Term
| What is the progression of EKG changes indicating acute ischemia/infarction? |
|
Definition
1) T-wave inversion
2) ST-segment changes
3) Q waves |
|
|
Term
What are the possible explanations for the following PE signs?
1) JVD
2) Hepatojugular Reflex
3) Kussmaul Sign |
|
Definition
1) > 7cm above sternal angle
- Volume overload in RHF and pulm HTN
2) Distention of neck veins upon applying pressure to liver.
- Volume overload in RHF and pulm HTN.
3) Increase in JVP with inspiration
- Tampenade or Constrictive pericarditis |
|
|
Term
| What are the major diastolic murmurs in adults? |
|
Definition
1) Aortic Regurgitation: Early decrescendo
2) Mitral Stenosis: Opening snap followed by Mid-to-late low pitched murmur |
|
|
Term
Why might a patient have each of the following pulse abnormalities?
1) Bounding
2) Decreased
3) Decrease in systolic BP with inspiration
4) Alternating weak and strong
5) Weak and delayed |
|
Definition
1) Compensated aortic regurgitation or coarctation (UE>LE)
2) PAD, late stage HF
3) Pulsus Paradoxus: Pericardial tamponade, tension pneumo, foreign body in airway
4) Pulsus alternans: Cardiac tamponade, impaired LV systolic function
5) Aortic Stenosis |
|
|
Term
How are each of the following arrhythmias managed?
1) Sinus bradycardia
2) First degree AV block
3) Second degree Mobitz 1
4) Second degree Mobitz 2
5) Complete heart block
6) Sick sinus/tachy-brady syndrome |
|
Definition
1) Can result from sinus node dysfunction or drugs
- Atropine can be used in symptomatic cases, or pacemaker
2) Nothing: PR > 200
3) Increased Vagal tone or drugs: Can use atropine if indicated for symptoms, otherwise nothing
4) Fibrotic disease of conduction system or MI
- Place pacemaker
5) No P-to-QRS relationship
- Place pacemaker
6) Place pacemaker |
|
|
Term
How are each of the following supra ventricular arrhythmias managed?
1) A fib
2) A flutter
3) MAT
4) AVNRT
5) AVRT |
|
Definition
1) No p waves with variable QRS response
- Rate (beta blockers, CCB or dig)
- Anticoagulate if CHADVASC>2
- If new (<2d) or unstable, cardiovert
- If > 2d or unclear duration, get TEE first
2) sawtooth at > 300 ppm
- Anticoagulate and rate control. Cardiovert as in AF
3) >3 different p wave morphologies
- Rate control and pacemaker less effective
4) Reentry circuit in AV node: P wave buried in QRS or shortly after
- Cardiovert if HDS, carotid massage, adenosine can help
5) Ectopic connection between A and V (seen in WPW)
- Preexcitation delta wave. Treat as AVNRT |
|
|
Term
| How does paroxysmal atrial tachycardia differ from AVNRT and AVRT? |
|
Definition
1) PAT has rapid ectopic pace maker in atrium (not sinus node)
- P wave with unusual axis before QRS
2) AVNRT has reentry circuit in AV node that depolarizes A and V simultaneously
- P is buried in QRS or shortly after
3) AVRT: ectopic connection between atrium and ventricle that causes reentry (such as in WPW)
- Pre-excitation delta wave |
|
|
Term
How are each of the following ventricular tachy-arrhythmias managed?
1) PVCs
2) WPW
3) VT
4) VF
5) Torsades |
|
Definition
1) Hypoxia, electrolytes, hyperthyroidism
- Symptomatic management with beta blockers and address underlying cause
2) Observation if asymptomatic. Cardiovert if HD unstable
3) Cardiovert if unstable. Otherwise amiodarone, lidocaine or procainamide
4) Immediate defibrillation and ACLS protocol
5) Give magnesium and cardiovert if unstable. Correct K+ and withdraw offending drugs. |
|
|
Term
| What are the common causes of acute A fib? |
|
Definition
PIRATES
Pulmonary
Ischemia
Rheumatic HD
Anemia/Atrial myxoma
Thyroid
Ethanol
Sepsis |
|
|
Term
| What are the management steps in acute CHF exacerbation? |
|
Definition
LMNOP
Lasix, Morphine, Nitrates, Oxygen, Position |
|
|
Term
| What are the management steps for non-systolic cardiac dysfunction? |
|
Definition
EF will be normal, but diastolic filling is impaired.
1) Diuretics first line
2) DO NOT give fluids or Digoxin
3) Beta blockers, ACEIs, ARBS or CCBs to maintain rate and BP |
|
|
Term
What are the important side effectives of each of the following diuretic classes?
1) Loops
2) Thiazides
3) K- sparing
4) CA inhibitors
5) Osmotics |
|
Definition
1) Ototoxicity, Hypokalemia, Hypocalcemia, Gout
2) Hypokalemic MA, hyponatremia, hyperGLUC (glucose, lipids, urea, calcium)
3) Spironolactone: hyperkalemia, gynecomastia, sexual dysfunction
4) Hyperchloremic metabolic acidosis, neuropathy, armonia toxicity
5) Pulmonary edema, dehydration, NOT used in CHR or anuria |
|
|
Term
| Which drugs are known to cause dilated CM? Which viruses? |
|
Definition
1) Doxorubicin, AZT, cocaine, ethanol
2) Coxsackie, HIV, Chagas, parasites |
|
|
Term
| How can you differentiate between dilated and hypertrophic CM on echo? |
|
Definition
In Dilated, EF will be decreased and there will be an S3, whereas in hypertrophic EF will be maintained or increased and there will be an S4.
Also wall thickness increased in hypertrophic but not dilated |
|
|
Term
| What is the appropriate diagnostic test and management of HOCM? |
|
Definition
1) Echo
2) Beta blocker first line, CCB 2nd. Avoid intense athletics |
|
|
Term
| What are the major etiologies of restrictive CM? How is it diagnosed and treated? |
|
Definition
1) Infiltrative disease: Sarcoid, Hemochromatosis, Amyloidosis, Radiation
2) Echo: rapid early filling and near normal EF
3) Palliation with diuretics and vasodilators |
|
|
Term
| what is the appropriate management of chronic stable angina? How does this management change in the case of unstable angina or NSTEMI? |
|
Definition
ASA, beta blockers and nitroglycerine.
If UA or NSTEMI, add O2, IV nitro, IV morphine. Look at TIMI/enzymes/ST and consider enoxaparin and glycoprotein inhibitors + early angiography
**HRT is not protective in post-menopausal women** |
|
|
Term
| What is the best predictor or survival in ST elevation MI? |
|
Definition
|
|
Term
Match location of MI to ST abnormalities
1) ST elevation in II, III and aVF
2) ST elevation in V5, V6
3) ST elevation in V1-V4
4) ST. depression in V1-2 |
|
Definition
1) Inferior wall (RCA/PDA)
2) Anterior (LAD)
3) Lateral (LCA)
4) Posterior |
|
|
Term
| What type of MI should NOT be treated with beta blockers? What about nitrates? TPA/reteplase? |
|
Definition
1) Patient with HF or carcinogenic shock: give ACE instead
2) Inferior wall: risk of hypotension
3) history of hemorrhagic stroke, recent ischemic CVA, severe HF or carcinogenic shock |
|
|
Term
| What are the indications for CABG? |
|
Definition
1) Unable to perform PCI (diffuse disease)
2) Left main disease
3) Triple vessel disease
4) Depressed ventricular function |
|
|
Term
| What is the most common cause of death following acute MI? |
|
Definition
| Arrhythmia. Also Reinfarction, LV rupture, VSD, papillary muscle rupture, aneurysm |
|
|
Term
What are the common post-MI complications by time window?
1) First day
2) 2-4d
3) 5-10d
4) Weeks-months |
|
Definition
1) Heart failure
2) Arrhythmia, pericarditis
3) LV rupture, papillary muscle rupture
4) Aneurysm, thrombus |
|
|
Term
| What are the diagnostic criteria for hyperlipidemia and who should be screened? |
|
Definition
1) > 35 or > 20 with CAD risk factors
2) Total > 200 on 2 occasions, or LDL > 130, HDL < 40 |
|
|
Term
What are the important SE of the following lipid-lowering agents?
1) Statins
2) LPL stimulators (fibrates)
3) Cholesterol absorption inhibitors (Ezetimbe)
4) Niacin
5) Bile acid resins |
|
Definition
1) LFTs, myositis, warfarin potentiation
2) GI, cholelithiasis, myositis, LFTs
3) Diarrhea, abdominal pain, angioedema
4) Flushing (prevented with ASA), paresthesias, pruritus, GI upset, LFTs
5) Constipation, GI, LFTs, decreased absorption of other agents in small intestine |
|
|
Term
| What are the major causes of secondary HTN? |
|
Definition
CHAPS
1) Cushing syndrome
2) Hyperaldosteronism (Conns)
3) Aortic coartcation
4) Pheo
5) Stenosis of RA |
|
|
Term
| What is the BP lowering goal for hypertensive emergency in the first 2h? |
|
Definition
| 25%. Lower more aggressively might cause cerebral hypo perfusion or coronary insufficiency! |
|
|
Term
| What is the management of the cause of secondary hypertension that presents with episodic HA, sweating and tachycardia? |
|
Definition
Pheo: adrenal tumor secreting epi/NE
Diagnose with urianry metanephrines and catecholamine levels.
Surgery and alpha + beta blockage |
|
|
Term
| What are the important causes of Pericarditis? |
|
Definition
CARDIAC RIND
Pleuritic chest pain worse while supine
- CVD
- Aortic dissection
- Radiation
- Drugs
- Infection
- Acute renal failure
- Cardiac (MI)
- Rheumatic fever
- Injury
- Neoplasms
- Dressler |
|
|
Term
| What are the different types of CCB and their common SE? |
|
Definition
1) Dihydropyridine: Nifedipine, Felodipine, Amlodipine
- HA, flushing, peripheral edema
2) Non-dihydropyridine: Diltizaem, Verapamil
- Decreased cardiac contractility |
|
|
Term
| What are the important side effects of the vasodilator Minoxidil? |
|
Definition
| Orthostasis and Hirsutism |
|
|
Term
| How do methyldopa and clonidine act to lower BP? What are the SE? |
|
Definition
Centrally acting alpha 2 agonists inhibit sympathetic nervous system
Somnolence, orthostasis, impotence, rebound HTN |
|
|
Term
| What is the management of a patient with electrical alternans on EKG? |
|
Definition
Pericardial effusion: rate >> amount
JVD, hypotension and distant heart sounds: beck's
1) Aggressive volume expansion
2) Pericardiocentisis
3) If decompensating, pericardial window may be necessary |
|
|
Term
| What is the most common risk factor predisposing to aortic aneurysm? How big does a AAA have to be to operate? |
|
Definition
1) Atherosclerosis, HTN
2) > 5cm
Screen all men 65-75 with smoking history once by ultrasound |
|
|
Term
| How is aortic regurgitation managed? |
|
Definition
Blowing diastolic murmur at left sternal border with widened pulse pressure (femoral bruit and head bob)
1) Vasodilators (dihydropyridines or ACEis) until severe enough for valve replacement |
|
|
Term
| What is the treatment of mitral valve stenosis |
|
Definition
Diagnose with Echo
1) Antiarythmics (beta blocker and digoxin) for symptoms
2) Balloon valvuloatomy and valve replacement if severe |
|
|
Term
| What is the most common etiology underlying aortic dissection? What types are surgical emergencies? How its it diagnosed? |
|
Definition
1) HTN
2) Ascending (proximal to left subclavian), descending medical with beta blockers before vasodilation (reflex tachycardia)
3) Get CTA |
|
|
Term
| What is the appropriate management of DVT? |
|
Definition
| Heparin IV/SQ followed by Warfarin for 3-6 months. If contraindications, use IVC filters. |
|
|
Term
| What are the common causes of lymphedema? How is it managed? |
|
Definition
NOT diuretics. Exercise, massage, pressure garments
1) Post-mastectomy
2) Filariasis in immigrants with normal hearts and progressive swelling of LE
3) Hereditary in children
4) Turner's |
|
|
Term
| Why are neonates susceptible to bleeding unless they receive a vitamin shot? |
|
Definition
| The enteric bacteria synthesizing vitamin K are absent at birth |
|
|
Term
| Which hemophilias are XL inheritance and which are autosomal? |
|
Definition
XL is A (VIII) and B (IX)
Autosomal is C in ashkenazi (XI) |
|
|
Term
What are the actions of the following anti-coagulants? How are they reversed or toxicity treated?
