Internal Medicine - Emma Holliday Ramahi - Flashcards

Q: Ventricular septal rupture

Post-MI complications: \"step up\" in [O2] from RA-;RV?

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2mm ST elevation - STE immediately - T wave inversion 6hrs-yrs - Q waves last forever new LBBB (wide, flat QRS)

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STEMI on ECG?

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Anterior: LAD - V1-4 Lateral: Circumflex - I, aVL, V4-6 Inferior: RCA - II, III, aVF RV: RCA - V4 on R side ECG!

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Localized infarcts on ECG? [Anterior, Lateral, Inferior, RV]

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*Cath lab* ... *Thrombolytics* w/in 6hrs Contra: bleeding, hx hemorrhagic stroke, recent closed head trauma

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Emergency reperfusion options? Contraindications?

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Sx: HoTN, tachycardia, clear lungs, JVD, and NO pulsus paradoxus. Txt: vigorous fluid resuscitation, increase preload. DON'T give nitro, will worsen sx

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RV infarct Sx? Txt?

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ECG Cardiac enzymes

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CP workup?

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NSTEMI Check enzymes q8h x 3 to look for trend

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Normal ECG, elevated cardiac enzymes. Dx? Workup?

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*Myoglobin* Rises 1st, peak 2h, nml by 24h (detect NEW infarct) *CKMB* Rise 4-8, peak 24h , nml by 72h *Troponin I* Rise 3-5h, peak 24-48h, nml by 7-10d

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Cardiac enzymes? (3)

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*M*orphine *O*2 *N*itrates *A*SA/clopidogrel *B*eta-blocker Coronary angiography w/in 48h

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NSTEMI acute txt? Immediate workup?

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PCI w/ stenting CABG if: - L main dx - 3 vessel dx - 2 vessel dx in DM - ;70% occlusion - pain despite txt - post-MI angina DC on: *B*eta-blocker (Metoprolol, Labetalol) *A*CEI if CHF or LV dysfxn *S*tatin *H*eparin (while in hospital) +Nitrates

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NSTEMI interventions and discharge Rx?

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Exercise ECG - dc Beta-blockers and CCB before If + -; Coronary angiography

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Unstable angina workup?

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Contra: - old LBBB - bilat STE - on Digoxin Exercise ECHO Chemical stress test w/ Dobutamine or Adenosine MUGA

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Contraindications to exercise stress test and alternatives?

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Multi Gated Acquisition Scan nuclear medicine test shows perfusion areas of heart DC caffeine or Theophyline before

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MUGA

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Arrhythmias (most Vfib)

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Post-MI complications: Most common cause of death?

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Papillary muscle rupture

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Post-MI complications: New systolic murmur 5-7d s/p?

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Ventricular free wall rupture

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Post-MI complications: Acute severe hypotension?

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Ventricular septal rupture

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Post-MI complications: "step up" in [O2] from RA-;RV?

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Ventricular wall aneurysm

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Post-MI complications: Persistent STE ~1mo later + systolic MR murmur?

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AV-dissociation Valve not opening properly -; blood bounds back to neck Either V-fib or 3rd degree heart block

blood bounds back to neck Either V-fib or 3rd degree heart block" alt="AV-dissociation Valve not opening properly -; blood bounds back to neck Either V-fib or 3rd degree heart block">

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Post-MI complications: "Cannon A-waves"?

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Dressler's syndrome (probably) autoimmune pericarditis Txt: NSAIDs, ASA

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Post-MI complications: 5-10wks later pleuritic CP, low grade temp? Dx? Txt?

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Pericarditis diffuse STE on ECG Txt: NSAIDs

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Young, healthy pt w/ CP: worse w/ inspiration, better w/ leaning forward, friction rub. Dx? Txt?

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costochondriasis

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Young, healthy pt w/ CP: worse w/ palpation

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myocarditis

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Young, healthy pt w/ CP: vague w/ hx of viral infxn and murmur

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Prinzmetal's angina Dx: Ergonovine stimulation test to ID blood vessel spasms Txt: CCB or Nitrates

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Young, healthy pt w/ CP: occurs at rest, worse at night, few CAD risk factors, hx migraine headaches (~female), w/ transient STE during episodes. Dx test? Txt?

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Wenkebach/ Mobitz Type I 2nd deg heart block

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Progressive, prolongation of the PR interval followed by a dropped beat

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3rd deg heart block

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regular P-P interval and regular R-R interval, Cannon-a waves on physical exam.

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MAT (multifocal atrial tachycardia

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varying PR interval with 3 or more morphologically distinct P waves in the same lead. Old person w/ chronic lung dx in pending respiratory failure

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Ventricular tachycardia Unstable pt: cardiovert Stable pt: Lidocaine, Amiodarone

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Three or more consecutive beats w/ QRS 120bpm Txt?

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Wolf-Parkinson-White Delta wave representing early ventricular activation via the bundle of Kent Txt: Procainamide Contra: Beta blokers, Digoxin, CCB (Verapamil, Diltiazem), anything that slows AV node conduction will worsen arrhythmia

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Short PR interval followed by QRS >120ms with a slurred initial deflection. Txt? Contraindications?

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Atrial flutter "sawtooth waves" Unstable pt: cardiovert Stable pt: Beta blockers, Digoxin

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Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm. Txt?

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Torsades de pointe Seen in a pt w/ low Mg and low K. Lithium or TCA OD

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prolonged QT interval leading to undulating rotation of the QRS complex around the EKG baseline

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Supraventricular tachycardia Txt: carotid sinus massage, ice to the face, Adenosine

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Regular rhythm w/ a rate btwn 150-220bpm. Sudden onset of palpitations/ dizziness. Txt?

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Hyperkalemia

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peaked T-waves, wide QRS, short QT and long PR. Renal failure patient/ crush injury/ burn victim.

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Cardiac tamponade "electrical alternans"

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Alternate beat variation in direction, amplitude and duration of the QRS in a pt w/ pulsus paradoxus, HoTN, distant heart sounds, JVD

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Atrial fibrillation Dilation of RA predisposes Txt: rate control w/ Beta blockers or Digoxin

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Undulating baseline, no p-waves, irregular R-R interval in a hyperthyroid pt (too much Synthroid), old pt w/ SOB/ dizziness/ palpitations w/ CHF or valve dx. Txt?

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Aortic Stenosis Cause: degeneration Txt: replace valve

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SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvus et tardus

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HOCM younger pt

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SEM *louder w/ valsalva,* softer w/ squatting or handgrip.

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Mitral Valve Prolapse

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Late systolic murmur w/ *click* louder w/ valsalva and handgrip, softer w/ squatting

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Mitral Regurgitation

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*Holosystolic* murmur radiates to axilla w/ LAE

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VSD

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Holosystolic murmur w/ late diastolic rumble in kiddos

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PDA

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Continuous machine like murmur

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ASD

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Wide fixed and split S2

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Mitral Stenosis

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Rumbling diastolic murmur with an opening snap, LA enlargement and A-fib

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Aortic Regurgitation

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Blowing diastolic murmur with widened pulse pressure.

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nitrates, lasix and morphine

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Txt for acute pulmonary edema?

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myocarditis (Coxsackie B)

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young person w/ CHF?

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primary pulomnary HTN R heart cath --> PCWP normal (elevated in CHF)

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young pt w/ no cardiomegaly on CXR

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EF<55% ischemic, dilated Reversible: EtOH w/ abstinence

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Systolic CHF

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normal EF Reversible cause: Hemachromatosis w/ phlebotomy

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Diastolic CHF

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*ACE-I* improve survival - prevent remodeling by aldo. *B-blocker* (metoprolol and carveldilol) improve survival- prevent remodeling by epi/norepi *Spironolactone* - improves survival in NYHA class III and IV *Furosemide* - improves sxs (SOB, crackles, edema) *Digoxin* - decreases sxs and hospitalizations. NOT survival

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CHF Txt

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Pneumonia

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Opacification, consolidation, air bronchograms

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COPD

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hyperlucent lung fields with flattened diaphragms

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CHF

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heart > 50% AP diameter, cephalization, Kerly B lines & interstitial edema

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Pulmonary abscess (anaerobes, Staph)

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Cavity containing an air- fluid level

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Tuberculosis

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Upper lobe cavitation, consolidation +/- hilar adenopathy

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Mediastinal mass (LAD, CA) LA enlargement from mitral stenosis

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Thickened peritracheal stripe and splayed carina bifurcation

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Systemic causes: CHF, nephrotic sx, cirrhosis

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Transudative Pleural Effusion

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Local causes: parapneumonic, CA

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Exudative Pleural Effusion

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+ gram or Cx pH < 7.2 glucose < 60 Txt: drain w/ test tube

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Complicated Pleural Effusion

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RA TB malignant or pulmonary fibrosis

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Transudative Pleural Effusion buzzwords: low pleural glucose? high WBC? bloody?

