Notes From Listening To Goljan Step 2 Audio

Front 1

positive ANA

ddx?

Back 1

Lupus
Mixed CT disease
CREST syndrome
Progressive syst. sclerosis

Front 2

positive ANA

lupus confirmatory tests?

Back 2

anti-Smith Ab (sens 30%, spec 100%)

anti-dsDNA Ab (lupus w/ renal disease)

Front 3

positive ANA

MCTD confiramtory test?

Back 3

anti-RNP Ab (100% spec)

Front 4

positive ANA (w/ dysphagia for solids and liquids, sclerodactyly, Reynaud's)

CREST syndrome confirmatory test?

Back 4

anti-centromere Ab

Front 5

positive ANA

Progressive systemic sclerosis
confirmatory test?

Back 5

anti-Scl-70 Ab

Front 6

High sensitivity

Uses and assocaied PV?

Back 6

Exclude when negative
Include when positive
High NPV

"SNout"

Front 7

ELISA positive (HIV screen)

Confirmatory test?

Back 7

Western blot (measures 3 Ab all present for +, ELISA just gp120 +)

Front 8

High specificity

Uses and associated PV?

Back 8

Confimatory
High PPV

"SPin"

Front 9

Prevalance

Relation?

Back 9

Incidence X duration

Front 10

LDL calculation?

Back 10

Total Chol - HDL - (TG/5)

Front 11

cytP450 enhancers?

Back 11

EtOH
Phenobarbitol
Rifampin
Phenytoin

Increase enzyme activity leading to loew Vit D and drug levels (if liver metabolized)

Front 12

Rifampin uses?

Back 12

Chr. carrier states of S. aureus
N. meningitidis carrier (family member of infected pt)
H. influenza

Front 13

Most common neonatal meningitis?

Back 13

GBS
E. Coli

Front 14

Most common cause of meningitis ages 1 mo to 18 years?

Back 14

N. meningitidis

Front 15

Most common cause of meningitis 18+ years?

Back 15

S, pneumoniae

Front 16

cytP450 inhibitors?

Back 16

H2 blockers (cimetidine-Tagamet)
Omeprazole

Decrease enzyme activity leading to drug toxicity (ex. theophylline)

Front 17

Newborn girl with vaginal bleeding, galactorrhea, Hb of 18?

Back 17

Normal - estrogen crosses placenta, endometrium becomes hyperplastic, when estrogen withdrawn, sloughs

High HbF

Front 18

IgM in newborn cord blood?

Back 18

Abnormal - no IgM until made until after born, check TORCH titers

Front 19

TORCH infections?

Back 19

Toxoplasma
Other
Rubella
CMV (most common)
Herpes

Front 20

HIV + pregnant woman

Baby's ELISA test?

Back 20

Positive, IgG comes from mom, test based on IgG

Front 21

Most sensitive test for HIV?

Back 21

HIV PCR (for DNA)

Front 22

Alkaline phosphatase and phosphate levels in kids?

Back 22

Higher, bones growing so more OB, more alk phos (3x higher), also higher P (slightly higher) for Ca X P

Front 23

Pregnancy vitamin losses?

Back 23

Fe (lose 500 mg, total store nl 400mg) and folate (nl supply 3-4 mo)

prenatal vitamins w/Fe and folate (B12 if vegan - if not have 6-10 yr store)

Front 24

Men vs women Fe, ferritin, HDL?

Back 24

Women < men for Fe and ferritin, > men for HDL (due to estrogen)

Front 25

Pregnancy blood changes?

Back 25

2x more plasma volume than RBC mass, Hb diluted (11+g/dl), GFR increased, Cr Cl high, BUN and Cr low, uric acid low, alk phos high (from placenta), serum blood gases resp alkalosis (progesterone stimulates resp center), high T4 and cortisol (estrogen [estriol] increased TBG and transcortin)

Front 26

Most common cause of HTN in young woman?

