Medicine Shelf Part 2

Key signs of hypercalemia?

ABd pain, consitpation and polydipsia. Can cause renal vasoconstriction and decreased glomerular flow, inhibits Na-K2Cl and ADH activity casuing loss of Na and free water = hypovolemia and metabolic alkalsosis, hypoMg, hypoP, decreased PTH and AKI.

Differential dx and tx for chronic chough?

ACEI = Stop ACEI UACS = give 1st gen H1 blocker Asthma get PFTs with spirometery to asses bronchodilator response. Methacoloamine challenege if no bronchodialotr resoponse is seen. GERD = emperic PPIs If worse at knight and no improvement with antihistmaines asthma is your best bet.

Pathophysiology of TTP

ADAMTS13 activity decrease which presents with fever, microangiopathic hemolytic anmia, thrombocytopenia, non-papaple purpura with kidney injury and confusion/stroke. Severely anemic.

Presentation of Bernard-Soulier Syndrome?

AR disorder due to absent platelet glycoprotein Ib-IX-V which is the receptor for vWF patients have mild thrombocytopenia (compared to ITP) and circulating giant platets with increased bleeding time only.

Patient on TB tx develops microcytic anemia. Why?

Acquired sideroblastic anemia due to defective heme syntehsis due to pyridoxine dependant impairment in the early steps of protoprphyrin sythesis from INH. Iron studies will show increased iron,

34 year old woman blood tinuged sputum for weeks. No weight loss, no travel non-smoker. No PE findings dx?

Acute bronchitis. X-ray will be clear Tx is only symptomatic with NSAIDS/bronchodilators. Often after a URI.

3 types of conjunctivitis and how to tell the apart.

Allergic = bilateral Bacterial = unilateral with purlent discharge that reappears after whiping. Viral = unilateral wit hwatery scant stringy mucus;.

Presentation of Giant Cell Arteritis?

Almost exclusively in patients >50.. Typically with temporal or scalp tenderness and most patients have chronic pain and stiffness of the shoulders and hips (polymyalgia rhumatica)

What is the tx of CN toxcitiy

Antidotes such as hydroxocobalamin or Na Thisulfate which directly bind CN molecules. Alternatives include an induction of a methemoglobinemia with nitrates to increase Fe3+ which avidly binds to CN.

Main differences between MEN2A and MEN2B?

B has marfanoid body with mucosal neuromas. Both have medullary thyroid and pehochromocytomas with RET mutation. MEN2A has primary hyperparathyroidism.

Patient has DVT with elevated homocysteine What additional therapy other than anticoagulation is used?

B6 (pyridoxine) B12 should be added if B12 def is documented. Will lower homocysteine and thereby the atheroscleoris and thromboembolus risk

PE and imaging findings in bronchogenic carcinoma

Bibasilar end insipiratory cracks with fingernail clubbing. With bibasilar reticulonodual inflilfates, honeycombing nad bilaterla pleural thickening on imaging.

How does Clopidogrel act as an antiplatlet agent

Blocks Adenosine diphosphate receptors on the surface of platelets.

What two cancers are commonly seen in smokers with absetoses exposure?

Bronchogenic carcinoma (more commonly) and Pleural mesothelioma. However, pleural mesothelioma typically presents as a UNILATERAL pleural abnormality with a large pleural effusion on x-ray.

What is thromboangitis obliterans?

Buerger disease. Primarily in men who are heavy smokers. Superficial thrombophlebitis and ischemia and gangrene of the digits.

What are disorders of phageocytosis?

CGD Chediak-Higashi Hob syndrome and LAD ---> severe bacterial infections

Presentation of Isopropyl alcohol ingestion

CNS depression, with disconjugate gaze, high osmolar gap but NO INCREASED ANION GAP OR MA.

How to Dx polymyocytis?

CPK elevation, autoAb (ANA and Anti-Jo-1) Or Muscle biospy (best test) to show mononuclear infiltrate surroudning necrotic and regenerating muscle fibers.

How to Dx Takaysu arteritirtis. Tx?

CT and MRI may reveal thickening of large artery walls and lumenal narrowing with increased ESR and CRP. Tx is with steroids.

Interesting lab value in patietns iwth CO posioning

Carboxyhemoglobin has an affniity much greater than that of o2 making tissue hypoxia present and kidney produces EPO resulting in a secondary polycythemia. Looks normal on pulse ox need ABG with Cooximetry.