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Transudative if: LDH < 200 LDH eff/serum < 0.6 Protein eff/serum exudative)

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Light's Criteria?

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Pleural Effusion Txt: thoracentesis

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>1cm fluid on lateral decubitus CXR. Txt?

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after surgery long car ride hyper coagulable state (cancer, nephrotic)

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Risks for PE?

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Sxs: pleuritic CP, hemoptysis, SOB, Decr pO2, tachycardia. Random signs: R heart strain on EKG, sinus tachy, decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2. Westermark Sign on CXR - focus of oligemia (leading to collapse of vessel) seen distal to a pulmonary embolism (PE)

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Signs of PE

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Give Heparin 1st! V/Q scan Spiral CT pulmonary angiography (gold standard)

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Suspect PE, workup?

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Heparin/Warfarin overlap Thrombolytics if severe (NOT if s/p surgery or hemorrhagic stroke) Surgical thrombectomy if life threatening IVC filter if contraindications to chronic coagulation

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Txt for PE?

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Acute Respiratory Distress Syndrome impaired gas exchange, inflammatory mediator release, hypoxemia

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bilateral fluffy infiltrates

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Sepsis gastric aspiration trauma low perfusion pancreatitis

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Causes of ARDS?

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1) PaO2/FiO2 < 200 (<300 means acute lung injury) 2) Bilateral alveolar infiltrates on CXR 3) PCWP is <18 (r/o cardio cause of pulmonary edema)

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Dx criteria for ARDS?

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mechanical ventilation w/ PEEP

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Txt for ARDS?

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low FVC, low FEV1 -> *low FEV1/FVC* high TLC high RV DLCO reduced in emphysema 2/2 alveolar destruction-> more space Ex: COPD, emphysema, asthma (FEV1 improves >12% w/ bronchodilator),

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Obstructive lung dx PFTs?

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low FVC, low FEV1 -> *normal FEV1/FVC* low TLC low RV DLCO reduced in ILD 2/2 fibrous thickening distance Ex: interstitial lung dx (sarcoid, silicosis, asbestosis), structural (obesity, MG/ALS, phrenic nerve paralysis, scoliosis)

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Restrictive lung dx PFTs?

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Productive cough >3mo for >2 consecutive yrs

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COPD dx criteria?

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1st line = ipratropium, tiotropium 2nd Beta agonists 3rd Theophylline Goal SpO2: 94-95% bc pts are chronic CO2 retainers so hypoxia is the only drive for respiration

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COPD txt? Goal SpO2?

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PaO2 <55 (If cor pulmonale, <59) SpO2<88%

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Indications to start O2 (in COPD)?

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Change in sputum, increasing SOB

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COPD exacerbation criteria?

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O2 to 90% albuterol/ipratropium nebs PO or IV corticosteroids Abx: FQ or macrolide

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COPD exacerbation txt?

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FEV1

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Best prognostic factor for COPD?

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1) Quitting smoking (can decr rate of FEV1 decline 2) Continuous O2 therapy >18hrs/day

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Interventions shown to improve COPD mortality? (2)

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Pneumococcus w/ a 5yr booster annual influenza vaccine

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Vaccinations for COPD pt?

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Hypertrophic Osteoarthropathy Next best step... get a CXR Most likely cause is underlying lung malignancy

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New clubbing in a COPD pt?

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Mild intermittent asthma Step 1: SABA (Albuterol)

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Asthma: sx 2x/wk, normal PFts. Txt?

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Mild persistent asthma Step 2: SABA + ICS

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Asthma: sx 4x/wk, PM cough 2x/mo, normal PFTs. Txt?

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Moderate persistent asthma Step 3: low dose ICS + LABA (Salmeterol)

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Asthma: daily sx, PM cough 2x/wk, FEV1 60-80%. Txt?

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Severe persistent asthma Step 4-6: med-high dose ICS + LABA (+ PO steroids)

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Asthma: daily sx, PM cough 4x/wk, FEV1 <60%. Txt?

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inhaled albuterol + PO/IV steroids monitor Peak flow rates and blood gas (low PCO2) Normalizing PCO2 --> impending respiratory failure --> INTUBATE

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Asthma exacerbation Mgmt? Sign of impending respiratory failure?

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*Silicosis* Get yearly TB test! More predisposed. Give INH for 9mo if >10mm

10mm" alt="*Silicosis* Get yearly TB test! More predisposed. Give INH for 9mo if >10mm";

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1cm nodues in *upper lobes* w/ *eggshell calcifications*. Mgmt?

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*Asbestosis* Most common cancer is broncogenic carcinoma, but incr risk for mesothelioma

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Reticulonodular process in *lower lobes* w/ *pleural plaques*. Associations?

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*Hypersensitivity Pneumonitis* = "farmer's lung"

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Patchy *lower lobe* infiltrates, thermophilic actinomyces.

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*Sarcoidosis* Also hypercalcemia 2/2 increased macrophages making vitamin D Dx: biopsy - non-caseating granuloma Txt: steroids

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Hilar LAD, ?ACE *erythema nodosum*. Dx? Txt?

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Ophthalmology -; uveitis conjunctivitis in 25%

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Important referral for pt w/ sarcoidosis?

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Pt ;4oyo size ;3cm well circumscribed popcorn calcification = hamartoma (most common) concentric calcification = old granuloma Mgmt: CHR or CT q2mo to monitor for growth

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Characteristics of benign pulmonary nodules? Mgmt?

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smoker older pt size ;3cm eccentric, spiculated calcification Mgmt: open lung bx, remove nodule

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Characteristics of malignant pulmonary nodules?

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lung CA

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A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated PNA or lung collapse

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*Adenocarcinoma* Occurs in scars of old PNA

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Most common lung CA in *non*smokers?

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AdenoCA (peripheral) --> liver, bone, brain, adrenals

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Lung CA mets?

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*Squamous cell carcinoma* paraneoplastic syndrome 2/2 PTHrP secretion -; low PO4, high Ca

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Pt w/ nephrolithiasis, constipation, malaise, low PTH, *central* lung mass?

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exudative high hyaluronidase

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Characteristics of AdenoCA pleural effusion?

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Superior Sulcus Syndrome from *small cell lung carcinoma* (central CA)

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Pulmonary patient with shoulder pain, ptosis, constricted pupil (mitosis), and facial edema?

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Lambert Eaton Syndrome from *small cell lung carcinoma*. Abs to pre-synaptic Ca channels

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Patient with ptosis better after 1 minute of upward gaze?

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SIADH from *small cell lung carcinoma*. Produces euvolemic hyponatremia. Txt: Fluid restriction +/- 3% saline in ;112

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Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD? Txt?

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*Large Cell Carcinoma* Peripheral CA more likely to cause cavitation highly metastatic

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CXR showing *peripheral* cavitation and CT showing distant mets?

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NSCLC easier to resect SCLC more sensitive to chem/rads

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Which lung cancer has a better prognosis, NSCLC or SCLC?

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Crohn's disease mimics appendicitis Fe deficiency

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IBD involving the terminal ileum?

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Ulcerative Colitis Rarely ileal backwash but never higher

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Continuous IBD involving the rectum?

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Ulcerative Colitis PSC increases risk of cholangioCA

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IBD w/ increased for Primary Sclerosing Cholangitis (PSC)?

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fistulae - Crohn's, give Metronidazole granulomas on bx - Crohn's transmural inflam - Crohn's high risk CRC - UC pANCA - UC

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IBD with: fistulae? granulomas on bx? transmural inflam? high risk CRC? pANCA?

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Crohn's Disease

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Smokers have a higher risk of which IBD?

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Txt: ASA, sulfasalzine to maintain remission. Corticosteroids to induce remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine, 6MP and methotrexate for severe dx

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IBD Txt?

