Internal Medicine Flashcards
37 y/o man brought to ED, after been found yelling obscenities at drivers, responding to internal stimuli, slamming body against passing cars. In ED has seizures, treated with Benzos. Remains psychotic for next 2 days, but then S+S eventually subside. What did he take?
Bath saltshave Amphetamine like properties, inhibiting uptake of NE, DA, and 5-HT. S+S: psychosis, seizures, severe agitation. TQ: these S+S last as long as a week, and then subside!
67 y/o women has had periodic confusion, memory loss, and poor sleep for past 1-2 years. Tells her son there "are strangers in the backyard." Can only recall 1/3 items, can't count backwards. MRI shows generalized cortical atrophy. Dx?
Dementia with Lewy Bodiesoccurs due to accumulation of Eosinophilic intracytoplasmic inclusion bodies. S+S: alterations in consciousness, visual hallucinations, out of it.
#1 test to order for pt with syncopal episodes and evidence of Left Ventricular Hypertrophy?
EchocardiogramPt who faints and has LVH, probs has Aortic Stenosis. Echo is test of choice to detect structural heart probs (LVH, Aortic Stenosis, Hypertrophic Cardiomyopathy, Pericardial Tamponade)
When to order a Holter moniter?
24-hour EKG (aka Holter moniter) used to detect Arrhythmias (AV block, V-tachy, A-Fib, etc.)
74 y/o man with urinary frequency, mild straining during urination, microscopic hematuria, and 30 yr pack year history. Next best step?
Cystoscopy (examines lining of bladder)Risk factor for Bladder Cancer include cig. smoking.
Treatment of E.D. in man with history of Acute Coronary Syndrome?
Oral Sildenafil (PDE5 inhibitor)Key: E.D. is common in patients with Cardiovascular disease. 1st line is Sildenafil. TQ: PDE5 inhibitors are C.I. in patients taking Alpha-blockers (Prazosin) or Nitrates bc it can cause life threatening hypotension.
21 y/o male brought to ER due to dizziness, and palpitations. He had similar episodes in past, which was usually relieved by squatting and taking a deep breath. However, this time that didn't work. ECG shows: regular, narrow-complex tachycardia. Next best step?
Synchronized Cardioversion TQ: Pt has regular, narrow-complex tachy (SVT). This is causing him hemodynamic instability.Must treat all patients with Tachyarrhytmias with Immediate Synchronized Cardioversion, which will deliver shock to QRS waves, to get them synchronized.
37y/o man with HIV has had a productive cough, with no hemoptysis. Drinks a lot, and smokes a lot. CXR shows Right upper lobe infiltrate. Microbe?
Mycobacterial infectionTQ: Patients with HIV are at higher risk of reactivation TB. TB is reactivated in UPPER lung lobes bc of higher O2 concentration.
Aspiration pneumonia
also common in alcoholics, but affects LOWER lung lobes. (specifically the RLL)foul-smelling sputum
Pt with Aortic Stenosis required Aortic Valve replacement. Peripheral Blood Smear shows Schistocytes (Helmet Cells). Labs?
Low free Haptoglobin, High LDH, High BilirubinSchistocytes occur in patients with prosthetic heart valves.
33 y/o postpartum woman has severe onset SOB and right sided chest pain after breastfeeding. In ER, has obvious distress, and use of accessory muscles. Labs show Resp. Alkalosis. Next best step?
IV heparin infusionTQ: In patient with PE, must anticoagulate to decrease mortality PRIOR to confirming diagnosis with CT-pulm. angiogram. Note: in patients where anticoag. is C.I., use an IVC filter to get rid of the P.E.
32y/o woman with persistent cough, SOB, and 3 episodes of pneumonia over last 3 years. Also had severe sinusitis, and an episode of bloody diarrhea. P.E. shows fine crackles over Right Lower Lung. Which lab to order?
Quantitative measure of serum immunoglobulin levelsRecurrent bacterial infection in an adult should raise suspicion for Common Variable Immunodeficiency. CVID occurs due to impaired B-cell differentiation and Hypogammaglobulinemia.
What does Alpha-1-Antitrypsin deficiency cause?
Leads to Emphysema and Liver Damage. Does NOT increase risk of recurrent infections though.
Best treatment for patient that you hear an S3 heart sound on?
Diuretics Causes of S3 ("Kentucky")1. young athlete2. CHF3. pregnancydecrease fluid overload and early diastolic filling by giving patient a diuretic!
62 y/o male presents for evaluation of weakness. Six hours ago, felt weak in Right arm and leg, which resolved in 30 minutes. Has history of HTN, Diabetes, and S4. Next best step?
AspirinTQ: Pt has ischemic stroke. Aspirin is only anti-platelet agent that's effective in reducing risk of recurrence of ischemic stroke, but MUST be given within 24 hours. Risk factors for Ischemic Stroke: Smoking, HTN, Hyperlipidemia.
34y/o woman comes with midepigastric abdominal cramping, pain, N/ watery diarrhea, and gas for past 4-5 months. Episodes occur within hour of eating. Also has gas and bloating. Cause?
Deficiency of Brush Border EnzymePatient has Lactose Intolerance. Lactose is made in BB of Duodenum. TQ: presents in patients 20-40 years old. S+S: crampy abdominal pain, bloating, watery diarrhea, gas.
Salvage therapy
Ex: patient with prostate cancer undergoes radical prostatectomy, but continues to have elevated PSA. So radiation therapy is used. Radiation therapy is the Salvage therapy, when Standard therapy (surgery) fails.
Treatment of frostbite?
first must rapidly rewarm tissue with warm bath water.
When to give pneumococcal vaccine?
For patients over >65y/o, must give 1. 13-valent pneumococcal conjugate vaccine, followed by the 23-valent pneumococcal polysaccharide atleast 6-12 months later. Influenza vaccine should be given annually.
35 y/o male from Wisconsin, with fever, night sweats, productive cough, weight loss. Skin exam shows multiple well circumscribed verrucous crusted lesions. CXR shows left upper lobe consolidation and lytic lesions in anterior ribs. Microbe?
BlastomycosisBroad-based budding yeasts Endemic in Great Lakes, Ohio, and Mississippi River. Causes: skin, bone, lung probsTx: Itraconazole and Amphotericin B.
54 y/o male presents with SOB and cough. Physical exam shows dullness to percussion over RLL. Most likely cause of SOB?
Consolidation of the lungKey: "Dullness to percussion" means patient has Pneumonia. Common in RLL.
45 y/o woman has a 10 day history of pruritic rash. Rash started on hands and now has pustules on finger webs, palms, and wrsit creases. Cause?
Scabies Tx: Topical Permethrin or Oral Ivermectin
35 y/o with LBP, worse at end of day, worse with felxion and extension. Pain started 3 months ago, without any trauma. Negative Straight Leg Raise Test. Tx?
Exercise TherapyManagement of Chronic LBP should include exercise program that encourages stretching, strengthening of Lower back muscles.
Lumbar spinal stenosis
back pain radiating to thighs, worse with extension, and prolonged standing. better with standing. n, t, p to LEX
Lumbar disc herniation
Acute LBP, unilateral. Flexion makes pain worse
Torticollis is a form of?
Focal dystonia, involving SCM
Akathisia
restlessness
Athetosis
slow, writhing movements. Huntington's Disease
Side effect of Nitroprusside drip?
prolonged infusion of Nitroprusside can lead to Cyanide poisoning. S+S: headache, confusion, arrythmias, flushing, resp. distress, hyperreflexia.
U.C. and PSC are both associated with what markers?
+p-ANCAPSC causes both intra and extra hepatic destruction of bile ducts (with fibrosis and strictures) and can cause fatigue/pruritis
Amantadine
NMDA Glutamate-rec inhibitor that increases release and prevents reuptake of DA for P.D.Side effect: Livedo reticularis
Side effect of Levodopa/Carbidopa?
Levidopa/Carbidopa are most effective meds for P.D.Early common side effects include hallucinations.
45 y/o man comes to ER with severe SOB, fatigue, and weight gain for past 2 weeks. Worsening SOB, especially at night when he lays down. BP is 200/120. Has anasarca, distended JVD, and RBCs in urine. MOA of edema?
Primary glomerular damageTQ: Pt's RBC casts are clue that he has Nephritic Syndrome--->glomerular damageTQ: Glomerular damage causes decreased GFR and increased fluid overload/edema (JVD, weight gain, anasarca)
Causes of hypoalbuminemia?
1. Nephrotic syndrome (increased protein loss in urine)2. Cirrhosis (decreased synthesis of Albumin)Low Albumin leads to low Oncotic pressure and increases Hydrostatic pressure in tissues, leading to edema
Risk factor in PCOS?
can cause "Androgenic Alopecia" (aka male-patterned hair loss), along with irregular menses, and obesity. Pts with PCOS must get oral glucose tolerance test bc they are at risk for T2DM.
55 y/o woman has pain, itching, and red streaks on left arm. Occurred on chest 2 weeks ago, but went away. Pt has upper abdominal pain. Has a 15 year smoking history. P.E. shows tender, red, cord-like veins on left arm and chest. Best imaging?
CT scan of abdomen TQ: This pt has migratory superficial thrombophlebitis (Trousseau's syndrome)MOA: Trousseu's syndrome is a hypercoagulable disorder, that causes superficial clots at weird locations (arm, chest) It is associated with cancer (pancreatic cancer is most common), as well as stomach cancer, etc. Must do an abdominal CT scan to actually look for the cancer.
27 y/o man comes to office with fever, joint pain. Started Cephalexin for a skin infection. His urine is dark, and he has a temp. of 101.3. P.E. shows skin rash, and UA shows RBC and WBC casts, and Eosinophiluria. Next best step?
Stop CephalexinTQ: Pt has Drug-induced Interstitial NephritisS+S: fever, rash, joint pain, dark urine, and WBC/RBC casts, with Eosinophils in pee. Causes: taking NSAIDs, Penicillin, Cephalosporins, and Sulfa drugsTx: for Drug-induced Interstitial Nephritis is to just stop the drug.
Pt has an NSTEMI. Coronary angiogram shows near-total occlusion of the left Circumflex artery, which is treated with a stent. Pt is started on Aspirin, Beta Blocker, Statin, and ACE inhibitor. What other med should he be put on?
P2y12 receptor blockerTQ: P2y12 receptor blockers include (Clopidogrel, Prasigrel, Ticagrelor, Ticlopidine) TQ: Pts with NSTEMI and/or who've gotten a Stent, should receive P2y12 receptor blockers, to reduce recurrent MIs, and stent thrombosis.TQ: Best to give Dual antiplatelet therapy (tPA), with Aspirin, and P2y12 rec. blockers, rather than just Aspirin alone
NSTEMI with CAD tx. regimen?
1. tPA, Aspirin, P2y12 rec. blockers2. Beta Blockers3. ACE inhib/ARBs4. Statins5. Aldosterone antagonists
MOA of Milrinone?
PDE inhibitor that increases cAMP, and increases cardiac contractility.
Group on teens have an indoor BBQ, where they serve potato salad and BBQ chicken. Few hours later, come to ER with headache, N/V, abdominal pain, and confusion. P.E. shows "pinkish-hue" to skin. Dx?
Carbon monoxide poisoning. Tx: 100% O2 face mask or Hyperbaric oxygen chamber
LEMS
Occurs in Small Cell Lung CarcinomaS+S: SYMMETRICAL proximal m. weakness, decreased DTRs, Ex: can't get up from chair, or comb hair, or put dishes in overhead cabinet Clue: CT would show a lung mass
65 y/o woman complaints of fatigue, and SOB on exertion. She has a mid-systolic murmur, and tachycardia. Negative stool gauiac test. Low serum Iron, with elevated TIBC. Next best step?
Colonoscopy and Endoscopy TQ: #1MCC of fatigue with Iron def. anemia in elederly is GI blood loss. Even if Fecal occult blood came back negative, should still do colonoscopy/endoscopy to check for possible GI bleed. S+S of Iron def. anemia: tachycardia, systolic murmur
Drug approved for tx. of ALS?
Riluzole MOA: NMDA-Glutamate receptor inhibitor, which inhibits neuro excitation. Approved for ALS, by prolonging survival and time till Tracheostomy
Main tx. for GBS?
Plasmapheresis and IVIG
Best tx. for exacerbations of MS?
steroids
50 y/o man has hx of HTN, and DM. Has been on Hemodialysis for past 3 years. Also had a BKA for a non-healing foot ulcer. P.E. shows a Right carotid bruit. Pt. dies within next 5 years. Cause?
Cardiovascular diseaseTQ: Just know that Cardiovascular disease is the #1MCC of death in pts on dialysis. (50% of deaths in Dialysis population is bc of CVD)Ex: M.I. or Sudden Cardiac Death in pts on Dialysis
25 y/o has painless ulcer with smooth base on penis. Recently had sex with commercial sex worker. +RPR. However, pt has severe allergy to Penicillin. Tx?
Oral DoxycyclineTQ: Single dose of IM Benzathine Pen. G is tx. of choice in early Syphillis. If pt has severe Penicillin allergy, must receive Doxycycline.
Hepatorenal syndrome?
decreased GFR, low urine output, increased serum Cr. Lack of improvement with volume resuscitation. Occurs due to Sphlanic Arterial Dilation
Torsades de pointes
Prolonged QT interval Causes: HypoK+, HypoMg2+, HypoCa2+Note: Congenital Long QT Syndrome= occurs in pts with :family history of sudden cardiac death."
Man has syncopal episode. EKG shows Prolonged PR, prolonged QRS, normal QT, and occasional premature ventricular contractions. Cause of syncope?
BradyarrythmiaClue: Prolonged PR and QRS complexes are sign of intraventricular conduction delay--->Bradyarrhythmias
Electrical Alternans is associated with?
Electrical Alternans with Sinus Tachycardia is high specific for Pericardial Effusion (Cardiac Tamponade). S+S: hypotension, tachycardia, JVD, "distant heart sounds." Tx: Need to treat with pericardiocentesis to remove fluid stat
Tx. of CAP in hospitalized pt?
Moxifloxacin and admit to hospitalTQ: Tx. of CAP in hospitalized patients are either1. Fluroquinolones (Moxifloxacin) 2. or Beta Lactams and a Macrolide (Ceftriaxone plus Azithromycin)
21 y/o African American man asks for refill of opiod meds due to new-onset left hip pain. No local tenderness, but there is restricted ABduction and INternal rotation of left hip. Right hip and other joints are normal. Temp is 99, and ESR is normal. Dx?
Osteonecrosis of Proximal femurTQ: Osteonecrosis (aka Avascular Necrosis) of femoral head causes hallmark: Hip pain, with limited Internal Rotation and ABduction. Normal X-ray, normal Temp, and normal ESRCause: Occlusion of end arteries of Femoral Head with sickled cells, leading to necrosis and collapse.
Emplyer wants to find out info about Pt's status and if he will be able to return to work. Response?
Dr. can talk to employer if patient has either given Verbal or Written Consent to Doctor.
Risk of taking Fluroquinolones?
Ex: Ciprofloxacin---> can lead to Tendinopathy and rupture of Achilles Tendon. Tx: immediately stop taking drug, avoid exercise of affected area, and change to a different antibiotic.
Adult Jehovah's witness blood transfusion, in absence of advanced directive?
In absence of advance directive card (stating refusal of blood transfusion) in wallet, etc. you can proceed with blood transfusion
Screening for Bladder Cancer
Screening for Bladder Cancer is not recommended, even in patients with family hx or hx of smoking/exposure to industrial chemicals, unless they are symptomatic
Most common kind of kidney stones?
Calcium oxalate kidney stones
Calcium phosphate kidney stones occur in?
pts with HyperPTH or Type 1 RTA
24 y/o man has back pain, and a single episode of red urine. Had a sore throat for past 4 days. Cause of urinary complaints?
IgA Nephropathy (Berger's Dx)= #1MCC of Glomerulonephritis in AdultsOccurs about 5 days after URT infection
Clue: Lung pathology = think SIADH!
Labs: hypotonic, hyponatremia, but Euvolemia
Most likely location for Ulnar nerve entrapment?
Elbow TQ: HY TQ!Most common site for ulnar nerve entrapment is the elbow, where the ulnar nerve lies at the Medial Epicondylar GrooveEx: prolonged compression of ulnar nerve, by leaning on elbows while working at desk can lead to ulnar nerve S+S: n, t, p in 4th and 5 th digits, with weak grip.
Osteolytic lesions
occurs in pts with Multiple Myeloma Can get recurrent infections due to impaired Antibody production (Hypogammaglobulinemia), bc neoplastic cells will infiltrate bone marrow and cause ostelytic lesions/prone to infection.
MS pt has "decreased sensation to pinprick (STT), below the nipple line." Decreased proprioception (DCT), and muscle weakness present (CST). Where is the new plaque?
Thoracic spinal cord TQ: Nipples are innervated by T4.
Hepatic Hydrothorax
Pts with liver cirrhosis and Portal HTN can develop Abdominal ascites, and peripheral edema, due to low Albumin. Can also develop SOB, due to a "hepatic hydrothorax," a pleural effusion not due to any underlying cardiac or pulmonary abnormalities. Hepatic Hydrothorax occurs due to small defect in diaphragm, which allows passage of fluid into pleural space. Occurs on RIGHT side, bc of less muscle in that side of diaphragm and no heart.
Man just returned from 7 day Caribbean vacay where he ate cured fish, hiked and snorkeled. He is having dry mouth, slurred speech, difficulty swallowing and blurry vision. Pupils are dilated and sluggish. Difficulty holding head up, and muscle strength is 1/5 in UEX, and 5/5 in LEX. Next step?
Equine antitoxin therapy TQ: Pt has foodborne botulism (canned foods, cured fish), S+S: 1. bilateral mydriasis and sluggish pupils, blurry vision2. difficulty swallowing talking3. Descending skeletal muscle weakness/hypotonia UEX--->LEXTQ: Respiratory failure will require mechanical ventilator (diaphragmatic paralysis)TQ: Tx of adults >1y/o is with horse-derived (equine) antitoxin
Diagnosis of Lactose Intolerance?
+Hydrogen Breath Test
64 y/o woman complains of "irritating sore throat" for past 3 months. Admits to smoking 1 pack of cigarettes daily, and also drinks heavily. P.E. shows a 1.5 cm right Cervical lymph node. Biopsy shows Metastatic Squamous Cell Carcinoma. Next best step?
PanendoscopyTQ: Suspect Squamous cell carcinoma of mucosa of head and neck in pts that smoke and drink a lot. Hallmark: "Palpable Cervical lymph node." Best initial test: Panendoscopy (triple endoscopy= esophagoscopy, bronchoscopy, laryngoscopy) to detect primary tumor.
72 y/o woman brought to ER with sudden-onset, right-sided weakness/numbness. Extremely somnolent. Pt has history of HTN, and A-Fib, and takes Warfarin. INR is 5.2. CT scan shows brain bleed. Next step?
Prothrombin complex concentrate TQ: Pts with "Supratherapuetic" INR have a Warfarin O.D. which causes brain bleeds due to inhibition of clotting factors. Tx: Vit. K (promotes synthesis of 2,7,9,10, C and S in Liver) but takes 12-24 hoursTx: Prothrombin complex concentrate (PCC) also contains Vit K cofactors and is rapid for Warfarin reversalTx: can also give FFP/Cryopercipitate
65 y/o man complains of decreased appetite, N/V, abdominal bloating, and early satiety. Has history of longstanding T2DM, and has been taking insulin for 15 years. Blood glucose ranges from 40-400, and low blood glucose readings usually occur after meals. Tx?
Metoclopramide TQ: Pt has Diabetic Gastroparesis (delayed gastric emptying) S+S: anorexia, N/V, early satiety, bloating. Note: Hypoglycemia occurs after meals, bc insulin is injected before meals, but after eating there is delayed gastric emptying and absorption.
62 y/o man complains of anorexia, fatigue, and 20 pound weight loss, over past 6 months. Smokes a pack of cigarettes per day for past 40 years. P.E. shows a soft abdomen, mildly tender to deep palpation in mid-epigastric area. Pt has scleral icterus and jaundice. Best imaging?
Abdominal CT scan TQ: To detect pancreatic cancer, should perform abdominal U.S. or abdominal CT. S+S of Pancreatic cancer: abdominal pain radiating to back, weight loss, jaundice.
Risk factors for C. Difficile infection?
1. Gastric acid suppression (aka use of PPIs)2.Fluroquinolones/Clindamycin Tx: Oral Vancomycin
Risk of INH in tx of TB?
Peripheral neuropathyTQ: INH inhibits Vit B6 (Pyridoxine), leading to numbness and tingling in a stocking and glove distribution. Must supplement pt with Vit B6, if they are taking INH
TB Tx?
2 months of RIPE4 months of only RI
67 y/o man complains of 2 days of back pain, started after moving boxes in garage. Pain not relieved by lying down, and increases in intensity when straining and coughing. Negative straight leg raise test. Pt has point tenderness to palpation of vertebrae. Cause?
Loss of bone mineral densityTQ: Acute back pain with point tenderness after strenuous activity (moving boxes), is indicative of vertebral compression fracture. S+S: LBP, decreased spinal mobility, pain with standing, walking, lying, sneezing, etc.Cause: VCF occurs due to Osteoporosis (loss of bone mineral density)
34 y/o woman complains of diarrhea, weight loss, fatigue. Has very foul-smelling and floating poop, as well as diffuse bone pain. Labs?
Pt has Celiac's disease--->leads to fat malabsoprtion, steathorrhea, and foul-smelling, greasy poop. Fat malabsorption leads to lack of Vit ADEK,Labs: Low Vit D, Low Ca2+, Low Phosphorous, and high PTH
Man found wandering streets, brought to ER. Confused, lethargic, but follows commands. Has extensive dental carries. P.E. shows bilateral nontender submandibular enlargement and swelling of salivary glands. Cause?
Alcoholism TQ: Pt has Sialadenosis: benign, nontender enlargement of submandibular and salivary glands. Common in pts with Liver Dx (Alcoholics), and malnourished pts.
32 y/o woman has a nagging dry cough for past 8 weeks. Has history of chronic rhinorrhea. One week tx. with Chlorpheniramine improves her S+S. Decrease of what is responsible for her relief?
Decrease of nasal secretions TQ: 3 most common causes of chronic cough:1. postnasal drip2. GERD3. Asthma If pt's S+S are relieved with an Antihistamine H1-Blocker (Chlorpheniramine), then you know her cough was due to excess post nasal drip/allergic rhinitis MOA of H1 blockers: reduce action of Histamine, decreasing the Allergic response, and also decreases release of Histamine from mast cells, leading to decrease inflammation.
24 y/o woman has orthostatic hypotension. Missed last 2 periods, and recently lost 11 pounds. BP is 80/55. Labs: HypoNaHypoKHypoClUrine electrolytes:elevated Naelevated KCause of her S+S?
Diuretic abuseTQ: Diuretic abuse can be used to lose weight! Ex: Loops (FTBS) can cause loss of Na, K, 2Cl, Ca, and Mg and water in loop of Henle. Leads to Increased urinary electrolytes, and decreased serum electrolytes, along with hypotension.
Laxative abuse/Vomiting?
HypoCl (from vomit) and fluid loss, will ause increased RAAS cascade, which allows increased Na/H2O re-absorption, and K/Cl excretion.Labs: HypoK, Hypo Cl, with increased serum Na/H20.
65 y/o man found on floor of apartment. Had stroke. EKG shows Peaked T-waves, and labs show Hyperkalemia. Best immediate tx?
IV Calcium Gluconate TQ: Most immediate tx for Hyperkalemia is IV Calcium Gluconate to stabilize cardiac myocytes and make it resistant to effects of Hyperkalemia. Later, can give IV (not subcut) of IV insulin (in combination with Glucose) to shift K+ into cells.
72 y/o man brought to ER after being intubated. Found unconscious, with weak pulse and "agonal" breathing. BP is 80/40, and pulse in 120. Upper and Lower extremities are cold/clammy. Labs:Right Atrial Pressure: highPulmonary Artery Pressure: HighPCWP/LAP: normalDx?
Pulmonary embolism TQ:Pts with acute P.E. can develop acute rise in Pulmonary artery pressure, and Right Atrial Pressure, associated with Pulmonary HTN.Impaired blood flow out into Pulmonary vein and systemic circulation can cause low CO, and low BP, syncope/shock. Pt will have normal PCWP/LAP.
When are antibiotics indicated for COPD exacerbation?
Antibiotics should be given to pts with acute COPD exacerbation, with moderate to severe S+S, or those pts needing a mechanical ventilator. (Antibiotics are not needed for mild COPD exacerbation)S+S of severe exacerbation: SOB, cough, excess sputum production, need for mech. ventNote: Antibiotics will improve S+S, reduce subsequent attacks, and decrease hospital M+M, especially if on vent.
When to begin screening for Colonoscopy?
starting at age 50-75 years oldIf you have a first degree relative with hx of CRC, must screen 10 years before their diagnosis
Screening for CRC
start at 50-75 y/o1. Colonoscopy every 10 years2. or: Flexible sigmoidoscopy every 5 years, combined with a Fecal Occult Blood Test (FOBT) every 3 years.
Target of tx for Restless Leg Syndrome?Ex: "feeling of spider crawling up leg" when pt gets into bed, wiggling leg makes it better.
