2 review Flashcards
Classic findings of Wiskott-Aldrich syndrome : WisPER
stands for ???
(Wiskott-Aldrich syndrome, Purpura, Eczema, Recurrent infections)
genetic condition characterized by impaired function of T cells and thrombocytopenia
Epidemiology: occurs primarily in males
Etiology: mutated WASp gene (X-linked recessive inheritance) → impaired signaling to actin cytoskeleton reorganization → defective antigen presentation
patients which high disease activity of UC should have what treatment and subsequent workup ??
begin TNF-a inhibitor therapy (infliximab) + TB rule out
what is the first and main step in mngmt of acute pain crisis of sickle cell disease
***FLUIDs + pain management
blood transfusion only held for severe sickel crises w/anemia and end-organ damage
??? typically occurs within minutes or a few hours of blood product transfusion. It manifests with acute hypoxemic respiratory failure and bilateral pulmonary infiltrates.
Transfusion-related acute lung injury
In contrast to patients with transfusion-associated circulatory overload, those with TRALI typically have normal brain natriuretic peptide and no jugular venous distension.
patients after gastric bypass surgery are at risk for vitamin def.
presentation with ataxia, opthalmoplegia (nystagmus), and acutely altered mental status suggest which def ???
thiamine (B4)
when are fluids indicated for infection in patient with HF w/ reduced EF, cirrhosis, and ESRD
ex. CAP infection
**give fluids if evidence of hypoperfusion/severe sepsis: hypotension, altered mental status, or labs pointing toward organ dysfunction
**if no signs of hypoperfusion; (NORMAL BP) just febrile, tachy - just remove volume-depleting and BP lowering meds
when should screening for hyperlipidemia begin
35 in asymptomatic men
40-45 in asymptomatic women
ulcers caused by PAD vs. venous insufficiency
PAD typically occurs at distal digits/toes
Venous insufficiency typically at medial malleolus/lower leg + also accompanied with bronzing of skin, dermis changes
which finding ??
sun-bursting as part of osteosarcoma
- Frequently first manifests with pain (progressive, worsens at night and with activity)
- Progressive swelling (tissue mass that is tender to palpation and accompanied by erythema)
- Pathologic fractures
- Limping, decreased range of motion
patients with HIV are considered to have a postive PPD with induration above ???
5mm
**also applies to immunosuppressed/comprimised and known recent exposure to active TB
if CD4 count <200; need a retest after CD4 is above 200
???? is a type of cancer that typically occurs in the urinary system. It is the most common type of bladder cancer and cancer of the ureter, urethra, and urachus. It accounts for 95% of bladder cancer cases
Transitional cell carcinoma, also called urothelial carcinoma,
women with unexplained late-term stillbirth at greater than 32 weeks should undergo what ??
weekly nonstress testing in the 3rd trimester starting at 32 weeks
in general: prior hx of fetal demise requires serial US, screening for anomalies, amniotic fluid volume, and routine monitoring for fetal growth
??? heart condition can occur in children born to mothers of SLE and Sjogren’s syndrome
Congenital AV block
as a result of developing AV node to maternal autoantibodies
**associated with Anti Ro and La
comparing tampon use accross two groups is a comparison of categorical values (presence vs absence), this is best assessed by ? test
chi-square test
patient with liver disease has wound on foot from beach and has pain radiating to groin developing into hemorrhagic bullae over the leg
what is the diagnosis and tx?
likely vibrio vulnificus and tx is surgical debridement and antibiotics due to rapid progression to nec fasc.
what are the two necessary tx for anaphylactic shocks ???
epinephrine AND fluids
what finding
tx ?
pterygium - benign growth of conjuctival tissue
tx. topical lub and avoidance of UV
*thought to be caused by UV exposure
older man presents with hematuria + lytic bone lesion; what is the most likely cause ???
metastatic renal cell carcinoma
commonly metastasizes to bone, lung, and brain
MM may cause renal problems but not gross hematuria
three types of spinal muscular atrophy - what are they ??
The most common causes of death among patients with SMA are respiratory insufficiency (due to respiratory muscle weakness) and aspiration pneumonia (due to bulbar weakness)!
The older the age of onset, the better the prognosis!
Type I → non-sitters, type II → sitters, type III → walkers
which EKG pattern is indicative of PE
S1Q3T3
S wave in Lead I, Q wave in Lead I, inverted T wave in lead III
? is the most likely diagnosis with an aortic aneurysm, livedo reticularis, petechiae, and renal dysfunction
multiple cholesterol emboli syndrome
aortic dissection increases the risk for atherosclerotic plaque disruption and can lead to emboli
asthma was ??? peak expiratory flow rate
decreased **
*FEV and expiratory flow rate may be normal during asymptomatic periods; but signs of wheezing suggest sx onset and lower respiratory function values
??? is the most frequent pathogen that causes suppurtive parotitis (infection of the parotid gland)
staph aureus
apart from protein and Cr clearance, what lab is important to check for CKD ??
hemoglobin concentreation
CKD leads to decreased EPO; often see normocytic anemia
how should babies born to mothers with a family hx of hemophilia be checked??
only males; check factor VIII concentration immedietly after birth through sampling of umbilical cord blood
genetic counseling for BRCA is indicated for who (3)
personal breast cancer diagnosed before 45
personal/family history of ovarian cancer
personal/family history of male breast cancer
**this is the first step before any additional imaging/diagnostic is done
a postpartum patient with fever and severe uterine tenderness raises suspicion for ???
endometritis - polymicrobial infection of uterine endometrium involving aneorobes and aerobes
severe tenderness of uterine fundus and mucupurulent vaginal discharge
Tx is antibiotics ; **no cultures needed in suspected case
protective factors for ovarian cancer: (4)
removal of ovaries, use of OCPs for >5 yrs, lactation, multiple pregnancies
increased rx: nulliparity, early menarche/late menopause, decreased fertility, delayed childbearing, family history, mutation
common presentation includes cryptorchidism or small testes, learning disabilities, delayed pubertal development, signs of androgen deficiency (gynecomastia), infertility in a patient who is tall with disproportionate leg-arm length
Klinefelter caused by XXY genotype
sx caused by lack of testosterone production due to fibrotic semniferous tubules and leydig cells
first step in tx of diabetic ketoacidosis??
first step is volume repletion with isotonic fluids , followed closely by IV insulin and electroylte correction
??? can occur in patients taking long term corticosteroids after they stop and/or have a physiologic stressor such as surgery, trauam, or infection
sx include altered mental status, tachycardia, abnormal vasodilation
**adrenal crisis
treatment is administration of IV corticosteroids
?? should be done after consumption of drain cleaners (alkali solution)
Esophogoscopy - in order to evaluate damage
*gastric lavage, ipecac, charcoal all not recommended
patients with multiple myeloma are sensitive to which infections??
encapsulated organisims: strep pneumo, h flu, neisseria meng, Salmonella typhi, klebsiella pneumo, and group B strep
which toxicity can occur from benzotropine administration with antipsychotics
anticholinergic toxicity - seadation, delirium, dry mouth, urinary retention, constipation
**benzotropine antagonizes muscarinic ACh rc
tx for empyema / complicated parapneumonic effusion
placement of chest tube (thoracostomy) + antibiotic administration
Randomized control trial with a large number of patients with a specific disease (∼ 100–1000)
which phase of clinical trial ??
phase 3
what is the test for oral herpes (presents with vesicular eruption of the posterior oropharynx and mouth + cervical lymphadenopathy)
PCR of sample from unroofed vessicle
?? can cause ipsilateral hearing loss and positional dizziness, and if compressing the trigeminal nerve can lead to facial numbness and paresthesia
acoustic neuroma
cultures are imperfectly sensitive for gonococcal septic arthritis (no organisms visible on gram stain either becase N. gonorrhoeae is an intracellular organism). Diagnosis should be made by strong clinical suspicion. Treatment is for how long??