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Alcoholic Hepatitis

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AST>ALT (2x) + high GGT?

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Viral Hepatitis

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ALT>AST & in the 1000s?

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Ischemic Hepatitis ("shock liver")

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AST and ALT in the 1000s after surgery or hemorrhage?

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Obstructive (stone/cancer) Dubin's Johnsons, Rotor

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Elevated direct bili?

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Hemolysis Gilbert's, Crigler Najjar

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Elevetated indirect bili?

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Bile duct obstruction, if IBD -> PSC

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Elevated alk phos and GGT?

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Paget's disease Sx: incr hat size, hearing loss, HA Txt: Bisphosphonates

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Elevated alk phos, normal GGT, normal Ca? Txt?

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Primary Biliary Cirrhosis Txt: bile resins More common w/ UC

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Antimitochondrial Ab? Txt?

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*Autoimmune Hepatitis* Txt: steroids

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ANA + antismooth muscle Ab? Txt?

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*Barium swallow* - best 1st test *Endoscopy* - next best test, can be dx and allow for bx of suspicious masses or tx in dilation of peptic strictures or injecting botox for achalasia. *Manometry* - achalasia. *24 pH monitoring* - GERD If HIV+ (CD ;100) or otherwise immunocompromised, remember Candida, CMV and HSV esophagitis

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Dysphagia workup?

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Achalasia Txt: CCB, nitrates, botox, or heller myotomy Assoc w/ Chagas dx and esophageal cancer.

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Dysphagia to liquids ; solids?

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Diffuse esphogeal spasm Txt: CCB or nitrates

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Dysphagia worse w/ hot ; cold liquids + chest pain that feels like MI w/ NO regure?

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GERD Most sensitive test is 24-hr pH monitoring. Do endoscopy if "danger signs" present. Txt: behav mod 1st, then antacids, H2 block, PPI.

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Epigastric pain worse after eating or when laying down cough, wheeze, hoarse? Workup? Txt?

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*Boerhaave's Sx - Esophageal Rupture* Next best test - CXR, gastrograffin esophagram. NO edoscopy Txt: surgical repair if full thickness

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If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ?amylase. Workup? Txt?

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Gastric Varices Txt: *Endoscopic sclerotherapy or banding*. Don't prophylactically band asymptomatic varices. Give *Beta blockers* If in hypovolemic shock? do ABCs, NG lavage, medical tx w/ Octreotide or Somatostatin. Balloon tamponade only if you need to stablize for transport

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If gross hematemesis unprovoked in a cirrhotic w/ pHTN? Txt? Acute Mgmt?

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Esophageal Carcinoma Squamous cell CA in smoker/drinkers in the middle 1/3. AdenoCA in ppl with long standing GERD in the distal 1/3. Workup: barium swallow -; endoscopy w/ bx -; staging CT

endoscopy w/ bx -; staging CT" alt="Esophageal Carcinoma Squamous cell CA in smoker/drinkers in the middle 1/3. AdenoCA in ppl with long standing GERD in the distal 1/3. Workup: barium swallow -; endoscopy w/ bx -; staging CT">

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If progressive dysphagia and weight loss? Workup?

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#1 cause is *non-ulcerative dyspepsia*. Dx of exclusion. Txt: H2 blocker and antacid. • If GERD sx, tx empirically w/ PPI for 4 wks then re-evaluate. • If biliary colic sxs predominate ->RUQ sono • If hx of stones or drinking, check amylase and lipase, CT scan best imaging for pancreatitis.

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Mid-epigastric pain

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>50 y/o hx of smoking and drinking recent unprovoked weight loss odynophagia Fe-def anemia melena

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Danger sxs warranting endoscopic work up in pt w/ mid-epigastric pain?

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Gastric Ulcers - *Double-contrast barium swallow* shows punched out lesion w/regular margins. - *EGD w/ bx* - H. pylori, malign, benign. - Txt: Sucralfate, H2-block, PPI. Surgery if ulcer remains s/p 12wks txt.

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Mid-epigastric pain worse w/ eating and hx of NSAID and/or steroid use? Workup? Txt?

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Duodenal Ulcers - 95% assoc w/ H. pylori. Dx: blood, stool or breath test but EGD w/ bx (CLO test) can also r/o CA. - Txt: Healthy pts <45yo can try H2 block or PPI - H. pylori txt: PPI, Clarithromycin + Amoxicillin for 2wks

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Mid-epigastric pain better w/ eating? Workup? Txt?

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Zollinger-Ellison Syndrome - Best test is *secretin stim test* (finding high gastrin) - Txt: resection if localized, long term PPI if metastatic. - Look for pituitary and parathyroid problems (MEN1)

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Suspect this if Mid-epigastric pain/ulcers don't improve w/ eradication of H.pylori, large, multiple or atypically located ulcers? Workup? Txt?

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Acute Cholecystitis US -> thickened wall HIDA-> shows non-visualization of GB. Txt: cholecystectomy. If too unstable, can place a percutaneous cholecystostomy

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RUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy's. Normal labs. Workup shows? Txt?

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Choledocolithiasis - Same sxs as acute cholecytitis - US will show stones. - Txt: cholecystectomy or ERCP to remove stone

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RUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy's. Labs: obstructive jaundice, high bili, alk phos Txt?

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Ascending Cholangitis Txt: fluids, broad spec Abx, ERCP and stone removal

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RUQ pain, fever, jaundice (+hypotension and AMS)? Txt?

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Rare Primary sclerosing cholangitis (Ulcerative colitis) Liver flukes Thorothrast exposure Txt: surgery

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Risk factors for cholangiocarcinoma?

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Acute Pancreatitis - most 2/2 Gallstones & ETOH - Amylase >1000 means stone - Dx: CT scan imaging - Txt: NG, NPO, IVF, Observe - Prognosis: worse if old, WBC>16K, Glc>200, LDH>350, AST>250... drop in Hct, decr calcium, acidosis, hypox - Complications: pseudocyst (no cells!), hemorrhage, abscess, ARDs

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Mid-epigastric pain radiating to the back, N/V, Turner's sign, Cullen's sign. Labs: incr amylase & lipase Txt? Complications?

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Chronic Pancreatitis Can cause splenic vein thrombosis

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Chronic mid epigastric pain, DM, malabsorption (steatorrhea)? Complication?

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*Pancreatic adenoCA* *Usually don't have sxs until advanced, only if in head of pancreas - Dx: EUS and FNA biopsy - Tx: Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoineal mets.

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Courvoisier's sign = large, nontender GB, itching and jaundice Trousseau's sign = migratory thrombophlebitis. Dx? Txt?

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Hemachromatosis Sx: hepatitis, DM, golden skin

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High Fe, low ferritin, low Fe binding capacity?

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Wilson's Disease Sx: hepatitis, psychiatric sxs (basal ganglia), corneal deposits

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Low ceruloplasmin, high urinary Cu?

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NS if HoTN, tachycardia Fecal WBC - tests for invasion stool Cx Most commonly - viral, Rotavirus in daycare, Norwalk, cruise ships Picnic - B. cereus, Staph, sx after 1-6hrs Hx Abx use - stool for C. diff antigen

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Diarrhea workup? Most commonly? Picnic? Hx Abx use?

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EHEC Shigella Vibrio parahaemolyticus, Salmonella Entamoeba histolytica

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Bloody diarrhea?

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Sprue Chronic pancreatitis Whipple's dx CF if young person

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Foul smelling, bulky diarrhea in malnourished pt?

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consider carcinoid syndrome (metastatic) *Can cause niacin deficiency! (2/2 using all the tryptophan to make 5HT) -> Dementia, Dermatitis, Diarrhea.

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Diarrhea + flushing, tachycardia/ hypotension

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Strep Pneumo H. Influenza N. meningitidis Empiric txt: Ceftriaxone and Vancomycin

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Most common meningitis bugs? Empiric txt?

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Lysteria Txt: Ampicillin

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Common extra meningitis bug in old and young pts? Txt?

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Staph aureus Txt: Vancomycin

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Common extra meningitis bug in pts w/ brain surgery?

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RIPE + steroids

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TB meningitis txt?

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IV Ceftriaxone

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Lyme meningitis txt?

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Empiric Abx (+steroids if you think bacterial) Exam for high ICP LP, Gram stain

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1st steps in meningitis management?

