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184 Cards in this Set
- Front
- Back
Signs & tx of a right ventricular infarct |
Signs: hypotension, tachycardia, clear lungs, elevated JVP, and NO pulsus paradoxus
Tx: fluid resuscitation, don't give nitro! |
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Tx for CHF exacerbation
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LMNOP: lasix, morphine, nitro, O2, position (elevate head) or positive pressure ventilation
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Tx for stable CHF that has mortality benefit
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ACEi, Beta-blockers, spironolactone
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Tx for ACS (UA, NSTEMI, STEMI)
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BEMOAN: beta-blockers, enoxaparin, morphine, O2, ASA, nitro
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Long-term tx post-MI
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"ASA-Beta-Stati-Pril": ASA, Beta-blocker, Statin, ACEi
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Most common cause of death post-MI
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Arrhythmias (VFib)
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Post-MI complication: New systolic murmur 5-7 days after
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Mitral regurgitation due to papillary muscle rupture
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Post-MI complication: Cause of acute severe hypotension
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Cardiac tamponade due to ventricular free wall rupture
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Post-MI complication: "step-up" in O2 concentration from RA to RV
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Ventricular septal rupture leading to left-to-right shunt
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Post-MI complication: persistent ST elevation ~1mo later + systolic murmur
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Ventricular wall aneurysm
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Post-MI complication: Cannon A-waves
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AV dissociation either due to VFib or 3rd degree heart block
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Post-MI complication: pleuritic chest pain and fever 5-10 wks later
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Dressler's syndrome (likely autoimmune pericarditis). Tx with NSAIDs and ASA.
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Diagnose: chest pain worse with inspiration, better with leaning forward, friction rub, and diffuse ST elevation
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Pericarditis
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Diagnose: chest pain worse with palpation
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Costochondritis
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Diagnose: chest pain with vague hx of recent viral infection and murmur
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Myocarditis
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Diagnose: chest pain that occurs at rest, worse at night, few CAD risk factors, with migraine H/As, transient ST elevation during episodes
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Prinzmetal's angina (tx with CCB or nitrates)
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EKG rhythm: progressive prolongation of PR interval followed by a dropped beat
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2nd degree AV block - Type I
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EKG rhythm: Cannon-a waves on physical exam and regular P-P interval and regular R-R interval
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3rd degree AV block
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EKG rhythm: varrying PR interval with 3 or more morphologically distinct P waves in the same lead; seen in older person with chronic lung dx (COPD) in pending resp failure
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MAT: multifocal atrial tachycardia
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EKG rhythm: short PR interval followed by QRS>120 ms with a slurred initial deflection representing early ventricular activation via the bundle of Kent
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WPW: Wolff-Parkinson-White syndrome
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EKG rhythm: regular rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm
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Atrial flutter
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EKG rhythm: prolonged QT interval leading to undulating rotation of the QRS complex around the EKG baseline in a pt with low Mg, low K, lithium overdose, or TCA overdose
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Torsades de pointes
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EKG rhythm: renal failure pt OR crush injury OR burn victim with peaked T-waves, widened QRS, short QT and prolonged PR
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Hyperkalemia
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EKG rhythm: undulating baseline, no P waves, irregular RR interval in a pt with hyperthyroidism OR old pt with SOB/dizziness/palpitations with CHF or valve disease
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AFib
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Murmur: systolic ejection murmur, crescendo-decrescendo, louder with squatting, softer with valsalva, +parvus et tardus
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Aortic stenosis
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Murmur: systolic ejection murmur louder with valsalva, softer with squatting or handgrip
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Hypertrophic cardiomyopathy
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Murmur: late systolic murmur with click, louder with valsalva and handgrip, softer with squatting
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Mitral valve prolapse
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Murmur: Holosystolic murmur radiates to axilla with left atrial enlargement
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Mitral regurgitation
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Murmur: Holosystolic murmur with late diastolic rumble in kids
