Medicine UW, NMBE Questions

Treatment for cocaine-induced MI?

1. Benzos- decrease BP, anxiety 2. ASA 3. CCB, NO- decrease pain *NO b-blockers!!! --> unopposed alpha-receptor stimulation

Workup for aortic dissection? -what if has renal insufficiency?

1. CT chest with contrast 2. TEE if renal insufficiency

Tx for PCP pneumonia with PaO2 <70?

1. Corticosteroids 2. Antibiotics *If PaO2 >70, would go straight for Bactrim

Signs of acute liver failure

1. Elevated AST/ALT (> 1000) 2. Hepatic encephalopathy 3. INR > 1.5

Cardiac structural abnormalities that cause a. fib?

1. LA dilatation (secondary to rheumatic fever --> mitral stenosis --> blood pools in LA) 2. LV hypertrophy

3 Main risk factors for abdominal aneurysm expansion?

1. Large diameter 2. Rate of expansion 3. Current cigarette smoking *HTN not well-related -b-blockers/ACE-Is don't reduce rate of rupture!

Mechanism of systolic murmur heard in HOCM

Anterior motion of mitral valve toward the interventricular septum

Causes of widened mediastinum?

"Terrible T's" -T-cell lymphoma (Hodgkin's) -Thymoma -Thyroid nodule -Teratoma, germ cell tumors -Thoracic aorta

Pulsus paradoxus causes -drop by over 10mmHg in systolic pressure between inspiration, expiration (usually only drops 2-5mmHg)

*Anything that takes up room in thoracic cavity --> pushes on heart (air, blood, etc) Cardiac tamponade Asthma COPD OSA Pericarditis Croup

Ickthyosis vulgaris

*Chronic, inherited skin disorder characterized by diffuse dermal scaling *Genetics- mutations in filaggrin gene Symptoms -dry, scaly skin -worse in winter because more dry

Fat embolism presentation

*Classic triad 1. Hypoxemia (Dyspnea) 2. Neuro symptoms (Confusion) 3. Petechial rash

Types of selection bias

*In appropriate selection OR POOR RETENTION OF SUBJECTS 1. Ascertainment/sampling bias- sampled population different from target population 2. Nonresponse bias- high number of nonresponders cause errors if nonresponders act differently from responders 3. Berkson bias- only study inpatient/hospitalized patients, not applicable to general population 4. Prevalence/Neyman bias- exposures that happen long before assessment can cause study to miss diseased patients that die early or recover 5. Attrition bias- significant loss of study participants cause bias if those lost to follow-up differ significantly from remaining subjects

Types of observational bias

*Inaccurate classification, measurement of disease, exposure, or other variable 1. Recall bias- subjects with negative outcomes more likely to report exposure than subjects with out negative outcomes 2. Observer bias- observers misclassify data because of individual differences in interpretation OR preconceived expectations regarding study 3. Reporting bias- subjects over or under report exposure history because of perceived stigma 4. Surveillance/detection bias- risk factor itself causes increased monitoring in exposed group vs. unexposed group, increasing chances of catching a disease

Indications for Lyme disease prophylaxis after tick bite

*Needs to meet all 5 1. Adult deer tick 2. Attached for >36hrs, or engorged 3. Prophylaxis started within 72hrs of tick bite 4. Local Lyme rate >20% (New England) 5. No contraindications to doxy (pregnant, lactating, <8yo)

25yo man with HIV who hasn't been adherent to HAART has pneumonia; best way to confirm diagnosis?

*PCP pneumonia! Bronchoscopy Biopsy of lung mass

45yo woman has 3days fever, malaise, dyspnea on exertion, dry cough, abdominal pain, bright red blood in stool; had renal transplant 6mo ago, was leukopenic until stopped taking bactrim and valgancyclovir; PE- bilateral lung crackles, abdominal tenderness; AST= 125, ALT- 139; CXR- bilateral interstitial infiltrates; Dx?

*Solid organ transplant --> CMV *tissue-invasive CMV -GI -pulm -mild hepatitis -pancytopenia

Behcet disease

*Vasculitis Oral ulcers Genitail ulcers Uveitis

Orthostatic hypertension causes

-Decreased baroreceptor responsiveness (autonomic reflexes defect) -Decreased intravascular volume

SE of albuterol?

-HYPOKALEMIA!! --> muscle weakness, arrhythmias, EKG changes -Tremor -Headache -Palpitations Eg. PT with asthma who gets albuterol nebulizers, starts to feel weak, hand tremors

Vitiligo associated with what other autoimmune disorders?

-Hashimoto's -Graves -Alopecia acreta -Pernicious anemia -Addison's -RA -Srogren's

Signs of severe heart failure?

-Resting tachycardia -S3 gallop -Increased JVP -Hypotension (<100/60) -Mitral regurg -HYPONATREMIA -Elevated BNP -Renal insufficiency -QRS >120s -LBBB

Signs of renovascular HTN?

-Severe HTN (>180/120) after 55yo -Recurrent flash pulmonary edema, OR resistant heart failure -Unexplained rise in urine Cr -ABDOMINAL BRUITS!!!

Scleroderma renal crisis -features

-Vascular permeability -Coagulation pathway activation -Increased renin secretion -DIC --> schistocytes Symptoms -sudden onset renal failure -malignant HTN (blurry vision, headache, nausea) -UA- normal or mild proteinuria *Usually in 1st 5 years of scleroderma dx

C. diff risk factors

1. ABX 2. Hospitalization 3. PPIs --> gastric acid suppression

HIV patients get what prophylaxis drugs?

1. Bactrim- PCP 2. Azithromycin- MAC *NOT acyclovir (HSV), fluconazole (candida)

When is it ok to accept gifts from pharma?

1. Benefits patient care 2. Small monetary value (drug samples, unbiased educational materials)

Acanthosis nigracans associated with what?

1. Benign --> insulin resistance -DM -PCOS *younger patients, obese 2. Malignant -GI cancer *older patients, lose weight, uncommon places (mucus membranes, palms, soles)

PT suspected of Cushing's syndrome; Next best test?

1. Late-night salivary cortisol test (should be low) 2. 24hr urine-free cortisol levels 3. Overnight low-dose dexamethasone suppression test *Need 2/3 abnormal to be considered abnormal *Then measure serum ACTH levels (differentiate between central, peripheral)

Causes of secondary clubbing?

1. Lung malignancy 2. CF 3. L --> R cardiac shunts *COPD by itself doesn't cause clubbing --> should look for occult malignancy!!!

Amitriptyline SEs

1. Muscarinic --> anticholinergic --> hot as a hare, dry as a bone, etc 2. Histamine --> lethargy 3. alpha-receptors --> ORTHOSTATIC HYPOTENSION

Serotonin syndrome

1. Neuromuscular Activity 2. Autonomic stimulation -increased temp -sweating -diarrhea 3. Agitation

Indications for starting long-term O2 therapy in COPD patients?

1. PaO2 <55mmHg OR pulse sat <88% 2. PaO2 <59 or SaO2 <89% in patients with evidence of cor pulmonale, RH failure, hematocrit >55%

Light's Criteria

1. Pleural: serum protein > 0.5 2. Pleural: serum LDH >0.6 3. Pleural fluid LDH > 60 (2/3 normal)

Absolute contraindications for tPA

1. Prior brain bleed/hemorrhage 2. Brain cancer 3. Active internal bleeding (except menses) 4. Suspected dissection, pericarditis

Osteomyelitis in deep puncture wound in a diabetic- what organisms?

1. S. aureus 2. Pseudomonas, esp through sole of shoe *S. aureus and Pseudomonas = most common causes of osteomyelitis from deep wound penetration

Polycythemia treatment

1. Serial phlebotomy 2. Hydroxyurea

What markers should we monitor to see if treatment working in DKA?

1. Serum AG 2. Direct b-hydroxybutyrate

When do we use synchronized cardioversion?

1. Symptomatic or sustained monomorphic v. tach 2. Hemodynamically unstable a. fib

Sequence of EKG changes in MI

1. T-wave changes 2. ST elevation 3. Q waves

Causes of lumbar stenosis?

1. Thickened ligamentum flavum 2. Hypertrophied bone facets (osteophytes) 3. Bulging intervertebral disk

How to treat prolactinoma

1. Try dopamine agonists (cabergoline, bromocriptine) --> reduces prolactin secretion, reduces tumor size 2. Transphenoidal resection -if refractory to treatment -or too large >3cm

Peripheral nerve compression symptoms (common fibular neuropathy)

1. Uninlateral foot drop 2. Numbness/tingling over dorsal foot and lateral skin 3. IMPAIRED ankle dorsiflexion (walking on heels) and great toe extension 4. PRESERVED plantar flexion (walking on toes) and reflexes

Nonpharm ways to decrease BP?

1. Weight loss by 10% 2. DASH diet 3. Exercise 4. Decreased Na intake 5. Decreased alcohol consumption

EPO injection SEs?

1. Worsening of HTN (tx with dialysis, BP-lowering drugs) 2. Headaches 3. Flu-like syndrome 4. Red cell aplasia

Treatment for nonbleeding esophageal varices?

1. b-blockers 2. Endoscopic variceal ligation (if contraindication for b-blockers)

Tx for chronic stable angina?

1. b-blockers --> lower CO, HR (1st line) 2. CCBs -Nondihydropyridine- lower CO, HR (alternative to b-blockers) -Dihydropyridine- lower afterload (added to b-blocker when needed) 3. Nitrates 4. Ranolazine- alternative for refractory angina -lower myocardial Ca2+ reflux

Most effective way to lower BP in overweight patients?

10% weight loss!!! *Smoking doesn't have as big of a benefit as this!

If someone got meningococcal vaccine <16yo, when should they get a booster?

16-21yo -if traveling to endemic areas (Africa, Muslim hajj pilgrimage to Mecca/Saudi Arabia) -military recruits, college students

BPH treatment?

1st line = a1 blockers -terazosin -tamsulosin 2nd line = 5a-reductase inhibitors -finasteride *if can't tolerate a-blockers (hypotension) *slower because decrease prostate mass

If patients get splenectomy, when should they get vaccines for encapsulated bacteria?

2 weeks before or after splenectomy

Pes anserinous pain syndrome

Anserine bursitis -obese females -DM -evolves over months, not years

Meds to hold prior to cardiac stress testing

48hrs -b-blockers -CCBs -nitrates 48hrs prior to vasodilator stress test -dipyridamole = PDE3 inhibitor, used for coronary steal testing 12hrs prior to vasodilator stress test -caffeine products

Causes of aortic stenosis?

Senile aortic valve calcification Bicuspid aortic valve- <70yo Rheumatic heart disease

42yo man with newly diagnosed polycystic kidney disease; siblings and parents don't have this; likelihood that 3 children will have it?

50% for each since PKD = autosomal dominant!

Osteomalacia -Serum Ca -Serum P

Serum Ca- low Serum P- low

Indications for surgery on AAA?

>5.5cm in size Rapid rate of expansion (>0.5cm in 6mo, or >1cm/year) Symptoms (abdominal/back/flank pain, limb ischemia) regardless of aneurysm size

What patients with flu get oseltemavir?

>65yo chronic medical problems Pregnant

When should adults start to get pneumococcal vaccine?

>65yo --> 13-valent *Then 23-valent every 5yrs

Malaria CBC characteristics

Anemia Thrombocytopenia (LOW PLTS!!)

previously healthy 67 y/o F admitted b/c fever, hypotension and resp distress. temp 101.1 pulse 112 rr 28 bp 98/50. diffuse crackles. 2/6 systolic mumur. extremities warm and well perfused. CO 6, LVEDP 11 PCWP 14 . leukocytes 18k, ABG pH 7.3 CO2 18 PO2 64 what is mechanism for resp failure A decreased hypoxic drive B decreased contractility C decreased pulm vasc flow D increased pericardial pressure E Increased regurgitatnt mitral flow F Increased vascular permeability

ARDS in setting of septic shock CO = normal PCWP = normal (<18)

Origin of arrhythmias (location) -atrial fibrillation -atrial flutter -AVNRT (AV nodal reentry tachycardia) -AV reentrant tachycardia

A. fib- pulmonary veins (near LA) A. flutter- tricuspid annulus AVRNT- AV node AV reentrant tachycardia- accessory AV bypass tract

62yo male has pulsating mass right above his umbilicus; PMH- HTN, chronic renal insufficiency, MI, PAD; BP = 160/100; Dx? Next step in diagnosis?

AAA = abdominal aortic aneurysm Diagnosis- Abdominal ULTRASOUND!!! *100% sensitivity + specificity

P450 inhibitors

AAA RACKS IN GQ Magazine -Acute alcohol abuse -Ritonavir -Amiodarone -Cimetidine/ciprofloxacin -Ketoconazole -Sulfonamides -INH = isoniazid -Grapefruit juice -Quinidine -Macrolides (except azithromycin)

P450 inducers

AAA RACKS In GQ Magazine Acute alcoholics Ritonavir Amiodarone Cimetidine Ketoconazole Sulfonamides INH Grapefruit juice Quinidine Macrolides -ACETAMINOPHEN/NSAIDS -Metronidazole -Cranberry juice -Ginkgo -Vit E -Omeprazole -Thyroid hormone -SSRIs

22yo woman playing soccer, trying to run around another player on her R; heard a popping sound from her R knee, became swollen and painful; hesitates to bear weight on it; aspiration of knee fluid yields grossly bloody joint fluid; Dx?

ACL injury -rapid onset pain -"popping" sensation -significant swelling -effusion, hemarthrosis -joint instability Mechanism -rapid deceleration or direction changes -pivoting on LE with foot planted

64yo man had MI with complete obstruction of proximal LAD; started on appropriate medical therapy, no stent intervention; next day, reports leg pain- leg cold, mottled-looking, minimal swelling with absence of distal pulses; Dx? Next step?

ACUTE LIMB ISCHEMIA from ARTERIAL OCCLUSION!!! *Large anterior STEMI --> LV EF <40% --> systemic embolization Causes -cardiac emboli -LV thrombus -thrombus (usually LA) from atrial fibrillation -aortic atherosclerosis -thrombosis (vascular stents, hypercoagulable states) -trauma Next step -Anticoagulation -TRANS-THORACIC ECHO!!! -Vascular surgery consult

82yo man with history of BPH, mild cognitive impairment had surgery, uncomplicated; 2 days after, becomes confused + agitated; IV lines look clean, no foley, no elevated WBC; lower abdomen tender to palpation; Dx? Next step?

ACUTE URINARY RETENTION!!! -Male -Old (>80yo) -BPH -Neuro deficits (eg. mild cognitive impairment) -Recent surgery -Recent meds (opioids, etc) Next step = bladder US

What is a P2y12 receptor blocker?

ADP-receptor inhibitors Clopidogrel Prasugrel Ticagrelor

34yo woman with occasional headaches and palpitations, smokes 1.5 packs/day; BP = 170/110 in both arms; exam shows bilateral flank masses; BUN = 26 Cr = 1.6 UA- 10-20WBC/hpf Dx? Complications?

ADPKD -flank pain -hematuria -HTN -urinary infection Complications -brain cysts -hepatic cysts -valvular heart disease (MVP, AR) -colonic diverticula -abdominal wall + inguinal hernia *Pheos usually not bilateral

42yo man comes in with difficulty breathing, wheezing; diagnosed with stable angina 6mo ago; currently on aspirin, diltiazem, atorvastatin, albuterol; Dx? Cause of respiratory symptoms?

AERD = aspirin-exacerbated respiratory disease -comorbid asthma -chronic rhinosinusitis -nasal polyps -chronic urticaria *Asthmatic symptoms 30min-3hrs after aspirin ingestion *10-20% of asthmatics get AERD Mechanism -increased production of pro-inflammatory leukotrienes -decreased production of anti-inflammatory prostaglandins *NOT IgE MEDIATED!!!

35yo woman slipped and fell on her side; XR found to have shoulder sprain; also finds a coin-shaped lesion in periphery of R lung; Next step?

ASK FOR PREVIOUS IMAGING!!! -most incidentally discovered pulmonary nodules benign (hamartomas, infectious granuloma) *Don't order CT without making sure it isn't a stable pulmonary nodule!

Poor dentition + GERD puts patients at greater risk for what kind of pneumonia?

ASPIRATION!!! *Cover with clindamycin!!!

AST, ALT levels in NASH?

AST/ALT < 1

42yo obese woman with history of chronic alcoholism has RUQ pain that began shortly after had dinner at steakhouse; sharp, 7/10, radiates to R scapula, pain worsens with inspiration; has history of asymptomatic gallstones; Dx? Tx?

Acute cholecystitis (impaction of stone in cystic duct) -onset of steady epigastric, RUQ pain after ingestion of fatty meal -Murphy's sign- RUQ pain increases with inspiration, sometimes causes patients to hold their breath Tx- supportive care -laparoscopic cholecystectomy shortly after hospitalization (and immediately if have perforation or gangrene)

A previously healthy 47-year-old man comes to the physician because of a 6-month history or progressive weakness that began in his right leg and has gradually spread to his other extremities. During this period, he has had mild difficulty swallowing solids and liquids. Examination shows atrophy of the right quadriceps and both deltoid muscles and fasciculations in bothe quadriceps muscles. Babinsking sign bilaterally positive. Electromyography and nerve conductionstudies are most likely to show which of the following A. Absence of bilateral nerve sensory responses B. Fibrillation potentials in multiple muscles of multiple extremities C. Myotonic discharges D. Normal spontaneous and insertional activity E. short duration, low amplitude motor unit potentials

ALS EMG --> fibrillation potentials in multiple muscles of multiple extremities

72yo woman has acute kidney failure after being treated for pyelo secondary to multi-drug resistant bacteria; urine has epithelial cell casts; FENA > 2%; which drug most likely -nafcillin -vanc -levofloxacin -amikacin -doxy -azithromycin

AMIKACIN = AMINOGLYCOSIDE -often used for Gram (-) rods --> PYELO/UTI *most likely to cause severe nephrotoxicity --> acute renal failure! *NOT NAF because doesn't cover most UTI bugs, and would and eosinophils in urine

Auer rods in...?

AML!! *NOT CML!!!

Tx for Lyme disease in pregnant woman?

AMPICILLIN!!! *Ceftriaxone only good for early, localized disease, and also requires hospitalization since IV and also very empiric *Doxy not good for kids or fetuses

fluffy bilateral interstitial infiltrates indicates what?

ARDS --> Alveolar-arteriolar mismatch

55yo man has increased dyspnea on exertion, dry cough, wheezing over past 2mo; never had before, worse at night; PMH- HTN, CAD, obesity, smoked for 30yrs but quit 10yrs ago; SaO2 = 95% on room air; faint S4; lungs show good air movement with wheezes and crackles -Pre-bronchodilator FEV1/FVC = 67%; DLCO = 80% (nl or increased) -Post-bronchodilator FEV1/FVC = 79% Dx?

ASTHMA!!! -only asthma completely reverses with bronchodilators *COPD DOESN"T!!! -DLCO - increased in asthma, decreased in COPD *Many asthma cases can only present in adulthood!

Best test to diagnose diverticulitis?

Abdominal CT with contrast! *Don't do barium enema until certain no perforation!

Workup for toxic megacolon?

Abdominal XR

68yo has acute liver failure, kernicterus, scleral icterus; takes hydrocodone-acetaminophen for spinal stenosis; taking extra acetaminophen for toothache in past 2 weeks; remote history of IV drug use; drinks 2 shots of whiskey/day AST- 3207 ALT- 4180 INR- 1.5 Dx?

Acetaminophen-induced injury --> Acute liver failure

56yo man getting EGD for evaluation of esophageal varices; given benzocaine throat spray for topical anesthesia, procedural sedation with midazolam and fentanyl; during procedure, O2 saturation drops to 85%, doesn't improve with supplemental O2, fingers and lips turn blue; Dx?

Acquired methemoglobinemia -Topical anesthestics (benzocaine) -Dapsone *Cause Fe component of Hb to be oxidized *Large O2 saturation gap!!!

Active external rewarming consists of what? Active internal rewarming consists of what?

Active external rewarming -Warm fluids -Warm blankets -Heating pads Active internal rewarming -Warmed peritoneal, pleural irrigation -Warmed humidified O2

68yo man has R leg pain for past 6hrs; recently suffered acute myocardial infarction resulting in cardiogenic shock; R leg pale, cool to touch, distal pulses not palpable; loss of sensation over dorsum of R foot and mild weakness with dorsiflexion; Dx?

Acute arterial occlusion *Typically caused by -Embolus from cardiac or arterial source -LA atrial fibrillation -LV thrombus after MI -infective endocarditis -Arterial thrombosis -Iatrogenic -Blunt trauma to artery 6 P's -Pain -Pallor -Paresthesias -Pulselessness -Poikilothermia -Paralysis

Aortic dissection treatment algorithm?

Acute chest pain suggestive of dissection-> 1. Lower BP (labetalol, nadolol) 2. CXR *If stable --> CT with contrast *Unstable --> TTE

33yo had 2 episodes of vomiting with small amount of blood; last night, drank alcohol and took cocaine; this morning, had hangover and took some aspirin; no previous episodes of this; smokes pack of cigarettes per day, drinks 1-2 cans of beer daily; PE- mild epigastric tenderness; Dx?

Acute erosive gastropathy -severe hemorrhagic lesions after exposure of gastric mucosa to 1. Injurious agents (aspirin, alcohol) 2. Significant reduction in blood flow (cocaine --> vasoconstriction)

A 25 year old woman comes to the physician because of a 5 day history of fatigue, nausea, and decreased appetite. Her temp is 37 C, Pulse 86/min, BP 110/50. She is told that she has a viral infection and is sent home. One week later, she returns because of continued fatigue and jaundice. Now her pulse is 80/min, respiratory 12/min, and BP 110/64. Examination shows scleral icterus. CVS examination normal. Liver edge is palpable 1cm below the right coastal margin, and is slightly enlarged, smooth and tender to palpation. Labs show: Hb 13.2 Total bili 4.2 Direct bili 3.6 Alk Phos 120 AST 350 ALT 280 LDH 410 a) acute hepatitis b) alpha-1 antitrypsin deficiency c) biliary atresia d) cholangiocarcinoma e) choledocholithiasis (that's what I marked, and is wrong) f) Gilberts g) G6PD deficiency h) Liver abscess i) Peptic ulcer disease

Acute hepatitis! -causes DIRECT HYPERBILIRUBINEMIA!!!

53yo woman has L-sided chest pain and suddenly collapses; BP = 80/40; diagnosed with colon cancer few months ago; was hypertensive for years and noncompliant with meds; diaphoretic + tachycardic; JVP = 13cm; Dx?

Acute massive PE! -syncope -hemodynamic collapse *Malignancy = prothrombotic state Pathophys- acute increases in pulmonary vascular resistance, RV pressures --> increased RV wall tension, cardiac muscle stretching, RV dilation --> RV dysfunction --> hemodynamic collapse

42yo man has severe abdominal pain, vomiting; pain constant and nagging, localizes to upper abdomen, radiates to back; drinks lots of alcohol; BP = 80/40; BUN, Cr, CRP elevated; Dx? Mechanism of hypotension? Tx?

Acute severe pancreatitis!! -precipitated by alcohol Mechanism of hypotension -pancreatic enzyme release --> vascular permeability Tx -Supportive -Liters of IV fluids

82yo man agitated + confused on day 2 after surgery for R hip fracture; surgery uncomplicated; no problems with wound site, peripheral lines, etc; history of BPH + mild cognitive impairment, lives with daughter; Dx? Next step?

Acute urinary retention *Risk factors -Male -Old (> 80yo) -BPH -Neuro disease (mild cognitive impairment) -Surgery (esp abdominal, pelvic, joint arthroplasty) Dx: Bladder ultrasound --> will show over 300cc urine Tx -Insert Foley catheter -UA r/o UTI

How to diagnose -acute pancreatitis -chronic pancreatitis

Acute- lipase levels Chronic- CT abdomen --> pancreatic calcification *"burned out" pancreas --> normal or only slightly elevated lipase levels

50yo man with nonbleeding esophageal varices from cirrhosis complication; started no spironolactone + furosemide; Next step?

Add nadolol (nonselective b-blocker)!!!

42yo woman has 2 syncopal episodes in past week; has been feeling fatigued, weak, nauseous, has abdominal pain; BP = 86/42, hyperpigmentation in palmar creases; Dx?

Addison's -weakness -fatigue -volume depletion -low BP -hyperpigmentation

Autoimmune adrenalitis aka...?

Addison's = primary adrenal insufficiency

Previously healthy 82 yo. man presents with a 2 mo. hx of decreased energy, 7 lb. weight loss due to loss of appetite, and is mildly emaciated. 5'7", 132 lbs. 98.6F, 68 bpm, 90/50 mmHg. Lungs are CTA and cardiac exam is normal. Hemoglobin- 14 Leukocyte count- 7500 (Neutrophils = 56%, Eosinophils = 23%, Lymphocytes = 14%, and Monocytes = 7%). Serum- Na = 128, K = 6, BUN = 30, and Cr = 1.6. Next step? A) ACTH stimulation test. B) 3 serial stool tests for ova and parasites. C) Blood culture. D) HIV Ab test. E) Renal US. F) Bone Marrow Biopsy.

Addison's!! --> ACTH stimulation test -Eosinophilia -Weakness, fatigue -Weight loss -Low Na, K

What cancers are membranous nephropathy associated with?

Adenocarcinoma -breast -lung

Cryptogenic organizing pneumonia -symptoms

Affects bronchioles and alveoli AKA bronchiolitis obliterans with organizing pneumonia

Anabolic steroid effects

Aggressive behavior Gynecomastia Mood disturbances Erythrocytosis Hepatotoxicity Dyslipidemia

Conn syndrome- levels for -aldosterone -renin -HCO3

Aldosterone- high Renin- low (because negative feedback) HCO3- high (metabolic alkalosis)

What drug to use to prevent uric acid stones?

Alkalinize urine with potassium citrate!

Substrates

Always Think When Outdoors -Anti-epileptics -Theophylline -Warfarin -OCPs

52yo man develops renal failure 2wks after being discharged from hospital; current meds- acetazolamide, lisinopril, heparin, amikacin, naproxen; has muddy brown casts; Which drug caused this?

Amikacin = aminoglycoside *NNOT -nephrotoxicity -NM blockade -Ototoxicity -Teratogen

HF with small pericardial effusion, concentric ventricular thickening, normal heart size, diastolic dysfunction?

Amyloidosis *If alcohol related, would have dilated heart size

56yo man has morning facial puffiness, pedal edema, recurrent respiratory infections due to bronchiectasis, psoriasis, BP = 142/92; PE- hepatomegaly, palpable kidney, 2+ pitting edema; UA- 4+ proteinuria; Dx? How to diagnose?

Amyloidosis! *Mechanism -Primary deposition of amyloid in various tissues -Could be secondary to chronic conditions -Inflammatory arthritis -Chronic infections (TB, bronchiectasis) -IBD (Crohn's) -Malignancy (multiple myeloma) -Vasculitis Symptoms -nephrotic -hepatomegaly -sensory + motor peripheral neuropathy, autonomic neuropathy -visible organ enlargement -bleeding tendency -waxing thickening of skin Diagnosis- abdominal fat pad aspiration biopsy

34yo man has back pain that's worse in morning and at night; Dx? Mechanism?

