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396 Cards in this Set

  • Front
  • Back
bordetella pertussis presentation in adults
usu do not have inspiratory whoop, but vomit with cough;
diagnostic clues for bordetella
leukocytosis and lymphocytosis, afebrile pt, nl CXR
3 MCC chronic cough
postnasal drip syndrome, asthma, GERD
presentation of postnasal drip syndrome
postnasal drainage, throat clearing, nasal discharge, cobblestone appearance of oropharyngeal mucosa, mucus in oropharynx
how to r/o cough-variant asthma?
methacholine challenge
tx of postnasal drip
intranasal corticosteroids and antihistamines; if cough, consider cough suppressant (eg codeine)
most sens/spec test for GERD, when used
24hr esophageal pH monitoring (only for pts who don't respond to initial acid-suppression tx)
how prevalent is cough-variant asthma among asthmatics?
most appropriate test to dx cystic fibrosis
pilocarpine iontophoresis sweat chloride test
suspect what dz in outpatient with pseudomonas postive sputum culture?
cystic fibrosis
recent URI, nasal exudate, and cobblestoning in posterior pharynx with cough -- whats the etiology of the cough?
post-nasal drip
presentation of viral vs bacterial pharyngitis (5)
bacterial infection made more likely by: 1) duration > 7d; 2) purulent nasal discharge; 3) worsening of sx after initial improvement; 4) tooth pain; 5) failure to improve with decongestants
PE findings of otitis externa
TTP of tragus, traction of pinna
tx of otitis externa
ear drops -- hydrocortisone, neomycin, polymixin; NOT oral abx
how to remove cerumen plugs that completely occlude external ear canal?
1) ceruminolygic (incl H2O2); curettes only if partial occlusion, like irrigation
causes of heterophile-negative mono
EBV! Heterophile antibody test often negative at first --> should be repeated; CMV can cause heterophile negative mono-like Sx but is more rare
what is oxymetazoline?
topical decongestant usu in nasal spray; sympathomimetic effects (like sudafed) but no systemic effects b/c only used topically
where do you get histoplasmosis?
disruption of soil / spelunking
what population most often afflicted by hantavirus?
native americans and other residents from southwest
findings in atypical mycobacterial infections
similar to TB: upper-lobe cavitary infiltrates in I/C or pts with underlying pulm dz
complications of varicella
pneumonia (in adults, esp pregnant women)
empiric tx for community-acquired pneumonia
cephalosporin/macrolide or cephalosporin/fluoroquinolone
risk factors for pseudomonas
bronchiectasis, daily corticosteroid tx, recent abx tx, malnutrition
most common organisms in pt with bronchiectasis
pseudomonas and staph aureus
empiric tx of pseudomonas
usually double coverage, eg fluoroquinolone and an aminoglycoside; alternatives include 3rd or 4th gen cephalosporin, aztreonem, others
risk factors for aspergillus pneumonia
prolonged neutropenia / other significant immunsuppression (eg HIV)
what bug suspected in pneumonia with diarrhea and mental status changes
risk factors for legionella
smoking; underlying diseases (renal failure, cancer, DM, COPD, immunsuppression from chemo); EtOH; steroids; >40yo
first step when suspecting legionella
empiric abx -- diagnostic measures have either poor sensitivity or long turnaround times
Management of exercise-induced (asthma/bronchospasm)
if severe, use prophylactic inhaled beta-2 agonist (eg albuterol) 5-10min before exercise
results of methacholine challenge testing in exercise-induced asthma
equivocal -- exercise-induced asthma not necessarily correlated with allergic asthma
classic presentation of interstitial lung disease
crackles, clubbing, chest radiograph changes
causes of interstitial lung disease
pneumoconiosis (from occupational exposures to dust, asbestos, coal mining, etc.); hypersensitivity pneumonitis (from birds, molds, etc.); medications (eg cytotoxic drugs, abx, antibiotics -- busulfan, bleomycin, amiodorone, nitrofurantoin)
defn and mgmt of mild intermittent vs mild persistent asthma
mild intermittent: <= 2 days of sx/wk, <= 2 nocturnal events / month; both treated with albuterol prn, mild persistent also tx with corticosteroid
use of ipratropium bromide in asthma control
only for acute exacerbation in emergency situation; not useful for longterm management
what to do in moderate persistent asthma if steroids are not sufficient?
add long-acting beta agonist
does myesthenia gravis better or worsen as the day progresses?
worsens (unlike lambert eaton)
vocal cord dysfunction vs asthma
difficult to distinguish; vocal cord dysfunction: not responsive to asthma tx, nl spirometry, no nocturnal sx, difficulty with INSPIRATION > EXPIRATION; Tx of vocal cord dysfunction: speech therapy
DOE with nocturnal cough suggestive of what etiology
heart failure
why don’t you always hear rales with chronic heart failure?
dilation of pulmonary lymphatics ==> no pulmonary edema at baseline
what test to rule out heart failure?
BNP: if < 100, HF unlikely
carotid upstrokes in MR vs PDA
brisk in PDA (increased stroke volume); not brisk in MR b/c decreased forward flow
changes to pulse pressure with PDA
widened b/c of diastolic runoff into pulmonary artery
risk factors for stroke in pt with afib
hx of stroke, hx of MI, hx of HTN, age > 65, DM, LAE, LV dysfunction
tx of afib
warfarin + betablocker/amiodarone
pathophys and tx of peripartum cardiomyopathy
in 3rd trimester, increased volume load --> failure (pulm edema, SOB, tachy); tx with delivery (vaginal if possible), no ARB/ACEi (teratogenic)
risk factors for peripartum cardiomyopathy
black women, multi gestations/parity, >30yo, hx
characteristics of mitral stenosis
1) opening snap; 2) diastolic rumble; 3) pre-systolic accentuation (atrial kick)
easy way to tell if pulmonary hypertension is 2/2 ASD or VSD
how to prevent influenza in a high risk pt?
vaccination + amantadine/rimantadine x 2wk (only bc high risk) for Influenza A, oseltamivir for Influ A and B
prophy for influenza B
only tx proven to prolong life in hypoxemic COPD pts
O2 (also smoking cessation, lung-volume-reduction surgery)
supplementary O2 prescribed at what PaO2?
