1 Flashcards
Most common cause of post-operative hematoma in patients with no personal or family history of easy bleeding or bruising?
Insufficient hemostasis
Presentation - chronic or fluctuating conjugated hyperbilirubinemia and intermittent jaundice
Dubin-Johnson syndrome
Cause of Dubin-Johnson syndrome?
Benign, hereditary defect in hepatic excretion of conjugated bilirubin
Positive urine bilirubin reflects a build-up of conjugated bilirubin - explain.
Conjugated bilirubin is water soluble and readily excreted in urine. Normally, conjugated bilirubin is degraded in the intestines. If levels rise, some will be excreted in urine.
Positive urobilinogen reflects a build-up of unconjugated bilirubin - explain.
Unconjugated bilirubin is highly insoluble and cannot be excreted in urine. Excess undergoes metabolism to form urobilinogen, which is excreted in feces and urine.
What causes Gilbert syndrome?
Decreased bilirubin glucuronidation
Differentiate between Rotor and Dubin-Johnson syndromes?
Histology - black, pigmented liver in DJ, normal in Rotor
Presentation of disseminated gonococcal infection?
Purulent monoarthritis without systemic symptoms
OR
Triad of tenosynovitis, dermatitis, and migratory polyarthralgia
Rx disseminated gonococcal infection
3rd generation cephalosporin IV AND oral azithromycin
Dx disseminated gonococcal infection?
Culture or PCR of blood, synovial fluid, potentially infected mucosal sites
Gram stain and culture are highly specific but insensitive, as >50% have negative culture
Osteogenesis imperfecta:
- Inheritance pattern
- Mutation
Autosomal dominant
Mutations in type 1 collagen
5 U/S findings of type II osteogenesis imperfecta?
- Multiple fractures
- Short femur
- Hypoplastic thoracic cavity
- Fetal growth restriction
- Intrauterine demise
Features of achondroplasia?
- Macrocephaly
- Frontal bossing
- Midface hypoplasia
- Rhizomelia (shortened limbs, especially proximally)
- Trident hand
- Genu varum (bowing of the tibia)
Features of amniotic band sequence?
Limb defects (eg, amputation, hand defects, clubfoot) Craniofacial defects Abdominal wall defects
Features of Potter sequence?
Pulmonary hypoplasia
Limb deformities (eg, clubfoot, hip dislocation)
Oligohydramnios
Most commonly caused by urinary tract abnormalities
Diagnose menopause?
Clinical symptoms
Increased FSH
Presentation - glazed, erythematous vulvar erosions bordered by white striae +/- associated vaginal and oral lesions
Vulvar lichen planus
Rx vulvar lichen planus?
High-potency topical corticosteroids
Dx vulvar lichen planus?
Biopsy (excludes cancer)
What is Todd paralysis?
Transient, focal neurologic deficit, typically manifested by hemiparesis that occurs after either a focal or generalized seizure
What is spondylolisthesis and how does it present?
Anterior slippage of a vertebral body due to bilateral defects of the pars interarticularis (spondylolysis), classically presents in an adolescent with LBP exacerbated by lumbar extension
Rx initial episode of C. difficile?
Vancomycin PO or fidaxomicin
Rx first recurrence of C. difficile?
Vancomycin PO in a prolonged pulse/taper course or fidaxomicin if vancomycin was used in initial episode
Rx multiple recurrences of C. difficile?
Vancomycin PO followed by rifaximin or fecal transplant
Rx fulminant C. difficile (hypotension, shock, ileus, megacolon)?
Metronidazole IV + high-dose vancomycin PO (or PR if ileus present)
Surgical evaluation
Why is IV vancomycin not effective against C. difficile?
It is not excreted into the colon
Diagnostic criteria for acute bacterial rhinosinusitis?
1 of 3:
- Persistent symptoms for 10+ days without improvement
- Severe onset (fever 39+ with drainage) for 3+ days
- Worsening symptoms following initial improvement
Rx acute bacterial rhinosinusitis?
Amoxicillin +/- clavulanate
Most common causes of acute bacterial rhinosinuisitis?
Non-typeable H. influenzae
S. pneumoniae
M. catarrhalis
Most common risk factor for acute bacterial rhinosinusitis? Second most common?
Viral URI; allergic rhinitis
Classic lab findings in infantile hyeprtrophic pyloric stenosis?
Hypochloremic, hypokalemic metabolic alkalosis
Why should electrolytes be normalized and alkalosis corrected prior to surgery in hypetrophic pyloric stenosis?
Decreases the risk of post-operative apnea, improves overall outcomes
Cause of Reye syndrome?
