UWorld Notes part 2

56 Notes

Question Main Id

Division

Sub Division

Notes

angioedema from ace inhibitors can occur at any time, not just within weeks of starting the medicine -check for airway compromise, vasomotor stability, give epi if needed -emergency trach sometimes if needed

2770

Medicine Allergy & Im Immunology

3650 3650

Medi Medici cine ne Bios Biosta tati tist stic ics s & Epi Epide demi miol olog ogy y Case Case Con Contr trol ol = Det Deter ermi mine ne pre predi disp spos osin ing g RFs RFs for for a con condi diti tion on

4178

attrition bias is a type of selection bias where pts are lost of follow up which can skew data. Medicine Biostatistics & Epidemiology reporting bias = ppl are reluctant to report an exposure due to stigma about the exposure (sexual behaviors, drug use, et cetera.

7691

Susceptibility Bias -if treatment regimen "selected" "selected" for a pt is a function of how sick that patient is, then results are likely to be skewed (sicker Medicine Biostatistics & Epidemiology patients will do more poorly than healthier patients as a whole) -Do an ITT (intention to treat) analysis to compare initial randomized treatment groups instead of groups that eventually get treated on to avoid this sort of bias.

Medicine Cardiovascular System

Uremic Pericarditis: -high BUN -> pericardial inflammation inflammation -Look for in pts with CKD who present with pleuritic CP that improves with siting up +/- pericardial friction rub -nonspecific T wave changes -tx with dialysis +/- rule out tamponade

2663


BB overdose: bradycardia, AV block, hypotension, *diffuse wheezing* (specific to BBs vs. CCBs) -tx with glucagon: increases intracellular cAMP. Also could give epinephrine, iv lipid emulsion therapy

2687


HOCM is auto dominant inheritance


MVP mid to late systolic click that shortens with squatting. young females. atypical CP, dyspnea, palpitations, dizziness, anxiety, panic d/o


Amyloidosis: -cardiac (restrictive cardiomyopathy) cardiomyopathy) CHF + ECHO findings of constrictive LV hypertrophy with predominant RHF sx -asymptomatic proteinuria, proteinuria, nephrotic syndrome, waxy skin, anemia, bruising, hepatomegaly, subq nodules, enlarged tongue, peripheral/autonomic peripheral/autonomic neuropathy.


AAA "pulsatile "pulsatile mass" first first test is the abdominal abdominal u/s. 100% sensitive and specific. can measure size, associated thrombus can be found, and then f/u wih surgery or nah.


Prinzmetal Angina -Tx with Diltiazem or nitrates -young females, RF = smoking; seen with transient ST elevations on EKG.

2224

2696

2699

2717

2723


thoracic abdominal aneurysm -vague CP, negative markers, asx but may present with back, flank, abdominal pain -more with EDS and marfans -desc AA = atherosclerosis atherosclerosis -asc AA = due to cystic medial necrosis (age, EDS, marfans)

4190


furosemide = increased K excretion acei + loops = correct electrolyte abnormalities abnormalities hypoNa in CHF = bad = high renin, nepi, adh. restrict fluids, add acei and loops

4243

Medicine Cardiovascular Sy System

cardiac in index = ca cardiac ou output / body su surface area

4277


aortic valve closure in aortic stenosis is delayed and thus there is a soft and single 2nd heart sound.


beck's triad -hypotension -distended neck veins -muffled heart sounds pulsus paradoxus drop in bp with inspiration greater than 10mmhg -positive hepatojugular hepatojugular reflux on abd exam -look for viral pericarditis in a patient with a recent URI. -clear lungs on exam in tamponade

4377


orthostatic hypotension can cause syncope in old people, or people with prolonged recumbency, or ppl with autonomic neuropathy (dm2, parkinson's) parkinson's)

4396


CXR findings are nonspecific in PE


Infective Endocarditis in IV Drug Users -Staph most common -HIV increases IE risk -Tricuspid valve involvement more common than aortic valve -septic embolus common *to the pulmonary circuit, which is why pts have multiple round peripheral opacities in their lungs -fewer peripheral manifestations manifestations of IE (no splinter hemorrhages, janeway lesions) -HF rare with tricuspid disease -present with cough, CP, hemoptysis

4450


"abrupt onset of reg tachycardia resolving with cold-water immersion" = AVNRT (type of PSVT) -nl hearts young ppl, presents with palpitations +/- dizziness, SOB, CP -2 conduction pathways slow and fast in the AV node. atrial premature beat --> reentry mechanism sustained loop. anterograde through slow, retrograde through fast -VAGAL MANEUVERS - carotid sinus massage, cold water immersion, diving reflex, valsalva, eyeball pressure -> PNS tone increases --> slows condution AV

4451


noncompliance noncompliance is the MC cause of acute decompensated heart failure

4129

4345

4398


digoxin toxicity -renally cleared, narrow therapeutic index -n/v, confusion, weakness, blurry vision/blindness -precip by viral infx, excessive diuretic use, renal injury --> acute elevation of digoxin level -HYPOKALEMIA is assoc with loop diuretic use; inc susceptibility to toxic effects of digoxin.


pulsus parvus et tardus = delayed, slow-rising and diminished (weak) carotid pulse. It is a sign of aortic stenosis will also see single and soft 2nd heart sound S2 mid to late peaking systolic murmur


arterial occlusion of artery -left atrial thrombus (afib), LV thrombus after an anterior MI; infective endocarditis / prosthetic valve


apixaban (and other nti-xa inhibs) shown to significantly reduce risk of systemic embolization -antiplatelet therapy with aspirin or clopidogrel is leff effective than warfarin or DOACs


HOCM: The classic HOCM murmur is a crescendo-decsecendo murmur in the L sternal border that does not radiate to the carotids. Also will be seen in younger more athletic male patients


ADPKD = bilateral asx masses + hypertension -early flank pain, stones, UTIs -cerebral aneurysms, hepatic/pancreatic cysts; MVP/AorRegurg; colonic diverticula; ventral/inguinal hernias -tx ACE

4725


Pulseless electrical activity: -very different from pulseless lack of electrical activity (in which case you shock) -if there is any sort of rhythm that is appreciable on the cardiac monitor, do CPR + give epinephrine uninterrupted. There is no role for cardioversion or defibrillation in this case

4742


asthma can be exacerbated by aspirin. Also nonselective beta blockers.

4771


pulsus paradoxus = >10mmhg drop of BP during inspiration (tamponade, severe asthma, COPD) -

9648


decreased tracer uptake with exercise with normal tracer uptake at rest = inducible ischemia. Likely CAD

10179


add an ACEi or ARB to reduce CCB-assocaited peripheral edema


nitroprusside infusion for hypertensive emergency to rapid BP lowering. breaks down into cyanide and nitric oxide. --> arteriolar / venous vasodilation --> lower BP -BUT it causes cyanide toxicity if too high dose. MC in pts with renal insufficiency. AMS, lactic acidosis, seizures, coma.

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4673

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2747


Medicine Dermatology

constrictive pericarditis -RHF important cause! -progressive peripheral edema, ascites, elevated JVP, pericardial knock; pericardial calficiations on CXR -usually idiopathic or viral, surgery, radiation, TB -EKG: "low voltage QRS + Afib" -pericardial thickening, calcifications -prominent x/y descents on JVD tinea versicolor = ptiaryasis = malasezia furfur/globosa infection. Will see spagetti and meatballs -hot humid weather -KOH prep budding yeast -tx with selenium sulfide, ketoconazole dermatophyte infection = ringworm. tinea corporis. these need keratin for growth.


bullous pemphigoid -tx clobetasol ->65 in MS or parkinsons pts -IgG autoantibodies vs hemidesmosomes


diffuse dermal scaling = ichthyosis vulgaris. chronic inherited skin disorder --> diffuse dermal scaling. basically just ashy skin disorder

2776


Rosacea rash tx: -avoid etoh, spicy foods -sun protection -cleansers/emolients -topical metronidazole for papulosquamous type -laser -topical brimonidine for erythematotalngiectactic type

2777


Classic infectious cause of TEN/SJS is mycoplasma pneumoniae

2779


vitiligo = autoimmune destr of melanocytes -tx steroids topical then steroids

3811


nickel allergy = type 4 = tx with topical corticosteroids


SCC is the most common malignancy in pts on immunosuppressive therapy for a history of organ transplantation -more aggressive, higher risk of recurrence and regional metastasis


PCT seen in HepC, HIV, Etoh, estrogen use, smoking pts -test for urine or plasma porphryn levels -pct sx include blisters/bullae/scars in sun exposed areas; similar to scleroderma


senile purpura -skin fragile, ecchomoses, nl lab results -seen with extensive sunlight -loss of elastic fibers in perivascular connective tissue -no further w/u required, but need careful wound care

