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396 Cards in this Set
- Front
- Back
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bordetella pertussis presentation in adults
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usu do not have inspiratory whoop, but vomit with cough;
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diagnostic clues for bordetella
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leukocytosis and lymphocytosis, afebrile pt, nl CXR
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3 MCC chronic cough
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postnasal drip syndrome, asthma, GERD
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presentation of postnasal drip syndrome
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postnasal drainage, throat clearing, nasal discharge, cobblestone appearance of oropharyngeal mucosa, mucus in oropharynx
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how to r/o cough-variant asthma?
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methacholine challenge
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tx of postnasal drip
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intranasal corticosteroids and antihistamines; if cough, consider cough suppressant (eg codeine)
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most sens/spec test for GERD, when used
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24hr esophageal pH monitoring (only for pts who don't respond to initial acid-suppression tx)
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how prevalent is cough-variant asthma among asthmatics?
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57%
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most appropriate test to dx cystic fibrosis
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pilocarpine iontophoresis sweat chloride test
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suspect what dz in outpatient with pseudomonas postive sputum culture?
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cystic fibrosis
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recent URI, nasal exudate, and cobblestoning in posterior pharynx with cough -- whats the etiology of the cough?
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post-nasal drip
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presentation of viral vs bacterial pharyngitis (5)
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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
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PE findings of otitis externa
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TTP of tragus, traction of pinna
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tx of otitis externa
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ear drops -- hydrocortisone, neomycin, polymixin; NOT oral abx
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how to remove cerumen plugs that completely occlude external ear canal?
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1) ceruminolygic (incl H2O2); curettes only if partial occlusion, like irrigation
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causes of heterophile-negative mono
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EBV! Heterophile antibody test often negative at first --> should be repeated; CMV can cause heterophile negative mono-like Sx but is more rare
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what is oxymetazoline?
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topical decongestant usu in nasal spray; sympathomimetic effects (like sudafed) but no systemic effects b/c only used topically
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where do you get histoplasmosis?
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disruption of soil / spelunking
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what population most often afflicted by hantavirus?
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native americans and other residents from southwest
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findings in atypical mycobacterial infections
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similar to TB: upper-lobe cavitary infiltrates in I/C or pts with underlying pulm dz
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complications of varicella
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pneumonia (in adults, esp pregnant women)
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empiric tx for community-acquired pneumonia
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cephalosporin/macrolide or cephalosporin/fluoroquinolone
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risk factors for pseudomonas
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bronchiectasis, daily corticosteroid tx, recent abx tx, malnutrition
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most common organisms in pt with bronchiectasis
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pseudomonas and staph aureus
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empiric tx of pseudomonas
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usually double coverage, eg fluoroquinolone and an aminoglycoside; alternatives include 3rd or 4th gen cephalosporin, aztreonem, others
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risk factors for aspergillus pneumonia
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prolonged neutropenia / other significant immunsuppression (eg HIV)
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what bug suspected in pneumonia with diarrhea and mental status changes
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legionella
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risk factors for legionella
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smoking; underlying diseases (renal failure, cancer, DM, COPD, immunsuppression from chemo); EtOH; steroids; >40yo
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first step when suspecting legionella
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empiric abx -- diagnostic measures have either poor sensitivity or long turnaround times
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Management of exercise-induced (asthma/bronchospasm)
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if severe, use prophylactic inhaled beta-2 agonist (eg albuterol) 5-10min before exercise
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results of methacholine challenge testing in exercise-induced asthma
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equivocal -- exercise-induced asthma not necessarily correlated with allergic asthma
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classic presentation of interstitial lung disease
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crackles, clubbing, chest radiograph changes
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causes of interstitial lung disease
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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)
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defn and mgmt of mild intermittent vs mild persistent asthma
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mild intermittent: <= 2 days of sx/wk, <= 2 nocturnal events / month; both treated with albuterol prn, mild persistent also tx with corticosteroid
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use of ipratropium bromide in asthma control
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only for acute exacerbation in emergency situation; not useful for longterm management
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what to do in moderate persistent asthma if steroids are not sufficient?
