15 Flashcards
Classic triad - respiratory distress, neurologic dysfunction (eg, confusion), petechial rash
Fat embolism syndrome; however, rash is only present 50% of the time
Presents 24-72 hours following inciting event (fracture, orthopedic surgery, pancreatitis)
Explain the pulmonary findings in patients with fat embolism syndrome.
Patients typically develop pulmonary edema (mimicking ARDS) after 24-48 hours (bilateral ground-glass opacities on chest CT)
No pulmonary arterial filing defects, because emboli obstruct the pulmonary capillaries and are too small to be detected
Patients with persistent tachyarrhythmia (narrow- or wide-complex) causing hemodynamic instability should be managed with ___. How does the management differ in patients who do not have hemodynamic instability?
Immediate synchronized cardioversion; adenosine or vagal maneuvers can be considered, followed by IV beta blockers or CCBs if these fail
IV antiarrhythmics like amiodarone and procainamide can be used in patients with stable recurrent or refractory ___.
Wide-complex tachycardia
When is defibrillation (unsynchronized cardioversion) indicated?
Pulseless cardiac arrest with a shockable rhythm (VFib, pulseless VTach)
Risks of intrahepatic cholestasis of pregnancy?
Intrauterine fetal demise
Preterm delivery
Meconium-stained amniotic fluid
Neonatal respiratory distress syndrome
What is polymorphic eruption of pregnancy?
Aka pruritic urticarial papules and plaques of pregnancy -> cause pruritis within the abdominal striae that spreads centrifugally but spares the palms and soles
Manage polymorphic eruption of pregnancy?
Topical steroids
Most appropriate initial imaging study for fecal impaction when necessary?
Plain XR
Post-menopausal women with endometrial cells on Pap test require what next step?
Endometrial biopsy
Note - if pre-menopausal, only if abnormal uterine bleeding or risk for endometrial hyperplasia
Who gets endometrial evaluation when atypical glandular cells are found on Pap?
Women age 35+ OR at risk for endometrial hyperplasia
Risk factors for pPROM?
Prior pPROM
GU infection (including ASB, BV)
Antepartum bleeding
Dx and Rx postpartum urinary retention (inability to void 6+ hours after vaginal delivery)?
Urethral catheterization
Up to 70% of patients with mitral stenosis will develop AFib - why?
Significant L atrial dilation
All non-immune asymptomatic healthy patients age >1 year with varicella exposure should receive post-exposure prophylaxis with ___.
Varicella vaccine
At-risk patients who CANNOT receive the varicella vaccine should receive VZIg instead
Lobes impacted by aspiration while upright and aspiration while recumbent?
Upright -> lower lobes or R middle lobe
Recumbent -> posterior segment of the upper lobes
What determines blood flow across the large unrestrictive VSD in Tetralogy of Fallot?
Relative resistance between the systemic pulmonary circulations
If SVR > pulmonary vascular resistance, blood will shunt from ventricles to the pulmonary artery
If PVR > SVR, blood will shunt from ventricles into the aorta, resulting in cyanosis
Treatment of a tet spell?
- Immeidate knee-chest positioning (kinks the femoral arteries and increases SVR, reducing R to L shunting)
- Inhaled O2 (stimulates pulmonary vasodilation and decreases SVR)
- IV fluids (improve RV filling and pulmonary flow)
What is HSP?
IgA-mediated vasculitis that presents with palpable purpura on the lower extremities, arthralgia/arthritis, abdominal pain (+/- intussusception), and renal disease (similar to IgA nephropathy, usually presents with hematuria, +/- mild proteinuria)
Management of HSP?
Supportive (hydration and NSAIDs) for most patients
Hospitalization and systemic glucocorticoids (severe symptoms)
Timing of renal manifestations of HSP?
Can develop at symptom onset or months after the initial presentation
Features of Turner syndrome (external)?
Narrow, high-arched palate Low hairline Webbed neck Broad chest with widely spaced nipples Cubitus valgus Short stature
Features of Turner syndrome (internal)?
Coarcatation of the aorta
Bicuspid aortic valve
Horseshoe kidney
Streak ovaries, amenorrhea, infertility
Complications of Turner syndrome?
