IMisaac

Diabetic Foot Ulcers

*- result from neuropathy, microvascular insufficiency, and immunosuppression - classically occur on plantar surfaces of foot under points of greatest pressure i.e. under head of first metatarsal bones*

What is serous otitis media?

*Commonly seen in HIV pts It is the presence of a middle ear effusion without signs of an active infection. Examination commonly reveals a dull tympanic membrane that is hypomobile on pneumatic otoscopy

Why do patients in ESRD have edema?

*DEC GFR is cause*

Histoplasmosis

- *Mississippi + Ohio River basins* - present in soil, bird, bat droppings - no spread person to person CFs - *PULMONARY HISTOPLASMOSIS: present like sarcoidosis - cough, hilar adenopathy, erythema nodosum, non caseating granulomas, AA individual*; *suspect when suspected sarcoidosis patient on corticosteroids begins deteriorating*; - Disseminated Histoplasmosis in *HIV PTS CD4<100* - *immunocompromised patients*; *lymphadenopathy, pancytopenia, hepatosplenomegaly, caseating granulomas*; *mucocutaneous lesions*; *pneumonia w/diffuse reticulonodular or cavitary lesion* *VS BLASTOMYCOSIS OCCURS IN NON IMMUNE COMP PTS (CHECK IN TEST Q TO IMMED DIFFERENTIATE)* Dx - *urinary or serum antigen testing = GOLD STD* - cytopenias - anemia, leukopenia, thrombocytopenia - markedly *inc LDH + Ferritin* - *elevated Liver enzymes* Tx - *ITRACONAZOLE* - histoplasmosis + blastomycosis present like sarcoidosis or Tb

Prosthetic Valve Endocarditis Cause

- *S. epidermidis*; also causes *infectious endocarditis secondary to venous umbilical catheter infection in neonatal ICU*

What conditions is *episcleritis* found in?

- *inflammation of white of the eye w/o involvement of uvea tract (iris, ciliary body, choroid)* - think *RA + IBD*

How long should patient wait with infectious mononucleosis to play a sport again?

- Patients with infectious mononucleosis are at high risk for splenic rupture. *Sports, especially those involving significant contact should be avoided for >3 weeks.*

What is most common cause of pneumonia in HIV patients?

- Pneumococcus (strep pneumo) I. suspect when there is *acute onset, high grade fever, and pleural effusion* - *in HIV patients we always want to jump to pneumocystis because it is a classic - understand pneumocystis cxr will show BILATERAL DIFFUSE INFILTRATES (VS UNILOBULAR INFILTRATE IN PNEUMOCOCUS) w/dry cough (VS PRODUCTIVE IN PNEUMOCOCCUS) + dyspnea*

Arthritis + Rash of Lyme disease?

- RASH OCCURS FIRST - erythema migrans i. occurs at SITE OF TICK BITE, BULLS EYE - arthritis = MONOARTICULAR ARTHRITIS USUALLY OF KNEE THAT OCCURS * 2 MONTHS* AFTER RASH

Rental Tubular Acidosis

- RTA I + II - hypokalemia - RTA I, II, IV - non anion gap metabolic acidosis

Molluscum contagiosum

- caused by pox virus - characterized by centrally umbilicated - dome shaped papules that are non pruritic

Toxic Shock SYndrome

- caused classically by tampons - classic presentation is *fever, rash, hypotension* - *diffuse skin involvement with ERYTHEMATOUS SKIN PRIOR TO sloughing INCLUDING PALMS + SOLES*

Most sensitive measure of impending DIabetic Nephropathy?

- *measure for microalbuminuria via looking for urine protein excretion of 30-300mg/24 hours where normal urine protein excretion is <30 mg/24hrs - *spot urine collection + timed urine collection* for *screening for microalbuminuria - best indicators of diabetic nephropathy onset*

Skin Findings of Syphilis

- *painless ulcer of genitalia in primary stage; maculopapular rash of palms + soles in secondary stage*

Pulmonary Embolism

- *pats w/hx of recent ortho surgery followed 0 w/bedrest are at risk of developing LE DVT + PE. Elevated A-a gradient commonly seen in pts w/PE (UWORLD)* Presentation - acute onset dyspnea - tachypnea - pleuritic chest pain - HYPOXEMIA - *respiratory alkalosis (vs COPD for ex w/resp acidosis)*

X ray findings COPD

- *radiolucency of lung parenchyma* - *elongated + narrow heart shadow* - *barrel shaped chest - flat diaphragm* - air trapping + progressive hyperinflation

Anerobe induced pneumonia

- *think lung abscess* - *think aspiration or poor dentition* - *if lung abscess present, will see fluid filled cavity on x ray*

Choice of drug therapy in SLE

- *usually start on HYDROXYCHLORQUINE - patients should have baseline ophthalmologic examination w/annual reassessment beginning after 5 years*

What is the most common cause of endocarditis following dental procedures?

- *viridans streptococci (most commonly Strep mutans; less common = S. salivarius, S. sanguis, S. mitis) - this type of endocarditis is a *subacute infective endocarditis* of the mitral valve secondary to dental surgery is common - preexisting factors to subacute endocarditis = *pre-existing mitral valve stenosis*

Human Papilloma Virus

- *warts - cutaneous verrucae* - most common cutaneous manifestation of *HPV* - can occur in *PALMAR, GENITAL, PLANTAR REGIONS* - virus transmitted through tiny cuts or skin abrasions after direct contact with an HPV infected individual - *lesions are painful with putting pressure* - Dx - clinically on appearance + location*

Posterior Interosseous Nerve Entrapment

- *weakness of extrinsic extensors of hand + fingers*

Psoriasis

- *well circumscribed raised papules + plaques* covered with a thick *silvery scale* - lesions are located on the *scalp, trunk, and extensor regions (ELBOWS + KNEES)*

Urinary retention due to inability to Valsalva in patient with preexisting mild urinary obstruction (i.e. BPH) can occur in with what?

- *with extreme pain (answer)* - there may be inability to Valsalva and therefore inability to pee in scenarios where pt has mild urinary obstruction such as BPH that is already making it difficult to urinate. Such "extreme pain" may come from I. *exam scenario - pt that lifted box, herniates disk L4/L5 most likely with sciatica radiation down one leg and one foot. ii. The anal wink is intact and no saddle anesthesia so cauda equine syndrome can be ruled out. iii. the presence of BPH in pt signifies need to Valsalva in order to pee. Cannot Valsalva if there is radiculopathy making coughing and straining painful

Steven Johnson Syndrome Rash

- - severe skin rxn to certain meds - prodrome of fever + influenza like sx followed by development of mucocutatneous erythematous + purpuric macules that progress to necrosis + sloughing of the epidermis.

Complications of Hep B

- 90% recover spontaneously - minority proceed to develop chronic hepatitis B infection - 0.1 - 0.5% will develop fulminant hepatic failure (defined as hepatic encephalopathy that develops within 8 weeks of onset of acute liver failure - even clinical signs like asterixis or confusion + agitation) Tx if fulminant hepatic failure as indicated by development of hepatic encephalopathy in presence of Hep B occurs: *ORTHOTOPIC LIVER TRANSPLANTATION (UWORLD Q)*

What blood pressure medication is most proven to have the greatest beneficial effect in controlling HTN in diabetes?

- ACE-I is most effective in slowing progression of diabetic nephropathy - *give ACE-I in diabetic w/HTN as 1st choice* - it is *recommended in patients with *microalbuminuria even if blood pressure is normal* - b/c microalbuminuria is sensitive marker of renal Microvascular damage - *beneficial effect of ACE-I In diabetic with microalbuminuria is due to REDUCTION BP + DIRECT EFFECT OF DEC INTRAGLOMERULAR PRESSURE*

HIV associated Kaposi Sarcoma

- AIDs defining malignancy - *look for violaceous papules of oral region or genitalia in presence of oral thrush* - due to HHV-8 - most commonly affect - *LE, face, oral mucosa, genitalia* appearing as *multiple violaceous (purple) papules* - *dx = clinical but can do bx for confirmation*

Alcohol Withdrawal Syndrome

- Alcohol Withdrawal Treatment I. Benzodiazepines - lorazepam, diazepam, chlordiazepoxide a. lorazepam - USE IN PT WITH LIVER DZ - DUE TO ABSENCE ACTIVE METABOLITES b. USE IV c. simultaneous admin of THIAMINE + FOLATE + NUTRITIONAL SUPPORT

Primary Biliary Cirrhosis Antibodies?

- Anti mitochondrial antibodies

36 y/o F comes to ED w/severe epigastric + r SHoulder pain for 2 hours. Pt had emesis also. Pt when asked about diet said she had fasted all day and had cheeseburger 2 hours ago. Explains she had similar episode last month but did not seek medical attention as it was less severe and resovled spontaneously in a few hours. PMH sig for heartburn + takes ranitidine. After 4 hour of pain, it resolves - what explains episode?

- Biliary colic - "HOLLOW ORGAN CONTRACTION + OUTLET OBSTRUCTION"

When + for what is MgSO4 used for in pulmonary setting?

- IV MgSO4 - bronchodilation for severe and life threatening asthma exacerbations

72 y/o M to Ed w/ non productive cough, fever, malaise, runny nose , and severe body aches. Sx came on suddenly last night. Has no other medical problems .PE show temp of 102 + 88% sat O2 on room ai. Lung exam showed iffuse crackles + occasional wheezes. Chest x ray show diffuse interstitial infiltrates bilaterally. What is dx? What is Tx?

- Influenza - osteltamivir - looked like pneumocystis but no copresentation of HIV and no choice for TMP SMX (tx of pneumocystis)

What is suspected in *Asian patient with insensate hypopigmented patch of skin*?

- KNOW THE DESCRIP ON LEFT - UWORLD Q - *Leprosy* - *dx made by DEMONSTRATION ACID FAST BACILLI ON SKIN BX*

Histoplasma Capsulatum

- Mississippi River Valley + Ohio River Valley (like blastomycosis) - histo hides in MACROPHAGES - bird + bat droppings - presentation - usually self limited fever, chills, and non productive cough - CXR - *patchy lobar or multinodular lobar infiltrates* I. *CALCIFIED NODES ON MEDIASTINUM OR LUNG* ii. *DO NOT SEE CAVITARY LESIONS UNLIKE ASPERGILLOSIS* *chronic cavitary pulmonary histoplasmosis - occurs in elder COPD patients* - usually resolve WITHOUT TX

Pulmonary Cavitation in HIV patient can be caused by?

- Mycobacterium tuberculosis, atypical mycobacteria, Nocardia, gram (-) rods, anerobes

Acute Tubular Necrosis

- causes acute renal failure - most commonly seen in ischemic or nephrotoxic ARF - muddy brown granular casts - *know image - in image, renal ischemia is due to HYPOTENSION - LOOK FOR TRAUMA SCENARIO (TEST Q)* Labs I. *BUN:Cr < 20:1* ii. *Urine Osmolality of 300-350 mOsm/L but never <300* iii. *Urine Na of >20mEq/L* iv. *FENa > 2%*

Ureteral Colic

- causes by ureteral stone often - uncomplicated stones <1 cm can be managed conservatively: I. hydration ii. analgesics (NSAIDs) iii. Alpha blockers (i.e. tamsulosin) - found at base of detrusor, bladder neck, and urethra (antagonism of these help relieve muscle tone that normally maintains continence)

TT elevated

- fibrin split products - severe hypofibrinoginemia - DIC

Pityriasis rosea

- first sx = *pink or brown scaly plaque with central clearing + collarette of scale (herald patch)* on trunk, neck, or extremities - *2nd step - Christmas tree patterned macuolopapular rash*

Coccidiomycosis

- fungal infection lungs - fever, cough, night sweats - extrapulmonary manifestations may involve the I. skin ii. skeleton iii. meninges - endemic I. SOUTHWEST US ii. Wisconsin

Sporotrichosis

- gardener's disease: initial lesion, a reddish nodule that later ulcerates, appears at site of thorn prick or other skin injury - from site of inoculation, fungus spreads along the lymphatics forming subcutaneous nodules + ulcers

Gastrinoma

- gastrin producing neuroendocrine tumor - presents with abdomen pain (upper GI Ulceration), diarrhea, anemia,

aPTT elevated

- hemophelia - vWB factor - heparin therapy - factor 12, 11, 9 def - DIC

Ig Deficiency

- history of recurrent bacterial infections that is highly suggestive of immunodeficiency - diagnosis is via measurement of Ig levels - USMLE question

Electrolytes deficiencies in Chronic Alcoholism

- hypomagnesemia - causing *refractory hypokalemia* I. therefore always checkmangesium levels in alcoholic - correct this and existing hypokalemia if present - hypokalemia - hypophosphatemia I. cause weakness, *rhabdomyolysis, paresthesias, respiratory failure (if severe)* - hypoalbuminemia I. indicates poor nutrition, decerased hepatic synthetic function, or proteinuria

Guidelines for adding insulin to metformin

- if HBA1c > 8.5% then add insulin to metformin

Diagnostic approach to hypercalcemia

- if multiple myeloma suspected - look for elevated M-protein level seen in multiple myeloma - to distinguish primary or tertiary hyperparathyroidism versus familial hypercalcemia hypocalciuria - do *urine calcium/creatinine ratio - HIGH IN PRIMARY/TERITIARY HYPERPARATHYROIDISIM VS LOW IN HYPERCALCEMIA HYPOCALCIURIA*

Major Depressive Episode

- if person qualifies, AUTOMATIC SSRI INITIATION

Indications of tracheostomy

- if prolonged intubation is foreseen - if patient has difficulty maintain airway patency and managing secretions following weaning from mech. ventilation

Major Depressive Episode

- if there is 4 SIGECAPS AND depressed mood OR anhedonia for at least 2 weeks I. depressed mood Ii. Sleep disorder Iii. Loss of interest Iv. Guilt (worthlessness, hopelessness, regret) v. loss of energy Vi. Poor concentration Vii. Dec. Appetite Viii. psychomotor retardation ix. suicidality Tx = SSRI (if patient lifespan is expected decent length) 2nd line = amphetamines or modafinil - stimulants for patients with expected shorter lifespans cuz SSRIs take a while to take effect

Disemminated Gonococcal Infection

- if you see *fever, polyarthralgia, and PUSTULAR (SPECIFIC TRIGGER WORD) rash* think *disseminated gonococcal rash* - Neisseria gonorrhea is most commonly sexually transmitted disease causing septic arthritis - involve wrist, ankles, fingers, and knees - *Dx test of choice = NUCLEIC ACID AMPLIFICATION TESTING OF GENITAL TRACT OR ANOTHER MUCOSAL SITE*

Staph aureus toxin

- in foods such as dairy, salad, meat, eggs

Lumbar Spine Stenosis

- is a degenerative condition where the spinal canal is narrowed resulting in compression of one or more spinal roots - *usually > 60* - *gradual onset (vs lumbar disk herniation)* - combination of 2 factors - *enlarging osteophytes + hypertrophy of ligamentum flavum* - back pain that *radiates to the buttocks + thighs* - *numbness + paresthesias* - sx *worse during walking + lumbar extension; better on flexion of spine* - Dx - confirmed with *MRI*

Isoniazid Therapy

- isoniazid has averse effects: INH Hepatitis + much milder hepatotoxicity - Isoniazid hepatitis presents with clinical manifestation that are similar to those with viral hepatitis - if sighs + sx of INH hepatitis are observed, the drug should be discontinued immediately - approximately 10-20% of patients on isoniazid will develop (subclinical hepatic injury) aminotransferase elevation (<100) within first few weeks of treatment. This hepatic injury is typically self limited and will resolved without intervention (KEEP DOING TREATMENT)

Left Sided Vs R Sided Colon Cancer

1. Left Side Colon Cancer - Present with obstructive dz 2. Right side colon cancer - present w/anemia

hat is most common site of Colon Cancer Mets?

1. Liver ****** - manifest as- I. RUQ pain ii. mildly elevated liver enzymes (50's or 60's - gen <100) ci iii. Firm hepatomegaly **** (CLASSIC)

Causes of Digital Clubbing

1. Lung Cancer 2. ILD 3. CF

Which medicine will you not use in immunotherapy?

BB because it can interfere with epinephrine therapy

How do you medically manage patient with HOCM?

BB improves symptoms CCB for chest pain

SE of albuterol + systemic steroids

B2 agonists - *hypokalemia* - muscle weakness, arrhythmias, EKG abnormalities - *tremor, palpitations, headache*

Pt develops swelling of his arms post exercise. He has no history of trauma. Father died at an early age. wtd?

Test C2, C4

Patient who has been taking Naproxen for arthralgia for the past couple of months presents with complaints of fatigue. Hb is 10.5. Fecal occult positive. EGD negative. wtd next?

Colonoscopy

Pt with low Hb, BRBPR and EKG reveals ST depression. PRBCs transfused. wtd?

Colonoscopy

What would be the next step if you find 2 cm pancreatic cyst with 5mm duct, EUS FNAB negative cytology and CEA WNL.

repeat MRI or CT MR in 2-3 years

What would be the next step if you find 3 cm pancreatic cyst on CT Abdomen, EUS with normal main duct, 3 cm side branch lesion?

repeat MRI or CT-MR in 3-6 months

Which nutrients are absorbed in the ileum?

Fatty acids, amino acids, fat soluble vitamins, B12 and bile salts

Which nutrients are absorbed in the jejunum?

Fatty acids, amino acids, water soluble vitamins and monosaccarides

What is an important cause of hypocalcemia, particularly in alcoholics?

Hypomagnesemia, can decrease level of PTH release & increase PTH resistance

Pt with Hep C on Sofosbuvir, ribavirin and IFN has to be monitored for?

Hypothyroidism/hyperthyroidism

What would be the next step if you find 2 cm pancreatic cyst with thickening of main duct 7mm and CEA elevated.

resect

What is the treatment of a patient with Stage I Colon Cancer?

resection

What is the treatment of patient with Stage IV Colon cancer?

resection (palliative) 5 FU+ Leucovorin + Irinotecan +Bevacizumab (FOLFIRI) + Ziv- Aflibercept

Pt on HCTZ 25 mg/day and still have high blood pressure. What to do next?

restrict fluid and salt in diet

Patient with history of UC presents with diarrhea and leukocytosis, what to do next?

rule out C. diff

ulcerated lesions of the small bowel peers patches and follicles diarrhea and fever

salmonella typhi

Bile acid derivatives- effect on lipids/cholesterol and side effects?

secondary LDL TX- decrease LDL, TGAs and increase HDL bloating, constipation, nausea

Ezetimibe- effect on lipids/cholesterol and side effects?

secondary LDL treatment- decrease LDL and TGAs

Pt with erythematous annular scaly rash with central clearing. Active advancing red border. Scraping with KOH will reveal? mgmt?

septate branching hyphae Topical azole

which valvular disorder can lead to cardiac arrest with even a small hypotensive episode?

sever aortic stenosis

How do you describe a pericardial knock?

sharp early diastolic sound

Spinal Epidural Abscess

trai 1. fever 2. localized back pain 3. neurologic deficits - motor weakness I. i.e. motor weakness, paresthesias, bowl/bladder dysfunction

What is the triad of clinical features seen with disseminated gonococcal infection?

"STD" (Synovitis, Tenovitis, & Dermatitis) 1. Polyarthralgias 2. Tenosynovitis 3. Vesicular skin lesion

Dementia with lewy bodies causes: (3)

1. Alterations in alertness (cognitive impairment) 2. Visual hallucinations 3. EPS (parkinsonism)

Bipolar 1

1. At least 1 manic episode 2. Psychotic symptoms if present must occur EXCLUSIVELY during mood episodes

List 4 AV nodal blockers?

1. BBs 2. CCBs 3. Digoxin 4. Adenosine

US used in which gallbladder pathologies as first step?

1. Cholelithiasis 2. Cholecystitis 3. Choledocholithiasis

Hep C is RF for what diseases?

1. Cryoglobulinemia 2. Hepatocellular cancer 3. Cirrhosis 4. Glomerulonephritis

Common AEs of these HIV drugs? -Indinavir (PI) -Didanosine (NRTI) -Abavacair (NRTI) -Nevirapine (NNRTI)

1. Crystal-induced nephropathy 2. Pancreatitis 3. Hypersensitivity syndrome *Lactic acidosis results from NRTIs in general 4. Liver failure *SJS can be caused by any NNRTI

Causes of normal AG metabolic acidosis? (low serum HCO3- and hyperkalemia) (6)

1. Diarrhea 2. Fistulas 3. Carbonic anhydrase inhibitors 4. RTA 5. Ureteral diversion (ileal loop) 6. Iatrogenic

bronchoalveolar lavage

- method of sampling lung cells during bronchoscopy - has greatest dx utility in *suspected malignancy + opportunistic infection*

Nephrotic Syndrome Types

- minimal change disease - children - membranous glomerulopathy - adults - IgA nephropathy I. present with meaturia after URI ii. latency period between infection + actual onset of disease iii. serum complement levels are normal in such cases - FSGS I. associations: *African American, HIV, heroin use, Morbid obesity* - Minimal Change Disease I. *children* ii. *NSAIDs + Hodkin Lymphoma*

Typical CSF findings in bacterial meningitis? (3)

1. Elevated WBCs 2. Elevated protein 3. Decrease glucose *Meningococcal infections will present with petechiae & purpura

What are the 2 drug options for TXing chronic HBV?

1. Entecavir 2. Tenofovir *These have less liver toxicity AEs

Histrionic Personality dIsorder

1. Excessive emotionality 2. Excess attention seeking

Define & list common RFs (3) for Molluscum contagiosum?

1. Firm, flesh-colored, dome-shaped, umbilicated papules 2. Cellular immunodeficiency (commonly seen in HIV pts), CS use, & chemotherapy

In 2 scenarios (memorize) of 1. Acute GI bleeding for patients who are otherwise stable but have Hb < 7 g/dL OR 2. A higher threshold of Hb < 9g/dL for pts w/sx related to anemia or ACS w/active ischemia you will do what action?

1. GIVE PACKED RBCs (PRBCs) to inc. O2 carrying capacity in patients

Cirrhosis due to hemochromatosis or alcoholism will have the following effects: (6)

1. Hypogonadism 2. Telangiectasias 3. Palmar erythema 4. Testicular atrophy 5. Gynecomastia 6. Erectile dysfunction

Main 3 side effects with radioactive iodine?

1. Hypothyroidism 2. Worsening of ophthalmopathy 3. Long term radiation effects

65 y/o woman comes in w/ 2mo history of fatigue + dyspeea on exertion. BP 162/83 and rectal exam shows guiac negative brown stool. Hb is 8.6 w/ normal platelets, MCV of 76. Fe is dec, TIBC inc. inc ferritin. What to do next?

1. IF YOU SEE ELDERLY + FE DEFICIENCY ANEMIA - IMMEDIATELY THINK GI CAUSE VIA BLOOD LOSS UNTIL PROVEN OTHERWISE. 2. 1st step = FOBT; 2nd step a single negative FOBT - do COLONSOCOPY/ENDOSCOPY (MUST DO BOTH STEPS)

45 y/o M presents for a routin checkup b/c he wishes to purchase life insurance. He says he feels perfectly health w/no complaints. His medical hx is significant for a remote bout of cellulitis and a fractured clavicle from playing football in high school. He works as a supervisor at a corporate call corporate call center. He is monogamous + lives w/wife - labs show inc AST + ALT. Next step?

1. IN evaluating asx elevation of amintransferases, FIRST STEP - is to TAKE A THOROUGH HX to rule out the more common hepatitis risk factors (eg alcohol or drug use, travel outside of country, blood transfusion, high risk sexual practices)

Anytime There is Elevation of Alkaline Phosphatase by itself, first step?

1. INDICATES CHOLESTASIS - FIRST STEP = RUQ ULTRASOUND to assess for INTRA OR EXTRAHEPATIC CAUSE OF BILIARY OBSTRUCTION

TX of histoplasma: -Mild-to-mod DS -Severe DS (fever >103.1, lab abnormalities, fungemia)

1. Itraconazole 2. IV AMP-B for 2 weeks followed by itraconazole for x 1 yr *Fluconazole if pt can't tolerat itraconazole

Phenelzine

1. MAOI - for depression 2. for REFRACTORY CASES

TSS caused by Staph. aureus is associated with? (3)

1. Menstruation (tampons) 2. Nasal packing 3. Post-surgery infections *Pts usually develop fever, myalgias, marked hypotension, & diffuse erythematous macular rash (erythroderma) that can progress to multiorgan involvement.

Dopamine Pathways in Schizophrenia

1. Mesolimbic - inc. dopamine activity here causes positive symptoms (suppressed by TYpical antipsychotics) 2. Mesocortical - inc. dopamine act. here causes negative symptoms (suppressed by atypical antispychotics) 3. Nigrostriatal - when antipsychotics cause dec. dopamine here, note parkinsonian symptoms + EPS symptoms 4. tuberoinfundibular - antipsychotics dec. dopamine here to cause hyperprolactinemia, galactorrhea, and amenorrhea, gynecomastia, and sexual dysfunction

Thiazide diuretics unfavorable metabolic side effects (3) & electrolyte abnormalities (3)?

1. Metabolic effects: -Hyperglycemia -Increased LDL & TGs -Hyperuricemia 2. Electrolyte disturbances -Hyponatremia -Hypokalemia -Hypercalcemia

Ziprasidone

1. Metabolic syndrome 2. prolonged QT syndrome (DO ECG Monitoring)

Clozapine SE

1. Metabolic syndrome, 2. agranulocytosis (weekly CBCs for 1st 6 months)

Liver Mets

1. Mets are the most COMMON MALIGNANT NEOPLASMS of ADULT LIVER + x20 more common than Hepatocellular Carcinoma 2. LYMPH NODES are most common source of MET SPREAD; LIVER is 2nd MOST COMMON SITE OF SPREAD i. liver b/c large size, dual blood supply, high perfusion rate, and the filtration function of kupffer cells. 3. Clinical Presentation of Liver Mets - variable - look for liver involvement w/ hepatomegaly, jaundice, cholestasis, elevated ALK PHOS 4. US + CT to assess

Crigler Najjar 2

1. Milder version Crigler Najjar 1 2. AR 3. Indirect Bilirubin levels < 20 mg/dL + survival inton adulthood w/no kernicterus or neurologic impairment 4. liver enzymes + histology are normal 5. Tx = often unnecessary in milder cases - 6. RESPONSIVE TO IV PHENOBARB + CLOFIBRATE CAN REDUCE SERUM BILIRUBIN

What are the main RFs for development of an AAA? (5)

1. Older age (>60) 2. Cigarette smoking 3. Family HX of an AAA 4. White race 5. Athersclerosis

Spontaneous Bacterial Peritonitis

1. PRES w/ABD DISTENTIN + PAIN, maybe fever 2. Predisposing factors = ASCITES (LOOK FOR ON PE) + CIRRHOSIS)

Panic DIsorder

1. Palpitations, sweating, trembling or shaking. SOB, choking sensations, chest pain, Nausea, dizziness, chills or heat sensations, paresthesia, fear of dying 2. At least 1 attack followed by 1 or both of following for >1 month I. worry about additional panic attacks Ii. Changes in behavior related to attacks (avoidance) 3. Tx short term = benzodiazepines Tx long term = SSRI/SNRI + CBT 4. Comorbidities I. MDD Ii. Agoraphobia Iii. SUBSTANCE abuse Iv. Bipolar disorder

Define multiple system atrophy (Shy-Drager syndrome)? (3)

1. Parkinsonism 2. Autonomic dysfunction (postural hypotension, abnormal sweating, disturbance of bowel/bladder control, impotence, etc..) 3. Widespread neurological signs (cerebellar, pyramidal or LMN)

Aripiprazole

1. Partial Agonist D2 receptors (dopamine) 2. Atypical Antipsychotic BUT BECAUSE PARTIAL AGONIST (VS ANTAGONIST THAT RISPERIDONE IS) DOES NOT CAUSE GALACTORRHEA + AMENORRHEA

Oppositional Defiant Disorder

1. Pattern of angry/irritable mood + argumentative/defiant behavior toward authority figures 2. Less severe than conduct disorder + does not include aggression 3. DO NOT include aggression toward people or animals, stealing, or destruction of property

OCD Treatment

1. SSRIs (Paroxetine, Sertraline, Fluoxetine) or Clomipramine = 1st LINE 2. 2nd line = fluvoxamine

Major RFs for SQUAMOS CELL CANCER OF ESOPHAGUS

1. Smoking **** 2. Alcohol *** 3. dietary deficiency of Beta carotene, Vit B1, Zinc, Selenium, environmental viral infections, toxin producing fungi, hot food + beverages, pickled vegetables, food rich in N-nitroso compounds

3 main causes of secondary bacterial PNA?

1. Strep. pneumoniae 2. Staph aureus 3. Haemophilus influenzae

Post traumatic stress disorder

1. Symptoms of anxiety after witnessing a bad event 2. Relive event through FLASHBACKS OR NIGHTMARES 3. Avoid stimuli related to trauma 4. Feel detached rom others 5. GREATER THAN ONE MONTH

What conditions are these markers found in: -Anti-topoisomerase-I Abs -RF -Antimitochondrial Abs -ANCA -Anti-smooth muscle Abs

1. Systemic sclerosis 2. RA (Also, SLE, sjogrens, dermatomyositis, HCV infection) 3. Primary biliary cirrhosis 4. Wegners ("granulomatosis with polyangitis") 5. Autoimmune hepatitis

Imipramine

1. TCA 2. although medications in this class are not considered 1st line agents for depression 3.

Amitryptyline

1. TCA 2. when there is DEPRESSION + I. DIABETIC NEUROPATHY or ii. MIGRAINE HEADACHE (PREVENTION)

What prophylaxis & vaccinations should all post-transplant pts receive?

1. TMP-SMX (PCP, toxoplasmosis, nocardiosis, UTIs, PNA) + Ganciclovir/Valganciclovir (CMV infections) 2. Flu, pneumococcus, & Hep B

Osteopenia/osteoporosis in a pt with ankylosing spondylitis is mediated by? (2)

1. TNF-α 2. IL-6

Carbamazepine

1. Tx for BIPOLAR + SEIZURES 2. SE = i. APLASTIC ANEMIA ii. SIADH

Buproprion

1. Tx for depression 2. help w/smoking cessation also

Lamotrigine

1. Tx of EPILEPSY + BIPOLAR DISORDER 2. SE i. RASH ii. Steven Johnson Syndrome + TEN can develop

Characteristic findings of systemic blastomycosis? Also, where does this infection occur? DX? TX?

1. Ulcerated skin lesions & lytic bone lesions. CXR findings similar to TB & histoplasmosis 2. Found in the great lakes, Misssissippi river valley, & ohio river basins (Wisconsin has the highest infection rate) 3. Broad-based budding yeast grown from sputum 4. Itraconazole or AMP-B

Most common complications of untreated hyperthyroidism - most dangerous + most common

1. Untreated Hyperthyroid patients are also risk for cardiac tachyarrhythmias INCLUDING AFIB 2. OSTEOCLASTIC BONE ACTIVITY

Pronator drift is an indication of? What about upward drift?

1. Upper motor neuron lesion 2. Cerebellar lesion

3 vagal maneuvers that increase vagal tone and decrease conduction through the AV node?

1. Valsalva 2. Carotid sinus massage 3. Immersion in cold water

Pts with pernicious anemia need to be monitored for what? (2)

1. Vitamin B12 deficiency 2. Intestinal-type gastric cancer & gastric carcinoid tumors

Selenium Deficiency

1. WHEN GIVEN TPN 2. deficiency = CARDIOMYOPATHY

What are the MC AEs of erythropoietin therapy? (4)

1. Worsening of HTN 2. HAs 3. Flu-like symptoms 4. Red cell aplasia

Homicide RFs

1. Young Male 2. Unemployed 3. Impoverished 4. Access to firearms (GREATEST RF FOR COMPLETING HOMICIDE) 5. Substance abuse *** 6. Antisocial Personality Disorder 7. History of violence *** 8. Impulsivity *** 9. Hx of childhood abuse *** = important ones

Crohn's Presentation Classic

1. Young Pt w/FIBROSTENOTIC OBSTRUCTING PATTERN or PENETRATING FISTULOUS PATTERN*** - (VS PERSISTENT BLOODY DIARRHEA + GROSS RECTAL BLEEDING + WEIGHT LOSS + FEVER) 2. can involve GI Tract anywhere from MOUTH TO ANUS - USUALLY RESTRICTED TO ILEUM 2.5. TRANSMURAL INVOLVEMENT 3. Common stuff = intestinal fistula, strictures, anal disease 4. ALL CHRONIC INFLAMM DISEASES HAVE ANEMIA + REACTIVE THROMBOCYTOSIS 5. pathognomonic = NON CASEATING GRANULOMAS 6. SKIP LESIONS, COBBLESTONE APPEARANCE OF COLON, CREEPING FAT APPEARANCE OF MESENTERY, FISTULAS, FISSURES, PERIANAL DZ

Aspergilloma

1. composed of fungal hyphae, inflammatory cells, fibrin, and tissue debris that *collect in pre existing lung cavity* 2. Cavitary lung dzs complicated by aspergillosis include: I. tb ii. sarcoidosis iii. bronchial cysts iv. neoplasm

After Treating an episode of major depression and response Is seen by patient - can see improvement of symptoms - next step?

1. continue antidepressant for extra 6 months following patient response - if multiple episodes of depression have occurred, maintenance therapy will be necessary for longer period of time

Legal Standard for Hospitalization

1. danger to self or others 2. grave disability 3. or presence of mental illness

Common Acute Life Threatening Reactions associated with HIV therapy include:

1. didanosine induced pancreatitis 2. abacavir related HS syndrome 3. Lactic acidosis secondary to use of any of the NRTIs 4. Steven Johnson Syndrome secondary to use of any of the NNRTIs 5. Nevirapine associated liver failure 6. *not life threatening but common SE - UWORLD Q: Idinavir -- protease inhibitor - CRYSTAL INDUCED NEPHROPATHY (NEEDLE SHAPED CRYSTALS), present as flank pain + red urine*

Most common sources of PE

- most common source of symptomatic PE are *proximal deep leg veins (MEANING ABOVE KNEE)* - other sources include *calf veins, renal veins, pelvic veins, UE veins, and right heart* - LE DVT is divided into 2 categories - I. proximal vein thrombosis (above the knee) - - include *iliac, femoral, and popliteal veins - most common source of symptomatic PE from DVT* ii. calf vein thrombosis - common to get DVT but very rare to get PE

Causes of Recurrent Pneumonia

- most concerning cause of recurrent pneumonia - not necessarily most common though is *bronchogenic carcinoma* I. smoking is the primary RF for bronchogenic carcinoma ii. *next step in patient with smoking + recurrent pneumonia is CT (due to suspicion of bronchogenic carcinoma)* iii. *next next step in above scenario once CT is done - BRONCHOSCOPIC (IF CENTRAL) OR CT -GUIDED BIOPSY (IF PERIPHERAL SUSPECTED)

Klebsiella pneumonia

- most often causes pneumonia in diabetics, alocholics, and nosocomial setting - *gram (-) encapsulated rods* - *currant jelly sputum, cavitation, and empyema are common*

Erythema Nodosum

- multiple, tender, erythematous nodules/plaques on *SHINS/LE* that is often associated w/AI disease or infections - do not usually ulcerate - resolve often after 2-8 weeks w/o scarring

Heroin Withdrawal

- muscle spasms - joint pain - nausea + vomiting - diarrhea - abd cramps - rhinorrhea + lacrimation + sweating + PUPILS DILATED

Most common causes of Proximal Muscle weakness

- non elevated CK causes i. polymyalgia rheumatica, glucocorticoid induced therapy - CK elevation causes i. hypothyroidism, statins, inflammatory causes (poly and dermatomyositis)

Features of Carcinoid Syndrome

- normally founds in *distal small intestine, proximal colon, and lung* - secrete *histamine, serotonin, VIP that are all METABOLIZED IN LIVER* - in the case of carcinoid tumor mets to liver, the 3 listed above can't be metabolized, get released into circulation - heart manifestation specifically includes - TRICUSPID REGURGITATION - reason for niacin deficiency - serotonin synthesized in carcinoid tumor via utilizing tryptophan - this depletes reserve of Trp for making niacin i. niacin deficiency - dermatitis, dementia, diarrhea, glossitis, etc

Screening for Bladder Cancer

- not recommended even in patients who are at risk for developing disease (DX) - average age of diagnosis = 65 years

bleeding time

- platelet dysfunction - thrombocytopenia - vWBF

Signs of Pulmonary INfarction

- pleural effusion on affected side - wedge shaped opacity in infarcted segment (Hampton's Hump)

Leading Cause of Pneumonia in nursing home patients

- pneumonia is the leading cause of death in nursing homes, and Streptococcus pneumonia is the most common cause of pneumonia in nursing home residents. - also the most common cause of community acquired pneumonia in adults

Zinc Deficiency

1. in animal prot, whole grains, beans, nuts 2. digested in JEJUNUM 3. TPN MAY LACK ZINC 4. Deficiency = ABN TASTE, ALOPECIA, BULLOUS OR PUSTULAR LESIONS SURROUNDIG BODY ORIFICES and/or extremities, IMPAIRED WOUND HEALING

Amphetamines

1. inc. NEp + Dopamine

Obstructive Uropathy

- present with *flank pain, low-volume voids with or w/o occasional high volume voids, and if bilateral, renal dysfunction* I. if patient has hx of total nephrectomy and has sx, think of unilateral obstructive uropathy due to renal calculi ii. sx that support the dx = *flank pain (renal capsular distention), poor urine output (mechanical obstruction to urine outflow)*, *intermittent* episodes of high volume urination when the obstruction is *overcome* by large volume of retained urine (*post obstructive diuresis)* iii. excessive diuresis - *potassium wasting + dehydration - may cause weakness* - differentials I. Renal artery stenosis - will cause hypertension w/or w/o kidney injury; does not cause flank pain or urinary sx ii. interstitial nephritis - fever, rash ,AKI, eosinophiluria, WBC casts due to drug reaction

Mallory Weiss Tear

- presentation is a drinker that has been VOMITING INCESSANTLY i. inc intra epigastric pressure too much ii. tear in ARTERIES (****) AT DISTAL ESOPHAGUS to PROXIMAL STOMACH (MUCOSAL) iii. Next step - usually resolve spontaneously but if not, vasopressin or Endoscopic injection required

Nonclassical CAH presents like what?

- presents similarly to PCOS

In the case of Inc pH w/dec pCO2 - what is next step?

- respiratory alkalosis - therefore DEC VENTILATION

Cervical Spondylosis

- scenario I. 60 y/o m c/o right sided neck pain + numbness over posterior surface of forearm. Had several such episodes over last 2 years that responded to NSAIDs. Limited neck rotation + lateral bending now. There is decreased pinprick sensation on posterior aspect of right forearm. No m. weakness. What is likely finding on neck radiography of patient? A: Bony spurs - history of chronic neck pain is typical - limited neck rotation + lateral bending due to *osteoarthritis + secondary neck spasm = classic* - sensory deficit - due to osteophyte induced radiculopathy - *radiographic findings = those classic of OA b/c that is what causes cervical spondylosis - narrowing of disk spaces + hypertrophic vertebral bodies + bony spurs + sclerotic facet joints*

Schizophreniform Disorder

- schizoaffective disorder - need to have at least 2 week history of delusions or hallucinations in absence of prominent mood symptoms - delusional disorder - delusion of greater than one month, no other psychotic symptoms + NO IMPAIRMENT FUNCTIONING

Osteoid Osteoma

- sclerotic + cortical lesion on imaging with central nidus of lucency - typically causes pain that is worse at night but unrelated to activity - pain relieved by NSAIDs

Hypertensive Nephrosclerosis

- seen in patients with chronic hypertension - associated with retinopathy, LVH, progressive renal failure, and mild proteinuria (<1g/day) - kidneys = small + hepatomegaly is not present

S. aureus pneumonia

- serious *complication of influenza pneumonia *(classic association: look for in test question "JANUARY" and "productive cough after initial complaints of fever, myalgias, etc)* - can occur in children + adults - must treat with anti staphylococcal antibiotics when post influenza pneumonia suspected

What is purpose of incentive spirometry?

- to prevent atelectasis in bed bound pts - esp. post surgery

SE of Rifampin

- turns urine red - *"DRUG REACTION"*

Scaphoid Fractures

- typically during forceful hyperextension of wrist - pain localizes to anatomic snuffbox

rash of rocky mountain spotted fever

- typically petechial - start in extremities, usually OCCURS few days AFTER FEVER ONSET

Ecthyma Gangrenosum (EG)

- typically present as *hemorrhagic pustules w/surrounding erythema* that evolve into *necrotic ulcers* - skin infection due to *pseudomonas aeruginosa* - occur most commonly in setting of *profound neutropenia + P aeruginosa bacteremia*

Where are neurophatic ulcers likely to occur?

- under bony pronminences such as *metatarsal heads underneath* - *appearance = PUNCHED OUT OR UDNERMINED BORDER* - *peripheral sensory neuropathy can be documented by testing for pressure sensation with a 10g monofilament (place on plantar surface)*

Post Exposure Prophylaxis for rabies

- unvaccinated individuals - should receive PEP with active + passive immunization

Drugs with Anticholinergic Properties can cause urinary _________

- urinary retention - b/c as above flashcard showed, inhibition muscarinic receptors causes inhibition of contraction of detrusor + inhibition of relaxation of trigone + urinary sphincter

Evaluation of Vertebral Osteomyelitis

- usually present as *fever (may or may not be present), back pain, and exquisite focal spinal tenderness* - Staph Aureus accounts for 50% of cases of recent pyogenic spinal osteomyelitis - can result in epidural abscess if infxn spreads posteriorly - *Leukocyte count may be normal but ESR + CRP ELEVATED VERY HIGH* - evaluation - includes blood cultures + inflammatory markers (ESR + CRP). - MRI = Gold Std Dx

Nocturnal Penile tumescence

-helps differentiate psychogenic from organic causes of male erectile dysfunction - it is positive (present) in psychogenic causes + negative in organic causes (not present)

Patient with Barrett's esophagus and low grade dysplasia seen on EGD, 6 months later still low grade dysplasia is found. When to repeat EGD?

1 year

For General Population, lifetime risk of developing bipolar disorder is ____

1%

How often would you repeat TTE in a patient with moderate AS who is asymptomatic?

1-2 years

Risk Factors for diabetic Foot Ulcers

1. *diabetic neuropathy - most important contributing factor * 2. previous foot ulceration 3. vascular disease 4. foot deformity *monofilament test = predicts risk of future ulcers* = *TEST Q*

Approach to solitary nodules

1. *low risk pt: <40 + non smoker* with *solitary nodule* I. *next step = OLD X ray* - if no change within last 12 months - consider it benign. ii. next next step = follow for 12 months via CXR every 3 months to ensure no growth or sx 2. *high risk pt = > 40 or Smoker* with *solitary nodule* I. *next step = CT followed by FINE NEEDLE ASPIRATION*

Hyperprolactinemia is a side effect of which Psych drugs?

1. 1st generation antipsychotics + Risperidone (only 2nd gen to have this SE)

DX of acute pancreatitis requires 2 of the following criteria:

1. Acute onset severe epigastric pain radiating to the back 2. Increased Amylase/Lipase levels to > 3 times normal 3. Characteristic ABD imaging findings (focal/diffuse pancreatic enlargement)

Rocky mountain spotted fever

1. Agent: Rickettsia rickettsii (Gram negative bacteria Rickettsia rickettsii may cause what? South central US, classsic rash (*red rash on both wrists and ankles that spread centrally with involvement of the palms and the soles*) systemic symptoms-*high fever*, headache, *myalgia, conjunctivitis*. can cause death if not treated with the first 8 days of symptoms 2. disease also called *erlichiosis*

Nicotine Withdrawal

1. irritability, anxiety, depression ,insomnia, restlessness, poor concentration, inc. appetite, weight gain, bradycardia

Schizoid Personality Disorder

1. lifelong pattern of detachment from social relationships + restricted range of emotions 2. no interest in socialization 3. few supports other than family members

Amphetamine Withdrawal

1. like cocaine - irritability, inc. appetite, psychomotor agitation, fatigue

signs of pulmonary venous congestion

1. seen in *CHF patients* 2. cardiomegaly 3. cephalization of pulmonary vessels w/prominent vascular markings 3. kerley B lines 4. pleural effusions

Toxic Megacolon

1. toxic megacolon i. when young pt in 20s w/lower abd pain, bloody diarrhea, and tensmus over past several weeks (suggestive of IBD) suddenly presents with ACUTELY WORSENED FEVER, ELEVATED WBC, HYPOTENSION, TACHYCARDIA INDICATING SEPSIS - THINK TOXIC MEGACOLON ii. SOMETIMES TOXIC MEGACOLON IS 1st PREZ OF UC iii. diagnostic criteria of toxic megacolon (AT LEAST 3 OF FOLLOWING) 1) fever > 38 C (100.4F) 2) HR > 120 3) Neutrophilic Leukocytosis > 10500 4) Anemia PLUS ONE OF FOLLOWING 1) volume depletion 2) altered sensorium 3) electrolyte disturbances 4) Hypotension iv. NEXT STEP ON PRESENTATION = XRAY - CONFIRM PRES OF DILATED COLON > 6CM v. Tx = NG tube decompression, steroids if caused by IBD or antibiotics if 2ndary to infxn, and bowel rest vi. other causes - ischemic colitis, volvulus, diverticulitis, infections like C Dif, obstructive colon cancer (MEANING LEFT SIDED COLON CANCER - R SIDED COLON CANCER PRES W/ANEMIA)

Screening test for CAH?

17-Hydroxyprogesterone levels

55 year old F with 1 tubular adenoma 2.5 cm removed. When do you do next colonoscopy?

3 years

Patient found to have Barrett's esophagus on EGD with low grade dysplasia. On repeat EGD 6 months later, biopsy reveals metaplasia, when do you repeat following EGD?

3 years later

How often would you repeat TTE in a patient with mild AS who is asymptomatic?

3-5 years

Metabolic Syndrome

5 criteria - must have at least 3 1. abdominal obesity: men waist circumference >40 in; women waist circumference > 35inc 2. fasting glucose > 100-110 mg/dL 3. Blood pressure > 130/80 4. triglycerides > 150mg/dL 5. HDL cholesterol (MEN < 40mg/dL vs WOMEN <50 mg/dL - *key pathogenic factor* for development of type 2 diabetes mellitus + associated abnormalities such as HTN + DYSLIPIDEMIA + REST OF (*METABOLIC SYNDROME* = *INSULIN RESISTANCE* (UWORLD)

55 year old F with 2 adenomas <1 cm removed, when do you do next colonoscopy?

5-10 yeras

Which medication would you use for maintenance treatment in UC or Crohn's disease?

5-ASA +/- flagyl

Define angiodysplasia?

A common cause of recurrent or occult painless lower GI bleeding in pts > 60 yo. Have been reported to cause lower GI bleeding in pts with aortic stenosis (Heyde's syndrome) & ESRD

TX of cryptococcal meningoencephalitis?

AMP-B + Flucytosine *Maintenace with fluconazole

What are the immunologic markers in discoid lupus?

ANA - Anti ds DNA - Anti Sm - Lesional direct immunofluorescence +

MCC of hospital acquired acute renal failure

ATN

Pt with chronic A fib refractory to medical treatment. wtd?

AV node ablation and pacemaker- need to anticoagulant for life

65 year old m with PMH severe AS presents with recurrent melena. Colonoscopy reveals angiodysplasias. What is the best treatment?

AVR

D-xylose test with oral xylose is used to assess?

Absorptive capacity of the proximal small intestines. Used is the DX of celiac sprue

Pt who is a chronic heavy drinker of beer had myalgias and a HA. Now presents with N/V and abdominal discomfort. AST 11,000 and ALT 9000. INR 3.0. Most likely diagnosis? Treatment?

Acetaminophen toxicity Give NAC

Patient with dysphagia and normal EGD. Barium swallow shows diffuse dilatation and narrowing of the lower esophagus. Most likely diagnosis?

Achalasia

Middle aged patient who presents with acne like lesions on face and has flushing with exertion or in the sun. You also note fine telangiectasias and scattered tender papillose. Dx? treatment?

Acne rosacea Oral Tetracyclines Topical Metronidazole

What is the precursor to squamous cell carcinoma?

Actinic keratosis

Indications for PCI

Acute STEMI ST elevation with chest pain > 12 hours MI with shock and pt is <2 hours away from PCI center and <75 STEMI post CABG pts if tPA contraindicated

Fever (>103) + Jaundice + RUQ pain - what do you think

Acute cholangitis - usually due to biliary obstruction i.e. gallstones.

5 MCCs of acute acalculous cholecystitis?

Acute inflammation of the GB in the absence of gallstones: 1. Extensive burns 2. Severe trauma 3. Prolonged total parenteral nutrition 4. Prolonged fasting 5. Mechanical ventilation

Pt with HTN on HCTZ 25 mg/day. BP drops from 160/90 to 148/86. Exam reveals S4+. Wtd?

Add ACEi

Patient with sore throat then develops hematuria about 10 days later. What is the pathophysiology?

Ag/Ab complex deposition- Type III HS reaction

When would you recommend against colonscopy screening?

Age >75 years

What happens to murmurs with increased volume?

All increase except MVP and HOCM

55 year old pt with melanoma of leg has LN +. Lesion was excised and further LN dissection was done. What further TX can improve survival?

Alpha interferon

What drugs increase Digoxin level?

Amiodarone Spironolactone Chlorthalidone HCTZ

Pt w/panacinar empysema + history of repeated attacks of breathlessness that forced him to stop joggin. Recently has had anorexia, general malaise of insidious onset. Physical Exam of gynecomastia, scattered spider nevi, hepatomegaly. Albumin = 3.7; Total Bili = 6.3; Alk phos = 66; AST = 194; ALT = 215 Dx?

A: Alpha 1 antitrypsin deficiency I. on chr 14 ii. European heritage people have this lacking iii. granules in hepatocytes as result - stain w/PAS + resist digestion by DIASTASE iv. deficiency cause PANACINAR EMPHYSEMA v. LIVER DZ IN 15% HOMOZYGOUS PTS - affected pts show hepatosplenomegaly, cholestasis, elevation of hepatocellular enzymes - most severe consequence = CHOLESTASIS vi. Dx = SERUM [A1AT] + THEN GENETIC TESTING FOR CONFIRMATION vii. Testing - indicated in all patient with premature onset of chronic bronchitis, emphysema, and dyspnea, and non smokers suffering from COPD Learning point = A1AT DEFIC = ASSOC W/PANACINAR EMPHYSEMA + CIRRHOSIS

What is the diagnostic criteria for HNPCC?

AD, need to have at least 3 relatives with colon cancer. One must be primary of other two, two generations with colon cancer. May have extracolonic cancer as well. At least one relative with CRC <50 years

48 year old M presents with acute onset of periumbilical pain. Exam reveals a HR of 130/min irregularly irregular. BP is 110/70. Temp 99F. wtd?

Arteriography- do anticoagulation first, then angion then tPA

Prednisone is tx for what anemia disorder?

Autoimmune hemolytic anemia

26 year old woman with jaundice. ALT 350, alk phos 115, ANA +, ASMA + 1280, AMA negative, IgG elevated, liver biopsy shows piecemeal necrosis of hepatocytes. Most likely diagnosis? treatment?

Autoimmune hepatitis Steroids +/- azathioprine

What is the role of HLA II antigen and where is it found?

B cells, macrophages, langerhan cells, dendritic cells. Presented to T4 Helper cells. Responsible for cell mediated immunity

Erythropoietin is a treatment for?

Anemia of chronic disease, anemia associated with CKD, and transient BM failure after chemo or bone marrow transplantation

Patient presents with painful "cuts" in the corner of her mouth. Dx?

Angular chelitis 2/2 B2 (Riboflavin) deficiency

What is the first sign of digoxin toxicity?

Anorexia

60 year old M with h/o CAD with severe chest pain radiating to the back. BP 190/100. HR 90/min. Decrescendo murmur. most likely dx? Best test to do? wtd next?

Aortic dissection TEE best, but if don't have can do CT with contrast give BB and IV nitroprusside then surgery

The most common heritable hyperlipidemia is familial combined hyperlipidemia. The best test would be?

Apo Protein B

Side effects Cyclophosphamide

- *acute hemorrhagic cystitis* - *bladder carcinoma*

What is the goal blood pressure for a patient <60 yo?

<140/90

What is the goal blood pressure for a patient >60 yo?

<150/90

How do you prevent a re-bleed in a patient with PUD?

PPI

How do you treat ZE?

PPI or resection of tumor

Treatment of Akisthisia in Neuroleptic SE

PROPANOLOL

What is Koebner's phenomenon?

abrasion of skin resulting in psoriatic lesion in that area in a patient with psoriasis

Pancreatic + Biliary Duct System

-

meningovascular syphillis

1-10years after syphillis infection stroke and seizure symptoms

What vitamins must you replace in short bowel syndrome?

A,D, E, K, B12, Ca, Mg, Zn

HTN and CHF

ACEI

Pt received successful series of Hep B vaccine. What will most likely be positive

Anti-HBs

Differentiation of exudative from transudative fluid?

The Light's criteria define an exudate as having ≥ 1 of the following: 1. Pleural fluid protein/serum protein ratio >0.5 2. Pleural fluid LDH/serum LDH ratio >0.6 3. Pleural fluid LDH >2/3 of the upper limit of normal for serum LDH Causes of exudative effusions: Infections (PNA, tuberculosis), malignancy, PE, CT DS, & iatrogenic causes

Pt with Hep B has decompensated cirrhosis. Viral load >10,000. wtd?

Transplant- treat Hep B first if possible

syphillitic meningitis

early neurosyphilis, 1st year

40 year old ex IVDU presents with severe seborrheic dermatitis. wtd?

check HIV

The most common cause of sudden cardiac death is?

ischemia

tt of aspergillosis

voriconazole

VIPoma (pancreatic cholera)

Clinical Presentation - *water diarrhea* - *hypo-or achlorydia* due to dec gastric acid secretion - *associated flushing*, lethargy, N/V, muscle weakness/crampness (due to hypokalemia)* Lab Findings - *hypokalemia (intestinal potassium secretion)* - *Hypercalcemia* - inc bone resorption - *hyperglycemia* - due to increased glycogenolysis Diagnosis - *water diarrhea w/VIP > 75 pg/mL* - *test of choice - ABDOMINAL CT to localize tumor in PANCREAS - USUALLY IN TAIL* Treatment: i] IV volume repletion + ii] OCTREOTIDE TO DEC DIARRHEA + iii] POSSIBLE HEPATIC RESECTION IN PTS W/LIVER METS *LOOK FOR COEXISTING MEN SYNDROME* *VERSUS CARCINOID SYNDROME - bronchospasm, diarrhea, flushing, DO NOT INVOLVE PANCREAS*

PPIs side effects?

Can predispose to i. long term acid suppression giving IMPAIRED CA2+ ABSORPTION - OSTEOPOROSIS ii. inc colonization pathogens of UPPER GI TRACT - INC CHANCE OF PNEUMONIA iii. PREDISPOSE TO C DIF COLITIS

65 year old F presents with new onset CHF. Loud S4 and soft S3 +. JVD 12 cm. Few basal rales heard. EKG reveals BBB. ECHO reveals EF 25%. Pt is started on IV lasix and IV ACEi and her symptoms improve. What is the most appropriate next diagnostic step?

Cath

Pt s/p small bowel resection and has significant diarrhea the following day. What is the most likely cause and treatment?

Bile acid malabsorption. Treat with cholestyramine

Pt with Hep B with ALT 1x ULN. Viral load >20,000. wtd?

Biopsy

A young woman suffers laceration which is cleaned and sutured. An antibiotic cream is applied with occlusive dressing. 3 days later the presents with itching and pain. On exam the band aid is uncovered revealing clean suture line but surrounding erythema and eruptive vesicular lesions. Most likely diagnosis is?

Contact dermatitis

Medical records clerk presents with vesicular lesions which are itchy on his fingers. Most likely diagnosis?

Contact dermatitis

You are consulted to clear cirrhotic patient for an elective major surgery. MELD 16. Recommendation?

Contraindicated

What is the most important prognostic factor for melanoma?

Depth of tumor- <0.76 mm- 99% alive at 5 years >3 mm <50% alive at 5 years

Bipolar and Related Disorders

Diagnosis of hypomanic + manic episodes - require elevated/irritable mood + increased energy plus 3 of following symptoms (4 if mood is irritable) - thnk if mnemonic DIGFAST 1. Distractability 2. Impulsivity 3. Grandiosity 4. Flight of Ideas 5. Activity (inc. goal directed activity/psychomotor agitation) 6. Sleep (dec. need) 7. Talkativeness/pressured Speech

All inflow into the ventricles gives you what type of murmur?

Diastolic

What drugs do not improve survival in CHF?

Digoxin (improves functional capacity, decreases hospitalizations) CCB Lasix

In what diseases do you see finger clubbing?

Familial Hypertrophic osteoarthropathy Lung: Cancer, empyema, idiopathic lung fibrosis Heart: Congenital heart disease, bacterial endocarditis GI: cirrhosis, IBD Cancers Pregnancy

65 year old M presents with fatigue, chronic diarrhea and itching. Pallor +. Exam shows bulls skin lesions. Hb low, MCV low, TIBC increased, ferritin low. Occult negative. Blood smear with howell jolly bodies. Colonoscopy negative for lesions or blood. Patient takes oral ferrous sulfate without any improvement. He is already on gluten free diet. What test can you do to evaluate for celiac disease?

HLA DQ 2 or 8

In which condition will you have increase intensity of murmur with standing, valsalva, post-PVC and decreased intensity with hand grip?

HOCM

On palpation of the apex you feel a bifid or trifid impulse. What is the diagnosis?

HOCM

Young patient with papule on finger for several months and gradually increasing in size. It causes pain occasionally on holding a pen. Exam reveals veracious 1/2 cm papillose on sides of fingers in the DIP. Dx? TX?

HPV 8,11 Verruca Vulgaris (common warts) Topical salicylic acid in the form of plasters, liquid, cream, etc. Genital warts TX Imiquimod

40 year old smoker presents with swelling of apocrine glands in her groin. What is the diagnosis and treatment?

Hidradenitis suppurativa Tetracycline or erythromycin Quit smoking

Diabetic Ketoacidosis vs Hyperosmolar Hyperglycemic State

Hyperosmolar Hyperglycemic State - most common precipitator is *infection - same as DKA* - also may be caused by *MI, stroke, trauma, burns, drugs, thiazide diuretics* - has severe lethargy, weakness, altered mental state that is not in DKA - due to EXTREME HYPEROSMOLALITY - *gradual hyperglycemic sx in presentation - i.e. polyuria, polydipsia* - end game - severe hyperglycemia + hyperosmolality that causes glycosuria + severe volume depletion* *IN SUSPECTING EITHER DKA OR HHS - FIRST STEP IS SERUM CHEMISTRY PROFILE FOR DIAGNOSIS - UWORLD QUESTION*

Hypoventilation

I. acidosis accompanied by hypercarbia + normal or elevated serum bicarbonate is diagnostic of respiratory acidosis 2. hypoventilation is major cause of respiratory acidosis + may occur in the post-ictal state

The best management for a patient with family history of sudden cardiac death is?

ICD

What is the etiology of patent foramen oval?

Incomplete fusion of septum primum

57 year old F with DM has an MI. She quits smoking and changes her diet. She is started on atorvastatin 40 g/day. LDL decreases from 180 to 140. TGAs decrease from 350 to 250 in about 3 months. HDL is 48. wtd next?

Increase atorvastatin to 80

75 year old M presents to the ER with complaints of painless bright red blood per rectum. He has no other past medical history. Blood pressure is 130/80, HR 92 bpm. Rectal exam reveals bright red blood in rectal vault. Most likely diagnosis?

Diverticulosis

What are the side effects of procainamide?

Drug induced lupus

Define ichthyosis vulgaris?

Dry & rough skin with horny plates over the extensor surfaces of the limbs

Infective Endocarditis Modified Duke Criteria

Dx criteria for IE - Major criteria I. blood culture (+) for typical organism i.e. strep viridans, staph aureus, enterococcus ii. echo - show valvular vegetation - Minor criteria I. predisposing cardiac lesion ii. IVDU iii. Temp > 38 iv. embolic phenomena v. immunologic phenomena (i.e. glomerulonephritis) vi. (+) Blood culture not meeting above criteria Definite IE - 2 major or 1 major + 3 minor criteria Clinical Findings - Fever (90%) - Heart murmur (85%) - Petechiae (<50%) - Subungual splinter hemorrhages (<50%) - osler nodes, janeway lesions (<50%) - Neurologic phenomena (embolic) (<40%) - splenomegaly - roth spots (retinal hemorrhages <5%)

Acute Pancreatitis

Etiology - chronic alcohol use (40%) - gallstones (40%) i. sudden onset severe persistentBi abdominal or epigastric pain, nausea, vomiting ii. abdominal radiographs - usually reveal LOCALIZED OR DIFFUSE ILEUS of small intestines iii. NO FREE AIR UNDER DIAPHRAGM - hypertriglyceridemia - drugs (azathioprine, valproic acid, thiazides) - infections - CMV legionella, aspergillus - iatrogenic - post ERCP, ischemic, atheroembolic ****PATIENT WITH RFS FOR AORTIC ATHEROSCLEROSIS (e.g. hypercholesterolemia, diabets, PVD,) who undergo CARDIAC CATHETERIZATION or VASCULAR PROCEDURE - INC. RISK OF CHOLESTEROL EMBOLI THAT CAN OCCLUDE BLOOD VESSELS CAUSING a. skin manifestation - lived reticularis, blue toe syndrome b. kidney manifestations - AKI c. GI: PANCREATITIS (THIS Q***), mesenteric ischemia Clinical Presentation Diagnosis (require USUALLY ONLY FIRST 2 of following 3) 1. acute SEVERE EPIGASTRIC pain radiating to back + NAUSEA + VOMITING 2. inc. amylase or lipase >3 times normal limit (WHEN YOU HAVE 1., THE NEXT STEP = AMYLASE + LIPASE LEVELS ****** DO NOT DO CT/US UNLESS YOU DONT HAVE ACCESS TO AMYLASE + LIPASE)******* TEST Q 3. abnormalities on imaging consistent with pancreatitis i. PLEURAL EFFUSION ii. ATELECTASIS iii. ELEVATED DIAPHRAGM iv. PULMONARY INFILTRATES v. ARDs vi. ILEUS vii. RENAL FAILURE 4. RELIEF BY SITTING UP + LEANING FORWARD Other Findings - ALT > 150 U/L = BILIARY PANCREATITIS (MEANING GALLSTONE INDUCED - ENSURE THAT AS NEXT STEP YOU DO US) - severe disease: fever, tachypnea, hypoxemia, hypotension Treatment - UNTREATABLE CAUSES OF ACUTE PANCREATITIS = HYPOTENSION, ISCHEMIA, VIRUSES, ATHEROEMBOLISM i. pain control, IV fluids, BOWEL REST Management - Next step in management - WHEN YOU SUSPECT B/C PT COMES W/EPIGASTRIC PAIN RADIATING TO BACK, DO AMYLASE + LIPASE LEVELS IMMEDIATELY**** - when you SUSPECT GALLSTONE PANCREATITIS - NEXT STEP IS US********* (EVEN THO THIS IS 3rd MODALITY AND NOT NECESSARY FOR DX) - KEY PT - GALLSTONES + CHRONIC ALCOHOL ABUSE = MOST COMMON CAUSES OF ACUTE PANCREATITIS - ABD US = MOST SENS + SP TO DETEC GALLSTONES + MSUT BE PERFORMED ON ALL PTS W/SUSPECTED GALLSTONE INDUCED PANCREATITIS - NEXT NEXT STEP: when cause of Acute Pancreatitis is GALLSTONES + BILIARY COLIC OR CHOLECYSTITIS - ELECTIVE CHOLECYSTECTOMY -

Behcet Disease

Epidemiology - YA - Turkish, MIddle Eastern, Asian descent Clinical Findings - *recurrent*, painful *oral apthous ulcers* - *genital* ulcers - *eye lesions (uveitis)* - *skin lesions (erythema nodsoum of shins, acneiform lesions)* - differentiatior b/c other dzs will have mouth, penis, eye lesions but not skin manifestations - *thrombosis - major cause of morbidity* Evaluation - *pathergy* - exaggerated skin iulceration with minor trauma (i.e. needlestick) - *biopsy* - nonspecific vasculitis of different sized vessels Dx - made by clinical features

Human Monocytic Ehrlichiosis

Epidemiology - transmitted by tick vector (lone star tick) - seen in SOUTHEASTERN + SOUTH CENTRAL STATES (i.e. ARKANSAS) Clinical manifestations - flu-like illness (*high fever (>101)*, headache, myalgia, chills) - neurologic sx (confusion, mental status changes, clonus, or neck stiffness) - rash uncommon (Rocky mountain spotted fever without the spots) Labs - HALLMARK FINDINGS - *leukopenia + thrombocytopenia* - *elevated liver enzymes + LDH* Dx - *intracytyoplasmic morulae in monocytes* - PCR testing for E chaffeensis Tx - *empiric doxycycline while awaiting confirmatory testing*

Trichinellosis

Epidemiology + life cycle - ingestion of undercooked meat (usually pork) - more endemic in Mexico, China, Thailand, parts of Europe + Argentina - gastric acid releases larvae (within 1st wee of ingestion) that invade small intestine + develop into worms - female worm releases larvae (up to 4 weeks later) that migrate + encyst in striated muscle Clinical Presentation - intestinal stage (within 1 week of ingestion): can be asyx or include abd pain, N/V/D - Muscle stage (up to 4 weeks after ingestion): *myositis, fever, subungual splinter hemorrhages, conjunctival or retinal hemorrhages, periorbital edema, eosinophilia (HALLMARK OF DZ >20%) w/possible elevated CK + Leukocytosis* Suspect in patient with characteristic triad of *periorbital edema, myositis, eosinophilia*

V3-V4

Anterior LAD

Initial TX of chronic venous insufficiency?

Leg elevation, exercise, & compression therapy

Which bugs does erythromycin have activity against?

Legionella + mycoplasma

40 year old M with strong family history of premature CAD and father who passed away at age 45 of MI. LDL 130, HDL 28, TGAs 175. What is most likely to be elevated? What is the best treatment?

Lipoprotein A Niacin

Young patient who says he gets food stuck in his throat while at a steakhouse. It has happened a couple of times before. Occurs with the first bite then he regurgitates. He doesn't have any issues during the rest of the meal. What is the most likely diagnosis? treatment?

Lower esophageal ring. Key words: First bite dysphagia Treat with pneumatic dilatation

How do you treat a patient with local DCIS?

Lumpectomy + RT or mastectomy; If ER + add Tamoxifen and Aromatase Inhibitor

Pt with celiac sprue responds well to gluten free diet for 10 years. Now presents with diarrhea, abdominal pain and weight loss. What disease must you rule out?

Lymphoma

What are the causes of macroglossia?

MM Amyloidosis Acromegaly Downs syndrome

In which condition will you have increased intensity with hand grip, decreased with standing, valsalva and post-pvc?

MR

What murmur decreases in intensity post PVC?

MR

What murmurs are best heard at apex?

MR MS Severe AS (Austin flint murmur)

In what conditions would you have a mid-diastolic murmur? Why?

MS, TS already mid-diastolic when pressure is high enough in atria to have blood go to ventricle

In what conditions do you hear loud S1?

MS, short PR interval WPW, Tachycardia, thyrotoxicosis

In what conditions would have have late systolic murmur?

MVP

Pt /sp small bowel resection of about 50 cams. after a gun shot wound presents with diarrhea. What is the mechanism of his diarrhea?

Malabsorption of bile acids

Patient who is post gastrectomy is complaining of greasy stools and fatigue. Most likely diagnosis?

Malabsorption of fat and B12 2/2 blind loop synrome with bacterial overgrowth which causes deconjugation of bile salts and steatorrhea

Membranous GLN is the MC form of nephrotic syndrome associated with?

Malignancies. However, these are solid cancer (lung, colon, prostate, breast)

35 year old M presents with Nausea, vomiting and epigastric pain for the past couple of months. N/V mainly in the morning and gets better with a hot shower. Most likely diagnosis?

Marijuana induced.

What infections are you prone to if you have deficiency in MAC?

Meningococcus and gonococcus (Complement 5-9 deficiency)

Define degenerative central canal stenosis (lumbar spinal stenosis)?

Most affected pts are > 60 yo & experience lower back pain that radiates to the buttocks & thighs. Paresthesias & numbness may occur. It is exaggerated by walking & lumbar extension

What is the MC valvular disorder seen in pts with infective endocarditis?

Mitral valve DS, usually mitral valve prolapse

How would you treat a 50 year old patient with DM and LDL 130?

Moderate intensity statin

How would you treat the cholesterol in a 76 year old with DM and stroke?

Moderate intensity statin

What test predicts the risk of future foot ulcers in a diabetic pt?

Monofilament testing

Pt presents with severe pancreatitis. Temp 101.2F, WBC 15, Lipase 920. Blood lactate 2.4. CT scan reveals undifferentiated mass. Does this patient need antibiotics?

NO

What is Kussmaul's sign and when would you see it?

Neck vein distention on inspiration Constrictive pericarditis Cardiac Tamponade RV Infarct Pulmonary: Asthma and COPD

Can you give allergy injections to prevent contrast dye reactions or hypersensitivity pneumonitis?

No, not IgE mediated

In IgA nephropathy what is the complement level?

Normal

What are causes of erythema nodosum?

OCPs, sulfa drugs TB, strep or fungal infections Behcet's dz Sarcoid IBD

Pt eats fish and minutes later develops paresthesias, weakness, ascending paralysis and shortness of breath. Most likely diagnosis?

Offer fish tetrodotoxin

65 year old man s/p orthopedic surgery on antibiotics and morphine for pain. Next day has abdominal pain and distention. Labs reveal hypokalemia, no leukocytosis. KUB shows 6 cm distention of cecum up to splenic flexure. Most likely Dx? How to establish diagnosis? Management?

Ogilvie's syndrome- Acute pseudocolonic obstruction CT scan or gentle hypaque (water soluble) enema remove precipitating causes: correct electrolytes, d/c opiates; d/c anticholinergics-> rectal tube-> neostigmine

SCC is usually found where?

On the lips *BSC is hardly ever found on the lips (very rarely, the upper lip)

In what conditions would have hear a mid-systolic murmur? Why?

Once pressure in ventricle reaches 51, for example, if the pressure in the aorta is 50, then blood can leave LV and go to aorta. Must reach higher gradient to get through narrow valve AS, PS; crescendo-decrescendo murmur

What murmurs best heard in left base of heart?

PS PR AI PDA- L 3rd ICS- heard in systole and diastole

22 year old with palpitations and pounding sensation in neck for several years now has gotten worse. She gets slightly dizzy at times. Symptoms occur without warning while resting. When she breathes slowly and deeply the palpitations resolve on its own. EKG at presentation is normal. Most likely diagnosis?

Paroxysmal SVT

Acute Respiratory Distress Syndrome

Pathophysiology - *impaired gas exchange* - *CAUSE HYPOXEMIA VIA SHUNTING EQUIVALENT MECHANSIM W/INC A-a AS A RESULT* - *diffuse alveolar damage with pulmonary edema* - *dec lung compliance* - *pulmonary hypertension - due to hypoxic vasoconstriction + destruct lung parenchyma* - due to inflammatory reaction from lung injury that causes rel of inflamm cytokines, neutrophils into alveolar space - leads to leakage of bloody and proteinaceous fluid INTO ALVEOLI. Alveoli collapse due to loss of surfactant giving diffuse alveolar damage. Cause - inflammatory condition due to infections (sepsis, pneumonia), trauma (fractures, pulmonary contusion), other causes (i.e. massive transfusion, pancreatitis). Clinical Presentation - new or worsening respiratory sx during past week or WITHIN 1 WEEK OF KNOWN CLINICAL INSULT - respiratory distress, diffuse crackles on LE, severe hypoxemia - *bilateral lung opacities (ALVEOLAR INFILTRATES) on imaging - meaning pulmonary edema* - no signs of cardiac failure or fluid overload - objective assessment - *ECHO to definitively exclude hydrostatic pulmonary edema in patients W/O ARDS RFs - severity of hypoxemia as defined by PaO2/FiO2 ratio (PF) < 300 mm Hg w/PEEP > 5 cm H20 where I. mild: PF 200-300 mm Hg ii. moderate: PF 100-200 mm Hg iii. Severe: PF <100 mm Hg *logic = as PaO2 falls due to alveolar collapse, person requires greater FiO2, causing the PF (fraction) to DEC AS SEVERITY INC* - *A-a gradient inc* Tx - b/c ARDs causes hypoxemia refractory to high inspired O2 concentrations, adequate oxygenation in ARDs often requires *PEEP via mech ventilation* Guidelines for Mechanical Ventilation - low tidal volume ventilation (6-8 mL/kg) - inspiratory plateau pressure (pressure applied to small airways) of < 30cm H2O - arterial oxygenation tension (PaO2) of 55-80 mm Hg - high positive end expiratory pressure for moderate to severe hypoxemia CXR - *bilateral alveolar opacities* ***FiO2 = fraction of inspired oxygen ***PaO2 = partial pressure of oxygen

Which patients are at a higher risk for psoriasis?

Patients with DM, Heart disease and renal disease - treat these patients more aggressively

Patient with history of long standing heartburn for several years now presents with progressive dysphagia to solids. This patient most likely has?

Peptic stricture

Which cancers present with skin findings?

Peutz- jeghers syndrome Sweet Syndrome Glucagonomas

hypoparathyroidism Ca and Ph levels

Ph high Ca low

You are consulted to clear cirrhotic patient for an elective major surgery. MELD 10-15. Recommendation?

Proceed with caution

How do you treat papular acne?

Inflammatory acne- topical benzoyl peroxide and erythromycin

In elderly patient w/bilateral OA w/limited mobility on NSAIDS + Acetaminophen has conjunctival pallor - what do you think?

Iron Deficiency Anemia - common cause = NSAIDS***** via CHRONIC BLOOD LOSS FROM GI (COMMON CAUSE IN ELDERLY***) - conjunctival pallor = nonspecific finding for ANEMIA - NSAID + ASPIRIN - both cause GASTRITIS +/- GASTRIC ULCERS - lead to GI blood loss - eval = CBC + Fe Studies + FOBT - if Fe DEFIC CONFIRMED + EVIDENCE OF ONGOING BLOOD LOSS - UPPER + LOWER GI ENDOSCOPY = NEXT STEP****

What is the most common cause of CHF?

Ischemia>dilated CM>HTN

Patient presents with abdominal pain, hematochezia and significant diarrhea after eating. What is the best diagnostic test? Most likely Diagnosis? Treatment?

Ischemic colitis Thumbprinting colon-> paucity of vessels, aphthoid ulcerations on colonoscopy TX: rehydration and antibiotics

What are the causes of Strawberry tongue?

Kawasaki syndrome and scarlet fever

Which bacteria can cause Tropical Sprue?

