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294 Cards in this Set
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What is the SIRS criteria? |
Systemic Inflammatory Response Syndrome criteria. |
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What is the most common drug that causes acute pancreatitis?
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Thiazides (HCTZ, chlorthalidone)
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What are the serological tests for Hep B?
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HBsAg (active infx)
Anti-HBsAg (immune, cure, no active disease) Anti-HBcAg (IgM = acute, IgG = chronic) |
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What bacteria are most common causes of meningitis?
How about aseptic causes? |
Strep pneumonia
H influenza Neisseria meningitidis Aseptic causes: • Tuberculous meningitis • Viral - HSV - HIV - Mumps - LCM (lymphocytic choriomeningitis virus) - Enterovirus ← most common - VZV • Fungi - Cryptococcus - Coccidioides • Drugs - NSAIDs - Septra - IVIg |
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What are early adverse effects of systemic steroid therapy?
What major drug class do you have to watch for interactions with? |
Psychosis
Hyperglycemia (can unveil glucose intolerance) Hypokalemia (metabolic alkalosis) Hypertension (fluid retention, CHF exacerbation, edema) Osteonecrosis of humeral and femoral heads Drug interactions - NSAID - risk of GI bleed |
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How many phases of the JVP pulsations are there?
What do each of them represent? Which waves are enlarged with tricuspid regurgitation? |
a wave - RA contraction
c wave - tricuspid valve closing v wave - passive filling of RA during systole c and v waves are large in tricuspid regurgitation |
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What are the qualities you must try to describe when assessing cardiac apex beat?
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SALID
S - Size - Is it larger than one interspace? A - Amplitude - Is it weak? L - Location - Is it in the fifth intercostal space at the mid-clavicular line? I - Impulse - Is it monophasic or biphasic? D - Duration - Is it abnormally sustained? |
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On cardiac exam, how can you tell if the PMI is sustained?
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Need to be auscultating and palpating at the same time.
Sustained if upstroke is ≥ 1/2 duration of systole. |
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What heart murmurs are louder with inspiration, and which ones are louder with expiration?
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Right sided murmurs are louder with inspiration.
Left sided murmurs are louder with expiration. |
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What is the most common organism of acute endocarditis?
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Staphylococcus aureus
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What is the prophylactic treatment for varices?
For active bleed? |
Prophylactic: propanolol 20 mg bid, titrate to maximal tolerable dose.
Active bleed: somatostatin (Octreotide) 50 mcg bolus followed by 50 mcg/hour infusion until stopped bleeding. |
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What is pulsus paradoxus?
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> 10 mmHg drop in systolic BP during inspiration.
It indicates either cardiac tamponade, or acute asthma. It is also an uncommon finding in constrictive pericarditis, right ventricular infarction, PE, and severe pectus excavatum |
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What drugs can cause prerenal failure?
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NSAID
Tacrolimus Calcium Cocaine Cyclosporine |
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What is a risk of causing renal atheroemboli?
What helps to make this a more probable diagnosis? |
Angiography, angioplasty, surgery.
+ eosinophilia |
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What are causes of acute tubular necrosis?
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Ischemia (chronic prerenal failure)
Toxins (AG, amphotericin, cisplatin, myoglobin, hemoglobin) Contrast dye |
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What criteria helps determine pretest probability of pulmonary embolism?
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Well's Criteria
3 pts each: • No other diagnosis is more likely • signs/symptoms of DVT 1.5 pts each: • HR > 100 bpm • Prior DVT or PE • Immobilization > 3 days, surgery in last 4 weeks 1 pt each: • Hemoptysis • Malignancy Score ≤ 4: PE unlikely Score > 4: PE likely |
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What are the most common sign/symptoms of PE?
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Clinical manifestations
Dyspnea, pleuritic pain, cough, hemoptysis Physical exam Tachypnea, crackles, tachycardia, fever, cyanosis, pleural rub, loud P2, ↑JVP, R-sided S₃, pulmonary regurgitation murmur |
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What is the definition of febrile neutropenia?
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ANC < 0.5
Single temperature of > 38.3, or more than 1 hour of > 38 |
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Empiric treatment of febrile neutropenia
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Low risk (ANC>0.1):
Cipro 750 mg PO q12h Amox-clav 500 mg PO tid High risk (ANC<0.1): Vancomycin dosing varies - 1g IV q12h Pip-tazo IV 3.375g IV q6h |
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What are the most useful physical exam findings for confirming or ruling out pleural effusion?
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If pretest probability of pleural effusion is high, then dullness to percussion makes it much more likely. However, CXR needs to be done to confirm it.
If pretest probability of pleural effusion is low, then absence of tactile fremitus is helpful to rule out pleural effusion. No CXR needs to be done in this case. |
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What are the most common causes of pleural effusion?
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CHF
Pneumonia Malignancy Pulmonary embolus Viral disease Coronary artery bypass surgery Cirrhosis with ascites (and diaphragm defect) |
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What are the big categories when thinking of ddx for fever of unknown origin?
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Infection (TB, endocarditis, occult abscess, OM)
Collagen vascular disease Others (drugs, DVT, PE, thyroid, Familial Mediterranean fever) Neoplasm |
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What physical exam findings helpful in making DVT a more likely dx?
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Asymmetric calf swelling > 3 cm (measure 10 cm below tibial tuberosity)
Superficial vein dilation Swelling of entire leg Asymmetric skin warmth |
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How do you assess a patient's gait velocity?
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Get up and go test
• Stand up from sitting position in chair • Walk 3 m • Turn around • Walk back to chair and sit down Normal is < 10 seconds Abnormal is > 20 seconds |
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What is acropachy?
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Clubbing with new periosteal bone formation in the phalanges or metacarpal bones. Sign of hyperthyroidism.
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What can cause clubbing?
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1. Lung disease (bronchogenic carcinoma, lung abscess, bronchiectasis, CF, chronic fungal or TB infection, ILD)
2. Cardiovascular disease (cyanotic congenital heart disease, infective endocarditis) 3. GI disease (IBD, Celiac, liver disease) 4. Thyroid acropachy |
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What can you do if a patient does not respond to furosemide?
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Give metolazone 2.5-5 mg po daily, 30 mins before dose of lasix
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What is the treatment for a bleeding peptic ulcer?
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Pantoprazole 80 mg IV bolus, followed by 8 mg/hr IV infusion x 72 hours.
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What is the treatment for H pylori gastroduodenal ulcers?
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Rabeprazole 20 mg + amox 1g + clarithro 500 mg po bid x 5 days
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What are signs/symptoms of myxedema coma?
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Hypoventilation, hypotension, hypothermia, change in mental status.
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What is the maximum injected dose of lidocaine?
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5 mg/kg/dose
Do not repeat within 2 hours |
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How do you convert from a dose of morphine (say 5 mg PO q4h) to a dose of hydromorphone and achieve equianalgesic effect?
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Divide morphine dose by 5.
So hydromorphone 1 mg PO q4h. |
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How do you calculate opioid dosing for breakthrough pain?
Use example of hydromorphone 1 mg po q4h |
• 10% of daily total dose
• or 50% of q4h dose So hydromorphone 0.5 mg po q1h prn |
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What is the treatment for opioid induced nausea?
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Haloperidol 0.5 mg PO q12h
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What can precipitate DKA?
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Infection or inflammation
Infarction or ischemia Insulin deficiency Intoxication (EtOH, drugs) Iatrogenic (corticosteroids, TZD) |
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Treatment of DKA.