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VSD
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Murmur: Continuous machine-like murmur
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PDA
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Murmur: wide fixed and split S2
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ASD
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Murmur: rumbling diastolic murmur with an opening snap, left atrial enlargement, and AFib
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Mitral stenosis
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Murmur: blowing diastolic murmur with widened pulse pressure
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Aortic regurgitation
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Diagnose CXR: hyperlucent lung fields with flattened diaphragms
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COPD
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Diagnose CXR: opacification, consolidation, air bronchograms
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Pneumonia
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Diagnose CXR: heart>50% AP diameter, cephalization, Kerly B lines, interstitial edema
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CHF
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Diagnose CXR: cavity containing air-fluid level
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Abscess
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Diagnose CXR: Upper lobe cavitation, consolidation, +/- hilar lymphadenopathy
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TB
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Common causes of transudative pleural effusion
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CHF, nephrotic, cirrhotic
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Diagnose: transudative pleural effusion low in pleural glucose
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Rheumatoid arthritis
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Diagnose: transudative pleural effusion high in lymphocytes
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TB
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Common causes of exudative pleural effusion
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Cancer or parapneumonic (pleural effusion secondary to pneumonia)
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Light's criteria
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Exudative pleural effusion if:
1. LDH > 2/3 of upper limit of normal 2. LDF effusion/serum >0.6 3. Protein effusion/serum >0.5 |
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Sx of a PE
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Sx: pleuritic chest pain, hemoptysis, tachypnea, tachycardia
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Signs of a PE
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right heart strain on EKG, sinus tachycardia, decreased vascular markings on CXR, wedge infarct, ABG with low CO2 and O2
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Causes and tx of ARDS
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Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis
Tx: mechanical ventilation with PEEP |
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Tx for COPD that has mortality benefit
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Quitting smoking and continuous O2 therapy >18 hrs per day
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Important vaccinations for COPD pts
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Pneumococcus with a 5yr booster and yearly influenza vaccine
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Diagnose: 1 cm nodules in upper lung lobes with eggshell calcifications
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Silicosis
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Diagnose: Hilar lymphadenopathy, increase ACE, erythema nodosum
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Sarcoidosis = syndrome involving abnormal collections of chronic inflammatory cells (granulomas) that can form as nodules in multiple organs
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Diagnose: pt with kidney stones, constipation, low PTH, and CENTRAL lung mass
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Squamous cell carcinoma of the lung (paraneoplastic syndrome secondary to secretion of PTH-rP = low PO4 and high Ca)
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Diagnose: pt with shoulder pain, ptosis, constricted pupil, facial edema, wt loss, cough + hemoptysis
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Superior Sulcus Syndrome from Small Cell Carcinoma (also a central lung cancer)
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Diagnose: pt with ptosis that improves after 1 min of upward gaze
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Lambert Eaton Syndrome (autoimmune Ab production against pre-synpatic Ca channels)
-Around 60% of those with LES have underlying malignancy, most commonly Small Cell lung cancer; it is therefore regarded as a paraneoplastic syndrome |
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Diagnose: old smoker presenting with hemoptysis, wt loss, Na=125, moist mucus membranes, and normal JVP
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SIADH from small cell lung cancer (produces euvolemic hyponatremia)
Tx: fluid restrict (if Na>112, add 3% saline) |
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Diagnose: pt with hemoptysis and wt loss, with CXR showing PERIPHERAL cavitation and CT showing distant mets
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Large Cell Carcinoma of lung
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IBD that increases risk for Primary Sclerosing Cholangitis
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Ulcerative colitis (PSC leads to higher risk of cholangiocarcinoma)
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IBD in which fistulas, granulomas, and transmural inflammation are likely
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Crohn's
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Tx of IBD
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Corticosteroids to induce remission, ASA and sulfasalazine to maintain remission. For Crohn's, give metronidazole for any ulcer or abscess. If severe disease, give azathioprine, 6MP, and methotrexate.
