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Emma Holliday Ramahi - Internal Medicine

Terms in this set (556)

Risks for PE?
after surgery
long car ride
hyper coagulable state (cancer, nephrotic)
STEMI on ECG? (2)
when does T wave invert?
what lasts forever?
2mm ST elevation
- ST elevation immediately
- then T wave inversion 6hrs-yrs
- Q waves last forever
new LBBB (wide, flat QRS)
Localized infarcts on ECG? what leads and what artery?
[Anterior, Lateral, Inferior, RV]
Anterior: LAD - V1-4
Lateral: Circumflex - I, aVL, V4-6
Inferior: RCA - II, III, aVF
RV: RCA - V4 on R side ECG!
Emergency reperfusion options (2)?
Contraindications (2)?
*Cath lab*
*Thrombolytics* w/ in 6hrs
Contra: bleeding, hx hemorrhagic stroke, recent closed head trauma
RV infarct BP, pulse, Sx (2) no what? Tx?
Low BP, tachycardia
clear lungs, JVD
No pulsus paradoxus

Txt: vigorous fluid resuscitation, increase preload. DON'T give nitro, will worsen sx
STEMI work up after EKG? then what?
cardiac enzyme
Normal ECG, elevated cardiac enzymes. Dx? Workup?
NSTEMI
Check enzymes q8h x 3 to look for trend
3 Cardiac enzymes? (3)
*Myoglobin*
Rises 1st, peak 2h, nml by 24h (detect NEW infarct)
*CK-MB*
Rise 4-8, peak 24h , nml by 72h
*Troponin I*
Rise 3-5h, peak 24-48h, nml by 7-10d
NSTEMI acute txt (8)? Immediate workup?
*M*orphine
*O*2
*N*itrates
*A*SA/clopidogrel
Coronary angiography w/in 48h
NSTEMI interventions (2)?
PCI w/ stenting
CABG if:
- L main dx
- 3 vessel dx
- 2 vessel dx in DM
- >70% occlusion
- pain despite txt
- post-MI angina
NSTEMI discharge Rx?
DC on:
*B*eta-blocker (Metoprolol, Labetalol)
*A*CEI if CHF or LV dysfxn
*S*tatin
*H*eparin (while in hospital)
+Nitrates
CP w/out ST elevation & normal cardiac enzyme (how many repeats)?
normal cardiac enzyme x 3
if both negative, then unstable angina
Unstable angina workup (4)? what if the result is positive?
1. Exercise EKG
2. if EKG not possible, exercise echo
3. if pt cannot exercise, do chemical stress test (Adenosine/Dobutamine; Thallium-Dipyridamole)
4. multiple gated acquisition scan MUGA is nuclear medicine test that shows perfusion of the heart
If +, coronary angiography
What to avoid b/f exercise EKG (2)?
beta-blocker, CCB
Exercise ECG
Contraindications to exercise stress test (3)
- old LBBB
- baseline STE
- on Digoxin
meds for chemical stress test (3)
dobutamine
adenosine
thallium-dipyridamole
(cardiac vasodilator - dilate coronary vessels causing better flow in normal vessels & less response in stenotic vessels; perfusion defects will show up in scan, may have ST changes)
what needs to be avoided before MUGA (2)
caffeine
theophyline (PDE inhibitor)
Unstable angina treatment (3)
Beta-blocker
nitrate
ASA
Post-MI complications:
Most common cause of death?
Arrhythmias
(most Vfib)
Post-MI complications:
New systolic murmur 5-7d s/p? what type of murmur?
Papillary muscle rupture
mitral regurgitation: holosystolic murmur radiating to axilla
Post-MI complications:
Acute severe hypotension?
Ventricular free wall rupture
Post-MI complications:
"step up" in [O2] from RA->RV i.e. more O₂ in RA than RV?
Ventricular septal rupture
Post-MI complications:
Persistent ST elevation ~1mo later + systolic mitral regurgitation murmur?
Ventricular wall aneurysm
Post-MI complications:
"Cannon A-waves" i.e. bounding JVP
AV-dissociation i.e. Either V-fib or 3rd degree heart block
tricupspid valve not opening properly -> blood bounces back to neck
Post-MI complications:
5-10 (or 2.5) wks later pleuritic CP, low grade temp? Dx? Tx (2)?
Dressler's syndrome (probably) autoimmune pericarditis
Txt: NSAIDs, ASA
Young, healthy pt w/ CP:
worse w/ inspiration, better w/ leaning forward, friction rub. Dx? EKG? Txt?
Pericarditis
diffuse ST elevation on ECG
Txt: NSAIDs
Young, healthy pt w/ CP:
worse w/ palpation
costochondriasis
Young, healthy pt w/ CP:
vague w/ hx of viral infxn and murmur
myocarditis
Young, healthy pt w/ CP:
occurs at rest, worse at night, few CAD risk factors, hx migraine (~female), w/ transient STE during episodes. Dx test? Txt?
Prinzmetal's angina
Dx: Ergonovine stimulation test to identify blood vessel spasms
Txt: CCB or Nitrates
EKG: Progressive, prolongation of the PR interval followed by a dropped beat; txt?
Wenkebach/ Mobitz Type I 2nd deg heart block
Tx: reassurance
EKG: regular P-P interval and regular R-R interval,
Cannon-a waves on physical exam
(cannon a waves seen on JVD)
3rd deg heart block
Tx: pacemaker (also for Mobitz 2)
EKG: varying PR interval with 3 or more morphologically distinct P waves in the same lead. Old person w/ chronic lung dx in pending respiratory failure
MAT (multifocal atrial tachycardia)
in sick sick pt
EKG: Three or more consecutive beats w/ QRS <120ms @ a rate of >120bpm
Txt stable (2), unstable (1)?
Ventricular tachycardia

Unstable pt: cardiovert
Stable pt: Lidocaine, Amiodarone
EKG: Short PR interval followed by QRS >120ms with a slurred initial deflection. what wave is that? Txt? Contraindications (3)?
Wolf-Parkinson-White
Delta wave representing early ventricular activation via the bundle of Kent
Txt: Procainamide
Contra: Beta blokers, Digoxin, CCB (Verapamil, Diltiazem), anything that slows AV node conduction will worsen arrhythmia
EKG: Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm. Txt?
Atrial flutter

"sawtooth waves"

Unstable pt: cardiovert
Stable pt: Beta blockers, Digoxin
EKG: prolonged QT interval leading to undulating rotation of the QRS complex around the EKG baseline
Torsades de pointe

Seen in a pt w/ low Mg and low K. Lithium or TCA OD
EKG: Regular rhythm w/ a rate btwn 150-220bpm. Sudden onset of palpitations/ dizziness. Txt?
Supraventricular tachycardia

Txt: carotid sinus massage, ice to the face, Adenosine
EKG: peaked T-waves, wide QRS, short QT and long PR. Renal failure patient/ crush injury/ burn victim.
Hyperkalemia
EKG: Alternate beat variation in direction, amplitude and duration of the QRS in a pt w/ pulsus paradoxus, . buzzword?
Cardiac tamponade

"electrical alternans"
In cardiac tamponade, diastolic failure is affected by what factor?
how fast the fluid is building up & not how much
what's Beck's triad for cardiac tamponade?
JVD
hypotension
Distance heart sound↔
what predisposes pt to A-fib?
dilation of right atrium
(iatrogenic: fluid overload)
Undulating baseline, no p-waves, irregular R-R interval in a hyperthyroid pt (too much Synthroid), old pt w/ SOB/ dizziness/ palpitations w/ CHF or valve dx. Txt?
Atrial fibrillation

Dilation of RA predisposes

Txt: rate control w/ Beta blockers or Digoxin
(nbme) systolic ejection murmur at right 2nd intercostal space, S4 + ejection "click"
Aortic stenosis from calcification of bicuspid valve
"click" is when valve pushes open
systolic ejection murmur cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvus et tardus
Aortic Stenosis

Cause: degeneration
Txt: replace valve
systolic ejection murmur *louder w/ valsalva,* softer w/ squatting or handgrip. Tx?
HOCM
younger pt
tx: beta blocker
Late systolic murmur w/ *click* louder w/ valsalva and handgrip, softer w/ squatting
Mitral Valve Prolapse
Holosystolic murmur radiates to axilla w/ LAE
Mitral Regurgitation
causes left atrial enlargement
Holosystolic murmur w/ late diastolic rumble in kiddos
VSD
Continuous machine like murmur
PDA
Wide fixed and split S2
ASD
Rumbling diastolic murmur with an opening snap, left atrial enlargement and A-fib
Mitral Stenosis
Blowing diastolic murmur with widened pulse pressure; pulse buzzword?
Aortic Regurgitation
"water hammer pulse"
SOB: if murmur & hx of CHF, NBS? what lab
echo to check ejection fraction
BNP to check myocytes stress
SOB: Txt for acute pulmonary edema? (3)
nitrates, lasix and morphine
SOB: young person w/ CHF?
consider myocarditis (Coxsackie B)
SOB: young pt w/ no cardiomegaly on CXR?
primary pulomnary HTN

