Internal Medicine Shelf - 2

Goal of Hemoglobin A1C levels? Goal of LDL cholesterol in diabetics?

"< 7%" ~ 150 mg/dL. <100 mg/dL

Erythema infectiosum?

"Fifth disease" ..caused by parvovirus infection and typically presents with a "slapped cheek" sign that progresses to a generalized erythematous rash

Classic triad for Aortic Stenosis? Most common cause of aortic stenosis?

"SAD" Syncope Angina Dyspnea Most common cause is 1. age related calcifications 2. Congenital bicuspid valve

Malassezia furfur?

"Sphaghetti and meatballs" pattern on 10% KOH staining Also known as TINEA VERSICOLOR..causes hypo or hyper pigmentation of the skin *Patients complain that they have areas on their skin that never tan*

Distinct characteristic of Seborrheic keratosis?

"Stuck on" appearance Pseudocysts

What statistical tests to rule IN and OUT a disease?

"spIN" "snOUT" A highly specific test, when positive, rules IN a disease A highly sensitive test, when negative, rule OUT a disease

Causes of Hyperprolactinemia?

(decrease dopamine) 1. Meds: TCA, Metoclopramide, Anti-psychotics 2. Primary hypothyroidism (elevated TRH --> stimulates prolactin) 3. Pituitary tumors (prolactin adenoma) **Causes galactorrhea**

What is a blister?

**Hallmark - blister is a small bubble in the skin that results form separation of layers of the skin

Treatment for general heart block/bradycardia? Treatment for B-blocker overdose?

*Atropine / Isoproterenol* Glucagon

TTP-HUS

*Both have consumptive thrombocytopenia and microangiopathic hemolysis* TTP - deficiency or autoantibody against ADAMTS 13 (a metalloproteinase) that usually cleaves large vWF mutlimer into smaller fragments - associated with increased neurological signs - treatment with plasmapheresis HUS - prominent GI symptoms from Shiga toxin-producing enterin bacteria (E.Coli O157:H7) - associated with increased kidney involvement (uremia)

Treatment of choice for DVT?

*General concept - Heparin for prevention and acute management Warfarin for long term prevention of DVT recurrence 1. Heparin for at least 5 days. 2. Warfain should be started at the same time that heparin is administered and the 2 drugs should be overlapped until the INR reaches >2 measured on 2 occasion approx. 24 hours apart.

Best diagnostic test for diffuse parenchymal lung disease (DPLD)?

*High resolution chest CT* --> will reveal honey combing (suggest IPF), ground glass opacities

Paget's disease of the bone?

*Increased Alkaline Phosphatase* Pathogenesis: Imbalance between osteoclast and osteoblasts function OSTEOCLASTS RESORB BONE WITHOUT PERMISSION FROM OSTEOBLASTS --> SO MUCH BONE IS BEING RESORBED THAT OSTEOBLASTS ARE TURNED ON AND START TO BUILD BONE --> OSTEOCLASTS BURNED OUT 3 Stages: 1. Osteoclastic 2. Mixed osteoblastic-osteoclastic 3. Osteoblastic Clinical features: Increasing hat size (skull commonly affected) High output Cardiac Failure (due to shunt formation from bone) Osteosarcoma (malignant tumor of osteoblasts 3rd stage) Pathology: Mosaic pattern of lamellar bone

Who to screen for osteoporosis? How to screen?

*Men >70, Women >65 regardless of risk factors* Corticosteroid therapy for > 3months Primary hyperparathyroidism (resorption of bone) DEXA scan (x-rays) --> extimate mineral content of bone in spine and hip

When to screen for colon cancer? Types of screening tests

*Normal* risk for colon cancer: >50 years - 1 colonoscopy every 10 years *High* risk for colon cancer: >40 years or 10 years before earliest family member = 1 colonoscopy every 3-5 years 1. Colonoscopy 2. Barium enema 3. FOBT - fecal occult blood test

Treatment to restore asthma control in previously well-controlled patients who have developed unstable disease as a result of a URI?

*Short course* of oral corticosteroids

Physical exam tests for disc herniation?

*Straight leg raise* - lift leg 30-70 degrees --> results in electric shock sensation on the affected side *Crossed straight leg raise test* - passively lift unaffected leg --> reproduces pain in the affected leg

Treatment of right sided STEMI?

*Treatment of right sided STEMI includes volume expansion (increased preload) with IV bolus of 0.9% saline, followed by potentially an ionotropic agent like Dobutamine.

CML characteristics?

- 9:22 reciprocal translocation (Philadelphia chromosome)--> results in abnormal tyrosine kinase protein - Granulocytic cells in all phases of development on the peripheral blood. - will eventually transform into acute leukemia - *Splenomegaly is major presenting symptom* - Basophilia - Thrombocytosis: PLT >1,000,000 cells/uL can be seen - Treat w/ Imatinib (tyrosine kinase inhibitor)

ITP

- Autoimmune antibody formation against platelets --> platelet destruction --> removed by splenic macrophages - 3 main causes: in response to a drug, disease, or idiopathic - Often in response to a *viral infection* in children --> self -resolves over 6 months - Increased megakaryocytes on bone marrow biopsy - PLT count is usually <20,000 (pretty low) --> but only mild petechiae and ecchymoses on the skin - Treatment for ITP is corticosteroids; 2nd line IVIG

Characteristics of CLL?

- CD19, CD20+, CD5+ B cell neoplasm (CD5+ is a T lymphocyte antigen - Absolute increase in mature lymphocytes >5,000/uL - Indolent course - Hypogammaglobulinemia --> predisposed to infections with encapsulated organisms - Smudge cells in peripheral blood (flattened lymphocytes) - Autoimmune hemolytic anemia

HIT

- Development of IgG antibodies against heparin bound to platelet factor 4 --> activates platelets --> thrombocytopenia - Mostly occurs with unfractionated heparin --> much lower with LMWH - *Decrease in PLT count by 50% suggests HIT* - *Onset is usually 5-10 days after initiating therapy*; small subset will have a delayed onset a mean of 14 days after heparin exposure* - Some people can have a rapid response of HIT if they have previously been exposed to Heparin **Most important complication of HIT is DVT and PE** - Stop heparin immediately and replace with a direct thrombin inhibitor such as Lepirudin or Argatroban

ALL presentation?

- Mediastinal mass (leukemic infiltration of the thymus) - Very aggressive , increased circulating lymphoblasts - ages <15 years - associated with Downs syndrome

Prinzmetal's angina?

- Transient coronary vasospasm - classically occurs at night - associated with ST elevation - Give *IV ergonovine* (to provoke chest pain) and perform CT angiography - Treatment - Ca2+ channel blockers

AML presentation?

- increased circulating myeloblasts on peripheral smear - DIC is a common presentation secondary to release of Auer rods - age >65 years

**Remember, psychiatric drugs take 2-4 weeks to notice improvement in symptoms**

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ACE I may increase Creatinine up to 33% ...up to 33% is acceptable

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Always consider smoking cessation and ACE I as a cough of cough!

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Always make sure people know how to properly use their inhalers! Make them demonstrate to you!

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Cauda equina vs. Conus medullaris

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Chylothorax?

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Coombs test

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Criteria for Framingham socre / Metabolic syndrome

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Empyema?

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Flow-volume loops?

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Hydropneumothorax

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JAK 2 kinase

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Leukoplakia vs. Candida scraping off?

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Lung volumes?

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No C waves on pulmonary capillary wedge pressure waveform b/c there is no tricuspid valve

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Pneumothorax causes shunt physiology (V/Q = 0) not improved with 100% O2

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Psychiatric drugs

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Schilling test?

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What is the cause of hyperkalemia in DKA?

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What is the troubling Breslow's thickness for melanoma?

0.75 mm - 1mm

Rate of transformation from MGUS to MM correlates with what?

1-2% / year M protein level - the higher the level, the greater the risk

Prevention options for breast cancer?

1. 5 year course with anti estrogen medication (Tamoxifen/raloxifene) 2. Prophylactic mastectomy/oopherectomy

Incidental pulmonary nodule findings?

1. <3 cm 2. no growth in 2 years 3. Central calcification = benign (eccentric calcification = malignant)

Consequences and target organs of sickle cell?

1. Acute chest syndrome (ACS) - MOST COMMON CAUSE OF DEATH --> vaso-occlusive crisis of the pulmonary vasculature due to a lung infection --> exacerbating pulmonary and systemic hypoxemia 2. CNS stroke 3 Avascular necrosis --> involves the hips and shoulders 4. Infection --> related to functional asplenia 5. Splenic sequestration --> Autosplenectomy as a result of splenic infarction --> **Increased risk of infection with encapuslated organisms** 6. Dactylitis - associated with painful swelling of the hands or feet 7. Osteomyelitis --> Salmonella 8. Renal papillary necrosis

Serious 6 chest pain conditions?

1. Acute coronary syndrome (Unstable angin, NSTEMI, STEMI 2. PE 3. Aortic dissection 4. Pericarditis/Pericardial tamponade 5. Pneumothorax 6. Esophageal rupture

2 main types of polyps?

1. Adenomatous (precancerous) --> tubular + villous - Risk of malignancy associated with size and histology type (villous) - Transformation of adenomatous polyps --> CRC via the Adenoma-carcinoma sequence aka. AK 53 1. Loss of tumor suppressor APC gene 2. KRAS mutation 3. Loss of tumor suppressor p53 2. Hyperplastic polyps (benign)

Indications for cardiac catheterization?

1. After a positive stress test* 2. Pt. who is severely symptomatic and urgent diagnosis and management are necessary 3. Determining the need for surgical intervention

Breast cancer screening?

1. Age > 20 --> self breast exams 2. Age 20 - 39 --> breast exam every 3 years 3. Age > 40 --> breast exam annually 4. Age 50-79 --> mammogram every other year

Important diagnostic criteria for lymphadenopathy?

1. Age > 40 associated with 20x more likely malignancy! 2. Acute onset following infection --> reactive lymphadenopathy Subacute onset in a person who smokes --> malignancy 3. Timing - resolves in 2-4 weeks = benign Persistent/Progressive lymphadenopathy = malignant 4. Presence of systemic symtpoms (B symptoms = Hodgkins lymphoma)

1st line treatment against Streptococcal pharyngitis?

1. Amoxicillin/Penicillin 2. Erythromycin

Causes and characteristics of restrictive cardiomyopathy?

1. Amyloidosis (#1 cause) Sarcoidosis Hemochromatosis Delayed diatolic relaxation *Elevated filling pressures*

Causes of abnormal uterine bleeding?

1. Anovulation (most common) - PCOS Pregnancy Polyps, Fibroids Endometrial hyperplasia Endocrine disorders (hyperprolactinemia will cause anovulation; hypothyroidism, Cushings)

Acquired thrombophilia?

1. Antiphospholipid syndrome --> antibody to a protein (B2 glycoprotein) **In vitro --> prolongs aPTT time --> not corrected by mixing study** **In vivo --> predisposes to clots --> strong correlation b/w antiphospholipid syndrome and recurring pregnancy loss** 2. Cancer 3. Pregnancy 4. Smoking

Types of cough medications? Indications for therapy?

1. Antitussive agents 2. Expectorants 3. Mucolytic agents 4. Antihistamines 5. Nasal anticholinergics *treat a cough if sleep disruption, painful cough, debilitating cough*

Prognosis and metastases rate for the 2 different kinds of SCC? Overall point??

1. Arising from actinic keratosis--> recurrence 3-10% Metastasis - 5% 2. Arising in scars, old burns --> Metastais 18-40% **Overall point is that SCC arising from actinic keratosis has better prognosis

Treatment for stable angina?

1. Aspirin (lowers mortality) 2. B-blockers (lowers mortality) 3. Nitrate (relieves preload myocardial oxygen demand)

Mechanisms of cardiac arrhythmias?

1. Automaticity 2. Conduction 3. Reentry circuit 4. Triggered activity (leakage of ions into myocyte)

3 types of bronchodilators used for *stable* COPD?

1. B-agonists (short acting used for acute exacerbations; long acting used for control of chronic symptoms) 2. anticholinergic agents (ipratropium, tiotropium) --> anticholinergics best used when combined with B-agonists and/or theophylline *Do not mix short and long acting anticholinergics* 3. Methylxanthines (theophylline) - phophodiesterase inhibitor --> increased intracellular cAMP *all relax airway smooth muscle*

Treatment of thyroid storms?

1. B-blockers (prevents hyperadrenergic state and also blocks 5' deiodinase 2. Methimazole/PTU 3. Glucocorticoids (to prevent hyperadrenergic state and block peripheral conversion of T4 --> T3

Severity of COPD classification?

1. Based on FEV1 (<80, >50, >30, <30) 2. BODE index" BMI Airflow obstruction Dyspnea Exercise capacity (6 minute walk) **Higher BODE scores associated with increased death

Characteristics of MM?

1. Bone marrow failure (from uncontrolled plasma cell proliferation) 2. Hypogammaglobulinemia --> predisposing to infection w/ encapsulated bacteria (from inadequate levels of normal plasma cells) 3. Hypercalcemia and bone damage (from osteoclast activation (MM releases IL-1) --> increases the risk of fracture 4. Renal tubular injury --> from M protein being filtered through the glomerulus 5. Bence jones protein --> Ig light chains (kappa or lambda) in the urine

What are the 4 myeloproliferative disorders?

1. CML 2. Polycythemia vera 3. Essential thrombocythemia 4. Myelofibrosis **all have increased risk of transofrmaitng to acute leukemia**

Most common phsyical causes of weight loss?

1. Cancer 2. Nonmalignant GI disease (ulcer, malabsorption, dysphagia) 3. Infections, endocrine disorders, chronic disease 4. *Medications* - digoxin, ACE I, SSRIs, anticholinergics 5. Psychiatric - depression, dementia, eating disorders

3 main groups of causes of syncope?

1. Cardiac (arrhythmias, structural heart disease, ischemic heart disease) **Increased mortality** 2. Neurocardiogenic causes - refers to increase parasympathetic tone or decreased sympathetic tone **No increased mortality** 3. Orthostatic hypotension - autonomic dysfunction (diabetic neuropathy), medication effect, hyopvolemia

Treatment of atrial tachycardia, AVRT, AVNRT? (These are all types of SVT, also known as PSVT)

1. Carotid massage 2. Adenosine 3. B-blockers or non-DHP Ca2+ channel blockers

Diagnostic tests to get for evaluation of lung cancer?

1. Chest X-ray 2. CT scan of chest with IV contrast (useful for staging, lymphadenopathy) 3. Cytological exam of sputum 4. Transthoracic needle biopsy 5. Whole body PET (look for metastatic disease)

Most powerful clinical features indicative of MI?

1. Chest pain that radiates to both arms 2. S3 3. Hypotension

Causes of primary amenorrhea? Diagnostic test for primary amenorrhea?

1. Chromosomal disorders - 50% (Turner syndrome) 2. Hypothalamic hypoandrogenism - 20% 3. Other (mullerian agenesis, Androgen insensitivity (testicular feminization), endocrine abnormalities Elevated FSH

Myocaridal O2 demand determined by what 4 factors?

1. Contractility 2. HR 3. Afterload 4. Left ventricular wall stress = preload/myocardial mass

2 main categories of causes of thrombocytopenia?

1. Decreased platelet production - Vitamin B12/Folate defieincy - Bone marrow disorder (aplastic anmeia, MDS, leukemia) - Alcohol (BM toxin) - Infection (HIV, Hep B/C) 2. Increased platelet destruction - ITP - TTP-HUS - HIT - DIC - HELLP

Pericarditis EKG changes? Physical presentation?

1. Diffuse ST segment elevation 2. PR segment depression Pleuritic chest pain and worsened by supine position. Better when leaning forward. At least 2 of the following 3: 1. Pleuritic chest pain 2. *Friction rub* 3. Diffuse ST segment elevation

Screening of prostate cancer? Indications for biopsy?

1. Digital Rectal Examination 2. PSA 3. Transrectal ultrasound with biopsy Screening ages 50-75 Indications for biopsy: 1. Abnormal DRE 2. PSA > 10 3. PSA increasing >0.75 per year

When do you not tap a pleural effusion?

1. Doesn't layer > 10 mm on CXray 2. Bilateral CHF, no fever 3. Asymptomatic with known disease

Diagnosis of lyme disease?

1. ELISA (lots of false positives from other spirochetal diseases) 2. Western Blot confirmation (same as HIV)

Mechanisms for supraventricular arrhythmias?

1. Enhanced automaticity (*cause of atrial tachycardia*) - accelerated generation of action potential, which normally occurs in SA node, but can occur in diseased myocardial tissue 2. Reentry - responsible for most forms of SVT

Treatment for urticaria + angioedema?

1. Epinephrine 2. Anti-histamine 3. Possible corticosteroids Same treatment as in anaphylactic shock

Choice of diagnostic stress test in patients with probably CAD?

1. Exercise ECG --> for patients who can exercise and have NO RESTING ECG ABNORMALITIES. 2. Exercise ECG with myocardial perfusion imaging or exercise ECHO --> for patients who can exercise but have either WPW or > 1 mm ST depression on resting ECG 3. Pharmacologic stress myocardial perfusion imaging or Dobutamine ECHO --> for pts. who cannot exercise

Clinical features of stable angina?

1. Exertional (not present at rest) 2. Relieved with rest or nitroglycerin 3. Lasts less than 10-15 minutes (usually 1-5 minutes) 4. Ischemic pain in general does NOT change with breathing or body position

Inherited colon cancer syndromes?

1. FAP (familial adenomatous polyposis) - Autosomal dominant mutation of APC gene on Chr. 5 - 100% progress to CRC unless colon is resected - Thousands of polyps starting at a young age 2. HNPCC - Autosomal dominant mutation of DNA mismatch repair genes - Increased risk of other cancers (endometrial, ovarian, gastric , pancreatic, etc) 3. Peutz-Jeghers syndrome - Autosomal dominant hamartomatous polyps in children - Pigmentation of the lips

Common causes of hypercoagulable states (GENETIC THROMBOPHILIA)?

1. Factor 5 Leiden mutation (resistant to activated protein C) 2. Prothrombin gene mutation (increased production of prothrombin) 3. Antithrombin deficiency (inherited or acquired --> NEPHROTIC SYNDROME) 4. Protein C/S deficiency 5. Hyper homocystinemia (vit B6, vit B12 , folate acid deficiency) 6. Increased factor 5 & 8 --> leads to activated protein C deficiency

Fibromyalgia?

1. Fatigue 2. Point tenderness 3. Weakness secondary to pain Normal CK, muscle biopsy, ESR

Leading causes of pleural effusions?

1. Heart failure 2. Pneumonia 3. Cancer

What conditions do you see spherocytes?

1. Hereditary spherocytosis 2. Warm antibody mediated hemolysis

Acanthosis nigricans associated with what?

1. Hyperinsulinemia (diabetes, Cushings, obesity) 2. Visceral malignancy (gastric adenocarcinoma)

3 causes of hypercapnia?

1. Increased CO2 production (fever, thyrotoxicosis) 2. Increased dead space (COPD, ARDS, ILD) 3. Decreased ventilation (opiates, neuromuscular disease)

Compensatory mechanisms to maintain oxygen delivery to tissues during anemia?

1. Increased Cardiac output 2. Rightward shift of oxyhemoglobin curve 3. Increased extraction ratio

2 main mechanisms for accumulation of excessive fluid in pleural space?

1. Increased capillary hydrostatic pressure (HF, constrictive pericarditis) 2. Decreased plasma oncotic pressure (cirrhosis, nephrotic syndrome, hypoalbuminemia)

Most common causes of hemoptysis?

1. Infection (bronchitis, pneumonia) 2. Malignancy

Treatment for cyanide poisoning?

1. Inhalation of amyl nitrite 2. IV sodium thiosulfate

Features of a myocardial infarction?

1. Intense substernal chest pressure (crushing / elephant on chest 2. Radiation to neck, jaw, arms, left side 3. More severe and longer duration than angian 4. Dyspnea, diophroesis, Nausea, vomitting, syncope, weakness

How to rule out pneumonia as a cause of acute cough?

