Step Up Quick Hits Flashcards
(308 cards)
1
Q
What is standard of care for stable angina?
A
ASA + B Blocker for mortality
Nitrates for CP
2
Q
What type of infarct will present w/ clear lungs?
A
RV infarct
3
Q
What EKG changes in anterior, posterior, lateral, and inferior MI?
A
anterior: ST elevate in V1 - V4, Q in V1-V4
posterior: R in V1, V2, ST depression in V1 V2
lateral: Q in I, aVL
inferior: Q in II, III, aVF
4
Q
What agents decrease mortality in MI?
A
ASA, B lockers, ACEi
5
Q
What tx are indicated in MI?
A
O2 nitroglycerin B Blocker ASA morphine ACEi IV heparin
6
Q
What is MCC death in first few days after MI?
A
ventricular arrhythmia (VT or VFib)
7
Q
What is tx for VT after MI?
A
if unstable – cardioversion
if stable –> IV amiodarone
8
Q
What should you think if pt w/ MR after MI?
A
papillary muscle rupture
9
Q
What are indications for using dig?
A
EF
10
Q
What are side effects of dig tox?
A
N/v/anorexia
ectopic ventricular beats, AV block, AFib
visual disturbances, disorientation
11
Q
What are indications for cardioversion vs defibrillaton?
A
cardioverson = AFib, A flutter, VT w/ pulse, SVT defibrillation = VFib, VT w/ a pulse
12
Q
WHat are steps before cardioversion in AFib?
A
- if can cardiovert
if > 48 hrs or unknown: - do TEE if no thrombus can cardiovert, if yes thrombus anticoagulate for 3 wks then cardiovert
- or just skip TEE and anticoagulate 3 wks then cardioert
13
Q
What is dz for paroxysmal SVT?
A
valsalva, carotid massage
if doesnt work –> IV adenosine
14
Q
What are side effects of adenosine?
A
AH, flushing, SOB, chest pressure, nausea
15
Q
What drug treatments for WPW?
A
procainamide or quinidine
avoid digoxin, verapamil b/c may increase accessory path conduction
16
Q
What is tx if pt w/ non-sustained VT and underlying heart dz?
A
implantable defibrillator
17
Q
What should you do if pt in asystole?
A
defibrillation does not work –> do transcutaneous pacing instead
18
Q
What is pulseless electrical activity? next step?
A
electrical activity on monitor w/o pulse
19
Q
What are indications for cardiac pacemaker?
A
- sinus node dysfunction = sick sinus syndrome
- symptomatic heart block: mobitz 2 second degree or complete
- symptomatic brady arrhythmias
- tachyarrhythmias to interrupt rapid rhythm disturbances
20
Q
Which murmurs increase/decrease w/ squatting?
A
squatting increases all except MVP and HOCM
21
Q
What are cardinal manifestations of acute pericarditis?
A
CP, pericardial friction ru, EKG changes, pericardial effusion (+/- tamponade)
22
Q
What happens in early and late diastole in constrictive pericarditis?
A
early = rapid filling late = halted filling
(vs in cardiac tamponade have filling impeded throughout diastole)
23
Q
What cardiac process should you r/o if pt w/ sx of cirrhosis (ascites, hepatomegaly) and distended neck veins?
A
r/o constrictive pericarditis
24
Q
What dx test for pericardial effusion and cardiac tamponade?
A
echo
25
What is beck's triad for cardiac tamponade?
hypotension, muffled heart sounds, JVD
venous waveforms = prominent x descent and absent y descent
26
What is tx for AS?
```
asx = none
sx = surgery (aortic valve replacement
```
27
What are some specific physical findigns in aortic regurg?
- de mussets = head bobbing
mullers = uvula bob
duroziez = pistol shot sound heard over femoral arteries
28
What is tx for acute AR post MI?
medical emergency --> perform emergent aortic valve replacement
29
What are key features of MVP murmur?
mid systolic click
| systolic rumbling murmur increases w/ standing and valsalva and decreases w/ squatting
30
What are duke's criteria for endocaditis?
need 2 majoror 2 major and 3 minor or 5 minor
major:
- sustained bacteremia
- endocardial involvemeed (new regurg)
minor:
- predisposing
- fever
- vascular phenom: janeway, emboli
immune: glomerulonephritis, osler, roth
- postiive b cx
- positive echo
31
What is murmur of VSD?
harsh blowing holosystolic murmur w/ thrill at 4th left intercostal space
decreases w/ vlasalva and handgrip
32
What is tx in hypertensive emergency?
IV --> hydralazine
33
What are preferred tests for dx acute aortic dissection?
TEE and CT
34
What type of aortic dissection involves ascending vs just descending?
ascending = A
| just descending = B
35
What is lerische's syndrome?
atheromatous occlusion of distal aorta just above bifurcation causes B/L claudication, impotence, absent/diminished femoral pulses
36
Which vessels lead to calf claudication? vs buttock/hip claudication?
```
calf = femoral or popliteal
buttock/hip = aorto-iliac occlusive disease
```
37
What are sx of acute arterial occlusion?
pallor, pain, pulselessness, paresthesias, paralysis, polar (cold)
38
What is cholesterol embolization syndroem?
showers of cholesterol crystals from proximal source
- small discrete areas of tissue ischemia: blue toes, renal insufficiency, ab pain or bleeding
39
What is mycotic aneurysm?
aneurysm from damage to aortic wall 2/2 infection
| tx = IV abx and surgical excision
40
What is luetic heart?
complication of syphilitc aortitis, aneurysm of aortic arch ---> arotic regurg
41
What are characteristics of centrilobular emphysema?
