Ramani Lecture Flashcards
(167 cards)
1
Q
Contraindications for EKG stress test vs. Echo
A
Old left branch bundle or on digoxin
2
Q
What meds to stop for an EKG stress test?
A
Beta blockers, calcium channel blockers
3
Q
Positive stress test
A
Pain is reproduced, ST depression, or hypotension
4
Q
New systolic murmur 5-7 days post MI
A
Papillary muscle rupture
5
Q
Acute severe hypotension after MI?
A
Ventricular free wall rupture “step up in oxygen from RA to RV”
6
Q
Persistent ST elevation with mitral regurg post-MI
A
Ventricular wall aneurysm
7
Q
bounding pulsating JVP
A
Tricuspid malfunction 2/2 AV dissociation - check for third degree heart blok
8
Q
5-10 weeks post MI pleuritic CP and low grade temp (D/Tr)
A
Dressler’s autoimmune pericarditis, NSAIDS and aspirin
9
Q
Vague chest pain with viral infection and murmur
A
myocarditis
10
Q
Chest pain with rest and worse at night in person with migraine headaches, transient ST (D/BT/Tr)
A
Prinzmetal’s angina, ergonovine stim test, CCB or nitrates
11
Q
Third degree heart block finding
A
Cannon-a waves
12
Q
Varying PR intervals with 3 or more distinct P waves in same lead
A
Multifocal atrial tachycardia, bad prognosis, sick patients pending respiratory fialure
13
Q
Normal complex QRS tachy and treatment
A
Vtach - unstable - cardioversion, stable - lidicoaine or amiodarone
14
Q
Drug of choice for WPW
A
procainamide - do NOT give rate control
15
Q
Torsades risk factors
A
Low Mg, Low K, Li, TCA OD
16
Q
Young person with sudden onset and offset palpations normal rhythm 150-220 bpm
A
SVT - carotid massage first followed by adenosine
17
Q
Widened QRS, short Qt after crush or burn?
A
Hyperkalemia
18
Q
Electrical alternans? Low alternating qrs
A
Tamponade
19
Q
Undulating baseline irregularly irregular too much synthroid, CHF valve dizease, or SOB/dizziness
A
Afib - rate control
20
Q
Crescendo decrescenod, louder with squat, softer with valsalva +parvus et tardus
A
Aortic stenosis - replace
21
Q
Late systolic murmur with a click, louder with valsalva, quieter with squatting
A
Mitral valve prolapse
22
Q
Radiate to axilla, holosystolic
A
Mitral reguritation
23
Q
Rumbling diastolic murmur with opening snap, left atrial enlargement
A
Mitral stenosis
24
Q
Blowing diastolic murmur with widened pulse pressure and eponym parade
A
Aortic regurg
25
Suspect PE?
Heparin first!
26
O2 <90%
Give O2
27
Pneumonia?
CXR
28
Murmur or CHF?
Echo
29
Acute pulmonary edema?
Nitrates, lasix, and morphine
30
CHF in young person?
Myocarditis (coxackie B)
31
Young and no cardiomegaly on CXR
Right heart cath for pHTN -
32
Pulm cap wedge pressure in CHF and pHTN
High in CHF, normal in pHTN
33
Reversible cardiomyopathy
Alchol, hemochromatosis
34
Thickened peritracheal stripe and splayed carina bifurcation
Left atrial enlargement (mitral stenosis) and cancer
35
Transudative pleural effusion with low glucose
RA
36
Transudative pleural effusions with high lymphocytes
TB
37
Transient pleural effesuion with blood
Malignant or PE
38
What makes pleural effusion complicatied?