DopamineTx: DA antagonists
Urine dipstick findings in UTI?
+ Nitrities (signifies presence of E.coli)+Leukocyte esterase (signifies pyuria)
Man on Prednisone for 12 months, stopped it 7 days ago bc didn't like weight gain. Labs?
Sudden withdrawal of Prednisone (cortisol)Labs: low ACTH, Low Cortisol, normal Aldosterone (Central/Secondary Adrenal Insufficiency)vs Primary A.I. (low Cortisol, low Aldosterone, High ACTH)
60 y/o male complains of right sided neck pain and numbness over posterior forearm. Had prior episodes like this. Limited neck rotation and limited lateral sidebending. Decreased pinprick sensation over posterior right forearm. Cause?
Bony SpursTQ: Pt has cervical spondylosis, which affects >10% pts over 50y/o. Associated with chronic neck pain, and limited rotation/sidebending is due to Osteoarthritis. Sensory deficit is due to "bony spurs," (osteophytes)
48 y/o male complains of exertional SOB, even after climbing stairs. Exam shows "Harsh systolic murmur, best heard at Right 2nd ICS space, with radiation to Carotid Arteries." S4 is heard at apex. Cause?
Biscuspid Aortic Valve TQ: Pt has Aortic Stenosis (harsh, systolic murmur best heard at Right 2nd ICS space, with radiation to Carotid Arteries).Note: S4 occurs due to LVH due to stenosed Aortic valve. 3 causes of Aortic stenosis1. Calcific Aortic Stenosis2. Bicuspid Aortic Valve (common in younger pts)3. Rheumatic H.D.
#1MCC of UTI
E. coli (+Nitrites)
Tx for Subconjunctival hemorrhage?
Subconjuctival hemorrhage is a totally benign "red eye", that is totally asymptomatic. Causes: rubbing eye vigorously, violent coughing spells, HTN episodes, etcTx: Simple observation
Bernard Soullier's Syndrome
lack of Gp1b receptor"Big Shit" = Giant platelets dysfunctional platelets, increased bleeding time
Screening Colonoscopy shows Diverticulosis. What can pt do to decrease complications?
Increase dietary fiber intake (more intake of fruits and veggies)TQ: Diverticulosis is associated with Chronic Constipation (causes colonic outpouchings). Complications include--->>Diverticulitis (acute fever, abdominal pain, and perforation with abscess formation)
Tx of HTN African Americans?
won't response to ACE i/ARBsGive HCT
Improvement of M+M post-MI?
1. first give Heparin to decrease risk of future clot formation2. Then give TAB (tPA, ACEi/ARB, Beta Blocker)
Improvement of M+M in CHF?
1. ACEi/ARB2. Beta Blokers3. K+ sparing Diuretics (Spironolactone, Eplerenone, Triamotarone, Amilioride)
Interventions to prevent pressure ulcers?
Pressure redistributionmobilizecareful skin caremoisturizeproper nutrition
62 y/o male has fatigue and weight loss of 20 pounds. He smoked a pack a day for 35 years. Abdominal exam shows a liver span of 14cm, with no tenderness. CT of abdomen shows multiple nodules in Liver. Next best step?
Colonoscopy TQ: Multiple liver masses are most likely due to Mets from Colon Cancer
63 y/o man has vague abdominal pain, and increased fatigue. Smokes a pack of cigarettes a day, and drinks 5-6 beers on weekends. Liver edge is hard and palpated below costal margin. Fecal occult blood test in positive. Most likely reason for Hepatomegaly?
Metastatic disease TQ: Most common location for Colon Cancer to mets is--->Liver (RUQ pain, firm liver, hepatomegaly) Confirm diagnosis with abdominal CT
89 y/o patient has several flat, dark purple ecchymotic areas over dorsum of forearms. Cause?
Perivascular connective tissue atrophyTQ: Pt has "senile Purpura," associated with ecchymoses in elderly pts exposed to repeated trauma in extensor surfaces of hands/forearms. Age-related loss of elastic fibers in CT. Benign.
Pt presents with S+S of Cirrhosis. Which imaging is best?
Upper GI Endoscopy TQ: Pt with Cirrhosis should undergo screening Endoscopy to Exclude Varices, and look for signs of Variceal hemorrhage.
Upper GI Endoscopy shows esophageal varices. Best intervention?
NadololTQ: Nonselective Beta Blockers (Nadolol, Propranolol) are best for Esophageal Varices, because by Blocking Beta rec. they allow for Alpha1-mediated vasoconstriction, which reduces portal blood flow. Can also treat with "Endoscopic Variceal Ligation"
Iron deficiency anemia in pts with ESRD on dialysis?
Iron deficiency anemia is common in pts with ESRD, on dialysis, bc of lack of EPO.Tx: IV Iron supplement
80 y/o man with advanced prostate cancer and bony mets, complains of severe back pain. Underwent an orchiectomy, from which bone pain subsided, but pain is back now. Tender in lumbar area. Next step?
Radiation therapy Radiation is best to manage bone pain in pts with prostate cancer, who've already gotten orchiectomy. Radiation will try to get rid of bony mets
Pt with PAD, complains that left leg is pale, and feels colder than right. Distal pulses are absent on left, decreased sensation to light touch on dorsum of left foot and leg. Weak Ankle dorsiflexion. Next best step?
IV Heparin infusion Pt has 6P's of PVD (pain, paresthesia, pallor, pulselesness, poiklothermia, paralysis) = signs of actual ACUTE arterial occlusion!Key: Pts with acute arterial occlusion are at risk for "threatened limb" and should be immediately started on IV Heparin infusion, to prevent further clot formation. Key: If pt has threatened limb, must start on IV Heparin BEFORE getting an Ankle-Brachial index
25 y/o woman has episodic palpitation, where she feels "her heart is racing." Episodes are unprovoked. BP is 100/60, and HR is 185. Cold-water immersion helps decrease S+S. How does this technique decrease palpitations?
Alters the AV node conductivity TQ: Pt has AVNRT (Atrioventricular nodal reentrant tachycardia) , which is the most common form of Paroxysmal Supraventricular Tachycardia. Cause: Reentry pathway, due to presence of dual slow and fast pathway in AV node. Key: Vagal maneuver increases PNS tone, and slows down AV node conduction, and terminates AVNRT.
manifestations of Crohn's Disease?
chronic abdominal pain, diarrhea, weight loss, erythema nodosum, inflammation (elevated ESR). Bleeding, formation of fistulas and strictures, abdominal abscesses, and malabsorption (terminal ileum Vit B12). TQ: Crohn's involves any part of GI tract (from mouth to anus) and can involve oral aphthous ulcers.
Tx of Crohns?
%-ASA, steroids, antibioticsAzothioprineAnti-TNF drugs
78 y/o woman brought to ER due to insomnia and agitation, over past 2 days. She was confused but calm on arrival, but now is yelling and trying to pull out her IV line. Has severe memory loss and gait disturbance. Temp is 99, and UA shows protein, leukocytes, and erythrocytes. Best initial tx?
HaloperidolTQ: pt has Delirium (waxing and waning level of consciousness). Risk factors for Delirium: advanced age, dementia, infection, etc.Workup of Delirium:1. review medication list2. Blood work3. UA4. Imaging Tx: for severe agitation is low-dose Haloperidol, or ACORZ Note: Benzos not recommended in old people (ex: Lorazepam)
67 y/o homeless man has Anterior wall MI with substernal chest pain. 2 years later, pt is found dead in street. Autopsy shows dilated left ventricle, with globular shape, and thinned walls along scar on Anterior wall. Which medication would have prevented this from happening?
Enalapril TQ: post MI, you should give 1. Heparinand (TAB)2. tPA3. ACEi/ARB4. Beta BlockerTQ: important to give ACE inhibitors to decrease Afterload and decrease "Ventricular remodeling."
Immune marker for Systemic Sclerosis (Scleroderma)/Raynaud's Phenomenon?
Systemic Sclerosis (Scleroderma) is associated with thickening of skin and sclerosis (Sclerodactyly), as well as Raynaud's Phenomenon.Complications: Esophageal dysmotility, interstitial lung disease (fine crackles, fatigue, SOB), Markers: 1. Anti-topoisomerase I (Anti-Scl-70) 2. Anti-RNA polymerase III Antibodies 3. Anti-Centromere Ab
Ab for RA?
Anti-cyclic citrullated peptide Ab
Arrhythmia seen in Digoxin toxicity?
Atrial tachycardia with AV block TQ: Digoxin causes increased "Ectopy" in Atrial or Ventricles-->causing Atrial tachycardia TQ: Digoxin also increases "Vagal tone" and decreases conduction through AV node--->causes AV Block
S. aureus Endocarditis
IVDA (Acute, Tricuspid valve)
S. epidermitis Endocarditis
occurs in pts with 1. indwelling catheters2. Prosthetic heart valves
Man complains of repeated episodes of pain, watering, and redness in left eye. Exam shows vesicles, and dendritic ulcers in cornea. Dx?
Herpes simplex keratitis Corneal blindness frequently occurs bc of HSV KeratitisPt will have prior episodes of corneal vesicles and dendritic ulcers
Dx of corneal abrasion?
Slit lamp test
67 y/o man develops pneumonia 5 days after being diagnosed with Influenza virus. Most likely organisms?
S. aureus TQ: Secondary bacterial pneumonia is the most common complication of influenza virus infection. Causes: Strep. pneumo or S. aureus
Pneumonia in Alcoholics?
commonly due to Aspiration pneumonia1. Klebsiella2. Anaerobes (B, F, P)Clue: S+S will describe "putrid sputum with infiltrates"
Risk factor for PBC
PBC (+AMA) can causefatigue, pruritis, hyperlipidemia, xanthelasmas, hepatocellular carcinomaTQ: PBC can also cause osteomalacia/osteoporosis, although reason is unknown.Note: PBC involves destruction of INTRA-hepatic bile duct only
Tx of PBC
Ursodeoxycholic acid (delays progression)
Common fibular nerve injury S+S?
Common fibular nerve injury occurs with: prolonged leg immobilization, leg crossing, etcS+S: Foot dropped, with loss of sensation over dorsum of foot and lateral shin. Impaired ankle dorsiflexion and Great toe extension. Normal plantar flexion KEY: Can't walk on heels, but can walk on toes
Cherry hemangiomas
benign, but don't really regress
Strawberry hemangiomas?
infantile
Kaposi's sarcoma
associated with HHV8 (in pts with HIV/AIDS)
Basal cell carcinoma
low metastatic potential Hallmark: "fleshy nodule" with central ulceration
NPH imaging
NPH Lumbar puncture would show normal CSF opening pressureMRI would show enlarged ventricles
HIT
IgG Ab against Platelet factor 4 causes thrombocytopenia (as spleen removes Ab-coated platelets)as well as widespread thrombus formation
Most reliable/predictive sign of opioid intoxication?
Decreased respiratory rate is most predictive of opioid intoxication. Also causes altered mental status, hypothermia, and miosis (may or may not be present depending on if pt ingested another drug) Tx: immediate Naloxone
66 y/o man has increasing pain in right arm. Started 3 months ago, near right elbow. Also has back pain, and headaches. X-ray shown---> Next best step?
SPEP (Serum protein electrophoresis) TQ: Pt has MM. Can see "osteolytic lesions" on X-ray. Screening test of choice for MM is SPEP. Clues of MM:osteolytic bone lesions, back pain, anemia MM is a Plasma cell dyscrasia. SPEP used to detect M-spike (IgG, IgA)
65 y/o woman has fatigue and weight gain. Has hx of RA, PUD, and HTN. UA shows +4 proteinuria, bilateral kidney enlargement. Most likely finding on renal biopsy?
Glomerular deposits seen after special staining TQ: RA predisposes pts to Amyloidosis, and can cause Amyloid deposits in kidney leading to Nephrotic syndrome Hallmark: "Amyloid deposits that stain Congo red and demonstrate Apple-green birefringence under polarized light." TQ: RA is most common cause of AA Amyloidosis
Hyalinosis that affects both afferent and efferent arterioles?
seen in Diabetic Nephropathy
Linear deposits
seen in Antiglomerular basement membrane disease (Goodpasture's Syndrome)
27 y/o male has cough, chest pain, and SOB with exertion. Lost 10 pounds over past 2 months. Has 10 pack year history. CXR reveals a "large anterior mediastinal mass," and elevated Beta-hCG and AFP. Dx?
Nonseminomatous germ cell tumors TQ: associated with young men, presents as large anterior mediastinal mass with high Beta hCG and AFP
Pt presents with sudden-onset palpitation and "fluttering in my chest" Rhythm strip shown. Tx?
Pt has wide-complex tachycardia (Ventricular tachy)Tx:1. Amiodarone antiarrhythmic2. if Amiodarone doesn't work, then need to Synch cardiovert Key: Amiodarone can convert Vent-tachy into sinus rhythm and avoid need for urgent synch cardioversion.
Tx of PSVT
Tx of Paroxysmal Supraventricular Tachy (narrow QRS complexes) is with carotid sinus massage/vagal maneuvers
Euthyroid sick syndrome
any pt with acute, severe illness may have slightly abnormal TFTsEuthryoid sick syndrome causes "low T3 syndrome," with a fall in total and free T3, with normal T4 and TSH.
Subclinical hyporthyroidism?
Causes rise in TSH, with normal T4 and T3Note: T3 is always last to fall/rise
Woman with Alcohol Use Disorder tried to quit before, but is having trouble controlling cravings. Has relapsed twice. Liver function tests show hepatomegaly. Best tx?
AcomprosateTQ: 1st line for Alcohol Use Dx is: Naltrexone and AcomprosateTQ: Naltrexone causes hepatotoxicity and cannot be given to pts with hepatomegaly. Note: Disulfuram is 2nd line bc pts have to be really strict with themselves. It inhibits Aldehyde dehydrogenase, but pts can easily skip a dose to avoid adverse side affects and drink.
Side effect of SSRIs
headache, insomnia, N/V, anxiety, and later can cause sexual dysfunction and weight gain. avoid abrupt discontinuation, and take for atleast 4-6 weeks to work
24 y/o man presents with hand shaking and involuntary movements. Was diagnosed with depression last year, but stopped taking SSRI. Liver is enlarged, firm, nontender. Tremor in both hands, and occasional jerky contractions of extremities. Dx?
Wilson's DiseaseTQ: combination of Liver disease and neuropsych. issues (depression, tremor, involuntary movements) in a young adult is highly suspicious of Wilson's DiseaseWilson's Disease (aka Hepatolenticular Degeneration) is Aut. RecessiveCommon in younger ptsCause: Decreased Cerulloplasmin (copper transporter), causes accumulation of excess copper, Kayer-Fisher Rings, and urinary copper excretion.
Alpha-1 Antitrypsin deficiency
can cause COPD (Emphysema), and Cirrhosis
Signs of Aortic stenosis in elderly
Age-related sclerocalcific changesAortic stenosis causes increased PMI (apical impulse), exertional syncope, LVH, and radiation to carotid arteries Other causes of Aortic Stenosis:1. Senior calcification2. Bicuspid Aortic Valve (younger pts)3. RHD (younger pts)
Best tx for Papillary thyroid Carcinoma (large cells with ground glass cytoplasm, pale nuclei, and inclusion bodies)
Surgical resection is primary tx for Papillary thyroid carcinoma
Woman has bilateral severe facial pain for past few days. Pain occurs in cheeks/jaw about 10-20 times a day. Pain with chewing, and with cold exposure. Also, had numbness of her right hand that lasted 2 weeks. Cause?
Demyelination of nerve nucleiTQ: MS is an autoimmune demyleinating CNS dx, and can cause bilateral Trigeminal neuralgia. Causes demyelination of nucleus of Trigeminal nerve and causes severe pain.Clue that pt has MS: "right hand numbness that lasted 2 weeks, and then spontaneously improved." Key: Suspect MS when Trigeminal Neuralgia presents "bilaterally."
24 y/o woman admits to ingesting 20 tablets of 500mg Acetomenophen after arguing with husband. She is alert and oriented, and no abnormalities on exam. Appropriate next step?
Administer Charcoal and obtain serum Acetaminophen levels stat TQ: Tylenol O.D., first step is Gastric decontamination (with Charcoal), and measurement of Tyelenol levels. usually pts are asymptomatic during first 24 hrs. Obtaining serum levels will indicate likelihood of liver failure.
56 y/o man has confusion, forgetful, irritable for past several days. Drinks half a pint of vodka daily, and was previously hx for Acute Alcoholic Pancreatitis. Speech is slurred, abdomen is distended, and has "bilateral hand flapping tremor." Tx to improve mental status?
Initiate lactulose TQ: Tx of Hepatic encephalopathy involves lowering the serum Ammonia level. Lactulose help to lower serum Ammonia. TQ: Hepatic encephalopathy involves: Asterexis (bilateral flappy hands), confusion, slurred speech, etc. Cause: Liver failure from cirrhosis, causes excess accumulation of toxic Ammonia. Ammonia causes neurotoxicity. Tx: Lactulose converts toxic Ammonia (absorbable) into nontoxic (nonabsorbable) Ammonium, which is later excreted in poop.
34 y/o man has severe epigastric pain and N/V. Has "crops of yellow-red papules on extensor surfaces of arms/shoulders." Lipase is 3,500 (normal is 0-160). Abdominal U.S. shows no gallstones. Which test to do next?
Fasting lipid profile TQ: Pt's epigastric pain, N/V and very high Lipases shows Acute Pancreatitis. Can be do to: Binge drinking, gallstones, OR Can be due to excess Triglycerides (Hypertriglyceridemia) Key: When serum TG are very very high, can cause pancreatitis, and deposit xanthomas over body. Familial HyperTG can cause acute pancreatitis. Key: A Fasting serum lipid profile needs to be done to determine pts TG level.
S+S of Wilson's Dx?
Liver failureKayer-Fischer rings in eyesyoung ptjerky movements/ataxiapersonality changesdepression
Postconcussive syndrome
constellation of symptoms:headache, confusion, amnesia, poor concentration, vertigo, irritable, poor sleep.
Korsakoff Syndrome
severe memory impairment that occurs due to Vit B1 (Thiamine) deficiency. (Alcoholics) Causes anterograde amnesia, confusion, confabulation Wernicke's encephalopathy= Thiamine deficiency, with ocular disturbances (nystagmus), ataxia, altered consciousness.
Side effect of Trimethoprim?
SMX-TMP can cause HYPERkalemia, along with an increase in serum Cr.
PCP pneumonia hallmark
bilateral interstitial infiltrates in immunocompromised pts.
Tx of swelling of right lower eyelid?
External hordeolum (stye) is often due to eyelash follicle infection, or infection of tear duct. Associated with Staph. aureus infectionTx. warm compress
Preseptal cellulitis
infection of anterior eyelid (anterior to orbital septum) S+S: fever, leukocytosis, erythema, edema of eyelid.
Man complains of back pain after carrying heavy boxes
Lumbosacral strain TQ: Lumbosacral strain is most common cause of acute LBP. Associated with LBP after physical exertion. Tx: NSAIDs and early movement
Herniated disc pain
acute pain, radiating to Thighs and knees.TQ: +Straight-leg raise test
Woman complains of right shoulder pain. Was diagnosed with RA 10 years ago, but believes current pain is not associated with RA. Has 25 pack year history. P.E. shows constricted pupil, and drooping eyelid. Next best step?
Chest X-rayPt has Pancoast tumor (tumor in superior sulcus)Ptosis, Miosis, Anyhydrosis, with pain due to impingement of brachial plexus (C8, T1, T2) associated with1. Bronchogenic Alveolar Carcinoma2. Squamous Cell Carcinoma
Reason for Hypocalcemia in Nephrotic Syndrome?
Decreased serum Albumin TQ: In Nephrotic syndrome, Hypoalbuminemia can cause Hypocalcemia, bc 50% of Calcium normally is bound to Albumin
Tx of Trigeminal Neuralgia?
Carbamazepine
S+S of Sarcoidosis
African American female with cough, hilar adenopathy, erythema nodosum, and non-caseating granulomas
Best way to differntiate Asthma from COPD?
Spirometry before and after an inhaled bronchodilator TQ: Asthma is reversible, using a bronchodilatorNote: Inhaled corticosteroids are the primary long-term intervention for asthma
Findings of Osteoarthritis on X-ray
narrowed joint spaces, osteophytes, subchondral sclerosis/cysts Note: pts with OA can have brief morning stiffness as well, get worse throughout day
Pseudogout
associated with Calcium pyrophosphate deposition, leading to calcification of joints (Chondrocalcinosis)Labs: +birefrinegent Rhomboid crystals
New drug significantly prolongs survival in pts with lung cancer. If this drug is implemented, how will it change prevalence and incidence?
Incidence will not change, Prevalance will increaseTQ: Incidence is measure of new cases diagnosedPrevalence is umber of total cases that exist at a particular time.
Risk of Loop Diuretics (FTBS)?
Can cause HypoK+, HypoMg2+, and HypoCa2+, leading to prolonged QT, Torsades de Pointes, and V-Tachy
32 y/o comes in with escalating LBP. Pain is dull, achy, present at rest, and worse with activity. He's a Heroin IVDA. Afebrile. Gentle percussion over lumbar spine (L3 and L4) elicits exquisite pain. Dx?
Vertebral osteomyelitis TQ: Tenderness to gentle touch is clue that pt has spinal Osteomyelitis. Pts may or may not have fever. Should have high suspicion in pts with hx of IVDA. Note: Spine is common site for osteomyelitis in IVDA. Cause: S. aureus Tx: long-term IV antibiotics
Lumbar spinal stenosis
narrowing of spinal canal with compression of nerve roots.S+S: Pain worse with extension back, and better with forward flexion. Pain radiates to buttocks and thigh.
Lumbar disc herniation
Acute LBP, pain is worse with activity, better with rest.
Pt in post-ictal state had a tonic-clonic seizure. Has Resp. Acidosis on ABG. Cause?
Hypoventilation TQ: Hypoventilation is major cause of respiratory acidosis in post-ictal state.
Lactic acidosis causes?
Increased AG metabolic acidosis
Viral Esophagitis in HIV pt?
Viral esophagitis is common in pts with advanced HIV, especially when CD4+ count is <100. Causes of Viral Esophagitis:1. CMV2. HSVTQ: Clue of Viral esophagitis is SEVERE odonyphagia (pain with swallowing) HSV Esophagitis: "circular/ovoid" vesicular ulcers CMV Esophagitis: large, linear ulcers Can confirm dx with upper GI Endoscopy
Candida esophagitis
pts with Candida Esophagitis usually have Oral ThrushS+S: DysphagiaTx: Fluconazole
Eosinophilic Esophagitis
seen in pts with hx of Atopic conditions (Asthma, etc)
Pleural Effusion Breath sounds
TQ: Will see "blunting of costophrenic angle" on CXRDecreased breath soundsDecreased tactile Fremitus Dullness to Percussion
Lobar pneumonia breath sounds?
TQ: Will see consolidation on CXRIncreased breath soundsIncreased Tactile Fremitus Dullness to Percussion
65 y/o man has a 4 week history of weakness and vague postprandial epigastric pain. Fecal occult blood test is +. He has an antral ulcer, and biopsies show Gastric Adenocarcinoma. Next best step?
CT scan For Gastric Adenocarcinoma, treatment is determined by disease stage. Surgical removal (Laparoscopy) is gold standard for therapy, but before you do that, you need to get a CT to show the stage of the disease. (Tumor stage at time of diagnosis determines prognosis)
69 y/o man has occipital headache, N/V. Describes as "worst headache of my life." Has history of high BP, but has not been taking meds. Noncontrast CT shows bleed on Right side of brain. What physical exam finding is most likely?
Right hemiataxia TQ: Spontaneous Cerebella hemorrhae, due to poorly controlled HTN can cause IPSILATERAL Hemiataxia.
Allergic Contact Dermatitis is a ?
Type 4 HSN reaction
Man complains of severe abdominal pain, that is "sharp" and "unbearable" and radiates to the groin. Has vomited twice. Best imaging?
Abdominal U.S. TQ: Kidney stones cause flank pain/abdominal pain radiating to groind with N/V. Use either1. Abdomnal U.S.2. Noncontrast CT scan of abdomen
Seborrheic Keratosis
benign "stuck on papule," described as oily/greasy/velvety Note: sudden overnight onset of tons of SK is "Sign of Lesser Trelat" meaning pt has GI cancer
BCC
"pearly, rolled border" with central ulceration
Melanoma
irregular border, changes in appearance over time, in sun-exposed areas.
Most common cause for COPD exacerbation?
URT infection is most common cause for COPD exacerbation S+S:coughsputum productionSOB
Man has recurrent blisters on skin on back of hands. Also feels extremely fatigued. Elevated Liver enzymes. Skin exam shows small vesicles and erosions on dorsum of hands, along with scarring and hyperpigmentation. Which co-existing condition is he gonna have?
Chronic Hep C infection TQ: HCV is strongly associated with Porphyria Cutanea Tarda. S+S: fatigue, skin blistering, photosensitivity, vesicles, bullae, elevated LFTs. TQ: All pts with Porphyria cutanea tarda must be screened for Hep C.
S+S of PBC?
pruritis, jaundice, hyperpigmentation, Xanthomas
Woman complains of epigastric pain and pain to Right shoulder for past 2 hrs. Didn't eat all day, and then just at a cheeseburger. 4 hours later, pain goes away. Cause?