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add long-acting beta agonist
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does myesthenia gravis better or worsen as the day progresses?
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worsens (unlike lambert eaton)
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vocal cord dysfunction vs asthma
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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
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DOE with nocturnal cough suggestive of what etiology
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heart failure
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why don’t you always hear rales with chronic heart failure?
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dilation of pulmonary lymphatics ==> no pulmonary edema at baseline
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what test to rule out heart failure?
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BNP: if < 100, HF unlikely
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carotid upstrokes in MR vs PDA
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brisk in PDA (increased stroke volume); not brisk in MR b/c decreased forward flow
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changes to pulse pressure with PDA
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widened b/c of diastolic runoff into pulmonary artery
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risk factors for stroke in pt with afib
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hx of stroke, hx of MI, hx of HTN, age > 65, DM, LAE, LV dysfunction
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tx of afib
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warfarin + betablocker/amiodarone
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pathophys and tx of peripartum cardiomyopathy
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in 3rd trimester, increased volume load --> failure (pulm edema, SOB, tachy); tx with delivery (vaginal if possible), no ARB/ACEi (teratogenic)
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risk factors for peripartum cardiomyopathy
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black women, multi gestations/parity, >30yo, hx
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characteristics of mitral stenosis
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1) opening snap; 2) diastolic rumble; 3) pre-systolic accentuation (atrial kick)
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easy way to tell if pulmonary hypertension is 2/2 ASD or VSD
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cyanosis
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how to prevent influenza in a high risk pt?
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vaccination + amantadine/rimantadine x 2wk (only bc high risk) for Influenza A, oseltamivir for Influ A and B
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prophy for influenza B
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oseltamivir
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only tx proven to prolong life in hypoxemic COPD pts
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O2 (also smoking cessation, lung-volume-reduction surgery)
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supplementary O2 prescribed at what PaO2?
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<55, or if cor pulmonale, < 60
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what causes morning headaches in COPD?
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CO2 retention
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indications for pulmonary rehabilitation
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pts with chronic resp impairment who are dyspneic despite optimal medical management
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tx of acute COPD exacerbation
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bronchodilators (eg albuterol -- not most effective, but v few s/e)
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effectiveness of influenza vax in preventing hospitalization of elderly for PNA / influenza
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good! 30-70%
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how often does elderly person at risk need to get vax for influenza/pneumococcus?
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influenza: yearly; pneumococcus: once
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what kind of surgeries pose greatest risk to COPD pts?
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upper abdominal / thoracic surgeries
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reasons to use ACEi or ARB in hypertension
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1) DM; 2) renal failure (elev Cre) -- also beta-blockers; 3)
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target BP in diabetics with HTN
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135/80
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what is characteristic of BP in hyperthyroidism?
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elevated SYSTOLIC ONLY (nl diastolic)
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lifestyle changes that decrease blood pressure
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AEROBIC EXERCISE, also weight loss (1kg --> 1mmHg), reduced salt intake, decreased alcohol / smoking
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hypertension at young age with hypokalemia
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look for hyperaldosteronism by measuring serum renin:aldo ratio; alt: herbal supplements, black licorice, beta agonist inhaler
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obstructive sleep apnea a/w what chronic condition?
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hypertension (independent of obesity)
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tx of gestational hypertension
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methyldopa -- doesn't decrease risk of preeclampsia, but also does not affect neonatal outcomes
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Cr changes after initiation of ACEi
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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)
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antihypertension efficacy in african americans
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beta blockers, ACEi, and ARBs LESS EFFECTIVE; thiazides, CCBs MORE effective (only when considering monotherapy -- no racial difference with combo therapy)
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what to look for if suspect glomerulnephritis?