Klebsiella and E.coli

What is the most likely etiology of tropical sprue?

Klebsiella or E.coli

What is the primary target for cholesterol therapy in a diabetic patient?

LDL

How would you treat a patient with Hep C who failed IFN therapy. he doesn't have cirrhosis.

Ledipasvir + Sofusbuvir 12 weeks Simeprevir + Sofusbuvir 12 weeks

What medications do you use to treat a patient for Hep C who is treatment naive without cirrhosis?

Ledipasvir + Sofusbuvir 12 weeks Simeprevir + Sofusbuvir 12 weeks

What would stridor due to allergic reaction cause?

Respiratory acidosis - trapping of CO2

Manifestations of Cyanide toxicity

Skin: *flushing (cherry red color), cyanosis (occurs later) CNS: headache, *altered mental status*, seizures, coma CV: arrhythmias Respiratory: Tachypnea followed by respiratory depression, *pulmonary edema* GI: Abdominal Pain, N/V Renal: *Metabolic Acidosis (form lactic acidosis)*, renal failure Causes: wool, silk exposure (contain Carbon + nitrogen), industrial exposure *metal extraction in mining*), and medications (*sodium nitroprusside - POTENT ARTERIAL + VENOUS DILATOR USED IN HYPERTENSIVE EMERGENCIES*) Path: CN- binds cytochrome oxidase and causes inhibition of mitochondrial oxidative phosphorylation Treatment I. if induced by Sodium Nitroprusside - tx = SODIUM THIOSULFATE

Pt has stopped ASA because of PUD 2 months ago. He was started on PPI. Now pt presents with chest pain. WTD?

Start ASA

Pt on simvastatin who presents 8 weeks later with generalized myalgias. CPK 75, AST/ALT 30/40, Most likely diagnosis and treatment?

Statin induced myalgia You can switch to pravastatin

Pt with epigastric pain and jaundice for a week. Noted to have vitiligo on PE. Alk phos 367, ALT/AST 76/114, Amylase 260. US reveals enlarged pancreas with mass, biopsy is negative for cytology. ERCP with dilated common bile duct with constriction in the pancreatic part of duct. What is the most likely diagnosis? Treatment?

Steroids Autoimmune Hepatitis

Pt with history of tine pedis with maceration between his toes presents with erythema of the foot. Most likely etiology of the cellulitis is?

Streptococcus

Define Paget's DS of the breast?

Suspect when a pt with no HX of skin DS presents with an eczematous rash near the nipple that does not improve with topical TXs. Usually due to an underlying adenocarcinoma

In an 18 year old with pancreatitis of unknown etiology what test will you do?

Sweat chloride testing

What is the most common presentation of Eisenmenger's syndrome?

Right to left shunt

What are the immunologic markers in subacute cutaneous lupus?

Ro/La + (ssa/SSB) Speckled ANA + anti dsDNA - anti smith -

65 year old M woke up early morning with severe retrosternal chest pain lasting up to 40 minutes with sweating and diaphoresis. EKG with ST depression and T wave in versions. Pt is started on ASA, iv nitrates, BB, LMWH and gpIIb/IIIa inhibitors. Anginal pain resolves but 24 hours later ST depression still persists. This represents?

Silent ischemia

Presentation & TX of Legionella?

Similar to other bacterial PNAs, but will also have: 1. Hyponatremia 2. GI symptoms 3. Elevated LFTs TX with a quinolone or macrolide

How do you treat closed comedones?

Topical retinoid

Pt with cirrhosis and ascites with RUQ pain. US shows hepatic vein thrombosis. wtd?

Triple phase CT scan to r/o HCC

Pt was treated for diverticulitis with cipro and flagyl 3 months ago and he has had 3 episodes of LLQ since that time. Each time he has no fever or leukocytosis. A colonoscopy is done which reveals left segmental diverticulosis. What is the diagnosis? Treatment?

Uncomplicated diverticular disease Treat with mesalamine or Rifaximin

Which maneuver will distinguish HOCM vs AS?

Valsalva- HOCM increase intensity, AS decrease intensity

When do you treat a patient with mitral stenosis?

Valvuloplasty if valve <1.3 cm2

Pt with parental exposure to Hep C presents 6 weeks later with malaise and fatigue. HBsAg -, HBcIgM -, HAV IgM -, HCV Ab -. You still suspect Hep C. wtd?

Viral load- HCV RNA

Pt presents after exposure to poison ivy within 2 hours. wtd?

shower

identifying PCP on smear

silver stain

Pt with Stage IV lung cancer with constipation not responding to stimulant laxative or polyethylene glycol. wtd?

sub q methylnaltrexone

What drugs can cause SJS?

sulfonamides, macrolides, dilantin, erythromycin

Which patients have a higher incidence of heart failure with preserved EF?

Women >75 with systolic HTN

Pt with steatorrhea of 40 g/day. D xylose test 8g/5h. Colonoscopy normal. Has history of lactose intolerance. What test should you do next?

X-ray abdomen- lactose is not fat so it won't cause steatorrhea. 50% of cases of chronic pancreatitis have calcification of abdomen

70 year old M with itching all over body sparing axillae. Hot shower helps but several hours later he itches again. Most likely diagnosis?

Xerosis

Pt. with diarrhea, RLQ pain, fever, rash and fecal leukocytes positive. No previous history of diarrhea. Most likely diagnosis?

Yersinia enterolitica

SE of gold therapy

abrupt and unpredictable thrombocytopenia

diffuse ST segment elevation

acute pericarditis (sometimes, less commonly acute MI)

What is the best way to treat a diabetic foot ulcer that is infected?

aggressive debridement and broad spectrum antibiotics

HTN and pregnancy

alpha methyl dopa

If a patient with GERD fails trial of PPIs and EGD is normal, what do you do next?

ambulatory pH monitoring

acute right angles, septae hyphae

aspergillus

needle shaped crystals obstructing an artery

cholesterol emboli

Elderly pt with Cr. 1.3 on lisinopril, glipizide, mirtazapine and digoxin -.25 mg/day with gradual weight loss. wtd?

decrease digoxin dose

hydroxyurea is used for?

decrease frequency + severity of pain crises in patients with sickle cell anemia by *increasing HbF*

Is complement normal or decreased in SLE?

decreased; C3 decreased more than C4

furuncle

deep nodule developed from folliculitis, red nodules that are firm and tender

While doing a renal US patient was found to have multiple stones in GB. WTD?

don't treat asymptomatic gallstones

Hemithorax opacification

due to 1. large pleural effusion 2. complete collapse of lung 3. possibly secondary to mucus plug in mainstem bronchus

Multislice CT is helpful to evaluate chest pain in what group of patient?

exclude diagnosis in low risk patients

What is the best way to screen for inflammatory bowel disease?

fecal calprotectin

histological finding of asbestosis

ferruginous bodies in the lung

gold therapy

for rheumatoid arthritis

Suicide Risk + protective factors

greatest RF = prior history of suicide attempt

Young patient presents with fever, malaise, and sore throat. It is followed by vesicular lesions on the tongue, buccal mucosa and later has painful vesicular lesions on dorsum of hands and feet. Dx?

hand foot and mouth disease 2/2 Coxsackie A virus

I, aVL

high lateral circumflex or diag branch of LCx

What are the nail findings in psoriasis?

ice pick pitting of nails onycholysis

What happens to the murmur of MR with handgrip?

increased after load causes decreased blood to go to aorta and increased LVEDV -> increased MR intensity

What happens to the murmur of MVP when you give amyl nitrate?

increased duration of murmur and decreased intensity blood leaves into aorta easily so the prolapse occurs earlier i.e. mid systolic click earlier

What happens to the murmur of HOCM with amyl nitrate?

increased intensity of murmur because more obstruction of LVOT with less blood in LV

What happens to blood that return to the heart during Valsalva maneuver?

increases intrathoracic pressure and decreases blood return to the heart

65 year old has MR murmur during exercise and disappears post exercise. S4 +. ECHO with mild hypokinesis and EF 60%. Most likely etiology?

ischemic

How to prevent rate related cardiomyopathy in atrial fibrillation?

keep HR <110

Where does squamous cell carcinoma arise from?

keratinizing epidermal cells in exposed areas like dorm of hangs, forearms ears and lower lip

What is the drug of choice to treat HTN with pregnancy?

labetalol, methyldopa, hydralazine

ankylostomiasis

laravae in soil> foot> lungs> small intestins intense itch at site of entry iron def anemia

Koilonychia

nails that have lost their convexity or are flat in shape 2/2 iron deficiency anemia

What are the screening guidelines for colorectal cancer in patients found to have tubulovillous adenomas?

no matter what size repeat 3 years

If a patient fails standard therapy for H. pylori, what is the second regimen you can try?

Tetracycline, metronidazole, bismuth salicylate, and PPI

Drug class that causes the most phototoxic RXNs?

Tetracyclines *Of these, doxycycline is the one that causes the most phototoxic adverse effects

What type of hypersensitivity reaction is Rh incompatibility?

Type II

What type of hypersensitivity reaction is hyper acute graft rejection?

Type II

What is preferred tx for hyperthyroidism including graves disease?

1. radioactive iodine ablative therapy

What type of hypersensitivity reaction is PAN?

Type III

What type of hypersensitivity reaction is hypersensitivity pneumonitis?

Type III

What type of hypersensitivity reaction is seen in Hep B?

Type III

What type of hypersensitivity reaction is seen in SLE?

Type III

What type of hypersensitivity reaction is serum sickness?

Type III

43 year old m pres w/ulcer on shaft of penis. Ulcer is non tender with raised border + smooth base. There is bilateral inguinal adenopathy. Dark field microscopy shows spirochetes. What next screening study should be performed?

- HIV antibodies by ELISA

Hepatic Angiosarcoma

1. rare neoplasm 2. VASCULAR SPACES LINED BY MALIG CELLS 3. Exposure to VINYL CHLORIDE GAS, INORGANIC ARSENIC CMPDS, THORIUM DIOXIDE 4. OLD MALE

What is the criteria of metabolic syndrome?

DXed when 3 of 5 of the following are met 1. ABD obesity (M>40 inches; F>35 inches) 2. Fasting glucose > 100-110 3. B/P > 130/80 4. TGs > 150 5. HDL (M<40; F<50)

Patient with deficiency of LDL receptors is what type of hyperlipidemia?

Type IIa

What type of hypersensitivity reaction is acute or chronic graft rejection?

Type IV

IN diabetic patient, Pseudomonas causes?

- malignant otitis externa

What causes loss of cortical bone mass?

- primary hyperparathyroidism

What is the drug of choice to treat elderly patient with isolated systolic HTN?

Thiazide diuretic 12.5 -25 mg/day

Pt gets urticaria when exposed to heat or hot shower, why?

Cholinergic urticaria

Pt with low Hb, melena and ST depressions on EKG. PRBCs transfused. wtd?

Coronary angiogram

Apart from HTN what other conditions can cause increased LV mass?

DM Obesity

Exertional dyspnea without chest pain in a pt may represent an anginal equivalent in the absence of pulmonary disease. Which patient populations is this commonly seen?

DM Women Elderly Post CABG

Pt with a fib started on Digoxin. Presents for follow up and now has regular a fib. wtd?

D/c digoxin

68 year old with DM and ESRD on HD on Atorvastatin 40 mg with leg pains. wtd?

D/c statin

What is a specific test to order when suspecting an adrenal-producing tumor?

DHEA-S (The "-S" part is only produced in the adrenal gland)

heberdens nodes

DIP

What causes abundant mineralization of periosteum?

Hypervitaminosis A

modified wells criteria for pretest probability of PE

Score +3 points - clinical signs of DVT - alternate diagnosis less likely than PE Score +1.5 points - previous PE or DVT - HR > 100 - Recent surgery Score +1 point - hemoptysis - cancer Total score for clinical probability - less than or equal to 4 - PE unlikely - >4 = PE likely

What drugs cause exanthematous or morbilliform reactions?

Sulfonamide, B lactams, PCN

All outflow from the ventricles gives you what type of murmur?

Systolic

What murmurs do you auscultate in LLSB?

TS TR ASD VSD HOCM

Signs of hypertrophic osteoarthropathy?

The development of digital clubbing and sudden-onset joint arthropathy. Usually seen in association with a lung malignancy in smokers

When is a stress test contraindicated?

unstable angina symptomatic AS

What are the DDx's for an anterior mediastinal mass? (4)

"4T's" -Thymoma, teratoma (& other germ cell tumors), Thyroid neoplasia, & Terrible lymphoma

Gilbert's Syndrome

***think of this disorder when pt has unconj bilirubinemia as part of differential as well as reduced uptake due to drug or shunt + hemolysis 1. FAMILIAL disorder of bilirubin glucoronidation - where UDP GLUCORONYL TRANSFEREASES IS REDUCED. 2. icterus secondary to mild predom unconj hyperbilirubinemia (normal levels in these patients are < 3 mg/dL) 3. Diagnosis is suggested in those patients with no apparent liver disease who have mild unconjugated hyperbilirubinemia thought to be provoked BY CLASSIC TRIGGER I. hemolysis ii. fasting iii. febrile illness iv. fat free diet v. physical exertion vi. stress or fatigue 4. CBC, Blood tests, blood smear and everything is normal except unconj hyperbilirubinemia

Indications for urgent dialysis

*AEIOU* - Acidosis I. metabolic acidosis w pH<7.1 refractory to medical therapy Electrolyte abnormalities - sx hyperkalemia: ECG changes or ventricular arrhythmias Ingestion - toxic alcohols (methanol, ethylene glycol) - salicylate - lithium - sodium valproate, carbamazepine Overload - volume overload refractory to diuretics Uremia - Sx - encephalopathy (test q presented with asterixis), pericarditis, bleeding (PLATELET AGGREGATION DEFECT W/ONLY INC BLEEDING TIME IN UREMIA)

Uworld Concept: What is the most common cause of bloody diarrhea in the absence of fever?

*E. coli*

Suspected DKA in stuporous patient with rapid breathing, hx of weight loss + polydipsia + polyuria - what is next step?

*Finger stick glucose* - confirm DKA fastest on suspicion

Crtyptococcal Meningitis

*Hints - in immunocompromised patient with HIV (indicated by presence of THRUSH) that presents with fevers, headaches, and/or elevated ICP (papilledema), think cryptococcal meningitis; may be given lab values as listed below* Presentation - headache, fever, and malaise; NO FOCAL DEFICITS, NO SEIZURES (VS HSV-1 encephalitis) - develops *over 2 weeks (subacute)* - can be more acute + severe in HIV - classically seen *CD4 < 100 - IMMUNOCOMPROMISED SEVERELY* - normally pulmonary dz but In immunocomp pts, meningoencephalitis occurs Diagnosis - CSF fluid analysis: - *high opening pressure (>200) (UNIQUE), low glucose, high protein, LOW WBC (<50/ul w/mononuclear predominance) (contradictory to what you'd suspect)*, - transparent capsule seen with india ink stain, - cryptococcal antigen positive - culture on sabouraud agar Treatment - Initial: *2 weeks of IV amphotericin B with flucytosine* - Maintenance: *fluconazole for 8 weeks + maintenance for 1 year* - *may require serial lumbar punctures to reduce ICP* Differential - HSV-1 Encephalitis -see in immunocomp or immunocompetent patients - cognitive + personality changes seen, focal neurologic deficits + seizures (due to temporal lobe involvement)

What is the initial treatment for *severe hypovolemic hypernatremia*?

*INITIALLY 0.9% isotonic saline* - gradually correct hyperosmolality while normalizing the patient's volume status I. 0.9% isotonic saline is considered hypoosmolar in comparison to the hypovolemic hypernatremic solution. ii. *Once volume deficit is restored* then patient is switched to *5% DEXTROSE (rather than 0.45% saline)F* to better replace free water deficit *rate of correction = 1mEq/L/h*

urine casts

*KNOW TABLE*

Prerenal Azotemia Vs Intrinsic Vs Postrenal Azotemia

*KNOW THIS CHART = GOLD* Prerenal Azotemia I. BUN/Cr > 20:1 but Cr still shoot up a lot

Diabetes Insipidus

*LEADING CAUSE OF EUVOLEMIC HYPERNATREMIA* - Complete DI - urine osmolality < 300mOsm/kg (often <100mOsm/kg) - Partial DI - urine osmolality ranges from 300-600mOsm/kg *serum osmolality increased in both types* Presentation: - complains of polydipsia, polyuria - maybe hx of bipolar disorder (to indicate Li use - to indicate nephrogenic DI) Based on Etiology 1. Central DI - due to decreased production of ADH: *trauma, hemorrhage, infection, and tumors* 2. Nephrogenic DI - from *resistance to ADH renally* - due to *hypercalcemia, hypokalemia, tubulointersitial renal disease, and medications* I. medications = lithium, democlocylcine, foscarnet, cidofovir, amphotericin

Neurogenic and Vascular Claudication

*MRI OF SPINE VS ABI - KNOW CHART* - lumbar spinal stenosis = neurogenic claudication I. contributing factors = degenerative spondylosis, degenerative disk disease, thickening of ligamentum flavum

In Patients with Chronic Renal Failure, what is most common cause of abnormal hemostasis?

*Platelet dysfunction* - *aPTT, Pt, TT are normal*. Bleeding Time *(BT) is elevated* b/c is reflective of platelet function. *platelet count normal* - *treatment of choice - DDAVP (inc vWF + Factor VIII release from platelets* - when you see *CRF indicated by high creatinine levels and see abnormal bleeding or bruising, think UREMIC COAGULOPATHY WHICH IS PROCESS OF PLATELET DYSFUNCTION*

Common causes of esophagitis in HIV pt table:

*Remember that an HIV pt with severe odynophagia suggest viral esophagitis

Categorizations of Community Acquired Pneumonia

*USE CURB 65* - *DET IF COMM ACQ PNEUMONIA NEED OUTPT TX, INPAT TX, OR ICU TX REGIMEN* - *C* - confusion - *U* - uremia (BUN > 20mg/dL) - *R* - respirations > 30 - *B* - hypotension (*B*lood pressure < 90/60) - *65* - age: *> 65* *each is 1 point above; score less than 2 means outpt tx; score 2 or up to 4 is inpt tx; score 4 or more is ICU tx* - major causes of CAP I. Strep Pneumo ii. Haemophilus iii. Atypical Organisms - i.e. mycoplasma - Tx regimen I. outpatient treatment: 1. *macrolide or doxycline* ii. Inpatient treatment 1. *macrolide + beta lactam* OR 2. extended spectrum fluoroquinolone - levofloxacin, moxifloxacin iii. ICU tx 1. macrolide (IV) + beta lactam 2. beta lactam + fluoroquinolone

Evaluation of Suspected Hyperaldosteronism

*Uworld question key point: ANYTIME YOU ARE GIVEN A PATIENT THAT HAS HYPERTENSION AND HYPOKALEMIA - NEXT STEP = PLASMA RENIN ACTIVITY + PLASMA ALDOSTERONE CONCENTRATION* *note that patients with mild primary Hyperaldosteronism may NOT HAVE hypokalemia but they are prone to developing diuretic induced hypokalemia* *if you suspect secondary Hyperaldosteronism (PAC/PRA = 10) due to renovascular hypertension (Renal artery stenosis or Fibromuscular dysplasia), then do CT Abdomen* *if you suspect other causes of hypertension and hypokalemia (presenting with decreased plasma renin and plasma aldosterone concentration* *Dexamethasone suppression test can diagnose cushing's syndrome when Plasma renin activity and plasma aldosterone activity are both decreased* *UWORLD OBJECTIVE: ratio of plasma aldosterone conc. to plasma renin activity is the preferred initial screening test for primary Hyperaldosteronism. Adrenal suppression testing can confirm the diagnosis and positive tests require further adrenal imaging. Adrenal venous sampling is the most sensitive test to differentiate adrenal adenoma vs bilateral adrenal hyperplasia* *tx for unilateral adrenal adenoma - surgery* *tx for bilateral adrenal hyperplasia - medical tx*

Microbiology of infective endocarditis table: -S. aureus -Viridans group streptococci -Coagulase-negative staph -Enterococci -Streptococcus bovis (S. gallolyticus) -Fungi

*Viridans group strep = S. sanguinis & S. mutans

66 y/o woman comes to clinic for eval of lesions of her left elbow that started at margin of a scar from a prior skin wound. She has no pain or itching but lesion has enlarged over last 2 months + developed oozing + crusting. Next Step?

*biopsy*

hallmark of osteoporosis

*bone demineralization

What is the most common skin malignancy in patients on *chronic immunosuppressive therapy for an organ transplant?*

*chronic immunosuppressive therapy for an organ transplant?* - *think SQUAMOS CELL CARCINOMA - in immunocomp pt, higher risk of local recurrence + regional mets*

Occupational HIV post exposure prophylaxis

*high risk contact* (prophlyaxis recommended) - Exposure of - mucous membrane, non intact skin, or percutaneous exposure - exposure to *blood*, semen, vaginal secretions, or any body fluid w/visible blood (uncertain risk is CSF fluid, synovial fluid, peritoneal fluid, amniotic fluid) Low Risk contact (prophylaxis not recommended) - exposure to urine, feces, nasal secretions, saliva, sweat, tears (no visible blood) Timing - initiate *urgently* preferable within first few hours - continue for *28 days* Regimen - *3 (or more) drug regimen* recommended I. *2 nucleotide/nucleoside reverse transcriptase inhibitors (I.e. tenofovir, emtricitabine) + ii. *integrase strand transfer inhibitor (i.e. raltegravir*), protease inhibitor, *or* non nucleoside reverse transcriptase inhibitor *if HIV status of dude infecting you is unknown, prphlylatic therapy should be initiated while awaiting results of HIV testing* Standard post exposure prophylaxis in HIV exposure includes *tenofovir, emtricitabine, and raltegravir*

Correlation between thyroid level and Prolactin level

*in primary hypothyroidism - there is decreased T4 and T3 - therefore TSH + TRH are increased; TRH IS A STIMULATOR OF LACTOTROPHS - MILD TO MODERATE HYPERPROLACTINEMIA DEVELOPS*

Asterixis or hand flapping is seen in which conditions?

*it is a direct indicator of encephalopathy* and is defined as *hand flapping tremor* - uremic encephalopathy - hepatic encephalopathy - CO2 retention - hypercapnia

OA of hip

*note that it is felt primarily in groin, buttock, or pelvis - can radiate to lower thigh or knee* - worst pain usually occurs with activity + weight bearing

Common Causes of Esophagitis in HIV

*presentation: HIV patient with dysphagia + odynophagia with substernal burning.* *most common in pts w/CD4<100* *most common cause = CANDIDA* Candida Albicans - white plaques - oral thrush Herpes SImplex Virus - herpetic vesicles + *round/ovoid ulcers* - concurrent perioral/oral HSV Cytmegalovirus - *deep, linear ulcers* - distal esophagus - *biopsy - shows INTRANUCLEAR+ INTRACYTOPLASMIC inclusions * - *Tx - IV GANCICOLOVIR* Idiopathic/Apthous - concurrent oral apthous ulcers *Next step if candida* (you see oral thrush that is peelable with the classic esophagitis presentation as given above): *EMPIRIC ORAL FLUCONAZOLE* I. *if unresolving: ESOPHAGOSCOPY* *infectious esophagitis - common in patients with CD4 < 50-100* - most common cause of esophagitis in HIV pts is candida albicans; Tx = fluconazole *if predominant sx is odynophagia or severe dysphagia WITHOUT THRUSH - think VIRAL ESOPHAGITIS - CMV + HSV (differentiate based on above) - DETERMINE WHICH IT IS WITH UPPER GI ENDOSCOPY (PART OF WORKUP - KNOW FOR EXAM); if thrush - then treat with fluconazole empirically*

Most common cause of osteomyelitis in adult with *nail puncture through sole of shoe into foot*? Tx?

*pseudomonas aeruginosa* Tx = *oral quinolones + debridement*

Coccidiomycosis

- "valley fever" - *Cutaneous features: erythema nodosum + erythema multiforme* - *southwestern US (ARIZONA), CENTRAL + SOUTH AMERICA + CALIFORNIA = CLASSIC* - *primary pulmonary infection has non specific features*

Bullous Pemphigoid

- (-) Nikolsky's sign. - BULLOw the BM --> autoantibodies against hemidesmosomes - autoimmune blistering disorder. Often in elderly patients on numerous meds. Pruritus, tense bullae, urticarial plaques I. furosemide, NSAIDs, captopril, penicillamine - Dx- skin biopsy, immunofluorescence: *subepidermal bullae with eosinophils*, * linear IgG/C3 deposits along basement membrane zone*

Women with average risk for cervical cancer - what screening tests?

- (Pap) test is recommended every 3 years from 21-29 - between ages 30-65 patients with initial negative testing may have PAP test alone every 3 years or a combination of PAP test + HPV testing every 5 years (preferred)

What is the most important prognostic consideration in treatment of patients with breast cancer (UWORLD Q straight up)?

- *"Tumor Burden" based on TNM staging - MOST IMPORTANT* - miscellaneous I. ER+ and PR+ - good prognostic features ii. overexpression of Her-2/neu oncogene is related to a worse prognosis

Epigolottitis

- *2 most common organisms causing it in adult population: HAEMOPHILUS INFLUENZA + STREPTOCOCCUS PYOGENES* - *epiglottitis = medical emergency + rapid tx must be initiated* - *high grade fever, severe sore throat with odynophagia (pain on swallowing) and drooling, and progressive airway obstruction* - *harsh shrill that most likely represents stridor often present*

Next step on suspected pneumonia

- *CXR* - test question - sputum testing - NOT USEFUL

What is most common side effect of Radioiodine Therapy?

- *Hypothyroidism* is most common side effect of radioiodine therapy i. easily treated with levothyroxine therapy ii. *patient's eye disease may worsen at beginning of radioiodine therapy*

"non functioning" pituitary macroadenomas

- *Low TSH + LH* - *compression thryotrophs + gonadotrophs* - *will see i] central hypogonadism aka hypogonadotropic hypogonadism (low LH + testosterone) ii] central hypothyroidism (low TSH + Low thyroxine) iii] mild elevation of prolactin due to COMPRESSION DOPAMINERGIC PATHWAYS VIA MASS EFFECT (THIS IS MOST COMMON AND ONLY PRESENTING SX WITH LEVELS OF 30-50) - *usually these "non functioning adeonomas" arise from GONADOTROPHS and instead of like normal where alpha + beta subunit is secreted, they secrete ONLY COMMON ALPHA SUBUNIT* - compression of gonadotropic pathways in pituitary stalk - giving *mildly elevated prolactin* - will secrete *biologically inert gonadotropin alpha subunit*

Scabies

- *Sarcoptes scaebiei mite* - burrows into skin + spreads via *person-person contact* - *intensely pruritic rash* - *flexor surfaces of wrist, lateral surfaces of fingers, elbows, axillary fold, and finger webs* - *due to delayed TIV HS reaction* to mite - small, crusted, red papules scattered around region - sometimes with *linear burrows* - mimics tinea, seborrheic dermatitis, eczema - dx - *skin scraping* from lesions revealing mites, ova, feces under light microscopy - Tx - *permethrin cream*

In a patient with organic hormonal cause of erectile dysfunction, what are next tests?

- *TSH, Prl, Testosterone* - hyper or hypothyroid can cause erectile dysfunction - *signs of cushing syndrome* - can cause ED - do *24 hour urinary cortisol if suspected* - signs of *autonomic dysfunction from Diabetes Mellitus - look for signs*

Diabetes Mellitus Screening Guidelines

- *USPSTF recommends screening in patients with sustained blood pressure (treated or untreated) > 135/80 mm Hg - *American Diabetes Association - recommends screening in all patients > 45 years old*

Treatment of Anemia of Chronic disease

- *UWORLD Q: if given scenario with patient with obvious RA but the focus of question is on blood studies and shows that there is some sort of anemia, think anemia of chronic disease. This is normocytic, normochromic anemia. If asked for treatment of this *Normocytic Normochromic Anemia - TREAT UNDERLYING DZ i.e. in this case with methotrexate*

Crystal Induced Acute Kidney Injury

- *WITHIN 1 to 7 DAYS (VS AIN - SEE AFTER 1-2 weeks)* - TEST Q I. b/c urinanalysis can be similar with hematuria, pyuria, and crystals - Note the damage is *TUBULAR DAMAGE VIA RENAL TUBULAR OBSTRUCTION* - meaning that proteinuria is limited (vs glomerular damage) - crystal induced AKI is more common with *LARGE DOSES OF IV ACYCLOVIR (more so than oral acyclovir)* I. mechanism of damage = *RENAL TUBULAR OBSTRUCTION (more common than through ATN or AIN)* ii. *most patients develop AKI within 24-48 hours after drug* exposure + can be asx iii. *hematuria, pyuria, and crystals* vs AIN - eosinophilia, skin rash, eosinphiluria, and pyuria *Tx = concurrent administration of IV fluids w/administration of drug reduces chances

Lumbar Disk Herniation (herniated disk)

- *acute* onset back pain *with or without radiation down one leg (maybe through things + below knee) DUE TO IMPINGEMENT OF NERVES* - Usually there is inciting event - Pain may be *radiating+ associated with neurologic sx* - *however in disk herniation, lumbar flexion (opposite of LUMBAR STENOSIS) + sitting will make pain worse* - *better with rest, worse with activity* -*(+) Straight leg raise - b/c of nerve root compression* Tx - *pain + stiffness - tx w/NSAIDs and muscle relaxants; if pain persists after 4-6 weeks after conservative treatment or progressive neurologic deficit worsens, then MRI INDICATED*

Nocardia

- *aerobic, gram (+) + partially acid fast filamentous branching rods* (UWORLD Q BASED ON DESCRIPTION - KNOW THIS AS IT IS KEY ON EVERY NOCARDIA Q) that affects the brain, soft tissue/skin, and lungs of immunocompromised individuals. - *found in soil + water* - often cause infxn in *IMMUNOCOMP HOST* - *Lung* most commonly involved; *manifest as nodules, a reticulonodular pattern, diffuse pulmonary infiltrate, abscess, or cavity formation* - pts with skin infection present with fever, purulent crusting lesions or ulcers following traumatic inoculation (i.e. puncture wound while gardening). - from lungs, *disemminated disease - most commonly goes to brain - presenting as abscess with seizures + skin (2 most common regions)* - *Tx = TMP SMX*

Patellofemoral syndrome

- *anterior knee pain; THINK WOMAN* - presentation = peripatellar pain worsened by activity or prolonged sitting (due to sustained flexion) - may have crepitus w/motion of patella

Reactivation Tuberculosis

- *apical* cavitary lesion (*upper lobe*) - fever, night sweats, weight loss, *cough w/blood tinged sputum* - *scenario must give endemic exposure -travel or move from Mexico, Phillipines, China, Vietnam, India, Dominican Republic, and Haiti* - highest rate in those arriving in last 5 years

Seborrheic Keratosis

- *characteristic waxy, "stuck on" warty, and well circumscribed appearance* - favor face + trunk - *"greasy" surface, flesh colored lesions or very dark* - *elderly* - some are *flat + lie just above surface of normal surrounding skin - scaling on the surface may be present* - *Dx - clinical* - Tx - *No tx required*

Porphyria cutanea tarda

- *deficiency of UROPORPHYRINOGEN DECARBOXYLASE - enzyme in heme synthesis pathway* - *painless blisters (back of hand) with increased fragility of the surrounding skin, hypertrichosis, and hyperpigmentation* - *ASSOCIATED WITH HEP C in hx* - can be triggered by ingestion of certain substances (i.e. *ethanol*, estrogens - *OCPs*) which should be discontinued once suspected - Dx - *elevated urinary porphyrin*

Actinic Keratosis

- *erythematous based papules with central scale due to hyperkeratosis* - classic description of *"sandpaper like" texture* to palpation - lesions are *small + flat at first; may enlarge + become elevated; may turn Into "CUTANEOUS HORNS" due to prominent central hyperkeratosis* - due to *sun exposure; 40-60* - *face, ears, scalp dorsa of arms + hands* - light microscopy: *acanthosis - thickening of epidermis, parakeratosis - retention of nucelei in stratum corneum, dyskeratosis - abn. keratinization, and hyperkeratosis (thickening of stratum corneum)* - *PRECURSOR LESION TO SQUAMOS CELL CARCINOMA aka carcinoma in situ*

Clinical Features of Toxic Shock Syndrome

- *fever > 102F* - *Hypotension w/systolic BP <90* - *diffuse macular erythroderma* similar to sunburn - *skin dequamation, including palms + soles, 1-2 weeks after* illness onset - multisystem involvement (3 or more) I. GI - D/V ii. Muscular - *severe myalgia* or inc. CK iii. mucous membrane hyperemia iv. renal (BUN or sCr > 1-2x upper) v. hematologic (platelets < 100,000) vi. liver (ALT, AST, total bilirubin >2x upper limit) vii. CNS altered mentation w/o focal neurologic signs Labs - *immature neutorphils elevated* - *thrombocytopenia may be present* Management - supportive tx - IV fluids - broad spec antibiotics UWORLD SCENARIO: *pt recently had NASAL PACKING followed a day after by rapid rash, fever ,hypotension, diarrhea, thrombocytopenia& - cause of toxic shock syndrome - TSS-1 superantigen tha activates T-cells releasing mass amounts of cytokines Etiology - 50% due to MENSTRUTION - *tampon use* - others due to *NASAL PACKING, surgic wound infections, sinusitis*, septorhinoplasty

Molluscum contagiosum

- *firm, flesh colored, dome shaped, umbilicated papules* - *IMPAIRED CELL IMMUNITY (i.e. HIV)* = main population of presentation - *skin to skin contact* = mode of transmission - dx = clinical - *self limited or tx with curettage, cryotherapy* - *if you see MC, do HIV testing (esp if lesions > 10mm)*

Thyroid Nodule Evaluation

- *first step in thyroid nodule evaluation is TSH + US of thyroid* i. *LOW TSH PTS NEED RADIONUCLIDE SCAN TO LOOK FOR HOT VERSUS COLD NODULE* - Cancer risk factors that require FNA immediately after [TSH] and US of thyroid include: family hx, radiation exposure in childhood, cervical lymphadenopathy, compressive sx such as dysphagia, hoarseness - Suspicious US findings requiring immediate FNA include - *hypoechoic, microcalcifications, internal vascularity*

Diabetic Nephropathy

- *glomerular hyperfiltration (EARLIEST RENAL ABNORMALITY - major pathophysiologic mechanism of glomerular injury) giving Inc extracellular matrix, basement membrane thickening (FIRST CHANGE THAT CAN BE QUANTITATED), mesangial expansion, and FINAL CHANGE IS NODULAR SCLEROSIS (KIMMESTIEL WILSON BODIES* characterize diabetes mellitus nephropathy. I. this is in order of occurrence - pathognomonic: *hyalinosis of afferent + efferent arterioles* - *most common histologic lesion in DM*: I. *diffuse glomerulosclerosis* - pathognomic histologic sign of DM: I. *Kimmelstiel-Wilson Nodules = pathognomonic* - *sign of nodular glomerulosclerosis* Slowing Down Disease: I. strict glycemic control ii. treatment of HTN iii. Angiotensin Axis Blockade: *USE ACE-I - effectiveness due to ability to DECREASE INTRAGLOMERULAR HYPERTENSION + THEREFORE DEC GLOMERULAR DAMAGE*

What is lumbar puncture used to evaluate?

- *guillain barre* (ascending weakness with paresthesias + ANS disturbances) - *MS* (episodic optic neuritis or transverse myelitis)

Echinococcus

- *hydatid cysts (trigger word)* caused by Echinococcus - most commonly associated *profession = SHEEP BREEDER* or *CONTACT WITH DOGS* - *hydatid cysts found in any part of body but LIVER MOST COMMON, THEN LUNGS* - *UNILOCULAR CYSTIC LESIONS w/POSSIBILITY OF SMALLER DAUGHTER CYSTS - classic EGGSHELL CALCIFICATION OF HEPATIC CYST = PATHOGNOMONIC* - *tx = surgical resection under cover of Albendazole*

Presentation of Malignant Hyperthermia (compare it to above thyroid storm)

- *hypercarbia*, sinus tachycardia, muscle rigidity, elevated CK, hyperkalemia, and hyperthermia (FEVER THAT IS VERY HIGH) - tx = IV dantrolene

Findings of Primary Hyperaldosteronism

- *hypokalemia + hypertension* - if mild, may not have spontaneous hypokalemia but will have DIURETIC induced HYPOKALEMIA EVEN WITH LOW DOSE - *metabolic alkalosis (hypokalemia) + mild hypernatremia* - *NO PERIPHERAL EDEMA DUE TO SPONTANEOUS DIURESIS VIA ALDOSTERONE ESCAPE* - AGAIN TO REITERATE *BEST SCREENING TEST = PAC/PRA RATIO* i. PAC/PRA ratio > 20 and PAC > 15 suggests dx ii. *confirmation of dx via ADRENAL SUPPRESSION testing with ORAL SALINE LOAD* iii. to distinguish then between 2 possible cause of Primary hyperaldosteronism, do *ADRENAL VENOUS SAMPLING* - *distinguish unilateral adrenal adenoma versus bilateral adrenal hyperplasia* a. if *unilateral adrenal adenoma* - *surgery preferred; aldosterone antagonists (spironolactone, epleronone for poor surgical candidates)* b. if *bilateral adrenal hyperplasia* - *aldosterone antagonists*

Next step in patient with presentation of hypercalcemia?

- *if asymptomatic - a SINGLE elevated serum ca2+ must always be confirmed by a second serum calcium value* - *next step after determining Ca2+ is elevated regardless of symptomatic or asymptomatic(2nd step) = serum [PTH]* I. *look at chart above to understand diagnostic workup of hypercalcemia*

Hyperthyroid Bone Disease

- *inc osteoclast activity* - bone resorption inc, bone density dec, fracture risk inc - *result = HYPERCALCEMIA* - *therefore, DEC PTH* - gives *dec renal Ca2+ reabsorption* + dec conversion 25 OH Vit D to 1,25 OH Vit D giving i. *dec GI Ca2+ absorption + Dec Renal Ca2+ absorption* - * net result of dec PTH + dec Vit 1,25 OH Vit D = Hypercalciuria + net calcium wasting*

Bronchiectasis

- *irreversible bronchial dilation* + *destruction of bronchi*, cyst formation, *poor mucus clearance*, and secretion pooling that results form severe repeated airway inflammation. - *likely associated in comparison with chronic bronchitis with HX OF RECURRENT RESPIRATORY TRACT INFECTIONS + CHRONIC COUGH W/MUCOPURULENT SPUTUM* I. *general presentation - pt w/chronic productive cough that is often treated with repeated course of antibiotics* - *see dec air entry at base of whichever affected side* - CT - *bronchial thickening (no cavitation) - dilated central bronchi larger than adjacent pulmonary arteries branches; also thickening of BRONCHIAL WALLS * - dyspnea, *CHRONIC cough*, and *obstructive lung disease pathology - BUT is NOT part of COPD (COPD = bronchitis + emphysema)* - PE: *crackles, rhonci, wheezing way more than in chronic bronchitis* - CXR - *signs of airway thickening with "tram track sign" and "ring sign"*

Tight Glycemic Control in TII DM via keeping A1c < 6.5% will best decrease what complications?

- *microvascular complications are best reduced with tight glycemic control - especially NEPHROPATHY + RETINOPATHY* - ONLY COMPLICATIONS OF DM THAT ARE REDUCED BY TIGHT GLYCEMIC CONTROL - *tight glycemic control INCREASES RISK OF HYPOGLYCEMIA + HAS UCNERTAIN EFFECT ON MACROVASCULAR COMPLICATIONS - i.e. MI, stroke* - *tight glycemic control INC "all cause mortality" when < 6%*

Toxoplasmosis in HIV

- *most common cause of CNS mass lesions in AIDS is toxoplasmosis* - *present as multiple ring enhancing lesions on CT in presence of HIV pt.* - *prophylaxis of toxo = TMP-SMX; Treatment of Toxo = sulfdiazine + pyrimethamine* - *administration of pyrimethamine + sulfdiazine = diagnostic + therapeutic*

De Quervain Tenosynovitis

- *new mother who hold infant with thumb outstretched (abducted/extended)* - inflammation of abductor pollicis longus + extensor pollicis brevis tendons - tenderness is elicited by with direct palpation of radial side of wrist at bade of hand - (+) finklestein test - passively stretching affected tendons by graspoing flexed thumb into palm with fingrs elicits pain

Entamoeba histolytica

- *patient history of Mexico travel* - *abd pain in RUQ*, *fever, leukocytosis, LIVER ABSCESS ON IMAGING* - *history of dysentery few months prior* - Labs: elevated alk phos, elevated transaminases - imaging - *solitary lesion* - *serologic testing for E histolytica Abs confirms dx* - Tx: *metronidazole PO + luminal agent (i.e. paramoycin) required to eliminate intestinal colonization* - *amebic abscess caused by Entamoeba histolytica - differentials include: I. pyogenic (bacterial) abscess - happen in *older patients w/underlying diabetes or hepatobiliary dz or following peritonitis* ii. hydatid cysts caused by Echinococcus - *not associated with fever, are freq asx, require animal contact (dogs, sheep), need to see eosinophila* (*tx = ASPIRATION + Albendazole*)

Infective endocarditis due to Eikenella corrodens is seen in the setting of what?

- *poor dentition or periodontal infection OR dental procedures that involve manipulation of gingival or oral mucosa - Eikenella corrodens*

Platelet dysfunction abnormalities Presentation

- *prolonged mucosal bleeding* - (oropharyngeal, GI, uterine)

Urinary Tract infection with alkaline urine

- *proteus species are most likely cause of UTI in pt with Alkaline Urine* (TEST CONCEPT; otherwise E.coli most common source of UTI - if you see alklaline urine, think proteus) - bugs such as proteus, klebsiella, pseudomonas, providncia, staphylococcus, and ureplasma urealyticium are all *urease producing bacteria* - cause for development of struvite stones via formation of ammonia + reduction of H+ in urine. *Struvite stones (staghorn calculi) become constant source of bacteria*

Lateral Epicondylitis

- *think tennis elbow* - *think of repeated forceful wrist extension + supination* = cause i. *backhand tennis or use of screwdriver* -*point tenderness distal to lateral epicondyle + pain during active extension of wrist* - *pathophysiology - due to degeneration of EXTENSOR CARPI RADIALIS BREVIS @ LAT EPICONDYLE*

Chikungunya fever

- *trip to Caribbean* - *polytarthalgias (always present)* - *lymphopenia + thrombocytopenia* - *PERIPHERAL EDEMA* - *CERIVAL LYMPHADENOPATHY* "marked pain in wrist + joints; swelling + tenderness of bilateral hand, wrist, and ankle joints" Differential I. acute Hep B infxn - icterus, urticarial rash, flulike sx, markedly elevated liver fxn tests ii. disemminated gonoccemia - tensynovitis, polyarthralgias, dermatitis (*pustular or vesicopustular)* iii. Reactive arthritis - oral lesions, conjunctivitis, oligoarthritis

Exudate vs Transudate

- 3 big causes of transudate - liver failure, renal failure (NEPHROTIC SYNDROME), heart failure, generalized ischemia - causes of exudate: para pneumonic effusion, malignancy, viral infection, pulmonary embolism

36 y/o M presents to clinic complaining of pruritic eruption on forearms. Denies F/c/malaise. PE show erythematous rash with occasional vesicles affecting both forearms. NO lymphadenopathy is appreciated. Vesicular fluid grows coagulase negative staphylococci. His only relevant hx is recent work in the woods behind his home chopping + transporting wood. What is dx?

- Allergic contact dermatitis I. due to TIV HS rxn resulting in pruritic + erythematous rash with vesicles occurring at site of exposure. ii. common causes = poison oak, poison sumac, cosmetics, nickel iii. sumac found during wood cutting iv. vesicular fluid in contact dermatitis is usually sterile but sometimes shows coagulase negative staphylococci (staph epidermidis) - consistent with S. epidermidis - organism native to skin that is non pathogenic)

Albumin and Calcium Concept

- Approximately 40-45% of total blood calcium is bound to albumin and other plasma proteins; the remainder is transported in blood as ionized calcium (40-55%) or complexed with phosphate + other anions (5-15%) - serum calcium concentration decreases by 0.8 mg/dL for for every 1 g/dL decreased in serum albumin, expressed in the following formula

Clinical Manifestations of Hemochromatosis

- Autosom. Recessive - due to mutated Human Hemochromatosis Protein (HFE) gene that leads to inc. intestinal Fe Absorption - gives inc GI absorption FE - Elevated transferrin saturation > 45% + serum ferritin > 200ng/mL in men or > 150 ng/mL in women suggest IRON OVERLOAD + SPEC HEREDITARY HEMORCHROMATOSIS i. TEST FOR C282Y or H63D muts - common pres is Elevated transferrin saturation > 45%, serum ferritin > 200ng/dL, diabetes (polydipsia, polyuria), dec libido (bronzed testes), etc - complications - ELEVATED LIVER ENZYMES W/CIRRHOSIS + INC RISK FOR HEPATOCELLULAR CARCINOMA***

Reactive Arthritis

- CLASSIC TRIAD = *arthritis (*knee + sacroiliac*), conjunctivitis, nongonococcal urethritis* - additionally - MUCOCUTANEOUS LESIONS + ENTHESITIS (ACHILLES TENDON PAIN) - preceded by acute GI (Salmonella, Yersinia) or GU infection (Chlamydia) - Tx = *NOT ANTIBIOTICS - FIRST NSAIDs*

66 y/o M present to ED w/sob + sx start 1 week ago w/dry cough and exertional dyspnea. Past medical history included HTN + recent stenting for double vessel coronary artery disease. Hospitalized 5 months ago for pneumonia. Temp is 98.9 + BP of 160/90 and HR is 90 and regular. ON exam, pt is in mild respiratory distress but can speak in full sentences. Chest auscultation reveals dec breath sounds at lung bases, bilateral crackles, and occasional wheezes. ABG shows pH of 7.46, Po2 of 72, and PCO2 of 31mmHg. Differentials? actual Dx?

- COPD or CHF - A: CHF - pt hx of CAD puts at risk for HF due to LV Dysfunction - uncontrolled HTN + Smoking hx are rfs for Coronary Vascular Dz - *bilateral basilar crackles -think CHF* - *dec breath sounds at bases from CHF could be due to pleural effusions* - *wheezing may be present in heart failure (cardiac asthma)* - * DIFFERENTIATING FACTOR OF COPD EXAC VS CHF - ABGS - Respiratory alkalosis in CHF vs Respiratory Acidosis in COPD* - *next step testing for CHF - BNP or PCWP*

Bacterial Meningitis

- CSF analysis: inc WBC (*neutrophil predominance*), low glucose, elevated protein - Tx - *empiric tx = IV ceftriaxone + vancomycin*

What type of azotemia can develop in patients given loop diuretics to reduce peripheral edema in Cor polmonale?

- Cor pulmonale may present with incrase JVP, hepatomegaly, peripheral edema in the presence of clear lungs - in cor Pulmonale - *use LOOP DIURETICS i.e. furosemide to LOWER RV filling volume + dec PERIPHERAL EDEMA: THIS CAN GIVE HYPOVOLEMIA, LOW CO, RENAL HYPOPERFUSION - LEAD TO PRERENAL AZOTEMIA/AKI*

Pramipexole uses

- DOPAMINE AGONIST 1. TREATMENT RESTLESS LEG SYNDROME 2. Also treat parkinsonian symptoms

Evaluation of Dysphagia

- Dysphagia can be classified as oropharyngeal or esophageal 1. oropharyngeal dysphagia - difficulty swallowing associated with coughing, swallowing, choking, nasal regurg - NEXT STEP = VIDEOFLUOROSCOPIC MODIFIED BARIUM SWALLOW 2. Patients with esophageal dysphagia - can do above but difficulty passing food down esophagus - follow algorithm below Once you have determined it is Esphageal Dysphagia: - PROGRESSIVE DYSPHAGIA: dysphagia that favors solids first but then moves to liquids - MECH OBSTRUCTION due to i. esophageal stricture ii. cancer - Next step - if History of prior radiation, caustic injury, stricture, or surgery for esophageal/laryngeal cancer DO BARIUM SWALLOW THEN ENDOSCOPY (not endoscopy first b/c fiear of rupture) - If Dysphagia at onset with BOTH LIQUIDS + SOLIDS - THINK i. ESOPHAGEAL RINGS OR MOTILITY DISORDER - Next Step = BARIUM SWALLOW FOLLOWED BY MANOMETRY***

Subclinical Hypothyroidism

- ELEVATED TSH + NORMAL T3 + T4

*TEST Q*: what is *therapeutic agent* of choice in *LIVER FAILURE* with *coagulopathy*?

- FFP

Familial Hypercalciuric Hypercalcemia

- FHH is rare AD + benign disorder caused by *abnormal calcium sensing receptor on PTH cells + renal tubules* - mild asx hypercalcemia + inappropriately high-normal to borderline-elevated PTH levels - *in contrast to primary hyperparathyroidism - FHH patients have VERY LOW URINARY CALCIUM LEVELS (<100mg in 24hours)* - *urinary calcium/creatinine clearance ratio (UCCR) value: UCCR<0.01 in FHH versus UCCR>0.02 in primary hyperparathyroidism*

Colon Cancer Screening in High Risk patients

- Family hx of adenomatous polyps or CRC (first degree relative at age < 60) i. Colonoscopy at age 40 or 10 years b/f age of dx in relative (whichever comes first) ii. repeat EVERY 3-5 YEARS - IBD - UC or Crohn's i. Begin 8 YEARS POST DX***; (12-15 YEARS IF DZ ONLY LEFT COLON) ii. Colonsocopy w/biopsies every 1-2 years - Familial Adenomatous Polyposis i. Begin at age 10-12 ii. Colonoscopy yearly - Hereditary Nonpolyposis CRC (Lynch) i. begin at age 20-25 ii. colonoscopy every 1-2 years

Acromegaly

- GH excess from SOMATOTROPH (PITUITARY) ADENOMA - CFs come from high GH concentration CAUSING HIGH IGF-1 CONCENTRATION i. overall leading cause of death in patients with acromegaly is *CARDIOVASCULAR (40-70%) DUE TO IGF 1* ii.* strokes iii. colon cancer iv. renal failure - due to HTN + HYPERGLYCEMIA (IGF 1 = DIABETOGENIC)*

Pancreatic Carcinoma

- Gen presentation: NAGGING EPIGASTRIC PAIN that radiates to back, weight loss, jaundice, PAIN WORSE AT NIGHT***, ENLARGED + NONTENDER GALLBLADDER, SCLERAL ICTERUS, FOOD INTOLERANCE, WEIGHT LOSS - tumors located in pancreatic BODY + TAIL - most likely to present w/pain + weight loss - tumors in PANCREATIC HEAD - steatorrhea, weight loss, jaundice (60-70%) I. with expansion of pancreatic head tumor, compress PANCREATIC DUCT - STEATORRHEA ii. compress COMMON BILE DUCT - JUANDICE iii. if PANCREAT + CBD COMPRESSED - RADIOLOGY - DOUBLE DUCT SIGN - physical Exam - unremarkable aside from jaundice, w/abdominal mass or ascites present in only 20% of patients w/pancreatic cancer - classic findings - i. NONTENDER BUT PALPABLE GALLBLADDER AT RIGHT COSTAL MARGIN IN JAUNDICED PATIENT (COUROVISIER's SIGN) ii. VIRCHOW's NODE (SUPRACLAVICULAR ADENOPATHY) iii. AROUND AGE 45; iv. RFs = CHRONIC PANCREATITIS, SMOKING, DM, HEREDITARY PREDISPOSTION Labs - INC SERUM BILIRUBIN + ALK PHOS W/MILD ANEMIA ****** THESE 3 VALUES - ABD US - INITIAL IMAGE; GOLD STANDARD - CT i. imaging - show PANCREATIC AND/OR "INTRA + EXTRAHEPATIC BILIARY TRACT DILATION", MASS LESIONS w/in PANCREAS, INIDCATIONS OF EXTRAHEPATIC SPREAD - i.e. ascites

Causes of Cough

- Gerd - nocturnal cough + wheezing - bronchiectasis - productive cough (lots of sputum) + tram track sign or ring sign on CXR + obstructive pathology - ACE-I - dry cough ("pril"ACEs) I. *due to: ACE - causes break down of Kinin but inhibition ACE builds up Kinin + causes more arachidonic acid pathway - inc cough* - *aspirin exacerbated respiratory disease* - associated with *refractory chronic rhinosinusitis* + *associated nasal polyposis*

Causes of Normal Anion Gap Metabolic Acidosis

- H = hyperalimentation (e.g., starting TPN). A = acetazolamide use. R = renal tubular acidosis (Type I = distal; Type II = proximal; Type IV = hyporeninemic hypoaldosteronism. D = diarrhea U = uretosigmoid fistula (because the colon will waste bicarbonate). P = pancreatic fistula (because of alkali loss--the pancreas secretes a bicarbonate-rich fluid).

Once Syphilis testing is confirmed, what is next screening test?

- HIV antibodies via ELISA

In a 35y/o m come to physician w/1 month hx of diarrhea, abd distention, and flatulence where he lost 15 lbs and has night sweats now w/arthralgias w/no recent travel. BP 112/74 and pulse of 104.PE show enlarged nontender cervical and inguinal lymph nodes. Small ulcer seen on buccal mucosa. He has no skin rashes or joint effusions. Abd is soft + nontender. What is most appropriate next step?

- HIV testing - it is cheap, easy access, and sx match

Allergic bronchopulmonary aspergillosis

- HS rxn to aspergillus colonization of bronchi - occur in *astma pts + CF pts* - present w/fever, malaise, productive cough, *eosinophilia*, *hemoptysis*

What are some cauess of membranous glomerulonephritis?

- Hep B + Hep C, syphilis, gold, penicillamine, SLE, and RA

hunters syndrome enzyme and inheritance and tt

- I sulfoiduronate sulfatase - X linked recessive - enzyme replacment

45 y/o M present to ED w/2 day hx of fever, dyspnea, abdominal pain, and diarrhea. No chest pain but dry cough. PMH for bone marrow transplantation for AML 3 months ago. Temp of 102.2 and BP of 122/80 with respiration of 22. Lung exam show bilateral diffuse rales, oropharynx has thrush, heart sounds regular but cxr show multifocal diffuse + patchy infiltrates. What is cause of condition?

- I though Pneumocystis jiroveci - saw thrush, diffuse infiltrates on CXR, and difficulty breathing w/RR of 22 - NOT CORRECT ANSWER - consider history of BONE MARROW TRANSPLANT followed by COLITIS + PNEOMONITIS = pathognomonic for CMV

Spontaneous Bacterial Peritonitis

- If there is CIRRHOSIS + ALTERED MENTAL STATUS, WE THINK HEPAT ENCEPHALOPATHY - BUT IF THERE IS CIRRHOSIS +/- ASCITES, ALT MENTAL STATUS, THEN FEVER***, THINK SPONTANEOUS BACTERIAL PERITONITIS Clinical Presentation 1. Temperature > 100F, abd tenderness, IN PRESENCE OF CIRRHOSIS OR HE 2. Hypotension, hypothermia, or paralytic ileus - indicate severe infection Diagnosis - DO PARACENTESIS AS FIRST STEP ON SUSPICION FOR DX W/DX CONFIRMED VIA (+) CULTURE + PMN >250/mm3 (TEST Q*****) - paracentesis should show 1. Ascitic Fluid w/PMN >250 cells/uL, (+) culture, exclusion of 2ndary causes of peritonitis 2. SAAG >1.1 g/dL 3. Ascites Protein < 1g/dL + glucose > 50mg/dL 4. Most commonly due to gram (-) organisms - KELBSIELLA, E. COLI**** Treatment 1. Empiric Antibiotics - 3rd gen cephalosporins - CEFOTAXIME while awaiting culture

Attention Deficit Hyperactivity Disorder

- Inattentive or hyperactive impulsive symptoms for > 6 months I. inattentive symptoms - difficulty focusing, distractible, does not listen, doesn't follow insturcitons, forgetful ii. hyperactive/impulsive symptoms - fidgety, unable to sit still, driven by motor, talkative, interrupts blurts answers - several symptoms before age 12 - symptoms must occur IN AT LEAST 2 SETTINGS - home + school + functional impairment - Tx I. stimulants - methylphenidate, amphetamine ii. non stimulants - atomexetine - alpha 2 adrenergic agonists

Euthyroid sick syndrome

- Most common pattern: i. *DEC TOTAL + FREE T3 with NORMAL LEVELS OF T4 and TSH* ii. aka "LOW T3 SYNDROME* - cause = DUE TO DECREASED PERIPHERAL 5'-DEIODINATION of T4 due to caloric deprivation, elevated glucocorticoid + inflammatory cytokine levels

Acute Kidney Injury or Prerenal Azotemia can cause of ABG disturbance?

- NON ANION GAP metabolic acidosis - due to impaired acid excretion (H+) or impaired ammonia generation OR - ANION GAP ACIDOSIS due to retention of UREMIC TOXINS (*NOTED BY ELEVATED BUN) - can cause encephalopathy - sx may present with lethargy, confusion, tremors Therefore in AKI, if there is question on ABG disturbance, look for metabolic acidosis. If there is, check anion gap to see which of the above is the cause. If anion gap is normal and still there is elevated BUN, the cause of elevated BUN is different source (i.e. in test question a GI bleed from trauma precipitated original AKI/prerenal azotemia - this was cause of elevated BUN and the non anion gap metabolic acidosis was of etiology above)

What values are elevated in Paget's Disease

- ONLY ALK PHOS IN SERUM - *but in urine, markers of bone degradation are also elevated i.e. hydroxyproline, deoxypyridinoline, N-telopeptide, and C-telopeptide*

Transplant Patients - should receive prophylaxis with what drug to prevent pneumocystis pneumonia?

- PCP prevented by giving *TMP-SMX prophylaxis to all post transplant patients; also prevents nocardiosis, toxoplasmosis, and other infxns* - *ganciclovir or valganciclovir can be given to prevent CMV infxn* - *VACCINATE ALL POST TRANSPLANT PATIENTS WITH INFLUENZA, PNEUMOCOCCUS, HEP B (HIP)*

What is CI to Radioactive Iodine ablation for hyperthyroidism?

- PREGNANCY - VERY SEVERE OPHTALMOPATHY (MADE WORSE BY TX USUALLY)

60 y/o old man undergoes a laparotomy for intestinal obstruction secondary to postoperative adhesions from a cholecystectomy 2 years ago. His other medical problems include type 2 diabetes mellitus, hypothyroidism, and hypertension. On postoperative day 3, he complains of intense pain around his laparotomy wound. His temperature is 101F, blood pressure is 121/76 mm Hg, pulse is 100/min, and respirations are 16/min. Examination of the wound shows abundant cloudy-gray discharge + dusky, friable subcutaneous tissue. Sensation is decreased at the wound edges. His serum glucose level is 312 mg/dL. Which of the following the most appropriate next step in management of this patient.

- Parenteral antibiotics + urgent surgical exploration

Urine Dipstick

- Positive leukocyte esterase - signifies LOTS OF PYURIA - Positive Nitrites - indicate presence of Enterobacteriaceae

Another way of asking same question above in a UWORLD format is - in mechanically ventilated patients with respiratory alkalosis in the setting of appropriate tidal volume, what is next step?

- RR should be lowered; know that if tidal volume is inappropriately high, you get resp alkalosis and opposite applies as well but reducing tidal volume can trigger reflex increase in ventilatory rate to potentially exacerbate the situation more

Exam shows right sided nasal congestion + necrosis of the right nasal turbinate with tenderness over the right maxiallry sinu. There is chemosis + proptosis of right eye. CT scan shows opacification of the right maxillary sinus. Which of the following is the causative organism?

- Rhizopus

Treatment of Lithium Induced Nephrogenic DI

- SALT RESTRICTION + DISCONTINUATION OF LI

Chronic COPD management

- SMOKING CESSATION - 1st LINE - Inhaled Bronchodilators - usually try and use combination of B-adrenergic agonists + Anticholinergics (albuterol + ipraptropium) - Use Inhaled glucorticoids - Oxygen therapy - Vaccination -Flu vaccine + Strep Pneumo vaccine every 5-6 years

A 23 y/o HIV female presents with 5 day history of fever + productive cough. - She is on antiretroviral tx and CD4 count is 300/mm3. Temperature is 102. RR are 22, pulse is 95. PE reveals dullness to percussion + bronchial breath sounds in right lung base. CXR shows pleural effusion - what bug is cause of presentation?

- Streptococcus pneumoniae

Definition of Osteoporosis

- T score < -2.5 *osteopenia = T score of -1 to -2.5 - *demineralization of bone*

53 y/o woman w/long standing RA comes to ED w/seizures. She has had cough, fever, night sweats for past 2 weeks. She is on immunosuppressive therapy for her RA. Temp is 102, BP 120/86. PE shows scattered raled in both lung fields. CT chest shows multiple nodules. CT brain shows left temporal lobe abscess. Bronchoalveolar lavage cultures grow partially acid fast, gram positive branching rods. Which of the following is the most effective treatment for this patient?

- TMP - SMX

Antibodies in Grave's Dz

- TSI aka thyroid stimulating immunoglobulins i. TSI stimulate TSH receptors on thyroid follicular cells thereby resulting in thyroid hormone overproduction

GVHD

- Target organs for GVHD: skin (maculopapular rash involving palms, soles, and face that may generalize), intestine (blood positive diarrhea), and liver (abnormal liver function tests + jaundice) - Basic pathophysiologic mechanism involved is recognition of host major + minor HLA Ags by donor T cells + consequent cell mediated humoral immune response - happens within weeks

Pt comes in w/PMH of Tb and is treated w/Isoniazid, rifampin, ethambutol, and pyrazinamide. Reports having taken OCPs for past 5 years. 2 months later when she returns, sputum is clear of acid fast bacilli but now has fatigue, malaise, nausea that began 10 days ago. PE reveals sclerae that are icteric + tender hepatomegaly. Lab Eval returns w/following - Alk phs of 98, AST of 373, ALT of 410, Total Bilirubin of 4.8. Dx?

- The lab values show ACUTE HEPATITIS - this is indicated by I. slight inc. in Alk Phos ii. AST + ALT inc to ~ 300/400 - etiology of ACUTE HEPATITS - can be viral or non viral. If non viral - this scenario has ISONIAZID I. normally drug induced acute hepatitis has rash, arthralgias, fever, leukocytosis, and eosinophilia BUT ISONIAZID HAS NON OF THESE EXTRA HEPATIC MANIFESTATIONS W/ONLY INC AST + ALT TO 300/400 AND SLIGH INC ALK PHOS ii. other direct toxins w/extrahepatic manifestations = amanita phalloides mushroom, TETRACYLCINE, ACETAMINOPHEN (ALSO CAUSE ACUTE LIVER FAILURE), CARBON TETRACHLORIDE iii. toxins W/O EXTRAHEPATIC MANIFESTATIONS = ISONIAZID, CHLORPROMAZINE, HALOTHANE, ANTIRETROVIRAL Tx

Common Causes Pleural Effusions

- Transudate - due to *inc hydrostatic pressure or hypoalbuminemia*; *pH of 7.4-7.55* I. CHF - usually causes transudative effusions - however, can meet exudative criteria if patient has received aggressive diuretics prior to thoracocentesis ii. cirrhosis iii. Nephrotic Syndrome iv. Peritoneal Dialysis (HEART, LIVER, KIDNEY) - Exudate - *pH of 7.3-7.45* I. infections ii. malignancy iii. Connective Tissue Diseases iv. Inflammatory Disorders v. Movement of Fluid from abdomen to pleural space vi. Coronary A. Bypass Surgery vii. PE (usually) - if there is *pleural fluid with pH < 7.30, low glucose (<60 OR pleural fluid/serum glucose ratio <0.5), normal arterial pH* - due to *INC ACID PRDXN FROM PLEURAL FLUID CELLS + BACTERIA* I. EMPYEMA FROM COMPLICATED PARAPNEUMONIC EFFUSION - HIGH ON DIFFERENTIAL ii. MALIGNANCY iii. TB iv. Rheumatoid Arthritis Light's Criteria - differentiate + define an exudate criteria (from transudate) - Pleural Fluid Protein/Serum Protein Ratio >0.5 - Pleural Fluid LDH/Serum LDH Ratio >0.6 - Pleural Fluid LDH >2/3 of the upper limit of normal serum LDH - also normal pleural fluid pH = 7.60

34 y/o woman comes to ED with rash + pruritis. She hada aore throat for several days + took some prescription medication (amoxicillin) left over from 1 year ago. The itchy rash developed about 20-30 minutes after she took the first 4 hours ago. She has no dyspnea, dizziness, n/d/, abd cramps.No prior hx of skin rashes + allegies. Temp of 98. O2 sat is 98. PE shows urticarial + multiple excoriations over the upper = lower extremities and upper body. Tonsils mildly erythematous without exudates or swelling. No lymph node enlargement. Lungs clear on auscultation. What is best next step?

- Treat with antihistamine: this was a drug induced TI HS reaction - *Drug induced TI HS reactions* I. immediate onset ii. mediated by IgE + mast cells/basophils iii. mild manifestations of drug allergy (i.e. urticarial + pruritis without systemic sx) - Tx with *antihistamines + discontinuing offending drug* - differential I. could have been amoxicillin rash in patient with EBV - but this patient does not have maculopapular rash, or fever + fatigue, exudative pharyngitis, or posterior cervical lymphadenopathy ii. tx with epinephrine + corticosteroids are reserved for more severe reactions accompanied by systemic sx (i.e. anaphylaxis)

Febrile Neutropenia

- a patient that is *febrile with no obvious focus of infection - i.e. normal CXR + urinalysis* - neutropenia = absolute neutrophil count < 1500/uL - Chemotherapy (PRECIPITATING FACTOR) may cause disruption of skin + mucosal barrier of the *mouth + GI tract* giving *mucositis + subsequent translocation of bacteria into bloodstream* - *gram (-) organisms* especially *PSUEDOMONAS AERUGINOSA ARE MORE FREQ IDENT* - this is *medical emergency* - start empric antibiotic therapy with *anti-pseudomonal beta lactam agent (cefipime, meropenem, piperacillin-tazobactam)* providing gram (-) + gram (+) coverage

Tb in HIV patients

- a positive PPD test in an HIV patient is *5mm (vs 15mm in non immunocompromised patient)* I. if (+) PPD, *next step = PROPHYLAXIS with ISONIAZID + PYRIDOXINE FOR 9 MONTHS (NOT FULL ON TX) (added pyridoxine to prevent peripheral neuropathy); continue doing regular LFTs b/c of isoniazid hepatitis complication*

Furunculosis

- abscess associated with a hair follicle due to *staph aureus* - can present as a single or multiple painful lesions (peri-follicular papules, pustules, or nodules) in the face, neck, axilla, or extremities. - These lesions can drain purulent material + are associated with fever. Resolving lesions can be hyperpigmented.

Acute Bronchitis

- acute bronchitis usually has clinical features without infiltrate on CXR - usually secondary to a cold or flu - usually viral in nature: if bacterial, think H influenza, M catharalis, S pneumo (READ IMAGE***) - hemoptysis may occur - low grade fever or may not even have fever - higher fever is highly unusual (consider pneumonia if present) - cough with purulent sputum >5 days but < 14 days - definition: acute cough of <14 days duration w/at least one other respiratory tract sx of I. URTI sx (rhinitis, sore throat) ii. Sputum production iii. dyspnea iv. wheeze v. chest discomfort - Tx - supportive care - do nothing, observe

Esophageal Perforation

- acute esophageal rupture presents with (ALL HIGH YIELF PREZ OF ESOPH PERF) I. acute chest pain ii. tachypnea iii. pleural effusion (OFTEN LEFT SIDED) iv. subcutaneous emphysema - Most common cause esophageal rupture = ENDOSCOPY; next SEVERE RETCHING; next penetrating trauma - Dx/Next step = WATER SOLUBLE CONTRAST I. once confirmed, PRIMARY CLOSURE OF ESOPHAGUS + DRAINAGE OF MEDIASTINUM - TO PREVENT MEDIASTINITIS Diff Dx 1. Pancreatitis I. salivary fluid amylase would be elevated (vs in esophageal perforation, ii. more likely to see left sided pleural effusion (similar to esophageal perforation) READ IMAGE

Pill Esophagitis

- acute odynophagia - include *KCl, Tetracyclines, bisphosphonates, and NSAIDs*

Principles of Pneumonia

- acute pneumonia will present with I. dec breath sounds ii. inc tactile fremitus - due to consolidation iii. consolidation = alveoli are filled with debris and exudative fluid iv. VENTILATION IN CONSOLIDATED AREA = 0; PERFUSION - STILL EXISTS - V/Q mismatch - b/c *non ventilated area cannot do gas exchange, blood remains deoxygenated when passing thorugh lung w/ V/Q = 0 - therefore consolidated regions act as physiologic R-L SHUNT via INC DELIVERY DEOXY BLOOD TO L HEART, THEREBY DEC SYSTEMIC ARTERIAL O2 CONC* - note that if patient is on side, if resting on dependent side with pneumonia - will see INC PHYSIOLOGIC SHUNTING - DEC O2 SAT SYSTEMICALLY AS A RESULT vs DEC SHUNTING + INC O2 SAT SYSTEMICALLY IF DEPENDENT SIDE IS NON PNEUMONIA AFFECTED SIDE *UWORLD nugget - early phases of acute pneumonia with consolidation can have persisten blood flow to area with impaired ventilation. This leads to physiologic intrapulmonary (R-L) shunt and arterial hypoxemia. Positions of atient on affected lung in dependent position can worsen shunt*

Hepatorenal syndrome

- acute renal failure in patients that HAVE STARTING PATHOLOGY OF ACUTE OR CHRONIC LIVER DISEASE W/PROGRESSIVELY RISING SERUM CREATININE WITH MINIMAL PROTEINURIA (<500mg/day)

When you see tinnitus, fever, tachypnea, nausea, and GI irritation - what do you think is cause and what other findings?

- acute salicylate toxicity - gives *primary respiratory alkalosis* by directly stimulating respiratory center - *primary anion gap metabolic acidosis* by uncoupling of oxidative phosphorylation in mitochondria giving anaerobic metabolism - *look for near normal pH indicating there are 2 primary disturbances* - Tx - alkalinization or dialysis* *a normal pH in an acid base disturbance typically signifies a mixed respiratory + metabolic acid base disorder

Felty Syndrome

- advanced RA associated with *splenomegaly + neutropenia* - *advanced RA - marked by significant morning stiffness*

Osteoporosis Risk Factors

- advanced age - medical history of fracture w/minmal trauma (fragility fracture) - low body weight (<127lbs) - current *smoking* - family hx of hip fracture - excess alcohol - *lack of weightbearing exercise* - medications (i.e. steroids, anticonvulsants) I. secondary causes of osteoporosis ii. premature menopause iii. hypogonadism iv. malabsorption (Celiac disease) v. inflammatory disorders (IBD, RA) vi. hyperthyroidism + hyperparathyroidism vii. cushing syndrome viii. Vitamin D deficiency ix. Chronic Liver or Renal Disease x. *post menopause state in general*

what increased mortality of CABG

- age >70 - LV EF <35% - additional cardiac procedures eg. valve - kidney/ diabetes

Diabetic Gastroparesis

- aka diabetic autonomic neuropathy of GI tract - predominant sx gastroparesis: delayed gastric emptying, anorexia, N/V***, Early satiety, post prandial fullness*** - occurs in >50% pts w/long standing TI or TII DM - other different manifestations of diabetes induced digestion issues: i. esophageal dysmotility: dysphagia ii. disorder of gastric emptying (gastroparesis) iii. intestinal function: diarrhea, constipation, or incontinence - Treatment of gastroparesis i. dietary modifications - inc fiber intake k+ small, frequent meals ii. meds - metoclopramide (SE of tardive dyskinesia); erythromycin (more useful in IV FORM FOR ACUTE EXACERBATIONS); cisapride (restricted due to cardiac arrhythmias + death) ******* (ABOVE) - additional less useful tx i. antihistamines - promethazine, diphendhydramine (antiemetics) ii. 5HT3 antagonists - odansetron, granisetron (antiemetics)

Tubulointerstitial nephritis (drug induced interstitial nephritis)

- aka drug induced interstitial nephritis I. drugs = penicillins, cephlaosporins, sulfonamides, rifampin, NSAIDs, phenytoin, Allopurinol* ii. *fever, maculopapular rash, arthralgia*; *in context of new drug exposure* iii. *eosinophilia, hematuria, sterile pyuria, URINARY EOSINOPHILS* iv. *maybe WBC casts* v. Renal biopsy - *inflammatory infiltrate, edema* - *Tx = discontinuing agent (TEST QUESTION UWORLD)*

Osteitis fibrosa cystica

- aka von Recklinghausen disease of bone - due to hyperparathyroidism from parathyroid carcinoma - osteoclastic resorption of bone - replacement with fibrous tissue - brown tumors WITH PAIN - imaging - *subperiosteal bone resorption* on radial aspect middle phalanges, distal clavivular tapering, "salt and pepper" appearance of skull, bone cysts, and brown tumors of long bones

Pt comes with painless ulcer on penis that is 26 y/o. Has no fever or urethral discharge. Previously hospitalized for activity with prostitute. Has had reaction b/f to PCN w/severe rash + facial swelling. Darkfield Microscopy shows spirocehtes - Tx?

- allergic to PCN so give Doxycycline for Primary Syphilis

Melanoma

- always suspect malignant melanoma in patient who presents with a changing mole - A - asymmetry - B - border irregularities - C - color variations - D - diameter > 6mm - E - enlargement - Most common malignancy in women between 25-29 - back is most common in men; legs in women - Presentation: mole that has changed in seize or color or a mole that has become symptomatic (pruritic, painful or bleeding) - RFs: sun burns, family history of melanoma, dysplastic nevus syndrome, atypical nevi, or greater than 100 typical nevi UWORLD Scenario: "28 y/o Caucasian woman comes to office for a routine skin exam. On skin exam you encounter a dark colored lesion. Pt states she had the spot there her whole life and that recently it has been itchy and hurts a little. Has hx of suburns during childhood + says she is very sun sensitive. What is dx? "

Rapidly developing *hyperandrogenism with *virilization* means what?

- androgen secreting neoplasm of ovary or adrenal - [serum testosterone + DHEAS] levels are very helpful in delineating the site of excess androgen production i. *elevated testosterone with normal DHEAS levels - indicate Ovarian source* ii. elevated DHEAS with normal testosterone - adrenal source*

Condyloma Acuminata

- anogenital warts - due to HPV - typical skin-colored, whitish or grayish, verrucous + filiform papules in the anal/perianal area (more often in men), penile shaft, or vulvovaginal region

manifestations of sarcoidosis

- anterior uveitis description = leukocytes in anterior chamber

Antibodies of Hashimoto's thyroiditis

- anti-TPO (thyroid peroxidase) (90% peeps w/hashimoto's have these) + anti thyroglobulin (anti-TBG) antibodies i. titers of Anti-TPO Abs are higher early in the course of Hashimoto's dz + these titers decrease with time + Thyroid hormone treatment

Which drugs have photosensitivity reactions?

