Clinical Medicine Midterm Fall 2008

Front 1

Blood

Back 1

a liquid tissue containing seven types of cells that are suspended in a watery substance called plasma

Front 2

Types of white blood cells (leukocytes)

Back 2

basophils, eosinophils, neutrophils, lymphocytes, monocytes (become macrophages)

Front 3

Functions of Blood (3)

Back 3

1. Transport oxygen and carbon dioxide
2. Transport of ions, glucose, wastes, and hormones
3. Acts as a defense for the body against foreign materials.

Front 4

Where are blood cells produced?

Back 4

Bone Marrow

Front 5

What single type of cell does blood form from?

Back 5

Multipotent Stem Cell

Front 6

Erythropoietin (EPO)

Back 6

produced by kidneys and increases production of red blood cells (tells bone marrow to produce more RBCs)

Front 7

Thrombopoietin (TPO)

Back 7

increases production of platelets

Front 8

Interleukin-7

Back 8

major cytokine that stimulates stem cells to increase lymphocytes

Front 9

Anemia

Back 9

shortage of RBCs, shortage of amount of hemoglobin in them, most commonly caused by inadequate intake of iron

Front 10

Definition of Anemic and tx

Back 10

hemoglobin < 10.....treat with PROCRIT

Front 11

#1 WBC

Back 11

T Lymphocytes

Front 12

Where do T Cells migrate from the bone marrow to mature?

Back 12

Thymus

Front 13

Components of Blood Plasma and Percentages

Back 13

Water 92%
Proteins 6%
Salt 0.8%
Lipids 0.6%
Glucose 0.2%

Front 14

Site of occlusion in vein occlusion

Back 14

lamina cribrosa

Front 15

How can you tell a vein occlusion is non-ischemic?

Back 15

LACK of hemes, CWSs, APD, and being able to see underlying choroid, px has good VA

Front 16

What is the main concern in ischemic CRVO?

Back 16

neovascular glaucoma

Front 17

What is a big cause of CRVO?

Back 17

glaucoma (bc lamina cribrosa is compressed in glaucoma)

Front 18

Hypoperfusion Retinopathy/Ocular Ischemic Syndrome

Back 18

usually unilateral, males > females 2:1, *dot/blot hemes and microanuerysms found only in mid-periphery (=Hypoperfusion Retinopathy); when above are associated with neo of disc, retina, iris, or angle = Ocular Ischemic Syndrome

Front 19

Pathogenesis of OIS

Back 19

atheromatous ulceration and stenosis at bifurcation of common carotid artery

Front 20

Symptoms of OIS (know)

Back 20

1) ocular and periorbital pain in 40% of cases
2) prolonged recovery of vision following exposure to bright light (Light Induced Amaurosis)
3) Amaurosis Fugax (TMB) in 5% of cases
4) TIAs

Front 21

Ocular Signs in OIS

Back 21

1) dilated but not tortuous veins
2) retinal hemes in mid-peripheral retina (80%)
3) CWSs (5%)
4) Neo of disc (35%)
5) Neo of retina (8%)
6) rubeosis iridis (65%)
7) uveitis- mild anterior (20%)

Front 22

What should you think if you see uveitis in older px?

Back 22

Carotid artery disease

Front 23

Work up for OIS

Back 23

Carotid artery evaluation & echocardiogram

Front 24

Tx for OIS

Back 24

carotid surgery if needed, aspirin, PRP for neo, stop smoking

Front 25

1st and 2nd leading causes of death in OIS

Back 25

1) Ischemic heart disease
2) Stroke

Front 26

Hypercoaguable State

Back 26

px is constantly making clots bc factor 5 is always turned on (someone below age 50 should not have vein occlusion; if they do, should think hypercoaguable state)

Front 27

Primary State conditions that can cause ocular problems (know)

Back 27

1. Protein C deficiency
2. Protein S deficiency
3. Antithrombin III
4. Factor V Leiden ** (1 out of 10 ppl)
5. Hyperhomocysteinemia
6. Prothrombin 20210 mutation
7. Antiphospholipid syndrome- miscarriages

Front 28

What proteins turn off the coagulation pathway?

Back 28

Protein C and S

Front 29

Protein C or S deficiency/Antithrombin III deficiency

Back 29

these proteins normally turn factor 5 off; deficiency would leave factor 5 on constantly resulting in venous thromboembolism

Front 30

What is the most common hereditary blood coagulation disorder in US?

Back 30

Factor V Leiden

Front 31

Factor V Leiden

Back 31

a defect in factor 5 so that it can never be turned off; resistant to Protein C, found in 10% of caucasions, rare in AA and asians

Front 32

Hyperhomocyteinemia

Back 32

causes high levels of the amino acid homocysteine; leads to artery and vein occlusion, stroke, upward lens subluxation, heart attack in older males, **treat with B6, B12, and folic acid

Front 33

Prothrombin 20210 gene mutation

Back 33

**second most common hereditary blood coagulation disorder; elevated levels of plasma prothrombin; increased risk of venous thrombosis; 4% of Caucasians

Front 34

Antiphospholipid syndrome

Back 34

antibodies to phospholipids activate coagulation cascade; **can lead to BOTH artery and vein occlusions; cause of most miscarriages

Front 35

Tx of Hypercoaguable State

Back 35

Coumadin, Heparin, Aspirin therapy**

Front 36

What ocular finding is characteristic of carotid artery disease?

Back 36

midpeipheral hemes

Front 37

What do you have to rule out if you see someone younger than 50 with a vein occlusion?

Back 37

hypercoaguable state

Front 38

Hyperviscosity Syndromes

Back 38

if px makes too many RBCs, WBCs, or platelets, buildup occurs and their byproducts make the blood very thck

Front 39

3 types of Hyperviscosity Syndromes

Back 39

1. Waldenstrom Macroglobulinemia (IgM)
2. Multiple Myeloma (tumor of B cells)
3. Leukemia

Front 40

What is the hallmark ocular sign of hyperviscosity?

