2 Flashcards
___ presents with chronic lateral hip pain and tenderness over the greater trochanter during flexion or when lying on the affected side.
Greater trochanteric pain syndrome
Rx greater trochanteric pain syndrome?
First: heat, activity modification, NSAIDs
If persistent: Local steroid injection
Diagnosis of greater trochanteric pain syndrome (trochanteric bursitis)?
Clinical (local tenderness over the greater trochanter during flexion on exam)
X-ray to rule out hip joint pathology
What are the two MOA of tamoxifen?
Estrogen antagonist on breast tissue (treat and prevent breast cancer)
Estrogen agonist in the uterus (increased risk of endometrial polyps, hyperplasia, and cancer)
What are the two SERMs (selective estrogen receptor modulators)?
Tamoxifen
Raloxifene
Indication for raloxifene?
Post-menopausal osteoporosis
AE of SERMs?
Hot flashes
VTE
Endometrial hyperplasia and carcinoma (tamoxifen only)
Indication for tamoxifen?
Adjuvant treatment for premenopausal women at low risk of breast cancer recurrence
Second-line for post-menopausal women who cannot use aromatase inhibitor therapy
___ are testosterone-secreting sex cord-stromal tumors that can present with rapid-onset virilization, amenorrhea, and a large pelvic mass.
Sertoli-Leydig cell tumors
What is a struma ovarii?
Type of teratoma (germ cell tumor) composed of mature thyroid tissue; patients present with amenorrhea, pelvic mass, and hyperthyroidism
Clinical features of congenital hypothyroidism?
Initially normal at birth
Symptoms develop after maternal T4 wanes: lethargy, enlarged fontanelle, hoarse cry, protruding tongue, umbilical hernia, poor feeding, constipation, dry skin, jaundice, poor feeding, weakness, hypotonia, apathy, sluggish movement, abdominal bloating
Most common cause of congenital hypothyroidism worldwide?
Thyroid dysgenesis (aplasia, hypoplasia, ectopic gland, etc.)
Prompt recognition and treatment with levothyroxine is necessary to prevent ___ in congenital hypothyroidism.
Neurodevelopmental injury
Differentiate between the 3 types of twin pregnancy.
Monochorionic, monoamniotic: 1 placenta, 1 amniotic sac
Mono, di: 1 placenta, 2 amniotic sacs, T-sign at intertwin membrane
Di, di: 2 placentas, 2 amniotic sacs, Lambda sign at intertwin membrane
4 maternal complications of twin pregnancy?
- Hyperemesis gravidarum
- Pre-eclampsia
- Gestational DM
- Iron-deficiency anemia
4 general fetal complications of twin pregnancies?
- Congenital anomalies
- Fetal growth restriction
- Pre-term delivery
- Malpresentation (eg, breech)
1 fetal complication of monochorionic twin pregnancies?
Twin-twin transfusion syndrome
2 fetal complications of monoamniotic twin pregnancies?
- Conjoined twins
2. Cord entanglement
Most common complication of twin pregnancies?
Pre-term delivery (<37 weeks)
Define fetal macrosomia?
Estimated fetal weight of 4,500+ g
Define intermittent asthma.
Symptom frequency/SABA use 2 or fewer days/week
Nighttime awakenings 2 or fewer times/month
Define mild persistent asthma.
Symptom frequency/SABA use >2 days/week, but not daily
Nighttime awakenings 3-4 times/month
Define moderate persistent asthma.
Symptom frequency/SAA use daily
Nighttime awakenings >1 time/week, but not nightly
Define severe persistent asthma.
Symptom frequency/SABAS use throughout the day
Nighttime awakenings 4-7 times/week
What are the steps of asthma management?
Step 1: SABA PRN
Step 2: Low-dose ICS
Step 3: Low-dose ICS + LABA / OR / Medium-dose ICS
Step 4: Medium-dose ICS + LABA
Step 5: High-dose ICS + LABA AND consider omalizumab for patients with allergies
Step 6: Step 5 + oral corticosteroid
Examples of low-dose inhaled corticosteroid?
Beclomethasone
Fluticasone
Examples of LABAs?
Salmeterol
What is theophylline and what is its role in asthma management?