R heart cath --> PCWP normal (elevated in CHF)
SOB: how can you tell pHTN from CHF in SOB?
Right heart cath
PCWP = Left atrial pressure ↑ in CHF (blood is backed up)
cardiomyopathy: teenagers, LOC during sport, family hx, drowning; dx? tx?
HOCM
beta blocker, mymectomy
cardiomyopathy: amyloid, sarcoid, hemachromatosis, fibroblast
restrictive
cardiomyopathy: most common cause of dilated cardiomyopathy
MI
lose tissue → floopy heart
Systolic CHF ejection fraction? 2 types of sys CHF
EF<55%
ischemic, dilated
Reversible: EtOH w/ abstinence
5 causes of sys CHF? which one is reversible?
viral
EtOH: reversible if quit
cocaine
Chargas
Idiopathic
Dias CHF ejection fraction?
normal EF (heart can't fill
Reversible cause: Hemachromatosis w/ phlebotomy
4 causes for dias CHF? which one is reversible
1. HTN → chronic LVH, <3 can't relax
2. amyloidosis
3. hemachromatosis: reverse w/ phlebotomy
4. mitral valve stenosis
Dias CHF hematochromatosis buzzword
Bronze diabetes
DM + bronze skin
lung sound clear, blood stuck in pulmonary veins
CHF Txt (3 cardiac protective + 2)
*ACE-I* improve survival - prevent remodeling by aldo.
*B-blocker* (metoprolol and carveldilol) improve survival- prevent remodeling by epi/norepi
*Spironolactone* - improves survival in NYHA class III and IV
*Furosemide* - improves sxs (SOB, crackles, edema)
*Digoxin* - decreases sxs and hospitalizations. NOT survival
digoxin OD (3)
Atach
AV block
visual changes
:D 3 causes for chronic cough; duration?
2 weeks
post nasal drip: anti-histamine
GERD: PPi or H₂ blockers
Asthma: albuterol or ICS
CXR: Opacification, consolidation, air bronchograms
Lobar Consolidation Pneumonia
(vs mycoplasma: interstitial infiltrate)
CXR: hyperlucent lung fields with flattened diaphragms
COPD
CXR: heart > 50% AP diameter, cephalization, Kerly B lines & interstitial edema
CHF
CXR: Cavity containing an air- fluid level; what bug (2)?
Pulmonary abscess
(anaerobes, Staph)
CXR: Upper lobe cavitation, consolidation +/- hilar adenopathy
Tuberculosis
CXR: Thickened peritracheal stripe and splayed carina bifurcation
Mediastinal mass (LAD, CA)
LA enlargement from mitral stenosis
Pleural effusions, how to you find it? what do you do?
see fluid < 1 cm on lateral decubitus
thoracentesis
Transudative Pleural Effusion causes (3)
likely systemic: CHF, nephrotic sx, cirrhosis
Exudative Pleural Effusion causes (2)
likely local: parapneumonic = pus + pneumonia, CA
3 criterias for Complicated Pleural Effusion, tx?
1. Gram+ or Cx
2. pH < 7.2 (very acidic)
3. glucose < 60
Txt: drain w/ test tube
Transudative Pleural Effusion buzzwords:
low pleural glucose?
high WBC?
bloody?
amylase?
milky?
low pleural glucose: RA
high WBC: TB
bloody: malignant or pulmonary fibrosis
amylase: pancreatitis, esophageal rupture
milky: chylothorax so trauma
Light's Criteria?
Exudative if:
LDH ↑ 200 (2/3 RUL)
LDH eff/serum ↑ 0.6
Protein eff/serum ↑ 0.5
(fluid always on top, we're looking at it)
Treatment for transudative pleural effusion (2) & exudative pleural effusion (2)
transudative: diuretic + salt
exudative: Abx + chest tube
Resp. failure: hypoxic type has what #? look for what in answer? what is the A-a gradient?
PaO₂ ↓60
look for V/Q mismatch in answer
A-a = ↑5 high
How do you find A in hypoxic resp failure
A=150-PaCO₂/0.8
Resp. failure: hypercapnic has what #?
PaCO₂ ↑50
Resp. failure pt, Abg ↓60, no improve w/ O₂; Dx? NBS?
Sepsis leads to ARDS
ventilation
increase PEEP
keep low: FiO₂ & tidal vol
Resp failure ARDS pt, work up after tx
Echo to r/o heart issue
type of CP in PE, what other symptom (2)?
what vitals?
Findings on EKG (2), CXR (2), Abg (2)?
pleuritic CP
Sxs: hemoptysis, SOB; vitals: Decr pO2, tachycardia.
Random signs: R heart strain on EKG, sinus tachy most common
CXR: decr vascular markings, wedge infarct, ABG w/ low CO2 and O2.
Westermark Sign on CXR - focus of oligemia (leading to collapse of vessel) seen distal to a pulmonary embolism (PE)
Suspect PE, NBS? workup (3)?
Give Heparin 1st!
V/Q scan
Spiral CT
pulmonary angiography (gold standard)
Txt for PE (4)?
1. Heparin bridge to Warfarin
2. thrombolytic if severe
3. thrombectomy if life threatening
4. IVC filter if contraindications to chronic coagulation
contraindications to thrombolytics in PE (2)?
s/p surgery
hemorrhagic CVA
CXR: bilateral fluffy infiltrates? how does it happen?
Acute Respiratory Distress Syndrome
impaired gas exchange, inflammatory mediator release, hypoxemia
5 Causes of ARDS?
Sepsis
gastric aspiration
trauma
low perfusion
pancreatitis
4 Dx criteria for ARDS?
1) PaO2/FiO2 < 200 (<300 means acute lung injury)
2) Bilateral alveolar infiltrates on CXR
3) PCWP is <18 (r/o cardio cause of pulmonary edema)
4) Echo to r/o heart issues
Txt for ARDS?
mechanical ventilation w/ PEEP
Obstructive lung dx & examples (3)?
FVC, FEV₁, FEV₁/FVC
TLC
RV
low FVC, low FEV1 -> *low FEV1/FVC*
high TLC
high RV
DLCO reduced in emphysema 2/2 alveolar destruction-> more space

Ex: COPD, emphysema, asthma
In obstructive lund dx, how is asthma different in bronchodilator challenge?
FEV₁ improves ↑12%
Restrictive lung dx 2 examples?
FVC, FEV₁, FEV₁/FVC
TLC
RV
low FVC, low FEV1 -> *normal FEV1/FVC*
low TLC
low RV
DLCO reduced in ILD 2/2 fibrous thickening distance
Restrictive lung disease examples (2)
interstitial lung dx (sarcoid, silicosis, asbestosis), structural (obesity, MG/ALS, phrenic nerve paralysis, scoliosis)
COPD dx criteria?
Productive cough >3mo for >2 consecutive yrs
COPD txt (3)? Goal SpO2?
1st line = ipratropium, tiotropium
2nd Beta agonists
3rd Theophylline :( narrow therapeutic window; messes up heart rate

Goal SpO2: 94-95% bc pts are chronic CO2 retainers so hypoxia is the only drive for respiration
Indications to start O2 (in COPD) (2)?
PaO2 <55 (If cor pulmonale, <59)
SpO2<88%
COPD treatment steps up?
FEV1/FVC
80%: albuterol/ipratropium
50%: add LABA
30-50%: add ICS
COPD exacerbation criteria? txt (3 meds; 2 abx)?
Change in sputum, increasing SOB
O2 to 90%
albuterol/ipratropium nebs
PO or IV corticosteroids
Abx: FQ or macrolide
Best prognostic factor for COPD?
FEV₁
Interventions shown to improve COPD mortality? (2)
1) Quitting smoking (can decr rate of FEV1 decline
2) Continuous O2 therapy >18hrs/day
Vaccinations for COPD pt (2)?
Pneumococcus w/ a 5yr booster
annual influenza vaccine
New clubbing in a COPD pt? NBS? why?
Hypertrophic Osteoarthropathy

Next best step... get a CXR
Most likely cause is underlying lung malignancy
Chronic cough pt, foul sputum, hemoptysis, Dx? NBS? what risk factor?
bronchiectasis
CT: signet ring
cystic fibrosis pt w/ Pseudomonas infection
Asthma: definition mild intermittent asthma, tx?
sxs twice/week; normal PFT
1. SABA (Albuterol)
Asthma: definition mild persistent asthma, txt? what is the rule of 2?
sxs 4x/wk, night cough 2x/mo, normal PFTs
Mild persistent asthma
1. SABA (albuterol)
2. low dose inhaled CS
mild intermittent ↓2 albuterol/wk, ↓2 night cough/mo; if more than 2 = mild persistent & need ICS
Asthma: definition moderate persistent asthma. Txt?
sxs daily, night cough 2x/wk, FEV₁ 60-80%
1. SABA (albuterol)
2. low dose inhaled CS
3. LABA (Salmeterol)
Asthma: definition severe persistent asthma. Txt?
sxs daily, night cough 4x/wk, FEV₁ < 60%
Step 4-6:
1. SABA (albuterol)
2. med-high dose inhaled CS
3. LABA (salmeterol)
4. Leukotriene modifying agent (montelukast)
5. oral steroid
Asthma exacerbation Mgmt? what 2 things to watch?
1. albuterol
2. PO/IV steroids
monitor Peak flow rates and blood gas (PCO2 should be low)
Sign of impending respiratory failure?
Normalizing PCO₂ (late sign) --> impending respiratory failure --> INTUBATE
what is asthma + eosinophilia + vasculitis
Churg Strauss
major asthma complication
allergic brochopulmonary aspergillus
random restrictive lung dz:
female s/p breast CA tx, cough, fatigue, SOB?
radiation pneumonitis
alveolar thickening + fibrosis
random restrictive lung dz:
honeycomb w/ heterogeneity? outcome?
interstitial pulmonary fibrosis
death in 5 yrs
random restrictive lung dz:
1cm nodues in *upper lobes* w/ *eggshell calcifications*. Mgmt?
*Silicosis*
Get yearly TB test! More predisposed. Give INH for 9mo if >10mm
random restrictive lung dz:
Reticulonodular process in *lower lobes* w/ *pleural plaques*. Associations (2)?
*Asbestosis*
Most common cancer is broncogenic carcinoma, but incr risk for mesothelioma
random restrictive lung dz:
Patchy *lower lobe* infiltrates, thermophilic actinomyces.
*Hypersensitivity Pneumonitis* = "farmer's lung"
random restrictive lung dz:
Hilar LAD, ↑ACE *erythema nodosum*. Dx? Txt? what abnormal lab?
*Sarcoidosis*
Also hypercalcemia 2/2 increased macrophages making vitamin D

Dx: biopsy - non-caseating granuloma
Txt: steroids
Important referral for pt w/ sarcoidosis?
Ophthalmology -> uveitis conjunctivitis in 25%
random restrictive lung dz:
hemoptysis + hematuria? Tx?
Good Pasteur
Tx: cyclophosphamide, plasmophresis (take out Ig)
random restrictive lung dz:
restrictive lung dz + URI?
Wegner (polyangiitis with granulomatosis); cANCA
benign pulmonary nodules
safe age? safe size?
work up? how often?
popcorn calcification = ?
concentric calcification = ?
Pt <40yo
size <3cm
well circumscribed
CXR or CT q2mo to monitor growth

popcorn calcification = hamartoma (most common)
concentric calcification = old granuloma
malignant pulmonary nodules?
risk factors (2)? bad size?
Xray finding (2)?
work up?
20 pk-yr smoker
older pt
size >3cm
eccentric, spiculated calcification

Mgmt: open lung bx, remove nodule
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse; dx?
lung CA (bronchogenic carcinoma)
tx for non-small cell & small cell tumor (logical)?
non-small cell: resection
small cell: chemo
what is a pancoast tumor? 3 syndromes associated
lung cancer (tumor) at apex of the lung; causing
1. Horner syndrome: ptosis, meiosis, hemianhydrosis
2. Thoracic Outlet syndrome: pressure on C8, T1, subclavian a. → pain to medial forearm & atrophy to intrinsic hand muscle
3. Superior vena cava syndrome: dilation of head & neck vein, facial swelling, cyanosis
2 nerves that can be damaged by lung cancer
1. paralysis of recurrent laryngeal nerve at diaphragm: hoarse voice
2. phrenic nerve: paralyze diaphragm
Most common lung CA in *non*smokers?
*Adenocarcinoma*