Ankylosing spondylitis -inflammation at ligamentous insertions

24yo man has dyspnea on exertion; worse at night and improves in the morning; also has chronic low back pain, takes naproxen; smokes 1pack cigarettes/day, drinks a 6pack beer every weekend; Vital capacity = 75% predicted FEV/FVC = 90% FRC (forced vital capacity) = 110% Dx?

Ankylosing spondylitis --> chest wall restriction!! -low back pain -hip and buttock pain -limited chest expansion, spinal mobility -enthesitis = inflammation at site of tendon insertion -acute anterior uveitis *If diffuse pulmonary fibrosis, FRC, VC would be decreased as well!!

25yo man has 3mo history of R shoulder pain; also has swelling and pain in heel that's worse when walking, jogging, or taking stairs; pain with resisted abduction at shoulder and tenderness in acromioclavicular joint; palpation over heels, iliac crests, tibial tuberosities also elicits tenderness; Dx?

Ankylosing spondylitis!!! -insidious onset <40yo -symptoms >3mo -RELIEVED WITH EXERCISE but not rest -nocturnal pain Exam -arthritis (sacroilitis) -reduced chest expansion, spinal mobility -ENTHETITIS = swelling at tendon insertion sites -dactylitis -uveitis Dx -XR of sacroiliac joints -MRI of sacroiliac joints

Thrombocytopenia Prolonged PTT Positive VDRL (negative FTS-AB)

Antiphospholipid syndrome

48yo man has sudden, unremitting chest pain that radiates to L arm and back; doesn't smoke or drink alcohol; 2/6 diastolic murmur heard at upper sternal border; ABG- normal findings; CXR- small pleural effusion; Dx? A. Aortic dissection B. Bacterial endocarditis C. PE D. Ruptured pulmonary bleb (pneumothorax) E. Unstable angina pectoralis

Aortic dissection

34yo man has Marfan's syndrome; has sudden, excruciating chest pain; what would we find on chest exam? -early diastolic murmur -fixed splitting of S2 -opening snap -pericardial friction rub -S3

Aortic dissection --> aortic regurgitation! --> Early diastolic murmur!

78yo man had syncope episode while working in garden, had chest and neck pain right before syncope; over past week, had cough, chest tightness, whitish sputum production; CXR- mediastinal widening; TTE- pericardial effusion; Dx? Next step?

Aortic dissection! Next step- CT angiogram -TTE (echo) if hemodynamically unstable or renal failure

33yo man has mild exertional SOB, "pounding" heart for last 5mo; uncomfortably aware of his heartbeat while lying on L side; BP = 154/56; Dx?

Aortic regurg -aortic root dilation (Marfan's, syphilis) -post-inflammatory (rheumatic fever, endocarditis) -bicuspid valve Symptoms -collapsing/water hammer pulse -widened pulse pressure -diastolic decrescendo murmur

64yo man gets aortic dissection; suddenly, gets SOB, doesn't want to lie flat, bibasilar crackles in lungs; Dx?

Aortic regurg!!! -worsening chest pain -hypotension -pulmonary edema -diabolic decrescendo murmur Complications of aortic dissection -stroke (carotid arteries) -ACUTE AORTIC REGURG -Horner syndrome (superior cervical sympathetic chains) -STEMI -pericardial effusion/tamponade -hemothorax (pleural cavity) -LE weakness or ischemia -abdominal pain (mesenteric artery)

20yo woman has early diastolic murmur best heard at L sternal border, best with expiration; Dx? Next step?

Aortic regurg!!! (even though at L sternal border) *All diastolic and continuous murmurs are pathologic! -need to be worked up! Next step = echo!!!

48yo Caucasian male has exertional dyspnea; harsh holosystolic murmur at RUSB; Dx? Mechanism?

Aortic stenosis caused by BICUSPID AORTIC VALVE!!! -cause in majority of patients with AS <70yo

40yo man restores antique wood as a hobby, has polyneuropathy, pancytopenia, transaminase elevation, hyperkeratoses, hypo and hyperpigmentation of skin; Dx?

Arsenic toxicity *Source -pesticides -contaminated water -pressure-treated wood

60yo man has appendicitis; taken to OR; vomits several times during intubation induction, requires multiple suctioning efforts; surgery successful- gets 2L fluid; 4hrs later, tachypneic and hypoxemic, has bilateral crackles; CXR- bilateral infiltrates; Dx?

Aspiration pneumonitis = aspiration of gastric acid *Vs aspiration pneumonia = aspiration of gastric microbes *2L fluid not enough to give someone cardiogenic edema, esp if no history of CHF

3 most common causes of chronic cough (>8weeks)?

Asthma GERD Postnasal drip (upper-airway cough syndrome)

Increased DLCO Causes?

Asthma HF Alveolar hemorrhage

Hypercalcemia tx -asymptomatic -moderate -severe

Asymptomatic -no tx needed Moderate (12-14) -don't need unless symptomatic Severe -Immediate- Saline hydration + calcitonin, avoid loop diuretics -Long-term- bisphosphonates

F waves on EKG mean?

Atrial flutter!

Arrhythmia most associated with digoxin toxicity?

Atrial tachycardia with AV block

Digitalis causes what arrhythmias on EKG?

Atrial tachycardia with AV block

Tx for hand-bite wounds?

Augmentin = Ampicillin-clavulanate *For coverage of polymicrobials -S. aureus -Eikinella -Streptococci -H. flu

Autoimmune adrenalitis (primary adrenal insufficiency) vs. Pituitary infarct (secondary adrenal insufficiency)

Autoimmune adrenalitis -MORE SEVERE -Hyperpigmentation -Hyperkalemia -Hyponatremia Pituitary Infarct -Less severe -No hyperpigmentation -No hyperkalemia -Possible hyponatremia

66yo man has SOB, started 1 week ago with dry cough and exertional dyspnea; PMH- HTN, recent stenting for double-vessel CAD; hospitalized 6mo ago for pneumonia; 35year smoking history; PE- decreased breath sounds at lung bases, bibasilar crackles, occasional wheezes pH- 7.46 pO2- 73 pCO2- 31 Dx?

CHF!!! --> causes RESPIRATORY ALKALOSIS!!!

26yo man has dysuria, pyuria (>10/hpf), urinary frequency, mucopurulent urethral discharge; no growth on Gram stain; culture after 48hrs show no growth; Dx?

CHLAMYDIA URETHRITIS!!! -can't visualize on Gram stain or recovered in traditional culture --> need to PCR amplify!

12 month old boy w/ temps to 105 w/ two infections in the last 8 months: pneumococcal bacteremia and periorbital cellulitis from h. influenza. Had all shots. LP shows bacterial meningitis w/ GP diplococci (s. pneumo). What cell type is most likely involved in the underlying condition?

B lymphocyte (X linked agammaglobulinemia These are encapsulated bacteria (SHiNE SKiS S.pneumo, H influ, Neisseria menningiditis, group B strep, klebsiella, salmonella) increased incidence of infection in pts w/ asplenia/functional asplenia and B cell disorders (antibody deficiency or opsonization defect)

2 studies conducted on same population A- relative risk 2.0, 95% CI 1.2-2.4 B- relative risk 2.1, 95% CI 0.8-3.4 What can you conclude -B p-value <0.05 -B result likely biased -B sample likely smaller than A

B sample likely smaller than A -As we get larger samples, confidence intervals tend to get more narrow *If CI includes 0, NOT STATISTICALLY SIGNIFICANT!!!

32yo man comes in for routine check; had appendectomy 8yrs ago; no family or personal history of serious illnesses; exam shows no abnormalities; what test should you do for him? -Test for fecal occult blood -Serum cholesterol concentration -Serum glucose level -CBC -EKG

CHOLESTEROL!! -Should be screened in all healthy people starting from 20yo

P450 INducers

CHronic alcoholics Steal Phen-Phen and Never Refuse Greasy Carbs -Chronic alcohol use -St. John's wort -Phenytoin -Phenobarbital -Nevirapine -Rifampin -Griseofulvin -Carbamazepine

45yo man has intermittent diarrhea, abdominal pain, 9lb weight loss, diagnosed with HIV 2yrs ago, CD4 = 28; T = 100.3F, moderate cervical lymphadenopathy; mild tenderness in LLQ, K = 3.2; Dx?

CMV -frequent, small volume diarrhea -hematochezia -abdominal pain -low-grade fever -weight loss

34yo woman has PE; also found to have elevated homocysteine levels; put on heparin + warfarin; What else should she be on?

B6 = pyrixdoxine -Homocysteine very reactive --> predisposes to venous thrombosis, atherosclerosis

Anemia complications in sickle cell patients?

B9 deficiency -Bone marrow often trying to compensate for lost RBCs --> uses up folate *NEED TO GIVE ALL SCD PTs FOLATE!!

37yo man running into street, yelling obscenities at drivers, slamming into cars, takes 4 officers to restrain him; stays like this for another week before benzos start to work; Dx?

BATH SALT INTOXICATION = longer version of PCP *Mechanism = amphetamine analogs -severe agitation -combativeness -psychosis -delirium -myoclonus -PROLONGED DURATION *PCP = shorter duration

Which part of lip does SCC, BCC tend to form on?

BCC- upper lip SCC- lower lip

Most sensitive test for CHF?

BNP levels! (90% sensitivity) -not S3, bilateral crackles, cardiomegaly, high JVP, LE edema

A 67-year-old man comes to the physician because of increasing nocturnal incontinence that began 2 months ago and now occurs nightly. He has a 20-year history of hypertension treated with verapamil. He has been taking amitriptyline for major depressive disorder since his wife died 3 months ago. His blood pressure is 158/78 mm Hg. There is lower abdominal distention with diffuse tenderness to palpation. Rectal examination shows a moderately enlarged, smooth prostate with no stool in the vault. Neurologic examinations show no abnormalities. Laboratory studies show: Serum creatinine Urine Protein WBC RBC 1.6 mg/dl 1+ 1-2/hpf 2-4/hpf Which of the following is the most likely diagnosis? A) Benign prostatic hyperplasia B) Cauda equina syndrome C) Dementia, Alzheimer type D) Normal-pressure hydrocephalus E) Urinary tract infection

BPH!!!

45yo man with HIV gets PCP pneumonia; pH = 7.45 PaO2 = 54 PaCO2 = 44 How to treat?

Bactrim + CORTICOSTEROIDS (if pO2 <70, Aa gradient > 35mmHg) *Start HAART after bactrim to minimize drug-drug interactions, pill burden, risk of immune reconstitution syndrome

55yo man had renal transplant, no complications; currently on immunosuppressants with prednisone and tacrolimus; What else should he be on?

Bactrim --> for PCP infections (opportunistic)

27yo woman found unconscious at scene of fire; black soot near nares and mouth; cap refill = 4sec; pH = 7.15 PaO2 = 114 PaCO2 = 33 Dx?

CN poisoning -from combustion of nitrogen-containing synthetic polymers (cotton, silk, foam, paint) *Produced from combustion in closed spaces -CO -CN

Hurthle cells seen in what?

Benign adenomas Hashimoto's Follicular thyroid cancer *NONSPECIFIC

What is an epidermal inclusion cyst?

Benign nodule with squamous epithelium that produces keratin -can remain stable or gradually increase in size -may produce cheesy white discharge -usually resolves spontaneously

Causes of aortic regurg?

Bicuspid aortic valve Aortic root dilation (Marfan's, syphilis) Inflammatory (rheumatic heart disease, endocarditis)

62yo woman has 3mo history of SOB, chest pain with exertion; pulse = 80 and regular; slow-rising carotid pulse, apical beat sustained and inferiorly and laterally displaced; 4/6 harsh systolic murmur; Cause? -ASD -Bicuspid valve -Coarctation of aorta -Dextrocardia -Rheumatic valvular disease -VSD

Bicuspid valve

What is haptoglobin, what's its function?

Binds free Hb in serum --> promotes excretion into reticuloendothelial system

Cyclophosphamide SEs?

Bladder carcinoma

Farmer in southern Wisconsin with low-grade fever, dry cough for 2mo; painless wart-like nodules, violaceous skin lesions, small peripheral ulcer; scrapings that show yeast; Dx?

Blastomycosis -South/southcentral states, Mississippi, Ohio River Valleys, Upper Midwest; Great Lakes -Acute + chronic pneumonia -Wart-like lesions, violaceous nodules, skin ulcers -Prostatitis -Epidydimo-orchitis -Ostoemyelitis

72yo man has SOB climbing 2 flights of stairs now (used to be 4), decreased appetite, liver 10cm, spleen 4cm, cervical, inguinal, supraclavicular lymphadenopathy, 2/6 systolic murmurat LUSB; Dx? -bone marrow infiltration -bone marrow aplasia -EPO deficiency

Bone marrow infiltration!! = LEUKEMIA/LYMPHOMA!!! *Aplasia = APLASTIC ANEMIA *failure/destruction of myeloid bone marrow cells from -radiation -viruses -Fanconi -idiopathic

32yo man has intense midline chest pain, diaphoresis 4hrs after a party; before the pain, had nausea and vomiting; uses cocaine regularly; injected conjunctivae, dilated pupils; CXR- widened mediastinum, pleural effusion; pleural effusion shows yellow exudate with high amylase level; Dx?

Borhaave Syndrome = esophageal rupture -esophageal transmural tear -esophageal air/fluid leakage --> PLEURAL EFFUSION (exudative, low pH, HIGH AMYLASE)

Difference between hemorrhoids and diverticula?

Both cause painless lower GI bleeding *Diverticula more likely to cause MASSIVE lower GI bleed!!

A 23-year-old man is brought to the physician by his mother because of auditory hallucinations and confusion since his wife was killed in a motorvehicle collision 1 week ago. His mother reports that he was unable to make any decisions regarding his wife's funeral and has been confused and disorganized since her death. Physical examination shows no abnormalities. He is oriented to person, place, and time. Mental status examination shows a sad affect. He appears preoccupied and has difficulty concentrating. He states that he hears his brother's voice telling him that everything will be okay; his mother reports that her other son lives in another state. Which of the following is the most likely diagnosis? Bereavement Brief psychotic disorder Post-traumatic stress disorder Schizoaffective disorder Schizophrenia

Brief psychotic disorder bereavement if px has auditory hallucinations without other psychotic features

A previously healthy 82year old woman comes to the physician because she is concerned that she has Parkinson disease. Over the past 6 months, she has had occasional difficulty finding the word that she wants to use, and her ability to distinguish smells has decreased. She reports that her reaction time to shifts in posture seems slow, and she needs to use a handrail to steady herself while walking on stairs. She lives alone and is able to manage her own finances. The pupils are 3 mm. There is mild reduction of upward gaze and brisk rotatory nystagmus on left lateral gaze. Audiometry shows mild high-frequency hearing loss. There are no tremors or rigidity. Her gait is normal. Her Mini-Mental State Examination score is 29/30. Which of the following neurologic findings warrants further evaluation ? A ) Brisk rotatory nystagmus on left lateral gaze B ) Decreased sense of smell C ) Decreased upward gaze D ) High-pitched tone hearing loss E ) Small symmetric pupils

Brisk rotatory nystagmus of L lateral gaze

55yo woman with 2yr history of chronic cough with productive, yellow sputum; 1st episode lasted nearly 3 weeks with chest congestion, cough productive of yellow sputum, SOB; got better with ABX; since has had 6 more episodes, all with cough, yellow sputum sometimes tinged with blood, SOB, sinus congestion; all got better with ABX; no fever, chills, chest pain, recent travels, smoking history; Dx? Next step in diagnosing?

Bronchiectasis -cough with DAILY production of purulent sputum -rhinosinusitis, dyspnea, hemoptysis -crackles, wheezing Pathophysiology -infection + impaired bacterial clearance Etiologies -airway obstruction (cancer) -rheumatic disease (RA, Sjogren's) -Toxic inhalation -Chronic/prior infection (aspergillosis, mycobacteria) -Immunodeficiency (hypogammaglobulinemia) -Congenital (CF, a1-antitrypsin deficiency) Next step- HIGH RESOLUTION CT SCAN!!! -immunoglobulin quantification -CF testing -Sputum culture -PFTs

What do these indicate -brown and waxy casts -RBC casts -WBC casts -fatty casts

Brown and waxy- Chronic renal failure RBC- glomerulonephritis WBC- pyelonephritis, interstitial nephritis Fatty casts- nephrotic

35yo man hospitalized for CHF exacerbation; smokes 1pack/day, drinks 4beers/day; last drink 4 days ago; Cr = 2.1; received furosemide + nitroprusside for CHF; next morning, nurse finds him agitated, confused, has tonic-clonic seizure; Dx?

CN poisoning from nitro!!! -altered mental status -coma -lactic acidosis -seizures *Esp vulnerable in pts with renal failure!!

Patient ate potato salad and chicken outside in cold weather in front of a barbeque; few hours later, had nausea, headache, vomiting, abdominal discomfort and confusion, tachypnea, tachycardia, pinkish-skin hue; Dx? Tx?

CO poisoning! Tx- hyperbaric O2

Cardiac Index =

CO/Body Surface Area

70yo woman has 2 days of cough, fever, increased somnolence; lives independently in skilled nursing facility; CXR- lower lobe infiltrate; Dx? Pathogen?

CA- pneumonia --> STREP PNEUMONIA!!! -S. pneumonia = most common cause of CAP!! *minimal aspiration risk, no signs of foul breath --> likely not aspiration pneumonia

19yo man had virus 1wk ago, now has confusion, severe dyspnea, cough productive of yellow sputum mixed with blood; fever 104F, bilateral crackles in mid-lung field, 2/6 ejection systolic murmur in LU sternal border, extremities warm with bounding pulses; CXR- alveolar infilatrates in midlung bilaterally with several thin-walled cavities; Dx? What bug?

CA-pneumonia --> S. AUREUS!!! -young patients with influenza -necrotizing pneumonia (hemoptysis) -leukopenia -cough -fever -MULTILOBULAR CAVITARY INFILTRATES!!! Tx -Hospital admission -Vancomycin -Linezolid

32yo man has fever, malaise, cough productive of clear sputum for past 3 days; 2yo son had cough, fever, rhinorrhea last week; crackles in L lower lobe; Dx? Next step?

CAP!! -crackles in lung fields indicate this Next step- CXR (necessary to diagnose CXR) -majority of CAP caused by bacteria --> need to decide whether to give empiric ABX *If only treat symptomatically, risk getting secondary bacterial pneumonia

23yo man has foul smelling, fatty stools; 10lb weight loss in past 3mo; poor energy, occasional joint pains; mild pallor; Hb = 10.2, ferritin = 10; IgA tissue trans-glutaminase negative; small bowel biopsy shows villous atrophy; Dx?

CELIAC!!! *Can be IgA tissue-transglutaminase negative!!! -associated with IgA deficiency!

CHADS-VASc scoring? Interventions for 0 1 >= 2

CHF HTN Age >= 75 DM Stroke/TIA Vascular disease Age 65-74 Sex- female 0- no intervention 1- aspirin >= 2- oral anticoagulants

52yo man has SOB, dry cough, feeling weak for past few days; some dyspnea on exertion; very high BNP; Dx? What other symptoms would he have?

CHF!! *High BNP very specific to CHF!!! *Would also have S3 heart sound -peripheral edema less specific!

50yo man with COPD, atrial fibrillation, HTN, DM2 comes in with COPD exacerbation; put on inhaled bronchodilators, steroids, high-flow O2 mask, and IV lorazepam; in 30min, becomes lethargic and confused; soon afterward, has generalized tonic-clonic seizure; Dx?

CO2 retention! -Acidosis caused by acute increase in CO2 --> brain gamma-amino butyric acid and glutamine, decreased brain glutamate and aspartate --> change in level of consciousness

What kind of cardiomyopathy seen in acromegaly?

CONCENTRIC (DIASTOLIC dysfunction, heart gets THICKER) *Eccentric = dilated cardiomyopathy

A previously healthy 32-year-old woman comes to the physician 1 day after a rash developed on her face, neck, and hands. Prior to onset of the symptoms, she was weeding and fertilizing her backyard while wearing a sleeveless shirt and shorts. She used a sunscreen but did not wear a hat or use insect repellant. She reports that she also received several scratches on her hands from the rose bushes. Examination shows bright red papules, vesicles, and bullae, some in linear pattern, on her forearms, neck, and face. There are oozing vesicles over the wrists. Which of the following is most likely to have prevented this rash? A) Avoidance of contact with fertilizers B) Avoidance of contact with rose thorns C) Avoidance of contact with weeds D) Avoidance of sunscreen E) Wearing insect repellant

CONTACT DERMATITIS --> avoidance of weeds! *If spirothrix, wouldn't affect the neck

36yo man was outside clearing bushes around his house; 2-day history of rash in between his fingers; began with small papules, progressed to oozing yellow fluid; severe itching that doesn't improve with antihistamines or calamine lotion; PE- erythematous plaques with eroded vesicles and small bullae between the fingers of his L hand and dorsum of hand; pus culture grows Strep; Dx?

CONTACT DERMATITIS!! -pruritic -red -vesicles + small bullae *Strep = skin contaminant in a lot of *Bullous impetigo, cellulitis = S. AUREUS!!!

82yo woman has acute onset epigastric pain; started 1hr ago, 8/10 in severity; nauseated, vomited 2x in past hour; PMH- HLD, HTN, PUD, cholelithiasis, 40yr smoking history; Murphy's sign negative; Next step? -Abdominal US -EKG -Serum amylase, lipase -EGD -Upright abdominal XR

COULD BE ATYPICAL ANGINA!!! -Esp for women, diabetics, elderly EKG!!!!

A 62-year-old man comes to the physician because of intermittent painless rectal bleeding over the past 3 weeks. He has a history of angina pectoris and is currently taking inhaled corticosteroids for moderate chronic obstructive pulmonary disease. He has smoked one and a half packs of cigarettes daily for 45 years. Vital signs are within normal limits. Scattered crackles and wheezes are heard bilaterally. Heart sounds are normal. Abdominal examination shows no abnormalities. Rectal examination shows a palpable mass 2 to 3 cm inside the anal verge. Anoscopy shows a 5-cm ulcerated mass; a biopsy specimen of the mass shows adenocarcinoma. Which of the following is the most appropriate next step in management? E9892 Colonoscopy to the cecum Sigmoidoscopy Radiation therapy to the rectum Transanal excision of the tumor Surgical resection of the rectum

COlonoscopy to cecum -then radiation to rectum (anal cancers rarely metastasize)

A 17-year-old girl is brought to the emergency department after a collision in which her motor vehicle crashed into a bridge abutment at high speed; she was the unrestrained driver. On arrival, she is immobilized on a backboard with a cervical collar in place. During attempts to administer 100% oxygen by face mask, the patient is combative. Examination shows obvious severe facial trauma with open fractures of her maxilla and mandible. Her chest is severely bruised. She remains combative and makes gurgling sounds when she breathes. Which of the following is the most appropriate initial step in management? A.Elevation of the head of the bed B.Arterial blood gas analysis C.X-ray of the chest D.Thoracostomy E.Cricothyrotomy

CRICOTHYROTOMY --> Secure ABC's first!!!

52yo man has pneumonia; 30year pack history; had 2 previous episodes of pneumonia, both in same lobe (R lower); Next step?

CT scan of chest --> could be cancer! Recurrent pneumonia causes -Local airway obstruction -Extrinsic (cancer, adenopathy) -Intrinsic (bronchiectasis, foreign body) -Recurrent aspiration -seizures -alcohol, drug use -GERD, dysphagia

Paget's disease labs -Ca -Phosphorus -Alk phos -Urine hydroxyproline

Ca- nl Phosphorus- nl Alk phos- HIGH Urine hydroxyproline- HIGH (high bone turnover)

CREST presentation?

Calcinosis Raynaud's Esophageal dysmotility Systemic sclerosis Telangiectasias

Hyperkalemia Tx?

Calcium gluconate --> cardioprotective!

Intertrigo = what?

Candida infection of intertriginous areas (axilla, etc)

52yo woman has pounding sensation in neck, LE edema, tricuspid regurg, lost weight recently, chronic diarrhea; severe post-menopausal flushing; echo- retracted and immobile tricuspid leaflets with poor coaptation and severe regurg; Dx?

Carcinoid syndrome -flushing -cyanosis -telangiectasias -diarrhea, cramping -valvular lesions (R > L)

58yo man with 1yr history of diarrhea, abdominal cramping, dizziness, wheezing, feeling of warmth, 2/6 diastolic murmur that increases with inspiration, hepatomegaly 3cm below costal margin; Dx? Most common vitamin deficiency? Tx?

Carcinoid syndrome = neuroendocrine tumor (increased 5-HT = serotonin) -flushing -telangiectasias -cyanosis -diarrhea, cramping -valvular lesions -Niacin deficiency --> dermatitis, diarrhea, dementia Tx = octreotide, resection

34yo male found on the ground next to empty bottle with 5mm pupils; tongue heavy, white, drooling, unable to swallow; Most likely explanation?

Caustic poisoning -GI tissue damage --> dysphagia, white tongue, heavy salivation

51yo man has difficulty walking, mild R-sided foot pain for past few weeks; PMH- DM, HTN, HLD; PE- significantly deformed L foot, mildly deformed R foot; XR- effusions in tarsometatarsal joints, large osteophytes, several extra-articular bone fragments; Dx?

Charcot joint = neurogenic arthropathy -deformed joints -mild pain -decreased sensation -fractures *Loss of neurologic input --> patients unknowingly traumatize their weight-bearing joints!! Associated conditions/causes -B12 deficiency -DM -peripheral nerve damage -spinal cord injury -syringomyelia -tabes dorsalis

63yo woman has recent onset of L-sided weakness, increased fatigue, low-grade fevers, palpitations over last 3mo; lost 13.2lbs in this time; PE- diastolic rumble over apex, TTE shows mass in L atrium; Dx?

Cardiac myxoma = primary heart cancer -constitutional (fever, weight loss) -cardiovascular symptoms -valvular abnormalities --> DIASTOLIC SOUND -HF from anatomical obstruction -myocardial invasion --> heart block, arrhythmias -embolization -lung invasion --> respiratory symptoms (mimics bronchogenic carcinoma) *80% in L atrium!!!

Complications of coronary artery bypass?

Cardiac tamponade!

Mechanism of pharmacological cardiac stress test (adenosine)?

Cardiac vasodilation -healthy vessels dilate more than unhealthy vessels --> more radiotracer in healthy vessels

What is elevated BNP associated with?

Cardiogenic pulmonary edema -used to differentiate between non-cardiogenic pulmonary edema

Most common cause of death in ERSD patients?

Cardiovascular disease -20% MIs -60% Sudden cardiac death

67 y/o postal worker comes to physician 1 day after 5 min. episode of weakness and numbness in right (dominant) hand while at work. No visual problems, headache, weakness, numbness in lower-extremities. Currently ASx. Smoke 1 PPD 45 years. He has not seen a physician in 40 years. Pulse 85 bpm, irregular, BP 140/90. Lungs are CTA. Pulses palpable. Carotids bruit heard bilaterally. Heart sounds normal except frequent premature beats. Neuro exam shows no abnormalities. An EKG shows normal sinus rhythm with multiple atrial premature contractions. Best next step? A) ECHO B) Carotid duplex US C) Heparin D) TpA E) Warfarin

Carotid duplex US *NO EVIDENCE OF TIA ON MRI!!!