1) Heparin
2) LMWH
3) Warfarin
4) Factor Xa (Apixaban, Riveroxaban)
5) tPA
6) DTIs (Dabigatrin, Argatroban) |
|
Definition
1) AT activator, prolongs PTT, reversed with protamine
2) Xa inhibitor, does NOT increase PTT, but use anti-factor Xa can be monitors. No reversal
3) Vitamin K-dependent factors (II, VII, IX, X, C, S). Reverse with FFP or vitamin K. PT increased
4) No reversal agent. No monitoring. PT/PTT not monitored
5) Aids conversion of plasminogen to plasmin, which breaks down fibrin. PT/PTT both increased
6) No reversal |
|
|
Term
Young boy presents with joint bleed and history of multiple GI bleeds in past. There is a + FH for bleeding
What is your next step in workup? |
|
Definition
Hemophilia?
1) Get coags: Increase PTT and normal PT and bleeding time
2) Hemophilia will correct with mixing, because normal plasma contains clotting factors
3) Get specific factor assays |
|
|
Term
| How is hemophilia treated? |
|
Definition
If non-emergent bleeding, give DDAVP, which causes release of factor VIII from endothelial cells
Emergent gets missing factor or Cryoppt |
|
|
Term
| How can vWB disease be differentiated from hemophilia? How is vWB disease treated? |
|
Definition
1) Bleeding time in vWB is abnormal, but normal in Hemophilia
2) Mixing corrupts Hemophilia, but not vWB
3) Ristocetin cofactor assay is specific for vWB
4) Give DDAVP for bleeding, OCPs for menorrhagia and Avoid ASA |
|
|
Term
| What are the factor genetic hyper coagulable states? |
|
Definition
1) Antithrombin III deficiency
2) Protein C/S deficiency: skin or tissue necrosis after Warfarin administration
3) Factor V Leiden: abnormal protein prevents inactivation by protein C. Don't give OCPs to patients with this
4) Hyperhomocysteinemia
5) APA syndrome: SLE and RA |
|
|
Term
| Can can HIT be confirmed? How about hereditary hyper coagulable states? |
|
Definition
1) HIT: PF4 antibody and serotonin release assay
2) Hereditary: two abnormal values while patient is asymptomatic and untreated, with similar values in two other family members |
|
|
Term
| What conditions are commonly associated with DIC. How can DIC be distinguished from liver failure? How is it managed? |
|
Definition
1) In DIC (not liver), factor VIII is depressed
2) Obstetric complications, sepsis, pancreatitis, ARDS, among others
3) Underlying cause is key. Transfuse RBCs, platelets, FFP and manage shock |
|
|
Term
| What is the mechanism underlying TTP? How is it diagnosed and differentiated form other MAHAs? |
|
Definition
1) Deficiency in ADAMTS-13 enzyme, which normally cleaves vWBF. With more vWBF, multimers form and create platelet micro thrombi.
2) Low platelets, hemolytic anemia with schistocytes,
If HUS, neurologic and renal changes are seen with fever (O157:H7 E cli) |
|
|
Term
|
Definition
Plasma exchange +/- steroids to reduce micro thrombi formation.
Platelet transfusion is contraindicated (they are being consumed!) |
|
|
Term
| How is ITP diagnosed and treated? |
|
Definition
IgG against platelets, with destruction in spleen and increased production of megakaryocytes by bone marrow
1) Childbearing woman with symptoms after viral illness. Diagnosis of exclusion.
2) IF platelets > 30K and no bleeding, no treatment
3) IF platelets < 30K or bleeding, give steroids or IVIG
4) Refractory needs splenectomy +/- rituximab or TPO receptor agonist (Romiplostim, eltrombopag) |
|
|
Term
| What is the differential for thrombocytopenia? |
|
Definition
HIT SHOC
- HIT or HUS
- ITP
- TTP or treatment (meds)
- Splenomegaly
- Hereditary (WAS)
- Other (malignancy)
- Chemotherapy |
|
|
Term
| What is the differential for microcytic anemia? |
|
Definition
TICS
1) Thalssemia
- normal iron studies. Diagnosed by electrophoresis
- only ones that need transfusions and deferoxamine (prevent iron overload) are Beta thalassemia major and Hemoglobin H
2) Iron: glossitis, conjunctival pallor, koilonychia
- Low ferritin, high TIBC and low reticulocyte count
3) Chronic disease
- High ferritin and low TIBC (hiding iron from bacteria)
4) Sideroblastic
- Alcohol, lead, chloramphenicol, INH, malignancy
- High iron, basophilic stippling (lead), ringed sideroblasts |
|
|
Term
| What is on the differential for Macrocytic anemia? |
|
Definition
1) Megaloblastic: impaired DNA synthesis
- Hypersegmented neurotrophils
- B12, folate, orotic acuduria
2) Non-megaloblastic
- Liver, alcohol, reticulocytosis |
|
|
Term
| How can foric acid deficiency be distinguished from B12 deficiency? |
|
Definition
B12: elevated MMA and homocystine
Folate: normal MMA and elevated homocysteine |
|
|
Term
| Why is pernicious anemia a particular concern? |
|
Definition
| risk of gastric cancer. Can confirm with Schilling test, when no radiolableled B12 is in urine. |
|
|
Term
| What are the major etiologies of hemolytic anemia? |
|
Definition
1) G6PD deficiency
2) PNH
3) Spherocytosis
4) Sickle Cell
5) Autoimmune
6) MAHA: TTP, HUS, DIC
7) Mechanical valves |
|
|
Term
| What are the classic laboratory findings for hemolytic anemia? |
|
Definition
Increased LDH, high Retic count, high bilirubin, low Haptoglobin
T/x varies by case, but often involves steroids and iron supplementation |
|
|
Term
Name the diagnostic test and t/x for each of the following types of hemolytic anemia.
1) XLR defect presenting as episodic dark urine and jaundice triggered by sulfa drugs or antimalarials
2) Deficiency in GPI-anchor molecules that keep CD55/CD59 attached to cells
3) Autosomal dominant loss of RBC membrane surface area |
|
Definition
1) G6PD deficiency: get CBC and smear showing bite cells and Heinz bodies. Get G6PD level 1 months after episode and AVOID triggers
2) PNH. Get CD55/CD59 absence via flow cytometry
3) Spherocytosis. Get CBC with smear to show spherocytes. Osmotic fragility is accurate test and need SPLENECTOMY |
|
|
Term
Which AR RBC disorder leads to decreased RBC survival and vaso-occlusive crises?
How is it diagnosed and treated? |
|
Definition
SSD: mutation in beta chain of hemoglobin with G to V switch.
1) CBC with smear showing sickle cells and Howell-Jolly bodies. Confirm with HG electrophoresis
- Sickling occurs with dehydration, deoxygenation and high altitude
2) Hydroxyurea stimulates fetal Hgb production, and if refractory, chronic transfusion
- Maintenance includes treating cholelithiasis with surgery, chronic folate supplementation, pneumococcal vaccine and PCN in patients < 5 years old. |
|
|
Term
| What are the two types of Autoimmune HA and how are they differentiated? |
|
Definition
+ Direct coombs test (uses patient's sensitized erythrocytes)
1) Warm (IgG): seen in SLE, CLL, drugs
- Severe cases need steroids
2) Cold (IgM): Seen in Mycoplasma PNA and mono
- severe cases need avoiding cold and Rituximab |
|
|
Term
| Which drugs are known to cause aplastic anemia? |
|
Definition
1) Methimazole
2) Chloramphenicol
3) Proplthiouracil
4) Sulfa drugs |
|
|
Term
| What is the most likely diagnosis in a patient with cafe-au-lait spots, short stature, thumb hypoplasia and aplastic anemia? |
|
Definition
|
|
Term
| What is the differential for Polycythemia? |
|
Definition
1) Hypoxia (lung disease, smoking)
2) Neoplasia (EPO-producing)
3) OSA
4) PCV; Jak2 mutation leading to clonal proliferation of pluripotent marrow cells (RBC/WBC/platelets will all be high and EPO will be LOW)
5) Relative from hypovolemia: EPO will be normal or high |
|
|
Term
|
Definition
1) Phlebotomy and ASA to prevent symptoms and thrombosis
2) Hydroxyrea and IFN can reduce cell counts |
|
|
Term
| What are the 3 major types of transfusion reactions and how are they treated? |
|
Definition
1) Febrile Non-hemolytic
- Cytokine formation during blood storage
- 1-6h after transfusion
- STOP and give acetaminophen
2) Febrile Hemolytic
- Preformed (acute) or formed (delayed) recipient antibodies against donor RBCs
- ABO mistmatch or Rh and Duffy antigens
- Shortly after transfusion
- STOP, give vigorous IV fluids and maintain urine output
3) Allergic
- Antibody against donor PROTEINs
- Urticaria
- Give antihistamines and if severe, STOP and give Epi |
|
|
Term
| What is Porphyria? What are the major types? |
|
Definition
1) Abnormality of heme production leading to accumulation of porphyrin
Usually se photo dermatitis, neuropsychiatric complaints and visceral complains
2) Acute intermittent, Erythropooietic and Porphyria cutanea trade (most common) |
|
|
Term
| What are the 5 sings of acute intermittent porphyria? |
|
Definition
5 Ps
- Pain abdomen
- Port-wine urine (pink)
- Polyneuropathy
- Psychological disturbance
- Precipitated by drugs, alcohol or starvation (college kid with barbs and alcohol) |
|
|
Term
| Why give high doses of glucose during porphyria attack? |
|
Definition
| Decreases eye synthesis, providing negative feedback to heme synthetic pathway |
|
|
Term
| What are the 4 variations of alpha thalassemia? |
|
Definition
1) 3/4: Silent carrier: No signs of symptoms
2) 2/4: alpha thalassemia trait: Low MCV, but asymptomatic
3) 1/4: Hgb H: Severe anemia and elevated relic count to compensate. Also skeletal changes
4) 0/4: Hydrops: die in utero |
|
|
Term
| What type of bone marrow findings are typical for ALL and AML? |
|
Definition
Infiltration with blasts. WBC may be high, but they are dysfunctional
1) AML: leukemic cells are myeloblasts: Auer Rods
2) ALL: leukemic cells are lymphoblasts |
|
|
Term
| What preventative treatment measures can be taken in patients with AML/ALL to prevent tumor lysis syndrome? |
|
Definition
Hyperuricemia and Renal failure in TLS
1) Hydrate well
2) If WBC high, give allopurinol or rasburicase |
|
|
Term
| How can leukemia reactions be differentiated from hematological malignancies? |
|
Definition
| LAP! Low in malignancy, high in leukemoid. |
|
|
Term
| What are the expected CBC and smear findings for CLL and CML, respectively? |
|
Definition
1) CLL: usually well-differentiated B cell phenotype
- Lymphocytosis with smudge cells
- Flow cytometry with CD5 + b cells (normally on t cells)
- Not curable, so hold off chemo until symptoms are really bad
2) CML
- Excess granulocytes and basophils.
- BCR-ABL translocation t (9, 22)
- Imatinib: TK inhibitor |
|
|
Term
| What is the stain used to diagnose Hairy Cell Leukemia? What types of cells are affected? How is it treated? |
|
Definition
1) TRAP
2) Well differentiated B cells
3) Cladribine or splenectomy + IFN-a |
|
|
Term
| What are the classic signs of leukemia vs. lymphoma? |
|
Definition
1) Leukemia: infection, petechiae/bleeding, anemia, DIC
2) Lymphoma: LNA, B symptoms |
|
|
Term
| What are the major distinguishing features between Hodkin's and NH lymphoma? |
|
Definition
1) Age: HL is bimodal, NHL is 65-75
2) B cells: HL has CD15+ and CD30+ and RS cells, NHL has many types
3) Virus association: HL with EBV, NHL with HIV and autoimmune |
|
|
Term
| What are the 4 major types of B cell NHL? What ages are affected and what is the course/therapy? |
|
Definition
1) Follicular
- Adults, indolent, usually localized and curable with radiation
2) Diffuse Large B cell
- Middle-aged, intermediate grade, single rapid growing mass
- Responds to R-CHOP
3) Burkitt
- Children and adolescents, high grade (starry sky)
- Jaw in Africa, Abomen in American
- EBV, t(8; 14) translocation.