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4812


Steroid-Induced Acne -systemic / topical steroids, azathioprine, cyclosporine, and other drugs like anti-TB or anticonvulsant drugs -vs. acne vulgaris: steroid-induced is more monomorphic and at the same stage of development -resolves upon d/c of tx

10298


idiopathic acute urticaria


Warts (HPV) -can be plantar, palmar, or genital -IC pts -look like little white circles


epidermal inclusion cyst waxes and wanes, freely movable cyst or nodule with a central punctum -leave alone

Medicine Ear, Nose & Throat (ENT)

malignant otitis externa -elderly diabetic with ear pain, drainage. poorly controlled dm2. granulation tissue visible inside the ear. -facial droop -- facial n destruction 2/2 osteomyelitis of the skull base


furosemide === hearing loss; med induced ototoxicity. also seen with aminoglycosides, chemo, aspirin, and loop diuretics -reverisble hearing loss and tinnitus


MC INFECTION IN AIDS -Serous otitis media -2/2 HIV lymphadenopathy leading to auditory tube dysfxn; -sx = conductive hearing loss -dull tympanic membrane hypomobile on pneumatic otoscopy


Nasal Polyps -NSAIDs + rhinitis + post-nasal drip = aspirin exacerbated respiratory disease (leads to nasal polyps) -food can taste bland, rec nasal discharge/block

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Medicine

Medicine

Medicine

Endocrine, Diabetes & Metabolism

Ovarian / Adrenal Tumors: If there is a precipitous rise in the manliness of a female patient (<6 mos) that occurs in a middle aged woman rather than a young one, or in a woman who's not fat enough to have PCOS, think of ovarian / adrenal masses first. Check DHEAS (adrenal) and Testosterone (ovarian) before checking LH / FSH


Cushing's Syndrome: Painless muscle weakness associated with wt gain, bone loss, htn, hirsutism. -myopathy caused by weakness in proximal muscles (catabolic effects of cortisol on skeletal muscles --> muscle atrophy) -be suspicious of this if the patient has bone demineralization and hirsutism as well.


HYPOPITUITARISM -LOW ACTH, CORTISOL, FSH, LH, TEST, FT4 -Aldosterone will be NL since it is mostly controlled by RAAS (vs. 1* adrenal insufficiency = low aldo, high K, low BP, high ATCH, hyperpigmentation)

2176

2178

Medicine

Medicine


symptomatic hypercalcemia necessitates parathyroidectomy


PTU / Methimazole -agranulocytosis -if pt with fever/sore throat --> D/C!!! especially if white count is <1000.


Graves Disease -Hyperthyroidism with diffuse RAI uptake -use anti-thyroid drugs like methimazole and propanolol as a bridge to thyroidectomy if pt has increased r of complications

2179

Medicine

2188

Endocrine, Diabetes & Medicine Metabolism

sulfonylurea OD can be hard to dx as c-peptide lvls will be high. they lead to extra insulin release from the beta cells. measure plasma sulfonulurea levels to dx.

2190

Medicine


best way to reduce progression of diabetic nephropathy is strict blood pressure control


-hashimoto's = hypothyroid = TPO antibody; diffuse goiter; variable uptake -painless thyroiditis = hyper then hypo, self-resolving. NONTENDER goiter; low uptake -subacute thyroiditis = postviral hyperthyroidism; PAINFUL goiter; high esr/crp, low radioiodine uptake


carcinoid syndrome -presents with flushing, telangiectasias, diarrhea, cramps, valvular lesions (R>L), bronchospasm -can co-present with sx of niacin deficiency (dermatitis, diarrhea, dementia) -dx with high 5-HIAA excretion; CT/MRI of abdomen/pelvis to localize tumor -ECHO

2191

Medicine

2220

Medicine

2630



MEN1 = parathyroid adenoma, gastrinoma, pituitary adenomas -symptomatic hypercalcemia looks like constipation, polyuria, abdominal pain VIPoma -watery diarrhea, low Cl (low gastric acid secretion), flushing, lethargy, n/v, muscle weakness/cramps -low k, high ca, high glu -high sodium in the poop with osmolal gap <50 -VIP level >75 dx-stic -CT/MRI to localize tumor

2649

Medicine

3230


patients with mild hyper-aldo may not have spontaneous hypo K, but they are prone to develop diuretic-induced hypokalemia when they take thiazides

3483


hypothyroidism can cause hyperlipidemia, hyponatremia, and asx elevations of creatinine kinase (<10x nl) and transaminases. Can cause hyper TGs also

3495

Medicine


normal everything else and low T3 = euthyroid sick synrome -caused by caloric deprivation, high inflammatory state, high glucocorticoids inthe blood, etc. -seen in hopital patients

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Medicine

Medicine

causes of recurrent preg loss include -thyroid, pcos, dm2, hyper PRL, celiac dz, and uterine structural probs of all kinds (fibroids, etc.)


DM neuropathy - axonopathy of large fibers. length-dependent axonopathy - longest = leg nerves = affected first. small fiber = pain, parasthesias, allodynia = "positive" sx large fiber = LOSS OF sensation, proprioception, vibration, reflexes


diabetic neuropathy (loss of reflexes, vibr/prop alterations, pain, paresthesias. -tx with TCAs, duloxetine, pregabalin, gabapentin. USE TCAs WITH CAUTION IN >65yo due to its ANTICHOLINERGIC EFFECTS!


polyuria with dilute urine in the setting of high serum Na points towards diabetes insipidus. central DI: low ADH from pituitary --> less water reabsorbed --> water loss with polyuria. nephrogenic: ADH receptor issue. intact thirst mechanism and may have a normal Na level.

3899

Medicine

3902


ACE-i -reduces urinary albumin -decreases intraglomerular pressure

3952

Medicine


thyrotoxicosis causes htn by directly increasing cardiac contractility. Not by increasing catecholamine release. -causes afib/flutter -sys HTN + high pulse pressure; high myocardiac o2 demand -leads to high output HF or exacerbation of pre-existing low-output HF -coronary vasospasm -effects on myocytes are mediated by T3 -there is a minor effect of inc catecholamines

3976


Pheochromocytoma -severe htn can be precipitated by surgical procedures, use of bb, induction of anesthesia, and serveral other medications.

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Medicine

Medicine


increased thyroid-binding globulin: estrogens (pregnancy, OCPs, HRT), hepatic dysfnction, tamoxifen. decreased TBG: cushings, glucocorticoids, nephrotic syndrome, starvation, niacin, androgens


Thyroid disease: If you do a radioactive iodine uptake test (RAIU) and you see lots of stuff lighting up then it's graves dz or a toxic nodular goiter (tx methimazole). If there is decreased uptake, then consider subacute thyroiditis or painless thyroiditis, where the sx are a result of released of preformed hormones from the thyroid (tx propanolol). CHeck peroxidase abs also for hashimotos.

4305

Medicine


1* Adrenal Insufficiency -50% of people with autoimmune adrenalitis have other autoimmune conditions involving the endocrine glands (thyroid, parathyroid, ovaries) -Also common are pernicious anemia and vitiligo -Presents with hypotension, pigmentation, hyponatremia, hyperkalemia, esinophilia, HIGH ACTH, low serum cortisol levels) -1* = autoantibodies vs. adrenal steroidogenic hormones

4307

Medicine


excess thyroid hormone leads to inc osteoclast activity --> high Ca --> low PTH --> calciuria, calcium wasting


Lid lag = thyroid hyperreflexia, afib, tremors, prox muscle weakness also = THYROTOXIC MYOPATHY -muscle atrophy in the prox polymyositis has muscle atrophy as a late finding instead of an early finding like in thyroid myositis

4382

Medicine

4415

Medicine


graves disease tx caveats -methimazole and ptu cause agranulocytosis ptu = heaptic failure raiu = WORSENING OPTHALMOPATHY surgery = risk of nerve damage hoarseness, r of hypoPTH ism.

4471

Medicine


hoarseness is apparently a sign of hypothyroidism, as are memory changes.


HHS - more AMS, gradual onset of hyperglycemic s/sx; glucose >600 (vs. <500 in DKA); bicarb >18, normal AG, trace ketones, high serum osm >320 -caused by things like steroid use, infections, thiazides, pentamidine, atypical antipsychotics, insulin thereapy noncompliance, trauma/acute illness


tight glycemic control has microvascular benefits (less retinopathy, nephropathy) but the macrovascular benefits (MI, stroke) are unknown. all-cause mortality is not affected by glycemic control.

