Internal Medicine Shelf

Modified Wells criteria for PE

*+3 points* -Clinical signs of DVT -Alternate diagnosis less likely than PE *+1.5 points* -Previous PE or DVT -Heart rate >100 -Recent surgery or immobilization *+1 point* -Hemoptysis -Cancer *Total score for clinical probability* <4 = PE unlikely >4 = PE likely

82yo male found to be agitated confused on post-op day 2 following surgery for right hip fracture -PMHx: benign prostatic hyperplasia and dementia -Exam is normal except lower abdomen is tender and palpation exacerbated agitation -Normal white count, no fever Most likely cause? Best next step?

*Acute urinary retention* -Next step: *Bladder ultrasound* -Presents with: agitation, tachycardia, lower abdominal tenderness (suprapubic) AUR risk factors -Male -Elderly (>80) -Hx of benign prostatic hyperplasia -Hx of neurologic disease (mild cognitive impairment) -Surgery Dx is confirmed by Bladder U/S showing >300mL of urine

40yo M with exertional dyspnea of 6 months duration. -occasionally expectorates mucoid sputum -Father died of nonalcoholic liver cirrhosis at age 58 -Smoked <1/2PPD x 15 yrs but stopped -Vitals are normal, SpO2 97% -Breath sounds are decreased b/l. -Albumin 4.2, TB 1.0, ALK 96, AST 44, ALT 55 Dx?

*Alpha-1 antitrypsin deficiency* -Presents similarly to COPD: chronic productive cough, dyspnea, wheezing, recurrent respiratory infections -Decreased breath sounds -Also affects the liver --> slight LFT abnormalities AAT deficiency should be considered in -Pts with COPD at a young age (<45) -COPD with minimal or no hx of smoking -FHx of emphysema or liver disease Tx: IV human AAT + bronchodilators and steroids as needed

Treatment for lyme disease in pregnant/lactating women and children <8yo

*Amoxicillin* Doxycyline is contraindiciated --> can cause *permanent discoloration of teeth* and *retardation of skeletal development* If allergic to amoxicillin and doxycycline --> azithromycin

25yo M c/o 3month history of right shoulder pain. He has swelling and pain at his heels. -Exam: pain with resisted abduction at the shoulder and tenderness at the acromioclavicular junction -Palpation over the heels, iliac crests, and tibial tuberosities also elicits tenderness Most likely Dx?

*Ankylosing spondylitis* -This patient presents mostly with Enthesitis = *Tenderness at tendon insertion sites* Other symptoms of ankylosing spondylitis -Back pain relieved with exercise but not rest -Nocturnal pain -Arthritis (*sacroiliitis*) -Reduced chest expansion and spinal mobility -*Enthesitis* -Dactylitis -*Uveitis* Dx imaging: X-ray and MRI of sacroiliac joints

27yo woman comes to the ED with 1 day of chest pain and SOB -chest pain increases with inspiration -Her right leg is swollen -She has a rash on her face that worsens in the sun -Recent painful swelling in both knees -Has had 2 previous miscarriages -CTA confirms PE Dx?

*Antiphospholipid Antibody syndrome* -Pt most likely has SLE seen by photosensitive rash and symmetric oligoarthritis -She has had 2 miscarriages, DVT, and PE -All together suggest Antiphospholipid syndrome It will show *prolonged PTT* -This is an artifact as Lupus anticoagulant prolongs PTT by binding the phospholipids. -PTT will not correct by 1:1 mixing with normal plasma -Lupus anticoagulant promotes coagulation in vivo

40yo M with progressively worsening burning and tingling sensations in hands and feet -restores antique furniture as a hobby -No PMHx -Skin over the neck has patchy areas of hyperpigmentation and hypopigmentation -Hyperkeratoses and scaling are present on palms and soles -Increased sensitivity to pinprick and light touch over fingers and toes -Weak ankle and wrist muscles -DTRs are 1+ -Anemic, leukopenic, thrombocytopenic -Slightly elevated AST and ALT Dx?

*Arsenic poisoning* -Disrupts cellular respiration and gluconeogenesis -Sources: Pesticides, Contaminated water, Pressure-treated wood Manifestations -Acute: garlic breath, vomiting, watery diarrhea, QTc prolongation. -Chronic: *Hypo/hyperpigmentation, hyperkeratosis, stocking-glove neuropathy* -Can lead to pancytopenia and hepatitis Tx: *Dimercapro*l, DMSA (succimer)

56yo man c/o progressively worsening exertional dyspnea over last 4 months -no fever, cp, orthopnea, cough, or ankle sweeling -works for a home insulation and plumbing company -Never been abroad and owns no pets -Exam shows digital clubbing and fine bibasilar end-inspiratory crackles -Jugular venous pressure is 5cm. Dx?

*Asbestosis* Presentation -symptoms develop >20yrs after initial exposure -*Progressive dyspnea* (over months), *bibasilar end-inspiratory fine crackles*, and *clubbing* -Increased risk of malignancies Diagnosis -Pathognomonic = *Pleural plaques* on chest imaging -Interstitial fibrosis and restrictive lung disease on PFT

32yo woman who recently delivered 6 wks ago c/o lightheadedness -fatigue has worsened since delivery -Intermittent generalized abdominal pain, loss of appetite, weakness -Says her skin is tanning even though she doesn't go outdoors -Found to have orthostatic hypotension -Lab results show hyponatremia, hyperkalemia, low bicarb. Dx?

*Autoimmune adrenalitis* -Most common cause of primary adrenal insufficiency -Loss of cortisol, aldosterone, and testosterone secretion -Symptoms are severe and pts develop significant *hypotension, hyperkalemia, hyperchloremic acidosis, hyponatremia* -*Hyperpigmentation* d/t excess secretion of ACTH vs. Secondary adrenal insufficiency (Sheehan syndrome and lymphocytic hypophysitis) -Normal aldosterone, decrease in cortisol d/t decreased ACTH -No hyperkalemia, no hyperpigmentation

18yo AA M c/o progressively worsening fatigue and exertional dyspnea -2wks ago, had URI and treated with amoxicillin -no medical problems -Splenomegaly. -Mild scleral icterus -Lab: Anemia with increased reticulocytes? Dx?

*Autoimmune hemolytic anemia* *Warm agglutinin AIHA* -cause: Drugs (penicillin), viral infections, autoimmune (SLE), Immunodeficiency states, Lymphoproliferative disease (CLL) -*IgG* -Tx: Corticosteroids. Splenectomy for refractory cases *Cold agglutinin AIHA* -cause: Infections *Mycoplasma pneumoniae, mono* -*IgM* -Tx: Avoid cold temperatures, Rituximab *Positive Direct Coombs'* in both cases

29yo F presents with primary adrenal insufficiency. -Most likely pathophysiologic mechanism of patient's disorder?

*Autoimmune* -Autoimmune adrenalitis (Addison's disease) is the most common cause of primary adrenal insufficiency in developed countries (80% of cases)

MOA of dobutamine

*B1-adrenergic agonist* -used for management of severe heart failure associated with severe left ventricular systolic dysfunction and cardiogenic shock -*Increases myocardial contractiliy (inotropic effect)*

45yo M presents with easy fatigability and exertional dyspnea. -Pt had a subtotal gastrectomy 5 yrs ago for nonhealing gastric ulcer -Takes daily iron supplementation -Exam: Shiny tongue and pale palmar creases -No lymphadenopathy, hepatomegaly, or splenomegaly -Hgb: 7.8, WBC 3800, TB 2.3, DirectB 0.4, Alk 20, AST 12, ALT 24, LDH 190 -Stool tests for occult blood are repeatedly negative Dx?

*B12 deficiency --> Impaired DNA synthesis* -Pt most likely has chronic anemia following subtotal gastrectomy --> loss of intrinsic factor -B12 is required cofactor for formation of thymidylate and purine molecules for DNA synthesis -Increased intramedullary hemolysis of immature megaloblasts --> heme, hyper indirect bilirubinemia, increased LDH

35yo woman with -Recurrent painful oral ulcers -Recurrent genital lesions -Diagnosed with anterior uveitis -Scattered hyperpigmented skin lesions and tender, indurated areas on her legs Dx?

*Behcet disease* -More common in young adults -Recurrent painful oral aphthous ulcers -Genital ulcers -Eye lesions -Skin lesions -Thrombosis Dx: Pathergy (exaggerated skin ulceration with minor trauma ex: needlestick) & biopsy *d/t nonspecific vasculities of small-medium sized vessels*

Most common lung cancer associated with asbestos exposure

*Bronchogenic carcinoma* -Esp. in smokers -Asbestosis is the only known risk factor for malignant pleural mesothelioma but it is more likely to cause bronchogenic carcinoma

34yo M was in a MVC. He suffers blunt abdominal trauma and bilateral femur fractures. -Hemodynamically unstable requiring several units of packed RBCs -Once stabilized pt begins complaining of a tingling sensation in his toes and fingers -Serum Ca2+: 7.2 Most likely cause?

*Calcium chelation* by a substance in the transfused blood -Prior to storage, blood is generally mixed with solutions containing citrate anticoagulant --> Packed cells derived from these whole blood collections also contain citrate --> citrate can chelate serum calcium (only after massive transfusion)

Pts with intermittent claudications, diminished distal pulses, and abnormal (<1) ankle brachial index suggestive of peripheral artery disease are most likely to suffer from what over the next 5 years

*Cardiovascular morbidity and mortality* -20% risk of nonfatal MI -15-30% risk of death due to CV causes Presence of PAD = CAD risk equivalent -manage PAD with aggressive risk factor modification

53yo M with increased urinary frequency for the past month -No dysuria, urgency, or difficulty initiating urination -Wakes up several times at night to urinate -His mouth feels dry all the time and drinks fluids almost every hour to alleviate his thirst Labs: -Glucose 93, Na 150, K 4.1, bicarb 24, BUN 21, Cr 1.1 -Serum uric acid 10.1, serum osm 314, urine osm 124 Dx?

*Central diabetes insipidus* -decreased ADH release from pituitary -High serum Na (vs. normal serum Na nephrogenic DI and low serum Na in primary polydipsia)

51yo pt with type 1 DM, HTN, DLD, with significantly deformed right foot and a mildly deformed left foot -X-ray: effusions in several tarsometatarsal joints, large osteophytes, and several extra-articular bone fragments Dx? Cause?

*Charcot joint* - neurogenic arthropathy -Nerve damage d/t Vit B12 deficiency, diabetes, peripheral nerve damage, spinal cord injury, syringomyelia, tabes dorsalis -Decreased proprioception, pain, and temperature perception --> unknowing trauma

47yo c/o recurrent blisters on the skin of the back of his hand and forearm. -Also been extremely fatigued for the past several months and has had occasional joint pain -Small vesicles and erosions on the dorsa of both hands. Prior lesions appear healed with scarring and hyperpigmentation -LFT: Alb 3.5, TB 1.2, AST 65, ALT 78, Alk 90 Most likely cause?

*Chronic hepatitis C infection* -Asymptomatic/nonspecific symptoms -Increased transaminases (normal in 33% of pts) -Hematologic: *mixed cryoglobulinemia syndrome* -Renal: *Membranoproliferative glomerulonephritis* -Skin: *Porphyria cutanea tarda (PCT)*, lichen planus *PCT* -Presents with fragile, photosensitive skin that develops vesicles and bullae with trauma or sun exposure -*All pts with PCT should be screened for HCV*

53yo M with 2 day hx of right calf pain and swelling -Hx of IV drug abuse, bacterial endocarditis, and embolic stroke -Wheelchari bound for past year due to stroke-related left sided hemiparesis -No JVD or hepatojugular reflux -Lungs are CTA b/l -Abdomen is distended with shifting dullness and fluid wave suggesting ascites Most likely cause of ascites in this patient?

