1
Q
Tumor lysis tx
A
IV fluids (6L/day), loop diuretic to maintain UOP if needed, and Rasburicase (preventative)
2
Q
Tumor lysis labs
A
hyperkalemia
hyperuricemia, hyperphosphatemia
acute kidney injury (d/t prior)
3
Q
Acromegaly etiology
A
Hypersecretion of of GH, d/t pituitary adenoma
GH –> liver –> IGF1–>acromegaly
4
Q
Diagnosis of acromegaly
A
IGF-1 level
not GH level b/c secreted in pulses
5
Q
Chronic paroxysmal hemicrania definition
A
- similar to cluster headaches
- trigeminal nerve pain with autonomic features (tearing, conjunctival injection, rhinorrhea)
- last 15 minutes, 8-40 times/day (cluster HA is 15-180 minutes and 1-8x/day)
6
Q
Cluster headache treatment
A
Indomethicin
not carbamazepine - that is trigeminal neuralgia
7
Q
Trigeminal Neuralgia treatment
A
Carbamazepine
not indomethicin - that is cluster headache
8
Q
Treatment of prostate cancer
A
Organ-confined dz: radical prostatectomy
Extension beyond prostate, PSA>20, high Gleason score (8-10): ADT + radiation
Brachytherapy - option for gleason
9
Q
Drug induced lupus erythematosus
A
- Drugs can induce auto-antibodies
- Can be d/t TNF-alpha inhibitors (etanercept)
- Most common drugs: procainamide, hydralazine, penicillamine
- fever, rash, arthritis, blood count abnormalities
- Dx with + ANA, anti-SSDNA antibody, and anti-histone antibodies (TNF alpha associated with anti-DSDNA)
10
Q
Benign Recurrent Lymphocytic Meningitis
A
- AKA Mollaret meningitis
- most comon cause HSV-2
- recurrent meningitis, lasting 2-5 days, spontaneous recovery
11
Q
Characteristics of inflammatory anemia (anemia of chronic dz)
A
- normal or low Fe
- low TIBC
- elevated ferritin
- smear is normal OR microcytic/hypochromic
- Retic low
12
Q
Bullous pemphigoid
A
- autoimmune
- older people
- treat with prednisone
Can persist months to years (if so, add azathioprine, cellcept)
13
Q
Fulminant liver failure
A
hepatic encephalopathy + jaundice (without preexisting liver disease)
Hyperacute: encephalopathy
14
Q
Indication for carotid artery stenosis intervention
A
Stenosis >70% or symptomatic
15
Q
Botulism Symptoms Triad
A
1- symmetric, descending flaccid paralysis with bulbar palsies (diplopia, dysarthrtis, dysphagia)
2- normal body temperature
3- clear sensorium
Diagnose with toxin detection in serum, stool
Treat with antitoxin
16
Q
Recommendations for microalbumin testing
A
Annually in patients with:
- DM I starting 5 years after diagnosis
- DM II starting at diagnosis
Measure by getting albumin-creatinine ratio
17
Q
Diagnosis of microalbuminuria
A
- albumin-creatinine ratio of 30-300
- requires elevated ratio on 2/3 random samples over 6 months
If diagnosed, use ACEi or ARB to delay progression
18
Q
Patient with anterior uveitis requires workup for systemic disease with
A
Chest xray first, looking for sarcoidosis.
Secondary workup: HLA-B27, ANCA, RPR
Worried for spondyloarthritis, sarcoidosis, Behcet, JIA, Wegener’s.
19
Q
anti-dsDNA antibody
A
Lupus
20
Q
Anti-Ro antibody
A
Sjogren
21
Q
SSA antibody
A
Sjogren
22
Q
Indications for long-term oxygen therapy
A
PO2
23
Q
Paroxysmal Nocturnal Hemoglobinuria features
A
Primary acquired stem cell disorder causing:
- unprovoked venous thrombosis
- hemolytic anemia
- pancytopenia
Diagnose with flow cytometry, looking for CD55 and CD59 + cells
24
Q
Resistant Hypertension
A
BP above goal despite optimal doses of three antihypertensives, including a diuretic
If resistant HTN with CKD on HCTZ, change to loop diuretic. Those patients tend to be volume overloaded.