MC type, smokers
- respiratory bronchioles destroyed
- upper lungs
42
What are characteristics of panolbular emphysema?
- a1 antitrypsin deficinecy
- proximal and distal acini
- lung bases
43
What happens to lung volumes in COPD?
- FEV1/FVC ratio
44
What are characteristics of pts w/ predominant emphysema?
- thin 2/2 increased energy expenditure w/ breathing
- lean fwd
- barrel chest
- tachypnea w/ prolonged exp. through pursed lips
- pt distressed and uses accessory muscles (esp strap muscles in neck)
45
What acid/base disturbanced in COPD?
chronic resp acidosis w/ met alklaosis as compensation
46
What is most important intervention for improving outcome in COPD?
smoking cessation
47
What are criteria for using O2 therapy in COPD?
PaO2
48
What is initial tx for mild-mod disease?
bronchidilator in metered dose inhaler --> anticholinergic or B agonist or combo
49
What are next steps if pt w/ COPD exacerbation?
```
- B agonist and anticholingeric
systemic steroid
abx (azithromycin or levo)
O2 to keep about 90
NPPV (BIPAP or CPAP) if neded
```
50
What are signs of impending resp failure in pt w/ asthma attack?
- paradoxic movement of ab and diaphragm on inspiration
- normalizing/increasing CO2
- decreases breath sounds/movement
51
What happens to PFTs in asthma?
- decreased FEV1, FVC, ratio
- increase in FEV1 > 12% w/ albuterol
- decrease in FEV1 > 20% w/ methacholine challenge
- increase in diffusion cpacaity CO
52
Which types of lung CA require surgery vs chemo vs radiation?
surgery for non small cell lung CA + adjunct radiation
for small cell
- chemo + radiation for limited dz
- chemo alone for extensive dz
53
What kind of mediastinal masses in
- anterior
- middle
- posterior
anterior: thyroid, teratogenic, thymoma, lymphoma
middle: lung CA, lymphoma, aneurysm, cyst
posterior: neurogenic tumor, esophageal mass, enteric cyst, aneurysm
54
What physical exam findings in pleural effusion?
dull to percussion
decreased breath sounds
decreased tactile fremitus
55
What 3 dx likely if pt w/ pleural effusion w/ high amylase?
esophageal rupture
pancreatitis
malignancy
56
What dx likely if blood pleural effusion?
malignancy
57
What dx likely if pleural effusion pH
parapneumonic effusion
| empyema
58
What should oyu r/o if pleural fluid w/ glucose
r/o RA
| also could be: TB, esophagela rupture, malignancy, lupus
59
What physical exam findings in pt w/ pneumothorax?
decreased breath sounds
hyperresonance
decreased/absent tactile fremitus
mediastinal shift toward side of pneumothorax
60
What is first tx for spontaneous pneumothorax?
give supplemental O2 = helps quicken resporption of air in pleural space
61
What meds associated w/ ILD?
```
bleomycin
gold
amiodarone
penicillamine
nitrofurantoin
phenytoin
```
62
What is MCC death in pt w/ sarcoid?
cardiac disease
63
What type of ILD w/ p-ANCA? c-ANCA?
p-ANCA: churg strauss (asthma + pulm infiltrates, eos), goodpasture (hemorrhagic pneumoinitis + glomerulonephritis)
c-ANCA: wegeners (necrotizing granuloma vasculitis of lung kidney upper-airway)
64
What ILD w/ pleural plaques?
asebestosis
65
What ILD w/ eggshell calcifications
silicosis
66
What are features of asbestosis?
lower lobe fibrosis
| CXR w/ hazy infilarates and b/l linear opacities
67
What are features of siloicosis?
localized and nodular peribronchial fibrosis, more common upper lobes
2/2 mining, stone cutting, glass manufacturing
increased risk for TB
68
What are features of berylliosis?
hypercalcemia, granulomas, skin lesions
tx - steroids
69
What is tx for goodpasture?
IgG antibodies against glomerular and alveolar bBM
renal failure
hemoptysis + dyspnea
tx = plasmapheresis, cyclophosphamide, steroids
70
What is pulm alveolar proteinosis?
bat shape B/L alveolar infiltrates w/ ground glass on CXR
| accumulation surfactant like protein and phospholipids in alveoli
71
What is hypoxemic resp failure? etiologies?
low PaO2 w/ PaCO2 low or normal
| 2/2 lung process --> ARDS severe pna, pulm edema
72
What is hypercarbic resp failure?
failure of ventilation --> decrease minute ventilation or increase in dead space
2/2 underlying lung dz (COPD, asthma, CF, severe bronchitis) OR 2/2 impaired ventilation due to neuromuscular dz, CNS depression, mechanic restriction of lung inflation, resp fatigue
73
What is tx for primary pulm htn?
IV prostacyclins, CCBs
74
What are 7 wells criteria for PE?
