medicine 2

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1. major risk factors DM 9. types of stress test * get the HR up to 85% (220-
for atherosclerotic Hyperlipidemia age)
heart disease hypertension exercise tolerance test
cigarette smoking (ST segment depression)
Age >45 M, >55 F exercise or dobutamine
family history of MI at young age echocardiogram (wall motion
high LDL level abnormalities)
exercise or dipyridamole
2. CAD prognostic LVF EF<50%
(dec. uptake of thallium isotope
factors left main
in ischemic area during
two or three vessel diseases
exercise)
3. 1. clinical 1. gradual onset chest or substernal
10. how does cause generalized coronary
presentation of pain brought on by inc. myocardial
dipyridamole/adenosine artery dilation
stable angina demand* (exertion/emotion)
work for pharmacologic *diseased coronaries are already
2. dx: relieved with rest or nitroglycerin
stress test maximally dilated so under
3. what to do with NO CHEST WALL TENDERNESS
dipyridamole/adenosine they
patients with NO CHANGE WITH POSITION
receive relatively less blood
positive stress or 2. normal PE/ECG
echo *stress test- (HR to 85% max (220- 11. holter monitor 1. detect silent ischemia,
age)) 1. use evaluating arrhythmias, monitor
-->subendocardial ischemia (ST pacemakers, evaluate
depression on ECG) unexplained syncope/dizziness
*stress echocardiography- shows wall
12. Cardiac catheterization 1. hemodynamics (CVP, PCWP,
motion abnormalities- akinesis or
1. info gathered SVC, CI), intracardiac pressure,
dyskinesis
2. coronary CO, oxygen saturation
3. cardiac catheterization
angiography/PCI/CABG 2. performed during cath,
4. what is the LV size/function eval visualizes the coronaries ~~~
advantage of stress dx. valvular disease 3. indications for can accomplish all of the above
echo vs stress ECG identifies CAD cardiac cath 3. positive stress test,
* if positive -->cardiac cath angina with non-diagnostic
non-invasive tests
5. what is a positive If during a stress test the patient
angina unresponsive to medical
stress test experiences:
therapy
ST depression
severely symptomatic
chest pain
evaluation of valvular disease
hypotension
arrhythmias 13. coronary angiography 1. identifies CAD, delineates
1. info gathered coronary anatomy
6. metabolic syndrome 3
2. what can be done 2. PCI, angioplasty/stenting,
X INSULIN RESISTANCE 2/2 OBESITY
diagnosis
-->
hypercholesterolemia/low HDL 14. at what level of coronary >70% occlusion
hypertriglyceridemia - >150 occlusion does angina
impaired glucose tolerance >110 occur
diabetes
15. stress echocardiography echocardiography after exercise
hyperuricemia
+ follow up with positive will show akinesis or dyskinesis
HTN
result ~ this is mores sensitive than
7. syndrome X exertional angina with normal ECG to detect ischemia
coronary arteriogram - follow up with positive result is
stress test shows evidence of ischemia CARDIAC CATHETERIZATION
8. indications for confirm angina DX 16. types of stress test exercise tolerance test
stress ECG evaluate therapy response in CAD pts dobutamine echocardiogram
identify pts with CAD dypyridamole thallium
may also use adenosine
17. thallium 201 use any type of stress test (exercise, 29. when is a drug needed to treat stage 1 or greater- patient
stress test dobutamine, or dypridamole) hypertension should be treated with
lifestyle + drug
18. give thallium - no ...
uptake indicates 30. stage 2 - lifestyle modification ...
ischemia and 2 drug como
19. secondary 1. renal artery stenosis, chronic renal 31. pre-hypertension just treat ...
hypertension failure, PKD with lifestyle modification
1. renal causes 2. hyperaldo, thyroid/parathyroid,
32. lifestyle modifications for HTN no-added salt or low-
2. endocrine cushings syndrome, pheo, acromegaly
sodium diet
causes 3. OCP****, decongestants, estrogen,
weight loss
3. medication steroids, TCA, NSAIDs
avoid alcohol (pressor
causes
action)
- others include
regular aerobic exercise
coarctation,
low sat fat, lots of fresh
cocaine, sleep
produce
apnea
stress management
20. HTN effect on inc SVR --> concentric LVH --> dec
33. best treatment for African thiazide diuretics (b/c
heart CO/sx of heart failure
Americans with hypertensino they usually have salt-
21. what other accelerates atheroscloerosis --> sensative HTN)
conditions accelerated CAD and peripheral vascular BUT* if there is also
comorbid with disease diabetes, ACE is best
HTN choice
22. what are is the heart - LVH, MI, CHF*, CAD, dissection 34. why are ACE inhibitors ACE inhibitors have a
end organ Brain - stroke (ischemic/lacunar), TIA prefered to treat HTN in protective effect on the
damage sites of encephalopathy diabetic patients kidneys
HTN CKD - nephrosclerosis, arteriosclerosis
35. drug choices to treat HTN thiazides
dec. GFR
beta blockers
PVD
ACE
retinopathy
ARB
23. HTN effect on the *early - AV nicking, cotton wool spots=> CCB
eyes hemorrhage and exudates alpha blockeres
*papilledema vasodilators
(hydralazine/minoxidil)q
24. cutoff for HTN in general - 140/90
general pop vs diabetics/renal disease - 130/80 36. what patients is alpha blockers those who have both
diabetics useful to treat HTN HTN and BPH
25. cardiac CAD, CHF, MI, PVD, aortic dissection 37. treatment of refractory HTN vasodilators
complications of (hydralazine, minoxidil)
HTN + beta blockers +
diuretics
26. CNS intracerebral hemorrhage, TIA,
complications of ischemic stroke, lacunar stroke (2/2 38. what is the goal BP in patients 135/85 minimum goal for
HTN small vessel hyalinosis + with HTN patients with diabetes or
microatheromas) renal disease
27. renal arteriosclerosis of afferent/efferent 39. what is first important test pregnancy test
complications of arterioles and glomerulus before starting an contraindicated-
HTN (nephrosclerosis) antihypretensive drug on a thiazides, ACE, CCBs
woman Safe - Beta blockers,
28. what labs to urinalysis
hydralazine
evaluate target BMP (K/BUN/Cr)
organ damage in Fasting glucose 40. which antihypertensives are ACE and ARB
HTN lipid panel associated with decreased risk
ECG of new-onset diabetes
41. side effects of anti- 1. hypokalemia, hyperuricemia, 50. statins 1. lowers LDL
hypretensive agents hyperglycemia, 1. effect on lipid panel 2. monitor LFTs, may be CPK
1. thiazides hypertriglyceridemia, met.alk, 2. side effects elevation
2. beta blockers hypomagnesemia - only lipid drug that
3. ace inhibitors 2. bradycardia, bronchospasm, reduces mortality,
insomnia, masked first line**
hypoglycemia
51. niacin 1. lowers TG, lowers LDL, inc.
3. dry cough, ARF,
1. effect on lipid panel HDL
hyperkalemia, rash, altered
2. what patients 2. diabetic patients- may worsen
taste
should not use niacin glycemic control
42. cardiovascular risk smoking, diabetes, DM, 3. 3. flushing, check LFT, CPK
factors hypercholesterolemia,
52. cholestyrine/colestipol 1. lowers LDL and TH
HDL<35
1. effect on lipid panel 2. bad taste, GI side effects
age>60, male, HTN, family
2. SE
history
53. fibrates 1. lowers TG, VLDL, inc. HDL
43. 1. screening for 1. every 5 years starting at age
1. effect on lipid panel 2. mild LFT, gynecomastia,
hyperlipidemia 20 with a fasting lipid profile
2. SE gallstones, weight gain
2. effect of high dietary 2. increases LDL and
sat.fat on lipid panel cholesterol 54. how to treat high TG exercise/diet, nicotinic acid,
3. effect of high calorie 3. increase TG fibrates, fish oil +/- statins
on lipid panel 4. increase TG and HDL 55. tension headache 1.worsens throught the day,
4. effect of alcohol on 1. clinical pres precipitated by stress/depression,
lipid panel 2. tx aching, viselike pain that is band
44. 1. age effect on 1. 2mg/dL per year increase like around head +/- tender
cholesterol 2. inc. LDL, cholesterol, TG muscles in posterior neck
2. thiazides effect on 3. inc TG, dec. HDL 2. NSAIDs, acetaminophen, or
lipid panel 4. inc. TG migraine medications
3. beta blockers "" 5. elevates serum lipids 56. emergency headache non-contrast CT, +/- LP because
4. estrogens "" evaluation CT may miss small bleeds
5. corticosteroids and
57. cluster headaches 1. episodic lasts - 2-3 months with
HIV proteases ""
1. clinical pres remission
45. 1.goal levels for 1. <200 cholesterol 2. tx chronic cluster - last 1-2 years
cholesterol, LDL, <130 LDL *excruciating unilateral periorbital
triglycerides <125 triglycerides pain "deep, burning, stabbing,"
2. LDL goal for diabetic 2. <100 ipsilateral lacrimation, flushing,
3. LDL goal for diabetic 3. <70 nasal stuffiness, ipsilateral
and CAD 4. >60, every inc. in 10 HDL horners syndrome
4. HDL goal lowers CAD by 50% 2. 100% O2 inhalation (acute) ***
46. physical symptoms of usually asymptomatic.... prednisone 40mg for several weeks
hyperlipidemia xanthelasma to abort the headache
xanthoma sumatriptan,
pancreatitis prophylaxis: verapamil (best for
cluster), or carbamazepine
47. what other labs should TSH - hypothyroidism
alternatives: ergotamine,
be ordered to rule out LFTs - chronic liver dz
methysergide, lithium (for chronic
secondary BUN/Cr - nephrotic syndrome
form), corticosteroids
hyprelipidemia glucose level - comorbid
diabetes 58. migraine 1. hormone changes, stress,
1. clinical pres sleeping disturbance, drugs/foods-
48. what labs must be LFTs
->
ordered when starting a
a. prodrome - elation, inc. appetite
patient on statins and
or depression/sleepiness
fibrates
b. severe throbbing unilateral
49. what effect can dietary drop LDL by 10% headache 4-72 hours, throbbing,
therapy have on LDL dull or achy, photophobia, inc.
sens to smell
59. migraine 2. NSAIDs or acetaminophen, DHE 69. acute 1. >10 days, prolonged nasal stuffiness,
2. tx (5HT1 ag.)., sumatriptan (selective sinusitis purulent discharge, cough, sinus
3. prophylaxis 5HT1 ag.) 1. clinical pres pain/pressure worse with bending head
3. TCA, beta blockers***, CCB, down/percussion, fever,
valproate, methysergide, NSAIDS maxillary - cheek pain
(menstrual migraines) frontal - lower forehead pain
ethmoid - retro-orbital pain/lateral nose
60. 1. DHE 1. CAD, pregnancy, TIA, PVD, sepsis
contraindications 2. CAD, pregnancy, uncontrolled HTN, 70. acute 1. common cold/polyps/deviated
basilar artery migraine, hemiplegic sinusitis septum/foreign body --> inflammation of
migraine, MAOI, SSRI, lithium 1. paranasal sinuses, obstruction of sinus
pathogenesis ostia, trapping of secretions--> s.pneumo, h.
61. rebound analgesic occur every 1-2 days, do not respond to
flu, moraxella, anerobes
headaches migraine medications
71. acute 1. purulent drainage from turbinates,
62. what does probably not a migraine
sinusitis transillumination, palpation, sinus
migraine that
1. dx radiographs, CT head
does not resolve
2. 2. mucocele, polyps, orbital cellulitis,
with medications
complications osteomyelitis of frontal/maxilla, cavernous
indicate
3. tx sinus thrombosis, meningitis, brain abscess
63. cough 1. <3 weeks, URI 3. saline spray,
1. acute cough 2. pneumonia, COPD, fibrosis, cancer, pseudoephedrine/oxymetazoline,
causes asthma, abscess, TB, pulmonary edema amoxicillin, amox-clavulanate, TMP/SMX,
2. chronic cough 3. CXR (if pulmonary cause, levofloxacin, moxifloxacin, cefuroxime
causes hemoptysis, chronic cough) 2nd gen antihistamines - loratadine,
3. dx 4. stop smoking, fexofenadine
4. tx antihistamine/decongestant, abx nasal steroids - fluticasone, beclomethasone
anti-tussives - codeine, DXM, benzoate,
72. chronic 1. staph aureus, gram negative rods -->
guaifenesin
sinusitis 2. nasal congestion, post-nasal discharge,
64. 1. causes of cough 1. smoking, postnasal drip (URI, 1. pain/headache >2-3 months.
in patients with rhinitis, sinusitus), GERD, Asthma, pathogenesis
normal CXR` ACE 2. clinical
65. what features of yellow sputum* pres
URI indicate fever and cough 73. laryngitis 1. viral, moraxella, h.flu --> hoarseness +/-
bacterial origin NO headache, myalgias, or rhinorrhea 1. patho + URI symptoms
66. acute bronchitis 1. cough 1-2 wks up to 1 month, cx pain, clinical pres 2. self limiting
1. clinical pres SOB, +/- fever 2. treatment
2. dx 2. clinical dx - no CXR, 74. sore throat 1. adeno, PIV, rhino, EBV, HSV,
3. tx 3. no abx, cough suppressants, 1. patho s.pyogenes*, chlamydia, mycoplasma,
bronchodilators 2. which can gonococcal, EBV, coryne.dip, candida -->
67. rhinosinusitis 1.hand-hand contact --> MCC URI - cause 2. EBV, c.dip, s.pyogenes, candida
1. patho rhinovirus, corona virus, PIV, exudative 3. dx - throat culture, rapid strep, monospot
2. clinical pres coxsackie, RSV, adeno tonsillitis tx - penicillin, erythromycin, viral, EBV
3. tx 2. 10-14 days rhinorrhea, sore throat, 3. dx/tx (dont give amox)
malaise, non-productive cough, nasal 75. treatment for acetaminophen, ibuprofen
congestion, fever in children (adults EBV NOT amox
indicates bacterial complication) pharyngitis
3. hydration, rest/analgesics (NSAIDs),
DXM/codeine, neo-synephrine spray
<3 days (affrin), antihistamines
68. what is influenza has more pronounced fever,
distinguishing headache, myaligas
features between
rhinosinusitis vs.
influenza
76. dyspepsia 1. GERD, PUD, functional dyspepsia, (90%) 84. acute diarrhea (2-3wks) 1. viral, bacteria, parasites,
1. patho + gastritis, hepatobiliary, pancreatic, 1. patho food poisoning
clinical pres esophageal spasm, DM gastroparesis, IBS, -- 2. common viral pathogens abx (c.diff),
2. dx > epigastric symptoms , heartburn, bloating, 3. common bacterial malabsorption
3. when to do nighttime awakening, infections Ischemic bowel disease
endoscopy for 2. response to empiric therapy, endoscopy, 4. common parasites 2. norwalk virus, rotavirus,
dyspepsia h.pylori stool antigen/urea breath test infections calicivirus, astrovirus,
3. weight loss, anemia, dysphagia, 5. pathogens in enterovirus
obstruction, upper GI bleeding, non- elderly/immunosuppressed 3. watery - ETEC, staph
responders to empiric therapy, aureus, c.perfringens
bloody - shigella,
77. dyspepsia 1. avoid alcohol, caffeine, smoking, raise
campylobacter, salmonella,
1. tx head of bed, avoid eating before sleep
EHEC
H2 blockers, PPI, endoscopy , h.pylori
4. giardia lamblia,
treatment
entamoeba histolytica,
78. peptic dysphagia and GERD cryptosporidium
stricture 5. MAC, cryptosporidium,
clinical cyclospora, CMV
presentation
85. chronic diarrhea 1. IBS, IBD, medications,
79. GERD 1. inappropriate relaxation of LES, dec. 1. patho bacterial, colon cancer,
1. esophageal motility, gastric outlet 2. pathogens that can cause diverticula, celiac, panc.
pathogenesis obstruction, hiatal hernia chronic diarrhea insuff, short bowel, bacterial
2. clinical 2. heartburn, dyspepsia (retrosternal burning overgrowth, post surgical,
pres after large meals) hyperthyroid, addisons,
regurgittation diabetes, gastrinoma,
waterbrash -reflex salivary hypersecretion VIPoma, laxatives
chronic cough 2. shigella, salmonella,
hoarseness, sore throat campylobacter, EIEC
early satiety, post-prandial n/v
86. important questions for blood/melena
80. complications erosive esophagitis, barrett's, peptic patient with diearrhea other assc. sx
of GERD strictures, esophagitis, aspiration sick contacts/travel
pneumonia (lipid laden macrophages), assc. with certain foods
dental erosion, other medical problems
81. diagnosis of 24 hour esophageal monitor, Upper GI series (AIDS etc)
GERD (barium contrast) recent med changes
endoscopy with biopsy (if refractory) 87. acute diarrhea 1. CBC
esophageal manometry 1. lab tests for suspicious (anemia/leukocytosis)
82. when to after 5 years of symptomatic GERD cases (chronic, severe stool sample - #1 fecal
screen for illness/fever, blood, IBD leukocytes/culture
barrett's suspicion, volume c.diff toxin (treat empirically
esophagus depletion) if suspicious),
ova/parasites, giardia
83. GERD behavior -avoid fatty foods, smoking,
ELISA,
treatment alcohol, orange juice, chocolate,
stool culture - very low
H2 blocker
sensitivity dont order
PPI
routinely (only detect
promotility agent - metoclopramide
shig/salm/camp)
(dopamine antagonist), bethanechol
flexible sigmoidoscopy with
nissen fundoplication (for stricture,
bx
intractability, hemorrhage, stricture,
barrett's) 88. 1. which causes of diarrhea 1. campylobacter,
have fecal leukocytes salmonella, shigella, EIEC,
2. what electrolyte c.diff
abnormality with diarrhea 2. hypokalemic met alk.
89. acute diarrhea 1. dehydration, PO intolerance, profuse 95. nausea/vomiting 1. CBC, electro, LFT, B-HCG,
1. when to bloody diarrhea, high fever/toxic 1. dx abdominal films upright/supine
hospitalize 2. stop cause (abx or food), rehydrate, 2. tx. (r/o obstruction).
2. tx monitor electrolytes, loperamide 2. self limiting, rehydration with
5 day course of ciprofloxacin - if bloody, 1/2 normal saline,
severe, + stool culture, traveler diarrhea prochlorperazine, promethazine,
c.diff- metronidazole avoid large fatty meals,
90. constipation 1. diet (fiber), meds, IBS, obstruction, 96. hemorrhoids 1. external = inferior hemorrhoidal
1. patho ileus, hemorrhoids/fissures, hypothyroid, 1. external vs internal plexus
2. what meds hypercalcemia, hypokalemia, uremia, 2. causes internal = superior rectal plexus
cause dehydration, neuromuscular disorders, 3. clinical pres 2. constipation, pregnancy, portal
constipation congenital HTN,l obesity, prolonged
3. what 2. anticholinergics, antidepressants, sitting/standing
neuromuscular narcotics, iron, CCB, aluminum/calcium 3. bleeding/rectal prolapse, BRB
causes "" antacids, per rectum,
3. parkinsons, MS, CNS lesions, external - painless unless
scleroderma, DM thrombosed
internal - painless mass when they
91. constipation 1. H&P, abdoinal films, TSH, serum
prolapse
1. dx calcium, CBC, electrolytes, r/o
2. complications obstruction!, rectal examination 97. hemorrhoids 1. sitz bath, stool softeners to
of chronic radio-opaque marker transit, anorectal 1. tx reduce strain, high fiber, high fluid
constipation motility study diet, topical steroids, rubber band
3. tx 2. hemorrhoids, rectal prolapse, anal ligation, surgical
fissures, fecal impaction hemorrhoidectomy
3. inc. physical activity, inc. fiber/fluid,
98. lower back pain 1. smoking, obesity, old age, low
enema, surgery
(acute >4 wk, chronic edu, workers comp, dissatisfaction,
92. see page 450 for ............. >12 wk) psychological factors (depression,
list of all 1. risk factors anxiety)
diarrhea - 90% of patients with
lumbar
93. irritable bowel 1. depression, anxiety, somatization -->
herniation/sciatica
syndrome abnormal resting activity of the bowel >3
improve with
1. patho + months --> diarrhea, constipation,
conservative care
clinical pres cramping relieved by defecation,
2. dx bloating/distention 99. 1. what exacerbates 1. coughing/sneezing increase
3. tx 2. diagnosis of exclusion use dx disc herniation pain intraspinal pressure
modalities for diarrhea 2. what exacerbates forward flexion, sitting, driving,
3. loperamide/diphenoxylate, spinal stenosis pain lifting
colace/psyllium/cisapride, tegaserod 2. standing, walking, relieved by
maleate (serotonin agonist) bending or sitting (walking on a
shopping cart)
94. nausea/vomiting 1. viral/food, preg, DKA, addisonian
1. patho crisis, uremia,electrolyte, PUD, GERD, 100. cauda equina 1. severe stenosis of the lumbar
2. bilious, SBO, ileus (hypercalcemia/hypokalemia), syndrome spine 2/2 disc herniation
feculent, hyperthyroid, pancreatitis, appendicitis, 1. patho 2. leg pain, bladder dysfunction
undigested, pyelo, chole, 2. clinical pres (retention/incontinence), saddle
projectile MI, cisplatin/chemo, digitalis*, 3. treatment anesthesia
erythromycin/abx, 3. immediate MRI, surgical
2. bilious - obstruction distal to vater emergency
feculent - distal intestinal obstruction,
101. 1. spondylolisthesis 1. forward slippage of cephalad
bacterial overgrowth, gastrocolic fistula
2. lumbar herniation vertebrae at L4-L5, L5-S1
undigested - esophageal problem
clinical pres. 2. radicular leg pain/back pain
projectile - inc. ICP, pyloric stenosis
3. lumbar disc 3. anti-inflammatory, physical
herniation treatment therapy, epidural steroid, early
mobilization,
ONLY MRI AFTER 4-6 WEEKS OF
CONSERVATIVE TREATMENT
102. spinal stenosis 1. degenerative changes (facet 110. cervical 1. spondylosis, herniation, impingement,
1. patho osteophytes/ligamentum flavum radiculopathy carpal tunnel, cubital tunnel, thoracic
2. clinical pres hypertrophy) --> narrowing of 1. patho + outlet, zoster, pancoast tumor -->
3. dx/tx spinal canal clinical pres compression of spinal nerve --> arm
**differentiate from 2. neurogenic claudication - 2. dx/tx pain, numbness, tingling, weakness,
arterial claudication radicular or buttock pain, cramping, unilateral neck pain
by checking pulses numbness, paresthesias- relieved by 2. dx = MRI of cervical spine
sitting, worse with tx = NSAIDs, time, PT, epidural
walking/standing injections
3. good distal pulses, straight leg
111. cervical 1. cervical stenosis --> spinal cord
test negative
myelopathy compression - unsteady gait, loss of
epidural steroid injections
1. patho + hand dexterity, cane/walker use
103. musculoligamentous 1. bending/twisting --> back "gives clinical pres 2. surgical decompression
back strain way" --> radiation to buttock/upper
112. evaluation of always consider cervical
1. patho posterior thigh/knee due to muscle
gait stenosis/cervical myelopathy and order
spasm
unsteadiness in an MRI
104. imaging in back pain what is seen on MRI/X Ray does not an elderly
necessarily correlate with what the patient
patient experiences
113. how to relief when inject subacromial space
*psychosocial variables have a
differentiate with cortisone
higher correlation
shoulder
105. vertebral 1. acute back pain from minor stress impingement
compression in elderly patients or pts on long (C5
fracture term steroids pain @ level of fracture radiculopathy)
1. patho 2. bracing, analgesics, from cervical
2. tx kyphoplasty/vertebroplasty, stenosis
106. physical exam test straight leg raise positive at 30-60 114. causes of osteoarthritis,
for radiculopathy degrees with the patient supine arthritis systemic autoimmune disease - RA, SLE,
IBD, psoriatic arthritis
107. spine pain 1. no imaging until 4-6 weeks of
crystal arthropathies
1. when to get symptoms, or prog. neuro deficits,
infectious - septic arthritis/lymes disease
imaging/MRI disability sx, osteoporosis, hx of
trauam
malig, constitutional sx, recent
chargot joint
trauma, IVDU
congenital - hip dysplasia, legg-calve
when patient has failed
perthe, SCFE
rest/PT/NSAIDs for >3 mo
sickle cell, hemophilia (recurrent
108. acute lower back 1. AVOID PROLONGED hemarthrosis)
pain INACTIVITY, ATTEMPT WALKING wilsons, hemochromotosis
1. tx ROUTINE
115. patellofemoral 1. pain worse with stair
NSAIDS, acetaminophen, activity
pain climbing/descending,
modification, slow return to
1. clinical 2. PT focuses on quads/hamstring rehab
activities
presentation
PT if above fails
2. tx
surgery if >1 year of failed
conservative tx 116. meniscal tears 1. knee effusions, tenderness along
1. dx medial/lateral joint lines,
109. 1. clinical 1. axial neck pain, cervical
2. tx McMurray+
presentation of radiculopathy, cervical myelopathy
2. arthroscopic meniscectomy or repair
cervical spondylosis 2. cervical strain
2. MCC acute neck 117. osteochondritis 1. necrotic area of bone and degeneration
pain dissecans of the overlying cartilage leadign to a free
1. patho + body in the joint space --> catching,
clinical pres popping, pain
2. tx 2. arthroscopy with removal of fragment
118. causes of septic 127. lateral 1. inflammation/degeneration of forearm
acute disseminated gonorrhea epicondylitis extensor tendons from excessive
monoarticular gout/pseudogout 1. patho supination/pronation
arthritis rheumatic fever 2. tx 2. PT, splinting, injections
lymes disease
128. medial 1. pain @ medial epicondyle from flexor
seronegative spondyloarthropathy
epicondylitis origin, from overuse of flexor/pronator
119. bakers cyst 1. intra-articular pathology (RA, OA) --> 1. patho muscles
1. patho cyst formation (MCC popliteal fossa -->
129. de quervain's 1. abductor pollicis longus and extensor
rupture that causes pain/swelling
tenosynovitis pollicis brevis tendon inflammation --> pain
extending into the calf
1. patho @ radial styloid, pain radiates to the elbow
when they burst they MIMIC -
2. dx or into the thumb
thrombophlebitis
3. tx 2. finkelstein's test, pain at radial wrist
(pseudothrombophlebitis), DVT
when pinch gripping
120. patellar 1. jumpers knee- anterior knee pain in the 3. thumb spica splint/NSAIDs, local
tendinitis inferior pole of the patella cortisone injections
1. patho tx = activity modifications, quad/hamstring
130. olecranon 1. trauma, overuses --> swelling over elbow,
2. tx rehab
bursitis from effusion into olecranon bursa
121. plica 1. repeated injury such as what is seen in 1. patho 2. conservative
syndrome athletes --> feeling of snapping in the knee, 2. tx
1. patho pain along medial ptella
131. trochanteric 1. trauma, overuse, weak hip muscles, -->
2. PT, anti-inflammatory meds,
bursitis pain over lateral hip from friction between
arthroscopy only if refractory
1. patho gluteus medius and tensor fascia lata
122. diagnosis of radiographs if suggest degernative/truam 2. tx 2. NSAIDs, activity modification, local
knee pain MRI for soft tissue/ligmentous damage cortisone injections
knee aspiration
132. ddx for hand cervical radiculopathy, peripheral
123. ligaments on ATFL, CFL, PTL numbness neuropathy (DM), median nerve in forearm
the lateral deltoid (carpal tunnel syndrome)
aspect of the Grade 1 - partial ATFL
133. carpal tunnel 1. median nerve compression in carpal
ankle Grade 2 - full ATFL, partial CFL
syndrome tunnel causes numbness/pain in median
ligaments on Grade 3 - full ATFL, full CFL
1. patho nerve distribution --> severe atrophy of
the medial
2. dx thenar muscles (later)
aspect of the
3. tx 2. tinels sign - tap median nerve causes
grade 1,2,3
paresthesias
ankle sprains
phalen test - wrist flexion 1 min -->
124. dx of ankle tenderness over ligmaents paresthesias
sprains no radiographs if ottawa rules are met 3. wirst splint @ night, NSAIDs, local
(patietn can walk four steps at time of corticosteroids, surgical release*
injury/evaluation, no bony tenderness over
134. hip groin pain that radiates to the anterior thigh
distal 6cm of the malleolus)
osteoarthritis
125. treatment of RICE, controlled weight bearing, gradual clinical pres
ankle sprains inc. to full weight bearing, PT
135. osteoarthritis 1. degeneration of cartilage from wear/tear
126. 1. 1. impingement syndrome of the C5 root - 1. patho of the weight bearing joints
supraspinatus impingement of greater tuberosity on 2. clinical 2. pain worsens with activity, stiffness in the
tendinitis + tx acromion, pt. will complain of pain with pres morning that gets worse during the day , NO
2. rotator cuff overhead activity 3. dx swelling or warmth, NO TENDERNESS TO
tear + dx tx = acromioplasty, steorid injections PALPATION
2. if there is weakness with abduction - dx progresses to limited ROM/bony crepitus*
= MRI 3. plain radiograph - joint space narrowing,
tx = PT, steroid injections, arthroscopic osteophytes, sclerosis of subchondral bony
surgery endplates, subchondral cysts
136. osteoarthritis 1. avoid excess movement, weight loss, PT 146. glaucoma 1. inc. IOP, ON damage,
1. tx (swimming), canes/walkers 1. patho cupping of ON, loss of
acetaminophen*, COX2 inhibitors, intra- 2. open angle ganglion cells
articular injections of corticosteroids, 3. closed angle glaucoma 2. impaired outflow, silent
viscoelastic supplementation, total joint 4. dx progression
replacement 3. rapid IOP from
obstruction of outflow by
137. heberden's bony overgrowth and osteoarthritic changes
iris- CAN BE CAUSED BY
nodes at DIP
DILATION DROPS****
bouchard's
4. tonometry,
nodes
ophthalmoscopy,
138. bouchard's ... genioscopy, visual field test
nodes - """ at
147. 1. OA glaucoma clinical 1. painless IOP, peripheral
PIP
pres scotoma
139. osteoporosis 1. failure to reach peak bone mass @ age 30 2. CA """ 2. red painful eye, sudden
1. patho Type 1 - post-menopausla women- loss of dec. VA, N/V (mimics acute
Type 1 trabecular bone - vertebral abdomen), headache,
Type 2 compression/colles fractures dilated non-reactive
Type 2 - loss of trabecular/cortical >70yo, pupil***, halos around light
femoral neck, intertrochanteric prox.
148. 1. OA glaucoma tx 1. beta blockers,alpha
humerus, pelvis fractures
2. CA """""" agonists, CA inhibitors,
140. secondary 2/2 steroids, immobilization, hyperthyroid, prostaglandin analogs,
osteoporosis long term heparin, hypogonadism, D3 def. laser/surgery
141. osteoporosis 1. estrogen depletion, eating disorders,early 2. immediate referral,
1. risk factors menopause, hyperthyroid, hypogonadism, pilocarpine drops, IV
2. tx smoking/alcohol, steroids, heparin acetazolamide, oral glycerin,
2. <2 bisphosphonates or SERM (raloxifene) laser/surgery
calcium/vitamin D, calcitonin (dec. hip fx), 149. risk factors for cataracts 1. old age, cigarettes,
weight bearing exercise, smoking cessation glucocorticoids, UV, trauma,
142. osteoporosis 1. DEXA (< - 2.5 compared to 30 year old diabetes, wilsons, downs
1. dx person) dual energy x-ray absorptiometry for syndrome
2. secondary all women >65 - use T scores (>50 yo)/Z 150. red eye 1. conjunctivitis
osteoporosis scores (pre-meno) 1. MCC 2. focal, unilateral rupture of
dx 2. Ca, phos, ALP, TSH, D3, PTH, Cr, CBC - refer if FFF, recent eye small conjunctival vessels by
143. osteoporosis diet, Ca 1200mg/day, 800IU D3/day, surgery, corneal valsalva, trauma, HTN
tx weight bearing exercise 3x/wk, opacification/ulcer/foreign 3. autoimmune, meds,
smoking/alcohol cessation, body, chemical exposure, CNV/VII, foreign body
bisphosphonates (aldronate/risedronate 2. subconjunctival sensation
inb. osteoclasts), PTH therapy, calcitonin, hemorrhage 4. inflammation of eyelid,
estrogen-progestin therapy 3. keratoconjunctivitis staph aureus
` sicca
4. blepharitis
144. ARMD 1. non-exudative ARMD form drusen under
1. patho RPE--> atrophy/degen of central retina 151. red eye 1. inflammation of episclera,
2. risk factors exudative - sudden vision loss from serous 1. episcleritis autoimmune, include dull
3. tx fluid leakage 2. scleritis ache/discharge, self limited
CENTRAL VISION LOSS**** 3. anterior uveits NSAIDs
2. HTN, caucasian, smoking, FH 2. pain with palpation of the
3. anti-VEGF injections/laser eyeball
photocoagulation (wet), OTC vitamins (dry) 3. iris/ciliary body inflamm,
circumcorneal injection,
145. MCC of vision diabetic retinopathy
blurred vision,
loss in ARMD (age > 65)
pain/photophobia,
developed cataracts
ipsilateral constriction-
countries glaucoma
assc. with sarcoid, ank
spondy, reiters, IBD
152. HSV keratitis 1. UNILATERAL similar to viral conj. 160. Insomnia 1. psychological stress/time zone crossing
1. clinical pres irritation, photophobia, DENDRITIC 1. transient 2. depression, anxiety, PTSD, mania,
2. tx ULCER insomnia schizo, OCD, meds/substance abuse,
2. acyclovir, topical antivirals 2. secondary alcohol, sedatives
insomnia 3. difficulty initiating/maintaining sleep,
153. viral conjunctivitis 1. adeno is MCC, hyperemia of both
3. definition non-restorative sleep >1 month, excessive
1. patho + clinical eyes, palpable pre-auricular node
of insomnia worry about not being able to fall asleep
pres
4. tx 4. underlying cause, sedative hypnotics as
154. bacterial 1. s.pneumo or gram neg -irritation, short as possible
conjunctivitis hyperemia, tearing, mucopurulent
161. treatment for 1. diet, exercise, lifestyle
1. patho exudate
obesity orlistat up to 4 years
2. tx 2. broad spectrum abx
bariatric surgery
- chlamydial = MCC
blindness 162. incontinence 1 BPH, neurologic disease
worldwide (tx = (urge, stress, 2. hormonal changes, or pelvic floor
tetra,doxy,erythro) overflow, dysfunction
functional) 3. recurrent UTI, immobility, dementia,
155. allergic 1. seasonal--> redness, itching,
1. usual spine injury, DM, CHF, multiparity, BPH,
conjunctivitis tearing, rhinorrhea,
causes in prostate cancer, diuretics, beta blockers,
1. patho 2. cold compress, topical
males anticholinergics/adrenergics (inc.
