$$$$$ UWORLD Internal Medicine II
acute interstitial nephritis vs tubulointerstitial nephritis
*Acute interstitial nephritis* - the tubular damage leads to renal tubular dysfunction, with or without renal failure. - - Regardless of the severity of the damage to the tubular epithelium, the renal dysfunction is generally reversible, possibly reflecting the regenerative capacity of tubules with preserved basement membrane. The principal mechanism in acute tubulointerstitial nephritis is hypersensitivity reaction to drugs such as penicillins, nonsteroidal anti-inflammatory drugs (NSAIDs), and sulfa drugs. Another mechanism is acute cellular injury caused by infection, viral or bacterial, often associated with obstruction or reflux. T *Chronic tubulointerstitial nephritis* - interstitial scarring, fibrosis, and tubule atrophy, resulting in progressive chronic renal insufficiency.
what is the fraction excreted sodium (renal sodium clearance: cr clearance ratio) during hypovolemia
FeNa <1% low urine Na during dehydration/hypovolemia
what is best approach to dealing with an angry/irritable patient?
- acknowledge the patient's distress - remain nondefensive - ask OPEN-ENDED questions regarding what is upsetting the pt!!
right placement of endotracheal tube at what location
2-6cm above carina
who should be screened for AAA
65-75 yo who have smoked one time abdominal u/s
when do you screen for colon cancer in pt with IBD
8-10 yrs postdx repeat q1-3yrs
65 yo man with irregulary irregular rhythem. which of the following anatomic sites is most likely origin or this arrhythmia? atrioventricular bypass tract AV node pulmonary veins sinoatrial node
A fib - absent P waves replaced by tiny chaotic fibrillatory waves, irregularly irregular R-R intervals and narrow QRS complexes - pulmonary veins (PVs) are the most freq location of the ectopic foci that cause AF - cardiac tissue (myocardial sleeves) extends into the PVs and normally functions like a sphincter to reduce reflux of blood into the PVs during atrial systole. - this tissue had different electrical properties than the surrounding atrial myocytes and is prone to ectopic electrical foci , which can initiate AF - origination of AF from PV is useful in pts who dont achieve rate/rhythm control with meds. in this pts, the myocardial tissue surrounding PVs can be disrupted by catheter-based radiofreq ablation, disconnecting the PV from the left atrium
bullous pemphigoid moa and rx?
AID IgG against hemidesmosome and basement membrane in dermal-epidermal region direct immunofluorescence microscopy show linear IgG and C3 deposits along basement membrane rx - high potency TOPICAL steroids eg clobetasol
46 yo woman 2 months pain and numbness in her right index and middle fingers, turns white when cold and hurt assoc with ulcers on those fingers smoker other sx: chronic cough, lower back pain and acid reflex disease left hand fingers normal what is next step? ANA studies arteriogram losartan thyroid function transthoracic echocardiogram
ANA studies likely has secondary raynaud phenomenon - caused by underlying disease eg CT disease, hyperviscosity syndrome, occlusive vascular conditions, nicotine - usually >45yo - assymetric sx primary raynauds -15-30 yo - symmetric sx note - arteriogram would be uses to dx thromboangitis obliterans (Buerger's disease), a vasculitis that affects small and medium sized arteries of yougn pts (<45) who smoke. it presents with distal extremity ischemia, ulcers, gangrene. Usually dx'd after exclusion of other systemic diseases (eg DM, AID, hypercoaguable states)
20 yo with diastolic mumur in LSB heard on PE what next?
echo! diastolic murmurs are concerning in adults and indicate pathology since diastolic, most like AR - early decrescendo murmur after A2 - high pitched blowing - heard best in LSB btw 4&5th intercostal space, pt leaning fwd while holding breath in full expiration
if a pt is in ovelume overload and started on furosemide days later, have 6 beats of wide complex ventricular tachycardia what is likely cause?
electrolyte imbalance - hypokalemia - hypomagnesemia both can lead to ventricular tachycardia
empyema vs lung abscess
empyema - puss in pleural space lung abscess - pus in alveoli
3 mo hx of squeezing chest pain that radiates to neck occurs at rest last 2hrs no t/e/d normal ECG normal vitals exercise stress test nml no leg swelling no sob
gerd
60 yo man with facial and leg edema for 2weeks no chest pain or dyspnea PMH: DM rx'd with lifetyle and glyburide A1c: 6.9% BP 146/87 bilateral pitting edema around ankles and periorbital edema EKG normal urine proteinuria >3000mg/24hr what is most appropriate next step in managing diabetic nephropathy? intense glyemic control intense BP control
BP control DM nephropathy begins with hyperfiltration (incr GFR) and microalbuminuria - if not rx'd adequately, microalbuminuria my progress to macroproteinura (protein >300mg/24hr) intensive BP control is primary intervention proven to slow decline in GFR once azotemia develops. BP goal 140/90 in DM meds; ACE-I or ARB reduce GFR and renoprotective BUT must be initiated carefully as they can cause acute decline in GFR and hyperkalemia
rx flu
symptomatic those with ris factors eg >65 yo, chronic medical conditions, preganncy....should receive antiviral rx eg oseltamivir
a pt comes for preconception counselling. she is concerned about anemia due to family ancestry, what is first text to order? CBC hemoglobin electrophoresis iron studies
CBC - if no normal, no further tests needed
teenagers attend an indoor barbecue ate potato salad and barbecue chicken few hours later, go to ED: HA, n/v, abd pain, confusion PE: tachypnea, tachycardic, pinkish-skin hue cause?
CO poisoning dx: carboxyhemoglobin levels rx: hyperbaric O2
35 yo rescued from fire burning building presents with seizure, confusion, agitation, wheezing what is cause and rx?
Co poisoning rx: 100% o2 facemask
32 yo brought to ED with left sided cheat pain, anxious, sweating, pupils dilated, nasal mucosa atrophic lungs clear heart normal ECG - ST segment depression and T wave inversion in leads V4-6 CK-MB and troponin normal CXR normal T99F BP160/90 P125 R20 what is going on? how do you rx?
cocaine abuse rx - benzos for anxiety
what is consumptive coagulopathy
DIC
what is vit B12 used for?
DNA synthesis - purine and thymidylate synthesis deficiency s/s - anemia - increased intramedullary hemolysis of megaloblasts releases heme causing indirect hyperbilirubinemia which can manifest as jaundice - hemolysis can also release LDH from cells into serum - thrombocytopenia ad leukopenia with hypersegmented PMNs - beefy shiny tongue causes: loss of intrinsic factor - gastric resection - AI gastritis
64 yo male had MI 2 weeks ago now presents with pt complain of chest pain that is worse with deep breaths and gets better when leans forward ECG: diffuse ST elevations (ST elevations in all leads) except aVR where ST depression is seen likely dx?
Dresseler syndrome - pericarditis that occur weeks after MI - immunologic phenomena - ESR elevated - rx: NSAIDs
31 yo went to arizona recently low grade fever dry cough right sided chest pain - sharp and worse with inhalation erythematous tender nodules on bilateral shins swollen right ankle and knee likely pathogen?
coccidiodes immitis - desert southwest - arthralgia - erythema nodosum note: blastomyces and histoplasma more common in central and midwestern states
64 yo woman headache and nausea ESRD due to DM nephropathy and started on dialysis recently also recently started on EPO for anemia BP210/121 P76 bilateral retinal hemorrhages finger glucose 186 what is cause of current condition? EPO therapy fibrinoid necrosis of renal arterioles osmotic shifts during dialysis
EPO - pt with ESRD has severe HTN, HA and retinal hemorrhages with acute hypertensive crisis - EPO related HTN, given pt's EPO therapy - large doses of EPO or rapidly rising Hgb soon after administration increase the risk of HTN. - need close monitoring of BP after give EPO to pt's with ESRD
52 yo obese woman complain of intermittent RUQ pain and nausea she had elective cholecystectomy a year ago pain located in right subcostal area and last 30-60min she has similar episode before surgery labs - t bili 2.1 - direct bili 1.2 - alk phos 185 - ast 84 - alt 72 u/s show mild dilation of common bile duct what is next step in management? anti-mitochondrial antibodies ERCP liver bx ursodeoxycholic acid therapy
ERCP pt has postcholecystecomy syndrome - persistent abdominal pain or dyspepsia (nausea) that occurs either postoperatively or month to years later after cholecystectomy - can be due to biliary (retained common bile duct stone, biliary dyskinesia) or extra0biliary (pancreatitis, peptic ulcer disease, CAD) - findings suggest common bile duct stones or biliary sphincter of Oddi dysfunction - ERCP or MRCP for dx
what is light's criteria to distinguish transudate from exudate pleural effusion
Exudates have: - protein pleural fluid/protein serum >0.5 pleural fluid LDH/serum LDH >0.6 pleural fluid LDH >2/3 upper limit normal LDH
what are the most common target organs for graft-versus-host disease?
