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USMLE Step 2 CK > Internal Medicine > Flashcards

Flashcards in Internal Medicine Deck (108):
1

DDX for WBC casts?

Pyelonephritis Acute intersitial nephritis

2

DDx for muddy brown casts?

Acute tubular necrosis

Can be caused by ischemic AKI or nephrotoxic AKI (antibiotics, radiocontrast agents, NSAIDs, poisons, myoglobinuria, hemoglobinuria, chemotherapy, AL in MM)

3

Metabolic derangements in AKI

Hyperkalemia Anion gap metabolic acidosis Hypocalcemia Hyponatremia Hyperphosphatemia Hyperuricemia

4

Metabolic derangements in CKD

Hyperkalemia Hypermagnesemia Hyperphosphatemia Metabolic acidosis Hypocalcemia

5

Side effects of ACEI

ACEI dilate afferent arteriole Hyperkalemia

6

Absolute indications for dialysis

Acidosis Electrolyte abnormalities Intoxications Overload, hypervolemic Uremia based on clinical presentation (e.g. AMS, pericarditis)

7

Minimal change disease

Most common in children

May present as nephrotic syndrome

A/w lymphomas

Microscopy: no changes on light microscopy, foot process fusion

Tx: 4-8 weeks of steroids

8

Focal segmental glomerulosclerosis (FSGS)

Nephrotic

More common in Blacks

Microscopy: focal segmental sclerosis, foot process fusion

A/w HIV, heroin use, sickle cell disease

Does not respond well to steroids

9

Membranous glomerulonephritis

Nephrotic

Microscopy: thick glomerular basement membrane

A/w: Hep B, Hep C, SLE

Does not respond well to steroids

10

Post-infectious glomerulonephritis

Nephritis 10-21 days following URI

Low C3 complement

Elevated anti-streptolysin O and/or anti-DNAse B

11

IgA nephropathy

Nephritis 5 days following URI

Normal complements

12

Prostate cancer

Risk factors include age, African American race, high-fat diet, FHx, exposure to herbicides and pesticides Mostly adenocarcinoma, starts at periphery Mostly asymptomatic but can cause obstruction in late phase Likes to metastasize to bone (pelvis, vertebral bodies, long bones in the legs) Indications for transrectal ultrasound: PSA > 4.1, abnormal DRE Tx: radiation + androgen deprivation OR prostatectomy OR orchiectomy, antiandrogens, leuprolide, GnRH antagonists

13

Treatment of CAD

Risk factor modification (HTN, DM, HLD control, etc.) Aspirin (reduces risk of MI) Nitrates Beta-blockers (reduces frequency of coronary events) + coronary angiography to assess for PCI (if moderate) + consider CABG (if severe)

14

Treatment of hypertrophic cardiomyopathy

Beta-blockers

15

Treatment of CHF

ACEI + loop or thiazide diuretic Beta-blockers Spironolactone/Eplerenone

16

Treatment post-stent placement

Dual platelet therapy (aspirin + clopidogrel) 1 month for BMS 12 months for DES

17

Treatment for aortic dissection

IV beta-blocker to SBP 100-120 If SBP still > 120, add sodium nitroprusside

18

Treatment for cocaine-induced chest pain

IV benzodiazepines Aspirin, nitroglycerin, CCB Beta-blockers contraindicated

19

Arrhythmia most specific for digitalis toxicity

Atrial tachycardia with AV block

20

Finds for aortic stenosis

Fatigue, lightheadeness with exertion, presyncope Midsystolic murmur over RUSB Diminished and delayed carotid pulse Soft and single S2

21

Tx for sinus bradycardia

IV atropine

22

Metabolic derangments in intravascular hemolysis

Hemoglobinemia
Hemoglobinuria
Elevated lactate dehydrogenase
Decreased haptoglobin (excess hemoglobin exceeds binding capacity)

23

Primary biliary cholangitis

S&S: pruritus, fatigue, jaudice, eyelid xanthelasma, portal HTN, osteopenia
Labs: antimitochondrial antibody, elevated Alk Phos
Tx: ursodeoxycholic acid, liver transplant for advanced disease
 

