question

What is a positive stress test

answer

Flat or Down sloping St-segment depression >1 mm occurring 80 msec after j point

question

When to stop a stress test

answer

St segment depression > 2 mm, ventricular tachycardia, drop in SBP > 15, CP, dyspnea, lightheadedness

question

Stress test of choice with a LBBB or ventricular pacing?

answer

Myocardial perfusion imaging with adenosine, NOT exercising!

question

When to not use doutamine for stress

answer

History of VT, severe HTN, Low BP, poor echo images

question

When to not use adenosine for stress

answer

Bronchospasm, severe valvular dysfunction, severe carotid stenosis, 2nd degree heart block, t heophylline dependent

question

Normals for PA catheter pressures

answer

RA <8 RV 30/8 PCWP 3-12 PAP 12-20 / 3-12

question

Diastolic pressures elevated & equalized in all chambers, low BP

answer

tamponade or restrictive pericarditis

question

Elevated RA and PA pressures, decreased or nl PCWP, hypotension

answer

RV MI

question

Elevated PCWP, RA pressure decreased SBP/cardiac output

answer

cardiogenic shock

question

high RA, PA very elevated high PCWP nl SBP

answer

mitral stenosis with RV failure

question

Elevated PAP, RAP nl PCWP, SBP

answer

pulmonary HTN

question

decr in SBP>10mmHg with nl inspiration; palpated as weakened pulse with inspiration & more heart contractions to pulse beats

answer

pulsus paradoxus: Constrictive or restrictive pericarditis, asthma, tension pneumothorax

question

What gives you pulsus bisferiens (two systolic peaks per cycle)

answer

Aortic regurgitation, HOCM

question

What causes pulsus alternans

answer

Severe LV dysfunction

question

What causes pulsus tardus

answer

Aortic stenosis

question

How do positional maneuvers affect blood flow and murmurs

answer

-standing/valsalva: decreased cardiac filling, decreases most murmurs except MVP and HOCM -squatting/ lying down: increase cardiac volume, increased murmurs except MVP, HOCM -sustained handgrip: increases systemic resistance decreases murmur in HOCM, AS

question

What causes a physiologic split S2

answer

Increased blood volume in the RV prolongs systole and delays pulmonary valve closure

question

What causes a fixed split S2

answer

Pulmonary stenosis, PE, LV pacer, RBBB, MR (early AV closure), ASD, RV failue

question

What causes a paradoxic split S2

answer

LBBB, RV pacing, HOCM

question

What causes an S3?

answer

Rapid LV filling: acute ventricular decompensation, severe AR or MR

question

What are the parts of the venous waveform?

answer

A wave - atrial contraction X descent - atria relax, RV fills rapidly Bottom of x descent is TC valve closure V wave - ventricle contacting against closed TC valve Y descent - TC valve opens, passive emptying into ventricle

question

What gives elevated a and v waves

answer

Pulmonary HTN, RV infarction

question

Large r side v waves

answer

Septal rupture

question

Large v waves

answer

TR (right), MR (left)

question

Rapid x and y descent

answer

Constrictive pericarditis, restrictive cardiomyopathy, tamponade (x descent only, loss of y descent)

question

Large a waves

answer

TS, severe RVH (on right), MS

question

Cannon a waves

answer

AV disassociation - complete heart block, ventricular pacing

question

Slow Y descent

answer

Delayed atrial emptying - TS

question

Most important prognostic factor with CAD

answer

Degree of LV dysfunction

question

Causes of resting ST elevation

answer

MI, pericarditis, LV aneurysm, LBBB, ventricular pacing, LVH, early repolarization

question

Hibernating myocardium

answer

myocardium near the infarction may be underperfused but not necrotic- the metabolism of the cells adapts to low energy supplies & are nonfunctional until perfusion is restored

question

Reperfusion injury

answer

the re-estab of blood flow after a coronary artery is blocked, which may further damage the heart tissue due to the formation of O2 free radicals

question

Stunned myocardium

answer

prolonged post ischemic dysfunction, salvaged by reperfusion, several days

question

NSTEMI have _____ initial mortality, but have the _____ one year mortality as a STEMI

answer

Lower, Same

question

NSTEMI have a higher risk of these vs. STEMI

answer

Persistent angina, reinfarction, and death within several months

question

MR due to papillary muscle rupture is most common with MI in this region

answer

Inferior

question

Types of arrythmias with IWMI

answer

Junctional escape, Mobitz I, and they are usually temporary

question

Types of arrythmias with AWMI

answer

Mobitz II, BBB. More of the myocardium is involved

question

Contraindications for B-blockers

answer

Bradycardia, hypotension, 2nd or 3rd degree AVB, pulmonary edema, asthma. NOT DM

question

When to use non-dihydropyridne CCBs in ACS

answer

Contraindications to B blockers, continued ischemia, but NO LV dysfunction

question

When to use fibrinolytics in ACS

answer

Not with UA/NSTEMI: increases mortality Use in STEMI, new LBBB if no contraindications and immediate PCI not available

question

What to give pt with UA/NSTEMI

answer

Plavix Lipid and BP control DC NSAIDs except ASA ASA, O2, B-blocker, nitrate prn Heparin, enoxaparin, Fondaparanux, or bilavirudin Gp IIa/IIIb if immediate PCI planned NO FIBRINOLYTICS!

question

When to do urgent PCI with UA/NSTEMI

answer

CHF or hemodynamic instability, recurrent or refractory angina, life threatening arrythmias

question

When to use invasive therapy within 48 hrs with UA/NSTEMI

answer

elevated troponin, dynamic ST changes, DM, GFR < 60, EF < 40%, Early post-MI angina, PCI in last 6 months, prior MI / CABG, intermediate/ high risk score

question

When to use conservative therapy with UA/NSTEMI

answer

no indications for invasive therapy, good response to initial treatment, low risk post-ACS stress testing. Has the same 1 yr mortality

question

Cocaine/ meth use and UA/NSTEMI

answer

give NTG and CCBs If no better, do cath If cath not available, give fibrinolytics No cath if no ST/T changes, neg stress, & neg biomarkers

question

Anti-platelet therapy after UA/NSTEMI

answer

no stent: ASA 75-162mg lifelong + Clopidogrel x 1-12 month Bare metal: ASA 162-325 x 1 mo, then 75-162 for life + Clopidogrel x 1 mo-1 yr Drug eluting stent:ASA 162-325 x 3-6 mo, then 75-162 for life + Clopidogrel x 1 yr minimum

question

Initial therapy for STEMI/new LBBB MI

answer

Same as NSTEMI, but can use fibrinolytics if PCI not available within 90min of ER arrival

question

EKG findings with posterior MI

answer

ST depression in V1, V2, tall R waves in V1+2

question

PCI vs. fibrinolytics

answer

Better outcome if experienced, done within 12 hrs of symptoms, 90 minutes from ER; substantially better patency of infarcted vessels

question

When to use fibrinolytic therapy

answer

ST elevation in 2+ contiguous lead, new LBBB, under 75 yo, within 12 hrs of sx, no PCI available

question

Contraindications to fibrinolytic therapy

answer

absolute - previous hem CVA, cerebrovascular event in last yr, intracranial neoplasm, active internal bleeding, suspected aortic dissection Relative - persistent BP > 180/110, remote CVA, INR > 2-3, bleeding disorders, recent (2-3 wks) major trauma, non-compressible venous puncture, previous exposure to streptokinase or antistreplase, pregnancy, active peptic ulcer, chronic HTN

question

Hypotension clear lung fields, elevated JVD; also often have Kussmauls sign

answer

RV infarct Avoid nitrates and preload agents, fluid support, may need inotropic support with dobutamine

question

AVB and bradycardia are most common with this MI

answer

Inferior MI If with anterior, it means a large part of the IV myocardium is destroyed - high mortality - usually require permanent pacer

question

Indications for temporary pacing with MI

answer

Asystole, symptomatic bradycardia (sinus brady or AVB with hypotension not responsive to atropine), complete AVB Mobitz type II

question

Mechanical complicatons of MI's 3-7d out

answer

1. Papillary muscle rupture - inferior. short early systolic murmur, sudden onset of shock. Dx with echo treat with urgent CT surgery 2. VSD - anterioseptal MI, s udden shock, loud holosystolic murmur. Oxygen step up 10% from RA to PA on RHC. Dx with echo, tx with urgent CT surgery. High mortality 3. Free wall rupture of LV - large AWMI, usually elderly HTN women. Sudden syncope, neck veins engorged, tamponade. Few survive with urgent surgery

question

ICD's post MI - indications

answer

EF < 35%, baseline episodes of VT

question

What affects HDL

answer

increases - exercise, small EtOH, niacin, estrogens Decreases - tobacco, androgens

question

Indications for CABG

answer

1. significant LMA or LMA equivalent (proximal LAD + proximal LCA) 2. 3 vessel disease - survival benefit even greater with EF<50 3. Diabetics Improves sx, not survival: 1. 2 vessel + prox LAD + (EF <50% or ischemia on stress) 2. 1-2 vessel dz w/o significant prox LAD, but large area of viable myocardium and high risk stress 3, 1 or 2 vessel dz

question

Restenosis rates

answer

Angioplasty- 30-50% on 6 mo Bare metal stent - 25% Drug eluting stent - 5%

question

PAD

answer

Arteriosclerosis Arteritis (CTD, Takayasu's) Trauma Buerger's disease (males <30, smokers, affects wrists, hands) Entrapment Dx: pre and post exercise ABI <0.9 or decr of the ABI by 20% after exercise Tx: 1. Exercise 2. Stop smoking 3. Pletal (Cilostazol) - can't use with grade III or IV CHF 4. Pentoxyfylline (Trental)

question

Unilateral HA, TIA or dilated pupil, unilateral neck pain in a HTN pt. cholesterol emboli on fundoscopy

answer

spontaneous internal carotid dissection No treatment needed occasionally needs stent or anticoagulation

question

Severe anterior CP + interscapular pain

answer

thoracic aortic aneurysm HTN, cystic medial necrosis, bicuspid aortic valve, coarctation of the aorta, 3rd trimester of pregnancy, Marfan's syndrome For surgery: 5.5 for ascending, 5.0 if Marfans, 6.5 for descending Decrease BP with B Blockers, nitroprusside Surgery for all ascending TAA due to risk of complications Surgery for descending if persistent pain, end-organ damage (renal insufficiency, limb compromise)

question

Surgery for AAA

answer

Monitor with q6mo CT or US if 0.5cm every 6 months Do cardiac testing pre op if two or more cardiac risks. Heart issues cause 70% of the mortality

question

when to replace prosthetic valve with endocarditis

answer

Less than 2 months from surgery, valve ring infection, myocardial penetration (new HB or BBB)

question

Indications for surgery in endocarditis

answer

CHF, extension into the myocardium, perivalvular abscess, failure of medical therapy, large vegetation with septic emboli

question

Drugs for endocarditis prophylaxis

answer

Dental - Amox, Amp, Cefazolin, Ceftriaxone; allergic - Clinda, Azithro, Clarithro GU/ GI - not needed! Respiratory tract procedures, skin or muscle infection - staph, strep coverage

question

Jones criteria for rheumatic fever

answer

Major: Carditis, Polyarthritis, Chorea, Erythema marginatum, Subcutaneous nodules Minor: Arthralgia, Fever, Elevated Acute Phase Reactants, Prolonged PR, Previous hx of GAS or RF 2 Major or 1 major 2 Minor

question

LV failure, syncope, angina slow upstroke to pulse (pulsus tardus), sustained apical impulse, diamond shaped SEM at RUSM with radiation to neck, S4 gallop, decreased or absent S2 (AV doesn't move well), ejection click

answer

Aortic stenosis Have a higher rate of CAD, so cath before fixing Severe AS = area 50 Treat all symptomatic pts with AoVR Post AovR, anticoagulation to INR 2-3 (2.5-2.5 with MVR)

question

decrescendo diastolic high pitched blowing murmur, RUSB (Root dz) or LUSB (Leaflet dz), wide bounding pulse (water hammer), can give low pitched rumble (Austin-Flint) with flow against MV; Becker's sign (pulsatile retinal arteries), de Musset's sign (bobbing head with pulse)

answer

Chronic AR Etiol - valve deformity or abnormal aortic root (Marfans, senile aortic dz, giant cell arteritis, relapsing polychondritis, syphilis) Causes LV volume overload ->LVH -> LV dysfunction Vasodilators (ACE, ARB, diuretics) Surgery if symptomatic, LV end systolic dimension > 55mm, LV end diastolic dimension > 75mm, EF <55%

question

severe pulm edema, low cardiac output, no bounding arterial pulse (low EF). short diastolic murmur

answer

Acute AR if significant AR and CHF without a reversible cause, usually require immediate surgery

question

diastolic murmur, low pitched rumble, accentuated S1, diastolic opening snap CXR - triad of prominent PA vascularity, enlarged LA, nl LV Often a fib. Can have CHF, usually have pulm HTN. Hemoptysis from pulm congestion Increased fluid state in pregnancy can cause acute exacerbation.

