Internal Medicine shelf and boards Flashcards

Terms Definitions
pathophysiology of stable angina
oxygen demands of the heart exceed the supply --> inadequate perfusion
clinical presentation of stable angina
pain lasts 10-15 minutes
heaviness, pressure, squeezing chest discomfort (rarely described as frank pain)
usually brought on by exertion or emotion
relieved with rest/nitroglycerin
what relieves stable angina?
what part of the heart does the LAD supply
anterior interventricular septum
what does the RCA supply
SA and AV node
inf. LV (via posterior desc artery)
what does a resting EKG look like in a person with stable angina
usually looks normal
what EKG finding is consistent with prior MI?
Q waves
how sensitive is a stress EKG in dx CAD?
75% sensitive if the target HR reaches 85% of maximum HR
what is seen on EKG when there is exercise induced ischemia
subendocardial ischemia --> ST segment depression
other than EKG findings what other things are seen in + stress test
onset of heart failure
ventricular arrhthmia
what is the next step if a pt is found to have a + stress test?
cardiac catheterization
what info can be obtained from cardiac cath?
intracardiac pressure measurements
O2 sat
what are the indications for performing cardiac cath?
+ stress test
non-dx non-invasive tests
angina that occurs despite medical tx
angina occurring soon after MI
urgent dx needed
evaluation of valvular dz
determine need for surgery
what is the cutoff for significant coronary stenosis?
>70% stenosis is significant
main purpose of coronary angiography?
ID pts with severe CAD to determine whether revasc is needed
advantages of echocardiogrphy
more sensitive in detecting ischemi a
assessment of LV size and fxn
dx valvular dz
what is seen on echocardiography in a pt with exercise induced ischemia
wall motion abnormalities not present at rest (eg akinesis or dyskinesis)
how can reversible ischemia be treated surgically?
what is the purpose of administering radioisotopes during exercise while imaging myocardial perfusion
viable myocardial cells take up radioisotopes from the blood
if there is no uptake, then the myocardial tissue si dead and not taking up any blood
what drugs can be given in pharmacologic stress test?
effect of adenosine in pharmacologic stress test
coronary vasodilation
b/c dzd coronary arteries are already maximally dilated at rest to increase blood flow, they receive less blood flow when coronary system is pharmacologically vasodilated
effect of dipyramidole in pharmacologic stress test
coronary vasodilation
b/c dzd coronary arteries are already maximally dilated at rest to increase blood flow, they receive less blood flow when coronary system is pharmacologically vasodilated
effect of dobutamine in pharmacologic stress test
increases myocardial o2 demand by increasing HR, BP, and contractility
1st line medical tx for stable angina
BAN chest pain
Beta blockers (reduces frequency of coronary events)
ASA (decreases morbidity and reduces risk of MI)
Nitroglycerin (--> general vasodilation)
2ndary tx for stable angina
--> vasodilation and afterload reduction
methods of revascularization of coronary arteries
benefits of revascularization of coronary arteries
does NOT reduce incidence of MI
will significantly improve sx
what is PTCA
using a balloon catheter to open up an occluded BV
when should PTCA be considered
proximal lesions in 1-2 vessel dz
what is a common complication of PTCA
restenosis (40% w/i first 6 months), but if there is no evidence of restenosis at 6 mo, it is unlikely to occur
(can also be improved with stents)
when is CABG indicated
pts with left main dz
3 vessel dz w reduced LV fxn
2 vessel dz w proximal LAD stenosis or severe ischemia
pathophysiology of unstable angina
o2 demand is unchanged
supply is decreased 2/2 reduced resting coronary flow
indicative of stenosis that has enlarged via thrombosis, hemorrhage, or plaque rupture --> total occlusion of coronary vessel
clinical presentation of unstable angina
increasing frequency, duration, and intensity of chest pain
angina at rest
dx of unstable angina
r/o MI
perform stress test only when medically stable or just undergo cardiac cath intially
medical tx of unstable angina
B blockers
LMWH to prevent thrombus (give for 2+ days)
glycoprotein IIb/IIIa inhibitors
examples of glycoprotein IIb/IIIa inhibitors
what should the PTT be kept at in unstable angina
long-term medical management of unstable angina
beta blockers
(BAN chest pain)
Pathophysiology of prinzmetal's angina
transient coronary vasospasm, usually accompanied by fixed atherosclerotic lesions (75% of time)
EKG changs in prinzmetal's angina
transient ST elevation on EKG during chest pain = transmural inschemia
what does ST elevation represent
ST depression?
transmural ischemia
subendocardial ischemia
what is given to pts to dx prinzmetal's angina during coronary angiography
ergovine to provoke chest pain, and shows coronary vasospasm
drugs helpful in treating prinzmetal's angina
development of MI
atheromatous plaque ruptures into vessel lumen, and thrombus forms on top of this lesion --> occlusion of BV
common cause of sudden cardiac death
effect of morphine on BP
--> vasodilation
effect of PVCs on SV and coronary artery filling time
lowers both
combo of antithrombolytic regimens that have the most benefit following MI
tPA and IV heparin
when should thrombolytic tx be given when there is chest pain?
ST elevations in 2 contiguous EKG leads in pt with pain onset w/i 6 hrs, who have not responded to nitro
alternative thrombolytic tx to tPA
alternative to thrombolytic tx in tx of MI
PTCA (reduces mortality more than tPA)
contraindications for thrombolytic tx
active PUD
previous stroke
dissecting aortic aneurysm
uncontrolled HTN
recent surgery
Q wave infarct indicates what type of infarction?
ttransmural, large
non-q wave infarct indicates what type of damage
subendocardial, smaller
similar presentation to unstable angina (look at cardiac enzymes for differentiation)
which is the first biomarker elevation seen following MI
myoglobin (not cardiac-specific)
when does CK-MB become elevated following MI? how long is it ielevated for?
48-72 hrs
frequency of CK-MB measurements following MI
measured on admission, then q8h for 24 h
when does troponin increase following MI?
how long are they elevated for?
how frequently should they be checked
3-5 hrs
5-14 d (peak in 24-48 hrs)
q8h for 24 h
in MI, which agents have been shown to reduce mortality
ACE inhibitors
treatment of mild CHF
ACE inhibitors
when should a person receive electrical cardioversion for VT?
When should a person receive antiarrhythmic tx for VT?
hemodynamically unstable
hemodynamically stable
tx of Vfib following mi
defibrillation and CPR
tx for sinus tachy following mi
treat underlying cause (usuallly d/t pain, anxiety, fever, pericarditis, meds, etc)
tx for sinus brady following mi
sinus brady is somewhat protective in that it reduces myocardial o2 demand
no tx necessary, just monitor, unless brady is very severe, then give atropine to increase HR
tx of asystole
begin with defibrillation to tx VFib, b/c it is more common and may be difficult so differentiate from asystole
if it is clearly asystole, treat with transcutaneous pacing
where are EKG changes seen in anterior infarct
Q waves in V1-V4
st elevation in V1-V4
where are EKG changes seen in posterior infarct?
R wave in V1, V2
ST depression in V1, V2
Upright and prominent T waves in V1, V2
where are EKG changes seen in lateral infarct
Q waves in I and aVL
EKG changes seen in inferior infarct
Q waves in II, III, aVF
what can cause improper o2 utilization?
cytochrome impairment, seen in CN poisoning, diptheria
what is the #1 cause of acute and chronic cough?
other common causes for cough?
postnasal drip syndrome
etiology of postnasal drip syndrome?
any cause of rhinitis
mechanism of cough in postnasal drip
secretions drip into hypopharynx triggering cough reflex
tx of postnasal drip syndrome if caused by a "cold"
1st generation antihistamines and decongestant
tx of postnasal drip syndrome if caused by allergic rhinitis
nasal corticosteroids
nasal cromolyn
nonsedating antihistamines
what is acute sinusitis '
chronic sinusitis
bacterial infx w an obstructed maxillary sinus
sinus inflammation for 3+ mo
si/sx of sinusitis
nasal discharge
sinus pain worse when bending forward
tenderness to percussion over sinuses
tx for acute sinusitis (specific drugs_)
amoxicillin or TMP-SMX x 1-2 wks
complication of untreated chronic sinusitis
preseptal or periorbital cellulitis
orbital cellulitis
epidural, subdural, or cerebral abscess
dural sinus venous thrombosis
bacteria commonly associated with acute bacterial sinusitis
S. pneumo
H. flu

