Internal Medicine

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- Acidemia that does not respond to bicarbonate therapy & other supportive measures.

- Electrolyte derangements that do not respond to supportive measures (for example hyperkalemia).

- Ingestion of toxins/medications that are water soluble & easily removed via dialysis.

- Volume Overload that does not respond to diuretic therapy or causes cardiopulmonary collapse.

- Clinical evidence of Uremia (persistent mental status changes, uremic pericarditis, etc.).
Image: Dialysis (AEIOU)
anemia post *gastectomy* think = ?B12 deficiency!!! *shiny tongue*!cause of HTN in HyperThyroidism = ?Hyperdynamic circulation from increased MyoCardial contractility + HR !can't lift arm above 90 degrees = ?- ROTATOR CUFF - NOT dislocation! - MRI shoulderhow does pancreatitis cause hypotension = ?- from increased vasc permeability + vasodilation! - loss of IV volume!normal thyroid except *low T3* in sick patient = ?- euthyroid sick syndrome - low T3 synrome - during acute, severe illnesscause of acute limb ischemia following MI ?- arterial embolus from Left Ventricular thrombus !!! - surgical consult - *ECHO* to look for the thrombus!best tests to ID *acute HBV infection* ?- HBsAg + anti-HBc - both elevated during initial infection - *anti HBc remains elevated DURING WINDOW PERIOD* - unlke HBeAg (which is good checking for INFECTIVITY)most common cause of MR in *developed* countries = ?- *MVP* (NOT rheumatic disease) - 2/2 *myxomatous degeneration of mitral valve leaflets*drug indiced pancreatitis- diuretics - *valproic acid* - *metronidazole* - mild, resolves w/ supportive care"strep gallolyticus" = ?- Strep Bovis !COPD w/ cor pulmonale exacerbation - 5 days into treatment, *bicarb lower*, *BUN 60* Cr up 1.1-2.4 = ?- furosemide *lowers RV filling volumes* + reduces peripheral edema - causes *reduced CO* -> *PRE RENAL FAILURE* - bicarb dropped due to *met acidosis from UREMIA*resp failure- means you *can't get rid of CO2* - therefore, if you ARE ABLE TO LOWER YOUR CO2 to compensate for met acidosis, for example, then you ARENT IN WORSENING RESP FAILUREDDx of *relative bradycardia* = ?- salmonella typhi - leptospirosis - brucelliosis - facticious - beta blockeracute urinary incontinence in the elderly: first test = ?- *UA + urine culture*! - infections most common! - only use head CT AFTER urineif you've had your childhood vaccines, what does an HIV+ patient NOT NEED again?- MMR - VZVresembles RA but 1-2wks duration?- Parvovirus B19! - RA must be *> 6 wks*metabolic syndrome criteria- Men waist *>40 inches* - women *>35 inches* - FBG *>100-110* - BP *>130/80* - TG *>150* - HDL <40 (men) - <50 (women)MI plus: hypotension, JVD, clear lung fields = ?- RIght sided MI!scant blood in yellow sputum cough - 10 days after URI = ? wheezes + rhonci = ?- acute bronchitis!! - NOT pneumonia unless there is *fever, consolidation etc*african american, loss of *peripheral vision* in one eye = ?- open angle glaucoma! - acute closed angle = sudden onset blurring, severe *pain*, N/V - red eye - *hazy cornea + fixed, dilated pupil*"ruptured submucosal *arteries* of distal esophagus + proximal stomach" = ? "rupture of dilated submucosal *veins* at GE junction" = ?- mallory weiss tears! - bleeding varicesrecurrent pneumonia in same location think what?- bronchial obstruction! - get CT chest if suspect lung cancer (smoker)PPD - 12mm induration - low risk, healthy patient = ?- considered negative! - Southern US - lots of exposure to non-tuberculous mycobacteria causes *false positives* !RA treatment: "anti metabolite" = "anti-cytokine" = ?methotrexate (can cause *oarl ulcers* / stomatitis) - give FOLIC ACID and TNF-a, infliximab, etanercept, anti IL-1, anti IL-6heart burn, weight loss, fatigue, smoking hx = ?- esophageal cancer! - *barium swallow* followed by *endoscopy*analgesic nephropathy- chronic *interstitial nephritis* - *hematuria* 2/2 papillary necrosis (constriction of vasa recta in medulla)nocturnal cough - think what ?- ASTHMAtx for low grade MALToma without metastisis = ?- omeprazole - clarithromycin - amoxicillin - treat *H pylori*!Hashimoto's antibodies - >anti TPOtx of uncomplicated cystitis = ?nitrofurantoin TMP SMX fosfomycin complicated cystisis = *fluoro*clopidogrel- for 12 months post UA/NSETMI - 30 days following PCI - or patient who can't tolerate aspirin"worsening post-prandial pain that leads to food avoidance / weight loss" = ?- atherosclerosis of mesenteric arteries - dx w/ angiography / dopplerwhite patch on oral mucos that can't be scraped off?- leukoplakia! - *chewing tobacco* + alcohol - progresses to squamous cell CAearly descrecendo diastolic murmur - patient sitting up, leaning forward, breath held OUT = ?- aortic regurg - eg bicuspid aortic valvetx of pyelonephritis in diabetic1) IV ceftriaxone 48-72 hrs - if response, 2) SWITCH to oral bactrim / fluororaynauds - what tests?- for auto-antibodies + inflammatory markers (might be secondary to other process)azathioprine toxicity- dose related diarrhea - leukopenia - hepatotoxicityMycophenolate tox= bone Marrow supressiontx of PCOS?- weight loss - oral estrogen / progestin contraceptives (regulate menses, lower serum androegns)MI with pulm congestion - give what medicien?- *Furosmide* NOT beta blocker - patient is acutely fluid overloaded!initial management of secondary pulmonary HTN?- loop diuretics - ACE I / ARBtx for PE with decreased renal function = ?- unfractionated heparin - can't use LMWH, fondiparinux or rivaroxaban in patient w/ renal failure !palpable purpura, glomerulonephritis, arthalgias, generalized sx, HSM, *low complement* = ?- cryoglobinemia!b/l flank pain, palpable right kidney enlarged liver = ?- ADPKD! - liver can be enlarged 2/2 cystic involvement - right kidney = lower + thus easier to feel!Nocardia vs Actinomycesboth branching filamentous rods both *gram positive* Nocardia: *partially acid fast* - aerobic - tx = *bactrim* Israeli: *anaerobe*- does NOT stain acid fast - *sulfur granules*cutaneous associated with PBC?- xanthelasma - chol-filled yellow plaques on medial eyelidsHBsAb positive means ?- immunity! - response to vaccination - no need for prophylaxis if needle stick!Strep sanguis Strep mutans Strep salivarus Strep mitis= VIRIDANS STREP - subacute bacterial endocarditis!tx of basal cell CA on the face / delicate skin = ?- Mohs micrographic surgery - thin layers removed to ensure clear marginsbeta blockers to pheo crisis = /- rapid increase in BP - unopposed alpha!chronic epigastric pain, malabsorption, DM = ?- chronic pancreatitis!TB drug that affects liver?- INH causes idiosyncratic liver damage - looks like viral hepatitisepigastric exertional pain = do waht?- IF baseline EKG is normal - *exercise EKG* - if baseline EKG is ABnormal, then do *exercise echo* - if positive stress test -> *angiography*tx: acute viral / idiopathic pericarditis = ? uremic (BUN > 60) pericarditis ?acute viral = *NSAIDs + Colchicine* uremic = *dialysis* - remember - doesn't have normal ECG findings!coronary steal- *dipyramidole* injected (*coronary vasodilator*) - myocardial perfusion scanning - BF redistributes to "non diseased" areas induced by the drugvent: fi02 70% and still hypoxemic ?- ARDS! - add PEEPcolloids = ?- albumin etc - NS, LR = Crystalloids!phenytoin causes what vitamin deficiency ?- folic acid!! (methotrexate, trimethoprim, phenytoin, pyrimethamine)statistical power- more power = larger sample size = *smaller confidence interval*knee injury: *hemoarthritis* (grossly bloody) + unable to bear weight = ?= ACL tear!!IV drugs + pnuemonia w/ multiple nodules in lung?- Tricuspid endocarditis -> emboli -> nodular infiltrate w/ cavitation - S Aureusmurmur w/ marfans ?- early diastolic murmur (aortic dilation, regurg) - aortic dissection - MVPdaily crampy ab pain + diarrhea, NO BLOOD no weight loss = ?- Irritable Bowel! - need blood / weight loss for inflammatorytinea versicolor- malassezia globosa - KOH prep *spaghetti + meatballs* - tx = *selenium sulfide / ketoconazole*edema in nephrotic vs nephritic syndrome ?- nephrotic = LE edema only - alveolar capillaries more permeable to albumin - nephritic = anasarca + *Pulmonary Edema* - due to primary glomerular damage -> *decreased GFR*to Dx ureteral stones = ?- NON CONTRAST CT or - US - don't be fooled by contrast CT!Pernicious anemia complication = ?- b12 deficiency (most common cause of b12 def = pernicious anemia!) - increased risk *gastric cancer* (stool testing for blood to monitor)false positive rate == 1 - specificity = inversely proportional to specprednisone + hip / groin pain normal ROM normal XR = ?- avascular necrosis of femoral head!cough w sputum, sometimes blood - *rhinosinusitis* , dyspnea, wheezing,c rackles etc- BRONCHIECTASIS - !!!high resolution CTasthma + chronic sinusitis = ?- ASA intolerance asthma!tx for toxic megacolon = ?1) IV *steroids* 2) NG decompression 3) antibiotics 4) IVFthings taht potentiate effects of warfarin = ?- *NSAIDs* - amidoarone - antibiotics - Green veggies *DECREASE* effects!Blood Transfusion Reactions: hemolytic anemia/ fever = anamnestic antibody response = ? resp distress - pulm edema fever + chills (1-6 hrs) fever, *flank pain, DIC* (within 1 hr)anamnestic = delayed hemolytic - *2-10 days* - pos direct Coombs within 6 hrs - donor anti-leukocyte abs fever _ chills = febrile non-hemolytic - caused by *cytokienes* flank pain, DIC = acute hemolytic - pos direct Coombs - *ABO incompability*tx for Vtachstable = IV *amiodarone* unstable = synchronic cardioversionwhat looks like endocarditis but with *20% EOSINOPHILS* ?- trichonellosis! - parasite - *mexico*, thailand, china - undercooked pork - *muscle pain* = buzzwordperiorbital edema, myositis, eosinophilia = ?- trichonosispost partum woman w/ multiple nodules on CXR + pulm sx = ?- choriocCA! - irregular bleeding, *enlarged uterus*, pelvic pain - measure *hCG* - CT to stage/ plan txrash on palms + soles + generalized LAD = ?secondary syphilis ! - IM dose benzathine penicilin - can get jarish-herxheimer acute febile rxn, myalgia, HA within 24 hrsrash that: 1) starts on trunk -> periphery (hands + soles) 2) starts on wrists + ankles -> trunk, extremities, palms, soles 3) palms + soles in child1) secondary syphilis 2) RMSF 3) Coxsackie virusclinical signs of hypOthyroid high T3, T4, *normal TSH* = ?- generalized resistance to thyroid hormones !exquisite pain with gentle palpation of vertebra = "- spinal osteomyelitis! - IV drug use, etcwhy increased orthostatic hypotension in the elderly?