Exudative with +gram or cx, pH<7.2, glc <60
39
Lights criteria
LDH<200
LDH eff/serum <0.6
Protein eff/serum <0.5
need all three to be transudative
40
Cancer and nephrotic syndrome dispose to PE
Hyperoagulable
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PE anticoagulation
Heparin right away then warfarin bridge
42
When to do surgical thrombectomy
If immediately life threatening
43
Criteria for ARDS
1. PaO2/FiO2 <200 (<300 means acute lung injury)
2. Bilateral alveolar infiltrates on CXR
3. PCWP <18
44
ARDS treatment
Mechanical ventilation w/ PEEP
45
when to start O2
PaO2<55 or if cor pulmonale, <59
46
Typical abx for COPD exacerbation
Macrolide
47
Best prognostic indicator for COPD
FEV1
48
New clubbing in COPDr
Hypertrophic ostearthropathy, get CXR for lung cancer
49
Normalizing PCO2 in asthma exacerbation
Impending respiratory failure, intubate
50
1 cm nodules in upper lobes with eggshell calcifications
Sillicosis - more predisposed to TB, INH if >10 mm
51
Reticulonodular markings in lower lobes with pleural plaques
Asbestosis, increased risk for bronchogenic carcinoma and mesothelemioma
52
Patchy lower lobe infiltrates (D/P)
Hypersensitivity pneumonitis, "farmer's lung"
53
Hilar lymphadenopathy
Sarcoid
54
Sarcoid with hypercalcemia
Increased vit D due to macrophages in granulomas producing vit D like substance
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Referral for sarcoid?
Opthalmology - uveitis conjunctivits in 25%
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How to dx sarcoid
Biopsy, treat with steroids
57
First step in pulm nodule workup
Look for old CXR
58
Characteristics of benign pulm nodule
```
Popcorn calcification (hamartoma)
Concentric calcification (old granuloma)
Pt<40 with well circumscribed <3 cm 0 watch with CT q2mo
```
59
Malignant nodule characteristics
Spiculated, large (>3 cm), old smoker
60
Weight loss, cough, dyspnea, hemoptysis, repeatned PNA or lung collapse
Cancer
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Most common non-smoker cancer
Adeno - scars of old pna
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Location and mets of adeno?
Periopheral cancer, liver bone brain and adrenal
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Characteristic pleural effusion of adeno?
Exudative with high hylauronidase
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Scary lung cancer symptoms with low PTH AND hypercalcemia
Squamous cell - PTH-rP
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Shoulder pain, ptosis, constricted pupil, facial edema
Superior sulcus syndrome, small cell carcinoma
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Cancer associated with Lamber-Eaton?
Small cell
67
Old smoker w/ Na=125, moist mucus membranes, no JVD
SIADH from small cell - euvolemic hyponatremia
68
CXR with peripheral cavitation and CT with distant mets
Large Cell carcinoma
69
Difference between small cell and Nsmall cell
Nsmall cell chemo, small cell resection
70
Crohn's deficiency by involving ileum?
Fe deficiency?
71
PSC associated with which IBD?
UC
72
Higher risk with colon cancer in crohn's or UC?
UC
73
Cured by colectomy?
UC
74
Associated with p-ANA IBD?
UC
75
Pyoderma gangrenosum with UC antibiotics?
No I+D, no antibiotics
76
AST>ALT with high GGT
Alc Hep
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ALT>AST in 1000's
Viral hepatitis
78
AST and ALT in 1000's after surgery?
Shock liver - ALT is NOT greater than AST
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Elevated alk phos AND GGT
Bile duct obstruction
80
Elevated alk phos, normal GGT and Ca
Paget's disease, hearing loss (bisphosphonates)
81
Antimitochondrial Ab
PSC - bile resins for treatment
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ANA + antismooth muscle Ab
Autoimmune Hepatitis - tx w/ roids
83
High Fe, low ferritin, low Fe binding capacity
Hemachromatosis, golden diabetes
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Low ceruloplasmin, high urinary Cu
Wilson's
85
Why add ampicillin for empiric meningitis treatment for old and young?
Lysteria coverage
86
TB treatment
RIPE and roids
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Lyme meningitids treatment
IV ceftriaxone
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Best 1st step
Start treatment with steroids if you think bacterial
89
Most common pneumoniae in healthy young people?
Mycoplasma - cold agglutainins
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HAP bugs?
