2025 Daily read Step2 CK Flashcards
SvO2 is ↓ in all types of shock, except which?
Septic (anaphylaxis)
- Type of distributive shock
Can give HPV vaccine to patients as young as which age?
age 9
Cervical cancer screening with pap test begins at which age?
age 21
What is the ML diagnosis in a patient post-gastrectomy with symptoms sounding like c.diff but also with symptoms like palpitations, sweating, or tachy?
Dumping syndrome has vasomotor sx (eg, palpitations, tachy), diarrhea. Seen post-gastrectomy, prolonged abx. Can seem like c.diff. Tx: Dietary mods.
What is the treatment for dumping syndrome?
Dietary mods
What is the treatment for specific phobia?
Exposure therapy
Which drugs improve mortality in heart failure with reduced ejection fraction?
- ACEi’s or ARBs
- B-blockers
- mineralocorticoid-R antagonists (*eplerenone, spironolactone)
- SGLUT-2 inhibitors
- Sacubitril- valsartan
- Hydralazine w isosorbide dinitrate in black patients
What intervention is most likely to improve cardiovascular and overall long-term mortality in patients with acute STEMI?
Prompt restoration of coronary blood flow (e.g., PCI, fibrinolysis)
- Percutaneous coronary intervention (PCI) = angioplasty + stent
- Early reperfusion also reduces likelihood of complications such as peri-infarction pericarditis
What is the recommended pharmacological therapy to reduce overall cardiovascular mortality in patients with peripheral arterial disease?
Anti-platelet agent (e.g., aspirin) and statin
- Recommended to prevent stroke and heart attack due to strong association between PAD and atherosclerosis
What are the skin findings in someone with PAD
Pale (no blood)
Hairless
Scaly, dry
Thin skin (no blood = no nutrients)
Ulcers = round and ‘punched-out’
In septic shock, all paramers are ↓ except for ___
CO
↓ breath sounds + dullness to percussion
Can be either pleural effusion, or hemothorax
Describe how late decelerations look in relation to a contraction
Late decelerations begin at the peak of a contraction.
The peak of the decel is at end of contraction.
(Note: late decels are d/t uteroplacental insuff and subseq fetal hypoxemia)
This is a fetal heart tracing showing what?
Late decelerations
Which type(s) of deceleration(s) may indicate fetal hypoxia and/or acidosis?
Late and recurrent variable decelerations
Which type of study is useful for calculating relative risk (RR)?
- CohoRt = Relative Risk
- Case contrOl = Odds ratio
What statistical test is used to compare 2 categorical values?
Chi-squared
What statistical test is used to compare 3 or more means (numerical) values?
ANOVA
Compared to:
- Checking differences between the means of 2 more groups = t-test
- Checking differences between two categorical groups = Chi-square (χ2 ) test
Hypercalcemia + ↓ PTH =
Malignancy - paraneoplastic syndrome PTHrP in SCC of the lung
Hypercalcemia + ↑ PTH =
Primary hyperparathyroidism
What is the FeNa+ in pre-renal azotemia?
FeNa+ < 1%
What is the FeNa+ in intra-renal azotemia?
FeNa+ >2%
What is a normal FEV1/FVC ratio?
FEV1/FVC > 70%
What is FEV1/FVC ratio in obstructive disease?
FEV1/FVC = ↓↓ / ↓ ➞ ratio ↓
If a patient is pulseless but we are getting a rhythm, what are the 3 potential diagnoses?
- PEA (has a nl rhythm!)
- Asystole (flatline)
- V-tach (can be pulseless or have pulse)
What is the treatment for:
VT + pulse + HDUS
Synchronized cardioversion
What is the treatment for:
VT + no pulse
UNsynchronized cardioversion (defibrillator)
What is the treatment for:
VT + pulse + HDS
Amiodarone (or sotolol or lodocaine or procainamide)
What is the treatment for:
SVT + HDS
Adenosine (or B-block or CCB)
AVNRT is a type of ___
SVT
What is a normal glucose level in CSF?
40-70
Low glucose level in CSF means ______
it could either be bacterial or TB meningitis
(viral has normal glucose level)
What is the CD4+ count in an HIV patient that would put them at risk for toxoplasmosis
CD4+ <100
What is the treatment for toxoplasmosis
Sulfadiazine + pyrimethamine
What do you give for prophylaxis against toxoplasmosis?
When do you give it?
TMP-SMX
Give if CD4+ count < 100
Tender erythematous streaks extending from wound + regional LAD =
Lymphangiitis
What is the treatment for HSV?
Acyclovir or valacyclovir
(not ganicyclovir - that’s CMV)
What are clinical features of genital herpes?
Group of painful ulcers/vesicles
Systemic sx (fever, malaise)
*Regional LAD
+/- Dysuria + sterile pyuria (can seem like UTI)
What is the treatment for CMV?
Ganicyclovir
(NOT acyclovir - that’s HSV)
Which pulmonary condition do you confuse with cardiac tamponade?
Exacerbation of COPD (can have JVD, muffled breath sounds, but non hypotension)
Tamponade has triad JVD + muffled heart sounds + hypotensionn
In which pediatric syndrome is subependymal nodules a characteristic feature?
Tuberous sclerosis
In which pediatric syndrome do you see hypopigmented macules?
Tuberous sclerosis
(ash-leaf spots)
In which pediatric syndrome do you see big red blotch on the face?
Sturge-Weber syndrome
(port wine stain)
Cardiac rhabdomyoma is a cardiac tumor associate with which pediatric condition?
Tuberous Sclerosis
In which pediatric syndrome do you see inguinal and axillary freckling?
Neurofibromatosis type 1
In which pediatric syndrome do you see Cafe-au-lait macules?
Neurofibromatosis type 1
In which pediatric syndrome do you see optic gliomas?
Neurofibromatosis type 1
What annual screenings do NF-1 patients need?
Annual ophthalmological screening exam + MRI brain / orbits for any new onset vision changes
In which pediatric syndrome do you see schwannomas
Neurofibromatosis type 2
↑ tactile fremitus + dullness to percussion =
Consilodation
How long does a patient need to have symptoms to be diagnosed with acute stress disorder?
If symptoms last longer than this, what is the diagnosis?
Symptoms for < 1 month after traumatic event
(If sx ≥1 mo it’s PTSD)
What is the treatment for transient synovitis?
Supportive, NSAIDs
How long does a patient need to have symptoms to be diagnosed with panic disorder?
Symptoms for ≥1 momnth
Kids aged 3-8 after viral illness. Poss fever (but low-grade, can be 100.1). Typ hip/thigh pain + limp +/- hip eff.
Diagnosis?
Transient synovitis
What is the likely diagnosis in a child that presents with hip pain and limp several days after a viral URI with normal physical exam, labs, and X-ray?
Transient synovitis (AKA toxic synovitis)
- Ultrasound reveals small unilateral or bilateral effusions (even when symptoms are confined to one hip)
What is the next best step in management of a patient with overlapping clinical features between transient synovitis and septic arthritis?
Bilateral ultrasound ± arthrocentesis
Most lung conditions have ↓/absent breath sounds, except which one?
Consolidation (has ↑ breath sounds)
Something is hypotonic is if _____ mOsm ; hypertonic is ______
< 275 mOsm. ; >295 mOsm
What is the treatment for empyema?
Chest tube (or video assist) AND abx
What is the pleural fluid like in a patient with empyema?
Thick, purulent, foul-smelling
What is lights criteria for exudative pleural effusions?
pl protein : ser protein > 0.5
pl LDH: ser LDH > 0.6
pl LDH > 133 (2/3 ULN)
Only has to meet 1 of the above criterias
What comes first in the ratio we calculate in lights criteria for pleural effusionn
always pleural fluid / serum
What is the ULN that LDH must be greater than in exudative pleural effusion
> 133
Which type of parapneumonic effusion is characterized by the following values:
pH < 7.2
Glucose < 60 mg/dl
WBC > 50,000/mm3
Gram stain/culture: negative
Complicated parapneumonic
- Bacteria eat the sugar (low glucose) and generate lactate (low pH)
- Ddx. with empyema which has a (+) pleural gram stain / culture
Which type of parapneumonic effusion is characterized by the following values:
pH < 7.2
Glucose < 60 mg/dl
WBC > 50,000/mm3
Gram stain/culture: positive
Empyema
- Ddx. with complicated parapneumonic effusion which has a (-) pleural gram stain / culture
Which type of parapneumonic effusion is characterized by the following values:
pH ≥ 7.2
Glucose ≥ 60 mg/dl
WBC ≤ 50,000/mm3
Gram stain/culture: negative
Uncomplicated parapneumonic
Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by pH < 7.2?
Complicated
(bacterial generate lactate)
Complicated or uncomplicated parapneumonic pleural effusion has the following:
- Leukocyte counts > 50,000
- pH < 7.2
- Glucose < 60
Complicated
- Glucose is lower since the bacteria are eating the sugar
- Empyema = if (+) gram stain showing bacteria / pus
What are the potential paraneoplastic syndromes in lung squamous cell carcinoma?
Hypercalcemia (↑ PTHrP, stones bones groans)
Hypertroph pulmonary osteoarthropathy (diffuse jt pains)
What are the potential paraneoplastic syndromes in small cell lung cancer?
SIADH (hyponatremia)
Cushings (↑ ACTH)
LEMS
SIADH is a paraneoplastic syndrome in which type of lung cancer?
Small cell lung cancer
Hypercalcemia is a paraneoplastic syndrome in which type of lung cancer?
Squamous cell carcinoma of the lung
Hypercalcemia (↑ PTHrP, stones bones groans),
What is the treatment for exacerbation of COPD?
IV abx + steroids (systemmic, not ICS) + inhaled bronchodilators
What statistical test is used to check differences between the means (numerical) of TWO groups ?
(e.g., comparing the mean blood pressure between men and women)
t-test
Compared to:
- Checking differences between the means of ≥3 groups = ANOVA
- Checking differences between two categorical groups = Chi-square (χ2 ) test
What is ambulation?
the act/action of moving about or walking
Where is a, b, c, d in the biostats table
How do you distinguish between syringomyelia and anterior cord syndrome
Syringomyelina = Cape-like distrib (upper extremities, neck), loss of pain/temp, preserved DCML. Poss weakness.
Ant cord syndrome = also preserved DCML. Also urinary incont. Here it’s everything below lesion affected, wouldn’t just be arms.
What happens to acetylcholine with a drug that inhibits acetylcholinesterase
↑ acetylcholine
(***OPPOSITE of anti-cholinergic toxicity symptoms!!)
↑ Preload = ↑ or ↓ intensity of HOCM murmur?
Decreased intensity
(Increased preload [blood return] means less obstruction = softer HOCM murmur)
What are the parameters in septic shock?
CO:
SVR:
PCWP:
CVP:
SvO2:
everything ↓, except CO and svO2(↑)
What is the treatment for shingles?
Antiviral agents (eg, acyclovir, famciclovir, valacyclovir)
-Not steroids
Hypotonic hyponatremia + low urine osm (<100 mOsm/kg) is diagnostic for _____ ?
Primary polydipsiaa
What value is considered low for urine osm?
<300 mOsm
Describe the HOCM murmur.
How is this differentiated from the AS murmur?
HOCM murmur = SEM, crescendo-decrescendo @ LSB. No carotid radiation
(AS radiates carotids, heard in R-2nd ICS, also cresc-decresc)
When calcium level is >14
What is the most like etio of the hypercalcemia?
Malignancy
Is the SN hearing loss in congenital infections B/L or U/L or either?
Can be either
Girl with yellow-green cervical discharge, friable cervix. She was treated for UTI but is having refractory symptoms.
Dx?
Chlamydia/ gonorrhea
(acute cervicitis +/- urethritis [dysuria, sterile pyuria])
Note: If cervical motion tenderness present - means PID
Microcytic anemia ↓Hb + ↓ ferritin = ACD or iron deficiency anemia?