answer

Mitral stenosis Usually from RF. heparin if a fib, cardioversion, procainamine, digoxin, verapamil Valvotomy or surgical replacement if sx, asx with pulm HTN (>50 rest, >60 exercising)

question

steady systolic murmur, often a fib, wide split S2, s3 if severe

answer

Chronic mitral regurgitation Causes - rheumatic HD, annulus dilation from LVH, endocarditis, ischemic papillary muscle Tx - diuretics, afterload reduction; surgery if symptoms, asx with EF 45, a fib, pulm HTN. Prefer repair to replacement

question

midsystolic click with late murmur if MR. Click louder and earlier if standing or valsalva

answer

Mitral valve prolapse Causes - weak papillary muscles, myxomatous leaflets Sx - none (do NOT get dyspnea, panic attacks, palps, CP, etc) No treatment

question

Presents with pulmonary edema decrescendo apical systolic murmur, nl size LA on echo, large L side v waves

answer

Acute mitral regurg Native valve - from flail leaflet (MVP, endocarditis), papillary muscle ischemia or rupture, chordae tendinae rupture Prosthetic valve - from tissue valve rupture, mechanic valve closure problem (thrombus), paravalvular vegetation Rx - afterload reduction, diuresis; IABP; often need surgery

question

diastolic murmur, LSB, increase with inspiration, giant a wave; ascites, edema; EKG - tall peaked P waves in II and V1

answer

Tricuspid stenosis Causes - RF, congenital, endocarditis, carcinoid syndrome (usually with TR as well) Tx - treat underlying, surgery

question

holosystolic LLSB murmur, parasternal heave; liver pulsations, ascites, edema; large v waves

answer

Tricuspid regurgitation Causes - functional RV dilation from end stage LV failure, submassive PE, pulmonary HTN, rheumatic HD, endocarditis (drug users, staph sometimes candida), carcinoid, congenital (Ebstein's anomaly) Tx - treat underlying, rarely needs surgery except candida

question

ejection click, jugular a wave widely split S2 SEM @LUSB

answer

Pulmonic stenosis Usually congenital, does not progress, rarely from rheumatic HD or carcinoid; with Noonan's syndrome (low set ears and hairline) May need balloon valuloplasty - peak systolic gradient >50 mm Hg - RV hypertrophy is present - symptomatic

question

Diastolic murmur @ LUSB "Graham-Steel" increases with inspiration

answer

Pulmonic regurgitation usually from pulmonary HTN, can be congenital, rheumatic, endocarditis. Occasionally see with WPW, PSVT

question

Cardioversion in A fib

answer

prefer electrical except <48 hr with EF <40, then give amiodarone Immediate cardioversion if 1. AF with RVR + ischemia, HoTN, CHF, angina 2. Preexcitation with RVR or hemodynamically unstable, 3. Severe symptoms If slow a fib, put in temporary pacer first - likely has nodal dz, may go into asystole

question

Pharmacologic cardioversion drugs for A fib

answer

If > 7 days: 1st Dofetilide; next choices - amio, ibutilide < 7 days: 1st - dofetilide, flecanide, ibutilide, or propafenone; 2nd line - amio

question

Maintenance drugs in a fib

answer

No or minimal HD: flecanide, propafenone, sotalol. If fail, use amio, dofetilide, ablation CHF, EF< 35%: amio, dolfetilide; fail - ablation CAD - dolfetilide, sotalol; fail - amio, ablation HTN with LVH - amio; fail - ablation HTN, no LVH - flecanide, propafenone, sotalol; fail - amio, ablation, dolfetilide

question

Chronic anticoagulation decision in a fib

answer

Based on CHADS2 score: C- CHF (1 pt) H - HTN (1 pt) A - Age >75 (1 pt) D - DM (1 pt) S - stroke or TIA in past (2 pt) 0 pts - ASA; 1 pt - either ASA or warfarin; 2+ pt - warfarin

question

Multifocal atrial tachycardia info

answer

Seen with pulmonary dz, especially on theophylline; also low K, Mg If due to theophylline and cannot stop theoph, rx with diltiazem or verapamil Digoxin can worse it - avoid Rx with ablation or pacing if refractory

question

PR 0.12, delta waves

answer

WPW Narrow complex tachy - vagal, cardioversion, procainamide, verapamil, adenosine A fib/ flut - usually wide complex - avoid dig, verapamil, B-blockers - can cause preferential conduction down accesory pathway and incite VF. Treat with Procainamide or shock if unstable Can cure with ablation

question

Treat PVC's?

answer

If structurally normal heart, no - even if couplets, lots of them Can use B-blocker, should get 80% reduction to call it effective If H/O MI, EF< 40%, PVC's, especially sequential, suggest high risk for sudden death

question

DDX of wide complex tachycardia

answer

1. Severe L axis deviation; 2. QRS >0.14 in RBBB, >0.16 in LBBB (usually 100; 7. capture beats

question

Treatment of monomorphic VT

answer

Stable - procainamide or amiodarone Unstable - shock Unstable and refractory to cardioversion - IV amio or procainamide VTwith MI - amio first, can use lidocaine

question

Treatment of polymorphic VT

answer

same as monomoprhic except: IV B-blocker if ischemia cannot be excluded IV amio if no prolonged QT Cath if ischemia suspected

question

torsades

answer

quinidine, procainamide, class Ia antiarrhythmics, dofetilide, class III antiarrhythmics (sotalol), tricyclics, low K, Mg Usually preceded by prolong QT interval, U wave Increase atrial rate (isoproterenol), overdrive pacing, MgSulfate shock is last resort

question

Rhythms to avoid verapamil with

answer

A fib/ flut with WPW Wide complex tachycardia B-Blockers - both negative chronotropes and inotropes

question

Indications for ICD

answer

VT with structural HD (esp HCM) VT and cannot correct CAD VT with EF < 30%

question

Indications for pacers

answer

Symptomatic bradycardia Complete HB Mobitz II after AWMI

question

Side effects of quinidine

answer

cinchonism (tinnitus), hemolytic anemia, sudden death(quinidine syncope) due to QT prolongation, torsade/polymorphic VT; fever, rash, ITP, psychosis

question

Side effects of Disopyramide

answer

Prolonged QT, QRS, torsades; (anticholinergic and vagolytic) urinary retention, dry mouth, constipation

question

Side effects of procainamide

answer

agranulocytosis, lupus (does NOT affect kidneys) with high ANA; also QT prolongation with torsades/VT; caution with CHF - slight myocardial depressant

question

Side effect of Lidocaine

answer

seizures

question

Side effect of tocainide

answer

aplastic anemia

question

Side effects of amiodarone

answer

corneal microdeposits, optic neuritis, pulmonary fibrosis (severe, fatal in 10%), bluish skin discoloration, photosensitivity, hypothyroids or hyperthyroids, elevated INRs in warfarin patients, may elevate digoxin levels; no hematologic effects

question

Harsh, non-radiating aortic midsystolic murmur, increases with Valsalva, decrease with handgrip; bifid pulse - strong upstroke, then falls off as it obstructs later in systole EKG - nl, can have inf to lat Q waves from the hypertrophy, with nl to high voltage from LVH (if low voltage, consider infiltrative CM - amyloid)

answer

HOCM Echo with doppler Exercise nuc stress Holter to look for ventricular arrhythmias Surgery (septal myotomy) - decr sx, no change in SCD risk B-blocked, Verapamil - improve sx Amiodarone if high risk for SCD (familial) RV pacing - can improve obstruction in some pts Avoid anything that decreases LV volume - diuretics, nitrates, volume depletion (can use diuretics very carefully if in CHF)

question

Risk factors for sudden death in HCM

answer

Septal thickness >30mm H/O syncope Fam hx sudden death in 1st degree relative NSVT/VT on holter Failure to increase SBP on treadmill test (<10mm)

question

Restrictive CM

answer

Causes - amyloidosis, sarcoidosis, hemochromatosis, lipid storage diseases Echo - thickened myocardium, may have granularity MUST differentiate from constrictive pericarditis - identical s/sx, but pericarditis is quickly treated with good results, restrictive CM is irreversable Treatment - diuretics. Avoid digoxin unless a fib

question

R & L HF, slow onset over months. Can form mural thrombi with arterial embolization. Slow, steady progression to death in 3 years

answer

Dilated cardiomyopathy Causes - idiopathic (usually viral), alcohol, cocaine, amphetamines, organic solvents, chemo, late hemochromatosis, possibly selenium or carnitine deficiency Rx - anticoagulate for thrombus risk, treat HF sx as usual - diuretics, B-blockers, ACE/ARB

question

NYHA CHF classes

answer

I - no limitation in activity II - slight limitation with activity, no sx at rest III - marked limitation of activity, comfortable at rest. Sx with even slight activity IV - sx at rest

question

ACC/AHA stages for HF

answer

A - at risk for HF, no structural dz B - structural dz, but no s/sx HF C - structural dz with s/sx D - Marked sx at rest

question

ACC/AHA stage A CHF - definition, goal, meds

answer

Def: at risk for HF - includes HTN, ASHD, DM, metabolic syndrome, cardiotoxins, FH of cardiomyopathy Goal - treat disorder, exercise, discourage alcohol/ illicit drug use Drugs - ACE/ARB for all

question

ACC/AHA stage B - definition, goal, meds

answer

Def - structural HD, no s/sx of HF - includes prior MI, LV remodeling from LVH, low EF, asx valvular dz Goals - same as stage A Tx - ACE/ARB + B-blockers, ICD if indicated

question

ACC/AHA stage C - definition, goal, meds

answer

Def - structural HD with s/sx HF - dyspnea, fatigue, decreased exercise tolerance Goals - like A/B, add dietary salt restriction Rx - ACE/ARB + BB + diuretics. May need aldactone, ARBs with ACE, dig, hydralazine/nitrate combo. BiV pacing +/or ICD as needed

question

ACC/AHA stage D HF - definition, goal, meds

answer

Def - marked sx at rest despite max therapy; frequently hospitalized Goals - A/B/C + discuss end of life care Meds - same as C. Discuss hospice vs. extraordinary measures (transplant, chronic inotropes, permanent mechanical support - ventricular assist device, experimental treatments)

question

BNP in restrictive CM vs. constrictive pericarditis

answer

Elevated in RCM, nl in pericarditis

question

Diastolic dysfunction

answer

Causes - ischemia, sever concentric LVH, HCM, diabetic CM CO is normal, HF develops from decreased relaxation/ increased stiffness of ventricle Elevated LVEDP, RVEDP, tachycardia, s4

question

Effects of ACE/ARB in CHF

answer

increase cardiac output, decrease LV filling, vasodilation, decrease tachycardia, decrease incidence of VT/VF, prolong survival

question

B-blockers in HF

answer

decrease remodeling, arrythmias. Coreg decreases mortality 65%, metoprolol + bisoprolol 35%

question

Diuretics in HF

answer

Help fluid control, symptom control, but no improvement in mortality

question

Spironolactone/ Eplerenone in HF

answer

effective only with class III/IV no decrease mortality

question

Digoxin in HF

answer

effective only in sever systolic failure - stage C or later; use after other standard therapies, EF <40, class II/III/IV Resets baroreceptors, dampens renin-angiotensin effects Improves symptoms, decreases hospitalization, no effect on mortality

question

Nitrates + hydralazine in HF

answer

Use in class III/IV, african american, still symptomatic despite other txs

question

Anticoagulation in HF

answer

start if EF<25% due to risk of mural thrombus

question

Meds in severe HF

answer

Dopamine - only for renal effects. Higher dose - vasoconstriction, tachycardia Dobutamine - inotropic, but no vasoconstriction Milrinone (Primacor)- inotrope, vasodilator - short term use in HF Nesiritide (natrecor) - BNP -improves clinical status, decreased PCWP/ PA pressure, improved stroke volume, no increase in HR Hydralazine+NTG - afterload and preload reduction CABG - only if acute MR, papillary muscle rupture

question

Transplant in HF

answer

Only at end stage - 65% 5 yr survival, 55% 10 yr

question

High output failure causes

answer

peripheral shunting (AV fistula, severe hepatic hemangioma, Pagets), low SVR (sepsis), hyperthyroidism, Beriberi, carcinoid, anemia

question

Effects of azotemia on diuretics

answer

Avoid spironolactone and triamterene - causes hyperkalemia Thiazides ineffective Lasix usually works, higher doses needed

question

Treatment of acute pulmonary edema

answer

Sit with legs dangling (decrease venous return) 100% O2, morphine Lasix - venodilation before diuresis IV NTG/ nitroprusside if BP>100 Dobutamine if BP <90 Aminophyline - occ used to improve repiratory muscle function Digoxin - contraindicated if WPW, severe concentric LVH, restrictive CM

question

Causes of non-constrictive pericarditis

answer

Idiopathic (90%, likely viral), TB, CT diseases, sepsis, renal failure, cancer, MI (dressler syndrome autoimmune, 1-2 wks after MI), procainamide, hydralazine

question

severe CP, pleuritic, better leaning forward, fever, tachycardia; pericardial friction rub (not always) EKG - diffuse, concave upsloped ST elevation, occasionally depressed PR in II Transient increase in CKMB

answer

pericarditis Tx: Stop/ treat cause NSAID's Steroids only if not idiopathic - higher risk of relapse; definitely use if TB Colchicine

question

Loud presystolic knock just after s2 (due to rapid early diastolic LV filling), pulsus paradoxus Kussmaul sign - heart encapsulated, can't accomodate extra blood in inspiration, so don't get usual drop in JVD with inspiration, can actually increase Large R sided x+y descent due to brisk collapse of the jugular during diastole Kussmauls & large x+y descent are HALLMARKS

answer

constrictive pericarditis Usually idiopathic, open heart surgery, radiotherapy, coccidiomycosis, TB CXR - calcification of pericardium - seem best in lateral over R ventricle - pathognomic for this CT/MRI/ echo - measures thickness of pericardium - >5mm Tx: pericardectomy. Fixes problem in 50%

question

Recurrent pericarditis

answer

problem is chest pain Does NOT progress to constrictive pericarditis Rarely gives arrythmias NSAIDs, colchicine, steroids to treat Pericardectomy not as effective, only use if other options fail

question

1. Hypotension and muffled heart sounds 2. Pulsus paradoxus 3. JVD with no collapse during diastole

answer

pericardial tamponade CT or MRI are better than echo, and can see small pockets of fluid Surgery if: traumatic hemopericadium, post surgical effusion, bacteria or TB suspected as cause

question

SEM at LSB (increased flow across pulm valve) occ diastolic murmur (flow across tricuspid valve) and a fixed split S2 (RVH) enlarged RV on CXR and shunt vasculature RAD and/or RBBB on ECG, can see A fib

answer

Ostium secundum ASD Most common CHD found in adults Tx: surgical closure or percutaneous closure (do if > 2:1 left to right (pulmonic/systemic) shunt Pulmonic HTN is considered a contraindication to surgery

question

loud pansystolic murmur 2/2 MR or TR (regurg because ostium is low on septum, interfering with function of AV valves or L mitral valve). ECG has left axis and RBBB

answer

Ostium primum ASD Surgery fixes problem Eisenmenger syndrome is a contraindication to surgery

question

Continuous "machinery" murmur LUSB CXR with calcification of ductus arteriosus Develop differential cyanosis - clubbed toes, nl fingers, pulmonary HTN

answer

Patent ductus arteriosus Usually asymptomatic Consider Eisenminger syndrome if develops pulm HTN Surgical or percutaneous closure

question

Delayed femoral/ brachial pulse CXR: rib notching

answer

Coarctation of the aorta bicuspid AoV in 70% Upper body HTN, HTN aneurysmal dilations, rupture in circle of willis

question

Causes of sudden cardiac death in exercising young people

answer

HCM - 36% Coronary anomalies Primary pulm HTN

question

Pulm HTN

answer

Includes sporadic idiopathic - young women, refractory, death in 5-10 yrs Tx - CCBs, sildenafil, heart lung transplant

question

Pregnancy heart issues

answer

Contraindication to pregnancy - pulm HTN, eisenmengers Watch closely - secundum ASD, AoS, dilated CM Bed rest - AoS, dilated CM

question

Causes of LAD

answer

L anterior hemiblock, so a marker of CAD

question

Causes of RAD

answer

nl in kids, young adults L posterior hemiblock, RVH, acute or chronic RV overload (pulm HTN, PE, pulm stenosis) If an adult has RAD, work it up!

question

Formula for QTc

answer

Nl 340-430 msec Estimate by 40% of RR QT/square root of RR, all in seconds.