4) Mantle Cell
- CD5+. Rare |
|
|
Term
| What are the 2 major types of T cell NHL? What ages are affected and what is the course/therapy? |
|
Definition
1) Adult T-cell lymphoma
- High grade, can progress to ALL
- Presents with cutaneous lesions, associated with IVDA and caused by HTLV
2) Mycosis fungoides/Sezary syndrome
- Skin lymphoma, with eczema-like lesions and pruritus
- Cerebriform lymphoid cells
- Can progress to Sezary syndrome (T- cell leukemia) with characteristic cells on smear |
|
|
Term
| What are the typical electrolyte finding of tumor lysis syndrome? |
|
Definition
1) Hyperkalemia
2) Hyperphosphatemia
3) Hyperuricemia
4) HYPOcalcemia |
|
|
Term
| How does treatment of low-grade and high-grade NHL differ? |
|
Definition
1) Low-grade: palliative
2) High-grade: aggressive and curative.
Staging is different, and is based on laterality and number of sites |
|
|
Term
What malignancy is associated with Pel-Ebstein fevers (1-2 weeks high, 1-2 weeks no fever) and Alcohol-induced pain?
How is this condition diagnosed and treated? |
|
Definition
Hodkins Lymphoma
Diagnose with excision LN biopsy showing RS cells
Combination chemo/radiation. Survival is good and lymphocyte-predominant has best prognosis |
|
|
Term
| How is Waldenstrom Macrogolbulinemia differentiated from Multiple Myeloma? |
|
Definition
1) WM is IgM and hyper viscosity with coag abnormalities
- Chronic and indolent course
- Diagnose with BMB and aspirate, look for Dutcher bodies (PAS+ IgM deposits win plasma cells)
2) MM: IgM and CRAB
- Get electrophoresis and skeletal survey |
|
|
Term
| What are the major sites of clinically important amyloid deposition in Amyloidosis? |
|
Definition
1) Kidney
2) Heart
3) Liver
**also brain** |
|
|
Term
| What are the classic signs of chronic and autoimmune neutropenia? |
|
Definition
< 1500 ANC
- Recurrent sinusitis
- Gingivits and stomatitis
- Perirectal infections
Consider workup for CVD. G-CSF can shorten duration and rarely IVIG and bone marrow t/x is used. |
|
|
Term
| What are the 5 major causes of secondary Eosinophilia? |
|
Definition
NAACP. > 350/mm
1) Neoplasm
2) Allergies (most common in developed world)
3) Asthma
4) CVD
5) Parasites (most common in undeveloped world) |
|
|
Term
What is suggested by a CSF analysis showing eosinophilia?
What about in the case of hematuria? |
|
Definition
Tx with steroids usually
1) Drug reaction or Infection with coccidioidomycosis or helminth
2) Hematuria + eosinophilia = Schistosomiasis |
|
|
Term
| What is the pathophysiology of GVHD is organ transplant and how is it treated? |
|
Definition
1) Minor histocompatibility antigens attack skin, liver, lungs and GI
2) High dose steroids |
|
|
Term
| What are the major differences between hyper acute, acute and chronic organ transplant rejections? How are they prevented and treated? |
|
Definition
1) Hyper-acute
- Minutes, with pre-formed antibodies
- Vascular thrombosis and ischemia
- Prevent with ABO check and treat with Cytotoxic agents
2) Acute
- 5d-3m, T cell mediated
- Increased GGT, Alk phos, LDH, BUN, Cr
- Confirm with sampling of tissue and treat with CS, OKT3, tacrolimus or MMF
3) Chronic
- months-years, chronic immune reaction leading to fibrosis
- no treatment, but biopsy to rule out acute reaction. |
|
|
Term
Match the associated neoplasm with the condition.
1) Xeroderma Pigmentosa
2) Actinic keratosis
3) Down syndrome
4) Pernicious anemia
5) Plummer-Vinson syndrome (iron deficiency) |
|
Definition
1) SC and BC carcinoma of skin
2) SCC of skin
3) ALL
4) Gastric adenocarcinoma
5) SCC of esophagus |
|
|
Term
Match the associated neoplasm with the condition.
1) Acanthosis Nigricans
2) Tuberous sclerosis
3) Paget's disease of bone |
|
Definition
1) Visceral malignancy (stomach, lung, breast, uterus)
2) Astrocytoma and cardiac rhabdomyoma
3) Secondary osteosarcoma and fibrosarcoma |
|
|
Term
| How is atopic dermatitis diagnosed/treated and how does it present in infants? |
|
Definition
Eczema
1) Erythematous weeping, pruritus papule sparing diaper
- Remember to r/o erythema toxic neonatorum 1-3 days after delivery, which will self-resolve
2) KOH distinguish from tine infection
3) Topical CS are first-line
- Topic immunomodulators can be used > 2 years (risk of lymphoma with prolonged use) |
|
|
Term
| What type of immunological reaction is involved in Contact Dermatitis? What are typical triggers? How is it diagnosed? |
|
Definition
1) Type IV
2) Nickel, poison ivy, perfume, neomycin
- NOT latex (type 1)
3) Patch test and topical CS and allergen avoidance |
|
|
Term
Describe the mechanism of each hypersensitivity section.
1) Anaphylaxis
2) Urticarial
3) Autoimmune HA
4) Polyarteritis nodosa
5) Hypersensitivity pneumonitis |
|
Definition
1 and 2) Type 1 Hypersensitivity
- Antigen cross-linked IgE on presensitized mast cell and triggers release of histamine
3) Cytotoxic, Type II (also erythroblastosis details, good pastures, rheumatic fever
- IgM and IgG bind antigen on enemy cell and leads to lysis by complement or phagocytosis
4) Immune complex (type 3) Also SLE, RA
- Antigen-antibody complexes bind complement and attract PMNs, which release lysosomal enzymes
5) Arthus reaction
- local reaction to antigen by pre-formed antibodies with vascular necrosis and thrombosis
- 4-12h after vaccination sometimes |
|
|
Term
| What is the most common cause of serum sickness? |
|
Definition
| Drug reaction- 5d after exposure with immune complex formation |
|
|
Term
| What type of hypersensitive reaction is found in contact dermatitis and TB skin tests? |
|
Definition
Type IV: Delayed (cell-mediated)
Sensitized T lymphocytes encounter AG and release lymphokines, leading to phage activation
Also seen in t/x rejection |
|
|
Term
| Which groups of patients develop severe Seborrheic dermatitis? How is it treated in all patients? |
|
Definition
1) HIV and Parkinson's
2) Shampoo and creams
- Selenium sulfide and zinc pyrithione shampoos for scalp
- Topical anti-fungals and/or CS for other areas |
|
|
Term
| How can rash location of extensor vs. flexor surface help your differential? |
|
Definition
Extensor: think Psoriasis
Flexor: think Atopic dermatitis |
|
|
Term
| How is local and disseminated Psoriasis managed? |
|
Definition
T-cell mediated inflammatory dermatosis
1) Local: CS topical, Calcipotriene (Vit D) and Tazarotene (Vit A)
2) Severe or arthritis (sausage digits, pencil-in-cup X-ray)
- MTX or anti-TNF
- UV light also unless immunocompromised |
|
|
Term
| How is Urticaria managed? |
|
Definition
1) Systemic anti-hiatmines
2) Anaphylaxis needs Epi IM, antihistamines, IV fluids and airway maintenance |
|
|
Term
| What skin condition is associated with "targeted" lesions usually triggered by an infection (such as HSV or mycoplasma)? How is it managed? |
|
Definition
Erythema Multiforme: usually affected palms and soles
Negative Nikolsky sign (compared to EN and SJS): no separation of skin layers with light rubbing
Symptomatic is all that is needed: NOT CS |
|
|
Term
| How can SJS be differentiated from TEN diagnostically? |
|
Definition
1) SJS < 10% BSA, TEN > 30% BSA
2) SJS: degeneration of basal layer of epidermis, whereas TEN has full-tuickness eosinophilic epidermal necrosis
Both both, cover skin, manage electrolytes and secondary infections |
|
|
Term
What condition presents with painful erythematous nodules appearing on anterior shines and slowly spreading with fever and joint pain?
What conditions is this seen in? |
|
Definition
Erythema nodosum: Panniculutis (sub-q fat inflammation)
1) Get ASO (strep), PPD (TB), CXR (sarcoid), IBD workup
2) NSAIDs and cool compresses can help, but address underlying cause |
|
|
Term
| Distinguish between Bullous pemphigoid and PV in terms of autoantibodies, appearance, nikolsky sign, diagnosis and treatment |
|
Definition
1) BP: hemidesmosomal, PV: Desmoglein (keratinocyte adhesion)
2) BP: firm and stable blisters, PV: erosions more common
3) BP: negative Nikolsky, PV: positive Nikolksy
4) BP/PV: skin biopsy with direct IF or ELISA
5) BP: Steroids, PV: Steroids + immunomodulatory therapy |
|
|
Term
| How is Dermatitis herpetiformis treated? |
|
Definition
| Dapsone and gluten-free diet (Celiac) |
|
|
Term
| How is HSV infection treated? |
|
Definition
1) First episode: acyclovir/valacyclovir can shorten. If immunocompromised, give drug within 72h of start.
2) Recurrent: Antivirals
3) Severe frequency recurrences (>6 per year): antiviral ppx |
|
|
Term
| Who needs post-exposure ppx for Varicella? |
|
Definition
| Immunocompromised, Pregnant and Newborns need VZIG within 10d |
|
|
Term
| Where is Molluscum Contagiosum seen most commonly? |
|
Definition
| Children and AIDS patients: Poxvirus |
|
|
Term
Young boy presents with pustules on his cheeks and chin. They are honey-colored crusts with erythematous base.
What is the most likely etiology. How is it treated? |
|
Definition
Impetigo: GAS or staph (sometimes can be bullies and evolve into SSSS)
Superficial bacterial infection of epidermis.
1) Treat mild/localized with with topical antibiotics (Mupirocin)
2) Severe (non-MRSA) needs oral cephalexin, dicloxacilin or erythromycin
3) Severe (MRSA) needs oral TMP/SMX, clinda or doxy |
|
|
Term
What layer of skin is affected by each of the following?
1) Erysipelas
2) Cellulitis
3) Impetigo
4) Nec fasc
5) Folliculitis |
|
Definition
1) Dermis
2) Dermis and sub-q fat
3) Epidermis
4) Sub-q fat and fascia
5) Follicle |
|
|
Term
What are the risk factors for the condition that presents with red, hot, swollen, tender skin with a clear damaged skin source?
How is it treated? |
|
Definition
1) Cellulitis: Diabetes, IVDU, venous stasis, immunosuppression
2) Need 5-10d oral antibiotics (strep or staph). If diabetes or orbital involvement, need IV. |
|
|
Term
What are you worried about in a post-op patient who develops acute onset pain and swelling around surgical site progressing to anesthesia? There is crepitus and putrid discharge.
What do you do next? |
|
Definition
1) Nec Fasc: mixed with S aureus, E. coli, C. perfringens
2) Immediate surgery with broad-spectrum coverage (usually PCN G or Clindamycin with MTZ) |
|
|
Term
What is the pathogenesis of Acne vulgaris.
What are the steps of management? |
|
Definition
1) Hormonal activation of sebaceous glands involvement Priopioibacterium acnes in hair follicles
2) Mild-to-moderate: Topical Retinoids for comedamal
- If response to b peroxide and retinoids fails, consider antibiotic
3) Moderate-severe:
- Oral doxycycline or minocycline
- If all fails, oral retinoids can be used (LFTs and teratogen) |
|
|
Term
Name that rash and first step in diagnosis and t/x:
1) Small scaly patches of varying color on chest or back.
2) Painless white laces in mouth that can be easily scraped off
3) Markedly erythematous patches with occasional erosion and smaller satellite lesions |
|
Definition
1) T versicolor: Fungal M. furfur
- Get KOH prep, look for "spaghetti and meatballs"
- Treat with topical ketoconazole or selenium sulfide
2-3) Candidiasis
- KOH prep look for pseudohyphae
- Oral gets gluconazole tablets of nystatin switch
Skin gets topical antifungals
- Diaper gets topical nystatin |
|
|
Term
Name that rash and first step in diagnosis and t/x:
1) Scaly, pruritic eruption with sharp border and central clearing in immunocompromised patient
2) Thickened scaly skin on soles of feet
3) Jock itch
4) Scalp scaling and hair loss with a large boggy mass |
|
Definition
All are fungal dermatophyte infections: Trichopyton, Microsporum, Epidermophyton
1) Tinea corporis
2) Tinea pedis
3) Tinea cruris
4) Tinea capitis with Kerion
All get KOH test showing hyphae +/- fungal culture
Top with topical, then proceed with orals (capitus and immunosuppressed always needs orals) |
|
|
Term
| How are lice diagnosed and treated? |
|
Definition
Naked eye inspection!
