Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
1874 Cards in this Set
- Front
- Back
stable vs unstable angina -- oxygen demand and supply
|
stable is due to increased oxygen demand. unstable is due to constant limited supply
|
|
2 prognostic indicators of cad
|
LV function, # of vessels involved
|
|
metabolic syndrome x vs syndrome x
|
metabolic syndrome = insulin resistance. syndrome x = exertional angina w/ normal angiogram
|
|
mechanism of chemical stress test
|
adenosine and dipyramidole cause vasodilation, due to steal, that causes decreased flow and st changes. dobutamine increases hr, bp, contractility, :. increase work
|
|
bb and cad
|
reduces freq of coronary events
|
|
revascularization after cad and incidence of mi
|
revasc doesn't affect MI incidence
|
|
how to dx b/w unstable angina and nstemi
|
cardiac enzymes elevated in nstemi
|
|
how to manage pt with unstable angina
|
need meds - aspirin, heparin, bb, nitrate. no difference b/w invasive or conservative mgmt. can perform stress test to assess
|
|
what vitamin can be used to help tx cad
|
folic acid
|
|
mortality of MI
|
30%, 1/2 of these prehospital
|
|
pathophys of most mi
|
plaque rupture forms thrombus
|
|
results of care trial
|
tx of pts w hx of mi result in decreased poor outcomes when tx w statin
|
|
percutaneous transluminal coronary angioplasty vs thrombolysis
|
ptca has more reduction in mortality
|
|
CI to cardiac thrombolysis
|
high htn, recent trauma, active pud, prev stroke, recent surgery, dissecting aortic aneurysm
|
|
renal fail and cardiac enzymes
|
elevated troponin in renal fail
|
|
medical tx for mi
|
mona, bb, acei, statin, heparin
|
|
av block after mi
|
caused by ischemic conduction tissue. if 2nd degree type ii or 3rd degree, then need emergent temporary pacemaker
|
|
when do these occur after mi: free wall rupture, IV septum rupture
|
<2w, <10d
|
|
tx for pericarditis
|
aspirin, but not another nsaid
|
|
causes of systolic dysfunction
|
post mi (most common), cardiomyopathy, myocarditis
|
|
what is high output hf
|
tissues have increased demand for CO -- due to increased o2 consumption, poor o2 capacity of blood, "short circuit of bloodstream" (av fistula)
|
|
causes of diastolic dysfunction
|
htn, valvular dz, restrictive cardiomyopathy
|
|
nyha classification
|
1 = sx with vigorous. 2 = sx with moderate. 3 = daily activities. 4 = rest
|
|
initial tx of chf
|
salt restriction <4g/day
|
|
what imaging test can be used to diagnose EF when echo fails
|
radionuclide ventriculography
|
|
effect of diuretic on systolic dysfunction
|
symptomatic, no effect on mortality or prognosis
|
|
results of RALES trial
|
spironolactone reduces morbidity and mortality in pts with class iii/iv hf
|
|
effect of acei on systolic hf
|
improves mortality and symtoms
|
|
results of COMET trial
|
carvedilol is better than metoprolol for chf
|
|
dig tox
|
nv, av block, afib, visual disturbances
|
|
how to tx chf
|
start w/ salt restriction/activity restriction,acei and diuretic if volume overload, then add bb, then finally my add dig and spirinolactone
|
|
causes of PACs
|
adrenergic excess, drugs, alcohol, tobacco, electrolyte imbalance, ischemia, infection
|
|
prevalence of pacs and pvcs
|
will find in 50% of normal people
|
|
CAST trial results
|
supression of PVCs after MI increases mortality
|
|
causes of afib
|
heart dz, pericardial issues, pulmonary dz, thyroid issues, systemic dz, stress, alcohol, sick sinus, pheo
|
|
cardioversion vs defibrillation
|
cardioversion delivers shock sync'd with qrs, terminates dysrhythmia. defib isn't sync'd, use only for vfib or vt w/o pulse
|
|
tx of afib/aflutter
|
if unstable, electric shock. control vent rate, restore sinus rhythm, possibly anticoagulate
|
|
tx of choice for rate control for afib
|
ccb, unless lv systolic dysfunction
|
|
results of affirm trial
|
rate control more important than rhythm control in afib
|
|
risk of cva if afib
|
if just afib, then 1%/yr. if heart dz, 4%/yr
|
|
afib and cardioversion. tx options
|
if afib >48h, then risk of embolization during cardioversion (incl spontaneous). therefore, need to anticoagulate. you could either anticoagulate for 3w then cardiovert, or get stat tee to look for thrombus, and if none, then can start heparin and cardiovert after 24h
|
|
how to tx chronic afib
|
rate control w/ bb or ccb
|
|
causes of aflutter
|
copd, heart dz, asd
|
|
dz assoc w/ multifocal atrial tachycardia
|
copd (hypoxia of conduction system)
|
|
how to tx multifocal atrial tachy
|
improve o2 and ventilation. if good lv function, then bb, flecainide, propafenone. if not, then diltiazem. can use amniodarone, dig for both.
|
|
most common arrythmia from dig tox
|
paroxysmal atach with 2:1 block
|
|
difference between orthodromic av reentrant tachy vs av nodal reentrant tachy
|
orthodromic is due to accessory tract b/w atria and ventricles whereas av nodal is in node. may see p waves in orthodromic
|
|
does wpw always have delta wave
|
not when there is an orthodromic reciprocating tachy (impulse traveling back from ventricles through accessory pathway to atria). other type of wpw is av node dysfunction in the context of afib/flutter (accessory tract permits conduction of impulse to ventricles)
|
|
what drugs to avoid in wpw
|
drugs that work on av node like digoxin
|
|
how to prevent psvt
|
dig
|
|
mcc of vtach
|
prior mi + cad
|
|
what is sustained vt
|
>30s, symptomatic
|
|
significance of nonsustained vtach
|
cad + lv dysfunction + nonsustained vt = independent risk factor for death
|
|
jvp sx of vtach
|
av disassociation causes cannon a waves
|
|
how to tx vtach
|
don't tx if nonsustained w/o heart dz or lv dysfunction. if stale, use iv amniodarone, procainamide or sotalol. if unstable then cardioversion (sync'd, dc)
|
|
how to tx refractory vfib (shock and epi fail)
|
amniodarone. could also try lido, bretylium, mag, procainamide
|
|
wenckebach vs type ii
|
1 = progressive prolonged pr until drop. 2 = sudden dropped beat. 2 needs tx
|
|
what maneuvers hcom made worse by
|
valsalva, standing = dec preload. hand grip = increased afterload
|
|
what maneuvers hcom made better by
|
increased preload = squat
|
|
how to tx symptomatic hcom
|
bb, then try ccb
|
|
surgical options for hcom
|
myomectomy
|
|
tx for myocarditis
|
supportive
|
|
complications of acute pericarditis
|
pericardial effusion, tamponade
|
|
what maneuver relieves pain w/ pericarditis
|
sitting up and leaing forward
|
|
ekg changes in pericarditis
|
diffuse st elevation, pr depression at first, then st normalization, then t wave inversion, then t wave normalization
|
|
constrictive pericarditis vs tamponade
|
tamponade is usually acute. lv filling is halted immediately after reaching point of noncompliance w/ constrictive. for tamponade, occurs throughout diastole
|
|
ekg changes in constrictive pericarditis
|
small qrs, t wave changes, left atrial abnormalities
|
|
when does cxr show enlargement after pericardial effusion
|
>250ml fluid
|
|
what is most important parameter to assess for cardiac tamponade
|
how fast fluid is accumulating
|
|
causes of tamponade
|
trauma, iatrogenic, pericarditis, post mi w rupture
|
|
beck's triad
|
hypotension, muffled heart sounds, jvd
|
|
jvp findings for tamponade
|
jvd + prominent x descent, no y descent
|
|
ekg changes in tamopnade
|
beat to beat variation in direction of ekg
|
|
renal failure + tamponade, tx
|
dialysis if stable
|
|
mitral valve murmurs heard best in what position
|
left lat decubitus
|
|
s1 in mitral stenosis
|
LOUD s1
|
|
survival for symptomatic aortic stenosis w/o replacement
|
25% 3-yr survival
|
|
poor prognosis in aortic stenosis
|
angina, syncope, hf
|
|
tx for mitral stenosis
|
1. tx afib 2. diuretics for pulmonary congestion & edema 3. prophylax ie 4. if symptomatic, then surgery
|
|
surgical options for mitral stenosis
|
percutaneous balloon valvuloplasty, open commisurrorotomy, mitral valve replacement
|
|
behcet's syndrome
|
vasculitis -- uveitis + apthous ulcers + genital ulcers
|
|
corrigan's pulse
|
water hammer pulse seen in aortic insufficiency
|
|
muler's sign
|
bobbing of uvula in aortic regurg
|
|
duroziez sign
|
pistol shot sound over femoral arteries in aortic regurg
|
|
austin flint murmur
|
aortic regurg causes mitral stenosis
|
|
tx for aortic regurg
|
if asymptomatic, can try salt restrict, diuretics, afterload reduction.
|
|
cxr changes for aortic regurg
|
lvh, dilated aorta
|
|
causes of acute mitral regurg
|
endocarditis, papillary rupture (mi, ischemia)
|
|
radiation of murmur in mitral regurg
|
back if posterior leaflet, or clavicular if anterior
|
|
cxr in mitral regurg
|
dilated lv
|
|
tx for for mitral regurg
|
1. tx afib 2. reduce afterload, salt, diuretics
|
|
causes of tricuspid regurg
|
1. any cause of rv dilation -- lv failure, rv infarction, inferior wall mi 2. tricuspid endocarditis 3. epstein 4. carcinoid
|
|
pulsatile liver is sx of what valvular dz
|
tricuspid insufficiency
|
|
role of echo in aortic regurg
|
perform serially in stable pt to assess need for surgery
|
|
what maneuver increases and decreases mvp
|
standing, valsalva -> less preload -> click occurs earlier cuz less filling.
handgrip -> afterload -> increases murmur |
|
major criteria for acute rheumatic fever
|
JONES - joints (migratory polyarthritis), pancarditis (O), subcutaneous Nodules, erythema marginatum, syndenham
|
|
tx for rheumatic fever
|
nsaids, monitor response w/ crp. prophylaxis before procedures
|
|
major duke's criteria
|
sustained bacteremia from known endocarditis organism, endocardial involvement
|
|
criteria for endocarditis
|
2 major, 1 major+3minor, 5 minor
|
|
minor criteria dukes
|
VIP FEC - vascular abnormalities (like janeway), immune, predisposing condition (like abnormal valve), fever, echo, cultures
|
|
test of choice for asd
|
tee
|
|
what kind of murmur seen in asd
|
systolic ejection murmur at pulmonary area (increased pulmonary flow) + fixed split s2 + diastolic rumble across tricuspid
|
|
when to tx asd
|
when pulmonary:systemic flow > 1.5:1
|
|
what kind of murmur in vsd
|
harsh holosystolic murmur w/ thrill @ 4th ics
|
|
what maneuvers can decrease vsd murmur
|
valsalva and handgrip (less flow)
|
|
what congenital defect is most likely to cause differential cyanosis
|
pda
|
|
tx pda
|
if no pulmonary vascular dz, do ligation. if pulmonary htn or r-l shunt, then don't correct
|
|
what is htn emergency
|
sbp >220 / dbp . 120 + end organ dmg
|
|
what to do for severe ha + high bp
|
lower bp, then ct to r/o bleed, if neg then do lp
|
|
how to lower bp in hypertensive emergency
|
reduce map by 25% in 1-2h
|
|
clinical features type a vs type b dissection
|
typa a is anterior cp, type b is interscapular pain
|
|
tx for dissection
|
iv bb, iv nitroprusside
|
|
most common site of AAA
|
b/w renal a and iliac bifurcation
|
|
grey turner's sign
|
ecchymoses on back and flanks, sx of aaa, pancreatitis
|
|
cullen's sx
|
ecchymoses around umbilicus, sx of aaa, pancreatitis
|
|
aaa triad rupture
|
abdominal pain + hypotension + palpable pulsatile abdominal mass
|
|
test of choice for aaaa
|
ultrasound
|
|
what is leriche's syndrome
|
atheromatous occlusion of distal aorta above bifurcation --> bilateral claudication + impotence + absent femoral pulses
|
|
what sites usually occluded in pvd
|
superficial femoral artery, politeal artery, aortoiliac
|
|
rest pain vs intermittent claudication in pvd
|
rest pain is worse cuz sx ischemia may lead to gangrene.
|
|
what is rest pain in pvd
|
pain usually over distal mt relieved with hanging foot over side of bed (gravity-related perfusion)
|
|
normal abi vs claudication abi vs rest pain abi
|
>1 vs <.7 vs <.4
|
|
what is leriche's syndrome
|
atheromatous occlusion of distal aorta above bifurcation --> bilateral claudication + impotence + absent femoral pulses
|
|
what sites usually occluded in pvd
|
superficial femoral artery, politeal artery, aortoiliac
|
|
rest pain vs intermittent claudication in pvd
|
rest pain is worse cuz sx ischemia may lead to gangrene.
|
|
what is rest pain in pvd
|
pain usually over distal mt relieved with hanging foot over side of bed (gravity-related perfusion)
|
|
normal abi vs claudication abi vs rest pain abi
|
>1 vs <.7 vs <.4
|
|
what is abi
|
ankle-brachial index, ratio of sbps
|
|
3 methods of dx'ing pvd
|
1. abi 2. pulse volume recodrings 3. arteriography (only needed for surgery)
|
|
conservative mgmt of pvd
|
1. prevent progression - stop smoking, foot care, control astherosclerosis risk factors, aspirin 2. restore arteries - exercise 3. symptomatic control
|
|
2 options for surgical tx of pvd
|
1. surgical bypass grafting 2. angioplasty
|
|
3 sources of emboli
|
heart (afib, postmi, endocarditis), aneurysms, atheromatous plaque rupture
|
|
6 p's of acute arterial occlusion
|
pain, pallor, polar (cold), paralysis, paresthesias, pulselessness
|
|
how long ischemia can skeletal mm tolerate before death
|
6h
|
|
what are sx that amputation might be necessary for ischemic injury to limb
|
paralysis or paresthesias
|
|
what is cholesterol embolization syndrome and how to tx
|
shower of cholesterol crystals originating from plaque, often triggered by surgical or radiographic intervention. DO NOT ANTICOAGULATE, control bp
|
|
doppler ultrasound for dvt vs location
|
better at detecting proximal thrombi over distal
|
|
most accurate test for dvt
|
venography
|
|
advantage of impedance plethysmography over doppler for dvt
|
less operator dependent accuracy
|
|
what is plegmasia cerulea dolens
|
major dvt -- leg edema compromises arterial supply
|
|
anticoagulation vs thrombolysis for dvt
|
anticoagulation prevents propagation, thrombolysis speeds up clot breakdown
|
|
goals of anticoagulation in dvt
|
heparin bolus that causes 1.5-2x aPTT, start warfarin once aPTT is therapeutic
|
|
when do you do thrombolysis for dvt
|
1. unstable 2. massive PE 3. RHF 4. no CI for thrombolytics
|
|
indications for ivc filter
|
absolute ci to other prophylaxis
|
|
how to prevent dvt after surgery
|
1. mechanical (leg elevation, ambulation, compression stockings) 2. drugs (lmwh until ambulatory)
|
|
3 compnents of LE venous system
|
deep, superficial, perforating
|
|
what causes discoloration of skin in chronic venous insufficiency
|
extravasation of rbcs into subcutaneous tissues
|
|
why do venous ulcers develop in chronic venous insufficiency
|
reduced capillary flow -> hypoxia and decreased healing
|
|
leg elevation producing relief vs aggravation of symptoms
|
relief = venous insufficiency. aggravation = arterial insufficiency
|
|
tx for venous insufficiency
|
leg elevation, avoid long periods of sitting or standing, elastic stockings
|
|
how to tx venous ulcers
|
dressings, venous boot
|
|
tx for superficial thrombophlebitis
|
aspirin if mild. if severe (i.e. has cellulitis), do bed rest, elevation, and compresses, usually don't need antibiotics unless suppurative
|
|
definition of cardiogenic shock
|
sbp <90, urine output <20ml/hr + good lv filling pressure
|
|
what is an intraaortic balloon pump
|
put in descending aorta, deflates right before systole (decreases afterload), inflates right before diastole --> improved mvo2, better o2. good for cardiogenic shock
|
|
causes of hypovolemic shock
|
hemorrage, vomiting/diarrhea, dehydration, burns, third spacing
|
|
best way to monitor response tx to shock
|
monitor i/o's
|
|
classes of shock
|
I = 10-15% blood loss, slightly dec blood loss. ii = 20-30% loss, tachycardia, tachypnea, decreased cr, anxious. iii & iv = confusion/lethargy, <20mL/hr urine output.
|
|
how to tx hypovolemic shock based on class
|
ii benefits from fluid, iii/iv need fluids
|
|
what is SIRS
|
2+: temperature instability, rr>20|paco2<32, tachycardia, increased wbcs
|
|
significance of SIRS
|
prodrome of sepsis
|
|
tx of neurogenic shock
|
main thing is fluids, cautious use of vasoconstrictors, maintain temp
|
|
what is an atrial myxoma an overgrowth of
|
interatrial septum
|
|
what kind of murmur w atrial myxoma
|
diastolic murmr that changes with position
|
|
centrilobular vs panlobular emphysema
|
centrilobular = smokers, proximal acini, upper. panlobular = antitrypsin, both prox & distal, bases.
|
|
dx of chronic bronchitis
|
chronic cough for >3mo for at least 2y
|
|
auscultation of copd findings
|
end expiratory wheezes on forced expiration, decreased breath sounds, inspiratory crackles
|
|
fev1 and age
|
starts decreasing 25ml/yr after 35
|
|
copd and ics
|
no benefit, reserve for refractory
|
|
when to start o2 in copd
|
pao2<55 or o2 sat<88 at rest or exercise, pao2 55-59 +polycythemia/cor pulmonale
|
|
sleep and copd
|
hypoxia in sleep might need to be tx'd w cpap
|
|
effect of o2 tx on copd
|
mortality and quality of life
|
|
3 characteristics of asthma
|
airway inflammation + airway hyperresponsiveness + reversible airflow obstruction
|
|
extrinsic vs intrinsic asthma
|
intrinsic = not related to atopy or environmental triggers
|
|
what is considered a bronchodilator response on pft for asthma
|
12% improvement on fev1 or fvc
|
|
what is methacholine challenge
|
will bronchoconstriction, hyperresponsive airways will develop obstruction earlier
|
|
when to get abg on asthma
|
significant respiratory distress, increased paco2 is suspicious for respiratory failure
|
|
how to decrease risk of oral infection w/ ics
|
spacer, rinsing mouth after use
|
|
mild persistent vs moderate persistent vs severe persistent asthma
|
>2/wk | 3-4 PMs/mo, daily | >1night/wk, continuous
|
|
how to dx bronchiectasis
|
high res ct
|
|
how to tx bronchiectasis
|
1. ab for acute exacerbation 2. bronchial hygeine - hydration, mucus removal, bronchodilators
|
|
what is a solitary pulmonary nodule
|
single well circumscribed nodule on cxr w/o mediastinal or hilar involvement
|
|
how to monitor solitary pulmonary lesion
|
if suspect malignancy, do needle aspiration biopsy or fiberoptic bronchoscopy. otherwise regular image q3-4mo, then q6mo
|
|
how to stage small cell lung carcinoma
|
limited = confinted to chest + supraclavicular nodes
|
|
where is scc usually located
|
usually central
|
|
what size of lung nodule is more suggestive of malignancy
|
>3cm
|
|
most common met sites of lung cancer
|
brain, bone, adrenal glands, liver
|
|
siadh and lung cancer
|
usually small cell
|
|
ectopic acth and lung cancer
|
usuall small cell
|
|
lung cancer and hypertrophic pulmonary osteoarthropathy
|
adenocarcenoma and squamous
|
|
eaton lambert and lung cancer
|
small cell
|
|
pleural effusion in lung cancer
|
tap it to look for malignant cells
|
|
tx for non small cell lung cancer
|
surgery + radiation
|
|
tx for small cell
|
chemo
|
|
sx of mediastinal mass
|
compression -> cough, chest pain, dyspnea, postobstructive pneumonia
|
|
how to evaluate solitary pulmonary nodule if new
|
do ct with thin sections through nodule
|
|
what type of pleural effusion does malignancy cause
|
exudative
|
|
what type of pleural effusion does PE cause
|
can cause either transudative or exudative
|
|
how to diff exudative vs transudative pleural effusion
|
exudative: protein ratio >0.5, ldh ratio >0.6, ldh > 2/3 * upper limit of normal serum ldh
|
|
how much effusion generated before seen on cxr
|
250ml
|
|
elevated pleural fluid amylase is sx of
|
esophageal rupture, pancreatitis, malignancy
|
|
frank purulent fluid in plureal effusion
|
empyema
|
|
what is pleural fluid that is pH <7.2
|
parapneumonic effusion or empyema
|
|
what is parapneumonic effusion
|
plerual fluid effusion as a result of pneumonia, bronchiectasis, abscess
|
|
ci for thoracentesis
|
if effusion is <10mm thick on lateral decubitus cxr. risk of ptx outweights benefit of thoracentesis
|
|
4's c's of fluid diagnostics (lp, pleural fluid, etc)
|
chemistry (glucose, protein, ldh, protein, pH0
cytology cell count culture |
|
how to tx pleural effusion
|
if transudative --- diuretics and sodium restriction. if exudative, tx dz.
|
|
how to tx parapneumonic effusion if complicated or empyema
|
chest tube, intrapleural thrombolysis (UNLESS MVA), possible surgical lysis of adhesion
|
|
3 locations of MEN1
|
pituitary, parathyroid, pancreas
|
|
what is secondary spontaneous pneumothorax
|
spontaneous pneumothorax that is due to complication to underlying disease. this is worse than primary cuz ppl usually don't have reserve pulmonary capacity
|
|
3 locations of MEN2A
|
parathyroid, pheochromocytoma, medullary thyroid
|
|
causes of tension pneumothorax
|
ventilation, cpr, trauma
|
|
blood pressure & ptx
|
decreased cuz of venous compression
|
|
are all mesotheliomas malignant
|
no, and benign ones have excellent prognosis
|
|
4 granulomatous interstitial lung dz
|
sarcoid, histiocytosis, wegeners, churg strauss
|
|
3 locations of MEN2B
|
pheochromocytoma, medullary thyroid, mucosal neuroma
|
|
best dz for interstitial lung dz
|
tissue biopsy
|
|
skin finding in sarcoid
|
erythema nodosum
|
|
sarcoid: cxr, blood findings
|
bil hilar adenopathy, elevated ace, hypercalcemia, hypercalciuria
|
|
how to tx sarcoid
|
most resolve w/in 2 yrs, but can use cs, mtx if refractory
|
|
what type of ppl are histiocytosis x w/ interstitial lung dz
|
smokers
|
|
canca vs p anca
|
canca = wegener, panca = churg strauss
|
|
where is silicosis located
|
upper lobes, localized and nodular
|
|
where is asbestosis located
|
lower lobes, diffuse
|
|
pleural plaques on cxr
|
asbestosis
|
|
"egg shell" calcification on cxr
|
silicosis
|
|
blood test in hypersensitivity pneumonitis
|
iga and igg to inhaled antigen
|
|
what dz assoc w churg strauss
|
asthma
|
|
what 2 interstitial lung dz have eosinophils
|
churg strauss, eosinophilic pneumonia
|
|
what is pulmonary alveolar proteinosis
|
accumulation of surfactant like proteins and phospholipids in alveoli
|
|
cxr of pulmonary alveolar proteinosis
|
ground glass w/ bilateral alveolar infiltrates
|
|
how to tx plumonary alveolar proteinosis
|
gcsf, lung lavage, NO STEROIDS
|
|
how to tx goodpastures
|
plasmapharesis, cyclophosphamide, cs
|
|
what is cryptogenic organizing pneumoniitis, tx
|
inflammatory lung dz that looks like pneumonia, spontaneous but try cs
|
|
how to tx radiation pneumonitis
|
cs
|
|
when does radiation pneumonitis occur after radiation
|
acute is 1-6mo, chronic is 1-2y
|
|
how to dx radiation pneumonitis
|
ct scan
|
|
how to dx pulmonary alveolar proteinosis
|
lung biosy
|
|
what defines acute respiratory failure
|
pao2 <60 or paco2>50
|
|
paco2 and a-a gradient in v/q mismatch or shunting
|
both are elevated, shunting has poor response to supplement o2
|
|
hypoxemic respiratory failure vs hypercarbic
|
hypoxemic -- low o2. hypercarbic -- high co2, due to decrease in ventilation rate or increased dead space
|
|
co2 in v/q mismatch
|
low to normal
|
|
what is intrapulmonary shunting
|
no ventilation to perfused areas -- atelectasis, fluid buildup in alveoli, right to left intracardiac shunt
|
|
ventilation vs oxygenation
|
oxygenation = o2 sat and pao2
|
|
ventilation vs oxygenation
|
ventilation is paco2. oxygenation is pao2 and o2 sat
|
|
how to improvement tissue o2
|
1. increase fio2 2. increase peep 3. extend inspiratory time 4. upright 5. increase CO or increase hemoglobin 6. decrease o2 requirements by decreasing work of breathing, fever, agitation 7. remove pulmonary vasodilators
|
|
diffusion impairment and co2 levels
|
normal
|
|
advantage of venturi mask
|
useful for co2 retainer, can deliver precise fio2
|
|
how to tx hypoxemic respiratory failure
|
use lowest concentration of o2 cuz of pottential free radical injury
|
|
can you give nppv to unconcious pt
|
no
|
|
triad of ards
|
hypoxemia refractory to o2 (pao2/fio2 <200) + bilateral diffuse pulmonary infiltrates + pcwp <18
|
|
tx for ards
|
oxygenation, peep, fluid management, tx underlying cause
|
|
how can you assess resopnse to mechanical ventilation
|
abg to get pao2 to 50-60, paco2 to 40-50, ph to 7.35-7.5
|
|
mechanism of assisted controlled ventilation
|
tidal volume delivered on inspiration, if no inspiration, tidal volume delivered at predetermined rate
|
|
mechanism of synchronous intermittent mandatory ventilation
|
like assisted controlled except if breathe on their own above mandatory rate, ventilator doesn't assist
|
|
how to tell if et tube placed correctly on cxr
|
et tip 3-5 cm above carina
|
|
what is pressure support ventilation
|
used when weaning... pressure delivered on inspiration
|
|
how to determine success of extubation
|
1. good respiratory drive and cough 2. pao2 >75, paco2 <45, o2sat >90 w/ peep < 5 & fio2 <40% 3. tidal volume >5ml/kg 4. rr<30 5. vital capacity > 10ml/kg
|
|
what is the normal inspiratory to expiratory ratio
|
1:2
|
|
what is good initial tidal volume
|
8-10ml/kg
|
|
what is good initial peep
|
2.5-10 cm h2o
|
|
what is tracheomalacia a complication of
|
softening of tracheal cartilage due to prolonged et tube
|
|
what is pulm htn
|
>25 mmhg at rest, >30 during exercise
|
|
signs of pulmonary htn on pe
|
rv heave and loud p2
|
|
tx for 1* pulmonary htn
|
pulmonary vasodilators (prostacyclins like epoprostenol, ccb0
|
|
what is pulm htn
|
>25 mmhg at rest, >30 during exercise
|
|
what is cor pulmonale usually due to
|
copd
|
|
signs of pulmonary htn on pe
|
rv heave and loud p2
|
|
what study provides guidelines for v/q results? spiral ct?