25
Microscopic colitis
- Commonly d/t lansoprazole, NSAIDs, sertraline, ranitidine
- Over age 40, more common women
- Sxs: watery diarrhea, relapsing/remitting, with abd pain and nausea
Bowel mucosa appears normal on cscope
Path: either lymphocytic (increased intraepithelial lymphocytes) or collagenous (subepithelial collagen band in the lamina propria)
Treatment: stop the med. Secondary option: mesalamine, budesonide
26
Antiepileptics in Asian patients
Can have the HLA-B1502 allele, associated with increased risk of Stevens-Johnson with: carbamazepine, lamictal, oxcarbazepine, and phenytoin. Must do genetic testing before using these
It is safe to start Keppra w/o testing.
27
Medical management of NSTEMI (if not cath candidate)
- antiplatelet agents (aspirin and Plavix)
- Beta blocker (if contraindicated, Diltiazem is second line)
- antithrombin therapy (heparin or Lovenox)
- high dose statin
28
Treatment of acute urticaria
Antihistamines: H1 and H2 together more effective than either alone - use Zyrtec + Zantac
29
Traveler's Diarrhea
Three or more unformed stools/day with abdominal pain, nausea/vomiting, bloody stools, or fever
Usually d/t enterotoxigenic E coli
Most common in Mexico, South/Central America, Asia, Africa (overall incidence 20-60%)
No need to prophylax unless pt with underlying condition (IBD, immunocompromised, chronic diseases)
Prophylaxis with RIFAXIMIN
30
Routine breast cancer follow up
If early-stage, recommend mammography every 3-6 mos, then spaced out to Q6-12 mos. Q1 year at the 5 year mark.
No need for other imaging (PET, CT, bone scans) or labs (tumor markers, etc.)
31
Patterns of lung nodules
Benign:
- smooth borders
- calcification that is: popcorn, lamellar, central, or diffuse
Malignant:
- spiculated
- calcification: eccentric, off-center
32
Diagnosis of Lambert-Eaton
Nerve conduction study: will have improved conduction with brief period of exercise
Patient will have proximal limb weakness, decreased reflexes, improved strength with exercise, and autonomc nerve dysfunction (dry mouth, orthostatic hypotension)
50% of patients with malignancy, usually SCLC
Etiology is antibody to voltage-gated calcium channels
33
Proliferative Lupus Nephritis
- 2/2 immune complexes. 6 histologic classes, I and II more indolent.
- New onset hypertension
- New onset edema
- high anti-dsDNA antibodies, low complement
- 24H urine protein >500 mg/24H
- UA with >10 RBCs, white or red cell casts
34
Treatment of Candidemia
Critically ill: echinocandins (Caspofungin or micafungin)
Not critically ill: Fluconazole
35
Chronic Mesenteric Ischemia
Abdominal pain after eating that leads to weight loss
Diagnose with MR or CT angiography
36
Pustular Psoriasis
Patients with hx psoriasis, treated with systemic steroids, can get acute pustular erythroderma skin flare after the oral steroids are stopped
Erythroderma: erythema over >90% body surface area
37
Hungry Bone Syndrome
Post-parathyroidectomy, unmineralized bone made when Ca was high begins to mineralize when PTH level becomes normal, dropping the Ca and phos quickly.
38
Pulmonary Histoplasmosis
Mild forms do not require treament, self limited.
Treat if immune compromised, severe illness results. Treat with Itraconazole, second line is Ambisome
39
Chronic Lymphocytic Leukemia (CLL)
Usually asymptomatic
Risk stratified based on:
- presence of LAD, HSM, anemia, low plts
- beta2-microglobulin level
- heavy gene mutational status
- cytogenetics
No need for bone marrow bx - all relevant info comes from peripheral blood
```
Stage 0 = increased circulating lymphocytes
Stage 1 = lymphadenopathy
Stage 2 = splenomegaly
Stage 3 = anemia
Stage 4 = thrombocytopenia
```
40
Opioid-induced constipation
Treat with methylnaltrexone - treats constipation without decreasing analgesic effects.
41
Sleep apnea in Heart Failure
First line tx is medical therapy to improve hrt fxn.
Second line is adaptive servoventilation (form of positive airway pressure therapy). CPAP can help if element of OSA, but can also worsen/exacerbate central sleep apnea of heart failure.