Primary ovarian insufficiency/estrogen deficiency -> increased bone resorption, decreased bone mineral density, increased risk of osteoporotic fracture
Serologies - acute HBV (early phase, window phase, and recovery phase)
Early: +HBsAg, HBeAg, anti-HBc IgM
Window: +ONLY anti-HBc IgM
Recovery: +anti-HBc IgG, anti-HBs, anti-HBe
Serologies - chronic HBV carrier
+HBsAg
+anti-HBc IgG
Serologies - acute flare of chronic HBV
+HBsAg, (likely) +HBeAg, anti-HBc IgM, anti-HBc IgG
Serologies - HBV vaccination
ONLY +anti-HBs
Serologies - immunity due to natural HBV infection
+anti-HBs, anti-HBc IgG
This antigen indicates HBV infectivity/active viral replication
HBeAg
Presentation - small (<4 cm), firm, unilateral or bilateral subareolar mass, no pathologic features (eg, nipple discharge, axillary LAD, systemic illness)
Pubertal gynecomastia (due to imbalance of estrogens and androgens during mid-puberty)
Management of pubertal gynecomastia?
Reassurance and observation, should resolve within 1 year
Presentation - small, firm testes and bilateral gynecomastia
Klinefelter syndrome (47, XXY)
Which symptom of Kawasaki is typically the last to manifest, and which is the least common?
Last - extremity changes
Least common - LAD
Rx Kawasaki disease?
Aspirin and IVIg
Presentation of scarlet fever?
Pharyngitis, fever, sandpaper-like rash (usually desquamates)
+/- strawberry tongue and cervical LAD
Rash prominent over skin folds
___ can cause an acute symmetric arthritis of the hands (MCP, PIP, wrist), knees, and ankle joints. How is the diagnosis confirmed and treated?
Parvovirus B19; anti-parvovirus B19 IgM (if immunocompenet) or NAAT for B19 DNA (if immunocompromised); self-limited, no treatment needed
Presentation - chronic vasculitic syndrome characterized by palpable purpura, LAD, nephropathy, neuropathy, and arthralgias
Mixed cryoglobulinemia (associated with chronic HCV)
Aminoglycosides are used to treat serious ___ infections.
Gram Negative
Major AE of AGs?
Nephrotoxic
What is pellagra and what causes it?
Dermatitis (sun-exposed areas, rough, hyperpigmented, scaly skin), diarrhea, and dementia
Niacin (B3) deficiency
In developing countries, niacin deficiency is seen in populations that subsist primarily on ___ products.
Corn
In developed countries, niacin deficiency is primarily seen in patients with impaired ___. Name 3 other instances.
Nutritional intake;
- Carcinoid syndrome (depletion of tryptophan)
- Hartnup disease (congenital tryptophan absorption disorder)
- Prolonged INH therapy (interferes with tryptophan metabolism)
Features of acute intermittent porphyria?
Abdominal pain, vomiting, diarrhea, neuro symptoms (agitation, paresthesias, confusion, etc.)
Episodic symptoms
Chronic transaminase elevation is common
F>M
What is erythema toxicum neonatorum and what should be done about it?
Benign neonatal rash characterized by blanching erythematous papules and pustules (spares palms and soles)
Reassurance, resolves spontaneously within 2 weeks of birth
3 complications associated with ankylosing spondylitis?
Osteoporosis/vertebral fractures
Aortic regurgitation
Cauda equina
What medications can cause a false-positive phencyclidine result?
Dextromethorphan, diphenhydramine, doxylamine, ketamine, tramadol, venlafaxine
Rx septic arthritis (GP cocci on Gram stain)?
Vancomycin
Rx septic arthritis (GN rods on Gram Stain)?
Third-generation cephalosporin
Rx septic arthritis (negative Gram Stain)?
Vancomycin (+ 3rd generation cephalosporin if immunocompromised)
Features of aspirin-exacerbated respiratory disease?
Patients with asthma and chronic rhinosinusitis
Sudden worsening of asthma and nasal congestion 30 minutes to 3 hours after ingestion of NSAIDs
Management of upper airway cough syndrome (postnasal drip syndrome)?
Diphenhydramine (anticholinergic effect)
When evaluating a patient with hypertension, one should look for secondary causes, including ___ in younger women.
OCPs
In a patient with Hepatitis A, what should be done to decrease risk of disease transmission?