2. tx antihistamines, systemic
2.. usual retention), CCBs, alcohol
antihistamines, NSAIDS
causes in
156. amaurosis fugax 1. monocular vision loss 2/2 females
1. patho embolization from carotid 3. risk factors
2. dx 2. carotid ultrasound, cardiac workup
163. 1. causes of c1. cerumen, OE, TM perf, OM, otosclerosis,
(lipids, ECG)
conductive pagets disease
157. OSA 1. obesity, structural abn. of hard/soft hearing loss 2. presbycusis (degen of sensory
1. patho palate, FH, alcohol/sedatives, 2. cells@cocholea, high freq->low freq),
2. dx hypothyroid--> intermittent sensorineural chronic loud noise >85db, infection,
3. tx obstruction of airflow--> daytime hearing loss aminoglycosides, aspirin (reversible)
sleepiness, snoring, personality 3.. treatment infection, menieres disease, TORCH
change, systemic/pulm HTN, for cerumen infections
arrhythmias impaction 3. carbamide peroxide, triethanolamine
2. polysomnography - measure
164. menieres 1. triggers - alcohol, caffeine, nicotine, high
apneas/hypopneas
disease salt foods --> fluctuating unilateral hearing
5-15 = mild
1. clinical loss, progressive hearing loss, vertigo,
15-30 = moderate
pres hearing loss, nystagmus, vomiting
>30= severe
2. patho 2. distention of endolymphatic compartment
3. <20 apneas/night - weight loss,
2. tx of the middle ear
sleep hygiene
2. salt restriction***, meclizine
>30 apneas/night - CPAP,
uvulopalatopharyngoplasty, 165. urge 1. dementia, stroke, illness, parkinson's -->
tracheostomy incontinence detrusor instability/involuntary
1. patho contractions
158. complications of inc. pulmonary vascular resistance,
2. clinical 2. sudden urge to urinate, large volume
OSA inc. pulm HTN, cor pulmonale,
pres voids, with low residual
systemic hypertension
3. dx 3. urodynamic study,
159. narcolepsy 1. inherited REM sleep regulation 4. tx 4. bladder training exercises,
1. clinical pres disorder -- >sleep attacks, excessive anticholinergics (oxybutynin), TCA
2. tx sleepiness, cataplexy, sleep paralysis, (imipramine)
hypnagogic hallucinations
2. methylphenidate, planned napping
166. stress 1. multiparity --> pelvic diaphragm 174. alcoholism 1. GI- gastritis, esophagitis, PUD, hepatitis,
incontinence weakness/loss of bladder 1. pancreatitis, mallory weiss tears,
1. patho support+hypermobility of bladder neck allows complications cardiomyopathy, essential hypertension (>3
2. clinical proximal urethra to descend below the drinks/day), wernicke korsakoff, thiamine
pres bladder floor B1 def, hypomagnesemia, folate def,
3. tx 2. involuntary small volume urine loss during peripheral neuropathy (B1 def), sexual
activities that inc. intrabdominal pressure dysfunction, inc. cancer (oral, esophagus,
(cough, laugh, sneeze, exercise) with small lung, liver)
post-void residual
175. alcoholism 1. AA, disulfiram, naltrexone, acamprosate,
3. urinalysis (r/o infection), kegel exercises,
1. treatment benzos (tx. withdrawal), thiamine, folate,
estrogen replacement, urethropexy,
multivitamins
167. overflow 1. neurogenic bladder (DM, LMN lesions)
176. most lung cancer, COPD, atherosclerotic
incontinence anticholinergics, alpha agonists, BPH**
important cardiovascular disease, varencline
1. patho (MCC), strictures, fecal impaction-->
causes of
2. clinical inadequate contraction (dec. detrusor
mortality with
pres contractility) causes overdistention -->
smoking
leakage after overcoming urethral resistance
2. nocturnal wetting, freq. loss of small 177. alcohol 1. tachycardia, sweating, anxiety,
volume urine, large post vol residual withdrawal hallucinations
3. self cath, cholinergics (bethanechol), 1. symptoms 2. delirium within a week after stopping
alpha blockers (terazosin prazosin), 2. DT alcohol, - hallucinations, confusion,
sweating, tachycardia, inc. BP
168. reflex 1. spinal cord injury, MS, DM, tabes,
tx = benzo taper
incontinence herniation, cord compression --> no sense of
1. patho urinary urge 178. health risks CAD, MI, stroke, COPD,
assc. with lung/eso/larynx/bladder/cervix/panc
169. incontinence 1. urinalysis*, post void catheterization
smoking cancers, PUD, osteoporosis, premature skin
dx (normal is <50ml), urine cultures, BUN/Cr,
aging, PVD, burgers disease, low birth
blood glucose, cystometry, uroflow, IVP,
weight/spon abortion
voiding cystourethrogram
179. smoking varenicline - partial a4b2 - subunit of the
170. fatigue 1. psych, endocrine (hypothyroid, DM,
cessation aids nicotinic acetylcholine receptor
1. causes addison's, anemia, occult malig (panc), CRF,
nicotine replacement
mono, HB/CV, mono, CMV, TB,
Buproprion**- use in combo with
endocarditis, OSA, CHF, antihypertensives,
replacement
171. fatigue lab CBC, TSH, fasting glucose, BMP, UA, LFTs,
180. 1. HTN 1. all adults >18yo every 2 years
workup ESR, HIV, calcium
screening 2. monthly self exams >20 years of age,
172. CFS 1. fatigue >6 months, triggered by flu like 2. womens physician physical every 3 years until age
1. patho illness, new or definite onset of unexplained breast 40, yearly after that
2. tx fatigue, not relieved by exertion, dec. memory, screening mammogram every 1-2 years for women
muscle pain, sore throat, tender nodes, >40, yearly >50, stop at age 70
unrefreshing sleep, joint pain, headaches,
181. 1. cervical 1. within 3 years of sexual activity or at age
malaise
cancer 21, if 2 consecutive smears negative, repeat
2. cognitive behavior therapy, exercise,
screening every 3 years until age 35 then every 5 years
social, psychological, antidepressants,
until age 65
NSAIDs
182. 1. STD 1. all women at risk screened yearly until
173. erectile 1. 80% organic 20% psychogenic
screening age 26
dysfunction - HTN, smoking, hyperlipidemia,
1. patho antihypertensives, sickle cell, pelvic surg, 183. 1. eye 1. all diabetics yearly fundus exam,
2. dx alcohol screening glaucoma only for high risk pts
3. tx 2. DRE, neurologic exam, check PVD. 2. ear 2. informally at visits, young adults only if
3. treat underlying cause (atherosclerosis), screening have risk factors (noise exposure)
PDE5 inhibitors, intracavernosal injections, 184. 1. 1. DEXA at age 65
implants. osteoporosis 2. ultrasound at age 65 with history of
screening smoking
2. AAA
185. page 481 for adult vaccine ..... 196. risk factor smoking cessation
schedule modification for HTN - <130/80 for diabetics
CAD HLD - statins and diet
186. HPV vaccine age 9-26 years of age
DM - strict glycemic control
reccomendation
obestity
187. contraindications of to hx. of anaphylaxis, mod-sev exercise
vaccination illness Diet
188. how to tell if a CXR film is intervertebral spaces visible 197. medical aspirin - reduces morbidity/MI risk
good vertebral bodies visible treatment for beta blockers - reduce cardiac work/O2
through cardiac silouette CAD demand
>9 ribs should be visible on Nitrates - reduce preload, dec. O2
inspiration demand
heart larger than normal with CCBs- coronary dilators, vasodilators,
inadequate inspiration reduce afterload
symmetrical spacing of the
198. what drugs beta blockers
clavicles
decrease ace inhibitor
clavicular heads should be
mortality in CHF hydralazine + isosorbide dinitrate
aligned
spironolactone (blocks aldosterone)
vertebral bodies should be
alignsed 199. treatment for aspirin, beta blocker, nitrates, pain
stable angina control, supplemental oxygen
189. positioning for 1. 4-6 cm above carina
1. ET tube 2. in SVC above right atrium 200. side effects of headache
2. central line 3. in the L or R main pulm nitrates orthostasis
3. swan ganz arteries tolerance
4. NG tube 4. proximal to the pylorus, syncope
distal to GE junction
201. indications for moderate disease - normal EF/mod.
190. abdominal images 1. supine, good for gas pattern CABG or angina, two vessel disease not well
1. standard abdominal 2. supine, upright look for free coronary controlled by medical therapy
film air, air fluid levels can be seen angioplasty
2. obstruction series on upright
202. severe disease - ...
191. ileus vs mechanical air in small intestine supports dec. EF, severe
obstruction on ileus b/c involves entire GI angina, 3 vessel,
obstruction series xrays tract left main, LAD
scattered dilated loops
203. acute coronary unstable angina, NSTEMI, STEMI
supports ileus
syndrome
stacked dilated loops supports
mechanical obstruction 204. unstable angina 1. stenosis has increased via
prominent/multiple air fluid 1. pathogenesis thrombosis, hemorrhage, or plaque
level supports mechanical 2. clinical history rupture --> decreased blood supply due
obstruction of unstable to reduced resting coronary flow***
angina 2. increasing frequency, duration,
192. ECG 1. # of large boxes/300=
3. how to intensity of chest pain, new onset severe
1. detemrine rate 1/#BPM
differentiate angina, angina at rest
2. determining axis 2. I and aVF should be positive
between unstable 3. no elevation of CK and troponin in
3. LAD axis (= normal axis)
angina and unstable angina
4. RAD axis 3. I positive, aVF negative
NSTEMI 4. rule out MI, stabilize, stress test, or
4. I negative, aVF positive
4. managment initial cardiac cath (without stress test)
I negative, aVF negative -
extreme LAD 205. treatment of IV access, pain control, oxygen,
unstable angina nitrates, aspirin (MONA)
193. 1. first degree heart block 1. PR>0.2
ECG 2. progressive PR lengthening
2. second degree "" and then dropped QRS
194. does Hib vaccine prevent no , because it is caused by
otitis NTHI
195. adult hep B vaccination 3 doses, 0,1-2,4-6
206. beta blockers ...
LMWH (enoxaparin) 2-2.5
INR
clopidogrel - reduces MI in
USA
gpIIb/IIIa inhibitors -
abciximab, tirofiban
K+ and Mg+ replacement
207. TIMI risk score risk of death/ischemia in
patients with unstable
angina/NSTEMI
Age>65
>3 CAD risk factors
known CAD >50% stenosis
2 episodes of angina in last
24 hours
aspirin use in last 7 days
elevated cardiac enzymes
ST change >0.5mm
0-1 point = 5%
2 points = 8%
3 points = 13%
4 points = 20%
5 points = 26%
6-7 points = 41%
208. when to proceed to medical therapy fails to
cath/revascularization in a reduce symptoms
patient with unstable ECG changes indicative of
angina ischemia,
ventricular arrhythmias
new mitral regurgitation
new septal defect
209. variant prinzmetals angina 1. transient coronary
1. patho vasospasm associated with
2. clinical pres atherosclerosis, smokers
3. diagnosis 2. angina pain, ventricular
4. tx dysrhythmias, night time
onset*
3. transient ST elevation
during chest pain
coronary angiography-
administer ergonovine
shows coronary vasospasm
4. CCBs***, nitrates,
smoking cessation
avoid aspirin (prostacyclin
inhibitor)
avoid beta blockers
210. myocardial infarction ...
1. patho
2. clinical pres
211. patients often have a 1. interruption of blood flow 2/2
history of angina, CAD, atheromatous plaque rupture and
or arrythmias acute coronary thrombosis
30% mortality rate 2. intense crushing substernal
chest pain
radiation to neck, jaw, arms,
back, left side
dyspnea, diaphoresis, weakness,
fatigue, n/v, impending doom,
syncope
does not respond to nitroglycerin
+/- epigastric discomfort
sudden cardiac death 2/2 V.fib
212. what patients have post operative
asymptomatic MIs diabetics
patients on beta blockers
women
213. myocardial infarction 3. ECG - ST elevation or
3. diagnosis depression, peaked T waves
(earliest), Q waves (late), T wave
inversion
cardiac enzymes - inc. 3-5 hours
post MI, peak 24-48 hours,
measure q8hrs for 24 hours
214. right ventricular MI 1. ECG changes, hypotension,
clinical presentation elev. JVP, hepatomegaly, clear
lungs*
215. 12 lead ECG findings of 1. ST elevation V1-V4
MI 2. large R wave V1-V2
1. Anterior MI ST depression V1-V2
2. posterior MI prominent upright T waves V1-
3. lateral MI V2
3. ST elevation/Q waves I, aVL
4. ST elevation/Q waves II, III,
aVF
216. what to look for during hyper/hypotension
cardiac monitoring in PVCs which predict Vfib or VT
patient with MI auscultation for lung crackles,
S3/S4, friction rubs
in unstable patient
hemodynamic monitoring with
pulmonary artery catheter
217. what hemodynamic CVP, PCWP, SVR, CI
information from a
pulmonary artery
catheter
218. NSTEMI 1. subendocardial ischemia
1. patho 2. non-ST elevation, ST
2. ECG findings depression, T wave inversions,
no Q waves
219. what patients may have patients with renal failure
falsely elevated
troponin
220. 1. medical treatment 1. IV access 227. complications of MI 1. PVCs, afib, PSVT, idioventricular
for acute MI supplemental oxygen - limits 1. arrhythmias + rhythm, sinus tach, sinus brady
2. surgical treatment myocardial damage (tx) (atropine)
for acute MI nitrates - dilate coronaries, 2. asystole tx VT (tx = cardioversion +
vasodilator, reduces preload amiodarone),
morphine - venodilator, analgesia Vfib (tx = defibrillation, CPR)
Aspirin - antiplatelet 2. defibrillation, transcutaneous
LMWH pacing
beta blockers - reduce MVO2,
228. complications of MI 1. ischemia to a conduction tract
reduce post-MI remodeling of
1. AV block 2. only treat second and third degree
myocardium
2. tx blocks
ACE inhibitors
pacemaker in the setting of anterior
atorvastatin - stabilizes plaques,
MI
lowers cholesterol
atropine in the setting of inferior MI
Stress EKG before leaving hospital
pacemaker for sustained conduction
--> angiography --> possible PCI
deficits
or CABG
2. early thrombolysis, PCI or 229. complications of MI 1.repeat ST elevation, enzymes are
CABG- within 90 minutes of 1. recurrent less reliable and may still be elevated
arrival improves outcome infarction dx from first infarction (check CKMB
2. tx because declines faster than
221. which drugs reduce aspirin, beta blockers, ace
troponin)
mortality in patient inhibitors
2. repeat thrombolysis or repeat
with MI
cath/PCI
222. troponin vs CKMB troponin - inc. within 3-5 hours
230. MCC death first few ventricular tachycardia or ventricular
post MI, returns to normal after 5 -
days after MI fibrillation
14 days
CKMB- rises within 4-8 hours, 231. 1. when is 1. present late to the hospital within
returns to normal in 48-72 hours thrombolytic first 6 hours
therapy (alteplase) patients in which PCI is
223. what medical therapy aspirin/clopidogrel for 12 months
prefered over PCI contraindicated
after a patient for patients with drug eluting
2.contraindications 2. recent head trauma or CPR, hx of
receives a stent stents
to thrombolytic stroke, recent surgery, dissecting
224. """ for at least 30 days ... therapy aneurysm, bleeding or diathesis
with bare stents
232. mechanical 1. peak occurrence 2 weeks after MI, -
225. complications of MI 1. MCC in hospital mortality, can complications of MI -> hemopericardium/tamponade,
1. pump failure lead to cardiogenic shock 1. free wall rupture 90% fatal
2. pump failure 2. ACE/diuretic, if severe + tx tx = hemodynamic stabilization,
treatment hemodynamic monitoring 2. interventricular pericardiocentesis, surgery
septum rupture + 2. """""
226. complications of MI pump failure
tx 3. mitral regurg
arrhythmias
3. papillary muscle tx = mitral valve replacement, IABP,
asystole
rupture+ tx sodium nitroprusside (dec. afterload)
AV block
4. ventricular 4. incomplete free wall rupture
recurrent infarction
pseudoaneurysm + contained by pericardium
interventricular septum rupture
tx dx/tx = bedside echocardiogram,
papillary muscle rupture
5. ventricular emergency surgical repair (HIGH
ventricular pseudoaneurysm
aneurysm risk of rupture)
ventricular aneurysm (persistent
5. rarely rupture, seen as persistent
ST elevation)
ST elevation
acute pericarditis
tx = medical management,
Dresslers syndrome
sometimes surgery
233. complications of MI 1. inflammation of the pericardium
1. acute pericarditis post MI. pleuritic type chest pain
2. tx 2. tx = time and rest, NSAIDs, NO
CORTICOSTEROIDS (inhibits
myocardial healing)
234. complications 1. immunological reaction- fever, malaise, 242. NYHA class 1 - symptoms with vigorous
of MI pericarditis, pleuritic type chest pain, classification of activities
1. dresslers leukocytosis WEEKS TO MONTHS post MI CHF class 2 - symptoms with moderate
syndrome tx. = aspirin, or ibuprofen, glucocorticoids exertion ex. climbing flight of stairs,
carrying packages - slight limitations
235. chest pain heart - angina, MI, pericarditis, dissection
class 3 - usual daily activities -
ddx lungs - embolism, pneumothorax, pleuritis,
walking across the room, getting
pneumonia,
dressed - marked limitations
GI - GERD, DES, PUD, esophageal rupture
class 4 - symptoms at rest -
chest wall - costochondritis, muscle strain,
incapacitating
rib fracture, herpes zos, thoracic outlet
psych - panic attack, anxiety, somatization 243. right heart failure peripheral pitting edema
drug - cocaine signs nocturia (venous return with leg
elevation)
236. chest pain ALL CASES - ECG, chest X Ray
JVD
workup CLINICAL SUSPICIONS - cardiac enzymes,
hepatomegaly/hepatojugular reflex
nitroglycerin, work up for PE, treat for
ascites
GERD (young, no risk factors), cardiac
right ventricular heave
workup (older, diabetic, with risk factors)
244. diagnostic tests for CXR - pulmonary edema,
237. characteristic changes with respiration
CHF cardiomegaly, kerley B lines (dilation
of pleuritic changes with position
of lymphatics), pleural effusion,
chest pain
prominent interstitial markings
238. high output inc. CO needed to maintain peripheral O2 ECG - chamber enlargement
heart failure - requirements cardiac enzymes -r/o MI
definition chronic anemia, pregnancy, hyperthyroid, CBC - anemia
and causes AV fistulas, wet beriberi, pagets disease of Echocardiogram - estimates EF (< or
bone, mitral regurg, aortic insufficiency > 40%), r/o pericardial effusion,
239. CHF 1. end point of many diseases, heart cannot determine sys/dias dysfunction
1. meet circulatory demands --> BNP
pathogenesis RAAS/sympathetic sys--> radionuclide ventriculography -
2. what does vasoconstriction/fluid retention--> inc. t99m, detects EF, used when severe
the frank preload--> inc. LVEDV (but failing heart pulmonary disease
starling curve does not inc. contractility) --> symptoms of cardiac cath- to r/o CAD induced
describe congestion CHF
2. increasing preload increases stroke stress testing
volume in a normal heart, but not in a 245. BNP 1. released by ventricles in response
failing heart 1. when is it to ventricular expansion and
240. 1. CHF clinical 1. dyspnea, orthopnea (pillows), released pressure overload`
presentation paroxysmal nocturnal dyspnea (waking 1-2 BNP can help
hours after going to sleep with SOB), differentiate
nocturnal cough, confusion, memory between CHF and
impairment, diaphoresis COPD causing
dyspnea
241. left sided displaced PMU
heart failure S3- rapid filling into non-compliant left
signs ventricle (@ apex with bell)
S4- atrial systole blood ejected into non-
compliant left ventricle
crackles/rales - fluid in small airways
dullness to percussion of lung fields -pleural
effusion
strong P2 component of S2 - from pulm.
HTN
246. CHF treatment 1.- sodium restriction <4g/day, 254. cardiac resynchronization therapy indications same as ICD, but for
1. MILD (I and II) exercise, smoking cessation patients with a QRS
2. MILD-MODERATE (II -diuretics (furosemide, HCTZ) - >120 msec
and III) symptom control
255. diastolic heart failure dysfunction beta blockers
3. MODERATE- - ACE inhibitors/ARBs -
diuretics
SEVERE(III and IV) systemic vasodilator, left vent.
ACEs/ARBS
4. what drug for patients systolic dysfunction,
DO NOT USE digoxin +
who cannot tolerate ACE 2. loop diuretic, ace inhibitor,
spironolactone
inhibitors beta blocker (esp. post MI
CHF) 256. 1. acute decompensated heart failure acute dyspnea assc.
3. loop diuretic, ace inhibitor 2. ddx with left sided sys/dias
digoxin - EF <40%, severe 3. dx function
CHF, afib 2. PE, asthma,
spironolactone - dec. pneumonia (all rapid
morb/mort in stage 3/4 CHF respiratory distress)
4. hydralazine and isosorbide 3. ECG, CXR, BNP,
dinitrate Echo, coronary
angiogram, serial
247. spironolactone vs eplerenone does not cause
weight measurements
eplerenone gynecomastia
257. treatment acute decompensated heart failure oxygenation/ventilation
248. what must be monitored renal function, and potassium
with non-rebreather,
for patient on levels
NPPV, intubation
spironolactone
diuretics***
249. which drugs reduce beta blockers nitrates
mortality for patients spironolactone (stage II and inotropes - dobutamine
with CHF III) (faster onset than
ACE inhibitors digoxin)
hydralazine + nitrate
258. premature atrial complexes ...
250. what must be monitored BP, potassium, BUN, Cr 1. patho
for a patient on an ACE 2. ECG findings
inhibitor 3. tx
251. digoxin toxicity N/V, ectopic beats, 259. http://meds.queensu.ca/central/assets/modules/ECG/Slide11.JPG 1. adrenergic excess,
symptoms arrhythmias: drugs, alcohol, tobacco,
ECG findings AV block,atrial tach (inc. electrolyte, ischemia,
ectopy) with 2:1 AV block (inc. infection--> atria fire on
vagal tone) their own without SA
Afib, visual disturbances, node
disorientation 2. early P waves with
*verapamil increases digoxin different morphology,
levels normal QRS
ECG - scooped ST segments, 3. asymptomatic, beta
prolonged PR, shortened QT, T blockers if symptomatic
wave inversion
260. premature ventricular complexes ...
252. what drugs are metformin - lactic acidosis 1. patho
contraindicated in TZDs - fluid retention 2. ECG findings
patients with CHF NSAIDs - CHF exacerbation 3. tx
antiarrhythmics with negative
inotropic effects
253. ICD indications implanted cardiac defibrillator-
prevents sudden cardiac death
in patients
>40 days post MI,
EF <35%
class II or III symptoms despite
medical tx
261. http://meds.queensu.ca/central/assets/modules/ECG/premature_ventricular_complex.html
265. atrial fibrillation 1. heart disease -1.CAD,
structural
MI, HTN,
heartmitral
1. causes valve disease, pericarditis,
dz, hypoxia, pericardial
2. patho trauma electrolytes,
pulmonary disease stimulants,
- PE meds
hyper/hypothyroid --> beat fires on
sepsis, malig, DM its own from a
excessive alcoholventricular focus
sick sinus syndrome2. wide QRS, lost
pheochromocytoma P wave (hiding in
2. multiple atrial;QRS
focicomplex),
fire continuously
causing rapid irregular
compensatory
ventricular rate -
-> thromboembolism,pause*hemodynamic
compromise couplet - two
successive PVCs
266. atrial fibrillation 1. fatigue, exertional dyspnea,
bigeminy - sinus
1. clinical palpitation, dizziness, angina, syncope
beat followed by
features 2. irregularly irregular rhythm, no
PVC
2. ECG identifiable P waves
trigeminy - two
3. tx 3. RATE CONTROLLED - *Beta
sinus beats
blockers or CCB
followed by PVC
*immediate electrical cardioversion if
3. asymptomatic
unstable
no treamtent, beta
*digoxin or amiodarone if LV
blockers if
dysfunction
symptomatic
*anticoag - if >48 hours,
(palpitations,
anticoagulation 3 weeks before and 4
dizziness)
weeks after cardioversion (INR 2-3)
262. should post MI PVCs be suppressed with antiarrhythmics TEE - to detect LA NO thrombus
NO NO -
*pharma cardioversion
increases - ibutilide,
risk of
procainamide, flecainide,
death sotalol,
amiodarone
263. management of patient with frequent PVCs workup for
267. how does afib under age 60, nostructural
other heart heart
disease
treatment differ do not need heparin/warfarin
disease
for patients with if heart disease is
lone afib found patient
should have
268. chronic afib beta blockers/CCBs
electrophysiologic
treatment warfarin
study and
269. 1. cardioversion 1. shock that is synchronous
possible ICDwith QRS
2. defibrillation (NOT T-wave) - used for afib, aflutter,
implantation to
VT with pulse, SVT prevent sudden
2. shock that is not synchronous
cardiac death with
QRS - Vfib, pulseless VT
264. causes of diastolic heart dysfunction infiltrative
270. indications for Vfib, or VT that is not controlled by
cardiomyopathies
automatic medical therapy (amyloid,
implantable sarcoid),
defibrillator hypertrophic
271. atrial flutter cardiomyopathy,
1. heart failure, rheumatic heart disease,
1. causes CAD, COPD, ASD
2. patho 2. right atrial macro-reentry focus firse
3. ECG 250-350BPM
4. tx 3. saw tooth baseline, with QRS every 2-
3 atrial contractions (II, III, aVF)
4. same as for Afib
272. multifocal atrial 1. COPD, or other pulmonary disease 278. ventricular 1. stable + sys BP>90: IV amiodarone,
tachycardia 2. >3 P wave morphologies tachycardia procainamide, or sotalol
1. causes - vagal maneuvers/adenosine show AV 1. sustained unstable or severe sx: synchronous DC
2. ECG findings + block does not disturb atrial tachycardia VT tx cardioversion, and amiodarone, and ICD
dx 3. same as MAT, rate 60-100 BPM 2. non- placement
3. wadering 4. improve oxygenation/ventilation sustained VT 2. electrophysiologic study, possible ICD
atrial pacemaker LV intact: BB, CCB, digoxin, tx placement, amiodarone
4. tx (w and w/o amiodarone, flecainide, propafenone
279. Ventricular 1. ischemia, antiarrhythmic drugs (QT
LV dysfunction) LV not intact: digoxin, diltiazem,
fibrillation prolonging), Afib (ex. in WPW)
amiodarone
1. causes 2. multiple ventricular foci firing in the
273. paroxysmal 1. PACs --> two paths in the AV node, 2. patho ventricles, no CO, usually starts with Vtach
supraventricular reentrant circuit within the AV node 3. clinical 3. loss of consciousness, no pulse,
tachycardia ECG - narrow QRS with no P waves (P pres 4. no P waves, no QRS, no waves can be
1. AV nodal re- waves inside QRS) 4. ECG identified
entrant 2. PAC or PVC --> retrograde accessory 5. tx 5. defibrillation(200,300,360) and CPR,
tachycardia + path between atria/ventricles epinephrine 1 mg IV every 3-5mins, defib
ECG ECG - narrow QRS, +/- P waves again after first epi.
2. orthodromic 3. ischemia, digoxin toxicity (PSAT w/ IV amiodarone before 1st defib
AV re-entrant 2:1 block) 2nd line: lidocaine, magnesium,
tachycardia + 4. vagal maneuvers, IV adenosine. procainamide
ECG IV verapamil
280. pulseless 1. 6Hs and 6Ts
3. causes IV esmolol
electrical H: hypovolemia, hypoxia, hyrogen ions,
4. tx
activity hypothermia, hypoglycemia,
274. vagal maneuvers valsalva, carotid sinus massage, breath 1. causes hyper/hypokalemia
holding, head submersion in cold water 2. clincial T: tamponade, tension pneumo, thrombosis
or ice pack findings (MI/PE), trauma (hypovolemia),
3. tx tablets(drugs), toxins
275. PSVT prevention digoxin*
2. monitor shows electrical activity, but no
verapamil, beta blockers
pulse present
radiofrequency catheter ablation
3. IV access and CPR/ACLS resuscitation
276. WPW syndrome 1. accessory conduction pathway with IV fluids, not cardioversion
1. patho through bundle of kent causes premature
281. sinus 1. ischemia, vagal tone, antiarrythmics,
2. dx ventricular excitement --> orthodromic
bradycardia athletes
3. tx reciprocating tachycardia (through AV
1. causes 2. fatigue, exercise intolerance, angina,
node), or supraventricular tachycardia
2. symptoms syncope
by avoiding AV node (afib or flutter)
3. tx 3. atropine
2. narrow complex tachycardia, short
PR, delta wave 282. sick sinus 1. sinus node causes persistent sinus
3. radio-frequency ablation of re-entrant syndrome bradycardia
loop accessory pathway 1. patho 2. dizziness, confusion, syncope, fatigue,
procainamide**, quinidine** (IA or 2. sx CHF
IC) 3. pacemaker
(AVOID digoxin/verapamil/beta
283. first degree due to delay in AV node
blockers which act @ AV node)
AV block prolonged PR, QRS follows each P
277. ventricular 1. rapid repetitive firing of >3 PVCs @
284. second 1. progressive PR interval elongation until
tachycardia 100-250BPM
degree AV there is a lost QRS, block within AV node
(sustained and 2. CAD post MI*, active ischemia,
block 2. sudden loss of P wave without preceding
nonsustained) cardiomyopathies, congenital defects,
1. type 1 PR interval prolongation, progressed to
1. patho long QT
(wenckebach) complete heart block, block within the his-
2. causes 3. AV dissociation is present, wide
2. type 2 purkinje system
3. ECG variable shaped QRS (>0.12s)
3. tx for type 1 3. pacemaker required for type 2
- no response to vagal manuevers or
vs 2
adenosine
285. third degree absence of atrial impulse conduction to the
AV block + tx ventricles, AV dissociation
286. tx = atropine ... 291. restrictive 1. amyloid, sarcoid,
acutely, cardiomyopathy hemochromatosis, scleroderma,
pacemaker 1. patho carcinoid, chemotherapy -->
implantation** 1a. clinical pres impaired diastolic ventricular
**** 2. dx filling
3. tx 1a. absent pulses, absent
287. dilated 1. CAD, alcohol (look for macrocytosis),
kussmaul's sign, prominent x
cardiomyopathy doxo, adriamycin,
descent
1. patho thiamine/selenium/phosphate
2. echocardiogram - shows
2. clinical pres deficiency
enlarged RA/LA sizes, sparkled
3. dx uremia
appearance in amyloidosis
4. tx viral (cox), chagas, lyme, HIV
ECG - low voltage,bundle branch
hyper/hypothyroid
blocks, LVH
SLE, scleroderma
endomyocardial biopsy
pheochromocytomas, cocaine
familial 292. 3. hemochromatosis - ...
