medicine shelf review

MEDICINE SHELF EXAM REVIEW

1. PFTS a. First thing to look at is FEV1/FVC

i. Normal: >70-75%1. FVC normal

1. Look at DLCO – a. Normal – your normal b. Abnormal – pulmonary vasculature problem

2. FVC LOW a. LOOK AT tlc b. TLC high – air trapping c. TLC

i. low with low FVC – small lungs, pure restrictive defect 1. DLCO

a. Normal – neuromuscular, chest wall defectb. Low – interstitial lung disease

ii. Not normal – look at FVC on its own 1. FVC is high then obstruction and nothing else 2. Low FVC = restriction

a. TLC i. High in obstruction with air trapping

ii. low means he has restrictive component 1. DLCO

a. Normal – asthma because doesn’t destroy alveolar membrane

b. DLCO low then he has emphysema > COPD b. Obstructive

i. Chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis

ii. Asthma

iii. Bronchiectasis

iv. Cystic fibrosis

c. Restrictivei. Interstitial lung disease , such as idiopathic pulmonary fibrosis

ii. Sarcoidosis

iii. Obesity , including obesity hypoventilation syndrome

iv. Scoliosis

v. Neuromuscular disease, such as muscular dystrophy or amyotrophic lateral sclerosis (ALS)

d. Mixed 2. MI

a. Door to balloon time – hit the door of the ER to when cardiologists opening up balloon in coronary artery <90 minutes PCI percutaneous coronary intervention, any intervention not necessarily a stent. Stent preferred for STEMI

b. Fibrinolytics – clot busters – streptokinase, urokinase when you can’t cath. Door to needle time <12 hours.

c. TPA i. Stroke – within 3 hours within seen normal hour, head CT in first 24 hr is normal

ii. Massive PE – hemodynamically unstable, hypoxic, tachypneic, Stat CT angio – no time limit

3. Stress versus cath a. STEMI – cath on spot – stent it

i. 1 avl – v5 v6 left circumflex lateral wall

ii. anterioseptal wall – lad iii. posterior – right circumflex iv. 2 3 avf rca inferior v. v1-v4 0 lad anterior

4. Bleeding disordersa. PT

i. Extrinsic pathwayii. Factor 7 and 3

b. PTT i. Intrinsic pathway

ii. 10 5 20 1 13 common iii. ptt is everything else 12 11 9 8 iv. order 1:1 mixing study when isolated high pt or ptt

1. deficient in factor – then normalizes 2. inhibitor then it does not normalize

a. high PTT, does not correct with 1:1 and prothrombic – lupus anticoagulant. And if they have evidence antiphospholipid syndrome

c. Von willebrandsi. Teenager who has had menorrhagia

ii. VWF bound to factor 8, helps platelets bidn to endothelial wall and bind to each other. It is a connector between coagulation and platelet side.

iii. PTT high because bound to factor 8 then half life of factor 8 go down so functional factor 8 deficiency.

iv. PT is normal d. Factor V Leidin - e. Ristocetin assay messed up then platelet function order and ifnormal then not vWDf. Hemophilia A

i. Factor 8 deficiency ii. XLR

g. Hemophilia B i. Factor 9 deficiency

h. Hemophilia C i. Factor 11 deficiency

i. Bernard soulier - platelet adhesion issue so platelet number normal but platelet function assay is jacked maybe factor 7 and ddavp?

j. Glanzmens thormbasthemia platelet aggregation issue so platelet number normal but platelet function assay is jacked IIB IIIA . give leukocyte depleted blood with platelets.

k. DIC - consumptive coagulopathy i. PT PTT high

ii. Platelets low iii. Fibrinogen low – must be low to diagnose DIC iv. D-dimer high – measures breaking up clots

5. TTP - Opposite of VWF a. Deficiency in ADAMST13b. AMS, fever, TCP, microangiopathic hemolytic anemia, AKIc. HUS – ecoli

6. SBP – PMN >250 7. SAAG

a. Serum albumin – ascites albumin i. <1.1 implies that ascites high – it is inflammatory something is spilling protine, also cuaed

by nephrotic syndrome ii. >1.1 hydrostatic pressure, portal hypertension

b. 40 year old women with ascities and pleural effusion – ovarian cancer (possible benign) – meigs syndrome –

8. heparin vs warfarin a. therapeuticb. prophylaxis – prevention of PE and DVT c. DVT/PE – treat 6-9 months

i. Start with heparin or lovenox 1. Heparin is unfractionated. Blocks factor 2 and 10 in 1:1 ratio. 2. Lovenox is low molecular weight. Lovenox sticks around longer. Lovenox does it in

3:1 ratio. 3. Don’t give lovenox in renal failure, give heparin.