GVHD is common after bone marrow transplant target organs: - skin: maculopapular rash palms, soles, face - intestine: bloody diarrhea - liver: transaminitis, low albumin, jaundice donor T cells recognize host major and minoe HLA antigens
what diseases (diarrhea) are assoc with spondylarthritis
IBDs can be complicated by spondylarthritis - 15 to 40 yo and 50 to 80 yo - extra intestinal manifestation: arthritis, eye (uveitis, episcleritis) and skin (pyoderma gangrenosum), hepatobiliary (PSC) pts with spondylarthritis or sacrolilitis commonly report prolonged stiffness and low back or buttock pain that improves with activity there is no specific test for dx IBD-assoc arthritis NSAIDs can relive arthritis sx but exacerbate underlying IBD therefore need t use meds such as sulfasalazine to rx the IBD and joint disease
if pt has infective endocarditis s. mutans identified and susceptible to penicillin how should pt be rx? oral penicillin V IV penicillin G or IV ceftriaxone IV vancomycin oral amox-clav
IV penicillin G or IV cefrtiaxone
pt with recurrent vasovagal syncope what would you recommend as ppx?
counter pressure maneuver education
if you suspect epidural spinal cord compression (conus medullaris syndrome) due to prostate cancer metastases, what do you give first?
MRI Steroids first!!! - decrease vasogenic edema caused by obstructed epidural venous plexus - help alleviate pain - may restore neurological function then radiation-oncology & neurosurgery consult
you suspect herniated dic in pt presenting with signs og lumbosacral radiculopathy (sciatica) next step? NSAIDs MRI XR
NSAIDs - most pts will have spontaneous resolution mri can confirm dx but will not change management
26 yo being rx'd for SLE with prednisone and cyclophosphamide presents with fever, chills, DOE, nonproductive cough, fatigue no chest pain or hemoptysis T101F, BP140/80 P112 R24 O286% ORA bilateral crackles normal heart sounds no JVD labs - hct 36% - wbc 12,400 ABG - pH 7.48 - PaO2 60mmHg - PaCO2 29mmHg serum - high LDH CXR: bilateral interstitial infiltrates what is likely cause? diffuse alveolar hemorrhage invasive aspergillosis PCP pneumonia pulmonary fibrosis caused by SLE
PCP pneumonia - fever, dry cough, low oxygen levels - HIV+ or immunocompromised work up - high LDH - diffuse reticular infiltrates on imaging - induced sputum or BAL (stain) rx - tmp/smx - prednison if low oxygen levels ppx - tmp-smx - ARTs in HIV pts
ppx for HIV pts against PCP Cadidiasis
PCP - TMP-SMX - Dapsone Candidiasis - Fluconazole
criteria for long term oxygen therapy in COPD
Resting arterial oxygen tension (PaO2) <55mmHg or Pulse Ox (SaO2) <88% ORA or PaO2 <59mmHg or SaO2 <89% in pts with corpulmonale or Evidence RHF or Hematocrit >55% the dose of supplemental O2 has to be titrated so that SaO2>90% during sleep, normal walking and at rest. Survival benefits of home O2 are sig when it is used >=15hrs/day
25 yo with history of 2 miscarriages now currently pregnant VDRL positive FTA-ABS negative Hct 33% WBC 7K Plat 80,000 PT 10s APTT 46s dx? rx during pregnancy?
dx -antiphospholipid syndrome - miscarriages - prolonged PTT - VDRL false positive rx - LMWH
42 yo man with cysts in liver + hepatomegaly + RUQ ain used to be in farmer in guatemala what is likely cause of cysts?
echinococcus - contact with dogs
normal BUN/Cr ratio
between 10:1 and 20:1
57 yo man with burning chest pain, not related to meals lost 40lbs, although attributes to eating a selective diet and careful chewing food +fatigue +malaise +decreased interest in activities PMH: GERD rx'd with ranitidine Social: - 20pack year smoker, quit 4 yrs ago - works as a missionary and frequent trips abroad vitals wnl PE (cervical, cardiopulm, abd) unremarkable CXR: no abnormalities next step? CT chest PPI for 2weeks h pylori test Upper GI endoscopy
Upper GI endoscopy pt likely has esophageal cancer - age - persistent chest pain - careful swallow of food (probably dsyphagia) - wt loss - dx need endoscopy + bx CT can be done later for staging
56 yo male just underwent surgery for coronary artery bypass presents with RUQ pain, leukocytosis and fever likely dx?
acute cholecystitis - prolonged surgery lead to stasis, ischemia and subsequently inflammation of gall bladder
acute kidney injury acute kidney insufficiency acute renal failure
acute kidney injury - trauma acute kidney insufficiency - elevated CR <2days, due to dehydration, hypovolemia acute renal failure - elevated Cr >2days that does not resolve
what are prophylaxis criteria for lyme disease
adult or nymphal ixodes scapularis (deer tick) tick attached for >=36hrs or engroged ppx start within 72hrs of tick removal local borrelia burgdorferi infection rate >=20% (eg New England area) No CI to doxycycline (eg age <8, pregnant, lactating)
main risk factors assco'd with abdominal AA
age >60 yo smoking family hx AAA white race artheroscleorsis
what is presbyopia
aging loss of lens elasticity prohibits accommodation of lens required to focus on near objects pt have to hold material further distance can be improved with reading glasses
36 yo man with skin lesions on right forearm and back of neck painless violaceous nodules and large wartlike lesions with sharp demarcated border dry cough + malaise for 2 months no fever, chills, night sweats, wt loss PMH: seasonal allergies works: agricultrual irrigation mechanic no recent travel lives in southern wisconsin vitals: T 99.2 wet prep of skin lesions show yeast likely dx?
blastomycosis - low grade fever - violaceous skin lesions + scrapings showing yeast - midwest and upper midwest regions of US, extending into southern mississipi valley - inhalation infection - extrapulmonary disease due to hematogenous spread most commonly affects skin, bone, prostate and CNS
40 yo man 1 month progressive worsening burn + tingling in hands and feet, difficult lifting heavy tools hobby: restores antique furniture no PMH BP 100.70 hyper and hypopigmented lesions in skin hyperkeratosis + scaling on palms and soles increased sensitivity to pinprick and light tough on fingers + toes DTR 1+ weak interossi and wrist flexors and extensors labs - hgb 10.4 - wbc 4K - plt 130K liver - ast/alt 50/62 likely dx? arsenic poison Guillan barre intermittent porphyia lead poisin
arsenic - antique wood - metals - binds to sulfhydryl groups and interfere with enzymes labs - pancytopenia - transaminitis skin - hyperkaratosis - hypo + hyperpigments - *mees lines* horizontal striations of fingernails neuro - polyneuropathy - hypersensitivity - distal weakness - hyporeflexia rx: chelation with dimercaprol, dimercaptosuccinic acid
mcc of ascending vs descending thoracic aortic aneurysm
ascending thoracic aortic aneurysm: arise anywhere from aortic valve to innominate artery - cystic medial necrosis (occur with aging) - CT disease (marfan, ehler-danlos) - descending thoracic aortic aneurysm: arise distal to left subclavian - atherosclerosis. risk factors: HTN, hypercholesterolemia, smoking both CXR - widened mediastinum - increased aortic knob - tracheal deviation
how does EBV cause anemia?
autoimmune hemolytic anemia and thrombocytopenia - rare complication of EBV - cross-reactivity of EBV-induced antibodies against RBCs and platelets - these are IgM cold-agglutinin antibodies cause complement mediated destruction of RBCs - elevated bilirubin and transaminase levels - Coombs test positive - Rct count elevated other complications EBV - splenic rupture - airway compromise
what is the ppx for mycobacteirum avium in HIV pts?