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Diagnose: AST>ALT (2x) + high GGT
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Alcoholic hepatitis
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Diagnose: ALT>AST and in the 1000s
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Viral hepatitis
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Diagnose: AST and ALT in the 1000s after surgery or hemorrhage
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Ischemic hepatitis (shock liver)
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DDx of elevated direct bili
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Obstructive liver dx (stone, cancer), Dubin-Johnson syndrome, Rotor syndrome
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DDx of elevated indirect bili
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Hemolysis, Gilbert's syndrome, Criglr-Najjar syndrome
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Diagnose: elevated ALP and GGT
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Bile duct obstruction. If pt has IBD, consider PSC
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Diagnose: elevated ALP, normal GGT, normal Ca
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Paget's disease of the bone (excessive breakdown and formation of bone causing bone pain, back pain, increase hat size, hearing loss, headache).
Tx with bisphosphonates. |
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Diagnose: liver disease pt with elevated antimitochondrial Abs
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Primary Biliary Cirrhosis
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Diagnose: liver disease pt with elevated ANA + antismooth muscle Abs
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Autoimmune hepatitis
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Diagnose: pt with low ceruloplasmin and high urinary Cu
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Wilson's disease (hepatitis, psych sx due to Cu deposition in the basal ganglia, corneal deposits=Kayser-Fleischer rings)
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Diagnose: liver disease pt with high Fe, low ferritin, low Fe binding capacity
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Hemachromatosis (hepatitis, DM, golden skin)
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Most common bugs causing meningitis
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Strep pneumo
H. influenza N. meningitidis |
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Tx for meningitis
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Ceftriaxone, Vancomycin, Ampicillin (for Lysteria), and Dexamethasone
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Pneumonia: most common bug?
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Strep pneumo
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Pneumonia: most common bug in healthy young people?
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Mycoplasma
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Pneumonia: most common bug in hospitalized pts?
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Pseudomonas, Klebsiella, E. coli, MRSA
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Pneumonia: most common bug in old smokers with COPD?
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H. influenza
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Pneumonia: most common bug in alcoholics with currant jelly sputum?
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Klebsiella
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Pneumonia: most common bug in old men with headache, confusion, diarrhea, and abdo pain?
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Leigionella
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Pneumonia: most common bug in pt who just delivered a baby cow and has vomiting and diarrhea
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Coxiella burnetti
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Pneumonia: most common bug in pt who just skinned a rabbit?
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Franciella tularensis
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Pneumonia: most common bug in pt who just had the flu?
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MRSA
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Positive TB test interpretation
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Induration >15 mm is positive TB test in general pop
Induration >10 mm is positive if prisoner, healthcare worker, nursing home, DM, EtOH, chronically ill Induration >5 mm if AIDS or immunosuppressed |
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Tx regimen for TB
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RIPE: rifampin, INH (isoniazid), pyrazinamide, ethambutol
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TB tx: s/e of Rifampin
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body fluids turn orange/red, induces CYP450
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TB tx: s/e of INH
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peripheral neuropathy and sideroblastic anemia (prevent by giving vit B6), hepatitis with mild bump in LFTs
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TB tx: s/e of Pyrazinamide
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benign hyperuricemia
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TB tx: s/e of ethambutol
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optic neuritis, other color vision abnormalities
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Acute endocarditis: most common bug?
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Staph aureus
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Subacute native valve endocarditis: most common valve affected and most common bug responsible?
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mitral valve and Viridens group strep
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IV drug use endocarditis: most common valve affected and most common bug?
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tricuspid valve and Staph aureus
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Endocarditis complications
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CHF is #1 cause of death, septic emboli to lungs or brain
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What is the next step if you find endocarditis caused by Strep bovis bacteremia?
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Colonoscopy to look for colon cancer!
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Criteria for diagnosing endocarditis?
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Modified Duke Criteria:
A definite diagnosis of IE can be established if the following conditions are fulfilled: 2 major criteria, 1 major + 3 minor criteria, or 5 minor criteria. |
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When to suspect HIV...
