Internal Medicine EOR Exam
Terms in this set (309)
From the hospital: What is a single antibiotic that can be used for colitis that covers all bacteria? It is NOT levofloxacin and metronidazole. What is a bad side effect of levo?
zosyn ie. piperacillin/tazobactam
CARDIOLOGY: EKG should be obtained if CP appears cardiac in nature. CXR is initial step to rule out pneumothorax, pulmonary infiltrates, and rib fractures. ____should be done for patients w worrisome histories for aortic dissection regardless of CXR or EKG results.
_____is minimally invasive and rapid for detecting aortic dissection at the bedside.
TEE - transesophageal echocardiogram
A ____ is used for pleuritic pain w normal CXR when a PE is suspected.
V/Q scan - but not good for a small PE
A _____is sensitive for small PE and may detect other chest abnormalities leading to pain.
helical chest CT
____is used when CP is esophageal in origin.
Esophageal pH monitoring
EKG: A ______suggests underlying heart disease (ischemic, hypertensive).
left bundle branch block
A _____may be indicative of right heart strain (as in pulmonary embolus).
right bundle branch block
____is a term used to describe decreased perfusion and oxygen delivery to the body. This is best defined by BP = CO x SVR. What are the three main types?
Shock; hypovolemic, cardiogenic, distributive
______shock can be from pump failure from infarction, cardiomyopathy, or tamponade, arrhythmia, valve failure, obstructed outflow from tension pneumothorax or massive PE.
______shock can be from hemorrhage, diarrhea, heat stroke, or third spacing.
______shock can be from sepsis, anaphylaxis, adrenal crisis, or myxedema coma.
The formation of _______occurs via:
a. endothelial dysfunction & formation of fatty streak
b. LDL enters fatty streak and attracts macrophages
c. proliferating smooth muscle cells, connective tissue, & lipids become incorporated into plaque
d. "fibrous cap" forms
Name some risk factors for CHD.
Peripheral Vascular disease
Chronic Renal Failure
Elevated homocysteine level
elevated inflammatory markers like CRP
Low Activity Level
Low intake of fruits and vegetables
lack of moderate alcohol intake
_____is insufficiently specific for assessment of patients with low (<10%) pretest probability of CHD. It is best reserved for patients with intermediate pretest probability. Sensitivity and specificity can be increased with imaging studies such as radionuclide imaging or echocardiography. What is the gold standard to diagnose coronary artery disease?
Exercise stress testing; coronary angiography
The AHA suggests the following mnemonic for the important elements in treatment of stable angina:
A: aspirin, ACEi, antianginals - nitrates/CCB
B: B-blocker, bp
C: cholesterol & cigarettes
D: diet and diabetes
E: education and exercise
CCB: Short acting dihydropyridine CCBs ie ____ have been shown to increase cardiac risk therefore nondihydropyridines are recommended. They are ___or___. Second generation dihydropyridines have fewer negative inotropic effects and can be used in settings of reduced ejection fraction. (ie. ___or___)
verapamil or diltiazem
amlodipine or nicardipine
Patients with stenosis of left anterior descending, left main coronary disease, three vessel disease, or survivors of sudden cardiac death or sustained VF/VT would benefit from _________.
coronary artery bypass grafting (CABG)
_______can be used to relieve symptoms in patients who fail medical therapy but who do not have significant enough disease to require CABG.
PCI - percutaneous coronary intervention
What are some physical exam findings in an acute MI?
entirely normal, fourth heart sound, third heart sound, systolic murmur of acute mitral regurgitation -- physical exam should focus on signs of PVD which may increase the suspicion for coronary disease
What is the typical evolution of the EKG in the setting of a STEMI?
1. increase in amplitude of the T wave
2. ST segment elevation
3. development of Q waves (hours to days)
4. resolution of ST-segment elevation
Cardiac-specific ____is drawn to detect damaged myocardium. It begins to rise is 6-9 hours, peaks at approximately 20 hours, and remains in the circulation for 7-10 days.
For patients with UA or NSTEMI to assess risk.
TIMI SCORE - 7 point system, more points, higher risk
at least 3 risk factors
known coronary artery disease w at least 50% stenosis
ST segment changes
2 episodes of angina in past 24 hours
aspirin use in past week
elevated CK-MB or troponin
What are the absolute contraindications to thrombolytic therapy? BHTASC
1. active Bleeding
2. previous intracranial Hemorrhage
3. intracranial tumor
4. aortic dissection
5. stroke within 1 year
6. closed head injury within past 3 months
Thrombolytics should be given within ______of pain onset. PCI needs to be performed within _____ of presentation to medical provider.
12 hours; 90 minutes
CHF: Systolic dysfunction is from decreased ____. Diastolic dysfunction is from a decrease in _____.
contractility (the pump); compliance (the fill)
Most symptoms of heart failure are pulmonary in nature ie. dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, & wheezing. Why?
because of increased LV end diastolic pressure that results in pulmonary venous and capillary congestion
What heart sound is indication of systolic dysfunction? diastolic dysfunction?
systolic - S3
diastolic - S4
What are the principal diagnostic testing for CHF?
chest radiograph, electrocardiogram, BNP, and echocardiogram
What is the acute treatment for pulmonary edema in heart failure? LMNOP
L = Lasix
M = morphine
N = nitroglycerine
O = oxygen
P = positive pressure ventilation
inotropic agents like dobutamine
In chronic CHF with systolic dysfunction, what three treatments are shown to decrease mortality? Digoxin, other inotropic agents, and loop or thiaxide diuretics are used as required for symptoms - benefit in fewer hospitalizations.
ACE inhibitors, cardioselective beta blockers (carvedalol, metaprolol, bisoprolol), and aldosterone antagonists(aldactone)
Hydralazine and nitrates in combination when combined with standard therapy is shown to reduce mortality for what race with class III or IV CHF?
What treatment is used in diastolic dysfunction to improve filling? A fib often worsens with diastolic dysfunction because of elevated HR and loss of atrial kick. What two treatments are sometimes necessary?
control of BP and HR; cardioversion and antiarrythmic medication
What treatments improve survival when EF <35% in class II/III CFH and sustained VT.
Automatic cardiac defibrillators, cardiac resynchronization through biventricular pacing
The following are systemic causes for what?
increased intracranial pressure
What medications may result in bradyarrhythmias?
BB, CCB, digoxin
Emergent treatment of bradyarrythmias is with _____for a patient with bradycardia causing hypotension, CHF, and syncope.
With sick sinus syndrome or complete heart block, when is a permanent pacemaker indicated?
for symptomatic patients
What type of block are pacemakers indicated even when the patient is asymptomatic?
type II second degree AV block (Mobitz) or bifascicular block with intermittent type II second degree AV block
When accessing for a tachyarrhythmia, what exacerbating conditions should be evaluated?
electrolyte disturbances (hypokalemia or hypomagnesemia), digoxin level, TSH, ethanol, cocaine
In patients with a hemodynamically _______wide QRS tachyarrhythmia/SVT, blocking the AV node with vagal maneuvers, adenosine, BB, CCB, or digoxin is done.
stable; unstable means synchronized cardioversion
_____toxicity can lead to paroxysmal atrial tachycardia with 2:1 block or nonparoxysmal junctional tachycardia.
The ____syndrome is characterized by a short PR interval, delta wave, and AVRT. AV nodal blocking agents (BB, CCB, dig, adenosine) should be avoided when AF is present with WPW.
