step 3
GLP-1 agonists
Exenatide, liraglutide
which nerve is injured? inability to extend the knee against resistance. Sensory loss over the anterior aspect and most of the medial aspect of the thigh. Sensory loss extends down the medial shin to the arch of the foot. Also a decrease in the knee jerk reflex
Femoral nerve injury. weakness involving the quadriceps muscle group
Sulfonylureas MOA
Increase insulin secretion from pancreatic beta cells
Metformin mechanism
Lowers blood glucose and improves glucose tolerance in 3 ways 1. inhibits glucose production in liver 2. reduces (slight) glucose absorption in gut 3. sensitizes insulin receptors in target tissue (fat & skeletal muscle) thereby increases glucose uptake in response to whatever insulin available
which scoring system is an objective measurement that is used to determine 90-day mortality in patients with advanced liver disease
MELD score: model for end-stage liver disease *also commonly used in assessing candidates for transplant livers
for patients with peri-infarction pericarditis, why is aspirin preferred to other NSAIDs or glucocorticoids?
NSAIDs and glucocorticoids should be avoided as they may impaire myocardial healing and increase the risk of ventricular septal or free wall rupture
What is raloxifene used for?
Prevention and treatment of osteoporosis in postmenopausal women and for breast cancer treatment; it works through its estrogenic effects on bones and anti-estrogenic effects on the breasts and uterus
Polymorphic eruption of Pregnany (PEP)/Pruritic urticarial papules and plaques of pregnancy (PUPPP)
Pruritic urticarial papules and plaques of pregnancy (PUPPP) - Urticarial papules and plaques that usually first appear within striae distensae and upper thighs during the latter portion of the third trimester or immediately postpartum *spares face, palms, soles
list of meglitinides
Repaglinide, Nateglinide
how to treat refractory ascites and uncontrolled variceal bleeding
TIPS procedure: transjugular intrahepatic portosystemic shunt
how to treat dumping syndrome?
a high protein diet, and fractionated, smaller, but more frequent food portions to decrease the speed of passage of fluids and food into the small gut. diet should be low in carbs
treatment for spontaneous bacterial peritonitis
a third generation cephalosporin such as cefotaxime; and IV albumin (prevent renal failure)
which complication most commonly associated with compartment syndrome?
acute renal failure *pts w/ compartment syndrome may develop rhabdomyolysis and release of myoglobin --> heme pigment from myoglobin is nephrotoxic --> acute renal failure esp if pt is volume depleted
what is often used for primary or secondary prevention of cardiovascular disease including CAD, heart attack, stroke?
anti platelet therapy such as aspirin
how to screen for celiac disease
anti-endomysial antibody and anti-tissue transglutaminase antibody levels *note gold standard for diagnosis is small intestinal biopsy
what antidepressant is not associated with weight gain
bupropion
for a pt trying to quit smoking and hx of seizure disorder, what therapy is contraindicated
bupropion as it lowers seizure threshold
most likely explanation for multi-nutrient malabsorption in a young patient with a nutritious diet
celiac disease
next best step in pts with typical biliary colic symptoms without gallstones on imaging
cholecystokinin-stimulated cholescintigraphy - if low ejection fraction, then cholecystectomy
characteristic EKG changes in pericarditis?
diffuse PR depression and ST elevation- though it may be masked by EKG changes of recent MI *pericardial effusion would be seen on TTE
painless hetamochezia and a hx of diverticulosis
diverticular bleeding is likely cause
preferred treatment for prolactin-secreting adenomas (prolactinomas)
dopaminergic medications such as cabergoline
following a gastrectomy, a patient is experiencing abdominal pain, diarrhea, and postprandial nausea and vomiting; also dizziness, generalized sweating, and dyspnea. abdomen is mildly distended. what is the diagnosis?
dumping syndrome; caused by liquid and food passage through the stomach into the jejunum being much faster
abdominal pain, epigastric fullness, and nausea that worsen after eating
dyspepsia
how to treat idiopathic pulmonary arterial hypertension?
endothelin receptor antagonists to dilate the pulmonary arteries. demonstrated delayed progression of disease *endothelin is a potent vasoconstriction hormone produced by endothelial cells and endothelia receptors are abundant in the pulmonary arteries of pts with idiopathic PAH
what leads to diverticular bleeding
eroded small artery of the colon. colonic diverticulosis results from outpouching of the colon wall at points of weakness where the vasa recta penetrate the circular muscle layer of the colon.