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1. young pt with new/bilateral Bell's palsy
2. young pt with unexplained thrombocytopenia & fatigue 3. young pt with unexplained wt loss >10% 4. young pt with thrush, Zoster, or Kaposi sarcoma 5. pt who "travels a lot for work" and have a lot of sex |
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Acute retroviral syndrome (initial post-HIV infection sx)
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Sx of HIV infection can occur 2-3 wks after exposure but 3 wks before seroconversion (so ELISA is still negative): fever, fatigue, lymphadenopathy, HA, pharyngitis, N/V, diarrhea, +/- aseptic meningitis
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Most common bug in HIV pt complaining of dyspnea, dry cough, fever, and chest pain? Findings on CXR? 1st line tx?
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Pneumocystis jiroveci
CXR shows bilateral diffuse symmetric interstitial infiltrates Tx: tmp-smx |
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Diagnose: HIV+ pt with multiple ring-enhancing lesions on CT or MRI
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CNS Toxoplasmosis
Tx: empiric pyramethamine sulfadiazine + folic acid for 6 wks; if no improvement, consider biopsy for CNS lymphoma |
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Diagnose: HIV+ pt with one ring-enhancing lesion on CT or MRI
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CNS lymphoma, associated with EBV infection of B-cells
Tx: HAART |
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Diagnose: HIV+ pt with seizure with de ja vu aura and 500 RBCs in CSF
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HSV encephalitis (predisposed for temporal lobe)
Tx: Give Acyclovir as soon as suspected |
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Diagnose: HIV+ pt with signs/sx of meningitis
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Cryptococcal meningitis
Diagnosis: positive India ink stain Tx: Amphotericin B (antifungal) |
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Diagnose: HIV+ pt with hemisensory loss, visual impairment, and +Babinski
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PML: Progressive Multifocal Leukoencephalopathy (widespread demyelinative lesions due to infection of oligodendrocytes by a polyomavirus)
Diagnosis: brain biopsy is gold standard Tx: experimental only (antiretrovirals) |
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Diagnose: HIV+ pt with memory problems and gait disturbance
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AIDS-Dementia complex
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Definition of febrile neutropenia
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FEVER: single oral temp equal to or greater than 38.3C or 101F AND a febrile state of >38C for at least 1h
NEUTROPENIA: absolute neutrophilic count of <0.5, or a count of <1 with a predicted decline to <0.5 in the next 24 to 48 hours |
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Common cause of febrile neutropenia
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Mucositis secondary to chemo that causes bacteremia (usually from the gut)
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Work-up for febrile neutropenia
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Tx: blood cx, then 3rd or 4th gen cephalosporin (ie. ceftazadime or cefipime); add Vanco if line infx suspected or if septic shock develops; add Amphotericin B if no improvement and no source found in 5 d
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Diagnose: pt with target rash, fever, CN7 palsy, meningitis, and AV block
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Lyme Disease
Tx: Doxycycline po; heart or CNS disease needs IV Ceftriaxone |
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Diagnose: pt with rash at the wrists and ankles (palms and soles), fever, and headache
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Rickettsia
Tx: Doxycycline po |
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Diagnose: pt with a tick bite, no rash, myalgia, fever, HA, decreased platelets and WBCs, and increased ALT
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Ehrlichiosis (tick-borne bacterial infection; bacteria live within WBCs of host)
Tx: Doxycycline po |
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Diagnose: immunosuppressed pt with cavitary lung disease, purulent sputum, weight loss, and fever; Gram+ aerobic branching, partially acid-fast
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Nocardia (bacteria normally found in soil; disease is one of the "great imitators" bc produces nonspecific sx)
Tx: tmp/smx |
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Diagnose: pt with neck or face infection with draining yellow material (+sulfur granules); Gram+ anaerobic branching
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Actinomyces
Tx: high dose PCN for 6-12 wks |
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Nephro: causes of hypervolemic hypoNa
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CHF, nephrotic, cirrhotic causes
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Nephro: causes of hypovolemic hypoNa
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diuretics or vomiting
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Nephro: causes of euvolemic hypoNa
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SIADH (check CXR if smoker!), Addison's, hypothyroidism
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If pt has hyponatremia, why should you not rapidly correct their serum Na?
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HypoNa: Correcting the serum Na faster than 12-24 mEq/day can cause Central Pontine Myelinolysis (severe damage of myelin sheath of neurons in the pons, causing paralysis, dysphagia, dysarthria, etc)
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If pt has hypernatremia, why should you not rapidly correct their serum Na?