Iron deficiency anemia
(ACD has ↑ ferritin)
Which blistering skin disorder presents as groups of itchy rash with vesicles (or papules) & some crusted over on extensor surfaces (forearms, elbows, knees)
Dermatitis herpetiformis (Celiac’s)
Is hypersensitivity pneumonitis an obstructive or restrictive lung disease?
Restrictive
What are the 3 potential causes of hyponatremia in a euvolemic patient?
- SIADH
- Primary polydipsia
- Beer potomania (malnutrition)
What is the triad seen in congential rubella?
- Cataracts
- PDA
- SN hearing loss
↓ breath sounds L-lung base with dullness to percussion =
- Pleural eff
- Atelectasis (eg, mucus plugging)
- Hemothorax
What is a common complication of mature cystic teratoma (dermoid cyst)
Ovarian torsion
Ultrasound findings that can include: heterogeneous, solid components, thin echogenic bands/hyperechogenic nodules, partial calcifications
Describe which pathology?
Mature cystic teratoma (dermoid cyst)
(Thin echogenic bands [hair] /hyper-echogenic nodules, partial calcifications [teeth])
Treatment for acute (<48h sx) symptomatic hyponatremia.
What does the Na+ level need to be to receive treatment?
hypertonic 3% saline if Na <130 ?or is it <120?
Treatment for chronic (≥48h) symptomatic hyponatremia
What does the Na+ level need to be to receive treatment?
Hypertonic 3% saline is reserved for those with severe hyponatremia (Na <120) with severe sx (seizures)
because chronic has lower risk brain issues.
How do you manage a newborn to hepB(+) mom?
Give HepB immune globulin + hepB vaccine (within 12h of birth) to the neonate
If you suspect septic arthritis in a kid or overlapping symptoms with transient synovitis, what is the NBS?
B/L hip ultrasound
Hypopigmented elliptical macule on chest =
Ash-leaf spot in tuberous sclerosis
What are charcot bouchard aneurysms?
Tiny aneurysm bubbles on lenticulostriate A.s ➞ affect deep brain structure
What virus do a lot of transplant patients get?
CMV
Treatment for botulism?
Equine anti-toxin (even before diagnostic confirmation testing)
What are some causes of conductive hearing loss?
Otosclerosis, Cholesteatoma
Chronic otitis media Foreign body
Which drug should be given to all SAH patients in order to prevent the complication of cerebral vasospasm ?
CCB
(Cerebral vasospasm = delayed cerebral ischemia/stroke - FNDs)
Management for peritonsillar abscess?
needle aspiration
Trismus, muffled voice, deviated uvula, unilateral swelling =
Peritonsillar abscess
(Treatment is needle aspiration)
Presence of WBC casts on urinalysis means it’s always either one of two things =
AIN or pyelonephritis!
ADHD/autism symptoms, long face w large ears =
Fragile X
(Also macroorchidism if >8yo)
Adolescent initially presenting with a single salmon-colored plaque that develops into a generalized rash with multiple, oval, scaly papules and plaques in a characteristic “christmas-tree” pattern on the trunk
Pityriasis rosacea
single salmon-colored plaque = herald patch
____
- Adolescent/young adult
- Self-limited
- Image on the right is a herald patch
With derm condition has the dandruff association?
Seborrheic dermatitis
CHF symptoms + holosytolic murmur @ LSB =
Tricuspid regurg
Normal PT
11-15 seconds
Normal PTT
25 - 40 seconds
Polyarteritis nodosa
Renal insuff/↑Cr (100%)
GI - abdo pain
Mononeuritis multiplex (70%)
Spares the lungs
(-)ANCA
Transient synovitis treatment
Supportive, NSAIDs
When testing hearing loss, the tuning fork lateralizes to the left ear. Then AC > BC in both ears.
=
Right SN hearing loss
(Weber test localizes to the unaffected hear)
Toxoplasomsis treatment
sulfadiazine + pyrimethamine
(note: CD4+ < 100)
Toxoplasmosis prophylaxis
TMP-SMX when CD4<100
Tender erythem streaks extending from wound + regional LAD =
Lymphangitis
Hyperaldosteronism presents with the following findings:
(write hyper- or hypo-
______tension
______natremia
______kalemia
______ (metab/resp) ______ (acidosis/alkalosis)
Hypertension
Hypernatremia
Hypokalemia
Metabolic alkalosis
Resistant hypertension, hypokalemia and abdominal bruit is suggestive of
Renal artery stenosis
(Due to hyperaldosteronism: low renal perfusion → activation of the RAAS → induces aldosterone secretion → augments potassium excretion → hypokalemia)
Treatment of primary hyperaldosteronism (conn’s)
Aldosterone antagonists such as spironolactone or eplerenone
Urinary chloride in metabolic alkalosis:
Vomiting + nasogastric aspiration causes metabolic alkalosis with ↑ or ↓ urinary Cl?
Decreased urinary Cl- (<10)
(volume loss, saline responsive)
(vs Mineralocorticoid excess state will result in a high urine chloride [>20] and hypervolemia that thus will not be saline responsive)
The next step in the workup of metabolic alkalosis is
Check urine Cl-
_______________
-Saline responsive (urine chloride low [<10] because low vol): think about volume loss, activation of RAAS, causing Na+ in and H+/K+ out; Cl- is lost through gastric secretions
- Saline resistant: think about other random causes (urine chloride high [>20] because hypervolemia) (e.g., hyperaldosteronism, Cushing’s, genetic stuff)
What acid-base disorder may be caused by thiazide diuretics?
Metabolic alkalosis
(same with loops)
What acid-base disorder may be caused by loop diuretics?
Metabolic alkalosis
(same with thiazides)
What acid-base disturbance is classically found in patients with laxative abuse?
Metabolic alkalosis
In laxative abuse, osmotic losses of potassium → hypokalemia → cellular buffering → H+ moves into cell → alkalosis
(vs. the metabolic acidosis typically found with diarrhea)
What is the likely diagnosis in a patient taking HCTZ, levothyroxine, and OTC mineral supplements (for osteoporosis) that develops symptomatic hypercalcemia, metabolic alkalosis, and AKI?
Milk-alkali syndrome
(Hypercalcemia causes renal vasoconstriction with ↓ GFR and also causes diuresis due to impaired ADH activity, with hypovolemia and contraction alkalosis)
What is the likely diagnosis in a young female with hypokalemia, metabolic alkalosis, normotension, and low urine Cl-?
Surreptitious vomiting
- Lose HCl and KCl via stomach
(Low urine Cl- helps distinguish vomiting from other causes of hypokalemia, alkalosis, and normotension (e.g., diuretic abuse, Bartter syndrome, and Gitelman syndrome which all have high urinary chloride)
What is the likely diagnosis in a young patient with hypertension that develops severe hypokalemia after beginning a low-dose thiazide diuretic (eg, muscle weakness, leg cramps)?
PRIMARY hyperaldosteronism
(Volume depletion → ↑ aldosterone → more Na+ in, H+/K+ out)
_______ is the probability that when the test is negative, the disease is absent
NPV
(vs - Specificity is the probability that when the disease is absent, the test is negative)
______ is the probability that when the disease is absent, the test is negative
Specificity
(vs- NPV is the probability that when the test is negative, the disease is absent)
What is the recommended primary prophylaxis against MAC for HIV patients with CD4 count < 50 for:
- Patient on or starting cART?
- Patient NOT on cART?
Patient on or starting cART = None
Patient NOT on cART = Macrolide (azithromycin or clarithromycin)
HIV with CD4 < 50, high fever, and watery diarrhea is suggestive of
MAC
Is primary prophylaxis against CMV recommended for patients with HIV?
No
(it’s coccidiomycosis not cryptococcus)
Pneumocystis jirovecii prophylaxis in HIV patients should be started at CD4 counts < ______ with TMP-SMX.
CD4 < 200
What is the likely diagnosis in an HIV patient with a CD4+ count of 25 that presents with 3 weeks of fever, night sweats, abdominal pain, diarrhea, and weight loss? CXR, CMV serology, and PPD are all negative
Disseminated MAC
(TB and CMV are less likely given the normal CXR, induration, and negative CMV IgG)
Normal ABG ranges for:
1. pH
2. pCO2
3. pO2
- pH = 7.35 - 7.45
- pCO2 = 33 - 45
- pO2 = 75 - 105
Normal serum calcium range
8.4 - 10.2
How do the following labvalues change in primary hyperparathyroidism?
PTH:
Ca2+:
Phosphorus:
PTH: ↑ or inappropriately normal
Ca2+: ↑
Phosphorus: ↓or can be nl in mild or early dz
Normal serum phosphorus range
3.0 - 4.5
How do the following labvalues change in secondary hyperparathyroidism due to chronic kidney disease ?
PTH:
Ca2+:
Phosphorus:
PTH: ↑
Ca2+: ↓
Phosphorus: ↑
Hypercalcemia + elevated PTH + high urine Ca2+ =
Primary hyperparathyroidism
- High urine Ca2+ helps distinguish from familial hypocalciuric hypercalcemia
In primary hyperparathyroidism, is serum phosphate ↑ or ↓ ?
Decreased (hypophosphatemia)
- Due to ↑ PTH secretion (the primary defect)
- Can be normal in mild disease (↓ in moderate to severe)
What is the likely diagnosis in a patient presenting asymptomatically with mild hypercalcemia, hypocalciuria and normal / increased PTH levels?
Familial hypocalciuric hypercalcemia (FHH)
- Due to defective Ca2+-sensing receptor (CaSR)
- Higher than normal Ca2+ needed to suppress PTH
- Hypocalciuria = want to reabsorb more Ca2+ to suppress the PTH
- Low urine Ca2+ helps distinguish from primary hyperparathyroidism
↑ HbA2 and ↑ HbF = alpha or beta thalassemia?
Beta
(↑ HbA2 and ↑ HbF is result of having little/no HbA)
-HbH and Hb Barts = alpha thalassemia
Ventilator settings:
If ↓ PaCO2 and ↑ pH → should _____(↑/↓) the RR or TV?
decrease RR or TV
How do SVR and afterload change during cardiogenic and obstructive shock?
↑
How do the following pressures change with pulmonary embolism?
RA pressure:
Pulmonary A. pressure:
LAP:
RA pressure: increased
Pulmonary A. pressure: increased
LAP: decreased or normal
How does cardiac index change in septic shock?
Increased
-Important distinguishing feature from cardiogenic and hypovolemic shock;
How does cardiac output change during cardiogenic and obstructive shock?
severely ↓
How does cardiogenic shock affect the following?
CVP:
PCWP:
Cardiac index:
SVR:
SvO2:
CVP: increased
PCWP: increased
Cardiac index: decreased
SVR: increased
SvO2: decreased
In cardiac tamponade, cardiac output decreases due to ________ (↓ / ↑ ) left ventricular _________
↓ CO due to: ↓ LV preload
What is the likely diagnosis in a patient on post-MI day 5 that presents with sudden-onset cardiogenic shock and a harsh holosystolic murmur at the left sternal border with a palpable thrill?
Interventricular septal rupture
- Compare with papillary muscle rupture, leading to MR (no thrill, soft murmur)
- Left-to-right shunt may manifest as an ↑ in O2sat from the right atrium to the right ventricle; signs of left and right heart failure are present (e.g., pulmonary edema, JVD)
What is the likely diagnosis in a patient s/p lung biopsy who presents with severe SOB and chest pain with a ↓ cardiac output and ↑ PCWP?
Cardiogenic shock (2/2 MI)
- ↑ PCWP is indicative of cardiac etiology (helps rule out pulmonary etiologies, such as pneumothorax and PE since less blood is flowing to the LA)
- Backup of blood into the lungs causes pulmonary edema
- Peri-operative MI is common in patients undergoing noncardiac surgery; intra-operative hemorrhage requiring blood transfusion ↑ the risk
Electrical alternans
is specific but poorly sensitive finding for pericardial effusion w cardiac tamponade; it results from heart changing position within the fluid-filled pericardial sac w each heartbeat.