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IV fluids (they are usually 6 L depleted)
• At least IV NS 2-3 L bolus at first • Run at 500 cc - 1 L / hour IV Insulin • Do not bolus insulin (high risk of causing hypokalemia) • Regular insulin 0.1 unit/kg/hr infusion • Attempt to keep the glucose level at 12-16 mmol/L • If glucose falls below 15, change fluid to 5% dextrose in NS Potassium • Try to maintain at 4-5 mmol/L • If fall below 5.5 mmol/L, add 40 mEq K to each liter of IV fluid |
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What target are you aiming for in the treatment of DKA before switching from IV insulin to SC insulin?
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Once anion gap normalizes, give insulin SC, and then stop IV insulin after 2 hours.
Do not use serum glucose as an endpoint, because glucose drops faster than the acidosis is corrected. |
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How do you distinguish abdominal wall pain from peritoneal pain?
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Abdominal wall pain: lifting head off bed either increases or does not change the amount of pain while palpating.
Peritoneal pain: Rigidity, guarding, rebound tenderness, hurts more with cough, Psoas sign, obturator sign. |
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What is Advair?
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Fluticasone and salmeterol
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Which are the atypical bacteria?
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Chlamydia
Mycoplasma Legionella They are culture negative |
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What determines if a sputum stain is a good sample?
How can you tell if it is purulent? |
< 10 squamous cells/lpf tells you that it is sputum and not spit.
Purulent - >25 PMN/lpf |
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What causes tumour lysis syndrome?
What are clinical manifestations? |
Caused by treatment (chemo or XRT) of high grade lymphoma or leukemia
• Burkitt lymphoma • ALL, AML, CML Tumour cells lyse and release electrolytes and nucleic acids, which get metabolized into uric acid Electrolyte abnormalities: ↑K, ↑PO which binds Ca causing ↓Ca ↑ uric acid Consequence: renal failure |
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What is considered prolonged QTc?
Why is it dangerous? What can cause it? |
QTc = QT interval ÷ square root of the RR interval (in sec)
> 0.45 (men), > 0.46 (women) is considered prolonged. Predisposes to Torsades de Pointes. Drugs (TCA, amiodarone, type Ia antiarrhythmic, antipsychotics) Electrolyte imbalance (hypokalemia, hypomagnesemia, hypocalcemia) |
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Dx criteria of ARDS
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1. acute onset
2. patchy air-space disease 3. PCWP < 18 mmHg 4. PaO2/FiO2 < 200 mgHg |
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What is the formula to correct the calcium level?
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For every 10 decrease in albumin (below 40), add 0.2 to calcium.
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What maneuvers typically decrease left ventricular volume?
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Standing, Valsalva.
Decreases intensity of all murmurs except for HCM and MVP. |
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What maneuvers typically increase intensity of murmurs?
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Squatting.
Increases intensity of all murmurs except HCM and MVP. |
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What are the characteristic ECG findings in acute pericarditis?
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1. ST elevation with PR depression
2. ST segment normalization 3. T wave inversion 4. T wave returns to normal |
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Which bacteria can cause bloody diarrhea?
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Shigella, Salmonella, Campy, Yersinia, pseudomembranous colitis, enteroinvasive E coli, Vibrio parahaemolyticus
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What is Caplan syndrome?
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Multiple pulmonary nodules associated with either RA or occupational dust exposure.
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What study must you order before Rx antipsychotics?
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ECG.
APs can prolong QTc. |
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Which bacteria can cause renal stones?
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Urea splitting bacteria: Proteus
Causes magnesium ammonium phosphate stones |
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What is fulminant hepatic failure? What are causes?
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Fulminant hepatic failure = development of encephalopathy within 8 weeks from onset of first symptoms.
Viral (HAV, HBV, EBV, CMV) Drugs (Tylenol, anti-TB) Vascular (ischemic liver, Budd-Chiari syndrome, malignant infiltration) Autoimmune hepatitis Others: Wilson, HELLP, Reye syndrome |
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What is Pott's disease?
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TB infection of the vertebral body
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Treatment for MI. Which components reduce mortality?
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ASA, ACEi, and BB reduce mortality.
- substitute CCB for BB if pt has asthma Morphine Nitro O2 Heparin Plavix If STEMI, consider thrombolytic or angioplasty. |
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What clinical observations distinguish hemorrhagic vs ischemic stroke?
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Hemorrhagic: coma, neck stiffness, seizures with neurologic deficit, diastolic BP > 110, vomiting, headache, loss of consciousness, xanthochromia on LP.
Ischemic: cervical bruit, absence of xanthochromia, hx of TIA, peripheral artery disease, hx of a-fib. |
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What percentage occlusion does a carotid artery need to be in order to qualify for carotid endarterectomy?
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> 70%
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What kind of stroke does hypertension most commonly cause?
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Lacunar infarcts - infarction of a 0.2-15 mm diameter non-cortical area, caused by occlusion of a single penetrating branch of a larger artery.
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What are the big categories in approach to chest pain?
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Cardiac (pericardial catch syndrome, angina, MI, pericarditis, myocarditis, aortic dissection)
Pulmonary (PE, pleuritis, pneumonia, pneumothorax, pulmonary htn) GI (GERD, Mallory-Weiss tear, pancreatitis, PUD, esophageal spasm, biliary disease, Boerhaave syndrome) MSK and anxiety |
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In an MI, what are indications for administering thrombolytics?
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ST elevation in 2 contiguous leads, and < 12 hours from onset of pain.
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What are the categories of shock?
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Distributive
• Sepsis • Anaphylaxis • Adrenal insufficiency • Neurogenic Hypovolemia • Hemorrhagic • Non-hemorrhagic (GI, renal, skin burns) Obstructive • PE • Cardiac tamponade • Tension pneumothorax Cardiogenic • Muscle (MI or cardiomyopathy) • Arrhythmia (brady or tachy) • Valvular (acute valve rupture) |
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What organisms are the cause of infective arthritis?
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Gm +ve:
S. aureus, S. epidermidis, Streptococci Gm -ve: N. gonorrhea, E. coli,Pseudomonas, Serratia |
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Most common causes of LGIB
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Diverticulosis
Angiodysplasia Neoplasm Colitis (ischemic, infectious, radiation, UC) Hemorrhoids Anal fissures |
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What are the physical findings that would suggest high risk for OSA?
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Neck circumference > 30 cm
Retrognathia Micrognathia Small hyomental distance Large tongue Mallampati 3 or 4 Hypertension |
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What is the management for atrial fibrillation?
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AV nodal mgt: beta blocker, CCB, digoxin.
If attempting to convert back to normal rhythm, need to anticoagulate first. Anti-arrhythmic: amiodarone. Cardioversion (but give ketamine before). |
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What is the pentad of clinical features found in TTP?
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Neurologic abnormalities
Renal insufficiency Thrombocytopenia Hemolytic anemia Fever |
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What are the causes of dilated cardiomyopathy?
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MI
Toxic (alcohol, cocaine, doxorubicin, adriamycin) Infection (viral, Chagas', Lyme, HIV) Metabolic (thiamine/selenium deficiency, hypophosphatemia, uremia, pheo, thyroid) Collagen vascular disease (SLE, scleroderma) |
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What are the causes of restrictive cardiomyopathy?
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Amyloidosis
Sarcoidosis Hemochromatosis Scleroderma Carcinoid syndrome Idiopathic |
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What are characteristics of the pain experienced in acute pericarditis?
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Pleuritic
Relieved by sitting up and leaning forward Radiates to trapezius ridge and neck May hear an associated pericardial friction rub |
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What are the clinical features of cardiac tamponade?
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JVD
Narrowed pulse pressure Pulsus paradoxus Muffled heart sounds Hypotension |
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What does a water-hammer pulse signify?
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Also called Corrigan's pulse - sign of aortic regurg
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What maneuvres help increase the systolic murmur of MVP?
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Standing, Valsalva, and sustained handgrip will increase the murmur of MVP.