<55, or if cor pulmonale, < 60
what causes morning headaches in COPD?
CO2 retention
indications for pulmonary rehabilitation
pts with chronic resp impairment who are dyspneic despite optimal medical management
tx of acute COPD exacerbation
bronchodilators (eg albuterol -- not most effective, but v few s/e)
effectiveness of influenza vax in preventing hospitalization of elderly for PNA / influenza
good! 30-70%
how often does elderly person at risk need to get vax for influenza/pneumococcus?
influenza: yearly; pneumococcus: once
what kind of surgeries pose greatest risk to COPD pts?
upper abdominal / thoracic surgeries
reasons to use ACEi or ARB in hypertension
1) DM; 2) renal failure (elev Cre) -- also beta-blockers; 3)
target BP in diabetics with HTN
what is characteristic of BP in hyperthyroidism?
elevated SYSTOLIC ONLY (nl diastolic)
lifestyle changes that decrease blood pressure
AEROBIC EXERCISE, also weight loss (1kg --> 1mmHg), reduced salt intake, decreased alcohol / smoking
hypertension at young age with hypokalemia
look for hyperaldosteronism by measuring serum renin:aldo ratio; alt: herbal supplements, black licorice, beta agonist inhaler
obstructive sleep apnea a/w what chronic condition?
hypertension (independent of obesity)
tx of gestational hypertension
methyldopa -- doesn't decrease risk of preeclampsia, but also does not affect neonatal outcomes
Cr changes after initiation of ACEi
slight elevation common after BP normalized (kidneys adjusting to lowered renal perfusion pressure); still, need to be vigilant due to potential occult bilateral RAS (usu see >20% inc in Cre)
antihypertension efficacy in african americans
beta blockers, ACEi, and ARBs LESS EFFECTIVE; thiazides, CCBs MORE effective (only when considering monotherapy -- no racial difference with combo therapy)
what to look for if suspect glomerulnephritis?
1) urine microscopy -- look for RBC casts and dysmorphic RBCs; 2) Serum Cre
how to approximate 24hr protein excretion?
spot urinary protein:creatinine ratio
use of alpha-blockers in hypertension
usually not a good idea -- shown by ALLHAT trial to increase risk of cardiovascular events, especially CHF
normal plasma aldo values
<10 ng/dL
plasma aldo:renin ratio in primary hyperaldosteronism
classic sites of cerebral hypertensive hemorrhages
basal ganglia, thalamus/internal capsule, pons, cerebellum
location of cerebral hypertensive hemorrhage vs amyloid angiopathy
amyloid angiopathy usu closer to cortex; hypertensive in BG, thalamus, internal capsule, pons, cerebellum
what drug given in pt with known CAD to reduce risk of MI/stroke?
statins, esp pravastatin and simvastatin
target LDL value
0-1 RF: <160; 2+ RF: <130; CAD/DM/PAD/AAA: <100, maybe <70
how to convert hba1c to average FSG
HbA1c * 33 - 86
causes of secondary hypertriglyceridemia
DM, Hypothyroidism, alcohol abuse, estrogen use
tx for hypertriglyceridemia
if secondary, treat 1' disorder; if 1', use NIACIN, fibric acid derivatives (?fibrates), or omega-3 fatty acids; also, lifestyle changes
use of bile acid sequestrants in hyperTG
contraindicated -- can actually increase TG
what TG level confers risk for pancreatitis?
>1000 (?>500)
classification of TG levels
<150: normal; 150-199: borderline; 200-499: high; >500: very high
what is total chol the sum of?
what is the non-HDL cholesterol goal?
non-HDL chol = totalchol - HDL = vLDL + LDL; non-HDL cholesterol goals are LDL goals + 30;
what risk with statin-fibrate combo?
what to do if LDL not adequately controlled on max dose statin?
add bile acid sequestrant or ezetimibe (as long as no hTG)
max dose simvastatin
criteria for metabolic syndrome
>= 3 risk factors (ABCDeFG): 1) Abdominal obesity; 4) BP > 130/85; 3) Cholesterol -- HDL<50 in women; 2) TG>150; 5) fasting glucose > 110
what drugs elevate HDL and decrease TG? Which to use with statin?
niacin and fibrates; niacin-statin preferred b/c of fibrate-statin risk of myositis
dosage of niacin
titrate up to 1500-2000 mg/d, depending on tolerance
ecg findings in pericarditis
diffuse pr depression, st elevation
mgmt of symptomatic aortic stenosis
valve replacement (3-5yr prognosis is poor)
symptoms of chronic pericarditis
dyspnea, signs of R-sided HF; no chest pain
PTCA vs CABG in diabetics
CABG shown to have better long-term mortality
which murmurs increase in intensity with valsalva?