- Tx: emerg pericardiocentesis(to relieve pericardial pressure).
Young boy presents with advanced bone age, coarse pubic hair, and severe cystic acne with low basal LH levels and normal testicular exam.
Diagnosis?
Late-onset (nonclassic) congenital adrenal hyperplasia
-Due to 21-hydroxylase deficiency → shunting to adrenal androgen production → peripheral precocious puberty
Late decelerations
Early decelerations
_______ measures ability of a test to correctly identify those with the disease
Sensitivity
- answers how often a test misses a dz
- It measures ability of a test to correctly identify those w the dz. A test w high sensitivity has low likelihood of missing dz.
- NBME Q: Pt concerned about the accuracy of a test and if could have missed the ca. Basically questioning the failure rate in detecting her breast ca.
disting from:
PPV: measures the probability that a person with positive test actually has the disease. Doesn’t tell you how often thw disease is missed.
Treatment?
Amiodarone
- MC benign bone tumor
Mgmt for stone retained in CBD (ie, choledocholithiasis)
ERCP immediately
If signs of cholecystitis + pericholecystic fluid (edema in gallbladder wall) or wall thicken.
Next best step?
Antibiotics first
Then cholecystectomy within 72h (gives time for abx to kick in)
Ascending cholangitis management
Antibiotics first
Then ERCP (within 24-48h)
Why do you see no/minimal breast development in Turner’s?
Ovarian dysgenesis causes EST deficiency → no breast development
(girl will be like 15yo w tanner 1 breasts).
-gpt: no breast devel means the ovaries are not functioning
What are the only times we do ERCP?
- Choledocholithiasis (stone in CBD)
- Ascending cholangitis: After antibiotics
Give magnesium sulfate for preterm labor if < _____ weeks gestation
<32 weeks gestation
Distinguish between:
- Chronic hypertension
- Gestational hypertension
- Preeclampsia
≥20 weeks = gestational HTN or preeclampsia. (preeclampsia if proteinuria or end-organ signs
<20 weeks = chronic HTN
Management for preterm labor if <32 weeks gestation?
- Tocolytics (nifedipine, terbutaline) ➞ delay delivery
- Corticosteroids (betamethasone) ➞ fetal lung maturity
- Magnesium sulfate ➞ neuroprotection, ↓ risk cerebral palsy
- If unknown GBS status/ no prenatal care ➞ GBS prophylaxis
What is the recommended management for
pregnant patient 35 weeks gestation presenting with preterm labor + fetus in vertex presentation on ultrasound?
Expectant management
- Betamethasone ± penicillin may be administered
Low serum osm
+ low urine osm(<300 mOsm)
+ hyponatremia
Diagnosis =
Primary polydipsia (ie, psychogenic)
Low ser osm
+ ↓ urine osm(<300 mOsm)
+ nl or ↑ Na+
Diagnosis =
DI (ADH deficient/resistant)
What level is considered low urine osmolarity?
<300 mOsm
What level is considered high urine osmolarity?
What does that indicate?
> 600 mOsm
Indicates solute diuresis/ concentrated urine (if also ↑ glu, it’s d/t hyperglycemia)
- don’t confuse this w SIADH, both can be w head injury, and have ↓ Na+
↑ HbA2 and ↑ HbF =
B-thalassemia
- Will have little/no HbA
Post-MI complication that looks like another MI several months later
LV aneurysm
How do the following laboratory values change in a patient with hypovolemia?
ADH:
Renin:
Aldosterone:
ADH: ↑
Renin: ↑
Aldosterone: ↑
- ↑ ADH due to angiotensin II, hypovolemia and hypotension. [goal is to replete volume]
- ↑ Renin/aldosterone due to decreased renal perfusion → RAAS
Hyponatremia, low plasma osmolality (< 280) and low urine osmolality (< 250) is suggestive of which diagnosis?
Primary polydipsia
- Hypo-osmolarity (< 280 mM) → ↓↓ ADH → pee out H2O → dilute urine - everything is diluted
NNT formula
NNT = 1/ARR
ARR = c/(c + d) - a/(a + b)
Distinguish between bipolar I and II
Bipolar I = requires a MANIC episode +/- depressive episode
Bipolar II = requires DEPRESSIVE episodes + hypomanic
(+) Antibodies in systemic sclerosis
Anti-topoisomerase I (anti-Scl-70) (diffuse SSc)
Anti-centromere (limited SSc)
Small L-sided pleural effusion, POD 2 + stable patient. NBS?
Observation
-if effusion grows or pt becomes symptomatic or an infection is suspected ➞ then do thoracocentesis
How do you know when to give a jaundiced infant an exchange transfusion?
If bilirubin levels>25
or signs of bili encephalopathy
Most likely diagnosis in a infants 2-8 weeks old with direct hyperbulirubinemia
Biliary atresia
-Direct bilirubin because it’s obstructive jaundice
What diagnosis is considered if a baby has persistent or worsening jaundice after 2 weeks of age?
Biliary atresia
What is the likely diagnosis in a 1-month-old with 1 week of jaundice, pale stool, hepatomegaly and conjugated hyperbilirubinemia?
Biliary atresia
- Should be suspected in newborns with conjugated hyperbilirubinemia and hepatomegaly
- Normal bilirubin production & conjugation; impaired excretion
What is the next step in management for an infant with high conjugated bilirubin?
RUQ ultrasound
-looking for absence of the gallbladder and/or no dilatation of the biliary tree
Does Dubin-Johnson syndrome result in unconjugated or conjugated hyperbilirubinemia?
Conjugated
- Normal LFTs and CBC
- Due to a defect in hepatic secretion of conjugated bilirubin
- episodic jaundice + direct hyperbili
Serotonin syndrome initial treatment?
Benzodiazepines
- disting from bromocriptine (DA agonist for NMS)
↑ Ca2+ ↑ PTH + ↓ phosphate =
Primary hyperparathyroidism
What happens to the levels of each of the following lab values in vitamin D Deficiency?
Ca2+
phosphate
PTH
Mg2+.
↓ Ca2+, ↓ phos, ↑ PTH
(secondary hyperparathyroidism)
normal Mg2+
- PTH ↑ to try to normalize calcium, but w/o vitamin D, calcium absorption from gut remains low
↓ calcium + ↑ PTH is the hallmark of which parathyroid disorder?
secondary hyperparathyroidism
(note: if normal Cr/kidney function it rules out CKD as the cause of 2ry hyper-PTH. NBS? ser 25-OHvitD [to see if vitD def])
↓ calcium + ↑ PTH + normal creatinine
NBS?
This is secondary hyperparathyroidism
Since a normal Cr/kidney function it rules out CKD as the cause, the NBS is to check serum 25-OHvitD levels (to see if vitamin D deficiency is the cause)
Pregnant lady with (+)HSV + active lesions during labor. NBS?
Requires cesarean delivery
-prevents vertical transmission and neonatal infect
- if no active lesions: can undergo vag deliv.
Pregnant lady with (+)HSV + no active lesions during delivery. Does she require c-section? or can she undergo vaginal delivery?
Vaginal
Lady at 36 weeks gestation + prior history of genital herpes BEFORE pregnancy. NBS?
Give acyclovir (HSV PPX)
- helps to prevent active lesions at delivery
- Acyclovir is given at > 36 weeks in pregnant patients with a prior history of genital herpes (either before or during pregnancy, doesn’t matter), REGARDLESS of whether or not there are currently active lesions
- No active genital lesions at deliver→ vaginal delivery
- Active genital lesions or prodromal symptoms (e.g., burning pain) at delivery → c-section
Lady at 36 weeks gestation + history of genital herpes during pregnancy but no current active lesions. NBS?
Acyclovir as HSV ppx
- Acyclovir is given at > 36 weeks in pregnant patients with a prior history of genital herpes (either before or during pregnancy, doesn’t matter), REGARDLESS of whether or not there are currently active lesions
Right sided murmurs increase or decrease with inspiration?
Increase
- remember, this is anatomical right-sided, not auscultation sites
Polyuria defines a urine output of > ____ L/day
> 3 L/day
Young girl wrecurrent UTIssince birth wB\Lfocalparenchymalscarring+bluntedcalyceson imaging
Most likely dx?
Vesicoureteral reflux
VUR or PUVs
Which one is only seen in boys?
PUVs
What are some classic s/s of methamphetamine?
- Tactile hallucinations (bugs crawling in skin, excoriations that don’t improve with derm tx)
- Psychotic sx/delusions
- Weight loss
- Poor dentition.
Patient with agitation, insomnia, paranoid delusions, and tactile hallucinations (bugs under skin).
On exam: patient appears thin and has poor dentition and multiple sores on his face and body.
Most likely diagnosis?
Methamphetamine abuse
- Severe tooth decay and excoriations due to skin picking are common signs of chronic methamphetamine abuse (Disting from: bipolar, which doesn’t have the physical findings)
Is the urine calcium level high or low in primary hyperparathyroidism?
What condition do we use urine calcium to distinguish this from?
High urine Ca2+.
- High urine Ca2+ helps disting from familial hypocalciuric hypercalcemia
Evaluate a breast mass with ______ if age > 30 , or _______ if age < 30
Mammography (if >30), or U/S (if <30)
MCC of mitral stenosis
Rheumatic heart disease
What is the location in which A-fib starts?
starts in the left atrium (pulmonary vein!)::LA/RA}
Patient with a BP of 95/64 and HR 74/min
are they stable or unstable?
Stable
-Would be HDUS if HR >100
- ALWAYS ALWAYS ALWAYS check HR if ambiguous BP (like 100/70, or 90/60) bc otherwise just athletic.
A PPD is considered positive in the general population if the induration measures ____ mm
≥ 15mm
In acute stress disorder, how long do symptoms last?
sx last from ≥3 days to ≤1 month.
-Note: Bizarre psychotic sx and disorganized behavior are not typical. If so - it’s prob acute psychotic disorder.
For the following conditions, when does the HTN need to start?
Chronic HTN
Pre-eclampsia w/o severe feats
Gestational HTN
Pre-eclampsia w/o severe feats & gestational HTN get dx’d when new HTN @ ≥20 weeks gestat.
Whereas dx would be chronic HTN if @ <20 weeks.
What is the BP criteria for any pregnant HTN condition?
SBP ≥140 or DBP ≥90
26M suicide attempt by med overdose. Had 2 seizures, fever, hypotension/tachy, AMS, dilated pupils that respond poorly to light, flushed & dry skin, ↓ bowel sounds, prolonged QRS =
TCA toxicity
Whatprophylactic medsshould be started if pt is beginninghigh-dose immunosuppression therapy s/prenaltransplant?
TMP-SMX (for PCP) & Ganciclovir (for CMV)
Adolescent tall & skinny boy with groin pain and limp =
SCFE
NBS? B/L hip xrays
Age of onset for
- common variable immunodeficiency (CVID)
- SCID
-Bruton
- CVID: later in life (15-35 yo) - After puberty
- SCID: is since birth
- Brutons is >6 mOL. Remember this is x-linked/only in boys!
Are the follow B or T or combo problems?
- common variable immunodeficiency (CVID)
- SCID
-Bruton
- CVID: just like Brutons but low plasma cells, not absent (all Ig levels are low)
- SCID: combo B&T, severe
-Bruton: B- cell defect (don’t mature into plasma cells —> ?absent plasma cells — decrease or absent? levels all Igs)
60-year-old man with HTN presents with acute shortness of breath and nonproductive cough. Exam shows:
*BP: 140/105 mmHg
*HR: 100/min, RR: 26/min
*JVD, bibasilar crackles
*S3 and S4 gallops
*Retinal arteriolar narrowing, no papilledema
*No peripheral edema
What is the most likely diagnosis?