Back 40

Sausage Link Vessels

Front 41

What is a bilateral vein occlusion indicative of?

Back 41

Hyperviscosity

Front 42

Tx of Leukemia

Back 42

Chemo and radiation therapy (ocular manifestations resolve after tx)

Front 43

Types of Leukemia

Back 43

1. Chronic Lymphocytic Leukemia
2. Chronic Myeloid Leukemia
3. Acute Lymphocytic Leukemia
4. Acute Myeloid Leukemia **most common

Front 44

Multiple Myeloma

Back 44

malignant plasma cell tumor- end stage B lymphocyte; tumors cells produce massive quantities of IgG or IgA

Front 45

Waldenstrom macroglobulinemia

Back 45

neoplastic B cells produce IgM at too high of a rate

Front 46

Anemia

Back 46

decrease in RBC count, hemoglobin, orhematocrit

Front 47

Causes of Anemia

Back 47

1. decreased RBC production
2. hemotopoietic cell damage from infection, drugs, or radiation
3. deficiency of factors like iron necessary for heme synthesis
4. increased RBC loss from external blood loss or red cell destruction

Front 48

Sickle Cell Retinopathy KNOW

Back 48

1. Seafan neo
2. Black sunbursts- RPE hyperplasia
3. Salmon Patch Hemorrhages

Front 49

***7 types of blood cells

Back 49

1. RBCs (Erythrocytes)
2. Platelets (Thrombocytes)
3. White Blood Cells (Leukocytes)
a. Basophils
b. Eosinophils
c. Neutrophils
d. Lymphocytes
e. Monocytes- become macrophagesd

Front 50

Difference between hypercoaguable and hyperviscosity

Back 50

1. Hypercoaguable=blood clots; mid-peripheral hemes
2. Hyperviscosity=too many cells and cell by-products; bilateral vein occlusions

Front 51

Tx of Hypercoaguable syndromes vs Hyperviscosity syndromes

Back 51

1. Hypercoaguable- Coumadin, Heparin, Aspirin
2. Hyperviscosity- chemo or radiation therapy, bone marrow transplantation

Front 52

Most common and second most common coaguable states

Back 52

1. Factor V Leiden
2. Prothrombin 20210 gene mutation

Front 53

Normal INR (International Normalized Ration) for a px on Coumadin

Back 53

2.0-3.0

Front 54

What disease do 50% of Giant Cell pxs have?

Back 54

Polymyalgia Rheumatic (PMR)- stiffness in neck, shoulder, and hip

Front 55

Ocular Manifestions of Giant Cell

Back 55

#1. ION
2. acute painless vision loss
3. pale swelling of optic nerve head with flame shaped hemes
4. CRAO
5. CN 3, 4, 6***
6. CWSs
7. OIS
8. Cilioretinal Artery Occlusion
9. Must refer to ER for sed rate and C-reactive protein

Front 56

Etiology of AAION (vs NAION)

Back 56

occlusion of short posterior ciliary arteries with giant white blood cells

Front 57

Systemic Presentation of AAION

Back 57

Headache, scalp tenderness, jaw claudication, night sweats, weight loss, fever, PMR, depression

Front 58

Systemic Testing for AAION

Back 58

Immediate C-reactive protein, CBC w/ platelets, Westegren Sed. Rate, carotid artery evaluation, echocardiogram, fluorescein angiography

Front 59

Tx for AAION

Back 59

IV steroids, temporal artery biopsy, followed by oral steroid

Front 60

Blood aqueous barrier

Back 60

tight junctions between non-pigmented epithelial cells of ciliary body and blood vessels of iris

Front 61

Most common WBC?

Back 61

T cell (apprrox 70%)

Front 62

What produces antibodies

Back 62

B cells

Front 63

What matures in bone marrow?

Back 63

B cells

Front 64

What matures in thymus?

Back 64

T cells

Front 65

What must you rule out if you see hemorrhages in mid-periphery?

Back 65

carotid artery disease

Front 66

2 main causes of carotid artery disease?

Back 66

1. cholesterol buildup due to high cholesterol
2. GCA

Front 67

Is tehre pain with carotid artery dx?

Back 67

yes; known as ocular angina from OIS

Front 68

Most common hypercoaguable syndrome?

Back 68

Factor V

Front 69

Tests for GCA?

Back 69

C-reactive protein and ESR

Front 70

Are RBCs nucleated?

Back 70

NO

Front 71

Which blood type is the universal recipient?

Back 71

Group AB- cant give blood to anyone unless AB too

Front 72

Which blood type is the universal donor?

Back 72

Group O- has neither A or B antigens

Front 73

Hemoglobin

Back 73

Oxygen carrying molecule (marrow stimulated to make hemoglobin by EPO; kidneys produce EPO in response to hypoxia)

Front 74

Microcytic Anemias (MCV<80)

Back 74

small red blood cells from:
1. iron deficiency**
2. thalassemias
3. sideroblastic anemias
4. lead poisoning

Front 75

Normocytic Anemias (MCV 80-100)

Back 75

1. anemia of chronic disease**
2. aplastic anemia
3. sickle cell disease
4. bone marrow infiltration
5. blood loss/hemolysis

Front 76

Macrocytic Anemias (MCV>100)

Back 76

1. liver disease
2. myelodysplasia
3. elderly
4. hypothyroidism
5. alcohol
6. drug induced
7. hemolysis
8. megaloblastic anemias (vitamin B12 and folate deficiencies**)

Front 77

Most common cause of anemia?