|
pioped study. christopher study
|
|
tx for 1* pulmonary htn
|
pulmonary vasodilators (prostacyclins like epoprostenol, ccb0
|
|
what is cor pulmonale usually due to
|
copd
|
|
what study provides guidelines for v/q results? spiral ct?
|
pioped study. christopher study
|
|
what to do if low or intermediate probability v/q scan
|
if high clinical suspicion, do lower extremity duplex ultrasound. if that is negative, then do pulmonary angiography
|
|
what are the wells criteria
|
sx/signs of dvt (3), alternative dx less likely than pe (3.0), tachycardia (1.5), hx of immobilization or surgery (1.5), previous dvt/pe (1.5), hemoptysis (1.0), malignancy (1.0). if >4.0, do spiral ct rather than d dimer
|
|
treatment goals for pe
|
o2, start heparin immediately getting aptt to 1.5-2.5x, then start heparin on day 1, continue for 3 months at least, longer if risk factors
|
|
when to consider thrombolysis for pe
|
massive pe w/ hemoinstability, rhf
|
|
when to consider ivc filter
|
ci to anticoagulation, low pulmonary reserve
|
|
abs for aspiration pneumonia
|
pen g or clinda
|
|
5 top causes of hemoptysis
|
bronchitis, lung cancer, TB, bronchiectasis, pneumonia
|
|
DLco in asthma pt
|
increased, cuz increased pulmonary capillary blood volume
|
|
what can cause a high DLco
|
obesity, asthma, intracardiac left-to-right shunt, exercise, pulmonary hemorrhage
|
|
what can cause a low DLco
|
emphysema, carcoid, interstitial fibrosis, pulmonary vascular dz, anemia
|
|
what studies to order for hemoptysis
|
cxr, fiberoptic bronchoscopy, chest ct
|
|
ppv of fobt
|
20%
|
|
advantage and disadvantage of barium enema
|
can see entire colon, but still need colonosocpy for abnormal findings
|
|
dukes staging vs tnm
|
d = metastasis. c = nodal involvement. b- t3-4. a = t1-2
|
|
most common presenting sx of crc
|
abdominal pain
|
|
melena vs hematochezia, anatomy
|
melena = rt sided, hematochezia = lt sided
|
|
when is adjuvant therapy used for crc
|
for duke's c colon cancer -- postop chemo, NO RADS
for duke's b2/c rectal cancer -- postop chemo + RADS |
|
what marker can be used to monitor response to crc remission
|
cea
|
|
prognosis - rectal vs colon cancer
|
rectal is worse and more recurrence
|
|
what % of crc recurrence occurs w/in 3 yrs of surgery
|
90
|
|
where are most polyps found
|
rectosigmoidal
|
|
malignancy: sessile vs pedunculated
|
sessile is more likely
|
|
dx test of choice for diverticulosis
|
barium enema
|
|
tx for diverticulosis
|
need to stop constipation -- so high fiber foods or psyllium
|
|
complications of diverticulosis vs diverticulitis
|
painless rectal bleeding & diverticulitis. bowel obstruction, abscess, fistula.
|
|
how to dx diverticulitis
|
ct scan of abdomen and pelvis w/ contrast (both oral and IV). DO NOT DO BARIUM ENEMA CUZ OF PERF
|
|
who is angiodysplasia symptomatic in, tx
|
common cause of bleeding >60yo, bleeding stops spontaneously, butr can do coloscopyic coagulation
|
|
common comorbidity assoc with angiodysplasia of colon
|
aortic stenosis
|
|
4 causes of acute mesenteric ischemia
|
arterial embolism, arterial thrombosis, nonocclusive mesenteric ischemia (low CO), venous thrombosis
|
|
sx of intestinal infarction
|
hypotension, fever, lactic acidosis, tachypnea, altered mental status
|
|
how to tx acute mesenteric ischemia
|
iv fluids and antibiotics. if arterial, can insert vasodilator during angiography. if venous, do heparin.
|
|
who is angiodysplasia symptomatic in, tx
|
common cause of bleeding >60yo, bleeding stops spontaneously, butr can do coloscopyic coagulation
|
|
common comorbidity assoc with angiodysplasia of colon
|
aortic stenosis
|
|
4 causes of acute mesenteric ischemia
|
arterial embolism, arterial thrombosis, nonocclusive mesenteric ischemia (low CO), venous thrombosis
|
|
sx of intestinal infarction
|
hypotension, fever, lactic acidosis, tachypnea, altered mental status
|
|
how to tx acute mesenteric ischemia
|
iv fluids and antibiotics. if arterial, can insert vasodilator during angiography. if venous, do heparin.
|
|
what exacerbates pain in chronic mesenteric ichemia
|
postprandial pain (akin to angina)
|
|
sx & symptoms of large bowel obstruction w/o mechanical obstruction
|
ogilvie's syndrome
|
|
cause of ogilvie's syndrome
|
recent surgery trauma, medical illnesses, medications (narcotics, anticholinergic)
|
|
what is risk of distention? what is threshold?
|
rupture and peritonitis. decompress when diameter >10cm
|
|
what is the min and max time after stopping antibiotics that can cause c diff
|
first week - 6 week
|
|
complications of c diff
|
toxic megacolon, colonic perforation, anasarca
|
|
what used to tx c diff if not metro
|
vanc
|
|
most common site of colonic volvulus
|
sigmoid colon, and then cecal
|
|
sx of colonic volvulus
|
acute colicky abdominal pain, obstipation, distention, NV
|
|
cxr sx of volvulus
|
bent inner tube shape for sigmoid, distention of cecum and small bowel (coffee bean) for cecal
|
|
how to tx colonic volvulus
|
for sigmoid volvulus, do sigmoidoscopy (both dx and tx). for cecal, do emergent surgery
|
|
what 5 things does child's classification measure? how many levels?
|
ascites, bilirubin, encephalopathy, nutritional status, albumin. a,b,c
|
|
how to tx esophageal/gastric varices after stabilization
|
endoscopy (emergent). tx options include variceal ligation, sclerotherapy, vasopressin, octreotide
|
|
causes of ascites
|
chf, portal htn, renal dz, fluid overload (which can be caused by hyperaldosterone, which can be due to decreased deactivation by liver), tb, malignancy, hypoalbumin, sepsis,
|
|
how to determine cause of ascites
|
paracentesis -- cell count, albumin, gram stain, culture
|
|
saag in portal HTN
|
>1.1
|
|
what precips hepatic encephalopathy
|
alkalosis, hypokalemia, sedating agents, gi bleeding, sepsis, hypovolemia
|
|
tx for hyperammonia
|
lactulose, neomycin (kills bowel flora -- no more intestinal bacteria production of ammonia)
|
|
why is kidney function important to assess liver dz
|
hepatorenal syndrome
|
|
what is hepatorenal syndrome
|
renal failure due to hypoperfusion that occurs from vasoconstriction of renal vessels (3rd spacing?) in advanced liver dz
|
|
complications of liver failure
|
AC9H -- ascites, coagulopathy, hypoalbumin, portal htn, hyperammonia, hepatic encephalopathy, hepatorenal, hypoglycemia, hyperbilirubin, hyperestrinsim, hcc
|
|
3 mcc of spontaneous bacterial peritonitis
|
ecoli, klebs, pneumococcus
|
|
how to tx coagulopathy from liver dz
|
ffp (vit K ineffective)
|
|
where does copper excretion normally occur
|
liver
|
|
renal manifestations of wilson's dz
|
aminoaciduria, nephrocalcinosis
|
|
tx options for wilson's
|
chelating agents (penicillamine), zinc (prevents absorption), liver transplant
|
|
why does fibrosis occur in hemochromatosis
|
free radicals generated by excess iron
|
|
what organs systems to look for dmg in hemochromatosis
|
liver, pancreas, skin, (bronze diabetes) heart, joints, gonads, thyroid, hypothalamus
|
|
how to dx hemochromatosis
|
iron studies (elevated iron, ferritin, transferrin sat, decreased tbc), LIVER BIOPSY IS REQUIRED
|
|
tx for hemochromatosis
|
repeat phlebotomies, tx complications
|
|
how to dx hepatocellular adenoma
|
ct scan, U/S, hepatic arteriography
|
|
when do you resect hepatocellular adenoma
|
>5cm
|
|
mc benign liver tumor
|
cavernous hemangioma
|
|
how to dx cavernous hemangioma
|
u/s, ct scan w/ iv
|
|
what is focal nodular hyperplasia
|
benign liver tumor in women of reproductive age, but not assoc with contraceptive
|
|
2 types of hcc
|
nonfibrolamellar (most common, assoc w/ hep b/c and cirrhosis, usually unresectable), fibrolamellar (not assoc w hbv/hcv/cirrhosis, resectable)
|
|
prognosis of resectable hcc vs unresectable hcc
|
25% live to 5 yrs vs <1yr
|
|
what is needed to definitively dx hcc
|
liver biopsy
|
|
associations with nash
|
obesity, hyperlipid, dm
|
|
causes of hemobilia
|
trauma, papillary thyroid carcinomy, surgery, tumor, infection
|
|
how to dx hemobilia
|
arteriogram, upper gi endoscopy
|
|
cause of pyogenic liver abscess
|
biliary tract obstruction, gi infection, trauma
|
|
mcc amebic liver abscess
|
e histolytica
|
|
tx of budd chiari
|
medical therapy usually not good, do balloon angioplasty w/ stent
|
|
dx of budd chiari
|
hepatic venography, saag>1.1
|
|
what bili level does jaundice show
|
tb > 2mg/dl
|
|
why is there dark urine with direct hyperbiliribunemia
|
cuz conjugated bilirubin is water soluble and it will be secreted by kidney
|
|
what is defect in dubin-johnson/rotor
|
liver can't secrete into bile ducts
|
|
lfts in dubin johnson/rotor
|
normal
|
|
which is more sensitive and specific for liver: alt, ast
|
aLt
|
|
mild elevation (low hundreds) in alt, ast
|
chronic viral hep, acute alcoholic hep
|
|
moderate elevation (high hundreds to thousands) in ast, alt
|
acute viral hep
|
|
alt, ast severely elevated (>10000)
|
ischemia/shock, acetaminophen, several viral hep
|
|
causes of transaminase elevation
|
ABCDEFGHI - autoimmune, hbv, hcv, drugs, ethanol, fatty livery, growths, hemodynamic problems, iron/copper/antitrypsin
|
|
10-fold increase in alp vs less intense increase
|
10-fold = cholestasis. if just elevated, get a ggt. if ggt is normal consider pregnancy or bone dz
|
|
boas sign
|
referred right subscapular pain of biliary colic
|
|
risk of developing acute cholecystitis after biliary colic
|
1/3 develop after 2y
|
|
complications of cholelithiasis
|
cholecystitis, choledocholithiasis, gallstone ileus, malignancy
|
|
dx of cholelithiasis
|
ruq us
|
|
complications of cholecystitis
|
gangrenous cholecystitis, gb perf, emphysematous cholecystytis, cholecystenteric fistula w/ gallstone ileus, empyema of gallbladder
|
|
bowel sounds in acute chole
|
hypoactive
|
|
findings in ruq us of acute chole
|
1. thickened gb wall 2. pericholecystic fluid 3. distention 4. presence of stones
|
|
what is most sensitive test to find complications of acute cholecystitis
|
ct
|
|
when to do a hida scan
|
when us inconclusive
|
|
what is + result on hida scan
|
no gb visualized after 4 hours
|
|
complications of choledocholithaisis
|
cholangitis, obstructive jaundice, acute pancreatitis, billiary cirrhosis
|
|
who is acalculous chole seen in
|
usually idiopathic, usually severe underlying illness like dehydration, burns, trauma
|
|
gold standard dx for choledocholithasis
|
ercp
|
|
primary vs secondary stones in choledocholithiasis
|
primar stones originate in cbd usually pigmented
|
|
charcot's triad.. what's it for
|
ruq pain + jaundice + fever, cholangitis
|
|
mcc of cholangitis
|
choledocholithiasis
|
|
what tests/interventions to run immediately in cholangitis
|
1. cultures 2. iv fluids 3. iv antibiotics 4. decompress cbc after pt stable
|
|
dx of cholangiitis
|
ruq ultrasound + lbs (cbc, bilirubin, lft). don't do ptc/ercp in acute
|
|
reynold's pentad
|
charcot triad + sepsis + altered mental status
|
|
prognosis of carcinoma of gb
|
90% die of advanced dz w/in 1 yr of dx
|
|
what is porcelain gb
|
calcification of gb wall
|
|
tx for porcelain gb
|
cholecystectomy cuz it is risk factor for gb carcinoma
|
|
associations with psc
|
uc
|
|
tx for psc
|
liver transplant, if there is a identifiable stricture, can do ercp with stent
|
|
who gets pbc
|
middle aged women
|
|
is psc intrahepatic or extrahepatic? pbc?
|
both, intrahepatic
|
|
what antibody is elevated in pbc
|
ama
|
|
associations with psc
|
uc
|
|
tx for psc
|
liver transplant, if there is a identifiable stricture, can do ercp with stent
|
|
who gets pbc
|
middle aged women
|
|
is psc intrahepatic or extrahepatic? pbc?
|
both, intrahepatic
|
|
what antibody is elevated in pbc
|
ama
|
|
associations with psc
|
uc
|
|
tx for psc
|
liver transplant, if there is a identifiable stricture, can do ercp with stent
|
|
who gets pbc
|
middle aged women
|
|
is psc intrahepatic or extrahepatic? pbc?
|
both, intrahepatic
|
|
what antibody is elevated in pbc
|
ama
|
|
what ig is elevated in pbc
|
ig M
|
|
causes of 2* biliary cirrhosis
|
mechanical obstruction, sclerosing cholangitis, cystic fibrosis, biliary atresia
|
|
bone consequences of pbc
|
osteoporosis
|
|
how to tx pbc
|
symptomatic (cholestyramine for pruritus, and osteoporosis). ursodeoxycholic acid to slow progression of dz. liver transplant
|
|
where does cholangiocarcinoma usually occur
|
proximal 1/3 of cbd (klatskin tumor), distal extrapeatic (most favorable), intrahepatic
|
|
what is choledochal cyst? complication? who does it occur in? dx? tx?
|
cystic dilation of biliary tree, women, leads to cholangiocarcinoma, us & ercp, surgical resection
|
|
mcc bile duct stricture
|
iatrogenic
|
|
tx of bile duct stricture
|
endoscopic stenting, surgical bypass
|
|
what is biliary dyskinesia, how to dx
|
dysfunction of sphincter of oddi. hida -- low ejection fraction
|
|
cause of acute appendicitis
|
obstruction by lymphoid hyperplasia (usually), fecalith, foreign body, other cause. obstruction leads to stasis and infection and distention. distention can lead to infarction or necrosis.
|
|
hunger and appendicitis
|
hunger is almost never present
|
|
psoas sx vs obturator sx
|
pain on rt thigh extension when lying on left vs pain on rt thigh internal rotation
|
|
causes of acute pancreatitis
|
GET SMASHED -- gallstone, ethanol, trauma, scorpion bite, mumps/malignancy, autoimmune, steroid, hypercalcemia/hyperlipidemia, ercp, drugs
|
|
3 sx of hemorrhagic pancreatitis
|
grey turner's sx (flank), cullen's sx (periumbilical), fox's sx (inguinal)
|
|
ranson's admission criteria
|
GA LAW -- glucose > 200, age > 55, LDH > 350, AST > 250, WBC > 16000
|
|
why does hypocalcemia result from acute pancreatitis
|
fat saponification (fat necrosis binds calcium)
|
|
how to predict mortality from ranson's criteria
|
<3 = 1%. 3-4 = 15%. 5-6 = 40. 7+ = 100%
|
|
48 hour ranson's critera
|
C HOBBS - calcium < 8, hemotocrit decrease >10%, pa02 < 60, BUN increase >8, base deficit >4, fluid sequestration >6L
|
|
dx of acute pancreatitis
|
labs, ct abdomen
|
|
possible signs of pancreatitis on axr
|
sentinel loop (air filled bowel in LUQ), colon cut off sign (air filled segment of transverse colon around pancreas)
|
|
complications of acute pancreatitis
|
necrosis (which may be sterile or necrosis -- need to do ct guided aspiration), pancreatic pseudocyst, hemorrhagic pancreatitis, ards, ascites/pleural effusion, ascending cholangitis, abscess
|
|
compliations of pancreatic pseudocyst
|
rupture, infection, fistula, hemorrhage into cyst, pancreatic ascites
|
|
how to tx pancreatic pseudocyst
|
>5cm, drain. <5cm = observe
|
|
tx for acute pancreatitis
|
NPO (rest pancreas), IV fluids, pain control but no narcotics, ng tube if NV or ileus
|
|
4 classic findings of chronic pancreatitis
|
chronic epigastric pain + calcifications on axr/ct + dm + steatorrhea
|
|
mcc of chronic pancreatitis
|
chronic alcoholism
|
|
medical tx for chronic pancreatitis
|
narcotics, NPO, h2 blocks = pancreatic enzymes, insulin, small frequent meals
|
|
surgical tx for chronic pancreatitis
|
pancreaticojejunostomy, pancreatic resection
|
|
mc locations for pancreatic cancer
|
head > body > tail
|
|
risk factors for pancreatic cancer
|
cigarette, chronic pancreatitis, dm, heavy alcohol, benzidine/b-naphthylamine
|
|
most sensitive test for pancreatic cancer
|
ercp
|
|
4 classic sx of pancreatic cancer
|
jaundice (usually NOT painless) + weight loss + migratory thrombophebitis + courvoisier's sx (palpable gallbladder)
|
|
tx for pancreatic cancer
|
whipple's
|
|
what is aortoenteric fistula
|
fistula in someone with aortic graft surgery -- they have a small GI bleed involving duodenum before massive hemorrhage hours to weeks later
|
|
causes of upper gi bleeding
|
PUD, reflux esophagitis, esophageal & gastric varices, erosions, mallory-weiss, hemobilia, dieulafoy's vascular malformation (submucosal dilated arterial lesion), aortoenteric fistula
|
|
causes of lower GI bleeding
|
diverticulosis, angiodysplasia, IBD, CRC/polyps, ischemic colitis, anal fissures, hemorrhoids, small intestinal bleeding
|
|
other causes of dark stools other than melena
|
bismuth, iron, spinach, charcoal, licorice
|
|
dx for gi bleeding
|
vs (is pt stable?), labs (stool guiac, h&h, bun:cr ratio increased in upper gi bleed), upper endoscopy, ng tube, anoscopy, colonscopy, bleeding scan, arteriography
|
|
how to evaluate ng aspirate -- bile w/ no blood vs bright red blood or coffee grounds vs nonbloody aspirate
|
upper GI bleeding unlikely vs upper GI bleed vs unlikely, but cannot be ruled out
|
|
how to tx upper GI bleed
|
egd with coagulation
|
|
how to tx lower gi bleed
|
colonoscopy (polyp excision, cautery), arteriographic vasoconstriction, surgical resection
|
|
indications for surgery for gi bleed
|
hemodynamically unstable w/o response to fluids, recurrence of bleed after endoscopy, continued bleed for >24h, vessel at base of ulcer, ongoing transfusion requirement
|
|
where is scc of esophagus located. where is adenocarcinoma of esophagus located
|
upper to mid third. distal third
|
|
risk factors for scc of esophagus
|
alcohol, tabacco, diet (nitrosamine, betel nuts, chronic hot food ingestion), hpv, achalasia, plummer vinson
|
|
risk factors for adenocarcinoma of esophagus
|
gerd, barretts
|
|
2 most common sx of esophageal cancer
|
progressive dysphagia and weight loss
|
|
how to dx esophageal cancer
|
barium swallow, upper endoscopy, transesophageal u/s
|
|
up to what stage is surgery curative for esophageal cancer
|
2A (no node involvement)
|
|
mcc of achalasia
|
idiopathic in US, chagas worldwide
|
|
sx of achalasia
|
dysphagia, regurgitation, chest pain, weight loss, aspiration
|
|
tx for achalasia
|
no cure. can try antimuscarinic (dicyclomine), nitrates, and ccbs. botox injections into LES. forceful dilation. "heller myotomy"
|
|
what is diffuse esophageal spasm
|
nonperistaltic contraction of esophagus and prevent advancement of food. sphincter is normal
|
|
sx of diffuse esophageal spasm
|
CHEST PAIN
|
|
dx of diffuse esophageal spasm
|
esophageal manometry
|
|
tx of DES
|
no good therapy. nitrates and ccbs
|
|
type 1 vs type 2 esophageal hernia. which one more common
|
sliding vs paraesophgeal. type 1
|
|
which type of esophageal hernia is riskier
|
type 2 can strangulate
|
|
sx of diffuse esophageal spasm
|
CHEST PAIN
|
|
dx of diffuse esophageal spasm
|
esophageal manometry
|
|
tx of DES
|
no good therapy. nitrates and ccbs
|
|
type 1 vs type 2 esophageal hernia. which one more common
|
sliding vs paraesophgeal. type 1
|
|
which type of esophageal hernia is riskier
|
type 2 can strangulate
|
|
tx of esophgeal hernia
|
type 1: medicially (antacid, small meal, elevation). nissen fundoplication of unresponsive. type 2 = surgery
|
|
complications of type 1 esophgeal hernia
|
grd, reflus esophagitis, aspiration
|
|
where is tear in mallory weiss
|
at or just below gastroesophgeal jcn
|
|
3 classic findings of plummer vinson
|
UPPER esophageal webs + iron deficiency anemia + atrophic oral mucosa
|
|
where are schatzki rings located
|
lower esophagus
|
|
what is schatzki's ring
|
ring in lower esophagus + sliding hiatal hernia
|
|
usual cause of schatzki ring
|
ingestion of caustic agents (like alkali, acids, bleach)
|
|
tx of schatzki ring
|
esophagectomy if full thickness necrosis (more likely with alkali)
|
|
3 types of esophgeal diverticula
|
zenkers in type 1/3, traction in midpoint, epiphrenic in lower 1/3
|
|
cause of zenkers
|
failure of cripharyngeal mm to relax during swallowing
|
|
cause of traction diverticula
|
occurs near tracheal bifurcation. due to traction from mediastinal inflammation and adenopathy (eg TB)
|
|
cause of epiphrenic diverticula
|
achalasia, esophageal dysmotility
|
|
hamman's sign
|
mediastinal crunch produced by heart beating against air filled tissue.... seen in esophageal perf
|
|
dx for esophageal perf
|
contrast esophagram 9using soluble gastrografin)
|
|
what is common b/w epiphrenic and zenkers
|
due to underlying dysmotility of certain mucles
|
|
most important prognostic factor in esophgeal perf
|
time interval b/w esophgeal perf and surgery.