sinusitis also caused by virus, fungus, allergy
when would you consider a cold vs. acute bacterial sinusitis
if a pt has a cold >8-10 days, or if cold sx improve and then worsen after a few days, consider sinus infx
organisms associated with chronic sinusitis
S. aureus
what is the "drying effect" seen with antihistamines
makes secretions thicker and can worsen congestion
tx of chronic sinusitis
broad-spectrum penicillinase resistant ABx
organism that causes whooping cough
B. pertusssis
how long does immunity last affter given immunization for pertussis
12 years after last administration
what are the stages of whooping cough?
catarrhal stage (1-2 wks, mild URI sx)
paroxysmal stage (2-4 weeks, prolonged paroxysmal cough, worse at night)
Conalescent Stage (gradual improvement of sx)
Dx of whooping cough
nasopharyngeal swab and culture
what causes the classic "whoop" in whooping cough?
rapid air inspiration against a closed glottis
tx of pertussis
macrolide abx which will reduce sx if started w/i 8 days
organisms causing community acquired typcial pneumonia
S. pneumo
H. flu
(normal inhabitants of the nasopharynx)
organisms causing atypical community acquired pneumonia
Chlamydia pneumo
M. pneumo
organisms causing hospital acquired pneumonia
S. aureus
Enteric orgs
typical sx of pneumonia
cough + sputum production
pleuritic chest pain
recommended preventive measures for pneumonia
flu vaccine
pneumococcal vaccine
sx of atypical pneumonia
sore throat
nonproductive cough
GI sx
clinical signs associated with typical CAP (community-acquired pneumo)
pulm exam:
late inspiratory crackles
bronchial breath sounds
increased tactile fremitis
pleural frinction rub (assocated with pleural effusion)
CXR findings of CAP
lobar consolidation
multilobar consolidation (v. serious)
clinical signs of atypical CAP
pulse-temp dissociation (noral pulse in setting of high feveR)
wheezing, rhonchi, crackles
which organisms --> pneumonia in upper lobes?
which organisms cause pneumonia and small cavities w/o air-fluid levels
which orgs cause pneumonia w large cavities + air fluid levels
which orgs cause diffuse bilateral infiltrate pnuemonia
what lab finding might suggest PCP
high LDH
what lab finding might suggest H. flu
small GNR with halo
what lab finding might suggest Legionella
no bacteria on gram stain
pneumonia + hyponatremia
what lab finding might suggest mycoplasma
no bacteria on gram stain
what are the steps that should be taken in a pt who comes into the hospital with suspected pneumonia
CBC and diff
O2 sat
2 pretreatment blood cultures
gram stain and culture of sputum
ABx tx
mechanisms for developing pleural effusions
increased drainage of fluid into pleural space
increased production of fluid by cells in pleural space
decreased draining of fluid from pleural space
what can cause increased drainage of fluid into pleural space
elevated capillary pressure in visceral or parenteral pleura (ex CHF)
decreased plasma oncotic pressure
increased permeability of pleural surfaces
what can cause decreased drainage of fluid from pleural space
decreaesd lymphatic flow d/t damage to pleural membranes or vasculature
etiology of pleural effusion
malignancy (esp lung, breast)
cirrhosis with ascites
clinical features of pleural effusion
often asymptomatic
peripheral edema
paroxysmal nocturnal dyspnea
signs of pleural effusion
dullness to percussion
decreased brerath sounds over effusion
decreased tactile fremitus
dx of pleural effusion on cxr
blunting of costophrenic angle
best to use lateral decubitus
how much fluid is required in order for pleural effusion to be detected on cxr
250 ml
what is the most reliable imaging to dx pleural effusion
ct scan
what is the role of thoracocentesis
can be diagnostic in 75% of cases
cna be therapeutic (drain large effusions)
what lab tests should be done on fluid obtained from thoracentesis
cell count (CBC + diff)
what should be considered when there is elevated pleural fluid amylase
esophageal rupture
renal failure
what is a chylothorax
milky, opalescent fluid (lymph in pleural space)
what does a bloody pleural effusion represent
pulmonary infarction
aortic dissection
what are characteristics of exudative effusions
pleural protein/serum protein >.5
LDH (pleural)/LDH (s) >.6
LDH > 2/3 upper limit of normal serum LDH
common causes of exudative pleural effusions
common causes of transudative pleural effusions
treatment of transudative effusions
Na restriction
therapeutic thoracentesis
tx for exudative effusions
treat underlying dz
tx for parapneumonic effusions
ABx if uncomplicated
intrapleural injection of thromboytic agents to accelerate drainage
surgical LOA
common cause of pleural fluid wiht glucose <60
rheumatoid arthritis
(also TB, esophageal rupture, malignancy, SLE)
what is a parapneumonic effusion
a pleural effusion associated with pneumonia
most are uncomplicated
w/u for sycope dx
most common cause for syncope in adolescence
vasovagal syncope
most common cause for syncope in elderly (broad)
cardiac conditions
definition of orthostatic hypotension
HR increases by 10
BP decreases by 20 systolic or 10 diastolic
pt has sx

2+ criteria must be met
4 triggers for situational syncope
micturition syncope
Carotid body sinus hypertension
post-tussive syncope
ekg criteria for syncope
VT (>150 bpm) --> VF --> death
delta waves (WPW)
increased QT interval
what does increased QT interval -->
increased risk of torsades de pointes
what are the conditions that have AST > ALT
what is the ratio
EtOh liver dz
Wilson dz
what are the 3 specific test that deal with liver fxn
is ALT affected in liver dz, cholestatic dz, or both?
H: ++++
C: +
is albumin affected in liver dz, cholestatic dz, or both?
H: low/nml
C: none
is AST affected in liver dz, cholestatic dz, or both?
H: ++++
C: +
is GGT affected in liver dz, cholestatic dz, or both?
H: +++
C: +++
is PT affected in liver dz, cholestatic dz, or both?
H: +/nml
C: +
is Alk-phos affected in liver dz, cholestatic dz, or both?
H: ++++
C: ++++
is bilirubin affected in liver dz, cholestatic dz, or both?
H: +
C: ++++
where is alkaline phosphatase made?
epithelium of hepatic ducts
why is PT affected in cholecystic dz?
if there si no bile production/secretion, then vit K can't be absorbed
what ist he first thing to rise when the liver fails?
causes of nephrotic syndrome --> >10 proteinuria
minimal change dz
membranous GN
Ranson criteria mnemonic for 1st 24 hrs
Glu > 200
Age > 55
LDH >350
AST >250
WBC > 16,000
dx test for osteomyelitis
what is teh most potent stimulus for ADH secretion
when should you treat HTN with IV
htn emergency... evidence of end-organ damage, encephalopathy, microangiopathy
causes of post-surgical htn
bladder distension
increased volume with renal insuff
what are the GFRs of the stages of renal failure
Stage 1 >90
Stage 2 60-90
Stage 3 30-60
Stage 4 15-30
Stage 5 <15
if there is a HTN emergency, what is the recommended reduction of BP
decrease by 15-20%
which anti-HTN med should be avoided in pregnancy
clinical features of pericarditis
pain improves with leaning forward
benefits of heparin/LMWH
fast acting
coumadin --> skin necrosis
drawback of LT heparin/LMWH use
tests used to dx PE
VQ scan
spiral CT
benefit to VQ scan