azithromycin disseminated m.avium complex infection - fever, cough, diarrhea, night sweats, wt loss, splenomegaly, elebated ALP - CD4 <50 - negative tuberculin skin test <5mm
pt intoxicated agitates, combative, psychosis, delirium, myocolnus prolonged duration (days to weeks) agitation rx'd with benzo UDS: positive weed what is likely cause? bath salts weed phenyclidine (PCP
bath salts - prolonged duration of sx PCP can cause psychomotor agitation, combative behavior, diminished pain eprception, hallucinations, HTN, tahcycardia and multidirectional nystagmus - however SHORTER duration compared to bath salts AND can be seen on UDS
pt has cirrhosis endoscopy reveal non-bleeding esophageal varicies what meds should pt be given to prevent risk of bleeding? bblocker octreotide
bblocker nonselective - decrease progression to large varicies
pt with cancer assoc'd with ch22 what is it? what is rx target? DNA methylation mutation folic acid metabolism retinoic acid tyrosine kinase
bcr-abl 9;22 transloctaion - cause leukemogenesis due to activation tyrosine kinase chronic myeloid leukemia rx: tyrosine kinase inhibitors eg imatinib
meds shown to improve morbidity and mortality in pts with known CAD
beta blocker ACE-I ARB HMG-CoA reductase inhibitors (statins) Dual Antiplatelet - aspirin - P2y12 receptor blocker (clopidogrel, prasugrel, ticagrelor)
74 yo woman diarrhea, nausea, decreased appetite, fatigue, occasional palpitations for a week PMH: chronic a fib and cardiomyopathy Meds: furosemide, metropolol, digoxin, warfarin PE - lung scattered wheezes - abdomen soft and nontender with 8cm liver span - INR 2.3 likely next test? echo CXR PFT thyroid test blood drug level
blood drug level: digoxin toxicity - diarrhea, nausea, fatigue, vomiting, confusion, weakness - renally cleared with narrow TPI - an inciting event eg viral illness or excessive diuretic use can lead to volume depletion or renal injury that acutely elevated digoxin level
32 yo man hx of splenectomy intermittent high fever, chills, drenching sweats malaise, fatigue, dark urine recently camped in New England and found 2 ticks on his leg T1003F, BP110/70, P116 conjuctival icterus no enlarged LNs or skin rash tender liver edge labs - hgb 9.4 - rct 10% - plt 110K - wbc 12K liver - t bili 4.3 - alk phos 150 - ast 62 - alt 74 serum ldh 300 what is most likely to yield dx? antirickettsial antibody assay blood smear exam lyme serology PCR ehlichia
blood smear serology pt has babesiosis - tick borne protozoa - northeast US - human trasmission via ixodes scapularis 48-72hrs after attachement - infection usually asymptomatic but immunocompromised, >50yo and hx splenectomy at incr risk of illness - sx: fatigue, malaise, weakness, chills, int fever - multiples in RBCs so pts may have anemia w/ since of intravascular hemolysis (jaundice, dark urine, indirect hyperbilirubinemia, recticulocytosis, liver transaminitis, LDH) - thrombocytopenia - mild hepatosplenomegaly - dx: blodo smear: maltese cross - rx: 7-10 days atovaquone plus azithromycin or quinine + clindamycin
60 yo male presents with R sided neck pain and numbness over the posterior surface of the forearm. He had several episodes over the last two years that responded to NSAIDs and PT. There is decreased pinprick sensation on the posterior aspect of the right forearm, but no muscle weakness is present. Triceps reflex is normal. what will be seen on radiography? reversed lordotic curve bony spurs vetebral body osteoporosis osteolytic lesions compression fracture
bony spurs pt has cervical spondylosis - chronic neck pain - limited neck rotation and lateral bending due to OA and secondary muscle spasm - sensory deficit is due to osteophyte-induced radiculopathy and isolated sensory abnormalities are assoc'd with goof prognosis -XR show bony spurs and sclerotic facet joints - narrowing disc spaces - hypertrophic vertebral bodies
which test has highest sensitivity for detecting left-sided HF
brain natriuretic peptide
pt in MVA given packed RBC blood transfusion few hours later, has tingling sensation in toes and fingers found to be hypocalcemic cause?
calcium chelation by substance (citrate anticoagulant) in transfused blood
when do you consider rx of hyperkalemia with - calcium gluconate or IV insulin +dextrose - dialysis
calcium gluconate or IV insulin+dextrose - K>7 +/- ECG changes - ECG changes dialysis - renal failure - severe life threatening hyperkalemia unresponsive to initial therapy
how does PE cause hypocalcemia?
calcium in blood is either - bound to albumin - ionized - bound to inorganic compounds PE - tachypnea lead to resp alkalosis - in resp alkalosis, H+ ions that are usually bound to albumin dissociate from it - this frees up albumin to bind to calcium - less ionized calcium in blood but total calcium is same - ionized calcium is the active form - leads to hypocalemic sx eg crampy pain, parasthesias, carpopedal spasm,
45 yo man eval for chronic diarrhea fecal fat content high no pathogens or leukocytes in stool pt given 25g oral D-xylose and urinary excretion is 1.2g (below normal) 4 weeks rx'd with rifaximin pt given 25g oral D-xylose and urinary excretion is still low what is most likely dx?
celiac disease - chronic diarrhea, steatorrhea, wt loss - malabaroption - atrophy of intestinal villi in proximal small bowel due to gluten containing wheat products - D xylose is a monosaccharide that can be absorbed in proximal small intestine without pancreatic or brush border enzymes - is subsequently excreted in urine - low d-xylose in urine means low absorption - pts with enzyme deficiencies (eg chronic pancreatitis) will have normal d-xylose absorption
cellulitis vs erysipelas
cellulitis - deep dermis and subq - flat irregular border - strep pyogenes or staph aureus erysipelas - superficial dermis - defined border - step pyogenes
what type of acid-base disturbance is caused by OSA?
chronic hypoxia and hypercapnia lead to resp acidosis body compensates by bicarb retention in metabolic alakalosis
what is icthyosis vulgaris
chronic, inherited skin d/o diffuse dermal scling mutation in filaggrin gene skin appears dry and rough with horny plats resembling reptile/fish scales worse during winter due to ambient humidity smollients ineffective rx for controlling sx - keratolytics eg coal tar, salicylic acid - topical retinoids
35 yo man comes to ER for SOB started 2 days ago and worsened last night + dry cough PMH: HTN meds: chlorthalidone, amlodipine and labetalol ran out of meds 3-4days ago smokes and drinks daily last drink was 4days ago T98F BP220/120 P105 RR20 O296% on 2L Nasal Cannula PE - bibasilar crackles on chest - 4th heart sound - normal optic discs - occasional cotton wool spots - K 5.0 - Cr 2.1 admitted and started on furosemide and nitroprusside infusion next morning: confused, agitated, GTC T98F BP176/95 P102 breathsounds clear likely dx? alcohol withdrawal aortic dissection cyanide toxicity
cyanide poisoning - nitroprusside is a vasodilator with quick onset and offset of action - used for rapid BP control in pts with hypertensive emergency (high BP and organ damage eg renal) - metabolism of nitroprusside release NO and cyanide ions - NO induce arteriolar and venous vasodilation - cyanide toxicity can occur in pts receiving prolonged infusions of nitroprusside sx: AMS, lactic acidosis, seizures, coma note - alcohol withdrawal peaks in Day2 following cessation, seizures occur 12-48hrs and delirium tremens 48-96hrs delirium tremens: acute change in attention + cognition due to alcohol withdrawal - tachycardia - HTN - tremulousness - diaphoresis - agitation - hallucination
which immunosuppresive med causes tremor and gingival hyperplagia?
cyclosporine
side effects cyclosporine renal vasculature glucose infection malignancy oropharynx skin GI
cyclosporine: inhibit transcription of IL-2 and other cytokines, and T-helper lymphocytes s/e cyclopsorine renal: nephrotoxicity - acute acotemia or irreversible progressive renal disease - hyperuricemia with accelerated gout, hyperkalemia, hypophosphatemia, hypomagnesemia hypertension - renal vasoconsriction and sodium retention neurotoxicity - often reversible - HA, visual probelmes, seizure, mild tremor, glucose intolerance - esp if taking prednisone infection malignancy - scc of skin and lymphoproliferative disease gingival hypertrophy and hirsutism GI manifestations - anorexia, n/v, diarrhea
17 yo hexagonal kidney stones urinary cyanide nitroprusside test is positive heriditary dx>
cystinuria - aa transport abnormality - cysteine poorly soluble in water - lead to formation radioopaque renal stones - cyanide nitroprusside test detect elevated cysteine in urine
65 yo with pain and swelling over inner aspect of right eye for 2days tenderness, edema, redness over medial cathus slight pressure cause purulent material to release dx?
dacryocystitis - infection of lacrimal sac - infants and adults >40yo - sudden onset of pain and redness in medial canthal region - purulent discharge - pathogen: s aureus and strep - rx: systemic abx
what is the most predominant mechanism responsible for the rapid pain relief of nitroglyceride during chronic stable angina? coronary vasodilation decreased LV contractility decreased LV wall stress dilation small arteries
decreased LV wall stress nitroglyceride decrease preload -> decreased LVED volume -> decreased LV wall stress coronary vasodilation can also happen but it is not the most sig mechanism responsible for rapid pain relief
65 yo man with decreased vision in both eyes dx'd with DM ten years ago and progressive worsening meds: metformin and glyburide optho exam - decreased vision bilateral - microaneurysms, dot and blot hemorrhages, hard exudates and macular edema what is likely dx? diabetic retinopathy central retinal vein occlusion macular degeneration
diabetic retinopathy - leading cause blindness in USA - microaneurysms, hemorrhages, exudates, retinal edema - pre-proliferative retinopathy with cotton wool spots - proliferative or malignant retinopathy with newly formed vessels note: central retinal vein occlusion - sudden unilateral vision loss - DM at increased risk - optic disc swelling, venous dilation, tortuosity, retinal hemorrhages, cotton wool spots macular degeneration - central vision/central scotoma - smoking increase risk - can be atrophic or exudative - strophic: multiple sores in macular region - exudative: new blood vessels that may leak, bleed and scar retina
pt with episodic retrosternal pain that radiates to interscapulr region lasts 15mins precipitated by emotional stress and hot/cold food regurgitates food intermittently sublingual nitroglyerin tablets alleviate the pain you do ECG, ECHO, lipid profile and r/o cardiac causes EGD normal likely cause?
diffuse esophageal spasm - spontaneous pain, odynophagia for cold and hot food - resolution with nitrogycerin - nitrates and CCB relax myocytes in esophagus - esophagraphy may or may not show corkscrew pattern - need to do esophageal motility studies (manometric recordings): show repetitive, non-peristaltic, high-amplitude contractions
what type of heart problem does alcohol use d/o cause?