question

Causes of prolonged QT

answer

Tricyclic OD, low Ca, K, Mg starvation, CNS insult, Type Ia (quinidine, procainamide), III (amiodarone, sotalol) antiarrhythmics, non sedating antihistamines + EES, azoles, ketoconazole, liquid protein diet

question

Causes of short QT

answer

digitalis, hypercalcemia

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Retrograde P wave

answer

neg in II, pos in aVR - ectopic AV focus in the inferior atrium or AV junction

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RAE findings

answer

Peaked P in II, V1 Causes - RA enlargement, hypertrophy, overload) nl P width (<0.12)

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LAE findings

answer

notched P in II, increase neg portion in V1 increased L side of the wave, so wide P wave >0.12, shortened PR interval

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Peaked T waves

answer

hyperkalemia Hyperacute MI intracerebral hemorrhage V1, V2 in evolving MI

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Focally flipped T waves

answer

Ischemia V1-2 with RBBB, RVH, RV HTN, LVH Lateral leads (I, aVL, V6) with LBBB Precordial leads in LVH with strain

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Diffuse flipped T's in

answer

pericarditis Diffuse ischemia, post resuscitation Metabolic abnormalities Intracerebral hemorrhage

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U waves

answer

Best seen just after T in V2-3 If prominent, risk for torsades - hypokalemia, bradycardia, digitalis, amiodarone Negative U wave: ischemia, HTN, AV valve dz, RVH. See in 60% on ant MI, 30% of IWMI

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ST elevation causes

answer

MI, prinzmetals angina, pericarditis Less seen in ICH, early repolarization, HCM, LVH, LBBB, cocaine abuse, myocarditis, hypothermia

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ST depression causes

answer

Subendocardial ischemia Posterior MI (V1-2) Reciprocal depression in V1-2 in some IWMI LVH with LV strain isolated RV infarction (ST elevation V1, depression in V2) RVH sometimes in V1 Digitalis toxicity Hypokalemia

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LBBB criteria

answer

QRS = 120-180 RR' in V6, SS' in V1 T opposite of mean QRS vector in anterioseptal and lateral leads

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RBBB criteria

answer

QRS >120 delayed depolarization of RV - RSR' or RR' in V1, slurred S in V5-6 Flipped T in V1, sometimes V2

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LAFB criteria

answer

LAD -45 to -90 degrees Large S in inferior leads Dominant R in I No other causes of LAD (LBBB) Poor R wave progression

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LPFB criteria

answer

Small Q, large R in inf leads Small R in I, large S in I, aVL R axis +80-+140 degrees

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Metabolic Syndrome Criteria

answer

Need 3/5 1. Fasting plasma glucose >110 2. HDL <40mg/dL in men, 150 mg/dL 4. Waist circumference >102cm/40in in men, >88cm/35in in women 5. BP >130 sys, or >85 diastolic

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CV disease associated with Ankylosing Spondylitis

answer

Prox. aortitis/valvulitis (25-60%) Aortic regurg (40%) Conduction sys disease (2-20%) LV diastolic dysfxn

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type B aortic dissection

answer

- descending - med tx - IV β-blockers - rapidly titratable IV agent (nitroprusside, fenoldopam, or enalaprilat) - surveillance CT at 1, 3, 6, 12 months

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type A aortic dissection

answer

- ascending - surgical emergency

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Coronary Calcium Testing: Appropriate in what groups

answer

- asymptomatic persons with a 10% to 20% Framingham 10-year risk - young persons with a strong family history

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Contraindications to NTG

answer

- severe symptomatic aortic stenosis - hypertrophic cardiomyopathy

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Brugada syndrome

answer

J-point elevation in V1-V3 & RBBB - incr risk of SCD due to V-tach

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Kussmaul sign

answer

Jugular veins may engorge with inspiration (constrictive pericarditis)

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LVH: Dx criteria on EKG

answer

Voltage Criteria (any of): R or S in limb leads >20 mm S in V1 or V2 > 30 mm R in V5 or V6 >30 mm CORNELL: S in V3 + R in aVL > 24 mm (men) , > 20 mm (women)

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RVH: Dx criteria on EKG

answer

Lead V1: - R/S ratio > 1 and negative T wave - qR pattern - R > 6 mm, or S 10 mm

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Afib: Electrical or pharm?

answer

Electrical if EF<40%, unless: - <48hrs (Amio) - dig, hypokalemia

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ICD placement in CHF?

answer

NYHA II: if EF 150ms NYHA III-IV: if EF 120ms

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CHF: worse prognosis if ...

answer

Low EF Low Na, K High or low Mg High BUN High norepi/catach levels. - exercise tolerance is not prognostic

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High risk cardiac conditions requiring antibiotic prophylaxis

answer

Prosthetic valves Previous endocarditis Congenital Heart dz: - unrepaired cyanotic CHD - Repaired, within 6 months - Repaired, with residual defects

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Aortic Stenosis symptoms / prognosis

answer

Angina (5 years) Syncope with exercise (3 years) CHF (2 years)

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Aortic stenosis murmur louder with ...

answer

Squat Expiration After PVCs

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MVP murmur louder with

answer

Stand Valsalva Handgrip Expiration

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Mitral regurgitation murmur louder with

answer

Squat Expiration

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Acute vs chronic MR

answer

Acute: descresendo murmur Chronic: Constant / holosystolic

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Aortic Regurgitation: Treatment

answer

ACEI/ARBs, diuretics. Surgery if LVESD>55, LVEDD>75, or EF<55%.

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Long QTc

answer

TCA overdose (also long QRS) Methadone Type Ia (quinidine) and III (amio) Low Ca (ST segment long) Low K (often with large U waves) Intracranial bleed (also inverted T)

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Contraindications to Adenosine or Dipyridamole (for stress tests)

answer

- hypotension - Sick Sinus Syndrome - High-degree AV block - bronchospastic disease (COPD, asthma)

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Systolic murmurs

answer

Mid: AS, PS< ASD, HOCM Late: MVP Holo: MR, TR, VSD

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Diastolic murmurs

answer

Early: AR, PR Mid: MS Holo: PDA

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CD4+ T-cells

answer

Primary defense against exogenous antigens 2 types: TH1- induce CD8 cells, lead to cell mediated immunity; TH2- induce B cells to produce Ab with humoral immunity HIV targets CD4+ T-cells (CD4 on marcophages/monocytes/mictoglial cells also affects) - weakens immune system activation NK T-cells- cytotoxic T cells, defense against viruses, neoplastic cells; see CD1 on lipid and glycolipid cells

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CD8+ cells

answer

cytotoxic, defense against viruses, neoplastics cells; activated by antigens presented on HLA class I antigen (most cells can present)

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non pitting edema, lasts 1-3 days, laryngeal obstruction, abdominal pain; can be brought on by minor trauma no urticaria or itching

answer

Hereditary angioedema Autosomal dominant decreased C1 inhibitor-> decrease C4 from ongoing consumption can be type I-decrease level (85%), or type II (decrease function-15%) Screening: C4 levels low; then check C1-INH assay- low=type I, n l = type II Rx: NO EPI! doesn't work; FFP, plasma-derived C1INH IV, kallikrein inhibitor SQ danazol / stanozolol for long term (incr hepatic synthesis of C1 inhib)

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Recurrent sinopulmonary infections, encapsulated bacteria Increased incidence in rheum dz, esp SLE (think about in early onset SLE)

answer

C1, C2, C4 deficiency decreased activation of classical pathway; autosomal recessive

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severe pyogenic bacterial infections

answer

C3 deficiency

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Meningococcal, gonococcal infections

answer

Terminal (C5-9)deficiency screen with CH50, can then do specific test for individual components

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Hypersensitivity reactions- types

answer

Type I= IgE mediated; immediate (anaphylactic, atopic) Type II= IgG or IgM mediated - cytotoxic Type III= immune complex mediated Type IV= cell mediated - delayed type

question

hives, urticaria, allergic rhinitis, reactions to stings, foods Immediate and delayed part

answer

Type I hypersensitivity Includes most "allergy" responses 3-A's - Avoidance of antigen, Antihistamines, Allergy immunomodulation Immunomodulation- 6 mo to effect, 3 yrs to max effect Anaphylaxis tx: Severe (with HoTN)- NS bolus, IV epi If on B-blockers, epi doesn't work as well- try glucagon, vasopressin

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anti-GBM dz anti-ACh receptor (MG) ITP, AIHA

answer

Type II hypersensitivity

question

Autoimm: SLE, Hashimoto's, pernicious anemia, rheumatoid arthritis External ag: Hepatitis-antigen-assc serum sickness, Td, DPT, local insulin reaction

answer

Type III hypersensitivity Immune complexes form (IC's), precipitate in small vessels, start complement reaction-> small vessel inflammation and necrosis Initially- huge excess of Ag- small, quickly cleared ICs 1-2 wks- more Ab formed, have just slight excess in Ag-> large, less soluble complexes-> precipitate in small vessels-> inflammation and necrosis = leukocytoclastic vasculitis Late- Ab excess, forms large, easily cleared ICs Examples: Serum sickness- large amount of Ag injected Arthus reaction- high Ab levels, Ag injected- indurated lesion in 4-6 hrs, can make sterile abscess

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Tb testing, some contact dermatitis

answer

Type IV hypersensitivity Cell mediated Sensitize T cell reacts to antigen- inflammatory response response peaks at 24-72 hrs

question

Urticaria pigmentosa (Darier sign: wheal forms on stroking macule) Abd sx fatigue HSM LAD

answer

Mastocytosis Abnormal mast cell proliferation in various organs 1. Cutaneous- mast cells in dermis 2. Systemic- mast cells in other tissues; abdominal sx, fatigue, anaphylaxis like symptoms + urticaria pigmentosa 3. Malignant- severe systemic sxs, no skin changes; HSM, LAD Tx: avoid cold, heat, EtOH, ASA, opiates; cromolyn for GI sxs

question

X-linked; susceptable to pyogenic and encapsulated organisms- sinopulmonary, ear infections, enteroviral, giardia

answer

Congenital agammaglobulinemia "Bruton" Good prognosis; check males on mom's side Dx- very low IgG, no IgA/M/D/E, no B-cells Rx- IVIG

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sinopulm infections, bronchiectasis, giardia Increased autoimmune dz, malignancy

answer

Common variable immunodeficiency deficiency in IgG, IgA, and/or IgM decreased resistance to encapsulated organisms Dx- low Ig levels, but do have B-cells Rx- IVIG

question

giardiasis, recurrent sinopulm dz, celiac, hashimotos most common deficiency

answer

IgA deficiency rx- prophylactic antibiotics if recurrent infection

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"Wisk thorough the EXIT"- Eczema X-linked Immune deficiency Thrombocytopenia

answer

Wiskott-Aldrich syndrome Low IgM, elevated IgA, IgE Rx- BM transplant

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Cardiac, Abnormal facies, Thymic hypoplasia, Cleft lip, Hypocalcemia, 22nd chromosome

answer

diGeorge syndrome- T-cell deficiency, in utero malformation of many tissues Can see hypocalcemic tetany as infant DiGeorge CATCH-22

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Acquired angioedema

answer

lymphoma MGUS SLE ACEI

question

direct mast cell stimulation vs Ig-E mediated mast cell stimulation

answer

Anaphylactoid (NSAIDs, contrast, opiates) vs anaphylaxis

question

"_____ is the itch that rashes"

answer

Atopic Dermatitis (Eczema) Flexural areas in adult Tx: Stop scratching -- Hydroxyzine or Benadryl "Wet" the skin with emollients mild/moderate: topical pimecrolimus or tacrolimus and emollients severe: topical glucocorticoids + topical pimecrolimus or tacrolimus and emollients

question

One of the primary symptoms that sets Allergic Contact Dermatitis apart from Irritant Contact Derm and other erythematous rashes is...

answer

INTENSE itching

question

Coin-shaped plaques consisting of grouped small papules and vesicles on an erythematous base.

answer

Nummular eczema hydrate/moisturize the skin glucocorticoids add systemic abx if Staph aureus is present

question

What is the appropriate Derm name for "

answer

Seborrheic Dermatitis

question

Orange-red or gray-white skin greasy, white, dry, scaling macules or papules

answer

Seborrheic dermatitis "cradle cap" or "dandruff" suspect: fungal or B6 or Zn deficiencies HIV if severe Tx: selenium sulfide or zinc pyrithione shampoos ketoconazole shampoos cradle cap: massage in baby oil/olive oil/mineral oil

question

Discrete erythematous micropapules and microvesicles appearing around the mouth, typically in female patients of childbearing age

answer

Perioral Dermatitis Unknown cause 1) avoid steroids 2) Topical metronidazole; systemic tetracyclines (minocycline, doxycycline, or tetracycline) 3) do NOT get pregnant!!

question

40F with DM: leg rash. Scaly erosions, sclerosis, and slight bronze-orange pigmentation

answer

Stasis Dermatitis hemoglobin deposits cause pigmentation topical glucocorticoids (short term) for secondary infections, topical antibiotics (Mupirocin)

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Pruritic, clear, tapioca-like vesicles on the medial and lateral aspects of the fingers and feet

answer

Dyshidrosis Eczema For vesicles: drain but don't unroof them; use Burow's wet dressings Fissures: topical application of flexible collodion Glucocorticoids wrapped with plastic occlusive dressings for 1-2 weeks

question

localized lichenification (thick, leathery, brownish skin)

answer

Lichen Simplex Chronicus -- chronic scratching/rubbing leads to lichenification of skin Suspect a psychological disorder (nervous, anxiety, depression, nervous tick) Tx: topical glucocorticoids with occlusive dressings; intralesional triamcinolone; oral hydroxyzine to stop the itching

question

purple, pruritic, polygonal papules "4 Ps"

answer

Lichen planus Wickham's striae Tx: topical or systemic glucocorticoids; cyclosporine or tacromilus solution; PUVA; systemic retinoids

question

A young male who has recently been treated for a viral infection has developed a single, oval, slightly raised plaque that is salmon-red

answer

Pityriasis rosea HHV 6 or 7 (herpes virus) next: exanthematous eruption -- fine scaling dull pink/tawny papules and plaques erupting in a Christmas tree pattern. Itchy Antihistamines for itching topical glucocorticoids may be improved by UVB/sunlight therapy

question

Describe Koebner's phenomenon (as it relates to Psoriasis). Describe Auspitz's sign (also associated w/ Psoriasis)

answer

physical injury or trauma can trigger a psoriatic outbreak picking off psoriatic scales causes microscopic bleeding

question

Sharp magins, bright erythema, nonconfluent white-silver scales; may be assoc with pitting of the nail bed.