Who gets S Bovis endocarditis

Colon cancer or IBD patients

What is Seborrheic Dermatitis?

Common inflammatory disease that affects the scalp (dandruff), face, eyebrows, nasolabial folds, external ear cancal, chest etc. AT ages but most common in 1st year of life and 30-60. Associated with PArkinson and HIV. Prutitic erythematous plqaues with GREASY LOOKING SCALES.

Presentation of Tension HA?

Constant pressure in the temporal and occipital regions without N/V or visual sx. More common in women and are usually bilateral, last 30 minutes to a week and have asscoiated muscle tenderness of the head and neck. More frequent during times of stress.

Major differences between the 4 HIV associated diarreahs?

Crypto = Severe watery low grade fever CD4 <180. Associated with animal/human contacts. Has acid fast oocytes. Tx = antiretorviral Microsporidium isosporidum is <100 with watery and fever is rare mycobacterium avium = <50 with HIGH FEVER >102.2 watery Cytomegalovirus <50 with frequent small volume hematochezia and low grade fever.

Side effects of exogenous steroid use

Decreased LH and FSH with infertilited (decreased sperm). Normal testerone levels because exogenous looks the same on serum. Acne, yecomastia, decreased testicular size, aggresiveness and psychotic sx. Erythrocytosis, increased hemoglobin, cholestasis, hepatic failure, dyslipidemia, and increased Cr (due to increased muscle mass)

Consequencys of untreated OSA

Depression, HTN, impotence, accidents related to daytime somnolency.

Dysfunction of inhibitory neurons on the esophegeus. Dx?

Diffuse esophageal spasm and presents with chest pain and dysphagia. Manometry is characterized by periodic high-amplitude, non-peristaltic contractions.

Why do patients with factor V Leiden get thrombosis?

Dominant point mutation in gene for factor V that makes it unable to respond to activated protein C.

What is Jarish-Herxheimer rxn? What is the clinical presentation?

Early syphllis tx with antiboitics causing rapid destruction of spirochetes causing an acute febrile illness. Typically 12 hours after tx. Sx = HA, myalgias, rigors, hypotension and WROSENED SYPHILITIC RASH. Sx resolve in 48 hours.

What on nocturnal polysomnography is dx of OSA?

Either cessation of breathing for >10s or hyponea (reduced airflow causing SaO2 to decreased by 4%) x5 per hour.

Presentation of Heritary hemochromatosis

Elevated LFTs,fibrosis and cirrhosis, skin pigmentation especially in sun-exposed areas, DM, arthopathy and hypogonadism (dimished libido and ED). 20x increased risk for heptocellular cancer.

HIV patient with previous CD4 count less than 100 complains of epigastric burning pain. Dx?

Esophagitis due to CAndida. But can also be HSV CMV. Tx with conazole. And only investigate if no response to drug with esophagoscopy with biospy, cytology and culture.

Complications of Systemic sclerosis

Fatigue, weakness, Telangiectasias, sclerodactlyl, digital ulcer,s arthraglias, dysphagia, esophageal dysmotility, Raynauds, intersitiual lung disease, pulmonaryHTN, scleroderma renal crisis, Myocardial fibrosis, pericarditis, pericardial effusion. Polymyocytisis presents similarlly but with symmetric muscle weakenss not arrthragias.

Presentation of invasive pulmonary asergillosis and Tx

Fever, pleuritic chest pain and hemoptysis. CY usually reveals nodules with surrounding groun-glass opacities (halo sign).; Postive galactomannan assay. BAL and biospy my be required. Tx is 1-2 weeks of voriconazole plus echinocandin (caspofungin) HIgh mortaolity rate. Only in immunocompromised people

Presentation and Tx of Ethylene glycol ingestion

Flank pain, hematuria, with anion gap MA and Calcium oxalate crystals in urine. Tx is with Foepizol which is a competitive inhibitor of alcohol dehydrogenase preventing further breakdown of ethylene glycol into its toxic metabolites. Hemodialysis may be required.

How to differentiate HA from Giant cell arteritis

GCA is in pateitns over 50 with NEW ONSET HA that localizes to temples and has fever, weight loss, vision changes and JAW CLAUDICATION like fatigue and pain with chewing.