1. Lack of vital sign abnormalities 2. Lack of chest X-ray findings (consolidation, infiltrates)

Cause of Sideroblastic anemias?

1. Lead poisoning 2. Pyridoxine deficiency (Vitamin B6 is a cofactor) 3. Alcohol (mitochondrial poisoning) Congenital deficiency in heme synthesis pathway **Find ringed sideroblasts on smear**

Causes of pulmonary hypertension?

1. Left ventricular dysfunction 2. Pulmonary disorders (COPD) 3. Sleep disorders (OSA) 4. Idiopathic 5. Collagen vascular diseases 6. Portal hypertension (hepatopulmonary syndrome)

Examples of acquired coagulopathies (secondary hemostasis disorders)

1. Liver disease 2. Vitamin K deficiency 3. Factor inhibitor 4. DIC

Conditions associated with acquired factor deficiency?

1. Liver disease (synthesized in liver) 2. Vitamin K deficiency

No bleeding after progesterone challenge in secondary amenorrhea means what?

1. Low serum estrogen 2. Anatomic abnormalities that prohibits blood flow (Asherman syndrome)

3 possible antibodies in antiphospholipid syndrome?

1. Lupus anticoagulant 2. Anticardiolipin antibody 3. Anti-B2-glycoprotein 1 antibody

Spirometry?

1. Measures FEV1/FVC (>80% = normal) 2. Measures *PEFR* (peak expiratory flow rate) --> max flow rate generated by pt. If spirometry suggests obstructive disease, --> repeat spirometry following inhalation of bronchodilator ....if increase in FEV1% >12% --> asthma!! (reversible) If a lack of response to bronchodilator --> COPD!!

2 main molecular pathways that lead to CRC?

1. Microsatellite instability pathway (~15%) - DNA mismatch repair gene mutations - HNPCC syndrome 2. APC - carcinoma sequence - loss of APC - KRAS mutation - loss of p53

When to biopsy lymph node?

1. Multiple risk factors for malignancy 2. >4 weeks persisting

Smoking cessation options?

1. Nicotine replacement (contraindicated in recent MI, unstable angina) 2. Buproprion 3. Vanenicline (nicotinic agonist --> works the best)

Smoking cessation pharmacologic options?

1. Nicotine replacement (gum, patch, tablet, etc. ) 2. Buproprion 3. Vareniciline (best)

Treatment for Acromegaly?

1. Octreotide (somatostatin analog, also known as Growth hormone inhibiting hormone) 2. Pegvisomant (Growth hormone refractory antagonist --> for refractory cases)

Types of ventricular arrhythmias?

1. PVC 2. Ventricular tachycardia --> often due to prior structural heart disease --> caused by a reentrant pathway. WIDE QRS 3. Ventricular fibrillation --> lack of organized ventricular activity --> sudden death

Unstable angina?

1. Patients w/ chornic angina with incresaing frequency, duration, intensity 2. Patients with new onset angina that is severe/worsening 3. Paitents with angina at rest

Causes of Vitamin B12 deficiency?

1. Pernicious anemia (most common in Western world) 2. Gastrectomy 3. Chrons disease + ileal resection 4. Fish tapeworm 5. Poor diet (vegetarian) 5. Alcohol

Diagnostic test for Coronary Artery Disease CAD?

1. Physical exam (usually normal) 2. Resting ECG - subendocardial ischemia --> ST segment depression (best initial test for all forms of chest pain) 3. Stress test a. Stress ECG (to 85% of maximal heart rate for age) b. Stress ECHO (if preexisting ECG abnormality ) --> LV size and function, ischemia, valvular disease c. Stress perfusion imaging with IV radioisotope Thallium 201 during exercise 4. Pharmacologic stress test (if pt. cannot exercise) a. IV adenosine (Coronary steel phenomenon) b. IV dipyridamole (Coronary steel phenomenon) c. IV dobutamine (increase myocardial oxygen demand by increasing HR, contractility) 5. Holter monitoring (ambulatory ECG) --useful for silent iscehmia (ECG symptoms not accompanied by symptoms) 6. Cardiac catheritization with coronary angiography (definitive test for CAD)

3 stages of mycosis fungoides?

1. Plaque stage 2. Patch stage 3. Tumor stage

Causes of secondary amenorrhea? Diagnostic test?

1. Pregnancy (most common) 2. Premature ovarian failure (chemotherapy, radiation, surgical oopherectomy) 3. PCOS 4. Hyperprolactinemia 5. Chronic anovulation (from long term oral contraceptive use) 6. Thyroid irregularities Elevated FSH

Contraindications to thrombolytic therapy?

1. Prior intracerebral hemorrhage 2. Ischemic stroke within 3 months 3. Active bleeding 4. Known cerebrovascular lesions (AVM)

Physical findings of Mitral stenosis?

1. Prominent a wave in the jugular pulse (decreased right ventricular compliance with pulmonary hypertension) 2. Signs of right sided heart failure (JVD, edema, hepatomegaly) 3. Right ventricular heave 4. Palpable thrill at the apex

Colon cancer symptoms/signs?

1. Right sided - iron deficiency anemia 2. Left sided - obstruction 3. "Apple core" lesion on barium enema 4. Pencil thin stools 5. Hematochezia (bright red blood) 6. Colicky pain 6. Partial obstruction

Complications of Obstructive sleep apnea?

1. Secondary polycythemia 2. Secondary HTN due to peripheral vasoconstriction from sympathetic discharge 3. Heart failure, stroke, decreased LV compliance, increased RV/LV afterload

Most predictive factors of COPD?

1. Self reported h/o COPD 2. >40 pack-year smoking history 3. age >45 yrs. 4. Maximum laryngeal height <4 cm

4 common Pulmonary Function tests?

1. Spirometry - 2. Lung volumes - increased lung volume --> obstructive disease; decreased lung volume --> restrictive disease 3. Flow-volume loops 4. Diffusing capacity for CO

Drugs to discharge MI patient on?

1. Statin 2. ACE I 3. B-blocker 4. Aspirin 5. Eplerenon (if EF < 40%)

Treatment for acute COPD exacerbation?

1. Supplemental O2 2. IV/oral corticosteroids 3. Short acting B-agonist 4. *ANTIBIOTICS* (levofloxacin monotherapy or Ceftriaxone/macrolide)

How to evaluate secondary amenorrhea?

1. TSH, FSH, prolactin to r/o thyroid disease, ovarian failure, and hyperprolactinemia 2. If normal, try progestin challenge to assess estrogen levels and anatomic abnormalities

Regulatory mechanisms of the clotting cascade?

1. Thrombin (factor 2) bound to thrombomodulin activates protein C --> resulting in degradation of factors 5 and 8 (this is a way that the clotting cascade regulates itself) 2. Antithrombin is a major regulatory protein of the coagulation cascade --> irreversibly binds and neutralizes activated factors 2,9, and 10.

Causes of prolonged bleeding time?

1. Thromboyctopenia 2. Platelet dysfunction (Bernard-Soulier, Glanzmanns thrombocytopenia) 3. von Willenbrand disease

Acute coronary syndrome encompasses what?

1. Unstable angina (nonocclusive thrombus)` 2. NSTEMI (nonocclusive thormbus) 3. STEM (occlusive thrombus)

Causes of chronic cough (>8 weeks)? Treatment?

1. Upper airway cough syndrome (post nasal drip) --> antihistamine + decongestant 2. Asthma 3. GERD - trial of PPI; followed by 24 hr. esophageal pH monitoring if still not confirmed 4. Nonasthmatic eosinophilic bronchitis - inhaled steroids and avoidance of allergens **Usually more than 1 cause in a patient's chronic cough**

Examples of neurocardiogenic syncope causes?

1. Vasovagal syncope (most common) --> occurs due to sudden vasodilation and bradycardia with hypotension and cerebral hypoperfusion (micturition, defecation, cough , fear, phlebotomy) 2. Carotid sinus hypersensitivity - cardiac reflex provoked by placing direct pressure on the carotid sinus, such as a TIGHT SHIRT COLLAR. (syncope with shaving or turning head to one side)

3 risk factors for VTE?

1. Venous stasis 2. Hypercoaguability 3. Enothelial damage *also consider =: estrogen therapy postpartum state pregnancy cancer

Most common cause of acute cough (<3 weeks)?

1. Viral URI 2. Bronchitis (mycloplasma, chlamydophila, bordatella pertussis) 3. Pneumonia (most serious) 4. Asthma

Left bundle branch block ECG? Right bundle branch block ECG?

1. Wide QRS (>120 msec) 2. Loss of Q waves in leads V5, V6 3. Wide R waves in lateral leads I, V5, V6 1. Wide QRS (>120 msec) 2. rSR in V1 3. Wide negative S wave in lateral leads I, V5, V6

Risk factors for complicated acute asthma exacerbation?

1. history of intubation, ICU admisstion 2. B-agonist dispensing frequency exceeding one cannister/month 3. poor adherence to inhaled corticosteroids 4. h/o depression, substance abuse, personality disorder

Most common causes of low back pain?

1. nonspecific MSK pain- radiates along the back in a *belt-like fashion* 2. Disc herniation - radicular pain down leg 3. Spinal stenosis - neuroclaudication pain

Pleural fluid evaluation?

1. pH (normal pleural fluid pH 7.6 - 7.66) 2. glucose 3. LDH 4. protein 5. bacterial/acid fast bacilli in stains 6. leukocyte count

Risk factors for lung cancer?

1. smoking 2. Second hand smoke 3. Asbestos 4. Radon 5. COPD

3 major treatment strategies for prostate cancer?

1. surgery 2. radiation 3. active surveillance

Normal A-a gradient?

10-15 mmHg ANything that increases the diffusion barrier b/w alveoli and capillaries (shunting, V/Q mismatch, fibrosis)

Treatment for an acute asthma attack?

100% oxygen Albuterol (B2- agonist) Ipratropium (Muscarinic antagonist) Oral corticosteroids

Normal levels of AAT?

150-350 Causes Panacinar emphysema (vs. smoking --> centriacinar emphysema)

1st, 2nd, 3rd degree AV block?

1st degree AV block - prolonged PR interval >200 msec 2nd degree AV block TYpe 1 - Wenckebach - progressive prolongation of the PR interval until there is a dropped beat --> secondary to a block at the AV node 2nd degree AV block TYpe 2 - dropped ventricular beat without antecendant PR prolongation. COnduction block usually within the ventricular conduction system (infranodal). Accompanied by widened QRS....TYpically proceeds to 3rd degree heart block 3rd degree AV block - Atria and ventricles beat independently of each other. Conduction defect at AV node or infranodal (more common)

Treatment for stage 2 hypertension?

2 drug therapy (HCTZ + Lisinopril)

How to diagnose hyperlipidemia?

2 measures of LDL cholesterol at least 1 week apart.

HPV vaccines?

2 types: Cervarix - bivalent vaccine against HPV 16, 18 Gardasil - quadravalent vaccine against HPV 6, 11, 16, 18 For women ages 9 - 26

What clotting factors require Vitamin K for activation?

2,7,9,10, protein C, protein S (are all activated by vitamin K in the LIVER)

Mechanical complications after MI?

2-7 days post MI 1. Papillary muscle rupture --> S3 (acute mitral regurgitaiton) 2. VSD (palpable thrill) 3. Free wall rupture --> cardiac tamponade (hypotension, pulseless electrical activity)

Cardiac symptoms of Lyme disease?

2nd or 3rd degree heart AV block Myocarditis

Cervical cancer screening in women >30?

3 consecutive normal pap smears --> pap smear every 3 years

Treatment of Atrial fibrillation?

3 principles: 1. Rate control (B-blockers / non DHP Ca2+ CB 2. Rhythm control (anti arrhythmic) 3. Stroke prevention **If patient is hemodynamically unstable --> direct cardioversion

When does LH surge occur?

36 hours BEFORE ovulation

What is the risk of developing invasive SCC from SCC in situ?

5%

Cardiac disease + syncope ....mortality rate? Neurocardiogenic syncope mortality rate?

50% mortality rate in 5 years!! No increased mortality rate for neurocardiogenic causes

Treatment / prognosis of acute low back pain ?

90% are self-limited Early mobilization is most beneficial Bed rest NOT effective First line meds: Acetaminophen or NSAIDs Second line meds: muscle relaxant , opioid analgesics muscle relaxants and opioid analgesics are NOT more effective than NSAIDs

Goal of LDL?

< 100 for chronic stable angina < 70 for chronic stable angina + increased risk for CAD

At what level of thrombocytopenia is bleeding time affected? When does spontaneous bleeding occur?

<100,000 --> bleeding time is affected but not until PLT 10,000 - 20,000 --> spontaneous bleeding

PCI most effective within what time period?

<12 hours from chest pain

Depression diagnosis?

> 2 weeks of anhedonia and/or depressed mood 5 total symptoms of SIGECAPS Sleep changes Interest (anhedonia) Guilt (hopelessness) Energy (decreased) Concentration (decreased) Appetite changes Psychomotor agitation Suicidal thoughts

What pressure constitutes pulmonary HTN?

> 25 mm Hg at rest >30 mm Hg at exercise

Gestational hypertension? Preeclampsia?

>140/90 at greater than 20 weeks in a previously normotensive woman HTN + proteinuria + edema

Involuntary weight loss?

>5% of total body weight over 6 months > 10% of total body weight over 1 year

When you find a mole, how should it be assessed?

A - Asymmetry B - borders (irregular) C - color (change in color) D - diameter (>6 mm)

Where does A fib originate? A flutter?

A fib = pulmonary veins in the left atrium A flutter = reentrant circuit that rotates around the tricuspid annulus (right atrium)

Parapneumonic effusion?

A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis. There are 3 types of parapneumonic effusions: 1. uncomplicated effusions --> ABX treatment alone 2. complicated effusions --> chest tube drainage 3. empyema --> ABX + drainage + reexpansion of lung Uncomplicated effusions generally respond well to appropriate antibiotic treatment. The criteria for a complicated parapneumonic effusion include the presence of pus or Gram stain-positive pleural fluid or a pleural fluid pH <7.0. Appropriate management includes chest tube drainage (tube thoracostomy). Treatment of empyemas includes antibiotics, complete pleural fluid drainage, and reexpansion of the lung.

What drug to place a diabetic with microalbuminuria?

ACE inhibitor

What leukemia is associated with Downs syndrome?

ALL

Therapy for Heart Failure by NYHA classifications?

ALL PATIENTS: ACE I B-blocker Stage 3/4: - Spironolactone/Eplerenone - Combined hydralazine/isosrobide dinitrate (African American patients) - Digoxin (reduces hospitalizations - Diuretics (to maintain evolemia) **DO NOT use CCBs --> only Amlodipine/Felodipine can be used if necessary

Mnemonic for Lymphadenopathy?

ALLSTAGES Age (<>40 years) Location (Cervical, axillary vs. Supraclavicular, mediastinal( Length of time present (< 2 weeks vs. > 4 weeks) Size (<>2 cm) Texture (mobile vs. fixed) Associated signs Generalized vs. Localized Extranodal associations Setting (recent infection)

AVRT? AVNRT?

AVRT - Accessory pathway b/w atria and ventricles not located within the AV node (also known as WPW). AVNRT - both pathways of reentrant circuit within the AV node

Which layer is affected in pemphigus vulgaris?

Ab against desmosomes in the stratum spinosum layer

Metabolic syndrome?

Abdominal obesity Low HDL Elevated triglycerides HTN Fasting blood sugar >110

DLCO measures what?

Ability of the lungs to transfer gas from alveoli to the RBC in pulmonary capillaries. It is low in conditions characterized by barriers to diffusion (interstitial edema, interstitial infiltrates, tissue fibrosis) or loss of lung tissue (emphysema)

Dyskeratosis?

Abnormal keratinization generally in the prickle cell layer (stratum spinosum)

Where do you perform thoracocentesis?

Above the 9th rib in midaxillary line

Acantholysis? Can help to distinguish what immunological blistering diseases

Acantholysis is the loss of intercellular connections, such as desmosomes, resulting in loss of cohesion between keratinocytes, seen in diseases such as pemphigus vulgaris. It is absent in bullous pemphigoid, making it useful for differential diagnosis.

Common characteristics of wart pathology?

Acanthosis Papillomatosis Hypergranulosis Hyperkeratosis Focal Parakeratosis Koilocytes Viral particles inside the nucleus

Infection in Acne and Rosacea?

Acne --> P. acnes Rosacea --> P. acnes & Demodex

Primary presentation of an inflammatory myopathy? Distinguishing feature?

Acquired muscle weakness Skin involvement in dermatomyositis vs. polymyositis

Risk of malignancy for acquired nevi vs. congenital nevi?

Acquired nevi --> Increased size correlated with increased risk of melanoma Congenital nevi --> Increased numbers increase risk of melanoma

Precursor to SCC?

Actinic keratoses

Use 5-Fu to treat what?

Actinic keratoses superficial BCC

Difference b/w actinic keratosis and seborrheic keratosis?

Actinic keratosis has an erythematous base

Functions of protein C and S ? Protein C and S deficiency?

Activated protein C --> inactivates Factor 5a and 8a Can't inactivate factors 5a and 8a --> results in increased coagulation **Skin and Subcutaneous necrosis after WARFARIN administration** --> think protein C deficiency

Complement levels in active and quiescent SLE?

Active states --> low complement (C3, C4) Quiescent states --> normal levels of complement

Most common causative organisms of native valve infective endocarditis? Subacute endocarditis? Prosthetic valve endocarditis?

Acute = Staph aureus Subacute = Strep viridans Prosthetic valve = staph epidermidis (coagulase negative)

Murphy's sign?

Acute cholecystitis - examiner palpates gallbladder beneath the liver edge, asks the patient to inhale, and obseves an arrest of inhalation as the patient experiences increased discomfort

Elevated triglycerides can cause what?

Acute pancreatitis

Acute vs. Chronic gout treatment?

Acute: 1. NSAIDs 2. Corticosteroids (for those not reactive to NSAIDs) Chronic: 1. Allopurinol 2. Colchicine

Smoking association with lung cancer?

Adenocarcinoma - lowest association with smoking

Why can babies have acne?

Adrenal androgens from mother

When to do a sentinel LN biopsy of melanoma?

After surgical excision, if lesion thickness *> 1mm*.

Risk factors used for cholesterol guidelines?

Age Heart disease Diabetes Hypertension Smoking

Indications for pneumococcal vaccine?

Age > 65 years Diabetes (immunocompromised - cell mediated immunity and vascular impariment of diabetes) Health care worker Heart disease

Clinical prediction rule for CANCER as a cause of involuntary weight lss?

Age > 80 y = +1 point Serum albumin > 3.5 = - 2 points WBC count > 12 K = + 1 point Serum alk phos > 300 = +2 points Serum LDH > 500 = +3 points Score of < 0 = low probability for malignancy Score of 0-1 =intermediate probability for cancer Score of >1 = high probability for cancer

Short acting B-agonists? Long acting B-agonists? Anticholinergics?

Albuterol, levalbuterol Salmeterol Ipratropium (short acting); tiotropium (long acting) --> blocks the M3 muscarinic receptor

Rosacea is most commonly triggered by?

Alcohol

Treatment for a solid breast mass?

All patients must get triple evaluation for a breast mass: 1. Palpatiion 2. Mammography with or without ultrasound 3. Aspiration (cyst) or biopsy (solid)

Who gets Herpes Zoster vaccination?

All pts older than 60 unless contraindications (active TB), regardless of previous shingles disease. Prevents herpes zoster and postherpetic neuralgia

Triad of atopic dermatitis?

Allergic rhinitis Atopic Dermatitis Asthma

Genetic cause of COPD?

Alpha 1 anti-trypsin deficiency (neutralizes neutrophil elastase which is responsible for breaking down elastin

Postmenopausal bleeding?

Always requires endometrial evaluation with ultrasound AND biposy R/o endometrial carcinoma

Abx. Treatment for diabetic foot ulcer?