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HyperNa: Correcting serum Na faster than 12-24 mEq/day may cause cerebral edema.
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Diagnose electrolyte abnormality: pt with peri-oral numbness, +Chvostek or Trousseau sign, and prolonged QT interval
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Hypocalcemia
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Diagnose electrolyte abnormality: "Bones, stones, groans, and psychiatric overtones", shortened QT interval
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Hypercalcemia
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Diagnose electrolyte abnormality: muscle weakness, ileus, ST depression, U waves
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Hypokalemia
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Diagnose electrolyte abnormality: peaked T waves, prolonged PR and QRS, sine waves
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Hyperkalemia
Tx: Ca-gluconate, then insulin +glucose, kayexalate, salbutamol, and NaHCO3; Dialysis is last resort |
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Diagnose: muddy brown casts in a pt taking Amphotericin or Aminoglycosides or Cisplatin
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Acute tubular necrosis (ATN)
Tx: fluids, avoid nephrotoxins, dialysis if indicated |
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Diagnose: protein, blood, & eosinophils in the urine, fever and rash, pt took tmp-smx 2 wks ago
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Acute interstitial nephritis (AIN)
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Diagnose: crush victim with very high serum CK, +blood on urine dipstick, but no gross hematuria
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Rhabdomyolysis, causing hyperkalemia
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Indicators for emergent dialysis
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AEIOU:
A-acidosis E-electrolyte imbalance (esp high K>6.5) I-intoxication (esp antifreeze and Li) O-overload of volume (sxs of CHF or pulmonary edema) U-uremia (pericarditis, altered mental status) *Dialysis not urgently indicated for rising Cr or oliguria alone!! |
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#1 cause of CKD
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Diabetes mellitus
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#2 cause of CKD
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HTN
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#1 cause of death in a CKD pt
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Cardiovascular disease
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Cx of CKD
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HTN, fluid retention = CHF
normochromic normocytic anemia (loss of EPO) hyperK hyperPO4 (can cause precipitation of Ca into tissues = renal osteodystrophy and calciphylaxis (skin necrosis)) hypoCa Uremia (confusion, pericarditis, pruritus, increased bleeding secondary to uremic-induced platelet dysfunction) |
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Diagnose: elderly pt with painless hematuria
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bladder cancer until proven otherwise
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Diagnose: pt with hematuria and progressive hearing loss & deafness
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Alport Syndrome ( genetic disorder characterized by glomerulonephritis, endstage kidney disease, and hearing loss); mutation in collagen IV
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Diagnose: pt with hematuria 1-2 wks after sore throat or skin infection
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Post-strep glomerulonephritis
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Diagnose: child with viral URI, abdominal pain, arthralgia, and purpura; can cause renal failure
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Henoch-Schonlein Purpura
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Diagnose: child who ate a hamburger and now has diarrhea, renal failure, petechiae, and MAHA (microangiopathic hemolytic anemia)
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Hemolytic uremic syndrome (HUS) = Most cases are preceded by an episode of infectious, sometimes bloody, diarrhea caused by E. coli O157:H7 or Shigella, which is acquired as a foodborne illness or from a contaminated water supply.
Tx: supportive; don't tx with ABx bc causes release of more toxins Mnemonic: DART - diarrhea, anemia, renal failure, thrombocytopenia |
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Diagnose: cardiac pt with renal failure, MAHA, thrombocytopenia, fever, and altered mental status; pt treated with ticlopidine (plt aggregation inhibitor)
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Thrombotic thrombocytopenic purpura (TTP)
Tx: plasmapheresis; don't give plts Distinguished from DIC bc PT and PTT are normal ins HUS/TTP Mnemonic pentad of TTP: FARTN = fever, anemia, renal failure, thrombocytopenia, neuro signs |
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Diagnose: + c-ANCA, kidney/lung/sinus involvement
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Wegener's Granulomatosis
Dx: most accurate test is biopsy Tx: steroids or cyclophosphamide |
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Diagnose: + p-ANCA, renal failure, asthma, and eosinophilia
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Churg-Strauss Disease (medium and small vessel autoimmune vasculitis, leading to necrosis. It involves mainly the blood vessels of the lungs (it begins as a severe type of asthma), gastrointestinal system, and peripheral nerves, but also affects the heart, skin, and kidneys)
Dx: best test is lung bx Tx: cyclophosphamide |
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Diagnose: + p-ANCA, NO lung involvement, 30% pts are Hep B+
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Polyarteritis Nodosa (PAN) = affects small/med arteries of every organ except the lungs!