24

Wernicke encephalopathy

Thiamine deficiency due to alcoholism, malnutrition
S&S: encephalopathy, oculomotor dysfunction, postural and gait ataxia
Tx: IV thiamine followed by glucose infusion

25

Indications for hospitalization for CAP

Confusion
Urea > 20
Respirations ≥ 30
SBP < 90, DBP < 60
Age ≥ 65

26

Treatment of diverticulitis

Uncomplicated: outpatient bowel rest, oral antibiotics, observation
Complicated (abscess): IV antibiotics if < 3 cm, CT-guided percutaneous drainage if > 3 cm, surgical drainage and debridement if no improvement in 5 days

27

Cellulitis vs. erysipelas

Cellulitis: S. pyogenes or MSSA infection of deep dermis and subcutaneous fat with flat edges with poor demarcations, indolent
Erysipelas: S. pyogenes infection of superficial dermis and lymphatics with raised, sharply demarcated edges, rapid spread and onset

28

Bounding pulses, fixed splitting of S2, pulsus paradoxus, pulsus parvus and pulsus tardus

Bounding pulses: AR
Fixed splitting of S2: ASD
Pulsus paradoxus (systemic arterial pressure falls > 10 mmHg during inspiration): cardiac tamponade
Pulsus parvus and pulsus tardus (decreased amplitude and delayed upstroke): AS

29

Diagnosis and management of carbon monoxide poisoning

Dx: ABG (carboxyhemoglobin level), ECG, cardiac enzymes if ischemia or CAD
Tx: high-flow 100% oxygen, intubation/hyperbaric oxygen therapy (if severe)

30

Treatment elevated homocystine

Pyroxidine, folate, B12 (if deficiency documented) as these are co-factors in homocysteine metabolism 

31

Treatment for PCP

AIDS-defining illness when CD4 count < 200

First line: TMP-SMX

Second line: pentamidine, atovaquone, TMP + dapsone, clindamycin + primaquine

Adjunctive corticosteroids if PaO2 Copyright  70 mmHg or A-a gradient > 35 mmHg

32

Diagnosis and management of heparin-induce thrombocytopenia

S&S: heparin exposure > 5 days + platelet reduction > 50% from baseline, arterial or venous thrombosis, necrotic skin lesions at heparin injection sites, anaphylactoid reaction

Dx: if suspected, STOP ALL HEPARIN PRODUCTS then do serotonin release assay

Tx: start direct thrombin inhibitor (e.g. argatroban) or fondaparinux (can switch to warfarin once platelets > 150,000)

33

Next best step of management for chest pain

ECG 

> 2 mm ST elevations or new LBBB concerning for STEMI → cath lab or thrombolytics if cath lab unavailable in reasonable amount of time

34

35

Leads I and aVL

Lateral MI --> left circumflex

36

Leads V1-V4

Anterior MI --> left anterior descending

37

Leads V1-V4, V5-V6, I, aVL

Anterolateral MI --> left main

38

Leads II, III, aVF

Inferior MI --> posterior descending (85% branches from right coronary)

39

Causes of dilated cardiomyopathy?

Alcohol abuse Wet beriberi Coxsackie A and B virus myocarditis Chronic cocaine use Chagas disease Doxorubicin toxicity Hemochromatosis Peripartum cardiomyopathy

40

Unilateral headaches, jaw claudication, blindness (if untreated)

Temporal (giant cell) arteritis Labs: elevated ESR and CRP Dx: temporal artery biopsy shows granulomas, intimal thickening, elastic lamina fragmentation, multinucleated giant cells Tx: corticosteroids Cx: polymyalgia rheumatica, IL-6 related to severity of disease

41

Weak upper extremity pulses, arrowing of aortic arch and proximal great vessels

Takayasu arteritis Tx: corticosteroids

42

Hepatitis B, hypertension, transmural inflammatory and fibrinoid necrosis of arterial wall, "string of pearls" on arteriogram

Polyarteritis nodosa Tx: cyclophosphamide, corticosteroids

43

Fevers, conjunctivitis, cervical lymphadenopathy, strawberry tongue, rash on palms and soles

Kawasaki disease Tx: aspirin, IV immunoglobulins Complications: coronary artery aneurysm

