14 Flashcards
How does SCFE occur?
Excessive shearing at the proximal femoral physis (growth plate)
Rx drug resistant CMV
Foscarnet
Cause of vaginal SqCC?
Persistent infection with HPV 16/18; chronic tobacco use increases risk
Rx limited plaque psoriasis?
Topical high-potency glucocorticoids or vitamin D derivatives (eg, calcipotriene), topical retinoids, calcineurin inhibitors
If moderate to severe - phototherapy or systemic treatment (MTX, biologics, etc.)
Is S3 or S4 an expected finding in patients with severe MR - why?
S3 gallop
Backflow of blood from LV during systole -> total amount of blood entering LV during diastole increases -> eccentric hypertrophy to compensate for increased volume load
Sudden cessation of blood flow into a dilated LV during the passive filling phase of diastole
S3 is commonly heard in ___.
Heart failure
Opening snap?
Mitral stenosis
S4 is commonly heard in ___ - why?
Concentric LVH due to systemic HTN or severe AS -> blood striking stiff L ventricle during atrial systole, just before mitral valve closure (S1)
Uvular pulsation may be appreciated with the high-amplitude systolic pulsation and rapid diastolic collapse that occurs with severe ___.
AR
Palpable fetal parts on abdominal exam, loss of fetal station
Uterine rupture
Clinical features of alpha-thalassemia minima (1 gene loss)
Asymptomatic, silent carrier
Clinical features of alpha-thalassemia minor (2 gene loss)
Mild microcytic anemia
Clinical features of Hemoglobin H disease (3 gene loss)
Chronic hemolytic anemia
Clinical features of hydrops fetalis, Hgb Barts (4 gene loss)
High-output cardiac failure, anasarca, death in utero
Of the 3 main causes of vaginitis, which one has normal pH (vs increased >4.5)?
Candida vaginitis
Vaginitis with clue cells and + whiff test?
BV
Vaginitis with motile trichomonads?
Trichomoniasis
Vaginitis with pseudohyphae?
Candida
Rx BV?
Metronidazole or clindamycin
Rx trichomoniasis?
Metronidazole + treat sexual partner
Rx candida vaginitis?
Fluconazole
Anaerobe that may cause PID associated with IUDs?
Actinomyces (filamentous, GP bacilli, branching)
Subluxation of the radial head is common in preschool children. The classic mechanism is swinging or pulling a child by the arm. Full recovery after ___ confirms the diagnosis.
Closed reduction by forearm hyperpronation or supination of forearm + flexion of the elbow
Physical findings of radial head subluxation
Arm held extended and protonated
NO swelling, deformity, or focal tenderness
Management of sharp foreign body?
Endoscopic removal due to the risk of esophageal perforation
Cause of methemoglobinemia?
Uncommon complication after excessive exposure to an oxidizing agent (eg, dapsone, nitrites, local/topical anesthetics)
Presentation of methemoglobinemia?
Cyanosis, pulse ox ~85% always, dark chocolate colored blood, no improvement with supplemental O2
Lab findings in methemoglobinemia?
Saturation gap (>5% difference between O2 saturation on pulse oximetry and ABG) Normal PaO2 (falsely elevated)
Rx methemobloinemia
Methylene blue or high-dose ascorbic acid
Presentation of premature adrenarche?
Early activation of adrenal androgens (more common in obesity)
Presentation of premature adrenarche?
Precocious development of pubic and axillary hair, acne, and body odor in a child with a normal bone age
Compare the joints involved in OA vs. RA.
OA: knees and hips, DIP, first CMC
RA: MCP, PIP, wrists
Compare the XR findings of OA vs. RA.
OA: narrowed joint space, osteophytes
RA: periarticular erosions
Case control vs. retrospective cohort studies
Case control: outcome first, then look for associated risk factors
Retrospective cohort: first ascertain risk factor exposure and then determine the outcome
What is supravalvular aortic stenosis?
Second most common type of AS
Congenital left ventricular outflow tract obstruction due to discrete or diffuse narrowing of the ascending aorta
Presentation of supravalvular AS?
Systolic murmur best heard at the FIRST RIGHT INTERCOSTAL SPACE
Unequal carotids
Differential blood pressure in the upper extremities
Palpable thrill in the suprasternal notch
Sequelae of supravalvular AS?
