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What is a consequence of cyanide poisoning on metabolism?
What is the antidote for cyanide poisoning?
What does carboxyhemoglobin level help confirm before treatment?
Which factor increases the likelihood of developing diabetes after a renal transplant?
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What must be considered when diagnosing post-renal acute kidney injury (AKI)?
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What is a common complication of prolonged lithotomy positioning in pregnant women?
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What is the first step in evaluating gastroparesis?
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What dietary change is recommended for managing gastroparesis?
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Which diagnostic method is considered the gold standard for confirming vascular conditions?
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What is the primary treatment recommended for patients with Barrett's esophagus?
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Which of the following is NOT a criterion for diagnosing acute pancreatitis?
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Which medication is considered first-line for a maintenance bowel regimen in older patients?
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In the presence of infected pancreatic necrosis, which imaging finding is diagnostic?
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What complication of chronic GERD often leads to the need for endoscopic screening?
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Which of the following is a common misconception concerning lactose intolerance?
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Why is long-term use of enemas not recommended in older adults?
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What are signs indicating airway obstruction?
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Which of the following is aimed at maintaining a brain-dead organ donor's viability?
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Which diagnosis can threaten the viability of an organ donor?
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In a patient with advanced HIV, what condition should be suspected related to lung pleural effusion?
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What characterizes TB pleural effusion when analyzed?
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Which of the following is a common finding in patients with silicosis?
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What distinguishes asbestosis from other lung conditions like silicosis?
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What is the most accurate diagnostic test for asbestosis?
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Which type of basal cell carcinoma presents as a shiny, pearly nodule with telangiectasia?
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What is the most appropriate initial treatment for alopecia areata?
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What is a common symptom of dengue fever?
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Which of the following is NOT a characteristic of drug-induced lupus?
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Identify the condition that presents with asymptomatic, firm, smooth, annular plaque with raised borders.
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What is the primary goal of a sensitivity analysis?
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How does NSAIDs usage lead to renal failure?
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What is a key feature of the holosystolic murmur associated with a VSD?
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What signifies delayed gastric emptying when an audible splashing sound is heard in the epigastric region during sudden movement?
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What is the initial test recommended for dysphagia that involves both solids and liquids?
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In cases of dysphagia that begins with solids and progresses to liquids, what is the initial step recommended?
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What is the preferred treatment for acute optic neuritis in patients with multiple sclerosis?
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What is the first-line treatment recommended for patients with heart failure and a reduced ejection fraction (HFrEF < 40%)?
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What distinguishes squamous cell carcinoma (SCC) skin cancer from other treatments when surgery is not an option?
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What is the appropriate next step if neither nasopharyngeal laryngoscopy nor barium swallow finds the cause of dysphagia?
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What is a contraindication for using cilostazol in patients?
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Study Notes
### Airway Obstruction
- Tracheostomy should be used as a last resort due to increased bleeding risk.
- Signs of airway obstruction include:
- Tracheal deviation
- Hoarseness
- Tripod position
- Dysphagia
- Voice changes
- Stridor
Brain-Dead Organ Donor
- The goal of managing a brain-dead organ donor is to maintain:
- Euvolemia
- Normotension
- Normothermia
- Supportive treatment includes:
- IV fluids
- Desmopressin
- Pressors
- Conditions that threaten organ donor viability:
- Central diabetes insipidus (depletes volume)
- Systemic hypotension (due to: loss of sympathetic tone, volume depletion)
- Hypothermia
Pleural Effusions
- In a patient with newly-diagnosed HIV and pleural effusion, tuberculosis should be suspected
- Advanced HIV increases the risk of TB infection or reactivation of latent TB
- Low CD4 count impairs the body's ability to form cavities that contain TB bacteria, leading to lobar, pleural, or disseminated infection.
- Patients with high CD4 counts usually present with cavitary lesions in the upper lobe.
- TB pleural effusion characteristics:
- Lymphocyte-predominant, exudative effusion
- Elevated adenosine deaminase levels
- Malignant pleural effusion shares similar characteristics but lacks elevated adenosine deaminase.
- Pleural biopsy is required for confirmation.