- sx of DVT: 3
- alternative diagnosis less likely: 3
- HR > 100: 1.5
- immobilization > 3 days or surgery in previous 4 wks: 1.5
- previous DVT/PE: 1.5
- hemoptysis: 1.0
- malignancy: 1.0
if total score > 4 --> high likelihood of PE skip D-dimer
75
What should happen to PH w/ every increased/decrease in PaCO2?
by 0.08
76
What are 3 sx specific to graves disease?
- exophthalmos
pretibial myxedema
thyroid bruit
77
What is effect of TBG on thyroid?
TBG increases w/ pregnancy, liver dz, OCP, asa
78
What does radioactive T3 uptake tell you?
radioactive T3 can bind to TBG or to resin
if increased radioactive T3 uptake to resin --> tells you true hyperthyroidism as T4 bound to TBG
if not --> just high TBG
79
What is likely cause of transient painful enlarged thyroid?
subacute granulomatous viral thyroiditis
80
What type of thyroid cancer cannot be dx w/ FNA?
follicular
81
What is hurthle's cell tumor?
variant of follicular thyroid ca
spread by lymphatics, does not take up iodine
tx = total thyroidectomy
82
What is biggest risk factor for papillary thyroid CA?
radiation head/neck
83
What type of thyroid CA produces calcitonin?
medullary CA from para-follicular C cells
84
What is MCC death in acromegaly?
cardiovascular disease
85
What lab abnormalities in pt w/ acromegaly?
- hyperprolactinemia
- high glucose, TG, phosphate
- high IGF1 (somatomedin C)
86
How do you dx acromegaly?
- high IGF1
| - oral glucose suppression test -- > glucose fails to suppress GH (as it should in healthy individual)
87
What does calcification of suprasellar region suggest?
craniopharyngioma
88
What is tx for central DI?
desmopressin
89
What is tx for nephrogenic DI?
Na restriction and thiazide diuretics
90
What are major characteristics of SIADH?
- hyponatremia
- volume expansion w/o edema
- natriuresis
- hypouricemia
- low BUN
- normal or reduced cr
- normal thyroid and adrenal
91
What is tx w/ SIADH?
for asx: water restriction, NS w/ loop diuretic or lithium
for sx: restrict water intake, give isotonic saline
92
What are lab findings in pseudohypoparathyroidism?
hypoa
hyperPhos
high PTH
low urinary cAMP
93
what EKG changes in hypoparathyroid?
long QT from hypocalcemia
94
What are relative indications for surgery in primary hyperparathyroid?
age 400mg in 24 hr
95
What is tx for 2ndary hyperparathyroid 2/2 renal failure?
calcitriol and oral Ca + dietary phos restriction
96
What is initial screening test for cushing?
low dose dexamethasone suppression test
- give dexamethasone
- if serum cortisol not scushing
if > 5 --> cushing dz
OR 24 hr urinary free cortisol
97
What does a high dose dexamethasone suppression test tell you?
if positive --> cushings disease
if negative:
- + low ACTH: adrenal tumor
- + high ACTH: ectopic ACTH produceing turmo
98
What does CRH stim test tell you?
if ACTH/cortisol increases = a response = cushing disease
| if ACTH/cortisol do not increase = no response = ectopic ACTH or adrenal tumor
99
What are rules of 10 for pheos?
- 10% familial
- 10% bilateraol
- 10% malignant
- 10% multiple
- 10% in kids
- 10% extra-adrenal
100
What is most common site of non-adrenal pheo?
organ of zuckerkandl = aortic bifurcation
will have high epi (vs adrenal cant methylate the norepi)
101
What should you give pt w/ pheo before/after surgery?
alpha block (phenoxybenzamine) for 10-14 d before surgery and B block (propanolol) for 2-3 days
```
alpha = for BP
B = for tachycardia
```
102
What are the findings in MEN1?
3 Ps
- parathryoid hyperplasia
- pancreatic islet
- pitutiary tumor
103
What are the findings in MEN2A?
- medullary thyroid ca
- pheo
- hyperparathryoidism
104
What are the findings in MEN2B?
- mucosal neuropa
- nedullary thyroid
- marfinoid body
- pheo
105
What is next step for adrenal incidentaloma?
r/o functioning tumor
| then resect any tumor > 6cm
106
how do you dx primary hyperaldosteronism?
aldo:renin ratio > 30
| saline infusion --> if primary aldo, aldo levels will not decrease after saline
107
What isMCC addisons worldwide? in US?
in world = TB
| in US = autoimmune
108
What are clinical findings in adrenal insufficiency?
```
wt loss
weakness
pigmentation
anorexia
nausea
postural hypotension
ab pain
hypoglycemia
```
109
if adrenal insufficinecy w/ hyperK and hyperpigmentation what should you think?
primary (not secondary) etiology
110
How do you dx diabetes?
- two fasting gluc > 126 or >200 2hr postprandial
- single gluc > 200 w/ sx
- increased glucose on oral glucose tolerance test
- hemoglobin a1c > 6.5%
111
What is mech of sulfonylureas (glyburide, glipizide, glimepiride)? side effects?
stimulate pancreas to produce more insulin
can cause hypoglycemia, wt gain
112
What is mech of metformin? side effects?
enhances insuline sensitivity
```
CI w/ cr > 1.5 b/c of lactic acidosis
GI upset (D/N, ab pain)
metallic taste
```
113
What is mech of acarbose? side effects?
reduces glucose absorption from gut, reduces calorie intake
SE = GI upset
114
What is mech of thiazolidinediones (rosiglitazone, pioglitazone)? side effects?
reduces insulin resistance
| hepatotoxic = need to monitor LFTs
115
What is difference between different types of insulin?