Occurs in scars of old pneumonia
Lung CA mets to (4)?
AdenoCA (peripheral) --> liver, bone, brain, adrenals
Pt w/ kidney stones, constipation, malaise, low PTH, *central* lung mass?
*Squamous cell carcinoma*
paraneoplastic syndrome 2/2 PTHrP secretion -> low PO4, high Ca
Characteristics of pleural effusion from adenocarcinoma?
exudative
high hyaluronidase
Pulmonary patient with shoulder pain, ptosis, constricted pupil (mitosis), and facial edema?
Superior Sulcus Syndrome from *small cell lung carcinoma* ("s"entral cancer)
Patient with ptosis better after 1 minute of upward gaze?
Lambert Eaton Syndrome from *small cell lung carcinoma*. Abs to pre-synaptic Ca channels
Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD? Txt?
SIADH from *small cell lung carcinoma*.
Produces euvolemic hyponatremia.
Txt: Fluid restriction +/- 3% saline in <112
("s"mall cells are the As, ACTH, ADH)
CXR showing *peripheral* cavitation and
CT showing distant mets?
*Large Cell Carcinoma*

Peripheral CA
more likely to cause cavitation
highly metastatic
Which lung cancer has a better prognosis, NSCLC or SCLC?
NSCLC easier to resect
SCLC more sensitive to chem/rads
IBD X-ray signs for Crohn & UC
Crohn: string sign
UC: lead pipe
IBD involving the terminal ileum? what does the pain mimic? what deficiency?
Crohn's disease- mimics appendicitis, Fe deficiency
Continuous IBD involving the rectum?
Ulcerative Colitis

Rarely ileal backwash but never higher
Skin signs associated w/ Crohn's dx
Pyoderma gangrenosum

Txt: address Crohn's, no I&D or Abx
IBD w/ increased for Primary Sclerosing Cholangitis (PSC)? increasing risk of what cancer?
Ulcerative Colitis

PSC increases risk of cholangioCA
IBD with:
fistulae? tx?
granulomas on bx?
transmural inflam?
high risk colon CA?
pANCA? symptom?
fistulae - Crohn's, give Metronidazole
granulomas on bx - Crohn's
transmural inflam - Crohn's
high risk colon cancer - UC
pANCA - UC; itching
Crohn's: depth, lesion type, skin sign, complication
UC: depth, lesion type, complication (2), spare what?
Which one has PSC? what marker?
Crohns: Transmural, Granuloma, Skip lesion, Fistula
U.C.: mucosa only + crypt abscess, colon CA, toxic megacolon, rectal sparing
U.C.: PSC, p-ANCA, beading
Smokers have a higher risk of which IBD?
Crohn's Disease
IBD Tx--2 meds to "induce remission," meaning getting symptoms and inflammation under control; 1 meds to "maintain remission" after remission is achieved, the goal is to "maintain remission"
In Crohn's, what abx for ulcer or abscess (anerobe); severe Crohn's need what?
Txt: ASA, sulfasalzine to maintain remission.
Corticosteroids to induce remission.
For Crohn's, give metranidazole for ANY ulcer or abscess.
Azathioprine, 6MP and methotrexate for severe dx
Inflammatory Bowel Disease is not Irritable Bowel Syndrome; what is the name of the definition for IBS?
ROME3
1. change in form + frequency
2. improve after BM
3. symptoms x 3 mos
AST>ALT (2x) + high GGT?
Alcoholic Hepatitis
ALT>AST & in the 1000s (1)? 1000s w/ INR >1.5?
Viral Hepatitis
Medicine induced/acetaminophen toxicity
AST and ALT in the 1000s after surgery or hemorrhage?
Ischemic Hepatitis ("shock liver")
Elevated direct bili?
Obstructive (stone/cancer)
Dubin's Johnsons, Rotor
Elevetated indirect bili?
Hemolysis
Gilbert's, Crigler Najjar
Elevated alk phos and GGT?
Bile duct obstruction, if IBD -> PSC
Elevated alk phos, normal
GGT, normal Ca? Txt?
Paget's disease: osteoclast overactive
Sx: incr hat size, *hearing loss*, HA; (uw) leg bowing, scoliosis
Txt: Bisphosphonates
Elevated alk phos + Antimitochondrial Ab? Txt?
Primary Biliary Cirrhosis/cholangitis - autoimmune destruction bile duct
Txt: bile resins = ursocholic acid
ANA + antismooth muscle Ab? Txt?
*Autoimmune Hepatitis*
Txt: steroids
Dysphagia workup (2 steps), then 2 specific test?
what 3 bugs for HIV?
*Barium swallow* - best 1st test
*Endoscopy* - next best test, can be dx and allow for bx of suspicious masses or tx in dilation of peptic strictures or injecting botox for achalasia.
*Manometry* - achalasia.
*24 pH monitoring* - GERD
If HIV+ (CD <100) or otherwise immunocompromised, remember Candida, CMV and HSV esophagitis
Dysphagia to liquids & solids? Barium: bird beak? Tx: 3 meds + 1 sx? 2 association?
Achalasia

Txt: CCB, nitrates, botox, or heller myotomy
Assoc w/ Chagas dx and esophageal cancer.
Dysphagia worse w/ hot & cold liquids + chest pain that feels like MI w/ NO regure?
Diffuse esphogeal spasm

Txt: CCB or nitrates
Epigastric pain worse after eating or when laying down cough, wheeze, hoarse? Workup? Txt?
GERD
Most sensitive test is 24-hr pH monitoring. Do endoscopy if "danger signs" present.
Txt: behav mod 1st, then antacids, H2 block, PPI.
If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase. Workup? Txt?
*Boerhaave's Sx - Esophageal Rupture*

Next best test - CXR, gastrograffin esophagram. NO edoscopy
Txt: surgical repair if full thickness
If gross hematemesis unprovoked in a cirrhotic w/ pHTN? best Txt w/ what med? Acute Mgmt - ABC, NG lavage, then what meds (2) & procedure to stabilize?
Gastric Varices - Txt: Best *Endoscopic sclerotherapy or banding*. Don't prophylactically band asymptomatic varices. Give *Beta blockers*

If in hypovolemic shock?
do ABCs, NG lavage, medical tx w/ Octreotide or Somatostatin. Balloon tamponade only if you need to stablize for transport
If progressive dysphagia and weight loss?
What 2 kinds? barium swallow, EGD, then what?
Esophageal Carcinoma
Squamous cell CA in smoker/drinkers in the middle 1/3 (uw) smoker with non tender, hard submandible mass w/out lymphadenopathy
AdenoCA in ppl with long standing GERD in the distal 1/3.
Workup: barium swallow -> endoscopy w/ bx -> staging CT
Epigastric pain #1 Cause? tx (2)? #2 cause? tx?
NBS if biliary colic?
NBS if hx of stones or EtOH? what imaging?
#1 cause is *non-ulcerative dyspepsia*. Dx of exclusion. Txt: H2 blocker and antacid.
• If GERD sx, tx empirically w/ PPI for 4 wks then re-evaluate.
• If biliary colic sxs predominate ->RUQ sono
• If hx of stones or drinking, check amylase and lipase, CT scan best imaging for pancreatitis.
Danger sxs warranting endoscopic work up in pt w/ mid-epigastric pain?
>50 y/o
hx of smoking and drinking
recent unprovoked weight loss
odynophagia
Fe-def anemia
melena
Mid-epigastric pain worse w/ eating and hx of NSAID and/or steroid use? Workup? Txt?
Gastric Ulcers
- *Double-contrast barium swallow* shows punched out lesion w/regular margins.
- *EGD w/ bx* - H. pylori, malign, benign.
- Txt: Sucralfate, H2-block, PPI. Surgery if ulcer remains s/p 12wks txt.
Mid-epigastric pain better w/ eating? Workup? Txt?
Duodenal Ulcers

- 95% assoc w/ H. pylori. Dx: blood, stool or breath test but EGD w/ bx (CLO test) can also r/o CA.
- Txt: Healthy pts <45yo can try H2 block or PPI
- H. pylori txt: PPI, Clarithromycin + Amoxicillin for 2wks
Suspect this if Mid-epigastric pain/ulcers don't improve w/ eradication of H.pylori, large, multiple or atypically located ulcers? Workup? Txt?
Zollinger-Ellison Syndrome

- Best test is *secretin stim test* (finding high gastrin)
- Txt: resection if localized, long term PPI if metastatic.
- Look for pituitary and parathyroid problems (MEN1)
RUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy's. Normal labs. Workup shows? Txt?
Acute Cholecystitis

US -> thickened wall
HIDA-> shows non-visualization of GB.
Txt: cholecystectomy. If too unstable, can place a percutaneous cholecystostomy
RUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy's.
Labs: obstructive jaundice, high bili, alk phos
Txt?
Choledocolithiasis

- Same sxs as acute cholecytitis
- US will show stones.
- Txt: cholecystectomy or ERCP to remove stone
RUQ pain, fever, jaundice (+hypotension and AMS)? Txt?
Ascending Cholangitis

Txt: fluids, broad spec Abx, ERCP and stone removal
Risk factors for cholangiocarcinoma (IBD, parasite, iatrogenic)? treatment?
Rare
Primary sclerosing cholangitis (Ulcerative colitis)
Liver flukes
Thorothrast exposure
Txt: surgery
Mid-epigastric pain radiating to the back, N/V, Turner's sign, Cullen's sign.
what amylase # = stone? Dx? Complications (4)?
Acute Pancreatitis: most 2/2 Gallstones & ETOH
- Amylase >1000 means stone
- Dx: CT scan imaging
- Prognosis: worse if old, WBC>16K, Glc>200, LDH>350, AST>250... drop in Hct, decr calcium, acidosis, hypox
- Complications: pseudocyst (no cells!), hemorrhage, abscess, ARDs
(uw) CT for pancreatic pseudocyst CT & tx
tx: endoscopic drainage
Chronic mid epigastric pain, DM, malabsorption (steatorrhea)? Complication?
Chronic Pancreatitis

Can cause splenic vein thrombosis
Courvoisier's sign = large, nontender GB, itching and jaundice
Trousseau's sign = migratory thrombophlebitis.