*Chronic liver disease* -Most likely due to chronic hepatitis C infection (hx of IV drug use) Most common causes of cirrhosis: Alcoholic liver disease and hepatitis C

83yo woman with postprandial epigastric pain. -Food aversion and weight loss due to the pain -PMHx of HTN, DM2, Hypercholestrolemia, peripheral vascular disease, coronary artery disease. -40 yr smoking history. -Abdominal x-rays reveal no abnormalities Dx?

*Chronic mesenteric ischemia* -Due to *atherosclerosis* of mesenteric arteries -CT angio to confirm diagnosis

42yo woman c/o 2 syncopal episodes in last 3 days -1month hx of increased fatigue and weakness -Anorexia, nausea, and abdominal pain for past 2 weeks. -BP 86/52, HR90 -Abdomen is mildyl tender -Skin shows hyperpigmentation in palmar creases Most likely Dx?

*Chronic primary adrenal insufficiency*/Addison disease -Fatigue, weakness, anorexia/weightloss, salt craving -GI symptoms -Postural hypotension -*Hyperpigmentation or vitiligo* (due to melanocyte-stimulating hormone with ACTH) -Hyponatremia, Hyperkalemia May lead to *Acute adrenal crisis* -Abdominal pain -Shock -Fever -AMS Dx by ACTH, serum cortisol, ACTH stimulation test

-Dysuria, and turbid, foul-smelling urine -Air bubbles white urinating -UA positive for WBC and bacteria -Urine cx --> multiple bacteria -PMHx of diverticular disaese, Crohn's, colonic malignancy Dx?

*Colovesical fistula* Next step: 1) Abd CT with oral or rectal contrast 2) Colonoscopy (r/o colonic malignancy) 3) surgical tx after resolution of infection

32yo F c/o persistent cough and SOB -Hx of 3 episodes of pneumonia over the last 3 years -Severe sinusitis a year ago -Episode of bloody diarrhea 6 months ago -Usually responds to Abx but takes time to clear the infection -No travel hx. No Family member with similar problems -HIV negative -CXR shows right lower lobe infiltrate Underlying disease? Dx test?

*Common variable immunodeficiency* -Most common primary immunodeficiency in adults -Very low IgG & low IgA and IgM -Does not respond to vaccination -Recurrent respiratory and GI infections -May have concomitant autoimmune disease -Dx by *quantitative measurement of immunoglobulin levels*

Pt with hypertensive emergency with severe HTN, renal failure, and signs of CHF is admitted and given IV furosemide and nitroprusside -Pt's symptoms improve -Next morning nurse finds him confused and agitated. Pt has a generalized tonic-clonic seizure. -Normal breath sounds, no focal muscle weakness Most likely Dx?

*Cyanide toxictiy* -d/t *Nitroprusside* (metabolism releases nitric oxide and cyanide) -altered mental status, lactic acidosis, seizures, coma -Occurs in pts who receive prolonged infusions, higher doses, or have underlying renal insufficiency

17yo with intensive L flank pain that radiates to the groin -Hx of recurrent stones since childhood -FHx of stones -Hexagonal crystals on urinalysis -Positive urinary cyanide nitroprusside test Dx? (specific stone/cause)

*Cystinuria* -Defective transport of dibasic amino acids by bruch borders of renal tubular and intestinal epithelial cells: *COLA (Cystine, Ornithine, Lysine, Arginine)* -Cystine (poorly soluble in water) --> radioopaque renal stones -Urinary cyanide nitroprusside test detects elevated cysteine levels

Homeless pt with -Flank pain, hematuria, oliguria -Anion gap matabolic acidosis -Calcium oxalate crystals in urine Dx? Tx?

*Ethylene glycol poisoning* -Tx: *Fomepizole* (competitive inhibitor of alcohol dehydrogenase)

Difference between Primary hyperparathyroidism vs. Familial hypercalcemia

*Familial hypercalcemia* is characterized by hypercalcemia with elevated PTH but low urinary calcium excretion (<100mg/24hr) vs. *Primary hyperparathyroidism* Hypercalcemia, elevated PTH, high urinary calcium excretion

35yo African American M c/o 2 wks of abd distension. -Drug rehab for 2 yrs d/t prior heroin abuse -Recent viral hepatitis and HIV were negative -Vitals are stable -Obese -Periorbital edema, ascites, and 2+ pitting edema in both legs up to knees -24hr urine shows protein excretion of 7.5g Most likely to be seen on kidney biopsy?

*Focal segmental glomerulosclerosis*: associated with -AA and Hispanics -obesity -HIV & Heroin use *FSGS is the most common cause of nephrotic syndrome in adults* (esp in AAs)

56yo F presents with eye irritation, painful eye movements, and diplopia -Over the last few weeks also experienced weight loss and fatigue -PPDx25yrs -PMHx: COPD -VS: BP 146/70, P 110, R 18 -On exam, pt is unable to maintain eye convergence and experiences diplopia on upward gaze Dx?

*Graves disease/ophthalmopathy* -*Exophthalmos with impaired extraocular motion* -d/t T cell activation and stimulation of orbital fibroblasts and adipocytes by TSH receptor autoantibodies --> *Orbital tissue expansion* and lymphocytic infiltration

45yo AA alcoholic F is diagnosed with TB. RIPE therapy is started. 2 months later she returns for f/u and her sputum is clear of AFB. -She now complains of fatigue, malaise, and nausea that began 10 days ago -Exam: Scleral icterus and hepatomegaly -Liver studies: TB 4.8, Alk 98, AST 372, ALT 410 -Normal coag -Negative hepatitis panel -Liver biopsy: panlobular mononuclear infiltration and hepatic cell necrosis Dx?

*Hepatitis secondary to isoniazid use* -While extrahepatic hypersensitivity manifestations like rash, arthralgias, fever, leukocytosis, and eosinophilia are common in pts with drug-induced liver injury, *they are characteristically absent in isoniazid-induced hepatic cell injury* -

38yo F c/o progressive muscle weakness over the last 6 months. -difficult to climb stairs, com hair, walk long distances -No associated muscle pain -Exam: facial hirsutism and mild proximal muscle weakness Dx?

*Hypercortisolism/Cushing syndrome* -Painless muscle weakness -Associated weight gain, bone loss, HTN hirsutism -Cortisol has direct catabolic effects on skeletal muscle --> muscle atrophy

45yo man with 2 days of b/l hand pain most severe in wrists -B/l wrist tenderness, thickening of distal fingers, convex nail beds -2PPDx25yrs -Chest exam shows decreased breath sounds Dx?Next step?

*Hypertrophic osteoarthropathy* -Commonly associated with *Lung cancer* Next step: *Chest X-ray* Digital clubbing and arthropathy can be d/t other underlying lun disease: Cancer, TB, bronchiectasis, or emphysema

25yo pt with status asthmaticus is intubated and treated with continuous albuterol nebulization and IV methylprednisolone. Her condition improves within 6 hours. -Next morning she complains of muscle weakness. On exam, she has difficulty lifting her arms over her head and has mild hand tremors. Most likely cause?

*Hypokalemia* d/t Beta-2 agnoist use -Beta-2 agonists drive potassium into cells --> hypokalemia Other side effects of B2 agonists: -tremor -headache -palpitations

25yo AA M c/o nocturia over past several months -wakes 2-3/night to urinate despite fluid restriction -Denies back pain, fever, dysuria, or urinary urgency -PMHx: otitis media in childhood, and hepA 2 years ago -SHx: one partner, no condoms -FHx: Brother died of a blood disease at age 10 -Lab: HCT is 49% Most likely dx?

*Hyposthenuria* - Sickle cell trait carrier -d/t *impairment in kidney's ability to concentrate urine = RBC sickling in the vasa rectae of the inner medulla --> impairs countercurrent exchange and free water reabsorption

66yo woman with diffuse dermal scaling. -Skin appears dry and rough -gets worse in winter Dx? Tx?

*Ichthyosis vulgaris* -Chronic, inherited skin disorder characterized by diffuse dermal scaling -Mutations in the filaggrin gene Tx: Simple emollients, keratolytics (coal tar, salicylic acid), and topical retinoids

Pt comes into ED with suspected PE -presents with dyspnea, tachypnea, crampy pain, and paresthesias in his extremities -Exam: carpopedal spasm and left calf swelling What alterations in Ca2+ homeostasis is most likely present in the patient?

*Increase in Ca2+ bound to albumin* --> hypocalcemic symptoms despite normal Ca2+ levels (d/t decreased ionized Ca2+) -Rise in pH (respiratory alkalosis in this pt) causes H+ ions to dissociate from albumin freeing it up to bind more Ca2+ --> decreased levels of ionized Ca2+

30yo man with low back pain and stiffness for 2months -Pain is worse in the morning but improves with activity -Pt also has had intermittent diarrhea and lower abdominal pain for past 3 months -X-ray shows sacroiliac joint inflammation Dx?

*Inflammatory bowel disease* (Crohn and Ulcerative colitis) -NSAIDS can relieve arthritis symptoms but exacerbate the underlying bowel disease Multiple extraintestinal manifestations -*Arthritis* -Eye: uveitis, episcleritis -Skin: pyoderma gangrenosum -Hepatobiliary disease (primary sclerosing cholangitis)

34yo woman with 4-5month hx of episodic mid-abdominal cramping pain, nausea, and watery diarrhea. -Increased flatus and bloating sensation -Episodes occur within an hour of eating -No other significant PMHx Most likely cause?

*Lactose Intolerance* -Brush border enzyme deficiency

Differential for proximal muscle weakness in person with Lung cancer

*Lambert-Eaton* -Proximal muscle weakness -Autonomic dysfunction (dry mouth) -Cranial nerve involvement (ptosis) -Diminished or absent deep-tendon reflexes *Dermatomyositis/Polymyositis* -Symmetrical and more proximal muscle weakness -Interstitial lung disease, esophageal dysmotility, Raynaud -Polyarthritis -Skin findings (Gottron papules, heliotrope rash) in dermatomyositis

57yo M just returned from a cruise vacation c/o fever, dry cough, and SOB for past 2 days -Also had HA, abd pain, and diarrhea -T 102.6, BP 110/65, P 80, R 18, SpO2 97 -Lung: crackles b/l -Serum sodium is 128 -CXR: b/l interstitial infiltrates Dx? Tx?

*Legionella pneumonia* -Tx: Fluoroquinolone Characteristics -Fever, bradycardia, GI symptoms, delayed pulmonary symptoms -*Hyponatremia* -Lobar infiltrate (CXR) -Few/no organisms seen on sputum Gram stain -*Urine legionella antigen*

54yo M with 2 days of severe diarrhea and 6 hrs of abd pain -confused and lethargic -Recently treated for strep throat -Moderate fever, hypotensive, tachycardic, tachypneic -Lab: Leukocyte count > 50,000 with increased bands and metamyelocytes; High leukocyte alk phos score Dx?