Back 26

OCP (estrogen increases angiotensinogen synthesis by liver)

Front 27

Kidneys in old age?

Back 27

Cr Cl decreases a lot (due to GFR decrease)

top cause ATN is aminoglycosides (given for sepsis, not dosed correctly, nephrotoxic)

Front 28

Lungs in old age?

Back 28

Look obstructive (TLC increased ue to Increased RV, FEV1 decreased, PaO2 decreased

Front 29

Edema

Definition?

Back 29

Fluid in the interstitial space (part of the ECF w/plasma)

Front 30

Pitting edema/ascites

Pathophysiology and causes?

Back 30

Alteration in Starling forces yo produce transudate (low protein, low cell fluid)
- Increased hydrostatic pressure (RHF - JVD, pleural effusion and dependent pitting edema) pushing transudate out, decreased oncotic pressure (hypoalbuminemia - also lowers total Ca) from chr liver disease or loss due to malabsorption or nephrotic syndrome (>3g/24h), decreased protein intake (kwashiorkor), 3rd degree burns

Front 31

Nonpitting/inflammatory edema

Back 31

Increased vessel permeability due to histamine - exudative (high protein, high cell fluid)

Ex. Pretibial myxedema in Graves and Hashimotos thyroidiits (accumulation of GAGs)

Front 32

Childs criteria?

Back 32

Apply when putting in portocaval shunt etc to assess prognosis

Measure albumin, PT, tranaminases, asterixis level

Front 33

Most common malabsorptive disease in US?

Back 33

Celiac, Crohns, bacterial overgrowth

Front 34

Lymphedema

Most common cause US? Worldwide?

Back 34

In US, postradical mastectomy with radiation

Worldwide, filariasis

Front 35

Pleural effusion

Most common cause?

Back 35

CHF

Front 36

Pleural effusion in 13 yo with CF

Organism responsible?

Back 36

Psuedomonas pneumonia exudate (Staph and Haemophilus earlier in disease)

Front 37

Lymphatic blockage leading to peau d'orange?

Back 37

Inflammatory breast cancer

Front 38

STI with local lymphedema

Back 38

Lymphogranulosa venereum, from blockage of vulvar or scrotal lymph drainage

Front 39

Breast cancer screening

Ages and methods?

Back 39

40-50 1 every 2 years (USPSTF doesn't recommend)

50+ yearly + CBE

If FHx, start 10 yrs earlier

Front 40

Prostate cancer screening

Ages and methods?

Back 40

50+ Annual DRE and PSA (USPSTF doesn't recommend)

If FHx, start 10 yrs earlier

Front 41

Cervical cancer screening

Ages and methods?

Back 41

Age 20 or after sexually active (whichever first), Pap smear yealry x3, if all negative, the every 3 years

Front 42

TBW formula?

Back 42

ECF(1/3) + ICF(2/3) = (plasma volume[1/3] + interstitial fluid[2/3]) + ICF

PV > IF > ICF

Front 43

Cheapest indicator of fluid status?

Back 43

Weight

Weight changes reflects a Na problem

Serum Na change reflects TBW problem.

Front 44

Serum osmolality formula?

Back 44

(2 x Na [Na + Cl]) + (Glucose/18) + (BUN/2.8)

Number of solutes in plasma, account for 90% osmolality, in nl peson Na predominates

Decreased osmolality is always hyponatremia

Increased could be due to Na, glucose, BUN etc

Front 45

Hyponatemic neurologic symptoms?

Back 45

Mental status changes and seizures from cerebral edema

Front 46

Hypernatremia neurologic symptoms?

Back 46

Mental status changes due to neuronal shrinkage due to water loss

Front 47

Alzheimer's disease pathophysiology

Back 47

Decreased ACh in frontal lobe learning center

Front 48

Osmotic compensation for cerebral edema/shrinkage

Back 48

Idiogenic osmoles made from amino acids gets pumped out of (or retained in) cells and bring fluid, takes 3-4 days

Front 49

Hyponatremia fluid resuscitation protocol?