LVH, coronary artery stenosis (associated anomaly) -> increase myocardial O2 demand during exercise
Stretching of the papillary muscles can lead to ___.
MR (holosystolic or mid to late systolic murmur at apex)
Systolic anterior motion of the MV is seen in patients with ___.
HOCM
Tendency of the study population to affect the outcome since they are aware they are being studied
Hawthorne effect
Physiologic changes to thyroid hormones seen in pregnancy?
Thyroid hormone production increases:
Total T4 - increased
Free T4 - unchanged or mildly increased
TSH - decreased
E2 increases thyroxine-binding globulin, leading to an increased total (but not free) thyroid hormone levels
hCG stimulates TSH receptors increasing production
Features of acute HIV infection?
Mono-like syndrome (fever, LAD, sore throat, arthralgias, etc.)
Painful mucocutaneous ulcerations are characteristic (if present)
Generalized macular rash
GI symptoms
In HIV, what 2 viruses can cause severe acute retinal necrosis associated with pain, keratitis, uveitis, and funduscopic findings of peripheral pale lesions and central retinal necrosis?
HSV and VZV
What other virus can cause retinitis in HIV and how can it be distinguished?
CMV -> PAINLESS, not usually associated with keratitis or conjunctivitis, and characterized by funduscopic findings of hemorrhages and fluffy or granular lesions around the retinal vessels
Exertional heat stroke occurs in otherwise healthy individuals undergoing conditioning in extreme heat and humidity due to ___.
Thermoregulation failure
What causes heat exhaustion?
Inadequate fluid and salt replacement
Rx primary biliary cholangitis?
Ursodeoxycholic acid (delays histologic progression, may improve symptoms/survival)
Advanced disease - liver transplantation
Rx autoimmune hepatitis?
Glucocorticoids
Autoimmune hepatitis antibodies?
+ANA
MOA - type 2 HI?
Heparin induces a conformational change in a platelet surface protein which exposes a neoantigen; antibodies are formed and bind to the surface of platelets -> platelet activation, thrombocytopenia, and a prothrombic state
Heparin MOA?
Binds antithrombin and inactivates 10a, prolongs aPTT
Type 1 vs. Type 2 HIT?
Type 1 - non-immune-mediated platelet aggregation, mild thrombocytopenia within 2 days, no intervention needed
Type 2 - immune-mediated, severe, D/C heparin
Risk = ?
Probability of getting a disease over a certain period of time -> # diseased subjects/# of subjects at risk
Renal injury usually causes hypocalcemia - why?
Reduced phosphorus clearance leading to calcium phosphate salt formation
In an older patient with an intrinsic AKI and hypercalcemia, what should be suspected?
ATN due to multiple myeloma
What is the most reliable and predictive sign of opioid intoxication?
Decreased RR
When is hormone replacement therapy indicated?
Treatment of severe vasomotor symptoms in women age <60 who have undergone menopause within the past 10 years
Long-term analgesic use with 1+ analgesics can cause CKD due to what?
Tubulointerstitial nephritis and hematuria due to papillary necrosis
Lab findings of analgesic nephropathy?
Elevated Cr
UA with hematuria, sterile pyuria, possible WBC casts, mild proteinuria
CT with small kidneys, bilateral renal papillary calcifications
Rx uric acid stones?
Alkalization of the urine to pH 6.0-6.5 with oral potassium citrate
3 possibilities when a patient has symptoms consistent with typical renal colic but no stones on conventional radiographs?
- Radiolucent stones (uric acid, xanthine)
- Small calcium stones (<1-3 mm in diameter)
- Nonstone ureteral obstruction (blood clot, tumor, etc.)
Uric acid stones are most commonly seen in patients with what 2 lab findings?
Unusually low urine pH (defect in renal ammonia excretion)
Hyperuricosuria
Which diuretics can cause stones? Which can treat stones?
Furosemide -> increases risk of calcium stone formation (hypercalciuria)
HCTZ -> management of hypercalciuric stones (decreases urinary calcium excretion)
Thiazides -> decrease uric acid excretion, but also lower urine pH and increase the risk of uric acid stones
LP or empiric ABX first in suspected meningitis?
LP prior to ABX UNLESS critically ill or some other barrier to getting the LP immeidately
Why is head imaging not required before LP in infants?