4516

Medicine

11367

Medicine

2605

Female Reproductive Medicine System & Breast

BRCA -best prognostic factor is TNM staging, following by receptor status (ER+ PR+)

Medicine Gastrointestinal & Nutrition

d xylose test = celiac's -absorbed by the small intestine without modification and is excreted in the urine. Can measure. -mucosal dz = poor absorption -enzyme deficiency = good absorotpion -

2198

toxic megacolon -IBD, c dif infection -fever, tachy, hypotn, bloody diarrhea, abd distention, peritonitis, colonic distention on imaging -mgmt bowel rest, NG suction, abx, +/- corticosteroids if IBD-related. -may be the initial presentation of IBD - be on the look out. Radiologic diagnosis with >6cm distention with severe systemic toxicity. Tx with conservative mgmt and corticosteroids

2205


2209

Pancreatic cancer: -mostly in head of pancreas -compress panc duct and common bile duct...painless Medicine Gastrointestinal & Nutrition jaundice! "double duct sign" -intra and extra hepatic biliary duct dilation, distended gallbladder (courvoisier's sign)

2341


lower GI bleeding MC due to diverticulosis -mc in sigmoid colon -painless, large-volume (+/- lightheadedness, hemodynamic instability) -most will relieve spontaneously -confirm on colonoscopy -AVMs less common than diverticulosis. ALso they don't cause large volume bleeds

2596


maltomas spontaneously regress most of the time when tx the underlying pylori infection unless there are already mets

2759


malabsorption related problems lead to the most of the complications of PBC --> osteoporosis, osteomalacia, HCC (not colorectal cancer) -osteomalacia is a big one

2920


PSC = UC = fatigue and pruritus; asx at time of dx

2921


pts with varices in cirrhosis should be started on a nonselectie B blocker to reduce risk of bleed. -1/3 of varices bleed. sig rr morbiditiy and mortality

2937

ALT more specific for hepatic injury AST all over body including liver heart kidney muscle Medicine Gastrointestinal & Nutrition -asx elevation can be caused by the following meds: NSAIDs, antibiotics, hmg-coa inhibitors, anti-epileptic drugs, antituberculous drugs, herbal preparations)

2950


Primary Biliary Cholangitis = + anti-mitochondrial ab -autoimmune destruction of intrahepative bile ducts -pruritis, fatigue are first sx -tx with ursodeoxycholic acid: decreases biliary injury by inc secretion, delay histologic progression in PBC. -late stage = liver transplant

2969


hepatic hydrothorax -cirrhosis pts with ascites -MC on right side bc less muscular hemidiaphragm -defects in the diagraphm lead to ascitic fluid to pass into the lung space -tx with salt restrict, diuresis, thora

2978


Acute cholangitis: tx with beta-lactam+lactamase; 3rd gen cephalosporin + metronidazole

2982

After Coronary Angiography -cholesterol embolism is common -leads to livedo reticularis (blue toe) or GI issues (mesenteric Medicine Gastrointestinal & Nutrition ischemia, acute pancreatitis) -if pt has acute panc d/t atheroembolism, mgmt is conservative and as usual

3086


b12 def = high methylmalonic acid levels


Pellagra = niacin deficiency -diarrhea, dementia, dermatitis -3rd world people who have corn based diets only -1st world in Etoh, chronic illness; carcinoid syndrome -hartnup disease -prolonged isoniazid therapy can mess with tryptophan metabolism and lead to pellagra


pneumoperitoneum = likely perforated PUD; peritonitis from acid from the stomach irritation -rebound tenderness, guarding -delay of dx inc mortality and complication rates

3467


Colovesical fistula -complx of acute diverticulitis -fecaluria, pneumaturia (air), rec UTIs; mixed flora,

3582


diarrhea, abd pain, weight loss in middle aged man with chronic ough. skin hyperepigmentation = whipple's disease


Gastrinoma -gastrin <100 r/o, 100-1000 secretin test, 1000+ diagnostic. -seen in pts with MEN1 also. -refractory GERD to PPIs, or super distal ulcer locations like in the duodenum or jejunum


collagenous collitis = chronic watery diarrhea in a pt with nl colonoscopy mucosa, subepi collagen deposition -biopsy-confirmed celiac dz can have negative results on anti-TTG ab screen d/t selective IgA deficiency that can be seen in pts with celiac disease!

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3603


small intestinal bacterial overgrowth -etiology: strictures, surgery, dm, scleroderma, esrd, aids, cirrhosis -s/sx: abd pain, diarrhea, bloating, flatulence, malabsorption, wt loss, anemia, nutr deficiencies -dx with endoscopy with jejunal aspirate showing >10^5 organisms/mL -glucose breath hydrogen testing -strep, bacteriodes, etc. -tx with rifaximin, amox-clav, NO narcotics, dietchanges, or pro-motilitity agents lactose tolerance test = measure breath H level after lactose ingestion. + = bacterial carbohydrate metabolism rather than metabolism by your body.

3605

Medicine Gastrointestinal & Nutrition Diarrhea 2/2 lactose intol has a high osmotic gap (unmetabolized lactose and other organic acids) 290 - 2*(na+k) = osm gap and is >50 porcelain gallbladder -chronic cholecystitis -CXR shows rimlike calcifications, CT = rim; high risk for progression into gallbladder adenocarcinoma. cut it out = tx

3732


3833

Acute Pancreatitis -2/2 to valproic acid use Medicine Gastrointestinal & Nutrition -furosemide, thiazides, sulfasalazine, 5-asa, azathioprine, HIV drugs, metronidazole, tetracyclines

3834


IBD / UC pts are high risk for getting toxic megacolon within 3 years of dx. s/sx of megacolon = total/segmental non-obstructive colonic dilation, bloody diarrhea,fever, tachycardia. treat with iv fluids, abx, and bowel rest. IV corticosteroids are for IBD-induced toxic megacolon. surgery if the colitis doens't resolve


Minimal BRBPR: <40: anoscopy, 40-49: sigmoidoscopy; 50+ colonoscopy. Has to do with risks for cancer vs. hemorrhoids (benign). If there are changes in bowel habits, IDA, abd pain, wt loss, or FH of colon ca, then go straight to the colonoscopy


Chronic giardiasis is a thing. Pts with nonbloody diarrhea for a long time after travel to an endemic location should be w/u for giardiasis. tx with metronidazole. Confirm first with stool microscopy or a nucleic acid amplification assay.

3936


nsaid + aspirin use in someone with conjunctival pallor = IDA. Look for gastritis or ulcers, or chronic GI blood loss. then panscope.

4085


angiodysplasia = mc painless GI bleed. cautery if pt is symptomatically anemic

3857

3887


osm vs. secretory diarrhea -stool osmolal gap = plasma osm - 2(stool Na + K) if osmotic, then >125 gap (high) if secretory, then there is increased secretions of ions and the plasma osm vs. fecal sodium difference is LOW (<50) -causes of secretory diarrhea: vibrio, rotavirus, CF, ileocolitis, postsurgical changes)

4188


zenker's -neck mass varies in size with intake of food and fluids -caused by sphincter dysfunction and esophageal dysmotility leads to posterior herniation between the fibers of the cricopharyngeal muscle

4226


tx diffuse esophageal spasm with CCBs (dilt) to relieve pain and reduce dysphagia

4278

Alcoholic Hepatitis -fever, jaundice, anorexia, tender hepatomegaly, and mild elevation of AST:ALT 2:1; macrocytic anemia; and thrombocytopenia and high INR. Medicine Gastrointestinal & Nutrition -Clinical dx; no need for RUQ U/S or anything -radiograph reveals fatty liver dz, cirrhosis, ascites -tx with abstinence, hydration, nutritional support, and acid suppression +/- biopsy if there is dx uncertainty

4150


the most common cause of cancer metastasis is the liver; if there is unexplained hepatomegaly, look for clues as to where the cancer could be (cough cough positive FOBT)


Biliary Colic -pain resolution within 4-6 hours and absence of abdominal tenderness, fever, leukocytosis


multiple liver lesions on CT; metastatic dz most likely originating in the COLON. Colon blood moves through the portal circulation directly into the liver. -lung and brca also. get a cxr, but not 1st

4694


GERD --> Barrett's --> Strictures --> progressive dysphasia (solid foods) + block reflux --> improved symptoms (strictures that are symmetric) --> DO A BIOPSY to r/o adenocarcinoma

4697


mesenteric ischemia = POOP to physical exam findings -cardiac embolus from afib, shock, vasoconstriction

4934


pill esophagitis = sudden onset odynophagia and retrosternal CP that can cause difficulty swallowing.