Always think Pseudomonas in a diabetic patient Treatment for pseudomonas is Zosyn + Vancomycin

Immunosuppressed pt. with sinus symptoms...diagnosis?

Always think fungal sinusitis in an immunosuppressed pt Amphotericin B is treatment

Drugs that can cause pulmonary toxicity?

Amiodarone Bleomycin Busulfan Methotrexate

1st line treatment of lyme disease?

Amoxicillin Doxycycline

Treatment for Cryptococcus neoformans (india ink stain)?

Amphotericin B

Kussmaul sign? Indicative of what?

An absence of jugular vein collapse on inspiration. Sign of impaired right sided heart filling (right sided heart failure)

Diagnosis of asthma?

An increase in FEV1 of 12% with a minimum increase of*200 mL in FEV1* *after bronchodilator* establishes the presence of airflow reversibility Best test to rule OUT asthma is a methalcholine challenge...if that is negative, then the person does not have asthma

How are hemidesmosomes attached to lamina densa? How is lamina densa attached to dermis?

Anchoring filaments Anchoring fibrils

Pathophys of acne? What are the enzymes produced by sebaceous gland?

Androgen synthesis in sebacous gland and follicular keratinocytes 3B and 17B hydroxysteroid dehydrogenase 5 alpha reductase

Medical conditions associated with depression?

Anemia B12 deficiency Hypothyroidism Post MI Post stroke B-blocker medications

Immediate drug reactions? Delayed drug reactions?

Angioedema Urticaria Anaphylaxis Exanthems Fixed drug eruption Systemic reactions

Anisocytosis, poikilocytosis?

Anisocytosis - heterogenous RBC size Poikilocytosis - heterogenous RBC shape

Prevention of viral influenza?

Annual immunization is the preferred strategy to prevent infection. Chemoprophylaxis should be restricted to: Residents in ALF High risk for influenza complications Health care workers with close contacts with influenza

Types of configuration

Annular Polycyclic Reticulate Targetoid Clustered Configuration

Cryptogenic organizing pneumonia?

Antecendant flu-like illness ...areas of consolidation that migrate from one location to another. Also known as Broncholitis obliterans --> subacute disease progression with bilateral alveolar opacities A non-reversible obstructive lung disease in which the bronchioles (small airway branches) are compressed and narrowed by fibrosis (scar tissue) and/or inflammation.[4]

Flattening of the deltoid?

Anterior humerus dislocation Axillary nerve injured --> motor innervation to deltoid sensory innervation to lateral arm

Key parts of inflammatory myopathy diagnosis?

Anti-Jo 1 antibody Elevated CK Positive ANA MUSCLE BIOPSY!!!

Serology markers for Mixed Connective Tissue Disease? How would they present?

Anti-RNP ab Myositis (an inflammatory myopathy that causes muscle weakness) , Raynaud's

Subacute cutaneous lupus associated with what antibodies? What drugs can cause this SCCL?

Anti-Ro antibodies HCTZ, Ca2+ channel blockers

Livedo Reticularis associated with what?

Anti-phospholipid syndrome (LUPUS)

Treatment for urinary incontinence?

Anticholinergics like oxybutynin or Tolterodine

What antibody is most specific for drug - induced lupus?

Antihistone antibodies

Positive FOBT...next step?

Any patient with a positive fecal occult blood test gets a colonoscopy

Pulse pressure in aortic stenosis vs. aortic regurgitation?

Aortic stenosis - narrow pulse pressure Aortic regurgitation - widened pulse pressure

Treatment for aortic stenosis?

Aortic valve replacement if valve area <1.0 cm^2

Besides valve replacements, medical treatment for valvular diseases?

Aortic/Mitral regurgitation: Nitroprussides (decrease preload), Ionotropic agents (dobutamine --> increased HR will decrease regurgiation time) Mitral stenosis: Beta blocker or CCB - increased diastolic filling time

How do the plaques appear in sarcoidosis?

Apple Jelly appearcance plaques located in old scars

How to diagnose CO poisoning?

Arterial blood gases w/ carboxyhemoglobin and methemoglobin

3 manifestations of late Lyme disease?

Arthritis Neurological disease (facial palsy) Carditis (heart block)

Round pneumonic lesion in a *PREEXISTANT* lung cavity...diagnosis?

Aspergilloma

Chronic stable angina medication regimen? 1st line therapy for chornic stable angina?

Aspirin B blocker Nitrate Statin *B-blocker * use CCB for those unsable to take B-blocker 1. reactive airway disease 2. bradycardia 3. decompensated heart failure

Patient with NSTEMI treatment?

Aspirin, IV nitro, LMWH, clopidogrel, statin + BETA-BLOCKER

What does Excedrin contain?

Aspirin/Acetaminophin/Caffeine

3 most common causes of cough?

Asthma GERD Post nasal drip (chronic sinusitis)

Premature ventricular contraction?

Asymptomatic

Young child comes in with intense pruritis since the age of 1 It has expanded to the flexure fold of extremeties..diagnosis?

Atopic Dermatitis

Chronic contact dermatitis on biopsy looks like what?

Atopic dermatitis

Triad of atopic dermatitis?

Atopic dermatitis Allergic rhinitis Asthma Associated with flexure surfaces Itching causes scaling and lichenification (excoriated and thickening of the lesions)

IL-31 is associated with what?

Atopic dermatitis severity

Treatment of a human bite?

Augmentin (Amoxicillin/Clavulanate

Vitiligo?

Autoimmune destruction of melanocytes b/w the ages of 20 - 30

Causes of extrinsic hemolytic anemia?

Autoimmune hemolytic anemia (warm vs. cold agglutinin) 2. Microangiopathic anemia (DIC, TTP (deficiency of ADAM13), HUS (EHEC 0157:H7) 3. Macroangiopathic anemia ( prosthetic heart valves, aortic stenosis) 4. Infections (malaria, Babesia)

Disgnosis of HTN?

Average of at least 2 measurements on two different office visits May use 24 hour ambulatory BP monitoring

Medications that can provoke asthma?

B-blockers

Description of BCC and SCC?

BCC - pink, pearly, dome shaped papule with telangiectasias **skin lesion that spontaneously bleeds** with palisading nuclei on pathology SCC - Firm keratotoic macule or patch; crater-like

BCC vs. SCC course?

BCC - slow growth with potential for destruction of local tissue along the nerves to penetrate into CNS if not treated SCC - good prognosis if treated early, but can metastasize *Both have good prognosis if treated*

Which is most common? BCC or SCC

BCC is most common skin cancer SCC is 2nd most common skin cancer

Prognosis for SCC, BCC, and melanoma?

BCC, SCC excellent prognosis Melanoma - most common cause of death from skin cancer

Prostate adenocarcinoma vs. BPH

BPH : smooth nodular enlargment of central and transitional zones Prostate adenocarcinoma: hard, firm nodular enlargment of peripheral zones. Starts in peripheral zones and move centrally --> THUS obstructive urethra symptoms are late

Cause of Bacilliary angiomatosis? Treatment?

Bartonella Henseleae Erythromycin / doxycycline

Skin tumor on the eyelid with loss of eyebrows?

Basal cell carcinoma is the most common tumor of the eyelid

Interface dermatitis? 2 big characterstics with interface dermatitis?

Basal cell vacuolization (hydropic degeneration) + keratinocyte apoptosis 1. Apoptosis 2. Hydropic degeneration **Around the DE junction

Best approach for smoking cessation?

Behavioral couseling + medications

Erythema toxicum neonatorum?

Benign neonatal rash characterized by blanching erythematous papules and/or pustules. It resolves spontaneously within 2 weeks of birth

Strawberry vs. Cherry hemangiomas?

Benign vascular tumors Strawberry hemangiomas - in kids, grow quickly during first 2 years, then regress spontaneously over time Cherry hemangioma - in adults, do not regress over time

Treatment for exercise induced asthma?

Beta agonists 20 minutes before exercise

Medications to hold prior to cardiac stress testing?

Beta blockers, Calcium channel blockers, nitrates

Causes of cellulitis? Treatment of cellulitis?

Beta hemolytic strep or Staph Aureus Nafcillin or Cefazolin

How does erythema nodosum present?

Bilateral , very tender nodules; NODULES DO NOT ULCER

What patients have increases in creatinine after an ACE I?

Bilateral Renal artery stenosis

For Heart Failure patients: Who is referred for biventricular pacing? Who is referred for implantable cardioverter/defibrillator?

Biventricular pacing - NYHA class 3/4 EF < 35% prolonged QRS > 120 msec Implantable cardioverter/defibrillator - NYHA class 2/3 already on optimal medical therapy + life expectancy > 1 yr.

Herpes encephalitis features?

Bizarre behavior, hypersexuality, fever, aseptic CSF findings

What is a blister?

Blister is a non medical term that represents a fluid filled lesion There are 2 types of blisters: Vesicle (<1.0 c) and Bulla (>1.0 cm)

Porphyria cutanea tarda?

Blistering cutaneous photosensitivity Associated with Hep C infection and can be triggered by ingesting estrogens (OCP)

What does the dermis contain?

Blood vessels Connective tissue Hair shafts Sweat glands Sebaceous glands

Length of time to cause B12 or folate deficiency?

Body has large stores of Vitamin B12, so it takes a long time to get a deficiency) Body has small stores of Folate, so deficnecy can arise after only months

What is the difference between SJS and TEN?

Body surface area: TEN > SJS

Causes of acute bronchitis causing cough?

Bordatella pertussis Mycoplasms pneumonia Chlamydophila pnemoniea **Antibiotic treatment recommended if clinically suspecting bordatella pertussis** Otherwise, symptomatic treatment for acute bronchitis

Hypersensitivity pneumonitis? Pneumoconioses?

Both *Restrictive* lung disease Hypersensitivity pneumonitis - Mixed type III/IV hypersensitivity reaction to environmental antigen (farmers, birds) Pneumoconioses - Anthracosis, silicosis, asbestosis

Relationship between furuncle and cellulitis?

Both are caused by S. Aureus organisms Furuncle --> may progress into Cellulitis

Somogyi effect vs. Dawn phenomenon

Both cause hyperglycemia in the morning in Diabetics *Dawn phenomenon*: Release of Growth hormone, coritsol, catecholamines in the early morning --> hyperglycemia ; in normal patients, insulin would be released to control this hyperglycemia, but in diabetics, its not able to control the sugars *Somogyi effect*: Nocturnal hypoglycemia --> causes release of Growth hormone, coritsol, catecholamines --> a rebound hyperglycemia

How to distinguish Vitamin b12 and folate deficiency?

Both cause macrocytic anemia and elevated homocystiene levels Vitamin B12 has elevated methylmalonic acid Vitamin B12 has neurological symptoms Vitamin B12 comes from animal meat Folate comes from green vegetables

How are bullous impetigo and SSSS related?

Both caused by S. Aureus mediated exfoliative toxins but impetigo is a localized reaction, SSSS is a systemic reaction

Small cell lung cancer vs. Squamous cell lung cancer treatment?

Both: Central lesions (vs. peripheral), strongly associated with Smoking SCLC - treated with chemotherapy + radiation SCC - treated with surgical excision

What medical conditions to routinely screen for?

Breast, colon, cervical cancer (mammogram, colonoscopy, HPV testing) Obesity Depression Fall risk AAA (for men aged 65-75 who have ever smoked) Dyslipidemia Osteoporosis (all women >65 years) Type 2 diabetes (all adults >45 years once every 3 years) STDs (all women <25 years old for Chlamydia to prevent PID) HIV (voluntary ages 13-64) Hypertension Immunizations (tDAP, MMR, HPV, Hep A/B, Varicella, Zoster) Influenza (vaccine to everyone >6 months) Pneumococcal vaccine (all adults >65 y, and anyone with risk factors; revaccinate if now >65 years and received pneumococcal <65)) Meningococcal immunization (young adults living in dormitories or with splenectomy)

What is the most important prognostic factor for survival and management in melanoma?

Breslow tumor thickness

How should you perform a history and physical in the skin exam?

Brief history --> then detailed physical exam --> then you can go back and do more history

Effect of cigarette smoking on lungs?

Bronchial mucous gland hypertrophy Goblet cell metaplasia Inflammatory cell infiltrates Squamous epithelial metaplasia Ciliary loss/dysfunction Increased proliferation of smooth muscle

Bronchiectasis? Causes?

Bronchiectasis - chronic necrotizing infection of bronchi --> permanently dilated airways, purulent sputum (smoking, cystic fibrosis, kartagener syndrome)

Drugs to help stop smoking?

Buproprion (Wellbutrin) --> Nicotinic receptor antagonist Varenicline (Chantix) --> Nicotinic receptor partial agonist

What does Fioricet contain?

Butalbital/Acetaminophen/Caffeine

Hereditary angioneurotic edema?

C1 esterase inhibitor deficiency Autosomal dominant

CHD risk equivalents?

CAD AAA PAD

Best first test for lymphadenopathy?

CBC Atypical monocytosis - EBV infection Anemia, thrombocytopenia - Connective tissue disease Blast cells - malignancy

Best forms of psychotherapy?

CBT - recognizing unhelpful patterns of thinking and reacting that lead to emotional distress Interpersonal therapy Problem-solving therapy

Main effector cells in Contact Dermatitis?

CD8+ cells

What causes spongiosis? What fills the space caused by spongiosis?

CD8+ mediated injury Because there is space between cells, inflammatory cells are often present

Risk score used to predict likelihood of stroke in patients with Atrial fibrillation? Treatment indications

CHADS2 score CHF Hypertension Age > 75 years Diabetes Prior Stroke (2 points) 0 score - no therapy or aspirin 1 score - aspirin or warfarin 2+ score - warfarin

Differential diagnosis for lymphadenopathy?

CHICAGO Cancer Hypersensitivity (drug reaction, vaccine reaction) Infection Connective tissue disease (SLE, RA, Sjogrens) Atypical lymphoproliferative disorder Granulomatous disease (Sarcoidosis, Silicosis, Berylliosis) Other

Chemotherapy combination for Hodgkin's lymphoma?

CHOP Cyclophosphamide Doxorubicin Oncovin (Vincristine) Prednisone

Causes of secondary HTN?

CKD Renovascular disease Hypercalcemia Hyperthyroidism Primary hyperaldosteronism Cushings Pheochromcytoma Obstructive sleep apnea Drug induced HTN

Definition of CKD? Stages of Chronic kidney disease (CKD)?

CKD defined as GFR < 60 or kidney damage persisting > 3 months Stage 1 - GFR > 90 Stage 2 - GFR 60 - 89 Stage 3 - GFR 30 - 59 Stage 4 - GFR 15 - 29 Stage 5 - GFR < 15 kidney failure

Most common leukemia in adults?

CLL

COPD is reversible or not reversible?

COPD is not fully reversible** this is a big distinguisher from asthma

COX 1 and COX 2 expression?

COX -1 constituively expressed COX -2 expression inducible in areas of inflammation

Where best to measure pallor?

COnjunctiva

1st line test for diagnosis of PE?

CT Pulmonary angiography (same thing as a VQ scan) also consider: 1. Doppler ultrasound of legs 2. D-dimer test of blood

Test of choice for diagnosis of pulmonary embolism?

CT pulmonary angiography

Best test for diagnosis of acute PE?

CT pulmonary angiography (if no kidney disease --> contrast) Ventilation/perfusion scan (if kidney disease) - *a negative V/Q scan is only test to definitively rule out a PE

Treatment of pulmonary HTN?

Ca2+ channel blockers Endothelin antagonists Anticoagulate w/ coumadin

What finding can you see exclusively in juvenile dermatomyositis?

Calcinosis

Cervical cancer invasion?

Can invade laterally, blocking the ureters, causing hydroureter and renal failure

Absolute contraindication to transplant?

Cancer

Cardiac tamponade? Associated with what characteristic findings

Cardiac tamponade, also known as pericardial tamponade, is an *acute type of pericardial effusion* in which fluid accumulates in the pericardium (the sac in which the heart is enclosed). Beck's triad: 1. JVD 2. Hypotension 3. Muffled heart sounds Pulsus Paradoxus - drop in systolic BP > 10 mmHg on inspiration

Chest X-ray findings of heart failure?

Cardiomegaly Pulmonary vascular congestion Kerley B-lines Pleural effusions

What medical conditions TO NOT routinely screen for?

Carotid artery stenosis Coronary artery disease in low risk pt. Testicular cancer Ovarian cancer Hypothyroidism Glaucoma Skin cancer

Phalen's sign / Tinel's sign?

Carpal tunnel syndrome Tinel's sign - tapping of the compressed median nerve reproduces pain Phalen's sign - Forced wrist flexion for 60 seconds reproduces symptoms

Lymphogranuloma venerieum (LGV)?

Caused by Chlamydia 3 stages: 1 - painLESS herpetiform ulceratoin 2 - painFUL unilateral inguinal lymphadenitis, presents at fluctuant buboes 3 - Elephantiasis

Scarlet fever rash?

Caused by exotoxins released from Strep. Pyogenes Rash is a fine-sand paper like rash over the upper body

If you see a linear blister, what should you be thinking?

Caused from the outside world Contact dermatitis

Cellulitis vs. Erysipelas?

Cellulitis - Strep pyogenes or Staph. aureus - flat border Erysipelas - Strep. pyogenes - sharply demarcated and raised edges

What infections are potentially dangerous in diabetics?

Cellulitis of the limbs, especially lower extremities, can cause amputations.

2 kinds of panniculitis?

Centered in the septate and does not involve the lobule - SEPTAL PANNICULITIS --> DOES NOT ULCERATE Entire lobule + septum = LOBULAR PANNICULITIS --> ULCERATES

What receptors sense changes in pCO2 and pO2?

Central/Peripheral chemoreceptors

Secondary syphilis rash?

Characteristically papular and involves *palms and soles*

Sympathetic ophthalmia?

Characterized by immune medicated damage (uveitis) against one eye after a penetrating injury to the OTHER eye. It is due to an immunologic mechanism involving the recognition of "hidden" antigens.

Best test for assessing dyspnea?

Chest x-ray

First test for pleural effusion?

Chest x-ray --> can quantify amount of fluid Chest CT- can also define the size and location of pleural effusion *usually shows blunting of the costophrenic angle due to fluid in the pleural space* *250 mL needed to blunt the costophrenic angle* **Obtain side (decubitus film) to evaluate whether fluid is free-flowing or localized and whether there is enough to do a thoracocentesis

DPLD Diffuse parenchymal lung disease)? 4 major causes

Chest xray findings of *diffuse pulmonary infiltrates* Major causes: 1. Idiopathic pulmonary fibrosis (IPF) (most common) --> "honey combing", 2. sarcoidosis (2nd most common cause) --> non caseating granulomas, hilar adenopathy, erythema nodosum, 3. collagen vascular disease, 4. hypersensitivity pneumonitis Physical exam findings: Velcro like crackles, clubbing of fingers

Biopsy of atopic dermatitis would look like what?

Chornic contact dermatitis

Causes of chronic vs. acute dyspnea?

Chronic (> 1 month): 1. COPD, 2. Bronchiectasis - chronic necrotizing infection of bronchi --> permanently dilated airways, purulent sputum (smoking, cystic fibrosis, kartagener syndrome) 3. Cystic Fibrosis Acute (minutes - 24 hours): 1. Heart failure 2. Cardiac Tamponade 3. Panic disorder

Pernicious anemia is associated with increased risk of what cancer?

Chronic atrophic gastritis --> Double the risk of gastric cancer

Distinct feature of urticaria pathology?

Circle the wheals ... 24 hours later it should be gone...should not be in the same place

Treatment for SCLC?

Cisplatin + Etoposide Prophylactic intracranial radiation

MDS? (myelodysplastic syndrome)

Clonal disorders of the hematopoietic stem cells --> ineffective hematopoiesis **risk of transformation to AML**

Preferred treatment for mucocutaneous and pseudomembranous candidiasis? (affects the immunocompromised population)

Clotrimazole

What % deficiency of clotting factors is necessary to prolong PT and aPTT times?