Methylxanthine PDE inhibitor that causes bronchodilation
Use somewhat limited by AE
Alternate Step 3
Features of tremor in Parkinson’s disease?
Resting tumor
4-6 Hz
Asymmetric
Associated with rigidity
Management of tremor in Parkinson’s disease?
Trihexyphenidyl (anticholinergic)
Management of essential tremor?
Propranolol (first-line)
Second-line: clonazepam, primidone
In addition to thyroid dysgenesis (most common cause), what are 2 other causes of congenital hypothyroidism?
- Inborn errors of thyroxin synthesis (10%)
2. Transplacental maternal thyrotropin-receptor blocking antibodies (5%)
What is Werdnig-Hoffman syndrome?
AR disorder involving degeneration of the anterior horn cells and CN motor nuclei, one cause of “floppy baby” syndrome
What is myotonic congenital myopathy?
AD disorder characterized by muscle weakness and atrophy (most prominent in distal muscles of upper and lower extremities), myotonia, testicular atrophy, and baldness
List 4 infectious complications of atopic dermatitis.
- Impetigo
- Eczema herpeticum
- Molluscum contagiosum
- Tinea corporis
Pathogen and presentation of impetigo?
S. aureus and S. pyogenes
Painful, non-pruritic pustules with honey-crusted adherent coating
Pathogen and presentation of eczema herpeticum?
HSV 1
Painful vesicular rash with “punched-out” erosions and hemorrhagic crusting
Pathogen and presentation of molluscum contagiosum?
Poxvirus
Flesh-colored papules with central umbilication
Pathogen and presentation of tinea corporis?
Trichophyton rubrum
Pruritic circular patch with central clearing and raised, scaly border
Risk factors for iron deficiency anemia in young children?
- Prematurity
- Lead exposure
- Age <1: delayed introduction of solids; cow’s, soy, or goat’s milk
- Age >1: >24 oz/day cow’s milk, <3 servings/day iron-rich foods
Lab findings of iron deficiency anemia in young children?
Decreased MCV Decreased MCHC Increased RDW (size variability) Low erythrocyte count Increased TIBC (upregulated transferrin production, lower serum iron)
Lab findings of beta thalassemia?
Decreased MCV Decreased MCHC Low RDW Normal/elevated erythrocyte count Abnormal Hgb electrophoresis
What is TIBC?
Direct measure of iron bound by transferrin
Indirect measure of transferrin levels
Presentation - <1 week of systemic (fever, malaise, myalgias, headache) and respiratory (rhinorrhea, sore throat, non-productive cough) symptoms
Influenza
Most common complication of influenza? Other complications?
Pneumonia (secondary bacterial infection or direct viral attack)
Muscle (myositis, rhabdomyolysis)
Heart (myocarditis, pericarditis)
CNS (encephalitis, transverse myelitis)
Typical XR findings of viral pneumonia?
Bilateral diffuse reticular infiltrates
In an infant with meningococcemia, watch out for ___.
Waterhouse-Friderichsen syndrome (sudden vasomotor collapse and skin rash due to adrenal hemorrhage)
Features of Sturge-Weber syndrome?
Capillary malformation (port wine stain) along the trigeminal nerve (V1/V2) distribution
Leptomeningeal capillary-venous malformations affecting the brain and eye
Seizures +/- hemiparesis, intellectual disability, visual field defects, glaucoma
Mutation causing Sturge-Weber syndrome?
GNAQ gene
Dx Sturge-Weber?
MRI of the brain with contrast demonstrating intracranial vascular malformation
Manage Sturge-Weber syndrome?
Laser therapy
Anti-epileptic drugs
Intraocular pressure reduction
Features of Klippel-Trenaunay syndrome?
Capillary, venous, and sometimes lymphatic malformations in combination with limb overgrowth
No neuro abnormalities
Port wine stain involving the lower extremity
Features of NF1?
Optic glioma Lisch nodules Cafe-au-lait macules Scoliosis Axillary and inguinal freckling Neurofibromas Pseudoarthrosis
Features of Tuberous sclerosis?
Seizures and ID
Retinal hamartomas
Hypopigmented ash-leaf spots
Angiofibromas (malar erythematous papules)
Shagreen patches (flesh-colored plaques on the back)
Rx carpal tunnel syndrome?