answer

Psoriasis peak incidence 22.5yo

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A patient taking an antibiotic for an infection has developed painful lesions on his hands and face. target-like lesion (papule with vesicles and bullae in the center) Fever and weakness.

answer

Erythema multiforme due to drug reaction

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F, joint pain for several days. Painful rash, conjunctival burning, and mouth lesions. Areas of epidermis appear to have crinkled surfaces, and they are enlarging. +nikolsky sign

answer

Stevens-Johnson & Toxic Epidermal Necrolysis (TEN) Classified by level of epidermal detachment: SJS: 30% Nikolsky sign -- put a pen on the skin, twist it, and remove to see if a blister forms

question

>60yo, Autoimmune disorder Pruritic bullae on erythematous base; axilla, medial thigh and groin, abdomen, forearm flexor surface, or lower legs."

answer

Bullous pemphigoid Systemic prednisone + azathioprine IV immunoglobulins plasmapheresis if needed

question

facial flushing increased skin temperature in response to hot liquids, spicy foods, and alcohol, has a higher likelihood of developing what derm disorder?

answer

Rosacea Topical metronidazole systemic minocycline or doxycycline rule out staph mites (Demodex)

question

On routine PE, you notice your patient has a brown plaque with a warty surface. It appears greasy and "stuck-on."

answer

Seborrheic Keratosis cauterize, or curretage after cryosurgery

question

Patient has a skin-colored, dry lesion on his upper arm that is rough like sandpaper. "Better felt than seen" You warn him that it is "_______" and use cryosurgery to remove it.

answer

precancerous Actinic Keratosis

question

A patient presents with itching of the back and sides of her scalp. There is a current outbreak of head lice in her classroom, but you can't see any nits with the naked eye. You pull out your ____ _____ to see them, because any nits in the hair will fluoresce under special lighting.

answer

Wood's Lamp Tx: permethrin malathione

question

pruritis in the hairy pubic region. PE shows tiny, brownish-gray specks in this area. Small white specks are seen at hte hair-skin junction, indicating active infestation of what organism?

answer

Pediculosis pubis -- crabs pthirius pubis

question

Intertrigonous skin problems are _____ until proven otherwise.

answer

Scabies Burrows/tunnels in intertrigonous skin areas. Place drop of mineral oil over burrow, scrape it off, & place on slide Permethrin cream Lindane cream Ivermectin

question

What are the "danger sites" associated w/ a nodular, translucent, pearlescent lesion with telangiectasia?

answer

bcc medial and lateral canthi, nasolabial fold, behind the ears

question

Tx of Squamous Cell Carcinoma?

answer

5-fluorouracil (topical) cryosurgery excision

question

Your 16 year old nephew tells you he has been diagnosed with "Jeep Rider's Disease." What is this, what are it's common causes, and how is it treated?

answer

1) Pilonidal disease -- painful, draining abscess in natal cleft (butt crack) 2) congenital defect, excessive sweating, ingrown hair 3) surgical removal

question

Double comedones is a sign unique to which skin disorder? tender, red inflammatory nodules/abscesses that drain seropurlent material

answer

hydradenitis suppuritiva Mostly resolves on it's own Can use intralesional glucocorticoids, surgery, oral antibiotics, and isotretinoin

question

When assessing burns, one hand area is ___% of the body surface. In an adult, the head and each arm is ___%. The chest, back, and each leg are ___%.

answer

10 9 18

question

Velvety, brown skin in the axillae, neck, groin, antecubital fossa, knuckles, submammary, umbilicus, or oral mucosa regions. Skin lines are accentuated

answer

Acanthosis nigricans: Endocrine (Cushing, thyroid, acromegaly, DM) Also seen in obesity, GI cancer autoimmune problems Niacin overuse

question

dry scaling or macerated skin between the toes, esp. common between 4th and 5th toes

answer

Interdigital tinea pedis Tx: Burow's sol'n, aluminum chloride hexahydrate Treatment for all is topical "azoles" applies 2x a day

question

Tinea Corporis infections do not affect which areas of the body?

answer

Feet, hands, groin only affect trunk, legs, arms, and/or neck animal worker T. rubrum Topical "azoles" applies twice a day for 4wks, including 1 week after lesions have cleared. Apply at least 3 cm beyond margin.

question

Well-demarcated round or oval scaling patches with variable pigmentation, occurring most commonly on the trunk and upper body. On KOH prep, a "spaghetti and meatballs" appearance is seen. Diagnosis is enhanced with use of Wood's Lamp because the affected skin will flouresce blue-green

answer

Pityriasis (Tinea) Versicolor Tx: Selenium sulfide/ketoconazole shampoo Terbinafine (Lamisil)

question

Name the elicting factors for eczema.

answer

1. Inhalants (dust mites and pollens) 2. Microbial Agents (exotoxins of Staphylococcus aureus) 3. Foods (eggs, milk, peanuts, soybeans, fish, and wheat)

question

Name the "other" exacerbating factors for eczema.

answer

Skin barrier disruption, Infections (s. aureus), Season (flares in winter, improves in summer), Clothing (pruritis flares after taking off clothing), emotional stress

question

Hasimoto's thyroditis, vitiligo, myasthenia gravis are associated findings with what disorder?

answer

alopecia areata

question

Caused by HPV "genital warts"

answer

condyloma acuminatum 4 kinds of lesions: small papular, cauliflower-floret lesions, keratotic warts, flat-topped papules/plaques Tx: Imiquimod, podofilox, cryosurgery and laser removal

question

pearly white or skin-colored, round, oval, hemispherical, UMBILICATED

answer

molluscum contagiosum persists up to 6mo then spontaneous regression Tx: imiquimod cream, tretinoin (retin-A), curettage, cryosurgery

question

What degree burn is this: red, dry or very small blisters, painful?

answer

1st

question

What degree burn is this? Pink or mottles red, bullae or moist weeping surface, painful.

answer

2nd

question

What degree burn is this: Pearly white, charred, translucent or parchment like; thrombosed vessels, dry and inelastic, insensate.

answer

3rd

question

Vitiligo. What else to think of?

answer

DM Graves or hypothyroidism Addison / adrenal insuff hypoparathyroidism pernicious anemia

question

Hyperpigmentation in sun-exposed areas

answer

amiodarone PCT phenothiazines pellagra biliary sclerosis scleroderma MTX can reactivate sunburn

question

hyperpigmentation, diffuse

answer

biliary sclerosis scleroderma Addison disease hemochromatosis (grayish-bronze) busulfan PBC PCT Whipple syndrome pellagra (niacin def) B12 def folate def metastatic melanoma (slate-blue)

question

itching

answer

dry skin thyroid lymphoma, breast ca iron deficiency (even without anemia) CRF cholestasis

question

Erythema nodosum

answer

IBD Tb coccidio sarcoid strep infxn Lofgren syndrome: bilateral hilar LAD EN LE arthralgia

question

Hormones of the posterior pituitary

answer

Oxytocin ADH (vasopressin)

question

Anterior pituitary hormones

answer

GH, ACTH, LH, FSH, PRL, TSH

question

Two most common causes of pituitary macroadenomas

answer

Lactotrophs (hyperprolactinemia) Gonadotrophs Somatotrophs (acromegaly) Corticotrophs (Cushings) Thyrotrophs (hyperthyroidism)

question

HA, visual field defects, diplopia and possibly seizures.

answer

Pituitary macroadenoma *** May also have hormone imbalance: (i.e. alopecia/constipation in hypothyroid, orthostatic hypotension & low Na in adrenal insufficiency)

question

What tests should be ordered if a pituitary tumor is seen on MRI

answer

PRL IGF-1 24-hour urine free cortisol/ ACTH stim/ 1mg overnight dexamethason suppression test TSH and FT4 FSH, LH *** if these are normal and mass is definitely present, likely is NON-pituitary tumor

question

visual field defect & erectile dysfunction (male) or amenorrhea/hirsuitism (female)?

answer

Prolactinoma - elevated prolactin level suppresses GnRH Tx: Dopamine agonists- bromocriptine and cabergoline Transphenoidal surgery- when cannot tolerate drugs or drugs ineffective

question

Causes of secondary hyperprolactinemia

answer

Dopa antagonists (reglan) Antihtn (methyldopa, aten, verap) Psychotropics Hormones, H2blockers Neuro (triptan, depakote, ergot) INH / Illicit (Mj, Amphet, Opi) Sandostatin Physio (preg, exercise, sex, nipple stim) Emotional stress All drugs above Chest wall injury/mass/zoster, CRF Hepatic cirrhosis Endo: PCO, hypothy, adrenal/ov tumor Synthesis inhib of PIF (masses, infarct, infilt - anything interrupting pit stalk)

question

What suppresses/stimulates GH?

answer

Suppress- Hyperglycemia, somatostatin, chronic corticosteroid use Stimulates- hypoglycemia and estrogens

question

large hands and feet, coarse facial features, deep voice, carpal tunnel syndrome, acanthosis nigricans skin tags colon polyps hyperglycemia

answer

Acromegaly Screen- check for high age-adjusted IGF-1 Dx- check for failure of GH to suppress to less than <1ug/L after 75g oral glucose load. Also check prolactin (cosecretion in 25%) **Do NOT order random GH, as it is secreted pulsatile from pituitary Tx: Transphenoidal surgery + octreotide +/- dopamine agonists (bromocriptine or cabergoline) or GH receptor antagonists (pegvisomant)

question

elevated TRH and TSH, but low thyroxine May also have what other hormone imbalance?

answer

Thyrotroph (TRH releasing tumor) Can see with severe primary hypothyroidism ** High TRH may also suppress dopamine, causing increased prolactin. Often mistaken for prolactinoma Tx: thyroxine replacement

question

Pt. with breast CA or lung CA, presents with polyuria and polydipsia.

answer

Diabetes insipidus (posterior pit) Lymphoma and leukemia can also present as primary ca of pitutary

question

Pt. longstanding uncontrolled DM or on coumadin or hx of radiation treatment to head severe headache ("mule kick"), N/V, meningeal signs, fluctuating consciousness.

answer

Pituitary apoplexy ***neurosurgical emergency, but mild cases can be treated with corticosteroids

question

Postpartum sudden onset lethargy, hypotension, coma.

answer

Sheehan syndrome - can also affect posterior pit, causing diabetes insipidus

question

How is diabetes insipidus diagnosed

answer

Water deprivation and measuring hourly plasma ADH and urine and plasma osmolality. Neurogenic- with inc plasma osm, there is no increase in ADH Nephrogenic- with inc plasma ADH, no increase in urine osmolality

question

Polyuria. Water deprivation: with inc plasma osm, there is no increase in ADH

answer

Central DI. Tx Desmopressin (DDAVP) MRI pituitary

question

low sodium, low serum osmolality, high urine osmolality. Normovolemic on exam.

answer

SIADH Tx: fluid restriction. Hypertonic saline only if symptomatic or if was sudden onset. Can also use demecloycline (limited by nephrotox & photosensitivity), conivaptan (inpt).

question

RAIU (radioiodine uptake) is increased in which states?

answer

Graves TSH secreting tumor Hot nodule hCG secreting tumor Iodine deficiency

question

RAIU is decreased in

answer

Thyroiditis Excess exogenous T4 or T3 Iodine excess Amiodarone (whether patient is hyper or hypothyroid, due to iodine contained in amiodarone)

question

What test should be checked if elevated prolactin and amenorrhea

answer

TSH Severe primary hypothyroidism causes incr TSH/TRH (thyrotroph hypertrophy - can look like a pit mass) which suppress dopamine and thus increase PRL. If TSH normal, then workup for prolactinoma

question

How do you differentiate between secondary and tertiary hypothyroidism?

answer

By imaging the sella tursica. No stimulation test exists to differentiate

question

slowly increasing lethargy over the past several weeks to months. Presents to ED with decreased LOC hypothermia, hypotension, bradycardia.

answer

Myxedema coma Had chronically worsening sx of hypothyroidism over past weeks. ***if patient hypoglycemic, consider autoimmune adrenalitis or anterior pituitary disease ***

question

Treatment for myxedema coma

answer

BOTH T3 and T4 Hydrocortisone 50mg q6h (adrenal gland does not fxn correctly in severe hypothyroidism) Broad spectrum abx until infection excluded (can look like sepsis)

question

goiter, exophthalmos, thickening of dermis with pock marks in front of ankle. thrombocytopenia.

answer

Graves disease Sx of hyperthyroid peau d' orange pretibial myxeema May have associated immune related heme dz such as ITP or pernicious anemia

question

Treatment for Graves disease?

answer

Beta blockers for short term Antithyroid drugs- PTU, methimazole Surgery, radioactive iodine, thyroid ablation

question

hypothyroidism jaundice and dark urine. May also have recurrent URIs.

answer

Liver toxicity and/or agranulocytosis secondary to methimazole or PTU

question

tachycardia, fever, CHF acute delirium soon after surgery. What is dx/tx?

answer

Thyroid storm 3 causes: surgery, infection, iodine load (such as in amiodarone or contrast dye) Tx:-LARGE amount of glucocorticoids (adrenals function correctly, but can't handle the stress of excess thryoid hormone) -IV Propanolol or esmolol (interrupt the response to high T4) - stable iodide (block release of preformed hormone) - High dose PTU/MMI (block new hormone production) -Broad spec abx until infection excluded

question

fever, neck pain, initially elevated T4, low TSH. Eventually thyroid studies normalize. What is dx/tx?

answer

Subacute thyroiditis. Dx: RAIU will be low No treatment, except NSAIDs if needed. Steroid taper for refractory sx.

question

What should you check to diagnose Hashimotos?

answer

Anti-TPO antibodies.

question

hyperthyroidism single hot nodule on thyroid scan. What procedure should be done next?

answer

Nothing...hot nodules are NEVER malignant. ***histology may be similar to follicular CA, so do NOT biopsy hot nodules.

question

Should thyroid be screened for nodules?

answer

NO...only if palpable. Most people have thyroid nodules and most are cold.

question

Risk factors for malignant cold nodules

answer

Hx of head/neck irradiation, FH of thyroid CA, Age 70, Male, growing nodule, hard consistency, Fixed, sx of compression

question

If thyroid nodule is normal appearing, when should you do FNA?

answer

If TSH is normal. If TSH is high, may have Hashimotos, check anti-TPO and treat if needed. If TSH is low, do scintography. If hot nodule, then no FNA. If cold, then get FNA.

question

In DIFFERENTIATED thryoid CA, what is treatment?

answer

Near total thyroidectomy Thyroixine (to suppress TSH levels and reduce recurrence)

question

Examples of goitrogens (that cause goiter)

answer

Anything that blocks iodine: Cabbage, cauliflower, brussels sprouts, cassava root, low iodine diet

question

HTN, alkalosis and hypokalemia

answer

Mineralocorticoid excess. Causes retention of Na (htn) & excretion of K+/H+ (hypotension and alkalosis)

question

What are 3 different screening tests for Cushing's syndrome?

answer

24 urine free cortisol late night salivary cortisol low dose dex supp test

question

What states cause pseudo-Cushings? What test checks for it?

answer

Alcoholism, obesity, depression, acute illness. low dose dex supp test will suppress cortisol in these states, true Cushings will not (from pituitary adenoma)

question

Steps to diagnosing cortisol excess

answer

1. establish cortisol excess (24 UFC, low dose dex supp) 2. Is Cushing's syndrome ACTH dependent? (check ACTH level) 3. If dependent on ACTH (if any is measured), either is ectopic or from ACTH producing tumor. Needs imaging. 4. If ACTH independent, likely due to adrenal tumor. Consider imaging adrenals.

question

Causes of adrenal insufficiency (6)

answer

Addison's (primary adrenalitis) Sarcoid Granulomatous infections AIDS CMV Amyloidosis

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severe weakness, weight loss, abdominal pain and moodiness. Low Na, high K. Develops into hypotension and hyperpigmentation.

answer

Adrenal insufficiency ***Secondary AI is not associated with hyperkalemia (zona glomerulosa is not diseased and responds normally to angiotensin II) TREAT with IVF and Dexamethasone. Can diagnose etiology later when more stable. Dx:Cosyntropin stimulation test: Abnl stim, High ACTH, low aldo = primary AI Abnl stim, low ACTH, nl aldo= secondary AI ***image sella

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Weakness, abd pain, weight loss. Low Na, high K. Cosyntropin stim: cortisol <18 ACTH low-nl Aldosterone nl

answer

Secondary/tertiary adrenal insuff. Image sella with MRI.

