Medicine Clerkship

Treatment of decompensated heart failure

1. Supplemental oxygen 2. Lasix as needed 3. Consider nitroglycerin if adequate end-organ pressure, if in shock, use IV norepi

Basic testing in initial diagnosis of HTN

1. UA for occult hematuria and P/C 2. CMP 3. Lipid profile 4. baseline ECG

Features of pericarditis

1. idiopathic, viral, TB, malignancy, prior cardiac surgery 2. fatigue, dyspnea, edema, ascites, increased JVP ↑ 8, pulsus paradoxus, pericardial knock (middiastolic sound) 3. Pericardial thickening and calcification, ECG may show a. fib

Mixed cryoglobulinemia syndrome

- Chronic HCV, HIV, SLE - Fever, arthralgias - Glomerulonephritis, HTN - Dyspnea, pleurisy - Palpable purpura, leukocytoclastic vasculitis - LOW C4

acute angle closure glaucoma

- more common in women - acute onset of severe eye pain - seeing halos - injected, pupil is dilated with poor response to light - tearing and HA, N/V - meds that precipitate: tolteridine, sympathomimetics, decongestants

Bacterial endocarditis

- normocytic anemia and elevated sed rate -splenic, cerebral, pulmonary infarcts from systemic emboli - janeway lesions (nontender) of palms and soles - osler nodes (painful) violaceous nodules seen on fingertips & toes - roth spots, edematous & hemorrhagic lesions of retina - fatigue, joint pains, low grade fever, dark urine, SOB

ITP

- preceding viral infection - petechiae, ecchymosis - mucosal bleeding - isolated thrombocytopenia - observe in children, in adults if cutaneous symptoms and platelets over 30 - treat with steroids, IVIG, anti-D if bleeding or platelets < 30

Bacterial conjunctivitis

-Adult: staph aureus - Child: h. flu, moraxella, strep pneumo - thick, purulent discharge that reaccumulates after wiping

age related sicca syndrome

-Exocrine output from lacrimal and salivary glands declines with age, associated with atrophy, fibrosis, and ductal dilation of the gland. -corneal erosions leading to impaired vision

polycythemia vera

-HTN -erythromelalgia (burning cyanosis in hands/feet) -aquagenic pruritis - facial plethora - ↑ Hgb, ↓ low EPO - JAK2 mutation

Patellofemoral syndrome

-aggravated by running, negotiating stairs, prolonged sitting -atrophy or weakness of the quadriceps or hip abductors - rotational or varus/valgus malalignment -provocation of pain during tonic contraction of the quad strongly suggests diagnosis

Calciphylaxis

-end stage renal disease -arteriolar & soft tissue calcification -local tissue ischemia & necrosis -painful nodules and ulcers -hypercalcemia, hyperphosphatemia, hyperparathyroidism

Walndenstrom macroglobulinemia

-excessive production of IgM antibody - CP: vision changes, HA, vertigo, ataxia, dilated segemented tortuous retinal veins - labs reveal anemia, gamma gap, and elevated ESR - order SPEP

Lead poisoning

-microcytic anemia - abdominal pain, constipation, anorexia - cognitive deficits, peripheral neuropathy - occupational exposure - basophilic stippling on peripheral smear

Febrile nonhemolytic transfusion reaction

1-6 hours, transient fevers and chills, malaise. Cytokines from leukocytes stored in blood product. Leukoreduction of donor blood helps

Initial management of DKA

1. NS in first 1-2 hours (Give D5 when glucose reaches < 200) 2. IV regular insulin 3. Serial assessment of electrolytes 4. Treatment of underlying precipitating factors

Behcet disease

1. middle eastern people 2. oral and genital ulcers, ocular involvement, 3. skin lesion: pathergy which is hyperreactivity to needle sticks--sterile skin abscesses. 3. treatment: steroid and colchicines

What test is used to compare proportions of a categorized outcome

2 x 2 table categorical variables Chi-square test Example: Outcome High | Outcome Low | Total No Intervention Intervention Total

Reversible causes of asystole/PEA

5 Hs = hypovolemia, hypoxia, hydrogen ions, hypo/hyperkalemia, hypothermia 5 Ts = tension pneumo, tamponade, toxins, thrombosis, trauma

Most common origin of PE

90% from deep leg veins i.e. iliac, femoral, popliteal

TEN vs. SJS

<10% = SJS 10-30% = overlap >30% = TEN

Organisms that cause epididymitis in ages < 35 and > 35

> 35 = E. coli, bladder outlet obstruction < 35 = STI, chlamydia or gonorrhea

Known asthma, symptoms twice per week, no nighttime awakenings, no limitation of activities. Best treatment?

Albuterol (step 1) Mild intermittent asthma

Recommended initial step in management in the setting of alkali ingestion

Endoscopy should be performed w/in the first 24 hours barring respiratory stress or clinical signs of perforation (pneumomediastinum, pleural effusion, subdiaphragmatic air)

86 y.o woman, progressive confusion and lethargy. Hx of Alzheimer dementia. Non-contrast CT shows parietal lobe hemorrhage. She withdraws to painful stimuli on her right but not her left. Likely cause?

Amyloid angiopathy i.e. Beta amyloid deposition in walls of small-medium cerebral arteries resulting in vessel weakness and predisposition to rupture

24 year old man with chronic low back pain. Pain is worse at night and improves upon arising and with exercise. Only takes naproxen. Elevated sed rate and restrictive pattern on PFTs.

Ankylosing spondylitis

Flat broad T waves, U waves, St depression and PVCs. CP of weakness, occasional pain in muscles.

Hypokalemia

What is true about both DKA and hyperosmolar hyperglycemic state

A deficit of total body potassium due to osmotic diuresis

contralateral somatosensory & motor deficit, predominant in lower extremity, abulia, dyspraxia, urinary incontinence

ACA infarct

Mainstay of scleroderma renal crisis

ACEi collagen deposition leads to renal ischemia, which results in activation of RAAS system. BP ↑ further damages the renal vasculature

42 year old presents to ED with weakness. Has been on alcohol binge the past 2 days. Also used cocaine previous night. He stumbled out of bed and fell several times while trying to get to the bathroom. He has no other medical problems. He is hypertensive, tachy, has mildly dilated pupils, no JVD, cardiopulmonary exam is normal. LE muscle strength is decreased but sensation is normal. Over the next few days he is at greatest risk for?

AKI alcohol induced myopathy can lead to rhabdomyolysis and subsequent AKI

Weight loss, diabetes, diarrhea, painful and pruritic papules that coalesce to form large, indurated plaques with scaling and central clearing on the face, groin, and extremities.

Glucagonoma with necrolytic migratory erythema

Most effective agent for allergic rhinitis

Glucocorticoid nasal spray

Back pain exacerbated by walking or prolonged standing, able to tolerate bicycling. Pain radiates to buttocks and thighs

Neurogenic claudication from lumbar spinal stenosis Shopping cart sign- pain relieved by bending forward (like on a bicycle)

How will changing the cutoff value of a test change the sensitivity of it?

Increasing a cutoff value will make it harder to get a positive so this means there will be more false negatives and less true positives (i.e. a decrease in sensitivity) Decreasing will do vice versa (i.e decreased specificity)

How does hypomagnesemia lead to hypocalcemia

Inducing resistance to PTH and decreasing PTH secretion.

Bought a watch from a street vendor, now pruritic rash around wrist. Likely material watch was made of?

Nickel

Medications associated with SIADH

carbamazepine, SSRIs (especially in elderly), NSAIDs present with hypotonic hyponatremia euvolemic

Shoulder pain with decreased passive and active range of motion in middle age woman with diabetes.

Adhesive capsulitis ddx: rotator cuff injury (though passive ROM would be normal), tendinopathy, OA (uncommon, usually caused by trauma)

35 y.o male presents with BP 220/120, SOB, and dry cough. Serum potassium is 5.0 and creatinine is 2.1 mg/dl. Started on nitroprusside infusion with improvement. Next morning he is confused, agitated, and has a generalized tonic-clonic seizure. Likely diagnosis?

Cyanide toxicity from nitroprusside Happens especially in patients with renal insufficiency

Imaging modalities to confirm diagnosis of ureteral calculi

ultrasound or non-contrast CT, utrasound preferred in pregnant patients

36 year old man, 2 day hx of trace blood on toilet paper, drops of blood in toilet from defecation. Otherwise feels well. PMH and FH unremarkable. Nontender and soft abdomen, normal bowel sounds. DRE unremarkable except for traces of red blood visible on the glove. Next step in management?

Anoscopy or proctoscopy Colonoscopy or sigmoidoscopy would be appropriate if patient were older and had more risk factors for cancer or IBD (change in bowel habits, weight loss, iron deficiency anemia, FH of cancer)

MI and coronary vessel involvement

Anterior MI- LAD (V1-V6) Inferior MI- RCA or LCX (II, III, aVF) Posterior MI- LCX or RCA (I and aVL) Lateral MI- LCX, diagonal (I, aVL, V5, V6) Right ventricle MI- RCA (V4-V6) RCA occlusion can cause AV nodal block

Babesiosis

Ixodes scapularis tick (Lyme, and anaplasma) Fever, fatigue, myalgias, HA Anemia, thrombycytopenia, ↑ bilirubin/LDH/LFTs Risk of immunocompromised, had a splenectomy, or over 50 Diagnose with intraerythrocytic rings on thin blood smear (maltese cross)

18 y.o AA male with 3 day hx of progressively worsening fatigue and exertional dyspnea. 2 weeks ago diagnosed with URI that was treated with amoxicillin. The spleen is enlarged. Sceral icterus is present. Labs show normocytic anemia with normal MCH. Likely diagnosis?

