18 Flashcards
Distinguish between causes of acute limb ischemia?
- Arterial emboli -> sudden symptoms, sources include L atrial thrombus (AFib), L ventricular thrombus (anterior MI), infective endocarditis, thrombus from valves
- Arterial thrombosis - PVD, less severe presentation, pulses diminished in both extremities
___ can cause recurrent respiratory papillomatosis, which results in hoarseness due to wartlike growths on the true vocal cords.
HPV (6 and 11)
Mainstay of treatment of recurrent respiratory papillomatosis?
Surgical debridement
MOA - calcineurin inhibitor (eg, tacrolimus, cyclosporine) renal toxicity?
Vasoconstriction
Presentation - N/V, RUQ/epigastric pain, fulminant liver failure in pregnancy
Acute fatty liver of pregnancy
May see profound hypoglycemia, increased AST/ALT, bilir, thrombocytopenia, DIC
Management of acute fatty liver of pregnancy?
Immediate delivery regardless of gestational age
In the US, what are the most common source of rabies transmission?
Bats (other causes in the US include raccoons, skunks, foxes; dogs in the developing world)
Acute unilateral cervical lymphadenitis in children is usually caused by ___.
Bacterial infection, most commonly S. aureus, followed by GAS
Cause of acute unilateral lymphadenitis in older children with a history of periodontal disease?
Peptostreptococcus
Cause of unilateral subacute-chronic LAD, usually <5 y/o, firm, non-tender, usually <4 cm
Non-TB mycobacteria
What does an S4 indicate?
Stiff L ventricle -> restrictive cardiomoypathy or LVH from prolonged HTN
Believed to result from blood striking a stiffened left ventricle during atrial contraction
Rx primary Raynaud phenomenon?
CCBs (eg, nifedipine, amlodipine), avoid aggravating factors
What is the primary MV abnormality in patients with HCM?
Systolic anterior motion of the MV -> anterior motion of MV leaflets toward the septum aka abnormal leaflet motion
How does HCM murmur change with preload?
Increased preload/increase afterload -> decreased murmur
Rx RTA?
Oral bicarbonate replacement
3 types of RTA?
1 (Distal) - poor hydrogen secretion into urine (urine pH above 5.5)
2 (Proximal) - poor bicarbonate resorption
4 - aldosterone resistance (high K)
Lab findings in all types of RTA?
Low serum bicarbonate
Hyperchloremia
Normal AG metabolic acidosis
Distinguish between types of RTA?
Urine pH and urine electrolytes
Fundoscopy findings of central retinal artery occlusion?
Whitened retina (edema) Cherry red spot (central fovea appears red from underlying choroid)
Fundoscopy findings of hypertensive retinopathy?
Hard exudates
AV nicking
Flame hemorrhages
Silver wiring
Fundoscopy findings of central retinal vein occlusion
Venous dilation/tortuosity
Scattered and diffuse hemorrhages (blood and thunder)
Cotton wool spots
Disc swelling
3 major side effects of MTX?
Oral ulcers
Macrocytic anemia
Hepatotoxicity
Vaginitis with NORMAL pH (3.8-4.5)
Candida vaginitis
How do endometrial polyps typically present?
Regular monthly menses with intermenstrual bleeding
Cafe-au-lait macules, skinfold freckling, Lisch nodules, neurofibromas, optic pathway gliomas
NF1
When should anticoagulation be given to a patient with suspected PE prior to diagnostic work-up?
Moderate to severe distress
High likelihood of PE
No absolute or relative contraindications
Modified Wells criteria for pre-test probability of PE?
+3: clinical signs of DVT, alternate diagnosis less likely than PE
+1.5: Hx of PE or DVT, HR>100, recent surgery/immobilization
+1: Hemoptysis, cancer
> 4 PE likely
Steps in managing patients with suspected PE
- Supportive care (O2, IVF for hypotension, etc.)
- Assess for absolute contraindication
2a. If contraindications -> Dx testing + IVC filter if positive
2b. If no contraindications -> Wells criteria
3a. If Wells criteria indicates PE is likely -> anticoagulate, then Dx
3b. If unlikely -> Dx then Rx if positive
Cause of phototoxic drug eruptions (exaggerated sunburn reactions with erythema, edema, and vesicles in sun-exposed areas)
ABX (tetracyclines)
Antipsychotics (chlorpromazine, prochlorperazine)
Diuretics (furosemide, HCTZ)
Amio, promethazine, piroxicam
Presentation - sensorineural hearing loss, cardiac defects (eg, PDA), cataracts
Congenital rubella syndrome
Other findings can include fetal growth restriction, HSM, purpueric blueberry muffin rash
Presentation - chorioretinitis, hydrocephalus, diffuse intracranial calcifications
Congenital toxoplasmosis
Presentation - chorioretinitis, periventricular calcificiations
Congenital CMV
Presentation - fever, disseminated abscesses in multiple organs, skin lesions in newborns
L. monocytogenes
Presentation - hepatomegaly, snuffles (nasal discharge), OA destruction, maculopapular rash
Congenital syphilis
Elevated BNP and S3 are signs of ___ and are noted in patients with CHF due to LV systolic dysfunction.