Back 77

iron deficiency (most common) and anemia of chronic disease

Front 78

Initial Tests to oder in anemia

Back 78

CBC, reticulocyte count, peripheral smear, iron, folate, and B12 levels

Front 79

Sideroblastic Anemia

Back 79

teardrop shaped cells

Front 80

Megaloblastic Anemia

Back 80

oval macrocytes, hypersegmented neutrophils, vitamin B121 or folate deficiency

Front 81

Neutrophils (myeloid family)

Back 81

mobile phagocytes, kill organisms covered with antibodies, fight bacterial infections, clean up dead/damaged tissue

Front 82

Basophils (myeloid family)

Back 82

granules contain histamine and heparin, role in immedate hypersensitivity rxns

Front 83

Eosinophils (myeloid family)

Back 83

increased numbers in parasitic infections

Front 84

Monocytes (myeloid family)

Back 84

clean up debris, phagocytic

Front 85

T-cells (lymphoid family)

Back 85

70%; initiate and regulate immune response; fight viral infections

Front 86

B-cells (lymphoid family)

Back 86

synthesize and secrete antibodies

Front 87

Platelets

Back 87

1st responder to stop bleeding

Front 88

Hemophilia- The Prototypical Coagulation Factor Deficiency

Back 88

X-linked recessive, low factor VIII or IX levels, deep soft tissue bleeds in joints and muscles, NO PETECHIAE**, tx w/ transfusion of deficient factors

Front 89

2 drugs that deactivate key clotting factors

Back 89

Heparin and Warfarin

Front 90

Acquired Hypercoaguable States- Virchow's Triad

Back 90

1. alteration in blood flow (venous stasis)
2. injury to vascular endothelium- major trauma
3. alteration in constitution of blood (hypercoaguability) from cancer, smoking, birth control pill, etc

Front 91

Symptoms of Acute Leukemia

Back 91

1. decrease WBC: fever, infection
2. decrease RBC: fatigue, pallor
3. decrease PLT: bleeding
4. enlarged liver, spleen lymph nodes
*adults: 80% myelogenous (AML), 20% lymphoblastic (ALL)

Front 92

Autologous (Bone Marrow Transplantation)

Back 92

stem cells harvested from patient himself

Front 93

Allogeneic (Bone Marrow Transplantation)

Back 93

stem cells harvested from a matched donor

Front 94

What kind of cells are present in Hodgkins (younger pxs) and non-hodgkins (older pxs)?

Back 94

Reed-Sternberg cells

Front 95

Transfusion Reactions

Back 95

1. Acute Hemolytic Transfusion Rxn (major ABO incompatibility; high mortality)
2. Delayed Hemolytic Transfusion Reaction (slow progression destruction of RBCs)
3. Febril Reaction (donor white cells release inflammatory substances during storage)
4. Allergic rxn

Front 96

Is preseptal cellulitis an orbital disease?

Back 96

NO; it is inflammation of periocular structures (lids and skin) ANTERIOR to the orbital septum

Front 97

Hordeolum dx and tx

Back 97

dx: focal, painless, hard lump; blockage of glands of Zeiss or Moll
tx: hot compresses and topical and/or oral antibiotic like doxycycline or Keflex

Front 98

Chalazion dx and tx

Back 98

dx: meibomian gland blockage
tx: hot compresses; can be lanced or removed bc not infectious; if multiple get biopsied

Front 99

Dacryocystitis dx and tx

Back 99

dx: painful, swollen and infected lacrimal sac and/or drainage system
tx: oral antibiotics with a topical antibiotic such as a fluoroquinolone or even Polytrim; also give tylenol and codeine
*never lance bc do not want to spread infection

Front 100

Clinical Presentation of Preseptal Cellulitis

Back 100

1.mild orbital edema usually involving UPPER eyelid only
2. unilateral
3. warmth of eyelid
4. eyelid erythema, tho bulbar conjunctiva is white and quiet
5. **no proptosis, no EOM restrictions, and no pain on eye movement
6. globe is uninvolved
7. VAs and pupils are normal

Front 101

Slit lamp evaluation of Preseptal Cellulitis

Back 101

1. AC rxn
2. corneal/conj changes
3. s-shaped inflammation of upper lid

Front 102

Tx of Preseptal Cellulitis

Back 102

1. Tetanus toxoid: if traumatic
2. oral antibiotics: Keflex, Ceclor, Augmentin, Bactrim (if px is allergic to PCN), Erythromycin (if px is allergic to PCN and sulfa)
3. warm compresses
4. topical and oral decongestants
5. topical antibiotic: esp Polytrim or Polysporin

Front 103

Is orbital cellulitis an orbital disease??

Back 103

YES; an infection/inflammation within retrobulbar tissues within orbit; life threatening; px must be put on IV antibiotics; watch for exudative retinal detachment*

Front 104

Etiology of Orbital Cellulitis

Back 104

1. extension of preseptal cellulitis
2. **direct extension of sinus infection (#1 cause of orbital and preseptal)
3. following dacryoadenitis, dacrocystitis, acute hordeolum, chalazion
4. following orbital trauma, ocular foreign bodies
5. post-surgical
6. following a systemic illness like bacteremia or septicemia

Front 105

Patient Symptoms/Signs of Orbital Cellulitis

Back 105

1. Red, injected eye (*globe is now involved)
2. decreased VA or blindness: ON involved
3. Proptosis (key to dx!)- may cause double vision
4. malaise, fever, and headache- acute illness
5. *external ophthalmoplegia- inability to move eye
**3 Ps: Proptosis, external ophthalmoPlegia, Pain
6. possible APD (if ON is involved)
7. disc edema
8. fever
9. increased IOP

Front 106

Tx of Orbital Cellulitis

Back 106

IV antiobiotic to cross BBB

Front 107

Forced Ductions (paresis vs mechanical involvement)

Back 107

1. a paresis will move with forced ductions
2. mechanical involvement: eye will NOT move

Front 108

Orbital Cellulitis with Cavernous Sinus Involvement

Back 108

spread of infection of orbital cellulitis to cavernous sinus, leading to cavernous sinus thrombosis; fatal outcome