1-2 weeks of IV ceftriaxone and oral azithromycin; need IV treatment for 1-2 weeks
??? is the most common supraventricular tachycardia and is often provoked by alcohol, caffeine, exertion, stress or sympathomimetic medications. Characterized by regular rythm along with abrupt onset and termination
AV nodal reentrant tachy
Valsalva maneuver does what for hypertrophic cardiomyopathy
murmur becomes louder
valsalva = decreased preload and increased afterload; worsens LVOT
what can reduce the risk of aspiration in a stroke patient with dysarthria
thickened liquids
when does a small pleural effusion not require any work-up
asymptomatic + a known cause
also no SOB, tachypnea, or chest pain
an example is a small pleural effusion after a treated pneumonia - no further work-up needed
**if the cause is unknown, pursue thoracentesis
antimitochondrial antibody is specific for which disorder?
primary biliary cholangitis/cirrhosis
lymphocytic infiltratios in portal tracts and bile ducts
?? is first line therapy for primary biliary cirrhosis/cholangitis
Ursodiol (ursodeoxycholic acid) - inhibits cholesterol secretion into bile = improvese biliary excretion
used to treat biliary colic, primary biliary cirrhosis, and intrahepatic cholestasis of pregnancy
(ex. 16 day old) infant with jaundice + preponderance of conjugated bilirubin (direct) is indicated of ???
biliary atresia
**use abdominal US to look for irregular gallbladder
tx is with surgery : hepatoportoenterostomy
patients with symptomatic postpartum thyroiditis can be treated with ??
oral b-blocker such as metoprolol or propanolol
what to do for a patient’s large firm, and irregulary shaped breast mass ??
mammography AND breast biopsy
macrosomia is defined as fetal weight > ???
if hx of macrosomia, what is the management ?
4000g
women should be followed in the postpartum period for development of DM with fasting serum glucose
marcosomia means maternal hyperglycemia/gestational DM most likely
what is the treatment for cardiogenic shock ??? (3)
positive inotrope
dobutamine, NE, or dopamine (at middle doses it works on B1 rc)
NE with combo of dobutamine is most commonly used
PPV and NPV vary with ??
disease prevalence
third trimester vaginal bleeding that is painless suggests???
how to diagnose ??
placenta previa
**need to use pelvic US
**also if found, C-Section is indicated
digital exam is not recommended due to disruption of placental bed
?? (2) is used to treat Clostridioides difficile infection in most patients, including those with nonsevere or severe disease.
Oral fidaxomicin or vancomycin
in fulminant Cdif add metronidazole
Severe acute pancreatitis (SAP) occurs in 15%-25% of patients with acute pancreatitis and causes failure of ≥1 organ systems lasting >48 hours. Predictors of SAP include signs of the systemic inflammatory response syndrome and evidence of ??? Patients with SAP have increased risk of morbidity and mortality and usually require intensive monitoring.
(eg, elevated blood urea nitrogen or hematocrit) of intravascular volume depletion.
for which procedures do patients with splenectomy require prophylactic antibiotics
procedures of the respiratory or paranasal sinuses because of colonization with encapsulated bugs
Patients with left-sided adenomas or adenocarcinomas detected on sigmoidoscopy have increased risk for ??
synchronous neoplasia on the right side and require visualization of the entire colon with colonoscopy
what is the management of asymptomatic sliding hiatal hernia ?
just observation
those with GERD should be managed medically
those with refractory GERD can be considered for Nissen fundoplication
when to iniate feeding in burn patient and which form of feeding?
Enteral nutrition is the optimal form of nutrition for patients with moderate to severe burn injuries. Early initiation helps offset the hypermetabolic response after burns and has multiple clinical benefits (eg, maintenance of gut integrity, reduced rate of sepsis, decreased mortality).
**ideally done within 24 hours
pooling of blood in anterior chamber of the eye is ??
caused by trauma
increased risk for??
hyphema
increased rx for gluacoma, corneal blood staining, and rebleeding
usually managed with topical agents
what are the signs of Felty syndrome in RA ??
what is the tx ?
new-onsent splenomegaly and neutropenia (+ infections and fever)
**rituximab - CD20 inhibitor is treatment of choice
increases rx of non-Hodgkin Lymphoma
Pyogenic liver abscess typically presents with fevers, right upper quadrant pain, leukocytosis, and altered liver function tests. It can result from direct spread from the biliary tract or from hematogenous seeding of distal infection, particularly those involving the portal system (eg, diverticulitis). Diagnosis requires abdominal imaging, and management includes blood cultures, antibiotics, and
aspiration + drainage
who should receive endocarditis prophylaxis for dental procedure (3)
Only if : unrepaired congenital cyanotic heart disease, prior hx of endocarditis, or those with prosthetic valves
what imaging for suspected gallstone pancreatitis (elevated LFTs and amylase/lipase)
first RUQ US, then ERCP if nondiagnostic US
long tern management of gallstone pancreatitis
Early cholecystectomy is recommended for medically stable patients who recover from acute pancreatitis and are surgical candidates. Cholecystectomy can markedly reduce the risk of recurrent gallstone pancreatitis.
imaging for suspected appendicitis ??
CT of abdomen and pelvis
US +/- MRI for pregnant patients
Perforated appendicitis management (2 options)
Treat with antibiotics and either percutaneous drainage (for stable patients with a contained RLQ abscess [ie, contained perforation]) or emergency appendectomy (for patients with diffuse intraabdominal contamination [ie, free perforation]).
conservative management for SBO (no fever, hemodynamic instability, gaurding, leukocytosis, or significant metabolic acidosis (low bicarb)
bowel rest, NG tube suction, and fluids
if progression at all, procedue with ex lap
??? is an uncommon but life-threatening complication of hematologic malignancy, infection, and systemic inflammatory disease, and anticoagulation increases the risk. Examination may reveal hemodynamic instability, diffuse abdominal pain, and signs of peritonitis (eg, rebound, guarding). On occasion, pain may be referred from the diaphragm and phrenic nerve to the left shoulder (Kehr sign). Focused abdominal ultrasound or CT scan demonstrates free intraperitoneal fluid.
Atraumatic splenic rupture
Splenectomy is the management of choice in hemodynamically unstable patients, although catheter-based angioembolization may be attempted in stable patients.
patients commonly present with ispilsateral cranial nerve dysfunction, contralateral hemiparesiss, and contralateral impairment in pain and temp sensation
**sx occur with neck movement
vertebral artery stenosis
if high suspicion for PE what imaging
first chest-xray, but diagnosis is commonly made via CT angiography (spiral CT scan)
cirrhosis causes excessive production of prostoglandins leading to release of what and which electrolyte abnormality??
prostoglandin stimulate release of ADH and cause hyponatremia
treatment of hep C includes treatment with ??/
combo antiretroviral therapy
ledipasvir-sofosbuvir or glecaprevir-pibrentasvir
most important recommendation for minimizing progression of liver disease in patient with hepatitis (C)
alcohol abstinence
scrotal pain + abdominal distension points to ??
incarcerated inguinal hernia
*indication for surgery
how can an Rh negative mother develop Rh isoimmunization in first pregnancy
via early term vaginal bleeding or amniocentesis
RhoGAM binds to RhD positive cells that enter maternal circulation, preventing the immune system from developing antibodies
RhoGAM is ineffective however in a patient that already developed Rh antibodies (fetus at risk for hydrops fetalis and death)
complication of amniocentesis/increases risk for ???