4 causes of CP that can quickly lead to death
1) MI; 2) Aortic dissection; 3) Tension pneumothorax; 4) PE
best rapid diagnostic test for aortic dissection
when to do echo/nuclear imaging vs electrocardiography in stress testing?
if baseline ECG is abnormal, difficult to interpret ECG changes
risk of thromboembolus with cardioversion in afib? How to avoid?
if afib < 48hrs, cardioversion usu safe; else, need anticoag first; TEE if need to confirm absence of thrombus formation
common causes of pleuritis in young people
viral pleurisy; also autoimmune dzs (SLE, RA), drug-induced lupus
VQ scan vs PECT for r/o PE
according to MKSAP, VQ unless high risk pt (not sure this is still true)
which drugs have mortality benefit in CAD?
beta blockers and ACEi (independent of effects on BP and LV function)
what change in heart sounds with WPW?
paradoxically split S2
P-P interval in mobitz I
pathophys of mobitz II
usu a/w L or R BBB; dropped beat when the remaining branch suffers intermittent block
detecting MI in pt with LBBB
cannot assess ST depression in presence of LBBB ==> need to do nuclear imaging
use of class Ia antiarrythmics in pts with frequent PVCs
contraindicated -- proarrythmic effects of class Ia drugs outweighs benefit
in-hospital mortality of cardiogenic shock
most important intervention in cardiogenic shock due to acute MI
restore patency of vessel - angiography/angioplasty
what immediate intervention in acute STEMI?
angioplasty (not thrombolysis)
what does persistent ST elevation very late after acute MI indicate? (3)
1) persistent myocardial injury; 2) ventricular aneurysm formation; 3) localized MI-related pericarditis
what is isosorbide mononitrate?
venous and arterial vasodilator used to tx angina
tx of choice for preventing post-MI remodeling
ACEi (improves LV function, reduces short- and long-term mortality, reduces incidence of heart failure, reduces incidence of recurrent reinfarction)
which cardiac pts benefit most from ACEi tx?
anterior wall MI, systolic dysfunction, or clinical evidence of CHF
when do most post-MI VSDs occur?
2-7 days after infarction (same timing as post-MI papillary rupture)
acute hypotension and bradycardia in setting of acute MI -- whats the cause?
vagal reaction
which vessels usu involved in RV infarction?
right coronary artery proximal to RV marginal branch
what can cause triad of hypotension, elevated JVP, and clear lung fields?
RV infarct or tamponade
what kind of arrythmia a/w RV infarct?
bradycardia (from SA or AV node ischemia)
therapy for RV infarct
standard MI tx + volume loading, avoid diuretics/venodilators (eg nitrates), ?pacing
survival rate 24hrs after large VSD/papillary muscle rupture
25% with medical therapy
tx of post-MI VSD
nitroprusside or intra-aortic balloon pump
where does free wall rupture typically occur after MI?
at juncture of infarcted myocardium with normal myocardium; less often in ccenter of infarct
when does free wall rupture occure post MI?
1-4d, rarely up to 3wks after MI
coronary angiography before discharge for which patients?
pts with angina or residual ischemia (at rest or with exertion) after successful thrombolysis; for pts w/o angina/ischemia, stress test sufficient for discharge
what leads involved in lateral MI?
I, aVL, V5, V6
presentation of posterior MI on ecg
prominent R waves + ST depression in precordial leads, often a/w inferior MI
vtach vs vfib
arbitrary distinction based on cycle length; both are fatal if not corrected
what drugs reduce m&m in CHF pts
when to use aldosterone antagonists in CHF?
only with NYHA class III/IV sx, and already on digoxin, diuretic, ACEi, beta blocker
causes of dilated cardiomyopathy
ABCD: Alcohol, Beriberi, Chronic Cocaine, Coxsacke B, Chagas, Doxorubicin, Diphtheria
which med reduces mortality in pts with severe heart failure due to systolic fxn with sx at rest?
most useful diagnostic test in presentation of new CHF
echocardiogram -- systolic vs diastolic failure, EF, wall motion abnormalities, valves
what durg indicated for pts with reduced EF?
beta-blocker, even if no hx of MI and even if asx; ACEi also proven beneficial
when to use digoxin in HF?
only when decompensated -- improves sx but no mortality benefit
when to administer beta blockers in CHF?
only in STABLE patients (use digoxin in decompensated pts); generally, need 2-4wks of stability before starting
what renal changes suggest decreasing ACEi dose?
if greater than 30% increase in baseline Cr, or sustained elevation for 2-4 wks, OR k>5.0; transient Cr elevation expected with ACEi initiation;
what kind of cardiac hypokinesia seen in alcohol cardiomyopathy vs CAD?
alcohol: global hypokinesia; CAD: focal
how long do you have to take anticoagulation after first "provoked" PE (i.e. after a transient risk factor)? Which anticoagulant?
warfarin for 3-6mos
how much does factor V leiden (heterozygous) increase risk of thromboembolic dz?
unprovoked episode of DVT in older pts a/w increased incidence of ___________________
occult malignancy
tx for symptomatic calf vein thrombosis? Risk if this tx not performed?
tx: LMWH followed by warfarin for 3 mos; if not, 20% develop clot extension
what are the indications for placement of IVC filter?
inability to undergo therapeutic anticoagulation or clot extension at a therapeutic level of anticoagulation
what renal dz a/w venous thrombosis?
NEPHROTIC syndrome! Pathophys unkown, maybe due to renal losses of antithrombin III
thrombolytics vs anticoagulation in newly disovered PE
anticoagulation! Thrombolysis not indicated in absence of hemodynamic compromise -- too many risks
what diagnostic test to pursue if intermediate pretest probability + low probability VQ scan?
low prob VQ scan doesn't eliminate risk of PE. Need to do d-dimer to r/o DVT. If d-dimer positive (not sensitive), do LENI.
what GI source of abdominal pain is often a/w menstrual cycle?
irritible bowel syndrome
best way to confirm diagnosis of uncomplicated GERD
try acid suppressive tx
when to use upper endoscopy in GERD?
if suspect complications (warning sx: dysphagia, odynophagia, weight loss, anemia)
when to use 24-hour esophageal pH monitoring?
pts not responsive to acid-suppressive therapy, or who might have dx other than GERD
what % of gastrinomas are malignant?
most effective study for demonstrating gastrinoma? What lesions shown?
octreotide scan; shows primary lesion + any mets to liver, lymph nodes
what dz process do multiple duodenal ulcers suggest?