*Leukemoid reaction* -caused by severe infection --> mobilization of mature and immature leukocytes from bone marrow -Must be differentiated from CML LR: WBC > 50,000, Metamyelocytes > myelocytes, High Leukocyte alk phos score, No absolute basophilia CML: WBC > 100,000, Myelocytes > Metamyelocytes, Low leukocyte alk phos score, Absolute basophilia

78yo woman with 1wk hx of worsening left-sided ear pain and drainage -unrelenting pain -Loss of hearing on left side -Left external auditory canal is edematous with purulent discharge and granulation tissue in the floor. Clear tympanic membrane -ESR is 89 Dx? Management?

*Malignant (necrotizing) Otitis externa* -Severe infection of the external auditory canal and base of the skull usually caused by Pseudomonas aeruginosa -Tx: IV ciprofloxacin

40yo M with 2wk hx of fatigue, lower extremity edema, and dark urine -symmetric pitting edema of lower extremities -UA: 4+ proteinuria and microhematuria -electron microscopy: *dense deposits within glomerular basement membrane* -Immunofluorescence is positive for C3 and not immunoglobulins Dx?

*Membranoproliferative glomerulonephritis, type 2* -Caused by *persistent activation of the alternative complement pathway* (IgG antibodies/C3 nephritic factor directed aginst C3 convertase of the alternative complement pathway) -*Dense intramembranous deposits that stain for C3* is charcteristic

34yr old homeless man is brought to ED in a confused state -c/o epigastric pain, vomiting and blurred vision -Found to have metabolic acidosis -poor oral hygiene and dry mucous membranes -Optic disc hyperemia on funduscopic exam Dx?

*Methanol poisoning* -Headache, n/v, epigastric pain -Vision loss and coma -Optic disc hyperemia -Anion gap metabolic acidosis vs. *Ethylene glycol* -Similar symptoms -Renal damage -No effect on vision

Treatment algorithm for rheumatoid arthritis

*Methotrexate* If symptoms persist for >6months add !) *TNF inhibitor* (biologic agent) -*Etanercept, Infliximab*, Adalimumab, Tocilizumab, Rituximab 2) add another nonbiologic agent such as *sulfasalazine, hydroxychloroquine*, leflunomide, azathioprine

17yo boy presents with a progressive papular rash involving the trunk, neck, upper arms, and genital area for 8 weeks. -Lesions are mildly pruritic, but no other associated symptoms -PMHx: asthma, eczema -Derm exam: widespread firm, dome-shaped, flesh-colored papules with central umbilication Dx? Further testing?

*Molluscum contagiosum d/t poxvirus* -small, pruritic, skin-colored papules with umbilicated centers -Transmission via skin-to-skin contact Patients with impaired cellular immunity may have prolonged course with widely distributed papules, facial involvement, and lesion counts number in hundreds -*HIV testing* should be considered for patients with MC (esp if lesions are large, numerous, widespread)

23yo F c/o R foot pain that started 6 weeks ago that has worsened over the past week -No trauma or inciding event. Pain is preventing her from her usual exrcise -No meds. Very active -Exam: clicking sensation when the 3rd and 4th metatarsal heads are squeezed together and reproduces the pani in the plantar surface Dx?

*Morton neuroma* -Numbness/pain btwn 3rd and 4th toes -Clicking sensation when palpating space between 3rd and 4th toes while squeezing the metatarsal joints

-Bone pain -Osteolytic lesions/fractures -Anemia -Hypercalcemia -Renal insufficiency Most likely?

*Multiple myeloma* -Characterized by monoclonal IgG, IgA, or light chains -Bone marrow biopsy: *>10% clonal plasma cells* (vs. >10% clonal B cells in Waldenstrom macroglobulinemia)

68yo M c/o exertional fatigue -Mild mucosal pallor -No lymphadenopathy,, normal cardiac exam -No splenomegaly or lower extremity edema -Labs show hypercalcemia, normocytic anemia, and a protein gap -Peripheral blood smear shows rouleaux formation of RBCs Dx?

*Multiple myeloma* -Constitutional symptoms (weight loss, fatigue) -Hypercalcemia, normocytic anemia, renal insufficiency, and *protein gap* (diff btwn total protein and albumin >4) -SPEP: M-spike -Peripheral blood smear: *Rouleaux formation* (stacking of RBcs like coins d/t elevated serum protein) -Bone marrow biopsy: *>10% clonal plasma cells*

45yo F c/o fatigue, weakness, and diffuse bone pain. She was diagnosed with celiac sprue 5 years ago and admits to being noncompliant with her diet -Hg 12.2 -Ca 9 -Ph 2.6 (3-4.5) -PTH 122 (10-65) -Alk 234 (36-92) Dx?

*Osteomalacia* -d/t *Impaired osteoid matrix mineralization* -Causes: malabsorption, intestinal bypass surgery, celiac sprue, chronic liver disease, chronic kidney disease -*Decreased vit D, Ca, Ph* -*Increased Alk, increased PTH* -Xray: thinning of cortex with reduced bone density -B/l and symmetric pseudofractures

MOA of clopidogrel, prasugrel, ticagrelor

*P2y12 receptor blocker* -Blocks platelet aggregation

Pneumococcal vaccine PCV13, PPSV23 What to give when?

*PPSV23* -Adults < 65 -With increased risk of invasive pneumococcal disease: Heart/lung disease, DM, smoking, liver disease *PCV13* followed by PPSV23 -All adults age >65 -Adults < 65 with very high-risk comorbid conditions: CSF leaks, sickle cell, cochlear implants, asplenia, immunocompromised

68yo F with 1yr hx of right leg pain. -pain has a relatively constant severity -Intermittent headaches over the last 6months -x-ray of skull: areas of bone resorption and sclerosis -x-ray of leg: cortical thickening with mild bowing Dx?

*Paget disease of bone* -Bone pain and deformity -Skull: headache, hearing loss -Spine: Spinal stenosis, radiculopathy -Long bones: Bowing, fracture, arthritis of adjacent joints -associated with Giant cell tumor, osteosarcoma *d/t osteoclast dysfuncton --> increased bone turnover* Lab: -Elevated *alk phos* and bone turnover markers (PINP, *urine hydroxyproline*) -Normal Calcium and phosphorus levels Imaging: -X-ray: Osteolytic or mixed lytic/sclerotic lesions -Bone scan: Focal increase in uptake Tx: Bisphosphonates

asymptomatic 75 yo with PMHx of osteoarthritis, HTN, and hyperlipidemia comes in for routine exam -Exams are normal -Rectal exam shows diffusely enlarged prostate without nodules -Distal interphalangeal joints are enlarged -Pt takes hydrochlorothiazide and atorvastatin Lab: Cr: 0.8 Ca: 8.8 PSA: 2.1 (<6.5 is normal) T.Bili: 1.0 Alk: 420 AST: 20 ALT:25 Most likely cause of elevated Alk phos?

*Paget disease of bone* -Most patients are asymptomatic -Higher risk of giant cell tumor, osteosarcoma -may have headache, hearing loss, spinal stenosis, radiculopathy -Bowing, fracture, arthritis of long bones -d/t *Osteoclast dysfunction* --> increased bone turnover -Xrays: osteolytic or mixed lytic/sclerotic lesions -*Focal increase in uptake in bone scan* -Tx: *Bisphosphonates*

58yo M c/o skin discoloration, anorexia and weight loss -Dark urine and pale stools -Hx of HTN and DLD -Enlarged, nontender gallbladder is palpated. No ascites Dx?

*Pancreatic cancer* --> compression of the pancreatic and CBD --> pain less jaundice

43yo woman with abdominal pain and dark urine -Exam shows RUQ tenderness without guarding or rebound -Labs: Hgb 8.9, Plt 134k, TB 6.3, LDH 740, Haptoglobin 30 (N 50-150) -MRI of abd shows hepatic vein thrombosis Dx?

*Paroxysmal nocturnal hemoglobinuria* -*Hemolysis* --> hemoglobinuria -*Cytopenias* (anemia, thrombocytopenia, leukopenia) -*Hypercoagulable state* --> thrombosis esp within intraabdominal or cerebral veins Dx: Flow cytometry --> *Absence of CD55 and CD59* Tx: *Eculizumab* (monoclonal Ab that inhibits complement activation)

26yo woman with week of fever, chills, dyspnea on exertion, nonproductive cough, and fatigue. No chest pain or hemoptysis -Hx of SLE treated with cyclophosphamide and prednisone -T 101, BP 140/80, P112, R24, spo2 86% -Elevated leukocytes, High LDH -CXR: bilateraly interstitial infiltrates. Most likely cause?

*Pneumocystis jirovecii pneumonia* (PCP) -Pts with PCP who do not have HIV develop *acute respiratory failure*, *dry cough*, and *fever* -*LDH* levels are usually elevated -CXR: bilateral, diffuse interstitial infiltrates

45yo female with progressive proximal muscle weakness for past several months -No pain -Normal sensation and DTRs Elevated ESR, CK Dx?Tx?

*Polymyositis* -If + for skin manifestations = dermatomyositis -Autoantibodies: ANA, Anti-Jo-1 -Commonly seen as a *paraneoplastic syndrome* --> appropriate workup should be done Dx: Biopsy = endomysial infiltrate, patchy necrosis Tx: Short term = *steroids* Long term = methotrexate, azathioprine

Pt with afib is given warfarin. Pt develops warfarin-induced skin necrosis a few days after. What is the primary cause of the pt's presentation?

*Protein C deficiency* -Giving warfarin greatly reduced protein C and S levels --> increased risk for VTE and Skin necrosis Tx: Immediate cessation of warfarin and administration of protein C concentrate

42yo man c/o periodic difficulty breathing and wheezing. -Persistent nasal blockage 2 weeks ago -Pt has stable angina and takes aspirin, diltiazem, atorvastatin, and albuterol Most likely cause of pt's respiratory symptoms

*Pseudoallergic drug reaction* = aspirin/NSAID-exacerbated respiratory disease -Not IgE-mediated -Typically occur in pts with *asthma, chronic rhinosinusitis with nasal polyposis, or chronic urticaria* -*d/t increased production of pro-inflammatory leukotrienes and decreased production of anti-inflammatory prostaglandins*

65yo Woman with AMS. -Pt woke up in the morning with a HA and became progressively inoherent over the course of the day -3wks ago, the pt was diagnosed with depression and started on SSRI -She has RA, treated with adalimumab -Disoriented, irritable -Neck is supple, no papilledema, mucous membranes moist, no JVD, Lungs are clear, rest of exam is normal -Na 119, K 4, Bicarb 24, Glucose 90, BUN 9.0, Uric acid 1.5 -Serum osm 265, Urine osm 500, urine Na 56 Dx?

*SIADH* -*Hypotonic, hyponatremia* -Serum osm < 275, Urine osm > 100, Urine Na > 40 -SSRI is a commonc cause of SIADH (other drugs: NSAIDs, carbamazepine)

Pt comes in with fatigue, weight loss, and persistent cough -Lethargic, confused over the last 2 days -X-ray shows a mass in the right hilar region -Hyponatremia: Na 117 -Serum osmolality <275mOsm/kg (Hypotonic) -Urine osmolality > 100mOsm/kg -Urine sodium > 40mEq/L Dx? Tx?

*SIADH* (paraneoplastic syndrome from lung cancer) Tx: *Hypertonic (3%) saline* -Becareful abut rate of correction: <8 mEq over first 24hrs -Rapid correction can lead to osmotic demyelination syndrome (*Central pontine myelinolysis*)

42yo man with subjective fever, sore throat, malaise, headache, skin rash -Rash began on his trunk and has now spread to his entire body -No CP, SOB, D, urethral discharge -3 new sexual partners over last year -Has not participated in any unusual outdoor activities -Full-body maculopapular rash w/o evidence of excoriations -Several raised, grey mucosal patches in the mouth -Cervical, axillary, inguinal, and epitrochlear lymphadenopathy is present -HIV negative Dx?