Autoimmune hemolytic anemia, confirmed with positive Coombs test, peripheral smear shows spherocytes, and reticulocytes -postviral -antibiotic related Sickle cell less likely because autosplenectomy would have occured already by adulthood and there is no hx of vasoocclusive crises

29 year old male with blood pressure 180/ 112 and pulse of 78. ECG shows normal sinus rhythm, high voltage QRS complexes, down-sloping ST segment depression, and T wave inversion in Leads V5 in V 6. Best next step in evaluation?

Bilateral arm and leg blood pressure measurements

19-year-old man presents with confusion, severe dyspnoea, and cough productive of yellowish sputum streak with blood, he recently visited urgent care last week for fever, rhinorrhea, and malaise. He was diagnosed with a viral infection and given a prescription that seemed to improve his illness. On exam he is febrile. Long exam shows bilateral crackles in the lungs mid fields. Chest X-Ray reveals alveolar infiltrates in the mid lung fields bilaterally as well as several thin-walled cavities. What is the most likely cause of this patient's condition?

CA-MRSA, secondary bacterial pneumonia post influenza

Treatment for vasospastic angina?

Nitro and diltiazem hyperreactivity of coronary smooth muscle young patients smoking recurrent chest discomfort occurs at rest or at night spontaneous resolution in < 15 minutes ambulatory ECG shows ST elevation but coronary angiography shows no CAD

Most appropriate indication for CT scan of abdomen pelvis in a patient with pyelo

No clinical improvement w/in first 72 hours on ABx

What medication reconciliation intervention is most likely to result in a decrease in adverse drug events and health care utilization

Pharmacist-directed interventions

Molluscum contagiosum is caused by

Poxvirus

Patient evaluated for chronic diarrhea, weight loss, increased fecal fat content. Renal function is normal. Stool microscopy shows no pathogens or leukocytes. 25g oral D-xylose solution is given before and after treatment with rifaximin and urinary excretion of D-xylose is consistently low. Most likely diagnosis?

Celiac disease, proximal small intestine pathology If enzyme deficiency, urinary excretion would be normal because D-xylose is unaffected by enzymes

Initial diagnostic testing on ascitic fluid

Cell count in differential, fluid color assessment, albumin and total protein

Blowing holosystolic murmur at the apex. Likely other exam finding?

S3, severe mitral regurgitation

Characteristic labs in alcoholic hepatitis

AST:ALT ratio of 2:1, elevated GGT and ferritin, absolute values of LFTs almost always less than 500 IU/L

Patient presents with epistaxis and ruby-colored papules on lips that blanch with pressure. Digital clubbing is present. What is the cause of increased hematocrit on his H&H?

AV shunting -chronic hypoxemia leading to reactive polycythemia hereditary hemorrhagic telangiectasia

Abdominal pain and distention. Several months of generalized pruritis worsened by water contact. Exam shows facial plethora and mild scleral icterus. Neck veins are flat, flank dullness to abdominal percussion, tender hepatomegaly, splenomegaly. Labs show Hgb 20.8, Hematocrit of 62%, increased T bili, alk phos, AST 506, ALT 614. Best step of evaluation

Abdominal doppler ultrasonography Patient has polycythemia vera leading to Budd Chiari sydnrome PV more susceptible to thrombosis

Fever, mental status change, hypotension, RUQ pain, jaundice, direct hyperbilirubinemia, leukocytosis, lactic acidosis. Likely diagnosis?

Acute cholangitis

Which hormone is not affected in panhypopituitarism

Aldosterone, primarily regulated by renin-angiotensin system TSH, FSH, LH , cortisol all affected

Patchy, nonscarring hair loss, treatment

Alopecia areata Treat with intralesional corticosteroids Autoimmune destruction

Patient presents with retinal arteriovenous nicking consistent with hypertensive retinopathy, increased QRS complex voltage consistent with LVH, normal BP in clinic. Best management?

Ambulatory blood pressure monitoring, concern for masked hypertension

72 year old F, DM2, just been treated for pyelonephritis with IV ABX due to a MDR organism. Creatinine 2.1 on admission, 4.9 today. UA reveals rare epithelial casts and no WBCs. FeNA is greater than 2%. What ABX did she receive?

Amikacin Aminoglycosides used in this setting, likely a gram negative organism

Substernal discomfort that feels like burning sensation. Left sided neck pain and feels sweaty and SOB. DM2, HTN, 30 pack year smoking hx. What is likely heard on auscultation?

S4 sound, decreased ventricular compliance acute MI

single photon emission CT post treadmill exercise shows decreased tracer uptake with stress, normal uptake at rest. This patient would benefit from what medication?

An anti platelet agent like aspirin for prevention of MI

What is an effect modifier/how different from confounder

An extraneous variable that modifies the relationship between a variable and a disease but is only related to the disease. A confounder is related to both the variable and the disease.

Respiratory distress and hypotension, nonbloody emesis, decreased lung sounds a few minutes after blood transfusion

Anaphylactic reaction -wheezing, decreased breath sounds - shock -seconds to minutes after transfusion -vomiting and urticaria -higher risk if IgA deficiency TRALI happens minutes to hours after, bilateral pulmonary infiltrates are present

65 year old woman with advanced renal disease, probable aortic stenosis, painless GI bleeding. Likely diagnosis?

Angiodysplasia

Normal T4, slightly elevated TSH. Exam shows symmetrically enlarged, nontender, firm thyroid gland. Here for recurrent miscarriage. What autoantibody is present?

Antithyroid peroxidase antibody (anti-TPO) Subclinical hypothyroidism assoc. w/ Hashimoto's

Patient presents to ED with LOC. Similar episode 1 month ago while carrying heavy bags. Extertional dyspnea and fatigue. Denies chest pain, palps, cough, LE swelling. PMH of DM2 and hypercholesterolemia. Likely exam findings?

Aortic stenosis weak and slow-rising carotid pulse "pulsus parvus and tardus" single soft S2 mid-to-late peaking systolic murmur at second right intercostal space radiating to carotids

64 y.o with confirmed aortic dissection. While being prepared for surgery he develops orthopnea and bibasilar crackles on lung exam. Likely cause of SOB?

Aortic valve insufficiency In type A dissection, intimal tear can involve the aortic valve leading to regurgitation, pulmonary edema, and orthopnea

Man has difficulty breathing and wheezing. Visited for persistent nasal blockage 2 weeks ago. Diagnosed with stable angina 6 months ago. Current mdx are aspirin, diltiazem, atorvastatin, and albuterol PRN. No tobacco or alcohol use. Vitals WNL. Likely cause of respiratory symptoms?

Aspirin-exacerbated respiratory disease (psuedoallergic reaction) Occur in patients with asthma, chronic rhinosinusitis with nasal polyposis, or chronic urticaria. Aspirin blocks COX shunts LOX into leukotriene production

Crampy postprandial pain immediately after eating. Weight loss, frequent bloating, loss of appetite. Hx of HTN, DM2, hypercholesterolemia, peripheral vascular disease, and CAD. 3 years ago suffered from inferior wall MI. 40 year smoking history. Likely cause of presentation?

Atherosclerosis of mesenteric arteries, i.e. mesenteric ischemia CTA preferred diagnostic choice

Wide and fixed splitting of S2, signs of right sided volume overload with flow murmurs, atrial arrythmias, RBBB on ECG

Atrial septal defect Present in adulthood (during pregnancy) diagnose with ECHO

Best treatment for hypersensitivity pneumonitis

Avoidance of exposure, use of steroids not well studied

Patient with positive C virus antibody and B surface antibody should be recommended to receive which of the following? A. furosemide and spiranolactone B. hep A vaccination C. hep B vaccination D. lamivudine E. prenisolone

B Measures to protect the liver from further damage. Patient is already immune to hep B. D, used for HIV and chronic hep B

Resting tremor that becomes more pronounced when the patient is engaged in mental tasks. Coffee and wine have no effect on the tremor. What is the likely responsible pathology?

Basal ganglia dysfunction, parkinson disease

25 year old, SOB and productive cough with blood-tinged sputum for past few days. No fever, arthralgias, weight loss. No remarkable PMH. Vitals WNL. Lung auscultation reveals patchy rales bilaterally. CXR bilateral pulmonary infiltrates. Creatinine is 2.6 mg/dL and urinalysis shows dysmorphic red cells. Likely cause?

Basement membrane antibodies (Goodpasture's)

Medical management of acute cocaine intoxication

Benzos for BP and anxiety aspirin Nitro and CCB for chest pain Beta blockers are contraindicated

32 year old male presenting with occasional palpitations. Family history of sudden death in uncle at age 40 and unknown heart surgery in cousin at young age. Cardiac exam reveals early diastolic murmur. Likely diagnosis?

Bicuspid aortic valve

Man with confirmed PE and GFR of 20. Best agent for anticoagulation

unfractionated heparin LMWH and DOACs cannot be used in severe renal impairment

Wisconsin, fever, night sweats, productive cough, weight loss. Multiple, well-circumscribed verrucous, crusted lesions. CXR shows left upper lobe consolidation and two lytic lesions in anterior ribs. Diagnosis?

Blastomycosis -skin involvement - lytic bone lesions - Great Lakes, Mississippi river and Ohio River basins - CXR may resemble TB or histo - treat systemic with ampho

Recurrent forceful contraction of eyelid muscles triggered by bright lights

Blepharospasm

Most significant complication of psuedotumor cerebri

Blindness Treat with weight reduction and acetazolamide

Untreated hyperthyroidism leads to what complication

Bone loss Increased osteoclast activity

Back/shoulder pain, loss of shoulder abduction strength, reduced sensation in left lateral forearm. Older man who was shoveling snow.