Case control vs Cohort study -what it looks for -what you start out with (disease vs. exposure)

Case control -exposure risk ratio -start with disease (figure out who had exposure) Cohort study -relativerisk -start with exposure (figure out who has disease) *Can be retrospective or prospective

What should you do before giving supplemental EPO for ESRD?

Check iron stores -If give EPO, could result in Fe deficiency anemia because will induce bone marrow to use up existing stores

Populations who should get HepA vaccine?

Chronic liver disease (HBV, HCV) Men who have sex with men IV drug users Travelers to places where HepA prevalent

A 32 y/o woman with asthma comes to the physician because of a 3-month history of progressive cough. Initially, the cough occurred once every 2 to 3 days and was nonproductive. For the post monthe, the cough has occurred daily and has been productive of thick yellow sputum occasionally tinged with blood. She also has a 1-month history of shortness of breath after walking two blocks. She received the diagnosis of asthma five years ago. Current medications include abuterol and budesonide inhalers, which she has had to use more frequently during the past month. She does not smoke. Today, she is in mild respiratory distress. Her temperatures is 37'C, pulse is 88/ min, respirations are 17/ min, and Bp is 110/65 mm Hg,. Pulse oximetry on room air shows an oxygen saturation of 93%. Scattereed end-expiratory wheezes are heard bilaterally with coarse rhonchi at the lung bases. The remainder of the examination shows no abnormalities. Lab: Hct 42% Wbc 10,000 /mm3 segmented neutrophils 67% Eosinophils 8% Lymphocytes 25% Platelet 160,000/ mm3 Serum IgE 1250 IU/mL A chest X-ray shows linear atelectasis at the lung bases and thickened airways and irregular cystic opacities primarily in a central distribution. Which of the following is the most likely diagnosis? A. allergic bronchopulmonary aspergillosis B. Alpha1-antitrypsis deficiency C. Common variable immunodeficiency D. cystic fibrosis E primary ciliary dyskinesia F. Pulmonary tuberculosis G. sinusitis-infertility syndrome

Central distribution for allergic bronchopulmonary aspergillosis *hypersensitivity of immune system to aspergillus -often in PTs with asthma, bronchitis

60yo man has R-sided neck pain, numbness over posterior forearm, had several similar episodes over past 2 years that responded to NSAIDs and physical therapy; PE- limited neck rotation and lateral bending, decreased pinprick sensation over posterior aspect of forearm, no muscle weakness; Dx? What would we see on neck XR?

Cervical spondylosis = cervical osteoarthritis -chronic neck pain -limited neck rotation, lateral bending (from osteoarthritis) -secondary muscle spasms Seen on neck XR -bony spurs -narrowing of disc spaces -vertebral body hypertrophy

Pulseless electrical activity treatment?

Chest compressions

35yo woman just came back from vacation in Caribbean; has fever, myalgias, joint pain in bilateral hand, wrist, ankle joints; maculopapular rash on skin, mild cervical lymphadenopathy; no oral ulcers, in monogamous relationship with fiance; Plts- 120,000 WBC- 2,000 (82% neutrophils) Dx?

Chikungunya -High fever -Severe polyarthralgias -Headaches, myalgias, conjunctivitis -Maculopapular rash -Lymphopenia -Thrombocytopenia

Coinfections with gonorrhea

Chlamydia HIV Syphilis HepB

Associations with pseudogout?

Chondrocalcinosis = meniscal cartilage calcification

60yo man has nausea, abdominal pain; 5 days ago, had coronary angiogram and stent placement; exam shows purple mottling of skin on bottom of his foot WBC- 10000 (12% eosinophils) BUN- 46 Cr- 3.0 C3- low UA -WBC: 5-10 Dx?

Cholesterol emboli!!! -Livedo reticularis -Blue toe syndrome -acute/subacute kidney injury -CNS (stroke, amaurosis fugax) -Hollenhurst plaques (ocular injury) -GI (intestinal ischemia, pancreatitis)

68yo woman just had a STEMI and gets cardiac catheterization + meds; on 3rd day, gets vague abdominal pain, bluish discoloration of L toes; lacy blue pattern on skin of L leg; pedal pulses full; Cr- 2.1 (previously 1.1) Dx?

Cholesterol embolism -blue toe syndrome = cyanotic toes with intact pulses -livedo reticularis -gangrene -ulcers -Hollenhorst plaques = bright, yellow plaques in retina *Often happens as complication of cardiac catheterization- breaks off a clot that goes elsewhere

Best ARDS treatment strategies for ventilation?

High PEEP (positive end-expiratory pressure > 5mmHg) Low tidal volume --> prevent alveolar overdistension Permissive hypercapnia (high CO2)

47yo man has recurrent skin blisters on backs of hands and forearms, feeling extremely fatigued for past few months, has had joint aches; PE- small vesicles on hands and dorsum, prior lesions healed with scarring and hyperpigmentation -AST- 78 -ALT- 80 -Total bili- 1.2 Dx?

Chronic HCV infection + PORPHYRIA CUTANEA TARDA!!! Extrahepatic manifestations of HCV -cryoglobulinemia --> JOINT PAIN/ARTHRALGIAS!!! -membranoproliferative glomerulonephritis -porphyria cutanea tarada -lichen planus = purple, itchy, flat bumps -HIGHLY ASSOCIATED!!

56yo man has increased urinary frequency, urgency, hesitancy for past few months; new onset lower back and perineal pain during ejaculation; smoked pack of cigarettes a day for 30yrs; PSA = 2 (nl <3.5); UA- many WBCs, no RBCs; Dx?

Chronic prostatitis! *Chronic pelvic pain >3mo without identifiable cause -voiding difficulties -ejaculation difficulties -irritative voiding symptoms -blood in semen Tx -tamsulosin (a-blockers) -finasteride (5-a reductase inhibitors) *Not BPH, prostate cancer because normal PSA

78yo man has kidney failure, BUN = 32, Cr = 3.5; after a blood draw, he keeps bleeding; reason for bleeding?

Chronic renal failure --> UREMIC COAGULOPATHY *Platelet vessel wall + platelet-platelet interaction problems! -Toxins -Guanidinosuccinic acid Tx- desmopressin, cryoprecipitate, conjugated estrogens

63yo woman has leg swelling that's worse at night, worsened over past year; med hx- HTN treated with lisinopril, OSA treated with CPAP; hospitalized 2 yrs ago for chest infection treated with abx; smoked 1pack/day for 30yrs; JVP = 2cm above sternal angle; scattered wheezes, prolonged expiration, bilateral 2+ pitting edema in LE, tortuous leg veins; Dx? Tx?

Chronic venous insufficiency (venous HTN) -leg pain (esp in evening, worse with standing) -pitting edema -if severe -telangiectasias -varicose veins -skin discoloration -liposcleromatodermatosis -skin ulceration (usually in medial aspect of leg) Tx -leg elevation -compression stockings -exercise *NOT CHF because NORMAL JVP!!!

29yo man has nosebleed requiring anterior nasal packing; at that time, his BP was 170/110; has occasional headaches and fatigue but no syncope, palpitations; EKG- high voltage QRS complexes, downsloping ST depression, T-wave inversion Dx? Next step?

Coarctation of aorta -well developed upper body, underdeveloped lower body -brachial-femoral pulse delay -upper, lower body BP difference -L interscapular systolic or continueous murmur -EKG- L ventricular hypertrophy Next step- bilateral arm, leg BP measurements Tx- balloon angioplasty, stent placement

ETEC treatment?

Ciprofloxacin

38yo woman was in MVA, lost lots of blood, got several blood transfusions; hand flexes inward when nurse takes her BP, numbness/tingling in her fingertips and around her lips; Mechanism?

Citrate in blood transfusions chelates Ca --> HYPOCALCEMIA!

A 72-year-old woman comes to the physician because she is concerned about her high blood pressure. Two days ago, her blood pressure was 200/105 mm Hg at the drug store. She has a 20-year history of hypertension that had been well controlled with a thiazide diuretic. At her last visit 3 months ago, her blood pressure was 140/75 mm Hg. Today, her pulse is 80/min, respirations are 12/min, and blood pressure is 210/114 mm Hg. Funduscopic examination shows arteriovenous nicking. A right carotid bruit is heard. Laboratory studies are within normal limits. Which of the following is the most likely cause of these findings? A) Acute glomerulonephritis B) Acute porphyria C) Coarctation of the aorta D) Cushing syndrome E) Hyperaldosteronism F) Hyperparathyroidism G) Hyperthyroidism H) Pheochromocytoma I) Renal artery stenos is

Coarctation of aorta -because labs all normal (all others would cause abnormal labs)

S4 indicates what? Seen in what conditions?

High atrial pressure -Hypertrophy

34yo man has frequent headaches, diagnosed with migraines and prescribed painkillers without relief; BP = 180/100; S4 heard on auscultation; continuous murmur noted in multiple locations across the thorax; Dx? CXR findings?

Coarctation of aorta! -proximal arterial pressure load -HTN -nosebleeds -headaches -brachial-femoral pulse delay -SYSTOLIC MURMUR AT LEFT INFRACLAVICULAR AREA and LEFT INTERSCAPULAR AREA POSTERIORLY -may be continuous if collateral vessels present -may have S4 -notching of ribs

More people seem to be suffering from leukemia in Town A than Town B; what kind of study can we use to determine whether there's a difference in incidence of leukemia?

Cohort study -risk factor = town of residence -outcome = leukemia *Can determine incidence because can follow these subjects over period of time to see whether they develop leukemia *Case-control measures ODDS RATIO, not incidence!!! (always retrospective, so not prospective to measure incidence?) *Cross-sectional used to look at incidence in a single population

What do we use to treat post-MI pericarditis?

Colchicine (tubulin inhibitor)

63yo man has anorexia and weight loss for past 3mo, hepatomegaly, occult blood found in stool; solitary mass found in liver on abdominal XR; Total bili- 1.3 AST- 32 ALT- 38 Dx?

Colon cancer --> liver mets!! *Can be solitary or multiple!!!

37yo man with 30yr smoking history comes in for routine health check; father had colon cancer at 50yo and had colectomy; oldest brother had small cell lung cancer at 50; most appropriate screening test? -Colonoscopy at age 40 -Colonoscopy at age 50 -Stress EKG -Low-dose CT chest -Sputum cytology -TSH level

Colonoscopy at age 40 -if have family history (normally would start at 50yo) *If have lung cancer risk (>30pack yrs, currently or quit smoking in past 15yrs), start annual low-dose CT at 55-80yo

A 47-year-old man comes to the physician because of a 9-month history of constipation and a 2-month history of blood in his stool. His symptoms are partially relieved by stool softeners and laxatives. He has hypercholesterolemia treated with atorvastatin, and he had an appendectomy at the age of 26 years. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender with no palpable masses. Rectal examination shows external hemorrhoids; test of the stool for occult blood is positive. His hematocrit is 35%. Which of the following is the most appropriate next step in diagnosis? A)Tagged red blood cell scan B)Anoscopy C)Colonoscopy D)Esophagogastroduodenoscopy E)Flexible sigmoidoscopy

Colonoscopy. Patient has numerous risk factors for diverticulosis and needs colon assessed for not only locating the bleed(s) but also to assess severity and cancer risk.

Lynch syndrome cancers

Colorectal Ovarian Endometrial

Cardiac problems in acromegaly?

Concentric dilated cardiomyopathy -mitral regurg -aortic regurg

Meralgia peristhetica = what?

Compression of lateral femoral cutaneous nerve at waist -burning pain, paresthesias at lateral thigh -unaffected by motion Causes -obesity -tight clothing -weight gain

S4 mechanism -examples

High atrial pressure (LA must push against stiff LV wall) -hypertrophy -increased stiffness of LV wall -aortic stenosis -chronic HTN with LVH

When seeing whether vasopressor antagonist increases overall survival in CHF pts, randomizing with computer-generated numbers prevents what kind of bias?

Confounding *How to reduce bias 1. Design stage -matching -restricting -randomization 2. Analysis stage -stratified analysis -statistical modeling

When choosing cohort study subjects who drank, took randomly selected people; then interviewed neighbors who matched race and gender who didn't drink; what kind of bias does this eliminate?

Confounding! -Matching decreases confounding!!! *select matching variables (race, gender) that could be confounders *Not selection bias because controls selected may not reflect exposure experience of general population

A 6wk/old boy is brought to d physician for his 1st well-child examination. He was born @ 41 weeks' gestation following a prolonged labor and forceps delivery. Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. He weighed 4111 g (9lb 1 oz) at birth and now weighs 5200 g (11 lb 7 oz). His temperature is 37.4°C (99.3°F). D head is rotated to d Lt. with d chin deviated to d Rt. His head can be moved to the midline only with difficulty. A 2cm, hard, nontender, oval mass is palpated in d Rt. side of the neck. Which of d ffing is d most likely cause of these findings? a) Abscess of a cervical lymph node b) Fibrosis of the sternomastoid muscle c) Fracture of the right clavicle d) Hemivertebra of the cervical spine e) Malignant tumor

Congenital torticollis = fibrosis of sternocleidomastoid muscle *Not hemivertebra of cervical spine (adult-onset torticollis)

45yo man has high BP, mass found on L adrenal gland; Na = 146, K = 3.0; plasma aldosterone:renin ratio = 30; refuses surgery; Dx? Next step?

Conn syndrome = adrenal adenoma --> Primary hyperaldosteronism! (high aldosterone, low renin) Tx 1. Sugery 2. Aldosterone antagonists (if refuse surgery) -Spironolactone -Eplerenone

Effect of Angiotensin II on glomerular arterioles?

Constriction of AFFERENT and EFFERENT (BUT MORE EFFERENT --> increases GFR) arterioles!!! --> overall decreased renal perfusion!!!

64yo man has LE edema, increasing abdominal discomfort, middiastolic heart murmur, serum albumin 3.2, 1g 24hr protein excretion, CXR- spotty calcifications on RH border, EF = 54%; had mitral valve prolapse that was surgically repaired 10yrs ago; Dx?

Constrictive pericarditis --> RH failure -peripheral edema -ascites -elevated JVP -clear lung fields -normal heart thickness

45yo man recently immigrated to US from China; has dyspnea, fatigue, abdominal distention for 2mo ; worked as farmer entire life; exam- pedal edema, ascites, elevated JVP without inspiratory decline; CXR- ring of calcification around heart; jugular venous tracings- prominent x and y descent; Dx?

Constrictive pericarditis secondary to TB!!! -pericardial knock (early heart sound after S2) *In 3rd world countries, TB = common cause of pericarditis

41yo Asian American woman has TB; put on isoniazid, rifampin, ethambutol, pyrazinamide; comes back 1mo later and says that she feels a lot better; AST = 75, ALT = 97; Next step?

Continue on current regimen *INH, pyrazinamide cause hepatotoxicity -BUT 10-20% PTs on INH will have mild, subclinical hepatic injury (AST, ALT <100), but good prognosis, self-limited

A 72 y/o man is hospitalized because of dyspnea for 6 weeks. He has a history of type 1 diabetes and angina pectoris. Medications include insulin and warfarin. During the past 4 months, he was hospitalized once for deep venous thrombosis and another time for pulmonary emboli. Examination shows jugular venous distention, ascites, and pitting pretibial edema of both lower extremities. An chest X-ray shows mild cardiomegaly and no evidence of pulmonary edema. Which of the following is the most likely casue of this patient's worsening condition? A. aortic stenosis B. Cor pulmonale C. ischemic heart disease D. Mitral regurgitation

Cor pulmonale massive pulmonary emboli causing right sides cardiac failure hence symptoms

69yo man has 2day history of increasing cough, SOB, LE edema; drinks half a bottle of vodka daily, 45yr smoking history; cardiac exam- faint lung sounds; JVP = 9cm; lung exam- decreased breath sounds; liver span = 18cm, ascites present; bilateral 3+ LE edema up to knees; CXR- enlarged central pulmonary arteries without evidence of vascular congestion; Dx?

Cor pulmonale secondary to COPD -dyspnea on exertion, fatigue, lethargy -exertional syncope (decreased CO) -exertional angina (increased myocardial output) -peripheral edema -increased JVP with prominent a-wave -loud S2 -R-sided heave -pulsatile liver from congestion -tricuspid regurg murmur *Not cirrhosis because cirrhotic livers small, shrunken

Test for lactose intolerance?

Hydrogen breath test

How to prevent vasovagal syncope?

Counterpressure maneuvers -leg crossing with tensing of muscles -handgrip and tensing of arm muscles with clenched fists

65yo man has 2wks of dysuria and turbid, foul-smelling urine; noticed air bubbles while urinating; PMH- BPH, long history of straining on urination; 1mo ago, was seen in ED for lower abdominal pain, was diagnosed with diverticulitis and discharged on oral abx; PE- mild tenderness in LLQ, no costovertebral tenderness; UA- white cells, bacteria- E. coli, Proteus, Klebsiella; Dx?

Costovesical fistula = complication of diverticulitis! *Ruptured diverticulum *Erosion of diverticular abscess into bladder Symptoms -Fecaluria -Pneumaturia -Recurrent UTI with mixed flora Dx -Abdominal CT with ORAL/RECTAL CONTRAST --> contrast in bladder

Null hypothesis for -cross sectional study -cohort study

Cross section- "There is no association between X, Y" Cohort- "There is no difference in risk for patients with and without X"

Investigation of lipoprotein with development of atherosclerosis; patients had blood samples taken, measured lipoprotein levels, US of carotid determined atherosclerosis development; study found that lipoprotein associated with development of atherosclerosis; What kind of study was this?

Cross-sectional study- measures exposure and outcome in a snapshot in time -Cohort study- certain time period separates exposure and outcome

37yo woman has HIV, thrush, 7 days of fatigue and headache, 1 episode of vomiting, bilateral papilledema, fever T = 101; Dx?

Cryptococcus -headache -fever -malaise -develops over 2 weeks -Meningoencephalitis --> INCREASED INTRACRANIAL PRESSURE!!!

A 42-year-old man has had a pruritic rash on his back for 4 days. He is employed as a plumber and often has to move around on his back under houses. His temperature is 37°C (98.6°F). There are multiple, erythematous, serpiginous tracks on his back that are 2 to 10 cm in length. His leukocyte count is 10,000/mm3 (45% segmented neutrophils, 15% eosinophils, 30% lymphocytes, and 10% monocytes). An x-ray of the chest shows no abnormalities. Examination of the stool for ova and parasites is negative. Which of the following is the most likely diagnosis? A) Ascariasis B) Cutaneous larva migrans C) Fire ant bites D) Hypereosinophilic syndrome E) Scabies

Cutaneous larva migrans. Parasite in soil that causes serpiginous tracks on skin where it enters.

72yo man has HTN emergency; given nitro, BP goes down to 140/80; HCO3 = 15, Cr = 2.5; starts to get confused; Dx?

Cyanide toxicity! -flushing -cyanosis -headache -altered MS -arrhythmias -tachycardia, then respiratory depression, pulmonary edema -abdominal pain, nausea, vomiting -metabolic acidosis, renal failure (EXPLAINS KIDNEY PROBLEMS) *NO releases CN

Pulmonary capillary wedge pressure indicative of what/

LA pressure, or LV end-diastolic pressure

Aortoiliac atherosclerosis presentation

LE pain with activity -in entire leg (thigh, foot, etc) -pedal pulses diminished

Treatment for stable a. fib?

Diltiazem b-blocker CCB *NOT CAROTID MASSAGE- only for paroxysmal SVTs

A 57-year-old woman with stage IV non-small cell lung carcinoma is admitted to the hospital because of a 2-day history of shortness of breath and fever. Her temperature is 39°C (102.2°F). She receives the diagnosis of postobstructive pneumonia. Treatment with intravenous antibiotics is begun, and her symptoms resolve 3 days later. During a family meeting to discuss her treatment options, the patient states that she wishes to discontinue chemotherapy and requests no resuscitation if she has a cardiac arrest. In addition to obtaining a signed advance directive and durable power of attorney for health care decisions, which of the following is the most appropriate recommendation for this patient? A. Discharge home with home hospice care B. Discharge home with physical and occupational therapy C. Discharge home with visiting nurse services D. Discharge to a skilled nursing care facility E. Remain in the hospital

DC home with home hospice care -terminal illness, needs palliative/home hospice

Treatment for V. fib?

DEFBRILLATION!!! *Not same as synchronized cardioversion -low E shock synced with peak of QRS complex -used for persistent wide or narrow tachycardia -SVT -a. fib -a. flutter -v. tachy with a pulse

54yo woman has nausea, vomiting, decreased appetite in past week; has chronic a. fib and cardiomyopathy; last EF = 40%; having palpitations, increased fatigue over past few days; smoked for past 40yrs; Meds- furosemide, digoxin, metoprolol, warfarin; INR = 2.3; PE- irregularly irregular pulse, scattered wheezes; Dx? Next step?

DIGOXIN TOXICITY!!! -nausea -vomiting -decreased appetite -confusion -weakness *Viral illness, excess diuretic use --> volume depletion, renal injury --> acutely elevates digoxin level! *Esp with hypokalemia (loop diuretic) Next step- blood level for digoxin!

63yo man has 2wk history of ulcer on his R foot; diagnosed with HTN 5yrs ago but never followed up; smoked for 30yrs; drinks 1-2 beers/day; walks several miles/day; PE- feet warm and dry, nontender ulcer with thick callus on sole of foot just below head of first metatarsal bone; Cause?

DM foot ulcer!!! -plantar surfaces, under bony prominences *NOT PAD because would have -ulcer at tips of toes -diminished pulses -decreased hair -cold feet -decreased exercise tolerance

Dermatitis herpetiformis tx?

Dapsone Gluten-free diet

Causes of methemoglobinuria?

Dapsone Nitrates Topical/local anesthetics

30yo new mom has pain over lateral side of wrist for past 2 days; pain felt whenever she lifts baby from crib; passive flexion of thumb over radial styloid with thumb held in flexion aggravates pain; Dx?

De Quervain's tenosynovitis *Inflammation of abductor pollicis longus + extensor pollicis brevis -Classic- new mother who holds infants with thumbs outstretched -Test they did = Finkelstein's test

43yo man has ARDS; started on PEEP; 10min after being intubated, pH = 7.42 PaO2 = 102 PaCO2 = 37 Next step in management?

Decrease fraction of FiO2 *PaCO2 normal, so tidal volume, minute ventilation, respiratory rate appropriate *Don't decrease PEEP --> would decrease oxygenation

Estrogen interaction on thyroid function?

Decreased TBG (thyroid-binding globulin) --> Increased TBG in circulation --> LESS T3 available --> need higher levothyroxine (if hypothyroid)

after 6 hours of chest pain, a 76 year old man collapses at home. in the ed, a diagnosis of acute anterior wall MI is made. Pulse 104, SBP is 80. ashen gray and has clammy skin. Diffuse b/l pulm crackles are heard. Heart tones are muffled and s3 is audible. WHich of the following is the most likely cuase of his hypotension? a. 3 degree av block b. dec'd intravas vol c. dec'd myocardial contractility d. dec'd ventricular filling p e. pulm edema

Decreased myocardial contractility Cardiogenic shock 2/2 MI and maybe sHF. Answer is C. Definitely not a volume issue; if anything, the bl crackles suggest volume overload.

49yo nurse has difficulty sleeping after got job promotion; used to work night shift, now needs to be in hospital at 7:30AM; used to have difficulty getting up in the morning for school and work too; Dx?

Delayed sleep phase syndrome = internal circadian rhythm naturally set later -lifelong pattern of difficulty with early morning starts -sleep onset insomnia -excess morning sleepiness *Different from shift work sleep disorder = can't stay awake during day because had night shift -not lifelong

26yo woman has 0.8cm hyperpigmented small bump growing on foot for last 6-7mo; has become firm and slightly pigmented; central dimple that develops when pinched at the sides; Dx?

Dermatofibroma *Fibroblast proliferation causing isolated or multiple lesions *Develops after trauma, insect bites Symptoms -Firm -Hyperpigmented -"Dimple" in center

65yo man has 25yr history of diabetes, not well-controlled (glucose 40-400); has decreased appetite, nausea, abdominal bloating, early satiety for past several months; no heartburn but has some vomiting; Dx? Tx?

Diabetic autonomic neuropathy of GI tract -gastroparesis = delayed gastric emptying Tx- metoclopramide -has both antiemetic, prokinetic properties

35yo has history of 5mo retrosternal back pain that radiates to interscapular area; episodes last 15min; precipitated by emotional stress or hot/cold food; regurgitates food intermittently; relieved with nitroglycerin; EKG- normal; stress test normal; Dx? Next step?

Diffuse esophageal spasm Next step -Esophageal manometry --> repetitive, nonperistaltic, high-amplitude contractions

Hypertrophic osteoarthropathy = what?

Digital clubbing accompanied by sudden-onset arthropathy -COPD (emphysema) -TB -CF (bronchiectasis) -lung cancer

65yo man on furosemide, carvedilol, lisinopril, digoxin, amiodarone, rivaroxaban comes in with anorexia, nausea, generalized weakness; Mechanism?

Digoxin toxicity (from amiodarone) -anorexia -nausea, vomiting -abdominal pain -fatigue -confusion -weakness -color changes

Steatorrhea levels of -Ca -Phosphorus -PTH

Lose ADEK --> No vitamin D! Ca- low Phosphorus- low PTH- high

36yo woman has malaise, fever with chills that started 12hrs ago, pain in multiple joints, several pustules on chest and extensor surfaces; IV drug user, sex worker; R ankle and wrist tender to palpation, palms and soles unaffected; Dx?

Disseminated gonoccocal infection -purulent monoarthritis -tenosynovitis -dermatitis -asymmetric migratory polyarthralgias

b-adrenergic agonists (albuterol) effects on K?

Drives K into cells --> HYPOKALEMIA!!!

67yo woman had operation for perforated diverticulitis; 2 weeks later, has fever for 2 days; current meds are metronidazole and levofloxacin; abdominal exam shows well-healing surgical scar; WBC- 8000 -Neutrophils- 60% -Eosinophils- 15% -Lymphocytes- 15% UA -LE- negative -Nitrates- negative Dx?

Drug allergy! -15% eosinophils! *Not intra-abdominal abscess because would have elevated WBC

28yo woman has worsening skin rash on back and arms for past 2 weeks; had same thing in teenage years that got better with topical meds; diagnosed with SLE 2mo ago and is on oral prednisone due to recent exacerbation of pain in small joints of wrist; also on hydroxychloroquine and NSAIDS; works in a dry cleaning facility; uniform-appearing 1-3mm erythematous papules and pustules across her back, shoulders, upper arms; mild symmetric synovitis in hands and wrists; Most likely cause?

Drug-induced acne! -monomorphic papules and pustules -no comedomes, cysts, nodules -location and age of onset abnormal for acne Triggers -glucocorticoids, androgens -immunomodulators -AEDs (phenytoin), antipsychotics -TB drugs (INH)

Ecthyma gangrenosum vs pyoderma gangrenosum?

Ecthyma gangrenosum- PSEUDOMONAS Pyoderma gangrenosum- Crohn's

45yo woman with history of depression has fever, abdominal pain, severe tinnitus, vertigo; overdosed on some medication several hours ago; pH, pCO2, HCO3 status?