Pediatric aspirin use during influenza or varicella infection
Clinical features of Reye syndrome?
Acute liver failure and encephalopathy
When should you stop Pap testing?
Age 65 or hysterectomy PLUS no history of CIN2 or higher AND 3 consecutive negative Pap tests OR 2 consecutive negative co-testing results
Consider if there are risk factors for cervical cancer.
Frequency of Pap tests?
Begin at age 21 without co-testing every 3 years
At age 30, Pap with co-testing may be done and repeated every 5 years if negative
Features of mild hypothermia?
32-35 C (90-95 F)
Tachycardia, tachypnea
Ataxia, dysarthria, increased shivering
Features of moderate hypothermia?
28-32 C (82-90 F)
Bradycardia, lethargy, hypoventilation, DECREASED SHIVERING, atrial arrhythmias
Features of severe hypothermia?
<28 C (82 F)
Coma, CV collapse, ventricular arrhythmias
General treatment for hypothermia?
Warmed (42 C) crystalloid for hypotension
Endotracheal intubation in comatose patients
Rewarming techniques by classification of hypothermia?
Mild: passive external (remove wet clothes, cover with blankets)
Moderate: active external (warm blankets, heating pads, warm baths)
Severe: active internal (warmed pleural or peritoneal irrigation, warmed humidified oxygen)
Why is the bradycardia associated with hypothermia often refractory to treatment with atropine and cardiac pacing?
Due to decreased reactivity of the pacemaker cells
Presentation - rash after amoxicillin?
Infectious mononucleosis
Lab findings in infectious mononucleosis?
Positive heterophile antibody (Monospot) test -> 25% false-negative rate during 1st week of illness
Atypical lymphocytosis
Transient hepatitis
Cause of hemineglect syndrome?
Non-dominant parietal lobe (R lobe in R-handed individuals)
Most common middle ear pathology in patients with AIDS?
Serous otitis media
Cause of serous otitis media in patients with AIDS?
Auditory tube dysfunction from lymphadenopathy or obstructing lymphoma
Characteristic feature of serous otitis media?
Midle ear effusion without evidence of an acute infection
Presentation of serous otitis media?
Conductive hearing loss
Dull tympanic membrane that is hypomobile on pneumatic otoscopy
4 lab findings of lactose intolerance?
- Positive hydrogen breath test
- Negative stool test for reducing substances
- Low stool pH (due to fermentation products)
- Increased stool osmotic gap (due to unmetabolized lactose and organic acids)
NO steatorrhea
Calculate stool osmotic gap?
290 - [2 (stool Na + stool K)]
> 50 in all forms of osmotic diarrhea
3 dietary recommendations for patients with renal calculi?
- Increase fluid intake
- Decrease sodium intake
- Normal dietary calcium intake
Manage acute low back pain?
Maintain moderate activity
NSAIDs or acetaminophen
Consider muscle relaxants, spinal manipulation, brief course of opioids
Manage chronic low back pain?
Intermittent use of NSAIDs or acetaminophen
PT
Consider TCAs, duloxetine
Common side effect of treatment with dihydropyridine calcium channel blockers (eg, amlodipine)?
Peripheral edema (due to vasodilatory effects on peripheral blood vessels)
What is the purpose of tuberculin skin testing?
Identify asymptomatic patients with prior exposure to M. tuberculosis and latent TB infection
When the PPD induration is 15+ mm, who is treated?
Everyone
When the PPD induration is 10+ mm, who is treated?
- Recent immigrants (<5 years) from TB-endemic areas
- Injection drug users
- Residents and employees of high-risk settings
- Mycobacteriology lab personnel
- Higher risk for TB reactivation (immunosupressed)
- Children <4, those exposed to adults in high-risk categories
When the PPD induration is 5+ mm, who is treated?
- HIV-positive patients
- Recent contacts of known TB case
- Nodular or fibrotic changes on CXR consistent with previously healed TB
- Organ transplant recipients and other immunosuppressed patients
Rx latent TB?
- Insoniazid + rifapentine weekly for 3 months under direct observation (not recommended in HIV)
- Isoniazid monotherapy for 6-9 months
- Rifampin for 4 months
Add pyridoxine to prevent neuropathies in patients taking isoniazid who have DM, uremia, alcoholism, malnutrition, HIV, pregnancy, epilepsy
Rx active pulmonary TB?
RIPE for 8 weeks, then isoniazid and rifampin for another 4 months
Presentation of AD PCKD?
Asymptomatic until age 30-40
HTN (early finding)
Hematuria, flank pain, nephrolithiasis, UTIs
May have elevated Hgb due to increased EPO
Palpable abdominal masses usually bilateral
CKD
List 5 extrarenal features of AD PCKD?