ii. Warfarin 1. If you don’t give heparin then skin necrosis- affects protein C 2. Give heparin 5-7 days 3. INR 2-3

iii. Filter – dvt with contraindication for anticoagulation – like a brain bleed. Once head bleed stabilizes then give them anticoagulant again. Filter is a temporary solution.

d. Afib i. Blood not moving so make clot and that clot can goes to brain

ii. Usually with warfarin iii. INR 2-3 iv. Do you have to anticoagulate patients with AFib? So figure it out via CHADS2 risk; CHF,

HTN, Age >75, Diabetes, Stroke, 1. 0-1 no anticoagulate2. 2 – consider 3. 3+ anticoagulate

v. pt comes in with afib and cardiovert, do we anticoagulate? 1. Previous episode? Anticoagulate 2. Reversible cause of afib – no anticoagulation 3. If cardiovert then HAVE TO anticoagulate for one month minimum.

e. Valve prosthetic i. Mechanical

1. Aortic – goal INR 2-3 2. Mitral goal INR 2.5-3.5 3. Guy who needs procedure witih mechanical valve then take of Coumadin but start a

heparin drip because short lived and stop heparin right before procedure and start heparin back when its safe an dultiamtely shift to Coumadin

ii. Bioprosthetic 9. AFIB causes

a. PHEART – pericarditis, htn/heart attack, embolism, alcohol/OSA, rheumatic heart disease, thyrotoxicosis

10. Interstitial lung diseases a. ILD 2/2 anotehr disease or known cause

i. Rheumaticii. Pneumoconiosis

b. Idiopathic interstitial pneumoniai. IPF

1. Idiopathic pulmonary fibrosis – short of breath for years, no pillow orthopnea, no heart failure, smoker, FINE bibasilar crackles, PFTs DLCO bad. High resolution CT scan honeycombing

ii. Everything else c. Granulomatous disease

i. Sarcoidosis – noncaseating granulomas, hilar adenopathy, erythema nodosum, African America, SOB

d. Other/lymphagio/pulmonary non histiocytosis

11. HTN <120/80 – pick higher number out of systolic and diastolic a. 3 separate readings b. first line therapy

i. no comorbidities thiazide diuretics ii. diabetes or CKD – aceI if cough then ARB

iii. heart failure – ACEI, betablocker, NO CCB because it causes fluid retention and then you don’t want that for CHF.

iv. CAD – BB ACEI, CCB v. If these don’t work then hydralazine or clonidine

c. Goal i. No comorb <140/90

ii. CKD diabetes <130/80 12. Hypertensive urgency vs emergency

a. Emergency – end organ damage b. Give labetolol CCB nifedipine/nicardopine drip c. Can give clonidine or hydralazine but not the best

13. Diabetes a. Diagnosis each confirmed two times

i. Random glucose >200 at any time in prescence of symptoms – only one not need repeattesting

ii. Fasting glucose >= 126 iii. Hga1c >=6.5 iv. Oral glucose tolerance test >= 200

b. Goal of A1C <7 c. Every year eye exam and check his feet

i. Feet – vanc +zosin or ceftazadime or cefepime something that covers pseudomonas d. Complication

i. Macro 1. CVD

ii. Micro 1. Retinopathy 2. Neuropathy – numbness tingling – give gabapentin 3. Nephropathy –

a. First sign start spilling protein b. ACEI decreases pressure on efferent arteriole

4. Treatment iin order of giving it to patient a. Diet and exercise b. Metformin – SE lactic acidosis, no metformin with Cr >1.6 c. Sulfonylurea - Glypizide glyburide d. Insulin

i. Long acting – glargine and levomar ii. Somoby effect 2 am glucose low, donns phenomen when don’t give

enough insulin e. Hold ACE in AKI but give in CKD f. DKA

i. First thing give fluids ii. Insulin drip

iii. Add dextrose to fluid once glucose starts going down because anion gap may not fully close so drive glucose into cells and shuts off signals for ketogenesis

iv. Transition from IV to subqv. if the potassium is 5.5 is he really hyperkalemic == NO hes vomited it and he’s dry and RAAS

activated which cause NA reabsorption and K excretion. K in blood stream and not in cells. So eventually add K into fluids 4-4.5 hours into treatment.

ELECTROLYTES 14. Na

a. Hyponatremia – N1V1 AMS weakness seizures – CPM if correct to fast i. If seizures – 3% saline hypertonic saline

b. Hypernatremia – seizures cerebral edema if correct too faste 15. K

a. Hypo – weak paralyzed, give K EKG – u waves, if you keep correcting and it doesn’t go up give Mg. Lasix causes hypokalemia and hypomag.

b. Hyper – peaked T waves, very pointy, PR bigger, QRS bigger like someone is taking EKG and stretching it out. Late finding also sign waves.