Dx? Txt?
*Pancreatic adenoCA* - Usually don't have sxs until advanced, only if in head of pancreas
- Dx: EUS and FNA biopsy
- Tx: Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoineal mets.
(Courvoisier just means it's not gallstone, can be pancreatic or gallbladder cancer; migratory-pain, itchy red streaks on arms & legs)
High Fe, low ferritin, low Fe
binding capacity?
Hemachromatosis

Sx: hepatitis, DM, golden skin
Low ceruloplasmin, high urinary Cu?
Wilson's Disease

Sx: hepatitis, psychiatric sxs (basal ganglia), corneal deposits
Diarrhea workup?
Most commonly?
Picnic (2)?
Hx Abx use?
Stool WBC & Cx
Most commonly - viral, Rotavirus in daycare, Norwalk, cruise ships
Picnic - B. cereus, Staph, sx after 1-6hrs
Hx Abx use - stool for C. diff antigen
Bloody diarrhea? (4 bug, 1 parasite)
EHEC
Shigella
Vibrio parahaemolyticus,
Salmonella
Entamoeba histolytica
Foul smelling, bulky diarrhea in malnourished pt (4)?
Sprue
Chronic pancreatitis
Whipple's dx
CF if young person
Diarrhea + flushing, tachycardia/ hypotension
consider carcinoid syndrome (metastatic)
*Can cause niacin deficiency! (2/2 using all the tryptophan to make 5HT) -> Dementia, Dermatitis, Diarrhea.
Most common meningitis bugs (3)? Empiric txt (2)?
Strep Pneumo
H. Influenza
N. meningitidis

Empiric txt: Ceftriaxone and Vancomycin
Common extra meningitis bug in old and young pts? Txt?
Lysteria
Txt: Ampicillin
Common extra meningitis bug in pts w/ brain surgery? tx?
Staph aureus
Txt: Vancomycin
TB meningitis txt?
RIPE + steroids
Lyme meningitis txt?
IV Ceftriaxone
1st steps in meningitis management?
Empiric Abx (+steroids if you think bacterial)
Exam for high ICP
LP, Gram stain
LP bacterial meningitis?
High protein
low glucose
>1000 WBC (diagnostic)
Advice for roommate of the kid in the dorms who has bacterial meningitis and petechial rash?
Ppx w/ Rifampin (for Neisseria & H. flu)
Most common pneumonia bug? Empiric txt (3)?
Strep pneumoniae - :O azithromycin, moxifloxacin, ceftriaxone

Txt: Macrolides, Fluoroquinolones, 3rd gen cephalosporine
Most common pneumonia bug in young healthy people? Txt (3)? what agglutinins?
Atypicals: Mycoplasma, :0 Zithromax, Moxifloxin, Doxcycline
assoc w/ cold agglutinins
Txt: Macrolides, Fluoroquinolones, Doxycycline
Most common pneumonia bugs in pt's hospitalized w/in 3mo or in the hospital for >5-7d (4)? Txt?
HCAP:
Pseudomonas
Kelbsiella
E. coli
MRSA

Txt: Pip/Tazo or Impipenem + Vancomycin
Most likely pneumonia bug in old smokers w/ COPD? Txt?
H influenzae
Txt: 3rd gen Cephalosporin
Most likely pneumonia bug in alcoholic w/ currant jelly sputum? Txt?
Klebsiella
Txt: 3rd gen Cephalosporin
Most likely pneumonia bug in old man w/ HA, confusion, diarrhea, and abdominal pain? Txt?
Legionella, aka "PNA+"
Dx: urine antigen
Txt: Macrolides, Fluoroquinolones, Doxycycline
Most likely pneumonia bug in a pt who just had the flu? Txt?
MRSA
Txt: Vancomycin
Most likely pneumonia bug in farmer who just delivered a baby cow and now has vomiting and diarrhea? Txt?
Q fever (Coxiella burnetti - tick feces, cow placenta -> aerosolized)
Txt: Doxycyline
Most likely pneumonia bug in a pt who just skinned a rabbit? Txt?
Franciella tularensis
Txt: Streptomycin, Gentamicin
TB screening test? Next step if +?
PPD
>15mm, >10mm if prison, healthcare, nursing home, DM, ETOH, chronically ill, >5mm for AIDS, immune suppressed

If + PPD --> do CXR.
Next step after +PPD and +CXR?
+ CXR --> acid fast stain of sputum (if negative x3 clear)
- CXR --> need negative acid fast stain of sputum x3
Txt for tuberculosis?
RIPE x6mo (12mo for meningitis, 9mo if pregnant)
*R*ifampin
*I*NH
*P*yrazinamide
*E*thambutol
Who should get chemoprophylaxis after a known TB exposure? What is the ppx?
children <4yo

Ppx: INH x9mo (+vit B6)
RIPE side effects?
*R*ifampin - orange/red fluids, +CPY450
*I*NH - periph neuropathy, sideroblastic anemia, hepatitis w/ mild LFT bump
*P*yrazinamide - benign hyperuricemia
*E*thambutol - optic neuritis, other color vision abnormal
Most common bug for acute endocarditis?
Staph aureus
Most common bug for subacute endocarditis of native valve? Which valve?
Viridens group strep
Mitral valve
Most common bug for endocarditis in IVDU? Murmur features?
Staph aureus
Tricuspid valve
R side murmurs worse w/ inspiration
Dx of endocarditis?
blood Cx, TTE then TEE
Major criteria: bacteremia, new murmur, vegetation
Minor criteria: risks, fever, emboli, rheum e.g. osler spot
Complications of endocarditis? (2)
CHF is #1 cause of death
septic emboli to lungs or brain
Endocarditis abx?
Strep viridens txt: PCN x4-6wk
Staph txt: Nafcillin + Gentamicin or Vancomycin
Who gets ppx for endocarditis?
Prosthetic valve
Hx of endocarditis
Uncorrected congenital lesion
Strep bovis bacteremia mgmt?
colonoscopy
assoc w/ CRC
What illness? Fever, fatigue, LAD, HA, pharyngitis, n/v/d +/- aseptic meningitis
*Acute retroviral syndrome*
(looks like mono)

2-3 wks s/p HIV exposure but
3wks before seroconversion, ELISA neg
What illness? A young patient with new/bilateral Bell's Palsy?
HIV
What ilness? Patient "travels a lot for work"?
that means they have sex with lots of strangers and are at risk for HIV
What illness? A young patient with unexplained thrombocytopenia and fatigue?
HIV
What illness? young patient with unexplained weight loss >10%?
HIV
What illness? A young patient with thrush, Zoster, or Kaposi sarcoma?
HIV
When to start HAART?
CD4 < 350 or viral load >55,000 (except preggos get tx >1,000 copies)
HIV Rx
SE: GI, leukopenia, macrocytic anemia
Zidovudine
HIV Rx
SE: Pancreatitis, peripheral neuropathy
Didanosine
HIV Rx
SE: Nephrolithiasis and hyperbilirubinemia
Indinavir
HIV Rx
SE: Sleepy, confused, psycho
Efavirenz
(nNRI)
HIV Rx
SE: hypersensitivity rash, F, N/V, muscle aches, SOB in 1st 6wks
Abacavir
DC drug and never use again!
Post-exposure ppx (HIV)?
AZT, lamivudine and nelfinavir for 4wks
HIV+ patient with DOE, dry cough, fever, chest pain, elevated LDH?
CXR: "bilat diffuse symmetric interstitial infiltrates"
How to Dx?
PCP
Dx: Bronchoscopy w/ BAL to visualize bug
Txt for PCP?
1st line: Trim-Sulfa
2nd line: Trim-Dapsone or Primaquine-Clindamycin or Pentamidine

+ Steroids when PaO2<70, A-a gradient >35
When to give ppx for PCP?
CD4<200 (can dc if >200 x6mo)

1st: Trim-Sulfa
2nd: Dapsone
3rd: Atovaquone
4th: aerosolized Pentamidine (~> pancreatitis)
HIV pt (CD4<50) w/ diarrhea? (3)
CMV
MAC
Cryptosporidium
CMV in HIV pt? Dx? Txt?
Sx: bloody diarrhea
Dx: colonoscopy w/ bx -> intranuclear inclusions
Txt: Gancyclovir (~> neutropenia), Foscarnet (~> renal tox)
HIV pt (CD4<50) w/ diarrhea, wasting, fevers, night sweats? Dx? Txt?
MAC
Dx: bx negative, exclude alternative causes
Txt: Clarithromycin and Ethambutol +/- Rifampin
MAC ppx in HIV pt?
CD4<50
Ppx: Azithromycin weekly
Cryptosporidium in HIV pt? Dx?
transmitted via dog poo, swimming pool
Sx: watery diarrhea w/ mucus
Dx: oocysts in stool are acid fast
HIV pt w/ multiple ring enhancing lesions on CT? Txt?
Toxoplasmosis

Txt: empiric *pyramethamine sulfadiazine* (+ folic acid) x6wks. If no improvement in 1wk, consider biopsy for CNS lymphoma.
HIV pt w/ one ring enhancing lesion on CT? Txt?
CNS lymphoma

Assoc w/ EBV infxn of B- cells
Txt: HAART.
HIV pt w/ seizure + *deja vu aura* and 500 RBCs in CSF?
HSV encephalitis (predisposed for *temporal lobe*)
Can be JC

Txt: Acyclovir ASAP!
Most common meningitis in HIV pt? Workup?
Strep pneumo

Also worry about Cryptococcus
Dx: +India ink
Txt: ampho IV x2wks then fluconazole maintenance
HIV pt w/ hemisensory loss, visual impairment, Babinski? Dx?
sounds like MS
*PML* - JC polyomavirus demyelinates at grey-white jxn.
Dx: Brain bx
HIV pt w/ memory problems or gait disturbance? Workup?
AIDS-Dementia complex

Check serum, CSF and MRI to r/o treatable causes
Neutropenic fever never does what?
Medical Emergency!
NEVER do a DRE - may induce bacteremia across gut wall

[single temp > 101.3 or sustained temp >100.4 x1hr. ANC < 500]
Etiology of neutropenic fever? Most common bugs?
[single temp > 101.3 or sustained temp >100.4 x1hr. ANC < 500]

Mucositis 2/2 chemo causes bacteremia (usually from gut)