*Secondary Syphilis* Primary: Painless genital ulcer (*chancre*) Secondary -*Diffuse rash* (palms and soles) -*Lymphadenopathy* (Epitrochlear) -Condyloma lata -*Grey mucous patches* -Hepatitis Latent: asymptomatic Tertiary: -CNS (tabes dorsalis, dementia) -AAA -cutaneous Gummas

28yo M c/o chronic diarrhea -reports 5-6 nonbloody liquid BM daily -Sometimes awakens him at night to poop -Lost 4.4lbs and has diarrhea even when not eating -Occasional bloating sensations but no abd pain, N/V -PMHx: shot in the abdomen and required multiple surgery several years ago -Serum electrolytes are normal -gap between measured and calculated stool osmolarity is low

*Secretory diarrhea* -Large daily stool volumes -*Diarrhea that occurs even during fasting/sleep* -d/t *diruption of luminal ion channels in GI tract (i.e. after multiple abdominal surgeries, infection, congenital disorders) *Stool osmotic gap* (distinguish osmotic vs secretory diarrhea) -SOG = plasma osm - 2 x (stool Na + stool K) -Osmotic D: elevated osmotic gap (SOG>125mOsm/kg) -Secretory D: low osmotic gap (SOG<50mOsm/kg)

80yo F presents with lethargy and confusion -PMHx: HTN, DM2, CAD, PVD, Prev stroke -Pt has been bed bound for past 2 years d/t stroke -BP 74/48, P 124, R 24 -She has a sacral decubitus ulcer with purulent drainage and surrounding erythema -PCWP 6 (N 6-12), Mixed venous oxygen sat (MvO2) is 82% (N 60-80) Most likely cause of hypotension?

*Septic shock* -*Decreased afterload* (d/t vasodilation) =*Decreased/low normal PCWP* d/t capillary leakage --> decreased preload -*Elevated MvO2 sat* d/t hyperdynamic circulation with inability of tissues to adequately extract O2

Two most common organisms responsible for deep infections following puncture wounds (osteomyelitis after stepping on a nail)

*Staph aureus *Pseudomonas aeruginosa

45yo man with skin rash, oral lesions, and fever -Unable to eat d/t pain in his mouth and throat -Prescribed TMP/SMX for sinusitis 5 days ago -Conjunctivae in both eyes are inflamed -Extensive erosions involving the oral mucosa -Erythematous, desquamating rash with scattered involvement of the trunk and proximal thighs Dx?

*Stevens-Johnson syndrome* -Less than 10% of body surface is affected -Once greater than 30% of body surface is affected = toxic epidermal necrolysis -Influenza-like prodrome -Rapid-onset erythematous macules, vesicles, bullae -*Necrosis and sloughing of epidermis* -*Mucosal involvement*

Pt recently diagnosed with Graves disease comes in with fever and sore throat. Next step?

*Stop antithyroid drugs*: Propylthiouracil or methimazole -Side effect: *Agranulocytosis* d/t immune destruction of granulocytes --> WBC < 1000

Pt being treated for asthma exacerbation now has leukocytosis with neutrophilic predominance Cause?

*Systemic glucocorticoids* --> leukocytosis d/t -*Mobilization of marginated neutrophils into blood stream* -Stimulation of release of immature neutrophils from bone marrow -Inhibition of neutrophil apoptosis

23yo woman c/o 3month hx of intermittent hand stiffness and pain -Also has fatigue, and occasional knee and chest pain -Easily sunburns -Bilateral hand joints and wrists are mildy tender and swollen -Mild b/l lower extremity edema Hgb 12.2 Plt 98,000 WBC 3,300 UA: 2+ protein, 5-10 erythrocytes Dx? Best next step?

*Systemic lupus erythematosus* -Next step: Antinuclear antibody test Presentation -gradual onset of symptoms -Malar or discoid rash -Jonit, renal, serosal, neurologic involvement Lab findings -*Anemia, leukopenia, thrombocytopenia* -*positive ANA, anti-dsDNA, anti-Smith* -*Low complement levels*, increased immune complexes Diagnose by first testing ANA. If positive test for anti-dsDNA and anti-Smith

What are following statistical analysis used for T-test Z-test Chi squared ANOVA

*T-test*: compare 2 means *Z-test*: compare 2 means taking into account population variances *Chi squared*: categorical data and proportions *ANOVA*: compare 3 or more means

40yo M with worsening SOB and nonproductive cough over last 3weeks -2months of fatigue, intermittent fever, and decreased appetite/weight loss -Hx of iv drug use, and smoker -released from 2 year incarceration 6 months ago -NAD -Crackles present through lung fields -Mild hepatomegaly -CXR: diffuse reticulonodular pattern Cause?

*TB (miliary TB - d/t CXR finding of diffuse reticulonodular/millet see pattern)*

45yo with PMHx of major depression and chronic back pain is brought to ER by ambulance after she was found in a obtunded state with an empty med bottle next to her. -Had a seizure in the ambulance -BP is low, HR is high -Pupils are dilated, skin is warm and flushed, decreased bowel sounds EKG shows QRS of 130msec. Dx? Tx?

*TCA overdose* -hyperthermia, dilated pupils, intestinal ileus, seizures, decreased myocardial conduction velocity --> QRS prolongation and risk of ventricular arrhythmia Tx: Sodium bicarb

45yo Mc/o headaches and confusion -No focal weakness or sensory symptoms -Exams are normal -Hgb 8.4, Plt 44,000, Leukocytes 5,500 -BUN 30, Cr 2.2, Ca 10 ,Glucose 98 -Peripheral blood smear: fragmented RBCs -Normal PT Dx? Next step?

*Thrombotic thrombocytopenic purpura* -Next: *Plasma exchange* -D/t decrease in ADAMTS13 --> uncleaved vWF multimers --> Plt trapping and activation -*Hemolytic anemia with schistocytes* -*Thrombocytopenia* (increased bleeding time, normal PT/PTT)

28yo F develops tachycardia in postop recovery room -admitted for R femur fx after MVC and had an open reduction and internal fixation of the fracture -No hx of alcohol use -In recovery area, began N/V, anxious and agitated -On exam: T 10, BP 160/90, P 148, R 24 -pt is delirious and has a fine tremor. Mild lid lag is present -No muscle rigidity, and DTRs are 2+ in b/l extremities -Serum CK is elevated Dx? Next best step?

*Thyroid storm* -Next step: *Thyroid function test and propranolol* -Precipitated by: Surgery, acute illness, pregnancy, iodine contrast -Presentation: High fever, Tachycardia, HTN, CHF, arrhythmias, Neurological symptoms (agitation, delirium, seizure, coma), Goiter, lid lag, tremor, N/V/D, Jaundice -Tx: Beta blocker, PTU followed by iodine solution, Steroids (decrease peripheral T4 to T3 conversion)

24yo woman with skin lesions on her trunk and proximal upper limbs -Noticed the lesions after a summer vacation at a beach a week ago -Had sun exposure without prior application of sunscreen -Lesions are mildly itchy but not painful -Skin exam: Hypopigmented lesions Dx?

*Tinea versicolor*/*Malassezia globosa infection* -Grows in exposure to hot and humid weather -Hypopigmented,hyperpigmented, or mildly erythematous lesions. (w/ or w/o fine scales, pruritus) -Dx: KOH prep --> hyphae and yeast cells in a *spaghetti and meatballs* pattern

55yo woman with 1wk hx of pain in multiple joints. -Achy pain and stiffness in both wrists and multiple metacarpophalangeal and proximal interphalangeal joints in both hands -Symptoms are worst in the morning and partially improve with activity -No fever, chills, rash, or weight loss -Mild swelling with no redness or tenderness of joints -Normal cbc, serum chem, ESR 12 Dx?

*Viral arthritis d/t Parvovirus B19* -Resembles RA in that it is acute, symmetric arthralgia/arthritis of hands, wrists, knees, feet. -In adults ParvoB19 causes more joint problems than skin symptoms (As seen in children) -*Polyarticular and Symmetric* -*Normal ESR* -*Brief morning stiffness* -Self-limited: resolves in 1-2months Dx by B19 antibodies (immunocompetent) or NAAT for B19 DNA (immunocompromised/reactivation of prev infection)

74yo man with "problems of old age": temporal headaches, fatigue, ears ring, eyes blurry, paresthesia. -moderate cervical lymphadenopathy -Hepatosplenomegaly -Anemia -Sharp IgM spike on serum protein electrophoresis Dx?

*Waldenstrom macroglobulinemia* -*Hyperviscosity syndrome* (diplopia, tinnitus, headache, dilated/segmented funduscopic findings) -Neuropathy -Bleeding -Anemia, thrombocytopenia -*Hepatosplenomegaly* -Lymphadenopathy -*IgM monoclonal antibody* (M-spike) -Rouleaux formation on peripheral smear -Bone marrow biopsy: >10% clonal B cells

Most common benign vascular tumors in adults

*cherry angiomas*/senile hemangiomas -Benign -typically seen 40-50s -Number increases with age -Sharply circumscribed areas of congested capillaries and postcapillary venules in the papillary dermis vs. Strawberry hemangiomas: appear during 1st weeks of life (infantile hemangiomas) -frequently regress spont. by age 5-8

Pathophysiology of heat stroke

*inadequate/failure of thermoregulation* (NOT inadequate fluid/salt replacement)

Management of STEMI

-*Aspirin* (reduce mortality) -*Beta blocker* (reduce mortality) -*ACE-I* (reduce mortality) -Morphine -Oxygen -Nitrates (*Not* if right ventricular infarction, hypotension, or severe aortic stenosis) -Low-molecular weight heparin (enoxaparin) -Statins -Revascularization with PCI (<90min of hospital arrival). If stented, add clopidogrel to regimen

Best drugs for malaria prophylaxis before traveling abroad

-*Atovaquone-proguanil* -Doxycycline -*Mefloquine* Treatment should begin greater than 2 weeks prior to travel, continued during the stay, and discontinued 4weeks after returning *Chloroquine resistance is common so not used very often*

Differential for microcytic/hypochromic anemia

-*Iron deficiency*: decreased intake or increased blood loss -*Defective utilization of storage iron*: anemia of chronic disease -*Reduced globin production*: Thalassemia and other hemoglobinopathies -*Reduced heme synthesis*: Lead poisoning, sideroblastic anemia

Myopathy differential

-*Steroid induced* (weakness, no pain, normal ESR, normal CK) -*Polymyalgia rheumatica* (no weakness, pain and stiffness, Increased ESR, normal CK) -*Inflammatory/-myositis* (pain and weakness, Rash and arthritis may be present, increased ESR, Increased CK) -*Statin-induced* (pain with or without weakness, Normal ESR, increased CK) -*Hypothyroid* (Pain and weakness, delayed reflexes, Normal ESR, increased CK)

Time guidelines for primary PCI in pts with acute STEMI

-*Within 12 hours of symptom onset* -*Within 90 min from first medical contact to device time at a PCI-capable facility* -Within 120 min from first medical contact to device time at a non-PCI capable facility (allow time for transport to PCI capable facility)

Drugs that can cause ototoxicity leading to hearing loss

-Aminoglycosides -Loop diuretics (furosemide) -Chemotherapeutic agents (Platinum containing agents: cisplatin, carboplatin) -Aspirin (more likely to cause tinnitus rather than hearing loss)

Prophylaxis for HIV patients depending on CD4 count: -CD4 < 100 -CD4 < 50

-CD4 < 100: *TMP-SMX* -CD4 < 50: *Azithromycin*

Causes of pulsus paradoxus (>10mmHg drop in SBP during inspiration)

-Cardiac tamponade -COPD or asthma (intrathoracic pressure is greatly exaggerated d/t exaggerated inspiration)

What anticoagulants are these: -Enoxaparin -Fondaparinux -Rivaroxaban

-Enoxaparin = LMW heparin -Fondaparinux = Injection factor Xa inhibitor -Rivaroxaban = Oral factor Xa inhibitor *All the above cannot be use in pts with sever renal insufficiency (estimated GFR < 30)*

Side effects of Leflunomide (Pyrimidine synthesis inhibitor)

-Hepatotoxicity -Cytopenias

Side effects of methotrexate (Purine antimetabolite)

-Hepatotoxicity -Stomatitis -Cytopenias

Side effects of sulfasalazine (TNF & IL1 suppressor)

-Hepatotoxicity -Stomatitis -Hemolytic anemia

The only two heart murmurs that get *louder with valsalva* and *softer with squatting*

-Hypertrophic cardiomyopathy -Mitral valve prolapse

Tumor lysis syndrome is seen in patients with aggressive hematologic malignancies (i.e. ALL) who begin cytotoxic chemotherapy. What electrolyte abnormalities will be seen?