WPW - wolfe Parkinson white
AVNRT and AVRT should be treated initially with _____. Radiofrequency ____should be considered for long-term management.
AV nodal blocking agents; ablation
Torsades de pointes is a multifocal VT, associated with a long QT interval. Treatment is _______&_______.
overdrive pacing and magnesium.
_____is the drug of choice to treat regular narrow complex tachycardias after vagal maneuvers have been unsuccessful.
Adenosine, BB or CCB
Treatment of ___&___involves rate control, rhythm control, and prevention of thromboembolism.
a fib and a flutter
Hypertension is defined as a blood pressure over ___. Over 95% of patients have HTN due to what cause?
140/90; essential hypertension with a UNKNOWN cause
The initial treatment of HTN is with what medication? What is the first line agent for patients with diabetes, heart disease, or proteinuria?
thiazide diuretic; ACE inhibitor
GO OVER MRTAPS
GO OVER MRTAPS
Mitral Stenosis impairs diastolic LV filling. Medical therapy involves heart rate control with what meds?
BB or CCB
Mitral Regurgitation results in left atrial enlargement and a dilated left ventricle. What meds are used for afterload reduction?
ACE inhibitors, ARBs, or a combination of hydralazine/nitrates
Aortic Regurgitation causes left ventricular hypertrophy. Afterload reduction with ___or___may decrease regurgitant volume and delay need for surgery but studies are conflicting.
ACEi or vasodilating CCB
There is no effective medical therapy for _______and several medications (nitrates, BB, CCB, ACEi) may precipitate hemodynamic instability in patients with severe or critical disease.
Valve replacement: Mechanical vs. Porcine. Explain the difference
Mechanical valves last forever but require lifelong anticoagulation. Porcine valves last 10-15 years and require no anticoagulation. Good for patients >75, women of childbearing age, or patients with contraindications to anticoagulation
Arterial disease may results from a variety of nonatherosclerotic disorders. Name some.
Marfan syndrome, Ehlers-Danlos disease, bicuspid aortic valve, HTN, Takayasu arteritis, giant cell arteritis, thromboangiitis obliterans, infectious diseases - syphilis
Aortic aneurysms should be electively repaired at what size?
>5.5 - 6cm
PAD is a coronary artery disease equivalent. Patients should be treated with what 3 things?
aspirin, statin, and tight blood pressure control
Intermittent claudication can be managed medically, but ischemic rest pain requires immediate what? What are the 6 P's of acute arterial occlusion.
evaluation by a vascular specialist, pulselessness, pallor, poikilothermia, pain, paralysis, paresthesia
What kind of disease should be considered in a young person with a thoracic aneurysm?
connective tissue disease - Marfan, Ehlers-Danos, bicuspid aortic valve
Dilated Cardiomyopathy: most common cause is ____. Others?
alcohol; may also be idiopathic, myocarditis, or drugs (doxorubicin) -- 1 in 3 cases of heart failure are caused by dilated cardiomyopathy
What PE and EKG changes are seen with dilated cardiomyopathy?
PE: S3, JVD, crackles - possible mitral regurg
EKG: nonspecific ST and T wave changes, LBBB
Hypertrophic cardiomyopathy: is due to hypertrophy of the _____? PE reveals mitral regurgitation, a ____heart sound, and prominent left ventricular impulse. EKG reveals LVH
cardiac septum; S4
Restrictive cardiomyopathy: often caused by a ____process, or post-radiation or post open-heart surgery. What is the most common first symptom?
--infiltrative process - amyloidosis, sarcoidosis, and hemochromatosis -- changes in myocardium
--most common first symptom is exertion intolerance and fluid retention, signs of right heart failure
____often follows an upper respiratory infection and may present with chest pain or signs of heart failure. EKG reveals cardiomegaly and contractile dysfunction. Treatment includes antibiotics sensitive after myocardial biopsy or MRI.
____refers to the sudden, transient loss of consciousness and postural tone. What are the most common etiologies?
1. neurally mediated (vasovagal, situational - micturition, tussive, valsalva, carotid sinus hypersensitivity)
2. orthostatic hypotension (volume depletion, medications, postprandial)
3. primary cardiac causes - structural, arrhythmic, decreased cardiac output
____is a systemic immune process that is a sequel of beta-hemolytic strep infection of the pharynx. Diagnosed based on Jones criteria.
Jones - 2 major or 1major and 2minor
Major = carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules
Minor = fever, arthralgia, previous Rheum fever, leukocytosis, ESR, CRP, prolonged PR
____ results from single or repeated attacks of rheumatic fever that produce rigidity and deformity of valve cusps, fusion of the commissures, or shortening and fusion of the chordae tendineae. The mitral valve is affected in 50-60% of cases.
Rheumatic heart disease
Endocarditis (or infection of the endothelial surface of the heart) is most commonly caused by what bacteria?
Strep Viradans, Staph Aureus, and enterococcus -- P aeroginosa and S. Marcescens with IV Drug users
What are some PE findings in infective endocarditis?
Roth spots - small white spots on retina surrounded by hemorrhage
Osler nodes - small tender lesions on fat pads of fingers and toes
Janeway lesions - painless, reddish, macular lesions on hands or feet
Duke Criteria for dx of infective endocarditis
Dx with 2 major or 1 major and 3 minor
a. positive blood cultures
b. endocardial involvelment on echo
a. predisposing condition: cardiac or IV drug use
c. vascular phenomenon
d. immunologic phenomenon
PULMONOLOGY: Which lung disease has an increased TLC (total lung capacity)?
emphysema - remember flattened diaphragms
From the hospital: You normally here COPD or asthma on ____wheezing. You normally here pleural effusion or right heart failure on _____wheezing.
expiratory wheezing = COPD
inspiratory wheezing = pleural effusion
In pleural effusion, pneumothorax, neoplasm, there is ____fremitus or transmitted voice sounds. In pneumonia, there is ____fremitus or transmitted voice sounds due to increased transmission through consolidated tissue.
On percussion, _____replaces resonance when fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussing fingers.
______on percussion is found in hyperinflated lungs like in COPD or asthma.
In emphysema, chronic bronchitis, & asthma, is the RV (residual volume) increased or decreased?
increased bc of air trapping
SPUTUM: What is the likely diagnosis if...
1. mostly WBC's
2. mostly eosinophils and mucous casts
3. mostly RBC's
1. pneumonia or bronchitis
3. chronic bronchitis, bronchiectasis, or tumor
What are four physiologic changes that result from COPD?
V/Q mismatches, pulmonary hypertension, abnormal ventilator responses, and right heart failure.
____is a complication of pulmonary hypertension. Right sided heart failure where the RV has a hard time pumping blood into the lungs. Causes: COPD, chronic PE, cystic fibrosis.