2. L/R CHF, S3, S3, mitral regurg, phlebotomy,
tricuspid regurg, cardiomegaly, deferoxamine
arrhythmias, sudden death sarcoidosis -
3. ECG, CXR, echocardiogram glucocorticoids
4. digoxin, diuretics, vasodilators, amyloid - none
transplant, anticoag. digoxin for systolic
failure
288. HCM 1. AUTOSOMAL DOMINANT-->
avoid
(hypertrophic diastolic dysfunction, worse with
diruetics/vasodilators
cardiomyopathy) exercise or valsalva + dynamic outflow
1. patho obstruction 293. myocaridtis 1. coxsackie, parvo b19, HHV6,
2. clinical pres 2. angina, syncope, dyspnea (on 1. patho bacteria, GAS, lymes,
3. dx exertion or valsalva), arrythmias, 2. clinical pres mycoplasma, SLE, sulfonamides -
SUDDEN CARDIAC DEATH 3. dx/tx -> inflammation of myocardium
3. loud S3, systolic ejection murmur @ 2. fatigue, fever, cx pain,
LSB, rapidly increasing two upstroke pericarditis, CHF, arrhythmia,
carotid pulse (bisferiens pulse) death
Echocardiogram - shows left ventricular 3. cardiac enzymes, ESR
hypertrophy esp. of septum tx= supportive
ECG, family history
294. acute pericarditis 1. idiopathic/infectious (cox*,
289. HCM 1. avoid strenuous exercise 1. causes (long list...) echo, adeno, ebv, flu, HIB,
1. treatment symptomatic: beta blockers* hep A/B, TB*, fungal, toxo)
CCBs, diuretics, myomectomy, mitral Acute MI (within 24 hrs)
replace, pacemaker uremia
collagen dz - SLE, scleroderma,
290. HCM murmur systolic ejection murmur @ LLSB
RA, sarcoid
features decreased with squatting/lying down
hodgkins lymphoma, breast/lung
(dec. outflow obstruction, sustained
cancer
hand grip
drug lupus: procainamide,
increased with valsalva and standing
hydralazine
(dec. LV size and inc. outflow
Dresslers syndrome- weeks to
obstruction)
months after MI
post pericardectomy sndrome
amyloid
radiation
trauma
295. acute pericarditis 1. supportive 1-3 weeks
1. treatment 2. pericardial effusion, pericardial
2. complications tamponade
296. acute pericarditis 1. preceeding viral illness 302. pericardial 1. ascites, pleural effusion, CHF,
1. clinical pres severe pleuritic chest pain, effusion cirrhosis, nephrotic syndrome OR
retrosternal, left precordial 1. pathogenesis acute pericarditis --> leads to
KUSSMAULS SIGN, PROMINENT Y 2. clinical pres exudation of fluid into pericardial
DESCENT 3. dx space
radiates to trapezius ridge/neck 2. muffled heart sounds, soft PMI,
positional - worse when lying dullness at left lung base, friction rub
supine***, coughing, swallowing, (+/-)
deep breathing 3. echo- see effusion (as little as
better when sitting up and leaning 20mL)
forward CXR- >250ml enlarged silhouette
*Pericardial friction rub (3 "water bottle"
components) ECG - low voltage, flat T waves,
electrical alternans
297. best positioning to seated upright during expiration
CT/MRI
hear a pericardial
pericardial fluid - glucose, cell
friction rub
count/diff, cytology, SG, Hct, gram
298. acute pericarditis 1. fever and leukocytosis stain, acid fast, fungal smear,
1. dx pericardial friction rub cultures, LDH
2. tx ECG -- diffuse ST elevation, PR
303. pericardial 1. repeat echo 1-2 weeks,
depression
effusion no pericardiocentesis unless there is
ST segment returns to normal in 1
1. tx tamponade
week
T wave inversion (then reverses later) 304. cardiac 1. >200ml of rapid fluid accumulation,
echocardiogram often normal (unless tamponade or 2 liters of slow fluid accumulation--
effusion) 1. patho > mechanical filling and diastolic
2. self limited 2. causes impairment--> chamber pressure
treat underlying cause - note also equalization-->dec. LV preload, dec.
NSAIDS interventricular SV, dec. CO
Colchicine septum bows into 2. trauma, malignancy, uremia
glucocorticoids (avoid if possible) LV during central line placement, pacemaker
inspiration insertion, pericardiocentesis
299. constrictive 1. post viral, uremia, radiation, TB,
further reducing pericarditis
pericarditis connective tissue disorders --> fibrous
LV filling POST MI free wall rupture
1. patho scarring and obliteration of
2. clincal pres pericardial cavity/LATE* diastolic 305. cardiac 1. elevated JVD*, narrow pulse
3. dx filling restriction tamponade pressure,
2. edema, ascites, pleural effusion, 1. clinical pres pulsus paradoxus- >10 mmHg
hepatomegaly DOE, fatigue, exercise 2. dx drop in arterial pressure during
intolerance, cachexia, JVD inspiration
kussmaul's sign muffled heart sounds
3. ECG: low voltage, T wave flattening tachypnea, tachycardia, hypotension,
Echo: inc. pericardial thickness, cardiogenic shock
limited diastolic filling 3. echocardiogram
CT/MRI - pericardial thickening CXR - enlarged silhouette
Cath - rapid y descent, dip and plateau ECG - electrical alternans alternate
(square route sign) variation in direction of ECG waves -
due to pendular heart swinging
300. diagnostic echocardiogram
Pulsus paradoxus - >10mmHg decline
modality of choice
in sys. pres with inspiration
for pericardial
cardiac cath - equal chamber
effusion and
pressures, elevated right atrial
cardiac tamponade
pressure, loss of Y descent
301. constrictive 1. underlying condition*
306. becks triad cardiac tamponade:
pericarditis diuretics
hypotension, muffled heart sounds,
1. tx monitor/treat for coagulopathy
JVD
307. cardiac 1. nonhemorrhagic and stable - 312. aortic 1. infective endocarditis, trauma, dissection,
tamponade monitor with echo/CXR/ECG, dialysis regurgitation iatrogenic
1. tx (for uremia) 1. rheumatic fever, bicuspid, marfans, ehlers,
hemorrhagic - emergent surgery*, causes/patho syphilis. OI, behcets, reiters--> inadequate
pericardiocentesis 2. symptoms closure of aortic valve leaflets--> LV
dilation/hypertrophy--> elevated pulmonary
308. mitral stenosis 1. rheumatic heart dz** --> cross
pressures
1. patho reactivity between streptococcal
2. DOE, PND, angina orthopnea,
2. clinical pres/PE antigen and valve--> scarring,
palpitations worse with lying down,
inc. LA pressure, pulm HTN,
cyanosis,
Afib**
2. DOE, orthopnea, PND, 313. aortic 1. decrescendo diastolic murmur at 3rd ICS
palpitations, CX pain, hemoptysis regurgitation left sternal border
(bronchial vein rupture), 1. clinical Widened pulse pressure
thromboembolism presentation corrigan's pulse (water hammer pulse)-
murmur - S2 followed by OS (closer = rapidly increase pulse that collapses
mores severe) followed by diastolic suddenly decreases
rumble, loud S1 in LLD position with austin-flint murmur - low pitched diastolic
bell rumble from competing retrograde flow,
LATE: JVD, hepatomegaly, ascites, increases with handgrip
right vent. heave, loud P2 (pulm HTN) S3, displaced PMI
de Musset's sign (head bobbing), mullers
309. mitral stenosis 1. CXR - left atrial enlargement
sign (uvula bobbing, duroziez's sign (pistol
1. dx echo - left atrial enlargement, thick
shot sound over femoral arteries)
2. tx mitral valve, fish mouth orifice
2. diuretics for pulm 314. aortic 1. CXR - LVH, dilated aorta
congestion/edema regurgitation ECG- LVH
beta blockers - lower CO/HR 1. dx Echo- LV size/function/reversal of flow in
endocarditis prophylaxis 2. tx aorta
anticoagulation with warfarin cardiac cath - severity of regurg, LV
percutaneous balloon valvuloplasty dysfunction
open commissurotomy/mitral 2. CCBs (nifedipine)***, salt restriction,
replacement diuretics, digoxin, ACE
aortic valve replacement
310. aortic stenosis 1. senile aortic calcification, bicuspid
1. patho aortic valve, rheumatic fever --> LV 315. mitral acute (high mortality) - endocarditis(staph),
2. clinical pres outflow obs, LVH, mitral regurg regurgitation papillary muscle rupture, chordae rupture
25% 3 year survival 2. angina (3 yr surv), syncope (2 yr 1. patho chronic MVP, rheumatic fever, marfans,
w/o treatment @ surv), dyspnea/heart failure (1.5 yr 2. clinical cardiomyopathy
time of surv.) pres 2. DOE, PND, orthopnea, palpitations,
presentation with * murmur - harsh crescendo- 3. dx pulmonary edema, holosystolic murmor @
symptoms decrescendo systolic murmur, @ right 4. tx apex, radiates to back or axilla, afib, S3,
2nd ICS, radiates to carotids, soft S2 wide S2, palpable P2
parvus et tardus - delayed carotid 3.CXR - cardiomegaly, dilated LV, pulm
upstrokes edema
sustained PMI, precordial thrill Echo - MR, dilated LA/LV, dec. LV function
4. afterload reduction w/ vasodilators
311. aortic stenosis 1. CXR - calcified aortic valve,
anticoagulation
1. dx dilatation of proximal ascending
IABP, mitral valve repair/replacement
2. tx aorta, enlarged LV/LA
ECG - LVH, LA abnormalities
Echocardiogram - immobile thickened
aortic valve, dilated aortic root, LVH
2. no sx = no tx
sx = aortic valve replacement
316. tricuspid 1. RV dilation 2/2 left ventricular failure, 322. MCC epiglottitis + haemophilus influenza (often beta
regurgitation right ventricular infarction, inferior MI, CXR finding lactamase producing), #2 is strep.
1.causes cor pulmonale, tricuspid endocarditis pyogenes
2. clinical pres rheum arthritis, ebstein's anomaly, CXR - lateral neck xray shows
carcinoid, SLE THUMBPRINT SIGN
2. RVF failure signs - ascites,
323. weil felix titer antibody titer for rickettsial
hepatomegaly, edema, JVD, pulsatile
organisms ie. rocky mountain spotted
liver
fever
prominent V waves and rapid Y descent
blowing holosystolic murmur @LLSB 324. neisseria gram gram negative diplococci
worse with inspiration, reduced with stain
expiration/valsalva 325. clinical both upper (sore throat, otitits) and
317. tricuspid 1. echocardiogram presentation of lower respiratory symptoms (CXR
regurgitation 2. diuretics for volume overload mycoplasma infiltrates), myringitis hemolytic
1. dx treat underlying cause pneumonia + dx anemia, no organisms on gram stain
2. tx valve repair, tricuspid ring dx = IgM cold agglutination, positive
complement fixation test
318. mitral valve 1. myxomatous degeneration of the mitral
prolapse leaflet/chordae leads to prolapse 326. methenamine silver pneumocystis
1. patho *common in marfans, OI, Ehlers danlos stain
2. sx/clinical 2. usually asymptomatic 327. dx EBV heterophile antibodies, and atypical
pres mid systolic click and mid to late systolic lymphocytes on peripheral smear
murmur, standing and valsalva increase
328. amoebic liver 1. indirect hemagglutination and
murmur (b/c they dec. LV chamber size),
abscess ultrasound
squatting decreases murmur
1. dx/tx tx = metronidazole
319. MVP 1. dx = echocardiogram 2. clinical 2. RUQ pain, possible history of
1. dx/tx tx = reassurance, beta blockers presentation diarrhea, history of travel or endemic
surgery rarely region
320. rheumatic heart 1. GAS immunological reaction with 329. Coxsackievirus can ...
disease valves produce a
1. patho 2.JONES CRITERIA- morbilliform
2. clinical pres MAJOR: migratory polyarthritis, vesiculopustular
3. tx erythema marginatum, carditis, chorea, rash, often with a
subQ nodules (over tendons) hemorrhagic
MINOR: fever, ESR, polyarthralgias, hx. component and
rheumatic fever, prolonged PR interval, with lesions of the
evidence of strep infection throat, palms, and
3. penicillin, erythromycin for strep soles.
pharyngitis
330. stages of lymes stage 1 - erythema chronicum
NSAIDs for rheumatic fever
disease migrans (bulls eye rash that
erythro/amox* for dental/GI/GU
enlarges)
prophylaxis
stage 2 - neurologic, cardiac, arthritic
321. infective 1. s.aureus on a normal valve (migratory monoarticular) symptoms
endocarditis 2. on DAMAGED valves s.viridans, weeks to months after stage 1
1. acute enterococcus on damaged valves
331. what lab test VDRL
2. subacute 3. s. viridans, s. aureus, s. epidermidis,
detects both
3. native valve HACEK - haemophilus, actinobacillus,
syphilis and lymes
endocarditis cardiobacterium, eikenella, kingella
disease
4. IVDU 4. IVDU = s.aureus***, enterococcus,
5. prosthetic strep, candida, pseudomonas 332. what toxin causes TSST 1 superantigen increases TNF,
valves 5. s.epidermidis toxic shock IL1 release from PMNs
6. pathogenesis 6. --> cardiac failure, myocardial 333. treatment of oseltamivir and flu vaccines for the
7. recent bladder abscess, septic emboli, influenza outbreak entire population
instrumentation glomerulonephritis in a nursing home
8. colon cancer 7. enterococcus
8. s.gallolyticus/bovis
334. what is sensitive and MRI of the spine 344. endocarditis indications: prior history of infective
specific for diagnosis of prior UTI is most common prophylaxis endocarditis, prosthetic heart valves,
vertebral osteomyelitis mechanism for bacteremia and indications + untreated CYANOTIC congenital heart
and what is the cause vertebral seeding tx disease, s/p <6 mon after
amoxicillin for patients with known
335. causes of fever of infections, malignancies,
valvular disease - for oral, GI/GU surgery
unknown origin collagen vascular disease,
granulomatous disease 345. non- 1. metastatic cancer --> sterile deposits of
thrombotic fibrin/platelets that forms ALONG LINES
336. stills disease (juvenile classic presentation is the triad
marantic OF CLOSURE OF VALVE LEAFLETS
RA) of persistent high spiking fever
endocarditis 2.embolizations of vegetations to brain or
1. clinical presentation (FUO), joint pain and a
1. patho body
2. diagnostic blood test distinctive salmon-colored rash
2.
337. 2. elevated serum ... complications
ferritin**, RF is often
346. non-bacterial 1. SLE --> warty vegetations on BOTH
negative
verrucous SIDES of the valve leaflets
338. acute hepatitis A 1 month****- does not endocarditis 2. embolization
incubation period neccessarily happen immediatly (libman tx = treat SLE and anticoagulate
after exposure sacks)
339. features of chickenpox papules vesicles and scabs in 1. patho
rash variable stages of development 2.
complications
340. what patients are most diabetics
+ tx
likely to get anaerobic
cellulitis 347. ASD 1. ostium secundum, ostium primum (low in
1. patho septum), sinus venosus (high in septum) -->
341. what are the causes of ureaplasma urealyticum,
2. clinical left to right shunt with RA/RV dilation -->
non-gonococcal trichomonas vaginalis ,
pres pulmonary hypertension (late)
urethritis chlamydia trachomatis
3. dx - 2. asymptomatic then develops into exercise
342. infectious endocarditis 1. new heart murmur, physical, intolerance, DriOE, fatigue @ age 40
1. clinical presentation unexplained fever Echo, CXR, 3. systolic ejection murmur at LSB, wide
endocarditis 2. cardiac failure, myocardial ECG fixed split S2* (inc. blood flow), RVF.
2. complications of abscess, solid organ damage Echocardiogram w/contrast bubble study
infective endocarditis from emboli, CXR - large pulmonary arteries, inc.
3. tx glomerulonephritis pulmonary markings
3. parenteral antibiotics for 4-6 ECG - RBBB
weeks
348. treatment of switch to oral vancomycin***
if cannot isolate culture - vanc +
refractory metronidazole has a failure rate of 25%
aminoglycoside until organism
c.difficile
is isolated
349. treatment for linezolid, daptomycin, vancomycin TMP
343. dukes criteria infective endocarditis
hospital SMX
diagnostic criteria
MRSA
Major - sustained bacteremia,
endocardial involvement by 350. HIV 1. integrase inhibitor
echo, new valvular treatment 2. CCR5 antagonist
regurgitation 1. raltegravir 3. 2 NRTI + 1 NNRTI, or 2 NRTI + protease
Minor - predisposing condition, 2. maraviroc inhibitor
fever, 3. basic
septic or pulm emboli, mycotic treatment of
aneurysm, intracranial HIV
hemorrhage, janeway lesions 351. prophylaxis atovaquone-proguanil, mefloquine, or
immune phenomenon - against primaquine, 2 days before trip starts based
glomerulonephritis, osler's malaria upon CDC sensitivities
nodes, roth spots, rheumatoid
352. catheter fungal, e.coli, other gram negatives
factor
associated
non major blood culture/echo
UTI
353. cervicofacial fluctuant lesion and fistula over 364. complications 1. pulmonary hypertension
actinomyces the mandible of ASD eisenmenger disease- irreversible
2. when to treat pulmonary hypertension leads to shung
354. blastomycosis clinical chronic respiratory infection,
ASD reversal, heart failure, cyanosis
presentation verrucous crusted skin lesions,
right heart failure
osteolytic bone lesions
A.fib
355. aspergillus related disseminated in stroke (PARADOXICAL EMBOLI), Afib
disease immunocompromised 2. when pulm:systemic > 2:1 or if
allergic bronchopulmonary - symptoms
young woman with asthma
365. VSD 1. right to left shunt leads to pulmonary
aspergilloma - bronchial plugs
1. patho hypertension
with hyphae
2. clinical pres 2. holosystolic harsh murmur @ 4th left
356. which diseases are staph toxic shock 3. ICS decreases with valsalva/handgrip,
associated with kawasaki complications prominent P2
peeling of the skin scarlet fever 4. dx/tx 3. CHF, growth failure, lower resp.
severe drug reaction infections, eisenmenger's, cyanosis, DOE,
357. which diseases meningococcus, gonococcemia, aortic regurgitation
associated with rickettsia, infectious endocarditis, 4. ECG - ventricular hypertrophy
peeling of the skin atypical measles, DIC associated CXR - PA
with sepsis echo - shows septal defect
tx = surgical repair if pulm:sys pressure
358. causes of dysphagia in candida***(empiric fluconazole),
2:1, no abx prophylaxis if uncomplicated
HIV patients HSV, cytomegalovirus
VSD
359. risk factors for IV 1. volume depletion, diabetes,
366. coarctation of 1. narrowing of aorta @ left subclavian
contrast induced CHF, CKD, multiple myeloma
the aorta origin near lig. arteriosum
nephropathy + 2. hydration*** with isosmolar
1. patho 2. brachiofemoral delay, underdeveloped
avoidance of fluids, and sodium bicarb, n-
2. clinical pres lower body, leg fatigue, claudication,
complications acetylcysteine
3. dx/tx headache, turner's features
360. treatment for COPD steroids 3. ECG - LVH
exacerbation - Bipap is better because is CXR - rib notching, figure 3 from
reduces CO2 retention, indentation of the aorta
- NOT OXYGEN THERAPY - tx = surgical decompression, percutaneous
because of haldane effect and balloon aortoplasty
hypoxia drives respiration in
367. coarctation of HTN, cerebral aneurysms, infectious
COPD patients
the aorta endocarditis,aortic dissection
361. causes of delirium medications (anticholinergics, complications
antihistamines, TCAs),
368. clinical congenital rubella syndrome, high
postsurgical, infection,
associations altitude, premature birth
electrolytes, benzos,
with PDA
fluoroquinolones.
369. PDA 1. asymptomatic, heart failure
362. healthcare associated 1. long term care, recent
1. clinical continuous machinery murmur, wide pulse
pneumonia hospitalization, chronic dialysis
presentation pressure, bounding peripheral pulses,
1. associated settings 2. inc. risk for acinetobacter, s.
2. tx LOWER EXTREMITY clubbing/cyanosis
2. bacteria aureus, pseudomonas
2. indomethacin, PGE, do not correct if
3. tx 3. carbapenem, fluoroquinolone,
severe pulm htn.
vancomycin
370. TOF 1. VSD, right ventricular hypertrophy,
363. what decreases risk of daily interruption of sedation
1. patho pulmonary stenosis, aortic override.
ventilator associated (sedation holiday),
2. tet spells 2. squatting after exertion increases SVR
pneumonia oropharyngeal intubation,
3. dx and increases blood flow from RV to lungs
elevating head of the bed
3. echocardiography
CXR - BOOT SHAPED HEART
EKG shows enlarged RA/RV
371. hypertensive 1. >220/>120 with end organ 376. aortic 1. CXR - widened mediastinum, right sided
emergency damage dissection pleural effusion
1. definition * requires immediate treatment 1. dx / tx*** TEE*** (NOT TTE)
2. clinical findings 2. altered mental status, CT*/MRI - disadvantage is it takes longer
papilledema, hypertensive aortic angiography
encephalopathy, renal failure, tx= ANTIHYPERTENSIVES FIRST***
hematuria, unstable angina, MI, IV beta blockers, IV nitroprusside
CHF, pulmonary edema, immediately
dissection Type A - surgical emergency
Type B - medical - lower bp, pain control, if
372. hypertensive urgency >220/>120 without evidence of
symptoms persist treat surgically
end organ damage
377. AAA 1. trauma, HTN, vasculitis, smoking,
373. posterior reversible 1. 2/2 hypertensive emergency -
1. patho syphilis, marfans (thoracic) --> dilatation
encephalopathy autoregulatory failure of cerebral
2. clinical of aorta between renal arteries and iliac
syndrome vessels leads to arteriolar dilation
pres bifurcation
1. patho and extravasation of fluid into the
3. ruptured 2. usually ASYMPTOMATIC, throbbing
2. symptoms brain
AAA clinical hypogastric and lower back pain, severe
3. dx 2. insidious onset headache,
pres pain in back or lower abdomen radiating to
seizures, visual changes
4. dx/tx groin, buttocks or legs, grey turner sign,
3. posterior cerebral white matter
cullen sign
edema
3.abdominal pain, hypotension, palpable
374. treatment for 1. lower the BP (hydralazine, pulsatile mass , syncope, n/v
hypertensive esmolol, nitroprusside, labetalol, 4. ultrasound = diagnosis of choice***
emergency nitroglycerin) 25% in 1-2 hours CT scan = only if hemodynamically stable
and then reduce gradually (with
378. AAA 1. >5 cm in diameter, surgical resection with
less intensive therapy)
1. tx graft placement
2. order CT to r/o intracranial
ruptured = open repair or endovascular
bleeding
3. negative CT proceed with 379. leriche atheromatous occlusion of distal aorta
lumbar puncture syndrome above the bifurcation causing
BILATERAL CLAUDICATION
375. aortic dissection 1. hypertension, smoking,
IMPOTENCE
1. risk factors cocaine, trauma, marfans, ehler
DEC. FEMORAL PULSES
2. type A vs type B danlos, bicuspid aortic valve,
3. clinical pres coarctation, third trimester 380. PVD 1. coexisting CAD, MI, diabetes, lung
*****BE CAREFUL pregnancy 1. associated disease
AND DO NOT GIVE 2. type A includes the ascending conditions 2. superficial femoral (in hunter's canal),
THROMBOLYTIC IF aorta 2. common popliteal, aortoiliac
PRESENTATION IS type B distal to the subclavian sites 3. smoking**, CAD, HLD, HTN, DM**
SIMILAR TO artery 3. risk factors
MYOCARDIAL 3. severe tearing, ripping
381. PVD ECG, CBC, BUN/Cr, coagulation profile
INFARCTION sensation anterior chest (type A),
evaluation (factor V, antithrombin III, protein S/C)
or interscapular (type B),
diaphoresis, pulse asymmetry 382. PVD 1. leg pain reproduced by same walking
between limbs, aortic regurg 1. intermittent distance relieved by rest
murmur (A), neurologic claudication 2. pain in distal metatarsals prominent at
(obstruction of carotid) 2. rest pain NIGHT awakens from sleep relieved by
3. clinical hanging legs over the bed
findings 3. dec. pulse, atrophy, loss of hair, thick
toenails, decreased skin temp, ischemic
ulcers, infarction, gangrene, pallor of
elevation, rubor of dependency (BUERGER'S
TEST)
383. brodie ...
trendelenburg
test
384. PVD 1. normal ABI between 1.0 and 1.3 390. DVT dx doppler analysis, doppler ultrasound -
diagnosis ABI > 1.3 is due to noncompressible vessels tx good for proximal thrombi, not for distal
PVD tx and is an indication of severe disease Venography - best for calf veins
claudication <0.8 impedance plethysmography
rest pain <0.4 D-dimer testing - high sens
pulse volume recordings (small waveform tx = if doppler is positive start
means poor collateral flow) anticoagulation, if non-diagnostic
arteriography/arterial doppler repeat every 2-3 days for up to 2 weeks
2. stop smoking, graduated exercise, foot - heparin bolus titrate up to 1.5-2x
care, atherosclerotic risk factor reduction, aPTT, start warfafarin for 3-6 months,
aspirin + ticlopidine/clopidogrel, cilostazol thrombolytic therapy (massive PE and
(PDE inhibitor), angioplasty, surgical bypass unstable)
grafting, bypass grafting IVC filter - prevents PE
385. acute 1. afib, post-MI, endocarditis, myxoma, 391. complications of PE
arterial aneurysm --> embolization most commonly DVT post thrombotic syndrome (chronic
occlusion the femoral artery venous insufficiency)
1. patho 2. pain, pallor, polar (cold), paralysis, phlegmasia cerulea dolens - severe leg
2. clinical paresthesias, pulselessness edema that compromises arterial supply
pres 3. arteriogram*, ECG, echocardiogram \ results in impaired sensory/motor
3. dx/tx tx = reestablish perfusion within 6 hours, function
immediate, fogarty balloon embolectomy,
392. how to prevent leg elevation, compression stockings,
thrombolytics
post-op DVT early ambulation, pneumatic boots
386. cholesterol 1. surgical or radiographic maneuvers,
393. heparin or ...
embolization thrombolytic therapy--> showers of
LMWH +
syndrome cholesterol from proximal source
pneumatic
1. patho (atherosclerotic plaque) from aorta, iliac, or
compression =
2. clinical femoral arteries
BEST COMBO
presentation 2. small discrete areas of tissue ischemia-
3. dx/tx black/blue toes, renal insufficiency, 394. chronic venous 1. history of DVT destroys venous
abdominal pain/bleeding insufficiency valves--> ambulatory venous
3. dx = Eosinophilia******* 1. pathogenesis hypertension --> edema and
tx = supportive, DO NOT extravasation of RBCs/proteins into
anticoagulate,control BP, AVOID amputation subQ tissue leads to pigmentation-->
or surgical resection reduced capillary flow and ulceration
with mild trauma
387. mycotic infection of the wall of the aorta leads to
aneurysm damage of the aortic wall 395. chronic venous 1. swelling worse at end of day,
cause and tx = IV abx and surgical excision insufficiency standing, sitting, elevation provides
treatment 1. clinical relief
presentation brawny, atrophic, shiny, indurated,
388. luetic heart 1. syphilitic aortitis leads to retrograde
2. tx cyanotic skin
1. patho extensionaortic regurgitation and stenosis of
venous ulcers - MEDIAL MALLEOLUS
the aortic branches (coronaries)
2. leg elevation avoid prolonged
tx = IV penicillin and surgical repari
standing, elastic stockings, wet to dry
389. DVT 1. virchows triad - endothelial injury, saline dressings, unna venous boot,
1. pahto hypercoagulability, venous stasis skin graft
2 risk 2. prior history, prolonged immobilization,
396. superficial 1. upper extremities - IV infusion
factors cardiac disease, CHF, obesity, major surgery
thrombophlebitis lower extremities - varicose veins
3. clinical (esp. ortho), pregnancy and estrogen use,
1. patho 2. pain tenderness, erythema along
pres smoking
2. clincal pres course of vein, with tender palpable
3. classic findings- unilateral leg
cord
swelling/pain better with elevation/rest
3. tx = no anticoagulation, aspirin,
HOMANS sign - calf pain with dorsiflexion,
severe with pain/cellulitis - rest,
palpable cord, fever
elevation, hot compresses, only use abx
if suppurative
397. septic phlebitis remove the offending IV canula and 405. hypovolemic shock 1. trauma, GI bleed,
tx treat with IV abx x -page 66 good retroperitoneal bleed
classification of shock vomiting, severe diarrhea,
398. migratory 2/2 occult malignancy especially
chart dehydration, burns, third
superficial pancreatic cancer
1. causes spacing
thrombophlebitis
2. dx/tx 2. central venous line or
399. 1. most common 1. metastasis from other primary tumors - cool skin pulmonary arterial catheter-
tumor of the 2. MCC primary heart tumor - usually ****MONITOR URINE dec. CVP/PCWP/dec. CO/inc.
heart from intratrial septum near fossa ovalis OUTPUT AND SVR
2. atrial myxoma 3/ fatigue, fever, syncope, positional HEMODYNAMIC tx = ABC, IV hydration (class
3. atrial myxoma murmur, DIASTOLIC TUMOR PLOP MONITORING ARE II,III,IV) with crystalloid if
clinical pres BEST INDICATORS OF non-hemorrhagic
400. shock 1. lactic acidosis, anuria/oliguria, SHOCK STATUS
1. clinical altered mental status 406. septic shock 1. shock induced by sepsis
presentation 1. definition unresponsive to fluid
401. CO/SVR/PCWP 1. dec,inc, inc 2. patho resuscitation
for 2. dec, inc, dec 3. clinical pres 2. pneumonia, pyelo,
1. cardiogenic 3. dec, dec, dec 4. tx meningitis, abscess,
shock 4. inc, dec, dec cholangitis, cellulitis,
2. hypovolemic peritonitis --> SIRS--> sepsis --
3. neurogenic > septic shock --> multi organ
4. septic dysfunction syndrome
3. signs of SIRS, signs of
402. cardiogenic 1. post MI, tamponade, tension
shock, temperature, severe
shock pneumothorax, arrhythmias, massive
peripheral vasodilation,
1. patho PE, cardiomyopathy, valve defects, VSD
WARM FLUSHED SKIN
2. clinical pres --> CO too low to maintain tissue
4. IV abx, including fungal
3. dx perfusion
coverage, fluid administration,
2. BP <90, urine output <20 ml/hr, inc.
vasopressors
JVP, pale cool skin, hypotension,
pulmonary congestion 407. 1. SIRS 2 or more of
3. ECG - ST changes, 2. sepsis fever >38 or hypothermia <36
echo - see MI changes, valve defects etc. 2a. severe sepsis hyperventilation >20 bpm, or
swan ganz cath - PCWP (<18), CO (>4), 3. septic shock PaCO2<32
CI (>2.2), SVR 4. multiorgan Tachycardia >90
dysfunction Inc. WBC >12000 or <4000 or
403. cardiogenic 4. NO IV FLUIDS IF LEFT
>10% bands
shock VENTRICULAR PRESSURES ARE
2. positive blood cultures (2
4. tx ELEVATED
different sites) before abx
ABCs,
administration + SIRS
identify cause, aspirin and heparin,
2a. sepsis with organ
treat arrhythmias/tamponade
dysfunction, hypoperfusion or
dopamine -
hypotension
dobutamine -
3. hypotension induced by
norepinephrine, or phenylephrine
sepsis despite adequate volume
do not use nitroprusside/nitroglycerin
resuscitation
- diuretics
4. altered organ function in
IABP
acutely ill patient leading to
404. intra aortic decrease afterload, increase CO, death
balloon pumps decrease myocardial demand, increases
effects diastolic pressure (inc. coronary flow)
408. neurogenic 1. failure of nervous system ot maintain 418. dermatomyositis dermatomyositis is immune complex
shock adequate vascular tone - results from vs. polymyositis deposition
1. patho spinal cord injury, severe head injury, etiology
2. clinical pres spinal anesthesia, sympathetic blockade
419. polymyositis is T ...