- arterial stiffness - decreased NE in nerve endings -* reduced sensitivity of myocardium to symp stim* - defects in myocardial responsebiased sample: definition= a sample that is not representative of the populationhawthorne effect- when people in a study act differently because they know they are being studiedinformation bias- occurs due to imperfect *assessment* of association between the exposure + outcome - as a result of errors in measurement of exposure + outcome status - minimize by *standardizing techniques for surveillance + measurement of outcomes*confounder- a variable that is independently associated with both the exposure + the outcome - eg smoking: alcoholic pregnant mothers + low birth weight babies (b/c it causes BOTH)"HIV p24 antigen + antibody screening"= initial, one time HIV screening "plasma HIV RNA" = for patients w/ *negative serology * but *high clinical suspicion of acute HIVbeta 2 + Kbeta 2 TREATS hyperKalemia!!!!!empiric therapy for immunocompromised with meningitis = ?- vanco - ampicillin - cefepime (pneumococcus, M meningitidis, lsiteria, gram neg rods)empirics for neurosurg / shunt or penetrating skull trauma = ?- vanco + - cefepimeepiglottitis: bugsH flu *strep pyogenes* immunocomp = *candida*hypOactive DTRs after trauma surgery = ?- hypOcalcemia!predictors of AAA expansion + rupture:1) large diameter (*>5.5cm*) 2) rapid expansion rate (1cm/yr) 3) *Cigarettes* - NOT HTN! (weak association)HIV: low grade fever, headache, *increased ICP* = ?- cryptococcal encephalomeningitisINH (isoniazid) + liver enzymes- 10-20% present w/ mild elevated LFTs within a few wks of treatment - self limited - *no intervention needed*sudden loss of vision in one eye, *floaters* ?- vitreous hemorrhage - fundus hard to visualize - 2/2 proliferative Diabetic retionopathy - tx = sitting upright while sleepingtx of intermittent claudication - ABI 0.72 = ?- aspirin 81 - statin - exercise therapy - smoking cessation! - *NO pentoxifulline* - cilastozol is ok if aspirin + exercise don't workAfib treatment -> HIT (plt 60) - what do you do?- stop hepatin - start *argatroban* - warfarin wait until platelets recover to *150K*gold standard dx for HIT = ?- serotonin release assaylung infiltrates with *multiple thin walled cavities* = ?- necrotizing bronchopneumona 2/2 S Aureus - *pneumatocoeles* !on furosemide, then get vtach = ?- SE from loop diuretics (low K and mg) - can cause Vtach! - digoxin can also be potentiated by these abnormalitiesLE edema - how to tell if cardiac or liver ?- hepatojugular reflex! - if due to CHF"persistent activation of complement alternative pathway"= membranoproliferative glomerulonephritis type II dense deposits in glomerular BM - positive for C3why does cold water stop paroxysmal SVT?- SVT from *accessory AV conduction pathways* - vagal maneuvers reduce this conduction!pulm nodule with *halo sign* / air crescent = ?- aspergillosusreliability- when successive measurements are similar to eachother - accuracy you must know the true # / gold standardpost bone marrow transplant with: pneumonitis, abdominal findings = ?- CMV pneumonitis - between 2wks + 4 months after transplant - multifocal, diffuse patchy infiltratesGraft vs Host always has?- SKIN findings ! - also intestine, liver, lung (bronchiolitis obliterans)hives after protected sex = ?- latex allergy! - also *hypotension, hives* when performing open surgery w/ gloves!Lyme disease serology- NOT early in disease (takes a long time to become positive) - use in early disseminated / later diseaseHTN, palpable b/l flank masses micro-hematuria = ?- ADPKD complications: - *ruptured berry aneurysms* - hepatic cysts - valvular heart disease - colonic diverticula - herniasstrep bovis associated with?- COLONIC neoplasms! - get colonoscopy !hepatic cyst with *eggshell calcification* + pet DOGS = ?- hydatid cystdermatofibroma- nnotender, firm , hyperpigmented npdules on LE - fibroblast proliferation - *center dimple* - tx if symptomatic / bleeding = *cryosurgery or shave excision*pyogenic granuloma- benign vascular skin tumor - small *red* papule that grows rapidly -> *pedunculated / sessile* - lip + oral mucosa - bleed w/ minor traumasteatorrhea + epigastric pain that radiates to the back after eating = ?- chronic pancreatitis!scleroderma, AKI, malignant HTN= scleroderma renal crisis! - MAHA w/ schistocytes - thrombocytopeniaBurr cells vs Spur cellsBurr (echinocytes): spiculated - liver disease - end stage renal disease Spur (acanthocytes): irreular, like paint blotchesis family permission legally required to unplug braindead person?- NO!can cardiac dysfunction in hemochromatosis be reversed with tx?- YESscreening tests need high __ confirmatory tests need high __screening = sensitivity confirmatory = specificitysensitivity= true positive tests / total # with disease on bimodal graphs, moving cutoff LEFT INCREASES sensitivity - moving right increases specificity - remember *specificity increases to the right*chest + neck pain, pericardial effusion, mediastinal widening= aortic dissection!! - *TEE*in a study, randomization controls what?- confounders!!! - effect modification: when an external factor affects a *risk factor* - eg smoking icnreases risk fo stroke with BC pillsmeds to withhold 48hrs prior to stress testing ?- beta blockers - CCBs - nitrates - unless patient has known CAD + test is to assess for efficacy of therapyassociation w/ dermatomyositis = ?- Cancer! - ovarian, lung, pancreatis, stomach, colorectal, NHL - need regular, age appropriate cancer screeningdisease associated with carpal tunnel ?RA sarcoidosis hypOthyroid amyloidosisendocarditis plus mention of *nosocomial UTI* = ?- enterococci!!!urethral catheter in acute bacterial prostatitis ?- NO - there may be inflammation - if needed, do *suprapubic cath*how to dx acute prostatitis- midstream urine sample - TMP SMX / fluoro for *4-6 weeks*what part of the spine is most often involved in RA ?- CERVICAL spine"transient ST elevations on EKG" = ?- prinzmetals angina - vasospasm - smokers - similar to Rayanauds!!Gout secondary to decreased uric acid excretion may be associated with what drugs? (painful tophi + feet need care)Pyrazinamide Thiazides Furosemide Niacin Cyclosporinfoot ulcers- diabetic / neuropathic - *under bony prominences, PLANTAR surfaces* - monofilament test - arterial ulcers = *tips of toes*tx of hairy cell leukemia (*leukemic reticuloendotheliosis*) = ?- *cladribine* ! - AR = neuro + kidney damage - TRAP stain - dry tap (fibrotic marrow) - *B cell* chronic leukemiatx of CLL ?- chlorambucil - prednisonetx of non-Hodgkin's lymphoma = ?- CHOP regimenbreast CA screening- mammogram - ages *50-75* - every *2 yrs*Cervical CA screening- pap smear - ages *21-65* - every *3 yrs*Screening for hyperlipidemialipid panel - *men 35+* - every *5 yrs*screening for HTN- measure BP - age *18+* - every *2 yrs*osteoporosis screening- DEXA - women *65+* - interval variesHSM, LAD tiredness / anemia easy bleeding / bruising night sweats HA, *dizziness* *visual* problems, retinal vein *engorgement* *pain + numbness in extremities*- Waldenstroms macroglobulinemia ! - hyperviscosity of blood 2/2 excess IgM production - demyelinating sensory neuropathyabdominal lymphoma, abnormal IgA= heavy chain diseasetx of goodpasture's ?- emergency plasmapheresishigh WBCs, anemia, chrom 22 problem = ?- CML! - 9,22 reciprocal translocation = Phil chrom - BCR ABL tyrosine kinase (fusion gene) - tx = gleevac / *imatinib* binds ATP binding site of BCR-ABL proteinAST, ALT, alk phos in DJ + rotor syndromes = ?- NORMALrapid virulization of woman - workup?- Ovarian tumor: high testosterone, *normal DHEAS* - Adrenal tumor: normal testosterone, *elevated DHEAS* - DHEAS secreted only from adrenals!patient with: recurrent nosebleeds, telangiectasias = ?- hereditary telangiectasia (Osler-weber-Rendu) - aut dom - telangiect, epistaxis, *widespread AV malformations* - in lungs, cause *AV shunting* -> chronic hypoxemia + *reactive polycythemia*carcinoid syndrome- dx: 24 hr *5-HIAA* - tx = *octreotide*nephrotic syndrome increases risk of what?- hypercoagulable!!! - risk arterial thrombosis, PE - *renal v thrombosis* = most common - other complications: - protein malnutrition, iron-resistanct microcytis hypochromic anemia, infections, *vit D deficiency*"curtain falling over vision"= amaurosis fugax - displaced *retinal EMBOLUS* from carotid - *eval carotids*! - whitened, edematous retina - central *retinal v occlusion* shows diffuse hemorrhagesage > 50, chronic pain shoulders /hips, morning stiffness, constitutional sx, *ESR > 40*= polymyalgia rheumatica! - tx = *low dose steroids* - PE: decreased *ACTIVE ROM*RUQ pain + nausea *post cholecystectomy* = ?- post-chole syndrome - high alk phos, mildly high AST/ALT, dilated CBD - dx: *US, ERCP, MR cholangiopancreatography*pruritis, fatigue, jaundice = ?- Prim Bil Cirrhosis!asymptomatic young patient, *soft, midsystolic murmur* workup = ?- doppler - usually benign, no further workup neededanatomic origin of Afib = ?- *pulmonary VEINS* - atrial *flutter* originates in *tricuspid valve annulus*scrotal mass that does not transillumate + decreaes when supine = ?- hernia OR *varicocele*varicocele tx- boys + young men w/ testicular atrophy = *gonadal vein ligation* - older men who don't want children = *scrotal support + NSAIDs*Tx for grave's ?- *radioactive iodine* - CI in pregnancy + very severe ophthalmopathy - PTU: during pregnancy, in *preparation for surgery / iodine therapy* - too many SE !what constitutes positive PPD in HIV+ patient ?- induration of *5mm or more* -> 9 months txHIV, pneumonia, *splenomegaly*, elevated *alk phos* = ?- MACacute epididymitis caused by: (painful enlargement of testis w/ UTI)young men: Chlamydia / Gon older men: *e coli* (gram negatives)Chikungunya- mosquito borne viral illness (*aedes* type) - S america / *caribbean* - high fever, *polyarthalgias*, *low WBC* low platelets elevated LFTs - *maculopap rash* - cervical LAD - dx: serology - tx: supportive - can rarely cause persistent arthritistrip to caribbean, fever, low WBC, mac pap rash, cervical LAD, polyarthralgias = ?- Chikungunyatenosynovitis, polyarthalgias, pustular / vesiculopustular lesions (NOT MAC PAP) = ?- disseminated gonnococal !mass in LA on echo ?- cardiac myxoma - constitutional sx - Mitral Valve disease - *embolization* - tx = prompt surgery!PR depression *aVR*= pericarditisappearance of MIGRATORY superficial thrombophlebitis on arms + *chest* = ?- Trousseu's! - esp w/ hx of SMOKING - occult visceral malignancy - CT abdomen"reentrant ventricular arrythmias" = ?