Front 109

Clinical Presentation of Orbital Cellulitis with Cavernous Sinus Involvement

Back 109

1. fever
2. progressive proptosis
3. BILATERAL**
4. EOM dysfunction
5. Rising IOP
6. Papilledema
7. Pain
*Remember 3 Ps: Pain, external ophthalmoPLEGIA, Proptosis
8. Purple lid skin
9. Severe congestion; bruit
10. fundus shows hemes, tortuosity, ON pallor
11. headache, nausea, vomiting, varying levels of consciousness
12. CN III, IV, and VI palsies

Front 110

Orbital Cellulitis with Mucomycosis

Back 110

life-threatening orbital FUNGAL infection; seen in diabetics, transplant pxs, and **severely immuno-compromised pxs

Front 111

Dx and tx of Orbital Cellulitis with Mecomycosis

Back 111

Dx: proptosis and EOM involvement, **black eschar: ischemic infarction and septic necrosis**; rapid deterioration
Tx:
1. Ketoconazole
2. Enucleation surgery
3. Amphotericin B to clean out hollow globe
4. Immediate hospitalization
5. Mortality rate: 30%

Front 112

Idiopathic Orbital Inflammation

Back 112

1. non-neoplastic, noninfectious space-occupying periocular lesion
2. may affect orbit focally, diffusely, or in a tissue-specific manner
3. 5% of all orbital lesions
4. may be acute, recurrent, or chronic
5. UNILATERAL*
6. males = females
7. peak incidence most frequently middle age

Front 113

Signs/Symptoms of Idiopathic Orbital Inflammation

Back 113

1. malaise and distress*
2. unilateral*
3. conjunctival chemosis and injection
4. uveitis
5. check vital signs*
6. sinuses are normal in CT scan* (in orbital cellulitis they are full of infectious material bc sinus infection is usually the cause)
7. no bony involvement of orbit*

Front 114

Treatment of Idiopathic Orbital Inflammation *impt

Back 114

trial of steroid therapy: 60 to 100 mg po once per day for 2 weeks to 1 month, with tapering dose over several months (also anti-ulcer meds, low dose radiation therapy, immunosuppressive agents, orbital biopsy)

Front 115

Anterior Uveitis

Back 115

inflammatory cells in the anterior chamber (ddx: HLA-B27, Bechet's, Sarcoidosis, Fuch's Heterochromic Iridocyclitis, JRA, Syphilis, Herpetic, Masquerade syndrome)

Front 116

Intermediate Uveitis

Back 116

inflammatory cells in vitreous

Front 117

Posterior Uveitis

Back 117

inflammtion of retina or choroid with or without vitritis

Front 118

Panuveitis

Back 118

all of above; entire eye involved

Front 119

Limited Uveitis

Back 119

duration of attack is <3 months

Front 120

Recurrent Uveitis

Back 120

>3 months between episodes

Front 121

Chronic Uveitis

Back 121

episodes <3 months apart, not including tx time

Front 122

What test should be ordered with anterior uveitis?

Back 122

HLA-B27
1. over 50% are HLA-b27 positive
2. 71% if unilateral and recurrent
3. 58% have seronegative spondyloarthropathy

Front 123

What systemic disease has a high association with anterior uveitis?

Back 123

Ankylosing spondylitis (45%)
-> 30-40% of pxs with AS will have at least 1 epidose of uveitis

Front 124

Duration of tx for uveitis***

Back 124

4-9 weeks per attack (mean duration 6 weeks)

Front 125

Avg number of uveitis attacks***

Back 125

Median = 3 (range 1-26)
Recurrent uveitis attacks can be associated with CME

Front 126

Reiter's Syndrome (reactive arthritis)***

Back 126

85-95% +HLA-B27
Triggers***:
1. Diarrhea or dysentery esp due to food poisoning
2. arthritis (usually within 30 days of infection)

Front 127

Tx for Uveitis***

Back 127

1. Topical corticosteroids for all **always use PRED FORTE
2. oral corticosteroids
3. periocular corticosteroids

Front 128

How to taper steroids

Back 128

only taper when there is a 2-step decrease in number of cells (= 1 grade level decrease)

Front 129

Topical corticosteroids

Back 129

for anterior disease

Front 130

Periocular steroid injections

Back 130

for unilateral, intermittent disease; CME

Front 131

Oral corticosteroids

Back 131

for bilateral, chronic, vision-threatening disease

Front 132

Immunosuppressive drug therapy

Back 132

steroid-sparing effect in chronic disease after steroids have been stopped

Front 133

Differences between Episcleritis and Scleritis

Back 133

Episcleritis
irritation
superficial inflammation
ocular complications uncommon
systemic disease uncommon
tx topical

Scleritis
painful
deep inflammation
ocular complications common
systemic disease common
tx systemically

Front 134

What can you get in Wegener's Granulomatosis?

Back 134

necrotizing scleritis
1. inflammation of small and medium sized blood vessels
2. scleral thinning
3. peripheral ulcerative keratitis

Front 135

Diagnostic Tests for Scleritis**

Back 135

1. always ddx syphilis & chest x-ray, RPR, FTA antibodies
2. ANCA C & P for Wegener's
3. Urinalysis
4. Chest x-ray
5. Lyme antibody
6. RF, ANA (rarely)

Front 136

4 Connective Tissue Diseases

Back 136

1. SLE
2. Scleroderma
3. Sjogren's
4. MCTD

Front 137

Systemic Lupus Erythematosus (SLE)

Back 137

1. 9 xs more common in women than men
2. 20-30 yrs
3. more common in AA, Hispanics, and Asians
4. autoimmune disease

Front 138

Clinical Manifestations of SLE (DOPAMINe RASH)

Back 138

Discoid rash
Oral ulcers
Photosensitivty
Arthritis
Malar rash: butterfly rash
Immunological: decreased WBC count
Neurological
Renal disorders
ANA +
Serositis +
Hematological: anemia, thrombocytopenia

**definite SLE: 4 or more criteria

Front 139

Auto-antibodies tests for Lupus

Back 139

1. Anti-dsDNA
2. Anti-Smith: specific for Lupus**
3. APLA
4. ANA

Front 140

What is the most sensitive test for SLE?