premature rupture of membraines
others include: fetal injury, maternal/fetal infection, and fetal demise
adults with DM1 are at increased rx of CAD - cardiomyopathy, atherosclerotic changes, and ????
dyslipidemia - thus should be screened annually if lipids are abnormal or DM is poorly controlled
what to administer to patient with elevated LFTs + altered mental status, bilateral nystagmus, ataxia/broad-based gait
thiamine
sx likely due to chronic alcohol abuse
cellulitis is most commonly caused by staph aureus and group ?? strep
group A (strep pyogenes)
Acute or chronic liver injury can lead to ????. This is usually multifocal and occurs most commonly in the setting of cirrhosis.
nodular regeneration
?? is a rare complication of umbilical artery catherization in infants and can present up to several weeks after catheter has been removed. Presents with HTN in infant
renal artery thrombosis
tx is systemic anticoag + fluids, surgery if refractory
which pharm can be used for irritable bowel syndrome (3)
loperamide - antidiarrheal
dicyclomine - antispasmodic
diphenoxylate - slows gut motility
Chest x-ray may show leaked fluid collecting in the mediastinum (mediastinal widening) or pleural space (pleural effusion). Pleural fluid analysis may show low pH and very high amylase (>2500 IU/L). Confirmation with esophagography or CT scan using water-soluble contrast should prompt emergent surgical consultation.
esophageal rupture
Recurrent, episodic pain in the right upper quadrant or epigastric region, with corresponding aminotransferase and alkaline phosphatase elevations, is common; visualization of a dilated common bile duct in the absence of stones increases the likelihood of ???
occurs in postcholecystectomy patients
Sphincter of Oddi dysfunction is a functional biliary disorder due to dyskinesia or stenosis of the sphincter of Oddi.
Sphincter of Oddi manometry is the gold standard for the diagnosis of SOD; sphincterotomy is the treatment of choice in most cases.
patient has turbid green drainage (gastrointestinal contents) into his chest tube following blunt chest trauma, most consistent with ???
esophageal perforation (EP).
??? should be suspected in patients with multiple duodenal ulcers refractory to treatment or ulcers distal to the duodenum or associated with chronic diarrhea. In these patients, inactivation of pancreatic enzymes by increased production of stomach acid may lead to malabsorption.
Zollinger-Ellison syndrome
Uncontrolled gastrin secretion leads to parietal cell hyperplasia, with excessive production of gastric acid. Multiple duodenal (and sometimes jejunal) ulcers are typical, and the ulcers can be refractory to standard acid-reducing medications. The excess gastric acid in the small intestine can cause diarrhea and steatorrhea due to inactivation of pancreatic enzymes and injury to the mucosal brush border.
??? is a prospective, systematic, team-based approach that consists of identifying steps in a process and finding solutions to any problems that may arise, with the goal of ensuring safe outcomes. It can be performed before any problems are identified.
Failure mode and effects analysis (FMEA)
recommendations for lung cancer screening???
age 50-80 yearly low dose CT scan IF:
current smoker/quit smoking <15 years ago
or
>20 pack year smoking history
**no screening if quit for more than 15 years
Falls are a major source of injury in older patients. In addition to primary prevention strategies (eg, supervised exercise, home safety assessment), patients at high risk for falls should be screened how ? (5)
Screening: musculoskeletal (eg, “get up & go” test*), vision, hearing, bone density, orthostasis
Elderly patients are vulnerable to both overprescribing and underprescribing of medications and have increased susceptibility to adverse drug events. Clinicians should tailor therapeutic decisions to each patient’s individual context, considering factors such the medication’s ?? and absolute treatment effects and the patient’s health status (eg, life expectancy) and goals of care.
time to benefit
A ?? is a quality improvement tool that graphs a process performance outcome (eg, no-show rate) over time (eg, before and after a quality improvement intervention). they allow visualization of trends (≥5 consecutive points with consistent directional change) and systematically determines effectiveness of a quality improvement intervention.
run chart
??? represent the most effective intervention to improve sign-out safety.
Standardized sign-out templates
Fall risk is multifactorial; therefore, fall prevention is best achieved using an individualized approach in which staff determine prevention strategies based on the patient’s ??? rather than a summary risk score.
individual risk factors
Valid informed consent for nonurgent treatment requires intact capacity. When the patient’s decision-making capacity is impaired by reversible factors (eg, acute psychosis), it should be restored by treating the underlying cause how ??
in this case of acute psychosis, administer antipsychotics and defer request for now
Low health literacy is associated with worse health outcomes and underuse of recommended care like ???. Signs may be subtle, but clinical clues include having a poor understanding of health conditions, not remembering medications, and asking to take forms home to review with family.
frequently missed appointments
lung transplant recipient with progressive dyspnea, an obstructive pattern (ie, FEV1/FVC <70%) on pulmonary function testing (PFT), and no evidence of infection (eg, no fever, chest x-ray abnormalities, or organisms on bronchoalveolar lavage) likely has ???
bronchiolitis obliterans, the major manifestation of chronic lung transplant rejection
*acute rejection occurs <6 months and tx with high dose glucocorticoids
what are an example of a environmental design intervention
Misreading look-alike drug vials is a leading cause of medication error in operative settings. Human factors engineering strategies can prevent such errors by designing systems that decrease human effort and facilitate correct action. Examples include environmental design changes separating look-alike medications, standardizing and simplifying processes, and using visual cues.
Errors in medication reconciliation (ie, the process of reviewing and updating the current medication regimen) occur frequently during the transfer of care. Prevention includes ?
independent review by multiple care team members, interprofessional review (eg, physicians, nurses, pharmacists), and updated review prior to medication orders.
Physicians are ethically obligated to report suspected physician impairment to protect patient safety. ??? are organizations designated to investigate reported concerns and arrange for comprehensive assessment and treatment if necessary.
Physician Health Programs
PHPs are confidential resources that provide extensive support and expert education and monitoring. If intervention is required, the PHP can assist the physician in getting necessary treatment.
Provision of data-driven feedback on physicians’ individual clinical performance (eg, rate of cesarean delivery) compared to peer performance or recognized benchmarks is effective in improving quality of care (eg, reducing unnecessary cesarean delivery).
true or false?
true
Female undergoing epidural analgesia for delivery : Patients have an exaggerated ascending paralysis with upper extremity weakness (eg, C5-C7 blockade) and respiratory paralysis due to blockade of the diaphragm (eg, C3-C5)
High spinal or total spinal anesthesia can occur if the epidural catheter accidentally punctures the dura and anesthetic enters the subarachnoid (ie, intrathecal) space
female under-going epidural anesthesia for delivery: When the anesthetic is absorbed into the maternal circulation, it initially blocks inhibitory neural pathways to cause CNS overactivity (eg, perioral numbness, tinnitus), potentially followed by seizure. In addition, patients often develop increased cardiovascular sympathetic activity (eg, hypertension, tachycardia), followed by cardiovascular collapse.
Local anesthetic system toxicity can rarely occur with epidural analgesia (eg, bupivacaine).
Hypotension, a common adverse effect of epidural analgesia, is caused how ??
blockage of L5 sympathetic fibers decrease lower extremity vascular tone. This causes vasodilation and venous pooling, which decreases right heart venous return, diminishes cardiac output, and often causes symptomatic hypotension (eg, light-headedness). Compensatory tachycardia develops in response to the decreased cardiac output.
Patients with prolonged or profound maternal hypotension from epidural anesthesia prior to delivery can have decreased uteroplacental perfusion, resulting in late fetal decelerations. Treatment includes ???
maternal position change (left uterine displacement) to improve venous return, intravenous fluid bolus, and/or vasopressor administration (eg, phenylephrine, ephedrine).