```
lispro = onset in 15 min, last 4 hr
regular = onset 30-60 min, last 4-6 hr
NPH = onset 2-4 hr, last 10-18 hr
```
glargine (lantus) = 3-4 hr onset, lasts 24 hr
116
What is definition of microalbuminuria?
30-300 mg/day
| albumin-cr ratio 0.02 to 0.20
117
What is diabetic retinopathy?
hemorrhage, exudate, microaneurysms
can be proliferative --> new vessel formation, scarring, vitreal hemorrhage
118
What is presentation of DM CN3 palsy?
eye pain, diplopia, ptosis, inability to adduct eye
| pupils are spared
119
What are two complications of treatment of DKA?
cerebral edema: if glucose levels rise too fast
| hyperchloremic nongap met acidosis: 2/2 rapid infusion of large amt of saline
120
What is the body's first line defense against severe hypoglycemia?
glucagon
121
What lab abnormalities in VIPoma?
watery diarrhea --> dehydration, acidosis, hypoK
achlorhydria
hyperglycemia
hypercalcemia
122
When should colon cancer screening begin in pt w/ family hx?
begin at 40 or 10 yrs before age of onset of family member
123
What are risk factors for CRC?
```
age > 50
adenomatous polyps
personal hx of CRC
IBD (UC?Crohns)
first degee relative dz
```
124
What is gardner syndrome?
FAP + osteomas, dnetal abnormalities, benign soft tissue tumors, desmoid tumors, sebaceous cysts
125
What is turcot syndrome?
ar polyps + cerebellar medulloblastoma or GM
126
What side of GI tract presents w/ melena vs hematochezia?
```
melena = R side
hematochezia = L side
```
127
How do R side vs L side colon cancer tumors usually present?
R = rare to obstruct, usually anemia, weak, RLQ weka, occult blood in stool
L side: obstruction, change in bowel habit, pencil stools
128
What is tx for colon cancer?
surgery
| radiation not indicated
129
What is MC location of diverticulosis?
sigmoid colon
130
What are complications of diverticulosis?
painless rectal bleeding
| diverticulitis
131
What are complications of diverticulitis?
absecess formation
fistulas
bowel obstruction
free colonic perforation
132
What is dx test of choice for diverticulosis? tx?
barium enema
tx = high fiber, psyllium
133
What is dx test of choice for diverticulitis?
CT scan w/ oral and IV contrast
contraindicated colonoscopy and barium enema 2/2 risk sof performation
134
What other disease process associated w/ bleeding AVM malformations in GI tract?
aortic stenosis
135
What is presentation of acute mesenteric ischemia? types?
compromised blood supply
- arteriol embolism: 2/2 a fib --> sudden painful
- arterial thrombosis: in pt w/ CAD/PVD, acute occlusion may be 22 plaque rupture or acute MI, more gradual sx
- nonocclusive: splanchnic vasoconstriction 2/2 low cardiac output in ill elderly
- venous thrombosis: in hypercoagulable states, portal HTN, malignancy
136
What are sx of acute mesenteric ischemia?
severe ab pain disproportionate to physical findings
pain 2/2 ischemia = like mI in CAD
anorexia, vomiting, tachypnea, hypotension, lactic acidosis, fever, mild GI bleed, AMS --> shock
137
What is dx test for acute mesenteric ischemia?
mesenteric angiography
| get ab xr to exclude other causes
138
What is tx for acute mesenteric ischemia?
IVF, broad spectrum abx
arterial causes --> direct infusion papaverine = vasodilator
avoid vasopressors
139
What is presentation of chronic mesenteric ischemia?
abdominal angina = postprandial pain, wt loss
dx by mesenteric arteriography
tx = surgical revascularization
140
What is ogilvie's syndrome?
sx of large bowel obstruction but no mechanical obstruction
decompress w gentle enemas of NG suction
141
What is next step if colonic distention w/ dm > 10cm?
decompress immediately --> bowel is at risk of impending rupture --> causing peritonitis and death
142
What is ppx tx for varices?
BBlocker
143
What is tx for variceal hemorhage?
IV abx
IV octreotide
emergent endoscopy once stabilize
144
What are features of ascites that suggest portal HTN is the cause?
serum ascites albumin gradient > 1.1
| = serum albumin - ascites albumin
145
What is hepatorenal?
azotemia, oliguira, hypoN, hypotension, low urine Na
146
What is tx for hepatorenal syndrome?
liver transplant
147
What is hepatocellular adenoma?
benign liver tumor in young women
| risks = OCP use, F, anabolic steroid use
148
What is MC benign liver tumor?
cavernous hemangioma
149
What type of bili high in filbert?
unconjugated
150
What is presentation of hydatid liver cysts?
2/2 echiinococcus granulosis
usually in R lobe
tx = surgical, give mebendaozle after surgery
151
What is presentation of amebic liver abscess?
M>F, fecal oral
entamoeba histolytica
fever, RUQ pain, N/V, hepatomegaly, diarrhea
tx = IV metronidazole
152
What kind of bilirubin can cause dark urine?
cnojugated bilirubin only
153
What are sx of cholestasis?