CHF
(likely diastolic dysfunction from hypertension)
- If constrictive pericarditis - would have pleuritic CP, poss coarse friction rub. Also possible hypotens, tachy, pulsus paradoxus, kussmal sign (↑ JVD during inspir)
ICU patient with new-onset fever, purulent drainage around NG tube, normal CXR.
NBS?
CT of the sinuses
Nosocomial sinusitis is common cause of unexplained fever in intubated ICU patients (with NG or endotracheal tubes)
13-month-old with:
*≥4 episodes of pneumonia
*Severe varicella at 8 months
*Oral thrush
*Failure to thrive
*WBC = 1500/mm³
*CD4+ count = 225 (low)
*Poor lymphocyte proliferation
What is the most likely diagnosis?
Severe Combined Immunodeficiency (SCID)
-Combined B- & T-cell dysfunction
- Recurrent bacterial, viral, and fungal infections
- Thrush = classic clue for T-cell defect
- CD4+ count <500 and poor lymphocyte proliferation = T-cell problem
- Early onset, FTT, life-threatening infections
USMLE loves: Low CD4 + mixed infections + FTT = SCID
Brutons - would only have bacterial infects (because B cell problem, normal T-cells)
POD2 patient with new AMS, RR = 6. Found unresponsive. Given morphine and enoxaparin
Pupils 3mm
No focal neuro signs
No spontaneous movements of the extremities.
Most likely cause?
Whats the best initial test?
Cause: opioid-induced respiratory depression
(Hypoventil ➞ ↑ CO2 ➞ resp acidosis ➞ CNS depression)
Best initial test: ABG (to confirm hypercapnia)
- RR <8 is red flag for opioid toxicity. Normal pupils don’t rule it out. No need for CT unless FND or trauma.
78F 2week hx right knee pain, worsens with activity (stairs), morning stiffness, no swelling or erythema, full ROM, crepitus. PMH: GERD on omeprazole.
What is the most approp initial pharmacotherapy?
A) Acetaminophen
B) Prednisone
C) Colchicine
D) Ibuprofen
E) Ciprofloxacinn
A) Acetaminophen
Dx: OA
- Acetaminophen is 1st line for OA in elderly ➞ safe GI profile (impt w PPI use = GI risk), avoid NSAIDS in elderly if risk GI bleed, AKI, CVD.
Clues: Elderly, weight-bearing joint, pain with use, brief morning stiffness, no signs of inflammation, crepitus, full ROM, no effusion
- Prednisone = RA/ inflammatory, not OA
- Colchicine = Gout (acute, red, swollen)
- Ibuprofen = effective but higher risk in elderly
- Ciprofloxacin = Irrelevant (no infection)
What is type I error (alpha)?
False positive
– concluding there’s an effect when there isn’t one. Rejecting a true null hypothesis.
What causes a Type I error?
Setting a significance level (α) too high (e.g., >0.05)
What is a Type II error (β)?
False negative
– failing to detect an effect that is truly there. Failing to reject a false null hypothesis.
What causes a Type II error?
Low power
– usually due to small sample size or small effect size.
- Power = Probability of correctly rejecting the null when it’s false (detecting a true effect). Power = 1 - β.
What is statistical power?
Probability of correctly rejecting the null when it’s false (detecting a true effect).
Power = 1 - β
- ↑ power by ➞ ↑ sample size, ↑ effect size, reduce variability, or ↑ alpha (risking more Type I error).
How can power be increased?
↑ sample size, ↑ effect size, reduce variability, or ↑ alpha (risking more Type I error).
What is the main benefit of a meta-analysis?
Increases power by pooling data from multiple studies to detect a true effect.
- In general, power gets increased by ➞ ↑ sample size, ↑ effect size, reduce variability, or ↑ alpha (risking more Type I error).
When is a meta-analysis most useful?
When individual studies are underpowered or show borderline p-values (e.g., 0.07)
- indiv studies are underpowered (like P=0.07, too high) → When indiv trials are too small to reach statistical signif (common p-values just above 0.05), meta-analysis lets us combine them to find a real effect!
Does meta-analysis reduce confounding or selection bias?
No – those are addressed during individual study design.
What is healthy worker effect (selection bias subtype)?
Workers tend to be healthier than the general population → underestimates disease rates when comparing occupational exposures.
What type of study design is most vulnerable to selection bias?
Case-control studies, because participants are selected based on outcome status.
What is the most effective intervention to prevent readmission after a COPD exacerbation in a stable outpatient already on optimal medical therapy?
Pulmonary rehabilitation
Is long-term prednisone recommended after a COPD exacerbation?
No
It increases risk of side effects (e.g., osteoporosis, DM) without long-term benefit
Is incentive spirometry useful in COPD management?
No
– Its used postoperatively to prevent atelectasis, not helpful in chronic COPD
What is the most appropriate management for a euthymic bipolar patient on lithium at 16 weeks gestation?
Continue lithium—do not switch or stop if patient is stable and past the 1st trimester.
- main risk of discontinuing mood stabilizers during pregnancy is relapse of bipolar disorder, espmania—this poses risks to both mother and fetus.
Which bipolar medications are contraindicated in pregnancy due to teratogenicity?
Valproic acid (neural tube defects), carbamazepine (NTDs, craniofacial defects)
- Lithium is not totally c/i (absolute risk of ebsteins anomaly is very low, and also only during 1st tri)
Why is switching from lithium to valproic acid or carbamazepine in pregnancy a bad idea?
Both are more teratogenic than lithium—do not switch stable patients to these during pregnancy.
Infant + irritable + vomiting + no testes palpable on one side
Testicular torsion (complication of cryptorchidism)
Disting from:
Incarcerated inguinal hernia - would have firm tender mass in inguinal canal
What is the strongest RF for developing breast ca in a 58yo woman with no persona history and a paternal cousin who was recently diagnosed with breast ca?
Age of the patient!
Age >50 is ↓1 RF for breast ca
Pneumothorax
Smoker + Horner’s + shoulder/arm pain + atrophy hand/arm muscles
NBS?
NBS is CXR
Pancoast (Superior sulcus) tumor
- Typical USMLE tries to mislead you think Rheumatoid arthritis (even if patient has RA), rotator cuff injury, or cervical radiculopathy
- Pancoast commonly affects ulnar N. too
What is the likely diagnosis in a patient with significant smoking history who presents with shoulder pain, weight loss, and this CXR?
Pancoast (Superior sulcus) tumor
- CXR shows apical mass
Q: What is the first step in managing bradycardia in a hypothermic patient (core temp <35°C)?
Active rewarming — not atropine or pacing.
USMLE loves this: Treat the hypothermia first — bradycardia often resolves with rewarming.
Ex’s of active rewarming methods”
*Warmed IV fluids
*Bair Hugger / forced-air blankets
*Heated oxygen
What is the MCC of primary adrenal insufficiency (Addison’s disease) in developed countries?
Autoimmune adrenalitis (often part of autoimmune polyglandular syndrome)
- Pt may have other autoimmune conditions
Hyperpigmentation + hyponatremia + hyperkalemia + hypotension + fatigue =
Primary adrenal insufficiency (Addison’s disease)
- Hyperkalemia is due to aldosterone deficiency, which impairs renal potassium excretion.
A patient with vitiligo, fatigue, postural hypotension, and oral pigmentation has low 8 AM cortisol, eosinophilia, tonsillar enlargement. NBS?
Suspect primary adrenal insufficiency (Addison’s)
→ so check ACTH (will be high)
- treat with hydrocortisone + fludrocortisone.
A study is underpowered if P-value is ______
> .05 (ie, if it’s not statistically signif), suggests not enough power to detect a difference
What type of bias occurs when a study fails to adjust for variables related to both the exposure and the outcome?
Confounding bias
- Occurs when extraneous variables (eg,, comorbidities) distort the observed association between exposure (eg, dialysis center) and outcome (eg, survival).
In outcome comparison studies, why is adjusting only for age and sex often insufficient?
Because comorbidities and other health factors may influence outcomes. Failing to adjust for these introduces confounding bias, invalidating conclusions about causality.
A study comparing 5-year survival rates between two dialysis centers finds a statistically significant difference (p = 0.0278), adjusted only for age and sex.
What is the most likely flaw?
Failure to adjust for comorbidities (confounding bias). Survival differences may be due to baseline patient health, not dialysis center quality.
↓ GnRH + ↓ FSH + ↓ EST =
Hypogonadotropic hypogonadism (eg, anorexia nervosa, stress, pituitary tumor)
↑ GnRH + ↑ FSH + ↓ EST in a patient with negative B-hCG, normal prolactin, normal thyroid panel =
Premature ovarian insufficiency
- Smoking is a RF
- Suspect if ↑ FSH in woman <40 w irreg cycles
- Always rule out pregnancy, thyroid, and PRL first - but if those are normal, test FSH
What is the most likely cause of hypokalemia and metabolic alkalosis in a patient with low urine chloride?
Vomiting or nasogastric suction.
-Low urine chloride (<20 mEq/L) suggests volume depletion with secondary hyper-aldosteronism (saline-responsive metabolic alkalosis).
What lab finding helps differentiate vomiting from diuretic use as a cause of metabolic alkalosis?
Urine chloride:
- Vomiting: Low (<20 mEq/L) due to volume depletion + Cl- loss in the vomit.
- Diuretics: High (>20 mEq/L) because chloride is lost in the urine.
What is the best treatment for chloride-responsive metabolic alkalosis caused by vomiting?
Normal saline (0.9% NaCl).
- It corrects volume depletion + provides chloride to allow kidneys to excrete bicarb and correct alkalosis.
What does high serum bicarbonate (>40) with hypokalemia and low urine chloride suggest?
Metabolic alkalosis 2/2 vomiting-induced volume depletion
- with RAAS activation worsening K+ and H+ losses.
What type of bias is introduced when treatment groups are chosen by clinicians rather than randomly assigned?
Confounding by indication (a form of selection bias).
- Physicians may preferentially give a treatment based on perceived patient risk (like giving to sicker patients), leading to unequal baseline characteristics.
What study design element minimizes selection bias and confounding?
Randomization.
It distributes both known and unknown confounders equally between groups.
Management for NMS?
1st discontinue drug!
Then give dantrolene
Distinguish placenta previa from placental abruption
Previa = painless vaginal bleeding w normal FHR tracing (no fetal distress)
Abruption = Painful vaginal bleeding, constant abdo pain w abnormal FHR tracing (eg, decelerations) (fetal distress)
A 44-year-old woman has difficulty combing her hair, brisk reflexes, unintentional weight loss, and a resting HR of 115.
Most likely diagnosis?
Hyperthyroid myopathy
- Proximal muscle weakness + hyperthyroid sx
- Myopathy isn’t only for hypothyroid
What neuromuscular condition is classically associated with proximal muscle weakness + brisk reflexes + weight loss + tachycardia?
Hyperthyroid myopathy
- Gpt says this is commonly tested on USMLE!
How do reflexes differ between polymyositis and hyperthyroid myopathy?
Polymyositis = Normal or ↓
Hyperthyroid myopathy = Brisk/ ↑
Breastfeeding baby with bloody stools in + eczema + poor weight gain
Milk protein allergy
Management for milk protein allergy
Switch to soy-based formula
- Remember milk protein allergy presents as breastfeeding baby with bloody stools in + eczema + poor weight gain
Management for infant with physiologic GERD
Reassure parents + give vitamin D (if breastfed)
- Remember physio GERD is the “happy spitter” + normal weight gain, non red flags.
14-year-old boy with back pain worse at night. No neuro signs. Relieved with ibuprofen.
Osteoid osteoma
- Night pain + NSAID relief = classic
- Diaphysis or posterior spine
- Xray: radiolucent core with sclerotic rim
Benign bone tumor near knee in adolescent. Painless, hard, non-tender mass.