NSAID ulcers usually found where?
stomach, not duodenum
alcoholic ulcers generally found where?
superficial gastric mucosa, not duodenal
what alarm symptoms are you worried about with dyspepsia? What would you do if you saw them?
age>50, weight loss, anorexia, dysphagia, GI bleeding, unexplained anemia, vomiting; if seen, need to do upper endoscopy to r/o ulcer complication and malignancy
charcot's triad
for cholangitis: 1) FEVER; 2) JAUNDICE; 3) RUQ pain
mgmt of acute cholangitis?
start on broad-spectrum abx, ERCP+sphincterotomy to remove stones; no surgery -- increased morbidity/mortality
what findings diff in acute cholangitis vs cholecystitis?
cholecystitis: no jaundice, elevated transaminases and alkphos
position preferred by pts with peritoneal signs?
fetal position
what finding expected on CXR with GI perf?
air in the peritoneum (under the diaphragm)
what is gallstone ileus?
large gallstone (usu >2.5 mm) into bowel lumen (usu thru fistula) --> impaction --> obstruction (usu at ileocecal valve); usu ocurs in elderly
what can cause pneumobilia?
either patent cystic duct or fistula involving common bile duct (or s/p TIPS procedure)
what is esophageal manometry used for?
diagnosing non-caridac chest pain and suspected motility disorders (measures pressure in lower part of esophagus)
tx of suspected SBP while cultures pending?
cephalosporin or fluoroquinolone
strictures in the terminal ileum are a common complication of which disease?
Crohn's (often seen as "string sign" on small bowel rads)
what can cause a mid-esophageal stricture?
alendronate, BARRETT'S, many others
gi s/e of alendronate
mid-esophageal stricture
what to do with pt < 45yo w dyspepsia?
if no alarm sx, test for h.pylori and try PPI; if alarm sx present, upper endoscopy needs to be done quickly to r/o malignancy [alarm sx include anemia, anorexia, dysphagia, vomiting, bleeding, wt loss]
typical features of henoch-schonlein purpura
HAAP: hematuria, arthritis, abdominal pain, purpura on lower extremities and IgA deposition
complement levels in henoch-schonlein purpura
normal (no immune complexes?, unlike SLE/post-strep GN)
what is the universal plasma donor type (A/B/AB/O)
AB (no antibodies in plasma)
whole blood vs FFP for coagulopathy?
FFP; whole blood loses labile factors during storage
electrolyte disturbance in bulemic patients
hypochloremia, hypokalemia
MCC acute lower GI bleed
DIVERTICULOSIS, neoplasm, vascular malformations
biggest concern in postmenopausal woman with Fe defic anemia
colorectal cancer
what diagnostic procedure if concerned about upper GI bleed?
upper endoscopy -- NOT upper GI series (not sensitive enough, can't be used to administer tx)
what does bile on nasogastric aspirate tell you?
that you're past the pylorus ==> if no blood, then upper GI bleed unlikely
which vessels most commonly involved in pancreatitis-induced pseudoaneurysm
splenic artery, gastroduodenal, pancreaticoduodenal
pseudoaneurysms and pancreatitis
pseudoaneurysms can form from autodigestion of arterial walls by elastase and pancreatic enzymes (10% of pts with acute pancreatitis)
risk of pancreatic pseudoaneurysm? Tx?
rupture --> life-threatening hemorrhage --> 50% mortality; tx early with transarterial embolization
main cause of upper GI bleed in pt with hepatitis? How to confirm?
variceal bleed -- confirm with endoscopy
when to use TIPS procedure?
only when medical therapy and tx of symptoms (eg banding of varices) has failed; major complication risk including infection, encephalopathy, and liver failure -- require transplant
when to do colonoscopy with minimal BRBPR?
AGE > 50; if h/o melena, DRBPR, or orthostatics, do UPPER GI first, THEN colonoscopy; if suspicion of malignancy, fecal occult blood positive stools (doesn't happen with hemorrhoids), Fhx of polyposis / HNPCC, pts without colonoscopy after BRBPR who dev new sx or change in bowel habits)
how much blood volume lost if orthostatics correctible by IVF alone?
when to use angiography in hematochezia? What are the advantages?
only useful if high blood flow (0.5mL/min), but allows for embolization of vessel
What gene is deficient in hemochromatosis?
When can hemochromatosis be treated, and how?
Before cirrhosis: with phlebotomy (after cirrhosis, phlebotomy doesn’t decrease risk of HCC)
What does hemochromatosis cause? (5)
Bronze skin, diabetes, cirrhosis, arthritis, heart failure
What is the diagnostic test for hemochromatosis?
Liver biopsy
How to test for hep A?
Look for IgM against Hep A
What is the sensitivity of Hep C Ab?
Very poor (40% have negative results) ==> need to test for HCV RNA
How to test for hep C?
Hep C viral load -- look for HCV RNA (not Ab test b/c of poor sensitivity)
Classic demographics for PBC
middle-aged female
Screening test for PBC?
AMA (anti-mitochondrial antibody)
What does IgG to HAV suggest?
old infection / immunity
when does HELLP syndrome occur?
3rd trimester of pregnancy
both have MAHA and thrombocytopenia; HUS has renal failure; TTP is +/- fever, MS changes, and renal failure
definition of fulminant hepatic failure
encephalopathy within 8 wks of liver injury
treatment of fulminant hepatic failure
transplant b/c of very high mortality rate
alcoholic hep vs acetaminophen tox (2)
EtOH: moderately elevated AST/ALT (<500), FEVER
what is gilbert's syndrome?
congenital unconjugated hyperbilirubinemia found in 5% of the population
lab findings in PBC
cholestatic picture -- elevated AlkPhos and maybe bili
how do you calculate globulin level?
total serum protein minus albumin
what liver dz a/w elevated globulins?
mgmt of NASH
wt loss
primary w/u of labs showing cholestatic picture?