Dx and Tx of Epiglottitis

GET DIRECT VISUALIZATION FIRST. Low thershold to intubation. Give Ceftriaxone plus vancomycin.

Who gets Virdians Step Endocarditis

Gengival maniputalation and respitory tract incision or biospy

36 year old patient comes with 1 month hx of diarrehea, abd distention, flatulance, arthraglia, weight loss, cervical and inguinal lyphnodes and ulcer in buucal mucosa. Dx?

HIV! Typically presents wtih mono-like sx fever, lyphadenopathy, arthraglias with GI sx. HV test is next best step in this patient but also consider IBD, CT diseases, WHIpple disease.

The rash of molescum contagiosum is most commonly associated with which condition?

HIV/Cellular immunodeficency as they have a rpolonged course wtih widely distrubted papules facial involvement and lesion counts numbering in the hundrreads. Get HIV test in MC patients with large numerous or widespread lesions.

Patient had diareah and now has sacroilitis. Dx?

IBD. NOT Reactive arthritis. That's only can't see can't pee can't climb a tree.

Which coagulation proteins are effected by Warfarin

II, VII, IX, X and Proteins C and S

Patient has endocarditis and had a cardioembolic stroke from vegitation what is the tx?

IV antiboitics surgery only if there is significant valvular dysfunction that leads to HF. Do not need anticoagulation.

1st line tx for patients with native-vlave endocarditis with Virdian step

If penecillin susecptile give Penicillin G aqueous.

Who gets Candida endocarditis?

Immunocompromised people, IV catheters or people on prolonged antiboitic therapy.

What is hyposthenuria?

Impairment of the kidney's ability to concentrate urine. Often found in patients with sickle cell disease but laso in sickle cell trait.

What is information bias?

Imperfect assessment of association between the exposure and outcome as a result of errors in teh measurment of exposure and outcome statu.s

How does asprin act as an antiplatelet agents

Inhibits COX1 and inhibiting Thromboxane A2 synthesis

Drugs associated wtih Esophagitis?

K supplements, tretracyclines, bisphosphonates

What is Takayasu arteritis?

Large artery vascultiis that predominatnly effects asian women <40. Primarily involves the arota and bronches and has mononuclear infiltrates and granulomatous inflammation of the vascular media leading to wall thickening with aneurysmal dilation or narrowing/occulsion. Sx are nonspecfic fever, weight loss, arterio occulisive manifestations like claudication, distal ulcers in the UPPER EXTREMEITIES. Pulse deficits and anemia.

What diseases present with basophilic stippling?

Lead Posioning, Thalessemias and Alcoholism due to ribsomal precipitates that form varying sizes of blue granues in the RBC cytoplasm.

Common Sequelae of Ankylosing spondylitis?

Longstnading AS can devleop osteopenia/osteoporosis due to increase osteoclast activity in the setting of chronic inflammation (via TNF-alpha and IL-6). Patients have spinal rigidity and increased risk of vertebral fracture from minimal trauma. Also associated with aortic regurg and Cauda equina,.

Patient has postural back pain shooting into legs that improves with sitting, worse when walking. Normal ABI. Dx?

Lumbar Spinal stenosis/OA of the spine. Pain is associated with acitivty as lumbar extension during walking worsens the narrowing of the canal = neurogenic claudication. SHoppingcart sign = pain improves with leaning forward.

How to tell the difference between Spinal stenosis and veretbral fracture

Lumbar spinal stenosis witll have more procnounced neuro signs than reflex loss (sensory loss, weakness in legs) and these signs GET WROSE WITH SPINAL EXTESION but improve with leaning forward or lying down which you will not see with vertebral fracture. Verebral fracture shouldn't have neuro signs but is commonly found in elderly who lose ankle reflex....

Patient holds their breath and the pressure in the lung is recorded. What is this pressure significant for

Lung compliance or Elastic pressure/recoil is inversely realted to lung compliance. Pulmonary fibrosis = stiffer lungs and higher elastic pressure.

1st line medication for glacoma? Other tx?

Mannitol IV. Can also use acetazolmide, pilocarpine (to open canalas of Schlemm) or timolol to decrease IOP

Fatigue, non-blanching Lower Leg spots, arthralgias and renal disease with peripheral neuropathyies. Dx?