Osteochondroma
-Metaphysis, near growth plate
- Xray: bony spur projects away from joint
- Cortex continuous with native bone
- Stops growing with skeletal maturity
What part of the bone is affected by osteochondroma?
Metaphysis
- Near growth plate
- Bone spur grows outward
- Cortex & medulla are continuous with parent bone
20–40yo with knee pain & swelling.
Xray: eccentric lytic lesion in epiphysis with “soap bubble” appearance.
Giant Cell Tumor of Bone
- Epiphysis of long bones (esp. distal femur, proximal tibia)
- Pain, swelling, possibly aggressive
- Xray: soap bubble lesion
- Tx: surgical curettage
What distinguishes delusional disorder from schizophrenia?
Delusional disorder = ≥1 delusion lasting ≥1 month, no functional impairment, no negative symptoms, and no bizarre behavior.
Schizophrenia = functional decline, may have bizarre delusions, and shows negative symptoms.
How is major depressive disorder with psychotic features distinguished from schizophrenia?
In MDD w psychotic features = psychosis occurs only during depressive episodes and mood symptoms are prominent
In schizophrenia = psychosis occurs independently of mood symptoms
Which disorder involves long-standing distrust and suspicion without psychosis?
Paranoid Personality Disorder
Which disorder involves social detachment, emotional flatness, and no interest in relationships, but no psychosis?
Schizoid Personality Disorder
Promethazine
Anti-emetic medication that has some DA antagonism and can therefore lead to NMS!
Rigidity + ↑ CK + antipsychotic use
NMS
What is the most characteristic neuromuscular finding in NMS?
Lead-pipe rigidity (sustained muscle rigidity without clonus)
What lab value is typically markedly elevated in NMS?
Creatine kinase (CK) — due to severe rhabdomyolysis
What is the most appropriate first step in management of NMS?
Discontinue the antipsychotic medication immediately
What are the two pharmacologic treatments that may be used in severe NMS?
(after discontinuing the drug)
Dantrolene (muscle relaxant) and bromocriptine (dopamine agonist)
What feature helps differentiate serotonin syndrome from NMS?
Hyperreflexia and clonus in serotonin syndrome
vs
Rigidity and ↓/normal reflexes in NMS
How do you differentiate lithium toxicity from NMS if both involve confusion and tremor?
Lithium toxicity typically includes GI symptoms, ataxia, and ↑ lithium levels (>1.5 mEq/L)
Wants relationships but fear rejection
Avoidant personality disorder
How does Paranoid Personality Disorder differ from Delusional Disorder, Persecutory Type?
Paranoid PD = generalized, non-fixed suspicion.
Delusional disorder = fixed false belief (eg, “My neighbor is poisoning me”) without broader personality traits.
What classic behavioral pattern helps distinguish Paranoid PD from Schizoid PD?
Paranoid = wants relationships but avoids them due to suspicion.
Schizoid = lacks interest in relationships altogether and is emotionally detached.
Dilated pupils, diaphoresis, myalgias, abdominal cramping, nausea, and restlessness, starting 1–2 days after hospital admission =
Opioid withdrawal
- Clue: Think: “flu-like + GI upset + autonomic signs (sweating, dilated pupils)”
- USMLE loves: Happens when opioids are suddenly stopped in the hospital
Patient on risperidone becomes febrile, confused, tachycardic, and develops lead-pipe rigidity.
What’s the diagnosis?
NMS
- Clue: Antipsychotic use + rigidity + fever + ↑CK
- Buzz: Dopamine blockade → rigid not clonic
Key distinguishing features of benzodiazepine withdrawal?
Seizures, insomnia, anxiety, psychosis, tremors
- Impt: Looks like alcohol withdrawal but no GI issues or hallucinations usually
Which toxidrome involves GI upset, tremor, and confusion with ataxia in late stages and is often dose-dependent?
Lithium toxicity
- Clue: GI first, then neuro signs (ataxia, tremor)
- Don’t fall for: Normal lithium level = not toxicity
What two toxidromes have dilated pupils and diarrhea, but differ based on reflexes?
Opioid withdrawal → no clonus, just myalgias/restlessness
Serotonin syndrome → clonus + hyperreflexia
How do bowel sounds differ in opioid withdrawal vs NMS?
Opioid withdrawal = Hyperactive bowel sounds
NMS = Normal or ↓ (due to rigidity)
What feature on neuro exam helps you rule IN serotonin syndrome and rule OUT opioid withdrawal?
Inducible or spontaneous clonus
- USMLE loves: “Lower extremity clonus” = serotonin syndrome
Nausea, vomiting, abdominal cramping, diarrhea, and muscle aches characterizes which common withdrawal syndrome?
Opioid withdrawal
Elderly patient with bipolar disorder that develops confusion, tremors, ataxia, vomiting, and seizures 2 weeks after beginning atenolol and hydrochlorothiazide?
Dx?
Lithium toxicity
What is the difference between Bipolar I and Schizoaffective disorder?
Bipolar I = Psychosis only occurs during mood episodes (manic or depressive).
Schizoaffective = Psychosis occurs for ≥2 weeks without mood symptoms
Psychotic features must present with mood symptoms for Bipolar (if psychotic features are present in the absence of mood symptoms, consider schizoaffective)
What makes a mood episode schizoaffective rather than mood disorder with psychotic features?
Presence of psychotic symptoms alone for ≥2 weeks, outside of any mood symptoms.
Can you diagnose Bipolar I disorder if the manic episode occurred years ago and isn’t current?
Yes.
A single manic episode ever = Bipolar I, even if current mood is depression or euthymia.
Diagnosis of _______ requires at ≥2 weeks duration of psychotic symptoms without a major mood episode
Schizoaffective disorder
A patient has persecutory delusions and hallucinations for the past 3 years.
6 months ago he started having sadness, guilt, insomnia, decreased concentration, and sleep issues.
Rapid dx
Schizoaffective disorder
- Delusions / hallucinations for > 2 weeks in absence of mood symptoms (ie, they are not mood congruent)
- If a mood disorder with psychotic features (i.e., depression or bipolar), psychotic features appear exclusively during manic or depressive episodes (ie, mood-congruent)
Patient presents with symmetric resting tremor in both hands, muscle stiffness, and slow finger movements. Also has history of bipolar disorder controlled with valproate and risperidone.
dx?
Drug-induced parkinsonism
- Typically presents with bradykinesia, rigidity, and tremor
Patient develops agitation and visual hallucinations 12 hours after hospitalization. Vital signs are within normal limits. Also has history of cocaine, marijuana, and alcohol abuse.
Alcoholic hallucinosis
- Typically develops within 12-24h and resolves within 24-48h
- Vital signs are stable and sensorium is intact (patient is alert, oriented, and not confused)
(vs. delirium tremens - agitated, disoriented, confused)
Which symptoms of alcohol withdrawal occur during the 12 - 48h time period?
Withdrawal seizures and alcoholic hallucinosis
What is the timing of onset for delirium tremens (DTs)?
48–96 hours after last drink.
What vital sign abnormalities are typical in delirium tremens but not in alcoholic hallucinosis?
Fever, HTN, tachycardia—autonomic instability.
Which alcohol withdrawal condition is a medical emergency requiring ICU admission and IV benzos?
Delirium tremens
What early symptoms of alcohol withdrawal can begin as early as 6–12 hours after last drink?
Tremulousness, anxiety, insomnia, palpitations.
What is the treatment for both alcoholic hallucinosis and delirium tremens?
Benzodiazepines (eg, lorazepam, diazepam) to prevent progression and control symptoms.
Alcoholic, confusion, agitation, hallucinations, fever, unstable vitals, 3 days after admission =
Delirium tremens
What drug withdrawal presents with nausea, muscle/joint aches, diarrhea, abdominal cramping, and pupillary dilation?
Opioid withdrawal (eg, heroin)
- Other common findings (but not req’d) include yawning, lacrimation, and piloerection.
- In contrast to other withdrawal states (eg, alcohol, benzo’s) w similar sx, in opioid dependence, HR, BP, and temperature are often normal and mental status remains unchanged.
Patient stopped taking fluoxetine and lorazepam yesterday after 2 years of continuous therapy and now complains of insomnia, dysphoria, irritability, and anxiety.
What is the most likely explanation?
Benzo withdrawal
- Abrupt discontinuation of benzos can result in life-threatening withdrawal syndrome and cause early rebound effects of insomnia and anxiety and it can be hard to differentiate between the return of the anxiety disorder; also ↑s risk for seizures
“Flu-like” symptoms
Myalgias, diarrhea, vomiting
Dilated pupils, yawning, lacrimation, rhinorrhea
Piloerection, insomnia, sweating
Patient profile: Young, thin, anxious, restless
Opioid withdrawal (heroin, oxy, morphine)
- USMLE Trick: Looks sick but vitals okay — NOT life-threatening
- In contrast to other withdrawal states (eg, alcohol, benzo’s) w similar sx, in opioid dependence, HR, BP, and temperature are often normal and mental status remains unchanged.
- Mnemonic: “It sucks to come off opiates” = everything runs (nose, eyes, bowels)
Miosis (pinpoint pupils)
Respiratory depression, bradycardia
Constipation, sedation, coma
Hypoventilation = cause of death
Opioid intoxication
- USMLE Trick: Sedated + slow + small pupils
- Tx: Naloxone (Narcan)
Anxiety, insomnia, tremors
Seizures, psychosis, hallucinations
Benzo withdrawal
- Can look like alcohol withdrawal
- USMLE Trick: Recent stop of benzo or taper after chronic use
- Mnemonic: “Benzo withdrawal = brain on fire”
Dangerous? Yes — can be fatal
Crash: Depression, fatigue, hypersomnia
Hyperphagia (eat a lot), vivid dreams
Stimulant withdrawal (cocaine, amphetamine)
- Not dangerous — just miserable
- USMLE Trick: Think of someone after a binge — sad + sleepy
- Intoxication? Opposite: agitated, tachy, mydriasis (big pupils)
Difference in presentation between placenta previa and vasa previa?
Placenta previa = heavy, persistent bleeding
- Placenta previa = Profound bleeding; Vasa previa = Vanishing bleeding
- Placenta previa reflects maternal blood loss and has signs of maternal hemorrhagic shock (eg, hypotens/tachy)
Vasa previa = minimal, transient bleeding
- Vasa previa reflects fetal blood loss
Painless ROM with blood-tinged fluid + known vasa previa
Mom: Stable
Fetus: Bradycardia or decels
NBS?
Vasa previa
Do emergency C-section immediately
- DO NOT wait for steroids or labs
- USMLE Trigger: In vitro fertilization (↑ vasa previa risk)
Painful bleeding, firm uterus, maybe contractions
Mom: May be unstable (shock, tender uterus)
Fetus: Can show distress or demise
Dx?
Placetal abruption
Pregnant patient with painless third-trimester bleeding with a normal fetal heart tracing?
Placenta previa
- Painless bleeding helps r/o placental abruption; normal FHR helps distinguish placenta previa from vasa previa (which would have a FHR <110 bpm)
What pregnancy complication is associated with painless third trimester bleeding with fetal bradycardia (FHR <110)?
Vasa previa
What pregnancy complication is associated with painless third trimester bleeding without fetal bradycardia?
Placenta previa
- Fetal bradycardia would suggest vasa previa
__________ is a complication of pregnancy that presents with a triad of ROM, painless vaginal bleeding, and fetal bradycardia (FHR <110)
Vasa previa
How is placenta previa usually diagnosed?
Ultrasound (prenatal visit)
True or false?
The majority of placenta previas resolve spontaneously
True
- Therefore continue with routine care and do an ultrasound in third trimester to check for resolution
Which pregnancy disorder may present with minimal vaginal bleeding, focal pain, and a distended uterus with high-frequency contractions?