42
Treatment of radicular back pain
- non-opioid analgesics
- mobilization as tolerated
3/4 of those with sciatica are much better in 3 mos w/o surgery
43
Tx of knee osteoarthritis
Obesity is the most modifiable risk factor - tx with weight loss and/or exercise programs. Sustained wt loss of only 15 lb results in symptomatic relief.
Do not use things like Celebrex in people with CAD - increased risk of MI
44
Reasons to not do ECG stress test
- pre-excitation (like WPW)
- > 1mm ST segment depression
- LBBB
Use exercise perfusion study instead
45
Hereditary Spherocytosis
- Can be asymptomatic or cause significant hemolysis
- Usually Autosomal Dominant
- Get splenomegaly, pigmented gallstones (2/2 chronic hemolysis), chronic fatigue/exercise intolerance
- Spherocytes on smear
- Labs: elevated retic, indirect bili, and LDH
Diagnose with osmotic fragility test
46
Age-related macular degeneration
- asympotmatic early on
- Get distortion of vision and central vision loss
- With advanced sxs, experience visual hallucinations (Charles Bonnet syndrome)
- On exam, see drusen (amorphous deposits behind the retina)
47
Central Hypothyroidism
2/2 pituitary etiology
Diagnosis varies from primary hypothyroidism: will have low-normal or low TSH, so must check free T4, which will be low.
48
Selective IgA deficiency
- Can have chronic/recurrent respiratory tract infections, eczema, high incidence of autoimmune dz
- Higher risk for severe anaphylaxis to blood
49
Management of blood pressure in intracerebral hemorrhage
- Use IV infusion medication, check vitals Q5 minutes.
| - If SBP starts >180, target 160/90. If evidence of increased ICP, target 140 systolic.
50
Hypertension with cocaine
Use Labetalol (mixed alpha and beta activity).
DO NOT USE METOPROLOL- unopposed alpha activity can lead to coronary and cerebrovascular vasoconstriction.
51
Management of Rheumatoid Arthritis joint disease
Should get yearly xrays of joint erosions to assess for control of dz - progression can be the only symptom, and would require change in medications
Should get TB and Hep C titers yearly
52
Laxative abuse findings
Chronic diarrhea --> normal anion gap metabolic acidosis
Colon bicarb loss > acid (ammonium) excretion by the kidney
53
Thinking through non-gap acidosis
Kidney vs not kidney etiology: is the kidney excreting enough acid load to make up for the low bicarb?
Acid leaves the kidney as ammonium. Not directly measured.
Urine ammonium ~ urine osmol gap/2
Osmol gap = measured-calculated
Calculated urine osmol =
2(UNa + UK) + UBUN/2.8 + Ugluc/18
If NON-kidney etiology, amoninum level should be >80.
Kidney etiology = Type I RTA
Non-kidney etiology = laxative abuse
54
Diuretic abuse lab findings
Hypokalemic metabolic ALKalosis
55
Surreptitious vomiting lab findings
Hypokalemic metabolic ALKalosis
56
Management of melanoma brain mets
If only one, or a few, mets --> surgical resection (or stereotactic radiosurger if available). This is the case even if there are mets elsewhere in the body, as long as they aren't causing symptoms.