A ??? study is an observational study in which groups are chosen based upon presence or absence of one or more risk factors. All subjects are observed over time for development of the disease of interest, allowing for estimation of incidence within the total population and comparison of incidences between groups.
cohort
In ecological studies, the unit of observation is a population. Disease rates and exposures are measured in 2 (or more) populations, and the association between disease rates and exposures is determined. However, results about associations at the population level may not translate to the individual level. Ecological studies cannot be used to determine ???
incidence
Loss to follow-up in prospective studies creates a potential for attrition bias, a subtype of ??? bias. When a substantial number of subjects are lost to follow-up, the study may overestimate or underestimate the association between the exposure and the disease. Investigators try to achieve high rates of follow-up to reduce the potential for attrition bias
selection
The odds ratio (OR) is a measure of association in case-control studies to compare the odds of exposure in cases relative to controls. The OR is not a direct measure of ???.
risk
The fishbone diagram (cause-and-effect diagram) is often used in root-causes analysis to ??? leading to a quality-of-care problem. Its main components include the problem being analyzed, main categories influencing the problem, and the specific sub-causes pertaining to each category
visually organize the categories and causes of errors
Hospital readmissions are used as a quality metric because they are often preventable through improved patient communication and follow-up. ??? after discharge reduces readmissions rates by preventing loss to follow-up, increasing patient engagement (proactively identifying and addressing potentially serious concerns) and care coordination (effective transition between inpatient and outpatient care).
Telephone-based outreach shortly
principles for medication prescribing in eldery (5)
- Limit the number of prescribers
- Review criteria for geriatric populations (eg, Beers,* START**)
- Consider time to benefit for drug
- Tailor regimen to the patient’s goals & life expectancy
- Frequently reassess appropriateness of medication
strategies to decrease fall risk inpatient
- Assess fall risk & customize strategies to patient’s specific risk factors
- Optimize environment (eg, minimize furniture, lower the bed, place in direct view of nurses if high risk)
- Perform frequent checks on high-risk patients
- Avoid restraints & overreliance on fall alert systems
Hospitalized patients who have infections caused by multidrug-resistant gram-negative organisms (eg, extended-spectrum beta-lactamase–producing Klebsiella pneumoniae) require contact precautions for the duration of their hospital stays. Contact precautions include ???
use of gowns and gloves when interacting with the patient and single-use equipment (eg, stethoscope).
metabolic acidosis + optic neuritis / vision symptoms
most likely which cause ???
methanol toxicity
is a type of reflex syncope typically preceded by a trigger (eg, strong emotion) and a prodrome (eg, pallor, light-headedness).
Vasovagal syncope
A neurally mediated reflex response (cardioinhibitory and vasodepressor) leads to brief (eg, <1-2 min) loss of consciousness, followed by rapid and complete recovery
patient with dementia has acute urinary incontinence (UI). what is the first step in workup
UA and culture
Acute urinary incontinence in elderly patients may have atypical presentations. Consider reversible etiologies first, especially if new onset (remember: DIAPPERS). Fever may not present with urinary tract infections limited to the lower urinary tract. Initial evaluation should include urinalysis with culture.
review murmurs
The risk for Clostridioides difficile infection is high in hospital settings and is increased for patients placed in rooms formerly occupied by infected patients. Infection-control measures include implementing ?? and strict adherence to hand hygiene and contact isolation precautions (use of gowns and gloves in patient rooms).
uniform cleaning and disinfection procedures to be performed by a dedicated team
patient visited East Asia and developed symptoms consistent with melioidosis, an uncommon infection caused by the facultative intracellular gram-negative bacilli ????. This organism is endemic to Thailand, Malaysia, Singapore, and Northern Australia and is transmitted primarily when contaminated soil or water gets inoculated in subcutaneous tissue. Severe disease is rare in healthy individuals, but those with diabetes mellitus, excessive alcohol use, or chronic lung/kidney disease are at higher risk of fulminant infection.
The following manifestations may occur:
- Pneumonia is the most common manifestation and usually presents with high fever, cough, rigors, respiratory distress, and (sometimes) shock. Chest imaging typically shows bilateral opacities.
- Skin ulcers/abscesses occur in approximately 25% of cases and frequently appear as purple-colored lesions.
- Organ abscesses in the kidney, prostate, spleen, and liver occur in a minority of cases. This patient’s abdominal pain and hyperechoic, septate masses suggest liver and spleen abscesses.
Burkholderia pseudomallei
Capnography is the measurement ofcarbon dioxide concentration over time. It can provide valuable information about ventilation/perfusion and metabolic status and is the most reliable method for verifying endotracheal tube (ETT) placement. Patients with abnormal waveforms should be assessed for ???
proper ETT placement.
uncomplicated parpneumonic effusion vs. complicated vs. empyema
uncomplicated vs. complicated : pH >7.2 (lower is complicated)
Empyema: pH >7.2 and LDH >1000 and positive gram stain and culture
sensorineural hearing loss and sytemic findings of hepatosplenomegaly and growth restriction point toward ???
rubella
(also cataracts + heart defects)
??? is a nonprogressive motor dysfunction (eg, hypertonia, hyperreflexia, seizures) that most commonly occurs in premature infants due to periventricular leukomalacia and intraventricular hemorrhage.
Cerebral palsy
Trigeminal neuralgia is characterized by episodic severe pain in the dermatome supplied by the trigeminal nerve (CN V). what is the work-up for someone presenting with symptoms ???
MRI with MR angiography should be obtained to evaluate for vascular or mass lesions that may be compressing the CN V root.
???? or (X-linked hyper-IgM syndrome) presents in infancy with recurrent sinopulmonary infections and is characterized by low IgG and elevated IgM due to defective class-switch recombination. This patient’s low IgM makes this diagnosis unlikely.
CD40 ligand deficiency
which bone finding ???
ewing sarcoma - onion skinning
2nd most common primary bone malignancy (typically adolescents)
Spiral fractures of the distal tibia can be seen in ambulatory children age ≤3 and are known as toddler’s fractures. workup??
no additional workup except for x-ray; treatment is immobilization + pain control
normal fracture in children
Defensive medicine refers to clinical services that are intended primarily to reduce physician liability without providing significant benefit to the patient. ??? can minimize physician liability and reduce defensive medicine.
Implementing evidence-based clinical pathways or practice guidelines
Adherence to recommended hand hygiene protocols remains low in most hospital settings. Suboptimal adherence that persists despite recommended systems changes (eg, increasing the number of hand hygiene stations) suggests the need to improve ??
organizational culture and individual accountability.
n elderly patients with end-stage renal disease, especially those with advanced comorbidities and functional decline, chronic dialysis does not significantly extend life expectancy when compared to conservative kidney care; it is associated with increased hospitalizations and diminished quality of life. These factors should be discussed prior to initiation of dialysis.
what does conservative care involve??
In this option, diet (eg, low sodium, low potassium, relatively low protein to minimize acid accumulation) and medications (eg, phosphate binder, erythropoiesis-stimulating agents) are used to ameliorate volume, electrolyte, and acid/base disturbances, as well as anemia and hypertension. Symptoms of fatigue, nausea, and pain associated with ESRD are also addressed. When patients elect to not initiate dialysis, the average life expectancy while on conservative kidney care is 6 months to 2 years.
Physicians can approach difficult conversations about prognosis and express empathy to patients using a ??? framework . Physicians should clarify patient priorities, avoid promoting false hope, and offer constructive suggestions to help patients reframe their goals in more attainable, realistic ways.