Explain how each of the following treatments for COPD helps to alleviate symptoms:
1. anticholinergics - ipratropium bromide, tiotropium
2. B-agonists - albuterol
3. Methylxanthines - theophylline
What is the only treatment proven to improve survival and quality of life?
1. bronchodilation - helps with bronchospasm
2. additional bronchodilation
3. infrequently used -- in some cases, it is useful for nocturnal symptoms
_____is an episodic disease characterized by abnormally heightened responsiveness of the tracheobronchial tree, leading to expiratory airflow obstruction.
Meds to treat asthma:
1. inhaled corticosteroids
2. cromlyn & nedocromil - blunt effects of bronchospastic triggers
3. theophylline - useful for nocturnal symptoms
4. leukotriene modifier - modify inflammatory mediators
5. po steroids
Asthma is treated depending on frequency of exacerbations.
>2x/month - one med
>1 x/week - two meds
frequent - 3 meds are referral
If a patient with a DVT has active internal bleeding, uncontrolled HTN, CNS tumor, recent trauma or surgery, or recurrent DVT despite anticoagulation, what alternative treatment should be considered?
What is the most common EKG changes in a PE? Other classic EKG changes?
sinus tachycardia and nonspecific ST-segment and T-wave changes - S1Q3T3
What are the two signs of PE on CXR?
Westermark's sign - area of decreased pulmonary vascularity with a cutoff sign
Hampton's hump - shadow or density in contact with one or more pleural space corresponding to lung segment involved
What is the criteria for the PERC SCORE????? HADCLOTS This is used to rule out the need for further imaging.
H - hormone/estrogen use
A - age>50
D - dvt/pe history
C - coughing up blood
L - leg swelling disparity
O - O2 sat<95
T - tachy>100
S - surgery/recent trauma
A newer modality for the noninvasive diagnosis of PE is the use of _______. What is the gold standard for diagnosis of PE?
helical chest CT; pulmonary angiogram
Morbidity from pulmonary emboli are best avoided by preventing the development of DVT's with subcutaneous heparin. What are some indications for prophylaxis with heparin bridge to warfarin?
major surgery, stroke, acute MI, prolonged immobility
_____refers to a group of disorders characterized by inflammation of the alveolar and perialveolar structures. The cardinal features are a history of progressive dyspnea on exertion accompanied by nonproductive cough. Fine crackles, reticular or reticulonodular infiltrates on CXR.
Interstitial lung disease
____are a group of disorders characterized by pulmonary exposure to inorganic and organic dusts and gases (asbestos, coal, rock, metals, graphite, cotton, grain, acid fumes, chlorine, nitrogen dioxide, phosgene). Chronic inflammation, mucous hypersecretion, scarring, and fibrosis.
_____is a condition in which lung inflammation is immunologically mediated. Deposition of antigen in the alveoli results in the formation of antigen-antibody complexes. Curable and reversible!
from aspergillus, botrytis cinerea, bird proteins, animal fur dust, wood dust, etc.
____is a well defined disease in which there is typical immunologic damage to the lung without identification of a causative agent as in HP. RA, SLE, Polymyositis, Good pasture, Wegener etc.
Idiopathic Lung Disease
_____is a systemic disease of unknown etiology characterized by granulomatous inflammation of the lung. S/S related to the lung, skin, eye, peripheral nerves, liver, kidney, heart, and other tissues. Biopsy demonstates noncaseating granulomas (not-necrosis or "cheese like). Tx??
Sarcoidosis; tx - corticosteroids
What does CXR show with pleural effusion? What is the tx?
blunting of costophrenic angle - free pleural fluid on lateral decubitis film; thoracentesis
Transudates vs. Exudates:
______occur when systemic factors that control formation and absorption of pleural fluid are altered. Left sided heart failure/cirrhosis, PE.
______occur when there is a loss of integrity of the pleural membrane and/or disruption of the lymphatic drainage - pneumonia, malignancy, viral infex, PE
Transudates can be distinguished from exudates by measuring the __&__contents in the pleural fluid and comparing them with serum values.
protein and LDH
The mainstay of treatment for transudates in with ____treatment. For complicated effusions, tube thoracostomy or surgical decortication may be required.
Management of an exudate requires local control of the effusions via drainage or sclerosis as well as correction of the _________.
_____presents with distended neck vein, indistinct heart sounds, narrow pulse pressure, and pulsus paradoxus. Tx: pericardiocentesis and treat underlying cause.
Hypotension, tracheal deviation, and elevated jugular venous pressure indicates that a simple pneumothorax has progressed to what? What does CXR show for this?
a tension pneumothorax; lack of lung vascular markings at periphery
Where is the needle decompression performed for a tension pneumothorax?
second intercostal space, mid clavicular line
What are the physical exam findings with signs of consolidation?
bronchial breath sounds, egophony (E to A changes), dullness to percussion, increased tactile fremitus
Explain how the CURB65 score should be used?
C - confusion
U - BUN >20
R - RR>30
B - bp Systolic <90, diastolic<60
65 - age>65
Pneumonia CXR findings and associated bacteria:
1. Strep Pneumo, H Flu, and Klebsiella have ____consolidations.
2. Staph Aureus, Legionella, and Mycoplasma appear ___.
3. Pneumocystitis jiroveci is common in AIDS patients and appears _____.
lobar; patchy; diffuse interstitial and alveolar infiltrates
Pneumonia treatment inpatient vs. outpatient?
--3rd generation cephalosporin - ceftriaxone
--macrolide - azithromycin
--vancomycin - if MRSA is a concern
--macrolide - azithromycin
--Fluoroquinolone - levofloxacin
A ____is a round opacity outlined by normal lung and not associated with infiltrate, atelectasis, or adenopathy. Often asymptomatic or present w s/s of underlying malignancy. Monitor closely. >35yo, consider potentially malignant and resect.
solitary pulmonary nodule
Small cell - 100% associated with smoking. Consider metastatic at time of diagnosis. Metastasizes rapidly. Where are mass usually found first?
Non small cell - discrete masses that can spread to regional lymph nodes and metastasize to distant sites. What are the three types?
Squamous - central airways
Large cell - central or peripheral
Adenocarcinoma - periphery
Lung cancer is more likely to produce active substances that result in a variety of paraneoplastic syndromes. Give some examples of some.
hypercalcemia, SIADH, hypercoagulable state, superior vena cava syndrome, Horner's syndrome, Pancoast's tumor
A ____is a low-grade malignant neoplasm that is slow-growing and rarely metastasize. symptoms include hemoptysis, cough, wheezing, and recurrent pneumonia. ___syndrome of flushing, diarrhea, and hypotension. Surgery is treatment of choice.
Carcinoid tumor; carcinoid syndrome
____is abnormal dilation of the large conducting airways often due to cystic fibrosis or alpha-1 antitrypsin deficiency. Treat underlying disorder.
____is when often obese patients fail to breath rapidly or deeply enough resulting in low oxygen or high carbon dioxide levels.
GI: The abdominal plain film may show free intraperitoneal air, seen under the diaphragm on an upright film, indicating what?
perforation of a hollow viscus
Hyperkalemia is seen in bowel infarction and represents what?