|
|
tx for esophgeal perf
|
if small perf -- iv vluids, npo, ab, h2 block. if large, surgery
|
|
pathogenesis: duodenal vs gastric ulcers
|
duodenal = increased acid. gastric = decreased defense (mucosa)
|
|
which has higher malignant potential -- dudoenal or gastric
|
gastric
|
|
blood type association of pud
|
duodenal = type O. gastric = type A
|
|
eating relieves pain in PUD?
|
for duodenal ulcer, not for gastric
|
|
dx of pud
|
endoscopy, needed esp for gastric ulcer cuz need biopsy to r/o malignancy. lab test for pylori. can measure serum gastrin for ze syndrome
|
|
advantage of quadruple therapy vs triple therapy for pylori
|
quad takes 1 week, triple is 2 weeks
|
|
what is regimen of quadruple therapy vs triple
|
ppi + bismuth + 2 ab's vs PPI + 2 ab's
|
|
relationship between eating and pain in acute gastritis
|
no relationship
|
|
complications of pud
|
perforation, gastric outlet obstruction, gi bleed
|
|
how to dx perf from pud
|
upright cxr
|
|
how to dx gastric outlet obstruction
|
barium swallow and upper endoscopy, saline load
|
|
what is saline load test
|
(empty stomach with ng, add 750 ml saline, if there is >400 mL of saline after 30 min then positive). used to dx gastric outlet obstruction
|
|
causes of chronic gastritis
|
h pylori, autoimmune
|
|
best dx for chronic gastritis
|
endoscopy
|
|
what is most common type of gastric cancer
|
adenocarcinoma
|
|
4 types of gastric cancer
|
ulcerative, polypoid, superficial spreading (most favorable), linitis plastica
|
|
risk factors for gastric cancer
|
chronic atrophic gastritis, h pylori, postanrectomy, pernicious anemia, menetrier dz, high intake of preserved foods, blood type A
|
|
dx gastric cancer
|
endoscopy
|
|
tx for gastric cancer
|
surgical resection with wide (>5cm) margins with lymph node dissection
|
|
what is krukenberg tumor
|
gastric cancer met to ovary
|
|
what is blumer's shelf
|
gastric cancer met to rectum that is palpable on rectal exam
|
|
what is sister mary josephs node
|
gastric cancer met to periumbilical lymph node
|
|
hat is virchow node
|
met of gastric cancer to supraclavicular fossa
|
|
what is irish's node
|
gastric cancer met to left axilla
|
|
3 classification of sbo
|
1. partial vs complete -- i.e. obstipation = complete. 2. closed loop vs open loop -- closed means lumen occluded at 2 points which can compromise blood supply 3. proximal vs distal -- distal obstruction causes distention of proximal segments, which eases dx. proximal obstruction also means frequent vomiting
|
|
why does dehydration occur in sbo
|
intestinal distention causes reflex vomiting
|
|
causes of sbo
|
adhesions from surgery, incarcerated hernias, malignancy, intussusception, crohns, superior mesenteric artery syndrome
|
|
how is pain from strangulated bowel different
|
it is continuous pain (vs colicky)
|
|
causes of large bowel obstruction
|
volvulus, adhesions, hernia, colon cancer
|
|
how to dx sbo
|
axr,barium enema, upper gi series
|
|
when is surgery needed for sbo
|
complete obstruction, persistent or constantly painful partial obstruction, strangulation
|
|
causes of paralytic ileus
|
drugs (narcotics, anticholinergic), postop, spinal cord injury, shock, metabolic dz (HYPOKALEMIA), peritonitis
|
|
axr finding of paralytic ileus
|
uniform distribution of gas in small bowel
|
|
what electrolyte disturbance can cause paralytic ileus
|
hypokalemia
|
|
ibd: erythema nodosum vs pyoderma gangrenosum
|
nodosum in crohn's, pyoderma in UC. erythema parallels ibd activity, pyoderma doesn't
|
|
ibd: episcleritis vs anterior uveitis
|
episcleritis follows ibd activity
|
|
ibd: arthritis vs sacroilitis
|
arthritis is migratory monoarticular and parallels ibd activity
|
|
what is sbo due to in ibd
|
at first edema and spasm of bowel. then scarring and thickening
|
|
mc location of crohn's dz
|
terminal ileum
|
|
ibd: erythema nodosum vs pyoderma gangrenosum
|
nodosum in crohn's, pyoderma in UC. erythema parallels ibd activity, pyoderma doesn't
|
|
ibd: episcleritis vs anterior uveitis
|
episcleritis follows ibd activity
|
|
ibd: arthritis vs sacroilitis
|
arthritis is migratory monoarticular and parallels ibd activity
|
|
what is sbo due to in ibd
|
at first edema and spasm of bowel. then scarring and thickening
|
|
why is risk of kidney stone higher in ibd
|
increased colonic absorption of dietary oxalate
|
|
when is sulfasalazine most useful
|
if colon involved
|
|
antidiarrheal agents and ibd
|
can cause ileus
|
|
surgery uc vs crohns
|
surgical resection often curative for uc
|
|
uc and rectum
|
always involves rectum
|
|
diarrhea in uc vs crohns. implications for dx?
|
uc is bloody, crohns is not. therefore need to workup infectious diarrhea (c diff, ova, paracytes, fecal leukocytes)
|
|
ibd: which one more assoc with anorectal complications
|
crohns
|
|
ibd: which one is transmural?
|
crohns
|
|
ibd: which one more likely lead to bleeding
|
uc
|
|
ibd: which one can lead to sclerosing cholangitis and cholangiocarcinoma
|
uc
|
|
what are "red flags" for abd pain that warrant surgical consult
|
peritoneal sx -- rigidity, guarding, rebound
|
|
respiratory causes of abd pain
|
upper quadrant pain -- pneumonia, pe
|
|
radioiodide scan and graves dz
|
diffuse uptake
|
|
what is plummer's dz
|
multinodular toxic goiter
|
|
bumpy irregular assymetric thyroid gland
|
plummer's dz, hashimoto
|
|
tender, diffusely enlarged thyroid
|
subacute thyroiditis
|
|
thyroid bruit is specific for
|
graves dz
|
|
what things can increase thryoid binding globulin
|
pregnancy, ocp, liver dz, aspirin
|
|
utility of radioactive t3 uptake
|
resin and radioactive t3 is given, so gives information on how much tbg is there.
|
|
ptu vs methimazole
|
both inhibit thyroid synthesis, but ptu also block conversion of t4 to t3
|
|
what is sodium ipodate or iopanoic acid do
|
lowers serum t3 and t4, tx acute mgmt of severe hyperthyroid
|
|
complications of subtotal thyroidectomy
|
permanent hypothyroidism, recurrence of hyperthyroid, recurrent laryngeal nerve palsy, hypoparathyroidism
|
|
tx for graves (nonpregnant)
|
start methimazle + bb, taper bb after 4 w, monitor thyroid igg, if absent d/c therapy
|
|
indications for radioactive iodine ablation
|
elderly pts with graves, solitary toxic nodule, failure with antithyroid drugs
|
|
mortality from thyroid storm
|
20%
|
|
tx for thyroid storm
|
iv fluids, cooling blankets, glucose, ptu q2h, bb, dexamethasone
|
|
why is dexamethasone given for thyroid storm
|
impair peripheral conversion of t3 to t4
|
|
what is myxedema coma
|
depressed consciousness, hypothermia, respiratory depression that occurs after several yrs of severe untreated hypothyroid
|
|
what antibodies assoc w hashimoto
|
antimicrosomal antibodies
|
|
lab findings of hypothyroid
|
high tsh (unless 2*), elevated ldl, anemia
|
|
what is subclinical hypothyroid
|
inadequate thyroid function, but increased tsh keeps t4 normal. tx if goiter, hypercholesterol, sx of hypothyroidism, or tsh >20
|
|
radioiodine uptake in subacute thyroiditis
|
decreased (damaged follciular cells)
|
|
what is subacute lymphocytic thyroidtitis
|
painless thyroiditis 2-5mo long
|
|
what is thyroid associated ophthalmopathy
|
autoimmune attack on periorbital connective tissue. may be hypothyroid, graves, or euthyroid. tx is not useful.
|
|
sx of malignant thyroid nodule
|
fast onset, no movement on swallowing, fixed, unusually firm or irregular, solitary, hx of radiation, cervical adenopathy, elevated serum calcitonin
|
|
dx of thyroid nodule
|
FNA biopsy, thyroid scan (iodine), thyroid u/s
|
|
what type of finding on thyroid u/s indicates benign
|
cystic masses >4cm
|
|
what type of thyroid cancer is fna poor at detecting
|
follicular
|
|
what % of cold nodules are malignant
|
20
|
|
most common type of thyroid cancer
|
papillary
|
|
how does papillary carcinoma of thyroid spread
|
lymphatics
|
|
how does follicular carcinoma spread
|
hematogenous
|
|
what is hurthle cell tumor
|
variant of follicular cancer but more aggressive, spreads by lymphatics
|
|
tx for thyroid cancer
|
papillary - lobectomy unless >3cm. follicular - total thyroidectomy + iodine. medullar - total. anaplastic - poor prognosis
|
|
size cutoff of microadenoma of pituitary
|
<10mm diameter
|
|
what is best tx for pituitary adenoma
|
transsphenoidal surgery
|
|
causes of hyperprolactinemia
|
prolactinoma, medications (psych, h2, estrogen), pregnancy, renal failure, suprasellar mass lesions, hypothyroidism, idiopathic
|
|
how to tx prolactinoma
|
bromocriptine, cabergoline (better tolerated)
|
|
mc cause of death in pts with acromegaly
|
cardiovascular dz
|
|
heart complication of acromegaly
|
hcom
|
|
parasellar manifestations of putuitary growth
|
superior growth -optic chiasm compression
lateral - cavernous sinus compression inferior - sphenoid sinus invasion |
|
glucose in acromeglay
|
glucose intolerance
|
|
tx for acromegaly
|
surgery, radiation if elevated igf-1 postop, octreotide
|
|
urine findings in DI
|
low specific gravity + low osmolality
|
|
how to dx DI
|
water deprivation (urine osmolality will stay normal), urine and plastma osmolality
|
|
how to tx central DI? how to nephrogenic DI?
|
ddavp, chlorpropamide vs thaizide
|
|
how does thiazide diuretics work in nephrogenic DI
|
increased reabsorption of sodium in pct works out in this disorder end up decreasing urine volume
|
|
why does edema not occur in siadh
|
sodium is excreted despite hyponatremia
|
|
why does natriuresis occur in siadh
|
1. volume expansion leads to ANP 2. volume expansion leads to decreasd sodium absorption 3. inhibition of raas
|
|
sx of acute hyponatremia
|
lethargy, somnolence, weakness, seizures
|
|
tx of siadh
|
water restriction, saline + loop diuretic if faster results, lithium/demeclocycline.
|
|
fastest rate of sodium replacement
|
0.5 meq/L/hr
|
|
what is chvostek's sx
|
tappng facial nerve elicits contraction, sign of hypocalcemia
|
|
calcium levels in hypoparathyroidism
|
low
|
|
ekg changes with hypopth
|
prolonged qt
|
|
urine findings of hypopth
|
low urine camp
|
|
uses of calcium gluconate
|
1. hypocalcemia 2. antidote to mgso4 3. cardioprotective in hyperkalemia
|
|
mcc hypercalcemia
|
primary hyperpth
|
|
mc causes of primary hyperpth
|
adenoma > hyperplasia >> carcinoma
|
|
normal pth levels + hypercalcemia indicate what
|
hyperpth
|
|
how can electrolytes be used to help dx hyperpth
|
1. high ca 2. low phophate 3. chloride/phosphorus ratio > 33
|
|
indications for surgery in primary hyperpth
|
age>50, bone decrease, ckd/nephrolithiasis, severe hypercalcemia, urine calcium >400 in 24h
|
|
one classic lab sx of iatrogenic cushing's
|
no androgen excess
|
|
dx for cushings
|
1.low dose dexamethasone suppression (1mg at night, measure in AM, <5 = r/o cushings). 2. 24 urine cortisol 3. acth level (if low then probably adrenal origin) 4. crh stimulation test
|
|
tx for cushings
|
surgery
|
|
where are pheochromocytomas located
|
90% in adrenal medulla, 10% extra-adrenal
|
|
what is the organ of zuckerkandl
|
chromaffin body near bifurcation of aorta which can be the cause of pheo
|
|
what radioactive test can be used to localize pheo
|
I-metaiodobenzlguanidine scan (norepi analog)
|
|
tx of pheo
|
bb, surgical resection w/ ligation of venous drainage
|
|
men 1 vs 2a vs 2b
|
wermer = pt+pancreas+pituitary. sipple = medullary thyroid + pheo+ hyperpt. mucosal neuroma + medullary thyroid + pheo + marfanoid
|
|
2 electrolyte abnormalities in hyperaldosterone
|
hypokalemia, metabolic alkalosis
|
|
what is conn's syndrome
|
adrenal adenoma producing purely aldosterone
|
|
tx of primary hyperaldosteronism
|
if adenoma, resection. if hyperplasia, use spironolactone
|
|
dx of hyperaldosteroneism
|
aldosterone to renin ratio >30, saline infusion test (saline infusion should decrease aldosterone below 8.5 normally)
|
|
mcc addison's? adrenal insufficiency in general
|
autoimmune in west, TB worldwide. chronic steroids.
|
|
aldosterone levels in primary vs secondary adrenal insufficiency
|
low in primary, normal in secondary
|
|
how to dx adrenal insufficiency
|
ACTH stimulation test
|
|
what is good drug for mineralocorticoid replacement
|
fludrocortisone
|
|
how to dx 21-hydroxylase cah
|
high levels of 17 hydroxyprogesterone
|
|
tx of cah
|
cortisol + mineralcorticoid, correct genitalia early
|
|
annual risk of developing type ii diabetes if impaired glucose tolerance
|
1-5% annual increase in risk
|
|
mechanism of obesity and insulin resistance
|
increased FFAs make muscles more insulin resistant, FFAs increase production of glucose, FFAs fail to stimulate pancreatic insulin secretion
|
|
dawn phenomenon vs somogyi effect
|
dawn phenomenon is noctural secretion of gh, somogyi is counterregulatory hormones activated in response to hypoglycemia. check glucose at 3AM, if elevated, then has dawn phenomenon and need more basal control. if low, then somogyi, and need less PM insulin to avoid hypoglycemia
|
|
typical insulin dosage for dm1 qday
|
0.5-1.0units/kg
|
|
general insulin dosage scheme
|
2/3 in morning (2/3 of this is nph), 1/3 in PM (1/2-2/3 is nph)
|
|
how often is glucose monitored for slidacting scale
|
4 times -- qhs and before meals
|
|
how does physical activity impact insulin dosage
|
lower by 1-2 units q20-30 min of activity
|
|
why is there accelerated atherosclerosis in diabetes
|
glycation of lipoproteins, incrased plt aggregation
|
|
typical scheme for sliding scale insulin dosage
|
start at blood glucose of 150-200 corresponding to 2 units of insulin. for every 50 increase in glucose, increase insulin by 2 units.
|
|
definition of microalbuminuria
|
1. 30-300 mg/day 2. 20-200g/min 3. albumin-cr ratio of 0.02-0.2
|
|
prognosis of diabetic nephropathy once proteinuria (not microalbuminuria) is reached
|
unaffected by glycemic control, at this point need to really start ACEi and restrict protein
|
|
2 types of retinopathy in dm. which one leads to blindness
|
proliferative and nonproliferative. both can lead to blindness -- nonproliferative can cause macular edema which leads to blindness.
|
|
most common cranial nerve affected in dm
|
cn3
|
|
respiratory & gi findings of dka.
|
kussmaul's breathing. N/V, abdominal pain
|
|
why do you see hyponatremia in dka? how much should sodium decrease for every 100 increase in blood sugar
|
fluid moves from ICF to ECF. sodium decreases by 1.6
|
|
potassium levels in dka
|
hyperkalemia (acidosis and low insulin cause k+ to come out of icf)
|
|
dosage of insulin for dka
|
0.1mg/kg bolus + 0.1 mg/kg/hr until anion gap closes and metabolic acidosis corrected
|
|
when do you start adding d5 to ivf for dka
|
once serum glucose is 250
|
|
what electrolyte needs to be replenished with dka. when do you start?
|
k+, start 1-2 hr after insulin
|
|
complications of dka tx
|
1. cerebral edema 2. hyperchloremic nongap metabolic acidosis
|
|
dx of dka
|
hyperglycemia, acidosis, ketonemia
|
|
dx of hyperosmolar syndrome
|
hyperglycemia, hperosmolarity, dehydration
|
|
what labs to order for hypoglycemia
|
insulin level, c peptide, anti-insulin antibodies, plasma and urine sulfonylurea level
|
|
what are neuroglycopenic symptoms
|
irritability, behavioral changes, drowsiness/lethargy, confusion
|
|
what do you need to assess before giving glucose to ANYONE (diabetic or not)
|
alcoholic? give thiamine
|
|
whipple's triad
|
for hypoglycemia. hypoglycemia brought on by fasting, glucose <50 during symptomatic attack, glucose administration brings relief
|
|
what is the gastrinoma triangle
|
cystic duct, junction of 2nd and 3rd parts of duodenum, neck of pancreas. location of 90% of tumors located here
|
|
how to dx ze syndrome
|
inject secretin (secretin inhibits gasrin)
|
|
is ze syndrome malignant
|
60%, that's why everyone with it should undergo exploratory surgery with attempted resection
|
|
what is necrotizing migratory erythema below the waist assoc with
|
glucagonoma
|
|
triad of somatostatinoma
|
gallstones + dm + steatorrhea
|
|
what is verner morrison syndrome
|
vipoma
|
|
4 classic sx of vipoma
|
watery diarrhea + achlorydia (vip inhibits gastric acid secretion) + hyperglycemia + hypercalcemia
|
|
risk of stroke after tia
|
30% 5-yr risk
|
|
carotid vs vertebrobasilar tia
|
dysphasia, contra weakness/numbness, amaurosis fugax (ipsi curtain-like vision loss to retinal ischemia) VS dizziness/ataxia, double vision, ipsi face/contra body numbness, dysphagia/dysarthria
|
|
most common sources of emboli for stroke
|
heart>ICA>aorta>paradoxical emboli
|
|
what causes lacunar stroke
|
thickening of small vessels narrows lumen and thus causes ischemia
|
|
which vessels affected in lacunar stroke
|
branches of MCA, vertebrobasilar arteries, circle of willis arteries
|
|
what is subclavian steal syndrome
|
stenosis of subclavian a proximal to origin of vertebral, therefore there is reversal of flow down the vertebral artery -- causes vertebrobasilar insufficiency and UE claudication
|
|
4 major syndromes seen in lacunar strokes
|
1. pure motor (involving internal capsule) 2. pure sensory (involving thalamus) 3. ataxic hemiparesis (incoordination ipsi) 4. clumsy hand
|
|
6 classic sx of vertebrobasilar stroke/insufficiency
|
ipsi: 1. ataxia 2. diplopia 3. dysphagia 4. dysarthria 5. vertigo; 6. CONTRA homo hemianopsia
|
|
why should you not use contrast ct for dx of new stroke
|
cuz hemorrhagic stroke hasn't been excluded
|
|
workup for acute stroke
|
1. noncontrast ct 2. ekg 3. cxr 4. cbc, plt, pt, ptt, electrolytes, glucose 5. echo 6. carotid doppler
|
|
3 orders to give after giving tpa
|
1. no aspirin 2. neuro check qh 3. bp < 185/110
|
|
bp control and strokes
|
unnecessary unless 1. sbp>220|dbp>120|map>130 2. pt has big need for antihypertensive 3. getting tpa
|
|
how to prevent strokes
|
1. atherosclerosis -- control risk factors, aspirin, carotid endarterectomy if symptomatic 2. embolic -- aspirin, reduce atherosclerotic risk factors 3. prevent lacunar -- control htn
|
|
what types of stroke does cocaine increase risk for
|
intracranial hemorrhagic stroke, ischemic stroke, AND subarachnoid hemorrhage
|
|
mc location of intracranial hemorrhage
|
basal ganglia >> pons = cerebellum
|
|
pinpoint pupils vs poorly ractive pupils vs dilated pupils in intracranial hemorrhage
|
involvement: pons, thalamus, putamen
|
|
tx for hemorrhagic stroke
|
abcs, GRADUAL bp reduction (only if sbp >160, dbp>105), mannitol/diuretics to reduce ICP
|
|
in which type of intracranial hemorrhage is surgical evacuation good
|
cerebellar hemmorhage
|
|
most common locations of subarachnoid hemorrhage
|
junction of anterior communicating with ACA, jcn of posterior communicating with ICA, bifurcation of MCA
|
|
what physical sx is a CI for LP
|
papilledema -- risk of herniation
|
|
what study to order once subarachnoid hemorrhage has been dx'd
|
angiogram
|
|
complications of subarachnoid hemorrhage
|
rerupture, vasospasm leading to infarction, hydrocephalus, seizures
|
|
tx for subarachnoid hemorrhage
|
surgery (clip aneurysm), stool softeners (avoids straining which raises ICP), CCB (to prevent vasospasm)
|
|
what is shy drager syndrome
|
parkinson + autonomic insufficiency
|
|
what type of parkinsons has better prognosis than others
|
tremor is better prognosis than bradykinesia
|
|
anticholinergic drugs are better for controlling what sx in parkinson
|
tremor
|
|
what is progressive supranuclear palsy
|
degeneration of BS, cerebellum, and basal ganglia. like parkinson's dz except NO TREMOR OR OPHTHALMOPLEGIA
|
|
what is trinucleotide repeat in huntington
|
CAG
|
|
how to dx huntington
|
MRI shows caudate atrophy
|
|
what type of tremor seen in essential benign tremor
|
intentional tremor
|
|
sensory deficits in friedreich's ataxia
|
vibratory sense and propioception
|
|
what is binswanger's dz
|
type of vascular dementia, slow insidious (rather than stepwise) diffuse subcortical white matter degeneration, in ppl with htn and atherosclerosis
|
|
what drug is associated with lower risk of developing alzheimers
|
hrt
|
|
how is dementia with lewy bodies different from parkinson's or alzheimer's
|
features of both, but often psychotic features while being extra sensitive to adverse effects of neuroleptics
|
|
causes of delirium
|
P DIMM WIT - postop, dehydration, infection, medications, metals, withdrawal, inflammation, trauma,
|
|
2 components of conciousness
|
arousal (brainstem) and cognition (cerebrum)
|
|
what is sundowning and what is it assoc with
|
worsening at night of symptoms, seen with dementia
|
|
ddx of coma
|
SMASHED - structural, meningitis/mental illness, alcohol/acidosis, seizures, hypercapnia/hyper|hypoglycemia/hyper|hypothermia,hyponatremia,hypoxia,hypotension, endocrine, drugs
|
|
describe the gcs in detail
|
E4V5M6. eyes: opens to pain (2), opens to command (3). voice: incomprehensible (2), inappropriate, confused (4). motor: decerebrate, decorticate, pain withdrawal, localizes pain
|
|
what is decorticate positioning
|
arms AND HANDS flexed, legs extended
|
|
what is decerebrate positioning
|
everything extended (back arched, elbows hyperextended, etc)
|
|
what is higher on gcs, decorticate or decerebrate
|
decorticate>decerebrate
|
|
ddx of abnormal pupilary light refle
|
structural intracranial lesions, drugs, anoxic encephalopahty, eye drops
|
|
what does bilateral fixed dilated pupils mean
|
severe anoxia
|
|
coma with bilateral fixed dilated pupils
|
severe anoxia
|
|
coma with unilateral fixed dilated pupil
|
herniation w/ cn3 compression
|
|
coma with pinpoint pupils
|
narcotics, intracranial hemorrhage
|
|
2 ways to check brainstem reflexes on coma pt
|
pupillary light reflex, oculocephalic test (head turning to once side should move the eyes conjugately to opposite side)
|
|
what is locked in syndrome
|
hemorrhage/infarction of ventral pons -- complete paralysis with sparing of respiration, blinking, vertical eye movement
|
|
motor findings of uncal herniation
|
contra hemiparesis
|
|
sx of central herniation
|
hypertonicity, bilateral babinski (i.e. UMN sx)
|
|
brain death vs persistent vegetatitve state
|
irreversible, apnea despite ventilation, no BS reflexes, no other explanation, not hypothermic, evidence for brain death, electrical silence on EEG vs unresponsive but eyes open, random movements
|
|
classic location of ms plaques
|
angles of lateral ventricles
|
|
geographical association with MS
|
lower incidence near equator, moving there before age 15 reduces risk of MS
|
|
what is internuclear ophthalmoplgia
|
ipsi MR palsy
|
|
how can optic neuritis present as clinically
|
vision loss/central scotomy, decreased pupillary light reflex, pain on mvmt of eye
|
|
how to tx acute attacks of ms
|
high dose IV CS (oral doesn't work)
|
|
what long term therapy can be used in MS for prophylaxis
|
interferon beta, glatiramer
|
|
what is most important prognostic factor for guiillain barre
|
recovery w/in 1-3 wks after onset. if >6w, chronic relapsing course more likely
|
|
sphincter control and guillain barre
|
preserved
|
|
dx of guillaine barre
|
elevated csf protein, decreased motor nerve conduction
|
|
tx of guillain barre
|
iv ig, plasmapheresis if severe. DO NOT GIVE STEROIDS
|
|
what are 2 indications for mri to r/o intracranial mass
|
new onset seizure, new + persistent/progressive HA
|
|
dx of cns newplasm
|
mri +/- gadolinium
|
|
6 ways to control increased icp
|
steroids, mannitol, hyperventilation/decrease co2, reverse trendelenberg position (elevate head of bed), lower body temperature
|
|
what is meningeal carcinomatosis. sx?