```
- jaundice, gray stool, dark urine
pruritis
high Alk Phos
high cholesterol
skin xanthomas
malabsorption fats and fat soluble vitamines
```
154
Who gets pigmented gallbladder stones?
hemolsis (sickle, thalassemia, spherocytosis) or alc cirrhosis
155
What is dx test of choice for gallbladder stones?
RUQ US
156
How can you differentiate cholecystitis vs biliary cholic pain?
cholecystitis pain = 2/2 gallbladder wall inflammation, persists for daysbiliary colic pain = 2/2 contraction of gallbladder against obstructed cystic duct, lasts onyl a few hrs
157
What is presentation of cholescytitis?
RUQ pain, fever, leukocytosis 2/2 gallblader inflammation
158
What is acalculous cholecytitis?
cholecystitis w/o stones obstrcuting cystic duct
usually idiopathic
tx = emergent cholecystectomy
159
How do sx differ in cholelithiasis vs choledocholithiasis?
```
cholelithiasis = stone in gallbladder, biliary cholic
choledocholithiasis = stone in common bile duct --> have jaundice
```
160
How do you dx choledocolithiasis?
US = initial study, ERCP is gold standard
161
What is charcot's triad of cholangitis?
RUQ pain, jaundice, fever
pentad = triad + septic shock and AMS
162
WHat is most serious complication of cholangitis?
hepatic abscess
163
What is porcelain gallbladder?
intramural calcification of gallbladder wall --> 50% will go on to develop carcinoma, recommend cholecystectomy
164
What are complications of primary sclerosing cholangitis?
cholangiocarcinoma
recurrent cholangitis
progression to 2ndary biliary cirrhosis, portal HTN
liver failure
165
What is PSC?
jaundice + pruritis
| ERCP to dx --> beeds on a string, stricturing and dialtiongs of intrahepatic and extrahepatic ducts
166
What is PBC?
cholestatic liver dz w/ destruction of intrahepatic bile ducts w/ inflammation and scarring
autoimmune
positive antimitochondrial antibodies, high chol, HDL, high IgM
167
What is tx for primary biliary cirrhosis?
cholestyramine for pruritis, Ca/vitd for osteoporosis
| ursodeoxycholic acid to slow progression of dz
168
What is tx for primary sclerosing cholangitits?
stent placement for symptoms 2/2 stricture
169
What are klatskins tumors?
cholangiocarcinoma tumors in proximal 1/3 of common bile duct, involve jucntion of R and L hepatic ducts
poor prognosis b/c unresectable
170
What are risk factors for cholangiocarcinoma?
PSC = major risk factor
171
What is biliary dyskinesia?
motor dysrunction of sphincter of Oddi --> recurrent biliary colic w/o evidence of gallstones
dx by HIDA scan --> give CCK and see low EF of gallbladder
172
What is presentation of carcinoid syndrome?
cutaneous flushing, diarrhea, sweating , wheezing, ab pain, heart valve dysfcuntion
173
What should you think if pt w/ chronic epigastric pain and calcifications on plain xr?
chronic pancreatitis
174
What is classic traid of chronic pancreatitis/
steatorrhea, DM, pancreatic calcification
175
What type of esophageal Ca associated w/ barretts?
adenocarcinoma
176
What are risk factors for squamous esophageal cancer?
smoking
alcohol
nitrosamines
achalasia
177
What are risk factors for adenocarcinoma of esophagus?
distal 1/3
GERD
barretts
178
What is presntation of diffuse esophageal spasm?
hard to differentiate from cardiac cause of CP --> do a cardiac workup
mims angina, radittes to jaw, arms, back, dysphagia
dx: manometry
tx = nitrates, CCPs
179
WHat is pathogenesis of mallory weiss syndrome?
forceful vomiting --> increasd intra-ab pressure transmitted to esophagus
tear in mucosa at GE junction
180
What is boerhaaves? presentation?
esophageal tear transluminal --> perforation
can be 2/2 forceful vomiting
present: pain (retrosternal/chest/shoulder), tachycardia, hypotension, tachypnea, dyspnea, fever, hammans sign = mediastinal crunch, pleural effusion
181
What are features of plummer vinson syndrome?
upper esophageal web (dysphagia), iron eficiency anemia, koilonychia, atrophic oral mucosa
182
What is difference in presentation between duodenal and gastric ulcers?
duodenal = increase in asid secretion, eating relieves pain, nocturnal pan more common, risks = NSAIDs, low malignancy potential, up to 90% H pyloir
gastric = decrease defensive factors, higher malignancy potential, older pts, smoking is risk factor, eating does not relieve pain
183
Is smoking or alcohol more associated w/ PUD?
smoking
184
What are locations of gastric Ca met?
```
krukenberg = ovary
blumer = rectum
sister mary joseph = periumbilical lymph node
virchow = supraclavicular
Irish = L axillary
```
185
What are sx of proximal vs distal bowel obstruction?