Increased cardiac filling pressures
Where is S3 best heard?
Over the apex in the LLD position
Rapidly progressive hirsutism with virilization suggests very high androgen levels due to ___. Elevated DHEAS is seen in ___.
An androgen-producing neoplasm; androgen-producing adrenal tumors
Vitamin C deficiency causes microvascular bleeding due to impaired synthesis of ___.
Collagen
For younger patients with minimal rectal bleeding (<40) and no risk factors, what is suspected and what can be done?
Hemorrhoids; office-based anoscopy
Mature cystic teratomas are common in premenopausal women - they may cause intermittent colicky pelvic pain, often triggered by physical activity - what is happening?
Partial adnexal rotation/intermittent torsion
Localized papule with ipsilateral regional LAD in the setting of cat exposure
Cat-scratch disease caused by Bartonella henselae; majority of patients do not recall a specific scratch or bite
Rx cat-scratch disease?
Azithromycin
Posterior urethral valves present in newborn boys with bladder distention, decreased urine output, and respiratory distress. Initial evaluation and management?
Renal and bladder U/S (dilated bladder with bilateral hydroureters/hydronephrosis) -> voiding cystourethrogram
If posterior urethral valves are confirmed -> bladder drainage and electrolyte correction, then cystoscopy to confirm the diagnosis and ablate
Medications for bipolar disorder that are safe in pregnancy?
Lamotrigine
Pathophysiology of androgen insensitivity syndrome?
X-linked mutation in the androgen receptor
During development, the testes produce AMH and testosterone. AMH causes regression of uterus, upper 1/3 of vagina, etc. Testosterone has no effect on peripheral tissues and male external genitalia do not develop.
Key clinical features of androgen insensitivity syndrome?
Genotypically male (46, XY)
Phenotypically female
+Breast development, female external genitalia
Absent/minimal axillary and pubic hair, absent uterus, cervix, upper 1/3 vagina
+Cryptorchid testes
Distinguish Mullerian agenesis from androgen insensitivity syndrome.
Mullerian - ovaries are present, normal axillary and pubic hair development
AIS - no ovaries (testes instead), minimal/no axillary/pubic hair development
Cause of BPP: Nonstress test (0) Amniotic fluid volume (0) Fetal movements (2) Fetal tone (2) Fetal breathing movements (0)
at 41 weeks gestation?
Uteroplacental insufficiency -> deliver
Distinguish RMSF from measles.
Both can have fever and conjunctival injection
RMSF: rash on distal extremities (includes palms/soles) and spreads centripetally
Measles: spreads cepahlocaudally
Features of roseola?
Fever first that completely resolves -> rash appears
Define acute liver failure.
Acute onset of severe liver injury (very elevated aminotransferases) with encephalopathy and impaired synthetic function (INR 1.5+) in a patient without cirrhosis or underlying liver disease.
The presence of ___ differentiates acute liver failure from acute hepatitis, which has a much better prognosis than ALF.
Hepatic encephalopathy
List the normal features of lymph nodes.
Soft, mobile, <2 cm, no systemic symptoms
List the abnormal features of lymph nodes.
Firm or hard, immobile, >2 cm, systemic symptoms
Empiric therapy for cervical lymphadenitis?
Clindamycin
Dx of vestibular schwannoma?
Audiogram
MRI with contrast of internal auditory canal
Eustachian tube dysfunction vs. vestibular schwannoma?
ET - conductive hearing loss, pain, popping sounds, middle ear effusion
VS - sensorineural hearing loss
Most common form of paroxysmal SV tachycardia + what causes it?
AV nodal reentrant tachycardia; reentry mechanism due to the presence of a dual electrical pathway (slow and fast) in the AV node
How can a patient terminate AVNRT themselves?
Vagal maneuvers (carotid sinus massage, cold-water immersion or diving reflex, Valsalva, eyeball pressure) that increase parasympathetic tone and temporarily slow conduction in the AV node/increase refractory period
Acute myeloid leukemia typically presents with fatigue + symptoms from 1+ cytopenias. How can APML present?
DIC
Effect of renin?
Converts angiotensinogen (liver) to angiotensin I
Effect of ACE?
Converts angiotensin I to angiotensin II
Effects of angiotensin II?
- Release of aldosterone from adrenal cortex
2. Vasoconstriction (receptors on blood vessels) -> HTN
Effects of aldosterone?