RUQ u/s
secondary w/u of labs showing cholestatic picture?
depends on RUQ u/s findings: if biliary dilitation, ERCP/MRCP; if evidence of infiltrative liver dz, liver biopsy
Recommended kCal deficit for weight loss
-500 to -1000 kCal/day ==> 1-2lb loss/wk
what drugs for wt loss? When to use them?
orlistat and silbutramine: only used in pts refractory to diet/exercise, and only serve as temporary measure (wt comes back once drugs d/c'ed)
aphthous ulcers are a/w what GI pathology?
what is a major non-neoplastic cause of hyperprolcatinemia?
hypothyroidism (TRH stims both TSH and prolactin release)
lab findings in primary vs secondary hyperprolactinema
secondary has lower levels of prolactin production (<200ng/ml)
test to dx cushing's dz
24hr urinary free cortisol
risk factors for esophageal carcinoma
white male, long-standing GERD, barrett's esophagus
what condition generaly necessary for infectious esophagitis
immunocompromise (eg CMV esophagitis in AIDS)
MCC relapse of sx in mgmt of Celiac dz?
dietary incompliance with gluten-free diet
anti-tissue trasnglutaminase used to dx which dz?
celiac dz
villous blunting a/w? (3)
tx of tropical sprue
folic acid + tetracycline
tests for bacterial overgrowth (2)
glucose hydrogen breath test, OR lactulose hydrogen breath test
IBS not a/w what common GI sx?
weight loss
usual location of primary anal fissure
posterior, midline; anything else suggestive of 2ndary cause, esp Crohn's (66% posterior midline, but 33% not)
Mechanism of hydroxyurea
ribonucleotide reductase inhibitor --> increased HbF
risks of hydroxyurea
mild! Can cause reversible myelosuppression, increased risk of AML in pts with polycythemia vera
lethal late complication seen in hodgkin's dz survivors treated with multimodal tx (pancytopenia): what is it and when does it occur?
secondary myelodysplastic syndrome, usually 3-11 yrs after tx
viral cause of anemia in immunocompromised pts?
parovirus b19 (reticulpenia)
dx of parvovirus anemia
parvovirus DNA in blood/marrow, detected via PCR
tx of parvovirus anemia
IV Ig containing anti-parvoviral IgG
Tx of choice for aplastic anemia? Which pts? Survival?
allogenic SCT; pts < 50yo with HLA-matched siblings; survival 75-90%
tx of chemo-induced anemia
weekly EPO
what does increased ferritin and decreased Fe levels in anemic pts with chronic inflam dz (eg RA) suggest?
Fe deficiency OR ACD: Although labs c/w ACD, could also be Fe deficiency since ferritin is an acute phase reactant
what does elevated HbA2 (alpha2delta2) suggest?
B-thal (trait)
lab findings in alpha-thal vs beta-thal
beta-thal: elevated HbA2 (alpha2delta2)
epi of myelodysplastic syndromes
MCV in myelodysplastic syndromes
increased total protein and decreased albumin levels suggests what with bone pathology?
elevated globulins -- multiple myeloma
hypercalcemia + anemia --> ?
?multiple myeloma (look for renal dysfunction)
nucleated RBCs seen when?
1) Hematologic causes (sickle cell, thal); 2) Marrow infiltrates (myelofibrosis, mets to bone)
Rate of relapse with advanced-stage (II-IV) NHL?
findings concerning for breast cancer
bloody nipple discharge, overlying skin changes, lump characterized as rock-hard/fixed/irregular-surface, spiculated calcifications on mammogram
false negative rat of mammography
premenopause: 25%; post-menopause: 10%
management of palpable breast mass
if no concerning features, watch for 1 menstrual cycle; if persistent or concerning features, FNA, follow until resolution or definitive diagnosis
definition of erythroplakia
velvety, red mucosal abnormality -- can be carcinoma in situ or frank carcinoma
management of erythroplakia
if persists > 1month, biopsy;
tx of metastatic prostate cancer
androgen ablation (blockade)
1st tx of h.pylori associated MALT lymphoma
eradicate h.pylori --> 50% complete remission! If no remission in 1 yr, try chemo
big picture requirement for palliative chemotherapy
adequate performance status
use of PSA in prostate Ca diagnosis
inappropriate -- 25% pts going to surgery have normal PSA
total vs free PSA in prostate cancer vs BPH
prostate Ca generally a/w lower free:total PSA ratio
management of discrete localized firm region in DRE
biopsy of prostate
left testicular varicocele that doesn't subside when supine
probably due to obstruction of venous outflow -- look for RCC
preferred imaging modality for testes
lab findings in seminoma vs nonseminomatous testicular cancer (vs malignant lymphoma)
seminoma: elev HCG; nonseminomatous: elev HCG+AFP; malig lymphoma: neither (occurs in old men)
tx of limited-stage small cell lung cancer
chemo! Not surgical resection b/c almost all SCLC a/w micrometasteses
tx of metastatic colon cancer
systemic chemo (if performance status allows) -- 5-FU; non-curative, therefore comfort measures only also an option
when to resect primary tumor in metastatic colon cancer?
only if symptomatic -- obstruction or bleeding
female with adenocarcimona and diffuse pertional involvement -- MCC
ovarian cancer
tx of breast cancer
mastectomy only if multifocal/multicentric or margins not obtainable with wide excisions; otherwise, breast-conserving surgery + XRT +/- chemo
role of tamoxifen in breast cancer with axillary lymph nodes
diagnostic step with new supraclavicular node + night sweats
FNA of new lymphadenopathy for diagnosis?
no -- not enough tissue for histologic/immunologic/genetic analysis
usual approach to new lymphadenopathy in a young person
watch and wait -- in young person, LAD usu benign
back pain + retrocardiac density on CXR suggests ______
descending aortic aneurysm
how to dx thoracic aortic aneurysm
helical CT w/ contrast, esp if ?rupture
what to do if CT w/ contrast contraindicated by renal insufficiency?