3. tx --> peripheral vasodilation and decreased
cell mediated
SVR
2. warm skin, low UOP, 420. emphysema 1. alveolar wall destruction to to excess
bradycardia/hypotension 1. patho protease (from PMNs/macrophages), or
3. IV fluids, cautious use of lack of anti-protease enlargement of the
vasoconstrictors, trendelenburg position, air spaces distal to the terminal
control body temp bronchioles

409. COPD 1. chronic cough producing sputum for >3 421. causes of COPD tobacco smoke
1. chronic months for >2 years alpha 1 antitrypsin
bronchitis 2. excess mucus production narrows environment (2nd hand smoke)
diagnostic airways--> productive cough--> scarring chronic asthma
criteria of airways, enlargement of mucus glands, 422. how does increases number of activated
2. pathogenesis smooth muscle hyperplasia tobacco smoke PMNs/macrophages and also inhibits
410. diagnostic test schirmers test with anti-Ro antibodies cause alpha 1 antitrypsin
for sjogrens emphysema

411. DMARDs methotrexate, anti-TNFs, antimalarials, 423. centrilobular destruction limited to respiratory
sulfasalazine emphysema bronchioles (proximal to acini) usually
in upper lung zones]
412. other associated uveitis, other joint disease, crohns
*** centrilobular is seen in
conditions with
SMOKERS**
ank-spondy
424. panlobular destruction involves proximal and distal
413. 1. what are the gonorrhea,non-gonococcal urethritis,
emphysema acini in the lung bases
causes of reiters GI infections - yersinia, campylobacter,
**panlobular is seen in patients
syndrome salmonella, shigella
with alpha 1 antitrypsin
2. clinical pres 2. oligoarticular arthritis, conjunctivitis,
deficiency**
3. clinical urethritis, keratodermia
associations blennorrhagicum (looks like papular 425. COPD 1. cough, sputum production,
psoriasis), spondylitis 1. clinical progressively worsening DOE, full
3. HLA B27, presentation exhalation >6 seconds, end expiratory
2. PFT findings wheezes, hyperresonance,
414. Scleroderma systemicvasculopathy of small and
that defines 2. dec. FEV1 FEV1/FEV <0.70 (= airway
systemic medium-sized vessels, excessive collagen
COPD obstruction), increased TLC, inc FRC,
sclerosis, depositionin tissues, and an abnormal
inc. RV
immune system. It is an uncommon
multisystemdisease affecting women 426. key history in history of cardiopulmonary disease,
more often than men. There are two COPD patients smoking history
variants of scleroderma family history
occupation
415. polymyalgia 1. proximal joint stiffness worse in the
overall health
rheumatic morning associated with giant cell
history of respiratory infections
1. patho + arteritis (50% of patients with GCA have
pulmonary medications
clinical polymyalgia rheumatica),
symptoms- cough, dyspnea, sputum,
association
wheezing
416. radiological pencil in cup deformity @ DIP
427. pink puffer emphysema
finding of
thin (inc. work of breathing)
psoriatic
lean forward
arthritis
barrel chested
417. chondromalacia common problem in runners - pain is tachypnea with prolonged expiration
patellae worse when walking down stairs - lateral through pursed lips
displacement of the patella with knee accessory muscles
extension
428. blue bloater chronic bronchitis 438. 1. acute COPD 1. pulmonary infections --> persistent
overweight and cyanotic exacerbation increase in dyspnea not relieved with
chronic cough with sputum 2. tx bronchodilators, inc. sputum/cough,
can lead to acute respiratory failure
429. Obstructive/restrictive 1. low/normal or slightly low
2. CXR, bronchodilators, systemic
lung dz 2. low/normal or high
corticosteroids, azithro or levofloxacin,
1. FEV 3. low/normal
supplemental O2, positive pressure vent
2. FEV1/FVC 4. high/low,normal or high
(CPAP/BIPAP), mechanical vent
3. peak expiratory flow 5. high/low
4. residual volume 6. low/low 439. asthma 1. TRIAD - airway inflammation,
5. TLC 7. <350 L/min 1. definition airway hyper responsiveness and
6. VC 2. extrinsic vs airway obstruction
7. peak expiratory flow intrinsic 2. extrinsic = atopic - IgE produced to
3. clinical pres environmental antigens, eczema and
430. COPD CXR hyperinflation, flattened
hay fever.... intrinsic has no
diaphragm, enlarged retrosternal
environmental triggers
space, dec. pulmonary vascular
3. WORSE AT NIGHT* intermittent
markings
SOB, wheezing, chest tightness, cough
431. what is the best peak flow meter ~ if <350L/min
440. 1. signs of acute 1. tachypnea, diaphoresis, wheezing,
screening test for then proceed to PFTs
severe asthma speaking in incomplete sentences, use
COPD
attack (acute of accessory muscles (**indicates
432. clinical monitoring of serial FEV1 measurements asthma impending respiratory failure)
COPD patients pulse OX exacerbation 2. nebulized albuterol, oxygen, IV
exercise tolerance 2. treatment corticosteroids/taper, IV magnesium
433. functional residual ERV + RV 441. what are the asthma
capacity causes of CHF - 2/2 edema/congestion
434. treatment of COPD 1. smoking cessation wheezing (4) COPD - inflamed narrow airways
beta agonist - salmeterol cardiomyopathies - pericardial diseases
ipratropium - longer lasting causing edema
combo therapy Lung cancer- obstruction of the airways
inhaled steroids- slow FEV1 442. asthma 4. Peak flows*** - normal 450-
decline minimally, use with 4. dx 650L/min
bronchodilators mild >300, mod 100-300, sev <100
exacerbations - steroids, PFTs*** dec. FEV1, dec. FEV1/FVC, at
antibiotics least 12% of airflow obstruction is
theophylline reversible (inc. in FEV1 by 12% with
oxygen therapy bronchodilator),
vaccination - strep.pneumo every dec. in FEV1 >20% with methacholine
5 years or histamine
pulmonary physiotherapy CXR- only mild hyperinflation
BETA BLOCKERS ABGs - if in respiratory distress-
CONTRAINDICATED IN ACUTE hypocarbia (LOW PaCO2), hypoxemia
COPD AND ASTHMA
435. what is the risk of long pulmonary hypertension and cor
term hypoxemia pulmonale
436. criteria for long term PaO2 55mmHg
oxygen in COPD O2 sat <88%
patient PaO2 55-59+ polycythemia
Hct>55 or cor pulmonale
hypoxia during exercise or sleep
(nocturnal)
**in the context of optimal
medical therapy
437. >15 hours a day shows ...
survival benefit
443. classification/treatment 1. sx 2 or less times/week - 449. cystic fibrosis 1. AUTOSOMAL RECESSIVE - defect in
asthma albuterol rescue inhaler 1. patho chloride proteins causing impaired
1. mild intermittent 2. >2x/wk but not every day - 2. clinical pres chloride/water transport leading to thick
2. mild persistent albuterol + low dose inhaled 3. tx secretions of respiratory tract, exocrine
3. moderate persistent steroid pancreas, sweat glands, intestines, GU
3. daily sx, freq exacerbations - 2. obstructive lung disease, chronic
daily inhaled corticosteroid or pulmonary infections (pseudomonas),
cromoly, nedocromil, pancreatic insufficiency, GI
methylxanthine, or complications
antileukotriene 3. pancreatic enzyme replacement, fat
4. daily high dose inhaled soluble vitamin supplement (ADEK),
corticosteroid, long acting beta vaccinations (flu, pneumo), abx, inhaled
2 agonist, or methylxanthine rhDNase
and systemic steroids
450. lung cancer 1. small cell (25%)
444. side effects of inhaled sore throat, oral candidiasis, 1. types squamous, adeno, large cell,
corticosteroids hoarseness 2. risks bronchoalveolar (75%)
3. clinical pres 2. smoking - pack years, adeno has
445. what to order in a PEF - decreased
- tends to lowest association with smoking,
suspected acute asthma ABG - inc A-a gradient
present late asbestos, radon, COPD
exacerbation CXR - rule out
4. sites of mets 3. cough, hemoptysis, obstruction,
pneumonia/pneumothorax
wheezing, dyspnea, recurrent
446. asthma complications status asthmaticus (no response pneumonia, constitutional symptoms
to standard meds), 4. brain, bone, adrenals, liver
acute respiratory failure
451. lung cancer 1. facial fullness, facial/arm edema,
(respiratory muscle fatigue)
clinical dilated veins of anterior chest, JVD
pneumothorax, atelectasis,
syndromes 2. destruction of phrenic nerve by tumor
pneumomediastinum
1. SVC syndrome causes hemidiaphragm paralysis
447. aspirin sensitive seen in patients with asthma 2. phrenic nerve 3. due to involvement of recurrent
asthma and nasal polyps, asthma is palsy laryngeal nerve
exacerbated by aspirin 3. hoarseness 4. cervical sympathetic chain -
448. bronchiectasis 1. CF***, infection, humoral 4. horners anhidrosis, ptosis, miosis
1. patho immunodeficiency, airway syndrome 5. superior sulcus tumor involves C8-T2
2. clinical pres obstruction --> permanent 5. pancoast causes radiation down the arm
3. dx/tx dilation of bronchial wall, tumor
damaged cilia 452. 1. which type of 1. SCC
2. chronic cough with foul lung cancer 2. SCC
smelling mucopurulent purulent associated with 3. bronchoalveolar
sputum, dyspnea, hemoptysis, airway
recurrent pneumonia involvement
3. high res CT, obstructive PFTs, 2. what kind of
abnl CXR, bronchoscopy lung cancer
tx = abx for exacerbations, associated with
hydration, chest physiotherapy, pancoast tumor
bronchodilators 3. which type of
lung cancer seen
in women, non-
smokers
453. paraneoplastic 1. SIADH, ectopic ACTH, hypertrophic
syndromes pulmonary osteoarthropathy, eaton
1. small cell lambert - similar to myasthenia gravis
2. squamous cell 2. PTHrp, hypertrophic osteoarthropathy
3. 3. hypertrophic osteoarthropathy
adenocarcinoma
454. lung cancer 1. CXR (stable >2 years = 459. mediastinal mass 1. mets, usually lung
1. dx BENIGN) NOT A SCREENING 1. MCC in older 2. thyroid, teratogenic tumors,
TEST patients thymoma, lymphoma
CT CHEST WITH CONTRAST 2. ant. mediastinal 3. lung cancer, lymphoma, aneurysms,
- useful for staging masses bronchogenic cysts, morgagni hernia,
sputum cytology - only 3. middle pericardial cysts
diagnoses central tumors mediastinal 4. neurogenic tumors, esophageal
fiberoptic bronchoscope w/ bx masses masses, enteric cysts, aneurysms,
- only diagnoses central 4. posterior bochdalek hernia
tumors mediastinal 5. cough, chest pain, dyspnea,
whole body PET scan - detects masses dysphagia, SVC syndrome, hoarseness
lymph node, thoracic, distant 5. symptoms of (RLN), horners (sympathetic ganglia),
metastasis mediastinal diaphragm paralysis (phrenic)
thoracic needle biopsy masses 6. CT scan
mediastinoscopy - identifies 6. dx
advanced disease and rules out
460. 1. transudative vs 1. transudative - elevated capillary
surgery as treatment
exudative pleural pressure in visceral or parietal pleura
455. lung cancer 1. NSCLC - surgery + radiation effusions or dec. plasma oncotic pressure
1. tx adjuvant 2. causes of """" exudative - increased permeability of
SCLC - chemotherapy and pleural surfaces
radiation, non-surgical 2. transudative - CHF, cirrhosis,
nephrotic syndrome, peritoneal
456. solitary pulmonary 1. granuloma, hamartoma,
dialysis, hypoalbuminemia, PE,
nodule adenoma, carcinoma
atelectasis
1. possible causes 2. age <50, non-smoker,
exudative - bacterial pneumonia, TB,
2. features favoring <1cm, smooth borders, central
malig, metastasis, viral infection, PE,
benign calcification, no change in
collagen vascular disease
3. feature favoring size
malignant 3. age >50 (50%), smoker, size 461. 1. what tests 1. differential cell count, glucose, pH,
- page 80- algorithm > 2cm, should be amylase, triglycerides, microbiology,
performed on an cytology
457. 1. radiographic features 1. central location, cavitary
exudative pleural 2. plerual protein:serum protein >0.5
of SCC lung cancer 2. peripheral location, plerual,
effusion pleural LDH: serum LDH >0.6
2. """""" less associated with smoking
2. lab findings that LDH > 2/3 upper limit of normal
adenocarcinoma 3. peripheral
distinguish
3. """""" large cell 4. central, extrinsically
exudative vs
4. """""" small cell compresses bronchi
transudative
458. 1. management for a SPN 1. serial CT scan effusion
that is at new, or has 2. PET scan
changed within 2 years
2. """ 1cm or larger that
has changed or is new or
films are not available
462. pleural 1. CXR - blunting of costophrenic angle 468. pneumothorax 1. traumatic (transthoracic needle
effusion (~250ml) lateral decubitus better than PA and 1. patho aspiration, thoracentesis, central line), or
1. dx lateral 2.secondary spontaneous (subpleural blebs) --> air in
2. tx CT scan is most reliable pneumothorax normally airless pleural space
thoracentesis (only if >10 mm deep on lateral 3. clinical pres 2. complication of COPD, asthma,
decubitus, complication = PTX ) --> SEND 4. dx/tx interstitial lung disease, neoplasms, CF,
FLUID TO BE TESTED FOR THE 4 C'S - TB
chemistry (glucose, pH, LDH, protein), 3. ipsilateral chest pain, dyspnea, cough,
cytology, cell count, culture (and gram stain) dec. breath sounds, hyperresonance, dec.
2. transudative - diuretics, sodium restriction , tactile fremitus, mediastinal shift toward
therapeutic thoracentesis if massive /dyspnea PTX****
exudative - treat underlying disease 4. CXR - visceral pleural line
parapneumonic - abx, chest tube, intrapleural tx = small just observe
thrombolytics, surgical lysis large or with symptoms - administer
oxygen and place a chest tube
463. special 1. esophageal rupture, pancreatitis,
pleural malignancy 469. fibromyalgia 1. diffuse musculoskeletal pain (WITHOUT
effusions 2. chylothorax 1. clinical pres weakness), worsens with exercise,fatigue,
1. elevated 3. empyema 2. dx non-restorative sleep, absence of joint
amylase 4. malignancy swelling
2. milky 5. TB 2. 11/18 tender point sites,
opalescent 6. parapneumonic effusion or empyema
470. tension 1. mechanical ventilation, CPR, trauma -->
3. frankly
pneumothorax air accumulate in pleural space through
purulent
1. patho opening that acts as a valve leads to
4. bloody
2. clinical pres collapse of ipsilateral lung and medi
5.
3. dx/tx 2. hypotension, distended neck veins,
lymphocytic
tracheal shift away from PTX, dec. breath
6. pH <7.2
sounds on affected side, hyperresonance to
464. what does ... percussion on affected side
low glucose 3. dx- DO NOT DO CXR IF SUSPECTED ,
in a pleural decompress via large bore cx tube
effusion
471. malignant asbestos exposure
indicate
mesothelioma
465. what does exudative effusion- rheumatoid arthritis, TB, clinical
low pH esophageal rupture, malignancy, lupus association
pleural
472. define inflammatory process of the alveolar wall
effusion
interstitial with widespread fibroelastic
indicate
lung disease proliferation/collagen deposition that can
466. empyema*** ... lead to irreversible lung damage
must place
473. what drugs are chemotherapeutics, amiodarone,
chest tube
known to be penicillamine, nitrofurantoin, bleomycin,
467. empyema 1. complicated bacterial pneumonia, exudative toxic to the phenytoin
1. patho pleural effusion --> empyema (pus) (ie. a lungs
2. tx complicated parapneumonic effusion)
474. end stage honeycomb lung
2. thoracentesis, abx, rib resection/open
interstitial
drainage
lung disease is
referred to as
475. sarcoidosis 1. chronic systemic NONCASEATING 480. wegeners 1. necrotizing granulomatous
1. patho GRANULOMAS of unknown etiology (more granulomatosis vasculitis affects lungs/upper
2. clinical common in AA women <40years old 1. patho airway**, kidneys, and other organs
pres 2. constitutional symptoms, dry cough, 2. clinical pres 2. upper and lower respiratory
erythema nodosum (painful skin lesions on 3. dx/tx infections, glomerulonephritis,
shins), DOE, erythema nodosum, plaques, pulmonary nodules, skin findings -
subQ nodules, anterior uveitis, arrhythmias, subQ nod, purpura, pyoderma
conduction defects, sudden death, arthritis, , gangrenosum
bone lesions, bells palsy, optic nerve 3. tissue biopsy positive for C-
dysfunction, papilledema, hepatomegaly ANCA*** ~ anti proteinase 3
tx = glucocorticoids +
476. sarcoidosis 1. CXR - bilateral hilar adenopathy (4 stages)
cyclophosphamide
1. dx skin anergy
2. PFTs elevated ACE 481. churg strauss 1. granulomatous vasculitis in asthma
3. tx hypercalcemia*, hypercalciuria syndrome patients,
elevated vitamin D (granuloma activates 25 -- 1. patho 2. pulmonary infiltrates, rash,
> 1,25D3) 2. clinical pres eosinophilia
low PTH 3. dx/tx 3. CBC - eosinophilia
**transbronchial biopsy showed p-ANCA (myeloperoxidase positive
noncaseating granulomas** tissue biopsy
2. dec lung volumes (VC and TLC), dec. tx = systemic glucocorticoids
DLCO, dec. FEV1/FVC
482. coal workers inhalation of coal dust with carbon
3. spontaneously improve in 2 years
pneumoconiosis and silica can progress to fibrosis of
systemic corticosteroids,
the lungs
methotrexate
483. substances that silica, berylium, asbestos, coal dust,
477. classic constitutional symptoms
cause graphite,carbon, aluminum, talc
clinical respiratory complaints
pneumoconiosis
presentation erythema nodosum
for blurred vision 484. asbestosis 1. diffuse interstitial lung fibrosis of
sarcoidosis bilateral hilar adenopathy 1. patho the LOWER LOBES
2. complications 2. bronchogenic carcinoma,
478. CXR staging stage 1 - bilateral hilar adenopathy without
3. dx/tx malignant mesothelioma
of parenchymal infiltrates
3. CXR shows pleural plaques and
sarcoidosis stage 2 - hilar adenopathy with parenchymal
hazy infiltrates with linear opacities
infiltrates
stage 3 - diffuse parenchymal infiltrates 485. CXR findings for asbestosis - pleural plaques
without hilar adenopathy asbestosis/silicosis silicosis - egg shell calcifications
stage 4 - pulmonary fibrosis with 486. silicosis UPPER LOBES nodular, localized
honeycombing and fibrocystic parenchymal 1. patho peribronchial fibrosis
changes 2. clinical pres 2. DOE, cough with sputum
479. histiocytosis 1. chronic interstitial pneumonia caused by 3. dx 3. CXR, restrictive PFTs
x proliferation of histiocytes 90% are cigarette 487. diagnosis of beryllium lymphocyte proliferation
1 patho smokers berylliosis test
2. clinical 2. dyspnea and nonproductive cough, lytic
488. hypersensitivity 1. inhalation of organic dusts,
pres bone lesions, spontaneous pneumothorax,
pneumonitis thermophilic actinomycetes, fungi,
3. dx/tx diabetes insipidus
1. patho avian proteins--> serum IgG/IgA -->
3. CXR shows honeycomb with cystic lesions,
2. causes flu like features
reticulonodular appearance
3. clinical pres 2. farmers lungs (moldy hay), bird
tx = corticosteroids or lung transplant
4. dx / tx breeders lung (avian droppings), air
conditioner lung, bagassosis,
mushroom worker's lung
3. cough, dyspnea, fever, chills,
myalgia 4-8 hours after exposure
4. IgG antibody to offending antigen
tx = steroids*****, and avoidance--
bronchodilators/antihistamines are
INEFFECTIVE
489. eosinophilic 1. fever, peripheral eosinophilia, CXR with 496. ventilatory 1. hypercapnia**** and hypoxemia
pneumonia peripheral pulmonary infiltrates respiratory 2. dec. minute ventilation or inc. dead
1. dx 2. systemic glucocorticoids failure space leads to CO2
2. tx 1. definition retention/hypoxemia
2. causes ex. CNS depression, mechanical
490. goodpasture's 1. IgG anti-GBM and alveolar basement
restriction, respiratory fatigue, COPD,
syndrome membrane -->
asthma CF, severe bronchitis
1. patho pneumonitis/glomerulonephritis
2. clinical pres 2. hemoptysis, dyspnea, hematuria 497. how to change a ventilation - PaCO2- inc. RR or tidal
3. dx/tx 3. tissue biopsy, IgG anti GBM patient's volume (minute ventilation = RR*TV)
tx = plasmapheresis*, cyclophosphamide, ventilation vs oxygenation - PaO2 - inc FiO2 or inc
corticosteroids oxygenation PEEP
491. pulmonary 1. accumulation of surfactant and 498. two causes of 1. hypoxia without hypercapnia, seen in
alveolar phospholipids in alveoli respiratory chronic lung disorders, RESPONSIVE
proteinosis 2. dry cough, dyspnea, hypoxia, rales failure TO OXYGEN
1. patho 3. CXR - ground glass, bilateral alveolar 1. VQ mismatch 2. no ventilation in perfused areas,
2. clinical pres infiltrates resembling a bat 2. venous blood shunted into arterial
3. dx/tx lung biopsy *** intrapulmonary circulation without oxygenation - ex.
tx= lung lavage, GCSF, dont give steroids shunting atelectasis, pneumonia, pulmonary
edema, NOT RESPONSIVE TO
492. idiopathic 1. gradual onset dyspnea, non-productive
OXYGEN
pulmonary cough
fibrosis 2. CXR - normal or honeycomb 499. what are causes sepsis, DKA, hyperthermia
1. patho lung biopsy*** of inc. CO2
2. dx PFTs - restrictive lung pattern (dec. TLC, production
FEV1/FVC normal, dec. FEV1, dec. FVC) leading to
tx = supplemental O2, corticosteroids with hypercapnic
and without cyclophosphamide, lung respiratory
transplantation failure
493. cryptogenic 1. virus/meds/connective tissue disease -- 500. clinical pres. of dyspnea, cough, inability to speak in
organizing > inflammatory lung disease that presents respiratory complete sentence, use of accessory
pneumonitis similar to pneumonia failure muscles, tachypnea, tachycardia,
1. patho 2. CXR similar to pneumonia, abx cyanosis, impaired mentation
2. dx ineffective
501. evaluation of get ABG
tx = corticosteroids
hypoxemic look at PaCO2 elevated or not
494. radiation 1. thoracic radiation --> interstitial patient look at A-a gradient
pneumonitis pulmonary inflammation--> 2 years later Pg 96 - evaluation look at response to oxygen
1 patho alveolar thickening, pulmonary fibrosis of hypoxic 1. if PaCO2 is elevated and A-a is
2. low grade fever, cough, chest fullness, patient normal = hypoventilation
dyspnea, pleuritic chest pain, hemoptysis 2. if PaCO2 is elevated and A-a is
3. normal CXR elevated = hypoventilation + another
CT scan - diffuse infiltrates, ground glass factor
densities, patchy consolidation, 3. if PaCO2 is normal, and A-a is
pericardial/pleural effusions normal = low inspired PAO2
tx = corticosteroids 4. if PaCO2 is normal, A-a increased,
and response to supp O2 = VQ
495. respiratory 1. PaO2 <60, and PaCO2>50
mismatch
failure 2. low PaO2 with PaCO2 either low to
5. if PaCO2 is normal, A-a increased,
1. hypoxia normal O2 saturation <90% with FiO2 >
no response to supp O2 = shunt
definition 0.6
2. hypoxemic 3. V/Q mismatch, intrapulmonary 502. treatment for treat underlying cause - ex.
respiratory shunting respiratory bronchodilators, corticosteroids, abx
failure ex. ARDS, pneumonia, pulmonary edema , failure provide supplemental oxygen at lowest
definition possible concentration
3. causes of NPPV for conscious patients with
hypoxemic possible impending respiratory failure
respiratory
failure
503. ways to inc. FiO2, inc. PEEP, inc. inspiratory time 510. ventilator settings 1. no volume breaths delivered,
improve fraction, inc. CO, inc. hemoglobin, remove 1. CPAP useful for weaning
tissue venodilators 2. pressure support 2. pressure is delivered with an
oxygenation ventilation initiated breath , enhances patients
respiratory efforts
504. NPPV 1. attempt to avoid intubation in patient
1. indications with impending respiratory failure 511. ventilator 1. 8-10ml/kg at 10-12 breaths per
2. 2. patient must be neurologically intact, 1. tidal volume minute, adjust to achieve patients
requirements awake and cooperative /minute ventilation baseline PaCO2
2. FiO2 setting 2. initially 100%, then titrate to
505. ARDS 1. bilateral inflammatory lung processes -->
3. I:E ratio lowest FiO2 to maintain PaO2 50-
1. patho inc. alveolar capillary permeability-->
4. PEEP settings 60 (>90% sat)
2. causes massive intrapulmonary shunting
If FiO2 0.5 is not adequate, add
(atelectasis, surfactant dysfunction)/no
PEEP to allow for lowering of FiO2
improvement with supplemental O2, dec.
3. 1:2 is the usual ration
pulmonary compliance, inc. dead space,
4. 2.5-10 cm H2O, prevents
inc. A-a gradient.
atelectasis,
2. sepsis***(pneumonia, urosepsis, wounds
etc), aspiration, severe trauma, pancreatitis, 512. extubation criteria 1. intact cough with secretion
massive transfusions, near drowning, suction, adequate respiratory drive
intracranial HTN PaO2 >75, PaCO2 <45
O2 sat >90 on PEEP of 5cm H2O
506. ARDS 1. dyspnea, tachypnea, tachycardia,
and FiO2 <40-50%
1. clinical pres hypoxemia
TV > 5ml/kg
2. dx hypoxemia unresponsive to oxygen
RR<30 breaths/min
3. tx PaO2/FiO2 <200
vital capacity - 10-15ml
2. CXR - bilateral* pulmonary infiltrates
PaO2/FiO2<200, PCWP <18 513. drugs used to nitric oxide, intravenous adenosine,
ABG- PaO2 <60, initially PaCO2 low, then diagnose pulmonary IV prostacyclin
PaCO2 high with inc. work of breathing hypertension
Pulmonary catheter - PCWP<18
514. what is the function inc. PaO2 at a constant FiO2
3. oxygenation, mechanical ventilation with
of PEEP and CPAP on
PEEP, lower intravascular volume to PCWP
mechanical
of 12-15 mmHg, vasopressors as needed
ventilation
507. complications scarring, honeycombing, barotrauma 2/2
515. what ventilator FiO2 >0.6 for 2-3 days
of ARDS mechanical ventilation,, PTX,
settings associated
pneumomediastinum, line infections, ileus,
with oxygen toxicity
stress ulcer, multiorgan failure, critical
illness myopathy 516. pulmonary 1. pulmonary arterial pressure
hypertension >25mmHg at rest or >30 during
508. mechanical 1. significant respiratory distress, impaired
1. definition exercise
ventilation LOC with lack of airway protection,
2. passive type 2. resistance to pulmonary venous
1. indications respiratory muscle fatigue
3. hyperkinetic type drainage - ex. mitral stenosis, LVF,
2. goals hypoxemia - PaO2 <70
4. obliterative myxoma
hypercapnia - PaCO2 >50
3. high pulmonary blood flow - ex.
2. PaO2 - between 50 and 60
left ot right shunts, ex.
PaCO2 - between 40 and 50
VSD,ASD,PDA
pH between 7.35-7.5
4. obliterative type - resistance from
509. ventilator 1. guarantees a preset minute ventilation-- destruction of small pulmonary
settings breath delivered when patient initiates, if vessels - ex. PPH, collagen disease,
1.assisted patient does not initiate ventilator takes CREST
controlled control, every breath over the determined
2. rate delivers the same tidal volume
synchronous 2. patients breathe on their own above set
intermittent mandatory rate* (volume is not determined)
mandatory without ventilator assistance or set volume,
ventilation if no breath initiated, ventilator will
determine breath
517. pulmonary 1. resistance to flow through large pulm 521. cor 1. COPD, PE, ILD, asthma, CF, sleep apnea,
hypertension arteries pulmonale PPH --> right ventricular
1. obstructive 2. hypoxia induced vasoconstriction - 1. patho hypertrophy/failure
type ex. chronic hypoxemia, COPD, 2. clinical 2. signs of RV failure, cyanosis, clubbing
2. obstructive sleep apnea pres 3. treat underlying disorder, USE
vasoconstrictive 3. inc. pressure to pulm vasculature - ex. 3. dx/tx DIURETICS CAUTIOUSLY THESE
type PEEP, COPD PATIENTS ARE PRELOAD DEPENDENT,
3. increased long term O2 therapy, digoxin for LV
intrathoracic failure,
pressure
522. how does PE hypoxemic respiratory failure
- inc. blood
cause death acute pulmonary hypertension and RV
viscosity
failure
*or classify by
post capillary, 523. pulmonary DVT
emboli fat embolism
518. complications of anxiety, sedation/discomfort (tx =
sources amniotic embolism
mechanical benzo, opioid, propofol)
air embolism
ventilation tracheal secretions - tx= suction
septic embolism (IVDU)
nosocomial pneumonia
schistosomiasis
barotrauma
oxygen toxicity 524. PE 1. thrombus from other region of the body
hypotension 1. patho embolizes to the pulmonary vascular tree -->
tracheomalacia - switch to 2. DVT dead space, inc PulmVR- acute cor
tracheostomy after 2 weeks sources pulmonale
laryngeal damage, 3. 2. deep veins of the lower extremities and
complications pelvis
519. pulmonary 1. DOE, fatigue, CX pain, syncope on
4. risk factors 3. recurrent PE, pulmonary HTN (66%)
hypertension exertion (50%)***, loud P2, JVD,
4. age >60, malig, hx of DVT/PE, hereditary
1. clinical pres hepatomegaly, peripheral edema (with
hypercoagulability, cardiac diseease,
2. dx heart failure later)
obesity, nephrotic syndrome, pelvic/ortho
2. RVH with RAD
surg, major trauma, pregnancy, estrogen
Echo- dilated pulmonary artery with
use
RA/RV hypertrophy
abnormal IV septum movement 525. two The PIOPED study, the Christopher study
cardiac cath - shows elevated important PE
pulmonary artery pressures studeies

520. PPH 1. abnormal pulmonary arteriolar 526. clinical dyspne, altered mental status, petechiae
1. patho resistance --> thickening of arteriolar presentation over the chest
2. dx/tx walls, most common in middle age of fat
-exertional women embolism
syncope common 2. cardiac cath*** 527. PE clincal dyspnea ***, pleuritic chest pain, cough,
- presents late, CXR - enlarged central pulmonary pres hemoptysis, sycope, S3/S4, inc. P2
very poor arteries, enlarged RV, clear lung fields PE mortality tachypnea, SOB - due to inc. dead space-->
prognosis only 2- PFT - restrictive pattern hypoxemia/hypercarbia
3 year survival ECG - right axis deviation 30% mortality, 10% if diagnosed within 1
tx = IV prostacyclins, CCBs (nifedipine hour,
or diltiazem), if untreated 30% will die from recurrent PE
nitric oxide/adenosine/CCB trials treatment reduces mortality to 2-8%
anticoag with warfarin
528. PE 1. ABG - low PaO2, low PaCO2, high pH 536. 1. aspiration 1. initially asymptomatic, then
1. dx elevated A-a gradient* pneumonia clinical cough, SOB, fever, tachypnea,
2. how to rule CT scan - intraluminal filling defects in pres hypoxemia, frothy sputum
out PE central/segmental or lobar pulmonary 2. dx 2. CXR similar to bacterial
3. what arteries 3. tx pneumonia, atelectasis,
patients Pulmonary angiogram**** definitive dx collapsed areas
cannot have D-dimer - 3. ABCs, clindamycin, early
spiral CT 2. negative pulmonary angiogram, bronchoscopy for obstruction,
negative D-dimer assay, low prob VQ scan
537. how to prevent keep head of bed elevated, NG
3. patients with renal failure due to the IV
aspiration pneumonia tube
contrast
538. dyspnea 1. acute vs chronic, heart/lung
529. PE 1. atelectasis, or pleural effusion,
1. key history disease, baseline level of activity,
1. CXR findings westermark's sign (prom central pulm
2. most common causes exertional component, smoking,
2. negative CT- artery with local oligemia), hampton's
sputum
A but high hump (lung infarction)
2. CHF exacerbation,
clinical 2. 5%
pneumonia, bronchospasm, PE,
suspicion= 3. supplemental O2, anticoag (START
anxiety
what prob of IMMEDIATELY with heparin and
PE warfarin), continue for 3-6 months 539. dyspnea 1. CHF, ischemia,
3. tx thrombolytics - TPA, streptokinase 1. cardiovascular pericarditis/tamponade,
IVC filter causes arrhythmias, valve disease,
2. respiratory causes congenital
530. complications higher risk for DVT
3. psychiatric causes 2. COPD, asthma, PE, ARDS,
associated perforation of the IVC wall
4. chest wall causes pneumonia, TB, bronchitis,
with IVC filters IVC obstruction
5. neuromuscular pleural effusion, pulmonary
531. indications for contraindication for anticoagulation causes edema, PTX, airway obstruction,
IVC filters complication of current anticoagulation 6. systemic causes ILD
failure of adequate anti-coagulation 3. GAD, panic attacks,
low pulmonary reserve at high risk for PE hyperventilation
4. kyphoscoliosis, rib fractures,
532. wells criteria symptoms/signs of DVT - 3
ank spondy
for acute PE alt diagnosis less likely than PE - 3
5. myasthenia , muscular
HR > 100 bpm - 1.5
dystrophy
immobilization >3 days or surgery in
6. chronic anemia, sepsis, DKA,
previous 4 weeks - 1.5
GERD, narcotics
previous DVT or PE - 1.5
hemoptysis - 1.0 540. dyspnea 1. pulse ox - COPD may be
malignancy - 1.0 1. dx chronically low
ABG - indicated if pulse ox is low
533. if <4 - get D- ...