Mixed cyroglobulinemia syndrome. Caused by immune complex deposition in small to medium size blood vessels leading to endotherlial damage and end organ damage. Renal is variable but most commonly with HTN. Liver inolvement with LFT increase is also common.

How to Dx mixed cyroglobulinemia. Tx?

Most commonly in a patient with Hep C abd SLE. All patients should also get HIV test. Often RF positive with low complement levels. Tx is with plasmaphoresis or immunosuppresion with steroids or rituximab.

Tx of Reiter Syndrome (Reactive Arthritis)

NSAIDs. Typically presents with can't see, can't pee can't climb a tree. But sx also include mouth ulcers.

What is Lymphatic filariasis?

Nematode that is endemic to AFrica, ASia and latin america. Fever, painful lymphadenopathy and lyphangitis wit hdisfiguring edema.

What drugs interact wtih Sidafinil?

Nitrates and Alpha-1 bockers. As it leads to severe hypotension. Use the lowest effective doses of both medications with careful dose titration. Take drugs 4 hours apart.

At what rate should hyponatremia be corrected?

No more than 0.5mEq/L/hf to avoid central nervous system osmotic demyelination syndrome.

Patient has WPW and afib. Tx?

Normally would beta blocker for afib but you can't since he has WPW (increases time to use the bundle of kent). If unstable shock for stable patients use antiarrythmic drugs since rate control is out = procainamide.

Who gets Enterococci endocarditis?

Nosocomial UTI infections

What is asprin-exacerbated respiratory disease?

Occurs in patients with asthma and chronic rhinosinusitis. Sx include sudden worsening of asthma and nasal congestion 30min-3hours after ingestion of NSAIDs.

Presentation of Epiglottitis

Often by H flu. Rapidly progressive and life threatnenign fever, sore thraot, drooling MUFFLED VOICE. Airway obstruction with stridor and dyspnea. Pooled oropharynx secretions and larygeotracheal tenderness.

Presentation of Graft vs. Host disease

Often post-bone marrow transplant. Often involvnig the skin (maculopapular rash involving palm, soles and face) intestine (bloody diarrehea) and liver (abnormal liver function tests and jaundice) Due to donor T lymphocyte activation around 2 weeks.

Presentation and Tx of Chikungunya fever

Patient who lives or visted central, south merica or Carribean via Aedes mosquito (same as Dengue). With high fever, severe polyarthragias, HA, maculopapular rash, lymphopenia, thrombocytopena and elevated liver enzymes. Tx is supportive resolves in 7-10 days.

Presentation of alpha-1-antitrypsin disease

Patients with COPD at a young age <35, COD with minimal or no hx of smoking. Decreased breath sounds bilaterally. FHx of ephysema or liver dx slightly elevated AST/ALT. Tx is with supplementation of human AAT and bronchodilattors/steroids as needed.

Absent or decreased breath sounds on the Left should immediately make you think?

Possible intubation of the right mainstem bronchus = ETT malpostion.

Most common side effect of steroids on labory studies

Post-steroids patients get leukocyosis with neutrophili predominance because they can't leave the blood vessels and are promoted to be mobilized into bloodstream. Steroids also decrease the number of circulating lymphocytes and eosinophils.

Best tx for cancer related cacexia/anorexia syndrome?

Progesterone analogues. Like megestrol acetate. Syntheetic cannabinoids are only good for HIV related.

Who gets S Aureus/Epi endocarditis

Prostatic valvues, IV catheters, implanted devices or IV drug users (often of the tricuspid).

Most likely orginiating location of a PE?

Proximal theigh (iliac, femoral or popliteral vien) are 90% of PEs. distal/calf are less likel y and more likely to spontanously resolve. Renal vien is possible in patients with nephrotic syndrome R atrium possible with patients with pacemakers

Presentation of polymyocytits?

Proximal uslce weakness of lower extremties (not able to rise from chair or climb stairs) then proximal arm weakness with difficulty putting arms overhead. Dysphagia due to involvement of muscles of the upper parnex.

Tx of CO posioning

100% o2 and hyperbaric o2 therapy if severe.

What is Behcet Syndrome?

Recurrent painful oral aphtous ulcers, genitial ulcers, eye lesions (uvetits), skin lesions like aerythema nodosum or acneiform lesions and thrombosis. Patients may also demonstrate pathergy an exaggerated ulcerating skin response following minor injuries like a needlestick.