C5-6 nerve root impingement from cervical radiculopathy. Get cervical spine MRI

Initial treatment for SVT

vagal maneuvers adenosine

CHAD2VASC score

CHF HTN AGE ( 0 if < 65, 1 if < 75, 2 > 75) DM TIA, STROKE, Thromboembolism Vascular disease i.e. plaque, CAD, PAD Sex (female 1, men 0)

26 year old, fever, malaise, fatigue, sore throat. 3 male sexual partners over the past year and uses condoms inconsistently. Febrile, pharyngeal erythema, mild splenomegaly, morbilliform rash. No enlarged lymph nodes. Labs reveal lymphocytosis, elevated Alk phos, AST, and ALT. Heterophile antibody testing is negative. Likely diagnosis?

CMV -mono-like syndrome -negative heterophile antibody testing

Signs and symptoms of TCA overdose

CNS depression, hypotension, dilated pupils, hyperthermia, QRS prolongation treat with sodium bicarb

XR reveals soft tissue swelling, small tibiotalar joint effusion, chronic calcification of the articular cartilage. Most likely diagnosis?

CPPD arthritis

Patient has antibodies against nicotinic receptors on motor endplates, initial step

CT of chest, assoc. w/ thymoma

43 year old man, 6 month hx of intermittent dull epigastric pain postprandial 15-30 min. after meal that last for a few hours. Not relieved by antacids but improves when leaning forward. Diarrhea, weight loss, pack a day smoker and alcohol consumption daily. Next step in management?

CT scan of abdomen Diagnosis of chronic pancreatitis

What is required for diagnosis of community-acquired pneumonia

CXR

Drugs that affect warfarin metabolism

CYP inhibitors ↑ warfarin effects (i.e. bleeding risk) -abx -azoles -amiodarone -cimetidine -grape fruit juice -acetaminophen CYP inducers ↓ warfarin effects (i.e. clotting risk) -carbamazepine -phenytoin -phenobarbital -rifampin -st. john's wort

How can tacrolimus cause AKI

Calcineurin inhibitors cause vasoconstriction and prerenal AKI CNIs are hepatically cleared and susceptible to drug interactions that cause fluctuating serum levels (P450 inducers and inhibitors)

How is ionized calcium affected by acid base status

Calcium competes with hydrogen ions to bind to albumin Alkalosis → more calcium bound by albumin → decreased ionized calcium Acidosis → more hydrogen ions bound by albumin → increase in ionized calcium

What will calcium, phosphate, and parathyroid hormone look like in the setting of chronic steatorrhea

Calcium low (Vit. D deficiency) Phosphate low Parathyroid hormone high

Conditions associated with pulsus paradoxus

Cardiac tamponade Asthma COPD

Difference between case control studies and retrospective cohort studies

Case control study = disease and no disease → look for associated risk factor Retrospective cohort = look for associated risk exposure → determine outcome

23 year old man with foul-smelling, bulky stools, weight loss, poor energy, joint pain. Exam shows mild pallor. IgA ant-tissue transglutaminase antibody screen is negative. Small-bowel biopsy shows villous atrophy. Most likely diagnosis?

Celiac disease IgA anti-tissue transglutaminase can be negative because selective IgA deficiency is common in Celiac disease. Subsequently total IgA should be measured.

63 year old patient vague abdominal pain and increased fatigability. Physical shows mildly distended soft abdomen. Liver edge is hard and palpated 5 cm below costal margin. Anemic, microcytic. CXR reveals small left-sided pleural effusion. Fecal occult blood test is positive. Likely cause of hepatomegaly?

Colon cancer malignancy

First line treatment for cognitive function in Alzheimer dementia

Cholinesterase inhibitors - donepezil - galantamine - rivastigmine

Antique furniture restoration as hobby, patient presents with burning and tingling sensations in the hands and feet. the skin over the neck has patchy areas of hyperpigmentation and hypo pigmentation. Hyperkeratoses and scaling present on palms and soles.

Chronic arsenic poisoning Acute: garlic breath, vomiting, watery diarrhea, QTc prolongation Lead poisoning similar but skin changes not usually seen, more GI complaints

prominent bronchovascular markings, diaphragmatic flattening. PFTs reveal decreased FEV1 and preserved FVC, FEV1/FVC ratio is .65. DLCO is 100%. What is the cause?

Chronic bronchitis COPD Emphysema alveolar destruction would cause decreased DLCO

Patient diagnosed with ulcerative colitis 8 years ago with involvement from hepatic flexure to rectum at the time. Disease is well controlled with oral medication. What is the most appropriate management at this time?

Colonoscopy now (8 years after diagnosis) and every 1-2 years after thereafter looking for colonic dysplasia.

Man with 2 day hx of calf pain and swelling. Hx of IV drug abuse, bacterial endocarditis and stroke. Ascites and hepatosplenomegaly present. Right calf is swollen and tender to palpation. Most likely cause of ascites?

Chronic liver disease, IV drug abuse puts at risk for Hep. C infection, likely DVT in calf from immobility from stroke.

Intermittent epigastric pain that radiates to the back and worsens after meals, CT shows pancreatic atrophy along with multiple calcifications in the pancreatic parenchyma. Labs show AST 32, ALT 24, Lipase 32 (10-140). Best next step in management?

Chronic pancreatitis -long standing alcohol use -pancreatic enzyme supplementation

W/u of suspected tinea pedis

KOH prep

Patient with hepatic encephalopathy on diuretics. Steps in management?

Contraction alkalosis and hypokalemia. Volume resuscitation, repletion of potassium, lactulose to reduce serum ammonia

What complication is associated with dry eyes from Sjogren Syndrome?

Corneal ulceration decreased tear volume → irritation → inflammation

What is the predominant mechanism of pain relief w/ sublingual nitroglycerin in chest pain

Decreased left ventricular wall stress Systemic vasodilation → decrease in preload → decrease wall stress → decrease afterload → decrease oxygen demand

How can hypothyroidism lead to amenorrhea

Decreased thyroid hormone → Increased release of TRH → Stimulation of prolactin → inhibition of GnRH → decreased FSH and LH

64 year old male presents with palpitations and progressive shortness of breath. he says he develops a choking sensation when he tries to lie down. He denies chest pain for syncope. Past medical history significant for hypertension in smoking. Blood pressure is 182/105 and heart rate is 120 and irregularly irregular. Lung exam reveals bibasilar crackles. He has 2 + pitting edema bilaterally. Echocardiogram shows LVH and EF 55%. What is the cause of his symptoms?

Diastolic dysfunction HFpef

A 50 year old woman, several month hx if intermittent, substernal chest pain. Pain not related to activity. Difficulty swallowing both liquids and solids. Physical exam and upper GI endoscopy reveal no abnormalities. Likely diagnosis?

Diffuse esophageal spasm Esophagram may show "corkscrew" pattern. First line treatment is CCB

Abrupt cessation of chronic therapy with glucocorticoidsm, labs will show

Disruption of HPA axis= Low ACTH Low cortisol Normal aldosterone (Primary adrenal insufficiency would show high ACTH, low aldosterone, low cortisol)

70 year old man, rectal bleeding. BM with large volume of bright red blood without associated abdominal pain. Persistent lightheadedness with several urges to defecate in which blood is produced. No prior hx of GI bleed. Hx notable for HTN and chronic constipation. Hypotensive, tachycardic, afebrile. Normal bowel sounds, rectal exam shows bright red blood. NG aspiration returns nonbilious stomach contents without blood. Likely cause of bleed?

Diverticulosis

Broca's aphasia affects what part of the brain

Dominant frontal lobe

Hydralazine and ACEi, presents with friction rub, join pains, difficulty breathing

Drug induced lupus anti-histone antibody

Patient has difficulty swallowing both solids and liquids. Progressive worsening over last 3 months. Regurgitation of undigested food and a nighttime cough. Weight loss, 20 pack year smoking hx. CXR reveals widened mediastinum, barium studies show a dilated esophagus with smooth tapering of distal esophagus. Next step in management?

Endoscopic evaluation Malignancy needs to be ruled out before diagnosis of achalasia.

Patient over 50, GERD symptoms, first step in managment?

Endoscopy if over 50 or alarm symptoms or chronic > 5 years, or tobacco use. All other patient started on empiric PPI therapy and are further evaluated if this fails.

38 wks G1 P0 complaining of fatigue, dyspnea, low exercise tolerance. Discomfort in sleep. Uncomplicated pregnancy. BP 140/85, HR 102/min. S3 present with II/VI holosystolic murmur at apex. Pitting edema bilaterally in LE. UA shows trace protein. ECG shows normal sinus tachy. Best step in management?

ECHO Patient may have peripartum cardiomyopathy leading to CHF. LVEF < 45% & absence of other causes of heart failure.

What is the difference between and ecological longitudinal study and a cross-sectional study

Ecological longitudinal studies target populations, not individuals Cross-sectional studies are a type of observational study with data gathered at one point in time i.e. individual survey data about a certain interest

HIV patient with CD4 count of 30. Complaining of severe odynophagia, no dysphagia, no thrush on exam. Likely causitive agent

Either HSV or CMV esophagitis Candida more common but typically dysphagia and oral thrush present

Tick bite southeastern and south central US. presents with malaise, confusion, thrombocytopenia, leukopenia, transaminitis.

Erlichiosis treat empirically with doxycycline

Dysphagia, regurgitaiton, chest pain precipitated by emotional stress. Odynophagia with cold or hot food. Relief of pain with nitrates. Best step in management?

Esophageal manometry for diagnosis of diffuse esophageal spasm

51 year old man, difficulty swallowing solids but not liquids. GERD hx for past 12 years. Endoscopy showed Barrett esophagus 6 months ago. Barium swallow shows an area of symmetric, circumferential narrowing affecting the distal esophagus. Likely diagnosis?

Esophgeal stricture Adenocarcinoma typically occurs with GERD hx greater than 20 years, narrowing would be assymetric on barium swallow.