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High protein low glucose >1000 WBC (diagnostic)

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LP bacterial meningitis?

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Ppx w/ Rifampin

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Advice for roommate of the kid in the dorms who has bacterial meningitis and petechial rash?

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Strep pneumoniae Txt: Macrolides, Fluoroquinolones, 3rd gen cephalosporine

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Most common pneumonia bug? Empiric txt?

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Atypicals: Mycoplasma assoc w/ cold agglutinins Txt: Macrolides, Fluoroquinolones, Doxycycline

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Most common pneumonia bug in young healthy people? Txt?

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HCAP: Pseudomonas Kelbsiella E. coli MRSA Txt: Pip/Tazo, Impipenem + Vancomycin

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Most common pneumonia bugs in pt's hospitalized w/in 3mo or in the hospital for >5-7d? Txt?

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H influenzae Txt: 3rd gen Cephalosporin

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Most likely pneumonia bug in old smokers w/ COPD? Txt?

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Klebsiella Txt: 3rd gen Cephalosporin

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Most likely pneumonia bug in alcoholic w/ currant jelly sputum? Txt?

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Legionella, aka "PNA+" Dx: urine antigen Txt: Macrolides, Fluoroquinolones, Doxycycline

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Most likely pneumonia bug in old man w/ HA, confusion, diarrhea, and abdominal pain? Txt?

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MRSA Txt: Vancomycin

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Most likely pneumonia bug in a pt who just had the flu? Txt?

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Q fever (Coxiella burnetti - tick feces, cow placenta -> aerosolized) Txt: Doxycyline

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Most likely pneumonia bug in farmer who just delivered a baby cow and now has vomiting and diarrhea? Txt?

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Franciella tularensis Txt: Streptomycin, Gentamicin

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Most likely pneumonia bug in a pt who just skinned a rabbit? Txt?

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PPD >15mm, >10mm if prison, healthcare, nursing home, DM, ETOH, chronically ill, >5mm for AIDS, immune suppressed If + PPD --> do CXR.

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TB screening test? Next step if +?

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+ CXR --> acid fast stain of sputum (if negative x3 clear) - CXR --> need negative acid fast stain of sputum x3

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Next step after +PPD and +CXR?

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RIPE x6mo (12mo for meningitis, 9mo if pregnant) *R*ifampin *I*NH *P*yrazinamide *E*thambutol

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Txt for tuberculosis?

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children <4yo Ppx: INH x9mo (+vit B6)

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Who should get chemoprophylaxis after a known TB exposure? What is the ppx?

question

*R*ifampin - orange/red fluids, +CPY450 *I*NH - periph neuropathy, sideroblastic anemia, hepatitis w/ mild LFT bump *P*yrazinamide - benign hyperuricemia *E*thambutol - optic neuritis, other color vision abnormal

answer

RIPE side effects?

question

Staph aureus

answer

Most common bug for acute endocarditis?

question

Viridens group strep Mitral valve

answer

Most common bug for subacute endocarditis of native valve? Which valve?

question

Staph aureus Tricuspid valve R side murmurs worse w/ inspiration

answer

Most common bug for endocarditis in IVDU? Murmur features?

question

blood Cx TTE then TEE Major and Minor criteria

answer

Dx of endocarditis?

question

CHF is #1 cause of death septic emboli to lungs or brain

answer

Complications of endocarditis?

question

Strep viridens txt: PCN x4-6wk Staph txt: Nafcillin + Gentamicin or Vancomycin

answer

Endocarditis abx?

question

Prosthetic valve Hx of endocarditis Uncorrected congenital lesion

answer

Who gets ppx for endocarditis?

question

colonoscopy assoc w/ CRC

answer

Strep bovis bacteremia mgmt?

question

*Acute retroviral syndrome* (looks like mono) 2-3 wks s/p HIV exposure but 3wks before seroconversion, ELISA neg

answer

Fever, fatigue, LAD, HA, pharyngitis, n/v/d +/- aseptic meningitis

question

HIV

answer

A young patient with new/bilateral Bell's Palsy?

question

that means they have sex with lots of strangers and are at risk for HIV

answer

Patient "travels a lot for work"?

question

HIV

answer

A young patient with unexplained thrombocytopenia and fatigue?

question

HIV

answer

A young patient with unexplained weight loss >10%?

question

HIV

answer

A young patient with thrush, Zoster, or Kaposi sarcoma?

question

CD4 55,000 (except preggos get tx >1,000 copies)

answer

When to start HAART?

question

Zidovudine

answer

HIV Rx SE: GI, leukopenia, macrocytic anemia

question

Didanosine

answer

HIV Rx SE: Pancreatitis, peripheral neuropathy

question

Indinavir

answer

HIV Rx SE: Nephrolithiasis and hyperbilirubinemia

question

Efavirenz (nNRI)

answer

HIV Rx SE: Sleepy, confused, psycho

question

Abacavir DC drug and never use again!

answer

HIV Rx SE: hypersensitivity rash, F, N/V, muscle aches, SOB in 1st 6wks

question

AZT, lamivudine and nelfinavir for 4wks

answer

Post-exposure ppx (HIV)?

question

PCP Dx: Bronchoscopy w/ BAL to visualize bug

answer

HIV+ patient with DOE, dry cough, fever, chest pain, elevated LDH? CXR: "bilat diffuse symmetric interstitial infiltrates" How to Dx?

question

1st line: Trim-Sulfa 2nd line: Trim-Dapsone or Primaquine-Clindamycin or Pentamidine + Steroids when PaO235

answer

Txt for PCP?

question

CD4200 x6mo) 1st: Trim-Sulfa 2nd: Dapsone 3rd: Atovaquone 4th: aerosolized Pentamidine (~> pancreatitis)

answer

When to give ppx for PCP?

question

CMV MAC Cryptosporidium

answer

HIV pt (CD4<50) w/ diarrhea? (3)

question

Sx: bloody diarrhea Dx: colonoscopy w/ bx -> intranuclear inclusions Txt: Gancyclovir (~> neutropenia), Foscarnet (~> renal tox)

answer

CMV in HIV pt? Dx? Txt?

question

MAC Dx: bx negative, exclude alternative causes Txt: Clarithromycin and Ethambutol +/- Rifampin

answer

HIV pt (CD4<50) w/ diarrhea, wasting, fevers, night sweats? Dx? Txt?

question

CD4<50 Ppx: Azithromycin weekly

answer

MAC ppx in HIV pt?

question

transmitted via dog poo, swimming pool Sx: watery diarrhea w/ mucus Dx: oocysts in stool are acid fast

answer

Cryptosporidium in HIV pt? Dx?

question

Toxoplasmosis Txt: empiric *pyramethamine sulfadiazine* (+ folic acid) x6wks. If no improvement in 1wk, consider biopsy for CNS lymphoma.

answer

HIV pt w/ multiple ring enhancing lesions on CT? Txt?

question

CNS lymphoma Assoc w/ EBV infxn of B- cells Txt: HAART.

answer

HIV pt w/ one ring enhancing lesion on CT? Txt?

question

HSV encephalitis (predisposed for *temporal lobe*) Txt: Acyclovir ASAP!

answer

HIV pt w/ seizure + *deja vu aura* and 500 RBCs in CSF?

question

Strep pneumo Also worry about Cryptococcus Dx: +India ink Txt: ampho IV x2wks then fluconazole maintenance

answer

Most common meningitis in HIV pt? Workup?

question

sounds like MS *PML* - JC polyomavirus demyelinates at grey-white jxn. Dx: Brain bx

answer

HIV pt w/ hemisensory loss, visual impairment, Babinski? Dx?

question

AIDS-Dementia complex Check serum, CSF and MRI to r/o treatable causes

answer

HIV pt w/ memory problems or gait disturbance? Workup?

question

Medical Emergency! NEVER do a DRE - may induce bacteremia across gut wall [single temp > 101.3 or sustained temp >100.4 x1hr. ANC < 500]

answer

Neutropenic fever cautions?

question

[single temp > 101.3 or sustained temp >100.4 x1hr. ANC < 500] Mucositis 2/2 chemo causes bacteremia (usually from gut) Bugs: Pseudomonas or MRSA (if port present)

answer

Etiology of neutropenic fever? Most common bugs?