- antibiotics - *tetracyclines (i.e. doxycycline) - FREQUENTLY ASSOCIATED IN TX OF ACNE THEN PT DEVELOPS RASH IN SUN* - Antipsychotics - *chlorpromazine, prochlorperazine* - diuretics - *furosemide, HCTZ* - others - *amiodarone, promethazine, piroxicam*

Anticholinergic Drugs (know them b/c cause anticholinergic effects aka urinary retention on bladder)

- antihistamines (diphenhydramine) I. 1st generation antihistamines - such as diphenhydramine, chlorpheniramine, doxepin, hydroxyzine - cause of Anti-ACh effects giving dryness of eyes, oral mucosa, respiratory passages, *urinary retention (DUE TO FAILURE OF DETRUSTOR CONTRACTION)* - TCAs (imipramine, amitriptyline) - 1st gen low potency antipsychotics (chlorpromazine) - 2nd generation antipsychotics - clozapine - antiparkinsonian drugs - i.e. benzotropine, trihexyphenidyl - *OXYBUTININ - THIS IS USED FOR IMPROVING BLADDER CAPACITY + TREAT OVERACTIVE BLADDER (DETRUSOR INSTABILITY* *Tx when medication induced - URINARY CATHETERIZATION + DISCONT DRUG)

Primary Biliary Cirrrhosis (cholangitis)

- antimitochondrial antibodies - POSITIVE - more common in WOMEN, MIDDLE AGE - CAUSES CIRRHOSIS - ELEVATED ALKALINE PHOSPHATASE out of proportion to AST + ALT - destruction of intrahepatic bile ducts giving bile stasis + cirrhosis i. VANISHING BILE DUCT SYNDROME - progressive destruction intrahepatic bile ducts - histological hallmark = ductopenia. PBC IS MOST COMMON CAUSE OF VANISHING BILE DUCT SYNDROME - PRESENTS MOST COMMONLY S MIDDLE AGE WOMAN W/SUDDEN ONSET OF ITCHING ALL OVER + FATIGUE - Afterwards, other CFs include: i. EYELID XANTHELASMA (FROM VERY HIGH HDL, BUT NO INC LDL - DOES NOT PREDISPOSE THEREFORE TO ATHEROSCLEROSIS****) ii. Hepatomegaly iii. STEATORRHEA - due to bile stasis - fat malabsorption iv. Portal Hypertension v. OSTEOPENIA W/PREDISPOSITION TO OSTEOPOROSIS (NOT REL TO FAT MALBS + VIT D FOR SOME WEIRD REASON b/c VIT D + Ca2+ SOMEHOW NORMAL) vi. associate w/ OTHER AI DZ IE THYROID**** vii. INC RISK FOR HEPATBILIARY MALIGNANCY Treatment i. Initial - UPON INITIAL DX - URSODEOXYCHOLIC ACID***** = DELAY HISTOLOGIC PROGRESSION ii. Later/advanced - LIVER TRANSPLANTATION

Diaphragmatic Tear

- appears on xray as abnormality in diaphragmatic shadow - herniation of abdominal contents into left pleural space - tip of NG tube seen in left hemithorax - more likely on *left side (more likely) due to right side protected by liver*

Giant Cell Tumor of Bone

- as can be seen on right *soap bubble appearance on xray* - giant cell tumor of bone - benign + locally aggressive skeletal neoplasm that usually *present with pain, swelling, and decreased range of joint motion at the involved site (TEST Q PREZ)* - *OSTEOLYTIC LESIONS* (with a "*soap bubble*" appearance on radiographs) in *EPIPHYSEAL REGIONS OF LONG BONES - MOST COMMONLY DISTAL FEMUR @ PROXIMAL TIBIA (KNEE)* - *1st line tx - surgery - intralesional curettage* - *young adult of 20-30, osteolytic lesion with soap bubble look at knee joint region with pain, swelling, dec ROM* = giant cell tumor of bone

How does mechanical Ventilation work?

- assist mode of mechanical ventilation - provides predetermined [tidal volume] with every breath. - inspiratory cycles can be intitiated by patient but if pt fails to breath at set minimum rate, ventilator will deliver tidal volumes (ideal of 6 ml/kg)

Dermatitis Herpetiformis

- associated with Celiac disease - *subsequent improvement of lesions after starting dapsone - considered diagnostic feature* - *erythematous papules, vesicles, and bullae that occur bilaterally, symmetrically + in a grouped herpetiform arrangement on the extensor surfaces, elbows, knees, and buttocks* - Tx = *gluten free diet + DAPSONE* (test q)

Mixed Cryoglobulinemia

- associated with underlying *HCV infection* - suspect in patient who presents with *palpable purpura, proteinuria, hematuria (GLOMERULONEPHRITIS)* - *arthralgias, PERIPHERAL NEUROPATHY, hepatosplenomegaly, hypocomplementemia* - *dx - circulating cyroglobulins*

Adults with Parvovirus

- asymptomatic or flu like sx - minority develop *symmetric + nonerosive arthritis or APLASTIC ANEMIA* - *acute onset of polyarticular + symmetric arthritis RESOLVING IN 2 MONTHS* I. *MCP + PIP + WRIST JOINTS - SIMILAR TO RA*

Lyme Disease Prophylaxis

- attached tick is an adult or nymphal ixodes capularis (deer tick) - tick attached for >36 hours or engorged - prophylaxis started within 72 hours of tick removal - local Borrelia burgdorferi infection rate >20% (i.e. new England area) - no contraindications to doxycycline (i.e. age < 8, pregnant, or lactating) *if all 5 present, do prophylaxis with a dose of doxycycline*

Epidermal Inclusion Cyst

- benign *nodules containing normal epidermis that produces keratin* - patients usually develop *dome shaped, firm, freely movable cyst or nodule with a small central punctum (small, dilated pore like opening)* - lesion can remain stable or gradually increase in size but usually resolves spontaneously - *look for it going away and then recurrence* - Dx - *clinical*

Dermatofibroma

- benign fibroblast proliferation that appears as a *firm, NONTENDER, discrete, and hyperpigmented nodules most often on LOWER EXTREMITIES* - have a fibrous component that causes dimpling of center when the area is pinched - "buttonhole sign"* - Dx - *clinical* - Tx - *cryosurgery or shave excision ONLY IF BLEED; otherwise let it resolve*

Lipomas

- benign painless subcutaneous masses with normal overlying epidermis - *in contrast to epidermal cysts, lipomas are usually soft to rubbery + irregular + do not regress or recur*

Frostbite Injury Treatment

- best treatment: *re warming rapidly with warm water* - *no attempt to debride tissue initially; rapid re warming with dry heat (like a fan) is not effective in frostbite* - scenario: 18 y/o male brought to ED after he was found lost in mountains for 3 days. Had gone hiking, become disoriented and lost all sense of direction. Had no gloves and on PE had apparent frostbite injuries to extremities - what is next best treatment step?

Bladder Cancer

- bladder tumors - most common malignancy associated with *Painless hematuria* in adults - *patients > 35 w/ gross hematuria* - EVALUATE ASAP FOR UROLOGIC NEOPLASM with diagnostic *CT UROGRAM + CYSTOSCOPY*

Clotting Factor Deficiencies Presentation

- bleeding into *deep tissue* - *joints, intramuscularly, GI or GU bleeding*

Dermatomyositis vs Polymyositis

- both have peak incidence between 40-50 - women > men - common findings: ILD, esophageal dysmotility, Raynaud's phenomenon, polyarthritis - *both are due PAHTOLOGIC DAMAGE AT LEVEL OF MUSCLE FIBER* Polymyositis - idiopathic inflammatory - presents with slowly progressive *proximal weakness of lower extremities + INC CK* - dififculties ascending + descending stairs or rising from seated position. - *later manifestation - proximal arm weakness - difficulty with combing hair* - *latest manifestation - may see dysphagia due to muscle involvement of upper pharynx striated muscle* - *NO SKIN MANIFESTATIONS (VS DERMATOMYOSITIS)* - Dx = *MUSCLE BIOPSY* - *EMG - can differentiate AML from from polymyositis* Dermatomyositis - AI condition more likely in *WOMEN* - proximal + symmetric muscle weakness with UE > LE - Gottron's papules - violaceous + slightly scaly papules overlying joints of knuckles, elbows, and knees - Gottron's Sign I. eruption of rash on knuckles, elbows and knees - Heliotrope sign I. eruption of rash with periorbital edema nder eyes - interstitial lung disease - dysphagia - myocarditis - Dx I. *inc CPK, aldolase, LDH ii. anti-RNP, anti-Jo-1, anti-Mi2 (SAME AS POLYMYOSITIS)* iii. *GOLD STD = MUSCLE BX* - Tx I. *high dose glucocorticoids+ GLUCOCORTICOID SPARING AGENT* -other management I. *SCREEN FOR MALIGNANCY - ovarian, lung, pancreatic, stomach, colorectal cancers, hodkgin's lymphoma*

pseudogout

- calcificiation of cartilaginous structures (chondrocalcinosis) = typical of pseudogout - due to CPPD deposition aka calcium pyrophosphate dehydrate deposition - usually *pt > 65* Causes - hemochromatosis - hyperparathyroidism giving high Ca2+ concentrations Presentation - *acute soft tissue swelling*, *stiffness*, and pain of KNEE, MAYBE ANKLE (LARGER JOINTS) - *usually monoarticular, can be oligoarticular* Cause - *after surgery or medical illness* - *trauma/overuse* Synovial Fluid Analysis - *know that next step on suspicion = ARTHROCENTESIS TO R/O URATE GOUT + SEPTIC ARTHRITIS* - WBC 2000-50,000 - rhomboid, positively birefringent crystals (yellow is perpendicular to polarization axis + blue is parallel) Imaging - chondrocalcinonsis - see white line in joint space Tx - intra articular glucocorticoids - NSAIDs - colchicine

Chronic Pyelonephritis

- can cause chronic tubulointerstitial nephritis

Horseshoe Kidney

- can cause complications such as I. ureteropelvic obstruction ii. renal stones iii. vescoureteric reflux iv. chronic UTIs due to iii

Cor Pulmonale DIfferntials

- cardiac tamponade I. inc JVD, hypotension, distant heart sounds, pulsus paradoxus (>10 mm Hg dec in systemic BP w/inspiration) - CAD I. will cause Left Heart Failure or BIVETNRICULAR failure w/evidenceof PULMONARY CONGESTION howevere these pts present w/ - chest pain - nausea - diaophoresis - hypotension - JVD - clear lungs

A large midline herniation can cause nerve root injury and most feared complication is?

- cauda equina syndrome I. bladder atony w/overflow incontinence ii. bilateral sciatica iii. saddle anesthesia iv. loss of anal sphincter tone

CMV in setting of Bone Marrow Transplant

- cause *upper + lower GI ulcers* - *diarrhea, abd pain* - cause *CMV pneumonitis - 45 days after transplant CXR w/multifocal diffuse patchy rales where CT show multiple small nodules* - Diagnostic standard = *bronchoalveolar lavage* *CONSIDER CMV as a late complication in POST - BONE MARROW TRANSPLANT RECIPIENTS WITH PNEUMONITIS + COLITIS*

When to suspect Mucormycosis?

- caused by *rhizopus fungus* - suspect in *diabetic pt, esp in diabetic ketoacidosis* - *see necrotic nasal turbinate region w/facial pain, bloody nasal discharge, fever in setting of DKA* - *tx = surgical debridement + amphotericin B&

Cysticercosis

- caused by larval stage of the pork tapeworm Taenia solium. - when a person consumes T. solium eggs excreted by another person - note that cysticercosis is not contracted by eating infected pork, so people who do not eat pork can still be affected - most common manifests of cysticercosis are neurologic. Neurocysticercosis (NCC) is characterized by multiple, small (usually < 1cm), fluid-filled cysts in the brain parenchyma. - characteristic invaginated scolex on neuroimaging - most common parasitic infection of the brain + characterized by multiple, small (usually < 1cm), fluid filled cysts in the brain parenchyma - *neurocysticercosis is the most common parasitic infection of the brain. It is most prevalent in rural areas with poorer, sanitary conditions and where pigs are raised.

Atypical Pneumonia

- causes = mycoplasma pneumonia, chlamydia pneumonia, legionella, coxiella, and influenza. - mycoplasma pneumonia is the *most common cause of atypical pneumonia in ambulatory setting* - distinguished from typical via *indolent course, non productive cough, higher extrapulm sx* - *CXR findings will be out of proportion to physical exam* - *ERYTHEMA MULTIFORME IS CHARACTERISTIC EXTRA PULM MANIFESTATION OF MYCOPLASMA (DUSKY, RED TARGET SHAPED LESION ON ALL 4 EXTREMITIES)* - *MYCOPLASMA DOESNT SHOW ON GRAM STAIN; only see PMNs on gram stain* Differentials - pneumococcus I. most common cause of community acquired pneumonia ii. *productive cough w/color of rust* iii. compared to atypical pneumonias, causes no extrapulm manifestations iv. *gram stain - gram (+) diplococci* - Hemophilus influenza I. typical pyogenic pneumonia ii. gram stain - *small gram (-) rods* - Legionella pneumonphila I. water source* ii. *elderly + smokers* iii. *urine Ag test = diagnostic*

Atelectasis

- causes may include MUCOUS PLUG or ENDOTRACHEAL TUBE SHIFT INTO FOR EX R MAIN STEM BRONCHUS (left lung atelectasis occurs) - no compression of mediastinum so NO HYPOTENSION OF SERIOUS VITAL SIGN DERANGEMENT

SIADH

- characterized by *hypotonic hyponatremia with euvolemia* - *low plasma osmolality (<280 mOsm/kg) w/high urine osmolality (>100-150mOsm/Kg) = diagnostic* in suspected patients is diagnostic - possible causes: *NSAID therapy* or lung mass - *i.e. CXR SHOWS A MASS IN HILAR REGION* - preferred diagnostic test = *simultaneous measurement of urine + plasma osmolality* - Tx: main concept is that *hypertonic saline used in some form or another if symptomatic; KNOW CHART*

Necrotizing Surgical Infection

- characterized by intense pain in wound, decreasing sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. - Early surgical exploration is essential - patient has the following signs + sx suggestive of necrotizing surgical site infection I. pain, edema, or erythema spreading beyond the surgical site ii. systemic signs such as fever, hypotension, or tachycardia iii. paresthesia or anesthesia at the edges of the wound iv. purulent, cloudy gray discharge ("*dishwater drainage*") v. subcutaneous gas or crepitus - necrotizing surgical site infections occur more commonly in *patient with diabetes* and are usually *polymicrobial* -*most important step in management of this condition is early *surgical exploration*

Influenza pneumonia

- characterized by onset of abrupt fever, chills, malaise, myalgias, cough, and coryza - *winter (LOOK FOR IF THEY GAVE YOU A MONTH WHEN SX STARTED)* time - PE: febrile pt + wheezes, crackles, coarse breath sounds on lung exam - leukopenia + proteinuria may be present - CXR - *interstitial or alveolar pattern bilaterally (i.e. bilateral interstitial infiltrates* - Fastest dx: *nasal swab for influenza antigen* - Tx - start antiviral *oseltamivir or zanamivir (neuraminidase inhibitors) within 48 hours* I. rimantidine + amantadine also work but only against influenza A

Stevens Johnson Syndrome

- characterized by sudden onset of *mucocutatneous lesions (POSSIBLY IN MOUTH - TEST Q PREZ) + systemic signs of toxicity* - *most often due to MEDS - antibiotics, anticonvulsant, allopurinol* - may see *erythematous macules, bullae, desquamation, and mucositis with systemic sx (fever, tachycardia, hypotension, conjunctivitis* - *on a spectrum: if <10% of body surface area = SJS; >30% toxic epidermal necrolysis* Clinical Features of SJS or TEN - 4-28 days after exposure to trigger (2 days after repeat exposure) - acute influenza like *prodrome* - rapid--onset erthyematous macules, vesicles, bullae - necrosis + *sloughing of epidermis on touching (NIKOLSKY POSITIVE SIGN)* - *mucosal involvement* Common Triggers - Drugs: *allopurinol, antibiotics (TMP SMX), anticonvulsants, NSAIDs, sulfasalazine, mycoplasma pneumonia Tx - treat like a burn - *aggressive fluid support*

Leprosy

- chronic granulomatous disease - caused by Mycobaccterium leprae - present as insensate hypopigmented plaque - *progressive peripheral nerve damage* causes (muscle atrophy* affecting *face, ears, wrists, buttocks, knees, eyebrows* *dx made by DEMONSTRATION ACID FAST BACILLI ON SKIN BX*

Signs + Sx of Ankylosing Spondylitis

- chronic low back pain in otherwise healthy young man Know the three - association with HLA-B27 - progressive stiffness of spine - sacroiliitis Extraarticular features - anterior uveitis - IBD - aortic regurgitation - cardiac involvement RESTRICTIVE PATHOLOGY (DEC TLC, DEC VC, NORM/INC RV, NORM/INC FRC, NORMAL FEV/FVC RATIO) I. due to fixation of rib cage in inspiratory position - *patients with ankylosing spondylitis can develop restrictive lung disease due to diminished chest wall + spinal mobility. PFT shows mildly restrictive pattern dec VC + TLC but normal FEV1/FVC* Differential - Patients with AS - develop pulmonary fibrosis - also causes restrictive pattern w/reduced FVC + FEV1 normal or inc FEV/FVC ratio + dec TLC - however, FRC, RV are decreased

Whipple's Disease

- chronic malabsorptive diarrhea - steatorrhea, flatulence, abd distention, protein losing enteropathy, weight loss, *migratory non deforming arthritis*, lymphadenopathy, low grade fever - caused by Gram (+) tropheryma whippelli - dx = made by *small intestinal biopsy + PCR* in patients with clinical sx consistent with disease I. small intestinal biopsy - show PAS (+) macrophages in lamina porpria containing non acid fast gram (+) bacilli)

Hidradenitis suppurativa

- chronic skin disorder that presents as a painful tender masses with inflammation, scarring, and sinus tract formation - most commonly in *axillae, groin, inner thighs, and perineal area* - due to follicular occlusion + inability of keratinocytes to properly shed from follicular epithelium - RFs - fam hx of HS, smoking, obesity, and mech stress on skin - dx - based on clinical findings without need for skin bx or bacterial cultures

Acute Cholecystitis

- classic presentation - RUQ abd pain, Fever, Leukocytosis, US showing gallbladder wall thickening + mild distention + pericholecysticpanc fluid - sudden onset RUQ pain, pain radiate to SCAPULA after LARGE OR FATTY MEAL, MURPHY SIGN (WORSEINING RUQ PAIN ON INSPIRATION) fever, vomiting, leukocytosis lab values - mild elevation in transaminsases, total serum bilirubin from 1-4 mg/dL; i. ALK PHOS - ONLY ELEVATED IF COMMON BILE DUCT IS ASSOCIATED - so CHOLANGITIS OR CHOLEDOCOLITHIASIS) primary inciting event = gallstone obstructing CYSTIC DUCT w/subsequent inflammation = infection - Imaging - ULTRASOUND = DIAGNOSTIC TEST OF CHOICE - SHOW GALLBLADDER WALL THICKENING + MILD DISTENTION W/STONES + PERICHOLECYSTIC FLUID - Tx for acute cholecystitis i. supportive care, NPO, IV antibiotics, ii. 2nd STEP = LAP CHOLE ELECTIVELY after hospitalization in case of perforation + or gangrene ***Note that COMMON BILE DUCT OBSTRUCTIOn w. STONE OR CARCINOMA - WOULD NORMALLY CAUSE OBSTRUCTIVE JAUNDICE CHARACTERIZED BY SEVERE ICTERUS + VERY HIGH ALK PHOS

GERD

- classic scenario: 35 y/o mm c/o *nocturnal wheezing* + *chest tightness* for past 3 months. *New hoarseness* particularly in *morning.* No history of bronchial asthma, HTN, or diabetes. He is a non smoker but occasionally drinks alcohol. Chest clar to auscultation and percussion. *Laryngoscopy - show red + inflamed posterior pharynx + larynx* - wheezing + chest tightness - concern for newe onset asthma I. GERD - in 75% asthma patients + is often primary trigger asthma in many patients. - *asthma that presents in ADULTHOOD, is WORSE ON LAYING DOWN, WORSE AFTER EXERCISE OR MEALS, SHOULD RAISE SUSPICION FOR GERD* - look for RFs and/or sx such as *obesity, hoarseness, redness of pharynx + larnx* - First step when GERD is suspected? *TRIAL OF PPIs = DX + TX*

Iliac Artery Atherosclerosis

- claudication thigh + buttocks - pain - occurs during activity, bettered with rest

Renal Artery Stenosis

- common finding in older patients - high prevalence in those severe HTN or Peripheral Arterial Disease - management I. RIsk Factor Reduction: hyperlipidemia control, aspirin, optimal diabetes control, smoking cessation to prevent CV disease ii. drugs: *first drug to add in RAS - ACE-I or ARB* iii. *surgery - reserved for pts w/resistant HTN or recurrent flash pulmonary edema*

Pressure Decubitus Ulcers

- common in patients with conditions that impair normal sensation or movement such as paraplegia + stroke. - most commonly occur over bony prominences where there is contact with bed. - classic: *sacrum heels, elbows, ears* - *UWorld objective: pressure on a bony prominence for a prolonged period of time can result in ischemic necrosis of overlying muscle, subcutaneous tissue, and skin, leading to formation of a pressure (decubitus) ulcer. Pt should be reposition patient to reduce pressure ulcer incidence* differential: I) venous stasis ulcers - associated with ulceration above medial malleolus; common pts with hx of venous thrombosis + occur primarily in pretibial area of lower leg; associated with stasis dermatitis ii) Arterial ulcers: due to insufficient blood supply that leads to tissue necrosis - usually occur in more distal parts of body where blood flow is lowest i.e. tips of toes

Herpetic Whitlow

- common viral infxn of hand - *HSV 1 or 2* - *direct innovulation of virus through broken skin = mode of transmission* - *most common in women with genital herpes or children with herpetic gingivostomatitis or health care workers touching orotracheal secretions* - presentation = *throbbing pain in distal pulp space which is swollen, soft, and possibly tender* -*systemic sx = fever + lymphadenopathy* - *dx confirmed - TZANCK SMEAR of vesicle - see MULTINUCLEATED GIANT CELLS* - self limited but to prevent secondary infection, give ORAL ACYCLOVIR + TOPICAL BACITRACIN

Meralgia Presthteica

- compression of lateral femoral cutaneous nerve at waist - it causes burning pain + paresthesia at lateral thigh

Scenario: 52 y/o m comes with 2 days of right leg pain + swelling. 3 weeks ago has cord like redness + tenderness in left leg that improved with Ibuprofen. No family history of blood clots. Temp of 99. CXR shows nothing abnormal. Venous duplex US shows thrombus in right popliteal + superficial femoral veins. What is next step?

- concept of provoked dvt I. *prolonged immobilization ii. surgery iii. trauma iv. pregnancy v. medications (OCPs) vi. CT diseases (SLE) vii. malignancy* - concept of unprovoked DVT I. none of the above are the cause - in *1st Unprovoked VTE* I. step 1 = *screen for malignancy using age appropriate screening - i.e. colonoscopy, mammogram PLUS CXR* - *recurrent unprovoked VTE or multiple site VTE i.e. in cerebral + hepatic veins* I. *1st step = detailed testing for malignancy i.e. CT scan of abdomen/pelvis/chest* - *when to test for hypercoaguability?* I. *patient age<45, there is family history of VTE, and recurrent or unusual site of VTE*

In a diabetic patient with non healing ulcer where the ulcer is surrounded by a halo of erythema + edema and x ray shows underlying bony destruction consistent with osteomyeltits, what is the mechanism of involvement? hematogenous, lymphogenous, direct inoculation, contiguous spread?

- contiguous spread

Cor Pulmonale

- core pulmonale = right sided heart failure form pulmonary hypertension. - due to I. COPD (MOST COMMON CAUSE) ii. interstitial lung disease (restrictive pathology) iii. OSA iv. Pulm HTN - ***RHF due to left sided or congenital heart disease is NOT considered cor pulmonale - has gradual onset *but can present acutely due to sudden inc in pulmonary artery pressures i.e. pulmonary embolus* - pts often see *exertional sx - dyspnea, angina, syncope* - PE - 1. *loud P2 (pulmonic component of 2nd heart sound), 2. tricuspid regurgitation murmur (holosystolic at LLSB), 3. INC JVP, peripheral edema, hepatomegaly, possible ascites); 4. if due to COPD then DISTANT HEART SOUNDS (due to HYPERINFLATED LUNGS) 5. Dependent pitting edema 6. possibly ascites due to backed up liver* - End stage cor pulmonale - *hypotension, tachycardia, other signs cardiogenic shock due to dec SV* -CXR: *enlarged central pulmonary arteries or loss of retrosternal air space due to RVH* - RH Catheterization: show *elevated CVP, inc RVEDP (same as CVP), elevated Mean Pulm Artery Pressure (>25 mm Hg at rest) without left heart disease* - Treatment I. optimize Right ventricular dynamics - preload, afterload, contractility w/ - supplemental O2 - diuretics - tx of underlying etiology - IV ionotropes for severe decompensation

Sarcoidosis

- cough + dyspnea - TH4 mediated non caseating granulomas - erythema nodosum, anterior uveitis, acute polyarthritis - *paratracheal adenopathy + reticulonodular infiltrates on CXR = highly suggestive* - *ACE levels are elevated* - *Tx = SYSTEMIC GLUCOCORTICOIDS*

Hodgkin's Lymphoma Pts

- curable lymphoma affect *young pts* - *pts treated before age 30 - can develop SECONDARY MALIGNANCIES FROM CHEMO/RADIATION* - most common secondary tumors malignancies = LUNG (esp smokers), BREAST, THRYOID, BONE, GI* - Hodgkin's lymphoma pts treated w/radiation or chemo have *inc chance of subsequent acute leukemia (or non Hodgkin's lymphoma)*

Current Guidelines About BPH

- current guidelines recommend evaluating all patients with probably *BPH* based on *history + rectal exam* with *URINALYSIS (NEXT STEP)(UWORLD QUESTION)* to assess for *urinary infxn + hematuria.* Patients with life expectancy >10 years should also have *PSA to screen for prostate cancer*

Empyema

- definition = *purulent pleural effusion* - caused by same as pneumonia bugs - *staph, strep, klebsiella - but mixed aerobic + anerobic population supersedes as disease progressed - therefore antibiotics for community acquired pneumonia not good enough* - presentation: SOB, cough (non or productive), pleuritic chest pain - most commonly occurs in *setting of untreated pneumonia due to bacterial seeding of pleural effusion* - inflammation + collection of pus in pleural cavity leads to formation *loculated, abn. contoured effusion w/ adjacent pulmonary consolidation*

Succinylcholine

- depolarizing neuromuscular blocker that can cause LIFE THREATENING HYPERKALEMIA - DO NOT USE IN PATEINTS W/OR AT HIGH RISK FOR HYPERKALEMIA SUCH AS BURN OR CRUSH INJUYR PTS OR PTS w/PROLONGED DEMYELINATION

Pyogenic Liver Abscesses

- develop following surgery, GI infection, or acute appendicitis - typical extreme pain, high fevers, and leukocytosis

Manic vs Hypomanic episode

- difference in severity of symptoms, duration, and degree of functional impairment - IF PSYCHOTIC SYMPTOMS PRESENT, MUST BE MANIC

Asthma vs COPD

- differentiating between the 2 is therapeutically relevant as *inhaled corticosteroids are the primary long term intervention for asthma whereas long acting anticholinergic inhaler is generally preferred for COPD* - most efficient test to *differentiate asthma + COPD = spirometry before and after administration bronchodilator (albuterol) I. pts with asthma show significant reversal (>12% increase in FEV1) in airway obstruction after administration of bronchodilator

Lung Abscesses

- due anaerobic bacteria - clinical features include indolent sx I. fould smelling sputum ii. CONCURRENT PERIODONTAL ABSCESS

Mucormycosis

- due most commonly *in diabetic patient by Rhizopus* - fever, bloody nasal discharge, nasal congestion, and involvement of the eye with chemosis, proptosis, and diplopia are impt. features. Involved turbinates can become necrotic. Invasion of local tissues can lead to blindness, cavernous sinus thrombosis, and coma.

Lambert Eaton Syndrome

- due to antibodies against presynaptic membrane voltage-gated Ca2+ channels - proximal muscle weakness - autonomic dysfunction (dry mouth, erectile dysfunction) - Cranial Nerve Involvement (i.e. ptosis) - *diminished or absent deep tendon reflexes* - repeat contractions can lead to temporary improvement of symptoms

Small Intestinal Bacterial Overgrowth (SIBO)

- due to overgrowth bacteria in PROXIMAL small intestine. - gastric acidity + peristalsis causes minimal bacterial colonization in proximal small intestine - Protective mechs agains SIBO i. closed ileocecal valve w/o reflux ii. trapping of bacteria by intestinal mucus iii. gastric acidity in prox portion iv. small bowel motility - peristalsis - causes are anything that disrupt protective mechs i. motility disorders - diabetes, systemic sclerosis, radiation enteritis ii. anatomical changes - surgically created anastomosis, strictures, fistulas iii. acid suppression, immundefic states, chronic pancreatitis, cirrhosis - presentation - daily bloating + inc flatulence; non bloody diarrhea several times per week. No fever, abd pain, weight loss, or recent travel. Look for Hx of systemic sclerosis or diabetes - Deficiencies may develop i. Vit B12, calcium, fat sol vitamins - Dx i. ENDOSCOPY W/JEJUNAL ASPIRATE - showing > 100,000 oranisms/mL = gold standard Diff Dx i. Partial small bowel obstruction - note OBSTIPATION - NO FLATUS + NO STOOL - postprandial abd. discomfort - nausea

Osgood Schlatter disease

- due to overuse injury by repetitive strain - young children that recently did growth spurt - x-ray knee show avulsion of the apopohysis of tibial tubercle

Babesiosis

- due to parasite Babesia; transmitted by *Ixodides tick* - *endemic to NE US - NY, Massachussettes, etc* - parasite enters pts *RBCs + cause hemolysis* - *hemolytic anemia w/jaundice, hemoglobinuria, renal failure, and death* - *NO RASH* - definitive diagnosis: *giemsa stained thick + thin blood smear* - Labs: *intravascular hemolysis, anemia, thrombocytopenia, atypical lymphocytosis, elevated ESR* - Tx: *atovaquone-azithro or quinine-clindamycin*

Shingles (herpes zoster) virus

- due to reactivation of varicella zoster virus - following primary infection (chicken pox), virus remains latent in dorsal root ganglia - any decrease in cell mediated immunity (i.e. older age, stressful situation - AFTER SURGERY, HIV, or lymphoma) can allow reactivation along *dermatome distribution* - *unilateral, dermatomal distribution of PAIN PRECEDING (1 WEEK BEFORE) THE RASH* - Tx = valacyclovir or acyclovir - Tx of postherpetic neuralgia - prevented or treated with *TCAs (amitriptyline or nortiptyline) along with antiviral tx

Ulcers from venous insufficiency

- due to venous valvular incompetence - ON MEDIAL ASPECT OF LEG ABOVE MEDIAL MALLEOLUS - SUCH ULCERS - preceded by CHRONIC LOWER EXTREMITY DEDEMA + STASIS DERMATITIS

Schizoaffective disorder

- during this you can have both manic + depressive episodes but as long as the psychotic symptoms occur at least 2 weeks straight outside of mood symptoms, think SA disorder

Features of Glucagonoma

- dx made by serum glucagon level measurement >500 pg/mL - UWORLD OBJ PRESENTATION: *mild diabetes mellitus, hyperglycemia with nicrotic migratory erythema, diarrhea, anemia, weight loss, glucagon > 500 pg/mL confirms dx)

Effects of Insulin Resistance

- dyslipidemia - endothelial dysfunction - procoaguable state - inc sympathetic activity - inc markers of inflammation - dec uric acid excretion - inc sodium absorption - inc testosterone production from ovaries

Malignant Otitis Externa

- ear discharge + severe ear pain - pain often radiates to temporomandibular joint. - worsening of disease despite use of topical antibiotics is classic indicator of condition's malignant source - PE: granulation tissue in external auditory meatus, may see necrotized tissue also - DM = biggest RF - causative organism = pseudomonas aeruginosa

How to prevent decubitus ulcers in bed-ridden patients of hospital?

- elderly + critically ill patients with immobility, poor nutrition, and sensory impairment are at risk of developing decubitus ulcers - ulcers form as a result of uninterrupted pressure on the tissue underlying bony prominences. - The elbows, coccyx, hips and heels are sites at especially high risk. - *tx = preventative measures of REPOSITIONING EVERY 2 HOURS + PRESSURE REDUCING DEVICES (AIR/FOAM MATTRESS)*

Dehydration Concepts

- elderly patients are particularly predisposed to dehydration after even minor insults - such as MINOR FEBRILE ILLNESS - classic signs: dry mucosa, *marginally high values for hematocrit + serum electrolytes (in the setting of hypotension*); BUN/cr > 20 - tx = IV Na+ containing crystalloid solutions - usually 0.9% NaCl (normal saline)

Enterocci induced endocarditis

- enterococci are normal inhabitants of GI tract - occasionally colonize the *anterior urethra* - *enterococcal endocarditis - generally hit older men after GU manipulation or younger women after obstretric procedures*

Biliary Colic

- episodic RUQ pain or epigastric pain - PAIN IS OFTEN CONSTANT RATHER THAN COLICKY - AND ASSOC W/N + V + R SIDEE SHOULDER PAIN + SUBSCAPULAR DISCOMFORT (REFERRED PAIN) - pain due to GALLSTONES PRESSING AGAINS OPENING OF CYSTIC DUCT S GALLBLADDER CONTRACTS in RESPONE TO FATTY MEAL + PRESSURE INC - AS GALLBLADDER RELAXES, STONE FALLS BACK FROM DUCT W/SUBSEQUENT PAIN RESOLUTION - NO SIGNS OF LOCAL OR GEN INFLAMMATION - Imaging studies (US***) - reveal gallstones - distinguish form cholecystitis i. resolution w/in 4-6 hours (biliary colic) ii. absence of abd tenderness, fever, leukocytosis (which is in acute cholecystitis)

Causes of Hypercalciuria or Excess Ca2+ excretion in urine

- excess Ca2+ ingestion, Vit D ingestion in excess, dehydration, prolonged immobilization

Organic Erectile Dysfunction

- failure to achieve a spontaneous erection during night and/or early morning is pathognomonic of organic erectile dysfunction (*NEUROGENIC*) - ED very common complication in patients with PELVIC FRACTURE + URETHRAL INJURY I. cause of impotence: *injury to parasympathetic nerve fibers + arterial insufficiency*

Nonallergic Rhinitis vs Allergic Rhinitis

- features that differentiate NAR (vasomotor rhinitis is another term) from allergic rhinitis include NAR (Vasomotor rhinitis) I. predominant nasal congestion or stuffinesss ii. post nasal drip (dry cough) iii. no specific identifiable triggers Allergic Rhinitis I. Predominant eye sx, itching, and sneezing Dx - clinical I. NAR - those with predominant rhinorrhea and/or postnasal drip sometimes respond to first generation oral H1 antihistamines (clorpheniramine) but rarely ever to antihistamines without antiACh properties (i.e. loratidine) - Tx - intranasal glucocorticoids or topical intranasal antihistamine spray (azelastine, olopatdine) OR BOTH IF MODERATE SX ii. Allergic Rhinitis - intranasal glucorticoids = Tx (contrary to what you would think with - would think we would use antihistamines)

Dengue Fever

- fever, headache, *retro-orbital pain*, rash, and significant myalgia, and arthralgias

Infectious Mononucleosis

- fever, sore throat, malaise, *jaundice, mild hepatosplenomegaly* - *symmetrical lymphadenopathy involving posterior cervical chain lymph nodes* - inguinal + axillary lymphadenopathy can be present - other physical findings include *pharyngitis, tonsillitis, TONSILLAR EXUDATES, maybe MILD PALATAL PETECHIAE (non specific - can be seen in strep pharyngitis also) - *hepatosplenomegaly, malaise, generalized lymphadenopathy esp of cervical chain = classic IM* - Cause: most commonly *EBV* - Dx - *monospot test that confirms atypical lymphocytosis* - Complications I. *AUTOIMMUNE HEMOLYTIC ANEMIA ii. thrombocytopenia (EBV induced Abs attack RBCs + platelets)* *these antibodies = IgM cold agglutinin antibodies; test COOMBs (+)* iii. splenic rupture - caused by trauma (*avoid contact sports such as football for at least 3 weeks - absolute value, test question*) iv. tonsillar enlargement - giving airway compression

36 y/o M to ED w/confusion for past 2 days. In Ed had seizure tonic clonic. Temperature of 104.0. PUlse is 105. Fundoscopy is normal. Upgoing plantar reflexes bilaterally. CT head is normal. LP performed with opening pressure normal, protein 85 (normal <40), WBCs of 90 (normal 0-5). Gram stain show no bacteria. What is tx?

- first of all - not bacterial meningitis - no gram stain - hx of seizure - think temporal lobe involvement - then think Herpes Simplex Virus - then think Tx = Acyclovir (answer)

18 y/o w/crohn's on adalmumab + MTX going to Africa. Which of the listed vaccines should he receive - intranasal influenza, MMR, meningococcal booster dose, varicella, or yellow fever?

- game the question: all of them are live vaccines that shouldn't be given to patient on TNF-Alpha inhibitor - therefore choose the meningococcal vaccine

Pseudomonas aeruginosa

- gram negative rod - *think CF + bronchiectasis*

21 y/o m comes to ED for evaluation of thigh pain. This morning he bumped into edge of table. Now has swelling + pain in right thing. Acetaminophen does not help. Fam hx sig for maternal uncle wit bleeding problems. Exam shows man with marked ecchymosis + swelling over right quadriceps. Which of the following will most likely be found on further history + examination of patient?

- hemarthroses - when you see bumping and therefore bleeding into muscle (thigh hematoma) - think factor deficiency - most common - FACTOR VIII + IX (hemophilia A +B)

G6PD deficiency

- hemolytic episodes in these patients are precipitated by i. *infections or medications (SULFA DRUGS SUCH AS TMP SMX, ANTIMALARIALS, NITROFURANTOIN)* ii. patient will have *(+) Prussian blue stain - indicating presence of hemosiderin - which is found in urine during hemolytic episodes* iii. underlying pathophysiology - need G6PD in RBCs to help produce NADPH from NADP+. This allows management of oxidative radicals. NADPH is necessary to form reduced glutathione which protects RBCs from oxidative injury. iv. in absence of G6PD in presence of oxidizing agents (i.e. bacterial agents, sulfa containing drugs), *Hb becomes oxidized to form methemoglobin which then precipitates to form HEINZ BODIES THAT ATTACH RBC MEMBRANE and ARE THEN REMOVED IN SPLEEN*

A very painful and pruritic rash occurs with *sharp pain in affected area before rash (wrapping around right below breast horizontally) appeared* soon after a elective cholecystectomy 10 days ago. Today she is afebrile + other vital signs are within normal limits. What is cause? Tx?

- herpes zoster (shingles) - tx = valacyclovir or acyclovir

Side effects of Thiazide Diuretics

- hyperglycemia - increased cholesterol + plasma TGs (hyperlipidemia) - hyperuricemia - hypercalcemia *above 4 = HYPER "GLUC" - also hyponatremia, hypokalemia, hypomagnesemia

In a healthcare worker that is exposed to HBV via pin prick, what is next step?

- if (+) HBe Ag + (+) HBsAg then consistent with acute Hep B infection. I. prophlylaxis for unvaccinated/unsure HCW - *complete HBV vaccine series + HBIg (TEST Q)* - if patient was previously vaccinated therefore having a Anti-HBS Ab - *REASSURANCE (TEST Q)*

Acid Base Disorders

- if when checking with these equations, both what you think is the compensatory reaction and the primary reaction in either combination don't explain the other with formula application, then both types of disturbances are present - i.e. in salicylate poisoning there is metabolic acidosis and respiratory alkalosis mixed *always after identifying a primary acid base disorder, the calculated expected pCO2 or HCO2- should be compared to measured values to distinguish between appropriate compensation + mixed disorder*

Management pulmonary embolus

- if you see sudden onset of pleuritic chest pain, dyspnea, tachypnea, tachycardia, hypoxemia after period of prolonged immobilization steps are in order: 1. supportive care with oxygen for hypoxia + IV fluids for hypotension 2. Assess CI for anticoagulation - - if CI - then look for possible placement of IVC filter - if NO CI - DO WELLS CRITERIA - i. if PE unlikely - do diagnostic testing - first D-dimer - if <500 ng/mL - EXCLUDE PE - if > 500 ng/mL - THEN DO CT PULMONARY ANGIOGRAPHY ii. if PE LIKELY - FIRST GIVE IV HEPARIN FIRST (STUDY THIS, WAS UWORLD Q) BEFORE DIAGNOSTIC TESTING - prevent further clotting without lysing current clot - start with CT PULM ANGIOGRAPHY (NOT D-DIMER) b/c you are pretty sure there is PE ***negative D-dimer is very helpful in excluding the diagnosis of pulmonary VTE in low risk patients. A positive D-dimer however, is far from diagnosistic and must be followed by more spec. studies

Esophageal Varices

- in contrast to Mallory Weiss tear with bleed of SUBMUCOSAL ARTERIES - varices involve SUBMUCOSAL VEINS - esophageal varices = DILATED SUBMUCOSAL VEINS in RESPONSE TO PORTAL HTN i. eventual rupture - ASYMPTOMATIC BLEEDING, NOT PRECEDED BY VOMITING (vs mallor Weiss) - endoscopy would identify these varices

Somatic Symptom and Related Disorders

- in conversion disorder - look for la belle indifference - patient seems indifferent to neurologic symptom I. common triggers = relationship conflicts or other emotional component stressors ii. symptoms are not feigned or intentionally produced iii. 1st line treatment = EDUCATION + ENCOURAGEMENT + MAYBE CBT - somatic symptoms disorder I. persistent symptoms > 6 months

Renal transplant dysfunction

- in early post operative period can be explained by a variety of causes, including I. ureteral obstruction - renal US will R/O ii. acute rejection - if this is answer, TREAT WITH IV STEROIDS iii. cyclosporine toxicity - renal biopsy findings will show iv. vascular obstruction v. ATN

HPV Vaccine Regulations

- in male + female patients 9-26

Osteomyelitis modes of spread

- in patient with *arterial insufficiency such as DIABETES - THINK CONTIGUOUS SPREAD* - hematogenous spread - most likely pathogenic mechanism of hematogenous osteomyelitis - typically observed in children - direct inoculation of pathogenic bacteria during trauma may be responsible for post traumatic osteomyelitis

Features suggestive of Testosterone Insufficiency

- incomplete sexual development - decreased libido and potency - dec early morning erections - gynecomastia - decreased secondary sexual characters (dec shaving freq) - Small testicles (normal testes are 4-7cm) - hot flashes (severe hypogonadism) - low sperm count - osteoporosis

Effect of Glucocorticoids on BUN

- increase BUN due to catabolic effect on body proteins; unlikely to increase creatinine

When do you use HIDA scan?

- indicated in patients with *acute Cholecystits* when ultrasonography cannot definitively obstruction at neck of gallbladder*

PCWP significance (pulmonary capillary wedge pressure)

- indicator of *left atrial pressure - when elevated, indicator of cardiac origin for sx*

Hypersensitivity Pneumonitis

- inflammation of lung parenchyma caused by Ag exposure I. often is aerosolized bird droppings - bird fancier lung ii. molds - farmer's lung - acute episode presents with I. cough ii. breathlessness iii. fever + malaise iv. *occur within 4-6 hours of exposure* - Chronic exposure I. *clubbing (makes sense because it is a form of ILD)* ii. *honeycombing of lung* iii. *weight loss* iv. *PULMONARY FIBROSIS* - *RESTRICTIVE PATTERN* - classic CXR FINDINGS I. *haziness of LOWER lung fields* - Management - *AVOID RESONSIBLE ALLERGEN*

Riedel's Thyroiditis (Fibrous Thyroiditis)

- inflammatory disorder characterized by fibrosclerosis of the thyroid surrounding tissues and remote nonthyroidal structures - SUBCLINICAL OR OVERT HYPOTHYROIDISM MAY BE SEEN - MOST PTS HAVE HARD GOITER

MOA of Colchicine

- inhibit tubulin polymerization thereby decreasing leukocyte activity

painless gross hematuria in patient >35 w/smoking hx

- initial assessment: urinanalysis to r/o UTI + confirm microhematuria (>3 RBC/hpf) as red urine can occur in other conditions I. myoglobinuria ii. beet ingestion iii. rifampin use

Vertebral Osteomyelitis

- injection drug users, sickle cell anemia pts, and those that are immunosuppressed are at highest risk - *most common pathogen = staphylococcus aureus* - *tenderness to gentle percussion over spinous process is most impt clue* - *WBC MAY BE NORMAL OR NOT ELEVATED BUT PLATELETS WILL BE ELEVATED AS MARKER OF INFLAMMATION/STRESS* - *ESR - ELEVATED > 100mm/h) - *MOST SENSITIVE DX TEST = MRI* - *HIGH SUPSICION FOR PT w/VERTEBRAL OSTEOMUYELTIIS SHOULD BE PRESENT IF THERE IS PT W/HX OF INJECTION DRUG USE OR RECENT DISTANT SITE INFECTION (UTI) - *Tx = Long Term IV antibiotics*

What are 2 important causes of hypoglycemia in non diabetic patients with elevated insulin levels?

- insulinoma (beta cell tumor) - see elevated C peptide levels + proinsulin levels > 5/mol/L - surreptitious use of insulin or sulfonylurea i. see dec C peptide levels + proinsulin levels

Types of Thyroid Cancer

- know chart - Papillary Carcinoma I. hurthle cells may be present ii. *lymph node involvement is common* iii. slow, infiltrative local spread iv. FNAB (fine needle aspiration biopsy) - large cells with ground glass cytoplasm + pale nuclei w/inclusion bodies w/central grooving (orphan annie nuclei) v. UNENCAPSULATED (vs follicular thyroid cancer - capsulated) - Follicular Carcinoma of thyroid I. early hematogenous spread to bone, lung, brain ii. histopathologically *must demonstrate invasion of capsule + blood vessels to differentiate follicular cancers from follicular adenomas (necessary to make dx - UWORLD)* iii. ENCAPSULATED (VS PAPILLARY CANCER)

Perforated Peptic Ulcer

- know images on right - first is xray, 2nd is CT - CHRONIC EPIGASTRIC PAIN THAT SUDDENLY WORSENS + BECOMES DIFFUSE W/PNEUMOPERITONEUM = CLASSIC PERF ULCER - peritonitis due to release gastric contents into peritoneal cavity -result in TENDERNESS + GUARDING. Diff Dx - pain on inspiration = murphy's sing - may be positive during perforated peptic ulcer though normally we think Acute Cholecystitis. Beware of xray though

Common Causes of Myopathy

- know the five most common ones listed in the chart - hypothyroid myopathy i. sluggish ankle reflexes ii. *elevated CK* iii. normal ESR iv. fatigue v. *no clear correlation from CK inc to hypothyroid severity - concept is that ALWAYS CONSIDER HYPOTHYROID MYOPATHY IN PATIENT WITH UNEXPLAINED CK ELEVATION* vi. *DTRs = normal* - Polymyositis i. *symmetrical proximal muscle weakness usually involving DELTOIDS + HIP FLEXORS + NECK MUSCLES* ii.*DTRs = Normal* iii. ESR normal + *Elevated CK* iv. can be associated with other findings like Raynaud's dz, ILD, etc -* in a patient with myopathy + inc CK, CLASSICALLY DO TESTING OF TSH (MOST SENS TO HYPO/HYPERTHYROID) + FREE T4 FIRST IF SX ARE VAGUE b/C THIS IS LEAST INVASIVE ROUTE + SIMULTANEOUSLY RULES OUT HYPOTHYROID (UWORLD Q)*...also if Hashimoto's is cause, ANA will be (+) - *if negative, then proceed to more invasive muscle biopsy or Electromyogram to r/o myositis causes*

Prevention of Recurrent Nephrolithiasis

- know this - WAS UWORLD QUESTION Dietary Measures - increase fluids (produce > 2L urine/day) - reduce Na+ (<100mEq/L) - helps to inhibit Ca2+ stones - Reduce protein - help with uric acid stones - *normal calcium intake (1200mg/day)* - Increase Citrate (fruits + vegetables) - reduce oxalate diet for oxalate stones (decrease dark roughage, Vitamin C) Drug Therapy - Thiazide Diuretic - help reduce calcium stones - Urine alkalinization (especially help in uric acid stones and cystinuria stones where precipitation occurs at dec pH) - Potassium Citrate/bicarbonate salt - allopurinol for hyperuricosuria related stones

When there is no food to eat in desert and body is in fasting state, what processes are utilized and what products are used in each?

- liver maintains glucose levels in blood via *glycogenolysis and gluconeogenesis* - during fasting states, *glycogen reserves drop dramatically in first 12 hours; glycogenolysis is primary source of energy in first 12 hours* - in *fasting state, 12 -24 hours glycogenolysis and gluconeogenesis both take place* - in *fasting state, after 24 hours, gluconeogenesis represents sole source* of glucose production i. main substrates for gluconeogenesis are: i] *gluconeogenic amino acids* (from breakdown muscle), ii] *lactate* (from anerobic glycolysis), iii] *glycerol-3-P* (from triacyglycerol in adipose) a. *lactate, alanine, and other gluconeogenic AAs are converted to pyruvate OUTSIDE OF LIVER* b. *glycerol 3 P feeds into becoming glucose directly outside of liver* c. *glutamine and other AAs - enter CAC in liver before exiting as pyruvate*

Patient comes in w/tonic clonic seizures. He is a heavy alcohol user + has previous hospitlizations for this. He now has BP of 155/92, pulse of 108/min, and respirations of 14/min. Urine sediment shows 5-10 wbcs, 0-1 rbcs, some epithelial cells. Dipstick shows large amounts of blood. What is most likely dx?

- look at seizures, consider rhabdomyolysis which will cause myogliburia giving renal damage. Causes the urine sediment that we saw. Also look at concept of *dipstick shows large amounts of blood but the urine sediment microscopy indicates that there are only 0-1 RBCs - meaning that this "large volume of blood on dipstick" is due to MYOGLOBINURIA - understand that dipstick does not differentiate myoglobin versus hemoglobin* - *myoglobinuria due to rhabdo will give TUBULAR damage which generally presents with a lesser degree of proteinuria* - *summary uworld: one should suspect myoglobinuria whenever test results large amount of blood with a relative absence of RBCs on urine microscopy. Myoglobinuria is usually caused by rhabdomyolysis, which frequently leads to ARF*

Pulmonary Embolus

- look for predisposing factors like MALIGNANCY - acute presentation of *dyspnea, chest pain, tachycardia, hypoxia, clear lungs* - highly suggestive of PE - *mass PE* - may present with *SIGNS OF LOW ARTERIAL PERFUSION* = *syncope + hemodynamic collapse* i. *INC PULMONARY VASCULAR RESISTANCE* give *acute right ventricular dilation* + failure due to RV outflow obstruction + increased pulmonary vascular resistance ii. dilated RV then impinges on LV causing dec LV output (*HYPOTENSION*) - DETECTED BY TEE - McConnell's sign - dilated RV + hypokinesis of RV wall with sparing of apex - *accentuate P2 heart sound, elevated CVP (i.e. JVP) indicating LVEDP elevated - both indicate RIGHT HEART PATHOLOGY* - *may see Right bundle branch block + RV strain pattern (RA deviation on EKG)*

Primary Sclerosing Cholangitis

- look for pt with i. pmh of UC and then presents ii. with alk phos way elevated iii. then presents with normal or very slightly elevated AST + ALT iv. ESR WAY HIGH due to underlying IBD v. (+) perinuclear - antineutrophil cytoplasmic antibodies (P-ANCA) - structuring + fibrosis medium + large size INTRAhepatic + EXTRAhepatic Bile ducts***** - continued bile duct destruction leads to end stage liver dz. + portal HTN*** - first presenting sx = FATIGUE + PRURITIS + LABS w/AST + ALT <300 BUT ALK PHOS WAY ELEVATED + BILI ELEVATED (CLASSIC CHOLESTATIC PATTERN) - other serologic findings i. hypergammaglobulinemia ii. inc. serum IgM iii. Atypical P-ANCA antibodies - Dx - EVEN THO CHOLESTATIC MECH, US NOT USEFUL - DO ERCP 1st CHOICE ***** i. show multifocal narrowing w/intrahepatic + extrahepatic duct dilation ("BEADING") - Pathology i. liver biopsy - intrahepatic ductular obliteration w/moderate lymphocytic infiltration + peri ductular "onion skin" fibrosis - Progression i. is a progressive CHOLESTATIC DZ - so see fatigue, pruritis, STEATORRHEA, FAT SOL VIT DEFICIENCIES, METABOLIC BONE DZ **** (OSTEOPOROSIS DUE TO DEC VIT D), and HEPATIC FAILURE

Lumbar Disk Degeneration

- low back pain in elderly - pain usually worsen with activity + relieved with reset

Keratoacanthoma

- low grade malignancy - pathologically resembles squamous cell carcinoma - appears as a solitary, firm, round, skin-colored or reddish plaque that develops into a nodule with a *central keratin plug*

Ascites Fluid Characteristics

- low protein ascites = Total Protein < 2.5g/dL I. cirrhosis ii. nephrotic syndrome - SAAG calculated by: SERUM ALBUMIN CONC - ASCITES ALBUMIN CONC. - Note mechanism of PORTAL HTN (when SAAG > 1.1g/dL indicating etiologies such as cardiac ascites, cirrhosis) - IS INC HYSTROSTATIC PRESSURE IN HEPATIC CAPILLARY BEDS - Mech of Non Portal HTN (when SAAG<1.1g/dL indicating etiologies such as malignancy, pancreatitis, nephrotic syndrome, TB) - IS MIXED BUT EX IS MALIGNANCY CAUSES INC CAPILLARY PERMEABILITY

In severe hypovolemia where there is hyponatremia i.e. BP is 95/44, what is the cause?

- mainly ADH regulated by osmolality but in severe hypovolemia, this becomes also a potentiator of ADH release and therefore ADH released making hyponatremia worse. Hyponatremia worsens as ADH increased until which point the regulation of ADH by osmalility is greater than by the severe hypotension - Hypovolemia also causes for induction of R-A-A system - Hypovolemia also activate sympathetic system

Evaluation of Hyponatremia

- majority of pathologies at bottom based on serum osmolality low, urine osmolality high then either urine Na low or high - Manifestations of Hyponatremia I. *test q - seizure*, lethargy, psychosis, seizures - Primary Polydipsia I. in algorithm: Hypoosmolar plasma (<290) + hypoosmolar urine (<100) ii. *test association: associated with psychiatric disorders i.e. schizophrenia (causing central defect in regulation of thirst* - SIADH I. causes include *drugs (carbamazepine, cyclophosphamide, SSRIs such as fluoxetine), lung cancer (i.e. small cell lung cancer)

Ureteral Calculi

- may cause flank or abdominal pain radiating to the perineum - often w/N + V - gross hematuria - *DIAGNOSTIC TOOLS OF CHOICE - EITHER ULTRASOUND OR NONCONTRAST SPIRAL CT OF ABDOMEN + PELVIS* I. *US - PREFERRED IN PREGNANT PATIENTS*

what is pain at tibial tuberosity an example of?

- may indicate ethesitis - inflammation at site of tendon insertion into bone - occurs in *spondyloarhtropathies such as ankylosing spondylitis*

Causes of Nephritic Syndrome

- membranoproliferative glomerulonephritis type II i. nephrotic range proteinuria ii. hematuria iii. dense intramembranous deposits that stain for C3 = characteristic microscopy finding iv. caused by *igG antibodies (C3 nephritic factor) that are directed against C3 convertase in alternate complement pathway to give persistent C3 activation (PRESENT WITH DECREASED C3 LEVELS) - Post Streptococcal Glomerulonephritis I. occurs 10-30 days after streptococcal throat or skin infection - present as: *hematuria, hypertension (classic nephritic syndrome sx not in nephrotic syndrome), RBC casts, mild proteinuria) - present also as: *periborbital swelling (classic nephritic syndrome) + OLIGURIA (UNIQUE)* - *C3 levels are low*

Pulmonary Flow Loops

- memorize the hell out of normal values being 6 to 2 L of lung volume on x-axis and 2 to 8 L/sec on y-axis. - Understand fixed airway obstruction has dec y-axis span but same x-axis span - on image understand acronym "OR" meaning obstructive lung disease will be shifted left on x-axis and Restrictive lung disease will be shifted right on x-axis I. note obstructive pattern is I] shifted left (expiratory flow volumes are decreased in comparison to given lung volumes), ii] scooped out pattern during exhalation ii. note restrictive lung patter is ii] shifted right - meaning expiratory flow volumes are increased in comparison to given lung volumes - examples of fixed airway obstruction I. laryngeal edema secondary to food allergy

Malignancy Associated Hypercalcemia

- metastatic breast cancer most commonly causes hypercalcemia by producing PTHrP i. this is not produced by primary breast tumor but rather *LOCALLY PRODUCED WHERE BREAST TUMOR HAS METS TO BONE* - PTHrP is not elevated in these patients - *some malignancies i.e. MULTIPLE MYELOMA, LYMPHOMAS, LEUKEMIA, OR EVEN BREAST IN AN ALTERNATE PATH* - YOU SEE *OSTEOCLASTIC BONE RESORPTION INCREASED BY CYTOKINE* PRODUCTION AFTER METS TO THE BONE*

Splenectomy is the treatment of choice for?

- moderate, symptomatic *hereditary spherocytosis* - also used as a treatment option for *AIH or those with massive splenomegaly b/c beta thalassemia major*

Radiation fibrosis

- more commonly in pts that received lugn field radiation - typically develop dyspnea, non productive cough, and chest pain *4-24 months after radiation* - CXR - *volume loss w/coarse opacities*

Lumbosacral strain

- most common cause of back pain - *start acutely after physical exertion + conc. in lumbar area w/o radiation to thighs* - *local tenderness + contraction of paraspinal muscles - SO PAIN IS IN PARASPINAL REGION WITHOUT SIGNIFICANT TENDERNESS TO PALPATION OF VERTEBRA* - *straight leg test - negative* -*no radiation* -*normal neurologic exam* - Treatment - *NSAIDS*

Evaluation of Hyperthyroidism

- most common cause of hyperthyroidism is GRAVES DISEASE I. cause: autoAb to TSH receptor - see diffuse goiter + ocular abnormalities (proptosis, periorbital edema) - understand in radioactive iodine uptake testing: I. low iodine uptake indicates that the hyperthyroidism is occurring due to release of *preformed T4* ii. high iodine uptake indicates that the hyperthyroidism is occurring due to *creation of new T4* - causes of thyroid toxicosis with reduced radioactive iodine uptake - causes of which are differentiated by [thyroglobulin] I. *thyroglobulin high causes include: a. subacute lymphocytic (PAINLESS) thyroiditis b. subacute granulomatous thyroiditis (De Quervain's - PAINFUL) c. iodine induced thyrotoxicosis d. struma ovarii - ovarian teratoma - extremely rare ii. thyroglobulin low causes include: a. exogenous levothyroxine uptake*

Basal Cell Carcinoma

- most common form in US - possible presentations: i] persistent open sore that bleeds, oozes, or crusts; ii] reddish patch or irritated area (superficial BCC); iii] pearly or translucent nodule with pink, red, or white color (nodular BCC); iv] *pearly papule or plaque with, rolled + elevated border with either central ulceration telengiectasias (more common test q) that bleeds easily (CLASSIC)*; v] pale, scar like area with poorly defined borders *MOST COMMON SKIN CANCER* Treatment: - if nodule on *trunk or extremity - SURGICAL EXCISION WITH 3-5 mm MARGINS* - if nodule *on face; Mohs micrographic surgery(sequential removal of skin layers w/microscopic exam to confirm margins are cleared)*

Analgesic Nephropathy

- most common form of drug induced renal failure - associated with *long term use of 1 or multiple analgesics for chronic headaches or other somatic complaints* - most common in *females* that habitually use *aspirin + naproxen* - 2 most common pathologies of analgesic nephropathy = *tubulointerstitial nephritis + papillary necrosis* - sx = microscopic hematuria (sx of papillary necrosis) + renal colic (following sloughing of renal papillae + significant papillary necrosis) + polyuria + sterile pyuria + maybe WBC casts - chronic analegesic abuse - *premature aging, Atherosclerotic vascular disease, Urinary tract cancer* - *labs - INC Cr* w/urinalysis giving *HEMATURIA* + *Sterile Pyuria* + *mild proteinuria (<1.5g/day)* - *CT w/bilateral renal papillary calcifications*

Myasthenia Gravis

- muscle weakness + *fatigability* - due to autoantibodies against AChR in postsynaptic membrane - *ocular defects (ptosis, diplopia) - bulbar (dysphagia, dysarthria) - Facial, neck, and limb deformities* - *CN defects (vision) + Proximal limb weakness that worsens on repeated activity, better w/rest* - Dx = *edrophonium - anticholinesterase test*

Microscopic Polyangitis

- necrotizing vasculitis - fever +malaise - *abd pain, hematuria, purpura,* - *P-anca; serum complement levels are normal*

When is Vancomycin added?

- no gram (-) activity - added to empiric drug therapy for patients with know colonization with Methicillin resistant staph aureus, probable catheter related infection, skin/soft tissue infection, pneumonia, or hemodnamic instability

S. bovis association

- normal inhabitant of GI tract - S. bovis bacteremia associated WITH GI CANCER - colonoscopy should be performed when this organism is isolated from blood cultures

67 y/o f PHM HTN, hypercholesterolemia, TII DM calls 911 for severe dyspnea. Sx started 2 hours ago w/chest pain + progressed to orthopnea + dyspnea. BP is 170/100 mm Hg + pulse is 120/min and regular. 3rd heart sound is present. Bilateral crackles are heard on chest auscultation. Her O2 saturation is 78% with 40% inspired oxygen. She is intubated in the filed by paramedics for progressive respiratory failure+ treated with nitrates + diuretics. After initial measures breath sounds on left side are markedly diminished. Her repeat BP is 168/96 mm Hg. Which of the following is most likely to restore breath sounds to the left hemithorax?

- note that ideal location of the distal tip of the endotracheal tube (ETT) is 2-6 cm above the carina. - because right mainstem bronchus diverges from the trachea at arelative non acute angle, ETT advanced too far *preferentially enters the right main bronchus* I. *gives overinflation right lung + underventialtion of the left lung and asymmetric chest expansion* ii. *auscultation - markedly dec or absent breath sounds* iii. *confirm dx via XRAY* iv. *tx = REPOSITION ETT via PULLING BACK SLIGHTLY*

Clinical Features of Acute Liver Failure

- note that sometimes patients with Acute Liver Failure may present with DECREASING TRANSAMINASES W/WORSENING PT/INR + BILIRUBIN (b/c after certain point, dec. transmaninases come to indicate worsening liver function) - THEREFORE PT/INR = MOST IMPT INDICATORS OF ALF - normally though MARKEDLY ELEVATED AST + ALT IN THOUSANDS **** + INR > 1.5 + PT WAY HIGH + SIGNS OF ENCEPHALOPATHY (CLASSIC) - IF YOU SEE THIS PICTURE THICK ALF AND LOOK FOR CAUSE Diff Dx - alcoholic hepatitis + NASH - w/AST + ALT elevations that RARELY EXCEED 500 U/L

Differential diagnosis based on carbon monoxide diffusing capacity of lung

- note: *panacinar emphysema - restrictive pattern*

Signs of COPD

- obstructive pathology - no reversibility with bronchodilator - FEV1 < 80% - FVC normal or slightly dec - FEV1/FVC <70% - recurrent cough productive of sputum - smoking history - AP chest diameter markedly increased - *INC TLC, INC FRC, INC RV - gives hyperinflation + diagrammatic flattening - CAUSES INC WORK OF BREATHING* (UWORLD Q)

Hidradenitis suppurativa

- occurs in *axilla, groin, or scalp* - usually patients develop *inflammatory nodules or abscesses* with purulent drainage accompanied by scar tissue in chronic phase

Indolent Late onset autoimmune type I diabetes

- occurs in *older patients* - initially present *similar to TIIDM * - patients have anti glutamic acid decarboxylase antibodies (*ANTI GAD Abs*) - *LOW INSULIN LEVELS* - progress quickly to insulin dependency compared to typical patients with TIIDM

PCP

- occurs in HIV Pts at CD4<200 - presentation: nonproductive cough, progressive dyspnea, weight loss, tachypnea, - CXR - *bilateral interstitial infiltrates and/or alveolar infiltrates* - 1st line for dx = *Sputum induction via Hypertonic Saline* - if no go, then *2nd line = BAL in bronchoscopy*

invasive aspergillosis

- occurs in immunocompromised patients - fever, cough dyspnea, or hemoptysis - *CXR show cavitary lesion* - *CT - pulmonary nodules with a halo sign or lesions with an air crescent*

Autoimmune Hemolysis

- occurs when IgG antibodies bind to RBC membrane and promote removal from circulation in spleen - direct COOMB's test will be (+) - *Alpha-methyldopa + PCN* can cause this type of reaction

Evaluation of suspected Ventilator Associated Pneumonia

- on a patient that is intubated, VAP occurs *>48 hours after endotracheal intubation* and is most commonly caused by *aerobic gram negatives such as pseudomonas, E.coli, klebsiella,) + gram (+) cocci (i.e. MRSA, streptococcus) - usually present with *fever, purulent secretions, difficulty with ventilation (inc RR, dec TV) after 48 hours post intubation* - *first step = CXR* - if normal, VAP unlikely - Abn CXR (alveolar infiltrates, air bronchograms, silhouetting of adjacent solid organs - *2nd step = LOWER RESPIRATORY TRACT SAMPLING* - *give patient empiric antibiotics (usually gram pos, anti pseudomonal, and gram negative coverage) until culture susceptibility results return

Gouty Arthritis

- on imaging - *PUNCHED OUT EROSIONS W/RIM OF CORTICAL BONE* - synovial fluid analysis - *2,000-50,000/mL (<100,000) + needle shaped, negatively birefringent crystals* I. *negative birefringene = yellow is parallel with polarization, blue is perpendicular* Causes - primary gout (idiopathic) - myeloproliferative/lymphoproliferative disorders I. ie. Polycythemia vera where there is triggering by hot baths (aquagenic pruritis), headaches, and hepatosplenomegaly; characterized by proliferation of all 3 marrow lineages (RBCs, WBCs, platelets). - tumor lysis syndrome - hypoxanthine guanine phosphoribosyl transferase deficiency I. a genetic deficiency of HGPRT is called Lesch Nyhan Syndrome - associated with overproduction of uric acid - chronic kidney disease - thiazide/loop diuretics Etiology - *80% of these occur in METATARSOPHALANGEAL JOINTS OR KNEES* Predisposing factors - high meat, seafood consumtion, volume depletion, excdss alcohol intake

Microprolactinoma

- one of most common pituitary tumors - classic presentation: *amenorrhea + galactorrhea in females*; *hypogonadotropic hypogonadism (secondary or central hypogonadism) in males where FSH + LH are low or normal and testosterone is low* - Tx I. *FOR ALL PROLACTINOMAS - MICRO OR MACRO = CABERGOLINE OR BROMOCRIPTINE - DOPAMINERGIC AGENTS - THESE DEC PRL + DEC TUMOR SIZE* ii. *surgery only indicated when impaired vision*

Progressive Multifocal Leukoencephalopathy

- opportunistic infection seen in IMMUNCOMP pts - it is caused by JC virus (human polyoma virus) - *predominantly white cortical matter involved but brainstem + cerebellum might be involved too* - Lesions typically do not produced mass effect - *most common sx = hemiparesis, disturbance of speech, vision, and gait (focal neurologic deficits* + *HIV PT (immuncomp)* = *PML* (UWORLD CONCEPT) - Confirmation dx = *MRI: multiple, demyelinatingn non enhancing lesions with no mass effect* - No tX

Acute Drug Intoxication

- other cannabis effects I. paranoia, anxiety ii. auditory or visual hallucinations iii. psychomotor impairment - LASTS BEYOND PERIOD OF EUPHORIA***** - high risk MOTOR VEHICLE ACCIDENT iv. gynecomastia in men - CHRONIC ABUSE - cocaine withdrawal I. dysphoria ii. difficulty concentrating iii. inc. sleep + appetite - Opioid Withdrawal I. papillary dilation Ii. Yawning Iii. Diaphoresis Iv. lacrimation v. GI - N + V + Diarrhea

Herpes zoster (shingles)

- painful reactivation of varicella zoster virus that causes a vesicular rash in a dermatome distribution - patients usually present *PAIN 48 HOURS BEFORE RASH ONSET* with a rash that starts as *UNILATERAL, DERMATOMAL erythematous papules + evolves into vesicles + bullae, with subsequent crusting in 7-10 days* - acyclovir + valcyclovir may be used to decrease both the duration of disease + incidence of post herpetic neuralgia - post herpetic neuralgia pain can be treated with amitryptiline and other TCAs

Pulmonary Auscultation Examination Findings

- palpable vibration felt on chest wall is known as fremitus - sound travels faster in solids (consolidation) than in aerated lung -resulting in increased fremitus in pneumonia -

complicated Parapneumonic effusion vs empyema vs uncomplicated parapneumonic effusion

- parapneumonic effusion usually occur from pneumonia - when associated with pneumonia, effusions can be parapneumonic uncomplicated, complicated parepneumonic effusion, or empyema which is when pleural effusion is left long enough after pneumonia to give pus in mediastinum presentation - may resolve with antibiotic therapy OR - may continue to have elevated temperatures, pleuritic chest pain, and dyspnea Dx - *CT THEN ASPIRATE* - analyze for *protein content (exudate have more than transudate), gram stain, cell count, cytology (rule out malignancy), and glucose levels (low in rheumatoid arthritis, tuberculosis, empyema, malignancy, and esophageal rupture) , AND pH (if <7.2, pathognomonic for empyema)* Tx - if pH <7.2 OR GLUCOSE < 60 (or glucose effusion/serum glucose <0.5) or LDH >1000 - i. you know that it is empyema, next step = TUBE THORACOSTOMY DRAINAGE (KNOW THIS INDICATION FOR DRAINAGE - TEST Q)

Anaphylactic Shock

- patient has acute onset of *hypotension + tachypnea after i.e. bee sting* that can progress rapidly to respiratory failure, circulatory collapse, and death. ALlergen exposure cause *sudden onset of sx in >1 organ sx* I. GI - lip/tongue swelling + vomiting ii. respiratory - dyspnea, wheezing, stridor, and hypoxia iii. cardiovascular - hypotension - most common allergens I. bee stings ii. food iii. medications - anaphylaxis patients usually have had prior exposure to offending substance I. have preformed IgE to cause TIHS reaction w/widespread *histamine mediate peripoheral vasodilation* - Next step - I. IS TX = *intramuscular administration of epinephrine into thigh* - epinephrine acts primarily on *alpha-1 adrenergic receptors to inc vasoconstriction + beta-2 adrenergic receptors to relax bronchial smooth muscles (bronchodilation) to dec vasc permeability*

Pneumocystis jirovecci pneumonia

- patient that has known *AIDS* - patients that specifically presents with *worsening dyspnea, hypoxia (specific for pneumocystis pneumonia) out of proportion to CXR* - patients that present with *bilateral diffuse interstitial infiltrates* - in *HIV pt w/CD4 < 200* - *elevated serum LDH levels* - 5 bolded things above - tell you that pneumocystic pneumonia - confirm Dx - *find organism in sputum or bronchoalveolar lavage aspirate* - most patients starting on antibiotic therapy will see *INITIAL WORSENING OF RESPIRATORY FUNCTION* - therefore patient with moderate to severe disease, significant pulmonary comorbidity, or uncertain access to follow up care should be managed initially in a hospital setting (even if receiving oral antibiotics) - *corticosteroid therapy* - *minimize initial antibiotic induced worsening of respiratory function; administer if PaO2 < 70 (COADMIN STEROIDS W/TMP SMX) or A-a gradient > 35*

CMV presentation

- patient with mononucleosis like syndrome (fatigue, muscle aches, low fever, arthralgias), lack of pharyngitis and cervical lymphadenopathy on exam - PE: may still have splenomegaly - atypical lymphoctyes present - (-) heterophile antibody (monospot) test most likely has CMV mononucleosis *atypical lymphocytes = large basophilic cells with vacuolated appearance

Ligamentous Back Sprain

- patients usually have pain that increases with movement + decreases with rest - pain is in * PARASPINAL AREA w/o SIG TENDERNESS TO PALPATION OF VERTEBRA*

Major Drug Interactions of Levothyroxine

- patients with *hypothyroidism* will have increased requirement for levothyroxine *after starting oral estrogen* i. *INC TBG - leads to DEC FREE THYROXINE* ii. inability to synthesize thyroxine as needed iii. this is the reason PREGNANT WOMEN NEED GREATER LEVOTHYROXINE - patients with *normal thyroid* function - can easily produce increased thyroxine to saturate inc TBG - results in *inc total TBG, slight inc or normal total levothyroxine, DEC Free T4* - drugs that inhibit conversion T4 to T3 are glucocorticoids, ipanoic acid (oral cholecystography agent), and PTU

Assessment of Hyperkalemia

- patients with chronic hyperkalemia may be asx until K+ gradually rises >7.0 mEq/L. However acute hyperkalemia can cause sx at lower levels. - patients may develop ascending muscle weakness w/flaccid paralysis + ECG changes (peaked T waves, short QT interval, QRS widening, and sine wave w/Vfib) - therapy of hyperkalemia when K+ > 7.0mEq/L w/o characteristic EKG changes, rapidly rising K+ due to tissue breakdown, or those with K+ > 5.0 w/EKG changes I. insulin + glucose ii. or calcium gluconate - in workup of hyperkalemia - consider secondary cause such as uncontrolled hyperglycemia, sx of tumor lysis syndrome; then check MEDS** (TEST Q)

Folic Acid Supplementation is the treatment for?