Post-exposure prophylaxis with either Hepatitis A vaccine or Hepatitis A Ig in those with close personal contacts (sexual, household), child care center contacts, and food preparation co-workers
In general, younger patients (40 and younger) -> vaccine; older patients (41+) -> IG
Persistence of HBsAg indicates?
Chronic infection (>6 months)
Most effective single agent for allergic rhinitis?
Glucocorticoid nasal sprays (eg, fluticasone, mometasone)
Other options - oral antihistamines, antihistamine or cromolyn nasal sprays, leukotriene modifiers
Hypovolemic hyponatremia occurs due to a multiple-pathway mechanism that illustrates the body’s priority to restore ___ at the risk of developing ___. Explain the mechanism.
Euvolemia; hypotonicity
Solute and water loss:
- Decreased renal perfusion -> RAS -> angiotensin II -> increased thirst -> increased water intake -> decreased serum Na
* Angiotensin also increases ADH
* Angiotensin also increased aldosterone -> increases Na reabsorption - Hypotension -> baroreceptor activation -> increased ADH (non-osmotic stimulation) -> increased water reabsorption -> decreased serum Na
- Hypovolemia -> L atrial stretch receptor stimulation -> increased ADH (#2)
Rx hypovolemic hyponatremia
Infusion of NS (replenishes the body’s depleted salt stores, restores euvolemia, and shuts off non-osmotic stimuli for ADH release)
Who gets screened for HIV and HepB?
History of high-risk sexual intercourse (unprotected or MSM)
Who gets screened for HepC?
IVDU, high-risk needlestick exposure, blood transfusions before 1992
Initial criteria for extubation readiness and first step?
pH >7.25
Adequate oxygenation on minimal ventilator settings (FiO2 40% or less, PEEP 5 cm H2O or less)
Sufficient mental alertness to protect the airway and intact inspiratory effort
Spontaneous breathing trial
Patients with a ___ (high or low) rapid shallow breathing index (RR per minute/TV in L) are unlikely to do well without continued vent support.
High (breathing fast and shallow)
Who can be extubated without an SBT?
May be appropriate for patients who were intubated for an elective surgical procedure
Appropriate compensation in a primary metabolic acidosis?
PaCO2 = 1.5HCO3 + 8 +/-2
Appropriate compensation in a primary metabolic alkalosis?
Increase PaCO2 by 0.7 mmHg for every 1 mEq/L rise in HCO3
Most common glomerulopathy associated with HIV?
Collapsing FSGS
Presents with heavy proteinuria with rapid development of renal failure
4 modifiable breast cancer risk factors
HRT
Nulliparity
Increased age at first live birth
Alcohol consumption
Hydroxyurea is a relatively safe therapy with a dose-limiting side effect of ___.
Myelosuppression
Maintenance management of sickle cell anemia?
Vaccination
PCN until age 5
Folic acid supplementation
Hydroxyurea (if re3current vaso-occlusive crises)
Rx polycythemia vera?
Serial phlebotomy
+/- bone marrow suppressive drugs (eg, hydroxyurea) if high risk of thrombosis
Mild reaction sometimes seen with MMR vaccination?
Fever and maculopapular rash 1-3 weeks after immunization
AVOID CONTACT WITH IMMUNOCOMPROMISED INDIVIDUALS
Causes of increased maternal serum AFP (3)?
- Open neural tube defects (eg, anencephaly, open spina bifida)
- Ventral wall defects (eg, omphalocele, gastroschisis)
- Multiple gestation
Causes of decreased maternal serum AFP (1)?
Aneuploidies (trisomy 18 and 21)
Next step if MSAFP is elevated?
U/S evaluation of the fetal anatomy
Clarify the number of fetuses
Confirm gestation age
Rx gonococcal urethritis
Azithro (or doxy) PLUS ceftriaxone (unless gonorrhea is ruled out)
Never ceftriaxone alone (increasing resistance)
Azithro or doxy alone can be used if gonorrhea is confidently ruled out
Normally, elevated plasma Ca2+ suppresses PTH secretion - if this is not the case, what should be suspected?
Primary hyperparathyroidism
Secondary hyperparathyroidism is characterized by increased secretion of ___ in response to ___. It is a common finding in what disease and why?
PTH; hypocalcemia; CKD due to inadequate phosphate excretion and low 1,25-hydroxyvitamin D levels
High phosphorus
Low/low-normal calcium
Expected levels of calcium and pTH in primary osteoporosis?