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Hypothyroid Not gaining weight Inappropriately low DBP K high normal Slight metabolic acidosis

answer

Schmidt syndrome: AI + Hypothyroidism Must replace dexamethasone 1st as if you increase metabolic demand without adequate cortisol, can cause or worsen shock

question

HTN and hypokalemia. Aldosterone level high, Renin levels are low. (aldo:renin ratio elevated)

answer

Primary aldosteronism Give NS challenge or oral sodium load (attempt to suppress adrenal). if PAC still elevated, likely PRIMARY ALDOSTERONISM If no suppression, then image adrenals

question

HTN, low K. Aldo high Renin high ratio <10

answer

Renovascular disease (secondary aldosteronism) Decreased renal blood flow ->increased renin ->inc ATII ->inc aldosterone Dx: renal angiography

question

How to screen for aldosteronism

answer

Check plasma aldosterone concentration AND plasma renin activity (PRA:PAC ratio) Primary- elev PAC, decreased PRA (increased PAC:PRA ratio) Secondary- elev PAC and PRA (PAC:PRA ratio <10) Cushings/Black licorice ingestion- PAC and PRA both decreased (nl or elevated PAC:PRA ratio)

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headache, orthostasis Refractory HTN in young pt no FH of htn dilated cardiomyopathy FH of MENII, neurofib, vHL

answer

Pheochromocytoma 7 H's: HTN, HA, hypermetabolism hyperhidrosis hyperglycemia hypokalemia hypotension (during anesthesia induction) Dx: 24 hr urine for fractionated metanephrines random free plasma metanephrines (wean off TCAs x 2wks) If positive, then CT or MRI of adrenals with contrast Tx: Surgery phenoxybenzamine (alpha blocker) & propanolol for tachycardia prior to surgery

question

Screening test for adrenal incidentaloma?

answer

BP, aldo:renin ratio Urine free cortisol or low dose dex test Plasma free metanephrines Estrogen/androgen if virilization or feminization If results nl & mass6cm, functioning, or growth.

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Female short stature wide spaced nipples no breast development webbed neck.

answer

Turner's syndrome (XO karyotype) LH, FSH constantly high can see htn, aortic stenosis

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Female no palpable cervix or uterus

answer

Androgen insensitivity syndrome (XY karyotype) or genetic absence of uterus

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Tests to check for in amenorrhea with low FSH/LH

answer

Low FSH/LH (secondary - pit not making hormones)- TSH, Prolactin, med hx (dopaminergic agents) exercise MRI of sella if no dx

question

amenorrhea, male pattern baldness, obesity and DM. What would you see on blood work?

answer

Likely has PCOS LH:FSH ratio > 2 (excess androgen production suppresses FSH, but increases LH) Nl or sl inc testos & DHEA Tx: weight loss If not hairy and no pregn desired: medroxyprogesterone q1-3mo Hairy and no pregn: est-progest OCPs insulin sensitizer (metf, thiazolid) Hairy and desires preg: clomiphene +/- metformin

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Polyuria. Water deprivation test: with inc plasma ADH, no increase in urine osmolality

answer

Nephrogenic DI. Kidney U/S. Tx: low sodium diet, thiazide amiloride if lithium

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DM, mild CRF High K metabolic acidosis (out of proportion to CRF)

answer

hypoaldosteronism Dx: 1. ACTH stim to r/o AI 2. Aldo, renin levels during upright posturing and salt restriction (will be low) Tx: fludrocortisone +/- lasix Review drug hx (ACEI, NSAIDs, heparin)

question

Amenorrhea high FSH and LH

answer

High FSH/LH (primary - lost ov feedback)- pregnancy, signs of premature ovarian failure, menopause, genetic abnormalities (Turner, galactosemia, autoimm polyglandular syndrome)

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Long arms/legs sparse hair growth low muscle mass gynecomastia Small testes fertility problems

answer

Klinefelter syndrome 47XXY Dx: karyotype. Testos low, FSH/LH up Tx: testosterone

question

Hypogonadism low testosterone low or inappropriately nl FSH & LH

answer

Secondary hypogonadism - hyperprolactin - anabolic steroids - cushings - congen deficiency + anosmia: Kallmann syndrome (also cleft palate, horseshoe kidney)

question

Gemfibrozil, fenofibrate

answer

fibric acid derivatives Decrease TG, raise HDL might increase LDL If with statin or zetia - use fenofibrate, not gem fib Side effects: abd pain, GB dz

question

Which drugs increase myopathy risk when given with statins?

answer

gemfibrozil cyclosporine erythromycin ketoconazole ezetimibe

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Niacin - contraindications

answer

gout, DM lowers TG, LDL, most effective drug for raising HDL (up to 30%)

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Meglitinides: Prandin (repaglinide) Starlix (nateglinide)

answer

Increases insulin secretion Major effect is on postprandial glucose Can be used in chronic kidney disease Prandin equivalent A1c lowering to metformin, but CV events lowered in metformin too.

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Metformin

answer

reduces hepatic glucose production Side effects: lactic acidosis abdominal pain, diarrhea Hold if: Cr >1.5 men, 1.4 women decomp CHF acutely ill pre-op, contrast

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alpha-glucosidase inhibitors: acarbose (Precose) miglitol (Glyset)

answer

delay carb absorption in gut biggest effect is on postprandial glu can use with sulfonylureas Side fx: flatulence, bloating, diarrhea

question

amylin analogs: pramlintide (Symlin)

answer

Treats fasting hyperglycemia. Amylin is a hormone secreted by beta cells with insulin that suppresses glucagon & slows stomach emptying. Cut insulin by 50% when initiating. Contraind: gastroparesis, insens to hypogly

question

glucagon-like peptide-1 agonists: exenatide (Byetta) liraglutide (Victoza)

answer

GLP-1 is an incretin hormone secreted by gut - stimulates insulin release - inhibits postprandial glucagon release - slows nutrient absorption - accelerates satiety. Side fx: V, D associated with pancreatitis

question

DiPeptidyl-Peptidase 4 inhibitors: sitagliptin (Januvia) saxagliptin (Onglyza)

answer

DPP4Is slow the inactivation of natural incretins, thereby increasing their concentration. Biggest effect is on postprandial glucose.

question

bone pain, kidney stones moth-eaten phalangeal cortex on xray elevated calcium phosphorus low

answer

primary hyperparathyroidism subperiosteal bone resorption ("osteitis fibrosa cystica") iPTH elevated 25% high-nl Tx: yearly Ca, Cr DEXA q1-2yrs check 25-OH2-D Do not restrict dietary Ca bisphosphonates build bone Cinacalcet being investigated Surgery if: - GFR<60 - osteoporosis - age 1mg/dl above nl Preop: sestamibi scans and ultrasound

question

Hypercalcemia What meds to check for?

answer

Vitamin A or D excess thiazides Lithium

question

Low calcium. Causes?

answer

- decreased PTH (thyroid surgery; very low Mg [required by parathy cells to secrete]) - vit D deficiency - severe, acute pancreatitis - acute hyperphos - increased PTH resistance - genetic short stature, absent 4th/5th knuckles

question

bone pain proximal muscle weakness "bilateral symmetric pseudofractures" low phos, increased alk phos, increased iPTH

answer

osteomalacia vitamin D deficiency - check 25-OH2-D levels, not 1,25-.

question

When would you check 1,25-OH2-D?

answer

- unexplained hypercalcemia (looking for granulomatous disease or lymphoma), - suspected genetic childhood rickets, - suspected tumor-induced osteomalacia, - some cases of nephrolithiasis or hypercalciuria.

question

hypercalcemia muscle, bone pain hepatic dysfxn dry skin ataxia alopecia hyperlipidemia nausea, HA, fatigue, irritability low PTH

answer

vitamin A excess (>10x daily allowance)

question

How does high iodine intake affect the RAIU test?

answer

this excess "cold" iodine competes with the radioactive iodine - greater amts of the cold iodine will be taken up. Thus, a lower uptake than expected will be seen. Check 24hr urine for iodine.

question

Irregular menses brisk DTRs weight loss RAIU slightly high diffuse uptake small thyroid nodule

answer

Graves with cold nodule -> surgical resection. (I131 won't be taken up by a cold nodule)

question

secondary causes of hyperlipidemia

answer

hypothyroid obstructive liver dz (PBC) nephrotic syndrome DM smoking, EtOH retin-A estrogens steroids protease inhibitors

question

Causes of iron deficiency anemia (3)

answer

Malabsorption Blood loss PREGNANCY Always identify cause of iron deficiency

question

low iron high TIBC low % sat low ferritin (acute phase reactant)

answer

Iron deficiency anemia

question

What test differenctiates iron deficiency anemia from anemia of chronic disease?

answer

Soluble transferrin receptor: HIGH in iron def (more transferrin made due to lack of iron) LOW in chronic disease

question

Gold standard test for iron deficiency

answer

bone marrow bx for iron stores

question

iron low TIBC low Ferritin high %sat low/normal soluble transferrin receptor normal Bone marrow assay- increased iron stores

answer

Anemia of inflammation. Tx: Transfusion support Treat underlying process Epo

question

Anemia, paresthesias. MCV is high. Hypothyroidism

answer

B12 deficiency (pernicious anemia) Has autoimmune process (hypothyroidism- likely autoimmune)

question

Reasons for folate deficiency

answer

Dietary deficiency Malabsorption- Crohns Pregnancy Chronic hemolytic states

question

Reasons for B12 deficiency

answer

Autoimmune Poor diet Small bowel malabsorption

question

B12 vs Folate deficiency

answer

MMA level elevated in B12 deficiency. Homocysteine levels high in BOTH B12/Folate deficiency. Folate deficiency NOT associated with neuro sx.

question

What are causes of aplastic anemia?

answer

Drugs- benzene, radiation, gold, sulfa, chloromphenicol PNH Viral infection

question

Recurrent infections recurrent anemia. thrombocytopenic. Peripheral smear is normal appearing. What is next step and what are you most likely to see?

answer

Bone marrow bx - hypo cellular, normal maturation of cell lines Likely aplastic anemia. Severe if : ANC <500, plt<20K, corr ret ct <1% Very severe if ANC<200.

question

Treatment for aplastic anemia?

answer

Immunosuppression- cyclosporine/ATG/ALG/steroids Bone marrow transplant- if <40 with donor (best outcomes)

question

Abdominal thrombosis of some sort. Hemolytic type picture (elev bili, inc LDH). WBC and plts normal. What is next test? What is likely dx?

answer

Paroxysmal Nocturnal Hemoglobinuria Test: flow cytometry- shows decrease in DAF (CD55) and HRF (CD59) May transform into aplastic anemia, acute leukemia, myelofibrosis

question

Treatment options for PNH

answer

RBC transfusions for hemolytic episodes Steroids Eculizumab (blocks C5- blocking hemolysis) Anticoagulation

question

How is someone with sickle cell trait (AS) treated?

answer

No treatment (no clinical significance)

question

Pancytopenia, bleeding and severe anemia. Hgb SS disease What is most likely cause of this?

answer

Parvovirus B19- aplastic crisis *can also microinfact (stroke), functional asplenia, priapism, retinal detachment

question

Chest pain, SOB. SaO2 82% bilateral infiltrates hemolysis Hgb SS disease

answer

Acute chest syndrome Tx: Red cell exchange

question

Microcytic anemia. Iron studies normal. Electrophoresis is normal.

answer

a-thalessemia

question

Microcytic anemia. Retic count is elevated. Iron levels normal. Electrophoresis shows decreased B chain

answer

b-thalessemia. Minor: no therapy Major: early & lifelong transfusion. Iron chelation if ferritin >1000 Severe: Allogeneic stem cell transplant

question

Macrocytosis Spherocytes elevated retic count Bili is elevated. Haptoglobin is low. high LDH

answer

Likley autoimmune hemolytic anemia Common in CLL, lymphoma, SLE, mono **dx with coombs test

question

How is direct Coombs test done?

answer

Remember- direct means antibody directly on patients blood cell. Add patients blood to antigen in test serum- if antibody present, will agglutinate

question

How is indirect Coombs test done?

answer

Antibody is NOT on patients blood, rather in patient's serum. Add patient's serum to known RBC with antigen on them, if agglutinates, then antibody present in patients serum.

question

Warm antibodies are usually what type? Cold autoautoantibodies are what type?

answer

Warm-IgG Cold- IgM

question

How is warm agglutinin PNH treated?

answer

immunosuppression splenectomy

question

How is cold agglutinin PNH treated?

answer

Keep patient warm Treat underlying lymphoproliferative disorder. Steroids NOT effective.

question

70yo pancytopenic Ret count 0.4%. Basophilic stippling and dimorphic population. What is next step? What is likely dx?

answer

Bone marrow bx (HYPERcellular, ringed sideroblasts, dysplastic cells) Myelodysplasia Usually in elderly (may only have one or two dysplasias)

question

Bad prognosis in MDS?