- V fib! - cause sudden cardiac arrest immediately following MIMolluscum Contagiosum common in what conditions?- *HIV* - steroids - chemotherapy (cellular immunodeficiencies)50 yo male diarrhea, ab pain, weight loss - arthralgias - aortic regurg= Whipples! - late manifestations = *dementia, myoclonus* - intermittent low grade fever, *hyperpigmentation*risk factors for polyps progressing to malignancy (3)1) villous adenoma 2) sessile adenoma 3) size *>2.5cm*2 main causes of osteonecrosis (avascular necrosis) = ?1) chronic steroids 2) high alcohol ingestionphenazopyridine- analgesic for urinary tract - used post-instrumentationat what serum glucose does glucose appear in urine?- 180!most common valve damaged in rheumatic fever = ?- Mitral Stenosis! -> LA dilation -> AFib"loud mid diastolic rumble at apex" =?- mitral stenosis (rheumatic fever)dandruff, greasy looking, waxy scales on erythematous base on face = ?- seborrheic dermatitis - esp Parkinson's + HIVsildenafil + alpha blocker?- give *4 hr window* - careful combining with *erythromycin, cimetidine* - CI with nitrateschronic, non allergic rhinitis + post nasal drip tx- intranasal antihistamine - intranasal glucocort - or combo therapyhow to measure progression of acute HBV infection (envelope present) ?- serial *ALT* measurements ! - every 3-6 monthsholosystolic murmur louder on inspiration- tricuspid regurg - IV drug user w/ many infiltrates on CXR (septic pulomnary emboli!)many round peripheral nodules b/l in lungs + IV Drugs?= septic pulm emboli from TRICUPSID REGURG FROM IV DRUGS - infective endocarditispancreatic cancer risk factors1) smoking (reversible) - first degree relative - obesity, low physical activity - *BRCA* - Peutz Jeghers syndromenew onset lupus w/ kidney disease = next step ?- kidney biopsy - tx depends on type of kidney disease! - also matters for prognosisrisk of pig farmers = ?- neuro cysticercosis (swiss cheese brain)risk of sheep farmers = ?- hydatid cystsevidence of COPD, digital clubbing, sudden onset wrist pain, chronic smoker = ?- hypertrophic pulmonary osteoarthropathy (HPOA) - due to: lung CA, TB, bronchiestasis, emphysema - *CXR* to r/o CAbest diagnostic test for acute aortic dissection = ?- TEE (preferred w/ elevated Cr / contrast allergy) - or CT w/ contrastwhat other STIs to screen for with PID?- syphilis - HIV - *Hep B* - cervical cancer - if IV drug use: Hep Cnull value for RR ?- *1.0* - thus if 95% confidence interval does NOT include 1.0, then P <.05 - thus if a question mentions relative risk use 1.0!screening for pancreatic cancer- NONE if asymptomatic - *CA19-9* is to monitor response to therapy - if symptomatic: test - *multi-phase thin-cut spiral CT* of abdomenposible GI bleed but negative guiac ?- still do colonoscopy + EGD! - one DRE does not exclude!"bright red, friable, exophytic nodule" in HIV patient = ?:- bacillary angio - bartonella (gram negative bacillus) - tx = *erythromycin*rate control of afib w/ RVR = ?- beta blockers - CCBs - lidocaine treats *ventricular arrhythmias* NOT AFibPVC treatmentasymptomatic: observation symptomatic: 1) *beta blockers* 2) amiodarone = second line"beta cell tumor"= insulinoma! - elevated insulin, c peptide, pro insulin w. hypoglycemia - non beta cell tumor = hypoglycema *independent of insulin*intitial BPH workup1) UA for hematuria + UTI 2) PSAbit with healthy appearing dog - what rabies precautions?- observe for 10 days for signs, without PEP - if can't observe, try to test animal, start PEP and d/c when test is negativesudden severe epigastric pain that *spreads over entire abdomen* = ?- chemical peritonitis 2/2 *perforated peptic ulcer*hematuria + needle shaped crystals in urine in HIV+ patient = ?- crystal induced nephropathy from *indinavir*!JVD, intense P2, hepatomegaly, dependent pitting edema, RV heave = ?- cor pulmonale! - R HF + - Pulm HTNPost infectious glomerulonephritis vs IgA NephropathyPIGN: - 10-21 days after URI - age 6-10 - *low C3 complement* - biopsy: subepithelial humps IgA Nephro: - w/in 5 days of URI (*synpharyngitic*) - age 20-30 - normal complement - biopsy: *mesangial IgA deposits*"increased hydrostatic pressure within hepatic capillary beds" -->- ascites 2/2 portal HTN - "increased capillary permeability" = malignant ascites, non-portal HTN - *SAAG < 1.1* - TB, peritoneal carcinomatosis, pancretis ascites, nephrotic syndrometreatment for Afib in WPW patients = ?- hemodynamically stable = *procainamide* - unstable = *electrical cardioversion* - avoid AV nodal blockers (beta, CCB, digoxin, adenosine) - cause *increased conduction thru accessory pathway!*hypercalcemia + gastric ulcers = ?- MEN1 - primary hyperPTH - *gastrinoma*hypercalcemia + hypoglycemia = ?- MEN1 hyperPTH insulinomahyperCalcemia, renal insufficiency, metabolic alkalosis= milk aklali syndromeherpetic whitlow- Herpes Simplex infection of the hand (1 or 2) - dentists!!! - non purulent vesiclesfelon= bacterial infection of *distal volar space* - *tense abscess* + intense throbbing pain - tailors from needle injuries - tx: I+D + *cephalosporins*fever + lobar infiltrates 48 hrs after *ventilation*?- ventilator associated pneumonia 1) gram stain + culture 2) antibioticswhat test to do for suspected MGUS ?- metastatic skeletal bone xray! - to r/o MM - *MM = elevated beta-2 microglobin*what does tight glucose control in DM reduce the risk of ?- microvascular complications (*nephropathy, retinopathy*) - no decreased risk of MI, CVA or all cause mortalitytx of PACs- if symptomatic - *beta blockers* - risk factors to reduce: tobacco, alcohol, caffeine, stressmetabolic alkalosis + low urine chloride = ?- *vomiting* - ng aspiration - prior diuretic useUrine chloride in Bartter + Gitelmans ?- high! - hypovolemia / euvolemia - metabolic alkalosismet alkalosis: ph + bicarb = ?- pH > *7.45* - HCO3 > *24*kidney damage from *cytotoxic antibodies* = ?- Goodpasture syndromemedication that decreases ventricular remodeling post MI ?- ACE I !!live vaccines = ?- MMR - varicella - zoster - live-attenuated influenzaages for HPV vaccine?- 9- 26vaccine for men who have sex with men ?- Hep Aangiomas: cherry vs strawberry- strawberry = young children, grow rapidly then regress - cherry = older adultsclonic jerks with syncope ?- common! - esp if prolonged! due to *brain hypoxia**pedunculated, exophytic* purple skin masses on abdomen, intrahepatic lesions (angioma-like blood vessel growths) = ?- Bacillary Angiomatosis - from Bartonella Henslae - dx tissue biopsy - *angiomatous histology* - *biospy risk HEMORRHAGE* - tx w/ antibiotics -> involutiondiagnosis of histoplasmosis ?- *serum or URINE antigen*!!!!!!tx of non-bleeding varices ?- *beta blockers* - reduce risk for progression - if contraIndicated then *endoscopic variceal ligation* - active variceal bleeding = *octreotride* - endoscopic *sclerotherapy*MI mechanical complications (3-7 days) 1) MR due to pap mm rupture 2) LV free wall rupture 3) IV septum ruptureall have hypotension 1) pansystolic, apical murmur - radiates to axila - *soft S1* 2) *pericardial tamponade* - JVD, pericardial rub, pulsus parodoxus 3) pansystolic murmur heard at *left sternal border* has thrill, does NOT radiate to axilla"Soft S1"= improper closure of mitral or tricuspid valve - MR or TR!CV conditions associated with AFib- Hypertensive heart disease - CAD - MS, MR - CHF - HOCM - ASD / VSD - post cardiac surgerypulmonary conditions associated with Afib- OSA - PE - COPD - acute hypoxia (pneumonia)obesity, Hyperthyroid, DM, alcohol abuse, amphetamines, cocaine associated with what CV issue?- A fib!urinary cyanide nitroprusside test for what?- cysteine stones - will turn *purple*where are VIPomas located ?- pancreatic *tail*tx of prolactinoma- DA agonists (*bromocriptine + cabergoline*) - pituitary tumor <10mm = microadenoma - amenorrhea + galactorrhea but no other problemsCMV retinitis vs HSV retinitis- both = acute *retinal necrosis*- pain, uveitis CMV: *painless* - NO keratitis / conjunctivitis - hemorrhages + *fluffy / ganular regions* around retinal vessels HIV: *keratitis, conjunctivitis, PAIN -> visual loss* - widespread, PALE, PERIPHERAL lesionsepisodes of: vertigo, ear fullness, tinnitus, hearing loss horizontal nystagmus = ?- menieres! Tx: 1) lifestyle mods *low salt diet* 2) diuretics, antihistamines, anticholcalcification of adrenal glands = ?- TB!RBC fragility, hypOreflexia, muscle weakness, *blindness* = ?- Vitamin E deficiencyhow to Dx pancreatic cancer (after ultrasound showed CBD dilation) = ?- CT abdomen! - ERCP follows if undiagnostic 1) US 2) CT 3) ERCPpalpable, nontender GB in jaundiced patient =- Courvoisier's sign - pancreatic cancerchlordiazepoxide= a BENZO = *Librium*drug induced esophagitis- direct mucosal injury 1) tetracyclines 2) ASA / NSAIDs 3) *Alendronate* 4) *KCl* 5) quinidine 6) Ironpleural fluid: indications for tube thoracostomy?- pH < 2 - glucose < 60patient is mentioned to be on diuretics... watch out for what?- be care of *urine electrolytes*! Will be false/ useless!quickest way to reduce serum K ?Insulin + Glucose ! FASTEST - hemodialysis takes 1hr - Kayexalate takes 1-2 hrsmeningococcal meningitis - man with children, refuses tx - what to do?- isolate + treat against his will - public safety issue!can stopping drinking reverse alcohol induced ischemic / dilated cardiomyopathy ?- YES -life threatening ARs from: didanosine abacavir NRTIs NNRTIs nevirapinedidanosine = pancreatitis abacavir = hypersensitivity syndrome NRTIs = lactic acidosis NNRTIs = SJS nevirapine = liver failureholosystolic murmur in lower sternum, louder with inspiration ?- tricuspid regurg! - think IV drug user - right sided endocarditis (fevere, weakeness) - usually *s aureus* (also strep, enterococci) - tx = *vancomycin*"use dependence" in antiarrythmics- eg HR + QT increase during exercise - class 1c *moricizine, flecainide, propafenone*painlful mouth ulcer with *granulomatous inflammtion* = ?- aphthous ulcer in *crohns disease*"broad casts" on UA= seen in chronic renal failure - from dilated tubules of enlarged nephrons s/p compensatory hypertrophy - also see *waxy casts*WBC casts on UAinterstitial nephritis, pyelonephritis etcfatty casts UA- nephrotic syndromecasts in pre renal azotemia ?- HYALINE casts = made of protein, pas unchanged along urinary tractfatigue, migratory arthralgias, palpable purpura, *low complement*, increased *RF*, elevated LFTs = ?= cryoglobulinemia - immune complex disorder (IgM against anti HepC IgG) - due to chronic hep Crecurrent thrombosis, neuro findings, MAHA = ?