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1) urine microscopy -- look for RBC casts and dysmorphic RBCs; 2) Serum Cre
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how to approximate 24hr protein excretion?
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spot urinary protein:creatinine ratio
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use of alpha-blockers in hypertension
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usually not a good idea -- shown by ALLHAT trial to increase risk of cardiovascular events, especially CHF
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normal plasma aldo values
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<10 ng/dL
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plasma aldo:renin ratio in primary hyperaldosteronism
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>20-25
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classic sites of cerebral hypertensive hemorrhages
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basal ganglia, thalamus/internal capsule, pons, cerebellum
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location of cerebral hypertensive hemorrhage vs amyloid angiopathy
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amyloid angiopathy usu closer to cortex; hypertensive in BG, thalamus, internal capsule, pons, cerebellum
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what drug given in pt with known CAD to reduce risk of MI/stroke?
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statins, esp pravastatin and simvastatin
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target LDL value
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0-1 RF: <160; 2+ RF: <130; CAD/DM/PAD/AAA: <100, maybe <70
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how to convert hba1c to average FSG
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HbA1c * 33 - 86
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causes of secondary hypertriglyceridemia
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DM, Hypothyroidism, alcohol abuse, estrogen use
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tx for hypertriglyceridemia
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if secondary, treat 1' disorder; if 1', use NIACIN, fibric acid derivatives (?fibrates), or omega-3 fatty acids; also, lifestyle changes
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use of bile acid sequestrants in hyperTG
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contraindicated -- can actually increase TG
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what TG level confers risk for pancreatitis?
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>1000 (?>500)
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classification of TG levels
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<150: normal; 150-199: borderline; 200-499: high; >500: very high
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what is total chol the sum of?
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LDL + HDL + vLDL
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what is the non-HDL cholesterol goal?
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non-HDL chol = totalchol - HDL = vLDL + LDL; non-HDL cholesterol goals are LDL goals + 30;
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what risk with statin-fibrate combo?
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myositis
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what to do if LDL not adequately controlled on max dose statin?
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add bile acid sequestrant or ezetimibe (as long as no hTG)
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max dose simvastatin
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40mg/d
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criteria for metabolic syndrome
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>= 3 risk factors (ABCDeFG): 1) Abdominal obesity; 4) BP > 130/85; 3) Cholesterol -- HDL<50 in women; 2) TG>150; 5) fasting glucose > 110
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what drugs elevate HDL and decrease TG? Which to use with statin?
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niacin and fibrates; niacin-statin preferred b/c of fibrate-statin risk of myositis
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dosage of niacin
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titrate up to 1500-2000 mg/d, depending on tolerance
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ecg findings in pericarditis
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diffuse pr depression, st elevation
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mgmt of symptomatic aortic stenosis
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valve replacement (3-5yr prognosis is poor)
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symptoms of chronic pericarditis
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dyspnea, signs of R-sided HF; no chest pain
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PTCA vs CABG in diabetics
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CABG shown to have better long-term mortality
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which murmurs increase in intensity with valsalva?
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MVP and HOCM
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4 causes of CP that can quickly lead to death
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1) MI; 2) Aortic dissection; 3) Tension pneumothorax; 4) PE
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best rapid diagnostic test for aortic dissection
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TEE
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when to do echo/nuclear imaging vs electrocardiography in stress testing?
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if baseline ECG is abnormal, difficult to interpret ECG changes
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risk of thromboembolus with cardioversion in afib? How to avoid?
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if afib < 48hrs, cardioversion usu safe; else, need anticoag first; TEE if need to confirm absence of thrombus formation
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common causes of pleuritis in young people
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viral pleurisy; also autoimmune dzs (SLE, RA), drug-induced lupus
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VQ scan vs PECT for r/o PE
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according to MKSAP, VQ unless high risk pt (not sure this is still true)
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which drugs have mortality benefit in CAD?
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beta blockers and ACEi (independent of effects on BP and LV function)
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what change in heart sounds with WPW?