EARLY ASPIRIN OD!!! --> RESPIRATORY ALKALOSIS!!! pH- high pCO2- low HCO3- low *Early --> RESPIRATORY ALKALOSIS *Late --> Metabolic Acidosis

Hepatorenal syndrome -mechanism -risk factors -symptoms/diagnostic criteria -tx

ESRD Complication *Mechanism -Cirrhosis --> splanchnic arterial dilatation, decrease in vascular resistance --> RAAS activation --> renal vasoconstriction, decreased perfusion/GFR *Risk factors -bacterial peritonitis -GI bleeding *Symptoms -Significant decrease in GFR without clear cause -No RBC, protein, granular casts in urine -Lack of improvement with volume resuscitation -No tubular injury *Tx -Address underlying cause -Splanchnic vasoconstrictors -Midodrine -Octreotide -NE -Liver transplant

How often should you check colonoscopy again if last one normal?

EVERY 10 YEARS!!! Up to 75yo

Ecthyma gangrenosum vs pyoderma gangrenosum

Ecthyma gangrenosum --> PSEUDOMONAS (icky = bacteria) Pyoderma gangrenosum --> IBD (pyo = heat, inflammatory --> autoimmune)

Study found association between OCPs and breast cancer; positive association found when looked at subgroup with family history of breast cancer; no association found with subgroup without family history of breast cancer; what kind of effect is this?

Effect modification = external variable positively or negatively impacts effect of risk factor on outcome Examples -family history breast cancer -effect of estrogen on DVTs- augmented by smoking -asbestos exposure on lung cancer- augmented by smoking *Distinguish effect modification vs. confounding by stratifying by variable of interest -if variable is cofounder, no significant difference in risk between stratified groups -if variable isn't cofounder, there is significant difference between stratified groups

23yo IVDU has CXR with multiple, bilateral nodules at lung periphery; What are they?

Endocarditis --> Septic pulmonary emboli!!!

32yo man with 3day history of cough, fever, fatigue; past IV drug user; CXR- scattered round lesions in peripheral part of lung; Dx? What kind of murmur would you hear?

Endocarditis --> Tricuspid regurgitation! -systolic murmur increased with inspiration! *Septic pulmonary emboli --> cough, hemoptysis, chest pain -appear as round alveolar lesions in peripheral lung

Hydrochloroquine -mechanism -SE

Mechanism -TNF, IL1 suppressor SE -retinopathy --> need ophthalmic eval 1x/yr after 5yrs

Acute cholecystitis -mechanism -presentation

Mechanism -Usually common bile duct obstruction due to gallstone or malignancy Presentation -fever -jaundice -RUQ abdominal pain -high alk phos

Pancreatic cancer risks

Environmental 1. Smoking (most significant) 2. Obesity, low activity 3. Nonhereditary chronic pancreatitis Genetic 1. 1st degree relative with pancreatic cancer 2. Hereditary pancreatitis 3. Syndrome (BRCA1, 2; Peutz-Jegher)

32yo man comes in with 2day history of fever, malaise, myalgias, no rash; 2wks ago, got bitten by a tick in woods in Arkansas; slightly confused; Plts- 78,000, WBCs- 2500; AST- 98, ALT- 87; Dx?

Erlichiosis! -Leukopenia -Thrombocytopenia -Increased LFTs -Increased LDH Dx- intracytoplasmic morulae in monocytes Tx- DOXY!

Information bias- what is it

Errors in measurement/outcomes status measurement -can be minimized by standardizing techniques for surveillance and outcomes measurement

65yo woman has 1day of painful swelling in R cheek, high fever 102F, chills; no facial trauma/injury; DM2 with good control; PE- warm, tender, erythematous rash with raised, demarcated borders + mild regional lymphadenopathy; Dx? Pathogen?

Erysipelas --> S. pyogenes! -SUPERFICIAL dermis -LYMPHATICS -rapid spread + onset -fever early in course

42yo woman has endoscopy done, Barrett's esophagus found; multiple biopsies taken; 4hrs after procedure, patient has worsening substernal pain that radiates to back, mild SOB, EKG- only sinus tachycardia, CXR- small pleural effusion; Dx? Next step?

Esophageal perforation -acute chest pain -tachypnea -L pleural effusion Common cause- endoscopy Dx- water-soluble contrast esophagram

41yo man has sudden-onset, severe retrosternal and upper abdominal pain; been vomiting for several hours after consuming alcohol; extensive alcohol use; smoked 15yrs; palpable crepitus in suprasternal area; abdomen tender to palpation in epigastric area; Dx?

Esophageal perforation -chest and abdominal pain -systemic findings (fever) -subcutaneous emphysema in neck -Hamman sign = crunching sound on chest auscultation CXR -wide mediastinum -pneumomediastinum -pneumothorax -pleural effusion (late)

Metabolic acidosis with AG and high osmolar gap?

Ethylene glycol Methanol Ethanol

Calcium oxalate crystals on UA indicates what?

Ethylene glycol toxicity!!! -Hypocalcemia -Flank pain -Hematuria -Oliguria -AKI -Anion gap metabolic acidosis

65yo man with MI has low T3, normal T4, normal TSH; Dx?

Euthyroid sick syndrome *Any PT with severe illness can have abnormal thyroid tests (most common is decrease in T3 levels) -thought to be because of decreased de-iodination of T4 from caloric deprivation

How often should women 50-75 get mammographies?

Every 2 years

How often should men 35+ get lipid panels?

Every 2 years *Women don't need

How often should women 21-29yo get Pap smears?

Every 3 YEARS!!!

How often should women 21-65 get pap smears?

Every 3 years

A 77 yo woman comes to the Ed because of a 3 month history of SOB when she climbs stairs. Her SOB resolves after 5 minutes of rest. Her last episode was 3 days ago. She has not had chest pain, palpitations, orthopnea, cough, wheezing, swelling, or difficulty sleeping. She has HTN and GERD. Current meds include HCTZ, omeprazole, and a multivitamin. BMI is 23. Her temperature is 37.2, pulse 72, respirations 12 and BP 144/92. Pulsox on room air shows 98%. There are jugular venous pulsations 3 cm above the sternal angle. The remainder of the exam shows no abnormalities. An EKG shows a left bundle branch block and no primary T wave changes, which is unchanged from an EKG 1 year ago. Which of the following is the most appropriate next step to determine the cause of the patient's dyspnea? A measurement of serum troponin I concentration B EKG exercise stress test C exercise stress echo D V/Q lung scan E coronary angiography

Exercise stress echo

38yo has witnessed seizure after high-altitude marathon; after race, vomited 2x and had seizure; trainer insists she had aggressively hydrated before, during, and after; only took ibuprofen in last 24hrs for aches and pains; Na- 116 BUN- 24 Cr- 1.0 Dx? Mechanism?

Exercise-induced hypovolemia -people participating in prolonged exercise, ingest large amounts of water -temporary inability to excrete dilute urine (because running?) --> SIADH -excessive ADH secretion triggered by nonosmotic stimuli (exertion, pain, physical/emotional stress, hypotension, hypovolemia, hypoglycemia)

What should normal head thrust show (for vestibular function)?

Eyes stay focused on target, then horizontal saccades in the direction that head moved to compensate *If abnormal, eyes move away from target, then eyes move back to target

42yo woman has 1yr history of intermittent ulcerating skin lesions on legs; low-grade fevers, inguinal lymphadenopathy; bilateral swelling and tenderness of hand joints; palpable spleen; Hb- 13.2 WBC- 1800 (20% neutrophils) Dx?

FELTY SYNDROME = RA + Neutropenia -RA -Neutropenia -Vasculitis (necrotizing lesions, mononeuritis multiplex) -Splenomegaly

Cholangitis = what?

Gallstones + inflammation in COMMON BILE DUCT *Charcot's triad -RUQ pain -Jaundice Fever +Reynold's pentad -Hypotension -Altered mental status

Cholecystitis = what?

Gallstones + inflammation in cystic duct! -specific to gallbladder, not common bile duct!!! -constant pain -Murphy's sign -inflammation (fever, high WBC)

Treatment for basal cell carcinoma -on face -on body

Face- Moh's (highest cure rate) Body- Wide excision with 4mm margins

Cystocele -mechanism -symptoms

Mechanism -bladder prolapse into anterior vaginal wall Symptoms -vaginal pressure -dyspareunia -urinary frequency + urgency -incontinence *Would be able to see from externally

Most common coagulopathy in Caucasians?

Factor V Leiden! -Mutated Factor V --> can't be inactivated by Protein C --> clotting cascade can't be turned off Symptoms -PE -DVT

Study randomizing ppl to b-blocker, CCB, ACE-I; measuring either 1 of 2 mean goal arterial pressures- what kind of study is this?

Factorial design -2/more variables + 2/more outcomes measured *Parallel study design- randomized to 1 of 2 groups, only 1 variable studied

ABO transfusion hypersensitivity symptoms

Fever Flank pain Hemoptysis Oliguric renal failure DIC (can be caused by ABO compatibility!!!)

Trichinella symptoms

Fever Vomiting Periorbital edema Myalgias (cysts in striated muscle cells --> muscle inflammation) Subungal splinter hemorrhages (not just in endocarditis)

77yo woman has L femoral fracture, admitted to hospital, develops dyspnea and confusion, RR = 24; O2 sat = 85%, not oriented to place or time; scattered rhonchi, petechiae over arms and legs; Plts- 300,000; Dx?

Fat embolism -Hypoxemia -Neurological abnormalities -Petechial rash

Hypercalcemia symptoms

Fatigue Constipation Depression

80yo woman has osteoarthritis and fatigue; meds include lisinopril, chlorthalidone, naproxen; takes aspirin because "good for the heart"; renal function norma; cause of anemia?

Fe deficiency anemia! *NSAIDs (naproxen), aspirin --> Gastritis, gastric ulcers --> GI bleeding --> depletion of Fe stores

Pica indication for what condition?

Fe deficiency!

42yo woman with RA discontinued methotrexate 8mo ago with 2yrs of continuous therapy; spleen tip palpated 3cm below L costal margin; pancytopenia; Dx?

Felty syndrome -RA -Splenomegaly -Neutropenia

25yo woman has "chest pain" that started 2 days ago; constant soreness, unable to sleep because of the pain; menstrual cycle 3 weeks ago; regular menses; bilateral, nonfocal chest tenderness and diffuse, cordlike thickening of the breasts; Dx?

Fibrocystic changes -diffusely nodular (cord-like thickening) -bilateral, nonfocal -premenstrual changes Tx- NSAIDs, OCPs for symptomatic relief

24yo woman has transient vision loss in R eye, HTN (BP = 164/100), bruit below R mandible; Cr- nl Plasma renin activity- high Plasma aldosterone: plasma renin activity = 10 Dx? Next step?

Fibromuscular dysplasia = abnormal cell development in arterial wall --> vessel stenosis, aneurysm, dissection *Typically involves -renal arteries -carotid arteries -vertebral arteries Symptoms -Resistant HTN (decreases perfusion to kidney --> kidney makes more renin, aldosterone) -Brain ischemia (amaurosis fugax, Horner's, TIA, etc) -Carotid, vertebral involvement --> headache, pulsatile tinnitus, dizziness Next step- Abdominal CT or US

A previously healthy 42-year-old woman comes to the physician 2 days after she noted a mildly tender bump on her neck. She has not had fever, chills, cough, sore throat, or palpitations. She has smoked approximately one-half pack of cigarettes daily for 20 years. She underwent a hysterectomy 2 years ago. Her only medication is conjugated estrogen. She is in no acute distress. She is 178 cm (5 ft 10 in) tall and weighs 57 kg (125 lb); BMI is 18 kg/m . Her temperature is 37°C (98.6°F), pulse is 82/min, and blood pressure is 120/78 mm Hg. Examination of the neck shows a 2-*cm lesion on the left lobe of the thyroid gland. There is no cervical lymphadenopathy. Her serum thyroid-stimulating hormone concentration is 1.5 μU/mL, and serum free thyroxine concentration is 1.4 ng/dL (N=0.9-2.1). Which of the following is the most appropriate next step in management? A) Reexamination and repeat thyroid function tests in 1 month (WRONG) B) Measurement of thyroid radioactive iodine uptake C) CT scan of the neck D) Fine-needle aspiration of the lesion

Fine needle aspiration for cold thyroid nodules!! --> high risk of cancer!!

RCC (renal cell carcinoma) symptoms

Flank pain Hematuria Abdominal mass Polycythemia (kidney makes EPO!!) Varicocele Fever Night sweats Anorexia Weight loss

22 year old man 2 days after closed head injury in MVA. CT scan on admission normal. Received D5 with .45% normal saline. Mental status last 12 hours has been normal. Urine output 50ml/hr last 24 hours. Physical is normal. Labs show sodium 120 and urine osmolality 340. What is next step? a. fluid restriction b. CT head c. ADH d. bolus normal saline e. bolus 3% saline

Fluid restrict *Don't give ADH because probably losing blood

Gastric vs duodenal ulcers sxs -BOTH ARE CALLED PUD!!! (peptic)

Food -makes gastric ulcers WORSE (because increased acid secretion) -makes duodenal ulcers BETTER *Duodenal ulcers worse on empty stomach because of unopposed acid secretions? -alkaline secretions when eat food

How to correct Ca with serum albumin level?

For every 1g drop in albumin, serum Ca falls by 0.8

47yo man has epigastric pain, diarrhea; has peptic ulcer disease; endoscopy shows prominent gastric folds, 3 duodenal ulcers, upper jejunal ulceration; Dx?

GASTRINOMA (Zollinger-Ellison!!) -multiple stomach ulcers -thickened gastric folds

56yo woman has progressive asthma symptoms; has worsening nighttime cough and wheezing; has had to use albuterol right after meals; tired every morning because she works late and has no time to relax; hoarseness in throat that clears in the morning; PMH- bronchial asthma, DM2, HTN; meds- lisinopril, aspirin, inhaled fluticasone, albuterol, amlodipine; BMI = 32; Dx?

GERD -nighttime cough and wheezing -sore throat -morning hoarseness -increased need for albuterol after meals *Common in patients with asthma -microaspiration of gastric contents --> increased vagal tone, bronchial constriction

Woman who just delivered baby 4 days ago has signs of PE; next step?

GIVE HEPARIN!! -safe to give 6-12hrs after delivery *Don't wait to get D-dimer!!

Man has suspected spinal cord compression from prostate met to spine based on symptoms; Next step?

GIVE IV GLUCOCORTICOIDS --> preserve neuro function!! -decrease vasogenic edema -alleviate pain -restore neuro function

56yo woman has diplopia, painful eye movements, eye irritation, weight loss, fatigue; smokes pack of cigarettes/day and has 25yr pack history; unable to maintain eye convergence and experiences diplopia on upward eye gaze; eyes look like they're bugging out; Dx?

GRAVES DISEASE!!! *Myasthenia doesn't have painful eye movements!

36yo woman unintentionally fasted all day, then had cheeseburger 2hrs ago; now has severe epigastric and R shoulder pain, vomiting; same thing happened last month; PMH- heartburn treated with ranitidine; Dx?

Gallstones! -RUQ, epigastric pain --> radiates to subscapular area -vomiting -nausea -Ingestion of large, fatty meal --> gallbladder contractions

8. A 27 yo man with moderate mental retardation is brought to the physician by his caretaker because of increasingly frequent episodes of intermittent vomiting over the past 3 weeks. The vomiting typically occurs within an hour after eating and usually contains partially digested food, no blood is noted in the vomitus. The patient's appetite seems unaffected, but he stops eating before he completes the meal. He has had a 8Ib weight loss since his last visit 6 mo ago. He takes phenytoin for a seizure disorder but is otherwise healthy. His vital signs are within normal limits. His speech is not intelligible. Exam shows a 3x4 cm area of alopecia in the R occipitoparietal area of the scalp. Bowel sounds are present. The abdominal musculature voluntarily contracts with palpation, no organomegaly or masses are palpated. There are minimal contractures in both upper and lower extremities and increased muscle tone. Which of the following is the most likely diagnosis? A achalasia B brain tumor C bulimia nervosa D cholecystitis E diabetic gastroparesis F drug toxicity (wrong) G food poisoning H gastric bezoar I gastric carcinoma J pyloric channel ulcer K small bowel obstruction L uremia

Gastric bezoar -mental retardation -already picks at hair alopecia

43yo man has episode of coffee-ground emesis; has had upper abdominal discomfort for months- burning and fullness relieved by food; over last month, had black, tarry stools associated with weakness + fatigue; Dx? What other lab ratios would be abnormal?

Gastric cancer --> GI bleeding --> Increased BUN/Cr ratio -increased urea production from Hb breakdown -increased urea reabsorption in proximal tubule from associated hypovolemia

Complications of pernicious anemia?

Gastric cancer! -2x risk than in normal population! *Chronic atrophic gastritis

Why does vomiting cause hypochloridia?

Gastrointestinal fluid rich in HCl, KCl!

Vascular complications of -Giant cell arteritis -Takayasu -Polyarteritis nodosa -Kawasaki

Giant cell -aortic aneurysm *Commonly affects CAROTID artery Takayasu -aortic arch -proximal great vessels Polyarteritis nodosa -renal and visceral vessels (NOT PULMONARY VESSELS) Kawasaki -Coronary artery aneurysm

The 24M with ACL repair has an elevated indirect bilirubin and LDH with otherwise normal labs. G6PD deficiency was incorrect, was the answer Gilbert syndrome? -Acute hepatitis -A1AT defiicency -biliary atresia -cholangiocarcinoma -choledocolithiasis -gilbert -G6PD -liver abscess -peptic ulcer disease

Gilbert's -asymptomatic young person with elevated indirect bili -more common than G6PD

34yo man with WPW comes in with palpitations for last 4hrs; EKG- irregularly irregular; shows atrial fibrillation; Next step?

Give PROCAINAMIDE!!! (for WPW) -a. fib occurs in 10-20% of patients with WPW --> can lead to rapid ventricular response --> deteriorates into ventricular fibrillation! *If hemodynamically unstable, cardioversion *If hemodynamically stable, antiarrhythmics like ibutilide or PROCAINAMIDE

24yo woman gets urticaria, excoriations all over her body 20min after taking amoxicillin; vitals stable; next step?

Give antihistamines *Don't give epi unless anaphylactic!

69yo man comes in with DVT; next step?

Give heparin! -prevent further thromboses

56yo woman with recently diagnosed diabetes (but now well-controlled) has 20lb weight loss, watery stools, eczematous perioral rash in thigh and perioral region (erythematous plaques with central clearing and eroded borders); no palpitations, abdominal pain, vomiting; Dx?

Glucagonoma -necrolytic migratory erythema -DM -GI symptoms (diarrhea, anorexia, pain, constipation) -weight loss -normocytic, normochronic anemia

56yo woman recently diagnosed with DM, lost 20lbs in last 9mo; DM now well-controlled with sitagliptin; has erythematous, eczymatous rash around mouth and on thigh- red plaques with central clearing and eroded borders; Dx? Next step?

Glucagonoma!!! -Necrolytic migratory erythema -DM -GI (diarrhea, anorexia, occasional constipation) -weight loss -venous thrombosis -neuropsychiatric (ataxia, dementia, proximal muscle weakness) Next step- measure glucagon levels

Empyema pleural effusion analysis? -Glucose -Protein -WBC -pH

Glucose- low Protein- high (increased microvascular permeability, cellular destruction) WBC > 50 pH < 7.2

SE of radioactive iodine ablation of Graves' disease?

Gradual development of hypothyroidism over months --> years -permanent hypothyroidism in months for 90% of patients

19yo man with aplastic anemia has bone marrow transplant from HLA-matched sibling; 2wks later, gets maculopapular rash on hands, feet, face; diarrhea with occult blood; liver function tests abnormal; Dx? Mechanism?

Graft vs. host disease! -Host T-cells attack immunocompromised host! *Happens to 50% of PTs with BMTs with matched siblings

45yo man has progressive SOB on exertion, fatigue for past few weeks; 2yrs ago, diagnosed wtih alcoholic cirrhosis with esophageal varices; had no alcohol for past 2yrs; no change in dyspnea in lying down or moving to upright position; dullness + decreased breath sounds on R lung fields; Dx? Mechanism?

Hepatic hydrothorax = pleural effusion not from cardiac or pulmonary abnormalities *Caused by small defects in diaphragm --> fluid leaks out from diaphragm! *more often on R side Tx -salt restrict -diuretics

Acidosis effect of Ca, albumin binding?

H+ binds to albumin usually -If H+ increases, H+ dissociate from albumin --> more Ca2+ binds to albumin --> hypocalcemia!!! *Only ionized Ca2+ physiologically active!

Loratadine = what kind of drug?

H1 antihistamine (2nd generation)

Chronic HCV infection requires what other prophylaxis?

HAV vaccine HBV vaccine Alcohol avoidance

72yo man had R femoral fracture after MVA; 6 days after surgical repair, found to be lethargic; PMH- HTN, osteoarthritis; Meds- hydrochlorothiazide, lisinopril, naproxen; multiple contusions on anterior thighs and abdomen; kernicterus Hb- 8.4 BUN- 78 AST- 112 ALT- 42 CK- 32000 Most appropriate next step?

HEMODIALYSIS!! Rhabdo --> uremic encephalopathy

75yo man with DM2 has weakness, blurred vision; over last few days, has had hacking cough, sore throat, poor appetite; fever 100.4; mucus membranes dry; K = 5.9; Cr = 1.5; BUN = 52; Dx? What else likely present in this patient?

HHS = hyperosmolar hyperglycemia nonketotic syndrome -glucose > 600 -HCO3 > 18 -Normal AG -Serum osmolality > 320 *Likely also has total body K depletion (like DKA --> K comes out of cells because of hyperosmolality) *Be careful of insulin therapy --> can lower K levels even more!

GGT, Ferritin levels in alcoholic cirrhosis?

HIGH -ferritin = acute phase reactant!

62yo woman had elective CABG 2 days ago; now has purple skin lesions on abdomen; currently receiving low-dose subcutaneous heparin for DVT prophylaxis, no oral anticoagulation; Dx? Mechanism?

HIT = heparin-induced thrombocytopenia -thrombocytopenia -VERY high APTT -PT can be high too Type 1 = nonimmune response -Heparin activates platelet response -Presents within 2 days of heparin exposure -Tx- give more heparin (plt count normalizes, no clinical consequences) Type 2 = immune response *IgG antibodies against heparin-bound PF4 --> bind to surface of platelets --> platelet aggregation --> thrombosis, thrombocytopenia -5-10 days after heparin exposure

Lamivudine used for ...?

HIV HBV

24yo man has syncope while shoveling snow; had some SOB, chest pains recently; crescendo-decrescendo murmur along L sternal border without carotid radiation; Dx?

HOCM!!!

62yo woman has 2 day history of confusion; has HTN, DM2, Ca = 13; Tx?

HYPERCALCEMIA --> PSYCHIATRIC OVERTONES -depression -anxiety -cognitive dysfunction -insomnia -coma

Nephrotic syndrome causes hypo or hypercoagulability?

HYPERcoagulability!!! -Pee out Antithrombin III, Protein C/S -Increased platelet aggregation -Hyperfibrinogenemia

47yo woman has 6wk history of puffy eyes, swelling in her legs; 15lb weight gain during this time; heavy bleeding with menses; heart sounds distant; upper and lower extremities tender to palpation; elevated CK; Dx?

HYPOTHYROID!! -myxedema

Osteoarthritis PE

Hard, bony enlargement of joints Crepitus with movement XR- joint space narrowing, osteophytes, subchondral sclerosis

60yo woman with hypothyroidism develops 4wks of voice hoarseness, increased difficulty in swallowing, fatigue, mild fever, night sweats, facial congestion, cyanosis, inspiratory stridor when elevating her arms, Dx?

Hashimoto's --> THYROID LYMPHOMA!! -60x greater if have pre-existing Hashimoto's -Pemberton sign = retrosternal extension (venous compression with distended neck veins, facial plethora)

If subjects in a clinical trial change their behavior because they know they're being observed, what kind of bias is this?

Hawthorne effect!

62yo man has occasional ear pain, lump in his throat; hard, nontender, submandibular mass 3cm in diameter; smokes 2packs/day; Dx?

Head and neck cancer = squamous cell carcinoma! -Hard, unilateral, nontender lymph nodes

CO poisoning symptoms

Headache Confusion Dizziness Malaise Nausea Polycythemia

65yo man has exertional dyspnea, choking sensation when lying flat, bibasilar rales, LE edema, normal ejection fraction; long history of smoking, BP =182/90, Dx?

Heart failure with normal ejection fraction = DIASTOLIC DYSFUNCTION!!! *Likely due to HTN

24yo military recruit training in hot and humid day; becomes disoriented; T = 105F, BP = 98/60, HR = 90, RR = 22, dry mucus membranes; large blood on dipstick but no RBCs on microscopy; Dx?

Heat stroke!! *Dehydration doesn't have altered mental status!!!

40yo man has ED, drinks 1-2 beers/day, 20yr smoking history; brownish skin pigmentation more pronounced over face and arms; fasting glucose = 130; AST- 78, ALT- 80; Dx? Mechanism? Most likely to die of?

Hemochromatosis = BRONZE DIABETES -arthralgias -elevated LFTs with hepatosplenomegaly -restrictive or dilated cardiomyopathy -secondary hypogonadismm, hypothyroid *Mechanism -recessive mutation in HFE --> abnormal Fe sensing --> increased intestinal absorption --> retains Fe in body Tx -phlebotomy -chelation with deferasirox, deferoxamine -oral deferiprone *Most likely to die of HCC

Treatment for -Hemodynamically stable A. fib? -Hemodynamically unstable A. fib?

Hemodynamically stable A. fib --> Diltiazem Hemodynamically unstable A. fib --> Cardioversion

For traveler going to North African (Egypt), what vaccines should they have?

HepA HepB Typhoid fever *Yellow fever- if going to sub-Saharan Africa

Testosterone level in anabolic steroid use?

High OR NORMAL (exogenous steroids suppress endogenous testosterone --> normal testosterone level)

PT with DM, sudden joint pain, chondrocalcinosis on x-ray?

Hereditary hemochromatosis *Secondary causes of pseudogout (chondrocalcinosis) -Hemochromatosis -Hypothyroidism -Hyperparathyroidism

42yo man has acute onset R knee pain; diagnosed with DM 1 year ago; PE- tender right knee, hepatomegaly, chondrocalcinosis with effusion; Dx? Next step?

Hereditary hemochromatosis -Bronze DM -Pseudogout -Hepatomegaly Next step- Fe studies -usually have elevated Fe, ferritin, transferrin saturation

MCL injury -mechanism -symptoms

Mechanism -pivoting/twisting injuries -or if knee stuck on lateral side when foot planted Symptoms -tenderness at medial knee -no hemarthrosis

69yo man has increasing confusion over past 2 days; nausea, vomiting, back and abdominal pain; PMH- DM2 treated with metformin, HTN treated with amlodipine; T = 99F, BP = 112/70, HR = 102; WBC- 3200 Hct- 32% Plts- 87,000 BUN- 36 Cr- 1.8 Glucose- 190 Dx? Next step?

