommend referring patients after

a minimum of 3 months to 2 years of failed nonsurgical interventions.

Failure is defined as progressive neurologic deficits and severe pain that is not responsive to conservative treatment

564

GERD diagnosis

Endoscopy if GERD sx + alarm sx (dysphagia)

Response to empiric treatment with a proton pump inhibitor such as omeprazole would be sufficiently sensitive and specific to diagnose GERD

Testing for H. pylori is not indicated for patients with GERD, because the presence or absence of H. pylori does not correlate with the presence or absence of GERD or guide therapy.

Ambulatory esophageal pH monitoring is the gold standard for diagnosing GERD and is typically used in patients in whom the diagnosis is uncertain or who are unresponsive to empiric therapy.

565

The diagnosis of diabetic ketoacidosis is based on

a blood glucose level greater than 250 mg/dL (13.9 mmol/L),

anion gap metabolic acidosis (arterial pH <7.30),

a serum carbon dioxide level less than 15 meq/L (15 mmol/L),

positive serum or urine ketone concentrations.

566

GERD diagnosis

Endoscopy if GERD sx + alarm sx (dysphagia)

Response to empiric treatment with a proton pump inhibitor such as omeprazole would be sufficiently sensitive and specific to diagnose GERD

Testing for H. pylori is not indicated for patients with GERD, because the presence or absence of H. pylori does not correlate with the presence or absence of GERD or guide therapy.

Ambulatory esophageal pH monitoring is the gold standard for diagnosing GERD and is typically used in patients in whom the diagnosis is uncertain or who are unresponsive to empiric therapy.

567

Diagnose spinal cord compression due to bone metastases with

MRI scan.

Radionuclide bone scanning is very sensitive for detecting bone metastases and has the advantage of visualizing the entire skeleton, but it has a high false-positive rate and provides no information about thecal sac compression.

568

the primary cause of morbidity in patients with systemic sclerosis;

Pulmonary disease

PAH is among the most common manifestations of lung involvement in these patients
Pulmonary function studies in patients with PAH usually reveal an isolated decreased DLCO in the setting of normal airflow and lung volumes

569

Cervicitis

is the presence of a mucopurulent cervical discharge or endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Cervicitis is commonly caused by either gonorrhea or chlamydial infection,

570

the primary cause of morbidity in patients with systemic sclerosis;

Pulmonary disease

PAH is among the most common manifestations of lung involvement in these patients

571

Routinely screen sexually active women under the age of 25 years for

chlamydia, gonorrhea, and HIV

572

Treat acute sinusitis with

symptomatic measures
Most cases of acute sinusitis are caused by a virus

NO abx unless:
symptoms lasting longer than 7 days,
facial pain,
purulent nasal discharge.

The data as a whole suggest that if antibiotics are to be used, amoxicillin or doxycycline are adequate first-line agents.

573

Routinely screen sexually active women under the age of 25 years for

chlamydia, gonorrhea, and HIV

574

Which is worse, ingesting alkali or acidic solutions on your esophagus?

Alkali

- causes liquefactive necrosis TRANSMURALLY

acidic is only on the surface

575

Smoking cessation is associated with

a decreased rate of decline in lung function.
Improved lung function

576

What do you measure on ppd?

The induration—not the erythema—resulting within 48 to 72 hours is then measured.

577

stage 2 hypertension

systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg

recommend initiating treatment with two medications in patients with stage 2 hypertension or those whose blood pressure is greater than 20 mm Hg systolic or 10 mm Hg diastolic above target. Low-dose hydrochlorothiazide and an angiotensin-converting enzyme (ACE) inhibitor

578

What do you measure on ppd?

The induration—not the erythema—resulting within 48 to 72 hours is then measured.

579

Ischemic colitis

older than 60 years and usually present with left lower quadrant pain, urgent defecation, and red or maroon rectal bleeding that does not require transfusion

Colonoscopic findings are generally segmental and include hemorrhagic nodules, linear and circumferential ulceration, and gangrene

vs mesenteric ischemia - in SI!
- Severe abdominal pain is almost invariably present, but early physical examination findings are minimal, illustrating the classic teaching of “pain out of proportion to examination.”

580

Acute small bowel (mesenteric) ischemia

should be suspected in patients who have risk factors for embolism or thrombosis and who present with sudden-onset, severe abdominal pain that, in the early stage, is out of proportion to the physical examination findings

581

Ischemic colitis is

due to a temporary interruption in mesenteric blood flow and typically occurs in older individuals with significant cardiac and peripheral vascular disease; patients present with abdominal pain.

582

Fitz Hugh Curtis syndrome

RUQ pain and pelvic adenexal tenderness

Gonococcal perihepatitis

583

To confirm that an elevated ALP is of liver origin,

measure other bile duct enzymes (γ-glutamyl transpeptidase, 5’-nucleotidase)

584

ALP indicates

cholestatic disease