Medicine Shelf Review

MEDICINE SHELF EXAM REVIEW 1.

PFTS a.

First thing to look at is FEV1/FVC i. Normal: >70-75% 1. FVC normal 1.

Look at DLCO – a. Normal – your normal b. Abnormal – pulmonary vasculature problem

2.

FVC LOW a. LOOK AT tlc b. TLC high – air trapping c. TLC i. low with low FVC – small lungs, pure restrictive defect  1. DLCO a. Normal – neuromuscular, chest wall defect  b. Low – interstitial lung disease ii. Not normal – look at FVC on its own 1. FVC is high then obstruction and nothing else 2. Low FVC = restriction a. TLC i. High in obstruction with air trapping ii. low means he has restrictive component  1. DLCO a. Normal – asthma because doesn’t destroy alveolar membrane b. DLCO low then he has emphysema > COPD

b. Obstructive i. Chronic obstructive pulmonary disease (COPD COPD)), which includes emphysema and chronic bronchitis ii. Asthma iii. Bronchiectasis iv. Cystic fibrosis c. Restrictive i. Interstitial lung disease, disease , such as idiopathic pulmonary fibrosis ii. Sarcoidosis iii. Obesity Obesity,, including obesity hypoventilation syndrome iv. Scoliosis v.  Neuromuscular disease, such as muscular dystrophy or amyotrophic or amyotrophic lateral sclerosis (ALS) d. Mixed 2. MI a. Door to balloon time – hit the door of the ER to when cardiologists opening up balloon in coronary artery <90 minutes  PCI percutaneous coronary intervention, any intervention not necessarily a stent. Stent preferred for STEMI b. Fibrinolytics – clot busters – streptokinase, urokinase when you can’t cath. Door to needle time <12 hours. c. TPA i. Stroke – within 3 hours within seen normal hour, head CT in first 24 hr is normal ii. Massive PE – hemodynamically unstable, hypoxic, tachypneic, Stat CT angio – no time limit  3.

Stress versus cath

a.

STEMI – cath on spot – spot  – stent it  i. 1 avl – v5 v6 left circumflex lateral wall ii. anterioseptal wall – lad iii. posterior – right circumflex iv. 2 3 avf rca inferior v. v1-v4 0 lad anterior

4. Bleeding disorders a. PT i. Extrinsic pathway ii. Factor 7 and 3 b. PTT i. Intrinsic pathway ii. 10 5 20 1 13 common iii. ptt is everything else 12 11 9 8 iv. order 1:1 mixing study when isolated high pt or ptt  1. deficient in factor – then normalizes 2. inhibitor then it does not normalize a. high PTT, does not correct with 1:1 and prothrombic – lupus anticoagulant. And if they have evidence antiphospholipid syndrome c. Von willebrands i. Teenager who has had menorrhagia ii. VWF bound to factor 8, helps platelets bidn to endothelial wall and bind to each other. It is a connector between coagulation and platelet side. iii. PTT high because bound to factor 8 then half life of factor 8 go down so functional factor 8 deficiency. iv. PT is normal d. Factor V Leidin e. Ristocetin assay messed up then platelet function order and ifnormal then not vWD f. Hemophilia A i. Factor 8 deficiency ii. XLR g. Hemophilia B i. Factor 9 deficiency h. Hemophilia C i. Factor 11 deficiency i. Bernard soulier - platelet adhesion issue so platelet number normal but platelet function assay is jacked maybe factor 7 and ddavp? j. Glanzmens thormbasthemia platelet aggregation issue so platelet number normal but platelet  function assay is jacked IIB IIIA . give leukocyte depleted blood with platelets. k. DIC - consumptive coagulopathy i. PT PTT high ii. Platelets low iii. Fibrinogen low – must be low to diagnose DIC iv. D-dimer high – measures breaking up clots 5. TTP - Opposite of VWF a. Deficiency in ADAMST13 b. AMS, fever, TCP, microangiopathic hemolytic anemia, AKI c. HUS – ecoli 6. SBP – PMN >250 7. SAAG a. Serum albumin – ascites albumin i. <1.1 implies that ascites high – it is inflammatory something is spilling protine, also cuaed by nephrotic syndrome ii. >1.1 hydrostatic pressure, portal hypertension b. 40 year old women with ascities and pleural effusion – ovarian cancer (possible benign) – meigs syndrome – 8. heparin vs warfarin a. therapeutic b. prophylaxis – prevention of PE and DVT c. DVT/PE – treat 6-9 months i. Start with heparin or lovenox

