19 Flashcards
___ is strongly associated with increased severity and progression of Crohn disease and should be avoided.
Smoking
Next step for patients with decreased fetal movement?
Antenatal fetal testing with a non-stress test followed by a BPP (if labor is contraindicated) or a contraction stress test if the NST is non-reactive
A non-stress test is an external monitor of fetal heart rate for 24-40 minutes. Define an abnormal result.
Reactive (normal): 2+ accelerations in 20 minutes, each peaking 15+/min above baseline and lasting 15+ seconds, baseline 110-160/min, moderate variability (6-25/min)
Non-reactive (abnormal): <2 accelerations
Recurrent variable or late decelerations (abnormal)
Abnormal BPP?
0, 2, or 4 points
Any result with oligohydramnios
Equivocal = 6 points
A contraction stress test is an external fetal heart rate monitor during spontaneous or induced uterine contractions. Define an abnormal result.
Late decelerations with >50% of contractions (abnormal)
No late or recurrent variable decelerations is normal
Umbilical artery flow velocimetry is beneficial in monitoring ___ fetuses.
Growth-restricted
An abnormal BPP score is consistent with ___. Next step?
Fetal hypoxia due to placental dysfunction (insufficiency); prompt delivery is indicated due to the high probability of fetal demise
Define oligohydramnios.
Single deepest pocket <2 cm or AFI 5 or fewer
Presentation - episodic flushing, secretory diarrhea, wheezing, murmur of tricuspid regurgitation
Carcinoid syndrome
Other symptoms may include telangiectasias, cyanosis, cramping, niacin deficiency
Dx carcinoid syndrome?
Elevated 24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)
CT/MRI A/P to localize
OctreoScan to detect mets
Echo if symptoms of carcinoid heart disease are present
Rx carcinoid syndrome?
Octreotide for symptomatic patients and prior to surgery/anesthesia
Surgery for liver mets
Preferred HIV screening test?
4th generation assay of HIV p24 Ag and HIV Ab
Define normal fetal activity?
10+ movements in 2 hours
Steps in work-up of suspected acromegaly?
- IGF-I level (if elevated -> #2)
- Oral glucose suppression test (if inadequate GH suppression -> #3)
- MRI of the brain (pituitary mass or normal -> evaluate for extrapituitary causes)
Features of Behcet disease?
Recurrent painful oral aphthous ulcers Genital lesions Eye lesions (eg, uveitis) Skin lesions (eg, erythema nodosum, acneiform lesions0 Thrombosis
Evaluation of Behcet disease?
Pathergy -> exaggerated skin ulceration with minor trauma (eg, needlestick)
Biopsy -> non-specific vasculitis of different-sized vessels
Reactive arthritis can share a number of features with Behcet syndrome, including arthritis, uveitis, and oral ulcerations. However, it can be distinguished with what 2 general features?
- Usually follows an acute GI or GU infection
- Subaacute to chronic symptoms (rather than episodic)
What is the most common source of symptomatic pulmonary emoblism?
Proximal deep leg veins (femoral)
Most common cause of sepsis in patients with sickle cell disease?
Pneumococcus
Most effective method of preventing the spread of measles once a person is infected?
Airborne precautions
Next step in management of suspected brain abscess?
Contrast-enhanced CT or MRI (ring-enhancing lesion)
Common physical exam finding of AR?
Bounding pulse
What is pulsus paradoxus and when is it seen?
Fall in the systemic arterial pressure by >10 mmHg during inspiration
Cardiac tamponade
What is pulsus parvus et tardus and when is it seen?
Decreased pulse amplitude and delayed upstroke; AS
Contraindications to PDE-5 inhibitors?
Nitrates or alpha blockers
Which patients with CAD should refrain from sexual activity until they have been appropriately evaluated and stabilized?
Ongoing stable or unstable angina, incomplete revascularization, L ventricular dysfunction or symptomatic heart failure, high-risk arrhythmias, very recent (<2 weeks0 MI
Painless vaginal bleeding >20 weeks gestation
Placenta previa
Why is a reactive fetal heart tracing usually seen in early placenta previa?
Bleeding is primarily maternal in origin
What condition is due to bleeding primarily of fetal origin?
Vasa previa
Drugs of choice for treating/preventing chemo-induced N/V?
5-HT3 antagonists (eg, ondansetron)
What is the primary anticholinergic agent used to treat vomiting and when is it indicated?
Scopolamine; reduce motion sickness
Define neutropenia.
ANC <1500
Rx bell palsy
GLUCOCORTICOIDS (+/- acyclovir or valacyclovir)
Major cause of chronic diarrhea in patients with HIV who have CD4 counts <180?
Cryptosporidium parvum
List 3 other causes of diarrhea in patients with AIDS and how to distinguish them from Crypto.
- Microsporidium/isosporidium:
- CD4 <100
- Fever is RARE - MAC
- CD4<50
- HIGH fever - CMV
- CD4 <50
- Hematochezia
Preferred initial treatment for uncomplicated BPH?
Alpha-1 blockers (terazosin, tamsulosin)
Alternative or additional treatment for BPH?