Hypercalcemia (likely from malignancy) -Weakness -GI distress -Neuropsych (confusion, stupor, coma) -Hypovolemia Tx 1. IV saline + calcitonin 2. Bisphosphonates

A 62-year-old man is brought to the emergency department 45 minutes after the sudden onset of shortness of breath. When paramedics arrived at his home, he was agitated but alert and oriented to person, place, and time. He was cyanotic and in severe respiratory distress. He was treated with 100% oxygen by face mask en route to the hospital. He has a 15-year history of chronic obstructive pulmonary disease treated with home oxygen therapy (1.5 L/min) over the past 2 years. He has smoked two packs of cigarettes daily for 40 years. On arrival, he is drowsy and awakens only to loud voices or painful stimuli. His temperature is 37°C (98.6°F), pulse is 104/min, respirations are 14/min and shallow, and blood pressure is 164/90 mm Hg. Breath sounds are diffusely decreased, and air movement is poor with prolonged expiration. Which of the following is the most likely underlying cause of this patient's decreased level of consciousness? A. Hypercarbia B. Hypoxemia C. Metabolic acidosis D. Oxygen toxicity E. Respiratory alkalosis

Hypercarbia Acute hypercapnia may produce the following effects on the brain [16,17]: ●An initial increase in respiratory drive followed by a depressed level of consciousness (also known as carbon dioxide [CO2] narcosis) and reduced respiratory drive

Metabolic syndrome

Hyperglycemia Dyslipidemia (high cholesterol) HTN *Insulin resistance for those with central obesity plays pathogenetic factor!

Amlodipine -mechanism -SEs

Mechanism- dihydropyridine CCB SEs -peripheral edema -flushing -dizziness -gingival hyperplasia

A previously healthy 57-year-old man comes to the physician because of a 1-month history of increasing pain at multiple sites in his back, arms, and legs. Examination shows no abnormalities. A bone scan is shown. Which of the following is the most likely diagnosis? A) Bone metastasis B) Hyperparathyroidism C) Osteoarthritis D) Osteomyelitis E) Osteoporosis

Hyperparathyroidism -systemic, diffuse -but too young for osteoporosis

Hidradenitis supportiativa AKA acne inversa -symptoms -mechanism

Mechanism- inflammation of folliculopilosebaceous units --> prevents keratinocytes from properly shedding from follicular epithelium -Solitary, inflamed nodules -last for days --> months -Chronic, relapsing course -Painful

34yo woman has fatigue for several months; gets tired after walking short distances, tired after combing hair; anxiety, irritability, weight loss of 8lb over past 2mo; her mom had DM, dad died of stroke at 54; awkwardly drops to chair when asked to sit slowly; decreased muscle mass on shoulders, but muscles nontender; Dx?

Hyperthyroidism -anxiety + insomnia -palpitations -heat intolerance -weight loss without appetite change -hyperreflexia -HTN -tremors -proximal muscle weakness (can be isolated) -lid lag -atrial fibrillation *Not myasthenia because would have ptosis, diplopia, facial weakness, -unusual to have isolated proximal muscle weakness

34yo man has sudden onset epigastric pain, vomiting; crops of yellow-red papules on his arms and back; lipase = 3000; alk phos = 101; Next step in diagnosis?

Hypertriglyceridemia --> acute pancreatitis!! *Get lipid panel!!!

Effect of H+ on Ca2+ availability?

Hypocalcemia -H+ binds to albumin --> releases more Ca2+ in blood

Chronic alcoholism causes what electrolyte disturbances?

Hypomagnesemia --> REFRACTORY HYPOKALEMIA!!!

55yo homeless man has muscle cramps, perioral numbness; history of alcohol intake -K- 3.1 -Ca- 6.0 -Mg- 0.8 -PO4- 2.0 -Albumin- 3.4 Cause of hypocalcemia?

Hypomagnesemia --> hypocalcelmia -increases PTH resistance -decreases PTH secretion Tx- replace Mg (can't just give Ca, usually refractory to just giving Ca back)

25yo African-American man has nocturia 2-3x/night; no dysuria, urinary urgency, back pain, fever; sexually active with 1 partner and doesn't use condoms; UA- no proteinuria, sediment abnormalities; brother died of "blood disease"; Hct = 49%; Dx?

Hyposthenuria -associated with sickle cell disease -RBC sickkling in vasa rectae of inner medulla

Hypopituitarism symptoms

Hypothyroidism Glucocorticoid deficiency Hypogonadism

59yo woman has lower GI bleed; urine output 300-400mL for past few days; becomes lethargic, confused on 4th day of hospitalization; PMH- HTN, COPD with cor pulmonale, diverticulosis; Meds- albuterol, aspirin, lisinopril; BP = 80/50; high WBC, high BUN, high Cr, low HCO3; pH = 7.12; pO2 = 80, pCO2 = 60; Reason for confusion, lethargy?

Hypoventilation + COPD --> CO2 narcosis -PaCO2 > 60% -different from acute hypercarbia because of -acidosis -associated low bicarb levels

Heparin mechanism?

II, X factor inhibitor

Health care worker has PPD of 12mm- next step?

INH prophylaxis (since >10mm)

34yo man has occasional dizziness, palpitations in crowded spaces; Hb = 14, plts = 80,000; peripheral smear- reduced platelet count without clumping or malignant cells; Dx? Next step?

ITP (likely induced by HIV) *All Pts with presumed should get HIV screening!!

Toxic megacolon Tx?

IV fluids Abx IV corticosteroids

Acute pancreatitis treatment?

IV fluids + supportive care

57yo woman has sudden onset of confusion, drowsiness; 2-day history of nausea, generalized weakness, has breast carcinoma metastatic to bone; BP = 140/90; dry mucus membranes; serum Ca = 16; Next step? -IM calcitonin -IV furosemide -IV mithramycin -IV pamidronate -IV saline

IV saline Tx for hypercalcemia -Saline + calcitonin -then bisphosphonates

Is it ethical to perform intubation, pericardiocentesis on a dead patient?

If have family's permission, yes

Pericarditis tx?

Ibuprofen, pain meds

Mechanism of Membranoproliferative glomerulonephritis Type II?

IgG Ab against C3 convertase of complement pathway --> persistent activation of complement pathway

17yo boy was in an MVA, became paraplegic, fell into coma, had acute kidney failure from rhabdomyolysis; wakes up 4weeks after initial injury and develops nausea, polyuria; Calcium- 12.1 Albumin- 3 (low) Cr- 1.4 (high) PTH- 9 (LOW; nl 10-65) PTHrP- undetectable 1, 25 Vit D- 19 (low; nl 20-60) Cause of hypercalcemia?

Immobilization -increased osteoclastic bone resorption -more likely in PTs with lots of bone turnover (younger, Paget's disease) -develops 4wks after immobilization (BUT IF RENAL INSUFFICIENCY, CAN DEVELOP IN 3 DAYS) Tx- bisphosphonates

Flecainide SEs

In pts with faster heart rates, has harder time dissociating from Na channels --> widening of QRS complex = USE DEPENDENCE!!! Esp with Class IC drugs!

A 42 year old woman comes to the physician because of a 4 month history of weakness in the right hand and a 2 month history of weakness in the left leg. She has had occasional twitching of muscles in all 4 extremities that she attributes to nervousness. She has migraines treated with sumatriptan. No family history of neurologic disease. Examination shows atrophy and weakness of the hands more on the right than on the left. frequent random twitching in the shoulder girdle muscles and the left foot drop. DTRs markedly increased in the extremities. Babinski is present on the right. Jaw reflex is brisk. Her speech is slurred. Sensory exam normal. Her CK is 335. Nerve conduction studies show no abnormalities. EMG shows acute and chronic denervation in several muscles of all extremities. Most likely diagnosis? A) Amyotrophic lateral sclerosis (could that be it?) B) Cervical myelopathy C) inclusion body mysositis D) multiple sclerosis (i chose this and is the wrong answer) E) Polymyositis

Inclusion body myositis = lowly progressive weakness and wasting of both distal and proximal muscles -general, progressive muscle weakness -frequent tripping, falling -foot drop

S3 indicates what? Seen in what conditions?

Increased filling pressure -Mitral regurg -HF

42 yr old woman comes to the physician for a follow up examination.She was diagnosed with hypertension 6 months ago,and hydrochlorothiazide therapy was begun.Eight weeks ago ,her blood pressure was 176/96 mm Hg,and Lisinopril was added to her regimen.She says she feels well.She has no other history of serious illness she occasionally takes Ibuprofen for muscle pain or headache.She walks for 30 minutes three times weekly.She is 170 cm,(5ft 7in)tall and weighs 66 kg(145 lb);BMI is 23 kg/m2.Her pulse is 76/min,and blood pressure is 160/98 mm Hg in the right upper extremity and 162/96 mm Hg in the left upper extremity while sitting and standing.Cardiopulmonary examination shows no abnormalities.There is no peripheral edema.Fsating laboratory studies show: serum Na+ 140mEq/L K+ 4 mEq/L Cl- 105 mEq/L HCO3- 24mEq/L urea nitrogen 16 mEq/L Glucose 94mg/dl creatinine 1 mg/dl urine protein 1+ The patient asks how she can decrease her risk of renal failure.Which of the following is the most appropriate recommendation? A) Protein restricted diet B) 24 hour urine collection for measurement of protein concentration C) Increasing the dose of lisinopril D) Switching from hydrocholothiazide to furosemide E) No further measures are indicated at this time

Increasing dose of lisinopril

42yo man has 4wks of fatigue, weakness, fleeting joint pains, low-grade fever, dark-cloudy urine, SOB when walking fast or climbing stairs, pain in fingertips; high ESR, high WBC; Dx?

Infective endocarditis --> FROM JANE -fever -Roth spots -Osler nodes -Murmur -Janeway lesions -Anemia -Nail-bed hemorrhage -Emboli

53yo man has squeezing chest pain; SOB that's worse when he lays down; BP = 98/60, grade III/IV holosystolic murmur at cardiac apex, bibasilar crackles in lungs; Dx?

Inferior MI --> papillary muscle displacement --> acute MITRAL REGURG!!! --> Elevated LV filling pressure!

NAFLD (nonalcoholic fatty liver disease) mechanism?

Insulin resistance -increased transport of free fatty acids (FFAs) from fat --> liver -decreased oxidation of FFAs in liver -decreased clearance of FFAs from liver (from decreased VLDL production) *Insulin resistance --> increased lipolysis, TG synthesis, and FFAs release -hepatic FFAs --> increased oxidative stress, production of inflammatory cytokine factors

47yo woman has lower abdominal pain relieved with urination; present for over 2mo, voiding more frequently than usual; sexually active with husband; pain with sex; external genitalia looks normal; palpation of anterior vaginal wall elicits severe pain; Dx?

Interstitial cystitis = painful bladder syndrome -bladder pain with filling -relief with voiding -increased frequency, urgency -dyspareunia *Functional problem/psychological *More common in women *Associated with anxiety, fibromyalgia Dx -normal UA -bladder pain with no other attributable cause for >6wks Tx -behavior modification, avoid triggers -amitriptyline -analgesics for pain control

Features of -intravascular hemolysis -extravascular hemolysis

Intravascular hemolysis -Haptoglobin- low -LDH- high -Retics- high *too much free Hb in serum --> haptoglobin can't bind it all --> lowers level of haptoglobin Extravascular hemolysis -LDH- high -Unconjugated bili- high

What is follicular thyroid cancer distinct for?

Invasion of tumor capsule and/or blood vessels (hematogenous spread)

47yo man recently had allogenic stem cell transplantation for AML, with acute graft vs. host disease and profound neutropenia 3 weeks ago; now has 3 days of fever, pleuritic chest pain, coughing up small amount of blood; started oral antibiotics for 2 days, but hasn't helped; PE- R-sided crackles; CXR- dense R upper lobe infiltrate; CT- several nodular lesions with surrounding ground-glass opacities; Dx?

Invasive aspergillosis! -fever -chest pain -hemoptysis -NEUTROPENIA -HALO SIGN = nodules with surrounding ground-glass opacities Tx- 2 weeks IV voriconazole, + caspofungin

74yo man has 2/6 systolic murmur at R sternal border, BP = 165/74, LV hypertrophy with secondary ST elevation + T-wave changes; EF = 60%; Dx? Pathophys?

Isolated systolic HTN *Mechanism- Increased stiffness of arterial walls in elderly patients --> increased pulse wave velocity, pulse wave reflection in systole --> increased pulse pressure

What kind of drugs are triamterene, amiloride?

K-sparing diuretics! -block ENaC!

Pulmonary capillary wedge pressure = measure of what?

L atrial pressure

50yo woman has 4wks of nonproductive cough; diagnosed with nonischemic cardiomyopathy 2mo ago and currently on carvedilol, lisinopril, spironolactone, torsemide; BMI = 32; jugular veins flat when lie down; faint systolic murmur at apex; CXR- mild cardiomegaly and clear lung fields; Dx? Next step?

LISINOPRIL SE!!! -nonproductive cough *Discontinue lisinopril! *If had CHF exacerbation, would have -lung crackles -JVP distention -LE edema -SOB -PRODUCTIVE cough

A 72-year-old woman is brought to the emergency department because of a 1-month history of progressive shortness of breath and fatigue. She has had no chest pain. There is no history of heart or pulmonary disease. She is in moderate respiratory distress. Her temperature is 37°C (98.6°F), pulse is 100/min, respirations are 22/min, and blood pressure is 135/85 mm Hg. Examination shows jugular venous distention. Crackles are heard halfway up both lungs. A grade 2/6, systolic ejection murmur is heard along the left sternal border. There is an S3. She has 2+ edema of the lower extremities. Rectal examination shows dark stool; test for occult blood is positive. Laboratory studies show: Hemoglobin Leukocyte count Serum Na+ K+ c1- Hco - 3 Urea nitrogen Glucose Creatinine Urine protein 5 g/dL 9000/mm3 140 mEq/L 4 mEq/L 105 mEq/L 25 mEq/L 28 mg/dL 120 mg/dL 1.2 mg/dL 1+ An x-ray of the chest shows a mildly enlarged cardiac silhouette with pulmonary vascular congestion. An ECG shows nonspecific ST-segment changes. Echocardiography shows trace mitral regurgitation and an ejection fraction of 70%; there are no wall motion abnormalities. Which of the following is the most likely cause of these findings? A) High-output heart failure B) Left ventricular diastolic dysfunction C) Left ventricular systolic dysfunction D) Nephrotic syndrome E) Valvular heart disease

LV Systolic dysfunction -S3 = high ventricular filling volume!

15 y/o girl with 2 week chest pain under left breast; dad had MI at 38yo; midsystolic click on auscultation; Dx? Tx?

Likely tender breasts from puberty or costochondritis Tx- Reassurance only

A 42 yo woman comes to the physician because of a 3 day history of dizziness and progressive difficulty with balance. She has been supporting herself against walls when she walks. She has not had numbness, weakness or palpitations. She has had nausea and a mild decrease in appetite but is able to drink fluids. There is no history of head trauma. She has mitral valve prolapse. She take no meds. Her sister has multiple sclerosis. Vital signs are normal. The optic disc appear normal and ocular movements are full. Tympanic membranes are dull bilaterally. The light reflex is distorted. There is no exudates on the pharynx. A grade 2/6 systolic murmur is heard best at the lower left sternal border. Muscle strength and deep tendon reflexes are normal. Her gait is unsteady. Which of the following is the most likely diagnosis? A acoustic neuroma (vestibular schwannoma) (wrong) B cerebral infarction C dehydration D endocarditis E labyrinthitis F multiple sclerosis

Labyrinthitis = inflammation of the inner ear. -vertigo -hearing loss -ringing in the ears

Metformin can damage what organs?

Lactic acidosis --> RENAL INJURY!!!

Best position to visualize L-sided pleural effusion?

Lateral decubitus CXR, L-side down -have affected side down!!!

55yo man has elbow pain; airport baggage handler; vague, achy pain at L elbow that radiates to forearm and worsens with activity and at the end of the day; with elbow held in extension, passive flexion of wrist reproduces pain; Dx?

Lateral epicondylitis = tennis elbow -tenderness at elbow, proximal extensor muscles -pain with resisted wrist extension or supination -pain with passive wrist flexion *Usually from overuse of extensor muscles

20yo man got into MVA; bruising over L leg and groin; abrasions, bruises over posterior, L lateral chest wall; 2 large-bore IV catheters and Foley are placed; 30min after arrival, patient reports difficulty breathing and lightheadedness; BP = 80/40, HR = 120; urticarial rash and wheals all over chest and abdomen; Dx?

Latex allergy! -can cause anaphylaxis! -hypotension -tachycardia -bronchoconstriction --> wheezing, dyspena

26yo woman has near-syncopal episode; began feeling dizzy, lightheaded at work at inpatient nursing facility; has had chronic diarrhea with 10-12 watery stools/day; associated with abdominal cramping; stool guaic negative; labs- metabolic alkalosis, hypokalemia; colonoscopy- dark areas of brown mucosal pigmentation in proximal colon; Dx?

Laxative abuse -watery, frequent, voluminous diarrhea (10-20/day) -nocturnal bowel movements -abdominal cramping -hypokalemia --> decreased Cl-HCO3 exchange --> HCO3 builds up --> metabolic alkalosis -melanosis coli = dark spots of colon with pale lymph follicles (look like alligator skin)

57yo man just got back from cruise in Bahamas, has fever, nonproductive cough, SOB for past 2 days; headache, abdominal pain, diarrhea for 1 day; PMH- DM2, 20yr smoking history; PE- bilateral lung crackles; seems confused throughout exam; Na- 124; CXR- bilateral interstitial infiltrates; Dx? Tx?

Legionella *Etiology- contaminated water -travel -hospital Symptoms -fever -nonproductive cough -meningitis -GI- diarrhea, vomiting, cramps -HYPONATREMIA -pulmonary symptoms delayed Tx -fluoroquinolones (cipro) -newer macrolide (azithromycin)

Difference between leukomoid rxn, CML

Leukemoid Rxn -high LAP score -more mature neutrophil precursors (metamyelocytes > myelocytes) -no absolute basophilia CML -low LAP score -less mature neutrophil precursors (metamyelocytes < myelocytes) -absolute basophilia

Systemic glucocorticoid (methylprednisone) SEs?

Leukocytosis (neutrophilia) -mobilization of marginated neutrophils into bloodstream -stimulation of release of immature neutrophils from the bone marrow -inhibition of neutrophil apoptosis

Tx for -limited prostate cancer -metastatic prostate cancer

Limited prostate cancer- orchiectomy, flutamide Metastatic prostate cancer- radiation

A 52-year-old woman with breast cancer is brought to the emergency department 8 hours after the onset of temperatures to 39.4•c (1 03.F), shaking chills, and generalized malaise. She has been receiving chemotherapy via an indwelling central venous catheter for 2 months; her last treatment was 3 weeks ago. She was treated in the hospital 1 month ago for pneumonia. She had diarrhea 2 days ago. Current medications include prochlorperazine as needed, lorazepam, and sertraline. She appears acutely ill. Her temperature is 39ZC (1 02SF), pulse is 120/min, respirations are 24/min, and blood pressure is 90/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Examination shows no erythema surrounding the catheter site. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard best at the upper left sternal border without radiation. Laboratory studies show: Leukocyte count 3200/mm3 Segmented neutrophils 70% Bands 10% Lymphocytes 12% Monocytes 8% Urine RBC WBC Bacteria 2/hpf 2/hpf occasional An x-ray of the chest shows no abnormalities. In addition to ceftazidime, empiric antibiotic therapy for this patient should include which of the following medications? A) lmipenem B) Levofloxacin C) Metronidazole D) Nafcillin E) Vancomycin

Levofloxacin- covers Pseudomonas! -for nosocomial infections

43yo woman has had high BP on multiple visits to doctor (150/90); no risk factors- exercises and eats healthy; Next step? -24hr cortisol collection -lipid panel + UA -plasma renin level -renal US -TSH

Lipid panel + UA (look for hematuria, urine to serum Cr ratio) + CMP + Baseline EKG *Most HTN = essential HTN -initial evaluation should look for primary causes *Secondary causes = RAS, Conn syndrome, etc

52yo man has decreased libido, inability to achieve erections in past 3mo; drinks alcohol but doesn't smoke; bilateral gynecomastia; Total T3 decreased but TSH normal; Dx?

Liver cirrhosis -Hypogonadism -Decreased thyroglobulin --> decreased TOTAL T3/4, but increased FREE T3/4

Pes anserinus syndrome

Localized pain over anteriorlateral tibia Causes -Overuse -Trauma -Abnormal gait -Valgus stress test negative --> no MCL involvement *NORMAL X-RAY!!!

Empyema treatment?

Long course of Abx DRAINAGE via chest tube!

What measure has been shown to increase long-term survival in COPD patients?

Long-term supplemental O2!!!

54yo man has 2 days fever, chills, dysphagia, drooling; unable to eat anything because of pain in mouth and neck; history of heavy alcohol use; PT appears toxic with drooling and muffled voice; tongue displaced posteriorly, superiorly because swollen area on floor of mouth; submandibular area tender, indurated, nonfluctuant with palpable crepitus;

Ludwig angina = cellulitis of submandibular space *Typically caused by dental infections in mandibular molars -polymicrobial -S. viridans -Anaerobes

Dermatomyositis associated with what cancers?

Lung Pancreas Cervical

A 40-year-old man with alcoholism has had a low-grade fever, malaise, and cough productive of purulent sputum for 2 weeks and hemoptysis for 24 hours; during this period, he has had a 4-kg (9-lb) weight loss. His temperature is 37.8°C (100°F). Hematocrit is 33%, and leukocyte count is 15,000/mm3. An x-ray of the chest shows a large cavitary lesion with an air-fluid level in the superior segment of the right lower lobe of the lung. Which of the following is the most likely diagnosis? A) Aspergilloma B) Bronchiectasis C) Lung abscess D) Lung cancer E) Tuberculosis

Lung abscess

a1-antitrypsin deficiency affects what organs/

Lungs- COPD Liver- HCC, neonatal hepatitis Skin- panniculitis

72yo Caucasian man has severe fatigue; SOB with exertion, decreased appetite; cervical, inguinal, supraclavicular lymphadenopathy, II/III systolic murmur along L sternal border, hepatosplenomegaly, Hb = 7.1; Dx?

Lymphoproliferative disorder -valvular, hemolytic disorder wouldn't have lymphadenopathy!!

45yo man with HIV has 3wks of fever, 10lb weight loss; splenomegaly, elevated alk phos; Dx? Prophylaxis?

MAC *Prophylax with azithromycin!

36yo man with Hodgkin's lymphoma has 4+ proteinuria; what kind of nephrotic syndrome does he have?

MCD!!! -also associated with lymphomas!!

Malaria prophylaxis for traveler to India?

MEFLOQUINE >2weeks BEFORE AND until 4 weeks AFTER RETURN!! *Lots of resistance to chloroquine

MEN 2A MEN 2B

MEN 2A -Parathyroid -Pheo -Medullary thyroid cancer --> elevated calcitonin MEN 2B -Parathyroid -Pheo -Mucosal neuromas

MEN1 MEN2A MEN2B

MEN1 -pituitary tumor -parathyroid tumor -pheochromocytoma MEN2A -Medullary thyroid cancer (calcitonin) -pheochromocytoma -Parathyroid hyperplasia MEN2B -Medullary thyroid cancer (calcitonin) -pheochromocytoma -Mucosal neuromas (neuromas on lips, tongue) *MARFANOID HABITUS!!!

Hereditary spherocytosis labs -MHCH -Coombs -Osmotic fragility

MHCH- HIGH -Coombs- negative -Osmotic fragility- HIGH

60yo man undergoes lung biopsy for restrictive lung disease; 2hrs after procedure, develops severe SOB, chest pain; PMH- HTN, HLD, pernicious anemia; BP = 70/40, RR = 30, HR = 114; elevated pulmonary capillary wedge pressure; Dx?

MI --> low cardiac index --> low BP, high HR --> cardiogenic shock!

Dressler syndrome

MI complication that occurs several weeks after MI -FIBRINOUS PERICARDITIS -fever -pleuritic pain -pleural effusion

PAD increases risk of developing what complications in next 5yrs?

MI- 20% AAA- 10%

37yo woman has L-sided weakness that started 2 hours ago; in past 6mo, has had progressive exertional dyspnea, nocturnal cough, occasional hemoptysis; frequent episodes of palpitations and irregular heartbeat; emigrated from Cambodia 5yrs ago; Dx?

MITRAL STENOSIS!!! *Likely developed rheumatic fever in foreign country -Dyspnea -Orthopnea -PND -Hemoptysis -Atrial fibrillation -Systemic thromboemboli -Ortner syndrome = Voice hoarseness from laryngeal compression due to LAE

22yo man with 2 weeks of fever, malaise, sore throat, white exudate on tonsils, palpable lymph nodes posterior to sternocleidomastoid muscle; returned from Honduras on a volunteer trip; grade 1/IV systolic murmur in L infraclavicular region; elevated LFTs; Dx?

MONO! -Prolonged fever -sore throat -malaise -jaundice -AUTOIMMUNE hemolytic anemia and thrombocytopenia!!!

24yo F has had migraines for past 6-7yrs; in past month, has had daily bifrontal headaches that induce N/V, also has occasional blurry vision; no focal neuro signs on exam; Next step?

MRI brain Indications for early imaging 1. Neuro signs -seizure -changes in consciousness -focal deficits 2. Differences from prior headaches -change in intensity, frequency, characteristics 3. Other -new onset at >4oyo -sudden onset -trauma -present on awakening

Prophylaxis for Lyme disease

MUST MEET ALL 5!!! 1. Attached tick = adult or nymphal Ixodes 2. Tick attached for >36hrs or engorged 3. Prophylaxis started within 72hrs of tick removal 4. New England area 5. No contraindications to doxycycline (pregnant, lactating, <8yo)

Hydroxyurea SEs?

Macrocytic anemia

Torsades Tx?

Magnesium sulfate

Cause of pityriasis versicolor

Malassezia furfur Malassezia globosa (NOT JUST ONE SPECIES!!!)

46yo man has bloody emesis; alcoholic; US- enlarged, hyperechoic liver and gallstones in gallbladder; endoscopy- mild esophagitis, gastritis; ALT = 104; AST = 45; endoscopy showed nothing; Dx?

Mallory-Weiss tear! -ALT = 2x AST --> alcohol -hiatal hernia association

75yo patient had surgery for strangulated hernia; on 3rd day of hospital stay, tries to get out of bed but falls; afterward, is responsive but confused; BP = 85/40; P =122, RR = 24; decreased bibasilar lung sounds, distended neck veins; EKG- new onset RBBB with nonspecific ST, T-wave elevations; soon after, pupils start to dilate; pulse drops to 45, becomes unresponsive; Mechanism of events?

Massive PE -defined by 1. RH failure 2. Hypotension *RH strain --> RV dysfunction, decreased return to LH, decreased CO --> LH pump failure --> bradycardia --> cardiogenic shock --> CNS effects (pupil dilation, unresponsive MS)

53yo woman collapsed suddenly while standing, lost consciousness for 3min; weak, dyspneic, reports L-sided chest pain; recently diagnosed with colon cancer; BP = 80/50, HR = 120 and regular, O2 saturation = 80% on room air; jugular venous pressure = 13mmH2O; Dx?

Massive PE!!! (cancer = hypercoagulable state) -Syncope -Hemodynamic collapse -Increased S2 sound -Increased JVP -RV dysfunction (because can't pump with clog upstream)

56yo woman has hypercalcemia (11.4) on routine testing, no symptoms; smokes 1ppd for 30yrs; last check was 10.4; Next step? Dx?

Measure PTH levels (NOT PTHrH!!!) *Likely Primary hyperparathyroidism -Mild, asymptomatic hypercalcemia

56yo woman has high calcium (11.3), 30yr smoking history; Next step?

