17 Flashcards
Persistent tachycardia and new arrhythmia (eg, PVCs) after blunt chest trauma are concerning for ___. Patients with these findings are admitted for what management?
Blunt cardiac trauma; continuous cardiac monitoring and echocardiography
Swimming in brackish water may expose people to what organism? It may cause cellulitis and, if ingested, sepsis, with hypotension and bullous skin lesions.
Vibrio vulnificus
What are the 2 general essential elements in defining brain death?
- Evaluating cortical and brain stem functions
2. Proving the irreversibility of brain activity loss
Symmetric fetal growth restriction begins in the ___ trimester and is due to what typical causes?
First; fetal conditions such as aneuploidy, congenital anomalies, and intrauterine infection
Asymmetric fetal growth restriction occurs in the second and third trimesters and is due to what typical causes?
Maternal conditions that cause placental insufficiency, maternal malnutrition
Define fetal growth restriction.
U/S estimated fetal weight <10th % for gestational age
What is asymmetric fetal growth restriction?
“Head-sparing” growth lag
3 steps in management of fetal growth restriction?
Weekly BPPs
Serial umbilical artery Doppler sonography
Serial growth U/S
Presentation - severe abdominal pain, uterine contractions, uterine tenderness, palpable, firm, tender mass, signs of inflammation (eg, leukocytosis) in pregnancy
Infarcted degenerating uterine fibroid
Dx and Rx uterine fibroid degeneration in pregnancy?
Dx - U/S
Rx - conservative management (acute pain control)
Primary responsibility of human chorionic gonadotropin (secreted by the syncytiotrophoblast)?
Preservation of the corpus luteum in early pregnancy
Presentation - medial deviation of the forefoot with a normal neutral position of the hindfoot, usually bilateral, most frequently in first-born infants
Metatarsus adductus
Distinguish congenital clubfoot from metatarsus adductus.
Clubfoot: rigid medial and upward deviation of both the forefoot and hindfoot, rigid positioning
Metatarsus adductus: flexible positioning, medial deviation of forefoot, neutral position of hindfoot
Management of MA vs. congenital clubfoot.
MA - reassurance
Clubfoot - serial manipulation and casting, surgery if refractory; consider karyotyping (increased risk of chromosomal abnormalities)
Presentation - erythematous, tender nodule at the lid margin
External hordeolum (acute inflammatory disorder of the eyelash follicle or tear gland)
Management of external hordeolum?
Warm compresses
If persistent or development of a large chalazion - possible incision and curettage
Features of blasts?
Fine nuclear chromatin
Small nucleoli
Scan agranular cytoplasm
Burkitt lymphoma is a neoplasm of mature B cells associated with ___ infection. Patients typically have a mass involving the mandible or abdominal viscera. Histologic exam shows a characteristic ___ appearance.
EBV; Starry sky
Hereditary spherocytosis inheritance pattern/associated ethnicity?
AD
Northern European
Clinical presentation of hereditary spherocytosis?
Hemolytic anemia (may present with RUQ pain from pigment gallstones)
Jaundice
Splenomegaly
Lab findings of hereditary spherocytosis?
Increased MCHC Negative Coombs Spherocytes on peripheral smear Increased osmotic fragility on acidified glycerol lysis test Abnormal esoin-5-maleimide binding test
Rx hereditary spherocytosis
Folic acid supplementation
Blood transfusion
Splenectomy if severe
H. ducreyi is a GN rod that causes STIs (chancroid) primarily in developing countries - when should it be suspected in the US?
People who trade sex for drugs or money
What is Gaucher disease?
Lysosomal storage disease with the accumulation of glucocerebroside in macrophages of the bone, liver, and spleen; accumulation results in cytopenias, bone pain, FTT, HSM, and delayed puberty
Inheritance pattern and ethnicity - Gaucher disease
AR
Ashkenazi Jews
Manage Gaucher disease?
Enzyme replacement
Acute symptomatic hyponatremia is a medical emergency that requires a prompt increase in the serum sodium concentration with ___ at a rate of no more than ___ to avoid causing CNS osmotic demyelination syndrome.
3% or hypertonic saline; 0.5 mEq/L/hr
Always consider ___ when a patient with parkinsonism experiences orthostatic hypotension, impotence, incontinence, or other autonomic symptoms.
Multiple system atrophy (Shy-Drager syndrome)
Distinguish benzo and opioid OD.
Benzo - lack of severe respiratory depression, lack of pupillary constriction
Normal pupillary size in bright light?
2-4 mm
Hypovolemia is a common cause of orthostatic hypotension and syncope, especially in elderly patients. What is the most sensitive indicator of this condition?
Decreased urine sodium (due to decreased renal perfusion -> RAAS activation -> aggressive sodium reabsorption)
Renal disease caused by rhabdo?