Tx: cyclophosphamide |
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Types of kidney stones and most common
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Most common: calcium oxalate
Others: cysteine, struvite (Mg/Al/PO4), and uric acid stones |
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Diagnose: pt receiving chemo tx for leukemia who develops flank pain radiating to groin + hematuria
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Uric acid stone (secondary to increased production of uric acid from purine breakdown during periods of active cell proliferation, especially following chemo treatment in pts with leukemia)
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What are the 4 histological subtypes of nephrotic syndrome?
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1. MCD = minimal change disease
2. FSGS = focal segmental glomerulosclerosis 3. MN = membranous nephropathy 4. MPGN = membranoproliferative glomerulonephritis |
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Most common cause of nephrotic syndrome in kids
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Minimal change disease (fusion of podocyte foot processes on electron microscopy)
Tx: steroids |
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Most common cause of nephrotic syndrome in adults
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Focal Segmental Glomerulosclerosis (FSGS)
= The individual components of the name refer to the appearance of the kidney tissue on biopsy: focal—only some of the glomeruli are involved (as opposed to diffuse), segmental—only part of each glomerulus is involved (as opposed to global), glomerulosclerosis—refers to scarring of the glomerulus |
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Second most common cause of nephrotic syndrome in adults
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Membranous glomerulonephritis (MGN)
= slowly progressive disease of the kidney affecting mostly patients between ages of 30 and 50 years, usually Caucasian; 85% idiopathic (aka unknown cause) |
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Which secondary cause of nephrotic syndrome is associated with chronic hepatitis and low complement?
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Membranoproliferative glomerulonephritis (MPGN)
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Which secondary cause of nephrotic syndrome is associated with heroin use and HIV?
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Focal Segmental Glomerulosclerosis (FSGS)
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What should you suspect if a nephrotic syndrome suddenly develops flank pain?
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Suspect renal vein thrombosis secondary to hypercoagulable blood b/c loss of anticoagulants in urine (antithrombin III, protein C & S)
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Diagnose: 30 yo F with thrombocytopenia, recurrent epistaxis, menorrhagia, and petechiae. Decreased plts only.
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ITP
Tx: prednisone 1st line, then splenectomy |
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Diagnose: 20 yo F with recurrent epistaxis, menorrhagia, petechiae, NORMAL plts, increased bleeding time and PTT
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VWD
Tx: dDAVP for bleeding or pre-op; replace Factor 8 (which contains vWF) if bleeding continues |
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Diagnose: 20 yo M with recurrent bruising, hematuria, hemarthroses, and increased PTT
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Hemophilia
Tx: if mild, use dDAVP, otherwise replace factors |
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Diagnose: pt develops arterial clot 1 wk post-op. Her plts are 50% less than pre-op.
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Heparin-induced thrombocytopenia (HIT)
Tx: stop heparin, reverse warfarin with Vit K |
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DDx of unprovoked thrombus
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-CANCER
-OCPs or HRT -nephrotic syndrome -lupus anticoagulant -protein c/s deficiency -+Factor 5 Leiden gene -Antithrombin III deficiency |
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What are examples of "great imitator" diseases? (diseases which can be confused with others and which feature nonspecific sx)
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-cancer
-fibromyalgia -MS -systemic lupus erythematosus -sarcoidosis -Infectious diseases: Lyme disease, Syphilis, & Nocardiosis -Celiac -Addison's -PE |
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Diagnose: pt with knee pain, DIP involvement, no swelling or warmth at joints, worse at the end of the day, crepitus
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OA
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Diagnose: pt with arthritis at PIP and wrists bilaterally, worse in the AM, low grade fever
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RA
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Diagnose: pt with arthritis at DIP joints, rash with silvery scale on elbows and knees, pitting nails, and swollen fingers
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Psoriatic arthritis
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Diagnose: symmetric bilateral arthritis, malar rash, oral ulcers, proteinuria, thrombocytopenia. Arthritis is not erosive or have lasting sequelae.