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paradoxically split S2
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P-P interval in mobitz I
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constant
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pathophys of mobitz II
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usu a/w L or R BBB; dropped beat when the remaining branch suffers intermittent block
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detecting MI in pt with LBBB
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cannot assess ST depression in presence of LBBB ==> need to do nuclear imaging
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use of class Ia antiarrythmics in pts with frequent PVCs
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contraindicated -- proarrythmic effects of class Ia drugs outweighs benefit
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in-hospital mortality of cardiogenic shock
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50%
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most important intervention in cardiogenic shock due to acute MI
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restore patency of vessel - angiography/angioplasty
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what immediate intervention in acute STEMI?
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angioplasty (not thrombolysis)
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what does persistent ST elevation very late after acute MI indicate? (3)
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1) persistent myocardial injury; 2) ventricular aneurysm formation; 3) localized MI-related pericarditis
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what is isosorbide mononitrate?
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venous and arterial vasodilator used to tx angina
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tx of choice for preventing post-MI remodeling
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ACEi (improves LV function, reduces short- and long-term mortality, reduces incidence of heart failure, reduces incidence of recurrent reinfarction)
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which cardiac pts benefit most from ACEi tx?
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anterior wall MI, systolic dysfunction, or clinical evidence of CHF
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when do most post-MI VSDs occur?
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2-7 days after infarction (same timing as post-MI papillary rupture)
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acute hypotension and bradycardia in setting of acute MI -- whats the cause?
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vagal reaction
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which vessels usu involved in RV infarction?
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right coronary artery proximal to RV marginal branch
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what can cause triad of hypotension, elevated JVP, and clear lung fields?
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RV infarct or tamponade
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what kind of arrythmia a/w RV infarct?
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bradycardia (from SA or AV node ischemia)
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therapy for RV infarct
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standard MI tx + volume loading, avoid diuretics/venodilators (eg nitrates), ?pacing
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survival rate 24hrs after large VSD/papillary muscle rupture
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25% with medical therapy
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tx of post-MI VSD
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nitroprusside or intra-aortic balloon pump
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where does free wall rupture typically occur after MI?
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at juncture of infarcted myocardium with normal myocardium; less often in ccenter of infarct
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when does free wall rupture occure post MI?
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1-4d, rarely up to 3wks after MI
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coronary angiography before discharge for which patients?
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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
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what leads involved in lateral MI?
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I, aVL, V5, V6
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presentation of posterior MI on ecg
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prominent R waves + ST depression in precordial leads, often a/w inferior MI
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vtach vs vfib
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arbitrary distinction based on cycle length; both are fatal if not corrected
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what drugs reduce m&m in CHF pts
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ACEi
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when to use aldosterone antagonists in CHF?
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only with NYHA class III/IV sx, and already on digoxin, diuretic, ACEi, beta blocker
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causes of dilated cardiomyopathy
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ABCD: Alcohol, Beriberi, Chronic Cocaine, Coxsacke B, Chagas, Doxorubicin, Diphtheria
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which med reduces mortality in pts with severe heart failure due to systolic fxn with sx at rest?
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spironolactone
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most useful diagnostic test in presentation of new CHF
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echocardiogram -- systolic vs diastolic failure, EF, wall motion abnormalities, valves
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what durg indicated for pts with reduced EF?
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beta-blocker, even if no hx of MI and even if asx; ACEi also proven beneficial
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when to use digoxin in HF?
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only when decompensated -- improves sx but no mortality benefit
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when to administer beta blockers in CHF?
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only in STABLE patients (use digoxin in decompensated pts); generally, need 2-4wks of stability before starting
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what renal changes suggest decreasing ACEi dose?
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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;
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what kind of cardiac hypokinesia seen in alcohol cardiomyopathy vs CAD?
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alcohol: global hypokinesia; CAD: focal
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how long do you have to take anticoagulation after first "provoked" PE (i.e. after a transient risk factor)? Which anticoagulant?