Head: topical permethrin, mechanical removal
Body: rarely topical permethrin, just hygeine
Pubic: topical permethrin |
|
|
Term
| How can scabies be differentiated clinically from lice? |
|
Definition
Both are parasitic infections
Scabies cause intense pruritus at night and after hot showers, and you see linear tracks (usually interdigital finger webs)
Scabies are only seen under microscope.
Scabies need permethrin from neck DOWN! Lice only need topical |
|
|
Term
| Why might you use hyperbaric oxygen for treatment of gangrene? |
|
Definition
| Post-op this will kill C. perfringens if ganrene is gas variety. |
|
|
Term
| What is on the differential for an observation of acanthosis nigerians? |
|
Definition
| DM, Cushing disease, PCOS, Obesity. Can be paraneoplastic of gastric adenocarcinoma |
|
|
Term
| What patients get lichen planus? What is the management? |
|
Definition
HCV and drugs
Topical CS, or systemic if severe |
|
|
Term
| What is Rosacea? How is it managed? |
|
Definition
1) Chronic disorder of pilosebaceous units (follicular) presenting with central facial erythema with telangiectasia and overgrowth of nasal connect tissue (rhinpphyma)
2) Topical MTZ. If severe ocular disease give oral doxycycline |
|
|
Term
Name that rash and first step in diagnosis and t/x:
Patient with recent HHV infection presents with herald patch with peripheral scale that 2 days later erupts into multiple scaling plaques with a "cigarette paper" feel in a "Christmas tree" distribution. |
|
Definition
Pityriasis Rosea
Dx: get KOH to rule out fungus (tinea)
Tx: Rash heals in 6-8w without treatment. Supportive only. |
|
|
Term
| What types of patients develop secondary deficiency of melanocytes and how is it managed? |
|
Definition
Vitiligo.
Look for serological markers of autoimmune disease
Topical steroids, tacrolimus ointment. |
|
|
Term
| What is the difference between Hordeolum and Chalazion? |
|
Definition
Both eyelid lesions
1) Hordeolum is gland infection, that is painful
2) Chalazion is blockage of gland and is painless cyst |
|
|
Term
| How should lesions in sun-exposed areas with well-demarcated erythematous bases and light-colored scale be managed? |
|
Definition
| Actinic Keratosis can progress to SCC, so Cryosurgery, or topical 5-FU |
|
|
Term
| How can Bacillary Angiomatosis be differentiated from Kaposi Sarcoma? |
|
Definition
BA is from Bartonella and is treated with erythromycin. Get biopsy
KS is vascular proliferative disease attributed to HHV-8 in HIV patients.
Give HAART and systemic chemo |
|
|
Term
| What is Mycosis fungoides? How is it diagnosed and treated? |
|
Definition
Progressive neoplastic proliferation of T cells (NOT fungus)
Psorioatic-appearing plaques that are pruritus with predilection from trunk and buttocks
1) Diagnose with EM showing typical Sezary or Lutzner cells (cerebriform lymphocytes)
2) Treatment with phototherapy |
|
|
Term
| What are the initial tests to run in suspected diabetes? |
|
Definition
1) Spot urine albumin-to-creatiine ratio (will be missed on dipstick)
- 30-300
2) Glucose
- Random > 200
- Post-prandial > 200 (repeat)
- Fasting > 126 |
|
|
Term
How do each of the following diabetes drugs work? What are their worrisome SE?
1) Metformin
2) SFU (glipizide, glyburide)
3) TZD (glitazones)
4) DPP-4 inhibitors (Liptins)
5) Incretins (tides)
6) SGLT2 inhibitors (Flozins) |
|
Definition
1) Inhibits liver gluconeogenesis and increases peripheral sensitivity to insulin
- LA, renal insufficiency, liver or heart failure are contra
2) Increase insulin production
- Hypoglycemia and weight gain
3) Increased insulin sensitivity
- Weight gain, edema, liver toxicity, NOT in heart failure
4) Inhibit degradation of GLP-1
- Weight neutral
5) Agonist of GLP-1
- Sub-q injection, Weight loss and pancreatitis
6) Decreased glucose absorption
- UTIs, weight loss, hypotension |
|
|
Term
| What are the distinguishing features of DKA vs. HHS? |
|
Definition
1) DKA
- Type 1 DM
- Glucose > 250 < 600
- AGMA with normal serum osmolality
- Give fluids, insulin, phosphorus (rarely bicarbonate). Monitor gap closure. Once glucose is 250-300, add dextrose!
2) HHS
- Type 2 DM
- Glucose > 600
- No acidosis or AG
- Give aggressive fluids, electrolytes and insulin
- Elevated serum osmolality > 320 |
|
|
Term
| What are the distinguishing features of DKA vs. HHS? |
|
Definition
1) DKA
- Type 1 DM
- Glucose > 250 < 600
- AGMA with normal serum osmolality
- Give fluids, insulin, phosphorus (rarely bicarbonate). Monitor gap closure
2) HHS
- Type 2 DM
- Glucose > 600
- No acidosis or AG
- Give aggressive fluids, electrolytes and insulin
- Elevated serum osmolality > 320 |
|
|
Term
| What are the criteria for metabolic syndrome? |
|
Definition
** Can use metformin to slow onset of diabetes in high risk patients **
WEIGHHT
- Waist Expanded
- Insulin resistance
- Impaired Glucose
- Low HDL
- TG high |
|
|
Term
| What is your differential for hyperthyroidism and what are the defining features of each condition? |
|
Definition
1) Graves
- Exopathlmos, pretrial myxedema, thyroid bruit
- TSH receptor stimulating antibodies
- Increased RAI uptake (diffuse)
2) Toxic adenoma
- NL or increase RAI update (focal)
3) MNG
- Nodular uptake
4) Postviral Thyroiditis
- Decreased uptake and increased TG |
|
|
Term
| What is the appropriate management of Thyroid storm? |
|
Definition
1) Antithyroid drugs
2) Iodine, IV esmolol, steroids
3) Admit to ICU |
|
|
Term
|
Definition
1) Symptomatic
- Propranolol
2) Pharmacological
- Methimazole, PTU
3) Definitive
- I ablation + Levo
4) Opthalmopathy
- Steroids can help |
|
|
Term
| What do you think about in an infant with FTT, hypotonia and umbilical hernias as well as prolonged jaundice? |
|
Definition
| Congenital hypothyroidism 2/2 dysgenesis |
|
|
Term
| How is Myxedema coma managed? |
|
Definition
Mortality 30-60%!
Give IV levo and IV hydrocortisone (if adrenal insufficiency not excluded) |
|
|
Term
| Describe your w/u for a thyroid nodule |
|
Definition
1) If > 1cm, on US, get TSH
2) If TSH is low, get I scan
- Hot, treat hyperthyroidism
3) TSH NL/Low, get FNA |
|
|
Term
| What is the general overview of calcium/phosphate regulation? |
|
Definition
Think about bone, gut, kidneys
1) Phosphate
- Low phosphorus triggers conversion of 25(OH)D to 1, 25 (OH) D in kidneys, which leads to increased absorption in intestine
2) Calcium
- Low calcium sensed by Parathyroid
- PTH stimulates bone and kidney (production of 1,25 D increases and phosphate reabsorption is inhibitied) |
|
|
Term
| What drugs are used in management of osteoporosis |
|
Definition
1) Bisphosphonates
2) SERMs
3) Denosumab (RANK-L inhibitor)
4) Teriparatide (PTH analogue) |
|
|
Term
| What does a high alk phos with normal GGT make you think of? |
|
Definition
BONE not liver.
If normal calcium and phosphate, think Paget's |
|
|
Term
| What is the workup and treatment for Paget's? |
|
Definition
1) Plain films and beeline radionuclide bone scan to characterize extent of disease
2) High Alk Phos and normal calcium/phosphorous
3) Calcium and vitamin supplementation with consideration of bisphophonates
Remember risk of Osteosarcoma, High output CF, and think about hearing loss |
|
|
Term
| Why might you see an elevated PTH with hypocalcemia and hyperhyphophatemia is patient with short 4th metatarsal and carpal bones? |
|
Definition
High PTH, with low Ca and high P suggest PTH resistance.
Bone features suggest Albright hereditary osteodystrophy |
|
|
Term
| What are the causes of hypoparathyroidism? |
|
Definition
1) Iatrogenic: surgical
2) Autoimmune
3) Congenital (DiGeorge)
4) Infiltrative (Hemochromatosis, Wilson) |
|
|
Term
| Why use phosphate binders in patients with renal failure? |
|
Definition
| Prevent secondary hyperparathyroidism! |
|
|
Term
| What is the workup for suspected hypopituitarism? Which hormones are released from the pituitary? |
|
Definition
1) Get morning cortisol, free T4, testosterone/estrogen, IGF-1
- TSH (+ by TRH)
- Prolactin (+ by TRH, - by dopamine)
- FSH/LH (+ by GnRH, - by prolactin via hypothalamus)
- GH (+ GHRH)
- ACTH (+ by CRH) |
|
|
Term
| What are the causes of Cushing syndrome? What is Cushing disease? |
|
Definition
1) Most common exogenous cortisol
2) Pituitary adenoma secreting ACTH (Cushing disease)
- Suppressed by high-dose deja test
3) Bilateral adrenal hyperplasia/tumor
- No suppression with lose-dose deja
- Low plasma ACTH
4) Occult neoplasm (carcinoid, medullary thyroid, SCLC) |
|
|
Term
| What is the workup for cushing syndrome? |
|
Definition
1) Overnight dexa (1mg) suppression test or 24h urine free cortisol
2) If not suppressed, get ACTH and cortisol in plasma
- suppressed ACTH suggests Adrenal etiology (neg feedback)
- If ACTH normal or elevated, think about Pituitary and get MRI
3) Pituitary adenoma indicates cushing disease
- If MRI negative/inconclusive, get petrosal sinus sampling with CRH
4) If central-peripheral ACTH gradient present, think Cushing disease, otherwise think Ectopic ACTH-dependent |
|
|
Term
| How can high-doses dexamethasone suppression test help in diagnosis of Cushing syndrome? |
|
Definition
Ectopic ACTH secretion and Pituitary hypersecretion (disease) will BOTH have elevated cortisol and lack of suppression with low-dose suppression.
If high-dose is suppressive, you think pituitary etiology
If high-dose is not suppressive, think ectopic |
|
|
Term
| What are the important comorbidities of acromegaly? What is the workup? |
|
Definition
- Screen with IGF-1 and confirm with oral glucose suppression test (NOT baseline GH). Get MRI for sellar lesion
**IGF-1 is produced by liver in response to GH stimulation**
1) Glucose intolerance
2) Diabetes
3) Cardiomyopathy |
|
|
Term
| How is Acromegaly managed? |
|
Definition
1) Transphenoidal surgical resection
2) Medical
- Octreotide/Lantreatide (Somatostain) to suppress GH
- Pegvisomant is a GH receptor antagonist |
|
|
Term
| What structure produces DHEAS? What else is produced here? |
|
Definition
Adrenal gland ONLY!
**GFR for Cortex**
- Aldosterone (Zona Glomerulosa)
- Cortisol (Zona Fasciculata)
- Sex hormones (Zona Reticularis)
- Catecholamines (NE, E) (Medulary Chromaffin Cells) |
|
|
Term
| Patient presents with weakness, fatigue, anorexia and hyper pigmentation. Describe your initial workup |
|
Definition
Worried about adrenal insufficiency 2/2 Addison's disease
1) get morning cortisol and ACTH.
- If morning cortisol non-diagnostic, get Cosyntropin stimulation test!
2) < 3 ug/dL in absence of exogenous GC administration, or failure of rise > 20 after Cosyntropin diagnostic of adrenal insufficiency
3) |
|
|
Term
| How can you clinically tell between primary and secondary adrenal insufficiency? |
|
Definition
1) Primary (Addison most common in US, or infection)
- Low cortisol
- high ACTH
- Skin hyperpigementation
- low Na
- low aldosterone
- high K
2) Secondary (cessation of long-time glucocorticoids)
- Low cortisol
- Low Low ACTH
- Normal skin
- Normal Na
- Normal K |
|
|
Term
| How is adrenal crisis managed? |
|
Definition
4 S's!
1) Salt: 0.9% saline
2) Steroids: IV hydrocortisone 100 mg q8h (for primary need glucocorticoid and mineralocorticoid, for secondary just glucocorticoid)
3) Support
4) Search for underlying illness |
|
|
Term
| What is a Pheochromocytoma and how does it present? |
|
Definition
1) Tumor of chromatin tissue of adrenal medulla (NE, Epi) either within medulla or extra-adrenal sites
- Seen in MEN2A/2B, vHLD and NF
2) Pain (head), Pressure (HTN episodic), Palpitations, Perspiration, Pallor |
|
|
Term
|
Definition
| Surgery. Give alpha blocker first, followed by beta blocker. (hypertension risk) |
|
|
Term
| What are the classic findings of the MEN syndromes? |
|
Definition
MEN1: 3 Ps
- Pituitary adenoma, Parathyroid, Pancreas (VIPoma, Gastrinoma, Insulinoma)
MEN2A: 2 P's
- Parathyroid hyperplasia, Pheochromocytoma, Medullary carcinoma
MEN2B:1 P
- Pheo, Medullary carcinoma, Neuromas |
|
|
Term
What type of CAH is described by each of the following?