question

Blood cx Start *3rd or 4th gen cephalosporin* (ceftazidime or cefipime) + *vanc* if line infxn suspected or if septic shock + *amphoB* if no improvement and no source found in 5 days.

answer

Neutropenic fever workup and mgmt?

question

Lyme Txt: Doxycycline (Amoxicillin for <8yo) Heart or CNS dx needs IV ceftriaxone

answer

Target rash, fever, CNVII palsy, meningitis, AV heart block? Txt?

question

Rocky Mtn Spotted Fever - Rickettsia "Rickettsia at wRists" Txt: Doxycycline even if <8yo

answer

Rash @ wrists & ankles (palms & soles), fever and HA? Txt?

question

Ehrlichiosis Dx: morulae intracellular inclusions Txt: Doxycycline

answer

Tick bite, *no rash*, myalgia, fever, HA, ?plts and WBC, ?ALT? Dx? Txt?

question

Nocardia (aerobic) Txt: trim-sulfa

answer

Immune suppressed, cavitary lung dx (purulent sputum) + weight loss, fever. Gram + aerobic branching partially acid fast? Txt?

question

Actinomyces (anaerobic) Txt: high dose PCN x6-12wks

answer

Neck or face infection w/ draining yellow material (+sulfur granules). Gram+ anaerobic branching? Txt?

question

Check osmolarity Check volume status Txt: - Correct w/ NS if hypoV - 3% saline only if seizures or [Na] < 120 - fluid restrict + diuretics Don't correct faster than 12-24mEq/day or else *Central Pontine Myelinolysis*

answer

Hyponatremia workup? TxT?

question

CHF nephrotic cirrhotic

answer

Hypervolemic hypoNa causes?

question

diuretics or vomiting + free water

answer

Hypovolemic hypoNa causes?

question

SIADH (check CXR if smoker) Addison's (adrenal insufficiency) Hypothyroidism

answer

Euvolemic hypoNa causes?

question

Replace water w/ D5W or other hypotonic fluid Don't correct faster than 12-24mEq/day or else *cerebral edema*

answer

Hypernatremia txt?

question

HypoCa

answer

tetany perioral tingling Chvostek (CNVII reflex) Troussaeu (BP cuff-> spasms) prolonged QT interval

question

HyperCa

answer

? kidney STONES ? psychic MOANS ? abdominal GROANS ? achy BONES Shortened QT interval

question

hypoK Txt: K+ (make sure pt can pee) max 40mEq/hr

answer

paralysis, ileus, ST depression, U waves? Txt?

question

hyperK Txt: Ca-gluconate, then insulin + glc, Kayexalate, Albuterol and Sodium bicarb, Last resort = dialysis

answer

peaked T waves, prolonged PR and QRS, sine wavesTxt?

question

Metabolic alkalosis Check urine Cl if [Cl]>20 +HTN - hyperaldo (Conns), if normoTN think Barter's or Gittlemans if [Cl]<20 - think vomiting, NG suction, antacids, diuretics

answer

HCO3 high pCO2 high Next test? Ddx?

question

Respiratory alkalosis hyperventilation from anxiety, high ICP, fever, pain, ASA

answer

pCO2 low HCO3 low Ddx?

question

Metabolic acidosis Check Anion gap (Na-Cl-HCO3) Gap -> MUDDLES non-gap -> diarrhea, diuretic, RTA (I, II, IV)

answer

HCO3 low pCO2 low Next test? Ddx?

question

Respiratory acidosis hypoventilation from opiates, brainstem injury, ventilation problems

answer

pCO2 high HCO3 high Ddx?

question

Distal tubule, can't excrete H+ Cause: Lithium/AmphoB, analgesics, SLE, Sjogrens, SCA, hepatitis Dx: Urine pH>5.4, *hypoK*, stones Txt: replete K, PO bicarb

answer

Type I RTA Causes? Dx/presentation? Txt?

question

Proximal tubule, can't reabsorb HCO3 Cause: Fanconi sx, myeloma, amyloidosis, vitD deficiency, autoimmune dx Dx: *hypoK*, osteomalacia Txt: replete K, mild diuretic, NO bicarb

answer

Type II RTA Causes? Dx/presentation? Txt?

question

hyperRenin, hypoAldo Cause: DM (>50%), Addison's dx (adrenal insufficiency), SCA, aldo deficiency Dx: *hyperK*, hyperCl, high urine [Na] even w/ salt restriction Txt: *Fludrocortisone*

answer

Type IV RTA Causes? Dx/presentation? Txt?

question

hereditary or acquired proximal tubule dysfxn defective transport of glucose, AA, Na, K, PO4, uric acid, bicarb -> Type II RTA, replete K, mild diuretic

answer

Fanconi's anemia

question

>25% or 0.5 rise Cr over baseline Workup: BUN/Cr -> prerenal if >20/1 Urine Na and Cr -> prerenal if FENA prerenal if <35%

answer

ARF? Workup?

question

fluids and treat underlying issue (reason for low renal perfusion)

answer

Prerenal ARF Txt?

question

*AEIOU* *A* - acidosis *E* - electrolyte imbalance (esp K>6.5) *I* - Intoxication (esp antifreeze, Li) *O* - overloaded V -> CHF sx or pulmonary edema *U* - uremia -> pericarditis, AMS NOT for high Cr or oliguria alone!

answer

Indications for emergent dialysis?

question

Intrinsic: *ATN* Txt: fluids, avoid nephrotox, dialysis if indicated

answer

Muddy brown casts in a pt w/ ampho, aminoglycosides, statins, cisplatin or prolonged ischemia? Txt?

question

Intrinsic: *AIN* Txt: Stop offending agent. Add steroids if no improvement.

answer

Protein, blood and Eos in the urine + fever and rash who took Trim-sulfa 1-2wks ago? Txt?

question

Intrinsic: *Rhabdomyolysis* 1st test is check [K+] or EKG. Txt: bicarb to alkalinize urine to prevent precipitation

answer

Army recruit or crush victim w/ CPK of 50K, +blood on dip but no RBCs? Txt?

question

Intrinsic: *Ethylene glycol intox* Txt: dialysis or NaHCO3 if pH<7.2

answer

Enveloped shaped crystals on UA? Txt?

question

Intrinsic: *Contrast nephropathy* Prevent by hydrating before or giving bicarb or NAC

answer

Bump in creatinine 48-72hrs s/p cardiac cath or CT scan?

question

#1 cause of death *CVD* -> goal LDL *CHF* *Normochromic normocytic anemia* -> loss of EPO *?K, ?PO4, ?Ca* (leads to 2ndary hyperPTH) ?PO4 leads to precip of Ca into tissues -> *renal osteodystrophy and calciphylaxis* (skin necrosis) *Uremia* -> confusion, pericarditis, itchiness, increased bleeding 2/2 platelet dysfxn

answer

Complications of CKD?

question

Uremia bleeding 2/2 platelet dysfxn

answer

confusion, pericarditis, itchiness, increased bleeding

question

Bladder/Kidney cancer until proven otherwise

answer

painless hematuria?

question

bladder CA or hemorrhagic cystitis (cyclophosphamide)

answer

"termina hematuria" + tiny clots?

question

Glomerular source

answer

Dysmorphic RBCs or RBC casts?

question

Proteinuria (but <2g/24hrs) hematuria edema azotemia

answer

Definition of nephritic syndrome?

question

Berger's Dz (IgA nephropathy)

answer

Hematuria *1-2 days* after runny nose, sore throat & cough?

question

Post-strep GN Sx: smoky/cola urine Dx: best 1st test is ASO titer EM: Subepithelial IgG humps

answer

Hematuria *1-2 weeks* after sore throat or skin infxn?

question

Goodpasture's Syndrome Abs to collagen IV

answer

Hematuria + Hemoptysis?

question

Alport Syndrome XLR mutation in collagen IV

answer

Hematuria + Deafness?

question

Henoch-Schonlein Purpura IgA. Supportive tx +/- steroids

answer

Hematuria in Kiddo s/p viral URI w/ Renal failure + abd pain, arthralgia and purpura? Txt?

question

HUS E.Coli O157H7 or Shigella. Don't tx w/ ABX (releases more toxin)

answer

Hematuria in Kiddo s/p hamburger and diarrhea w/ renal failure, MAHA and petechiae?