“wish…worry”
eg, “I wish you could stay alive much longer, but I worry you may not”
what are the 3 tenants of Cross-cultural care
- Patient-centeredness: identifying the patient’s values and aligning care with the patient’s priorities
- Cultural sensitivity: exploring the patient’s cultural beliefs and understanding how sociocultural background influences perceptions of health decisions
- Enhanced communication: addressing language barriers (eg, use of interpreter services) and tailoring communication styles (eg, adjusting eye contact, addressing family) to a patient’s preferences
what are the 4 types of quality improvement processes
lean, six sigma, change management, model for improvemet (Plan-Do-Study-Act)
postmenopausal women are at greatest increase risk of ?? following menopausal transition
cardiovascular disease
treatment of pneumothorax vs. hemothorax
pneumothorax recquires Tube thoracostomy
both require tube placement
vs. a large >1500ml drainage of a hemothorax requires thoracostomy (large incision in lung space)
contraindications for surgical resection of pancreatic cancer
metastases or vascular encasement
how to determine death in a premature newborn ??
reflexes are not fully developed
apnea test - rise in CO2 as ventilator is weaned or no spontaneous respirations
**can also use EEG but not commonly used
primary immunodeficiency with low serum levels of all immunoglobulins despite phenotypically normal B cells
Common variable immunodeficiency (CVID)
- B cells are phenotypically normal but are unable to differentiate into Ig-producing cells, resulting in low immunoglobulins of all classes.
- Quantitative immunoglobulin levels: low levels of IgG, IgA, and IgM
- Decreased number of plasma cells
- Flow cytometry shows subsets of normal B and T cells
post surgical patient recieves promethazine, hydromorphine, and enoxaparin
presents with altered mental status, pupil 3mm, and respiratory rate of 6/min
what is the cause??
opioid toxicity/overdose
*order ABG
??? is recommended for moderate to severe COPD symptoms/at risk for exacerbations and hospitilization & O2 sat >88%
pulmonary rehabilitation - improve symptoms and reduce hospital readmissions
severe headache w/hypertension and CT head is negative, what is the next step ???
with high suspicion of subarachnoid hemorrhage –> emergent lumbar puncture for CSF analysis - shows xanthrochromia, increased opening pressure, and increased RBCs
ovarion tumor that causes precocious puberty in a female (before the age of 8, there are changes in axillary and pubic hair development and sexual maturity rating)
what is the management
surgical removal – oophorectomy
*no need for FNA
what is the treatment of tinea capitis ??
**ORAL antifungals - griseofulvin or terbinafine
?? present raised nodule with central ulceration and waxy border
??? spread where
basal cell carcinoma
**typically spreads locally; does not metastasize
treatment of slipped capital femoral epiphysis
**surgical internal fixation with pinning of the femoral head
*salter-harris type 1 fracture of the growth plate
multiple sleep latency tests for narcolepsy show ???
shorter time from wakefulness to the initiation of REM sleep
?? is used to confirm the diagnosis of myasthenia gravis
nerve conduction studies with repetitive stimulation
ABG on PE shows ???
acute respiratory alkalosis, hypoxemia, and increased A-a gradient caused by ventilation -perfusion mismatch
*also syncope can occur; also OCP’s was the association in this case, look out for OCP as a risk factor
how is multiple myeloma diagnosed/confirmed (blood smear often shows RBC aggregation in a rouleaux formation)
bone marrow biopsy
which vaccinations are recommended for men who have sex with men (MSM)
hep A and hep B
facial swelling, erythema, and edema at the angle of the jaw w/fever raise suspicion for
typically older patient; rx eldery, dehydration, poor dentition, lack of salivary flow
acute suppurative parotitis
imaging with US or CT is best to evaluate
?? appears shortly after or during transfusion with isolated fever and possible rigors/chills
tx?
febrile nonhemolytic transfusion rx - release of cytokines from leukocytes during blood product storage
Tx: stop transfusion and treat the fever with Acetominophen
??? is caused by abnormal fibrovascular proliferation and is characterized by the triad of digital clubbing, periostosis, and severe arthralgia
usually 2/2 to lung malignancy, or primary cardiac, gastrointestinal, or hepatic disease
hypertrophic osteoarthropathy
diabetic patient has overflow incontinence, infrequent urination with incomplete bladder empting, and a weakened urinary stream
what is the cause ?
neurogenic bladder
interstitial disease can be confirmed with CT imaging showing interstitial fibrosis
definitive diagnosis requires ???
lung biopsy to determine underlying cause
pulsatile mass in the groin - frequently associated with PAD; can cause acute limb ischemia, rupture, or distal embolism
femoral artery aneurysm
**duplex US or CT angio is test of choice
treatment for allergic rhinitis - rhinorrea, sneezing, nasal congestion, “cobblestoning” or posterior pharynx and upper eyelids
second generation antihisamine (loratidine) and a glucocorticoid NASAL SPRAY (not prednisone)
age related macular degeneration initially presents with lines that appear curved/wavy
how is diagnosis established ??
dilated fundoscopic exam
*age is greatest rx factor , also smoking and genetics
what is the indication for a fine needle aspiration of a thyroid nodule
first do TSH and US
if the TSH is normal or increased, patient has rx factors for thyroid malignancy, or nodule has concerning features on US
??? is recommended if TSH is low in the setting of a thyroid nodule
iodine scintigraphy/radioactive iodine uptake scan
looking for signs of hyperfunctioning nodule, which are rarely malignant (no need for FNA, which is needed for elevated/normal TSH)
which is the confirmatory test for osteomyelitis ???
bone biopsy and wound culture
while x-ray may be the initial test, it can often miss cases of acute osteomyelitis; it is better at showing chronic changes
opsoclonus means ???
opsoclonus myoclonus syndrome is associated with ???
opsoclonus = rapid, arrythmic multivectorial ocular saccades
**often associated with neuroblastomas (most common tumor of the adrenal glands in children)
is antibiotic prophylaxis recommended for aplenia / spleen removal??
yes for **under age 5; prophylactic penicillin or amoxicillin
Daily antibiotic prophylaxis: oral penicillin or amoxicillin administration in asplenic children up to at least 5 years of age and at least one year after splenectomy
? is the most common cause of primary amenhorrhea - no mensturation in a 16 y.o female. Labs show elevated LH and FSH as a result of negative feedback. Also absence of secondary sexual characteristics
Turner Syndrome, diagnosed via karyotype analysis, XO
results in ovarian dysgenesis
?? is characterized by acute onset of pruritic patch followed by numerous smaller macules and patches in the setting of a recent viral illness
**patches are oval in shape and have a rim
pityriasis rosea
self resolves in 6-8wks, can be treated symptomatically with topical corticosteroids
**characteristic herald patch starts it all
untreated preecclampsia increases the risk of ?? during labor
placental abruption
this can occur during TPN; lab findings show dispraportionate rise in bilirubin and Alk Phoph in comparison to AST and ALT
Patient also has jaundice
cholestatic hepatic disease
managment is discontinuation of TPN and initiation of enteral feeding
biliary motility is stimulated by oral intake and gastric motility
patient has ascites, peritoneal fluid is collected
what tells you the patient has SBP even if there are no systemic signs of infection
total leukocyte count > 1000 OR neutrophils > 250
**third-generation cephalosporins are considered first line
hemolytic disease of the newborn typically effects the newborn (vs. Rh isoimmunization effecting the fetus) and is often caused by IgG against blood antigens crossing the placenta
which blood type is most common?
maternal blood type O; antibodies against A and B cross placenta
patients with preterm premature rupture of membranes (PPROM) are at incrased risk of preterm delivery; thus mothers are treated with ??
betamethasone (corticosteroids) to accelerate fetal lung maturity
differentiating pneumonia from acute chest syndrome is very difficult in sickel cell patients
x-ray findings show segmental consolidation or pleural effusion
thus, in patients who present with fever or acute chest syndrome what work-up is important ??