1. Heparin is unfractionated. Blocks factor 2 and 10 in 1: 1 ratio. 2. Lovenox is low molecular weight. Lovenox sticks around lon ger. Lovenox does it in 3:1 ratio. 3. Don’t give lovenox in renal failure, give heparin. ii. Warfarin 1. If you don’t give heparin then skin necrosis- affects protein C 2. Give heparin 5-7 days 3. INR 2-3 iii. Filter – dvt with contraindication for anticoagulation – like a brain bleed. Once head bleed stabilizes then give them anticoagulant again. Filter is a temporary solution. d. Afib i. Blood not moving so make clot and that clot can goes to brain ii. Usually with warfarin iii. INR 2-3 iv. Do you have to anticoagulate patients with AFib? So figure it out via CHADS2 risk; CHF, HTN, Age >75, Diabetes, Stroke, 1. 0-1 no anticoagulate 2. 2 – consider 3. 3+ anticoagulate v. pt comes in with afib and cardiovert, do we anticoagulate? 1. Previous episode? Anticoagulate 2. Reversible cause of afib – no anticoagulation 3. If cardiovert then HAVE TO anticoagulate for one month minimum. e. Valve prosthetic i. Mechanical 1. Aortic – goal INR 2-3 2. Mitral goal INR 2.5-3.5 3. Guy who needs procedure witih mechanical valve then take of Coumadin but start a heparin drip because short lived and stop heparin right before procedure and start  heparin back when its safe an dultiamtely shift to Coumadin ii. Bioprosthetic 9. AFIB causes a. PHEART – pericarditis, htn/heart attack, embolism, alcohol/OSA, rheumatic heart disease, thyrotoxicosis 10. Interstitial lung diseases a. ILD 2/2 anotehr disease or known cause i. Rheumatic ii. Pneumoconiosis b. Idiopathic interstitial pneumonia i. IPF 1. Idiopathic pulmonary fibrosis – short of breath for years, no pillow orthopnea, no heart failure, smoker, FINE bibasilar crackles, PFTs DLCO bad. High resolution CT scan honeycombing ii. Everything else c. Granulomatous disease i. Sarcoidosis – noncaseating granulomas, hilar adenopathy, erythema nodosum, African America, SOB d. Other/lymphagio/pulmonary non histiocytosis 11. HTN <120/80 – pick higher number out of systolic and diastolic a. 3 separate readings b. first line therapy i. no comorbidities thiazide diuretics ii. diabetes or CKD – aceI if cough then ARB iii. heart failure – ACEI, betablocker, NO CCB because it causes fluid retention and then you don’t want that for CHF.

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15.

iv. CAD – BB ACEI, CCB v. If these don’t work then hydralazine or clonidine c. Goal i. No comorb <140/90 ii. CKD diabetes <130/80 Hypertensive urgency vs emergency a. Emergency – end organ damage b. Give labetolol CCB nifedipine/nicardopine drip c. Can give clonidine or hydralazine but not the best  Diabetes a. Diagnosis each confirmed two times i. Random glucose >200 at any time in prescence of symptoms – only one not need repeattesting ii. Fasting glucose >= 126 iii. Hga1c >=6.5 iv. Oral glucose tolerance test >= 200 b. Goal of A1C <7 c. Every year eye exam and check his feet  i. Feet – vanc +zosin or ceftazadime or cefepime something that covers pseudomonas d. Complication i. Macro 1. CVD ii. Micro 1. Retinopathy 2. Neuropathy – numbness tingling – give gabapentin 3. Nephropathy – a. First sign start spilling protein b. ACEI decreases pressure on efferent arteriole 4. Treatment iin order of giving it to patient  a. Diet and exercise b. Metformin – SE lactic acidosis, no metformin with Cr >1.6 c. Sulfonylurea - Glypizide glyburide d. Insulin i. Long acting – glargine and levomar ii. Somoby effect 2 am glucose low, donns phenomen when don’t give enough insulin e. Hold ACE in AKI but give in CKD f. DKA i. First thing give fluids ii. Insulin drip iii. Add dextrose to fluid once glucose starts going down because anion gap may not fully close so drive glucose into cells and shuts off signals for ketogenesis iv. Transition from IV to subq v. if the potassium is 5.5 is he really hyperkalemic == NO hes vomited it and he’s dry and RAAS activated which cause NA reabsorption and K excretion. K in blood stream and not in cells. So eventually add K into fluids 4-4.5 hours into treatment. ELECTROLYTES Na a. Hyponatremia – N1V1 AMS weakness seizures – CPM if correct to fast  i. If seizures – 3% saline hypertonic saline b. Hypernatremia – seizures cerebral edema if correct too faste K a. Hypo – weak paralyzed, give K EKG – u waves, if you keep correcting and it doesn’t go up give Mg. Lasix causes hypokalemia and hypomag.

b. Hyper – peaked T waves, very pointy, PR bigger, QRS bigger like someone is taking EKG and stretching it out. Late finding also sign waves. 16. Mg a. Hyper lose DTRs like you do in pregnant women in mag land. b. Hypo spasms kinda like low calcium 17. Ca a.