Hollow organ contraction and outlet obstruction TQ: Biliary colic occurs due to increased Gallbladder pressure, created by GB contraction against an obstructed cystic duct that contains a stone. Pain made worse with fatty meals, lasts <6hrs
Pt with MS develops speech arrest and right arm weakness, lasts <30 minutes. Next best step?
Initiate Aspirin and Statin therapy TQ: Pt has TIA, due to acute demyelinating plaque of MS. Tx of TIA is Aspirin and Statin (to decrease risk of future clot and improve BP control)Note: Pt has Left MCA stroke bc of Right blurry vision and arm weakness.
Jarish-Herxheimer rxn
occurs shortly after initial tx of Syphillis, S+S; fever, myalgias, headache, sweating, really bad rash. Self-limiting Cause; rapid lysis of spirochetes after tx with Benzathine Penicillin G
Imaging for SBO/ileus
Abdominal X-rayor CT scan
Treatment options for pts with ESRD
1. Dialysis2. Renal transplant (longer survival) best to get from living relative
First line tx for Renal artery stenosis?
ACEi/ARBs are first line for unilateral Renal Artery stenosis Note: Loops are not recommended first line for HTN
Bacillary angiomatosis
non-tender, bright red nodules
Man suffers from Subarachnoid hemorrhage, and five days later has right-sided muscle weakness, and mild facial droop. Cause?
Cerebral vasospasm and infarctionTQ: Vasospasms are major cause of delayed M+M in pts with SAH. Can cause cerebral infarction. Tx: can prevent with Nimodipine
When to do an urgent Bladder catheterization?
Urgent Bladder cath should be done in all pts with oliguria/acute RF due to Bladder outlet obstruction in the postoperative setting.
Cryptosporidium parvum infection
major cause of chronic watery diarrhea in HIV pts with CD<180S+S: diarrhea, weight loss, fever, Stool exam will show cryptosporidial oocytes
Best way to inhibit progression of Diabetic Nephropathy?
BP control TQ: giving ACE inhibitors is best way to reduce progression of Diabetic Nephropathy. Should have a target BP of 130/80.
BP goal for pts >60y/o
<150/90
BP goal for pts with CKD/DM
<140/90
1st line for HTN in non-Blacks?
HCT, ACEi/ARBs
64 y/o male brought to ER with severe chest pain that feels "knifelike." CT angiogram shows Aortic dissection of Ascending Aorta. While preparing for surgery, pt develops increasing SOB and does not want to lie flat. Cause of SOB?
Aortic Valve insufficiency TQ: Aortic dissection involving the Ascending Aorta (Type A) requires emergency surgery. Can extend all the way to the Aortic Valve and cause Aortic Regurgitation (AR), leading to pulmonary edema and SOB.
64 y/o man has emergency colonic resection for Extensive Ischemic colitis. Consumes large amounts of alcohol. On postop day 7, has bleeding from Venipuncture site. Labs:Platelets: 160,000PT: 24 seconds (elevated)PTT: 44 seconds (elevated)Cause?
Vitamin K deficiency TQ: Alcoholics with liver failure can develop Vitamin K deficiency due to impaired production/malnourishment. Labs: Normal platelet countElevated PTElevated PTT Note: (vs DIC: low platelet count, high PT and high PTT)
Man has urinary frequency, dribbling, and weak stream. Was dx with T2DM 16 years ago, which has been controlled. Has history of HTN, MI, and decreased vision. Dipstick shows 3+ protein, no blood. Cr is 2.1 Cause of CKD?
Microangiopathy TQ: Pts with Type 2 DM can develop Diabetic microangiopathy--->nephropathy and KWN
Best tx for reducing progression of Diabetic nephropathy?
Strict BP control (ACEi)BP goal: 130/80
29 y/o woman complains of worsening pain in Right knee for 3 months. On exam, Right knee is swollen, and tender, with decreased ROM. X-ray shows "expansile and eccentrically placed lytic area in epiphysis of distal femur." Dx?
Giant cell tumor TQ: Giant cell tumor causes pain, swelling, and decreased ROM. Hallmark: Osteolytic "soap bubble," lesion in distal femur or proximal tibia around knee joint.
Osteoid osteoma
"sclerotic lesion with central nidus." Pain worse at night. better with NSAIDs
64 y/o man brought to ER with painless LEX weakness. He was swimming, and felt bilateral leg weakness, loss of strength, and couldn't move. Cannot pass urine. Shows weakness in both legs and numbness from belly button to soles of feet. No sensation in perianal area, and has loss of rectal tone. Next best step?
Surgical evaluation TQ: Pt has Acute Spinal Cord CompressionS+S: motor and sensory loss, loss of rectal tone, urinary retention. Must do emergency surgical evalCauses: disc herniation, compression fracture, malignancy
Cuada Equina Syndrome
LEX pain and weakness, saddle anesthesia, bowel/bladder dysfunctionaffects sacral roots
Man with BPH develops elevated serum Cr. Next best step in eval of pts Acute kidney injury?
Renal U.S. TQ: Pts with severe bladder outlet obstruction due to BPH can develop acute kidney injury. A Renal Ultrasound should be used to detect signs of Hydronephrosis
Vitiligo
Autoimmune destruction of melanocytes
Tinea versicolor
lightly scaled macules, primarily on chest and back
45 y/o man has epigastric pain and bad diarrhea. Has hx of PUD. Exam shows abdominal tenderness, gastric folds, and 3 duodenal ulcers and an upper jejunal ulcer. Next best step?
Serum Gastrin concentration TQ: Gastrinoma (ZES) should be suspected in pts with stomach ulcers and thickened gastric folds on endoscopy. Labs: measure the fasting serum Gastrin level>1,000. High Gastrin should then be evaluated with Secretin stimulation test.
Triple therapy for H. pylori?
PAC1. PPI2. Amoxicillin 3. Clarithromycin
Most significant risk factors for Pancreatic Cancer?
Cigarette smokingObesity
67 y/o male complains of progressive vision loss in Right eye for past several months. On eye exam, states that vertical lines on grid appear "wavy." Dx?
Macular degeneration TQ: Clue that pt has macular degeneration is "wavy" lines and "drussen spots"
Lens opacification
lens opacification causes cataracts
Dietary recommendation for pts with Kidney stones to prevent recurrence?
1. Increased fluid intake2. Decreased Sodium intake (to avoid drying out your kidneys)3. Normal dietary Calcium intake
24 y/o man faints during football practice on very hot summer day. Complains of dizziness/headache before passing out. Skin is dry and hot. Temp is 105. IV hydration is started. Best next step in tx of this pt?
Immersion in ice waterTQ: Pt has an exertional heat stroke (hallmark, is when Temp>104, with CNS changes). Tx: Best tx is rapid cooling, preferable with ice water bath.
42 y/o man complains of 2 day rash on lower back. Has itching, and burning pain, followed by eruption of small, red papules. Tx?
Valacyclovir TQ: Shingles (Herpes Zoster) causes small vesicles/bullae, with burning, itching, in a dermatomal distribution. Tx: Acyclovir/Valcyclovir, to decrease pain and post-herpetic neuralgia.
54 y/o male has chronic cough and bloody sputum. Has smoked 2 full packs of cigarettes daily, for past 22 years. Has weight loss, anorexia, constipation, and in increased thirst. Labs:Calcium: 12.9Chest X-ray: shows hilar mass in left lung. Dx?
Squamous cell carcinoma of lungsTQ: Suspect Squamous cell caricnoma of lungs in anyone who is a massive smoker, presenting with a "Hilar Mass" and HyperCa2+.TQ: The HyperCa2+ results from high levels of PTHrP and can cause constipation, increased thirst, etc. Clue: sCa++mous Cell Lung Carcinoma
Small Cell Lung Carcinoma
Associated with Parneoplastic effetcs(Ectopic ACTH/SIADH)
Tx of Carpel Tunnel Syndrome?
1st line: wrist splinting (if it doesn't work, then will need surgical decompression)+Tinnel sign+Phalen sign
Delayed Sleep-Wake phase disorder?
disorder of circadian rhythm, with inability to properly fall asleep at traditional times, causing excess daytime sleepiness.Ex: Can't fall asleep till 3am, have to be at work by 8am, and are tired all day. aka "night owls."
Advanced sleep wake phase disorder
can't stay awake till past 7pm, and wake up very early. Note: in normal aging, there is decreased Melatonin, so they require less sleep.
Woman has exercise induced asthma when working out, twice per week. Tx?
SABA (Albuterol ten puffs before exercise)= first line for pts with exercise-induced asthma that only exercise a few times per week.TQ: Tx of pts with daily exercise, require Montelukast.
Woman has burning epigastric pain, that waxes and wanes, and has N/V. Pain awakens her at night, and she has bloating after meals. Emigrated from India 20 yrs ago. Stool Guiac is +. Cause?
Urease-producing bacterial infectionTQ: H. pylori infection causes pts to have PUD.S+S: dyspepsia, "postprandial fullness, bloating" N/V.
34 y/o woman has hemoptysis and comes to ER. Had "sudden onset right sided chest pain, and mild SOB, while getting out of bed." Chest pain increases with deep breathing. Has a 15 pack year history. Chest CT shown: Dx?
P.E. TQ: P.E. causes classic "sudden-onset pleuritic chest pain, cough, and SOB." Can also cause hemoptysis due to pulmonary infarction. CT will show wedge-shaped infarct.
Hikers were lost in woods for several days. Glycogen stores were depleted, and now body is relying on Gluconeogenesis. Alanine is converted to what?
Pyruvate TQ: During fasting, Glycogen reserves drop dramatically within first 12 hours, and Gluconeogenesis takes over, especially by 24 hrs. Alanine is major amino acid in Liver and is converted to--->Pyruvate, which is then converted to--->Glucose
Woman has Hypercalcemia during routine lab work. Has a 30 yr smoking hx. Best way to determine cause of HyperCa2+?
Serum PTH level Causes of Hypercalcemia can be due to Primary HyperPTH (high PTH)or from PTHrP producing tumor in Squamous Cell Lung Carcinoma (low PTH)Need to check PTH levels to assess cause of HyperCa2+
75 y/o man with T2DM brought to ER with blurry vision and weakness. Had been sick for past few days with cough, sore throat, and dry mucous membranes. Labs: Glucose is 1070. What other finding?
Depletion of total body K+TQ: Pts with T2DM, recently sick/stressed, can have HHNKS, leading to severe hyperglycemia. This can cause excess urinary loss (glucosuria-induced osmotic diuresis) of K+ leading to HypoK+. Also, tx pt with insulin can further cause HypoK+.
Kaposi's sarcoma
common in pts with IVDA (who contract HIV), especially if these pts have oral thrush (clue)Kaposi's Sarcoma is an "AIDS-defining illness" due to HHV-8 infectionS+S; multiple violaceous papules in extremities, face, buttocks, genitals, etc.
Condylomata acuminata
aka Anogenital warts, due to: HPV
50 y/o man has PUD perforation and was hospitalized with fever and hypotension. Tx with broad-spectrum antibiotics and IV fluids. On 7th day, develops abdominal pain, and profuse watery diarrhea, along with pain in LLQ. Next best step?
Stoole toxin testing TQ: Risk factor for C. diff is hospitalization, increased age, antibiotics (Clindamycin, Fluroquinolones)S+S of C. diff colitis: watery diarrhea, fever, abdominal pain, elevated WBC count. Can also be really bad and cause fulminant colitis/toxic megacolonTest: Must test stool for C. diff toxin
56 y/o woman recently diagnosed with DM complains of 20 pound weight loss. Her DM has been controlled on Sitagliptin. Complains of watery stooles, and an eczematous perioral rash with plaques and central clearing on thighs and mouth. Labs: Hb A1c: 6.2GLucose: 112 Which test to order?
Glucagon levels TQ: Pt has classic Glucagonoma!Can cause mild T2DM, but bc this pt was placed on Sitagliptin, the HbA1c and Blood glucose levels are within normal limits. Glucagonoma causes NME (Necrotizing migratory erythema) on extremities/face.Labs: Glucagon is usually >500.
60 y/o woman has lethargy and confusion. She has a 40 pack yr history and has recently lost 10 pounds. Appears confused, and difficult to arouse. Labs:Serum osmolality: 250Urine osmolality: 500Chest X-ray: shows Right hilar massNext best step?
Hypertonic saline infusionTQ: Pt has Small Cell Lung Carcinoma with parneoplastic SIADH.Excess SIADH leads to hypotonic serum, and hypertonic urineTx: Must infuse with HYPERtonic saline in order to restore serum electrolytesKey: don't give normal saline/half-normal bc that will only cause more dilution of serum.
Imaging for suspected elevated Prolactin levels?
Need Pituitary MRI imaging
73 y/o woman complains of dry eyes, with burning discomfort, as if dust or sand is stuck in eye. Also has hard time reading small-print due to decreased visual acuity. Cause?
Age-relate exocrine gland atrophy TQ: Older pts develop "age-related Sicca Syndrome," due to atrophy of lacrimal/salivary glands.
Sjogren Syndrome
autoimmune disorder, associated with lymphocytic infiltrate in exocrine glands Causes:1. dry eyes (keratoconjunctivitis)2. dry mouth (xerostomia)TQ: Sjogren's Syndrome is associated with Systemic Sclerosis and is +ANA on labs (Anti-nuclear Ab), and occurs in middle aged pts.
BCC
slow-growing papule with "pearly rolled borders and central ulceration."TQ: can mets to local tissues so must be removed.
SCC
fast-growing, associated with precursor lesion (Actinic Keratosis)
53 y/o man complains of worsening SOB and weakness for past 2 days. Has hypotensive, tachycardia. Elevated JVD, and muffled heart sounds. Cause of complaints?
Decreased LV preloadTQ: Pt with Cardiac Tamponade have decreased LV preload, CO, and SV.
Side effect of long-term analgesic use?
Long-term "OTC pain meds" (aka NSAIDs/Aspirin) can cause CKD due to Tubulointersitital Nephritis and can cause Hematuria due to Renal Papillary Necrosis.
Woman has Hyperthyroidism with Proptosis. Which tx would worsen her Proptosis?
Radioactive Iodine TQ: Radioactive Iodine tx can actually worsen Hyperthyroidism if Iodine is absorbed into Thyroid gland. That's why you must first give K+Perchlorate.
23 y/o female runner complains of Right foot pain, that is sharp, and localized to forefoot. Currently an avid runner, and training for a long-distance race. Has tenderness to palpation on dorsum of foot. Dx?
Stress fractureTQ: common in female athletes with "female athlete triad" (oligomenorrhea, osteoporosis, and decreased caloric intake)
76 y/o man was treated for pneumonia twice last year. Complains of difficulty swallowing, and regurgitates undigested food sometimes. Exam shows foul-smelling breath, and a fluctuant mass in left neck. Best imaging?
Contrast Esophagram TQ: Pt has Zenker's Diverticulum (common in old men), due to weak posterior cricopharyngeal muscle. S+S: halitosis, risk of aspiration pneumonia, regurg of food, etc)TQ: Must do a Contrast Esophogram to properly visualize the ZD. (DO NOT do endoscopy due to risk of perforation)
Man has a 3.5cm AAA. Is current 1-2 pack/day smoker, and also has uncontrolled HTN of 160/90. Highest risk for Aneurysm rupture?
Active smoking TQ: Should surgically correct AAA >5.5cm. Risk factors for rupture: current cigarette smoking, and rapid expansion of aneurysm. Note: HTN has low association with risk of AAA rupture. Should still control BP in AAA pts (with Beta Blockers/ ACEi) though.
65 y/o man notices blood in urine. Has 90 pack year history. Cause?
Bladder cancer TQ: Bladder cancer is common in heavy smokers. Hallmark: PAINLESS hematuria/gross hematuriaImaging: CT urogram or Cystoscopy
Ethics
"Always should get a better understanding of the pts concerns and perspective"
Man wakes up in middle of night with severe pain in Right great toe. Also complains of unbearable pruritis after hot showers. Aspiration of synovial fluid shows negatively birefringent crystals. Cause?
Myeloproliferative disorderTQ: Gout is common complication of MPD, due to excess cell turnover of purines, resulting in excess uric acid production.
36 y/o woman complains of chest pain that started suddenly while she was shopping at the mall. Has SOB, palpitations, and diaphoresies. Pain is retrosternal and radiates to left arm (Clue of MI!!). Has history of Panic attacks, treated with Paroxetine. Next best tx?
Aspirin TQ: The pts "retrosternal pain, radiating to left arm" is clue that she is having an ACS (Acute Coronary Syndrome)Must admin. Aspirin as early antiplatelet therapy as soon as possible ASAP, to reduce risk of MI and M+M in pts with ACS.
59 y/o man has sudden onset, severe SOB, and right-sided chest pain. Has hx of COPD, and smokes cigs for past 35 yrs. Tactile fremitus and breath sounds decreased on right. MOA of pts condition?
Rupture of an apical alveolar bleb TQ: Sponataneous pneumothorax due to rupture of apical pleural bleb should be suspected in pts with lung disease, who present with rapidly worsening respiratory complaints. TQ: Rupture of blebs is most common in pts with COPD.
Man has HyperTG, and started on high-intensity Statin therapy. What other recommendation?
Reduce alcohol intake TQ: Pts with HyperTG should avoid alcohol intake
74 y/o presents with S+S of Alzheimer's Dx. Best tx?
Initiate Rivastigmine Donepezil, Rivastigmine, and Galantamine are all AchE inhibitors, leading to increased Ach to improve S+S of Alz. Dx.
Dx of Goodpasture's Syndrome?
Do a renal biopsy to show IgG antibodies deposited in a linear fashion against the basement membrane.
Heinz Bodies/Bite Cells
G6PD deficiency
Tx of Giant Cell Temporal arteritis?
S+S: Temporal headache, jaw pain, and vision loss.TQ: Especially in pts with vision loss, must immediately give high dose IV Methylprednisone, before temporal artery biopsy
48 y/o overweight man has right foot ulcer. Has hx of HTN, T2DM, and high cholesterol. Ulcer is on plantar surface of big toe. How to best assess risk of foot ulcers?
Monofilament testingTQ; Clue: Pt's history of T2DM means he probs has Diabetic neuropathy, causing Diabetic foot ulcers. Can cause loss of vibratory sensation, decreased pinprick, pain, temp, etcMonofilament test: Wire that you poke foot with increasing pressure, until wire buckles. Pts with decreased sensation will have increased risk of future ulcers.
32 y/o woman comes to hospital with palpitations and SOB. Has anxiety, poor sleep, and unintentional weight loss. Has diabetes, and recently has required more insulin to maintain blood glucose control. 6 hours later, is confused, diaphoretic, and agitated. Labs: Glucose: 320BP: 145/65HR: 154Dx?
Thyrotoxic crisis Pt's history describes undiagnosed Hyperthyroidism. Thyroid storm causes hemodynamic instability, cardiac arrhythmias, and hyperglycemia.
Pt has 6 week hx of progressive right hip pain. Pain present at rest, worse with weight bearing. Has hx of Sarcoidosis, and takes oral steroids. Muscle power decreased in proximal thigh muscles. Cause?
Disruption of bone vasculatureTQ: Long-term steroid use can cause Osteonecrosis (Avascular necrosis) of femoral head
Woman who had kidney transplant 6 months ago presents with fever, malaise, SOB, abdominal pain, and watery diarrhea. Her poop is loose and bloody. Gross blood on DRE. Cause?
CMVTQ: Pt's who get solid organ transplant are at risk for CMV infection (CMV viremia)
Side effect on Heart for pts with Acromegaly?
Causes Concentric LV hypertrophy TQ: Acromegaly causes concentric myocardial hypertrophy, causing a Diastolic dysfunctionNote: Other causes of LV hypertrophy include: OSA, HTN
30 y/o female postpartum mom complains of pain on lateral wrist. Worse when lifting baby from crib. Dx?
De Quervain tenosynovitis inflammation of 1. ABductor pollicis longus2. Extensor pollicies brevis+Finkelstein test Common in new mom who lift babies a lot
HIV vaccine protocol
First, loos at CD4+ count<200 means should not receive any live attenuated vaccines (Varicella, MMR)>200 can get live attenuated vaccines1. Varicella2. MMRNote: all HIV pts should also get the INactivated vaccines1. Influenza2. Tdap3. Pneumococcal4. Hep B
Note: Cause of increased malpractice (from delayed/missed diagnosis leading to death?)
communication failure between providers (docs don't talk to each other properly during pt handoffs--->cause medical errors/missed diagnosis)TQ: implementing signout checklists can prevent undesired medical outcomes that result from doctor communication failures during pt handoff process.
S+S of Bell's Palsy?
CN 7 PalsyS+S:1. unilateral facial paralysis2. inability to raise eyebrow3. inability to close eye4. drooping of corner of mouth5. Hyperacusis6: loss of sensation in Ant 2/3 of tongue
52 y/o man with alcoholic liver dx comes to hospital with fatigue and abdominal pain. Has chronic ascites, tx with Furosemide and Spironolactone. In ER, fails to "complete a connect the numbers test." Bowel sounds decreased. Abdominal X-ray shows dilated loops of large bowel, with air in colon and rectum. Dx?
Spontaneous bacterial peritonitis TQ: SBP should be suspected in pt with cirrhosis and ascites, with fever, abdominal discomfort, and alt. mental status.TQ: SBP is an ascitic fluid infection
75 y/o complains of intermittent right eye vision loss. Reports 3 episodes of "a curtain falling over right eye," before returning to normal. Has hx of HTN and Hyperlipidemia. Normal fundoscopic exam. Best imaging to reveal dx?
Duplex U.S. of neckTQ: Pt has "Amaurosis fugax" which causes sudden, painless loss of vision. Hallmark: Pt describes" curtain descending over visual fields." Causes: Retinal ischemia due to atherosclerotic emboli, originating from carotid artery. Diagnosis: Should do a Duplex U.S. of neck
28 y/o woman complains of recurrent nasal discharge and continuous nasal congestion. Always has feeling of dripping in back of throat, and food tastes bland. Has hx of wheezing after taking Naproxen for menstrual cramps a year ago. Dxx?
Nasal polypTQ: Nasal polyps are associated with 1. chronic rhinosinusitis, 2. asthma, 3. Aspirin/NSAID-induced bronchospasm S+S: post-nasal drip, anosmia, congestion, and Aspirin-induced asthma Note: Nasal polyp looks like a "glistening mucoid mass in nasal cavity"
Best tx for nodular BCC on face?
Mohs surgeryMohs micrographic surgery is good for BCC on face, where you sequentially remove layers of thin skin until BCC is gone. Mohs surgery has highest cure rate for BCC.
Tx of Diabetic neuropathy with pain/bruning?
Pregabalin decreases painNote: can also give TCAs (but not to older pt>65 due to anticholin effects)
Pressure necrosis
Pressure (decubitis) ulcer occurs around bony prominences (sacrum, malleoli, heels, 1st or 5th toes)Causes: prolonged pressure impairs blood blow to that area and causes necrosisCauses: poop mobility, malnutrition, abnormal mental status/dementia,Tx: frequently reposition pt, proper nourishment
60 y/o man has lightheadedness for past 3 momths. Especialy when walking too quickly or climbing stairs, fells like "I'm gonna pass out." On exam, has a murmur heard over Right Upper Sternal Border. Slow-rising carotid pulses. Other likely findings?
Soft second heart sound (S2) TQ: Pt has Aortic Stenosis, which causes SyncopeAnginaDyspneaStenosis of Aortic valve causes "Soft S2" heart sound.
Septic shock
decreased PVR, decreased PCWP/LAP, increased COTQ: causes an overall decrease in cardiac afterload (due to low PVR from excessive vasodilation)
Woman has weight loss, N/V, and postural dizzy. BP is 90/60, HR is 96. Increased skin pigmentation on palmar creases.Labs:HyponatremiaHyperkalemiaLow BPCBC shows moderate Eosinophilialow 8am serum cortisolCause of pts Adrenal insufficiency?
Autoimmune adrenalitisTQ: pt has Primary A.I.Low cortisolLow AldosteroneIncreased ACTH/MSH (POMC) leading to skin hyperpigmentation. TQ: Autoimmune adrenalitis is most common cause of primary A.I.
83 y/o woman complains of a full 1 year of severe, crampy abdominal pain that occurs right after she eats. Causes bloating, and sometimes diarrhea. Had 33 pound weight loss over past year, decreased appetite due to pain. Has hx of high cholesterol, CAD, and PVD. Last week had M.I. Rest of physical exam and Abdominal X-ray are normal. Cause of S+S?
Atherosclerosis of Mesenteric arteries TQ: Chronic mesenteric ischemia should be suspected in pt with unexplained pain "out of proportion" with P.E. S+S: chronic abdominal pain, weight loss, food aversion. Cause: Atherosclerosis of Celiac artery or SMA.
Risk of Hep C from IVDA?
Esopahgeal varices, portal HTN, cirrhosis, palmar erythema, spider angiomataTQ: Tx of Esophageal varices (which you must see using Endoscopy) is with non-selective Beta-blockers, TPN) to allow unopposed Alpha-mediated vasoconstriction
1st line for Fibromyalgia?
Exercise program with aerobic conditioningwater aerobics
55 y/o woman with hx of chronic LBP presents with elevated BUN/Cr. Cause of RF?