blood cultures and starting of empiric antibiotic therapy (due to asplenia in most cases)
+ analgesia and fluids
treatment of entamoeba histolytica liver abscess
immediete initiation of metronidazole or tinidazole + a luminal agent such as paromycin or iodoquiniol
**surgical drainage/aspiration are not necessary
can discontinue other empiric antibiotics like amp + gent
?? can lead to development of a colovesicul fistula in an older patient without a history of inflammatory bowel disease
diverticular disease
patients with chronic RA should be evaluated with what test prior to surgery that may require intubation
cervical spine X-ray to check for atlanto-axial instability
management of seborrheic keratosis
**benign and it needs to work-up
if there are sudden, numerous lesions on back and trunk, this is Leser-Trelat sign and can be a paraneoplastic manifestation of GI malignancy
sciatica (often caused by lumbar disc herniation) - is diagnosed clinically (via straight leg tests) - what is the management of mild to moderate pain ?
no imaging/testing – > analagesia and physical therapy/activity
CT or MRI only needed if severe motor or sensory dysfunction
patient with SLE on prednisone is admitted for sespsis - blood pressure does not improve with antibiotics and fluids
what is the next step ??
hypotension and tachycardia is likely 2/2 to adrenal insufficiency from chronic prednisone use
**tx is hydrocortisone
in setting of cardiogenic shock (tachycardia, borderline hypotension, cool extremeties, and pulmonary/venous congestion), what imaging is indicated ??
ECHO
?? defect is characterized by a holosytolic murmur best heard at the lower left sternal border
untreated/severe cases can result in Eisenmenger syndrome (fatigue with feeding, sweating with feeding, hepatomegaly)
VSD
for moderate adjustments in pain for cancer patients what is the next step ??
breakthrough pain can be treated by increasing the scheduled dose by 25-50%
patients with uncontrolled pain on high oral doses can benefit from transdermal patches or IV administration
one of the most effective strategies for minimizing dust exposure for allergy-induced asthma
allergen-impermeable mattress and pillow covers
can BPH present with acute symptoms ??
yes; bladder outlet obstruction predisposes to cystitis, hydronephrosis, or pyelonephritis which may be the presenting feature
also can present in middle-age to elderly men
corpus luteum develops from mature follicle after egg has ovulated during the menstrual cycle – in some instances corpus luteum can form a cyst (can be hemorrhagic) - if asymptomatic what is the tx ?
surveillance and monitoring; repeat transvaginal US in 6 weeks
in the case it ruptures - unilateral pelvic pain that is severe, can be removed surgically. But not until it causes severe symptoms
DM or childhood or adolescent obesity are a significant risk factor for ???
coronary artery disease
what is the next best step for a patient with altered mental status after a high speed blunt traumatic injury ??
CT scan of the head and neck
*even in pregnant patients , this is the first step
emergency splenectomy requires admin of which vaccinations, even if received in childhood ?
S. pneumoniae vaccines
Meningococcal quadrivalent vaccine → once after 2 weeks and then every 5 years
Hib vaccine → once after 2 weeks
Annual inactivated influenza vaccination
vesicourteral reflux which is diagnosed by voiding cystourethrography in children are managed how ??
for children with >1 UTI, with oral antibiotic prophylaxis
this is first step; if reccurent UTIs after prophylaxis, then surgery is indicated
for patients with adenomas or sessile polyps with dysplasia or tubublovillous histo, colonoscopy should be repeated ???
in 3 years
if >10 adenomas - 1 year
when to initiate statin in a routine exam patient (not hospital setting)
if LDL-cholesterol is >190 or if 10 year CAD risk is >10%
management of ARDS (signs of hypoxemia and diffuse pulmonary infiltrates)
intubation and mechanical ventilation
what is the US finding in mitterlschmerz
pain can mimic appendicitis or ovarian torsion
**first of all vital signs are normal
US shows small amount of free fluid in pelvis secondary to follicular rupture
decubitus or pressure ulcers can develop from limb prosthetics, management is ??
refitting of the prosthetic socket
**only a significant burden of necrotic tissue may benefit from surgical debridement
wound management for infected or traumatic wounds (ex. abdominal resection from gunshot)
delayed primary closure - leaving the wound open allows underlying tissues to drain
often with the addition of negative pressure
two EKG findings of pericarditis (substernal chest pain, pleuritic, worse when lying down, improves when leaning forward)
subsequent imaging and treatment ???
difusse ST segment elevation and PR segment depression
ECHO - assess for pericardial effusion and need for pericardiocentesis
Treatment is anti-inflammatory medications - indomethacin, glucocorticoids, and/or colchicine
diabetic ketoacidosis in DM1 causes what level of glucagon and catecholamines ??
increased glucagon and catecholamines
both are lipogenic and liberate lipids for metabolism to ketones in acute stress
what is the management of a patient with SLE who is showing signs of lupus nephritis ?
renal biopsy is needed to determine extent of disease
active diffuse or focal proliferative lupus require immunosuppressive therapy
mild mesangial or mesangial proliferation do not
what can be used to decrease airway secretions in patients who are in the process of dying
anticholinergics: glycopyrrolate or scopalamine
nonpharm: suction, position patient on side, reduce IV fluids
?? refers to onset of dispraportionate distress within ?? months of an identifiable stress and may be associated with anxiety, MDD, or conduct disturbances but no not meet full diagnostic criteria for these disorders
example here is sx after an MI
adjustment disorder, within 3 months
vs. PTSD, which is >1 month has sx of intrusive thoughts, memories of trauma, hyperarousal, negative mood
parathyroid may be removed from thyroidectomy procedure
what lab results ???
low PTH, leading to hypocalcemia (perioral paresthesia, carpopedal spasm, Chvostken + Trousseau signs), and increase in urinary calcium (low PTH prevents renal reabsorption of calcium)
what to do in setting of drug-induced neutropenia ??
ex. from TMP-SMX
withdrawal of the drug but then just repeat exam in 1 week with CBC
most cases will resolve in 1 week
no need for GCSF or prednisone
what is one type of acute renal injury that requires discontinuation of medication ?
acute interstitial nephritis
requires stopping of offending agent (often antibiotic)
US will show WBC in urine + Eosinophils, but no casts, maybe some RBCs and Protein
eosinophils in urine + acute renal injury is suggestive of ???
acute interstitial nephritis
often caused by acute hypersensitivity reaction to medications: NSAIDS, diuretics, sulfonamides, rifampin, PPI, antibiotics)
what acute disorder can be caused by valproate acid ?
drug-induced actue pancreatitis
patients with congenital uterine anomalies are at risk of what pregnancy complications ?
preterm delivery, fetal growth restriction, and malpresentation
patient with high-risk breast mass has negative mammography and FNA, what is the next step ??
excisional biopsy
FNA only has a sensitivity of 74%
how to calculate attributable risk (given RR) - what percent of the disease can be attributed to the exposure ?