Clotting factor levels <35% (this indicates that even a person with 50% of his clotting factors will not show prolongation of clotting times

Munro abscess? Seen in what?

Collection of neutrophils seen in foci of parakeratosis Psoriasis

Elderly patient with iron deficiency anemia...rule out?

Colon cancer

Hallmark lesion of acne? Pathophys of acne?

Comedone Androgens

Mongolian spots?

Common benign finding in blacks and asians? Caused by the delayed disappearance of dermal melanocytes

Seronegative spondyloarthropathies common features?

Common features of SpA diseases --> 1. Young males 2. Lack rheumatoid factor (seronegative) 3. Involve axial skeleton (spine) 4. HLA-B27 association

SA node dysfunction (also known as sick sinus syndrome)?

Common in elderly as a result of idiopathic degeneration of cardiac conduction system. 1. Carotid sinus hypersensitivity (wearing a tight collar --> syncope) 2. Brady-tachy syndrome (A fib --> followed by bradycardia)

Complement levels in SLE?

Complement levels are low in SLE b/c of activation of classic complement system by immune complexes, leading to accelerated consumption of complement factors. C3 and C4 are low

Prevention of prostate cancer?

Consider rophylactic use of 5 alpha reductase inhibitors (finasteride) --> (inhibit conversion of testosterone --> DHT **However do not have effect on mortality**

Stevens Johnson syndrome? Drugs that cause SJS?

Continuum with erythema multiforme and Toxic Epidermal necrolysis: Prodrome: fever, flu-like symptoms Nikolsky's sign is positive - sloughing of the skin INVOLVEMENT OF MUCOUS MEMBRANES Subepidermal blister Drugs that causes SJS: "SATAN" Sulfonamides Allopurinol Tetracyclines Anti-epileptics NSAIDs

Estrogen therapy in post menopausal women? Contraindications to estrogen therapy in women?

Controversial; Use the lowest dose for the shortest period of time to treat menopause symptoms. Contraindications: VTE Liver disease CAD stroke breast, endometrial cancer

MOA of dipyradamole and adenosine?

Coronary vasodilators

Most common cause of viral myocarditis?

Coxsackie B virus

Pica?

Craving for ice or other unusual substances Indicative of iron deficiency anemia

What does vesicle evolve into?

Crust (secondary lesion)

Common treatment? What if not treated?

Cryotherapy; Curettage and Dessication Resolve over time with no treatment

CAGE questionairre?

Cut down on drinking (have you felt the need to cut down) Annoyance (have people annoyed you by criticizing your drinking) Guilt about drinking (have you ever felt guilty about drinking) Eye opener

Cause of psoriasis? Presentation of psoriasis?

Cutaneous T cell mediated inflammation erythematous papules and plaques characterized by silvery sclaes and punctuate bleeding when scales are removed (Auspitz sign)

Diagnostic test for suspect DVT?

D-dimer Duplex doppler ultrasound Compression ultrasound Venography (Historical gold standard)

Dermatitis herpetiformis? vs. Erythema multiforme?

DH: Autoimmune disease associated with Celiac's disease Pathogenesis: IgA deposits in dermal papillae Treatment: gluten free diet / DAPSONE EM: Caused by drugs (penicillin, sulfonamides) or infections (mycoplasma, HSV) Target lesions with central clearing

How to distinguish asthma and COPD (chronic bronchitis, emphysema)?

DLCO (normal/increased in asthma); decreased in COPD Also, patients with COPD do not demonstrate reversibility to bronchodilator

How to distinguish dermatomyositis from Lupus?

DM: itchy and burns SLE: not itchy

Molluscum contagiosum is caused by what?

DNA double stranded POX virus replicates in the cytoplasm of host cells.

Treatment for hypertensive urgency?

DO NOT use IV drugs; use oral drugs Oral clonidine or oral CCB

Treatment for dermatitis herpetiformis?

Dapsone Gluten free diet (associated with Celiac's disease)

What causes nicotine cravings?

Decreased CNS dopamine during smoking abstinence --> nicotine cravigns (nicotine increases the release of dopamine in the nucleus accumbens)

Hypoxic vasoconstriction?

Decreased PO2 --> pulmonary blood vessel constriction --> increased pulmonary vascular resistance --> COR PULMONALE!!

Osteoporosis?

Decreased bone strength

use of ACE Inhibitors in patients with heart failure?

Decreased mortailiy in pts. with heart failure and left ventricular dysfunction (EF < 40%)

Bernard Soulier disease? Glanzmann thrombasthenia

Deficiency in Gp1b platelet receptor --> defect in platelet-to-vWF adhesion Deficiency in GpIIb/IIIa platelet receptor --> defect in platelet-to-platelet aggregation

Osteoarthritis?

Degeneration of articular cartilage due to aging, wear and tear Pathology: Osteophytes (bony outgrowths) develop at margins of the articular surface Heberden's nodes (DIP) / Bouchard's nodes (PIP) **Spares MCP joints**

WPW?

Delta wave due to *Ventricular preexcitation* due to a connection between atria and ventricles that bypasses the AV node

WPW/AVRT ECG findings?

Delta waves = widening of QRS Shortened PR interval upsloping of initial QRS

What correlates with the risk of metastasis in melanoma? Most important prognostic factor for melanoma?

Depth of tumor Number of positive nodes Tumor thickness

What is the major determinant of a nodule?

Depth!

HIstology of Rosacea?

Dermal edema

What if you see lesions in a linear pattern on the trunk?

Dermatomal configuration

Patient has trouble getting up from a chair...diagnosis? + skin involvement

Dermatomyositis

Difficulty standing up from a chair?

Dermatomyositis/Polymyositis

Statin use

Dermatomyosits

Treatment for von Willenbrand disease?

Desmopressin releases stored vWF from endothelial cells

Emphysema?

Destruction of alveolar air sacs --> loss of elastic recoil and collapse of airways during exhalation results in obstruction and air trapping *Pursed lip breathing* --> exhalation through pursed lips to increase airway pressure and prevent airway collapse during respiration

How to reduce the toxicity associated with doxorubicin? How to reduce the toxicity associated with Cisplatin?

Dexrazoxane is an iron chelator used to pretreat patients undergoing treatment with doxorubicin. Amifosting is an organic thiophosphate effective in preventing cisplatin induced renal toxicity

Diagnosis and treatment of Nocardia?

Diagnosis - filamentous gram positive branching rods ...buffered charcoal yeast extract Treatment - TMP - SMX

NSTEMI vs. unstable angina?

Differ in the severity of the myocardial ischemia. In NSTEMI, there is sufficient damage as to release biomarkers (Troponin). NSTEMI - elevated biomarkers

Acute pericarditis EKG changes?

Diffuse ST segment elevation

Progression of actinic keratosis into SCC Progression of seborrhexis keratosis into melanoma?

Directly progresses into SCC Doesn't directly progress into melanoma (only a marker for melanoma development)

Surgical treatment for disc herniation or spinal stenosis?

Disc herniation - diskectomy Spinal stenosis - lumbar decompression via laminectomy *Only consider therapy after minimum 3 months - 2 years of failed nonsurgical interventions*

Distribution vs. Configuration?

Distribution --> location on body Configuration --> how the lesions are arranged or relate to each other

Chylothorax? Most common cause?

Drainage of lymphatic fluid into the pleural space secondary to disruption or blockage of the thoracic duct Malignancy is the most common cause, Trauma 2nd most common cause *Milky* pleural fluid Pleural fluid Triglyceride level > 110 usually

What should always be on your differential diagnosis for a skin rash?

Drug reactions

Causes of itching?

Dry skin Aging Pregnancy Uremia Jaundice Lymphomas/leukemia Drug reaction Lice

Fat embolism triad?

Dyspnea Petechiae Altered mental status

Symptoms of PE?

Dyspnea, pleuritic chest pain, pain, cough, hemoptysis S4 gallop, tachypnea

Diagnostic tests for Lyme disease?

ELISA for Ab against B. Burgdorferi Western blot PCR of synovial fluid

ER+, PR+, HER2+?

ER+ and PR+ breast cancers predicts good results from endocrine therapy HER2+ is assocaited with a poor prognosis

Use of estrogen replacement therapy?

ERT provides effective relief of hot flushes, but its use must be weighed against the potential adverse effects including increased rates of breast cancer, thromboembolic events, and cardiac disease.

Treatment of otitis externa?

Ear cleaning, debridement, and acidifying drops

RDW in iron deficiency anemia?

Elevated

Venous waveform in pulmonary artery hypertension?

Elevated "A" wave (atrial contraction)

BNP test?

Elevated BNP a sign of heart failure <100 - no heart failure 100 - 300 - heart failure present > 300 - mild heart failure 300 - 600 moderate heart failure

Examples of Type 2 hypersensitivity reactions against endogenous antigens? Exogenous?

Endogenous --> Autoimmune Hemolytic Anemia, Autoimmune thrombocytopenia purpura, Graves disease, Hashimotos, Myasthenia Gravis, Goodpastures syndrome, Guillian Barre syndrome Exogenous --> Transfusion reactions

Examples of Type 4 hypersensitivity reactions against endogenous antigens? Exogenous?

Endogenous --> RA, MS, T1D, Autoimmune carditis Exogenous --> Celiac's disease, Contact sensitivity

Examples of Type 3 hypersensitivity reactions against endogenous antigens? Exogenous?

Endogenous --> SLE Exogenous --> Serum sickness, Arthus reaction

Features of acromegaly? Tests to confirm it?

Enlargement of the jaw, hands, feet, and coarsening of facial features 1. Increased IGF-1 levels (most sensitive) 2. Oral glucose tolerance test (in normal people GH levels followign 75-100 g glucose are suppressed; in acromegaly GH levels are not suppressed.

Pautrier's abscess?

Epidermal cluster of atypical lymphocytes...pathognomonic for mycosis fungoides..

Psoriasiform dermatitis?

Epidermal hyperplasia (acanthosis) with marked enlargement of rete ridges

3 layers of the skin?

Epidermis, Dermis, Subcutaneous layers

Candidiasis has what kind of secondary lesion?

Erosion

Pre tibial tender nodules in a young woman? Causes?

Erythema nodosum Idiopathic Strep pharyngitis reaction to OCP/NSAIDs Sarcoidosis TB IBD

Skin conditions associated with UC and Chrons?

Erythema nodosum - anterior tibial area (most common) Pyoderma gangrenosum

2 types of HTN?

Essential (unknown cause) - 90% Secondary HTN (known cause)- 10%

Mechanism of action of oral contraception?

Estrogen and Progestins inhibit LH/FSH and thus prevent estrogen surge. No estrogen surge --> no LH surge --> no ovulation.

Effect of estrogen on Acne?

Estrogen decreases sebum production That's why OCP can be used for acne **There is an association between acne and menses

Influenza and pneumococcal vaccine in COPD?

Everyone gets flu vaccine Everyone gets pneumococcal vaccine and revaccinate >65 years who were immunized > 5 years ago and less than 65 at the time

Ringed sideroblast?

Excess iron in the mitochondria

Parakeratosis?

Excess keratin with retention of nuclei

Thrombin time?

Excess thrombin is added to to assess the conversion of fibrinogen to fibrin (clotting time) Liver disease (not producing clotting factors), DIC can increase thrombin time Quantitative (fibrinogen deficiency) or qualititative (dysfunctional fibrinogen) problems can increase TT>

Leser-trelat sign?

Excessive Seborrheic keratosis can be indicative of stomach adenocarcinoma

What kind of biopsy for erythema nodosum (panniculitis)?

Excise the entire nodule

Treatment for melanoma?

Excision with wide margins Mohs surgery - excision of the tumor with 1-2 mm clear margins are excised and immediate preparation of tissue to allow histological examination

Diagnosis of Melanoma?

Excisional biopsy Sentinel Lymph Node biopsy

Best test for evaluation of melanoma?

Excisional biopsy + sentinel LN biopsy

Stable angina?

Exertional onset Prompt relief with nitroglycerin

Psoriasis notably on what surfaces?

Extensor surfaces

Amyloidosis? AL amyloisosis

Extracellular deposition of pathologic, insoluble fibrils in various tissues/organs. AL amyloidosis --> Associated with underlying plasma cell dyscrasia or actual multiple myeloma. Deposition of Ig light chains in kidney (nephrotic syndrome), heart (restrictive cardiomyopathy), liver (hepatomegaly), nerves (neuropathy).

Restrictive lung diseases with normal DLCO?

Extrapulmonary etiology: obesity neuromuscular weakness (Myasthenia gravis, ALS) Kyphoscliosis

Transudate vs. exudative pleural effusions? (Light's criteria)

Exudative: Pleural fluid to serum protein ratio > 0.5 Pleural fluid to serum LDH ratio > 0.6 Pleural fluid to serum upper limits of normal LDH ratio > 0.6 Transudate: Pleural fluid cholesterol < 60 Serum: pleural fluid albumin gradient >1.2

Ophthalmologic screening in patients with Type 2 DM?

Eye exam at the time of diagnosis + eye exam 1x / year.

How to reverse Warfarin?

FFP immediately Vitamin K takes 24 hours

Atopic dermatitis assocaited with what gene mutation? What cytokine level correlates with disease severity?

FLG gene --> flaggerin protein IL-31

Initial evaluation of a patient with secondary amenorrhea?

FSH TSH prolactin measurements consider serum testosterone / plasma DHEA if signs of androgen excess are present

Histology of Lichen Planus?

Features of both interface dermatitis and lichenoid dermatitis "L"ichen Planus has "L"ichennoid-Interface dermatitis

Risk factors for drug reactions?

Female Prior history of reaction HLA type Recurrent drug exposure Certain disease states (EBV or HIV)

Tense vs. Flaccid blister?

Flaccid blister = intraepidermal Tense blister = subepidermal

Tissue paper wrinkling?

Flaccid bullae in SSSS

Molluscum contagiosum? Commonly seen in whom?

Flesh-colored papules with central umbilication Kids *HIV adults*

Stevens Johnson syndrome presentation? Causes?

Flu-like prodrome followed by acute fever, typical rash, and ulcerated lesions on at least 2 mucous membranes Sulfonamides Penicillins Anticonvulsants NSAIDs

Guttate psoriasis caused by what?

Following a streptococcal infection

Presentation of radicular pain resulting from disc herniation? What level do most disc herniations occur?

Follows a dermatomal distribution and extends below the knee L4-L5, L5-S1

Treatment for ethylene glycol and methyl alcohol poisoning?

Fomepizole

Treatment for breast cancer?

For focal disease --> Surgery -->* lumpectomy* followed by radiation For more extensive disease --> Surgery --> *radical mastectomy* followed by radiation Sentinel LN biopsy (first draining LN from breast is analyzed)

Apocrine glands? Sebaceous glands?

Found in axillary and pubic regions; Not functional until puberty; Malodorous because of bacterial action Holocrine secretion of sebum; associated with hair follicle

Presentation of scabies mite?

Found in digital webbings often (area between the toes) Usually found in the genital areas: penis/scrotum in males and areolas/breasts in females **Head and neck spared in adults**

Difference between Ephelis (freckle) and solar lentigo?

Freckle (Ephelis) --> Increased number of melanosomes (increased melanin) --> NORMAL NUMBER OF MELANOCYTES Disappear when sun exposure discontinued Solar lentigo --> INCREASED NUMBER OF MELANOCYTES ; persist indefinitely

Treatment for Beta thal major?

Frequent Packed RBC transufsions are required for life Iron overload sometimes develops --> causing CHF due to hemochromotosis Give deferoxamine to remove excess iron (iron chelating agent)

G6PD deficiency? When to perform G6PD enzyme test?

G6PD produces NADPH --> which reduces glutathione --> which protects against RBC oxidative stress G6PD deficiency results in hemolytic anemia following oxidant stress (sulfa drugs, fava beans) **Perform G6PD enzyme test 3-4 days after an acute crisis b/c In patients with acute hemolysis, testing for G6PD deficiency may be falsely negative because older erythrocytes with a higher enzyme deficiency have been hemolyzed. Young erythrocytes and reticulocytes have normal or near-normal enzyme activity.

Most common side effects of Fluoroquinolones?

GI upset most common Tendon rupture - very rare

Type of distribution

Generalized Truncal Flexures Facial

Cutaenous drug reactions in general are ...

Generalized and symmetric

Acanthosis?

Generalized epidermal hyperplasia

Roseola?

Generalized macular rash in infants caused by HHV-6. The rash appears after the high fever resolves, at about 305 days

What is the hypothesized pathogenesis of Lupus?

Genetically susceptible genes --> Exposed to external triggers --> Apoptosis of cells --> Release of previously unseen self antigen --> Autoimmune antibody/ Immune complex formation --> perpetuated by TYpe 1 interferon released by DCs.

Which vasculitis are granuloma mediated? Which are IC mediated? Which are Pauci-immune?

Giant cell Takayasu Wegeners Churg strauss Buerger's disease Polyarteritis nodosa GoodPasture's Henoch Schlonein Wegener's Microscopic polyangitis Churg Strauss

Classification of prostate cancer?

Gleason score Tumors are graded 1 - 5 based on the degree of glandular differentiation and structural architecture Stage 1 - non palpable, confined to prostate Stage 2 - palpable, confined to prostate Stage 3 - extends beyond capsule w/out metastases Stage 4 - metastatic disease

Role of diet in acne?

Glycemic index and dairy consumption increased IGF-1 --> increase in androgen activity

Gout vs. Pseudogout?

Gout - negatively birefringent; Crystals are NEEDLE shaped and yellow when parallel to the light Pseudogout - weakly positive birefringent; Crystals are RHOMBOID shaped and blue when parallel to the light

What is normal skin flora?

Gram + S. epidermidis and S. Aureus Candida

Vancomycin lacks efficacy against what organsims?

Gram negative bacteria

In vasculitis, what does the histology of Large arteries look like? Muscular (medium sized arteries)?

Granulomatous inflammation Fibrinoid necrosis

Risk factors for melanoma?

H - history of previous melanoma A - age over 50 R - regular dermatologist absent M - mole changing M - male gender

Target cells?

HALT HbC Asplenia Liver disease Thalassemia

Etiology/pathophys of Ptyriasis Rosea?

HHV-6, HHV-7

What HLA is associated with early onset/family history of psoriasis?

HLA-Cw6

Prevention of SCC involves prevention of what virus? Giving what vitamins?

HPV Retinoids

HPV 16/18 associated with what gene products?

HPV 16 - E6 gene product --> inhibits p53 tumor suppressor) HPV 18 - E7 gene product --> inhibits RB suppressor gene)

Wart transformation to squamous cell carcinoma associated with what?

HPV 16, 18

Anogentital warts (condyloma acuminata) are caused by what?

HPV 6, 11

Causative agent of keratoconjunctivitis? Symptoms?

HSV Photophobia, constricted pupil, foreign body sensation) Dendrites visible on fluorescein staining

HTN treatment in the setting of certain comorbidities?

HTN + CAD --> B-blockers decrease cardiovascular mortality (Carvedilol) HTN + asymptomatic ventricular dysfunction and symptomatic heart failure --> ACE I HTN + diabetes --> ACE I

Most common infections in COPD?

Haemophilus influenzae Strep Pneumoniae Moraxella

TRAP + leukemia?

Hairy cell leukemia (cytoplasmic projections)

Comedone? What does it contain

Hallmark lesion of acne --> clogged hair follicle in the skin containing keratin

Bullous impetigo?

Has bullae and is usually caused by S. Aureus

When to perform blood transfusion?

Hb < 7 or patient requires increased O2 carrying capacity (CAD, COPD)

Rule of nines for burns?

Head = 9% Each Upper extremity = 9% Front of torso = 18% Back of torso = 18% Each lower extremity = 9% Groin 1%

Menorrhagia? Treatment for heavy periods?

Heavy menstrual bleeding Birth control - medroxyprogesterone acetate (Provera)

Hemoglobin is made up of what componenets?

Heme (iron + protoporphyrin) + globin chains Deficiencies in these are responsible for microcytic anemias

What connects keratinocytes (stratum basale) to the basement membrane? What attaches keratinocytes to each other?