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What is the approach to hypokalemia?
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Decreased intake
Increased output (renal vs GI) - Further breakdown renal into hypertensive vs normo/hypotensive Trancellular shift (insulin, beta agonist, alkalemia, hypokalemic period paralysis, thyroid hormone) |
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What is considered a hypertensive emergency?
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SBP > 220, DBP > 120, PLUS end-organ damage
End-organ damage: -papilledema -altered mental status/ICH -renal failure/hematuria -unstable angina, MI, CHF, aortic dissection -pulmonary edema |
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How is an aortic dissection classified?
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Type A involves ascending aorta.
Type B is limited to descending aorta. Type A is more dangerous (can block off big vessels as well as coronary arteries), and therefore is managed with surgery. |
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What drugs are used for pharmacological therapy of aortic dissection?
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IV beta blockers
IV nitroprusside to lower systolic BP below 120 mm Hg |
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What is the test of choice for detecting AAA?
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Ultrasound.
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What is the major criteria for diagnosing acute rheumatic fever?
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Jones criteria - need 2 or more of these major criteria.
Joint involvement Heart involvement Nodules Erythema marginatum Sydenham's chorea |
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What are the causes of upper GI bleeding?
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PUD
Reflux esophagitis Esophageal/gastric varices Mallory Weiss tear Hemobilia Dieulafoy's vascular malformation Aortoenteric fistula Neoplasm |
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What are the causes of lower GI bleeding?
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Diverticuluosis
Angiodysplasia IBD Colorectal carcinoma/polyps ischemic colitits Hemorrhoids, anal fissures |
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Definition of chronic bronchitis
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Cough productive of sputum for at least 3 months per year, for at least 2 consecutive years
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What is the definitive diagnostic test for COPD?
How do you grade severity of COPD? |
Spirometry.
FEV1/FVC < 0.70. Severity is based on post-bronchodilator FEV1 Mild ≥ 80% predicted Moderate 50-79% Severe 30-49% Very severe < 30% Also expect increased TLC, residual volume, FRC |
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What values in spirometry suggest restrictive lung disease?
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Low FRC, low vital capacity.
Normal or high FEV1/FVC. |
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What is the criteria for home O2 program in BC, for resting oxygen?
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After 10 minutes breathing room air at rest, perform ABG. Eligibility for resting oxygen is PaO2 < 55 or O2 saturation < 88% sustained for 6 minutes, or PaO2 < 60 with evidence of heart failure of pulmonary htn.
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What is the triad of Wernicke's encephalopathy?
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Encephalopathy, ataxia, nystagmus.
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What are the four main findings of cerebellar dysfunction?
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HAND:
Hypotonia Ataxia Nystagmus Dysarthria |
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What is the best way to measure the effectiveness of diuresis in a pt with CHF?
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Daily weight.
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Using a peak flow metre, what value would you use as criteria to perform further spirometry?
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< 350 L/min
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What are the two types of emphysema?
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Centriacinar emphysema - seen in smokers, has predilection for upper lung zones.
Panacinar emphysema - alpha-1-AT deficiency. Predilection for lung bases. |
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What are the most common causes of COPD exacerbation?
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Infection, non-compliance with therapy, cardiac disease.
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What is the most common cause of secondary hypertension?
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Renal artery stenosis
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What can cause acute interstitial nephritis?
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Allergy (sulfa, beta lactams, NSAID)
Infection (pyelonephritis) Infiltrative (sarcoid, lymphoma, leukemia) |
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What drugs can cause a decreased production in thrombocytopenia?
How about an increased destruction of platelets? |
Decreased production: thiazides, antibiotics, alcohol.
Increased destruction: heparin, abciximab, quinidine, sulfonamides, vancomycin. |
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What causes Cheyne Stokes breathing?
What is its clinical significance? |
Chronic CHF, and neurological disorders (hemorrhage, infarction, tumours, meningitis, head trauma to brainstem/higher levels).
In patients with heart failure, Cheyne Stokes breathing is associated with a poor prognosis. |
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What bugs cause ascending cholangitis?
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E. coli, Klebsiella, Enterobacter, Enterococcus, anaerobes.
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Well's score for DVT
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1. Cancer (active)
2. Immobilization 3. Bedridden > 3 d, or major surgery in last 4 weeks 4. Tenderness 5. Entire leg swollen 6. Asymmetric swelling 7. Superficial vein dilation 8. Asymmetric edema >= 3 is high risk 1-2 is medium risk 0 is low risk |
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What are the classic signs on CXR for PE?
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Westermark sign - abrupt cutoff of pulmonary vasculature distal to large pulmonary embolus.
Hampton's hump - wedge of opacified lung at the periphery, indicative of infarcted lung tissue. |
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How long should a patient be treated with anticoagulation for after a DVT?
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First DVT provoked by surgery or other transient risk factor - 3 months
First DVT unprovoked - 3 months, then re-evaluate with preference for long term Recurrent DVT or continuing risk factor - lifelong |
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Inherited causes of thrombophilia.
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Factor V Leiden
Prothrombin 20210 Antithrombin III deficiency Protein C deficiency Protein S deficiency |
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Acquired causes of thrombophilia.
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Antiphospholipid antibody
Vasculitis Hyperhomocysteinemia Malignancy Nephrotic syndrome IBD Drugs |
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How is asthma diagnosed?
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FEV1/FVC < 0.70
FEV1 increases by 12% after B2-agonist, and > 200 ml difference. |
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Is asthma typically worse in the morning or at night?
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Night
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Which lung cancers tend to occur peripherally, and which occur centrally?
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Central: SCLC, squamous cell carcinoma
Peripheral: adenocarcinoma, large cell carcinoma |
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How is small cell lung cancer staged?
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Limited - confined to one hemithorax.
Extensive - beyond one hemithorax. |
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Light's criteria for analyzing pleural effusion fluid.
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Exudate if at least one of these are true:
TP(eff)/TP(serum) > 0.5 LDH(eff)/LDH(serum) > 0.6 LDH(eff) > 2/3 ULN of serum LDH |
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What is the criteria for diagnosing endocarditis?
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Duke's criteria
Major: 1. Bacteremia 2. Echo evidence Minor: 1. Predisposed host 2. Fever > 38 3. Vascular phenomena (septic pulmonary/arterial emboli, Janeway lesions) 4. Immune phenomena (+RF, GN, Roth spots, Osler nodes) 5. Microbiological evidence not meeting major criteria Definitive IE: - 2 major - 1 major + 3 minor - 5 minor Possible IE: - 1 major + 1 minor - 3 minor |
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What findings are you looking for in a physical exam for infective endocarditis?
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Vitals
• Hypotension and tachycardia (CHF) • Febrile (IE) • Decreased SpO₂ (pulmonary infarcts, CHF) Cardiac exam • Heart block • Regurgitation • Signs of CHF (increased JVP, S3, edema) Pulmonary • Findings of consolidation (septic pulmonary emboli) • Crackles (CHF) Abdomen • LUQ tenderness, splenomegaly (splenic infarct) Neurologic • Decreased LOC or focal neurological deficits (cerebral emboli) |
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What is the treatment for infective endocarditis?
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(From antimicrobial guide, Fraser Health Authority)
Empirically Native valve: vancomycin + ceftriaxone Prosthetic valve: vancomycin + gentamicin + rifampin. Consult CVT. |
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How do you calculate the corrected anion gap?
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For every 10 that the albumin is below 40, add 3 to AG.
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Equation for A-a gradient
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150 - PaO2 - 5/4 (PaCO2)
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Classic manifestations of Dengue fever
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Fever, headache, retroorbital pain, muscle and joint pain.
Fever starts 3-14 days after mosquito bite. |
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What are precipitants of CHF?