Placental abruption (concealed)
- Abruption typically presents with abdo and/or back pain and vaginal bleeding (which can range from severe to absent, as bleeding may be concealed behind the placenta)
- Blood may have a uterotonic effect, causing a firm uterus and unusually low-amplitude but frequent contractions
What is the most common risk factor for placental abruption?
Hypertension (assoc preeclampsia, cocaine use)
Pregnant patient at 35 weeks gestation with abdominal pain, painful vaginal bleeding and a firm, tender uterus.
Dx?
Placental abruption
- Also may have high-frequency, low-intensity uterine contractions (abrupt and strong)
- Bleeding may be concealed
- Compare with uterine rupture (loss of contraction and loss of fetal station)
What is the initial management for a hemodynamically unstable pregnant patient who presents with placental abruption?
Hemodynamic support (IV fluids and/or blood transfusion)
followed by emergency C-section
- The left lateral decubitus position displaces the uterus off the aortocaval vessels and maximizes cardiac output
Pregnant patient with painful third-trimester bleeding, tender abdomen, an irregular mass, and prior cocaine use and C-section?
Uterine rupture
- Irregular mass due to palpable fetal parts through the ruptured uterus
- Placental abruption would present with a painful abdomen and a rigid/hypertonic uterus
Which childhood exanthem can present with a fine, blanching rash developing after a sore throat?
Scarlet fever (GAS)
- Kawasaki - would have no sore throat or pharyngitis. Would have conjunctivitis and fever for ≥5d
What pediatric infection is associated with “beefy-red tongue” concurrent with pharyngitis?
Scarlet fever
- “Strawberry” tongue (also seen in Kawasaki disease)
Child presents with a strawberry tongue. What are the two potential diagnoses?
Scarlet fever or Kawasaki
Kid with slapped cheek rash
fifth disease/erythema infectiosum due to parvo B19
_________ is a severe, traumatic vascular injury that should be suspected if there is a widened mediastinum, tracheal and esophageal deviation, and hemothorax
Aortic rupture
- Usually pt had a deceleration injury
- Confirm dx with CT angiography
Other findings may include:
- Pseudo-coarctation (due to obstructive intimal flap)
- Hoarseness (due to compressed left recurrent laryngeal nerve)
This on xray after deceleration injury =
Aortic rupture
xray shows widened mediastinum
- Do CT angio
Patient had a pure sensory stroke, which brain structure was most likely affected?
Thalamus
- Possibly lacunar infarct
- Lacunar infarct = lenticulostriate vessels
A child with a history of neurofibromatosis I that presents with unilateral vision loss, proptosis, and optic disc pallor.
NBS?
do brain MRI for optic glioma
What is the most appropriate routine screening in a child with NF1?
Annual ophthalmologic exam to screen for optic pathway gliomas (even if asymptomatic).
- USMLE trick: MRI is only done if symptomatic, not routinely.
What are the 3 skin findings in NF1?
- Café-au-lait spots
- Axillary or inguinal freckling
- Cutaneous neurofibromas
What would be the next step if a child with NF1 develops headaches, vision loss, or other neuro symptoms?
MRI of the brain to evaluate for CNS tumors (eg, optic glioma, astrocytoma)
- Note: Not done routinely — only if new symptoms develop.
- What is routinely done are yearly ophtho exams
What 3 syndromes/conditions are associated with pheochromocytoma?
- MEN 2A/2B
- NF-1
- VHL
What is the definition of precocious puberty?
Early onset of secondary sexual characteristics in girls <8, and boys <9
What is the key hormone profile in central precocious puberty?
High LH/FSH
Responds to GnRH stimulation with further rise in LH
What is the key hormone profile in peripheral precocious puberty?
Low LH/FSH
No response to GnRH stimulation
What are common causes of peripheral precocious puberty? (5 listed here)
- Estrogen-secreting ovarian tumor (eg, granulosa cell tumor)
- Adrenal tumors
- McCune-Albright syndrome
- Exogenous estrogen exposure
- CAH (eg, 21-hydroxylase deficiency)
A 7yo girl presents with breast development and vaginal bleeding. She has a large unilateral ovarian mass.
Dx?
Granulosa cell tumor (estrogen-secreting → peripheral precocious puberty)
- 1st line tx = unilateral oophorectomy
Treatment for tinea capitis
Oral antifungals (like griseofulvin or terbinafine)
- Presents with scaly patches with alopecia with black dots that represent broken hairs, and cervical LAD
Child has scaly patches on head with alopecia with black dots that represent broken hairs, and cervical LAD.
Dx?
Tinea capitis
- Tx = oral antifungals (like griseofulvin or terbinafine)
When is routine GBS screening performed in pregnancy?
36–38 weeks gestation with a rectovaginal culture.
What is the treatment for a GBS-positive rectovaginal culture?
Intrapartum IV penicillin during labor.
Who gets automatic intrapartum antibiotics for GBS (no need for culture)?
- GBS bacteriuria or UTI in current pregnancy
- Previous infant with early-onset GBS infection
- Unknown GBS status AND:
*<37 weeks gestation
*Intrapartum fever
*ROM ≥18 hour
What should you do if a woman at 30 weeks is worried about Group B Strept infectionn?
Reassure and tell her she will be screened with a culture at 36–38 weeks.
If a patient tests GBS(+) early in pregnancy from a urine culture and was treated. Does she still require intrapartum prophylaxis?
he still gets intrapartum IV penicillin, even if she was treated earlier.
Patient has a febrile non-hemolytic transfusion reaction.
NBS?
Stop transfusion
Give acetaminophen (anti-pyretic)
- Will be stable w no hemolysis
- Prevent by using leukoreduced blood products
What size induration is positive on a PPD test in a patient with HIV
positive if ≥5 mm for: immunocompromised patients (HIV, on prednisone, transplant)
or evid TB exposure or recent contact
What is bethanechol and what is it used for?
Muscarinic agonist drug that stimulates bladder detrusor contraction.
Used in urinary retention (esp, neurogenic bladder)
- It’s like the opposite of oxybutinin (which relaxes bladder detrusor to help treat overactive bladder/urge incont)
What is oxybutinin and what is it used for?
Anti-muscarinic drug used for urge incontinence (overactive bladder). It relaxes the detrusor muscle
- It’s like the opposite of bethanechol (which stimulates detrusor to help relieve urinary retention)
What is tamsulosin and what is it used for?
alpha-1 blocker
- It helps contract ureter smooth muscle to help distal ureteral stones pass
- Treats BPH ➞ relaxes smooth muscle in bladder neck & prostate to improve urine flow
- Occasionally used in urinary retention due to outlet obstruction (eg, post-op, neurogenic)
- AE ortho hypotens
Bladder training, mirabegron, and oxybutynin are used to treat what type of incontinence?
Urge incontinence (overactive bladder)
- 1st-line should consist of lifestyle mods (reduce alcohol/caffeine) + bladder training/ timed void
- Oxybutinin is anti-muscarinic (relaxes bladder detrusor)
- A newer agent, mirabegron (β3-adrenergic agonist) may be offered to patients who can’t take anti-muscarinic drugs (eg, glaucoma)
- Think about training the bladder to not be so hyperactive
Which NSAID is used as a tocolytic?
Indomethacin
(ENDOmethacin ENDs contractions caused by prostaglandins)
“It’s Not My Time”
I - Indomethacin
N - Nifedipine
M - Magnesium sulfate
T - Terbutaline
Which CCB is used as a tocolytic?
Nifedipine
“It’s Not My Time”
I - Indomethacin
N - Nifedipine
M - Magnesium sulfate
T - Terbutaline
Why would you give a tocolytic?
Tocolytics are generally used to decrease contraction frequency in {{c1::preterm}} labor
- Gives enough time to administer betamethasone (promote fetal lung maturity) or transfer to appropriate medical center for level of care needed
If there is fetal distress, and NBS maternal repositioning is unsuccessful, what are the subsequent intrauterine resuscitation measures that can be taken?
Amnioinfusion
C-Section (emergent)
Tocolytics (if tachysystole present)
If maternal repositioning is unsuccessful, then you must ACT (Amnioinfusion, C-section, Tocolytics)
Healthy patients in preterm labor at < {{c2::34}} weeks should receive _______ to postpone delivery.
Tocolytics
- eg, indomethacin (given <32 weeks), nifedipine (given 32-34 weeks)
- Benefits of tocolytics do not outweigh the risks after 34 weeks
What is a positive thompson test?
What does it indicate?
when there is lack of {{c2::plantar flexion}} when the {{c3::calf}} is squeezed
Due to Achilles tendon rupture
These skin findings + warm extremities
arterial or venous insufficiency?
Chronic venous insufficiency
Warm legs + edema + hyperpigmentation =
vs
Cool legs + hair loss + painful ulcers =
Warm legs + edema + hyperpigmentation = venous insufficiency
*img is venous
vs
Cool legs + hair loss + painful ulcers = arterial
What is the recommended treatment for atrophic vaginitis refractory to vaginal moisturizer and lubricant?
Topical vaginal estrogen
What’s another name for atrophic vaginitis?
GU syndrome of menopause
Postmenopausal woman presents with vaginal pruritus / dryness, dysuria / dyspareunia, and increased urinary frequency and urgency? Urinalysis is normal.
Dx =
Atrophic vaginitis (genitourinary syndrome of menopause)
- Next steps: lubricants & moisturizers. If refractory ➞ vaginal estrogen
- D/t ↓ EST support after menopause causing loss of epithelial elasticity
- In the urethra/trigone, this loss of support → urge incontinence
- Can also see petechiae/fissures/bleeding d/t thin tissue
- Dyspareunia d/t narrowed vagina and dryness from less lubrication
What is the initial management for mild atrophic vaginitis?
Vaginal moisturizer and lubricant
- Also called GU syndrome of menopause
- If refractory ➞ give vaginal EST
WAGR syndrome is a combination of:
Wilms tumor
Aniridia (absence of iris)
Genitourinary abnormalities
Range of developmental delay
- In children with known WAGR, abdo U/S is performed q3 months in infancy/early childhood to screen for early detection of Wilms tumor
What’s another name for hereditary hemorrhagic telangiectasia?
aka Osler-Weber-Rendu syndrome
- Presents with blanching skin lesions (telangiectasias), recurrent epistaxis, skin discoloration, AVMs (stroke in kids), GI bleeding, and hematuria
Presents with blanching skin lesions, AV malformations, recurrent epistaxis, skin discoloration, GI bleeding, and hematuria.
Dx =
Hereditary hemorrhagic telangiectasia (aka Osler-Weber-Rendu syndrome)
- Assoc with widespread AVMs
- AVMs in the lung can result in right-to-left shunting with chronic hypoxemia (clubbing), reactive polycythemia, and hemoptysis
-AVMs cause hemorrhagic stroke
Patient with epistaxis, red blanchable papules on the lips, digital clubbing, and isolated polycythemia on laboratory exam.
Dx =
Hereditary hemorrhagic telangiectasia (aka Osler-Weber-Rendu syndrome)
- Assoc with widespread AVMs
- AVMs in the lung can result in right-to-left shunting with chronic hypoxemia (clubbing), reactive polycythemia, and hemoptysis
Patient with one day of unilateral knee pain/swelling? Labs reveals significant hypercalcemia
Dx =
Pseudogout (acute calcium pyrophosphate deposition disease
- Note that pseudogout can happen acutely (just like regular gout)
- Likely 2/2 hyperparathyroidism; pseudogout is also seen with hypothyroidism and hemochromatosis
Patient with brownish skin pigmentation, elevated fasting glucose, and elevated LFTs.
Dx =
Hereditary hemochromatosis
- Other common manifestations: hypogonadism, arthralgias, and hepatomegaly
- “Bronze diabetes”; bronze color due to hemosiderin deposition in dermal macrophages
Middle-aged patient with recently diagnosed diabetes mellitus that presents with pseudogout and hepatomegaly?