What causes achalasia?
failure of the lower esophageal sphincter to relax due to degeneration of the ganglia of the auerbach plexus
how to manage an incidentally found adrenal mass
first must evaluate for hormone production. - should measure serum electrolytes, dexamethasone suppression testing, and 24 hr catecholamine, metanephrine, vanillylmandelic acid, and 17-ketosteroid measurement *all functional masses, masses with radiographic evidence of malignancy, or masses > 4cm in size should be removed
list of sulfonylureas
glyburide, glipizide, glimepiride
how to treat lithium toxicity?
hemodialysis for levels >4 or levels > 2.5 with sx or renal failure; also if get increasing level despite IV fluids.
how to manage dyspepsia in a patient over age 60
high risk pt due to age>60. should undergo upper gastrointestinal endoscopy with biopsy
What are kerley B lines?
horizontal lines representing interstitial edema, often seen in heart failure w/ pleural effusions and pulmonary edema
what hormonal disease can be caused by lithium?
hypothyroidism
who should be treated for respiratory syncytial virus
infants age <2 months, hx prematurity, congenital heart disease, and chronic lung disease of prematurity * treat with pavilizumab
Croup (laryngotracheobronchitis)
infection of the upper airways in children characterized by a barking cough, hoarseness, and inspiratory stridor
what is the most common complication for patients admitted to the hospital because of recent variceal bleeding?
infection: could be urinary tract infection, spontaneous bacterial peritonitis, respiratory infection, aspiration pneumonia, or primary bacteremia
how to treat delayed puberty in boys?
initial evaluation includes obtaining a bone age radiograph and measuring FSH, LH, and testosterone levels; also prolactin and TSH tests
how to treat a newborn with hypertrophic cardiomyopathy?
is asx, no tx required. spontaneous resolution is expected within a few weeks after birth; echocardiogram findings normalize within a year * if sx, propranolol and appropriate fluid management are indicated
how does metoclopramide work?
it stimulates the contraction of the lower esophageal sphincter and increases gastric emptying
vertigo, tinnitus, nausea, a loss of balance typically following a viral illness such as influenza
labyrinthitis *often self limited
how is delayed puberty in boys defined?
lack of testicular enlargement (>/= 4mL) by age 14 and is due to inadequate secretion of testosterone required for normal pubertal development
Primary adrenal insufficiency
loss of adrenal gland function = dec aldosterone and cortisol--->hypotension (hyponatremic vol contraction), hyperkalemia, metabolic acidosis, skin/mucosal hyperpigmentation
what hormone levels are characteristic in diagnosis of non functioning pituitary adenomas
low LH and FSH, but elevated alpha subunit
how to confirm diagnosis of Addison's disease?
measurement of morning plasma cortisol with concurrent ACTH *low cortisol with elevated ACTH is diagnostic. if results are equivocal, this can be followed with an ACTH stimulation test
best next step to diagnose when suspecting compartment syndrome?
measurement of tissue pressures *and should perform serial measurements even if initial pressure is wnl *pressure >30 mm hg or delta pressure <20-30 mm hg indicates significant CS
how can left ventricular dystolic dysfunction lead to heart failure with preserved ejection fraction?
most commonly, prolonged systemic hypertension causes LV hypertrophy and impaired diastolic filling --> leads to decompensated volume overload despite normal LVEF >50%
how to manage asymptomatic pregnant patients with gallstones
no treatment as most pregnancy-related gallstones resolve spontaneously within 2 months of delivery
commonly associated combordities in heart failure w/ preserved EF due to LV diastolic dysfunction
obesity, DM, OSA
what can make BNP levels unreliable?
obesity, which can lower BNP levels
what drug can be sued in growth hormone producing adenomas (acromegaly)
octreotide, a somatostatin analogue
pleuritic chest pain and pericardial friction rub <4 days following acute myocardial infarction
peri-infarction pericarditis
Thiazolidinediones
pioglitazone
triad of iron deficiency anemia, dysphagia, and esophageal webs
plummer-vinson syndrome
why is SBP often associated with renal dysfunction?
possibly exacerbated by decreased effective intravascular volume due to cirrhosis and hypoalbuminemia. this is why we treat with IV albumin *note if a pts renal fxn does not improve w/ albumin, treatment for hepatorenal syndrome with octreotide or midodrine may be indicated
pt presents with fatigue, weight loss, myalgia, increased pigmentation, and decreased axillary and pubic hair. Blood work done shows hyponatremia, hyperkalemia, hyperchloremic metabolic acidosis
primary adrenal insufficiency (Addison's disease)
indications for statins
primary prevention of atherosclerotic cardiovascular disease in pts with LDL >190 or its age >40 w/ DM. all other pts, can have their ASCVD risk calculated using pooled cohort equations calculator ( give statin for risk >7.5-10%)
due to the high risk of infectious complication for patients hospitalized for acute variceal bleeding, how should these patients be treated?