downside to VQ scan
no dye

poor sensitivity, poor availabilty
benefit of spiral CT
quick, and readily available
what is TEE good for?
visualizing large saddle emblism
what HTN medication is 1st line in DM
slows progression of renal dz in pts with DM and proteinuria
what is the max BP recommended in DM
if diastolic is <80, 50% reduction in CV mortalitity
what type of murmur would you get wtih bicuspid aortic valve
early systolic click + aortic murmur
what effect does weight loss have on BP
for every 1kg lost, BP decresaed 1 pt systolic adn diastolic
what effect does B-blocker have on K
what asssociation is there btwn OSA and HTN
OSA is associated with HTN
what is gestational HTN treated with
ACE-I contraindicated --> oligohydramnios, renal, and maturation failure + death
atenolol --> intrauterine growth retardation + low placental weight
what does a 20% increase in Cr after ACE-I tx suggest
renal artery stenosis
what is the tx of choice for blacks with HTN
--> decreaed proteinuria and increased GFR
how should exercise induced asthma be managed
proph use of inhaler 5-10 mins before exercise
features of mild persistent asthma
sx present >2+ days/week, >2x month at night
MOA of ipratropium bromide
blocks muscarinic receptors preventing bronchoconstriction, only for acute exacerbations
what type of lung dz is seen in myasthenia gravis
sx worse at night and occur from muscle weakness
what is intermittent asthma?
sx <1/wk, nocturnal sx 2 or less/wk, brief exacerbations
what is moderate persistent asthma
sx qd, nocturnal sx >1/wk, exacerbations may affect activity and sleep
severe persistent asthma
daily sx, frequent nocturnal sx and exacerbations
quick relief meds for asthma
albuterol (B2 agonist)
anticholinergics (ipratropium)
systemic corticosteroids
what is the most common cause of intrinsic renal failure?
2nd most common cause?
what causes AIN?
clue to suspect AIN?
(look for eos in blood and urine)
sx of acute pyelonephritis?
who usually gets it?
high fever, flank pain, pyuria
kids with urovescular reflux
sx of Reiter's syndrome
asymmetrical non-infectious polyarthritis
Achilles tendonitis
all followed by self liited diarrhea
si/sx of Felty syndrome
chronic RA
high titers of RF
subcutaneous nodules
which drugs --> neutropenia
when should you suspect a complicated parapnuemonic effusion
pleural fluid >50,000 WBC
orgs in fluid
decreased pH of fluid
what are potential complications of parapneumonic effusions?
how to treat?
loculation and adhesions
drain it with a chest tube
tx of advanced nurologic lyme dz
IV ceftriaxone x 10-21 days or IV PCN 10-20 d
what signifies a + PPD in a low risk population
15mm induration
potential complication of nephrotic syndrome
increased coagulation b/c losing anticoag proteins in urine
also losing volume --> intravasc depletion
tx of renal dz based on classification in SLE
type 1 and 2 - no tx, monitor complemetn levels and ANA studies
type 3,4 - tx with corticosteroids
type 5 - tx with cyclophosphamide
sx of types of renal dz in SLE
type 1: non observable renal involvement
type 2: mesangial form, focal and segmental glom involvement, slight proteinuria and minimal hematuria
type 3: <1/2 of all glomeruli, but --> extensive damage
type 4: most severe form of dz, nephrotic and nephritic syndrome, with involvement of almost all glomeruli, wire-loop abnormality
type 5: primary membranous glomerulonephritis
si/sx of lepramatous leprosy
granulomas with AFB
nodular lesions in skin
areas of anesthesia
bilateral ulnar neuropathy
tx of leprosy
dapsone + clofazimine + rifampin x 2 yrs
what is the #1 cause of bronchiectasis in young adults
cystic fibrosis
size of RBCs in hemolytic anemia
risk factors assoc with developing gonococcal arthritis
60% of solitary pulmonary nodules are categorized as...
benign granulomas
"popcorn" calcification on imaging
25% of pts with HBV present w:
causes for persistently wide-split S2
pulmonary stenosis
ectomic/pacemaker beats
T/F? PTH released by neoplasm is identifiable on IRMA
when should a PTH adenoma be removed
when pts have sx of hyper parathyroidism or asx with very high Ca levels, increased urinary Ca excretion, or extreme bone loss
#1 cause of increased PTH
increase fluid intake to prevent stone formation
how do high TG levels affect amylase/lipase levels
they can falsely decrease levels
how does pancreatitis affect Ca and CRP
decresaes Ca
increases CRP
what is the classic radiologic sign of pancreatitis
air filled loop of small bowel in LUQ
what is the most cost-effective way to prevent sudden cardiac death
careful H&P
what is the most common electrolyte abnormality seen in hospitalized HIV pts
impared excretion of free water, hypotonic fluid administration, CMV, mycobacterium --> destructive adrenalitis
ketoconazole can impair adrenal GC and MC production
pulm and CNS production --> SIADH
what is the first thing you do if a pt is actively hemorrhaging
give 3L+ of crystallokd soln for every L of blood lost
DDx of persistent non-bloody diarrhea in HIV
how to dx?
check AFB in stool
features of TB diarrhea
what drug can be used to decrease frequency of migraines
tx of struvate stones
caused by?
stones are soft, tx w percutaneous nephrostomy (caused by proteus)
how does scleroderma affect esophagus
msucle tissue in esoph is replaced by fibrotic, scar like tissue
what GI probs are associated with scleroderma
pneumatosis cystoides intestinalis
sacculations in colon and ileum
biliary cirrhosis
poorly functioning small bowel --> nutrient deficits
what is the #1 cause of acute pericarditis
renal failure (uremic pericarditis)
sx of polychondritis
bilateral swelling of external ears, nose, arthralgias, esp in costochondral joints
sx of Behcet syndrome
oral and genital ulcers, arthritis
which type of thyroid ca is associated with MEN
how to treat nosocomial infx introduced from an outside line
remove the line
what effect do TCAs have on the heart
they prolong the QT interval
what can happen to the parotid gland in sjogren's syndrome
it gets enlarged in 1/3 of cases
sx of MAI
FUO, weight loss, GI dz
what does PMR have a strong association w
temporal arteritis
association of pancreatitis with ARDS
occurs 3-4 days after acute pancreatitis
tx protocol for infective endocarditis
unless condition is critical, get 3 blood samples over 24 hrs before treating
would you expect to hear murmur in r-sided infective endocarditis
tx of severe aplastic anemia
cause of sudden acanthosis nigricans in elderly
other causes of it?
gastric ca