12406


small int. bacterial overgrowht = seen in DM or ppl with f istulae. asians = lactose intol

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2248

Medicine Hematology & Oncology

LOW HAPTOGLOBIN = intravascular hemoglobin -hgb-haptoglobin form a complex and are cleared by the liver. Will also see higher indirect bili and high LDH levels (which is released from RBCs) Extravascular hemolysis = nl ish ldh, bili, haptoglobin; usually due to antibody or intrinsic enzyme pathology (g6pd, hered. spherocytosis)

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2618



PNH -hemolysis, fatigue, cytopenia, VENOUS THROMBOSIS (intraabdominal + cerebral veins) -high LDH, low haptoglobin, indirect bili up, hemoglobinuria -flow cyt shows absence of cd55/59 -tx eculizumab; supp Fe folate young pt with swollen knee, soap bubble lesions on the epiphysis of bone == giant cell tumor of bone. seen with pathologic fractures sheets of giant cell osteoclasts on histology. osteitis fibrosa cystica = hyperPTH from cancer in multiple bones, presents with brown tumors. OSTEOID OSTEOMA = sclerotic cortical lesion with a central nidus of lucency. NOT IN THE EPIPHYSIS. pain is relieved with Nsaids.


migratory superficial thrombophlebitis (Trousseau's Syndrome) -hypercoagulable d/o presents with superficial venous thrombosis at unusual sites (arm, chest, etc.) and is usually dx'd weeks/months prior to dx of occult visceral malignancy (MC pancreatic cancer), followed by lung, prostate, stomach.


cancer-related anorexia can be managed by giving megestrol acetate (a progesterone analog) -nutritional counseling also HIV cachexia = synthetic cannabinoid tx


warfarin-induced skin necrosis occurs in normal people when they start warfarin without a bridge bc protein c depletes first. this process is accelarated in patients who have protein c deficiency as a defect


Hairy Cell -BRAF mutation, B cell neoplasm -middle age or older -pancytopenia, splenomegaly -bone marrow bx; hairy leukocyte cells -chemo with great life expectancy


aniscocytosis, poikilocytosis can be seen in b12 deficiency -basophilic stipping is assoc w lead poisoning but is nonspecific. also from etoh, thalassemias,e tc

2887


CLL = lymph nodes painless enlargement -hepatosplenomegaly, mild thrombocytopenia/anemia, asx -lymphocytosis + smudge cells on smear -flow cytometry to dx; LN / BM Bx not needed -complicated many times by being prone to infections, AHA, secondary malignancies - Richter transformation

2889


BM bx to confirm MM. should show >10% clonal plasma cells


chronic myeloid leukemia -BCR-ABL gene fusion causes it (9 and 22 chr fusion) -leukemogenesis due to tyr kinase activation. tx with imatinib.

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2894


Hereditary spherocytosis -hemolytic anemia, jaundice, splenomegaly -RR bilirubin gallstones, parvo v19 infections --> aplastic crisis -high MCHC, reticulocytosis, high RDW -osmotic fragiility or eosin-5-maleimide binding test -tx with folic acid


correction of the folic acid deficiency without correction of the B12 deficiency can lead to rapid progression of neurologic complications


pernicious anemia is associated with autoimmune thyroid problems and vitiligo in the eastern european population -shiny tongue atrophic glossitis -thrombocytopenia (sometimes) -b12 anemia = pernicious isoniazid tox = neuropathy, hepatotoxicity. that's it. Can also cause sideroblastic anemia


if there is confirmed clinical suspicion of PE, then anticoagulate before tests. If there is only signs of DVT, then do tests before anticoagulation bc anticoagulation has risk! 1st step is compression U/S


hereditary hemochromatosis = dark skin, diabetes, slightly elevated liver enzymes, future HCC risk, can also see erectile dusfunction.

3978


EPO deficiency: -common in ESRD. -SE include: worse HTN (mechanism unknown) also headaches, flu-like sx; red cell aplasia (rare)

4081


chronic GI blood loss even in asx pts is t he first thing to look for in IDA in males or post-menopausal females

4147


Phenytoin causes folic acid deficiency -also primidone, phenobarbital -less absorption in the small intestine -also bactrim, methotrexate

4151


GVHD disease = 50% of sibling to sibling BMTs -skin, intestine, and liver are most often affected

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3890

4329


Anemia: -loss of RBC production, increase RBC production, or blood loss loss of production = lymphoproliferative cancer (leukemia, lymphoma)

4339


TTP -thrombocytopenia -neurologic -maha -kidney failure -fever look for a normal PT, RBC fragments -tx with plasma exchange vs. HUS: HUS is assoc with O157H7, renal sx mostly. Will not see neuro and fever

4349


ESRD Anemia -low EPO --> normochromic, hypoproliferative, normocytic anemia -replete Fe with EPO because increase Hgb will deplete iron stores

4352


hard, unilateral non-tender lymph nodes = eval immediately. older pt === HNSCC


B12 deficiency: macrocytic anemia, glossitis, neurologic changes (neuropathy). pernicious anemia --> MC cause; -anti-intrinsic factor Abs block b12 absorption -chronic atrophic gastritis develops, with reduced intrinsic factor production, and inc rr of gastric and carcinoid tumors.


Anemia of Chronic Disease -low tranferrin saturnation, normal to elevated ferritin, and low TIBC. -tx the underlying chronic condition to resolve the anemia -RA: hydroxychloroquine, methotrexate, infliximab, etc.)


DVT + high homocysteine -high homocys = predisposed to thrombosis. tx with pyridoxine *(vitamin B6), and potentially B12 if it is found to be low.


anti-phospholipid syndome -1 clx + 1 lab criteria must be met -a/v thrombosis, >3 fetal losses before 10th week, >1 fetal loss after 10th week, >1 premie birth of nl neronate before 34th week d/t pre-e, e- or placental insufficiency -lupus anticoag, anti-cardiolipin, anti-b2GP1 ab


Pancytopenia in SLE is due to many mechanisms, including peripheral immune-mediated destruction of all 3 cell lines. there are also other mechanisms 2/2 to drugs, etc. but they are less common


osler-weber-rendu syndrome -AD -diffuse telangiectasias, recurrent epistaxis, widespread AVMs -ruby-colored lips lesions that blanche with pressure, GI bleeds, recurrent nosebleeds, +FH -lung AVM --> R to L chronic hypoxemia and reactive polycythemia

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multiple myeloma -bone pain, fractures, weight loss, fatigue, RECURRENT INFECTIONS, normocytic anemia, renal insufficiency, hypercalcemia, monoclonal paraproteinemia


Anaphylaxis after blood products = IgA deficiency -ABO mismatch - fever/flank pain within 1 hr -anamnestic ab response = delayed mild hemolysis 2-10 days after transfusion -TRALI = resp distress within 6 hours; pulm edema, bilatareal interstitial infiltrates (due to donor anti-leukocyte antibodies)


enoxaparin --> low platelet count a few days later --> heparin-induced thrombocytopenia -Platelet factor 4 IgG heparin complex --> thrombosis and thrombocytopenia -thrombocytopenia from splenic mphage removal of HIT-antibody coated platelets

6993


HIT = test with serotonin release assay - suspect HIT in anyone with >5d heparin and plt count drop, a/v thrombosis, necrotic skin at injection sites, and anaphylactoid reactions after heparin.

2239

Medicine Infectious Diseases

age >35 = epididimitis from bladder outlet obstruction like e coli. <35 from stds like chlamydia or gonorrhoeae

2265


even if VDRL is negative, do a test with FTA-ABS if the person looks like they have syphillis. not very good test.


hiv pts higher rr for CAP than nl ppl -strep pneumoniae MC -lobar, interstitial, cavitary infiltrate


pneumocystis jirovecii pneumonia -HIV / acute resp failure pts -tx with bactrim steroids -high LDH, reticular infiltrates on imaging -sx develop over several weeks


tx anaerobic pna with clinda tx gm- pna with cipro tx cap with macrolide resistance with doxy tx pneumocystic pna with bactrim don't use mtz for anerobic pna tx due to high rates of resistance


neutropenic fever: start broad-spectrum pip/tazo. Add vanc if there is an indication: known colonization with mrsa, ivda, catheter related infection, skin/tissue infection; pna, or hemodynamic instability

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***IF SOMEONE HAS BLOOD TRANSFUSION HISTORY, CHECK THEIR HEP B AND C HIV screening indications -15-65yo, tb or STD tx 2916


ANNUAL: IVDU, MSM, prostitutes, homeless, jail, partner of HIV+ EXTRA: preg, occup exposure to blood/body fluids -s/sx; -prior to any new sexual relationship


hydatid cyst = echinococcus granulosus infxn -dogs -unilocular cystic lesions incidental -fatty food intolerance, tx with resection + albendazole; can be sometimes aspirated

2993


Mucormycosis -IC pts get necrosis of the nasal turbinates -surgx debridement, antifungals, ctrl hyperglycemia