MRI with gadolinium (not nephrotoxic)
tx of thoracic aortic aneurysm + pain
surgery! (pain = bad; if no pain, beta blockers first to stabilize, then mgmt based on location of aneurysm)
location of pain with spinal cord compression
either radicular or localized to spine
what to do if suspect spinal cord compression (low back pain with known malignancy / osteoarthritis)
MRI -- can progress to myelopathy over weeks w/o tx, so can't afford to wait and watch
defn of cauda equina syndrome
low back pain, unilateral or usu bilateral sciatica, saddle sensory disturbances, bladder/bowel dysfunction, and variable LE motor/sensory loss
tx of sciatica
in absence of cauda equina syndrome, bed rest + NSAIDs is sufficient
cause of back pain worsened by coughing/sneezing
herniated disk
what findings suggest inflammatory source of back pain?
worse in morning, improves with activity, elev ESR, elev CRP
DIP joint involvement (2)
classically OA; also in psoriatic arthritis (red, warm, tender) -- ask abt back pain
what is c1-c2 subluxation?
partial dislocation of C1-C2 (atlantoaxial) joint; a/w neurologic sx including UE weakness, hypertonia, and paresthesias; often a/w RA
what risk a/w joints that have been replaced b/c of RA? What should you do?
INFECTION! (RA flares are relatively rare) --> joint aspiration --> Cx, gram stain, cell count
oligoarticular inflammatory arthritis following enteric infection
reactive (reiter's) arithritis (shigella, salmonella, campylobacter, yersinia, c.dif)
clinical course of chlamydial vs enteric reactive arthritis
chlamydial more likely to have recurrent/chronic dz
usefulness of aspirating synovial fluid from asymptomatic joint in ?gout/pseudogout
very high! Chance of finding crystals > 80%
diagnostic test with joint effusion
aspiration of synovial fluid
causes of bloody synovial fluid (4)
coagulopathy, trauma, tumor, Charcot's joint
first step in mgmt of pt with acute joint pain, physical immobility, and warmth
aspiration of synovial fluid -- must not miss infectious cause (esp in setting of underlying joint pathology, eg RA)
what dz a/w pain in ankles and LE + perisoteal new bone formation on radiograph?
hypertrophic osteoarthropathy
what is charcot joint (aka neuropathic joint)?
progressive joint degeneration caused by loss of proprioception --> gradual destruction by repeated subliminal injury, often seen in diabetcs / tabes dorsalis neuropathy
pathognomonic finding in hypertrophic osteoarthropathy
relief from elevation of extremities above head
what is hypertrophic osteoarthropathy a/w?
neoplasm (pulmonary, GI, lymphoma) and infection; MUST R/O LUNG CANCER (CXR --> ?CT); also a/w chronic hypoxic states (often see clubbing)
indication for total knee replacement in pt with osteoarthritis
pain + limitation of fxn --> interference with enjoyment of life
causes and dx of "locking" knee
mechanical injury, eg torn meniscus; arthroscopy is both diagnostic and therapeutic
role of menstrual cycle in disseminated gonococcal infection
more vulnerable during menses and pregnancy
initial tx of disseminated gonococcal infection, and why?
ceftriaxone until sens/spec known! (PCN-resistance is common)
location of parvovirus b19 rash in adults
macular rash anywhere! (not just slapped cheek as in kids)
other sx a/w parvovirus b19
arthritis (acute, symmetrical) usu improving after 2wks with lingering arthrlagias
what could be the cause of diffuse knee pain without morning stiffness and with a completely normal knee exam?
hip pain! ==> do hip exam (ROM, pain, etc.) followed by radiographs
what rheumatic pathology can mimic a DVT? What diagnostic step?
ruptured Baker's (popliteal) cyst; do u/s of calf
what clinical sx of rotator subacromial bursitis (aka cuff tenodinitis)?
tenderness over supraspinatus tendon, nocturnal pain, pain on abduction > 40degrees
tx of rotator subacromial bursitis
injection of corticosteroids + PT to regain fxn
when are radiographs indicated in shoulder pain?
if history c/w OA
PE in true arthritis vs bursitis
TRUE ARTHRITIS/SYNOVITIS: painful limitation of ROM in active AND passive motion; BURSITIS: no limitation of passive motion
tx of De Quervain's tenosynovitis
corticosteroid injection into tendon sheath
Tinel sign of carpal tunnel syndrome
distally radiating pain or paresthesias caused by tapping over site of superficial nerve
what is deQuervain's tenosynovitis?
inflammation of tendons at base of thumb, caused by stress (lifting heavy items)
what is cubital tunnel syndrome?
compression of ulnar nerve as it passes through cubital tunnel at medial elbow
medial epicondylitis vs cubital tunnel syndrome
medial epicondylitis: pain localized to medial elbow w/o radiation to hand, exacerbated by use of forearm/wrist; cubital tunnel syndrome: nerve compression --> paresthesias, weakness, numbness of 4th and 5th digits
effects of c7 radiculopathy
most common cervical radiculopathy -- sensory changes in digits 2-4, motor weakness of triceps, forearm pronation, wrist flexion/extension
medical conditions a/w carpal tunnel syndrome
DM, thyroid dz, obesity
clinical course of fibromyalgia and treatment options
progressive, no direct treatment, use behavioral therapy and supportive pharamcotherapy
"snapping" of hip with walking
iliotibial band syndrome
hip pain with walking and not at rest suggests
most common non-compressive cause of right upper lumbar radiculopathy
what is diabetic amyotrophy?