16. Mga. Hyper lose DTRs like you do in pregnant women in mag land. b. Hypo spasms kinda like low calcium

17. Caa. Hypercalcemia

i. Chronic – stones bone groans pyschosis polyuria polydipsiaii. Acute – AMS, N/V ,

b. Hypocalcemia i. Chovostks, trousseaus, seizures

18. Glucosea. Hypoglycemia shaky b. Hyperglycemia

i. HONKK – no ketones give fluids fluids fluids High yield questions

19. Sudden onset tachycardia plueric chest pain with sats of 90% - PE, CT angio, TX dying emoblectomy, tpa, not dying heparin then switch to coumdin

20. stary sky pattenr – burkits – CML – tx gleevac 21. tx of diffuse large b cell lymphoma – RCHOP rituximab, cyclophosapd, doxorubicin, oncovorin/vinclistin,

prednisone 22. rabbit farm – tularemia – streptomysin tx 23. recurrent hemarthorsises – hemophilia A 24. epilepsy with gingival hyperplasia – taking dylantin/phenytoin25. patient with septic shock low TSH slightly low free T4, - euthyroid sick syndrome, no tx check TFTS in few

weeks when pt is more stable 26. truncal obesity peripheral atrophy, striae- cushings syndrome – exogenous steroids 27. noniatrogenic – low dexamethasone suppression test, 24 hour urinary cortisol, salivary eventing cortisol

level – 2/3 positive then cushings syndrome. Cushings disease (pituitary adenoma) ectopic ACTH tumor adrenal tumor

a. ectopic is not suppressed by high dose suppression test but a pituitary tumor is so it will suppress cortisol levels

b. if ACTH is low then adrenal tumor 28. episodic hypetension, flushing dizziness hypertension – pheo – dx with serum free metapneprhines and

urine for confirmation tx – alpha blockaged then beta blockage then surgery 29. epigastirc pain with nausea avomint glean forwards – pancreatitis – tx supportive and necrotizing then

give antibiotcs – gallstones alcohol a. complications – immediate – hemorrhagic or ARDS and weeks later pseudocysts 6 week

later 30. feels beter leaning forward pericafrdiits31. productive fever, lobar consolidation onf cxray – CAP Moraxella strep mycoplasma chlamydia

hemophilus – levoflox or moxiflox or third generation cephalosporin with macrolide 32. empirical treatment for bacterial meningitis – vanc + cephtriaxone if over age 50 then add

ampicillin to cover for listeria 33. macrocytic anemia renal failure protein gap lytic lesion multiple myeloma – spep upep to dx

34. malignancy associated with psammomma bodies – papillary thyroid carcinoma (has generally good prognosis), serious papillary cysts ovarian , meningioma, RCC, mesothelioma

35. four days wcant move eyebrows and liips on one side – peripheral 7, in stroke the upper 7 is preserved. – bells palsy – look in ear and see vesicles – herpes – ramsy hunt syndrome

36. fever RUQ pain jaundice – acute cholangitis37. tx of choice STEMI Cath and stent38. positive urine dipstick for heme but no rbcs under microscope – rhabdo 39. negative urine dipstick for heem but urine looks red – porphyria, medications (rifampin) 40. beeturia 41. proximal muscle weakness CK 1000 polymyosiites – steroids 42. dermatomyositis is with rash – rule out cancer 43. strep bovis/glaoliticis bacteremia – colonoscopy 44. watery diarrhea abdominal lpain fever hospital c diff – metronidazole and if sepsis then po vanc and metro 45. INR mechanical mitral vlav e 2.5 – 3.5 46. Urine sodium 80, mild hyponatremia elevated urine specific gravity urne somolartiy 700 – SIADH – first

line tx fluid restriction47. Panacinar emphysema and liver disyfuntion alpha antitripysin 48. PVC antimitochondrial antibodies 49. Hgb 8.6 irone 50 tibc 450 feriting 9 – irone deficiency – Gi bleedis cause in postmenstrual women or old

men 50. Five cause of hypomicroanemia, irone deficinec, thalaseemia,, anemia of chronic disease, lead poisioning,

sideroblastics51. Macrocytics – b12 folate, hypothyroid, liver disease, alcohol, MDS, reticulocytosis, MM, medication side

effects 52. Smear

a. Hypersegmented neutorphls

b. Snudge cell CLL c. Target cell – thalaseemia, asplenia, hgb C disease, liver diz

53. ID a. Gramp ositive cocic b. Gram negative rod

c. Blastomycosis – budding yeast

d. Crytococcus – indian ink

e. Candidi – budding hyphae

f. Neisseria – CSF – kidney shaped