47 year old male presents to ED w/ right sided facial droop. Ptosis of right eye. Reports low grade fevers and fatigue past several weeks. Exam shows flattening of right nasolabial fold, drooping of the right corner of mouth, and right-sided hyperacusis. Sensation to touch on the face is normal bilaterally. Parotid glands are enlarged bilaterally. Scattered enlarged cervical lymph nodes are present. Labs show hypercalcemia. Likely cause of facial paralysis

Extrapulmonary sarcoidosis -hypercalcemia -enlarged parotid glands

65 year old male presents with fevers and confusion. 2 days of cough productive of greenish sputum. Hx of well-controlled DM2 and was treated for bronchitis twice in the last 4 months. Recieved flu vaccine this year. Temp. is 101.2 and has cervical lymphadenopathy. Scattered rales at right lung base. Palpable liver edge and spleen tip. CXR shows developing right lower lobe infiltrate. Labs show severe leukocytosis predominantly lymphocytic. as well as anemia and thrombocytopenia. Next step in management?

Flow cytometry of the peripheral blood to diagnose CLL Pneumonia with severe lymphocytosis, bicytopenia, lymphadenopathy, hepatosplenomegaly Usually bacterial infections cause a moderate leukocytosis with predominance of neutrophils

Oculogyric crisis

Forced upward gaze deviation associated with EPS from first-gen antispsychotics like haldol

15 year old patient with several adenomatous polyps with positive germline APC mutation.

Frequent colonoscopic surveillance, proctocolectomy can be delayed until 20s

2 + pitting edema bilaterally in lower extremities with tortuous superficial veins. a small ulcer is noted on the left medial ankle. JVP normal. What is likely to release the symptoms?

Frequent leg elevation, chronic venous insufficency not heart failure with normal JVP

chronic sinusitis, lung nodules/cavitation, rapidly progressive glomerulonephritis, livedo reticularis, nonhealing ulcers, hemoptysis

GPA

Prolonged chest pain for months. Not associated with activity, often occurring at rest. Episodes last about 2 hours. ECG and stress test normal.

Likely esophageal reflux or dysphagia

58 y.o apparent suicide attempt. Hx of CAD and HTN. Found down, lethargic, BP 76/40 mm Hg, pulse 40/min. Exam shows bilteral wheezing, extremities are cold and clammy. ECG shows sinus brady with 1st degree AV block. Atropine and fluids do not improve his condition. Next step after ensuring adequate oxygenation?

Glucagon likely Beta blocker overdose

Woman on adjuvant chemo for ovarian cancer. The trunk has several indurated nontender macules and pustules. Some of the lesions have become gangrenous ulcers. Labs show pancytopenia. Likely cause of skin lesions

Gram-negative bacteremia i.e. ecthyma gangrenosum from Pseudamonas

4 weeks of episodic upper abdominal pain. Pain waxes and wanes, a/w nausea. Pain awakens her at night. Bloating after meals. No dysphagia, regurgitation, weight loss, or change in bowel habits. Immigrant from India. Stool guaiac positive. Likely cause of symptoms?

H. pylori infection (urease-producing bacterial infection)

Most appropriate test to diagnose Hep B?

HBsAg and IgM anti-HBc (may be the only marker available during window period)

Hep B serology in patient in recovery phase

HBsAg negative HBsAb positive HBcAb positive HBeAb may or may not be positive

42 year old man with sudden onset of psoriatic plaques, should be screened for?

HIV -recurrent herpes zoster -severe psoriasis - disseminated molluscum contagiosum -severe seborrheic dermatitis

All patients with presumed ITP should be tested for...

HIV and Hep C

HAS-BLED score

HTN Abnormal renal or liver function Stroke Bleeding tendencies Labile INR agE Drugs (aspirin or NSAIDs) and alcohol

What is seen on renal biopsy in acute graft rejection

Heavy lymphocytic infiltration with vascular involvement, swelling of intima Happens within first 6 months In BK virus you would see lymphocytes and neutrophils, a tubulointerstitial nephritis would be present

brown sequard syndrome

Hemi-section of the cord - ipsilateral (same side) spastic paralysis and loss of position sense at level of lesion and below - contralateral (opposite side) loss of pain and thermal sense below level of lesion

24 year old Indian man, presents to ED with 3 days of LUQ pain. Pain began after flew back from India after visiting family. Had some alcohol on the plain to help him sleep. No significant hx. Stable vitals. No peritoneal signs. Increased indirect bilirubin. Ultrasound shows normal liver but slightly enlarged spleen with infarction. Order that would be helpful in finding the cause of the infarction?

Hemoglobin electrophoresis, patient likely had sickle cell trait exacerbated by flight and alcohol consumption

Causes of ITP

Hep C, HIV, lupus Get ANA testing

Patient with HIV. Painful mild conjunctivitis, rapid progressive visual loss. Exam reveals marked keratitis. Funduscopy shows widespread, pale, peripheral retinal lesions and central necrosis of the retina. Likely causal organism

Herpes simplex CMV retinitis is most common serious ocular complication of HIV-positive patients, however it is typically painless, fundoscopy shows fluffy or granular retinal lesions located near the retinal vessels and associated hemorrhages

hilar and mediastinal lymphadenopathy and B symptoms (fever and weight loss)

Hodgkin lymphoma PET scan radiotracer pools in healthy organs as well i.e. brain, kidneys, and liver

Test to confirm diagnosis of lactose intolerance

Hydrogen breath test, positive stool test for reducing substances, low stool pH and increased stool osmotic gap

56 year old male presents with severe nausea and vomiting. He has also had fatigue, poor appetite, polyurea, polydipsia, and Constipation for several weeks. He has a past medical history of hypertension and type 2 diabetes. Is home medications include metformin, lisinopril, and hydrochlorothiazide. He has a 40 pack-year smoking history. Labs show a calcium level of 14.8 and a parathyroid hormone level of 5 (10-65). He has a normal 25 hydroxyvitamin D and creatinine of 1.9. Likley cause?

Hypercalcemia of malignancy, PTHrp suppressed PTH means it is a PTH independent process, most commonly malignancy. Thiazides tend to only cause a mild elevation in calcium (below 12)

Treatment of necrotizing otitis externa

IV ciprofloxacin ± surgical debridement

What will CSF analysis show in Guillain-Barre

Increase protein, normal WBC, normal glucose

What leads to high blood pressure in thyrotoxicosis?

Increased inotropic and chronotropic effects ↑ contractility & CO ↑ myocardial oxygen demand ↓ SVR sinus tachy, premature atrial and ventricular complexes a. fib/flutter

Patient found to have ST elevations in II, III, and aVF. Given nitro and becomes profoundly hypertensive. 75/50, lightheaded pale. Best management?

Inferior MI affecting right ventricle. Nitro, morphine, diuretics decrease preload. 1. NS bolus 2. inotropic agents if refractory to volume resucitation

43 year old male, 1 month hx of worsening frontal headaches, blurred vision, and occasional falls. Blurry vision is provoked when he leans forward. No hx of head trauma or seizure. His mother has hx of glaucoma. On exam his pupils are equally round and reactive to light. Likely cause of patients condition?

Intracranial hypertension - Cushing reflex i.e. hypertension, bradycardia, respiratory depression (suggestive of brainstem compression) - Papilledema - Headache, N/V, mental status changes, focal deficits -worsened by leaning forward, valsalva, cough

How does pneumonia cause a change in O2 sats

Intrapulmonary shunting V/Q mismatch when increase of blood flow where alveolar consolidation is

Management of myasthenic crisis

Intubation, plasmapheresis or IVIG and steroids Hold pyridostigmine temporarily to reduce excess airway secretions and the risk of aspiration

80 year old woman with fatigue and conjunctival pallor. Lives alone, osteoarthritis and hypertension, takes low dose aspirin, naproxen, lisinopril, and clorthalidone. Likely cause of pallor?

Iron deficiency anemia NSAID and aspirin chronic blood loss from gastritis. Anemia of chronic disease is assoc. w/ inflammation from RA or lupus, not osteoarthritis

Elderly patient brought to ED found unresponsive. Febrile, hypotensive, low O2 sats. Leukocytosis, CXR reveals new upper lobe infiltrate. Treated with NS, ABX, vasopressors, and mechanical ventilation. Markedly elevated LFTs (in the 3000s). What accounts for abnormal liver function panel?

Ischemic hepatic injury from sepsis

Most common cause of oculomotor nerve palsy

Ischemic neuropathy from diabetes mellitus inner fibers- EOMs outer fibers- control pupil constriction therefore central infarct causes "down and out" palsy with preserved pupillary response

Patient with diagnosed meningococcal meningitis refusing to stay in hospital for treatment. What to do?

Isolate patient and hospitalize against wishes, duty to protect the public

sudden onset severe HA, N/V, photophobia, stiff neck (meningismus). Normal nonconstrast head CT. Next step

LP to rule out SAH Migraines would be unilateral and not have meningismus

48 year old male presenting with severe chest pain, "hurts all over chest." EKG reveals sinus tachycardia, voltage criteria for LVH, and T wave inversion in V 5 and V 6. CT scan shows Intimal tears aorta. Best first step in medical management.

Labetalol reduce systolic BP and contractility

56 year old man presents with severe dizziness, inability to walk, and stabbing pain on the right side of his face that started this morning. He has diet controlled type 2 diabetes, hypertension, and hyperlipidaemia. On exam his left pupil is larger than the right, there is reduced corneal reflex on the right directly but not consensually. There is partial ptosis of the right eye. Horizontal and rotational nystagmus is present. Gag reflex is diminished. There is loss of pain and temperature sensation in the right face and the left trunk and limbs what is the most likely location of the patients brain lesion.

Lateral medulla Wallenberg syndrome most likely due to intracranial vertebral artery

Which intervention has the max impact on survival in late stage COPD patients?