answer

Cytogenetics (chromosome 7) High % of blasts Number of cytopenias Increased age Favorable: deletion of chromosome 20q or 5q

question

Macrocytic red cells nucleated RBCs teardrop cells Pseudo-Pelger-Huet abnormality (sunglasses appearance) Dimorphic RBC polulation Large agranular platelets decreased retics

answer

MDS

question

Two hematologic disorders that cause anemia and thrombocytosis

answer

Iron deficiency 5q- syndrome (MDS, usually in women)

question

Treatment options for MDS

answer

B6,B12, folate supplementation Supportive care Neupogen/Epo Chemo (new drugs) Bone marrow transplant (if younger pt)

question

What differentiates chronic from acute myeloid leukemia?

answer

Acute- has blasts thrombocytopenia, rather than thrombocytosis

question

Fatigue, weight loss, early satiety. Hepatosplenomegaly. 30K WBCs with left shift. Myelocytes and promyelocytes. What else may be seen on CBC?

answer

Chronic myelocytic leukemia May also see basophilia and eosinophilia, low LAP score. **Philadelphia chromosome (t9,22)

question

How should CML be managed? Expected side effects?

answer

Hydration, hydroxyurea, alpha-INF, ara-C. Tyrosine Kinase inhibitors (Dasatinib, Imatinib [Gleevec], Nilotinib)- suppress t9,22 Gleevec side effects: edema, CHF, hepatotoxicity, cytopenias, hemorrhage. Bone Marrow Transplant- treatment of choice if young and matched donor, the earlier the better

question

Itching when taking a hot shower or bath. Early satiety Splenomegaly on exam. Gout from rapid cell turnover. What might a CBC show?

answer

Polycythemia Vera Will have isolated erythrocytosis "aquagenic pruritis"

question

What are diagnostic criteria for polycythemia vera?

answer

JAK-2 abnormality (tyrosine kinase) erythrocytosis normal PO2 low epo levels (suppressed) splenomegaly - no secondary cause of erythrocytosis (lung disease, renal disease, other malignancy, Gaisbock syndrome- male type A smoker, with decreased plasma volume)

question

Treatment for PV?

answer

Phlebotomy (if isolated red cell increase) Low dose ASA Drugs- hydroxyurea - may accelerate transformation to leukemia

question

Tx for essential thrombocytosis if asymptomatic?

answer

Observation- if <60 & asymptomatic & plt<1.5million. If older with risk or hx of CVA or CAD: plasmapheresis, hydroxyurea, anagrelide, interferon-a **low chance of acute leukemia transformation

question

What must be ruled out when making diagnosis of essential thrombocytosis?

answer

Iron deficiency anemia Malignancy Collagen vascular disease Infection Post-splenectomy Other myeloproliferative disorders JAK-2 mutation found in about half and can help distinguish essential from secondary thrombocytehemia.

question

Does secondary thrombocytosis increase risk for bleeding or clotting?

answer

NO

question

Massive splenomegaly Leukopenia or anemia. Teardrop shaped RBC on peripheral smear.

answer

Myelofibrosis - MASSIVE splenomegaly Progressive marrow failure. Worst myeloproliferative d/o. Splenectomy CONTRAINDICATED - assoc w/ hemorrhagic, thrombotic complications, increased risk of progression to leukemia, & no impact on survival

question

Reasons for thrombocytopenia with decreased production?

answer

Primary marrow failure- aplastic anemia Marrow replacement (ie. leukemia) Viral suppression- HIV, Hep C Drug suppression- chemo

question

Reasons of increased plt destruction?

answer

ITP TTP/HUS DIC HIT

question

What is the 30-30-30-10 rule regarding ITP?

answer

30% idiopathic 30% drugs 30% diseases- lymphoma, CLL, SLE 10% viruses - HIV, hep C

question

What is treatment for ITP and when should it been initiated?

answer

Tx if <30K Steroids- 1st line if immune mediated IVIG- works fast, use if bleeding Splenectomy- 2nd line tx of choice

question

Microangiopathic hemolytic anemia Thrombocytopenia Fever Neuro sx Renal dysfxn

answer

Diagnostic pentad for TTP. Suspect if >1 present, esp decreased plt + anemia peak 3rd decade

question

What things can cause TTP?

answer

Pregnancy Metastatic CA BMT SLE Drugs- Mitomycin C, Plavix, Cyclosporine, ticlid

question

Confusion and fever. Head CT is negative. Cr of 2.2, Plt 30 and Hgb 9. PT, PTT normal. schistocytes. What is dx? What else should you see on smear?

answer

TTP Smear: shift cells, nRBCs & normal WBC

question

If TTP suspected, what tests should you order?

answer

Indirect bili LDH Peripheral smear (don't order ADAMTS13 (vWF-cleaving protease) - not sens/sp)

question

Treatment for TTP?

answer

Plasma exchange- ideal Steroids If can't exchange - FFP NO Plt transfusions unless life threatening bleed follow LDH levels as marker of hemolysis & plt destruction

question

What two things cause microangiopathic hemolytic anemia?

answer

TTP DIC

question

How do you distinguish DIC from TTP?

answer

DIC will have abnormal coagulation PT, PTT prolonged Decreased fibrinogen Lower protamine levels

question

Treatment for DIC?

answer

Fix underlying cause Replete deficient products- plt, cryo, FFP, PRBC *Heparin tx rarely needed

question

When is the usual onset of HIT after exposure?

answer

5-8 days 1-2 days if prior exposure to heparin

question

When should you stop heparin tx when thrombocytopenia encountered?

answer

If 50% drop OR if <100,000

question

Treatment for HIT?

answer

STOP heparin/LMWH Start direct thrombin inhibitor- lepirudin (not if renal dz) or argatroban (not if hepatic dz) Do not start coumadin until plts normal and has been anticoagulated with something else

question

24yo with heavy menses and epistaxis. Normal PT, PTT, CBC.

answer

von Willebrands disease next step is PFA100/bleeding time

question

What is diagnostic test for vWD?

answer

ristocetin cofactor assay (rCoF) - decreased activity

question

Treatment for vWD?

answer

DDAVP- stimulates release of vWF from endothelium, problem with tachyphilaxis Can worsen type 2B Factor VIII concentrates will have some vWF in them Cryo only if emergency or prior to surgery - infxn risk

question

Mild thrombocytopenia. Increased bleeding time abnormal ristocetin aggregation. Giant platelets.

answer

Bernard-Soulier syndrome Looks like vWD except for giant platelets

question

Bleeding gums and epistaxis. Not thrombocytopenic. ADP and EPI aggregation is abnormal.

answer

Glanzmann Thrombasthenia- G IIb-IIIa defect. Has normal plts but cannot crosslink them.

question

Joint or soft tissue bleeding prolonged PT/PTT. What is next diagnostic test?

answer

1:1 mix of patient and normal plasma- see if test normalizes. If it does, there is factor deficiency. If not, then there is inhibitor (may need 2 hour incubation to reveal this)

question

When patient is suspicious for hemophilia A (factor VIII), what other disease must be considered?

answer

vWD (type 2 or 3) Factor VIII circulates with vWF, so low vWF may result in low FVIII, which produces hemophilia-like sx - pt. would be thrombocytopenic as well

question

Pt. with Hemophilia A has been treated with FVIII replacement chronically. Eventually develops increased bleeding again despite tx. 1:1 mixing study does not normalize. What is likely cause? What is treatment?

answer

Has developed FVIII inhibitor. Happens in 10-20% of pts receiving FVIII Trreat with activated IX product, procine VIII, FVIIa or immunosuppression

question

Chronic amyloidosis. Soft tissues bleeding. PT/PTT both prolonged. 1:1 mixing study normalizes test.

answer

Acquired factor X deficiency Occurs with amyloidosis Tx with FFP

question

Very prolonged PTT, but no bleeding issues. Has normal hemostasis by lab work.

answer

Factor XII deficiency (Hageman factor) No abnormal bleeding, only prolonged PTT

question

Reasons for Vit K deficiency? What factors are affected?

answer

Liver dz, poor absorption, TPN, warfarin, abx use Affects II,VII,IX, X

question

Recurrent unprovoked DVT as a child. Treatment with usual doses of heparin did not relieve latest DVT. What is likely source of hypercoaguability?

answer

Antithrombin III deficiency Presents with early age clotting May be heparin resistant Needs lifelong coumadin

question

Pt. who has unprovoked clotting. She also has a hx of recurrent fetal loss. PTT is abnormally long. PT is normal. What is likely dx?

answer

Antiphospholipid antibody syndrome

question

Microangiopathic hemolytic anemia Thrombocytopenia Fever Neuro sx Renal dysfxn

answer

TTP

question

What specific characteristics are seen on peripheral smear in ALL?

answer

Stains with PAS Less nucleoli

question

Pneumonia, not responsive to abx. Intermittent bruising and epistaxis. WBC 30,000, thrombocytopenia and anemia. What is next test? What is likely dx?

answer

Likely AML or ALL Bone marrow bx Stain (PAS, myeloperoxidase, Sudan black) Flow cytometry Marrow cytogenetics (best for prognosis)

question

Which sub-type of AML is important to distinguish? Why?

answer

M3 (promyelocytic, aPML) Has t(15,17) affecting retinoic receptor gene Good prognosis Will have prominent Auer rods ***commonly present with DIC - only one you treat with All Trans Retinoic Acid

question

What is characteristic of M5 AML?

answer

Monocytic origin Gum hyperplasia Skin/soft tissue infiltration

question

Treatment for AML

answer

Leukophoresis if blast count >100,00 Supportive transfusions Chemo- 7d ara-C + 3d daunorub. BMT **if M3, use all trans retinoic acid

question

Child with large anterior mediastinal mass. WBC 30,000. Has blasts.

answer

ALL (likely T-cell) 30% have CNS disease (need to do LP)

question

Where is Philadelphia chromosome convey a good prognosis? A bad one?

answer

Good- CML Bad- ALL

question

How is CLL diagnosed?

answer

High lymphocyte count, smudge cells. Flow cytometry Typically B cell disorder Will be positive for CD 19,20,23 Aberrant CD 5 marking (distinguishes it from normal B cells)

question

What are the stages/survivals of CLL?

answer

0- Lymphocytosis- >10 years 1- Lymphadenopathy- 9 years 2- Splenomegaly- 6-7 years 3- Anemia- 2-3 years 4- Thrombocytopenia- 2-3 years

question

Indications for treatment for CLL?

answer

Symptomatic Rapid double time (1 year) of WBC Anemia Thrombocytopenia

question

Pt's with CLL have which types of cancer associated with it?

answer

Lung CA Head and Neck CA **work these up if suspicious, do not assume it is just CLL

question

Older male Pancytopenia Massive splenomegaly. Hairy projections on the lymphocyte surface Bone marrow is inaspirable. What should you suspect?

answer

Hairy cell leukemia Tx: 2-CDA (cladribine, purine analog)

question

What will you see on workup of hairy cell leukemia?

answer

- Hypercellular marrow - TRAP (tartrate resistent, acid phosphatase+) stain positive - differentiate from myelofibrosis by presence of hair cells on peripheral smear - immune phenotyping - Will be CD 19,20 positive *B cell origin" - CD 5 negative, unlike CLL

question

Painless lymphadenopathy Fever Night sweats Wt. loss Pruritis

answer

lymphoma

question

Staging criteria for lymphoma

answer

1- 1 node or group 2- 2 or more node groups on same side of diapraghm 3- spans diaphragm 4- disseminated dz A- asymptomatic B- has "B" sx X- bulky disease, >10cm or 1/3 diameter of chest E- extranodal disease

question

Fever, pruritis and wt. loss. Pain in lymph node with alcohol ingestion. Reed-Sternberg cells on bx of affected lymph node

answer

Hodgkin's lymphoma

question

Long term complications of Hodgkin disease treatment?

answer

Hypothyroidism- from radiation Infertility Secondary malignancy- MDS/AML, solid tumors (breast and lung) **need early screening

question

What are characteristics of low grade non-Hodgkin lymphoma?

answer

Indolent course Fewer B sx Older pts Higher stage at presentation Sensitive to chemo, but not curable Survival 7-10 years

question

What are characteristics of high grade non-Hodgkin lymphoma?

answer

Younger pts Includes large B cell and Burkitt's Treat is with curative intent Median survival 1-2 years if not responsive to tx

question

Treatment for NHL.

answer

Low grade- watch and wait until symptomatic, treat sx when they arise, then watch High Grade- treat at time of dx, intend to cure disease, CHOP + rituximab, +/- radiation

question

Older pt. presents with back pain. Recurrent infection. Low anion gap on BMP. WBC 3.3, Hgb 12 rouleaux on smear mildly elevated AST/ALT, alb 2. high calcium Increased Cr with RTA What should next test be? Likely dx?

answer

Multiple myeloma Check SPEP/UPEP Tx when lytic lesions appear or M component >5. Remission: Thalidomide, dexamethasone Lenalidomide, bortezomib To prolong remission: transplant Older pts: cytoxan/melphalan with prednisone Plasmacytomas - local rad

question

How do you distinguish between MGUS and MM?

answer

MGUS: <10% marrow involvement, <3gm M spike, no end organ damage (renal failure, bone involvement)

question

How to find etiology of B12 deficiency?

answer

Remember that MMA and HC should be elevated. Anti-parietal cell antibodies or anti-IF antibodies. Schilling test no longer widely available.

question

Dapsone, sulfa, antimalarials, fava beans, DKA causing hemolysis? Heinz bodies / "bite cells" Coombs negative.

answer

G6PD deficiency. X-linked. Can see a false-negative - measure 2-3months after hemolytic event.

question

Bili stones, splenomegaly Spherocytes or elliptocytes Negative coombs Autosomal dominant, Northern European

answer

Hereditary spherocytosis or elliptocytosis Splenectomy sometimes required to increase RBC survival. Dx: Osmotic fragility test or molecular membrane studies

question

Cirrhosis Bronzed skin pigmentation Diabetes Also: fatigue, myalgias, arthralgias, abdominal pain

answer

hemochromatosis Transferrin sat >45% women, >50% men

question

Drugs that induce ITP?

answer

Quinidine Rifampin Sulfonamide Digoxin Acetaminophen

question

Which thrombocytopenias are thrombotic - i.e. not ever treated with plt transfusions?

answer

TTP HIT

question

How to treat uremic bleeding?

answer

Platelet transfusions conjugated estrogens DDAVP (pre-surgery)

question

Late postop bleeding and poor wound healing PT, PTT, plt function normal autosomal recessive

answer

Factor XIII deficiency. Clot lysis assay: if clot lyses with urea, then is deficient. Tx: FFP q3-4wks.

question

F, effusions (pleural, pericardial) respiratory distress hypotension aPML (M3) getting chemo.

answer

ATRA syndrome Tx: high dose dexamethasone, withhold ATRA

question

Which AML patients should be considered for transplant?