Pseudomonas, Klebsiella, E.Coli, MRSA - pit/tazo or imipenem + Vanc
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Old smokers w/ COPD
Hflu
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Old men with HA, confusion, diarrhea, and abd pain
Legionella - dx w/t urine antigents, M,FQ, doxy
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Farmers pneumonia
Q-fever, Coxiella burnetti, doxy
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Just skinned a rabbit in Arkansas
Franciella tularensis, streptamycin, gentamycin
95
Order of tests in TB workup
PPD, CXR, sputum stain
96
Who is given INH for prophylaxis
Kids <4TB
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+TB treatment
RIPE for 6 mo, 12 for meningitis, 9 if pregnant
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Rifampin side effects
Orange/red boddy fluids, induces CYP450
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INH side effects
Peripheal neuorpathy and sideroblastic anemia (prevent by giving B6(pyridoxine)), Hepatitis
100
Pyrazinamide
Benign hyperuricemia
101
Ethambutol
optic neuritis and impaired color vision
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Most common endocarditis bug?
staph aureus
103
Subacute native valve
Viridans group strep on MV
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IVDU endocarditis?
Staph on tricuspid - right sided heart murmurs worse w/ inspiration
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Strep bovis bacteremia?
Colonoscopy
106
Most common cause of death in endocarditis
CHF
107
Prophylaxis for endocarditis
Prostetic valve, hx of EC, or uncorrected congenital lesion
108
"travels a lot for work"
Code for lots of unprotected sex
109
Acute retroviral syndrom 2-3 weeks after exposure symptoms? Seroconversion?
Mono symptoms, ELISA is negative, converts aroudn 6 weeks
110
New bilateral bell's palsy
Can be HIV
111
young patient unexplainted thrombocytopenia
Can be HIV
112
Zidovudine side effects? Classic and important
GI, leukopenia, macrocytic anemia
113
Didanosine Side effects
Pancreatitis, peripheral neuropathy
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Abacavir side effects
Rash, fever, n/v, muscle aches, and SOB - never use again
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Nephrolithiasis and hyperbilirubinemia
Indinavir
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Efavirenz side effects
Sleepy, confusded, psycho
117
Post-exposure prophylaxis
AZT, lamivudine, and nelfinavir x 4 weeks
118
HIV patient with DOE, dry cough, fever, chest pain
Think PCP, CD4<200
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PCP blood elevation
LDH
120
Best test for PCP after CXR?
Boncoscopy w/ BAL
121
1st and 2nd line treatment for PCP
Trim-sulfa, then trim-dapsone
122
When to add steroids for PCP
PaO2 <70, high A-a gradient
123
When to start prophylaxis?
CD4<200, can come off after 6 mo >200
124
Three major causes of diarrhea in HIV+ patient
CMV, MAC, cryptosporidium
125
CMV dx in HIV
Colonoscopy with biopsy, treat with canciclovir
126
Cryptosporidium dx in HIV
Acid fast oocysts
127
Multiple ring enhancing lesions in HIV? One ring enhancing lesion?
Toxo multiple, CNS lymphoma if one, treat with pyramethamine sulfadiazine +folic acid then watchc for improvement, if it improves probably toxo
128
HIV seizure w/ deja vu aura and 500 RBC's in CSF
HSV - immediate acyclovir
129
HIV with s/s of meningitis
Strep pneumo most common, but thinkCrypto, +india ink, ampho IV 2wks then fluconazole
130
HIV hemisensory loss, visual impairmarment, Babinksi
PMLdue to JC virus, brain biopsy diagnosis
131
HIV memory problems or gait disturbance
AIDS-Dementia complex, work up to find other treatable causes
132
Define neutropenic fever
Super high temp or sustained low temp with ANC <500
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Most common cause of neutropenic fever
Meucositis 2/2 chemo causes bacteremia
134
Most common bugs of neutropenic fever?