LFT's show marked elevations in ______in hepatitis and elevation of _____in cholecystitis. LFTs may be normal in biliary colic.
amylase; alkaline phosphatase
Osmotic diarrhea usually ____(improves or worsens) with fasting whereas secretory diarrhea ____(improves or worsens) during fasting.
____is defined as a syndrome characterized by chronic abdominal pain and altered bowel habits (can be either diarrhea or constipation). Treat w diet modifications, addition of fiber, antispasmodics, stress reduction
Irritable bowel syndrome
Rome Criteria - pain at least 3 days over the last 3 months w 2 or more of the following:
1. relieved w defecation
2. associated w change in frequency of stool
3. associated w change in form of stool
____ is usually caused by contaminated eggs, dairy products, or poulty.
____is usually spread by the fecal-oral route.
_____is acquired from eating undercooked poultry or contaminated natural water sources.
Salmonella - use abx when signs of systemic illness
Shigella - abx
Campylobacter jejuni - abx
_____is an enterotoxin that causes profuse watery diarrhea; fecal/oral spread often from water contamination
____is most commonly acquired from eating undercooked beef. Can cause hemolytic uremic syndrome and thrombotic thrombocytopenic purpura.
A protozoa, _______, is one of the principal agents of traveler's diarrhea.
Vibrio Cholerae - tx: doxycycline
E Coli - no treatment - treatment of diarrhea can increase risk of TTP/HUS
Giardia lamblia - metronidazole
____ulcers which entails increased acid production and ____ ulcers which have normal or even reduced gastric acid.
What infection appears to be associated with most duodenal and peptic ulcers? How is this treated?
H Pylori; amoxicillin, omeprazole, clarithromycin
Gastritis is commonly due to direct mucosal injury. What are common agents that cause this?
NSAIDs, ethanol, steroids, and strong alkali and acid agents
What is the most common cause of esophagitis? What is H Pylori's role in this?
GERD; role is controversial, some say causative, some say protective
Treatment of dyspepsia involves inhibiting and neutralizing gastric acid. What meds are commonly used?
H2 receptor antagonists, antacids, proton pump inhibitors, sucralfate (mucosal protectant)
_____disease effects the entire GI tract; mostly small intestine and colon. Rectum spared. "cobblestone mucosa" Tx: is metronidazole and immunomodulators. Complications are bowel obstruction and fistulas
_____disease is limited to the colon, rectum involved. Blood diarrhea. Tx: Sulfasalazine or 5-ASA drugs, immunomodulators. Complications are toxic megacolon, colon carcinoma.
In addition to hepatitis viruses, what other viral infections and drugs can cause acute hepatitis?
Viruses: CMV, HSV, Coxsacke
Drugs: APAP, halothane, isoniazid, methyldopa, azole antifungals
Diagnoses of hepatitis is done via looking at the ___and___. How is alcoholic vs. acute viral hepatitis lab values different.
AST and ALT
Acute viral: Both AST & ALT together are greater than alcoholic
Which Hepatitis can become chronic?
Hep B, C, D
What does it mean if a patient has the
1. HepB surface antigen/HBsAg
2. HepB surface antibody/ANTIHBs
3. Hep B antibody to core antigen/ANTIHBc
1. HBsAg - patient has Hep B infection
2. ANTIHBs - patient has been immunized or has recovered from acute infection
3. ANTIHBc - indicates an acute infection
What drugs are used to treat chronic viral hepatitis (HBV and HCV)?
interferons and antivirals
HCV - ribavirin (terratogenic)
HBV - lamivudine, adefovir, entacvair
Prophylaxis against which forms of viral hepatitis are available?
Hep A vaccine and Hep B vaccine
____is defined as irreversible hepatic injury, characterized by fibrosis that distorts hepatic architecture and the presence of regenerative nodules.
Names some underlying causes of cirrhosis.
Alcohol, chronic Hep B&C, biliary disease, cardiac disease, Nonalcoholic fatty liver disease
The serum ascites-albumin gradient is the most specific test to differentiate between the causes of ascites. A gradient >1.1g/dL usually means ascites caused by ____. <1.1g/dL means ascites caused by __,__, or __.
cirrhosis; malignancy, pancreatitis, and tuberculosis
Laboratory findings seen in cirrhosis are:
low Na, low BUN, low albumin, low platelets; high bilirubin and high PT, MCV>100
In cirrhosis, ___develop from portal vein hypertension that is transmitted to system collateral veins in the gastroesophageal junction. Tx: vassopressin analogues (octreotide), sclerotherapy, band ligation
What are the laboratory findings in cholestatic liver disease?
increased alkaline phosphatase with normal to slightly elevated transaminases
Intrahepatic Duct Obstruction can cause either primary biliary cirrhosis or primary sclerosing cholangitis.
1. Primary biliary cirrhosis usually occurs in middle aged women and presents with pruritis or asymptomatic elevations in Alk Phos
2. Primary sclerosing cholangitis is usually in association w inflammatory bowel disease and patient present with ascending cholangitis
____is the consequence of inappropriate activation of enzymatic precursors (zymogens) in the pancreas. Activation leads to autodigestion of the organ. What are the two most common causes?
Pancreatitis; most common causes are alcohol and gallstones, less common causes are direct injury, viral infections, and metabolic abnormalities
Blue periumbilical discoloration or _____sign and bruising of the abdominal flanks or ____sign both suggest necrotizing disease in pancreatitis.
Cullen; Grey Turner
In pancreatitis, when the diagnosis is uncertain, is clinically severe, the patient appears septic, or the patient fails to improve, what diagnostic study is indicated? What lab value is most sensitive to pancreatitis?
Abdominal CT; amylase - lipase and amylase
The development of ____is a major cause of morbidity and mortality in pancreatitis. Empirical antibiotic use in cases of documented severe necrosis is advocated by some, nut not all experts. Abscesses require drainage.
_____cancers are believed to arise from malignant transformation of benign adenomatous polyps. Risk factors are: high fat diet, low fiber, obesity, ethanol, refined sugar, smoking
Colorectal screening for no risk factors starts at age ___with annual fecal occult blood test, DRE, & flexible sigmoidoscopy every 3-5 years or what other option?
age 50 - colonoscopy every 10 years
Invasive cancer involving the ___differs from other colon cancers in that local recurrences after resection are more common.
In ____cancer, most frequently they are metastatic tumors. Poor prognosis, mean survival 6 months. Prevention is most important.
liver -- most common primary malignancy is hepatocellular carcinoma - causes include Hep C infection, alcohol, hemochromatosis
What are the three types of esophageal strictures?
esophageal webs, lower esophageal ring (Schatzki's ring), Zenker's diverticulum
The two types of hiatal hernias are paraesophageal and sliding. Which is treated surgically?
sliding are only treated surgically if persistent or recurrent symptoms
_____is due to an abnormal immune response to gluten. Laboratory tests reveal the presence of antigliadin and antiendomysial antibodies. Abnormal immune response to gluten.
Rheumatology: Risk factors for ____include DM, HTN, obesity, hyperlipidemia, alcoholism, and thiazide use.
For acute monoarticular arthritis, ____is the definitive diagnostic procedure.