Long term oxygen therapy - sats < 88% - < 89% if signs of cor pulmonale or crit > 55%

What will be seen on thyroid studies if a patient is taking exogenous thyroid hormone for weight loss?

Low serum thyroglobulin levels Low radioactive iodine uptake

What part of the lung does aspiration pneumonia usually affect

Lower lobes, particularly the right

Prolonged PTT does not correct in mixing study. Likely cause?

Lupus anticoagulant, antiphospholipid syndrome

contralateral somatosensory & motor deficit, conjugate eye deviation to affected side, homonymous hemianopia, aphasia, hemineglect

MCA infarct

64 y.o with claudication in right thig. 35 pack year hx. Distal pulses in leg are diminished. ABI is .98 on left and .75 on right. Likely to suffer what in next 5 years?

MI

Patient in shock with low CI and increased PCWP. Likely cause?

MI, cardiogenic shock

60 year old man presents to emergency department with 10 day history of malaise and lower back pain. He has tried tylenol with no relief. Past medical history sig for BPH and recent urinary tract infection treated with ciprofloxacin. He reports no urinary symptoms. He is febrile. Exam shows exquisite tenderness over the L 4 - L 5 vertebrae and local paravertebral muscles. Labs show a Leukocytosis an elevated ESR. Plane X Rays of the lumbar spine show mild degenerative changes. Best next step in management?

MRI of spine for suspected vertebral osteomyelitis, likely from hematogenous spread from UTI no urinary symptoms and no prostate tenderness make pyelo and prostatitis less likely

76 year old man presenting with gait instability, cognitive dysfunction, urinary urgency/incontinence, depressed affect. Best initial step

MRI to rule out normal pressure hydrocephalus

Elevated TSH despite escalating levothyroxine doses

Malabsorption, check for celiac disease interaction with iron, calcium, sulcralfate, seizure meds and rifampin induce metabolism

34 year old male presents to ED with fatigue and fevers. He had chills and shivering 2 hours prior and then a high grade fever followed by fever. He had similar symptoms since returning from Kenya a few weeks ago that resolved. W/u shows mild anemia and thrombocytopenia. Diagnosis?

Malaria

AST 3207, ALT 4180, INR 1.6, mild flapping tremor in both hands. Likely cause of acute liver failure?

Medication-induced liver injury, acetiminophen metabolite NAPQI

Patient presents wtih nephrotic syndrome. Renal biopsy is performed and she is started on diuretics and salt restriction to help with edema. Suddenly she develops right-sided abdominal pain, fever, and gross hematuria. Likely diagnosis?

Membranous glomerulonephropathy assoc. w/ renal vein thrombosis because of urinary excretion of antithrombin III

Common causes of vertigo

Meniere disease- hearing loss, tinnitus, recurrent episodic BBPV- brief episodes triggered by head movement, Dix-hallpike maneuver Vestibular neuritis- acute single episode lasting days, follows viral syndrome, abnormal head thrust test Migraine- a/w visual aura, symptoms resolve completely between episodes Brainstem/cerebellar stroke- sudden onsent, persistent vertigo, other neurological symptoms

Patients with PBC are more susceptible to developing what complications?

Metabolic bone disease (osteomalacia, osteoporosis) due to malabsorption, HCC

61 year old with nocturnal urinary frequency, occasional dribbling, and weak urinary stream for 3 months. PMH sig for DM2 16 years ago, HTN, and MI 2 years ago. He has moderately decreased visual acuity. BP is 160/100 mm Hg and pulse is 60/min. Exam shows left-sided carotid bruit and trace bilateral ankle edema. Postvoid residual is 40 mL. Dipstick urinalysis reveals 2+ protein and no blood. Creatinine is 2.1 mg/dl. HgbA1C is 7.3%. Likely cause of chronic kidney disease?

Microangiopathy i.e diabetic nephropathy Although initially sounds like obstructive uropathy from BPH, creatinine elevation and proteinuria point more toward diabetic nephropathy

40-year-old male comes to the office due to progressively worsening shortness of breath and nonproductive cough over the last 3 weeks. He also notes 2 months of fatigue, intermittent fever, and decreased appetite. He has lost 6 kilos during this period. He has no other medical problems. He has a history of IV drug use and 20 pack-years of smoking. He was released from prison 6 months ago. On exam, he has a mild fever, temporal wasting, and crackles throughout the lung fields. He also has hepatomegaly. Chest X-Ray shows a diffuse reticulonodular pattern.

Miliary TB

Most common cause of MR in developed countries

Mitral valve prolapse -young female

Patient presents with proximal muscle weakness particularly after prolonged sitting or standing. She has had 2 episodes of double vision while driving home from work. She is on a statin and lisinopril. Exam shows mild right ptosis, symmetric proximal muscle weakness in UE, and weakness in head extensors. Likely site of pathology?

Motor end plate Myasthenia gravis weakness after prolonged activity. Myositis from statins etc. would have tenderness to muscle palpation

first line therapy for reactive arthritis

NSAIDs -urethritis -conjunctivitis -mucocutaneous lesions -enthesitis -asymmetric oligoarthritis

Drugs associated with acute pancreatitis?

valproic acid, furosemide, thiazides, sulfasalazine, 5-ASA, azathioprine, HIV medications, metronidazole and tetracycline

43 year old male with type 2 diabetes. Has followed a low fat diet in taken metformin as prescribed. no evidence of diabetic retinopathy on exam, foot exam is also within normal limits. Hg A1C is 7.0%. Creatinine is 0.9. Urine albumin/creatinine ratio is 15 next step in management?

No further interventions, diabetes is well controlled and a/c ratio is WNL. Add lisinopril if > 30.

55 y.o ICU after MVC. Ex lap for bowel perf. POD 2 he is hypotensive and requires fluids and pressors. Extremities are cold and fingertips are black. Likely cause?

Norepi induced vasospasm alpha 1 agonist properties decreased blood flow → vasoconstriction → ischemia

Best initial step in hyperosmolar hyperglycemic state

Normal saline infusion replenishes extracellular volume, lowers plasma osmolality, increases tissue perfusion and responsiveness to insulin

ECG shows normal QRS but prolonged PR interval. He has had chest pain for 1 day. Pain is reproducible with left-sided palpation to chest muscles. Next step?

Observation. 1st degree block with normal QRS is benign finding.

Treatment for central retinal artery occlusion

Ocular massage and high-flow oxygen presents with sudden painless loss of vision, amaurosis fugax, carotid bruit

29 year old male presents to emergency Department with one week of progressive bilateral lower extremity weakness. He has no history of trauma or back pain. 3 months ago was diagnosed with trigeminal neuralgia and a self-limited URI. Vitals are all within normal limits. Exam shows increased resistance to passive flexion and extension of the lower limbs DTR's are 3 + and plantar reflexes are up going bilaterally there is decreased vibratory and positional sensation in his left upper extremity but no other sensory deficits. What is shown on CSF analysis?

Oligoclonal bands, diagnosis likely multiple sclerosis -onset age 15-50 - optic neuritis - relapsing remitting - neurological deficits disseminated in space and time

Cupping of optic disc

Open angle glaucoma -higher risk in AA

3 week hx of hacking, nonproductive cough, more frequent at night. Sensation of liquid dripping in back of throat. URI 4 weeks ago that resolved except for cough. No runny nose, chest pain, heart burn, SOB, wheezing. Father died of lung cancer at 72. Best initial management?

Oral first generation antihistamine for upper-airway cough syndrome. (chlorpheniramine, or decongestant pseudoephedrine) If does not resolve after 2-3 weeks of empiric treatment, further investigation is required.

34 year old woman presents with dyspnea and severe chest pain. Pain is localized on the left side in increases with inspiration. She also had one episode of hemoptysis. 2 days ago she flew back to the United States from a trip to Central Asia. She is sexually active with one partner and uses OCPs. On exam she is tachycardic and tachypneic but afebrile.

PE, she needs CTA occlusion of peripheral pulmonary artery by thrombus may cause pulmonary infarction with pleuritic pain and hemoptysis risk factors: recent travel, OCP

55 y.o M, in ED with sudden onset of palps and chest tightness. PMH of HTN, gout, DM2. Cardiac monitor shows a. fib and rate of 120/140 bpm. Normotensive and satting appropriately. Suddenly, patient becomes unresponsive and no palpable pulse over carotids and femoral arteries. He has agonal breathing. Cardiac monitor shows a.fib at same rate.

PEA Begin chest compressions, PEA is non-perfusing, unshockable rhythm ACLS recommends CPR and epi

joint involvement in RA

PIP, MCP, MTP, spares DIP cervical spine- risk for atlanto axial subluxation

isolated asymptomatic elevation of alkaline phosphatase

Paget disease of bone

When do anginal symptoms occur in the setting of aortic stenosis?

valvular area < 1cm²

58 year old male patient with past medical history significant for 45 pack years of smoking. Over past 3 months has had several episodes of hemoptysis, weight loss, in temporal wasting. On exam mucous membranes are moist, neck is supple without lymphadenopathy, in heart and lung sound are normal. BNP shows sodium of 124. Best initial treatment?

Patient with this smoking history and severe hyponatremia likely has small cell lung carcinoma associated with SIADH. Best initial treatment is fluid restriction clinically appears euvolemic hypovolemic = fluids hypervolemic = albumin

Watery diarrhea, skin rash for last two months gets worse with sun exposure. Depression, loss of appetite, weight loss. Hx of latent TB, taking INH and pyridoxine. Vegetarian and diet consists of mostly corn and other cereal grains. Rash is pigmented, scaly, malar distribution of face, neck, and back of hands. Likely diagnosis?