```
proximal = frequent vomiting, severe pain, minimal ab distention
distal = less freq vomiting, significant ab distention
```
186
What are lab findings in small bowel obstruction?
dehydration
| low Cl, K, met alkalosis
187
What are extraintestinal manifestations of IBD?
eye: anterior uveitis, episcleritis
skin: erythema nodosum (crohn), pyoderma gangrenosum (UC)
arthritis: migratory monoarticular, ankylosing spondylitis (UC)
thromboembolic hyper coagulable
ITP
osteoporosis
gallstones in crohns
PSC in UC
188
What is tx for crohns?
sulfasalazine if colon involved
| systemic steroids for actue exacerbation
189
what are pathology findings in crohns vs UC?
crohns: transmural inflammation, non-caseating granulomas, mesenteric creeping fat
UC: crypt abscesses, mucosa/submucosa inflammation
190
What level of urine Na suggests prerenal vs intrinsic renal cause of AKI?
urine Na 40 = intrinsic renal
191
What are lab findings in rhabdo?
high CPK, K, uric acid
| low Ca
192
What is tx for rhabdo?
IVF, mannitol, HCo3
193
What are 2 MC deadly complications of AKI?
hyperkalemic cardiac arrest
| pulmonary edema
194
What lab abnormalities in AKI?
```
met acidosis
high K
low Ca
high Phos
high uric acid
```
195
What is mech of contrast causing ATN?
spasm of afferent arteriole
196
What should you worry about if pt w/ painless gross hematuria?
bladder CA or renal cell CA
197
What is next dx step if suspect bladder ca?
cytoscopy
198
What is rapid progressive glomerulonephritis?
clinical syndrome w/ any type of glomerulonephritis and rapid deterioration of renal function ove wks - mos
199
What underlying conditions associated w/ membranous glomerulonephritis?
infection (hep B, C, syphilis, malaria), drugs (captopril, penicillamine), neoplasm, lupus
200
What is usual underlying dz w/ membrano-proliferative glomerulonephritis?
usually w/ hep C, can also be hep B, syphilis, lupus
| associated w/ cryoglobulinemia
201
What is goodpasture? tx?
rapid progressive renal failure, hemoptysis, cough, dyspnea, igG anti glomerular abs
tx = plasmapharesis
202
What is analgesic nephropathy?
toxic injury to counter 2/2 over counter analgesic use (phenacetin, acetaminophen, nsaids, asa)
manifest as interstitial nephritis or renal papillary necrosis
203
What is mech of type 1 RTA? lab values?
distal = can't secrete H+
hypokalemia
renal stones / nephrocalcinosis 2/2 increased Ca and phos excretion
204
What is mech type 2 RTA? lab values?
proximal = can't reabsorb HCO3
hypokalemia
can be 2/2 multiple myeloma
205
What type of RTA w/ hyperkalemia?
type 4
206
What kind of RTA responds to HCO3?
type 1 = distal
207
What is hartnup syndrome?
AR, defect AA transporter, decreased reabsorption tryptophan --> nicotinamide deficiency
sx: dermatitis, diarrhea, ataxia, psych
208
What is fanconi syndrome?
prox tubul defect trasnport --> glucosuria, phophaturia, proteinuria, RTA type 2, hypercalciuria, hypkalemia
209
How do you dx RAS?
renal arteriogram
210
What are some causes of hypercalciuria leading to kideny stones?
- increased intestinal absorption
- decreaed renal reasborption
- increased bone reabsorption of Ca
- primary hyperparathyroid
- sarcoid
- malignancy
- vit D excess
211
What are some causes of hyperoxaluria leading to calcium stones?
- severe steatorrhea
- small bowel disease
- crohns
B6 deficiency
212
Are Ca stones radio-opaque or radiolucent?
radio-opaque = visible on xr
213
What are etiologies of uric acid stones? appearance?
flat square, radiolucent
| seen w/ acidic urine pH
214
What are etiologies of struvite stones? appearance?
radiodense, rectangular prisms
| in pts w/ recurrent UTIs from proteus, klebsiela, serratia, enterobacter
215
What is best test for diagnosing kidney stones?
noncontrast CT ? radiograph
216
What is next step for ongoing stone obstruction and pain not controlled by narcotics?
shock wave lithotripsy
| if fails --> percutaneous nephrolithotomy
217
What is next step if abnormal digital rectal exam?
trans-rectal ultrasound w/ bx
218
How can you distinguish metabolic alkalosis 2/2 volume contraction vs expansion?
2/2 contraction = urine Cl 20, ECF expansion, hypertension
219
How much does 1 unit of RBCs raise hct?
by 3-4 points
220
When do you give FFP?
for high PT/PTT and deficiency of clotting factors, if liver failure, or waiting for vit K to take efffect
221
When do you give cryoprecipitate?
for hemophilia A, decreased fibrinogen (DIC) and vWD
222
What are intravascular hemolytic transfusion rxns?
```
acute hemolytic reactions
- serious/life threatening
2/2 ABO mismatch
fever, chills, N, V, flank/bak pain, CP, dyspnea
tx: stop transfusion, give fluids
```
223
What are extravascular hemolytic transfusion rxns?
less severe, w/in 3-4 wks of transfusion
2/2 minor RBC antigens (kell)
sx = fever, jaundice, anemia
224
What does schilling test tell you?
- give IM dose unlabeled B12
- give oral dose radioactive B12
- measure B12 in urine and plasma to determine how much absorbed
- repeat w/ addition of intrinsic factor
if malabsorption --> IF will not help
if pernicious anemia --> IF will correct
225
What types of anemia present w/ schistocytes and helmet cells?