CXR - can show etiology
dimer
CBC - anemia, infection
if >4 get spiral
ECG - ventricular
CT scan
hypertrophy/ischemia
534. pulmonary 1. lower portions of the right upper lobe Echo- further eval
aspiration upper portions of hte right lower lobe VQ scan, bronchoscopy
1. anatomic 2. symptoms of pneumonia 2-4 days after
541. what are the lung aspiration/pneumonia
location aspiration (in 40% of patients who
complications of
2. clinical aspirate)
aspiration
presentation 3. reduced LOC, alcoholism, extubation,
3. excessive vomiting, ileus, tracheostomy, 542. what lab/studies used CXR, sputum gram stain, PFT,
predisposing anesthesia/surgery, NMJ diseases, to distinguish between ABG, ECG, echocardiogram
factors esophageal disorders (achalasia, GERD, lung/heart disease
cancer)
543. what will a chronic baseline - normal pH, elevated
535. what is the recurrent MI, antiphospholipid antibody COPD patient's blood HCO3-
indication for syndrome gas show at baseline exacerbation - low pH, normal
an INR 2.5-3.5 and during HCO3-
exacerbation
544. hemoptysis 1. >600 ml in 24 hours- 553. colorectal 1. FOBT (PPV 20%), DRE (10% palpable),
1. massive hemoptysis bronchiectasis ,and bleeding cancer colonoscopy, flexible sigmoidoscopy (2/3
definition + most diathesis 1. screening colon cancer) barium enema
common causes 2. bronchitis, TB, bronchiectasis, 2. staging 2. CT scan of chest, abdomen, pelvis
2. causes pneumonia, idiopathic, good 3. 3. CEA -
3. dx pastures, PE with infarction, recurrence 4. direct extension, portal systme to liver,
aspergilloma, mitral stenosis, surveilance lymphatic
hemophilia. 4. methos of
3. CXR - may show fungus ball, spread of
mass, granuloma, opacity CRC
fiberoptic bronchoscopy - if
554. colorectal age >50
suspicious for lung carcinoma
cancer risk adenomatous polyps
CT chest -
factors IBD - UC 20% at 30 years of age
545. indication for home O2 saturation <88% family history (first degree relatives
oxygen
555. CRC 1. tubular, tubulovillous, villous (worst)
546. acidosis expected 10 mmHg change in PaCO2 expect 1. 2. sessile, pedunculated
changes for 0.08 change in pH histological
respiratory/metabolic classes
on ABG 2.
morphology
547. what is normal PaO2 90 in a 20 year old person
types
what is the risk of will decrease
taking an ABG 556. FAP autosomal dominant APC mutation leads to
hundreds of adenomatous polyps in the colon,
548. radial artery spasm ...
and duodenum (90%), as well as stomach,
which can result in
jejunum, ileum
ischemia of the hand
tx = prophylactic colectomy
549. what is spirometry obstructive vs restrictive lung
557. gardners colon polyps, osteomas, dental abnormalities,
useful to evaluate disease
syndrome soft tissue tumors, desmoid tumors, sebaceous
what is DLCO useful degree of functional impairment
cysts, epidermoid inclusion cysts
to evaluate
what conditions have 558. turoct's AUTOSOMAL RECESSIVE
high vs low DLCO syndrome colon polyps, cerebellar medulloblastoma,
GBM
550. asthma vs COPD, ...
monitoring of 559. peutz hamartomas of entire GI tract - small bowel,
sarcoidosis and jeghers colon, stomach
emphysema pigmented spots of the face, lips, oral
mucosae, face, genitalia , palmar surfaces
551. High - asthma, ...
inc. incidence of stomach, ovary, breast,
obesity, left to right
cervix, lung cancer
shunt, exercise,
intussusception
pulmonary
hemorrhage 560. familial many juvenile polyps, low risk of CRC
Low - emphysema, juvenile
sarcoid, fibrosis, polyposis
pulmonary vascular coli
disease, anemia
561. HNPCC 1. early onset CRC, absence of antecedent
552. hemoptysis CXR, fiberoptic bronchoscopy, CT 1. lynch 1 multiple polyposis
evaluation chest 2. lynch 1 + early onset of other cancers -
female (endometrial 43%/ovarian) skin,
stomach, pancreas, brain, breast biliary
562. CRC 1. abdominal pain, large bowel 571. what is the NOT indicated for colon cancer
1. clinical obstruction, weight loss, blood in stool indication for radiation IS indicated for rectal cancer
presentation 2. no obstruction (large diameter), radiation in CRC
2. right sided melena, occult blood, IDA, change in
572. where are most in the rectosigmoid junction
clinical pres bowel habits, RLQ mass
colonic polyps most common symptom is painless
3. left sided 3. obstruction, hematochezia, change
found rectal bleeding
clinical pres in caliber of stools (pencil)
+ most common
4. rectal clinical 4. hematochezia, tenesmus, rectal
symptoms of
pres mass/feeling of incomplete evacuation
colonic polyps
563. what fraction of 20%
573. diverticulitis 1. CT abdomen with oral/IV contrast
CRC patients are
1. dx Ab XR - rules out ileus or obstruction (air
metastatic at
2. tx fluid levels), and perforation (free air)
clinical
BARIUM ENEMA/COLONOSCOPY
presentation
ARE CONTRAINDICATED
564. CRC 1. surgical resection of tumor and 2. IV abx (7-10 days) cipro/flagyl, bowel
1. tx regional lymphatics, pre-op CEA, post rest, NPO, IVF
2. follow up op chemo/radiation surgery if persists 3-4 days or
2. stool guaiac complicated
annual CT scan of pelvis + CXR for 5
574. angiodysplasia 1. tortuous submucosal vein in the colon
years
1. patho + --> bleeding, 15% massive bleeding
colonoscopy at 1 year and then every 3
clinical pres 2. colonoscopy (better than
years
2. dx/tx angiography)
CEA every 3-6 months
3. key clinical tx= 90% stops bleeding spontaneously,
565. non-neoplastic hyperplastic polyps, juvenile polyps association right hemicolectomy if persistent
polyps (remove), inflammatory polyps (UC) (non-GI) bleeding
3. AORTIC STENOSIS
566. adenomatous benign lesions with significant
polyps malignant potential (villous 575. acute mesenteric 1. arterial embolism (cardiac - afib, MI,
+ histology, size, >tubulovillous > tubular), (large > ischemia valves),
typia, and small), (atypia > no atypia), (sessile 1. patho (4) arterial thrombosis (atherosclerosis,
morphology >pedunculated) 2. mortality may be 2/2 dec. CO from MI),
non-occlusive (splanchnic
567. Diverticulosis 1. low fiber/constipation --> inner
vasoconstriction in critically ill/elderly),
1. patho colon bulges through weakness
venous thrombosis
2. clinical pres 2. asymptomatic or incidental finding,
(infection/hypercoagulable, portal HTN,
3. dx/tx LLQ pain, bloating,
malig, pancreatitis)
constipation/diarrhea
2. 60-70%, 90% if bowel infarction
3. barium enema
tx = high fiber foods, psyllium 576. acute mesenteric 1. abdominal pain disproportionate to
ischemia physical findings, anorexia, GI bleeding,
568. diverticulosis 1. painless rectal bleeding (5% is
1. clinical pres sepsis, shock, peritonitis
1. complications severe), diverticulitis
2. dx/tx 2. mesenteric angiography**, SERUM
569. diverticulitis 1. impacted feces in a diverticulum LACTATE***
1. patho leads to erosion/microperforation plain film abdomen (rule out other
2. clinical pres 2. LLQ pain, leukocytosis, altered causes
3. complications bowel habits, lower GI bleeding RARE thumbprinting on barium enema
4. recurrence rate (compare to diverticulosis) (edematous mucosal folds)
3. abscess, colovesical fistula, tx = IVF, broad spectrum ABX
obstruction, colonic papaverine vasodilator into SMA
perforation(peritonitis) thrombolytics/embolectomy
4. 30% of medically treated patients at heparin (for venous thrombosis)
5 years surgery - for non-viable bowel if
570. what is worse, rectal has higher recurrence rate, lower peritonitis symptoms
rectal cancer, or 5 year survival AVOID VASOPRESSORS - WORSEN
colon cancer ISCHEMIA
577. chronic 1. atherosclerotic occlusion of main 585. pseudomembranous 1. abx treatment kills normal flora
mesenteric mesenteric vessels colitis (antibiotic that inhibit growth of c.diff --> c.diff
ischemia 2. progressive *postprandial abdominal resistant colitis) overgrowth/toxin formation
1. patho angina, weight loss 1. patho 2. clindamycin, cephalosporins,
2. clinical pres 3. mesenteric angiography 2. most common abx ampicillins (but all abx can cause)
3. dx/tx tx = surgical revascularization associated 3. sx in the first week of abx
3. clinical pres treatment (or later) --> profuse
578. ogilvie's 1. SIGNS/SYMPTOMS/RADIOGRAPH
4. compliations watery diarrhea, crampy abdominal
syndrome of large bowel obstruction without
pain, toxic megacolon (risk of perf)
1. patho mechanical obstruction
4. toxic megacolon, colonic
2. causes 2. recent surgery/trauma, serious
perforation, anasarca
3 dx/tx medical illness, meds (narcotics,
psychotropics, anticholinergics) 586. pseudomembranous 1. c.diff stool antigen***
3. diagnosis of exclusion after colitis flexible sigmoidoscopy - shows
mechanical obstruction ruled out 1. dx/tx pseudomembrane
tx = stop offending agents, IV fluids, abdominal XR - rule out megacolon
electrolyte, decompression with tx = stop offending antibiotic
enemas/NG suction, surgical metronidazole, oral vanc if resistant
decompression (with recurrence in 2-8 weeks in 35%
cecostomy/colostomy)
587. colonic volvulus 1. twisting of intestine loop around
579. diagnostic test of diverticulosis - barium enema 1. patho mesenteric attachment site causes
choice for diverticulitis - CT scan with oral/IV 2. locations obstruction and vascular
diverticulosis vs contrast 3. risk factors compromise, necrosis, perforation
diverticulitis 4. clinical pres 2. sigmoid 75%, colonic 25%
3. chronic illness, inc. age,
580. comorbid aortic stenosis
institutionalization, CNS disease,
condition with
chronic constipation, laxative
AVM
abuse, anti-motility drugs
581. comorbid heart disease - CHF, coronary disease 4. acute colicky abdominal pain,
conditions with distension, obstipation, n/v
acute mesenteric
588. cecal volvulus congenital lack of fixation of the
ischemia
pathogenesis right colon in younger patients
582. clinical 1. sudden onset, more painful
589. colonic volvulus 1. Ab XR - sigmoid volvulus - omega
presentation of 2. more gradual and less severe than
1. dx loop sign
acute mesenteric embolic
cecal volvulus - coffee bean sign -
ischemia 3. occurs in critically ill patients
large air fluid level in RLQ
1. embolic 4. symptoms for days or weeks
sigmoidoscopy -
2. arterial
diagnostic/therapeutic for sigmoid
thrombosis
volvulus
3. nonocclusive
barium enema (don't do if suspect
ischemia
strangulation) - shows narrowing at
4. venous
twist = bird beak
thrombosis
tx = sigmoidoscopic decompression
583. signs of hypotension, tachypnea, lactic acidosis (sigmoid)
intestinal *****, altered mental status emergency surgery (cecal)
infarction
584. when should when the colon diameter exceeds 10cm -
colonic - RISK FOR RUPTURE AND DEATH
distension be
immediately
decompressed
590. cirrhosis 1. fibrotic replacement of normal liver 594. hepatic 1. ammonia + other toxic metabolites
1. patho architecture --> encephalopathy accumulate
2. causes decreased hepatic blood flow (portal 1. patho TRIGGERED BY alkalosis, hypokalemia,
hypertension) 2. clinical pres sedative drugs, infection, hypovolemia.
impaired biochemical function - albumin, 3. tx 2. dec. mental function, confusion, poor
clotting factors, urea cycle. concentration, asterixis (with arms
2. alcoholic liver (20% of heavy drinkers), extended, hands dorsiflexed),
chronic hep B/C, acetaminophen, MTX, rigidity, hyperreflexia
autoimmune, primary biliary cirrhosis, fetor hepaticus - musty breath
hemochromatosis, wilson's, right heart 3. lactulose - prevents ammonia
failure, alpha w antitrypsin, absorption (bacterial metabolism of
lactulose forms NH4+ in lumen of gut)
591. Childs 1: no ascites, no encephalopathy, bilirubin
neomycin (oto/nephro toxic) or rifaximin
classification <2, albumin >3.5, good nutrition
- kills bowel flora dec. ammonia
Childs 1 2: controlled ascites, minimal
production
Childs 2 encephalopathy, bilirubin 2-2.5, albumin 3-
limit protein to 30-40 g/day
Childs 3 3.5, good nutrition
ornithine aspartate
3: uncontrolled ascites, severe
sodium benzoate
encephalopathy, bilirubin >3, albumin <3,
BCAA
poor nutrition
595. hepatorenal 1. progressive FUNCTIONAL renal failure
592. cirrhosis 1. bleeding, hematemesis, melena,
syndrome in advanced liver disease, 2/2 renal
1. portal hematochezia, esophageal variceal bleeding
1. patho hypoperfusion from renal vessel
hypertension tx = TIPS- transjugular intrahepatic
2. clinical pres vasoconstriction TRIGGERED BY*
bleeding portosystemic shunt
3. tx diuretics/infection, large volume tap
complications 2. hematemesis, melena, hepatic
without albumin
+ tx encephalopathy
2. RENAL FAILURE THAT DOES NOT
2. variceal 3. non-selective beta blockers (prophylaxis),
RESPOND TO VOLUME
bleeding prophylactic abx , IV octreotide 3-5 days,
RESUSCITATION azotemia, oliguria,
clinical pres emergent upper GI endoscopy
hyponatremia, hypotension, low urine
3. variceal (ligation/sclerotherapy)
sodium (<10mEq/L)
bleeding tx
3. liver transplant
-rectal
hemorrhoids, 596. classic signs of ascites, varices, gynecomastia,
caput chronic liver hyperestrinism (not being cleared from
medusae disease blood + dec. HBG) - testicular atrophy,
palmar erythema, spider angiomas, hair
593. ascites 1. cirrhosis/portal hypertension -->
lossl
1. patho accumulation of peritoneal fluid due to
hemorrhoids, caput medusae
2. dx portal hypertension/hypoalbuminemia
hypothyroidism - primary failure of TSH
3. tx 2. abdominal ultrasound (as little as 30ml),
release
diagnostic paracentesis (cell count,
albumin, gram stain, culture) ascitic fluid 597. treatment of variceal ligation/banding
albumin >1.1 suggests portal HTN bleeding endoscopic sclerotherapy
3. tx = bed rest, low sodium diet, diuretics, esophageal IV vasopressin
therapeutic paracentesis, peritoneovenous varices IV octreotide - causes splanchnic
shunt or TIPS vasoconstriction, reduces portal pressure
esophageal balloon tamponade
TIPS, shunts, liver transplant
598. ddx of ascites cirrhosis, portal HTN, 604. wilsons disease 1. AUTOSOMAL RECESSIVE -
CHF, 1. patho deficiency of ceruloplasmin -->
chronic renal disease 2. clinical pres inability to excrete copper--> copper
massive fluid overload accumulation in liver, kidney, cornea,
tuberculous peritonitis brain (basal ganglia) (hepatolenticular
malignancy degen)r
hypoalbuminemia 2. acute hepatitis, cirrhosis/liver
peripheral vasodilation secondary to failure, kayser fleischer rings, EPS
endotoxin induced release of NO (--> inc. signs, (parkinsonism symptoms -
renin secretion resting tremor, rigidity, bradykinesia),
chorea, drooling, incoordination from
599. laboratory CBC, renal function
copper in basal ganglia
monitoring for electrolytes, LFTs, coagulation studies
patient with EVERY 3-4 MONTHS ^ 605. wilsons disease 1. dec. serum ceruloplasmin
cirrhosis endoscopy to find varices 1. dx/tx inc. urine copper
CT guided biopsy for suspected HCC elevated LFTs,
liver bx (shows elevated copper levels)
600. compliations of AC9H
tx = D- penicillamine (chelator)
liver failure ascites, coagulopathy
Zinc - prevents dietary copper uptake
hypoalbuminemia, hypoglycemia,
liver transplantation
hyperammonemia, portal hypertension,
hyperestrinism, hyperbilirubinemia, 606. hemochromatosis 1. AUTOSOMAL RECESSIVE (HLA-
hepatic encephalopathy, hepatorenal 1. patho A3) defect in HFE gene -->
syndrome, HCC. 2. organs effected inappropriate iron absorption and
3. clincal pres accumulation of iron in the intestines
601. spontaneous 1. infected ascitic fluid (e.coli, klebsiella,
4. complications and other organs as
bacterial s.pneumo) *ONE ORGANISM (vs
ferritin/hemosiderin --> excess free
peritonitis perforation is polymicrobial)
oxygen radicals
1. patho 2. abdominal pain, fever, altered mental
2. liver, pancreas (DIABETES) , heart,
2. clinical pres status, vomiting, rebound, sepsis
skin (BRONZE)
3. dx/tx 3. paracentesis - PMNs- >250, WBC
3. liver disease, fatigue, arthritis,
>500, positive ascitic cultures, protein
diabetes, arrhythmias, abdominal pain
>2.5. SAAG <1.1, SG >1.016
4. cirrhosis, cardiomyopathy (CHF),
tx = abx cefotaxime or ceftriaxone,
DM, arthritis (2nd/3rd MCP,
albumin,
hyperpigmentation (BRONZE),
repeat paracentesis in 2-3 days, look for
hypothyroid, cardiac condution
lower PMN/WBCs
abnormalities *
602. 1. 1. spider angiomas (dilated cutaneous
607. secondary 2/2 multiple transfusions or in chronic
hyperestrinism arterioles), palmar erythema,
hemochromatosis hemolytic anemia
in liver failure gynecomastia, testicular atrophy
clinical pres 2. inc. PT (vitamin K dependent factors) 608. signs of acute coagulopathy
2.coagulopathy liver failure jaundice
in liver failure hypoglycemia
hepatic encephalopathy
603. treatment of abstinence from alcohol
infection
cirrhosis interferons for hep B/C
elevated LFTs
avoid acetaminophen, alcohol
6 months abstinence to be eligible for liver 609. hemochromatosis 1. elevated serum iron, ELEVATED
transplant 1. dx/tx SERUM FERRITIN
elevated transferring saturation
(>50%), dec. TIBC
liver biopsy - determines hepatic iron
genetic testing
tx = repeated phlebotomies,
deferoxamine, liver transplant
610. hepatocellular 1. females, OCP use, anabolic steroid use 618. gilberts 1. AUTOSOMAL DOMINANT - decreased
adenoma 2. asymptomatic, but can rupture causing syndrome uridine diphosphate glucuronyl transferase
1. patho hemoperitoneum/hemorrhage 1. patho activity --> unconjugated
2. clinical pres 3. CT, ultrasound, hepatic arteriography 2. clinical hyperbilirubinemia***
3. dx/tx tx = dc OCP, resect tumors >5cm pres 2. asymptomatic jaundice with fasting, fever,
3. dx/tx alcohol, infection
611. cavernous 1. small vascular AVM liver tumors, inc. in
3. normal liver bx, no treatment necessary
hemangioma size from pregnancy/OCP
1. patho 2. asymptomatic, rupture/hemorrhage, 619. hemobilia 1. trauma, papillary thyroid carcinoma,
2. clinical pres obstructive jaundice, coagulopathy, CHF 1. surgery, tumors, infection -> blood draining
3. dx/tx from large AV shunt patho/clincal into the duodenum --> melena, hematemesis,
3. CT scan with IV contrast, NO BIOPSY pres jaundice, RUQ pain
WILL HEMORRHAGE 2. arteriogram, upper GI endoscopy (blood
tx = none required unless high risk for from ampulla of vater)
rupture tx = transfusion, resuscitation
612. focal nodular benign liver tumor with no malignant 620. polycystic 1. assc. with polycystic kidney disease, rarely
hyperplasia potential, no association with OCPs, no liver cysts progress to cirrhosis
treatment required 1. patho
613. HCC 1. non-fibrolamellar (hep B/C) 621. hydatid liver 1. echinococcus granulosus, or echinococcus
1.two unresectable with short survival cysts multilocularis --> CALCIFIED CYST****right
pathological fibrolamellar (not associated with hep 1. patho lobe of the liver--> rupture into peritoneal
types B/C) more often resectable 2. treatment cavity -- > fatal anaphylactic shock
2. risk factors 2. cirrhosis (alcohol, hep B or C 10% of 2. surgical resection (don't spill),
3. clinical pres patients get HCC)*** , aflatoxin, vinyl mebendazole after surgery
chloride, thorotrast, AAT,
622. pyogenic 1. biliary
hemochromatosis/wilson's,
liver abscess obstruction/appendicitis/diverticulitis -->
schistosomiasis, hepatic adenoma (10%),
1. patho bacterial proliferation - ecoli, klebsiella,
cigarettes, type 1 glycogen storage disease,
2. clinical proteus, enterococcus, anaerobes
tyrosinemia
pres 2. fever, malaise, anorexia, weight loss,
3. abdominal pain, weight loss, anorexia,
3. dx/tx nausea, vomiting, RUQ pain
fatigue, portal HN, ascites, jaundice,
3. CT scan, elevated LFTs
splenomegaly , paraneoplastic syndromes
tx = IV abx, percutaneous drainage
614. paraneoplastic erythrocytosis, thrombocytosis,
623. amebic liver 1. fecal oral - entamoeba histolytica -->
syndromes hypercalcemia, carcinoid syndrome,
abscess hepatic portal vein --> liver
associated hypertrophic pulmonary osteodystrophy,
1. patho 2. fever, RUQ pain, n/v, hepatomegaly,
with RCC hypoglycemia, high cholesterol
2. clinical diarrhea
615. HCC 1. liver bx pres 3. IgG assay, LFTs, E. histolytica stool
1. dx hep B/C serology, LFTs, coagulation 3. dx/tx antigen
2. tx studies Ultrasound, CT scan
ultrasound, CT cx/ab/pelvis, tx = IV metronidazole , aspiration if abscess
elevated AFP (40-70% of patients) is large
elevated alk phos
624. budd chiari 1. hypercoag, polycythemia, preg,
2. tx = liver resection, liver transplantation
syndrome inflammatory disease, cancer
616. most common HCC and cholangiocarcinoma 1. patho myeloproliferative --> occlusion of hepatic
malignant liver 2. clinical venous outflow --> hepatic congestion
tumors pres 2. hepatomegaly, ascites, abdominal pain,
3. dx/tx jaundice, variceal bleeding
617. nonalcoholic 1. no alcohol use, but have same changes
3. hepatic venography, serum ascites
steatohepatitis to liver --
albumin gradient >1.1g/dl
1. patho + risk risk factors = obesity, hyperlipidemia, DM,
tx = *balloon angioplasty with stent
factors usually asymptomatic/benign
placement, portacaval shunts
2. dx 2. routine LFT shows mild elevation of
liver transplant
ALT/AST
anticoag, thrombolytics diuretics
macrovascular liver changes on liver
biopsy
625. three major causes hemolysis, liver disease, biliary 631. Aminotransferases 1. ALT
of jaundice obstruction 1. which is more 2. alcoholic liver disease - AST:ALT
sensitive/specific for 2:1
626. jaundice 1. total bili >2mg/dl
liver damage 3. chronic viral hepatitis, acute
1. what level is 2. dark urine/pale stools b/c
2. what condition alcoholic hepatitis
clinical observable conjugated bili is loosely bound to
does ALT and AST 4. acute viral
2. clinical finding albumin
not rise at same rate 5. ischema, shock liver,
unique to 3. hemoglobin, myoglobin, liver
3. mildly elevated acetaminophen toxicity, viral
conjugated enzymes (--> unconj bilirubin in the
LFTs hepatitis
hyperbilirubinemia spleen)
4. moderate elevated
3. sources of 4. tightly bound to albumin, cannot
LFTs (100s-1000s)
bilirubin be excreted in the urine, cross BBB
5. severely elevated
4. clinical findings and causes neurological
LFTs (>10,000)
unique to damage/deficits
unconjugated 632. why are LFTs not because the number of functioning
bilirubin always elevated in hepatocytes is greatly reduced.
patients with
627. causes of 1. hepatocellular disease (viral or
cirrhosis or
conjugated alcoholic hepatitis, cirrhosis), Dubin
metastatic liver
hyperbilirubinemia johnson, rotors syndrome, PBC, PSC
disease
1. dec intrahepatic 2. gallstones, head of pancreas
excretion of carcinoma, cholangiocarcinoma, 633. causes of elevated Autoimmune hepatitis, hep B/C,
bilirubin periampullary tumors, extrahepatic LFTs in drugs, ethanol, fatty liver,
2. extrahepatic biliary atresia asymptomatic growths(tumors, hemodynamic
biliary obstruction patients (CHF), iron (hemochormatosis),
copper (wilsons, AAT)
628. causes of 1. hemolytic anemia
unconjugated 2. gilberts, crigler najjar, 634. alkaline phosphatase 1. extra hepatic obstruction of bile
hyperbilirubinemia sulfonamides, penicillin, rifampin, 1. what causes very flow,
1. excess radiocontrast agents, immature conj. high elevation 2. get a GGT which will tell if
production of system (physiologic jaundice of 2. if levels are mildly elevated ALP is from a hepatic
bilirubin newborn), hepatitis, cirrhosis elevated what should origin
2. reduced hepatic be the next step 3. pregnancy, bone disease
uptake of bilirubin 3. what is possibility
or impaired if ALP is elevated but
conjugation GGT is normal
629. what labs to order 1. CBC, retic, haptoglobin, LDH, 635. where is ALT - LIVER ONLY
for peripheral smear AST/ALT/ALP found AST - skeletal muscle, heart,
1. unconjugated 2. ultrasound or CT, ERCP, MRCP, in the body kidney, brain
hyperbilirubinemia liver biopsy ALP - bone, gut, placenta`
2. conjugated
636. at what hemoglobin > 4 g/dl desaturated
hyperbilirubinemia
level will central ie. 80% saturation in a COPDer
630. clinical jaundice cyanosis be present with hemoglobin 20
presentation of gray stools, dark urine (conjugated) or 60% saturation in IDA patient
cholestasis pruritus with hemoglobin of 10
serum alk phos
637. tachybradycardia 1. period tachycardia followed by
elevated cholesterol
syndrome sinus node suppression--
skin xanthomas
1. patho 2. pacemaker (prevents the
2. tx tachycardia)
medications for the bradycardia
638. contraindications to pre-existing ST depression, LVH
cardiac stress testing ** do nuclear testing instead
+ what to do to test
them for CAD
639. what conditions have low
albumin
640. what clotting factors not
synthesized by the liver
641. cholelithiasis
1. yellow/green stones\
2. black stones
3. brown stones
642. cholelithiasis
1. clinical pres
2. complications
3. dx
643. what fraction of patients
with biliary colic develop
cholecystitis in 2 years
644. what causes pain in
biliary colic vs
cholecystitis
645. biliary colic = contraction
of gallbladder against
obstructed cystic duct
acute cholecystitis = pain
from inflammation of the
gallbladder wall
chronic liver disease
nephrotic syndrome
malnutrition
inflammatory states -sepsis,
trauma, burns
III, VIII, vWF
1. obesity, diabetes, multi
partum, OCP, cirrhosis, CF
2. hemolysis (SCD,
thalassemia, spherocytosis,
cardiac valves,), or alcoholic
cirrhosis
3. biliary tract infection
1. biliary colic, from
temporary obstruction of the
gallbladder with gallstones
RUQ pain, radiates to the
right subscapular region
(BOAS SIGN)
2. cholecystitis,
choledocholithiasis, gallstone
ileus, malignancy
3. RUQ ultrasound (>2mm),
CT/MRI
...
30% (10% of patients with
gallstones develop
cholecystitis)
...
646. acute cholecystitis 1. obstruction of cystic duct -->
1. patho inflammation of gallbladder wall
2. clinical pres 2. RUQ/epigastric pain, radiates to
3. dx/tx right scapula/shoulder, N/V,
anorexia, MURPHY'S SIGN, fever,
leukocytosis
3. RUQ ultrasound - thickened
gallbladder wall, pericholecystic
fluid, distended gallbladder, stones
CT scan - higher sens for
complications - perforation, abscess,
pancreatitis
HIDA scan - positive if gallbladder
NOT visualized
tx = admission, hydration, IVF, NPO,
IV ABX, analgesics
Cholecystectomy within 24-48 hours
647. signs of biliary elevated ALP, GGT, jaundice,
tract obstruction pruritus, clay colored stools, dark
urine
648. acalculous 1. dehydration, ischemia, burns,
cholecystitis trauma --> non-obstructive
1. patho cholecystitis
2. tx 2. emergent cholecystectomy
649. complications of gangrenous cholecystitis, perforation,
cholecystitis emphysematous cholecystitis,
cholecystoenteric fistula with
gallstone ileus, gallbladder empyema
650. choledocholithiasis 1. gallstone in CBD
1. patho 2. elevated D-bili, ALP,
2. dx/tx RUQ ultrasound (only 50% sensitive)
ERCP is gold standard - and
therapeutic
PTC
tx = ERCP with
sphincterotomy/extraction/stent, lap-
cholecoholithotomy
651. complications of cholangitis, obstructive jaundice,
choledocholithiasis acute panc, biliary colic, biliary
cirrhosis
652. cholangitis 1. ERCP/PTC/choledochal
1. patho cyst/obstruction --> biliary
2. clinical pres stasis/bacterial overgrowth
3. dx/tx 2. CHARCOT-TRIAD: RUQ pain,
jaundice, fever
REYNOLDS PENTAD - charcot +
septic shock, altered mental status
3. RUQ ultrasound,
hyperbilirubinemia, leukocytosis,
elevated LFTs
PTC (when duct dilated)/ERCP - NOT
DURING ACUTE PHASE
tx = IVF, ABX, monitoring UOP/BP,
after afebrile 48 hours --> ERCP/PRC
653. complication of hepatic abscess- high fatality 659. biliary 1. motor dysfunction of the sphincter of
cholangitis dyskinesia Oddi (CCK relaxes) leads to recurrent biliary
1 patho colic without evidence of stones
654. primary sclerosing 1. idiopathic thickening of bile
2. dx/tx 2. HIDA + IV CCK and determine
cholangitis ducts/narrowing of lumen -->
gallbladder ejection fraction
1. patho cirrhosis, portal hypertension, liver
2. clinical failure 660. acute 1. lumen of appendix obstructed by:
associations 2. ULCERATIVE COLITIS ***, appendicitis lymphoid hyperplasia (60%), fecalith
3. dx/tx crohn's 1. patho (30%), foreign body --> bacterial growth,
3. ERCP/PTC - shows multiple bead 2. clinical inflammation --> compromised blood
like strictures of intra/extrahepatic pres supply --> necrosis, perforation, peritonitis
ducts 3. DX 2. epigastric pain that moves toward
tx = liver transplant***, ERCP stent umbilicus/RLQ with signs of peritonitis,
placement for strictures anorexia**, n/v, rebound, ROVSING'S
cholestyramine - for pruritus SIGN, PSOAS SIGN, OBTURATOR SIGN
3. CLINICAL DX, leukocytosis,
655. primary biliary 1 autoimmune process -->
CT scan (98-100% sensitive), ultrasound
cirrhosis progressive cholestatic livers disease
tx = appendectomy
1. patho with destruction of the intrahepatic
2. clinical pres bile ducts (ductopenia on biopsy) 661. carcinoid 1. neuroendocrine cells --> serotonin (10%
3. dx/tx 2. fatigue, pruritus, jaundice, RUQ syndrome of carcinoid tumors)
discomfort, 1. patho - located in appendix***, small bowel
xanthoma/xanthelasmata* 2. clincal pres (highest chance of mets), rectum, bronchus
3. positive antimitochondrial 2. cutaneous flushing, diarrhea, sweating,
antibodies*** wheezing, abdominal pain,
elevated ALP, elevated
662. appendicitis perforation of appendix 20%
cholesterol/HDL
complications - will present as high fever, tachycardia,
non caseating granulomas
leukocytosis, peritoneal signs
inc. immunoglobulin M
liver biopsy (showing 663. acute 1. alcohol/gallstones/POST ERCP/ viral
DUCTOPENIA), abd. US/CT scan pancreatitis /drugs/post-op/scorpion
tx = cholestyramine (pruritus), 1. patho bites/cancer/hypertriglyceridemia/
calcium, bisphosphonates, vitamin 2. what hypercalcemia/uremia--> inflammation of
D, viruses pancreas from prematurely activated
ursodeoxycholic acid (slows disease) associated pancreatic digestive enzymes
with acute 2. mumps, cox B
656. cholangiocarcinoma 1.adenocarcinoma of
panc 3. sulfonamides, thiazide, furosemide,
1. patho intra/extrahepatic bile ducts -->
3. what drugs estrogen, HIV meds
2. risk factors prox 1/3 = klatskin tumor, distal
associated
extrahepatic, intrahepatic
with acute
2. PSC, UC, choledochal cysts,
panc
clonorchis sinensis (hong kong)
664. acute 1. epigastric pain radiating to the back,
657. causes of secondary mechanical obstruction, sclerosing
pancreatitis worse when supine/after meals, low grade
biliary cirrhosis cholangitis, cystic fibrosis, biliary
1. clinical pres fever, tachycardia, epigastric tenderness,
atresia
2. dx dec. bowel sounds, leukocytosis, GREY
658. choledochal cysts 1.cystic dilations of the hepatic ducts TURNER'S SIGN, CULLEN'S SIGN, FOX'S
1. patho 2. epigastric pain, jaundice, fever, SIGN
2. clinical pres RUQ mass 2. serum lipase, amylase, LFTs, ,
3. dx/tx 3. ultrasound, ERCP hyperglycemia, hypoxemia, leukocytosis
4. complications tx = surgery glucose, calcium, hematocrit, BUN, ABG,
4. cholangiocarcinoma, hepatic LDH, AST, WBC
abscess, recurrent panc/cholangitis, CT abdomen - most sensitive/specific
rupture, biliary obstruction, ERCP - identify gallstones
cirrhosis, portal HTN abdominal XR -may show calcifications
abdominal ultrasound - may detect
calc/pseudocysts
665. ranson's 1. GA-LAW: glucose >200, Age >55, LDH 671. GI bleeding 1. prox to ligament of treitz - PUD,
criteria >350, AST>250, WBC >16000 1. upper GI duodenal ulcer, gastritis, reflux
1. admission 2. C HOBBS: calcium <8mg/dl, Hematocrit bleeding causes esophagitis, varices, mallory weiss,
2. 48 hours >10%, PaO2<60 mmHg, BUN >8mg/dL, 2. lower GI hemobilia, dieulafoy, aortoenteric fistula
3. mortality % Base deficit >4 mg/dl, fluid sequestration bleeding causes 2. diverticulosis, angiodysplasia, IBD
>6L (UC/crohn's), colorectal cancer/polyps,
3. <3 criteria - 1% ischemic colitis, hemorrhoids, anal
3-4 criteria - 15% fissure
5-6 criteria - 40%
672. GI bleeding 1. moderate-severe ONGOING upper GI
>7 criteria - 100%
1. hematemesis bleeding
666. acute 1. ARDS*** 2. coffee ground 2. lower rate of upper GI bleeding
pancreatitis pancreatic abscess emesis 3. upper GI black, tarry, foul smelling
1. pancreatic necrosis (sterile or infected) 3. melena stools (hemoglobin broken down by
complications pancreatic pseudocyst - 2-3 week to develop 4. hematochezia bacteria indicates blood has been in GI
2. tx no epithelial lining, (>5cm drain) - occult blood in tract for several hours
hemorrhagic pancreatitis - cullen, grey the stool 4. bright red blood per rectum typically
turner, fox, CT with IV contrast left colon or rectum
ascending cholangitis (gallstones)
673. causes of dark melena, bismuth, iron, spinic, charcoal,
2. NPO, IVF, pain control, NG tube, early
stools licorice
enteral nutrition via nasojejunal tube
AFTER RECOVERY FROM GALLSTONE 674. GI bleeding 1. hematemesis/melena - upper GI
PANCREATITIS ALL PATIENTS SHOULD 1. diagnostic test endoscopy
BE SCHEDULED FOR for hematochezia/occult blood -
CHOLECYSTECTOMY hematemesis, colonoscopy
hematochezia, 2. BP, pulse rate, CBC with diff, BUN/Cr,
667. chronic 1. chronic alcoholism --> fibrotic
melena, occult PT/PTT/INR stool guaiac,
pancreatitis replacement of the pancreas and dilation of
blood hemoglobin/hematocrit, upper
1. patho the pancreatic duct
2. dx endoscopy, NG tube (bile but no blood =
2. clinical 2. severe abdominal pain, n/v, aggravated
3. tx not upper GI), colonoscopy,
pres by drinking alcohol/eating, malabsorption,
radionucleotide scan (tagged RBCs),
3. dx/tx diabetes mellitus (triad)
arteriography (must be during active
3. CT scan shows calcifications
bleeding, therapeutic =
ERCP**- will show ductal
embolization/vasopressin)
dilation/strictures
3. ABCs- Oxygen, 2 large bore IVs, draw
abdominal xray - shows calcifications -
blood hgb/hct/pt/ptt/platelet, monitor
specific but not sensitive
hgb q4-8
serum amylase and lipase are normal
type and cross
stool elastase is decreased
EGD with coagulation
668. chronic 1. narcotics, NPO, pancreatic enzymes and colonoscopy
pancreatitis H2 blockers (dec. CCK release), insulin,
675. normal young adult >7-8
1. tx
hematocrit in elderly >10
669. complications narcotic addiction, DM (langerhans loss), young adult vs.
