16 Flashcards
Presentation - prolonged duration of sore throat with high fever, rigors, dysphagia, and neck pain and swelling along the SCM muscle
Lemierre syndrome
What is Lemierre syndrome and what causes it?
Severe life-threatening infection that affects young immunocompetent patients, usually caused by GN anaerobic bacillus Fusobacterium necrophorum
Pathogenesis of Lemierre syndrome?
Begins with an oropharyngeal infection (tonsillitis) or as a complication from dental work or mastoiditis -> bacterium invades lateral pharyngeal space through the lymphatic system and affects the neurovascular structures -> internal jugular vein thrombosis and infection -> may send septic thromboemboli to other organs, particularly the lungs
GP bacillus that commonly causes food poisoning and gas gangrene
C. perfringens
Patients with PCOS are at increased risk of developing ___ and should be screened with ___.
DM2; oral glucose tolerance test
When is BRCA mutation testing indicated?
Family history of ovarian cancer at any age
Personal/family history of breast cancer ate age 50 or less in a first-degree relative
Presentation - unilateral abdominal mass, +/- abdominal pain/HTN/hematuria, age 2-5
Wilms tumor (nephroblastoma)
Wilms tumor may be associated with what syndromes?
WAGR (Wilms tumor, Aniridia, GU abnormalities, mental Retardation)
Beckwith-Widemann
Denys-Drash
First step in work-up for abdominal mass/suspected Wilms tumor?
Abdominal U/S -> contrast-enhanced CT or MRI to evaluate extent of Mass + CT chest (pulm mets)
Distinguish neuroblastoma from Wilms tumor based on age.
NB - <2 y/o
Wilms - 2-5 y/o
DDx - hirsutism in women
PCOS Idiopathic Non-classic 21-hydroxylase deficiency Androgen-secreting ovarian tumors/ovarian hyperthecosis Cushing syndrome
What factors suggest a diagnosis of PCOS with a CC of hirsutism?
Oligomenorrhea, obesity, associated with DM, HLD, HTN
What factors suggest idiopathic hirsutism with a CC of hirsutism?
Normal menses
Normal serum androgens
What factors suggest a diagnosis of non-classic 21-hydroxylase deficiency with a CC of hirsutism?
Similar to PCOS
Elevated serum 17-hydroxyprogesterone
What factors suggest a diagnosis of androgen-secreting ovarian tumors with a CC of hirsutism?
More common in post-menopausal women
Rapidly progress + virilization
Very high serum androgens
Elevated testosterone + normal DHEAs -> ?
vs.
Elevated DHEAS + normal testosterone?
Elevated T/normal DHEAS -> ovarian source (eg, SL cell tumor)
Elevated DHEAS/normal T -> adrenal tumor
MR classically results in a ___ murmur heard best at the apex with radiation to the ___.
Holosystolic; axilla
Common signs of MR?
Exertional dyspnea and fatigue, signs of heart failure, AFib
___ infection in pregnancy can cause non-immune fetal hydrops (excessive fluid accumulation in the interstitium). List 3 other non-immune causes.
Parvovirus B19
Fetal aneuploidy, CV abnormalities, thalassemia
MOA leading to hydrops?
High-output heart failure from either immune or non-immune etiologies
Most common immune etiology of hydrops?
Rh(D) alloimmunization
List 4 common medications that may potentiate the anticoagulant effects of warfarin (CYP inhibitors), leading to variable dose response, and/or increase the risk of bleeding.
Acetaminophen
NSAIDs
Amiodarone
ABX
List 7 medications that may decrease the effect of warfarin as CYP450 inducers.
- Carbamazepine
- Phenytoin
- Ginsent
- St. John’s wort
- OCs
- Phenobarbital
- Rifampin
List the factor 10 a inhibitors.
Direct: rivaroxaban and apixaban
Indirect: fondaparinux
List the direct thrombin inhibitors.
Argatroban
Bivalrudin
Dabigatran
Presentation - diffuse breast erythema, warmth, pain, edema, peau d’orange appearance
Inflammatory breast carcinoma
Presentation - unilateral bloody nipple discharge, no other symptoms or skin changes
Intraductal papilloma
Patients with new-onset AFib should have what lab test completed to look for an underlying cause?