Tubulointerstitial nephritis TQ: Analgesic Nephropathy (KDINI, Aspirin, etc) is due to drug-induced RF
ATN
muddy brown castsTQ: ATN causes ACUTE onset RF.
70 y/o woman comes for routine preventive visit. 2 years ago, she had normal mammogram, pap smear, and lipid panel. Colonoscopy was 7 yrs ago. Which study to do now?
Mammogram TQ: Mammograms have to be done every 2 yrs starting at age 50y/o till 75y/o.
MOA of sublingual Nitroglycerin?
Decreases LV wall stressAlthough Sublingual Nitro does allow Coronary vasodilation, the main MOA is decreased LV wall stress. Sublingual Nitro is 1st line for pts with Angina pectoris for rapid relief of pain. Allows systemic vasodilation, which decreases LV end-diastolic volume, resulting in decrease LV wall stress and myocardial O2 demand.
54 y/o woman complains of fatigue, dizzy, palpitations after physical activity. Her feet "feel numb" and are less sensitive to cold. P.E. shows pale conjunctiva and a shiny tongue. Long-term complication?
Gastric cancer TQ: Pernicious anemia causes attack of Parietal cells, decreasing amount of IF and Vit B12 Cobalamin absorption, causing Megaloblatic anemiaPerncicious anemia is #1MCC of Vit B12 deficiency, and actually DOUBLES the risk of Gastric Cancer
Pt develops Acute Pancreatitis after undergoing stent placement for Left Circumflex artery stenosis. Best tx?
IV fluids, and supportive care only TQ: Cholesterol embolism after vascular procedures (cardiac catheterization) can lead to Acute Pancreatitis.Tx: just Morphine, or analgesics, and IV fluids. NPO (no food). Usually acute pancreatitis resolves in 4-7 days.
66 y/o woman complains of lesion near left elbow, for past 2 months. Developed at the margin of a scar from a prior skin wound. Has since enlarged, and developed oozing and crusting in area. Next best step?
Biopsy of lesionTQ: A nonhealing, bleeding/oozing skin ulcer, especially when within the margins of an old scar, should be Biopsied to check for SCC.
23 y/o man complains of 5 days of diarrhea and abdominal pain. Initially poop was watery, but now is bloody. Complains of colicky pain that is severe, and decreased appetite. Has prominent periumbilical and RLQ pain. Poop is brown, mixed with blood. Cause?
E. coliTQ: EHEC is a food-borne pathogen causing both watery and bloody diarrhea. Note: can confirm diagnosis with stoole assay, looking for Shiga toxin. TQ: Should not give antibiotics to pts with EHEC bc it can cause HUS.
34 y/o man comes to office for eval of Premature Atrial Complexes (PACs) found on routine EKG. Is completely asymptomatic. Smokes 2 packs per day, and drinks 1-2 beers/day for past 10 years. Best advice?
Advice him to stop alcohol and tobacco TQ: Tobacco and alcohol are reversible risk factors for PACs.
When to use a Holter moniter?
Holter moniter can be used in outpatient setting to identify arrythmias in Symptomatic pts (syncope, arrythmias, palpitations, etc)DO NOT need to use Holter in pts who have asymptomatic arrhythmias and are totally fine.
35 y/o man has U.C., and was diagnosed 8 yrs ago. Is currently maintained on 5-aminosalicylic acid and feels well. Had an exacerbation 6 months ago, which required antibiotics and steroids. Best management at this time?
Offer colonoscopy now and every 1-2 yrs thereafterTQ: Pts with UC are at increased risk for CRC. Screening colonoscopy should start 8 yrs after initial diagnosis, and be repeated every 1-2 yrs thereafter.
80 y/o woman brought to ER with confusion, weakness, and unsteadiness for past few days. Had a right femoral fracture 4 months ago and got hip surgery. Has been using a walker since. Cause of S+S?
Tearing of bridging veinTQ: This old lady probs suffered from a Subdural Hematoma after falling from her walker, and ruptured her Bridging veins. TQ: Subdural hematoma causes confusion, weakness, altered mental status in old people after few days. Looks concave on CT.
Where does a SAH bleed?
DAP, between arachnoid and pia mater.
Epidural hematoma
from blunt force trauma, rupture of MMA.Convex-shaped
72 y/o man presents to ER after passing out. Had watery diarrhea for past 2-3 days before admission. BP is 120/70 supine, and only 98/50 while standing. Which lab value is most predictive of current condition?
Decreased urine sodium TQ: Man has hypovolemia, and orthostatic hypotension, which causes upregulation of RAAS cascade, which will lead to more Na/H2O re-absorption and decreased urine Na+.
OSA
transient airway obstruction of upper airway due to laxity of pharyngeal tissue, resulting in nocturnal hypoventilation.S+S: daytime sleepiness, snoring, "brief choking/gagging" while sleeping. Note: CPAP machine provides positive airway pressure to allow air to pass to and from lungs, to avoid respiratory acidosis.
Risk of ADPKD (presents as HTN pt, with "bilateral flank masses," and increased BUN/Cr)
Intracranial bleeding TQ: ADPKD pts can end up with Intracranial Berry Aneurysms
Woman found to have irregular microcalcifications on mammogram, with a 4cm lump in 11' o'clock position. Single most prognostic factor in this pt?
TNM staging.TQ: Tumor burden is the single most important prognostic factor in regards to breast cancer and tx. Based on TNM staging.Note: Grade 4 disease is worst prognosis.
83 y/o woman has C.diff and lots of watery, foul-smelling diarrhea. Labs?
High Renin, High Aldosterone, High ADHTQ: Pts that are dehydrated (hypovolemic) from N/V, or diarrhea, will have both an increase in RAAS and ADH.
36 y/o commercial sex worker complains of fever, malaise, and chills that started 12 hours ago. Has pain in multiple joints. Has pustules in chest and extensor surfaces of forearms. Right wrist and right ankle are tender to palpation. 3 sets of blood cultures are negative. Dx?
Disseminated gonococcal infectionTQ: causes high fever, chills, joint pain in multiple joints, and pustules on trunk/extremities.HYTQ: Blood cultures will be negative due to the "fastidious nature" of N. gonorrhea.
80 y/o woman complains of LEX edema for past 2 months. Has JVD, LA enlargement, and marked concentric Left Ventricular Hypertrophy. LV ejection fraction is 70%. Cause of S+S?
Restrictive Cardiomyopathy TQ: Amyloid CM can occur in older pts with LV hypertrophy, and "preserved ejection fraction."Note: Amyloidosis can cause multisystem disease due to fibril deposits in tissues. Cardiac Amyloidosis is a form of Restrictive CM, with preserved Ejection Fraction.Other causes of Restrictive CM: 1. Sarcoidosis2. Amyloidosis3. HHC
Requirement for Hospice?
Palliative, interdisciplinary care with prognosis <6months. Focuses on symptom control, comfort, etc.
65 y/o woman has pain and swelling over inner aspect of right eye, with purulent material. Dx?
Dacryocystitis causes pus and inflammation in medial canthal region of eye, due to: S. aureus/ Strep.
Inflammation of Meibomian gland?
Chalazionpresents as lid pain/nodule
Hordeolum
Abscess over upper/lower eyelid Cause: S. aureus
Lab finding of A-a gradient in pt with Idiopathic Pulm. Fibrosis?
Pts with Idiopathic Pulm. Fibrosis have excessive collagen deposition in alveolar tissues. This leads to Decreased TLC, decreased Elastin, decreased Compliance, and Excessive Recoil.Increased FEV1/FVC ratioLow TLC, FRC, RVDecreased diffusion capacity of Carbon Monoxide** (due to fibrosis)Increased A-a gradient
Woman complains of 3 day history of LBP. She was at Home Depot and was lifting a potting soil when she felt "grabbing pain" in low back. Exam shows tenderness in right lumbar paraspinal muscles, with slight reduction in lumbar lordosis. ROM is normal, and so is gait, DTR, etc. Slight tightness to hamstrings, with no radiculopathy. Next step?
Short course of Naproxen Pts with acute, NON-complicated LBP just need NSAIDs. Symptoms usually go away in first few weeks. Key: Pts should be told to continue moderate activity, bc prolonged bed rest is bad. NSAIDs, or Acetomenophen are first line for uncomplicated LBP.
25 y/o man punched a guy in the teeth during bar fight, and now complains of swelling and pain in hand. Small laceration over 3rd and 4th MCP joints, with redness, and swelling. Tx?
Amoxicillin-Clavulanate Acid Pt suffers from a "fight bite" from teeth microbesTQ: Must tx with Amoxicillin-Clavulanate Acid for oral flora infection.
56 y/o woman comes to ER with fever, SOB, and cough with productive, foul smelling sputum. Temp is 101. Poor dentition. She underwent an Upper GI endoscopy 10 days ago for hx of heartburn. Has elevated WBC count, and a right upper lobe infiltrate. Tx?
Clindamycin TQ: This lady's poor dentition, and recent Endoscopy puts her at risk of Aspiration pneumoniaHallmark of Aspiration pneumonia: foul-smelling sputum, productive cough.Cause: Aspiration of anaerobic bacteria into lung Tx: Clindamycin is good for Anerobes coverage
Locations of aspiration in supine position?
Posterior aspect of upper lungsSuperior aspect of lower lungs
28 y/o woman has lightheadedness and syncopal episode. Lives in rural Massachusetts, but has not traveled recently. Right thigh has 2 erythematous skin lesions, and EKG shows sinus rhythm, with a 2:1 AV block. Cause?
Spirochete infection TQ: Lyme dx occurs due to a Spirochete infection (Borrelia burgdorferi) in NE U.S. S+S: Pts can have S+S (even without knowledge of tick bite).Erythema migrans rashcarditisneuro probsAV blockBell's palsy
Woman has a painless mass in right submandibular region. Occurred after a right molar extraction for severe tooth deay. Exam shows thick yellow discharge, and small yellow granules and fluid. Tx?
Penicillin HYTQ: Pt has Actinomyces Israelli infection (part of normal flora) but can cause invasive infection after dental trauma. Hallmark: Yellow sulfur granulesTx: penicillin
Cause of negatively birefringent needle-shaped crystals?
inflammatory reaction to monosodium urate crystalsTQ: Acute gouty arthritis occurs as a acute Monoarthritis, usually in 1st MCP or Knee as well.Tx: NSAIDs (Indomethacin is best), Colchicine, steroidsLong term tx: Allopurinol, Probenecid
1st line tx of Idiopathic Increase in Intracranial HTN (Pseudotumor Cerebri)?
Common in middle-age, fat women of child-bearing age.Tx: Acetozolamide (CA inhibitor)and weight loss
Risk of HyperPTH?
HyperPTH, with constant HyperCa2+ can actually cause Pseudogout (CPPD) leading to rhomboid shaped +birefringent crystals and inflammation of kneeTQ: Pseudogout also causes calcification of articular cartilage (Chondrocalcinosis)
Electrolyte risk in tx patients with Hepatic Encephalopathy?
Pts with Hepatic Encephalopathy on Diuretics (Furosemide/Spironolactone) can develop hypokalemia. Tx: K+ and Ammonia-lowering meds (Lactulose)
Entamoeba histolytica
A Protozoan that causes Amoebic liver abscess and RUQ pain, cysts in liver, etc.
Poxvirus
Molluscum contagiosum is caused by PoxvirusHallmark: small umbilicated papulesminor, and self-limiting
Woman with Lynch Syndrome is also at greatest risk for what other condition?
Endometrial cancerTQ: Pts with Lynch syndrome (Aut. Dominant dx) have a mutation in microsatellite pathway (DNA mismatch repair enzymes)TQ: In addn. to CRC, pts with Lynch are greatest at risk for Endometrial cancer, so must get yearly endometrial biopsies/prophylactic hysterectomy.
65 y/o man complains of intermittent right knee pain, worse at end of day. Has mild swelling of knee with increased exercise. Right knee has bony enlargements and a small effusion. Tx?
DiclofenacTQ: Initial tx of OA should always involve exercise and weight loss to decrease the DJD. NSAIDs are first line drigs for pain in OA
Febuxostat
used to tx Gout, as a XO inhibitor
Tx of RA
1. DMARDs2. MTX (give Folic acid) and check LFTs and PFTs3. NSAIDs (Endomethacin is best)4. TNF-Alpha inhibitors (Etanercept, Adelenumab)
Woman with Hyperthyroidism is experiencing A-Fib on EKG. Tx?
PropranololTQ: Hyperthyroidism causes increased SNS activity, and can cause A-Fib. Must tx with Beta Blockers.
Maintenance therapy for A-Fib?
Amiodarone
Kid accidentally splashed an unknown liquid in face and is complaining of severe pain in right eye. Next best course of action?
Wash the eye with copious amount of water TQ: For any acid/alkolotic fluid in eye, first must wash eye under water for atleast 15 minutes
Woman tx for TB with RIPE develops scleral icterus and tender hepatomegaly. Liver biopsy shows "panlobular infiltration and hepatic cell necrosis." Dx?
Hepatitis secondary to Isoniazid usage TQ: Isoniazid can cause liver injury and fulminant hepatitis
56 y/o man develops oliguria 3 days after kidney transplant. Biopsy shows lymphocytic infiltrate and vascular involvement with swelling of intima. BP is 160/100. Elevated BUN/Cr. Next step?
Give IV steroids very HYTQ:Renal transplant rejection post-op causes: oliguria, HTN, elevated BUN/Cr. Causes: uretral obstruction, acute rejection, etc.Tx: ASAP tx with IV high-dose steroids is extremely important to salvaging kidney!
Pillrolling (resting tremor)
Basal ganglia dysfunction (P.D.)
Essential tremor
essentially gets worse with activity (50% is familial)Ex: worse with reaching for a pen
1st line tx for Reactive arthritis (Reiter's syndrome)
NSAIDs are first line during the acute phaseS+S:1. arthritis2. urethrtitis3. conjunctivitis Causes:1. C. jejuni2. Chlamydia3. Y. entercolitica4. Salmonella5. Shigella
Best screening for Hyperaldosteronism?
Ratio of plasma Aldosterone: plasma Renin
Pt with Chronic Bronchitis has an acute exacerbation, with progressively worsening SOB. He is started on nebulized Albuterol. Next day, labs show: HYPOkalemia. Cause?
Increased Beta-adrenergic activity TQ: Pt's with COPD exacerbation, treated with inhaled SAB2As (Albuterol) can cause a shift of Potassium into cells, leading to Hypokalemia
Man on Warfarin for A-Fib is experiencing increased bleeding gums. Has increased exercise, eating more veggies, and sometimes takes Acetomenophen for joint pain. Cause of bleeding?
Acetomenophen Drugs that "potentiate" anticoagulant effects of Warfarin:1. Acetomenophen2. NSAIDs3. Amiodarone 4. Cranberry juiceall are CYP450 inhibitors
22 y/o woman at 12 weeks gestation has Lyme dx rash. Tx?
AmoxicillinTQ: Doxy is first line, but is contraindicated in pregnant, or lactating women, and kids <8y/o. Note: Lyme rash is Erythema Migrans
Tx of Trigeminal Neuralgia?
Carbemazapine
Pt taking Amytryptiline for Fibromyalgia. Claims S+S have improved, but frequently experiences bouts of dizziness. Which is most helpful test in determining cause of dizziness?
Orthostatic BP measurement TQ: Amytryptiline commonly causes 1. orthostatic hypotension, and 2. Anticholinergic S+S (dry mouth, urinary retention, constipation, etc)
32 y/o woman with Crohns Disease complains of decreased vibration and proprioception in LEX. What lab value is most likely increased?
Methylmalonic acid Crohn's pts (terminal ileum) have Vit B12 deficiency leading to: Subacute Combined DegenerationLabs: high levels of Homocysteine and MMA
VC is COPD pts?
COPD pts have decreased VC (due to air trapping on expiration)
Essential tremor
worse with activity, and especially worse at end of "goal-directed behavior" like try to touch doctors finger HYTQ: Tx of Essential tremor would be Propranolol
Risk of Woman with prior history of Rheumatic Heart Disease who presents with "mid diastolic rumble" heard at apex?
A-Fib due to LA dilationTQ: Pts with Rheumatic HD will develop Mitral Valve Stenosis in adulthood, which causes "Opening snap, followed by diastolic rumble."Key: This causes LA dilation, and increased risk of A-Fib.
Tx of severe Hypercalcemia in pt with PTHrP from squamous cell lung carcinoma?
Initial tx of Hypercalcemia is saline hydration.This is bc pts with Hypercalcemia are usually volume depleted from excess urination/kidney stones and constipation. Should also give Calcitonin to decrease serum calcium levels.
75 y/o man has enlarged DIP joints, and labs show elevated Alkaline Phosphatase. Cause?
Pagets disease of bone TQ: most common cause of asymptomatic elevation of Alk Phos in elderly is Paget's Disease of bone
Man who worked as a plumber for past 30 years has a 6cm cavitary mass, and pleural plaques on CXR, in Right lower lung field, along with worsening SOB, cough, and weight loss. Dx?
Brochogenic carcinomaTQ: Plumbers get exposed to asbestos!TQ: Clue of Asbestosis = "pleural plauqes on CXR"Note: Smoking acts "synergistically" with asbestos to increase risk of lung cancer
Man with history of allergic rhinitis, eczema, and asthma admitted to hospital for chest pain described as dull and radiating. EKG shows ST depression, but cardiac markers show no MI. Admitted for followup, and started on Aspirin, Clopidogrel, and LMWH, Metoprolol, Lisinopril. Later, he develops bilateral wheezing and SOB. Cause?
Adverse medication effectTQ: Cannot give Aspirin, or Beta Blockers (TPN) to pts with Asthma bc it causes increased bronchoconstriction
Asbestosis is a Pneumoconiosis!
S+S:+Ferrunguous bodies+Pleural plaquesDecreased diffusion capacity in lungs (of CO)Restrictive Lung Dx (ground glass appearance, with reticulonodular opacities, and honeycombing)
Toxoplasmosis infection
MRI will show multiple "ring-enhancing lesions" and intracranial calcification
First sign of Diabetic Nephropathy
1. first comes "Glomerular Hyperfiltration."2. Next, comes Thickening of Glomerular Basement Membrane3. And Lastly there's Mesangial Expansion Key: ACE inhibitors are best in Diabetic Nephropathy bc they reduce glomerular hyperfiltration
Medications/Diseases that can cause painful Priapism?
1. Trazadone2. Prazosin3. Sickle Cell Anemia
44 y/o woman complains of severe epigastric pain, radiating to back. She has N/V. Exam shows an agitated woman, who sit leaning forward on bed. Labs:Amylase: 2610Lipase: 3880Next best step?
RUQ UltrasoundTQ: Most sensitive and specific test for diagnosis of acute pancreatitis is a RUQ U.S. bc it can detect gallstones and alcohol abuse. Note: Only an Ultrasound is best at diagnosis of gallstones. No need to get CT or abdominal X-ray
TCA overdose
comacardiotoxicity (prolonged QRS intervals)convulsions Prolonged QRS can cause Ventricular arrythmiasTx: Na Bicarb stat
Difference between SJS and TEN?
SJS involves <10% bodyTEN>30%
Drugs that cause SJS?
1. SMX-TMP (Sulfa drugs)2. NSAIDs3. Phenytoin, Carbamazepine, Lamotrigine
Toxic Shock Syndrome
Occurs due to S. aureus S+S: fever, rash, hypotension, multiorgan injury. Looks like sunburn with desquammation
Cornerstone for tx of kidney stones?
Hydration! (Fluid intake of greater than 2L/day)
Risk of giving Na+ Nitroprusside in pts with HTN Emergency?
Na+ Nitroprusside is frequently given in pts with HTN Emergency (BP of 220/120) with end organ damage (Cotton wool spots, elevated BUN/Cr, etc.)MOA: Nitroprusside vasodilates by increasing release of NO and cAMP, allowing for rapid BP control However, can cause release of cyanide ions and lead to cyanide toxicity
Causes of Carpel Tunnel Syndrome?
obesityDMpregnancyoveruse injury hypothyroidismS+S: Thenar muscle atrophy, numbness and tingling in 1st three digits, pain over flexor reticulaculum+Tinnels sign+Phalens sign Note: The Flexor reticuluaculum is also called the "Transverse Carpel Ligament"
34 y/o female presents with vague chest pain. Had recent URT infection. Chest X-ray shows enlarged mediastinum. CT of chest shows mass in middle of mediastinum. Dx?
Bronchogenic cyst TQ: Bronchogenic cysts are found in middle of mediastinumvs Thymoma (found in Anterior mediastinum)
24 y/o man presents with fever, sore throat, and hoarseness. Not able to swallow bc of severe pain. Pt is drooling, and has "muffled voice" with "stridor." Temp is 103. Cause of current condition?
Lack of recommended immunizations TQ: Pt has Epiglottitis (due to H. influ B) S+S: muffled "hot potatoe" voice, drooling, dysphagia, and inspiratory stridor Increased risk fo airway compromise
42 y/o woman with severe uterine bleeding and iron-deficiency anemia scheduled for Hysterectomy. Gets a blood transfusion prior to hysterectomy. 30 minutes after transfusion starts, complains of chills and severe flank pain. Temp is 102. Transfusion is stopped, but she begins bleeding from IV site. Cause?
Acute hemolytic reaction due to ABO incompatability life-threatening reaction due to transfusion mismatch of blood (ABO mismatch)S+S: rapid fever, flank pain, RF, DIC...all within hour of transfusion.
IgA deficiency
Pts that are IgA deficient are at risk of developing Anaphylaxis after blood transfusion. (due to IgG Ab against IgA)S+S of IgA deficiency: angioedema, hypotension, difficulty breathing, shock. Tx: Rapid Epi and circulatory support
62 y/o woman presents with fatigue and yellow skin. Had 10 pound weight loss, and occasional nausea. Drinks 3 beers/night. Labs: AST highAlk phosphatase: 890Dx?
Malignant biliary obstructionTQ: painless jaundice with high AST and Alk Phosph should raise concern for biliary obstruction (biliary cancer) Note: Acute choledocholithiasis would present with elevated Alk Phosph as well, but is NOT painless, but rather presents with RUQ pain.
54 y/o comes to ER with fever, chills, dysphagia, and drooling. Temp is 101. Pt is toxic and drooling, with muffled voice. Tongue is displaced posteriorly and superiorly. Tender submandibular area with crepitus. Source of infection?
Teeth roots TQ: Ludwig angina causes rapidly progressive cellulitis of submandibular and sublingual space. Source: infection from poor oral hygiene of infected molar teeth. Tx: IV antibiotics Clue: floor of mouth is often elevated, displacing the tongue
S+S of Crohn's Disease
anal fissuresfistulasfocal ulcerspyoderma gangrenosumskin tagsoral ulcers transmurral inflammationskip lesionsnoncaseating granulomascobblestoneing
35 y/o male complains of bilateral gynecomastia and breast tenderness. Has a 1cm nodule in right testis. Labs:Elevated TestosteroneElevated EstradiolLow LH and FSHDx?
Leydig cell tumorTQ: Sertoli-Leydig cell tumors cause increased Estrogen/Testosterone production, and inhibit FSH/LH.S+S: gynecomastia, precocious puberty, etc.
Huntington's Dx
atrophy of Caudate and Putamen Huntington's dementia, depression, aggresion, chorea, athetosis
56 y/o man comes to ER after acute onset Right-sided weakness and numbness. Has Nausea and headache. Has HTN, but never takes meds. Noncontrast CT shows left sided infarction. Cause?
HTN encephalopathy TQ: Pts with uncontrolled HTN can have spontaneous intracerebral hemorrhage , caused by HTN vasculopathyS+S: Contralateral weakness, sensory loss, numbness
Cause of HTN in woman with Hyperthyroidism?
Increased myocardial contractility TQ: In Hyperthyroid pts, there is overall decrease in SVR. However, the BP is high (HTN) due to positive inotropic and chronotropic effects due to increased myocardial contractility and HR.
Small vessel lipohyalinosis
lipohylanosis is associated with pts with HTN, or Hyperlipidemia, or DM. Can cause a lacunar stroke (weakness and sensory loss on contralateral side)
26 y/o woman complains of near-syncope and dizziness. Has had chronic diarrhea with 10-12 nonbloody, watery bowel movements per day. Labs show hypokalemia and metabolic alkalosis. Colonoscopy shows: dark brown mucosal pigmentation in proximal colon. What findings would be expected?
Positive stool laxative screenClue of laxative abuse: colonoscopy shows "melanosis coli," (dark brown discoloration in colon)
VIPoma S+S:
diarrhea with "tea-colored" stoolsHypokalemiaAchlorydia
52 y/o man has pain and stiffness in small joints of hands. S+S worse in morning, and can last several hours. Also has digit swelling. Dx?
Psoriatic Arthritis occurs in 50% pts with arthrtitis. Swelling in digits, with morning stiffness "sausage fingers."
42 y/o with Crohn disease had partial ileal resection due to stricture. Required parenteral nutrition for past few weeks. Recently started oral feeds. Has nonbloody diarrhea, patchy alopecia, and pustular, crusty skin. Tx?
