Niveles de tensión en Torca

hematuria?

• Damage to the kidney or ureters

True or false: clots are not usually seen with renal causes of hematuria

• True; more likely a bladder pathology (cancer perhaps)

Clinical manifestations: acute aortic dissection

• severe, tearing pain w/ radiation to the back that is maximal at onset

Physical exam: acute aortic dissection (3)

• Hypo/Hyper-tension Difference in BP of > 30 mm Hg between arms AI murmur

Risk factors: aortic dissection (6)

• HTN (most common) Male sex Connective tissue disease Congenital aortic anomaly Aortitis Pregnancy Trauma

What are the diagnostic studies of choice in suspected aortic dissection? (2)

• TEE or chest CT

Definition: classic aortic dissection

• intimal tear leading to extravasation of blood into the aortic media

Definition: incomplete dissection

• intimomedial tear w/o significant intramural extravasation

Definition: intramural hematoma

• vasa vasorum rupture leading to medial hemorrhage

Definition: penetrating ulcer (aortic dissection)

• Ulceration of plaque penetrating intima leading to medial hemorrhage

Tx (medical): aortic dissection

• β-blockers first to blunt reflex ↑ HR & inotropy that will occur in response to vasodilators → ↓ SBP w/ IV vasodilators

(nitroprusside)

Tx: descending aortic dissection

• medical management (beta blockers, vasodilators)

Tx: ascending (proximal) aortic dissections • root replacement (surgery)

Complications: aortic dissection (3)

• Rupture → pericardial tamponade Obstruction of branch artery (MI, CVA, bowel ischemia, etc) Aortic insufficiency

Tx: external hordeolum (stye) (2)

• Warm compression (first-line) I&D if resolution does not begin in 48 hours

What is the normal response to a D-xylose test?

• Urinary excretion > 4.5 grams in 5 hours after a 25 gram ingestion

How does one distinguish between malabsorption due to bacterial

overgrowth vs. celiac disease using the D- xylose test?

• bacterial overgrowth: normal D- xylose response after abx Celiac: abnormal D-xylose despite abx

What type of glomerular disease is especially common in patients with HBV?

• Membranous nephropathy (glomerulopathy)

What type of glomerular disease is especially common in patients with HCV?

• Membranoproliferative glomerulonephritis type I

Criteria: diabetes mellitus (3)

• Fasting plasma glucose ≥ 126 mg/dl or 2-hour plasma glucose level of ≥ 200 mg/dl Casual plasma glucose ≥ 200 mg/dl if symptomatic

Criteria: Prediabetic glycemic states (2)

• 2-hour glucose levels of 140-199 mg/dl during an oral glucose tolerance test Fasting glucose level of 100-125 mg/dl

What is the insulin regimen for the average patient w/ type I DM?

• 0.5 units of insulin per kg body weight with 40 to 50% delivered as long-acting basal insulin; the remainder is short-acting (lispro) meal boluses

What are the ideal postprandial glucose excursions in a diabetic?

• 30-50 mg/dl above premeal glucose levels

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What is the next step in treating a patient with type 2 DM who is failing

pharmacological monotherapy?

• Add another class of drug, i.e. adding metformin to an existing sulfonylurea regimen

True or false: increasing sulfonylurea doses beyond half the maximal dosing range has minimal further benefits on treating hyperglycemia.

• True

Contraindication: zanamavir

• Contraindicated in patients with asthma because of risk of bronchospasm

Persistent rhinitis symptoms in the setting of nasal decongestant spray overuse suggest [...]

• Persistent rhinitis symptoms in the setting of nasal decongestant spray overuse suggest rhinitis medicamentosa.

Criteria: acute

bacterial rhinosinusitis (5)

• Duration of sx > 1 week Worsening sx after initial improvement Maxillary tenderness Purulent drainage Poor response to decongestants

Tx: acute bacterial rhinosinusitis (3) • Abx: amoxicillin, TMP-SMX, doxycycline

What oral abx can be used for outpatient treatment of pyelonephritis?

• Levofloxaxin x 7- 14 d

Clinical manifestations: botulism (5)

• Dysphagia Dysarthria Dysphonia Diplopia Descending paralysis

Clinical manifestations: hypokalemia

• Weakness Fatigue Muscle cramps

Arrhythmia/tetany/flaccid paralysis when < 2.5 mEq/ml

Thrombocytopenia and

hypercoagulation within days of initiating anticoagulant therapy are most likely cause by [...]

• Thrombocytopenia and hypercoagulation within days of initiating anticoagulant therapy are most likely cause by unfractionated heparin

What is the most common type of lung cancer? • Adenocarcinoma of the lung

Tx: febrile neutropenia (abx)

• IV cefipime to cover gram positives and pseudomonas

Clinical manifestations: nasal angiofibroma (3)

• Epistaxis Nasal obstruction Visible nasal mass

How long after splenectomy are patients with hereditary spherocytosis susceptible to sepsis?