TSH/Free T4 levels - occult hyperthyroidism
High-frequency hearing loss is associated with aging and certain ___ syndromes.
Congenital long QT
Suspect what 4 conditions when a patient presents with hypokalemia, alkalosis, and normotension? Distinguish them.
- Surreptitious vomiting - low urine Cl
- Diuretic abuse
- Bartter syndrome
- Gitelman’s syndrome
All others have high urine Cl
Septic arthritis is usually caused by ___. Therefore, empiric treatment with ___ is generally adequate. However, a minority of patients have continued symptoms despite a few days of this treatment, which usually indicates infection with ___. These patients require the addition of ___.
GP aerobic bacteria (especially S. aureus)
Vancomycin
GN bacterium
Ceftriaxone (good choice, as it has GP, GN, and some anaerobic coverage)
Why is doxycycline not often used to broaden antimicrobial coverage for severe infections when other ABX choices are available?
It is bacteriostatic (rather than cidal)
A ___ presents within the first few months of life as isolated hyperpigmented patches with an increased density of hair follicles.
Congenital melanocytic nevus
Describe the appearance of cafe-au-lait spots and 2 associated syndromes.
FLAT hyperpigmented patches
McCune-Albright
NF
DDx - bloody diarrhea?
- E. coli O157:H7
- Shigella
- Campylobacter
Key features of bloody diarrhea due to E. coli O157:H7 + treatment?
Associated with undercooked beef; can be complicated by HUS
Supportive care only
Key features of bloody diarrhea due to Shigella?
Associated with contaminated food or water; often implicated in outbreaks (eg, daycare)
Less commonly complicated by HUS
Supportive care + ABX (azithro, ceftriaxone, ciprofloxacin are options)
Key features of bloody diarrhea due to Campylobacter?
Associated with raw or undercooked meat
Can be complicated by GBS
Supportive only
Why is E. Coli O157:H7 infection treated with supportive care only?
The risk of HUS increases in patients who receive ABX or antimotility agents
Rx severe or high-risk cases of Salmonella gastroenteritis in children?
TMP-SMX
What are the main substrates of 4 gluconeogenesis?
Alanine
Glutamine
Lactate
Glycerol 3-phosphate
Alanine is converted to ___ during gluconeogenesis.
Pyruvate
Glutamine and other glucogenic amino acids enter gluconeogenesis at which step?
Citric acid cycle
The liver maintains glucose levels in the blood via glycogenolysis and gluconeogenesis. During fasting states, glycogen reserves drop dramatically in the first 12 hours, by which time gluconeogenesis represents the sole source of glucose production. The main substrates for gluconeogenesis are gluconeogenic amino acids (from ___), lactate (from ___), and G3P (from ___). Alanine is the major gluconeogenic amino acid in the liver and is converted into pyruvate by alanine aminotransferase.
Breakdown of muscle protein; anaerobic glycolysis; triacylglycerol in adipose
Presentation - microcephaly, wide anterior fontanelle, cleft lip and palate, distal phalange hypoplasia, cardiac defects
Fetal hydantoin syndrome (exposure to antiepiletpics like phenytoin and carabmazepine)
Features of chronic hyperthyroid myopathy?
Painless proximal muscle weakness in the setting of clinical features of hyperthyroidism, muscle atrophy
Matching is frequently used in case-control studies because it is an efficient method to control ___. What should the matching variables be?
Confounding; the potential confounders
Empiric therapy for UTI?
Third-generation cephalosporin (cefixime, ceftriaxone)
Rx otitis externa?
Topical antipseudomonal treatment (ciprofloxacin, other FQ) +/- topical glucocorticoid
What is the most common cause of death in patients with ESRD?
CV disease
Traditional risk factors - HTN, DM, dyslipidemia, LVH, advanced age, low physical activity
ESRD-specific risk factors: anemia of CKD, vascular calcifications (increased Ph, Ca2+)
Oxidative stress related to uremia and dialysis
For patients who present soon after a single, potentially toxic ingestion (>7.5 g) of acetaminophen, what is the first step in management? If they are asymptomatic?