2994


mucormycosis = tx with debridement and ampho B


Blastomycosis: -pneumonia, wartlike/violaceious lesions + ulcers, osteomyelitis, prostatitis/orchitis, abscesses/meningitis -itraconazole +/- amphotericin B if IC


MRI = temporal lobe abnormalities CSF = high white count, nl glucose, high protein normal opening pressures above = HSV encephalitis crypto meningitis = subacute for weeks, IC pts, high ICP (headache), high OPENING PRESSURE bacterial meningitis = low glugose and high protein (> 250) on CSF analysis

3007


recommend 3 week bed rest in mono pts -no abx or antivirals needed. -not contageous

3011


Amox-Clav for polymicrobial skin infections

3012


in pts with stable subacute illness, obtain serial blood cultures over several hours, delyaing abx therapy till after collection. obtain from 3 diff sites

3054


tx legionella with macrolide or fluoroquinolone


Baciliary Angiomatosis -bright red exophytic nodules in an HIV pt --- MC -Caused by bartonella henslae -tx oral erythromycin

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parvovirus B19 infection -erythema infectiosum (fifth disease) -fever, nausea, slapped cheeks; acute symmetric arthalgias (more common in children) -pure red cell aplasia -dx with B19 IgM abx in immunocompetent ppl -school teachers, daycare -nonspecific rash in adults + polyarticular arthalgia that is symmetric

3246


nearly a 1/3 of world has latent tb. Reactivation risk varies in different populations -hiv = 30-100x higher -9 months of isonizid + pyridoxine to prevent b6 peripheral neuropathy

3247


Ehrlichiosis = tick bite, fever, systemic sx, thrombocytopenia; tx with doxycycline


crypto meninoencha[elitis - tx with amphoB + flucytosine for 2 weeks, then 2 weeks fluconazole for consolidation, then maintanenece therapy for 1 year. + /- serial LPs

3259


malaria ppx -mefloquine until 4 weeks after they get back from india -chloroquine resistance is high -start it >2 weeks before starting the trip -se: anxiety, depression, restlessness in 5%

3261


dermatomyositis can cause AV block

3262


UTI with an alkaline pH is MC proteus (d/t urease production) -struvite stones d/t reduced solubility of phosphate in high pH (mg ammonia phosphate stones = struvite)

3264


ingested toxin = early vomiting after ingestion 1-6 hours


only give TIG if unsure about vaccination hisory + wound looks really bad. otherwise just a Tdap booster shot if >10 or >5 out from last booster (depending on severity of wound)


causes of diarrhea in AIDS patients crypto - <180 cd4 - severe watery, low fever micro/isosporidium - <100 - watery diarrhea, no fever MAC - <50 high fever, watery diarrhea CMV - <50 low fever, small vol diarrhea, hematochezia, abd pain


PCP pneumonia -dry cough, dyspnea, fever -"hypoxia out of proportion to radiographic findings" + b/l interstitial infiltrates on cxr -LDH elevated -bactrim + corticosteroids (decrease mortality in servere dz) -indications for steroids: paO2 <70, a-a gradient >35 on room air. -pentamidine = high adverse effects (low BP, low sugar, kidney failure, arrythmias)

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Puncture wounds -Pseudomonas most commonly if it's through the sole of a shoe since the warm, moist environment grows pseudomonas well -bony changes take >2 weeks to form -tx IV abx (cipro, zosyn)


meningococcal meningitis = neisseria -gm- diplococcus in young adolescents. loop for myalgias, DIC, adrenal hemorrhage; -ceftriaxone vanc -rifampin/cipro/ceftriaxone for sick contacts


Mononucleosis -EBV -Pharyngitis, lymphadenopathy, splenomegaly -Dx with heterophile abx test "monospot" as abs arise within a week of sx, but can be false neg in the 1st week. Will persist for 1 year in some cases -Usually will be a prolonged infection in a young person. Other infections will usually either get better or worse in a 2 week time span, but mono holds steady.


lumbar spinal stenosis >60+ back pain radiates to back and thighs worse with walking and lumbar extension; improve with lumbar flexion; numbness/parasthesias occur


Baciliary Angiomatosis -bartonella cat exposure, homelessness -advanced HIV (CD4 <100) -vascular cutaneous lesions (papular, nodular, peduncular; systemic symptoms (fever, sweats, fatigue) -lesional biopsy -doxy / erythromycin or ART


nocardia -partially acid fast gm+ branching rod -IC hosts brain lung abscess -tmpsmx or carbapenems

4478


Review this later! Vaccines for adults with HIV haemophilus vaccination is not indicated bc infxn is usually with non typable strains

4488


suspect syphillis in anyone that's sexually active. we don't routinely screen for HSV


diffuse rash + lympadenopathy + condyloma lata, grey mucous patches, hepatitis seen in 2* syphillis -epitrochlear lymphadenopathy pathognomonic

4662


Lyme Ticks -tick must be attached for >36h or be engorged -no CI to doxy -local inf rate >20% (must be endemic) -prophy started within 72 of tick removal

10301


p24 test is the 4th gen screening test

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incr rr of infection of vibrio vulnificus in pts with cirrhosis or hepatitis -cause by wound inf or ingestion -septicemia, cellulitis, rapidly progressive -iv ceftriazone, doxy

Medicine Male Reproductive System

Testicular cancer -Perform radical orchiectomy -no chemo -high cure rate

Medicine Male Reproductive System

leydig cell tumor = testosterone production. most common type. can also increase estrogen due to conversoin. seen in young people, presents with gynecomastia.

Medicine Nervous System

GBS -albuminocytologic dissociation: high protein with nl WBC -tx = supportive, IVIG, plasmapharesis


Unprovoked First Seizure -Do a CT or MRI as part of a work-up for all unprovoked seizures! -can exclude bleeds that require urgent intervention. -noncontrast -only do LP after you have excluded bleeds with CT


ALS = Upper and lower motor neuron lesions upper = spasticity, bulbar, hypperreflexia lower = fasciculations


Creuzfield-jacob -14-3-3 proteins -50-70 year olds with rapidly progressive dementia and myoclonus intracerebral hemorrhage -fast progression mins to hrs -first focal neuro signs -then high ICP (vomit, HA, bradycardia)

3060

Medicine Nervous System vs. emoblic stroke -abrupt and maximal sx at the start of the stroke

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3718


Head CT with parietal lobe hemorrhage mc due to cerebral amyloid angiopathy -spontaneous lobar hemorrhage mc cause -age>60 -same proteins as in alzeimers -hemorrhage occurs during nl activities and cause CONTRALATERAL hemineglect


Hand tremor in parkinson's disease -tx with trihexyphenydyl anti cholinergic -aka it occurs at rest and improves with activity (vs. essential tremor, which is the opposite) -usually presents asymetrically (one hand before other) -


stroke risk -htn strongest association with stroke -etoh consumption has a protective effect (higher HDL)


acoustic neuromas -NF2 -noisy ears with hearing loss on one side -do MRI -pts will be young and have cafe au lait spots


HSV Encephalitis -seen in healthy adults -lymphocytic pleocytosis -more RBCs in CSF (d/t hemorrhagic destruction of temporal lobes) -temporal lobe lesions! IV acyclovir


Angle-closure glaucoma -sudden narrowing of anterior chamber angle -prevents aqueous humor, increases IOP -more common in women >40, asians, inuit, ppl with farsightedness -severe eye pain, halos, injected, dilated, nonresp to light, headache that's bad + n/v -vision loss in 2-5 hours

4399


torticollis -caused by antipsychotics, metoclopramide, and proclorperazine

4427


Review common causes of gait disorders!