5-alpha-reductase inhibitors (eg, finasteride, dulasteride)
Effectiveness may take 6-12 months
What is masked HTN?
Isolated ambulatory HTN; normal BP readings during clinic visits, but average BP throughout the day and night are elevated. These patients often present with evidence of hypertensive end-organ damage (retinopathy, LVH, etc.)
Patients with clinical signs of HTN but normal BP readings should be tested for masked HTN with ___.
Ambulatory BP monitoring
Average 24-hour BP 135/85+ is diagnostic
___ closely mimics the presentation of sarcoidosis and should be considered when a patient with suspected sarcoidosis deteriorates after immunosuppressive therapy.
Histoplasmosis
Exclude dimorphic fungi infections before starting immunosuppression in endemic regions
Steps in working up suspected hyperaldosteronism (HTN + hypokalemia)?
- Plasma aldosterone/renin ratio (if elevated -> #2)
- Adrenal suppression tests (if positive -> #3)
- Adrenal imaging (if normal or age>40 with abnormal CT ->#4)
- If discrete unilateral adenoma and age <40 -> surgery - Adrenal venous sampling -> unilateral adenoma/hyperplasia (consider surgery) or bilateral adrenal hyperplasia (medical therapy)
New-onset hearing loss or chronic ear drainage despite ABX +/- granulation tissue and skin debris within retraction pockets in children
Cholesteatomas
Presentation of ACA stroke?
Contralateral motor and/or sensory deficits (Lower>Upper)
+/- urinary incontinence, abulia (lack of will or initiative), dyspraxia, emotional disturbances
Presentation of MCA stroke?
Contralateral somatosensory and motor deficit (face, arm, and leg)
+/- conjugate eye deviation toward side of infarct, homonymous hemianopia, aphasia (dominant), hemineglect (non-dominant)
Presentation of posterior limb of internal capsule infarct (aka lacunar)
Unilateral motor impariments
No sensory, cortical, visual field deficits
Presentation of vertebrobasilar system lesion?
Alternate syndromes with contralateral hemiplegia and ipsilateral CN involvement
+/- ataxia
Presentation of lesion occluding the internal carotid?
ACA and MCA lesions -> dense, contralateral hemiplegia (face, arm, and leg equally) with contralateral sensory, visual, language, or spatial impairments
PCA stroke?
Homonymous hemianopia
Alexia without agraphia (dominant)
Visual hallucinations (calcarine cortrex)
Sensory symptoms (thalamus)
CN3 palsy with paresis of vertical and horizontal eye movements
Contralateral motor deficits
Ear drainage, severe ear pain, granulation tissue on the floor of the external auditory canal, usually elderly patient with DM
Necrotizing (malignant) otitis externa
___ is a supraventricular tachyarrhythmia characterized by distinct P waves with 3+ different morphologies, atrial rate >100/min, and an irregular rhythm. What are 3 common etiologies and how is it managed?
Multifocal atrial tachycardia
Exacerbation of pulmonary disease (eg, COPD) Electrolyte disturbance (eg, hypokalemia) Catecholamine surge (eg, sepsis)
Correct underlying disturbance
AV nodal blockade (eg, verapamil) if persistent
Lab findings of Paget disease of bone (Ca, Ph, alk phos, urine hydroxyproline)
Elevated alkaline phosphatase and bone turnover markers (PINP, urine hydroxyproline)
Calcium and phosphorus are usually normal
Rx Paget disease of bone?
Bisphosphonates
Most common complication after ERCP?
Acute pancreatitis
Presentation - neonatal hypoglycemia, macrosomia/macroglossia, hemihyperplasia, umbilical hernia/omphalocele
Beckwith-Widemann syndrome
Next step in management of an infant with suspected Beckwith-Widemann syndrome?
Abdominal U/S and AFP level due to increased risk of Wilms tumor and hepatoblastoma
Rx ITP?
Plts >30,000 + no bleeding - observation
Pls <30,000 - steroids
Hemorrhage - IVIG and platelet transfusion
First step in diagnosing suspected gallstone-induced pancreatitis?
Abdominal U/S
ERCP if U/S is non-diagnostic and suspicion is high
To prevent cardiorespiratory arrest and permanent neurologic disability, victims of smoke inhalation injury should be treated empirically for ___. How is this done?
Cyanide toxicity; antidote such as hydroxocobalamin* or sodium thiosulfate or nitrites to induce methemglobinemia
Cyanide causes what acid-base disturbance? MOA?
Metabolic acidosis; cyanide binds ferric iron in cytochrome oxidase a3 in the mitochondrial electron transport chain; this blocks oxidative phosphorylation and promotes anaerobic metabolism -> lactic acidosis
Effects of shunting a large amount of blood through an AV fistula?
Decreases SVR
Increases preload
Increased CO
Clinical signs of AV fistula?
Widened pulse pressure Strong peripheral arterial pulsation (eg, brisk carotid upstroke) Systolic flow murmur Tachycardia Flushed extremities LVH
In patients with AVF and significant AV shunting, there is a compensatory increase in ___ and ___ to mee the O2 requirements of the peripheral tissues.