- anti phospholipid! also loss of pregnancywhen to biopsy a lymph node?when *over 2cm*!abscess associated with a hair follicle = ?- furuncle! - S Aureus!well defined erythematous plaques with *satellite vesicles / pustules* - axilla, groin, skin folds = ?- intertrigo! - candida82 yo woman with DM: ab pain, n/v - first test = ?- EKG! must rule out ACS!SE of thiazides- hyperGlycemia - hyperCalcemia - increased LDL + TG - hypOnatremia - hypOkalemiaHIV - low CD4 fundoscopy: yellow white patches of retinal opacification, retinal hemorrhages = ?- CMV retinitis!HIV retinopathy- cotton wool spots in retina which remit spontaneously - toxo can cause necrotizing retinochoroiditis + encephalitis - herpes simplex keratitis = *dendritic ulcer* + small vesicles - herpes zoster = conjuctivitis + *dendriniform corneal ulcers*, fever, malaiseavoid what meds in right MI?- nitrates - diruetics - opioids (reduce RV preload) - give *FLUIDS*S4 in hypertensive patient = ?- maybe jsut from LVH 2/2 HTN - NOT NECESSARILY heart failure !treatment of secondary amyloidosis (AA) = ?- colchicinesecondary amyloidosis- complication of chronic infections, IBD, RA - EC deposition of fibrils - nephropathy, heart failure, bronchiectasis, *macroglossia* / other organ enlargementhow to ace I prevent progression of diabetic nephropathy ?- reduce intraglomerular hypertension - thus reduce damage to glomeruli - earliest manifestation = glomerular hyperfiltrationwoman w/ children, pain relieved by bladder emptying, urinary frequency, painful intercourse, tender anterior vaginal wall = ?- interstitial cystitis (painful bladder syndrome) - tx: palliative - trigger avoidance, amitriptyline, analgesicscystocele- bladder prolapse into anterior vaginal wallecchymoses in elderly patients hands = ?- senile purpura - age related loss of elastic fibers in *perivascular CT* - not a problemfirst colonoscopy what age?- normally 50 (then every 10 yrs) - OR flexible sigmoidoscopy 5 yrs + FOBT every 3 yrs - 40 if colon cancer in first degree relative (or *10 yrs before age of dx*)infection prevention around splenectomy- risk sepsis up to *30 yrs after splenectomy* - anti pneumococcal, H flu, N mening - *2 wks before operation* - *daily oral penicillin* 3-5 yrs AFTER operationwhat 10 yrs risk of CV disease needed to start a statin ?1) >7.5%! 2) 45 + DM 3) symptoms of CAD 4) LDL > 190pulsus bisferiens (biphasic pulse)- seen in aortic regurg!- water bottle heart ?- pericardial effusion! - associated with *PMI hard to palpate*fixed split s2= ASD - CXR: enlarged RA / RV, prominent hilar / pulm aaJVD, increased P2, right ventricular heave, hepatomegaly, dependent pitting edema, sometimes ascites = ?- cor pulmonale!bite from raccoon, bat, skunk- get Post exposure rabies prophylaxis - if can test animal, can dc - low risk animals (squirrels, chipmunks) NO PEPfever, chills, sore throat - difficulty swallowing, *muffled voice*, large nope on ONE SIDE only with *tonsillar deviation* = ?- peritonsillar abscess! - needle peritonsillar aspiration - if doesn't work, surgery - prominent *UNILATERAL LAD* - fatal if: airway obstruction or involvement of carotid sheathScreening for DM in asymptomatic patients:- BP > 135/80 - 45 yrs and older - DM risk factorsScreening for lung CA- ages 55-80 - 30+ pack year smoking hx - currently smoke, or quit within 15 yrs - annual low dose CT scanmild unconjugated jaundice after *fasting* = ?- Gilbert! - triggers: fasting, fat free diet, physical exertion, fever, stress, fatiguehemorrhagic pustules with surrounding erythema -> necrotic ulcers - patient with severe neutropenia - Pseudomonas bacteremiasuicide attempt: bradycrdia, AV block, hypotension, diffuse wheezing - atropine doesn't work = ?- Beta Blocker overdose!! - give glucagon!hypertrophic osteoarthropathy = ?- clubbing!apophyseal joints= sacroileac! - for example, in ankylosing spondylitisdiabetes drugs CI in heart failure = ?- TZDs (glitazone)TB + Addison's disease- common cause! - aldosterone decifiency - low glucose - non-anion gap hypErkalemic hypOnatremic metabolic acidosis!acid base disorder from cyanide tox= metabolic acidosis - from lactic acidosis!drugs that cause crystal-induced AKI- acyclovir - sulfonamides - methotrexate - ethylene glycol (antifreeze) - protease inhibitorsmeningococcal vaccine dosing- first *age 10-11* - booster age *16-21* - also before travel to sub-Saharan Africa, Mecca, *Saudi Arabia* - military recruits, dorms!best lifestyle mods for lowering BP ?1) of OBESE = *weight loss* 2) *DASH* diet (*not smoking cessation*)complication of temporal arteritis = ?- aortic aneurysm! - follow w/ *serial xrays*alternative to Warfarin if patient doesn't comply with diet / follow up?- rivoroxaban (direct factor Xa inhibitor) - for for recurrent / refractorywhen to use thrombolytics in PE?- hemodynamically unstable - massive proximal LE thrombosis - iliofemoral thrombosis w/ significant swelling or limb ischemiamanagement of bone pain from prostate CA who have undergone *orchiectomy* = ? (castration)- radiation therapy! - flutamide doesn't help if s/p orchiectomy - can use *estramustine* (estrogen + nitrogen mustard) - works but CI with CV or blood disordersknee pain: episodic pain + tenderness at *inferior patella* = ?- patellar tendonitis (*jumpers's knee*) AS OPPOSED TO: - patellofem syndrome: with stairs, patellofem compression test! - tx w/ exerciseWhy low glucose in exudative pleural effusions?- due to metabolic activity of *WBCs + bacteria*high amylase in pleural effusions caused by?- esophageal rupture or pancreatitis!how to diagnose CLL ?- flow cytometry! - buzzword = smudge cellsG6PD enzyme levels during hemolytic crisis= enzyme activity NORMAL during hemolytic episodes - because RBCs are hemolyzed early + reticulocytes are abnormally high!testicular tumor buzzwords: + test and estrogen, low LH / FHS ? (gynecomastia) increased beta-HCG ? increased AFP ?= Leydig = chorioCA = Yolc sac tumor teratoma = higher afp OR HCG (indicate other germ lines)tx of cerebral toxoplasmosis ?= sulfadiazine + pyrimethamine!!!!!25 yo man tenderness of *heels, tibial tuberosities, iliac crests*AStiming of acute intersitial nephritis- 7-10 days after drug exposure! - penicillins, cepahlos, PPIs, etc PNADCPSRatrial tachycardia + AV block = ?- Digoxin toxicity!alcoholic with difficult to correct *hypOkalemia*- due to low mg ! - also malabsorption, but this would correct with IV K!hx of polyuria / peeing on self dehydrated semi consicous = ?- DKA!!!! DUH DUH DUHcauses of renal transplant rejection in early post op period ?- ureteral obstruction (look for dilation of calices) - acute rejection (lymph infiltrate -> steroids) - *cyclosporine tox* (check levels) - vascular obstruction - ATN (IV diuretics)cluster analysis- grouping of different data points into similar categories - randomization at the level of *groups*parallel study- randomizes one treatment group to one grp + a different treatmetn to another group (eg placebo + non)factorial study design- involves randomization to different interventions with additional study of *2 or more variables*otosclerosis- common cause of *conductive hearing loss* - in 20's to 30's - abnormal remodeling of otic capsule - *autoimmune* process - stapes footplate fixed to oval window - tx: hearing amplification / *surgical stapedectomy*compensation for chronic hypercapnea in COPD?- increased bicarb resorption! - still doesn't totally normalize (pH < 7.35)back pain after lifting boxes, pain not diminished by rest, point tenderness vertebra L4 = ?- vertebral compression fracture! - trauma, *osteoporosis*, osteomalacia, infection, mets, hyperPTH - ligamentous sprain = PARASPINAL tenderness + better w/ restFulminant Hepatic Failure (FHF)= *hepatic encephalopathy* that develops within 8 wks of onset of acute liver failure +++ ALT + PT = needs transplant ASAPDietary recommendations for patient with renal calculi1) less protein + oxalate in diet 2) less sodium intake 3) MORE fluid 4) MORE calciumtx acute alcoholic hepatitis- high dose steroidstx for afib due to hyperthyroidism = ?- propranolol - NOT digoxin (rapid vent response = resistant to glycosides)breast CA most important prognostic factor?- TMN staging! - Er + PR good, but not as importantmurmurs that shorten/reduced by squatting ?HOCM MVPValsalva does what to MVP / HOCM murmurs- makes them LOUDERstepwise tx for ascites1) Na + water restriction 2) spironolactone 3) loop diuretic 4) frequent paracentesis (2-4L per day!)Most common organisms: erysipelas? purulent cellulitis? non-purulent cellulitis?erysipelas = *S pyogenes* purulent = S Aureus non-purulent = StrepIf first colonoscopy is normal, what are guidelines ?- every 10 years after first onesynonym for Osteitis Deformans ?= Pagets! - osteoClast overactivity -> inc bone turnoverclues for posterior wall MI = ?- ST depression V1,V2associated symptoms with inferior MI (RCA)?- hypotension - bradycardia - AV blockPatient with HIV + positive PPD = ?- prophylaxis w/ *INH + pyrazinamide* - for *9 months*Does COPD cause digital clubbing ?- NO! - look for occult malignancydigital clubbing, painful joint enlargement, periostosis of bones, synovial effusions = ?Hypertrophic osteoarthropathyCommon causes of priapism:1) sickle cell + leukemia (children/adolescents) 2) perineal / genital trauma (lac of *cavernous a*) 3) neuro lesions (spinal cord injury, cauda equina) 4) trazodone + *prazosin*hyposthenuria- SSA + sickle cell trait - sickling in vasa rectae of inner medulla -> impairs urine concentration - manifests as *nocturia*necrolytic migratory erythema, DM, D/const/ab pain, weight loss = ?glucagonomaPancreatitis patient, what tests to find etiology ?- US for gallstones - Hx etoh use - *lipid panel* for TG - ERCP with *more than 1 episode without known cause*large dose NSAIDs, alcohol -> bloody emesis = ?- acute erosive gastritisScreening for bladder cancer- NOT recommended EVER - EVEN in patients at risk!elderly patient bone pain, rnal failure, hyperCalcemia= MM - 50% develop renal insufficiency 2/2 BJ proteins (*paraproteins*) that obstruct tubulestick bite: fever, leukopenia / ttpenia, elevated AST/ALT = ?erlichiosis! - NO rash! tx = doxycyclineBasic workup for HTN1) UA (occult hematuria / pr:cr ratio) 2) chem panel 3) *lipid panel* (risk stratification for CAD) 4) baseline EKG (CAD, LVH)antibiotic used to treat hepatic encephalopathy = ?