1) Low mineralocorticoids, low cortisol, high sex hormones, hypotension, hyperkalemia
2) High mineralocorticoids, hypokalemia, HTN, low sex hormones, low cortisol
3) High sex hormones, HTN, hyperkalemia |
|
Definition
1) 21 hydroxylase: High renin activity, high 17 hydroxy-progesterone
- XX will show virilization
- Most common- salt wasting infancy and precocious puberty in adolescent
2) 17a hydroxylase: Low androstenedione
- XY: pseudohermaphroditism
- XX: lack secondary sex characteristics
3) 11b hydroxylase: low renin activity
- XX: civilization |
|
|
Term
| How are sensitivity and specificity calculated? How about PPV and NPV> |
|
Definition
1) Sensitivity
- positive test with disease/ (disease positive test + disease negative test)
- a/ a + c
- False negative ratio= 1 - sensitivity
2) Specificity
- neg disease and neg test/ neg disease and neg test + pos disease and neg test
- d/ d + b
3) PPV
- + test + disease/ (+test + disease) + (+ test - disease)
- a/ a + b
4) NPV
- - test - disease/ (-test - disease) + (-test +disease)
- d/ c + d |
|
|
Term
| How are PPV and NPV affected by disease prevalence? |
|
Definition
1) PPV increases with prevalence
2) NPV decreases with prevalence |
|
|
Term
| What is a likelihood ratio? How is it calculated? |
|
Definition
The extent to which a given test result is likely in diseases people as opposed to non-diseased people.
- Posttest odds = pre-test odds X LR |
|
|
Term
| How does absolute risk differ from attributable risk. How is attributable risk calculated and how does it relate to NNT? |
|
Definition
1) Absolute risk is incidence
2) Attribute risk is difference in risk between exposed and unexposed groups
- Incidence of disease in exposed - incidence in unexposed
NNT= 1/attributable risk
** so if exposed is 60 % and unexposed is 30%, attributable risk is 0.3 and NNT is 3.3** |
|
|
Term
| How does OR differ from RR? |
|
Definition
1) RR is incidence in exposed/incidence in unexposed
2) OR = odds that diseased person is exposed/ woods diseased person is unexposed
AT LOW INCIDENCE, OR approximates RR well |
|
|
Term
| What are the advantages and disadvantages of a cross-sectional study? |
|
Definition
Snap-shop in time that looks at correlation, not causation
1) Advantages
- Efficiency means to examine a population
- Basis for diagnostic testing
2) Disadvantage
- No causation
- Risk or incidence cannot be directly measured |
|
|
Term
| How do primary, secondary and tertiary prevention differ? |
|
Definition
1) Primary: preventative measures to decrease incidence of disease
- Diet/weight loss
2) Secondary: Identifying disease early and preventing progression
- Mammogram
3) Tertiary: Decrease morbidity/mortality resulting from disease
- Tamoxifen adjacent for breast cancer treatment |
|
|
Term
What are the live attenuated vaccines?
What are the inactivated vaccines
What are the toxic vaccines?
What are the conjugate vaccines? |
|
Definition
1) Polio (sabin), MMR, VZV, Yellow fever, Flu (spray)
2) Polio (salk), cholera, HAV, rabies, influenza (injection)
3) Tdap
4) His, S. pneumonia |
|
|
Term
| What are the classic findings of Plummer vinson syndrome? |
|
Definition
| Iron deficiency anemia, esophageal webs and glossitis |
|
|
Term
| What are the 3 major causes of infectious esophagitis? How are they managed? |
|
Definition
1) Candida: yellow white plaques adherent to mucosa
- Fluconazole PO
2) CMV: Retinitis, colitis, intranuclear and intarcycloplasmic inclusions on biopsy
- Gangciclovir IV
3) HSV
- Oral ulcers with MN giant cells and intranuclear inclusions
- Tzanck smear + and treat with IV acyclovir |
|
|
Term
| What is the first step in the workup of esophageal dysphagia (solids >> liquids) |
|
Definition
EGD
For oropharyngeal (liquids >> solids, get barium swallow first) |
|
|
Term
Which type of esophageal dysphagia is worsened by hot/cold foods and relieved by nitroglycerine?
What is your first step and how is it treated? |
|
Definition
Esophageal Spasm (vs. achalasia, GERD, stricture)
- Get EGD to r/o structural, and look for corkscrew on barium swallow. CONFIRM with manometry (high-amplitude, simultaneous contractions)
- Treat with CCB, TCA. If severe, surgery can help. |
|
|
Term
| How do esophageal spasm and achalasia differ on barium swallow? What is the definitive test? |
|
Definition
1) ES: Corkscrew
2) Achalasia: birds beak (failed LES relaxation, loss of aurbach's plexus)
3) MANOMETRY: high-amplitude contractions (ES) vs. increased LES resting pressure and decreased peristalsis (Achalasia) |
|
|
Term
| What is the treatment of choice for a Zenker diverticulum |
|
Definition
Remember, this is a false diverticulum, involving cricopharynxgeus muscle.
Diagnose with barium swallow. Myotomy of muscle is required to relive high-pressure zone |
|
|
Term
| What are the two major types of gastritis and how are they managed? |
|
Definition
1) Type A (10%)
- Autoantibodies against parietal cells leading to pernicious anemia. Affects fundus
2) Type B (90%)
- 2/2 H. pylori or NSAIDsAffects antrum
For type B with H. pylori, give triple therapy (Clarithromcyin, Omeprazole, Amoxicillin) |
|
|
Term
| What is the most cost effective test for H. pylori? |
|
Definition
Stool antigen test.
Most invasive (gold standard) is Endoscopic biopsy |
|
|
Term
| What is the only malignancy that can be cured with antibiotics? |
|
Definition
| MALT lymphoma 2/2 H. pylori. Give triple therapy (amox, clarithromycin, omeprazole) |
|
|
Term
| What type of ulcer improves after meal and which worsens? |
|
Definition
| Gastric is Greater. Duodenal Decreases |
|
|
Term
Patient presents with unresponsive, recurrent gnawing, burning abdominal pain and diarrhea. You order serum gastrin and it is elevated.
What is next? |
|
Definition
ZES is concern. Secretin test should lead to increased gastrin secretion and get CT to characterize extent of disease.
Treat with high-dose PPIs and surgical resection after localization (octreotide scan or CT) |
|
|
Term
| How can stool osmotic gap help you is the differential diagnosis of diarrhea? |
|
Definition
Gap= 290 - 2 * (stool Na + stool K)
Low gap (< 50) indicates Secretary: ETEC, cholera, VIPOMA, gastronome, medullary thyroid cancer (MEN)
High gap ( > 100) indicates Osmotic: celiac, whipple disease, pancreatic insufficiency, laxative abuse |
|
|
Term
Name that infectious diarrhea and how it is treated?
1) Young child with bloody diarrhea after ingestion of contaminated meat
2) Severe abnormal pain and fever with "flask-shaped" ulcers on EGD in someone with recent travel history to developing country
3) Ingestion of raw eggs presenting with prodromal H/A, fever, and myalgia and then bloody diarrhea
4) Fecal-oral transmission leading to bloody diarrhea and severe dehydration |
|
Definition
1) C. jejuni: R/O IBD and appendicitis
- t/x is supportive, then FQ or azithromycin
2) E. histolytica
- Treat with MTZ
- Steroids can lead to PERF!
3) Salmonella
- First fluids, and treat bacteremia with oral quinolone or TMP-SMX
4) Shigella
- TMP-SMX to decrease spread (extremely contagous) |
|
|
Term
| What does a positive hydrogen breath test indicate in a patient with diarrhea after drinking milk? |
|
Definition
Lactose intolerance
Oral lactase replacement and/or avoidance is key |
|
|
Term
Why might patients with carcinoid syndrome present with dermatitis, dementia and diarrhea?
What is the treatment of carcinoid syndrome? |
|
Definition
1) Niacin (B3) deficiency from increased metabolism of tryptophan into serotonin leads to Pellagra
** also flushing, and cardiac valvular disease**
2) Octreotide and surgery |
|
|
Term
| What is the definitive diagnostic test in suspected AMI? |
|
Definition
Mesenteric CTA
Volume resuscitation
- Venous needs anticoagulation
- Arterial needs laparotomy or angioplasty with anticoagulation |
|
|
Term
| True or False: Colonoscopy should be performed immediately to diagnose acute diverticulitis |
|
Definition
FALSE! perforation risk
bowel rest, NG tube placement and broad spectrum antibiotics |
|
|
Term
| How can you differentiate between SBO and LBO? How does the treatment differ? |
|
Definition
1) SBO: copious emesis with abdominal distention
- Hospitalize, NG decompression and NPO. If complete, may need surgery
2) LBO
- Constipation, less intense pain, feculent vomiting
- More commonly caused by colon cancer
- Received with gastrografin enema, colonsocpy or rectal tube, but surgery usually needed |
|
|
Term
| How can you clinically differentiate between right-sided and left-sided CRC lesions |
|
Definition
| Right sided bleed, Left sided obstruct |
|
|
Term
| Why get a colonoscopy in a patient with endocarditis? |
|
Definition
| S. bovis association with CRC |
|
|
Term
Which type of IBD is associated with perianal issues, fistulas and extraintestinal manifestations.
What is the first step in workup and how is it treated? |
|
Definition
1) Colonscopy with biopsy showing "cobble stoning" and "skip lesions"
2) Treatment is 5-ASA agents, steroids for flares, sometimes immunomodulators |
|
|
Term
| How is CRC screened for in IBD? |
|
Definition
In UC, every 1-2 years 8-10 years after diagnosis
CD less association |
|
|
Term
| What are the 3 major types of hernias and the common underlying etiologies? |
|
Definition
1) Indirect: lateral to IEVs
- congenital patent processus vaginalis
- herniation through both rings
2) Direct: medial to IEVs
- mechanical breakdown of transversalis fascia from age
3) Femoral: below inguinal ligament through femoral canal
- weakened pelvic floor and increased IAP |
|
|
Term
37 yo woman presents with postprandial abdominal pain, in RUQ with radiation to right subscapular area. She has had some N + V.
What is the first test and how is this managed? |
|
Definition
Fat, female, fertile, forty: Cholelithiasis
Pain sounds like biliary colic. Get RUQ ultrasound.
Since symptomatic, cholecystectomy |
|
|
Term
| How can you differentiate between cholecystitis and cholangitis? |
|
Definition
1) Cholecystitis involves inflammation of GB 2/2 stone in cystic duct
- RUQ pain and fever, but no jaundice or hyperbilirubinemia
- Order RUQ US (if equivocal get HIDA) and treat with Lap chole
2) Cholangitis
- Infection of CBD 2/2 choledocholithiasis
- RUQ pain, fever, jaundice, hyperbilirubinemia
- Get ERCP and look for biliary dilation (diagnostic and therapeutic). Surgery if patient too toxic |
|
|
Term
What is the t/x for each of the following
1) Cholecystitis
2) Choledocholithiasis
3) Acute cholangitis
4) Gallstone illness |
|
Definition
1) RUQ (or HIDA) US to confirm and t/x with antibiotics and cholecystectomy
2) ERCP with sphincteroctomy followed by cholecystectomy
3) Start with RUQ US (CBD dilation), then ERCP with ICU admission and IV antibiotics
4) Stone passes through colecystoduodenal fistula to obstruct illeocecal valve
- Subacute SBO in elderly woman
- AXR shows pneumobilia in biliary trees
- Laparotomy and fistula closure with cholecystectomy. |
|
|
Term
Interpret each of the following hepatitis serological markers
1) IgM HAVAb
2) HBsAg
3) HBsAb
4) HBcAg
5) HBcAb
6) HBeAg
7) HBeAb |
|
Definition
1) diagnostic of acute HAV
2) Continued presence is carrier state. Also positive in incubation and acute disease
3) Indicates immunity
4) Not measured clinically
5) IgM positive during window period. IgG indicates prior or current infection
6) Transmissibility
7) Low transmissibility |
|
|
Term
| What are the classic laboratory findings for Autoimmune hepatitis, Hemochromatosis, and Wilson's disease (all can lead to liver failure). |
|
Definition
1) Autoimmune: Anti-nuclear and anti-smooth muscle Ab (type 2). Anti-liver-kidney microsomal-1 antibodies and anti-liver cytosol antibodiies (type 2).