On crystal examination, ____shows needle shaped negative bifringent crystals and ____shows rhomboid or weakly positive birefringence.
Bacterial infection in joint: suspicion is high when ____is >100, 000.
______lumbar discs radiate pain to anterolateral leg and great toe and affect dorsiflexion.
______lumbar discs radiate pain to posterior leg and lateral toes and affect plantar flexion.
____is a symmetric inflammatory peripheral polyarthritis characterized by lymphocytic infiltration of the synovial joints and granulomatous extra-articular nodules.
Name some criteria for the diagnosis of RA.
--morning stiffness >1hr for at least 6 weeks
--arthritis of 3 or more joint for 6 weeks
--Arthritis in wrist, MCP, or proximal intraphalangeal joints
--hand or wrist films showing erosions or periarticular osteopenia
The RF factor can be positive in other conditions like older age, SLE, sarcoid, endocarditis, chronic infections, hyperglobulinemic states. What other lab test is more specific to RA? What is drawn for inflammatory markers?
anti-CCP; ESR and CRP
____syndrome in RA is the combination of RA, splenomegaly, and leukopenia.
Treatment of RA consists of analygesia and early institution of DMARDs. Name some and their side effects.
Methotrexate (bone marrow toxicity, pneumonitis, stomatitis, hepatic fibrosis, Sulfasalisize (rash), Hydroxychloroquine (retinopathy), leflunomide (diarrhea, rash), minocycline (hyperpigmentation), azathioprine (immunosuppression)
If first-line treatment in RA fails, then biologic agents are used. Name some.
infliximab, rituximab, ehtanercept, anakinra, adalimumab
____presents with pain in 11+ pressure points, no abnormal labs. Treatment is exercise and behavioral therapy then TCA's, gabapentin, and anxiolytics.
What two rheumatoid diseases are more prevalent in men than women?
anklyosing spondylitis & reactive arthritis
For the treatment of spondyloarthropathies which are an interrelated group of inflammatory disorders affecting the psine, joints, and periarticular structures, what is treatment focused on?
treatment of underlying disease
______arthritis appears to be precipitated by enteric infection caused by Salmonella, Shigella, Campylobacter, Yersinia, or CHLAMYDIA.
In ______, can include heel pain, uveitis or conjunctivitis, sausage digits, and positive HLA-B27 (not recommended for screening). Skin involvement with circinate balanitis and/or keratoderma. Labs show a elevated CRP and ESR.
"Can't see, can't pee, can't climb a tree"
________diseases are characterized by alterations in immune function often leading to the production of autoantibodies.
1. immune complex deposition
2. vascular damage
3. overproduction and accumulation of extracellular matrix
4. altered immune responses
What diseases have increased ANA ie. are the connective tissue disease?
SLE - lupus
____presents with myalgias, arthralgias, fever, malar rash, photosensitivity, and alopecia. Tx: NSAIDs, prednisone, immunosuppressants. What specific labs are positive?
SLE; ANA, anti-Sm & anti-dsDNA
Scleroderma presents with the CREST syndrome. What does CREST stand for? Tx: ACEi for renal crisis, MTX possible help in early disease.
C - calcinosis
R - Raynaud's phenomena
E - esophageal hypomotility
S - sclerodactyly
T - telangectasias
______presents with proximal limb muscle weakness and _______presents with proximal limb muscle weakness and heliotrope rash and gottron papules. Tx: prednisone
___presents with dry eyes and dry mouth. No specific treatment other than treating the symptoms.
____is inflammation of the synovial lining of the bursa and joints -- often in shoulder, neck, and hips. Tx: NSAIDS and prednisone cornerstone.
_____is a vasculitis disease of the medium-sized arteries. Middle aged men. Palpable purpura, High ESR, leukocytosis, anemia, thrombocytosis, urine positive protein and blood if kidney involved.
PAN - polyarteritis nodosa
____is a systemic disorder characterized by extracellular deposition of an amorphous eosinophillic protein that stains positive with Congo red stain. How is diagnosis made?
Amyloidosis, abdominal fat pad aspirate -- treatment is supportive and prognosis is poor
ENDOCRINOLOGY: Involuntary weight loss of 5% or more of body weight in <12 months should prompt medical evaluation. What level/lab test can evaluate the degree of malnutrition?
Hyperthyroidism is diagnosed by the presence of increased ____. TSH is suppressed in primary hyperthyroidism and increased in secondary hypothyroidism (rare). An exception is is T3 thyrotoxicosis.
_____disease is an autoimmune thyroid disease caused by production of antibodies to the thyroid gland's TSH receptor. DeQuervain or painful thyroiditis is most likely viral in origin, following a flulike syndrome.
Graves -s/s are proptosis and pretibial myxedema
The treatment of hyperthyroidism includes radioactive iodine, antithyroid drugs which are:_____which is TID and ____which is qd and not safe in pregnancy, and surgery.
Hypothyroidism is characterized by low ___and high ___. Hashimoto's thyroiditis (MC!) is an autoimmune disease that is the most common cause of hypothyroidism in the US. Most patients have _____antibodies.
low T4 and high TSH; anti-TPO
Replacement of thyroid hormone in patient with central hypopituitarism or myxedema coma may cause ____by increasing the metabolism of cortisol.
To diagnose DMI or II, a fasting glucose should be _____or a random or OGTT reading should be _______.
1. Firstline tx is with metformin, a biguanide which should not be given in what instances?
2. _____are secondline and squeeze pancreas -- s/s are hypoglycemia and weight gain - not w renal failure.
3. Meglitinides are newer ______that are not renally secreted.
renal or hepatic failure; sulfonylureas; sulfonylureas
1. TZD's (pioglitazone, rosiflitazone) have _____negative side effects and should only be used for patients refusing insulin.
2. Alpha-glucosidase inhibitors (acarbose) have the side effect of __.
3. DDP-4 inhibitors or ____ are limited to combination therapy.
cardiac; flatulence/bloating; sitagliptine
The two most common etiologies of hypercalcemia are primarily ____&_____.
hyperparathyroidism and malignancy (lung, renal, breast, MM)
The simple mnemonic for hyperparathyroidism is what? What cardiac manifestations are present with hypercalcemia?
stones, bones, growns, physic overtones; shortened QT interval
Treatment of hypercalcemia consists of hydration with IV normal saline and long term control using ____. Primary hyperparathyroidism is treated ____most commonly by resection of a solitary parathyroid adenoma.
Primary adrenal insufficiency is usually _____in etiology. It may be associated with other diseases like T1DM and hypothyroidism as part of type II polygland autoimmune syndrome.
Adrenal insufficiency (Addison's disease) presents how?
weakness, weight loss, abdominal pain, hyponatremia, and hyperkalemia
ACUTE presents with h/a, n/v, diarrhea, and abdominal pain
Diagnosis of adrenal insufficiency is confirmed with 1 hour cortisol response to cosyntropin with level ____. Treatment consists of hydrocortisone replacement and stress doses used for illness or stress.
____is a rare form of thyrotoxicosis which occur with stressful illness, thyroid surgery or radioactive iodine. High mortality rate. Marked delirium, tachycardia, vomiting, diarrhea, dehydration, high fever, high T4, low TSH.