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FAILURE
Forgot to take med Arrhythmia, anemia Infection, ischemia, infarction Lifestyle change Upregulators (thyroid, pregnancy) Rheumatic heart disease, acute valvular disease Embolism |
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What are the most useful features in the physical exam/lab tests/imaging to rule in CHF in a dyspneic patient?
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1. S3
2. JVD 3. CXR - pulm edema, pulm venous congestion 4. ECG - a-fib |
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What are signs of RA enlargement and LA enlargement on ECG?
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RAE:
P pulmonale in II > 2.5 mm high. Positive deflection in V1 > 1.5 mm LAE: P mitrale in II > 0.12 sec wide Negative deflection in V1 > 1 mm wide and deep |
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What are causes of left axis deviation? right axis deviation?
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Left Axis (-30 to -90 degrees)
i. LVH ii. LAFB iii. LBBB iv. Inferior MI Right Axis (90 to 180 degrees) i. RVH ii. LPFB iii. Right Heart Strain (Eg. PE, COPD) |
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What is the ECG finding in RVH?
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R in V1 > 6 mm, S in V5 or V6 > 7 mm.
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What measurements on an ECG qualify Q wave as pathological?
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Normal in aVR and III.
If > 0.04 s or > 1/4 the height of the R wave. |
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What is considered an abnormal ST elevation?
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i. > 0.2mV (2mm) in lead V2 and V3 for men > 40
ii. > 0.25mV (2.5mm) in lead V2 and V3 for men < 40 iii. > 0.15mV (1.5mm) in lead V2 and V3 for women iv. > 0.1mV (1mm) in all other leads for men and women |
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What is considered an abnormal ST depression?
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i. >0.05mV (0.5mm) in lead V2 and V3
ii. >0.1mV (1mm) in all other leads |
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What is the ddx for ST elevation?
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i. Transmural Ischemia
ii. LVH iii. LBBB – cannot diagnose anterior MI in presence of LBBB iv. Pericarditis – Diffuse ST elevation and PR segment depression v. Coronary Spasm vi. LV Aneurysm vii. Myocarditis viii. Pulmonary Emboli ix. Hyperkalemia x. Normal Variant |
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What is the ddx for ST depression?
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i. Subendocardial Ischemia
ii. Digoxin iii. Strain Pattern iv. Hypokalemia, Hypomagnesemia v. Bundle Branch Blocks |
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What are ECG findings in hyperkalemia? hypokalemia?
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Hyperkalemia
- Peaked T wave - Wide QRS - Flat P wave - Prolonged PR interval - May degenerate to Sinusoidal wave Hypokalemia - ST depression - Flat T wave - Prominent U wave |
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ECG findings in RBBB
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i. QRS > 0.120seconds; incomplete if 0.100-0.120 seconds
ii. rsr’, rsR’ or rSR’ in V1, V2 iii. Wide S (S > duration than R or > 40ms) in I and V6 iv. ST-depression or T-wave inversion in right sided pre-cordial leads v. Incomplete RBBB if QRS duration 0.110-0.120 seconds |
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ECG findings in LBBB
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i. QRS > 0.120seconds; incomplete if 0.100-0.120 seconds
ii. Broad R (Peak time > 60 ms) in I, aVL, V5 and V6; RS pattern possible in V5 and V6 iii. Absent q-waves in I, V5, V6 iv. Left Axis Deviation v. ST-depression or T-wave inversion in left sided pre-cordial leads vi. Incomplete LBBB if QRS duration 0.110-0.120 seconds |
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ECG findings of LAFB
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i. LAD not otherwise explained
ii. QRS < 0.120 seconds iii. qR in left sided leads (I, aVL) and rS in inferior leads (II, III, aVF) iv. aVL R peak time of > 45 ms |
|
|
What are the ILD's associated with granulomas?
|
Churg-Strauss syndrome
Histiocytosis X Wegener's granulomatosis Sarcoidosis |
|
|
What are the main occupational hazards that expose a patient to silicosis?
|
Mining, stone cutting, glass manufacturing.
|
|
|
Definition of cor pulmonale.
|
RV hypertrophy and eventual RV failure resulting from pulmonary HTN 2ndary to pulmonary disease.
|
|
|
Is venous duplex US sensitive or specific for DVT?
|
Low sensitivity
High specificity |
|
|
What are clinical features of the carcinoid syndrome?
|
Bronchospasm (wheezing)
Cardiac valvular lesions Diarrhea Flushing Telangiectasia (venous) |
|
|
What are causes of acute pancreatitis?
|
BAD HITS
Biliary stones Alcohol Drugs (sulfonamides, thiazides, furosemide, tetracycline, antiretrovirals) Hypertriglyceridemia, hypercalcemia Infection, idiopathic, inherited Trauma Surgery |
|
|
Symptoms of hyperthyroidism
|
Nervousness, insomnia, irritability
Hand tremor Sweating, heat intolerance Weight loss Diarrhea Palpitations (due to arrhythmias) Muscle weakness |
|
|
What can cause atrial fibrillation?
|
Cardiac:ischemia, infarction, CHF, myo/pericarditis, HTN crisis, cardiac surgery.
Pulmonary:COPD flare, pneumonia, PE Metabolic:hyperthyroidism, high catecholamine (stress, infx, postop, pheo) Drugs: EtOH, cocaine, amphetamines, theophylline, caffeine |
|
|
What signs of hyperthyroidism are specific to Graves' disease?
|
Pretibial myxedema
Exophthalmos Thyroid bruit |
|
|
What does a concave vs convex ST segment elevation tell you?
|
Convex: ischemic process.
Concave: benign process. |
|
|
Name all of the short-acting insulins and their effective durations.
|
Regular: 2-5 h
Humalog (lispro): 2-4 h Novorapid (aspart): 2-4 h Apidra (glulisine): 1-3 h |
|
|
Name all of the long-acting insulins and their effective durations.
|
NPH: 10-16 h
Lente: 8-16 h Detemir: 16-23 h Glargine: 20-24 h |
|
|
What are some important contraindications to using Metformin?
|
Cr > 132 in males, > 123 in females.
During any studies requiring IV contrast. Advanced heart failure. |
|
|
What medications can cause pill-induced esophagitis?
|
Tetracyclines
Anti-inflammatories KCl Quinidine Fe Alendronate |
|
|
Manning criteria for dx IBS
|
Pain relief with defecation
Looser stools at pain onset More frequent stools at pain onset Visible abdo distention Mucus per rectum Feeling of incomplete evacuation |
|
|
What is the primary treatment agent for patients with diarrhea due to IBS?
|
Loperamide.
Alosetron is also used, but only if loperamide fails. There is a risk of ischemic colitis. |
|
|
Signs/symptoms of polycythemia vera.
|
Pruritus while showering.
Elevated hematocrit. Low serum ferritin. Mildy elevated leukocyte or platelet count. |
|
|
What do you see on peripheral blood smear in AIHA?
|
Microspherocytes.
|
|
|
How do you test for B12 / folate deficiency?
|
B12 deficiency: methylmalonic acid and homocysteine are elevated.
Folate deficiency: homocysteine is elevated. |
|
|
What is the initial treatment in patients wtih warm-antibody AIHA?
|
Corticosteroids
|
|
|
What are clinical manifestations of Common Variable Immunodeficiency?
What is the dx test? |
Recurrent lung infx, recurrent giardiasis.
Dx: decreased serum IgG levels. |
|
|
Different clinical manifestations of bacterial vaginosis VS Candida vaginitis VS Trichomonas vaginalis.
|
Bacterial vaginitis: malodorous discharge w/out irritation or pain, white discharge smoothly coats vaginal walls, absent vaginal erythema, clue cells, pH > 4.5, fish odor.