prophylactically with antibiotics; preferred regimen involves the use of a fluoroquinolone (ofloxacin, norfloxacin, or ciprofloxacin) agent for 7-10 days
describe how rhabdomyolysis can cause kidney injury?
released myoglobin filtered and degraded in kidney --> heme pigment from myoglobin degradation: is directly toxic to proximal tubular cells, combines with tamm-horsfall protein to form tubular casts, and induces vasoconstriction, reducing medullary blood flow
pts who develop venous thrombosis while on menopausal hormone therapy should discontinue MHT and begin an alternate treatment such as ...?
selective serotonin reuptake inhibitor or SNRI
what criteria dose MELD scoring system take into account?
serum bilirubin, INR, serum creatinine, serum sodium
1st line treatment for ADHD in adolescents and school age children
stimulant medications including methylphenidate and amphetamines
how can thiazide diuretics (hydrochlorothiazide, chlorthalidone) and loop diuretics (furosemide) cause drug induced pancreatitis?
sulfonamide class of drugs. can lead to DIP via hypersensitivity to the sulfonamide molecule, ischemia due to decreased intravascular blood volume, and increased viscosity of pancreatic secretions
which hypoglycemic agents can lead to hypoglycemia
sulfonylureas and or meglitinide *these drugs increase insulin secretion by pancreatic beta cells even when blood glucose levels are normal
which drugs can lead to lithium toxicity when co-administered?
thiazide diuretics, ACE inhibitors, and NSAIDs (not aspirin)
what is the most important determinant in prognosis of compartment syndrome?
timing of surgical intervention: fasciotomy *also: remove any constrictive coverings such as casts and dressings, give supplemental oxygen, keep limb at torso level to maintain perfusion pressure, and treat hypotension if present
primary treatment modality for nonfunctioning pituitary adenomas (which usually arise from the gonadotropin-secreting cells -gonadotrophs- in the pituitary gland)
trans-sphenoidal surgery
newborn with respiratory distress (tachypnea, nasal flaring, retractions) and a heart murmur born to a mother with gestational dm
transient hypertrophic cardiomyopathy. due to fetal hyperinsulinemia in response to maternal and fetal hyperglycemia. Insulin triggers glycogen synthesis and excess glycogen and fat are deposited within the myocardium, particularly the inter ventricular septum
for pts with acute pericarditis and persistent symptoms despite high dose aspirin, how to manage?
treat with colchicine or narcotic analgesics
what infection can lead to secondary achalasia
trypanosoma cruzi (chagas disease)
how to manage dyspepsia in pts age <60 with significant weight loss, overt gastrointestinal bleeding, or >1 alarm feature (persistent vomiting, progressive dysphagia, odynophagia, palpable mass, or lymphadenopathy, unexplained iron deficiency anemia, or family hx of GI malignancy)
upper GI endoscopy
if you suspect gallstone pancreatitis complicated by acute cholangitis, what is the next best step?
urgent endoscopic retrograde cholangiopancreatography for diagnosis and drainage
next best step for pts with symptomatic gallstones who are poor surgical candidates
ursodeoxycholic acid *can also use this as a trial to pts with confirmed gallstones but have atypical sx (lack biliary colic)
what is rifaxamin used for in alcoholic cirrhotics?
used for additional treatment of hepatic encephalopathy caused by bacterial overgrowth and ammonia formation in the gut
how should patients with regular, narrow complex tachycardia be initially managed?
vagal maneuvers such as carotid sinus massage and/or IV adenosine
if pregnant w/ biliary colic
will try to traet with IV fluids and pain control; however if cannot be controlled with supportive care, cholecystectomy is often performed during the second trimester
how should patients with persistent tachyarrhythmia (narrow or wide complex) causing hemodynamic instability be managed?
with immediate synchronized direct-current cardioversion
should women who take anti epileptics breastfeed after giving birth?
yes, benefits outweigh the risk of exposure. so it is generally not contraindicated
Vertebrobasilar insufficiency
☼ Reduced blood flow in the posterior circulation of the brain (base of brain) Vertigo, Dysarthria, diplopia, and numbness ☼ brainstem, cerebellum, inner ear labyrinth *typically secondary to emboli, thrombi, or arterial dissection *should suspect in its with a hx of HTN, DM, CAD, HLD, arrhythmia, smoking hx
GLP-1 mechanism
*Incretin mimetic* Stimulates GLP-1 receptors which increases the production of insulin in response to high BG levels, inhibits postprandial glucagon release, slows gastric emptying
how would you treat acute pericarditis?