acromegaly, cushing's hyperthyroid, glucose intolerance
which dzs are associated with cd4 count <500
which dzs are associated with cd4 count <200
which dzs are associated with cd4 count <50
typical sx of legionella
GI sx
currant jelly sputum
rusty sputum
post-influenza pneumonia
bulging fissure on cxr
no bacteria on gram stain in resp infx
what infx is elevated LDH associated with
which pulm infx are associated with infiltrates in the UL
which pulm infx are associated with small cavities w/o air-fluid levels
which pulm infx are associated with large cavities wih air-fluid levels
which pulm infx are associated with diffuse bilateral infiltrates
which organisms will show a haol (quellung reaction)
h. flu
n. meningigitidis
what effect does o2 tx have on ARDS
ineffective, since there is AV shunting
what is the difference between intrinsic and extrinsic asthma
extrinsic: elevated igE, eosinophilia
intrinsic: exercise adn respiratory infx
aside from asthma, what else causes wheezing
reactive airway dz
foreign body aspiration
indications for intubating asthmatics
severe tachypnea
MS changes
what is the only tx for COPD that is proven to extend life
supplemental o2
is pco2 low/nml/high in copd?
low pco2
nml/low p02
(pink puffer)
is pco2 low/nml in chronic bronchitis?
high pco2
low po2
(blue bloater)
who should get supplemental o2
paO2 <55 mmHg
SaO2 <88%
PaO2 55-59, if with cor pulmonale, erythrocytosis, or who desat during exercise
most common organisms to colonize bronchiectic lungn
H. flu
S. aureus
etiology of bronchiectasis
retained foreign body
severe pneumonia
what is the #1 cause of hemoptysis
si/sx of bronchiectasis
chronic cough
failure to thrive
treatment of bronchiectasis
chest physiotx
common causes of hemoptysis
lung ca
uncommon causes of hemoptysis
tx for hemoptysis
supplemental o2
place pt bleeding side down
suppress cough reflex (w/ codeine)
pt with dyspnea, hemoptysis, and acute renal failure
masses in the anterior mediastinum
t-cell lymphoma
masses in middle mediastinum
vascular lesions
lymph nodes
masses in posterior mediastinum
neurogenic tumor
causes of pneumomediastinum
rupture of alveolus, bronchus, trachea
esophageal rupture
dissection of neck or abdominal free air into mediastinum
physical finding associated with pneumomediastinum
Hamman's sign (crunching sound occurring wiht heartbeat)
t or f: small cell carcinoma of lung is sensitive to chemo
t or f: nsclc of lung is sensitive to chemo
false, slow growing
2 types of cancer with a central location in lung
small cell
squamous cell
("s"entral location)
SVC syndrome
obstruction of svc, impairing venous return --> facial swelling, dyspnea, cough, ha, epistaxis, syncope
sx worse with bending over
eaton-lambert sx
presynaptic nerve terminals attacked by abs, decreasing ACh release
ekg changes seen with pe
s1-q3-t3 all are inverted
sinus tachy
when should d-dimer test be used to dx pe
if clinical suspician is low, pe r/o with - d-dimer
what should be done if there is intermediate/high suspiciaon of dvt
do doppler u/s
what to do if doppler is neg for DVT
if high clinical prob, do venography
if intermed clinical prob, repeat u/s in 1 week
what to do if doppler u/s is + dvt
treat with heparin
interventional pulmonary angiography (mechanical disintegration or local thrombolysis)
embolectomy (surgery)
how to test if unlikely suspicion for pe
d-dimer to r/o
how t otest if pe is likely
spiral ct or v/q scan
types of stains used to look for afb
what is measured in + ppd, induration or erythema
causes of false-positive ppds
BCG vaccination
non-tb mycobacterial infx
preventive tx for pts iwth + ppd
INH 300 mg PO QD x 12 mo reduces risk by 90%
DOT (direct observed tx) improves compliance
standard tb tx
6 mo of inh, rifampin, and pyrazinamid + ethambutol/streptomycin
when are pts no longer infected iwth tb
10 days following tx
3 consecutive sputum smears negative for tb
tx for pregnant woman with tb
inh, rifampin + ethambutol x 9 mo
toxicities assoc with inh
peripheral neuropathy
sz in od (give B6 - pyridoxine)
hepatitis (check lft)
what is given to counteract the seizure activity seen wiht inh in od
toxicity of rifampin
induces hepatic microsomal enzymes
red-orange compound in urine, stools, sweat, tears
toxicity of ehtamobuol
opti neuritis and impaired color vision
pathophysiology behind tension ptx
air is trapped in pleural space and exerts pressure on lung and mediastinum --> reduced oxygenation and venous return
which way does trachea deviate in tension ptx
away from affected side
which way does trachea deviate in spontaneous ptx
towards affected side
tx of tension ptx
needle decompression followed by tube thoracostomy
tx of spontaneous ptx
if >20%, thoracostomy
which lung dz increases risk of developing tb
what is the utility of sigmoidooscopy in detecting crc?
finds 50-70% of polyps
diagnostic in ~2/3 cases
involvement of duodenum in fap?
involved 90% of the time
clinical features of turcot's syndrome
polyps + cbl medulloblastoma or GBM
clinical features of peutz-jeghers
single or multiple hamartomas that can be scattered through gi tract (small bowel, colon, stomach)
low malignancy potential
intussusception or gi bleeding can occur
which polyposis syndrome is associated with small crc risk
familial juvenile polyposis coli
lynch syndrome I
early onset of nonpolyposis crc, no polyposis
lynch syndrome II
lynch I features + increased # AND EARLY OCCURRENCE OF OTHER CANCERS
is melena or hematochezia more common wiht right sided tumors?
left sided tumors?
does rectal or colon cancer have a higher recurrence rate and lower 5 yr survival rate?
rectal ca
what role does radiation tx play in colorectal ca
not indicated in colon ca, only in rectal ca
what changes in bowel habits are seen in crc
with right sided tumors, change in bowel habits is not common
with left sided tumors, see alternating constipation/diarrhea, narrowing of stools
most common sx of rectal ca
features of juvenile polyps
tend to be vascular, should be removed
what are pseudopolyps also called? what are they associated with?
inflammatory polyps
pathophysiologic cause of diverticulosis
increase in intraluminal pressure --> outpouching of inner layer of colon through a weakness in the wall, usually at a site of BV penetration
where are most colonic polyps found
rectosigmoid region
complications of diverticulitis
abscess formation
colovesical fistula (50% close spontaneously)
obstruction (caused by inflammation)
free colonic perforation
test of choice for dx diverticulosis
pathophysiology of diverticulitis
feces becomes impacted in diverticulum --> erosion and microperforation
how to dx diverticulitis
CT scan of abdomen and pelvis --> swollen, edematous bowel wall or abscess
what is contraindicated in dx of diverticulitis
barium enema and colonoscopy d/t risk of perforation
what is a common association with AVM
aortic stenosis (no cause effect relationship is proven)
tx for acute mesenteric ischemia
iv fluids
broad spectrum abx
papaverine (vasodilator) into teh superior mesenteric system during arteriography (relieves occlusion and vasospasm)
heparin if there are venous thrombosis
possibly surgery if --> acute peritonitis
what is ogilvie's syndrome
si/sx of large bowel obstruction but there is no obstruction present
causes of ogilvie's syndrome
recent surgery or trauma
medications (narcotics, psychotropics, anticholinergics)
tx of ogilvie's syndrome
stopping offending agents
supportive measures
decompression with enema or ng suction
colonoscopic decomprsesion
last resort = cecostomy or colostomy
abx frequently --> pseudomembranous colitis
clinical features of pseudomembranous colitis
profuse watery diarrhea
crampy abdominal pain
toxic megacolon with risk of perforation
complications of severe pseudomembranous coliltis
toxic megacolon
colonic perforaation
electrolyte disturbances
tx of pseudomembranous colitis
d/c offending abx
oral vanco (if can't take metronidazole)
cholestyramine useful to tx diearrhea sx
when and what is the recurrence rate in pseudomembranous colitis
2-8 weeks after d/c abx
15-35% of treated pts
clinical features of colonic volvulus
acute onset of colicky abdominal pain
anorexia, n/v
dx of volvulus
if sigmoid - omega loop sign
if cecal - coffee bean sign (air fluid level rlq)
dx of sigmoid volvulus
sigmoidoscopy, it's dx adn therapeutic --> untwisting and decompression
what is colonic volvulus
twisting of a loop of intestine about its mesenteric attachment sit e--> vascular compromise
most common site for colonic volvulus
sigmoid coloon (75%)
cecal (25%)
risk factors for cecal volvulus
congenital lack of fixation ofo right colon (seen in younger pts)
gold standard for dx cirrhosis
liver biopsy
what effect does biliary cirrhossi have on liver
--> hepatic cirrhosis
how to determine whether or not ascites is from portal htn or from some otehr cause
performmeasure serum ascites albumin gradient via paracentesis
if <1.1 then from aanother prcoess, if >1.1, then from portal htn
tx of hepatic encephalopathy
lactulose (bacterai metabolise it adn form NH4 which is poorly absorbed from gi tract, promoting excretion of ammonia)
neomycin (decreases ammonia production by bacteria)
limit protein to 30-40 mg/day
what is hepatorenal syndrome
indicates end-stage liver dz
progressive renal failure in advanced liver dz, secondary to renal hypoperfusion resulting from vasoconstriction of renal bv) kidneys are nml though
clnical features of hepatorenal syndrome
azotemia, oliguria, hyponatremia, hypotension, low urine na (<10)
tx of hepatorenal syndrome
liver transplant
etiology of sbp
pts with ascites caused by chronic liver dz
infx with e coli, klebsielal, strep pneumo
dx fo sbp
paracentesis with >500 wbc and pmn >250
treatment for sbp
see improvment 24-48 hrs, then repeat paracentesis
pathophysiology of wilson's dz
deficiency of ceruloplasmin (binds copper and is needed for cu excretion)
so, cu accumulates in liver cells... as cells die, cu goes into plasma and then into organs
what is the first manifestation of wilson's dz
liver dz (hepatits, cirrhosis, fulminant hepatic failure)
cns findings in wilson's dz
extrapyramidal signs (parkinsonian sx)m chorea,m drooling, incoordination
psych probs (depression, neurosess, personality changes)
what renal sx are present in wilson's dz
dx of wilson's dz
hepatic dz
serum ceruloplasmin levels
liver bx (elevated cu)
screem FDR of pts
tx of wilson's dz
chelating agenst
liver transplantation if unresponsive to tx
monitor cu levels
clinical features of hemochromatosis
liver dz
ab pain
complications of hemochromatosis
dx of hemochromatosis
liver bx - required for dx
fe pattern in blood test
tx of hemochromatosis
repeated phlebotomies
tx complications
liver tx in advanced dz
what is the #1 type of benign liver tumor
cavernous hemangiomas
tx of hepatocellular adenoma
if greater than 5cm, resect if does not regress on it's own after stopping contraceptives/steroids use
focal nodular hyperplasia - does it have association with oral contraceptives?
tx of ventricular tachyarrhythmia (esp in acute MI)
IV lidocaine
tx of paroxysmal supraventricular tachyarrhythmia
IV verapamil or IV adenosine
what are meds used to treat toxo
pathophys of primary biliary cirrhosis
what lab values are seen
progressive destruction of intrahepatic bile ducts with concurrent bile duct proliferation