Pseudomonas and MRSA
135
Lyme disease treatment for <8
amoxacillin
136
Rash at wrists and ankles, fevers, and headache
Rikettsia, everyone get doxy
137
Tick bite w/o rash but myalgias, fever, headaches, low plts and WBC, up ALT
Ehrlichiosis, Can dx with morulae intracell inclusion, tx w/ doxy
138
Immune suppressed pt with cavitary lung dz, wegith loss, fever, gram +aerobic branching bugs
Nocardia - tx w/ trim-sulfa
139
Numbness, Chvostek, prolonged QT
Hypocalcemia
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Paralysis, ileus, ST depression, U waves
Hypokalcemia
141
Treatment for hyperkalemia
Ca-gluconate, insulin +glc, kayexalate, albuterol, and NaBicarb - last resort diuretics then dialysis
142
Best test for metabolic alkalosis
Urine chloride - high urine chloride? hyperaldo, barters, gittlemans. Cl low, vomitting, NG suction, antacids, diuretics
143
RTA Type I (proximal or distal, cause, presentation, treatment)
Distal
Lithium/AmphB, analgesics
Urine pH>5.4 with hypoK and stones, cannot secrete H+
Give K and oral bicarb
144
RTA Type II (proximal or distal), cause, presentation, treatment
Proximal
Fanconi's syndrome, myeloma, amyloid
Hypokalemia, osteomalacia, cannot reabsorb HCO3
Bicarb won't help (because they can't reabsorb), replete K
145
RTA Type IV
Hyperrenin hypoaldo - Mostly caused by diabetes, HyperK, high urine NA even with salt, treat with fludrocortisone
146
what to use for urine concentration if on diuretic
FENurea
147
Muddy brown casts in ampho, aminocglycosides, cisplatin, or prolonged ischemia?
ATN
148
Protein, blood and eosinophils in urine plus fever and rush after trim-sula?
AIN. stop offending agent
149
Treatment for rhabdo
Deal with hyperkalemia nad bicarb to alkalinize urine and prevent precipitation
150
Enveloped shaped crystals in UA
Ethylene glycol (AGMA), Tx w/ dialysis or bicarb if low pH
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Cr up 48-72 hrs post cardiac ccath or CT scan
Contrast nephropathy, hydrate before and give bicarb or NAC
152
Indications for emergent dialysis
```
A - acidosis
E-Electrolye impalance (high K)
I- Intoxication - antifreeze, Li
O- Overload of volume, CHF or Pulmonary edema
U-uremia -> pericarditis, AMS
```
153
Most common CKD complications
Cardiovascular dizease - LDL <100
154
Complications of CKD
HTN - up aldo
Anemia of chronic disease - loss of Epo
Hyper K, hyper phos, low calcium -> 2nd HPTH, renal osteodystrophy from Ca into tissues, calciphylaxis (skin necrosis)
Uremia
155
Peeing blood 1-2 days after runny nose, sore throat, and cough
Berger's Dz, IgA neprhopathy
156
1-2 weeks after sore throat
Post-strep CN
157
Hematuria + hemoptysis
Goodpastures - Abs to collagen IV
158
Heamturia + deafness
Alport, XLR collagen IV
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Kid s/p viral URI with renal fialure, abdominal pain, arthralgia, and purpura
HS purpura, IgA, steroids
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Kiddo after beef ingestion with diarrhea and renal failure, MAHA and petechiae
HUS E. Coli - no ABX - more toxin
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Cardiac patient after ticlopidine w/t renal failure, MAHA, low plts, fever, and AMS
TTP - plasmapheresis, no platelets, differentiate from HUS/TTP by PT and PTT
162
c-ANCA kidney, lung, and sinus
Wegener's Granulomatosis - need biopsy
163
p-Anca, renal failure, asthma, eosinophilia
Churg strausss - lung bx, steroid
164
P-anca, no lung involvement, Hep B
PAN, small/med arteries everywhere but lung
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Kid w/t family hx of stones
Cysteine stones
166
Chronic indwelling foley stones and alkaline pee
Struvite stones with bacteria
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Nephrotic patient suddenly develops flank pain
Renal vein thrombosis - peeins out AT III, protein Cand S, stat CT or U/S