Measure PTH!! -If suppressed, then do PTHrP

65yo man has 1yr history of erectile dysfunction, decreased libido, minimal gynecomastia without galactorrhea; decreased testicular size; LH, FSH low; testosterone low; Next step?

Measure prolactin level!! -Could be prolactinoma --> suppresses LH, FSH --> decreased testosterone

31yo woman has 3wk history of periorbital edema, abdominal distension, 4+ proteinuria; started on salt + protein restriction and diuretics; then develops severe R-sided abdominal pain, fever, gross hematuria; Dx?

Membranous glomeropathy --> high chance of developing RENAL VEIN THROMBOSIS!!!

Who benefits from AAA screening?

Men 65-75yo who have smoked!

74yo man with advanced colon cancer has appetite loss; lost 50lbs; no nausea/vomiting; Best treatment?

Megestrol acetate = progesterone analog *Cannabis hasn't been proven to help in cancer cachexia; helps in HIV cachexia

74 yo has MI; admitted to hospital to ICU. BP decreased from 148/74 to 80/62. Confused and has cool clammy skin. ABG will show what? A. Hypoxemia with normal PH B. Met acidosis C. met alk D. Resp Acidosis E. Resp alkalosis

Metabolic acidosis MI --> lactic acidosis buildup --> metabolic acidosis

58yo man has witnessed tonic-clonic seizure; headaches for past few weeks; 45ppd smoking history; MRI- multiple discrete, circumscribed lesions at junction of gray-white matter with surrounding edema; HIV testing negative; Dx? -glioblastoma -MS -metastatic lung cancer -primary CNS lymphoma

Metastatic lung cancer *Mostly seen in lung > breast >unknown primary > melanoma > colon *Multiple well-circumscribed lesions with vasogenic edema at gray-white junction *Solitary brain mets -breast -colon -RCC *Multiple brain mets -lung -melanoma *MS- inflammatory, not well-circumscribed lesions

32yo woman has weakness, progressive SOB over past few weeks; smoked 1ppd for 17 yrs; uses methanphetamine; BP = 88/60, HR = 105 regular, RR = 22/min; PMI palpated in L anterior axillary line, extra low-pitched sound in early diastole, best heard when stethoscope bell placed on apex; legs cool, pulses diminished, 1+ bilateral pitting edema; Dx? Tx?

Methamphetamine --> cardiomyopathy *here, decompensated heart failure Tx- dobutamine = b-agonist -decreases LV end-diastolic volume

Methimazole SE? PTU SE?

Methimazole- agranulocytosis PTU- liver failure

24yo man has asthma; uses inhaler 2x/week, nighttime awakenings 3-4x/mo; Classification? Tx?

Mild persistent Tx- inhaled corticosteroid

65yo woman has 2wk history of constipation, abdominal pain, urinary frequency, constant thirst; PMH- atrial fibrillation, HTN, hypothyroidism; meds- dilitiazem, rivaroxaban, hydrochlorothiazide, levothyroxine, started OTC med; mucous membranes dry; Dx? Mechanism?

Milk-alkali syndrome -nausea, vomiting -constipation -polyuria -polydipsia -neuropsychiatric symptoms Mechanism -increased intake of Ca, absorbable alkali --> renal vasoconstriction, decreased GFR --> renal loss of Na, water, HCO3 reabsorption Tx -discontinuation of agent -isotonic saline, then furosemide

Type of murmur with endocarditis?

Mitral REGURGITATION!! -Mitral stenosis = rheumatic fever!!

62yo woman has dry cough, dyspnea on exertion, syncope, holosystolic murmur at apex; Dx?

Mitral regurg -has cough because of pulmonary congestion + edema

Aortic dissection treatment?

Morphine b-blockers --> get systolic 100-120 Start NO if BP still elevated

38yo woman has occasional palpitations; fast and irregular heartbeat; apical impulse deviated to L; 3rd heart sound heard at apex; holosystolic murmur loudest at apex, radiates to axilla; Dx? Pathophys?

Mitral valve prolapse *Myxematous degeneration of mitral valve

45yo man has 2mo history of nonpruritic, nonblanching purpura on both legs, fatigue, fleeting joint pain in elbows + knees, weakness Plts- nl WBC- 3000 Cr- 1.9 AST- 78 ALT- 98 C3 complement- low C4 complement- very low Rheumatoid factor- positive UA- 3+ protein, 3+ blood Dx? Next step?

Mixed cryoglobulinemia = immune deposition in small/medium-sized vessels --> endothelial damage --> END ORGAN DAMAGE -fatigue -nonblanching palpable purpura -arthralgias -RENAL DISEASE *Associated with -HCV -SLE Next step = HepC test! *NOT Henoch-Scholein purpura

Palpable purpura Proteinuruia Hematuria Dx?

Mixed essential cryoglobulinemia

pH = 7.23 PaCO2 = 40 PaO2 = 88 Serum HCO3- = 16 What kind of acid-base disorder?

Mixed metabolic and respiratory acidosis! *If compensated, (PaCO2 = 1.5HCO3 + 8 +/- 2), CO2 would be 30-34. But it isn't compensated, suggesting another primary respiratory acidosis process taking place

Aspirin toxicity causes what metabolic disorder?

Mixed respiratory alkalosis + metabolic acidosis

42yo man comes in for regular physical; everything normal except AST = 244, ALT = 154; Next step?

More questions about drug, alcohol use!! *AST/ALT can be elevated from -alcohol -drugs (NSAIDS, Abx, statins, antiepileptic drugs, INH = isoniazid, herbal preps) -viruses *If persistently elevated, then can do viral panel -HepB/C -hemochromatosis -fatty liver *Then search for muscle disorders and thyroid disorders -polymyositis

23yo woman has pain localized to R forefoot; runs 3x/week, hikes occasionally; clicking sensation when squeezing metatarsal joints together; Dx?

Morton's neuroma = mechanically induced neuropathic degeneration of interdigital nerves that causes numbness, aching, burning in distal forefoot from metatarsal heads to 3rd/4th toes

What cancer is amyloid nephropathy associated with?

Multiple myeloma!

66yo man has several weeks of constipation, back pain for 2 mo, takes lisinopril for HTN, ibuprofen for back pain; mucosal pallor, anicteric; high BUN, high Cr; slightly elevated Ca; Dx?

Multiple myeloma!!! *CRAB -HyperCalcemia -Renal involvement -Anemia -Bone lytic lesions/Back pain

Tiotropium = what kind of drug?

Muscarinic ANTAGONIST!!!

Trihexyphenidyl = what kind of drug? SEs?

Muscarinic anti-Parkinson's drug SE- anticholinergic -blind as a bat, mad as a hatter, red as a beet, etc

19yo man has 1week persistent dry cough, sore throat, fatigue, malaise; yesterday, noticed rash on arms and legs; fever T = 100F; mild pharyngeal erythema; CXR- increased interstitial markings, small R-sided pleural effusion; Dx?

Mycoplasma!! = atypical pneumonia!!! *Mono wouldn't have CXR changes!!

Polymyositis associations?

Myocarditis Malignancy Interstitial lung disease

Why should ppl with kidney stones decrease Na intake?

Na intake increases Ca excretion!!

How does sodium bicarb work relieving TCA OD?

Na load decreases depressant action on myocardial Na channels -arrhythmia caused by Na channel inhibition

Felty syndrome

RA Splenomegaly Neutropenia

Pulmonary embolism -R atrial pressure -Pulmonary artery pressure -Pulmonary capillary wedge pressure

RA pressure- high Pulmonary artery pressure- high Pulmonary capillary wedge pressure- normal

previously healthy 27-year-old woman comes to the physician because of swelling of her face and legs for 2 weeks. As the day progresses, her facial swelling resolves, but her legs become increasingly swollen. Her pulse is 64/min and regular, and blood pressure is 110/70 mm Hg. Cardiopulmonary examination shows no abnormalities. There is 1+ presacral edema and 2+ edema of the lower extremities. Her prothrombin time is 12 seconds (INR=1.1), and serum albumin concentration is 2.3 g/dL. Which of the following is the most likely cause of this patient's edema? A. Cellulitis G. Malnutrition B. Cirrhosis H. Nephrotic syndrome C. Congestive heart failure I. Postphlebitic syndrome D. Deep venous thrombosis J. Pulmonary hypertension E. Lymphangitis K. Stasis dermatitis F. Lymphedema L. Varicose veins

Nephrotic

Pathophys of hyponatremia in heart failure?

RAAS system + increased ADH secretion

Topical capsaicin use?

Neuropathic pain

When to use tetanus IgG?

Never had vaccines before, or very serious infection

24yo male has testicular mass likely to be testicular cancer; Next step

RADICAL ORCHIECTOMY!!! -no need to biopsy, etc!

If have R ventricular MI and accidentally give nitro, next step?

Nitro reduces preload --> NEED TO GIVE MORE PRELOAD --> GIVE NORMAL SALINE BOLUS!!! *If doesn't work, give dobutamine/dopamine (inotropes)

If patient brain dead, what more steps need to be taken to remove mechanical ventilator?

No more steps necessary! *don't need family permission if brain dead

23yo woman has nasal breathing, stuffy nose, occasional dry mouth for over 1yr; symptoms fluctuate in intensity without any pattern; tried loratadine without improvement; nasal mucosa boggy + erythematous; Dx? Next step in management?

Nonallergic rhinitis -nasal congestion -rhinorrhea -sneezing -later onset (>20yo) -no obvious allergic trigger -erythematous nasal mucosa Next step- topical intranasal glucocorticoids

Henoch-Scholein purpura triad

Nonblanching palpable purpura Arthalgias GI- abdominal pain *NO COMPLEMENT ABNORMALITIES!!! *Skin form of IgA nephropathy! -IgA immune complex deposition

b-thalassemia treatment?

None- resassure with no specific treatment needed

Cancer with high b-hCG, AFP, large anterior mediastinal mass?

Nonseminiferous germ cell tumor

55yo M was in MVA; requires ex lap for suspected bowel perforation; 2 days after surgery, remains hypotensive, requires aggressive vasopressors and IVF to maintain BP; fingertips on all fingers of R hand are blue and cold; Dx?

Norepinephrine-induced vasospasm -NE = levophed = used as vasoconstrictor to keep pressures up -can cause ischemia, necrosis of distal fingers and toes

Hereditary spherocytosis labs

Normocytic anemia MCH- high Serum lactate dehydrogenase- high (1000) Retics- high (12%)

PCOS treatment?

OCPs Weight loss

Loop diuretic SEs?

OH DANG Ototoxicity Hypokalemia Dehydration Allergy (sulfa) Nephritis (interstitial) Gout

35yo homeless man found obtunded on the street; T = 93F, BP = 90/60, RR = 5, HR = 95, 87% on room air; dry oral mucosa, extremities cold to touch, unresponsive to verbal or noxious stimuli, pupils 3mm (normal), decreased bowel sounds; large IV bore placed, given IV fluids, glucose, thiamine; Dx? Next step?

OPIOID INTOXICATION!!! -Next step = NALOXONE!! *Doesn't need miosis because could have mixed in other drugs like meth! *Not hypothermia because more strongly points to opioid intoxication (very low RR, decreased bowel sounds)

Systolic-diastolic abdominal bruit indicates what?

RENAL ARTERY STENOSIS!! *NOT AAA --> pulsatile mass!!

Carpal tunnel risk factors

Obesity Pregnancy DM Hypothyroid RA

22yo woman bitten by neighbor's dog; dog not vaccinated for rabies but is healthy; Next steps?

Observe dog for 10 days No immediate prophylaxis for patient *Only need immediate prophylaxis for high-risk animals -wild raccoons, bats, skunks, BATS

Asbestos exposure occupations Asbestos exposure fields

Occupations -plumbers -electricians -carpenters -pipe fitters -insulation workers Fields -Construction -Shipbuilding -Plastic/rubber manufacturing

Immediately after undergoing an upper gastrointestinal endoscopy and dilatation for achalasia, a 32-year-old woman has moderate substernal and midback pain. She has no history of serious illness. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 22/min, and blood pressure is 110/80 mm Hg. The lungs are clear to auscultation. The abdomen is soft and nondistended. Esophagography shows a small leak of contrast from the distal esophagus into the left chest. In addition to intravenous antibiotic therapy, which of the following is the most appropriate next step in management? A. Placement of an intraluminal esophageal stent B. Placement of a left chest tube C. Nissen fundoplication D. Esophagogastrectomy E. Operative repair of the esophageal injury

Operative repair of esophageal injury -surgical repair for esophageal perforation!!

32yo man with known IV drug use history has R arm pain, swelling, redness; given IV clindamycin; WBCs go down; next day, complains of vomiting, diarrhea, myalgias, abdominal cramps; Dx? Next step?

Opioid withdrawal!!! --> start methadone! *Not C. diff (no myalgias, and his WBC went down)

Asplenectomy causes risk of encapsulated organisms via what pathway?

Opsonization = Ab-mediated phagocytosis!

25yo man with early syphilis (painless chancre) who had severe penicillin allergy should be treated with what?

Oral doxycycline x 14days! *Can't just desensitize them and give penicillin because severe allergy!

Thyroid storm symptoms

Palpitations High fever Tachycardia HTN CHF A. fib JAUNDICE + ELEVATED LFTS Nausea Vomiting Diarrhea

27yo man has unremitting nosebleed; happened last year too; several ruby-colored papules on lips that blanch with pressure; digital clubbing present; Hct = 60%, WBC + Plts normal; Dx?

Osler-Weber-Rendu = hereditary telangiectasias -diffuse telangiectasias -recurrent epistaxis -widespread AVMs (in lung, shunt blood from R --> L heart --> chronic hypoxemia, reactive polycythemia) -GI bleeding -hematuria

52yo woman has L knee pain for 6mo; BMI = 52, 304lbs, joint aspiration shows -WBC- 1000 -Straw-colored fluid (90% neutrophils) XR of L knee shows -narrowing of medial joint space -subchondral bone sclerosis Dx? What could have been done to avoid this?

Osteoarthritis *Weight loss!

78yo man has 6mo history of progressive bilateral buttock pain that radiates to thigh, leg; worse with ambulation but improves with leaning on a cane or sitting; history of CAD with 3-vessel CABG, DM2, HTN, hypercholesterolemia; straight leg raise doesn't reproduce pain; ankle-brachial index normal in both legs; Dx?

Osteoarthritis of leg --> lumbar spinal stenosis -neurogenic origin -worsens if going downhill -improves if lean forward *If vascular, would have decreased pulses, cool extremities

64yo man has increasing pain in R groin for past few months; increases with activity, relieved with rest; sometimes radiates to upper thigh; history of lumbar disc herniation but no pain currently; BMI = 34, PMH- HTN, DM2, obesity; pain with passive internal rotation of hip; Dx?

Osteoarthritis! -worse with activity -reduced range of motion ->40yo Risk factors -old age -obesity -DM

Rheumatoid arthritis in women gives them bigger risk of what other bone issue?

Osteoporosis Osteopenia Bone fractures

Malignancies associated with dermatomyositis?

Ovarian Lung Pancreatic Stomach Colorectal Non-Hodgkin's lymphoma

58yo man with skin discoloration, anorexia, unintentional weight loss of 13.2lb over past 3mo, dark urine, pale stools; scleral icterus; enlarged, nontender gallbladder palpated 3cm below R costal margin; Dx? -clot in portal vein -gallstone obstructing cystic duct -intra and extra-hepatic biliary duct dilatation -intrahepatic biliary cyst -pancreatic calcifications

PANCREATIC CANCER --> intra + extra-hepatic biliary duct dilation -painless jaundice (pruritis, pale stools, dark urine) -intra + extra-hepatic biliary duct dilation -nontender, distended gallbladder = Courvoisier sign

56yo woman has SOB that started 2hrs ago while she was watching TV; sharp, L-sided chest pain that worsens with cough, in acute distress, diaphoretic, BP = 110/60, O2 = 86%, BMI = 38, pulse 140 + irregular; EKG- irregular R-R intervals + no P-waves, narrow QRS; Most likely cause of her symptoms?

PE!!! -acute-onset dyspnea -pleuritic chest pain -tachypnea -tachycardia -low-grade fever -CXR- Hampton's hump = dome-shaped, pleural opacification from PE + lung infarction -Westermark sign = dilation of pulmonary arteries proximal to lesion + collapse of distal vasculature --> creates appearance of sharp cut on CXR -atrial fibrillation (from RH strain from increased RA pressure)

38yo white male from Eastern Europe comes in with 2mo history of exertional SOB, easy fatigability; started taking INH for TB 5mo ago; also became a vegan 5mo ago; has glossitis, conjunctival pallor, areas of pigmentation suggestive of vitiligo; macrocytic anemia; Dx?

PERNICIOUS ANEMIA!!! --> B12 deficiency!! *Common in whites from Eastern Europe -associated with other autoimmune conditions like vitiligo, thyroid disease *NOT DIETARY because would take 4-5years to deplete B12 stores (folate takes 3mo)

PIP (peri-infarction pericarditis) vs. Dressler syndrome?

PIP -local inflammation from infarction -<4 days after MI Dressler -autoimmune -weeks after MI *Both result in pericarditis

Tx for TTP?

PLASMA EXCHANGE -replenishes ADAMTS13 -Removes antibodies *NOT WHOLE BLOOD TRANSFUSION!

54yo man has SOB, cough; breath sounds increased during expiration, esp over R lung base; Dx?

PNEUMONIA!!! *Breath sounds increased during respiration! -different from wheezing!!

51yo gets ARDS; being positively ventilated with PEEP; FiO2 = 60%, PEEP = 15cm H2O; all of a sudden, pulse goes 100 --> 140, SBP goes 120 --> 90, central venous pressure goes 10 --> 15 cm H2O; breath sounds no longer present on L side; Dx?

PNEUMOTHORAX = complication of PEEP -ruptures parenchyma *Mechanism- tension pneumothorax compresses mediastinum --> impairs RV filling --> hypotension, tachycardia, central veins lose ability to stretch (increased venous pressure) Other complications -hypotension -pneumothorax -alveolar damage *If had been caused by endotracheal tube slipping into R main stem bronchus, wouldn't compress mediastinum --> wouldn't have such severe vital sign changes

43yo woman has abdominal pain, dark urine, RUQ tenderness without guarding; Hb- 8.9, plts- 134,000, total bili- 6.3; MRI shows hepatic vein thrombosis; Dx? Tx?

PNH = paroxysmal nocturnal hematuria -Coombs (-) hemolysis --> fatigue -pancytopenias --> impaired hematopoisis -venous thromboses (intra-abdominal, cerebral veins) *BOTH INTRAVASCULAR and EXTRAVASCULAR HEMOLYSIS!!! Tx- eculizumab

35yo man has 3 weeks of hacking, nonproductive cough that occurs more frequently at night; had URI 4 weeks ago that resolved, except for cough; Dx? Next best diagnostic test?

POST-NASAL DRIP!!! -upper airway cough -after URI -at nighttime -nonproductive Tx- Oral antihistamines

Polymyositis treatment?

PREDNISONE!!!

Antiphospholipid syndrome effect on PTT?

PROLONGED! -Lupus anticoagulant increases PTT in vitro -Don't know how it causes coagulation

34yo patient has hyperthyroidism, in acute atrial fibrillation with RVR; Next step?

PROPRANOLOL!! -used for all heart-related symptoms of hyperthyroidism -also used in a. fib in general *Adenosine only for SVT (=/= a fib); not for a fib because short duration of action and pro-arrhythmic

68yo man has 2-day history of R ankle swelling; at first, just pain with dorsiflexion, now has pain with plantarflexion; PE- warmth, swelling, tenderness over dorsum of foot; XR- soft tissue swelling, small tibiotalar joint effusion, chronic calcification of articular cartilage; Dx?

PSEUDOGOUT!!! - >65yo -monoarticular arthritis -chondrocalcinosis = calcification of articular cartilage

Difference between PTH, PTHrP?

PTH converts 25-VitD --> 1, 25 VitD PTHrP doesn't do that!!!

50yo woman has R shoulder pain that radiates to her hand; has history of RA; cough for several months, fatigue; 25year smoking history; R pupil constricted, drooping of eyelid; ESR = 55, CRP = 30; Dx? Next step?

Pancoast tumor -shoulder pain (most common) -Horner syndrome -C8-T2 neuro involvement -weakness of intrinsic hand muscles -pain/paresthesias in 4th, 5th fingers, medial arm, forearm -supraclavicular lymph node involvement -weight loss Next step- XR of chest

53yo man was in MVA; unrestrained driver, DUI; bilateral chest pain, L leg pain; sustained traumatic fracture of L femur; diffuse chest tenderness; reports increasing SOB, O2 saturation of 90% on 2L O2; CXR- alveolar opacities in R + L lower lobes; pO2 = 75; Dx?

PULMONARY CONTUSION!!! -<24hrs after blunt chest trauma -tachypnea -tachycardia -hypoxia -rales/decreased breath sounds -CT/CXR with patchy, alveolar infiltrates not restricted by anatomical borders Pathophys -intraalveolar hemorrhage, edema -25-35% of blunt thoracic trauma!

Origin of rhythm for atrial fibrillation?

PULMONARY VEINS!!!

Patient found to have DM nephropathy; Next step?

PUT ON ACE/ARB!! --> intensive BP control *Protein restriction has had conflicting results!!!

Osteitis deformans aka ...?

Paget's disease of bone -increased bone turnover from osteoclast activity -lamellar bone replaced with abnormal woven bone

Morton neuroma

Pain between 3rd, 4th toes on plantar surface -clicking sensation when palpating this space and squeezing metatarsal joints

Plantar fasciitis features

Pain in heel, bottom of foot *No inflammatory features

Tarsal tunnel syndrome symptoms?

Pain, numbness over bottom of foot, esp near toes *Compression of tibial nerve at ankle

Acute intermittent porphyria

Painful abdomen Port-wine urine Polyneuropathies Psych disturbances Precipitated by drugs (P450 inducers), alcohol, starvation

48 year old man with upper abdominal pain, n/v X 2 days. Productive cough for 3 mo. Alcoholic and drinks a 12 pack daily. Smoked 2ppd X30 years/ Temp is 101, pulse 120, resp 16, bp 90/55. Coarse breath sounds are head on auscultation. CV exam is normal. Tenderness with voluntary guarding in the LUQ, - bowel sounds. +occult blood in stool. Calcium is 7.6, and serum albumin is 3.5... Diagnosis? - addisons - hyperPTH - hypoalbumin - hypomag -hypoPTH - lithium carbonate tox - massive cell lysis - metastatic malignancy - milk alkali - pancreatitis - rhabdo - sarcoid - TB -vit D def

Pancreatitis!!

63yo woman has "sore throat" for 3mo; smoked 1pack cigarettes/day for 29yrs, still smokes; 1.5cm cervical lymph node; biopsy reveals metastatic squamous cell carcinoma; Next step?

Panendoscopy to find primary tumor! -esophagoscopy -bronchoscopy -laryngoscopy

65yo woman has MI; 3 days later in hospital, has severe shortness of breath, hypotension, diaphoretic, tachypneic; What MI complication does she have?

Papillary muscle rupture!

86yo woman with Alzheimer's and a. fib had to stop her warfarin; becomes somnolent; CT head shows parietal lobe hyperintensity; Dx? Cause?

Parietal lobe hemorrhage --> CEREBRAL AMYLOID ANGIOPATHY *b-amyloid deposition in small-medium sized cerebral arteries -Old ppl >60yo -Alzheimer's *If were caused by a. fib, would show multiple areas of infarct with in gray-white matter junction

27yo woman complaining of joint pain; bilateral pain in MCPs, ICPs, wrists, knees, ankles; joint stiffness 10-15min in morning; associated fatigue, some loose bowels; mild skin itching, patchy redness; tenderness of involved joints without erythema or swelling; Dx?

Parvovirus B19!!! -75% asymptomatic or have flulike illness -acute, symmetric arthralgia/arthritis, usually in hands, wrists, feet (resembles RA) *RA would have -joint SWELLING -morning pain > 1hr -symptoms >6wks

24yo woman has 4week history of joint pain; moderate, achy pain in multiple metacarpophalangeal joints; intermittent fevers since joint pain began; married with 2 young kids; relieved with ibuprofen; Dx?

Parvovirus B19- in adults, -arthalgias, arthritis (RESEMBLES RA) -fevers -transient pure red blood cell aplasia

What conditions is seborrheic dermatitis associated with?

Parkinson's HIV

25yo woman has occasional palpitations; feels like "heart racing inside of chest"; fast and regular heartbeats; cold water on her face helps her relieve these episodes within a few minutes; Dx? Mechanism by which cold water helps?

Paroxysmal supraventricular tachycardia -AVNRT = AV nodal reentrant tachycardia = most common form Symptoms -dizziness -SOB -chest pain -young person with structural disease *Vagal maneuvers (carotid sinus massage, cold water on face, Valsalva, eyeball pressure) help by increasing parasympathetic tone in heart --> temporary slowing of AV node conduction, increase in AV refractory period

A 57-year-old man is brought to the emergency department 30 minutes after a 3-minute episode of unconsciousness. The patient says that the episode began with an impending sense of feeling ill while watching television. He quickly became confused, swayed in his chair, and fell to the floor. He had no bowel or bladder incontinence during this episode. His mental status spontaneously recovered fully within 3 minutes. He has a 10-year history of hypertension well controlled with hydrochlorothiazide. He had a myocardial infarction 4 years ago. He is 183cm tall and weighs 95 kg; BMI is 29 kg/m2. His pulse is 86/min, respirations are 12/min, and blood pressure is 124/86 mmHg. Neurologic and cardiac examinations show normal findings. An ECG shows Q waves in leads II, III, and aVF. Which of the following is the most likely explanation for these findings? A) Hypoglycemia B) Paroxysmal ventricular tachycardia C) Pulmonary embolus D) Seizure E) Transient ischemic attack

Paroxysmal ventricular tachycardia -Prior MI + reduced EF --> ventricular arrhythmia

17yo female has been training for dance competition, has 3mo of progressive, achy knee pain in anterior knee worse with running, sitting for extended period of time, going up/down stairs; feels like knee giving way or buckling; when knee extended, compressing patella into trochlear groove reproduces the pain; mild crepitus with range of motion at R knee; Dx? Tx?

Patellofemoral pain syndrome -chronic overuse/malalignment of knee OR trauma -young female athlete -pain with going up/down stairs Tx -Activity modification -NSAIDs -Stretching, strengthing exercises of quadriceps, knee extensors, hip abductors

24yo woman has knee pain over anterior knee; gradually worsened over past 3mo; sharp, seems worse when she climbs stairs; ibuprofen doesn't relieve the pain; Dx?