a type of diabetic neuropathy seen in elderly: u/l or b/l anterior thigh pain, weakness, atrophy
what is restless leg syndrome?
uncontrollable urge to move limbs to stop uncomfortable/odd sensations (usu also in legs) -- moving affected body part provides temporary relief; 4 criteria: 1) urge to move limbs +/- sensations; 2) worse with rest; 3) improve with activity; 4) worse in evening/night
what medical conditions a/w restless leg syndrome?
fe deficiency (20%), many others
tx of restless leg syndrome
dopanine antagonists or gabapentin
what does joint crepitus suggest?
degenerative or mechanical joint disease
maneuver to dx anserine bursitis
pain on medial aspect of knee, focal tenderness over anserine bursa (2inches below joint line)
tx of anserine bursitis
corticosteroid injection, isometric exercises, weight reduction
screening test for osteoporosis
dual-energy x-ray absorptiometry
sensitivity of standard radiographs for osteoporosis
not good -- only consistently demonstrate significant demineralization once 30-40% bone mineral has been lost
defn of osteoporosis vs osteopenia based on DXA (dual-energy xray absorptiometry) test
>2.5 std devs below "young normal" (t score < -2.5) = OSTEOPOROSIS; t-score in (-1, -2.5) = OSTEOPENIA; t-score > -1.0 = NORMAL (within 1 std dev of nl)
what is teriparatide?
recombinant PTH (stimulates bone deposition --> increased bone mass ==> used to tx osteoporosis)
how do most osteoporosis treatments work?
inhibiting osteoclastic resorption (bisphosphonates, estrogens, raloxifene, calcitonin); teriparatide is unique in stimulating bone deposition (recombinant PTH)
best imaging for suspected renal stones
NONCONTRAST CT -- can detect both radiolucent and radio-opaque stones in ureters or kidneys, as well as hydronephrosis (u/s also good for renal stones, but can't see ureteral stones)
mgmt of recurrent UTIs
symptom-initiated (by patient) fluoroquinolones (more and more organisms becoming resistant to bactrim)
how to treat asymptomatic hyponatremia asociated with SCLC?
chemo! Not fluid restriction / other tx of hyponatremia
most common metabolic complication of malignancy
appropriate respiratory compensation in metabolic alkalosis
10mmHg increase for every 14 inc in HCO3-
hypomagnesemia, hypokalemia, hypocalcemia: which one explains the others?
HYPOMAGNESEMIA: if < 1.0, induces renal potassium wasting and suppression of PTH secretion and peripheral effects
risk factors for calcium nephrolithiasis (PO)
low daily fluid intake, high dieteray sodium and oxalate, high animal protein intake
what diet decreases risk of calcium stones?
high dietary calcium intake! (maybe b/c calcium binds oxalate and lessens oxalate reabsorption) ==> mg also useful
winter's formula for resp compensation in metab acidosis
PCO2 = 1.5 * HCO3- + 8 +/- 2
how to use delta-delta in AG metab acidosis
calculate anion gap, calculate drop in HCO3; if equal (or close, ratio 1-2), no concomitant pathology; if >1-2, concomitant metab alkalosis; if < 1, concomitant non-AG metab acidosis
what is hyporeninemic hypoaldosteronism
hyperkalemia seen in 20-30% diabetic pts
what causes decreased anion gap?
unmeasured cation or decreased albumin; cations include Ca, Mg, Lithium, or positively charged paraprotein (eg myeloma --> can cause RTA)
lab findings in SIADH
nl K, low BUN, Cr, and serum Uric Acid
why would you get mixed resp+metab alkalosis with kidney stone?
tachypnea --> resp alkalosis; vomiting --> metab alkalosis
24-hr urinary findings in primary hyperaldosteronism
k > 30meq, serum k < 3.0
ethanol vs isopropyl alcohol vs methanol role in metabolic acidosis
only methanol a/w AG metabolic acidosis
how to calc osmolar gap?
2*Na + BUN/2.8 + gluc/18 - S_osm[measured]; should be < 10, else ?unmeasured osmotic substance active in serum
hypokalemia, metabolic acidosis, and inappropriately alkaline urine suggests what dz? What is a possible complication?
distal renal tubular acidosis -- can result in nephrolithiasis
acid-base disorder in seizure
usu lactic acidosis, reverses with cessation of seizure -- no intervention necessary
cause of hyponatremia in cirrhosis
splanchnic vasodilation --> decreased effective circulating volume --> nonosmotic stimulation of ADH
what is pseudohyponatremia?
LAB ARTIFICAT which looks like low serum sodium [] due to volume displacement by very high protein or lipids (also refers to low sodium seen in high glucose)
MCC mild hypercalcemia + osteoporosis of hip, and mgmt
primary hyperthyroidism ==> parathyroidectomy
what risk with post-menopausal estrogen therapy for osteoporosis?
inc risk of breast cancer and CV dz
labs in pitutary vs adrenal source of adrenal insufficiency (secondary vs primary)
don't see hyperkalemia in pituitary insufficiency
MCC adrenal insufficiency
Addison's (autoimmune adrenalitis)
how to correct calcium for albumin?
add 0.8 to Ca for every 1g/L reduction in albumin below 4
effect of large-volume blood transfusions on calcium
decrease serum calcium (as well as ionized calcium) by complexing with citrate
how to estimate renal function?
creatinine-based formulae (not serum creatinine alone!)
timing of AIN 2/2 tx with TMP-SMX
severla days after treatment, a/w eos in urine, fever, and rash
effect of TMP and other organic cations (like cimetidine) on creatinine
competitively inhibitt creatinine secretion in the distal tubule --> creatinine bump
when to use radioisotope renal scan?
to evaluate asymmetric blood flow when renal artery disease suspected
new renal insufficiency with pyuria after tx with antibiotics
what renal pathology a/w indinavir?
indinavir crystal nephrolithiasis
what electrolyte abnormality can cause renal failure? How?
hypercalcemia -- interferes with renal concentrating function and leads to volume depletion, deposits in the renal parenchyma causing fibrosis, and causes afferent arteriolar constriction --> drop in GFR
common cause of renal failure in HIV pts? Tx?