+++ GGT
+++ alk phos
+ bilirubin
anti-mitochondrial AB
what AB is associated with SLE
long term side effect of amiodarone
short term?
pulmonary fibrosis
hypotension seen with loading dose
edema and cerebral infarcts - when is the peak in swelling? what can occur? how to treat?
48-72 hrs
cerebral hernaition
steroids reduce swelling
serious complication from c diff
toxic megacolon and perforation
side effect of hydralazine
reflex tachycardia
adverse effects to colchicine
tx of gout
first line: indomethacin
2nd line: colchicine (can't be tolerated in high doses)
if all else fails, steroids
sx assocated with Behcet syndrome
autoimmune multisystem vasculitis
there are recurrent oral and genital ulcers and arthristis
also eye sx, fever, weight loss, CNS involvement

sx wax adn wane
tx of Behcet syndrome
what dz is RNP seen in
mixed CT dz
sx of uremic peripheral neuropathy
stocking and glove pattern
develops when gfr is <10% of normal
what is seen on xray in pagets dz?
lab abnormalities in pagets?
cortical thickening, microfx
nml serum ca, nml serum protein, increased alk phos
which organism --> external otitis --> osteomyelitis of cranial base in DM
AB associated with CREST
anti-centromere AB
antiphospholipid syndrome
elevated PTT but actually is a syndrome --> recurrent arterial and venous thromboses
how to dx a perforated ulcer
sx of ankylosing spondylitis
arge joint arthritis
aortic regurg
what murmur is associated wiht ankylosing spondylitis
aortic regurg
pathology of echinococcus
affects liver and lungs
primary cysts --> daughter cysts --> 3rd generation cysts
asx until palpating in liver --> compression of bile ducts --> jaundice
disease associated with a dural tail
how is malaria dx
bl cx q8h x 3d
what region of the brain is affected in hsv encephalitis
inferior and frontal lobes --> seizures
what is the #1 cause of community acquired pneumonia in alcoholics
k. pneumo
which ekg leads are associated with rca
II, III, avf
which ekg leads are associated with lad
which ekg leads are associated with circumflex
v5, v6
which ekg leads are associated with left coronary
V1-V6, I, avL
which ekg leads are associated with circumflex
V5-V6, I, avl
ekg abnormalities seen with pda
tall r waves in v1 and v2
presentation of food poisoning seen with staph aureus
sudden, abrupt onset
non-bloody diarrhea (not bloody b/c no penetration or mucosal ulceration)
recovery w/i 12 hrs
addison dz
autoimmune destruction of adrenal glands --> increased ACTH
x linked do
accumulation of long chain fatty acids in adrenals and testes and cns --> adrenal insuff, neurologic deficits and hypogonadism
what happens ot co in constrictive pericarditis?
filling pressures?
diastolic p?
= in all 4 chambers of the heart
what heart dz are associated with = diastolic p in all 4 chambers
what is kussmaul's sign?
jugular veins are distended and htis increases with inspiration
heart sounds associated wiht restrictive pericarditis
decreased s1 adn s2 b/c decresaed sound transmission through thickened pericardiu
sx of brain abscess as seen in ivda
progressive neurologic dysfxn
when is a herald patch seen
pityriasis rosea
xmas tree appearance distribution throughout the trunk
scaly, ova lesions
what equation is used to determine what PCO2 compensation should be if there is metabolic acidosis with respiratory compensation?