2) Hemochromatosis: increased ferritin and transferrin saturation with liver biopsy findings.
3) Low ceruloplasmin, high urine copper. Biopsy diagnostic. |
|
|
Term
| How is chronic HCV managed? What about chronic HBV? |
|
Definition
1) HCV
- usually two anti-vitals, or one anti-viral and ribavirin. Sometimes IFN is used.
- Sometimes transplant
2) HBV
- Tonofovir and Entecavir are first line |
|
|
Term
| What is Budd Chiari syndrome? |
|
Definition
| Hepatic vein thrombosis leading to Cirrhosis 2/2 to hyper coagulability |
|
|
Term
| What is Budd Chiari syndrome? |
|
Definition
| Hepatic vein thrombosis leading to Cirrhosis 2/2 to hyper coagulability |
|
|
Term
| What is the appropriate diagnostic test to determine the etiology of ascites and how is it interpreted? |
|
Definition
Serum-ascites albumin gradient (SAAG)
1) > 1.1 indicates portan htn
- Presinusoidal: splenic or portal vein thrombosis, schistosomiasis
- Sinusoidal: Cirrhosis
- Postsinusoidal: RHF, Constrictive pericarditis, Budd-chiari
2) < 1.1: Not portal htn
- Nephrotic syndrome, TB, Malignancy |
|
|
Term
What is the management strategy for each of the following cirrhotic complications?
1) Ascites
2) SBP
3) Hepatorenal
4) Hepatic Encephalopathy |
|
Definition
1) Sodium restriction and diuretics (furosemide, spironolactone). Paracentesis and TIPS also available.
2) IV antibiotics, IV albumin, ppx with FQ to prevent recurrence
3) Volume repletion and r/o other causes of RF. May use octreotide and midodrine, but poor prognosis
4) Lactulose and Rifaxamin |
|
|
Term
| What is the pathophysiology and treatment of esophageal varices? |
|
Definition
Portal hypertension leads to increases flow through portosystemic anastomosis.
1) medical ppx with beta blockers or endoscopic band ligation to prevent bleeding in known varices
2) for acute bleeds, endoscopy with band ligation or sclerotherapy. TIPS if refractory |
|
|
Term
| What is Primary Sclerosing Cholangitis and what are the important complications? |
|
Definition
Progressive thickening of bile duct walls and narrowing of ducts (either intrahepatic or extra hepatic) leadings to cirrhosis, pHTN and liver failure.
**Associated with UC (50-70%)**
**Diagnose with PTC/ERCP (bead-like strictures) and requires liver transplant**
1) Cholangiocarcinoma
2) Recurrent cholangitis
3) Can progress to secondary biliary cirrhosis, portal HTN and liver failure |
|
|
Term
How do PBC and PSC differ in terms of each of the following
1) Pathology
2) Demographics
3) Associated IBD
4) Diagnosis
5) Treatment |
|
Definition
PBC
1) Intrahepatic bile duct obstruction
2) F> M
3) None
4) +AMAs and confirm with liver biopsy
5) Ursodeoxycholic acid slows progression and ultimately requires liver transplant
PSC
1) Intra and extra hepatic bile duct obstruction from wall thickening and luminal narrowing
2) M>F
3) UC> CD
4) PTC/ERCP (bead-like structuring)
5) Liver transplant |
|
|
Term
|
Definition
1) Weight loss, diet and exercise (insulin resistance and metabolic syndrome drive NASH)
2) Vitamin E and Pioglitazone |
|
|
Term
| What are the 2 major types of HCC and in what groups are they seen? |
|
Definition
80% of liver cancer (primary) is HCC
1) Nonfibrolamellar (most common)
- Hepatitis B or C and Cirrhosis
- Very low survival
2) Fibrolamellar
- Not associated with Hep B or C or Cirrosis
- Often resectible
- Seen in adolescents and young adults |
|
|
Term
|
Definition
Use AFP for screening and response to therapy
1) Resection in 10% who have resectible tumors
2) Transplant if early ddx
3) transcatheter arterial chemoembolization (TACE) may work |
|
|
Term
| Name 2 common causes of secondary hemochromatosis |
|
Definition
1) Iron overload from multiple transfusions
2) Chronic hemolytic anemia |
|
|
Term
| What organs are typically affected by Hemochromatosis? |
|
Definition
AR disease with Hyper-absorption of iron in intestine
**Patients are often asymptomatic other than slightly elevated ALT and AST early in the course**
1) Liver (cirrhosis is major worry)
2) Pancreas (diabetes)
3) Heart (cardiomyopathy)
4) Joints (arthritis)
5) Skin (hyper pigmentation)
6) Thyroid (hypothyroidism) |
|
|
Term
| How is Hemochromatosis diagnosed and treated? |
|
Definition
R disease of excessive iron absorption in intestine
1) Diagnosis
- elevated serum iron/ferritin
- elevated iron saturation (transferrin saturation)
- decreased total iron-binding capacity (TIBC)
- Liver biopsy REQUIRED
- genetic testing
2) Treatment
- Repeated phlebotomies and treat complications (consider liver transplant in advanced disease)
- Defferoxamine can be used for maintenance |
|
|
Term
| What would you suspect the cause to be of RUQ pain and fullness in a 20 year old woman who uses contraceptives? |
|
Definition
Hepatocellular Adenoma (Benign liver tumor)
- Also increased risk with anabolic steroid use
- Major worry is Adenoma rupture, so confirm with CT, US or arteriography.
- Stop contraceptives and resect if >5cm and does not regress after stopping contraceptives. |
|
|
Term
| What is the most common type of benign liver tumor? |
|
Definition
Cavernous Hemangioma
- vascular tumors that only cause issues when they get really big or rupture
- UC or CT with IV contrast but do not biopsy because of rupture risk |
|
|
Term
| What is the appropriate treatment for Wilson's disease? |
|
Definition
1) Penicillamine or Trientine (copper chelators)
2) Dietary restriction (avoid shellfish, liver, legumes) |
|
|
Term
| Why might a patient with hypercalcemia present with watery diarrhea, dehydration and flushing with a low stool osmotic gap |
|
Definition
Sounds like a VIPoma in a patient with MEN 1A (with hyperparathyroidism)
Look for elevated VIP levels, achlorydia (inhibits gastrin), hyperglycemia
Get a CT and surgery |
|
|
Term
| How is carcinoembryonic antigen (CEA) used in the treatment of colorectal cancer? |
|
Definition
Useful for monitoring treatment efficacy and recurrence surveillance.
Patients with preoperative CEA> 5ng/mL have worse prognosis.
NOT used in screening |
|
|
Term
What major polyposis syndrome is described by each of the following and how are they treated?
1) AD disease caused by mutations in APC tumor suppressor
2) AD disease with adenomas and osteomas, as well as dental abnormalities, desmoid tumors and/or sebaceous cysts
3) Can be AD or AR and is associated with cerebellar medulloblastomas and gliomastoma multiformes
4) AD disease with single or multiple, scattered hamartomas throughout the GI tract and pigmented spots around the lips, oral mucosa, face, genitalia and palmar structures
5) Rare disease present in childhood characterized by >10 juvenile colonic polyps
6) Hereditary CRC without adenomatous polyposis |
|
Definition
1) Familial adenomatous polyposis (FAP)
- 100% get CRC by 3rd or 4th decade so prophylactic colectomy is recommended
2) Gardner syndrome (variant of FAP)
- 100% get CRC by age 40, so prophylactic collectomy
3) Turcot syndrome
4) Peutz-Jeghers
- Hamartomas are less likely to become malignant compared to adenomas, so risk of CRC is only slightly increased (Intussuseption or GI bleeding can occur however).
5) Familial juvenile polyposis coli
- low risk of CRC
6) Hereditary nonpolyposis CRC
- Lynch syndrome 1 (site-specific CRC): early onset without antecedent multiple polyposis
- Lynch syndrome 2 (cancer family syndrome): Lynch 1 plus increased number of early occurrent of other cancers |
|
|
Term
What is diverticulosis and how does it relate to diverticulitis?
How do you diagnose it and treat it? |
|
Definition
1) Diverticulosis is caused by increased intraluminal pressure in the colon, typically in the sigmoid region, leading to out pouching of colonic tissue
- associated with low-fiber diets and family history, in older adults
2) Diverticulitis is inflammation and/or infection of diverticula (it is a complication of diverticulosis)
3) Diagnose with Barium enema and treat with high-fiber foods and Psyillium (if patient cannot tolerate bran) |
|
|
Term
| Patients with bleeding colonic AVMs also tend to have which particular heart disease? |
|
Definition
|
|
Term
What differentiates acute and chronic mesenteric ischemia?
How are they diagnosed? |
|
Definition
Both need mesenteric arteriography
1) Acute is more common and typically involves acute embolic and/or thrombotic events
- abdominal pain out of proportion to PE is classic
2) Chronic is caused by atherosclerotic occlusive disease of main mesenteric vessels
- Abdominal angina with dull, postprandial pain is typical, as well as weight loss due to pain. |
|
|
Term
| How are bleeding esophageal varices treated? |
|
Definition
**Pharmacologic treatment with IV Octreotide and Endoscopy treatment (vatical ligation or Sclerotherapy)**
1) Variceal ligation/banding
- Emergent upper GI endoscopic treatment with low rate of re-bleeding
2) Endoscopy sclerotherapy
- risk of re-bleeding in 50% of patients
3) IV vasopressin
- Alternative to octreotide, but risk of complications includes mesenteric ischemia.
4) IV octreotide infusion
- First line therapy, causes splanchnic vasoconstriction and reduces portal pressure |
|
|
Term
| Why do spider angiomas, palmar erythema, gynecomastia and testicular atrophy occur in cirrhosis? |
|
Definition
| Hyper-estrinism because of decreased hepatic catabolism. |
|
|
Term
| How is coagulopathy treated in cirrhosis? |
|
Definition
FFP
Vitamin K cannot be used by diseased liver. |
|
|
Term
| What are the major types of liver cysts and what are their usual consequences? |
|
Definition
1) Polycystic
- AD associated with polycystic kidney disease
- Kidney disease is the problem, whereas liver generally is not
2) Hyatid
- Echinococcus granulosus (tapeworm) infection in right lobe
- Treatment is resection and Mebendazole after surgery (because of chance of rupture and anaphylactic shock) |
|
|
Term
| What are the major types of liver abscesses and where are they found? |
|
Definition
Right lobe- treat early or life threatening!
1) Pyogenic: most common cause of biliary tract obstruction
- E. coli, Klebsiella, Proteus, Enterococcus and anaeurobes
- Diagnose with US or CT
- Treat with IV antibiotics and percutaneous drainage (otherwise fatal!)
2) Amebic: common in homosexual men transmitted via fecal oral contact.
- Entamoeba histolytica (reaches liver via HPV)
- Diagnose with IgG enzyme immunoassay and stool antigen test
- IV metronidazole and therapeutic aspiration may be necessary. |
|
|
Term
| What is the workup for a suspected Choledochal cyst? |
|
Definition
| Ultrasound and then treatment is surgery with complete resection (risk of cholangiocarcinoma) |
|
|
Term
Define the following important signs of appendicitis
1) Rovsing
2) Psoas
3) Obturator |
|
Definition
Lumenal obstruction leads to stasis, promoting bacterial growth and inflammation, which can lead to necrosis, perforation and peritonitis.
1) Deep palpation of LLQ leads to pain in RLQ
2) RLQ pain when right thigh is extended as patients lies on left side
3) Pain in RLQ when flex right thigh is internally rotted while patient is supine |
|
|
Term
| What medical options are there for treating chronic pancreatitis? |
|
Definition
1) Pancreatic enzymes (decrease CCK release and decrease pancreatic secretions after meals)
2) H2 blockers (stop gastric acid from degrading pancreatic enzymes)
3) Insulin |
|
|
Term
| What are the most important risk factors for pancreatic cancer and where are the common locations? |
|
Definition
Seen in older african americans
1) **Cigarrettes (even though alcohol is for chronic pancreatitis)
- chronic pancreatitis, DM, alcohol
2) Head>body>tail |
|
|
Term
What unites Zenker's and Epiphrenic Diverticula?