Patellofemoral syndrome -young female patients -subacute --> acute pain with squatting, running, prolonged sitting, using stairs

A 37 YRS old male comes to physician because of persistent numbness in his hands and feet for 10 months and weakness in his left wrist for 3 wks. he renovates old houses. during this past year, he has made several visists to the ER because of abdominal pain and was subsequently diagnosed with gastritis. his BP 135/95, mucous membranes are pale. Abdominal examination show no abnormalities. neurological exam show weakness with dorsiflexion of the left wrist and loss of sensation in stocking-glove distribuation bilaterally. his hematocrit is 32% and serum urea nitrogen concentration is 35. A blood smear shows microcytic hypochromic ertyhtorcytes. Early treatment with which of following is most likely to have prevente this patient condition: A) calcium disodium edetate B) Disulfrum C)iron sulfate and vitamic C D) prednisone and cyclophosphamide E) vitamin B1 (thiamine) F) Vitmain B6

Pb poisoning --> Calcium EDTA!!! pain muscle weakness numbness and tingling metallic taste Abdominal pain nausea/vomiting diarrhea constipation

67yo man has 1mo of increasing forgetfulness; gait unsteady, increased fatigue, microcytic anemia, increased constipation; worked as automobile mechanic for 30yrs; smoked 1pack/day; recently started distilling own whisky; PE- weakness in dorsiflexion in wrists and ankles, decreased pinprick sensation in hands and feet, 1+ reflexes; Dx?

Pb poisoning!!! -microcytic anemia -neuropathies -abdominal pain, constipation *Often from distillation of alcohol using parts with LEAD SOLDERING!!! *Not B1 because Wernicke's doesn't have microcytic anemia, hematuria!

Drugs that cause AIN

Penicillins Bactrim (TMP-SMX) Cephalosporins NSAIDs

A 62-year-old man is brought to the emergency department 24 hours after the onset of fever, right-sided abdominal pain, and confusion. He has no history of serious illness. Current medications include daily aspirin. He drinks one glass of wine daily. On arrival, he is oriented to person but not to place or time. He becomes light-headed on sitting up. His temperature is 38.7°C (101.7°F), pulse is 120/min, and blood pressure is 84/50 mm Hg while supine. Abdominal examination shows right lower quadrant tenderness with guarding and rebound; there is a suggestion of a mass. The upper and lower extremities are cool and clammy. Urinalysis shows no abnormalities. Additional laboratory studies show: Arterial blood gas analysis on room air shows: Leukocyte count 25,400/mm3 with a shift to the left Serum Na+ 140 mEq/L K+ 4.5 mEq/L Cl- 103 mEq/L HCO3- 19 mEq/L Urea nitrogen 40 mg/dL Creatinine 1.6 mg/dL pH 7.2 Pco2 34 mm Hg Po2 84 mm Hg Which of the following serum concentrations is most likely to be increased in this patient? A) Acetone B) Alcohol C) Ethylene glycol D) Glucose E) Lactic acid F) Salicylate

Perforated appendix (RLQ mass) --> septic shock --> LACTIC ACIDOSIS!!

28yo woman is IV drug user, feels weak, hasn't eaten much past 2 weeks, feels "dehydrated", oral mucosa dry, dentition poor, early diastolic murmur, 2:1 second degree AV block; Dx?

Perivalvular abscess, secondary to endocarditis --> AV conduction block, syncope *seen in 30-40% endocarditis patients *Tricuspid endocarditis usually tricuspid REGURG --> SYSTOLIC MURMUR

Drugs that cause folate deficiency?

Phenytoin Trimethoprim Methotrexate

46yo man undergoes elective inguinal hernia repair; after anesthesia, becomes very pale and tachycardic; medical history significant for frequent headaches, HTN, anxiety disorder; outpatient meds- lisinopril, alprazolam, naproxen as needed; BP = 250/140 (before induction 144/90); Dx?

Pheochromocytoma! -Frequent headaches -HTN (super high) -Pale -Sinus tachycardia *Catecholamine storm after anesthesia *Don't give nonselective b-blockers before anesthesia -need to 1st give alpha blockers, then b-block!

Circumferential, deep ulceration surrounded by relatively normal mucosa?

Pill-induced esophagitis

32yo man had DVT; now has leg swelling 1 week later; INR = 1.2, says he takes warfarin every day, but he missed last anticoagulation check-in; Next step?

Place him on rivaroxaban = direct X inhibitor --> NEEDS ACUTE BLOOD THINNING!! *Works immediately -equally effective for acute DVT, PE -no lab monitoring

Abdominal succussion splash used to test what? -how is it done?

Place steth over upper abdominal area, rock patient back and forth from hips -if still retaining food >3hrs after meal, makes splash sound --> hollow viscus filled with gas and fluid -Used to test gastric outlet obstruction (pyloric stenosis, etc) -

An asymptomatic 27 year old woman who is HIV positive comes to the physician requesting advice concerning immunization.All her childhood immunizations are upto date.She recieved a MMR vaccination when she was a graduate student 4 years ago.Her last tetanus vaccine was 6 years ago.A test for hep B antibody was positive 3 weeks ago.her CD4 count was 450/mm3 3 weeks ago.examination today shows no abnormalities.Which of the following immunizations is most appropriate to administer to this patient? A.Hep A vaccine B.Hep B vaccine C.MMR vaccine D.Pneumococcal Vaccine E.Tetanus toxiod F.No immunizations are necessary

Pneumococcal + influenza vaccines indicated for -IMMUNOCOMPROMISED -elderly

Difference between pleural effusion, pneumonia consolidation on physical exam?

Pneumonia- INCREASED TACTILE FREMITUS Pleural effusion- DECREASED TACTILE FREMITUS

51yo man with HTN, renal failure, nocturia 2-3x/night for past 10yrs; liver enlarged, mass felt at R flank; BP = 164/100; Dx?

Polycystic kidney disease -HTN -palpable kidneys on exam

48. A 67-year-old man comes to the physician because of pain of the fingertips for 1 month. Examination shows plethora and splenomegaly. Laboratory studies show: Hemoglobin 20.2 g/dL Leukocyte count 14,500/mm3 with a normal differential Platelet count 400,000/mm3 Arterial blood gas analysis on room air shows: Po2 92 mmHg O2 saturation 94% Which of the following is the most appropriate next step in management? A) Administration of chlorambucil B) Administration of heparin C) Thrombopheresis D) Phlebotomy E) Splenectomy

Polycythemia vera! --> phlebotomy!

70yo man has pain and stiffness in neck, shoulders, hips for last 3mo; stiffness worse in morning, lasts 1-2 hrs; recent weight loss of 7lbs; Hct- 31% Plts- 450,000 ESR- 85 TSH- 1.8 (nl) CK- 33 (nl) Dx?

Polymyalgia rheumatica - >50yo -bilateral pain, morning stiffness for over 1mo -involvement of at least 2 -neck, torso -shoulders, proximal arms -proximal thigh, hip -constitutional (fever, malaise) -decreased ROM in shoulders, neck, hips -high ESR -high CRP -normocytic anemia possible *ASSOCIATED WITH GIANT CELL ARTERITIS!!! Tx- glucocorticoids

52yo obese woman has intermittent, colicky pain in RUQ of abdomen; had gallbladder removed 1 year ago for gallstones; Total bili- 2.1 Direct bili- 1.2 Alk phos- 185 Ultrasound- mild dilatation of common bile duct; pancreas visualized, appears normal Dx? Next step?

Postcholecystectomy syndrome -abdominal pain after cholecystectomy Causes 1. Biliary -Retained common bile duct -Cystic duct stone -Biliary dyskinesia 2. Extra-biliary -Pancreatitis -PUD -CAD Next step- ERCP

32yo woman has nagging dry cough over 8 weeks; bothers her during the day, awakens her at night; PMH- chronic rhinitis and occasional skin rash; 1 week of chlorpheniramine improves her symptoms; Dx? Mechanism of symptom improvement?

Postnasal drip associated with allergic rhinitis -Antihistamines decrease nasal secretions

47yo man with history of elevated glucose comes in with increased urinary frequency -Glc- 165 -Total cholesterol- 210 -LDL- 140 -TG- 140 -A1C- 7.2% Next step?

Prescribe -Lifestyle modification -Rosuvastatin (for all ppl with DM and increased atherosclerotic disease) -Metformin (he has DM2) *Don't prescribe sulfonylurea at this point!! Too early!

17yo boy comes in with palpitations; has had fluttering in chest before but this time is sustained; EKG shows SVTs; Dx? -Re-entrant AV pathway -Cocaine abuse -dilated cardiomyopathy -hyperthyroidism -hypokalemia -long QT syndrome -rheumatic heart disease

Re-entrant AV pathway --> WPW causes SVT!!!

45yo woman with fatigue, intense generalized pruritis for 4mo, skin excoriations, mild hepatosplenomegaly, xanthomas below eye, ANA positive; Dx?

Primary Biliary Cholangitis *Autoimmune destruction of intrahepatic bile ducts Symptoms -insidious onset of pruritis, fatigue, -Labs- high alk phos, AST/ALT, ANA + -Complications -malabsorption -osteoporosis, osteomalacia (don't know why) -HCC Tx- ursodeoxycholic acid (delays progression)

52yo woman with hepatomegaly, hypothyroid, itching, bilateral xanthelesma, skin excoriations; alk phos = 410; total cholesterol = 503; Dx?

Primary Biliary Cholangitis -Hepatomegaly -Jaundice -Middle-aged women -Hyperlipidemia -XANTHELESMA -autoimmune disorders (THYROID DZ)

42yo woman has depression, mood swings, poor sleep, mild headaches, muscle weakness, kidney stones; Ca = 11.2; BP = 162/100

Primary Hyperparathyroidism 1. Hypercalcemia -Polyuria -Polydipsia 2. Kidney stones 3. Neuro/psych symptoms -confusion -depression -psychosis

Primary vs secondary Raynaud's

Primary Raynaud's -Young patients (15-30yo) -Usually female -SYMMETRIC episode attacks without tissue injury *No underlying disease Tx- CCBs Secondary Raynaud's -Older (>40yo) -Male -ASYMMETRIC attacks with clinical features of tissue ischemia (ulcers, numbness) *AUTOIMMUNE DISEASE (ANA, RF, ESR positive)!

54yo man has 2-day history of fever, chills, perineal pain; has repeated urges to urinate with pain on micturition; T = 100; leukocyte esterase positive; rectal exam- boggy, tender prostate; Dx? Next step?

Prostatitis Next step- get mid-stream urine sample *No foley because may have urethral inflammation

Cause of edema in nephritic syndrome?

Primary glomerular damage --> decreased GFR --> volume overload --> edema *NOT ALBUMIN LOSS (only in NEPHROTIC syndrome)!!!

55yo man had transient loss of vision in 1 eye; diagnosed with HTN 3mo ago, BP = 154/101 currently; on lisinopril, aspirin, low-dose hydrochlorothiazide K: 3.1 Cr: 0.9 Plasma renin activity- undetectable Dx?

Primary hyperaldosteronism! *Causes -adrenal adenoma -bilateral adrenal hyperplasia Symptoms -HTN -mild hypernatremia (don't have edema because of ALDOSTERONE ESCAPE) -hypokalemia (TRIGGERED WITH THIAZIDES) -metabolic alkalosis

40yo man has primary parahyperthyroid; PTH = 114; Ca = 11.2; Phosphorus = 2.2, Cr = 1.2; renal ultrasound shows 2 <5cm stones; Next step?

Primary parahyperthyroid, most likely from -parathyroid adenoma -hyperplasia -carcinoma *PARATHYROIDECTOMY!! because SYMPTOMATIC -renal stones -osteoporosis -nephrocalcinosis -urinary calcium >400

54yo man has ruddy cyanosis (facial plethora), increased Hct, WBC, plts; aquatagenic pruritis (itching after bathing), splenomegaly; How are EPO levels? How is ESR?

Primary polycythemia vera *Mutation in JAK2 --> drives clonal proliferation of all 3 cell lines (EPO activates JAK2 --> EPO LEVELS LOW!!! *If secondary polycythemia vera (chronic hypoxia, EPO-secreting tumors), EPO levels HIGH *ESR LOW because more RBCs compared to fibrinogen (fibrinogen causes sticking) Symptoms -increased blood viscosity -HTN -erythromelalgia -increased RBC turnover --> gouty arthritis -itching after bathing -bleeding Tx -Phlebotomy -Hydroxyurea

42yo man with progressive fatigue, history of ulcerative colitis, no weight loss, LLQ pain, ESR= 102, pANCA +, Dx?

Primary sclerosing cholangitis *Unknown cause of concentric "onion skin" bile duct fibrosis *Middle-aged men with IBD (UC) -UC -pANCA -can lead to secondary biliary cirrhosis -increased risk of cholangiocarcinoma, gallbladder cancer, cholestasis,

D-xylose test for malabsorption -Returns to normal levels after antibiotics (rifaximin = rifamycin) -Doesn't return to normal after antibiotics

Returns to normal after Abx --> Small bowel overgrowth Doesn't return to normal after Abx --> Celiac disease

Most common vein source (90%) for PEs?

Proximal thigh -iliac vein -femoral vein -popliteal vein

Lichen planus features

Pruritic Purple Polygonal Planar Papules Plaques

52yo man has 24hr history of pain and swelling in R knee; for past few months, has also had constipation, excessive urination, fatigue; had kidney stone over a year ago; WBC = 13000; Dx? What would be found on arthrocentesis?

Pseudogout = Calcium pyrophosphate dihydrate crystals! *Symptomatic hypercalciuria -Fatigue -Constipation -Nephrolithiasis Arthrocentesis- rhomboid-shaped crystals

64yo man has burning chest pain; ST elevations in II, III, aVF; given sublingual nitroglycerin; BP = 70/50; pulse = 85/min; Dx? What to do next?

R ventricular MI! --> impaired RV filling --> highly sensitive to intravascular volume depletion --> inadequate RV preload *DON"T GIVE NITRATES!!! Tx- Isotonic saline bolus

Most common cause of infection in febrile neutropenia? Tx?

Pseudomonas Gram (-) organisms Tx- Piperacillin-tazobactam

52yo man has long history of joint swelling; mostly on DIPs, worse in morning, lasts 1hr; also has digit swelling; Dx?

Psoriatic arthritis -DIP --> PENCIL IN CUP DEFORMITY -asymmetric oligoarthritis -symmetric polyarthritis -spondyloarthrhihtidies (sacroillitis, spondylitis) -dactylitis -swelling of hands, feet with pitting edema -PLAQUES WITH SILVERY SCALE ON FINGERS

32yo man had stab injury in R leg, 6mo of progressive weakness and exertional dyspnea; R leg feels warmer than L; carotid upstroke brisk, PMI displaced to L, soft systolic murmur heard over cardiac apex that doesn't change with Valsalva; Dx?

R leg knife injury --> Symptomatic AV fistula of popliteal, iliac artery!!! --> High-output heart failure!

34yo woman just had a long flight 2 days ago, tachypneic RR = 28, 1 episode of hemoptysis, chest pain localized to L side, increases with inspiration; Dx?

Pulmonary infarction *10% of PEs --> pulmonary infarction = occlusion of peripheral pulmonary artery -pleuritic chest pain -hemoptysis

When do we use unsynchronized cardioversion?

Pulseless cardiac arrest with shockable rhythm -v. fibrillation -pulseless ventricular tachycardia *In other circumstances, can lead to v. fibrillation!

45yo man on TB (RIPE) treatments has progressive fatigability, microcytic anemia, high serum Fe, decreased TIBC (total Fe binding capacity); Dx? Tx?

Pyridoxine deficiency (from isoniazid) --> acquired sideroblastic anemia -B6 involved in heme synthesis

What molecule in citric acid cycle does alanine enter as to be used as fuel?

Pyruvate! -Alanine -Lactate -Glucogenic amino acids

A 72-year-old woman comes to the emergency department because of a 1-day history of fever, chills, and cough. She had pneumococcal pneumonia 1 year ago. Her temperature is 39°C (102.2°F). Examination shows bronchial breath sounds at the right lung base with increased dullness and egophony. Her leukocyte count is 87,000/mm3 (15% segmented neutrophils, 82% lymphocytes, and 3% monocytes). A Gram stain of sputum shows gram-positive, lancet-shaped diplococci. Which of the following is most likely to confirm this patient's deficit in host defenses? A) Assessment of segmented neutrophil function B) Measurement of CD4+ T*lymphocyte count C) Measurement of serum IgE concentration D) Measurement of T*lymphocyte count E) Quantitative immunoglobulin assay

Quantitative Ig assay

44yo woman has severe epigastric pain that radiates to her back; sudden onset, persists for several hours; nausea, vomiting, had appendectomy as child; doesn't drink alcohol Amylase- 1200 Lipase- 2000 Next step in diagnosis?

RUQ Ultrasound!! -likely pancreatitis caused by gallstones --> use ultrasound to diagnose!!! (female, fat, 40, fertile) *Don't use CT abdomen because can't see gallstones

Hyperkalemia -rapid treatments for serum? -treatments to protect heart? -removal of K from body?

Rapid treatments for serum 1. Insulin + glucose to rapidly decrease K 2. b-2 adrenergic agonists 3. Sodium bicarb Treatments to protect CARDIAC MEMBRANE 1. Calcium GLUCONATE Removal of K from body (SLOW) 1. Diuretics 2. Cation exchange resins 3. Hemodialysis

Prinzmetal angina associated with what other disorders

Raynaud's migraine headaches *All caused by vasospasm *Intermittent claudication (leg cramping) caused by atherosclerosis!

A 77-year-old woman comes to the physician because of a 1-year history of progressive swelling of the ankles and a 3-month history of shortness of breath with exertion. She has not had chest pain, orthopnea, or paroxysmal dyspnea. She takes hydrochlorothiazide for hypertension, verapamil for paroxysmal atrial tachycardia, and levothyroxine for hypothyroidism. Her blood pressure is 145/72 mmHg, pulse is 78/min and regular, and respirations are 18/min. there is no jugular venous distention. The lungs are clear to auscultation. Examination shows large superficial venous varicosities on the lower extremities and moderate ankle and pedal edema bilaterally. There is loss of hair and mild hyperpigmentation over the legs. Oxygen saturation is 96% at rest and 90% with exertion. An X-ray of the chest and ECG shows no abnormalities. Ventilation-perfusion lung scans show two subsegmental perfusion with defects but no ventilation abnormalities. Echocardiography shows mitral annular calcifications. Which of the following is the most likely explanation for this patient's dyspnea? A Cardiac emboli secondary to intermittent arrhythmia B Coronary ischemia (wrong answer) C Left ventricular diastolic dysfunction D Mitral insufficiency E Recurrent pulmonary emboli

Recurrent PEs!!! -VQ mismatch on VQ scans!!! *No JVP elevation --> not diastolic dysfunction!

Contraindications for -enoxaparin (low molecular weight heparin) -fondaparinux (injection factor Xa inhibitor) -rivaroxaban (DOAC)

Renal insufficiency! -can't use if GFR <30 because decreased clearance from blood --> increased anti-Xa activity --> increased bleeding risk

20yo man has HSV encephalopathy; started on acyclovir and neurological status improves; 2 days later, Cr 0.8 --> 2.2, BUN = 30; Cause? -AIN -Bladder neck obstruction -Glomerular injury -Prerenal azotemia -Renal tubular obstruction

Renal tubular obstruction Crystal-induced AKI -Acyclovir -Sulfonamides -Methotrexate -Ethylene glycol -Protease inhibitors

In Conn syndrome, what are levels of -renin -aldosterone -bicarb

Renin- low Aldosterone- high Bicarb- high (Hypokalemia directly increases bicarb secretion??)

Management of post-ictal lactic acidosis?

Repeat tests in 2hrs, see if it resolves -if doesn't, look for other reasons for AG metabolic acidosis

A 42-year-old man comes for a routine health maintenance examination. There is no family history of coronary artery disease, and he does not smoke. His weight is appropriate for his height. His blood pressure is 120/80 mm Hg. Serum lipid studies show a total cholesterol level of 190 mg/dL, HDL-cholesterol level of 40 mg/dL, and triglyceride level of 150 mg/dL. Which of the following is the most appropriate next step in management? A) Recommend the Step 2 National Cholesterol Education Program diet B) Measure serum LDL-cholesterol level now C) Measure total serum cholesterol level in 5 years D) Prescribe prophylactic aspirin E) Begin treatment with lovastatin

Repeat total serum cholesterol level in 5 years

23yo nurse gets needlestick injury from HBV-positive patient; was vaccinated 5 yrs ago, was found to be HbsAB positive; Next step?

Resassurance --> she's immune to HepB!

44yo Asian immigrant has persistent cough, dyspnea on exertion for 3mo; progressively worsening SOB, can't sleep flat; has had palpitations in past; L main bronchus appears to be elevated; EKG shows irregularly irregular rhythm; Dx? Pathophys?

Rheumatic fever --> mitral stenosis -Gradual, progressively worsening dyspnea on exertion -Orthopnea -Hemoptysis (from pulmonary edema) -L bronchus enlargement (MS --> LA, pulmonary pressure increase --> LA enlargement --> L main bronchus enlargement) ALSO COMPRESSES LARYNGEAL NERVE --> HOARSENESS -70% develop atrial fibrillation

Best imaging for rib fractures?

Rib XRs- NOT CXR! -CXR obscures ribs, could hide fractures

20yo man has jaundice, dark urine, scleral icterus; otherwise asymptomatic; urine positive for bilirubin, negative for urobilinogen; Dx?

Roter's syndrome = impaired hepatic secretion of bilirubin -chronic/fluctuating conjugated hyperbilirubinemia -bilirubin buildup --> overflows into urine

In study, 40% of subjects lost to follow up and weren't included in final analysis; what kind of bias is this?

Selection bias!!!

Mallory-Weiss presentation

Self-limited hematemesis without pneumomediastinum

62yo woman has acute leg pain; BMI = 41, recently started weight loss program; felt pain at R knee when on the treadmill --> developed swelling at R ankle and calf; tenderness and induration at medial head of gastrocnemius; moderate pitting edema of ankle, crescent-shaped patch of ecchymosis at medial malleolus; Dx?

Ruptured popliteal cyst -extrusion of fluid from Baker cyst into gastrocnemius or semimembranous bursa

IVDU drug user who's HIV-positive has cavitary lesions on CT chest; What bug?

S. AUREUS!!! --> IVDU!!

Endocarditis pathogens' associations -S. aureus -S. epidermidis -Viridans streptococci -Enterococci -S. bovis -Fungi (Candida, etc)

S. aureus -prosthetic valves -intravascular catheters -implanted devices (AICDs, pacemakers) -IVDU S. epidermidis -implanted devices -prosthetic valves -intravascular catheters Viridans -Gingival manipulation -Respiratory tract incision or work ENTEROCOCCI -NOSOCOMIAL UTIs!!!! S. bovis -colon cancer -IBD Fungi -Immunocompromised -Intravascular catheters -Prolonged abx courses

What is a Marjolin ulcer?

SCC arising from prior burn or wound

46yo man had surgical treatment of bleeding duodenal ulcers; now mechanically ventilated; T = 103.6F, HR = 110, BP = 90/50, Hct = 35%, Cardiac output 8-9L/min (nl = 4-5L/min); being aggressively resuscitated with IV fluids; most appropriate next step? A. Dexamethasone B. Isoproterenol drip C. Blood transfusions D. Systemic broad-spectrum antibiotics E. Total parenteral nutrition

SEPSIS!! -NEED SYSTEMIC ANTIBIOTICS!! *Already has IV fluids going

PT has suspected infective endocarditis; Next step?

SERIAL BLOOD CULTURES (3 within 1 hr) *SHOULD BE DONE BEFORE GIVING ABX!!!

35yo woman just finished chemo; has abdominal pain; intense pain just when you lightly brush skin; Dx?

SHINGLES!!!

60yo woman has lethargy and confusion over past 2 days; lost 10lbs in last 3mo; smoked 40 years; Na = 117 Serum Osm = 250 Urine Osm = 500 Next step?

SIADH 1. Fluid restrict with or without salt tablets 2. Hypertonic saline! -used in severe SIADH!!

65yo woman has altered mental status; 3 weeks ago, diagnosed with depression, started on sertraline Na- 119 Serum osmolality- 265 mOsm Urine osmolality- 500 mOsm Dx?

SIADH -hypotonic hyponatremia -euvolemic Meds that cause this -SSRIs -NSAIDs -carbamazepine

37yo man with HIV (noncompliant with meds) has fever, nonproductive cough, dyspnea on exertion; Na = 124; euvolemic; gotten >7L since admission; Dx?

SIADH! -Low Na but euvolemic *Causes -PCP -Ongoing NS boluses

30yo woman had 1 incident of seizure 5yrs ago; was put on phenytoin, now stable and on therapeutic dose; wants to get pregnant; How should you proceed?

SLOW TAPER of phenytoin -otherwise could result in seizure from rapid withdrawal

ARDS causes

SPARTAS -Sepsis -Pancreatitis -Amniotic fluid embolism -uRemia -Trauma -Aspiration -Shock

Drugs that cause SIADH?

SSRIs NSAIDs Carbamazepine

30yo woman has intermittent dizziness, unsteadiness for past 2wks; had uveitis 6mo ago that was treated with topical agents; EKG- 2:1 heart block with L bundle branch block; CXR- bilateral opacities in mid-lung fields; Dx?

Sarcoidosis with cardiac involvement -AV block (most common) -restrictive cardiomyopathy -dilated cardiomyopathy -valvular dysfunction -heart failure

Man has lower back pain that radiates to lower leg when leg raised; Dx? Mechanism? Next step?

Sciatica = pinched nerve -can be pinched by bone, muscle, etc Next step- NSAIDs -don't need further workup because most resolve spontaneously

43yo man has nagging L-sided chest pain, increases with inspiration, 3-4wks of productive cough; no recent weight loss, fevers, chills; had Hodgkin's lymphoma treated with chemo and radiation 20yrs ago; CXR shows solid round mass on upper R lobe; Dx? -Aspergillus -TB -Radiation-induced fibrosis -Secondary malignancy -Recurrence of Hodgkin's lymphoma

Secondary malignancy after Hodgkin's lymphoma chemo + radiation -18.5x increased risk of secondary malignancy *most common = lung -also breast, thyroid, GI

28yo with chronic diarrhea, 5-6 nonbloody bowel movements every day, sometimes awaken him at night, has diarrhea even when not eating, lost 4.4lbs; occasional bloating sensations; several years ago, was shot in abdomen, gap between measured and calculated stool osmolality low; Dx?

Secretary diarrhea -larger daily volumes (>1L/day) -diarrhea even during fasting or sleep -SOG <50 Common causes -Infections (vibrio, rotavirus) -CF -Surgical --> SHORT GUT SYNDROME (removal of large part of small intestine) --> DUMPING SYNDROME (diarrhea after removal of stomach)

28yo man has chronic diarrhea, lost 4.4lbs; 5-6 nonbloody liquid BMs daily; has diarrhea even when not eating; several years ago, had surgery because was shot in abdomen; has PTSD; gap between measured and calculated stool osmolality low; Type of diarrhea?

Secretory -Infections (Vibrio, rotavirus) -Early ileocolitis -Postsurgical changes -larger than usual stool volumes (>1L/day) -even when fasting/sleeping

89yo woman has ecchymoses on dorsum of forearms episodically for past few months; no pain or itching; thin, hyperpigmented skin with several flat, dark ecchymotic areas over the dorsum of both forearms; PT, PTT normal; RBC, WBC, plt countsn normal; Dx?

Senile/solar/actinic purpura -loss of elastic fibers in perivascular connective tissue

Measures of validity in biostats?

Sensitivity Specificity

What does raising cut-off point do for -sensitivity -specificity

Sensitivity- decreases Specificity- increases

Gold standard in diagnosing HIT?