Thyroid cancer always manifests as a palpable ____. Cause unknown. Papillary most common and least aggressive. How is it diagnosed?
thyroid nodule; iodine scan (cold is positive) or ultrasound
__disease is a disorder of bone metabolism. Most common in pelvis, lumbar spine, and femur. High alkaline phosphate, treat with calcitonin and bisphosphonate.
Pagets disease of the bone
____syndrome is caused by excess levels of circulating cortisol. Names some PE findings
Cushings; truncal obesity, moon face, purple striae, muscle atrophy, hypertension
Excess cortisol production in Cushings can be ACTH dependent/high which is a ___or____source or ACTH independent which is a ____source.
pituitary or ectopic; adrenal
Diagnostic work up of Cushings includes measurement of __, __, or __ to measure cortisol. If hypercortisolism is determined, high dose dex suppression test is done to determine source. If suppressed, then source is ____.
urine free cortisol, late night salivary cortisol, or overnight dexamethasone suppression test; pituitary
___is effective in remission in 60-80% of cases of Cushings.
Name the anterior and posterior pituitary hormones.
FLATPIG - anterior, FSH, LH, ACTH, TSH, PL, ignore, GH
posterior oxytocin, vasopressin
The most common pituitary adenomas are ____followed by adenomas producing GH causing ___, and those that produce ACTH causing ____.
prolactinomas, acromegaly, Cushings
In prolactinomas, ____is elevated. In acromegaly, GH is pulsatile and can't be reliably measure, therefore, ___ is measured. In Cushings, ___is completed after high cortisol is found. ____is the test of choice for pituitary adenoma.
prolactin, IGF-1, dexamethasone suppression test, MRI
____(loss vasopressin/ADH) is suggested by low urine osmolality in the setting of high serum osmolality. Treatment is fluid restriction until urine osmolality is >295. Administration of ____confirms central etiology.
Diabetes Insipidus; vasopressin
Symptomatic ____are treated with dopamine agonists ie. bromocriptine or cabergoline. Surgery is required with refractory disease.
If pituitary adenomas are secreting hormones other than prolactin, surgery is indicated. Has radiation been effective? What is a side effect for most patients?
____ is a tumor of the medulla of the adrenal glands. Secretes norepi and epinephrine. Treatment is usually surgical resection.
Alcoholics are susceptible to deficiencies of ___, ___, and ___.
thiamine, folic acid, and vitamin B12
At what age does dyslipidemia become a risk factor for disease?
Men greater than 45 or women older than 55
Levels of LDL at which to begin dietary or drug therapy treatment:
0-1 risk factor?
2+ risk factor, CHD risk <10%
2+ risk factor, CHD risk 10-20%
CHD risk >20%
1. 0-1 risk factor
dietary >160, drug >190
2. 2+risk factor, CHD<10%
dietary >130, drug >160
3. 2+risk factor, CHD >10%
dietary >130, drug >130
4. CHD risk >20%
dietary >100, drug >130
1. ___are firstline, s/s myalgias.
2. ___previously firstline - s/s flushing
3. ____, s/s bloating/constipation, LDL lowering and TG raising
4. ____, s/s/ GI, increase gallstones
5. ____, lower LDL, s/s myalgias
Statins, Niacin, Bile Acid sequestrants, fibric acid derivatives, ezetimibe
When combination therapy is required in dyslipidemia, which meds are best to add to statins because of side effect profile?
bile acid resins or ezetimibe
NEUROLOGY: ___is an acute and fluctuating state of impaired cognition and consciousness. Common precipitants are medication side effects, drug-drug interactions, medication withdrawal, and illicit substance use.
In delirium, what medications can be used in low doses only when necessary for patient safety.
Haldol, respiridone, olanzapine
In BPPV, on the Dix-Hallpike maneuver, the patient will exhibit a ____&____nystagmus with the upper pole of the eye beating toward the dependent/affected ear.
horizontal and torsional
For the diagnosis of ____, both memory loss and one other cognitive impairment must be present ie. agnosia, aphasia, or loss of executive function.
The most common form of dementia is ___ Its short term memory loss insidiously progresses to severe dependency for ADLs in about 10 years. Tx: cholinesterase inhibitors (donepazile) and NMDA receptor blocker (memantine.
Dementia with _____results in cognition fluctuations, hallucinations, and parkinsonism. Cholinesterase inhibitors should be tried before antipsychotics to treat hallucinations in order to avoid worsening parkinsonism.
____causes of dementia such as normal pressure hydrocephalus, depression, hypothyroidism, and vitamin B12 deficiency should be assessed and treated.
What meds should be avoided in patients with dementia?
____is a dilation of cerebral ventricles and secondary to a prior CNS insult. The tx is a VP shunt.
Normal pressure hydrocephalus
Stroke: Which vascular supply is affected with the following common manifestations?
1. contralateral extremity weakness - lower > upper; altered reasoning; bowel & bladder incontinence
2. contralateral face and arm weakness greater than leg; contralateral sensory deficits; dysphasia
3. contralateral visual field deficits; altered mentation; cortical blindness
4. vertigo/nystagmus; dysarthria; dysphagia; contralateral pain and temperature sensory deficits; syncope
1. anterior cerebral artery
2. middle cerebral artery
3. posterior cerebral artery
4. vertebrobasillar arteries`
___should be rapidly performed in all patients suspected of stroke. Thrombolysis within _____ of symptom onset. No tPa if risk of intracranial or life-threatening bleeding. BP should be <_____.
non-contrast CT, 3 hours, <185/110
Longterm treatment of stroke includes what three treatments?
statin and aspirin qd, carotid Doppler screening
____is a focal neurologic deficit of acute onset, resolves in 24 hours, patient has risk factors of vascular disease - which are often present.
Transient ischemic attack
_______seizures have preserved consciousness and may have prior "aura", and present as diverse as repetitive muscular activity, speech difficulty, or distortions of sound perception.
_______seizures present with impaired consciousness and automatisms (facial movements, repetitive speech etc.), and patient may appear awake but does not respond appropriately.
_______seizures have impaired consciousness, staring episodes, often pediatric population.
_______seizures often have "yell" at onset, initial tonic clonic back arching, cyanosis, tongue biting, loss of bowel/bladder control.
Tonic Clonic/Grand Mal seizure
____levels are often elevated within 30 minutes and normalized after 6 hours. Head CT, MRI, lumbar puncture, and EEG are used to assess patient. Which is the most definitive test for detection of epileptic activity?
_____presents with seventh (facial) cranial nerve palsy, loss of taste on the anterior 2/3 of tongue, and hyperacusis. Dx of exclusion. Rule out Ramsay Hunt syndrome.
_____is an acute or subacute polyradiculoneuropathy most likely due to an immune-mediated mechanism. Typically follows a type of infection such as Campylobacter, mononucleosis, CMV, herpes, and Mycoplasma, weakness is ascending pattern. Tx: plasmapheresis and human immunoglobulin.
____is an autoimmune disorder that causes a decrease in acetylcholine receptors -- patients have trouble combing hair, climbing stairs, lifting overhead. Tx: anticholinesterase - pyridostigmine bromide, neostigmine bromide.