Bugs: Pseudomonas or MRSA (if port present)
Neutropenic fever workup and mgmt?
Blood cx
Start *3rd or 4th gen cephalosporin* (ceftazidime or cefipime)
+ *vanc* if line infxn suspected or if septic shock
+ *amphoB* if no improvement and no source found in 5 days.
Target rash, fever, CNVII palsy, meningitis, AV heart block? Txt?
Lyme
Txt: Doxycycline
(Amoxicillin for <8yo)
Heart or CNS dx needs IV ceftriaxone
Rash @ wrists & ankles (palms & soles), fever and HA? Txt?
Rocky Mtn Spotted Fever - Rickettsia
"Rickettsia at wRists"
Txt: Doxycycline even if <8yo
Tick bite, *no rash*, myalgia, fever, HA, ↓plts and WBC, ↑ALT? Dx? Txt?
Ehrlichiosis
Dx: morulae intracellular inclusions
Txt: Doxycycline
Immune suppressed, cavitary lung dx (purulent sputum) + weight loss, fever.
Gram + aerobic branching partially acid fast? Txt?
Nocardia (aerobic)
Txt: trim-sulfa
Neck or face infection w/ draining yellow material (+sulfur granules).
Gram+ anaerobic branching? Txt?
Actinomyces (anaerobic)
Txt: high dose PCN x6-12wks
Hyponatremia workup? TxT?
Check osmolarity
Check volume status

Txt:
- Correct w/ NS if hypoV
- 3% saline only if seizures or [Na] < 120
- fluid restrict + diuretics

Don't correct faster than 12-24mEq/day or else *Central Pontine Myelinolysis*
Hypervolemic hypoNa causes?
CHF
nephrotic
cirrhotic
Hypovolemic hypoNa causes?
diuretics or vomiting + free water
Euvolemic hypoNa causes?
SIADH (check CXR if smoker)
Addison's (adrenal insufficiency)
Hypothyroidism
Hypernatremia txt?
Replace water w/ D5W or other hypotonic fluid

Don't correct faster than 12-24mEq/day or else *cerebral edema*
tetany
perioral tingling
Chvostek (CNVII reflex)
Troussaeu (BP cuff-> spasms)
prolonged QT interval
HypoCa
■ kidney STONES
■ psychic MOANS
■ abdominal GROANS
■ achy BONES
Shortened QT interval
HyperCa
paralysis, ileus, ST depression, U waves? Txt?
hypoK
Txt: K+ (make sure pt can pee) max 40mEq/hr
peaked T waves, prolonged PR and QRS, sine waves? Txt (4 then dialysis)?
hyperK
Txt:
1. Ca-gluconate 2. then insulin + glc 3. Kayexalate 4. Albuterol and Sodium bicarb
HCO3 high
pCO2 high
Next test? Ddx?
Metabolic alkalosis
Check urine Cl
if [Cl]>20 +HTN - hyperaldo (Conns), if normoTN think Barter's or Gittlemans
if [Cl]<20 - think vomiting, NG suction, antacids, diuretics
pCO2 low
HCO3 low
Ddx?
Respiratory alkalosis
hyperventilation from anxiety, high ICP, fever, pain, ASA
HCO3 low
pCO2 low
Next test? Ddx?
Metabolic acidosis

Check Anion gap (Na-Cl-HCO3)
Gap -> MUDDLES
non-gap -> diarrhea, diuretic, RTA (I, II, IV)
pCO2 high
HCO3 high
Ddx?
Respiratory acidosis

hypoventilation from opiates, brainstem injury, ventilation problems
Type I RTA
Causes?
Dx/presentation?
Txt?
Distal tubule, can't excrete H+
Cause: Lithium/AmphoB, analgesics, SLE, Sjogrens, SCA, hepatitis
Dx: Urine pH>5.4, *hypoK*, stones
Txt: replete K, PO bicarb
Type II RTA
Causes?
Dx/presentation?
Txt?
Proximal tubule, can't reabsorb HCO3
Cause: Fanconi sx, myeloma, amyloidosis, vitD deficiency, autoimmune dx
Dx: *hypoK*, osteomalacia
Txt: replete K, mild diuretic, NO bicarb
Type IV RTA
Causes?
Dx/presentation?
Txt?
hyperRenin, hypoAldo
Cause: DM (>50%), Addison's dx (adrenal insufficiency), SCA, aldo deficiency
Dx: *hyperK*, hyperCl, high urine [Na] even w/ salt restriction
Txt: *Fludrocortisone*
Fanconi's anemia
hereditary or acquired proximal tubule dysfxn
defective transport of glucose, AA, Na, K, PO4, uric acid, bicarb
-> Type II RTA, replete K, mild diuretic
ARF?
Workup?
>25% or 0.5 rise Cr over baseline
BUN/Cr -> prerenal if >20/1; Urine Na and Cr -> prerenal if FENA<1%
If pt on diuretic measure FENurea -> prerenal if <35%
Prerenal ARF Txt?
fluids and treat underlying issue (reason for low renal perfusion)
Indications for emergent dialysis?
*AEIOU*
*A* - acidosis
*E* - electrolyte imbalance (esp K>6.5)
*I* - Intoxication (esp antifreeze, Li)
*O* - overloaded V -> CHF sx or pulmonary edema
*U* - uremia -> pericarditis, AMS
NOT for high Cr or oliguria alone!
Muddy brown casts in a pt w/ ampho, aminoglycosides, statins, cisplatin or prolonged ischemia? Txt?
Intrinsic:
*ATN*

Txt: fluids, avoid nephrotox, dialysis if indicated
Protein, blood and Eos in the urine + fever and rash who took Trim-sulfa 1-2wks ago? Txt?
Intrinsic:
*AIN*

Txt: Stop offending agent. Add steroids if no improvement.
Army recruit or crush victim w/ CPK of 50K, +blood on dip but no RBCs? Txt?
Intrinsic:
*Rhabdomyolysis*

1st test is check [K+] or EKG. Txt: bicarb to alkalinize urine to prevent precipitation
Enveloped shaped crystals on UA? What toxic ingestion? Txt?
Intrinsic:
*Ethylene glycol intox*

Txt: dialysis or NaHCO3 if pH<7.2
Bump in creatinine 48-72hrs s/p cardiac cath or CT scan?
Intrinsic:
*Contrast nephropathy*

Prevent by hydrating before or giving bicarb or NAC
Complications of CKD? #1 COD, heart? blood? electrolyte? calcium d/o? BUN?
#1 cause of death *CVD* -> goal LDL<100
*HTN* (2/2 ↑aldo), fluid retention -> *CHF*
*Normochromic normocytic anemia* -> loss of EPO
*↑K, ↑PO4, ↓Ca* (leads to 2ndary hyperPTH)
↑PO4 leads to precip of Ca into tissues -> *renal osteodystrophy and calciphylaxis* (skin necrosis)
*Uremia* -> confusion, pericarditis, itchiness, increased bleeding 2/2 platelet dysfxn
confusion, pericarditis, itchiness, increased bleeding
Uremia
bleeding 2/2 platelet dysfxn
painless hematuria?
Bladder/Kidney cancer until proven otherwise
"termina hematuria" + tiny clots?
bladder CA or hemorrhagic cystitis (cyclophosphamide)
Dysmorphic RBCs or RBC casts?
Glomerular source
Definition of nephritic syndrome?
Proteinuria (but <2g/24hrs)
hematuria
edema
azotemia
Hematuria *1-2 days* after runny nose, sore throat & cough?
Berger's Dz (IgA nephropathy)
Hematuria *1-2 weeks* after sore throat or skin infxn?
Post-strep GN

Sx: smoky/cola urine
Dx: best 1st test is ASO titer
EM: Subepithelial IgG humps
Hematuria + Hemoptysis?
Goodpasture's Syndrome

Abs to collagen IV
Hematuria + Deafness?
Alport Syndrome

XLR mutation in collagen IV
Hematuria in Kiddo s/p viral URI w/ Renal failure + abd pain, arthralgia and purpura? Txt?
Henoch-Schonlein Purpura

IgA. Supportive tx +/- steroids
Hematuria in Kiddo s/p hamburger and diarrhea w/ renal failure, MAHA and petechiae?
HUS

E.Coli O157H7 or Shigella. Don't tx w/ ABX (releases more toxin)
Hematuria in Cardiac patient s/p ticlopidine w/ renal failure, MAHA, ↓plts, fever and AMS? Txt?
TTP, Txt: plasmapheresis. DON'T give platelets.
vs. DIC: PT and PTT are normal in HUS/TTP.
Thrombotic Thrombocytopenic Purpura: FAT RN
Fever, Anemia, Thrombocytopenia, Renal Failure, Neural ∆
c-ANCA, kidney, lung and sinus involvement? Txt?
Wegener's Granuolmatosis

Dx: Most accurate test is bx
Txt: steroids or cyclophosphamide.
p-ANCA, renal failure, asthma and eosinophilia? Txt?
Just p-ANCA?
Churg Strauss (eosinophilic granulomatosis polyangiitis)
Dx: Best test is lung bx
Txt: Cyclophosphamide
Just p-ANCA: microscopic polyangiitis
p-ANCA, NO lung involvment, Hep B? Txt?
Polyarteritis Nodosa

Affects small/med arteries of every organ except the lung!
Txt: cyclophosphamide
Best test for pt w/ flank pain radiating to groin + hematuria?
CT for kidney stones
Most common type of kidney stones? Txt?
Calcium oxalate stones
Txt: HCTZ
Kid w/ family hx of stones?
Cysteine stones
Can't resorb certain AA
Kidney stones in pt w/ chronic indwelling foley and alkaline pee?
Struvite stones = Mg/Al/PO4

Proteus
Staph
Pseudomonas
Klebsiella
Kidney stones in pt w/ leukemia being treated w/ chemo? Txt?
Uric Acid stone

Txt: alkalinize urine + hydration
Kidney stones in pt s/p bowel resection for volvulus?
Pure oxylate stone

Ca not reabsorbed by gut (pooped out)
Txt for kidney stones of different sizes?
<5mm - will pass spontaneously, hydrate
>2cm - open or endoscopic surgical removal
5mm-2cm - extracorporal shock wave lithotripsy
Best 1st test for pt w/ proteinuria?
Repeat UA test in 2 weeks, then quantify w/ 24hr urine
Definition of nephrotic
syndrome?
>3.5g protein/24h
hypoalbuminemia
edema
hyperlipidemia (fatty/waxy casts)
Most common nephrotic sx in kids? also most common with what? Txt?
Minimal Change Disease - Fusion of foot processes
also with Hodgkin
Txt: steroids
Most common nephrotic sx in adults? associated with what?
Membranous Nephropathy
Associated with renal vein thrombosis
Nephrotic syndrome associated w/ heroin use and HIV?
FSGS

Mesangial IgM deposits
Limited response to steroids
Nephrotic sx assoc w/ chronic hepatitis and low complement?
Membranoproliferative GN
tram track BM w/ subbed deposits - may have low C3
If nephrotic pt suddenly develops flank pain?
suspect rental vein thrombosis