Back 140

ANA (97%) but has poor specificity

Front 141

Tx of SLE

Back 141

treat symptoms only:
1. NSAIDS for joints
2. High-dose glucocorticoids if severe and major organ involvement
DMARDS: disease-modifying agents
1. antimalarial druge
2. methotrexate: anti-neoplastic agent for disease control

Front 142

Scleroderma

Back 142

presence of thickened, sclerotic skin lesions; includes abnormalities of vasculature and involvement of multiple organ systems, **can often affect KIDNEY
Also:
1. peak ago of onset 30-40s
2. more common in females and AA
3. ***90% of pxs also have Raynaud's phenomenon

Front 143

Clinical Manifestations of Scleroderma (CREST)

Back 143

Calcinosis: calcium deposits in skin, nodules
Raynaud's Phenomenon
Esophageal dysmotility: trouble swallowing and acid reflux
Sclerodactyly: fibrosis of skin on fingers, long tapering thin fingers
Telangiectasia: small red blood vessels all over body

*scleroderma renal crisis: malignant HTN with renal failure is a medical emergency

Front 144

Tx of Scleroderma

Back 144

difficult to treat; no cure
1. D-penicillamine for skin disease
2. calcium channel blocker for Raynaud's phenomenon
3. ACE inhibitor for renal crisi
4. corticosteroids for pulmonary fibrosis

Front 145

Sjogren's Syndrome

Back 145

chronic inflammatory disorder caused by a lymphocytic infiltrate that destroys the lacrimal and salivary glands

Front 146

Clinical Manifestations and Dx of Sjogren's

Back 146

1. keratoconjuctivitis sicca, or KCS = dry eyes
2. Xerostomia (dry mouth)
3. 70% with +ANA, SS-S in 60-70%
4. + Schirmer test

Front 147

Tx of Sjogren's

Back 147

wetting agents, corticosteroids if severe symptoms, anti-malarial agents

Front 148

Mixed Connective Tissue Disease (MCTD)

Back 148

overlap syndome that has features of several connective tissue diseaes such as SLE, scleroderma
*characteristic antibody: Anti-RNP

Front 149

Seronegative Spondyloarthropathies (SpA)

Back 149

Features:
1.**more common in males than females (unusual for an autoimmune disease)
2. inflammatory back pain worse upon waking
3. peripheral arthritis (joints)
4. enthesitis (inflammation where tendons and ligaments attach to bone)
5. dactylitis (sweating and pain in fingers)
6. UVEITIS
7. sacroiliitis
8. spondylitis (vertebrae)

Front 150

Ankylosing Spondylitis

Back 150

1. male: female ratio of 4:1
2. 97% of AS px have HLA-B27
3. Get diarrhea after being infected with bug
4. predilection for sacro-iliac joints and spine (bamboo spine); px cant bend over and touch toes
5. elevated ESR
6. **Uveitis: acute, unilateral, recurrent

Front 151

Tx of Ankylosing Spondylitis

Back 151

1. exercise
2. posture training
3. NSAIDS
4. Sulfasalazine, Methotrexate
5. Anti-TNF agent: Etanercept***

Front 152

Reiter's Syndome: Post-Infectous Arthritis or "Reactive Syndrome" Classic Triad

Back 152

1. Urethritis
2. Conjunctivitis
3. Arthritis

Front 153

Reiter's Syndrome

Back 153

1. most cases occur within 1 to 4 weeks of dysenteric infection
2. 65-85% are HLA-B27+
3. Arthritis: 100% (predominantly of lower extremeties)
4. Enthesitis 70%
5. Dactylitis 20%
6. Spinal disease 20-30%
7. **Ocular: Uveitis (acute, unilateral and recurrent) and Conjunctivitis
8. **Urethritis (part of classic triad)

Front 154

Tx of Reiter's

Back 154

No good tx:
1. NSAIDS
2. Antibiotics for venereal infection
3. Sulfasalazine, Chloroquine, or Methotrexate

Front 155

Psoriatic Arthritis

Back 155

1. male:female ratio is 1:1
2. Often HLA-B27+
3. Arthritis: usually upper extremities
4. "sausage digits" dactylitis
5. extensive skin manifestations (scaly)
6. Tx: NSAIDS, Methotrexate, Cyclosporine, Etanercept, Infliximab, T-cell inhibitors: Efalizumab, Alefacept

Front 156

Inflammatory Bowel Disease-Associated Spondyloarthropathy

Back 156

1. can occur w/ Crohn's or Ulverative Colitis
2. oligoarthritis predominanly in lower extremities
3. sacroiliitis and spondylitis
4. uveitis**
5. HLA-B27 associated with #3 (but NOT peripheral arthritis

Front 157

Bechet's Disease

Back 157

1. small medium or large blood vessels
2. associated with HLA-B51
3. TRIAD***1) oral and genital ulcers, 2) uveitis, 3) arthritis
4. Skin: folliculitis, e. nodosum-like lesions 70%
5. tx topical steroids

Front 158

Dx of Polyarteritis Nodosa

Back 158

1. medium-sized vessel vasculities (ie vessels to heart)
2. joint inflmmation
3. cutaneous ulcers
4. mesenteric ischemia
5. dx: mesenteric or renal angiography showing microaneurysms, or biopsy**

Front 159

Wegener's Granulomatosis

Back 159

1. granulomatous vasculitis of small arteries, arterioles, and capillaries
2. Triad of organ involvement: upper respiratory tract, lungs, kidney
3. *necrotizing scleritis
4. dx + ANCA (antibody against own neutrophils)
5. tissue dx**: biopsy (sinuses or lung) = GOLD STD
6. tx: steroid & cyclophosphamide

Front 160

Osteoporosis

Back 160

1.common in elderly men with Vit D deficiency or post-menopausal women
2. **most common skeletal disorder in the world
3. bone mass value 1 to 2.5 SD below DEXA score = osteopenia
4. bone mass value 2.5 or more SD below DEXA score = osteoporosis
5. Type 1: Post-menopausal
6. Type 2: Senile (age-related)
7. dx with DEXA Scans (Dual Energy X-ray Absorptiometry): calculates bone mineral density

Front 161

Prevention and Tx of Osteoporosis

Back 161

Prevention:
1. calcium intake
2. Vitamin D intake
3. healthy weight
4. avoidance of ETOH, tobacco, and caffeine
Tx of Disease:
1. Calcitonin
2. Biphosphonates
3. estrogen
4. Fluoride

Front 162

Most common joint disease?