Hemidesmosomes Desmosomes

How to differentiate normocytic anemias?

Hemolytic vs. Nonhemolytic Nonhemolytic: CKD Aplastic anemia Anemia of Chronic disease Hemolytic: Intrinsic vs. Extrinsic Intravascular vs. Extravascular

H/o gingival bleeding after brushing teeth and painful knee swelling after a fall (hemarthrosis)...diagnosis?

Hemophilia A or B Also, recurrent hemarthsois

Side effect of Statins?

Hepatotoxicity - check ALT/AST levels Myopathy - check Creatinine phosphokinase (CPK)

How does Pityriasis Rosea start? Often confused with what?

Herald Patch Tinea fungal infection

Pityriasis Rosea? What condition must you rule out that presents with a similar rash?

Herald patch - a single larger lesion, approximately 1 week prior to the eruption of multiple lesions covering the trunk in a "Christmas tree" distribution **Herald patch usually appears on patient's trunk --female patient on the cleavage lines** Associated with viral/bacterial rash (streptococcus) Must rule out secondary syphillis

Increased MCHC?

Hereditary spherocytosis

What disease process produces vesicles?

Herpes Zoster

Viral infection of the finger?

Herpetic whitlow (HSV 1 or HSV 2) -- health care workers

Treatment for spinal cord compression? Greatest predictor of prognosis in surgical emergencies of the spinal cord?

High dose corticosteroids immediately , followed by surgical decompression. pretreatment neurological status

What is the most important mediator of acute urticaria?

Histamine

Histoplasmosis? Coccidoides? Blastomycoses?

Histoplasmosis - Mississippi river valley; spelunking (bats), pigeon droppings; can cause erythema nodosum Coccidoides - Southwestern United states, San Joaquin Valley fever - rash erythema nodosum, Blastomycoses?

Red flags in the evaluation of back pain?

History of cancer with new onset of back pain Unexplained wieght loss Fever, IV drug use Urinary retention, Saddle anesthesia Pain that wakes pt. from sleep Morning stiffness before age 40 (ankylosing spondylitis)

Another name for urticaria?

Hives...pruritic papules that vary in size and appear and disappear in a matter of hours

Hodgkins Lymphoma vs. Nonhodgkins lymphoma

Hodgkins lymphoma = better cure rate NHL - worse cure rates...

Treatment of abnormal uterine bleeding?

Hormone therapy (oral contraceptives, cyclic progestins, progesterone containing IUD).

Medications that cause drug induced lupus? Mechanism? Present with what serology?

Hydralazine Procainamide Isoniazid TNF-a inhibitors Inhibit DNA methylation Present with anti-histone antibodies

First line treatment for SLE?

Hydroxychloroquine (antimalarials) Corticosteroids for acute flares

Treatment of sickle cell?

Hydroxyurea --> augments Hemoglobin F RBC Exchange transufsions BMT

Women with irregular menses and hirsutism? Diagnosis?

Hyperandrogenism

xray findings of emphysema?

Hyperinflated lungs with Flattening of the diaphragms Increased A-P diameter (1:2 --> 1:1) irregular lung lucency increased vascular markings

Physical exam signs of COPD?

Hyperinflation: barrel chest, hyperresonant percussion, distant breath sounds, prolonged expiratory time *Pursed lip breathing* --> exhalation through pursed lips to increase airway pressure and prevent airway collapse during respiration

What is happening on a microscopic level in a plaque (psoriasis)

Hyperkeratosis and Acanthosis

Hypergranulosis?

Hyperplasia of stratum granulosum (granular cell layer)?

Erythema Multiforme?

Hypersensitivity reaction to a drug or Infectious trigger (HSV, mycoplasma) Targetoid rash with central clearing, with NO mucous membrane involvement

Hypertensive emergency vs. Hypertensive urgency?

Hypertensive emergency --> symptoms/signs of end organ damage Hypertensive urgency --> no symptoms/signs of end organ damage

Tumor lysis syndrome? Treatment?

Hypocalcemia Hyperuricemia Hyperkalemia Hyperphosphatemia Uric acid elevations can cause urate-induced kidney failure **Allopurinol reduces acute urate nephropathy** **Treatment includes IV fluids + allopurinol (xanthine oxidase inhibitor).

Definition of aplastic anemia? Causes of aplastic anemia?

Hypoplastic BM <20% cellularity Decrease in all lineages of hematopoiesis 1. Intrinsic stem cell defect 2. Immune mediated stem cell destruction

Physical exam findings most predictive of acute coronary syndrome?

Hypotension S3 murmur Bibasilar crackles

Definition of hypoxemia vs. hypoxia? Examples of both?

Hypoxemia is decreased PaO2 (partial pressure of Oxygen in arterial blood) Normal A-a gradient 1. High altitude 2. Hypoventilation Increased A-a gradient 3. V/Q mismatch 4. Diffusion limitation (pulmonary fibrosis) 5. Right-to-left shunt Hypoxia is decreaed oxygen delivery to tissues 1. Anemia 2. Carbon monoxide poisoning 3. Hypoxemia 4. decreased cardiac output

Secondary causes of hypercholesterolemia?

Hypthyroidism Obstructive jaundice Nephrotic syndrome

What is a V/Q mismatch?

Ideally, ventilation is matched to perfusion in order for adequate gas exchange. (normally with exercise V/Q approaches 1) Apex of lung, V/Q = 3 (wasted ventilation) Base of lung, V/Q = 0.6 (wasted perfusion) *Both ventilation and perfusion are greater at the base of the lung* V/Q = 0 --> airway obstruction/shunt physiology (100% O2 does not improve PO2) PO2 - 40 PCO2 - 46 **Shunt physiology refers to an area of lung that is perfused with blood, but not receiving adequate ventilation --> thus the blood returning to the arterial system is not oxygenated** V/Q = infinity --> blood flow obstruction (Pulmonary Embolism PE) (assuming <100% physiologic dead space --> 100% O2 improves PO2 PO2 - 150 PCO2 - 0

How to tell the difference between idiopathic and drug induced Lichen planus?

Idiopathic - mucous membrane involvement Drug induced - no mucous membrane involvement

Cardiac conduction defects and bradyarrhythmias most commonly the result of what?

Idiopathic degeneration of conduction system

Progesterone challenge?

If estrogen levels are low or anatomic abnormalities --> progesterone challenge --> NO bleeding If estrogen levels are normal --> progesterone challenge --> bleeding

Current recommendations for colonoscopy?

If no family history of colonoscopy --> 50 years old If family history of colonoscopy --> 40 years old or 10 years before relative was diagnosed with colon cancer

Before you perform a lumbar puncture, what do you have to do?

Imaging (CT or MRI) to assess for increased ICP

Henoch-Schonlein purpura?

Immune mediated vasculitis associated with IgA deposition in affected organs **Renal disease similar to IgA nephropathy** Tetrad of: 1. Athralgias 2. *Abdominal pain* 3. NON BLANCHING Palpable Purpuric rash 4. Renal disease (similar to IgA nephropathy) **Usually follows an upper respiratory tract infection** in young boys between ages 2-11.

Examples of primary disease prevention? Examples of secondary disease prevention? Examples of tertiary disease prevention?

Immunizing patients against disease Wearing seat belts Mammograms for early detection of breast cancer Colonoscopy for early detection of colon cancer Treating a patient after an MI with a cholesterol-lowering drug to prevent a second cardiovascular event

Patient has recurrent syncopal episodes and you suspect an arrhythmia...how to test?

Implantable loop recorder

Cholesterol guidelines?

In a healthy person with 0-1 risk factors, LDL cholesterol <160.. Only use pharmacologic therapy if > 190, though LDL between 160-190 can be treated with lifestyle changes.

Goal of HTN treatment?

In normal people, goal is <140/90 In diabetics, goal is <130/80

Physiologic anemia?

In pregnant women, RBC mass increases, but plasma volume increases to a greater extent This is physiologic dilutional anemia

SCC in situ vs. Invasive SCC

In situ --> Full thickness nuclear atypia with no invasion into papillary dermis Invasive carcinoma would invade the papillary dermis

Therapy for HTN?

In stage 1 HTN with no end organ damage or heart disease --> 6-12 months of lifestyle changes before drugs Stage 2 HTN --> immediate drugs + lifestyle changes Initial drugs of choice: HCTZ (especially black & elderly patients) ACE I/ ARB CCB Loop diuretics (pts. with CKD or elevated serum creatinine) B-blockers are NOT CONSIDERED first line therapy anymore.

Heart failure respiratory signs?

Increased CVP S3 murmur crackles on lung auscultation *Patients with heart failure typically have normal PFTs, except with interstitial edema)*

Change in thyroid hormone in pregnancy?

Increased TBG - thyroid binding globulin ---> increased total amount of thyroid hormone --> however the amount of "FREE" thyroid hormone is the same

Most common side effect of B-agonist therapy? Anticholinergics?

Increased heart rate; Tremor Dry mouth; be careful in urinary retention and glaucoma pts.

Change in intensity of hypertrophic cardiomyopathy and MVP with Valsalva (decreased venous return)

Increased murmur both HOCM and MVP increase in murmur intensity when decreased chamber size and decreased preload.

VTE cardiovascular effect?

Increased pulmonary vascular resistance --> increases demand on right ventricle --> lower Cardiac output (CO)

How does sepsis cause pulmonary edema?

Increases capillary permeability

What hormone decreases/increases sebum production?

Increases: DHT (that's why sebaceous glands have 5 alpha reductase) Decreases: Estrogen

Ankylosing spondylitis?

Infalmmation of sacroiliac joints Worse in the morning, *improves with a hot shower or exercise* HLA-B27 Considered a seronegative spondyloarthropathy - negative for any antibodies, etc. Bamboo spine - vertebral fusion

Most common causes of DIC?

Infection (gram NEGATIVE sepsis) Cancer OBGYN complications

Asplenic patients at risk for what? What is empriric abx therapy?

Infection with encapsulated organisms (Strep pneumoniae, Haemophilus influenzae, Neisseria meningitidis) Vancomycin + Ceftriaxone

Pustule on hand + arthritis?

Infectious arthritis (GONOCOCCAL)

Panniculitis? Examples of panniculitis diseases?

Inflammation involves subcutis (fat) with extension into adjacent reticular dermis Erythema nodosum Pancreatic panniculitis

Lichenoid dermatitis?

Inflammatory dermatitis with infiltrate of lymphoctes and histiocytes obscuring the DE junction

Severe Acute asthma exacerbation treatment?

Inhaled B-agonist Anticholinergic medication by nebulizer IV steroids supplemental Oxygen

First line treatment for long-term control of asthma?

Inhaled corticosteroids (Fluticasone)

Use of corticosteroids in COPD?

Inhaled corticosteroids should not be used alone. Use with a long-acting bronchodilator *Limited knowledge about corticosteroid safety and management of COPD* *Be careful in elderly patients b/c of risk of steroid --> osteoporosis, cataracts, hyperglycemia, pneumonia

Progression of HIV infection? When to treat HIV?

Initially acute seroconversion, the viral load will peak and the CD4+ count will plummet, until a set point is reached. Then the CD4+ count will rise back up , and the viral load will decrease Treat HIV when CD4+ count <350 or the presence of symptoms

Pap smears screening?

Initiated at 21 years old or within 3 years of vaginal intercourse

Chest tube thoracostomy?

Inserted through the chest wall and into the pleural space or mediastinum. Used to remove: 1. air (pneumothorax) 2. fluid (pleural effusion, blood, chyle), or 3. pus (empyema) from the intrathoracic space.

Spongiosis?

Intercellular edema of epidermis Because there is edema in between cells, inflammatory cells usually are present

4 classes of asthma?

Intermittent Mild Moderate Severe Defined by frequent of rescue inhaler use and night time symptoms as well as FEV1 or peak expiratory flow rate (PEFR) measurement.

Medication of choice for reversal of acute asthma symptoms? Treatment for Intermittent Mild Moderate Severe

Intermittent - Short acting inhaled B-agonist AS NEEDED Mild - 1 medication --> *low-dose inhaled CORTICOSTEROID* Moderate - 1 or 2 medications --> *low-dose inhaled CORTICOSTEROID and potentially add a long-acting B-agonist* **Do not use a long acting B-agonist alone, b/c there is increased mortality associated with long acting B-agonist monotherapy...must use with an inhaled corticosteroid** Severe - may require up to 3 medications: high dose - 1. inhaled corticosteroids + 2. long acting bronchodilator and possibly 3. oral corticosteroids. Leukotriened modifier can also improve symptoms

Asthma pathophysiology?

Intermittent and reversible airway obstruction associated with chronic inflammation and a disordered immune response. Airway inflammation contributes to airway hyperresponsiveness Structural atlerations can occur in the lungs of some patients --> *airway remodeling* (fibrosis, increased smooth muscle, hyperplasia of mucous glands)

Findings of intravascular hemolysis vs extravascular hemolysis?

Intravascular: 1. Decreased haptoglobin (haptoglobin is a serum protein that binds to free Hb. Haptoglobin levels decrease when itnravascular hemolysis releases hemoglobin into the circulation 2. Hemoglobinemia 3. Hemolgobinuria 4. Hemosidinuria Extravascular hemolysis (spleen): 1. Increased unconjugated bilirubin 2. Jaundice 3. Bilirubin gallstones 4. Splenomegaly

Examples of intravascular hemolysis and extravascular?

Intravascular: Paroxysmal nocturnal hemoglobinuria Extravascular: Hereditary Spherocytosis G6PD deficiency Pyruvate kinase deficiency HbC Sickle Cell anemia

Anemia of chronic disease?

Iron is present in the body but not available for Hb synthesis (iron trapping in macrophages)

What is the difference between dermatomyositis and polymyositis?

It is the spectrum of skin and muscle disease Dermatomyositis has both skin and muscle involvement Polymyositis has only muscle involvement Amyopathic dermatomyositis has only skin involvement

How to diagnose PML?

JC virus --> PCR of CSF

Signs/Symptoms of Cor pulmonale Most common cause of cor pulmonale?

JVD Increased intensity of P2 Right ventricular heave Hepatomegaly/ascites Dependent pitting edema COPD

Maturation of an acquired nevi?

Junctional (Macular) Compount (Maculopapular) Intradermal (Papular)

In epidermyloysis bullosa, what is the defect in: simplex type (basal keratinocytes) junctional type (anchoring filaments) dermal/dystrophic type (anchoring fibrils) ALSO, WHERE ARE THE BLISTERS?

Keratin 5 & 14, pectin, a6B4 integrin (Intraepidermal) Collagen 17 & Laminin 332, a6b4 integrin (Lamina lucida) Collage 7 (Intradermal)

Who does molluscum contagiosum usually affect?

Kids ****HIV immunocompromised adults***

L5 nerve impingement from L4-L5 disc hernation causes what symtpoms S1 nerve impingement from L5-S1 disc hernation symptoms?

L5 - Radicular pain in the anterolateral leg and great toe with weakness in dorsiflexion of great toe S1 - Radicular pain in the posterior leg with decreased ankle jerk reflex and ankle plantar flexion

What lab value is elevated in PCP pneumonia infections?

LDH

how to calculate LDL cholesterol from lipid profile?

LDL = total cholesterol - HDL - (triglycerides/5)

2 components of Basal lamina? Which one is higher?

Lamina Lucida - electron lucent layer Lamina densa - electron dense layer Lucida higher than densa

Which lung cancer causes gynecomastia?

Large cell carcinoma (thing large cell --> large breasts)

Atrial flutter? Atrial fibrillation?

Large reentry circuit in RIGHT ATRIUM atrial rate 240-300/min usually associated with 2:1 or 3:1 atrial:ventricular rate, so ventricle rate usually 100-150 300:100 ATRIA:Ventricular rate Atrial fibrillation: Increased pressure in atrium causes micro-reentrant cirucits. *Absent P waves* atrial rate >350 bpm

Appearance of reticulocytes on Wright Giemsa stain?

Larger than peripheral RBCs. Polychomasia (purple) due to increase ribonucleoproteina and RNA not present in mature RBCs.

Treatment of acute pulmonary edema?

Lasix Morphine Nitrates

Lead-time bias? Length bias?

Lead-time bias is the artificial increase in survival time introduced with every screening test by simply diagnosing the disease earlier without necessarily increasing overall life expectancy Length bias occurs with every screening test, because screening is less likely to detect rapidly progressive disease than to detect slowly progressive diseases

What causes an S4?

Left atrial kick against a stiff left ventricle

Where are the murmurs of AR and PR heard best?

Left sternal border (diastolic murmurs)

What is contained inside a pustule?

Leukocytes and free fluid

Treatment of OSA?

Life style changes and CPAP (raises intraluminal airway pressure) (weight loss at least 10%, avoidance of alcohol/sedatives before bedtime, lateral sleeping position

Modifiable and non modifiable risk factors for osteoporosis?

Lifestyle modifications = Vitamin D/Calcium intake, physical activity, BMI, smoking, Alcohol Nonmodifiable risk factors = increase age, female sex, race (white,asian), impaired mobility , familiy history)

Chediak Higashi?

Light skinned **Increased susceptibility to infection that results from defective neutrophil granulation** Patients are at increased risk of hemophagocytic syndrome following viral infection

What are likelihood ratios?

Likelihood rations tell us how much we should shift our suscpicion for a particular test result. The LR+ tells us how much to INCREASE the probability of disease if test is positive. The LR- tells us how much to DECREASE the probability of disease if test is negative.

Staging of SCLC?

Limited: confined to chest plus supraclavicular nodes, but not cervical or axillary nodes vs. Extensive : outside of chest and supraclavicular nodes

Danger areas for SCC metastasis?

Lip mucosa Ear Old burn scars

Treatment for common warts?

Liquid nitrogen

What vaccines are contraindicated in immunocompromised individuals?

Live vaccines LIVE! one night only...come see small yellow chickens get vaccinated with MMR and Sabin's polio Small pox Yellow fever Varicella MMR (can be given to HIV pts. with no signs of immunodeficiency)****** Oral poliovirus (sabin

Hyatid cyst? Characteristic CT scan finding? Treatment?

Liver cyst caused by infection with Echnococcus granulosius (close contact with dogs) **Eggshell calcification of a hepatic cyst** DO NOT aspirate due to risk of anaphylactic shock secondary to spilling of cyst contents Treatment by surgical resection + ALBENDAZOLE

Acanthocyte?

Liver disease Abetalipoproteinemia

Chest x-ray findings of pneumonia?

Lobar consolidation Interstitial infiltrates Vacitation

Difference between lobular and septal panniculitis?

Lobular --> ulcerates (PANCREAS PANNICULITIS) Septal --> does not ulcerate (ERYTHEMA NODOSUM

Morphea?

Localized form of scleroderma; NOT associated with systemic disease

What are the criteria for a parapneumonic effusion?

Loculated pleural fluid (a pocket --> not free flowing) Pleural fluid w/ pH < 7.2 Pleural fluid w/ glucose < 60 Pleural fluid w/ LDH > 1000 positive pleural fluid Gram stain/culture Presence of gross pus **These all indicate a poor response to ABX --> confirm complicated parapneumonic effusion --> chest tube drainage + thrombolytics

Acantholysis

Loss of intercellular junctions (desmosomes) of keratinocytes

Physical signs of elevated pulmonary artery pressure include?

Loud P2 Fixed split S2 Pulmonic flow murmur Tricuspid regurgitation Parasternal heave (if chronic pulmonary HTN)

What is an indication of active Lupus disease?

Low complement levels

Lower respiratory viruses --> cough Upper respiratory viruses --> rhinitis

Lower respiratory viruses: Influenza A, B, Parainfluenza virus RSV Upper respiratory viruses: Coronavirus Adenovirus Rhinovirus

Air-fluid levels on chest X-ray?

Lung abscess (localized collection of pus withing parenchyma) often caused by aspiration (alcoholics, epileptics), cancer

Lung compliance increase/decrease?