HR; SV
Dx AVF in the extremity?
Doppler U/S
The primary anti-ischemic and anti-anginal effects of nitrates are due to what effects?
Systemic vasodilation and venodilation
Lowers preload and LV EDV -> reduces wall stress and myocardial O2 demand
Medications that can trigger acute angle closure glaucoma?
Decongestants, antiemetics, anticholinergics (trihexphenidyl, etc.)
MOA/indication of entacapone?
Increases dopamine stimulation, potentiate effects of carbidopa/levidopa in Parkinson disease
MOA/indication of pramipexole?
Dopamine agonist; symptomatic Parkinson disease
2 types of fibroids associated with recurrent pregnancy loss?
Submucosal and intracavitary
Infection of the lacrimal sac, often presents with sudden onset pain and redness in the medial canthal region?
Dacryocystitis
Abscess located over the upper or lower eyelid?
Hordeolum
All patients with acute exacerbation of COPD should receive what treatments?
Inhaled bronchodilators (beta agonists and anticholinergics) and systemic glucocorticoids
+/- supplemental O2, ABX, and vent support when indicated
___ is a mucolytic agent useful in patients with abnormal/thick mucous secretions.
Acetylcysteine
Rx SCID
Stem cell transplant (long-term)
Prevent febrile non-hemolytic reaction to blood transfusions?
Leukoreduction
3 electrolyte causes of QT prolongation?
Hypocalcemia
Hypokalemia
Hypomagnesemia
Features of congenital long QT syndrome?
Sudden death, congenital sensorineural deafness, QT interval of ~600 ms
Rx long QT syndrome?
Maintain normal levels of Ca, K, Mg
Beta-blockers (blunts exertional HR, shortens the QT interval)
Symptomatic patients or those with a history of syncope also require long-term pacemaker placement
Which beta blocker should be avoided in long QT syndrome?
Sotalol (class III anti-arrhythmic, can prolong QT by blocking K channels)
For anticoagulation, unfractionated heparin is preferred over LMWH, fondaparinux, and rivaroxaban in patients with ___. Why
Severe renal insufficiency (GFR <30) -> reduced renal clearance increases anti-Xa activity levels and bleeding risk
What are Howell-Jolly bodies and what does their presence suggest?
Nuclear remnants within RBCs typically removed by the spleen; asplenia or functional hyposplenism
Precipitation of ribosomal ribonucleic acid is seen in patients with ___ and appears as ___ on smear.
Lead poisoning; basophilic stippling
Hypotension is a common side effect of epidural anesthesia - MOA?
Blood redistribution to the lower extremities and venous pooling from sympathetic blockade
Define prolonged QT interval.
QTc > 450 ms in males
>470 ms in female
Characteristic ECG findings of WPW?
Short PR (<120 ms) Slurred initial upstroke of QRS Widening of QRS complex with St/T wave changes
Cause of WPW?
Accessory pathway that bypasses the AV node and directly connects the atria to the ventricles
First line therapy for nocturnal enuresis?
Desmopressin
AA amyloidosis occurs in the setting of chronic inflammation and is most commonly seen in patients with long-standing ___. Dx?
RA; biopsy demonstrating amorphus hyaline material that stains with Congo red
List the live-attenuated vaccines (6).
Polio (oral) MMR Rotavirus Influenza (INTRANASAL) Yellow fever VZV
Most common side effect of tamoxifen?
Hot flashes
All estrogen agonists increase the risk of VTE by increasing ___.
Protein C resistance
In hyperthyroidism, increased radioactive iodine uptake suggests what cause vs. decreased RAIU?
Increased - de novo TH synthesis
Decreased - release of preformed hormone or exogenous hormone intake
Thyrotoxicosis due to exogenous thyroid hormone is characterized by what lab finding?
Low serum thyroglobulin levels
PPx for antiphospholipid antibody syndrome in pregnant patients?
Low dose aspirin + LMWH
In a ___ study, risk factor and outcome are measured simultaneously at a particular point in time.
Cross-sectional
TCA overdose can present with CNS, cardiac, and anticholinergic findings. How is it treated and what is the MOA?
Sodium bicarbonate
Increases serum pH and extracellular sodium, thereby alleviating the cardiodepressant action on sodium channels
Rx urgency incontinence?
Antimuscarinics (oxybutynin) -> prevent bladder spasms/promote relaxation
Timed voiding
Rx urinary overflow incontinence?
Cholinergic therapy (bethanechol)
Rx minimal change disease?
Steroids
Dx - thickened BM and subepithelial spikes?
Membranous glomerulonephritis
Dx - mesangial hypercelluarity?
Membranoproliferative GN
Chronic GI disease can cause vitamin D deficiency due to malabsorption - levels of Ca, Ph, and PTH?
Hypocalcemia
Low phosphorus
Elevated PTH
Because Vitamin D mediates intestinal Ca and Ph absorption
Symptoms of Vitamin D deficiency?
Osteomalacia, bone pain/tenderness, muscel weakness or cramps, gait abnormalities, etc.
___ are due to microatheroma formation and lipohyalinosis in the small penetrating arteries of the brain.
Lacunar strokes