ATN
What is the mechanism of the change observed during the stress portion of a pharmacologic vasodilator stress test (when disease is present)?
Marked increase in blood flow in normal coronary arteries and a relatively small increase in blood flow in stenotic coronary arteries
3 types of stress tests?
Exercise EKG
Pharmacologic (adenosine or dipyridamole)
Dobutamine stress echo
Mechanism, indications, and contraindications to exercise EKG test?
Increased HR and BP
Best for patients able to reach target HR (85% of 220-age)
Not for LBBB, pacemaker, patients unable to reach tHR
Mechanism, indications, and contraindications to pharm stress test?
Non-selective adenosine agonist that dilates coronary arteries without increasing HR or BP
Best for LBBB, pacemarker, patients unable to reach tHR
Not for reactive airway disease, patients on dipyridamole or theophylline
Mechanism, indications, and contraindications to dobutamine stress echo?
Beta-1 agonist, increase HR +/- BP
Best for RAD, patients unable to reach tHR
Not for tachyarrhythmias
PPH typically occurs within hours of delivery and uterine atony is the most common cause. In post-C/S patients with hemorrhagic shock and no signs of uterine atony, what should be done?
Suspect intra-abdominal bleeding from uterine artery injury (possible retroperitoneal hematoma) -> emergency laparotomy
Erythematous papules that evolve into target lesions with a dusky central area, a red inflammatory zone surrounded by a pale ring, and an erythematous halo at the periphery; primarily located on the extremities
Erythema multiforme
What causes erythema multiforme?
Cell-mediated immune process that is typically associated with certain infections (HSV, mycoplasma, etc.) and may be an immune response against antigens deposited in skin. Can also be associated with certain medications (eg, sulfonamides), malignancies, and vascular diseases
Typical pH of transudative pleural fluid?
7.4-7.55
Typical pH of exudative pleural fluid?
7.30-7.45
Decreased glucose in pleural fluid is usually seen in what settings?
Complicated parapneumonic effusion, malignancy, TB, or RA
Distinguish between lumbar spinal stenosis and lumbar disk herniation?
Spinal stenosis: chronic, worse with extension
Herniation: acute, unialtearl radiation, inciting event, worse with flexion
Potential clinical features of mitral stenosis?
Dyspnea, orthopnea, PND, hemoptysis
AFib, systemic thromboembolism
Voice horasness from recurrent laryngeal nerve compression due to LAE (Ortner syndrome)
Physical exam findings of mitral stenosis?
Mitral facies (pinkish-purple patches on cheeks)
LOUD S1, loud P2 if pulmonary HTN
Opening snap (early diastolic sound)
Mid-diastolic rumble (apex)
CXR findings of mitral stenosis?
Pulmonary blood flow redistribution to upper lobes, dilated pulmonary vessels, LAE, flattened L heart border
EKG findings of mitral stenosis?
“P mitrale” (broad and notched P waves), atrial tachyarrhythmias, RVH (tall R waves in V1 and V2)
Why are patients with asplenia at risk for fulminant infection with encapsulated bacteria?
Deficits in antibody response and Ab-mediated phagocytosis/complement activation
Features of bacillary angiomatosis?
Vascular cutaneous lesions (papular, nodular, peduncular)
Systemic symptoms (fever, night sweats, fatigue)
Organ involvement rarely (liver, bone, CNS)
Cause of bacillary angiomatosis?
B. henselae/quintana Cat exposure or homelessness (lice) Severe immunocomprmoise (HIV, CD4 <100)
Dx bacillary angiomatosis?
Lesional biopsy with microscopy/histopathology
Rx bacillary angiomatosis?
Doxycycline or erythromycin
HAART
The single most important cause of pulmonary hypertension in COPD is?
The narrowing (constriction) of the pulmonary arteries that occurs as a result of low blood oxygen levels
Organophosphate poisoning involves what receptors?
Peripheral muscarinic and nicotinic receptors
General mechanism of thyroiditis?
Release of preformed thyroid hormone
Family history of early onset dementia, Alzheimer type, is a strong predisposing factor for developing dementia, Alzheimer type.
Know this.
Unique symptoms of LEMS?
Weakness of proximal muscles along with depressed or absent DTRs*
Extraocular, respiratory, and bulbar muscles are typically spared*
Weakness will IMPROVE with increased activity***
Dx LEMS?
Repetitive nerve stimulation (characteristic incremental response)
Autoantibodies to presynaptic Ca channels
CT indicative of a lung neoplasm
RMSF vs. Lyme Disease
RMSF: characteristic rash that is initially macular (beginning on wrist and ankles) -> petechial/purpuric as it spreads centrally; may develop into AMS, DIC
Lyme: erythema migrans begins as a small erythematous macule or papule at the site, expands slowly over days to weeks
When there is concern for a pelvic fracture, what should always be done?