- Cerebral aneurysms
- Hepatic and pancreatic cysts
- MV prolapse and aortic regurgitation
- Colonic diverticulosis
- Ventral and inguinal hernias
___ should be suspected in patients who have hemolytic anemia, cytopenias, and hypercoagulable states (intra-abdominal or cerebral venous thrombosis).
Paroxysmal nocturnal hemoglobinuria
Dx PNH?
Flow cytometry to assess for absence of CD55 and CD59 proteins on RBC surface
Lab findings in PNH?
- Hypoplastic/aplastic anemia, thrombocytopenia leukopenia
- Elevated LDH, low haptoglobin (hemolysis)
- Indirect hyperbilirubinemia
- Hemoglobinuria
Rx PNH?
Iron and folate supplementation
Eculizumab (MAB that inhibits complement activation)
Relative risk can be calculated in ___ studies by comparing the risk (incidence) of disease among exposed individuals to the risk among unexposed individuals.
Cohort
Why can relative risk not be directly calculated in case-control studies?
They do not follow patients over time or measure disease incidence
When can OR generally approximate RR in a case-control study?
If the disease is rare (low disease prevalence) -> disease incidence is typically low
RR = ?
(a/a+b)/(c/c+d)
OR = ?
ad/bc
7 clinical features of Cushing syndrome (hypercortisolism)?
- Central obesity
- Skin atrophy and wide purple striae
- Proximal muscle weakness
- HTN
- Glucose intolerance
- Skin hyperpigmentation (due to ACTH excess)
- Depression, anxiety
Possible causes of Cushing syndrome?
Exogenous glucocorticoids (most common)
ACTH-producing pituitary tumor (Cushing disease)
Ectopic ACTH production (eg, small cell lung cancer)
Primary adrenal disease
Initial step in evaluation of Cushing syndrome?
Confirm hypercortisolism with a late-night salivary cortisol essay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone suppression test (2 should be abnormal to diagnose)
If confirmed, ACTH levels measured
Compare clinical features of nephrotic syndrome vs. nephritic syndrome.
Nephrotic: edema, fatigue, proteinuria, NO hematuria, hypoalbuminemia
Nephritic: HTN, oliguria, hematuria, proteinuria, casts
Pediatric etiologies of nephrotic syndrome vs. nephritic syndrome?
Nephrotic: minimal change disease
Nephritic: PSGN, HUS
Adult etiologies of nephrotic syndrome vs. nephritic syndrome?
Nephrotic: FSGS, membranous nephropathy, membranoproliferative GN
Nephritic: IgA nephropathy, Membranoproliferative GN, crescentic GN
Significant risk factor for membranous nephropathy?
Hepatitis B infection
Infection most commonly associated with FSGS?
HIV
Features of beta blocker overdose?
Bradycardia AV block Hypotension Diffuse wheezing Hypoglycemia Neurologic dysfunction
Intoxication with CCBs, digoxin, and cholinergic agents cause symptoms similar to beta blocker intoxication - which feature is specific for beta blockers?
Wheezing
Management of beta blocker OD?
- Secure airway and give isotonic fluid boluses with IV atropine for initial treatment of hypotension and bradycardia
- If refractory or profound hypotension -> IV glucagon
May also use IV calcium, vasopressors, (epi/norepi), high-dose insulin and glucose, and IV lipid emulsion therapy
Features of digoxin toxicity?
Life-threatening arrhythmias
Anorexia, N/V, abdominal pain
Fatigue, confusion, weakness, COLOR VISION ALTERATIONS
Risk factors for intestinal atresia in neonates?
- Poor fetal gut perfusion from maternal use of vasoconstrictors (medications, cocaine, tobacco, etc.)
- Chromosomal abnormalities (duodenal only)
Triple bubble sign + gasless colon?
Jejunal atresia
Double bubble sign + gasless colon?
Duodenal atresia
Cause of hypoxemia due to pneumonia?
Inflammatory exudate fills alveoli -> marked impairment of alveolar ventilation
R to L intrapulmonary shunting (extreme form of VQ mismatch)
Pulmonary capillary wedge pressure reflects what?
L atrial pressure
Presentation - bilateral symmetric macules on sun-exposed areas of the face during pregnancy (other risk factors include darker skin color, thyroid dysfunction, medications, cosmetic use)
Melasma (acquired hyperpigmentation disorder)
Rx superficial infantile hemangioma?
Observation
If ulcerated, disabling, life-threatening, or in cosmetically sensitive areas -> topical beta blocker
3 characteristic biochemical abnormalities of secondary hyperparathyroidism in chronic renal failure?