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SLE
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Diagnose: Pt with acute swollen painful joint and aspirated fluid with needle-shaped, negatively birefringent crystals
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Gout (monosodium urate crystals)
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Acute and chronic tx of gout
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Acute tx: indomethacin & colchicine (steroids if CKD)
Chronic tx: Allopurinol if overproduction of crystals, Probenecid if undersecretion of crystals |
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Diagnose: pt with acute swollen painful joint and aspirated fluid with rhomboid-shaped, positively birefringent crystals
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Pseudogout (calcium pyrophosphate)
Tx: NSAIDs, colchicine, corticosteroids |
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Which Abs are most sensitive for SLE?
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Anti-dsDNA and Anti-Smith
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Abs positive in Sjogren's syndrome
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Anti-Ro and Anti-La
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Ab positive in CREST syndrome
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Anti-Centromere
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Abs positive in Systemic Sclerosis
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Anti-Scl-70 and Anti-topoisomerase
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What is CREST syndrome?
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Limited cutaneous form of systemic scleroderma:
C - calcinosis R - Raynaud's E - esophageal dysmotility S - sclerodactyly T - telengiectasia |
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Name this skin sign of systemic disease (may indicate internal malignancy): explosive onset of multiple seborrheic keratoses
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Sign of Leser-Trelat
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Diagnose: pt has this skin finding and also has difficulty combing hair and getting up from a chair
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Dermatomyositis features:
-heliotrope rash -Gottron's papules -periungal erythema -proximal muscle weakness |
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Pruritic rash that begins on extremities, lasts 7-10 d, unknown cause
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Erythema multiforme
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What is the Ddx of this skin findings (brown to black, poorly defined, velvety hyperpigmentation of the skin)
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Acanthosis nigricans:
-occurs in individuals younger than age 40, may be genetically inherited, associated with obesity or endocrinopathies, such as: - hypothyroidism or hyperthyroidism, -acromegaly, -polycystic ovary disease, -insulin-resistant diabetes, -Cushing's disease |
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Diagnose: 50 yo male presenting with blisters which become ulcerated in areas of the skin exposed to sunlight, especially on the face, ears and dorsum of the hands; his labwork shows iron overload
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Porphyria cutanea tarda:
-a genetic photosensitive skin disease with onset in adult life with substances called uroporphyrins in the urine due to a deficiency of uroporphyrinogen decarboxylase (UROD), an enzyme required for the synthesis of heme -The hallmarks of porphyria cutanea tarda (PCT) are blisters which become ulcerated in areas of the skin exposed to sunlight -Iron overload is frequently present in porphyria cutanea tarda and may be associated with varying degrees of damage of the liver |
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What is the precursor lesion of squamous cell carcinoma?
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Actinic keratosis
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What are the 4 subtypes of melanoma?
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1. Superficial spreading (most common, best prognosis)
2. Nodular (poor prognosis) 3. Acral-lentiginous (palms, soles, mucous membranes, more prevalent in darker skin individuals) 4. Lentigo maligna (head & neck, good prognosis) |
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What is the #1 prognostic indicator for melanoma?
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Breslow's depth: tumor thickness remains the most powerful prognostic indicator hence why it's critical to get a full-thickness biopsy
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Most common pituitary adenoma?