Candida vaginitis: cottage cheese-like discharge. Vaginal irritation, inflammation, lack of odor. Trichomonas vaginalis: discharge is yellow-green and pruritic, may be frothy. Not malodorous. |
|
|
What is rhinitis medicamentosa?
|
Persistent rhinitis symptoms due to nasal decongestant spray overuse. Overuse causes decreased sensitivity, and a rebound increase in nasal congestion and discharge.
|
|
|
Which bugs are most implicated for acute bacterial sinusitis?
|
Strep pneumoniae
Haemophilus influenzae |
|
|
Causes of hypercalcemia
|
Hyperparathyroidism (1ᵒ and 3ᵒ)
FHH: familial hypocalciuric hypercalcemia Malignancy Nutritional -Vitamin D excess (supplements, granulomatous disease) -Milk-alkali syndrome -Calcium supplementation ↑ bone turnover (hyperthyroidism, immobilization in Paget, vitamin A) Drugs (thiazides, lithium, theophylline, tamoxifen Endocrine (tyrotoxicosis, adrenal insufficiency, Zollinger-Ellison syndrome, acromegaly) |
|
|
Treatment of hypercalcemia
|
IV fluids (4-6 L/day)
Furosemide Bisphosphonate Calcitonin Glucocorticoid (for malig and vit D intoxication) |
|
|
What are causes of hypocalcemia?
|
Hypoparathyroidism
Pseudohypoparathyroidism Vitamin D deficiency/resistance Chronic renal failure Sequestration |
|
|
What is the treatment of symptomatic hypocalcemia?
|
§ Calcium gluconate 1-2 g IV over 20 mins + vit D ± Mg 50-100 mEq/d
|
|
|
What is the treatment for acute bacterial rhinosinusitis?
|
Amoxicillin
|
|
|
Staging of non-Hodgkin's lymphoma.
|
I - single node region
II - two or more node regions on same side of diaphragm III - involvement on both sides of diaphragm IV - diffuse foci of 1 or more extralymphatic sites. |
|
|
Which inflammatory diseases can cause lymphadenopathy?
|
• RA
• Still's disease • SLE • Dermatomyositis • Churg-Strauss syndrome |
|
|
What features/patient characteristics makes the finding of lymphadenopathy more serious?
|
• Age > 40
• Size > 9 cm² • Generalized pruritus • Supraclavicular nodes • Hard • Fixed • Associated with weight loss |
|
|
What are some drug-related causes of seizures?
|
Withdrawal
• Alcohol • Benzodiazepines Overdose • Methanol • Ethylene glycol • TCA Illicit drug use • Cocaine • Methamphetamines • LSD |
|
|
What is status epilepticus?
|
Seizure > 30 minutes
|
|
|
What are the signs/symptoms of acute retroviral syndrome (primary HIV infection)?
|
Fever (97%), fatigue (90%), lymphadenopathy (50% to 77%), pharyngitis (73%), transient rash (40% to 70%), and headache (30% to 60%).
|
|
|
What is the triad often seen in acute interstitial nephritis?
|
Fever, rash, eosinophilia
|
|
|
What are characteristics of acute glomerulonephritis?
|
Hypertension
Edema Proteinuria On U/A: dysmorphic RBC and RBC casts |
|
|
What kind of glomerulonephritis causes low C3 and normal C4?
|
Post-infectious GN.
|
|
|
Clinical manifestation of Wegener's granulomatosis.
|
Upper/lower RTI
Pulmonary nodules Glomerulonephritis Dx with c-ANCA |
|
|
What is the formula to calculate expected PCO2 in a patient with anion gap metabolic acidosis?
|
Expected PCO2 = 1.5 × [HCO3-] + 8 ± 2
|
|
|
Distinguishing features of a migraine headache.
|
POUND
pulsatile one-day duration unilateral nausea disabling |
|
|
What is the usual minimum time to seroconvert after exposure to HIV?
|
6 weeks.
|
|
|
Treatment modality for limited stage SCLC. Extensive stage?
|
Limited stage: chemo + radiation.
Extensive stage: chemo alone. |
|
|
Treatment modality of NSCLC.
|
Localized disease: surgery +/- chemoradiation.
Metastatic disease: chemoradiation. |
|
|
What kind of disease are patients with polymyositis or dermatomyositis at risk of?
|
Malignancy (of multiple sites). They should receive sex-appropriate screening. Colonoscopies, mammography, pap-smears, pelvic exams.
|
|
|
What maneuvers help identify HCM?
|
Gets louder with valsalva.
Gets quieter with stand-to-squat, passive leg raise. |
|
|
What maneuvers help identify MVP?
|
Valsalva causes click and murmur to occur earlier in systole.
Squat, leg raise and isometric exercises cause click-murmur complex to move toward S2. |
|
|
What is the treatment for acute ischemic stroke vs. hemorrhagic stroke?
|
Ischemic stroke: iTAB
TPA (if within 3 h of onset) ASA 160-325 mg daily (give 24 h after tPA, or right away if no tPA). BP lowering (only if giving TPA, BP very high > 220/120, or having acute MI/dissection/heart failure/hypertensive encephalopathy) Keep NPO, keep head of bed at 30 degrees to prevent aspiration. Heparin and warfarin are not indicated. Hemorrhagic stroke: BP control (gradual, with target SBP<140) Coagulopathy reversal For intracerebral hemorrhage: no surgery. For SAH: surgical decompression, nifedipine to prevent vasospasm. |
|
|
What colour is ischemic stroke vs hemorrhagic stroke on CT?
|
Ischemic stroke is dark, whereas hemorrhagic stroke appears white on CT.
|
|
|
What are symptoms and physical findings indicative of uremia?
|
Pericardial rub
Encephalopathy Asterixis |
|
|
What are indications for dialysis?
|
Any of the following that are refractory to medical treatment:
Acidosis Electrolyte abnormality Intoxication with dialysable drug Overload (fluid) Uremia |
|
|
What do teardrop cells on a peripheral blood smear signify?
|
Myelofibrosis
|
|
|
What do bite cells on a peripheral blood smear signify?
|
G6PD deficiency
|
|
|
Intracerebral hemorrhage with extensive subarachnoid hemorrhage is the hallmark of ...
|
Ruptured arteriovenous malformation
|
|
|
What are the most common clinical manifestations of polyarteritis nodosa?
|
Systemic (fever, malaise, weight loss).
Mononeuritis multiplex, polyneuropathy. Arthralgia/myalgia, especially in lower extremities. Livedo reticularis, purpura, ulcers. Renal disease. |
|
|
How does alcoholism lead to hypocalcemia?
|
Acute alcohol ingestion induces urine magnesium loss. Hypomagnesemia causes supression of PTH and resistance to PTH action.
|
|
|
What are the anaerobic bugs, and where would you typically find them?
|
Above diaphram: Peptostreptococcus, Actinomyces.
Below diaphragm: Clostridium, Bacteroides. |
|
|
What bacteria does Penicillin cover?
|
Strep
N. meningitidis (only Pen G) Oral anaerobes |
|
|
What bacteria does amoxicillin/ampicillin cover?
|
Enterococcus, Strep, Listeria, some Gm -ve.
|
|
|
What bacteria does imipenem cover?
|
Gm +ve (incl Enterococci, Listeria)
Gm -ve (incl Pseudomonas, SPACE and ESBL) Anaerobes |
|
|
What bacteria are azithromycin and clarithromycin good at covering?
|
Atypicals and intracellulars.
|
|
|
What is doxycycline good at covering?
|
Strep
CA-MRSA Some Gm -ve Atypicals |
|
|
What is Clindamycin good at covering?
|
Gm +ve
Anaerobes |
|
|
What is Ciprofloxacin good at covering?
|
MSSA
Listeria Most Gm -ve Atypicals |
|
|
What is Septra good at covering?
|
S. aureus
Gm -ve PCP |
|
|
What abx are good for atypical coverage?
|
Macrolides
Quinolones Doxycycline |
|
|
Which abx are good for anaerobic coverage?
|
Metronidazole
Clindamycin Tigecycline Imipenem Moxifloxacin |
|
|
Typical presentation of polymyalgia rheumatica.
|
Person older than 50.