• Up to 30 years

What are the major risk factors for lacunar infarcts? (2) • Diabetes Hypertension

Definition: transient ischemic attack (TIA)

• neurological deficit that lasts from a few minutes to no more than 24 hours

Clincial manifestations: ACA stroke (5)

• Hemiplegia (leg > arm) Confusion Abulia Urinary incontinence Primitive reflexes

Clinical manifestations: PCA stroke (3)

• Contralateral hemisensory disturbance Macular- sparing homonymous hemianopia Aphasia

What are the 4 "deadly D's" of posterior circulation strokes?

• Diplopia Dizziness Dysphagia Dysarthria

Clinical manifestations: basilar stroke (4)

• Pinpoint pupils Long tract signs (Quadriplegia/sensory loss) Cranial nerve palsies Cerebellar dysfunction

Clinical manifestations: vertebral stroke (4)

• numbness of ipsilateral face and contralateral limbs Diplopia Dysarthria Ipsilateral horners

Clinical manifestations: lacunar stroke (internal capsule)

• Pure motor hemiparesis

Clinical manifestations: lacunar strok (pons) (2) • Dysarthria Clumy hand

Clinical manifestations: lacunar stroke (thalamus) • Pure sensory deficit

What are the possible locations for pure motor hemiparesis strokes? (4)

• Posterior limb of the internal capsule Ventral pons Corona radiata Cerebral peduncle

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Dx: stroke (4) • Noncontrast CT EKG CMP CTA (after noncontrast)

Tx: TIA (3)

• Heparin IV with bridge to warfarin Antiplatelet therapy: ASA, clopidogrel or ASA + dipyridamole Carotid revascularization if > 70% stenosis

What scoring system is used to predict risk of progression of TIA to stroke?

• ABCD2: Age ≥ 60 y; BP ≥ 140/90 Clinical features: unilateral weakness or speech impairment w/o weakness, Duration ≥ 60 mins or 10-59 min; Diabetes

Tx: ischemic stroke (3)

• Supportive treatment Thrombolytic therapy (t-PA) if administered within 4.5h of onset Antiplatelet therapy: ASA, dipyridamole + ASA

Contraindications: t-PA therapy s/p ischemic stroke (12)

• SAMPLE STAGES Stroke or head trauma within the last 3 monts Anticoagulation w/ INR > 1.7 MI (recent) Prior intracranial hemorrhage Low platelet count (< 100K) Elevated BP: SBP > 185 Surgery in past 14 days Age < 18 GI or urinary bleeding in past 21 days Elevated blood glucose Seizures at onset of stroke

Etiologies: hemorrhagic stroke (2) • Intracerebral (90%) Subarachnoid (10%)

Clinical manifestations: hemorrhagic stroke (3) • AMS Vomiting Headache

Etiologies:

intracerebral stroke (5)

• HTN (most common) AVM Amyloid angiopathy (lobar) Anticoagulation/thromblysis Tumors

Dx: hemorrhagic stroke (3)

• CT scan CT angiography LP to check for xanthrochromia if no evidence of hemorrhage on CT or suspicious for SAH

Tx: hemorrhagic stroke (3)

• Admission to ICU ABCs BP reduction (gradual) with nitroprusside w/ goal of SBP < 140

What conditions makes subarachnoid hemorrhage more likely? (7)

• Marfan's syndrome Aortic coarctation Kidney disease (PKD) Ehlers-Danlos syndrome Sickle cell anemia Atherosclerosis History (familial)

Tx: cerebral vein thrombosis • angicoagulation w/ IV heparin

Tx: RV infarct (5)

• Optimize preload (IV fluids; don't give nitrates) ↑ contractility (dobutamine) reperfusion mechnical support pulmonary vasodilators (inhaled NO)

What is the single most important intervention for preventing contrast nephropathy?

• Adequate pre-CT intravenous hydration

What is the histopathological criterion for differentiating thyroid follicular adenomas from follicular carcinomas?

• Demonstration of invasion of the capsule and blood vessels

What is the drug of choice for chemoprophylaxis against P. falciparum malaria?

•

Mefloquine

How does the clinical presentation of EHEC differ from that of other bacteria that cause bloody diarrhea?

• EHEC lacks fever

What electrolyte abnormality makes a concurrent hypokalemia refractory to treatment?

• Hypomagnesemia makes hypokalemia refractory

Tx: symptomatic hypercalcemia • Vigorous hydration with IV normal saline

What neuromuscular blocker should be used in patients with renal or hepatic insufficiency? Why?