answer

<60 All relapsed Pts who fail to get remission after 1st induction chemo Poor risk cytogenetics inv(3), -5/del(5q), -7, or complex

question

ALL: unfavorable prognosticators

answer

Age >30 WBC>30K Mature B or early T cell types Persistent minimal residual disease Philadelphia chromosome t(9;22) translocation

question

Anemia, thrombocytosis Female with MDS

answer

5q- syndrome Favorable. Prolonged survival with decreased risk of transformation to AML. Tx: Lenalidomide

question

HA, visual disturbances Erythromelalgia Miscarriages bleeding High plt

answer

Essential thrombocythemia (sx from microvessel thrombi) Tx if sig sx and high risk for thrombosis (>60 or hx) High risk: hydroxyurea to plt <400K Everyone else: ASA Preop: platelet pheresis if urgent Can progress to myelofibrosis and acute leukemia

question

CLL/SLL with fever rapid enlargement of previously stable nodal dz rising LDH

answer

Richter transformation to diffuse large cell lymphoma. 10% of CLL.

question

HA, dizzy, vision disturbance LAD, splenomegaly

answer

Waldenstrom Macroglobulinemia monoclonal IgM Hyperviscosity syndrome - tx with plasmapheresis

question

Causes of dry bone marrow aspirate

answer

CML Hairy cell leukemia (indolent NHL) metastatic cancer myelofibrosis

question

elevated PT, normal PTT

answer

Factor VII deficiency

question

normal PT, elevated PTT (corrects with plasma)

answer

Factor VIII, IX, XI, or XII deficiency

question

Where does osteosarcoma usually metastasize to?

answer

Lung - Rarely to brain

question

How does osteosarcoma usually present?

answer

Painful bone mass in younger patient.

question

Fatigue, constipation, anorexia nausea, polyuria, altered MS Cancer

answer

Hypercalcemia: Squamous cell CA of lung, or head/neck MM Breast CA T-cell lymphoma Renal cell

question

What is America Cancer Society recommendations for prostate CA screening?

answer

PSA and DRE annually in men age 50 with life expectancy > 10 years. Age 40 if hx of prostate CA or African American. ** USPTF- no sufficiency evidence to screen, but definitely STOP screening at age 75

question

What is ACOG recommendations for screening for cervical CA?

answer

q2y age 21-29 in all women q3y in women age > 30 with no hx of CIN 2 or 3, HIV negative, no immunocompromise and no in utero DES eposure

question

ASCUS is identified on PAP smear, what is next step?

answer

- check DNA for high risk HPV, colposcopy/bx if identified, or - colposcopy right away, or - treat underlying infection and repeat PAP in 3 months

question

Chronic smoker presents with back pain. WBC 6000, Hgb 8, Ca 12. Bone scan is negative. What is likely dx?

answer

Multiple myeloma - remember, bone scan is NEG in MM

question

Bone pain Hyperviscosity Recurrent bacterial infections Rouleaux on smear Hypercalcemia Inc cr Normocytic/normochromic anemia Elev T protein with decreased alb ***DECREASED anion gap***

answer

Multiple myeloma

question

Hx of numerous basal cell CA palmar and planar pits mandibular cysts. Father has same syndrome since childhood.

answer

Nevoid basal cell carcinoma synrome Removal of basal cell CA, good prognosis

question

When can malignant melanoma be excised with 1cm border with no further tx?

answer

If penetration is <0.75 mm deep

question

Risk factors for testicular germ cell tumors?

answer

Cryptorchidism personal or fam hx of testicular CA infertility HIV (risk 21x normal!)

question

Which type of testicular germ cell tumor does NOT produce AFP?

answer

seminoma

question

What cancers and disease states elevate AFP?

answer

Hepatocellular CA Non-seminoma Chronic liver dz GI tract tumor

question

Staging for testicular CA?

answer

1- limited to testicle 2- involves RP nodes 3- metastatic dz (usually to lung or brain)

question

Treatment for testicular seminoma?

answer

orchiectomy - if RP nodes, then radiation - if distant mets, then chemo

question

Screening recommendations for breast CA (combined recs)?

answer

Yearly mammography age 50-74. Self screening or CBE at age 40.

question

You have suspicion for HNPCC, when should screening C-scope start for offspring? Why not use flex sig?

answer

Age 25 No flex sig due to likelihood of right sided colon CA

question

When should anti-hormonal therapy be offered to patient's with prostate CA?

answer

- Metastatic disease- with sx, or rising PSA - Pt's with PSA only recurrence and short doubling time (<6-10 months) - Adjuvant tx for RT for 4-12 months

question

Most significant side effect for androgen deprivation in prostate CA

answer

Cardiac mortality - also causes wt. gain, osteoporosis, gynecomastia, loss of muscle mass, anema, sex dysfunction, hot flashes, inc risk DMII

question

Most common side effect of 5-FU

answer

GI side effects and mucositis

question

Most common side effect of Cisplatin?

answer

Renal tox. Also the most emetogenic.

question

Most common side effect of Vinblastine?

answer

Myelotoxicity

question

Most common side effect of Vincristine?

answer

Neurotoxicity

question

Ovarian cancer in the older population is usually of what origin?

answer

Epithelial cell (Germ cell in younger pop usually)

question

Acanthosis nigricans is associated with cancer in what organ?

answer

Stomach

question

In men >50yo, testicular masses are usually of what origin?

answer

Lymphoma (usually seminoma in men <50)

question

What causes increase risk for squamous cell CA in the esophagus?

answer

Achalasia, alcoholism, tylosis, smoking (recall, Barrett's increases risk for ADENOcarcinoma)

question

basophilic stippling anemia

answer

check lead level

question

Prostate cancer prevention?

answer

Finasteride x 7yrs decreases risk by 25%. No change in mortality. But higher percentage of high-grade ca.

question

Flushing (ppt by etoh or stress) Valvular heart dz (right) Diarrhea. Also can have bronchospasm venous telangiectasia

answer

Carcinoid syndrome. Check urine 5-HIAA and serum chromogranin A. Localize: abd CT & s omatostatin receptor scintigraphy Tx: 80% cure if <1cm resected. Mets - still fairly benign. Symptomatic - anti-diarrhea, avoid offending foods & EtOH, octreotide.

question

Fatigue pallor easy bleeding / thrombocytopenia Elevated WBC - >20% blasts NO LAD or HSM

answer

AML Tx: (non M3) Hydration Allopurinol or rasburicase cytrabine + anthracycline SCT for first relapse or second complete remission If leukostasis syndrome (CNS, hypoxia, diffuse infiltrates) then leukapheresis

question

BRAF gene mutation and thyroid cancer

answer

specific for papillary type (75% of thyroid ca) & more aggressive forms

question

Which thyroid cancer has elev calcitonin / calcium & is hereditary?

answer

Medullary (5%). Screen family members for dz. Tx: thyroidectomy, neck dissection. Not Radioiodine.

question

When should you do an EGD for dyspepsia?

answer

If alarm sx (wt. loss, dysphagia) Failure of treatment

question

Risk factors for squamous cell esophgeal CA

answer

Smoking, EtOH, Lye stricture, head/neck malignancy

question

Risk fx for esophageal AdenoCA

answer

Reflux/Barretts, white male

question

Treatment of H. pylori causes regression of which cancer?

answer

MALT lymphoma of the stomach

question

When should you check for H.pylor?

answer

Any hx of PUD EGD sows gastritis or gastric/duodenal ulcer MALT lymphoma family hx of gastric CA Dyspeptic sx

question

When can you "test and treat" dyspeptic sx?

answer

If <50 yo and NO alarm sx

question

How should you check for H. pylori eradication?

answer

Urease breath test or stool antigen test? **always confirm eradication

question

Most common causes of PUD?

answer

H.pylori NSAIDS Zollinger-Ellison syndrome

question

Highest risk of NSAID use for causing PUD?

answer

High doses First 3 months of treatment Advanced age Hx of PUD Concaminant steroids Serious medical illness

question

Which has more risk, non-selective steroid use or Cox-2+ASA?

answer

They are the same!

question

If pt. with PUD presents with severe abd pain, what should you do before an EGI or UGI?

answer

Acute abd series to rule out perforated ulcer

question

Indications for endoscopy

answer

Dysphagia/odynophagia Suspected ulcer Follow up for healing of gastric ulcer UGI bleeding Foregin body Abnormal UGI series or CT Anemia (start with C-scope)

question

First line regimen for H. pylori?

answer

BID PPI + metronidazole + bismuth + tetracycline

question

When is NG lavage negative for UGI bleeding?

answer

When bile is aspirated and no blood

question

How long should IV PPI be used in patient with endoscopic therapy?

answer

72 hours

question

hx of AAA repair. Melena that progresses to severe UGI hemorrhage and shock.

answer

Aorto-enteric fistula

question

melena. dark pigmentation around the mouth.

answer

Peutz-Jeghers (hamartomas of GI tract that can bleed) - AD - polyposis of the colon and small bowel - predominantly hamartomas - perioral pigmentation - Extracolonic tumors of the breast, pancreas, ovaries, and lung

question

GI bleeding. Has hx of nose bleeds Red lesions on fingers and oral mucosa. familial

answer

Osler-Weber-Rendu (hereditary emorrhagic telangiectasia) Has strong familal component

question

heartburn and diarrhea. Not relieved by PPI. EGD shows multiple duodenal ulcers.

answer

Fasting gastrin level after stopping PPI Check for ZE syndrome Think of this if chronic PUD AND chronic diarrhea Also if MULTIPLE recurrent duodenal ulcers Dx:Somatostatin-receptor scintigraphy and endoscopic US Surgical exploration

question

Most common cause of increased gastrin levels

answer

achlorhydria (atrophic gastritis, chronic PPI use, chronic gastritis)- this is why PPI must be stopped before checking gastric otherwise will be elevated

question

N/V/abd pain early satiety scleroderma or DM

answer

Gastroparesis Order gastric emptying study Order EGD to rule out obstruction as well Tx: **improve glycemic control low fiber diet (liquid if severe) Reglan Erythromycin is NOT indicated but can help

question

3 extra-intestinal manifestations that have NO effect on IBD severity?

answer

Primary sclerosing cholangitis Axial Arthropathy Uveitis

question

Abd pain, diarrhea in 27yo. No bleeding. heavy smoker. Has mother with same sx. Colonoscopy shows patchy ulcerations colon, but nothing in rectum.

answer

Crohn's disease - rectal sparing - skip lesions (intermittent normal colon) - String sign= ileal disease on UGI study - Can have diease anywhere in GI tract (mouth, anus, stomach and duodnum included) - small bowel involved >50% - ASCA

question

If a colonic lesion bx shows granulomas, what is diagnosis?

answer

Crohns, but bx may not always have granulomas

question

Is surgical resection for Crohn's curative?

answer

NO- pt's can have resurgence

question

What are some complications of Crohns resection?

answer

**Cacluim oxalate kidney stones **B12 deficiency Vit D Deficiency/Hypocalcemia (malabsorption) Steatorrhea due to depleted bile acids Osteoporosis

question

Treatment for mild to moderate Crohns

answer

Mesalamine, sulfasalazine or budesonide

question

Treatment for Crohn's flare?

answer

Prednsione with taper

question

When should immunocompromising drugs (Azathathioprine, 6MP or MTX) be used in Crohns?

answer

save immunocompromising drugs for refractory diseaase (steroid sparing) **NOT good for induction due to length of time to achieve effect

question

Pt. with Crohn's disease presents with Cr of 2. Not dehydrated. High eosinophil count.

answer

Mesalamine induced interstitial nephritis **should follow renal function when on Mesalamine

question

Most common side effect of infliximab when used in Crohns?

answer

Arthralgias

question

bloody diarrhea acute abdominal pain. may have ocular inflammation and arthalgias. C-scope shows uniform colonic inflammation.

answer

Ulcerative colitits - shallow, continuous lesions - rectum always involved. - no perianal dz - backwash ileitis in <10% - p-ANCA

question

chronic back pain "bamboo spine" on lumbar back xray a severe chronic, bloody diarrhea. Treatment for ulcerative colitis does not work. Why?

answer

Pts with HLA-B27 associate tend not to improve with colitis treatment *same true for Crohns

question

IBD jaundice, diarrhea elevated LFTs. No RUQ pain or gall stone seen on imaging.

answer

Primary Sclerosing Cholangitis Jaundice, increased alk phos, chronic diarrhea. - UC (80%) - Cholangiocarcinoma (10%) - "beading of the bile ducts" on ERCP - "onion-skin" lesion of ducts on liver bx - male - anti-smooth muscle Ab, ANA - ursodiol NOT effective

question

Treatment for mild UC

answer

Sulfasalazine, 5-ASA * 30% remission after 2 months, 75% response

question

Screening C-scopes for UC for cancer? What if patient has PSC?

answer

q 1-2 years after 10 years of diagnosis **NOW if PSC

question

Treatment for mass lesion or stricture in UC?

answer

Total colectomy (not just partial)

question

Treatment for UC proctitis? Proctosigmoiditis?

answer

Mesalamine suppositories mesalamine enema **follow with oral tx with continued topical treatment

question

What should be ruled out in a UC flare?

answer

C. diff

question

Treament for travelers diarrhea?

answer

Prevention - Rifaxamin, Bactrim, doxy, quinolone if active

question

F, D Has diagnosis of C. jejuni. What should be watched for down the road?

answer

Guillan Barre

question

Treatment for Salmonella

answer

Levaquin

question

Treament for Shigella

answer

Ampicillin (Bactrim if allergic)

question

Most common cause of infectious diarrhea

answer

Campylobacter jejunum

question

Pt. eats undercooked beef. bloody diarrhea, N/V. CT shows right sided colitis.

answer

Hemorrhagic E.coli (O157:H7) **Do NOT treat with abx or can lead to hemolytic-uremic syndrome

question

Day care worker with recent travel to Rocky Mountains fishing. Develops very foul smelling flatus.

answer

Giardiasis. Dx with stool antigen. Start Flagyl.

question

Initial abx treatment for C.diff?

answer

Flagyl Recur: Flagyl again, then PO Vanc

question

Hows is stool osmotic gap calculated?

answer

OSM-[(Na + K) x2] = Gap If > 50, then osmotic diarrhea

question

Workup for chronic diarrhea

answer

OCP, fat stain, Giardia/Crypto, C. diff, WBC C-scope if colitis

question

Recurrent abd distention, pain, flatulence, diarrhea. Before working up for IBS, what should be tested for?

answer

Lactase deficiency Try lactose free diet

question

Chronic diarrhea, iron deficiency anemia itchy rash on extremities.

answer

Celiac Sprue Check tissue transglutaminase **rash is dermatis herpataformis**' - can see wt. loss, abnormal LFTs, infertility, osteoporosis

question

Diagnositic tests for celiac disease

answer

Antigliadin Ab Antiendomysial Ab Tissue Transglutaminease

question

What skin issue is associated with celiac disease?