dilated cardiomyopathy - reduced LV systolic function - lead to decompensated CHF
impt s/e of rifampin
discoloration - urine, tears, saliva, sweat - soft contact lenses hepatotoxicity - monitor liver enzymes
physician at a conference and needs a flash drive pharmaceutical company offers free flash drive should he/she take it? yes/no and why?
dont take flash drive as only small gift that directly benefits patients are acceptable
32 yo man 2 day hx of fever, HA, malaise, myalgia, confusion 2weeks ago was walking through woods in arkansas T102F BP 125/80 P100 neck supple, no LAD oropharynx clear no rash CV exam nml no focal neurologic deficits cbc - hgb 14 - plt 78,000 - wbc 2,500: 60% PMNs, 1%eosinophils, 30%lymhocytes, 10%monocytes liver - t bili 1 - alk phos 110 - ast 98 - alt 105 next step? - BM bx - ceftriaxone - doxy - lyme serology
doxycycline human monocytic ehrlichiosis - tick borne - southeastern and south central US - acute febrile illness with malaise and AMS - no rash usually -"rocky mountain spotted fever without spots" - leukopenia and thrombocytopenia - elevated transaminases
epidermal inclusion cyst vs lipoma
epidermal inclusion cyst - *dome-shaped, firm, freely movable cyst or nodule with central punctum (pore opening)* - discrete benign nodule lined with squamous epithelium that contains a semisolid core of keratin and lipid - occur in epidermis and becomes lodged in dermis due to trauma or comedones - gradually increase in side and may produce white cheesy discharge - *resolve spontaneously and recur* - lipoma - benign painless subcutaneous mass with normal overlying epidermis - soft, rubbery - *do not regress and recur*
how can you differentiate ethylene glycol vs methanol poisoning since both cause high anion gap met acidosis
ethylen glycol - damage to kidney: calcium oxalate crystals methanol - damage to eyes: optic disc hyperemia
what is the antidote for the following toxins ethylene glycol methemoglobinemia acetaminophen cyanide
ethylene glycol - fomepizole: competitive inhibitor of alcohol dehydrogenase prevent further breakdown of ethylene glycol into its toxic metabolites methemoglobinemia (eg dapsone or anesthia agents) - methylene blue acetaminophen - n-acetylcysteine cyanide - sodium thiosulfate
milk alkali syndrome
excessive intake calciium and absorbable alkali hypercalcemia, metabolic alkalosis, AKI bicarbonate elevated due to increased intake and decreased renal excretion of bicarb
if a male athlete uses exogenous steroids, how would they present?
exogenous/anabolic steroids used by athletes for muscle mass enhancement - contain testosterone analogs - negative feedback to hypothalamus - suppress GnRH - suppress LH and FSH from pituitary - small testes - gynecomastia (androgen converted to estrone) - acne - erythrocytosis (increased erythropoieses) - elevated hemoglobin - cholestasis - hepatic failure - dyslipidemia (low HDL) - elevated creatine (due to incr muscle mass) note - labs may show normal testosterone level in serum because it also detects exogenous testosterone analogs
signs of graves you only see in graves and no other hyperthyroidism
exopthalamous (bulging eyes) pretibial edema diffuse uptake RAI
are pleural effusions from pulmonary embolism exudative or transudative?
exudative PE can cause hemorrhage or inflammation leading to pleural effusion - exudative and bloody - assoc'd with pain due to pleural irritation id you suspect PE, confirm with CT pulmonary angiography
pt with inflammatory arthritis, splenomegaly and neutropenia(<1500) PE: sever joint disease, nodules at joints, vasculitis (necrotizing skin ulcers) +RF in serologies thoughts?
felty syndrome - pts with longstanding RA - extra-articular manifestations eg splenomegaly, skin ulcers - neutropenia put pt at increased risk of bacterial infections
which antiahhrytmic drug can cause widening of QRS complex at high heart rate
flecainide and propafenon Class IC
45 yo man with progressive DOE and fatigue has hx of alcoholic cirrhosis with ascites, esophageal varices dullness and decreased breath sounds on the right left sided breathsounds normal abdomen is distended 1+ bilateral LE edema what is cause of lung sx
fluid passage through diaphgragmatic defects - hepatic hydrothorax, a pleural effusion not due to underlying cardiac or pulmonary abnormalities - results in transudative pleural effusions - due small defects in diaphragm - more common on right due to less muscular hemidiaphragm - dyspnea, cough, pleuritic chest pain, hypoxemia rx: salt restriction and diuretics, therapeutic thorocentesis
rx SIADH
fluid restriction hypertonic saline - only is severe eg coma, seizure, profound confusion
what is the mcc of megaloblastic anemia is chronic alcoholics
folate deficiency alcohol abuse impair its enterohepatic cycle and inhibit its absorption develop anemia within 5-10 weeks as body stores of folate are limited other heme manifestations in alcoholism - fe def anema from chronic blood loss (microcytic) - anemia of chronic disease (normocytic or microcytic) - thrombocytopenia -
33 yo male abdominal pain, nausea 2episodes vomitting and blood never had this before went out drinking last night and used cocaine woke up with HA and took several aspirin pills PE - mild epigastric tenderness, no masses or guarding what is likely cause of hematemesis? gastric mucosal erosion partial esophageal tear dilated esophageal vessels
gastric mucosal erosion (acute) - severe hemorrhagic lesions - after exposure of gastric mucosa to various injurious agents or after substantial reduction in blood flow - aspirin decreases the protected prostaglanding production - cocaine causes vasoconstriction, reducing blood flow - aspirin and alcohol cause direct mucosal injury which decreased normal protective barriers eg secreted mucins, bicarb...permits acid and proteases to penetrate lamina propria - results in injury to vasculature and subsequent hemorrhage
52 yo woman comes to office with intense itching and fatigue. pmh; hypothyroidism and carpel tunnel syndrome hepatomegaly present no scleral icterus or jaundice bilateral xanthelasma and skin exocriations labs - Cr 1 - total cholesterol 503 - total bili 1.5 - ALP 410 - AST 42 - ALT 42 RUQ us show normal common bile duct next step? - check anti-mitochondrial antibody - check anti-smooth antibody - stop levothytoxine - MRI abdomen
get anti-mitochondrial antibodies pt likely has PBC - cholestasis (impaired biliary flow) - fatigue - pruritis - high ALP - RUQ u/s suggest intrahepatic cholestasis - complications: hyperlipidemia (with xanthelasma) and metabolic bone disease - assoc with other AID eg hypothyroidism
IE by staph vs strep viridans - what type of valves
good valve - staph damaged valve - strep viridans
24 yo penile lesion a wek ago - painful papule - had unprotected sex 2 weeks ago PE - tender, 1.5cm ulcer on the prepuce with well demarcated, undermined borders and a purulent exudate - two smaller ulcers with similar appearance near the larger ulcer - no penile discharge - scrotum normal - several inguinal LNs enlarged and tender - skin exam show track marks in antecubital area with no other rash likely cause? acute HIV hemophilus ducreyi infection N gonorrhea infection staph ecthyma
hemophilus ducreyi infection - painful deep ulcer with exudate - painful LAD
vaccine for north africa travel
hep a hep b typhoid polio booster
32 yo male pain, watering + redness in left eye for 2 days left eye has vesicles and dendritic ulcers vital wnl likely cause? herpes zoster herpes simplex
herpes simplex keratitis - can cause corneal blindness - pain, photophobia, blurred vision, tearing, redness - recurrences are precipitated by excessive sun exposure, outdoor occupation, fever, immunodef - *corneal vesicles and dendritic ulcers* - rx: antivirals herpes zoster - periorbital vesicular rash and swelling in CNV1 region - burning, itching periorbital region - conjuctivitis and dendriform corneal ulcers
why is there leukocytosis during stress
high cortisol level - demargination wbcs (pmns) from vascular wall
what metabolic abnormalities does hypothyroidism cause
hyperlipidemia hyponatremia asymptomatic Cr kinase increase Serum transmaninase elevated hypercholesterolemia - decreased surface LDL receptors - decreased LDL receptor activity hypertriglyceridemia - decreased lipoprotein lipase activity
how can hypokalemia and metabolic alkalosis worsen hepatic encephalopathy in the setting of alcoholic cirrhosis
hypokalemia - intracellular acidosis - excreted intracellular potassium replaced by hydrogen ions maintain electroneutrality - causes increased NH3 produced (glutamine conversion) in renal tubular cells metabolic alkalosis - promote conversion NH4 to NH3 which can enter CNS pt with HE and hypokalemia need prompt potassium repletion and intravascular volume repletion disaccharides eg lactulose can be given to lower NH3 levels
pt with alcohol withdrawal has hypokalemia and given oral and IV potassium....but potassium level remains low why? hypoalbuminemia hypomagnesemia hypophosphatemia
hypomagnesemia - chronic alcoholism assoc with high incidence of electrolyte abnormalities - hypomagnesemia is most common due to poor nutritional intake, alchol-induced renal losses, diarrhea - hypomagnesemia occur together with hypokalemia and can cause refractory hypokalemia intracellular magnesium inhibit potassium secretion by renal outer medullary potassium (ROMK) channels in the collecting tubules of kidney normalization of magnesium levels restores ROMK channel potassium transport regulation, decreased renal K+ losses and allows correction of hypokalemia with oral (preferred) or IV potassium replacement
what is cause of infection of b.cereus? ingestion of preformed toxins bacteria invasion of intestinal mucosa intestinal bacteria colonization and toxin production
ingesting preformed toxins acute onset 1-6hrs
what can you give to rapidly lower serum potasium in pt with hyperkalemia furosemide hemodialysis insulin and glucose high dose inhaled b2 agonist
insulin and glucose note - furosemide takes 30min for onset
what do you expect to see on imaging in pancreatic cancer
intra and extrahepatic dilated bile ducts compression pancreatic duct and common bile duct (double duct sign) non-tender, distended gall bladder painless jaundice pale stools dark urine
what does high LDH indicate
it is an intracellular enzyme intravascular hemolysis of cells
nephrolithiasis - imaging choice - rx for pain - rx to remove stones - when to consult urology
kidney stones - - CT is best imaging; detect radiolucent stones eg uric acid - rx pain: nsaid and norco. nsaids better because dont worsen n/v - rx stone: lots fluids 2L/day - refer tto urology if urorspesis, acute renal failure, anuria note - anuria <50ml urine output - oliguria <500ml urine output - urinary retention: no urine output but bladder has urine
pt has flank pain radiating to perineum, penis, scrotum, inner thigh has difficulty lying still on exam table due to discomfort what do you suspect? what imaging do you do to confirm?