Zinc supplementsZinc is a "trace mineral"TQ: Zinc deficiency causes:1. impaired taste2. alopecia3. hypogonadism4. skin rash
Dermatomyositis
idiopathic inflammatory myopathy, causing symmetrical proximal muscle weakness and violaceous helioptropic rash over "dorsum of fingers." (Gottron's sign)
58 y/o man brought to ER after apparent suicide attempt. Found lethargic. Has history of CAD and HTN. Has diffuse bilateral wheezing, cold/clammy extremities, and EKG shows PROFOUND sinus bradycardia with first degree AV block. BP is: 76/40. Pt given Atropine, however his bradycardia and hypotension don't improve.Next best step?
GlucagonTQ: Beta-bloker O.D. causes:PROFOUND hypotension, bradycardia, wheezing, and hypoglycemia. 1st line: IV fluids and Atropine2nd line: IV glucagon
25 y/o man has progressive SOB, dry cough, fever and chills. Has been in relationship with male partner. Temp is 101.7. Chest X-ray shows scattered white plaques in oropharynx. Diffuse bilateral crackles present. Tx of condition?
SMX-TMP and Prednisonesame sex partners with resp. complaints, suspect HIV"bilateral interstitial infiltrates" and scattered white plaques = Pneumocystitis pneumonia. TQ: Pts with HIV and low CD count have Pneumocystis pneumoniaTx: SMX-TMP and Prednisone
71 y/o woman brought to office by son, concerned that mother had unprovoked fall a year ago. Has since relied on him to coordinate activities and make decisions. Pt is mildly forgetful, seems sad most of time, and has weakness and sensory deficits on right side. Neuroimaging would show?
cortical and subcortical infarctions TQ: Woman has Vascular dementia (stepwise progressive decline in executive function and mild memory loss) and can also one sided sensory deficits/hemiparesis. Neuroimaging shows cortical/subcortical infarcts
Strep viridans Infectious Endocarditis
Strep Viridans include (strep mutans, Strep Sanguins, Strep Mitis, Strep Oralisall in oral flora, and cause IE in "previously damaged heart valves."
55 y/o woman has left-sided should stiffness. Unable to raise her arm or reach for objects, past 2 months. Decreased passive and active abduction, flexion, and rotation of left shoulder. Cause?
Adhesive capsulitis results from chronic inflammation, fibrosis, and contracture of joint capsule. Reduced passive and active ROM.
Subacute (De Quervain's Painful) thyroiditis
fever, neck pain, and tender goiter after URT infectionLabs: acute thyrotoxic hyperthyroid phase, followed by hypothyroid phase, and eventual recovery to normal thyroid function.
Tx of Torsades de pointes to prevent progression to V-tachy?
Mg2+ Sulfate Note: EKG of Torsades is Prolonged QT-intervals
Note: Overflow incontinence in men occurs bc of
BPHUrethral stricture (VUR)Nuerogenic bladder (DM)
Tx of mild persistant ashtma (S+S >2 times/week, or 3-4 nights per month)
As needed SABA and an inhaled corticosteroid
62 y/o woman has acute leg pain. Felt pain at right knee and posterior calf while walking on treadmill. Had swelling of calf and right ankle. Exam shows tenderness and induration at medial head of gastrox. Has pitting edema at ankle and ecchymosis of medial malleolus. Cause?
Ruptured popliteal cyst TQ: A popliteal (Baker's) cyst is due to movement of synovial fluid from knee joint into gastrox or semimembranous bursa. S+S: bulge in popliteal space, and cyst can rupture causing severe pain.
57 y/o woman with Lymphoma is getting chemotherapy. Has had several bouts of N/V, malaise, and abdominal cramping. Exam shows dry mucus membranes and enlarged cervical lymph nodes (from vomiting). Tx?
Serotonin receptor antagonist (Ondensteron) are best for treating chemo-induced nausea (5HT3 receptor antagonists)
65 y/o man has sudden loss of vision in right eye. Has hx of diabetes, and is tx with Metformin for Glyburide. Has reduced light perception in right eye, with "floating debris" and a dark red glow. Dx?
Virteous hemorrhage causes sudden onset vision loss with onset of "floaters"TQ: Virteous hemorrhages occur in pts with DM
35 y/o has 5 month history of episodic retrosternal pain that radiates to scapula. Can last couple minutes or couple hours. Episodes are made worse by emotional stress, and hot/cold food. She throws up food sometimes. Sublingual Nitro alleviates pain*** (Clue!) Next best step?
Esophageal motility studies (mannometry) TQ: Episodes of dysphagia, regurgitation, and chest pain made worse by emotional stress = esophageal spasmsHallmark: made better with Sublingual Nitro
68 y/o man has coffee-ground emesis, followed by lightheadedness. Has black, tarry stools for past few days. Abdomen is slightly tender.Labs: Hb: 6.8Platelets: 130,000WBC: 9,500INR: 1.2In addn to fluids, what's the next best step?
Packed RBC transfusion TQ: Must give a stat packed RBC transfusion for pts with acute GI bleeding, or with Hb<7.0
60 y/o woman comes to ER with decreasing vision and dull ache over left eye. Had successful cataract extraction in left eye 5 days ago. Left eyelid is swollen, edematous, and exudates are present in anterior chamber. Decreased visual acuity in left eye. Dx?
Postoperative Endophthalmitis TQ: occurs within 6 weeks of eye surgery. Pain and decreased vision, swollen eyelid/edema/infection
Most common nephropathy in African Americans/HIV pts?
Focal and segmental glomerulosclerosis
54 y/o woman with several hours of severe epigastric abdominal pain, radiating to back. Has N/V and several episodes of N/V. Has history of abdominal pain after eating sometimes.Bp: 110/66Lipase: 2,192Expectations for RAAS cascade?
High Renin (high RAAS cascade), causing Efferent arteriole constriction, and increased tubular sodium reabsorptionTQ: Pt with acute pancreatitis (due to gallstones getting stuck, etc) can develop HYPOvolemia (due to continues N/V), leading to high RAAS cascade.
Lab values for pt with Alcoholic Hepatitis?
AST:230ALT:111GGT:HighFerritin: HighTQ: Pt's with Alcoholic Hepatitis will have AST about x2 that of ALT, elevated GGT, and elevated Ferritin.
35 y/o woman fell while going downstairs and has a shoulder sprain. X-ray shows a 1.5cm coin-shaped lesion in periphery of right lung. Next best step?
Ask for any previous X-rays for comparison TQ: First step in eval of any solitary pulmonary nodule is to ask for previous radiographic images. If prior films not available, need to then get a CT.
67 y/o woman has progressive fatigue and anorexia. Lost 9 pounds, which she thinks is due to early satiety. Palpable spleen tip. Fluorescence in situ hybridization shows abnormality of chromosome 22. What is the target of tx in this pt?
Tyrosine kinase TQ: Pt has CML (Philadelphia chromosome 9;22, BCR-ABL fusion protein)TQ: This gene creates active Tyrosine Kinase.Tx: Imatinib is a tyrosine kinase inhibitor used to tx CML.
56 y/o man with transient right eye blindness that lasted an hour. Abdominal exam shows splenomegaly.Labs:H: 20HCT: 60%Platelets: 545,000What is recommended tx?
PhlebotomyTQ: PV is a myeloproliferative disorder due to excess Erythrocytosis. Can cause HTN, vision loss, pruritis, and clots. Can also cause splenomegaly. Tx: Serial phlebotomy. Note: PV is a Myeloproliferative dx associated with +JAK2 mutation
56 y/o woman has sudden SOB, which suddenly started 2 hours ago while she was enjoying her favorite TV show. She has left-sided chest pain, that worsens with cough. Pt has a 30 pack yr history of smoking, but claims she doesn't currently smoke. JVD is present. RR is 30 (tachypneic) and HR is 140 (tachycardia). Oxygen saturation is 84% (hypoxic). EKG shows: irregular RR intervals, with no definite P waves, and narrow QRS complexes. Cause of pts current S+S?
PEDiagnosis of PE should be suspected in any patient who has "sudden-onset SOB, pleuritic chest pain, tachypnea, tachycardia.
Eikenella corrodens infection
Eikenella corodens is an anerobe that lives in normal human oral flora. Can cause infective endocarditis due to poor oral dentition/periodontal infection.
Common cause of conductive hearing loss in adults?
Otosclerosis(overgrowth of bone in middle ear)
MEN2B
Medullary thyroid carcinomaPCCMarfans
67 y/o man brought to ER after LOC while shoveling snow. Had similar episode last month when carrying heavy grocery bags. Has reduced physical activity over past year due to progressive exertional dyspnea. Most likely finding?
weak and slow-rising carotid pulseTQ: Pt's with Aortic Stenosis are SAD1. Syncope2. Angina3. Dyspnea4. along with delayed/diminished carotid pulse5. Soft 2nd heart sound
S+S of Thyroid Storm (Thyrotoxicosis)?
rapid rise in serum Thyroid level with tachycardia, HTN, "lid lag", and possible A-Fib, and increased Temp, tremorTx: check TFTs and admin. Propranolol
Tx of DTs
IV Lorazepam (Ativan)
42 y/o man comes in with nonpainful skin lesion on left upper arm, that started 2 months ago. Has numbness and tingling in left fingers. Moved from Asia to Connecticut a year ago. Exam shows a hypopigmented patch on left upper arm with no sensation to pinprick. Ulnar nerve is thickened and tender. Absent sensation to touch. How to confirm dx?
Skin biopsy from edge of lesion TQ: Man has Leprosy from Mycobact. leprae (transmitted through respiratory droplets). Common in immigrants.Hallmark: chronic, "anesthetic" hypopigmented skin lesion, with loss of sensation. Causes demyelination of nerve. Need biopsy to confirm bacterial presence.
Theophylline toxicity S+S?
headache, insomnia, seizures, N/V, arrhythmias (tachycardia)
31 y/o man has headache and progressive confusion. Friends are concerned of slowly progressive behavioral changes. Has hx of HIV, but not sure if taking meds. Has ataxia and right-sided hemiparesis. MRI shown--> This condition could have been prevented by taking which med?
SMX-TMPTQ: Pt has Toxoplasmosis (opportunistic infection in pts with HIV with low CD4+ count). SMX-TMP is used as primary prophylaxis for Toxoplasmosis with low CD count. Note: SMX-TMP is also good at preventing Pneumocystis pneumonia
14 y/o boy playing outdoors today noticed tick attached to right thigh. Vital signs normal. Next best step?
Remove tick with small forceps and reassure patientTQ: Ticks should be removed with tweezers as soon as you notice them. Antibiotics not needed for Lyme dx is tick has been attached <36 hours.
Tx of choice for Pulmonary HTN?
Loop diuretics (FTBS) and ACE inhibitors/ARBs
45 y/o man has recurrent sinusitis and otitis. Tx with antibiotics and intranasal steroids, and has scant yellow nasal DC mixed with blood. Ex-smoker, with 15 pack yr history. Has a small ulceration in right auditory canal.UA:+Blood Next best step?
Qualitative serum autoantibodies TQ: Granulomatosis with polyangitis is a vasculitis affecting small/medium blood vessels. Associated with Respiratory tract illness and glomerulonephritis.Can confirm dx with p-ANCA antibody positive tissue biopsy.
Tx of uncomplicated cystitis?
Oral Nitrofurantoin S+S: frequency, dysuria, without CVA tenderness/flank painNote: only need UA to confirm dx (no need for urine culture)
55 y/o man has sudden onset palpitations and chest tightness. Cardiac monitor shows A-Fib. Suddenly, pt becomes unresponsive, there is no palpable pulse over carotids or femoral arteries, and he goes into "agonal breathing." Next best step?
Chest compressions TQ: Pt has gone from A-FIb into Pulseless Electrical Activity (PEA). Tx of PEA is with uninterrupted CPR along with vasopressors to maintain adequate cerebral and heart perfusion. No need for debrillator/synchronized cardioversion.
Pt on medication for A-Fib has progressive fatigue, difficulty concentrating, and vague RUQ pain and constipation. Which med?
Amiodarone TQ: Amiodarone, used for maintenance therapy for A-FIb, can cause hypothyroidism and hepatotoxicity
Cause of absence of marked acidosis in pts with COPD?
renal tubular compensationTQ: Pt's with chronic hypercapnea (resp. acidosis) will have compensatory renal bicarb retention (met alkalosis)
<an with fever, chills, cough, pleuritic chest pain. Dullness to percussion. O2 sat drops from 94%--->89% when he lies on left side. Cause of drop in O2 sat with change of position.
Intrapulmonary shuntingTQ: Pts with pneumonia can have intrapulmonary shunting with change in position, which can worsen hypoxemia.
Allergic conjunctivitis
Acute HSN rxn, with bilateral clear, watery eye discharge
Benzodiazepine O.D.?
Slurred speech, unsteady gait, drowsiness can be seen in O.D. of Benzos. Clue: Can be differentiated from opioid O.D. bc Benzo O.D. has lack of respiratory depression and lack of pupillary constriction.
MOA of Sublingual Nitroglycerin?
Primary anti-ischemic and antianginal effect of Nitrates is due to: Systemic vasodilation (rather than coronary vasodilation)The systemic vasodilation lowers the preload and lowers the LV end-diastolic volume, which reduces wall stress and myocardial oxygen demand
Miliary TB
S+S of Miliary TB: fever, weight loss, fatigue, and Chest X-ray reveals hallmakr: "diffuse reticulonodular pattern (millet seeds)."Key: Risk factors for Miliary TB spread: incarceration, IVDA
22 y/o man has dark urine. Had an URT infection that started 4 days ago. Normal serum complement levels (C3 and C4). UA shows RBC casts.Dx?
IgA Nephropathy (Berger's Dx)TQ: IgA Nephropathy is most common cause of glomerulonephritis in adults. Causes gross hematuria, within 5 days of URT infection. Normal serum complement levels.
Medication of choice to reduce risk of embolization/stroke in pts with A-Fib?
Warfarin (Coumadin)
Tx of Hypovolemic Hypernatremia in pt with Nephrogenic DI?
IV (0.9% (normal) saline)
Nerve responsible for corneal abrasion leading to impaired corneal sensation?
Trigeminal nerve (V1 branch-opthalmic)= controls corneal sensation.
S+S of TSS?
Cause: S.aureusS+S: sunburn type desquamating rash, severe thrombocytopenia, hypotension,
Lacunar stroke
contralateral full face, arm, and leg weakness
48 y/o homeless man with HIV comes to ER with floaters and blurry vision in right eye. Has no pain, but has decreased vision and yellow-white exudates on fundoscopic exam. Several white patches present on oropharyngeal mucosa. Dx?
CMV retinitis TQ: CMV retinitis causes blurry vision, floaters, and "flashing lights," blindness/retinal detachment are risks Clue: Fundoscopic exam will show yellow-white hemorrhagic lesions
22 y/o soccer player comes to ER with knee pain. Was playing soccer and felt a popping sensation in right knee with rapid pain and swelling. Right knee is swollen, tender and aspiration shows bloody joint fluid. Dx?
ACL injury TQ: ACL injury occurs in young athletes that do rapid direction changes/twisty movements. Hallmark of ACL tear: RAPID onset pain and swelling, bloody synovial fluid (hemarthrosis)+Anterior Drawer sign
Meniscal tear
also occur with rapid direction changes and can hear locking/popping noiseHowever, no bloody synovial fluid (hemarthrosis) and no rapid onset of S+S either, just maybe some swelling.
82 y/o man has sudden onset epigastric pain, with 2 episodes of N/V. Which test should be performed first?
Electrocardiogram TQ: Abdominal pain with N/V can be "atypical" presentations of Acute Coronary Syndrome
64 y/o woman hospitalized for Anterior wall MI. Had occlusion of mid-LAD artery, and received percutaneous stenting. On 4th day of hx, pt develops acute-onset SOB and confusion. BP is 72/40. EKG shows sinus tachy with T-waver inversion in leads V1-V5. Cause?
Rupture of the interventricular septumTQ: rupture of IV septum occurs withint 3-5 days post MI, and causes severe hypotension, and cardiogenic shock.TQ: Ventricular free wall rupture occurs between 5days-14days post MI and can cause cardiac tamponade
24 y/o woman complains of knee pain. Pain is located on anterior knee, and worsens when she climb stairs or descends stairs. Trial of Ibuprofen did not lessen pain. Inspection of knee is normal. Most appropriate next step to confirm dx?
Extension of knee while compressing patella TQ: Patellofemoral syndrome is very common cause of "Anterior knee pain" in women. Hallmark: Pain in anterior knee, worse with climbing or going down stairsSpecial test: Patellofemoral grind test reproduces painTx: Exercises to stretch and strengthen the thigh muscles.
Risk factor for pneumonia?
TQ: Pneumonia can cause ARDS, which leads to decreased lung compliance and severe hypoxia. Can also cause decreased gas exchange and pulmonary HTN.
S+S of CHF
elevated BNP audible 3rd heart sound (S3) due to early diastolic filling
Risk of Hydroxychloroquine use (Used for SLE and Malariae)?
Retinal toxicity TQ: Pts must have annual optho exams
What kind of shock do pts with MI develop? Tx?
Cardiogenic shock (due to inadequate CO from ventricles)Tx: IV normal saline bolus (to increase preload and improve CO)
Labs for Hypovolemic shock?
Hypovolemic shock Ex: Pregnant woman bleeds out in bedCO: lowPCWP: lowSVR: highBP: low
Septic Shock
CO: high PCWP: normal/lowSVR: lowBP: low
Diabetic pt currently on Metformin and very compliant. However, still has HbA1c of 8.0. In addition to lifestyle changes, which drug can be given to patient to lose weight and control Blood sugar?
GLP-1 agonists (Exenatide and Liraglutide)TQ: these meds induce weight loss and lower blood sugar. Side effect: can cause acute pancreatitis
22 y/o man just returned from volunteer work in Honduras. Has 2 weeks of fever, sore throat, malaise. Examshows enlarged tonsils, with white exudate. Enlarged lymph nodes are palpable posterior to SCM bilaterally. Has hepatosplenomegaly. Dx?
Infectious mono TQ: Mono presents with Posterior lymphadenopathy, enlarged tonsils, with whitish exudate, hepatosplenomegaly. Can also cause anemia and thrombocytopenia.
Findings of Follicular thyroid carcinoma?
Invasion of tumor capsule and/or blood vessels TQ: Follicular thyroid carcinoma can look like Benign follicular adenoma on tissue sample (histology). Must get a FNA biopsy to diagnose. Exam of the surgically excised nodule will show invasion of the tumor capsule and/or blood vessels. TQ: FTC can mets via hematogenous spread to distant tissues. Note: FTC is a "cold" nodule
Medication for woman with Fibromyalgia who's not responding to other therapies?
AmitriptlyineTQ: Use TCAs, Pregabalin, or Dluoxetine in pts with Fibromyalgia
Tx of cocaine-induced ischemia/vasospasms?
1. IV Diazepam (Benzos)2. CCBs3. Aspirin4. Nitroglycerin
55 y/o male complains of fatigue, occasional heartburn, and has hepatomegaly secondary to fatty liver. Has been drinking 3-4 shots of alcohol per day, for past 30 years. MCV is 110.Cause of anemia?
Folate (Vit B9) deficiencyTQ: Pt with chronic alcoholism most likely has nutritional deficiency, leading to megaloblastic anemia from Folate acid (Vit B9) deficiency.
55 y/o man has puffy face and abdominal distension for past 4 weeks. Has periorbital edema, and moderate ascites, and +1 pitting pedal edema. 24 hour urine protein shows 5g/day excretion. Pt is at increased risk for developing what?
Accelerated atherosclerosis TQ: Pts with Nephrotic syndrome are at increased risk for atherosclerosis (from hyperlipidemia) and clot formation (due to excretion of Antithrombin III).TQ: The Liver tried to produce more Albumin, but also ends up produces increased hepatic lipoproteins.
Screening age for Osteoporosis?
Screening for osteoporosis with DEXA scan is recommended for all women >65y/o
Tx of GBS?
Causes Ascending paralysisTQ: GBS will show "Albuminocytogenic dissociation" on CSF (normal WBC count)Tx: IVIG and Plasmapheresis
MOA of Finasteride?
5-alpha-reductase inhibitor that inhibits conversion of Testosterone to DHT (used as 2nd line agent in pts with BPH)
Medication to help pt pass a 6mm ureteral stone?
Tamsulosin TQ: an alpha blocker that will relax ureter and allow passage of stone
Migraine prophylaxis in pts not responding to Sumitriptan/100% O2?
Topiramate (Topamax)= an anticonvulsant used in Migraine prevention TCAs (Amtitriptyline)
Cause of Niacin flush in pt taking Niacin for highTG?
PGE-releaseTQ: Niacin causes cutaneous flushing and pruritis due to excess PGE-related vasodilationTx: Give Aspirin 30-60 minutes before
24 y/o woman comes to office with hypopigmented skin lesions on trunk. Recently was in Florida and spent lots of time in sun. Cause?
Malassezia globosa infectionTQ: Pt has a Tinea versicolor infection due to fungal infection from Malassezia species. Causes hypopigmented macules.TQ: Can confirm dx with KOH prep of skin scrapings
Best index to monitor response to tx for pt with DKA?
Serum Anion GapTQ: Best marker for resolution of DKA (increased AG Metabolic acidosis with compensatory respiratory alkalosis) is to measure the serum A.G.Anion Gap should return to normal with disappearance of Ketoacid anions once insulin is given to pt with DKA.
Pathophysiology of Sarcoidosis?
Chronic granulomatous inflammation (noncaseating granulomas on tissue biopsy) TQ: Bilateral hilar adenopathy on Chest X-ray
Side effect of Bisphosphonates (Alendronate, etc.)?
can cause medication-induced esophagitis (pt will have sudden-onset odonyphagia and "be afraid to swallow" due to severe pain)
35 y/o woman recently returned from Caribbean vacation. Complains of fever, malaise, marked pain in hands and wrists. Has a macular rash on body, and cervical lymphadenopathy. Has swelling in bilateral hands, wrists, and ankle joints. Dx?
Chikungunya fever TQ: Chikungunya fever is a mosquito-borne viral infection, causes flu-like S+SClue: causes symmetrical swelling of hands, feet, and rash
45 y/o woman complains of fatigue, myalgias, muscle weakness in LEX for past month. Has cramping in legs after walking short distances. Has decreased strength in proximal muscles of LEX and sluggish ankle jerk reflexes. Labs: elevated Creatine Kinase levelsNext best step?
Serum TSH and Free T4 levelsTQ: Pt has "Hypothyroid myopathy" causing myalgias, proximal muscle weakness, and elevated Creatine Kinase levelsCauses delayed reflexesTesting: check serum TSH and Free T4.
60 y/o farmer has sore on lower lip. Has ulcer and some pain. Biopsy of lesions would show?
Invasive cords of squamous cells with keratin pearlsTQ: Pt's occupation as a farmer (lots of sun exposure) means he has SCC of lower lip. Note: SCC is most common cancer of lower lip. Sun exposure is big risk. Hallmark on biopsy: "Squamous keratinized pearls"
Antibodies in Hashimotos thyroiditis?
Anti-TPOAnti-thyroglobulin
When to admin. Meningococcal vaccine?
Admin. 1st dose at age 11-12y/oAdmin the booster dose at 16
42 y/o man has periodic difficulty breathing and wheezing. ENT found a persistent nasal blockage 2 weeks ago. Current meds include Aspirin. Cause of rep. complaints?
Pseudoallergic drug reactionTQ: Pts can have "Aspirin-exacerbated respiratory disease" (AERD). MOA: a non-IgE mediated reaction. Common in pts with asthma and chronic rhinosinusitis with nasal polyps. S+S: bronchospasms and congestion following aspirin ingestion. Note: Monteleukast (Leukotriene receptor antagonist) helps pts with Aspirin induced Asthma.
45 y/o man has fatigue and SOB. Takes daily iron supplements. 5 years ago, had a subtotal gastrectomy for a nonhealing gastric ulcer. Exam shows a shiny tongue and pale palmar creases. Cause?
impaired DNA synthesisTQ: Pt's gastrectomy leads to decreased parietal cells (low IF and Vit B12)VitB12 is crucial for purine synthesis and DNA synthesisdeficiency can cause Glossitis (beefy red shiny tongue)
Common causes of SAH?
Nontraumatic SAH can be due to ruptured saccular (berry) aneurysm
Neurocysticerosis?
Cause: parasite eggs in contaminated food/waterTQ: Taenia solium is a pork tapeworm whose eggs cause neurocystericercosisS+S: seizures
S+S of Tabes Dorsalis?
tabes Dorsalis is late stage NeurosyphillisS+S: sensory ataxia, wide-based gait, "Lancinating pains" that are sharp, Argyll-Robertson pupil (can accomodate but won't react)Tx: IV Penicillin G
Condyllomata accuminatum?
HPV 16 and 18
Condylomata lata
Syphillis
Tx of acute MS exacerbation?
steroids (IV methylprednisone) Note: INF-Beta used for maintenance therapy with prevent relapses
Nonalcoholic fatty liver disease
causes hepatomegaly with mild elevations in LFTs (high AST/ALT, without actual alcohol abuse Clue: Most common in pts with T2DM and obesityTx: weight loss
Prebycusis
sensorineural hearing loss that occurs with increased aging. Presents as high-frequency hearing loss, bilaterally. Clue: "Pt has difficulty hearing in noisy, crowded environments."