Serotonin release assay

65yo man overweight, smokes 1pack/day; brother had stroke, both parents died in 40's; BP = 150/100; grade 2 hypertensive retinopathy, PMI 2cm displaced lateral from midclavicular line; As part of initial assessment, which tests should you order? -plasma renin activity -serum aldosterone concentration -serum Cr concentration -urine metanephrine concentration -urinary Na/Cr ratio

Serum Cr concentration -even if he has RAS, first need to determine extent of kidney damage!

How to diagnose GPA?

Serum autoantibodies (cANCA)

SAAG criteria?

Serum: ascites ALBUMIN >1.1 --> Portal HTN -Ascites -Cirrhosis -Budd-Chiari <1.1 --> No portal HTN -TB -Peritoneal carcinomatosis -Pancreatic ascites -Nephrotic syndrome

Severe aortic stenosis features Mild/Moderate aortic stenosis features

Severe aortic stenosis -Parvus + tardus -Mid-late peaking systolic murmur -Soft, single S2 (thickening, calcification of aortic leaflets) Mild/Moderate aortic stenosis -early peaking systolic murmur

Hyperhemolytic crisis = what?

Severe, acute reticulocytosis in sickle cell patients

71yo man has worsening back pain at night; had prostate cancer with mets in his spine, received radiation therapy; tried taking ibuprofen 3-4 times/day but minimal relief; no LE weakness or numbness, no bladder dysfunction; Next step?

Short-acting opioids for severe pain -Local glucocorticoids- for single/limited number of painful MSK lesions (eg. bursitis) -Systemic glucocorticoids (dexamethasone) for spinal cord compression with neurological compromise

Sildenafil SEs

Sildenafil = PDE5-I *SE -Headache -Heartburn -Hypotension (DON"T TAKE WITH ZOSINS --> a1 blockers --> vasodilate)

45yo woman has difficulty swallowing food (only solids, liquids fine), dry eyes, thrush, dental caries, bilateral submandibular lymphadenopathy; arthritis, Dx?

Sjogren's -dry eyes -dry mouth -difficulty swallowing -thrush (because lack of saliva) -dental caries (because lack of saliva) -Raynaud's -interstitial lung disease -arthritis

Acrochordon = aka?

Skin tag

31yo woman has 3mo of daily abdominal bloating and increased flatulence; has watery, nonbloody diarrhea 3x/week; PMH- systemic sclerosis, GERD, DM2, open cholecystectomy for gallstones; Dx?

Small intestine bacterial overgrowth -abdominal pain -diarrhea -bloating -excess flatulence -malabsorption Etiologies -anatomical abnormalities (strictures, surgeries) -motility disorders (DM, scleroderma) -Other (ESRD, AIDS, cirrhosis, old age) Dx -endoscopy with jejunal aspirate showing >10^5 organisms -glucose breath hydrogen testing Tx- Abx -rifampin -ampicillin-clavulanate

How to diagnose CLL?

Smear with lymphocytosis + smudge cells Flow cytometry *Don't need lymph node biopsy to diagnose!! -use for Hodgkin's lymphoma, non-Hodgkin's lymphoma

Mechanism of esophageal dysmotility in CREST?

Smooth muscle atrophy and fibrosis

Most specific for ankylosing spondylitis? -HLA-27 -Spine XR

Spine XR!!! *only 5% of ppl with HLA-27 have ankylosing spondylitis

Fever Chills LUQ pain Splenic fluid collection Dx?

Splenic abscess -can be from infective endocarditis spreading hematogenously

Most sensitive test for diabetic nephropathy?

Spot urine microalbumin:Cr ratio *Cr not sensitive because can be normal even in nephropathy -Cr/GFR actually goes up at first because kidney trying to compensate

47yo man with DM2 controlled with meds and lifestyle; takes daily aspirin; cholesterol levels normal; TG = 160 (high); What do we give him?

Statins! -Give statins to ALL DIABETICS 40-75yo *also lowers TGs

A 67 years old man comes to the physician because of easy fatigeability and general weakness for 3 months and left chest pain for 1 month. The chest pain is worse in deep inspiration. He appears slightly pale. There is tenderness over the left 8th and 9th ribs laterally. Examination shows no other abnormalities. His hematocrit is 28%. Serum and urine protein electrophoresis shows a monoclonal spike. A biopsy specimen of bone marrow shows greater than 50% plasma cells. A xray of the chest shows 1 to 1.5 cm areas of radiolucency in both ribs corresponding to the sites of tenderness. This patient condition makes him most likely susceptible to infection with which of the following organisms? a. Aspergillus Fumigatus b. Eschericha Coli c. Herpes Zoster Virus d.Mycobacterium Tuberculosis e. Pnemocystitis Jirovechi (formerly P. Carinii) f. Streptococcus Pneumoniae

Step pneumo is encapsulated bacteria and we have defective antibody production in multiple myeloma -also question suggests splenomegaly --> decreased functionality against encapsulated organisms

36yo man on chronic steroids for sarcoidosis; has L leg pain with internal rotation and hip flexion, starts at groin; plain films show no significant abnormalities; Dx?

Steroids --> AVASCULAR NECROSIS Causes -steroids -alcohol use -SLE -antiphospholipid syndrome -Sickle cell disease -Infections (osteomyelitis, HIV) -Renal transplant -Decompression syndrome

Difference between Stevens-Johnson and TEN?

Stevens-Johnson- 10-30% body TEN- >30% body

23yo woman training for a marathon, has R foot pain localized to dorsal-lateral part of foot, worsening over past week, tenderness to palpation in 2nd metatarsal over dorsal part of foot; Dx?

Stress fracture!!!

24yo woman has severe substernal pain when she exercises; noticed 6mo ago when she started to exercise, didn't do it before; -BP 130/90 in R arm, 110/55 in L arm -palpable thrill in substernal notch -loud midsystolic murmur at 1st R intercostal space Dx?

Supravalvular aortic stenosis! = 2nd most common type of aortic stenosis -congenital LV tract obstruction -unequal carotid pulses -different BPs in both arms -palpable thrill in substernal notch -coronary artery stenosis --> ischemia during exercise

Regular, narrow complex tachycardia (QRS < 120s) at a rate of 160bpm = what kind of rhythm? -Retrograde P-waves (Pseudo P' waves) -Pseudo S waves -RR intervals constant

Supraventricular tachycardia

Frozen shoulder -symptoms -causes

Symptoms -decreased ROM both PASSIVE + ACTIVE -More stiffness than pain Causes -rotator cuff tendinopathy -subacromial bursitis -paralytic stroke -DM -humeral head fracture

PE symptoms -CXR findings (if any)

Symptoms -pleuritic chest pain (pain with inspiration) -dyspnea -tachypnea -cough -hemoptysis -LE edema (DVT) CXR findings -often none -atelectasis -infiltrates -pleural effusions -Westermark's sign (peripheral hyperlucency from oligemia) -Hampton's hump (peripheral edge of lung opacity from pulmonary infarction) -Fleischner sign (enlarged pulmonary artery)

Acalculus cholecystitis -presentation -risk factors -mechanism -Dx

Symptoms -unexplained fever -RUQ pain -leukocytosis -possible jaundice, RUQ mass, abnormal LFTs *Usually seen in hospitalized, critically ill patients Risk factors -surgery -trauma -burns -sepsis, shock Mechanism -Leads to gallbladder stasis/ischemia with local inflammation --> gallbladder distension, necrosis, secondary bacterial infection Dx -abdominal US

Man from Russia has TB, Na = 132, K = 5.9; What acid-base disturbance does he have?

TB --> ADRENAL INSUFFICIENCY/ADDISON"S in endemic areas! --> Normal AG metabolic acidosis

37yo man with HIV comes in with productive cough over past 2mo; no hemoptysis; drinks heavily and was hospitalized 6mo ago for alcohol-withdrawal seizures; CD4 at that time was 520; CXR- R upper lobe density; Dx?

TB reactivation -substance abuse = most common risk factor *Aspiration pneumonia affects LOWER lobes, more acute (hours --> days) *PCP if CD4 <200

fibromyalgia treatment?

TCA = amitriptyline

Which causes hyperkalemia -albuterol -azithromycin -ceftriaxone -insulin -prednisone -trimethoprim

TRIMETHOPRIM -blocks ENaC!!!

35yo man has been "acting weird", has untreated HCV, HIT; mild scleral icterus -Hb = 7.6 -Plts = 45,000 -BUN = 30 -Cr = 2.2 -Total bili - 3.2 -Indirect bili = 2.0 -AST- 62 -ALT- 78 Dx?

TTP!!! = thrombotic thrombocytopenic purpura -hemolytic anemia -thrombocytopenia -renal symptoms -neuro symptoms -fever *NOT hepatic encephalopathy because AST, ALT elevations too mild

Where's the problem in AIN (acute interstitial nephritis)?

TUBULES (tubulointerstitial nephritis)

Best treatment for HBV infection? In what circumstances would we use -Tenofovir -IFN -Lamivudine -Entecavir

Tenofovir = BEST TX!!! IFN- younger patients, compensated liver failure Lamivudine- HIV patients Entecavir- decompensated cirrhosis

A 72-year-old woman comes to the physician because of an increase in abdominal girth over the past 2 months. She has had a 3.6-kg (8-lb) weight gain during this period despite being unable to finish any meal. She has one martini daily after her 3-mile walk. She underwent lumpectomy and radiation therapy for stage I breast cancer 4 years ago and has been treated with tamoxifen since then. Abdominal examination shows a fluid wave. Pelvic examination shows an 8-cm, fixed, nontender mass in the cul-de-sac. Laboratory studies show normal findings. Which of the following is the most appropriate next step in management? A) Intravenous albumin therapy B) Intravenous antibiotic therapy C) Intravenous cisplatin and paclitaxel therapy D) Oral angiotensin-converting enzyme (ACE) inhibitor therapy E) Oral spironolactone therapy F) Therapeutic paracentesis G) Exploratory laparotomy

The main knowledge gap is to know that ovarian masses can present with ascites, and that an ovarian mass of 8-cm (which is quite large!) needs to be removed asap. There is a high likelihood that this is cancer, and it needs to be staged, which can only be accomplished with an ex-lap. Remember that we do NOT biopsy these masses (for risk of seeding among other reasons). She drinks only 1 martini a day (most med students drink more than that), so her ascites is likely not due to alcoholic liver disease. A therapeutic paracentesis might be an ok thought, but she's going to ultimately need surgery asap, so you should skip the paracentesis and go to surgery. Furthermore, we don't even know exactly how much fluid she has in her belly, something they should probably tell you if they want you to choose paracentesis. She has no signs of infection, and no other pertinent history pointing to anything else, which should help you eliminate other choices.

65yo man has palpitations, headaches, insomnia, 2 episodes of vomiting this morning; PMH- COPD, pulm HTN, essential HTN, hyperlipidemia; takes tiotropium, inhaled fluticasone/salmeterol, theophylline, simvastatin, lisinopril, hydrochlorothiazide; EKG- multifocal atrial tachycardia with premature ventricular beats; Dx?

Theophylline toxicity! (FROM CIPRO INDUCTION) *Narrow therapeutic index -CNS stimulation (headaches, insomnia, seizures) -Cardiac toxicity (arrhythmias)

Metolazone = what kind of drug?

Thiazide

Located in what part of mediastinum -thymoma -neuroblastoma -bronchogenic cyst -thyroid

Thymoma- anterior Neuroblastoma- posterior Bronchogenic cyst- middle Thyroid- anterior

28yo woman develops tachycardia in postop recovery room; admitted for R femur fracture after MVA, had open reduction and fixation; in recovery room, started to have nausea/vomiting, anxiety, agitation, T = 103, HR = 148, RR = 24; delirious, fine tremor, mild lid lag; nothing in medical history; Dx? Tx?

Thyroid storm -after stress/surgery, acute illness, childbirth -tremor -lid lag -agitation -delirium -seizure -coma Tx- propranolol -PTU + iodine solution -glucocorticoids

Chronic transplant rejection -timeline -mechanism -symptoms

Timeline -months --> years Mechanism -T-cells respond to recipient APCs with donor peptides (Type II, IV) Symptoms -bronchiolitis obliterans (lung -accelerated atherosclerosis (heart) -chronic graft nephropathy (kidney) -vanishing bile duct (liver)

Acute transplant rejection -timeline -mechanism -symptoms -Tx

Timeline -weeks --> months Mechanism -T-cells activated against donor MHCs (Type IV hypersensitivity) Symptoms -vasculitis of graft vessels with dense interstitial lymphocytic infiltrate Tx -immunosuppressants

Hyperacute transplant rejection -timeline -mechanism -symptoms -tx

Timeline -within minutes Mechanism -Preexisting Ab react to donor antigens (Type II hypersensitivity) Symptoms -widespread thrombosis of graft vessels --> ischemia/necrosis Tx -remove graft

How to diagnose carpal tunnel?

Tinel's Phelan's NERVE CONDUCTION STUDIES!! *NOT XR of hand!

Hyperthyroidism + 1 hot nodule?

Toxic adenoma *If diffuse radio uptake, Graves disease

Tx for 3rd degree heart block?

Transcutaneous pacing

67yo man has fatigue, bilateral leg swelling; JVP distended when patient sitting down; takes lisinopril, amlodipine for HTN; 6mo ago, had permanent pacemaker placement for sick sinus syndrome; 3/6 holosystolic murmur at L sternal border; Dx?

Tricuspid regurg = complication of pacemaker placement -1 lead goes from RA --> RV (PASSES THROUGH TRICUSPID VALVE --> DAMAGES TRICUSPID VALVE)

A 42year-old woman comes to the physician because of intermittent loss of small amounts of urine over the past 3 weeks. Her symptoms occur only after voiding; she is otherwise asymptomatic. Pelvic examination shows a 3cm, midline, cystic, tender mass in the midthird of the vagina. Urinalysis is within normal limits. Her postvoid residual volume is 50 mL. Which of the following is the most likely diagnosis ? A ) Interstitial cystitis B ) Neurogenic bladder C ) Stress incontinence D ) Urethral diverticulum E ) Urethral syndrome F ) Urinary tract infection G ) Vesicovaginal fistula

URETHRAL DIVERTICULUM Pxs w/ Urethral Diverticulum have some retained urine in the diverticulum *Classic presentation is a women with postvoid leaking of a SMALL amount of urine that was retained in the diverticulum

55yo woman has pain, itching, red streaks on L arm; had this 2wks ago on chest, improved on its own; ROS- heartburn, mild epigastric pain for last several months relieved with antacids; 15-30yr smoking history; tender, erythematous, palpable cord-like veins on L arm and upper chest; Dx? Next step?

Trousseau syndrome!! -migratory superficial thromboses at unusual sites (arm, chest) *Cancer likely releases mucins that interact with platelets --> platelet-rich microthrombi Next step- CT of abdomen!

What is salvage thereapy?

Tx when standard therapy fails

66yo man has poorly-controlled HTN and DM, CMP 2mo ago showed hyperkalemia; PCP discontinued lisinopril at that time; Meds- glipizide, furosemide, nifedipine, aspirin; Na = 136 K = 5.6 Bicarb = 18 (low) BUN = 28 Cr = 1.4 Dx?

Type IV RTA -Non-AG metabolic acidosis -Persistent HYPERkalemia -Mild --> moderate renal insufficiency

68yo man has increased urinary frequency, nocturia, hesitancy has enlarged prostate on exam; Next step in diagnosis?

UA -Hematuria -Bladder cancer -kidney stones -Infection

40yo swallowed unknown amount of caustic drain cleaner; difficulty swallowing; drooling, oropharyngeal edema and erythema; IV fluids started; Next step? Caustic ingestion algorithm?

UPPER GI ENDOSCOPY!! -within 24hrs to assess degree of damage -only if no respiratory compromise or perforation 1. Secure ABCs 2. Decontaminate 3. CXR if have resp symptoms 4. EGD in 24hrs

46yo man has intermittent severe R flank pain over the past few days; decreased urination over last week, occasional episodes of high urine output + feeling of generalized weakness; BP = 145/86; Dx?

Unilateral obstructive uropathy from renal calculi! -flank pain not typical of nephritis, RAS, etc

34yo man has SOB, difficulty swallowing; agitated, gasping for breath; past history of difficulty breathing, food intolerances, skin allergies, PE- excessive accessory muscle use, retraction of subclavicular tissue, scattered urticaria; Dx?

Upper airway obstruction = laryngeal edema -usually peanut allergies look like this -acute onset dyspena -stridor -harsh upper respiratory sounds

98yo man has sharp, L-sided chest pain that's worsened on inspiration and by leaning forward; BUN = 91, Cr = 5.1; Dx? Treatment?

Uremia-induced PERICARDITIS! Other causes of pericarditis -viral (most common) -bacterial -surgery, trauma, drug-related -rheumatoid arthritis, SLE -Dressler syndrome -Uremia -Malignancy Tx- Hemodialysis (fix underlying problem)

Primary biliary cholangitis tx?

Ursodeoxycholic acid

45yo woman with watery diarrhea for past few months, occasional flushing, cramps in leg muscles, feels dehydrated; 3cm mass in head of pancreas; Dx?

VIPoma WDHA syndrome -Watery Diarrhea -Hypokalemia -Achlorhydria *Also has flushing associated *not carcinoid because would more likely be in small intestine!!!

VIPoma secretes what? Carcinonid secretes what?

VIPoma- VIP Carcinoid- urinary 5-HIAA

Effect PE has on Alveolar-arterial gradient?

VQ mismatch --> Increased A-a gradient!

45yo man with hemochromatosis went sailing, cut his foot as he jumped to the dock; used direct pressure to stop bleeding and applied antiseptic; last night, awoke with throbbing pain in R foot; PE- 1.5cm cut with extensive erythema, streaking erythema all the way up to proximal thigh, several dark-colored bullae; What pathogen?

Vibrio vulnificus!!! -marine environment -ingestion OR wound infection -Increased risk in liver disease (hemochromatosis, cirrhosis, hepatitis)

Pathogenesis of IV induced nephropathy?

Vasoconstriction + tubular injury

PVCs come from what part of the heart?

Ventricles!

2wks after MI, 60yo man comes in with exertion dyspnea, SOB, difficulty falling asleep; bilateral crackles in lower lung fields; API displaced to L, faint systolic murmur heard over apex; Most likely complication from MI?

Ventricular aneurysm -thin/scarred myocardium in remodeled areas 2 weeks --> 3mo after MI -persistent ST elevation -Deep Q waves

67yo man was moving boxes in garage when had sudden back pain; lasted for past 2 days; tried to take acetaminophen but didn't help; point tenderness to palpation and percussion along midline 4th lumbar vertebrae; Dx? Most common cause?

Vertebral compression fracture *Most common cause = osteoporosis

42yo man has severe back pain following a fall out of his car; has history of ankylosing spondylitis; in pain, with grimacing and diaphoresis; midline tenderness over upper lumbar region; Dx?

Vertebral fracture *more likely in ankylosing spondylitis (develop osteopenias/osteoporosis, and spinal rigidity more easily)

43yo woman has fatigue, SOB over 2 weeks; recent URI; BP = 98/60; JVP elevated; enlarged cardiac silhouette; Dx? Additional findings?

Viral pericarditis --> pericardial effusion --> early cardiac tamponade *CAN"T FEEL PMI BECAUSE OF TAMPONADE -Pericardial effusion --> "water bottle heart"

Pericarditis causes

Virus- Coxsackie Neoplasia Autoimmune- SLE, RA Uremia -CKD --> pleuritic chest pain (don't know why) -no ST elevation cardiovascular- acute STEMi or Dresser syndrome Radiation

64yo man has emergency colonic resection; lives alone and drinks lots of alcohol; extubated on 4th postop day; after extubation, has episodes of confusion, agitation --> treated with lorazapam, haldol; also receiving piperacillin-tazobactam; starts bleeding from venipuncture site; Plts- 160,000 PT- 24 sec (INR 2.2) PTT- 40 sec (nl 25-40) Dx?

Vitamin K deficiency -NPO -broad-spectrum antibiotics

Osteitis fibrosa cystica aka...?

Von Recklinghausen disease of bone -excessive osteoclastic resorption of bone --> replacement with fibrous tissue (brown tumors) -cystic bone spaces -in PTs with parathyroid carcinoma

Imaging in low back pain -X-ray indications -MRI indication

X-ray -osteoporosis -malignancy (helps rule out cancer vs vertebral fracture quickly) -ankylosing spondylitis MRI -sensory/motor deficits -cauda equina -epidural abscess/infection

72yo man has 3mo of daily temporal headaches, feels fatigued, ears ring and become blurry, feet feel like someone's "sticking them with needles", hepatosplenomegaly; fundoscopy- dilated, segmented, tortuous retinal veins; sensory deficits in his feet; Hb- 9.6 Plts- 136,000 WBC- 6200 BUN- 18 Cr- 0.9 Serum protein electrophoresis shows sharp IgM spike Dx?

Waldenstrom macroglobulinemia -Hyperviscosity syndrome -Neuropathy -Bleeding -Hepatosplenomegaly -Lymphadenopathy *IgM light chains (Multiple myeloma = IgG, IgA) *>10% clonal B-cells

18yo African American man with fatigue, dyspnea; 2wks ago, had URI treated with amoxicillin; nontender abdomen; spleen enlarged, mild scleral icterus; retics- high, MCV- normal; Hb- low; Dx?

Warm-agglutinin Autoimmune hemolytic anemia -normocytic anemia -hemolysis signs (jaundice, high indirect bili, high serum LDH, low serum haptoglobin) -splenomegaly (RBC entrapment) *Not sickle cell because in 18yo, sickle cell patients would have auto-splenectomized (and would have hx of vasoocclusive crises)

DM meds that are -weight neutral -weight gain -weight loss

Weight neutral -metformin -DDP-4 (linagliptin, saxagliptin, sitagliptin) Weight gain -sulfonylureas (chlorpropamide, tolbutamide, glimepiride, glipizide, glyburide) -glitazones/thiazolidinediones (pioglitazone, rosiglitazone) -meglitinide (nateglinide, repaglinide) Weight loss -GLP-1 analogs (exenatide, liraglutide)

Sample distortion bias- what is it

When estimate of exposure and outcome association biased because sample not representative of the prevalence/incidence of the disease with respect to the joint distribution of exposure and outcome

When can we assume odds ratio approximates relative risk?

When incidence low (a/(a+b))/(c/(c+d)) -if a, c negligible, ~(a/b)/(c/d)

Immune reconstitution syndrome

When you boost an immunocompromised person's immune system (HIV, etc) and it overactivates in response to an existing infection --> bad for patient

PAS positive material found in lamina propria of small intestine = diagnostic for what?

Whipple's disease

Hepatolenticular degeneration = aka?

Wilson's disease

Benefits of transplant over dialysis?

With dialysis, still have anemia, bone disease, HTN

Upper limit for age of catch-up HPV vaccine for -women -men

Women- 26 Men- 21

42yo man has microcytic anemia, fatigue; low Fe, ferritin stores; next step?

Workup for occult blood loss!!! -most likely cause in man this age = colon cancer!!

Side effect of using folic acid for B12 deficiency?

Worsening of neuro deficits! -tingling/neuropathy, etc

Radioactive iodine for Graves' disease causes what SEs?

Worsens ophthalmopathy -if concerned about this, use thyroidectomy instead

Fondaparinux mechanism?

X factor inhibitor

CA-MRSA pneumonia features

Young patients -Severe, necrotizing PNA (hemoptysis) -Quickly progressive, often fatal -High fever -Leukopenia -Multilobular cavitary infiltrates

45yo man has -2 duodenal ulcer, 1 jejunal ulcer -refractory to H2B, PPIs, antacids -steatorrhea Dx?

ZES = Zollinger-Ellison Syndrome = gastrin-producing tumor -multiple duodenal (sometimes jejunal) ulcers -refractory to meds -pancreatic enzyme inactivation --> steatorrhea

65yo man has several month history of difficulty swallowing, frequent coughing during meals; noticed neck mass that grows in size when swallowing liquids; change in breath odor, occasionally regurgitates meds; Dx? Mechanism?

Zenker's diverticulum -dysphagia -halitosis -regurgitation + aspiration -variable neck size Mechanism- abnormal motor function -esophageal sphincter dysfunction -esophogeal dysmotility Diagnosis -barium swallow -manometry

42yo man with Crohn's had partial ileal resection for stricture; had multiple surgeries to treat enterocutaneous fistula; received TPN for past several weeks; has nonbloody diarrhea, patchy alopecia, vesicular, crusting skin lesion around mouth and on extremities; Dx?

Zinc deficiency! -Hypogonadism -delayed wound healing -alopecia (axillary, facila, pubic) -acrodermatitis enteropathica = vesicular rash

75yo man has 6mo history of substernal chest pain; stress EKG shows horizontal ST depressions in II, III, aVF; started on aspirin, sublingual NO; X; what mechanism does X work through?

b-blocker --> reduced myocardial contractility!! Tx of chronic stable angina -b-blockers (first line therapy for improving exercise tolerance) -non-dihydropyridine CCBs (alternative to b-blocker) -dihydropyridine CCBs (added to b-blocker when needed) -nitrates -ranolazine (for refractory angina)

OD with bradycardia, AV block, hypotension, diffuse wheezing; What drug? Tx?

b-blocker OD *Wheezing distinctive for this Tx- 1. Secure airway 2. IV fluid boluses 3. IV atropine 4. glucagon

HOCM treatment

b-blockers CCBs

In cocaine vasospasm, what drug don't we give? -metoprolol -diltiazem -NO -aspirin -benzos

b-blockers/Metoprolol!!! -Opposes b-receptors --> a-receptors unopposed --> increased stimulation by cocaine Tx for cocaine vasospasm 1. Benzos- pain relief, decreases central sympathetic outflow 2. CCB 3. ASA 4. NO

What do we use ANOVA for?

comparing 3 or more means

What is the strongest predisposing factor for perioperative MI

mi with in past 6 mo ( in this question) *Stronger than smoking!

24yo F primi at 38 weeks' gestation admitted in labor. Spontaneous ROM 2 hrs ago. Contractions are moderate and occur every 5-6 min. Was treated at 20 wks with ampicilin for GBS UTI. Temp 37C, p 82/min, resp 18/min, BP 122/74. Cervix 2 cm dilated and 80% effaced; vertex at -1 station. Most appropriate rx to prevent GBS infection in the newborn? a. IM vanco b. IV cephalothin c. IV clindamycin d. IV pen G e. No prophy needed

penicillin G, but not because we're not sure. *you give EVERY lady penicillin G without testing in weeks 35-38 if she 1. had GBS at all during labor or 2. ever had GBS at a previous labor 3. prolonged rupture of membranes anyway, this woman had GBS during this current pregnancy so you don't need to even test for it, automatically treat with penicillin G

A 72 year role man admitted to hospital with SOB for 3 days. Long standing hx of HTN & CAD. Receiving 2L/min of O2 via nasal cannula. Temp is 98.6F, pulse 110, RR 20. BP 150/80. Bilateral crackles & wheezes head in all lung fields. Hct 28%, WBC 8000/mm3. Pulm artery cath shows CI of 2L/min/m2 and a pulmonary artery occlusion pressure of 28mmHg. ABG shows pH 7.49, pCO2 30, POs 58. What's the next step? A.) Blood transfusion B.) Diuretic therapy C.) Heparin D.) Thrombolytic therapy E.) Pericardiocenteis F.) Tube thoracostomy G. )Pulmonary Embolectomy

pulm edema due to CHF