of chronic pseudocysts, pancreatic duct dilation, CBD elderly
pancreatitis obstruction (2/2 fibrosis), B12
676. indications for hemodynamically unstable and not
malabsorption
surgery in responding to IV fluids,
670. pancreatic 1. cigarette smoking (NOT ALCOHOL), patient with GI severe initial bleed or recurrence after
cancer chronic pancreatitis*, diabetes, obesity bleed endoscopic treatment
1. risk factors benzidine/beta naphthylamine exposure continued bleeding >24 hours
2. clinical 2. dull abdominal pain, obstructive jaundice visible vessel at base of ulcer
pres (head), weight loss, depression, fatigue, 5 units of blood within 4-6 hours
3. dx migratory thrombophlebitis, courvoisier's
4. tx sign
3. ERCP**, CT scan***, CA 19-9, CEA
4. whipple procedure (10% survival at 5
years), ERCP with stent placement if
unresectable
677. esophageal 1. AA, alcohol, tobacco, nitrosamines, hot 682. esophageal 1. gastroesophageal junction/stomach
cancer foods/beverages hiatal hernias herniate into thorax associated with
1. risk factors 2. GERD, barrett's 1. sliding (type GERD
for SCC 3. dysphagia (solids--> solids/liquids), 1) 2. stomach herniates into the thorax, but
2. risk factors weight loss, anorexia, odynophagia, 2. NOT GE junction- risk for strangulation
for adeno hematemesis, hoarseness, aspiration, paraesophageal and should be repaired
- 5-15% 5 year 4. barium swallow (type 2) 3. barium upper GI series, upper
prognosis upper endoscopy with biopsy/brush 3. dx/tx endoscopy
3. clinical pres cytology*** 4. type 3 tx = type 1 = antacids, small meals,
4. dx/tx metastatic work up - CT cx/abd, CXR, nissen's fundoplication
bone scan type 2 = elective surgery
tx = palliation, surgery (0,1,2a), adjuvant 4. combination of type 1 and 2
chemo/radiation
683. mallory weiss 1. mucosal tear at the GE junction, after
678. achalasia 1. LES fails to relax when swallowing and syndrome repeated vomiting
1. patho abnormal peristalsis of esophagus 1. patho 2. hematemesis
2. causes 2. idiopathic, adenocarcinoma, chagas 2. clinical pres 3. upper endoscopy
3. clinical pres 3. dysphagia to both solids/liquids, 3. dx/tx tx = stops on its own, or angiographic
patients eat slowly, and drink a lot of embolization, acid suppression
water with food, food gets stuck in
684. plummer 1. iron deficiency --> upper esophageal
esophagus, regurgitation/aspiration, CX
vinson webs, koilonychia, atrophic oral mucosa,
pain, weight loss
syndrome iron deficiency anemia
679. achalasia 1. barium swallow*** - BIRD BEAK 1. patho 2. progress to SCC of the oral cavity
1. dx/tx upper GI endoscopy rules out 2. 3. esophageal dilation, correct nutritional
esophagitis/esophageal cancer complications deficiency
manometry***- failure of LES relaxation 3. dx/tx
biopsy - absent myenteric plexus
685. schatzki's ring 1. ingestion of acid (mucosal necrosis),
tx = sublingual nitroglycerine, CCBs,
1. patho alkali (liquefactive full thickness
botulinum toxin, mechanical dilation,
2. clinical pres necrosis), detergents -> lower esophageal
heller myotomy
3. tx ring and sliding hiatal hernia
680. what cancer squamous cell cancer of the esophagus 2. dysphagia
are patients 3. esophagectomy for full thickness
with achalasia necrosis
at increased
686. zenker's failure of cricopharyngeal muscle to relax
risk for
diverticula + tx during swallowing increases pressure and
681. diffuse 1. non-peristaltic contractions preventing causes outpouching of mucosa (false
esophageal advancement of food bolus, LES function diverticula)--> dysphagia, regurgitation,
spasm is normal halitosis, chronic cough
1. patho 2. non-cardiac chest pain that mimics tx = cricopharyngeal myotomy,
2. clinical pres angina diverticulectomy
3. dx/tx 3. esophageal manometry- simultaneous,
687. traction mid esophagus, near tracheal bifurcation
multiphasic repetitive contractions after
diverticulum from mediastinal inflammation and
swallow with normal sphincter
adenopathy (ex. tuberculosis)
Barium swallow - corkscrew esophagus
tx = nitrates, CCBs, TCAs 688. epiphrenic lower 1/3 of esophagus, associated with
diverticulum esophageal dysmotility/achalasia
689. boerhaave's 1. blunt trauma, medical tubes, vomiting, 695. *Gastric outlet ...
syndrome alcohol binges, bulimia --> TRANSMURAL obstruction-
1. patho tear in esophagus barium swallow,
2. clinical 2. severe chest pain, tachycardia, upper endoscopy,
pres hypotension, tachypnea, dyspnea, fever, saline load test
3. dx/tx HAMMANS SIGN (mediastinal crunch from (750
heart hitting air filled tissues), PTX injected, after 30
3. gastrografin swallow min aspirate
CXR - air in mediastinum >400ml = + test)
tx = IV, NPO, abx, H2 blockers tx = NG suction,
surgery if patient is unstable volume
replacement,
690. peptic ulcer 1. h.pylori, NSAIDs, gastric acid
surgery
disease hypersecretion (ZES), smoking,
1. causes alcohol/coffee 696. *GI bleeding - stool ...
2. clinical 2. aching, gnawing pain, nocturnal guaiac, upper GI
pres symptoms and variable effects of food, upper tx= resuscitation,
3. dx/tx GI bleeding, n/v, early satiety, weight loss diagnose site of
3. endoscopy (also therapeutic) bleeding, surgery
H.pylori detected on biopsy for acute bleeding
urea breath test
697. acute gastritis 1. inflammation of the gastric mucosa
h.pylori serology (false negative with PPI,
1. patho 2/2 NSAIDs, H.pylori, cigarette
bismuth, antibiotics, upper GI bleeding)
2. clinical pres smoking, caffeine, shock, sepsis,
serum gastrin
burns
tx - acid suppression (PPI or H2),
2. epigastric pain
triple/quadruple therapy
3. PPI, stop NSAIDs, test for H.pylori
cytoprotection - sucralfate, misoprostol
(reduces ulcers with NSAID therapy) 698. gastric cancer 1. ulcerative, polyploid (solid mass),
1. morphologies superficial spreading, linitis plastica
691. duodenal 1. low
2. risk factors 2. atrophic gastritis, gastric polyps,
ulcers 2. 1-2 cm distal to pylorus (posterior wall)
3. clinical pres h.pylori (3-6x the risk), pernicious
1. malignant 3. <40
anemia, low vitamin C, high salt diet,
potential 4. O
menetrier's disease, preserved foods
2. location 5. NSAID use, pain that is relieved by food,
(salt, nitrates), blood type A
3. age nocturnal pain
3. abdominal pain, weight loss, dec.
4. associated
appetite, anorexia, melena, guaiac
blood type
positive stools
5. clinical
pres 699. 1. krukenberg 1. stomach cancer met to the ovary
tumor 2. stomach cancer met to the rectum
692. gastric ulcers 1. high - 5-10%
2. blumers shelf (pelvic cul de sac)
1. malignant 2. type 1 70% on lesser curvature,
3. sister mary 3. met to periumbilical lymph nodes
potential type 2 - gastric AND duodenal
joseph node 4. met to supraclavicular fossa nodes
2. location type 3 - pre-pyloric
4. virchows node 5. met to left axillary adenopathy
3. age type 4 - near GE junction
5. irish's node
4. associated 3. >40
blood type 4. A 700. chronic gastritis 1. H.pylori, autoimmune (anti-parietal
5. clinical 5. smokers, eating does not relieve pain 1. patho cell/anti-intrinsic factor antibodies),
pres 2. dxt/tx 2. upper endoscopy with biopsy

693. lifestyle stop smoking, stop NSAIDs, decrease eating 701. autoimmune serum anti-parietal cell and anti-
modifications before bed gastritis intrinsic factor antibiotics -->
for PUD pernicious anemia

694. complications *perforation -CXR free air under diaphragm

of PUD (3) + tx = emergency surgery - vagotomy
dx/tx
702. gastric cancer 1. upper endoscopy with multiple biopsies 708. celiac sprue 1. hypersensitivity to gluten --> loss of
1. dx/tx barium upper GI series 1 patho microvilli--> weight loss, abdominal
abdominal CT for staging/mets 2. dx/tx distension, bloating, diarrhea
FOBT 2. anti-endomysial, anti-transglutaminase
tx = surgical resection with wide margins small bowel biopsy shows flattening of villi
>5cm tx = avoid wheat, barley, rye
703. small bowel 1. partial vs complete obstruction, closed vs 709. crohns disease 1. chronic flaring/remitting
obstruction open loop (closed has vascular 1. patho TRANSMURAL inflammatory disease that
SBO compromise/necrosis/peritonitis), proximal 2. clinical pres can affect any part of the GI tract, usually
1. three ways vs distal SBO (distal has more dilated 3. includes terminal ileum, skip lesions,
to proximal loops) extraintestinal FISTULAS, STRICTURES, NON
differentiate 2. adhesions (MCC), incarcerated hernias, manifestations CASEATING GRANULOMAS*, mesenteric
small bowel malig, intussus, crohn's, SMA syndrome --> fat wrapping
obstruction 3. obstruction --> dehydration, inc. 2. diarrhea, malabsorption/weight loss,
2. intestinal secretions proximal to the abdominal pain, n/v, fever, malaise
patho/clinical obstruction, distention/vomiting 3. uveitis, arthritis, ank spondy (C<UC),
pres (hypokalemic, hypochloremic met.alk), erythema nodosum (C>UC), pyoderma
obstipation, abdominal distention, gangrenosum (C<UC), aphthous oral
nausea/vomiting, ulcers, cholelithiasis, nephrolithiasis
strangulation --> shock, peritonitis, free air,
710. epidemiology caucasians, jewish, age of onset 15-35
lactic acidosis
of IBD years
704. SBO 1. plain abdominal films- show dilated
711. crohns disease 1. fistulae (vagina, skin, intestine,
1. dx/tx loops of small bowel/air fluid levels
1. bladder), anorectal fissures, abscesses,
proximal to the point of obstruction,
complications SBO, B12/bile acid malabsorbtion,
minimal gas in colon.
2. dx/tx cholelethiasis, neprholithiasis (inc. abs of
Barium enema - identifies site of
oxalate), aphthous ulcers, narcotic abuse,
obstruction, follow up for inconclusive XR
psychosocial issues
upper GI series
2. endoscopy with biopsy- cobblestone
serum lactate - to detect
appearance, pseudopolyps
strangulation/necrosis
barium enema
tx = non-operative if incomplete and no
tx = sulfasalazine (5 ASA aka
fever, peritoneal signs, leukocytosis, IVF w/
mesalamine)- blocks prostaglandin
K+, NG tube, abx, surgery for complete
release, reduces inflammation
obstruction (ex. lysis of adhesion/bowel
metronidazole
resection)
prednisone - for exacerbations
705. difference in proximal - frequent vomiting, severe pain, azathioprine, 6MP with steroids for
clinical pres minimal abdominal distension exacerbations
between distal - less frequent vomiting, significant cholestyramine/colestipol for terminal
proximal vs abdominal distention ileal disease
distal SBO surgical - high recurrence rate
706. large bowel 1. volvulus, adhesions, hernias, colon 712. ulcerative 1. relapsing and remitting MUCOSAL
obstruction cancer (MCC) colitis inflammation of the rectum (always) and
1. causes - fluid/electrolyte imbalances not as severe 1. patho colon
as SBO 2. clinical pres 2. hematochezia***, abdominal pain,
3. dx/tx frequent small bowel movements, fever,
707. paralytic 1. absent peristalsis, without mechanical
anorexia, weight loss, tenesmus (rectal dry
ileus obstruction
heaves), extraintestinal findings (see
1. patho 2. narcotics, post-operative, spinal cord,
crohns card)
2. causes shock, hypokalemia, peritonitis
3. stool cultures/ova/parasites - negative
3. dx 3. abdominal plain films show uniform gas
fecal leukocytes
distribution in small bowel,colon, and
colonoscopy
rectum
PANCA positive
failure to pass contrast past a fixed point
- crypt abscesses
tx = IVF, NPO, electrolytes (hypokalemeia),
NG suction,
713. ulcerative 4. IDA, hemorrhage, electrolytes, 719. postpartum ...
colitis strictures, benign/malignant, colon thyroiditis
4. extra cancer, ankylosing spondylitis*, primary iodine induced
intestinal sclerosing cholangitis, hyperthyroidism
manifestations cholangiocarcinoma (50% of patient have iatrogenic
/ complications UC), toxic megacolon, growth hyperthyroidism
retardation, narcotic abuse, psychosocial
720. causes of pregnancy, liver disease, OCP, aspirin
tx = corticosteroids for exacerbations
elevated TBG
sulfasalazine (5ASA after bacterial
metabolism) by suppository 721. hyperthyroidism thionamides - methimazole (men/non-
immunosuppressants for resistant tx child age women), PTU (for pregnant -
disease- prevents relapses dec. conversion of T4-T3) - SE =
surgery often curative (compare to agranulocytosis (MONITOR
crohns) LEUKOCYTES)
iopanoic acid - dec. thyroid hormone
714. graves disease 1. diffuse uptake on thyroid scan, anti-
release from thyroid gland
1. dx TSH-R antibodies
beta blockers - for symptoms (tachy,
low TSH
sweating, weakness)
elevated T4
sodium ipodate - rapid improvement for
only order T3 if T4 is normal and TSH is
medically refractory hyperthyroidism
low
I-131 ablation of thyroid follicular cells -
T3 TBG resin study - radioactive T3 binds
repeat after 6-12 months if initially
to TBG or resin - if resin binds alot of
unsuccessful- (can cause temporary
radio-T3 TBG is probably normal, if resin
worsening)
does not bind much elevated TBG is
subtotal thyroidectomy - SE- recur hyper,
probably causing elevated thyroid
hypothyroidsm
hormones.
722. graves disease beta blocker - for symptom control, taper
715. graves disease 1. anti TSH-R antibodies triggers excess
treatment @ 4-8 weeks
(80% of hormone release,
methimazole- for 1-2 years, remeasure
hyperthyroid) 2. **exophthalmos (edema of
anti-TSH, if relapse 1 more year of
1. patho extraocular muscles/retroorbital
methimazole
2. clinical pres tissue) , *pretibial myxedema
radioactive iodine ablation
(mucopolysaccharides), **thyroid
bruit nervousness, arrhythmias (sinus 723. graves treatment endocrinology consult and PTU
tach, afib, PVCs) in pregnant
warm moist skin women
insomnia, tremor, hyperactivity, 724. thyroid storm 1. acute exacerbation of thyrotoxicosis in
tremulousness, sweating, heat 1. patho response to stress (infection*, DKA,
intolerance, weight loss, diarrhea, 2. tx stress, childbirth)-->20%
palpitations mortality/coma
hypertension (2/2 inc. expression of SR 2. fever, tachycardia, agitation,
calcium dependented ATPase) psychosis, confusion,n/v, diarrhea
716. plummer's 1. multinodular toxic goiter - multiple 3. IVF, cooling blankets, glucose, PTU
disease (15% of hyperfunctioning areas q2hour + iodine, beta blockers for heart
hyperthyroid) 2. see graves disease card rate, dexamethasone (blocks T4-T3
1. patho 3. patchy uptake on thyroid scan , conversion)
2. clinical pres possible bruit over thyroid gland
3. dx see graves disease card
717. toxic thyroid single hyperfunctioning nodule, single
adenoma nodule
718. 1. hashimotos 1. transient hyperthyroid,
thyroiditis multinodularity,
2. de quervain's 2. exquisitely tender diffusely enlarged
(subacute, gland after/during viral illness
granulomatous)
thyroiditis
725. hypothyroidism 1. hashimoto's (autoimmune), 731. chronic 1. hashimoto's/lymphocytic
1. causes iatrogenic- radioiodine, thyroidectomy, lymphocytic 2. goiter, slow decline in thyroid function
2. clinical pres mediations, secondary/tertiary thyroiditis 3. antiperoxidase, antithyroglobulin
hypothyroidism (low T4/T3 and low 1. patho antibodies
TSH) 2. clinical pres irregular distribution of I-131 not
2. fatigue, weakness, heavy menstrual 3. dx/tx required for diagnosis
periods*, weight gain, cold intolerance, tx = thyroid hormone replacement
dull expression, muscle
732. thyroid autoimmune destruction of periorbital
weakness/rhabdomyolysis, arthralgias,
associated connective tissue - lid retraction,
depression, dry skin, coarse hair,
ophthalmopathy proptosis (lymphocytes invade EOM and
hoarseness, non-pitting edema
stimulate GAG deposition),
(myxedema), dec. DTRs, bradycardia,
lagophthalmos, - may be
goiter
hypo/hyperthyroid or euthyroid
726. associated lupus, pernicious anemia, thyroid
733. fibrous 1. fibrous tissue replaces thyroid
conditions with carcinoma, thyroid lymphoma
thyroiditis 2. surgical removal
hashimotos
1. patho
thyroiditis
2. tx
727. myxedema hypothermia, respiratory depression, dec.
734. thyroid nodules 1. 4-10%
coma + tx consciousness from chronic
1. what fraction 2. nodule is fixed, no movement with
hypothyroidism exacerbated by stress,
are cancerous swallowing
elevated PCO2, hyponatremia (trauma,
2. features of solitary, history of neck radiation, history
infection, cold, narcotics)
malignant of rapid development, vocal cord
tx = IV levothyroxine (500 mcg bolus,
nodule paralysis, cervical adenopathy
then daily), hydrocortisone for impaired
3. diagnosis 3. Ultrasound guided FNA (reliable for
adrenal reserves
all cancers except follicular)
728. hypothyroidism 1. high TSH, low TSH (2' thyroid scan (radioactive iodine) - cold or
1. dx hypoparathyroidism), low free T4, anti- hot
2. tx microsomal/antithyroglobulin antibodies thyroid ultrasound - diff between solid
(hashimotos), anti thyroid peroxidase and cystic
elevated LDL, dec. HDL
735. risk factors for head/neck radiation
normocytic anemia
thyroid cancer gardner's syndrome/cowden's syndrome
2. levothyroxine, TSH monitoring
(papillary cancer)
729. subacute 1. post viral HLA-B35 associated --> MEN type 2 - medullary thyroid cancer
thyroiditis leakage of thyroid hormone from thyroid
736. papillary 1. radiation to the head/neck
(granuomatous) gland --> hyperthyroid-->euthyroid--
thyroid cancer 2. cervical lymph nodes, with rare distant
1. patho >hypothyroid
(most common) mets, iodine uptake positive
2. clinical pres 2. painful tender thyroid gland, history of
1. risk factor 3. orphan annie eye nuclei, psammoma
3. dx/tx viral illness, and symptoms of
2. pattern of bodies on biopsy
hyper/hypothyroid
mets
3 radioiodine uptake is low
3. dx
TSH is low from elevated T4/T3
high ESR 737. follicular 1. hematogenous spread*** to
tx = NSAIDs/aspirin, corticosteroids, carcinoma brain/lung/bone/liver, 20% of pts have
recovery of thyroid function after 1 year 1. pattern of distant mets
mets 2. iodine deficiency
730. subacute 1. transient thyrotoxicosis, followed by
2. risk factor 3. tissue sample because need to see
lymphocytic hypothyroidism
3. dx extension past fibrous capsule
thyroiditis 2. similar to subacute thyroiditis, but
4. hurthle cell 4. abundant cytoplasm, tightly packed
1 .patho without pain
carcinoma mitochondria, oval nuclei with
2. clinical pres 3. low iodine uptake (vs graves), low TSH
prominent nucleoli - radioiodine
3. dx anti-TPO antibodies
resistant
738. medullary 1. 1/3 sporadic, 1/3 familial, 1/3 745. acromegaly 1. GH secreting adenoma --> excess
carcinoma of the MENII (also screen for pheo)-- arises 1. patho GH AFTER*** epiphyseal closure
thyroid from parafollicular C cells --> excess 2. clinical pres (before closure = gigantism)-->
1. risk factors + calcitonin production broadening of the skeleton
patho 2. sheets of cells in an amyloid 2. coarse facial features, abnormally
2. dx stroma (APPLE GREEN large hand/feet, organomegaly,
BIREFRINGENCE CAD, arthralgia, HCM,
macrognathia,
739. anaplastic longstanding follicular/papillary
glucose intolerance, hyperhidrosis
carcinoma thyroid carcinoma - death within a
headache, bitemporal hemianopsia,
1. risk factors + few months- metastasis is by direct
cavernous sinus compression, HTN,
patho extension
sleep apnea
740. thyroid cancer 1. lobectomy with isthmusectomy,
746. acromegaly 1. IGF 1 (somatomedin C levels)
treatment total thyroidectomy if >3cm or
1. dx oral glucose suppression test (oral
1. papillary bilateral, TSH suppression,
2. tx glucose does not suppress GH)
2. follicular radioiodine therapy
random GH level
carcinoma 2. total thyroidectomy with post op
2. transsphenoidal resection of
3. medullary iodine ablation
pituitary adenoma
carcinoma 3. total thyroidectomy, radioiodine,
radiation if post op elevation in IGF-1
4. anaplastic modified neck dissection
octreotide/somatostatin suppresses
4. chemotherapy and radiation ,
GH
palliative surgery
747. craniopharyngioma 1. suprasellar tumor from remnants
741. 1. what fraction of 1. 20%
1. patho of rathke's pouch- usually adenoma
cold nodules are - thus a cold nodule on thyroid scan
2. clinical 2. parasellar effects - headache,
malignant does not tell very much about the
presentation bitemporal hemianopsia,
mass, however a warm nodule
papilledema, changed in mentation,
greatly reduces risk of malignancy
hyperprolactinemia, diabetes
742. pituitary adenomas 1. inc. prolactin/GH/ACTH/TSH, or insipidus, panhypopituitarism
1. what hormonal hypopituitarism from compression of 3. MRI
abnormalities the causes hypopituitarism surgical excision with or without
2. other non- 2. headache, bitemporal radiation
hormonal clinical hemianopsia (compression of the
748. causes of pituitary tumor, radiation, sheehan's
clues optic chiasm)
hypopituitarism syndrome, sarcoidosis,
3. dx/tx 3. MRI, pituitary hormone levels
hemochromatosis, head trauma,
tx = transsphenoidal resection,
cavernous sinus thrombosis
radiation/medical therpy
749. top ddx of diabetes mellitus, diuretics, DI,
743. hyperprolactinemia 1. prolactinoma (MCC),
polyuria/polydipsia primary polydipsia
1. causes antipsychotics, H2 blockers,
2. clinical pres in metoclopramide (DA antagonist), 750. cause of central DI central - dec. release of ADH from
men verapamil, estrogen, pregnancy, cause of posterior pituitary* - idiopathic,
3. clinical pres in renal failure, hypothalamic lesions, nephrogenic DI trauma/surgery, tumors (#1 =
females hypothyroidism, idiopathic breast), sarcoid, TB, syphilis, hand-
2. hypogonadism, dec. libido, schuller-christian, eosinophilic
infertility, impotence, galactorrhea, granuloma, encephalitis
gynecomastia, parasellar signs nephrogenic - lithium use,
3. menstrual irregularities, hypercalcemia, hypokalemia
amenorrhea (prolactin inhibits pyelonephritis, demeclocycline,
GnRH release and thus LH/FSH), mutations in ADH receptor or
vaginal dryness, aquaporin 2 gene
744. hyperprolactinemia 1. elevated serum prolactin,
1. dx pregnancy test (r/o), TSH level (r/o
2. tx hypothyroid),
CT or MRI
2. bromocriptine, cabergoline
(dopamine agonists) for 2 years
surgery
751. diabetes 1. 5-15 liters of urine/day, polydipsia, minimal 754. hypoparathyroidism 1. head and neck surgery,
insipidus hypernatremia (patients drink water) 1. causes THYROIDECTOMY,
1. clinical 2. low urine SG, low osmolarity 2. dx/tx parathyroidectomy,
pres plasma osmolality normal to slightly elevated 2. arrhythmias,
2. dx (280-310) PROLONGED QT, rickets,
3. tx withhold fluids measure hourly, when stable <30 osteomalacia,
mOsm/kg increase, inject 2G desmopressin, neuromuscular irritability
measure urine osmolality in 1 hour numbness/tingling -
nephrogenic - no response with dehydration, no circumoral, fingers, toes
response with DDAVP tetany, hyperactive DTR,
central - no response with dehydration, inc. urine CHVOSTEK SIGN (tap
osmolarity with DDAVP CNVII causes muscle
primary polydipsia - inc. urine osmolality with twitch), TROUSSEAU'S
dehydration, no further response with DDAVP SIGN (carpal spasm w/
3. central DI: DDAVP, chlorpropamide (inc. 3min of BP cuff)
ADH secretion) 3. low calcium, high
nephrogenic DI - sodium restriction, THIAZIDE phosphate, low PTH, low
diuretics urine cAMP
tx = IV calcium gluconate,
752. SIADH 1. neoplasms (lung, pancreas, prostate, bladder,
D3 supplementation, (
1. patho lymphoma, leukemia)
target calcium is 8-8.5)
2. clinical stroke, head trauma, infection
pres pneumonia, TB 755. primary 1. adenoma*, hyperplasia,
positive pressure ventilation hyperparathyroidism carcinoma (<1%) -->
meds - vincristine, NSAIDs, SSRI, 1. patho parathyroids making too
chlorpropamide, oxytocin, morphine, 2. clinical pres much PTH
desmopressin 3. dx 2. nephrolithiasis, bone
2. acute hyponatremia --> brain swelling--> 4. radiographic dx aches/pains, osteitis
lethargy, somnolence, weakness, seizures, coma, fibrosa cystica (brown
death tumors), muscle pains,
chronic hyponatremia - asymptomatic or n/v, pancreatitis, PUD, gout,
anorexia, neuro symptoms less common constipation, depression,
NO EDEMA********* fatigue, anorexia, sleep
disturbances, anxiety,
753. SIADH 1. hyponatremia,
lethargy, nephrolithiasis
1. dx serum hypoosmolality
3. serum calcium/albumin,
2. tx inappropriately elevated urine osmolality
PTH, hypophosphatemia,
low serum uric acid (hemodilution)
hypercalciuria, elevated
low BUN/Cr (diluted)
urine cAMP, Cl:phos ratio
normal thyroid/adrenal
>33:1***
plasma/urine ADH level
4. subperiosteal bone
2. underlying issue
resorption at radial aspect
water restriction, normal saline
of 2nd/3rd phalanges
lithium or demeclocycline (ADH blocker)
if symptomatic - restrict water intake, give 756. primary 1. hyperplasia - remove all
isotonic saline, hypertonic saline in severe cases hyperparathyroidism 4 glands, small amount of
**DO NOT CORRECT FASTER THAN 1. tx tissue implanted in forearm
0.5mEq/L/hour surgical removal of
adenoma (age <50, dec.
bone mass,
nephrolithiasis, marked
elevated serum calcium,
urine calcium >400 mg in
24 hours)
757. pseudohypoparathyroidism end organ PTH resistance -
elevated PTH, low urinary
cAMP, hypocalcemia,
hyperphosphatemia
758. secondary 1. chronic renal failure, vitamin D 763. Cushing syndrome iatrogenic - taper glucocorticoid
hyperparathyroidism deficiency, renal hypercalciuria --> tx pituitary Cushing- transphenoidal
1. patho elevated PTH and low or low surgery
normal serum calcium adrenal Cushing's - adrenalectomy
tx - renal failure - give calcitriol,
764. pheochromocytoma 1. chromaffin cells or sympathetic
oral calcium supplements,
1. patho ganglia--> tumors that produce
phosphate restriction, sinacelet
2. clinical pres catecholamines 90% are adrenal
furosemide (NOT THIAZIDE)
3. lab findings 2. HTN, persistently high with
inc. fluid intake
during a paroxysm paroxysms of severe HTN, pounding
759. cushing syndrome 1. iatrogenic (MCC), cushing's headache, sweating, tachycardia,
1. causes disease (pituitary), adrenal palpitations, anxiety, impending
2. clinical pres adenomas/carcinomas ectopic doom, hypertension assc. with surgery
ACTH (2/3 of SCC of lung, 3. hyperglycemia, hyperlipidemia,
bronchial carcinoma, thymoma) hypokalemia
2. central obesity, hirsutism, moon
765. pheochromocytoma 1. urine screen: metanephrine, VMA,
facies, buffalo hump, striae,
1. dx HVA, normetanephrine (also check
lanugo, acne, easy bruising,
2. tx creatinine to see if good sample)
diabetes, hypogonadism,
plasma metanephrines
masculinization in females
urine/serum epi/norepi - if elevated
(cushing disease), depression,
indicates that the tumor is adrenal or
mania, infections (impaired
organ of zuckerkandl)
immunity)
CT/MRI for tumor localization
760. effects of cortisol impaired collagen production, 2. FIRST - phenoxybenzamine (dec.
enhanced protein catabolism BP) SECOND - beta blocker (dec.
anti-insulin effects/glucose tachycardia)
intolerance surgical tumor resection and ligation
impaired immunity of the venous supply
enhanced catecholamine effects
766. pheochromocytoma 10% are...
761. Cushing syndrome 1. overnight low dose rule of 10s familial, bilateral (MEN II), multiple,
1. dx dexamethasone suppression test: if pediatric, extra adrenal (organ of
serum cortisol <5 this excludes zuckerkandl)
Cushing's syndrome, >5 is
767. primary 1. conns syndrome/adrenal
Cushing's syndrome
hyperaldosteronism hyperplasia/adrenal carcinoma
high dose dex suppression test -
1. patho excessive aldosterone production
>50% suppression = Cushing
2. clinical pres independent of RAAS --> inc. Na/K
disease (pituitary), <50%
pump activity in cortical collecting
suppression = ectopic ACTH
ducts--> sodium
pyelonephritis
retention/HTN/hypokalemia/met.alk*
24 hour urine cortisol >4x normal
2. HTN, headache, fatigue, weakness,
ACTH level - low = adrenal tumor,
polydipsia, nocturnal polyuria, no
high = pituitary source, ectopic
peripheral edema
ACTH
CRH stimulation test- no
response= ectopic ACTH tumor,
positive response = pituitary
Cushing's
762. response to low 1. suppress/suppress/mild increase
dex/high dex/CRH : 2. no suppress/suppress/LARGE
1. healthy INCREASE
2. Cushing disease 3. no suppress/suppress/NO
3. adrenal tumor CHANGE
4. ectopic ACTH 4. no suppress/no suppress/NO
CHANGE
768. primary 1. aldo:renin ratio*** - shows inc.
hyperaldosteronism aldo, dec. renin >30:1
1. dx oral sodium loading - 3 days of high
2. tx salt diet - high aldo + high urine
sodium = + dx
saline infusion test - will not inc.
aldosterone, normal patient will be
<8.5 ng/dL
adrenal venous sampling
renin-aldo stimulation test-
recumbency/upright position +
measure serum aldo
BMP - hypokalemia
CT/MRI of adrenals will show
hyperplasia or adenoma
iodocholesterol scanning
2. surgical resection for adenoma
spironolactone for bilateral
hyperplasia
769. 1. MEN type 1 1. MENIN GENE: parathyroid
2. MEN IIA hyperplasia, pancreatic islet cell 773.
3.MEN IIB tumors, pituitary tumors
2. RET GENE: MTC, pheo,
hyperparathyroidism
3.RET GENE: mucosal neuromas
(nasopharynx, oropharynx, larynx,
conjunctiva)
MTC, Marfanoid body habitus,
pheochromocytoma
770. adrenal non-functioning adrenal tumor,
incidentaloma most are benign, inc risk with inc.
size, resect any tumor >6cm
771. adrenal 1. addisons (MCC), tuberculosis
774.
insuficiency (MCC), cytomegalovirus,
1. primary causes fungal/parasite (cryptococcus,
2. secondary causes pneumocystis, toxoplasmosis),
3. tertiary adrenal iatrogenic, lung/breast mets
insufficiency 2. long term steroid therapy + stress 775.
of surgery/trauma/serious injury -->
symptoms of adrenal insufficiency
3. hypothalamic disease
772. adrenal 1. anorexia, n/v, abdominal pain,
insufficinecy lethargy, confusion, psychosis
1. clinical hypoglycemia (cortisol deficiency)
pres hyperpigmentation (1' deficiency from inc.