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Prolactinoma
-consider if pt presents with amenorrhea or hypothyroidism |
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Treatment of prolactinoma
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1. Bromocriptine = dopamine agonist that decreases synthesis and secretion of prolactin; long track record and safety, dosed daily
2. Cabergoline = long-acting dopamine agonist, better safety and efficacy profile; convenience of twice-weekly administration |
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What are the causes of hypopituitarism? (mnemonic: 8 "I"s)
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❏ Mnemonic: eight “I”s
• Invasive: generally primary tumours • Infarction: e.g. Sheehan’s syndrome • Infiltrative disease e.g. sarcoidosis, hemochromatosis, histiocytosis • Iatrogenic: following surgery or radiation • Infectious: e.g. syphilis, TB • Injury: severe head trauma • Immunologic: autoimmune destruction • Idiopathic: familial forms, congenital midline defects |
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In hypopituitarism, what is the sequence of hormone loss?
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A compressive adenoma in the pituitary will impair hormone production in this order (i.e. GH-secreting cells are most sensitive to compression)
Mnemonic: “Go Look For The Adenoma Please” 1. GH 2. LH 3. FSH 4. TSH 5. ACTH 6. Prolactin |
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Diagnose: pt presents with polyuria, polydipsia, hyperNa, and dilute urine
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Diabetes Insipidus (lack of ADH)
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How do you distinguish between central and nephrogenic Diabetes Insipidus.
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Do a water deprivation test:
Central DI = urine osmolality still decreased after water deprivation test, but increases with administration of dDAVP Nephrogenic DI = urine osmolality still decreased after water deprivation test and administration of dDAVP (1st line tx: HCTZ and amiloride to reduce flow to the ADH-sensitive distal nephron) |
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What are the 5 types of thyroid cancer?
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1. Papillary = most common, characterized by psammona bodies on histology (round collection of Ca), spreads via lymphatic system, good prognosis
2. Follicular = hematogenous spread, more aggressive, must do total thyroidectomy 3. Medullary = associated with MENII (look for pheochromocytoma and hyperparathyroidism=hyperCa), amyloid on histology, secrets calcitonin 4. Hurthle cell 5. Anaplastic/undifferentiated = giant cells on histology, poor prognosis |
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7 "P"s of papillary thyroid carcinoma
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PAPILLARY CANCER:
Popular (most common) Psammoma bodies Palpable lymph nodes (bc lymphatic spread) Positive Iodine131 uptake Positive prognosis Postoperative Iodine131 scan to dx/tx metastases Pulmonary metastases |
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3 "F"s of follicular thyroid carcinoma
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FOLLICULAR CANCER:
Far-away metastasis (spreads hematogenously) Female (3 to 1 ratio) Favorable prognosis |
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4 "M"s of medullary thyroid carcinoma
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MEDULLARY CANCER:
MEN II aMyloid (histology) Median lymph node dissection Modified neck dissection if lateral nodes are positive |
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Diagnose: female pt presenting with osteoporosis, central obesity, diabetes, and hirsutism
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Suspect Cushing's syndrome
Best screening test: 1 mg overnight dexa suppression test or 24h urine cortisol If dexa test abnormal, next best test is 8 mg overnight dexa suppression If suppression <50% of control = pituitary adenoma (Cushing's Disease) If no suppression = either adrenal neoplasia OR ectopic ACTH (measure plasma ACTH, chest CT if smoker, abdo CT) |
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Diagnose: pt presenting with weakness, weight loss, hypotension, hyperpigmentation, hyperK, and hypoNa
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Suspect adrenal insufficiency = main cause is Addison's Disease (autoimmune adrenal destruction)
Tx: long-term replacement of aldosterone (ie. with fluodrocortisone) and cortisol (ie. with hydrocortisone or prednisone), androgen replacement tx in women |
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Diagnose: pt involved in MVA with whip-lash presents with loss of pain and temperature sensation on neck and arms and intact sensation
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Suspect post-traumatic syringomyelia = CSF from the central spinal canal dissects into the surrounding white matter, forming a cystic cavity or syrinx
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Diagnose: pt with chronic high cholesterol presents with acute onset of flaccid paralysis below the waist, loss of pain/temp with preserved vibration of position sense
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Suspect anterior spinal artery occlusion (aka Beck's Syndrome)
-affects the spinothalamic tract (pain/temp) and corticospinaltract (motor), but not the dorsal columns (proprioception) |