TTP, DIC, hemolytic anemia 2/2 prosthetic heart valve
226
What is splenic sequestration syndrome?
suddne pooling blood in spleen --> rapid splenomegaly and hypovolemic shock
227
What is presentation of acute chest syndrome?
CP, resp distress, pulm infiltrates, hypoxia
228
What are the causes of spherocytosis?
```
- hereditary spherocytosis
G6PD deficiency
ABO incompatibility
hyperthermia
autoimmune hemolytic anemia
```
229
What is presentation of G6PD deficiency?
heinz bodies in RBC from denatured RBCs
bite cells after removal of heinz bodies by spleen
deficiency NADPH formation on G6PD assay
230
What kind of hemolysis, Abs, etiology in warm AIHA?
IgG
extravascular hemolysis
splenomegaly
idiopathic or 2/2 lymphoma, CLL, SLE, a-methyldopa
231
What kind of hemolysis, Abs, etiology in cold AIHA?
IgM
intravascaular hemolysis --> in liver
2/2 idiopathic, mono, or mycoplasma
232
How can you tell difference between warm and col hemolytic anemia on coombs/smear?
direct coombs:
- if coated w/ IgG = positive direct coombs = warm AIHA
- ir RBCs coatd w/ complement alone = cold AIHA
if spherocytes may be warm AIHA
233
What are HIT type 1 and 2?
type 1: heparin directly causes platelet aggregation,
234
What test for vWD?
ristocetin assay
235
What happens to PT, PTT, thrombin time, fibrinogen, platelets in liver disease?
high PT, PTT
| normal TT, fibrinogen, platelets
236
What happens to PT, PTT, TT, fibrinogen, PC in vit k deficiency?
long PT
| normal PTTT, TT
237
What is tx for DIC?
FFP
| platelet transfusions
238
What factors synthesized by vit K?
II, VII, IX
239
What clotting factor has shortest half life?
VII
240
What drug is not succsesful in pt w/ ATIIII?
heparin
241
What are actions for DVT ppx?
LMWH
low dose unfractionated heparin
pneumatic compression boots
242
What is mech of action of clopidogrel?
blocks binding of ADP to specific platelet ADP receptor P2Y12
243
WHen is clopidogreal indicated?
for ACS --> unstable angina, MI, NSTEMI
pretrement for PCI
receive for 1 yr after PCI
244
What are risk factors for breast cancer?
age
fam hx
anything that increases number of menstrual cycles --> early menarche, late menopause, nulliparity
245
What is tx of lobular carcinoma in situ?
removal of lesion does not reduce risk of progression to invasive CA
can tx w/ SERM, prophylactic B/L mastectomy
246
What should you do for small vs large breast CA lesions?
for small do systemic chemo
247
What is MCC death in MM?
recurrent infections
248
What is mech of bony lesions in M?
osteolytic lesions are secondary to release of osteoclast-activating factor by neoplastic plasma cells
249
What are sequela of waldenstrom macroglobulinemia?
IgM
--> hyperviscosity
no bony lesions
have fatigue, wt loss, neuro sx, lymphadenopathy, splenomegaly, anemia, abnormal bleeding, hypervsiscosity ---> can lead to retinal vessel dilation and hemorrhage --> blindness
250
What locations associated w/ adult T cell lymphoma?
japan and caribbean
251
What is rituximab? use?
monoclonal CD20 antibody
| use to treat NHL
252
What are key features of SLL?
closesly realted to CLL
| indolent course
253
What are key features of follicular lymphoma?
painless peripheral lymphadenopathy
| MC form of NHL
254
What are key features of diffuse large cell lymphoma?
locally invasive
| large extranodal mass
255
What are key features of burkitt?
AA --> facial bone and jaw, associated w/ EBV
american --> ab organs
t8;14 translocation
256
When should you bx lymph node?
any node > 1cm present for more than 4 wks not attributed to infection
257
What is CHOP therapy for NHL?
- cyclophosphamide
- hydroxydaunomycin (doxorubicin)
- oncovin (vincristine)
- prednisone
258
What translocation in Acute promyelocytic leukemia?
t15;17
foten have pancytopnea
tx w/ all trans retinoic acid
259
What age ranges for ALL, AML, CLL, CML?
ALL 65
| AML/CML 40-60yo
260
What type of leukemia can present w/ AIHA?
CML
261
How do you differentiate from leukemoid reaction and CML?
leukemoid:
- no splenomegaly
- increased leukocyte alk phosphatase
- hx of infection
CML = opposite
262
What translocation in CML?
t(9;22) --> philadelphia
| BCR-ABL -> activates tyrosine kinase protein
263
What type of leukemia do you tx w/ imatinib?
CML = tyrosine kinase inhibitor
264
What is presentation of polycythemia vera?
pruritis and hot batch or shower
265
What is presentation of polycythemia vera?
hyperviscosity
thrombotic phenomena
bleeding
splenomegaly, hepatomegaly, htn
266
What levels of EPO, B12, uric acid in PV?
high B12 and uric acid
| low EPO
267
What is presentation of carotid TIA?
loss of speech, paralysis/parasthesias
| amaurosis fugax
268
What is subclavian steal syndrome?
stenosis of subclavian artery proximal to origin of vertebral artery to fill subclavian artery distal to stenosis b/c cannot supply adeqaute blood to L arm
269
What is location of dysarthria and clumsy hand stroke?
pons
270
When do you give hypertensives in acute stroke?