Guillain-Barre -URI or diarrheal illness precedes it -CSF shows high protein 2/2 inc permeability of the BBB. Albumin and other things are normal (albuminocytlogic dissociation); Tx = IVIG or plasmapheresis. -monitor for resp failure


Lacunar Strokes -internal capsule = one sidedpure motor hemiparesis -caused by microatheroma formation and lipohyalinosis that leads to thrombotic small-vessel occlusion -often missed on noncon-CTs


Alcoholic Cerebellar Degeneration -gait dysfunction, truncal ataxia, nystagmus, intention tremor/dysmetria, impaired rapid alternating movements (dysdiadocokinesia), hypotonia, pendular knee reflex (persistent swinging movements of the libs after liciting the deep tendon reflxes)


Cancers of the spine: -breast, lung, renal, prostate, and multiple myeloma -thoracic 2x vs. lumbar -progressive back pain worse with recumbency, point tenderness, 3+ DTRs, upgoing plantar reflexes

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Medicine Ophthalmology

age-related macular degeneration -> pts >50yo; progressive/b/l loss of central vision; peripheral fields and navigation vision are always maintained. -d/t degen and atrophy of the outer retina, RPE, bruch's membrane, and choriocapillaries


Open Angle Glaucoma -"Cupping of the optic disc" + asyx -periph vision loss -high IOP, beta blockers (timolol eye drops), laser trabeculoplasty (adjunctive) if there is a continuous increase in IOP


bacterial keratitis = contact lenses after corneal trauma with hazy cornea dacryocystitis = tear duct redness herpes keratitis = clear vesicles in the corneal epithelim. no rash outside eye.


central retinal vein occlusion --> painless monocular visual loss. amaurosis fugax --> atheroemboli (arterial) temporary vision loss + optic disk swelling optic neuritis --> MS presentation. F < 50yo ant. uveitis --> vision loss, eye is red and painful angle closure glaucoma --> super painful, blurry vision, n/v, "steamy cornea", dilated pupil.


diabetic eyes -microaneurysms, hard exudates, macular edema -cotton wool spots; newly formed vessels


acute glaucoma - tx with pilocarpine, AVOID atropine (dilate the pupil, wrosen the glaucoma) IT can even precipitate glaucoma. 1st line tx of glaucoma is to give mannitol IV. to diurese and work immediately. also acetazolamide to reduce aqueous humor production. also timolol to do the same.


Fluorescein examination = after a wood's lamp or slip lamp examination to assess for intraocular foreign objects following high-velocity injuries


sympathetic eye injury = contraleteral eye becomes inflamed when the other eye is hurt. hypersensitive to existing antigens aka "uncovered antigens"


acute retinal necrosis in HIV pt = herpes simplex. usually very painful; see wit keratitis, conjunctivitis + eye pain, visual loss, central necrosis of retina -CMV retinitis = MC in HIV pts; PAINLESS and funduscopy shows fluffy granular retinal lesions instead.


NF type 1 - 15% get optic gliomas -axillary freckling, cafe au lait spots -progressive unilateral visual loss, dyschromatopsia; exopthtlamos, optic dick looks variable. sometimes nl sometimes not

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Medicine

Medicine

types of conjunctivitis -bacterial: erythmryomicin/polymyxin-trimethoprim drops -viral: warm/cold compresses; antihistamine drops -allergic: OTC H1/decongestant; mast cell stabilizers / drops for freq episodes -adenovirus = MC pink eye. small children, caregivers, rarely bacterial superinfection

Poisoning & Environmental Exposure

caustic ingestion -IV hydration -serial cxrs to identify perforation -early endoscopic eval --> only if hemodynamically stable to assess degree of damage -avoid activated charcoal - will obstruct view during scope and does not actually help with lye, which causes immediate damage.


diphenhydramine toxicity -antihistamine + anticholinergic -confusion, drowsiness, blurry vision, dry mouth, urinary retention, hyperthermia, low bowel sounds -delirium if severe

3138

Medicine


TCA OD --> give NaHCO3 --> helps bc increase sodium to increase serum pH and extraceulluar sodium. this decreases drug affinity for sodium channels. -TCA usually bind to fast Na channels in the his-purkinje system and myocardium --> decreased conduction velocity; more repolarization; --> hypoten, qrs prolongation; ventricular arrythmias.

4511

Medicine


flank pain, hematuria, calcium oxalate crystals --> AGMA; high osm gap --> EG ingestion

11811

Psychiatric/Behavioral & Medicine Substance Abuse

In veterans with amnesia, nightmares, sleep disturbances, irritability, numbness, and hypervigilance, increased startle response, think of PTSD

Medicine Pulmonary & Critical Care

convex nail beds = digital clubbing. Get a chest xray -hypertrophic osteoarthropathy = digital clubbing + sudden onset arthropathy in the wrist and hand joints


Apical Pancoast Tumor -shoulder pain, horner's, C8-T2 neuro involvement -weakness/atrophy of handmuscles, 4/5 digits, medial arm/forearm -supraclav lymph node enlargement -wt loss


adenocarcinoma of lung -nonsmokers, clubbing, hypertrophic osteoarthorpathy -periphery -solitary nodule -stage at dx is the most important prognostic factor** -survival determined by resectability

2298

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2615


Check the PaCO2 in a patient who is acidotic. If it is high, hypoxemia is likely from alveolar hypoventilation instead of something like a PE, atelectasis, PEffusion, edema where you would have compensatory tachypnea to decrease the CO2 with a high A-a gradient

3020


ARDS -decreased lung compliance -decreased PaO2 / FiO2 ratio (<300) -nl PCWP -high pulm art pressure -decreased lung compliance -pulmonary htn

3022


asbestosis without mention of mesothelioma presents just like any ole pneumoconiosis, RLD pattern

3026


Watch out for hypokalemia and subsequent muscle weakness in pts on beta2 agonists, also EKG abnls, tremor, headaches


Bronchiectasis -cough with daily mucopurulent sputum production, dyspnea, hemoptysis, rhinosinusitis, crackles/wheezing -caused by poor bacterial clearance -can be caused by CF, RA, sjogren's, toxins, IC, A1AD -Tx with HRCT scan and f/u with PFTs and Ig quantification -Look for bronchial wall thickening, bronchial dilation, and lack of airway tapering as findings

3049


granulomatosis with polyangiitis -wegeners -whites 30-50yo -chronic rhinosinusitis, tracheal narrowing with ulceration****, cavitation in the lung, anemia of chronic disease, renal involvement (fast worsening, very common - high creatinine, high rr of ESRD) -check ANCA, tx with steroids -definitive dx by bx

3579


goospastures = linear IgG abs olong the GBM


mitral stenosis = LAE --> recurrent largyn n compression cough, displace L main bronchus upwards. 70% get afib; palpitations


Hypovolemia -diarrhea, poor diet, flat neck veins, orthostatic hypotn, orthostatic syncope -accompanied by aggressive RAAS activation: high aldo, Na reabsorption, Super low FENa (<1%)

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4024


Inpatient tx of CAP: -IV Fluoroquinolone (Moxi usually) OR Beta lactam +macrolide Outpatient tx of CAP: -Doxy or Azirthy if healthy OR, if unhealthy, then Moxi OR azithro + beta lactam ICU CAP: -beta lactam + IV macrolide or fluoroquinolone


-Mg Sulfate used for severe life threatening asthma exacerbations -Only check sputum cultures if there are risk factors for pseudomonas infection -Roflumilast = PDE inhibitor that decreases inflammation and mucociliary malfunction. Maintenance therapy for COPD.

4048


theophylline toxicity -CNS stim - headache, insomnia, seizures, n/v, arrythmias -cipro decreases clearance of theophylline -also cimetidine, erythromicin, calrithro, verapamil, cirrhosis, cholestasis, resp infs

4053


Transudate has higher pH (7.4) than exudate (<7.3)


aspirin-exacerbated respiratory disease (AERD) pseudoallergic rxn to NSAIDs -occur in pts with asthma, chronic rhinosinusitis w/ nasal polyps. -presents with asthmatic sx (cough, wheeze, chest tightness), nasal and ocular sx, and facial flushing within 30 mins to 3 hours after nsaid ingestion -incr released pro-infl leukotrienes, dec anti-infl prostaglandis. -tx with avoid nsaids


Pt with a PE that is malignant vs. infectious -do a frickin thoracentesis first, if it's loculated then you can think about doing a VATS or anything else -look for cytology


advanced dementia pts frequently have impaired swallowing, cough reflex. cannot properly form food into a bolus.supine pt = posterior portions of RUL and superior segments of RLL most affected. -clinda, amox-clav


LTOT indicated if <59 mmhg or < 89 in patients with -cor pulmonale -right hf -hematocrit >55%

4201


Non-allergic rhinitis -no allergies or assoc prodrome -poor response to oral antihistamines -tx with intranasal steroids or intranasal antihistamine spray (azelastine, olopatadine) or both

4208


A-a gradient elevated in patients with PE


RHF 2/2 to LHF or congenital heart disease is not considered cor pulmonale -loud p2, tric regurg, jvp, hepatomeg, etc.distant heart sounds (as in all copders bc of hyperinflated lungs)


Comorbid GERD and ASTHMA -microaspiration of GI contents can irritate the bronchi, leading to inc vagal tone, sore throat, morning hoarseness, and worsening cough only at night. -tx with PPI

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pulmonary auscultation exam findings - important to look over


obesity hypoventilation syndrome: -chronic r acidosis -high bicarb -can't breathe bc weight and altered lung mechanics -won't breathe becuase of decreased chemosensitivty to hypercapnia from persistent nocturnal hypoventilation

4520


Rupture of Alveolar Bleb -COPD with acute SOB, hypoxia, with dec breath sounds on one side == 2* spont. pneumothorax. Rupture of a large sac of air (alveolar bleb) can rupture and lead to leak of air into the pleural splace. -Dx CXR, no tracheal dev -tx with supp O2, consider tube thoracotomy

4536


Pts on ventilators need to have FiO2 < .6 (60%) to prevent O2 toxicity


ARDS Management -resp distress + bilateral opacities + hypoxemia -Look for hypoxemia if pt is on ventilator PaCO2 <60mmHg == poor oxygenation. Increase FiO2 or increase PEEP (preventing alveolar collapse, allowing for greater recruitment). We don't want FiO2 to be too high in the patient (< 60% pref) bc of risk of O2 toxicity - free radical formation.