Gastric decontamination with activated charcoal (if within 4 hours of ingestion) and measurement of acetaminophen levels, use nomogram to guide N-acetylcysteine
Doesn’t matter - patients can be asymptomatic during the first 24 hours
Empiric ABX Rx of native-valve endocarditis should be geared toward what bugs? What is the best choice?
MRSA, streptococci, enterococci; Vancomycin
5 classes of medications that commonly cause urinary incontinence?
- Alpha-adrenergic antagonists (relax urethra)
- Anticholinergics, opiates, CCBs (urinary retention/overflow)
- Diuretics (excess urine production)
Defense mechanism - transferring feelings to a less threatening object/person
Displacement
Defense mechanism - expressing unacceptable feelings through impulsive physical actions
Acting out
Defense mechanism - attributing one’s own feelings to someone else
Projection
Defense mechanism - transforming unacceptable feelings into their extreme opposite
Reaction formation
Patients with hepatic encephalopathy on diuretics can develop low intravascular volume despite having total volume overload, leading to a ___ with associated ___. Management?
Metabolic alkalosis; hypokalemia
Volume resuscitation and repletion of hypokalemia in addition to serum ammonia-lowering medications (eg, lactulose)
When is TIPS indicated?
When a patient has ascites that does not respond to medical therapy or has ongoing active or recurrent variceal bleeding even after appropriate treatment with upper endoscopy
Presentation - high fevers, severe polyarthrlagias, fever, malaise, rash, LAD, lymphopenia, thrombocytopenia, recent travel to tropical/sutropical parts of Central/South America, Africa, and Asia
Chikungunya fever
Transmission of Chikungunya fever?
Aedes mosquito
Expected murmur in IVDU + bacterial endocarditis?
Tricuspid regurgitation (R-sided heart valve involvement) -> systolic murmur that increases on inspiration
Cause of Wernicke encephalopathy?
Thiamine deficiency (followed by glucose infusion)
PVCs are often present in patients with recent or prior MI; routine therapy for suppression of PVCs is not indicated in asymptomatic patients. Patients with frequent symptomatic PVCs should be treated with what medications?
Beta blockers or CCBs
If maxed out doses - consider amiodraone
EKG features of PVCs?
QRS >0.12 seconds
Bizarre morphology not resembling any conduction abnormality
T wave in the opposite direction of QRS axis
Compensatory pause
All patients with carotid artery stenosis should receive what treatment?
Medical therapy with antiplatelet agents and statins
Findings suggestive of renal artery stenosis in the setting of renal allograft?
Within 2 years of transplant Persistently elevated BP DECLINE IN RENAL FUNCTION WITH THE ADDITION OF ACEIs Lateralizing abdominal bruit Recurrent flash pulmonary edema
Although the majority of affected infants with NEC are premature or have very low birth weight, term infants with what conditions are also at risk?
Reduced mesenteric oxygen delivery from cyanotic congenital heart disease and/or hypotension
Peak airway pressure is the sum of what two factors?
Airway resistance and plateau pressure
What is plateau pressure?
Sum of the elastic pressure and positive end-expiratory pressure (PEEP)
(When pulmonary airflow and thus resistive pressure are both 0)
What is calculated by performing the end-inspiratory hold maneuver?
Plateau pressure
What is calculated with the end-expiratory hold maneuver?
PEEP
What is peak airway pressure?
Maximum pressure measured as the TV is being delivered
What is elastic pressure?
Product of the lung’s elastance and the volume of gas delivered
Can be calculated as TV/compliance -> decreased compliance = stiffer lungs and higher elastic pressure
Increased peak pressure + normal plateau pressure DDx
Bronchospasm
Mucus plug
Biting endotracheal tube
Increased peak pressure + increased plateau pressure DDx
Pneumothorax Pulmonary edema Pneumonia Atelectasis R mainstem intubation
Dx and Rx intussusception?
U/S-guided air (or saline) contrast enema
+/- surgery to remove the lead point
Arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts - caused by what process?