|
cancer that mets to meninges. focal neurological deficits or hydrocephalus
|
|
what is cerebral perfusion pressure, what is it normally
|
MAP - ICP. >50mmHg.
|
|
what is mechanism of death with increased ICP
|
decreases cerebral perfusion pressure, which results in loss of autoregulation, which leads to cerebral vasodilation, and thus vasogenic edema, further increasing ICP. ALSO, SBP IS THE ONLY DETERMINENT OF CEREBRAL BLOOD FLOW
|
|
6 secondary insults that need to be potentially reversed in head trauma
|
1. hypotension (decreased cerebral perfusion) 2. hypoxia (chest wall or respiratory injury, brainstem injury) 3. hypercapnia (causes vasodilation) 4. increased ICP 5. mass effect (hematoma) 6. anemia
|
|
4 sx of basilar skull fx
|
raccoon eyes, battle's sx (postauricular ecchymoses), hemotympanum, csf rhinorrhea/otorrhea
|
|
what is diffuse axonal injury
|
global dmg to brain during impact, elevated ICP not seen, but small hemorrhages in many tracts, 1/3 mortality
|
|
what is cushing's triad
|
HTN + bradycardia + respiratory irregularity
|
|
eye finding on epidural hematoma
|
ipsi blown pupil (i.e. fixed and dilated)
|
|
acute vs chronic subdural hematoma
|
chronic = sx at least 1 week after injury, better prognosis
|
|
what sx after concussion suggest elevated icp? what needs to be done?
|
vomiting, delirium, focal deficit. r/o hematoma.
|
|
what is emergency in myasthenic crisis
|
respiratory arrest
|
|
dx for myasthenia
|
achr antibody test, emg shows stepwise decrease in responsiveness, ct scan of thorax to r/o THYMOMA, edrophonium test has high fp
|
|
when should a thymectomy be done in myasthenia pt
|
always should be offered cuz even in absence of thymoma OFTEN get benefit and remission. obviously, if have thymoma then do it
|
|
what medicines can exacerbate sx of myasthenia
|
antibiotics, bb, antiarrythmics
|
|
options if achei fails for myasthenia
|
immunosuppression (corticosteroids), plasmapharesis, ivig.
|
|
what is lambert eaton assoc with. how different from myasthenia
|
small cell. sx improve with use
|
|
dx of duchenne's
|
DNA testing, elevated CPK
|
|
bone findings in nf1
|
bone erosion, scolioisis, congential tibial dysplasia
|
|
eye findings of nf1 vs nf2
|
lisch nodules (iris hamartoma) vs cataracts
|
|
what type of CNS neoplasm assoc with von hippel lindau
|
cavernous hemangioma
|
|
sx of syringomyelia
|
bilateral loss of p&t over shoulders (capelike)
|
|
how to tx syringomyelia
|
syringosubarachnoid shunt
|
|
sx of brown sequard
|
contra loss of p&t, ipsi hemiparesis, ipsi dorsal column
|
|
what is transverse myelitis
|
rare condition which horizontally affects spine and presents with LE weakness, back pain, sensory deficits, incontinence
|
|
how to dx transverse myelitis
|
mri with contrast
|
|
3 sx of horners
|
ptosis , miosis, anhidriosis
|
|
sx of polio
|
asymmetric muscle weakness, no reflexes, but normal sensation
|
|
danger of polio
|
bulbar involvement sometimes (cn 9-10) -- respiratory/cv problems
|
|
what test to order for dizziness + vestibular sx
|
audiogram
|
|
3 causes of central vertigo
|
MS, vertebrobasilar insufficiency, migraine associated vertigo
|
|
5 causes of peripheral vertigo
|
bpv, menieres, acute labyrinthitis, ototoxic drugs, acoustic neuroma
|
|
5 causes of syncope
|
seizure, cardiac, vasovagal, orthostatic, severe cerebrovascular dz, others
|
|
what is vasovagal syncope
|
some kind of trigger causes vagal response (bradycardia and vasodilation)
|
|
tx for vasovagal syncope
|
avoid circumstances, tx with bb and disopyramide
|
|
main priority in dx of syncope
|
differentiate b/w cardiac and noncardiac causes
|
|
8 causes of seizures
|
4M4I - metabolic (hyponatremia, glycemia, thermic, uremia), mass lesion, missing drugs, misc (pseudoseizure, eclampsia, hypertension), intoxication, infection, ischemia, ICP
|
|
2 main types of seizure
|
partial (one part of brain) vs generalized (spread to many parts of brain)
|
|
2 types of partial seizures
|
simple (no loss of consciousness) vs complex (impaired consciousness)
|
|
tonic vs clonic phase in grand mal
|
tonic = muscle rigidity, clonic = repetitive muscle jerking
|
|
workup for new onset seizures
|
cbc, electrolytes, glucose, lfts, renal, calcium, UA, eeg, ct, lp
|
|
how long to keep on seizure medicine for
|
2 yrs
|
|
sx of als
|
UMN and LMN lesions, SYMMETRIC
|
|
what does an EMG test
|
neuropathy (LMN), myopathy, nmj dz
|
|
how are the following affected in als: bowel/bladder, cognition, extraocular mm
|
none of these affected
|
|
how to dx als
|
2 regions on emg and nerve conduction affected = probable, 3+ = definite
|
|
how does conduction aphasia present as. what is it physiologically
|
disturbance in repitition. disturbance in connection b/w wernicke and broca
|
|
how to tx bells palsy
|
usually no tx, resolve w/in 1 mo. consider emg if not resolved by 2w. wear eye patch. NO STEROIDS IF LYME SUSPECTED
|
|
what needs to be r/o for trigeminal neuralgia
|
CPA tumor
|
|
aphasia vs visuospatial defects in terms of cortex deficits
|
left = aphasia. right = visuospatial
|
|
race predilection for sle
|
african american
|
|
what antibodies assoc with drug induced lupus
|
antihistone
|
|
most specific ab's for sle
|
anti dsdna, anti smith
|
|
tx for apls
|
anticoagulation to inr 2.5-3.5
|
|
what type of renal glomerulonephritis is associated with renal failure in lupus
|
type iv -- diffuse proliferative
|
|
what hla type is sle, sjogren and ra assoc with
|
dr2/dr3, dr3, dr4
|
|
mcc death from scleroderma
|
pulmonary fibrosis
|
|
2 antibodies for scleroderma
|
ANAs are nonspecific, but anticentromere for limited, anti-topoisomerase for diffuse
|
|
2 main sx of sjogrens
|
dry eyes, dry mouth
|
|
sx of CREST syndrome
|
calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasias
|
|
who is more likely to have a child with neonatal SLE/congenital heart block
|
someone with Ro (SSA)
|
|
what is mixed connective tissue disease
|
has features of many connective tissue dz. presence of anti U1 RNP ab
|
|
what spinal problem assoc with RA
|
cervical spine instability -- GET CERVICAL XR BEFORE SURGERY
|
|
characteristics of pleural fluid effusion in RA
|
low glucose and low completement
|
|
what is feltys syndrome
|
RA, neutropenia, splenomegaly
|
|
4 indicators of poor prognsois in RA
|
high RF titers, subcutaneous nodules, erosive arthritis, autoantibodies to RF
|
|
what is Still's Dz
|
JRA
|
|
first line dma's for tx of ra
|
mtx, hydroxychloroquine, sulfasalazine
|
|
what is risk of tx with hydroxychloroquine
|
retinopathy, so do eye exams q6mo
|
|
surgical options for ra
|
synovectomy (does not improve rom), joint replacement
|
|
relationship of gender to gout
|
women notaffected till after menopause
|
|
what can cause decreased excretion of uric acid
|
renal dz, nsaid/diuretics, acidosis
|
|
what things can precipitate an acute gout attack
|
decrease in temperature, dehydration, stress, alcohol, starvation
|
|
likelihood of gout attack w/in first 2 yrs of acute gouty attack
|
75%
|
|
how is chronic tophaceous gout different from acute gouty attack
|
in ppl with poorly controlled gout for long time, tophi are aggregates of urate crystals
|
|
joint aspiration results of gout
|
needle shaped negatively birefringent
|
|
what medicines can increase uric acid levels
|
thiazide/loops
|
|
side effects of colchicine
|
n/v/cramps, diarrhea
|
|
when is colchicine CI
|
renal insufficiency, cytopenia
|
|
when to start prophylactic therapy for gout
|
2+ attacks/yr
|
|
should you use uricosuric drug or allopurinol for gout prophylaxis
|
if 24-hr urine uric acid <800, then give uricosuric if no renal insufficiency
|
|
joint aspirate of pseudogout
|
weakly positively birefringent, rod/rhomboid shaped
|
|
xr findings of pseudogout
|
cartilage calcification
|
|
5 causes of acute polyarticular arthritis
|
septic joint, viral, lyme, reiters,rheumatic FEVER
|
|
what is special about inclusion body myositis
|
men>women, no autoantibodies, DISTAL muscle involvement, low CPK,poor prognosis
|
|
pathogenesis: dermatomyositis vs polymyositis
|
humoral immune activation vs cell mediated immunity
|
|
4 main features of dermatomyositis
|
1. symmetric proximal muscle weakness 2. elevated cpk 3. EMG 4.biospy
|
|
what are gottron's papules
|
papular, erythematous, scaly lesions over knuckles
|
|
is there any increased neoplasia risk in polymyositis? dermatomyositis?
|
only dermatomyositis
|
|
what antibodies associated with myositis
|
anti-jo
|
|
what factor may lead to better prognosis in myositis? worse prognosis
|
anti-mi-2 = good. anti-signal recognition = worst. anti-synthetase = abrupt onset.
|
|
muscle biopsy results in dermatomyositis vs polymyositis
|
dermato = perimysial. poly = endomysial.
|
|
relationship b/w temporal arteritis and polymyalgia rheumatica
|
40-50% of temporal arteritis may have PMR
|
|
sx of polymyalgia rheumatica
|
hip and shoulder pain + flu-like + joint swelling
|
|
tx of PMR
|
cs 4-6w,but may need for up to 2 yrs
|
|
special consideration in someone with ankylosing spondylitis and trauma
|
if even minor trauma + neck/back pain, strictly immobilize to prevent injury until proper imaging (high risk of fx)
|
|
complications of anklyosing spondylitis
|
restrictive lung,cauda equina, osteoporosis -> spine fx, spondylodiscitis
|
|
what is enthesitis
|
inflammation at tendinous insertions into bone
|
|
where does reactive arthritis usually occur
|
LE
|
|
tx for reactive arthritis
|
NSAID
|
|
what type of arthritis is psoriatic arthritis
|
asymmetric polyarthritis
|
|
what is undifferentiated spondyloarthropathy
|
features of reactive arthritis but no past infection
|
|
tx for temporal arteritis
|
oral steroids based on suspicion for at least 4 weeks, iv if visual loss present
|
|
constitutional sx + absent pulses/bruits
|
takayasu
|
|
labwork for churg strauss
|
panca, eosinophilia
|
|
3 major sx areas for churg strauss
|
constitutional + respiratory + skin lesions
|
|
mc death from wegeners
|
renal
|
|
what body parts does wegeners involve
|
kidneys, upper & lower respiratory tract
|
|
what organ systems does PAN involve
|
medium sized vessels in nervous system and GI
|
|
dz associatiosn of PAN
|
hbv, hiv
|
|
dx of PAN
|
biopsy, esr, panca, fobt
|
|
triad of behcet
|
aphthous ulcers, uveitis, genital ulcers
|
|
what is affected mostly in hypersensitivity vasculitis
|
small vessel, mostly skin -- palpable murmura, etc
|
|
what is azotemia
|
elevated bun and cr
|
|
urine osmolarity, urine na, fena in prerenal failure
|
>500, <20, <1%
|
|
urine osmolarity, fena in atn
|
>350, >1%
|
|
bun/cr ratio in prerenal failure
|
>20:1 (kidney can ramp up BUN absorption)
|
|
phases of ATN
|
oliguric phase, diuretic phase, recovery phase
|
|
bun/cr in atn
|
<20:1
|
|
3 tests to perform for postrenal failure
|
palpate bladder, u/s, catheter to look for urine
|
|
ARF + rbc casts
|
glomerular dz
|
|
ARF + protein dipstick
|
intrinsic renal failure
|
|
ARF + WBC cast
|
renal parenchyal inflammation
|
|
what is renal failure index
|
Una/Ucr/Pcr. <1% = prerenal, >1% = ATN
|
|
early causes of death from ARF
|
hyperkalemic cardiac arrest, pulmonary edema
|
|
metabolic consequences of arf
|
hyperkalemia, metabolic acidosis, hypocalcemia, hyperphosphatemia, uremia
|
|
medications and ARF
|
must be adjusted for lvl of renal fcn
|
|
3 prognostic factors for arf
|
severity of renal failure, overall health of pt, clinical course
|
|
what is chronic renal insufficiency
|
no renal failure but elevated cr
|
|
why might a person with ckd be at increased risk for bleeding
|
platelet dysfunction due to uremia
|
|
what is calciphylaxis
|
vascular calcifications result in necrotic skin lesions
|
|
what is tachyphylaxis
|
desensitization to drug
|
|
why might you see hypercalcemia in ckd pt
|
long term hyperpth and use of calcium based phosphate binders
|
|
tx for ckd
|
1. low protein (0.7g/kg), low salt if volume issues or oliguria, restrict potassium, phosphate, mg 2. acei (monitor k+) 3. bp control 4. glycemic control 5. correct hyperphosphatemia, hypocalcemia 6. epo 7. capsaicin/uv/cholestyramine for pruritus
|
|
why is there increased risk of infection in ckd
|
uremia
|
|
absolute indications for dialysis
|
AEIOU -- acidosis, electrolytes (hyperkalemia), intoxications (methanol, ethylene glycol, lithium, aspirin), overload (hypervolemia), uremia (eg uremic pericarditis)
|
|
what is continuous AV hemodialysis and continuous venovenous hemodialysis used in
|
hemodynamically unstable pts, minimizes rapid shifts in volume and osmolality
|
|
advantage/disadvantage of hemodialysis
|
more efficient, less time needed, but less similar to kidney physiology, which can lead to hypotension and hypoosmolality
|
|
advantage/disadvantage of PD
|
natural kidney physiology, but high glucose load, peritonitis
|
|
types of proteinuria
|
glomerular, tubular, overflow (eg bence jones)
|
|
what is definition of proteinuria
|
>150mg/day
|
|
level of proteinuria in nephrotic syndrome
|
>3.5g /day
|
|
why is there hyperlipidemia in nephrotic syndrome
|
generalized increased hepatic synthesis
|
|
what is urine dipstick able to detect in level of protein
|
1+ = 15-30
|
|
is urine dipstick able to detect all types of urine protein equally
|
no. more sensitive to albumins
|
|
best test to detect chronic pyelo
|
ivp
|
|
what health maintenance item required for chronic proteinuria
|
vaccination (pneumo, flu)
|
|
definition of hematuria
|
>3 rbcs/hpf
|
|
what type of hematuria most associated with glomerular dz
|
microscopic, usually not gross
|
|
workup hematuria
|
urine dipstick & UA (look for sediment/casts), cytology, blood tests, ivp/ct/us
|
|
classic sx of nephritis syndrome
|
hematuria, htn, azotemia
|
|
associations with minimal change dz
|
hodgekins and nonhodgekins
|
|
mcc of glomerular hematuria
|
berger's dz, aka iga nephropathy
|
|
what proteins are deposited in berger's dz
|
iga, c3. rmr berger's dz is iga nephropathy
|
|
mcc of membranoproliferative glomerulonephritis
|
hcv>hbv, syphilis, lupus
|
|
association with membranoproliferative
|
cryoglobulinemia
|
|
how long does glomerulonephritis take to develop after infection with gas
|
2w
|
|
lung dz vs kidney dz time course in goodpasture
|
lung dz occurs earlier
|
|
what type of histopathology in hiv nephropathy. tx?
|
like fsgs. prednisone, acei, arv
|
|
3 causes of acute interstitial nephritis
|
drug allergy (penicillin, diuretic, nsaid, anticoagulation, pheyny, sulfa), infection, collagen vascular dz
|
|
dx of acute interstitial nephritis
|
eosinophils in urine
|
|
acute vs chronic intersitital nephritis
|
acute has rapid decline in renal fcn. chronic has an indolent course with slow fibrosis and atrophy
|
|
causes of chronic interstitial nephritis
|
chronic obstruction, chronic analgesic, arteriolar nephrosclerosis (htn), heavy metal exposure
|
|
do you see eosinophils in chronic interstitial nephritis
|
no
|
|
causes of renal papillary necrosis
|
analgesic, dm, sickle cell, transplant rejection, obstruction
|
|
what type of metabolic d/o with rta
|
nonanion gap hyperchloremic metabolic acidosis
|
|
what is type 1 rta, causes, effects on electrolytes. tx
|
can't secrete h+ at distal tubule, due to kidney dmg or systemic dz. all ions secreted (na, ca, k, po4)... so can get hypokalemia and renal stones. tx = bicarb, which also helps stones
|
|
what is type 2 rta. causes. electrolyte effects. tx
|
can't absorb bicarb at pct. fanconi, kidney dmg. hypokalemia. sodium restriction (will cause increased bicarb reabsorption)
|
|
what is type 4 rta. cause. electrolyte effects.
|
hypoaldosteroneism .. so increased acid and k+. cause is interstitial dz and dm.
|
|
what is hartnup dz, sx?
|
can't absorb neutral amino acids ... so similar sx to pellagra (dermatitis, diarrhea, dementia)
|
|
associated findings with adpkd
|
berry aneurysm, valvular dz, abdominal hernias, cysts in other organs
|
|
what antihypertensive to avoid in renovascular htn
|
acei
|
|
is magnetic dye in mra nephrotoxic
|
no
|
|
what test can be used to dx renal artery stenosis if renal fcn is good? if not?
|
renal arteriogram, captopril renal scintigram (not invasive). mra
|
|
dx test for renal vein thrombosis
|
selective renal venography, ivp
|
|
what is nephrosclerosis
|
thickening of glomerual afferent arterioles due to htn
|
|
can nephrosclerosis be acute problem
|
can cause malignant dz
|
|
tx for nephrosclerosis
|
control bp
|
|
how to tx sickle cell nephropathy
|
control sickle cell, acei
|
|
most common locations of nephrolithaisis
|
ureterovesicular jcn, calyx, ureteropelvic jcn, pelvic brim
|
|
what types of stones are radiolucent
|
uric acid stones
|
|
what size kidney stones can pass sponteeously
|
<.5cm
|
|
what are causes of hyperoxaluria
|
severe steatorrhea, small bowel dz, pyridoxine deficiency
|
|
hematuria + pyuria with kidney stone
|
comorbid infection
|
|
workup for kidney stone
|
UA (look for coexisting infection and low pH maybe uric acid stone, high pH maybe struvite), 24-hr urine (what type of stone), serum chemistry (electrolytes can hint at what type of stone), KUB, ct
|
|
when would you need to admit pt for nephrolithiasis
|
intractable pain, anuria, renal colic + UTI/fever, large stone
|
|
surgical options for kidney stone
|
extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy
|
|
lower vs upper urinary tract obstruction
|
lower affects urination, upper causes renal colic
|
|
causes of lower urinary tract obstruction
|
BPH, stricture, neurogenic bladder, bladder cancer
|
|
causes of upper urinary tract obstruction
|
intrinsic causes like stones, clots, crystal deposits, strictures, or extrinsic like pregnancy, AAA, endometriosis, IBD, etc
|
|
workup for urinary obstruction
|
us, ua/labs, kub, ivp, voiding cysurethrography, cystoscopy, ct
|
|
risk factors for prostate cancer
|
age, bllack, fatty diet, famhx, chemical exposure
|
|
indications for prostate biopsy
|
psa >10, psa velocity >.75, dre
|
|
tx for prostate cancer
|
if localized -- radical prostatectomy. if locally invasive, radiation + androgen deprivation. metastasis -- severe androgen reduction (orchiectomy, antiandrogen, leuprolide)
|
|
prognosis of bladder cancer
|
high recurrence
|
|
how does bladder cancer spread
|
local extension
|
|
initial presenting sx of bladder cancer
|
painless hematuria
|
|
dx for bladder cancer
|
ua/uc (r/o infection), urine cytology, ivp, CYSTOSCOPY, cxr/ct (tumor hunting)
|
|
tx for bladder cancer
|
if CIS, intravescle chemo. if involves lamina propria, TUR. if muscle invasion, radical cystectomy+lymph nodes+removal of surrounding. if met -- cystectomy + chemo
|
|
why is it important to be careful with pe for scrotal mass
|
testicular cancers are almost always maligant, extratesticular scrotal cancers almost always benign
|
|
afp and what type of testicular tumor
|
embryonal tumors
|
|
staging of testicular tumor
|
a = confined. b = lymph nodes below diaphragm. c = met
|
|
by when does infarction occur in testicular torsion
|
6h
|
|
tx for testicular torsion
|
urgent bilateral orchiopexy
|
|
cause of epidydimits
|
ecoli in age extremes, stds in young males.
|
|
what are the sizes of the fluid compartments
|
60-40-20. 1/4 of ECF is plasma.
|
|
normal i/o's
|
input: 1500 fluids, 500 solids/metabolism
output: minimum 500 urine, 250 stool, 600 minimum insensible |
|
what is normal hourly urine output
|
>1mL/kg/hr
|
|
is D5W good at maintaining intravascular volume? LR?
|
no (11/12 diffuses into TBW). yes
|
|
can you use LR in pt with potential hyperkalemia
|
no
|
|
how does hct change with hypovolemia
|
3% increase for every liter of deficit
|
|
how to use crystalloid solution to replace fluids
|
3 times as much blood lost to replace intravascular compartment
|
|
why is dextrose added to maintenance fluids
|
to inhibit muscle breadown
|
|
tx for hypervolemia
|
fluid restriction, diuretics
|
|
2 homeostatic mechanisms to regulate water
|
osmoreceptors in hypothalamus cause thirst when >295mosm. posterior pituitary gland secretes adh.
|
|
what is hyponatremia (definition)
|
<135
|
|
hypotonic vs isotonic vs hypertonic hyponatremia
|
hypotonic = "true hyponatremia". isotonic = pseudohyponatremia (lab error caused by lipids/protein/etc). hypertonic = osmoactive substances causes dilution.
|
|
causes of hypotonic hyponatremia
|
can be hypovolemic (if low urine sodium, kidneys trying to conserve sodium for extrarenal losses. if high, then renal loss), euvolemic, hypervolemic (water retaining states).