What differentiates them? |
|
Definition
Both caused by underlying motility disorder and treated with surgery. Diagnosed with barium swallow
1) Zenker's
- upper 1/3 due to failure of cricopharyngeal muscle to relax during swallowing
2) Epiphrenic
- lower 1/3 associated with spastic esophageal dysmotility or achalasia
**Traction diverticula associated with traction from mediastinal inflammation and adenopathy (in TB) |
|
|
Term
| Describe the workup for Dysphagia |
|
Definition
1a) Solids only: mechanical obstruction
- intermittent: lower ring
- progressive: weight loss (carcinoma) or no weight loss (peptic stricture)
1b) Solids and liquids: Mobility problem
- Intermittent with chest pain: diffuse spasm
- Progressive with GERD: scleroderma
- Progressive with weight loss and regurg (Achalasia) |
|
|
Term
Describe each of the following important metastases of gastric carcinomas.
1) Krukenberg tumor
2) Blummer's shelf
3) Sister Mary Joseph node
4) Virchow node
5) Irish node |
|
Definition
1) ovary
2) rectum (can palpate on rectal exam)
3) periumbilical LN
4) supraclavicular foss node
5) left axillary adenopathy |
|
|
Term
| How is the need for hospitalization in PNA determined? |
|
Definition
CURB-65. > 4= admission
- Confusion
- Uremia (BUN > 19)
- RR (> 30)
- BP (< 90/60)
- > 65 |
|
|
Term
What are the most common causes of PNA in the following age groups?
1) Neonates
2) Children (6w- 18 years)
3) Adults (18-65)
4) Elderly (> 65) |
|
Definition
1) GBS, E. coli, Listeria
2) Viruses, S. pneumo, Mycoplasma, Chlamydia
3) S. pneudmo, Mycoplasma, H. influenza, Viruses
4) S. pneumo, H. influenza, GNRs |
|
|
Term
| What are the common causes of recurrent PNA? |
|
Definition
1) obstruction
2) bronchogenic carcinoma
3) lymphoma
4) Wegeners
5) immunodeficiency |
|
|
Term
What is the appropriate antibiotic for the following cases of PNA?
1) Outpatient CA PNA, < 65
2) Outpatient CA PNA > 65 or with comorbidity
3) Hospital CA PNA
4) HA PNA
5) MRSA |
|
Definition
1) Macrolide (azithro) or Doxycycline
2) FQ or Beta lactam + macrolide
3) FQ or betake lactam + macrolide
4) Think GNRs, legionella: Extended spectrum cephalosporin or carbapenem, with antipseudomanl activity
5) Add vanco or linezolid |
|
|
Term
| What are the side effects of RIPE therapy for TB? |
|
Definition
2 months with all 4, then 4 months with INH & Rifampin
1) Rifampin: orange body fluids
2) INH: peripheral neuropathy (Give B6), hemolytic anemia
3) Pyrazinamide
4) Ethambutol: optic neuritis |
|
|
Term
How is a PPD interpreted in the following cases
1) > 5 mm
2) > 10 mm
3) > 15 mm |
|
Definition
1) positive IF HIV, close TB contact and/or CXR evidence of TB
2) Positive in High risk (homeless, developing nation, IVDU, jail, health care worker)
3) Positive in everyone |
|
|
Term
| What is the CENTOR criteria for pharyngitis? |
|
Definition
4-5 points gets empiric treatment (10d PCN). 2-3 points gets RA test.
1) Age (3-14 years)
2) Absence of cough
3) Tonsillar exudates
4) Tender anterior LNA
5) Fever |
|
|
Term
| How is Coccidiomycosis managed? |
|
Definition
Fungal respiratory infection in patients from southwest US.
Black, filipino, HIV + and pregnant are at high dissemination risk
1) Acute: PO fluconazole or itraconazole
- If severe and protracted, give IV amphotericin B
2) Chronic: Progressive actuary of symptomatic disease needs surgery + long-term azole for 8-12 months |
|
|
Term
| What is the best initial step in management for suspected influenza? |
|
Definition
Rapid influenza test of viral antigens for nasopharyngeal swab
Antivirals helpful if used within 2 days of onset (shorten 1-3d) |
|
|
Term
What are the most common causes of Meningitis in the following age groups?
1) Neonates (0-6 months)
2) Children (6m to 6y)
3) Adults (6-60)
4) Elderly (>60) |
|
Definition
1) Neonates (0-6 months)
- GBS, Listeria, E. coli
2) Children (6m to 6y)
- S. pneumo, N. meningiditis, H. influenza, enterovirus
3) Adults (6-60)
- N. meningitides, S. pneumo, Enterovirus, HSV
4) Elderly (>60)
- S. pneumo
- GNRs
- Listeria |
|
|
Term
What is the empiric treatment regimen for the following age groups in the case of bacterial meningitis?
1) < 1 month
2) 1-3 months
3) 3 months - adulthood
4) > 60 years/ alcoholic, chronic illness |
|
Definition
**steroids given 15-20 min before antibiotics reduces mortality, hearing loss and near sequeli**
1) GBS, E. coli and Listeria high on differential
- Ampicillin + Cefotaxime or Gentamicin
2) Vancomycin IV + ceftriaxone or cefotaxime
3) Vancomycin IV + ceftriaxone or cefotaxime
4) Ampicillin (listeria again) + vancomycin + cefotaxime |
|
|
Term
| How do you treat close contacts of patients with bacterial meningitis? |
|
Definition
|
|
Term
| What do you think about in a patient with RBCs in CSF without history of trauma. What do you do next? |
|
Definition
HSV encephalitis
Get PCR for HSV, CMV, EBV, VZV, enterovirus. Maybe giemsa stain for trypanosomes.
Get CT/MRI |
|
|
Term
| What is the most common organism causing post-influenza PNA? |
|
Definition
|
|
Term
| Should you perform CSF analysis in suspected brain abscess? How are they treated? |
|
Definition
1) NO. Herniation risk
2) IV cephalosporin + MTZ + vancomycin for 6-8w + surgical drainage. Dexamethasone for edema and IV mannitol for ICP. Propylactic anti-convulsants as well. |
|
|
Term
| What do CD4+ count and viral load tell you about HIV progression? |
|
Definition
| CD4 tells immunosuppression degree, and viral load indicates rate of progression |
|
|
Term
| What is the correct management of HIV in pregnancy? |
|
Definition
| Mother gets Zidovudine (AZT) intrapartum and infants gets AZT for first 6 weeks after birth. |
|
|
Term
What are the SE of PI for HIV treatment?
What about NRTIs? What about Indinavir in particular? |
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Definition
1) Hyperglycemia, HLD, lipodystrophy
2) Bone marrow suppression, neuropathy
3) Crystal-induced nephropathy, nephrolithiasis |
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Term
Which ART for HIV causes each of the following?
1) Crystaline nephropathy
2) Pancreatitis
3) Hypersensitivity
4) Liver failure
5) Vivid dreams and hallucinations |
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Definition
1) Indinavir
2) Didanosine
3) Abacavir
4) Nevirapine
5) Efavirenz |
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Term
When should you start HIV ppx treatment for the following? How do you treat them?
1) P jirovecii
2) MAC
3) Toxoplasma
4) TB
5) Candida
6) HSV
7) S. pneumo
8) Influenza |
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Definition
1) < 200 or prior PCP. TMP-SMX
2) < 50, Azithromycin weekly
3) < 100 or + IgG, TMP-SMX double strength
4) PPD > 5, INH 9 months
6) Esophagitis (fluconazole), Oral (nystatin wash)
7) Acyclovir daily
8) All patients, every 5 years as long as CD4 > 200
9) All patients |
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Term
| How is Cryptococcal meningitis detected and treated? |
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Definition
Fungal. Think about in HIV.
1) WITHOUT typical meningeal signs and CSF that looks bacterial (except for monocytic predominance)
Antigen testing of CSF/blood and India ink stain
2) IV Amphotericin B + flucytosine x 2 weeks, then flucytosine for 8 weeks.
- Lifelong maintenance with Fluconazole typical. |
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Term
| What are the classic findings of Histoplasmosis? |
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Definition
1) Yeast from ohio mississippi river valley
2) CXR shows nodular, diffuse densities
3) Urine and serum polysaccharide antigen test most sensitive. Yeast can be seen on Giemsa stain
4) Treatment
- mild/stable nodules: consider itraconaozle of supportive
- chronic cavitary lesions: itraconazole for > 1 year
- Severe: Lisposomal Amphotericin B x 14 days followed by Itraconazole for 1 year |
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Term
| How do you manage lung/cns infection with partially acid-fast, branching gram positive rods? |
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Definition
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Term
| Which HIV infection is diagnosed with silver stain? |
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Definition
| PCP. Treat TMP-SMX high dose 21 days often with prednisone taper |
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Term
| How do you treat MAC in HIV? |
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Definition
**Increased serum Alk phos and LDH with foamy macrophages on biopsy**
Prophylaxis with Azithromycin, but treatment is different
1) Clarithromycin 1st line
2) Ethambutol 2nd line |
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Term
| How is Toxoplasmosis treated? |
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Definition
PO Pyrimethamine + Sulfadiazine and Leucovorin (folic acid analog to prevent hematologic toxicity)
PPX with TMP-SMX |
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Term
| When may a VDRL test be false positive? |
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Definition
| Viruses, Drugs, Rheumatic fever/RA, Lupus/Leprosy |
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Term
| How are PCN-allergic pregnant patients with + antibody titers for Syphillis treated? |
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Definition
| Cannot give them Doxy or Tetracycline, so give then PCN desensitization! |
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Term
| Who is Neurosyphilis treated? |
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Definition
Tabes dorsalis, Meningitis and AP pupils
IV PCN for 14d
**Remember Jarisch-Herxheimer reaction can occur with Syphilis treatment (acute flulike illness) because of release of endotoxins from kills organisms** |
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Term
| What are the common UTI bugs? |
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Definition
SEEKS PP
1) Serratia
2) E. coli
3) Enterobacter
4) Kelbsiella
5) Staph
6) Pseudomonas
7) Proteus |
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Term
How are the following UTIs treated?
1) Uncomplicated
2) Complciated
3) Pregnancy
4) Urosepsis |
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Definition
1) Outpatient with PO Bactrim or FQ or Nitrofurantoin
2) 7-14d of same antibiotics
3) Nitrofurantoin, oral cephalosporin or amoxicillin.
4) IV antibiotics |
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Term
There are a number of sexually-transmitted genital lesions.
Name the diagnostic test and treatment for each of the following
1) Papule evolving into beefy-red ulcer with rolled edge of granulation tissue. Painless
2) Painful pustules with inguinal LNA
3) Multiple painful vesicles
4) Multiple irregular, pink, cauliflower-like papule without pain, but with pruritus.
5) Single painless red, round and raised papule with regional LNA |
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Definition
1) Klebsiella Granulomatis (granuloma inguinale)
- Get biopsy (donovan bodies) and give doxy or azithromycin
2) H. ducreyi (chancroid)
- Usually clinical and give Azithromycin or ceftriaxone
3) HSV-1 or -2
- Tzanck smear showing MNG cells. Acyclovir for primary infection
4) HPV
- Biopsy for confirmation
- Cryotherapy, laser excision or topical
5) Syphilis Chancre
- PCN IM |
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Term
| How is Malaria diagnosed. What is the treatment? |
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Definition
1) Giemsa or Write stained thick and thin blood films
2)
- Uncomplicated: Chloroquine (resistance common)
- Vivax, Ovale or unknown: Primaquine
- Severe: IV quinidine + transition to oral as tolerated
- Atovaquone-proguanil and Mefloquine are first-line chemo-ppc against chloroquine-resistant malaria |
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Term
| In acute mononucleosis, how sensitive is the heterophiles antibody test? |
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Definition
NOT, can be negative for first few weeks.
Remember, atypical cells are T cells, but lympocytosis is B cells |
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Term
| Why should rectal exam be avoided in patients with Neutropenic fever? What it the appropriate pharmacologic management? |
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Definition
Risk of bleed with low platelets.