1st - splinting
May add - glucocorticoids
Surgery only if severe (atrophy, weakness) or refractory
Most common childhood cancer?
Acute lymphoblastic leukemia
M vs. F distribution of ALL
Peak age of ALL
M>F
2-5 years
Dx ALL?
BM biopsy with >25% lymphoblasts
Dx and manage epiglottitis?
Direct laryngoscopy during intubation to secure the airway
Thumb sign?
Epiglottitis
Steeple sign?
Bacterial tracheitis or croup
Causes of Cushing syndrome (hypercortisolism)?
Exogenous glucocorticoids
ACTH-producing pituitary tumor
Ectopic ACTH production
Primary adrenal disease
3 electrolyte disturbances that can cause muscle weakness?
Hypokalemia
Hypomagnesemia
Hypercalcemia
1 electrolyte disturbance that can cause tetany?
Hypocalcemia
Diagnose chronic pancreatitis?
Pancreatic calcifications on CT or plain film
Note that amylase and lipase can be normal and non-diagnostic
What is Chagas disease and what causes it?
Chronic disease that can cause megaesophagus, megacolon, and/or cardiac dysfunction
Trypanosoma cruzi (protozoa), endemic to Latin America
Lab abnormalities of bulimia nervosa?
Hypokalemia
Hypochloremia
Metabolic alkalosis
What is a hazard ratio?
Ratio of an event rate occurring in the treatment arm vs. the non-treatment arm
Hazard ratio <1 ?
Treatment arm had a lower event rate
Hazard ratio >1?
Treatment arm had a higher rate of events
What type of study design involves randomization to different interventions with additional study of 2+ variables?
Factorial design studies
What type of study involves the grouping of different data points into similar categories?
Cluster analysis
What type of study randomizes one treatment to one group and a different treatment to the other group?
Parallel study
What type of study involves two groups of participants receiving different treatments for a period of time followed by switching treatments?
Cross-over study
Features of a non-functioning pituitary adenoma?
- Arise from gonadotropin-secreting cells in the pituitary
- Dysfunctional cells secrete common alpha-subunit of LH and FSH (rather than the normal alpha and beta)
- Production of most pituitary hormones will be decreased due to compression of neighboring normal pituitary cells
- Prl levels are mildly to moderately elevated due to anatomic disruption of the dopaminergic pathways that normally suppress secretion
Features of Klinefelter syndrome?
47, XXY
Hypogonadism, small testes, decreased virilization
HPA axis intact, LH increased
Affect of antipsychotics on HPA axis?
Can cause hyperprolactinemia (due to blockade of dopamine)
TSH is usually unaffected
Lab abnormalities caused by HCTZ?
Hypokalemia
Hyperglycemia
Hyperuricemia
Common causes of sciatica (aka lumbosacral radiculopathy)?
Nerve root compression usually from herniated disc or lumbar spondylosis
Management of sciatica?
Because most patients experience spontaneous resolution, begin with NSAIDs or acetaminophen
MRI not indicated initially, as it does not change management (so long as there are no associated symptoms concerning for cauda equina syndrome or epidural abscess)
2 main causes of symptomatic cholelithiasis in pregnancy?
Increased biliary cholesterol excretion (estrogen effect)
Decreased gallbladder motility (progesterone effect)
Management of symptomatic cholelithiasis in pregnancy?
Conservative (eg, pain control)
Cholecystectomy for complicated, recurrent cases
Why can pre-eclampsia cause RUQ pain?
Stretching of the liver capsule
Diagnostic test with high sensitivity and specificity for severe pancreatic exocrine insufficiency?
Fecal elastase (low levels indicate insufficiency)
Increased fecal calprotectin and leukocytes occur in patients with what condiiton?
IBD
Most common form of drug-induced renal failure?
Analgesic nephropathy
Most common pathologies seen in drug-induced renal failure?
Papillary necrosis
Chronic tubulointerstitial nephritis
Common drugs associated with pancreatitis?
- Diuretics (furosemide, thiazides)
- IBD drugs (sulfasalazine, 5-ASA)
- Immunosuppressives (azathioprine)
- HIV-related (didanosine, pentamidine)
- ABX (metronidazole, tetracycline)
- Anti-seizure medications (valproic acid)
Features of Down syndrome?