what if the PCO2 is outside of this range?
1.5(HCO3) + 8 +/-2

there is a separate respiratory acid/base d/o
what are the dangers of giving HCO3
induces decreased Ca
worsening of acidosis
worsens intracellulr edema by blocking the Na/H antiporter and Na/K pump --> water into cell
induces increased apoptosis by blocking
what does the LDH have to be in order for there to be a risk of tumor lysis syndrome?
greater than 600
which cancer is most commonly associated with tumor lysis syndrome?
causes of euvolemic hyponatremia
psychogenic polydipsia
beer drinkers potomania/tea and toast diet
adrenal insufficiency
what things other than tumor can lead to ectopic production of ADH
CNS probs (bleeds, meningitis, CVA)
pneumonia/lung infx
what are the electrolyte features of RTA type I?
what type of acidosis is seen?
non anion gap
give bicarb
what are the electrolyte features of RTA type II?
what type of acidosis is seen?
non anion gap
DO NOT give bicarb... it just gets excreted and makes it worse, instead treat with na restriction, to increase HCO3 and Na absorption in proximal tubule
where is defect in RTA I?
distal tubule
proximal tubule
what abnormalities are seen in urine of RTA I?
pH can never get below 6.0 b/c the distal tubule is unable to secrete H+
pH is acidic b/c proximal tubule can't excrete HCO3
clinical features of RTA I?
nephrocalcinosis (from increased Ca and PO4 secretion into alkaline urine)
tx of PE
Iv heparin
when is esophageal manometry used?
just prior to having esophageal surgery to treat reflux
how to evaluate pt with acid reflux who doesn't respond to acid suppression tx
evaluate 24 hr esophageal pH monitoring
when is esophageal pH monitoring done (2 instances)
to evaluate a pt who doesn't respond to acid suppression tx
to dx esophageal motility do
what is the best way to demonstrate a gastrinoma?
octreotide scan (can see primary and mets)
who should get upper endoscopy
pt >50yo with dyspepsia
or <50 if having anorexia, weight loss, dysphagia, vomiting, or with UGI barium findings
what is charcot's triad
RUQ pain
indicates acute cholangitis
how to treat acute cholangitis
broad spectrum abx to cover areobes, anaerobes, GNR , and enteroccoccus
if stones are present, do ercp and sphincterotomy to remove the stones
what does a cecal volvulus look like
kidney shaped mass extending to luq
what does a colonic volvulu look like
bent inner tube
tropical sprue
small bowel overgrowth of anaerobes --> villous blunting
tx of tropical sprue
folic acid
what can cause villous blunting (3 causes)
celiac sprue
tropical sprue
bacterial overgrowth
what is the most common location of anal fissures?
what if htey are found someplace else?
posterior midline
thye are secondary to something else (often seen in Crohn's)
the most important things to check in a pt with nephrotic syndrome
lipid panel (TGs can be very elevated)
coagulopathy (hypercoagulable)
which renal dz is associated specifically with HIV
which renal dz is associated w SLE
membranous GN
what are the major changes related to nephrotic syndrome
massive proteinuria
what lab values will tell you if renal dz is associated with SLE
rbc casts
low complement levels
can look at how active anti ds dna is
which renal dz is associted with hbv
membranous gn
which renal dz is most commonly associated with renal vein thromboses
absolute indications for dialysis
Acisosis (significant, irretractable)
Electrolytes (persistent hyperkalemia)
Ingestion (methanol, ethylene glycol, li, asparin)
Overload (hypervolemia)
ua of ain
wbc casts
ua of atn
muddy granular casts
causes for an osmolar gap
any sort of alcohol
etoh, methanol, ethylene glycol
ingestion, ischemia
lactic acid
ethylene glycol
causes for non-gap metabolic acidosis
rta (decreased H excreted in the urine)
how do nsaids cause prerenal aki?
they inhibit pgs so they --> vasoconstriction which lowers the gfr
first way to dx urinary tract obstx
renal us is first test
which type of prostate ca is most common
when should ns be given for fluid replacement
increases intravascular volume if pt is dehydrated or has lost blood (don't use in chf)
when should D5 .5NS be used for fluid replacement
can spare muscle breakdown and has water for insensible losses
often is given with k
(usuallly the maintenance fluid of choice)
when is d5W used in fluid replacemebt
used to dilute powdered meds
can be used to correct hypernatremia
only 1/12 remains intravascularly and the rest diffuses, so not effective at maintaining intravasc volume
when is lr used in fluid replacement
not a maintenance fluid, but is often used for trauma resusc
don't use if hyperkalemic b/c it contains k
causes of hypovolemic hypernatremia
renal failure
insensible losses
causes of euvolemic hypernatremia
insensible losses
causes of hypovolemic hyponatremia
low aldosterone
3rd spacing
causes of euvolemic hyponatremia
psychogenic polydipsia
causes of hypervolemic hyponatremia
nephrotic syndrome
liver dz
when are pts iwth dm most at risk for hypoglycemia
a way to prevent this?
when they have tight glycemic control
more frequent glucose checks
can often occur as behavior problems
what medication should be added to a pt who is on an oral hypoglycemic agent for type 2 dm who still has an elevated hba1c
a long active basal insulin at night before bed
what is fructosamine?
glycosylated albumin
can be used to monitor glycemic control
what is seen with poliferative retinopathy?
new bv on the optic disk or elsewhere on the retina
laser photocoagulation to prevent blindness
frequency of optho visits in dm?
type I, if they have it for >5 yrs
type II, as soon as they are diagnosed, unless they have no proteinuria and no hyperglycemia
when are hyaline casts seen in urine
can be seem when there is no disease, or when there is diabetic nephropathy
what imaging study can give the most information about renal stones?
non-contrast spiral ct of abdomen (detects radiolucent and radioopaque)
drawback of ivp?
it misses small radio-lucent stones
what is the utility of u/s in detecting stones
it can't be used to detect ureteral stones
tx of gonorrhea
1 dose of ciprofloxacin
what blood type is the universal plasma doner
why should whole blood not be used in transfusion
it loses soe of the clotting factors during storage
which modality can dx and control rapid LGI bleeding
how to determine with certainty if gi bleeding is coming from UGI or LGI?
pass ng tube
what is the pathophysiology behind necrotizing fasciitis + shock
2/2 rupture of intra-abdominal pseudoaneurysm --> autodigestion of arterial walls by elastase and other pancreatic enzymes
which artery is the most commonly affected in necrotizing pancreatitis with shock?
splenic artery
complication of pseudoaneurysm in necrotizing pancreatis?
how is dx confirmed?
can rupture --> life threatening hemorrhage, melena, etc
what should be used to acutely treat variceal bleeding?
B-blockers are effective, but not good for acute situations
how to differentiate between bronchitis and pneumonia
the only way is with cxr
clinical features do not ohelp
what is the #1 cause of pneumonia in nursing home pts
where is infiltrate seen?)
pseudomonas (seen in upper lobes)
what is the most common type of pneumonia sen in transplant pts
legionella (can be seen in urine)
Which pneumonia causing organism normally follows flu?
what type fo organisms does metronidazole cover?
what are the most common infectious agents seen in pts with bronchiectasis
Pseudomonas and Staph
what dz is associated with bilateral inguinal lymphadenopathy?
primary syphilis
what is the best way to dx primary syphilis
dark filed microscopy
morphology of histoplasmosis
dimorphic fungus found in moldy soil in ohio river valley
who is generally infected with histoplasmosis
cxr findings of histo
physical findings
hilar lympadenopathy
palatal ulcers, hepatosplenomegaly, pancytopenia
which drugs treat herpes zoster
valacyclovir (1st line)
acyclovir (2nd liine)
what med can be administered to tret neuralgias associated with shingles
what are the differences in findings in CMV and EBV?
CMV: mono picture, but no pharyngitis; no cervical lymphadenopathy, negative monostat test, atypical lymphos