HTN
Increased extracellular matrix, BM thickening, mesangial expansion, and fibrosis of the kidneys - caused by what process?
DM nephropathy
Primigravida patient with hematochezia, abdominal pain, and tenesmus (aka fecal urgency followed by straining and inability to defecate)
UC
Maternal and fetal complications associated with maternal UC?
Pregnancy is a high-risk period -> worsening UC disease (severe hematochezia, anemia, toxic megacolon)
Fetal risks - preterm delivery, SGA
Management of UC in pregnancy?
Ideally, remission before conception
Medication management - meds are considered safe throughout pregnancy and breastfeeding (except for sulfasalazine during breastfeeding - lack of safety data)
The primary anti-ischemic and anti-anginal effects of nitrates are due to what?
SYSTEMIC vasodilation (rather than coronary vasodilation) -> lowers preload and LV end-diastolic volume -> reduces wall stress and myocardial oxygen demand
What is the most significant risk factor for spontaneous preterm delivery?
Hx of spontaneous preterm delivery in a prior preganncy
Management of patients with a history of spontaneous preterm delivery?
IM Progesterone supplementation in T2/3 and serial cervical length measurements (TVUS) during T2
Cerclage placement if needed
Distinguish between the 2 major types of painful genital ulcers.
- HSV - small vesicles, erythematous base, mild LAD
- H. ducreyi (chancroid) - large, deep ulcers with gray/yellow exudate, soft friable base, severe LAD that may suppurate
Features of Lambert-Eaton syndrome?
Proximal muscle weakness
Autonomic dysfunction (eg, dry mouth, erectile dysfunction)
CN involvement (eg, ptosis)
DIMINISHED OR ABSENT DTRs
Features of dermatomyositis?
Symmetrical proximal muscle weakness, erythematous rash on dorsum of fingers (Gottron’s sign) and/or upper eyelids (heliotrope eruption)
Screening lab findings of muscular dystrophies?
Elevated serum creatine phosphokinase and aldolase levels
Muscle biopsy findings in muscular dystrophies?
Fibrosis and fatty infiltration, absent dystrophin on staining
Gold standard diagnosis of Duchenne muscular dystrophy?
Genetic testing - deletion of the dystrophin gene on Xp21 (X-linked recessive condition)
Atopic keratoconjunctivitis is a severe form of ocular allergy - how can it be distinguished from allergic conjunctivitis?
More severe symptoms, prolonged course, potential visual impairment if corneal involvement, and thickening of the eyelids and surrounding skin
What is endophthalmitis and how does it present?
Invasive infection of the globe due to disruption of the external surface of the eye (eg, trauma) - purulent haziness of the ocular contents, may have a layering-out of pus in the anterior chamber (hypopyon)
What is viral keratitis and how does it present?
Infection of the cornea related to HSV or VZV; corneal vesicles, opacification, and/or dendritic ulcers
Patients with COPD who have resting arterial oxygen tension (PaO2) of ___ or pulse oxygen saturation (SaO2) ___ are candidates for long-term home oxygen treatment.
55 or less mmHg; 88% or less
If signs of right heart failure or Hct >55%, start if PaO2 59 or less/SaO2 89% or less
Goal SaO2 for patients with COPD on supplemental O2?
> 90% during sleep, normal walking, and rest
For a normal distribution, what % of all observations lie within 1, 2, and 3 SD from the mean?
68%; 95%; 99.7%
First question to ask in treating a patient with a proximal (eg, popliteal, femoral) lower extremity DVT?
PE with hemodynamic instability or massive proximal (eg, extensive iliofemoral) DVT with severe swelling or limb-threatening ischemia?
If yes -> consider thrombolytics
If no -> consider anticoagulation
When should an IVC be placed in the setting of proximal lower extremity DVT?
Contraindications to anticoagulation
Failure of anticoagulation
Recurrence of DVT
Options when a patient needs thrombolytics in the setting of a proximal lower extremity DVT but there are contraindications (or thrombolytics fail)?