Lung compliance increases in emphysema and normal aging Lung compliance decreases in pulmonary fibrosis, pneumonia, pulmonary edema

Rash that spares the knuckles and the nasolabial folds?

Lupus

Lupus band test

Lupus band test is done upon skin biopsy, with direct immunofluorescence staining, in which, if positive, IgG and complement depositions are found at the dermoepidermal junction.

Livdeo reticularis would be seen in what kind of patient?

Lupus patient with antiphospholipid antibody

Bilateral Bell's Facial Palsy?

Lyme disease

What infection causes 3rd degree AV heart block?

Lyme disease

What type of pleural effusion does TB present with? Next step in diagnosis?

Lymphocyte predominatnt exudative effusion *Pleural biopsy*

Histology of Pyoderma Gangrenosum?

Lymphocytic infiltration first Followed by "NEUTROPHILIC DERMATITIS" , ulcer with marked neutrophilic infiltrate

What tests to order after diagnosis of anemia?

MCV and Reticulocyte count

Difference between MGUS and MM?

MGUS 1. Bone marrow clonal plasma cells <10% 2. Low levels of serum monoclonal protein <3 g/dL 3. No MM symtoms MM 1. Bone marrow clonal plasma cells >30% 2. High levels of serum monoclonal protein >3 g/dL 3. MM symptoms

Acute treatment fr ACS (MI)?

MONA 1. Morphine, Oxygen, Nitrates, Aspirin 2. PCI or fibrinolytic therapy within 12 hours 3. B-blockers Antiplatelet (Aspirin/Clopidogrel) Nitrates LMWH Morphine (reduces preload, and reduces sympathetic tone)

Most useful imaging modality for low back pain?

MRI (emergently if suspect: systemic illness, cord compression, infection, cauda equina) (unless suspect vertebral fracture --> Xray)

Causes of mitral stenosis? Aortic stenosis Aortic regurg? Mitral regurg?

MS - chronic rheumatic disease AS - wear and tear, bicuspid valve AI - Aortic root dilation, dissection, Marfan's, RPR, Endocarditis, Rheumatic fever MR - Chordae tendinae rupture, papillary muscle rupture in pts. with ACS, myxomatous degeneration, endocarditis, trauma

Most common cause of Mitral regurgitation?

MVP (most common) Rheumatic heart disease

What is a risk for native valve endocarditis?

MVP (particularly as a complication of rheumatic heart disease) is a risk factor for native valve infective endocarditis

1st line treatment for community acquired pneumonia?

Macrolide (Azithromycin)

Signs of malignant HTN end organ damage?

Malignant HTN = >180/120 Hypertensive encephalopathy papilledema Retinal hemorrhages Stroke MI Aortic dissection AKI

Multiple myeloma?

Malignant plasma cell clone that secretes a specific immunoglobulin (intact IgG, IgA, IgM or monoclonal light chain: kappa or lambda) These monoclonal proteins are called M proteins

Atypia?

Marked nuclear pleomorphism and mitotic figures

Lichenification? Caused by what?

Markedly increased skin lines Increased scratching (common in Atopic dermatitis)

DLCO? Abnormal DLCO means what?

Measurement of rate of diffusion of CO across alveolar-capillary membrane DLCO > 80% is normal Abnormal DLCO --> indicative of parenchymal lung disease DLCO is normal in conditions associated w/ abnormal spirometry measurements and lung volumes, but NORMAL lung parenchyma (asthma, neuromuscular disease --> ALS, myasthenia gravis) DLCO is decreased in disease w/ decreased alveolar capillary membrane surface area (emphysema) or thickened alveolar-capillary membrane (ILD, pulmonary fibrosis) Also decreased DLCO in: anemia (no RBCs to transport CO) Pulmonary embolism (Ventilation-perfusion mismatch) Pulmonary edema (edema is a barrier to gas flow)

Treatment of chronic stable angina - medical therapy or early revascularization?

Medical therapy = early revascularization (efficacy) Medical therapy = aspirin, statin, B-blocker, nitrate

What should always be considered as a cause of skin reactions?

Medications

How to characterize Macrocytic anemias?

Megaloblastic vs. Nonmegaloblastic Megaloblastic: Folate deficiency Vit B12 deficiency Orotic aciduria Nonmegaloblastic: Liver disease Alcoholism Reticulocytosis

How do keratinocytes become pigmented?

Melanocytes synthesize melanin from tyrosine in melanosomes Melanocytes then pass melanosomes to keratinocytes which become pigmented when they take them up

What is the most important related physical finding to dysplatic nevi?

Melanoma

Arterial blood gases compensations?

Metabolic acidosis --> use Winters formula Metabolic alkalosis --> for every 1 mEq/L of HCO3 , expect 0.7 mmHg PCO2 For ACUTE respiratory disturbance, pH will change by 0.08 for every 10 mmHg change in PaCo2 For CHRONIC respiratory disturbance, pH will change by 0.08 for every 10 mmHg change in PaCo2 Acute respiratory acidosis: 1 mmHg increase PCO2 = 0.1 mEq/L increase HCO3 Chronic respiratory acidosis: 1 mmHg increase PCO2 = 0.4 mEq/L increase HCO3 Acute respiratory alkalosis: 1 mmHg decrease PCO2 = 0.2 mEq/L increase HCO3 Chronic respiratory alkalosis: 1 mmHg decrease PCO2 = 0.4 mEq/L increase HCO3

Diabetes drugs?

Metformin --> **decreases hepatic gluconeogenesis** Sulfonylureas --> (2nd generation) Glyburide, Glimepiride, Glipizide --> insulin secretogues (closes K+ channel in Beta cell membrane --> depolarizes cell --> triggers Ca2+ influx --> insulin release) **requires islet function** (TZDs) --> Pioglitazone, Rosiglitazone --> **increase insulin sensitivity in peripheral tissue by binding to PPAR nuclear transcription regulator** --> increase adiponectin transcrption alpha-glucosideas inhibitors --> Acarbose --> **Inhibits intestinal alpha glucosidases --> decrease absorption of carbs --> decreases post prandial hyperglycemia Amylin analog --> Pramlintide **GLP-1 analog** --> Exenatide, Liraglutide --> increase insulin release, decrease glucagon DDP-4 inhibitors --> Sitagliptin, Saxagliptin, Linagliptin --> **increase concentration of GLP-1 by inhibiting its breakdown by DDP-4** --> increase insulin release, decrease glucagon

Metformin use in a hospitalized patient?

Metformin should be discontinued in a hospitalized patient b/c of potential for lactic acidosis + aggravation of contrast induced nephropathy.

If normal spirometry in suspected asthma patient, what test to do next?

Methalcholine challenge --> >20% decrease in FEV1 from baseline is called the provovative concentration. A PC <4 mg/dL is consistent with asthma (has a high sensitivity and a nigh negative predictive value for asthma)

How to check for asthma (reactive airway disease) in person w/ normal spirometry findings?

Methalcholine challenge --> if >20% decrease in flow parameters --> diagnosis of asthma *DO NOT perform methalcholine challenge in known COPD, MI, stroke*

How to prevent thyroid storm in patients receiving radioablation for hyperthyroidism?

Methimazole (inhibits thyroidperoxidase)

Treatment for methemoglobinemia? Treatment for Cyanide poisoning? Treatment for CO poisoning

Methylene blue (reducing agent) + vitamin C Nitrates + Thiosulfate 100% hyperbaric oxygen

1st line treatment for Rosacea?

Metronidazole gel/cream Azaleic acid

Exacerbations of COPD treatment?

Mild - short acting bronchodilators (B-agonists preferred) Moderate - short acting bronchodilators AND systemic corticosteroids, and/or Antibiotics Severe - hospital management (O2 therapy --> goal is arterial pO2 >60 mmHg or O2 sats >90%) *Consider ANTIBIOTICS for moderate/severe COPD exacerbation (Ceftriaxone/Macrolide or monotherapy with Fluoroquinolone) **O2 therapy is the only therapy proven to improve survival in COPD**

Initial management of acne? MOderate acne? Severe acne?

Mild acne --> Topical retinoids, Benzoyl peroxide Moderate acne --> addition of topical antibiotics (erythromycin) Severe acne --> Oral isoretinoin

Treatment for mild to moderate depression? Severe depression?

Mild, moderate depression --> **psychotherapy and pharmacotherapy are equally effective** Severe depression --> psychotherapy + pharmacotherapy

Beta thalassemia minor vs. major?

Minor - very mild anemia, increased HbA2 (a2delta2) Major - severe anemia; increasd HbF (a2gamma2)

Which murmurs increase with handgrip?

Mitral regurgitation Atrial regurgications VSD All increase in murmur intensity with increased afterload (handgrip)

Opening snap?

Mitral stenosis As the severity of the stenosis worsens, the opening snap moves closer to S2

High titers of anti-RNP are diagnostic of what?

Mixed connective tissue disorder (MCTD)

How to distinguish presence of a factor inhibitor from factor deficiency?

Mixing study with patient serum with normal serum

Mobitz type 1 vs. Mobitz type 2?

Mobitz type 1 --> progressive prolongation of the PR interval until a dropped beat Mobitz type 2 --> no progressive prolongation

What are the drug reactions we discussed?

Morbilliform Fixed drug reactions Urticaria/Angioedema Lichenoid reaction Serum Sickness Drug induced vasculitis Photosensitive

Use of morphine in kidney stones? Best pain analgesic to use in kidney stones?

Morphine causes ureteral vasospasm Demerol (Meperidine) does not cause this ureteral vasospasm

Epidemiology of MM?

Most common in 7th decade

von Willenbrand disease?

Most common inherited bleeding disorder (primary hemostasis problem --> epistaxis, menorrhagia, gingival bleeding) Autosomal dominant *vWF also is a carrier of factor VIII* -->disorders of secondary hemostasis can also occur

Risk factors for cervical cancer?

Multiple sexual partners History of DES exposure Smoking HIV positive or immunocompromised

Risk factors for HPV?

Multiple sexual partners Intercourse at an early age Smoking

Treatment for impetigo?

Mupirocin

What must you rule out before you diagnose someone with an inflammatory myopathy like dermatomyositis/polymyositis?

Must rule out MEDS!! Statins are a major cause of myopathy

Factor 5 Leiden mutation?

Mutant factor 5 that is resistant to degradation by activated protein C --> most common cause of hypercoaguability in whites

Unstable angina vs. NSTEMI?

NSTEM- increse in cardiac enzymes *Both lack ST elevation or pathologic Q waves

Clinical stages of heart failure? AHA and NYHA function class

NYHA - symptoms + limitation of physical activity AHA - symptoms + structural disease

Ranolazine?

Na+ channel blocker used as an antianginal agent in CHRONIC STABLE ANGINA Only to be used in patients who remain symptomatic despite OPTIMAL doses of medications.

What part of the body is very commonly affected in psoriasis?

Nail changes

Spinal stenosis?

Narrowing of the spinal canal presenting with back pain radiating to the butt and upper thighs Pain of spinal stenosis is classically exacerbated by standing erect or walking, and relieved by sitting or leaning forward

Potential complication of cellulitis if not treated properly?

Necrotizing fascitis

Mycoplasma pneumoniae on gram stain?

Negative gram stain b/c no bacterial cell wall! also, lack of growth on bacterial agar "Walking pneumonia" **Check serum cold agglutinins*

2 types of glomerular disease?

Nephrotic syndrome: Proteinuria > 3 g/24 hours Edema Hypoalbuminemia Minimal change disease FSGS Membranous Nephropathy Diabetic glomerulonephropathy Amyloidosis Nephritic syndrome: Hematuria Hypertension Post infections glomerulonephritis IgA nephropathy Membranoproliferative disease

Melanocytes are derived from what cells?

Neural crest cells

Spinal stenosis pain?

Neuro-claudication Pain worsened with prolonged standing and when upright Pain relieved with sitting or leaning over (shopping cart sign)

Are newborns affected with sickle cell disease?

Newborns are initially asymptomatic b/c of increased HbF and decreased HbS

Common antigens to contact dermatitis?

Nickel Poison ivy

What is the Nikolsky sign and what infections can you distinguish with it?

Nikolslky sign --> slight rubbing of the skin results in exfoliation of the outermost layer forming a blister within minutes. Bullous impetigo --> negative Scalded skin syndrome --> positive

Treatment for Congestive heart failure --> pulmonary edema?

Nitroprusside --> afterload reduction 100% oxygen under positive pressure Dobutamine --> ionotropic support Morphine (reduces preload) Furosemide/Lasix

Treatment of hypertensive emergencies?

Nitroprusside agent of choice Others: Labetalol, Nicardipine, Fenoldopam, Nitroglycerine **Only in aortic dissection do you decrease BP diastolic <100 quickly**

Do cutaneous drug reactions vary with dose?

No

How to diagnose syncope from an arrhythmia?

No prodromal symptoms + a *FOREHEAD BRUISE/LACERATION*

How to tell the difference between atopic dermatitis and mycosis fungoides?

No spongiosis in mycosis fungoides***

Should you wear gloves during skin exam?

No. Only very infrequently It helps you to use bare hands to feel the texture

Non DHP vs. DHP CCB?

Non DHP - Verapamil, Dilitiazem DHP - Amlodipine, Nifedipine

Honey-yellow crusting?

Non bullous Impteigo - caused by Strep. pyogenes or Staph. aureus --treat with dicloxacillin Treat with oral cephalexin

How are drug reactions classified

Non immunological Immunological

Treatment for Coccidoides in immunocompetent pt. Same concept in other Fungal infection (Histo, Blasto)

None necessary... Fluconazole if not immunosuppressed Amphotericin B if immunosuppressed or an extrapulmonary infection

Ventilation for COPD?

Noninvasive positive pressure ventilation - moderate acidosis, RR >25 Invasive - severe acidosis, RR > 35, cardiovascular shock, PE, pleural effusion, altered mental status, high aspiration risk

Prevention of osteoporosis?

Nonpharmacologic preventative/ lifestyle modifications BEFORE pharmacologic drugs. DEXA T score < -1

S2 splitting types?

Normal S2 split - with inspiration --> delayed closure of pulmonic valve Wide S2 split - pulmonic stenosis or RBBB Fixed S2 split - ASD Paradoxical splitting - Aortic stenosis, LBBB --> with inspiration, split dissapears b/c pulmonic valve closes later

Anemia in sickle cell disease?

Normochromic Normocytic If elevated hemoglobin A2 --> presence of B-thalassemia

Most common place for skin cancer?

Nose Bottom lip --> squamous cell carcinoma

What does CMV cause in AIDS patients?

Not pneumonia! Retinitis Esophagitis Treatment is gancyclovir or FOSCARNET

What does the culture of someone with SSSS produce?

Nothing...S. Aureus releases exfoliative toxin

When to order MRI for suspected disc herniation/spinal stenosis?

ONLY if candidate for surgery or intervention (epidural corticosteroid injection for radiculopathy)

BRCA1 and BRCA2 screening in women?

ONLY women with a family history of breast/ovarian cancer with a known relative with the mutation

Risk factors for obstructive sleep apnea?

Obesity increased waist-hip ratio large neck circumference Crowded pharynx

Obstructive vs. Restrictive lung diseases breathing type?

Obstructive --> Increased airflow resistance --> take slow, deep breaths (increased tidal volume, decreased respiratory rate) Restrictive --> increased elastic resistance --> take fast, shallow breaths (decreased tidal volume, increased respiratory rate)

Anti-phospholipid syndrome?

Occurs in Lupus (SLE) *Promotes coagulation in vivo, but in vitro, prolongs the PTT* PTT does NOT correct with addition of 1:1 dilution with normal plasma (Russel viper venom test)

Complications observed in atopic dermatitis?

Ocular (keratoconjunctivitis) Infections (HSV, S. aureus)

Risk factors for depression?

Older age Chronic disease/pain Females nonmarried **Depression is associated with increased mortality in patients with CAD, cancer, stroke**

Presentation of PCOS? Diagnostic criteria?

Oligomenorrhea (periods > every 35 days) Androgen excess (elevated testosterone levels) (hirsutism, acne) Insulin resistance Obesity LH:FSH ration >2:1 Diagnostic criteria: 2 of the following 1. ovulatory dysfunction 2. Evidence of hyperandrogenism 3. ultrasound evidence of cystic ovaries

Which Hypersensitivity reactions can involve endogenous antigens? Exogenous antigens?

Only Type 2-4 can involve self antigens All of the hypersensitivities can involve Exogenous antigens

RBC casts in the context of vasculitis?

Only when small vessels (like the renal capillaries) are involved (Wegeners, Microscopic polyangitis, Churgg-strauss) NOT medium sized (like renal arteries) vasculitis --> Polyarteritis nodosa, Kawasaki disease

Naltrexone?

Opiod receptor antagonist...enhances abstinence

A-a gradient in opioid overdose?

Opioid overdose --> hypoventilation --> No change in A-a gradient

Opioids used for pulmonary edema?

Opioids (morphine) can be used as a treatment for pulmonary edema by: 1. Reducing preload (venodilator effect( 2. Decreasing the pain/anxiety associated with dyspnea **Do NOT give in acute decompensated heart failure

How to prevent erythema multiforme?

Oral antivirals (acyclovir ) to prevent HSV

Syncope in a person with diabetic or alcoholic neuropathy?

Orthostatic hypotension is common in these patients due to *AUTONOMIC DYSFUNCTION*

Treatment of CA-MRSA cellulitis infection OUTPATIENT? INPATIENT?

Outpatient --> Doxycycline or TMP-SMX Inpatient --> Vancomycin or Daptomycin

2 question screening tool for depression?

Over the past 2 weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? If yes, proceed to PHQ-9 questionnaire

What are the 2 main options for treatment of MI?

PCI (preferred) Thrombolytics *Both should be initiated <12 hrs. from chest pain*

PCI vs. CABG?

PCI: considered in pts. with 1,2, or 3 vessel disease (restenosis is a big problem) CABG: 3 vessel disease with >70% stenosis in each vessel Left main coronary disease with >50% stenosis Left ventricular dysfunction

Appearance of the following brain lesions in HIV patients: PML CMV Cryptococcal Toxoplasmosis Neurocysticercosis

PML - NONENHANCING WHITE MATTER LESIONS CMV - asymmetric lesions with meningeal enhancement after contrast Cryptococcal - Clustered hyperintesne lesions Toxoplasmosis - Ring enhancing lesions Neurocysticercosis - Scattered cystic lesions with edema

Treatment for hyperthyroidism?

PTU (inhibits thyroidperoxidase and 5' deiodinase) Methimazole (inhibits thyroidperoxidase) Side effects of these drugs: hepatotoxicity, agranulocytosis

Pemphigus vulgaris vs. Bullous Pemphigoid

PV: Autoantibodies against desmogliein Blisters are FLACCID, intraepidermal, Nikolsky's sign is positive, INVOLVEMENT OF MUCOUS MEMBRANES BP: Autoantibodies against hemidesmosomes glycoprotein antigens in the basement membrane Blisters are TENSE, subepidermal, Nikolsky's sign in negative, NO INVOLVEMENT OF MUCOUS MEMBRANES

Atypical presentation of MI?

Painless (asymptomatic) much more likely in diabetics, women, the elderly

Example of lobular panniculitis? Septal panniculitis?

Pancreatic panniculitis Erythema nodosum

What are the 2 layers of dermis?

Papillary dermis (upper) Reticular dermis (lower)...

Aplastic anemia in sickle cell is associated with what infection?

Parvo B19

Aortic stenosis pulse?

Parvus et tardus (weak and delayed) carotid upstroke Also associated with a weak S2 and/or S4

Homan's sign?

Passive dorsiflexion of the ankle elicits sharp pain in the calf (Deep vein thrombosis)

Pathogenesis of ANCA vasculitis?

Pathogenesis: Infection inititiates cascade --> ANCA to cell surface --> binding of antibody --> Cytokine storm --> destruction of endothelial lining --> release of interferon gamma IFN-gamma

Pulmonary rehabilitation?

Patient education Exercise training Psycho-social support Nutritional intervention

Do not give nitroglycerin to whom?