2. dx ACTH/MSH breakdown product)
3. tx stress in tolerance
low aldosterone (ONLY*** in 1' adrenal
insuff NOT secondary) --> sodium loss,
hyponatremia, hyperkalemia, hypovolemia,
hypotension, shock, syncope, renal failure
2. low plasma cortisol, high/low plasma
ACTH (1' vs 2'),
Cosyntropin test - infusion of ACTH measure
plasma cortisol: primary = no inc. in cortisol,
secondary = first test no response, second test
4-5 days later WILL get a response
MRI of brain for 2' and 3' disease
3. 1' = daily glucocorticoid and daily
mineralocorticoid
2' = daily glucocorticoid
congenital 1. AUTOSOMAL RECESSIVE 21
adrenal HYDROXYLASE (90%) DEFICIENCY/11
hyperplasia HYDROXYLASE DEFICIENCY--> dec
1. patho cortisol/aldosterone production and inc.
2. clinical ACTH secretion + shunting of intermediates
pres (male toward DHEA and testosterone
vs female) 2. female - ambiguous genetalia but normal
3. salt ovaries/uterus
wasting male - no genital abnormalities
form clinical 3. emesis, dehydration, hypotension, shock
pres1 in first 2-4 weeks of life total lack of aldo
activity --> hyponatremia/hyperkalemia,
hypoglycemia
congenital 1. 17 hydroxyprogesterone elevated
adrenal 2. cortisol and mineralocorticoid
hyperplasia surgery - early correction of female genital
1. dx abnormalities
diabetes 1. autoimmune destruction of beta cells in
mellitus response to environmental/genetic factors
1. patho type (HLA DR/DQ)
1 2. obesity, age, genetic (>type 1) --> inc. fatty
2. patho type acids causes muscle insulin resistance -->
2 beta cells desensitized to glucose, dec. insulin
secretion
776. 1. dawn 1. inc. nocturnal GH secretion inc. morning 782. focus on: feet, vascular disease 1. daily blood glucose
phenomenon hyperglycemia (CAD/PVD), neurologic disease, levels
2. somogyi 2. episodic hypoglycemia at night eye disease, renal disease, 2. HbA1c every 3
effect counterregulation system leads to morning infectious disease months keeping below
3. how to hyperglycemia (2/2 adrenergic response to 7.0
diagnose/treat hypoglycemia) screen for
for the above 3. measure 3am blood glucose - microalbuminuria
Low = somogyi - dec. evening insulin to 1x/year
avoid nocturnal hypoglycemia BUN/Cr 1x/year
High = dawn - inc. evening insulin eye screening yearly by
ophthalmologist
777. diabetes two* fasting blood glucose >126
feet check at every visit
mellitus dx single glucose level >200 with symptoms
yearly LDL (treat if
inc. glucose level on oral glucose tolerance
>100)
hemoglobin A1c >6.5
target BP <130/80
778. diabetes 1. all adults over age 45 every 3 years, test (ACE/ARB)
mellitus anyone with symptoms daily aspirin if >30
1. screening years old
779. impaired fasting blood glucose 110-126 pneumococcal vaccine
glucose 2 hour postprandial 140-200 783. five stages of type 1 diabetes stage 1 - genetic
tolerance dx hemoglobin A1c 5.7 -6.4 susceptibility
780. diabetes polyuria (osmotic retention) stage 2 - autoimmune
mellitus sx polydipsia (to maintain plasma volume) beta cell destruction
fatigue (inc blood glucose) stage 3 - continuded
weight loss (loss of anabolic insulin beta cell destruction
effects) and dec. insulin
blurred vision (swelling of lens from release, glucose
osmosis) normal
fungal infections (candida albicans) stage 4 - insulin
numbness/tingling (neuropathy, dependent C-peptide is
mono=microscopic vasculitis, poly = present
multifactorial) stage 5 - no C - peptide
present
781. diabetes ...
maintenance 784. side effects 1. hypoglycemia,
1. patient 1. sulfonylureas weight gain
monitoring 2. metformin 2. GI upset, n/v,
3. acarbose abdominal pain, lactic
4. TZD (rosiglitazone, acidosis, metallic taste
pioglitizone) 3. GI upset (diarrhea,
- pramlintide, repaglinide, cramping flatulence)
nateglinide 4. hepatotoxicity -
monitor LFTs
785. mechanism 1. stimulates pancreas
1. sulfonylureas to make more insulin
2. metformin 2. enhances insulin
3. acarbose sensitivity, dec.
4. TZD (rosiglitazone, gluconeogenesis in the
pioglitizone) liver
3. reduces glucose
absorption from the GI
tract
4. reduces fat/muscle
insulin resistance
786. advantages 1. cheap 792.
1. sulfonylureas 2. mild weight loss
2. metformin 3. low risk, non-toxic
3. acarbose
4. TZD (rosiglitazone,
pioglitazone)
787. 2/3 rule calculation for insulin kg * 0.5 units/kg =
dosing units/day
- in addition to a regimen, the 2/3 morning (all 793.
patient should use a sliding scale 70/30) or 2/3 NPH,
of intermediate insulin insulin, 1/3 regular
monitor 4 times/day - before 1/3 evening (all
meals and at bedtime 70/30) or 2/3 NPH,
1/3 regular
788. how to decide insulin vs. oral severe hyperglycemia
hypoglycemic and type 1 patients -
>240 use insulin 794.
oral hypoglycemia for
type 2 with moderate
795.
hyperglycemia 110-
240
789. onset/duration 1. 15 min/4hr
1. human insulin lispro 2. 30-60 min/4-6hr
2. regular insulin (only insulin given
3. NPH insulin/lente insulin IV)
4. ultralente insulin 3. 2-4 hr/10-18 hr
5. 70/30 mixture 4. 6-10 hr/18-24 hr
6. glargine (lantus) 5. 30min/10-16 hr
6. 3-4hr/24hr (@
796.
bedtime)
790. modifying insulin dosage for 1. total number of SSI
1. illness, or unclear home insulin regular insulin on
dose day 1 divide into 2/3
2. illness morning 70/30 and
3. before surgery 1/3 evening 70/30
2. normal insulin
dosing - to avoid
DKA
3. 1/3-1/2 of usual
797.
daily insulin
requirement
791. 1. why is diabetic goal BP 130/80 1. accelerated
and LDL <100 atherosclerosis in
2. macrovascular complications diabetics, 2-4x risk of
of DM CAD, MCC death in
3. microvascular complications diabetics is CAD
of DM 2. CAD, PVD (60%),
cerebrovascular
disease
3. diabetic
nephropathy,
diabetic retinopathy,
diabetic neuropathy
diabetic 1. increased GFR**, glomerular
nephropathy basement membrane thickening,
1. pathology hyaline nodular glomerulosclerosis
2. dx (kimmelstiel wilson syndrome),
3. tx diffuse glomerulosclerosis
2. microalbuminuria 30-300mg/day,
albumin:creatinine ratio 0.02-0.2
3. strict glycemic control
progression of microalbuminuria --> progression to
diabetic proteinuria, progressive sclerosis and
nephropathy ESRD
what drugs if *ONCE GET PROTEINURIA
patient has HTN DAMAGE IS IRREVERSIBLE
and AND GLYCEMIC CONTROL
microalbuminuria DOES NOT PREVENT
PROGRESSION ANYMORE***
ACE inhibitors or ...
ARB
diabetic 1. 75% after 20 years of retinopathy
retinopathy 2. hemorrhages, exudates,
1. frequency microaneurysms, venous dilation,
2. background macular edema, asymptomatic if no
3. proliferative retinal edema
4. other ocular 3. NEOVASCULARIZATION and
problems scarring, vitreous hemorrhage, retinal
detachment
4. cataracts, retinopathy, glaucoma
#1 cause of blindness in the US
diabetic 1. stocking glove numbness and
neuropathy paresthesias
1. peripheral ulcer formation, charcot joints,
neuropathy hypersensitivity to light touch,
clinical pres burning pain at night
2. peripheral 2. gabapentin, TCA, pregabalin
neuropathy 3. CNIII palsy - eye pain, diplopia,
treatment ptosis, inability to adduct the eye,
3. CN abnormalties pupils are spared
also CN VI and CNIV
diabetic 1. median nerve, ulnar nerve, common
neuropathy peroneal
1. diabetic lumbosacral plexopathy-
mononeuropathies severe deep pain in thigh,
2. autonomic atrophy/weakness in thigh/hip
neuropathy muscles
truncal neuropathy in distribution of
intercostal nerves
2. impotence in men (MCC),
neurogenic bladder
(retention/incontinence),
gastroparesis (n/v early satiety)
alternating constipation/diarrhea,
postural hypotension
798. does diabetic microvascular by 50%, no clear 804. DKA 1. insulin immediatly - 0.1units/kg of
control help improvement in macrovascular 1. tx regular insulin bolus followed by infusion
micro or of 0.1 units/kg/hour **CHECK
macrovascular POTASSIUM BEFORE STARTING
disease continue insulin until ion gap closes and
metabolic acidosis is corrected , give SC
799. diabetic foot 1. arterial ischemia and neuropathy -->
insulin after patient begins eating
1. patho ulcers/infections, repetitive injuries, masks
IVF immediatly, then 5% glucose once
symptoms of rest pain, falsely elevated BP
blood glucose reaches 250
readings
check BUN/Cr then prophylactically
800. diabetic 1. cellulitis, candidiasis, pneumonia, replace potassium
infections polymicrobial foot ulcers, osteomyelitis
805. DKA ddx alcoholic ketoacidosis
1. which
hyperosmolar hyperglycemic nonketotic
infections
syndrome
801. treatment of 1. risk reduction, aspirin, glycemic control hypoglycemia
diabetic 2. ACE inhibitors (slows sepsis
complications microalbuminuria-->proteinuria, slows intoxication - MUDPILES
1. GFR decline)
806. lab orders blood glucose, CBC, BMP, BUN/Cr,
macrovascular 3. ophthalmology/photocoagulation
when a patient urinary analysis, ECG, CXR, blood
disease 4. NSAIDs, TCA, gabapentin,
presents with cultures
2. metoclopromide,
suspected DKA Start IVF, start insulin, start potassium
nephropathy 5. foot care, podiatry visits
3. retinopathy 807. DKA cerebral edema if glucose is dropped too
4. neuropathy complications rapidly
5. diabetic foot hyperchloremic anion gap acidosis from
too rapid saline infusion
802. DKA 1. more common in type 1 - insulin
1. patho deficiency and glucagon excess --> severe 808. hyperosmolar 1. type 2 diabetics: stress/illness + low
2. causes hyperglycemia and accelerated hyperglycemic insulin --> hyperglycemia --> severe
3. clinical pres ketogenesis,osmotic diuresis, volume nonketotic hyperglycemia, hyperosmolarity,
depletion, metabolic acidosis syndrome dehydration
2. stress or illness, trauma, surgery, sepsis, 1. patho ketones low b/c small amount of insulin
GI bleeding, inadequate insulin 2. clinical pres stops glucagon release
3. n/v, KUSSMAUL RESPIRATIONS 3. dx 2. thirst, polyuria, dehydration/volume
(rapid/deep), abdominal pain, acetone depletion, hypotension, tachycardia
breath odor, orthostasis, CNS: seizures (hyperosmolarity), lethargy,
tachycardia, polyuria, polydipsia, confusion
polyphagia, weakness, drowsiness, or 3. hyperglycemia >900, hyperosmolarity
coma 320 mOsm/L
serum pH>7.3, serum HCO3- >15,
803. DKA 1. hyperglycemia >450, or <850 (recent
elevated BUN (pre-renal azotemia)
1. dx alcohol consumption can produce
euglycemia 809. hyperosmolar 1. ***Fluid replacement - 1L NS in first
met. acid pH <7.3, HCO3- <15 mEq/L, inc. hyperglycemic hour, 2nd liter in second hour, then
anion gap nonketotic switch to 1/2NS
ketonemia/acidosis 1. tx low dose insulin to lower blood glucose
others: hyperosmolarity, hyponatremia (5-10 unit bolus then infusion at 2-4
(dilutional- 1.6mEq/L for every 100mg/dl units/hour)
of glucose), hypokalemia (exacerbated by switch to D5 1/2NS when blood glucose is
treatment with insulin) 250
810. physiologic @ 80 insulin decreases
response to low lower than 80 glucagon increases
blood glucose epinephrine/cortisol are next hormone
@ 50s symptoms of hypoglycemia occur
811. hypoglycemia 1. brain cannot use FFA as an energy 817. zollinger ellison syndrome 1. pancreatic islet tumor that
1. why is source, symptoms correlate with blood 1. patho secretes gastrin leading to
brain so glucose levels 2. anatomic location gastric acid
sensitive to 2. overdosing insulin (see low C-peptide), 3. clinical pres hypersecretion/ulcers (assc
hypoglycemia' anti-insulin antibodies, factitious 4.dx/tx with MEN1)
2. causes hypoglycemia, insulinoma, ethanol 2. gastrinoma triangle -
ingestion (inc. NADH, dec. cystic duct, 2nd/3rd portion
gluconeogenesis), postoperative of duodenum, and pancreatic
hypoglycemia (ex. dumping syndrome), neck inferiorly
adrenal insufficiency, liver failure, glycogen 3. peptic ulcers, diarrhea,
storage diseases weight loss, abdominal pain
4. secretin injection**
812. hypogycemia 1. blood glucose of 40-50, inc epi -->
(normally inhibits gastrin
1. clinical sweating, tremors, inc. BP/pulse, anxiety,
secretion) but in gastrinoma
pres palpitations
paradoxical increase in
2. dx neuroglycopenic sx - irritability, behavioral
gastrin
3. tx changes, weakness, drowsiness, HA,
fasting gastrin, basal acid
convulsions, coma, death
>15 mEq/hour (normal <10)
2. blood glucose <50, serum insulin, C-
tx = PPI, exploration and
peptide, sulfonylurea levels, 72 hour fast
resection
diagnoses insulinoma
3. 1/2-2 ampules D50W, then switch to 818. glucagonoma 1. glucagon producing tumor
D10W when glucose is >100 mg/dL 1. patho of the pancreas
if patient is alcoholic, give THIAMINE 2. clinical pres 2. TRIAD- hyperglycemia,
BEFORE***GLUCOSE to avoid wernickes necrotizing dermatitis,
endcephalopathy weight loss
813. hypoglycemic 1. diabetic neuropathy and blunted 819. necrotizing migratory ...
unawareness autonomic response leads to loss of erythema, glossitis,
1. patho neurogenic symptoms and do not recognize stomatitis, hyperglycemia,
hypoglycemia with low amino acids, high
glucagon
814. insulinoma 1. insulin tumor from beta pancreas cells,
tx = surgical resection
1. patho associated with MEN1, usually benign
2. sympathetic activation - diaphoresis, 820. somatostatinoma 1. TRIAD gallstones, diabetes
tremors, high BP, anxiety 1. clinical pres , steatorrhea
neuroglycopenic symptoms - headache,
821. VIPoma (verner- 1. watery diarrhea(--
visual disturbances, confusion, seizures,
morrison, WDHA >dehydration, hypokalemia),
coma
syndrome) achlorhydria (VIP inhibits
3. WHIPPLE'S TRIAD - fasting
1. clinical pres gastric acid), hyperglycemia,
hypoglycemia symptoms, blood glucose <50
2. dx/tx hypercalcemia
during attack, glucose relieves symptoms
2. CT/MRI, octreod
815. how to insulinoma shows elevated proinsulin
822. what is the #1 cause of stroke aka cerebrovascular
distinguish (>20% insulin level) and sulfonylurea abuse
neurologic disability, and accident
between shows normal proinsulin level (<20%
the 3rd leading cause of
sulfonylurea insulin level)
death
abuse and
insulinoma 823. classes of ischemic stroke TIA, reversible ischemic
neurologic deficit (>24 hours,
816. BOTH have ...
<2wks),
inc. insulin,
evolving stroke - stroke that
dec. glucose,
worsens
and inc. c-
complete stroke - maximal
peptide levels
deficit has occured
824. TIA 1. embolic, hypotension, carotid stenosis - 829. thrombotic stroke 1. patient often awakens from sleep
1. patho -> blockage of blood flow does not last 1. clinical pres with neurologic deficits
2. clinical pres long enough to cause permanent 2. MCA clinical 2. contralateral hemiparesis,
3. future risk infarction pres hemisensory loss
after TIA 2.max 24 hours, usually less than 30 3. lacunar stroke aphasia (left), apraxia, contralateral
4. risk factors mins, but indistinguishable from a stroke clinical pres hemineglect (right parietal), confusion
at time of presentation 4. anterior (non-dominant hemisphere
3. 30% 5 year stroke risk cerebral artery 3. small lacunar vessels --> isolated
4. age, HTN, smoking, afib, HLD, findings, limited deficits
hypercoagulability, vasoconstrictive drugs pos limb internal capsule = pure motor
(cocaine/amphetamines), polycythemia lacunar stroke
vera, sickle cell VPL thalamus = pure sensory lacunar
stroke
825. ischemic 1. heart - embolization of mural thrombus,
ataxic hemiparesis (pos limb IC),
stroke or afib
clumsy hand syndrome (pons),
1. sources of internal carotid, aorta, paradoxical (via
dysarthria (pons)
emboli vein to ASD)
4. contralateral lower extremity/face
2. thrombotic 2. atherosclerotic lesions in the carotid @
stroke bifurcation or MCA 830. causes of carotid murmur referred from the heart
locations 3. HTN/DM causes narrowing of arterial bruit turbulent flow in the internal carotids
3. lacunar lumen by thickening of the vessel wall in
831. stroke 1. CT scan without contrast -
stroke the basal ganglia, thalamus, internal
1. dx / workup differentiates ischemic from
capsule, brainstem
2. complications hemorrhagic - ischemic = dark,
826. source of 1. echocardiogram hemorrhage = bright
embolic stroke carotid doppler MRI - more sensitive - takes longer in
evaluation ECG/Holter monitor emergency setting
ECG - to detect MI or atrial fibrillation
827. symptoms of 1. temporary loss of speech, paralysis,
carotid duplex - detect stenosis
TIA paresthesias of contralateral extremity,
MRA - evaluate carotids,
1. carotid amaurosis fugax (curtain like loss of sight
vertebrobasilar MCA/ACA/PCA, circle
system TIA 2. dizziness, double vision, vertigo,
of willis
2. ipsilateral facial numbness, contralateral
2. cerebral edema/mass effect 1-2 days
vertebrobasilar limb weakness, dysarthria, hoarseness,
after stroke - lower ICP with
TIA dysphagia, projectile vomiting, headaches
hyperventilation/mannitol
3.
hemorrhage into infarction
828. subclavian stenosis of subclavian artery PROXIMAL seizures
steal syndrome to vertebral artery - left arm exercise causes
832. stroke 1. supportive - airway, oxygen, IV fluids
vertebral artery flow reversal -->
1. treatment tPA within 3 hours
vertebrobasilar insufficiency/upper
aspirin if patient presents after 3 hours
extremity claudication
clopidogrel if patient cannot take
tx= surgical bypass
aspirin, if cant take clopidogrel take
ticlopidine
bed 30 degrees to prevent aspiration
BP control ife >220/120, or MAP >130,
acute MI, aortic dissection, heart
failure, hypertensive encephalopathy,
patient is undergoing thrombolysis
833. contraindications > 3 hours after stroke onset
to tPA uncontrolled HTN, bleeding,
anticoagulation, no aspirin for 24
hours after tPA (all inc. risk for
hemorrhagic conversion)
834. stroke control risk factors, aspirin, carotid
1. prevention endarterectomy for symptomatic and
>70% stenosis
835. intracerebral 1. sudden inc. in BP (50-60%), amyloid 841. parkinsons 1. loss of dopamine containing neurons in
hemorrhage angiopathy, anticoagulation/thrombolytic, disease substantia nigra/locus ceruleus, shifts
1. brain tumors, AVM --> rupture of deep 1. pathophys dopamine/acetylcholine balance in the
causes/patho vessels in basal ganglia, pons, cerebellum, 2. clinical basal ganglia toward acetylcholine
2. clinical other pres 2. pill rolling tremor at rest that goes away
pres 2. focal deficits that worsen over 30-90 3. pathologic when performing routine takes,
3. dx minutes , altered LOC, stupor, coma, finding bradykinesia, cogwheel rigidity*,
4. tx headache, inc. ICP expressionless facies/dec. blinking,
3. CT of head **( shows bright white signal) dysarthria, dysphagia, micrographia,
coagulation panel, platelet count impaired cognition, orthostasis,
4. ICU, ABCs, gradual BP reduction constipation, personality changes,
(nitroprusside) if >160/>105 depression, significant disability within 5-
mannitol/diuretics reduce ICP 10 years
surgical evacuation of CEREBELLAR 3. lewy bodies (hyaline inclusion bodies)
hematomas only
842. shy drager parkinsonian symptoms + autonomic
836. 1. inc. ICP, seizures, rebleeding, vasospasm, syndrome insufficiency (orthostasis, constipation, inc.
complications hydrocephalus, SIADH 1. sweating, oily skin, incontinence)
of 2. ICH, ischemic stroke, SAH patho/clincal * risk of laryngeal stridor/bulbar dysfunction
hemorrhagic pres 2. volume expansion - fludrocortisone, salt
stroke 2. tx supplementation, alpha agonists,
2. brain compression devices
complications
843. parkinson 1. no cure
associated
syndrome carbidopa-levodopa (Sinemet) relieves
with cocaine
1. treatment symptoms - shows "on-off" phenomenon
use
bromocriptine, pramipexole (dopamine
837. pupillary pinpoint - pons agonists)
findings in poorly reactive pupils - thalamus selegiline - MAOI ~ L-dopa adjunctive agent
intracerebral dilated pupils - putamen amantadine - for early or mild disease
hemorrhage anticholinergic drugs - trihexyphenidyl
benztropine *best for tremor/rigidity
838. subarachnoid 1. saccular aneurysms at bifurcations of
dominant disease
hemorrhage arteries of circle of willis, trauma, AVM -->
amitriptyline - both anticholinergic and
1. bleeding into subarachnoid space
antidepressant
causes/patho 2. junction of ACA with anterior
DBS for patients that don't respond
2. anatomic communicating, junction of PCA with
medications or develop disease before age 40
locations internal carotid, MCA bifurcation
3. clinical 3. sudden "worst headache of my life", 844. what drugs metoclopramide (gastrokinetic), typical
pres transient LOC, vomiting, meningeal cause antipsychotics, reserpine (antipsychotic-
irritation, nuchal rigidity, photophobia, parkinsonian antihypertensive)
retinal hemorrrhages side effects
839. subarachnoid 1. non-contrast CT scan 845. huntington's 1. AUTOSOMAL DOMINANT chromosome
hemorrhage lumbar puncture if CT scan is inconclusive-- chorea 4 CAG trinucleotide repeat disorder that
1. dx/tx see blood in SAF, and xanthochromia from 1. patho shows genetic anticipation, degeneration of
RBC lysis 2. clinical the GABAergic neurons of the caudate
tx = neurosurgery, pres nucleus
reduce risk of rebleeding, stool softeners, 2. onset between age 30-50, chorea of
analgesia, HTN, lower BP gradually (to face/head/tongue, irritability, personality
account for possible decreased CPP), CCB change, antisocial behavior OCD, impaired
for vasospasm mentation, incontinence dementia before
age 50
840. SAH rerupture, vasospasm, communicating
complications hydrocephalus, seizures, SIADH
846. huntingtons chorea 1. MRI - caudate/putamen atrophy, 852. ataxia 1. autosomal recessive - Frederich's
1. dx/tx bilateral enlarged ventricles telangiectasia ataxia + telangiectasia + increased risk
PET scan - dec. glucose metabolism 1. patho/clinical of cancer (ESPECIALLY NON-
DNA testing, genetic counseling for pres HODGKIN S LYMPHOMA, ALL,
family members STOMACH CANCER,), IgA deficiency
tx= symptomatic, dopamine
853. tourettes 1. AUTOSOMAL DOMINANT -
antagonists help with
syndrome associated with OCD
psychosis/chorea,
1. patho 2. multiple motor tics - blinking,
anxiolytics/antidepressants
2. clinical pres grimacing, head jerking, shoulder
847. physiologic tremor 1. fear, anxiety, fatigue, 3. tx shrugging
1. causes hypoglycemia, hyperthyroidism, phonic tics (>1 kind)- grunting, sniffing,
pheochromocytoma, clearing throat, coprolalia
alcohol withdrawal, valproate, 3. clonidine, pimozide, haloperidol
lithium, caffeine, theophylline
854. dementia 1. progressive loss of intellectual
848. essential tremor 1. autosomal dominant inheritance, 1. diagnostic function, with PRESERVATION OF
1. patho 2, exacerbated by intentional criteria CONSCIOUSNESS, associated with inc.
2. clinical pres activities, DECREASED BY 2. vascular age
3. tx ALCOHOL USE, no parkinsonism dementia 2. stepwise deterioration in intellectual
symptoms present 3. binswanger's function from cerebral infarction
3. propranolol, primidone disease 3. diffuse subcortical white matter
(anticonvulsant, can precipitate degeneration in patients with
acute intermittent porphyria attack- atherosclerosis/HTN
abdominal pain, confusion,
855. primary causes alzheimer's disease, vascular dementia,
headache, hallucinations - check
of dementia binswanger's disease, brain tumors,
UA)
chronic subdural hematomas, NPH, lewy
849. different tremors 1. tremor at REST, pill rolling, body dementia, picks disease, MS,
clinical associated with rigidity, parkinsons, huntington, wilsons
pres/associated bradykinesia, shuffling gait,
856. infectious HIV infection (AIDS dementia),
symptoms improved by action
causes of neurosyphilis, cryptococcus, CJD,
1. parkinsonian 2. intention tremor, coarse,
dementia progressive multifocal
2. cerebellar associated with ataxia, nystagmus,
leukoencephalopathy
3. essential tremor dysarthria, improved by rest
3. associated with postures - ex. 857. metabolic thyroid disease, B12 deficiency, thiamine
outstretched hands, fine tremor, causes of deficiency (--> korsakoff dementia),
associated with head tremor or dementia niacin deficiency
vocal tremulousness, improved by 858. what toxins chronic alcoholism, aniline dyes, lead,
alcohol cause dementia mercury
850. ataxia 1. alcohol, B12/thiamine deficiency, 859. pseudodementia severe depression that can cause a
1. causes cerebellar infarction, neoplasm, decline in cognition but is responsive to
(acquired/inherited) demyelinating disease (MS/HIV), antidepressants
tabes dorsalis patients are overly concerened about
inherited = friedreich's ataxia, their memory loss
ataxia telangiectasia
860. 1. dementia lab 1. CBC with diff, chemistry panel, TSH,
851. friedreich's ataxia 1. Autosomal recessive chromosome workup B12, folate, VDRL, HIV screening, CT or
1. patho/clinical pres 9 defect --> degeneration of dorsal 2. dementia MRI of head
columns, corticospinal tract, pharmacologic 2. vitamin E, tacrine, donepezil
spinocerebellar tracts, cerebellum treatment
Clinical pres= ataxia , nystagmus,
impaired vibratory sense,
proprioception, kyphoscoliosis
861. alzheimers 1. age : 10-15% of people over age 65, 15- 867. delirium 1. rapid deterioration of mental status,
disease 30% over age 80 1. clinical FLUCTUATING LEVEL OF
1. risk factors family history, downs syndrome, pres CONSCIOUSNESS, disorientation, frequently
2. pathology chromosome 21, 14, 19 abnormalities, loss 2. dx/tx abnormal vital signs, may include
findings of CHOLINERGIC neurons* hallucinations
3. dx/tx 2. senile plaques- dilated, tortuous neuritic 2. MMSE, chemistry panel, B12, thiamine
plaques around beta amyloid core, tx = underlying cause, haloperidol for
neurofibrillary tangles - in cytoplasm of agitation, supportive
neurons
868. ddx for SMASHED
3. clinical diagnosis, CT or MRI shows
coma/stupor structural brain pathology - stroke,
diffuse cortical atrophy with
subdural/epidural, tumor, abscess,
ventriculomegaly
herniation
tx = cholinesterase inhibitors - donepezil,
meningitis, mental illness
rivastigmine, galantamine
alcohol, acidosis
memantine - NMDA antagonist
seizures, substrate deficiency (thiamine)
ginkgo, lecithin
hypercapnia, hyperglycemia, hyperthermia,
vitamin E 2000IU/day
hyponatremia hypoglycemia, hypoxia
HRT associated with lower risk of
endocrine - addisonian crisis, thyrotoxicosis,
alzheimers disease
hypothyroidism, encephalitis (uremia)
862. alzheimers 1. early - forgetfulness, impaired ability to drugs - opiates, barbiturates, benzos,
disease learn, poor performance, change in dangerous compounds - monoxide, cyanide,
1. clinical pres judgement methanol
intermediate - progressive memory
869. coma 1. decreased LOC, patient unresponsive to
impairment, visuospatial disturbances
1. criteria any stimuli
later stages- help needed for daily living,
2. causes 2. bilateral structural brain lesions, or
difficulty remembering names of relatives
3. diagnosis brainstem, or cerebellum, or RAC damage,
advanced- complete debilitation, loss of
global brain dysfunction - metabolic or
bowel/bladder control,
systemic disorders
death 2/2 infection
psychiatric - conversion, malingering
863. lewy body 1. visual hallucinations predominant 3. ABC, assume trauma, stabilize cervical
dementia initially, disorganized speech, spine, assess LOC (via GCS)
1. clinical pres extrapyramidal symptoms, fluctuating asymmetric movement = most likely mass
2. tx mental status, faster progression lesion
2. selegiline, neuroleptic agents (for pupillary light reflex - indicates midbrain
hallucinations/psychosis) intact, morphine, anoxic encephalopathy,
bilateral fixed/dilated (severe anoxia),
864. altered mental 1. RAC in brainstem
unilateral fixed /dilated uncla herniation,
status 2. cerebral cortex
pinpoint pupils - ICH, narcotics
1. what part of
independent breathing - intact brainstem
the brain is
toxicologic analysis
responsible for
CT or MRI of brain
arousal
LP if suspect meningitis or SAH
2. what part of
the brain is
responsible for
cognition
865. causes of P.DIMMWIT
delirium postoperative, dehydration/malnutrition,
infection, medications, metals,
withdrawal stages, inflammation/fever,
trauma/burns
866. what drugs can TCAs, corticosteroids, anticholinergics,
cause delirium hallucinogens, cocaine
870. coma 1. correct cause: airway, supp. o2, naloxone, 874. multiple 1. high dose IV methylprednisone for acute
1. dextrose, thiamine before glucose, BP, sclerosis attack
treatment electrolytes, lower ICP if herniation 1. tx plasma exchange therapy for steroid refractory
2 brain 2. irreversible absence of brain/brainstem acute attacks
death function, no brainstem reflexes (pupils, calorics, DMT- interferon B1a, B1b, glatiramer acetate
3. gag, cornea, dolls eyes) reduce relapse rates by 35% (SE is flu like
persistent no drug intox or metabolic condition symptoms)
vegetative core body temp >32 C cyclophosphamide for rapidly progressing
state clinical evidence or CT/MRI shows causative disease
explanation for brain death baclofen or dantrolene for spasticity
repeat examinations, or EEG shows isoelectric carbamazepine or gabapentin for neuropathic
activity pain
3. comatose, but eyes are open, appear awake,
875. locked in 1. patients completely paralyzed except for
may have random limb/head movements,
syndrome respiration, blinking, and vertical eye
spontaneous respirations
1. clinical movement, patients are fully aware of their
871. multiple 1. selective CNS white matter demyelination of pres surroundings and can feel pain
sclerosis the brain and spinal cord, classically at the 2. patho 2. hemorrhage or infarction of the ventral pons
1. patho angles of the ventricles, pyramidal, cerebellar
876. guillain 1. mycoplasma, campylobacter jejuni, CMV,
2. clinical pathways, MLF, optic nerve, posterior columns
barre hepatitis, HIV, hodgkins disease, lupus, HIV
pres 2. transient sensory deficits, paresthesias/dec.
syndrome seroconversion --> inflammatory
sensation of upper/lower limbs, fatigue*,
1. patho demyelinating polyneuropathy of peripheral
weakness/spasticity, leg stiffness, optic neuritis,
2. clinical nerves
central scotoma, dec. pupillary reaction,
pres 2. abrupt onset of ascending symmetric
INTERNUCLEAR OPHTHALMOPLEGIA
weakness/paralysis of all four extremities,
(adduction deficit), bilateral trigeminal
PRESERVED SENSORY* respiratory, facial,
neuralgia
bulbar muscles, spares sphincter
cerebellar involvement- ataxia, intention tremor,
control/mentation
dysarthria,
autonomic features - arrhythmias, tachycardia
incontinence, impotence, constipation
memory loss, personality change, emotional 877. guillain 1. **CSF shows elevated protein**, normal
lability, anxiety, depression barre cell count, dec. NCV on EMG
neuropathic pain/hypersesthesas 1. dx/tx tx= pulmonary monitoring/mechanical
ventilation, IVIG, plasmapheresis,
872. multiple 1. clinically definite - two episodes, evidence of
DO NOT GIVE STEROIDS IN GUILLAIN
sclerosis white matter lesions clinical or imaging
BARRE SYNDROME
1. dx laboratory supported - two episodes of
recovery usually occurs in 1-3 weeks, but if
symptoms, at least one white matter MRI lesion,
persists >6 weeks probably will have relapsing
abnormal CSF
course
probable MS- two episodes of symptoms, and
either one white matter lesion, or oligoclonal 878. myasthenia 1. autoimmune disorder against nicotinic Ach-
bands gravis R, results in muscle fatigue especially rapidly
evoked potentials - remyelinated neurons 1. patho stimulated muscles
conduct slowly 2. clinical 2. skeletal muscle weakness exacerbated by
pres use, involves cranial nerves
873. multiple clinically silent - stable or benign disease
3. first symptoms often diplopia, ptosis, blurred
sclerosis relapsing and remitting -
myasthenic vision, dysarthria, dysphagia
1. clinical primary progressive - onset typically later
crisis + tx 3. infection or stressor -->
course 1/3 of patients develop debilitating disease
diaphragm/intercostal fatigue results in
respiratory failure
ET tube + withdrawl anticholinesterases +
plasmapheresis
879. myasthenia gravis 1.anti- Ach-R test 885. tuberous AUTOSOMAL DOMINANT - cognitive
1. dx EMG shows decremental response sclerosis impairment, epilepsy, facial angiofibromas,
CT scan of thorax to rule out 1. adenoma sebaceum, retinal hamartomas,
thymoma (10% of patients 75% patho/clinal renal angiomyolipomas, rhabdomyomas of
histologically abnormal) pres the heart, retinal hamartomas
edrophonium tensilon test - hard nodules throughout the brain,
tx = pyridostigmine, seizures, mental retardation
thymectomy - can cause complete
886. sturge weber 1. facial vascular nevi capillary
remission
1. angiomatosis of the pia (ipsilateral to
3rd line agents: corticosteroids,
patho/clinical vascular nevi)
azathioprine, cyclosporine
pres epilepsy, mental retardation
IVIG for exacerbations
serial FVCs <15 ml/kg = indication for 887. von-hippel 1. AUTOSOMAL DOMINANT - cavernous
intubation lindau hemangiomas of the brain stem, renal
disease angiomas and multiple organ cysts, assc.