|
|
causes of euvolemic hypotonic hyponatremia
|
siadh, psychogenic polydipsia, postop, hypothyroid, haldol/cyclophosphamide/antineoplastics
|
|
how does hyponatremia cause neurologic sx
|
causes increased icf volume --> icp
|
|
3 dx for hyponatremia
|
plasma osmolality, urine osmolality, urine sodium
|
|
how to tx hyponatremia
|
if isotonic or hypertonic, tx the underlying d/o. if hypotonic, then if mild -- withhold free water. if moderate, give looops. if severe, give hypertonic soln to increase serum sodium by 1-2meq/L/hr
|
|
causes of hypernatremia
|
hypovolemic = extrarenal loss of water, renal loss of water > sodium. isovolemic = di/insensible. hypervolemic = iatrogenic, cushing, hyperaldosterone
|
|
max rate of correction for hypernatremia
|
12meq/L/day
|
|
how to workup hypernatremia
|
check kidneys (low urine volume and urine osmol > 800), try desmopressin challenge to see if DI suspected
|
|
how to tx hypernatremia
|
for hypovolemic -- give nacl. if isovolemic -- give fluids, adh if di. hypervolemic -- give diuretics.
|
|
how can you calculate the water deficit
|
tbw * (1 - actual na/desired na)
|
|
how can you estimate ionized calcium
|
total calcium - .8 * albumin
|
|
why can hypomagnesium result in hypocalcemia
|
cuz decreased mg causes less pth
|
|
ekg changes of hyper vs hypocalcemia
|
qt shorten vs qt prolonged
|
|
how to tx hypercalcemia
|
increase urine (fluids and diuretics), inhibit bone resorption (bisphosophates, calcitonin)
|
|
what is effective for tx of hypercalcemia from vitamin D related issues
|
glucocorticoids
|
|
what is the only cause of hypokalemia that also causes htn
|
hypoaldosterone
|
|
sx of hypokalemia
|
arrythmia w/ twave inversion, muscle weakness, decreased dtrs, decreased gi motility, nv
|
|
how to replace k+
|
oral is safest -- 10meq increases by .1meq/L. if potassium <2.5, can do IV (mas 10meq/hr peripheral, 20meq/hr in central)
|
|
watch out for what drug when potassium is low
|
dig
|
|
sx of hyperkalemia
|
arrythmia (peaked t wave, prolonged pr, wide qrs), muscle weakness, decreased dtr, respiratory failure
|
|
why might k+ be falsely elevated
|
venipucture injury releases k+ from cells (ie prolonged use of torniquet)
|
|
tx for hyperkalemia
|
give IV calcium (to stabilize mycardial excitability), glucose, insulin and bicarb (all move k+ into cells), kayexalate (k+ binder), dialysis
|
|
causes of hypomagnesium
|
gi problems, alcohol, renal
|
|
ekg changes of hypomagnesium
|
prolonged qt, t wave flattening, torsades
|
|
causes of hypermag
|
renal fail,
|
|
what can be given for mg tox
|
calcium gluconate
|
|
ekg changes of hypermag
|
similar to hyperkalemia (wide qrs, elevated t, increased pr)
|
|
causes of hypophosphatemia
|
GI (absorption, malnutrition), increased renal excretion (incl hyperglycemia)
|
|
causes of hyperphosphatemia
|
renal failure (decreased excretion), bisphosphanates, rhabdo
|
|
how to tx hyperphosphate
|
phosphate binding antacid (aloh)
|
|
bicarb in serum chemistry vs abg
|
bicarb in abg is calculated so less reliable
|
|
why is respiratory + metabolic acidosis bad
|
sx of impending respiratory failure
|
|
ecf contraction vs expansion in metabolic alkalosis
|
ecf contraction is sensitive to saline, urine cl <10. ecf expansion has htn, urine cl >20.
|
|
2 main determinents of paco2
|
respiratory rate, tidal volume
|
|
how does 1 unit of packed rbcs affect hgb
|
raises by 1, raises hct by 3
|
|
when might a hgb of 7 or 8 not be well tolerated
|
impaired cardiac fcn
|
|
what is cryoprecipitate
|
contains factor 8 and fibrinogen (for hemophilia & vwd)
|
|
effect of 1 unit of plts
|
raises plt by 10000
|
|
what 3 groups of ppl have increased iron requirements
|
infants, adolescents, pregnants
|
|
how to dx beta thalassemia
|
elevated hbf on electrophoresis, microcytic hypochemoia on pbs
|
|
what is hbh dz
|
mutation/deletion of 3 alpha loci
|
|
causes of sideroblastic anemia
|
drugs (chloarmphenicol, inh, alcohol), lead, collagen vascular dz, neoplasm
|
|
how to do shillings test
|
give unlabeled b12 IM to saturate. then give labeled b12 PO, then measure in urine. then give intrinsic factor andsee if that changes anything
|
|
extravascular vs intravascular hemolysis: haptoglobin
|
lower in intravascular
|
|
most common clinical manifestation of sickle cell
|
painful crisis of bone (bone infarct)
|
|
what is splenic sequestration crisis
|
seen in sickle cell with sudden pooling of blood into spleen resulting in hypovolemia and splenomegaly
|
|
prophylaxis for sickle cell
|
AVOID high altitude, dehydration, TREAT infections aggressively, do penicillin prophylaxis for children until 6yo, folic acid supplements, hydroxurea
|
|
tx for hereditary spherocytosis
|
splenectomy
|
|
what dz has bite cells and heinz bodies
|
g6pd. heinz bodies are hgb precip and bite cells result after removal
|
|
ab in warm vs cold autoimmune hemolytic anemia
|
igg vs igm
|
|
type of hemolysis in warm vs cold autoimmune
|
extravascular (digested by splenic macrophages) vs intravascular (complement mediated destruction)
|
|
causes of warm autoimmune hemolysis
|
lymphoma/leukemia(cll), collagen vascular dz, drugs (methyldopa)
|
|
ab in warm vs cold autoimmune hemolytic anemia
|
igg vs igm
|
|
how to dx autoimmune hemolysis
|
direct coombs --- if igg then warm, if complement then cold.
|
|
type of hemolysis in warm vs cold autoimmune
|
extravascular (digested by splenic macrophages) vs intravascular (complement mediated destruction)
|
|
tx for warm hemolysis
|
glucocorticoids, other imunosppression
|
|
causes of warm autoimmune hemolysis
|
lymphoma/leukemia(cll), collagen vascular dz, drugs (methyldopa)
|
|
how to dx autoimmune hemolysis
|
direct coombs --- if igg then warm, if complement then cold.
|
|
tx for warm hemolysis
|
glucocorticoids, other imunosppression
|
|
mutated proteins in pnh
|
cd55,59
|
|
dx for pnh
|
ham's test (put into acid which causes lysis), sugar water test, flow cytometry
|
|
what type of hemolysis in pnh
|
intravascular
|
|
definition of thrombocytopenia
|
<150k
|
|
HIT type 1 vs type 2
|
aggretation <48h after initiation vs 3-12 days. type 1 don't do anything, type 2 stop heparin
|
|
when do you run risk of bleeding during surgery/ trauma? minor spontaneous? major spontaneous?
|
<50000. <20000. <5000
|
|
cause of ttp
|
unknown but platelet thrombi occlude small vessels and cause dmg to rbcs
|
|
5 sx of ttp
|
hemolytic anemia + thrombocytopenia + renal failure + fever + fluctuating neurologic sx
|
|
how is ttp different from hus
|
ttp tends to have fever and altered mental status
|
|
tx for ttp
|
plasmapharesis, cs. DONT DO PLT TRANFUSION
|
|
what proteins affected in bernard soulier vs glanzmann
|
gp1b, gp2b
|
|
bleeding study results of bernard soulier vs glanzmann
|
bernard has low but large platelets. glanzmann has high bleeding time, but normal plt
|
|
what is factor VIII antigenic protein
|
vWF
|
|
how to dx vWF deficiency
|
prolonged bleeding time, decreased plasma vWF, reduced ristocetin induced platelet aggregation
|
|
what metabolic condition can cause impaired platelet fcn
|
uremia
|
|
tx for vWD deficiency
|
DDAVP, factor VIII concentrate, don't give cryoprecipitate (viral risk)
|
|
joint problems in hemophiliacs
|
joint destruction
|
|
how severe is hemophilia A usually
|
usually severe (<1% of normal levels of 8)
|
|
can you use DDAVP for hemophilia
|
mildly useful in hemophilia A only
|
|
PT, PTT, PLT, fibrinogen levels in vitamin k deficiency
|
only PT prolonged
|
|
what can be done as supportive tx for dic
|
use FFP/cryoprecipitate to replace clotting factors, PLT transfusion. o2, ivf to maintain bp and renal perfusion. may use heparin if lots of thrombosis
|
|
which clotting factor has the shortest half life
|
VII
|
|
which clotting factor is not produced by liver
|
vWF
|
|
why does coagulopathy develop in liver failure
|
decreased synthesis of clotting factors, cholestasis prevents vitamin K absorption, hypersplenism causes thrombocytopenia
|
|
is antiphospholipid syndrome arterial or venous thromobisis
|
both
|
|
what does protein S bind to
|
protein C
|
|
how is standard heparin given
|
therapy: bolus of 80 U/kg then 15 U/kg/hr infusion
prophylaxis: 5000 U subcut q12h |
|
when is the only situation heparin is given as prophylaxis
|
for DVT
|
|
what anticoagulation drug has risk of alopecia and rebound hypercoagulability
|
heparin
|
|
mechanism of LMWH
|
mostly inhibition of Xa
|
|
what to do if severe bleeding with heparin or warfarin
|
FFP
|
|
how long does warfarin take to reach therapeutic levels
|
4 days
|
|
hematological abnormalities in MM
|
pancytopenia
|
|
electrolyte abnormalities in MM, why
|
hypercalcemia, bone destruction
|
|
how many plasma cells must be abnormal to dx MM
|
10%
|
|
how long does it take to correct warfarin OD with vit K
|
4-10h
|
|
are there bone lesions in waldenstrom
|
no
|
|
cutoff of immunoglobulins to call it MGUS
|
IgG spike < 3.5g, <10% abnormal plasma cells in BM; bence jones proteinuria <1g/day
|
|
ann arbor staging of hodgekins
|
stage 1 = 1 lymph node. 2 = same side diaphragm. 3 == boxth sides of diaphragm.
B = constitutional sx |
|
other than rs cells, what histological characteristic of hodgekins that sets it appart from nhl
|
inflammatory cells reacting to rs cells
|
|
what types of hodgekins require chemo
|
3b,4
|
|
staging system of nhl vs hodgekins
|
same
|
|
what types of autoimmune dz may increase risk of nhl
|
hashimoto, sjogren
|
|
most common type of nhl
|
follicular
|
|
grade of small lymphocytic lymphoma vs follicular vs diffuse large cell vs lymphoblastic vs burkitt
|
2x indolent, intermediate, high grade
|
|
what type of cells are involved in lymphoblastic lymphoma
|
t cells
|
|
which type of lymphoma usually presents as large extranodal mass
|
diffuse large b cell
|
|
what test may help to gauge tumor burden for lymphoma
|
ldh, b2 microglobulin
|
|
low grade vs high grade lymphoma: cure vs survival
|
high grade have higher rates of cure but less survival w/o tx
|
|
what is CHOP therapy
|
cyclophosphamide, hydroxydaunomycin (doxorubicin), oncovin (vincristine), prednisone
|
|
most common malignancy in children under 15
|
ALL
|
|
poor prognostic indicators for ALL
|
age <2 or >9, wbc >100000, cns involvement (b cell phenotype, lots of LDH, rapid proliferation)
|
|
which type of leukemia tends to have testicular involvement
|
ALL
|
|
which type of leukemia tends to have skin nodules
|
AML
|
|
prognosis of ALL
|
75% children get complete remission.
|
|
what leukemia has smudge cells
|
cLL
|
|
which leukemia is most at risk of blast crisis
|
CML
|
|
leukemoid rxn vs CML
|
leukemoid rxn: no splenomeglay, increased LAP, hx of precipitating event like infection
|
|
tx for CML
|
chemo to control sx before blast crisis. hard to prevent it
|
|
tx for CLL
|
symptomatic tx with chemo
|
|
dx for polycythemia vera
|
major (need all, or 2 with 2 minor) elevated RBC (>36 in men, >32 in women), o2 sat >92, splenomegaly.
minor: thrombocytosis, leukocytosis, LAP>100, B12 >900 |
|
2 main life threatening features of polycythemia vera
|
thrombotic phenomena, bleeding
|
|
peripheral blood smear of myelodysplastic syndrome
|
low reticulocyte, howell-jolly/basophilic stippling
|
|
what is erythromelalgia
|
burning pain and erythema of extremties due to occlusions
|
|
whats anagrelide
|
antiplatelet agent
|
|
prognosis of myelodysplastic
|
oft progress to acute leukemia
|
|
prognosis of agnogenic myeloid metaplasia
|
AML, death from bleeding/infection
|
|
mc organisms cap
|
s pneumo, hi, aerobic gnrs (klebs, enterobacteria
|
|
how do you differentiate b/w pneumonia and acute bronchitis
|
clinical features (cough, sputum, fever, dyspnea) not great. do CXR
|
|
what is pulse temperature disassociation commonly seen in
|
atypical cAP
|
|
likelihood of pneumonia in outpt with normal vs
|
<1%
|
|
how do you know if a sputum sample collection is good
|
>25 pmns, <10 epithelial cells per low power field
|
|
what to order on sputum taken for pneumonia
|
gram stain in all pts, culture in all pts needing hospital, if suspect hiv, then do silver stain. if suspect tb, then do acid fast
|
|
why is sputum studies helpful in pneumonia
|
cuz may identify resistance
|
|
first line tx for cap <60yo? older?
|
macrolide, doxy. 2nd/3rd gen ceph, fluoroquinolone.
|
|
when do you tx parapneumonic effusion? how do you analyze fluid?
|
>1cm effusion on lateral decubitus film. gram stain, culture, ph, cell count, determine glucose, protein, ldh
|
|
what is main risk factor for lung abscess
|
predisposition to aspiration, poor dental hygeine
|
|
what bacteria must be covered for in lung abscess
|
gpc (penicillin, or vanc if mrsa), anaerobes (clinda/metro). if you think gnr, then add quinolone
|
|
primary vs secondary tb
|
secondary = reactivation
|
|
what is progressive primary TB
|
incomplete immune response leads to symptoms of TB during primary phase
|
|
ghon's complex vs ranke's complex. what do both indicate
|
calcified primary focus vs calcified primary focus + calcified hilar lymph node. healed primary tb
|
|
how long does culture of tb take
|
4-8w
|
|
what induration of ppd is positive
|
>15mm, >5 if hiv or if close contact with active tb pt
|
|
first line tx for active tb
|
inh + rifampin + pyranzimide + ethambutol/streptomycin x2 months, then inh+rifampin x4months
|
|
prophylaxis for latent tb
|
9 mo inh
|
|
what URI sx does flu present with
|
fever, nonproductive cough, sore throat
|
|
brudzinski's sx vs kerning
|
flexing neck causes reflex flexion of legs. vs inability to extend knees when supine and hips flexed.
|
|
what to do if suspected meningitis and focal neurological deficits, why?
|
ct cuz there might be a space occupying lesion
|
|
nl csf findings: wbc coung, glucose, protein
|
<5, 50-75, <60
|
|
empiric tx for acute bacterial meningitis, what organisms?
|
infant = gbc/ecoli/listeria = cefotaxime+ampicillin
<50yr=neisseria/pneumo/hi=ceftriaxone+vanc >50yr=pneumo/neisseria/listeria=ceftriaxone+amp+vanc if IC, then do 4g ceph instead to cover pseudomonas |
|
workup for encephalitis
|
1. r/o nonviral causes -- cxr, urine/blood cultures, UDS, chemistries, LP w/ PCR, MRI
|
|
organisms that cause brain abscess
|
strep (sinusitus), saureus (trauma, postop), anaerobes (OM, COPD)
|
|
what infectious dz is polyarteritis nodosa assoc w
|
hbv
|
|
utility of hbv viral load
|
if persists for >6w, likely to develop chronic dz
|
|
if someone has hepatitis sx, and hbv is positive and then sx resolves, is repeat testing necessary
|
yes hdv may be missing in acute illness
|
|
progression to chronic state in hbv vs hcv
|
10% vs 90%
|
|
risk of developing cirrhosis/hcc in chronic hbv vs hcv
|
30% vs 15%
|
|
tx of chronic hbv vs hcv
|
ifn-alpha or 3tc vs ifn-alpha+ribavirin
|
|
how does botulism start
|
dry mouth, diplopia, dysarthria
|
|
how to dx botulinum
|
toxin in serum or stool
|
|
causes of intraabdominal abscess
|
spontaneous bacterial peritonitis, pelvic infection, pancreatitis, GI perforation, osteomyelitis of vertebral bodies
|
|
when might you suspect midstream clean catch might be contaminated
|
epithelial cells
|
|
what tests to get for UTI
|
dipstick, UA, urine gram stain, urine culture
|
|
what is phenazopyridine
|
urinary analgesic
|
|
tx options for UTI
|
bactrim, cipro, metro
|
|
how to tx pregnant lady with uti
|
amp/amox/ceph x7-10d
|
|
what is recurrent infection uti? how to prophylax
|
>2uti/yr. single dose tmp/smx after intercourse or after sx, or do 6mo prophylax
|
|
how to tx pyelo
|
if uncomplicated, tx based on gram stain. bactrim/cipro for gnrs. amox for gpc.
|
|
what is complicated pyelo
|
pyelo due to functional or structural problems of tract. these groups assumed to have complicated: men, elderly, renal dz, dm, ic
|
|
what do you do if no response to uncomplicated pyelo
|
perform urologic investigation for functional/structural causes
|
|
how long do you tx pyelo in hospital
|
broad spec (amp+gent/cipro) until pt is afebrile, then oral ab until 14-21day course
|
|
organisms behind acute prostatitis
|
gn
|
|
when should you dre for suspected prostatitis
|
avoid in straightforward cases of acute bacterial prostatitis cuz of risk for bacteremia
|
|
tx for prostatitis
|
if mild can use bactrim + fluoro/doxy
|
|
mcc reiters
|
chlamydia
|
|
men or women more likely to have sx with chlamydia? gc?
|
men > women both
|
|
what is seen on gram stain with gc
|
urethral dc shows organisms within leukocytes
|
|
how long doxy given for std
|
7d
|
|
monitoring for hiv
|
cd4 count, viral load (rna) q3-4mo. if viral load >50 after 4mo therapy, reconsider modification of tx
|
|
what cd4 count with aids? is this only way to dx
|
<200. but dx can also dx with aids defining infection
|
|
when do you start arv for hiv
|
if symptomatic or if cd4<500
|
|
what is haart
|
2 nrti's + nnrti/pi
|
|
leading cause of death in aids pts
|
pcp
|
|
what cd4 count do you see cmv? mac?
|
<50
|
|
what cd4 is candida seen
|
<100
|
|
what is hiv wasting syndrome
|
loss of >10% tbw + chronic diarrhea/fever&weakness
|
|
hiv prophylaxis -- organism, cd4, and tx
|
pcp, <200, bactrim. tb, yrly ppd, inh+pyridoxine. mac, <100, azithromycin. toxo, <100, bactrim.
|
|
how often to do pneumovax in ic
|
q5-6y
|
|
complications of neonatal hsv
|
congenital malformation, iugr, chorio, death
|
|
what is herpetic whitlow
|
painful vesicular hsv infection of finger
|
|
what is paronychia
|
infection of skin around cuticle
|
|
how long after exposure does syphilitic chancre take
|
3-4w
|
|
mc presentation of 2* syphilis
|
maculopapular rash
|
|
appearance of ulcer in chancroid vs chancre vs granuloma inguinale
|
chancre is clean raised ulcer. chancroid is shaggy and purulent. GI is coalescing ulcers and nodules
|
|
what stds may produce painful inguinal lymphadenoapthy
|
herpes, chancroid, LV
|
|
what is definitive test for syphilis
|
darkfield microscopy
|
|
how to dx syphilis
|
vdrl/rpr then confirm with fta abs
|
|
how to dx chancroid
|
clinically. r/o syphilis, hsv
|
|
is the ulcer produced by LV painful or painless
|
painless
|
|
tx for chancroid
|
azithromycin, ceftriaxone, or azithromycin
|
|
tx for LV
|
doxy x 21d
|
|
mcc cellulitis
|
saureus, gas
|
|
cellulitis: mc bacteria ssociated with -- local trauma, wound/abscess, immersion in water, acute sinusitis
|
gas, saureus, pseudo/aeromonas/vibrio, hi
|
|
when do you get cultures for cellulitis
|
blood culture if fever, tissue culture if wound
|
|
when is cellulitis emergent
|
orbital involvement
|
|
tx for cellulitis
|
based on hx. can use antistaph pen, or cephalosporin
|
|
what is erysipelas
|
cellulitis confined to dermis and lymphatics caused by gas.
|
|
mcc nectrotizing fasciitis
|
gas, c perfringens
|
|
what is lymphadenitis
|
inflammation of lymph node caused by skin or soft tissue bacterial infection
|
|
what is trismus
|
lockjaw, oft seen in tetanus
|
|
how long after infection does tetanus take to occur
|
1-7d
|
|
when do intervene with antitetanus for clean minor wounds? other wounds?
|
clean: use Td only if <4 doses of Td in past. other: use both Td and TIG if not had >3 doses of Td in past
|
|
what types of wounds are at risk for tetanus
|
if not clean (contamination w dirt/feces/saliva)
if major (deep puncture) |
|
mc type of osteomyleitis in prosthetic joint
|
coag neg staph
|
|
mc type osteomyelitis in diabetic foot
|
polymicrobial
|
|
what is risus sardonicus
|
grin due to forced contraction of facial mm (tetanus)
|
|
what is opisthotonus
|
arched back (tetanus)
|
|
mc osteomyelitis
|
saeurs, coag neg staph
|
|
mc finding in osteomyletis
|
tenderness over bone
|
|
use of esr/crp in osteomyeltis
|
monitor response to therapy
|
|
how long to see xr changes in osteomyelitis? what are they?
|
periosteal reaction takes 10d
|
|
gold std dx for osteomyelitis
|
needle aspiration of infected bone
|
|
empiric tx for osteomylitis
|
antistaph pen, 1g ceph. add aminoglycoside for gnr
|
|
causes of infectious arthritis
|
hematogenous spread is mc, local extension, trauma, iatrogenic after procedure
|
|
mc organisms of acute bacterial artheritis
|
saureus, then strep.
|
|
what organisms seen in arthritis in pt with sickle cell? IC? iv drugs?
|
pseud, salmonella
|
|
what studies should be run on aspirated joint fluid for suspected septic joint
|
cytology w differential, gm stain, culture, PCR, crystal studies if possible
|
|
how is septic arthropathy tx'd
|
if healthy adult -- antistaph pen or 1g ceph x4w. if sexually active young adult, 3g ceph until clinical improve, then switch to gnr coverage cipro x10d. if IC, use broad spec (glycoside/3g ceph) x3-4w
|
|
3 areas of lyme dz in u s
|
NE, north central, west coast
|
|
most common sx of stage 2 lyme
|
flu/mono prodrome,
|
|
dx for lyme dz
|
ELISA then western blot. unless you see erythema migrans in endemic area
|
|
complications of stage 3 lyme
|
arthritis, chronic cns dz, acrodermatitis chronica (red plaques and nodules on extensor leg)
|
|
tx for lyme
|
if stage 1 and localized to skin only, 10d doxy. if spread beyond, 20-30d. can use macrolide and amox.
|
|
tx for rmsf
|
7d doxy, or chloarmphenicol if CNS sx or pregnant
|
|
dx of malaria
|
blood smear w/ giemsa stain
|
|
sx of rabies
|
bite pain -> prodrome -> encephalitis -> hydrophobia -> paralysis
|
|
tx for rabies
|
wound cleaning, capture animal and send brain for analysis or if animal is not suspicious then observe it for 10d, give both ig (in butt and wound) and vaccine (in arm or thigh)
|
|
organs affected in severe leptospirosis
|
renal/liver fail
|
|
what things carry leptospirosis
|
rodents, farm animals
|
|
tx for oral candida
|
clotrimazole troche 5x/d, nystatin swish and swallow
|
|
tx for vaginal candida
|
miconazole/clotrimazole
|
|
what is invasive aspergillosis. who at risk
|
when fungus invade lung vasculature and cause thrombosis. IC
|
|
3 types of aspergillus. dx of aspergillus
|
allergic, aspergilloma, invasive. cxr (pulmonary consoidation), sputum.
|
|
tx of aspergillus
|
if allergic, avoid exposure. if aspergilloma, and if having hemoptysis may need lobectomy. invasive, need amphotericin
|
|
presentation of cryptococcus
|
cns dz, maybe pulmonary
|
|
dx of cryptococcus
|
latex agglutination and india ink on csf
|
|
sx of histo, how u get?