Normal
When should you suspect aortic dissection?
- Risk factors (Marfan syndrome, CTD, HTN, etc.)
- Tearing chest/abdominal pain radiating to the back
- Perfusion deficits (eg, pulse deficit, >20 mm Hg BP difference between R and L arm, AR murmur)
Work-up if aortic dissection is suspected?
CXR and EKG; if these suggest other diagnoses -> evaluate and treatment appropriately
If no, check serum creatinine/constrast allergy
If normal/no allergy -> TEE, chest CT with contrast, MRI if non-emergency and patient can lie still
If not normal or allergy or unstable -> TEE preferred
Target screening for elevated blood lead levels should be performed in children with risk factors. What should be done if a capillary test is elevated?
Repeat testing by venous blood draw to verify a high blood lead level from capillary screening (5+)
When is chelation therapy given for lead poisoning in children?
Dimercaptosuccinic acid (succimer) - lead levels 45-69
Dimercaprol (British anti-Lewisite) PLUS calcium disodium edetate (EDTA) for lead levels 70+ or acute encephalopathy
What else should be checked when suspecting lead poisoning in children?
Iron deficiency (Rx with oral ferrou sulfate if deficient), as comorbid iron deficiency can increase GI absorption of lead
First step (and subsequent steps in management of a newborn with respiratory compromise and suspected congenital diaphragmatic hernia?
Endotracheal intubation
(Bag-and-mask ventilation can exacerbate respiratory decline)
Then place a G-tube to decompress the stomach and bowel (continuous suction)
Then place an umbilical A-line (blood gases and BP) and an umbilical venous catheter (fluids and meds)
When stable, CXR
Features of congenital diaphragmatic hernia on exam?
Concave abdomen
Barrel-shaped chest
If left-sided -> absent L breath sounds
Deviation of heart into R thorax impairs R lung development –> R-sided heart sounds, fair right lung aeration
Unlike in adults, GAS pharyngitis in children should always be confirmed by ___ or ___ prior to initiating ABX.
Rapid streptococcal Ag testing; throat culture
Discuss the use of Centor criteria in adults vs. children.
Adults with a 4 can receive empiric ABX without testing
The criteria are NOT reliable in pre-adolescents. Clinical features do not reliably distinguish bacterial from viral pharyngitis in children except when obvious viral manifestations (eg, conjunctivitis, rhinorrhea, cough, exanthem, oral ulcers) are present
Patients with long-standing ankylosing spondylitis are at increased risk for ___.
Vertebral fracture, often resulting from minimal trauma
Bedwetting is normal before what age?
Age 5
First-line therapies in patients seeking treatment for nocturnal enuresis (urinary incontinence in children age 5+)
Enuresis alarm therapy
Desmopressin
2 conditions associated with acanthosis nigricans
Insulin resistance (DM, PCOS, etc.) - younger patients GI malignancy - older patients
3 conditions associated with multiple skin tags?
Insulin resistance
Pregnancy
Crohn disease (perianal skin tags)
1 condition associated with porphyria cutanea tarda and cutaneous leukcytoclastic vasculitis (palpable purpura) 2/2 cryoglobulinemia?
Hepatitis C
1 condition associated with dermatitis herpetiformis?
Celiac disease
1 condition associated with sudden-onset severe psoriasis, recurrent herpes zoster, or disseminated molluscum contagiosum
HIV
2 conditions associated with severe seborrheic dermatitis
HIV
Parkinson disease
1 condition associated with explosive onset of multiple itchy, seborrheic keratoses
GI malignancy
1 condition associated with pyoderma gangrenosum
IBD
Inability to life the skin of the dorsum of the second toe (positive Stemmer sign) is higly specific for ___.
Lymphedema
D-xylose is a monosaccharide that is absorbed in the proximal SI without degradation by pancreatic or brush border enzymes. Compare the findings of the D-xylose test in patients with SI mucosal disease vs. enzyme deficiencies.
Impaired absorption if small intestinal mucosal disease vs. normal absorption if malabsorption is due to enzyme deficiencies
Normal test: high urine levels (minimal fecal excretion)
Abnormal test: low urine levels (high fecal excretion), low venous levels - patient cannot absorb into the intestines
What can cause a false-positive D-xylose test (low urinary level despite normal mucosal absorption)?