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warfarin for 3-6mos
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how much does factor V leiden (heterozygous) increase risk of thromboembolic dz?
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8x
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unprovoked episode of DVT in older pts a/w increased incidence of ___________________
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occult malignancy
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tx for symptomatic calf vein thrombosis? Risk if this tx not performed?
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tx: LMWH followed by warfarin for 3 mos; if not, 20% develop clot extension
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what are the indications for placement of IVC filter?
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inability to undergo therapeutic anticoagulation or clot extension at a therapeutic level of anticoagulation
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what renal dz a/w venous thrombosis?
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NEPHROTIC syndrome! Pathophys unkown, maybe due to renal losses of antithrombin III
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thrombolytics vs anticoagulation in newly disovered PE
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anticoagulation! Thrombolysis not indicated in absence of hemodynamic compromise -- too many risks
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what diagnostic test to pursue if intermediate pretest probability + low probability VQ scan?
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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.
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what GI source of abdominal pain is often a/w menstrual cycle?
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irritible bowel syndrome
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best way to confirm diagnosis of uncomplicated GERD
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try acid suppressive tx
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when to use upper endoscopy in GERD?
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if suspect complications (warning sx: dysphagia, odynophagia, weight loss, anemia)
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when to use 24-hour esophageal pH monitoring?
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pts not responsive to acid-suppressive therapy, or who might have dx other than GERD
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what % of gastrinomas are malignant?
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65%
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most effective study for demonstrating gastrinoma? What lesions shown?
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octreotide scan; shows primary lesion + any mets to liver, lymph nodes
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what dz process do multiple duodenal ulcers suggest?
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gastrinoma
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NSAID ulcers usually found where?
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stomach, not duodenum
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alcoholic ulcers generally found where?
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superficial gastric mucosa, not duodenal
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what alarm symptoms are you worried about with dyspepsia? What would you do if you saw them?
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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
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charcot's triad
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for cholangitis: 1) FEVER; 2) JAUNDICE; 3) RUQ pain
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mgmt of acute cholangitis?
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start on broad-spectrum abx, ERCP+sphincterotomy to remove stones; no surgery -- increased morbidity/mortality
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what findings diff in acute cholangitis vs cholecystitis?
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cholecystitis: no jaundice, elevated transaminases and alkphos
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position preferred by pts with peritoneal signs?
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fetal position
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what finding expected on CXR with GI perf?
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air in the peritoneum (under the diaphragm)
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what is gallstone ileus?
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large gallstone (usu >2.5 mm) into bowel lumen (usu thru fistula) --> impaction --> obstruction (usu at ileocecal valve); usu ocurs in elderly
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what can cause pneumobilia?
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either patent cystic duct or fistula involving common bile duct (or s/p TIPS procedure)
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what is esophageal manometry used for?
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diagnosing non-caridac chest pain and suspected motility disorders (measures pressure in lower part of esophagus)
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tx of suspected SBP while cultures pending?
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cephalosporin or fluoroquinolone
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strictures in the terminal ileum are a common complication of which disease?
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Crohn's (often seen as "string sign" on small bowel rads)
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what can cause a mid-esophageal stricture?
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alendronate, BARRETT'S, many others
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gi s/e of alendronate
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mid-esophageal stricture
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what to do with pt < 45yo w dyspepsia?
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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]
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typical features of henoch-schonlein purpura
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HAAP: hematuria, arthritis, abdominal pain, purpura on lower extremities and IgA deposition
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complement levels in henoch-schonlein purpura
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normal (no immune complexes?, unlike SLE/post-strep GN)
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what is the universal plasma donor type (A/B/AB/O)
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AB (no antibodies in plasma)
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whole blood vs FFP for coagulopathy?