880. duchenne's 1. X LINKED RECESSIVE - mutation
1. with RCC, assc. with pheochromocytoma
muscular in dystrophin causes muscle fibers to
patho/clinical
dystrophy die and replaced by fibrous scar tissue
pres
1. patho 2. progressive, symmetric proximal
2. clinical pres muscle weakness, especially the pelvic 888. syringomyelia 1. abnormal collection of fluid in the spinal
3. dx/tx girdle 1. cord parenchyma--> bilateral loss of
Gowers maneuver (proximal lower patho/clinical pain/temp sensation in a cape like
extremity weakness), pres distribution with preservation of fine touch,
pseudohypertrophy (fat replaces 2. associated areflexia, fasciculations, muscular atrophy
muscle), wheelchair confinement, conditions 2. arnold chiari, post traumatic/infectious,
respiratory failure/death by third intramedullary tumors
decade. 889. brown 1. cord hemisection - fracuture/stab wound -
3. serum CK, muscle biopsy, DNA sequard -> contralateral loss of pain/temperature,
testing syndrome ipsilateral loss of position/vibration,
881. Becker's muscular 1. x linked recessive, similar to 1. patho ipsilateral hemiparesis
dystrophy duchennes muscular dystrophy but 890. transverse 1. post-viral --> thoracic spine
less severe, some dystrophin present myelitis demyelination --> weakness, back pain,
882. what drugs aminoglycosides, tetracyclines 1. sensory deficits, sphincter disturbance
exacerbate beta blockers patho/clinical 2. MRI with contrast
myasthenia gravis quinidine, procainamide, lidocaine pres tx = high dose steroid therapy

883. neurofibromatosis 1. AUTOSOMAL DOMINANT 891. horners cervical sympathetic disruption -->
type 1 DISEASE NF1 - cafe au lait spots, syndrom ipsilateral ptosis (levator palpebrae still
1. patho/clinical macrocephaly, short stature, learning 1. intact), miosis, anhidrosis
pres disabilities neurofibromas, CNS patho/clinical 2. idiopathic, pancoast tumor (superior
2. complications tumors (gliomas, meningiomas), pres sulcus), internal carotid dissection,
axillary or inguinal freckling, iris 2. causes brainstem stroke, neck trauma
hamartomas (lisch nodules), bony 892. poliomyelitis 1. anterior horn destruction and motor
lesions 1. patho neuron destruction of the spinal cord-->
2. scoliosis, disfiguring 2. tx asymmetric weakness inc. in the legs,
neurofibromas, scoliosis, optic nerve absent DTRs ,flaccid atrophic muscles,
gliomas*, renal artery stenosis, normal sensation
884. neurofibromatosis 1. AUTOSOMAL DOMINANT - 2. no treatment available
type 2 bilateral acoustic neuromas*, multiple 893. dizziness 1. pre-syncope, vertigo, multisensory stimuli
1. patho/clinical meningiomas, cafe au laits, 1. causes (profound shock or overwhelming sensory
pres neurofibromas, cataracts 2. dx overload), cerebellar disease, cardiovascular
2. complications disease, TIAs, hyperventilation, anxiety,
2. audiogram, CT/MRA, MRI of posterior
fossa
894. 1. central vertigo 1. gradual onset, look for 900. what must be HCM, aortic stenosis, + other causes
2. peripheral cardiovascular risk factors, considered if of cardiac syncope
vertigo nystagmus can be bidirectional or patient has syncope
vertical, dysarthria, dysphagia, on exertion
diplopia, facial numbness, weakness,
901. seizures vs. seizures tend to be longer
hemiplegia ~ ie. significant neuro
syncope seizures bladder control is lost,
deficits associated
syncope bladder control is retained
2. cochlear or retrocochlear - abrupt
onset, head position has strong effect, 902. evaluation of history - before, during, after
brainstem deficits absent except syncope syncopal episode, patient meds,
tinnitus witnesses
physical exam - BP/pulse in 3
895. peripheral vertigo 1. vertigo associated with position
positions, MS, murmurs, carotid
1. benign positional change, usually in patients >60 years
pulses
vertigo + tx of age 2/2 labyrinthine dysfunction
ECG**, CBC, CMP
2. menieres tx = meclizine
holter monitoring, tilt table testing,
disease + tx 2. TRIAD - vertigo, tinnitus, hearing
CT scan, EEG, echocardiogram,
loss
attacks last for hours to days and 903. seizure 1. sudden abnormal discharge from
recur 1. definition the brain
hearing loss becomes permanent 2. epilepsy 2. recurrent idiopathic seizures
tx = sodium restriction, diuretics definition 3. four Ms, four Is
3. causes metabolic/electrolytes -
896. peripheral vertigo 1. viral infection of cochlea and
hyponatremia, hypo/hyperglycemia,
1. acute labyrinth
hypocalcemia, uremia, thyroid storm,
labyrinthitis 2. aminoglycosides, furosemide,
hyperthermia
2. ototoxic drugs aspirin, cyclophosphamide
mass lesions - tumors, hemorrhage
3. acoustic 3. 8th CN, ataxia, gait unsteadiness,
missing drugs - non-compliance with
neuromas nystagmus, hearing loss, tinnitus
anticonvulsants, withdrawal from
897. central vertigo MS, vertebrobasilar insufficiency, alcohol/benzo/barbiturates
1. casues migraine associated vertigo 4 Is = intoxications, infections,
ischemia, inc. ICP
898. syncope 1. transient loss of
1. definition consciousness/postural tone 904. H&P for patient witness account
2. cardiac syncope secondary to decreased cerebral blood who just had a baseline, anticonvulsants, recent
clinical pres flow + rapid recovery of consciousness seizure dose changes, seizure disorder
3. vasovagal without resuscitation examine for head inj, spine fractures,
syncope 2. sudden without prodrome - face hits tongue lacerations, bowel/bladder,
(neurocardiogenic, floor- from arrhythmias, aortic papilledema/signs of inc. ICP
vasodepressor, stenosis, HCM, pulmonary HTN, do complete neuro exam
simple faints) + dx prolapsed mitral valve, massive MI
905. 1. pseudoseizures 1. psychiatric in origin, diagnose
+ tx 3. MCC syncope - emotional stress,
2. which drugs with EEG
fear, fatigue, diagnose with the *TILT
(intoxications) can 2. cocaine, lithium, lidocaine,
TABLE STUDY - patient will have
cause seizures theophylline, mercury/lead
symptoms when upright or standing,
3. what infections poisoning, CO poisoning
but not when supine
can cause seizures 3. septic shock, bacterial or viral
tx = supine posture, elevate legs, B-
4. what ischemic meningitis, brain abscess
blockers, disopyramide
events can cause 4. strokes, TIAs
899. syncope 1. ganglionic blockers, DM***, old seizures
1. orthostatic age, bed rest - defect in vasomotor -inc. ICP (4 Ms and
hypotension + reflex , common in elderly, diuretics 4 Is)
dx/tx TILT TABLE TEST POSITIVE
906. treatment for magnesium infusion
- also consider tx= inc. sodium intake, inc. fluid
eclampsic seizure
vertebrobasilar intake, fludrocortisone
TIA, hypoglycemia,
hyperventilation,
hypovolemia,
907. epilepsy 1. begins in one part of the brain and 912. status prolonged sustained unconsciousness with
1. partial produces symptoms referable to that part of epiliepticus persistent convulsive activity - 20% mortality,
seizure that part of the brain caused by med non-compliance, alcohol
2. simple 2. CONSCIOUSNESS REMAINS INTACT- withdrawal, intracranial infection,
partial may progress to a complex partial, may have neoplasm, metabolic disorder
seizure unilateral clonic tonic movement
913. Amyotrophic 1. anterior horn/corticospinal tract
3. complex 3. CONSCIOUSNESS IMPAIRED, postictal
lateral degeneration --> upper AND lower motor
partial confusion, automatisms*** last from 1-3
sclerosis neuron signs onset between age 50-70
seizure minutes- inc. lip smacking, chewing,
1. patho 80% mortality at 5 years
4. gneralized aggression, olfactory/gustatory
2. clincal 2. PROGRESSIVE MUSCLE WEAKNESS -
sizure hallucinations
pres first in arms/legs (DISTAL), no pain,
4. LOSS OF CONSCIOUSNESS - disruption
cramping, spasticity, fasciculations*,
of entire brain activity
impaired speech/swallow-->aspiration,
two types - tonic clonic, absence
DOE, orthopnea, respiratory failure
908. epilepsy 1. aka grand mal bilaterally symmetric and (terminal)
1. tonic clonic without focal onset, begins with loss of PRESERVATION of bowel/bladder,
2. absence consciousness, tonic phase (rigidity/risk of sensation, cognition, extraocular, sexual
^ both of the apnea), clonic phase (jerking), flaccid function
above are phase, regain consciousness - both upper and lower motor neuron signs
generalized postictal confusion for 10mins - hours
914. Amyotrophic 1. EMG*/ NCV - confirms lower motor
seizures 2. school age children- patient stares into
lateral neuron disease,
space, looks absent minded, each episode
sclerosis two regions (probable), or three-four regions
several seconds , may include, tongue biting,
1. dxt/tx (definite) - bulbar (face, larynx, tongue, jaw),
vomiting, apnea, incontinence, no loss of
cervical, thoracic, lumbosacral
postural tone
tx = supportive,
909. epilepsy 1. first seizure - CBC, electrolytes (*esp. Ca, riluzole - glutamate blocker, delay death by 3-
1. dx Na, glucose, BUN*), blood glucose, LFTs, 5 months
BUN/Cr, serum calcium urinalysis
915. epilepsy tx = airway, IV diazepam, IV phenytoin, 50
EEG - abnormal EEG is not necessarily a
1. tx mg dextrose, IV phenobarbital if resistant
seizure, and a patient may have a normal
Long term tx - only treat patients with
EEG after a seizure
abnormal EEG, MRI, or >1 seizure:
CT of head to identify structural lesions
phenytoin*, carbamazepine
MRI of brain with and w/o gadolinium -
2nd line - valproate, phenobarbital,
LP and cultures if patient is febrile
primidone
910. epilepsy tx ABCs- secure airway, roll patient on side to absence seizures - ethosuximide, valproic
prevent aspiration acid
history of non-compliance with anti- B-HCG in women before starting drug
convulsants (teratogenic)
one drug therapy, inc. dose, then add second
916. aphasia 1. loss or defect of language (speaking,
agent if neccessary
1. definition fluency, reading, writing, comprehension)
If seizures controlled for 2 years, taper very
2. patho 2. injury to the left cerebral hemisphere
slowly, and with EEG monitoring
(dominant in 95% of right handed people),
first seizure--> EEG/neuro consult,
for left handed people 50% are left dominant-
anticonvulsant therapy
- stroke, trauma, brain tumor, alzheimers
911. seizure risk 15% vs 41% disease
of recurrence
with normal
EEG vs
abnormal
EEG
917. aphasia 1. receptive, fluent aphasia - patient cannot 924. brainstem crossed hemiplegia - ipsilateral face,
1. wernicke's comprehend written or spoken language, clinical pres contralateral body deficits
aphasia speech is grammatically correct but doesn't (localization)
2. brocas make sense, patients cannot understand
925. spinal cord spinal shock, upper motor neuron signs
aphasia their own words
clinical pres UMN signs - spasticity, inc. DTR, clonus,
3. conduction 2. expressive, non-fluent aphasia, no
(localization) pos. babinski
aphasia grammatical construction, good
decrease in sensation below a sharply
4. global comprehension
demarcated band
aphasia 3. disturbance in repetition, defect in arcuate
fasciculus 926. plexopathy trauma is MCC, deficits are in more than
4. disturbance in all areas of language clinical pres one nerve, , post-surgical hematoma is
function - comprehension, speaking, (localization) MCC of lumbosacral plexopathy
reading, fluency associated with right Erb C5-C6, Duchenne C8-T1
hemiparesis Lumbosacral plexus L5-S3

918. EMG/NCV 1. EMG fibrillations/fasciculations at rest, 927. radiculopathy effects a myotome and a dermatome -
findings dec. NCV (GB, MG, MS), clinical pres weakness
1. lower motor 2. repetitive stimulation causes fatigue (localization) and dermatomal sensory deficit
neuron 3. no electrical activity at rest, dec. 928. peripheral diabetes/trauma/entrapment/vasculitis --
disease amplitude with muscle contractions neuropathy > distal nerve injury typically asymmetric,
2. myasthenia clinical pres dec.DTRs, can include numbness,
gravis (localization) paresthesias, tingling, muscle atrophy,
3. myopathy fasciculations
919. bells palsy 1. idiopathic, HSV, borrelia, GB, tumor --> diabetes --> nerve infarction
1. swelling of CN VII leading to hemifacial common locations -
causes/patho weakness/paralysis--> full recovery in radial/ulnar/median/musculocutaneous,
2. dx weeks to months long thoracic, axillary, femoral
3. tx 2. consider lymes disease, clinical diagnosis 929. neuromuscular FATIGABILITY, recovery with rest
3. usually no treatment required junction
EMG if persists >10 days, short course of clinical pres
steroid/acyclovir (localization)
patch eye to prevent abrasion
930. myopathy 1. symmetric weakness of proximal >
do not use steroids if lyme is suspected
clinical pres distal muscles, patient has normal reflexes
920. trigeminal 1. idiopathic --> severe lancinating pain, no (localization) (initially), normal sensation, no
neuralgia (tic motor or sensory paralysis fasciculations
douloureux) 2. dx - clinical dx, MRI to rule out
1. cerebellopontine angle tumor
patho/clinical tx= carbamazepine***,
pres baclofen, phenytoin, surgical
2. dx/tx decompression
921. cerebral sensory motor deficits of the contralateral
cortex lesions face/trunk/extremities, upper extremities
clinical pres worse than lower extremities
(localization) aphasia if left hemisphere, visual spatial
deficits if right hemisphere
922. subcortical internal capsule, cerebral peduncles,
lesions thalamus, pons -
clinical pres COMPLETE hemiparesis (compare to
(localization) cortical lesion)
923. cerebellar incoordination, intention tremor, ataxia
lesion clinical
pres
(localization)
931. systemic lupus 1. genetic/environ/hormonal --> 936. 1. C-anca 1. wegeners granulomatosis
erythematosus autoantibodies, deposition of immune 2. P-anca 2. polyarteritis nodosa
1. patho complexes, complement activation, tissue 3. lupus 3. antiphospholipid
2. subtypes of destruction/vasculitis --> damage to anticoagulant 4. sjogrens, subacute cutaneous SLE,
lupus multiple organ systems 4. anti-Ro, complement deficiency (C2/C4), ANA
3. clinical pres 2. spontaneous, discoid, drug induced, anti-La negative lupus
ANA negative 5. ESR/CRP 5. infection, malig, rheumatologic disease,
3. fatigue, malaise, fever, weight loss tissue necrosis, preg, vasculitis,
butterfly rash, photosensitivity, discoid pancreatitis
lesions, alopecia, raynauds, joint pain,
937. systemic lupus 1. avoid sun, NSAIDs, local or systemic
arthritis (symmetric inflammatory),
erythematosus corticosteroids
myalgia, pericarditis**, libman sachs
1. tx antimalarials - hydroxychloroquine - req.
endocarditis, myocarditis
annual retinal exam
pleuritis*, pleural effusion
cyclophosphamide -for glomerulonephritis
hemolytic anemia,
monitor renal function/HTN
leukopenia,lymphopenia,
thrombocytopenia 938. scleroderma 1. cytokines stimulate fibroblasts cause inc.
proteinuria >0.5g/day, azotemia, (systemic collagen deposition + widespread fibrosis
glomerulonephritis, pyuria sclerosis) 2. raynauds**, ulceration, gangrene
impaired immune response 1. patho periungual telangiectasias
n/v, dyspepsia, dysphagia PUD 2. clinical pres mat telangiectasia - 2-7mm on the
seizures, psychosis, depression, face/hands
headaches, TIA, CVA cutaneous fibrosis/ SCLERODACTYLY
conjunctivitis, raynauds, sjogrens GI- dysphagia, reflux from esophageal
syndrome dysmotility
pulm- interstitial fibrosis**** or pulm HTN
932. ANA negative 1. raynauds, arthritis, subacute cutaneous
(only 10%)
lupus lupus
pericardial involvement, pericardial
1. clinical pres 2. anti-Ro (SS-A) positive, ANA negative
effusions, CHF, arrhythmias
2. dx anti- Ro is risk for neonatal lupus
renewal crisis- rapid malignant
3. neonatal 3. skin lesions, AV block, transposition of
hypertension
lupus clinical great vessels, valvular and septal defects
pulmonary artery hypertension/right heart
pres
failure
933. systemic lupus 4 or more:
939. drug induced 1. drug induced lupus like syndrome that
erythematosus mucocutaneous signs - rash, photosens,
lupus DOES NOT AFFECT the CNS or kidneys
1. dx oral or nasopharyngeal ulcers, discoid
1. patho 2. hydralazine, procainamide, isoniazid,
rash,
2. what drugs chlorpromazine, methyldopa, quinidine
arthritis, pericarditis, pleuritis, hemolytic
3. dx 3. anti-histone positive***, ANA positive,
anemia, leukopenia, thrombocytopenia,
no anti-dsDNA/anti-Sm
proteinuria,
seizures, psychosis, VDRL positive 940. scleroderma 1. ANA positive, anti-centromere positive
positive ANA screening 1. dx/tx (for CREST), anti-topo 1 (anti- Sc-70)
anti-dsDNA (correlates with disease barium swallow and PFT detects common
activity), anti-Sm, anti-histone esp. in drug complications
induced lupus, tx = no cure,
anti-Ro(SS-a), anti-La(SS-B) assc. with symptomatic treatments - NSAIDS for pain,
sjogrens, subacute cutaneous SLE, H2 blockers
avoid cold/smoking, CCBs to prevent
934. neonatal lupus ...
raynauds
CBC, bun/Cr,
treat pulm/renal complications
urinalysis,
serum 941. CREST calcinosis of the digits, raynauds,
electrolytes syndrome esophageal dysfunction, sclerodactyly,
telangiectasias (mat like patches over
935. conditions SLE, RA, scleroderma, sjogren's, mixed CT
digits/under nails and on the face)
with elevated disease, polymyositis, dermatomyositis,
- more limited than diffuse scleroderma
ANA drug induced lupus
942. ddx for raynauds primary raynaud's, scleroderma, SLE, 948. rheumatoid 1. autoimmune disease of the joint
mixed CT disease, buerger's vasculitis, arthritis synovium + extraarticular manifestations
beta blockers, nicotine, bleomycin, 1. patho (IgG anti-Fc IgG)
thromboangiitis obliterans 2. clinical pres 2. inflammatory polyarthritis that spares
3. the DIPs, morning stiffness*** pain
943. what CREST does not involve renal, lung, and
extraarticular commonly includes hands (MCP, PIP),
distinguishes heart early in the disease
manifestations knees, ankles, elbows, hips, shoulders,
CREST from anti-centromere positive
ulnar deviation of MCP joint, boutonniere's
diffuse
deformity of PIP, swan neck contractures,
scleroderma
inc. atlanto occipital instability
944. antiphospholipid 1. hypercoagulable state associated with 3. low grade fever, weight loss,
syndrome SLE or other collagen vascular disease pericarditis, pericardial effusions,
1. patho 2. recurrent venous thrombosis, conduction abnormalities, valvular
2. clincal pres recurrent fetal abortion, incompetence, pleural effusions,
3. dx/tx thrombocytopenia, livedo reticularis interstitial fibrosis (similar to IPF),
3. lupus anticoagulant anti-cardiolipin episcleritis, scleritis, sjogrens xerostomia,
antibody, PTT or PT is prolonged , and rheumatoid nodules over extensor surfaces
not corrected with adding normal and organs
plasma
949. rheumatoid 1. thin, atrophic easy bruising, ulcerations,
tx = long term anticoagulation INR 2.5-
arthritis rheumatoid nodules
3.5
1. skin 2. pleural fluid with low glucose/high
945. sjogrens 1. lymphocytic infiltrates destroy 2. pulm protein/high LDH, pulmonary fibrosis,
syndrome lacrimal and salivary glands - can also 3. cardiac restrictive PFTs CXR shows honeycomb
1. patho involve lungs, skin, thyroid, vessels, 4. ocular 3. rheumatic nodules, pericarditis (40%)
2. primary liver 5. nervous 4. scleritis, scleromalacia (softening of
sjogrens 2. dry eyes, dry mouth but no other system sclera), dry eyes
3. secondary rheumatologic disease 6. felty's 5. mononeuritic multiplex - infarction of
sjogren's 3. dry eyes, dry mouth and connective syndrome nerve trunk,
tissue disease (RA, systemic sclerosis, 7. blood 6. RA, neutropenia, splenomegaly,
SLE, polymyositis, inc. risk of non- 8. vasculitis anemia, thrombocytopenia,
hodgkins lymphoma),. patients have lymphadenopathy,
dry eyes, dry mouth, arthralgias, 7. AOCD, normocytic, normochromic
fatigue, chronic arthritis, interstitial anemia
nephritis, vasculitis 8. microvascular vasculitis, can progress to
946. sjogrens disease 1. ANA, anti-Ro(SSA), anti-La (SSB), mesenteric vasculitis, PAN
1. dx inc. ESR, normocytic normochromic
2. tx anemia, leukopenia, schirmers test
2. pilocarpine, or cevimeline, artificial
tears, good oral hygiene, NSAIDs,
steroids for arthralgias/arthritis
947. mixed connective 1. has many features of SLE, RA,
tissue disease systemic sclerosis, and polymyositis
1. patho 2. anti-U1-RNP, ANA, anti-RF
2. dx
950. rheumatoid arthritis 1. high RF titers, subQ nodules,
953. erosive
arthritis- 1. insidious/weight bearing
1. poor prognostic indicators arthritis, autoantibodies to RF onset/location/presence joints/no inflam/narrowed joint
2. dx 2. inflammatory arthritis of 3 or more
of inflam/XR/labs/other space, osteophytes, subchondral
3. tx joints, symptoms >6 weeks, 1. osteoarthritis sclerosis/subchondral cysts
high anti-RF titers (higher titers=2.poorer
RA 2. insidious/PIP, MIP, wrists,
prognosis), anti-ACPA, anti-CCP3. gouty arthritis ankles, knees, ulnar deviation,
inc. ESR/CRP swan neck deformity, boutonniere
AICD deformity/yes inflam/narrowed
XR- loss of juxta articular bone mass joint space, bony EROSIONS/inc.
near finger joints, NARROWING of joint ESR, RF, anemia/extra-articular
space findings
3. tx exercise , NSAIDs, low dose 3. sudden/great toe, knees, ankles,
corticosteroids, elbows/Yes inflamm/punched out
DMARDs- MTX - SE= GI upset, oral erosions with rim of cortical
ulcers, alopecia, bone marrow bone/crystals/tophi,nephrolithiasis
suppression, hepatocellular injury,
954. gout 1. asymptomatic, 40-60 years old,
interstitial pneumonitis
1. clinical pres initial attack typically one joint,
supplement MTX with folate
2. chronic tophaceous often first MTP (podagra), pain,
sulfasalazine
gout erythema, warmth, desquamation
etanercept, infliximab - anti-TNF, use if
of overlying skin, 60% have second
MTX does not control the disease
attack within one year,
leflunomide
2. >10-20 years, tophi-
hydroxychloroquine - eye exam every 6
aggregations of urate crystals
months from retinopathy
surrounded by giant cells 2/2
951. Gout 1. OBESITY/ALCOHOL/PURINE multiple gout attacks- located: ext.
1. causes/patho INTAKE, renal surface of forearm, elbow, knees,
disease/NSAIDs/diuretics/acidosis/lesch achilles tendons, pinna of ear
nyhan/ PPRPS
955. gout joint aspiration- needle shaped
overactivation/chemotherapy/hemolysis-
1. dx/tx negatively birefringent urate
-> hyperuricemia crystallization of
crystals
monosodium urate in joints --> IgG
serum uric acid - NOT helpful can
coating/PMN infiltration inflammatory
be normal
monoarticular arthritis
XR - punched out erosions with
952. synovial fluid - 1. clear/<200/<25% cortical bone
appearance/WBCs/PMN/other 2. clear, yellow, red tx= lifestyle modification (low
1. normal (trauma)/<2000/<25%/RBCs for trauma purine diet), early bed rest ,
2. non-inflam arthritis - 2a. / /2000-5000/<50% NSAIDs* (indomethacin),
OA/trauma 3. cloudy yellow/>5000/50-70%/ colchicine (contraindicated in
2a. inflammatory arthritis- positively birefringent pseudogout, renal insufficiency or stones*
RA/gout/SLE negatively birefringent gout /cytopenia)
3. gout 4. 7-10 day oral prednisone if no
4. septic arthritis turbid/purulent/>50,000/>70%/synovial response to NSAID/colchicine, or
fluid culture positive for bacteria except intra-articular injection
gonococcal (only 25% +) prophylaxis - >2 attacks
probenecid/sulfinpyrazone (if urine
urate is <800mg/day) or
allopurinol (if >800mg/day) +
colchicine/NSAID for 6 months to
prevent another attack (SE = SJS)
956. pseudogout 1. 963. inflammatory myopathy 1. CK, LDH, aldolase,
1. patho age/hemochromatosis/hyper (polymyositis/dermatomyositis) AST/ALT elevated
2. clinical pres PTH/hypothyroid/Bartter's 1. dx ANA, anti-Jo-1 (anti
3. dx/tx syn--> calcium pyrophosphate 2. tx + monitoring synthetase), anti -
crystals in joints, inc. with SRP, anti-Mi2, fever
age, EMG- myopathic
2. knees***/wrists, can be potentials/fibrillations
mono or polyarticular, fever, muscle biopsy - shows
leukocytosis inflammation/necrosis
3. joint aspirate weakly 2. corticosteroids then
positively birefringent rod slowly taper,
shaped and rhomboid crystals MTX,
(CPP crystals) cyclophosphamide,
XR - chlorambucil, Pt for
CHONDROCALCINOSIS** refractory disease
tx= underlying cause, MONITOR: with
NSAIDs/colchicine, intra muscle strength and
articular steroid injections* CK levels
957. what precipitates a gout attack dec. temp, dehydration, stress,
964. inclusion body myositis 1. common in elderly
inc. alcohol intake, starvation 1. clinical pres (M>F), proximal AND
2. dx/tx distal muscle
958. what should always be done on a gram stain and culture
weakness, loss of
joint aspirate in a patient with a
DTRs
painful joint
2. elevation in CK,
959. complications f gout nephrolithiasis, tophaceous absence of
gout, degenerative arthritis autoantibodies,
960. what NSAIDs should not be used aspirin can aggravate, tx = treatment
in gout acetaminophen has no anti- refractory
inflammatory properties 965. polymyalgia rheumatica 1. autoimmune (HLA-
961. idiopathic inflammatory 1. polymyositis, 1. patho DR4)
myopathy dermatomyositis, childhood 2. clinical pres 2. hip/shoulder muscle
(polymyositis/dermatomyositis) onset dermatomyositis, 3. tx pain after a period of
1. diseases collagen vascular disease inactivity, pain with
2. childhood onset myositis, myositis of movement, but
dermatomyositis key clinical malignancy, inclusion body strength is normal.
myositis constitutional
2. subcutaneous calcifications symptoms - malaise,
fever, depression,
962. inflammatory myopathy 1. symmetrical proximal***
weight loss, fatigue
(polymyositis/dermatomyositis) muscle weakness of neck
joint swelling of knees,
1. common clinical pres flexors, shoulder girdle, pelvic
wrists, hands
2. dermatomyositis unique girdle, dysphagia (30%),
signs/symptoms of
features arthralgias, CHF/conduction
temporal arteritis
defects/ILD both rarely ,
3. elevated ESR
2. heliotrope rash around
correlates with disease
eyes, bridge of nose, cheeks
activity
gottron's papules - papular
tx = corticosteroids
erythematous knuckle lesions
V-sign - rash over face, neck,
ant. chest
shawl sign - shoulders, upper
back, elbows, knees
periungual
erythema/telangiectasias
subcutaneous calcifications
vasculitis of GI tract, kidneys,
lungs, eyes
966. fibromyalgia 1. multiple tender TRIGGER POINTS, 971. psoriatic 1. 10% of patients,usually preceded by skin
1. clinical pres symmetrical, stiffness, constant aching arthritis disease, tends to affect smaller joints,
2. dx pain, aggravated by weather, stress, sleep 1. clinical pres asymmetric, polyarticular, NAIL
3. tx deprivation, cold temperature, worse in the INVOLVEMENT***
morning
972. temporal 1. inflammatory arteritis of temporal, aorta,
*sleep is disrupted, anxiety/depression is
arteritis or carotids
common
1. patho 2. fatigue, malaise, weight loss, fever,
2. widespread pain >3 months, 11/18
2. clinical headaches*, visual impairment**, jaw
trigger point sites, r/o myofascial
pres claudication, tenderness over temporal
syndromes, rheumatoid arthritis, ank
3.comorbid artery, absent temporal pulse
spondy, CFS, lyme, hypothyroid,
conditions 3. polymyalgia rheumatica** (40%),
polymyositis
4. dx/tx aortic aneurysm*, aortic dissection**
3. tx = SSRI, TCAs, CBT, psych eval
(follow with serial cxr)
967. ankylosing 1. HLA B27 Male>females, ascending 4. ESR elevated, temporal artery biopsy
spondylitis fusion of the spine, (90%)
1. patho 2. MORNING STIFFNESS, lower back pain tx = high dose prednisone early before bx
2. clinical pres bilateral sacroiliitis, lower back pain, results. if bx positive, treat for 4 weeks, then
3. dx/tx limited lumbar spine motion, neck pain is taper for 2-3 YEAR*, FOLLOW ESR to
late, loss of lordosis, enthesitis (inflamm@ determine efficacy
site of tendon attachments), fatigue, low
973. takayasu's 1. vasculitis of the aortic arch and major
grade fever, weight loss, vertebral fractures
arteritis branches
with minimal trauma
1. patho 2. fever, night sweats, arthralgias, fatigue,
extra articular: anterior uveitis, iridocyclitis
2. clinical absent carotid, pain radial, or ulnar pulses,
3. MRI/CT/plain film - sacroiliitis,
pres discrepancy in 4 limb BP
sclerotic sacro-iliac junction, eventually
3. tx 3. tx - steroids, treat HTN, surgery or
bamboo spine from column fusion
4. angioplasty for stenosed vessels
inc. ESR
complications 4. limb ischemia, aortic aneurysms, aortic
4. indomethacin,
regurgitation, stroke
anti-TNF (etanercept, infliximab)
PT, surgery, strict immobilization with 974. vasculitis by 1. takayasu's, temporal
back injury vessel size 2. PAN, kawasaki's disease, wegener's
1. large vessel granulomatosis, churg-strauss microscopic
968. causes of 1. osteoarthritis, gout, pseudogout, trauma,
2. medium polyangiitis
monoarticular septic arthritis, hemarthrosis
vessel 3. henoch schonlein purpura,
joint pain 2. RA, SLE, viral arthritis, rheumatic fever,
hypersensitivity virus, behcets syndrome
2. causes of lymes, gonococcal arthritis, drug induced
polyarticular arthritis 975. churg strauss 1.P-ANCA -multi organ vasculitis including
joint pain 1. patho respiratory, cardiac, GI, skin, renal, neuro
2. clinical 2. fever, fatigue, weight loss,
969. reactive 1. preceding infection:: salmonella,
pres respiratory - asthma, dyspnea
arthritis shigella, campylobacter chlamydia,
3. dx/tx skin lesions - subQ nodules, palpable
1. patho yersinia --> asymmetric inflammatory
purpura
2. clinical pres oligoarthritis
3. biopsy of lung/skin, p-ANCA
3. dx 2. TRIAD, arthritis, urethritis,
tx = steroids
conjunctivitis/anterior uveitis,
fatigue, malaise, weight loss, fever, joint
pain
3. synovial fluid analysis
4. NSAIDs***, no response sulfasalazine,
azathioprine
970. ankylosing 1. restrictive lung disease, cauda equina
spondylitis syndrome, spine fracture with spinal cord
1. injury, osteoporosis ,spondylodiscitis,
complications aortitis