### Pneumocystis Pneumonia
- Does not present with lobar infiltrates or pleural effusions
- Diagnosis:
- Induced sputum sample (first-line)
- Bronchoalveolar lavage (second-line)
### Silicosis
- More common in miners, sandblasters, foundry workers, and masons
- Foundry workers melt metals
- Masons lay bricks with cement in construction
- Does not cause pleural effusion or pleural thickening
- CXR findings:
- Upper lobe nodules
- Lower lobe emphysema
### Asbestosis
- More common in workers handling cement, tile, automobile brake pads, or shipbuilding
- Associated with malignant mesothelioma
- Pleural effusion is almost always present
- CXR findings:
- Pleural thickening
- Calcifications
- Mass
- Most accurate diagnostic test:
- Video-assisted thoracoscopic biopsy
- Open thoracotomy
- Treatment:
- Surgery
- Chemotherapy
- Radiation
- Prognosis: 9-13 months to live
### Pulmonary Embolism
- Pulmonary artery filling defects on CTA are diagnostic
- S1Q3T3 pattern and T-wave inversion in V1-4 indicate right heart strain, associated with PE
### Cyanide Poisoning
- Cyanide inhibits oxidative phosphorylation, halting aerobic metabolism and forcing the body to use anaerobic metabolism.
- This leads to:
- Lactic acidosis
- Cellular hypoxia
- Neurological dysfunction
- Rapid cardiopulmonary compromise (hypotension, bradycardia)
- Antidote: hydroxocobalamin
- Hydroxocobalamin binds to cyanide, forming cyanocobalamin which can be excreted.
### Carbon Monoxide Poisoning
- CO binds to hemoglobin more readily than oxygen, preventing oxygen delivery to tissues.
- Treatment: 100% oxygen
- Confirm poisoning with carboxyhemoglobin levels before treatment, as this will guide further management.
Renal Transplant Patients
- Increased risk of developing diabetes within the first few months post-transplant
- Contributing factors:
- Immunosuppressant medication side effects
- Glucocorticoids
- Calcineurin inhibitors
- Antimetabolic agents
- Healthier kidney
- Increases insulin excretion and gluconeogenesis
- Immunosuppressant medication side effects
### Acute Kidney Injury (AKI)
- AKI is rarely caused by unilateral renal obstruction (e.g. ureterolithiasis) when there is a functional contralateral kidney, as the normal kidney can compensate.
- Post-renal AKI obstruction must be bilateral.
- Post-renal AKI can be caused by bladder outlet obstruction due to BPH.
### Femoral Neuropathy
- Can be caused by compression from an iliopsoas hematoma
- In pregnant women, prolonged lithotomy positioning can cause this.
### Gastroparesis
- Common in diabetic patients
- Difficult to time insulin doses due to delayed glucose absorption
- Diagnosis:
- Rule out mechanical obstruction first with upper GI endoscopy or barium swallow.
- CT AP and MRI AP can be used to rule out extrinsic compression.
- If no obstruction is found, perform a nuclear gastric emptying study to assess gut motility and confirm the diagnosis.
- Management:
- Eat small, frequent meals with reduced fat and fiber intake
### Aortic Aneurysm
- Diagnosis:
- CT angiogram
- MRI angiogram
- Duplex ultrasound (non-invasive)
- Gold standard for confirmation: angiography
- Treatment: angioplasty (stent placement)
### Barrett's Esophagus
- Precancerous condition characterized by metaplastic changes in the esophageal lining
- Patients with risk factors should undergo endoscopic screening (EGD) to look for these changes:
- Chronic GERD (>5 years)
- Age > 50
- Male
- White race
- Hiatal hernia
- Central obesity (waist circumference > 102 cm)
- Current or former smoker
- First-degree relative with Barrett's esophagus or esophageal adenocarcinoma
- Patients with Barrett's should be on lifelong PPI to prevent cancer and control reflux.
### Acute Pancreatitis
- Requires two of the following criteria:
- Acute onset of persistent, severe epigastric pain
- Elevated lipase or amylase (>3 times the upper limit)
- Lipase is more specific
- CT AP with contrast shows pancreatitis
- Imaging is reserved for cases where lab results are inconclusive, as CT sensitivity is low in the first 72 hours.
Infected Pancreatic Necrosis
- Complication of acute pancreatitis
- Develops typically > 7 days after initial presentation
- Presenting signs:
- Persistent abdominal pain
- Fever
- Leukocytosis
- Hypotension
- Diagnostics:
- Gas within pancreatic necrosis is diagnostic
- CT AP with IV contrast is the best diagnostic tool
- Treatment:
- IV antibiotics (meropenem, fluoroquinolone + metronidazole)
- Surgical debridement if antibiotic therapy fails
Fecal Impaction
- Prescribe a maintenance bowel regimen to prevent it.
- First-line for older adults: polyethylene glycol
- Avoid long-term use of:
- Bisacodyl (increased protein-losing enteropathy and electrolyte imbalances)
- Enemas (hypotension, electrolyte abnormalities, inconvenience)
- Docusate is a stool softener without a strong laxative effect.
### Lactose Intolerance vs. Celiac Disease
- Lactose intolerance:
- GI symptoms are temporally related to mealtimes
- Celiac disease:
- No temporal relation between mealtimes and GI symptoms
- Lactose intolerance does not present with iron deficiency anemia
### Peptic Stricture
- Well-known complication of GERD caused by healing of ulcerative esophagitis.