-Hyperuricemia -Hyperkalemia, Hyperphosphatemia -Hypocalcemia Cardiac arrhythmias and acute kidney injury are common complication Tx: IVF and allopurinol or rasburicase (reduce risk of uric acid mediated renal damage)

Paroxysms of severe HTN in pts with pheochromocytoma can be seen in what situations?

-Increased intra-abdominal pressure (palpation, positional changes) -Surgical procedures -Medications (especially anesthetic), Beta blockers (unopposed alpha --> vasoconstriction)

Side effects of TNF Inhibitors (Adalimumab, Certolizumab, Etanercept, Glimumab, Infliximab)

-Infection -Demyelination -CHF -Malignancy

Management of acute exacerbation of COPD

-Initial: *inhaled short-acting bronchodilators, glucocorticoids, and antibiotics* -Continued symptoms despite medical management: *Noninvasive positive pressure ventilation*

Treatment for urge incontinence

-Initial: Bladder training and Kegel exercises -If doesn't respond: *Antimuscarinic drug (Oxybutinin)* Urge incontinence is d/t detrusor overactivity

MUDPILES

-Methanol/formaldehyde -Uremia -Diabetic ketoacidosis -Propylene glycol -Infection, Iron, Isoniazid -Lactic acidosis -Ethylene glycol -Salicylates

Management of acute COPD exacerbation

-O2 -Combination short-acting bronchodilators (b2 agonist and anticholinergic agents) -*Systemic glucocorticoids* (NOT inhaled) -Abx

ECG changes of hyperkalemia

-Peaked T waves -Short QT interval -QRS widening -Sine wave with ventricular fibrillation

Prolactin, LH, and TSH levels in pt with Prolactinoma

-Prolactin (normal <15): > 200 -Decreased LH and FSH: due to GnRH inhibition -TSH may be normal or low (if low, due to compressive effect) Relationship btwn TSH and prolactin: Low TSH may cause mild-moderate hyperprolactinemia. (d/t TRH stimulating lactotrophs)

Threshold to perform a resection of a pituitary tumor

-Size > 1cm -Symptomatic mass < 1cm that doesn't respond to treatment or increase in size during treatment

Recommended vaccines for adults

-Td/Tdap: Tdap once then Td every 10 years -Influenza: yearly Pneumococcal *Adults < 65* -PPSV23 alone (one time) for adults who are current smokers or have other chronic medical conditions -Sequential PCV13 + PPSV23 (only for very high risk patients) = immunocompromised, CKD, Sickle cell, asplenia, CSF leaks, etc. *Adults > 65* -Sequential PCV13 + PPSV23

Pt presents with hypokalemia, alkalosis, and normotension Differential?

-Vomiting (*LOW* urine Cl-) -Diuretic abuse (HIGH urine Cl-) -Bartter syndrome (HIGH uCl-) -Gitelman syndrome (HIGH uCl-)

When to treat hyperkalemia with calcium gluconate

-pts with ECG changes -K+ > 7.0mEq/L without ECG changes -Or rapidly rising K+ d/t tissue breakdown

Felty syndrome -What are the three main characteristics?

1) *Rheumatoid arthritis* -severe erosive joint disease/deformity -Rheumatoid nodules -Vasculitis (mononeuritis multiplex, necrotizing skin lesions) 2) *Neutropenia* (Abs Neutro <1500) 3) *Splenomegaly* -Anti-CCP & RF are positive -Markedly elevated ESR (>85) -Rule out other causes of neutropenia by peripheral smear and bone marrow biopsy

Best next steps in pt with symptoms/signs of adrenal insufficiency

1) Morning cortisol and plasma ACTH 2) ACTH stimulation test Plasma ACTH assay can take several days so an ACTH stimulation test is usually performed concurrently to rapidly confirm diagnosis

Sequence of ECG changes in Hyperkalemia

1) Tall peaked T waves with shortened QT interval (K+ = 6 - 7) 2) PR prolongation & QRS widening (K+ = 6 - 7) 3) Disappearance of P wave (K+ = 7 - 8) 4) Conduction blocks, ectopy, or sine wave pattern (K+>8)

*Patellofemoral pain syndrome (PFPS)* -Poorly localized anterior knee pain -D/t chronic overuse or malalignment but can also be seen acutely following trauma -Positive patellofemoral compression test Management: *Activity modification*, NSAIDS, *Stretching and strengthening exercises* of quadriceps and hip abductors

17yo F c/o knee pain -Progressive 3 month history of poorly localized, achy pain at the anterior right knee that is worse with running, sitting for an extended period, and going up or down stairs -has been training intensively for competitive dancing -Has a sensation that the knee is giving away or buckling -No visible deformity at the knees -Mild crepitus with range of motion at the right knee -With knee extended, compressing the patella into the trochlear groove reproduces the pain Dx? Management?

3rd gen and 4th gen cephalosporins

3rd gen -Ceftriaxone -Cefotaxime 4th gen -Cefepime -Ceftazidime

Reversible causes of asystole/pulseless electrical activity

5Hs and 5Ts *5Hs* -Hypovolemia -Hypoxia -Hydrogen ions (acidosis) -Hypo or hyperkalemia -Hypothermia *5Ts* -Tension pneumothorax -Tamponade -Toxins (narcotics/benzos) -Thrombosis (pumonary or coronary) -Trauma

In a healthy individual, born in US, no risk of TB contact, no comorbitities, what is the PPD induration size needed to treat?

>15mm >5mm - HIV+, Recent contact of known TB case, CXR showing prev healted TB, Organ transplant/immunosuppressed >10mm - Recent immigrants, injection drug users, high risk settings (prison, hospital, nursing home, etc), Higher risk of TB reactivation (DM, Steroid, ESRD), Children <4yo or exposed to adults in high-risk categories

Signs of AD polycystic kidney disease and best method of diagnosis

ADPKD -Most are asymptomatic -Painless hematuria -Flank pain -HTN, proteinuria, palpable abdominal masses, CKD Extrarenal complcations -Cerebral aneurysms -Hepatic and pancreatic cysts -Cardiac valve disorders -Colonic diverticulosis -Hernias *Dx by U/S* or CT or MRI

Mechanism of action of adenosine

Acts on vascular smooth muscle and vasodilates coronary arteries and increases myocardial blood flow. -Blood flow is increased in stenosed coronary arteries but to a lesser extent --> detectable reduction in radioactive isotope uptake by myocardial cells in areas of stenotic coronary artery

56yoM presnets to ED c/o 5days of dyspnea. He wakes up during the night with difficulty breathing that keeps him from going back to sleep. -PMHx: uncontrolled HTN -BP 182/109, HR 110, SaO2 90% -Lung auscultation: bibasilar crackles and scattered wheezes Dx? Next step?

Acute decompensated heart failure -Presenting in this case with acute pulmonary edema -Give supplemental O2, *IV loop diuretic (furosemide)* -IV nitroglycerin (make sure pt is NOT hypotensive)

Acute pericarditis vs. Dressler

Acute pericarditis -Peri-infarction (occurs less than 4 days following MI) Dressler syndrome -Postcardiac injury (occurs several weeks after MI)

Tx for patient with severe hyperkalemia: -Hyperkalemia w/ ECG changes -Potassium > 7.0mEq/L (with or without ECG changes) -Rapidly rising potassium d/t tissue break down

Acute therapy: *Calcium gluconate* or *Insulin with glucose*

28yo with nasal congestion, rhinorrhea, and dry cough -used OTC allergy meds with some relief but still has symptoms -Transverse nasal crease, Swollen and pale nasal turbinates -Clear nasal discharge -Posterior pharyngeal wall "cobblestone" appearance Dx?

Allergic rhinitis -Tx: Intranasal glucocorticoid

Pt is diagnosed with multi-drug resistant pyelonephritis and treated with an antibiotic. After several days she is found to have acute renal failure with creatinine of 4.9 and FENa greater than 2% What abx did she most likely receive?

Aminoglycoside

Drugs that may lead to digoxin toxicity if given with digoxin

Amiodarone Verapamil Quinidine Propafenone -Increases serum levels of digoxin --> toxicity -Recommend decreasing digoxin dose by 25-50% when initiating amiodarone therapy and closely monitoring digoxin levels once weekly

65yo woman with PMHx of aortic stenosis c/o episodic painless GI bleeding Most likely dx?

Angiodysplasia -More frequently seen in pts with advanced renal disease, vWF disease, and aortic stenosis Dx with endoscopic evaluation Tx: Endoscopic cautery

Masses in the mediastinum

Anterior mediastinum (4Ts) -Thymoma -Thyroid mass -Teratoma -Terrible lymphoma Middle mediastinum -Bronchogenic cyst -tracheal tumors -pericardial cysts -Lymphoma -Aortic aneurysms of the arch Posterior mediastinum -Neurogenic tumors (Neuroblastoma)

65yo M c/o 2wks of progressive SOB and nonproductive cough. -No CP or orthopnea -6 months ago he was hospitalized d/t ventricular tachycardia and is being treated with antiarrhythmic therapy. -B/l inspiratory crackels are heard on lung auscultation -No cardiac murmurs or peripheral edema -b/l lung infiltrates involving pimarily the middle lung fields Most likely dx?

Antiarrhythmic toxicity/*amiodarone-induced interstitial pneumonitis* -Amiodarone is often used for management of ventricular arrhythmias in patients with CAD nad ischemic cardiomyopathy -Chest X-ray: localized or diffuse reticular or ground-glass opacities -PFTs would show restrictive pattern Side effects: -Pulmonary: *Chronic interstitial pneumonitis* (cough, fever, dyspnea, pulmonary infiltrates) -GI: Elevated transaminases, hepatitis -Dermatologic: *blue-gray skin discoloration* -Ocular: Corneal microdeposits, Optic neuropathy -Neurologic: Peripheral neuropathy

Common complication of giant cell arteritis

Aortic aneurysm

43yo M with acute onset right knee pain -recently diagnosed DMII -Exam: slightly swollen and tender right knee and mild hepatomegaly -Xray: chondrocalcinosis and moderate effusion Dx?