Patients w/ inferior STEMI and right ventricular infarction who may experience treatment related hypotension *Treatment of right sided STEMI includes volume expansion (increased preload) with IV bolus of 0.9% saline, followed by potentially an ionotropic agent like Dobutamine.*

Which is more severe: bullous pemphigoid or pemphigus vulgaris?

Pemphigus vulgaris

Common drugs that cause cutaneous reactions?

Penicillins Cephalosporins Sulfonamides Allopurinol Anti-seizure drugs

Electrical alterans specific for what?

Pericardial effusion

Chronic bronchitis and Emphysema both result in what?

Peripheral airway obstruction, parenchymal destruction, pulmonary vascular abnormalities --> arterial hypoxemia, hypercapnia, and cor pulmonale.

Physical exam findings for restrictive cardiomyopathy?

Peripheral edema JVD Hepatojugular reflex Kussmaul sign

Ventricular aneurysm after an MI?

Persistent ST segment elevation + Deep Q waves in the same leads

What common skin findings do dermatomyositis and Lupus have? How to distinguish them?

Photosensitive malar rash Dermatomyositis --> Itch/Pruritic

Presentation: Primary lesion is well demarcated, 2 weeks later a secondary eruption Diagnosis?

Pityriasis Rosea

Psoriasis has what kind of primary lesion and secondary lesion?

Plaque --> scale

Which vasculitis is associated with an infection?

Polyarteritis nodosa (Hep B infection)

Gold standard test for OSA?

Polysomnogram

Diagnosis of COPD?

Post-bronchodilator FEV1 < 80% of predicted Post-bronchodilator FEV1/FVC < *.70* (not 0.8!!) Demonstrates irreversibility

Causes of iron deficiency anemia?

Pre menopausal women - menstruation, pregnancy! pregnancy increases iron demand Men - GI loss (peptic ulcer disease) other causes: Breast feeding (no iron in human breast milk) Celiac disease - malabsorption of iron in duodenum Lack of dietary iron (meat derived foods) Gastrectomy / PPI/ H2 blockers (HCl acid aids in iron absorption by maintaining Fe2+ state, which is more readily absorbed then Fe3+).

If treating RA, which treatment option would give the FASTEST relief? What is 1st line option?

Prednisone Methotrexate

In what situations might you treat Lyme disease with Amoxicillin instead of Doxycycline?

Pregnancy and children under 8 **Remember, Doxycycline is a teratogen and causes tooth discoloration

Most important factor predicting the course of low back pain?

Presence of psychosocial distress (may be associated with pain in a *nondermatomal* pattern)

Hallmark of Sezary's syndrome

Present > 80% erythematous + blood involvement with sezary cells

Types of Anti- phospholipid Ab? Associated with what findings?

Present in 40-50% of SLE patients Associated with: Recurrent miscarriages, DVTs (thrombosis), Thrombcytopenia, Livedo reticularis Type of antibodies --> Lupus anticoagulant (a misnomer) --> it is actually a procoagulant; anti cardiolipin antibody (can lead to false positive SYPHILIS TEST

Formula for post test odds?

Pretest odds * Likelihood ratio = Post test odds

Cause of ventricular tachycardia?

Previous ischemic disease causes a reentrant pathway

Primary vs. Secondary Amenorrhea?

Primary amenorrhea is the absence of menarche in females aged >16 years Secondary amenhorrhea is the cessation of menstruation for 3 cycles or 6 months in females previously menstruating normally?

Anti - mitochondrial ab associated with what disease?

Primary biliary cirrhosis...autoimmune disease characterized by immune-mediated destruction of the intrahepatic bile ducts leading to cirrhosis Associated with xanthomas and xanthelasmas (soft yellow plaques containing lipid-filled macrophages that appear on the medial aspects of the eyelids)

Primary vs. Secondary hemostasis?

Primary hemostasis - Adhesion of platelets to exposed subendothelial matrix --> formation of a platelet plug Secondary hemostasis --> Exposure of tissue factor at the site of vascular damage --> Clotting cascade --> generation of thrombin and fibrin

How to distinguish disorders of primary hemostasis vs. secondary hemostasis?

Primary hemostasis - mucocutaneous bledding: epistaxis, gingival bleeding, easy bruising, manorrhagia Secondary hemostasis - bleeding into muscles and joints

Difference between primary and secondary lesion?

Primary lesion --> arises de novo Secondary lesion --> arises from primary lesion

Diagnosis of a factor inhibitor antibody? Most common factor inhibitor?

Prolonged clotting time that does NOT correct with a mixing study. Antibody against factor 8 *

Risk factors for breast cancer?

Prolonged estrogen exposure 1. early menarche 2. late menopause 3. nulliparity (no progesterone)

Androgen deprivation therapy?

Prostate cancers are dependent on testosterone for growth --> thus ADT is often used to treat higher - risk localized cancers, advanced disease, or local treatment failures *treat patients with metastatic prostate cancer with ADT* (Leuprolide --> gnRH agonist) (Flutamide --> testosterone receptor antagonist)

How to reverse Heparin?

Protamine sulfate (positively charged molecule)

Chagas disease?

Protozoal infection associated with dilated cardiomyopathy and Toxic megacolon/mega esophagus Organism: Trypanosoma cruzi (protozoa)

Besides Rickets/osteomalacia what is another symptom of Vitamin D deficiency?

Proximal myopathy

In diabetic patients, what is the cause of otitis externa?

Pseudomonas

An example of a disease with plaques?

Psoriasis

What is the classic papulosquamous disease?

Psoriasis

Peeling a scale reveals pinpoint bleeding...diagnosis?

Psoriasis (Auspitz sign)

Histology associated with Psoriasis Lichen Planus Actinic keratosis Contact dermatitis?

Psoriasis - Acanthosis Lichen planus - Hypergranulosis Actinic keratosis - Hyperparakeratosis Contact dermatitis - Spongiosis

When to give a tetanus booster?

Pt. with a purulent wound who has not received a booster in the past 5 years

People with OSA are at risk for developing what?

Pulmonary arterial hypertension and Hard to control systemic HTN

Lung disease associated with systemic sclerosis? PFTs in this?

Pulmonary arterial hypertension associated with collagen vascular disease related to systemic sclerosis Pulmonary arterial hypertension (PAH) --> shows isolated decreased DLCO in the setting of normal air flow and lung volumes **Key point here is normal lung volumes (excludes restrictive lung disease)

How to tell difference between purpura/petechiea and telengiectasias?

Purpura/petechiae will not blanch b/c they are just pools of blood under the skin Telengiectasias will blanch because the blood vessels are intact

Hemolytic anemia in a new born?

Pyruvate kinase deficiency

How to prevent genital infections (warts)? What age is appropriate?

Quadrivalent vaccine against HPV 6, 11, 16, 18 for men ages 9026

Most common drug associated with ITP? Diseases associated with ITP?

Quinidine/Quinine HIV, SLE, Lymphomas (CLL)

Rheumatoid arthritis associated lung problems?

RA - interstitial lung disease (restrictive lung disease) Decreased TLC Decreased DLCO Normal FEV1/FVC ratio *Low glucose on pleural effusion*

Why would a RA patient present with nerve damage?

RA induced vasculitis

Best test for folate stores?

RBC folate, not serum folate

2 growth phases of melanoma?

Radial phase - growth along epidermis --> no significant metastatic potential Vertical growth - growth downward into the dermis --> significant metastatic potential

3 growth patterns of melanoma?

Radial phase - growth along epidermis --> no significant metastatic potential Vertical growth - growth downward into the dermis --> significant metastatic potential

Most sensitive test for diabetic nephropathy?

Random urine for microalbumin/creatinine ratio Microalbumin = 30 - 300 mg/24 hr

Achilles Tendon arthritis

Reactive arthritis

Sexually active + Achilles Tendon arthritis?

Reactive arthritis

Q wave on ECG?

Recent MI

Staining for TB?

Red, acid fast Ziehl Neelsen staining (

Treatment of PTLD? Cause of PTLD?

Reduction of immunosuppression + Acyclovir Primary or reactivation of Epstein Barr virus

Abnormal PSA..what next?

Refer for transrectal ultrasound-guided prostate biopsy

Pap smear results ACS-US (atypical squamous cells of undetermined significance)...what to do next?

Reflex HPV testing...If results are positive for high-risk HPV --> colposcopy If results are negative for the high risk subyptes, the pap smear is repeated in 1 year

Tachycardia with regular rhythm vs. irregular rhythm?

Regular rhythm AVRT (WPW) AVNRT Sinus tachycardia Atrial tachycardia Irregular rhythm Atrial flutter Atrial fibrillation (atrial rate usually >350 bpm)!

Creatinine clearance in diabetic nephropathy?

Remember, there is glomerular hyperfiltration and an INCREASE in creatinine clearance in the early stages of diabetic nephropathy.

Pt. with well controlled blood pressure, then suddenly develops HTN even on medication...diagnosis?

Renal artery stenosis

Refractory hypertension to > 3 drugs should cause suspicion of what?

Renal artery stenosis --> the kidneys perceive hypovolemia, activating the RAAS to retain sodium and water

What factors have a worse prognosis for SLE?

Renal disease Anti-ds DNA Ab CNS disease

Secondary causes of osteoporosis?

Renal disease (chronic renal failure) Endocrine - hyperparathyroidism, cushings, osteomalacia Hematopoietic disorders - myeloma, leukemia, lymphoma Nutritional - malabsorption GI - celiac disease Medications - corticosteroids Genetic - Osteogenesis Imperfecta, turner syndrome, klinefelter syndrome

Heterozygotes (sickle cell trait)?

Resistance to malaria

Indications for intubation and mechanical ventilation in patients w/ acute exacerbation of asthma?

Respiratory acidosis, hypoxemia, fatigue are all indications for mechanical ventilation

Corrected reticulocyte count?

Reticulocyte count * (pt. HCT/45) Corrected reticulocyte count >3% indicates good marrow response and suggests peripheral destruction Corrected reticulocyte count <3% indicates poor marrow response and indicates underproduction

Reticulocyte count?

Reticulocytes are immature RBCs. Reticulocyte indicates whether effective erythropoiesis is occurring >2% (>100,000 absolute) reticylocyte count implies RBC desctruction or blood loss. The bone marrow is responding appropriately. Lower than expected reticulocyte count implies erythrocyte underproduction due to: 1. deficient EPO (kidney disease) 2. Nutritional deficincies (iron, folate, B12) 3. primary RBC disorder (RBC aplasia)

Rocky mountain spotted fever rash?

Rickettsia rickettsii infection Rash typically spreads from wrists and ankles to the trunk, often involving the palms and soles at some stage (extremeties to trunk)

Rash that starts on wrists and ankles and spreads to trunk? Treatment?

Rickettsia rickettssi Doxycycline (even in children)

Side effects of TB drugs?

Rifampin - Cyp450 inducer, orange body fluids (tears, sweat, urine) Isoniazid - hepatotoxicity, neuropathy Pyrazinamide - hepatotoxicity Ethambutol - optic neuritis

PE most common cause of death?

Right ventricular dysfunction

TInea corporis?

Ringworm...superficial fungal infection treated with topical antifungals ...TERBINAFINE *ring shaped scaly patches with central clearing and distinct borders* **Patient went swimming in a pool and got a rash**

What test to assess von Willebrand disease?

Ristocetin test causes vWF to bind the platelet receptor glycoprotein 1b --> platelet aggregation In vWD, where vWF is absent or defective, abnormal agglutination occurs during the ristocetin test

Treatment for Pemphigus Vulgaris?

Rituximab

How to distinguish acne and roasacea?

Rosacea causes pustules Involves the nasolabial folds NO Comedones

How to tell apart Rosacea and SLE? (They both have a malar rash)

Rosacea has pustules SLE no pustules

Blood smear of MM?

Rouleaux formation (RBCs stacked like poker chips)

Rubella vs. Rubeola?

Rubeola (measles) - oral Koplik's spots (whitish-bluish papules) Rubella (German measles - Conjunctivitis, post auricular lymphadenopathy

Asthma during pregnancy?

Rule of 1/3s: 1/3 of patients improve, stay the same, worsen. Short acting B-agonists are safe during pregnancy Inhaled corticosteroids are also safe *Best treatment for asthma during pregnancy is normal first line treatment: inhaled steroids*

Patients with Atopic Dermatitis are susceptible to what infections?

S. Aureus HSV

EKG changes with PE?

S1Q3T3 --> right heart strain Wide S in lead 1 Large Q in lead 3 Inverted T in lead 3

Physical findings in Mitral regurgitation?

S3 holosystolic blowing murmur, radiates to the carotids Eccentric LVH Hypotension

Causes of S3 murmur and S4 murmur

S3 murmur: Mitral valve regurgitation Dilated cardiomyopathy Young kids Pregnant women S4 murmur: Filling against a stiff left ventricle Hypertrophic cardiomyopathy Chronic hypertension

Actinic keratosis are a precursor for what?

SCC

Often gets confused with Psoriasis?

SCC

Transplant patient with skin changes?

SCC

Types of LUNG cancers?

SCLC - 25% Non SCLC - 75%

Treatment for SCLC vs. Non-SCLC?

SCLC - radiation + chemotherapy Non-SCLC - surgery

How to distinguish Erythema multiforme from SJS?

SJS patients are very sick Erythema multiform patients are not

False positive Syphilis test?

SLE patient with anti-cardiolipin antibodies RPR/VDRL test uses cardiolipin as a reagent, so you get a false positive test

What is seen in Acute Contact Dermatitis histology (poison ivy)? Chronic Contact Dermatitis histology (necklace for example)?

SPONGIOSIS! --> causes vesicle formation Acanthosis! No spongiosis --> no vesicle formation; instead you will just see erythema

STEMI ECG findings? NSTEMI ECG findings?

ST elevation > 1 mm in 2 or more contiguous leads Elevated cardica biomarkers in avsence of ST elevation (can be associated with ST depression)

Respiratory alkalosis?

Salicylate intoxication --> Hyperventilation High altitude --> hyperventilation

Long term complication of lichen planus?

Scarring alopecia

Where to assess jaundice?

Sclera

Screening/Treatmetn of newborns?

Screen all infants and treat with prophylactic *PENICILLIN* for 5 years to reduce mortality from *PNEUMOCOCCAL INFECTIONS*

Different types of glands?

Sebaceous --> produce a fatty substance secreted onto the skin surface through hair follicles --> all over the body except palms and soles Sweat glands --> 2 types: Eccrine --> all over the body Apocrine --> found in axillary and genital regions

Important differential dianosis of Pityriasis Rosea? How to tell the difference?

Secondary Syphilis** Tinea infection Blood titer in syphilis

Lichenification? Due to what?

Secondary lesion --> thickening of epidermis Chronic rubbing or scratiching of an area

Sensitivity, Specificity, NPV, PPV formulas?

Sensitivity = TP / (TP + FN) Specificity = TN / (TN + FP) PPV = TP / (TP + FP) NPV = TN = (TN = FN)

What statistical measures change as disease prevalance changes?

Sensitivity and Specificity, and Likelihood Ratios DO NOT change as disease prevalence changes PPV and NPV DO change as disease prevalence changes As the disease prevalence decreases, the PPV decreases and the NPV increases. As the disease prevalence increases, the PPV increases and NPV decreases.

2 phases of contact dermatitis?

Sensitization phase --> requires prior exposure to allergen Ellicitation phase

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Sensorineural hearing loss

What type of panniculitis is Erythema nodosum?

Septal pannciulitis --> Septal panniculitis (inflammatory cells only in the septal part of subcutis fat

Most useful test in evaluating iron deficiency?

Serum ferritin

Diagnostic tests for MM?

Serum protein electrophoresis Urine protein electrophoresis (looking for Bence Jones protein)

Which drug reaction can present like the morbilliform rash? How to distinguish from morbilliform

Serum sickness can also present like a morbilliform rash (generalized maculopapular rash) Can distinguish by Serum sickness having systemic sequelae

Therapy for gestational hypertension?

Severe gestational HTN is treated with: Methyldopa, labetalol, Nefedipine, Hydralazine Mild gestational HTN is treated with lifestyle modifications

Trigeminal neuralgia most often affects what nerve distribution?

Sharp, burning pain lasting a few seconds V2 distribution

Psoriasis histology? Treatment?

Sharply defined erythematous papules and plaques, with whitish scaling, on EXTENSOR SURFACES Epidermal hyperplasia with parakeratotic scaling, and inflammatory cell infiltrate Topical glucocorticoids (BETAMETHASONE)

Leser-Trelat sign?

Simultaenous appearance of numerous Seborrheic keratoses associated with GI or lung cancer

Sand in my eyes?

Sjogrens

Trouble eating and swallowing crackers?

Sjogrens

Treatment for a sliding hiatal hernia?

Sliding hiatal hernia can cause GERD, b/c the LES and a portion of the stomach rise above the diaphragm --> treat with H2 blocker (ranitidine) or PPI (omeprazole)

CHD risk factors?

Smoking HTN Low HDL Family History of CHD Age

Difference between Spongiosis and Hydropic degeneration? Spongiosis vs. Urticaria?

Spongiosis - fluid in between cells Hydropic degeneration - fluid accumulation inside cells

Spongiosis vs. Urticaria/Angioedema

Spongiosis = Edema between cells in the epidermis; causes intracellular connections to be lost; can cause blisters Urticaria = Edema in the dermis Angioedema = Deep dermis edema ; also can involve the subcutaneous tissue

Spongiosis vs. Urticaria vs. Angioedema?

Spongiosis = epidermal edema Urticaria = superficial dermal edema Angioedema = deep dermal edema

If someone is on immunosuppressives (Transplant patient), what is the most common kind of cancer they will get?

Squamous cell carcinoma (SCC)

Lesion in the vermilion zone of the lower lip?

Squamous cell carcinoma (SCC)

Paraneoplastic syndromes associated with lung cancers?

Squamous cell carcinoma - Parathyroid hormone-related protein (PTHrP) ---> HYPERCALCEMIA Small cell lung cancer - SIADH, Cushings

How to stage pressure ulcers?

Stage 1 - skin is red, but not broken Stage 2 - partial thickness damage through epidermis and dermis Stage 3 - full thickness loss of skin through to SQ tissue Stage 4 - full thickness loss of skin through to muscle, bone

Staging of cancer and Treatment?

Stage 1: Confined to muscularis propria (RESECTION FOR CURE) Stage 2: Extends into subserosa or directly invades other structures (RESECTION OF CURE) Stage 3: Metastatic to regional LNs (RESECTION AND ADJUVANT CHEMOTHERAPY) Stage 4: Distant metastases (PALLIATIVE RESECTION, MULTI-AGENT CHEMO)

Staging of lung cancer for Non-SCLC?

Stage 1: Tumor surrounded by lung or pleura --> SURGICAL RESECTION Stage 2: Locally advanced disease without mediastinal involvement --> SURGICAL RESECTION Stage 3: Mediastinal involvement --> SURGICAL + ADJUVANT CHEMOTHERAPY/RADIATION Stage 4: Metastatic - CHEMOTHERAPY

Most common cause of osteomyelitis?

Staph. Aureus

Cause of SSSS?

Staphylococcal exotoxins cause high fever and erythematous rash with sloughing of skin (positive Nikolsky sign). Seen in young kids

What drugs can cause drug induced dermatomyositis?

Statins Skin only: Hydroxyurea

Culture of SSSS?

Sterile, becuase this is a exotoxin -mediated process...toxins target demoglein 1

Extra cutaneous presentation of Rosacea?

Stinging and burning of eyes

5 layers of the epidermis from top to bottom?

Stratum Corneum - Pink keratin within anucleated cells Stratum Lucidum Stratum Granulosum - Granules within the keratinocytes Stratum Spinosum - cells are connected by desmosomes Stratum Basale - stem cell layer

Underlying causes of Erythema nodosum ?

Strep infection TB Hep B Sulfa drugs Oral contraceptives

3 most common organisms in bacterial sinusitis (most are viral)?