Back 162

Osteoarthritis

Front 163

Osteoarthritis

Back 163

-degenerative wear and tear
-NOT inflammation
-90% of pxs over ago 40
-causes: *obesity, wear & tear, previous inflammation, aging, genetic

Front 164

Symptoms of Osteoarthritis

Back 164

-joint degeneration but no systemic manifestation
-minimal morning stiffness
-pain
-crepitus
-warmth (will NEVER be hot)

Front 165

Degenerative Changes in Osteoarthritis

Back 165

early: narrowing of joint space
advanced: enzymatic degradation and thinning of cartilage
end stage: bones start touching/rubbing against one another

Front 166

Three characteristic of Osteoarthritis (KNOW)

Back 166

1) narrowing of joint space
2) osteophytes
3) bony cysts

Front 167

Gout

Back 167

-crystal deposition disease
-hyperuricemia (high uric acid levels cause crystals to form in joints)

Front 168

Causes of Hyperuricemia (2)

Back 168

1) under-excretion of uric acid
2) overproduction of uric acid

Front 169

Acute Gout Attack

Back 169

Podagra- big red inflammation of big toe
Polyarticular- involve multiple joints
Tx: resolves on its own

Front 170

Which drug helps inhibit uric acid formation?

Back 170

Allopurinol

Front 171

When should allopurinol not be given?

Back 171

during an acute gout attack bc it will make it worse

Front 172

Which drug increases secretion of uric acid?

Back 172

Probenecid

Front 173

Pseudogout

Back 173

Calcium Pyrophosphate Dihydrate Deposition (CPPD): NOT uric acid

Front 174

Difference in crystals Gout vs Pseudogout

Back 174

Gout crystals are needle-shaped and yellow
Pseudogout crystals are round and blue

Front 175

Etiology of Infectious arthritis: Septic Arthritis **

Back 175

Neisseria gonorrhea & Staphylococcus sp.

->rapidly destructive; can lost joints

Front 176

Septic Arthritis: Dx

Back 176

Arthrocentesis: important to culture bc if there is an infection, steroids are contraindicated!

Front 177

What is an IgM marker for rheumatoid arthritis?

Back 177

RF

Front 178

How much is life expectancy decreased in RA?

Back 178

3-18 yrs bc of disease and tx

Front 179

Pathological hallmark of RA?

Back 179

pannus (inflammation of tissues lining joints and is a systemic dx); inflammatory, proliferative synovial membrane (vs osteoarthritis which is not inflammatory and is limited to joints)

Front 180

What is the leading cause of death in RA?

Back 180

Coronary Artery Disease: due to inflammation of blood vessels

Front 181

Tx of RA

Back 181

NSAIDS
Steroids
DMARDS (Methotrexate, Hydroxychloroquine)
Antibodies
Aggressive early tx

Front 182

Relapsing Polychondritis

Back 182

episodic inflammation and destruction of cartilaginous structures and connective tissue (cartilage in EARS, nose, respiratory tract)

Front 183

What is the gold standard for dx of Inflammatory Myopathies?

Back 183

Muscle biopsy

Front 184

Inflammatory Myopathies

Back 184

cannot comb hair, cannot climb stairs
-polymyositis and dermatomyositis: inflammation of muscles with skin changes
-proximal muscle weakness(big muscles) and elevated CPK (muscle enzyme)

Front 185

Tx of Inflammatory Myopathies **

Back 185

Corticosteroids
Other immunosuppressants
IVIG: immunoglobulin
Physical therapy

Front 186

Most commonly involved sites in Paget's Disease of Bone

Back 186

**Skull
Sacrum
Spine
Femur
Tibia
Pelvis

Front 187

Paget's Disease

Back 187

abnormal bone remodeling: new weaker bone is formed, resulting in skeletal deformities and pain

Front 188

What are the main symptoms of Paget's?

Back 188

*bone pain and deformity
leg bowing

Front 189

Tx for Paget's

Back 189

analgesics
bisphosphonates to prevent bone resorption (Boniva)
surgery
NSAIDS

Front 190

"Everywhere hurts"

Back 190

Fibromyalgia

Front 191

Most common cause of musculoskeletal pain in US in women 20-55 yrs

Back 191

Fibromyalgia

Front 192

DDx of Fibromyalgia

Back 192

Depression, Chronic Fatigue Syndrome

Front 193

What is the most common presenting symptom everywhere (in MD office/ER)?

Back 193

acute back pain

Front 194

What is the most common cause of acute back pain?

Back 194

70% are lumbar strains and sprains

Front 195

How do you treat acute back pain?

Back 195

40% pxs are better in 1 week
90% pxs are better in 2 months
tell px to take NSAIDS and wait it out

Front 196

What 4 things are most likely associated with carpal tunnel syndrome?

Back 196

1) pregnancy, and women using oral contraceptives
2) Hypothyroidism
3) Diabetes
4) Dialysis pxs

Front 197

Symptoms of Carpal Tunnel Syndrome

Back 197

numbness and tingling in median nerve distribution; this nerve innervates thumb, pointer, and middle finger, and half of ring finger

Front 198

Lateral epicondylitis

Back 198

"tennis elbow"; involves extensor muscles of forearm and lateral epicondyle

Front 199

Medial epicondylitis

Back 199

"golfer elbow"; involves flexor muscles of forearm and medial epicondyle

Front 200

Which muscle is most common torn in Rotator Cuff Tear?