question

TTP Txt: plasmapheresis. DON'T give platelets. vs. DIC PT and PTT are normal in HUS/TTP.

answer

Hematuria in Cardiac patient s/p ticlopidine w/ renal failure, MAHA, ?plts, fever and AMS? Txt?

question

Wegener's Granuolmatosis Dx: Most accurate test is bx Txt: steroids or cyclophosphamide.

answer

c-ANCA, kidney, lung and sinus involvement? Txt?

question

Churg Strauss Dx: Best test is lung bx Txt: Cyclophosphamide

answer

p-ANCA, renal failure, asthma and eosinophilia? Txt?

question

Polyarteritis Nodosa Affects small/med arteries of every organ except the lung! Txt: cyclophosphamide

answer

p-ANCA, NO lung involvment, Hep B? Txt?

question

CT for kidney stones

answer

Best test for pt w/ flank pain radiating to groin + hematuria?

question

Calcium oxalate stones Txt: HCTZ

answer

Most common type of kidney stones? Txt?

question

Cysteine stones Can't resorb certain AA

answer

Kid w/ family hx of stones?

question

Struvite stones = Mg/Al/PO4 Proteus Staph Pseudomonas Klebsiella

answer

Kidney stones in pt w/ chronic indwelling foley and alkaline pee?

question

Uric Acid stone Txt: alkalinize urine + hydration

answer

Kidney stones in pt w/ leukemia being treated w/ chemo? Txt?

question

Pure oxylate stone Ca not reabsorbed by gut (pooped out)

answer

Kidney stones in pt s/p bowel resection for volvulus?

question

2cm - open or endoscopic surgical removal 5mm-2cm - extracorporal shock wave lithotripsy

answer

Txt for kidney stones of different sizes?

question

Repeat UA test in 2 weeks, then quantify w/ 24hr urine

answer

Best 1st test for pt w/ proteinuria?

question

>3.5g protein/24h hypoalbuminemia edema hyperlipidemia (fatty/waxy casts)

answer

Definition of nephrotic syndrome?

question

Minimal Change Disease Fusion of foot processes Txt: steroids

answer

Most common nephrotic sx in kids? Txt?

question

Membranous Nephropathy thick capillary walls w/ subepi spokes

answer

Most common nephrotic sx in adults?

question

FSGS Mesangial IgM deposits Limited response to steroids

answer

Nephrotic syndrome associated w/ heroin use and HIV?

question

Membranoproliferative GN tram track BM w/ subbed deposits

answer

Nephrotic sx assoc w/ chronic hepatitis and low complement?

question

suspect rental vein thrombosis 2/2 peeing out ATIII, protein C and S Do CT or US ASAP

answer

If nephrotic pt suddenly develops flank pain?

question

Orthostatic Bence Jones in multiple myeloma UTI pregnancy fever CHF

answer

Random causes of proteinuria?

question

Iron deficiency anemia hypochromic microcytic anemia

answer

Microcytic anemia MCV = 70, ?Fe, ?TIBC, ?retic, ?RDW, ?ferritin

question

Anemia of chronic disease

answer

Microcytic anemia MCV = 70, ?Fe, *?TIBC*, ?retic, nl ferritin.

question

Thalassemia RDW - little variation, suggests genetic cause

answer

Microcytic anemia MCV = *60*, ?RDW

question

Sideroblastic anemia May be caused by INH

answer

Microcytic anemia MCV = 70, ?Fe, ?ferritin, ?TIBC

question

Folate deficiency

answer

Macrocytic anemia MVC = 100, ?retics, ?homocysteine, nl methylmelonic acid.

question

B12 deficiency

answer

Macrocytic anemia MVC = 100, ?retics, ?homocysteine, ?methylmelonic acid

question

Acanthocytosis (spur cell) -> Liver dx

Liver dx" alt="Acanthocytosis (spur cell) -> Liver dx";

answer

Macrocytic anemia MVC = 100

question

Aplastic Crisis Sickle Crisis from hypoxia, dehydration or acidosis

answer

Normal MCV, ?LDH, ?indirect bilirubin, ?haptoglobin in Sickle cell kid w/ sudden drop in Hct?

question

Cold Agglutinins Destruction occurs in the liver. IgM mediated

answer

Normal MCV, ?LDH, ?indirect bilirubin, ?haptoglobin w/ Cyanosis of fingers, ears, nose + recent Mycoplasma infx?

question

Warm Agglutinins Destruction in spleen. IgG. Drug rxn or malignancy Txt: steroids 1st, then splenectomy.

answer

Normal MCV, ?LDH, ?indirect bilirubin, ?haptoglobin w/ sudden onset after PCN, ceph, sulfas, rifampin or Cancer?

question

Hereditary spherocytosis (AD loss of spectrin) Txt: splenectomy.

answer

Normal MCV, ?LDH, ?indirect bilirubin, ?haptoglobin w/ Splenomegaly, +FH, bilirubin gallstones, ?MCHC?

question

Paroxysmal Nocturnal Hemoglobinuria Defect in PIG-A. Lysis by complement. Incr risk for aplastic anemia

answer

Normal MCV, ?LDH, ?indirect bilirubin, ?haptoglobin w/ Dark urine in AM, Budd-Chiari syndrome?

question

G6PDH def Heinz bodies, Bite cells. Avoid oxidant stress.

answer

Normal MCV, ?LDH, ?indirect bilirubin, ?haptoglobin w/ sudden onset after primiquine, sulfas, fava beans?

question

ITP Txt: prednisone 1st. Then splenectomy. IVIG if ;10K. Rituximab

answer

A patient walks in with thrombocytopenia: 30 y/o F recurrent epistaxis, heavy menses ; petechiae. ?plts only? Txt?

question

VWD Txt: DDAVP for bleeding or pre-op. Replace factor VIII (contains vWF) if bleeding continues.

answer

A patient walks in with thrombocytopenia: 20 y/o F recurrent epistaxis, heavy menses, petechiae, normal plts, *? bleeding time and PTT*? Txt?

question

Hemophilia Txt: DDAVP if mild, otherwise replace factors

answer

A patient walks in with thrombocytopenia: 20yo M w/ recurrent bruising, hematuria, and hemarthrosis, ? PTT that corrects w/ mixing studies? Txt?

question

VitK def ? II, VII, IX and X. Same for warfarin toxicity. Txt: *FFP* acutely + vitK shot

answer

A patient walks in with thrombocytopenia: 50y/o M "meat-a-tarian" just finished 2wks of clinda has hemarthroses ; oozing at venipuncture sites? Txt?

question

Liver Disease. GI bleeding is most common 1st depleted: VII, so PT increases 1st not depleted: VIII and vWF b/c they are made by endothelial cells.

answer

A patient walks in with thrombocytopenia: 50y/o M "beer-a-tarian" w/ severe cirrhosis? 1st factor depleted? 2 factors not depleted?

question

Schistocytes! DIC Causes: Sepsis, rhabdo, adenocarcinoma, heatstroke, pancreatitis, snake bites, OB stuff, Tx of M3 AML (Auer rods) Txt: FFP, platelet transfusion, correct underlying d/o

answer

A patient walks in w/ thrombocytopenia and this smear... If PT and PTT are ?, fibrinogen ?, D-dimer and fibrin split products ?? Causes? Txt?

question

TTP/HUS Causes: O157:H7, Ticlopidene Txt: plasmapheresis, NOT platelets

answer

A patient walks in w/ thrombocytopenia and this smear... If PT and PTT are normal? Causes? Txt?

question

HIT IgG to heparin bound to PF4 Txt: stop heparin, reverse warfarin w/ vitK, start Lepirudin

answer

7 days post-op, a patient develops an arterial clot. Her platelets are found to be 50% less than pre-op? Txt?

question

Cancer Nephrotic sx - pee out ATIII protein C and S preferentially, at risk for RVT

answer

What to look for in someone w/ unprovoked thrombus?

question

Lupus anticoagulant

answer

What to look for in someone w/ unprovoked thrombus? ?PTT, multiple SABs, false+ VDRL?

question

Protein C/S deficiency

answer

What to look for in someone w/ unprovoked thrombus? Skin necrosis after warfarin is started?

question

Factor V Leiden V is resistant to C

answer

What to look for in someone w/ unprovoked thrombus? Most common inheritable pro-coag state?