- Delayed gastric emptying
- Impaired glomerular filtration
- SIBO
Rx SIBO?
Rifaximin
Imaging findings of NPH?
Enlargement of the ventricles out of proportion to the sulci
Dx NPH?
Improvement after high volume LP or lumbar drain placement, normal opening pressure
Definitive Rx of NPH?
Ventricular shunt
What is Felty syndrome?
Formation of autoantibodies against neutrophil components and granulocyte colony-stimulating factor
Complication of seropositive RA (severe erosive joint disease/deformity, rheumatoid nodules, vasculitis) characterized by neutropenia (ANC <2000) and splenomegaly
Dx Felty syndrome
Anti-CCP and RF + in 90%
Markedly elevated ESR, often >85
Peripheral smear and BM biopsy to r/o other causes of neutropenia
[Most patients are HLA-DR4 positive]
Features of Mobitz type I second degree (Wenckebach) AV block?
Progressive prolongation of PR interval leading to a non-conducted P wave and a “dropped” QRS complex
Constant P-P interval Increasing PR interval Decreasing R-R interval Group beating (repeating clusters of beats followed by a dropped QRS)
Cause of Wenckebach AV block?
Impaired AV node conduction
Features of PACs?
Normal rate
Irregular rhythm
P wave of PAC often has a different shape from the one originating in the SA node
Normal QRS
Cause of PACs?
Depolarization of the atria originating in a focus outside the SA node
Cause of sick sinus syndrome?
Impaired SA node automaticity (often due to degeneration and/or fibrosis of the SA node and surrouding atrial myocardium)
Drug-induced acne is a common side effect of __ and is characterized by monomorphic papules without associated comedones, cysts, or nodules.
Systemic glucocorticoids
Management of drug-induced acne?
D/C offending medication
Standard acne therapy unlikely to be effective
Endoscopic and biopsy findings of UC?
Erythema, friable mucosa Pseudopolyps Involvement of rectosigmoid Continuous colonic involvement Mucosal and submucosal inflammation Crypt abscesses
Complications of UC?
Toxic megacolon Primary sclerosing cholangitis Colorectal cancer Erythema nodosum/pyoderma gangrenosum Spondyloarthritis
___ results when an external variable positively or negatively impacts the effect of a risk factor on a disease of interest. Stratified analysis helps determine whether a variable is ___ or ___.
Effect modification; confounder or effect modifier
Secondary bacterial pneumonia is the most common complication of influenza, but is rare in young individuals. What is the one major exception?
Community-assoicated MRSA -> preferentially attacks young patients with influenza
Manifestations of community-associated MRSA pneumonia?
High fever, productive cough with hemoptysis, leukopenia, multilobar cavitary infiltrates
4 risk factors for placental abruption?
Maternal HTN or preeclampsia/eclampsia
Abdominal trauma
Prior placental abruption
Cocaine and tobacco use
Clinical presentation of placental abruption?
Sudden-onset vaginal bleeding
Abdominal or back pain
High-frequency, low-intensity contractions
Hypertonic, tender uterus
Management of asymptomatic microprolactinoma (<10 mm)
No treatment
Management of macroprolactinoma (>10 mm) or symptomatic micro?
Dopamine agonists (Cabergoline or bromocriptine) –> resect if very large (3+ cm) or increase in size while on treatment
Key blood smear finding in AML?
Auer rods
Also numerous atypical promyelocytes (large myeloid cells with intracytoplasmic violet granules)
Confirm diagnosis of APL?
Cyotgenetic analysis for the characteristic mutation (t[15;17])
Why is APL considered a medical emegency?
High risk of pulmonary/CV hemorrhage from tumor-induced consumptive coagulopathy
Rx APL?
All-trans retinoic acid
___ is an idiopathic chronic condition characterized by pain that is exacerbated by bladder filling and relieved by voiding. Additional features may include dyspareunia, frequency, and urgency.
Interstitial cystitis (painful bladder syndrome)
Dx idiopathic cystitis?
Clinical, diagnosis of exclusion - UA, post-void residual, STI screening
Rx uremic pericarditis.
Dialysis
Which anti-depressant can cause dose-dependent HTN?
Venlafaxine (SNRI - via norepinephrine reuptake inhibition)