Back 200

supraspinatus tendon

Front 201

What is the purpose of the rotator cuff?

Back 201

to rotate and lift arm; stabilizes shoulder joint; a single tendon

Front 202

Largest tendon in body?

Back 202

Achilles Tendon

Front 203

Most commonly ruptured tendon?

Back 203

Achilles Tendon

Front 204

Familial polypoosis coli

Back 204

Colon cancer 100%

Front 205

What is the most prevalent cancer in men?

Back 205

prostate

Front 206

What is the most prevalent cancer in women?

Back 206

breast

Front 207

What is the most common cause of death from cancer in men and women?

Back 207

lung

Front 208

Carcinomas arise from which type of cells?

Back 208

epithelial cells

Front 209

Sarcomas arise from what type of cells?

Back 209

cells that make up bone or connective tissue

Front 210

Leukemias and lymphomas arise from cells from where?

Back 210

marrow/immune system

Front 211

Which type of cancer does not have a reliable screening dx?

Back 211

Lung cancer

Front 212

Screening applies to which types of cancer?

Back 212

cervix, breast, colon, prostate

Front 213

TNM System

Back 213

tells whether cancer is curable or not
Tumor: size, amt of local invasion? Label T1-T4
Node involvement: any/which ones? Label N0-N3
Metastasis: Yes/no? Label M0 for no, and M1 for yes

Front 214

Does chemotherapy or radiation therapy damage nuclear DNA?

Back 214

radiation therapy

Front 215

What are the risk factors of breast cancer?

Back 215

1. Increased age
2. 1st degree relatives afflicted (3x risk)
3. Genetics
4. Early menarche/late menopause
5. late first pregnancy or nulliparity
6. alcohol comsumption

Front 216

Breast Cancer Tx

Back 216

1. Surgery
2. Chemotherapy: all tumors >1cm
3. Hormonal Therapy: Tamoxifen: anti-estrogen drug
4. Biologic agents: Herceptin
5. Aromatase inhibitors: Arimidex, Femara *used only in post-menopausal women w/ HR positive tumors

Front 217

American Cancer Society recommends colonoscopy when?

Back 217

-beginning at age 50, every 10 yrs
-1st degree relative w/ cancer age >60: colonoscopy beginning at age 40, every 10 yrs
-1st degree relative w/ cancer age <60: colonoscopy beginning at age 40, every 5 yrs

Front 218

Hereditary Non-Polyposis Colon Cancer (HNPCC)

Back 218

when 3 1st degree relatives in 2 generations are diagnosed with colon cancer before age 50; almost everyone in family has some colon cancer

Front 219

Tx for Colon cancer?

Back 219

Hemicolectomy (removal of polyp) followed by chemotherapy
**Avastin is approved for metastatic colon CA and has minimal SE

Front 220

How do you grade a tumor in prostate cancer?

Back 220

Gleason score- a high gleason score is worse

Front 221

Hormone Therapy for Prostate Cancer

Back 221

LHRH (Luteinizing Hormone Releasing Hormone): agonist combined with testosterone receptor antagonist

Front 222

When is chemotherapy used in prostate cancer?

Back 222

only in refractory cases and widespread disease

Front 223

What type of lung cancer is most aggressive?

Back 223

small cell lung ca

Front 224

What is the #1 risk factor for lung ca?

Back 224

smoking
(also smoking + asbestos exposure)

Front 225

Is adenocarcinoma more common in males or females?

Back 225

females

Front 226

Which type of lung ca is commonly found in smokers?

Back 226

squamous cell carcinoma

Front 227

aka oat cell carcinoma

Back 227

small cell lung ca

Front 228

Locations of adenocarcinomas, squamous cell carcinoma, and large cell carcinoma

Back 228

adenocarcinoma: peripheral
squamous cell carcinoma: central lesions
large cell carcinoma: central

Front 229

Where does lung ca often spread to?

Back 229

bone and brain

Front 230

Prognosis for lung ca?

Back 230

poor; overall 5 yr survival is 10%

Front 231

Is there a screening for lung ca?

Back 231

NO

Front 232

Gardasil

Back 232

Vaccine to protect against cervical cancer; approved for 9-26 yr olds; effective against HPV 6, 11, 16, 18 (16 and 18 cause 75% of cervical CA)

Front 233

Prognosis for Cervical Cancer

Back 233

-94.6% survival at 5 yrs in early stages
-22% survival at 5 yrs in late stages

Front 234

Risk Factors for testicular cancer

Back 234

-undescended testis (*increased risk even with surgical correction)
-family hx
-infertility
-HIV infection

Front 235

Survival Rate of testicular cancer?

Back 235

one of most curable cancers; 5 yr survival exceed 90%

Front 236

What should you never do on a testicular cancer px?

Back 236

trans-scotal biopsy

Front 237

What is done during orchidectomy in testicular cancer pxs?

Back 237

retro-peritoneal lymph node dissection

Front 238

ABCDs of skin lesions

Back 238

Asymmetry
Borders: irregular
Color: not uniform
Diameter: larger

Front 239

Major determinant of prognosis of skin cancer?

Back 239

depth of tumor invasion

Front 240

What are risk factors for cancer of the esophagus?

Back 240

cigarettes and alcohol

Front 241

Barrett's esophagus

Back 241

change in epithelium over time with GERD: predisposes px to esophageal ca

Front 242

Dx of esophageal ca?

Back 242

CT of chest/abdomen: *look for enlarge lymph nodes

Front 243

Prevalence of ovarian cancer?

Back 243

affects post-menopausal women

Front 244

What is associated with decreased risk of ovarian cancer?