- patients with megaloblastic anemia due to folate deficiency - *also helpful for hereditary spherocytsois, PNH, sickle cell disease* - *beta thalassemia MAJOR*

Hashimoto's Thyroiditis

- patients with this disorder may be *hypothyroid or euthyroid* - *histologic diagnosis but (+) anti TPO antibodies with enlarged rubbery goiter = diagnostic* - *PREDISPOSES TO LYMPHOMA* - *typical presentation - RAPID ENLARGEMENT OF THYROID GLAND IN PATIENTS WITH PREEXISTING HASHIMOTO'S THYROIDITIS; compressive symptoms (dysphagia, voice change) may be seen. i. *CT scan of the neck - enlargement of thyroid gland around trachea = donut sign* ii. *US of thyroid - shows pseudocystic pattern*

Pelvic Inflammatory Disease

- pelvic pain - cervical motion tenderness - fever - Urinary sx are usually not present

Delusional Disorder

- persecutory type of delusional disorder is most common - where one has delusions of being i.e. poisoned or someone trying to poison him or her - other subtypes I. erotomanic - false belief that someone of higher status is in love with them Ii. Grandiose (great talent, insights, or achievements) Iii. Jealous (unfaithful partner) Iv. Somatic - bodily functions + sensations - Also in differential listed: I. schizophrenia - >6 months sx ii. Schizophreniform - 1-6 months sx iii. brief psychotic disorder - 1 day to 1 month

Meningococcemia classic presentation

- petechial rash - HIGH FEVER - headache, N/V, neck stiffness - photophobia

rash associated with meningococcemia?

- petechial rash progressing to ecchymosis, bullae, vesicles, and ultimately gangrenous necrosis - usually pts copresent with f/n/v/myalgias, meningeal signs, and shock

What is best initial diagnostic test for patients with suspected hyperthyroidism?

- plasma TSH - if Plasma TSH low, next do T4 - if Plasma TSH is low, free T4 is high, DO 24 HR RADIOIODINE UPTAKE SCAN - differentiate graves hyperthyroidism from other causes I. graves will have high uptake diffusely of radioiodine

Multiple Myeloma

- plasma cell neoplasm - can present with constitutional sx (fatigue, weight loss) or *bone pain - back + chest* - characterized by proliferation of neoplastic cells in the bone marrow - *bone destruction, hypercalcemia, anemia* + excess production of one protein - *monoclonal protein* I. *accumulation of monoclonal protein* in BM is filtered at kidney - *RENAL INSUFFICIENCY w/GRANULAR CASTS, HIGH Cr, BUN* ii. *glomerular damage* due to monoclonal protein - *may see amyloidosis, monoclonal Ig deposition disease - GIVING NEPHROTIC SYNDROME*

Bed Bugs

- present with *painless, pruritic + purpuric macules* - *appear as clusters of 2 or 3 papules over exposed areas*

Prepatellar bursitis

- present with pain + swelling directly over patella - *following patella trauma* - Exam- cystic swelling over patella w/variable signs of inflammation

Zenker Diverticulum

- presentation i. neck mass - ON CZXR AND OTHERWISES ii. regurgitation + aspiration iii. halitosis - FOUL BREATH iv. dysphagia v. more common in MALES vi. age > 60 (ELDERLY) vii. develop above upper esophageal sphincter w/POSTERIOR HERNIATION between fibers of CRICOPHARYNGEAL MUSCLE - UPPER ESOPHAGEAL SPHINCTER DYSFUNCTION + ESOPHAGEAL DYSMOTILITY = RESULT viii. PREDISPOSE TO ASPIRATION PNEUMONIA - CAVITATION ON CXR - Diagnose i. BARIUM CONTRAST ESOPHAGRAM (NEXT STEP****)****** ii. esophageal manometry - 2nd - Tx i. open/endoscopic surgery*** ii. cricopharyngeal myotomy Complications - tracheal compression, ulceration w/bleeding, regurg, pulmonary aspiration

CTS (Carpal Tunnel Syndrome)

- presents with nocturnal sx of pain + paresthesia in right median nerve distribution (radial half of arm and palmar 3.5 fingers including half of ring finger) - *worse with flexion of wrist and holding for 30 seconds - (+) phalen test* - pathogenesis - *due to mucopolysaccharide protein complexes within PERI + ENDOneurim of median nerve and in tendon + synovial sheath* that cause direct pressure on median nerve in carpal tunnel. - Various Etiologies i. if due to hypothyroid - *bilateral CTS; findings improve w/tx of hypothyroid; ALL PTS W/BILAT CTS MUST BE SCREENED W/TSH; 30% patients with hypothyroid will have bilat CTS* ii. pregnancy - due to accumulation of fluid in carpal tunnel in 3rd trimester iii. most common CTS due to *amyloid* deposition - *END STAGE RENAL DISEASE OR CHRONIC HEMODIALYSIS* from deposition of *BETA 2 MICROGLOBULIN* iv. Acromegaly - *associated with bilateral CTS* due to *soft tissue enlargement caused by synovial edema + tendon hyperplasia* v. RA - inc compartmental pressure due to inflammation

Rash of Scarlet Fever

- primarily in *children* - *Group A strep* occurs at another site - tonsillitis, pharyngitis - *skin findings preceded by FEVER, headache, vomiting, sore throat* - 12-48 hours later, *fine pink blanching papules appear on neck + upper trunk and quickly generalize to FLEXURAL ACCENTUATION (rough, sand paper like texture)

Complicated Pyelonephritis

- progression of initial pyelonephritis to renal corticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or papillary necrosis - patients can develop sepsis with multiorgan failure, shock, and renal failure. - occur more commonly with *diabetes, kidney stones, immunosuppression* - require imaging immediately

Typhoid Fever

- progressive manner with fever in the 1st week of illness; salmon colored rash + abdominal pain in 2nd week; hepatosplenomegaly with abdominal complications (i.e. intestinal bleeding, perforation) during 3rd week

Clinical Features of Thyroid Storm

- proposed mechanisms - rapid increase in serum thyroid hormone levels or inc. sensitivity to thyroid hormone - dx- suspected clinically + confirmed by thyroid function studies documenting hyperthyroidism i. *classic signs = cardiac arrhythmias, hypertension, tachycardia, high fever, tremor, altered mentation, lid lag*

Polymyalgia Rheumatica

- proximal muscle weakness w/o inc in CK - *association with temporal arteritis (giant cell arteritis)* - signs of inflammation of joints are absent but rather patients will point to *soft tissue pain* - *Tx of choice = low dose glucocorticoids (Prednisone 10-20 mg daily)

USMLE SCENARIO FOR ASPIRATION PNEUMONITIS

- pt had *witnessed aspiration event* (during intubation that required suctioning) few hours ago. Now patient has profound *hypoxemia* + *bilateral infiltrates on CXR*. *Gastric acid* induces chemical burn and consequent inflammatory responses usually within *hours* of aspiration event.

Facts About Colon Cancer Screening

- pts at average risk of developing colon cancer should begin screening AT AGE 50: FOBT annually or FLEXIBILE SIGMOIDOSCOPY EVERY 5 YEARS W/FOBT EVERY 3 YEARS or COLONSCOPY EVERY 10

Effect of Arterial Oxygenation + Ventilation in Various Environments

- pulmonary edema I. V/Q mismatch due to worsened imbalance of blood flow + ventilation resulting in depressed PaO2 ii. pulmonary edema increases the A-a gradient due to V/Q mismatch, and the excess fluid iii. REDUCES LUNG COMPLIANCE by preventing further alveolar expansion iv. supplemental oxygen usually corrects the hypoxemia, V/Q mismatch, and A-a gradient

Pyoderma Gangrenosum

- quickly read over and remind yourself of UC vs Crohn's - *50% patients with PG is associated with underlying SYSTEMIC DISORDER - i.e. IBD, arthropathies (RA), or hematologic conditions (Acute myeloid leukemia)* - starts as papule, pustule, vesicle, or nodule - *rapidly progressive + painful ulcer with purulent base + violaceous borders* - *30% are triggered by local trauma (pathergy) - *neutrophilic ulcerative skin disease* - *dx = skin bx - also helps rule out venous ulcers, panniculitis, cutaneous cancers* - Tx = *SYSTEMIC CORTICOSTEROIDS*

Ludwig Angina

- rapidly progressive *bilateral cellulitis of submandibular + sublingual spaces* - infection classically arises from an infected second or third mandibular molar - streptococcus + anerobes - present with fever, dysphagia, odynophagia, drooling - sx result form swelling of the submandibular + posterior displacement of the tongue - most common cause of death = asphyxiation - PE: reveals firm induratin of submandibular space - antibiotics + removal of the infected tooth = treatment of choice

When you see "crescent formation" what do you think?

- rapidly progressive glomerulonephritis

Treatment of Pheochromocytoma

- read blurb on right - understand CANNOT GIVE B-blockers First - causes unopposed stimulation of vascular alpha receptors by circulating catecholamines - gives rapid, catastrophic increase in blood pressure i. therefore, *always first give alpha blocker then beat blocker in this order in pheochromocytoma, then if needed, surgical resection*

Duodenal Ulcer

- read chart - reasoning for why meal makes it better- food releases alkali solutions to be released into duodenum + relieves the pain via dec. acidic environ created by ulcer. - in duodenal ulcer - see PAIN BETTER W/MEAL; PAIN IS EPIGASTRIC - THINK H PYLORI W/DUODENAL ULCER - Tx for PUD w/H PYLORI AS CAUSE i. Amoxicillin ii. Clarithromycin iii. Pantoprazole (PPI)

27 y/o m w/episodic gastric pain conc in epigastrium + gnawing in quality. Wakes him up during night + promptly relieved by water + piece of bread. Denies vomiting or diarrhea. Has dark stool. Smokes 1 pack cigs per day + one can of beer per day. PE show mild epigastric discomfort on deep palpation. Dx? Treatment?

- recognize melena, food makes dz better, pain in epigastrium - DUODENAL ULCER - Tx = pantaprazole + amoxicillin + clarithromycin

What are complications of subtotal thyroidectomy?

- recurrent laryngeal nerve paralysis - hypoparathryoidism - hypothyroidism

Cystocele

- refers to bladder prolapse into the anterior vaginal wall, which can cause vaginal pressure, dyspareunia, urinary frequency + urgency, and incontinence. - should be evidence on a physical evidence

How does Respiratory Alkalosis affect Ca2+ levels?

- remember Ca2+ in 3 forms 1. ionized calcium - 45% 2. Albumin-bound calcium - 40% 3. Inorganic + organic ion bound Ca2+ - 15% - *IN PE - KNOW THAT THERE IS RESPIRATORY ALKALOSIS - MEANS INC PH - MEANS ALBUMIN LOSES ITS H+, BECOMES (-) CHARGE, BIND MORE IONIZED Ca2+ THEREBY THERE IS LESS PHYSIOLOGICALLY ACTIVE Ca2+ - SIGNS OF HYPOCALCEMIA*

Tick Removal Protocol

- remove asap via *tweezers as close to skin as possible while pulling straight up w/steady pressure* (UWORLD Q)

How to treat repeated Vomiting?

- repeated vomiting gives *hypokalemic, hypochloremic, metabolic alkalosis* I. repeated vomiting leads to depletion of total body acid - normally acidic gastric secretions stimulate pancreas and liver to excrete bicarbonate into duodenum - therefore bicarb excretion does not occur in repeated vomiting - gives buildup of alkali (METABOLIC ALKALOSIS) - aldosterone then acts to restore water by excreting K+ and retaining Na+ thereby giving *contraction alkalosis* Tx - restoration with *IV fluids such as normal saline* - removes stimulus for R-A-A activation thereby restroing kidney ability to excrete excess bicarb - also *simultaneous K+ supplementation*

Tension Pneumothorax

- respiratory distress - HYPOTENSION - tachycardia *** - *INC CVP* = inc LVEDP - acute onset pleuritic chest pain - *hyperresonance to percussion* - *diminished tactile + vocal fremitus* - *dec or absent breath sounds in affected area*

Differential Diagnosis of Metabolic Alkalosis

- saline responsive metabolic alkalosis commonly due to loss of gastric secretions (i.e. self induced or spontaneous vomiting, nasogastric suctioning) that results in ECF loss. I. actually causes increased renal mineralcorticoid levels causing inc. H+ + K+ excretion in urine (METABOLIC ALKALOSIS); ALSO, Cl- EXCRETION IN URINE IS DECREASED ii. gastric contents are rich in hydrogen, chloride, and potassium therefore vomiting causes dec in all three. - in primary hyperaldosteronism - there is no stimulus for NaCl retention so it is not retained. Cl- excretion in urine is very high.

Obesity Hypoventilation Syndrome

- same as *pickwickian syndrome* - due to *obesity block expansion of chest + abdomen in breathing - gives inc. respiratory work + dec respiratory drive* - *underventilation of lungs at all times (vs in OSA sx disappear on waking)* - complications I. elevated PaCO2 + dec PaO2 (*vs ABGs in OSA are normal b/c sx resolve during wakefulness - UWORLD Q)* - *compensatory action of kidney - retain HCO3- and excrete Cl- (we know this acid/base concept generally to hold true)* ii. *secondary polycythemia as a result, pulmonary HTN, cor pulmonale - same as OSA* - *often have concomitant OSA* - can be a long term consequence of severe obesity + untreated OSA

HIV pt w/cytomegalovirus

- see *retinitis* - *CD4 < 50* - *MRI - periventricular enhancement*

Pes Anserinus Pain Syndrome (anserine bursitis)

- sharp, localized pain + tenderness over anteromedial part of tibial plateau just below joint line of knee - valgus stress test will not aggravate pain - x ray- normal - pes anserinus = semitendinosus, Sartorius, gracilis - caused by *abn gait, overuse, or trauma* - *local pain often apparent when lying on side w/unaffected knee pushed on pes of affected knee*

On suspected urinary retention, next step?

- signs = palpation of abdomen showing fullness + tenderness along midline below umbilicus w/o guarding or rigidity - might be in setting of a medication with anticholinergic properties - next step = urinary catheterization is DX + TX (a postvoid residual bladder volume > 50mL = diagnostic for urinary retention)

Osteoarthritis

- six criteria used to establish dx of OA in the setting of painful knee i. age > 50 ii. crepitus iii. bony enlargement iv. bony tenderness v. lack of warmth vi. lack of morning stiffness (<30 minutes if present) *if 3 or more of these are met, then specificity is 69%* - *see narrowed joint space, osteophyte formation, subchondral sclerosis/cysts - leading RF = increasing age - *WBC count of 200-2000/mL (vs in normal join is 0-200/ml)* - most common distribution i. knee, hip, spine, fingers - *often monoarticular + slowly progressive* - *OA = non inflammatory - so joint effusion + soft tissue swelling is minimal* - *pain better at REST + WORSE ON ACTIVITY* - *see nodular protrusion at PIP (Bouchard) + DIP (Heberden) nodules (VS RA - see subcutaneous nodules at extensor surfaces of forearm + sites of repeated trauma* - RFs i. obesity - note slight elevation in uric acid = nonspecific - in the presence uric acid elevation, + acute monoarticular arthritis - can think of gout

acrochordon

- skin tag - *flesh colored or pedunculated papules in regions of body subjected to friction - neck, axillae, inner thighs*

Narcolepsy

- sleep disorder characterized by *poorly regulated REM sleep* - *excess daytime sleepiness (like OSA) but has cataplexy, sleep attacks, hypnagogic/hypnopompic hallucinations, and sleep paralysis

Renal Papillary Necrosis

- sloughing of renal papilla giving non glomerular hematuria (meaning gorss hematuria) - seen with "NSAID" I. N- NSAIDs ii. S- sickle cell disease iii. A- analgesic abuse iv. I - infection (pyelonephritis) v. D - diabetes mellitus

Actinomycosis

- slowly progressive disease - anerobic bacterium that typically causes pneumonia in the *lower lung fields* - pneumonia can progress to *abscess + empyema with chst wallextension + rib osteomyelitis*

Vitiligo

- special form of leukoderma that peaks in *persons of 20-30* - depigmentation has *predilection for acral areas + body orifices* appearing as *pale whitish macules* with hyperpigmented borders - *due to autoimmune process which causes destruction of the melanocytes* differential - mycobacterium leprae - areas of hypopigmentation + *anesthesia* - superficial fungal infection - decreased pigmentation in areas but never complete loss

What all vaccinations should a patient manifesting with spider angioma get (*vaccinations in patient with chronic liver disease)*?

- spider angioma means chronic liver disease - *HAV + HBV vaccine = unique to liver disease pt* - *get classic Td booster every 10 years as usual* - *inactivated influenza as usual* - *uniquely give PPSV23 alone for reasons listed in above slide*

Effects of Chronic GI disease on Calcium

- steathorrhea or celiac disease are examples - cause *deficiency of vitamin D* due to malabsorption i. hypocalcemia, low phosphorus, elevated PTH in response ii. patients = asx or c/o bone pain or tenderness, muscle weakness or cramps, and gait abnormalities

When you see Strep bovis, what is next step

- strong association between *strep bovis + colonic neoplasms - EVAL ALL PTS W/STREP BOVIS WITH COLONOSCOPY FOR UNDERLYING OCCULT MALIGNANCY*

46 y/o M present to ED w/diabetic ketoacidosis 3 days ago develops now low grade fever, dull facial pain, and bloody nasal discharge. He also complains of diplopia and a headache. On exam his right sided nasal turbinates are necrotic and his right eye has chemosis and proptosis. KOH staining of scraping shows hyphae. What is best tx?

- surgical debridement + IV amphotericin

Tropical Sprue

- suspect if CHRONIC DIARRHEA w/Pt hx of living in endemic area ie PUERTO RICO for more than one month - malabsorption of nutrients - ESP DEC B12 + FOLCI ACID ABSORPTION - PRESENT W/MEGALOBLASTIC ANEMIA i. cheilosis ii. glossitis iii. protuberant abdomen iv. pallor v. pedal edema - etiology - INFECTIOUS - other sx i. fatty diarrhea, cramps, gas, fatigue, progressive weight loss - PE i. borborygmi - a rumbling or gurgling noise made by the movement of fluid and gas in the intestines. ii. hyperactive bowel sounds - Dx - SMALL INTESTINAL MUCOSAL BIOPSY i. BLUNTING VILLI ii. Infiltration of CHRONIC INFLAMMATORY CELLS i.e. LYMPHOCYTES, EOSINOPHILS, PLASMA CELLS

Rosacea

- suspect in *30-60 year old patient with TELENGECTASIAS OVER CHEEKS, NOSE, AND CHIN* - *flushing of these regions over cheeks, nose, and chin due to hot drinks, heat, emotions, and other causes of rapid body temp changes* - sometimes *papules, pustules present* - *fair skin, light hair and light eye color patients only - *topical antibiotic = metronidazole* Differentials - carcinoid syndrome I. may see flushing + telangiectasia development but lasts only 20seconds (lasts much longer in rosacea); diarrhea and cyanosis also need to be present for carcinoid ii. seborrheic dermatitis - does not have pustules and papules; scale are present around nose, ear, and scalp

Bacillus cereus

- suspect whenever you read about *pt who eats rick and subsequently develops N + V* - produces *heat stable toxin (PREFORMED) - sx noted quickly 1-6 hours*

CHF exacerbation

- tachypnea (due to LV dysfunction causing fluid to pool in lungs causing pleural effusion + hypoxemia due to reduced ventilation) - Respiratory alkalosis with HYPOXEMIA - bibasilar crackles - maybe wheezing - maybe dec breath sounds at bases of lungs (pleural effusion) - PE: s3+s4 gallops, cardiomegaly

Signs Adrenal Insufficiency

- there are 2 simultaneous ways of diagnosis - *KNOW THAT THESE ARE FIRST STEPS (i + ii) ON SUSPECTING ADRENAL INSUFFICINECY PRIMARY OR SECONDARY (UWORLD Q)* i. *administer 250 ug Cosyntropin and measure ACTH + Cortisol levels a. look for inc. serum cortisol levels >20ug/dL 30-60 minutes after admin 250 ug Cosyntropin (ACTH analogue) - RULES OUT PRIMARY AI ii. measure directly without administration ACTH + BASAL EARLY MORNING Cortisol levels* - low cortisol means < 5 ug/dL wheras high cortisol means >15 ug/dL

53 y/o m to ED w/SOB + dry cough over past few days. Hospitalized with candida esophagitis a month ago but left against medical advice. ON physical exam - his temperature is 101F, BP is 121/72, HR is 124 + regular. Respirations are 22/min. O2 sat is 89. Faint bilateral crackles. There is a soft crescendo/decrescendo murmur that is systolic. Which of following is most likely underlying mechanism for patient hypoxemia?

- think he had candida infection - he is immunocompromised. Now he has fever and respiratory distress - think immediately PCP pneumonia causing Sx - Pneumonia, as shows in chart above causes hypoxemia via V/Q mismatch as do "PAPO" - Pulmonary edema - atelectasis - pneumonia - obstructive lung disease - understand that *fever* causes sometimes *soft systolic crescendo decrescendo murmur*

Hepatorenal Syndrome

- to recognize - i. pt PREZ W/ PRE EXISTING CIRRHOSIS ii. then suddenly KIDNEY STARTS FUNCTIONING POORLY - sCr VALUES KEEP INCREASING - IMMED THINK HEPATORENAL SYDROME - what is it? dec glomerular filtration in the absence of shock, proteinuria, or other clear cause of renal dysfunction, and failure to respond to a 1.5 L normal saline bolus - when you suspect, NEXT STEP = 1.5L normal saline bolus - if no response then know it is hepatorenal syndrome - 2 types; Type 1 = rapidly progressive + diet w/in 10 weeks w/o tx; Type 2 = progress slowly w/average survival of 3-6 months - most common cause of death = INFECTION + HEMORRHAGE **** - DEADLY COMPLICATION OF CIRRHOSIS CHARAC BY RENAL FAILURE THAT DOES NOT RESPOND TO VOL RESUSCITATION - Tx = LIVER TRANSPLANT ***** (TEST Q)

Fibromyalgia

- trigger points (aka points of pain) = trapezius, lateral epicondyle, costochondral junction in chest, and greater trochanter Tx = exercise regimen + better sleep hygiene 1st; if unsuccessful 2nd line = amytrypitiline (TCA); 3rd line = duloxetine or milnacipran(SNRI),

Bacillary Angiomatosis

- typical presentation *liver form*: *HIV (+)* male presents to your office with several *exophytic* purple skin masses OR RED on his lower abdomen. Physical examination reveals tender hepatomegaly + abdominal CT scan shows nodular, contrast-enhanced intrahepatic lesions of variable size. Liver bx attempted but severe hemorrhage results" - *need HIV to have this* - typical *skin form* presentation*characteristic lesions of skin + viscera; classic cutaneous lesion in BA - large, BRIGHT + RED, pedunculated exophtyic papule with a collarette of scale* - Tx = *erythromycin*

Meningococcal INfection

- typical skin lesions: *petechiae + purpura* - *myalgias are common + can be more intense + painful than those seen in viral influenza* -*fever, stiff neck, headache, nausea (meningitis sx), MYALGIAS (normally think viral but CSF tells us bacterial), PURPURIC SKIN LESIONS (in combo with previous stuff the dx is clear) Differential Dx - syphilitic meningitis - does not have such sudden onset; peripheral rash occurs on palms of hands + soles of feet*; generalized lymphadenopathy - Pneumonococcal meningitis: similar CSF findings but NO ACUTE ONSET OF PURPURA OR SKIN LESIONS - Rocky Mountain Spotted Fever - rash that begins on the ankles + wrsits + spreads both centrally and to the palms and soels

Acanthosis nigricans

- typically present as hyperpigmented plaques in the flexural and intertriginous skin regions with hyperkeratosis (skin thickening) - patients commonly have associated skin tags (acrochordon) in affected areas (axilla, groin, back of the neck) - acanthosis nigricans - can be familial or *ASSOCIATED WITH DIABETES, OBESITY, OR PCOS*

Hypercalcemia of Immobilization

- unclear mechanism - *due to inc. osteoclastic bone resorption* - *risk is increased in PATIENTS WITH PRE EXISTING HIGH BONE TURNOVER - LOOK FOR IMMOBILIZED PT W/YOUNGER INDIVIDUALS, OLDER PATIENTS WITH PAGET'S DISEASE)* - *median onset - 4 weeks after immobilization and w/RFs described above* - *however, pts w/CKD or Chronic Renal Insufficiency develop hypercalcemia as early as 3 days after immobilization* - *Tx = BISPHOSPHONATES + HYDRATION* (UWORLD Q)

Eosinophilic esophagitis

- uncommon disorder causes dysphagia, heartburn, and refractory acid reflux - typically have other atopic conditions (i.e. asthma, seasonal allergies)

Conjugated vs Unconjugated Hyperbilirubinemia

- unconj bilirubin - highly bound to albumin - highly insole + in excess in exerted into feces or urine - POSITIVE URINE UROBILINOGEN ASSAY - CONJ BILIRUBIN (loosely bound to albumin) is WATER SOLUBLE - CAN BE EXCRETED INTO URINE B/C IS WATER SOLUBLE - DARK URINE + POSITIVE URINE BILIRUBIN ASSAY

Note Uremic Encephalopathy versus Hepatic Encephalopathy

- uremic encephalopathy: treat with dialysis immediately - hepatic encephalopathy: treat with lactulose for decompensated cirrhosis I. to differentiate look for AST AND ALT levels to be incredibly elevated; look for bilirubin inc, albumin dec

35 y/o man comes w/recent dx of HIV to ED w/3 week hx of cough, fatigue, night sweats, weight loss of 10lb over past month. CD4 < 80 1 month ago and not receiving antiretroviral tx. Traveled to ohio, Vermont, Georgia in past 5 months. Temp of 101.3, BP 123/78, pulse 98. 2 small ulcers present on hard palate. Liver palpated 3 com below right rib margin. CXR show bilateral reticulonodular opacities. What is next step in dx disseminated fungal infxn as in this patient?

- urine antigen testing - b/c it is histoplasmosis

Fluoroquinolone SE

- use is associated *TENDINOPOATHY (TENDOR RUPTURE) in ACHILLES CLASSICALLY* - patients should stop drug at onset of sx, avoid exercise, and/or use of affected area. - in *kids - stunted growth of epiphyseal growth plate*

guidelines for lithium therapy

- used for ACUTE MANIA + maintenance of CHRONIC BIPOLAR DISORDER - CI - RENAL OR CV DZ - teratogen - cause EBSTEIN ANOMALY, OR POLYHYDRAMNIOS, DI, FLOPPY INFANT SYNDROME - obtain baseline urinalysis, BUN ,sCr, Thyroid Function Test before starting lithium Tx + ECG if CV dz present - monitor drug levels every 6-12 months and 5-7 days after dose changes or after starting other meds - during Tx, measure calcium, sCr (renal function, thyroid function

Uncomplicated Pyelonephritis

- usually develop sx of cystitis (dysuria, frequency, urgency, suprapubic pain, and/or hematuria) along with flank pain, abd or pelvic pain, N/V, fever >101, or CVA tenderness - bacteria classically ascend bladder, invade ureters, and enter bloodstream to cause gram (-) sepsis *patients should have urine culture + blood culture before receiving empiric oral antibiotics against gram (-) organisms (FLUOROQUINOLONE)* When is imaging necessary in uncomplicated pyelonephritis with CT abdomen/pelvis? - *Uncomplicated pyelonephritis - does not require imaging (CT abdomen/pelvis) - if pt has persistent clinical sx for 48-72 hours of therapy, history of nephrolithiasis, complicated pyelonephritis, or unusual urinary findings (i.e. gross hematuria, suspicion for obstruction) then imaging* - TEST Q

Acute Rheumatic Fever Presentation

- usually preceded by 2-4 weeks by PHARYNGITIS - sx of acute rheumatic fever include: i. J - large Joint migratory arthritis ii. O - Carditis iii. N- subcutaneous nodules iv. E- erythema marginatum (raised ring shaped lesions over trunk + extremities) v. Sydenham chorea - random movements extremities

Perforated Peptic Ulcer

- usually present w/ i. sudden EPIGASTRIC PAIN ii. NAUSEA + VOMITING iii. HEMATEMESIS iv. peritoneal signs - rigidity, guarding, rebound tenderness v. CXR = free air under diaphragm

What is purpose of chest physiotherapy and other mechanical techniques to aid sputum clearance (intermittent positive pressure breathing)?

- utilized in pts with PNEUMONIA or ATELECTASIS or BRONCHIECTASIS (DO NOT CONFUSE W/COPD - don't use in COPD) (require long term) - to LOOSEN + PROMOTE EXPECTORATION OF SECRETIONS

PT elevated

- vit K def - liver disease - oral anticoagulation - DIC

Liver Failure/Cirrhosis Presentation

- when given history of IV DRUG USE + ENDOCARDITIS + STROKE - think DRUG INDUCED ENDOCARDITIS THAT LEAD TO EMBOLIC STROKE FROM VEGETATIONS ON VALVE; PERHAPS DVT IN R CALF DUE TO IMMOBILITY FROM STROKE - SHIFTING FLUID WAVE + HEPATOSPLENOMEGALY - AUTOMATIC THINK ASCITES - RECOGNIZE 80% ASCITES IS DUE TO CIRRHOSIS - THEREFORE WHEN YOU SEE ASCITES, THINK CIRRHOSIS USUALLY - NOW RECOGNIZE 2 MOST COMMON CAUSES OF CIRRHOSIS 1) ALCOHOLIC LIVER DZ 2) HEPATITIS C Cirrhosis Presentation - anorexia, jaundice, pruritis, confusion, or new onset ascites - PE - show stigmata of liver i. spider angiomas ii. palmar erythema iii. caput medusase iv. asterixis v. fluid wave (indicates ascites) vi. shifting dullness vii. dec. breath sounds due to PLEURAL EFFUSION viii. splenomegaly from portal HTN - cirrhotic liver on biopsy - SHRUNKEN/FIBROTIC - Dx - clinical, lab eval - to EVALUATE COMPLICATIONS - SPLENOMEGALY OR HEPATOCELLULAR CARCINOMA, DO ULTRASOUND **** - IF YOU SEE ASCITES, FIRST STEP HOWEVER IS PARACENTESIS TO DETERMINE ITS CAUSE

When is Fetal Hyperthyroidism seen?

- when patient has GRAVES DISEASE ACTIVELY - the TSH RECEPTOR ABs CROSS PLACENTA + AFFECT FETAL THYROID.

Negative Pressure Pulmonary Edema

- when patient has upper airway obstruction i.e. laryngospasm during extubation - gives large negative intrathoracic pressure - due to inspiration against obstruction - gives *noncardiogenic pulmonary edema* - *common in young men after neck + head surgery*

zollinger ellison

- where peptic ulcers are focused in DUODENUM (WEIRD) - Sx i. recurrent Peptic Ulcer Disease w/multiple ulcers ii. Ulcers in JEJUNUM (NOT COMMON UNLESS IN ZE) iii. dyspepsia (gastric fullness, discomfort) iv. reflux sx v. abd pain vi. weight loss, CHRONIC diarrhea vii. frank GI bleeding - associated with MEN 1 - males 20-50 - endoscopy - shows i. thickened gastric folds ii. multiple peptic ulcers iii. refractory ulcers despite proton pump inhibitor use (PPI) iv. ulcers distal to duodenum - confirmation/diagnosis - FASTING SERUM GASTRIN LEVEL - WHEN > 1000 pg/mL in PRESENCE NORMAL STOMACH pH of < 4 i. if unsuccessful and still suspicious - DO SECRETIN STIMULATION TEST - STIMULATES RELEEASE OF GASTRIN BY GASTRINOMA CELLS - NORMAL G CELLS ARE INHIBITED ii. next next step - 2nd step - ONCE ZE SYNDROME CONFIRMED, do SCREEN FOR MEN1 via 1. [PTH] 2. [ionized calcium] 3. [prolactin] - pathophysiology i. diarrhea - due to INACTIVATION PANCREATIC ENZYMES B/C INC PRODUCTION OF STOMACH ACID CAUSING INACTIVATION IN DOUDENUM OF SEC PANCREAT ENZYMES; also ACID DAMAGE MUCOSAL BRUSH BORDER (further cause diarrhea) ii.

Neurofibromatosis type I

- widespread subcutaneous nodules associated with multiple café-au-lait spots

Q Fever

- zoonosis caused by *Coxiella burnetii* - *main source of infection - CATTLE, GOAT, SHEEP* - professions at risk: *meat processing workers, veterinarians* - *flu like x, hepatitis, or pneumonia*

25 y/o woman comes to office for the evaluation of pale patches of skin around her mouth. She noticed these lesions a few months ago but they have become more prominent now. There is no itching, burning, or numbness over the patches. Her vital signs are stable. On exam you notice pale white patches symmetrically distributed around her mouth. The borders of these macules are well circumscribed. Similar lesions are also found over the areola of her breast. What is pathology?

-*destruction of melanocytes*

Asthma

-dyspnea, wheezing, and cough - usually present in younger individuals but *mauy be dx in 50s as "adult onset asthma"* - adult onset asthma - more severe + less likely to go into remission - *(+) bronchodilator response* - where *>12% Inc in FEV1* with administration of bronchodilator confirms asthma diagnosis - difficult to distinguish asthma from COPD in adults, esp smokers - both are obstructive lung diseases but... I. asthma has (+) bronchodilator challenge with >12% inc in FEV1 - indicates *complete reversibility in asthma whereas COPD is only partially reversible* ii. Diffusion capacity of carbon monoxide *(DLCO)* - in asthma is *NORMAL OR INC (IF SEVERE ASTHMA)* vs in *COPD, DLCO is DEC*

Obstructive Sleep Apnea

-phenomenon of nocturnal hypoventilation - 2 types of abnormal ventilation in sleep 1) apnea - cessation of breathing for >10 seconds 2) hypopnea -reduced airflow causing SaO2 to decrease by > 4% I. most common cause of both = *obstructive sleep apnea* - patient contracts diaphragm in attempt to breathe but airlow is impeded by *upper airway obstruction due to increased soft tissue in oropharynx* - Risk Factors for OSA I. tonsillar hypertrophy ii. hypothyroidism iii. obesity - Typical sx I. daytime sleepiness ii. morning headaches iii. impotence iv. snoring Dx Tests I. 1st line = POLYSOMNOGRAPHY Labs - may show erythrocytosis Complications I. *pulmonary hypertension, cor pulmonale, erythrocytosis (reactive)* Tx I. weight reduction, avoidance of sedative + alcohol, avoidance of supine posture during sleep ii. can do uvulopalatopharygoplasty or CPAP during sleep

45 year old man's brother diagnosed with malignant melanoma. The 45 year old man has multiple nevi and has not seen any changes in them. You will do all of the following except: -photograph nevi and follow periodically -remove all nevi immediately - check for nevi in family and advise to follow up - counsel on avoiding sun exposure and using sunscreen

-remove all nevi immediately

benign adenomatosus polyp familial polyposis Gardner syndrome Turcot' syndrome cancer family syndrome malignant polyps

neoplastic polyps

SE of amphotericin B

nephrotoxic, distal tubule damage

73 year old M chronic smoker with family history of abdominal aortic aneurysm has a negative abdominal US for AAA. When to do next US?

no additional US needed

What are the screening guidelines for colorectal cancer in patients found to have hyper plastic polyps?

no malignant potential so repeat colonoscopy in 10 years

Inflammatory "pseudopolyps" juvenile polyps Peutz-Jeghers syndrome

non neoplastic polyps

Is complement normal or decreased in Churg Strauss?

normal

Is complement normal or decreased in IgA nephropathy?

normal

Is complement normal or decreased in PAN?

normal

Is complement normal or decreased in Wegener's granulomatosis?

normal

Is complement normal or decreased in Goodpasture's syndrome?

normal- antibody mediated reaction

In a patient with multiple PVCs and no history of heart disease, what should you do?

nothing

acetylcholine is found in

nucleus basalis of meynert of basal forebrain

Patient with colon cancer underwent hemicolectomy. Histopathology with infiltration of muscular is but serosa clear. LN -. Wtd?

observe

Pt presents with chest pain and EKG reveals MI that is treated with tPA, heparin, nitrates, BB and ACEi. Within 24 hours pt develops NSVT of <30s. wtd?

observe

58 year old F with CHF presents with mild lung crackles, S3, JVP 12, 2+ BLE edema. She takes lasix 20, lisinopril 5, atorvastatin 20, coreg 6.125 BID, spironolactone 25 mg qd and ASA 81 mg. EKG with QRS 0.13. ECHO with EF 35%. She was started on IV lasix. What is the best mgmt for this patient?

optimize medical therapy

enterobiasis vermicularis

perianal pruritis tt pyrantel pamoate

treatment of porphyria cutanea tarda

phlebotomy (decrease inhibition by ferritin of UROD) high carb diet avoid alcohol

blistering in sunlight brown urine ethanol abuse

porphyria cutanea tarda

Pt with MI presents 9 days later with persistent chest pain worse on deep breath. Found to have pericardial friction rub. Pt put on BB, ASA 81mg statin and ACEi. CXR with effusion. EKG with diffuse ST elevations. Dx? Tx?

post MI pericarditis- Dressler's syndrome- can occur as early as 1 week post MI but usually 2-3 weeks High dose ASA 6-8 gm/day

What happens to murmur post PVC?

post PVC volume potentiation and decreased after load leads to rapid emptying and decreased volume

V1, V2

posterior RCA

Wegeners granulomatosis treatment

prednisone and cyclophosphamide

What type of hypogonadism does Klinefelter's cause?

primary - HPA axis intact - basis is small, non functional testes and therefore *dec testosterone + inc LH*

Which patients get gated pool studies or MUGA scans?

pts to determine LVEF and wall motion abnormalities. Decreased LVEF is a poor prognostic factor on MUGA

What type of pulse do you have in aortic stenosis?

pulsus parvus et tardus- slow rising pulse because takes longer to get blood out of LV into aorta

What extra-colonic manifestations of UC mirror disease activity?

pyoderma gangrenosum, peripheral arthritis and erythema nodosum

Patient with colon cancer Duke B and underwent resection of colon. When do you repeat colonoscopy?

q1 year then 3 years then 5 years

Pt on ASA, nitrates, BB and statin. Hb normal and no signs of infection or stress with increasing episodes of angina on exertion. Angiogram reveals multi vessel disease not amenable to revascularization. Best Management?

ranolazine- causes decreased frequency of anginal episodes and improved exercise tolerance. Wont decrease mortality

seratonin is found in

raphe nuclei in pns and medulla

dystrophic calcifications in lung

recent lung injury and healing

HAV vs HBV vs HCV vs HIV

recognize - HAV is fecal - oral and spread via homosexual anal sex or IVDU vs HBV, HCV, HIV are spread through blood - so if screening for HBV, HCV, and HIV together

If you find young kid around 19-20 w/BRB + sticky blood and changing consistency + you do lower colonoscopy to find 1000's of polyps - what do you do?

recognize dx = FAM = FAMILIAL ADENOMATOUS POLYPOSIS - FOR THIS YOU AUTOMOTICALLY DO PROCTOCOLECTOMY - because 100% chance of cancer in future

40 year old with no risk factors for CAD with LDL 175. wtd next?

recommend diet and exercise

USPSTF for Osteoporosis

recommend screening women greater than or equal to 65

which is worse rectal or colon cancer

rectal

If angioplasty is done immediately in patients this has shown to decrease?

recurrent ischemia at 6 months

Step to Assess Acute Low Back Pain

red flags - age > 50 - nighttime pain - constitutional sx - history malignancy - trauma - IVDU - infectious risk - >1 month w/o improvement - *if either xrays or ESR are abnormal, 2nd step = MRI*

serum analysis, what tube

red top, doesn't have anticoagulation so that the blood can clot and serum can seperate

Pt with cirrhosis presents with hepatic encephalopathy. He quit drinking a couple of years ago. Ascitic fluid WBCs 70. what to do?

refer for transplant

Nurse gets stuck with a needle treating Hep C patient. Blood is negative for Hep C RNA and Hep C Antibodies. wtd next for nurse?

repeat Hep C Antibodies and RNA in 4 weeks

What would be the next step if you find 2 cm pancreatic cyst with RBCs and inflammatory cells on FNAB?

resect

70 year old M presents with dusky discoloration over medial malleolus. Prominent veins with varicosities in BLE and loss of hair. Bilateral pulses are decreased. Best management?

revascularization

Pt presents with chest pain and low blood pressure. You suspect RV infarct. What is next diagnostic step?

right sided EKG with V3R and V4R

Seabather's eruption

salt water jelly fish larvae get stuck between clothing drying or showering with fresh water kills them

Pt in their 20s with rectal bleeding with tenses. Anal fissure +. On exam 6 x 6 cm ulcer on back of leg. Next diagnostic step? Most likely diagnosis?

sigmoidoscopy/anoscopy to r/o UC. Treat with 5- ASA suppository

folliculitis

small papule with central pustule, spares palms and soles hot tub= pseudomonas MCC S.aureus

ecthyma

small vesicle penetrating through the epidermis, "punched out" with green yellow crust and raised margins MCC S pyogenes

What are worrisome features on CT scan of abdomen for pancreatic cyst?

solid component=resection dilated duct >10 cm resect

Pt with AICD placed after having VF 48 hours post MI has had 2 discharges from AICD in the past 2 months. What to do next?

start amio if happens again the do radio frequency catheter ablation

Pt has an MI. He was stabilized. A few months later stress test was abnormal so he underwent cardiac cath which showed 70% stenosis in Lcx. He was started on ASA now. What medication will increase his long term survival?

statin ACEi BB

dopamine is found in

substantia nigra of midbrain

ballismus is a lesion to...

subthalamic nuclei

Cercarial dermatitis

swimmer's itch- after swimming in lakes, ponds or oceans. 2/2 Larvae entering skin and dying. causes skin eruption with ithcing

Bladder Receptors

sympathetic activation - bladder wall (detrusor B1 + B2) relax - sphincter (and trigone) contract (alpha 1) Parasympathetic activation - bladder wall (detrusor) contracts (M) - sphincter (and trigone relax) (M)

What drugs can precipitate pustular psoriasis outbreak?

systemic steroids

60 year old M presents to a small community hospital with chest pain and is found to have an anterior wall MI. The nearest tertiary center is 2 hours away. What is the best management?

tPA and then transfer to do PCI

65 year old M presents with AWMI and BP 80/60. Pt was put on IABP. Nearest PCI center is 2.5 hours away. Wtd?

tPA and then transfer to do PCI

Pt with 3 hours of chest pain presents to the ER with St elevations in II, III, and aVF. Trop negative. PCI not available. What is the best management?

tPA then can do PCI >2 hours later

goiter of a singular nodule MC

thyroid adenoma

65 year old M presents with fatigue, chronic diarrhea and itching. Pallor +. Exam shows bulls skin lesions. Hb low, MCV low, TIBC increased, ferritin low. Occult negative. Blood smear with howell jolly bodies. Colonoscopy negative for lesions or blood. Patient takes oral ferrous sulfate without any improvement. What to do next?

tissue transglutaminase IgA abs to rule out Celiac sprue. If abs positive then do small bowel biopsy

Why do you use diltiazem or BB in mitral stenosis?

to increase diastolic filling time

How do you treat open comedones?

topical retinoid

Pt with VT or VF 48 hours after MI. No evidence of reinfarction. wtd?

treat medically and place AICD after acute treatment- this is an independent risk factor for mortality after discharge from hospital

patient went to far east, has diarrhea and changes on jejuna biopsy, symptoms resolve with antibiotics

tropical sprue

seborrheic dermatitis

tt ketoconazole and topical steroid yellowish greasy scaling rash

Treatment of Acute Cystitis + Pyelnonenphritis in non pregnant women

uncomplicated cystitis - dysuria, urinary frequency, suprapubic tenderness - *nitrofurantoin for 5 days (avoid in suspected pyelonephritis) - *TMP SMX* for 3 days - *fosfomycin single dose* - *urine culture only if tx fails* Complicated cystitis *(if sx present in conjunction with diabetes, renal failure, indwelling catheter, urinary procedure (cystoscopy for example), pregnancy [no fluoroquinolone; use amoxicillin-clavulanate, fosfomycin, cephalexin], immunocompromised state, Urinary tract obstruction)* - *fluorquinolones *5-14 days), extended spectrum antibiotic (ampicillin/gentamicin (aminoglycoside)) for more severe cases obtain sample for urine culture before initiating therapy Pyelonephritis - outpatient - fluroquinolone (i.e. ciprofloxacin, levofloxacin) - inpatient: IV antibiotics - (i.e fluoroquiniolone, aminoglycoside +/- ampicillin) - obtain urine culture prior to initiating therapy

allopurinol and gout

used long term to reduce serum rate after an acute attack

Reye's syndrome

viral illness + asprin+ lethargy and liver dysfunction

hyponaetremia ur Na >20 ur Cl<10 BUN:Cr> 20 metabolic alkalosis

vomiting induced

Seborrheic kertosis

warty brown plaques in the elderly with stuck on appearance on face, back, and neck in the exposed and non exposed areas. Can be pigmented or dark Not malignant or pre-malignant usually no treatment required

multi system necrotizing granulomatosis, paucci immune vasculitis, red cell cast+ renal failure, recurrent pneumonia like illness, C-ANCA +

wegeners granulomatosis

necrotizing granuloma in bronchovascular pattern

wegeners granulomatosis

In a patient with ASD, when do you do surgery?

when L to R shunt is >1.7:1

When to give platelet transfusion?

when platelet < 10,000 (inc risk of spontaneous hemorrhage) or active bleeding + platelets < 50,000

Seborrheic Dermatitis

white flakes on face, scalp, upper chest and auditory canal. caused by Pityrosporum severe cases seen in HIV TX: oral or topical ketoconazole

Patient found to have Primary sclerosing cholangitis. How do you monitor these patients?

yearly US of GB to look for polyps

What is the best way to monitor a patient for dissection in Marfan's syndrome? When would you repair? What is the best way to prevent dissection?

yearly echo Repair when >5.5 cm Atenolol- (BB)- if still enlarging then add losartan (ARB)

What four values characterize tumor lysis syndrome - Test Q?

1) *HYPERphosphatemia* 2) *HYPOcalcemia (due to hyperphosphatemia)* 3) *HYPERkalemia* 4) *HYPERuricemia* - *GIVE ALLOPURINOL - to REDUCE ACUTE URATE NEPHROPATHY*

Lactose Intolerance

1. (+) hydrogen breath test (DIAGNOSTIC CHOICE) 2. also see (+) stool test for reducing susbtances 3. LOW STOOL pH 4. NO STEATORRHEA 5. Presentation i. bloating, flatulence, abd cramps, explosive + watery diarrhea (OSMOTIC DIARRHEA***) AFTER INGESTING DAIRY 6. Concept i. lactase - brush border enzyme that hydrolyses lactose - lactase enzyme dec w/age 7. 90% in ASIAN AMERICANS

Definition of Solitary Nodule

1. 3 cm or less coin shaped lesion in middle to lateral one third of lung of the lung surrounded by normal parenchyma 2. most are benign 3. types I. calcification = benign ii. "popcorn" calcification - hamartoma iii. "bulls eye" = granuloma

Bereavement

1. <2 months *** 2. guilt + suicidal ideation less common ***** ---- if thoughts of dying present, should be to join decease - if not ***** treat as MDD 3. if bereaved patient experiences depressive symptoms for at least 2 weeks after major loss - consider treatment with PSYCHOTHERAPY + TRIAL OF ANTIDEPRESSANTS

What is bullous pemphigoid & what are the classic IF findings?

1. A autoimmune blistering disorder marked by pruritis, tense bullae (that do NOT easily rupture), & urticarial plaques 2. IgG & C3 distributed linearly along the BM zone

What features suggest abd malignancy that has mets to liver?

1. ABD PAIN 2. MICROCYTIC ANEMIA 3. POSITIVE FOBT 4. HEPATOMEGALY W/HARD LIVER EDGE TO PALPATION 5. General signs of malignancy - FATIGABILITY, LEFT SIDED PLEURAL EFFUSION (HEPATIC HYDROTHORAX DUE TO CIRRHOSIS CAN OCCUR ON RIGHT)*** NEXT STEP ON SUSPICION = CT ABDOMEN W/CONTRAST

Agents responsible for drug-induced interstitial nephritis? (6)

1. ABXs (PCNs, cephalosporins, rifampin, TMX, sulfonamides) 2. NSAIDS 3. Diuretics 4. Captopril 5. Phenytoin 6. Allopurinol

Other causes of chronic cough

1. ACE inhibitors 2. chronic bronchitis 3. bronchiectasis 4. malignancy 5. pulmonary parenchymal disease - lung abscess, ILD

When to Administer FFP?

1. ACTIVE BLEED W/SEV COAGULOPATHY - LIVER DZ, INTRAVASCULAR COAG, SUPRATHERAPEUTIC WARFARIN ANTICOAGULATION (ESP IF INR>1.6)

A pt with chronic Hep B needs these serial measurements every 3-6 months? (2)

1. ALT 2. HBeAg

Crigler Najjar 1

1. AR - 2. dz of CHILDHOOD 3. disorder bilirubin metabolism characterized by severe jaundice + neurologic impairment due to kernicterus (bilirubin encephalopathy). 4. Indirect Bilirubin of 20-25 mg/dL but can rise to as high as 50 mg/dL. 5. Liver enzymes + histology are normal 6. IV PHENOBARB HAS NO EFFECT, PHOTOTX + PLASMAPHERESIS - NO EFFECT; ONLY Tx = LIVER TRANSPLANT

State which renal pathology you will see these associated with: -Muddy brown granular cast -RBC casts -WBC casts -Fatty casts -Broad & waxy casts

1. ATN 2. GLN 3. Interstitial nephritis & pyelonephritis 4. Nephrotic syndrome 5. CRF

Role of aldosterone?

1. Absorbs Na+ (Hypernatremia → Hypertension) 2. Secretes K+ (Hypokalemia → ↑ HCO3- reabsorption) 3. Secretes H+ (Metabolic alkalosis)

If Given Manometry Readings for UE, ME, LES, which diseases give what readings?

1. Achalasia i. normal UE ii. DEC ESOPHAGEAL BODY peristalsis - DEC ME WAVES iii. INC LES TONE/WAVES - achalasia present with PROGRESSIVE DYSPHAGIA (FROM SOLID TO LIQUID), CHEST PAIN, FOOD REGURG, ASPIRATION iv. Barium Swallow - Show DILATED ESOPHAGUS + BIRD BEAK DEFORMITY AT LES 2. Cricopharyngeal Dysfunction i. failure of cricopharyngeus to relax during swallowing = "CHOKING" or "FOOD STICKING" sensation ii. PAIN WITH SWALLOWING iii. Diagnosis - VIDEO FLUOROSCOPIC SWALLOWING STUDY **** 3. Diffuse Esophageal Spasm i. esophageal motility disorder ii. present w/SEVERE + NONCARDIAC CHEST PAIN iii. due to UNCOORD CONTRACTIONS OF ESOPHAGEAL BODY iv. Esophageal Manometry - MULITPLE CONTRACTIONS ON TRACINGS IN MIDDLE + LOWER ESOPHAGUS

Differentia for PCP intoxication

1. Alcohol intoxication i. ataxia ii. nystagmus iii. aggression iv. BUT HALLUCINATIONS - PRESENT WITH WITHDRAWAL NOT OD 2. Heroin Intoxication i. pinpoint pupils ii. drowsiness iii. CNS depression iv. Constipation 3. LSD i. mood impairment ii. hallucinations iii. perceptual intensification - colors richer, tastes are heightened, iv. depersonalization v. illusions vi. 2 of following: sweating, tachycardia, pupillary dilations, palpitations, tremors, and poor coordination 4. Cocaine Intoxication i. anxiety + aggression ii. psychosis - delusion + hallucination + disorganized speech iii. delirium iv. high or low BP v. Tachycardia or Bradycardia vi. PUPILLARY DILATION vii. N + V viii. TACTILE SENSATION (FORMICATION) "COCAINE BUGS" ix. NOSE BLEEDS + SEPTAL PERFORATION IN PTS SNORTING COCAINE

Criteria for Home Oxygenation of COPD Patients

1. All COPD patients with PaO2 < 55 mm Hg or SaO2 < 88% on room air 2. Patients with cor pulmonale, evidenced of pulmonary hypertension or hematocrit > 55% - should be started on home O2 therapy WHEN PaO2 is 56-59 3. patients who have resting awake PaO2 > 60 mm Hg with SaO2 > 90% if they become hypoxic during exercise or sleep (nocturnal hypoxia) ****NOTE THAT SUPPLEMENTAL O2 THERAPY WILL IMPROVE QUALITY OF LIFE AND PROLONG PATIENT SURVIVAL

Eating DIsorders

1. Also, Binge Eating disorder i. clinical features a. recurrent episodes of binge eating b. No compensatory behaviors c. lack of control during eating i. treatment a. cognitive behavioral therapy b. behavioral weight loss therapy c. SSRI d. Lisdexamfetamin, topiramate 2. Anorexia Nervosa i. adolescent girls ii. physical exam - see EMACIATION iii. LANUGO - FINE DOWNY BODY HAIR ON BACK + ABDOMEN iv. patients that induce vomiting - PAROTID GLAND HYPERTROPHY + DENTAL CARIES + HALITOSIS + SCARS ON HAND FROM CONTACT WITH THE TEETH

What are the complications of ventilation with a high PEEP? (3)

1. Alveolar damage (barotrauma) 2. Tension pneumothorax 3. Hypotension

4 drugs that increase the serum level of digoxin?

1. Amiodarone 2. Verapamil 3. Quinidine 4. Propafenone

Rapidly developing hyperandrogenism with virilization is highly suggestive of? Also, what lab test should be ordered?

1. An androgen-secreting neoplasm of the ovary or adrenal gland 2. Order serum testosterone & DHEAS levels -Ovarian source = Elevated testosterone -Adrenal source = Elevated DHEAS

What is Primidone? When is it used? What are its AEs?

1. An anticonvulsant that converts into phenylethylmalonamide & phenobarbital 2. To TX benign essential tremors (also, BBs) 3. Can precipitate acute intermittent porphyria (ABD pain, neurologic & psychiatric abnormalities). DX this condition by checking a urine porphobilinogen level

What androgens are produced by women and where?

1. Androstenedione (AS) 2. Dehydroepioandrosterone (DHEA) 3. Testosterone (T) 4. Dehydroepiandrosterone sulfate (DHEA-S) *AS, DHEA, DHEA-S are not true androgens - do not interact with androgen receptor -are converted peripherally to testosterone* *AS, DHEA, T are produced by OVARIES + ADRENALS* *VS DHEA-S made only by ADRENALS* * THEREFORE -ADROGEN PRODUCING ADRENAL TUMORS SPECIFICALLY HAVE INC DHEA-S*

Angiodysplasia

1. Angiodysplasia i. also cause RIGHT COLON BLEED -FAR LESS COMMON ii. caue LOW VOL VENOUS BLEED (vs DIVERTICULOSIS - CAUSE LARGE VOL ARTERIAL BLEED) iii. PAINLESS + EPISODIC GI BLEED w/recent NEGATIVE COLONSCOPY ******* = CLASSIC iv. essentially = DILATED SUBMUCOSAL VEINS + AV MALFORMATIONS v. most common AFTER 60*** vi. MOST COMMON IN R COLON vii. MORE FREQ IN RENAL DZ PTS, VWF DEFIC PTS,( b/c both of these have inc bleeding tendency), AND AORTIC STENOSIS (DUE TO ACQ VWF DEFIC - remits post Aortic valve replacement)***** viii. Dx = COLONOSCOPY ix. Tx = NONE unless anemia or bleeding - cautery

What are some drugs that can: -Impair folic acid absorption -Antagonize folic acids physiological effects

1. Anti-epileptics (phenytoin, etc..) 2. Methotrexate & trimethoprim *MCC of folic acid deficiency is nutrtional due to poor diet (not enough greens) or alcoholism

Meds that Cause Intrahepatic Cholestasis

1. Antibiotics - Macrolides 2. anabolic steroids 3. OCPs

Major Depressive Disorder

1. Associated with early morning awakening, frequent awakening during night, or difficulty falling asleep

TX of symptomatic bradycardia?

1. Atropine 2. Transcutaneous pacing 3. Pacemaker placement if a identifiable/fixable cause is not located

Neuroimaging findings in psychiatric disorders

1. Autism - INCREASED total BRAIN VOLUME 2. Obsessive Compulsive Disorder - Abn. in Orbitofrontal cortex + stratum 3. PAnic Disorder - DEC volume of Amygdala 4. PTSD - Dec. HIPPOCAMPAL VOLUME 5. Schizophrenia - enlargement of CEREBRAL VENTRICLES LATERALLY

Hepatic Adenomas

1. BENIGN epithelial tumors of liver that arise as a SOLITARY mass in RIGHT HEPATIC LOBE 2. found predominantly in YOUNG WOMEN + MIDDLE AGED WOMEN 3. Hx of OCPS*** 4. Physical Findings i. palpable abd mass ii. hepatomegaly iii. jaundice 5. LFTs can be elevated 6. AFP - normal unless malignant transformation occurred

Social Anxiety Disorder Tx

1. Beta blocker - propanolol

Serum markers for: -Seminomatous tumors -Nonseminomatous germ cell tumors (mixed germ cell tumors)

1. Beta-hCG 2. AFP + Beta-hCG

When is prophylaxis (& what is it?) for an HIV pt given in these situations: -Pneumocystis PNA -Mycobacterium avium complex -Mycobacterium tuberculosis -CMV

1. CD4 < 200 (TMP-SMX; Dapsone is an alternative) 2. CD4 < 50 (Prophylaxis = Azithromycin; TX = Clarithromycin + Ethambutol) 3. PPD induration > 5 mm (Isoniazid) 4. CD4 < 50 + CMV IgG is positive (Propylaxis & TX = Gangciclovir)

Important classifications of Drug Induced Liver Disease

1. CHOLESTASIS - chlorpromazine, nitrofurantoin, erythromycin, anabolic steroids 2. Fatty Liver - tetracycline, valproate, anti retrovirals 3. HEPATITIS - HALOTHANE, PHENYTOIN, ISONIAZID*** (TEST Q LOOK FOR inc AST + ALT around 300 + ALK PHOS SLIGHT ELEV), alpha methyl dopa 4. TOXIC OR FULMINANT LIVER FAILURE a.k.a. ACUTE LIVER FAILURE - CARBON TETRACHLORIDE OR ACETAMINOPHEN ******* (TEST Q ) 5. GRANULOMATOUS - allopurinol, phenylbutazone Key test point = ISONIAZID CAUSES IDIOSYNCRATIC LIVER INJURY (NO EXTRAHEPATIC MANIFESTATIONS) w/HISTOLOGIC FEATURES SIMLAR TO THOSE SEEN IN PTS w/VIRAL HEPATITIS

Inhalant intox

1. CNS depressnats 2. slurred speech, dizziness, transient euphoria,\ 3. effects 15-45 mintues

Most common complications of untreated hyperthyroidism?

1. Cardiovascular arryhthmias (A-fib) 2. Bone loss due to increased osteoclastic activity

Most COmmon Causes of Mass Lesions in HIV

1. Cerebral toxoplasmosis: multiple ring enhancing mass lesions on MRI; located @ basal ganglia; 2. Primary CNS lymphoma - second most common cause mass lesion in HIV infected patients: *single ring enhancing mass lesion that is weakly enhancing + periventricular*

Adjustment DIsorder

1. Characterized by depressed mood or functional impairment that occurs WITHIN 3 MONTHS OF IDENTIFIABLE STRESSOR 2. STRESS OVER ONE ASPECT ASSOCIATED WITH EVENT

Acute Cholangitis

1. Charcot Triad = FEVER (HIGH***), JAUNDICE, RUQ pain i. also see MENTAL STATUS CHANGES, HYPOTENSION (REYNOLD's PENTAD) WHEN SEE THESE ALSO 2. due to biliary tract obstruction + resultant bacterial contamination of bile 3. common causes = CHOLEDOCHOLITHIASIS, BILIARY TRACT MANIPULATION, HEPATOBILIARY MALIGNANCIES 4. LABs = WBC w/NEUTROPHIL SHIFT + CRP + ALK PHOS ****** WAY INC.; GGT + DIRECT BILIRUBIN 5. Dx = BILIARY DILATION**** ON US OR CT***** 6. Tx = i. Biliary Drainage - ERCP w/sphincterotomy or PTCA ii. Broad Spectrum Antibiotics - Beta Lactam/beta lactamase inhibitor, 3rd gen cephalosporin + metronidazole 7. Predispositions i. BILIARY STASIS - most common causes = BILE DUCT OBSTRUCTION FROM GALLSTONES, MALIGNANCY, OR STENOSIS

Antidepressant Addiction Potential

1. Climipramine, paroxetine, venlafaxine are antidepressants 2. addictive potential is not present - treat anxiety or depressive disorder

Vascular Rings

1. Congenital anomalies 2. aortic arch vessels encircle trachea and/or esophagus 3. sx of airway obstruction; more likely first presenting sx is DYSPHAGIA 4. No association w/GERD or BARRETT's

Narcolepsy

1. Daytime drowsiness 2. cataplexy (sudden loss muscle tone triggered by strong emotions) Tx 1. Maintain good sleep habits 2. Minimize alcohol, avoid Benzos, opiates, antipsychotic, 3. modafinil or armodafinil = address excessive, uncontrollable daytime sleepiness (STIMULANT) - 1st LINE*** 4. Amphetamine stimulants = methylphenidate, dextroampehtamine, methamphetamine - 2nd line 5. CATAPLEXY Tx = SODIUM OXYBATE (1st line) + amphetamines (2nd line)

Physical examination findings of effusion without cardiac tamponade include: (2)

1. Diminished heart sounds on auscultation 2. Maximal apical impulse that is difficult to palpate

Drugs that cause pancreatitis

1. Diuretics - furosemide + thiazides 2. Drugs for inflammatory bowel disease (sulfasalazine, 5-ASA) 3. Immunosuppressive agents (azathioprine) 4. HIV-related medications - didanosine, pentamidine 5. Antibiotics - metronidazole, tetracycline 6. Anti seizure drugs - VALPROIC ACID

Pellagra

1. Due to NIACIN DEFICIENY 2. 3 Ds i. DERMATITIS - ON SUN EXOSED AREAS OF BODY + ROUGH, HYPERPIGMENTED, SCALY SKIN ii. WATERY DIARRHEA - assoc w/ABD PAIN, NAUSEA, LOSS OF APPETITE iii. DEMENTIA - DUE TO NEURONAL DEGENERATION in BRAIN + SP CORD can lead to MEMORY LOSS 3. synthesized from TRYPTOPHAN 4. DEFICIENCY IN people EATING ONLY CORN 5. Prolonged ISONIAZID therapy - USUALLY CAUSE VIT B6 DEFIC BUT SOMETIMES ALSO NIACIN DEFIC Diff Dx 1. seborrheic dermatitis - erythematous, scaly plaques affecting scalp, face, chest, and intertriginous areas; sometimes dementia; no GI

45 y/o man comes in w/epigastric pain, diarrhea, PMH for PUD. 20 pack year history of smoking but does not use alcohol or illicit drugs. PE show abd. tenderness w/o rebound or rigidity. Endoscopy shows prominent gastric folds, 3 duodenal ulcer, and upper jejunal ulceration. Next step?

1. Dx = ZE syndrome 2. next step - serum gastrin concentration

Dyspepsia Management

1. Dyspepsia - epigastric fullness or discomfort after eating; sometimes waking at night to have snack but no pain 2. associated w/N + sx of GERD such as heartburn 3. causes of dyspepsia i. GERD ii. NSAIDs iii. Gastric/esophageal cancer iv. functional dyspepsia 4. Dx - depends on which of the causes you think it is: i. either >55 OR alarm sxs - weight loss, gross occult bleeding, anemia, dysphagia persistent vomiting, or early satiety - IMMEDIATELY DO ENDOSCOPY ii. if patient <55 + no alarm sx; if on NSAIDs - Discontinue NSAIDs iii. if patient <55 + no alarm sx: if typical GERD sx - PPI trial iv. if patient <55 + no alarm sx: if NO GERD Sx + NO NSAID Hx - DO "TEST-AND-TREAT" STRATEGY - BREATH TEST OR STOOL ASSAY FOR H PYLORI + GIVE ANTIBIOTIC TX IF POSITIVE

Bloody diarrhea in the absence of recent travel is most likely caused by? (3)

1. E. coli (EHEC) - DX with stool assay for Shiga toxin -Dont give ABX b/c can cause HUS 2. Shigella 3. Camphylobacter

Narcissistic Personality DIsorder

1. Exaggerates sense of self importance 2. Feelings of entitlement 3. Egocentrism 4. No empathy for others

Borderline Personality Disorder

1. FREQ DIAGNOSED IN PATIENTS SUFFERING FROM BULIMIA NERVOSA 2. Associated with patterns of instability in interpersonal relationships 3. Marked impulsivity

Diagnostic study of choice for an esophageal perforation? (2)

1. Gastrografin-contrast esophagraphy 2. CT esophagraphy

List the progression of changes seen in the kidney in a pt with DM? (4)

1. Glomerular hyperfiltration 2. Thickening of the GBM (first change that can be quantified) 3. Mesangial expansion 4. Nodular sclerosis

Most Common Causes of Hyperthyroidism?

1. Graves disease 2. Toxic Adenoma 3. Multinodular goiter - IN ORDER OF MOST COMMON - *initial treatment of TA or multifocal (MNG) follicular hyperplasia = BETA BLOCKER + THIONAMDIE (METHIMAZOLE OR PTU - dec thyroid secretion) - *definitive treatment TA = SURGERY OR RADIOIODINE ABLATION*

In which hyperthyroid disease is radioiodine therapy more likely to cause permanent hypothyroidism in patients?

1. Graves disease (much more likely that multinodular goiter or toxica adenoma) - because whole thyroid gland is hyperfunctional in Graves' dz and radioiodine taken up by entire gland giving entire gland ablation

Primary CNS lymphoma features? (3)

1. HIV infected pt with AMS 2. EBV DNA in the CSF 3. Solitary, weakly ring-enhancing lesion on the MRI

Hypothyroidism can cause these metabolic abnormalities? (4)

1. HLD 2. Hyponatremia 3. Elevated CK 4. Elevated ALT/AST *Most pts will have hypercholesterolemia alone or combined with hypertriglyceridemia

MCC of epiglottitis, especially in adult population & immigrant population? (2)

1. Haemophilus influenzae 2. Streptococcus pyogenes (GAS)

Side effects of levodopa/carbidopa therapy?

1. Hallucination (older pts), somnolence, & confusion 2. Dyskinesia (after yrs of therapy)

Paranoid Schizophrenia

1. Hallucinations + delusions 2. Eccentric behavior 3. Cognitive difficulties 4. AT LEAST 6 MONTHS 5. DO NOT RESOLVE SPONTANEOUSLY

Chlamydia infection hallmark feature and TX?

1. Has no growth on the gram stain & urine culture. A mucopurulent D/C in a pt who is sexually active -Nucleic acid amplification confirms DX 2. Azithromycin or doxycycline -Add ceftriaxone for the probable concommitent gonnococcal infection

Alcoholic Hepatitis Findings on Pathology

1. Hepatocyte swelling + necrosis 2. Mallory bodies 3. neutrophilic infiltration 4. macrovescicular fatty infiltration

What Predisposes to GERD?

1. Hiatal Hernia - protrusion of stomach above diaphragm i. when you see this think Hiatal hernia to GERD to BARRETT ESOPHAGUS + PEPTIC STRICTURE + ADENOCARCINOMA ii. Barium swallow for Hiatal Hernia - show Gastric Folds protruding above diaphragm

What are the only 2 modalities that have been shown to *decrease mortality in COPD*?

1. Home Oxygen Therapy 2. Smoking Cessation

List some common symptoms of hypocalcemia? (3)

1. Hyperactive DTRs 2. Muscle cramps 3. Convulsions (rarely)

TX of A-Fib in these 2 different types of pts: -Hemodynamically unstable (Hypotension, AMS) -Hemodynamically stable

1. Immediate DC cardioversion 2. Digoxin

Asperberger's

1. Impairment in reciproca lsocial interaction 2. restricted interests 3. desire relationships but lack awarenss of social conventions 4. absence of language delay - distinguish from AUTISM******

Name 3 agents used to shift potassium intracellularly?

1. Insulin & glucose 2. Sodium bicarbonate 3. Beta-2-agonists

Acanthosis nigracans is associated with 2 things?

1. Insulin resistance states (DM, PCOS) 2. GI malignancy in older individuals

Main RFs for aneurysm expansion & rupture include? (3)

1. Large diameter 2. Rate of expansion 3. Current cigarette smoking

Paranoid Personality Disorder

1. Long pattern of distrust + suspiciousness of others 2. Read too much into things, accuse others of trying to harm them in some way 3. bear grudges 4. Suspiciousness not at level of delusion

Spirometry

1. Low FEV1/FVC - obstructive disease - do BRONCHODILATOR challenge a. Inc FEV1 - Asthma b. no Change in FEV1 - COPD (INC RV) 2. Normal of high FEV1/FVC (BUT LOW VC) - restrictive disease - check DLCO a. NORMAL DLCO - chest wall weakness (i.e. mass obesity or other neuromuscular pathology) b. DEC DLCO - Interstitial Lung Disease - includes pneumoconiosis ***meaning of DLCO - indicates diffusion across alveolar-epithelial membrane

3 main causes of digital clubbing?

1. Lung malignancies 2. CF 3. R-to-L cardiac shunts

What types of neuropathies seen in diabetics?

1. MOST COMMON type = SYMMETRICAL DISTAL SENSORIMOTOR POLYNEUROPATHY - STOCKING + GLOVE SENSORY LOSS - present AT REST + WORSE IN NIGHT 2. related to *duration of dz + level of glycemic control* 3. possible to see *older males get symmetrical + proximal predominantly motor neuropathy - giving weakness of hip muscles. 4. Diabetic Autonomic Neuropathy I. *cardiovascular, GU, GI systems* a. *gastroparesis b. enterophaty c. postural hypotension d. abnormal sweating e. cystopathy f. erectile dysfunction* 5. predisposition to pressure palsies 6. mononeuropathies of cranial + peripheral nerves

Abdominal Succussion SPlash

1. Maneuver - placing steth over upper abdomen, rock patient back and forth at hips i. retained gastric material > 3 hours after a meal - generate splash sound - indicate HOLLOW VISCUS FILLED W/FLUID + GAS ii. SUGGEST GASTRIC OUTLET SYNDROME 2. initial management gastric outlet syndrome i. decompress stomach via NG tube ii. IV hydration iii. Endoscopy for definitive dx DIff Dx 1. chronic pancreatitis - rarely lead to inflammation + fibrosis of adjacent structures (IE DUODENUM) that RARELY lead to obstruction.mes

metabolic effects of second generation antipsychotics

1. Metabolic Syndrome I. weight gain ii. dyslipidemia iii. hyperglycemia (including new onset diabetes) 2. highest risk drugs I. clozapine ii. olanzapine 3. Monitoring guidelines I. BMI - monthly ii. fasting blood glucose + lipids - every 3 months iii. blood pressure - every 3 months iv. waist circumference - every 3 months

Whipple Disease

1. Mulitsystemic Disease 2. Caused by Trophyerma Whipplei 3. see in WHITE MEN, 40s-60s 4. PRES W/WEIGHT LOSS 5. GI sx i. abd pain, diarrhea, malabsorption w/distention****, flatulence, STEATORRHEA**** 6. Extraintestinal Sx i. MIGRATORY POLYARTHROPATHY ii. CHRONIC COUGH iii. MYOCARDIAL OR VALVULAR INVOLVEMENT - LEADING TO CONGESTIVE FAILURE OR VALVULAR REGURGITATION iv. LATER STAGE - DEMENTIA + CNS FINDINGS (MYOCLONUS, SUPRANUCLEAR OPHTALMOPLEGIA) 7. Random features i. LYMPHADENOPATHY *** ii. PIGMENTATION *** iii. LOW GRADE FEVER 8. Biopsy - classic PAS (+) material in LAMINA PROPRIA of SMALL INTESTINE

Management of hypercalcemia: -Asymptomatic (<12) -Moderate (12-14) -Severe or symptomatic (>14)

1. No immediate TX -Avoid thiazide diuretics, lithium, volume depletion & prolonged bed rest 2. Usually no TX unless symptomatic. If symptomatic TX like you would for severe hypercalcemia 3. Short-term (immediate) TX -NS + Calcitonin -Avoid loop diuretics unless volume overload (HF) exists Long-term TX -Bisphosphonates

Bulimia Nervosa

1. Normal body weight 2. NOT amenorrheic 3. Recurrent episodes of uncontrolled binge eating followed by feelings of extreme disgust or guilt 4. Repeated compensatory behavior to prevent weight gain after binging 5. Dissatisfaction w/body weight + shape

Obstructive Sleep Apnea

1. Obesity is predisposing factor 2. Tx = NOCTURNAL CPAPA 3. Heavy snoring *** 4. Waking during night 5. Frequent daytime fatigue 6. Morning headaches

Histological Findings Primary Sclerosing Cholangitis

1. Periductal portal tract fibrosis 2. segmental stenosis of extrahepatic + intrahepatic bile ducts

Postcholecystectomy Syndrome

1. Persistent ABDOMINAL PAIN OR DYSPEPSIA (nausea) that occurs Postop (early) or MONTHS TO YEARS (LATE) after CHOLECYSTECTOMY 2. can be due to - biliary causes I. retained CBD (common bile duct) ii. Cystic Duct stone iii. biliary dyskinesia - extra biliary causes I. pancreatitis ii. peptic ulcer dz iii. CAD 3. pts notice same pain as before the surgery, new pain just after surgery, or the same pain that never went away 4. Labs I. INC ALK PHOS ii. mildly abn. serum Aminotransferases iii. Dilated CBD on Abd US ***above 3 findings suggest - COMMON BILE DUCT STONES or BILIARY SPHINCTER OF ODDI DYSFUNCTION 5. PCS suspicion Next Step (SAME AS DIANGOSTIC STEP) I. 1st is ULTRASOUND, FOLLOWED BY ERCP (ALWAYS USED TO VISUALIZED ILATED DUCTS)

Social Phobia

1. Persistent fear of social performance situations that will trigger panic attacks if forced into them

OCD (ego dystonic)

1. Persistent intrusive thoughts and/or compulsive acts to allay inherent anxieties. 2. Patients with this condition - perform multiple time wasting rituals 3. recognize irrational nature of behavior but feel unable to stop 4. First line Tx = SSRIs - AFFECT SEROTONIN (TEST Q) I. sertraline Ii. clomipramine (only one on here that is TCA and not SSRI) Iii. Fluoxetine Iv. Paroxetine v. sertraline

In the case of stillbirth

1. Physician should DIRECTLY EXPRESS EMPATHY + ACKNOWLEDGE LOSS

Reversal toxic CNS effect caused by anticholinergic drugs

1. Physostigmine

Name 2 associations of pts with chronic Hep C infection?