Dx =
Hereditary hemochromatosis
- Hereditary hemochromatosis is assoc with pseudogout and should be suspected in a young patient w diabetes and hepatomegaly
Late decels
Bronchiectasis (recurrent respiratory infections) + recurrent sinusitis + situs inversus + infertility.
Dx =
Primary ciliary dyskinesia (Kartagener’s)
- Bronchiectasis may present with dyspnea, {{c1::hemoptysis}}, and purulent sputum. Also foul-smelling sputum, recurrent infections, digital clubbing, nasal polyps. It’s obstructive lung dz.
Who needs endocarditis prophylaxis for dental/respiratory procedures?
- Prosthetic heart valves
- Prior infective endocarditis
- Unrepaired cyanotic congenital heart defects (or repaired with residual defects)
- Heart transplant recipients who develop valve abnormality
Not needed for regular valve defects (like MVP w or w/o murmur), rheumatic heart dz, CABG, pacemaker or ICD
What drug is used for infective endocarditis prophylaxis?
What if they are allergic?
Amoxicillin/Ampicillin/Cefazolin
If allergic ➞ Macrolide (eg, azithromycin) or doxycycline
Which skin cancer typically presents as an elevated nodule with telangiectasias, rolled borders, central crusting, and/or ulcerations?
Basal cell carcinoma (nodular type)
- Photo shows SCC (ulcerated) 1st vs BCC (nodular type) 2nd
Which skin cancer presents as an ulcerative red lesion with frequent scale?
Squamous cell carcinoma
- Photo shows SCC 1st vs BCC 2nd
Which skin cancer presents as a “pink, pearl-like papule” with telangiectasias?
Basal cell carcinoma
- Photo shows SCC 1st vs BCC 2nd
What skin malignancy is most likely in a patient with a significant history of sun exposure and a slow-growing lesion (pictured below)?
Basal cell carcinoma
- Typically appears as a pearly-pink papule with telangiectatic vessels; it may have central ulceration!
Basal cell carcinoma:
- Favors the upper part of the face
- Evolution is measured in years
- Does not metastasize. Death is due to local invasion (“rodent ulcer”). Can be a waxy, raised lesion, or an ulcer.
Treatment for tinea versicolor?
Topical anti-fungal (ketoconazole or selenium sulfide)
What skin condition presents as erythematous, greasy patches w yellow scale in oily areas like: sides of nose, eyebrows, along ears and beard area, and scalp (dandruff). Rash worsens w cold weather and stress.
Seborrheic dermatitis
Vasovagal syncope with typical prodrome + normal ECG + exam.
NBS?
No further workup
- Don’t pick Tilt table testing (this is reserved for patients with recurrent syncope of unclear origin, not a single classic vasovagal syncope episode)
What is a tilt table test used for?
To distinguish between vasovagal or orthostatic syncope
(like if a patient had recurrent syncope of unclear origin, not a single classic vasovagal syncope episode)
- Normal = HR ↑ , BP barely changes
- Positive test = development of hypotension and bradycardia OR slow progressive hypotension with presyncope/syncope
Which type of syncope is often preceded by nausea, bradycardia, and/or a feeling of warmth throughout the body?
Vasovagal syncope
- Triggers include prolonged standing, emotional distress, and painful stimuli
- In patients with single, classic episode of vasovagal syncope, no further workup is needed!
Loss of consciousness after shaving / head turning / tight collars.
Dx =
Carotid sinus hypersensitivity
Young adult with 1 month history of fever and malaise who develops symptoms of CHF with cardiomegaly on imaging.
Dx =
Viral myocarditis
- Symptoms are those of decompensated HF (dyspnea, orthopnea, peripheral edema)
Patient with a recent URI presents with CHF, dilated ventricles with diffuse hypokinesia, and low ejection fraction on echo.
Dx =
DCM
- Often seen following viral myocarditis (particularly after Coxsackievirus B infection)
- Treatment is supportive
A child presents with fever and signs of heart failure after several days of a URI (runny nose and nasal congestion).
Dx =
Viral myocarditis
- Signs of HF include cardiomegaly, mitral regurg, pulm edema, hepatomegaly, etc. (left-HF → right-HF)
- Inflammatory damage (eg, virus, toxin, HSR) induces release of cross-reactive antigens and auto-Abs against heart tissue causing myocarditis
- Acute rheumatic fever can also cause myocarditis, but typically presents with fever + arthritis weeks after untreated GAS pharyngitis
What cardiac pathology results in inflammation with global enlargement, 4-chamber dilation, and diffuse hypokinesis?
Myocarditis
- Major cause of sudden cardiac death (SCD) in adults < 40yo
- Due to lymphocytic inflammation of myocardial tissue + edema → weakened tissued + dilated chambers
What is pulsus paradoxus and where do we see it?
↓ in amplitude of systolic BP by > 10 mmHg during inspiration
Seen in cardiac tamponade.
Also asthma, OSA, pericarditis, and croup
NOT myocarditis
Postpartum woman presents with lactation failure, amenorrhea, fatigue, and hypotension for months after a spontaneous vaginal delivery that was complicated by uterine atony.
Dx =
Sheehan syndrome (pituitary INFARCT - not hemorrhage)
- Symptoms are due to hypopituitarism 2/2 ischemic infarction and necrosis of the pituitary gland following massive obstetric hemorrhage
Paroxetine
SSRI
Which type of psychotherapy seeks to correct faulty assumptions and negative feelings that exacerbate psychiatric symptoms?
CBT
(specifically exposure with response prevention subtype)
- The patient is taught to identify maladaptive thoughts and replace them with positive ones
- MC used to treat depressive and anxiety disorders
- May also be used for paranoid personality disorder, OCD, somatic sx disorders, hoarding disorder, eating disorders
Patient s/p Roux-en-Y gastric bypass surgery presents with abdominal bloating, diarrhea, and macrocytic anemia.
Dx =
SIBO
- Macrocytic anemia due to vitamin B12 deficiency
- Contrast with dumping syndrome - which presents as colicky abdominal pain, nausea, shakiness, and diarrhea 15-30 minutes post-prandial
What does PTH normally do to phosphate?
PTH normally lowers phosphate by ↑ing urinary excretion
so if ↓ PTH (hypoparathyroidism) ➞ phosphate will ↑
What electrolyte abnormality is typically the cause of hypocalcemia in a patient with alcohol use disorder?
Severe hypomagnesemia
- Severe hypomagnesemia → ↓ PTH release and resistance to PTH → hypoparathyroidism with ↓ Ca2+ and ↓ phosphate
(vs. other causes of hypoparathyroidism)
What is the total body phosphate level in a patient with type 1 diabetes? (↑ or ↓ )
Decreased
- Phosphate and glucose are buddies. If glucose can’t get into the cell, phosphate can’t either (both stay in serum). Cells deplete their intracellular stores. This causes low total body phosphate despite high concentrations in serum
What is the serum level of calcium in secondary hyperparathyroidism? (↑ or ↓ )
Decreased (hypocalcemia)
- Decreased calcium is the defect causing the ↑ PTH
How do the following laboratory values change in patients with osteomalacia?
PTH:
Serum calcium:
Serum phosphorus:
Alkaline phosphatase:
Parathyroid hormone: {{c1::increased}}
Serum calcium: {{c1::decreased or normal}}
Serum phosphorus: {{c1::decreased}}
Alkaline phosphatase: {{c1::increased}}
How do you distinguish Huntington disease from Wilson disease?
Both have neuropsych symptoms and some parkinsonism symptoms
but hungintons has no assoc with liver disease!
Which blistering skin disorder presents as groups of pruritic vesicles, papules, or bullae located on extensor surfaces?
Dermatitis herpetiformis
- Often found on the extensor surfaces (eg, knees, elbows), also buttocks, back.
- Do not confuse with contact dermatitis (eg, poison ivy): Typically localized itchy erythematous papules + vesicles (in severe cases) with serous oozing.
Adolescent with history of T1DM presents with weight loss, iron deficiency anemia and a pruritic, vesicular rash on the elbows and knees.
Dx =
Celiacs
- Iron deficiency results from poor iron resorption in the duodenum
- Assoc with other autoimmune conditions like T1DM
- Dermatitis herpetiformis
- Confirm with anti-TTG antibody testing
Patient with an intensely pruritic and burning rash (pictured below)? The patient has also experienced occasional diarrhea and weight loss.
Dx =
Celiacs with dermatitis herpetiformis
What is the heme AE with clozapine that must be monitored for?
Agranulocytosis but answer is specifically Neutropenia!
Thus, monitor WBCs/absolute neutrophil count frequently
- Neutrophils are the main components of the granulocyte population.
- Agranulocytosis = severe neutropenia
- They test agranulocytosis is neutropenia - don’t fall for distractors like “lymphocytopenia” or “all leukocytes low”
Patients taking clozapine require regular monitoring of ________
absolute neutrophil count (because AE agranulocytosis)
- Discontinue if agranulocytosis develops
- Neutrophils are the main components of the granulocyte population.
- Agranulocytosis = severe neutropenia
For SBO:
If the patient had abdominal surgery/cesarean-section, the SBO is due to _________ .
If the pt has Crohn’s, the SBO is due to ________.
Abdominal surger or C-section ➞ adhesions
Crohn’s ➞ strictures
What is lead time bias?
The typical example is apparent prolongation of survival in patients to whom a test is applied, without changing prognosis of the disease
↑ FSH with absent breast development and no pubic hair.
NBS?
Karyotype analysis
- Likely Turners ➞ 1ry ovarian insufficiency (streak ovaries)
Adolescent girl with primary amenorrhea + uterus present on ultrasound + high FSH levels.
NBS?
Karyotype analysis
- High FSH indicates a peripheral cause, such as hypergonadotropic amenorrhea (eg, Turner syndrome)
Primary amenorrhea + cubitus valgus + short height =
Turners
- NBS? karyotype
Trauma patient with a widened mediastinum ± left-sided hemothorax with tracheal deviation.
Dx =
Aortic injury / rupture
- Hemothorax leads to the tracheal deviation; rupture will lead to hypotension
- Xray shows the widening/tracheal deviation/hemothorax
- Dx conf: with CT scan + angiography
- Other findings may include pseudocoarctation (due to obstructive intimal flap) and hoarseness (due to compressed L-recurrent laryngeal N)
What is the best initial test for blunt aortic trauma?
CXR
- Should be ruled out in patients with blunt deceleration trauma (MVA or fall from > 10 feet)
- Xray shows the widening/tracheal deviation/hemothorax
Which one usually occurs in children between 5-7 years old.
Legg-Calve-Perthes or SCFE?
Legg-Calve-Perthes
(xray attached)
- while SCFE occurs in individuals aged 10-16 years old
Which of the following is self-limited (~2-3 years)
Legg-Calve-Perthes or SCFE?
Legg-Calve-Perthes
(xray attached)
- Femoral head begins healing after 1y and new subchondral bone develops; new bone replaces the old bone in 2-3 years
Which of the following is associated with an insidious onset of hip pain
Legg-Calve-Perthes or SCFE?
Legg-Calve-Perthes
(xray attached)
- Initially a painless limp, followed by an insidious onset of hip pain
Which of the following is associated with acute hip/knee pain and altered gait
Legg-Calve-Perthes or SCFE?
SCFE
- Typically has more pain associated with it than Legg-Calvé-Perthes
Which of the following always requires surgery
Legg-Calve-Perthes or SCFE?
SCFE
- Requires fixation with a screw, and there may be a prophylactic screw fixation of the contralateral hip as well
- Note: Legg-Calvé-Perthes requires surgery if patient is ≥ 6 years old
What is the management for patients < 6 y/o with refractory Legg-Calvé-Perthes?