45 y/o woman complains of nocturnal substernal chest pain, that wakes her up from sleep. Episodes last 10-15 minutes and go away on their own. Has a sedentary lifestyle, but can still climb stairs without discomfort. Ambulatory EKG shows transient-ST segment elevation in leads V4-V6 during one of her pain episodes. Her condition is most similar to what?
Raynaud Phenomenon TQ: "Vasospastic angina" is characterized by recurrent chest discomfort, due to hyperactivity of vascular smooth muscle. It leads to intermittent coronary artery vasospasm, with transient ST-segment elevation. Raynaud phenomenon=affects digital arteries and has similar MOA.
46 y/o man has gait disorder. Has frequent falls. Pt has history of chronic alcoholism. Exam shows broad-based, unsteady gait. Also has Nystagmus and truncal ataxia. What other finding would he have?
Intention tremor TQ: Pt's with history of chronic alcoholism can have severe Cerebellar DysfunctionS+S: intention tremor, truncal ataxia, dysdyadokinesia (can't do rapid alternating movements)
24 y/o man has worsening productive cough, and increased sputum production, with fever, and SOB. Has blood streaked sputum. Had similar episodes in past. Has decreased exercise tolerance, fatigue, and weight loss. Temp. is 102. Exam shows crackles in both upper lung fields, and digital clubbing is present. CXR shows right upper lober infiltrate, and sputum culture grew Pseudomonas aeriginosa. Cause?
Defective chloride channels TQ: Pts with CF can have impaired mucociliary clearance and develop Bronchiectasis, and also Pseudomonas pneumonia.
65 y/o female complains of difficulty eating over past 2 days. Says food drops out of her mouth. Also has discharge in left ear. Has fever (101). Exam of left ear canal shows granulations. There is facial asymmetry, and angle of mouth on left is deviated downward. Causative microbe?
Pseudomonas TQ: Malignant otits externa (MOE) is a serious infection of ear seen in older pts. Cause: Pseudomonas. S+S: ear pain/ear discharge, granulation tissue in ear canal. Infection can progress to skull and cause facial asymmetry.
Man with Ankylosing Spondylitis fell down and now has severe LBP. Has midline tenderness over the upper lumbar region. Restricted spinal ROM. Cause?
Vertebral fracture TQ: Pts with long-standing ankylosing spondylitis can develop bone loss due to increased osteoclast activity, due to chronic inflammation.The spinal rigidity in these patients can increase risk of vertebral fractures, even from minimal trauma.
27 y/o man has periorbital swelling. Took Dicloxacillin for skin infection 3 wks ago. His urine has turned darker. Has RBC casts, and proteinuria. Labs:Low Serum C3Dx?
PSGNTQ: PSGN occurs 10-20 days after strep throat or skin infectionsS+S: Dark (coca-cola colored) urine, RBC casts, proteinuria, perioribiral swelling
17 y/o girl has irregular menses. since she was 13 y/o. Her most recent period was 6 weeks ago, and it lasted 10 days, with heavy bleeding and large clots. Pt gained 22 pounds over last year. Has coarse chin hair. Next best step for tx her irregular menses?
Sprinkle some combined OCPsPt has PCOS (with irregular menses and hyperandrogenism/hirsutism)Tx: weight loss and OCPs (to regular menstrual cycles)
54 y/o man comes to ER after episode of hematemesis and lightheadedness. Has hx of IVDA, Hep C, and Cirrhosis due to heavy alcohol use. BP is 105/60. Exam shows blood in oropharynx. Abdomen is distended with fluid wave. Next best step?
Octreotide infusion TQ: Tx of actively bleeding esophageal varices is Ocretotide (Somatostatin/GHiH analog). Note: Give Beta-Blockers as prophylaxis once bleeding is under control.
Tx of testicular cancer?
After diagnosis of solid testicular mass has been made (painless hard mass on testicle), should tx with removal of testis (radical orchiectomy) to prevent testicular cancer.
Risk of EPO therapy for pt with ESRD?
"Opthalmoscopic exam shows bilateral retinal hemorrhages"TQ: EPO can tx anemic pts with ESRD. HTN is a common side effect of EPO, and pts getting large doses can be at high risk for severe HTN and retinal hemorrhages.
Woman complains of SOB on exertion. CXR shows prominent pulmonary arteries and an enlarged right heart border. EKG shows right axis deviation. Dx?
Pulmonary HTNTQ: Middle-aged pts can develop primary pulmonary HTN. CXR shows enlarged pulmonary arteries and enlarged RV.
24 y/o man has syncope while shoveling snow. Regains consciousness in 1 minute. A "crescendo-decrescendo murmur" is heard along left sternal border. Cause of syncope?
Interventricular septal hypertrophy. TQ: HCM can cause crescendo-decrescendo murmur in left sternal border.
23 y/o woman has nasal breathing, stuffy nose, and occasional dry cough for more than a year. S+S fluctuate in intensity without any obvious inciting factors. Has no itching, wheezing, or skin rash. Has tried OTC oral Loratidine, with no improvement. Exam shows boggy and erythematous nasal mucosa. Next best step?
Topical intranasal steroids TQ: This pt has Nonallergic Rhinitis S+S of Nonallergic Rhinitis (nasal congestion, rhinorrhea, sneezing, postnasal drainage) without any specific etiology. Note: Pts with Nonallergic Rhinitis should be treated with Intranasal Antihistamines, Intranasal steroids, or both.
23 y/o woman has fatigue, anxiety, and difficulty sleeping for past few months. Has history of menorrhagia, but takes combination OCPs. Exam of neck shows a normal sized thyroid gland, without nodules. Serum TSH is 1.5 (normal), and total T4 is 15 (high). Cause?
Increased thyroid hormone-binding protein level TQ: Estrogen increases level of T4-Binding Globulin. Key: This effect is seen in both pregnancy and OCP usage. Labs will show: Elevated Thyroid Hormone level (high T4), but normal TSH.
72 y/o woman has history of HTN, and T2DM, and CAD. At dinner, she suddenly drops her fork. Her speech becomes slurred and she develops right-sided weakness. Has an episode of vomiting. In hospital, she is stuporous, does not respond to verbal stimuli, and grimaces to pain. Her BP is 185/107. Has +Babinski reflex on right side. Glucose is 365. Cause of current condition?
Intracranial bleeding TQ: Pts with HTN can develop intracranial hemorrhage, which causes rapid S+S and causes increased ICP. Key: Must get brain CT to confirm intracranial hemorrhage.
Note: Treatment of essential (action) tremor?
Propranolol
Tx of acute hallucinations and agitation in DT?
Lorazepam (will revive GABA inhibition)
#1MCC of CAP in pts with HIV?
Step. pneumo Clue" "Rusty Sputum"
68 y/o man complains of deep headache which he's had for past 2 months. His hard hat has felt unusually tight.Labs: Elevated Alk Phosph.CT scan of head shows skull to have thickened cortices with mixed lytic and osteoblastic lesions. Best tx?
Aldrendronate TQ: Pts with Paget Disease of bone have high risk of skeletal fx (thick skull, etc)Tx: Bisphosphonates (Ex: Aldrendronate) are used to reduce pain and inhibit Osteoclasts and Suppress bone turnover.
Woman found wandering streets with abnormal gait. Brought to hospital by police officers. Mumbles incoherently, and not oriented to time or place. BP is 160/100, BMI is only 16. Pupils are 3mm and react slowly to light. Best initial tx?
Thiamine TQ: Pts that are malnourished/alcoholics can have Wernicke's encephalopathy, due to Thiamine (Vitamine B1) deficiency. S+S: encephalopathy, ocular dysfunction, and gait ataxia. Tx: Thiamine (B1) BEFORE Glucose admin.
Recommended vaccines for 54 y/o man with history of HTN and T2DM?
Tdap, Intramuscular influenza, and PPSV23 vaccines TQ: 1. 13-valent pneumococcal vaccine is recommended for all adults >652. 23-valent pneumococcal vaccine is recommended for all adults <65, and pts with DM, HTN, smoking history, etc. 3. Adults also need a one-time dose of Tdap4. Annual IM influenza vaccine
Imaging for murmurs
Echo(Arrythmias=EKG)
Woman with RA comes to ER with seizures. Has cough, fever, night sweats. On immunosuppressive therapy for RA. CT scan of chest shows multiple nodules. Brain shows left temporal lobe abscess. Broncheoalveolar lavage shows acid-fast, gram-positive, branching rods. Tx?
SMX-TMP TQ: Nocardia is a filamentous, aerobic, gram-positive bacteria that is partially acid-fast. Causes brain abscesses and pulmonary nodules, especially in immunocompromised pts.Tx: SMX-TMP
45 y/o woman complains of progressive weakness for past few months. Has difficulty lifting foster kids and getting in/out of car. Has difficulty swallowing, and choked several times while drinking water. Normal DTRs and sensation. Normal ROM. Labs: Elevated serum Crteatine Kinase and ESRTx?
Prednisone TQ: Polymyositis is associated with proximal muscle weakness and elevated Creatine kinase.Tx: systemic steroids (Prednisone)
MOA of Memantine?
Memantine is an NMDA receptor antagonist used to tx. Alzheimer's dementia.
58 y/o woman complains of difficulty walking. Over past few weeks has experienced bilateral foot numbness and tingling. Was diagnosed with Hodgkin's lymphoma and is getting chemo with Bleomycin, Doxorubicin, and Vincristine. Has bilateral weakness on dorsiflexion of feet, and loss of pain and temp. Absent ankle jerk reflexes. Cause?
Chemotherapy-induced peripheral neuropathy TQ: Chemo-neuropathy causes "stocking-and-glove" pattern
Pt has a HIV-1 positive immunoassay.CD4+ cell count is 420. Tuberculin skin testing shows an 8mm induration at 48 hours. Chest X-ray is unremarkable. What other tx is necessary?
INH with Vit B6 (Pyridoxine) TQ: Pt with HIV needs to get a PPD test. An induration >5mm is considered positive in pts with HIV. If pt is asymptomatic, tx of latent TB is with 9 full months of INH and Vit B6 (Pyridoxine)
Surreptitious vomiting
HypoKHypoCl-Metabolic alkalosisnormal BPLow urinary chloride
Diuretic abuse
HypoK+HypoCl-metabolic alkalosisBut: Will have high urinary Cl-
Man presents to ER after episode of syncope. Had an URT infection a week ago. BP is 100/60, Temp is 99. Neck veins are distended and his heart sounds are distant. Chest X-ray shows small bilateral pleural effusions and an enlarged cardiac silhouette. Which EKG finding is likely?
Electrical alternans TQ: PEA is common in pts with Pericardial effusion.Hallmark: Enlargement of cardiac silhouette on chest X-ray.
Tx of HZV (Shingles)
Valcyclovir, etc.
Angiodysplasia
dilated submucosal veins and AVMs seen on colonoscopy, that cause painLESS GI bleeding.
Tx of Hypothermia?
external rewarming and warmed IV fluids
Tx of Asterexis in hospitalized pts?
Asterexis is flapping mvoements of hands that occur in pts with: hepatic encephalopathy, uremic encephalopathy, etcMust tx with Hemodialysis to clean out blood and improve neurologic status
65 y/o woman has progressively worsening right knee pain. Has had pain for past 2 years. Pain has been worse lately, especially in evenings. BMI is 34. Knee exam shows tenderness over medial tibial condyle, and a small joint effusion. ROM of knee elicits bony crepitus. Dx?
Osteoarthritis TQ: OA causes chronic joint pain. Common with increased age, obesity, and prior joint injury. Exam findings: tenderness, bony enlargement, crepitus with movement, pain and decreased ROM.
Patellofemoral pain syndrome
overuse disorder, seen in younger women. Causes diffuse anterior knee pain, reproduced by patellofemoral compression during knee extension.
Pt comes in for pre-conception counseling. She is Greek and her partner is of Mediterranean decent. Afraid Thalassemia runs in her family. Most appropriate initial screening test?
Complete blood count in the patient Key: Preconception counseling and testing can help identify couples at risk of hemoglobinopathies which might affect offspring. First, must get a CBC (complete blood count). to see Hb structure and MCV.
29 y/o man has splenectomy after a MVA. On day 3, he gets a packed RBC transfusion. Minutes after transfusion, he begins to wheeze, and has respiratory distress, and low BP, and loses consciousness. Cause of his transfusion rxn?
Anaphylactic reaction TQ: Anaphylactic rxn to transfused blood products occur rapid onset (seconds to minutes)S+S: respiratory distress, hypotension, respiratory failure, shock. Ex: Pts with IgA deficiency are at risk due to presence of anti-IgA Antibodies. Acute tx: Immediate Epinephrine and respiratory support.
Woman admitted to hx for labor. Has PROM. On day 3 of hospitalization, she develops fever, chills, and lower abdominal pain, and hypotension. Postpartum endometritis is suspected. Pt is started on broad-spectrum antibiotics and IV fluids. Over next 24 hours, has increased SOB. She gets 5 L of normal saline to treat hypotension. Temp is 101. Cardiac exam shows tachycardia, and lungs have diffuse bilateral crackles. Bilateral pitting edema is present in LEX. Pulse Ox is 80%. She is intubated, and PaCO2 drops of 34. Cause of resp. S+S?
ARDSS+S of ARDS: diffuse crackles, severe hypoxemia, bilateral alveolar infiltrates.Risks for ARDS: infections, trauma, massive transfusions
72 y/o man complains of fatigue and LEX swelling. Has pulsation in neck when he lies down. Has a permanent pacemaker implantation for sick sinus syndrome, 6 months ago. Jugular veins are distended. Liver is enlarged, and tender. Bilateral 3+ edema in LEX. Dx?
Tricuspid regurgitation TQ: Transverse lead placement through Tricuspid valve can cause severe tricuspid regurgitation, due to direct valve leaflet damage. Can then lead to Right-sided HF (LEX edema, JVD)
Febrile nonhemolytic transfusion rxn?
occurs within 1-6 hours of transfusion. During storage of blood, leukocytes release cytokines, and when transfused, cause transient fevers, chills, and malaise. Note: Does NOT cause respiratory distress or shock.
Woman has knee pain. Has history of RA, and takes low-dose MTX. Pain in her knee has been much more severe over past few days. Also has chills. Temp is 101. Exam shows swelling in joints of hands and wrists. Right knee is red and swllen, and limited active/passive ROM due to pain. Tx?
Antibiotics TQ: Septic arthritis (most commonly presents as acute monoarthritis), presents with fever, and restricted ROM. Tx: must do immediate synovial analysis and antibiotics.
47 y/o man has mid-sternal chest pain and diaphoresis during office meeting. Complains of dizziness, and becomes unresponsive. Coworkers perform CPR and he regains consciousness. EKG shows normal sinus rhythm, premature ventricular complexes, and ST-segment elevation. MOA responsible for his syncope?
Reentrant ventricular arrhythmias TQ: Reentrant ventricular arrythmias (aka V-Fib) are most common cause of sudden cardiac arrest in immediate post-infarction period in pts with Acute MI. Can cause syncope.
Alcoholic hepatitis: S+S?
associated with chronic heavy alcohol use. S+S: fever, jaundice, anorexia, and tender hepatomegalyAST>ALT (2:1)
Candidal esophagitis
odynophagia, with visible oral thrush.Tx: 1-2 wks of oral fluconazole Note: can diagnose with endoscopy with biopsy
HSV esophagitis
small, well-circumscribed, round/ovoid ulcers with intranuclear inclusionsTx: Acyclovir
CMV esophagitis
large, linear ulcers, with "intranuclear and intracytoplasmic inclusions."Tx: Gangcyclovir
GBS labs
High Protein,normal WBC countnormal RBC countnormal Glucose (Albuminocytogenic dissociation)
S+S of Waldenstrom macroglobulinemia?
Hyper-IgM spikehyperviscosityneuropathyblurry vision
Cause of anemia and fragmented RBCs in pt with calcified Aortic Stenosis?
Macrovascular traumatic hemolysis TQ: can cause microcytic anemia in pts with artificial heart valves/severely calcified aortic valves.
72 y/o man comes to hx with 12 hours of worsened SOB and nonproductive cough. Was in usual state of health until 3 days ago, when he abruptly developed fever, headache, sore throat, runny nose, anorexia, and severe body aches. 5 days spent a long time in the mall shopping for Christmas gifts. Temp is 102, has pharyngeal erythema (sore throat), bilateral crackles and a 4th heart sound (S4). Chest X-ray shows bilateral, diffuse reticular opacities. Cause?
Influenza virus Note: In pts >65y/o, or with chronic medical illnesses, influenza can lead to secondary bacterial pneumonia (S. pneumonia), or direct viral attack (influenza pneumonia)
Man complains of fatigue, and dark urine. He is an IVDA in past. Has 25 pack year history. Has scleral icterus and yellow skin. Labs: Alk Phosph is 822. AST: 55ALT: 40Next best step to dx?
Ultrasound of abdomen TQ: Elevated serum alkaline phosphatase is indicative of cholestasis. These pts needs RUQ ultrasound to look for intra/extrahepatic biliary obstruction.
43 y/o woman brought to ER with bloody emesis. Has cirrhosis. Was hospitalized 5 months ago for variceal band ligation. BP is 88/52. Pt is somnolent, and barely arousable to sternal rub. Dried blood is in her mouth. Pt is given 2 large-bore catheters, and 2L normal saline. Despite resuscitation with crystalloids, she is unresponsive. Keeps having bloody vomiting and clots. She's given a unit of packed RBCs. Next best step?
Endotracheal intubation TQ: Pts with upper GI bleeds with decreased level of consciousness and ongoing hematemesis must be intubated to protect airway. Next, should do endoscopic ligation/sclerotherapy to stop bleeding.
60 y/o male is hospitalized for tonic-clonic seizures. Heavy alcohol user. In hospital, urine sediment shows 5-10 WBCs, RBCs, and some epithelial casts. Urine analysis shows lots of blood. Dx?
RhabdomyolosisTQ: Should suspect myoglobinuria whenever UA shows large amount of blood and RBC casts. Key: Seizures can lead to myoglobinuria/rhabdo. Myoglobinuria is usually caused by rhabdomyolysis, which then can lead to acute renal failure.
Woman brought to ER due to lethargy. Had a "stomach bug" 4 days ago, with N/V, and abdominal pain after eating at a restaurant. Vomiting has resolved, but she has worsened oral intake. Also had 9 pound weight loss, and excessive thirst. On exam, pt is lethargic. Dry mucus membranes, and has diffuse abdominal tenderness. Next best step?
Fingerstick glucose TQ: Pts with T1DM can develop DKAS+S: weight loss, abdominal pain, altered mentation. Key: Get a blood glucose level. Tx of T1DM: immediate IV fluids and insulin
previously healthy man has nausea, loss of appetite, malaise, and upper abdominal discomfort. Recently went to Phillippines 2 weeks ago, and did not get any vaccines before leaving. Says he did not consistently consume bottled water while there. Exam:Temp is 100, has scleral icterus and tender hepatomegaly. Labs:AST: 7,000ALT, 8,000most likely outcome of this pt's condition?
Complete recovery TQ: Pt has Hep A (trAvelers)S+S: N/V, abdominal pain, jaundice, hepatomegaly, elevated LFTsKey: Pts recover in 3-6 weeks.
70 y/o man is lethargic and confused. He was sick with "a cold" for past 2 days. Temp is 100, BP is 90/65. Dry mucus membranes. Glucose: 1,000pH: 7.40PaCO: 38Bicarb: 22Best initial tx?
Normal saline TQ: In pts with Hyperosmolar, Hyperglycemic, Nonketotic syndome, they experience change in mental status. Severe hyperglycemia causes osmotic diuresis, low BP, and hyperglycemia. Tx: Immediate fluid replacement with normal saline.
Woman complains of periods of visual deficit. She goes blind for several seconds when standing up or stooping forward. Also has frequent morning headaches for past 2 months. BMI is 35. Visual field testing shows enlarged blind spots. Which ocular feature is most associated with this pt's condition?
Papilledema TQ: Papilledema is caused by increased ICP. Causes transient vision loss, lasting a few seconds with changes in head position. Headaches secondary to Increased ICP are usually worse in morning. This pt probs has increased ICP due to Pseduotumor Cerebri
52 y/o male complains of black stools. Has abdominal discomfort as well. Food helps his abdominal pain, so he eats frequently during the day. Exam shows mid epigastric tenderness and right-sided carotid bruit. Fecal occult blood testing is positive. Dx?
PUD TQ: Key: PUD can involve ulcers in either stomach OR duodenum. Causes: H. pylori/NSAIDsS+S of PUD: epigastric pain, nausea, melena (black tarry stools), early satiety. Duodenal ulcers get better with food (gets worse pain on empty stomach/at night)Note: PUD is one of most common causes of Upper GI Bleeding. Dx: With Upper GI endoscopy.
54 y/o woman complains of difficulty walking. Has severe weakness and occasional pain in thigh muscles. Has stumbled and fallen several times. Younger brother died from neurological disease when he was 20y/o. Exam: shows hyporeflexia and decreased strength in all muscle groups. EKG shows flat, and broad T waves with occasional premature ventricular contractions. Cause of her complaints?
Electrolyte disturbance TQ: HYPOkalemia causes weakness, fatigue, and muscle cramps. When severe, can cause paralysis and arrhythmias. EKG: U-waves, flat and broad T waves, and premature ventricular beats.
27y/o woman comes to ER after losing consciousness for 2 minutes while standing in line at supermarket. Had nausea and feeling of warmth spreading over body, immediately before passing out. EKG shows normal sinus rhythm, with no abnormalities. Cause of episode?
Neurocardiogenic syncope TQ: Neurocardiogenic (aka vasovagal) syncope occurs in pts with excessive vagal tone. Episodes are preceded by nausea, diaphoresis, bradycardia, pallor. Causes: pain, stress, prolonged standing, medical needles, urination
28y/o Kindergarten teacher has gritty sensation and discharge from right eye for past 3 days. Has rhinorrhea, sore throat, and fever. Exam shows mild injection and granular appearance of conjunctiva, with profuse watery discharge. Next best step?
Cool, moist compress TQ: Viral conjunctivitis is often unilateral, profusely watery.Cause: AdenovirusTx: just warm/cold compresses
Man complains of fever, dry cough, and right sided chest pain. Pain is intermittent, sharp, and worse with deep inhalation or cough. Also has achiness in knees and ankles. Just returned from Arizona, after completing desert training. Exam: right sided crackles, erythematous, tender nodules on bilateral shins. Chest X-ray: right lower lobe infiltrate with prominent right hilum.Cause?
Coccidiodes immitis TQ: endemic mycosis in desert southweat that can cause fever, chest pain, lobar infiltrate, erythema nodosum, and arthralgias.Endemic regions: Arizona or California
20 y/o college student brought to ER after ingesting 30 pills of Acetomenophen at 500mg each in suicide attempt. Has high serum acetominophen levels, and is started on N-acetylcysteine therapy. He becomes markedly confused and incoherent. Has scleral icterus and asterixis. Labs: Elevated ALT/AST (8,000/7,000)Elevated Total BilirubinElevated PTElevated serum Creatinine Next best step?
Refer to liver transplant center TQ: This patient is in Acute Liver Failure (ALF), due to Acetominophen toxicity. Causes Elevated LFTs, encephalopathy, elevated PT. (Fulminant hepatic necrosis)Key: Must get liver transplant ASAP to survive.
female complains of fever, malaise, chills, and breathlessness and a dry cough for past 6 months. She breed budgerigars (small Australian parrots) as a hobby...PFTs show a reduced lung volume and an FEV/FVC ratio of 87%. Serology shows Antibodies to Bugerigars antigens. Best tx?
Avoid exposure to birds TQ: This pt has Hypersensitivity pneumonitis (HP) to the bird antigens, which is why she has antibodies against the antigen. S+S: inflammation of lung parenchyma caused by antigen exposure. Cough, breathlessness, fever, etc. Tx: just avoidance of responsible antigen.
52 y/o woman complains of intense itching and fatigue. Has hepatomegaly, but no scleral icterus or jaundice. Has bilateral Xanthelasma and Skin excoriations. Total cholesterol: 503Alkaline phosphatase: 410RUQ Ultrasound shows normal common bile duct. Next best step?
Check anti-mitochondrial antibodies TQ: This pt has PBC (intrahepatic cholestasis due to autoimmune destruction of small bile ducts)S+S of PBC: fatigue, pruritis, hepatomegaly, elevated Alk Phosph. Also: Xanthelesmas (from severe hyperlipidemia) Confirm dx of PBC with: +AMA Antibody titers
Woman with anorexia is admitted to hospital. Develops confusion and is unsteady when walking. Her lateral gaze is restricted on both sides and evokes a horizontal nystagmus. Pt walks slowly with short and wide-based steps. Best next step?
Thiamine supplementsTQ: This pt has Wernicke's encephalopathy due to Vit B1 (Thiamine) deficiency. S+S: encephalopathy, horizontal nystagmus, gait ataxia. Key: Occurs in malnourished pts (chronic alcoholics, anorexics)KEY: Must tx with Vit B1 (Thiamine) BEFORE admin. of Glucose to avoid exacerbation of S+S, bc Thiamine is required for glucose metabolism.
Man complains of easy fatigability. He is a vegetarian, and has limited dairy consumption, and drinks alcohol daily. Started on thiamine infusions and folic acid 1mg daily. After several months, reports recurrent falls and increasing forgetfulness. Most likely finding at this point?