Back 49

Give slowly, half calculated dose to prevent central pontine myelinolysis (irreversible demyelination)

Front 50

Hypernatremia fluid resuscitation protocol?

Back 50

Give slowly, to prevent cerebral edema and uncal herniation (press on oculomotor nerve, abducens nerve, PCA and midbrain) leading to death, or cerebellar tonsillar herniation leading to respiratory arrest

Front 51

Osmolal gap?

Back 51

If calculated and measured differ by >10, usually any alcohol

Front 52

Ethylene glycol (antifreeze)ingestion?

Back 52

Converts to oxalic acid: Osmolal gap, breath smelling of alcohol, Urine with Ca oxalate crystals leading to BUN/Cr ratio of 10 (renal failure),

Front 53

Methyl alcohol (windshield cleaner, sterno) ingestion?

Back 53

Converts to formic acid, injures optic nerve leading to blurry vision and optic atrophy

Front 54

Isopropyl alcohol (rubbing alcohol) ingestion?

Back 54

Converts to acetone, fruity breath, no metabolic acidosis but brain problems

Front 55

Diabetic emergencies for type I and II?

Back 55

I: Diabetic ketoacidosis, 15% mortality, glucosuria with osmotic diuresis leading to polyuria

II: Hyperosmolar nonketotic coma (enough insulin to prevent ketogenesis, but not hyperglycemia) - 50% mortality, older, more often with end-organ disease (can't handle fluid shift), tx with less than half insulin use for DKA - prevent hypoglycemia

See hyponatremia in both

Front 56

Corrected serum Na calculation?

Back 56

Na + [(glucose/100) X 1.6]

Front 57

1st step in DKA management?

Back 57

Volume replacement with crystalloid (NS or LR), average deficiency of 6-8 L, give massive amounts until BP normalizes, then slow

Front 58

How to get intravascular fluid repletion (to increase BP)?

Back 58

3:1 ratio, give 3L fluid for every 1 L lost (even if it was blood lost)

Front 59

Myotonic dystrophy?

Back 59

Most common muscular dystrophy in adults, difficulty relaxing muscle, weakness if face and jaw

Front 60

General causes of hyponatremia?

Back 60

Losing water - SIADH
Adding Na and water - edemas
Losing Na and water - Addison's disease, 21 OHase deficiency

Front 61

Changes with decreased effective arterial blood volume?

Back 61

- Baroreceptors (CN IX,X) sense low CO, catecholamine release, venoconstrict to raise VR, constrict arteries to raise TPR, raising afterload, positive inotrope and chronotrope of cardium increasing HR and force of contraction, stimulate RAAS (increase thirst, vasoconstrict peripheral resistance arterioles, stimulate release of aldosterone - reabsorbs Na and water from kidney at distal tubule)
- Low CO, low renal perfusion, JGA stimulates RAAS
- ADH (vasopressin) vasoconstricts and retains water in kidney

Front 62

Ruptured esophageal varix treatment?

Back 62

IV ADH (vasopressin) as vasoconstrictor

Front 63

Volume depletion lab changes?

Back 63

Decreased GFR leads to increased urea reabsorption > increased Cr retention leading to increased BUN/Cr ratio (20:1+) = prerenal azotemia

Overall try to gain hypotonic salt solution

Front 64

Postrenal azotemia

Most common cause in male?

Back 64

Prostate hyperplasia, (periurethral)

Cancer more likely pericapsular

Other causes bilateral stones, pregnancy (with postpartum diuresis)

Front 65

Volume overload ddx?

Back 65

SIADH, pregnancy, primary aldosteronism (mineralocorticoid excess), too much saline given in OR

Front 66

Volume overload changes

Back 66

No baroreceptor, RAAS activity

Overall lose hypotonic salt solution from kidney