TTP; tx with plasma exchange, +/- concurrent antiretrovial tx; can also have classic HIV nephropathy usu a/w significant proteinuria
decreased anion gap + anemia + proteinuria + hypercalcemia + ARF
multiple myeloma
hypercalcemia + acute renal failure
multiple myeloma (rare otherwise, b/c hyperphosphatemia and decreased renal VitD synth ==> hypocalcemia)
what is milk-alkali syndrome?
hypercalcemia caused by ingestion of calcium and alkali (eg calcium carbonate for peptic ulcers) ==> metastatic calcification and renal failure
incidence of depression among elderly who lose a spouse
15-35% in first year
what is megestrol acetate and what is it used for?
synthetic progestin used an an appetite stimulant in cancer pts w/ cachexia
which antidepressants classically a/w weight gain?
TCAs and mirtazapine (SSRIs have variable effect, fluoxetine causes the least wt gain)
which antidepressant NOT a/w weight gain
bupropion (maybe even weight loss!)
which antidepressants safe in pregnancy?
SSRIs, probably TCAs as well
common cause of recurrent depression in elderly
noncompliance with meds (rates as high as 50%)
dementia vs mild cognitive impairment
dementia requires chronic memory impairment and impairment of other aspects of intellect severe enough to affect social or occupational functioning
how to dx carotid sinus syncope?
carotid sinus massage while checking pulse, look for asystole > 3sec or >50 pt decrease in SBP
empirical tx for pneumococcal meningitis
vanc + ceftriaxone (not vanc alone because of unreliable CSF penetration)
tx of suspected HSV encephalitis
IV acyclovir (even before confirmation of diagnosis)
what adjunct tx needed when giving antimicrobials for meningitis? Which bugs?
corticosteroids (eg dexamethasone) to prevent inflammation from microbe lysis; esp useful with HIB and pneumococcal meningitis
listeria found in what foods? (2)
processed meats and coleslaw
tx of choice for listeria meningitis
amp/pcn + aminoglycoside (ie amp-gent or pcn-gent)
TPA in acute ischemic stroke
only within 3 hrs
corticosteroids in ischemic stroke
can be HARMFUL; only used for vasogenic edema from mass lesions (eg tumors)
IV heparin in pts with acute ischemic stroke
not necessarily indicated (although used often) -- can increase risk of hemorrhagic transformation of infarction
what is vegetatitve state?
complete unawareness of self/environment, preservation of sleep/wake cycles, brainstem, and hypothalamic autonomic functions
defn of persistent vegetative state
veg state 1mo after brain injury
vegetative state vs brain death
brain death = complete absence of cerebral hemispheric and brainstem function (incl resp drive)
aura seen with what type of seizure? Most common sensation?
(complex) partial seizures; aura often consists of rising epigastric sensation; other auras include affective (eg fear), cognitive (eg déjà vu), and sensory (eg olfactory hallucinations)
what does a complex partial seizure look like?
lasts < 3mins, pt appears awake but loses contact w environment / doesn’t respond normally. Pts stare, remain motionless, or engage in repetitive, semi-purposeful behavior (automatisms)
what population most commonly gets absence seizures?
non-seizure condition with two or three tonic-clonic jerks
seen with hypoxia to the brain, as in vasovagal syncope
mgmt of symptomatic, intermittent complete heart block
what drug decrease frequency of relapse in alcohol abuse?
which benzos preferred to manage alcohol withdrawal?
long-acting (eg diazepam) to minimize risk of seizures and delirium
criteria for at-risk (heavy) alcohol use
>14drinks/wk for men, >7drinks/wk for women, w/o evidence of abuse or dependence
pts with cocaine-related hemorrhagic stroke must be evaluated for what?
cerebral AVM; though cocaine-induced HTN could alone cause hemorrhage, if no h/o chronic HTN, likelihood of underlying AVM is high ==> need cerebral angiography
initial tx for cocaine intox (3)
1) sedation with lorazepam (IV or IM); 2) IVF to ensure adequate UOP for possible rhabdomyolisis; 3) EKG to assess for myocardial ischemia
recommended tx for drug-induced seizures
benzos (NOT phenytoin! -- poor response)
s/e of anabolic steroid abuse
acne, decreased HDL, elevated platelet counts + increased platelet aggregability --> hypercoagulability, libido changes, aggression/rage, testicular atrophy / female virilization
gynecomastia is a s/e of what recreational drug?
recreational drugs that can cause panic reactions (3)
marijuana, cocaine, amphetamines
how to manage tachycardia in cocaine tox?
benzos: decrease anxiety, heart rate, and blood pressure; no need for antihypertensive; beta-blockers esp bad because they can unmask alpha-adrenergic effects of cocaine --> inc BP
in what patients is bupropion contraindicated?
pts with past or current seizure disorder (bupropion lowers seizure threshold)
effects of smoking cessation on lung function
decreased rate of decline of lung function, plus slight IMPROVEMENT in lung function