kidney stones - abdominal ultrasonogram - non contrast CT abdomen and pelvis
kussmaul sign
lack of decrease in JVP on inspiration seen in pericarditis
man risk factors for rupture of AAA
large diameter rate of expansion current cig smoking
26 yo female had near syncope episode dizzy and lightheaded chronic diarrhea 10-12 nonbloody watery BM + abdominal cramping vitals: T98.8F BP 112/71 supine 91/50 standing P94 PE normal stool guaiac negative labs: hypokalemia and metabolic alkalosis colonoscopy: dark brown mucosal pigmentation in proximal colon likely cause? c diff infection high vasoactive peptide concentration laxative use
laxative use - factitious diarrhea - watery, frequent and voluminous - nocturnal BM - abd pain - hypokalemia is due to increased loss of potassium in stool. this impairs Cl absorption and results in decreased activity of the chloride-bicarb exchange, increasing serum bicarb concentration (met alkalosis) - may be hypermagnesemia if magnesium-containing laxative is used stool screen: - +ve for diphenolic (eg bisacodyl) or polyetheylene laxatives colonoscopy: melanosis coli - dark brown discoloration of the colon with pale patches of lymph follicles that give appearance of alligator skin. will disappear when laxative dc'd. histo of colon: - melanosis coli in macrophages
35 yo woman with hx of Rheumatic Heart Disease presents with acute onset dyspnea denies cough, chest pain or fever PE - first heart sounds loud - mid diastolic rumble heard at apex - crackles in both lungs ECG - irregular irregular heart rhythm - absence of P waves what is likely cause?
left atrial dilatation Rheumatic Heart Disease can cause mitral stenosis which in turn lead to dilatation of left atrium and resulting a-fib note - while RHD can cause damage to any heart valve, mitral stenosis is most common valve damage
oral thrush that does not scrape off with tongue depressor
leukoplakia - precancerous lesion - hyperplasia of squamous epithelium cells - risk factors: smokeless tobacco, alcohol use - resolve after cessation of tobacco use
pattern of bed bug bites
linear tracks or clusters: breakfast, lunch, dinner small, punctate lesions with surrounding erythema
meds that cause sensorinural hearing loss
loop diuretics aminoglycoside chemotherapeutic agents aspirin (very high doses)
what are lab values of aldosterone, ACTH and cortisol in a pt who was on chronic steroids and stopped abruptly?
low ACTH low cortisol normal aldosterone exogenous steroids inhibit CRH (from hypothalamus) which decrease ACTH and cortisol
how does patient on TPN diet have high PT and PTT time w/ increase risk of bleeding
low vitamin k - decreases plasma levels of PT complexes - 2,7,9, 10, protein C and protein S give vit K to replenish stores in 8-10hrs FFP can be given for management of acute hemorrhage
67 yo man complains of progressive vision loss in right eye when asked to cover his left eye and look at a small spot on a grid made of parallel vertical and horizontal lines, he descibres the vertical lines as being bent and wavvy. what is likely cause of vision loss? peripheral retinal degeneration macular degenaration lens opacity increase IOP
macular degeneration - leading cause blindness in developed countries - distortion of straight lines that appear wavy - risk factor: increase age, smoking - optho exam: drusen deposits in the macula
pt with dermatomyosistis are most likely to get? alveolar hemorrhage aortic aneurysm carpal tunnel syndrome malignancy
malignancy eg ovarian, lung, pancreas, colorectal, NHL - need screening
46 yo several episodes of vomiting + hematemesis has alcohol abuse and chronic dyspepsia. he was evaluated 3 days ago with upper GI endoscopy and abdominal u/s the u/s showed enlarged hyperechoic liver and gallstones in gallbladder endoscopy found mild esophagitis and gastritis labss - ast 100 - alt 45 - bun 26 - cr 1.1 nasogastric suction returns normal stomach contents and mixed with bright red blood what is cause of bloody vomit?
mallory weiss tear at GEJ - sudden increase in abdominal pressure eg forceful retching - mucosal tear in esophagus or stomach - vomiting, retching, hematemesis, epigastric pain - longitudinal laceration on endoscopy - assoc with alcohol abuse, alcohol hepatitis (2:1 ast/alt ratio) rx - heal spontaneously - endoscopy therapy for persistent bleeding
70 yo woman no meds no sig fmh normal mammogram, pap smear, lipid panel at her last exam 2yrs ago colonoscopy 7yrs ago was normal what is needed now? CXR colonoscopy mammogram pap smear lipid profile
mammogram - every 2 yrs for women 50-75
what meds can be used to decrease IOP in acute glaucoma
mannitol acetazolamide timolol pilocrapine
_________ is likely in a postoperative patient with hypotension, jugular venous distension, new-onset right bundle branch block, ECG showing non-specific ST and T wave changes
massive pulmonary embolism (bilateral pulmonary arteries) - decreased bibasilar lung sounds - unable to send blood from right heart to lung - lead to RHF -> cardiogenic shock - hypotension - JVD - ECG changes
28 yo w/ worsening skin rash on her back and arms for past 2 weeks no pain or pruritis in her teen years, she had comedonal acne on her face, which resolved with topical meds recently dx with SLE 2 yrs ago, on oral prednisone due to recent exacerbation with pain and swelling in small joints of hnds pt also takes hydroxychloroquine and NSAIDs prn works at dry-cleanining place sexually active with BF, used IUD for contra ception skin: uniform 1-3mm erythematous papules on back, arms and shoulders ther eis muld symmetric synovitis in hands and wrists what is most likely cause of skin rash? acne vulagria cutaneous SLE disseminated gonococcal infection medication side effect
med s/e drug-induced acne triggers: steroids, androgens, immunomodulatos eg ADA, anticonvulsants (eg phenytoin), antipsychotics, antituberculous drugs (INH)
what is pathophys of meniere disease
meniere disease - episodic vertigo, sensorineural hearing loss, tinitus - caused by fluid build up/elevated endolymphatic fluid initial management - restrict sodium, caffeine. alcohol
unfavorable metabolic and electrolyte effects of thiazides
metabolic - hyperglycemia - high LDL - hypertriglycerides - hyperuricemia electroloytes - hypercalcemia - hyponatremia - hypokalemia - hypomagnesemia
65 yo w/ decreased appetite, nausea, vomiting, abdominal bloating, early satiety for past few months. no heartburn or epigastric pain PMH: T2DM rx'd with insulin and complicated by nonproliferative retinopathy BG readings: 40-400. Low readings occur after meals what is most helpful rx? h pylori test lansoprazole metoclopramide ondansetron promethazine ranitidine
metoclopramide pt has diabetic autonomic neuropathy of the GI tract - sx: delayed gastric emptying, gastroparesis - occurs in >50% pts with longstanfing T1 or T2 DM - can manifest as disorders of esophageal motility (dysphagia), gastric emtpying (gastroparesis), intestinal function (diarrhea, constipation, incontinence) - gastroparesis presents with sx of anorexia, nausea, vomit, early satiety or postprandial fullness - hypoglycemic episodes occur with insulin adminisitration prior to meals rx - optimize diabetes control - dietary modifications with increased fiber and small, frequent meals - meds for gastric emptying - metoclopramide has both prokinetic and antiemetic properties in daibetic gastroparesis - alternative: erythromycin (better IV) note - antihistamines (promethazine, diphenhydramine) and 5HT3 blocker (ondansetron) are antiemetics only and not prokinetics
50 yo skin rash joint pains malaise hematuria RBC casts protienuria IVDU BUN 30 Cr 2 complement low anti-HCV positive dx? HSP IgA nephropathy mixed essential cryoglobulinemia
mixed essential cryoglubulinemia - clue: HCV infection
65 yo female recurrent CAP and sinusitis infections XR show osteolytic lesions in rib bones dx?