1. Porphyria cutanea tarda (PCT) 2. Essential mixed cryoglobinemia

OCPD (ego syntonic)

1. Preoccupation with orderliness + perfectionism that negatively impact their functioning 2. Devoted to work, stubborn, and believe there is only 1 way to do things 3. Difficulty throwing out worn items, trouble w/relationships due to need for perfection

TX of myasthenia gravis? (3)

1. Pyridostigmine/Neostigmine (acetylcholinesterase inhibitors) - first initial choice in therapy 2. Immunosuppressive agents - Induces remission 3. Thymectomy - Induces remission

List what DS's these markers are associated with? -RF & anti-CCP Abs -Anti-dsDNA Abs -Glutamic acid decarboxylase Abs -HLA-B27/p-ANCA -Acetylcholine receptor Abs

1. RA 2. SLE 3. DM type 1 4. AS (Ankylosing spobylitis)/IBD (UC) 5. MG

Chronic Bronchitis

1. RFs of *longstanding smoking + chronic productive cough* 2. *hemoptysis* 3. defined as: CHRONIC PRODUCTIVE COUGH FOR 3 months in 2 successive years w/cigarette smoking as leading cause 4. due to hyper secretion of mucus + structural changes in tracheobronchial tree after prolonged exposure to nonspecific irritants 5. usually presents with prominent BRONCHOVASCULAR MARKINGS, MILDLY FLATTENED DIAPHRAGM, NORMAL DLCO

Causes of Esophageal Strictures

1. Radiation 2. systemic sclerosis 3. caustic ingestion 4. GERD

Define Creutzfield-Jakob DS? (3)

1. Rapidly progressive dementia 2. Myoclonus 3. Sharp, triphasic, synchronous discharges on EEG

What are the 6 indications for hemodialysis?

1. Refractory hyperkalemia 2. Volume overload or pulmonary edema not responding to diuretics 3. Refractory metabolic acidosis (pH <7.2) 4. Uremic pericarditis 5. Uremic encephalopathy 6. Coagulopathy due to renal failure

Immune responses initiated by the: -23-valent pneumococcal vaccine (contains capsular polysaccharides) -13-valent pneumococcal vaccine (contains capsular polysaccharides conjugated to a protein antigen)

1. Relatively T-cell-independent B-cell response 2. Robust T-cell-dependent B-cell response

Obsessive compulsive disorder

1. Repetitive, compulsive acts in response to recurrent, obtrusive thoughts 2. No restless sleep or fatigue or poor concentration

Neuroleptic Malignant syndrome

1. SE of neuroleptic meds (antipsychotics) 2. cardinal features = hyperthermia, autonomic instability, muscular rigidity, altered sensorium 3. lab values = elevated CPK 4. rhabdomyolysis followed by myoglobinuria that can cause ARF 5. Treatment = I. discontinue agent ii. DANTROLENE SODIUM = DIRECT MUSCLE RELAXANT OR AMANTADINE and/or dopamine agonist (bromocriptine)

Antidepressant Classifications

1. SSRIs i. citalopram ii. fluoxetine iii. paroxetine iv. sertraline *SE i. anorexia ii. sexual dysfunction - dec. libido, delayed ejaculation, erectile dysfunction 2. SNRIs i. duloxetine ii. venlafaxine iii. desvenlafaxine 3. TCAs i. amitriptyline ii. clomipramine iii. doxepin iv. nortriptyline 4. MAOIs i. phenylzine ii. tranylcypromine 5. Atypical Antiderpressants i. Buproprion ii. mirtazapine iii. trazadone a. majorly used to treat INSOMNIA related to DEPRESSION (BECAUSE INDUCES SLEEP) b. SE = sedation + PRIAPISM

Anorexia Nervosa

1. Same as above but I. irregular menstrual cycles ii. abn low BMI

Schizophreniform

1. Same as schizophrenia but 1month < x < 6 months

Treatment of Acute Mania

1. Second gen antipsychotic (risperidone, olanzapine) 2. First gen antipsychotic (haloperidol) 3. Lithium (avoid in renal dz) 4. valproate (avoid in liver dz) 5. Carbamazepine (Inc. metabolism of other drugs) 6. adj. Benzes for insomnia or agitation 1st line = first antipsychotics for acute mania - faster acting, then think mood stabilizers lithium, valproate, or carbamazepine)

Alprazolam

1. Short acting benzodiazepine 2. Withdrawal - GIVE SEIZURE 3. Effects - sedative

Leukocyte esterase in a U/A signifies? Positive nitrites in a U/A signifies?

1. Significant pyuria 2. Presence of Enterobacteriaceae *Pyuria + significant bacteriuria is highly suggestive of acute pyelonephritis

Treatment of Ascites Steps IN ORDER

1. Sodium + water Restriction 2. SPIRINOLACTONE 3. LOOP DIURETIC - NOT > 1L/Day of diuresis 4. FREQUENT ABD PARACETNESIS - 2-4 L/DAY as long as RENAL FUNCTION OKAY

Causes of thyroidtoxicosis with reduced radioactive iodine uptake? (3)

1. Thyroiditis 2. Levothyroxine OD 3. Iodine-induced thyrotoxicosis

Generalized Anxiety Disorder

1. Treatment = SSRIs, Buspirone, Venlafaxine

Clinical features of Meniere's DS & its typical TX?

1. Vertigo, ear fullness, tinnitus, & hearing loss 2. Dietary modifications, including maintenance of a low-salt diet

When is ERCP the next step?

1. When US first done and suggests some type of obstruction due to cholelithiasis or malignancy - can be dx + therapeutic

Risperidone

1. Works by blocking D2 Receptors 2. Atypical antipsychotic I. less likely to cause EPS 3. Also offer Alpha-1 Adrenergic Receptor anatagonization 4. Binds to SEROTONIN RECEPTORS ALSO I. improve negative symptoms of schizophrenia*** Ii. Dec. EPS Iii. Concomitant treatment of depression*** ***general concept - atypical antipsychotic all have additional affinity for serotonin receptors that typical antipsychotic don't have - this allows LESS EPS

Emphysematous Cholecystitis

1. acute cholecystitis that arises due to secondary infection of GALLBLADDER WALL w/gas forming bacteria - i.e. clostridium, eschericia, Staph, Strep, pseudomonas, klebsiella 2. AGE of 50-70 3. Predisposing factors - VASCULAR COMPROMISE (OBSTRUCTION OR STENOSIS OF CYSTIC ARTERY - only arterial supply to gallbladder), IMMUNOSUPPRESSION (SEEN W/DIABETES), GALLSTONES, and INFECTION W/GAS FORMING BACTERIA (ESSENTIALLY LOOK FOR ELDERLY DIABETIC MALE) 4. manifestations i. RUQ pain ii. N/V iii. LOW GRADE FEVER iv. CREPITUS IN ADJ ABD WALL TO GALLBLADDER v. NO PERITONEAL SIGN 5. Complications = GANGRENE + PERFORATION 6. Dx = CONFIRM W/ABD XRAY demonstrating AIR FLUID LEVELS in GALLBLADDER OR US w/CURVILINEAR GAS SHADOWING IN GALLBLADDER ; LABs - insig 7. Tx = immed fluid = electrolyte, early cholecystectomy, parenteral antibiotic therapy against gram (+) aerobics - Amp-Sulbactam, piperacillin-tazobactam, or combo aminoglycoisde or quinolone Diff Dx 1. peptic ulcer perforation i. free air under diaphragm ***

Patient found to be psychotic on streets - what to do?

1. admit to hospital if he/she agrees 2. next pharmacologic treatment I. prefer second generation antipsychotic - risperidone, olanzapine, aripiprazole, ziprasidone, palperidone, (clozapine - only used in refractory treatment when 2 other trials of atypicals have failed) ii. special populations a. chronic noncompliance - consider long acting injectable b. treatment resistance - 2 failed trials - clozapine

Pneumococcal Vaccines Guidelines

1. adults > 65 then PCV13 then 6-12 months later PPSV23 2. In adults < 65 with high risk underlying conditions (CSF leaks, sickle cell disease, cochlear implants, congenital or acquired asplenia) GIVE PCV13 + PPSV23 3. in adults < 65 who are current smoker or have chronic medication conditions, including heart or lung disease, diabetes, Chronic Liver Disease give PPSV23 ALONE

Complications of Ventilation with High PEEP

1. alveolar damage 2. tension pneumothorax - present with sudden onset SOB, hypotension, tachycardia, tracheal deviation, unilateral absence of breath sounds 3. hypotension (compression mediastinal cavity) - used in patients with hypoxemic respiratory failure - i.e. ARDS, cardiogenic edema, and obstructive airway disease - *increases FRC + dec work of breathing* - *having ARDS and using PEEP as tx predisposes pt to barotrauma such as tension pneumothorax, a complication of high PEEP levels*

Bath Salts

1. amphetamine analogs 2. cause combativeness + severe agitation 3. DO NOT inc. sociablity 4. hyperthermia (due to physical agitation) but NOT VERY HIGH FEVERS

Buproprion

1. antidepressant 2. produced effects primarily through inhibition of reuptake of NEp, Dopamine, and 5-HT 3. improving concentration + diminished energy in depressed patients 4. good choice in YOUNG PTS WHO ARE CONCERNED ABOUT SEXUAL SIDE EFFECTS (LESS SEXUAL SEs) 5. dec. seizure threshold - CI IN SEIZURE DISORDER + CONCURRENT ALCOHOL USE + EATING DISORDERS

Chronic Inflammatory Diarrhea

1. associated with inflammatory changes in blood i. anemia ii. ELEVATED ESR iii. REACTIVE THROMBOCYTOSIS iv. INC ACUTE PHASE REACTANTS 2. Blood/leukocyte positive stool - CONFIRMATORY FINDING **** 3. If its occurring in young pt as in <30 - THINK IBD (AS LONG AS DURATION > 4 weeks TO R/O INFXS CAUSE)

Avoidant personality disorder

1. avoid socializing + intimate relationships due to feeling of inadequacy + fear of rejection

RFs for Adenocarcinoma of Esophagus

1. barrett's esophagus 2. obesity 3. high dietary calorie intake 4. high fat intake 5. smoking (COMMON TO BOTH) 6. medications that promote GERD 7. GERD**** (KNOW HIATAL HERNIA GIVES GERD GIVES ADENOCA.)

PCP intoxication

1. behavioral changes i. physical aggression ii. severe agitation iii. impulsivity iv. PSYCHOSIS v. HALLUCINATIONS vi. PARANOIA 2. Physical Signs i. NYSTAGMUS ii. ATAXIA iii. AGGRESSION iv. tachycardia v. HTN vi. MUSCLE RIGIDITY OR DYSARTHRIA

Treatment of EPS (usually SE of neuroleptics)

1. benzotropine

What drugs caue Raynaud's Phenomenon (digital vasospasm)?

1. beta blockers 2. ergotamine

Folate vs Vit B12 deficiency

1. both MACROcytic anemias 2. B12 deficient in VEGEETARIANS (VEGANS) - SEE ANEMIA + NEUROLOGIC DEFICITS - STORES SUFFICIENT IN BODY TO LAST 3-4 years 3. FOLATE - DEPLETE IN 4-5 MONTHS, IS HEAT SENSITIVE SO COOKED FOODSO ARE LACKING - NEED VEGGIES SPEC FOR THIS

Hypochondriasis Treatment

1. brief psychotherapy + discussion of current emotional stressors (because this only develop during times of stress)

Presentation of Hypocalcemia

1. can be asx at initial presentation or may have involuntary contractions (tetany) involving lips, face, extremities - seen in severe hypocalcemia

Subphrenic Abscess

1. cause Fever + Abd Pain 2. develops due to PERITONITIS due to i. perforated ulcer ii. appendicitis iii. abdominal surgery **** (NEED SOME ABDOMINAL PROCEDURE MOST COMMON CAUSE) 3. can have RIGHT SIDED PLEURAL EFFUSION

Malingering

1. characterized by intentional production of false physical symptoms or grossly exaggerated physical or psychological complaints for the purpose of SECONDARY GAIN (financial compensation, avoidance of work, obtaining narcotics)

Depersonalization Disorder

1. characterized by persistent or recurrent feelings of detachment from one own physical or mental processes in context of an intact sense of reality. 2. Patients tend to feel they are observing their body and thoughts from afar

Disruptive Mood Dysregulation

1. childhood disorder 2. chronic irritability manifested as temperamental outburst s + persistent angry/irritable mood 3. added to DSM 5 to differentiate children with chronic persistent irritability from those w/classic episodic bipolar disorder

What drugs cause cochlear dysfunction?

1. cisplatin 2. carboplatin

Pancreatic Pseudocyst

1. classic development of mass in epigastrium JUST WEEKS AFTER episode of ACUTE PANCREATITIS 2. associated with CHRONIC PANCREATITIS 3. pancreatic pseudocysts - not real cysts - lined (walled) by thick fibrous capsule w/o epithelial lining. 4. have lots of INFLAMMATORY FLUID - HIGH [AMYLASE], [LIPASE], [ENTEROKINASE] 5. preferred modality of imaging pseudocysts = ULTRASOUND 6. Treatment I. let resolve spontaneously - unless a. > 5 cm in diameter b. becomes SECONDARILY INFECTED c. persist > 6 WEEKS 7. feared complication - growth pseudocyst into blood vessel - gives HEMORRHAGE INTO PSEUDOCYST

Antisocial Personality Disorder

1. disregard for + violation of rights of others 2. engage in illegal activities 3. History of conduct disorder in past

Diverticulosis

1. diverticula = outpouchings of colonic wall that form at points of weakness 2. deformation in wall cause weakness in associated arterial supply - lead to bleeding into diverticular lumen 3. diverticulosis = most common in SIGMOID COLON (LEFT COLON)**** VS DIVERTICULAR BLEED MOST COMMON IN RIGHT COLON 4. diverticular bleeding i. painless ii. large volume bleeding - assoc w/light headedness + hemodynamic instability iii. if moderate volume - may present as hematochezia iv. lesson = CAN BE BRB OR HEMATOCHEZIA DEPENDING ON VOLUME OF BLEED 5. Dx = COLONOSCOPY***** 6. most RESOLVE SPONTANEOUSLY Differential Dx in 70 y/o male 1. Angiodysplasia i. also cause RIGHT COLON BLEED -FAR LESS COMMON ii. caue LOW VOL VENOUS BLEED (vs DIVERTICULOSIS - CAUSE LARGE VOL ARTERIAL BLEED) 2. Colon cancer i. CHRONIC OCCULRT BLOOD LOSS w/abd pain + altered passage of stool + WEIGHT LOSS 3. Hemorrhoids - Int hemorrhoids cause painless rectal bleed w/BRB on Toilet paper + RARELY CAUSE MASS BLEED 4. Ischemic Colitis i. SUDDEN ONSET OF ABD PAIN + TENDERNESS - followed by RECTAL BLEED ii. due to INADEQ PERFUSION OF WATERSHED AREAS (i.e. SPLENIC FLEXURE) - in setting of NONOCCLUSIVE ischemia or surgical or endovascular interventions 5. Acute Mesenteric thrombus i. ABDOMINAL PAIN OUT OF PROPORTION****** TO PHYSICAL FINDINGS ii. N/V iii. BLOODY DIARRHEA DUE TO MUCOSAL SLOUGHING iv. LOOK FOR NUMEROUS ATHEROSCLEROTIC RFs 6. Brisk Upper GI bleed i. i.e. due to peptic ulcer disease ii. present w/BRB per rectum IF BRISK ENOUGH OF BLEED + may have hematemesis iii. if UPPER GI, SHOULD SEE ON NG TUBE ASPIRATE

Where do you find anemia of chronic disease?

1. due to inflammatory cytokines - suppresss Red Cells 2. occurs especially in INFLAMMATORY ARTHROPATHIES - RA, LUPUS, BUT NOT OA

Pathological Gambling

1. dx in individual with chronic history of gambling and inability to stop. 2. significant financial losses and damaged relationships are common consequences

Benzos/Barbiturates Intoxication

1. dysarthria, ataxia, sedation 2. lower heart rate + BP 3. are ANTICONVULSANTS 4. test for via routine urine tox

Schizotypal Personality disorder

1. eccentric behavior + Odd but NOT delusional thinking

Portal Hypertension presentation

1. esophageal varices, spider nevi, palmar erythema, caput medusa 2. THROMOCYTOPENIA 3. COAGULOPATHY

Optic neuritis is a SE of what drugs?

1. ethambutol 2. hydroxychloroquine

Atypical Antipsychotic SE

1. example = Risperidone i. used to Tx a. SCHIZOPHRENIA b. BIPOLAR ii. dopamine antagonist that also acts on serotonin receptors a. dopamine antagonism causes HYPERPROLACTINEMIA = AMENORRHEA, GALACTORRHEA iii. Risperidone INC PROLACTIN MORE THAN OTEHR ANTIPSYCHOTICS iv. ALL ATYPICAL ANTIPSYCHOTICS AUSE WEIGHT GAIN

Medication induced psychosis

1. examples of drugs that can cause this are high dose glucocorticoids I. glucocorticoids can also cause MANIA + DEPRESSIVE SYMPTOMS 2.

Generalized Anxiety Disorder

1. excess anxiety about MULTIPLE EVENTS 2. 3 or more following symptoms for at > 6 months: impaired sleep, poor concentration, easy fatigability, irritability, muscle tension, and restlessness

Derealization Disorder

1. experiencing familiar persons + surroundings as if they were strange or unreal

Where would you see Vit ADEK defic?

1. fat malabsorption dz - celiac dz, small bowel crohn dz, pancreatic insufficiency

Major Depressive Order Treatment

1. first line = SSRI 2. if NO IMPROVEMENT - SWITCH TO DIFFERENT MEDICATION IN SAME CLASS 3. if still NO IMPROVEMENT - THEN SWITCH TO DIFFERENT CLASS ENTIRELY

Acute Psychotic Patients Assessment

1. first look for suicidal or homicidal ideation I. command hallucinations - to hurt self or others 2. look for ability to care for self 3. indications for involuntary psychiatric hospitalization I. being danger to self or others or grave disability

Chronology of Abdominal Pain in Acute Pancreatitis?

1. first, ONLY VISCERA INFLAMED - therefore INITIAL VISCERAL PAIN IS PERI UMBILICAL b/c afferent visceral pain fibers from appendix accompany simp. nerves + go to T10 segment leading to pain at peri-umbilical region (AKA REFERRED PAIN) 2. as dz progresses, SUBSEQUENT INFLAMMATION of PARIETAL PERITONEUM + SK MUSCLES causes SOMATIC PAIN LOCALIZED TO RIGHT LOWER QUADRANT + MORE SEVERE (gives "SHIFTING PHENOMENON"

Benzodiazepine Toxicity Treatment

1. flumazenil - beware of precipitating seizures in patients with history of seizures

What to do with noncompliant patients who display psychotic features - auditory hallucinations + non bizarre delusions; are unaware of his/her issue; has responded previously to haloperidol, risperidone, and olanzapine. But now what to do?

1. give Long acting injectable version of either haloperidol, fluphenazine (1st gen antipsychotics) or LAI version of 2nd gen (olanzapine, risperidone, palperidone)

Inhalant Abuse

1. glue, tuolene, nitrous oxide 2. signs of acute intoxication - transient, brief euphoria + loss of consciousness 3. immediate effects lasting 15-45 minutes 4. CNS depressants - may cause death 5. dermatitis around mouth or nostrils is apparent 6. liver function tests - may be elevated with repeated use

Common Causes of Hypogonadotropic Hypogonadism (aka central hypogonadism) in MEN

1. gonadotroph cell damage - tumor, trauma, suprasellar surgery or radiation, infiltrative diseases, apoplexy 2. prolactinoma 3. narcotic use 4. severe systemic illness 5. *cushing syndrome (endogenous + iatrogenic)* unsure why 6. hemochromatosis 7. *DM - not sure why* 8. *anabolic steroid + testosterone use* 9. *morbid obesity* 10. *excess alcohol intake - can act at level of pituitary and directly suppress LH release causing central hypogonadism or act at testes to dec testosterone*

Brief Psychotic Disorder

1. hallucinations, delusions, disorganized speech, grossly disorganized behavior for at least 1 day (LESS THAN ONE MONTH) w/complete resolution of symptoms

Causes of elevated prolactin

1. high prolactin of >200 - classic for pituitary prolactinoma 2. milder elevations of prolactin I. hypothyroidism ii. renal failure

When is Bronchoscopy a test of choice?

1. if there is OBSTRUCTING MASS that may be causing RECURRENT PNEUMONIAS in same anatomical location 2.

Complications of GERD

1. if there is long Hx of GERD + new dysphagia + symmetric lower esophageal narrowing i. THINK ESOPHAGEAL STRICTURE - present with slow progression dysphagia - FROM LUIQUID TO SOLID W/O ANOREXIA OR WEIGHT LOSS - can BLOCK REFLUX - pt THAT DEVELOPS THIS CAN SUDDENLY ADMIT TO DEC REFLUX SX - SYMMETRIC + CIRCUMFERENTIA NARROWING ON BARIUM SWALLOW - NEXT STEP ON SUSPICION = ENDOSCOPY - TO SIMULT R/O ADENOCARCINOMA - WEIGHT LOSS ii. BARRETT's ESOPHAGUS - intestinal metaplasia of lower esophagus iii. Adenocarcinoma - if GERD PREZ FOR >20 years - present w/retrosternal discomfort, mild dysphagia to solid food, burning sensation - Barium swallow - ASYMMETRIC NARROWING OF ESOPHAGEAL LUMEN iv. Erosive Esophagitis

Valproic Acid Side Effect

1. inc. GABA 2. BLOOD DYSCRASIAS 3. LIVER TOXICITY

Patients w/upper GI bleeding who have depressed level of consciousness + ongoing hematemesis w/sig PMH of CIRRHOSIS, VARICEAL BAND LIGATION. She is having episodes of bloody vomiting with clots - she should be _________

1. intubated to protect the airway as a part of initial stabilization + resuscitation i. ABCs FIRST ii. prompt endoscopic treatment w/band ligation or sclerotherapy should then be performed to stop bleeding for variceal hemorrhage iii. platelet transfusion - not done until platelets drop below 50,000 iv. eventually administer PROPHYLACTIC ANTIBIOTICS + SOMATOSTATIN v. eventually DIAGNOSTIC PARACENTESIS - FOR EVAL FOR SPONT BACTERIAL PERITONITIS (SBP) - COMMON COMPLIC OF CIRRHOTIC PTS w/ESOPHAGEAL VARICEAL HEMORRHAGE vi. after stabiliization and all that crap, DO UPPER ENDOSCOPY W/BAND LIGATION OR SCLEROTHERAPY TO STOP VARICEAL HEMORRHAGE

Abrupt Cessation of Cocaine

1. irritable, drowsy, fatigued, hungry (vs anorexic when intoxicated + full of energy) 2. psychomotor agitation or retardation

What causes Gallbladder Stasis - and what is complication?

1. it causes GALLSTONES which may lead to CHOLECYSTITIS 2. Stasis of gallbladder is caused by i. TPN - this causes for lack of proteins + FAs in DUODENUm - so no stimulus for CCK release into duodenum = no gallbladder contraction, leading to stasis = GALLSTONES + BILIARY SLUDGE ii. Small Bowel Resection - ESP ILEAL RESECTION - THINK OF CROHNS PT FOR EX W/LOTS OF SMALL BOWEL RESECTION - no Ileum = NO BILE SALTS REABSORBED = DEC ENTEROHEPATIC CIRC OF BILE SALTS*** = HEPATIC BILE DUCT BECOME SUPERSATURATED W/CHOLESTEROL = INC GALLSTONE SATURATION iii. Pregnancy OR OCPs - INC ESTROGEN = INC CHOLESTEROL SEC + more saturation of bile w/cholesterol = inc thickness = stasis

Approach to Hypocalcemia

1. low serum calcium - *confirm with repeat measurement IF ASX (SAME AS W/HYPERCALCEMIA)* - correct for serum albumin or measure ionized calcium (if needed) 2. Low magnesium level? - is it due to a drug? - recent blood transfusion (inc citrate, volume)? - alcoholic (they have dec Mg2+) *ALSO CHECK FOR HYPOALBUMINEMIA - WILL CAUSE HYPOCALCEMIA* i. if yes - treat underlying cause, replete magnesium, IV Ca2+ if sx severe ii. if No - measure serum PTH a. if NORMAL or LOW PTH - hypoparathryoidism - surgical (MOST COMMON): parathyroidectomy, thyroidectomy, radial neck surgery - autoimmune: polyglandular autoimmune syndrome - infiltrative disease - mets cancer ,Wilson dz, hemochromatosis - genetic: PTH gene or Ca2+ sensing receptor gene mutations b. if HIGH PTH - metabolic: Vit D defic, CKD - inflammatory: pancreatitis, sepsis - oncology: tumor lysis syndrome - PTH resistance: pseudo hypoparathyroidism ______________________________________________________ - understand that alcoholics - have HYPOMAGNESEMIA i. hypocalcemia due to hypomagnesemia - refractory to tx w/calcium unless Mg2+ replaced as well. ii. understand that hypomagnesemia - DECREASES PTH SEC + CAUSES RESISTANCE TO PTH FOR unknown reason iii. although PTH levels inc. rapidly after Mg2+ replacement, hypocalcemia takes longer to improve b/c PTH resistance persists despite improvement in Mg2+ levels iv. also oddly enough: despite PTH deficiency, when deficiency is due to Mg2+ deficiency, PHOSPHORUS LEVELS ARE NORMAL OR LOW - understand that hypophosphatemia in presence of hypomagnesemia is a result of that hypomagnesemia and does non itself cause hypocalcelmia

Besides antipsychotics, what else helps decrease risk of relapse in patients with schizophrenia?

1. minimizing conflict + stress 2. family psychosocial interventions help do this and should be done for patients who will have contact again after recent episode

Bipolar Disorder Treatment

1. mood stabilizer monotherapy 2. some atypical antipsychotics are approved for monotherapy 3. atypical antipsychotics may also serve as adjuncts to mood stabilizers - for mild or moderate bipolar - give atypical antipsychotic - for severe - give LITHIUM (OR VALPROATE) + atypical antipsychotic

Echinococcus granulosus

1. most common cause of hydatid cysts (cystic echinococccosis) 2. seen in IMMIGRANTS or ENDEMIC Countries 3. Exposure to SHEEP or DOGS 4. Initia linfxn - asymptomatic 5. organs infected i. LIVER - hydatid cysts here cause HEPATOMEGALY + URQ PAIN + NAUSEA + VOMITING 6. Microscopic Exam i. characteristic encapsulated + calcified cyst - that contains fluid + budding cells that eventually become daughter cysts

MALT lymphoma

1. most commonly caused by H. pylori *** (TEST Q) 2. WHEN MALT LYMPHOMA W/O METS i. FIRST LINE OF TX = ANTIBIOTIC TX (OMEPRAZOLE, CLARITHROMYCIN, AMOXICILLIN) 3. MALT LYMPHOMA W/METS i. Tx = CHOP (cyclophosphamide, Adriamycin, vincristine, prednisone) + BLEOMYCIN

Treatment opioid overdose

1. naloxone/naltrexone

Obsessive Compulsive Personality Disorder

1. need for order perfection 2. do not complete tasks in timely manner due to extremely rigid + meticulous, focus on need for perfection. 3. Anxiety, indecisiveness, perseveration on assignments 4. ego syntonic - pt unawarer

Obsessive Compulsive Disorder

1. obsession causing anxiety 2. compulsions to relieve anxiety 3. ego dystonic - pt aware of issue

Folie a Deux

1. one person's delusion is transferred to another person 2. Tx - don't admit separately - first DETERMINE DEGREE OF IMPAIRMENT OF EACH BY INTERVIEWING EACH SEPARATELY

hypochondriasis

1. overly concerned with idea that they have serious or life threatening disease that has not been diagnosed 2. causes significant anxiety that goes on for months or longer

2 major indications that fluid needs to be drained from the pleural space by thoracostomy tube?

1. pH < 7.2 of pleural fluid 2. Glucose < 60 of the pleural fluid

Patients taking MAO-I like ____ should avoid foods high in _______ as combination can cause __________

1. pehnelzine, tranycypramine, selegeline 2. tyramine 3. Hypertensive crisis

Inhaled corticosteroids have a risk of what in long term exposure?

1. pneumonia 2. fractures

Body Dysmorphic disorder

1. preoccupation with >1 perceived physical defects 2. defects are not observable or appear slight to others 3. repetitive behavior or mental acts performed in response to preoccupation 4. significant distress or impairment 5. Specify insight (good, poor, absent/delusional beliefs) Tx = establish therapeutic alliance with patient initially - "let continue to meet regularly to discuss your concerns" + then PSYCHOTERAPY (empathic, sensitive measured approach taking into account patient insight)

Dissociative Identity Disorder

1. presence of >2 identities that control person's behavior 2. amnesia regarding important personal information about some of the identities

Dissociative Amnesia

1. presence of one or more episodes of inability to recall important personal information 2. memory disturbance is usually related to traumatic or stressful event and is too extensive to be considered ordinary forgetfulness

Shingles

1. present w/localized pain, regional hyperesthesia/allodynia, and/or burning 2. common features of HERPES ZOSTER - TO RECUR WHEN UNDER STRESS IE CANCER Tx, PHYSICAL STERSS, IMMUNOSUPPRESSED STATES 3. develop when there is reactivation of VZV in DRG (DORSAL ROOT GANGLION) 4. occur around AGE 50 5. should see PAIN + HYPOESTHESIA PRECEDE VESICULAR RASH BY SEVERAL DAYS 6. some cases: POST HERPETIC NEURALGIA - HYPERSESNSITIVITY OF AFFERENT PAIN FIBERS LEADING TO CHRONIC PAIN . i. Tx = ANTIVIRAL MEDS - ACYCLOVIR, VALCYCLOVIR - GIVE IN 1st FEW DAYS OF SHINGLES OUTBREAK + SHORTEN DURATION OF Sx + DEC RISK OF POST HERPETIC NEURALGIA

When to Administer CRYOPRECIPITATE?

1. pts. w/deficiency of FIBRINOGEN, VWF, or FACTOR VIII

Most common cause of Hemoptysis

1. pulmonary airway disease - chronic bronchitis, bronchogenic carcinoma, bronchiectasis **** RARE CAUSE OF HEMOPTYSIS = SEVERE THROMBOCYTOPENIA

3 likely possibilities when patient has sx consistent with renal colic but no stones are seen on xray

1. radiolucent stones (uric acid stones, xanthine stones) 2. Calcium stones (<1-3mm in diameter) 3. non stone ureteral obstruction (i.e. blood clot, tumor)

If asked what is best option with regards to firearms, knowing patient has any type of SI? i.e. "single most effective approach to preventing firearm injuries and death is ____________"

1. remove firearms completely A: removing firearms from home FIrearm Injury - RFs I. male adolescent ii. behavioral or psychiatric problems iii. low SE - Prevention I. remove all firearms from home ii. store firearms unloaded iii. lock firearms + ammunition in separate containers

Goodpasture's Syndrome

1. renal findings i. nephritic range proteinuria (<1.5g/day) ii. ARF iii. Urinary sediment with dysmorphic RBCs + RBC casts 2. pulmonary findings i. SOB ii. cough iii. hemoptysis 3. systemic sx - UNCOMMON - no fever, weight loss, arthralgias 4. Underlying Cause i. *antibodies to alpha-3 chain of TIV collagen - expressed most in glomerular + alveolar basement membranes* (TEST Q) 5. Dx = Renal biopsy - show *linear IgG deposition in glomerular basement membrane on IF* =

Diagnosis of Hyperosmolar Hyperglycemic State

1. serum glucose > 600 mg/dL (vs > 250 in DKA) 2. Plasma Osmolality > 320 mOsm/L (pH < 7.3 or bicarb 15-20) 3. Absent Ketonemia (vs ketonemia in DKA)

Mesenteric Ischemia

1. severe acute PERIUMBILICAL ABD pain OUT OF PROPORTION TO PE 2. RFs i. adv. age ii. diffuse aththerosclerosis iii. valvular abnormality iv. cardiac arrhythmias (AFIB) v. recent MI 3. also known as INESTINAL ANGINA - PAIN BROUGHT ABOUT INTERMITTENTLY BY EATING 4. Pts may have SIG WEIGHT LOSS

acute stress disorder

1. similar to PTSD 2. anxiety symptoms develop after experiencing an event that is serious except SYMPTOMS ARE NOT LONGER THAN 1 MONTH

Squamos Cell Carcinoma of Mucosa of head and neck

1. suspect if STRONG HX ALCOHOL + TOBACCO 2. first manifestation = PALPABLE CERVICAL LYMPH NODE 3. Best Initial Test = PANENDOSCOPY - esophagoscopy, bronchosocopy, laryngoscopy***** (TEST Q - PANENDOSCOPY) TO DETECT PRIMARY TUMOR 4. After panendsocopy - NEXT STEP = BIOPSY

MDMA

1. synthetic amphetamine that inc. 5-HT, DOPAMINE, NEp (recogn. therefore it may cause serotonin syndrome) 2. association with raves + dances 3. neurotoxicity with long term use 4. enhance euphoria + sexual desire + sociability 5. not detected in regular urine tox screen 6. intoxication I. hypertension, tachycardia, hyperthermia, serotonin syndrome (autonomic dysregulation, high fever, altered mental status, neurmusucal irritability, seizures), HYPONATREMIA, and death

Major Depressive Disorder (MDD)

1. tearfulness, feelings of worthlessness 2. Multiple recent life change events (deaths of spouse or retirement) 3. In many patients - headaches or other physical complaints (fatigue, insomnia) - indicative of depression 4. Headaches in younger patients - benign but if in OLDER patients - think underlying medical condition 5. At least 5/9 - recurrent episodes of these I. depressed mood Ii. Sleep disorder Iii. Loss of interest Iv. Guilt (worthlessness, hopelessness, regret) v. loss of energy Vi. Poor concentration Vii. Dec. Appetite Viii. psychomotor retardation ix. suicidality After dx, always ASSESS SUICIDALITY NEXT BY ASKING IF THERE IS SPECIFIC PLAN - DET IF HOSPITALIZATION IS NECESSARY - MOTIVATION + INTITIATIVE WILL IMPROVE BEFORE DEPRESSED OUTLOOK

Indication for MRI of pituitary

1. testosterone <150ng/dL 2. visual field defects 3. features of other pituitary hormonal dysfunction 4. high serum prolactin

What are red flags for secondary causes of hypogonadotropic hypogonadism (secondary or central hypogonadism)?

1. testosterone levels < 150ng/dL 2. significant gynecomastia w/ or w/o galactorrhea 3.significant headaches 4. other pituitary hormone deficiencies

Modafinil

1. tx for narcolepsy

Dissociative Fugue

1. unexpected + sudden travel 2. inability to remember past 3. confusion about personal identity 4. pt. may assume new identity

3 most common causes of chronic cough defined as *>8 weeks*?

1. upper airway cough syndrome (*postnasal drip*) I. if you think it is this, look for *dry cough* - *Dx + tx = trial with 1st gen antihistamine (i.e. chlorpheniramine) and look for resolution sx - other antihistamines without antiACh properties will not work 2. *asthma* I.*1st step* = DO PFTs - *1st line = bronchodilator challenge; 2nd line = methacoline challenge* ii. suspect in chronic cough that is primarily nocturnal 3. *GERD* I. *1st step on suspicion - trial PPI* 2. RFs I. obesity ii. supine positions soon after large meal iii. laryngitis - *look for sore throat* iv. *change in voice quality - i.e. hoarseness* v. *if you see sx of sore throat and hoarseness then asthma like sx of cough + wheezing - think worsening of asthma due to GERD* (common is 50-80% pts) 3. Pathophysiology of asthma exacerbation I. exacerbate airflow obstruction in asthmatic through *increased vagal tone, heightened bronchial reactivity, and microaspiration of gastric contents into upper airway*

INR Ranges

1. warfarin dosing should be adjusted to maintain goal INR appropriate for condition being treated I. pts with *idiopathic VTE or AFIB* - *INR OF 2.0 - 3.0* ii. maintained *at least 3 months In pts with reversible RF* iii. maintained *6-12 months in pt with idiopathic DVT* 2. *Prosthetic Heart Valve* I. range is *2.5-3.5*

When do you suspect Vit K Deficiency?

1. when patient is NPO FOR TOO LONG OR 2. ANTIBIOTICS THAT DAMAGE GUT FLORA

Can Hypothyroidism cause Anemia?

1. yes - but mild, less likely to show on exam

76 y/o pt w/cough + low grade fever. Treated for pneumonia x2 in last year. For past 6 months, had swallowing difficulty + regurgitation undigested food. Temp fo 101, fould smelling breath, fluctuant mass neck, CXR show cavitation in Right lower Lung field. Dx?

1.Zenker Diverticulum

55 year old F with screening colonoscopy done. 2 hyper plastic polyps removed. When do you do next colonoscopy?

10 years

For individual with 1st degree relative (parent, sibling, or dizygotic twin) who has bipolar disorder, risk of developing condition is ____

10%

general paresis

10-30 years after syphillis alzheimers+ tremors or argyll robertson

tabes dorsalis

10-30 years after syphillis lightening pains, sensory ataxia and dysuria

Treatment Of Hyperosmolar Hyperglycemic State

1st - Aggressive hydration with *NORMAL 0.90% SALINE, then 0.45% Saline once patient is either sodium is high or normal* 2nd - *IV INSULIN OR SHORT ACTING INSULIN (OVER SUBCUTANEOUS INSULIN - WHICH DOESNT FXN PROPERLY DUE TO ERRATIC ABSORPTION FROM TISSUE due to dec volume* 3rd - Careful monitoring + *K+ supplementation* ****IF YOU NOTE, SAME STEPS AS Tx OF DKA****

What is the treatment of choice for MAT?

1st oxygen, Mg and inhaled bronchodilators 2nd CCB

What clinical features do you need to DX dementia with lewy body (DLB)? (3)

2 of the following core features are essential for DX of probable DLB, & 1 for possible DLB: 1. Fluctuating cognition 2. Visual hallucinations 3. Parkinsonism features

rate of CSF production

25cc/hr 500cc/day

Clozapine

2nd gen antipsychotic for RESISTANT SCHIZOPHRENIA. Requires CBC monitoring due to risk for agranulocytosis

Diagnosis of DKA

3 things necessary 1. blood glucose > 250 mg/dL 2. pH < 7.3 or low serum bicarb (15-20) i. anion gap - of >12: Na+ - (HCO3- + CL-) 3. detection of plasma ketones *IN SUSPECTING EITHER DKA OR HHS - FIRST STEP IS SERUM CHEMISTRY PROFILE FOR DIAGNOSIS - UWORLD QUESTION*

What is the gene mutation in FAP?

5q gene mutation of APC gene

72 year old M ex smoker with no family history of abdominal aortic aneurysm has small aneurysm on US. When to do next US?

6 months

Patient with Barrett's esophagus is found to have low grade dysplasia on biopsy. When to repeat EGD?

6 months

How often would you repeat TTE in a patient with severe disease who is asymptomatic?

6-12 months

What are the screening guidelines for colorectal cancer in patients found to have tubular adenomas?

<1 cm: repeat 5-10 years 2x <1 cm: repeat 5-10 years >/= 1 cm repeat 3 years 3 polyps <1 cm repeat 3 years 10 polyps <1 cm repeat 3 yeras

What systolic BP would you aim for in an elderly patient with HTN?

<150mmHg

What are poor prognostic factors on stress test?

>2mm ST depression Persistent ST depression 5 min post exercise Fall in BP >15mmHg ST elevation Ventricular ectopi, VT global ischemic changes

Patients to Treat in Tuberculosis

>5mm - HIV (+) patients - Recent contacts of known Tb case - Nodular or fibrotic changes on CXR consistent with previously healed Tb - Organ transplant recipients + other immunosuppressed patients >10mm - recent immigrants (<5 years) from TB-endemic areas - Injection drug users - Residents + employers of high risk settings (prisons, nursing homes, hospitals, homeless shelters) - mycobacteriology lab personnel - higher risk for reactivation - diabetes, prolonged corticosteroid tx, leukemia, ESRD, chronic malabsorption syndromes >15 mm - all of the above + *healthy individuals* *latent Tb - means no sx but (+) PPD I. *treatment regimens (for all cases of above without symptoms but pos. ppd)* - *isoniazid (+ pyridoxine) + rifapentine weekly for 3 months; INH + pyridoxine for 6-9 months monotherapy; or rifampin 4 months*

Define Chronic bronchitis?

A chronic productive cough for 3 months in 2 consecutive years, with cigarette smoking as the leading cause

Define emphysematous cholecystitis?

A form of acute cholecystitis that arises due to secondary infection of the gallbladder wall with gas-forming bacteria. Usually seen in older diabetic pts (50-70 yo) DX is confirmed with an ABD radiograph showing air fluid levels in the GB or an U/S showing curvilinear gas shadowing in the GB

Aspergillosis infection?

A fungal infection, characterized by coarse fragmented septae. A mobile cavitary mass in the lung, which presents with intermittent hemoptysis, is usually indicative of aspergilloma

Define Behcet's syndrome?

A multi-systemic inflammatory condition characterized by: -Recurrent oral & genital ulcers -Eye lesions (anterior or posterior uveitis; retinal revascularization) -Skin lesions (Erythema nodosum, acneiform nodules, papulopustular lesions) *Usually seen in Turkish, Asian, & Middle eastern population

24 y/o man from Long Island New York present's with fever, drenching sweats, and malaise form past week. For last few days has had jaundice + dark colored urine. Recalls being bitten by tick 2 weeks ago. Surgical hx includes splenectomy. Temp of 103, pulse of 106. What is cause? Malaria, Babesiosis, ehrlichiosis, Q fever, or lyme disease?

A: Babesiosis

5 mo hx episodic retrosternal pain that radiates to interscapular region w/episodes lasting 15 minutes. Precipated by emotional stress, hot or cold food. Regurigate food intermittently. Nitroglycerin alleviates pain. What is it, next step?

A: DIffuse Esophageal Spasm - Sx I. spontaneous pain ii. odynophagia for cold + hot food iii. emotional stress iv. resolution of chest pain after taking Nitrate + CCB **** (b/c MYOCYTES IN CORONARY VESSELS + ESOPHAGEAL MUSCLE CELLS RELAXED BY NITRATES + CCBS) v. Next step = ESOPHAGEAL MANOMETRY **** (TEST Q) - should see high amplitude contractions either spontaneously or after ergonovine stimulation

Most common cause of SVC syndrome

A: MALIGNANCY 1. lung cancer *especially small cell lung cancer* and *NHL* are *most common causes of SVC* 2. other possible causes I. fibrosing mediastinitis (secondary to histoplasmosis or Tb infection) ii. thrombosis secondary to indwelling catheter 3. *NEXT STEP IN EVAL - CXR* 4. Signs + Sx I. dyspnea ii. venous congestion iii. swelling of head, neck, and arms UNILATERALLY + SIMULTANEOUSLY

35 y/o M comes in presenting w/inc SOB, fever, and malaise for several days. PMH is sig. for 2 years of recurrent sinusitis. Former smoker + has occasional glass of wine. Temp today is 101.4 F. BP is 110/65 mm Hg, pulse of 110/min, and RR of 22. Exam shows ill appearing male in mild resp. distress. Patchy rales are appreciated on lung exam. CXR reveals multiple nodular densities bilaterally. sCr is 2.7. Urinalysis shows RBC casts. What is the way to diagnose the condition?

A: Serum Antineutrophilic Cytoplasmic Antibodies - if you see *upper + lower respiratory tract dz and kidney dz* - think *Wegener granulomatosis* - test for w/serum C-ANCA

53 y/o woman comes to urgent care clinic w/R side abd pain that started 2 days ago. Describes pain as constant, burning, severe enough to interfere w/sleep. No associated nausea, vomiting, diarrhea. Pt tried tx sx w/antacids + ibuprofen - no relief. PMH sig for breast cancer dx 1 year ago and last course of chemo given 3 weeks ago. VSS. Liver span is 8 cm. Spleen is not palpable. Bowel sounds are normal. Light brushing of skin to right of umbilicus - extreme pain. What additional feature is likely to develop?

A: Skin lesions - patient above isp resenting w/burning. localized pain, regional hyperesthesia/allodynia in context of recent cancer treatment - common features of herpes zoster (shingles). Pain from shingles precedes onset of classic vesicular rash by several days.

38 y/o w to office w/cough + blood tinged sputum. Developed malaise, nasal congestion, sore throat, and dry cough 10 days ago. Most sx improved but cough persisted + became productive of yellowish sputum. For past 2 days - multiple episodes of blood tinged sputum but has never had similar sx in past. Pt is non smoker + has no other medical problems. Temperature is 98F, blood pressure is 132/81, HR is 87/min. Scattered bilateral wheezes + rhonci that clear wit coughing are heard on chest auscultation. Chest x ray reveals clear lung fields. Which of following is the next step?

A: supportive care - this is young nonsmoker that developed productive cough w/purulent sputum AFTER URI. Mild wheezing on exam signifies airway involvement. Rhonchi that clear with coughing suggest airway secretions that are easily mobilized by coughing. - findings listed are consistent with acute bronchitis which is usually - the sputum is yellow due to sloughing of epithelium, not bacterial infection. - presence of small amounts of blood in sputum in acute bronchitis - NORMAL I. due to erosion of superficial vessels form inflammation + epithelial damage - giving minor bleeding ii. *in pt w/new onset, small volume bleed following an acute infection, with no RFs for malignancy (i.e. smoking), or signs of bronchiectasis such as recurrent infections, no further workup is necessary*

What drugs improve mortality in CHF?

ACEI ARB Spironolactone for NYHA III or IV Hydralazine + nitrate BB

What is the drug of choice to treat HTN in patient with renal insufficiency?

ACEi

What is the drug of choice to treat HTN with DM/proteinuria?

ACEi

What is the drug of choice to treat HTN with LVH (S4)?

ACEi

65 year old with angina had CABG 2 years ago. HR 72/min, BP 124/84. No DM. LVEF normal. He is currently on ASA, BB, and Nitrates. Which drug will decrease the likelihood of another cardiac event?

ACEi (Ramipril)

What is the drug of choice to treat HTN with aortic regurgitation?

ACEi, ARB, dihydropyridine CCB

What is the drug of choice to treat HTN with CHF?

ACEi, Diuretics coreg

AL amyloidosis + AA amyloidosis

AL amyloidosis - Associated conditions i. multiple myeloma (MOST COMMON CAUSE OF AL AMYLOIDOSIS) ii. waldenstrom macroglobulinema - composition of amyloid I. light chains (usually lambda) AA amyloidosis - associated conditions I. Chronic inflammatory conditions (rheumatoid arthritis - MOST COMMON FOR AA AMYLOIDOSIS, IBD) ii. chronic infections: osteomyelitis, Tb - Abnormally folded proteins: beta-2 macroglobulin, apolipoprotein or transthyretin Rheumatoid arthritis induced AA amyloidosis - may see enlarged kidneys, hepatomegaly - biopsy will show amyloid deposits that stain with congo Red + characteristic apple green birefringence under polarized light I. see amyloid deposits in glomerular BM, blood vessels, interstitium of kidneys

In a Patient with hypoxemia that is mechanically ventilated, what should be increased first to adjust for low PaO2?

ALWAYS 1. *First adjust FiO2* - if possible - increase as necessary but *KEEP BELOW 40%* at all times - otherwise fear of *oxygen toxicity or barotrauma* I. *if let's say FiO2 >>>40% and is at for example 70%, before decreasing FiO2, INC PEEP THEN DEC FiO2* 2. *if FiO2 is maxed out, NEXT ADJUST PEEP* (UNLESS ARDs - WHERE YOU ADJUST PEEP FIRST) I. prevent alveolar collapse

In what conditions would you have early diastolic murmur?

AR and PR- once LV pressure reaches <80 for example if aortic pressure is 80, blood is sucked back into LV through incompetent valve

In which condition will you have increased intensity post-PVC, but decreased intensity with standing, valsalva and hand grip?

AS

What is the most common valvular disease in adults?

AS

In what conditions do you hear paradoxical split in heart sounds?

AS HTN LBBB

62 yo presents with palpitations. EKG reveals a fib with HR 100/min. you start him on BB. TTE shows no valvular abnormalities and normal wall thickness. BP 130/84. wtd?

ASA

What is the best treatment for flushing associated with niacin?

ASA 30 minutes before

What has been shown to decrease risk of colon cancer?

ASA >20 years, Celebrex and Sulindac (shown to decrease polyps in colon), Estrogens

What drugs cause urticaria and angioedema?

ASA, PCN, blood products

Pt with fixed split 2nd heart sound and mid-diastolic rumble. Most likely diagnosis?

ASD

75 year old with AS has a gradient of 80 and syncope. He has a hip fracture after fall. wtd?

AVR before surgery for hip

75 year old pt post hip replacement is recovering well. 6 days later onset of pain in the upper abdomen with T max 103. AST/ALT 40/52, TBili 1.1, Amylase 90. US reveals thickened GB (>3.5 mm), HIDA with non visualization of GB but CBD visualized. IV Abx started. Most likely dx? Treatment?

Acalculous cholecystitis Tx. Percutaneous cholecystectomy

Middle aged woman comes back from vacation from Florida with lesion on the back of her neck which is keratotic area with erythematous base. Most likely diagnosis? Best mgmt?

Actinic keratosis. Bx now

35 year old F in the ER for evaluation of jaundice, confusion, malaise and RUQ pain. Afebrile, HR 96, mild icterus. Noted to have mild ascites and hepatomegaly. AST 205, ALT 90, BR 15. PT/INR 1.5. Hb 12, WBC 18,000, Plt 175,000. Paracentesis with 200 WBCs. Most likely diagnosis? What is the best treatment?

Acute alcoholic hepatitis If no GIB or SBP: steroids GIB or SBP: pentoxyphylline

Define pseudogout?

Acute inflammatory arthrits caused by calcium pyrophosphate dehydrate crystals. Occurs in the setting of recent surgery or medical illness. DX with rhomboid-shaped positively bifringent crystals on joint aspiration & radiographic evidence of chondrocalcinosis (calcified articular cartilage)

Pt had A fib and you were treating him with diltiazem for rate control. TTE has structurally normal heart. A few days later he comes back with increased symptoms of palpitations. 24 hour hotter wit many episodes of A fib while he had symptoms. What to do?

Add BB

PT with raised erythematous area with itching for the past couple of months on and off. She takes loratadine and when she stops it gets worse. Wtd?

Add H2 blocker

Obese F with atypical CP undergoes exercise stress test. She stops the test after 5 minutes due to fatigue but no chest pain. HR increased by 50%. No EKG changes. wtd?

Adenosine stress or stress ECHO

What is the most important step in management of lactic acidosis from septic shock?

Admin NS .9% (with vasopressors if BP fails to respond) to maintain intravascular pressure & ABXs to correct the underlying infection

Best way to lower homocysteine levels?

Admin Vitamin B6 (pyridoxine) *Also, Vitamin B12 (cobalamin) & folate are involved in its metabolism

Primary versus central adrenal insufficiency

Adrenal Insufficiency Symptoms - weakness, abd pain, loss of appetite, *mild hyponatremia* - may see *hyperkalemia*, *postural hypotension* - *common in postpartum period* Patients with PRIMARY AI (*ADDISON'S DISEASE*): causes include *autimmune process most common but also less commonly infections as Tb, viral, fungal, surgical removal, adrenal hemorrhage* 1. *loss of glucocorticoid, mineralcorticoid, and adrenal androgen secretion* - sx are severe i. *significant hypotension, hyperkalemia, HYPERCHLOREMIC ACIDOSIS* ii. *hyperpigmentation* due to *ACTH VERY HIGH* + CROSS REACT W/MSH 2. pathology = HUMORAL + CELL MEDIATED IMMUNE DESTRUCTION ADRENAL CORTEX Patients with Secondary AI (CENTRAL - PITUITARY OR HYPOTHALAMIC DISORDER) 1. only *GLUCOCORTICOID + ADRENAL ANDROGEN DEFICIENCY (NO MINERALOCORTICOID DEFIC)* due to defect being in pituitary i. therefore *NO SIG HYPERKALEMIA, SIG HYPOTENSION, OR HYPOCHLOREMIC ACIDOSIS OR HYPERPIGMENTATION SEEN b/c R-A-A axis preserved* ii. some hyponatremia, little dec BP iii. *in postpartum setting - common causes of secondary AI = SHEEHAN + LYMPHOCYTIC HYPOPHYSITIS)* a. Sheehan - pituitary infarction due to hemorrhage/hypotension during labor b. Lymphocytic hypophysitis = lymphocytic infiltration of pituitary gland iv. *when due to WITHDRAWAL FROM exogenous glucocorticoid tx (most common cause), more likely to see in patient that had developed CUSHINGOID APPEARANCE DUE TO ADMIN AND DEPENDENCE ON EXOG GLUCOCORTICOIDS*. a. *recovery *- take up to *6-12 months*

Post gastrectomy patient presents with abdominal pain and bloating 15minutes-1 hour after eating. Symptoms are relieved by vomiting bilious liquid. Most likely diagnosis?

Afferent loop syndrome

Recommended Vaccines for Adults

Age 19-64 and >65 - Td/Tdap - Tdap once as substitute for Td booster (AT ANY POINT GIVE TDAP ONCE AT LEAST THEN TD BOOSTERS AGAIN) then Td every 10 years Influenza at all ages - annually Pneumococcus - PPSV23 alone (19-64): chronic heart, lung, or liver dz; diabetes, current smokers, and alocholics - Sequential PCV13 + PPSV23 - very high risk patients (19-64) i. csf leaks, cochlear implants ii. sickle cell disease, asplenia iii. immunocompromised (i.e. HIV, malignancy) iv. CKD (chronic renal failure) - Sequential PCV13 + PPSV23 (ages >65) I. 1 dose of PCV13 followed by PPSV23 in 6-12months

Risk factors for Colon Cancer

Age >50, Long standing UC and Crohn's Disease >8 years, First degree relatives with CC before age 60, history of other cancer (Breast, ovarian, or endometrial), FAP, HNPCC, Adenomas

Conduct Disorder

Aggression towards people and animals - initiating physical fights - bullying, threatening, or intimidating other - using weapon to cause serious harm - being physically cruel to people - being CRUEL TO ANIMALS - stealing while confronting victim - forcing someone into sexual activity Destruction of property - setting of fires - intentionally destroying others property Serious violation of rules - running away overnight at least x2 - being truant from school often starting before age 13 - frequently staying out at night despite parental prohibitions starting before age 13 deceitfulness or theft - breaking into car or building - frequently lying to obtain goods or favors - stealing items of nontrivial value without confronting a victim ***conduct disorder is when at least 3 behaviors are present within 12 months and at least 1 in past 6 months ***called Antisocial personality disorder after age 18

Alcoholic Withdrawal Syndrome

Alcohol Withdrawal Syndrome - Mild withdrawal (can progress to DT) Symptoms and Signs - anxiety, tremulous, sweating, palpitations Time of Last Drink - 6 hours Alcohol Withdrawal Syndrome - Withdrawal Seizures (can progress to DT) Symptoms and Signs - single seizure or multiple in small period of time Time of Last Drink - 12-48 hours Alcohol Withdrawal Syndrome - alcoholic hallucinosis Symptoms and Signs - auditory, visual, tactile hallucinations with normal vital signs + intact sensorium Time of Last Drink - 12-24 hours Alcohol Withdrawal Syndrome - delirium tremens Symptoms and Signs - fever, hypertension, tachycardia, diaphoresis, hallucinations, disorientation Time of Last Drink - 48-96 hours

3 most common causes of pancreatitis? List all of the subclasses of the third MCC of acute pancreatitis? (6)

Alcohol, Gallstones & Medications 1. Anti-epileptics (Valproic acid) 2. Diuretics (furosemide, thiazides) 3. Drugs for IBD (Sulfasalazine, 5-ASA) 4. Immunosuppresive agents (Azathioprine) 5. HIV medications (didanosine, pintamidine) 6. ABXs (metronidazole, tetracycline) *Also, hypertriglyceridemia

What is a hallmark sign of a UTI caused by Proteus mirabilis?

Alkaline urine. The Proteus spp. secrete urease to alkalinize the urine, leading to formation of struvite stones. The stone becomes a permanent source of bacteria to perpetuate the cycle

Microcytic Anemias

Alpha Thalassemia Minor - *SOUTHEAST ASIA* - table - 2 missing of the 4 alpha globin chains - *target cells* Beta Thalassemia Minor - *MEDITERRANEAN DECENT (ITALIAN, GREEK)* - *Look at table* - one abnormal beta globin allele, one normal beta globin allele - *target cells* *UNIQUE TO THALASSEMIAS NOT IN TABLE - as COMPARED TO Fe DEFICIENT ANEMIA: I] microcytosis out of proportion to degree of anemia, ii] hemoglobin >10g/dL, and iii] disproportionately high RBC count* vs *iron defic anemia - I] LOW RBC, ii] Hb<10* *Tx thalassemias - NONE (TEST Q)*

Pt with history of chronic diarrhea and traveled to third world country last year. Colonoscopy shows flask shaped ulcers. Most likely diagnosis?

Amoebic colitis

Pt comes back after traveling to a third world country and presents with right upper quadrant pain, fever, leukocytosis and transaminitis. History of bloody diarrhea recently. Most likely diagnosis? What is best next test?

Amoebic liver abscess- do stool culture for ova and cysts or serum Elisa Then CT Abdomen- if Positive aspirate and treat with flagyl

What happens to murmurs when you give amyl nitrate?

Amyl nitrate decreases after load making it easy for blood to be pushed into the systemic circulation making LVEDV less

Define P. jiroveci?

An opportunistic pathogen, & an important cause of PNA in IC hosts. Classic X-ray finding is B/L diffuse interstitial infiltrates beginning in the perihilar region.

What is the MCC of drug-induced CRF?

Analgesic nephropathy. 2 MC pathologies are: 1. Papillary necrosis 2. Chronic tubulointerstitial nephritis

What is one restrictive lung DS that produces a increased FRC (instead of the normal decrease in FRC)?

Ankylosing spondylitis -Due to chest wall motion restriction during inspiration

Mediastinal Masses by Location

Anterior 1. thymoma i. presentation - YOUNG male or female - chest heaviness or discomfort - hoarseness, horner's syndrome (PANCOAST TUMOR), or upper extremity + facial edema w/local invasion - may see MYASTHENIA GRAVIS or PEMPHIGUS 2. terrible lymphoma I. weight loss ii. cervical, supraclavicular, and axillary nodes affected 3. teratoma (including seminoma - *inc B hcg but not AFP*; non seminoma - *inc b-hcg + afp*) ***TEST Q*** I. *confirm dx - BIOPSY; testicular US MUST BE DONE 2nd TO R/O small primary tumor that has metastasized* ii. *almost all germ cell tumors in anterior mediastinum - primary* 4. thyroid carcinoma Posterior 1. ALL neurogenic tumors i. meningocele 2. enteric cysts 3. lymphomas * 4. diaphragmatic hernias 5. esophageal tumors 6. aortic aneurysm of arch * 7. Esophageal Leiomyomas i. submucosal + asx generally ii. only produce sx if > 5cm 3. best way for eval posterior mass - MRI*** Middle 1. bronchogenic cysts - assess with CT 2. tracheal tumors 3. pericardial cysts 4. lymphoma * 5. aortic aneurysm of arch *

Young woman with diarrhea, bloating, fatigue fogginess and headache comes to your office. She went on a gluten free diet with fewer symptoms. Recurrence of symptoms arose when she started eating gluten again. What to do next?

Anti-gliadin antibody test- non-celiac gluten sensitivity

Pt with history of PUD on PPI should undergo what test for H. pylori?

Antibody testing

HR is 74 and BP stable. Pt then becomes confused and both pupils are dilated. What is the diagnosis?

Anticholinergic delirium

What is a common complication of giant cell or temporal arteritis?

Aortic aneurysm. This is due to the DS's involvement of the aortic branches

V5-V6

Apical/lateral LAD/LCx

Recommended antimalarial chemoprophylaxis options for short term travelers

Areas with *chloroquine resistant P falciparum (sub-Saharan Africa, SE + south Asia like India)* I. atovaquone-proguanil (GI disturbance, inc LFTs), doxycycline, or mefloquine (*agent of choice in pregnancy*) Areas with *chloroquine susceptible P falciparum in addition to option above* - chloroquine, hydroxychloroquine

Age Related Sleep Changes

As age increases 1. Sleep less at night 2. Nap during day 3. Period of deep sleep (3 + 4) become shorter 4. Periods of light sleep 1+2 increase

Assessment and management of suicidality

Assessment: 1. SAD PERSONS I. sex ii. age iii. depression iv. previous attempt v. EtOH use vi. Rational thought loss (psychosis) vii. Social support (lack of) viii. organized plan ix. no spouse x. sickness or injury Plan: 1. High imminent risk (ideation, INTENT + PLAN) I. ensure safety - hospitalize immediately INVOLUNTARILY IF NECESSARY Ii. Remove personal belongings + objects in room that may present self harm risk Iii. Constant observation + security may be required to hold against will 2. High non-imminent risk (ideation, intent, but NO PLAN TO ACT IN NEAR FUTURE) I. treat modifiable risk factors - underlying depression or psychosis Ii. recruit family or friends to support patient Iii. reduce access to potential means - secure firearms, medications

Hodgkin's Disease Associations

Associated with - minimal change disease - nephropathy

Reversible airway obstruction with normal diffusion capacity post bronchodilator TX suggest?

Asthma

Pt with angina controlled on BB, ASA and nitrates presents with recent increased frequency and now chest pain lasting >30 minutes. EKG with ST depression in II, III, aVF. MOst likely mechanism of chest pain in this pt is?

Atherosclerotic plaque with intermittent rupture and thrombolysis

32 year old F with mitral stenosis has sudden palpitations. Pulse rate is 150/min and regular. Carotid massage decreased the pulse rate to 76/min with rapid return to 150/min when massage was stopped. These are symptoms of

Atrial flutter

In what conditions would you have a late-diastolic murmur?

Atrial myxoma- once the valve closes, the "ball" falls or plops on valve in diastole

Pt post inferior wall MI receives tPA. About 30 minutes later HR 30 bp and BP 70/40. wtd?

Atropine to treat increased vagal tone

Autoimmune Hepatitis

Autoimmune Hepatitis - i. LARGE INC. in AST + ALT - FLUCTUATING HEPATIC INJURY - RATHER THAN CHOLESTASIS ii. LOOK FOR IN WOMEN, iii. ANTINUCLEAR ANTIBODIES (SENS) + ANTISMOOTH MUSCLE TITERS (SENS + SPEC) iv. First Line Tx - Oral Glucocorticoids

Church group goes on picnic and eats precooked foods of turkey and beef. 8 hours later all have non-bloody diarrhea and vomiting. Most likely diagnosis? Treatment?

B. cereus Supportive

25 year old with palpitations, gradual onset. During episodes sinus tachycardia of 140/min were noted on EKG. Asymptomatic resting EKG normal. TTE normal. Pt diagnosed with inappropriate sinus tachycardia. Best management?

BB

What is the drug of choice to treat HTN post MI?

BB + ACEi

How do you medically manage dissecting aortic aneurysm?

BB then nitroprusside- if you did reverse order you would vasodilate which would cause increased HR and worsening of dissection

What is the drug of choice to treat HTN with ischemic hart disease?

BB, CCB

60 year old F complains of recurrent exercise induced palpitations with near syncope. Family history of near syncope in her elderly mother and daughter as well. EKG shows QTc of 480. LVEF 55%. Ischemic workup is negative. what is the next step in management?

BB- sotalol

Medications to withhold 48 hrs prior to a stress test? (3)

BBs, CCBs, Nitrates *withhold caffeine 12 hrs prior to stress test

Comparison of Benign Prostatic Hyperplasia and Prostate Cancer

BPH - RFs: Age > 50 - Affected part: *central* portion (*Transitional zone*) - examination: symmetrically enlarged + smooth - can have elevated PSA - miscellaneous I. causes lower urinary tract sx (inc feq, urgency, weak stream, nocturia) - tx = alpha 1 blockers (tamsulosin, doxazosin) +/- 5 alpha reductase inhibitors (finasteride) - surgery for patients w/severe sx (bladder outlet obstruction, recurrent UTIs) - complications I. complete bladder outlet obstruction - look for bladder scan showing > 100 mL of urine Prostate Cancer - RFs: Age > 40, *African American* + family hx - affected part: Usually *lateral* lobes of prostate but anywhere really - Examination: *asymmetrically enlarged, nodules*, firm prostate; markedly elevated PSA (when PSA >7.0, you worry about cancer) - next step: if persistently elevated PSA >4.0 or abnormal prostate exam (nodules, asymmetry, or induration) - PROSTATE BIOPSY

Bacterial Causes of Diarrhea

Bacillus cereus - diarrhea, abd cramping - ingestion of preformed toxin in starchy food such as *rice* Staphylococcus aureus - *vomiting*, abdominal pain - diarrhea not typical but may occur - caused by *preformed toxin with RAPID ONSET* symptoms Clostridium Dificile - Abd pain, watery diarrhea, possible fever - bloody stools unusual - associated with *antibiotic exposure* Clostridium Perfringens - brief illness with watery diarrhea, cramps, fever - associated with undercooked or *refrigerated food* Salmonella - watery diarrhea, fever, abd pain, and vomiting - associated with undercooked foods, especially *poultry + eggs* - antibiotic treatment needed only for severe disease or immunocompromised patients Vibrio vulnificus - vomiting, diarrhea, and bad pain - *raw or undercooked shellfish* - may cause *invasive* life threatening disease of immunocompromised patients or those with liver disease E. coli - watery diarrhea, may be *BLOODY* if associated with EHEC (shiga toxin producing) - associated with *undercooked beef or food w/bovine feces* - EHEC - inflammatory diarrhea syndrome with BLOODY stools due to making SHIGA TOXIN from BEEF PRODUCTS confirmed for with STOOL ASSAY FOR SHIGA TOXIN I. *if EHEC suspected, avoid empiric antibiotic therapy b/c inc risk of HEMOLYTIC UREMIC SYNDROME* Shigella - *bloody diarrhea* with fever and often *bacteremia* - associated with contaminated *food or water* especially during *travel outside of US* Campylobacter species - abdominal pain, *bloody diarrhea* - highest incidence in *children + young adults* - associated with *raw or undercooked meats*

When will you have 14C Xylose test positive?

Bacterial overgrowth

Patient who are neutropenic are at high risk of developing which infections?

Bacterial: pseudomonas, corynebacterium Fungal: Candida, aspergillus, mucor

What does palpable popliteal mass suggest?

Baker's cyst - most commonly affect patient with *rheumatoid arthritis, OA, and cartilage tear* - develop as a result of excessive fluid production by *inflamed synovium* (even though in OA we don't see inflammation OA still has baker cysts sometimes) - occasionally the cyst burst + release contents in to calf giving appearance similar to DVT

What is the first step to work up dysphagia?

Barium swallow

An IC pt presents with cutaneous & visceral angioma-like blood vessel growths, what is the cause?

Bartonella spp. TX with ABXs & the lesion will regress

What is the most common cause of skin cancer?

Basal cell

Patient post surgery is found to have icterus. AST/ALT WNL, direct bili and ALK phos elevated. Most likely diagnosis?

Benign post operative cholestasis

Patient who has predominantly comedone acne wants to know what can be used for treatment?

Benzyoyl peroxide, topical tretinoin

Lithium

Bipolar Disorder Tx

Categorization of bleeding at different times in Urination

Blood at beginning of urination - initial hematuria - indicates *lesion of urethra i.e. urethritis* Blood at end of voiding - *terminal hematuria* - due to *prostatic or bladder* cause I. evaluate via cystoscopy or PSA, etc Hematuria during entire cycle - *total hematuria* - due to disease in *ureter or kidney*

In what conditions would you have Holosystolic murmur? Why?

Blood is moving from high pressure chamber to low pressure chamber- MR, VSD, TR

How to Explore MINIMUM BRIGHT RED BLOOD PER RECTUM

Breakdown of MINIMAL BRIGHT RED BLOOD PER RECTUM 1. if age <40 w/o red flags ***(only one where Anoscopy may be valid) i. ANOSCOPY - if source is a. hemorrhoids - no further eval b. no source is identified - NEXT SIGMOIDOSCOPY OR COLONOSCOPY 2. If age 40-49 w/o red flags i. COLONOSCOPY (or SIGMOIDOSCOPY) 3. If age > 50 or red flags i. COLONSCOPY Red Flags - change in bowel habits, abd pain, weight loss, Fe Defic, fam hx of colon ca.

Benign Breast Disease

Breast cysts - solitary well circumscribed mobile mass - +/- tenderness Fibrocystic changes - multiple, diffuse nodulocystic masses (*cord like thickening*) - *bilateral, nonfocal premenstrual tenderness* - common in *women of reproductive age* *due to fluctuating estrogen + progesterone during menstrual cycle* - *NSAIDs + OCPs = tx* - cyclic premenstrual tenderness Fibroadenoma - solitary, mobile, and well circumscribed mass - cyclic premenstrual tenderness Fat necrosis - *post trauma/surgery* - *firm + irregular mass* - +/- ecchymosis, skin/nipple retraction

What are the PE findings for consolidation?

Bronchial breath sounds, dullness to percussion, & increased tactile fremitus/egophony/whispered pectoriloquy/bronchophony

42 year old Asian man has a history of sudden cardiac arrest. EKG revealed V fib and patient was defibrillated successfully. EKG now shows ST elevation in Rt precordial leads. He is asymptomatic. Father died at the age of 40. Most likely diagnosis? What is the best treatment?

Brugada syndrome- Na channel abnormality ICD

70 year old presents with blisters on body for the last 10 days. When you press on the end of one lesion the lesion does not extend to the other end. Lesions do not rupture easily. Dx?

Bullous pemphigoid ab to bullous pemphigoid Antigen 1 and 2 located at dermal epidermal junction See IgG, C3 and Eosinophils at the dermal-epidermal junction. Treat with oral tetracycline or steroids

30 year old F presents with early satiety and vomiting when she eats even a small portion of her sandwich for the past couple of months. A scintiscan is done which shows normal emptying. wtd?

Buspirone

Apical Lung Tumor

By Location has different possible Sx 1. compression of sympathetic trunk - horner syndrome 2. compression brachial plexus - pancoast syndrome I. pain + paresthesia and/or weakness right arm ii. *PANCOAST SYNDROME* = shoulder pain radiating into arm in *ulnar distribution* caused by *tumor invasion of C8 + T1* 3. right recurrent laryngeal nerve compression - hoarseness 4. Superior Vena Cava compression - SVC syndrome

What are the side effects of chronic PPI usage?

C. diff colitis, hospital acquired PNA, osteoporosis (2/2 Vit D def), hypomagnesemia, microscopic colitis, B12 deficiency

What causes hereditary angioedema? Treatment?

C1 Esterase inhibitor deficiency Does not respond to Epinephrine! Give FFP

Pt presents after a pillow fight with non pitting facial edema and no itching. Her sister had the same symptoms in the past. Most likely diagnosis?

C1 esterase deficiency

Pt was hiking in Shenandoah mountains and presents with facial swelling, no erythema or itching. wtd next?

C1 esterase inhibitor activity level

Pt with SLE has undetectable CH50. which complement component deficiency will you suspect?

C3

Pt with recurrent infections including skin, sinusitis, pneumonia now has liver abscess. Immunoglobulins are normal. CH50 is low. Which complement is going to be deficient?

C3- it is the major opsonin of the complement system responsible for defense against encapsulated organisms

70 year old F presents to the ED with episode of pulmonary edema. She has had two earlier similar episodes. The pulmonary edema responds well to IV diuretics. Hx of HTN with current BP 160/95. Lungs are clear and she has no chest pain. Systolic murmur II/VI heard at apex radiating to axilla. TTE with mild LVH and EF 60%. Most likely etiology?

CAD

angina and HTN

CCB

Prolactinoma Overview

CFs - premenopausal women I. oligo/amenorrhea ii. infertility iii. galactorrhea iv. hot flashes v. *dec bone density due to dec GnRH giving less estrogen* - post menopausal women I. mass effect sx - headache, visual field defects - men I. infertility, decreased libido, impotence, gynecomastia (33% of men, may be accompanied by galactorrhea) Lab/Imaging I. serum prolactin > 200ng/mL ii. cause hypogonadotropic hypogonadism in men: low testosterone levels + low or inappropriately normal LH iii. rule out renal insufficiency (creatinine) + hypothyroidism (TSH, thyroxine) iv. *MRI Brain + pituitary* v. other pituitary hormones unaffected UNLESS THERE ARE COMPRESSIVE EFFECTS DUE TO MACRO lesion Tx I. *Dopamine agonist - cabergoline or bromcriptine* = *1st line* ii. transphenoidal surgery

Patient with history of menigococcemia and gonorrhea. Which test would you order?

CH50 If low then check C5 to C9

Pt with chronic a fib on warfarin going for major surgery. wtd?

CHAD </=2 d/c warfarin 5 days prior no need to bridge CHAD >/=3 d/c warfarin 5 days prior and bridge with LMWH

Presentation of 1. CHRONIC DIARRHEA 2. STEATORRHEA 3. WEIGH LOSS tell us what?

CHRONIC MALABSORPTION - most common cause? i. CELIAC DZ - INTESTINAL ATROPHY OF VILLI IN PROXIMA LSMALL BOWEL DUE TO EXPOSURE TO GLUTEN OCNTAINING WHEAT PRODUCTS - INC w/AGE, N EUROPEAN DESCENT - it could also be w/presentation of malabsorption? i. PANCREAT INSUFFIC - it could also be what? i. SMALL INTESTINAL BAC OVERGROWTH - cause malabsorption also - also could be? i. CROHN DZ - transmural inflammation of GI tract w/most commonly in DISTAL ILEUM. - Pts may have STEATORRHEA DUE TO ABN ABSORPTION BILE SALTS IN ILEUM BUT D-xylose ABSORBED NORMALLY - NOTE THEN D-XYLOSE TEST NORMAL - how to differentiate PANCREAT INSUFFIC VS CELIAC DZ vs SIBO? i. D-xylose test - normal absorption and excretion in urine w/pancreat insuffic vs in Celiac Dz, you see DEC D XYLOSE IN URINE, INC IN FECES ii. SIBO will have ABN D XYLOSE W/DEC IN URINE, INC IN FECES BUT SHOULD SEE IMPROVEMENT WITH TREATMENT W/RIFAXIMIN

What is classic diagnosis for WORSENING POSTPRANDIAL PAIN THAT IS BAD ENOUGH TO CAUSE AVOIDANCE OF FOOD?

CHRONIC OCCLUSION OF VISCERAL ARTERIES (ABDOMINAL ANGINA) - WORSENING POSTPRANDIAL PAIN THAT IS BAD ENOUGH TO CAUSE AVOIDANCE OF FOOD - look for signs of ATHEROSCLEROSIS i. atherosclerosis of mesenteric arteries then becomes a possibility ii. Dx = ANGIOGRAPHY OR DOPPLER - abd exam = BRUIT*** - findings of CHRONIC ABD PAIN, WEIGHT LOSS, AND FOOD AVERSIOn Diff Dx 1. Cholelithiasis - RUQ pain + fat food intolerance but does not cause chronic diarrhea or weight loss

Which NSAIDs have decreased incidence of PUD?

COX2 inhibitors, non-acetylated NSAIDs (salsalate), non-acidic prodrugs- nambumetone and co-administer with COX-1 (misoprostol)

25 year old asymptomatic patient with family history of HNPCC. wtd?

COlonoscopy now and then q 2 years up to age 40 then yearly

What blood level should you check in a pt presenting with myalgias and is on statins?