R/o injuries to other pelvic structures - rectal exam and/or proctoscopy, retrograde cystogram (bladder), pelvic exam, retrograde urethrogram (urethra in men)
Superficial thrombophlebitis vs. cellulitis vs. lymphangitis?
ST: erythema and induration of the involved vein
Cellulitis: rarely streaky
Lymphangitis: linear, streaky, erythematous lesion, often an initiating lesion or skin infection is present
Suspected basal cell carcinoma? Most appropriate next step?
Excisional biopsy with narrow margin
3 types of juvenile idiopathic arthritis?
- Pauciarticular (oligoarthritis)
- Polyarthritis
- Systemic onset (aka Still disease)
Compare the presentation of the 3 types of juvenile idiopathic arthritis.
- Pauciarticular (oligoarthritis) - 4 or fewer joints, weight-bearing, no systemic symptoms (most common)
- Polyarthritis - 5+ joints, generally symmetric, systemic symptoms rare
- Systemic onset (aka Still disease) - recurrent high fever, HSM, salmon-colored macular rash
Compare the ANA/RF status of the 3 types of JIA.
- Pauciarticular (oligoarthritis) - ANA+, RF-
- Polyarthritis - RF rarely positive, ANA+ in young children with mild disease
- Systemic onset (aka Still disease) - both negative
Common additional finding in pauciarticular JIA?
Uveitis (slit-lamp for diagnosis)
Abortive vs. PPx medications for migraines?
Abortive - triptans (+/- analgesics like naproxen)
PPx - anticonvulsants (valproate, gabapentin, topiramate), TCAs (eg, amitriptyline), beta-blockers (propranolol), and CCbs
Most appropriate pharmacotherapy to prevent chronic pain in a patient with herpes zoster?
PO acyclovir
Rx acute symptomatic ischemia of the limbs?
Heparin and prompt revascularization
Strongest predisposing factor for asthma in general?
Family history
Surprise, household bleach ingestion is not that big of a deal.
Wut.
In a 12 year old boy with chronic renal failure 2/2 glomerulonephritis who has HTN controlled with ACEI, what is one way to minimize complications of renal failure
Restrict phosphorus intake
Where is folic acid and B12 absorbed?
Folic acid - duodenum and jejunum
B12 - ileum
What is the absolute risk? What is the absolute risk reduction?
Incidence of disease; absolute difference in outcome rates between control and treatment groups (not confounded)
What is the relative risk? What is the relative risk reduction?
How much more likely an exposed person is to get the disease in comparison to an unexposed person
1 - RR
Specificity = ?
d/b+d
Sensitivity = ?
a/a+c
PPV = ?
a/a+b
NPV = ?
d/c+d
True or false - circumcision can be done without the consent of parents.
False
Management of PCP intoxication?
Benzos
Haloperidol -> 2nd line
(Propofol -> 3rd line)
When are breath-holding spells common in children?
6 months to 2 years
What is thyroglobulin?
Precursor to active T3 and T4
Rising thyroglobulin in patients s/p total thyroidectomy and RAI treatment indicates?
Recurrent differentiated thyroid cancer
Patient with untreated HIV - headaches, N/V, confusion, abducens nerve palsy, scattered, umbilicated skin papules?
Cryptococcus neoformans infection
When is Cryptococcus neoformans see in patients with AIDS (CD4 count)?
<100
Mechanism of C. neoformans in AIDS?
Replicates in the CNS, clogs the arachnoid villi with yeast components and capsular polysacchardies -> CSF outflow obstruction and increased ICP
Dx C. neoformans?
LP with CSF pressure, analysis, and capsular polsaccharide Ag testing or INDIA INK STAIN
Rx toxoplasmic encephalitis?
Sulfadiazine + pyrimethamine
TMP-SMX is 2nd line and PPx
Patient with advanced AIDS - subacute confusion, diplopia
PML
Dx PML?
Gadolinium-enhanced MRI of the brain - multifocal white matter demyelination, no mass effect
Patients with advanced AIDS - retina, colon, lung manifestations (neuro disease is rare)
CMV
Symptoms suggesting unstable AAA?
Abdominal/flank/groin/back pain
Pulsatile mass
Flank ecchymosis
Limb ischemia
In a patient with suspected unstable AAA and hemodynamic instability, what is the next step?
If known AAA -> emergency repair
If unknown -> focused abdominal U/S -> repair if identified
In a patient with suspected unstable AAA and hemodynamic stability, what is the first test?
CT Abdomen
Rx acute dystonia?
Anticholinergics like benztropine or antihistamines like diphenhydramine
What is valbenazine?
Vesicular monoamine transporter 2 inhibitor - treats TD
Management of cat bites?
Copious irrigation and cleaning
PPx Amox/clav (covers P. multocida and oral anaerobes)
Tetanus booster as indicated
Avoid closure