-NSAIDs and colchicine for viral or idiopathic etiology -variable for other etiologies: if peri-infarction pericarditis, this is usually self-limited and some pts may not require treatment, but for those with significant discomfort, high dose aspirin 650 mg TID is the treatment of choice for symptom relief. high dose aspirin is believed to provide analgesia and anti-inflammatory effect while having a relatively small effect on myocardial healing and scar formation compared to other anti inflammatory drugs
what analgesics can lead to drug induced pancreatitis?
-acetaminophen -NSAIDs -mesalamine, sulfasalazine -opiates
random other drugs that can cause drug induced pancreatitis
-asparaginase -estrogens
what immunosuppressants can lead to drug induced pancreatitis?
-azathioprine, mercaptopurines -corticosteroids
most frequent etiologies of acute cholangitis?
-choledocholithiasis -biliary stenosis -compression from malignancy
diagnostic criteria for acute cholangitis
-fever or other signs of inflammation (hgih wbc, CRP) -jaundice or abnormal liver chemistries in the setting of -biliary dilation or evidence of the etiology on imaging
which groups of patients are at higher risk for drug induced pancreatitis?
-heart failure or htn (ACE, ARB, diuretics) -autoimmune diseases (azathioprine, mesalamine, corticosteroids) -chronic pain (acetaminophen, opiates, NSAIDs) -seizure disorder (valproic acid, carbamazepine) -HIV (lamivudine, didanosine, trimethoprim-sulfamethoxazole)
other possible complications for patients admitted bc of recent variceal bleeding (besides infection)
-hepatic encephalopathy -renal failure
when can you assume that hematochezia (bright red or maroon colored stool) is due to an upper GI source? and then what would the next step be?
-if there is also hemodynamic instability and there is no strong suggestion of a lower GI source (such as passage of clots or known recent diverticular bleed) -EGD should be pursued after initial volume resuscitation
what antibiotics can lead to drug induced pancreatitis?
-isoniazid -tetracyclines -metronidazole -trimethoprim-sulfamethoxazole
what antivirals can lead to drug induced pancreatitis?
-lamivudine -didanosine
how to diagnose diffuse esophageal spasm and how to treat
-manometry showing disordered and premature simultaneous contraction of the distal esophagus with normal distal esophageal sphincter relaxation (though not first line, an esophagram would show corkscrew pattern) -treat with CCBs
how to best manage SSRI-induced sexual dysfunction in a patient on SSRI therapy
-switch to a non SSRI antidepressant such as bupropion or mirtazapine *alternatively could add adjunctive therapy with sildenafil or bupropion; or do dose reduction for its on high dose SSRI (if in remission)
how to manage dyspepsia in pts age <60 with no alarm signs
-test for H pylori infection (eg stool antigen, urea breath test); and treated if positive -those who are negative for H pylori or fail to respond to therapy can be treated empirically with a proton pump inhibitor such as pantoprazole or omeprazole
what antihypertensives can lead to drug induced pancreatitis?
-thiazides, furosemide -enalapril, losartan
what antiepilectics can lead to drug induced pancreatitis
-valproic acid -carbamazepine
What BNP level suggests that CHF is unlikely?
<100 pg/mL
what would you expect the SAAG (serum-ascites albumin gradient) to be in patients with SBP in the setting of portal hypertension (eg cirrhosis)
>/= 1.1 g/dL
best next step in management of a patient with deep venous thrombosis or pulmonary embolism who does not have cancer and is at low risk for bleeding complications? and if pt does have cancer?
>/= 3 months anticoagulation with an oral factor Xa inhibitor such as rivaroxaban - if pt does have underlying malignancy, low molecular weight heparin is considered more efficacious
BPPV (benign paroxysmal positional vertigo)
Common cause of recurrent peripheral vertigo resulting in dislodged otolith that leads to disturbances in semicircular canals (95% horizontal, 5% horizontal). Presents with transient vertigo (lasting <1min) and mixed upbeat-torsional nystagmus triggered by changes in head position. N/V uncommon due to short lived. Dx by Dix-Hallpike maneuver. Tx Epley maneuver