44

Smoking, claudication,gangrene, autoamputation, Raynauds

Buerger disease (thromboangiitis obliterans) Tx: smoking cessation

45

c-ANCA (PR3-ANCA), involvement of nasopharynx, lungs, kidneys

Granulomatosis with polyangiitis (Wegners) Tx: cyclophosphamide, corticosteroids

46

p-ANCA (MPO-ANCA), invovlement of lungs, kidneys

Microscopic polyarteritis No nasopharyngeal involvement and no granulomas distinguishes from Wegners

47

p-ANCA (MPO-ANCA), asthma, palpable purpura, GI complaints, increased IgE

Churg Strauss (eosinophilic granulomatosis with polyagiitis) Granulomas with eosinophils

48

Indications for CABG over stent

Left main disese or 3-vessel disease (or 2-vessel disease + DM)

> 70% occlussion

Pain despite maximal medial treatment

Post-infarction angina

49

Medical management post-MI

Aspirin (+ clopidogrel if stent  for 9-12 months)

Beta-blocker

ACEI (if CHF or LV dysfunction)

Statin

Nitrates for pain

50

Exercise stress test

Indicated for patients with intermediate pre-test probability of cardiac ischemia

Avoid beta-blockers, CCB

Need to do echo stress test if old LBBB, baseline ST elevation, or digoxin

If pt cannot exercise, chemical stress test with dobutamine or adenosine

Positive if --> ST depressions, chest pain, hypotension --> coronary angiography

51

Treatment of WPW

Procainamide

Avoid beta-blockers, digoxin, CCB (anything that slows AV conduction)

52

Treatment of SVT

First line: carotid massage, face in ice water (for children)

Second line: adenosine

53

Cardiac tamponade

Clinical indicators: hypotension, distant heart sounds, JVD, pulsus paradoxus, electrical alternans

Tx: pericardiocentesi

54

Crescendo-decrescendo systolic ejection murmur, louder with squatting, softer with valsalva + parvus et tardus

Aortic stenosis

Tx: valve replacement

55

Systolic ejection murmur, louder with valsalva, softer with squatting/handgrip

Hypertrophic obstructive cardiomyopathy

56

Late systolic murmur with click, louder with valsalva and handgrip, softer with squatting

Mitral valve prolapse

57

Holostystolic murmur, radiates to the axilla

Mitral regurgitation

58

Rumbling diastolic murmur with an opening snap, left atrial elargement and afib

Mitral stenosis

59

Blowing diastolic murmur with widened pulse pressure, waterhammer pulse

Aortic regurgitation

60

Most specific arrhythmia associated with digitalis toxicity

Atrial tachycardia with AV block

61

Treatment for long QT syndrome

Beta-blockers and pacemaker

62

Indication for antithrombotic therapy in afib

> 4 on CHA2DS2-VASc 

C = CHF (1 point)

H = HTN (1 point)

A = age > 75 (2 points)

D = DM (1 point)

S2 = stroke/TIA/thromboembolism (2 points)

V = vascular disease (1 point)

A = age 65-74 (1 point)

Sc = sex (female = 1 point)

63

Most likely location following aspiration?

Right mainstem bronchus wider and more vertical than the left While upright --> lower portion of right inferior lobe While supine --> superior portion of right inferior lobe or posterior segments of the right upper lobe

64

What factors shift the oxygen-hemoglobin curve to the right?

Right shift = reduced affinity = more oxygen is offloaded at a given pO2 ↑ in Cl-, H+, CO2, 2,3-BPG, temperature, altitude, and exercise

65

What factors shift the oxygen-hemoglobin curve to the left?

Left shift = greater affinity = less oxygen is offloaded at a given pO2 ↓ in Cl-, H+, CO2, 2,3-BPG, and temperature

66

Methemeglobinemia

Oxidized hemoglobin (with Fe3+) has reduced affinity for oxygen and increased affinity for cyanide S&amp;S: cyanosis and chocolate-colored blood Tx: methylene blue

67

Cyanide poisoning

Nitrites to oxidize hemoglobin to methemeglobin which binds CN Thiosulfate to bind this cyanide, forming thiocyanate, which is renally excreted

68

Lobes of the lungs affected by pneumoconioses

Asbestosis --> lung bases

Silica and coal --> upper lobes

69

Light's criteria?