SABA SABA + ICS SABA + ICS + LABA SABA + ICS + LABA + PO Steroids


Fixed upper-airway obstruction -limits air flow during in and out, which causes flattening of the Flow-Vol loop. -Usually 2/2 laryngeal edema from a food allergy (tx with epinephrine, systemic corticosteroids, and antihistamines)


Endotracheal tube placement -2-6cm above the carina -preferentially enter RM bronchus --> quiet L sounds -asym chest exp


Hodgkin's lymphoma -young patients and treatable -high risk of 2* malignancies down the line -lung, breast, thyroid, bone, GI cancers


Signs to intubate asthma/copd exacerbation -elevated or normal PaCO2 (resp fatigue) -dec breath sounds markedly -absent wheezes -decreased AMS -hypoxia/cyanosis

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Pneumonia mechanisms -Causes R to L shunting 2/2 V/Q mismatch -perfusion of lung tissue without alveolar ventilation (the alveoli get filled with inflammatory exudate, preventing effective air flow) -cannot correct hypoxemia with more FiO2. -

4718


Hypercapnia can cause reflex cerebral vasodilation that can induce seizures

4753


parapneumonic effusion -ALL are due to imbalances b/w hydrostatic and oncotic pressures glucose <60 = rheumatoid pleurisy, complicated effusion or empyema, malignant effusion, TB, lupus, or esophageal rupture. there is metabolic activity of leukocytes in the fluid which eats up the glucose

8815


tx postnasal drip with 1st gen antihistamine

11669


witnessed aspiration event followed by hypoxemia with bilateral infiltrates on cxr. aspiration pneumonitis --> acidic/sterile stomach contents aspiration, happens within hours of the aspiration event it's PNEUMONITIS not PNEUMONIA

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Medicine

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Medicine

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Medicine

Renal, Urinary Systems & Electrolytes

FHH = normal or slightly elevated PTH levels in the setting of hypercalcemia that is asx


Hypovolemic Hypernatremia: -pt gets NS until euvolemic, then give 5% dextrose -finally can switch to free watch when pt is not shocky -correct slowly or else cerebral edema


Hepatorenal syndrome: splancnic vasodilation --> blood gets diverted away from the kidneys; any insult that would decrease intravascular volume flow can precipitate hepatorenal syndrome


scrotal l sided varicoecele in a patient with the RCC trifecta = metastatic RCC. flank pain, hematuria, palpable abdominal renal mass) +/- family history, ectopic EPO producton --> polycythemia (sometimes)


calcium oxalate = envelope shaped = radioopaque on xray -ca phosphate stones in 1* hyperPTH, RTAs -Uric acid stones - cell turnover, dehydration, -struvite = alkaline urine - proteus


uncomplicated cystitis: tx first with bactrim or nitrofurantoin or fosfomycin. If there are contraindications to the above, then consider fluoroquinolones. -cystitis becomes complicated if it's in a man, dm2, ckd, pregnancy, IC, UTObstruction; hospital-acquired infection


ureteral colic --> vagal rxn --> ileus needle shaped crystals = uric acid stones = radiolucent, need CT or IV pyelography -can apparently precipitate ileus.


2633

Medicine

2803

Renal, Urinary Systems & Medicine Electrolytes

2810

2817

Medicine

Medicine

avoid loop diuretics in hypercalcemia aspirin tox -met acidosis (low bicarb) -resp alkalosis (high CO2)


RTA -metabolic acidosis with hyperkalemia!!! -renal dysfunction -non-anion gap metabolic acidosis and hyperkalemia that occur out of proportion to renal dysfunction indicates an RTA. Hyperkalemia and met. acidosis are normal parts of CKD, but you would expect your BUN/Cr to be very elevated at that point and the patient would likely be on dialysis -RTA type 4 = hyperkalemic RTA and is seen when you have impaired function of the collective tubuls due to aldo deficiency. DM.


1* Adrenal Insufficiency (Addison's) -low cortisol, low adrenal sex hormone, and aldosterone secretion -high K, low Na --- NL AG met acidosis


Aspirin 1. AG metabolic acidosis due to decreased elimination of organic acids (lactic, keto) 2. Medullary resp centers of the brain - tachypnea and resp alkalosis

2820

Medicine

2821


post-ictal lactic acidosis is transient and resolves in 90 minutes. -due to skeletal muscle hypoxia and impaired hepatic lactic acid uptake

2826


loop diuretics will cause a metabolic alkalosis eventually -loss of Na; volume contraction; high aldo levels --> secrete H in urine.

3061

Medicine


AIN: bactrim, cephalosporins, nsaids, occasionally mycoplasma -maculopapular rash, fever, arthralgias -AKI, wbc casts, urinary eosinophils, edema -tx glucocorticoids

3085

Medicine


Diuretic Abuse -dehydrated patient who continues to have high UNa and UK


Calcium Oxalate stone prevention -low Na diet -> decreases Ca excretion -> prevent stones -also consider HCTZ -fructose may worsen calciuria -high vit C increases oxaluria (restrict chocolate, tea, peanuts)

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Medicine

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Abnormal Platelet Fxn in CKD -ecchymoses and epistaxis are the only major bleeding manifestations now bc of dialysis -Uremic coagulopathy can still cause gi bleeds, hemopericardium, subdural hematoma, and surg site bleeding -uremic toxin = ganidinosuccinic acid accumulation = nl PT, PTT, TT; prolonged bleeding time to fix coagulopathy: DDAVP, cryo, conjugated estrogens


glomerular hyperfiltration earliest sign of T2DM. will cause intraglomerulatr HTN and lead to damage and renal fxn loss. NEXT comes thickening of the GBM. FOLLOWED by mesangial expansion. Nodular sclerosis is an endpoint that is specific for diabetic nephropathy


acyclovir, MTX, sulfonamides, ethylene glycol, and protease inhibitors can cause a crysta-induced AKI where the kidney excretes the drug but it has low solubulity and clumps up the tubules leading to an AKI. Seen 1-2d after starting the IV drug. dc drug, fluids.


AA Amyloidosis -seen in chr infl conditions RA IBD -osteo, TB -beta2 microglobulin, transthyretin -cause a nephrotic syndrome and bilaterally enlarged kidneys

4027

Medicine


URIC ACID STONES = tx with potassium citrate to alkalinize urine CALCIUM OXALATE STONES = tx with HCTZ to re-absorb calcium

4034

Medicine


prolonged prerenal will lead to ATN


Renal Transplant Dysfunction -Immediate rejection - oliguria, hypertension, bun/cr up; MAY OR MAY NOT BE acute rejection. Could also be ureteral obstruction, cyclosporine tox, vasc obstruc, ATN -tx with high dose IV steroids

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Medicine

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Medicine


Thiazides -impair insulin release from panc and glucose use i the periphery -causes glucose intolerance as a side effect in patients -dose dependent -causes low Na, K, Mg, and high Ca; reduce

4337

Medicine


HOLD metformin in AKI as it can cause lactic acidosis. Should be withheld until Renal Fxn improves

4379

Medicine


amikacin can cause ARF and is used to treat MDR pyelo


Inclusion Body Myositis -adult-onset musc weakness + atrophy -usually present with dysphagia -2/2 other medical conditions, poor free h2o intake

4424

Medicine

4435


COPD exacerbation tx: Be careful with using diuretics to alleviate sx of cor pulmonale as they can lead to AKI *(prerenal)

4491


avoid ct contrast AKI -IV fluids, isotonic bicarb, acetylecysteine (vasodilatory/antioxidant properties)

4502

Medicine


no good screening tools for bladder cancer. mean age of dx 65 in smokers and chemical exposure ppl mostly

4591

Medicine


Edema in nephritic syndrome is usually 2/2 decreased GFR and retention of water and sodium by kidneys

4733


Urinary Retention in H1s given to elderly -detrusor muscle contraction is impaired; poor voiding ability -inc risk in males bc BPH