- rifaximinwhen is tactile fremitus INCREASED ?tactile fremitus = palpable vibration felt on chest wall - increased in *consolidation* (pneumonia)bronchial breath sounds- heard in consolidation - due to over-transmission of sound over chest wall - also egophony, *crackles*elderly diabetic patient: ear pain, drainage, *granulation tissue* = ?- malignant otitis externa (MOE) - *pseudomonas* ! - can progress to osteomyelitis of skull base + destruction of *facial nerve*Rhozipus infection- poorly controlled DM - paranasal sinuses -> orbit + brainRamsay Hunt syndrome- herpes zoster in ear 1) *facial nerve palsy* 2) *vesicles* in earPatient w/ multiple blood transfusions gets *hypOcalcemia* why?- transfusions contain *citrate* - which *chelates Ca + mg* -> reduces their plasma levels!treatment for polycythemia vera?- phlebotomy to keep *hct < 45* - can present as *HTN*tx for Pagets- bisphosphonateswhat to do when someone swallows draino ?- *endoscopy* within 12-24 hrs - NOT charcoal, steroids, emetics, acid !patient with chronic renal failure bleeds excessively. why?- platelet dysfunction (normal platelet count) - uremic coagulopathy! - tx = *DDAVP* - increases release of *VIII:vWF multimers* from endothelial storage sites - NO platelet transfusion b/c they would just inactivate!elderly man, fluctuant mass in neck, halitosis, regurgitation = ?- zenkers! - dx with *contrast esophagram* - tx = *surgical* - risk aspiration pneumonia !test if obstructing mass is causing recurrent pneumonias in same location ?- CT chest - then bronchoscopySE of EPO therapy = ?1) *worsening of HTN* (tx with IVF, beta clockers) 2) headaches 3) flu like syndrome 4) red cell aplasia (rare)when to give recombinant EPO ?- ESRD + *Hb < 10*trochanteric bursitis- pain on lateral hip when lying on it!stiff, limited rom, painful hip on passive movement?- OA (degenerative joint disesae) - no point tenderenss - no systemic findingsparaneoplastic syndromes of RCC?- anemia / erythrocytosis - fever - hyperCalcemia - *cachexia*tx of legionella- *fluoro* (better for more severe) - macrolidesamebiasis liver abscess tx (bloody diarrhea + fever)- *oral metronidazole* - luminal agent like *paromomycin* - NOT DRAINAGE! risk of rupture - echinococcus hydatid = no fever, animals, eosinophilia = aspiration + albendazoletx of echinoccus hydatid cyst in liver (no fever - contact w/ animals + eosinophilia)- aspiration - albendazoleTarget cells + Italian = ?- beta thalassemia! - microcytic anemia - no tx required if asymptomatic - beta thal major = *splenectomy*Do SLE patients present with diarrhea ?- NO! - also usually have *rash* - if it looks like SLE but has *diarrhea + weight loss* think HIVpatient after chemo/rad for Hodgkins, then new chest mass on CXR = ?- secondary malignancy! - lung (smokers) - breast - thyroid - bone - colorectal, esophageal, gastrictx of cryptococcal meningitis- amphotericin B + flucytosine - for 2 weeks! - then after = anti retroviralstx for cerebral toxoplasmosis = ?- sulfadiazine-pyrimethamine - multiple ring enhancing lesions w/ edema!griseofulvin used to treat?- dermatophytosis + onychomycosisestrogen therapy requires higher doses of levothyroxine for hypOthyroid - why?- estrogen increases thyroid-binding globuin *TBG* - made in liver! - binds more T4 + T3! - often need to do this during *pregnancy*CRAB- for MM Calcium (high) Renal impairment Anemia Bone pain, lytic lesions, fracturestx for Pagetstreatment of hepatitis B infectionInterferon Lamivudinecbc, bmp in cirrhosis show ?- decreased platelets - *hypOnatremia* - prolonged *PT*prolactinoma- prolactin levels *>200* - normal TSH (generally)alkalosis (for example, PE) - does what to Ca?- decreases! - more binds to albuminpoor prognostic indicator in CLL ?- low platelets!vaccines for chronic liver disease = ?- Tdap - influenza - HAV - HBV - *PPSV23* (PCV13 at age 65)patient w/ scant blood w/ defecation - test = ?- *<50 yo* = ANOSCOPY - *>50* = colonoscopyBuzzwords for renovascular HTN- recurrent *flash pulm edema* - diffuse atherosclerosis - *assymetric kidneys* - severe HTN onset after *age 55* - Cr > 30% after starting ACE/ARBcarcinoid vitamin deficiency?- niacin! - b/c of tryptophan, or whateverbuzzword: "corn eating people"- Pellagra! - Diarrhea, dermatitis, dementia - niacin deficiencySun exposed rash ?- SLE - Porphyria - Pellagra (niacin deficiency)fever, polyarthralgia, *pustular rash*, NO LAD = ?- disseminated gonoccocal infection! - syphillis: rash is maculopapular WITH LAD - dx *nucleic acid amplification testing* - cultures usually NEGATIVEsyphilis tx if allergic to penicillin ?- doxycycline - tx for *tertiary* syphilis = *ceftriaxone* - tx for during *pregnancy* = desensitize + *penicillin*tx for central retinal artery occlusion = ?- ocular massage - *high flow O2* OR - intra*arterial* thrombolytics (not IV) DUhtachycardia, HTN, arrythmia, high fever *fine tremor*, AMS *lid lag* = ?- thyroid storm! Malignant Hyperthermia = hypercarbia, tachy, RIGIDITY, CK, hyperK, hyperthermiapain anteromedial tibial plateau below knee after trauma ?- *ANSERINE* bursitis! - *NOT* reproduced by *valgus stress test* (unlike MCL!!!!)Eastern European, megaloblastic anemia *atrophic glossitis* *vitiligo* thyroid disease, neuro abnormalities = ?- pernicious anemiacauses of macrocytic anemia- folate, b12 - *MDS* - *AML* - hydroxyurea, zidovudine, chemo - liver disease - alcohol abuse - hypOthyroidismproximal mm weakness, *finger tremor* anxiety, palpitations, weight loss = ?- hyperthyroidism!causes of proximal mm weakness / myopathy- poly/dermatomyositis - hypothyroid - hypERthyroid - Cushings - Lambert Eaton - MG - steroidsporcelain GB- risk GB carcinomablood transfusions! when do you give: cryoprecipitate ? FFP? platelet? packed rbcs? whole blood?cryo = (fibrinogen, vwF, 8,13) - to replace if deficient in these factors! FFP: active bleeding + severe coagulopathy (INR >1.6) platelets: unver 10,000 or active bleeding + under 50,000 packed RBCs: hb < 7 whole blood: severe hemorrhage/trauma requiring massive transfusions - NOT COMMONhemochromatosis: suscpetible to what pathogens?- listeria - vibrio vulnificans - yersinia enterocoliticasymmetric inflammation of small joints (hand) - ANA *weakly* + RF positive - *resolves* in 4 weeks = ?- VIRAL arthritis! - b/c resolves itself - parvo, hepatitis, HIV, mumps, rubellaWhere is vitiligo commonly seen?- peri oral - acral (armpits, areolae)piebaldism- inherited absence of melanocytes - present at birth - confined to *head + trunk*velvety pink, whitish areas of LESS pigmentation + hyperpigmented patches = ?- superficial fungal infectionis osteoarthritis associated with anemia of chronic disease?NO! - only RA, lupus etcclues for Iron Deficiency Anemia- use of NSAIDs + Aspirin - gastric ulcers -> chronic GI blood loss + depletion of iron stores !looks like celiacs but negative *IgA anti-tissue transglutaminase* antibody = ?still celiacs! - just with IgA deficiency! - buzzword *villous atrophy*collagenous colitis- chronic watery diarrhea - *normal mucosa* on colonoscopy - biopsy: mucosal *sub endothelial collagen* depositionmedication that causes *hypothermia* = ?- fluphenazine - atypical antipsychotic - eg for schizo*serpiginous* reddish brown elevated lesions after touching *sand* = ?- cutaneous larva migrans - helminth (Ancyclostoma Braziliense) - dog/cat *hookworm* - in sand contaminated with fecespruritic rash: volar wrist interdigital webs elbows penis= scabies - parasite - person to personSynovial fluid: 0-200 200-2000 WBC/m 2000-50000 >50,0000-200 = normal 200-2000= OA 2000-50,000 = inflammatory condition (RA) >50,000 = septic arthritishypertensive emergency - treated then gets AMS, lactic acidosis, seizures, coma = ?- CYANIDE toxicity from nitroprusside!strep sanguinis= type of strep viridans! - subacute endocarditis - *dental* procedurescolonoscopy for UC- first *8 yrs after dx* - then repeat *every 1-2 yrs*unexplained heart failure (diastolic), increased vent wall thickness w/ normal cavity size - NO HTN - *low voltage EKG* proteinuria, waxy skin, easy bruising = ?= cardiac amyloidosis - dx w/ *abdominal fat pad biopsy*pulsus paradoxus- fall in systemic bp suring inspiration - card tamponade - asthma - COPDSx Vitamin D overdose = ?- due to hypercalcemia! - constipation - polyuria - polydypsia - ab pain"dishwater drainage"= purulent discharge from necrotizing surgical infection - decreased sensitivity at wound edge - severe paincontact-lens infectious keratitis- medical emergency - usually *gram negatives* (pseudomonas, serratia) - topical broad spectrum antibiotics - can lead to corneal perforation, scarring, vision loss"curtain coming down over the eyes"= retinal detachmentpost splenectomy vaccines- *14 days* after - *PCV13* - H flu type B - meningococcalappendicitis: umbilical then LRQ why?- umbilicus = referred, *visceral* pain - shifts to LRQ with involvement of *pareital preitoneum* -> *SOMATIC* pain !pathophys of pulm fibrosis?- cyclic injury -> release *TGF beta* -> fibrosis! - thickened interface b/t alveoli begins in *sub-pleural* region then spreads! when all over lung = *honeycomb*pneumoconioses- occupational exposure -> *restrictive lung disease* / interstitial fibrosis - small tiny particles induce *macrophages* to cause fibrosis (macros eat them + then freak out) - as opposed to TGF beta in idiopathic pulm fibrosisRA + coalworkers pnuemoconiosis= Caplan syndrome!anthracosis- mild carbon exposure (like living in a city) - asymptomatic - builds up in *macrophages + hilar lymph nodes*fibrotic nodules in upper lung ?- silicosis! (sand blasters) - restrictive lung disease - impairs *phago-lysosome formation* in mcropahges ! - *increased risk TB*!!!!!!buzzword: workers in aerospace= berylliosis! - noncaseating granulomas in hilar nodes - *looks like SARCOIDOSIS* - increased risk lung CAHow to confirm Dx of esophageal rupture?- water soluble contrast esophogram!flu: tx + dx- fever, chills, etc + *wheezes, crackles, diffuse infiltrates* - dx: CXR = interstitial infiltrates - *nasal swabs for influenza antigens* = fastest dx - start antivirals *within 48hrs* - oseltamivir / zanamivir (neuraminidase inhibitors) - for influenza A: rimantadine / amantadinealcohol cessation: can reverse what?- can reverse steatosis, alcoholic hepatitis and even early fibrosis!! only true cirrhosis w/ regenerative nodules = irreversible!!!ichthyosis vulgaris- normal skin at birth -> progression of dry scaly skin - horny plates cover *extensor surfaces of limbs* - "lizard skin" - worse in dry weatherlynch syndrome: risk for what tumors?- colon - *endometrial* CA in women!patient > 50 with: chronic neck pain, limited neck rotation + *lateral bending*, sensory deficit in dermatome = ?