Open anterior fontanelle eliminates risk for herniation
What causes renal failure in HUS?
Thrombotic angiopathy (NOT glomerulonephritis)
Most common cause of pediatric stroke?
Sickle cell disease
Acute pancreatitis complicated by hypotension is thought to arise from what process?
Intravascular volume loss secondary to local and systemic vascular endothelial injury -> vasodilation, increased vascular permeability, and plasma leak into the retroperitoneum
Most common acid-base disturbance caused by a PE? Explain
Respiratory alkalosis - hyperventilation as a patient tries to overcome hypoxia and V/Q mismatching
Presentation - decreased sensation over 4th and 5th fingers, weak grip due to involvement of interosseous muscles?
Ulnar nerve entrapment
Most common site of ulnar nerve entrapment?
Elbow (where the nerve lies at the medial epicondylar groove)
May occur due to leaning on the elbows while working at a desk or table
What is Budd-Chiari syndrome?
Hepatic venous outflow obstruction
3 general causes of Budd-Chiari syndrome?
- Myeloproliferative disorder (eg, polycythemia vera)
- Malignancy (eg, HCC)
- OC use/pregnancy
Acute presentation of Budd-Chiari syndrome?
Jaundice, hepatic encephalopathy, variceal bleeding
Prolonged INR/PTT; elevated transaminases
Subacute/chronic presentation of Budd-Chiari syndrome?
Vague, progressive abdominal pain
HSM, ascites
Mild/moderate elevation in bilirubin/transaminases
Dx Budd-Chiari
Abdominal Doppler U/S -> decreased hepatic vein flow
Investigation for underlying disorders (JAK2 testing for PV)
What are the 2 phases of the first stage of labor and what defines normal labor progression?
Latent phase (0-6 cm) Active phase (6-10 cm) Active phase, 1+ cm/2 hours
Define active phase labor arrest.
No cervical change for 4+ hours with adequate contractions or 6+ hours with inadequate contractions
When is an intrauterine pressure catheter placed?
When labor has not completely arrested but cervical change slows to <1 cm/2 hr (labor protraction)
Define inadequate contractions.
<200 MVU
When is an operative vaginal delivery performed?
Expedite delivery for category III tracings or maternal exhasution during stage 2 (10 cm dilation)
Define chronic or pre-existing HTN in gestation.
Systolic 140+ AND/OR diastolic 90+ BEFORE 20 weeks during 2 separate measurements taken at least 4 hours apart
Risks related to HTN in pregnancy?
Superimposed preeclampsia Postpartum hemorrhage GDM Abruptio placentae C/S Fetal growth restriction Perinatal mortality Preterm labor Oligohydramnios
May be linked to increased SVR and arterial stiffness -> placental dysfunction
Although patients with biliary pancreatitis may sometimes have a normal U/S (especially if the stone is pased), they typically have an elevated ___ level.
ALT (>150)
In patients with a history of splenectomy or functional asplenia, ___ would be an expected finding on peripheral smear.
Howell-Jolly bodies (small purple dots within the RBCs)
What are Heinz bodies?
Small inclusions within an RBC -> aggregates of denatured Hgb, common in patients with hemolysis due to G6PD deficiency and thalassemia
What are bite cells?
RBCs with Heinz bodies removed by phagocytes
Risk factors for brain abscess?
Mastoiditis Otitis media Sinusitis Dental infection Cyanotic heart disease (hematogenous spread of bacteria)
Rx tinea corporis?
Topical antifungal (clotrimazole, terbinafine, etc.)
What type of anemia is seen in sickle cell disease?
Normocytic, normochromic, hemolytic anemia with compensatory reticulocytosis
Why may patients with SCD develop folate deficiency?
Chronic hemolysis without adequate supplementation
What is Diamond-Blackfan anemia?
Congenital pure red cell aplasia characterized by macrocytic anemia and several congenital abnormalities (cleft palate, webbed neck, triphalangeal thumbs)
Cause of Diamond-Blackfan anemia?
Congenital erythroid aplasia
Lab findings of Diamond-Blackfan anemia?
Macrocytic anemia
Reticulocytopenia
Normal platelets and WBCs
Rx Diamond-Blackfan anemia?