RR-1 / RR
ex. ( (4-1)/4)
routine screening for varices with what test ?? is recommended for patients with known liver cirrhosis
EGD (esophogastroduodenscopy)
patient with a hx of BCG vaccine has a 15 mm induration on PPD; what to do next ???
false-positive BCG effect wanes after 5 years; latent TB is considered 15mm OR greater, including 15mm
thus 15mm requires first check of CXR for active TB and if negative, treatment of latent TB with initiation of isoniazid therapy for 9 months
what is the initial management of mild carpal tunnel syndrome ?
wrist splint or use of ergonomic changes at keyboard (wrist pad)
*physical therapy will not treat
??? are primary risk factors for morbidity for in-hospital DVT or PE
age and presence of obstructive shock (RV failure from pressure, compression on LV - altogether results in decreased CO and increased SVR)
pediatric patient has normal labs but persistent HTN, what is the work-up ??
renal US
OSA can occur in children from tonsillar hypertrophy, but does not cause increase in HTN
neonate that develops bilious emesis suspicious for midgut volvulus, what is the diagnostic test ??
upper GI barium series
UC (colonoscopy shows crypt branching and abscesses) is treated initially with ?? to induce remission
then after remission, patients are treated with mesalamine or glucorticoid enemas, progressing to oral mesalamine or oral glucocorticoid
systemic glucocorticoids to induce remission
contact precautions for EBV after monospot positive test ??
none; not very contagious
just avoid sports/contact that can cause splenomegaly
asymptomatic prostate nodule on digital rectal exam, what is the next step ??
protate biopsy
all nodules on DRE, or increases in PSA require biopsy
MRI or transrectal US are useful
?? is a type III HS reaction that occurs due to deposition of immune complexes after exposure to a non-human antigen (anti-venom or anti-toxin). Sx develop 1-2 weeks after exposure and include fever, rash, arthralgia, arthritis
Management is supportive and to stop offending agent
serum sickness
treatment of high grade second-degree and third degree AV blocks require what treatment ?
urgent placement of a pacemaker
even in infants with neonatal lupus AV block
treatment of hyperemesis gravidum involves IV fluids, antiemetics, and supplemental ????
vitamin B6
?? supplementation should be encouraged for exclusively breastfed infants
vitamin D
breastfeeding fulfills the nutritional needs for an infant up to 6 months; after 6 months food should be introduced (rice cereal and pureed meats)
patients with sickle cell anemia and signs of infection should be treated with ???
parenteral (IV) empiric antibioitics - ex. ceftriaxone
who should be screened for abdominal aortic aneurysms
men aged 65-75 who have a hx of tobacco use per USPSTF
painless vaginal bleeding and exam revealing friable, ulcerate, or exophytic lesion on cervix
even in a pregnancy patient
cervical cancer
celiac disease can cause malabsorption of vitamind D, leading to hypocalcemia and secondary ??
osteomalacia - manifests as bone pain and tenderness
sx improve w/gluten-free diet
?? adenocarcinoma can present with painless jaundice
(nontender bladder, no hepatosplenomegaly, no abdominal masses, no rectal mass, no occult blood in stool)
pancreatic adenocarcinoma
serial ??? are important for patients with signs of myocardial contusion after MVC (blunt trauma to the chest)
ECG
myocardial contusion can cause ECG changes
?? meng: CSF shows leukocytes <100; normal/increased protein, and normal glucose
aseptic/VIRAL meningitis
?? meng: CSF shows leukocytes > 1000; increased protein >250, and decreased glucose <40
bacterial
?? meng: CSF shows leukocytes <500, lymphocytes; increased protein >250, and normal/decreased glucose <40
fungal
?? meng: CSF shows leukocytes 5-1000, lymphocytes; increased protein >250, and very low glucose <10
TB
transition to ??? is recommended in patients with prolonged mechanical ventilation, usually 10-14 days
tracheostomy tubes
patient with sickle cell trait has community-acquired pneumonia, what is the treatment ?
For patients without COPD, diabetes, liver or cardiace disease, the first-line is oral azithromycin, doxycycline, or amoxicillin
with comorbidities: amox + clauv or levofloxacin
in constitutional growth delay, what is true of bone age ??
it is less than chronological age
*important thing is that growth is at a consistent velocity (slow)
both pregnant and nonpregnant patients with overt signs of hyperthyroidism should be treated how ??
initially with B-blocker therapy along with antithyroid medication (methimazole, unless first trimester of pregnancy give PTU)
evaluation for new onset exercise intolerance
ECG is normal. What to do next for patient with osteoarthritis ??
adenosine nuclear stress test ; *also for those with abnormal EKGs
**for normal patients, exercise stress test is preferred
tinea versicolor, infection with Malassezia furfur, is treated how ??
topical ketoconazole or selenium sulfide
live MMR vaccine can cause what reaction in some babies ??
transient morbilliform rash, fever, or joint pain due to replication of the viral strain contained in the vaccine
Bony outgrowth (exostosis) with a cartilaginous cap on the surface of long bones adjacent to growth plates
Osteochondroma
vs. chondroblastoma shown here: benign growth near epiphyses of long bones
treatment of central diabetes insipidus (hypernatremia)
administration of desmopressin (ADH analog)
newly diagnosed patients with HIV infection should recieve ???
3-drug antiretroviral therapy from at least 2 different classes
CD4<200 = pneumocystis prophylaxis with TMP-SMX, or atovoquone or dapsone
chronic constipation in a newborn suggests ??
*another common finding is explosive expulsion of feces on rectal examination
What is the workup ???
hirschsprung disease
can be diagnosed with rectal manometry, or rectal suction biopsy
barium enema is also possible but less sensitive
obesity hypoventilation syndrome has what FEV and total lung capacity findings ??
restrictive disease; low FEV1 and low total lung capacity
management of preterm labor at the onset of uterine contractions (4 things)
tocolytic therapy with nifedipine or terbutaline
corticosteroids if <34 weeks to improve fetal lung maturity
magnesium sulfate for <32 weeks for neuroprotection
GBS prophylaxis (penicillin)
?? is a subtype of malignant melanoma that occurs on the fingers and toes of asians + african americans
acral lentiginous melanoma
colonic pseudo-obstruction, usually present in the setting of recent surgery, opiates, trauma, or serious illness is treated how ?
mechanical obstruction excluded via CT abdomen or barium contrast enema
with pro-cholinergic agent neostigmine and colonic decompression
the failure rate of a test is most easily determined from the ??
sensistivity
sensitivity = 1 - false negative rate
false negative rate is the failure rate
intrapartum = onset of birth to delivery of placenta
which sexually transmitted infection requires intrapartum treatment ?
HIV
intrapartum treatment with zidovudine immedietly prior to or during delivery helps reduce vertical transmission in women with HIGH viral load (noncompliant or untreated)
neonates should be given prophylactic antiviral and should be bottle-fed exclusively
??? diet is proven to reduce cardiovascular morbidity and mortality in patients with CAD
mediterranean: high in fresh fruits, vegetables, and legumes
?? is a disorder of conjugated bilirubin excretion. Patients present asymptomatically with conjugated hyperbilirubinemia that may cause icterus or jaundice
**no treatment is warranted
Dubin Johnson
*Gilbert syndrome is a disorder of benign unconjugated hyperbilirubinemia
hyperosmoler hyperglycemia nonketotic state can cause what change in sodium ?
hyponatremia - hypertonic solute draws out water into the plasma and dilutes sodium
in general, hyponatremia should be investigated by calculating serum osmolality
asthma has whwat FEV1, FVC, and Total Lung Capacity findings
decreased FEV1, normal FVC, increased TLC
women of reproductive age who are not immune to rubella should recieve the vaccine when ?
ASAP; cannot be given during pregnancy, so soon after
pneumocystis infection shows what on CXR
diffuse, bilateral infiltrates
methenamine silver/toluidine blue stains confirm the diagnosis
patients with CKD should minimize their intake of (3)
fluids, potassium, and phosphate
*prone to volume overload, hyperkalemia, and hyperphophotemia
also metabolic acidosis
diabetic foot ulcers are cause by ??
mixed aerobic and aneorobic organisms
proximal muscle weakness & tenderness to palpation is a hallmark of ?? and should be evaluated with what test ??