- cervical spondylosis Xray: - osteophyes / spurs - narrowing of disc spaces - hypertrophic vertebral bodiesHep B tx- *tenofovir* - entecavirinitial Tx DKA = ?- rapid IV - NS - regular Insulinmefloquine- to prevent *chloroquine resistant malaria* - also atozaquone-proguanil, doxcycline - Sub saharan Africa - Amazon - South + Se Asiatreated for asthma exacerbation: NO eosinophils low lymphocytes = ?- glucocorticoid-induced neutrophlia! - fewer eosinophils - fewer lymphocytes - increased neutrophils - by *mobilizing marginated neutrophil pool*patient after *cardiac cath* / angiography: eosinophilia, renal failure, blue toes = ?- cholesterol embolization! - livedo reticularis / blue toe syndrome - ocular involvement *Hollenhorst plaques*patient with: dizziness, headache, pruritis after shower splenomegaly = ?- polycythemia vera! - dizziness/headache (hyperviscosity) - pruritis (histamine) - low EPO - *JAK2 mutation*Tx of acute limb ischemia = ?1) IV heparin immediately on suspicion 2) embolectomy (definitive) / intra arterial fibrinolysis (IR)CI to succinylcholine- hypERKalemia! - crush / burns more than 8 hrs old - GBS - tumor lysis syndromecase control study: select population, then select people with same demographics as population = controls... this eliminates what problem?- matching eliminates *CONFOUNDING* - match people with similar variables such as age and raceexercise induced asthma tx1) few times a week: beta agonist 10-20 min before 2) *daily* exercise: inhaled *steroids / anti leukotrienes*Cancer treatments- salvage therapy - when there is failure of primary / recurrence - adjuvant = in addition to standard at same time - induction - an initial dose to rapidly kill tumor cells - consolidation: therapy after induction w/ multiple drug regimen - maintenance: after induction + consolodation - eg daily anti androgen for prostate ca - neo-adjuvant: tx given BEFORE standard therapy - eg radiation before radical prostatectomyDiabetics 40-75 always get what med?- statin! - regardless of baseline lipid levels - TG > 500, consider other lipid lowering drugs alsoFluids for hypovolemia and: mild hypernatremia severe hypernatremiamild = 5% dextrose in 0.45 saline severe (Na 164) = 0.9% NS - to gradually replete volume, THEN 0.45 + dextrose!tx for euvolemic + hypervolemic hypERnatremia = ?- 5% dextrose in water (D5W)back pain: better with *flexion* worse with extension - ?spinal stenosis! leaning forward = relief!Patient w/ RA - tx = ?- always *methotrexate!* - best EARLY in disease - after 6 months, if not improved, THEN etanercept/ infliximab = *step up therapy* - NSAIDS = symptomatic relief while waiting for DMARD effects - Cox inhibitors also - but these DON'T slow disease progression !test for what before starting DMARDs for RA ?- hep B - hep C - TBwhat is elevated in Pagets?- alk phos (isolated) - urine hydroxyproline !bone tumor: *epiphysis* distal femur / prox tibia expansive, lytic (soap bubble) = ?- giant cell tumor - benign, locally aggressiveOsgood Schlatter disease- overuse injury - young children / adolescents underying *growth spurts* - avulsion of *tibial tubercle*knee pain: sclerotic, cortical central nidus of lucency worse at night unrelated to activity relieved by NSAIDS = ?- osteoid osteoma!what drug is CI in glaucoma ?- atropine! - can dilate pupil + make it worsetx for glaucoma- decrease IO pressure - mannitol - acetazolamide - timolol - pilocarpinealbumin + calcium- low albumin causes low total blood caldium - but SAME ionized plasma calcium - for every one drop in serum albumin, Ca drops by 0.8most common cause of pneumonia in nursing home residents = ?- S pneumo !aspergilloma fungal ballyoung person - heart failure symptoms for several weeks after URI = ?- dilated cardiomyopathy 2/2 viral myocarditis! - diffuse hypokinesia, dilated ventriclesabortions, thrombocytopenia, prolonged PTT = ?- antiphospholipid ab syndrome - give LMWH to pregnant patient - also low dose aspirin - to avoid pregnancy losstx for dermatitis herpetiformis- *dapsone* - gluten free diet"dendriniform corneal ulcers"= herpes zoster ophthalmicus - also vesicular rash in trigeminal distributionEffects of TMP on electrolytes?- increased Cr - *hyperKalemia* !!! - blockage of epithelial Na channel in collecting tubulePleural fluid pH- normal = 7.60 - transudate = 7.4-7.55 - exudate = 7.3-7.45 - < 7.3 = empyema, pleuritis, tumor, pleural fibrosisManagement of hypercalcemia: severe: > 14 moderate 12-14 mild < 12severe: NS + calcitonin - NO loop diuretics - bisphosphonate long term moderate: only if symptomatic mild: no immediate tx: avoid thiazides, lithium, volume depletion + prolonged bed restconstipation, fatigue, excessive urination = ?- hyper Calcemia !pseuodogout- patients w/ hyper PTH - mono arthropathy (knee) - Ca-pyrophosphate deposition - + birefringence - rhomboid shaped !elecrtical alternans + sinus tachycardia = ?- pericardial effusion! - eg tamponadevanishing bile duct syndrome- progressive destruction of intrahepatic bile ducts- *ductopenia* - also *primary biliary cirrhosis*!!! - failed liver transplant - GvH disease sarcoid CMV HIVhepatocyte swelling + necrosis mallory bodies neutrophilic infiltrate = ?- alcoholic hepatitis !man steps on nail, gets osteomyelitis. what bug?- pseunomonas! - especially when *punctures sneaker* / rubber sole! - tx: *quinelones* + debridementtx of anemia 2/2 chronic renal failure (dialysis patient)- less EPO -> normocytic, normochromic, hypoproliferative anemia 1) EPO (kidneys cant make it) - this increases iron usage -> *fe deficiency* 2) so give *iron* after!when to give folate ?- pregnant - folate deficiency - *hereditary spherocytosis*SE of cyclophosphamide ?1) hemorrhagic cystitis 2) *bladder CA* - due to acrolein (fluids + MESNA rescue!) 3) sterility 4) myelosuppressiondrugs that cause Raynaudsbeta blockers ergotaminedrugs that cause thyroid dysfunctionamiodarone lithiumdrugs that cause optic neuritisethambutol hydroxychloroquinestiffness + pain of *shoulders + pelvic girdle* = ?- polymyalgia rheumatica - associated with *giant cell arteritis*DIP joints affected by?- OSTEOarthritis (degenerative joint disease)osteophyes, narrowed joint space, *subchondral bone cysts* = ?- osteoarthritis!nail pitting + sausage fingers =?psoriatic arthritismost common COD in dialysis patients = ?- cardiovascular disease - also in renal transplant patientsmyopathy with *normal ESR* elevated CK = ?- hypothyroidism! - SLOW DTRsmyopathy with: elevated ESR + CK = ?- polymyositis - *DTRs NORMAL* (unlike hypothyroid)Definition of malignant HTN- severe HTN with - *retinal hemorrhages* - exudates, OR - *papiledema*Definition: hypertensive encephalopathy- severete HTN with: cerebral edema + non-localizing neuro signs + symptomsfemale athlete triad1) oligomenorrhea 2) osteoporosis 3) decreased caloric intake - runners especially -> *stress fractures*pain b/t 3rd + 4th toes on *plantar* surface = ?- Morton neuroma! - clicking sensation when palpating this space while squeezing joint (*Mulder sign*)localized pain over bony surface of foot local swelling- stress fracture! eg training for a marathon, woman w/ female athlete triadTarsal Tunnel Syndrome- *ankle fracture* -> - compression of *tibial nerve* - burning, numbness, aching of distal *plantar* foot - can radiate to calfcomplications of TPN?- 2-3 weeks -> cholestasis -> fibrosisHIV + low CD4 - MRI: multiple *non-enhancing* lesions - NO mass effect - hemiparesis = ?Progressive Multifocal Leukoencephalopathy! - hemiparesis, disturbances in speech, vision + gait - Toxo + CNS lymphoma = *enhancing*HIV, low CD4 - MRI: 1) multiple, spherical, ring enhancing lesions in basal ganglia = ? 2) solitary, weakly ring enhancing lesion - periventricular = ?1) toxo (most common) - if mentions BACTRIM then NO! - serology meaningless! 2) primary CNS lymphoma! - EBV DNA on CSF = diagnostic!Subacute sclerosing pan-encephalitis- years after *measles* - CT scan shows *scarring + atrophy*ulcer in vermillon zone of lips = ?sq cell CAulcer in mouth: shallow, fibrin coated ulcerations with underlying mononuclear infilrates =?- aphthous ulcers (canker sores) - oral mucosa only - not vermillion zone / gingivaLung cancer associations: 1) clubbing, hypertrophic osteoarthropathy = ? 2) hypercalcemia = ? 3) cushings, SIADH, lambert eaton = ? 4) gynecomastia, galactorrhea?1) adenoCA 2) squamous cell CA 3) small cell CA 4) large cell CAFamilial Hypocalciuric hypoercalcemia (FHH)- aut dom, benign - abnormal Ca sensing receptors on parathyroid cells + renal tubules - inhibits PTH suppression during hypercalcemia - mild hypercalcemia + *borderline PTH* - urine *ca/cr clearance ratio* (UCCR) *<.01* - would be *>0.02* in primary hyperPTH!anti-endomysial antibodies = ?- dermatitis herpetiformis - pruritic papules, vesicles on elbows, knees, buttocks, posterior neck + scalp - IF shows *granular IgA deposits along dermal papillae* - associated w/ *gluten-sensitive enteropathy*acute MI what finding on cardiac exam?1) *atrial gallop* (S4) - due to LV stiffening + dysfunction 2/2 myocardial ischemia 2) *paradoxical splitting of S2* - due to delayed myocardial relaxation + delayed closure of aortic valvepulsus paradoxus seen in who?- cardiac tamponade - severe asthma / COPD - hypovolemic shockAzathioprine Side Effects- pancreatitis - liver toxicity - dose dependent bone marrow suppressionhydroxychloroquine SE- a DMARD - GI distress - visual disturbances - G6PD hemolysiscyclosporine: use? SE?USE: immunosuppresant post transplant SE: - nephrotoxic - predisposes to viral infections / lymphoma - gingival hyperplasiaTc-99m stress test w/ SPECT- shows blood moving through heart - decreased uptake at rest + exercise (fixed) = scar tissue w/ decreased perfusion + CAD - if decreased uptake only during exercise (normal at rest) = *inducible ischemia = CAD*!!! - antiplatelet therapy to prevent MI - beta blockers - lifestyle modsbest kidney donors:1) living related 2) living unrelated 3) cadaverminutes after RBC transfusion: wheezing resp distress *low BP* = ?- anaphylactic rxn -*IgA deficient* people more prone - also angioedema, LOC - IM epi - histamine blockers - glucocorticoids future transfusions: *IgA deficient plasma + washed red cell products*bone pathology buzzwords: 1) abundant mineralization of periosteum 2) cortical bone loss 3) disorganized bone remodeling 4) fibrous replacement of bone 5) increased deposition of poorly mineralized osteoid1) hypervitaminosis A 2) primary hyperParathyroidism 3) Paget's 4) fibrous dysplasia 5) vitamin D deficiencyMeds w/ mortality benefit in CHF- ACE I - beta blockers - ARBs - spironolactonePericarditis + BUN > 60 = ?