Arthritis with chondrocalcinosis = *Calcium pyrophosphate dehydrate crystal deposition* / *Pseudogout* most likely d/t hemochromatosis in this case (recently diagnosed DM and hepatomegaly) Often d/t secondary causes: Hyperparathyroidism, hypothyroidism, hemochromatosis

Most common location of ectopic foci that causes atrial fibrillation? Most common cause of atrial flutter?

Atrial fibrillation: *Pulmonary veins* Atrial flutter: reentrant circuit around the tricuspid annulus

Arrhythmia most specific for digitalis toxicity

Atrial tachycardia with AV block

Which immunosuppressant has the following side effects? -*Hepatotoxicity* -*Leukopenia* -GI (diarrhea)

Azathioprine -Purine analog that is converted to 6-mercaptopurine --> *Inhibits purine synthesis* -*side effects are dose-related*

Bright red, firm, friable, exophytic nodules in an HIV pt Dx?

Bacillary angiomatosis - Bartonella Tx: Erythromycin

37yo man brought to ED after being found by police acting insane. -Remains combative in ED -Disoriented, yelling, responding to internal stimuli -BP 190/96, HR 142, RR 20 -Exam shows no abnormalities except severe agitation and hyperreflexia -Labs are normal, UTox is positive only for THC -Head imaging is negative. -Pt remains psychotic for another week, but his symptoms subside and disappear with occasional use of benzodiazepines and supportive care. Most likely cause?

Bath salts -amphetamine analogs -Severe agitation, combativeness, psychosis, delirium, myoclonus, seizures -*prolonged duration of effect* (days to weeks)

58yo woman with advanced breast cancer with mets to bone comes to the office. -c/o mild, vague bone pain relieved by occasional use of tylenol -Calcium 11.4 Best next step?

Bisphosphonate therapy -best treatment for hypercalcemia of malignancy

24yo M c/o worsening productive cough with tenacious sputum, fever, and SOB for a week -Pt had similar episodes in the past ad symptoms usually improved somewhat w/abx but never went away completely -Exam: Crackles in both upper lung fields -Digital clubbing is present -Sputum culture: Pseudomonas aeruginosa Dx?

Bornchiectasis d/t *Cystic fibrosis* -Defective chloride channels

Waldenstrom macroglobulinemia vs Monoclonal gammopathy of undetermined significance (MGUS)

Both WM and MGUS have monoclonal IgM spike on serum protein electrophoresis. BUT *IgM spike in MGUS is smaller*, bone marrow biopsy shows *<10% monoclonal plasma cells* in MGUS, and there are no end-organ effects (no anemia, hepatosplenomegaly, lymphadenopathy, or systemic symptoms)

When are live vaccines (MMR, zoster, varicella) contraindicated in HIV pts?

CD4+ cell count < 200

55yo woman c/o pain, itching, and red streaks on her left arm -similar episode on her chest 2 weeks ago that improved on its own -Mild epigastric tenderness to palpation -She has tender, erythematous, and palpable cord-like veins on left arm and upper chest Next step?

CT scan -Pt has signs of *Trousseau's syndrome* = *migratory superficial thrombophlebitis* -Associated with *visceral cancer* Pancreas is most common, lung, prostate, stomach, and colon, and acute leukemias

52yo woman with symptoms of pounding sensation in her neck and lower extremity edema -has lost weight recently -chronic diarrhea -severe post-menopausal flushes -Poor oral hygiene -Echo: immobile tricuspid valve leaflets and severe tricuspid insufficiency most likely Dx?

Carcinoid syndrome -Skin: *Flushing*, *telangiectasias*, cyanosis -GI: *Diarrhea, cramping* -Cardiac: *Valvular lesions/Tricuspid regurg* (Right>Left) -Pulmonary: *Bronchospasm* -Misc: *Niacin deficiency* (pellagra: dermatitis, diarrhea, dementia) Dx: Elevated 24hr urinary excretion of 5HIAA Tx: Octreotide for symptom control, surgery for liver mets

Symptoms of digoxin toxicity

Cardiac -*Life-threatening arrhythmias* GI -Anorexia -N/V -Abd pain Neuro -Fatigue, confusion -Weakness -*Color vision alterations*

MOA of nitroglycerin for relief of pain in pts with stable angina

Causes *systemic vasodilation* --> decrease in cardiac preload --> decrease in LVED and LVES volume --> *reduction in left ventricular systolic wall stress* --> *decrease in myocardial oxygen demand*

Causes of digital clubbing and pathophys?

Causes: -May be hereditary -Most often pulmonary or CV diseases -Most common causes of secondary clubbing: *Lung malignancies, cystic fibrosis, and right-to-left cardiac shunts* Pathophys: *Megakaryoctes* skip the normal route of fragmentation within pulmonary circulation and enter systemic circulation --> become entrapped in distal fingertips d/t their size and release PDGF and VEGF --> growth = clubbing

dermatitis herpetiformis is associated with

Celiac disease

45yo woman with progressive fatigue, myalgias and muscle weakness in both lower extremities for past month -difficulty getting up from a chair -weakness and cramping in legs after walking a short distance -Exam: decreased strength in proximal muscles of lower extremities -Sluggish ankle jerks b/l -Normal ESR, elevated CK -electrolytes are normal Best next step?

Check Serum TSH and free T4 -although the presentation seems like polymyositis, sluggish DTRs and myalgias are not commonly seen with polymyositis -r/o hypothyroidism first. If normal, test for ANA, anti-Jo-1 Ab, and muscle biopsy

33yo Black F comes to the office d/t skin lesions and pain in her ankes for a week -On exam: patient has multiple tender pink to reddish nodules below the knee -No other symptoms or abnormal exam findings Next step?

Chest x-ray -Pt has *erythema nodosum* = painful, subcutaneous, nodules -Erythema nodosum is associated with... Strep infection, *sarcoidosis*, *TB*, Coccidioidomycosis, Inflammatory bowel disease, Behcet disease

35yo previously healthy F presents with 3 days of fever and malaise -recent 2wk vacation to Caribbean islands -Fever, malaise, macular skin rash, cervical lymphadenopathy -*Polyarthralgias* -*Lymphopenia and thrombocytopenia* Dx?

Chikungunya fever -Central and south america, tropical regions of africa, south asia -Vector: Aedes mosquito -*Polyarthralgias* is always present with infection -*Lymphopenia and thrombocytopenia* Tx: Supportive care

26yo M with 1wk hx of dysuria and increased urinary frequency. -Multiple sex partners and raw dogs -Mucopurulent discharge seen at the urethral meatus -Urinarlysis: +Leukocyte esterase, WBCs, no bacteria -Gram stain shows no bacteria -Culture shows no growth Most likely organism?

Chlamydia trachomatis -Cannot be visualized by gram stain or in conventional culture -Dx by *Nucleic acid amplification test* -Tx: Azithromycin or Doxycycline Neisseria gonorrhoae is most common cause of urethritis in men but will show on gram stain

Elderly pt with lymphocytosis and presence of mature lymphocytes with smudge cells on peripheral smear Dx?

Chronic Lymphocytic leukemia -Most common leukemia in US -*Hepatosplenomegaly* and *Lymphadenopathy* -*Dramatic lymphocytosis* is classic hallmark -*Smudge Cells w/ mature lymphocytes* on peripheral smear is pathognomonic

Antibiotic for anaerobic coverage in cases of aspiration pneumonia

Clindamycin Metronidazole + amoxicillin Amoxicillin-clavulanate

-Sudden onset of blurred vision -Severe eye pain -N/V -Red eye with hazy cornea and fixed, dilated pupil Dx?

Closed angle glaucoma

31yo woman with 7kg weight gain over last few months -unable to lose weight despite rigorous dieting and exercise -proximal muscle weakness -BP 160/100 HR 88 -Dark terminal hair is present on lower abdomen -Irregular menses -increasing anxiety and insomnia Dx? Tests to run first?

Cushing syndrome -*24 hr urinary cortisol excretion* -*Late-night salivary cortisol assay* -*Low dose dexamethasone suppression test* If hypercortisolism is confirmed, ACTH levels are then measured

Pt admitted for hypertensive shock develops altered mental status, seizures, and headache -Skin: flushing -CV: arrhythmias -Respiratory: Tachypnea followed by depression -GI: abdominal pain, n/v -Metabolic acidosis Dx?

Cyanide poisoning d/t nitroprusside administration -Cyanide binds to cytochrome oxidase and inhibits mitochondrial oxidative phosphorylation--> lactic acidosis

Which immunosuppressant has the following side effects? -*Nephrotoxicity* -*Hypertension -*Neurotoxicity* (headache, visual disturbances, seizure, tremors, etc) -*Glucose intolerance* -Infection -Malignancy (increased risk of SCC of skin) -*Gingival hypertrophy* -*Hirsutism* -GI (anorexia, N/V, diarrhea)

Cyclosporine -acts by *inhibiting the transcription of interleukin-2* and other cytokines, mainly the T-helper lymphocytes

Common causes of constrictive pericarditis

Developing countires: *TB* US: *Idiopathic or viral pericarditis*, cardiac surgery or radiation therapy, connective tissue disorders

74yo F presents with diarrhea, nausea, and decreased appetite for past week -Also c/o increasing fatigue and occasional palpitation over the past few days -PMHx: chronic afib, cardiomyopathy -cardiac EF 40% (3months ago) -Meds: furosemide, metoprolol, digoxin, and warfarin -Latest INR: 2.3 (2wks ago) Best next step?

Digoxin level *Digoxin toxicity* -diarrhea, nausea, fatigue, vomiting, decreased appetite, confusion, weakness. -Visual symptoms of scotomata, blurry vision with changes in color or blindness -Arrhythmias

45yo M with HIV and CD4 cell count of 22 presents with... -Fever, cough -Abdominal pain, diarrhea -Night sweats, weight loss -Presence of splenomegaly -Alkaline phosphatase level: 412 w/normal PPD and negative serum CMV IgG Most likely Dx? How to prevent?

Disseminated *Mycobacterium avium complex (MAC)* -HIV patients with CD4<50 should receive *azithromycin prophylaxis* against MAC

Most common cause o gross lower GI bleeding in adults?

Diverticulosis

Common triggers of steven-johnson syndrome

Drugs: -Allopurinol -Antibiotics (sulfonamides) -Anticonvulsants (carbamazepine, lamotrigine, phenytoin) -NSAIDs (piroxicam) -Sulfasalazine

45yo F with 3 months of excessive hair growth over her face and body -Last menstrual period was 4 montsh ago but has been regular all her life prior. -electrolytes are normal -Physical exam is normal except for the hirsutism Dx?Next step?

Dx: *Androgen-secreting neoplasm of the ovary or adrenal glands* Next step: Testosterone and DHEAS levels -Elevated testosterone and normal DHEAS: *Ovarian source* -Elevated DHEAS: *Adrenal source*

32yo M, with 2 day hx of fever, headache, malaise, and myalgias, confusion -recalls getting tick bite 2 wks ago -T 102, BP 125/80, HR 100 -No lymphadenopathy, claear oropharynx -Exams are normal. No rash. No neurologic deficits CBC -Hgb 14, Plt 78,000, Leukocytes 2500. AST 98, ALT 105 Dx? Tx?