* no constitutional signs present
myopathy
test for serum creatine kinase
*commonly statin-induced myopathy
definition of primary amenorrhea:
no menarche at 15 with appropriate sexual characteristics/growth
or no menarche at 13 y.o. with no sexual characteristics/growth (tanner 1)
?? is the most common form of thyroiditis and is characterized by the presence of antithyroid peroxidase and antithyroglobulin antibodies
hashimoto disease - or chronic lymphocytic thyroiditis caused by autoimmune infiltration of the thyroid by lymphocytes
valproic acid can cause hepatoxicity and what other side effect ??
hemotologic (leukopenia, thrombocytopenia) - can present with epistaxis
AML presents with fever, anemia, thrombocytopenia, and diffuse lymphadenopathy (and increased WBC)
what is the tx ??
induction chemo
+ all-trans retinoic if there are promyelocytes (APML)
and for severe cases bone marrow transplantation
ACOG recommends mammography breast cancer screening every 2 years for what ages ?
**BRCA patients should undergo screening every year
40-74
at 74, reevaluate to see if patient has 10+ year life expectancy, continue screening
presence of an arterial emboli, ex that causes acute limb ischemia in the arm, warrants examination with what test ??
ECHO to look for patent foramen ovale, ASD, VSD, or pulmonary AV malformation causing paradoxical emboli
management of a rapidly growing, painless parotid mass
FNA, core needle biopsy, excional biopsy, or excision
what lab to be checked AFTER initiation of infliximab?
CBC - look for side effect of anemia
**before, use PPD or interferon gamma release assay to make sure there is no latent TB
type ?? error occurs when a study demonstrates no difference between the null and alternative hypotheses, when in fact, there is a difference
II
“false negative” error
B level represents likelihood that a type II error will be committed
fibroussarcoma, a form of soft tissue sarcoma (smooth muscle, adipose, or fibrous tissue) if found, should prompt what test ?
tumor metastases via hematogenous spread to distant sites
**CT chest and abdomen recommended to look for distant metastasis
how to confirm the diagnosis of Hep A virus (jaundice after travelleing)
Hep A IgM
(IgG does not develop for 4-6 weeks after exposure)
Positive predictive value is based on both ?? and pretest probability of the disease
specificity
Negative predictive value dependent on pretest probability and sensitivity
squamous cell carcinoma of the skin - usuall risk factors are UV exposure with age and family history
what is the rx solid organ transplant recipients
chronic immunosuppression increases the rx 65x
rx increases in a dose-dependent fashion
first line therapy for ovarian cancer (increased CA 125) is surgical resection and ???
systemic chemotherapy, preferably with a platinum-based agent
atrial fibrillation with rapid ventricular response (pulse > 100 bpm) present in ED, what is the treatment ?
metoprolol - rate control agent, reduce pulse, increase LV filling, and increase CO
what is a definitive treatment for hereditary spherocytosis ??
splenectomy
- prevents accumulation of spherocytes and destruction of blood cells in microvasculature of spleen
what is the best imaging choice for a suspected perforated peptic ulcer - fever, abdominal pain, peritonitis with a hx of epigastric pain w/antacid use
X-ray of the chest and abdomen
which patients should discontinue OCPs for increased rx of stroke ?
patients older than 35 who smoke greater than 15 cigarettes daily
?? is the first-line therapy for impetigo
topical mupirocin
has coverage against Staph aureus and Group A Streptococcus
COPD is treated with what three medications ?
long-acting B-adrenergic agonists, inhaled muscarinic antagonists (ipratropium), and inhaled glucocorticoids
??? is the inability to voluntarily empty the bladder. The causes can be either mechanical (e.g., benign prostatic hyperplasia, tumors, urethral strictures) or functional (e.g., detrusor underactivity due to peripheral neuropathy, anticholinergic drugs). Patients with present acutely with a sudden, painful inability to void and a tender, distended bladder on palpation.
Urinary retention
methimizole, an antithyroid drug, can cause what effect on CBC
agranulocytosis
**patients can present with fever
rapidly reversible with discontinuation of treatment
all pregnant patients should be screened for HIV, t/f ???
True, should be offered as an opt-out test — also consider risk factors; also syphilis, Hep B, Chlamydia and Gonorrhea
rapidly progessing dementia (ex. 6 weeks) should prompt evaluation for ??
Crtuzfield-Jacob (CSF with 14-3-3 concentration)
hep C screening should be done for whom ??
hepatitis C screening at least once in a lifetime for all adults aged ≥18 years
& hepatitis C screening for all pregnant women during each pregnancy
Rapid growth (within 2–3 months) in areas of skin exposed to the sun (e.g., the ears)
Lesion: round dome-shaped, erythematous nodule with central crater
Histology: central, hyperkeratotic crater surrounded by squamous epithelium
Keratoacanthoma
Treatment: The tumor usually heals without treatment. Nonetheless, surgical removal is preferred because keratoacanthoma histologically resembles a cSCC, which is malignant.
what is the cutoff between viral acute rhinosinusits vs. bacterial
what is the difference in treatment ??
10 days
prior to 10 days, considered viral - treat supportively with ibuprofen and decongestant, saline, intranasal steroids
if bacterial suspected after 10 days of no improvement: antibiotics
First-line antibiotic therapy: amoxicillin, with or without clavulanate
what lab findings of estrogen, LH, and FSH are present with primary ovarian insufficiencey (typically <40)
follicular depletion results in low estrogen levels,
this results in feedback leading to elevated FSH and LH
*confirmed via FSh and estradiol levels at least 1 month apart
children with sickle cell disease < 5 y.o. receive ???
oral prophylactic penicillin therapy
(also treatment with hydroxyurea)
MEN syndromes consist of ???
medullary thyroid cancer
also pheocytochroma
Type A: hyperparathyroidism (parathyroid hyperplasia) + pancreatic tumors
Type B: marfinoid habitus & mucosal neuromas
??? is an acute, life-threatening condition in which a part of the umbilical cord lies between the antecedent part of the fetus and the pelvic wall, following rupture of membranes. Umbilical cord compression can lead to decreased perfusion. Delivery is usually via emergency cesarean section.
Overt umbilical cord prolapse
Red flags that suggest ??? infection include the presence of crepitus, bullous lesions, skin necrosis, pain out of proportion to examination, and signs of systemic toxicity (especially altered mental status).
necrotizing fasciitis
infection of deep tissue
what surgery needed for treatment of a colon adenocarcinoma ??
typically hemicolectomy; removal of part of colon, not just mass
test to diagnose abdominal aortic aneursym? for males 65-75 who have EVER smoked
abdominal US
why no hydrochlorathiazide if a patient has gout ?
Diuretics reduce urate excretion by both directly and indirectly increasing urate reabsorption and decreasing urate secretion
bernard-soulier vs. glanzmann thrombasthenia
bernard-soulier - adhesion disorder, LARGE platelets
glanzmann thrombasthenia - aggregation disorder, normal platelets
androgen insensitivity - XY, female external genitelia, elevated testosterone
what treatment needed ??
gonadectomy: prevents malignant transformation of the abnormally localized gonads
name of lesion and treatment ???
typically in patients > 50 in sun-exposed areas
Actinic keratosis (AK)
- single lesions (defined as 1–5 lesions): cryotherapy with liquid nitrogen
- Multiple lesions (defined as ≥ 6 lesions): 5-fluorouracil, imiquimod, Photodynamic therapy
Lesions may either regress, persist, or progress to squamous cell carcinoma (SCC).
TLC in obstructive vs. restrictive
TLC is normal or increased in obstructive and decreased in restrictive
RV and VC in obstructive disease vs. restrictive
RV increased in obstructive and decreased in restrictive
**VC is lower for both