Hip and shoulder girdle pain and stiffness, esp in morning. No weakness. High ESR, but normal CK. |
|
|
Which abx are used to treat bacteria meningitis?
|
Ceftriaxone + Vancomycin.
Give dexamethasone prior to or with first abx dose if altered LoC and suspected pneumococcus. It helps decrease risk of hearing loss and other neurological complications. |
|
|
What abx are used for cellulitis?
|
No MRSA
IV: Ancef Oral: Keflex or Clinda |
|
|
What abx are used for osteomyelitis?
|
Vancomycin (+ Ceftazidine for Gm -ve and Pseudomonas coverage)
|
|
|
What abx are used for septic arthritis?
|
Vancomycin +/- Ceftriaxone
|
|
|
What abx are used for intra-abdominal sepsis?
|
Ceftriaxone/Flagyl or
Pip-tazo or Imipenem |
|
|
What is used to treat heart failure during pregnancy?
|
Hydralazine and nitrates
|
|
|
What are the criteria for using spironolactone for the treatment of CHF?
|
Severe CHF class III or IV
LVEF < 35% Serum Cr < 2.5 mg/dL Serum K+ < 5.0 mEq/L |
|
|
What is the most sensitive finding for ruling out severe aortic stenosis?
|
Physiological splitting of S2.
|
|
|
What are physical findings that suggest aortic stenosis that is SEVERE?
|
1. Lengthening murmur with a peak later in systole
2. Paradoxical splitting of S2 3. Presence of pulsus parvus et tardus |
|
|
What causes widened splitting of S2? Fixed splitting? Paradoxical splitting?
|
Widened: RBBB, pulmonic stenosis.
Fixed: ASD Paradoxical: LBBB, advanced aortic stenosis. |
|
|
What does a positive abdominojugular test indicate?
|
Elevated left atrial pressure. In a dyspneic patient, it tells you that at least some of the dyspnea is due to left side heart disease.
|
|
|
On JVP exam, what do each of these tell you?
- W or M pattern - Diminished x' descent - Absent y descent |
W or M pattern
- ASD - Constrictive pericarditis Diminished x' descent - A-fib - Cardiomyopathy - TR (mild) Absent y descent - Cardiac tamponade - Tricuspid stenosis |
|
|
What causes intermittent cannon A waves on JVP exam? how about regular cannon A waves?
|
Intermittent cannon A waves: complete atrioventricular dissociation.
Regular cannon A waves: paroxysmal supraventricular tachycardia, or junctional rhythm. |
|
|
What is an abnormal Valsalva response indicative of?
|
CHF
|
|
|
What is Kussmaul's sign indicative of?
|
Constrictive pericarditis
Severe heart failure Pulmonary embolism RV infarction |
|
|
What is the treatment for hyperkalemia?
|
1. Calcium gluconate
2. Insulin 10 U IV bolus, 500 ml D5W 3. Bicarb 4. Beta agonist (inhaler or IV) 5. Kayexalate 30-90 g po 6. Diuretic (furosemide) 7. Hemodialysis if refractory to the above |
|
|
What is the endpoint in treatment of HHS?
|
Patient mentally alert and the plasma effective osmolality is below 315 mosmol/kg.
|
|
|
What is the legal limit of blood alcohol levels in BC?
|
0.05%
|
|
|
What is the expected ECG changes in acute PE?
|
S1Q3T3 pattern, right ventricular strain, new incomplete right bundle branch block
|
|
|
What is the best method of preventing ventilator-associated pneumonia in intubated patients?
|
Keep patient at a 45-degree angle.
|
|
|
How do you adjust anion gap with albumin?
|
For each 10 drop in albumin, minus 3 from anion gap.
|
|
|
Nephrotic syndrome definition
|
Proteinuria > 3.5 g/day
Hypoalbuminemia < 30 Edema Thrombotic disease Hyperlipidemia |
|
|
Secondary causes of membranous nephropathy.
|
NHL
Solid tumors - breast lung bowel Hep B Thyroiditis SLE Gold, penicillamine, captopril, NSAIDs |
|
|
Secondary causes of minimal change disease
|
Hodgkin's lymphoma (paraneoplastic)
NSAID use |
|
|
What are secondary causes of warm autoimmune hemolysis?
What is the treatment? |
Lymphoma
Drugs Connective tissue disease Treat with steroids, underlying cause. Azathioprine, cyclophosphamide for steroid-sparing. |
|
|
What are secondary causes of cold autoimmune hemolysis?
What is the treatment? |
Lymphoma
Infections (EBV, Mycoplasma) Treat underlying cause. Cyclophosphamide can be used. Transfuse through blood warmer. |
|
|
Common side effects of IVIG? Serious reactions?
|
Common: fever, chills, malaise, h/a, dyspnea, urticaria
Pt with active infections may have fever, rigors, flu-like symptoms due to lysis of bacteria, release of cytokines AKI, hemolysis, neutropenia, thrombosis |
|
|
What is considered a weakly positive ANA? Which pattern is clinically useful?
|
1:80 is weakly positive.
Centromeric, is more indicative of CREST (limited scleroderma). |
|
|
What is included in an ENA panel?
|
1. Smith
2. RNP 3. Scl-70 4. ssA (Ro) 5. ssB (La) 6. Jo-1 |
|
|
What can cause drug-induced lupus?
|
CHIMP PIQ
Chlorpromazine Hydralazine Isoniazid Methyldopa Procainamide Penicillamine Interferon alpha Quinidine |
|
|
What dose anti-histone ab indicate?
|
Drug induced lupus. But non-specific, as 60-80% of spontaneous lupus will also be anti-histone positive.
|
|
|
Classification of vasculitides into large, medium, small vessel vasculitis.
|
Large vessel
Takayasu Giant cell arteritis Medium vessel Polyarteritis nodosa Kawasaki disease Primary CNS vasculitis Small vessel Churg-Strauss Wegener's MPA HSP Cryoglobulinemic vasculitis Vasculitis secondary to CTD Vasculitis secondary to viral infection (HBV, HCV, HIV, CMV, EBV, Parvovirus B19) |
|
|
What disease is commonly associated with polyarteritis nodosa?
|
HBV
|
|
|
What is a therapeutic range for PTT for someone on standard heparin infusion? How about on low target?
|
60-120 sec
50-85 sec |
|
|
Lymphoma can be a cause or consequence of what sort of immune dysregulation?
|
Lymphoma may be either a cause or consequence of immune dysregulation such as...
Immunosuppresion (post-transplant LPD, HIV related lymphoma, etc) Chronic infection (EBV, H. pylori, HCV, etc) Autoimmune disease (lupus, ITP, AIHA, etc). |
|
|
How common is MGUS? What is the rate of progression to MM?
|
MGUS is present in 3% of people age > 70.