57
Treatment of cancer-associated venous thromboembolism
Use Lovenox (or heparin) over warfarin
58
Acute angle-closure glaucoma features
Symptoms: halos around light, severe unilateral eye pain, HA, N/V
Exam: conjunctival erythema, sluggish pupil
Treat: Topical beta blockers, pilocarine, carbonic anhydrase inhibitors
59
Use of hsCRP
high-sensitivity CRP can guide prevention in patients with interediate (10-20%) cardiac risk (JUPITER trial)
The JUPITER trial found that healthy individuals with elevated CRP (>0.2 or 0.3) AND LDL
60
Hypertension in pregnancy
If hypertensive at
61
Steroid-induced osteoporosis
In women >50 needing steroids, even if otherwise low risk of fx, should give Ca, Vit D, and bisphosphonate to prevent osteoporosis IF STEROIDS >3 MOS AT 7.5 MG/DAY
62
Subungual melanoma
- Pigmentation extending to proximal nail fold, wider at the proximal end (indicating expanding lesion)
- Form of acral lentiginous melanoma, originates under the nail
63
Capgras Syndrome
- Delusional misidentification syndrome
- Associated with R hemisphere lesions - focal lesion or Alzheimers can cause
- Get delusions of imposters, believe that important/familiar people have been replaced by fraudulent doubles
64
Eosinophilic Esophagitis
- Can be 2/2 GERD
- To tx, first use PPI for 6 weeks to exclude GERD
- If no response to PPI, then start swallowed Flovent
65
Insulinoma diagnosis
- Suspect with fasting hypoglycemia and inappropriately elevated insulin level
- Diagnose: fasting BG 5-6)
- Image with CT. If nothing seen, do EUS - 90% detection rate
66
Secondary osteoarthritis
- Hemochromatosis causes secondary arthritis
- Suspect if OA of MCP joints in the absence of trauma
- Typically in MCP and wrist joints, bilaterally
- Can also affect shoulders, knees, hips, ankles
- Xray with HOOK-shaped osteophytes (different than normal osteophytes)
If suspect, get a ferritin
67
Transverse Myelitis
- Can get post-infectious idiopathic transverse myelitis
- see elevated WBCs in CSF
Treat:
- High dose steroids
- If not responding, do plasmapheresis and/or cyclophosphamide
68
Assessing cardiac risk in women
- Reynolds risk score is sex-specific and includes family hx and hsCRP - better for women
- Framingham is suboptimal in younger women (most are classified as low risk)
69
Asthma tx troubleshooting
If not responding to inhaled medications, before adjusting check technique - poor technique is a common cause of lack of response to therapy
70
Indications for valve replacement in endocarditis
- Heart failure
- Abscess
- Severe regurgitation
- Hemodynamic derangements
71
Fungal infection after transplant
Aspergillus is the most common cause of invasive fungal infection after transplant, esp lung and stem cell
- Infection is typicallyin the lungs, presents with fever, dry cough, hemoptysis, chest pain
- Can disseminate to the brain
Treat with Voriconazole
72
Dermatitis Herpetiformis
Strongly associated with celiac disease - if patient develops it, should be on gluten free diet
- Autoimmune bullous dz - itchy papulovesicles on scalp, elbows, knees, back, and buttocks
- On biopsy, see granular IgA in the dermal papillary tips
- Treat the skin rash with DAPSONE, but should also go on gluten free diet.
73
Indications for thrombolytics in PE
Persistent hypotension and hemodynamic instability. If patient stabilizes with fluids, etc., not needed (even if enlarged RV, etc. on imaging)
74
Primary Membranous Glomerulopathy
- Manifests as nephrotic syndrome
- Generally occurs as the primary disease, but can also be 2/2 hep B/C, malaria, syphilis, SLE, DM, or RA
Biopsy: characteristic diffuse glomerular membrane thickening without cellular infiltration. Also, coarse granular deposits of IgG and C3
EM: moderate podocyte foot process effacement (explains how protein leaks out)
75
BRCA testing
- for at risk individuals, testing can inform plans for breast cancer surgery.
Options:
- Breast-conserving surgery with intensive surveillance for second primary breast and ovarian ca (would require breast MRI + mammography yearly)
- Prophylactic b/l mastectomy and salpingo-oophorectomy with no further surveillance needed
76
Evaluation of thunderclap headaches
Severe and explosive, maximal intensity w/in 60 seconds of onset. Worry about SAH. Usually an underlying vascular etiology
Recurrent thunderclap HAs can be reversible cerebral vasoconstriction syndrome. Neuroimaging and CSF are normal, without evidence of SAH. Should get CT or MR angiography. Segmental cerebral artery vasoconstriction is often found - more common during/immediately after pregnancy.
77
Post-exercise hyperglycemia
usually 2/2 too little insulin
Low insulin triggers hepatic gluconeogenesis. Prolonged exercise also stimulates hepatic glucose release, which further exacerbates. If hyperglycemic after exercising, need more insulin
78
Treatment of fistulizing Crohn's Disease
1. Exam under anesthesia
2. Infliximab
Exam will allow abscesses to be drained
Infliximab is FDA approved and the most effective treatment of fistulizing Crohn's Dz.
