only do rabies post-exposure prophylaxis if ?
animal is unavailable or symptomatic
diarrhea in AIDS pt
think Cryptosporidium parvum (CD4 less than 180)
CMV typically causes colitis, esophagitis, retinitis, may cause frequent small volume stools +/- blood (typically CD4 less than 50!)
how do anticholinergics cause urinary retention
impaired detrusor muscle contraction
less so due to impaired internal sphincter relaxation
(PS input from pelvic splanchnic nerves
what is generalizability (aka external validity)?
applicability of obtained results beyond the cohort studied
“How generalizable are the results of a study to other populations?”
IgM spike think ?
what are consequences of this condition?
Waldenstrom macroglobulinemia
hyperviscosity, neuropathy, cryoglobulinemia, bleeding, hepsplenmeg, LAD
strawberry vs cherry hemangioma
strawberry: kids (think strawberry shortcake)
cavernous hemangiomas of the brain/viscera are associated with
von Hippel-Lindau disease
pneumococcal vaccines to give to chronic liver disease patients
PPSV23 alone
then PCV13 and PPSV23 at age 65
treatment of symptomatic hyperPTH
parathyroidectomy
bisphosphonate therapy if decline
when to CT in hyperPTH
if suspect malignancy: severe, symptomatic hypocalcemia, low PTH, elevated PTHrP
if suspect MEN: evidence of multi glandular hyperPTH or additional endocrine tumors
MEN1
PPP (primary)
hyperPTH (^Ca2+)
Pituitary tumors (PRL, vision changes)
Pancreatic tumors (gastrinoma)
MEN2A
MPP (middle)
Medullary thyroid cancer (calcitonin)
Pheochromocytoma
Parathyroid hyperplasia
MEN2B
MPM (2 Big Ms)
Medullary thyroid cancer (calcitonin)
Pheochromocytoma
Mucosal neuromas/marfanoid habitus
acute thyrotoxicosis with mild thyroid enlargement, suppressed TSH, and decreased radio iodine uptake think ?
painless thyroiditis
how to manage infective endocarditis with cardioembolic stroke
IV antibiotics, observation
antiplatelet, anticoagulants not indicated
if dirty wound but completed tetanus vaccines as child (3+ tetanus toxoid doses) ?
only Tdap if haven’t had in last 5 years
NO TIG
if dirty wound and uncertain history or did not complete vaccines as child
Tdap + TIG
if clean wound and received all childhood tetanus vaccines
only Tdap if haven’t had in last 10 years
NO TIG
if clean wound and uncertain history or did not complete vaccines as child
only Tdap
NO TIG
fatigue, arthralgias, peripheral neuropathy
low C3, C4, RF+, ^AST, ALT, kidney injury, palpable purple lesions on leg, think ?
mixed cyroglobulinemia:
immune complex deposition disorder associated with chronic hep C
calcium oxalate crystals and hypocalcemia are associated with what ingestion?
what should be given?
ethylene glycol
fomepizole or etOH to inhibit alcohol dehydrogenase
+/- NaHCO3- to alleviate the acidosis
hemodialysis if severe
fibromyalgia tx
amitriptyline, pregabalin, duloxetine, milnacipran
S3 is associated with ?
what treatment typically indicated?
LV failure
IV diuretics for decompensated HF
post-exposure prophylaxis for HIV exposure
3+ drug regimen started immediately for 4 weeks
i.e. 2 NTRI/NSRI + Integrase strand transfer inhitibor, PI, or NNSRI
painful, red eye with opacification and ulceration of the cornea associated with contact lenses, think ?
pseudomonal keratitis
ddx:
acute angle-closure glaucoma typically does not have ulceration and pupil is fixed and mid-dilated
anterior uveitis typically spares the cornea
what meningitis most likely to present with shock and petechial rash
meningococcal
Echinococcus granulosus vs Entamoeba histolytica
both involve liver abscesses
E. granulosus may be afebrile and liver cysts have “daughter” cytes (internal septations)
E. histolytic typically is febrile +/- dysentery/colitis, cyst is smooth and has a capsule
how does oral estrogen therapy affect thyroid hormones?
decrease clearance of thyroxine-binding globuline (TBG) leading to elevated levels
this leads to less FREE thyroxine and ^TSH in thyroid-dependent patients, may need to increase levothyroxine dose (also ^ in pregnancy)
what drugs decrease levothyroxine absorption
cholestyramine, iron, calcium, aluminum hydroxide, PPIs, sulcralfate
what drugs ^TBG concentration
estrogen, tamoxifen, raloxifene, heroin, methadone
what drugs decrease TBG concentration
androgens, steroids, nicotinic acid
what drugs ^thyroid hormone metabolism
rifampin, phenytoin, carbamazepine, phenobarbital
dyspnea, tachypnea, tachycardia, hypoxia worsened with IVF + patchy irregular alveolar infiltrates on CXR, think ?