Back 244

early first pregnancy, multiparity, oral contraceptive use, breast feeding

Front 245

Risk factors for Liver Cancer

Back 245

*Cirrhosis (fibrosis of liver)
*Alcohol
*Hepatitis B and C

Front 246

Should you dilate pregnant pxs?

Back 246

every trimester with tropicamide only

Front 247

What is the best glaucoma med for a pregnant px?

Back 247

Propine (alphagan p is 2nd best)

Front 248

What is a good rule of thumb for pregnant pxs?

Back 248

No drops of any kind should be given! (do NCT, not goldmann, do no use proparacaine)

Front 249

Is there an increase or decrease in BP in pregnant women?

Back 249

decreased blood pressure

Front 250

Dermatologic Changes in pregnant px

Back 250

1. Chloasma: blotchy brown hypermelanosis that occurs around eyelids and fades post-partum; due to increased levels of MSH
2. Pre-existing nevi, freckles, and scars increase in size and pigmentation
3. Spider angiomas due to increased estrogen levels (abnormal change)

Front 251

Visual function in pregnant px

Back 251

-refractive errors remains constant**
-decrease in amplitude of accommodation in 2nd half of pregnancy (may need readers)

Front 252

IOP in pregnant px

Back 252

decreases

Front 253

Pre-eclampsia

Back 253

hypertensive disorder unique to pregnancy; after 20th week of gestation; overall edema of body

Front 254

Eclampsia

Back 254

same as pre-eclampsia PLUS seizures and/or coma

Front 255

Symptoms of Eclampsia

Back 255

*visual disturbances
*blurred vision
*30-100% have ocular symptoms

Front 256

Hallmark retinal sign of Eclampsia

Back 256

***focal retinal arteriolar vasospasm and narrowing
-also hemorrhage, exudates, CWSs, and eventually disc edema

Front 257

Should you dilate pxs with PIH (pregnancy-induced hypertension)?

Back 257

YES

Front 258

Central Serous Chorioretinopathy (CSC)

Back 258

spontaneous, localized serous retinal detachment (usually in area of macula)

Front 259

Symptoms of CSC

Back 259

**Metamorphopsia
-reduced VA
-micropsia
-dyschromatopsia
-refractive shift towards hyperopia

Front 260

Clinical Manifestation of CSC

Back 260

increased incidenve of gray or white subretinal exudates within the detachment (unique to pregnancy); presumed to occur due to fibrin in subretinal space

Front 261

Purtscher-like Retinopathy

Back 261

specifically related to child birth; occlusive vascular disorder; lack of blood flow to eye bc of retinal arteriolar occlusions during pregnancy

Front 262

Funduscopic Findings in Purtscher-like Retinopathy

Back 262

multiple, superficial, white retinal patches, resembling large CWSs, often associated with superficial peripapillary hemorrhages (right at disc); resolves spontaneously

Front 263

Etiology of Disseminated Intravascular Coagulation

Back 263

disturbance in homeostasis of body's clotting cascade

Front 264

Disseminated Intravascular Coagulation occurs in:

Back 264

-complicated abortions
-placental abruption; separation of placenta from uterus b4 baby is born
-pre-eclampsia

Front 265

Clinical Manifestation of Disseminated Intravascular Coagulation

Back 265

-widespread thrombus formation
-choroid most commonly involved
-serous retinal detachment due to occlusion of choriocapillaris
-fibrin deposition cause by clot formation in microvasculature

Front 266

Funduscopic Findings of Disseminated Intravascular Coagulation

Back 266

-choroidal hemorrhage
-cystoid macular edema
-serous retinal detachment

Front 267

Amniotic Fluid Embolism

Back 267

-occurs during labor, delivery, or in immediate post partum pd
-mortality rate in 80% range***
-embolic material within amniotic fluid deposits in microvasculature of heart, lung, brain, and eye

Front 268

Symptoms of Pseudotumor Cerebri (PTC)

Back 268

-increased intracranial pressure
-disc edema
-Paton's lines around ONH due to disc edema
-CN VI palsy
-visual disturbances
-headache, nausea, and vomiting

Front 269

Visual Field of PTC patient

Back 269

enlarged blind spot

Front 270

Management of PIH

Back 270

***immediate delivery of baby due to increased mortality risk of mother

Front 271

Management of PTC

Back 271

-weight loss
-Diamox, Naptazene
-**termination of pregnancy considered last resort (unlike PIH)

Front 272

2 idiopathic miscellaneous disorders during/after pregnancy

Back 272

1) ptosis
2) Idiopathic Facial Palsy (3x more likely during pregnancy)

Front 273

Definition of CSME

Back 273

1) exudates within 500 microns of foveola, if associated w/ adjacent retinal thickening
2) thickening of retina within 500 microns of foveola
3) zones of retinal thickening one disc area or larger, any part of which is within one disc diameter or foveola

Front 274

Are pxs with gestational diabetes at risk for diabetic retinopathy?

Back 274

NO- do not need to be dilated unless they have symptoms

Front 275

What is a pathogenic mechanism for diabetic retinopathy?

Back 275

increased retinal blood flow

Front 276

Risk factors for progression of DR**

Back 276

1. increased cardiac output
2. increased plasma volume
3. decreased peripheral vascular resistance

Front 277

Category A Drugs during pregnancy

Back 277

Controlled Studies show NO RISK

Front 278

Category B Drugs during pregnancy

Back 278

No Evidence of Risk in Humans; adverse findings in animals

Front 279

Category C Drugs during pregnancy

Back 279

Risk cannot be ruled out; human and animal studies are lacking

Front 280

Category D Drugs during pregnancy

Back 280

Positive Evidence of Risk; studies in humans have demonstrated fetal risk

Front 281

Category X Drugs during pregnancy

Back 281

Contraindicated in Pregnancy; studies have demonstrated positive evidence of fetal abnormalities or risk that clearly outweighs any possible benefit to px