10287

Medicine


microscopic hematuria = glomerular. Will see blood and protein on UA + RBC casts. Non-microscopic hematuria = blood, no protein. nl appearing RBCs. proteinuria and transient gross hematuria after haryngitis = I gA nephropathy (starting <5d of URI)

11109

Medicine


alpha blockers kidney stones -sympathetic activation --> alpha receptors in the urinary tract clamp down; use alpha blockers to open up the pathways -facilitates stone passage and reduces the need for analgesics


URGE INCONTINENCE -detrusor overactivity -tx 1st with bladder training (kegels) -reduce caffeine, etoh, etc. -oxybutynin = antimuscarinic to tx by reducing ach activity -monitor for urinary retention

12033

Medicine

2144

paget's bone -skull, spine, and long bones -HA, hearing loss -spinal stenosis, radiculopathy -bowing, fracture, arthritis Rheumatology/Orthopedics -giant cell tumor, osteosarcoma Medicine & Sports -high alk phos, high PINP, urine hydroxyproline -nl ca and phos -xray showing osteolytic or mixed lytic/sclerotic lesions bone scan shows focal inc in uptake bisphosphonates to tx

2305

Medicine

Rheumatology/Orthopedics no crystals in arthrocentesis = no gout attack. treat as OA --> & Sports diclofenac

2314

Pseudogout ->65, monoarticular arthritis, chondrocalcinosis -MC knees and ankles -occurs in the setting of trauma, overuse, or medical illness Rheumatology/Orthopedics Medicine -inflammatory effusion + rhomboid shaped positively & Sports birefringent cyrstals -tx with rest, corticosteroids, and arthocentesis *key difference vs. urate gout is the chondrocalcinosis!*

2315

Medicine

Rheumatology/Orthopedics felty syndrome = advanced RA assoc with splenomegaly, & Sports neutropenia

3169

Medicine

Rheumatology/Orthopedics cyclophosphamide = hemorrhagic cystitis but also bladder & Sports cancer and myelosuppresion

3171

WORK IN A FUCKING DAY CARE CENTER = PARVO Rheumatology/Orthopedics Medicine -FUCK & Sports -polyarticular symmetric arthritis in adults. tx with nsaids

3177

sarcoidosis Rheumatology/Orthopedics Medicine -young AA with hilar adenopathy, hypercalcemia, skin lesions, & Sports uveitis, ACE level high

3208

Dermatomyositis: -prox, symmetric muscle weakness -heliotrope rash + grotton's papules -ILD, dysphagia, myocarditis -Dx with high CPK, aldolase, LDH, anti Jo1 mi2 Rheumatology/Orthopedics -Do an EMG or bx if you are suspicious Medicine & Sports -tx with high dose steroids AND a glucocortidoid-sparing agent. -SCREEN FOR MALIGNANCY *15% inc risk for ovarian, lung, panc, stomach, colorectal cancers; NHL.

3209

polymyositis is assoc with ILD, myocarditis, and malignancy Rheumatology/Orthopedics -tx with systemic glucocorticoids, methotrexate, azathioprine Medicine & Sports -lower extremity weakness precedes upper extremity weakness

3303

per anserinus pain syndrome = PAPS -medial knee pain, focal tenderness. -pain over the anteromedial tibia caused by overuse, trauma, or abnormal gait. Rheumatology/Orthopedics patellofemoral: women, worse with activity or prolonged sitting, Medicine & Sports creptius -prepatellar bursitis - pain and swelling over patella after trauma. -medial compartment OA - pts >40y, stiffness pain of joint. xray = narrowing of joint space, osteophyte formation

3304

Paget's Dz of Bone (AKA osteitis deformans) -Isolated elevated of Alk Phos in the 400s that is asx Rheumatology/Orthopedics -Alk phos found in the hepatobiliary tree and the bones Medicine & Sports -caused by osteoclast dysfunction --> defective osteoid formation -osteolytic/sclerotic mixed lesions everywhere

3318

-RA pts should be on MTX asap to prevent joint damage progression. NSAIDs only provide sx relief; glucocorticoids block sx + reduce progression but not as good as DMARDS (also result in eventual bone loss). Rheumatology/Orthopedics Medicine choose from: mtx, hydroxycholoroquine, sulfasalazine, & Sports leflunomide, azt) - dmards before starting mtx, check for hep b/c/TB. If no response in 6 months, start etanercept, infliximab as step-up therapy.

3322

Medicine

3576

de quervain tenosynovitis = new mothers who hold their Rheumatology/Orthopedics Medicine infants with the thumb outstretched. abductor pollicis longus & Sports and extensor. stupid fucking question

3778

Medicine

3815

Behcet Dz -middle easten young adults with oral ulcers that are recurrent, Rheumatology/Orthopedics Medicine genital, eye lesions, erythema nodosum, acne, thrombosis & Sports -path: exaggerated skin ulceration with minor trauma -bx: vasculitis of the different sized vessels

4047

avascular necrosis Rheumatology/Orthopedics -common complication of SLE Medicine & Sports -inc rr in pts on glucocorticoids -xray may be normal, f/u with MRI if clx suspicion

4083

Medicine

4123

paraneoplastic syndromes with lung ca include LEMS, dermatomyositis, myasthenia. Rheumatology/Orthopedics -dermatomyositis: symmetrical prox muscle weakness, Medicine & Sports erythematous rash ont he dorsum of the fingers (grotton's sign) and/or upper eyelides (heliotrope rash). It effects peripheral nerve and/or muscle.

4205

Bone spur = cervical spondylosis Rheumatology/Orthopedics -10% of ppl >50yo Medicine & Sports -limited rotation, lateral bending of neck -aka osteophytes (low specificifity)

4295

check blood smears every 3 months in pts taking mtx. can Rheumatology/Orthopedics also cause ILD, alopecia, hepatotoxicity. Medicine & Sports hydroxychloroquine = g6pd exacerbation cyclosporine = nephrotoxic, viral infection predisposition

Rheumatology/Orthopedics anti scl 70 = topoisomerase 1 = systemic sclerosis & Sports

Rheumatology/Orthopedics uric acid tophi = white chalky blobs in the fingers. bad gout. & Sports

Rheumatology/Orthopedics acute back pain and point tenderness after lifting = vertebral & Sports compression fracture.

4328

4368

systemic sclerosis -tissue fibrosis that is insidious, vasc dysfxn -telangiectasias, sclerodactyly, digital ulcers, calcinosis cutis, Rheumatology/Orthopedics Medicine contractures of extremities, esoph dysmotility, dysphagia, & Sports dyspepsia, raynaud's -complications: ILD, pulm arterial HTN, HTN, renal crisis (MAHA), pericardititis/effusion Eval of LBP: 1. radiograph + ESR. 2. MRI if 1. is abnormal or if there are neurological deficits. 3. bone scan if MRI is not feasible. Only do #1 if there are alarm symptoms. Otherwise Rheumatology/Orthopedics Medicine the LBP doesn't need imaging. & Sports Alarm sxs: >50yo, history of ca, fever, wt loss, nocturnal pain, no response to pain tx, neuro deficits

4369

lumbar spinal stenosis -thickened ligamentum flavum -back pain radiating to thighs, seen in degen arthrtis with Rheumatology/Orthopedics Medicine osteophyte formation affecting the facet joints (spondylosis). & Sports -the s/sx are posture-dependent; extension of the lumbar spine = narrows spinal canal, worse sx. flexion = nl no pain ("neurogenic claudication")

4460

Medicine

4565

AVN = groin pain on weight brearing -no redness swelling or point tenderness Rheumatology/Orthopedics -normal esr, crp, white count Medicine & Sports MRI to dx -trochanteric bursitis = lateral hip pain localized, caused by friction of the tendons

4574

Medicine

4583

posterior knee pain swelling or stiff = baker cyst Rheumatology/Orthopedics can lead to venous compression = swelling Medicine & Sports can dissect into the calf = red, edema rupture = ecchymosis, acute calf pain

8895

ACL tear = pulled forward easily relative to the femur -assoc with sig. knee effusion d/t hemarthrosis. dx confirmed on MRI. Rheumatology/Orthopedics vs. MCL tear --> laxity on abduction; not usually assoc with Medicine & Sports hemarthrosis. vs. meniscal tear --> subacute sx, sx develop slowly vs. stress frac of tibial plateau --> fat ppl starting to exercise 1st time after long time.

8933

Medicine

Rheumatology/Orthopedics aortic aneurysm is a complication of giant cell arteritis & Sports

Rheumatology/Orthopedics RA joint involvemt = cervical spine. trigger finger. RA nodules & Sports on elbows.

Rheumatology/Orthopedics pseudogout = rhomboid crystals & Sports gout = needles, negatively birefringent

UWorld Notes part 2

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