question

ATIII Deficiency

answer

What to look for in someone w/ unprovoked thrombus? Still clots on heparin?

question

OCPs/HRT

answer

What to look for in someone w/ unprovoked thrombus? Female smoker ;35yo?

question

OA

answer

Knee pain, DIP involvement no swelling or warmth, worse @ the end of the day, crepetence.

question

RA

answer

PIP and wrists bilaterally, worse in the AM, low grade fever.

question

Psoriatic Arthritis.

answer

DIP joint involvement, rash w/ silvery scale on elbows and knees, pitting nails and swollen fingers.

question

SLE

answer

Symmetric, bilateral arthritis, malar rash, oral ulcers, proteinuria, thrombocytopenia. Arthritis is not erosive or have lasting sequellae.

question

Septic arthritis

answer

A patient comes in w/ acute swollen painful joint... tap: WBCs ;50K

question

Gonococcal Cx may be negative. Look also for tenosynovitis and arm pustules. Txt: *Ceftriaxone*

answer

Septic arthritis in 30yo who "travels a lot for work"? Txt?

question

Staph aureus Txt: *Nafcillin or Vancomycin*

answer

Septic arthritis in 70yo nun? Txt?

question

Inflammatory If no crystals, think RA, ank spon, SLE, Reiter's

answer

A patient comes in w/ acute swollen painful joint... tap: WBCs 5-50K

question

Gout - Monosodium Urate Acute TX? *Indomethacin + colchicine* (steroids if kidneys suck). Chronic TX? *Probenecid* if undersecreter. *Allopurinol* if overproduc.

answer

Inflammatory arthritis w/ needle shaped, negatively birefringent crystals? Txt?

question

Pseudogout Txt: Calcium pyrophosphate

answer

Inflammatory arthritis w/ rhomboid shaped, positively birefringent crystals? Txt?

question

OA hypertrophic osteoarthropathy trauma

answer

A patient comes in w/ acute swollen painful joint... tap: WBCs 200-5K

question

Normal

answer

A patient comes in w/ acute swollen painful joint... tap: WBCs <200

question

ANA - peripheral/rim staining.

answer

Ab If negative, rules out SLE?

question

Anti-dsDNA or Anti-Smith

answer

Ab Most sensitive for SLE?

question

Anti-histone

answer

Ab Drug induced lupus? (hydralazine).

question

Anti-Ro (SSA) or Anti-La (SSB)

answer

Ab Sjogren's Syndrome?

question

Anti-centromere

answer

Ab CREST syndrome?

question

Anti-Scl-70, Anti-topoisomerase

answer

Ab Systemic Sclerosis?

question

Anti-RNP

answer

Ab Mixed connective tissue disease?

question

RF (against Fc of IgG) Anti-CCP (cyclic citrullinated peptide)

answer

2 Ab tests for RA?

question

Leser Trelat sign

answer

Sign of systemic disease

question

Dermatomyositis

answer

Sign of systemic disease

question

seborrheic dermatitis

answer

Sign of systemic disease

question

erythema multiforme

answer

Sign of systemic disease

question

acanthosis nigricans

answer

Sign of systemic disease

question

Dermatitis herpetiformis

answer

Sign of systemic disease

question

Porphyria Cutanea Tarda

answer

Sign of systemic disease

question

Erythema nodosum

answer

Sign of systemic disease

question

Necrolytic migratory erythema

answer

Sign of systemic disease

question

Bullous pemphigoid

answer

Sign of systemic disease

question

Pemphigus vulgaris

answer

Sign of systemic disease

question

Behcet's syndrome

answer

Sign of systemic disease

question

Shave or punch bx then surgical removal (Mohs)

answer

Txt basal cell carcinoma

question

treat precursor lesions (actinic keratosis or keratoacanthoma) Txt: Excisional bx at edge of lesion, then wide local excision. Can use rads for tough locations.

answer

Txt squamous cell carcinoma

question

Superficial spreading (best prog, most common) Nodular (poor prog) Need full thickness biopsy b/c depth is #1 prog Tx w/ excision - 1cm margin if 4mm High dose IFN or IL2 may help

answer

Mgmt for melanoma

question

Prolactinoma Sx: amenorrhea/hypoT Txt: Bromocriptine or Cabergoline even if large (>10mm)

answer

Most common pituitary adenoma? Sx? Txt?

question

#1 FSH and LH #2 GR #3 TSH #4 ACTH

answer

Order of hormones lost in hypopituitarism?

question

DI lack of ADH (or nonfunctional)

answer

Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine?

question

Nephrogenic DI Txt: HCTZ/amiloride

answer

Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ? s/p ddAVP? Txt?

question

Central DI

answer

Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ? s/p water deprivation, ? w/ DDAVP?

question

I123 RAIU scan. If ? = Graves If ? = factitious or thyroiditis 1st Txt: propanolol + PTU/MTZ I123 ablation surgery (pregnant, children)

answer

See low TSH, high free T3/T4. Next best step? Txt?

question

PTU + Iodine (Lugol's sol'n) + propranolol

answer

Thyroid storm txt?

question

1st: check TSH if low -> RAIU if normal -> FNA

answer

Workup for thyroid nodule?

question

"hot nodule" -> excision or radioactive I131 "cold nodule" -> surgically excise and check pathology

answer

RAIU workup (s/p low TSH)?

question

Papillary

answer

Most common type of thyroid nodule, spreads via lymph, psammoma bodies?

question

Follicular must surgically excise whole thyroid

answer

thyroid nodule that spreads via blood?

question

Medullary Assoc w/ MEN2 (look of pho, hyperCa)

answer

Thyroid nodule associated w/ calcifications and amyloidosis?

question

Anaplastic

answer

Thyroid nodule w/ 80% in 1st yr?

question

Thyroid lymphoma

answer

Hashimoto's predisposes you to this type of thyroid nodule?

question

Suspect Cushing's 1mg ON dexa suppression test or 24hr urine cortisol if abnormal, dx Cushing's 8mg ON dexa suppression test

answer

Osteoporosis, central fat, DM, hirsutism? Best screening test?

question

adrenal neoplasm vs ectopic ACTH plasma ACTH Chest CT if smoker abdominal CT/DHEAS

answer

Osteoporosis, central fat, DM, hirsutism? No adrenal suppression after 8mg ON dexa? Nest test?

question

Suspect Adrenal Insufficiency Cosyntropin stimulation test (60min after 250mcg)

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Weakness, hypotension, weight loss, hyperpigmentation, ?K, ?Na, ?pH? Best screening test?

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Autoimmune (Addison's disease) Txt: NaCl resuscitation, Long term replacement of dexamethasone and fludrocortisone

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Most common cause of adrenal insufficiency? Txt?

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hypoparathyroidism

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Perioral numbness, Chvortek, Trousseau s/p Thyroidectomy, ?[Ca], ?[PO4], ?[PTH]?

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hyperparathyroidism Dx w/ FNA of suspicious nodules. Can use Sestamibi scan. Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4 glands and implant 1 in forearm.

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Kidney stones, constipation/abd pain or psychiatric sxs, ?[Ca], ?[PO4], ?vitD, ?[PTH]? Dx? Txt?

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*MEN1* - pituitary adenoma, parathyroid hyperplasia, pancreatic islet cell tumor. *MEN2a* - parathryoid hyperplasia, medullary thyroid cancer, pheochromocytoma *MEN2b* - medullary thyroid cancer, pheochromocytoma, Marfanoid

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MEN?

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FBGL > 126 x 2 2hr OGTT > 200 random glc > 200 + sxs (polyuria, polydipsia, blurred vision)

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Dx of DM?

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DKA Dx: ketones in blood and urine, AGMA, hyperK Txt: high volume NS + insulin bolus and drip, add K once peeing, add glucose<200

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Nausea, vomiting, abdominal pain, Kussmaul respirations, coma w/ BGL=400? Dx? Txt?

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HHS Txt: high volume fluid and electrolytes, may require insulin

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Polyuria, polydipsia, profound dehydration, confusion and coma w/ BGL = 1000? Txt?

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CVD

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Most common cause of death in DM pts?

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Heart: LDL<100, BP vitreous humor/neovasc Nerves: podiatric exam qyr. Tx gastroparesis w/ metoclopramide or Eythromycin, may get ED, 3rd, 4th, 6th CN palsy

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Important screening for DM pts?