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FFP; whole blood loses labile factors during storage
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electrolyte disturbance in bulemic patients
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hypochloremia, hypokalemia
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MCC acute lower GI bleed
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DIVERTICULOSIS, neoplasm, vascular malformations
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biggest concern in postmenopausal woman with Fe defic anemia
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colorectal cancer
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what diagnostic procedure if concerned about upper GI bleed?
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upper endoscopy -- NOT upper GI series (not sensitive enough, can't be used to administer tx)
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what does bile on nasogastric aspirate tell you?
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that you're past the pylorus ==> if no blood, then upper GI bleed unlikely
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which vessels most commonly involved in pancreatitis-induced pseudoaneurysm
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splenic artery, gastroduodenal, pancreaticoduodenal
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pseudoaneurysms and pancreatitis
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pseudoaneurysms can form from autodigestion of arterial walls by elastase and pancreatic enzymes (10% of pts with acute pancreatitis)
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risk of pancreatic pseudoaneurysm? Tx?
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rupture --> life-threatening hemorrhage --> 50% mortality; tx early with transarterial embolization
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main cause of upper GI bleed in pt with hepatitis? How to confirm?
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variceal bleed -- confirm with endoscopy
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when to use TIPS procedure?
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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
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when to do colonoscopy with minimal BRBPR?
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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)
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how much blood volume lost if orthostatics correctible by IVF alone?
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10%
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when to use angiography in hematochezia? What are the advantages?
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only useful if high blood flow (0.5mL/min), but allows for embolization of vessel
|
|
|
What gene is deficient in hemochromatosis?
|
HFE
|
|
|
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
|
|
|
TTP vs HUS
|
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?
|
AIH
|
|
|
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?
|
IBD
|
|
|
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)
|
1) CELIAC SPRUE 2) TROPICAL SPRUE 3) BACTERIAL OVERGROWTH
|
|
|
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
|
>50yo
|
|
|
MCV in myelodysplastic syndromes
|
increased
|
|
|
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?
|
50-60%
|
|
|
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
|
ultrasound
|
|
|
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
|
none!
|
|
|
diagnostic step with new supraclavicular node + night sweats
|
CXR
|
|
|
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
|
OA
|
|
|
most common non-compressive cause of right upper lumbar radiculopathy
|
DM
|
|
|
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
|
hypercalcemia
|
|
|
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
|
AIN
|
|
|
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)
|
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|
what does a complex partial seizure look like?
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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)
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what population most commonly gets absence seizures?
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kids
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non-seizure condition with two or three tonic-clonic jerks
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seen with hypoxia to the brain, as in vasovagal syncope
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mgmt of symptomatic, intermittent complete heart block
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pacemaker
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what drug decrease frequency of relapse in alcohol abuse?
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naltrexone
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which benzos preferred to manage alcohol withdrawal?
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long-acting (eg diazepam) to minimize risk of seizures and delirium
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criteria for at-risk (heavy) alcohol use
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>14drinks/wk for men, >7drinks/wk for women, w/o evidence of abuse or dependence
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pts with cocaine-related hemorrhagic stroke must be evaluated for what?
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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
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initial tx for cocaine intox (3)
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1) sedation with lorazepam (IV or IM); 2) IVF to ensure adequate UOP for possible rhabdomyolisis; 3) EKG to assess for myocardial ischemia
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recommended tx for drug-induced seizures
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benzos (NOT phenytoin! -- poor response)
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s/e of anabolic steroid abuse
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acne, decreased HDL, elevated platelet counts + increased platelet aggregability --> hypercoagulability, libido changes, aggression/rage, testicular atrophy / female virilization
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gynecomastia is a s/e of what recreational drug?
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marijuana
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recreational drugs that can cause panic reactions (3)
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marijuana, cocaine, amphetamines
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how to manage tachycardia in cocaine tox?
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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
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in what patients is bupropion contraindicated?
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pts with past or current seizure disorder (bupropion lowers seizure threshold)
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effects of smoking cessation on lung function
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decreased rate of decline of lung function, plus slight IMPROVEMENT in lung function
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