CPK level *If high, D/C the statin

Systemic Sclerosis vs CREST

CREST - on image on right Systemic Sclerosis -

If you suspect pancreatic carcinoma - whats next step?

CT

Pt with diverticulitis has a 4 cm abscess. Wtd?

CT guided drainage first then elective surgery

45 year old M presents with coffee ground vomitus. He drinks 2 glasses of wine every day. He is afebrile, HR 100 bp, BP 120/80. EGD reveals only gastric varices. Wtd next? Most likely diagnosis?

CT scan of the abdomen to evaluate for thrombus Most likely diagnosis Splenic V Thrombus

Best initial step in DXing chronic pancreatitis?

CT-ABD or ABD plain films will show calcifications. If they don't and clinical suspicion is high, MRI or ERCP to establish the DX. Non-invasive/inexpensive TX first.

After gastric adenocarcinoma has been DX by a endoscopy/biopsy, what is the next step?

CT-scan for staging. This will help determine the prognosis and TX plan.

CAP criteria for TX?

CURB-65 Confusion Uremia (BUN > 20) Tachypnea (Respirations > 30) Hypotension (B/P < 90/60) Age (>65) <2 TX as out-pt; 2-4 in-pt TX; ≥4 ICU admission

Clinical Features of Diabetic Autonomic Neuropathy

CV - tachycardia, impaired exercise tolerance - postural HYPOtension with loss of diurnal blood pressure variation Peripheral Nerves - dry skin, pruritis, callus formation - foot ulcer + poor wound healing - *charcot arthropathy - increased fracture risk with resultant secondary ulceration* GI - gastroparesis with delayed gastric emptying - esophageal dysmotility with probably dyspepsia - intestinal involvement with possible diarrhea, constipation, or fecal incontinence Genitourinary - erectile dysfunction + retrograde ejaculation in men; women with dyspareunia + dec libido - decreased ability to sense full bladder (NEUROGENIC BLADDER); causes filling of bladder and eventually gives way to OVERFLOW INCONTINENCE - Eventual recurrent urinary tract infections +/or overflow incontinence (i.e dribbling, poor urinary stream) i. physical exam- show distended bladder + high post void residual urine volume > 50mL

Relative contraindications for thrombolytic therapy

CVA >1 year ago Recent internal bleed or major trauma <2-4 weeks BP >180/110 Pregnancy Active PUD

Which nutrients are absorbed in the duodenum?

Ca, iron, Mg, Folate; Water soluble vitamins, monosaccarides

Patient presents with bloody diarrhea and crampy abdominal pain. He works at an animal hospital and cleans the dog crates. Most likely diagnosis?

Campylobacter jejuni

Pt presents with diarrhea, fever and crampy abdominal pain. 2 days ago had undercooked chicken. Fecal leukocytes positive. Most likely diagnosis?

Campylobacter jejuni

What type of hypersensitivity reaction is Latex?

Can be either type I or IV

What is the drug of choice to treat systolic HTN in elderly woman

Candesartan

CO poisoning is called?

Carboxyhemoglobinemia

Symptoms of Digoxin Toxicity

Cardiac - life threatening arrhythmias GI - Anorexia - N + V - Abdominal Pain Neurologic - fatigue - confusion - weakness - COLOR VISION ALTERATION - scotomas, blindness Acute Toxicity - present w/GI sx first along w/possible weakness + confusion; chronic digoxin toxicity - present w/less pronounced GI sx but more significant neurologic sx Interactions - Amiodarone, Verapamil, Quinidine, Propafenone (VPAQ) - increase DIGOXIN CONC. + GIVE TOXICITY - RECOMMENDED TO DEC DIGOXIN DOSE BY 25 -50% WHEN INITIATING AMIODARONE TX W/CLOSE MONITORING OF DIGOXIN LEVELS ONCE WEEKLY FOR NEXT SEVERAL WEEKS

What is most common cause of death in renal transplant patients?

Cardiovascular disease

How does Tropical Sprue differ in Carribean population vs. Asian population?

Caribbean: folate normal, B12 low Asia: folate low, B12 normal

What is the first step in management of AVRT? Then?

Carotid sinus massage Adenosine 6 mg then 12 mg

Pt with retrosternal chest pain > 1 hr, diaphoretic. EKG with LBBB, and ST elevation in anterior leads. Old EKG not available for comparison. CK and Trop pending. wtd?

Cath

Pt admitted with MI. 3 days later with chest pain relieved with MTG. wtd?

Cath. post infarct angina

Define Molluscum contagiosum

Caused by a poxvirus & is characterized by small papules with central umbilication. Lesions may be more widespread in a an IC pt (such as an HIV pt with < 100 CD4)

Acute Hypocalcemia

Causes - *neck surgery (parathyroidectomy), pancreatitis, sepsis, tumor lysis syndrome, acute alkalosis (HYPERVENTILATION - cause pH to inc, loss of H+ ions to surrounding, albumin more likely to bind Ca2+), chelation (blood (citrate) transfusion), EDTA, lactate, foscarnet (all listed chelators will bind Ionized Ca2+ and dec active Ca2+ in blood)* - *remember always check magnesium levels in hypocalcemia workup (look up other flashcard on this concept) b/c hypomagnesemia can cause inactivation of PTH + dec sec PTH + directly cause Hypocalcemia* Clinical Features - muscle cramps, Chvostek (carpal pedal spasm - forceful contraction of hand) + Trosseau sign - paresthesias - hyperreflexia/tetany - seizures - potentially tetany, laryngospasm, seizures, encephalopathy, and heart failure Tx - IV calcium gluconate/chloride

High Anion Gap Metabolic Acidosis

Causes 1. lactic acidosis (measure lactate) I. look for *hypoperfusion + shock states (i.e. sepsis or cardiogenic shock)* 2. Ketoacidosis (measure beta hydroxyl butyrate) 3. Methanol/formaledehyde ingestion (formic acid) I. *blindness* 4. ethylene glycol ingestion (measure glycolic acid, oxalic acid) I. look for *ENVELOPE SHAPED (COFFIN SHAPED) URINARY CALCIUM OXALATE CRYSTALS* ii. can cause *acute renal failure* iii. *a.k.a. antifreeze* 5. Salicylate poisoning (measure salicyclic. lactic, sulfuric, and phosphoric acids) I. *tinnitus, vomiting/nausea* Ii. *also cause PRIMARY RESPIRATORY ALKALOSIS* 6. Uremia (ESRD) (impaired excretion of H+) I. *increased BUN* 7. Isioniazid/Iron overdose *only three of these above have an osmolal gap associated with the high anion gap metabolic acidosis - I. ethylene glycol ii. methanol iii. propylene glycol

Clinical Features of Osteomalacia

Causes (THINK MALABSORPTION) - malabsorption - intestinal bypass surgery - celiac sprue - chronic liver disease - chronic kidney disease - CROHN's Disease - SMALL BOWEL RESECTION Symptoms/signs - may be asx - *bone pain + muscle weakness* (VERSUS OSTEOPOROSIS) i. ***DECREASED PO43- CAUSES ADP-ATP CYCLE DEFECT IN MUSCLES - GIVING CRAMPS*** - *Muscle Cramps* (VS OSTEOPOROSIS) - Difficult walking, waddling gait Diagnosis - *INC ALK PHOS, INC PTH* - *DEC OR NORMAL SERUM Ca2+, EVEN MORE SIG DEC SERUM PO43-, dec urinary Ca2+* - *DEC 25-OH VIT D* - x rays - show *THINNING OF CORTEX W/REDUCED BONE DENSITY - eventual codfish vertebral bodies (CONCAVE SHAPE)* - *bilateral + symmetric pseudofractures (looser zones) = characteristic radiologic finding* - *ESP IN FEMORAL REGION* Pathology - *defective mineralization of organic bone matrix* - during new bone formation + remodeling, osteoclasts create a cavity at the bone surface that osteoblasts fill with osteoid (organic matrix); then Ca2+ + PO43- fill deposit into the matrix (called mineralization) - *inciting incident = malabsorption of Vit D- gives dec Ca2+ + PO43-: dec Ca2+ causes INC PTH - therefore final Ca2+ is normal/slightly low and PO43- levels dec greatly* Osteomalacia of Children - called *rickets - defective mineralization of growth plate - occurring only in children*

Paradoxical Hyperkalemia in DKA

Causes (Where there appears to be hyperkalemia by serum numbers in DKA but truth is that patient is still K+ depleted) 1. extracellular shift of K+ in exchange to hydrogen ion with resultant intracellular K+ deficit 2. impaired insulin dependent cell entry of K+ ion into cell Treatment 1. Acutely: Insulin + IV fluids may lead to quick dropping of K+ even if appearing elevated originally 2. all hyperkalemic patients should begin receiving K+ once serum K+ level goes below 4.5 mEq/L

What is the treatment for SBP?

Cefotaxime (3rd generation cephalosporin)

Which anti-inflammatory drug is contraindicated in a patient with sulfa allergy?

Celebrex

Pt presents with foul smelling fatty stool, itchy skin with grouped vesicular lesions. He is anemic. Small bowel biopsy with mononuclear infiltrate in lamina propr.. Most likely diagnosis of underlying disease and skin manifestation?

Celiac sprue Dermatitis herpetiformis

Which antibiotic induces the BI/NAP1 strain C. diff which causes colitis with toxic megacolon?

Cephalosporins or Quinolones

Define & list the TX (& AEs of that TX) of HCL?

Characterized by lymphocytes with fine, hair-like irregular projections & are TRAP +. The bone marrow becomes fibrotic; thus, leading to dry taps. TX: Cladribine (purine analog) -It is toxic to bone marrow, & its AEs include neurological & kidney damage

Define Tinea corporis & its TX?

Characterized by ring-shaped scaly patches with central clearing & distinct borders. TX with 2% antifungal lotions & creams (Terbinafine) or systemic TX with griseofulvin for extensive DS

Nurse previously vaccinated for Hep B now with needle stick injury from pt with Hep B. wtd next?

Check Anti- HBs titer. if > 10 u/l reassurance if < 10 u/l HBIG + Booster Hep B vaccine

Patient with colon cancer infiltrating serosa and pericolic structures. After hemicolectomy wtd?

Chemo with FOLFOX- 5 FU + Leucovorin + Oxaliplatin

Indications for thrombolysis

Chest pain typical for infarction >30 minutes with LBBB ST elevation >1mm in 2 contiguous leads <12 hours post MI Pt >2hrs away from PCI center and not in shock

Pt found to have incidental finding of calcification of gall bladder on US of abdomen. wtd?

Cholecystectomy

42 y/o Caucasian F c/o dyspepsia + bloating post meal. RUQ pain that is steady + severe, radiating to r scapula. Sx occur after fatty meal. VSS. Next Step?

Cholelithiasis i. Dx = cholelithiasis (gallstone disease) - which is most common in ii. "FAT, FERTILE, FORTY, FEMALE" - target group iii. Native American heritage, OCP use, RAPID WEIGHT LOSS, OBESITY, DM - predispose to Native American Heritage iv. Sx - RUQ pain after eating fatty food; bloating + dyspepsia v. Dx choice - FIRST MODALITY = ULTRASOUND - BEST FIRST INVESTIGATION FOR ALL GALLBLADDER DZ vi. Tx - ONLY if SX PRESENT - ELECTIVE CHOLECYSTECTOMY

TPN can predispose to?

Cholestasis

Patient has a history of recurrent infections with staph, gram negatives, fungi and nocardia. His uncle had the same problems. What is the most likely diagnosis? Etiology? How do you test? Treat?

Chronic granulomatous disease 2/2 phagocytic defect and NADPH oxidase deficiency- failure to produce free radicals NBT normal Treat: Interferon gamma and antibiotics

What is most common cause of hypothyroidism?

Chronic lymphocytic thyroiditis (hashimoto's thyroiditis)

Patient presents with history of recurrent thrush, onychomycosis and vaginitis. What is the most likely diagnosis? What do you expect to see on skin?

Chronic mucocutaneous candidiasis Skin may assume hyperkeratotic, crusted appearance on face, scalp, and hands

When will fecal fat be >50 g/day?

Chronic pancreatitis

Korsakoff syndrome? (3)

Chronic thiamine deficiency: 1. Irreversible amnesia 2. Confabulation 3. Apathy

Pt with diarrhea, nausea, vomiting and abdominal pain. Occurs a couple of hours after eating fish. Also complains of perioral paresthesias and reversal of hot and cold sensation. Most likely diagnosis?

Ciguatera toxin from large reef fish

Non Gonococcal Septic Arthritis

Classic Scenario - immunocompromised patient such as *DIABETES OR OA* patient that has *SINGLE JOINT INVOLVEMENT* - Dx = *GRAM STAIN + BLOOD CULTURE* *IF THERE IS PT W/FEVER + ACUTE MONARTICULAR ARTHRITIS - 1st STEP = ALWAYS ASPIRATION + JOINT FLUID ANALYSIS* RFs - abn joint: *OA, DIABETES, RA, PROSTHETIC JOINT, GOUT* - age > 80 - IVDU, alcoholism - intra articular glucocorticoid injections CFs - acute monoarthritis - hot, swollen, dec ROM, - fever - inc ESR + CRP Dx - blood cultures - synovial fluid analysis - leukocytosis (>50,000), gram stain, culture Initial Tx - 1st DRAINAGE OF JOINT, THEN - *Gram (+) cocci - vancomycin* - *Gram (-) rod - 3rd gen cephalosporin* - *negative microscopy - vanc (+ third gen cephalosporin if immunocomp)*

45 year old healthy man who exercises everyday and asymptomatic is going for major surgery. EKG reveals multiple PVCs. wtd?

Clear for surgery

Manifestations of Systemic Lupus Erythematosus

Clinical Features - constitutional: Fever, fatigue, weight loss - *symmetric, polyarticular, and migratory arthritis (knees, carpal joints, joints of fingers)* - skin: *buttefly rash + photosensitivity* - *serositis* - pleurisy, pericarditis, peritonitis - Thomboembolic events - due to *vasculitis + Antiphospholipid antibodies* - Neurologic -cognitive dysfunction + seizure - *painless oral ulcers* - *morning stiffness like RA but <30minutes (RA is >30mins)* Lab Findings - hemolytic anemia, thrombocytopenia, leukopenia - *hypocomplementemia (C3+C4)* - antibodies: *ANA (sensitive) + Anti-dsDNA (specific) + anti-SM (specific)* - renal involvement: *proteinuria + elevated creatinine with lupus glomerulonephritis* Randoms - *young AA women at highest risk* - *xray - show NO EVIDENCE OF JOIN DESTRUCTION OR EROSION unlike RA*

Amyloidosis

Clinical Features - extracellular deposit of insoluble polymeric protein fibrils in tissues + organs, elevated amyloid A - can be secondary to chronic inflammatory conditions I. inflammatory arthritis (i.e. rheumatoid arthritis) ii. chronic infections (i.e. bronchiectasis, tuberculosis, osteomyelitis) iii. inflammatory bowel disease (crohn's disease) iv. malignancy (lymphoma) v. vasculitis Clinical Presentation - asx proteinuria or nephrotic syndrome I. possible presentation - bilateral lower extremity edema; facial swelling; massive proteinuria - cardiomyopathy with heart failure - hepatomegaly - mixed sensory + motor peripheral neuropathy &/or autonomic neuropathy - visible organ enlargement (i.e. macroglossia) - bleeding diathesis - waxy thickening, easy bruising of the skin Dx - abd fat pad aspiration biopsy Treatment - tx of underlying condition - *colchicine for prophylaxis + treatment*

Clinical Features of Hep C

Clinical Presentation - asx or develop fatigue (MOST COMMON) - Other nonsp. sx - nausea, anorexia, myalgia, arthralgia, weakness, weight loss ** - SERUM TRANSAMINASES ELEVATED OR NORMAL - INTERMITTENT ELEVATIONS transaminases - progress to CIRRHOSIS in UP TO 20% - increased Risk of HEPATOCELLULAR CARCINOMA Extrahepatic Manifestations - Heme: Essential Mixed Cryoglobulinemia i. circulating immune complexes deposit in SMALL TO MED VESSELS + assoc w/low SERUM COMPLEMENT LEVELS ii. PALPABLE PURPURA, ARTHRALGIAS, RENAL COPMLICATIONS - Renal i. due to mixed cryoglobulinemia - MEMBRANOPROLIF GLOMERULONEPHRITIS - Skin i. Porphyria Cutanea Tarda - fragile skin, PHOTOSENS, VESICLES + ERUPTION ON DORSUM OF HAND**** ii. LICHEN PLANUS - Endocrine i. INC RISK OF DIABETES Classic Presentation: "57 y/o w/INTERMITTENT arthralgias for past x years,during this time has had INTERMITTENTLY ELEVATED LEVELS OF TRANSAMINASES. PE shows "VESICLES + EROSIONS ON DORSUM OF HANDS"

Clinical Features of Asbestosis

Clinical Presentation - prolonged asbestos exposure (shipyard, mining + construction workers, pipe fitters) - sx develop >20 years after exposure - *progressive dyspnea (over months), bibasilar end inspiratory crackles + clubbing* - *cough, sputum, wheezing = UNCOMMON* - can see *signs of cor pulmonale in adv. disease - peripheral edema, hepatojugular reflux, JVD, and/or right ventricular heave* Diagnostic Evaluation - History + clinical findings of exposure (i.e. *pleural plaques* on chest imaging - PATHOGNOMONIC) - insterstitial fibrosis on imaging or histology &/or pulmonary function tests with restrictive pattern

Asbestosis

Clinical Presentation - prolonged asbestos exposure - shipyard, mining + construction workers, pipe fitters - sx develop > 20 years after initial exposure - progressive dyspnea over months, *bibasilar end inspiratory crackles*, *clubbing* - *but no cough, sputum, wheezing* - inc risk for malignancies - ie..e I. bronchogenic carcinoma - more common if CONCURRENT Hx OF SMOKING ii. malignant pleural mesothelioma - will see unilateral pleural abnormality + large pleural effusion on CXR Diagnostic Evaluation - PLEURAL PLAQUES ON CHEST IMAGE - PATHOGNOMONIC - bibasilar reticulonodular infiltrates (classic ILD), honeycombing (cystic areas surrounded by interstitial infiltrates), w/PFTs showing restrictive pattern

Acute urticaria

Clinical Presentation - well circumscribed + raised, erythematous plaques - lesions can be oval, round, serpiginous up to several centimeters in diameter - *intense pruritis* - *lesions worsen over mins to hours then disappear within 24 hours* Etiologies - infections -viral, bacterial, parasitic - IgE mediated - antibiotics, insect bites, latex, food, blood products - Direct mast cell activation - narcotics, muscle relaxers, radiocontrast medium - NSAIDs - idiopathic Pathology - due to *mast cell activation in superficial dermis - localized swelling in upper layers of skin* - *can be accompanied by angioedema - mast cell activation in deeper dermal + subcutaneous tissues (face, hands, buttocks); present as NON pitting + NON pruritic edematous swelling involving subcutaneous tissues, abdominal organs, or upper airway* Acute vs chronic - acute lasts <6 weeks whereas chronic lasts > 6weeks

Clinical Features of Severe Pancreatitis

Clinical Presentation i. fever, tachycardia, hypotension ii. dyspnea, tachypnea, &/or basilar crackles iii. abd. tenderness +/or distention iv. Cullen sign: periumbilical bluish coloration indicating hemoperitoneum v. grey turner sign - reddish-brown coloration around flanks indicating retroperitoneal bleed - "iv" + "v" represent HEMORRHAGIC PANCREATITIS - characterized by NECROSIS + RETROPERITONEAL HEMORRHAGE Associated w/Inc Risk of Severe Pancreatitis i. age > 75 ii. obesity ***** iii. alcoholism **** iv. CRP > 150mg/dL at 48 hours after presentation v. Rising BUN + Cr in first 48 hours vi. CT/MRCP - w/PANCREATIC NECROSIS + EXTRAPANCREATIC INFLAMMATION vii. CXR - PULMONARY INFILTRATES or PLEURAL EFFUSION Complications i. Pseudocyst ii. peripancreatic fluid collection iii. necrotizing pancreatitis - infected pancreatic necrosis - is diffuse infection of necrotic pancreatic tissue - usually occurring 1-2 weeks after episode of acute pancreatitis*** - pres: SPIKING FEVERS, LEUKOCYTOSIS, SHOCK + ORGAN FAILURE - tx of choice = SURGICAL DEBRIDEMENT iv. ARDS (CAN HIT LUNGS) v. ARF **** (CAN HIT LIVER) vi. GI bleed (CAN HIT GI) Presentation: man w/severe abd pain + vomiting. Pain is constant , nagging, localized to upper abdomen, radiating to back. Drinks large amounts alcohol. BP is 80/60 suddenly, o2 sat is 92%, exam shows normal JVP, bilateral crackles heard on lung auscultation. Urine output is 8mL/hr. Leukocytosis w/low platelets of 120,000. ***KNOW CONCEPT OF HYPOTENSION IN SEVERE PANCREATITIS + LESSER DEGREE IN ACUTE PANCREATITIS (TEST Q***) - CAUSE OF LOCAL RELEASE OF ACTIVATED PANCREATIC ENZYMES that enter VASCUAL SYSTEM + INC VASCULAR PERMEABILITY WITHIN + AROUND THE PANCREAS. Cause large fluids to GO FROM VASCULATURE TO RETROPERITONEUM. - Tx of HYPOTENSION IN SEVERE PANCREATITIS = SEVERAL LITER IV FLUID

Pt with recurrent pericarditis treated with NSAIDs and Steroids. The pericarditis pain is resolved. The best medication for prophylaxis is?

Colchicine

What is the mechanism of urticaria in a patient when exposed to the cold?

Cold cryoglobulin or IgE mediated

Patient with UC diagnosed recently. wtd in regards to CRC screening?

Colonoscopy 8 years later then q 2 years

35 year old asymptomatic patient with father with CRC at age 65. wtd?

Colonoscopy at age 50

40 year old asymptomatic patient with father who had Colon cancer at age 55 years. wtd?

Colonoscopy now then q 5 years

young patient with family history of FAP. wtd?

Colonoscopy starting age 16 years

35 year old asymptomatic patient has a father who had CRC at age 45. wtd?

Colonscopy now

Acne Vulgaris

Comedonal Acne - closed or open comedones on forehad, nose, and chin - Tx: *topical retinoids* I. if inflammatory acne (papules <5 mm) and pustules, *OR NO AVAIL add BENZOYL PEROXIDE* ii *if still no avail, add TOPICAL ANTIBIOTICS (i.e. erythromycin, clindamycin)* iii. if still no avail and is nodular (cystic) acne or severe Inflammatory Acne - *oral antibiotics - tetracyclines*

Clinical Features of Interstitial Lung Diseases

Common Etiologies 1. sarcoidosis, amyloidosis, alveolar proteinosis 2. vasculitis - granulomatosis with polyangitis 3. infections - Fungal, Tb, viral pneumonia 4. Occupational + Environmental - i.e. silicosis, asbestosis, Hypersensitivity Pneumonitis 5. CT disease - SLE, scleroderma 6. Idiopathic Pulmonary Fibrosis, Interstitial Pneumonia 7. Cryptogenic Organizing Pneumonia Clinical Presentation - progressive exertional dyspnea or persistent dry cough - >50% w/sig smoking history - lung examination - *fine crackles during mid-late inspiration, possible digital clubbing* Lab/Imaging - CXR - reticular or nodular opacities - classic ILD (we saw in description of Asbestosis as well) - High Res CT - fibrosis, honeycombing, traction bronchiectasis - *Pulmonary Function tests - RESTRICTIVE PATHOLOGY: normal or INC FEV/FVC ratio, DEC DLCO, DEC TLC, DEC RV, INC A-a GRADIENT* - Resting ABGs - normal or show slight hypoxemia - *Exertion Usually cause significant hypoxemia due to diffusion limitation - THIS IS MECHANISM OF HYPOXEMIA - DIFFUSION LIMITATION (V/Q Unaffected)* Pathphysiology - increased deposition of collagen around alveoli giving scarring and *INC ELASTICITY + DEC COMPLIANCE* How To Dx - First CLINICALLY + PFTs - IF UNSURE, LUNG BX

Raynaud's Phenomenon

Common pathophysiology - due to increased vascular response to cold temperature or emotional stress; skin can be white or blue Primary Raynaud Phenomenon - Cause I. no underlying cause - Clinical Presentation I. usually *women age < 30* + *SYMMETRIC ATTACKS* ii. *no tissue injury* iii. negative ANA + ESR - Management I. avoid aggravating factors ii. *Dihydropyridine CCB (nifedipine, amolodipine) for persistent sx* Secondary Raynaud Phenomenon - Cause I. *CT disease (SLE, scleroderma)* ii. Occlusive vascular conditions (thromboangitis obliterans) iii. sympathomimetic drugs iv. vibrating tools v. hyperviscosity syndromes - Clinical Presentation I. usually *men > 40*+ *ASYMMETRIC ATTACKS* ii. sx of underlying disease iii. *tissue injury or digital ulcers* iv. *abnormal nail fold capillary examination - look for dilated or dropout vessels - these indicate oncoming CT disease* - Next step if suspecting secondary Raynaud's - *workup for ANA antibodies to identify host of possible CT diseases + Inflammatory markers such as ESR + CRP* VS *if you suspect thrombangitis obliterans* as cause: think of *vasculitis small + medium arteries; age < 45 AND smoker; distal extremity ischemia, ulcers, or gangrene; next step = arteriogram* - Management I. evaluate + treat underlying disorder ii. *DIhydrophyridine CCB (nifedipine, amolodipine) for persistent sx* ; *asprin for pts at risk for digital ulceration*

Define herpetic whitlow?

Common viral infection of the hand. Caused by either type 1 or 2 HSV, & is self-limiting. Healthcare workers who come into direct contact with infected orotracheal secretions are at increased risk for developing whitlow

plateau pressure + peak pressure diagram and concept

Concepts - these measurements shown are taken in mechanically ventilated patients - peak airway pressure - the maximum pressure measured as the tidal volume is being delivered - peak airway pressure = resistive pressure + plateau pressure - plateau pressure = pressure measured during *inspiratory hold maneuver - this eliminated pulmonary airflow thereby making resistive pressure 0* - you are left with plateau pressure i. also *plateau pressure = pressure after inspiratory hold after tidal volume place = elastic pressure + PEEP* - Elastic pressure - product of lung's elastance+ volume of gas delivered - *elastic recoil is inversely proportional to COMPLIANCE - therefore as compliance dec, recoil pressure inc* i. example = pulmonary fibrosis - decreased compliance - gives inc. elastic pressure - gives Inc plateau pressure - *Inc peak pressure associated with unchanged plateau pressure* - signifies: i. pathology that has increases Resistive pressure - means AIRWAY RESISTANCE INCREASED - due to: *i. bronchospasm, ii. mucous plug, iii. endotracheal tube obstruction* - *elevation of both peak + plateau pressures* i. signifies that resistive pressure is still same; PEEP is what we administer so its the same: *signifies that ELASTIC PRESSURE INCREASED* - *therefore COMPLIANCE DECREASED*** - causes of dec compliance = *i. PULMONARY EDEMA, ii. PULMONARY FIBROSIS, iii. ATELECTASIS, iv. PNEUMONIA, v. RIGHT MAINSTEM INTUBATION*

Patient presents with painless broad plaques in groin and on penis. DX?

Condyloma lata- do RPR

Pt with chronic a fib on warfarin going for minor surgery. wtd?

Continue warfarin

How do you treat digoxin toxicity?

Correct electrolytes BB Lidocaine or phenytoin Digoxin binding antibodies- only in life threatening situations NO QUINIDINE OR PROCAINAMIDE

How do you measure the corrected serum calcium?

Corrected Ca = (measured total Ca) + 0.8 (4.0 - Serum albumin) *Pts with hypoalbuminemia can have decreased total serum calcium. Thus, the corrected level will be higher

What is a main complication caused by status epilepticus?

Cortical laminar necrosis due to excitatory cytotoxicity

Patient presents with well defined reddish lesion in the axilla, groin and toe webs. Most likely caused by what type of bacteria? What do you see under woods lamp? TX?

Corynebacterium Fluorescence with bright red Treat with oral erythromycin

Nephrotic Syndrome

Criteria 1. proteinuria > 3.5 g/day 2. hypoalbuminemia 3. hyperlipidemia + lipiduria (fatty casts) 4. edema (bilateral lower extremity edema) Presentation: - weight gain + facial edema that resolves but at end of day, ankle edema - the hypoalbuminemia will cause peripheral edema BUT NOT PULMONARY EDEMA (vs Nephritic syndrome) b/c alveolar vessels have greater permeability to albumin thereby dec the gradient + inc lymphatic flow to rid extra fluid - protein 4+ on dipstick; fatty casts See - hyperthromboembolic events (*HYPERCOAGUBILITY - most likely cause of death*) b/c (*MOST LIKELY RENAL VEIN THROMBOSIS*) I. loss of Prot C +S ii. inc platelet aggregation iii. hyperfibrinogenemia iv. impaired fibrinolysis - protein malnutrition - iron resistant microcytic hypochromic anemia (due to loss of ferritin) - Vit D deficiency (due to inc urinary excretion of cholecalciferol binding protein) - dec thyroxin levels due to loss of thyroxine binding globulin - inc susceptibility to infection

Pt with diarrhea and right lower quadrant pain. temp 101F and has ulcer seen on tongue. Most likely diagnosis?

Crohn's

Common causes of Diarrhea in Patients with AIDS

Cryptosporidium - *CD4 <180* - *severe watery diarrhea*, low grade fever, weight loss Microsporidium/isosporidium - *CD4 < 100* - *fever is rare*, weight loss, crampy abdominal pain, watery diarrhea Mycobacterium Avium Complex - *CD4 < 50* - watery diarrhea - *HIGH FEVER > 102.2* - weight loss CMV - *CD4 < 50* - *frequent, small volume diarrhea* - *hematochezia (only AIDS diarrhea w/blood)* - *abdominal pain* - low grade fever, weight loss - *Tx = Ganciclovir* UWORLD STATEMENT: *any patient with HIV who has bloody diarrhea + CD4<50 should have COLONSCOPY WITH BX to look for CMV. ANY PT WITH ACTIVE CMV NEEDS OCULAR EXAM TO R/O CONCURRENT RETINITIS*

Pt with HIV and T cells <200 presents with chronic diarrhea and weight loss. No fever or bloody stool. Most likely diagnosis? What test to do diagnosis? Treatment?

Cryptosporidium Stool AFP will show small round organisms If stable treat with hydration if not give Nitazoxanide

75 year old F brought to ER with LLQ pain for the past 2 days. Last BM was a week ago. Exam reveals abdominal distention with tenderness without rebound. Bowel sounds are heard. KUB with colonic dilation with distention of sigmoid loop. What would you see on CT? Most likely diagnosis? Treatment?

Ct: partial obstruction of sigmoid with whirl sign Sigmoid Volvulus Flex sig - only go to surgery if in shock

Type II Hypersensitivity reactions are mediated by _____. Examples_____.

Cytotoxic- IgG/IgM Hemolytic reactions, Goodpasture's, hyperacute graft rejection NO Antigen-Antibody complex deposition

What is most common cause of gross lower GI bleed in adults?

DIVERTICULOSIS ***** TEST Q

Patient presents with some abdominal discomfort and abdominal xray reveal calcification in the mid abdomen level. What complication will this patient most likely develop? What is the most likely diagnosis? Treatment?

DM Chronic pancreatitis treat empirically with high dose pancreatic lipase enzymes for 6 weeks; if doesn't improve Pregabalin

For early MEN-2A syndrome what is the most effective screening measurement?

DNA testing *Serum calcium measurements after total thyroidectomy

Effective TX for dermatitis herpetiformis?

Dapson & a gluten free diet (often associated with celiac DS)

What is the treatment for dermatitis herpetiformis?

Dapsone

Pt post bullet injury with extensive bowel resection presents couple of months later with greasy foul smelling stools and weight loss of about 8 lbs. Fecal fat is 20 g/day. PT/INR 1.2. D-xylose excretion WNL. Betacarotene is low. Most likely etiology of diarrhea?

Decreased bile acids

Rate control and anticoagulation in a fib compared to cardioversion has shown?

Decreased stroke and hospitalizations

Type 1 Hyperlipidemia

Defect Familial decrease in lipoprotein lipase or Apo Protein C II Have eruptive exanthomas Content of CM with TGAs

Type V Hyperlipidemia

Defect familial Lipoprotein lipase or Apo C II Eruptive xanthomas VLDL + CMs with TGAs

Type III Hyperlipidemia

Defect is abnormal Apo E Palmar or Tuberous Xanthomas- Yellow Palms Content of IDL with LDL+TGAs

Type II Hyperlipidemia

Defect is decrease in LDL receptors Tendon Xanthomas Content of CM with LDL

Type IV Hyperlipidemia

Defect is familial decrease in Lipoprotein lipase or Apo C II Eruptive xanthomas VLDL with TGAs

Define osteomalacia & give typical lab values?

Defective mineralization of the organic bone matrix. Results in a secondary hyperparathyroidism. Hypocalcemia, hypophosphatemia, increased ALK-P & PTH, decreased Vit. D

Nonalcoholic Fatty Liver Disease

Definition - Hepatic Steatosis on imaging or biopsy - Exclusion of Sig Alcohol use - exclusion of other causes Clinical Features - Mostly asymptomatic - metabolic syndrome - +/- steatohepatitis (AST/ALT ratio < 1) (mild elevations of AST + ALT)**** - hyperechoic texture on US **** - hepatic fibrosis seen in 40% of individuals in NAFLD Tx - diet + exercise w/WEIGHT LOSS - Consider bariatric surgery if BMI > 35****

Nonalcoholic Fatty Liver Disease

Definition - hepatic steatosis on imaging or bx - exclusion of sig alcohol use - exclusion of other causes fatty liver CFs - mostly asymptomatic - metabolic syndrome - central obesity, DM, hyperlipidemia, hypertension - +/- steatohepatitis (AST/ALT ratio <1 but elevated; but <300) - hyperechoic texture on US Patholophysiology - can range from bland steatosis to inflammation + necrosis (steatohepatitis) to fibrosis + cirrhosis. - histologically - resemble alcohol induce liver disease - MACROVESICULAR FAT DEPOSITION - due to inc. transport of Free FA from adipose tissue to lvier- Dec oxidation FFA in liver, dec clearance of FFA from liver (due to dec VLDL) - ALL CAUSED BY PERIPHERAL INSULIN RESISTANCE ***** (TEST Q) + INC PERIPHERAL LIPOLYSIS (TEST Q) + TG SYNTH + HEPATIC UPTAKE FA + PRODUCTION PROINFLAMMATORY CYTOKINES SUCH AS TNF ALPHA Treatment - Diet + exercise - Consider bariatric surgery if BMI >35

Hypertrophic Osteoarthropathy

Definition - 2 things I. clubbing 2. sudden onset joint arthropathy - usually *wrists + hand joints* - both in CHRONIC SMOKER Cause - when due to pulmonary reasons, called hypertrophic pulmonary osteoarthropathy - attributable to underlying lung disease like: *lung cancer (MOST COMMON), tuberculosis, bronchiectasis* First step on seeing hypertrophic osteoarthropathy I. *CHEST X RAY - TO RULE OUT LUNG MALIGNANCY*

What is hallmark of hypovolemic hypernatremia?

Dehdyration - patients such as this will show I. *INC URINE OSMOLARITY + INC SERUM OSMOLARITY*

Treatment of pyelonephritis

Diabetic patients with pyelonephritis - treat with IV antibiotics for 48-72 hours - ceftriaxone - if responsive, after 48-72 hours, switch to PO TMP SMX/fluoroquinolone for 10-14 days *all of above with exception of image is a test question about diabetic pyelonephritis management*

Lynch Syndrome (hereditary Non polyposis Colorectal cancer - HNPCC)

Diagnosis given by criteria: 1. at LEAST 3 relatives w/colorectal cancer, one of whom must be 1st deg relative of the other 2. 2. involvement of 2 or more generations 3. at least one case diagnosed BEFORE AGE 60 4. FAP has been excluded 2 subtypes 1. Hereditary Site Specific Colon Cancer i. LYNCH SYNDROME 1 2. Cancer Family Syndrome or Lynch Syndrome II i. HIGH ASSOC W/EXTRA COLONIC TUMORS - MOST COMMON IS ENDOMETRIAL CA. (43% WOMEN GET IT W/LYNCH II) - EVALUATE FOR THIS **** (TEST Q****)

What are 2 options once ESRD develops?

Dialysis or Renal transplantation (renal transplantation) Advantages of Renal Transplantation of over dialysis are: I. better survival + quality of life ii. anemia, bone disease, HTN persist in spite of dialysis; there are better controlled w/transplantation iii. transplant patients have return of normal endocrine, sexual, and reproductive functions, enhanced energy levels iv. improvement of autonomic neuropathy in diabetics Priorities in terms of donors: living related donor preferred, then living non related donor, then finally cadaveric donor

What can cause lung pleural calcifications?

Diff Dx = 1. asbestosis (CLASSIC PLEURAL PLAQUES - PATHOGNOMONIC) 2. silicosis (egg shell calcifications of hilar lymph nodes) 3. hemothorax 4. empyema

Pt comes in to the ED and says that he is on a medication for atrial fibrillation but can't remember the name. He is complaining of anorexia and weight loss. What medication do you suspect he is on?

Digoxin

78 year old M with SOB and Cr 1.5 on Digoxin and Warfarin. EKG with HR of 96/min, looks regular with retrograde 'P' wave. Dx?

Digoxin toxicity- paroxysmal atrial tachycardia with block

What can cause gum hypertrophy?

Dilantin or Nifedipine

DIaltiazem effects on calcium

Diltiazem - CCB that *can cause constipation* - *does not cause other sx of hypercalcemia such as polyuria + polydipsia*

60 year old patient presents with fever, leukocytosis and LLQ abdominal pain. Most likely diagnosis?

Diverticulitis

Pt with PAD schedules for bypass surgery. On exam patient wheezing +. HTN has been controlled to 150/90 from 170/110. wtd?

Dobutamine stress test.

PCOS (polycystic ovary syndrome)

Dx Criteria - 2 or more of 3 of following I. *androgen excess* - biochemical or clinical (*hirsutism, acne, androgenic alopecia*) ii. *oligo or anovulation - MENSTRUAL IRREGULARITY* iii. Polycystic Ovaries on US: >12 follicles 2-9 mm in diameter and/or ovarian volume > 10mL - *if cannot be dx clinically* then do *PELVIC US* Treatment Options - *weight loss* I. reduce hyperandrogenism + improve insulin resistance - combines hormonal OCPs for *hyperandrogenism (block adrenal androgen secretion, LH, inc SHBG) + menstrual dysfunction + progestin decreases effects of endometrial hyperplasia* - *clomiphene citrate - for inducing ovulation* - *metformin - if coexisting DMTII* I. *if glucose 2hr is >200 - overt DMTII is dx and GIVE METFORMIN* - *spironolactone - aldosterone + androgen receptor antagonist tha reduces hirsutism* because ****1st line Tx = WEIGHT LOSS + COMBINED OCPs* Comorbidities - overweight/obesity - glucose intolerance/DM - dyslipidemia - OSA - endometrial hyperplasia/cancer

Patient presents with steatorrhea and epigastric pain. You do an EGD and find multiple ulcers in the duodenal bulb and stomach. What is the most likely diagnosis? How do you diagnose?Once you have diagnosis what do you do?

Dx: Zollinger Ellison Syndrome- Associated with MEN I check fasting gastrin levels, if non-diagnostic then you can give IV secretin--> increase gastrin to >1000 Do CT scan or somatostatin receptor scintigraphy to localize tumor

What are the 5 strongest modifiable risk factors for MI in descending order?

Dyslipidemia Smoking Psychosocial stressors DM HTN

63 y/o M comes to physician with 2 day hx of ever +left sided scrotal pain. Pain has progressed in severity + radiates to flank. He has also had increased urinary frequency + urgency along with dysuria. His temp is 38.1 (100.8F). Blood pressure is 130/75 mm Hg, pulse is 86/min and RR of 15. PE shows left scrotal swelling + tender scrotal mass. There is no urethral discharge. Rectal exam shows a tender prostate. Lab studies show WBC of 14,000 with left shift. Urinalysis shows bacteriuria + pyuria. Which of the following is the most likely organisms responsible for patient's findings? E. coli, pseudomonas, chlamydia trachomatis, gonoccus, staph aureus?

E. coli

Pt presents with bloody diarrhea. Ate hamburger about 36 hours ago at a fair. Platelets are low. Most likely diagnosis? Best way to establish diagnosis? Treatment?

E. coli O157:H7 MacConkey's agar with sorbitol No antibiotics- if renal failure may need to place on HD prn and can possibly use Eculizumab

What are the most common organisms to cause SBP?

E.coli (MCC), Klebsiella, S. pneumo

Pt who has been taking Naproxen for arthralgia for the past couple of weeks presents with complaints of fatigue and bright red blood per rectum. He says that 1 week ago he had black tarry stools. Hb 9 g. Wtd?

EGD

Pt presents with pain on swallowing for more than 10 days. Wtd? Differential diagnosis?

EGD - pill esophagitis, radiation therapy, infections

What must you do prior to surgical myotomy in a patient with Achalasia?

EGD for biopsies to rule out secondary achalasia due to lymphoma or cancer

HIV +ve patient with oral thrush complains of odynophagia. He was treated with fluconazole without improvement. What to do next?

EGD to rule out CMV or HSV esophagitis

Pt presents with palpitations and EKG shows a fib. After BB pt feels better and repeat EKG reveals shortened PR interval. wtd next?

EPS and ablation of errant tract

Patient with pancreatitis found to have common bile duct dilated. What will you do next?

ERCP

Pt with severe pancreatitis, US negative for gall stones. Triglycerides normal. What will you do next?

ERCP

Pt with severe pancreatitis with increased AST and dilated CBD on US is on antibiotics in MICU. wtd next?

ERCP and remove stone. Once inflammation subsides and enzymes decrease can do cholecystectomy

In a patient with severe pancreatitis who has a history of severe pancreatitis 2x in the past year is found to have biliary sludge in GB. Wtd?

ERCP for biliary sampling to r/o microlithiasis

Pt with UC in remission presents with elevated LFTs and bilirubin. US with focal dilatations. wtd? most likely diagnosis?

ERCP or MRCP to diagnose Primary sclerosing cholangitis and brush biopsy to rule out cholangiocarcinoma

24 year old with history of UC for the past 4 years presents with jaundice and fever. Exam reveals jaundice, hepatomegaly. Bilirubin 3.5, Alk phos 950. AST 240, ALT 258. ANA negative, ASMA negative, AMA negative, P-ANCA +. The most appropriate diagnostic test is?

ERCP/MRCP will reveal beading and focal dilatation of biliary tree

What would be the next step if you find 1.5 cm pancreatic cyst with thickening of cyst wall?

EUS

What would be the next step if you find 2 cm on CT abdomen, 7 mm duct?

EUS

What would be the next step if you find a 3 cm pancreatic cyst on CT abdomen?

EUS

diphtheria is what kind of toxin

EXOTOXIN

Lyme Disease

Early Localized (days - 1month after tick bite) - *erythema migrans* - only thing needed for diagnosis of early lyme dz(80%) - fatigue, malaise, lethargy - mild headache, neck stiffness - myalgias + arthralgias - low fever (<100F) Early disseminated (weeks - months after tick bite) - *TREAT WITH CEFTRIAXONE THE CARDIAC + NEUROLOGIC MANIFESTATIONS* - *carditis* - AV block, cardiomyopathy - *neurologic* - unilateral or bilateral cranial nerve defects (*bilateral bell's palsy*), meningitis, encephalitis -*muscular* - migratory arthralgias - *conjunctivitis* - *skin - multiple erythema migrans* - regional lymphadenopathy Late or chronic (months-years after tick bite) - *muscular* - arthritis - *Neurologic* - *encephalomyelitis, peripheral neuropathy* - borrelia burgdorferi is spirochete that is responsible - transmitted by *ixodes scapularis - deer tick* - recent travel hx to NE or upper Midwestern parts of US i.e. Massachussettes - *NEVER ANY HEMATOLOGIC ABNORMALITIES - IF YOU SEE ANY, THINK SOME OTHER DZ* - *tx = doxycycline - prevents simultaneously human granulocytic anaplasmosis (also carried by ixodes scapularis)* I. CI in *children < 8, pregnant women, lactating women b/c permanent discoloration of teeth + retardation of skeletal development in exposed children*; *GIVE AMOXICILLIN FOR THESE PTS* ii. may see *dry cornea* due to poor eyelid closure + reduced tearing; Tx = *ARTIFICIAL TEARS + EYE PATCHING* - sx resolve within 3 weeks of tx

What should first be initiated in a pt with a high clinical suspicion of acute PE?

Early empiric anticoagulation (IV Heparin infusion) if there is no contraindication

HIV +ve patient with oral thrush complains of odynophagia. wtd?

Empiric treatment with fluconazole or itraconazole

What infections are you at high risk of if you have low antibodies?

Encapsulated organisms: SHiN S. pneumo, H. influenza, N. meningitides

When can you see splinter hemorrhages?

Endocarditis Trichinellosis- people who hunt bears

Types of Endocarditis

Endocarditis in general Inflammation of the heart valve, usually secondary to infection - usually left-sided - unless patient has *hx of IVDU* - think *right-sided* due to infected venous blood returning first to the right-heart + *involving tricuspid valve* •Types - Acute endocarditis i. associated with fever and rapid degradation of heart tissue ii. caused by: *Staphylococcus aureus (IVDU)* iii. can infect healthy or damaged valves (e.g. from *mitral valve prolapse or rheumatic heart disease*) iv. *mitral valve prolapse* = *most common predisposing cardiac condition* acute form - Subacute bacterial endocarditis i. slower onset of symptoms with less severe symptoms ii. caused by: *Enterococcus (bacteremia most commonly caused by GI/GU interventions)* (growth in 6.5% NaCl differentiates it from S. viridans); strep viridans (*oral interventions)*; staph epidermidis (*prosthetic valves*); Strep bovis (*secondary to UC or colorectal cancer*); Eikenella corrodens (dental manipulation) - Marantic endocarditis = paraneoplastic syndrome (sterile vegetations on the valves as a result of ↑ coagulability secondary to ↑ mucin production - same process underlying Trousseau's sign) i. primary cancers in GI tract ii. may produce emboli to periphery ◾note: "marantic" derives from "marasumus" wasting associated with cancer - Libman-Sacks endocarditis i. caused by systemic lupus erythematous (SLE) ii. remember: SLE : LSE iii. usually asymptomatic but mitral regurgitation murmur can be heard •Complications ◦chordae tendineae rupture ◦emboli ◦glomerulonephritis ◦suppurative pericarditis

What is the MC extracolonic cancer associated with HNPCC in females?

Endometrial cancer

Elderly woman with alternating constipation and diarrhea. Rectal exam reveals hard stool in left quadrant. wtd?

Enema

Pt with diarrhea while vacationing in Mexico. No blood, no fever. Stool culture shows normal flora. Most likely diagnosis? treatment?

Enterotoxigenic E. coli Treat with Loperamide +/- azithromycin for 3 days

Young patient with history of food impaction which has happened several times before. EGD reveals crepe paper sign. Patient also has history of seasonal allergies. Most likely diagnosis? Best treatment?

Eosinophilic esophagitis- also can see friable mucosa or concentric rings Treat with PPI; if doesn't work swallow budesonide

Pt presents with diarrhea. Has history of food intolerance, nausea, vomiting and abdominal pain. Steatorrhea positive. Ova, cysts and parasites negative. Peripheral eosinophilia positive. Most likely diagnosis? Treatment?

Eosinophilic gastroenteritis Treat with steroids- must rule out parasitic infection before starting steroids

Blastomycoses

Epidemiology - south/south-central states, Mississippi + Ohio River Valleys, Upper Midwest states, Great lakes states - *Disseminated disease may occur even in immunocompetent patients (NOT THE CASE IN HISTOPLASMOSIS - DIFFERNTIATOR)* CFs - Lung: acute + chronic pneumonia - Skin: wartlike lesions, *CLASSIC VERRUCOUS OR NODULAR LESIONS WITH VIOLACEOUS HUE* - Bone: *osteomyelitis (lytic bone lesions)* - GU: *prostatitis*, epididymo-orchitis - CNS: *meningitis, epidural or brain abscess* - most common = *SKIN, BONE, PROSTATE* Dx - culture - microscopy - *URINE Ag TESTING* Tx - oral itraconoazole + if too severe, amphotericin B - associated with contact with *soil or rotting wood*. - *UWORLD/TEST PRESENTATION: low grade fever, violaceous skin lesions, skin scrapings showing yeast, in the Midwest region, - *Mississippi* - *IF YOU SEE HILAR ADENOPATHY, THEN YOU KNOW IT IS NOT BLASTOMYCOSES BUT HISTOPLASMOSIS*

Acute HIV infection

Epidemiology - typically presents 2-4 weeks after exposure Clinical Features - *mononucleosis like syndrome* (i.e. fever, lymphadenopathy, sore throat, arthralgias) - generalized macular rash - GI sx - *presence of mucocutatneous lesions (buccal lesion) is classic, prolonged diarrhea (30%), or skin rash (50%)* Dx - viral load *markedly elevated >100,000)* - HIV Ab may be *negative due to lack of yet seroconversion* - CD4 count may be normal - HAVE A LOW THRESHOLD FOR HIV TESTING - IF SX LINE UP A LITTLE AND HIV TESTING IS NEXT CHOICE - PICK IT DUE TO LEAST EXPENSE Management - combo of antiretroviral therapy - partner notification - consider secondary prophylaxis

Where does basal cell carcinoma arise from?

Epidermal basal cells

Pt with V fib collapses in the ER. Pt is defibrillated successfully but a short while later goes into V fib and is shocked twice more. wtd next?

Epinephrine then amiodarone if necessary

Types of Thyroid Malignancies

Epithelial (thyroid follicular cells) (90-95%) - Papillary (>70%) i. spread via lymphatic dissemination - Follicular i. spread via hematogenous route - Anaplastic i. occurs in older patients ii. present with RAPIDLY ENLARGING THYROID MASS iii. worst prognosis of all Parafollicular Cells (3-4%) - medullary thyroid cancer i. sporadic in 80% Other cells (<5%) - lymphoma (think in association of rapidly enlarging gland in someone with preexisting hashimoto's) - sarcoma - mets

Pt with bipolar disorder treated with Lithium presents with erythematous skin lesions which have punctate bleeding spots when peeled. Dx and Tx?

Erythematous psoriasis d/c Lithium

Patient presents with severe retrosternal chest pain which is worse with swallowing and breathing. CXR with left sided pleural effusion and subcutaneous emphysema. Most likely diagnosis? How to diagnose?

Esophageal rupture. Gastrograffin swallow study

Compression fracture of vertebrae (vertebral fracture)

Etiologies - trauma - *osteoporosis + osteomalacia* (MOST COMMON CAUSES OF NON TRAUMATIC VCF) I. chronic steroid use - infection (i.e. osteomyelitis) - bone metastasis - metabolic (i.e. hyperparathyroidism) - paget disease Clinical Presentation - Chronic/gradual VCF I. painless ii. progressive kyphosis iii. loss of stature - Acute VCF I. *acute Low back pain + dec spinal mobility* ii. *pain inc w/standing, walking, lying on back* iii. *POINT TENDERNESS AFTER STRENUOUS ACTIVITY ON SPINAL REGION* iv. *can present with sudden onset low back pain + dec spinal mobility post bending, coughing, or lifting* Complications - inc risk for *future fractures* - *hyperkyphosis*, possible leading to *protuberant abdomen, early satiety, weight loss, DEC RESP CAPACITY* - *acute intense pain* - *local spinal tenderness* - *postmenopausal or senile osteoporosis, steroid treatment* - PREDISPOSING FACTORS

Clinical features of Primary Adrenal Insufficiency

Etiology - Autoimmune (MOST COMMON PRIMARY FORM IN US) - infections (i.e. tb (MOST COMMON PRIMARY FORM WORLWIDE), HIV, disemminated fungal) - hemorrhagic infarction (meningococcemia, anticoagulants) - Metastatic cancer (i.e. lung) Clinical Presentation - Acute I. most commonly in shock ii. abdominal tenderness with deep palpation (unclear etiology) iii. unexplained fever iv. N/V/weight loss + anorexia v. *hyponatremia, hyperkalemia, HYPERCALCEMIA, + eosinophilia* - chronic I. fatigue, weakness, anorexia ii. GI - N/V/abd pain iii. Weight loss iv. *hyperpigmentation or vitiligo* v. *hypotension, hyponatremia, hyperkalemia, HYPERCALCEMIA* vi. *ANEMIA+ eosinophilia* ***REMEMBER HYPERKALEMIA = METABOLIC ACIDOSIS, NO ANION GAP***

Clinical Features of Malignant Biliary Obstruction

Etiology - cholangiocarcinoma - pancreatic or hepatocellular carcinoma - metastatic cancer (colon, gastric) Clinical Presentation - Jaundice - can be painless - pruritis, weight loss, ACHOLIC stools w/dark urine - exam - normal or URQ mass, tenderness, or hepatomegaly - LAB****: INC DIRECT BILIRUBIN (ALL CLIN PRES ARE MANIFESTATIONS OF THIS), INC ALK PHOS, INC GGT, NORMAL AST + ALT Evaluation - abdominal imaging - US OR CT - 2nd line if US or CT not good = ERCP OR MRCP Diff Dx 1. acute choledocholithiasis I. INC ALK PHOS ii. INC GGT iii. NORMAL AST + ALT iv. VERSUS CHOLANGIOCARCINOMA OR PANCREATIC + HEPATOCELLULAR CARCINOMA: ACUTE ONSET RUQ PAIN/EPIGASTRIC PAIN (vs in pancreatic cancer pain is chronic, worsens in supine pos + at night) 2. Primary Biliary Cirrhosis - present w/fatigue, itching, jaundice, weight loss, and elevated ALK PHOS ONLY + ANTI MITOCHONDRIAL ABs ELEVATED

Define pulsus paradoxus and list the top 3 conditions its seen with?

Exaggerated fall in systemic BP > 10 mm Hg during inspiration 1. Cardiac tamponade/pericardial effusion 2. Asthma 3. COPD

45 year old Type II DM F with chest pain. EKG negative. What test is unlikely to be accurate in her?

Exercise stress test

45 year old F with vague chest pressure on exertion. EKG normal. Exercise stress test with nonspecific changes. The next step is?

Exercise stress test with imaging

Causes of Vitamin D Induced Hypercalcemia

Exogenous - non prescription: i. supplemental megadoses or fortified foods - Prescription i. Vitamin D2 or D3 ii. Calcidiol (25-0H-Vitamin D) iii. Calcitriol (1,25-OH-Vitamin D) iv. Calcipotriene (topical vitamin D derivative) Endogenous (both of the listed cause conversion of 25-OH Vitamin D to 1,25 OH Vitamin D) - Granulomatous Diseases (i.e. sarcoidosis) - lymphoma

Clues for Increasing index of suspicion for legionella Pneumonia

Exposure to possibly contaminated water - *recent travel* - esp hotel or cruise - contaminated potable water in hospitals/hursing homes Clinical Clues - fever > *102.2F* - *Bradycardia rel to high fever* - *Neurologic Sx* - *confusion* - *GI Sx - esp diarrhea* - unresponsive to Beta lactams + aminoglycoside *see confusion + gi diarrhea+ 102F + bradycardia - you have answer* Lab Clues - *hyponatremia* - *hepatic dysfunction - INC AST + ALT + maybe a little alk phos* - hematuria + proteinuria - *sputum gram stain - MANY NEUTROPHILS BUT FEW ORGANISMS* CXR - *UNILATERAL LUNG FINDINGS - patchy infiltrates +/- diffuse crackles over one lung field* Legionnaire's Dz - presentation of *atypical commjnity acquired pneumonia w/ GI (DIARRHEA, ABD PAIN, HEPATITIS) + NEUROLOGIC SX* - primary source = *water* - *hotels + cruise ships or w/water supply involved or air conditioner* - *hyponatremia, mild hepatitis, fever w/paradoxic bradycardia* - Dx - *GO TO = URINE AG TESTING - Tx = *AS SOON AS YOU SUSPECT - FLUORQINOLONE OR MACROLIDE*

What is the most important RF for developing SCC?

Exposure to sunlight (next would be chronic scars & chronic osteomyelitis)

45 y/o female comes to ED w/painful abd cramps + watery diarrhea w/ 10-20 bowel movement/day w/nocturnal bowel movements. PMH w/simliar issues - on lower GI endoscopy - DARK BROWN DISCOLORATINO OF COLON W/LYMPH FOLLICLES SHINING THROUGH AS PALE PATCHES

FACTITIOUS DIARRHEA due to LAXATIVE ABUSE diarrhea w/laxative = watery, inc frequency + volume, 10- 20 bowel movemens per day, nocturnal bowel movement + painful abd. cramps may be accompanying sx. Diagnosis - confirmed with characteristic biopsy - DARK BROWN DISCOLORATION OF COLON w/LYMPH FOLLICLES SHINING THROUGH AS PALE PATCHES (MELANOSIS COLI) - melanosis coli develops w/in 4 months of onset of laxative abuse. HIstological - PIGMENT IN MACROPHAGES OF LAMINA PROPRIA *** NOCTURNAL DIARRHEA - RULES OUT IBS IMMEDIATELY

What disease puts you ar the highest risk of colon cancer

FAP- begin screening at age 12 with sigmoidoscopy then at age 16 yearly colonoscopy

What is the best management for a patient with facial swelling, laryngeal edema and a history of C1 esterase inhibitor deficiency? What is the best long term management?

FFP Danazol or stanazol

What is the MC inheritied disorder causing hypercoagulability & predisposition to thrombosis, especially DVT of the LEs?

Factor V Leiden deficiency

What is most common inherited disorder causing hypercoaguability + predisposition to thrombosis especially DVT of lower extremities?

Factor V leiden - factor V become resistant to inactivation by protein C

37 year old F with family history of breast cancer in mother at age 65, sister with breast cancer at age 35. Most important risk factor for pt getting breast cancer is?

Family history

21 year old F is awakened by alarm clock and minutes later has syncope. EKG reveals prolonged QT interval and T wave inversions. History most likely to be helpful is?

Family history of SCD

Patient with C diff who failed treatment with Fidaxomycin. What to do next?

Fecal transplant

25 y/o woman comes to office w/chest pain that began 2 days ago. Pain is constant soreness and patient unable to sleep b/c of it. Avid runner that has been unable to run due to discomfort wearing her sports undergamrnet.s She is sexually active + stopped taking OCPs recently b/c trying to get preggers. Pt takes folic acid only. Maternal aunt died of breast cancer at 52. On exam, palpation reveals bilateral, nonfocal chest tenderness + diffuse cordlike thickening of breasts. Which of the following is the most likely diagnosis?

Fibrocystic changes

What causes fibrous replacement of bone?

Fibrous dysplasia

How to Evaluate Hypercalcemia

First Step - measure PTH Hypercalcemia with Low PTH - causes include: I. malignancy ii. Vit D toxicity iii. Granulomatous Disease (sarcoidosis) Hypercalcemia with Elevated/Inappropriately Normal PTH - Due to Primary Hyperparathyroidism I. with these patients, PTH is increased so will so will see *dec. PO43-*

Pt with C. diff and WBC 12,000. How to treat?

Flagyl

Pt. with C. diff and WBCs 12,000 was treated with flagyl 2 weeks ago presents again complaining of diarrhea. How do you treat now?

Flagyl again

In a patient with BLUNT THORACIC TRAUMA and RESP DISTRESS EVEN WITH BILATERAL CHEST TUBES - WHAT DO YOU THINK?

Flail chest - > 3 ribs broken - flail segment does PARADOXIC BREATHING - retract during inspiration and bulge in expiration - present with resp distress + tachypnea w/shallow breaths = note theat positive pressure ventilation will minimize paradoxical wall motion - *management = PAIN CONTROL + SUPPLEMENTARY O2; possibly MECHANICAL POSITIVE PRESSURE VENTILATION* - NOTE THAT IT PUTS PT *AT RISK FOR PULMONARY CONTUSION* - predispose to *pneumonia + ARDs* - *multiple rib fractures + respiratory distress = think flail chest*

When is an exercise stress test considered positive?

Flat or sloping ST depression >1mm and longer than 0.08s. If ST elevated then there is high grade stenosis

52 year old F with chronic watery diarrhea about 5-6x/day. No history of constipation. No blood, fever or weight loss. Stool Culture, ova, cysts and parasites negative. EGD and colonoscopy also normal. What is the best way to establish diagnosis? What do you suspect is diagnosis? What is the cause?

Flex sig with biopsy- either collagenous/microscopic colitis or lymphocytic colitis- biopsy will show inflammation of lamina propria NSAIDS, PPI, sertraline or diabetes treat by stopping offending agent or oral budesonide

Define AERD?

Following ASA or NSAID use. Consists of : -Asthma, chronic rhinosinusitis with nasal polyposis, & bronchospasm or nasal congestion

When is a cystoscopy recommended?

For all pts with unexplained gross hematuria or with microscopic hematuria & other RFs for bladder cancer (smoking, painters, metal workers, chronic cystitis, cyclophosphamide, & pelvic radiation exposure)

Patient with obstructive colon cancer has resection. wtd next?

Full colonoscopy to rule out concomitant lesions. If no other lesions then repeat colonscopy in 1 year then 3 years then 5 years Also measure CEA q3-6 months for 2 years then q 1 x 5 years

Woman with sharp RUQ pain for a year, described as severe. CT and US are normal. Exam reveals when she raises her legs she has pain. Most likely diagnosis?

Functional Abdominal wall pain

Wegener Granulomatosis (granulomatosis w/polyangitis or GPA)

Gen info - systemic vasculitis of small + medium sized arteries - highest incidence among CAUCASIAN 30-50 Symptoms - KNOW TRIFECTA (UPPER/LOWER AIRWAY + KIDNEY + SYSTEMIC VACULITIS) 1. upper airway involvement - see blood nasal discharge, oral ulcers, or sinusitis/otitis; over time saddle nose deformity due to destruction of nasal cartilage - lower airway sx - dyspnea, cough, hemoptysis 2. renal dz - renal insufficiency, microscopic hematuria, RBC casts (*rapidly progressive glomerulonephritis*) 3. Systemic Vasculitis - has cutaneous manifestations I. painful subcutaneous nodules ii. palpable purpura iii. pyoderma gangrenosum like lesions - *ulcers with rolled, undermined borders on legs (looks like cancer), etc* *UWORLD SUMMARY: Wegener's classically defined as triad of systemic vasculitis, upper + lower airway granulomatous inflammation, and glomerulonephritis. Nasal cartilage destruction + vasculitis cutaneous lesions (tender nodules, palpable purpura, ulcerations) are common external manifestations* CXR 1. nodular densities + alveolar/pleural opacities Next Step on suspicion - *(+) C-ANCA* due to *antibodies against proteinsase-3* + *inc CRP* - definitive dx - biopsy from a site of active Treatment 1. high dose corticosteroids 2. cytotoxic agents - cyclophosphamide

What should any pt who returns from a developing country & has symptoms suggestive of malabsorption be considered for & TXed with?

Giardiasis & metronidazole

Pt with diarrhea after camping. Associated with bloating, flatus, frothy stool and weight loss. Most likely diagnosis? What test to do?Treatment?

Giardiasis. Stool Elisa for Giardia antigen Treat with flagyl

Pt post surgery NPO develops icterus. AST/ALT normal, alk phos normal. Indirect bilirubin elevated. Direct normal. Most likely diagnosis? Etiology?

Gilbert's syndrome 2/2 Decreased glucoronyl transferase

pt with LDL 140, TGAs 600. Family history of hypertriglyceridemia. wtd?

Give Fibrate- Gemfibrozil or fenofibrate

Pt from a low endemic area who has no risk factors for Hep B has anti-HBc antibodies only. Possibly received one shot in the past. wtd?

Give Hep B vaccin

Pt with CHF on lasix, coreg, spironolactone and atorvastatin presents 6 months later with bilateral breast enlargement. You d/c spironolactone and switch to eplerenone but the patient says he can't afford it. Wtd?

Give amiloride

Glomerual Hematuria versus Non glomerular hematuria

Glomerular Hematuria - Type of hematuria I. microscopic > gross hematuria - Common Etiologies I. glomerulonephritis ii. basement membrane disorder (i.e. alport syndrome) (patient will present with transient gross hematuria - Clinical Presentation I. non specific or no sx ii. nephritic syndrome (HTN, oliguria, elevated creatinine) - Urinalysis I.*blood AND PROTEIN* ii. *RBC casts, dysmorphic RBCs* Non-glomerular hematuria - Type of hematuria I. gross > microscopic hematuria - Common Etiologies I. nephrolithiasis ii. cancer (i.e. renal cell, bladder cell carcinoma are 2 most common) a. prostate carcinoma, benign prostatic hypertrophy (BPH), or prostatitis can cause non glomerular hematuria; prostate carcinoma or BPH present in men age >55 w/sx of Urinary tract obstruction iii. polycystic kidney disease iv. Infections (cystitis) v. papillary necrosis, renal infraction - Clinical Presentation I. dysuria or sx of urinary obstruction (flank pain, renal or ureteral colic, anuria) - Urinalysis I. *blood BUT NO PROTEIN* ii. *NORMAL RBCs* *source of hematuria more likely to be glomerular if urine studies reveal proteinuria, dysmorphic RBCs, or RBC casts

Pt on beta blocker receives immunotherapy and gets anaphylactic reaction. In addition to epinephrine, what else will you give?

Glucagon to reverse BB effect

Pt presents with beefy red tongue and skin rash with central clearing most prominent in perineum. Also pt has lost about 20 lbs unintentionally. Dx?

Glucagonoma Rash is called narcoleptic migratory erythema

Foot Ulcer Classifications

Grade 0: high risk foot without an ulcer Grade 1: superficial ulcer w/*full skin thickness* involvement but not involvement of underlying tissue Grade 2: deep ulcer penetrating to *ligament or muscle*, but no bone involvement or abscess formation Grade 3: Deep ulcer w/cellulitis, abscess formation or osteomyelitis Grade 4: Localized Gangrene Grade 5: Extensive gangrene involving the whole foot - wound care Grade 1 + Grade 2 = *proper wound care + debridement* - *grade 3 ulcers tx = short hospitalization, surgical debridement, culture of material obtained from deep in ulcer, bone biopsy, and IV antibiotic therapy* - *grade 4 + 5 - ulcers need urgent hospitalization + amputation*

Vaccines Recommended and listed indications for Adults with HIV

HAV - chronic liver disease (or if having HBV or HCV) - homosexuals - IVDU HBV - all patients without documented immunity to HBV HPV - men and women ages 9-26 Influenza - annually for all patients Meningococcus - all patients age 11-18 - large groups living in close proximity (college students, military recruits, incarcerated patients) - asplenia or complement deficiency Pneumococcus - PCV13 once after diagnosis - PPSV23 8 weeks later, then every 5 years Tetanus Diptheria and Pertussis - Tdap once after diagnosis, repeat Tdap for women during each pregnancy - Td every 10 years following Tdap *live vaccines are contraindicated - exceptions are Varicella zoster, MMR which can be given if CD4 >200, there is no hx of AIDs defining illness*

What diuretic is contraindicated in a patient with sulfa allergy?

HCTZ

55 year old presents with fatigue. He has no significant PMH. ALT 500, AST 400. Takes Tylenol occasionally for arthralgias, most likely diagnosis?

HCV

37 year old M presents with history that his father had colon cancer at age 65 and brother at age 50. Aunt had uterine cancer at age 48. What is most likely diagnosis?

HNPCC

A crescendo-decrescendo murmur at the left lower sternal border suggest?

HOCM

MaHuang causes?

HTN

Clinical Clues to Renovascular Disease

HTN related Sx - resistant HTN - uncontrolled despite 3 drug regimen - malignant HTN (w/end organ dmg) - onset of severe HTN (>180/120 mm Hg) after age 55 - Recurrent flash pulmonary edema with severe HTN Supportive Evidence - Physical Examination I. Asymmetric Renal Size (>1.5cm) ii. Abdominal Bruit - Lab results I. *unexplained rise in serum creatinine (>30%) after starting ACE-I or ARBs* - Imaging results I. *unexplained kidney atrophy*

Pt comes in complaining of areas on the lateral aspect of tongue that are white. Do not scrape off. Diagnosis?

Hairy leukoplakia. seen in HIV patients. Treatment usually not required Caused by CMV

Thyroid Scan Uptake Comparison

Hashimoto's - heterogenous uptake - depending of enough of thyroid was destroyed Graves - diffuse inc uptake Multinodular goiter - patchy in distribution of uptake Toxic adenoma - inc radioiodine uptake In nodule but suppression of uptake in rest of thyroid gland - *these patients DO NOT HAVE INFILTRATIVE OPHTALMOPATHY* painless thyroiditis/painful thyroiditis - decreased iodine uptake diffusely

A patient remains symptomatic despite the best efforts of physician to treat with multiple medication trials + rejects all recommended pharmacological approaches. What are these patients called?

Help rejecters - believe no Tx will help + appear not to want to improve - leave physician feeling angry manipulated - these patients often have underlying DEPRESSION - needy for attention + unconsciously wish to remain symptomatic so that they can continue to see physician - best approach = EMPATHIZE WITH PATIENT + ATTEMPT TO ENGAGE IN COLLABORATIVE PLAN

45 y/o m comes c/o 2 mo weight loss + weakness. Has had skin pigmentation, polydipsia, polyuria, dec. libido. Ferritin = 1100, Transferrin = 55% where normal = 45%. Dx?

Hemochromatosis

What is the MC complication of PUD?

Hemorrhage

Pt returns from a trip to indonesia and had contact with commercial sex worker. He now complains of N/V, anorexia and malaise. Previous labs 6 months ago reveal Hep Bs Ab +, and Hep Bc IgG Ab +. Most likely diagnosis? How would you follow this patient up to establish diagnosis?

Hep A Hep A serology

Elderly pt presents with weakness of L side of body. EKG shows a fib. IV heparin is given and weakness resolves. Carotid doppler with <50% stenosis of R ICA and >70% L ICA. The best Tx at this time is?

Heparin + Warfarin- a fib caused stroke!

65 year old woman with Fhx of mother with breast cancer at age 67. Most important risk factor for her to acquire breast cancer is?

Her age

Major Risk Factors for Pancreatic Cancer

Hereditary 1. First deg relative w/pancreatic cancer 2. hereditary pancreatitis 3. germline mutations (eg BRCA1, BRCA2, peutz-jeughers) Environmental 1. Cigarette Smoking (most significant ***** TEST QUESTION) - MOST CONSISTENT REVERSIBLE RISK FACTOR FOR PANCREATIC CANCER 2. Obesity, low physical activity 3. Nonhereditary chronic pancreatitis****

MRI used to evaluate?

Herniated disk - *think back/radicular pain, straight leg test (+), pain worse with flexion* Cauda Equina Syndrome - think *bowel/bladder dysfunction* Cord Compression - *abnormal sensory examination* Epidural Abscess - *fever or IV drug use*

Differential of Behcet Disease

Herpes Simplex Virus - can cause *oral + genital ulcers + uveitis* but SKIN STUFF = vesicles which coalesce to form lobe shaped ulcers that recur at same location Sarcoidosis - can be associated with arthritis, uveitis, and erythema nodosum (no genital ulcers or oral ulcers)

A middle aged woman presents with recurring episodes of lumps in her axilla that occasionally drain serous fluid. Every episode resolves by itself after spontaneously draining. Exam does not reveal any enlargement of lymph nodes. The pt has a cat for the past 2 months and she loves to garden. What is the most likely diagnosis?

Hidradenitis suppurativa

48 year old F ℅ exertional CP, stress test done. Stopped in 5 minutes due to CP and ST depression V4-V6. What is the diagnosis?

High grade LAD stenosis

62 year old F with HTN and type II DM requests advice about coronary risk reduction. BP is 162/92, HbA1c 7.6%. Plasma cool 268, LDL 190, HDL 42. The most appropriate treatment would be?

High intensity statin

What is the most rapid/sensitive/specific test to DX a disseminated Histoplasmosis infection?

Histoplasma antigen immunoassay of the urine (sensitivity >95%) or serum

Minimal change DS is the MC nephrotic syndrome associated with?

Hodgkin lymphoma

Pt presents with chronic diarrhea, fecal fat is 14g/day. D xylose test is near normal. Vitamin B12 level is 190, folate 18. Small bowel follow through reveals diverticula. wtd next? Most likely diagnosis?Treatment?

Hydrogen breath test or Xylose 14C breath test to evaluate for bacterial overgrowth cipro and flagyl

What is the main AE of succinylcholine?

Hyperkalemia *Thus, do not use in pts at high risk for hyperkalemia (burn & crush injury pts; Pts with prolonged demyelination)

Hypertension effects on Kidney

Hypertension Induced Nephrosclerosis - *NEPHROPATHY* - most common lesions seen - *arteriosclerotic lesions of afferent + efferent renal areterioles + glomerular capillary tufts* - as HTN progresses - progressive decrease in RBF + GFR - sequence of damage: *nephrosclerosis (hypertrophy + intimal medial fibrosis of renal arterioles) to glomerulosclerosis (progressive loss of glomerular capillary SA w/glomerular + peritubular fibrosis)* I. *glomerulosclerosis causes HEMATURIA + PROTEINURIA* - *see bilaterally SMALL KIDNEYS* - *"intimal thickening + luminal narrowing of renal arterioles w/evidence of sclerosis" (TEST DESCRIP)*

On palpation of the apex you feel hyper dynamic impulse, what conditions should you consider? why does this occur?

Hyperthyroid, Anemia, primary MR, AR with normal EF, PDA, VSD. 2/2 increased LV Volume

What would asthma exacerbation cause?

Hypocapnea and respiratory alkalosis due to tachypnea

Patient complains of palpitations, tachycardia and confusion about 2 hours after eating. What is the most likely diagnosis?

Hypoglycemia 2/2 dumping syndrome

What are the MC electrolyte abnormalities found in Cushing's syndrome due to CS excess?

Hypokalemia & Hypernatremia *B/c cortisol has some affinity for the aldosterone receptor

What are predisposing factors for digoxin toxicity?