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80% ischemic 20% hemorrhagic

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Most common cause of stroke?

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noncontrast CT to r/o hemorrhage diffusion-weighted MRI best for ischemic, CT can be negative for 1st 48hrs

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Best 1st test for stroke? Most accurate test?

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TPA w/in 3-4.5hrs ASA >4.5hrs Heparin only for those in Afib, basilar clot

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Stroke txt w/in 3-4.5hr? later?

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stroke w/in 3mo surgery w/in 2wks LP w/in 1wk

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Contraindications to tPA?

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Add dipyridamole or switch to clopidogrel. Don't use ticlopidine! (why?)

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If pt has stroke while on ASA?

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Nimodipine to reduce ischemic stroke from vc (most common cause of M;M)

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If pt has SAH?

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W/in days or rupture or when ;10mm

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When to clip an aneurysm?

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When occlusion ;70% and is symptomatic. (;60% if ;60y/o)

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When to do endarterectomy?

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R MCA stroke

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Where's the lesion? L hemiplegia/hemisensory loss, L homonomous hemianopsia w/ eyes deviated twoards the R + apraxia.

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R ACA stroke

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Wheres the lesion? L hemiplegia/hemisensory loss in the leg>arm. Confusion, behavioral disturbance.

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R Webber's

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Where's the lesion? L hemiplegia + R ptosis & eye deviated to the right and down

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R Benedikt's

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Where's the lesion? Falling to the L + R ptosis & eye deviated to the right and down.

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R Wallenburg (PICA)

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Where's the lesion? L hemisensory loss + Horners + R facial sensory loss.

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Major R cerebellar arteries

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Where's the lesion? Vertigo, vomiting, nystagmus and clumsiness with the right arm.

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Paramedial branches of the basilar artery

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Wheres the lesion? Total paralysis except for vertical eye movements.

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Lorazepam + LD of phenytoin. Then phenobarbitol. Then anesthesia

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Status Epilepticus Txt?

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simple if no LOC and complex if LOC (may have lip smacking) Both can generalize. Txt: 1st line = carbamazepine or phenytoin. Then valproate or lamotrigine

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Partial seizures begin focally. (Arm twitch, de-ja-vu, burning rubber smell)? Txt?

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1st line = valproic acid, then lamotrigine, carbamezepine, phenytoin

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Generalized seizures txt?

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ethosuximide

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Absence sz txt?

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Absence Seizure. Tx w/ ethosuxamide

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EEG buzzword: 3 Hz spike-and- wave Txt?

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Creutzfeldt Jakob. Dementia + myoclonus

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EEG buzzword: Triphasic bursts

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Delirium. Contrast w/ psychosis that has no EEG changes

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EEG buzzword: Diffuse background slowing

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Infantile spasms. Tx w/ ACTH. Most are associated w/ mental retardation.

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EEG buzzword: Hypsarrhythmia Txt?

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Subarachnoid hemorrhage. Noncon CT 1st!

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Acute HA: "Worse headache of my life"

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Meningitis. Abx then CT then LP

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Acute HA: + Fever and Nuchal rigidity

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consider space occupying lesion (brain tumor) most important prognostic feature is grade (degree of anaplasia)

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Acute HA: deep pain that wakes pt up at night, worse w/ coughing or bending forward

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Temporal arteritis Check ESR, then give steroids, then to temporal artery dx Can lead to blindness

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Acute HA: unilateral pounding, w/ changes in vision and jaw claudication

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Pseudotumor cerebri also assoc w/ OCPs Normal CT, elevated P on LP Txt: wt loss, Acetazolamide, then shunt or optic nerve sheet fenestration

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Fat lady on minocycline or who takes isotreintoin w/ abducens nerve palsy/diplopia

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Guillain-Barre CSF shows albumino-cytologic dissociation Campylobacter, HHV, CMV, EBV Txt: IVIG or plasmapheresis, monitor VC for intubation req

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Diarrhea 3wks ago, now areflexia and ascending paralysis? Most likely bug? Txt?

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Myasthenia Gravest 1st test: ACh-Ab Most accurate test: EMG, decrease in muscle fiber contraction Acute txt: IVIG or plasmapheresis, monitor VC for intubation req Chronic txt: Pyridostigmine, GCs/Azathioprine, thymectomy (<60yo) Rx to avoid: Aminoglycosides, beta blockers

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Nasal voice, ptosis, dysphagia, respiratory acidosis? Dx? Txt?

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Multiple sclerosis neurodeficits separated by time and space Dx: MRI, increased T2 at periventricular white matter Acute txt: steroids (3d IV then 4wk PO), plasma exchange is 2nd line Chronic txt: IFN-beta1a, beta1b, Glatiramer reduces exacerbations

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urinary retention, Babinski on R, episode of double vision 6mo ago? Dx? Txt?

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Acute Leukemia on Biopsy

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A patient presents w/ fatigue, petechiae, infection bone pain and HSM... If >20% blasts?

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ALL. Most common cancer in kids

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A patient presents w/ fatigue, petechiae, infection bone pain and HSM... CALLA or TdT?

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AML. More common in adults. RF = rads exposure, Down's, myeloprolif. M3 has Auer Rods and causes DIC upon tx.

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A patient presents w/ fatigue, petechiae, infection bone pain and HSM... Auer rods, MPO, esterase?

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Hairy Cell Leukemia. See enlarged spleen but no adenopathy. Hairy Cells have numerous cytoplasmic projections on smear. Tx w/ cladribine 5-7day single course

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A patient presents w/ fatigue, petechiae, infection bone pain and HSM... Tartate resistant acid phosphatase, ?monos ; CD11 and CD22+?

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Danorub, vincris, pred. Add intrathecal MTX for CNS recurrence. BM transplant after 1st remission.

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Tx of ALL?

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Danorub + araC If *M3 -; give all trans retinoic acid

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Tx of AML?

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CML- 9:22 transloc --> tyrosine kinase Tx w/ imantinib (Gleevec), inhibits tyrosine kinase. 2nd line is bone marrow transplant. Cx = blast crisis.

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A patient presents w/ fatigue, night sweats, fever, splenomegaly and elevated WBCs w/ low LAP and basophilia?

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CLL

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Asymptomatic elevation in WBCs found on routine exam - 80% lymphs.

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If Lymphadenopathy - Stage 0 or 1 need no tx- 12 yrs till death If Splenomegaly - Stage 2 tx w/ fludrabine If Anemia, If Thrombocytopenia - Stage 3 or 4 tx w/ steroids

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Staging CLL: If LAD? If splenomegaly; If anemia? If thrombocytopenia?

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Think Lymphoma

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Enlarged, painless, rubbery lymph nodes

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"B-symptoms" = poor prognosis along w/ ;40, ?ESR and LDH, large mediastinal LND

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Drenching night sweats, fevers ; 10% weight loss

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Hodgkin's Lymphoma

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Orderly, centripetal spread + Reed Sternberg cells?

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Lymphocyte predominant

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Hodgkins lymphoma w/ best prognosis?

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Non-hodgkin's Lymphoma

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Lymphoma most likely to involve extra nodal sites?

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I = 1 node group II = 2 groups, same side of diaphragm III = both sides of diaphragm, extension into organ IV = BM or liver

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Lymphoma staging?

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Stage I/II get rads Stage III/IV get ABVD Chemo

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Lymphoma txt?

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Multiple myeloma 1st test: serum protein electrophoresis - IgG monoclonal spike Confirmatory test: BM bx showing ;10% plasma cells Txt: if young, BM transplant. If old, melphalan + prednisone. Hydration and Lasix, then Bisphosphonates for hyperCa

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Bone pain, "punched out lesions" on x-ray, hyper Ca? Best 1st test? Txt?

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Waldenstrom Macroglobulinemia

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Dizziness, HA, hearing/vision problems and monoclonal IgM M-spike?

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MGUS

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No sxs, immunoglobulin spike found on routine exam?

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Polycythemia Vera 1st test: EPO, make sure it isn't secondary (PSG, carboxyHbg) Txt: scheduled phlebotomy, Hydroxyurea can prevent thromboses

answer

Older pt w/ generalized pruritis and flushing after hot bath. Hct of 60%? Best 1st test? Txt?

Internal Medicine – Emma Holliday Ramahi – Flashcards

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