Pellagra, niacin deficiency from corn diet, niacin derived from tryptophan (Hartnup disease, carcinoid syndrome, corn products) Prolonged INH therapy can interfere with niacin metabolism and occasionally cause pellagra

Electrical alternans (varying amplitude of QRS) and sinus tachycardia. Patient presents with syncope 2 weeks after viral URI.

Pericardial effusion from viral pericarditis

"muffled hot potato" voice, deviation of uvula

Peritonsillar abscess Needle aspiration and antibiotics

28 year old, ED, CC is syncope. Weak and hasn't eaten much for 2 weeks. Hx of IV drug use and hospitalized for aspiration pneumonia 6 months ago. Febrile. Poor dentition. Early diastolic murmur heard at left sternal border at full expiration. Lungs are CAB. ECG shows sinus rhythm with 2:1 second degree AV block. Likely diagnosis?

Perivalvular abscess -early diastolic murmur (AR) -infective endocarditis -cardiac conduction abnormalities are more common with aortic valve than with tricuspid

Patient presents with horizontal nystagmus, ataxia, dysmetria, and hyperreflexia. Worsening gait. Only medication she is on is phenytoin for seizure prophylaxis. She had a recent UTI for which she received bactrim. Likely cause of her symptoms

Phenytoin toxicity Bactrim is a CYP 450 inhibitor, increasing the plasma concentration of phenytoin and side effects

65 y.o known cardiac ischemia. Presents with SOB and nonproductive cough. He was instructed to increase Lasix one week ago but this did not help. Cardiac ROS negative. Has a AICD and has been on antiarryhthmic therapy due to ventricular tachycardia. Exam normal except for bilateral inspiratory crackles. CXR reveals bilateral lung infiltrates involving the middle lung fields.

Pneumonitis caused by amiodarone

Slowly progressive proximal weakness of lower extremities.

Polymyositis

Derm diseases assoc. w/ Hep C

Porphyria cutanea tarda Lichen planus Croglobulinemic vasculitis

Patient with diabetes managed with metformin has an elevated A1C despite normal fasting glucose levels

Postprandial hyperglycemia

66 year old diabetic with neuropathic pain and NSTEMI 4 years ago. A1C is 8.6%. On exam there is loss of ankle reflexes bilaterally, loss of vibratory sensation, and altered proprioception below the knee. Serum creatinine is 1.55 mg/dL. Best treatment?

Pregabalin Amitriptyline also first line but should be used with caution in patients > 65 due to its anticholinergic effects, not recommended in patients with preexisting cardiac disease (conduction abnormalities)

Patient with advanced AIDS presents with solitary, irregular, nonhomogenous ring-enhancing mass in periventricular area. CSF PCR positive for EBV

Primary CNS lymphoma

Hyponatremia, low serum osms, low urine osms, urine specific gravity 1.002

Primary polydipsia common in patients with psychiatric conditions

Assessment of polyuria

Primary polydipsia or diabetes insipidus. DI will have high serum sodium and dilute urine whereas polydipsia will have hyponatremia. DI is due to lack of ADH either nephrogenic or central.

Increase appetitie in cancer-related anorexia/cachexia

Progesterone agonists or corticosteroids

What lab abnormality is likely to be seen in a patient with antiphospholipid-antibody syndrome

Prolonged PTT antibodies bind the phospholipids used in most testing assays and prevent them from inducing coagulation

Likely cause of erectile dysfunction in male with normal nonsexual nocturnal erection

Psychogenic factors (anxiety, conflict, etc.)

Found at home unconscious, weak pulse, agonal respirations. PMH of HTN, hyperlipidemia, DM2, CAD, metastatic prostate cancer. Hypotensive, tachy, patchy rales present with 2/6 systolic murmur present. UE and LE cold and clammy. RA pressure 18 mm Hg, PA pressure 43/21 mm Hg, PCWP 9 mm Hg. Most likely diagnosis

Pulmonary embolism Initial presentation with shock and syncope

ED for hemoptysis. Yesterday sudden right-sided chest pain and mild dyspnea. Last 4 days has had diarrhea, nausea, vomiting after eating at a new restaurant. Feels weak and thinks her respiratory symptoms are due to inactivity. Med hx sig for HIV, injection drug use, and cellulitis on right arm. CD4 count 350, recent PPD was 2 mm of induration, 15 year smoking hx, febrile, normotensive, mucous membranes dry. Breath sounds diminished at right lung base. CT shows wedge-shaped opacification on right side with right-sided pleural effusion. Likely cause?

Pulmonary embolism leading to pulmonary infarct

18 year old complaining of dyspnea. Cardiac ROS otherwise negative. Hx of menorrhagia for which she takes OCPs. FH of younger sister with "hole in her heart." Vitals stable. Cardiac exam reveals extra high-pitched sound after S1. 3/6 systolic crescendo-decrescendo murmur that is loudest at left upper sternal border. Split S2 throughout that increases with inspiration. Dorsalis pedis pulses 2+ bilaterally. Mechanism of murmur?

Pulmonic stenosis diagnose with ECHO, made need surgical intervention

Assoc. w/ drug induced lichen planus

Purpl, pruritic, polygonal, papules and plaques wickham striae ACEi, thiazide diuretics, beta blockers, hydroxychloroquine

Rheum antibodies

RA: CCP SLE: ANA, Anti-dsDNA, anti-Smith Drug-induced lupus: antihistone SS: anti-scl-70, anticentromere poly/dermatomyositis: anti-Jo1

Attributable risk percent

RR-1/RR if relative risk is 4 4-1/4 = .75 meaning 75% of sed disease can be attributed to particular risk factor

Initial management of frostbite

Rapid rewarming with warm water bath

FiO2 = .8 RR = 14 Tidal volume = 380 PEEP = 7 pH = 7.42 PaO2 105 mm Hg PaCO2 37 mm Hg Best next step in management?

Reduce FiO2 to prevent oxygen toxicity Ventilation is adequate

80 y.o presents with lethargy and confusion. PMH of HTN, DM2, CAD, PAD, and stroke. Quit smoking 10 years ago after MI. BP is 74/48. Pulse is 124/min. RR is 24/min. She has a sacral decubitus ulcer with drainage and surrounding erythema. Chronic venous stasis changes present in bilateral LE. CMP is WNL except for creatinine of 2.2. PCW is normal and mixed venous oxygen saturation is mildly increased. Which is associated with this patient's hypotension?

Reduced cardiac afterload i.e. decreased SVR This patient has sepsis. normal PCW. Nidus of infection. Increased mixed venous due to lack of perfusion.

Exam findings suggestive of ank spon

Relieved with exercise but not rest Sacroiliitis Reduced chest expansion & spinal mobility Enthesitis Dactylitis Uveitis Aortic Regurgitation Cauda Equina HLA B27

Flank pain, hematuria, proteinuria, wedge-shaped renal parenchymal defect on CT

Renal infarction - a. fib - renal artery trauma - hypercoagulability - infective endocarditis

Fibromuscular dysplasia most commonly affects

Renal, carotid, and vertebral

How is calcium metabolism altered in a patient with a pulmonary embolism

Respiratory alkalosis → increased extracellular pH → dissociation of hydrogen ions from albumin → more free albumin to bind calcium → manifestations of decreased ionized calcium

Reduced vital capacity and TLC, normal FEV1/FVC ratio. FRC and RV are increased.

Restrictive lung pattern

Headaches, epistaxis, and high blood pressure in young male. What is seen on X Ray?

Rib notching Coarctation of the aorta

53 year old presents to ED after sudden LOC for 3 min. She recovered spontaneously but was very weak and dyspneic. She also reports left sided chest pain. No tonic clonic activity or incontinence. Recently diagnosed with colon cancer on routine colonoscopy and is scheduled to undergo surgical resection. BP is 86/50, pulse 120/min, 80% on room air, she is diaphoretic and tachypneic. JVP is 13 cm H20. Lungs are clear to auscultation. Further workup would reveal?

Right ventricular dysfunction acute presentation of PE → right outflow obstruction → increased RV pressure and wall tension→ increased O2 demand → ischemia and infarction → RV failure and shock -Risk for thromboembolism with malignancy

How are Rinne & Weber tests used

Rinne- if conductive loss, lateralizes to affected ear if SN then same in both ears Weber- if conductive, then lateralizes to affected ear if SN, then lateralizes to unaffected ear

4 days after MI affecting LAD. Positive for JVD, crackles, loud systolic murmur at left sternal border with palpable thrill. Likely causes

Rupture of interventricular septum Pap muscle rupture would be MI affecting RCA, would have mitral regurgitation with flail leaflet

Common contributers to blepharitis

Seborrheic dermatitis Rosacea Allergic disorders Infections Demodex mite infestation

43 year old complains of nagging left-sided pain worse on inspiration and 3-4 weeks of nonproductive cough. Hx of Hodgkin lymphoma treated 20 years ago with chemo and radiation. CXR shows left pulmonary mass. Likely cause?

Secondary malignancy 18 fold more likely in hx of Hodgkin lymphoma

42 year old male presents with fever, sore throat, malaise, headache, in skin rash. He has had 3 new sexual partners over the last year. He has not participated in any unusual outdoor activities. Vitals are all within normal limits. Exam shows a full body maculopapular rash without evidence of excoriation. Several raised gray mucosal patches are seen in the mouth. Cervical axillary inguinal and epitrochlear lymphadenopathy is present. HIV testing is negative. Diganosis?

Secondary syphilis -diffuse maculopapular rash -epitrochlear LAD

Patient with chronic diarrhea, 5-6 nonbloody liquid bowel movements daily, sometimes awakens him during night. Lost 2 kg and has diarrhea even when not eating. Occasional bloating but no abdominal pain, nausea, or vomiting. Hx of multiple abdominal surgeries. Stool osmotic gap is low. Likely cause of diarrhea?