Epicathnic folds Upslanting palpebral fissures Low-set small ears Flat facial profile Short neck with excess skin Furrowed tongue Sandal-toe deformity Hypoplastic incurved 5th finger Single transverse palmar crease Brushfield spots
Low birth weight
Hypotonia (may present with poor feeding due to weak suck)
Features of Beckwith-Wiedemann syndrome?
Macrosomia
Hemihyperplasia (asymmetric overgrowth of one side of the body)
Omphalocele
Macroglossia
Features of Fragile X syndrome?
Neurobehavioral problems Prominent forehead Large ears Long, narrow face Prominent chin Macroorchidism
Filamentous, aerobic, gram-positive bacteria that is partially acid-fast?
Nocardia
Typical disease caused by Nocardia?
Pulmonary or disseminated disease (particularly to the brain, also the skin) in immunocompromised hosts
Rx pulmonary nocardiosis? If brain involved?
TMP-SMX; add carbapenems
6-12 months of treatment
ABX type, organism targeted - aztreonam
Monobactam
GN, including P. aeruginosa
Rx of choice for Actinomyces?
Penicillin G
Key differences between Actinomyces and Nocardia?
Anaerobic
NOT acid-fast
Sulfur granules
Well-known AE of high-dose niacin therapy? What is its MOA?
Cutaneous flushing and intensive generalized pruritis; prostaglandin-induced peripheral vasodilation
Rx with low-dose aspirin
How is pulmonary hypertension classified?
Group 1: pulmonary arterial HTN
Group 2: due to L-sided heart disease
Group 3: due to chronic lung disease (COPD, ILD, etc.)
Group 4: due to chronic thromboembolic disease
Group 5: due to other causes
Physical exam signs of pulmonary HTN
L parasternal life R ventricular heave Loud P2, right-sided S3 Pansystolic murmur of TR JVD, ascites, peripheral edema, hepatomegaly
CREST syndrome?
Calcinosis cutis Raynoud phenomenon Esophageal dysmotility with reflux Sclerodactyly Telangiectasia
CREST syndrome is a part of what illness?
Systemic sclerosis (limited cutaneous)
Compare the findings of limited vs. diffuse cutaneous systemic sclerosis.
Limited:
- Scleroderma on head and distal UE
- Prominent vascular manifestations (Raynaud, cutaneous telangiectasia, pulmonary arterial HTN)
- CREST
Diffuse:
- Scleroderma on trunk and UE
- Prominent internal organ involvement (renal crisis, MI and myocardial fibrosis, ILD)
Which type of systemic sclerosis has a better prognosis?
Limited cutaneous
Ab of limited cutaneous?
Anticentromere
Ab of diffuse cutaneous?
Anti-Scl-70 (topoisomerase-1)
Anti-RNA polymerase III
Histologic findings of pulmonary arterial hypertension?
Intimal hyperplasia of the pulmonary arteries
Cause of brachial-femoral pulse delay?
Aortic coarctation
Cause of systolic ejection murmur radiating to the carotids?
Aortic stenosis
Cause of systolic ejection murmur WITHOUT radiation to the carotids?
HCM
S3 heard at the apex on end-expiration indicates?
LV failure
S3 heard at the LL sternal border on end-inspiration
RV failure
Cause of wide fixed splitting of S2?
ASD
Most accurate method for measuring pulmonary arterial pressure? Least invasive?
Right heart catheterization; Echo
Define pulmonary HTN.
Resting pulmonary arterial systolic pressure >30
Alveolar spaces filled with fibroblasts?
ILD
Initial management of plantar fasciitis?
Activity modification, stretching, padded heel inserts
Cause of tarsal tunnel syndrome?
Compression of the tibial nerve
Most patients with parvovirus B19 infection are asymptomatic or have flu-like symptoms. However, there are 3 unique presentations caused by this virus. What are they?
- Erythema infectiosum (fifth disease) - fever, nausea, slapped cheek rash (more common in kids)
- Acute symmetric arthralgia/arthritis: hands, wrists, knees, feet; may have morbilliform exanthem
- Transient pure red cell aplasia (aplastic crises in patients with underlying hematologic disease like sickle cell)
What patient characteristic can be used to effectively rule out polymyalgia rheumatica?
Age - almost exclusively occurs in patients >50