79
Diagnosis of Rhuematoid Arthritis
Suspect with b/l synovitis of small joints and associated morning stiffness
- RF can be negative
- get anti-CCP antibody - present on 40-60% of patients, and 95% specific for RA
80
Management of superficial venous thrombophlebitis
Generally managed with NSAIDs and compression stockings
There is potential to progress to DVT and PE - if recurrent, should consider Warfarin
81
Diagnosis of anthrax
Can be inhalational - spores in the soil.
Get prodromal flu-like state, then develop rapid sepsis
CXR: wided mediastinum and bloody pleural effusions
Diagnose: organism by PCR in blood or sputum
82
Management of a sellar mass
Assess for hormone hypersecretion --> IGF-1, morning cortisol, thyroid studies, and PRL
Sxs of hyperprolactinemia (in a male): testosterone deficiency, leading to diminished libido and ED.
If diagnose prolactinoma, use dopamine agnoist to reduce PRL level and tumor size.
83
Morphea diagnosis
Cutaneous sclerosis that involves only the skin - no systemic manifestations.
Can be limited or generalized - limited = one or more discrete plaques, generalized = entire trunk and limbs
This differs from limited cutaneous systemic sclerosis, which has skin disease not progressing proximal to the elbows/knees,but also has extracutaneous findings (e.g. CREST).
Also different from linear scleroderma = onset in childhood, skin thickening that follows a dermatomal distribution, only on one side of the body
84
Autoimmune pancreatitis
Painless jaundice with diffusely enlarged pancreas and narrowed duct. Will have no mass on CT, and normal CA 19-9.
- Elevated IgG4 is highly suggestive (though can also occcur in pancreatic ca)
- Treatment: trial of steroids, 3-4 mos. Avoid Bx as increased risk of pancreatitis and duct injury
- If no improvement with steroids, then consider f/u imaging for alternative diagnosis.
- Can tx with Azathioprine if no steroid response
85
Central DI
UOsm 600
Distinguish from cerebral salt wasting: usually does not cause hypernatremia and polyuria. Hypovolemia leads to release of ADH, causing retention of water and HYPOnatremia (would have higher UOsm).
86
Evaluation of leg arterial insufficiency
If normal resting ABIs, can get exercise ABIs if high clinical suspicion - a decrase in the ABI of 20% immediately after exercise is diagnostic of PAD.
Use angiography in anticipation of planning surgery, not to diagnose PAD.
87
Management of ARDS
- Tidal volume should be 4-6 mL/kg of IDEAL body weight
Will have hypoxemia requiring O2 and PEEP.
88
Calculation of ideal body weight
Men: 50 kg + 2.3 kg for each inch over 60
Women: 45.5 kg + 2.3 kg for each inch over 60
89
Management of acute sinusitis
Usually viral, and resolves in 7-10 days. Should treat symptomatically only
Use ABX if high/continued fever or worsening Sxs.
90
Evaluation of dyspnea in coal miner
1. CXR
2. (if ongoing Sxs despite normal xray) PFTs looking for obstructive lung dz - will see decline in FEV1
3. chest CT looking for interstitial dz
91
Diagnosis of carotid artery dissection
Abrupt onset cervical pain and Sxs of Horner's syndrome (ptosis, miosis). Can also get amaurosis fugax, retinal infarction, diplopia, other stroke Sxs.
Dissection can occur spontaneously, but usually has traumatic cause (cervical manipulation at chiropractor).
92
Anemia of kidney disease
Normochromic, normocytic, with low retic count (lacking EPO).
- Can measure serum EPO to confirm
- Smear may show "burr cells"
93
Use of Ranexa
- Consider for patients with chronic STABLE angina despite BB, CCB, AND nitrate
- contraindicated in long QT
- Inhibits metabolism of Digoxin and Simvastatin (may need to decrease doses)
- Requires renal dosing
94
Post-polypectomy surveillance
Sessile polyp removed piecemeal = 2-6 mos
Family hx hereditary colon ca or IBD = 1 year
High-risk polyp (>3 adenomas, >1cm villous adenoma, high-grade dysplasia) = 3 years
1 or 2 small (
95
Treatment of Shigella
If Sxs are severe, should treat with Cipro even prior to stool culture results
If mild sxs and + culture, should treat with Ciprox 3 days to hasten clearance of bacterial shedding and reduce spread to others (even if diarrhea has resolved).