Secretory diarrhea, low stool osmotic gap, large daily stool volumes greater than 1L per day, diarrhea during fasting or sleep. Osmotic diarrhea has elevated stool osmotic gap

Common screening test for multiple myeloma?

Serum (or urine) protein electrophoresis see M-spike Confirm with bone marrow biopsy

53 year old woman comes to urgent care with right-sided abdominal pain started 2 years ago. Pain is constant, burning, and severe enough to interfere with sleep. Hx sig for chemotherapy from breast cancer, last dose 3 weeks ago.Lightly brushing the skin to the right of the umbilicus elicits intense pain. There is no conclusive evidence of disease to local internal organs. Which additional feature will likely develop soon?

Skin lesions, Herpes Zoster reactivation from chemotherapy

Steps to treat hyperkalemia with potassium greater than 6.5

Stabilize cardiac membrane with calcium gluconate Shift potassium intracellularly with insulin/glucose Prepare for hemodialysis if refractory to these measures

Most common cause of septic pulmonary emobli in endocarditis

Staph aureus

Acute MI. Lung exam shows bibasilar crackles that extend halfway up lung fields bilaterally. S3 present. He is started on aspirin, plavix, and lipitor. Next best move?

Start lasix, flash pulmonary edema post MI

10-20 bowel movements a day, watery and frequent, nocturnal bowel movements and abdominal cramps. Metabolic alkalosis and profound hypokalemia. Colonoscopy shows dark brown discoloration of mucosal pigmentation in proximal colon. Young healthcare worker in nursing facility. Next step in management?

Stool laxative screen for factitious diarrhea/laxative abuse

Takotsubo cardiomyopathy

Stress induced cardiomyopathy A bulging out of the left ventricular apex with a hypercontractile base of the left ventricle is often noted. Risk factors: postmenopausal woman, recent physical or emotional stressor CP: decompensated HF, moderate trop elevation, ECG shows ischemic changes in precordial leads Cath shows no obstructive CAD

What is the most important factor in reducing the progression of diabetic nephropahty

Strict blood pressure control with an ACEi to stop hyperfiltration

Amyloidosis

Suspect in unexplained CHF, LVH, and proteinuria/nephrotic syndrome in absence of HTN -bruising -hepatomegaly -enlarged tongue -neuropathy -restrictive cardiomyopathy

Recurrent pneumonia in same anatomic location of lung

Suspicious for localized airway obstruction -neoplasm, lymphadenopathy -foreign body - bronchiectasis Get chest CT

Rome diagnostic criteria for IBS

Symptom improvement with bowel movement Change in frequency of stool Change in form of stool

Narrow complex tachycardia and not hemodynamically stable

Synchronized cardio version

54 year old complains of several months of increased fatigability. He eats meat occasionally and drinks two to three cans of beer on weekends. Exam reveals pale conjunctivae and hyperdynamic carotid pulses. Hgb is 7.7, folic acid therapy. 4 weeks later Hgb is 9.1, but he complains of new tingling in his toes. Likely cause of this patient's current symptoms?

Vitamin deficiency B12 often precipitated after folate is started

What kind of immunity due polysaccharide vaccines induce

T-cell independent B-cell response

29 year old Asian woman presenting with numbness and pain in her upper arms. Associated symptoms are fatigue, weight loss, and joint pain no past medical history. Patients blood pressure is 140/90 in right arm and 90/55 in left arm. Bruit is heard in right supraclavicular fossa and left radial and brachial pulse is decreased. ESR is elevated.

Takayasu arteritis Coarctation would be diagnosed earlier in life and blood pressure discrepancies usually in LE.

Unable to open mouth completely. painful spasms of neck muscles triggered by physical stimuli

Tetanus -trismus/lockjaw -toxin mediated blockage of GABA and glycine

Treatment of viral conjunctivitis?

Warm or cold compresses adenovirus

Treatment of patient with WPW and a. fib with RVR

cardioversion or antiarrythmics like procainamide AV nodal blockers should be avoided as they will increase the conduction through the accessory pathway (CCB, beta blockers, digoxin, adenosine)

nystagmus that is not fatigable

central vertigo, get noncontrast CT to assess for hemorrhage -headache -postural instability

Indications for CABG

■ Left main coronary artery disease. ■ Triple-vessel disease with ≥ 70% in each vessel. ■ Two-vessel disease in diabetic patient. ■ Symptomatic patient despite maximal medical therapy.

Intervention that leads to the greatest drop in systolic BP in HTN

Weight loss

Tetanus prophylaxis

clean/minor- vaccine if last dose > 10 years ago ,or unimmunized dirty- vaccine if last dose ≥ 5 years ago, vaccine pluse TIG if unimmunized

CURB 65

confusion BUN > 20 respirations > 30/min BP sys < 90 or di < 60 age > or = 65 Treat with fluoroquinolone (moxifloxacin) or beta-lactam plus macrolide for CAP Doxy can be used for outpatient CAP

Patients in status epilepticus are at increased risk for developing...

cortical necrosis

dark urine, AKI, on statin and colchicine, what test to order

creatine phosphokinase to confirm rhabdo

Post MI complications

day 1: heart failure/cardiogenic shock-decreased ejection fraction days 2-4: arrhythmias/dysrhythmias-disturbance of cardiac rhythm, occurs with 80-90% of MI (most common complication) 5-10: LV wall rupture, pap muscle rupture weeks to months: ventricular aneurysm

34 year old woman with history of dilated cardiomyopathy presenting with weight gain and dyspnea On exertion. Grade 3/6 holosystolic murmur heard at apex. What explains the murmur?

decompensated heart failure, increased LVEDV, dilation of mitral annulus, lateral displacement of papillary muscles

Strategies to prevent mortality of patients on ventilator

low tidal volume to reduce alveolar distention in ARDS increasing oxygenation by FiO2 > .6 increasing PEEP to 15-20 preventing SpO2 < 88%

goal A1C of 6.5% with use of insulin reduces the risk of what

microvascular complications retinopathy, nephropathy

Asian woman, hx of rheumatic heart disease in a. fib. What caused this?

mitral stenosis leading to left atrial dilation

Short systolic murmur at apex that dissapears with squatting

mitral valve prolapse

anti-U1 RNP

mixed connective tissue disorder SLE + Scleroderma + polymyositis

Mild to moderate acne vulgaris that fails initial therapy

add topical abx like erythromycin

HIV associated nephropathy

advanced HIV sub-Saharan African descent heavy proteinuria with rapidly progressive renal failure collapsing focal segmental glomerulosclerosis, tuboreticular inclusions direct infection of renal tubular and glomerular cells by HIV virus

Difference between typical and atypical chest pain

Typical chest pain is exertional, crushing, radiating Atypical chest pain is sharp, pleuritic, worse w/ movement (i.e. not from ischemia caused by the heart)

Decreased sensation in medial hand, decreased grip strength, weakness in intrinsic hand muscles

Ulnar nerve injury at elbow

Patient presents with intermittent cough and dyspnea. PMH of allergic rhinitis, DMII, and eczema. ECG shows ST depression in lateral leads and he is admitted for further eval and started on aspirin, beta blocker, ACEi, statin, plavix, and LMWH. The next morning he is short of breath and has a dry cough. Exam reveals prolonged expiration with bilateral wheezes. No crackles. Cardiac exam normal. What is responsible for his symptoms?

Undiagnosed asthma exacerbated by aspirin 1.aspirin 2. chronic rhinitis 3. nasal polyps

Main side effect of antithyroid drugs methimazole and PTU

agranulocytosis methimazole- 1st trimester teratogen, cholestasis PTU- hepatic failure, ANCA-associated vasculitis

Treatment for uric acid stones?

alkalinization of urine with potassium citrate, allopurinol if gout acidic urine pH

Young patient with symptoms of COPD, CXR reveals bilateral basilar lucency

alpha 1 antitrypsin level - < 45 years old - basilar-predominant disease

Stable patients with wide-complex tachycardia

amiodarone, procainamide, sotalol, lidocaine

Initial treatment for peripheral artery disease

aspirin, statin, supervised exercise program

Most specific clinical sign that correlates with increased BNP level?

Third heart sound, S3

Anterior mediastinal mass on CT. Swallowing problems for 1 month. Upper endoscopy and esophageal manometry normal.

Thymoma Myasthenia gravis- decreased available acetylcholine receptors

Preferred intervention in grave's disease with exopthalmos

Thyroidectomy RAI can acutely worsen ophthalmopathy due to increased titers of thyroid-stimulating immunoglobulins

52 y.o F w/ 1 week of intermittent pain on right side of face. Pain is intense, sharp, and on right cheek and lips and lasts several seconds. It recurs several times a day. Brushing teeth and drinking cold water are triggers. On exam she does not have a rash. Her face demonstrates normal sensation and muscle strength. Likely cause?

Trigeminal neuralgia -compression of trigeminal nerve root

42 year old man with positive HIV testing, CD 4 count is 45, and viral load is 45,000 primary prophylaxis with what is required?

Trimethoprim-sulfamethoxazole cover PCP and toxoplasmosis prophylaxis for MAC is not indicated anymore

45 y.o man from China, CC of dyspnea, fatigue, and abdominal distention for 2 months. Farmer entire life. Exam shows pedal edema, increased abdominal girth with free fluid, JVD, and Kussmaul sign. Decreased heart sounds and a sound directly after S2 early in diastole is heard. CXR reveals calcification around the heart and jugular venous pressure tracings show prominent x and y descents. Likely cause?