Hypokalemia, hypomagnesemia, low renal function, hypoxemia

Causes of Hyponatremia

Hypovolemic Hyponatremia - volume depletion (i.e. acute blood loss) - primary adrenal insufficiency - GI losses (diarrhea, vomiting) - Renal Losses (i.e. diuretics) Euvolemic Hyponatremia - Syndrome of Inappropriate ADH secretion (due to drugs like NSAIDs, malignancy) - Primary (psychogenic) polydipsia - secondary adrenal insufficiency - hypothyroidism Hypervolemic Hyponatremia - CHF - Cirrhosis - CKD or nephrotic syndrome

Blastomycosis

I. pulmonary fungal infection endemic to Great Lakes, and the Mississippi and Ohio River Basins ii. Systemic blastomycosis - may cause 1. SKIN LESIONS 2. BONE LESIONS 3. PULMONARY MANIFESTATIONS iii. Dx - BROAD BASED BUDDING YEAST GROWN FROM SPUTUM iv. tx of symptomatic disease - ITRACONAZOLE + AMPHOTERICIN B v. CXR + Pulmonary sx may resemble Tb + histoplasmosis

*indications for evaluation in BLOOD IN SPUTUM* where *modality of choice - CT*

I. recurrent bleeding ii. risk factors for malignancy - in order of low risk, intermediate risk, high risk: - nodule size of <0.8cm, 0.8-2cm, >2.0cm - age of <40, 40-60, >60 - smoking status of never smoked, current, and current - smoking cessation (yr) of >15, 5-15, and <5years ago - nodule margin characteristics of smooth, scalloped, and corona radiate/speculated iii. abn. CXR iv. those who are stable but have active bleeding >30mL from sputum

Prevention of Future Gout Attacks

I. weight loss with BMI target < 25 ii. low fat diet iii. decrased seafood + red meat intake iv. protein intake preferably from vegetable + low fat dairy products v. avoidance of organ rich foods (liver + sweetbreads) vi. avoidance of beer + distilled spirits vii. avoidance of diuretics when possible *lifestyle modifications as those above are recommended in addition to if recurrent, think of using allopurinol or febuxostat. These are for RECURRENT GOUTY DISEASE OR GOUTY DISEASE W/COMPLICATION (i.e. tophi or kidney stone)* *for acute attack, tx = NSAIDs (indomethacin, colchicine, and corticosteroids (systemic or intraarticular)*

Pt with chest pain and ST elevation in anterior leads. s/p tPA with BP 90/60. 2 hours later ST elevation in lateral leads. BP drops to 80 and patient is short of breath. No new murmurs at LSB or apex. CXR with pulmonary edema. wtd next?

IABP then go to PCI

A woman presents with chronic diarrhea of several years. She has frequent small stools with mucus and alternates with constipation. Her abdominal pain does not wake her up at night. Denies any fever, weight loss or anemia. Flex sig is negative. Most likely diagnosis? Treatment?

IBS Reassurance Diarrhea: Rifaximin, Antispasmodic, anticholinergics Pain: TCAs Constipation: increase fiber in diet

In a patient with HOCM who has one run of NSVT on Holter and family history of sudden cardiac death. wtd?

ICD placement

Staging of Gastric Adenocarcinoma

IF test question says there is antral ulcer and there is proven adenocarcinoma, next step is CT - H. pylori - significant RF for GASTRIC ADENOCARCINOMA + LYMPHOMA ***** - ONCE CT IS DONE + RESECTION OR CHEMO IS CHOSEN, DO ERADICATION - CURATIVE FOR MALT LYMPHOMA BUT NOT ADENOCARCINOMA -

Which medication would you need to stop if patient presents with diverticulitis? Why?

IL-6 inhibitors because could cause DIC rupture- ex. Tocilizumab

Which is the best prognostic tests in cirrhotics according to MELD score?

INR, bili and Cr

Patient come in presenting with PMH of CAD w/coronary stenting 2 years ago DM, HTN, stroke. Hospitalized 2 months ago w/pneumonia + upper GI bleed during which he received IV antibioitics + 4 blood transfusions. In ER today, BP is 70/40 w/elevated temp, O2 Sat of 79%. CXR shows new RU lobe infiltrate - treated w/saline antibioitics, vasopressors, mech. ventilation. Next day, lab analyses reveal dec Hb, 15000 wbc, bicarb of 19, AST + ALT in 2000's, alk phosphate of 162. Diagnosis?

ISCHEMIC HEPATIC INJURY in setting of HYPOTENSION - manifest as ACUTE MASSIVE INC IN AST + ALT w/MILDER ASSOC INC IN TOTAL BILI + ALK PHOS if patient survives inciting cause of hypotension (septic shock, heart failure) - liver enzymes typically return to normal w/in few weeks Diff Dx Acute Hepatitis - AST:ALT >1.5 AST <300 Acalculous cholecystitis - common complication of critical illness that arises secondary to gallbladder stasis. Patient presents with sx of biliary obstruction - ALK PHOS + TOTAL BILIRUBIN LEVELS WILL BE MORE ELEVATED THAN THE AST + ALT Autoimmune Hepatitis - LARGE INC. in AST + ALT - however, LOOK FOR IN WOMEN, ANTINUCLEAR ANTIBODIES (SENS) + ANTISMOOTH MUSCLE TITERS (SENS + SPEC)

Pt with diarrhea and WBC 18000. C diff is positive. KUB shows ileum. How to treat?

IV Flagyl and PO Vanc

Elderly patient with inferior wall MI and receives tPHA. He becomes hypotensive and HR is 38. wtd?

IV atropine then dobutamine

Management of DKA

IV fluids *(1st STEP)* - high flow 0.9 NS initially recommended - add dextrose 5% when serum glucose is <200mg/dL Insulin *A SIMULANTANEOUS FIRST STEP W/IV FLUIDS* - initial continuous* IV insulin* infusion - *switch to SQ* (Basal bolus) insulin for the following: able to eat, glucose < 200mEq/L, serum HCO3 > 15, ESP ONCE ANION GAP CLOSES - overlap IV + SQ Insulin by 1-2 hours Potassium - *add IV K+ if serum K+ < 5.2 mEq/L* - *Hold insulin for serum K+ < 3.3 mEq/L* - nearly all patients w/DKA are K+ depleted, even if labs show hyperkalemia ******** Bicarbonate - consider infusion for patients w/pH <6.9 Phosphate - consider for serum phosphate <1.0mg/dL, cardiac dysfunction, or respiratory depression - monitor serum calcium frequently ---------------------------------------------------------- - purpose of treatment of DKA i. to FIRST CORRECT DEHYDRATION VIA IV FLUIDS, TO SECOND CORRECT HYEPRGLYCEMIA + ELECTROLYTE IMBALANCES + KETONEMIA + ACIDSOSIS, THEN Tx PRECIPITATING CAUSE - best markers indicating resolution of ketonemia are i. SERUM ANION GAP ii. DIRECT ASSAY OF BETA HYDROXYBUTYRATE (predominant ketone in DKA) *** KNOW BOTH - Beta hydroxybutryate is converted to acetoacetate + acetone hich can be measured by using nitnroprusside test for urine - REMEMBER THAT CONC IN URINE LAGS BEHIND CONC KETONE IN BLOOD

What is the TX of choice for pts with cellulitis with systemic signs?

IV nafcillin or cefazolin *IV Vancomycin in areas with a high MRSA prevalence

tt of syphillis

IV penicillin for 10-14 days

Pt presents with coffee ground emesis and dizziness. NGT reveals blood tinged fluid. HR 120/min, BP 90/60. wtd next?

IVFs

Pt has severe IgA deficiency, which of the following is contraindicated? Hepatitis A vaccine Hepatitis B vaccine IVIG FFP Platelets

IVIG

When would you do surgery to repair a VSD?

If L to right shunt >1.7:1

When would you operate on a patient found to have a thoracic aortic aneurysm?

If symptomatic- any time Asymptomatic- >6 cm

Pt presents with chest pain and EKG reveals MI that is treated with tPA, heparin, nitrates, BB and ACEi. Within 24 hours pt develops VT. wtd?

If unstable- cardiovert then amio If stable- amio or lidocaine

Management of Cirrhosis

If you see AST: ALT > 2:1 then you know its alcoholic cirrhosis - especially with signs of cirrhosis. to determine next step once you recognize signs of cirrhosis, do periodic surveillance of liver function tests - i.e. INR, ALBUMIN, BILIRUBIN i. if you determine that patient is compensated (ASYMPTOMATIC OR VAGUE SX like anorexia, weakness, fatigue) then 1. US for hepatocellular carcinoma every 6 months 2. Alpha-fetoprotein every 6 months 3. EGD (upper esopagheal endoscopy) - sureveillance of varices ii. if you determine that patient is NOT COMPENSATED - PRES W/JAUNDICE, PRURITIS, UPPER GI BLEED, ABD DISTENTION DUE TO ASCITES OR CONFUSION DUE TO HEPATIC ENCEPHALOPATHY THEN DO 1. Variceal hemorrhage - start NON SELEC BETA BLOCKERS + REPEAT EGD ONCE PER YEAR (TEST QUESTION********) - IF VARICES ARE SMALL AND NON BLEEDING, GIVE PROPHYLACTIC NON SELEC BETA BLOCKERS; IF BLEEDING, THEN DO SCLEROTHERAPHY****** 2. Ascites - diuretics, Na+ restriction, paracentesis*** CASH (ALL 3 TEST QUESTIONS) 3. Hepatic Encephalopathy Treatment i. treat ELECTROLYTE DEFIC FIRST ALWAYS now lower serum ammonia via ii. LACTULOSE iii. Rifaximin iv. Laxatives DIAGNOSIS OF CIRRHOSIS - LIVER BIOPSY - BUT DONT NEED TO DO THIS AS NEXT STEP (MANAGE VARICES FIRST IF YOU KNOW ITS CIRRHOSIS)

What is the most common immunoglobulin deficiency?

IgA

Type I Hypersensitivity Reactions are mediated by_____. Examples of atopic reactions_______, anaphylactic reactions______.

IgE mediated Atopic: weed, pollen, dust, grass, mold, cat or dog proteins Anaphylactic: latex, peanuts, shellfish, bees, drugs

Effective immunotherapy causes an increase in which antibody isotype?

IgG

In a pregnant woman how will you determine past infection with Hepatitis A?

IgG +/IgM-

Type III Hypersensitivity reactions are mediated by ____. Examples_____.

Immune complex IgG/IgM Serum sickness, SLE, PSGN (sub endothelial deposit, low C3), PAN, RA, Arthus reaction, Hypersensitivity pneumonitis

Patient is receiving antibiotics for endocarditis and starts to complain of arthralgias. Mechanism of arthralgias?

Immune complex deposition- serum complement low

Pt with recurrent bronchitis for the past 25 years. He takes bactrim and his infection resolves. CXR normal. wtd?

Immunoglobulin titers

What is the most common diagnosis in a patient with history of cholecystectomy and now has RUQ pain?

Impacted stone in CBD

A post-splenectomy is at increased risk for sepsis from encapsulated organisms due to?

Impaired Ab-mediated opsonization in phagocytosis

Cushing's syndrome metabolic changes? (4)

Important cause of secondary HTN. Increased levels of ACTH-dependent hormones (deoxycorticosterone, corticosterone, cortisol) can cause: 1. HTN (vasoconstriction) 2. Hyperglycemia (insulin resistance) 3. Hypokalemia (mineralcorticoid activity) 4. Central adiposity, proximal muscle weakness, thinning skin, weight gain, & psychiatric problems

What is the main difference between bronchiectasis & chronic bronchitis?

In bronchiectasis it is more likely associated with a HX of URT infections & chronic cough with daily production of mucopurulent sputum.

In a patient with pancreatitis, what suggests biliary etiology?

Increased ALT >2x ULN, ALK phos will increase later

Application of pressure in the RUQ causes engorged R jugular vein which rapidly improves with release of pressure. This indicates?

Increased JVP

What happens to murmur of AS with amyl nitrate?

Increased intensity of murmur- decreased after load causes more blood to leave LV and enter aorta

What happens to volume in heart when sitting?

Increases

What happens to murmur during handgrip or on phenylephrine?

Increases afterload-> LV cavity size-> Volume increases

ECT

Indications 1. For severe depression 2. Depression in pregnancy 3. Refractory mania*** 4. NMS *** 5. Catatonic schizophrenia*** Side Effects 1. Retrograde + anterograde Amnesia (MOST COMMON BY FAR) 2. Prolonged seizures, delirium, headache, nausea, skin burns (LESS COMMON, all of these) 3. Muscle soreness

Pt presents with generalized erythema, exfoliating dermatitis with bull. Punch biopsy done and shows cleavage plane in stratum corneum. Dx?

Infectious etiology

A young male pt presenting with a short HX of fever, malaise, pharyngitis with exudate, & posterior cervical lymphadenopathy is suspicious for?

Infectious mononucleosis due to EBV

Leads II, III, aVF

Inferior RCA

Seronegative Spondyloarthritis (i.e. ankylosing spondylitis)

Inflammatory Back Pain - think *YOUNG MEN < 40* - sx > 3 months - *relieved with exercise (WORSE IN AM, IMPROVE OVER DAY LIKE RA)* but not rest - nocturnal pain - *nocturnal pain* Exam Findings - arthritis (sacroilitis) - reduced chest expansion + spinal mobility - enthesitis (tenderness at tendon insertion sites) - dacytylitis (swelling of fingers + toes) - uveitis Complications - *Osteoporosis - THIS IS BECAUSE OF INCREASED OSTEOCLAST ACTIVITY* - *Vertebral fractures b/c THERE IS SPINAL RIGIDITY - MINIMAL TRAUMA GIVES VERTEBRAL FRACTURE IN AS PATIENTS* - *Aortic regurgitation* - *cauda equina* Associations - IBD - especially co presents with other manifestations such as erythema nodosum, pyoderma gangrenosum,episcerlitis, arthritis, cholangitis Laboratory - Elevated ESR + CRP - *HLA-B27* association Imaging - *IF YOU WANT TO CONFIRM DX, DO SACROILIAC JOINTS XRAY (TEST QUESTION UWORLD*

young woman with chronic diarrhea wakes up in the night to use the bathroom, What is the most likely diagnosis?

Inflammatory bowel disease

What diseases cause patients to wake up during the night to poop?

Inflammatory bowel disease, microscopic colitis, bacterial overgrowth syndrome

Hemophilia A + B

Inheritance - X linked recessive CFs - delayed/prolonged bleeding after mild trauma or procedure I. hemarthrosis, hemophilic arthropathy ii. intramuscular hematomas iii. GI or GU bleeding Lab Findings - prolonged aPTT - normal platelet count, BT (bleeding time), and PT - *dec or basent factor VIII (hemophilia A) or factor IX (hemophilia B) activity* Treatment - administer factor VIII of IX - *desmopressin for mild hemophilia A*

HIV screening indication

Initial screening - *Age 15-65 (+ younger or older if at risk)* - *treatment for Tb* - *Treatment for another STD* Annual - IVDU + sex partners - *homosexual* - sex for money or drugs - partner HIV (+) - homeless shelter living - correctional facility incarceration Additional Screening - pregnancy - occupational exposure to blood/body fluids - any new STD sx - Suggested: prior to any new sexual relationship

Asthma Classifications

Intermittent a. criteria: I. <2 days/week ii. night time awakenings < 2 nights/month iii. use of beta agonists < 2/week iv. baseline FEV1 + FEV1/FVC are normal v. no limitations of daily activity b. treatment I. short acting bronchodilators (i.e. albuterol) PRN ii. Mild Persistent a. criteria: I. >2 days/week; less than daily ii. night time awakenings x3 or x4 nights/month iii. baseline FEV1 + FEV1/FVC are normal v. minor limitations of daily activity b. treatment I. short acting bronchodilators (i.e. albuterol) PRN ii. low dose inhaled corticosteroids Moderate Persistent a. criteria: I. DAILY sx ii. WEEKLY nighttime awakenings iii. FEV1 around 60-80 of predicted v. minor limitations of daily activity b. treatment I. short acting bronchodilators (i.e. albuterol) PRN ii. low dose inhaled corticosteroids iii. LABA Severe Persistent a. criteria: I. sx throughout day ii. frequent nighttime awakenings iii. extremely limited activity v. FEV < 60% predicted b. treatment I. short acting bronchodilators (i.e. albuterol) PRN ii. HIGH dose inhaled corticosteroids iii. LABA iv. systemic corticosteroids *theophylline - can be used as a CONTROLLER MEDICATION in persistent asthma; causes bronchodilation (methylxanthine PDE inhibitor)

Pt with h/o aortic aneurysm is scheduled for surgery is getting a stress test. Recent EKG, PFTs, chest XR are normal. During stress test patient has ST depression in lateral leads and 2/6 systolic murmur at apex but 5 minutes after test there is no murmur. What is the most likely diagnosis?

Ischemic MR- seen in post menopausal women

How do you treat cystic and nodular acne?

Isotretinoin

What does increased production of stomach acid by parietal cells (stimulated by excess gastrin in ZES) do to pancreatic enzymes?

It inactivates them. Causing steatorrhea & malabsorption

Infliximab is used in treatment of?

It is TNF-alpha blocker (BIOLOGIC DMARD) for 1. IBD 2. Ankylosing spondylitis 3. RA

What does HIT predispose the pt to?

It is very thrombogenic (even though it causes thrombocytopenia)

rheumatic fever criteria

Joints (migratory polyarthritis) <3 carditis Nodules (subcutaneous) Erythema mirginatum Sydenhams chorea (jerky movments) Tachy disproportionate to fever

Pt with history of CP has EKG stress study which reveals depression in lateral leads. Nuclear imaging reveals antero-septal ischemia. Where is the lesion?

LAD stenosis

In a patient who presents to ED with chest pain and ST depressions. Wtd?

LMWH + gpIIb/IIIa inhibitors + clopidogrel

In a patient with MR when do you perform surgery in asymptomatic patients?

LV systolic dysfunction EF<60% Pulmonary HTN Atrial fibrillation Symptoms

On palpation if you feel sustained apical impulse, what conditions should you consider?

LVH- 2/2 HTN, CM, IHD, AR with low EF

Pt presents with complaints of long standing diarrhea for a couple of years. Associated with bloating sensation and crampy abdominal pain. About 3 BMs/ day. No blood, weight loss or fever. Stool culture negative. Osmolality 290. Stool Na 50 and K 25. Most likely etiology?

Lactose intolerance

Patient with biliary pancreatitis. A week later with normalizing enzymes and clinically improved. What will you do next?

Laparoscopic cholecystectomy

Patient with heartburn with partial response to PPI and EGD reveals severe GERD. wtd?

Laparoscopic fundoplication

Pt with chronic diarrhea has stool osmolarity of 300. Na 40 and K 30. On addition of Na OH turns red. Most likely diagnosis?

Laxative abuse Measure phosphate and sulfate in stool

What medications do you use to treat a patient for Hep C who is treatment naive with cirrhosis?

Ledipasvir + Sofusbuvir 12 weeks Simeprevir + Sofusbuvir 24 weeks

How would you treat a patient with Hep C cirrhosis who failed IFN therapy.

Ledipasvir + Sofusbuvir 24weeks Simeprevir + Sofusbuvir 24 weeks

When is CABG better than PCI?

Left main disease 3 vessel disease with decreased LVEF <30% Two vessel disease with proximal LAD and decreased LVEF DM and CAD

Leukemoid Reaction vs Chronic Myeloid Leukemia

Leukemoid Reaction - Leukocyte Count: >50,000/m3 - Cause: Severe infection - *LAP score - HIGH (ALWAYS USED TO DIFFERENTIATE LEUKEMOID VS CML - TEST Q)* - Neutrophil precursors: more mature (metamyelocytes > myelocytes) - *Absolute basophilia: Not present* Chronic Myeloid Leukemia - Leukocyte Count: elevated >100,000/m3 - Cause: *BCR-ABL Fusion* - *LAP score - LOW* (ALWAYS USED TO DIFFERENTIATE LEUKEMOID VS CML - TEST Q) - Neutrophil precursors: less mature (metamyelocytes < myelocytes) - *Absolute basophilia: present* *WHEN LEUKOCYTES ARE >50,000 - IMMEDIATELY THINK CML OR LEUKEMOID RXN* LAP = leukocyte alkaline phosphatase

Pt who presents with papulosquamous lesions of skin or mucus membranes. Diagnosis? TX?

Lichen planus High potency topical steroids can see purplish papillose with white lines on surface

Onycholysis

Lifting off of the nail Idiopathic Trauma Psoriasis Hyperthyroidism

Elderly patient with diarrhea and confusion after eating goat cheese. Most likely 2/2?

Listeria

Live Attenuated Vaccines vs. Non-live (toxoid, subunit, conjugate, inactivated) vaccines

Live attenuated Vaccines: *do not vie in patients receiving TNF antagonists (adalimumab)* - polio (oral) - measles/mumps/rubella - rotavirus - influenza (intranasal) - yellow fever - varicella, zoster Non live (toxoid, subunit, conjugate, inactivated) vaccines - influenza (IM) - pneumococcus - diphtheria/tetanus, pertussis - typhoid - Hep A + Hep B - Haemohpilus influenza type B - HPV - Meningococcus - Polio (inactivated)

52 y/o M presents to clinic complaining of very dark urine for past 2 days. Admits to alt. bouts of diarrhea + constipation w/occasional blood in stool for past year. VS of 99.5 deg, and is pale + cachetic on PE> Mild hepatomegaly present, abdomen is soft + nontender. FOBT is positive. Labs show highly elevated alk phos of 510 and AST of 62 w/ALT of 70. Serum AFP is 12 ng/mL (norm is 0-15). US reveals multiple hepatic nodules of varying sizes - whatis most likely diagnosis?

Liver Mets

53 y/o M come to physician w/2 day hx of calf pain + swelling. Pain is constant + worsen w/knee flexion. Hx of IV drug abuse, bac endocarditis, and embolic stroke. Pt has been wheelchair bound for past year due to stroke rel to left sided hemiparesis. Temp is 98, BP is 140/90. PE is good. Lungs clear. Hepatosplenomegaly present w/abdomen distention wi/shifting dullness + fluid wave suggesting ascites. R Calf swollen + tender to palpation. WHat is cause of patient ascites?

Liver failure

Untreated Acromegaly

Local Tumor effect i. pituitary enlargement, visual field defects, headache, CN defects MSK/Skin i. gigantism, mal occluded jaw, arthralgias/arthritis, proximal myopathy, hyperhidrosis, skin tags, carpal tunnel syndrome CV i. cardiomyopathy, HTN, Heart failure, valvular disease (mitral + aortic regurg) Pulm/GI i. sleep apnea, narcolepsy, colon polyps/cancer, diverticulosis Enlarged organs i. thyroid, tongue, salivary glands, liver, spleen, kidney, prostate Endocrine i. galactorrhea (*GHRH CAUSES INC PRL*), decreased libido (*INC PRL DEC GNRH*), DM (*IGF 1 = DIABETOGENIC*), HYPERTRIGLYCERIDEMIA, HYPERPARATHYROIDISM

A teenager presents with swelling of his arms and forearms. No erythema or itching noted. Sister had similar complaints some time ago. What do you expect on lab analysis?

Low C4/CH50

Young patient who is short in stature with short neck, short metacarpals and phalanges. What lab tests would you expect to find abnormal? Most likely diagnosis?

Low calcium and high phosphorous with normal PTH 2/2 end organ resistance Pseudohypoparathyroidism

After treating for H. pylori, which type of cancer may regress?

MALToma

loss of rural folds in antrum mucosa B lymphocytes resolves with antibiotics

MALToma associated with H. pylori

carbuncle

MCC S aureus large deep nodule covered by thick skin at neck/back/thigh hard palpation

Major Depressive Episode vs Grief Reaction (bereavement)

MDE 1. 5 of 9: sleep disturbance, appetite change, guilt, dec. energy, concentration difficulties, anhedonia, psychomotor changes, suicidal ideation 2. low mood or anhedonia must be present 3. duration of GREATER THAN 2 WEEKS 4. may occur in response to stressors including loss of loved one 5. Social + occupational dysfunction 6. Suicidality related to hopelessness + worthlessness Grief Reaction 1. Normal reaction to loss 2. Feelings of loss or emptiness 3. Symptoms revolve around deceased 4. Functional decline less severe 5. Waves of grief at reminders 6. Worthlessness, self loathing, guilt + suicidality less common ***** 7. Sad feeling specific to deceased 8. Thoughts of dying involve joining the deceased 9. Intensity decreases over time (weeks to months) 10. <2 months

46 year old M with CP lasting 15 mins. IN the ER CP is resolved. HR 72, BP 118/76. EKG with no ST elevation, only deep T wave inversion from V1-V4. The represents?

MI- Wellen's syndrome- LAD T wave inversion syndrome

In what diseases do you see decrease in antibodies?

MM AIDS Asplenia ALL/CLL CVID Remember- B cells->plasma cells ->antibodies

In what conditions is S2 split increased and aortic valve closes sooner?

MR VSD

In what conditions do you have soft S1?

MR, Long PR, elevated LVEDP

What is the most sensitive test to measure pericardial thickness?

MRI

In which condition will you have increased intensity of murmur with standing, valsalva, post-PVC, handgrip and decreased duration with handgrip?

MVP

Bipolar and Related Disorders

Manic Episode 1. symptoms more SEVERE 2. 1 WEEK unless hospitalized 3. MARKED IMPAIRMENT socially or functionally or HOSPITILIZATION NECESSARY Hypomanic Episode 1. symptoms LESS SEVERE 2. >4 CONSECUTIVE DAYS 3. unequivocal, observable change in functioning form patient's baseline 4. symptoms not severe enough to cause marked impairment or necessitate hospitalization 5. NO PSYCHOTIC FEATURES Bipolar 1 - MANIC EPISODE - Depressive episode common but not required for dx Bipolar II - HYPOMANIC EPISODE - 1 or more Major Depressive Episodes required for dx Cyclothymic Disorder - at least 2 YEARS of fluctuating, mild hypomanic + depressive symptoms that do not meet criteria for hypomanic episodes or major depressive episodes

What must you do prior to laparoscopic fundoplication?

Manometric studies to confirm good motility of esophagus, otherwise iatrogenic achalasia will result

Patient presents with small white vesicles on an erythematous base in mouth as well as fever. Maculopapular rash noted behind both ears. Most likely diagnosis?

Measles Kopek's spots precede skin lesions by several days. Patient has fever, malaise, coryza, cough and conjunctivitis rash from face to trunk

Causes of Chronic Low Back Pain

Mechanical (muscle strain, disc degeneration) - normal neurologic examination - *paraspinal tenderness* - *(-) straight leg raise test* Radiculopathy (herniated disk) - *radiation below knee on one side (i.e. UNILATERAL sciatica)* - *usually L4-L5* - *(+) straight leg raise test* - *possible neurologic deficits* Spinal stenosis - psuedoclaudication - relieved by leaning forward (spine flexion); worse with extension - *older age* Compression Fractures *older age* - *common in women* - *trauma/fall usually precipitate or steroids* Inflammatory (spondyloarthropathy,- ankylosing spondylitis, psoriatic arthritis, arthritis associated with IBD) - worse with rest, better with activity - sacroiliitis - often immune mediated - common in < 40 - *affect sites of ligamentous insertion (enthesitis) - which is MOA of listed spondyloarthropathies (TEST Q) leading to gradual onset of lower back pain + progressive stiffness* Metastatic cancer - age > 50 - *NOCTURNAL PAIN* - not relieved with rest - weight loss - *hx of malignancy* - *cauda equine syndrome - weakness, urine retention/incontinence, saddle anesthesia* Infectious (i.e. osteomyelitis, discitis) - *recent infection or Intravenous drug use* - Fever, exquisite point tenderness - diabetes

Main stay therapy for pts with ARDs?

Mechanical ventilation with low tidal volumes and PEEP

Patient with severe ischemic colitis s/p extensive small bowel resection. Pt now presents with bulky greasy stool 3-4/day. He has had weight loss post surgery. Stool fat is 20 g/day, Albumin 2.6, and Ca 7. Most appropriate treatment?

Medium chain triglycerides

Pt diagnosed with invasive aspergillum in the lung is started on Voriconazole. Avoiding sun exposure will prevent what?

Melanoma/skin cancer- important to remember in patients who are being treated for aspergillus

Patient who is pregnant presents with hyper pigmentation on her face. She wants to know what this is and how she can treat it?

Melasma Sunscreen Bleaching cream- Hydroquinone

18 y/o woman comes to ED b/c of acute onset of headache, muscle pains, nausea. She has had sx for one day, soon after returning from a camping trip. The illness started with fever + muscle pains that progressed to include headache + nausea over the next several hours. She says that she went hiking twice during the trip + participated in many outdoor activities with her friends. She says that she problems. Her temperature 102F, BP is 90/60. Pules is 120/min, RR are 18/min. PE shows a nect stiff with pain to passive flexion. Careful exam reveals a few purpuric lesions on both legs. Exam of CSF reveals. CSF glucose 20mg/dL, protein 175 mg/dL, WBC 2000/cmm.

Meningococcal Infection

70 year old M is brought with severe abdominal pain for the past day. His last Bm was normal several hours ago. PMH DM, HTN, CHF. Exam reveals HR 110/min. JVD +, S3+. Palpation of abdomen reveals mild tenderness with no guarding. Rectal exam is normal, FOBT negative. Amylase elevated. KUB normal and CT Abdomen shows small bowel wall thickness and intestinal pneumatosis. How will you establish diagnosis?

Mesenteric angiogram

Hypothyroidism associated Metabolic Abnormalities

Metabolic Abnormalities *1. hyperlipidemia 2. HYPOnatremia I. cause: dec free water clearance 3. asymptomatic elevations of CK + Aminotransferase (ALT +AST) 4. Some have HYPERCHOLESTEROLEMIA ALONE I. cause: dec LDL receptors 5. Some have HYPERTRIGLYCERIDEMIA ALONE (OR #4+#5 are presented together) I. cause: decreased Lipoprotein Lipase Activity*

Diabetes Medications

Metformin (biguanide) - dec A1c 1-2% - initial therapeutic agent for most TIIDM - *weight neutral, low risk of hypoglycemia* - *lactic acidosis is life threatening complication* Sulfonylureas - A1c dec by 1-2% - generally added in patients with metformin failure - *weight gain + hypoglycemia* Pioglitazone (TZDs) - A1c dec by 1-1.5% - used if unable to tolerate metformin or sulfonylureas - side effects - *weight gain, edema, CHF, bone fracture, bladder cancer* - *NO HYPOGLYCEMIA* DDP-IV Inhibitors (i.e. sitagliptin) - A1c dec by 0.5-0.8% - *low risk of hypoglycemia - weight neutral* - *can be used in renal insufficiency* GLP-1 Receptor agonist (i.e. exenatide) - A1c dec by 0.5-1.0% - *possible second agent for metformin failure especially if weight loss is desired* - *low risk of hypoglycemia* - *risk of ACUTE PANCREATITIS*

Disease Modifying Antirheumatic Drugs

Methotrexate (Non Biologic DMARD) - mechanism - inhibitor of Dihydrofolate reductase such that intracellular folate is decreased - SE: *hepatotoxicity, stomatitis, cytopenias, megaloblastic anemia w/high MCV, ILD, Alopecia* - *do peripheral blood counts every 3 months* Leflunomoide (non biologic DMARD) - MOA: pyrimidine synthesis inhibitor - SE: hepatotoxicity, cytopenias Hydroxychloroquine (non biologic DMARD) - MOA: TNF + IL-1 Suppressor - SE: retinopathy, hemolytic anemia via triggering G-6-PD deficiency induced anemia, GI Sulfsalazine (non biologic DMARD) - MOA: TNF + IL-1 Suppressor - SE: hepatotoxicity, stomatitis, hemolytic anemia TNF inhibitors (biologic DMARD) - adalimumab, certolizumab, etanercept, golimumab, infliximab - MOA - SE: infection, demyelination, CHF, *malignancy*

HTN and MI

Metoprolol

Microadenoma vs Macroadenoma

Microadenoma: <10 mm diameter Macroadenoma: >10 mm diameter

Features of Necrotizing Fascitis

Microbiology - streptococcus pyogenes (GAS) - staphylococcus aureus - clostridium perfringens - polymicrobial Pathogenesis - bacteria spread rapidly through subcutaneous tissue + deep fascia undermining the skin - most commonly involves extremities + perineal region Clinical Manifestations - often antecedent history of minor trauma - abrasion, etc - erythema of overlying skin - swelling + edema - *pain out of proportion to exam findings* - systemic sx (*fever + hypotension*) - *crepitus in 50% cases* - CT scan will show air in tissue Treatment - *surgical debridement + broad spectrum antibiotics* Differentials - abscess: skin + soft tissue infxn that is successfully limited by immune system + tissue barriers. Tender, fluctuant areas that do not spread aggressively (vs necrotizing fasciitis). Systemic signs such as hypotension + high fever unusual. - cellulitis - acute skin infection that present with warmth, erythema, edema, and tenderness. Evidence of underlying tissue necrosis including severe pain or crepitus or systemic signs should raise concern for more aggressive process like necrotizing fasciitis.

What diarrheal disease is most likely associated with Celiac sprue?

Microscopic colitis

Clostridium Dificile Colitis

Mild-Moderate: i] WBC < 15,000, ii] Creatinine < 1.5x baseline - next step = ORAL METRONIDAZOLE Severe: i] WBC > 15,000; ii] cr > 1.5x baseline; iii] serum albumin < 2.5 g/dL i. if wbc > 20,000; or lactate > 2.2 mg/dL; or toxic megacolon; or Severe ileus a. subtotal colectomy b. diverting loop ileostomy w/colonic lavage ii. if i] wbc 15,000 < x< 20,000; lactate < 2.2 mg/dL; no toxic megacolon + no severe ileus; cr > 1.5 x baseline ii. tx = ORAL VANCOMYCIN + IV METRO Presentation: I. LOW GRADE FEVER ii. ACUTE WATERY DIARRHEA - MULTIPLE PER DAY iii. GUIAC POS STOOL + ABD PAIN iv. Presence of RFs a. clindamycin, penicillin, cephalosporin, fluoroquinolone ("oxacin") use, PROLONGED PPI OR H2 REC ANTAGONIST USE (TEST Q***) Diagnosis Confirmation (NOT NEXT STEP - NEXT STEP USUALLY TREATMENT AS ABOVE GUIDELINES THEN CONFIRMATION): i. STOOL ASSAY FOR C DIFF TOXIN (PCR FOR TOXIN A + B)

Pt presents with small keratin containing cysts on eyelids, cheeks, nose and forehead. Dx? Treatment?

Milia I and D

Middle aged woman born in China has dyspnea, hemoptysis. On exam loud S1, loud P2, opening snap +. Mid diastolic rumble at apex. Swan: PCWP 18, PAP 80/34, RAP 15. CXR with cardiomegaly and straightening of left heart border. Dx?

Mitral stenosis

The best management for a patient with mitral stenosis with valve surface area <1.5 cm2 and moderate MR?

Mitral valve repair

Pt presents with complaints of leg lesions which have not gotten better in couple of months. Pt had received blood transfusion in 1990 and was diagnosed with Hep C. Exam reveals palpable purport in the extremities. BUN/Cr 60/7.2. Serum complement CH50 and C4 decreased. Most likely diagnosis?

Mixed cryoglobulinemia

Clinical Clues for Common Etiologies of Cirrhosis

More Common i. chronic Hep B or hep C - iv drug use, blood transfusions ii. Alcoholic liver disease - excess alcohol intake iii. nonalcoholic Fatty Liver Dz - diabetes, obesity or metabolic syndrome iv. hemachromatosis - Fam Hx of cirrhosis; history of diabetes, "bronze" skin appearance; high transferrin saturation Less Common i. AI - fam hx of cirrhosis, hx of other coexisting AI disorders, anti-sm. muscle/liver kidney microsomal type I antibodies ii. primary biliary cirrhosis - more common in women, fatigue, pruritic, elevated alk pos, positive antimitochondrial antibody iii. primary sclerosing cholangitis - ASSOC W/IBD iv. Alpha-1 antitrypsin deficiency - coexisting lung involvement, fam hx of cirrhosis v. cardiac cirrhosis - coexisting R Sided HF vi. Meds - MTX, Isoniazid vii. Wilson Disease - Fam Hx of cirrhosis at young age, Kayser-Fleischer Rings in eyes Cirrhosis should be suspected in any pt presenting w/stigmata of Chronic Liver Dz (new onset ascites, pedal edema, spider angiomata, palmar erythema, caput medusa, nail changes, gynecomastia, splenomegaly, testicular atrophy). MOST COMMON CAUSES ARE THE 4 ABOVE SO KNOW THEM

Female with severe acne wants Accutane. wtd?

Must be on OCP and another method of contraception during and one month after completing therapy because it is teratogenic

Pt presents with discrete patches on arms and legs and severe pruritus. Biopsy shows eosinophilic infiltrates of lesions. Blood smear has lymphocytes with hyper chromatic and convoluted nuclei. Dx? TX?

Mycosis fungoides or cutaneous T cell lymphoma Topical nitrogen mustard or Psoralen PUVA

Pt presents with acute chest pain and ST elevation. PCI is done. The next day the patient has chest pain. What would be the best way to diagnose MI?

Myoglobin- has the shortest t1/2- up in 1 hour and down in 4-6 hours

Work Up of Isolated Alk Phos

NEXT STEP FOR ANYTHING W/INC ALK PHOS: 1. FIRST CHECK GGT - IF THIS IS ELEVATED - YOU KNOW OF BILIARY ORIGIN (IF NOT, OF BONE ORIGIN IS ELEV. ALK PHOS) 2. NEXT ABDOMINAL US RUQ, ANTIMITOCHONDRIAL ANTIBODIES i. if BOTH NORMAL - DO LIVER BIOPSY, ERCP, and OBSERVATION ii. if AMA (+) or ABN HEPTATIC PARENCHYMA ON US - LIVER BIOPSY iii. if AMA (-) BUT DILATED BILE DUCTS - ERCP ****

What do you do in a patient with ASD and they develop R to L shunt?

NO surgery- Eisenmenger's syndrome at any degree no surgery. It denotes onset of pulmonary htn

tt of acute gouty attack first line

NSAID indomethacin

Which drugs should not be used in CHF patients?

NSAIDs Glitazones CCBs Cilostazol Metformin- advanced CHF

Middle aged man clutches his chest and complains of severe chest pain. In the ER EKG reveals a diffuse ST elevation with concavity up and PR depression. wtd?

NSAIDs for pericarditis

Lady with itchiness and eczema of her upper eyelids. Most likely etiology?

Nail polish

Patient presents with solitary furuncle infection 4 times in the past 5 years that is easily treated with I/D. Otherwise healthy. Dx?

Nasal colonization with Staph. Can eradicate with mupirocin ointment and rifampin

What is effective in any type of rhinitis including perennial allergic rhinitis?

Nasal glucocorticoids Cromolyn helpful only in allergic rhinitis

What is a test you can do in a patient who you suspect allergic rhinitis?

Nasal secretion smear for eosinophils

60 year old pt undergoes CABG, couple of months later he is doing fine but has problem with keeping accounts occasionally. This represents?

Neurocognitive defect. up to 40% of CABG patients in varying degrees of severity

When is screening for bladder cancer recommended?

Never. Even in pts with smoking HX &/or occupational exposure HX

For a pt who has an average risk of ovarian cancer, when should screening be performed?

Never. There is no proven benefit to mortality *In pts with increased risk (heriditary factors [BRCA gene]), serum antigen CA125 & pelvic U/S is recommended but do not reduce mortality

Can treatment with PPIs or fundoplication surgery reverse epithelial changes of Barrett's?

No

Do HOCM patients need endocarditis prophylaxis?

No

Does IVIG help in IgA deficiency?

No

Pt presents with chest pain and EKG reveals MI that is treated with tPA, heparin, nitrates, BB and ACEi. Within 24 hours pt develops VT. 5 days later is ready for discharge. Does he need long term anti-arrhythmic?

No

Young athlete on routine physical exam found to have EKG with WPW. He is asymptomatic. Should you restrict him from athletic activities?

No

Can you give allergy injections in ABPA?

No because it will make it worse

Pt with Hep B has normal transaminases and viral load >20,000. wtd?

No treatment

Can you do skin testing if patient is on an antihistamine?

No, decreases sensitivity for about 7 days

What is a gram (+), weakly acid-fast, filamentous branching rod found in soil & water that is an important cause of infection in IC hosts, such as HIV pts or organ transplant recipients?

Nocardia spp. (Usually, N. asteroides)

What is common cause of relapse in patients with schizophrenia?

Non compliance with antipsychotic medicating - so give these patients Long acting injectables of either 1st or 2nd gen

Patient with cirrhosis and spider angioma presents to hospital. EGD reveals varices, wtd?

Non-selective BB- Propanolol, coreg, nadolol

What prophylactic TX is recommended in pts with small nonbleeding varices?

Non-selective beta-blocers *Endoscopic variceal ligation if the pt has a C/I to BBs

43 year old M presents with complaints of upper abdominal pain. He denies any weight loss or diarrhea. PE is normal. Upper endoscopy and biopsy is negative for H. pylori, no ulcer seen. This represents?

Non-ulcer dyspepsia

TX of premature atrial beats?

None, they are completley benign. However, they can be due to an electrolyte abnormality in a pt with a comorbidity (increased age, renal failure, CHF, etc..) and in those cases should be followed-up with an electrolyte panel.

Approach to Hyperbilirubinemia in Adults

Note normally bilirubin is around 0.2- 1 mg/dL of which direct will be < 0.2mg/dL Mainly Unconjugated overproduction - hemolysis i. unconj hyperbili - NEGATIVE BILIRUBIN URINE ASSAY BUT POS URINE UROBILINOGEN ASSAY - overproduction due to hemolysis - reduced uptake (drugs, portosystemic shunt) - Conjugation defect (i.e. Gilbert's Syndrome) ii. Mainly Conjugated (bilirubin in urine, scleral icterus, jaundiced skin) Evaluate Liver Enzyme Pattern i. Predominantly elevated AST + ALT - viral hepatitis, AI hepatitis (alk phos also), Toxin/drug related hepatitis, hemachromatosis (SKIN PIGMENTATION, DIABETES, HEART FAILURE, CIRRHOSIS), ischemic hepatitis, alcoholic hepatitis Normal AS, ALT, Alk Phos i. Dubiin-Johnson ii. Rotor Syndrome - benign, hereditary condition w/chronic or fluctuating conjugated hyperbilirubinemia due to defect in hepatic sec of bilirubin Predominantly Elevated Alkaline Phosphatase i. cholestastis of pregnancy ii. malignancy - pancreas, ampullary iii. cholangiocarcinoma iv. primary biliary cirrhosis v. primary sclerosing cholangitis vi. choledocolithiasis - NEXT STEP FOR ANYTHING W/INC ALK PHOS: Immediate = RUQ US **** alk phos - indicator of injury to biliary duct; ALT/AST indicators of liver health

What is the best long term management of atrial septal aneurysm?

Nothing- do not even need to resect it

Pt with chest pain, ST elevations and troponins elevated. s/p tPA and chest pain resolved. New blood draw troponin much more elevated. wtd?

Nothing- patients who are reperfused will have a faster peak and higher peak of troponin levels than those not successfully perfused.

What is best treatment strategy for new onset blood tinged sputum in an afebrile patient with acute bronchitis but no significant signs of more serious disease?

Observation + close clinical follow up - acute bronchitis is a common cause of blood tinged sputum + mostly viral in etiology

How do you treat LCIS?

Observation or Tamoxifen is ER+

Obstructive Vs Restrictive Lung Disease

Obstructive Lung Disease - FEV1: < 80% - FEV1/FVC: <70% - FVC: normal to dec - RV inc, TLC inc, VC inc, - diseases include I. emphysema ii. chronic bronchitis iii. asthma Restrictive Lung Disease - FEV1: <80% - FEV/FVC: >70% - FVC: <80% - diseases include: I. obesity ii. panacinar emphysema iii. interstitial lung disase iv. sarcoidosis v. asbestosis vi. heart failure vii. MSK deformity viii. neuromuscular disease - RV normal or dec, TLC dec, VC dec or normal

Cerebral salt-wasting syndrome

Occurs in pts with SAH Pathology includes: 1. Inappropriate secretion of vasopressin (water retention) 2. Increased secretion of A/BNP (Cerebral salt wasting)

CO2 Narcosis

Occurs when paCO2 > 60 - see signs of CNS depression - i.e. lethargy, confusion, tremors, etc - note above slide with anion gap acidosis due to uremic toxins in AKI - test q may ask to differentiate between coexisting CO2 narcosis + AKI induced acidosis. Test Q on uworld presented that AKI gave non anion gap metabolic acidosis (therefore, uremic encephalopathy was not a factor) and CO2 narcosis occurred in coexisting respiratory acidosis that cause the lethargy sx

What is the treatment regimen for H. pylori?

PAC:PPI, Amoxicillin and Clarithromycin for 14 days or MOC: Metronidazole, omeprazole, clarithromycin for 14 days

Young man brought in to the ER with severe chest pain. EKG shows ST elevations and MI is diagnosed. His UDS is positive for cocaine. WTD? If his BP 160/100 wtd?

PCI Give benzos- # 1 thing to do is calm patient down, then can give nitrates and ASA

What factors have shown to improve survival in patients with MI?

PCI Thrombolytic therapy after q wave MI BB ASA ACEi stop smoking statins ICD (40 days later)

Pt with CP for 3 hours with ST elevations in V2-4. Troponins +. tPA was given within 30 minutes of arrival. Pt developed crackles in the lungs and SOB. What is the best management?

PCI now b/c patient unstable

55 year old with recurrent pain and swelling of shoulders and knee for several years. Unintentionally lost 15 lbs. LAD positive. Aspiration of knee shows 13000 WBCs. wtd?

PCR of Synovial fluid for T. whippelei

In what conditions do you have hyperkinetic pulse?

PDA, thyrotoxicosis

Bouchard nodes

PIP

Elderly patient with C diff. How to treat?

PO Vanc or Fidaxomycin

Pt with C diff and WBC >15000. How to treat?

PO Vanc or fidaxomycin

Pt with C. diff and WBCs 13,000 received a course of metronidazole 5 weeks ago. She then returned to the clinic 2 weeks after that still with diarrhea and took another course of flagella. She now again presents with diarrhea. How to treat?

PO Vancomycin Pulse therapy. 125 mg QID x 7-14 days, then BID for 7 days, then qd x 7 days then every other day for 7 days then every 3rd day for 14 days

45 year old M with hypercholesterolemia and smoking presents with 2 hours of chest pain. EKG shows no ischemic changes. Cardiac enzymes are negative, TTE normal. He denies any history of odynophagia or dysphagia. The next step in management of this patient is?

PPI

An elderly patient has GERD not responding to H2 blockers undergoes EGD and is found to have stricture. Pt undergoes dilation of stricture and biopsy is negative for malignancy. What is the best way to manage this patient long term?

PPI lifelong

In what conditions is S2 split increased and P2 closes much later?

PS Pulm HTN (Loud S2) RBBB

Black Stools + NSAIDS - what do you think?

PUD

What are the differential diagnoses for upper GI bleed?

PUD, Varices, Mallory Weiss tear, Splenic V thrombosis

What is winters formula & when is it used?

PaCO2 = 1.5 (HCO3-) + 8 *Use this to determine what the expected PaCO2 should be. If it is within +/- 2 the pt is appropriately compensating with respiration

What is the MCC of asymptomatic elevation of ALK-P in an elderly pt?

Pagets DS of the bone (osteitis deformans)

Paronychia

Pain, redness, swelling of nail folds 2/2 placing hands in water for long periods of time and infection with Staph or Candida

Pt with history of pancreatitis twice in the past year presents with abdominal pain radiating to back. AST/ALT normal. TGs 350, Lipase elevated. ERCP reveals contents flowing normally through the ventral duct but the dorsal duct is dilated and content is moving sluggishly through minor papilla. Most likely reason for pancreatitis? Treatment?

Pancreatic Divisum; treat with sphincterotomy

42y/o Caucasian man with hx of chornic alcoholism admitted to hospital for acute pancreatitis - treated supportively w/IV fluids + meperidine + given nothing by mouth. After several days, WBC + Serum amylase dec so he is discharged home. Vital signs stable. Lab eval shows marked inc. in serum amylase to 308 - what is dx?

Pancreatic Pseudocyst

What are the main categories to consider when evaluating a patient for malabsorption?

Pancreatitis Bile salt problem Mucosal Problem Lymphatic issue Misc- ZE, Carcinoid

64 y/o F comes to hospital w "irritating sore throat for 3 months". Admits to smoking 1 pack of cigs daily for past 29 years + continues to smoke. Jailed twice for alcohol + went to AA last year. PE shows 1.5 cm R cervical lymph node - rest of exam normal. Biopsy lymph node shows metastatic squamous cell carcinoma. Ct chest is (-). Best step in management?

Panendsocopy

Young woman presents to you after unprotected sexual encounter with a person who has multiple sexual partners and he had a wart on his penis. Pt is worried she might catch it. wtd next?

Pap smear

Pt with long standing cirrhosis is brought in with lethargy, asterixis, and ascites. INR 3, Platelets 40,000. wtd next?

Paracentesis

Malaria

Pathogenesis - transmission of plasmodium falciparum, P vivax, P ovale, or P malariae parasites by the bite of infected anopheles mosquito CFs - *hallmark = CYCLIC FEVER coinciding with plasmodium induced RBC lysis* - nonspecific malaise, headache, nausea, vomiting, abd pain, diarrhea, myalgia, pallor, *jaundice, petechiae, hepatosplenomegaly* Complications - *children: seizure, coma, hypoglycemia, metabolic acidosis - * adults: jaundice, ARF, acute pulmonary edema* Dx - *thin + thick peripheral blood smears = gold std* - *ANEMIA + THROMBOCYTOPENIA* Protection - hemoglobinopathies -Hgb S, Hgb C, thalassemia - partial immunity from previous malarial illness Prevention - Antimalarial drugs - atovaquone-proguanil, doxycline, mefloquine, chloroquine, hydroxychloroquine Differentials: I. babesiosis - similar to Malaria but found in *NE US + Midwestern US* ii. mosquito born dengue fever- see retro orbital pain, marked muscle + joint pains (esp pronounced), rash, leukopenia*

Charcot Joint Arthropathy (neurogenic arthropathy)

Pathophysiology *decreased proprioception, pain, and temperature perception which occur due to following listed conditions causing loss of NORMAL NEUROLOGIC INPUT (*NERVE DAMAGE*) causing unknown trauma of patients to feet. Associated Conditions *understand the concept of peripheral neuropathy as being the cause* - vitamin B12 deficiency - Diabetes - Peripheral Nerve damage - Spinal Cord Injury - Syringomyelia - Tabes dorsalis (tertiary syphilis) Pathophysiology - patients unknowingly traumatize their weight bearing joints causing secondary degenerative joint disease, joint deformation, functional limitation Clincial Manifestations - *deformed joints* - Lacking/decreased senseation (proprioception, pain, temperature) with *loss of neurologic input* - arthritis or arthropathy - *mild pain* - fractures (may be unsuspected by patient) - *degenerative join disease + loss bodies on joint imaging* Management - treat underlying condition - mechanical devices (assist in weight bearing + decrease further trauma) - xrays if trauma is present

Acute Exacerbation of chronic Obstructive Pulmonary Disease (COPD)

Pathophysiology - airway obstruction due to infectious/inflammatory mucosal edema, bronchial smooth muscle hypertrophy, bronchial submucosal gland hyperplasia Diagnostic Testing - chest x ray i. hyperinflation (flattened diaphragms) - ABG i. hypoxia, CO2 retention, *respiratory acidosis +/- metabolic alkalosis compensation* (*vs respiratory alkalosis in PE*) - CULTURE - NOT INDICATED - won't see infiltrates, may see inc WBC - PE: bilateral wheezing + prolonged expiration w/end expiratory wheezes + crackles at lung bases + hyperinflation (increased resonance on percussion) + maybe distant heart sounds Management - *oxygen (target saturation is 88-92%)* - *inhaled bronchodilators* (albuterol + ipratropium) (*short acting antimuscarinic + beta adrenergic agonist* better than either one alone - *test question to know both*) - *systemic(NOT INHALED) glucocorticoids* (dec inflammation associated with COPD; dec risk of relapse + tx failure) (*prednisone 40 mg daily for mild dz; IV methylprednisolone for moderate to severe dz*) *above 3 are trifecta that must be given in acute exacerbation* *the following are conditional items that are administered* - *antibiotics if >1 cardinal symptom (1); moderate to severe exacerbation (2); or those on MECH VENTILATION (3)* i. inc dyspnea ii. inc cough (frequent + more severe) iii. inc sputum production (change in color + volume) - the antibiotics are administered without culture - targeting *HAEMOPHILUS, MORAXELLA, S PNEUMO* - give *MACROLIDES (AZITHRO), FLUOROQUIHNIOLONES, PCN/Beta-Lac Inhibs* - give *3-7 days* - *if moderate to severe exacerbation - i. NPPV - give if TRIFECTA IS NOT ENOUGH* (noninvasive positive pressure ventilation) ii. Antibiotics - tracheal intubation IF i. no improvement with NPPV (LAST RESORT) FOR 2 HOURS OR ii. if NPPV is contraindicated *note digital clubbing - IS NOT feature of AECOPD - indicates either CF, lung cancer, etc*

When has serial monitoring of BNP not shown to decease mortality?

Patients >75 years of age

Overview of Hep B Virus Treatment

Patients that should be treated - acute liver failure - clinical complications of cirrhosis - advanced cirrhosis with high serum HBV DNA - patients without cirrhosis but with positive HBeAg, HBV DNA >20,000 + serum ALT >2x upper limit of normal - patients whose HBV must be prevented from reactivating during chemotx or immunosuppression Available txs - *ENTECAVIR (CAN USE IN DECMP CIRRHOSIS) OR TENOFOVIR (PREFERRED DRUG)*

Which patients are unable to undergo exercise EKG stress testing?

Patients with pacemaker, LBBB, repolarization abnormalities, left anterior hemi-block

What is caused by a dietary deficiency of niacin?

Pellegra: ("4D's) -Diarrhea, Dermatitis, Dementia, & Death *Also seen in alcoholics, pts with hartnup DS, & carcinoid syndrome

60 year old M with 10 day history of severe oral sores and rash on his trunk and upper arms. On PE you see multiple oral erosions on the buccal mucosa and tongue. There are numerous edematous papule and bull (1-1.5 cm) in diameter. Pressure applied to the edge of one of the blisters results in extension. Most likely diagnosis?

Pemphigous vulgaris 2/2 Ab to desmoglein 1 and 3 protein- intraepidermal bullae

53 y/o man comes to ED w/sudden onset intense epigastric pain. Vomited once + noticed sudden, dull, aching, diffuse abdominal pain. Had episodic + nonspecific abd pain for past several months. Abd US 2 weeks ago showed stones in gallbladder. 45 pack year smoking history. 100.4 temperature. BP of 160/95, rectal exam shows empty vault. No guarding or palpable mass; pain in upper abdomen upon deep inspiration + palpation. Xray shown. What is dx?

Perforated Peptic Ulcer

Pt post CABG 4 years ago now has increasing SOB for the past 3-4 months. Exam reveals JVD 9 cm, Hepatomegaly and pedal edema. EKG and CXR normal. Most likely diagnosis?

Pericarditis

What is a common side effect of dihydropyridine CCBs (Amlodipine, Nicardipine, Nifedipine, "-ipine")?

Peripheral edema. Studies have shown that the administration of an ACE-inhibitor in combo with these CCBs will reduce the risk of developing peripheral edema

What conditions other than ZE can you see elevated Gastrin levels?

Pernicious anemia/chronic gastritis renal failure hyperthyroidism PPI

What is a drug that is used to treat dysuria of cystitis?

Phenazopyridine - an analgesic for urinary tract mucosa

What occupation associated with neurocysicercosis?

Pig farmer

Patient is taking pill daily for STD presents with painful swallowing. Most likely cause?

Pill esophagitis 2/2 Doxy

What is the best test in a patient with rhinitis and ocular itching exacerbated by pollen?

Pin Prick test

In a patient with heart disease, multiple PVCs and Low EF, what should you do?

Place ICD

Aspiration Syndromes

Pneumonia - Pathophysiology i. lung parenchyma *infection* ii. aspiration of *oropharyngeal* cavity microbes (*anerobes*) - CFs - more often *in patients with impaired consciousness - following OD, seizure, or anesthetic use. I. present *days* after aspiration event ii. *fever*, cough, inc sputum iii. CXR infiltrate in dependent lung segment (*classically Right Lower Lobe*) iv. can progress to *abscess* - Management I. *antibiotics - clindamycin or B-lactam + B-lactamase inhibitor* (*ANEROBE COVERAGE*) Pneumonitis - Pathophysiology I. lunch parenchyma *inflammation* ii, aspiration of *gastric contents* - CFs I. present *hours* after aspiration ii. range from *no sx to nonproductive cough*, *DEC O2, respiratory distress* iii. *bilateral infiltrates on CXR* - Management I. *SUPPORTIVE - NO ANTIBIOTICS*

Elderly patient presents with chronic constipation not responding to increased fiber. Wtd?

Polyethylene glycol

Alcoholic patient presents with tense non pruritic blisters in sun exposed areas on hands. Also has hyperpigmentation. Most likely diagnosis? Pathophysiology? Screening? Treatment?

Porphyrea cutanea tarda 2/2 decrease uroporphyrinogen activity leading to increased uroporphyrinogen under skin Screening: urine will have increased urine coproporphyrins and uroporphyrins Treatment: phlebotomy, anti-malarials

What GI problems can result in osteomalacia?

Post gastrectomy (43%) Celiac sprue (26%) Biliary cirrhosis Pancreatic insufficiency Crohn's disease

35 year old F presents with complaints of abdominal fullness and discomfort and occasional vomiting for the past 2 years. She has not lost weight. Exam is normal and so are all labs. EGD and US of abdomen also normal. Most likely diagnosis?

Post prandial Distress Syndrome

Pt presents with complaints of regurgitating food eaten several days ago. He has occasional dysphagia. Dx?

Pouch in hypo pharynx seen on barium swallow

Patient with history of subtotal colectomy with ill-anal anastamosis presents a year later with increased bowel movements >6/day and blood. Stool cultures negative. Most likely diagnosis?

Pouchitis- treat with Flagyl

Clinical Features of hepatic encephalopathy

Precipitating Factors I. drugs -sedatives, narcotics ii. hypovolemia - diarrhea, vomiting, diuretics, high vol paracentesis **** iii. excess nitrogen load - GI bleed, constipation, high protein diet iv. hypokalemia + metabolic alkalosis v. hypoxia + hypoglycemia vi. infection (eg, pneumonia, UTI, spontaneous bacterial peritonitis) vii. Portosystemic Shunting (i.e. surgical shunts) Clinical Presentation i. stage 1 - hypersomnia, insomnia, inverted sleep cycle, slightly impaired cognition, mild confusion, tremor w/possible asterixis ii. stage 2 - lethargy w/slow responses to stimuli, moderate confusion, difficulty writing + slurred speech iii. stage 3 - marked confusion iv. stage 4 - stupor or coma Test Q - if you see PT W/SIGNS OF CIRRHOSIS (PE SIGNS) + PRESENTS W/ALTERED MENTAL STATUS - AUTOMATICALLY NEXT STEP = SERUM AMMONIA CONC. **** - TEST Q - due to inability to break ammonia into urea. Treatment 1. SUPPORTIVE CARE (VOLUME REPLETION IF NEEDED, ELECTROLYTES - CHECK NA+ THEN K+ - FOLLOW THIS ALGORITHM) 2. NUTRITION - WITHOUT PROTEIN RESTRICTION 3. TREAT PRECIPITATING CAUSSE - i.e. gi bleed, hypovolemia, infection, electrolyte abn. 4. Last but not least LOWER SERUM AMMONIA i. LACTULOSE. RIFAXIMIN AT 48 HOURS IF NO IMPROVEMENT(ANTIBIOTIC) (dec. ammonia producing bacteria in colon), FINALLY LAXATIVES ***** (KNOW ALL #) KNOW ORDERED APPROACH OF TX

Adverse effects of drug regimens for pneumocystis pneumonia

Preferred Regimen - TMP-SMX (IV for acutely ill, oral for non acutely ill) - *rash, neutropenia, hyperkalemia, elevated transaminases* Alternative Regimens - Pentamidine (IV) - nephrotoxicity, hypotension, hypoglycemia, cardiac arrhythmias, pancreatitis, elevated transaminases Atovaquone (oral) - GI distress, rash Trimethoprim + Dapsone (both oral) - dapsone - hemolytic anemia (check for G6PD deficiency) Clnidamycin (IV or oral) + Primaquine (oral) -- primaquine: methemoglobinemia, hemolytic anemia (check for G6PD deficiency)

Disseminated Gonococcal Infection (AKA Gonococcal Septic Arthritis)

Presentation - classic triad: polyarhtralgia (often at WRIST, ELBOW, ANKLE w/o warmth + effusion), tenosynovitis (wrist, ankles, fingers and knees), painless vesiiculopustular skin lesions OR - purulent arthritis (SEPTIC ARTHRITIS) without skin lesions Dx - confirm with: *gram stain of synovial fluid, blood cultures, or genital/pharyngeal mucosal nucleic acid amplification tests& - synovial fluid analysis may show *wbc of up to 50,000 cells/mm3 (LESS THAN SEPTIC ARTHRITIS) - ARTHROCENTESIS IS FIRST STEP IF PURULENT JOINT* - recommend *HIV + Syphilis screen* - *IF THIS DISEMMINATED GONOCOC. INFX IS RECURRENT -CHECK COMPLEMENT LEVEL* Tx - IV ceftriaxone 1g/day for 7-14 days + switch to PO cefiximie when clinically improved - Joint drainage if purulent - empiric Azithromycin (single 1 g dose) OR Doxycycline for 7 days for concomitant chlamydial infection (*ACD = chlamydia w/doxy or azithro*) - *tx sexual partners* - History of UNPROTECTED SEX WITH NEW PARTNER

Tuberculosis

Presentation - cough,*hemoptysis*, weight loss, *intermittent fevers* - apical cavitary lesions instead of solid appearing mass - may see kidney involvement i. dysuria ii. secondary amyloidosis - GIVE NEPHROTIC RANGE PROTEIN LOSS (>3.5g/day) - may see cutaneous findings I. scrofuloderma overlying infected lymph nodes ii. lupus vulgaris - facial eruption RFs - HIV - immigration from endemic country - homelessness - residence in institutional setting or IV drug/alcohol abuse Xray findings - hilar adenopathy - cavitary/patchy lung lesions

Community Acquire Pneumonia (CAP)

Presentation - fever - cough w/or w/o sputum production - pleuritic chest pain - tachycardia/tachypnea - dyspnea - maybe GI complaints - N/V/Abd pain Dx - *CXR - showing infiltrate = gold standard, OFTEN NEXT STEP ON SUSPICION* I. *can be normal in neutropenic pts, dehydration, atypical infection such as pneumocystis, or even w/in early <24 hours of CAP*

Mycoplasma Pneumonia

Presentation - fever - dry cough - *bilateral perihilar infiltrates on CXR* - extrapulm complications - GI upset, rash, renal failure Next Step - treat empirically with coverage via Azithro, Levofloxacin - no need usually to test for organism

pneumocystis pneumonia

Presentation - CD4 < 200/uL - common cause of dyspnea in pts with HIV/AIDS Imaging - *diffuse interstitial pattern*

Pulmonary Thromboembolism

Presentation - sudden onset pleuritic chest pain - cough - dyspnea - hemoptysis** - tachypnea ** - low grade fever + mild leukocytosis Lab Tests - EKG - *RIGHT AXIS DEVIATION* - CXR - *NORMAL* CT - *WEDGE SHAPED INFARCTION* - PATHOGNOMONIC I. occurs distal to completely occluded pulmonary artery - may see *PLEURAL EFFUSION* ON AFFECTED SIDE - Pathophysiology - V/Q scan - DO THIS IN PATIENT THAT HAS RENAL INSUFFICIENCY (OVER CTA) I. should see Ventilation is good, PERFUSION IS PROBLEMATIC *Treatment* - on suspicion of PE, even w/o dx, IMMEDIATELY DO HEPARIN DRIP I. can use fondaparinux (Xa inhibitor), LMWH (enoxaparin), rivaroxaban (oral Xa inhibitor), - IN RENAL INSUFFIC AS DEF BY GFR < 30 - MUST USE LMWH (others are renally processed) - Give heparin until goal PTT > 1.5-2 times normal - THEN INITIATE WARFARIN which will take up to 5-7 days to reach therapeutic levels (bridge with heparin due to warfarin skin necrosis effect*)

Lung Abscess

Presentation - thick walled cavitary lesions*

ADPKD (autosomal dominant polycystic kidney disease)

Presentation (UWORLD Q) - episodes of bilateral flank pain over the past several years - nocturia 2-3 times per night for past 10 years - Mass at right flank on deep palpation - HTN - *FAM HX* Characteristics - Pts often have *HTN + Palpable kidneys (often times right kidney is only one to be palpated b/c lies lower than left kidney* - *liver may be palpable due to cystic enlargement* - *multiple renal cysts, intermittent flank pain, UTIs, Nephrolithiasis* - *MICROHEMATURIA (10-12 RBCs HPF) OR GROSS HEMATURIA* Extrarenal complications - *hepatic cysts - MOST COMMON MANIFESTATION* - valvular heart disease - most often *mitral valve prolapse + aortic regurgitation* - colonic diverticula - abdominal wall + inguinal hernia - *MOST COMMON COMPLICATION = INTRACRANIAL BERRY ANEURYSM*

Absolute Contraindications for thrombolytic therapy

Previous hemorrhagic stroke Other CVA events <1 year Intracranial neoplasm Active internal bleed

Primary vs Secondary Hypogonadism

Primary Hypogonadism - low Testosterone + above normal LH and FSH Secondary Hypogonadism - also known as hypogonadotropic hypogonadism I. low testosterone + low OR NORMAL LH and FSH ii. found in DMTII - is a form of *CENTRAL HYPOGONADISM - THEREFORE WORKUP: 1st do MORNING TESTOSTERONE; 2nd DO GONADOTROPIN LEVELS (FSH + LH); 3rd CHECK PROLACTIN LEVELS* I. *if Prl levels high, 4th step = MRI* Physiology of Prolactin - recall *high prolactin levels will suppress GnRH - giving low FSH + LH giving low Testosterone and SECONDARY (CENTRAL) HYPOGONADISM* ***as a result - IN ALL DIABETICS - EARLY MORNING TESTOSTERONE LEVELS COLLECTED TO SCREEN FOR TESTOSTERONE DEFICIENCY

Statins- effect on lipids/cholesterol and side effects?

Primary LDL Tx decrease LDL, small decrease TGAs, increase HDL increase LFTs, CPK, weight gain and glucose intolerance

Primary vs Secondary Polycythemia

Primary Polycythemia - *low erythropoietin* - polycythemia vera - *JAK2 mutation* - primary familial + congenital polycythemia: erythropoietin receptor mutation Secondary Polycythemia - *high erythropoietin* - hypoxemia (lung disease, smoking, OSA, high altitude) - congenital - high affinity Hb - Hepatic or renal tumor - post renal transplantation - androgen supplementation (i.e. testosterone) Presentation - headache, dizziness, and visual disturbances - due to *hyperviscosity* - *pruritis especially after warm shower* due to *mass release histamine (mast cells) + PGs (RBCs)* - *GI sx - peptic ulceration* - due to histamine release - *HTN* - due to inc in blood volume - PE: *facial plethora, splenomegaly*, hepatomegaly Labs - *elevated Hb/Hct, platelets, and WBC* - *normal resting O2 sat* Complications - *risk of both thrombosis (markedly elevated platelet count) + bleeding out (impaired platelet function)*

Sjogren Syndrome

Primary SS - no associated connect tissue disease Secondary SS - comorbid CT disease *(i.e. SLE, RA, Scleroderma, hashimoto's lymphocytic thyroiditis)* Clinical Features - *sicca syndrome = any combo following 3* i. ocular sx - *dry eyes, dec tears = keratoconjuctivitis sicca* ii. oral sx - *dry mouth = xerostoma* + swollen salivary glands iii. *dyspareunia* - *occasionally may see optic neuritis* rather than keratoconjunctivitis sicca Tests - objective signs of *dec lacrimation - confirm via schirmer test* - Autoantibodies to *Ro (SSA) & La (SSB) & ANA* - *salivary gland bx w/ focal lymphocytic sialoadenitis (autoimmune sialedinitis)* I. bilateral enlargement of parotid + submandibular glands Dx - diagnosed when subjective + objective evidence of dry eyes + dry mouth exists in presence of either histologic evidence of lymphocytic infiltration of salivary glands or serum antibodies against SSA (Ro) + SSB (La) Extraglandular Features - arthritis - lymphadenopathy - Raynaud phenomenon - vasculitis

stage of syphilis

Primary Syphilis - painless genital ulcer (chancre) - Tx = PCN G (IM) x1 dose; if PCN allergic, Doxycycline x14 days Secondary Syphilis - diffuse rash (*MACULOPAPULAR RASH starts ON TRUNK, EXTENDS TO PERIPHERY ON PALMS + SOLES*), *generalized lymphadenopathy*, *condyloma lata (painless, mucosal, warty lesions on penis)*, oral lesions, hepatitis - *initial testing - RPR + VDRL; confirm with FTA-ABS (more specific)* - Tx = PCN G (IM) x1; if PCN allergic, Doxycycline x14 days I. possible *SE: Jarisch-Herxheimer reaction - acute febrile reaction with headaches + myalgias)* Latent Syphilis - Asx - Tx = PCN G (IM) x3 doses; if PCN allergic, Doxycycline x 28 days Tertiary Syphilis - CNS sx [tabes dorsalis (dorsal column destroyed so impaired proprioception, ataxia at night, absence of DTR, pos Romberg), Argyll Robertson pupil (*A*ccomodation *R*eflex *P*resent but *P*upillary *R*eflex *A*bsent), dementia]; CV sx - aortic aneurysm, aortic insufficiency; Cutaneous - gummas (granulomas that are most common in liver) - Tx = PCN G (IV) x 14 days; if PCN allergic, Ceftriaxone x14 days Pregnancy - Intrapartum transmission + congenital disease - PCN - desensitize if allergic + finish course

Fibrates- effect on lipids/cholesterol and side effects?

Primary TGAs TX-increase/no change LDL, decrease TGAs, increase HDL gall stones, hepatoma

Meningococcal Vaccination

Primary Vaccination - age 11-12 (or age 13-18 if not previously vaccinated) - optional at age 19-2 (if not previously vaccinated) I. high risk patients ii. first year college students living in residential housing Booster Vaccination - age 16-21 if primary vaccination before 16th birthday Age > 21 - consider if high risk

26 year old woman with jaundice. ALT 100, alk phos 550, ANA negative, ASMA negative, AMA positive, IgM elevated, IgG normal. Liver biopsy with lymphocytic destruction of bile ducts. Most likely diagnosis? Treatment?

Primary biliary cirrhosis Give ursodeoxycholic acid which will delay progression but doesn't prevent it. Will ultimately need transplant

26 year old F with jaundice. ALT 40, alk phos 290, ANA negative, ASMA negative, AMA negative, IgM normal, IgG normal. Liver biopsy with mild inflammation with concentric fibrosis around bile ducts. Most likely diagnosis? treatment?

Primary sclerosing cholangitis- treat UC

Nicotinic acid- effect on lipids/cholesterol and side effects?

Primary treatment for increase HDL, secondary for LDL or TGAs; decrease LDL, bigger decrease TGAs, large increase HDL abdominal pain, nausea, flushing, dry skin

77 year old M admitted with pneumonia and started on Rocephin and Levaquin. What would likely decrease the risk of this patient getting C. diff?

Probiotics

Pt presents with wide complex tachycardia. HR 200/min. QRS 0.14s, PR <0.12s. Pt has h/o WPW. Unable to decide if it is SVT with aberration or V tach. You would treat this patient with?

Procainamide

What are the toxic effects of quinidine?

Prolongs QT, decreases platelets, cold AIHA

Management of a diabetic ulcer?

Proper wound care and debridement. Along with, HOSP admission & IV ABX

Prophylaxis & TX for cerebral toxoplasmosis?

Propylaxis: TMP-SMX TX: Sulfadiazine + Pyrimethamine

When is TEE the diagnostic modality of choice?

Prosthetic valve endocarditis Descending aortic aneurysm Left atrial thrombus, PFO

Pts with an established DX of nephrolithiasis should be advised to restrict what?

Protein & oxalate intake in their diet

Pt with history of acute pancreatitis 2 weeks ago presents for follow up. A mass in the abdomen is palpable, non-tender, bowel sounds heard. Amylase 435. What is the most likely diagnosis?

Pseudocyst

A nail puncture wound in an adult resulting in osteomyelitis is most likely due to?

Pseudomonas aeruginosa

In what condition would have pulse alternating between high amplitude then low amplitude? What is this called?

Pulsus alternans- you have it in severe heart failure

What type of pulse do you have in HOCM?

Pulsus biferiens- fast rising pulse (rapid upstroke) and bifid or trifid pulse at apex- as there is less blood in the LV there is more obstruction in LVOT

In what conditions would you have SBP lower on inspiration than expiration? What is this called?

Pulsus paradoxus- see it in tamponade SVC obstruction Pulmonary obstruction PE RV infarct

Small vs Large fiber neuropathy

Pure small fiber neuropathy - PAIN, ALLODYNIA, PARESTHESIAS - ANKLE JERKS PRESERVED Pure Large Fiber Neuropathy - LESS PAIN, MORE NUMBNESS + PRESSURE + PROPRIOCEPTION + VIBRATORY SENSATION DECREASE, LOSS ANKLE JERKS

Pt with no med history wants advice on decreasing CAD risk. Which one of the following is the most important advice. He is a smoker, HTN and LDL 100.

Quitting smoking

Rheumatoid Arthritis vs OA and treatment of Rheumatoid Arthritis

RA - will see *progressive erosion of bone + cartilage and significant joint destruction + deformity* - *radiographs - classic EROSIONS and or/PERIARTICULAR OSTEOPENIA* - *HAS MARKED MORNING STIFFNESS > 30 MINUTES)* - *EXTRAPULM MANIFESTATION - MAY SEE PLEURAL EFFUSION* - Tx of RA i. *START WITH NON BIOLOGIC DMARD METHOTREXATE (PREFERRED DMARD* which come in nonbiologic = MTX, Hydroxycholorquine, sulfasalazine, leflunomide, azathioprine versus biologic = etanercept, infliximab, adalimumab, tocilizumab, rituximab) a. *b/f starting MTX, must check for TB, HEP B, HEP C; don't take if wanting to become pregnant, if severe renal insufficiency, liver disease, or excess alcohol intake* ii. *if after 6 mos, no response, then add biologic DMARD - such as TNF alpha inhibitors (eteanercept, infliximab)* iii. drugs like glucocorticoids + NSAIDS + COX-2 Inhibitors are adjunctive tx but do not reduce disease progression

Nursing student started using latex glove for the first time and presents with hives. Best test to confirm is?