• Atracurium; degraded independent of kidneys or liver

Definition: malignant otitis externa

• severe pseudomonal infection of the external auditory canal

Clinical manfiestations: malignant otitis externa (2)

• Severe ear pain w/ drainage Fever

Otoscopic finding: malignant otitis externa

• granulation tissue in the external auditory canal

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What is the drug of choice for malignant otitis externa? • Ciprofloxacin

If suspicion for an intraocular foreign body is high, what test should be performed?

• Fluorescein examination

What agents most quickly reduce serum potassium levels? (3)

• Calcium gluconate Insulin Beta agonists

Tx: sinus bradycardia (2)

• IV atropine Permanent pacemaker if bradycardia doesn't resolve

Complications

(extrahepatic): Hepatitis C (7)

• Cryoglobulinemia B-cell lymphomas Plasmacytomas Autoimmune disease (Sjogren's, thyroiditis) Lichen planus Porphyria cutanea tarda ITP

What type of contrast agent is the least nephrotoxic? • Non-ionic contrast agent

Definition: presbycusis • Sensorineural hearing loss that occurs with aging

Clinical manifestation: presbycusis (2)

• High-frequency, bilateral hearing loss Difficulty hearing in noisy, crowded environments

What is the test of choice for diagnosisng renal cancer? • CT abdomen

What positioning makes the patient more aware of aortic regurgitation? Why?

• Lying supine and turning to the left brings the heart closer to the chest wall and makes the patient more aware of the forceful heartbeat

What is the most common middle ear pathology in patients with HIV?

• Serous otitis media

Definition: serous otitis media

• Presence of middle ear effusions without the evidence of acute infection

Tx (pharmacological): hepatitis B (2) • intereron lamivudine

How does the clinical presentation of CMV retinitis in and AIDS patient differ from that of HSV/VZV?

• CMV retinitis is typically painless and does not cause initial conjunctivitis or keratitis (in contrast to HSV/VZV)

What are common middle mediastinal masses? (5)

• Bronchogenic cysts Tracheal tumors Lymphomas Aortic arch aneurysms Pericardial cysts

What are anterior mediastial masses? (4)

• Thymoma Teratoma "Terrible" lymphoma Retrosternal thyroid

Tx: uncomplicated pyelonephritis (2)

• IV abx in first 48-72 h Transition to oral abx (e.g. TMP-SMX) if responsiv to parenteral abx

Dx: diffuse esophageal spasm • Manometry

Account for the metabolic acidosis that follows a grand-mal seizure.

• Lactic acidosis due to accelerated production of lactic acid and reduced hepatic lactate uptake

How does one manage post-ictal lactic acidosis?

• Observation; resolves without tx in 60- 90 mins

Tx: ventricular tachycardia (2)

• Loading w/ lidocaine or amiodarone (drug of choice) Cardioversion if hemodynamically unstable

HIV patients with what CD4 count warrant pneumococcal vaccination?

• CD4 > 200 cells/uL

Tx: bleeding 2/2 coagulopathy • Fresh frozen plasma administration and IV fluids

When should colonoscopic surveillance begin in a patient with ulcerative colitis? How frequently should it be conducted thereafter?

• 8 years after diagnosis and then q1-2y

thereafter.

Definition: chalazion

• A cyst in the eyelid caused by inflammation of a blocked meibomian gland, usually in the upper eyelid

Clinical manifestations: chalazion

• Painful swelling that progresses to a nodular rubbery lesion

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chalazion? carcinoma

What diagnostic test should be performed on recurrent chalazion?

• Histopathological examination to r/o malignancy (meibomian gland carcindoma or BCC)

Criteria: SLE (11)

• DOPAMINE RASH Discoid rash Oral ulcers Photosensitivity Arthritis Malar rash Immunologic critera (anti-Sm, anti-dsDNA, anti-Ro/La) Neurologic changes ESR increased Renal disease ANA+ Serositis Hematologic disease (hemolytic anemia, thrombocytopenia, leukopenia)

Is the arthritis of SLE deforming or non-deforming? • Non-deforming

What are the most common side effects of digoxin toxicity?

• GI distress: N/V, anorexia

Clinical manifestations: toxic shock syndrome (4)

• Diffuse erythema that starts on the trunk Strawberry tongue Conjunctival hyperemia Desquamation (1-2 weeks later)

What animals are the definitive hosts for E. granulosis? • Dogs

What is the preferred test for HIV screening? • ELISA for gp120

Dx: prostatitis (4)

• 1. Mid-stream urine sample 2. Blood culture 3. CBC 4. Prostatic massage

[...] should always be considered in a patient with an unexplained elevation of serum CK and myopathy.

• Hypothyroidism should always be considered in a patient with an unexplained elevation of serum CK and myopathy.