2/2 peeing out ATIII, protein C and S
Do CT or US ASAP
Random causes of proteinuria? orthostatic, UTI, pregnancy, fever, CHF & what in multiple myeloma?
Bence Jones in multiple myeloma
Microcytic anemia
MCV = 70, ↓Fe, ↑TIBC, ↓retic, ↑RDW, ↓ferritin
Iron deficiency anemia

hypochromic microcytic anemia
Microcytic anemia
MCV = 70, ↓Fe, *↓TIBC*, ↓retic, nl ferritin.
Anemia of chronic disease
Microcytic anemia
MCV = *60*, ↓RDW; appropriate screening?
Thalassemia: target cells, RDW - little variation, suggests genetic cause
Dx: screen w/ CBC
Microcytic anemia
MCV = 70, ↑Fe, ↑ferritin, ↓TIBC
Sideroblastic anemia

May be caused by INH
Macrocytic anemia
MVC = 100, ↓retics, ↑homocysteine,
nl methylmelonic acid.
Folate deficiency
Macrocytic anemia
MVC = 100, ↓retics, ↑homocysteine, ↑methylmelonic acid
B12 deficiency
Macrocytic anemia
MVC = 100
Acanthocytosis (spur cell)
-> Liver dx
Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin in Sickle cell kid w/ sudden drop in Hct?
Aplastic Crisis

Sickle Crisis from hypoxia, dehydration or acidosis
Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ Cyanosis of fingers, ears, nose + recent Mycoplasma infx?
Cold Agglutinins: autoimmune Destruction occurs in the liver. IgM mediated
Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin
w/ sudden onset after PCN, ceph, sulfas, rifampin or Cancer?
Warm Agglutinin: Destruction in spleen. IgG. Drug rxn or malignancy
Txt: steroids 1st, then splenectomy.
Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin
w/ Splenomegaly, +FH, bilirubin gallstones, ↑MCHC?
Hereditary spherocytosis
(AD loss of spectrin)
Txt: splenectomy.
Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin
w/ Dark urine in AM, Budd-Chiari syndrome?
Paroxysmal Nocturnal Hemoglobinuria

Defect in PIG-A. Lysis by complement. Incr risk for aplastic anemia
Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ sudden onset after primiquine, sulfas, fava beans?
G6PDH def

Heinz bodies, Bite cells. Avoid oxidant stress.
thrombocytopenia: 30 y/o F recurrent epistaxis, heavy menses & petechiae. ↓plts only? Txt?
ITP; Txt: prednisone 1st. Then splenectomy. IVIG if <10K. Rituximab
thrombocytopenia: 20 y/o F recurrent epistaxis, heavy menses, petechiae, normal plts, *↑ bleeding time and PTT*? Txt?
VWD-Txt: DDAVP for bleeding or pre-op. Replace factor VIII (contains vWF) if bleeding continues.
thrombocytopenia: 20yo M w/ recurrent bruising, hematuria, and hemarthrosis, ↑ PTT that corrects w/ mixing studies? Txt?
Hemophilia

Txt: DDAVP if mild, otherwise replace factors
thrombocytopenia: 50y/o M "meat-a-tarian" just finished 2wks of clinda has hemarthroses & oozing at venipuncture sites? Txt?
VitK def

↓ II, VII, IX and X. Same for warfarin toxicity.
Txt: *FFP* acutely + vitK shot
thrombocytopenia: 50y/o M "beer-a-tarian" w/ severe cirrhosis?
1st factor depleted?
2 factors not depleted?
Liver Disease. GI bleeding is most common

1st depleted: VII, so PT increases 1st
not depleted: VIII and vWF b/c they are made by endothelial cells.
thrombocytopenia and this smear...
If PT and PTT are ↑, fibrinogen ↓, D-dimer and fibrin split products ↑? Causes? Txt?
Schistocytes!
DIC

Causes: Sepsis, rhabdo, adenocarcinoma, heatstroke, pancreatitis, snake bites, OB stuff, Tx of M3 AML (Auer rods)
Txt: FFP, platelet transfusion, correct underlying d/o
thrombocytopenia and this smear...
If PT and PTT are normal? Causes? Txt?
TTP/HUS
Causes: O157:H7, Ticlopidene
Txt: plasmapheresis, NOT platelets
7 days post-op, a patient develops an arterial clot. Her platelets are found to be 50% less than pre-op? Txt?
HIT
IgG to heparin bound to PF4
Txt: stop heparin, reverse warfarin w/ vitK, start Lepirudin
What to look for in someone w/ unprovoked thrombus?
Cancer
Nephrotic sx - pee out ATIII protein C and S preferentially, at risk for RVT
What to look for in someone w/ unprovoked thrombus? ↑PTT, multiple Spontaneous abortions, false+ VDRL?
Lupus anticoagulant/Anti-phospholipid
What to look for in someone w/ unprovoked thrombus? Skin necrosis after warfarin is started?
Protein C/S deficiency
What to look for in someone w/ unprovoked thrombus? Most common inheritable pro-coag state?
Factor V Leiden; V is resistant to C - mixing study does not correct
What to look for in someone w/ unprovoked thrombus? Still clots on heparin?
ATIII Deficiency
What to look for in someone w/ unprovoked thrombus? Female smoker >35yo?
OCPs/HRT
Knee pain, DIP involvement no swelling or warmth, worse @ the end of the day, crepetence.
OA
PIP and wrists bilaterally, worse in the AM, low grade fever? + splenomegaly & neutropenia/low platelet?
Rheumatoid > Felty
complications: osteoporosis
DIP joint involvement, rash w/ silvery scale on elbows and knees, pitting nails and swollen fingers.
Psoriatic Arthritis.
Sausage finger
Symmetric, bilateral arthritis, malar rash, oral ulcers, proteinuria, thrombocytopenia. Arthritis is not erosive or have lasting sequellae.
SLE
A patient comes in w/ acute swollen painful joint...
tap: WBCs >50K
Septic arthritis
Septic arthritis in 30yo who "travels a lot for work"? Txt?
Gonococcal

Cx may be negative. Look also for tenosynovitis and arm pustules.
Txt: *Ceftriaxone*
Septic arthritis in 70yo nun? Txt?
Staph aureus
Txt: *Nafcillin or Vancomycin*
A patient comes in w/ acute swollen painful joint...
tap: WBCs less than 5-50K? 4 possibilities?
Inflammatory
If no crystals, think RA, ank spon, SLE, Reiter's
Inflammatory arthritis w/ needle shaped, negatively birefringent crystals?
Acute (2), chronic (overproduction, under secretion)
Gout - Monosodium Urate
Acute TX? *NSAID (Indomethacin) + colchicine* (steroids if kidneys suck).
Chronic TX? *Probenecid* if undersecreter. *Allopurinol* if overproduc.
Inflammatory arthritis w/ rhomboid shaped, positively birefringent crystals? Txt? what dz to look for?
Pseudogout - more usual in the knees; loo k for hematochromosis or T3/PTH
Txt: Calcium pyrophosphate
A patient comes in w/ acute swollen painful joint...
tap: WBCs less than 200-5K
OA
hypertrophic osteoarthropathy
trauma
A patient comes in w/ acute swollen painful joint...
tap: WBCs <200
Normal
Must know: what serology r/o SLE If negative?
ANA - peripheral/rim staining.
Most know: 2 Ab for Rheumatoid
RF (against Fc of IgG)
Anti-CCP (cyclic citrullinated peptide)
Ab for SLE nephritis?
Anti-dsDNA (Anti-Smith?)
Ab Drug induced lupus? (hydralazine)
Anti-histone
Ab CREST syndrome?
Anti-centromere
CREST: calcinosis, Raynaud, Esophagus, Scars, Telangiectasia
Ab Systemic Sclerosis?
Anti-topoisomerase (Anti-Scl-70)
If you can remember:
Ab Sjogren's Syndrome?
Ab dermatomyositis, polymyositis?
Ab for autoimmune hepatitis?
Primary biliary cholangitis?
Sjogren: Anti-Ro (SSA) or Anti-La (SSB)
Myositis: Anti-Jo
Autoimmune hepatitis: Anti-smooth muscle
Anti-mitochondria
Ab Mixed connective tissue
disease?
Anti-RNP
Signs of systemic disease - flip
...
Leser Trelat sign
GI cancer
Dermatomyositis - cancer
also Heliotrope sign, Gottron papule, shawl sign
seborrheic dermatitis - AIDS?
erythema multiforme
acanthosis nigricans
Dermatitis herpetiformis
Porphyria Cutanea Tarda - Hepatitis C
Sign of systemic disease
Erythema nodosum - IBD, sarcoid
pInful, red purple subQ nodule; get CXR even without symptoms
Sign of systemic disease
Necrolytic migratory erythema - glucagonoma
Sign of systemic disease
Bullous pemphigoid
Sign of systemic disease
Pemphigus vulgaris
Sign of systemic disease
Behcet's syndrome
Acrodermatitis enteropathica
(Zn deficiency)
Dermatitis of Pellagra
Tinea capitis
Actinic keratosis
precursor lesion for squamous cell CA
Txt: 5FU or excision
Kaposi sarcoma
Bacillary angiomatosis
basal cell carcinoma
Shave or punch bx then surgical removal (Mohs)
What is it?
Treatment?
squamous cell carcinoma
treat precursor lesions (actinic keratosis or keratoacanthoma)
Txt: Excisional bx at edge of lesion, then wide local excision.
Can use rads for tough locations.
What is it?
Treatment?
Superficial spreading (best prog, most common)
Nodular (poor prog)
Need full thickness biopsy b/c depth is #1 prog
Tx w/ excision
- 1cm margin if <1mm thick,
- 2cm margin if 1-4mm thick
- 3cm margin if >4mm
High dose IFN or IL2 may help
Treatment for melanoma
<1mm thick, <4mm thick, >4mm thick
meds (2)
no graphic, flip back
...
Most common pituitary adenoma? Sx? Txt?
Prolactinoma
Sx: amenorrhea/hypoT
Txt: Bromocriptine or Cabergoline even if large (>10mm)
Order of hormones lost in hypopituitarism?
#1 FSH and LH
#2 GR
#3 TSH
#4 ACTH
Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine?
DI
lack of ADH (or nonfunctional)
Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ↓ s/p ddAVP? Txt?
Nephrogenic DI