The cause is unknown for an _____, can be inherited in an autosomal dominant pattern. Typically involves hand or head. No hypokinetic features or rigidity of PD. Tx: BB and modest doses of alcohol.
_____disease is a genetic disorder characterized by choreiform movements, mental status decline, and personality changes. Insidious onset of clumsiness and random, brief, fidgety movements. Gait is dancelike.
MRI shows cerebral atrophy
death in 15 years
____is a progressive degenerative disease resulting from loss of dopaminergic neurons in the substantia nigra. Pill-rolling tremor, cogwheel rigidity, bradykinesia, shuffling gait.
_____ generally presents with fever, headache, and signs of meningeal irritation. What is the essential diagnostic tool? What should be administered IMMEDIATELY if LP is delayed?
Meningitis; LP; antibiotics
Which clinical features of CSF are AVM, which are ABM?
A. WBC 200-10,000, PMN mostly; 100-500 protein; <40 glucose; >200 opening pressure; winter months; age - older adults and infants
B. WBC 25-100; lymphocyte mostly; 50-100 protein; >40 glucose; <180 opening pressure; summer months; children and young adults
bacterial meningitis; viral meningitis
What is the classic antibiotic treatment for meningitis? Length of course?
14 day course
1. 3rd generation cephalosporin - ceftriaxone or cefotaxime - covers Strep pneumo, N meningitis
2. Vancomycin - covers MRSA
3. Ampicillin - Listeria monocytogenes
____sign refers to pain in the neck or back that occurs when a pt with meningitis attempts to extend the leg at the knee while the thigh is held in 90 degrees of flexion.
____sign refers to spontaneous flexion of the hips during attempted passive flexion of the hips during attempted passion flexion of the neck.
Concussion grading - American Academy of Neurology:
____=confusion but no LOC for <15 minutes.
____=confusion but no LOC for >15 minutes.
____=LOC either brief or prolonged.
Grade I, Grade II, Grade III
It is vital to make sure the symptoms of the first concussion have subsided because of the gloomy possibility of ________ ie. when the brain swells catastrophically - patient either dies or is left severely disabled
second impact syndrome
GLASCOW COMA SCALE
Severe, with GCS < 8-9
Moderate, GCS 8 or 9-12
Minor, GCS ≥ 13.
4 - spontaneous
3 - open to speech
2 - open to pain
1 - no response
5 - alert and oriented
4 - disoriented conversation
3 - inappropriate words
2 - nonsensical sounds
1 - no response
6 - spontaneous
5 - localizes pain
4 - withdraws to pain
3 - decorticate posturing
2 - decerebrate posturing
1 - no movement
____is infection of the brain parenchyma. CSF: Gram stain usually negative, WBC majority is mononuclear leukocytes, protein >100, CRP normal, glucose normal to slightly decreased.
The most common cerebral aneurysm is a ____aneurysm that is typically located on the circle of Willis or major branches. Treated is surgical clipping.
DX of aneurysms with CT, MRA, or angiography
What are the common causes of anion gap acidosis? MUDPILES
M, Methanol. U, Uremia. D, Diabetic Ketoacidosis. P, Paraldehyde. I, Infection. L, Lactic Acidosis. E, ethylene glycol. S, salicylates
A ____aneurysm is an elongated dilation of large arteries, associated with atherosclerosis, typically develop in basilar artery. Frequently multiple and found in the distal cerebral arteries. Treated with total occlusion.
Some causes of _____which is an excess of water relation to total solute is volume depletion, edematous states, euvolemic hypo-osmolar states, hyperglycemia, hyperlipidemia, hyperproteinema. S/S = lethargy, confusion, coma, hyperexcitality.
---serum osmolality ---
The causes of ____are pure water deficits, water loss, and sodium overload. S/S = CNS dysfunction.
As a rule of thumb, only ___ of the free water deficit should be replaced in the first 24 hours, and the remainder of the deficit over the next 24 to 48 hours.
Hypokalemia causes ____waves on EKG and ____waves with hyperkalemia.
U waves; peaked T waves
Emergent treatment of hyperkalemia is via ____administration. Intracellular shift of potassium is accomplished by __&__ administration. Elimination of K is by use of potassium-binding resins, diuretics/saline infusions, or via dialysis.
Calcium; insulin and bicarbonate
The etiologies of ARF are divided into three major groups based on the anatomic nature of the lesion. What are they?
Prerenal, Intrinsic, or postrenal
_____etiologies could be hypovolemia, decreased cardiac output, renovascular disease, systemic vasodilation, renal vasoconstriction, impairment of renal autoregulation of blood flow (caused by drugs like ACEi or NSAIDs)
_____etiologies are vasculitis or microangiopathy, glomerulonephritis, acute tubular necrosis (caused by ischemic insult or nephrotoxic drugs), interstitial nephritis, or tubular obstruction.
_____etiologies are ureteral obstruction, bladder neck obstruction, or urethral obstruction.
Chronic kidney disease is defined as a GFR below ____ and end stage kidney disease is defined as a GFT below ____. What is seen on urinalysis?
Stage I - >90
Stage II - 60-89
Stage III - 30-60
Stage IV - 15-29
Stage V - <15
broad waxy casts
___&____are the most common complication that causes CKD. 70%
Diabetes and hypertension
The ____ syndrome is a constellation of symptoms and PE findings that result from the accumulation of toxins normally handled by the kidney pericarditis, dyspnea on exertion, anorexia, n/v, fatigue/weakness, AMS, SOB, pruritis and easy bruising..
_____casts are seen in interstitial nephritis. _____casts are seen in acute tubular necrosis
white cell casts (WBC's), muddy brown casts
The ____are disorders characterized by direct injury to the glomerulus. Because the glomerulus provides primary filtration for the urinary system, disease should be suspected when urine contains findings consistent with abnormal filtration ie. dysmorphic red cells, red cell casts, significant proteinuria, or lipiduria
glomerulopathies -- TEA COLORED URINE
Glomerulonephritis is an uncommon cause of acute renal failure.
Poststreptococcal = high _____titer
IGa nephropathy = elevated ____ levels
Wegeners = ____positive
Goodpasture's = ____positive
Lupus nephritis = ____positive
Poststreptococcal = ASO titer
IGa = elevated IGa levels
Wegener's = ANCA positive
Goodpasture's = Anti-GMB positive
Lupus = ANA positive
Causes of glomerular injury can be divided into those that cause inflammation or ____ and those that alter the permeability of the glomerular membrane (_____).
Nephrotic syndrome has proteinuria greater than what? Edema and ascites!!!! What about fat in urine?
>3.5 grams/day; fatty casts, oval fat bodies, Maltese crosses
Nephritic syndrome has what color urine? Protein <3.5g/day, and what about the red cells?
tea colored urine, dysmorphic red cells and red casts
Acute _____is an acute injury - either ischemic or toxic, you see muddy brown casts. Pigmented granular casts and/or epithelial cells.