Empiric anti-pseudomonal agent and admission. If > 72h, start anti fungal as well. |
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Term
| How should Lyme disease be treated? |
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Definition
1) Doxycycline (Amoxicillin in children < 8 and in pregnancy)
2) Ceftriaxone in advanced disease (CNS or arthritis) |
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Term
| Which tick-borne disease presents with an initially macular rash on writs and ankles that spreads centrally? What is the treatment and worriesome complications? |
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Definition
Fever, malaise and rash
1) RMSF: R. rickets carried by American dog
2) Doxycylcline or Chloramphenicol (pregnancy)
3) DIC, AMS |
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Term
| What are the classic presenting features of infective endocarditis? |
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Definition
FROM JANE
1) Fever
2) Roth spots
3) Osler nodes
4) Murmur
5) Janeway lesions
6) Anemia
7) Nail hemorrhage
8) Emboli |
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Term
Name the likely endocarditis organism
1) IVDU
2) Dental procedures in native valves
3) Prosthetic valves
4) GI malignancy
5) Long-erm indwelling IV catheter |
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Definition
1) S. aureus
2) S. viridian's
3) Coagulase (-) staph
4) S. bovis (get colonoscopy)
5) Candida and Aspergillus |
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Term
| What are the correct pre-procedure prophylaxis recommendations to prevent endocarditis? |
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Definition
Give amoxicillin, or cephalexin in PCN allergic
1) Significant cardiac defects
AND
2) Undergoing high-risk procedure (Dental work, GI/GU surgery) |
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Term
| How is Anthrax identified and treated? |
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Definition
1) Pruritic papule tha enlarges to form ulcer and ultimately black eschar. Also can have hemorrhagic mediastinitis
2) Ciprofloxacin or doxy + 2 others for at least 14d
- Continue post-exposure ppx with copra for 60d |
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Term
What type of osteomyelitis is associated with:
1) No risk factors
2) IVDU
3) SSD
4) Hip replacement
5) Foot puncture wound
6) Chronic
7) Diabetic |
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Definition
1) S. aureus
2) S. areas or Pseudomonas
3) Salmonella
4) S. epidermis
5) Pseudomonas
6) S. aureus or Pseudomonas
7) Polymicrobial, Pseudomonas, S. aureus |
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Term
| What is on the differential for obstructive lung disease? |
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Definition
ABCO
1) Asthma
2) Bronchiectasis
3) COPD/CF
4) Obstruction |
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Term
| What is the appropriate management for an asthma exacerbation? |
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Definition
ASTHMA
1) Albuterol
2) Steroids
3) Theophyline (rare)
4) Humidified O2
5) Magnesium (severe)
6) Anticholinergics |
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Term
| When is Cromolyn used in the treatment of Asthma? How does it work? |
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Definition
Only for ppx to prevent exercise-induced bronchospasm.
Prevents release of vasoactive compounds from mast cells |
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Term
What medication is appropriate for each asthma type?
1) Mild intermittent (<2 days per week, <2 nights month)
2) Mild persistent (> 2 days per week, < once daily, > 2 nights per mont)
3) Moderate persistent (Daily and > 1 night/week)
4) Severe persistent (continual) |
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Definition
1) FEV1 > 80%
- PRN short acting BA
2) FEV1> 80%
- Inhaled CS low dose and PRN BA
3) FEV1 60-80%
- Low-medium dose inhaled CS + long acting BA
- PRN short acting BA
4) FEV1 < 60%
- High-dosed inhaled CS and long acting BA
- Possible PO CS
- PRN short acting BA |
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Term
| What is the diagnostic study of choice for Bronchiectasis? How is it treated? |
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Definition
**Associated with CF and persistent pulmonary infection history
1) High-resolution CT: dilated airways (larger than PAs)
2) Antibiotics, inhaled CS, Bronchopulmonary hygiene |
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Term
| What is the treatment of an acute COPD exacerbation? |
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Definition
1) Inhaled Beta agonists, Anticholingergics + IV CS and antibiotics
2) Supplemental O2, and BIPAP or intubation if severe |
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Term
| Which COPD patients get O2? |
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Definition
1) Exacerbation
2) Maintenance if < 88%, if RHF is present or if Polycythemia is present |
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Term
| What is the differential for restrictive lung disease? |
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Definition
AINT compliant
1) Alveolar (edema, hemorrhage, pus)
2) ILD (idiopathic) Inflammatory (sarcoid), IPF
3) Neuromuscular (M. gravis, phrenic nerve palsy, myopathy)
4) Thoracic wall (Kyphoscoliosis, obesity , ascites, pregnancy, AS) |
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Term
| Which meds/interventions contribute to interstitial lung disease? |
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Definition
1) Amiodarone
2) Busulfan
3) Nitrofurantoin
4) Bleomycin |
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Term
| What are the principle characteristics of Sarcoidosis? |
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Definition
GRUELING
1) Granulomas
2) aRthritis
3) Uveitis
4) Erythema nodosum
5) LNA (perihilar)
6) Interstitial fibosis
7) Negative TB
8) Gammaglobulinemia |
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Term
| What is Lofgren syndrome? |
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Definition
| Form of Sarcoid with Arthritis, Erythema nodosum and bilateral hilar LNA |
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Term
| How is sarcoid managed medically? What are the classic lab findings? |
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Definition
1) Steroids
2) Hypercalcemia, elevated ACE, elevated alk phos |
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Term
Which type of Pneumoconiosis is associated with each of the following?
What is an important complication?
1) Works on break linings, insulation and shipbuilding. CXR shows linear opacities at lung bases
2) Small nodular opacities in upper lung zones
3) Works in mines or quarries or with glass or pottery. Egg shell calcifications in upper lung zones on CXR.
4) Work in high-tech fields like aerospace, nuclear and electronics plants. Also dye manufacturing. HIlar LNA and diffuse infiltrates on CXR |
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Definition
1) Asbestosis: Risk of mesothelioma and lung cancer
2) Coal worker's: progressiv massive fibrosis
3) Silicosis: Risk of TB (annual TB test)
4) Berylliosis: Requires chronic CS treatment |
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Term
| What is the initial test for acute respiratory failure. How is it interpreted? |
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Definition
ABGs. A-a gradient should be calculated
1) Normal A-a gradient
- Is PaCo2 high? (hypoventilation)
- Is PaCo2 normal? (low inspired O2- high altitude)
2) Increased
- Correctable by O2? V/Q mismatch
- Asthma, COPD, ILD, alveolar disease, vascular disease
- If not correctible, it is a R-L shunt (Intracardiac, Vascular shunt within lungs) |
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Term
| What are the determinants of Oxygenation and Ventilation, respectively? |
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Definition
1) Oxygenation: FiO2 and PEEP
2) Ventilation: RR, Vt |
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Term
| What are the diagnostic criteria for ARDS? What are the important management steps? |
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Definition
1) Criteria
- Acute onset (<1w)
- PaO2/FiO2 ratio < 300 with PEEP/CPAP > 5cm
- Bilateral infiltrates on CXR
- Not explainable by HF alone
2) Low volume PEEP (goal is PaO2 > 55 and SaO2> 88%) |
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Term
| How is Cor pulmonale defined? |
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Definition
| Pulmonary HTN leading to Right Heart Failure with mean PAP > 25 |
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Term
What type of procedure is associated with each of the following embolic diseases?
1) Fat
2) Air
3) Cholesterol
4) Amniotic fluid |
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Definition
1) Fracture
2) Cardiac surgery
3) Endovascular procedure
4) Postpartum status |
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Term
| What are the common paraneoplastic syndromes associated with SCLC? |
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Definition
1) ACTH-secreting tumor (cushing's syndrome)
2) SIADH
3) Lambert-eaton |
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Term
| Which lung cancers are central, and which are peripheral? |
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Definition
1) Central: SCC, SCLC
2) Peripheral: Adenocarcinoma, Large cell |
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Term
| Where does lung cancer metastasize to? |
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Definition
LABB
1) Liver
2) Adrenals
3) Bones
4) Brain |
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Term
| How do you tell between an exudative and transudative pleural effusion? |
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Definition
Light's Criteria
1) Exudative (ANY OF THESE)
- Pleural/Serum LDH> 0.6
- Pleural LDH > 2/3 upper limit of serum LDH
- Pleural/Serum Protein > 0.5 |
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Term
| Describe your workup for Hypernatremia |
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Definition
6 D's
Dehyration, Diuresis, Diabetes Insipidus, Docs, Diarrhea, Disease (kidney, sickle cell)
1) Check urine osmolality
- < 100 central DI
- 100-300 nDI
2) High osmolality (> 600)
- Extrarenal losses (Vomiting, dairreah, NGT, insensible)
- Na gain (hypertonic saline) |
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Term
| How do you calculate a water deficit? |
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Definition
Deficit= Total body water (60% of weight) x ([serum sodium/140]-1)
In hypernatremia, replace with D5W, once euvolemic |
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Term
What is the cause of the following hyponatremia presentations
1) Low serum osmolality (<280) with normal volume status and elevated urine osmolality (> 100)
2) Low serum osmolality (<280), hypervolemic, with Urine Na > 10
3) Low serum osmolality (<280), hypervolemic, with Urine Na < 10
4) Low serum osmolality (<280) with normal volume status and low urine osmolality (< 100)
5) Hypovolemic, hypotonic with urine Na < 10
6) Hypovolemic, hypotonic with urine Na > 10 |
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Definition
1) SIADH, Drugs, Hyppothyroidism, GC deficiency
2) Renal failure, AKI
3) CHF, nephrotic syndrome, Cirrhosis
4) Psychogenic polydypsia, Beer drinkers
5) GI losses, skin losses, third spacing
6) Diuretics, Adrenal insufficiency, RTA |
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Term
| Why might someone have hypertonic hyponatremia? |
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Definition
Usually glucose issue.
Hyperglycemia, Mannitol or contrast agents |
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Term
| Why might someone have isotonic hyponatremia? |
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Definition
| Hyperlipidemia, Hyperproteinemia, Hyperglycemia, Mannitol |
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Term
| How do you treat Hyperkalemia (> 6.5 or EKG changes)? |
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Definition
1) Calcium gluconate
2) Insulin + glucose or Bicarb
3) Beta agonists
4) Kayexalate
5) Loops and dialysis if severe |
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Term
| How do you treat Hypokalemia? |
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Definition
Usually 2/2 renal or GI losses
Oral and/or IV (don't exceed 20 per hour)
Also replace magnesium |
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Term
| What electrolyte abnormality is associated with Digitalis toxicity? |
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Definition
| Hypokalemia (both compete for same sites on Na/K pump) |
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Term
| How do you correct for falsely low Ca seen in hypoalbuminemia? |
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Definition
| Corrected = Total Ca + 0.8 (4- serum albumin) |
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Term
| What is the differential for AG MA? |
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Definition
MUDPILES
1) Methanol
2) Uremia
3) DKA
4) Paraldehyde, Phenformin
5) Iron, INH
6) Lactate
7) Ethylene glycol
8) Salicylate (alkalinize urine) |
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Term
| What do you think of with AG metabolic acidosis, blindness and optic disc hyperemia? |
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Definition
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Term
| What do you think of with AG metabolic acidosis and calcium oxalate (envelope-shaped) stones? |
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Definition
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Term
| What combination of acid-base disorders is associated with ASA use? |
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Definition
| Metabolic acidosis and respiratory alkalosis |
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Term
| What is the differential for Metabolic alkalosis? |
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Definition
1) Chloride sensitive (hypochloremic, saline responsive, urine Cl < 20)
- Vomiting, Diuretics
2) Chloride resistant (saline resistant, Urine Cl > 20)
- Hyperaldosteronism |
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Term
| Differentiate between 3 types of RTA |
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Definition
Type 1
- Defect is H+ secretion
- Serum K+ is low, urinary pH > 5.3
- Seen in Autoimmune disorders
- REPLACE BICARBINATE
- watch out for kidney stones
2) Type 2
- Issue with HCO3- resorption
- serum K+ is low
- Urinary pH is acidotic
- Associated with MM, Amyloidosis, Cystinosis
- Give thiazides, volume depletion (increase reabsorption)
3) Type 4
- Aldosterone resistance
- Serum K is high
- Urine is acidotic <5.3
- Hyporeninemic hypoaldosteronism (renal insufficiency), ACE/ARBs, or heparin
- Give furosemide, mineralocorticoid replacement |
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Term
| What are the indications for dialysis? |
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Definition
AEIOU
1) Acidosis
2) Electrolyte (K+)
3) Ingestion
4) Overload (fluid)
5) Uremic |
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Term
| Why might you use DDAVP in CKD? |
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Definition
| Cases of abnormal bleeding |
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Term
| How can you distinguish between pre-renal, intrinsic renal and post-renal AKI? |
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Definition
Pre-renal
- BUN:Cr > 20
- FeNa < 1%
- Urine sodium < 20
- Urine osms > 500
2) Intrinsic
- BUN/Cr < 15
- FeNa> 2
- Urine Sodium > 40
- Urine osm < 350
3) Post-renal
- Urine sodium > 40
- Urine osms < 350
- PVR > 50 |
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Term
| What are the most common causes of death in CKD? |
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Definition
Cardiovascular: MI or sudden cardiac death
Watch out for acquired renal cysts as well |
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