Steroids
RBC transfusions
Compare Fanconi and Diamond-Blackfan anemia.
Fanconi - pancytopenic BM failure
DBA - pure red cell aplasia, normal platelet and WBC counts
Unfavorable metabolic side effects of thiazide diuretics?
Hyperglycemia
Increased LDL and triglycerides
Hyperuricemia
Electrolyte abnormalities due to thiazides?
Hyponatremia
Hypokalemia
Hypomagnesemia
Hypercalcemia
Patients with androgen insensitivity syndrome are genotypically male but appear phenotypically female. Management?
Elective gonadectomy (increased risk of testicular cancer due to bilateral cryptorchid testes)
Management of Turner syndrome?
Estrogen replacement (development of secondary sexual characteristics, prevention of osteoporosis) GH therapy (management of short stature)
First-line ABX in pregnant patients with asymptomatic bacteriuria?
Cephalexin
Amox-clav
Nitrofurantoin
Fosfomycin
Define mild UC.
<4 bowel movements/day
Intermittent hematochezia
Normal inflammatory markers
No anemia
Dx with colonoscopy - inflammation and superficial ulcerations extending from the anorectum continuously to more proximal regions of the colon
First-line treatment of mild UC?
5-aminosalicylic acid medications (mesalamine, sulfasalazine) -> suppositories or enemas preferred if limited to rectosigmoid
First-line therapy in moderate to severe UC?
Anti-tumor necrosis factor-alpha inhibitors (infliximab, adalimumab, golimumab)
Complications of temporal arteritis?
Permanent vision loss
Aortic aneurysm
What causes increased alveolar-arterial oxygen gradient?
R->L intrapulmonary shunting
VQ mismatch
Impaired gas exchange
3 major complications of cocaine use?
Acute MI
Aortic dissection
Intracranial hemorrhage
Changes to management of chest pain 2/2 cocaine use?
Benzos for blood pressure and anxiety
NO BETA BLOCKERS
No fibrinolytics
What is indicated in all patients with new-onset ascites?
Paracentesis to determine the etiology
Most common malignancy diagnosed in patients exposed to asbestos?
Bronchgenic carcinoma
Clinical features of aortic dissection?
History of HTN (#1 risk factor), Marfan syndrome, cocaine use
Severe, sharp, tearing chest or back pain
+/- >20 mm Hg variation in SBP between arms
Distinguish acute aortic regurgitation/heart failure due to aortic dissection vs. cardiac tamponade due to aortic dissection.
Tamponade will NOT have pulmonary edema
Serum-to-ascites albumin gradient of 1.1+ indicates vs. <1.1?
1.1+ - portal hypertensive etiologies (cardiac ascites, cirrhosis, etc.)
<1.1 - non-portal hypertension
Neutrophil count of ascites indicating peritonitis?
250/mm^3 or higher
Total protein count in peritonitis (high vs. low)?
2.5+ g/dL (high-protein) - CHF, constrictive pericarditis, etc.
<2.5 g/dL (low-protein) - cirrhosis, nephrotic syndrome
Screening mammography?
Biennial for women 50-74
AAA screening recs?
Men age 65-75 who ever smoked (abdominal U/S 1x)
What is mixed connective tissue disease?
Clinical features of SLE, SS, and polymyositis (sequential)
Important manfiestations include Raynaud, swelling of the fingers and hands, inflammatory arthritis, and myositis
Autoantibodies for ___ have high sensitivity and specificity for MCTD.
U1 ribonucleoprotein
Most common cause of death in MTCD?
Pulmonary HTN
Most common type of kidney stone?
calcium oxalate stones
3 common types of kidney stones?
Calcium (oxalate, phosphate)
Magnesium ammonium phosphate (struvite)
Uric acid
Appearance of the 3 common types of kidney stones on radiography?
Calcium - small, radiopaque
Struvite - large, radiopaque
Uric acid - small, radiolucent
Crystal morphology - rectangular/prism kidney stones
Struvite
Crystal morphology - yellow/brown, rhomboidal kidney stones
Uric acid
Crystal morphology - octahedron or envelope kidney stones
Calcium oxalate
Crystal morphology - wedge or rosette kidney stones
Calcium phosphate
Most consistently replicated neuroimaging finding in schizophrenia?
Enlargement of the lateral cerebral ventricles