1%/yer progress to symptomatic myeloma. |
|
|
What is the criteria for classification as smoldering multiple myeloma?
|
M-protein > 30 g/L and/or 10-60% bone marrow clonal plasma cells
AND no lytic lesions, anemia, hypercalcemia or renal failure. |
|
|
What are secondary causes of palpable purpura?
|
ANCA+ vasculitis
Bugs (GAS, Rickettsia, HIV, Hep C, B, A), Bowel (UC) Cancer (HL, mycosis fungoides, CLL), CTD (SLE, RA, SS) Drugs (NSAID, antibiotics, anti-TNF agents, antibodies) |
|
|
Which level of SCI causes autonomic dysreflexia?
|
Any injuries above T6.
|
|
|
What is Evans syndrome?
|
Evans syndrome (ES) refers to the combination of Coombs-positive warm AIHA and immune thrombocytopenia (ITP)
|
|
|
What are secondary causes of ITP?
|
Autoimmune disease (SLE, antiphospholipid syndrome)
Neoplasm (Lymphoma, CLL) Drugs (quinine, vancomycin, linezolid, thiazides) Infection (HIV, HCV, CMV, VZV) |
|
|
What are secondary causes of TTP?
|
E. coli (Shiga toxin producing, bloody diarrhea)
Disseminated cancer Drugs (quinine is the most common cause, chemotherapy, cyclosprine, tacrolimus, sirolimus) Pregnancy or postpartum Autoimmune (SLE) Cardiovascular surgery, most commonly CABG Kidney transplant Allogeneic hematopoietic cell transplantation (HCT) |
|
|
What are secondary causes of warm AIHA?
|
Lymphoma, CLL
SLE Drugs (quinine, cephalosporins, penicillin, NSAID) Prior blood transfusion, HCT, solid organ transplant |
|
|
What is POEMS?
|
It is a plasma cell neoplasm.
Polyneuropathy Organomegaly Endocrinopathy (especially hypogonadism) Monoclonal plasma cell disorder Skin changes (hyperpigmentation, hypertrichosis) |
|
|
Which subtype of AML is important to know about?
|
APL M3, acute promyelocytic leukemia, M3 variant.
Important to know because often presents with DIC. Good prognosis if pt survives DIC. Treatment is different from other AML - use ATRA (tretinoic acid). |
|
|
What antibody is useful in the diagnosis of Miller Fisher syndrome?
|
Anti-GQ1b IgG
Present in 85-90% of cases. |
|
|
Classifications of synovial fluid.
|
Type 0: normal. < 200 WBC/mm3
Type 1: OA. < 2000 WBC/mm3 Type 2: RA. > 25,000 WBC/mm3 Type 3: Septic. Often > 100,000 WBC/mm3 Type 4: Hemorrhagic. |
|
|
Liver enzyme levels with different disease states.
|
ALT and AST mild to 400 IU/L → chronic hep b, c, or autoimmune.
ALT and AST > 1000 IU/L → acute hep a, b, c (rare), or drug hepatotoxicity. ALT and AST > 5000 IU/L are uncommon in viral hepatitis. Usually due to drug toxicity, or ischemia. |
|
|
What is the therapeutic range for digoxin?
|
0.6-1.0 nmol/L
|
|
|
What is the therapeutic range for Vancomycin?
|
15-20
|
|
|
ECG changes suggesting dig toxicity.
|
PACs PVCs
Arrhythmias AV block Long PR interval Scooping of ST segment |
|
|
When does painless postpartum thyroiditis present? What is its time course?
|
1-6 months after delivery.
Causes thyrotoxicosis for 1-2 months, then hypothyroidism for 4-6 months. Some develop permanent hypothyroidism. |
|
|
What are type 1 and type 2 amiodarone-induced thyrotoxicosis? How do you treat each?
|
Type 1: due to excess iodine in the presence of existing multinodular goiter, or latent Graves' disease. Thyroid antibodies often present, increased uptake on radioactive iodine intake scan. Stop amiodarone, start high dose anti-thyroid med.
Type 2: destructive thyroiditis. Stop amiodarone, start prednisone. |
|
|
Epidemiology of Brugada syndrome.
|
Men > women 9:1
Autosomal dominant, variable expression Average age 41 |
|
|
3 distinct types of Brugada pattern.
|
Consists of pseudo-RBBB and persistent ST segment elevations in leads V1-V3
Type 1: ST segment gradually descends to an inverted T wave Type 2: T wave is positive or biphasic, and the terminal portion of the ST segment is elevated ≥ 1 mm Type 3: T wave is positive and terminal portion of the ST segment is elevated < 1 mm. |
|
|
Which vasculitides are known to cause vasculitic neuropathy?
|
ANCA vasculitides
- Churg Strauss - Wegener (granulomatosis with polyangitis) - Microscopic polyangitis Polyarteritis nodosa (PAN), commonly associated with HBV Mixed cryoglobulinemia HSP |
|
|
Side effects/toxicities of TB drugs
|
Isoniazid
-Peripheral neuropathy, mediated by drug-induced vitamin B6 deficiency. Prevent by giving pyridoxine -Hepatitis Rifampin -Hepatitis -High drug interaction potential, esp with HAART Ethambutol -Optic neuritis Pyrazinamide -Hepatotoxicity -Hyperuricemia -Avoid in pregnant women. Controversial, WHO says it's safe |
|
|
In myasthenic crisis, what parameters should you follow to determine when to consider elective intubation?
|
Elective intubation when VC is <20 mL/kg, or when MIF is < -30 cmH2O, or when signs of respiratory distress are present
|
|
|
Name the common adulterant of cocaine, and the complications that it can cause.
|
Levamisole, now used primarily as antihelminthic agent in vet medicine.
Causes agranulocytosis, leukoencephalopathy, and cutaneous vasculitis. |
|
|
What agents are used to counteract cardiovascular toxicity of cocaine (e.g. hypertension)?
|
Diazepam 5-10 mg IV q 3-5 minutes
Phentolamine 5-10 mg IV q 5-15 minutes PRN AVOID BETA BLOCKERS due to unopposed alpha agonism |
|
|
What drug is used for pre-operative preparation in patients with pheochromocytoma?
|
Phenoxybenzamine
|
|
|
In sepsis, how much does mortality increase each hour of delay for antibiotics?
|
For each single hour in delay of abx administration during the initial 6 hours following hypotension from septic shock, the mortality increases by ~8%, according to study by Kumar et. al in Journal of Critical Care Medicine, 2006.
|
|
|
In which people do you consider a 5-9 mm TB skin test abnormal?
|
HIV
Other immune suppression (TNF alpha inhibitors, chemotherapy) Close contact with known active TB infected person Children suspected of having TB Abnormal CXR with fibronodular disease |
|
|
How long does it take for someone, after exposed to TB, to have a positive skin test?
|
6-8 weeks
|
|
|
Formula to calculate fluid rate to correct hyponatremia.
|
Change in serum Na per L of infusate = [Na infusate] - [Na serum] / TBW + 1
|
|
|
Formula to calculate free water deficit in hypernatremia.
|
Free H2O deficit = ([Na serum] - 140 / 140) * TBW
|
|
|
What do you do if corrected hyponatremia too rapidly?
|
Stop IV NS
DDAVP 2 mcg IV/SC q6h Give H2O po, or IV D5W - Rate should match urine output |
|
|
How does amiodarone usually cause hypothyroidism?
|
Blocks conversion of T4 to T3.
|
|
|
When is it useful to order a free T3?
|
When there is clinical suspicion of hyperthyroidism, the TSH is low, fT4 is not elevated.
BC guidelines |
|
|
When is treatment recommended for subclinical hypothyroidism?
|
TSH greater than 10mU/L;
TSH is above the upper reference interval limit, but ≤10 mU/L and any of the following are present: -elevated thyroid peroxidase (TPO) antibodies -goitre -strong family history of autoimmune disease -pregnancy BC guidelines |
|
|
What are the appropriate initial investigations when there is a thyroid incidentaloma (discovered on imaging, or on physical exam)?
|
TSH, neck ultrasound
Proceed with FNA if nodule > 1.5 cm, or has worrisome features (intranodular calcifications, high intranodular blood flow, absence of "capsule", "taller than wider") |
|
|
What are risk factors for thyroid cancer?
|
FHx of medullary thyroid cancer or MEN2
FHx of thyroid cancer FHx of familial adenomatous polyposis (APC mutation) - colon cancer Age < 20, or > 70 Male > female H+N radiation Inflammation: ↑ risk with Hashimoto's ↑ risk of thyroid cancer with ↑ TSH |
|
|
Difference between SJS and TEN.