RAST for allergy to latex do NOT want to do skin test because could cause anaphylaxis

Squamos Cell Carcinoma

RFs - UV, ionizing radiation - immunosuppression - *chronic scars/wounds/burn injuries - classic when new lesion develops on one of these old ones that is oozing, crusting, etc* CFs - scaly plaques/nodules - *rough scaly nodule or nonhealing, painless ulcer developing in setting of scar or chronic inflammatory lesion* (TEST PREZ) - +/- hyperkeratosis or ulceration - *neurologic signs with perineural invasion - IF YOU SEE SKIN CANCER WITH NEUROLOGIC SIGNS - THINK SCC - numbness, paresthesias (PATHOGNOMONIC ALMOST)* Dx - *biopsy (PUNCH, SHAVE, OR EXCISIONAL) - dysplastic/anaplastic keratinocytes* Tx - *small or low risk lesions - surgical excision or local destruction via cryotherapy, electrodessication; lesions of cosmetically sensitive regions - do "Mohs micrographic surgery* Miscellaneous - *SCC arising in a wound or burn = Marjolin ulcer - INC RISK OF METS*

Clinical Features of Cervical Actinomycosis

RFs - dental caries, extractions, infected tooth - gingivitis and/or gingival trauma - diabetes or immunosuppression - malnutrition - local tissue damage from malignancy or irradiation Clinical Presentation - chronic, slowly progressive, non tender indurated mass - extends through tissue planes to form *abscess* (*CLASSIC ABSCESS IN REGION OF HEAD + NECK)*, fistula, and draining sinus tract - *mandible* is most commonly involved site Actinomycosis facts - *gram (+), filamentous branching, ANEROBIC bacteria that colonizes oral cavity* - organism forms characteristic sulfur granules (yellow) in infected tissue. - Diagnosis - confirmed by tissue culture, but actinomyces is a fastidious organism that can take up to 3 weeks to grow in culture - Treatment: *HIGH DOSE PCN often for a prolonged period (12 weeks); if allergic to PCN, then do clindamycin*

Pulmonary Aspergillosis

RFs - immunocompromised - asthma, COPD - cavitary lung disease (i.e. Tb) - sarcoidosis, malignancy Clinical Presentation - *pleuritic chest pain* - dyspnea - cough + *hemoptysis* Lab/Imaging -* Positive Aspergillus IgG PLUS radiographic evidence*: I. *single/multiple nodules ii. cavities (+/- fungal ball) - a fungal ball presentation: *chronic cough + hemoptysis + cavitary lesion on CXR; occur in PREEXISTING CAVITIES FORMED BY IE TB OR PT W/PREV SARCOIDOSIS, BRONCHIECTASIS, BRONCHIAL CYSTS* iii. consolidation iv. peribronchial infiltrates* Treatment - aspergilloma - surgical resection - invasive aspergillosis - voriconazole or caspofungin

Clinical Features of Splenic Abscess

RFs - infection (i.e. *infective endocarditis - MOST COMMONLY ASSOCIATED WITH SPLENIC ABSCESS*,) with hematogenous spread -hemoglobinopathy (i.e. sickle cell disease) - immunosuppression (i.e. HIV) - IVDU - trauma Clinical Presentation - classic triad *fever, leukocytosis, LUQ pain* - *left sided pleuritic chest pain with LEFT PLEURAL EFFUSION* - possible splenomegaly - most commonly due to *staphylococcus, streptococcus, and salmonella* - usually diagnosed by *abdominal CT* - splenic fluid collection Tx - *broad spectrum antibiotics + splenectomy* - possible percutaneous drainage in poor surgical candidates Example of Infectious Endocarditis and how it works - likely mechanism include hematogenous seeding or septic emboli to the spleen.

Overview of Infectious ;Endocarditis

RFs RFs - poor dentition - cardiac causes - i.e. congenital heart disease, valvular abnormalities/repair - intravascular catheters (i.e. hemodialysis catheters) - IVDU PE - skin: osler's nodes (painful, palpable nodes on pads of fingers and toes), subungual hemorrhages (reddish/brown lines under nails), janeway lesions (flat reddish,bluish spots on palms + soles; *due to septic emboli*), petechiae - ocular - Roth's spots (retinal hemorrhages) - cardiac - heart murmurs - GI: splenomegaly - neurologic: sx related to stroke, meningitis, or brain abscess FROM JANE (fever, roth spots, osler nodes, murmur, janeway lesions, anemia, nail hemorrhage (splinter hemorrhages), emboli Lab Imaging/testing - (+) blood culture - INC WBC OR NORMAL (subacute endocarditis) - hematuria/proteinuria (glomerulonephritis) - septic emboli - *TEE - GOLD STANDARD FOR DX* Treatment - initial tx = Vancomycin - Subsequent tx based on cultures Presentation of Infectious Endocarditis - fevers, chills, malaise (*systemic sx)*, *underlying heart condition (heart murmur)*, *indwelling structures (catheters)*, or history of *IVDU*. - most common underlying Valvular disease in Infectious Endocarditis = *MITRAL VALVE PROLAPSE W/COEXISTING MITRAL REGURGITATION* - *second most* common underlying valvular disease = *bicuspid aortic valve with associated aortic stenosis*

Ventilation is a product of?

RR x TV

How to you treat anal cancer affecting anal canal mucosa?

RT + Mitomycin + 5 FU

V3R, V4R

RV RCA

On palpation if you feel sustained Left parasternal heave what conditions should you consider?

RV HTY 2/2 MS, Pulm HTN or PS 2/2 increased pressure overload

On palpation if you feel hyper dynamic impulse in LSB, what conditions should you consider? why does this occur?

RV area- feel in ASD or TR (pulmonary HTN leading cause of TR) 2/2 Increased LV volume

Pt post radiation therapy in the pelvis presents 1.5 years later with rectal bleeds. Colonoscopy shows friable mucosa, atrophy and fibrosis. What is the diagnosis?

Radiation proctitis

Appropriate management of a pt with prostate cancer who has had an orchiectomy who is having bone pain?

Radiation therapy

Infectious Arthritis

Radiograph - normal joint space; soft tissue swelling Cell Count - WBC > 50,000 (up to 150,000)/mL

Patient complaining of palpitations, sweating and low BP about 15 minutes after eating. what is the most likely diagnosis?

Rapid emptying- Dumping syndrome Treat with frequent small meals, complex sugars

Best TX for frostbite injuries?

Rapid re-warming with warm water.

What is a fixed drug reaction?

Rash occurring at the same spot after rechallenge

Tx of pt with A-fib with RVR?

Rate control with BBs or CCBs *If hemodynamically unstable, synchronized electrocardioversion

What is the first-line TX of reactive arthritis?

Reactive arthritis is a seronegative spondyloarthropathy resulting from enteric or GU infection. NSAIDs are the first-line therapy

Nurse gets stuck with a needle treating Hep C patient. Blood is negative for Hep C RNA and Hep C Antibodies. 4 weeks later Viral load is 45,000 copies/ml. wtd next for nurse?

Reassess HCV RNA at 12 weeks. if still high then begin treatment

24 year old F with hair loss. She gave birth to a baby about 2 months ago. wtd?

Reassurance- Telogen efluvium

Young man was picking apples and was stung by a bee. Next day he presents to you with a large wheal on his right arm which is itchy. wtd?

Reassure that this is a normal reaction to insect bite

What can cause erythema multiform?

Recurrent HSV, mycoplasma, PCN, sulfa drugs, phenytoin

What is the MCC of sudden cardiac arrest in the immediate post-infarction period in pts with acute MI?

Reentrant ventricular arrhythmias (eg, V-fib)

70 year old Pt presents for routine checkup. Says lesion on cheek has grown bigger and pigmented gradually over about 10 years. No itching or pain. No complaints about the skin lesion. wtd?

Refer for biopsy to rule out lentigo maligna melanoma which is a precursor to malignant melanoma

What would be concerning on an EKG in a patient who takes digoxin for atrial fibrillation?

Regularized A fib= junctional rhythm Paroxysmal atrial tachycardia with block and PVCs

After DX of a solid testicular mass has been made (painless hard mass in testicle + suggestive U/S), what is the initial step in management?

Removal of the testis & its associated cord (Radical orchiectomy)

Secondary Causes of Hypertension Clues/features

Renal Parenchymal Disease i. elevated serum Cr ii. abnormal unrinalysis (proteinuria, RBC casts) Renovascular disease i. severe hypertension (>180 mm Hg systolic &/or 120mm Hg diastolic) AFTER AGE 55 ii. *possible recurrent flash pulmonary edema* or resistant heart failure iii. unexplained rise in serum Cr iv. abdominal bruit Primary aldosteronism i. easily provoked hypokalemia - especially with even just low dose diuretics ii. slight hypernatremia iii. HTN w/adrenal incidentaloma Pheochromocytoma i. paroxysmal elevated BP w/tachycardia ii. pounding headaches, palpitations, diaphoresis, weight loss iii. HTN w/adrenal incidentaloma Cushing Syndrome i. central obesity, facial plethora ii. proximal muscle weakness, abdominal striae iii. ecchymosis, *amenorrhea/erectile dysfunction* iv. HTN w/adrenal incidentaloma v. *elevated blood glucose, HTN, and weight gain* vi. most cases of cushing syndrome are due to *exogenous glucocorticoid intake, ectopic ACTH production (eg small lung cancer) or ACTH producing pituitary adenomas (cushing disease) vii. associated hypokalemia - implies that sx are very severe - b/c large amounts of cortisol are needed to cross react with aldosterone receptors; most often seen in ACTH producing tumors Primary Adrenal Hypercortisolism i. adrenal adenoma or carcinoma, adrenal hyperplasia = causes Hypothyroidism - fatigue, dry skin, cold intolerance - constipation, weight gain, bradycardia Primary Hyperparathyroidism i. hypercalcemia (polyuria, polydipsia) ii. kidney stones iii. neuropsychiatric presentation (confusion, depression, psychosis) Coarctation of the aorta i. differential hypertension with brachial=femoral pulse delay

What is a systolic-diastolic bruit over the ABD in a pt with HTN & atherosclerosis associated with?

Renal artery stenosis in 40% of the cases

What is an important complication of nephrotic syndrome?

Renal vein thrombosis. Commonly caused by membranous GLN in adults b/c Antithrombin III is lost in the urine.

Pt who has been taking Naproxen for arthralgia for the past couple of weeks presents with complaints of fatigue and bright red blood per rectum. He says that 1 week ago he had black tarry stools. Hb 9 g. EGD is performed and does not reveal any source of bleeding. wtd?

Repeat EGD and if negative do colonscopy

What would be the next step if you find 2 cm pancreatic cyst, 4 mm duct and on EUS no solid elements or wall thickening?

Repeat MRI or CT- MR in 2-3 yrs

What would be the next step if you find 1.5 cm pancreatic cyst, MRCP 3mm duct, pancreatic duct normal, no thickening of wall?

Repeat MRI or CT-MR in 2-3 years

How would you treat a patient who is found to have dilated lymphatics in the GIT?

Replace long chain fatty acids with medium chain fatty acids. Diagnosis- Intestinal Lymphangiectasia

What would be the next step if you find 1.5 cm pancreatic cyst with ductal dilatation 10 mm on CT Abdomen?

Resect

What would be the next step if you find 1.5 cm pancreatic cystic with solid elements on CT abdomen?

Resect

What is the treatment of patient with Stage II Colon cancer?

Resection

What is the treatment of patient with Stage III Colon cancer?

Resection + 5 FU, + Leucovorin + Oxaliplatin (FOLFOX)

Is obesity restrictive or obstructive lung disease?

Restrictive

3 days Post laparoscopic cholecystectomy, patient complains of nausea, vomiting, upper abdominal pain and chills. Labs show T bill 4.5 mg, ALT 130, Amylase 600. Dx?

Retained common duct stone

What is the MC AE of hydroxychloroquine therapy?

Retinopathy. Pts should have eye examinations every 6 months

70 y/o m pres to ED w/weakness, dizziness, back pain. No N/V/Diarrhea, Chest pain, palpitations, SOB, black stools. PM for DM, Diabetic Nephropathy, retinopathy, HTN, AFib, Chronic Leg cellulitis. Takes warfarin for chronic anticoagulation. BP is 120/70, WBC is 11,000; Hb = 7.0 g/dL. Platelet count is 170,000. Ct shows blob (dark) displacing right kidney anteriorly. What is Dx?

Retroperitoneal Hemorrhage - patient is on ANTICOAGULATION, CT SHOWS DARK MASS DISPLACING RIGHT KIDNEY ANTERIORLY (think hemorrhage); Should see BACK PAIN + SX of HEMODYNAMIC COMPROMISE (NOT SEEN HERE); RFs of age > 60, HTN, alcoholism. - image, Anticoag, back pain - just think hemorrhage

Common Causes of Shoulder Pain

Rotator Cuff Impingement or Tendinopathy - pain with *abduction, + external rotation* - subacromial tenderness - normal range of motion with *(+) impingement tests - i.e. NEER + HAWKINS* - *active ROM dec BUT PASSIVE ROM INTACT* - *same presentation may occur as adhesive capsulitis but MORE PAIN THAN STIFFNESS* Rotator Cuff Tear - similar to rotator cuff tendinopathy - weakness with external rotation - *age > 40* - *active ROM Dec but PASSIVE ROM INTACT* Adhesive capsulitis (frozen shoulder) - decreased *PASSIVE + ACTIVE RANGE OF MOTION* - *more stiffness than pain* - glenohumeral joint loses distensibility due to chronic inflammation, fibrosis - *can be secondary to conditions such as rotator cuff tendinopathy (MOST COMMON), subacromial bursitis, paralytic stroke, DM, or humeral head fracture* - *Dx = >50% reduction in BOTH ACTIVE + PASSIVE ROM on PE* Biceps tendinopathy/rupture - *ANTERIOR* shoulder pain - pain with lifting, carrying, overhead reaching - *bulge halfway down arm* - *weakness less common* - *active ROM dec, PASSIVE ROM INTACT* Glenohumeral OA - uncommon + usually caused by *trauma* - gradual onset of *anterior or deep shoulder pain* -* decreased active+ passive abduction + external rotation (SAME PRES AS ADHESIVE CAPSULITIS EXCEPT ADDITIONAL SIGN HX OF TRAUMA TO SHOULDER*

What are poor prognostic factors in CHF?

S3 Hyponatremia PCWP >12 PAP>50 Peak O2 uptake <14 ml/kg

What are signs of severe AS?

S4, paradoxical split S2, late peaking murmur, ECHO with gradient >40, valve <1cm2

Ascitic fluid protein 1.8 g, serum albumin 3.5 g, ascitic fluid albumin 2.5 g. DDx?

SAAG: <1.1 (exudate) Nephrotic syndrome

Ascitic fluid protein 2.5 g, serum albumin 3.5 g, ascitic fluid albumin 2.5 g. DDx?

SAAG: <1.1 (exudate) Pancreatitis

Ascitic fluid protein 1.5 g, serum albumin 3.5 g, ascitic fluid albumin 2 g. DDx?

SAAG: >1.1 (transudate) Cirrhosis or liver failure

Ascitic fluid protein 2.8 g, serum albumin 3.4 g, ascitic fluid albumin 1.8g. DDx?

SAAG: >1.1 (transudate) right heart failure Budd Chiari Syndrome

A nonhealing, painless, bleeding ulcer that develops associated with a chronic scar suggests?

SCC. Biopsy is recommended

When should you stop a stress test?

ST depression >2mm SBP decrease >15 mmHg VT Chest pain/SOB

Patient who raises iguanas comes to you because of diarrhea and abdominal cramping. Most likely diagnosis?

Salmonella

Pt presents with diarrhea with abdominal cramping after eating raw eggs. Most likely diagnosis?

Salmonella

Pt has allergy to ASA. Which NSAID can you use?

Salsalate

30 year old AA pt is brought to the ER with palpitations. He is found to have arrhythmia and is hypotensive. He is defibrillated twice and an IV medication is started. PE shows cervical, axillary and epitrocheal LAD. Most likely underlying disease?

Sarcoidosis

Patient presents with red painful nodules on her shins. She also complains of shortness of breath. CXR with hilar adenopathy. Dx?

Sarcoidosis

Pulmonary Fibrosis/Sarcoidosis/Hypersenstivity Pneumonitis

Sarcoidosis - bilateral hilar adenopathy w or w/o scattered opacities - may have arthritis Pneumonitis - fevers, chills, malaise, cough, dyspnea - tachypnea + diffuse fine crackles - diffuse reticular or ground glass opacities seen in xray

55 year old F presents with generalized itching especially at night. Exam reveals widespread excoriations between ring and middle finger. Her 3 year old granddaughter has similar symptoms. Dx? TX?

Scabies Permethrin 5% from neck to toe and wash off in morning or PO Ivermectin

Onychomycosis, diagnosis and treatment

Scrap nail and do KOH prep Treat with Terbinafine or Griseofulvin

Pt eats fish and minutes later has flushing, urticaria and paresthesias. Most likely diagnosis?

Scromboid poisoning due to built up histamine in fish

EEG used to evaluate which disorders of?

Seizure + sleep

What is the best way to manage opioid induced constipation?

Senna

What is the etiology of septum primum defect?

Septum primum does not connect to endocardial cushion. Associated with MR

What is SAAG?

Serum-to-ascites albumin gradient -SAAG > 1.1 (indicates portal HTN etiologies [cardiac ascites, cirrhosis]) -SAAG < 1.1 (non-portal HTN etiologies [malignancy, pancreatitis, nephrotic syndrome, TB])

Hepatorenal syndrome?

Severe liver DS can develop systemic hypoperfusion & subsequent renal failure

45 y/o Mexican female presents to office with right upper quadrant discomfort + nausea. She has no other medical problems. Denies smoking + drinking alcohol. No known allergies. ON exam, she has hepatomegaly. US of liver shows smooth, round big cyst with daughter cysts in it. hat is the occupation of person?

Sheep breeder - think echinococcus - also may be due to CONTACT WITH DOGS

Iron Studies in Microcytic Anemia

Sideroblastic Anemia - MCV <60 - Iron High, TIBC normal or high, Ferritin High - BM - ringed siderblasts

Clinical Features of Paget's Disease

Signs + Sx - majority are asx - skull: deformity with enlargement, hearing loss, dizziness - spine + pelvis: bone pain, spinal stenosis, nerve compression - long bones - bowing deformities with inc fracture risk - bone tumors - *osteosarcoma, giant cell tumors (usually benign)* *PAGETS IS OG BONE DZ* Lab +imaging - elevated serum + bone specific ALP - everything else is normal - plain radiographs - OSTEOLYTIC OR MIXED LYTIC/SCLEROTIC LESIONS Dx - radiographs + ONLY ALP ELEVATION Tx - *BISPHOSPHONATES (TEST Q) - INHIBIT OSTEOCLAST TO SUPPRESS BONE TUNROVER* Indications for Tx in Paget's - bone + joint pain - hypercalcemia of immobilization - neuro-compressive syndromes - *high output cardiac failure - KNOW THIS AS POSSIBLE CAUSE OF DEATH (MOST LIKELY)* - Involvement of weight bearing bones (to prevent deformities) - *IF INVOLVING NON WEIGHT BEARING BONES, DOES NOT REQUIRE TREATMENT* - sx pseudofractures Primary Defect - *abnormal focal bone remodeling - excess bone resorption coupled with DISORGANIZED BONE REMODELING (TEST Q PHRASE) by osteoblasts giving CHAOTIC, MOSAIC PATTERN OF LAMELLAR INTERSPERSED WITH WOVEN BONE*

Lung Cancer

Small Cell Carcinoma - in the case of SIADH I. euvolemic ii. HYPOnatremia - may see *seizures* iii. HYPOkalemia iv. *Urine osmolality > 100; urine osmolality > serum osmolality* - *CENTRAL (may be called PARAHILAR MASS* - Tx = 1. remove offending cause 2. *FLUID RESTRICTION* 3. *if no response to fluid restriction, do HTS ADMINISTRATION* - likely to cause local compression syndromes i.e. *SVC SYNDROME - flushing face, arms + legs unilaterally* - biggest RF = SMOKING - CENTRAL but pts develop HILAR MASS W/MEDIASTINAL ADENOPATHY, COUGH, DYSPNEA, and WEIGHT LOSS - at time of Dx - usually present with mets to LIVER, BRAIN, BONE, ADRENAL - Tx = SYSTEMIC CHEMO IS BEST (vs surgery) Adenocarcinoma - most common type of primary lung cancer in smokers + non smokers BUT *most common type in nonsmokers* - *peripheral* -*solitary nodule* - *stage at dx is most important prognostic factor - survival det by resectability* Squamos Cell Carcinoma - *Sq++mos Cell Carcinoma* I. represents Ca2+ overdose - due to *PTHrP -cause for hypercalcemia* - presents as *hilar mass - generic of all lung cancer* - if hypercalcemia present - look for *anorexia, constipation, weight loss, inc thirst, easy fatigability*

Pt returns from third world country and presents with diarrhea, foul smelling oily stools. Steatorrhea +. Hb low with high MCV. D-xylose test abnormal. wtd next?

Small bowel biopsy

55 year old M with history of long standing RA controlled with ASA and Naproxen for the past 14 years presents with complaints of abdominal pain for past 4 months. EGD and colonoscopy are negative. Small bowel barium enema reveal multiple concentric constricting lesions. Most likely diagnosis?

Small bowel diaphragm disease 2/2 chronic NSAID use

What are the extra hepatic manifestations of Hep C?

Small vessel vasculitis Glomerulonephritis Neuropathy Mixed cryoglobulinemia (C4<<C3) Porphyria Cutanea Tarda

Risks for bladder cancer

Smoking Rubber and aniline dyes Cyclophosphamide Phenacetin Schistosoma hematobium

53 year old M who received multiple blood transfusions in 1990 after MVC presents with fatigue. AST/ALT 200/120. Hep C Abs + and liver biopsy reveals mild to moderate bridging fibrosis. Viral load is 250,000. A couple of months later AST/ALT 120/90 and viral load is 210,000. wtd?

Sofosbuvir + IFN + Ribavirin for 12 weeks

Pt with Hep C with high viral load and compensated cirrhosis is depressed. What is the best management for Hep C?

Sofusbuvir and Simeprevir. Depression is contraindication for alpha IFN

High SPF lotion will help protect a patient from developing what type of skin cancer?

Solar keratoses and Squamous cell carcinoma

African american patient with scar for a few years on right forearm recently notices it enlarging. Most likely diagnosis?

Squamous cell carcinoma

What are the Stages of Colon Cancer?

Stage I/Duke A: Mucosa Stage II/Duke B: II A: Submucosa; IIB: Submucosa and Muscularis II C: To Serosa Stage III: Duke C: Adjacent LNs Stage IV: Duke D: distant mets

What are the stages of breast cancer?

Stage I: <2 cm and No LN Stage II: some axillary LN involvement or tumor 2-5 cm Stage III: Locally advanced disease- skin, chest wall, mass > 5 cm, or matted LN, supraclavicular LN, infraclavicular LN or mediastinal LN Stage IV: Mets

Pt attends a party where she eats rice, chicken and salad. Upon reaching home about 4 hours later has non bloody diarrhea. Most likely organism?

Staph aureus

Most common cause of osteomyelitis in children + adults?

Staphylococcus aureus

58 year old F with CHF presents with mild lung crackles, S3, JVP 12, 2+ BLE edema. You had adjusted her regimen 3 months prior to this hospitalization. She takes lasix 60 with metolazone 30 min prior, lisinopril 40, atorvastatin 40, coreg 25 BID, spironolactone 25 mg qd and ASA 81 mg. EKG with QRS 0.13. ECHO with EF 35%. What is the best management?

Start ICD with cardiac resynchronization therapy- pt with prolongation of QRS complex place AICD with pacer capability.

78 year old diabetic patient presents with C. diff. WBC 12,000. Given PO flagyl and symptoms improved. However, a week later pt is brought to the hospital with diarrhea, abdominal distention, and tenderness. BP 90/50, HR 116/min, T 101.8F. WBC 24,000. X ray shows ileum. How to treat?

Start PO Vanc, rectal Vanc and IV flagyl; possible fecal transplant Consult surgery

76 year old F presents with complaints of progressive SOB for past 2 months. Her PMH significant for HTN, Lungs revealed bibasilar crackles. S1-S2 heard, no murmurs. There is 1+ pitting bilateral pedal edema. TTE with LVH an LVEF 65%. What is the best mgmt for this patient?

Start candesartan

Pt over the age of 50 with LDL 130, CRP more than 2. What has shown to decrease mortality?

Statin

What is the initial drug you will start in a patient with DM who has the following: LDL 160, TGA 250, HDL 45?

Statin

67 year old M presents with complaints of pain and weakness in his legs. Difficult to get up from a sitting position. He had stopped taking atorvastatin about 3 months ago after CPK was found to be elevated. Repeat CPK now is 1925 which has not changed much from before. Muscle biopsy reveals necrotizing muscle fibers with no inflammation and no vacuoles. What is the most likely diagnosis? TX?

Statin induced myopathy secondary to 200/100. anti-3 hydroxy-methylglyaryl-coenzyme A reductase- HMGCR Treat with steroids

Clinical Suspicion of Acromegaly

Steps - KNOW ORDER 1. clinical suspicion of acromegaly, *FIRST CHECK IGF1 LEVEL*; if normal - r/o acromegaly; *if elevated*... i. *oral glucose suppression test* a. if adequate suppression - r/o acromegaly b. if INADEQUATE SUPPRESSION - MRI OF BRAIN - DET PITUITARY MASS VS EXTRA PITUITARY CAUSE i.e. ectopic tumor - *we measure IGF-1 FIRST in suspected Acromegaly because GH is diurnal and fluctuates; SECOND FOR CONFIRMATION WE MEASURE FOR NONSUPPRESSIBLE GH LEVELS following oral glucose load*

lancet shaped diplococci optochin sensitive

Strep pneumo

What is the MCC of PNA in NH residents & CAP in adults?

Strep. pneumoniae *Anaerobic bacteria in pts with advanced dementia, Parkinson's DS & Stroke

24 year old M with UC presents with abdominal pain, distention to 7 cams, bleeding and diarrhea. He has been treated with steroids and sulfasalazine, iv hydration and antibiotics. A day later the pain has gotten worse and so has the distention. Abdominal X-ray with distended large bowel with thumb printing. The best treatment is?

Subtotal cholectomy

What is Gardner syndrome?

Subtype of FAP involving adenomatous polyps of colon, osteomas of mandible skull and long bones, soft tissue tumors, thyroid and adrenal tumors, epidermoid and sebaceous cysts

Esophageal Cancer

Subtypes - Adenocarcinoma i. distal esophagus (NEAR GastroEsophageal JUNCTION); from BARRETT's ESOPHAGUS - Squamos Cell Ca. i. ANYWHERE IN ESOPHAGUS - RFs - acid reflux, obesity, smoking (adenoca) - smoking, alcohol, caustic injury (sq cell carcinoma) Sx - persistent burning chest pain - weight loss - dysphagia (solids****) Dx - if YOUNG (<55) + lower risk patient with NO ALARM SX (weight loss, gross or occult bleeding, early satiety) - DO CONTRAST ESOPHAGOGRAM; but if >55 or ALARM SX, ENSDOCOPY with biopsy ***** NEXT STEP ON SUSPICION

Indications for AICD?

Sudden cardiac death: V fib or V tach EF <35% with CHF Non ischemic- 3 months after optimal medical therapy Ischemic- 40 days after MI HOCM with NSVT and family history of SCD

34 year old F with UC now complains of pain in small joints of the hand with 30 minutes of early morning stiffness. What is the most appropriate treatment?

Sulfasalazine- treats both UC and arthritis

HIV pt c/o headache + left sided weakness of recent onset. Temp of 101, Neuro exam show dec power, hyperreflexia, and upgoing plantars in left upper + lower limb. Neuroimaging on CT shows multiple ring enhancing lesions. What is most appropriate next step?

Sulfdiazine + Pyrimethamine

Which migraine treatment is contraindicated in a patient with sulfa allergy?

Sumatriptan

What conditions can precipitate or exacerbate psoriasis?

Sunburn Viral/bacterial infections Antimalarials, Li, gold BB anti TNF therapy

Pt with III/VI holosystolic murmur at apex radiating to axilla. Pt is asymptomatic. BP 130/84. HR 86/min. TTE shows severe MR. LVEF 50%. LV 72 mm in diastole, 51 mm in systole. Appropriate management?

Surgery

Patient with hyperthyroidism has double vision and exophthalmos. Treatment?

Surgery to remove thyroid RAIA worsens ophthalmyopathy

Pt diagnosed with acute diverticulitis and develops 9 cm dilatation with 5 cm abscess formation. wtd next?

Surgical intervention

60 year old pt with history of renal transplant on tacrolimus develops squamous cell carcinoma. What will improve carcinoma free survival?

Switch from Tacrolimus to Sirolimus

Giant Cell (temporal) arteritis

Sx - *think jaw claudication (MOST SPEC SX OF GCA)*, - *headache (temporal area) - *association with polymyalgia rheumatica - diffuse pain in shoulders + hips but no weakness* - scalp tenderness + decreased temporal artery pulse - visual sx I. *amaurosis fugax* - transient vision field defect progressing to monocular blindness ii. *AION* - most common ocular manifestation; anterior ischemic optic neuropathy - most common ocular manifestation detected on fundsocopy by presence of swollen + pale disc w/blurred margins - ESR > 50 - can involve *branches of aorta - AORTIC ANEURYSM = WELL KNOW COMPLICATION (FOLLOW PT W/SERIAL CXRs)* - *CNS: TIAs/stroke, vertigo, hearing loss* Dx/1st step - *Temporal Artery Biopsy - 1st step on suspicion; UNLESS THERE ARE ALREADY VISUAL SX SUCH AS VISUAL LOSS - THEN FIRST STEP = ADMINISTRATION GLUCOCORTICOIDS* Tx: - PMR only: low dose oral glucocorticoids - prednisone 10-20 mg daily - GCA: intermrediate to high dose oral glucocorticoids (prednisone oral 40-60mg daily) - GCA with vision loss: pulse high dose IV glucocorticoids (methylprednisone 1000mg daily) for 3 days followed by intermed - high dose oral glucocorticoid

Clinical Features of Cirrhosis

Sx - can be asymptomatic or w/non specific sx (i.e. anorexia, weight loss BUT LATER WEIGHT GAIN DUE TO ASCITES, ETC) 2. JAUNDICE + PRURITIS 3. GI bleed (melena, hematemesis***) 4. encephalopathy (confusion, sleep disturbances) WOMEN - AMENORRHEA OR IRREGULAR MENSES DUE TO ANOVULATION Men - HYPOGONADISM - dec. libido, erectile dysfxn, loss axillary + pubic hair, MORE COMMON in cirrhosis due to ALOCHOL or HEMOCHROMATOSIS******* PE - Skin - telengiectasias, caput medusae - chest - gynecomastia (bilat, may be unlit) - Abdomen - ascites, hepatomegaly, splenomegaly - GU - testicular atrophy - extremities- palmar erytehma, muehrcke or terry nails, dupuytren's contracture, clubbing - hepatsplenomegaly or ascites ***IN MEN, INC ESTROGEN CAUSES TELENGECTASIAS, PALMAR ERYTHEMA, TESTICULAR ATROPHY, GYNECOMASTIA, ERECTILE DYSFUNCTION (TEST QUESTION****) Labs 1. TOTAL T3 + T4 DEC LEVELS (b/c liver makes binding proteins i.e. Thyroxine binding globulin that no longer are made) but free T3 + T4 UNCHANGED

Viral (herpes simplex virus) encephalitis

Sx - fever - altered mental status - *SEIZURES (TEMPORAL LOBE INVOLVEMENT)* Exam - *hemiparesis, cranial nerve palsies (signs of FOCAL NEUROLOGIC DEFICITS)* - hyperreflexia Lab/imaging - CSF analysis: Inc WBCs (*lymphocyte predominant*), normal glucose, increased protein - *MRI - temporal lobe abnormalities* - *Diagnosis - CSF analysis show presence of viral DNA on PCR* Tx - *IV acyclovir - start empirically + immediately after obtaining CSF fluid - don't wait until results come back*

Ulcerative Colitis

Sx 1. Persistent Bloody Diarrhea + gross rectal bleeding 2. Weight Loss + Fever Endoscopic Findings 1. Erythema, friable mucosa 2. Pseudopolyps + inflammatory polyps (more LIKELY IN UC) 3. Involvement of rectosigmoid 4. continuous colonic involvement (no skip lesions) - RECTUM ALWAYS INVOLVED Biopsy 1. Mucosal + submucosal inflammation 2. Crypt Abscesses (TH2) MEDIATED Complications - MUCH MORE LIKELY TO BE AUTOIMMUNE 1. Toxic Megacolon 2. primary sclerosing cholangitis 3. colorectal cancer 4. erythema nodosum, pyoderma Gangrenosum 5. Spondyloarthritis 6. Episcleritis ***OF ALL COMPLICATIONS LISTED, ONLY COLORECTAL CANCER SPECIFICALLY CAN BE SCREENED FOR IN ULCERATIVE COLITIS - PROTOCOL = BEGINNING 8-10 YEARS AFTER INITIAL DX - Typical Pres: REALLY YOUNG GUY IN 20s W/LOWER ABD PAIN, BLOODY DIARRHEA, TENESMUS OVER PERIOD OF FEW WEEKS

General Manifestations of Hyperthyroidism

Sx - anxiety + insomnia - palpitations - heat intolerance - increased perspiration - weight loss w/o decreased appetite - goiter PE - Hypertension - tremors involving fingers/hands i. *high frequency, low amplitude tremor WITH MOVEMENT (UNLIKE PARKINSONS - RESTING)* - hyperreflexia - proximal muscle weakness i. i.e. inability to comb hair with difficulty holding arms up ii. *proximal muscle weakness without atrophy can occur in 60-80% of patients with untreated hyperthyroidism and correlates to duration of hyperthyroid state. Hip flexors + quadriceps are predominantly affected. Weakness can gradually progress to involve the proximal muscles of upper extremities (UWORLD LEARNING OBJ)* - lid lag - atrial fibrillation Differential - parkinsons - resting tremor, rigidity, bradykinesia, postural instability - cerebellar lesions or dysfunction typically present with gait and balance problems with weakness, unsteadiness, or incoordination in legs. Prox muscle weakness and/or atrophy are usually not seen in pts with cerebellar issues Myasthenia gravis - due to Abs against *postsynaptic* membrane of neuromuscular junction. Pts develop *fluctuating ocular (ptosis, diplopia), facial, and/or bulbar muscle weaknes*s that becomes *worse on repetitive tasks*

Causes of Primary Adrenal Insufficiency

Sx of Adrenal Insufficiency caused by tuberculosis - CT shows calcifications in the adrenal glands is adrenal tuberculosis - most common cause of primary adrenal insufficiency in developing countries - - in contrast autoimmune adrenalitis is currently the most common cause of primary adrenal insufficiency in developed countries Causes of Primary Adrenal Insufficiency 1. autoimmune adrenalitis 2. tuberculosis 3. fungal infections 4. CMV *for this reason HIV patients we will see these infections and therefore Primary Adrenal Insufficiency

Irritable Bowel Syndrome

Sx suggesting NOT IBS - pain wakens from sleep - rectal bleeding - weight loss - abnormal lab findings Differential Dx 1. Crypt Abscesses - UC - present w/fever, colicky abd. pain, chronic diarrhea w/bloody stool + weight loss 2. Intestinal Villous Atrophy - HALLMARK OF CELIAC DISEASE - gluten intolerance - prsent w/ GI distress (diarrhea, abdominal distention) i. atypical presentation - minor abd. complaints, iron deficiency anemia, inc. Transmanisases ***, arthritis, neurologic Sx 3. Perianal Fistulas - suggest possible Crohn's Disease Rome Criteria 1. at least 3 days/month for 3 months of abdominal pain chronic in nature 2. altered bowel habits 3. Feeling incomplete evacuation of stool post bowel movement. 4. stool urgency

Peptic strictures cause?

Symmetric & circumferential narrowing of the involved esophagus with dysphagia for solids but typically no weight loss

When would you operate on a patient found to have abdominal aortic aneurysm?

Symptomatic any time Asymptomatic >5 cm

Schizophrenia

Symptoms > 6months

clinical features of systemic sclerosis

Systemic - fatigue - *joint stiffness + pain* Skin - telangiectasia - sclerodactyly- thickening or hardening of skin, edema, pruritus with flexion contractures - face may take on mask look due to skin thickening - digital ulcers - calcinosis cutis Vascular - Raynaud phenomenon GI -dysphagia, dyspepsia (SMOOTH MUSCLE FIBROSIS + ATROPHY IN LOWER ESOPHAGUS) I. esophageal manometry gives rise to HYPOMOTILITY + INCOMPETENCE OF LES - angiodysplasia of stomach (watermelon stomach) with GI bleeding - malabsorption due to bacterial overgrowth Pulmonary - pulmonary fibrosis (ILD manifestations with inspiratory crackles) - MOST COMMON PULMONARY COMPLICATION - Pulmonary arterial hypertension Renal - Scleroderma Renal Crisis I. acute onset oliguric renal failure with malignant hypertension ii. thrombocytopenia iii. microangiophatic hemolytic anemia Cardiac - myocarditis - pericarditis - pericardial effusion - right heart failure from PAH Cause = atrophy + fibrosis of smooth muscle in lower esophagus Pathogenesis = CT thickening, product of myofibroblast proliferation + inc collagen + ground substance production Antibodies - *ANA + Anti-Topoisomerase Abs*

What is the strongest predisposing factor to development of aortic dissection?

Systemic HTN *Marfan's syndrome & Ehlers-Danlos syndrome are seen in younger pts

Pt with recurrent itching, wheezing, SOB, dizziness with hypotensive episodes, abdominal pain and diarrhea. Exam with hepatosplenomegaly. Most likely diagnosis? Best screening test?

Systemic mastocytosis Serum typtase test

Is systolic or diastolic blood pressure more important as a CAD risk factor?

Systolic

Type IV Hypersensitivity reactions are mediated by ____. Examples ______.

T Cell mediated PPD, poison ivy, Ni, Type I DM, acute and chronic graft rejection Latex

What is the drug of choice in diabetic neuropathic pain?

TCAs - beware SE: I. urinary sx - due to cystopathy ii. orthostatic hypotension (due to cardiovascular autonomic neuropathy) Alternative if (i + ii present) i. GABAPENTIN

Pt presents with generalized erythema, exfoliating dermatitis with bull. Punch biopsy done and shows cleavage plane in stratum germinatum?.

TEN 2/2 Drugs- treat with IVIG

60 year old F evaluated for 3 month history of SOB on exertion. She does not complain of chest pain. Her PMH is significant for HTN, Type II Dm, HLD for which she takes medications. wtd next?

TTE

65 year old M admitted with PMH to the MICU on IV Abx. EKG reveals normal sinus rhythm. Troponin is 1.3. What to do?

TTE

What must you do before you label a patient with IBS?

TTG antibody testing

Young woman with Hepatitis B presents to you in 3rd trimester. How will you prevent Hep B in child?

Telbivudine for mother and Hep B vaccine and HBIG in newborn

Pt calls you with onset of bullous lesions on his chest after taking bactrim. Wtd?

Tell him to come to office right away

What is the best medication to treat a patient co-infected with Hep B and HIV?

Tenofovir

What medications do you use to treat Hepatitis B/

Tenofovir, Entecavir, Telbivudine, Adefovir, Lamivudine or alpha interferon

Which nerve controls corneal sensation?

The opthalamic branch of the trigeminal nerve (V)

Modes of Treatment of Hyperkalemia

Therapy involves 3 steps I. membrane stabilization with calcium ii. shifting K+ intracellularly iii. decreasing total body K+ insulin/glucose - fastes way of dec serum K+ concentration 1. hemodialysis - most definitve way to remove K+ from body in patients with renal failure 2. Kayexelate - K+ binding resin that dec total body K+ by catharsis in gut via Na+ exchange for K+ (1-2 hours to work) 3. Calcium Gluconate - stabilization of cell membrane

In the context of nephritic or nephrotic syndrome, low complement levels mean what?

They Suggest *I. postinfectious GN ii. lupus nephritis iii. Membranoproliferative glomerulonephritis iv. mixed cryglobulinemia*

Define Wernicke's encephalopathy?

Thiamine deficiency causing: 1. Encephalopathy 2. Oculomotor dysfunction 3. Gait ataxia

What is the drug of choice to treat patient with mild to moderate HTN?

Thiazide diuretic/Chlorthalidone

HTN and african

Thiazides

What drugs are associated with pancreatitis?

Thiazides L-asparginase Pentamidine Bactrim Azathioprine HCTZ

HTN and hyperlipidemia

Thiazides NO BETA BLOCK

TX of a PVC identified on the EKG?

This is frequently seen in pts that are post-MI: -No TX is indicated with asymptomatic pts -Beta-blockers for pts that are symptomatic

38 year old M presents with complaints of bald patch which has started over the past several weeks. Exam reveals dark dots. Microscopic exam reveals broken hair follicles and under woods lamp there is bright green fluorescence. Most likely diagnosis? TX?

Tinea capitis Griseofulvin or Terbinafine or Ketoconazole

What is the best way to treat a diabetic foot ulcer that is not infected?

Total contact cast to keep pressure off the ulcer

Pt presents with 13 hours of chest pain. She had taken antacids without relief. EKG reveals ST elevations in the anterior leads. BP 140/80. She is given ASA to chew, iv nitrates, iv BB and IV morphine. The closest PCI facility is at least an hour away. wtd?

Transfer and do PCI

50 year old F with HNPCC had colonoscopy done which revealed adenomatous polyps. What to do next?

Transvaginal US to look at ovaries

What are the different causes of chylous ascites?

Trauma, tumors, TB, filariasis

Pt with Hep B has compensated cirrhosis. Viral load >10,000. wtd?

Treat

Pt with Hep B with ALT 3x ULN. Viral load >20,000. wtd?

Treat

Pt with PUD and takes ibuprofen for osteoarthritis. H pylori test is +. wtd?

Treat H pylori and switch NSAIDs

Clinical Features of Hyperkalemia

Treatment - emergent treatment if *i] K+ rising rapidly, ii] is >6.5mEq/L, or iii] there are ECG changes w/inc K+* I.*MOST IMMED Tx = IV CALCIUM GLUCONATE TO STABILIZE CARDIAC MYOCYTE MEMBRANE* inducing resistance to hyperkalemia (*TEST Q - WHAT IS 1st STEP IN HYPERKALEMIA*) ii. *second step = push K+ into cells with IV Insulin (NOT SUBQ) w/Glucose OR BETA AGONISTS (Albuterol)* iii. 3rd step = reduce total body K+ a. reversal of correctable etiology (i.e. IV fluids for pre renal azotemia) b. diuretics (CI in dehydrated patients) c. exchange resins (Kayexelate - remove via GI catharsis but takes hours) d. hemodialysis

Treatment of Grave's Disease

Treatment + Adverse Effects listed below 1. antithyroid drugs (thionamides) i. *agranulocytosis - those developing sore throat and fever should stop the ATD and get WBC count checked (BUT NO ROUTINE MONITORING OF WBC)* ii. methimazole: *1st trimester teratogen, cholestasis* iii. PTU: *Hepatic Failure, ANCA associated vasculitis* 2. Radioiodine Ablation i. permanent hypothyroidism ii. worsening of opthalmopathy - sometimes pretreat with glucocorticoids to prevent worsening of disease iii. possible radiation side effects 3. Surgery i. permanent hypothyroidism ii. risk of recurrent laryngeal nerve damage iii. risk of hypoparathyroidism

Patient with nocturnal cough who also wakes up with water brash not relieved by antacids. The best initial diagnostic step is?

Trial of PPIs

What is the mechanism of reperfusion arrhythmias?

Triggered activity; change in cardiac frequency due to accumulated Ca

What medications can cause prolonged QT?

Triple AAA Takes Care of Ford Engine Antihistamine Anticholinergic Antiarrhythmic- Sotalol, Quinidine, Disopyramide, Procainamid TCAs Fluoroquinolones Erythromycin

25 year old F from Dominican Republic presents with diarrhea, bloating and weight loss of about 10 lbs. in the past couple of months. Hb 11.2, MCV 110, WBC 3500. Albumin 3.1, folate WNL, B12 low. Stool sudan stain positive for fat globules. Most likely diagnosis?

Tropical Sprue

Patient who has steatorrhea and small bowel biopsy shows flattened villi with lymphocytic and plasma cell infiltrate in lamina propria. Most likely diagnosis?

Tropical sprue

Best initial treatment for any hyperthyroidism?

Tx - 1st GIVE PROPANOLOL for sx relief of any hyperthyroidism until underlying cause is identified

Best Treatment for Graves disease

Tx - initial treatment is PROPANOLOL - SX CONTROL - serum TSH low; Free T4 level is high (these 2 show hyperthyroidism); 24 hour thyroid radioiodine uptake and scan should be done to differentiate graves hyperthyroidism from other causes - definitive treatment - radioactive iodine; if CI such as in pregnancy *2nd line is PTU - stop peripheral conversion T4 to T3 which is active form*; if PTU is to no avail, then *surgery = 3rd line*

What is Hydroxychloroquine used for?

Tx of 1. RA 2. Prophylaxis + acute treatment of malaria 3. SLE

Types of Kidney Stones

Tx of uric acid stones - HYDRATION, ALKALINIZATION URINE (WITH POTASSIUM CITRATE to a PH OF 6.0-6.5), LOW PURINE DIET Tx/Prevention of Calcium Stones - *DEC NA INTAKE* - there is cotransporter in TALOH - Ca2+ restriction IS NOT SOLN **INSTEAD, NORMAL CA2+ INTAKE*) b/c this increases free oxalate absorption giving hyperoxaluria and calcium oxalate stones - *Avoid Vit C* (inc hyperoxaluria) - *INC FLUID INTAKE* Calcium Oxalate stones - 75-90% of kidney stones are calcium oxalate stones - envelope shaped + can be seen on microsocopic examination of urine - *small bowel diseases, resection of bowl, or chronic diarrhea* - ANYTHING GIVING MALABSORPTION OF FAT CAUSING CHELATION OF CA2+ AND LOSS IN DIARRHEA - can INC ABSORPTION OF OXALIC ACID - GIVING INC Ca2+ OXALATE STONES) Calcium Phosphate stones -seen primarily in PRIMARY HYPERPARATHYROIDISM+ RENAL TUBULAR ACIDOSIS Uric Acid Stones - dehydration is important risk factor Cystinuria - inherited disease - cause recurrent renal stone formation - look for personal history or recurrent kidney stones FROM CHILDHOOD + (+) FAM HX - Radiopaque - *hexagonal crystals* - *qualitative screening procedure - URINARY NITROPRUSSIDE TEST* - pathology: *defective transport of dibasic amino acids (cysteine, lysine, arginine, ornithine) at brush borders of renal tubular + intestinal epithelial cells

Patient with pancreatitis is most likely to have what type of hyperlipidemia syndrome?

Type I

What type of hypersensitivity reaction is allergic bronchopulmonary aspergillosis?

Type I

Classification of multiple endocrine neoplasias

Type I - primary hyperparathyroidism (>90%) - enteropancreatic tumors (60-70%) - pituitary tumors (10-20%) Type 2A - MTC - medullary thyroid cancer (>90%) - Pheochromocytoma (40-50%) -****MTC + PBM = Pneumonic for 2a + 2b - Parathyroid Hyperplasia (10-20%) Type 2B - MTC - Pheochromocytoma - other i. mucosal (tongue) + intestinal (GI Tract) neuromas ii. marfanoid habitus iii. skeletal deformities = kyphoscoliosis, lordosis - Pheochromocytoma presentation i. fam hx of i.e. sister w/htn ii. sx of palpitations, headaches, diaphoresis iii. to officially diagnose, MUST MEASURE 24 HOUR URINE FOR METANEPHRINES + FREE CATECHOLAMINES or PLASMA FREE METANEPHRINES - For MEN2A + MEN2B i. testing = PCR DNA TESTING FOR GERMLINE MUTATION IN RET PROTO ONCOGENE ii. if positive DNA test - TOTAL THRYOIDECTOMY IN EARLY CHILDHOOD INDICATED

What type of hypersensitivity reaction is ABO incompatibility?

Type II

Patient with Apo protein E deficiency is what type of Hyperlipidemia?

Type III

What type of hypersensitivity reaction is Arthus reaction?

Type III

Patient with Tendon Xanthomas has what type of hyperlipidemia?

Type IIa

Pt has been having bloody diarrhea for the last 2 years. About 3 weeks ago went to Mexico. Colonoscopy revealed erythematous appearance with friable mucosa in the distal colon. What is the most likely diagnosis?

UC

18 year old woman who has bp 170/105. wtd next?

UDS

Pt has a cardiac cath and 2 days later presents with pain in right groin. Exam reveals erythematous and pulsatile mass. wtd?

US

Pt with pancreatitis presents with increased AST and Alk phos. What is the appropriate diagnostic step?

US GB to evaluate for gallstones and dilated CBD

Patient with pancreatitis, elevated AST and Alk Phos. What will you do next?

US Gall bladder

If a pt presents with achalasia and some alarm symptoms (excessive weight loss, onset in <6 months, >60 yo), what should you perform before TX?

Upper GI Endoscopy to r/o malignancy

TX of primary biliary cirrhosis?

Ursodeoxycholic acid relieves symptoms & lengthens transplant-free survival time

Pt with latex allergy when using condoms. wtd?

Use polyurethane condoms

Use of table tilt testing?

Used to confirm the DX of vasovagal syndrome. Although, it usually is a clinical DX and no further testing is necessary

What arrhythmias are independent risk factors for in house mortality for patients post MI?

V Tach and V fib. But don't increase risk of subsequent mortality from arrhythmia after discharge

Distinguishing Features of Common Upper Respiratory Illness

VIral Upper Respiratory Syndrome - onset of sx: slow, stepwise, migratory, or evolving - upper respiratory sx: rhinorrhea, coryza, sneezing, mild pharyngitis - systemic sx: usually mild - exam: nasal edema with normal or slightly erythematous pharynx Influenza - onset of sx: abrupt + dramatic - upper respiratory sx: usually mild - systemic sx: prominent with *high fever, myalgia, headache* - exam: variable but often unremarkable - *THEY WILL TELL YOU Strep Pharyngitis - onset of sx: variable - upper respiratory sx: predominantly pharyngeal sx - systemic sx: variable with possible fever + myalgias - exam: pharyngeal erythema, tonsillar hypertrophy, tender cervical lymph nodes TREATMENT OF INLFUENZA: - *neuraminidase inhibitor (i.e. oseltamivir, zanamivir) can decrease severity + duration by 2-3 days of influenza* - *ONLY TREAT WITHIN 48 HOURS OF ONSET WITH ABOVE DRUGS - if PRESENTING AFTER 48 HOURS, SYMPTOMATIC TX (UWORLD QUESTION)*

16 year old M presents for routine checkup. Physical exam reveals a murmur at the L sternal border radiating throughout the precordium. There is no change in Valsalva maneuver or respiration. EKG reveals mild LVH. Most likely diagnosis?

VSD

What are poor prognostic factors in HOCM?

VT Age <30 Septal thickness >3cm Syncope Failure to increase BP 20 mmHg upon exercise Familial form and family history of SCD

Pt planning on going to Mexico for 2 weeks. He is scheduled to leave in 4 days. What should you give him to protect against Hep A?

Vaccine- Hep A has about 2 week incubation period and vaccine will be effective by then

Compared to surgery, what complications are greater with TAVR?

Vascular complications Strokes Heart blocks

Pt has dinner at seafood restaurant and presents with diarrhea. Gram stain shows comma shaped gram negative organism. Most likely diagnosis? Treatment?

Vibrio parahemolyticus Cipro

70 year old M is diagnosed with stroke. Hemiparesis + on L side, cranial nerves intact. He has coughing and choking sensation with regurgitation of fluids through the nose. The best diagnostic test is?

Video fluoroscopic swallowing study- aka modified barium swallow

What causes increased deposition of poorly mineralized osteoid

Vit D deficiency

Which vitamin do you have to supplement in patients with Celiac sprue?

Vitamin D

Which drug genotyping with VKORC1 +/- CYP 2C9 has helped dosing for?

Warfarin

What is the best management for hyperlipidemia in pregnancy?

Welchol, colsevelam

Acalculous Cholecystitis

What is it? - acute INFLAMMATION of gallbladder in ABSENCE OF GALLSTONE that is commonly seen in HOSPITALIZED+ SEVERELY ILL pts RFs - these all CAUSE GALLBLADDER STASIS OR ISCHEMIA i. severe trauma ii. extensive burns iii. recent surgery **** (KNOW DIS TEST Q) iv. prolonged fasting or TPN **** v. Critical Illness (Sepsis, ICU, mechanical ventilation) Clinical Presentation i. Unexplained fever ii. Vague/RUQ pain/discomfort iii. leukocytosis iv. possible jaundice RUQ mass, abnormal LFTs (very limited abnormality) Diagnosis i. abdominal US (preferred) ******* TEST OF CHOICE Complications i. gangrene ii. perforation iii. emphysematous cholecystitis

When is IVC filter placement a better option than anticoagulation?

When anticoagulation is C/I (hemorrhagic stroke, active bleeding). Or when anticoagulation has failed (recurrent DVT formations while fully anticoagulated)

Patient presents with history of arthritis >2 years. He complains of diarrhea >3x/day, oily and foul smelling stools. Positive weight loss, adenopathy and increased skin pigmentation. Small bowel biopsy PAS + with foamy macrophages. Most likely diagnosis? Etiology? Treatment?

Whipple's disease Tropheryma Whippelei Treat with bacterium or tetracycline for 1 year

Leukonychia

White spots in nails 2/2 hypoalbuminemia or renal failure can also be seen in normal people

How would you treat a patient with infiltrating ductal carcinoma with LN -?

Wide excision of mass with free margins + RT Adjuvant Chemo for size >1 cm Tamoxifen or Aromatase inhib if ER +

A young pt has cirrhosis, neuropsychiatric symptoms, green/brown deposits in his corneas?

Wilson's DS (Hepatolenticular degeneration) -Confirmed with low ceruloplasmin and increased copper excretion in the urine

20 y/o M presents with tremors, hemolytic anemia and AMS. LFTs mildly elevated. What is the most likely diagnosis? What is the etiology? treatment?

Wilson's disease 2/2 impaired excretion of Copper--> accumulation in liver and other body tissues Serum ceruloplasmin is low Liver biopsy confirms diagnosis Treat with penicillamine + pyridoxine or Trientine

An advanced-HIV pt with oral thrush is treated how?

With empiric oral antifungal agents (fluconazole). *If the pt's thrush fails to respond, do an esophagoscopy (endoscopy) with biopsy, cytology, & culture to clarify the DX

Pt received 1st dose of Hep B vaccine last year, presents for regular follow up. Can you give 2nd dose now?

Yes

76 year old with HTN presents with palpitations. Found to have a fib with RVR. Do you anticoagulate?

Yes- warfarin

A pts endoscopy shows multiple stomach/duodenal ulcers & thickened gastric folds, what should you do next?

You are working up a possible gastrinoma (ZES). You should check a serum gastrin level (pt should be off of any PPIs for at least 1 wk).

Before beginning Hep C TX, what should happen?

You should offer a liver biopsy to the pt. This will help with evaluating the progression of the DS and its response to therapy

Define a classic pseudotumor cerebri case?

Young obese female with a headache that is suggestive of a brain tumor, but normal neuroimaging & elevated CSF pressure. Pathophys: Impaired absorption of CSF by the arachnoid villi TX: Weight reduction and acetazolamide. Shunting or optic nerve sheath fenestration to prevent blindness

A pt with extensive bowel resection secondary to Crohn's DS presents with alopecia, skin lesions, abnormal taste, and impaired wound healing?

Zinc deficiency

Patient presents with eczematoid rash on nasolabial folds, extensor surfaces and perineum. Dx?

Zinc deficiency

55 year old presents with fever, RUQ pain and jaundice. AST 220, ALT 310. Alk phos 450, Tbili 10.5, indirect bili 2.2, amylase 355. US negative. What to do next? If the patient then becomes hypotensive what is the best management after IVFs?

Zosyn ERCP

How do you calculate stool osmotic gap? What is considered secretory vs. osmotic?

[Na+K] x 2 Secretory: <50 Osmotic: >50

50 year old pt presents with sudden onset of severe abdominal pain, nausea and vomiting. Has leukocytosis. KUB with ileus. What is the best diagnostic test? Most likely Diagnosis? Treatment?

acute mesenteric ischemia 2/2 embolism in celiac or superior mesenteric artery: Valvular heart disease, a fib, low flow hypercoag state Do angiography Treat with thrombolysis or surgery

Pt with history of chronic angina controlled on ASA and nitrates with increasing frequency of angina. wtd?

add BB

Pt with hepatic encephalopathy was started on lactulose with little improvement and cannot tolerate higher doses because of diarrhea. wtd?

add Rifaximin- decreases inpatient mortality! and decreases risk of hepatic encephalopathy if used prophylactically

MC benign neoplasms of the intestine

adenoma leiyomyoma lipoma

tt of pregnant patient with pyelonephritis

admit to hospital tt with IV antibiotics

tt of cryptococcus menigitis

amphotericin B and 5-fluorocytosine

zidovudine

analogue of thymidine, inhibits trial reverse transcriptase metabolized fast (1hr half life)

sudden severe headache, rtetroorbital pain, double vision, slow reactive blown pupil

aneurysm

V2-V4

anteroseptal LAD

A 26 year old F complains of passing fecal material through the vagina. Recto-vaginal fistula is diagnosed. Colonoscopy reveals skip ulceration in large bowel. Which medication would you start?

anti-TNF agent

diaphragmatic fibrosis interstitial fibrosis pleural plaques

asbestosis

milling/ mining/ demolition/ ship breaking/ brake-pads/ insulating material

asbestosis

Atopic dermatitis

associated with asthma and rhinitis increased IgE later on in life may see scabbed or excoriated lesions mainly on flexural surfaces TX hydrants, emollients or hydrocortisone

If patient has bleeding ulcer, varices or visible vessel, how long should you monitor patient after EGD?

at least 72 hours

HTN and renal artery stenosis

avoid ACEI

HTN and renal failure

avoid thiazides

sulfonamides and pregnancy

avoid, due to increase in bilirubin causing kernicterus in 3rd trimester

beta hemolytic, motile, gram positive box car shaped

bacillus cereus

neutrophilic infiltrates in lungs

bacterial pneumonia

If a patient is found to have varies but also has moderate asthma, wtd?

band ligation

Patient presents with translucent pearly papule with telangiectasias on pinna of ear. Most likely diagnosis?

basal cell carcinoma

HTN and MVP, anxiety, panic attacks, A FIB

beta blocker

HTN and dissecting aortic aneurysm

beta blocker

HTN and delerium tremens

beta blocker clonidine

How is sulfasalazine activated?

by bacterial action in the colon it is split into 5-ASA and Sulfapyridine

40 year old M who presents with history of severe CP two days ago. EKG with deep T wave inversions in V2-V4. wtd?

cardiac cath- Wellen syndrome

ascariasis lumbrisocides

cause obstructions of small bowel and biliary duct tt mebendazole

Diagnosis of Upper Airway Cough Syndrome (Postnasal Drip)

caused by rhinosinus conditions including 1. allergic 2. perennial nonallergic 3. vasomotor rhinitis 4. acute nasopharyngitis 5. sinusitis *test question - when giving clorpheniramine (generation 1 H1 antagonist that has ANTIACh properties vs gen 2 loratidine would have no effect due to lack of ANTIACh properties) - DEC ALLERGIC RESPONSE (*nasal discharge improves) giving resolution to postnasal drip*

Metabolic Alkalosis

causes I. vomiting (most common) ii. hyperaldosteronism iii. excessive volume contraction (i.e. thiazides, loop diuretics) iv. all forms of renal tubular acidosis

lactulose on Na

causes diarrhea, therefore hyponaetremia

Schizoaffective Disorder

characterized by significant mood episode (depressive or manic) with concurrent psychotic symptoms in addition to period of psychosis WITHOUT mood symptoms for at least 2 weeks

Patient with Stage B2 rectal Ca. Local resection done. What else will you do?

chemo +RT (B4 surgery- chemo is sensitizing agent)

Patient with colon cancer not infiltrating serosa but 4/10 LN +. After hemicolectomy what else will you do?

chemo with FOLFOX- 5 FU + leucovorin + oxaliplatin

How would you treat locally invasive breast carcinoma involving the skin or chest wall?

chemotherapy followed by Mastectomy + Tamoxifen/ aromatase inhib if ER +

IN a patient with anti HBc IgG ab +, HBsAg -, and Anti HBs ab -. What are the possibilities?

chronic hepatitis or past infection could be false positive if from low prevalent area

65 y/o pt presents with post prandial abdominal pain, weight loss and fear of eating. What is the best diagnostic test? Most likely Diagnosis? Treatment?

chronic mesenteric ischemia Doppler US or angiogram Angioplasty or surgical revascularization

Young patient with recurrent a fib refractory to medical treatment. wtd?

circumferential pulmonary vein ablation

Acute Epididymitis

classic presentation: acutely inflamed structure that is tender and swollen region of testes and may be difficult to distinguish from the testis; scrotum may be reddened and vas deferens inflamed; occurs chiefly in adults coexisting UTI (pyuria, RBCs in urine dipstick) or prostatitis (tender prostate on exam) supports the diagnosis - (+) prehn sign - elevation of pubic symphysis improves pain (UNIQUE) - presentation in young men: severe testicular pain of sudden onset with fever, pyuria (dipstick), bacteruria (dipstick), tender cordj, (+) prehn sign, tender prostate on exam (prostatitis), tender cord + swelling/mass on testicle - UWORLD POINT: *acute epididymitis in younger patients occurs due to sexually transmitted C. trachomatis or N. gonorrhea; in older men it is due to NON sexually transmitted gram negative rods (i.e. E. coli most common)* - systemic sx - slight fever

You are consulted to clear cirrhotic patient for an elective major surgery. MELD 8, Recommendation?

clear for surgery

50 year old woman presents for regular checkup. The best way to screen her for breast cancer is?

clinical breast exam and routine mammogram q2 y

40 year old asymptomatic pt with a father who had Colon cancer at age 60 and brother with Colon cancer at age 52. WTD

colonoscopy now

Nephritic Syndrome

common presentation: anasarca, pulmonary + facial edema, hypertension, abdnormal urinanalysis w/proteinuria + microscopic hematuria - nephritic syndrome causes *primary glomerular damage* - giving decreased glomerular filtration rate thereby giving *VOLUME OVERLOAD (HTN - not in nephrotic syndrome) - manifest as ANASARCA, DISTENDED NECK VEINS, PULMONARY EDEMA* *therefore important lesson: EDEMA in nephritic syndrome is due to INC RENAL SODIUM + WATER RETENDION + DEC GLOMERULAR FILTRATION (DUE TO PRIMARY GLOMERULAR DAMAGE - TEST QUESTION ABOUT MECH OF NEPHRITIC SYNDROME)* - abnormal urinary sediment (RBC + RBC Casts) - variable degrees of proteinuria

In a patient with atrial fibrillation who presents with wide complex tachycardia, wtd?

concern for Wolf Parkinson White- treat with procainamide. Digoxin, BB and CCB contraindicated- shown to increase mortality

What is the most common cause of eczematous lesion of nipple?

contact dermatitis

Patient on 40 mg Atorvastatin only had decrease in LDL to 180 mg. You increase her dose to 80 mg. Repeat labs show LDL 80, HDL 59, TGA 135 and AST/ALT 70/80. Her previous AST/ALT was 30/45. wtd?

continue current dosage. Only decrease dose when LFTs 3x above normal. If >3x above normal d/c statin

Pt with wasp sting has local wheal and burning sensation. wtd?

cool compression, antihistamines, topical calamine, elevated for local reaction

In a patient you has CHF exacerbation and you start ACEi. When he follows up his Cr increased from 1.1 to 2 and K from 4 to 5.6. What is the best management?

d/c ACEi and start hydralazine and nitrates

What would you do in a patient with CHF on atorvastatin 20 mg with muscle aches and normal CPK?

d/c statin In patients with CHF there was not improvement in mortality with statin use

tt of AML

daunarubicin and ara-C

Is complement normal or decreased in membranoproliferative nephritis?

decreased

What happens to murmur of MR with amyl nitrate?

decreased after load causes more blood to go into aorta and less in LV to go through MV.

A hispanic M complains of food regurgitation several hours after eating. He denies any heartburn. He has dysphagia to both solids and liquids. On barium swallow you see dilated esophagus with tapering at GE junction. What would you expect to see on manometry? Most likely Dx? How to treat?

decreased peristalsis and increased LE pressure Achalasia Treat with surgical myotomy or pneumatic dilatation

Is complement normal or decreased in cryoglobulinemia?

decreased; C4 decreased more than C3

Is complement normal or decreased in PSGN?

decreased; low C3, C4 normal

What happens to volume in heart when standing?

decreases

What happens to volume in heart when valsalva?

decreases

What does Omega 3 fatty acid do?

decreases TGAs

What are the common sequelae of erythematous psoriasis?

dehydration hypo/hyperthermia hypoalbuminemia- high anion gap anemia of chronic disease

Contact dermatitis

delayed type IV reaction commonly caused by nickel, chromium or oleoresin- poison ivy, poison oak or poison sumac TX cold compresses or local steroids

What are the characteristic findings of WPW on EKG?

delta wave (slurring of upstroke of R wave) shortened PR interval 2/2 impulse via accessory pathway which reaches ventricle earlier than one via AV node

What is the best way to follow a patient with gastric ulcer?

demonstrate healing on EGD

most common cause of neuropathy in USA

diabetes mellitis

Pt with celiac sprue confirmed with TTG abs and started on gluten free diet. Initially was doing well. 3 months later patient continues to lose weight and has diarrhea. Most likely diagnosis?

dietary non- adherence

Pt with intermittent dysphagia to solids and liquids associated with chest pain. What is the most likely diagnosis? What test do you want to do next to diagnose? How do you treat?

diffuse esophageal spasm Barium swallow will show corkscrew esophagus Treat with PPI and if no response can add Ca channel blocker such as dilt

What is the best way to reduce reaction in a patient allergic to radio contrast media?

diphenhydramine, steroids and lower osmolar radio contrast

A woman with Hep C wants to know what precautions should be taken with her husband. If he asks if it is safe to have sex with a condom, share utensils or toothbrush, how would you answer?

don't share toothbrush

What is the most important prognostic factor in acute pancreatitis?

elevated BUN

Interstitial Cystitis (painful bladder syndrome) amitriptyline

epidemiology - more common in women - associated with psychiatric disorders (anxiety) + pain syndromes (fibromyalgia) Clinical Presentation - *bladder pain with filling, relief with voiding* - *inc. frequency, urgency* - dyspareunia - worsened by exercise, sexualy intercourse (dyspareunia), alcohol consumption Diagnosis - bladder pain with no attributable cause for >6 weeks duration - normal urinalysis Treatment - not curative; focus is on quality of life - behavioral modification + trigger avoidance - amitryptiline - analgesics for exacerbations

In a pt with normal BP, after age 18 how often do you screen for HTN?

every 2 years

HOCM and MVP murmur is best heard in Valsalva on inspiration or expiration?

expiration

Obese patient weighing 275 lbs, IDDM, HLD. ALT 100, AST 50. FBS 160. Total Cholesterol 280. What would you expect to see on liver biopsy?

fatty changes and some fibrosis

If patient presents with UGIB and EGD reveals a clean base ulcer <2 cm, wtd?

feed patient, give PPI and send home or to medical floor

What is the role of HLA I antigen and where is it found?

found on most body tissues and it is presented to T8 cells Responsible for transplant rejection reaction and destroying tumor cells

A 55 year old M presents for routine checkup. FOBT -ve. Sigmoidoscopy with tubular adenoma. Wtd?

full colonoscopy

SE of lactulose

gas

Patient who is chronically treated with Sulfasalazine for UC develops flare. You give the patient steroid to treat. When tapering the steroids, patient has another flare. What do you do?

give 6-mercaptopurine and azathioprine

In a patient with multiple PVCs, no heart disease but is having symptoms, what should you do?

give BB

Patient currently being treated for distal Ulcerative Colitis with 5- ASA suppositories develops flare. What do you do?

give cortisone foam

Patient with cirrhosis and varices develops UGIB. Octreotide is started and banding is performed. Patient is started on BB to prevent rebleeding. Paracentesis reveals 150 WBCs with 40% PMNs. wtd?

give rocephin for 1 week (not SBP but in the setting of UGIB want to decrease incidence of SBP)

what is the anti leukemic effect of allegoric bone marrow transplant

graft versus leukemia/host disease

most common cause of neuropathy world wide

hanses disease (aka leprosy)

What are the indications for EGD in GERD?

heartburn not responding to PPI for 4-6 wks heartburn >5 years heartburn with weight loss heartburn with melena heartburn with anemia heartburn with dysphagia or odynophagia

which is better small size or hemorrhage present

hemorrhage b/c detected sooner, size dose not indicate prognosis

mass in liver made of mono normal hepatocytes exclusivley in females associated with OCP risk of rupture

hepatocellular adenoma

What are the metabolic abnormalities associated with tumor lysis syndrome? -Phosphate, calcium, potassium, & uric acid

hyperphosphatemia, hypocalcemia, hyperkalemia, hyperuricemia

What conditions can you see onycholysis?

hyperthyroidism psoriasis (separation of distal nail from nail bed)

Aldosterone Antagonists

i. spironolactone - is an aldosterone antagonist and is preferred initial medical therapy for PRIMARY HYPERALDOSTERONISM (in BILAT ADRENAL HYPERPLASIA OR UNILATERAL ADRENAL ADENOMA) a. *progesterone + androgen receptor antagonist that can cause significant side effects in both men + women (eg decreased libido, gynecomastia) + women (i.e. breast tenderness, menstrual irregularities)* ii. epleronone - very selective mineralocorticoid antagonist with low affinity for progesterone + androgen rfeceptor

32 year old pt with recurrent sinusitis for the past 5 years had nasal endoscopic surgery done a couple of years ago. Now presents with facial pain and X ray shows complete opacification of maxillary sinuses. wtd next?

immunoglobulin titers

What is the etiology of secundum ASD? What to do?

incomplete covering of foramen oval by septum primum. Ideal candidates for percutaneous repair because can lead to MVP

What happens to the murmur of MVP with handgrip?

increased after load causes decreased blood to go aorta and increased LVEDV which causes flopping of the valve later i.e. click later. Duration of murmur shorter because occurs later Intensity greater

What happens to murmur post PVC with AS?

increased intensity because more blood gets out

What happens to the murmur post PVC with HOCM?

increased intensity because volume decreased but after load also decreased and blood leaves quickly resulting in quick decrease in volume and increased murmur 2/2 increased obstruction

What happens to volume in heart when leg raised?

increases

What happens to volume in heart when squatting?

increases

Ankylosing Spondylitis

inflammatory back pain - insidious onset at age < 40 - sx > 3 months - *relieved with exercise but not rest* - *nocturnal pain* Exam - arthritis (*sacroiliitis*) - *reduced chest expansion + spinal mobility due to APICAL PULMONARY FIBROSIS* - *MOA MAIN MEDIATOR = ENTHESITIS (TENDERNESS AT TENDON INSERTION SITES) - dactylitis (swelling of fingers + toes) - *uveitis* - *anterior uveitis (iritis) - MOST COMMON EXTRAARTICULAR MANIFESTATION OF AS* - inflammation of uveal tract (*iris, ciliary body, choroid*) presenting *with PAIN + PHOTOPHOBIA* Complications - *osteoporosis/vertebral fractures - AORTIC REGURGITATION - CAUDA EQUINA SYNDROME* Labs - inc *ESR + CRP* - *HLA - B27* association Imaging - *DX MADE BY X RAY SACROILIAC JOINTS*

When do you use percutaneous transhepatic cholangiogram?

invasive procedure - needle inserted into dilated bile duct + contrast material is injected for bile duct opacification - PT used in evaluation of patients who have previously identified biliay that dilation but are not candidates for ERCP, PTC also allows certain therapeutic interventions including drainage of infected bile

How to test for cushing's syndrome?

late night salivary cortisol

How do you treat anal cancer that is at the anal margin?

local excision

NE is found in

locus cereuleus of pons

graft vs host disease

look at bottom line on GVHD

What is the drug of choice to treat HTN with gout?

losartan

hypoproteinemia and Ca

low serum Ca but normal free ionized Ca because Ca usually binds serum protein

blood streaked sputum + hyperchormatic pleomorphic cells with scant cytoplasm

lung carcinoma

Alcoholic Liver Disease Steps

major pathologic stages of Alcoholic Liver Disease 1. Fatty Liver - Steatosis i. short term result of alcohol ingestion (other two are result of long term) 2. Alcoholic Hepatitis i. pathology: MALLORY BODIES, NEUTROPHILIC INFILTRATE, LIVER CELL NECROSIS, PERIVENULAR DISTRIB INFLAMMATION 3. Alcoholic Fibrosis/Cirrhosis i. later, irreversible cirrhosis - defined by REGENERATIVE NODULES ("TRUE CIRRHOSIS") ***FATTY LIVER, ALCOHOLIC HEPATITIS, EARLY ALCOHOLIC FIBROSIS/CIRRHOSIS ARE COMPLETELY REVERSIBLE **** W STOPPAGE OF ALCOHOL

3 months post cholecystectomy patient still complains of right upper quadrant pain. US reveals dilated CBD. What to do?

manometric studies of sphincter of oddi for possible sphincterotomy

In ZE, where are the tumors usually found?

mid duodenum, pancreas, porta hepatis

what kind of murmur is tricuspid stenosis?

mid-diastolic

Nevus

mole; pigmented skin blemish that is usually benign but may become cancerous

What happens to the murmur of HOCM with handgrip?

more volume in the LV causes less of an obstruction of the LVOT and decreased murmur

erythema and stiffness of right ankle joint

most likley pseudo gout (Ca pyrophosphate arthropathy)

What are risk factors for melanoma?

multiple sunburn in childhood dysplastic nevus >6 mm in diameter family history of melanoma >25 nevi fair, blond hair immune suppression ****- pts on chemo or post transplant

40 year old was diagnosed with melanoma and asks what was his greatest risk factor for acquiring disease?

multiple sunburns in childhood

What happens to murmur post PVC with MVP?

murmur occurs earlier because blood goes quickly into aorta and have flop of valve faster and increased duration of murmur

Mirtazapine

1. antidepressant with side effect 2. SE = weight gain

Trigger Thumb

- pain over *palmar aspect of 1st metacarpophalangeal joint and locking of thumb in flexion*

Esophageal Rupture

- subcutaneous crepitus in chest - on CXR as penumomediastinum

how long tick has to be attached to cause lymes

24-36hrs

What is the goal blood pressure for patient with DM and ESRD?

<140/90

HTN and DM

ACEI

HTN and Angina

CCB

What is most common cause of death in dialysis patients?

Cardiovascular disease

HTN and elderly w/ orthostasis

Clonidine

TX of Cryptococcus & candida infections?

Flucytosine

Pt with CP for 3 hours comes to ER with ST elevations in II, III, aVf. Troponin negative. wtd?

PCI

What is the most common incidental finding on CT scan of the abdomen?

Pancreatic cyst

lowenstein jensen medium

TB culture

Buspirone

Tx for GAD

non caseating granuloma with asteroid bodies in lung

sarcoidosis

rifampin decreased absorption

with food