96
Lead nephrotoxicity
Lead can cause kidney injury (think worker in battery factory). Get chronic tubulointerstitial nephritis, low grade proteinuria
- Can get blood lead level, but may be normal (most lead resides in the bones, esp if no longer being exposed)
- Should get chelation mobilization testing (EDTA mobilizes lead in the tissues, then can measure it in the urine)
- If high levels detected, would then administer chelation
97
Unna boots
Multilayered compression bandages - inner layer of zinc oxide bandage, outer layer of elastic wrap.
Good for tx of venous stasis ulcers
98
Diagnosis of Brain Death
Exam c/w brain death: coma, no motor response, no pupillary response, no corneal reflex, no gag
In addition to above, need apnea test: get the PCO2 to 40-60 and the patient normothermic, then d/c the ventilator and trend ABGs at 1,5, and 8 minutes. If PCO2 rises >20 without observed respirations, confirms brain death.
EEG is not needed unless apnea test cannot be performed
99
Diagnosis of male infertility
Semen analysis - abstain from sex for 48-72 hours to have an adequate sample. If test is abnormal, should be repeated
If repeat is abnormal, then get LH, FSH, testosterone (looking for Leydig and Sertoli cell function)
No testicular U/S needed unless abnormality detected on exam
100
Cryoglobulinemic vasculitis
Associated with Hep C (also MM, CTD, Waldenstrom macroglobulinemia)
Manifests as palpable purpura on the lower extremities
Diagnose: cryoglobulins in the serum
Labs: low C4, elevated RF
Skin bx: leukocytoclastic vasculitis
101
Vocal Cord Dysfunction
- Inspiratory and expiratory wheezing, respiratory distress, and anxiety
- Attacks are difficult to distinguish from asthma, but: sudden onset, abrupt termination, lack of response to asthma therapy, lack of hypoxemia, lack of hyperinflation in CXR
Diagnose with laryngoscopy
102
Chondrocalcinosis
Manifestation of calcium pyrophosphate deposition
Crystals deposit in the cartilage, or can get released causing pseudogout.
Can get low phos, mag, hypothyroidism, hemochromatosis, and high PTH - should screen for this.
Can see on xray. If otherwise asymptomatic and labs ok, NTD.
If Sxs, use NSAIDs, corticosteroids, or colchicine
103
Treatment of GERD
If no response to high dose PPI for 8-12 weeks, should get endoscopy looking for alternative diagnosis
Should also have endoscopy in men with long-standing (>5 years) symptoms
104
ACEi/ARB use
can cause rise in serum Cr, or uncover previously undetected kidney dysfunction
Both meds decrease GFR by their mechanism of action, thus increasing the Cr. Not necessarily an indication to stop therapy.
105
Management of atrial myxoma
Should be surgically resected - increase the risk of embolism and stroke.
106
Polycythemia vera
- Hemoglobin >18.5 men, 16.5 women
- Leukocytosis
- Thrombocytosis
- Hepatosplenomegaly
- Erythromelalgia (burning on palms/soles)
- Warm water pruritis
Diagnose with JAK2 V617F analysis
107
BCR-ABL Association
CML
108
Takotsubo (stress) cardiomyopathy
- Can present with anginal CP, ECG changes, and elevated troponin, even in the setting of normal coronaries
Criteria for diagnosis:
- ST segment elevation
- Transient wall motion abnormalities of the apex and mid-ventricle
- Absence of CAD
- Absence of other causes of transient LV dysfunction (recent trauma, myocarditis)
Prognosis is good - usually LV dysfunction resolves with BB, ACEi
109
Lemierre Syndrome definition
Septic Thrombosis of the jugular vein
Pharyngitis, persistent fever, neck pain, septic pulmonary emboli
Diagnose with CT with contrast of the affected vessel
110
Management of newly diagnosed
HIV Recommend starting antiretrovirals if:
- hx opportunistic infection or malignancy
- presence of symptoms
- CD4 count
111
Treatment of alcoholic hepatitis
Grade severity based on Maddrey discriminant function score. Severe = 32 or greater
If severe, treat. First line is steroids (avoid with GI bleeding, kidney failure, active infection). Second line is Pentoxifylline.