multiple myeloma - cause recurrent infections due to hypogammblobulinnemia
intermittent claudication
muscle cramps due to exertion-induced ischemia that typically occurs in LE in the setting of artherosclerotic peripheral artery disease
60 yo man fatigue + muscle weakness in extremities lost 15lbs in 3 mo smoker muscle strength 3/5 in proximal muscles b/l CTR 2+ b/l erythematous to violaceous papules on dorsum of fingers CXR: ill defined mass in RLL where is lesion? muscle fiers peripheral nerves presynaptic membrane postsynaptic memb
muscle fibers likely dermatosytosis from paraneoplastic syndrome - proximal weakness - skin findings: gotrron papules, heliotrope rash
what is antidote for acetaminophen toxicity
n-acteylcysteine rx: liver transplant if it cause acute liver failure eg encephalopathy, increased INR
if pt has flu with fever, can they get flu vaccine?
no until get better
27 yo man large anterior mediastinal mass blood - elevated b-Hcg and AFP dx? choriocarcinoma bronchogenic syst hepatocellular carcinoma nonseminomatous germ cell tumor seminoma
nonseminomatous germ cell tumor - high AFP and bhcg - locally invasive - do testicular u/s to exclude a small primary tumor as management and prognosis differ between primary mediastinal and metastatic germ cell tumors - almost all germ cell tumors in anterior mediastinum are primary rather than metastatic note - seminoma have only high bhcg
how does fat malabsorption in Chron's disease lead to hyperoxaluria and oxalate stones?
normally calcium binds oxalate in gut and decrease its absorption in fat malabsorption, calcium binds fat more and excreted in feces leaves more oxalate absorbed in blood stream a
presentation of superior vena cava syndrome
obstruction of SVC impedes venous return from head, neck and arms to heart s&s -dyspnea - venous congestion - swelling of head, neck and arms - face plethoric and dark appearing - wt loss - assoc with smoking hx - do CXR then CT
treatment of disseminated lyme disease - rash, HA, fatigue, malaise, myalgia, fever IV ceftriaxone or oral doxycycline
oral doxy!!! IV cef - early localized lyme disease
73 yo man presents to ED after syncopal episode he had been resting in bed for one week after injruing his right knee this morning he tried to get out of bed and had brief LOC meds: nsaids likely cause?
orthostatic hypotension - drop in SBP >20mmHg moving from lying down to standing - elderly, hypovolemic or autonomic neuropathy (eg DM, PKD) - meds: diuretics, vasodilators, adrenergic-blocking agents - prolonged recumbence increases the risk - can have pre-syncopal lightheaded
rx of CAP outpatient inpatient (non-ICU) inpatient (ICU)
outpatient - macrolide or doxycyline (healthy) - fluroquinolone OR betalactam + macrolide (comorbitidies) inpatient (non-ICU) - fluroquinolone (IV) - betalactam + macrolide (IV) inpatient (ICU) - betalactam + macrolide (IV) - betalactam + fluoroquinolone (IV)
23 yo AA rx'd with abx for UTI few days later, has dark urine urine sample stains positive with prussian blue what is the mechanism behind cell damage responsible for pt's sx?
oxidative stress pt has G6PD def G6PD needed to convert NADP to NADPH NADPH reduces gluthathione in RBCs without this, leads to oxidative stress hemoglobin converted to methemoglobin and sulfhemoglobin - these bind to RBC membrane, forming heinz bodies and decrease membrane pliability promote RBC removal by spleen; hemolysis hemosiderin released during hemolysis and is detected as positive in prussian blue stain! hemolytic episodes are precipitated by infetcions and medications that increase oxidative stress eg sulfa drugs (tmp-smx), anti-malarials, nitrofurantoin
pt with BP 178//102 + severe chest pain found to have aortic dissection on CT angiography how do you rx?
pain control eg morphin IV beta blocker +/- sodium nitroprusside second line (if SBP >120) - urgent surgical repair of ascending dissection
PCP can be treated with either TMX alone or TMX and corticosteroids what is the indication of adding steroids?
partial pressure of oxygen (PaO2) <70mmHg alveolar-arterial (A-a) gradient >35mmHg steroids decrease mortality in severe PCP by reducing inflammation due to dying organisms
51 yo man with ARDS while hospitalized for cute pancreatitis he is intubated with PEEP 15cm and FiO2 60% Pulse increases from 100 to 140 SBP drops from 120 to 90 on chest auscultation, breath sounds absent on left side what is likely cause?
penumothorax - caused my mechanical ventilation - absent breath sounds on the affected side - compression of structures in mediastinum and impaired RV filling, resulting in hypotension and tachycardia - as the intrapleural space fill with air, intrathoracic pressure increased and results in decreased venous compliance - when the central veins lose their ability to stretch and expand (venous stiffness), the central venous pressure also rises
50 yo pt with epigastric pain melena FOBT positive pain improved with eating
peptic ulcer disease; duodenal ulcer - h pylori
pt has macrocytic anemia, shiny tongue and vitiligo what is likely cause of anemia? dietary vit b12def vit b6 def pernicious anemia
pernicious anemia - AID - anti intrinsic factor or anti gastric parietal cells - more likely as the cause of vit b12 def as pt has vitiligo
what drugs cause folic acid deficiency
phenytoin MTX TMP (trimethoprim)
46 yo man prepping for surgery after induction of general anesthesia, he is pale and tachycarduc PMH: frequent HAs, HTN and anxiety d/o meds: lisinopril, alprazolam, naproxen prn T98.4F BP250/140 (was 140/90 prior) P125 ECG: sinus tachycardia with no ischemic changes likely dx? anaphylaxis panic d/o pheochromocytoma serotonin syndrome thyroid storm
pheochromocytoma - hx HTN, frequent HAs - presentation of severe HTN, pallor and sinus tachy - indicate cathecolamine surge due to anesthesia paroxysms of severe HTN can be precipitated by - increases in intra-abdominal pressure eg tumor palpitation, positional change - surgical procedures - meds esp anesthesia - nonselective BB cause unopposed alpha-adrenergic stimulation leading to vasoconstriction and paradoxical HTN - administer alpha adrenergic blockers eg phenoxybenzamine prior to BB in pts with pheochromocytoma note - thyroid storm be precipitated by surgery in pts with pre-existing thyrotoxicosis, but the presentation is usually less acute, alomost all pts will have pyrexia
moa sildenafil for ED
phosphodiesterase (PDE-5) inhibitor note: CI in pts on nitrates as concomitant use can cause drop in BP -> syncope
what is mcc of abnormal bleeding in chronic renal failure
platelet dysfunction - causes by uremic toxins - damage to platelet wall - high bleeding time. normal PT and PTT
60 yo woman just had cataract surgery a week ago of left eye left eye today: complain of swollen eyelid, edematous conjunctiva, exudates in anterior chamber decreased visual acuity cause? conjuctivitis postoperative endopthalmitis carvenous sinus thrombosis
postoperative endopthalmtis - occurs within 6weeks of surgery - pain and decreased visual acuity - swollen eyelids, conjuctiva, corneal edema and infection - infection of vitreous - gram stain anc culture vitreous may be done - rx: intravitreal antibiotic injection OR vitrectomy
70 yo man with pain, stiffness of necj, shoulders and hips for 3 months worse in morning and lasts 1-2hrs general malaise wt loss 7lbs no swollen joints good ROM labs - low hct - high pltlets - high ESR next? prednisone nsaids temporal artery biopsy measure ANA and RF
prednisone pt has polymyalgia rheumatica >50 - bilateral pain and morning stiffness > 1mo - neck/torso, shoulder or prox arms, prox thigh/hip - decreased ROM in shoulder, neck, hips - labs: ESR>40, high CRP, normocytic anemia,
42 yo woman with depression, mood swings, poor sleep, mild HAs, muscle weakness, kidney stones and high BP labs - high Ca what is cause of HTN? cushing primary hyperparathyroidism
primary hyperparathyroidism - hypercalcemia (polyuria, polydipsia) - kidney stones - neuropsychiatric: confusion, depression, psychosis abdominal moans, bones, stones, psych undertones - unclear how it caused HTN but possible link to MEN2 with pheochromocytoma
what is vasospastic angina
prinzmetal angina (formerly) - vascular smooth muscler hyperactivity leads to focal diffuse spasm of the coronary arteries, transient MI and resulting angina pts present with recurrent episodes of chest discomfort that occur at rest or during sleep sig smoking is known risk factor but pts typically young and lack other risk factors for CAD (eg HTN, DM) ECG shows ST and T wave changes during episode of chest discomfort similar to raynaud phenomenon: cold or stress induced hyperactivity of arterial smooth muscle, leading to episodic vasospam in fingers and toes
HIV pt with "white matter lesions with no enhancement/edema" on CT brain dx?
progressive multifocal leukoencephalopathy note - toxoplasmosis: ring enhancing lesions with edema - primary CNS lymphoma: well-defined focal and one enhancing lesion
which veins cause PEs more?