What dietary factors increase the risk for nephrolithiasis?
low fluid intake, grapefruit juice, high sodium intake, high protein intake, low dietary calcium intake, hyperparathyroidism, obesity, gout, DM, renal tubular acidosis
_______is the most common type of kidney stone. What are the other three less common types of kidney stones.
Calcium (hypercalciuria, hypocitruria, hyperoxaluria, hyperuricosuria); uric acid, struvite, cystine
Which stone is radiolucent? Which stones have an increased pH?
uric acid; calcium & struvite
If ______predominates the picture, renal malignancy, pyelonephritis, glomerulonephritis, or trauma should be considered.
What is the diagnostic test of choice for nephrolithiasis? Stones that are smaller than ____usually pass on their own.
helical CT - IVP used to be but dye has decreased its use; 5mm
Systemic conditions often predispose to nephrolithiasis. ___stones may be caused by hyperparathyroidism, sarcoidosis, or Cushings. _____stones are associated with myeloproliferative disorders, chemotherapy/tumor lisis, or gout. Patients w intestinal malabsorption and ileal disease usually have ______stones.
Calcium; Uric acid; calcium oxalate stones
_____of urine using potassium citrate and allopurinol reduce recurrence of uric acid stones.
The presence of _____indicates a renal origin for hematuria.
RBC's originating from glomerular disease are often ____in shape.
Men over age 50, smokers, people treated with cyclophosphamide, and those using high dose analgesics are at increased risk for ________.
urinary tract malignancy
What is the first imaging technique used to detect a urinary malignancy? If nonglomerular bleeding persists, what test is typically performed?
helical CT; cytoscopy
UTI's are usually caused by _________ie. E Coli, Enterobacter, Klebsiella, Proteus, and Pseudomonas.
Gram positive: Staph saprophyticus and enterococci
What are the standard oral drugs to treat UTI's?
Bactrim, quinolones, or beta lactams
azo/phenazopyridine for symptomatic relief
PSA is a serine protease produced by the prostate and a value ____ug per mL are highly suspicious for prostate cancer.
A Gleason score from 1 as well differentiated to 5 as poorly differentiated are added together to 1 through 10. What scores have the worst prognosis?
scores from 8-10
_______carcinoma presents with flank pain, abdominal mass, and hematuria. The most common type is clear cell. Tx: surgical removal or immunomodulatory therapy with interleukin-2 for metastatic disease
HEMATOLOGY: General criteria for anemia are a hemoglobin level of <____in men and <____in women.
<13 in men; <12 in women
____is caused by either increased destruction (hemolysis), decreased production (low retic count), or blood loss.
If microcytic (MCV<100), what are possible dx?
iron deficiency, thalassemia, anemia of chronic disease, or sideroblastic anemia
If MCV is low and RDW is low but RBC is high, what is the diagnosis? What is it?
thalassemia - decreased production of globin chain
--Mediterranean, ME, or Southeast Asian for Beta
--those plus AA for alpha
With liver disease, thalassemia, and hemolysis, what kind of cells might you see?
Iron deficiency anemia has MCV<100 and ____ferritin and ____RDW.
low ferritin and high RDW
If MCV is >100, what levels should you check first?
Vitamin B12 and folate deficiency
Megaloblastic anemias include B12 and folate deficiencies and on smear what might you see?
hypersegmented PMN's and ovalocytes
Myelodysplastic syndrome, MCV>100 is a stem cell disorder characterized by an arrest in maturation of all blood cells, usually presenting as pancytopenia. Often occurs in the elderly. What do you often see on the peripheral smear?
Anemia of chronic disease presents with ____MCV and is most commonly caused by infection, inflammation, cancer, ESRD, or liver disease.
______is an autosomal recessive disease the results in production of hemoglobin S that leads to vaso-occlusion in the microvasculature that causes pain and organ dysfunction.
Sickle cell disease
An oxidative stress often precedes the hemolysis in _____. Stress, ingestion of fava beans or certain drugs causes this ie. Sulfonamides, Nitrofurantoin, Methylene blue, Dapsone, or Primaquine
__________states include the postpartum period, malignancy, oral contraceptives, deficiencies of protein S, protein C, and antithrombin III, lupus anticoagulant, activated protein C resistance, prothrombin gene mutations, hyperhomocysteinemia.
Hemophilia A has a factor ____deficiency. Hemophilia B has a factor ____deficiency. vonWillibrand disease has a deficiency of factor ____and platelet aggregates. What about Vitamin K?
Hem A - factor VIII
Hem B - factor IX
vW disease - factor VIII and platelet aggregates
Vitamin K - factor II, VII, IX, and X
_____is an autoimmune disorder in which patients develop antibodies against their own platelets. Superficial bleeding of skin, mucous membranes, and GI tract. Chronic disease will need high dose steroids and possible splenectomy.
Idiopathic thrombocytopenia purpura (ITP)
_____is comprised of microangiopathic hemolytic anemia, thrombocytopenia with normal coagulation, and CNS symptoms. Renal failure and fever compose the pentad of symptoms.
Thrombotic thrombocytopenia purpura
Leukemia can be either acute or chronic.
1. ____- most common leukemia, smudge cells! "mature appearing lymphocytes". Can live for decades without treatment.
2. ____ - high WBC, bcr/abl gene, Philadelphia chromosome
3. ___ - is acute, blasts! cytophenia!
4.___ - is acute, hallmark is Auer rod
CLL, CML, ALL, AML
A decreased anion gap in the presence of anemia, proteinuria, leukopenia, hypercalcemia, and renal failure suggests ____, "Rouleux formations".
Lymphoma is divided into Hodgkin lymphoma or non-Hodgkin's lymphoma. Which one is characterized by the presence of Reed-Steinberg cells? What diseases are highly associated with NHL?
Hodgkin's lymphoma; HIV or immunosupression
INFECTIOUS DISEASE: HIV is considered AIDS once the ___is <200 and a patient has at least one AIDS defining illnesses.
AIDS defining illnesses: Pneumococcal Pneumonia, Kaposi's sarcoma, lymphoma, TB, toxoplasmosis, HSV, candida esophagitis, wasting syndrome, CMV, PML
____is the most common fungal infection. Oropharyngeal, Vulvovaginitis, Cutaneous. KOH/gram stain shows budding yeast.
____is common in the immunosuppressed. Pigeon droppings, Meningismus, fungus. Tx: Amphotericin B
____is the MC case-defining illness in AIDS, hacking non-productive cough, fever, dyspnea, interstitial infiltrates, butterfly pattern.
____is common in Mississippi and the Ohio River Valley. Patchy, multilobal infiltrate. Immunocompromised. Intraconazole or Amphotericin B.
_____is a bacterial infection common in food borne, canned goods, wounds contaminated with soil, or in infants that ingested soil or honey.
_____can cause trachoma/conjunctivitis, cervicitis, epididymitis/salpingitis, or atypical pneumonia.
_____causes rice water diarrhea from Vibrio Cholerae most commonly from ingesting food or water from an endemic area.
_____causes tonsillopharyngitis/laryngitis due to Cornebacterium diptheriae. Sore throat, grayish pseudomembrane. Tx: immunization!!
____is a parasitic infection often acquired after eating undercooked meat, an opportunistic infection in HIV.