Complications: central lines (2)

• Venous thrombosis (subclavian in particular) Infection

Tx: venous thrombosis 2/2 central lines (3)

• First: catheter removal Second: carotid duplex Third: anticoagulation

Indications: cardioversion (4) • AFib Atrial flutter VT w/ pulse SVT

Indications: defibrillation (2) • VFib VT w/o pulse

Clinical manifestations: atrial fibrillation (6)

• Fatigue Exertional dyspnea Palpitations Dizziness Angina Syncope

What is the most common cause of atrial flutter? • COPD

EKG findings: multifocal tachycardia

• variable P wave morphology and variable PR and RR intervals (at least 3 different ones for dx)

EKG findings: PSVT • narrow QRS complexes w/ no discernible P waves

Pathophysiology: paroxysmal supraventricular tachycardia (2 mechanisms)

• (1) AV nodal reentry due to circuit within AV node (2) orthodromic AV reentry via accessory pathway

Tx: PSVT (2) • Vagal maneuvers IV adenosine (agent of choice)

What drug is used for prevention of PSVT? • Digoxin

Tx: Wolff-Parkinson-White syndrome

• Radiofrequency ablation of one arm of reentrant loop

Tx: hemodynamically stable VT (3)

• pharmacological therapy: IV amiodarone, procainamide or sotalol

Tx: hemodynamically unstable VT (2)

• immediate synchronous cardioversion Follow w/ IV amiodarone to maintain sinus rhythm

What is the imaging study of choice for pericardial effusion or tamponade?

•

Echocardiogram

Tx (medical): mitral stenosis (3)

• Diuretics for pulmonary edema Infective endocarditis prophylaxis Chronic anticoagulation (warfarin)

Clinical manifestations: aortic stenosis (3) • Angina Syncope HF sx

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aortic stenosis (5)

intercostal space w/ radiation to carotids 2. precordial thrill 3. sustained PMI 4. S4 5. Carotid pulses parvus et tardus

Tx: aortic stenosis

• AV replacement is tx of choice; indicated in all symptomatic patients

Dx: aortic stenosis (4)

• CXR EKG Echocardiogram Cardiac catheterization (definitive)

Clinical manifestations: aortic regurgitation (6)

• Exertional dyspnea PND Orthopnea Palpitations Angina Cyanosis/shock in acute aortic regurgitation

Physical exam: aortic regurgitation (4)

• Widened pulse pressure Diastolic decrescendo murmur at LSB Austin-Flint murmur Head-bobbing/uvula bobbing

What compensatory structural changes does the heart make in response to aortic regurgitation?

• LV dilation and hypertrophy

What is the definitive treatment for aortic regurgitation? • AV replacement

Tx: acute aortic regurgitation

• Medical emergency - perform emergent aortic valve replacement

Tx: unruptured abdominal aortic aneurysm

• If aneursym > 5 cm in diameter or symptomatic, surgical resection w/ synthetic graft placement is recommended

Tx: ruptured abdominal aortic aneurysm • emergent surgical repair

Clinical triad: ruptured AAA

• abdominal pain hypotension palpable pulsatile abdominal mass

Definition: peripheral vascular disease

• occlusive atherosclerotic disease of the lower extremities

Clinical manifestations: PVD (2)

• Intermittent claudication Rest pain, prominent at night

Physical exam: PVD (5)

• Dimished/absent pulses Muscular atrophy Decreased hair growth Ischemic ulcertation Thick toenails

Dx: peripheral vascular disease (3)

• Ankle-to-brachial index < 1.0 Pulse volume recordings Arteriography (gold standard)

Tx (medical): peripheral vascular disease (4)

• Smoking cessation Graduated exercise program Atherosclerotic risk factor reduction Aspirin

Tx (surgical): peripheral vascular disease (2)

• Surgical bypass grafting Angioplasty

Dx: acute arterial occlusion • Ateriogram

Classification: Shock (4) • Hypovolemic Cardiogenic Septic Neurogenic

When shouldn't IV fluids be used in cardiogenic shock?

• If LV pressures are elevated, IV fluids are likely to be harmful

Tx: cardiogenic shock (4)

• ABCs Identify and treat underlying cause Vasopressors (dopamine/dobutamine) IABP

What are the recommendations for screening with DEXA scans for osteoporisis?

• One-time screening of all women who are 65 and older

Tx: acute acalculous cholecystitis

• Percutaneous drainage followed by cholecystectomy

Dx: biliary dyskinesia • HIDA scan

Definition: biliary dyskinesia

• Motor dysfunction of the sphincter of Oddi which leads to recurrent episodes of biliary colic w/o evidence of gallstones on diagnostic imaging studies

Tx: biliary dyskinesia (2)

• Laparoscopic cholecystectomy Endoscopic sphincterectomy

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In document Denice Jeanneth Romero López Universidad de La Salle, Bogotá (página 92-0)