112
Humoral Hypercalcemia of malignancy
Due to tumor production of PTHrP, increases serum calcium by acting on bones, kidney, intesntial absorption
Usually associated with squamous cell carcinoma of the lung (rarely with B cell lymphoma)
113
Metastatic colorectal cancer
Typically goes to the lung, usually w/in 5 years of treatment
Survey with yearly exam, CEA, CT, and c-scope
If lung met develops, should be resected, chemo/radiation not necessarily needed
114
Pheochromocytoma
Causes sustained or paroxysmal hypertension, diaphoresis, headache, and anxiety.
Can get surge in BP with anesthesia 2/2 catecholamine release (mostly norepinephrine)
Diagnose with plasma metanephrines
115
Myelodysplastic Syndromes (MDS)
Higher risk MDS associated with presence of blasts, and two or three cytopenias vs just one.
For high risk MDS, should give Azacitidine
116
Diagnosis of rheumatoid arthritis
Involves wrists and small hand joints symmetrically. The swelling can lead to carpal tunnel syndrome (the most common neurologic complication of RA)
Associated with prolonged (>60 min) morning stiffness/fatigue
117
Diagnosis of multiple myeloma
SPEP and UPEP
lab abnormalities: AKI, elevated urine protein, hypercalcemia, anemia
118
CMV after kidney transplant
presents as CMV syndrome in the first few months after transplant
Fevers, cytopenias, hepatitis (can also cause pneumonitis or colitis)
Increased risk if sero+ donor and sero- recipient.
Treat with IV ganciclovir or oral valganciclovir
119
BK virus after kidney transplant
A late complication (not in the first few months)
- Get BK-related nephropathy, organ rejection, ureteral strictures
- Urine has "decoy cells," cells with intranuclear inclusions
120
Management of temporal lobe epilepsy
If refractory to medications (i.e. refractory to more than two), the likelihood of remission by adding of substituting a med is low
If patient has mesial temporal sclerosis (temporal lobe lights up on MRI), or a known low grade tumor or vascular malformation, highest likelihood of remission is with R temporal lobectomy.
121
Impetigo
Yellow/crusted skin lesions
Staph or Strep. If staph, has exfoliative toxin that can lead to superficial blister formation
Treatment: TOPICAL MUPIROCIN (not Bacitracin d/t high rate allergic contact dermatitis). If widespread or complicated, oral Keflex.
122
Management of ankylosing spondylitis
Leads to ossification of intervertebral disks, ligaments, and joints of the spine, making the spine more rigid. Can then get vertebral fractures more easily
If patient with back pain, should get xray to r/o vertebral fx.
123
Secondary causes of dyslipidemia
- Hypothyroidism
- DM
- Obstructive liver disease
- Nephrotic syndrome
If difficulty controlling lipids, test for these.
Note: do not increase Simvastatin to 80 - high risk of myopathy. If needing higher dose statin, switch to lipitor or crestor.
124
Management of Acute Limb Ischemia
revascularization vs amputation
Signs of late presentation, which requires amputation:
- dense anesthesia
- severe motor impairment
- lack of any doppler-able pulses
125
Opiate-induced Secondary Hypogonadism
Chronic opiate use can lead to secondary hypogonadism. Thought to be central. Downregulation of GnRH --> decreased FSH and LH --> testosterone
126
Management of Barrett's esophagus
Once identified (by bx), should have repeat endoscopy 1 year later with repeat bx. If ok, can then space out to Q3 years.
If dysplasia (vs metaplasia) is identified, would need to consider further management vs esophagectomy
127
Focal Segmental Glomerulosclerosis (FSGS)
The most common cause of idiopathic nephrotic syndrome, esp blacks
Can be primary or secondary (usually more mild)
Presents with nephrotic-range proteinuria, hypoalbuminemia, severe edema, hyperlipidemia
Diagnose with kidney bx
128
IgA nephropathy
Men and white/Asian people (rarely black)
| Presents after URI, can have microscopic or gross hematuria, with only mild proteinuria
129
Diagnosis of allergic contact dermatitis
Patch testing. (Prick and RAST testing more appropriate for immediate hypersensitivity reactions)
A type IV (delayed) hypersensitivity reaction
130
Acute coccidiodomycosis
SW US
Acute infection = "valley fever" with subacute respiratory illness, fever, fatigue, joint pain, erythema nodosum.
Labs will have elevated ESR
131
Alpha thalassemia
Get ineffective erythropoiesis, intravascular hemolysis, decreased Hgb production.
Labs: mild anemia, microcytosis, hypochromia, target cells.