- uremic pericarditis! - do NOT have diffuse ST elevation (inflammatory cells do not penetrate myocardium) - Tx = dialysisDressler syndrome- post MI pericarditis - 1-6 weeks post MIMalignancy induced hyperCalcemia1) PTHrP production - 80% 2) 1,25(OH)2 vit D production (lymphomas - excessive *GI Ca absorption*) 3) bone mets (*CYTOKINES* stimulate resorption) 4) ectopic PTH = RARECauses of death in acromegaly:1) CV 2) strokes 3) colon cancer 4) renal failure (HTN + hyperglycemia) 5) adrenal failuregoals for cardiac cath: time90 minutes door to cath onset of sx to cath = <12hrsaortic dissection - what do you hear on cardiac exam?- diastolic murmur - due to aortic insufficiency!Stable versus Unstable AnginaStable angina describes symptoms that have been occurring *chronically and are predictable* with exertion. It is thought to be caused by a *stable atherosclerotic plaque.* Unstable angina is when the chest pain occurs *at rest*, is new, is *increasing in frequency*, or when its onset is *triggered with a lower level of exertion*. Unstable angina is caused by an unstable plaque that has* ruptured and caused a non-occlusive thrombus*.PO metoprolol for suspected ACS - why?- reduce infarct size + frequency of myocardial ischemia - improve short- and long-term survival - decrease myocardial oxygen demand by reducing heart rate, blood pressure, and myocardial contractility. The prolonged diastole may also help to augment myocardial perfusion, which occurs mainly during diastole.What test to estimate GFR (if creatinine is constant) ?- chronic kidney disease epidemiology collaboration (*CKD-EPI*) equationacanthocytes on UA microscopy = ?- *glomerular hematuria* -Initial test for sustained, isolated proteinuria = ?- *split urine collection* - collect during day + during night, and compare - can Dx orthostatic proteinuria (more proteinuria at night) - DDx: febrile illness, rigorous exerciseorthostatic proteinuria- protein excretion that increases during the day but decreases at night during recumbency - Dx with *split urine collection* (collect during day + during night, and compare) - 8 hr nighttime collection showing *<50%* of daytime protein = essential for Dx - benignGold standard test for proteinuria = ?- 24 hr urine collectiontx of rhabdo1) rapid infusion IV saline (enough to maintain 300+mL output per hour) 2) dialysis 3) Mannitol - Dx: serum creatinine kinase > 5000 - blood without red cellscomplications of rhabdo- *hypOcalcemia - hyPERphosphatemia - hypERuricemia* - metabolic acidosis - acute muscle compartment syndrome - limb ischemia - 33% get AKI (from *acute tubular necrosis*)Give GI cocktail + feel better - does this r/o ACS?- NO!Causes of a Mid-Systolic Non-Radiating Murmur- Anemia, fever, thyrotoxicosis, pregnancy (*high output states*) - AS (ejection systolic murmur that radiates to carotids) - Aortic *sclerosis* (valve thickening *NO outflow obstruction*) - Pulmonic stenosis - Hypertrophic cardiomyopathy ( younger patients)When to use BNP?A BNP assay improves the accuracy of diagnosis of acute heart failure in patients presenting with dyspnea. This test is most useful in settings of *dyspnea* when the pretest probability is *intermediate* for heart failure. BNP level has a *high negative predictive value* for the diagnosis of heart failure.HF treatments: Hydralazine + nitrates*Hydralazine* reduces *afterload.* *Isosorbide dinitrate reduces both preload and afterload*. Mortality decreased (in African Americans). Recommended for patients intolerant to ACE-I or in addition to standard heart failure therapy in African American patients.Neurohormonal hypothesis of heart failureDecreases in BP, SV (PP) + perfusion (flow) in heart failure are sensed by mechanoreceptors in LV, carotid sinus, aortic arch + renal afferent arterioles. Diminished activation of these receptors, as in heart failure, leads to: - Augmentation of symp outflow -> tachycardia /arrhythmias - Activation of renin-angiotensin-aldosterone system (RAAS) -> myocyte hypertrophy + collagen synthesis, and *Nonosmotic release of arginine vasopressin (AVP)*, which can lead to hyponatremia. - *Heightened peripheral vasoconstriction* (which causes edema) occurs along with *increased blood volume*Precipitants of acute decompensated heart failureIschemia Arrhythmias (atrial or ventricular) Acute valvular disorders Nonadherence to diet and/or medications Infections Uncontrolled hypertension Medications that can worsen heart failure, like NSAIDs, rosiglitazone Acute renal failure Pulmonary embolus Anemia Endocrine problems, like thyrotoxicosisParaphasiatype of language output error commonly associated with aphasia, and characterized by the production of unintended syllables, words, or phrases during the effort to speak. Paraphasic errors are most common in patients with fluent forms of aphasia, and comes in three forms: phonemic or literal, neologistic, and verbalImplantable cardioverter defibrillators (ICDs)#1 cause of sudden death in CHF = arrhythmia (VTach / bradyarrhythmia) - Prophylactic implantation of ICDs = survival benefit in patients with: 1) ischemic cardiomyopathy (with asymptomatic nonsustained vatch, prior MI and LVEF </= 30%) and 2) nonischemic cardiomyopathy (LVEF </= 35%).Biventricular pacemakers - who gets them?- HF w/ severe symptoms (*NYHA class III or IV*) AND - evidence of ventricular dyssynchrony (*LV enlargement + QRS prolongation*) - for cardiac resynchronization therapy -> reduction in symptoms and improved functional capacity -> reduction in # of hospitalizations + increased survival.Heart Failure Discharge CriteriaExacerbating factors are addressed Near optimal volume status is achieved Transition from IV to oral diuretic Education completed, including clear discharge instructions LVEF documented Smoking cessation counseling initiated Near optimal pharmacological therapy achieved, or intolerance documented Follow-up clinic visit scheduled, usually for *7 to 10 days*Prognosis of Symptomatic Heart FailureDespite many recent advances in the evaluation and management of HF, the development of symptomatic HF still carries a poor prognosis. Patients with symptoms at rest (NYHA class IV) have a 30-70% annual mortality rate, whereas patients with symptoms with moderate activity (NYHA class II) have an annual mortality rate of 5-10%. Thus, functional status is an important predictor of patient outcome.PR depression on ECG = ?- pericarditis ! - also diffuse ST elevationnon-pleuritic, sharp anterior CP, non-exertional, reproducible point tenderness, poorly localized, insidious onset= costochondritis!man w/ chest pain, negative troponins - next step?- admit to tele for serial trops! - only need intermediate risk for admitWhen to use thrombolytics for ACS?- if you missed cath window OR - cath not availableT-wave inversion V2 V6 without Q waves = ?unstable angina!MONA BASHMONA = acute ACS (morphine, O2, nitro, aspirin) BASH = on discharge beta blockers - ACE I - STATIN - HEPARINTx for Afib = ?warfarin! NOT clopidogrel!CHADS = ? (Afib stroke risk)CHF HTN Age > 75 DM Stroke / TIA previously (2 pts) score 0 = ASA 1 = Warfarin / ASA 2 = Warfarin 3 = 5.9% annual stroke risk w/out CoumadinMultifocal Atrial Tachy- 3 different types of p waves - think *COPD*Indications for pacemaker placement- *sinus node dysfunction* - *AV block* - neurocardiogenic syncope - iatrogenic causes (eg, post-AV node ablation)CHF meds that help Sx but do NOT prolong life = ?- CCBs - Digoxin - DiureticsHeart Failure med- everyone gets *ACE I, Beta* - stage 3-4 add *spironolactone*PE - causes of compromised physiology1) anatomical obstruction 2) release of vasoactive + bronchoactive agents such as *serotonin* from *platelets* may lead to deleterious ventilation-perfusion matching 3) increased RV afterload -> RV failurePVCs (ventricular premature beat / VPB)- wide, bizarre morphology, *>0.16 seconds* - originate in LV when it has a positive deflection or tall R wave in V1 (RBBB configuration) - while a negative complex with a deep S wave in V1 (resembling a LBBB) originates in RVSx of digoxin toxicityarrythmias anorexia N/V ab pain fatigue, confusion, weakness *color vision* alterationsWhat drug increases effect of digoxin?- amiodarone! - must reduce dose 25-50%patient with: GI symptoms (N/V) confusion weakness = ?- digoxin toxicity!Pulmonary HTN- primary pulm HTN due to *increased pulm ARTERIAL P* - LV failure -> *increased pulm VENOUS P* - chest auscultation: *loud S2*Alcohol Withdrawal - intro- requires long binge - most people don't get, because they drink in an episodic fashion - requires high blood concentrations - sx due to withdrawal of: 1) enhanced inhibitory tone (GABA) 2) inhibited excitatory tone (Glutamate + NMDA) - only constant presence of alcohol preserves homeostatis -> abrupt cessation -> *CNS overactivity*Alcohol Withdrawal minor symptoms- insomnia - tremulousness - mild anxiety - GI upset, anorexia - headache - diaphoresis - palpitations - present *within 6 hrs* of cessation of drinking - can occur *with high BAC* - resolve 24-48rsAlcohol withdrawal seizures- generalized tonic clonic - *singular* or *brief flurry* - *12-48 hrs* after last drink (can be as early as 2 hrs) - usually w/ *Long hx of chronic alcoholism* - if are reccurent/prolonged, look for infection / structural source (*CT + LP*) - *NO phenytoin* !!! - *1/3 progress to DT*Alcoholic Hallucinosis vs DT1) alcoholic hallucinosis: develop in *12-24 hrs* - resolve in 24-48 hrs - *specific*, usually *visual* (can be auditory / tactile) - *NOT* associated w/ global clouding of sensorium - *vitals NORMAL* 2) DT begins *48-96 hrs lasts 1-5 days* - hallucinations, disorientation, tachycardia, HTN, hyperthermia, agitation, diaphoresis - *AMS!!!