Casting and bracing
- If femoral head deformity develops or ROMO worsens
- 1st-line treatment before for patients < 6 y/o with Legg-Calvé-Perthes is reduced weight-bearing and physical therapy
8 year old boy presents with chronic hip/knee pain with limited internal rotation/abduction of the affected hip. The gait is antalgic.
Dx =
Legg-Calvé-Perthes
= Idiopathic osteonecrosis of the femoral head that typically presents in boys age 4 - 10 years old; initial Xrays may be negative
- Antalgic = shorter time weight bearing on the bad side secondary to pain
- Compare with SCFE (10 - 16 y/o and obese with posterior displacement of femoral head; “slip on the fat”)
What is the initial management for patients < 6 years old with Legg-Calvé-Perthes ?
Limited weight bearing and physical therapy
- If age <6 and refractory ➞ cast and brace (if femoral head deformity develops or ROM worsens).
- If age ≥ 6 ➞ surgery is more beneficial (bc the bone formation capacity is too limited to repair the femoral head damage)
What is postexposure prophylaxis for hepatitis B?
Unvaccinated/incomplete vaccination:
Non-responder:
Previous vaccination (confirmed antibody response) or prior resolved infection:
Un-vaccinated/incomplete vaccination: {{c1::Hep B immunoglobulin + full vaccine series}}
Non-responder: {{c1::2 doses Hep B immunoglobulin}}
Previous vaccine series (confirmed antibody response) or prior resolved infection: {{c1::none}}
13M with right thigh pain
Dx =
Tx =
SCFE
with Salter-Harris type 1 fracture at growth plate
➞ tx: surgical stabilization of the femoral head
- Xray img is from NBME (as so is the info below)
- Limp
- Can have fracture at growth plate
- Usually kids 10-15yo
- Pain often refers to the knee
- Dx: xray both hips, lateral & frog-leg
A young woman presents with irritability, weight loss, and decreased sleep. She has lots of energy and isn’t eating because she’s not hungry. Exam: erythema of the turbinates and nasal septum. BMI is 19.5.
Dx =
Cocaine use disorder
A seemingly manic patient that also has autonomic hyperactivity (dilated pupils, diaphoresis, tremor, HTN) ➞ think?
Stimulant intoxication (cocaine, amphetamines..)
- Dont confuse with PCP (nystagmus!)
What is the preferred diagnostic study for suspected aortic dissection in hemodynamically unstable patients or those with renal insufficiency?
Transesophageal echocardiography (TEE)
- vs. CT angiography in stable patients without renal insufficiency
What is the preferred route of intubation in a cervical spine trauma patient without significant facial trauma?
Orotracheal intubation (because risk respiratory compromise)
- Doing it orally is best (better than NG or surg tracheostomy)
What is the first step in the management of cervical spinal trauma?
Spinal immobilization
Patient is in preterm labor at 36w gestation. What is the management?
Expectant labor management
- do NOT give tocolytics (only if <32w or 32-34w) – too risky now
FEV1 = 67% of predicted
FVC = 95% of predicted
FEV1/FVC ratio = 0.65
Obstructive or restrictive?
Obstructive
- obstructive is anything with FEV1/FVC <70% or 0.70 (even 67% is enough) = low
What acid/base disturbance does primary hyperaldosteronism cause?
Metabolic alkalosis
- Pt w HTN + hypokalemia
Which immunodeficiency presents with recurrent infection, failure to thrive, chronic diarrhea, and thrush?
SCID
- Susceptible to viral and fungal infections due to no T cells
- Susceptible to bacterial and protozoal infections due to no B cells
Infant that presents with failure to thrive, lymphadenopathy, and leukocytosis with a history of Pneumocystis jirovecii and Candida infection?
HIV infection
- Due to selective loss of CD4+ T lymphocytes; however, absolute lymphocyte count is normal (vs. SCID)
- Dx is confirmed with PCR reaction testing
- LAD and leukocytosis = HIV
- Absent lymph nodes, and leukopenia or ↓ absolute lymphocyte count = SCID
Best long-term treatment for SCID
stem cell transplant
- IVIG is a treatment option, but not best long-term/definitive
Patient with progressive achy left groin pain
Dx =
Avascular necrosis (osteonecrosis)
- most likely due to alcohol
LH & FSH levels in turners
Increased
- if ↓ LH/FSH (means functional hypothal amenorrhea d/t stress/*strenuous exercise/anorexia)
The absence of bleeding following a progestin withdrawal challenge indicates?
low estrogen in functional hypothalamic amenorrhea (eg, high performing athletes, anorexia nervous)
or ovarian failure (eg, Turners?)
or from inadequate endometrial lining (eg, Asherman syndr)
What is the first-line treatment for trigeminal neuralgia?
Carbamazepine or oxcarbazepine
- Carbamazepine was on actual exam!
- Trigeminal neuralgia causes repetitive, unilateral, shooting pain in a distribution of CN V lasting < 1min.
What hematologic pathology is associated with restless legs syndrome (RLS)?
Iron deficiency anemia
Other possible causes of RLS include:
- Uremia
- Diabetes mellitus
- Parkinson disease
- Pregnancy
↓ mobility and bulging of the tympanic membrane.
Dx =
Acute otitis media (AOM)
What is the next step for a child that presents with symptoms concerning for acute mastoiditis?
Empiric IV antibiotics & drainage
- Abx should cover: Strep pneumo, Strep pyogenes, and Staph aureus (Pseudomonal coverage if hx of such infection or recent abx use) → ceftriaxone, ampicillin/sulbactam, levofloxacin
- Drainage of purulent material can be achieved with tympanostomy (± ear tube placement) or mastoidectomy
- If 2/2 exacerbation of chronic otitis media → surgical debridement and vancomycin
Imaging (eg, CT or MRI [children]) indicated for:
- Sx that don’t improve after 48h of treatment
- Suspected intracranial complication
- Planned surgical intervention
Patient noticed hypopigmented skin lesions on her trunk after returning from a summer vacation in Florida.
Dx =
Pityriasis versicolor
- Typically noticed after sun exposure as the surrounding skin gets darker (lesions do not tan in the sunlight, so they will be more prominent in summer/after sun exposure)
Child notices multiple, pruritic hypopigmented skin lesions on the face and trunk after beginning summer camp.
Dx =
Pityriasis versicolor (aka tinea versicolor)
- Typically noticed after sun exposure as the surrounding skin gets darker (lesions do not tan in the sunlight, so they will be more prominent in summer/after sun exposure)
Tx tinea versicolor
Topical anti-fungals incl:
topical ketoconazole
selenium sulfide
terbinafine
- Mupirocin = tx’s impetigo & other superficial bact infections
- Oral griseofulvin = tx’s tinea capitis.
Newborn with bilious emesis and dilated loops of bowel on X-ray.
NBS?
Contrast enema
Helps differentiate between:
Meconium ileus (microcolon on enema due to unused colon) and
Hirschsprung disease (transition zone on enema)
What congenital disease can present as failure to pass meconium in a 2 day old, or as constipation in a 2 year old?
Hirschsprung disease
- FTPM → explosive diarrhea (squirt)
- Constipation → overflow incontinence
Rapid diagnosis:
Tight anal sphincter with explosive release of stools and air upon removal of finger.
Hirschsprung disease
(“squirt sign”
What intervention prevents errors when concerns are raised but dismissed by senior staff?
Team-based safety communication (eg, simulation training)
- Poor teamwork is the leading root cause of sentinel events
What MSK pathology is characterized by impaired relaxation after a single muscle contraction?
Myotonic dystrophy
- Myotonia = difficulty relaxing muscles
What is the recommended treatment for a newborn of a mother with active hepatitis B?
Hepatitis B immune globulin + HBV vaccine
within 12 hours of birth
- Compare with routine HBV vaccination, which is recommended within 24hof birth
- Same ppx as healthcare worked exposed to blood from hepB positive patient.
What is the recommended prophylaxis for an unvaccinated healthcare worker that is exposed to blood from a hepatitis B positive patient?
Hepatitis B vaccine and hepatitis B immune globulin
- Same as newborn to active hepB mom
No.1 RF for cerebral palsy
Prematurity
Until what gestational age are tocolytics given in the management of preterm labor?
<34 weeks
- Give along with steroids (for lung maturity)
- Tocolytics = to postpone deliv
- At >34 weeks gestat, tocolytics such as indomethacin and nifedipine are not recommended as risks of indomethacin (oligohydramnios, closure of ductus arteriosus) and nifedipine (maternal hypotens/tachy) outweight the risks of premature deliv.
Meds that improve mortality in HFrEF=
- ACEi’s/ARBS
- B-blockers
- mineralocorticoid-R antagonists (*eplerenone, spirono)
- SGLUT-2 inhibitors.
- CCBs (eg, amlodipine, diltiazem) have not been shown to provide sympto or mortality benefit in HFrEF and have no direct role in mgmt!!
What pulmonary pathology is shown in the CXR?
Pneumothorax
- Presence of the white visceral pleural line, pulmonary vessels are not visible beyond the visceral pleural boundary
Hemodynamically unstable patient with penetrating trauma to the 6th intercostal space and an equivocal FAST exam.
NBS?
Ex-lap
- Indics for ex-lap are: HDUS, peritoneal signs, evisceration
- Anything below 4th ICS (nipple) can affect abdo organs.
hemodynamically stable patient with penetrating abdominal trauma, rebound tenderness, and guarding.
NBS?
Ex-lap
- Indics for ex-lap are: HDUS, peritoneal signs, evisceration
Hemodynamically stable patient with penetrating abdominal trauma without peritonitis, evisceration, or impalement?
NBS?
FAST → if negative → {{c1::CT}}
- With peritonitis → exploratory laparotomy
Which heart chamber composes the majority of the anterior surface of the heart?
Right ventricle
- Thus in a penetrating trauma at the LLSB, the right ventricle would be hit (pleura would be injured but the lung would not be).
Which movement-related symptom presents as slow, writhing movements, especially in the fingers?
Athetosis
-“writhing, snake-like movement”; seen with Huntington disease
Which movement-related symptom presents as a sudden, brief, uncontrolled muscle contraction?
Myoclonus
- eg, jerks, hiccups
- May be seen with Creutzfeldt-Jakob disease and renal / liver failure
- May also be seen in traumatic settings, eg, cardiac arrest causing prolonged cerebral hypoxia (posthypoxic myoclonus)
Young patient with hepatosplenomegaly, resting tremor, dysarthria, parkinsonism, and dementia.
Dx =
Wilson disease
- D/t copper bound to DA and accumulation of copper in the putamen/basal ganglia/striatum
MCC of viral meningitis
Enteroviruses (like coxsackie B)
What is the treatment for delirium tremens?
Benzo’s (eg, chlordiazepoxide, lorazepam)
Patient develops confusion, agitation, diaphoresis, and tremors three days after being admitted to the hospital following a motor vehicle accident. Exam: tachycardia, tachypnea, hypertension.
Dx =
Delirium tremens
- Defined by autonomic excitation, agitation, tremor, and altered sensorium 48 - 96h after the last drink
Vital sign changes (tachycardia, hypertensive), tremors, and anxiety POD 2-4.
Dx =
Delirium tremens
- Defined by autonomic excitation, agitation, tremor, and altered sensorium 48 - 96h after the last drink
Tx: Benzo
Formula for sensitivity
a/a+c
Patient with a long history of schizoaffective disorder presents with lip smacking, sticking out their tongue, and squirming movements of the torso.
Dx =
TArdive dyskinesia
Farmer presents to the hospital with agitation, vomiting, and watery eyes? Exam: 1 mm pupils bilaterally and increased bowel sounds.
Dx =
Organophosphate (AChEi) poisoning
A woman presents with infertility and chronic pelvic pain with a fixed, immobile uterus on exam?
Endometriosis
- Pelvic adhesions may interfere with oocyte release and/or block sperm entry, thus causing infertility; resection of lesions improves conception rates
Dysmenorrhea, dyspareunia, and dyschezia -=
Endometriosis