Hypocalcemia
Hyperphosphatemia
Increased PTH levels
Presentation - continuous, painless leakage of urine, pooling clear fluid in the vagina, raised red granulation tissue or a vaginal defect
Vesicovaginal fistula
Causes and timing of vesicovaginal fistula development?
Immediately: intraoperative bladder injury (C-section, hysterectomy, etc.)
Weeks or months: tissue necrosis and sloughing (surgery, childbirth, etc.)
Years: radiation-induced microvascular injury and progressive tissue ischemia and breakdown (pelvic radiotherapy, etc.)
What can be used to identify a small vesicovaginal fistula?
Bladder dye test
Rx transient synovitis in young children?
Rest and NSAIDs
What develops abnormally in Mullerian agenesis?
Uterus, cervix, upper 1/3 of vagina
Presentation of mullerian agenesis?
Primary amenorrhea Normal female external genitalia Blind vaginal pouch Absent or rudimentary uterus Bilateral functioning ovaries -> normal FSH, estrogen, secondary sexual characteristics
Management of mullerian agenesis?
Vaginal dilation
Renal U/S to assess for renal system abnormalities
Most common cause of myocarditis in children?
Viral infection (Coxsackievirus B, adenovirus)
Presentation of viral myocarditis?
Viral prodrome
Chest pain and respiratory distress from acute L heart failure and pulmonary edema
Dilated cardiomyoapthy with mitral regurgitation -> S3 gallop and holosystolic murmur
Hepatomegaly
Diagnostic criteria of Kawasaki disease?
5+ days of fever and 4+ clinical criteria (rash, LAD >1.5 cm, conjunctivitis, mucosal changes, extremity changes)
Rx moderate to severe dehydration in children?
IV bolus of isotonic fluid
Method of assessing dehydration in children?
- Mild dehydration (3-5% volume loss): decreased intake or increased fluid loss with minimal or no clinical symptoms
- Moderate dehydration (6-9% volume loss): decreased skin turgor, dry mucus membranes, tachycardia, irritability, delayed capillary refill (2-3 seconds), decreased urine output
- Severe dehydration (10-15% volume loss): cool, clammy skin, delayed capillary refill (>3 seconds), cracked lips, dry mucus membranes, sunken eyes/fontanelle, tachycardia, lethargy, minimal or no urine output
Rx mild to moderate dehydration in children?
Oral rehydration
What is tinea versicolor?
Superficial fungal skin infection caused by Malassezia species
Characteristic features of tinea versicolor?
Salmon-colored, hyper- or hypopigmented macules that are sometimes covered by fine scales, most commonly on the upper trunk and extremities
Dx tinea versicolor?
KOH preparation showing large, blunt hyphae and thick-walled budding yeast (spaghetti and meatballs appearance)
Rx tinea versicolor?
Selenium sulfide or ketoconazole
Rx patient with AFib w/RVR who also has WPW syndrome?
Cardioversion (hemodynamically unstable) or antiarrhythmics such as procainamide (stable patients)
Why should AV node blockers like BBs, CCBs (especially verapamil), digoxin, and adenosine by avoided in patients with WPW?
Increase conduction through the accessory pathway
Unilateral (L-sided) varicoceles that fail to empty when a patient is recumbent raise suspicion for what?
Underlying mass pathology such as RCC that obstructs venous flow
Compare syncope due to arrhythmia vs. vasovagal or neurocardiogenic.
Arrhythmia: underlying structural heart disease, may not have prodromal symptoms
Vasovagal/neurocardiogenic: prodrome with nausea, pallor, diaphoresis, generalized sense of warmth
Most common cause of acquired angioedema?
ACE inhibitors (note - can occur ANYTIME, not just within weeks of starting the medication)
Common AE of beta-blockers?
Bradycardia, AV block, bronchoconstriction (significant in patients with asthma and COPD), male sexual dysfunction
Common AE of nitrates?
HA, hypotension, tolerance with continued use
Common AE of clopidogrel?
Uncommonly - TTP
Common AE of aspirin and NSAIDs?
Allergic angioedema
Common AE of statins?
Hepatotoxicity and myopathy
Common AE of ACEIs?
Angioedema, cough, hyperkalemia, precipitation of acute renal failure if bilateral renal artery stenosis
Necrotizing (malignant) otitis externa represents osteomyelitis of the skull base and is most commonly caused by ___. What is the classic presentation?
Pseudomonas aeruginosa
Severe ear pain and ear drainage, possible granulation tissue in ear canal, cranial neuropathies (7, 10, 11) with progression
3 risk factors for necrotizing otitis externa?