Sodium reabsorption -> HTN
Effect of alpha-adrenergic blockers?
Direct vasodilators used to treat HTN
Cause of hemolytic anemia in patients with G6PD deficiency?
Oxidative injury (medications like dapsone, TMP-SMX, primaquine, infections, foods like fava beans)
Although most patients are asymptomatic, how does symptomatic Paget disease of bone present?
Skeletal deformities (femoral bowing, etc.)
Bone pain
Fractures
If cranial bones are involved (enlarging cranial bones) -> headaches and hearing loss
Mechanism of injury in Paget disease of bone?
Osteoclast dysfunction with a focal increase in bone turnover, progresses to osteoblast dysfunction later in the disease
Major etiologies of constrictive pericarditis?
- Idiopathic or viral pericarditis
- Cardiac surgery or radiation therapy
- Tuberculous pericarditis (endemic areas)
Clinical presentation of constrictive pericarditis?
Fatigue and DOE Peripheral edema and ascites Increased JVP Pericardial knock Pulsus paradoxus Kussmaul's sign
EKG findings of constrictive pericarditis?
Non-specific, AFIb, or low-voltage QRS complex
Imaging findings of constrictive pericarditis?
Pericardial thickening and calcification
Jugular venous pulse tracing findings of constrictive pericarditis?
Prominent x and y descents
Rx options for bacterial conjunctivitis?
Erythromycin ointment
Polymyxin-trimethoprim drops
Azithromycin drops
Preferred agents in contact lens wearers -> FQ drops
Rx options for viral conjunctivitis?
Warm or cold compresses
+/- antihistamine/decongestant drops
CXR findings of coarctation of the aorta?
Inferior notching of the 3rd to 8th ribs
“3” sign due to aortic indentation
Prominent R atrial contour on CXR?
Ebstein congenital anomaly
Upturning of the cardiac apex (“boot-shaped heart”)?
Tetralogy of Fallot
Conditions associated with gastroschisis?
Psych - there are none.
Pharm management of symptomatic patients with HCM?
Negative inotropes (beta, blockers, non-di CCBs - verapamil, disopyramide) -> start with beta-blockers
Prolong diastole, decrease contractility, decreases LVOT obstruction, improves angina symptoms
NOTHING that reduces LV preload
When evaluating secondary sexual development, what is the first step in the work-up?
Bone age
If there is early secondary sexual development and normal bone age, what is the DDx?
Premature thelarche (isolated breast development)
Premature adrenarche (isolated pubic hair development)
If there is early secondary sexual development and advanced bone age, what is the next step?
Check basal LH
If high -> central precocious puberty
If low -> GnRH stimulation test
If high -> central precocious puberty
If low after stim test -> peripheral precocious puberty
Cause of central precocious puberty?
Early activation of the HPG axis (check MRI to look for tumor, otherwise idiopathic)
Cause of peripheral precocious puberty?
Gonadal or adrenal release of excess sex hormones
Rx central precocious puberty?
GnRH therapy
Severe aortic stenosis indicated by valve area ___ cm^2?
<1 cm ^2
In patients with mild to moderate AS, what is the cause of anginal symptoms?
Another cause - most commonly obstructive CAD
Angina due to AS only occurs if severe (<1 cm^2)
Severe aortic stenosis leads to low pulse pressure (<25 mm Hg) - how is this calculated?
Systolic - diastolic BP
Nephrotic syndrome is frequently complicated by ___.
Hypercoagulation (most commonly manifested by renal vein thrombosis)
Other complications include protein malnurition, iron-resistant microcytic hypochromic anemia, increased infection susceptibility, vitamin D deficiency
List features that help differentiate UC from CD.
CD: multiple portions of GI tract involved, rectal sparing, presence of non-caseating granulomas, fistula formation, cobblestoning, creeping fat, transmural inflammation
UC: bloody diarrhea, continuous involvement of the rectum and colon, toxic megacolon
Presbyopia is a common age-related decrease in ___ that leads to difficulty with near vision.
Lens elasticity (prevents accommodation)
Hydatidiform mole can present with ___ at <20 weeks gestation.
Preeclampsia with severe features
What causes early preeclampsia in hydatidiform mole?
Abnormal placental spiral artery development
Presentation - abdominal mass, elevated beta-hCG, ascites in an adolescent
Embryonal carcinoma
Dx Retinoblastoma
MRI of the brain and orbits
___ is used as a measure of association in cohort studies.
Relative risk (ratio of the risk in the exposed group to that in the unexposed group)
Interpret RR <1 and >1.
> 1 means there is a positive association between the risk factor and the outcome
<1 means that there is a negative association
Farther from one, stronger association
Most common cause of GN in adults?