Ehrlichiosis -*Luekopenia & Thrombocytopenia* -Elevated liver enzymes and LDH -Flu-like illness, confusion -rash is uncommon Diagnosed by: *Intracytoplasmic morulae in monocytes* Tx: Empiric doxycycline

32yo M with PMHx of asthma c/o SOB -Pt has low grade fever, rhinorrhea, and generalized body aches -2 days later he develops dyspnea and dry cough -T 98.6, BP 110/70, P 120, R 28, SpO2 84% on RA -CXR reveals no infiltrates but hyperinflated lungs -Pt is started on albuterol, inhaled ipratropium, and a dose of methylprednisolone -1 hr later ABG on 3L of O2 is pH 7.32, PaO2 65, PaCO2 50 Next best step?

Endotracheal intubation -Impending respiratory failure. PaCO2 should be low. Normal or elevated PaCO2 is a BAD sign

23yo F c/o fatigue, anxiety, and difficulty sleeping over the last several months. -Meds: OCPs -Vitals are normal -TSH: 1.5 (normal), Total T4: 15 (high) Dx? Cause?

Euthyroid state with *Increased TBG* d/t OCP use -Increase or decrease in TBG is seen in total T4 levels

Pt with SLE is being treated with hydroxychloroquine What evaluation should be done periodically while pt is taking this medication?

Eye exam -Hydroxychloroquine is a TNF & IL-1 suppressor that can cause *Retinopathy*

Chronic diffuse musculoskeletal pain accompanied by -fatigue -mood disorders -insomnia

Fibromyalgia

30yo woman presents with diffuse aching muscle pain that has been present for 6 months -fatigue, impaired concentration -Costochondral junction tenderness -Normal ESR, CK, CRP Dx?

Fibromyalgia -greater than 3 months of symptoms with widespread pain -Normal lab studies Tx: TCA (amitriptyline)

36yo M being treated for TB comes in d/t progressive fatigue -Hgb 8, MCV 77, MCHC 30%, Iron 170 (N 50-150), TIBC 280 (N 300-360) -Microscopy reveals 2 populations of RBCs: hypochromic and normochromic Best next step?

Give *Pyridoxine* -Pt has acquired *Sideroblastic anemia* d/t defective heme synthesis - pyridoxine dependent impairment in early steps of protoporphyrin synthesis

Earliest renal abnormality that can be seen in diabetic nephropathy

Glomerular hyperfiltration -Thickening of the Glomerular basement membrane is the first change that can be quantitated -Followed by mesangial expansion -Nodular sclerosis comes later (specific for diabetic nephropathy)

Necrotic migratory erythema is associated with

Glucagonoma

50yo pt with recurrent flares of joint pain -x-ray shows punched-out erosions with a rim of cortical bone -aspiration: needle-shaped, negatively birefringent crystals Dx?

Gout

60yo pt c/o severe pain in his right great toe which is suddenyl swollen and very tender to touch -He also had occasional headaches and unbearable pruritus after hot shower over the past several weeks Dx?

Gout d/t *myeloproliferative disease* most likely *Polycythemia vera* --> pruruitus after hot showers, headaches, hepatosplenomegaly

36yo M c/o 1month hx of diarrhea, abdominal distension, and flatulence -6.8kg weight loss over this period -night sweats and occasional arthralgias -No hx of recent travel -T 99.5, BP 112/74, HR 104, RR 16 -Enlarged, nontender cervical and inguinal lymph nodes -Small ulcer on buccal mucosa -No skin rashes or joint effusions Next step?

HIV testing Acute HIV infection -mononucleosislike syndrome -generalized macular rash -GI symptoms Out of the large differential, HIV testing is the most immediate action to take in the situation

Woman taking OCP has been found to have a mass in her liver. -No other symptoms except discomfort with RUQ palpation. Dx?

Hepatic adenomas -Increased risk with long-term COP use

Patient with alcoholic cirrhosis presents with shortness of breath on exertion and fatigue for past several weeks. -Only abnormal exams are dullness and decreased breath sounds present on right side -1+ b/l lower extremity pitting edema -Normal cardiac exams Dx?

Hepatic hydrothorax -*transudative pleural effusions d/t small defects in the diaphragm* -Happens more commonly on right side (less muscular hemidiaphragm) Tx: *salt restriction and diuretic*

55yo F with 2 yrs of recurrent episodes of productive yellow sputum, congestion, and SOB that improves after Abx. -Episodes always improve with Abx but past 2 weeks, her cough has continued to worsen. -Lung exam: diffuse rhonchi and wheezes with coarse crackles b/l in the bases -CXR: linear atelectasis in the mid and lower lung fields b/l Next step to confirm dx?

High-resolution CT scan of the chest -Patient has *Bronchiectasis* -Cough with daily mucopurulent sputum production (large amounts) -Rhinosinusitis, dyspnea, hemoptysis -Crackles, wheezing -caused by *infectious insult with impaired bacterial clearnace* -High-resolution CT scan: *characteristic bronchial dialation, lack of airway tapering, and bronchial wall thickening*

Treatment of uric acid stones

Hydration, *alkalinization of urine*, and low purine diet -alkalinize with *oral potassium citrate* -Uric acid stones are highly soluble in aklaine urine if recurrent uric acid stones despite initial measures *allopurinol* may be used

Which chemical can pts in a house fire inhale most often other than carbon monoxide

Hydrogen *cyanide* --> cyanide poisoning -Cyanide is a potent *inhibitor of cytochrome oxidase a3* in the mitochondrial electron transport chain --> increased lactic acid --> metabolic acidosis -Tx: *Hydroxocobalamin or sodium thiosulfate* or *induction of methemoglobinemia with nitrites* to increase ferric iron (Fe3+) in circulating hemoglobin. Cyanide binds avidly to Fe3+.

34yo pt with fatigue -Tired easily after walking short distances -Difficulty combing hair due (can't hold hands over her head for long periods) -Anxiety, irritability, unintentional weight loss over last 2 months (no loss of appetite) -Tachycardic: HR 115 -Decreased muscle mass and weakness but nontender -DTRs are normal Dx?

Hyperyhroidism -Anxiety, insomnia -Palpitations -Heat intolerance -Increased perspiration -Weight loss without decreased appetite -Fatigue (d/t chronic sympathetic hyperstimulation) *Thyrotoxic myopathy* -Severe distal/proximal muscle weakness (without bulbar or respiratory muscle involvement) -Muscle atrophy

How does hypomagnesemia cause hypocalcemia

Hypomagnesemia *induces resistance to parthyroid hormone and decreases PTH secretion* -Need to treat both hypocalcemia and hypomagnesemia

32yo M comes into ED with sudden onset chest pain -T 37.2, BP 160/90, P 125, R 20 -Anxious, agitated, sweating profusely -Both pupils are dilated and nasal mucosa is atrophic -Normal cardiac exam -ECG: ST depression and T-wave inversion in leads V4-V6 -Cardiac enzymes are normal -CXR normal Next step?

IV diazepam -DO NOT give beta blocker to pt with acute cocaine intoxication

69yo pt with PMHx of afib presents with acute arterial occlusion of the left lower extremity. Best first step?

IV heparin infusion

Best treatment for pericarditis

Ibuprofen

Thrombocytopenia without anemia or leukopenia

Idiopathic thrombocytopenia purpura (ITP)

Why is hypoxemia seen in consolidative pneumonia

Impaired alveolar ventilation --> *Right-to-left intrapulmonary shunting* = extreme form of V/Q mismatch*where *V=0* Characteristic: *Inability to correct hypoxemia with increased FiO2*

What study designs to use to determine incidence vs. prevalence

Incidence - Cohort Prevalence - Cross sectional

Kussmaul's sign

Increase in JVD with inspiration

Clinical suspicion of acromegaly. Best next step?

Insulin-like growth factor 1 level (GH stimulates hepatic IGF-1 secretion) If positive --> Oral glucose suppression test

37yo man with fever, pleuritic chest pain, and hemoptysis -CXR/CT: nodular lesions with surrounding ground-glass opacities Dx?

Invasive aspergillosis -Triad of *fever, chest pain, hemoptysis* -Imaging: nodular lesions with surrounding ground-glass opacities = *Halo sign* -Occurs in immunocompromised pts -Tx: Voriconazole +/- caspofungin

Lab findings and renal findings in SLE

Labs: -*Hemolytic anemia*, *Thrombocytopenia*, *Leukopenia* (d/t autoimmune destruction) -*Hypocomplementemia* (C3, C4) -ANA antibody, Anti-dsDNA and anti-smith Renal: -Proteinuria and elevated creatinine -*Focal proliferative glomerulonephritis* or *membranous glomerulonephritis*

Best test for lactose intolerance

Lactose hydrogen breath test

-Microcytic anemia -Basophilic stippling -Hyperuricemia (high uric acid) in a pt presenting with fatigue, irritability, insomnia, unsteady gait, forgetfulness dx?

Lead poisoning -Lead disrupts heme synthesis --> microcytic anemia

58yo M c/o 3 day hx of fever, malaise, nonproductive cough, abdominal pain, diarrhea, and SOB -Travels frequently within the US -T 102, BP 98/59, HR 75, RR 29 -Hyponatremic -Mildly elevated liver enzymes -Sputum gram stain shows many neutrophils but no organisms Dx?

Legionella pneumonia

42yo M presents with a nonpruritic, nonpainful skin lesion on L upper arm that began 2 months ago -tingling and numbness of the left fingers -No PMHx, no meds -Immigrated from southeast Asia a year ago -Exam: 4cm, well-circumscribed, hypopigmented patch on L upper arm with no sensation to pinprick -Ulnar nerve is thickened and tender at left elbow -Touch and pain sensation is absent in the L ulnar nerve distribution Dx?

Leprosy -*Mycobacterium leprae* -Macular, *anesthetic skin lesions* w/ raised borders. -*Nodular, painful nearby nerves with loss of sensory/motor function* -Tx: *Dapsone+rifampin*

Management in COPD

Mainstays of treatment: -inhaled bronchodilators: *Anticholinergic medications* (ipratropium, tiotropium) May be combined with short-acting beta agonists Inhaled steroids and long-acting beta agonists for severe COPD

76yo man with no PMHx has an operation for hernia. On 3rd postop day he falls while getting out of bed. -Pt is responsive but confused with slurred speech. +LOC -BP 89/50, HR 122, RR24 -Decreased bibasilar lung sounds and distended neck veins -ECG: new-onset right bundle branch block with nonspecific ST- and T-wave changes -Shortly thereafter pt dies Most likley cause of death?

Massive pulmonary thromboembolism -Hypotension -Acute right heart strain -Syncope -JVD

Guidelines for abdominal aortic aneurysm screening

Men 65-75yo who have smoked cigarettes should receive a one time abdominal ultrasound

Acid-base change to be expected with loop-diuretic administration

Metabolic alkalosis

Most common valvular abnormality detected in pts with infective endocarditis

Mitral valve prolapse with coexisting *Mitral valve regurgitation*

66yo M c/o constipation. -Lower back pain -Normocytic anemia -Hypercalcemia Most likely dx?

Multiple myeloma

Which immunosuppressant has the following side effect? -*Bone marrow suppression*

Mycophenolate -reversible inhibitor of inosine monopohsphate dehydrogenase (IMPDH) --> *inhibits de novo purine synthesis*

Drug of choice for Tx of osteoarthritis

NSAIDs (i.e. diclofenac) If NSAID fails, Intra-articular glucocorticoid injection

X-ray findings in osteoarthritis?