In adults, will have NORMAL Hgb electrophoresis.
Often mistaken for Iron deficiency, but Fe studies not consistent
132
Iron deficiency labs (Fe, Ferritin, Transferrin, TIBC)
Fe low
TIBC HIGH
Transferrin low
Ferritin low
133
Compressive cervical myelopathy
Cervical cord compression can cause acute leg weakness without other symptoms (neck pain, a sensory level, bowel/bladder impairment)
134
Anchoring error
When a clinician holds to an initial impression and fails to consider other possibilities
135
Availability error
When a clinician makes a diagnosis based on what is available in his/her mind, rather than what is most probable
136
No-fault error
The presentation is misleading and the clinician has little opportunity to pick up clues of an underlying problem
137
Representativeness error
The clinician applies pattern recognition in making a diagnosis, and thus fails to consider other possibilities
138
Diagnosing obscure GI bleeding
First line workup:
- Scopes
- Capsules
Secondary Workup:
- Angiography (fast bleeds)
- Tagged RBC
If not seen on repeated scopes or capsule, angiography and tagged RBC scan both options.
Angiography requires brisker bleeding, and is therefore less sensitive than tagged RBC.
139
Acute HIV diagnosis
Get acute illness 2-4 weeks after infection with fever, LAD. Will usually resolve without treatment. In the acute period, seroconversion has not occurred so antibody testing will be negative
Diagnose at this time with viral-specific nucleic acid amplicification
140
Cancer of unknown primary site
When a met is found without primary site identification.
In women with axillary LAD and nothing else, should treat for stage II breast ca - will find the primary after mastectomy 50-60% of the time.
141
Acute interstitial nephritis
Typically d/t hypersensitivity to a medication
Classic presentation (only 10% of the time): fever, rash, eosinophilia, elevated creatinine
Diagnosis: UA with whites, white casts, and no bacteria.
Treatment: stop the offending medication
Common meds: PPIs
142
Dermatomyositis
- Proximal muscle weakness
- heliotrope rash
- Gottron papules (pink/skin colored papules over DIP and PIP joints). Alternatively, Gottron sign (redness over joint spaces of the hands)
- Erythema over malar area, including nasolabial fold
- shawl sign - lacy rash in V over chest, shoulders, upper back
- rash can be exacerbated by sun exposure
143
Management of osteoporosis in men
Half will have an identifiable cause, so should screen for secondary osteoporosis rather than just treat with bisphosphonate.
Look for hypogonadism, vit D deficiency, high PTH, myeloma
Also, consider celiac disease (can get 24 H urine calcium excretion while on supplement - if low U calcium, may indicate calcium malabsorption)
144
Fibromyalgia
Signs:
widespread pain/tenderness for at least 3 mos.
Treatment:
regular aerobic exercise (walking, water aerobics)
Meds:
Lyrica, also SNRIs (Cymbalta)
145
Spontaneous Bacterial Peritonitis (SBP)
Diagnosis: >250 PMNs
Treat with Cefotaxime
If having associated kidney failure, at increased risk of mortality. In that case should concurrently be giving albumin.
146
Polyarteritis Nodosa (PN)
Symptoms:
fever, weight loss, abdominal pain, testicular pain, palpable purpura, livedo reticularis
Mesenteric angio shows aneurysms of medium caliber and small muscular arteries (also renal, GI, heart).
Labs:
anemia, leukocytosis, elevated ESR
Treatment:
50% of patients with PAN also have hep B. If both, treat with 2 week course of steroids + antiviral therapy (entecavir)
If no hep B, do steroids + Cyclophosphamide
147
Cervical radiculopathy
If neuro symptoms are progressive and obvious compression on imaging, should be referred for surgery to avoid permanent loss of function.
If no progressive neuro symptoms, should to PT, consider local steroid injection
148
Management of lung nodules
Nodule = 3 cm or less (>3cm = mass)
If low-risk patient (no smoking, asbestos), no f/u for nodule
149
Balkan Nephropathy
chronic tubulointerstitial condition, unclear etiology, in the Balkan region.
maybe d/t a plant in that region that produces aristolochic acid
Increased risk of urothelial cancers
150
Herpes labialis and sunlight
UV light can reactivate HSV
Those at risk can take prophylactic antivirals when planning to be in the sun.