|
flu like sx, erythema nodosum, hsm, bat/bird drop in ohio/mississippi river
|
|
how is crytosporidiosis usually spread
|
feco oral
|
|
what parasite may cause bloody diarrhea, tenesmus, abdominal pain, liver
|
entamoeba
|
|
classic definition of fever of unknown origin
|
fever >101f, >3w, no dx with 1 week of intensive workup
|
|
hyperthermia vs fever
|
hyperthermia is elevation in temp not caused by hypothalamus, usually due to inability to dissipate heat. therefore antipyretics does not work
|
|
when is it important to tx fever
|
temp >105, pregnancy, cardiopulmonary dz
|
|
definition of toxic shock syndrome
|
needs involvement of 3 organ systems
|
|
risk factors for catheter related sepsis
|
emergent placement, femoral line, prolonged indwelling
|
|
do people with catheter sepsis have evidence at site of insertion
|
only 50%
|
|
what is definition of neutropenia
|
anc <1500, with <500 leading to severely high risk of infection
|
|
what to order for neutropenic pt with fever
|
cxr, culture of everything, cbc, cmp
|
|
most common physical sx in ebv
|
lymphadenopathy, esp of tonsillar and post cervical
|
|
whiteheads vs blackheads
|
closed vs open
|
|
mechanism of benzoyl peroxide
|
drys skin (prevents pore clogging), kills bacteria
|
|
mechanism of topical retinoids
|
cause peeling of skin (prevents pore clogging)
|
|
tx for mild to moderate acne vs severe
|
for severe, do systemic ab and if no response do oral retinoids
|
|
difference b/w acne vulgaris and rosacea
|
1. older population (30-50yo) 2. no comedones 3. can cause rhinophyma (thickened greasy nose)
|
|
tx for rocacea
|
1. avoid alcoholic, hot beverages, reduce stress, avoid extreme temp 2. topical metronidazole
|
|
sx of seborrheic dermatotis
|
scaly pathes with erythema in scalp, hairline, skin folds
|
|
tx for seborrheic dermatitis
|
sunlight, dandruff shampoo, topical ketoconazole, cs if severe
|
|
2 types of contact dermatitis, which one more common
|
irritant >> allergic
|
|
pathophys of allergic contact dermatitis
|
hs4 with sensitization having occurred 1-2w before, dermatitis occurs several hours after reexposure
|
|
appearance of contact dermatitis
|
erythema + papules/vesicles that progresses to crusting/thickening/scaling
|
|
tx for pityriasis
|
antihistamine for pruritus, remits on own
|
|
sx of erythema nodosum
|
painful red subcut nodules on tibia (usually)
|
|
causes of erythema multiforme
|
hsv, drugs, idiopathic
|
|
drugs that can cause erythema nodosum
|
sulfa, penicillin, pheny, allopurinol, barb
|
|
4 p's of linchen planus
|
pruritic, polygonal, purple, papules
|
|
age group of pemphigoid
|
elderly
|
|
are warts ever erythematous
|
no
|
|
are warts always hyperkeratotic
|
usually, but flat wart (verrucua plana) isnt
|
|
tx for warts
|
cryotherapy, salicylic acid, 5-fu cream, excision
|
|
how to tx genital warts
|
podophyllin
|
|
3 main organisms causing tinia
|
trichophyton, microsporum, epidermophyton
|
|
type of rxn in scables
|
hs4
|
|
tx for scabies
|
permethrin applied to all areas of body, lindane (if age >2)
|
|
3 p's of bcc
|
pearly, pink (telangiectasia), papule
|
|
what is marjolin's ulcer
|
scc arising from chronic wound
|
|
who is predisposed to melanoma
|
fair complexion esp if easily sunburned, reckles, red hair, or with numermous moles
|
|
what is dysplastic nevus sndrome
|
large nevi with indistinct borders and varied color. if fam hx, then 100% of getting melanoma
|
|
what are spitz nevi
|
well circumscribed raised lesion confused with melanoma... but still excise
|
|
4 most common site of met for melanoma
|
lymph, lung, liver, brain
|
|
most important prognostic factor for melanoma
|
depth of invasion
|
|
4 stages of decubitus ulcers
|
1 = intact skin w/ erythema. 3-4 = full thickness skin loss. 4=extension past subcut tissue
|
|
how to prevent decubitus ulcers
|
turning and repositioning q2h
|
|
pathophys of psoriasis
|
abnormal proliferation of skin cells causing defective keratinization
|
|
what is auspitz sx
|
bleeding when scales of psoriasis removed
|
|
tx for psoriasis
|
cs, calcipotriene (works very well, vit D derivative), tazarotene (vit a derivative)
|
|
what is vitiligo assoc with
|
dm, hypot, pernicious anemia, addisons
|
|
progression of urticaria
|
wheals that disappear within hours and then return in another place
|
|
what is missing in hereditary angioedema
|
c1 esterase inhibitor deficiency
|
|
life threatening consequence of angioedema
|
airway obstruction
|
|
4 most common medicines associated with drug allergy
|
beta lactams, aspirin, nsaid, sulfa
|
|
what timeframe do drug allergies usually appear
|
within 1 mo, but usually more than 1 week
|
|
2 types of skin rxns to insect sting
|
1. nonallergic - localized swelling, erythema, pain that subsides in hours 2. allergic - large area of swelling and erythema that can last for several days and can sometimes have systemic sx
|
|
mcc 2* htn
|
renal artery stenosis
|
|
alcohol and htn
|
>2 drinks a day assoc w htn
|
|
goals for tx of htn (3)
|
1. look for 2* cause 2. assess dmg to target organs 3. assessing cv risk
|
|
htn tx goals for htn
|
130/80
|
|
what lipoprotein is affected in each of the following familial dyslipidemias: 1, 2a, 2b, 3, 4, 5
|
cm, ldl, ldl+vldl, idl, vldl, vldl+cm
|
|
effect of alchol on cholesterol
|
increase tg and hdl
|
|
effects of propranolol on cholesterol
|
increase tg (vldl) and lower hdl
|
|
effects of thiazide on cholsterol
|
increase ldl, tg
|
|
risk of cad vs hdl level
|
every 10 hdl = decrease in cad risk by 50%
|
|
average TC-to-hdl ratio
|
5 = average
|
|
why would you want to check renal function for dyslipidemia
|
nephrotic syndrome
|
|
when to tx hypertg
|
>500
|
|
tx for tension ha
|
stress reduction, nsaids,
|
|
prophylaxis for cluster
|
verapamil
|
|
which foods associated with migraine trigger
|
chocolate, cheese, alcohol, tobacco,
|
|
CI for ergotamines
|
CAD, pregnancy, TIA, PVD, sepsis
|
|
CI for triptans
|
uncontrolled htn, basilar or hemiplegic migraines, use of MAOI or SSRI or Li
|
|
first line prophylaxis for migraine
|
tca, bb
|
|
what is chronic cough
|
>3w
|
|
likelihood of bacterial URI: rhinorrhea, myalgia, HA, sputum
|
rhinorrhea, myalgias, HA are more likely with viral
|
|
likelihood of fever with cold
|
uncommon in adults, commin in children
|
|
tx for cold
|
hydration (inhale steam, drink water) loosens secretions and prevents airway obstruction, cough suppressant, nasal decongestent
|
|
usual causes of acute bacterial sinusitis
|
pneumo, hi, anaerobes
|
|
pain of sinus may mimic
|
dental caries (toothache)
|
|
pain of sinus worsens with
|
percussion, bending head down
|
|
complications of sinusitis
|
orbital cellulitis, osteomyelitis, cavernous sinus thrombosis
|
|
tx for sinusitis
|
acute: nsal irrigation, decongestant, antibiotics, avoid antihistamine
chronic: broad spec penicillinase-resistant ab |
|
why are antihistamines avoided in sinusitis
|
can dry out secretions and worsen congestion
|
|
tx for laryngitis
|
rest voice cuz don't want to form vocal nodules
|
|
what is dyspepsia
|
spectrum of epigastric sx (hearburn, bloating, indigestion)
|
|
when should you perform endoscopy for dyspepsia
|
new onset in >45yo, alarming sx, no resopnse to empiric, recurrence, systemic sx
|
|
conservative measures for dyspepsia
|
avoid alcohol, caffeine, tobacco. rest head of bed, avoid eating before meals. small frequent meals.
|
|
sx of gerd
|
heartburn after meals, exacerbated by lying down
|
|
surveillance for berrett's
|
q3y to look for dysplasia
|
|
bronchospopic finding of recurrnet aspiration
|
lipid laden macrophages
|
|
6 stages of tx for gerd
|
antacid+behavior. h2. ppi. promobility (metaclopramide). combinations. surgery (eg nissen)
|
|
causes of acute diarrhea
|
infection, medications, malabsorption, ischemic bowel, tumor
|
|
causes of chronic diarrhea
|
ibs, ibd, medications, infection, cancer, diverticulitis, malabsorption, postsurgical, endocrine, fecal impaction
|
|
4 main flag symptoms for acute diarrhea
|
1 blood stool 2. systemic sx or fever 3. dehydration 4. NV, pain
|
|
things that can be tested from stool
|
stool wbc, ova¶sides, culture, c diff, giardia
|
|
what drugs may cause constipation
|
anticholinergic, narcotic, CCB!, antacid, laxative
|
|
transmission of shigela
|
feco oral
|
|
tx for salmonella
|
cipro
|
|
tx for shigella
|
bactrim
|
|
tx for c jejuni
|
erythromycin
|
|
tx for chonric constipation
|
find 2* cause, physical activity, high fiber food, fluids
|
|
diarrhea from c perfringes -- main sx
|
crampy abdominal pain within 24 hours of ingestion
|
|
what is tegaserod
|
serotonin agonist for ibs
|
|
mc electrolyte abnormality after severe vomit
|
hypokalemia + metabolic alkalosis
|
|
risk factors for hemorrhoids
|
constipation, preganancy, portal htn, obesity, inactivity
|
|
mc location of lumbar disk herniation
|
l5-s1 or l4-l5
|
|
tx options for vetebral compression fx
|
kyphoplasty
|
|
complications of vertebral osteomyelitis
|
epidural abscess with compromise of blood supply, compression fx
|
|
what is scotty dog sign
|
normal appearance of vertebrae in oblique position. defect in pars interarticularis
|
|
spondylosis vs spondylolysis vs sponddylolisthesis
|
spondylosis = osteoarthritis of vertebrae. spondylolysis = defect in pars interarticularis (oft caused by spondylolisthesis). spondylolisthesis = ant or post slippage of vertebrae.
|
|
what nerve largely responsible for hip flexion
|
l2
|
|
what nerve largeley responslile for knee extension
|
l3
|
|
what nerve largely responsible for ankle dorsiflexion
|
l4/5
|
|
what nerve largely responsible for great toe dorsiflexion
|
l5
|
|
what nerve largely responsible for ankle plantar flexion
|
s1
|
|
aggrevating/alleviating of patellofemoral. tx?
|
climbing/descending stairs. strengthen quads, hamstrings
|
|
when is surgery good for meniscus problem
|
when no arthritic changes associated
|
|
what is osteochondritis dissecans
|
area of necrotic bone + degenerative changes in cartilage
|
|
where is pain in patellar tendinitis
|
anterior knee at inferior pole of patella
|
|
ligaments in medial ankle? lateral ankle
|
deltoid. anterior talofibular (mc injured), calcaneofibular, posterior talofibular
|
|
where is pain in patellar tendinitis
|
anterior knee at inferior pole of patella
|
|
ottowa rules for ankle
|
don't need xr if: pt is able walk steps at injury and at time of injury, no bony tenderness over distal 6 cm of either malleolus
|
|
ligaments in medial ankle? lateral ankle
|
deltoid. anterior talofibular (mc injured), calcaneofibular, posterior talofibular
|
|
where is tenderness with supraspinatus tendonitis
|
subacromial and lateral aspect of shoulder if arm abducted
|
|
ottowa rules for ankle
|
don't need xr if: pt is able walk steps at injury and at time of injury, no bony tenderness over distal 6 cm of either malleolus
|
|
tx for lateral epicondylitis
|
splinting with couterforce
|
|
where is tenderness with supraspinatus tendonitis
|
subacromial and lateral aspect of shoulder if arm abducted
|
|
tx for lateral epicondylitis
|
splinting with couterforce
|
|
which mucle group assoc with lateral vs medial epicondylitis
|
extensor vs flexor
|
|
risk factors for carpal tunnel
|
hypothyroid, dm, repetitive use, pregnancy, trauma/fx wrist
|
|
ddx of hand numbness
|
carpal tunnel, cervical radiculopathy, peripheral neuropathy, median nerve compression
|
|
first line tx for carpal tunnel
|
nsaid + wrist splint
|
|
bouchard vs heberden node
|
bouchard = pip. heberden = dip
|
|
where should cane be held for leg pain
|
opposite hand
|
|
type 1 vs type 2 primary osteoporosis
|
type 1 = postmenopausal, excess loss of trabecular bone, vertebral. type 2 = elderly, equal cortical and trabecular, femoral.
|
|
mechanism of bisphosophnates
|
decrease osteoclastic activity by binding to hydroxyapatite
|
|
PROOF trial
|
calcitonin decreases vertebral fx by 40%, but no effect at hip
|
|
what type of age related macular degen most common? most severe? what does ranibizumab do
|
dry. wet. reduces rate of vision loss due to wet armd
|
|
risk factors for glaucoma
|
age>50, afam, asian/eskimo, famhx, eye trauma, steroids
|
|
physical sx of closed angle glaucoma
|
NV, HA, dilated fixed pupil
|
|
dx of glaucoma
|
tonometry, fundoscopic exam, gonioscopy, visual field testing
|
|
what medicines good for glaucoma
|
bb, alpha agonist, carbonic anhydrase inhibitor, prostaglandin
|
|
risk factors for cataract
|
old age, smoking, steroid, UV, dm, trauma, metabolic dz
|
|
sx of scleritis
|
pain with palpation, deep pain
|
|
classic finding of herpes simplex keratitis
|
dendrite on cornea with fluorescein staining
|
|
sx of anterior uveitis
|
injection around cornea, blurry vision, pain, photophobia, constricted pupil
|
|
mc of bacterial conjunctivitis
|
pneumococcus, then gn
|
|
trachoma vs inclusion conjunctivitis of chlam
|
trachoma can cause blindness, caused by different subtypes
|
|
what is chemosis
|
buildup of fluid under bulbar conjunctiva
|
|
tx for bacterial conjunctivitis
|
broad spec + culture, if hyperacute rmr to think of gonoccocus
|
|
what is def of mild to mod OSA? tx?
|
<20 apnea episodes, tx conservatively w/ weight loss, avoid things that will reduce airway tone eg alcohol, sedatives
|
|
why does systemic htn occur in OSA
|
increase in sympathetic tone
|
|
what is exostoses
|
bony outgrowth of external auditory canal due to repititve exposure to cold water
|
|
how long does perf'd TM take to heal on its own
|
6w
|
|
what is presbycusis
|
degeneration of sensory cells in cochlea in elderly
|
|
decreased perception of sound with response to increasing voluem vs difficulty with high frequency and word deciphering with no response to increasing volume
|
conductive vs sensineural
|
|
what medicines can favor urinary incontinence
|
diuretics, anticholergics/adrenergics cause urinary retention, bb diminish sphincter tone, ccb/narcotics decrease detrusor contraction
|
|
what is reflex incontinence
|
inability to sense need to urinate due to spinal cord injury
|
|
what is normal postvoid residual volume
|
<50ml
|
|
what is chronic fatigue syndrome
|
fatigue >6mo w/o medical/psychiatric d/o
|
|
what tests are available for evaluation of ED
|
lipid panel, testosterone lvl, prolactin lvl, thyroid, vascular testing (u/s, arteriography)
|
|
what vaccine to avoid if egg allergy
|
flu
|
|
how do you assess quality of cxr
|
1. assess penetration (visible intervertebral spaces and outline of vertebrae should be seen through heart) 2. assess inspiratory effort (should see 9 post ribs above diaphragm) 3. assess rotation (sternum should bisect clavicles)
|
|
when you place ET tube, how do you know it's right spot in xr
|
4-6 cm above tracheal carina
|
|
how do you assess central line placement by xr
|
tip should be above RA
|
|
how do you know which ribs are which on pa xr
|
on pa cxr, ant ribs are angle downward
|
|
what type of xr needs to be ordered to evaluate abd perf
|
either upright (free air under diaphragm), or if too sick than lat decubitus
|
|
mobitz 1 vs 2
|
1 -- progressive lengthing until drop. 2 = nonconduction of p waves in some ratio
|
|
what is central line good for
|
placement of catheters into heart, transvenous pacing, emergency dialysis, emergency iv meds or meds that cause problems if given peripherally, high volumes
|
|
3 sites for central line
|
IJ, subclavian, femoral
|
|
what are arterial lines used for
|
bp monitoring, frequent abg
|
|
when doing tube feeding, how often should they be checked? when to hold them?
|
q4h. if residual > 150ml
|
|
how is peg tube inserted
|
1. with endoscope through mouth 2. open abdominal incision
|
|
are cyclines static or cidal? macrolides
|
both static
|
|
what condition may pyrazinamide precip
|
hyperuricemia -> gout
|
|
spectrum of tmp/smx
|
uti, pcp, shigella/salmonella
|
|
4 types of breath sounds
|
1. vesicular (soft and low pitch, in most lung fields, during inspiration and some of expiration) 2. bronchial (loud, high pitch, in central areas, mostly in expiration, suggest consolidation if heard peripherally) 3. bronchovesicular sounds 4. adventitious breath sounds (crackles, wheezes, rhonchi)
|
|
how to grade muscle strength
|
0 = no contraction. 4 = weak against some resistance. 3 = weak against ANY resistance. 2 = weak against gravity. 1 = ANY evidence of contraction
|
|
definition of oliguria
|
<400mL/day, <15mL/hr
|
|
forward vs backward heart failure
|
forward is sx due to not having enough CO (fatigue, lethargy, hypotension), backward failure is sx due to congestion due to inability to pump out
|
|
what drug can be used to lower mortality in chf if cannot use acei/arb
|
hydralzine+nitrate (bidil), bb
|
|
mc aortic stenosis in pts <30 vs >30
|
congenital bicuspid valve vs degenerative calcific stenosis
|
|
valve replacement vs balloon valvuloplasty for as
|
valvuloplasty is only temporary
|
|
causes of AFib
|
I SMART CHAP - inflammatory, surgery, medications, atherosclerosis, rheumatic, thyrotoxis, CHD, HTN, alcohol, pulmonary dz
|
|
causes of AFib
|
I SMART CHAP - inflammatory, surgery, medications, atherosclerosis, rheumatic, thyrotoxis, CHD, HTN, alcohol, pulmonary dz
|
|
4 major goals of AFib
|
stabilization, rate control, rhythm conversion, anticoagulation
|
|
4 major goals of AFib
|
stabilization, rate control, rhythm conversion, anticoagulation
|
|
how to tx hemodynamically unstable AFib
|
DC cardioversion
|
|
how to tx hemodynamically unstable AFib
|
DC cardioversion
|
|
what do you have to check before cardioverting AFib
|
is there a clot in atrium? if less than 48h of AFib, then don't need to worry
|
|
what do you have to check before cardioverting AFib
|
is there a clot in atrium? if less than 48h of AFib, then don't need to worry
|
|
prognostic factors for refractoriness of AFib
|
left atrial dilitation (>4.5cm), duration of AFib
|
|
prognostic factors for refractoriness of AFib
|
left atrial dilitation (>4.5cm), duration of AFib
|
|
risk reduction of stroke with warfarin
|
2/3
|
|
when should an echocardiogram be ordered based on auscultation of a murmur
|
if cardiac sx, if continuous systolic or if > 3/6, or if diastolic
|
|
what are benign murmurs
|
midsystolic <3/6
|
|
what sx are assoc w neurogenic syncope
|
lightheadedness, nausea, diaphoresis, blurred vision
|
|
synonym for neurocardiogenic syncope
|
vasovagal
|
|
what common drug used to tx acs is ci in cocaine induced mi
|
bb
|
|
what is pseudoclaudication
|
spinal stenosis - pain on standing that also occurs with walking, and relieved by sitting
|
|
when to do bariatric surgery
|
>40 bmi, cannot maintain weight loss and have comorbidity
|
|
how to distinguish bw vtach and wpw + af conducting to ventricles
|
wpw+af will have irregular
|
|
why is dig, bb, cardiosuppressive ccb a good tx for wpw
|
trick q! not good. cuz they block av node, which gives more leeway to the accessory node. use procainamde or ibulitide instead
|
|
when do you do endoscopy for new onset dyspepsia
|
>45yo, or if alarm sx, failure to respond to empirics
|
|
2 complications of pud
|
perforation/hemorrhage, gastric outlet obstruction (vomit+weight loss w/o distention)
|
|
why does increased or decreased sodium cause neurologic sx
|
cerebral edema or cerebral shrinkage
|
|
3 categories of hyponatremia
|
hypertonic, normotonic, hypotonic
|
|
how to measure tonicity of blood
|
osmolality is a very good predictor of tonicity
|
|
mechanism of hypertonic hyponatremia
|
some osmotically active agent is added to ECF that draws water out and dilutes sodium.Usually GLUCOSE (1.6 change in sodium for every 100 glucose), or MANNITOL (often seen post-TURP)
|
|
mechanism of hypotonic hyponatremia. how much free water can kidney usually clear per day. therefore what can cause it?
|
ALWAYS occurs when free water is added -- so either impaired free water excretion or free water addition. 18L/day. 1. Primary sodium loss leading to secondary water gain (from ICF) -- sweating, renal losses, GI loss. 2. Primary water gain -- polydipsia, renal insufficiency, adh. 3. Primary sodium gain but with greater water gain (HF, cirrhosis, nephrotic)
|
|
how to workup hypotonic hyponatremia
|
divide by volume status. if hypovolemic, is kidney working correctly (get urine sodium). if hypervolemic, is kidney working correctly, what's the 2* cause (eg chf, etc). if euvolemic, get a urine osmolarity cuz kidneys should be trying to make dilute urine, to correct hyponatremia. if kidneys not making dilute urine, check for hypoT and adrenal insufficiency cuz that can cuase water retention. once these ruled out, suspect siadh
|
|
how fast can u correct chronic hyponatremia
|
0.5-1 mEq/h
|
|
why can hyponatremia occur postop or while in pain
|
SIADH
|
|
definition of hyponatremia
|
<135
|
|
complications of aortic dissection
|
intimal flap that occludes branching vessels, rupture into pericardial sac or pleural space, severe aortic regurg
|
|
mechanism of thrombolytics/anticoagulation in aortic dissection
|
WTF DO NOT DO
|
|
does nitrate relieve pain of aortic dissection
|
no
|
|
where are most aortic dissections located
|
ascending aorta
|
|
next step in mgmt for aortic dissection
|
bb to lower pulse pressure, then imaging to see if it's type a or b. A needs surgery
|
|
when do surgery for aaa
|
>5.5cm or if >.5cm/yr expansion
|
|
if an aids pt has thrush with unknown cd4, what is likely cd4
|
<250
|
|
tx for pcp
|
tmp/smx + steroids when pao2 < 70 or aa gradient > 35
|
|
opportunistic pneumonia with increased ldh is
|
pcp. <220 ldh r/o pcp
|
|
diffuse vs patchy infiltrates in aids
|
diffuse - tb, pcp, histo. patchy - tb, cryptococcus
|
|
when to prophylax pcp? toxo? mac?
|
cd4<200, tmpsmx. <100, tmpsmx. <50 azithromycin
|
|
claudication abi vs critical limb ischemia
|
.4-.9
|
|
what is pentoxifylline
|
increases erythrocyte elasticity, supposedly helps in pad
|
|
what is cilostazol
|
pde inhibitor, vasodilatory and antiplatelet that helps with pad
|
|
6 p's of acute limb arterial occlusion
|
pain, pallor, pulselessness, paresthesias, poikilothermia, paralysis
|
|
5 things that thiazides can increase/decrease
|
hypokalemia, hyponatremia, hyperuricemia, hyperlipidemia, hypercalcemia
|
|
hypertensive emergency vs hypertensive urgency vs crisis
|
emergency has complications, urgency doesn't. both are crises
|
|
bp reduction goal in htn emergency
|
reduce map by 25% or less, or to diastolic of 100-110 over few hrs
|
|
ast:alt in alcohol
|
ast>alt
|
|
what drug can tx chronic hep b
|
lamivudine
|
|
toxic dose of acetaminophen
|
10g
|
|
when should n acetylcysteine be started for how long for tylenol od
|
within 10 hours, continued for 3d
|
|
effect of TRH on prolactin
|
stimulates prolactin
|
|
what is brugada syndrome
|
ion channel dysfunction, common cause of sudden death, ekg changes
|
|
how long does TSH take to respond to thyroid hormoen replacement
|
8w
|
|
tx for hep c
|
alpha interferon and ribavirin
|
|
utility of saag gradient
|
if >1.1, then portal htn. if <1.1, then not.