*Delerium Tremenshallucinations, disorientation, tachycardia, HTN, hyperthermia, agitation, diaphoresis - *elevated cardiac index, O2 delivery, O2 consumption* - *hyperventilation* (removal of inhibition) -> *resp alkalosis* -> *decreased cerebral BF* -> *hypovolemic* (sweating, vomiting etc) -> *hypOkalemic* -> *hypOMg* (predisposes to dysrhythmias + seizures) -> *hypoPhosphatemia* (malnutrition, cardiac failure, *rhadbo*)Risk factors for delerium tremens- 5% of alcohol withdrawal patients - *5% mortality* (arrythmia, pneumonia, pancreatitis, hepatitis, CNS injury) - hx sustained drinking - previous DT - *age > 30* - concurrent illness - presence of withdrawal w/ elevated BALTx for alcohol withdrawal- benzodiazepines (*long acting = diazepam/valium*) - IVF - thiamine + glucose (prevent Wernicke's encephalopathy) - multivitamins w/ *folate* - 2 days = *IV tx* (chronic alcoholics have impaired absorption) - NPO (prevent aspiration) - then lots of nutrition (high need due to excited autonomic state)Labs for alcoholic liver disease- AST:ALT ratio > 2:1 - Gamma-glutamyl transpeptidase (GGT) elevation (also seen in *biliary, pancreatic disease, barbituates, phenytoin*) - decompensated cirrhosis -> *elevated bilirubin* - malnourished / cirrhosis -> low albuminPulsus Paradoxus= >10mg Hg *drop* in SBP during *inspiration* = cardiac tamponade - decreased RV compliance - shifts IV septum toward LV -> *less LV filling*"Spared Eye Injury"- sympathetic ophthalmia - immune mediated inflammation of *NON injured eye* when the other has penetrating injury - anterio uveitus / panuveitis, papillary edema -> *blindness* - antigens within eye protected by barriers, when broken are *"un hidden"* from immune systemEye disease/injury associations: 1) Reagin-mediated (IgE) 2) cirulating immune complexes 3) non-caseating granulomas1) = vernal (allergic) conjunctivitis 2) SLE 3) sarcoidosisHow can O2 cause CO2 retention (hypercapnia) during COPD exacerbations?- increased dead space perfusion -> V/Q mismatch (loss of compensatory vasoconstriction) - decreased affinity of oxyHb for CO2 (reduces CO2 uptake from tissues) - reduced resp drive -> reduced alveolar ventilation - goal sat for these patients is *90-93%*How does hypercapnia (high CO2) cause AMS ?1) high CO2 -> *acidosis* -> - increases brain *GABA + glutamine* - decreased glutamate + aspartate 2) reflex cerebral *vasodilation* -> seizuresflushed face (rosy hue), *telangiectasias*, cheeks, nose, chin= Rosacea! - precipitated by heat, emotion - intermittent -> permanent - sometimes *papules / pustules* - 30-60 yo - fair skin, light eyes - DDX = *carcinoid* - flushing lasts on *20-30seconds* + telangiectasias + *diarrhea, cyanosis*scales around nose, eyebrows, ears, scalp = ?- seborrheic dermatitis! (or maybe psoriasis)What kind of bias when many subjects are lost to follow-up in a prospective study?- attrition bias = subtype of *selection bias*What is reporting bias?- when a subject is reluctant to report an exposure due to stigma (sexual behaviors, drug use)dusky red, target shaped lesions on extremities = ?- erythema multiforme! - seen in mycoplasma pneumoniaefever, cough, rash, headache, target shaped dusky red lesions on extremities, interstitial infiltrates LL Lobe Sputum Gram stain = PMNs and *no organisms* = ?- Mycoplasma pneumonia!D Xylose test- simple sugar, passively absorbed - tests *absorptive capacity of sm intestine* - low urinary excretion means its not absorbed + instead excreted in *feces* - false positive = bacterial overgrowth - tests for *celiac* NOT Crohns (terminal Ileum)Painful, subcutaneous reddish nodules in *pre tibial* area = ?- Erythema Nodosum - Sarcoidosis (african american) - TB - histoplasmosis - recent strep infection - IBDcough, arthritis, uveitis, nodules on shins = ?- sarcoidosis! - also hilar LAD - nodules = erythema NodosumWorkup of Erythema nodosum = ?- CXR (sarcoidosis, histo, TB) - PPD (if TB risk factors) - ASO titer (strep)diabetic with deformed, mildly painful foot?= charcot joint (neurogenic arthropathy)Charcot joint (neurogenic arthropathy)causes: *B12 deficiency, DM*, peripheral nerve damage, spinal cord injury, syringomyelia, tabes dorsalis - deformed, mildly painful joints - loss of sensation (*loss of neurologic input*) - fractures - degenerative joint disease + *loose bodies* on imaging + *osteophytes* - Tx: underlying condition, mechanical devices, Xrays for traumaWhy fractures w/ charcot joints?- without neuro input, patients cant' sense damage!Patient taking PTU / methimazole presents w/ fever + sore throat = ?- risk *agranulocytosis* 1) D/C drug 2) take *WBC count* - if *< 1000* cubic mm = permanent d/c - if *> 1500* - drug isn't to blame"mid-diastolic sound" on cardiac auscultation = ?- pericardial knock = constrictive pericarditis!progressive peripheral edema, ascites, elevated JVP, pericardial knock *mid diastolic sound*, heart calcifications on CXR = ?- constrictive pericarditis !Echo: increased ventricular wall thickness w/ non dilated Ventricle cavity heavy proteinuria, *periorbital purpura*, hepatomegaly = ?cardiac amyloidosis!Etiologies of constrictive pericarditisidiopathic prior cardiac surgery (valve, CABG) mediastinal irradiation TB malignancy *uremia*young woman, Hx HTN, carotid bruit = ?- fibromuscular dysplasia (*renal, carotid, vertebral aa* = high renin! resistant HTN - CNS involvement - amaurosis fugax, Horner's syndrome, TIA, stroke 1) CT abdomen / duplex US 2) catheter subtraction arteriography (if inconclusive) 3) f/u BP/Cr every 3-4 mo - renal US every 6-12 moLower GI bleed (hematochezia) workup1) NG lavage (check for UGI bleed) 2) consider upper endoscopy in case bleed is in duodenum 3) if likely large bowel -> colonoscopy to look for site of bleed 4) if nothing on colonoscopy, then *Technetium-99 labeled erythrocyte scintigraphy* 5) still can't find + still bleeding = laparotamyInfliximab used to treat what?= TNF alpha blocker treats: 1) IBD 2) ankylosing spondylitis 3) RATx for SLE w/ renal involvement = ?= cyclophosphamidetx of sarcoidosis= systemic glucocorticoidshypoglycemia, hyponatremia, *esosinophilia* fatigue + loss of appetite = ?- glucocorticoid deficiency!cold intolerance, constipation, bradycardia= hypothyroidism!Ventricular bigeminy- when a premature ventricular complex follows each sinus beat (waveform 3) - may become self-perpetuating, a situation known as the rule of bigeminy - This occurs because the long cycle length after the prior PVC tends to precipitate the next PVC after a sinus beat - indicates a repeating pattern but has no other clinical implicationsBenzonatatenon-narcotic oral cough suppressant, or antitussiveHIV + cardiac disease- HTN, (hyperglycemia, hyperlipidemia, lipodystrophy), and accelerated atherosclerosis + CAD - focal myocarditis - cardiomyopathy (Left ventricular diastolic dysfunction)HIV-associated nephropathy= a collapsing form of *focal segmental glomerulosclerosis (FSGS)* - with associated tubular microcysts and interstitial inflammation - significant proteinuria and rapidly progressive kidney disease in the setting of *normal BP* + normal to enlarged kidneys - not seen in patients on ART who have a normal CD4 T cell count and an undetectable HIV viral load Infection of kidney epithelial cells by HIV and expression of HIV genes within infected kidney cellsPCP pneumonia- CD4 under 200 - ground-glass appearance on imaging - elevated serum lactate dehydrogenaserecurrent infections + nasal polyps = ?- CF - accumulation of inspissated mucus -> bact proliferation + reccurent infections - Tx = intranasal glucocorticoidsGold Standard to Dx CF- quantitative pilocarpine iontophoresis - measurement of sweat ChlorideMusculoskeletal sequelae of CF = ?- osteopenia -> fractures - kyphoscoliosis - digital clubbinghomeless man - confused, flank pain, AKI hematuria, met acidosis hypOcalcemia + Ca oxalate crystals in urine- ethylene glycol poisoning (antifreeze) - calcium oxalate (envelope shaped) crystals 1) fomepizole / ethanol 2) sodium bicarb (to alleviate acidosis) 3) hemodialysis (for severe acidosis / end organ damage)Membranous Nephropathy buzzwords- adenoCA (breast, lung) - NSAIDs - Hep B - SLEFSGS buzzwords- African American / Hispanic - obesity - HIV + IV drugsMembranoproliferative glomerulonephritis buzzwords- Hep B+C - lipodystrophyminimal change disease clinical associations- NSAIDs - lymphomaIgA Nephropathy clinical association- URIbilateral, symmetric *pseudofractures* (Looser zones) = ?- sign of *osteomalacia* - *low Vit D* -> low Ca + phos -> secondary hypERparathyroidism -> bone resorptiondehydration, weight loss, orthostatic hypOtension hypOkelmia hypOnatremia, *elevated urine Na + K* = ?- diuretic abuse! - to lose weight!Distortion of straight lines to appear wavy = ?- early sign of *macular degeneration* risk factors: - age - smoking - drusen deposits in maculaOphtho buzzwords: 1) lens opacification = ? 2) enlarged blind spot = ?1) = cataracts 2) = papilledemanephrotic syndrome, rheumatoid arthritis, enlarged kidneys, hepatomegaly = ?- amyloidosis - Congo red, apple green birefringence under polarized light - deposits on glomerular BM, blood vessels, kidney interstitium (on EM *thin fibrils*) - light chains (AL amyloidosis) - abnormal proteins (AA amyloidosis)pyelonephritis w/ *MDR organism* think ?- gram negative rod = tx w/ *aminoglycosides*amikacin= aminoglycoside - can be nephrotoxic! - monitor renal function during therapydoxycycline used to treat ?- CAP - Lyme - Chlamydia - acneLab results for lactose intolerance = ?- positive hydrogen breath test (indicates bacterial carb metabolism) - positive stool test for reducing substances - low stool pH (due to fermentation products) - increased stool osmotic gap (due to unmetabolized lactose + organic acids - >50)screening test for thalassemia in a non african ?= CBC (eg mediterranean) - if African Descent, screening test = Hb electrophoresis - only test partner of woman wanting to get pregnant if SHE has abnormal valueskeratoacanthoma- rapidly growing "volcano like" nodule - central keratotic plug - may regress, but treated like well differentiated sq cell CAs - early tx indicated if near eye/other important structureHTN + hypokalemia (ALWAYS)- hyper aldosteronism! - esp YOUNG patient - more prone to hypOK due to diuretics!jaundice, pruritis anti MITO Abs = ?- primary biliary cirrhosis - lymphocytes, macrophaes, plasma cells, eosinophils - noncaseating granulomas -> cirrhosisanti sm muscle abs = ?- auto immune hepatitis!risk factors for non-Alcoholic steato-hepatitis (NASH)- obesity - DM - hyperlipidemia - *TPN* - medicationscause of NASH- impaired responsiveness of fat cells to insulin -> fat accumulation in liver -> hepatitis/fibrosis - 2/2 *lipid peroxidation + oxidative stress*rapid changes in color perception = ?= optic neuritis! - afferent pupillary defect - scotomagradual loss of peripheral vision -> tunnel vision = ?- open angle glaucoma!eye with: perilimbal injection, keratic precipitates, corneal stromal edema = ?- anterior uveitis !HIV esophagitis round/avoid ulcers = ? deep, linear ulcers = ? oral thrush = ?round = HSV linear = CMV candida esophagitisTx of moderate acne- topical retinoids - topical antibiotics - benzoyl peroxide