Tuberculosis endemic region, constrictive pericarditis

most common cause of primary adrenal insufficiency

autoimmune adrenalitis -primary hypothyroidism -vitiligo - pigmentation and hyperkalemia (not seen in secondary AI)

Dressler syndrome

autoimmune phenomenon resulting in fibrinous pericarditis (several weeks post-MI), fever, pericarditis, pleural effusion, leukocytosis, ↑ ESR

Discuss acute coronary syndrome

Unstable angina- ECG- no ST elevation, no cardiac biomarkers, chest pain that is 1) new onset 2) accelerating or 3) occurs at rest NSTEMI- elevations of troponin I and CK-MB w/o ST elevation on ECG STEMI- cardiac biomarkers + ST elevation on ECG

Coffee ground emesis, upper abdominal discomfort, burning and fullness relieved by food. Black tarry stools associated with weakness and fatigue. Conjunctivae and palmar creases appear pale. What lab test is most likely increased in this patient?

Upper GI bleed likely elevated BUN/creatinine ratio due to hypovolemia

Patient with muscle wasting, enlarged parotid glands, multiple spider angiomas, ascites and DRE reveals internal hemorrhoids. Abdominal ultrasound reveals splenomegaly, ascites, echogenic and shrunken liver without any mass. Next step in managment?

Upper GI endoscopy to evaluate for varices CT would be appropriate if liver masses were found on ultrasound. Patients with cirrhosis should receive screening ultrasound every 6 months.

Drug of choice in treatment of PBC?

Ursodeoxycholic acid. Advanced disease requires liver transplantaiton.

Used to confirm venous stasis

Venous doppler ultrasonography, though usually a clinical diagnosis Venous dermatitis, edema, leg pain, scaling, weeping, woody induration and brown discoloration, ulcers Tx: compression stocking and elevation

contralateral hemiplegia w/ ipsilateral cranial nerve involvement, ataxia

Vertebrobasilar infarct

Coughing, chokes, and nasal regurgitation when swallowing liquids or solids. Preferred step of evaluation of dysphagia?

Videofluoroscopic modified barium swallow, oropharyngeal dysphagia Esophageal dysphagia is evaluated with barium swallowed followed by manometry

What is necessary for the diagnosis of ankylosing spondylitis

X-ray of the sacroiliac joint HLA-B27 not specific to ank spon

acute-onset of unilateral facial weakness involving upper and lower face, treatment

bell's palsy, glucocorticoids stroke spares forehead

AS in patients under 70 y.o

bicuspid aortic valve

Signs of early septic shock

bouding peripheral pulses, hyperdynamic phase

single ring enhancing lesion in frontal lobe, patient presented with seizure

brain abscess strep viridans or staph aureus direct spread from otitis media, mastoiditis, sinusitis, endocarditis

What causes isolated systolic hypertension?

decreased elasticity of the arterial wall in elderly patients

Diagnosis requirements for acute liver failure

elevated LFTs > 1000 signs of hepatic encephalopathy impaired synthetic function INR greater than 1.5

Tremor that tends to worsen with goal-oriented actions. Bilateral hands and head. Best treatment

essential tremor propranolol, primidone

w/u of acute limb ischemia after MI

evaluate possible arterial embolus from LV with ECHO

nonproductive cough, pleuritic chest pain, CXR reveals right pleural effusion protein 5.2, LDH 340, cell count 4,500, 82% lymphocytes serum protiein 6.0, serum LDH 120 likely mechanism of effusion

exudative, increased capillary permeability, infectious in origin Light criteria 5.2/6 = .9 340/120 = 2.8

Light criteria

fluid/serum protein ratio > .5 fluid/serum LDH ratio > .6 fluid LDH > 2/3 of ULN for serum LDH low glucose suspicious for empyema, high metabolic rate of WBCs

Progressive proximal muscle weakness without pain or tenderness, normal ESR and CK

glucocorticoid-induced myopathy exogenous or Cushing i.e. ACTH dependent

drug induced acne

glucocorticoids, immunomodulators, anticonvulsants, INH monomorphic papules and pustules, no comedones/cysts/nodules

Riluzole

glutamate inhibitor for ALS

Treatment for cyanide poisoning

hydroxycobalamin thiosulfate (directly binds CN) nitrites (to induce methemoglobinemia)

Labs consistent with rhabdo

hyperkalemia and hyperphosphatemia (lysed muscle cells) hypocalcemia blood on UA but no RBCs on microscopy RFs- opiates, immobility, statins, crush injury, seizures

Electrolytes in Conn syndrome

hypernatremia, hypokalemia, ↑ bicarbonate, ↓ renin

Side effects of macrobid

hypersensitivity pneumonitis agranulocytosis

Gait present in parkinson disease

hypokinetic gait

Recommendation about varicella vaccine in individuals with HIV

if CD4 > 200, then can administer

Unilateral motor impairment No sensory or cortical deficits No visual field abnormalities

lacunar infarct

Initial testing in suspected Cushing syndrome

late-night salivary cortisol 24 hour urine free cortisol low dose overnight dex suppression test

Dig toxicity

look for patient with a. fib with diarrhea, nausea, fatigue Can cause AV nodal block get Dig level, ECG, and PT/INR

Initial evaluation of suspected primary adrenal insufficiency

morning cortisol, ACTH stim test low cortisol, high ACTH → PAI low cortisol, low ACTH → secondary AI

Paraneoplastic syndromes

myasthenia gravis- postsynaptic membrane, fluctuating muscle weakness lambert eaton- presynaptic membrane, dry mouth, ptosis, diminished or absent DTRs dermatomyositis/polymyositis- muscle fiber injury, ILD, dysmotility, raynaud phenomenon, polyarthritis, esophageal dysmotility, Gottron's papules, heliotrope rash

Primary prophylaxis for esophageal variceal hemorrhage

non-selective beta blocker, nadolol or propranolol

Amaurosis fugax

painless, rapid, transient monocular vision loss. Curtain descending over visual field. most common etiology is atherosclerotic emboli from ipsililateral carotid, get carotid duplex ultrasound

APL

pancytopenia, promyelocytes with Auer rods, t15;17 risk of hemorrhage from consumptive coagulopathy treat with all-trans retinoic acid

Principals of a. fib treatment

paroxysmal- < 7 days persistent- > 7 days permanent- > refractory to all intervention (medical, ablation) 1. Anticoagulation i.e. warfarin, eloquis, xarelto 2. Rate or rhythm control- start with metoprolol or diltiazem, then can use amiodarone

What causes the flushing caused by niacin

prostaglandin and histamine release. give niacain with aspirin

Common lung finding in systemic sclerosis (CREST syndrome)

pulmonary arterial hypertension

Most frequent location of ectopic foci that cause a. fib

pulmonary veins

nephrotic syndrome, dilated tortuous veins in left scrotum

renal vein thrombosis, hypercoaguability from nephrotic syndrome

Progressively worsening dyspnea on exertion for several months. Frequent awakenings during night due to choking sensation. Blood pressure is 166/100 mm Hg and pulse is 80/min. BMI is 48. Jugular venous pressure difficult to assess because of neck fat. What is most likely to be found in terms of acid base status?

respiratory acidosis with metabolic alkalosis hypercapnia, hypoxia, and bicarbonate retention with chloride secretion obesity hypoventilation syndrome

Cardinal signs of parkinson disease

rest tremor, rigidity, bradykinesia

Important adverse effect of hydroxychloroquine

retinopathy

Hep C diagnosis

screen with Hep C antibody confrim with HCV RNA

Common triggers of ARDS

sepsis, pneumonia, aspiration, multiple blood transfusion, inhaled/ingested toxins, drowning, trauma cp: noncardiogenic pulmonary edema, acute onset respiratory failure

Pain management in severe cancer

short acting opioids

abdominal pain, bloating, flatulence, watery diarrhea, positive carbohydrate breath test

small intestinal bacterial overgrowth -risk factors: DM, chronic opiate use - treat with rifamixin

heart burn, sticking in chest during eating, end-inspiratory crackles on lung exam, mild hyperemia in distal esophagus, esophageal manometry shows lack of peristaltic waves in the lower 2/3 of the esophagus and significant decrease in lower esophageal sphincter tone. Likely mechanism

smooth muscle atrophy and fibrosis -systemic sclerosis

Diseases associated with erythema nodosa

streptococcal infection, sarcoidosis, tuberculosis, endemic fungal disease i.e. histoplasmosis, IBD, Behcet disease

Management of metastatic brain cancer from non small cell carcinoma

surgical resection of the mass

coarse facial features, arthralgias, uncontrolled HTN, enlargement of digits, carpal tunnel syndrome, hyperhidrosis

suspect acromegaly, get IGF-1 level and then confirm with glucose supression test. final step is imaging the pituitary

signs and symptoms of interstitial lung disease

symptoms- exertional dyspnea, dry cough signs- fine crackles during mid-late inspiration, possible digital clubbing CXR showing reticular or nodular opacities normal FEV1/FVC, ↓ DLCO

What should be given in acute COPD exacerbation with mechanical ventilation requirement or increased sputum, dyspnea, and cough?

systemic glucocorticoids oxygen supplementation target SpO2 > 88% antibiotics inhaled bronchodilators

Types of strokes

thrombotic; stuttering progression, hx of TIA/atherosclerosis risk factors embolic; a. fib, endocarditis, carotid atherosclerosis, abrupt onset of symptoms, maximal at start hemorrhagic; uncontrolled HTN, coagulopathy, cocaine, amphetamines, progression over minutes to hours, focal neurologic deficits followed by ↑ ICP i.e. headache, vomiting, lethargy SAH; saccular aneurysm, severe HA at onset, meningeal irritation, focal deficits uncommon

Most specific finding related to epilepsy vs. syncope?

tongue biting, especially lateral

Patient with DM with hyperkalemia and mildly decreased bicarb and increased creatinine. Likely cause?

type 4 RTA non-anion gap metabolic acidosis seen in elderly patients with poorly controlled diabetes. damage to juxtaglomerular apparatus causes hyporeninemic hypoaldosteronism.