EBV: severe pharyngitis, + lymphadenooathy, + monostat test
clinical features of HSV encephalitis
temporal lobes affected --> strange behaviour and hallucinations, abrupt onset of MS changes
what organisms --> cavitary pulmonary lesions in HIV
atypical pneumonia
what organism --> gardner's dz
clinical presentation
red mpdi;e tjat i;cerates; fungus spreads through lymph nodes --> sub q noodules and ulcers
what does clindamycin treat
gm +
what infx is commonly associated with intubation
what infx is more likely in pts with hemochromatosis and cirhosis?
what is the relationship between congenital rubella and the administration of hte vaccine early in pregnancy
there is no relationship; no reported problems
skin lesioin assoc with leprosy
hypopigmented plaque --> progressive nerve damage
tx of PCP in HIV +
steroids + bactrim (steroids decrease mortality)
Proph of MAI in HIV+
what is given proph in HIV for CMV
when is it given?
Administer if CD4 <50 and pt is IgG +
What med is used as proph for PCP in HIV
clinical features of CMV colitis
bloody diarrhea with nml stool exam, + abd pain
skin lesion seen in meningococcus
petechiae, purpura
lab dx of CMV colitis
see large cells with eosinophilic intranuclear inclusions
basophilic inclusions, as well

#1 cause of osteomyelitis in SCD
what is used as Toxo proph in HIV + pts
what can bactrim be used to prevent in HIV
what dz is associated wiht a halo sign on cxr
tx of toxo in hiv+
most common causes for meningitis in infants <3 mo
GBS > E. coli > Listeria
most common causes for meningitis in children > 3 mo
N. meningitides > S. pneumo > Hib
most common causes for meningitis in 18-50 yo
S. pneumo > N. meningitis > Hib
most common causes for meningitis in adults > 50 yo
S. pneumo > N. meningitis > Listeria
most common causes for meningitis in immunocompromised
Listeria > GNR > S. pneumo
which type of meningitis has the best prognosis
aseptic (viral) meningitis
what is india ink used to detect
what is the nml composition of csf
wbc count
wbc differential
NO polys (all lymphos or all monocytes)
50-75 (2/3 the amount in blood)
what is the composition of csf with bacterial meningitis
wbc count
wbc differential
mostly polys
what is the composition of csf with aseptic meningitis
wbc count
wbc differential
mostly lymphos/monos
moderate elevation
which orgs should sickle cell pts be vaccinated against
S. pneumo
N. meningitis
tx for infants with meningitis
vanco + cefotaxime + ampicillin
tx for children with meningitis
ceftriaxone (or cafotaxime) + vanco
tx for 18-50 yo with meningitis
ceftriaxone or cefotaxime + vanco
tx for adults >50 yo with meningitis
vanco + ampicillin + ceftriaxone or cefotaxime
tx of immunocompromised pts with meningitis
ceftazidime + vanco + ampicillin
clinical features of encephalitis
ha, malaise, myalgias
sk/sx of meningitis
confusion, delirium, disorientation and behavior problems
sz, focal neuro deficits
dx of encephalitis
LP (similar to viral meningitis pic)
csf pcr to look for hsv, vzv, cmv
eeg to look for discharge for temporal lobe
tx for hsv encephalitis
tx for cmv encephalitis
ganciclovir or fosacarnet
in addition to neurologic findings what is a finding associated with n. meningitis
maculopapular rash with petechiae-purpura
how is hcv most commonly spread
parenteral (sexual and perinatal are much less common)
which serology is positive in a pt with hbv who is in the window period?
which serology is positive in a pt with hbv who is vaccinated
which serology is positive in a pt with hbv who is newly infected
which serology is positive in a pt with hbv who is actively replicating the virus
what is the most common outcome for a pt infected w hbv
resolution (90%)
what is the most common outcome for a pt infected w hcv
chronic hepatitis (85-90%)
clinical manifestation of botulism
symmetric descending flaccid paralysis
how is botulism presentation different from G-B?
G-B is an ascending paralysis (although 1 variety, Fischer, is descending)
dx of botulism
toxin in serum, stool or gastric contents
can't be dx from presence in food
tx of botulism
observe respiratory status closely
gastric lavage helpful within first few hrs following ingestion
if high suspicion, give antitoxin (do not wait for results)
orgs most commonly assoc with uti
E. coli
how is urine screened for pyuria
leuk. esterase
what org is associated with high nitrite levels in urine
e coli
tx for uti
3 days of ciprofloxacin or bactrim (but may have resistance)
tx of pyelonephritis
can give ceftriaxone or gent prior to longer tx of bactrim or FQ for 10-14 days
which is the most common bacterial std
tx of chlamydia
1 dose of azithromycin \
or 7 day tx of doxicyline
what is the #1 cause of infertility in women
chlamydia --> scarring of tubes
nonpainful genital lesions
primary syphilis
lymphogranuloma venereum
granuloma inguinale
genital ulcers usually --> B lymphadenopathy
primary syphilis
which genital lesions are painful
how is erysipelas different from cellulitis
erysipelas: infx of dermis and lymphatics
cellulitis: infx of skin and subq tissue
endemic location of coccidiomycosis
SW US, Central/South america
endemic location of histoplasmosis
SE, Mid-Atlantic, Central US
Ohio River Valley
endemic location of blastomycosis
middle US
clinical presentation of blastomycosis
wart like skin lesions
clinical presentation of histoplasmosis
skin sx rare
clinical presentation of coccidiomycosis
pleuritic CP
erythema nodosum/multiforme
in immunocompetent host, tx for blastomycosis
itraconazole x 6-12 mo
in immunocompetent host, tx for histoplasmosis
in immunocompetent host, tx for coccidiomycosis
itraconazole or fluconazole (x 6 mo)
in immunocompromised host, tx for blastomycosis
amphotericin B
in immunocompromised host, tx for histoplasmosis
amphotericin B
in immunocompromised host, tx for coccidiomycosis
amphotericin B
complications of mono
splenic rupture
neuro complications (rare)
airway obsx if there is excess lymphadenopathy
tx for mono
supportive tx
glucocorticoids if there is airway obstruction
# 1 cause for erysipilas
Group A strep
tx for pseudomonas
tobramycin (aG) + anti-pseudomonal PCN
which flu meds treat flu A and B?
clinical features of trichorella
periorbital edema, myositis, eosinophilia, splinter hemorrhages, abd pain, n/v/d
describe lesion seen in bartonella
bright red, friable, exophytic lesions
they are angioma-like
alternate tx to bactrim in pcp
tx of nocardia
(nocardia mimics tB)
tx of neutropenic fever
usually caused by endogenous skin or gut flora
tx with 3/4th gen ceph
tx of bartonella
5d azithromycin
when are palatal petechiae seen
what bacteria is associated with food poisoning from seafood
vibrio haemolyticus
acute, life-threatening complications of hiv tx
pancreatitis (didanosine induced)
hypersensitivity rxn (abacavir)
lactic acidosis (nrtis)
stevens johnson syndrome (nnrtis)
liver failure (nevapine)
MAI proph in HIV
azitromycin or clarythromycin
dx of osteomyelitis
if in spine or foot, MRI
anywhere else, use 3 phase technetium bone scan
describe rash of rubella
starts on face --> trunk/extremities
sx associated with rubella, esp in women
how should cat bites be treated proph?
when are blood transfusions recommended in anemia
if hb <7 or pts that require increased o2 carrying capacity (cardio-pulm dz)
how much does hct rise for each unit of prbc
what is implied if the retic count >2%
excessive RBC destruction/loss
bone marrow is responding appropriately
suspect hemolysis or blood loss
what is implied if the retic count <2%
inadequte RBC production by bone marrow
other than folate and B12 deficiencies what else can --> high mcv
liver dz (altered metabolism of plasma lipoprotiens, altering rbc shape and increasing volume); mcv <115