- Elderly (>60)
- DM
- Aural irrigation (cerumen removal)
Rx necrotizing otitis externa?
Prolonged IV anti-pseudomonal ABX (eg, ciprofloxacin)
+/- debridement
What is Ramsay Hunt syndrome?
Herpes zoster infection in the ear
Cause of blindness leading to distortion of straight lines
Macular degeneration
Ophthalmologic exam finding of macular degeneration?
Drusen deposits in the macula
Cause of lens opacification?
Cataracts
Management of chronic pancreatitis
Alcohol and tobacco cessation
Rx DM if present
Pancreatic enzyme supplementation (lipase, protease, amylase) - helps with pain as well as exocrine insufficiency
May consider TCAs or pregabalin for pain
3 treatment options for Graves’ disease?
Anti-thyroid drugs (thionamides)
Radioactive iodine ablation therapy
Thyroidectomy
AE of anti-thyroid drugs?
Agranulocytosis
If methimazole - T1 teratogen, cholestasis
If propylthiouracil - hepatic failure, ANCA-associated vasculitis
AE of radioiodine ablation?
Permanent hypothyroidism
Worsening of ophthalmopathy
Possible radiation AE
AE of thyroidectomy?
Permanent hypothyroidism
Risk of recurrent laryngeal nerve damage, hypoparathyroidism
Tournique test?
Dx dengue fever
Babesiosis is a tick-borne protozoal illness found primarily in the ___ US. Labs usually show what findings? Dx?
Northeastern
Anemia, thrombocytopenia, signs of intravascular hemolysis
Peripheral smear (Maltese cross)
Rx Baesiosis
7-10 days atovaquone + azithromycin OR quinine + clindamycin
Goal rate of warming in treating hypothermia?
1-2 C/hr
Features of cardiac sarcoidosis?
Complete AV block (most common)
Restrictive cardiomyopathy early, dilated cardiomyopathy late, valvular dysfunction, heart failure, sudden cardiac death
Management of stress fracture?
Reduced weight bearing for 4-6 weeks, referral to ortho surgeon for fracture at high risk for malunion (eg, anterior tibial cortex, 5th metarsal)
Pain between 3rd and 4th toes on the plantar surface, clicking sensation when palpating and squeezing the metatarsal joints?
Morton neuroma
___ can occur after head trauma and result in episodic vertigo with nystagmus triggered by sudden pressure changes or loud noises.
Perilymphatic fistula
Patients receiving solid organ transplantations require high-dose immunosuppressive medication to prevent organ rjection. This results in systemic immunosuppression, which puts them at risk for opportunistic infections, most notably which 2?
Pneumocystis penumonia (PCP)
Cytomegalovirus (CMV)
Prophylaxis for PCP and CMV?
TMP-SMX and valganciclovir, respectively
Symptoms of tissue-invasive CMV disease?
Pneumonitis, gastroenteritis, hepatitis
What is a urethral diverticulum and how does it present?
Abnormal localized outpouching of the urethral mucosa that can collect urine and cause inflammation in the surrounding tissue
Dysuria, post-void dribbling, dyspareunia, tender anterior vaginal wall mass that expresses a purulent or bloody urethral discharge
Dx urethral diverticulum?
UA, urine Cx, MRI of the pelvis*, TVUS
Cause of S3 heart sound?
Results when inflow from the L atrium strikes blood that is already in the L ventricle, causing reverberation of blood between the walls
Normal in young people and well-trained athletes
Sign of LV failure in older people
Hexagonal crystals, recurrent kidney stones since childhood, family history?
Cystinuria
Cause of cystinuria?
Impaired transport of cystine and dibasic amino acids (ornithine, lysine, arginine) by brush borders of renal tubular and intestinal epithelial cells -> decreased reabsorption (increased urinary excretion) or cystine, poorly soluble in water -> stones (radiolucent)
Dx cystinuria?
Cyanide-nitroprusside test
Dx myasthenia?
Edrophonium (tensilon) test, ice pack test
ACh receptor Ab (highly specific); if negative, check for muscle-specific tyrosine kinase Ab
CT scan for thymoma
Rx MG?
ACh-esterase inhibitors (eg, pyridostigmine)
+/- immunotherapy (eg, corticosteroids, azathioprine)
Thymectomy
Slit lamp exam?
Evaluate for abnormalities of anterior segment of eye (conjunctiva, cornea, anterior chamber, iris)
CHF due to LV systolic dysfunction is characterized by ___ cardiac output/index, ___ SVR, ___ LVEDV.
Decreased; increased; increased