Loss of proprioception in LEXTQ: Suspect Vit. B12 deficiency in strict vegetarians with anemia and neurological complications. Key: Folic acid supplements may correct the megaloblastic anemia, but it won't fix the rapid progression of neurological complications.
Woman has intermittent, substernal chest pain. Her pain is not related to activity, and lasts several seconds-few minutes. During episodes, she has difficulty swallowing both liquids and solids. In ER, has normal EKG, normal cardiac biomarkers, and negative myocardial perfusion scan. Upper GI endoscopy shows no abnormalities. Dx?
Diffuse esophageal spasm TQ: Diffuse esophageal spasm causes uncoordinated contractions of esophagus and causes chest pain and dysphagia. Esophageal manometry shows contractions in middle/lower esophagus.Esophagram shows "corkscrew" pattern.Tx: 1st line for Esophageal spasms: CCBs
Variant Prinzmetal angina
causes coronary artery spasms. Causes episodic chest pain at rest, normal EKG findings between attacks, with variable ST-abnormalities during acute attacks.
Eosinophilic esophagitis
causes food impaction, dysphagia, and heartburnEndoscopy shows: esophageal rings/strictures
62 y/o hospitalized woman is evaluated for worsening skin lesions. Was admitted 6 days ago for CABG due to CAD. She has recovered well, but noticed red patches on abdomen that progressed to purple lesions today. She is receiving low-dose subcutaneous Heparin for prophylaxis of DVT. Exam shows purple/black patches in periumbilical area, surrounded by erythema. Cause of skin lesions?
Antibodies against a platelet component TQ: This pt is suffering from HIT. Always suspect HIT in pts on Heparin who develop thrombocytopenia and purple/black spots. Tx: Stop Heparin and start 2a inhibitors (Argatroban/Dabigitran)
68 y/o man brought to ER due to right red blood in rectum. 6 months ago, had a diverticular bleed that required hospitalization. 3 weeks ago, had a COPD exacerbation and was hospitalized, and found to have a right femoral and popliteal vein thrombosis. He was discharged on warfarin. Currently, his BP is 80/60, and hd has significant right calf and ankle swelling. Warfarin is stopped. He is given blood transfusion and FFP. Lower endoscopy shows a diverticular bleed. Management of his DVT?
Place a retrievable IVC filter TQ: IVC filters are placed to prevent P.E.'s in pts with contraindications to or complications from anticoags (like active diverticular bleeds)
Man comes to ER with sudden onset severe epigastic pain. Has sudden, dull, aching, and diffuse abdominal pain. Abdominal ultrasound performed 2 weeks ago shows small stones in gallbladder. Exam shows diffusely tender abdomen with rebound tenderness. Increased pain in upper abdomen, when palpating after deep inspiration. Chest X-ray shown---> Dx?
Perforated peptic ulcer TQ: This pt has chemical peritonitis due to perforated peptic ulcer. Suspect in pts with sudden onset severe epigastric pain all over abdomen. X-ray shows free air under diaphragm.
Woman complains of chronic diarrhea. Has lost 15 pounds over last year. Has fecal fat content of 10g/day. Pt is given 25 grams oral D-xylose solution, and his urinary excretion of D-xylose at 5 hours is 1.2 grams (normal 4-7 grams). After 4 weeks, D-xylose test is repeated, and urinary excretion at 5 hours is 1.3 grams. Dx?
Celiac Disease TQ: D-xylose is a monosaccharide that is usually absorbed in proximal small intestine without degradation by pancreas/brush border enzymes. Pts with small intestine disease (Celiac's Dx), will have impaired absorption of D-xylose.
MOA of Celiac Dx?
common cause of malabsoprtion due to atrophy of intestinal villi in small intestine due to exposure to gluten-containing wheat products.
78 y/o woman has worsening left-sided ear pain and drainage. Has increased sever pain at night, worse with chewing. Reports sense of fullness in ear, and mild hearing loss on left side. Temp of 101. On exam, left external auditory canal is edematous with purulent discharge and granulation tissue in the floor. Clear tympanic membrane. Best initial tx?
IV Ciprofloxacin TQ: Malignant (necrotizing) otitis externa is a severe infection of external auditory canal caused by: Pseudomonas. Seen in elderly pts. S+S: External auditory cancal edema and drainage/granulationTx: Fluroquinilones
Choleseatoma
keratinized epthelial growth in middle ear, with hearing loss and drainage, that requires surgical excision.
Man complains of right foot and leg pain. Yesterday, sailed a friend's boat, and sustained a small cut to right foot while jumping onto dock. Last night , awoke with throbbing pain in right foot. Also developed fever, with rigors. Exam shows laceration on dorsum of foot with erythema, and dark-colored bullae. Cause?
Vibrio vulnificus TQ: Vibrio vulnificus is a free-living marine bacterium that is is oysters and can cause bad wound infections.
58 y/o man has sudden-onset severe difficulty speaking and weakness that developed. Has history of HTN, and severe left atrial enlargement (seen previously on echo). Also has carotid artery disease and ADPKD. Is speaking in very short sentences and has difficulty finding words while trying to speak. Also has severe right facial droop. Glucose value is 345. Cause of current condition?
Cardiogenic emboli TQ: Embolic strokes have sudden onset maximal S+S immediately. Occur commonly in pts with structural heart diseases (A-Fib, Endocarditis). Note: Pts with A-Fib PLUS structural heart diseases are at increased risk of cardioembolic strokes.
67 y/o man complains of increasing forgetfulness for past month. Has noticed unsteady gait, and fatigue. Has worked as an automobile mechanic for past 30 years before retiring last year. Weakness on dorsiflexion of bilateral wrists and feet, and reduced pinprick sensation over hands and feet. Labs: MCV is 74. Cause of pt's S+S?
Impaired heme synthesis TQ: This pt has lead toxicity due to lead expsure at work/home. S+S: low MCV, fatigue, irritability, congitive decline, peripheral neuropathy
26 y/o man has fever, malaise, and sore throat. He is excessively tired. Temp is 101, and physical exam shows pharyngeal erythema, mild splenomegaly, and morbilliform skin rash. Labs:Lymphocytes: 70%Peripheral blood smear shows following--->Dx?
CMV infection TQ: CMV mono causes fever, malaise, and fatigue.Hallmark: "Atypical lymphocytosis" on CBC/peripheral blood smear. Key: Unlike EBV, CMV is less likely to cause lymphadenopathy or splenomegaly like EBV mono. CMV mono: negative heterophile antibody test, with positive IgM positive serology.
54 y/o man complains of 2 days of fever, chills, and perineal pain. Has repeated urgency to urinate, along with pain on micturition. Not sexually active. Temp is 100. Rectal exam shows a boggy and tender prostate. Dipstick urinalysis shows positive leukocyte esterase. Next best step?
Culture of mid-stream, urine sample. TQ: Acute bacterial prostatitis often presents similar to UTI, but clue is: "Perineal pain" and fever, chills, etc. Pts with prostatitis will have tender, boggy prostate on exam. Urine culture (mid-stream urine sample) should be obtained to help direct antibiotic therapy.
33 y/o woman complains of dull, aching pain in RUQ for past few weeks. Takes no meds except for OCPs, which she's been taking for past 12 years. Exam shows hepatomegaly, with moderate discomfort on deep palpation in RUQ. Labs:Normal ALT, ASTElevated GGTAbdominal ultrasound shows a solitary hyperechoic 7cm lesion in right lobe of liver. Dx?
Hepatic adenomaTQ: Hepatic adenomas are benign tumors in women who take OCPs. Presents as large, painful hepatic mass. Elevated GGT suggests compression/obstruction of biliary tree.
Hydatid cysts caused by?
Echinococcus tapeworms
63 y/o man complains of increasing scrotal pain. Pain is worse with touch or movement. Also has mild burning sensation on urination and increased urinary frequency. Is married and sexually active with wife. Exam shows tender mass in left scrotum, that is mildly erythematous. Cremasteric reflex in tact. Likely cause?
E. coliTQ: Acute epididymitis auses unilateral testicular/scrotal pain and epididymal swelling. In pts >35y/o, usually occurs due to bacteruria from bladder outlet obstruction. (Ascending E.coli infection)Note: In pts <35y/o, Epididymitis usually occurs from STDs (Chlamydia/Gonorrhea)
Man comes to office four weeks after experiencing an ischemic stroke. You notice he only has shaved the right side of his face. When you ask him to raise his left arm, he only raises his right. Ask him to fill out clock, only fills out right side. Which area of brain is affected by the stroke?
Right parietal cortexTQ: Right parietal cortex stroke will lead to contralateral (left) hemispace neglect syndrome
Drugs that can cause folic acid deficiency?
1. Phenytoin2. MTX3. SMX-TMPKey: All require Folic-acid supplements to avoid megaloblastic anemia.
45 y/o brought to doctor for nausea, fever, upper abdominal discomfort. Has history of depression, migraine, and rheumatoid arthritis. Severe tinnitus and vertigo. Admits to overdosing on one of her meds. Temp is 100. Which acid base finding is most likely to be present on ABG?
TQ: this pt overdosed on Aspirin (causes respiratory alkalosis, with increased A.G. metabolic acidosis)pH: 7.39PaCO2: 20HCO3: 12(Pt would have pH close to normal pH bc of mixed-acid-base disturbance)
Best way to decrease M+M in pts with COPD?
smoking cessation Smoking cessation is associated with a mortality benefit and reduced progression of disease in pts with COPD
Note: TMJ can cause nocturnal grinding of teeth, and referred ear pain that is worse with chewing.
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23 y/o woman complains of hair loss. Developed loss of large numbers of hair fibers when washing or brushing hair. Has had 2 pregnancies, and a spontaneous abortion. Has a normal pregnancy and delivery 4 months ago. Exam shows diffuse hair loss, with no erythema or scaling. When tracts of hair are pulled, >20% fibers are pulled out. Dx?
Telogen effluvium TQ: causes acute, diffuse, noninflammatory hair loss. Telogen effluvium is often caused by stressful event, weight loss, pregnancy, psychiatric trauma, etc. S+S: widespread thinning.
Man complains of SOB and a "pounding" sensation of heart over last 5 months. He is uncomfortably aware of his heartbeat while lying on his left side. BP is 150/45. Cause?
Aortic regurgitationTQ: AR causes blood to leak back from Aorita--->LV, leading to increased LV end-diastolic volume, widened pulse pressure (150/45), "water hammer" bounding pulses, and enlarged LV.Key: Sitting in left lateral decubitus position brings enlarged LV closer to chest wall and causes pounding sensation and "increased awareness" of heartbeat.
HCM
Autosomal dominant
85 y/o man complains of rash over forehead, tip of nose, and left eye. Also complains of pain and decreased vision. Has burning sensation around left eye for past 5 days. Exam shows a vesicular rash on periorbital region and lid margins. Dendriform ulcers are seen on cornea. Dx?
Herpes zoster opthalmicus TQ: Herpes zoster opthalmicus causes "dendriform corneal ulcers" and a vesicular rash in trigeminal nerve distributionBuzz words for Herpes Zoster: "bruning," "vesicular"Tx: High-dose Acyclovir
In what nerve does Herpes Zoster virus remain latent in?
Trigeminal nerve (CN 5)
Dacryocystitis
infection of lacrimal sac due to obstruction of nasolacrimal duct(redness, pain in tear sac area)
Woman comes to ER with severe right-sided headache, that started 2 hours ago. Pain is located all around the eye. She is seeing "halos" around lights. Exam shows a nonreactive, dilated right pupil and eythematous right eye. Decreased visual acuity
Acute angle-closure Glaucoma Causes dilated pupil with poor response to light. Untx. patients can have permanent vision loss within 2-5 hours of symptom onset.
Causes of TEN:1. Sulfa drugs (SMX-TMP)2. Anticonvulsants (Phenytoin, Lamotrigine, Carbamazepine)
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Acute cholecystitis S+S?
sudden onset RUQ pain, fever, vomiting, and leukocytosis.Key: The PRIMARY inciting event is a gallstone obstructing the cystic duct---> next comes inflammation and infection.
Which Vitamin/Mineral deficiency would be seen in Carcinoid syndrome?
Niacin (Vitamin B3) deficiency TQ: Carcinoid tumors cause watery diarrhea, flushing, bronchospasms. Key: Carcinoid cells cause increased conversion of Tryptophan--->Serotonin (increased urine 5-HIAA), and thereby decrease the available conversion of Tryptophan--->Vit B3 (Niacin).This causes Pellagra (Dermatitis, dementia, diarrhea, death)
34 y/o homeless man comes to ER in confused state. Complains of epigastric pain, vomiting, and blurred vision. Fundoscopic exam shows optic disc hyperemia. Cause of S+S?
Methanol poisoning TQ: Methanol and Ethylene glycol can both be used by homeless people for alcohol substitution. Methanol: causes vision loss (blurry vision) and comaEthylene glycol: causes kidney damage
Labs for old man with Paget Disease?
S+S of Paget disease:1. increased hat size2. cortical thickening with mild bowing Labs:Serum Ca2+: normalSerum Phosphorous: normalAlk. Phosphatase: highUrine hydroxyproline: highNote: Paget's disease of bone occurs bc of disordered osteoclastic bone resorption
Man has burning substernal chest pain after every meal. Undergoes upper GI endoscopy, which shows mucosal irregularity and ulceration of squamocolumnar junction above lower esophageal sphincter. Multiple biopsies taken.4 hours after procedure, has worsening substernal and left-sided pain radiating to back. Chest X-ray shows small, left-sided pleural effusion that was not present on X-ray 2 weeks ago. Next best step to confirm dx?
Water-soluble contrast Esophagogram TQ: This patient had an endoscopy that led to Esophageal perforation. S+S: acute chest pain, subcutaneous emphysema, and left-sided pleural effusion. Key: Contrast Esophagram can confirm the diagnosis.
23 y/o man complains of severe abdominal pain and fatigue. Has N/V and is unable to eat. Exam shows tenderness in RUQ, exacerbated y deep breath. Also has splenomegaly, and jaundice. Labs:Total Bili: 2.3Direct Bili: 0.5Serum lactate dehydrogenase: 1000Coombs test: negative Cause of pts anemia?
congenital RBC defectTQ: This pt has Hereditary Spherocytosis. RBC rupture causes production of pigmented gallstones--->acute cholecystitis
68 y/o woman has acute ST-elevtation MI. Undergoes successful stenting of LAD. On 3rd day, has vague abdominal pain. Has bluish discoloration right great toe and all toes on left foot. Cause?
Cholesterol embolism TQ: Atheroembolism (cholesterol embolus) is complication of cardiac cath. Can cause "blue toe syndrome" (livedo reticularis), intestinal ischemia, and acute kidney injury. Tx: Statin therapy to prevent recurrent cholesterol embolism.
Woman complains of "pounding" sensation in neck and LEX. Lost weight recently. Also has chronic diarrhea, and post-menopausal flushes. Echo shows retracted, immobile tricuspid valve leaflets, with poor coaptation and severe tricuspid insufficiency. Dx?
Carcinoid syndrome TQ: Carcinoid tumor can mets to heart and lead to right-sided HF with Tricuspid regurgitation
Man complains of difficulty hearing in left ear. No ear discharge. Exam shows dull, hypomobile tympanic membrane. Cause of his hearing loss?
Non-infectious effusion TQ: Serous otitis media causes a "middle ear effusion", without signs of an actual infection. Hallmark exam: dull tympanic membrane, that is hypomobile on pneumatic otoscopy.
Woman has jaundice, palmar erythema, distended abdomen, and spider angiomata. Which vaccines are recommended?
HAVHBVAnnual Influenza vaccineTdap PPSV23TQ: Pts with Chronic liver disease require regular influenza vaccines, and Tdap, but also need Hep A and Hep B vaccines to protect Liver. Also need 23-valent PPSV vaccine Young people get PPSV23, old people>65, get PPSV13, then PPSV23.
Man has skin discoloration, anorexia, and unintentional weight loss over past 3 months. Has dark urine, and pale stools. BMI is 32. Has scleral icterus. Has an enlarged, nontender, gallbladder. Abdominal imaging would most likely reveal?
Intra and extra-hepatic biliary tract dilation TQ: Tumors at head of pancreas can cause painless, obstructive jaundice, weight loss, and distended gallbladder. Causes intra and extra hepatic biliary tract dilation.
45 y/o woman has fever, chills, N/V. Has had progressive worsening RUQ abdominal pain for past 2 days. BMI is 36. Temp is 103. Appears very ill and confused. Pt appears very ill and confused. Skin and sclera are icteric. Tenderness in RUQ. Alkaline phosphatase is 714. Further workup would show what?
Common bile duct dilationTQ: fever, jaundice, and RUQ abdominal pain are associated with Acute Cholangitis. Often causes elevated Alk Phosph. and confusion/hypotension.Ultrasound/CT show common bile duct dilation
Man complains of exertional SOB and dry cough. Also has suffocating nighttime cough, that is only relieved by sitting up. Cardiac apex is palpated in left sixth ICS. Bilateral pitting leg edema is present. What is most likely associated with her condition?
Constriction of the efferent renal arterioles TQ: In pts with CHF, activation of RAAS cascade will allow constriction of efferent arteriole, to maintain adequate GFR. This also helps maintain cardiac output and systemic pressure.Note: pts with CHF have decreased renal perfusion, which causes subsequent RAAS activation.
54 y/o man complains of 6 months of fatigue, anorexia, and 15 pound weight loss. Despite his weight loss, his pants are getting tighter, and socks leave deep imprints on legs. Drinks 1 or 2 cans of beer on weekends. Has a remote history of injection drug use. Has bilateral gynecomastia, and spider angiomas. Abdomen is distended, with shifting dullness. Has bilateral LEX pitting edema. Cause of pts underlying condition?
Chronic viral infectionTQ: This pt has Cirrhosis. Given his history of IVDA, it's most likely that he has viral hepatitis causing his cirrhosis. TQ: Most common causes of cirrhosis in U.S.: Viral hepatitis, chronic alcohol abuse, nonalcoholic fatty liver disease, HHC.Viral Hepatitis C (more so than Hep B) causes Cirrhosis
Woman has fatigue, and exertional SOB. Has hard time walking more than 1 or 2 blocks, without becoming SOB. Uses 2 pillows to sleep. Abdomen is obese and nontender. BMI is 55! Trace bilateral LEX edema. EKG shows low-voltage QRS complexes, but no ST-segment or T-wave abnormalities. Predominant cause of pt's dyspnea?
Alveolar hypoventilationTQ: Obestiy hypoventilation syndrome occurs in pts with BMI>30. Can cause daytime hypercapnea (PaCO2>45) due to all that fat sitting on lungs, leading to alveolar hypoventilation. ABG would show:hypercapniahypoxemiarespiratory acidosis
18 y/o girl complains of mild dyspnea with climbing stairs. During expiration, there is an extra high-pitched sound heard after the S1. There is also a crescendo-decrescendo murmur, loudest at left upper sternal border. S2 is split throughout the respiratory cycle, and splitting increases with inspiration. MOA of her murmur?
Pulmonary stenosis TQ: Pulmonic stenosis usually occurs as a congenital defect, and can often times remain asymptomatic until adulthood. Cardiac exam reveals an "ejection click, followed by a crescendo-decrescendo systolic murmur" over Left 2nd ICS, and a "widened splitting of S2"
68 y/o man is admitted with left lower lobe pneumonia, and started on antibiotics. Has an arterio-venous fistula placed for possible dialysis. After having his blood drawn for some lab work, he bleed persistently. Labs: elevated BUN/Cr.Mostly likely cause of bleeding?
Platelet dysfunction HYTQ!!TQ: Platelet dysfunction is most common cause of abnormal hemostais in pts with CRF. Often have abnormal bleeding and bruising due to "uremic coagulopathy."Key: Pts with CRF will have normal PT, PTT, and platelet count. However, will have elevated Bleeding time. Uremic coagulopathy causes platelet dysfunction, leading to increased bleeding time.Tx: DDVAP is the tx of choice (increases release of Factor 8 and vWF from endothelial storage sites.
64 y/o man complains of palpitations and progressive SOB. He develops a choking sensation with dry cough every time he tries to lie down. No chest pain. Has HTN for past 20 years, and medication noncompliance. 2+ pitting edema in LEX. Bedside echo shows a normal-size left ventricle, with left ventricular hypertrophy, and a left ventricular ejection fraction of 55%. What is responsible for his S+S?
Diastolic dysfunction TQ: Pts with LVHypertrophy, with a preserved ejection fraction, can squeeze, but not die in diastole. LV wall stiffness leads to an increased LV end-diastolic pressure.
27 y/o man complains of episodic abdominal pain, concentrated in epigastrum and is "gnawing" in quality. Wakes him up in middle of night, and is relieved by a glass of water and some bread. Also has occasional dark stools. Smokes cigs and a can of beer daily. Best long-term relief of this pts S+S?
Antibiotics and PantoprazoleTQ: This pt has a Duodenal ulcer (epigastric pain, better with eating)TQ: Most Duodenal ulcers occur due to H. pylori or NSAIDs. Tx: Acid suppression with a PPI and antibiotic eradication therapy. Note: smoking/alcohol cessation won't help.
Man has syncopal episode. He got up to pee in the middle of the night, and felt lightheaded while urinating, and fell to floor. Sometimes he has difficulty intiating a urinary stream. BP is 130/80 supine and standing. EKG shows normal sinus rhythm. Cause of his syncope?
Cardio-inhibitory response TQ: Situational syncope is a form of reflex or neurally mediated syncope that occurs with triggers (peeing, pooping, coughing). These triggers alter the ANS response and can cause cardio-inhibition effects and syncope.
67 y/o woman hospitalized for sepsis secondary to UTI. Admitted to ICU and treated with IV fluids and broad-sepctrum atibiotics. Urine culture grows E.coli. Her antibiotics are changed to oral Ciprofloxacin on 3rd day of hx. She becomes confused, and has 6 watery bowel movements with lower abdominal pain. Temp is 100. Abdomen is tender in LLQ. Has a WBC count of 14,000. Repeat UQ shows occasional yeasts. Next best step?
Send stool studies, and start oral VancomycinTQ: This pt has C. diff colitis after being started on Cipro. Must send stool studies to collect C. diff toxin to confirm dx. Tx with either IV Metro or Oral Vanco.
Man has had an extensive small bowel resection for Crohn disease and has been on TPN for past 2 years. Presents to hospital for epigastric and RUQ pain. Has mild RUQ tednerness. Ultrasound shows several gallstones, whereas US 2 years ago did not show any gall stones. Most likely cause of gallstones?
Gallbladder stasis Pts with TPN can have gallbladder stasis, which predisposes them to gallstone formation, and bile sludging, both leading to cholecystitis. TPN requires no CCK or gallbladder contraction.
62 y/o man brought to ER with fever, headache, confusion, and vomiting for past 2 days. Has history of Liver transplant secondary to Wilson's disease. Temp is 103. Neck is stiff. Pt is awake, but confused. WBC count is 17,000. Lumbar puncture is pending. Most appropriate empiric antibiotic therapy?
Cefepime,Vancomycin, and Ampicillin TQ: Empiric antibiotics should not be delayed in pts with bacterial meningitis, even while waiting for results of LP. Give Cefepime, Vanco, and Ampicillin for pts that are immunocompromised.
Man has anorexia and weight loss for past 2 months. Has history of HTN and latent TB, treated 30 years ago. Exam shows mucosal pallor and hepatomegaly. Fecal occult blood testing is positive. On ultrasound, there's a solitary liver lesion measuring 2x3cm. Dx?
Metastatic disease to the liver TQ: Most common malignancy of Liver is metastasis from another source (aka Colon cancer with +fecal occult blood)
Man complains of weakness, fatigue, and weight loss. Has reduced appetite, and intermittent diarrhea. BP is 106/66. Labs:Serum Na+: 130 (low)Serum K+: 5.5 (high)8AM cortisol (on low side of normal)Next best step?
Next best step?ACTH stimulation test TQ: This pt has Adrenal insufficiency (Addison's disease) causing weakness, weight loss, hyponatremia, and hyperkalemia. Causes low cortisol, and low aldosterone.ACTH stimulation test can identify if pt has primary vs secondary AI
Man has worsening pain and swelling in right leg. Was hospitalized 2 weeks ago for right LEX DVT. Was discharged on Warfarin. Takes Warfarin daily, but has missed follow-up appointments. Exam shows moderate pre-tibial edema in right leg. Has right popliteal vein thrombus that extends to femoral vein and is worse than previous ultrasound. Next best step?
Replace Warfarin with Rivaroxaban TQ: Oral direct Factor Xa inhibitors (ApiXaban, RivaroXaban) have similar efficacy to Warfarin when it comes to tx of acute DVTs and do not increase risk of bleeding. Don't even require lab monitering or overlap therapy with Heparin. Actually, Xa inhibitors are becoming preferred agents for tx of acute DVTs.
Man complains of elbow pain. Has had vague elbow pain that radiates to forearm, and is worse with activity at end of day. Works as airport baggage handler. When elbow is held in extension, passive flexion of wrist reproduces pain. Dx?
Lateral epicondylitis (Tennis elbow)Causes tenderness of lateral epicondyle, and reproduction of pain with passive flexion or resisted extension at wrist.