Pleural effusion is exudative if:

PF/serum protein > 0.5

PF/serum LDH > 0.6

PF LDH > 2/3 upper limit of normal (about 200)

Exudative processes (inflammation that causes increased permeability): parapneumonic, lung adenocarcinoma (high hyaluronidase)

Transudative processes (imbalance between hydrostatic and oncotic pressures): RA (low glucose 2/2 leukocytosis), TB (high lymphocytes), malignant or pulmonary embolus (bloody) → treat underlying disease

70

Locations of primary lung cancers

Adenocarcinoma, bronchioalveolar, large cell --> peripheral Squamous cell, Small cells --> central

71

Adenocarcinoma

Most common lung cancer in nonsmokers and overall Found in periphery

Bronchioloalveolar subtype looks like pneumonia on CXR --> good prognosis

72

Squamous cell carcinoma

Most common lung cancer in male smokers

Centrally located as hilar mass from the bronchus

a/w cavitation, cigarettes, hypercalcemia (from PTHrP)

Keratin pearls and intercellular bridges on histology

73

Small cell (oat cell) carcinoma

Centrally located

Undifferentiated neuroendocrine cells --> very aggressive May produce ACTH, ADH, antibodies against presynaptic calcium channels (Lambert-Eaton)

Inoperable, must treat with chemotherapy

74

Large cell carcinoma

Found in periphery

Highly anaplastic undifferentiated tumor --> mets

Less responsive to chemotherapy, removed surgically

Pleomorphic giant cells on histology

a/w gynecomastia and glactorrhea

CXR shows peripheral cavitation

75

Bronchial carcinoid tumor

Nests of neuroendocrine cells (chromogranin A +) 

Excellent prognosis, metastasis rare

Symptoms due to mass effect or carcinoid syndrome (5-HT --> flushing, diarrhea, wheezing)

76

Common sites of primary lung cancer metastasis?

Adrenal glands, brain, bone, liver

77

The terrible T's of a mediastinal mass

Teratoma Thymoma Thyroid cancer Terrible lymphoma

78

Hamartoma of the lung

Benign lesion Typicallly a solitary lung nodule ("coin lesion") with "popcorn" calcifications Often contains islands of mature hyaline cartilage, fat, smooth muscle, and clefts lines by respiratory epithelium

79

Smoking-related vs. A1AT deficiency emphysema

Smoking-related emphysema: centriacinar in the upper lobes

A1AT deficiency emphysema: panacinar in the lower lobes

80

Which pneumoconicosis is associated with increased risk of TB?

Silicosis

Silica particles internalized into macrophages disrupt phagolysosomes and cause release of the particles and viable mycobacteria limiting the immune system's ability to combat TB infection

a/w eggshell calcifications

81

Chronic rejection of a lung vs. kidney transplant

Kidney --> inflammation of vasculature Lung --> inflammation of small bronchioles (bronchiolitis obliterans)

82

Causes of deviated trachea

Tension pneumothorax --> trachea deviates away from the collapsed lung Collapsed lung due to bronchial obstruction --> trachea deviates towards the affected side

83

Diagnostic criteria and management of ARDS

Dx: PaO2/FiO2 < 200, bilateral alveolar infiltrates on CXR, PCWP < 18

Tx: mechanical ventilation with PEEP

84

Treatment for COPD

First line: ipratropium, tiotropium

Second line: beta agonists

Third line: theophylline

85

Indications to start oxygen in COPD

PaO2 < 55 or SpO2 < 88%

86

Best prognostic indicator for COPD

FEV1

87

Interventions shown to improve mortality from COPD

Smoking cessation

Continuous oxygen therapy > 18 hours/day (is PaO2 < 55 or SpO2 < 88%)

88

Sarcoidosis

Hilar lymphadenopathy, increased ACE, hypercalcemia, erythema nodosum

Refer to ophthalmology 2/2 uveitis conjunctivitis

Dx: biopsy

Tx: steroids

89

COPD + new-onset clubbing

Occult malignancy of the lung --> get CXR

90

Diagnosis and treatment of asthma

Dx: obstructive process on spirometry (decreased FEV1/FVC) with reversibility after SABA (> 12% improvement)

Tx:

<= 2x/week + normal PFT → albuterol prn

More frequent symptoms + normal PFT → albuterol + inhaled corticosteroids

More frequent symptoms + FEV1 60-80% → albuterol + inhaled corticosteroids + LABA

Daily symptoms + FEV1  60% → albuterol + inhaled corticosteroids + LABA + montelukast or oral steroids

91

Complications of inflammatory bowel disease?