Treatment. |
SJS: < 10% of body surface
TEN: > 30% of body surface SJS/TEN overlap syndrome: 10-30% body surface Treatment: Supportive care, steroid for mild-moderate SJS, IVIG for severe SJS and TEN. |
|
|
Which meds can cause SJS or TEN?
|
Anti-gout (especially allopurinol)
Antibiotics (sulfonamides >> penicillins > cephalosporins) Antipsychotics and antiepileptics (carbamazepine, dilantin, lamotrigine, valproic acid, phenobarbital) Analgesiscs and NSAIDs (especially piroxicam) |
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Describe the 2 types of hepatorenal syndrome.
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Type 1: the more serious type. Doubling of serum creatinine within 2 weeks, to a level > 221 micromol/L.
Type 2: renal impairment less severe than type 1. Major feature is ascites resistant to diuretics. |
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What is the pathophysiology of hepatopulmonary syndrome?
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It is hypothesized that platypnea and orthodeoxia are caused by preferential perfusion of intrapulmonary vascular dilatations - IPVDs (which disproportionately occur in the lung bases) when the patient is upright
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What is the normal aortic valve area?
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Normal - 3.0-4.0 cm2
Mild AS - > 1.5 cm2 Mod AS - 1.0-1.5 cm2 Severe AS - < 1.0 cm2 |
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What are the causes of IRREGULAR narrow complex tachycardia?
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Sinus tachycardia with PACs
Atrial fibrillation MAT WAP |
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What causes of narrow complex tachycardia have short RP interval?
How about long RP interval? |
Short RP: sinus tachy (1st degree AVB), ectopic atrial tachycardia (1st degree AVB), AVNRT, junctional
Long RP: sinus tachy, ectopic atrial tachycardia, AVRT, PJRT |
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What are the 5 causes of wide complex tachycardia?
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VT
SVT with abberancy Paced Pre-excitation Artifact |
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What are class I indications for mitral valve surgery in nonischemic mitral regurgitation?
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Symptomatic, with LVEF > 30 and LVESD < 55 mm
Asymptomatic with LVEF 30-60%, and/or end-systolic dimension ≥40 mm. |
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What are the ways that myeloma causes renal failure?
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Glomerular causes
-Primary amyloidosis -Monoclonal immunoglobulin deposition disease (MIDD) -Miscellaneous (monoclonal cryoglobulinemia, proliferative GN due to monoclonal IgG deposition) Tubular -Light chain cast nephropathy (myeloma kidney) -Distal tubular dysfunction, due to the toxic effect of filtered light chains -Acquired Fanconi's syndrome Interstitial -Interstitial nephritis -Plasma cell infiltration Other causes -Hypercalcemia -Volume depletion -Drug induced (Bisphosphonates) -Hyperviscosity syndrome |
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Criteria for diagnosing PD-related peritonitis
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Peritoneal WBC > 100, and > 50% neutrophils
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What are indications for surgical management of native valve endocarditis?
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Heart failure
Severe aortic or mitral regurgitation Fungal or other highly resistant organisms Persistent infection, abscess or fistula formation Less well established: -recurrent emboli and persistent vegetations -mobile vegetation > 1 cm |
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Sequential staging of clinical manifestations of Tylenol poisoning
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Stage I (0.5 to 24 hours) - N/V lethargy. Labs normal.
Stage II (24 to 72 hours) - symptoms resolve, but labs show hepatotoxicity, sometimes renal toxicity. RUQ pain, liver enlargement. Stage III (72 to 96 hours) - N/V lethargy recur, signs of acute liver failure such as jaundice, hepatic encephalopathy, hypoglycemia, bleeding diathesis. Liver enzymes peak. Stage IV (four days to two weeks) - Recovery, may take weeks. |
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When would you use antibiotics in acute pancreatitis?
Which antibiotics should be used? |
If there is > 30% necrosis of the pancreas on CT scan.
Moxifloxacin or imipenem (Sanford) |
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What is the acute presentation of erythema nodosum, hilar adenopathy, migratory polyarthralgia (men usually present with bilateral ankle arthritis), fever called?
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Lofgren's syndrome, a primary manifestation of sarcoidosis.
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Causes of massively enlarged spleen.
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CML
Myelofibrosis Gaucher disease Lymphoma, usually indolent Kala-azar (visceral leishmaniasis) Malaria Beta thalassemia major AIDS with MAC |
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What disease is mechanics hands associated with?
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DM/PM
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What is the presence of anti-Jo-1 antibodies predictive of in PM/DM?
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Interstitial lung disease
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How will you know if AG metabolic acidosis is due to ethylene glycol poisoning?
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Elevated osmolar gap.
Can look at U/A, may see calcium oxalate crystals, since metabolism of ethylene glycol produces oxalate. |
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What is the pH of normal saline?
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5.5
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What is the classic clinical triad for cholesterol emboli?
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Tissue biopsy is not necessary when all of the following features are present:
Precipitating event Acute kidney injury Skin findings (blue toe syndrome) and/or livedo reticularis |
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What drug is useful in the treatment of complement-mediated HUS?
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Eculizumab, which is a monoclonal antibody to C5, and prevents the terminal complement cascade.
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JAMA: what examination maneuver for ascites has the best +ve likelihood ratio? second best?
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Fluid wave, LR+ 6.0. Sens 0.62, Spec 0.9.
Shifting dullness, LR+ 2.7. Sens 0.77, Spec 0.72. |
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JAMA: which examination maneuver for splenomegaly is the most specific? sensitive?
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Most specific: Nixon's has 94% specificity
Most sensitive: Castell's has 82% sensitivity sens spec -------------------------- Traube 62 72 Nixon 59 94 Castell 82 83 |
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JAMA: which features of history/physical/labs/imaging are most useful to increase the probability that a dyspneic patient has CHF?
How about to decrease the probability? |
Increase probability:
- CXR show pulmonary venous congestion: LR+ 12 - S3: +11 - PMHx of CHF: +5.8 - ECG shows AF: +3.8 - PND: +2.6 Decrease probability: - BNP < 100: LR- 0.11 |
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JAMA: pleural effusion. Most useful features to increase/decrease probability.
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Increases probability:
Dullness to percussion is the most accurate: LR+ 8.7 But requires CXR to confirm the diagnosis Decreases probability most: Reduced tactile fremitus: LR- 0.21 |
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JAMA: OSA. Most useful features to increase/decrease probability.
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Increases probability:
Nocturnal choking or gasping LR+ 3.3 Decreases probability: Mild snoring and BMI < 26: LR 0.07 |
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JAMA: osteoporosis. Most useful features to increase probability.
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+ LR
Self-reported humped back 3.0 Weight < 51 kg 7.3 Kyphosis 3.1 Tooth count < 20 3.4 Rib-pelvis distance ≤ 2 finger breadths 3.8 Wall-occiput distance > 0 cm 4.6 |
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Indications for surgical parathyroidectomy for primary hyperparathyroidism. |
1. Symptomatic from the hypercalcemia (bones stones groans moans)
2. Serum calcium concentration of 0.25 mmol/L or more above the ULN 3. CrCl < 60 ml/min 4. BMD at the hip, lumbar spine, or distal radius that is T-score < -2.5 and/or previous fragility fracture 5. Age < 50 years |