proximal veins - iliac, femoral, popliteal less likely calf veins
features of papillary thyroid cancer
psamomma bodies Orphan annie cells "large cells with ground glass cytoplasm and pale nuclei containing inclusion bodies and central grooving" clue: pap and mom had an orphan rx - surgical resection
psc vs bc antibodies
psc - perinuclear anti-neutrophil cytoplasmic antibodies (p-anca) pbc - anti smooth muscle antibodies - anti mitochondrial antibodies
42 yo with periodic difficulty breathing and wheezing visited otorlaryngologist for persistent nasal blockage 2 weeks ago PMH: stable angina 6 mo ago meds - aspirin, diltiazem, atovarstatin, albuterol vitals wnl what is cause of pt's resp symptoms: cell- mediated HSR IgE mediated Immune complex deposits pseudoallergic drug rxn
pseudoallergic - aspirin exacerbated resp disease - NSAIDs block Cox1/2 which lead to promotion of leukotrienes from arachidonic acid - leukotrienes are proinflammatory - present with asthma like sx eg cough, wheeze, chest tightness, nasal and eye sx eg nasal congestion, periorbital edema
65 yo female complains of difficulty eating over last two days - food drops out of mouth left ear discharge (has granulations) no sore throat/cough/chest pain/diff breathing T101.7 P96 BP140/90 R18 facial asymmetry and angle of mouth on the left is deviated downward cause? herpes pseudomonas
pseudomonas this is malignant otitis externa - ear pain and ear drainage that are not responsice to topical meds - granulation tissue in ear canal - usually in pts with poorly controlled DM - can lead to osteomyelitis of the skull base and CN damage - CT/MRI confirm dx rrx - systemic abx eg cipro,
29 yo man with 2 weeks of epistaxis requiring anterior nasal packing, high BP (170/110), occasional HAs and fatigue no chest pain, palpitations or syncope no murmurs or additional heart sounds no periumbilical bruits ECG normal sinus rhythm with high voltage QRS complexes, ST depression and T wave inversion in V5 and V6 thoughts?
pt has CoA most likely - epistaxis, HA, high BP and LVH check bilateral arm and leg blood pressure - arm in supine - leg in prone position
20 yo with bloody diarrhea, wt loss, fever sigmidoscopy show mild erythema involving the rectum and distal sigmoid colon, rectal bx show mucosal inflammation and crypt abscesses pt would require screening to for which of following complication? colorectal cancer perianal fistula toxic megacolon sclerosing cholangitis uveitis
pt has UC - mucosal inflammation and crypt abscess - can lead to psc and tosic megacolon but screening cannot prevent this - screen for colorectal cancer
64 yo uncontrolled HTN had MI last week ECG showed STEMI in anterior leads Coronary angiography show complete occlusion of LAD no intervention was done but pt started on medications next day, pt has leg pain, cold with mottled appearance and absence of distal pulses what is likely cause> next steps? ECHO CXR d-dimer venous doppler
pt has acute limb ischemia likely cardiac embolic source vs thrombosis (vascular stents, hypercoag states) vs trauma major cardiac sources of arterial emboli include; - LV thrombus - thrombus (left artrial) formation due to afib - aortic atherosclerosis this pt with large anterior STEMI is at risk of LV thrombus esp with reduced LVEF (<40%) - can have systemic embolization - require immediate anticoagularion - TTE to screen LV thrombus
34 yo woman occasional HA and palpitations no meds BP 170/100 both arms P80 PE: bilateral flank masses UA: 10-12 RBC/hpf most likely complication? liver necrosis intracranial bleed restrictive cardiomyopathy pancreatic cancer aortic dissection
pt has autosomal dominant polycystic kidney disease - HTN - palpable abd masses - microhematuria complications - intracranial berry aneurysm - hepatic cysts - valvular heart disease eg MVP and AR - colonic diverticula - abdominal wall and inguinal hernia
27 yo recurrent nose bleeds ruby colored papules on lips that blanch with pressure digital clubbing labs show high Hct what is cause of high hct?
pt has hereditary telangiectasia (osler-weber rendu syndrome) - AD - diffuse telangiectasia - recurrent epistaxis - widespread AVMs in skin, GI, lung, liver, brain: in lungs, these can cause aterio-venous shunts leading to chronic hypoxemia and reactive polycythhemia
24 yo man comes to ED due to fever, sore throat, hoarseness. not able to swallow due to pain muffled voice and stridor drooling likely cause?
pt has infectious epiglottis - did not get h. influenze vaccination (mcc) - rapid progressive - fever, sore throat, drooling, muffled voice - airway obstruction (stridor) - pooled oropharynx secretions dx - direct visualization, imaging rx - early articifial airway - IV abx (ceftriaxone and vanc) not - herpes, from unprotected sex can cause epiglottitis but much less common!
pt on chemotherpy meds presents with fever labs sshow WBC 650 with 20% neutrophils what empiric meds does pt need?
pt has neutropenic fever start on anti-pseudomonas drugs eg cefipime, pip-taz,
30 yo teacher with 3d hx of fever, chills and sore throat difficulty swallowing denies cough, CP or dyspnea voice is muffled *hot potato vice* tender left cervical LAD uvual deviate to right what is dx and next step?
pt has peritonsillar abscess - need to be drained with needle aspiration - can be fatal 2/2 either airway obstruction or spread of infection into parapharyngeal space - surgery may be needed if abscess cannot be removed by aspiration alone
14 yo with tick bite for one day and tick visible on exam what next?
pull tick out with forceps and reassure pt tick need to be attached for >=36hrs for engorged to you to require ppx for lyme's disease
test for initial screening/early signs of DM nephropathy
random urine microalbumin/cr ratio normal <30 DM: 30-300/24hr inital stages of DM nephropathy: microalbuminuria the 24hr microalbuminuria is more accurate but incovenient
rx frostbite
rapid re-warming in warm water
ludwig angina
rapidly progressive cellulitis of submandibular space arise form dental infections spread down to root into submylohyoid then sublingual space polymicrobial infection with oral aerobic and anerobic bacteria rx - IV clindamycin or amox-sulbactam
rx AF
rate control - bb, ccb, digoxin rhythm control
35 yo male takes foudn to have nonocclusive clot in popliteal vein started n warfarin with goal INR 2-3 pt missed doses warfarin for few days when he started warfarn again and went to check INR was 1.2 found to have bigger clot now in femoral v what should be done next? insert IVC filter thrombolysis replace warfarin with rivaroxaban
replace warfarin with rivaroxaban - warfarin needs 5day bridging with heparin before onset of action - direct Xa inhibitors thrombolytic therapy = reserved for hemodynamically unstable pts with PE - less commonly used in massive proximal DVTa ssoc with symptomatic swelling or limb ischemia - not indicated in this pt with moderate pretibial edema and absence of hypotension or tachycardia IVC filtre - used for anticoag failure (reucrrent or extending thromboembolism while fully anticoagulated or anticoag CI (active bleeding)
if a pt has STEMI, immediate intervention aimed at achieving which of the following goals would most improve this pt's long term prognosis? decrease afterload decrease myocardial contractility prevent ischemia-induced arrhythmias prevent reperfusion injury restore coronary blood flow
restore coronary blood flow - primary percutaenous intervention (PCI) within 90min of first medical contact in a PCI-capable hospital - PCI within 120min if transportation required to PCI-capable hospital - fibrinolyis
what causes acute renal failure in person with cocaine OD
rhabdomyolysis - high creatine phosphokinase (CPK) from muscle break down - acute tubular necrosis from excessive filtered myoglobin - urine dipstick tests positive for blood but no RBC seen on microscopy also cocaine is vasconstrictor and can cause ischemia insult to renal arteries
24 yo male with nonprod cough + dull back pain PE - no deformity/tenderness in back - neg straight leg test - muscles 5/5 LE bilaterally imaging - several pulmonary nodules and retroperitoneal LAD what is likely cause?
scrotal malignancy do scrotal u/s to confirm likely unilateral testicular cancer
54 yo man facial puffiness and bilateral leg swelling recurrent pulmonary infections due to bronchiectasis and psoriases high BP with 4th heart sound hepatomegaly palpable kidneys 2+ pitting edema in LE 4+ proteinuria likely dx? amyloidosis hepatorenal syndrome PKD
secondary amyloidosis - causes nephrotic syndrome: bilateral pittine edema, facial swelling, proteinuria - palpable kidneys - hepatomegaly - ventricular hypertrophy 4th heart sound - chronic inflamm (recurrent infections) rx - rx underlying condition - colchicine for ppx and rx
pt has URI a week ago now presents with worsened sx CXR show multilobar nodular or cavitary infiltrates likely causes?
secondary bacterial pneumonia - pt likely had influenza infection earlier - due to staph aureus - *multilobar cavities* - fever, dyspnea, cough,
difference between rinne and weber in sensorineural vs conductive hearing loss
sensorineural hearing loss - rinne: AC>BC both ears - weber: lateralize to good ear conductive hearing loss - rinne: BC>AC in bad ear, AC>BC in good ear - weber: lateralize to bad ear
38 yo man with progressive SOB and cough with mucoid sputum over past 6 mo his SOB is worse with exertion denies chest pain, wt loss or night sweats smoked cigs for 5 yrs but quit 13 yrs ago BP128/78 P78 R16 O2sat96% ORA breath sounds decreased at bases and there are no crackles or wheezes heart sounds normal. no JVD or edema chest image: bilateral basilar lucency (air...look like COPD) likely cause?