Txt: HCTZ/amiloride
Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ↓ s/p water deprivation, ↑ w/ DDAVP?
Central DI
See low TSH, high free T3/T4.
Next best step? Txt?
Iodine RAIU scan - If ↑ = Graves; If ↓ = factitious or thyroiditis
1st Txt: propanolol + PTU/MTZ
2nd ablation surgery (pregnant, children)
Thyroid storm txt?
PTU + Iodine (Lugol's sol'n) + propranolol
Workup for thyroid nodule?
1st: check TSH
if low -> RAIU
if normal -> FNA
RAIU workup (s/p low TSH)?
"hot nodule" -> excision or radioactive iodine
"cold nodule" -> surgically excise and check pathology
Most common type of thyroid nodule, spreads via lymph, psammoma bodies?
Papillary
thyroid nodule that spreads via blood?
Follicular
must surgically excise whole thyroid
Thyroid nodule associated w/ calcifications and amyloidosis?
Medullary
Assoc w/ MEN2 (look of pho, hyperCa)
Thyroid nodule w/ 80% mortality in 1st yr?
Anaplastic
Hashimoto's predisposes you to this type of thyroid nodule?
Thyroid lymphoma
Osteoporosis, central fat, DM, hirsutism? Best screening test?
Suspect Cushing's, 1mg overnight dexa suppression test or 24hr urine cortisol
if abnormal, dx Cushing's; 8mg overnight dexa suppression test
Osteoporosis, central fat, DM, hirsutism? No adrenal suppression after 8mg overnight dexa? Nest test?
adrenal neoplasm vs ectopic ACTH
plasma ACTH
Chest CT if smoker
abdominal CT/DHEAS
Weakness, hypotension, weight loss, hyperpigmentation, ↑K, ↓Na, ↓pH? Best screening test?
Suspect Adrenal Insufficiency

Cosyntropin stimulation test (60min after 250mcg)
Most common cause of adrenal insufficiency? Txt?
Autoimmune (Addison's disease)
Txt: NaCl resuscitation, Long term replacement of dexamethasone and fludrocortisone
Perioral numbness, Chvortek, Trousseau s/p Thyroidectomy, ↓[Ca], ↑[PO4], ↓[PTH]?
hypoparathyroidism
Kidney stones, constipation/abd pain or psychiatric sxs, ↑[Ca], ↓[PO4], ↑vitD, ↑[PTH]? Dx? Txt?
hyperparathyroidism
Dx w/ FNA of suspicious nodules. Can use Sestamibi scan.
Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4 glands and implant 1 in forearm.
MEN1, MEN2a, MEN2b
*MEN1* - parathyroid, pituitary adenoma, pancreatic islet cell tumor.
*MEN2a* - parathryoid, medullary thyroid cancer, pheochromocytoma
*MEN2b* - medullary thyroid cancer, pheochromocytoma, Marfanoid
Dx of DM?
FBGL > 126 x 2
2hr OGTT > 200
random glc > 200 + sxs (polyuria, polydipsia, blurred vision)
Nausea, vomiting, abdominal pain, Kussmaul respirations, coma w/ BGL=400? Dx? Txt?
DKA
Dx: ketones in blood and urine, AGMA, hyperK
Txt: high volume NS + insulin bolus and drip, add K once peeing, add glucose<200
Polyuria, polydipsia, profound dehydration, confusion and coma w/ BGL = 1000? Txt?
HHS
Txt: high volume fluid and electrolytes, may require insulin
Most common cause of death in DM pts?
CVD
Important screening for DM pts?
Heart: LDL<100, BP<130/80
Kidney: microalbuminemia (30-300 in 24hrs), start ACEI
Eye: annual screening for proliferative retinopathy -> vitreous humor/neovasc
Nerves: podiatric exam qyr. Tx gastroparesis w/ metoclopramide or Eythromycin, may get ED, 3rd, 4th, 6th CN palsy
Most common cause of stroke?
80% ischemic
20% hemorrhagic
Best 1st test for stroke? Most accurate test?
noncontrast CT to r/o hemorrhage
diffusion-weighted MRI best for ischemic, CT can be negative for 1st 48hrs
Stroke txt w/in 3-4.5hr? later?
TPA w/in 3-4.5hrs
ASA >4.5hrs
Heparin only for those in Afib, basilar clot
Contraindications to tPA (3)?
stroke w/in 3mo
surgery w/in 2wks
LP w/in 1wk
If pt has stroke while on ASA?
Add dipyridamole or switch to clopidogrel.
Don't use ticlopidine!
If pt has SAH?
Nimodipine to reduce ischemic stroke from vc (most common cause of M&M)
When to clip an aneurysm?
W/in days or rupture or when <10mm
criteria for endarterectomy?
When occlusion >70% and is symptomatic. (>60% if <60y/o)
Where's the lesion? L hemiplegia/hemisensory loss, L homonomous hemianopsia w/ eyes deviated twoards the R + apraxia.
R MCA stroke
Wheres the lesion? L hemiplegia/hemisensory loss in the leg>arm. Confusion, behavioral disturbance.
R ACA stroke
:O ACA - contralateral leg
:O MCA - contralateral arms
Where's the lesion? L hemiplegia + R ptosis & eye deviated to the right and down
R Webber's -
:O Right posterior cerebral artery - occipital lobe so vision
Weber's = midbrain part so hemiplegia
Where's the lesion? Falling to the L + R ptosis & eye deviated to the right and down.
R Benedikt's
:O posterior cerebral a. occipital lobe so cortical blindness
R Benedikt's - hemi-ataxia
Where's the lesion? L hemisensory loss + Horners + R facial sensory loss.
R Wallenburg (PICA)
Where's the lesion? Vertigo, vomiting, nystagmus and clumsiness with the right arm.
Major R cerebellar arteries
:0 vertebral a. - cerebella so syncope, ataxia, cerebellar sign i.e. no repeat motion & coordination
Wheres the lesion? Total paralysis except for vertical eye movements.
Paramedial branches of the basilar artery - pons so lock-in syndrome
Status Epilepticus Txt?
Lorazepam + LD of phenytoin.
Then phenobarbitol.
Then anesthesia
Partial seizures begin focally. (Arm twitch, de-ja-vu, burning rubber smell)? Txt?
simple if no LOC and complex if LOC (may have lip smacking)
Both can generalize.
Txt: 1st line = carbamazepine (Tegretal) or phenytoin. Then valproate (Keppra) or lamotrigine (Lamictal)
Generalized seizures txt?
1st line = valproic acid, then lamotrigine, carbamezepine, phenytoin
Absence sz txt?
ethosuximide
EEG buzzword: 3 Hz spike-and- wave
Txt?
Absence Seizure.
Tx w/ ethosuxamide
EEG buzzword: Triphasic bursts
Creutzfeldt Jakob.
Dementia + myoclonus
EEG buzzword: Diffuse
background slowing
Delirium.
Contrast w/ psychosis that has no EEG changes
EEG buzzword: Hypsarrhythmia
Txt?
Infantile spasms.

Tx w/ ACTH. Most are associated w/ mental retardation.
Acute HA: "Worse headache of my life"
Subarachnoid hemorrhage.
Noncon CT 1st!
Acute HA: + Fever and Nuchal rigidity
Meningitis.
Abx then CT then LP
Acute HA: deep pain that wakes pt up at night, worse w/ coughing or bending forward
consider space occupying lesion (brain tumor)
most important prognostic feature is grade (degree of anaplasia)
Acute HA: unilateral pounding, w/ changes in vision and jaw claudication
Temporal arteritis
Check ESR, then give steroids, then to temporal artery dx
Can lead to blindness
Fat lady on minocycline or who takes isotreintoin w/ abducens nerve palsy/diplopia
Pseudotumor cerebri
also assoc w/ OCPs
Normal CT, elevated P on LP
Txt: wt loss, Acetazolamide, then shunt or optic nerve sheet fenestration
Diarrhea 3wks ago, now areflexia and ascending paralysis? Most likely bug? Txt?
Guillain-Barre
CSF shows albumino-cytologic dissociation
Campylobacter, HHV, CMV, EBV
Txt: IVIG or plasmapheresis, monitor VC for intubation req
Neuraomuscular disease: Nasal voice, ptosis, dysphagia, respiratory acidosis? Dx? Txt? what chronic meds? what surgery should she get? 2 drugs to avoid?
Myasthenia Gravest
1st test: ACh-Ab
Most accurate test: EMG, decrease in muscle fiber contraction
Acute txt: IVIG or plasmapheresis, monitor VC for intubation req
Chronic txt: Pyridostigmine, GCs/Azathioprine, thymectomy (<60yo)
Rx to avoid: Aminoglycosides, beta blockers
urinary retention, Babinski on R, episode of double vision 6mo ago? Dx? Txt?
Multiple sclerosis
neurodeficits separated by time and space
Dx: MRI, increased T2 at periventricular white matter
Acute txt: steroids (3d IV then 4wk PO), plasma exchange is 2nd line
Chronic txt: IFN-beta1a, beta1b, Glatiramer reduces exacerbations
Cancer: A patient presents w/ fatigue, petechiae, infection bone pain and HSM...
If >20% blasts?
Acute Leukemia on Biopsy
Cancer: A patient presents w/ fatigue, petechiae, infection bone pain and HSM...
CALLA or TdT?
ALL. Most common cancer in kids
Cancer: A patient presents w/ fatigue, petechiae, infection bone pain and HSM...
Auer rods, MPO, esterase?
AML. More common in adults. RF = rads exposure, Down's, myeloprolif.
M3 has Auer Rods and causes DIC upon tx.
A patient presents w/ fatigue, petechiae, infection bone pain and HSM...
Tartate resistant acid phosphatase, ↓monos & CD11 and CD22+?
Hairy Cell Leukemia. See enlarged spleen but no adenopathy.
Hairy Cells have numerous cytoplasmic projections on smear.
Tx w/ cladribine 5-7day single course
Tx of ALL?
Danorub, vincris, pred. Add intrathecal MTX for CNS recurrence. BM transplant after 1st remission.
Tx of AML?
Danorub + araC
If *M3 -> give all trans retinoic acid
A patient presents w/ fatigue, night sweats, fever, splenomegaly and elevated WBCs w/ low LAP and basophilia?
Chronic Myelogenous Leukemia- 9:22 transloc --> tyrosine kinase