Mechanical thrombectomy
Iliac stenting
Surgical thrombectomy
Presentation - progressive dyspnea, decreased exercise tolerance, AF with RVR, and LV systolic dysfunction
Tachycardia-mediated cardiomyopathy (many tachyarrhythmias can lead to this)
Rx of tachycardia-mediated cardiomyopathy?
Aggressive rate control or restoration of normal sinus rhythm (due to potential reversibility and normalization of LV function)
Level of block in Mobitz type I vs. II
I: usually AV node
II: below level of AV node (eg, bundle of HIS)
EKG findings in Mobitz type I vs. II
I: progressive prolonged PR interval leads to a non-conducted P wave (“group beating”)
II: PR interval remains constant with intermittent non-conducted P waves
QRS complex in Mobitz type I vs. II
I: narrow
II: narrow or wide
Effect of exercise or atropine in Mobitz type I vs. II
I: improves type I AV block
II: worsens type II AV block
Effect of vagal maneuvers (carotid sinus massage) in Mobitz type I vs. II
I: worsens type I AV block
II: paradoxically improves type II AV block
Risk of complete heart block in Mobitz type I vs. II
I: low risk
II: higher risk
Rx Mobitz type I?
Observation if asymptomatic and correction of reversible causes
___ can cause low back pain associated with claudication of the hip muscles and possibly impotence.
Iliac artery thrombosis
___ during patient handoffs are a large contributor to medical errors and adverse patient outcomes.
Communication failures between physicians
Medical errors resulting from communication failures between medical providers are most effectively addressed with what intervention?
Systematic signout process that includes checklists to improve efficacy and accuracy
Features of granulomatosis with polyangiitis (upper respiratory, lower respiratory, renal, skin)
UR: sinusitis/otitis, saddle-nose deformity
LR: lung nodules/cavitation, tracheal narrowing with ulceration
Renal: rapidly progressive GN (extremely common)
Skin: livedo reticularis, non-healing ulcers
Anemia of chronic disease
Dx GPA?
ANCA (PR3 in 70%, MPO in 20%)
Bx: skin (leukocytoclastic vasculiti), kidney (pacui-immune GN), lung (granulomatous vasculitis)
Management of GPA?
Steroids and immunomodulators (eg, MTX, cyclophosphamide, rituximab)
Gold standard method of diagnosing CIN?
Colposcopy
___ causes acute, diffuse, non-inflammatory hair loss and is often triggered by a stressful event. Presentation?
Telogen effluvium; widespread thinning of hair, but the scalp and hair shafts appear normal (self-limited, resolves within a year)
Circumscribed patches of hair loss, hair shafts show narrowing close to the surface and may be broken off
Alopecia areata (autoimmune disorder)
Uneven hair loss in a characteristic pattern (M - frontotemporal hairline and vertex, F - vertex and sides, preservation of hairline)
Androgenetic alopecia
Fragility of hair with breaking of strands, fractured strands with splitting of fibers
Trichorrhexis nodosa
Who gets a statin?
- Clinically significant ASCVD (ACS, stable angina, arterial revascularization, stroke, TIA, PAD); high-intensity unless age >75 (moderate)
- LDL 190+
- Age 40-75 with DM; high-intensity unless 10-year ASCVD risk <7.5% (moderate)
- Estimated 10-year ASCVD risk 7.5% or higher (moderate to high)
LP findings in GBS (Guillain-Barre syndrome)?
Elevated protein level with NORMAL CELL COUNT, normal RBCs and glucose levels
Most common predisposing factor for orbital cellulitis?
Bacterial sinusitis
Amantadine is a drug that may be used in the Rx of ___.
Parkinson disease
Drugs used in the treatment of Alzheimer dementia?
Donepezil (cholinesterase inhibitor)
Memantine (NMDA receptor antagonist)
3 methods to control confounding in the design stage?
Matching
Restriction
Randomization
2 methods to control confounding in the analysis stage?
Stratified analysis
Statistical modeling
Secondary malignancy is common in patients with Hodgkin lymphoma treated with chemo and radiation. What are the most common secondary solid tumor malignancies?
Lung, breast, thyroid, bone, GI