stimulated erythropoiesis (retics are larger than normal RBCs); mcv <110
things that would fall under normocytic anemia
lead poisoning
clinical features of B-thal major
severe microcytic anemia
massive hepatosplenomegaly
frontal bossing
natural course of b-thal major
death occurs within first yrs of life if untreated. give blood transfusions
dx of b-thal major
hb electrophoresis (elevated HbF)
microcytic hypochromic anemia
clinical features of b-thal minor
mild microcytic, hypochromic anemia
dx of b-thal minor
natural course
hb electrophoresis
pts not transfusion dependent
tx of b-thal intermedia
don't require transfusions
what is HbH dz
mutations in 3 alpha chains
splenectomy, transfusions
what is lacking in pernicious anemia
intrinsic factor
clinical features of B12 deficiency
stomatitis and glossitis (sore tongue)
demyelination of posterior columns
dx of b12 deficiency (other than the obvious)
elevated serum methylmalonic acid and homocysteine levels
schilling test: saturate B12 binding sites, give oral dose of radioactive B12 and measure hte amount in urine and plasma to see how much is getting absorbed
then, add intrinsic factor to B12 administration and see if it improves
tx for b12 deficiency
parenteral admin of b12
describe intravascular hemolysis
there is IgM on the surface of RBCs and they are destroyed by complement. Haptoglobin picks up the Hb and delivers it to the spleen.
haptoglobin is decreased in hemolytic anemia
tnere is hb in the urine
describe extravascular hemolysis
there is some intrinsic abnormality with the rbc and it is broken down by macrophages. it releases unconjugated bili
hand foot syndrome
painful swellin of dorsum of hands and feet
seen in early infancy and childhood
usually first manifestation of scd
caused by vasc necrosis of metacarpal and metatarsal bones
acute chest syndrome
many episodes of lung infarction, similar presentation to pneumonia
--> cp, resp distress, pulm infiltrates, hypoxia
what effects does scd have on spleen (aside from autosplenectomy)
blood pools in the spleen --> rapid splenomegaly and hypovolemic shock
can be a fatal complicdation b/c hteir spleens are still intact
when should transfusions be done in scd
only when absolutely necessary, based on clinical presentation
consider in acute chest syndrome , stroke, and priapism that don't respond to fluids, analgesia, and cardiac decompensation
when is direct coomb's test +? -?
+ in autoimmune hemolytic anemia
- in hereditary spherocytosis
differences in hemolysis in warm and cold AIHA
warm is extravascular, see splenomegaly
cold is intravascular, see hepatomegaly
(if you are cold you stay inside and if you are warm you go outside)
tx of WAIHA
cyclophosphamide or azathioprine
splenectomy if no response to steroids
folic acid supplements
clinical features of PNH
intravascular hemolysis (complement mediated); occurs b/c there is a defect in DAF which breaks down complement inactivating factors. this is defective so there is increased complement

dark urine in morning following respiratory acidotic stress
dx of pnh
ham test
sugar osmolarity test
tx of pnh
bone marrow transplant
difference between hereditary spherocytosis vs waiha
in Hs there is - coomb's test
IgG mediated destruction of platelets, removed by spleen (no splenomegaly though)
tx of itp
adrenal corticosteroids
IVIG to saturate res so there is less uptake by spleen
splenectomy induces remission in 70-80%
clinical features of ttp
hyaline microthrombi occluding small bv
life threatening emergency

renal failure
tx of ttp
corticosteroids and splenectomy
platelet transfusion is contraindicated
what are the 2 classes of strokes
hemorrhagic (intracerebral hemorrhage and subarachnoid hemorrhage)
causes of ischemic strokes
usually embolism or atherosclerotic lesion
most common cause of intracerebral hemorrhage
HTN and sudden increase in BP
HTN -> rupture of microvasculature --> microaneurysms --> rupture
most common cause of subarachnoid hemorrhage
berry aneurysm
best way to dx cva
ct s contrast
tx of ischemic stroke
tpa within 3 hrs of onset
keep bp <185/110 if using tpa, but otherwise don't treat high bp unless >220/120
surgical tx of pts w tia
only treat if symptomatic and carotid artery stenosis >70%
in asx pts, don't treat surgically, just treat risk factors
tx of intracerebral hemorrhage
monitor abcs
only lower bp if >160-180/105, and lower it gradually if it is treated (use nitroprusside)
mannitol if increased icp
what medication is contraindicated in intracerebral hemorrhages
which type of stroke can be associated with hematomas
intracerebral hemorrhage
dx of subarachnoid hemorrhage
ct scan
lp to look for xanthochrmoia (yellow csf) if ct scan is unrevealing but still suspect stroke
what should always be done before doing lp
opthalmic exam to look for papilledema; if present DO NOT perform lp --> herniation
tx for parkinsons
da-receptor agonists (pergolide, bromocriptine, pramipexole)
selegiline (mao-b inhibition, increases da)
amantadine (inicreases availability of endogenous da, transiently)
anticholinergics (benztropine)
amitriptyline (anticholinergic and antidepressant)
relationship of wilson's dz and movement do
seen in youbng pts, who have parkinsonism, chorea, drooling, inccordination
what is progressive supranuclear palsy
similar to parkinsons...
degenerative do of brainstem, basal ganglia, cbl
--> bradykinesia, limb rigidity, cognitive decline, and is progressive
NO TREMOR, yes ophtalmoplegia
pathogenesis of huntington's
cag repeats --> loss of gaba-ergic neurons
sx of friedreich's ataxia
impaired proprioception
sx of ataxia telangiectasia
friedreich's ataxia + telangiectasia... increased incidence of ca
when are tremors seen in parkinson's
when are tremors seen in cerebellar dz
intention tremor (with action)
when are tremors seen in essential tremor
with certain postures/tasks
describe the tremor seen in parkinsons
describe the tremor seen in cbl dz
describe the tremor seen in essential tremor
what improve tremor seen in parkinsons
what improve tremor seen in cbl dz
what improve tremor seen in essential tremor
what causes death in alzheimers
secondary infx or other complication to debilitated state
mainstay tx for alzheimers
AChE inhibitors (donepezil and tacrine)
what effect do dietary supplements have on the progression of alzheimers
gingko not helpful
high dose vitamin E may slow progression
sx/si of lewy body dementia
parkinsons + alzheimers (but more rapid than alz)
initially visual hallucinations predominate, eps, fluctuating mental status
causes of delirium
Post-op state


tx of delirium
tx underlying cause
supportive tx
features of uncal herniation
ipsilateral CN III compression ---> impaired pupillary reflex, dilated pupil
ipsilateral paresis from contralateral compression of crus cerebri
progressive brainstem compression --> changes in resp and cardiac status
tx of brain herniation
lower icp - reverse trendelenberg, mannitol, lower body temp
intubation + hyperventilation
sx of tonsillar herniation
cbl herniates through foramen magnum
--> compression of cardioresp centers --> rapid death
sx of central heriation
supratentorial lesions --> change in ms, midpoint small pupils, posturing, cheyne-stokes, hyperventilation
--> increased muscle tone, bl babinski
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