IgA nephropathy
Distinguish IgA nephropathy from post-infectious GN
Earlier onset of URI-related GN (within 5 days)
Normal serum complement levels
Kidney biopsy
Endemic mycosis of the desert SW that causes community-acquired pneumonia (fever, chest pain, cough, lobar infiltrate) often accompanied by arthrlagias, erythema nodosum, and erythema multiforme
Coccidioides
Rx Coccidioides?
Healthy patients usually do not require antifungal therapy
High risk for dissemination - ketoconazole or fluconazole
Milk-protein-induced allergic proctocolitis can cause painless rectal bleeding that resolves with elimination of dietary cow’s milk. It is virtually exclusive to what age group?
Infants (resolves by age 1)
Presentation - painless hematochezia without abdominal pain, diarrhea, or vomiting in young toddlers
Meckel diverticulum
Abnormal ABI?
0.90 or less
ABI 1.30+?
Suggests calcified and uncompressible vessels -> TBI
Acute digoxin toxicity?
GI, weakness, confusion
Chronic digoxin toxicity?
Less GI, more neuro symptoms, visual changes
___ increases the serum levels of digoxin.
Amiodarone
Define active phase protraction of labor.
<1 cm cervical dilation in 2 hours during the active phase of labor (6-10 cervical dilation)
Common cause of labor protraction?
Cephalopelvic disproportion
Risk factors for cephalopelvic disproportion?
Late-term pregnancies
Fetal anomaly or malposition (occiput anterior)
Maternal obesity, excessive weight gain, nulliparity, advanced maternal age, inadequate contractions
Adequate contraction strength?
200+ MVUs
Neuraxial anesthsia can length which stage of labor?
2nd stage (10cm until fetal delivery)
Symptoms of GU syndrome of menopause?
Vulvovaginal dryness, irritation, pruritus Dyspareunia Vaginal bleeding Urinary incontinence, recurrent UTI Pelvic pressure
Physical exam findings of GU syndrome of menopause?
Narrowed introitus
Pale mucosa, decreased elasticity, decreased rugae
Petechiae, fissures, loss of labial volume
Rx GU syndrome of menupause?
Vaginal moisturizer and lubricant
Topical vaginal estrogen
Presentation - symptoms within 1-2 weeks of ovulation induction for infertility treatment, including abdominal pain, ascites, bilateral enlarged cystic ovaries, third spacing -> intravascular volume depletion, can result in thromboembolism, multiorgan failure, death
Ovarian hyperstimulation syndrome
Cause of ovarian hyperstimulation syndrome?
Increased hCG enhances ovarian vascular permeability -> acute fluid shift into extravascular space
Manage ovarian hyperstimulation syndrome?
Correct lytes
Paracentesis and/or thoracentesis
Thromboembolism PPx
Most common extraskeletal complication of ankylosing spondylitis?
Anterior uveitis
Episcleritis is inflammation seen at the white of the eye, without involvement of the uveal tract. It is most strongly associated with what 2 AI conditions?
RA; IBD
Over 15% of adult patients with dermatomyositis will have or develop ___.
An internal malignancy (regular age-appropriate cancer screening is essential)
3 possible extramuscular findings of dermatomyositis?
ILD
Dysphagia
Myocarditis
Ab findings of dermatomyositis?
Anti-RNP
Anti-Jo-1 (anti-synthetase)
Anti-Mi2 (anti-helicase)
Pathognomonic exam finding of dermatomyositis?
Gottron’s papules
Acute erosive gastropathy is characterized by the development of hemorrhagic lesions after ___ or exposure of the gastric mucosa to various injurious agents (eg, alcohol, aspirin, cocaine).
Ischemia
Most common pathogen isolated in infants and young children with CF?
S. aureus
Most common cause of CF-related pneumonia in adults?
P. aeruginosa
Patients with hyperthyroidism and a suppressed TSH should undergo thyroid radioiodine scintigraphy to distinguish ___ from ___.
Painless thyroiditis; Graves disease
Decreased uptake in painless due to release of preformed thyroid hormone
Increased uptake in Graves due to increased synthesis
Key distinguishing feature of subacute thyroiditis (aka De Quervain)
Hyperthyroidism, decreased uptake, PAINFUL AND TENDER
What causes the low glucose concentration in exudative effusions of empyemas?
High metabolic activity of leukocytes and bacteria within the pleural fluid
2 causes of elevated pleural amylase concentrations found in pleural effusions?
Esophageal rupture or pancreatitis
List 2 important dopamine antagonists that are not antipsychotics.
Antiemetics metoclopramide and prochlorperazine
Immediate and long-term management of severe (>14 or symptomatic) hypercalcemia?
NS hydration + calcitonin
Avoid loop diuretics unless heart failure exists
Bisphosphonate (long-term)