Hypercalcemia i. Chronic – stones bone groans pyschosis polyuria polydipsia ii. Acute – AMS, N/V , b. Hypocalcemia i. Chovostks, trousseaus, seizures 18. Glucose a. Hypoglycemia shaky b. Hyperglycemia i. HONKK – no ketones give fluids fluids fluids High yield questions 19. Sudden onset tachycardia plueric chest pain with sats of 90% - PE, CT angio, TX dying emoblectomy, tpa, not dying heparin then switch to coumdin 20. stary sky pattenr – burkits – CML – tx gleevac 21. tx of diffuse large b cell lymphoma – RCHOP rituximab, cyclophosapd, doxorubicin, oncovorin/vinclistin, prednisone 22. rabbit farm – tularemia – streptomysin tx 23. recurrent hemarthorsises – hemophilia A 24. epilepsy with gingival hyperplasia – taking dylantin/phenytoin 25. patient with septic shock low TSH slightly low free T4, - euthyroid sick syndrome, no tx check TFTS in few weeks when pt is more stable 26. truncal obesity peripheral atrophy, striae- cushings syndrome – exogenous steroids 27. noniatrogenic – low dexamethasone suppression test, 24 hour urinary cortisol, salivary eventing cortisol level – 2/3 positive then cushings syndrome. Cushings disease (pituitary adenoma) ectopic ACTH tumor adrenal tumor a. ectopic is not suppressed by high dose suppression test but a pituitary tumor is so it will suppress cortisol levels b. if ACTH is low then adrenal tumor 28. episodic hypetension, flushing dizziness hypertension – pheo – dx with serum free metapneprhines and urine for confirmation tx – alpha blockaged then beta blockage then surgery 29. epigastirc pain with nausea avomint glean forwards – pancreatitis – tx supportive and necrotizing then give antibiotcs – gallstones alcohol

a. complications – immediate – hemorrhagic or ARDS and weeks later pseudocysts 6 week  later 30. feels beter leaning forward pericafrdiits 31. productive fever, lobar consolidation onf cxray – CAP Moraxella strep mycoplasma chlamydia hemophilus – levoflox or moxiflox or third generation cephalosporin with macrolide 32. empirical treatment for bacterial meningitis – vanc + cephtriaxone if over age 50 then add ampicillin to cover for listeria 33. macrocytic anemia renal failure protein gap lytic lesion multiple myeloma – spep upep to dx 34. malignancy associated with psammomma bodies – papillary thyroid carcinoma (has generally good prognosis), serious papillary cysts ovarian , meningioma, RCC, mesothelioma

35. four days wcant move eyebrows and liips o n one side – peripheral 7, in stroke the upper 7 is preserved. – bells palsy – look in ear and see vesicles – herpes – ramsy hunt syndrome 36. fever RUQ pain jaundice – acute cholangitis

37. 38. 39. 40. 41. 42. 43.

tx of choice STEMI Cath and stent  positive urine dipstick for heme but no rbcs under microscope – rhabdo negative urine dipstick for heem but urine looks red – porphyria, medications (rifampin) beeturia proximal muscle weakness CK 1000 polymyosiites – steroids dermatomyositis is with rash – rule out cancer strep bovis/glaoliticis bacteremia – colonoscopy

44. watery diarrhea abdominal lpain fever hospital c diff – metronidazole and if sepsis then po vanc and metro 45. INR mechanical mitral vlav e 2.5 – 3.5

46. Urine sodium 80, mild hyponatremia elevated urine specific gravity urne somolartiy 700 – SIADH – first  line tx fluid restriction 47. Panacinar emphysema and liver disyfuntion alpha antitripysin 48. PVC antimitochondrial antibodies 49. Hgb 8.6 irone 50 tibc 450 feriting 9 – irone deficiency – Gi bleedis cause in postmenstrual women or old men 50. Five cause of hypomicroanemia, irone deficinec, thalaseemia,, anemia of chronic disease, lead poisioning, sideroblastics 51. Macrocytics – b12 folate, hypothyroid, liver disease, alcohol, MDS, reticulocytosis, MM, medication side effects 52. Smear a. Hypersegmented neutorphls

b. Snudge cell CLL c. Target cell – thalaseemia, asplenia, hgb C disease, liver diz 53. ID a. b.

Gramp ositive cocic Gram negative rod

c.

Blastomycosis – budding yeast 

d.

Crytococcus – indian ink 

e.

Candidi – budding hyphae

f.

Neisseria – CSF – kidney shaped