pulmonary contusion
commonly caused by blunt thoracic trauma, initial CXR may be negative, CT is more sensitive
in contrast, hemothorax will present with pleural effusion on CXR
info to include on signout
DNR/DNI, hospital course and recent events, current condition, anticipatory info (“if the patient’s mental status changes, check blood gas and consider transfer back to ICU”)
eye probs: horldeoum vs chalazion vs dacryocystitis
hordeolum: abscess over eyelid, tender and swollen
chalazion: granulomatous inflammation of meibomian gland, hard and painless nodule
dacryocystitis: inflammatory changes in medial canthal region of eye
infective endocarditis etiology associations S. aureus: Viridans: S. epidermidis: Enterococci: S. bovis: Fungi (Candida):
S. aureus: prosthetic valves, IV caths, ICDs, IVDU
Viridans: gingival manipulation, resp. tract incision/bx
S. epidermidis: prosthetic valves, IV caths, ICDs
Enterococci: nosocomial UTIs
S. bovis: Colon cancer, IBD
Fungi (Candida): immunocompromised, IV caths, prolonged abx
screening for bladder cancer?
USPSTF recommends AGAINST screening for bladder cancer due to low incidence and poor positive predictive value of screening tests
most effective for reducing HTN
weight loss
then DASH, Na restriction, exercise, etOH reduction
smoking inconclusive but recommended
what therapy for managing bone pain in patients with prostate cancer AFTER androgen ablations (orchiectomy)
radiation, focal external beam is a good choice
goal PaO2 when ventilating to prevent ARDS
why?
55-80 mmHg, corresponding to about 88-95% O2 sats
FiO2 less than 60% (0.6) are considered generally safe (reduced risk of O2 toxicity)
what to give if homocysteinemia
vitamin B6 (pyridoxine) lowers homocysteine levels by acting as a cofactor for enzyme cystathionine B-synthase, which metabolizes homocysteine to cystathionine
best imaging for ureteral/kidney stones
Ultrasound or noncontrast spiral CT
hypopituitarism will lead to what levels of
free T4, cortisol, and aldosterone?
low T4, low cortisol, NORMAL aldosterone
as ACTH is low resulting in secondary (central) adrenal insufficiency but aldosterone is regulated by RAAS and not affected in hypopituitarism
in contrast to primary AI: low aldo, ^ACTH
isolated thrombocytopenia think ?
and get what tests?
think ITP BUT diagnosed after excluding other causes such as HIV or Hep C infection
thrombocytopenia may be the initial presentation of HIV in 5-10% of pts
+VDRL, prolonged PTT, thrombocytopenia, think?
antiphospholipid antibody syndrome, ppx with low dose ASA and LMWH to prevent pregnancy loss in pregnant females
RV failure, tachycardic, hypotensive, ^JVD, consider
massive PE
fever and sore throat in pt taking antithyroid drug suggests?
agranulocytosis
CSF with ^lymphocytes, ^RBCs, ^protein
HSV encephalitis
dx with HSV PCR
how to tx pseudotumor cerebri?
complication of untx?
weight reduction, acetazolamide
blindness! use shunting or optic nerve sheath fenestration to prevent
pt with HA, n/v, abdominal pain, confusion, tachycardia, tachypnea, and pinkish-skin hue think ?
carbon monoxide poisoning
exposure to burning rubber or plastic, bitter almond breath, think ?
cyanide poisoning
cyanosis and bluish discoloration of skin and mucous membranes, think ?
methemoglobinemia
when to use hinged knee braces vs knee immobilizers
hinged: prevention and treatment of ligamentous injuries
immobilizer: patellar fractures or tears of quads or patellar tendon
SEs of cyclosporine
nephrotoxicity, hyperkalemia, HTN, gum hypertrophy, hirsutism, tremor
tacrolimus SEs
nephrotoxicity, hyperkalemia, HTN, tremor
azathioprine SEs
dose-related diarrhea, leukopenia, hepatotoxicity
mycophenolate SEs
BM suppression
what is haptoglobin? elevated or decreased in hemolytic anemia?
protein that binds free Hbg to form Hgb-haptoglobin complexes that are easily removed by the liver
haptoglobin DECREASED in hemolytic anemia
AFP is elevated in ?
testicular germ cell tumors and hepatocelluare carcinoma