Olecranon bursitis
occurs due to repetitive pressure/frixn. on elbows. Causes posterior elbow pain, with visible swelling of bursal sac.
75 y/o man complains of progressive hearing loss and ringing in ears. Has had declin in ability to hear social conversations, especially with competing background noise. Also has hard time tolerating loud noises. Also has high-pitched ringing in both ears. Normal otoscopic exam. Dx?
Presbycusis TQ: causes progressive, bilaterally symmetric hearing loss with tinnitus, advanced age, and absence of other neurologic findings.
Otosclerosis
sceloritc damage within ossicles of middle ear, causing progressive conductive hearing loss
Meniere disease
excess accumulation of endolymph in membranous labyrinth. Causes recurrent vertigo and tinnitus, sensorineual hearing loss.
Choleasteatoma
erosive, expansile growth consisting of keratinizing squamous epithelium. causes destruction of bones of middle ear (ossicles)
Woman complains of 15 pound weight gain over last few months. Unable to lose weight despite diet and exercise. Also has weakness and cannot lift weights. Has been experiencing irregular menses, and increasing anxiety and insomnia. BP is 160/100. Has proximal muscle weakness, and dark terminal hair present on lower abdomen. Labs:Fasting Glucose is: 130Next best step in evaluating her condition?
Overnight low-dose Dexamethasone suppression testTQ: Initial step in evaluating Cushing's syndrome is to confirm presence of Hypercortisolism via1. Late night salivary cortisol assay2. 24 hour urine free cortisol measurement3. overnight low-dose Dexamethasone suppression test TQ: If Hypercortisolism is confirmed, then ACTH levels can be measures to differentiate ACTH-dependent vs ACTH-independent causes.
45 y/o woman complains of excessive hair growth over face and body. Last menses was 4 months ago. Previously had normal menses. TSH is normal. BMI is 24. Pt is muscular with an enlarged clitoris. Has temporal balding, and a large amount of coarse terminal hair present on face, back, chest, and abdomen. Next best step in eval?
Testosterone and DHEA sulfate levels TQ: Rapid-onset Hyperandrogenism (virlization) suggests an Androgen-secreting ovarian or adrenal neoplasm. Must obtain serum Testosterone and DHEA levels to find out site of excess Androgen production.Ex: Elevated Testosterone with normal DHEA suggests ovarian tumorEx: Elevated DHEA suggests Adrenal source
What kind of heart sound would pts with history of IVDA have?
Pts with IVDA are at risk for Tricuspid Valve Endocarditis (Right side)...Tricuspid regurgitation. Causes a Systolic murmur that increases on Inspiration
Man complains of worsening headache over past week. He is having trouble sleeping due to constant headache. Was bit by an insect 2 weeks ago on right cheek, and now both his eyes are swollen. Temp is 101. Exam shows erythema and swelling of right cheek and bilateral eyelid edema. Restricted EOM bilaterally. Forehead and face are extremely tender to palpation. Dx?
Cavernous sinus thrombosis Infection of skin/sinuses and orbit can spread to carvernous sinus. Inflammation of cavernous sinus causes life-threatening intracranial HTN and constant headache ("intolerable headache"). Also causes fever and perioribital edema, due to impaired venous flow.
Woman comes to ER with Generalized tonic-clonic seizures. Has history of schizophrenia, but stopped taking her meds 3 weeks ago. Labs:Serum Na+: 118 (very low)Serum K+: 3.4Serum osmolality: 252Urine osmolality: 78Cause of pt's electrolyte abnormalities?
Primary polydypsia This pt has HYPOnatremia, most likely due to excessive water intake from Primary Polydipsia. Common in pts with psychiatric conditions (Schizophrenia), possibly due to central defect in thirst regulation. Labs: serum HYPOnatremia, and low urine osmolality (dilute urine). HYPONa+ can cause confusion, lethargy, psychosis, and even seizures. Note: Pts with Nephrogenic D.I. will develop serum HyperNa+
25 y/o African American woman comes to physician with diffuse joint pain and rash on her face. Has low-range proteinuria and abnormal urinary sediment. Renal biopsy shows focal proliferative glomerulonephritis. Platelets: 60,000Most likely cause of pt's thrombocytopenia?
Peripheral destruction TQ: Pt's with SLE can have Pancytopenia (decreased RBC, WBC, and platelets) Due to peripheral immune-mediated destruction of all 3 cell lines. Clue: Focal proliferative glomerulonephritis is a subset of SLE.
Woman complains of palpitations and weight loss. Now weighs 243 pounds, but 3 months ago weighed 260 pounds. Menses have been regular. Thyroid gland can't be clearly felt bc she's so fat. Normal ocular exam. Has an elevated serum free triiodothyronine and elevated thyroxine, and low TSH. Negative urine pregnancy test. Radioactive iodine scan reveals uptake of tracer only in right thyroid lobe. Cause of elevated TH?
Autonomous thyroid hormone production TQ: Hyperthyroidism from toxic adenoma is due to autonomous production of thyroid hormones from the hyperplastic thyroid follicular cells. Radioactive iodine uptake scan reveals uptake only in the "hyperactive nodule."Note: Surreptitious intake of TH is seen in pts trying to lose weight. In these cases, Radioiodine uptake would be reduced.
Most important information in determining whether to start lipid-lowering therapy in pt with atherosclerosis that wants to discuss heart disease prevention?
Quantitative estimate of 10 year CV riskAtherosclerotic cardiovascular disease risk can be calculated using 10 year risk calculator. Initiation of Statin therapy is recommended for prevention of CV disease in pts with a 10 yr risk of CV disease >7.5%.
Man has chronic diarrhea. Reports 5-6 nonbloody liquid bowel movements daily, that sometimes awaken him at night. Lost 4 pounds, and even has diarrhea while not eating. Several years ago, was robbed at gunpoint and shot in abdomen, and underwent multiple surgeries. MOA of his diarrhea?
Secretory diarrheaHallmark of secretory diarrhea is large daily stool volumes and diarrhea that occurs during fasting/sleeping.
Osmotic diarrhea
occurs with ingestion of osmotically active substance, that is poorly absorbable.Ex: Lactose intolerance is classic example of osmotic diarrhea.
17 y/o boy comes to office for rash. Has a papular rash involving trunk, neck, and arms. Lesions are mildly pruritic. Widespread, firm, dome-shaped and have central umbilication. Rash is most common;y associated with which of the following conditions?
Cellular immunodeficiencyTQ: Molluscum contagiosum causes firm, flesh-colored, dome-shaped, umilicated papules.Occurs in pts with impaired cellular immunity (Ex: HIV), who are at risk for severe, widespread disease.
Fibromuscular dysplasia
most commonly affects women. Causes headaches*, due to internal carotid artery stenosis, and secondary HTN due to renal artery stenosis. Also has bruit heard in neck/abdomen.
Man has 2 weeks of SOB. Gets out of breath easily when walking short distances, and also feels more fatigues. Has a nighttime dry cough. What has the greatest Sensitivity for dx of HF?
Elevated BNPTQ: Elevated plasma BNP levels have high sensitivity for dx of CHF.High Specificity: bilateral lung crackles, elevated JVD, LEX edema, and 3rd heart sound are all Specificity.
54 y/o woman complains of worsening epigastric pain over last 2 months. Pain worse at night, and now somewhat constant and radiates to back. Lost 15 pounds over past 3 months. 2 yrs ago was diagnosed with idiopathic chronic pancreatitis, and started on pancreatic enzyme replacement therapy. BMI is 21. Abdominal exam shows mild epigastric tenderness on deep palpation. Next best step?
CT scan of abdomen with contrast TQ: Pancreatic cancer should be suspected in pts with history of chronic pancreatitis who go on to develop abdominal pain and weight loss. Should get a abdominal CT with contrast.Note: CA-19-9 is pancreatic tumor marker.
RBC abnormalities seen in Scleroderma on peripheral blood smear?
Schistocytes TQ: Scleroderma can cause MAHA with fragmented RBCs (Schistocytes) and also cauce thrombocytopenia.
Woman comes to clinic complaining of LEX swelling for past 2 years. Has had several episodes of cellulitis involving left leg. During most recent episode, underwent tx. with IV antibiotics, which was complicated by catheter-related axillary vein thrombosis, requiring 3 months of anticoags. Has hx. of T2DM. BMI is 34. Exam shows firm edema of left LEX. Doctor can't lift skin off of dorsum of toes on left foot like he can on right. Cause?
Disruption of lymphatics TQ: This pt has chronic lymphedema. Pts develop pitting edema that later becomes nonpitting edema, with firm/thickened skin. Causes: radiation/lymph node dissection (especially when tx. a malignancy)
Man brought to ER after found lying next to bottle of unknown substance. Pt is conscious/alert, but in severe pain. Tongue is white, and has heavy drooling of saliva. Pt unable to swallow. Cause?
ingestion of caustic substance TQ: Caustic poisoning causes dysphagia, pain, and heavy salivation/drooling. Causes necrosis of tissue lining GI tract. Can also perforate stomach and esophagus, and create strictures.
Male has mild persistent asthma and comes for routine checkup. Is taking low-dose Bleclomethasone inhaler daily, and inhaled Albuterol, as needed, for past 1 year. Most likely complication of chronic Beclomethasone use in this pt?
ThrushTQ: Most common adverse side effect of INHALED steroids is oropharyngeal thrush (oral Candida)
51 y/o man complains of difficulty swallowing solids, but not liquids. Has hx of GERD for past 12 years. Underwent endoscopy and was diagnosed with Barrett's esophagus 6 months ago. Barium swallow shows an area of symmetric, circumferential narrowing affecting the distal esophagus. Cause?
Esophageal stricture TQ: GERD predisposes pts to Barrett's esophagus, but can also cause Esophageal stricture formation. Peptic strictures cause SYMMETRIC circumferential narrowing of esophagus, with dysphagia to solids. Note: Other causes of peptic strictures: radiation, systemic sclerosis, and caustic ingestions.
Achalasia
esophageal motility disorder that causes dysphagia to both solids and liquids. Causes regurgitation of undigested food or saliva. Hallmark: "Birdsbeak pattern" on barium swallow.
34 y/o woman complains of SOB and severe chest pain. Pain is localized on left side, and increases with inspiration. Also has had 1 episode of hemoptysis. 2 days ago, she flew back to US from a trip to Central Asia. Cause of chest pain?
Pulmonary infarctionTQ: PE presents as dyspnea, tachypnea, and tachycardia. Occlusion of peripheral pulmonary artery by thrombus occurs due to a pulmonary infarction. Causes pleuritic chest pain and even hemoptysis.
Man comes to office with progressive difficulty walking and frequent falls, for past 1 year. Initially had trouble walking up and down stairs, but now has to hold a wall even to walk on flat surfaces. Has history of T2DM and HTN, but is not compliant with meds. Has history of long-term, heavy alcohol and tobacco use. Pt has a wide-based gait, and is unable to perform tandem walking. Also has abnormal heel-to-shin testing. Cause?
Cerebellar degeneration due to alcohol neurotoxicity.TQ: Alcoholic cerebellar degeneration occurs due to damage to Purkunje cells of cerebellar vermis. Causes slowly progressive ambulation problems, and a "wide-based cerebellar gait," with posturual instability.
Vascular dementia
occurs from multiple small infarcts from uncontrolled HTN. Causes a stepwise decline over years.Gait: "short, shuffling gait, and postural instability."
Man has fatigue, poor appetite, and lower-leg swelling. Has 4- year pack year history. Exam shows a barrel-shaped chest, with bilateral scattered wheezing on auscultation. Has distended abdomen, and hepatomegaly, with 2+ pitting edema. Has dilated, tortuous superficial veins in LEX. Also has JVD. What is causing his pitting edema?
Pulmonary artery systolic pressureTQ: This pt has cor pulmonale, due to impaired function of right ventricle due to pulmonary HTN (from Emphysema)S+S of Right Ventricular failure:1. elevated JVP2. RV 3rd heart sound3. Tricuspid regurg. murmur4. Hepatomegaly5. LEX edema, ascites, pleural effusionsKEY: Echocardiogram would show increased Right Heart Pressures, and Right heart cath. would show increased Pulmonary Systolic Pressure>25 mmHg.
Elevated PCWP
PCWP is an estimate of LV end-diastolic pressure. It is elevated in pts with LV systolic/diastolic dysfunction. TQ: Pts with elevated PCWP (Left heart failure) will have pulmonary edema.
Man comes to office with intermittent abdominal pain with nausea. Has episodes of dull epigastric pain, usually worse 15-30 min. after meals. Pain better when leaning forward. Also has occasional diarrhea. Lost 15 pounds over past 12 months. Pt consumes pack of cigs daily and consumes alcohol daily. How to confirm dx?
CT scan of abdomen TQ: This pt has Chronic pancreatitis--->progressive inflammation of pancreas with recurrent bouts of upper abdominal pain, diarrhea/steatorrhea, and weight loss. TQ: Confirm diagnosis of chronic pancreatitis with CT (to see the pancreatic calcifications) Key: chronic alcohol abuse causes chronic pancreatitis (better when leaning forward)chronic pancreatitis can cause steatorrhea, diarrhea, weight loss.
Man with alcoholism complains of generalized weakness, anxiety, and tremors. He is disheveled and malnourished. His K+ is 2.9 (low), and is given IV K+ as well as K+ supplements. 3 days later, his K+ is only 3.1 (still low). Cause?
HypoMg2+TQ: Pts with chronic alcoholism often present with multiple electrolyte abnormalities (HypoK+, HypoMg2+, and HypoPhosphatemia) Key: HypoMg2+ can cause refractory HypoK+
55 y/o white male comes in for routine check-up. Has long hx of HTN, and takes HCT and Enalapril. Exam shows a moderately overweight man (BMI of 27) with a waist circumference of 41 inches. Labs:Fasting Glucose: 112Total cholesterol: 220LDL: 140TG: 240What is the most important pathogenic factor for this pt's condition?
Insulin resistance TQ: Insulin resistance occurs in pts with "central type" obesity, and is the key pathogenic factor for development of T2DM and HTN, Hyperlipidemia.
30 y/o white man comes to ER with SOB that started this morning. Has no chest pain. He described himself as generally healthy, and physically active. Has not traveled recently. There is mild swelling in right lower leg, and EKG shows sinus tachy, but is otherwise normal. D-Dimer: 1200 (normal<500)Cause of pt's current condition?
Activated Protein C resistance TQ: Factor 5 Leiden mutation is MOST commonly inherited hypercoagulable disorder in White people, and leads to increased risk of thrombosis.Clue: should suspect Factor 5 Leiden mutation in pt <45y/o with a totally unprovoked first-time thrombus, especially in an unusual site.
65 y/o man comes to ER after having seizure. Had Non-small cell lung cancer diagnosed 2 years ago, that was treated surgically. MRI of brain shows a solitary cortical mass in right hemisphere, that is most consistent with mets. Pt is admitted, and started on Phenytoin. Next best step?
Surgical resection of mass TQ: Surgical resection is recommended for solitary brain mets in pts with good performance status and stable extracranial disease.Note: If multiple/many brain mets seen on brain MRI, must do whole brain radiation.
Man has sensation of RUQ fullness. He has been obese since adolescence. Has hx of T2DM and HTN. On Metformin and HCT. On exam, pt has acanthosis nigricans. Also has Hepatomegaly. BMI is 36.Labs:Elevated ALT and AST. Fasting Blood Glucose: 168Most likely cause of pt's elevated Liver enzymes?
Insulin resistance TQ: Nonalcoholic fatty liver disease resembles alcohol-induced liver dx. but occurs in pts with minimal or no alcohol history. NAFLD occurs in pts with Insulin resistance. Can cause things like bland steatosis/steatohepatitis, and even fibrosis/cirrhosis.
82 y/o man presents for eval. of chronic back pain. On exam, has BP of 160/85 sitting, and 135/70 standing. He is otherwise healthy. Just takes Ibuprofen for back pain. Which "age-related" changes best explains his findings?
Decreased baroreceptor responsiveness TQ: With increased age, pts develop progressively decreasing baroreceptor sensitivity and defects in myocardial response to this reflex. Causes increased incidence of orthostatic hypotension in elderly.
65 y/o man complains of 3 week history of rash and generalized pruritis. Exam shows scattered excoriated plaques and small bullae. Punch biopsy and immunofluorescence studies show linear IgG deposits at dermal-epidermal junction. Best next step?
Topical Clobetasol TQ: Bullous pemphigoid is an autoimmune dx. that causes tense bullae and pruritis. Causes uticarial and eczematous lesions. Dx. is confirmed with skin biopsy, and 1st line tx: High-potency topical steroid (Clobetasol)
Woman complains of 4 hour history of acute-onset SOB and chest pain. BMI is 36. Bilateral wheezing is heard on auscultation. Pt's right leg is swollen. What would be present on further evaluation?
High A-a gradient on arterial blood gas. TQ: Obesity and malignancy are risk factors for DVT/PE. Note: PE can cause wheezing and increased A-a gradient.
65 y/o woman complains of 1 month of back pain. Pain is primarily in lumbar and thoracic spine, and is partially relieved with Acetomenophen. Worse with activity. Takes OTC Calcium and Vit D. Has yearly physical exam 4 months ago, and lab findings at that time were normal. Pt is thin, but appears well. No lymphadenopathy. Labs:Ca2+: 10.9 (high)Urine dipstick is negative, and urine sediment shows a few granular casts. Cause of current condition?
Monoclonal protein TQ: Multiple myeloma is a plasma cell neoplasm. Causes excessive production of monoclonal protein, which can accumulate in kidneys. 50% pts with MM have renal insufficiency at diagnosis. S+S of MM: fatigue, weight loss, bone pain (usually in Thoracic/Lumbar spine), Hypercalcemia, anemia. Causes excess production of monoclonal protein--->which can accumulate in renal tubules--->Bence Jones proteins (granular casts) and renal failure. Note: monoclonal protein can also deposit in glomeruli and lead to Amyloidosis.
53 y/o woman collapsed while standing and lost consciousness for about 3 minutes. Recovered spontaneously, but was weak and dyspneic. Reports left-sided chest pain. BP is 86/50. Pulse Ox is 80%. She is diaphoretic and tachypneic. JVP is 14. Lungs clear to auscultation. Further workup would show what?
RV dysfunctionTQ: Pt's with massive P.E. can have S+S of hypotension and syncope, acute SOB, pleuritic chest pain, and tachycardia. The thrombus causes increased pulmonary vascular resistance and increased RV pressure/RV dilation and causes hypotension. Clue: Massive PE can cause "dramatic hypoxia" (Ex: Pulse Ox 80%)
Dawn Phenomenon?
a hyperglycemic surge in the early morning hours due to diurnal increase in counter regulatory hormones (GH, cortisol)Causes elevated Fasting (not postprandial) hyperglycemia in early morning.
Woman complains of 2 weeks of worsening headaches and low-grade fever. Has had significant amount of weight loss over past 6 months. Temp is 100. BMI is 18.5. Pt's neck is stiff and has cervical lymphadenopathy. Oropharyngeal exam shows thrush. CSF shows encapsulated yeasts. Next best step?
Amphotericin B plus Flucytosine TQ: Cryptococcal meningoencephalitis occurs in pts with advanced HIV (CD<100). Induction therapy included Amphotericin B and Flucytosine--->followed by Fluconazole for "maintenance therapy."Cause: Cryptococcal neoformans (causing an invasive fungal infection)Key: can see encapsulated yeasts in CSF
20 y/o man brought to ER with fever, headache, and altered mental status. CSF shows lymphocytic plecytosis, elevated protein, normal glucose. Started on high-dose Acyclovir. PCR is +for HSV DNA. Pt later complains of N/V, abdominal pain. Labs:elevated BUN/CrCause of his Acute Kidney Injury?
Renal tubular obstructionTQ: High-dose Acyclovir can cause "Crystalluria" with Renal Tubular Obstruction.Key: If pt is on Acyclovir, must admin. IV fluids concurrently with the drug to reduce risk of Acute Kidney Injury.
Best way to diagnose Hepatitis B infection?
HBsAg (Antigen), and IgM anti-HBcHBsAg and anti-HBc are the most accurate tests to see of pt has acute Hep B infection.Both HBsAg and IgM anti-HBc are elevated during initial infection, and IgM anti-HBc remains elevated during "window period."
How to check for Hep B immunity?
Hepatitis B surface Antibody (anti-HBs) indicates recovery/immunity from Hep B infection.Note: HBsAg is the antigen used to make the Hep B vaccine.
Homeless man brought to ER with severe muscle pain and stiffness. Has a history of alcohol and IVDA. Temp is 100. There are marks on his arm from injection use, and several abrasions and lacerations on LEX. He s unable to open mouth completely. Painful spasms of neck muscles are triggered by physical stimuli. Cause of condition?
Toxin-mediated neurotransmission blockageTQ: Tetanus is a presynaptic NMJ disorder (C. tetani toxin). Toxin blocks neurotransmission by inhibiting release of neurotransmitters (GABA and Glycine) across synaptic cleft. S+S: fever, painful muscle spasms, trismus (lockjaw)
40 y/o man has exertional dyspnea for past 6 months. Sometimes expels mucoid sputum. His father died of nonalcoholic liver cirrhosis at 58 y/o. Labs:AST: 44ALT: 55Dx?
Alpha-1-AT deficiency TQ: genetic disease that causes S+S of Liver Disease with COPDClue: Family hx of Emphysema or Liver DiseaseNote: severe candidates can get lung/liver transplants.
72 y/o white male complains of severe fatigue. 5 months ago, was able to climb stairs without SOB. But now, he must rest after just a few steps. Decreased appetite. Exam shows firm, enlarged cervical, inguinal, and supraclavicular lymph nodes. Enlarged liver and spleen. Hb is 7.1. Cause of pts anemia?
Bone marrow infiltrationAnemia can occur in lymphoproliferative dx (leukemia/lymphoma) due to bone marrow infiltration with cancerous cells.
19 y/o man complains of persistent dry cough that disturbs his sleep. Has sore throat, headaches, and fatigue. Yesterday, noticed rash on arms/legs. Temp of 100. Mild pharyngeal erythema, no cervical lymphadenopathy. Faint macular rash on extremities. CXR shows interstitial markings and small right-sided pleural effusion. What microbe?
Mycoplasma pneumoniae TQ: causes atypical pneumonia with "indolent" S+S (headache, malaise, low-grade fever, incessant cough, rash, and non-exudative pharyngitis)CXR: shows interstitial infiltrateTx of Mycoplasma pneumo: Azithromycin
71 y/o man complains of sharp chest pain for 2 hours. Worse with deep breaths. Has advanced CKD and preparing to initiate dialysis soon. When pt is supine, has chest pain, and improves when he sits back up. EKG shows nonspecific T-wave abnormalities. Normal CXR, normal cardiac enzymes. Labs:BUN: 68Cr: 5.3Dx?
Pericarditis TQ: Uremic pericarditis causes inflammation of pericardium. Pts with advanced RF can have uremic pericarditis with pleuritic chest pain and pericardial friction rub. Hallmark of Pericarditis: EKG with diffuse ST elevation
71 y/o man has progressively deterioating behavior over past year. Frequently forgets grandkids names, and has routine difficulty finding words. Sometimes is found lost and roaming his apartment building. Once, daughter found him urinating in wastebasket in room. Montreal Cognitive Assessment score is 15/30 (should be >26/30)What abnormality would be seen on MRI?
Temporal and Parietal lobe atrophy TQ: Alzheimer's Disease initially presents with memory impairment. Neuroimaging would show Temporal and Parietal Lobe atrophy, along with Hippocampal atrophy.
MRI findings of Vascular dementia?
diffuse cortical and subcortical infarcts
MRI findings of NPH?
enlarged lateral ventricles WITH cortical atrophy (Hydrocephalus ex-vacuo)
63 y/o man is following up for recent hx for a sudden-onset right-sided weakness 1 week ago, that went away after 30 min. Had so S+S since then, and feels normal. Neuro exam is normal. EKG shows sinus rhtyhm. Doppler US shows a 75% stenosis of proximal left internal carotid artery. Next best step?
Referral for left carotid endarterectomy TQ: Initial tx of pt with Carotid artery stenosis involves intense medical management (Apsirin, Statin, BP control (Lisinopril) Pts who've experiences TIA with high-grade Carotid Stenosis (>70%) require carotid endarterectomy to reduce risk of future stroke.
68 y/o man has right sided hemiplegia, headache, and impaired consciousness. S+S started an hour ago, and are getting worse. Neuro exam shows right-sided weakness and hemi-sensory loss. There's a carotid bruit on left side. Next best step?
CT of head without contrast TQ: Any pt with Intracranial hemorrhage that presents with focal neuro deficits/elevated ICP (headache, N/V, altered mental status), or pts suspected of having acute stroke should always get a non-contrast head CT to rule out hemorrhage.
17 y/o boy complains of worsening acne. Mild-moderate pustules seen. Tried topical tretinoin and washed face with benzoyl peroxide. Next step?
Add topical ErythromycinTQ: Tx of inflammatory acne1. 1st try topical retinoids and benzoyl peroxide2. mod-severe acne: add topical antibiotics (TOPICAL Erythromycin)3. Lastly, try oral antibiotics (like oral minocycline or oral Isotretinoin) for severe/recalcirtant acne.