Toxic megacolon → surgery

Pyoderma gangrenosum → NO antibiotics

Erythema nodosum (painful nodules on anterior tibia)

92

Which IBD is a/w increased risk of primary sclerosing cholangitis?

Ulcerative colitis

PSC confers and increased risk for cholangiocarcinoma

93

How do you treat ulcers, abcesses, or fistulas associated with Crohn's disease?

Metronidazole

94

Treatment for IBD

ASA, sulfasalazine to maintain remission

Corticosteroids to induce remission

Azathioprine, 6MP, and methotrexate for severe disease

95

ALT > AST and in the 1000s

Viral hepatitis

96

AST and ALT in the 1000s after surgery or hemorrhage

Ishemic hepatitis (shock liver)

97

Antimitochondrial antibodies

Primary biliary cirrhosis

Steroids not effective

98

ANA + antismooth muscle antibodies

Autoimmune hepatitis

Tx: steroids

99

Cholestatic pattern of liver enzymes?

Think obstruction → RUQ ultrasound → if equivocal, do abdominal CT (painless jaundice in elderly = pancreatic CA) → if equivocal, do ERCP

 

100

Prophylaxis for people exposed to bacterial meningitis?

Rifampin

101

Treatment of meningitis

Empiric treatment (+ steroid if you think bacterial), exam/CT to access for ICP, LP (+ gram stain, > 1000 WBCs diagnostic)

N. meningititis, H. flu, S. pneumo → ceftriaxone, vancomycin

Listeria → ampicillin

Staph (brain surgery) → vancomycin

TB → RIPE + steroids

Lyme → ceftriazone

102

Diagnosis of TB

PPD (+ if > 15 mm or > 10 mm if prison, healthcare, DM, ETOH, chronically ill, > 5 mm if AIDS/immunosuppressed)

If PPD+ → CXR

If CXR+ → acid fast stain of sputum → treat with RIPE for 6 months (12 if meningitis, 9 if pregnant)

If CXR- → need 3 negative sputums to rule out TB

103

Side effects of RIPE drugs

Rifampin: turns body fluids orange/red, induces CYP450

INH: peripheral neuropahty and sideroblastic anemia (prevent by giving B6), hepatitis with mild bump in LFTs

Pyrazinamide: benign hyperuricemia

Ethambutol: optic neuritis, other color vision abnormalities

104

Definition of and management of neutropenic fever

Neutropenic fever = absolute neutrophil count (ANC) < 1500 (severe if < 500)

Increased risk of mucositis and translocation of bacteria into bloodstream (NEVER DO A DRE)

Treat empirically with anti-pseudomonal beta-lactam (cefepime, meropenem, piperaciilin-tazobactam) then blood and urine cultures

105

Hepatitis B postexposure prophylaxis 

If completed Hep B vaccine series + documented response → no prophylaxis

If did not complete Hep B vaccine series/unvaccinated → test source patient blood → if HBsAg and no anti-HBsAg → hepatitis B immunoglobulin + initiate vaccine series → viral serology

106

Diarrhea + solitary cyst in the right lobe of the liver (anchovy paste)

Entamoeba hystolytica

Tx: metronidazole + intraluminal antibacterial (e.g. paromomycin)

107

Filamentous, branching bacteria

Nocardia: gram +, aerobic, partially acid-fast, tx with TMP-SMX

Actinomyces: gram +, anaerobic, not acid fast, sulfure granules, tx with penicillin G

108

Acid-base disturbances in saicylate toxicity

ASA overdose causes respiratory alkalosis (early) and anion-gap metabolic acidosis (late) which together give nearl-normal pH, low pCO2, and low HCO3