What disease does selective IgA defiency predispose to?

Respitory infections and chronic giardiasis

How to tell if something is Rosacea or some other photosensitivy/SLE?

Rosacea is commonly assocaited with Telangiectasias, is long lasting and commonly presents with triggers like alcohol, speci foods or sun. Can have ocular conjectival hyperemia and lid margin telangectasas as well.

Patient stepped on nail and now has osteomylitis? Which organism?

S Aureus OR P aeruginosa (Peudo is more than S epi).

Patient drinks acid/base. Next best step?

Secure ABS. CXR if respitory sx. Upper GI endoscopy.

What is the tx of chemotherapy induced nasuea?

Serotonin (5HT) receptor antagonists. Less good options are anticholinergic scopolamine or Dopamine antagonists like metoclopramide or prochlormperazine

Diseas associated with erythma nordosum

Step infection, Sarcoid, TB, coccidoidomycosis, IBD and Behcet disease. Sarcoid being one of the most common. Dx with CXR.

What is the Hawthrone effect?

Subjects of the study change their behavior because they are aware that they are under observation.

What is Leser-Trelat sing?

Sudden development of seborrheic keratoses. Associated with gastric adenocarcinoma. Also associated is acanthosis nigricans.

2cm Solitary lung nodule is a found in a man with 30 pack years who says he feels well and is full of energy. Next best step?

Surgical resection. Solitary nodules are defined by rounded opacity <3cm completely surrounded by pulmonary parchyma and no associated lymph node enlargement. If patient is at high risk for malignany (smoking) then resect or if there is lesion growth.

Patient has an especially loose esopheageal sphinuter. Esophageal manometry shows hypomotility and incopetence of LES/

Systemic sclerosis. Also has thickening or hardening of skin, edema and prutitis. GI joint and resp disease are also common. Has Anti-topoisomerase (Anti SCl 70) ab.

Ab seen in Hashimoto's thyroditis

Thyroid peroxidase Ab

Increased corpuscular hemoglobin concentration Dx?

spherocytosis patients often need folate supplementation as hemolysis takes up folate and many patients also require splenectomy to minimize hemolysis

What is the cut off between acute and chronic urticaria?

6 weeks.

When do you add inhaled steroids to someone's asthma tx?

>2days per week with nighttime awakenings >2 times per month. Mild persistant.

What is Staph ecthyma?

A depp form of impetigo that typically begins as a vesicle/pustule on an inflamed area of skin and then converts to an indurated purulent ulcer. Lesion common on butt, thighs and legs.

Tx if Seborrheic Dermatitis

Topical antifungal like ketoconzole, selenium sulfide

Tx for LBP that does not have any red flag sx?

Tx with NSAIDs for pain relief and maintain moderaty actity/aerobic exersise to stretch and strengthen back muscles. Muscle relaxants are not advised for routine use. Some patients may benefit from TCA or duloxetine.

Describe the different types of Cryoglobinemia

Type 1 = lyphoproliferative or hematologic (multiple myeloma) often asymptomatic with hyperviscosity presenting with blurry vision thormbosis or Raynauds with Livedo retiuclaris. Normal Complement Type II and III (Mixed) is with Hep C or SLE with arthralgias, renal problems like glomerulonephritis, HTN and palpable purpura with a LOW C4!!

Presentation of Cluster HA?

Unilateral recurrent periorbital pain that resolves and recurs with ipsilateral miosis and ptosis.

Presentation of Methanol ingestion

Visual blurring, central scotomata, afferent pupillary defect, alterned mention. With increased anion gap MA.

When do you do pulmonary function testing?

When patients have choronic cough and you suspect asthma or COPD.

What are the current guidelines recommended for PCI in acute STEMI patients?

Within 12 hours of sx and within 90mins from first medical contact to device time at facility that has PCI or 120 mins from first medical contact to device time a non-PCI capable facility. Much better than fibrinolysis which can be done within 12 hours of sx onset for patients who can't undergo PCI (no available within timeframe)

Pathophysiology of HIT

conformational change to a platlet surface protein (platelet factor 4) due to heprin. Which creates a neoantigen. IgG autoAb to this coat the surface of platlets cuasing, thrombocytopenia, THROMBUS of atrial and venous thrombi.