Strep. pneumoniae Haemophilus influenzae Moraxella Catarrhalis (same as otitis media)

What bacterial organism can be detected by a rapid antigen test?

Streptococcal pharyngitis (strep throat - Group A streptococci) Mucus swab is exposed to a reagent containing antibodies that will bind specifically to a GAS antigen

How to differentiate SSSS and SJS?

Subcorneal vs. Subepdiermal histology History: S. aureus vs. drug reaction Mucous membrane involvment: SJS always has mucous membrane involvement

What part of heart muscle most susceptible to ischemia?

Subendocardium (receives blood supply during diastole --> tachycardia shortens diastole --> ischemia)

Mycosis fungoides? Sezary syndrome?

Subtype of cutaneous T-cell lymphoma. rarely seen "leonine facies" MF with presence of atypical T lymphocytes in the blood

SPF stands for? Measures?

Sun protection factor Mainly assesses UVB

Malassezi furfur?

Superficial fungal infection Tinea versicolor Hypo/hyperpigmented lesions

4 subtypes of melanoma?

Superficial spreading (most common; good prognosis) Nodular (poor prognosis) Subungual/Acral - arises on palms or soles; not related to UV light exposure Lentigo Maligna - (good prognosis)

Papillomatosis?

Surface elevation due to acanthosis and enlargement of dermal papillae

Treatment for a solitary brain metastasis with stable extracranial disease? Multiple brain metastases?

Surgical resection of the mass Whole brain radiation

Drugs of choice for chemoprophylaxis of viral influenza and H1N1?

Susceptible to Oseltamivir and Zanamivir (neuraminidase inhibitors) Resistant to amantadine and remantadine (influenza M2 protein inhibitors)

How to measure pulmonar artery pressure/PCWP?

Swan ganz catheter

Rheumatoid arthritis?

Synovitis leading to PANNUS formation (inflamed granulation tissue) --> Bone erosion Diagnostic tests: Anti-CCP, RF (IgM anti Fc portion of IgG) *Spares DIP joints*

Treatment for: Syphilis HSV-2 Chancroid (Haemophilus ducreyi)

Syphilis - penicillin (doxycycline if allergic) HSV-2 - acyclovir Chancroid (Haemophilus ducreyi) - Ceftriaxone (broad spectrum against gram -)

1st line option of severe, scarring acne or cystic/nodular acne?

Systemic retinoid therapy

DEXA scan scores?

T scores <-2.5 (standard deviation) = osteoporosis T scores between -1 and -2.5 = osteopenia

ECG with Pulmonary embolism?

T wave inversion in leads V1 - V6

How are erythema nodosum and erythema multiforme similar? Underlying causes?

THey are both reactions to underlying disease processes If you biopsy the lesions, you WILL NOT find the underlying cause Erythema nodosum - Strep infection, TB, Hep B, Sulfa drugs, oral contraceptives Erythema multiforme - HSV, Mycoplasma

Lung volumes in COPD?

TLC increased RV increased FRC increased DLCO decreased

Treatment for Pneumocystis jiroveci in HIV/AIDS patients?

TMP-SMX

Treatment for uncomplicated cystitis (UTI)?

TMP-SMX

Breast cancer staging?

TNM T - tumor size* N - axillary lymph node status* M - metastatic disease * most important

Drugs used in breast cancer?

Tamoxifen - anti estrogen (used for ER+ or PR+ breast cancers) -- PRE MENOPAUSAL WOMEN Aromatase inhibitors (ANASTRZOLE) - used for ER+ cancers in POST MENOPAUSAL WOMEN ONLY

Thalssemia RBC findings?

Target cells Teardrop cells Basophilic stippling

Diagnosis of viral influenza?

Temp > 100 F and either cough, pharyngitis, or rhinorrhea

Test with the best accuracy will have the greatest Area under the curve.

Test will crows the left upper margin

What antibiotics are used in the treatment of acne? What is a side effect of this medication?

Tetracyclines Phototoxic drug eruptions...manifest as sunburn reactions

Revascularization for stable angina?

The COURAGE trial showed no difference in mortality b/w patients with stable angina treated with maximal medical therapy alone vs. PCI.

What is the TIMI score and what does it indicate?

The TIMI score is a risk of having an MI or death in pt. with unstable angina or NSTEMI within 14 days. Age > 65 years > 3 risk factors for CAD Known CAD (>50% stenosis) 2 episodes of sever angina in last 24 hours Aspirin use in past 7 days Elevated serum cardiac enzymes ST changes >0.5 mm The TIMI stratifies which patients will benefit with a GIIb/IIIa inhibitor + early PCI

Obesity - hypoventilation syndrome?

The combination of: 1. obesity (body mass index above 30 kg/m2), 2. hypoxia (falling oxygen levels in blood) during sleep, and 3. hypercapnia (increased blood carbon dioxide levels) during the day, resulting from hypoventilation (excessively slow or shallow breathing).

Liver disease effect on clotting factors?

The liver synthesizes almost all proteins involved in hemostasis, except vWF. PT is most sensitive indicator of hepatic synthetic function due to short half-life of *factor 7* (6 hours), which the failing liver cannot maintain PT and aPTT are both increased in advances liver disease

Cause of warfarin induced skin necrosis?

The short half-life of protein C (6 hours) actually makes people initially hypercoagulable who take Warfarin. *Concominantly treat with heparin initially*

Hallmark of scleroderma?

Thick, hard skin Loss of hair on the skin affected by scleroderma

What happens to the skin affected by scleroderma?

Thickens, hardens due to fibroblast proliferation and collagen deposition Also, LOSE HAIR**

Thoracic vs. Abdominal dissections?

Thoracic dissections are surgical emergencies Aortic dissections distal to subclavian artery are treated medically w/ Beta Blockers

Aplastic anemia is associated with what physical finding?

Thymoma

Patient went swimming in a pool, and now has a rash?

Tinea corporis (ringworm)

Treatment of scabies mite?

Topical permethrin or ivermectin

TEN?

Toxic epidermal necrolysis

Syncope?

Transient loss of consciousness and postural tone caused by global cerebral hypoperfusion, followed by spontaneous recovery. Major purpose of evaluation is to distinguish CARDIAC VS. NONCARDIAC causes.

What causes transudative pleural effusions vs. exudative pleural effusions?

Transudate: Heart failure Nephrotic syndrome Liver failure Exudative: Malignancy Abscess Pancreatitis Pulmonary emboli

Treatment of anemia of chronic disease?

Treatment of underlying disease **Can give recombinant Epo**

What cytokine is thought to perpetuate Lupus autoantibody formation?

Type 1 Interferon released by DCs that acts on B cells

Urticaria can occur as a result of what hypersensitivities?

Type 1 and 3

What kind of collagen is in the skin?

Type 1 collagen

Acute urticaria can be what type hypersensitivity? Chronic urticaria? Eczema? Contact dermatitis?

Type 1 or Type 3 (complement mediated urticaria) Type 1 Type 4 (non immunological basis) Type 4 (immunological basis)

Immunologic drug reactions?

Type 1-4 hypersensitivity reactions (most Type 1 and 3) Type 4 cause serious injury Mast cells --> urticaria/angioedema Basophils --> Anaphylaxis Mediators --> Histamine, Leukotriences

Lichen planus is what kind of hypersensitivity?

Type 4 Mediated against matrix metalloproteinases

Vesicular and bullous diseases are what kind of hypersensitivity? Pemphigus vulgaris Bullous pemphigoid

Type II an autoimmune disease caused by antibodies directed against both desmoglein 1 and desmoglein 3 resulting in the loss of cohesion between keratinocytes in the epidermis Antibodies directed to proteins that attach cells to basement membrane --> cells start to detach from basement membrane

Hemothorax criteria?

Type of pleural effusion (w/ blood) pleural fluid HCT > 50% peripheral blood HCT

Melanin is made from what precursor AA?

Tyrosine

Associations of Pyoderma Gangrenosum?

UC/Chrons Leukemias

Most common cancer in women in the US? Most common cancer in women worldwide?\ Worst gynecological cancer prognoses?

US - endometrial cancer Worldwide - cervical cancer Worst prognosis = ovarian > cervical > endometrial

Pathogenesis of actinic keratosis?

UV induced cumulative mutations in p53

PABA (esters) containing sunscreens will only protect against?

UVB - which is the major cause of ultraviolte radiation

What is actinic keratosis?

UVB induced DYSPLASIA of the keratinocytes

What is found on the fingers and toes in Scleroderma?

Ulcerations

How to distinguish solid breast masses from cystic masses?

Ultrasound

Infiltrative SCC can affect what?

Underlying nerves and bone

Drugs of choice for routine venous thrombosis prophylaxis interventions?

Unfractionated heparin, LMWH, fondparinux all options (aspirin is not sufficient alone)

Who would you treat with IV heparin and nitroglycerin?

Unstable angina

How does an atherosclerotic plaque occlude the lumen of a vessel?

Unstable atherosclerotic plaque ruptures --> activates the clotting system --> formation of a thrombus (fibrin + platelet aggregation) in the vessel lumen --> occlusion Complete occlusion: STEMI Incomplete occlusion: NSTEMI

Stable vs. unstable plaque?

Unstable plaque - large lipid core with a thin fibrous cap made of smooth muslce -- can easily rupture Stable plaque - small lipid core with a thick fibrous cap made of smooth muscle -- doesn't easily rupture

Sensitivity to NSAIDs (aspirin) in asthmatics?

Up to 20% of people may experience bronchoconstriction after taking aspirin/NSAIDs. H/o *nasal polyps*

Genetics of Basal Cell Carcinoma?

Upregulation of Hedgehog signaling pathway, leading to mutations in PTCh1 and SMO proteins Also UVB induced muatations in p53

How to diagnose legionella pneumoniae?

Urine antigen test Direct fluorescent antibody (DFA) staining of sputum

Positive Nikolsky sign?

Usually indicative of an intraepidermal (flaccid) blister

Red man's syndrome?

Vancomycin mediated rash from giving it too quickly Involves a rash over the entire body and flushing, *specifically in the head and neck areas*

Keratoacanthoma?

Variant of SCC that rapidly grows but rarely progresses to cancer and usually spontaneously resolves

Multifocal atrial tachycardia?

Varying PR interval with 3 or more morphologically distinct P waves in the same lead

Drugs that cause orthostatic hypotension?

Vasodilatory anti-hypertensive + preload reducing agents: Diuretics, nitrates, alpha blockers, beta blockers

Patient has a prodrom of symptoms of nausea, lightheadedeness, and diaphoresis before fainting...diagnosis?

Vasovagal (neurocardiogenic syncope)

What vessel associated with: Ventricular free wall rupture? Papillary muscle rupture?

Ventricular free wall rupture - LAD Papillary muscle rupture - RCA

Arrhythmias causing syncope?

Ventricular tachycardia Atrial arrhythmia Bradyarrhythmia ECG can also show: prolonged QT interval AV block Delta wave (preexitation syndrome - WPW)

Presence of canon a waves on jugular pulsations?

Ventricular tachycardia - h/o prior MI very supportive

Example of common warts? Common warts (non-genital infections) are caused by what?

Verruca vulgaris, verruca plana, verruca plantaris HPV 1,2,4,7

How to identify mycosis fungoides?

Very asymmetric lesions

What kind of skin lesion does herpes zoster produce?

Vesicles

Chronic urinary tract infections as a child...diagnosis? How to diagnose?

Vesicoureteral reflux Voiding cystouregrogram

Shingles?

Vesicular eruption that occurs in a dermatomal distribution caused by varicella zoster virus

Treatment of viral vs. bacterial conjunctivitis?

Viral - topical acyclovir (or eye drops) Bacterial - Erythromycin or Sulfa eye drops **Can distinguish by the presence of purulent discharge in bacterial conjunctivitis)

Morbilliform drug reactions should be differentiated by what other diagnosis? How to distinguish?

Viral infections Eosinophils would point to a drug infection

Causes of vitamin K deficiency?

Vitamin K is modified in the gut flora to the active form. 1. Malabsorption 2. Long term ABX therapy --> elimination of intestinal flora 3. Neonates don't have fully developed intestinal flora *PT prolongs first, but eventually so does aPTT*

Difference between vitiligo and albinism

Vitiligo - autoimmune destruction of melanocytes Albinism - enzyme deficiency (unable to make melanin) ; NORMAL NUMBERS OF MELANOCYTES

Causes of metabolic alkalosis?

Vomiting Hyperaldosteronism Volume contraction

Metabolic acidosis compensatory changes expected?

WInters formula = Expected PCO2 = (1.5 x HCO3) + 8 +- 2

Difference b/w Waldestrom macroglobulinemia and MM?

Waldestrom - mostly IgM; more hyperviscosity symptoms; no lytic bone lesions MM - mostly IgG or IgA

Wells criteria and probability of DVT? Diagnostic test based on Wells score?

Wells score of: >3 - high probability DVT - doppler ultrasound 1-2 - moderate probability of DVT - doppler ultrasound 0 - low probability DVT - D-dimer assay (if positive --> doppler ultrasound)

Difference between basal cell carcinoma and squamous cell carcinoma?

Where they arise from in the epidermis Basal cell --> (lowest) basal layer Squamous cell --> upper layer

Prostate cancer screening recommendations?

White/hispanic men - age 50 African American men - age 40 (highest-risk ethnic group for Prostate cancer).

Lichen Planus? Associated with what systemic disease?

Wickham striae (reticular white lines on mucosal areas) 6 P's: Pruritic Purple Polygonal Planar Papules Plaques Hepatitis C

Lichen planus associated with what hallmark?

Wickham striae (reticular white lines on surface)

Most sensitive radiographich finding for thoracic aortic dissection? Physical finding?

Widened mediastinum Unequal BP measurements on opposite sides of body

Who is at risk of atypical presentation of Acute coronary syndrome? What is an atypical presentation?

Women Elderly Diabetics Dyspnea without chest pain

Hemophilia?

X-linked disorders Hemophilia A - Factor 8 deficiency Hemophilia B - Factor 9 deficiency Treat with recombinant factors **Patient will present with a prolonged aPTT that corrects with a mixing study**

Physical signs of elevated lipids?

Xanthomas (cutaneous, tendinous) Commonly seen in familial hypertriglyceridemia, hypercholesterolemia Xanthelasms - flat yellow papules or plaques seen around the eyelids in familial hypercholesterolemia

Should you tell the patient what you find in exam?

Yes, keep communication with the patient and tell them diagnostic impression

PPD test in a patient with HIV?

You may get a false negative if CD4 < 500 b/c of anergy, so not a good test

Acute respiratory distress syndrome?

acute onset hypoxemia Diffuse alveolar damage --> increased capillary permeability --> protein rich leakage into alveoli and noncardiogenic pulmonary edema --> formation of intraalveorlar hyaline membrance *Noncardiogenic pulmonary edema* --> normal PCWP ARDS is the presence of pulmonary edema in the absence of volume overload or depressed left ventricular function. (non cardiac source) 1. Acute onset 2. Bilateral alveolar infiltrates on CXR 3. Pulmonary capillary wedge pressure < 18 4. PaO2:FIO2 ratio < 200

What is the only SLE antibody that is a marker for lupus nephritis along with disease activity?

anti-ds DNA

Autoantibody involved in drug induced SLE? Other autoantibodies involved in SLE?

anti-histone antibodies positive in 100% of patients with drug induced SLE Anti-sm (smooth muscle) Anti-RNP (ribonucleoprotein)

Comorbidities with asthma?

atopic dermatitis or eczema Family history of asthma

Dressler syndrome?

autoimmune post MI pericarditis occurring weeks to months following MI

Asbestosis Chest xray findings?

bilateral partially calcified pleural plaques **Pleural involvement is a hallmark of asbestos exposure, whereas it is unusual in other interstitial lung disorders**

VTE prevention?

cancer patients -->LMWH Hip/knee replacement --> Fondaparinaux High risk/medical and surgical patients --> UFH or LMWH

Hepatopulmonary syndrome?

dyspnea in the setting of chronic liver disease The hypoxemia results from pulmonary vascular dilatation with intrapulmonary shunt and V-P mismatch.=, *which may worsen when person is in upright posture* Orthodeoxia - fall in partial pressure of oxygen with upright posture Platypnea - dyspnea worse when sitting upright

Describe the skin rash distribution in acute Lupus...

erythematous, sharply demarcated plaques **Sparing of nasalabial folds on face and knuckles on the hands*

How often to reassess asthma patients?

every 3-6 months

Where is the best place to assess central cyanosis?

lips, oral mucosa, and tongue

Chest x-ray findings of pneumothorax?

loss of normal lung markings in the periphery of the hemithorax presence of a well-defined, visceral pleural line at some point b/w chest wall and the hilum

Cause of Atrial fibrillation?

loss of sinus node function --> leading to uncontrolled atrial contraction ECG - *absent P waves* atrial rate >350 bpm

Omalizumab?

mAb that binds to EgE and is useful for patients with SEVERE persistent asthma to reduce exacerbations Side effect: severe anaphylaxis

Anti-RNP ab?

more frequent in AA DIagnostic for MCTD --> which presents with myositis and Raynaud's

Anti-smith Ab?

more frequent in AA Specific for SLE

Cause of MVP?

myxomatous degeneration of the mitral valve leaflets

Causes of respiratory acidosis?

narcotic overdose (opioids) Neuromuscular weakness (ALS, myasthenia gravis) COPD

Aortic stenosis findings?

narrow pulse pressure parvus et tardus carotid upstroke S4 systolic ejection murmur

Treatment for iron deficiency anemia?

oral Ferrous sulfate 325 mg 3x/day

p-ANCA c-ANCA against which antigens?

p-ANCA against Myeloperoxidase c-ANCA against PR3

When does pharmacologic therapy for osteoporosis begin?

patients with a DEXA T score < -2.0 patients with a DEXA T score < -1.5 + additional risk factors patients with prior fractures

Cobblestone appearacne on posterior pharynx...diagnosis?

post-nasal drip (allergic rhinitis)

Contraindications for oral contraceptives?

pre-existing cardiovascular disease h/o thromboembolism smokers >35 - 40

Chronic bronchitis?

productive cough for 3 months in each of 2 successive years with chronic sputum production. Associated with an increase in the volume of tissue in the bronchiolar wall and an accumulation of inflammatory exudate (HYPERTROPHY OF THE BRONCHIAL MUCINOUS GLANDS --> INCREASED THICKNESS OF MUCUS GLANDS)

Psoriasis affects what surfaces? Atopic dermatitis?

psoriasis = extensor surfaces Atopic dermatitis = flexure surfaces

Heliotrope rash? Gottron's papules?

rash of the upper eyelids red papules on the hands

Cor pulmonale (right ventricular hypertrophy) as a result of COPD

right heart failure due to long standing pulmonary hypertension increased intensity of pulmonic sound fixed S2 split *parasternal lift due to RVH* signs of right sided heart failure: JVD, peripheral edema, liver enlargement

What is the initial treatment for acute cocaine intoxication?

sedation with a BENZODIAZAPINE

Sickle cell mutation?

single base change in the 6th codon of exon 1 of the B-globin gene Replacement of glutamic acid with valine Low o2, dehydration, or acidosis --> causes Deoxygenated hemoblobin S *polymerize* to form fibrils, causing RBS to sickle and hemolyze

Exercise induced bronchospasm?

typically begins at the start of exercise and peaks 5-10 minutes after exercise Use short acting B agonist (albuterol) 15 minutes before exercise

Hallmark feature of molluscum contagiosum?

umbilicated central Molluscum bodies - large eosinophilic cytoplasmic inclusions

Oxygen therpay in COPD?

used for Stage IV (severe) COPD: arterial PO2 < 55 or O2 sat < 88% also used if pulmonary HTN, evidence of cor pulmonale, edema/right sided heart failure O2 therapy for >15 hrs/day **O2 therapy is the only therapy proven to improve survival in COPD**

Tooth extraction bleeding...diagnosis?

vWD disease

Young patient who develop CHF randomly...diagnosis?

viral myocarditis

If common warts are NOT treated, what is outcome?

~80% are resolved within 2 years