|
|
dx of spontaneous bacterial peritonitis
|
>250 pmns on paracentesis or if + culture
|
|
what relieves pain of pancreatitis
|
sitting up and bending forward
|
|
tx for pancreatitis
|
npo, narcotics, ivf +/- suction
|
|
what is a phlegmon
|
solid mass of inflamed pancreas with patchy necrosis, complication of pancreatitis
|
|
mcc early death in pancreatitis
|
hypovolemic shock from third spacing
|
|
how to dx choledocholithiasis
|
u/s
|
|
abd pain + abd mass + high amylase in pt w prev pancreatitis
|
pseudocyst
|
|
mechanism of syncope
|
GLOBAL cerebral hypoperfusion
|
|
what types of neurologic dz are most assoc w syncope
|
dysautonomia -- parkinsonism, diabetes
|
|
major risk factors, complication and finding of aortoenteric fistula
|
surgery/gi bleed. hemorrhage, hypotension
|
|
mcc high blood pressure in left arm vs right
|
subclavian atherosclerosis. NOT COARC CUZ THAT WOULD INCREASE R>L
|
|
4 categories of asthma
|
intermittent, persistent: mild, mod, severe
|
|
intermittent vs mild persistent asthma
|
sx or need rescue <2/wk, wake up <2/mo = intermittent. both have normal pfts
|
|
mild vs mod persistent asthma
|
mod: daily sx, weekly wake up. mild has normal pfts.
|
|
risky sex + fever + negative cultures + pustules + tampon usage
|
disseminated gonococcus! NOT TSS CUZ TSS DUN HAVE PUSTULES
|
|
why do you get hypotension with severe acidosis
|
tachycardia can result in inefficient pumping with reduces CO (inefficient because poor response to epi and arrythmias)
|
|
how do you dx cll/sll
|
flow cytometry
|
|
CV, eye, mental, lung, GI findings of opioid intoxication
|
bradycardia+hypotension (due to histamine). mioisis. lethargy. bradypnea. hypoactive BS.
|
|
bradypnea vs hypopnea.
|
brady = slow rate. hypo = low amplitude of breathing, shawllow
|
|
what type of lung cancer is siadh assos cw
|
small cell
|
|
risk factors for hepatic angiosarcoma
|
VAT - vinyl chloride, arsenic, thorotrast
|
|
goals for treating benign intracranial htn
|
1. prevent vision loss 2. reduce pressure 3. symptomatic
|
|
how to tx pseudotumor cerebri
|
acetazolemide, lp if infrequent. surgery is final option.cs if acute loss of vision.
|
|
mechanism of acetazolemide in intracranial htn
|
inhibits carbonic anhydrase which reduces csf production
|
|
would you see pleural plaques in bronchogenic carcinoma
|
yes you could
|
|
ddx for colitis
|
ischemia, infectious (c diff, e coli, sal/shig, campy), radiation, ibd
|
|
age group of ibd
|
young (15-25) nand old (60-70)
|
|
wall involved uc vs crohns
|
mucosa vs transmural
|
|
surgery for crohn vs uc
|
curative for uc, but only symptomatic for crohns
|
|
what is infleximab
|
anti tnf ab
|
|
screning for uc pts
|
annual or q2y colonscopy
|
|
which ibd is associated more with arthritis
|
crohn
|
|
why are gallstones more common in crohns
|
kills the ileum and prevents bile absorption
|
|
how can a hypervolemic pt get prerenal failure
|
third spacing, congestion, etc
|
|
how is postrenal failure usually dx'd
|
hydronephrosis on renal us
|
|
how can fena be obscured in chf pt with prerenal failure
|
diuretic use can increase sodium excretion
|
|
what are the indications for dialysis in akd
|
fluid overload (eg pulmonary edema), metabolic acidosis, hyperkalemia, uremia (pericarditis), severe hyperphosphatemia
|
|
how do you tx severe hyperkalemia
|
give calcium, then give d50 + 10u insulin or beta agonist or bicarb. long term can do furosemide, kayexalate, or dialysis.
|
|
how to distinguish rub of pericarditis from murmur
|
sometimes hard, need ekg
|
|
ekg in pericarditis
|
diffuse st elevation, sinus tachy, pr segment depression
|
|
what are the 11 criteria for SLE
|
IM DAMN SHARP - immunologic, mucositis, discoid, ana, malar rash, neurologic, serositis (incl pericarditis), arthritis, renal, photosensitivity
|
|
what study to do for probable nephritic syndrome as evidenced by h&p, ua
|
urine microscopy for sediment examination
|
|
how can you tell from urine microscopy whether hematuria is glomerular in origin
|
dysmorphic/fragmented rbcs, or rbc casts
|
|
what nephritic dz is low complement
|
SLE, MPGN, poststreptococcal, postinfectious, cryoglobulin
|
|
triad of churg strauss
|
granuloma, asthma, eosinophilia
|
|
which dz have + panca
|
churg strauss, pan
|
|
nephritic dz -- what two categories of dz have immune complex deposition without anti-gbm or anca
|
complement mediated and antibody mediated
|
|
when is topical cs not first line for dermatitis
|
if on face, neck, or intertriginous areas (suscep to cs atrophy)
|
|
acute erythema nodosum + arthritis. what if + fever + hilar LAD
|
acute sarcoid. lofgrens syndrome (variant of sarcoid)
|
|
ddx of thickened and dystrophic nails
|
psoriasis, pad, lichen planus, atopic dermatitis, onychomycosis
|
|
seasonal variation of seborrheic dermatitis
|
improves in summer, worse in winter/fall
|
|
which fungus has spaghetti and meatballs
|
tinea versicolor
|
|
tx options for warts
|
salicylic acid, cryotherapy (care when near sensitive areas incl nail bed). topical imiquimod (not approved), candida ag injection (not approved)
|
|
activities of daily living vs instrumental activities of daily living
|
adl = basic things like toileting, eating, dressing. can't live alone. iadl = shopping, finances, etc. may live alone but need some mgmt
|
|
nsaids and hypertension
|
decrease sodium excretion and contribute to htn
|
|
when is stage 1 htn goals changed
|
dm2, renal failure
|
|
what is scleroderma renal crisis, how to tx
|
sudden increase in renin, tx with short acting acei, like captopril
|
|
what are 2 categories of thrombocytopenia. what is the ddx for both
|
BM vs non-BM. BM will have depression of other cell lines. DDx for non-bm = itp/hit/ttp/hus, sepsis, ***hiv, sle***, dic, hypersplenism
|
|
pentad for ttp
|
fever, thrombocytopenia, hemolytic anemia, neurologic sx, renal sx
|
|
what grade does hsil correspond to. what is mgmt?
|
cin2/3. either 1) pap + endocervical curettage q6mo x3 (all have to be -) 2) pap + hpv testing q6mo x3
|
|
why can't you use ampicillin for cap? cipro?
|
pneomococcus resist + no atypical coverage. no atypical or strep coverage.
|
|
what type of pneumonia clinda good for
|
aspiration
|
|
another name for detrusor instability
|
urge incontinence
|
|
how can pain cause urinary retention
|
in pt with bph, bladder can't generate enough force to pass urine, so need valsalva. if pain with valsalva, then this is impaired
|
|
what is necrolytic migratory syndrome
|
erythematous blisters often on butt that is assoc w glucagonoma
|
|
bronchovascular markings: emphysema vs chronic bronchitis
|
emphysema has decreased marks whereas brochitis has increased markings
|
|
panacinar vs centriacinar emphysema
|
panacinar = antitrypsin. centriacinar = copd
|
|
dlco: emphysema vs chronic bronchitis
|
emphysema is decreased, whereas chronic bronchitis is nl
|
|
how much bronchodilator response needed to dx asthma
|
>12% and >200cc
|
|
dlco in asthma
|
can be nl or increased
|
|
+ HBsAg and + HBV DNA means
|
chronic infection
|
|
how to tx chronic hbv
|
3tc or interferon IF PERSISTENTLY ELEVATED ALT
|
|
proximal muscle weakness + tremor + anxiety + weight loss
|
hyperthyroidism
|
|
how to tx solitary brain met w/ controlled extracranial dz
|
surgical resection followed by whole brain radiation
|
|
how to tx multiple brain met
|
palliative whole brain radiation
|
|
causes of early renal transplant dysfunction
|
ureteral obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, ATN
|
|
when is the odds ratio equal to the risk in a study
|
when the dz is rare and it's a case control study
|
|
best test to dx pancreatic exocrine insufficiency
|
fecal elastase
|
|
what % of ppl presenting w nephrotic syndrome have systemic dz
|
1/3
|
|
how to manage edema of nephrotic syndrome
|
salt restrict + diuretics (oft large doses cuz they are protein bound) + protein restrict (causes greater proteinuria) + acei
|
|
life expectancy for dm + esrd
|
<2y
|
|
albumin/cr ratio
|
>100 = microalbuminuria
|
|
migratory arthralgia + tenosynovitis (usually wrist and hands) + pustular skin lesions that progresses to mono/oligoarthritis
|
gonococcal arthritis
|
|
how to distinguish arthritis from inflammatory conditions near joint
|
painful limitation of motion in all planes during active and passive movement
|
|
wbc count in septic arthritis
|
>100000
|
|
birefringence of gout
|
negative
|
|
why do false negatives occur when trying to dx septic arthritis
|
oft fastidious organisms, so can do blood cultures or skin cultures of lesions.
|
|
what is chondrocalcinosis, what arthritis is it asoc with
|
linear calcium deposits in joint cartilage. pseudogout
|
|
mcc nongonoccocal septic arthritis
|
gp organisms, oft saureus
|
|
tx for acutely swollen and red joint with numerous PMNs and leukocytes + few negatively birefringent crystals
|
abx (still suspicious for infection)
|
|
suspect what if peripheral ischemia after any invasive procedure involving artery? what lab findings
|
cholesterol emboli, urinary eosinophilia
|
|
how to tell between mobitz 2 and 3rd degree av block on ekg
|
mobitz 2 will have a regular interval b/w p wave and qrs, just some will be dropped
|
|
ekg findings of lbbb vs rbbb
|
lbbb=large R in 1,vL,v6
rbbb = small Q, tall R in 1. small R, small S in v6 |
|
abi >1.3 indicates
|
calcification
|
|
ekg change in hypokalemia
|
inverted t, large u wave,
|
|
ekg finding in dig tox
|
atrial tach w variable block
|
|
sx of thoracic duct obstruction
|
lymphedema
|
|
htn and OCP mechanism
|
OCP can cause HTN by increased angiotensinogen or RAAS involvement
|
|
ddx of decreased leukocyte alkaline phosphatase
|
CML, hypophosphatemia, PNH
|
|
what is spikes method for bad news
|
set up, patient's perception, invitation (how much they want to know), give KNOWLEDGE, emotions, summary/strategy
|
|
does sunscreen protect against melanoma
|
no evidence to suggest, but protects against scc
|
|
3 types of parapneumonic effusions, how to dx, how to tx each type
|
uncomplicated, complicated (pus, gpc's, or pleural fluid pH <7), empyema. abx, abx + tube, abx+complete drainage+reexpansion
|
|
mechanisms of metoclopramide
|
d2 antagonist, muscarinic agonist
|
|
indications for tube thoracostomy for parapneumonic effusion
|
<7.0 ph, gluc < 60, ldh >1000.... correlate highly with either complicated or empyema. also tx if loculations or empyema seen
|
|
what to give babies born to mothers with active hbv
|
hbig and vaccine
|
|
how to differentiate overflow incontence vs urge incontinence via labs
|
overflow will have high postresiduals
|
|
ekg changes in PE
|
classically s1q3t3, which indicates acute cor pulmonale with RAD
|
|
mnemonic to remember lbbb vs rbbb
|
WiLLiaM MaRRoW
LBBB - W in V1, M in V6 RBBB - M in V1, W in V1 |
|
active vs passive mvmt and arthritis
|
will have pain with both in arthritis, only active pain with parajoint things
|
|
mcc viral arthritis
|
hbv**, hcv, rubella, parvovirus
|
|
arthritis + sausage digits
|
psoriatic arthritis or reactive arthritis
|
|
how many joints have to be affected in RA
|
at least 3
|
|
bannworth syndrome
|
lyme dz with radicular pain, csf pleocytosis
|
|
how do you tx 2* or 3* lyme dz
|
iv abx like ceftriaxone
|
|
when does bell's palsy occur in lyme dz
|
2* dz
|
|
how to see posterior wall infarct on ekg
|
v1-v2 st depression
|
|
for a stemi, fibrinolytics vs pct
|
prefer pct. do either if <12h. but goal is <90min. if don't have facility to do pct, and can't transfer w/in 2 h, do fibrinolytics unless CI, >12h with residual st elevation or complication, s/p CABG, cardiogenic shock (sbp <100 + pulmonary edema)
|
|
can you use fibrinolytics in nstemi
|
no
|
|
name a type of AV reentrant tachycardia
|
wpw
|
|
how to distinguish AVNRT and AVRT on ekg
|
AVRT has a short RP segment cuz the retrograde pathway is fast, and you see atrial activity in ST segment. AVNRT either has no p waves, or small deflection. BOTH ARE REGULAR UNLIKE AFIB
|
|
mcc multifocal atrial tachycardia
|
illness
|
|
what dose of bb to use in heart failure
|
raise dose until bp "appropriately low"
|
|
can you have as and physiologically split s2
|
unlikely cuz as aortic valve stiffens you get loss of aortic component of s2
|
|
significance of ejection click and as
|
stenosis is at valvular level and there is mobility to valve
|
|
thyroid hormone requirements during pregnancy
|
goes up by 30%
|
|
iodine uptake in thyroiditis
|
decreased
|
|
lab abnormal in paget dz
|
alp
|
|
cutoff for osteoporosis
|
2.5
|
|
when do you start bisphosphonate for chronic cs therapy
|
if prednisone >5 qd or equivalent used >3 mo or if t score < -1
|
|
when to do dexa, 5 major risk factors for osteoporosis (that u use)
|
65 or <55 if 1+ risk fx. fx as adult, fragility fx in 1st deg relative, smoking, low body weight, cs > 3mo
|
|
name some associations (dz) with chronic hcv
|
cryoglobulinemia (that can lead to glomerulonephritis), PCT, ITP, autoimmune dz, lichen planus
|
|
trigeminal neuralgia is assoc w what dz
|
ms
|
|
tx for febrile neutropenia
|
admit, cultures, BS abx
|
|
tx for hairy cell
|
purine analogs (cladribine, pentostatin)
|
|
sudden loss of vision + hard to visualize fundus using ophthalmoscope + floating debris
|
vitreous hemorrhage
|
|
sudden painless loss of vision + htn + disk swelling + venous dilation
|
central retinal vein occlusion
|
|
by when should common lower back pain resolve
|
4-6w
|
|
normal daily intake of iron, how much absorbed
|
15, 1mg
|
|
iron studies in sideroblastic anemia
|
increased iron and ferritin and percent sat
|
|
how to tx ida, how long to take. adverse effect of iv form
|
po iron 325mg bid, 6 weeks. anaphylaxis risk w iv
|
|
what are diverticula histologically
|
pseudodiverticula through weakness in muscle lining
|
|
llq pain + peritoneal sx + abd pain
|
acute diverticulitis
|
|
how to xr help in pt with diverticulitis
|
help to identify pts with pneumoperitoneum
|
|
how to dx diverticulitis, what are findings
|
ct. pericolic fat stranding, bowel wall thickening, peridiverticular abscess
|
|
what type of abx coverage needed for diverticulosis
|
abdominal gnrs + anaerobes (tmpsmx or cipro+metro or clinda+gent)
|
|
when should pt be considered for elective surgery to prevent complications of diverticulitis
|
2+ episodes of diverticulitis
|
|
do you need to have fever in neutropenic pt to suspect sepsis
|
ANY CLINICAL DETERORIATION
|
|
what to cover for neutropenic fever
|
gnr incl pseudomonas, gp (esp if catheter)
|
|
when can you leave a line in during suspected sepsis
|
alwyas remove if nontunneled or implanted. if permanent, then what is condition of pt? if erythema on subcut,then remove. if not, then put abx into catheter.
|
|
what to suspect when >7d of fever despite bs abx in neutropenic fever
|
fungus
|
|
what is acute chest dyndrome
|
vasoocclusive crisis in lungs usually caused by infection
|
|
tx for vasoocclusive crisis in sickle cell
|
hydration, o2, pain control. if chest syndrome, then use empiric abx as well. transfusion can be used.
|
|
what agents can increase hemoglobin f
|
hydroxyurea, decitabine
|
|
brudzinski vs kernig
|
leg flexion on passive neck flexion vs pain on passive knee flexion
|
|
when can you do lp w/o ct beforehand
|
if no papilledema, focal neurologic sx, ams
|
|
general empiric therapy of meningitis
|
3g ceph + vanc
|
|
is any prophylaxis needed for neisseria meningitis in regular person
|
if they have it then give rifampin bid x2d for close contacts
|
|
hallmark csf finding in tb meningitis
|
fall of csf glucose at 48h
|
|
osler nodes vs janeway lesions vs roth spots, what are the seen in
|
ie. tender nodules on fingers or toes. painless macules on palms and soles. hemorrhagic retinal lesions with WHITE CENTERS
|
|
what to do for suspected endocarditis
|
serial blood cx (3x over 2-3h acutely, 3x over 24h if subacute)
|
|
how long to tx endocarditis
|
4-6w
|
|
how to tx hacek endocarditis
|
ceftriaxone
|
|
when should you do surgery for endocarditis
|
intractable chf, embolic episode, or >10mm vegetation indicating high risk of embolism, uncontrolled infection, no effective antimicrobial tx (fungal), prosthetic endocarditis
|
|
how, when? to prophylax endocarditis
|
amox. prosthetic valve, previous ie, chd, cardiac transplant w/ valve regurg
|
|
what area of lung does primary tb affect? reactivation?
|
middle & lower. upper.
|
|
what is a rasmussen aneurysm
|
rupture of dilated vessel in tb
|
|
mc sites of extrapulmonary tb
|
lymph > pleura > GU > bone/joints > meninges > peritoneum
|
|
cutoff's for ppd test
|
5 mm if HIV, close contact of TB, cxr findings of TB. 10 if IC or other risk factors. 15 otherwise
|
|
tx for active TB
|
2 month INH + rifampin + pyrazinamide
|
|
how much fluid in pericardium does it take to produce tamponade
|
if acute, then 200ml. if chronic then 2000ml
|
|
ekg finding of cardiac tamponade
|
low voltage, electrical alternans
|
|
do you see pulsus paradoxicus in constrictive pericarditis
|
no
|
|
how do you distinguish bw restrictive cardiomyopathy and constrictive pericarditis
|
mri, endomyocardial biopsy
|
|
what is kussmaul sx? what is it seen in
|
fail to DECREASE JVD on inspiration. constrictive pericarditis
|
|
what imemdiate supportive care is available for tamponade right before pericardiocentesis
|
fluids
|
|
neurological findings of neurosyphilis
|
tabes dorsalis, argyll robertson or other crania nerve, vasculitis leading to ischemia, dementia
|
|
tx for syphilis
|
if 1* or 2*, then single dose of IM penicillin. if latent, then 3x IM penicillin qweek. if 3*, IV penicillin for 10-14d
|
|
how to monitor response to tx for syphilis
|
4-fold drop in titers within 3 mo, and negative titer after 1 yr
|
|
indications for lp to r/o neurosyphilis
|
if symptomatic, or if hiv+ and cd4 <350 or rpr > 1:32
|
|
when to start o2 in copd
|
pao2<55
|
|
expiratory vs inspiratory wheezing
|
inspiratory wheezes usually associated with upper airway (negative airway compression occurs during inspiration). expiratory wheezes usually associated with lower airways (negative airway compression occurs during expiration)
|
|
is barium study diagnostic for achalasia
|
pseudoachalasia can occur with malignancy
|
|
best dx test for ibd
|
colonoscopy/endoscopy
|
|
how to tx acute diverticulitis
|
empiric abx that covers anaerobes
|
|
what drug is useful for diarrhea predominant ibs
|
loperamide
|
|
no gb wall thicken + no pericholecystic fluid + dilated bile duct... is this cholangitis or cholecystitis
|
cholangitis
|
|
what supportive measure is critical for acute pancratitis
|
fluids
|
|
how to tx gallstone pancreatitis
|
urgent ercp
|
|
most common reason for decreasing h&h in stable pt after ugib
|
redistribution of fluid into vascular space
|
|
what do you suspect when decompensation in context of cirrhosis
|
sbp
|
|
how to prophylax bleeding from esophageal varices if cirrhosis
|
bb
|
|
how to distinguish appropriate vs inappropriate erythrocytosis
|
look at o2 sat
|
|
what is seen on blood smear of autoimmune hemolytic anemia
|
microspherocytes
|
|
how to tx autoimmune hemolytic anemia
|
cs
|
|
what is mgus
|
ig spike w/o mm sx, <10% plasma cells in bm
|
|
mgmt for drug fever
|
if on tail end of drug, stop it, should go away by 3d. if not, then sub with another drug class
|
|
hwo is septic shock diff fromsevere sepsis
|
refractory to fluids
|
|
how to prophylax flu in IC
|
deactivated viral vaccine + ostelvamir
|
|
what drugs fight both flu a & b? which one ci in asthma
|
ostelmivir and zanamivir. zanamivir is ci
|
|
effect of pt positioning and ventilator assoc pna
|
45 degreee angle is best
|
|
which organisms need special coverage in hospital assoc pneumonia
|
mrsa, x2 coverage of pseudomanos
|
|
does bcg vaccine change interpretation of ppd
|
no
|
|
empiric tx for hospitalized cap pt on general floor
|
iv quinolone or iv blactam+po macrolide/doxy
|
|
empiric tx for hospitalized cap pt on icu
|
iv blactam + iv macro/quinolone
|
|
sx of legionellosis, how to tx
|
pneumonia, hyponatremia, azotemia, elevated lfts/ck. macro + bb if high risk
|
|
do you need predental abx prophylaxis if have mild regurg
|
no
|
|
red flags for HA
|
rapidly increasing freq, dizziness or incoordination, focal neurologic sx, wake from sleep
|
|
sx of west nile
|
like polio-- muscle weakness and flaccid paralysis
|
|
empiric meningitis tx
|
vanc, amp, ceftriaxone
|
|
eye findings of locked in syndrome
|
vertical movement or blinking are only possible things
|
|
hallmark of ruptured av malformation in brain
|
intracranial hemorrhage + sah
|
|
how to r/o sah
|
lp for xanthochromic bloo
|
|
what areas affected by lynch syndrome
|
colon, endometrium, ovary, stomach, small intestine, hepatobiliary
|
|
what is isolated systolic htn, pathophys
|
sbp>140, dbp<90 usually in elderly. calcified vessels.
|
|
is alcohol a risk factor for htn
|
yes
|
|
best tx for frostbit
|
rapid rewarming with warm water. do not debride right away
|
|
how to work up conjugated bilirubinemia
|
is it intra or extra hepatic? (look at liver enzymes -- if aminotransferase elevation then hepatocellular. if alp, then is it intrahepatic obstruction or extrahepatic (do u/s or ct)
|
|
2 types of metabolic alkalosis
|
saline responsive (urine cl < 20) and saline resistent. saline responsive is due to gi loss, vomiting, or diuretics. can tx by giving ns fluids
|
|
does acute intermittent porphoria have photo
|
no
|
|
traid of niacin deficiency
|
dermatitis, dementia, diarrhea
|
|
dx of gc vs chlam urethritis
|
gc is usually on gram stain and is PURULENT. chlam is not on gram stain (cytoplasmic inclusion), has MUCOPURULENT
|
|
first line for cocaine mi
|
benzo, aspirin, nitrate
|
|
skin lesions with blasto
|
either ulcerations or verracuous (warty, violaceous, or papulopustular)
|
|
which systemic fungi can have skin findings
|
blasto, coccidiodes, aspergillosis
|
|
skin lesion of coccidioides
|
erythema multiforme/nodosum
|
|
how to tx acute hypercalcemia
|
hydration + loops
|
|
virchow's triad
|
endothelial injury, hypercoagulability, stasis
|
|
cause of death in PE
|
progressive RHF
|
|
heart sounds in PE
|
loud s2
|
|
westermark sign
|
congested central pulmonary artery with decreased pulmonary vascularity seen in cxr of pe
|
|
what is aggressive tx for pe? who gets it?