serum alpha-1antitrypsin level - causes panacinar emphysema - lung disease similar to COPD - liver disease - PFT should be done - rx: IV supplementation with pooled human AAT smoking COPD - centriacinar emphysema
32 yo woman with recurrent sinusitis, pneumonia over last few years also had bloody diarrhea that required hospitalization what is likelay cause? low CD4 Tcells asthma cystic fibrosis low serum IgG levels (common variable immunodef)
sinusitis, pneumonia and bloody diarrhea lead to common variable immunodef (CVID) CVID - impaired b cell differentiation - hypogammaglobulinemia - increased susceptibility to bacterial infection - recurrent resp infections eg pneumonia, sinusits, otitis - recurrent GI infections eg salmonella, campylobacter - chronic giardiasis may occur - concomitant with AID eg hemolytic anemia, RA, pernicious anemia, IBD - most CVID are due to sporadic mutation, family history is typically absent - most dx in adulthood 20-45
med TCA overdose
sodium bicarab; improves systolic BP, narrows QRS and decreases incidence of ventricular arrhythmia secure ABC TCA overdose - hyperthermia and other anticholinergic effects - seizures - decrease myocardial conduction velocity leading to prolonged QRS and risk of V arrhythmia
best imaging for aortic dissection in pts that are - hemodynamically stable - hemodynamically unstable or renal insufficient
stable - CT angio unstable or renal problems - TEE
if a pt has heparin induced thrombocytopenia what do you do next?
stop heparin start direct thrombin inhibitor eg argatroban OR factor 10 inhibitor eg fondaparinux
breathing sounds from upper airway obstruction (laryngeal edema) due to allergic rxn?
stridor and harsh resp sounds from trachea no wheezing from lower lungs
which renal calculi assoc'd with alkaline pH urine?
strivite stones(mg ammonia phosphate) urease producing proteus mirabilis pathogen
54 yo man comes to ED 2 days fever, chills, dysphagia, drooling unable to eat or drink due to pain in his mouth and neck hx heavy alcohol use T101.8F BP110/70 P108 R22 pt appear toxic with drooling and muffled voice tongue displaced posteriorly and superiorly due to swollen area on the floor of mouth bilateral submandibular area tender, indurated and nonfluctuant with palpable crepitus source of infection? blood epiglottitis LN tonsils teeth roots
teethroots pt has ludwig angina
45 yo woman 3months excessive hair growth over face and body LMP 4mo ago menstrual period has previously been regular and she has had 2 successful pregnancies in the past PMH: hypothyroidism rx'd with levo smoker for 25yrs BP124/82 P72 BMI24 PE: large amount coarse terminal hair on face, back, chest, lower abdomen labs Na 136 K 4 Cl 102 Bicarb 22 BUN 10 Cr 1.2 ca 8.8 Glu 80 TSH nml Hgb 16 (1 yr ago it was 14) next step? 17-hydroxyprogesterone level CT abdomen EPO level Insulin-like growth factor level LH and FSH level testosterone and DHEAS levels
testosterone and DHEAS levels although hirsutism suggests PCOS, rapid-onset hirsutism +/- virilization (vocal deepening, excessive muscular development, clitoromegaly) suggests very high androgen levels due to androgen-secreting neoplasm of ovaries or adrenal glands primary ovarian androgens: testosterone, androstenedione, dehydroepiandrosterone adrenal androgens: *DHEAS*, testosterone, androstenedione, dehydroepiandrosteone
37 yo on immunosuppressant fever, pleuritic chest pain, cough productive brown sputum (hemoptysis) right upper lobe infiltrate several nodular lesions with surrounding ground glass *halo sign* opacities in right upper lobe sputum gram stain show inflammatory cells but no organiss likely cause?
this is invasic aspergillosis this is not PCP - non productive cough, fever, dyspnea - b/l diffuse interstitial infiltrates on XR - NO halo sign, no hemoptysis -
28 yo woman develops tachycardia in postoperative recovery room T103F BP160/90 P148 R24 O2sat98% ORA delirious and fine tremor mild lid lag present no muscle rigidity DTR 2+ b/l extremities creatine kinase is high what is likely cause?
thyroid storm - check thyroid function test and propanolol
rx pulmonary norcardia
tmp=smx
what provides the best chance of survival in diabetic pt with ESRD? dialysis transplant living related donor transplant living non-related donor
transplant living donor
what medication cause painful erections (priapism)?
trazodone other causes of painful erections: - sickle cell disease and leukemia - usually in children and adolescents - neurogenic lesions - spinal cord injury, cauda equina compression - perineal or genital trauma - results in laceration of cavernous artery
pts with chronic analgesic use are likely to develop what type of renal disease? labs - high bun - high Cr UA - WBC 10 to 15/HPF - WBC casts - no glucose/RBC/nitrite/esterase acute tubular necrosis tubulointerstitial nephritis recurrent pyelonephritis
tubulointerstitial nephritis - analgesic nephropathy is mcc of drug-induced chronic renal failure - papillary necrosis and chronic tubulointerstitial nephritis are most common pathologies seen - polyuria and sterile pyuria (WBC casts may also be seen) - microscopic hematuria and renal colic may occur following sloughing of renal papilla more acute form is acute interstitial nephritis (fever, rash, eosinophilia) and involves primarily HSR to drug note: -acute tubular necrosis cause acute renal failure, rather than insidious progression of renal dysfunction - common in ischemic r nephrotoxic acute renal failure. muddy brown granular casts
16 yo receiving chemo what would you expect levels of ca, phos and potassium in blood
tumor lysis syndrome - high potassium and phos from cells - low ca, as phosphate binds to it -acute kidney inury from uric acid...give allopurinol ppx - cardiac arrhythmias rx - continous telemetry - aggressive electrolyte monitor ppx - iv fluids - allopurinol or rasburicase
what is rx for unilateral RAS vs bilateral RAS
unilateral RAS - aspirin, rx DM, rx HLD, stop smoking - *ACE-I* or *ARB* - ACEI or ARB reduce the RAAS effect, dilating the glomerular efferent arterioles - the stenoic kidney receives reduced RBF and results in fall GFR. the unaffected kidney compensates for the fall in GFR as it is no longer subject to ang-II induced renal vasoconstriction. bilateral RAS - ACEI is contraindicated
71 yo sharp chest pain for 2hrs; worse with deep breaths and when laying supine. better with sitting up PMH: CKD preparing for starting dialysis soon T99.8F BP160/98 P98 R20 PE - diastolic sound with squeaking quality heard in LSB - breathsounds normal ECG - nonspecific Twave abnormalities CXR normal BUN 68 Cr 5.3 dx?
uremic pericarditis - seen BUN>60 in CKD - will resolve with *dialysis* NOT nsaids - ECG does not usually show diffuse ST elevations like other pericarditis - pleuritic chest pain - pericardial friction rub: high pitch sound/squeaking sound
46 yo man with right flank pain for few days has decreased urination over last week occassional episodes of high urine output along with feeling of generalized weakness PSH: left total nephrectomy 25yrs ago MEDS: recently started on lisinopril for HTN no FMH of renal disease BP 145/86 labs - low K+ - Cr 1.7 UA trace protein 4 WBC 2 RBC no casts most likely cause of sx? interstitial nephritis renal artery stenosis urinary outflow obstruction
urinary outflow obstruction - likely has renal calculi - flank pain - intermittent high volume urine occur when obstruction if overcome by large volume of retained urine - excessive diuresis may lead to potassium wasting and dehydration, which can both cause weakness
what is megestrol acetate (progesterone analog) used for?
used for palliation of cancer-related anorexia and cachexia syndrome - improve appetite and wt gain
hepatojugular reflex
used to detec RHF press on RUQ abdomen or mid upper abdomen normal person - no rise in JVP or transient rise and fall to normal RHF - A positive result is either a sustained rise in the JVP of at least 3 cm or more or a fall of 4 cm or more after the examiner releases pressure.
35 yo woman presents with intermittent chest pain with sweating and palpitation ECG show ST elevation in lateral leads Echocardiogram show no coronary obstruction dx? rx?
vasospastic (prinzmetal angina) rx: CCB eg diltiazem (ppx) nitroglycerin (abortive)
if a pt with ankylosing spondylitis has a fall, what is likely complication
veterbral fracture - pain - midline tenderness over lumbar region pts with longstanding AS can develop osteopenia/osteoporosis due to increased osteoclast activity in the setting of chronic inflammation (mediated by TNF-a and IL-6). In addition, spinal rigidity in these pts can increase the risk of vertebral fracture, which often results in minimal trauma. other findings - thoracic wedging - hyperhyphosis
how does niacin cause flushing and pruritis
via prostaglandin-induced vasodilation can be reduced with low-dose aspirin
when can odds ratio be used as an approximation of RR
when low prevalence disease - rare disease assumption odds ratio: odds of exposure in diseased vs odds of exposure in non-disease