Tx w/ imantinib (Gleevec), inhibits tyrosine kinase. 2nd line is bone marrow transplant.
Cx = blast crisis.
Asymptomatic elevation in WBCs found on routine exam - 80% lymphs.
CLL
Staging CLL:
If LAD?
If splenomegaly>
If anemia?
If thrombocytopenia?
If Lymphadenopathy - Stage 0 or 1 need no tx- 12 yrs till death
If Splenomegaly - Stage 2 tx w/ fludrabine
If Anemia, If Thrombocytopenia - Stage 3 or 4 tx w/ steroids
Enlarged, painless, rubbery lymph nodes
Think Lymphoma
Drenching night sweats, fevers & 10% weight loss
"B-symptoms" = poor prognosis along w/ >40, ↑ESR and LDH, large mediastinal LND
Orderly, centripetal spread + Reed Sternberg cells?
Hodgkin's Lymphoma
Hodgkins lymphoma w/ best prognosis?
Lymphocyte predominant
Lymphoma most likely to involve extra nodal sites?
Non-hodgkin's Lymphoma
Lymphoma staging (4)?
I = 1 node group
II = 2 groups, same side of diaphragm
III = both sides of diaphragm, extension into organ
IV = BM or liver
Lymphoma txt?
Stage I/II get rads
Stage III/IV get ABVD Chemo
Bone pain, "punched out lesions" on x-ray, hyper Ca? Best 1st test? Txt?
(uw) old woman, anemia, back pain, acute renal failure, granular cast?
Multiple myeloma
1st test: serum protein electrophoresis - IgG monoclonal spike
Confirmatory test: BM bx showing >10% plasma cells

Txt: if young, BM transplant. If old, melphalan + prednisone. Hydration and Lasix, then Bisphosphonates for hyperCa
Dizziness, HA, hearing/vision problems and monoclonal IgM M-spike?
Waldenstrom Macroglobulinemia
No sxs, immunoglobulin spike found on routine exam?
MGUS
Older pt w/ generalized pruritis and flushing after hot bath. Hct of 60%? Best 1st test? Txt?
Polycythemia Vera
1st test: EPO, make sure it isn't secondary (PSG, carboxyHbg)
Txt: scheduled phlebotomy, Hydroxyurea can prevent thromboses
(uw) can be from testosterone abuse
Screening and confirmatory test for Aortic aneurysm
Abdominal ultrasound
CT with contrast
Screening and confirmatory test for Aortic disection
CT with contrast
MRA or TEE
Screening and confirmatory test for Aortic trauma
CT with contrast
MRA or TEE
Screening and confirmatory test for Carotid stenosis
Duplex US
MRA
Screening and confirmatory test for Abdominal abscess
CT scan with contrast
Screening and confirmatory test for abdominal trauma
Focused assessment with sonography for trauma
CT with contrast
Laparotomy gold standard
Screening and confirmatory test for Appendicitis
US
CT with contrast
Screening and confirmatory test for bowel obstruction
AXR
CT with contrast
(uw) Screening and confirmatory test for Bowel perforation, buzzword
Upright abdominal film/xray
CT with contrast; will show free air
Screening and confirmatory test for Cholecystitis
US
HIDA
Screening and confirmatory test for Choledocholithias
US
ERCP/MRCP
Screening and confirmatory test for cholelithiasis
US
Screening and confirmatory test for Diverticulitis
CT with Contrast
Screening and confirmatory test for Esophageal disease
Gastrografin or barium
CT with contrast for rupture
Screening and confirmatory test for GI bleeding
Endoscopy
Tagged red cell scan if unable to visualize on endo
Screening and confirmatory test for Hematemesis
Endoscopy
Screening and confirmatory test for Meckel divirticulum
Meckel scan
Screening and confirmatory test for PUD
Endoscopy
Screening and confirmatory test for pyloric stenosis
US
Barium xray
Screening and confirmatory test for Fibroids
US
MRI
Screening and confirmatory test for Ovarian disease
US
MRI
Screening and confirmatory test for Pelvic mass female
US
MRI or ct with contrast or laproscopy
Screening and confirmatory test for pregnancy eval
US
Screening and confirmatory test for Acute stroke
Noncontrast Ct
MRI
Screening and confirmatory test for brain tumor
CT with contrast
MRI with contrast
Screening and confirmatory test for head trauma
Non contrast ct
Screening and confirmatory test for intracranial hemorrhage
Noncontrast ct
Screening and confirmatory test for MS
MRI
Screening and confirmatory test for skull fracture
Non contrast CT
Screening and confirmatory test for arthritis
xray
Screening and confirmatory test for bone mets
Bone scan
Pet scan
plain xray for MM
Screening and confirmatory test for fracture
X-ray
Noncontrast CT
Screening and confirmatory test for osteomylitis
X-ray
Bone scan or tagged white blood cell
Screening and confirmatory test for Pelvic trauma
Xray
Non contrast ct
Screening and confirmatory test for scaphoid fracture
xray
MRI
Screening and confirmatory test for chest mass
xray
ct with contrast
Screening and confirmatory test for hemoptysis
xray
bronchoscopy or ct with contrast
Screening and confirmatory test for pneumonia
xray
ct with contrast
Screening and confirmatory test for PE
CT with contrast
Pulmonary angiogram
Screening and confirmatory test for pulmonary nodule
xray
ct with contrast
Screening and confirmatory test for hematuria
Ct with contrast w/o if painful
cytoscopy
Screening and confirmatory test for hydronephrosis
us
ct with contast
Screening and confirmatory test for nephrolithiasis
noncontrast ct
intravenous pyelography
Screening and confirmatory test for uretal reflux
VCUG
Screening and confirmatory test for suspected urethral trauma
Retrograde urethrogram
newborn whose mother is hepatitis B virus (HBV) surface antigen positive
Hepatitis B vaccination and hepatitis B immune globulin within 12 hours of birth, a second dose of hepatitis B vaccine at 1 to 2 months, and a third dose of vaccine
at 6 months
Hib vaccine will...
95% to 100% effective in preventing invasive Hib disease
When can pregnant women get varicella vaccination?
After birth
Who should get the hep A vaccine?
GAY & IV drug
persons working with hepatitis A virus chronic liver disease
pts that receive clotting factor
Tdap when should it be given
19 to 64 to replace the next booster dose of tetanus
min age for flu shot
6 months TIV
2 years LAIV

administer two doses of
vaccine (separated by at least 4 weeks) to children between the ages of 6 months and 8 years who are receiving the seasonal influenza vaccine for the first time
HPV vaccination age criteria?
<26
can be given under any condition except pregnancy
Who can use the intranasal flu vac?
Healthy adults younger than 50
zooster vaccination begins at
60
Screening for lipid disorders begin at
35
only thing to improve baby outcome before pregnancy
.4-.8 folic acid daily
Recommendation for BSE
USPSTF and the AAFP to recommend against the performance of BSE for women at average risk
for breast cancer
cervical cancer screening
21 to 65 years with cytology (Pap smear) every 3 years or

To increase length between tests..

30 to 65 years combination of cytology and human papillomavirus (HPV) testing every 5 years.
guideline for lung cancer screening
annual (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years.
discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
How long should you wait to have another surgery after a revasculariztion surgery
6 months
MCC of death in international travelers
Heart Disease
Traveling to mexico can you use a prohylaxis for travelers diarrhea?
No
Only legally required vaccine for international travelers
Yellow fever
Patient using OCP's has continued high BP what should you do
DZ, use a barrier method

both estrogen and Progest ^bp
MCC reason for dz COC
irregular bleeding
COC's increase the chance of....
Venous thromboembolism
Which type of contraceptive pill must be taken everyday without a hormone free period
Progest only pills
COC's contraindicated in who?
smokers older than 35
Best contraception to use in a pt older than 35, obese, and smokes
Long acting injectable progest only
Native americans have a higher incidence of....
obesity
Homeless children have a higher number of...
ear infections
uninsured patients generally have..
few chronic health problems as compared to insured
contraindications to bupropion use
Eating disorders
seizures
use of moa;s in past 2 weeks
bloody poop infections
etec, yersina, shigella, entamoeba
when is osteporosis diagnosed
t-score is -2.5 sd's below the young adult
uspstf age to start screen for osteoporosis
65 dxa
size of benign nevus's
less than 6mm
greatest risk factor to developing skin cancer
Exposure to UV rays

weird risk...Creosote used for wood preservative
most common type of melenoma
superficial spreading melanoma..
horizontal growth phase slower than vertical
Least common type of melenoma
Lentigo maligna

Most common in elderly
Most common in Hawwaii
most common melanoma in africans and asians
Acral lentiginous melanoma

A for African and Asian
Most aggresive melanoma
Nodular

usually invasive at the time of diagnosis
Where do basal cell and squamous cell carcinomas arise from
Epidermal layer
how are the following areas usually imaged..
Upper Urinary tract
Lower Urinary tract
Upper; intravenous pyelogram or ct
Lower; Cytoscopy
what compromises the lower urinary tract
Bladder and urethra
you got a patient with asymptomatic hematuria, you culture the urine and find a UTI, when should you repeat the urinanlysis
6 weeks
Ways to pre-treat to help avoid contrast nephropathy
N-acetylcysteine, IV sodium bicarb
Hyperthyroid patients most likely to get which arrythmia
A-fib
Which thyroid cancer cannot be diagnosed by FNA?
Follicular cell malignancies cant be differentiated from its benign equivalent, need to be sent to surgery to get definitive answer.
most common cause of end stage renal disease
Diabetes
PH in hyperosmolar hyperglycemic state
pH i > 7.3,
bicarbonate > 15 mEq/L (>15 mmol/L)
Criteria to diagnose diabetes
1. A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia like polyuria or unexplained weight loss, or hyperglycemic crisis.

2. A fasting plasma glucose of greater than or equal to 126 mg/dL.

3. A hemoglobin A1C greater than or equal to 6.5%.
Metformin causes Gi disturbances and Lactic acidosis(sometimes) what is the other thing is causes
Decreased B12 levels
USPSTF starting age for BP/HTN
18
BP Goals...

Age < 60 years old
Age > 60 years old
All ages With CKD or DM
Age < 60 years old General population < 140/90
Age > 60 years old General population < 150/90
All ages W/CKDisease or Diabetes mellitus < 140/90
USPSTF & aspirin
men 45 to 79 reduce risk of MI
women 55 to 79 reduce risk of ischemic stroke.
Two question depression screening
"During the past month:"
1. "Have you often been bothered by feeling down, depressed or hopeless?"
2. "Have you often been bothered by little interest or pleasure in doing things?"
NSAIDS....
Decrease effect of
Increase effect of
HTN meds
sulfonylureas
USPSTF & chlamydia
All sexually active non-pregnant young women aged 24 and younger
All non-pregnant women age 25 and older who are at increased risk
How long is abortion legal
up to 22 weeks
USPSTF grade on skin cancer screening by full body skin examination
I...insufficient evidence
...
...
THIS SET IS OFTEN IN FOLDERS WITH...