- Dysphagia:
- First with solids, followed by liquids.
### Succussion Splash
- Audible splashing sound in the epigastric region during sudden movements of the patient
- Sign of delayed gastric emptying
- First step in evaluation is to rule out obstruction with EGD
- Nuclear gastric emptying study is then performed
- Gastroduodenal manometry can distinguish between myopathic (e.g., amyloidosis) and neuropathic etiologies.
### Dysphagia
- Dysphagia involving both solids and liquids suggests neuromuscular disorders (motility).
- Initial test: Barium swallow/esophagram
- Confirmatory test: Manometry
- Dysphagia starting with solids followed by liquids suggests mechanical obstructions (structural)
- Initial test: Nasopharyngeal laryngoscopy (most effective for visualization)
- Barium swallow/esophagram can also be helpful.
- Barium swallow: XR exam that assesses the esophagus, throat, and back of the mouth.
- Video-assisted barium swallow: modified version of barium swallow/esophagram used to assess the oral cavity, pharynx, and cervical esophagus.
- EGD is the next step if nasopharyngeal laryngoscopy/barium swallow cannot determine a cause:
- You cannot visualize the upper esophagus upon insertion
- Increased risk of perforation leading to upper GI/esophageal bleed.
### Esophageal Cancer
- Squamous cell carcinoma (SCC) is more common in the upper esophagus.
- Adenocarcinoma is more common in the mid-distal/lower esophagus.
### Heart Failure with Reduced Ejection Fraction (HFrEF)
- All patients with HFrEF (< 40% EF) should be placed on ACE-i/ARBs + beta-blockers.
- ACE-i/ARBs are initiated first.
- Beta-blockers are added once a stable and non-hypotensive dose of ACE-i/ARBs is found.
- Diuretics are NOT indicated for asymptomatic CHF (NYHA class I).
### Squamous Cell Carcinoma (SCC) of Skin
- Needs to be surgically excised (diagnostic and curative)
- For patients who do not want surgery, alternatives include:
- Cryotherapy
- Electrosurgery
- Radiation therapy
- Radiation therapy is usually reserved for older patients who refuse surgery due to the need for multiple visits and increased risk of future cancers.
### BRAF Gene Therapy
- Used for melanoma, not squamous cell skin cancer.
### Acute Multiple Sclerosis (MS) Exacerbation
- Treated with oral or IV corticosteroids.
- IV corticosteroids are preferred for acute optic neuritis as the oral route increases the risk of recurrent optic neuritis.
### Advanced MS
- Signs:
- Inability to sustain simple voluntary acts
- Inevitable cognitive decline
- Progressive deterioration in cognitive and motor function over 10-20 years following symptom onset, leading to death.
- No cure or disease-modifying therapy.
### Alopecia Areata
- Discrete, smooth, and circular areas of hair loss.
- Develops over a few weeks with a recurring pattern.
- Most cases resolve spontaneously over time, with hair regrowth.
- Disease can recur even after successful treatment.
- Treatment:
- Topical or intralesional corticosteroids
- Patient education
- Benign disease
- Multiple relapses are possible despite treatment
- Most patients have normal hair growth within 1-2 years, even without treatment.
### Sensitivity Analysis
- Repetition of the primary analysis with changes to criteria or ranges.
- Goal: To evaluate whether changes to variables or ranges affect the results.
- Similar results after changes increase confidence in the results.
### Ventricular Septal Defect (VSD)
- Holosystolic murmur with a palpable thrill is characteristic.
Basal Cell Carcinoma (BCC)
- There are three types:
- Nodular BCC: Shiny, pearly, skin-colored nodule with telangiectasia
- Superficial BCC: Second most common; presents with pink/red macules, patches, or thin plaques. Can appear atrophic.
- Morpheaform/Infiltrative BCC: Least common; presents with pale, scar-like indentations
### Granuloma Annulare
- Asymptomatic, firm, smooth, annular plaque with raised borders
### Drug-Induced Lupus
- Can be caused by hydralazine.
- Does not cause renal failure.
### Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
- Can cause renal failure/nephropathy by inhibiting prostaglandin (PG) production.
- PG causes renal artery vasodilation.
### Dengue Fever
- Mosquito-borne virus
- Endemic areas: Asia (India), Africa, South America, Pacific and Caribbean Islands.
- Look for recent travel history.
- Symptoms begin 4-7 days after transmission:
- High fever
- Retroorbital pain
- Severe arthralgia and myalgia ('breakbone fever')
- Hemorrhagic symptoms:
- Petechiae
- Mucosal bleeding
- Petechiae may be provoked by the tourniquet test (inflating blood pressure cuff midway between diastole and systole for 5 minutes).
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