BP > 220/120 or acute MI, aortic dissection, severe HF
271
When do you do carotid endarterectomy?
in symptomatic pt w/ stenosis > 70%
272
What are pupil findings in CH 2/2 pons? thalamus? putamen?
```
pons = pinpoint
thalamus = poorly reactive pupils
putamen = dilated pupils
```
273
What is shy drager?
parkinson + autonomic insufficiency
274
What is progressive supranuclear palsy?
degernative brainstem, basal ganglia, cerbellum
have bradykinesia, limb rigidiy, cog decline
but no tremor
also have opthalmoplegia
275
What is mech of pramipexole?
dopamine agonist
276
What are characteristics of essential tremor?
w/ certain postures or tasks
fine
head tremor, vocal tremulousness
improved by alcohol
277
What is tx for tourettes?
clonidine, pimozide, haloperidol
278
What is tx for guillan barre?
IVIG, avoid steroids
279
What is etiology of MG?
postsynaptic receptor antibodies to Ach
280
What is mcardles?
AR, muscle cramping after exercise 2/2 glycogen phosphorylase deficiency
281
What is presentation of NF1 (von recklinghausen dz)?
```
AD
cafe au lait
neurofibromas
CNS tumors
axillary freckling
iris hamartomas (lisch nodules)
bony lesions
cutaneous neurofibromas
```
282
What is presentation of NF2?
```
AD
b/l acoustic neuromas
multiple meningiomas
cafe au lait spots
neurofibromas
cataracts
```
283
What is tuberous sclerosis?
AD
cognitive impairment, epilepsy, skin leasions (facial angiofibromas, adenoma sebaceum)
retinal hamartomas, renal angiomyolipomas, rhabdomyomas of heart
284
What is presentation of polio?
LMN involvement, asymmetric muscle weakness, absent DTR, flaccid, atrophic muscles, normal sensation
285
How do you distinguish between central and peripheral vertigo?
central: gradual, mild, N/V, neuro findings, mild nystagmus, mild effect w/ position change, multidirectional nystagmus
peripheral: sudden onset, severe intensity, intense N/V, no associated neuro findings, intense nystagmus, intense effect w/ position, unilat/vertical nystagmus
286
What is tx for uncomplicated cap in pt w/o significant comorbidities? if older or w/ comorbidities?
azithromycin or clarithromycin or doxy
if older/comorbidities --> fluoroquinolone
287
WHat is tx for ventilator associated pna?
```
cefepime or pip/tazo or carbapenem
AND
aminoglycoside or FQ
AND
vanc or linezolide
```
288
What is empiric tx for meningitis in HIV?
ceftazidiem + amp + vanc
289
What is in pt hospital treatment for pyelo?
cipro or amp + gent
290
At what CD4 count is pt at risk for CMV or MAC?
50
291
What is presentation, tx for CMV?
present = disseminated GI or pulm sx, retinitis, colitis, esophagitis
tx = ganciclovir, foscarnet
292
What is presentation of chancroid?
haemophilus ducreyi
painful genital ulcer(s) w/ ragged borders, purulent base
unilateral tender inguinal lymphadenopathy that appear 1-2 weeks after ulcer
tx = azithromycin or ceftriazone
293
WHat is presentation of lymphogranuloma venereum?
chlamydia trachomatis
painless ulcer, a few weeks later have tender inguinal lymphadenopathy (unilateral)
and constitutional symptoms
294
What is presentation of rocky mountain spotted fever?
rickettsia rickettsii
| papular rash starts peripherally and spreads centrally
295
What is tx for rocky mountain spotted fever?
doxy
296
What is tx for malaria ppx?
mefloquine if chloroquinolone resistant area
297
What is licehn planus?
pruritic, polygonal, purple, flat topped papules
on wrists, shins, oral mucosa, genitalia
tx: steroids
298
What is bullous pemphigoid vs pemphigus vulgaris?
bullous pemphigoid: elderly, easily rupture, autoimmune
pemphigus vulgarus: loss of normal adhesion between cells, can involved oral mucosa, IgG against desmoglein, assocaited w/ lymphoma, CLL
299
What is marjolins ulcer?
scc from chronic wound such as previous burn scar
300
What is spitz nevi?
well circumscribed raised lesion often confused w/ melanoma
tx = complete resection
301
What do you need to check yearly in pt on hydroxychloroquine?
annual eye exam
302
What are sx of drug induced lupus?
SLE but not renal or CNS involvement
usually 2/2 hydralazine, procainamide, INH, chlorpromazine, methyldopa, quinidine
303
What type of ab in diffuse vs limited scleroderma?
```
diffuse = antitopoisomerase (antiscleroderma 70)
limited = anticentromere
```
304
What are poor prognostic indicators in RA?
high RF titer
subcutaneous nodules
erosive arthritis
autoantibodies to RF
305
What thigns can precipiate acute gouty attack?
```
decrase temp
dehydration
stress
excess alcohol
starvation
```
306
What are complications of gout?
nephrolithiasis
| degenerative arthritis
307
What meds should you avoid in acute gout?
```
asa and acetaminophen
also allopurinol (mayybe)
```
308
When should you suspect takayasu arteritis?
decreased absent peripheral pulses
discrepancies of bp arm vs leg
arterial bruits
young woman
