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Questions and Answers
What is a consequence of cyanide poisoning on metabolism?
What is a consequence of cyanide poisoning on metabolism?
What is the antidote for cyanide poisoning?
What is the antidote for cyanide poisoning?
What does carboxyhemoglobin level help confirm before treatment?
What does carboxyhemoglobin level help confirm before treatment?
Which factor increases the likelihood of developing diabetes after a renal transplant?
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)?
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?
What is a common complication of prolonged lithotomy positioning in pregnant women?
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What is the first step in evaluating gastroparesis?
What is the first step in evaluating gastroparesis?
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What dietary change is recommended for managing gastroparesis?
What dietary change is recommended for managing gastroparesis?
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Which diagnostic method is considered the gold standard for confirming vascular conditions?
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?
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?
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?
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?
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?
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?
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?
Why is long-term use of enemas not recommended in older adults?
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What are signs indicating airway obstruction?
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?
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?
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?
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?
What characterizes TB pleural effusion when analyzed?
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Which of the following is a common finding in patients with silicosis?
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?
What distinguishes asbestosis from other lung conditions like silicosis?
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What is the most accurate diagnostic test for asbestosis?
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?
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?
What is the most appropriate initial treatment for alopecia areata?
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What is a common symptom of dengue fever?
What is a common symptom of dengue fever?
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Which of the following is NOT a characteristic of drug-induced lupus?
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.
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?
What is the primary goal of a sensitivity analysis?
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How does NSAIDs usage lead to renal failure?
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?
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?
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?
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?
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?
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%)?
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?
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?
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?
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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