|
thromboylysis/surgerical embolectomy if RHF or hypotension. otherwise anticoagulation -- goal is to prevent thrombus extension or recurrence
|
|
how long to anticoagulate pe
|
depends on risk of recurrence. if provoked (i.e. trauma/surgery) of calf/UE, then 3 mo. if provoked LE , 6 mo. if unprovoked, then controversial
|
|
mc hereditary thrombophilia
|
factor v leidin
|
|
how to tx dvt if anticoagulation is ci
|
ivc filter
|
|
blood streaked purulent sputum vs chronic copious sputum vs hemoptysis + acute pleuritic chest paina nd dyspnea
|
bronchitis, bronchiectasis, pe
|
|
what is massive hemoptysis? tx>
|
>100mL. need to maintain airway, keep affected side in dependent position, suppress cough
|
|
which lung cancers are central? peripheral?
|
small cell, scc. adeno, large cell.
|
|
which lung cancer most likely to cavitate
|
scc
|
|
which lung cancer mets early
|
adenocarcinoma
|
|
which lung cancer mets to cns/bones/adrenal? cns/mediastinum?
|
adenocarcinoma. large cell (look for svc syndrome/hoarseness)
|
|
limited stage vs extensive stage lung cancer
|
ways to describe sclc. if one hemithorax vs distant met/contra lung.
|
|
tx modalities for lung cancer
|
sclc is usually radio/chemo. nsclc is usually resection/radio
|
|
workup for solitary pulmonary nodule
|
"popcorn"/"bullseye" = benign. if young age and nonsmoker, do serial chest ct, is benign if no growth after 2y (risk of malig <2%). lesions > 2.5 cm are risky
|
|
how you know when sputum is good quality
|
>25 pmns, <10 epithelial cells
|
|
aspiration pneumonitis vs aspiration pneumonia
|
pneumonitis also produces infiltrate, but resolves within 2d.
|
|
how to tell b/w adrenal crisis vs septic shock
|
hypoglycemia in adrenal crisis, hypotension refractory to pressors
|
|
definition of adrenal insufficiency in acutely ill pt
|
AM cortisol <5
|
|
in chronic steroid use, how to prophylax adrenal crisis before surgery
|
stress dose before surgery
|
|
location of dz: primary sclerosing cholangitis vs primary biliary cirrhosis
|
larger intra/extrahepatic ducts vs smaller intrahepatic bile ducts
|
|
work if abd u/s shows extrahepatic bile duct dilation w/o stones
|
do ct/ercp to detect occult stones/strictrictures & exclude malignancy
|
|
first step in evaluation of microscopic hematuria
|
is it glomerular or nonglomerular (glomerular = dysmorphic erythrocytes)
|
|
what is max tolerable increase in cr afte radding acei
|
30%
|
|
hallmark sign of atheroembolic acute renal failure
|
reticular rash
|
|
how to differentiate causes of renal failure in cirrhotic
|
give them volume to exlude prerenal. then what's left is hepatorenal, ischemic tubular injury, sepsis-induced AKD
|
|
name some sx of tumor lysis syndrome
|
cell breakdown -> hyperkalemia, hyperphosphatemia, hyperuricemia leading to akd
|
|
which fungi cause lung dz
|
PNA: histo, blasto, coccidio
cavity: aspergillus |
|
progression of iron tox
|
gi sx within 30min-6h, then hepatotox
|
|
how does amyloid affect: kidney, GI tract, heart, msk, nervous sx
|
nephrotic syndrome, hepatomeglay, cardiomyopathy, pseudohypertrophy, peripheral neuropathy
|
|
htn in child + bruit at cva + string of beads angiogram
|
fibromuscular dysplasia
|
|
how to give tetanus shot as adult
|
Td q10 y. TdaP once under age 65 as booster.
|
|
tx for 2* spontaneous ptx
|
immediate thoracostomy cuz 2* dz is more serious cuz of underlying lung compromise
|
|
how does crest syndrome affect lungs
|
pulm htn
|
|
how do you know when pleural fluid is malignant
|
hx, rbc >100k, no trauma or infarction, lymphocytic exudate
|
|
lights criteria
|
effusion = exudative. plerual protein:serum >.5|ldh ratio >.6|LDH > 2/3 serum
|
|
what is poor prognosis for malignant pleural fluid
|
ph < 7.3|glucose<60 means <6mo survival
|
|
when do you tx acute bronchitis with abx
|
copd
|
|
ci for lung volume reduction
|
fev pred <20, homogenous emphysema, dlco <20, non upper lobe emphysema or high exercise capacity
|
|
bibasilar end inspiratory dry crackles like velcro + clubbing
|
idiopathic pulmonary fibrosis
|
|
how to prophylax dvt in cancer pt
|
use lmwh rather than warfarin
|
|
mc cancer after tx'ing hodgkins w radiatio
|
breast
|
|
management of supraclavicular lad
|
if <2cm, monitor 3mo. if >2cm, excision (rather than needle biopsy cuz will get preserved architecture)
|
|
do ppl with cholangiocarcinoma have dilation of cbd?
|
no intrahepatic ducts only
|
|
masectomy vs breast conserving surgery with radiation and lumpectomy in early stage breast cancer
|
equal outcome
|
|
sclc: rad vs chemo vs surg
|
surg is best, but only for stage 1 local. rad is also very local and offers limited benefit.
|
|
xr appearance of malig solitary pulm nodules
|
spiculated margins, >2.5, little-no calcification
|
|
dysplasia seen on colonoscopy in uc
|
do colectomy cuz 25% risk of progression
|
|
tx widespread sclc vs squamous nsclc
|
chemo+brain radiation vs hospice
|
|
4 mc locations pseudogout
|
knee meniscus, symphisis pubis, glenoid/acetabulum, triangular cartilage of wrist
|
|
impotence + fatigue + abnormal lfts + arthropathy, what test to order
|
iron studies
|
|
cpk: polymyositis vs pmr
|
elevated in polymyositis
|
|
sulfonylurea and renal function
|
can accumulate in renal insuffiency
|
|
quartad of thyroid storm
|
tachycardia, fever, agitation/delirium/psychosis, vomiting/diarrhea
|
|
indications for subtotal thyroidectomy
|
large goiters with obstructive symptoms
|
|
what to suspect if not recovering after pneumonia
|
parapneumonic effusion
|
|
what type of pleural effusion does tb cause
|
exudative
|
|
what type of pleural effusion does connective tissue dz occur
|
exudative
|
|
what type of pleural effusion does pancreatitis cause
|
exudative
|
|
mc hemorrhagic pleural effusion
|
malginancy, pe, tb
|
|
3 mcc tia/stroke. what things are life threatening and need to be checked for
|
carotid atherosclerosis, cardioemboism, lipohyalonisis. hemorrhage
|
|
rickets w normal serum calcium, normal serum alp, normal vit D
|
hypophosphatemic rickets
|
|
how is erysipelas diff from ordinary cellulitis
|
erysipelas caused by gas. erysipelas has sharp borders (cellulitis is poorly defined), and is on face or legs
|
|
what is bullous myringitis
|
blistering of TM due to otitis media
|
|
when are diuretics necessary to tx MI
|
flash pulmonary edema caused by MI
|
|
which nephrotic syndrome is assoc with hodgkins
|
minimal change
|
|
skin findings: tss vs meningococcemia vs scarlet fever
|
diffuse confluent erythematous vs stellate purpura w central gray vs rough sandpaper
|
|
what do you do for stable pt recovering from pancreatitis
|
cholecystectomy
|
|
how to tx long qt syndrome
|
bb
|
|
how to tx long qt syndrome
|
bb
|
|
mtx effect on heme
|
macrocytic anemia
|
|
how to tell b/w hemorrhagic shock and neurogenic shock
|
neurogenic has high vagal tone so bradycardia
|
|
if central skeleton is affected by RA, which area would be most likely to be affected
|
cervical spine, esp c1-2
|
|
bacterial vs viral gastroenteritis: vomiting
|
vomiting usually more assoc with viral ge
|
|
4 types of shock, how to differentiate
|
1. septic 2. neurogenic 3. hypovolemic 4. cardiogenic.
cardiogenic and hypovolemic will have low co (cold & clammy), but cardiogenic will have high pwcp and hypovolemic oft has low pwcp. septic will have have high co (hot), oft low pcwp due to low preload from dilation and normal-high mvo2. |
|
esr in polycythemia vera
|
decreased
|
|
what is primidone used to tx? what can it precipitate?
|
essential tremor. aip
|
|
do cat bites need to be ppx'd?
|
x5d of augmentin to cover pasturella
|
|
when do the following post-mi complications occur: free wall rupture, papillary mm rupture, septal rupture, ventricular aneurysm
|
5-10d, 5-10d, 5-10d, 7weeks
|
|
what type of fungal infection assoc w palatal ulcers? mucosal ulcers?
|
histo. blasto
|
|
what type of lung findings in histo
|
hilar lad +/- pneumonitis
|
|
fungal infection -- palatal ulcers, hsm, pancytopenai
|
histo
|
|
hemodynamics in HIT
|
thrombocytopenia but also platelet activation (PF4) that causes hypercoagulability
|
|
mc site of compression for ulnar nerve
|
cubital tunnel at elbow
|
|
aspirin vs heparin for ami
|
aspirin actually decreases mortality. but use both
|
|
causes of 2* livedo reticularis
|
vasculitis, pancreatitis, tb, lymphoma, capillary obstruction
|
|
what chemical is notorius for causing pancytopenia
|
benzene
|
|
what to suspect in someone with chronic inflammatory dz + hip pain
|
consider avascular necrosis 2/2 cs
|
|
skin findings in fanconi
|
vitiligo, cafe au lait, freckles
|
|
how to distinguish bacterial atypical pneumonia vs influenza pneumonia
|
both can have leukopenia, bilateral infiltrates. influenza is 1. sudden 2. often in winter 3. fever is more common
|
|
kaposi vs ba based on hx
|
ba is more likely to have 1. exposure to some animal (cats, lice) 2. systemic effects esp liver issues
|
|
how to distinguish lmwh vs hep usage on labs
|
hep will elevate ptt
|
|
associations with pseudogout
|
hyperpth, hypoT, hemochromatosis,
|
|
herxheimer rxn
|
after using abx, develop sepsis like rxn incl fever and hypotension, due to widespread release of toxin from bacteria
|
|
stool osmotic gap is used to...
|
low = secretory diarrhea, high = osmotic diarrhea
|
|
how to dx lactose intolerance
|
hydrogen breath test in adults , stool ph in infants (bacteria make acid)
|
|
tx for cholesteatoma
|
surgery
|
|
sx of cholestatoma
|
painless otorrhea + hearing loss
|
|
why might you have decreased brath sounds in pe
|
pulmonary edema
|
|
what type of bias does loss to follow up cause
|
selection bias
|
|
mechanism of postictal metabolic acidosis
|
increased lactic acid from muscle activity during seizure
|
|
mobile cavitary mass in lung + intermittent hemoptysis
|
aspergilloma
|
|
choleastoma vs malignant otitis externa
|
choleasteoma = painless otorrhea + hearing loss + granulation tissue in middle ear
moe = painful ear canal esp on movement of ear + dc |
|
what is trihexyphenidyl, what is it used for
|
m1 antagonist used for symptomatic tx in parkinson
|
|
vitamin a effect on brain
|
pseudotumor cerebri
|
|
cardiac manifestation of hemochromatosis
|
dilated cardiomyopathy, conduction problems, chf
|
|
central retinal vein occlusion vs central retinal a occlusion
|
both are permanent. artery is more acute, and see pallor and cherry red fovea in funduscopic. crvo is more subacute and optic disk swelling, retinal hemorrhage, vein dilation
|
|
appearance of porcelain gallbladder on ct
|
calcified rim with dark bile in center.
|
|
what is aspirin sensitivity syndrome
|
shutdown of cycloxygenase pathyway shunts to lipooxygenase and causes bronchoconstriction, polyp formation
|
|
vestibular neuritis vs labyrinthitis
|
labyrinthitis usually has hearing loss, vn doesn't
|
|
muscle strength in polymyalgia rheumatica? polymyositis?
|
normal, decreased
|
|
lifestyle tx for menieres
|
salt restricted diet
|
|
which nephritic syndrome needs emergent plasmaphoresis
|
goodpasture
|
|
what arv can cause crystal nephropathy
|
pi (indinivir)
|
|
which arv most likely to cause pancreatitis
|
didanosine
|
|
which arv most likely to cause hypersensitivity
|
abacavir
|
|
which arv most likely to cause sjs
|
nnrti
|
|
which arv most likely to cuase lactic acidosis
|
nrti
|
|
which arv most likely to cause liver failure
|
nevirapine
|
|
why do you get hypocalcemia in tumor lysis syndrome
|
released phosphate binds up the calcium
|
|
tx for mild acne
|
topical retinoids, benzoyl peroxide, azeleic acid
|
|
sspe vs pml
|
pml: more assoc with IC, jc, like ms except quick progression, dx by dna or by mri w multifocal non enhancing w/o mass effect
sspe: personality changes first, white matter affected |
|
most serious complications of tx w hydroxychloroquine
|
macular toxicity (do eye exams)
|
|
expectoration: chronic bronchitis vs bronchiectasis
|
bronchietctasis is purulent, chronic bronchitis is not.
|
|
mc isolated & asymptomatic elevated alp in elderly
|
paget's dz
|
|
what types of seizure most likely to have aura
|
partial seizures
|
|
complex partial seizure vs partial seizure with secondary generalization
|
complex partial usually have automatiusms during loc, but partial seizure with generalization tends to have tonic clonic movements
|
|
tx for sickle cell stroke
|
exchange transfusion
|
|
pruritic eruption that occurs in person in contact with a bunch of stuff and grows coag neg staph
|
contact dermatitis (the s epidermis is just contaminant)
|
|
how to tx siadh
|
jif symptomatic (lethargy, coma etc) do hypertonic saline. fluid restriction, demeclocycline (can cause nephrotox, nephrogenic DI), vaptans, urea
|
|
physiologic acid base in pregnancy
|
respiratory alkalosis
|
|
mechanism of spironolactone in cirrhosis
|
fights 2* aldosteronism
|
|
memory impairment + personality changes + visuospatial intact
|
frontotemporal
|
|
disadvantage of tx'ing heat stroke with immersion in cold water
|
causes immediate vasoconstriction which limits heat dispersion
|
|
what causes zenker's
|
motor dysfunction and incoordination causing herniation b/w UES and cricopharyngeal mm
|
|
nasal obstruction + epistaxis + visible nasal mass in adolescent
|
angiofibroma
|
|
mechanism of analgesic nephropathy
|
papillary necrosis and chronic tubulointerstitial nephritis
|
|
4 criteria of brain death
|
1. absent CN reflexes 2. fixed & dilated pupils 3. no spontaneous breaths 4. agreement of 2 physicians
|
|
why would lying on your affected side in a PNA cause decreased o2 sat
|
v/q mismatch (bad lung will get dependent increase in ventilation and perfusion)
|
|
5 dietary recommendations for nephrolithiasis
|
1. decrease protein 2. decrease oxalate 3. decrease sodium 4. increase calcium 5. increase fluids
|
|
can NASH have macrovesicular steatosis, PMNs, and necrosis
|
yes
|
|
most common complication of pud
|
hemorhage
|
|
pickwickian and abg
|
increased pco2
|
|
why doesn't lp in bih cause herniation
|
pressure is evenly distributed in bih. not so with mass lesion
|
|
IM injection to which mm group has highest bioavailability
|
anterolateral thigh
|
|
sjs vs ten
|
>30% = ten
|
|
what pharmacologic tx other than epi can you use for anaphylaxis
|
diphenhydramine, ranitidine, albuterol, glucagon (if pt on bb), steroids (to prevent delayed rxns)
|
|
mechanism of radiocontrast "allergy", how to prevent
|
hyperosmolar dye causing degranulation of mast/basophil. pre-tx w diphenhydramine, h2 block, cs
|
|
fever, lad, maculopapular rash, arthralgia in response to drug
|
dilantin
|
|
what are reversible causes of dementia?
|
thyroid, syphilis, hiv, b12/folate, depression, CNS diseases (incl nph, use MRI),
|
|
what part of prostate does bph affect? cancer?
|
center? peripheral
|
|
tx for gastric outlet syndrome
|
vomiting -> hypokalemic hypochloremic metabolic alkalosis. :. NG, IVF, potassium
|
|
mc brain abscess
|
strep (anaerobic and aerobic) + anaerobes
|
|
what to suspect in young pt w htn, muscle weakness, numbness
|
1* aldosteronism
|
|
orbital cellulitis vs preseptal cellulitis
|
orbial involves fat and mm within orbit. preseptal = superficial only. orbital cellulitis has pain w eye mvmt, proptosis, and decresaed vision
|
|
mc mets to brain. what if hemorrhage? what if single vs multiple?
|
lots of bad stuff kills glia: lung, breast, skin, kidney, GU/GI. hemorrhage = melanoma. multiple = melanoma & lung, single = breast, colon, renal
|
|
what nerves does cauda equina contain
|
starts l1.
|
|
damage to what nerve in cauda equina syndrome causes urinary sx? what is the urinary sx?
|
urinary retention due to loss of pelvic nerve
|
|
definition of microscopic hematuria
|
>2 rbc/hpf
|
|
what is bartter's syndrome
|
defect in TAL. behaves exactly like thiazide diuretics
|
|
how is saline sensitive metabolic alkalosis diff from saline resistant. how to tx?
|
saline-sensitive involves volume contraction, saline-resistant involves expansion. tx: fix underlying cause (esp for saline resistant). if volume depleted, then give normal saline + potassium. if volume expanded, then just give potassium cl. if you need diuresis, use acetazolemide
|
|
what type of study seeks to measure odds ratio? how about relative risk?
|
case control. cohort
|
|
10 causes of pulseless arrest
|
H: hypovolemia, hypothermia, hypo/hyperkalemia, hypothermia, hydrogen
T: toxin, tamponade, tension ptx, thrombosis, trauma |
|
does scc skin met to brain? how about esophageal carcinoma? oropharyngeal? prostate?
|
none of these do
|
|
tx for recurrent chalazion
|
biopsy to r/o carcinoma
|
|
how to workup syncope
|
if h&p (incl carotid sinus pressure to r/o sinus hypersensitivity), routine labs, and ekg reveal cause, then good. if unexplained, then if cardiac etiology then do cardio workup, if not then do tilt table & psych.
|
|
blood tests in cholesterol embolization
|
low c3, high eosinophils
|
|
what do you get echinococcus from? what imaging finding
|
close contacts w dogs, eggshell calcifications on ct
|
|
how does theophylline cause toxicity
|
phosphodiesterase inhibition, adenosine antagonism, stimulation of epinephrine release
|
|
what is susceptibility bias
|
a tx regimen is selected based on the severity of their condition
|
|
ekg finding with hypercalcemia
|
shortened qt
|
|
how do you get attributable risk %
|
(rr-1)/rr
|
|
how to culture for suspected acute prostatits
|
cx urine, DO NOT DO PROSTATE MASSAGE CUZ YOU WILL SEPSIS
|
|
histopathology of reye's
|
fatty vacuolization of hepatic cells (remember that salicylates are a mitochondrial poison and fats need energy to be broken down)
|
|
top causes of bacterial sinusitis
|
pneumo > hi > moraxella
|
|
liver histopathology: rotor vs dubin johnson
|
rotor doesn't have black pigment
|
|
csf WBC and RBC in g-b
|
normal
|
|
best tx for cancer-related cachexia
|
progestin
|
|
prognosis in cll: splenomeglay, anemia, tcp
|
spleen better than anemia better than tcp (worst)
|
|
mc organism septic joint in artificial joint
|
saureus
|
|
what's hepatolenticular degeneration
|
wilson's dz
|
|
infection of what spaces can lead to infection of: mediastinum, ludwig's angina, carotid sheath
|
retropharyngeal, submandibular, parapharyngeal
|
|
mcc spinal stenosis
|
osteoarthritis
|
|
herniated disk vs spinal stenosis
|
spinal steosis doesn't have any neurologic sx and pain is better with sitting/lying. herniated is worse with sitting, +dslr
|
|
mc thyroid malignancy
|
papillary
|
|
ocular trauma -> central scotoma, retinal edema, hemorrhagic detachment of macula, subretinal hemorrhage, crescent shaped streak concentric to optic nerve w/ blurred vision
|
choroidal rupture
|
|
sudden painless loss of vision w/ pallor of optic disk, cherry red fovea, boxcar segmentation of blood in retinal veins
|
central retinal artery occlusion
|
|
who is bronchoalveolar lavage mostly useful for
|
evaluation of malignancy or opportunistic infection *esp pcp)
|
|
most effective lifestyle intervention for reducing bp
|
if obese, then weight loss. if nonobese, dash diet
|
|
necrosis of nasal turbinate in diabetic is highly suggestive of
|
mucormycosis
|
|
bb and potassium
|
bb causes hyperkalemia
|
|
mgmt for suspected testicular tumor
|
do u/s -> if +, then radical orchiectomy -> ct for staging
|
|
WTF IS GUTTATE PSORIASIS
|
infection -> psoriasis with multiple salmon color papules
|
|
which thyroid cancer causes following: secretes calcitonin, has psomomma bodies, invades hematogenously
|
medullary, papillary, follicular
|
|
what does lambert eaton antibody bind
|
calcium channel on PRESYNAPTIC neuron
|
|
causes of secondary pellegra
|
hartnup disease (decreased absoprtion) carcinoid (shunting to serotonin), inh
|
|
what test to do after dx'ing myasthenia
|
ct for thymoma
|
|
what to do for acute UMN lesion + sensory deficit
|
MRI
|
|
anemia, mouth ulcers, lft abnormalities after tx for RA
|
mtx side effects
|
|
ddx for anterior mediastinal mass
|
thymoma, teratoma, thyroid neoplasm, and terrible lymphoma
|
|
prisoner with fluid collection in spleen, fever, leukocytosi, abd pain
|
ie to spleen
|
|
histology of ALL lymphoblasts
|
PAS+
|
|
acid fast oocysts in IC pt
|
cryptosporidium > isosporodium
|
|
mcc bloody emesis in pt abusing alcohol and aspirin
|
acute gastritis.
|
|
most sensitive test for disseminated histo infection
|
urine antigen
|
|
tx for histo in ic
|
itraconazole
|
|
most common organism in pneumonia after flu
|
saureas
|
|
dendriform corneal ulcers + vesicular rash in trigeminal distribution vs pain, photophobia, decreased vision, dendritic ulcer, vesicles in epithelium
|
herpes zoster ophthalmmicus vs herpes simplex keratitis
|
|
hazy cornea with central ulcer and ajacent stromal ulcer
|
bacterial keratitis
|
|
invasion of the tumor capsule and blood vessels in thyroid cancer
|
follicular cancer
|
|
cbc abnormality in ashtmatic tx'd with ics
|
neutrophilia
|
|
pyelo unresponsive to abx for 72h
|
look for obstructions or complications - renal u/s
|
|
change in gross appearance of eye in glaucoma
|
red eye
|
|
bone cancer pain
|
unrelenting pain not responsive to rest
|
|
tx for acute hypercalcemia
|
iv saline -> loop
|
|
usptsf osteoporosis
|
65+ do screening, or younger if risk factors
|
|
def of osteoporosis on bone mineral density
|
-2.5sd
|
|
pecularities in legionaries dz
|
fever with bradycardia (temperature disassociation), hyponatremia
|
|
wernicke vs korsokoff
|
mamillary body
confusion + ophthalmoplegia + ataxia amnesia + confabulation + personality change |
|
peculiarity in histo lesions radiographically
|
tend to calcify
|
|
which fungus can have lytic bone lesions
|
blasto
|
|
physiology of histamine
|
h1: nasal and bronchial mucus secretions, bronchiolar constriction, pruritus, pain, increased capillary permeability leads to wheals
h2: gi acid secretion |
|
what is polyarteritis nodosa assoc w. what does it affect
|
hepatitis b. renal and visceral
|
|
what is microscopic polyangiitis
|
like wegener's except no granulomas that is panca +
|
|
microscopic polyangiitis vs pan
|
pan = different aged lesions. microscopic poly = same aged
|
|
osler weber randu
|
abnormal vessel proliferation that can lead to bleeding AD
|
|
what drug can u use to tx wpw with afib
|
amniodarone, procainamide, dc. don't use avn blockers
|
|
pulmonary causes of pulsus paradoxicus
|
asthma, copd, tension ptx
|
|
gold std test for acromegaly
|
measure gh after oral glucose
|
|
what secondary pneumonia can cause a necrotizing bronchopneumonia resulting in pneumatoceles
|
saureus
|
|
endocarditis following GU procedure usually caused by
|
enterococci
|
|
palpable purpura + glomerulonephritis w/ proteinuria + hematuria + hep C
|
mixed cryoglobulinemia
|
|
metabolic abnormality assoc w ischemic bowel
|
lactic acidosis
|
|
workup for new onset lupus nephritis
|
kidney biopsy cuz diverse effect on kidney with diverse management
|
|
tx for polymyalgia rheumatica
|
low dose steroids
|