Narrowing of joint space and osteophytes

42yo man is brought to ED immediately after seizure -ABG shows pH 7.20 -Na 140, Cl 103, Bicarb 17 -Anion gap of 20 -No other issues -Next step?

Observe and repeat lab tests after 2 hours -anion gap metabolic acidosis is likely due to postictal lactic acidosis -*Rise in serum lactic acid levels d/t/ skeletal muscle hypoxia and impaired hepatic lactic acid uptake*

Best next step for pt presenting with central retinal artery occlusion (most likely secondary to embolism)

Ocular massage and high flow oxygen

75yo black M with DM and HTN -Fundus reveals cupping of optic disc -Visual field exam reveals constricted peripheral vision Most likely diagnosis?

Open angle glaucoma -More common in african americans -*gradual loss of peripheral vision over period of years and eventual tunnel vision* -High intraocular pressure -*Cupping of the optic disc* on fundoscopy

Most common complication of chronic use of inhaled corticosteroid

Oropharyngeal thrush/candidiasis

Adverse effect involved in giving Sildenafil for pt who has both BPH and Erectile dysfunction -Pt is taking doxazosin

PDE-5 inhibitor combined with alpha blocker (doxazosin) can lead to *Severe hypotension* -Similar effect can be seen with nitrates

24yo with symptoms of hyperthyroidism. Thyroid gland is midly enlarged, mobile, and non tender. -T4, T3: increased -TSH: decreased -Radioactive iodine uptake is less than normal -Thyroid gland is not visualized on thyroid scan dx?

Painless/Silent thyroiditis -Variant of Hashimoto's -Mild, brief hyperthyroid phase -Nontender goiter *(distinguish from Subacute/granulomatous/De Quervain thyroiditis)* -Spontaneous recovery -Low radioiodine uptake *(distinguish from Graves)*

52yo man with black stools -abdominal discomfort and nausea but no hematemesis -Food helps the abdominal pain -Fecal occult blood is positive -Mild epigastric abdominal tenderness and right-sided carotid bruit on exam Most likely Dx?

Peptic ulcer disease -Classic symptoms of duodenal ulcer occur in the absence of a food buffer and can include epigastric pain 2-5hrs after meals, on an empty stomach, or at night.

38yo eastern european man with 2 month hx of exertional SOB and easy fatigability -Has been taking isoniazid for latent TB for last 5 months -Became vegan 5 months ago -Exam findings: Conjunctival pallor, Areas of depigmentation on his arms suggestive of vitiligo, Tongue appears shiny -Spleen is not palpable Lab results show macrocytic anemia Most likely Dx?

Pernicious anemia -Autoantibodies against gastric intrinsic factor --> decreased B12 absorption -Pernicious anemia is most common cause of vitamin B12 in whites of northern european background -Pts frequently have other associated autoimmune disorders such as vitiligo or thyroid disease -Pts with severe deficiency can also have thrombocytopenia and/or leukopenia

common complication of PEEP

Pneumothorax -d/t alveolar damage on top of preexisting alveolar damage (d/t ARDS or pneumonia)

60yo woman presents with stiffness and pain in shoulders, hipgirdle, and neck -Elevated ESR and C-reactive protein Most likely dx? Next step?

Polymyalgia rheumatica -Tx: Steroids *associated with giant cell (temporal) arteritis*

Most common source of PE

Proximal/thigh veins (iliac, femoral, popliteal) - account for > 90% of acute PEs

ECG findings of -non specific ST-segment or T-wave changes -new-onset RBBB -S1Q3T3 pattern Dx?

Pulmonary Embolism

80yo M with advanced prostate cancer and bony metastasis is complaining of severe back pain that has been progressively worsening for past 2 weeks -Orchiectomy 8months ago which relieved his bone pain until now -exam: tenderness at 2 sites in lumbar region -Bone scan: increased uptake in these areas Best next step?

Radiation therapy -Alleviates bone pain in pts with prostate cancer who have undergone orchiectomy

Management of a painless hard mass in the testicle with U/S that shows likelihood of a testicular tumor?

Radical orchiectomy -Removal of the testis and associated cord -Then chemo or radiation therapy depending on cancer type DO NOT FNA or Biopsy --> risk of spillage of cancer cells --> spread

Rapid and Slow-acting treatments to remove potassium in hyperkalemia

Rapid: -*Insulin with glucose* -B2-adrenergic agonists -Sodium bicarb Slow: -Diuretics -Cation exchange resins (Sodium polystrene sulfonate) -Hemodialysis

Pt with resistant HTN (uncontrolled despite 3+ drug regimen) and *systolic-diastolic abdominal bruit* Dx?

Renal artery stenosis

-Increased serum PTH -decreased serum calcium levels -Increased phosphate levels Most likely cause?

Renal failure CKD --> Decreased GFR --> phosphate retention and decreased 1,25-dihydroxyvitaminD --> Decreased intestinal calcium absorption, high serum phosphorus

Causes of S4 heart sound

S4 is an indicator of stiff left ventricle d/t... -*restrictive cardiomyopathy* -*left ventricular hypertrophy from prolonged HTN* = most likely presence of diastolic heart failure

54yo pt with cough, weight loss, anorexia, constipation, increased thirst and fatigue. -Lab comes back with a serum calcium level of 14.5 Next best step?

Saline hydration -Pt has severe hypercalcemia (most likely a paraneoplastic syndrome: secretion of parathyroid hormone-related protein) -Symptoms: weakness, GI distress, confusion, stupor, coma Management of hypercalcemia Severe (Ca >14) - Immediate Tx: Normal saline + calcitonin -Avoid loop diuretics -Long term: Bisphosphonate Moderate (Ca = 12-14) -No immediate Tx unless symptomatic (Tx same as severe) Asymptomatic/mild (Ca <12) -No immediate tx. Avoid thiazide diuretics or anything that will deplete volume

First line treatment for chemotherapy-induced nausea

Serotonin (5HT) receptor antagonists -Ondansetron If refractory --> second or third line: dopamine antagonists (metoclopramide and prochlorperazine)

32yo pt with HIV c/o hearing loss in his left ear for past month. -No other problems -Exam: dull, hypomobile tympanic membrane in left ear Dx?

Serous otitis media (non-infectious effusion) -d/t HIV lymphadenopathy or obstructing lymphomas

50% of circulating calcium is protein bound (albumin). Decrease in albumin concentration therefore can cause hypocalcemia. How to interpret serum calcium level with correction for the serum albumin level

Serum Ca2+ falls by 0.8 for every 1 decrease in albumin

Calcium correction in hypoalbuminemia

Serum [Ca] decreases by 0.8 for every 1 decrease in serum [albumin] Corrected Ca = [Ca] + 0.8(4-[albumin])

Ideal treatment for hypovolemic hypernatremia

Severe cases: 0.9% saline Mild cases: 5% dextrose in 0.45% saline

Antidoe for cyanide poisoning

Sodium thiosulfate (Pts with cyanide poisoning have *markedly elevated lactic acid levels* (>10))

Management of TCA overdose

Supportive therapy: -Supplemental O2, intubation -IVF -Activated charcoal for patients within 2 hours of ingestion -IV *Sodium bicarb* to treat QRS widening or ventricular arrhythmia: Increased pH decreases drug avidity for sodium channels and the sodium load alleviates depressant action on myocardial sodium channels

HIT symptoms and management

Symptoms -Platelet count reduction >50% from baseline -Arterial or venous thrombosis -Necrotic skin lesions at heparin injection sites (esp in heparin subQ) -Acute systemic (anaphylactoid) reactions after heparin Tx -Stop ALL heparin products -Start a *direct thrombin inhibitor (argatroban) or fondaparinux*

Beck's triad -what is it? -what are the 3 features?

Symptoms of *Cardiac tamponade* -Hypotension -Distended neck veins -Muffled heart sounds Pulsus paradoxus may also be seen Cardiac tamponade leads to decreased venous return/preload --> decreased SV and CO

Medicine treatment for fibromyalgia

TCA (amitriptyline) -If TCAs don't work, SNRI (duloxetine, milnacipran) and pregabalin -Conservative treatment first (aerobic exercise, good sleep hygiene) then medication.

Which immunosuppressant has the following side effects? -*Nephrotoxicity* -*Neurotoxicity* -*Glucose intolerance* -GI (diarrhea) -*No* gingival hypertrophy

Tacrolimus -*inhibits the transcription of interleukin-2* and other cytokines, mainly T-helper lymphocytes

What is the D-xylose test for?

Tests *proximal small intestinal absorption* -D-xylose is given to the pt orally. If normal, urine levels of d-xylose will be high -If abnormal, urine d-xylose level is low since it doesn't get absorbed A positive test in pt with symptoms of malabsorption, most likely *Celiac disease* However, pts with malabsorption due to enzyme deficiencies (pancreatic insufficiency), absorption of D-xylose will be normal since it is a monosaccharide (doesn't need to be degraded)

Management of Acetaminophen intoxication

Toxic dose = single dose > 7.5g (peds > 150mg/kg) -If within 4 hrs of ingestion --> *activated charcoal* -Obtain *serum acetaminophen levels* -If dangerous level of acetaminophen is found --> *N-acetylcysteine*

-Painless hematuria -sterile pyuria -WBC cast -Trace proteinuria -Elevated creatinine In pt with chonic low back pain. Most likely Dx?

Tubulointerstitial nephritis -d/t chronic NSAID use

Best management of Pulseless electrical activity

Uninterrupted *CPR* with *vasopressor therapy (epinephrine)*

46yo man with chest tightness and lightheadedness -Found to have supraventricular tachycardia on ECG Next step in tx?

Use of *vagal maneuvers* (carotid sinus massage, Valsalva, eyeball pressure) or IV *adenosine* -to *identify the type of SVT* -temporarily slow conduction and unmask "hidden" P waves (a.flutter or a.tach) -Can also cause transient AV nodal block and terminate paroxysmal SVT

45yo man presents with 2 month hx of painless, nonpruritic, purple lesions on his legs -Also has fatigue, weakness, and fleeting joint pains in his knees and elbows for past several months -No fever, weight loss, diarrhea, or abdominal pain -UA: 3+ blood, 3+ protein, few dysmorphic RBCs -AST 78, ALT 99 -C3 low-normal, C4 very low, RF+, ANA -, HIV- Next step?

Viral hepatitis serology *Mixed cryoglobulinemia syndrome* (most commonly d/t chronic inflammatory conditions such as HCV infection and SLE) Symptoms: -Systemic: Fatigue, *arthralgias* -*Renal: Glomerulonephritis, HTN* -Pulmonary: Dyspnea, pleurisy -Skin: *Palpable purpura* Complement levels: Low C4

65yo with PMHx of diabetes c/o sudden loss of vision in his right eye -visual acuity is reduced to light perception in his right eye normal in his left -Ophthalmoscopy: loss of fundus details, floating debris, and dark red glow Dx?

Vitreous hemorrhage -most common cause is diabetic retinopathy

Cavernous hemangiomas of the brain and viscera Most likely associated with which disease?

Von-Hipple-Lindau

How to calculate respiratory compensation?

Winter's formula PacO2 = 1.5*(HCO3)+8 (+/-2)

Pathophysiology and Symptoms of Meniere disease

d/t *defective resorption of endolymph* --> increased volume and pressure of endolymph -Low frequency *tinnitus* -*Episodic vertigo* -*Sensorineural hearing loss*

Treatment of syphilis in pts allergic to penicillin

oral Doxycycline (for early syphilis) If tertiary syphilis: Ceftriaxone