answer

Dermatitis herpataformis pruritic papulovesicular rash on extensor surfaces

question

Older male patient wt. loss arthralgias abd pain and diarrhea. Endoscopic bx shows foamy macrophages and bacterial remnants with PAS stain.

answer

Whipple Disease Troperyna whippelii Ceftriaxone, then Bactrim for 1 year

question

Best indicator for malabsorption? Best screening test?

answer

Steatorrhea >14g fecal fat/day Best screen- Sudan stain

question

chronic diarrhea. If "low iron", likely what disease? If "low B12", likely what disease?

answer

Low iron- celiac dz Low B12- Crohns

question

Which disease is characterized by a high degree of fecal fat?

answer

Pancreatic insufficiency *will likely not have associated iron deficiency or extra-GI manifestations

question

If pt. has steatorrhea, what is next test for malabsorption?

answer

Nl D-xylose, will exclude small bowel disease -Low D-xylose- small bowel disease, poor gastric emptying, ascites, old age, bacterial overgrowth -If low D-xylose, then check panc enzymes, change diet or biopsy

question

Normal D-xylose level excludes what?

answer

Small bowel malabsorption

question

DM abdominal distension and chronic diarrhea. UGI series shows multiple diverticula.

answer

bacterial overgrowth 2 weeks Augmentin Macrocytosis with high folate and low B12. Lactulose breath test. Seen in: - Structural dz - diverticula, ileocecal resection, fistulae, strictures -Motility dz - DM, scleroderma -Achlorhydria -Immune disorders - IG secreted in small bowel may decrease bacterial growth

question

Diagnosis for bacterial overgrowth?

answer

Lactulose breath test or empiric trial of abx **may have high MCV from B12 deficiency, but high folate levels

question

chronic diarrhea intermittent flushing episodes. Abd CT is normal.

answer

Carcinoid urine 5-HIAA

question

alternating diarrhea and constipation. No wt. loss. No nocturnal sx.

answer

Likely irritable bowel syndrome High fiber diet Sexual abuse hx Then try diclomine (TCA for refractory sx)

question

How do hyperplastic polyps change the colon CA screening protocol?

answer

They don't. They have no malignant potential.

question

3-10 adenomas adenoma > 10mm Any villous adenoma Any adenoma with high grade dysplasia When to repeat C-scope?

answer

3 years

question

1 non-villous adenoma <10mm, low-grade dysplasia. when should follow C-scope be done?

answer

5-10 years

question

GI bleed oral pigmentation

answer

Peutz-Jegers (GI hamartomas) Complication: small bowel intussusseption and malignancy risk

question

What is the diagnostic criteria for HNPCC

answer

"3-2-1" rule: 3 1st degree relatives with colon CA over 2 generations, 1 of which <50 years old Offer early C-scope screening (age 25) Usually right sided colon

question

What are 4 appropriate colon CA screening tests and how often?

answer

FOBT q1 year Flex sig q4-5 years Double contrast BE q 5 years Colonoscopy q10 years (if 1st one normal)

question

What is Duke's A colon CA involve and how is it treated?

answer

Local tumor, does not extend beyond muscularis propria Resection and careful follow up

question

What is Duke's B colon CA involve and how is it treated?

answer

Local tumor that extends beyond muscularis but does not involve lymph nodes. Chemo if locally advanced

question

What is Duke's C colon CA involve and how is it treated?

answer

Lymph node involvement 5 FU, leucovorin, oxaliplatin

question

What is Duke's D colon CA involve and how is it treated?

answer

Metasatic disease 5 year survival= 5%

question

When should radiation be used in colon CA?

answer

Only for rectal involvement (colon not tethered in body well)

question

painless maroon stools. Abd exam is benign. Stops spontaneousely.

answer

Diverticular bleeding

question

70yo LLQ pain, fever and leukocytosis. Diagnosed with diverticulitis and treated with Cipro and Flagyl. What follow up test must be done?

answer

Flex sig/C-scope in 4-8 weeks after acute condition resolves as sigmoid CA can present similarly to diverticulitis

question

When should capsule endoscopy be used?

answer

Pt. with occult bleeding and repeat EGD and C-scopes are negative for source

question

Elderly patient LLQ pain followed by urge to defecate. Red stool the next day.

answer

Colonic ischemia Good prognosis Usually due to low flow or hypercoag state. Never embolic. Treat with bowel rest, fluids, abx

question

Abd pain out of proportion to physical findings. Usually after eating a meal. wt loss over past several weeks. Abdominal bruit.

answer

LIkely has chronic mesenteric ischemia Dx: Order MRA or CTA of abd Tx: surgical bypass or angioplasty

question

What is most likely source of acute mesenteric ischemia?

answer

Embolic (valvular heart disease or arrhythmia). SMA. Tx: Papaverine (vasodilator) if non-occlusive Ex-lap if peritoneal signs

question

Which surgical procedure leads to refractory constipation in 5% of patients?

answer

Hysterectomy

question

Causes of acute pancreatitis?

answer

Alcohol abuse Gallstones ERCP Hypertryglyceridemia hypercalcemia trauma drugs

question

What drugs can cause acute pancreatitis?

answer

Loop diuretics Thiazides Estrogens Azathioprine 5-ASA deriatives Sulfa/tetracycline HIV drugs

question

What are exam findings of severe (necrotizing) pancreatitis?

answer

Erythema of flanks (from extracasated pancreatic exudates) Cullen sign- faint blue discoloration around umbilicus (hemoperitoneum) Turner sign- bluish-reddish-purple discoloration around flanks suggesting catabolism of hgb from retroperitonal blood

question

recurrent pancreatitis. No etoh, no gallstones. No other obvious cause of pancreatitis.

answer

cholecystecomy - may have microlithiasis

question

acute pancreatitis. Sx are improving, but amylase remains up 10d after sx improve. What is possible cause?

answer

Leaking pseudocyst

question

chronic pancreatitis UGI bleeding. EGD shows gastric varices, but no esophageal varices. No hx of cirrhosis.

answer

Splenic vein thrombosis Can occur severe acute pancreatitis or chronic pancreatitis

question

chronic alcoholism steatorrhea and brittle DMII. What would likely be seen on abd CT?

answer

Chronic pancreatitis Will see calcified pancreas Tx:Pancreatic enzymes (must give with antacids/H2 blockers) Low fat diet Adding medium chain triglycerides to diet

question

Middle aged woman with no sx has elevated alk phos on lab work. No hx of stones. Eventually has itching and fatigue. history of autoimmune thyroiditis Progresses to jaundice.

answer

Primary biliary cirrhosis - female - 1st degree relative - other autoimmune disorder - tobacco - hx of UTIs - possibly some bacteria, viruses, and toxins Dx: Check antimitochondrial antibody, but dx is confirmed with liver bx Tx: Ursodiol initially, but will only delay Will eventually need liver transplant

question

Male pt. in 40s with UC Has persistent elevation of alkaline phosphatase and eventually jaundice. Antimitochondrial ab is negative.

answer

Primary sclerosing cholangitis Dx: MRCP or ERCP

question

Hep B associations: "B A CHAMP"

answer

Aplastic anemia Cryoglobulinemia, mixed (C>B) HCC Arthralgias MGN and MPGN PAN

question

Hep C: C SPiLT Milk

answer

Sjogren's Syndrome Porphyria Cutanea Tarda, Plasmacytoma Leukocytoclastic vasculitis; Lichen planus; Lymphoma Thyroiditis MIxed cryo

question

Dysphagia solids and liquids Food regurg, esp at night no odynophagia no coughing/gagging "bird-beak" on barium swallow

answer

Achalasia Loss of peristalsis Incr LES pressure Failure of LES relaxation w/ swallow 3 tests: BS, EGD, manometry Tx: 1: Botox, CCBs, nitrates 2: Dilation 3:Surgery (lap myotomy)

question

- painless jaundice - pruritus - associated weight loss - CA19-9 elevated

answer

Cholangiocarcinoma - primary sclerosing cholangitis - ulcerative colitis - intrahepatic bile duct stones - liver fluke infections

question

Short Bowel Synd: Intestine length

answer

< 200 cm

question

IBD: Extraintestinal manifestations

answer

Joint: RF- polyarthritis Skin: E nodosum, pyoderma gangrensoum Eyes: Iritis/episcleritis/uveitis Mouth Also Ankylosing Spondylitis B27 PSC - HLA-B8 DVT Pericholangitis

question

Prior to use of 6-MP or azathioprine in IBD

answer

Check TPMT (inactivates 6-MP to metabolites)

question

IBD: Tx

answer

5-ASA (UC > CD) 6-MP, Azathioprine Methotrexate Steroids (prednisone, budesonide) TNF-α inhib (infliumab, adalimumab) Cyclosporine

question

FAP: Screening

answer

- annual flex sig starting at age 10-12 - EGD at 25-30 years, then q1-3 years - Attenuated need full colonoscopy

question

HNPCC: Assoc. cancers

answer

- colon - endometrium and ovaries - small bowel - ureter - renal pelvis - pancreaticobiliary system

question

HNPCC: Screening

answer

- colonoscopy every 1 to 2 years beginning at age 20 to 25, annual after age 40 - pelvic examination with endometrial sampling, transvaginal U/S, and CA-125 every 1 to 2 years from age 30 years - urine cytology and renal U/S every 1 to 2 years beginning at age 30

question

Colonoscopy: Repeat screening guidelines

answer

-5-10y: 1-2 small (1cm, villous features, high-grade dysplasia - 10 adenomas - 2-6mo: sessile adenoma

question

Wilson's Disease: Tx

answer

- copper chelators (penicillamine and trientine) - zinc (decr copper absorpt'n)

question

Autoimmune Hepatitis: Assoc. Ab's

answer

- anti-smooth-muscle - ANA - anti-LKM1 - p-ANCA

question

discriminant function (DF) calculation (alcoholic hepatitis)

answer

- if > 32, > 50% 30-day mortality risk - based on PT and bili - if high, tx with prednisone

question

Chronic, replicative Hep B: Tx

answer

interferon (standard and pegylated), lamivudine, adefovir, entecprednisone telbivudine

question

Chronic Hep B: monitoring

answer

Hepatic U/S and α-fetoprotein q6-12 months

question

Diseases that elevate iron saturation:

answer

- Hemochromatosis - alcohol use - hepatitis C virus infectio - fatty liver disease - neoplasms

question

Varices: Primary prophylaxis for bleeding

answer

Propranolol or nadolol Only if large.

question

Acute Variceal Bleed: Tx

answer

- endoscopic band ligation and/or endoscopic sclerotherapy - Abx - Octreotide (Splanchnic vasoconstrictor)

question

SAAG

answer

- Serum - ascites albumin - > 1.1 = Portal HTN (if low protein in ascities) = Rsided CHF, Budd chiari (if high) <1.1 Nephrotic (if low protein) Malignancy, Tb (if high protein)

question

SBP Prophylaxis

answer

daily low-dose or weekly high-dose fluoroquinolone Needed if: - previous SBP - ascitic protein <1g/dL

question

Hepatorenal Sydrome: Tx

answer

- systemic vasoconstrictor midodrine - splanchnic vasoconstrictor octreotide - albumin - Liver Transplant

question

Hepatocellular Carcinoma: Milan Criteria for trpt

answer

- one tumor no larger than 5 cm in diameter or - no more than three tumors, none of which is larger than 3 cm

question

Amanita mushroom poisoning: Tx

answer

penicillin or silymarin (milk thistle)

question

Hepatic adenoma: Tx

answer

- Discontinue hormone therapy - Resection only if planning on pregnancy due to risk of rupture in pregnancy

question

Secretory Diarrhea: Fixed by fast?

answer

NO. Unless fatty-acid or bile-acid related. Ddx: Enterotoxins Villous adenomas Gastrinomas Microscopic colitis Bile acids VIPomas

question

Osmotic Diarrhea: Fixed by fast?

answer

YES. Ddx Lactase deficiency Mg - laxatives or antacids Sorbitol, fructose Malabsoption

question

dysphagia, CP precipitated by cold or carbonated liquids Corkscrew esophagus on BS

answer

Diffuse esophageal spasm Confirm: manometry - intermittent nonperistaltic contractions EGD not helpful. Tx: Reassurance. Med tx: diltiazem or imipramine isosorbide or sildenafil botox

question

Travel to India or Puerto Rico Malabsorption Weight loss, malaise Folate or B12 deficiency Steatorrhea

answer

Tropical sprue Dx: Small bowel biopsy Tx: Tetracycline or sulfonamide, folic acid

question

Gilbert: How to verify normal?

answer

normal aminotransferase levels No hemolysis - nl hct, ret count

question

Hep B non-liver associations

answer

Polyarteritis Nodosa (PAN) membranous GN cryoglobulinemia

question

Acute diarrhea: foodborne

answer

1-6hrs: S. aureus or B. cereus 8-14hrs: C. perfringens >14hrs: E. coli

question

B1 deficiency (thiamine)

answer

Beriberi: Wet: CHF, ascitis, edema Dry: Nervous system - peripheral: symmetric sensory, motor, reflex loss - Wernicke enceph (vomiting, nystagmus, ophthalmoplegia, ataxia, mental deterioration) - Korsakoff syndrome (confab, poor recent memory and learning) (thiamine reverses sx in only 1/2) Wernicke's can be precipitated be glucose infusions

question

Dermatitis (mucosal) Diarrhea Dementia

answer

Niacin deficiency Pellagra dermatitis (esp sun-exposed), glossitis, stomatitis, proctitis, diarrhea, changing mental status (depression to dementia), hyper pigmented - carcinoid syndrome, INH

question

scurvy petechial hemorrhages hyperkeratotic papules around follicles Sjogren syndrome hemorrhage into muscles and joints splinter hemorrhages

answer

Vitamin C deficiency

question

older pt with pain / weakness esp if h/o fat malabsorption or pt doesn't eat meat

answer

Vitamin D deficiency

question

macrocytic anemia smooth tongue subacute degeneration of spinal cord - initially pins and needles then decreased vibration and proprio and stocking/glove decreased reaction to pinprick dementia

answer

Vitamin B12 deficiency

question

Vitamin deficiencies that take only weeks to develop

answer

Water-soluble vitamins Mg (muscle stiffness/cramps; Crohn's - tetany) Zinc (acrodermatitis, poor wound healing) essential fatty acids

question

Vitamin deficiencies that take months

answer

Copper (hypochromic, microcytic anemia) Vitamin K (bleeding, high PT)

question

Vitamin deficiencies that take a year

answer

Vitamin A and D Selenium (myalgias, cardiomyopathy, hemolytic anemia) Chromium (glucose intolerance, peripheral neuropathy)

question

Vitamin deficiencies that take several years

answer

Iron, cobalt, B12.

question

testing

answer

test

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