3CK PART I Flashcards
<p>What are absolute contraindications to solid organ/ heart transplant?</p>
<p>1. Systemic illness with life expectancy of < 2 years despite heart transplant
2. Irreversible pulmonary hypertension
3. Clinically severe cerebrovascular disease
4. Active substance abuse ( drugs or alcohol) ( tobacco,alcohol, drugs is a relative contraindication-- if within 6 months)
5. inadequate social support or cognitive behaviorall disabilitiy-> inhability to comply to medical therapy
6. multisystemic disease with severe extracardiac dysfunction ( ie. amyloidosis) </p>
<p>Transfusion related acute lung injury ( TRALI)</p>
<p>Respiratory distress and signs of non-cardiogenic edema
WITHIN 6 hours of transfusion
caused by donor anti-leukocyte antibodies.
</p>
diagnosis of type 2 HIT
HIT antibody testing, -Serotonin release assay
Absence of breathing for more than ___ time is abnormal in children
> =20 is apnea
When do you screen for HTN
> 18 years
2 year interval in healthy patient
1 year interval in pts with pre-hypertension
first-line treatment for cystitis in nonpregnant women
TMP/SMX
Viral illness + bleeding mucosa+ petequia+thrombocytopenia
Immune thrombocytopenia
If a patient develops Heparin-induced thrombocytopenia, what are the recommendations for subsequent anticoagulation?
patients who develop type 2 HIT are advised to avoid all forms of heparin for life to limit the risk of new antibody formation (and recurrence).
Unfractionated heparin, low-molecular-weight heparin, heparin flushes for arterial lines, and heparin-coated catheters all require avoidance, and a “heparin allergy” should be listed in the medical record
Causes /precipitating factors of hepatorenal syndrome
Decreased glomerular pressure: NSAIDs use
Reduced renal perfusion: GI bleeding, SBO , Vomiting , sepsis, excessive diuretic use
labs in sarcoidosis
hypercalcemia/hypercalciuria ( may lead to nephrolitiasis)
high ACE levels
Osteoma>
Bone growth from another bone - usually skull
Presentation of mycotic aneurysms and what can they cause
Is a complication of infective endocarditis.
Systemic or intracerebral
Occur due to septic embolization and vessel wall destruction.
In brain– can grow progressively and due to compression lead to focal deficits
If ruptured may lead to subarachnoid hemorraghe – headache, lethargy, neck stiffness
Explain non inferiority and superiority trials
GRAPH
Medications that can cause SJS
sulfonamides, quinolones, aminopenicillin, cephalosportin
ASM: lamotrigine, CBZ, Phenytoin
Treatment of impetigo
Mupirocin and retapamulin are first-line treatments
Mupirocin is applied three times daily and retapamulin is applied twice daily. The recommended length of treatment is five days
antibiotics (eg, cephalexin) are warranted for extensive infection.
Criteria for endocarditis?
Modified Duke Criteria
Definite Dx: 2 major OR 1 major and 3 minor OR 5 minor
Major:
2 positive cultures
Echo showing valvular vegetation or de novo lesion
minor:
Fever> 38
Immunologic phenomena ( GM, Osler nodes, Roth sportS)
Vascular/emboli phenomena
Hx of IV drug use/ predisposing cardiac disease
1+ culture
Colloid what are they , examples
Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid.
albumin and fresh frozen plasma.
There is no evidence that colloids are better than crystalloids in those who have had trauma, burns or surgery and as they are more expensive their use is not recommended.[1]
<p>Congenital pulmonary valve stenosis associated to which syndrome?</p>
<p>Noonan syndrome</p>
should breast-feeding be avoided with silicone implants?
NO, All women, even those with breast implants, should be encouraged to breast feed their babies. There is no risk in breast-feeding with a silicone breast implant.
Pathology in HCM
sarcomere mutation
<p>Stages of CPRS ( Complex pain regional syndrome) </p>
<p>Stages:
1. Burning pain, edema and vasomotor changes
2. Edema, skin thickening and muscle wasting
3. Most severe and includes limited range of motion and bone demineralization on xray
</p>
Meniere’s disease presentation and pathogenesis
At any age, MC 20-40s
TRIAD:
hearing loss- sensorineural, usually fluctuating and often affects the lower frequencies. - hearing loss progresses over time and may result in permanent hearing loss at all frequencies.
Tinnitus- low pitch (like listening to a seashell or machinery) and may be associated with auditory distortion.
PERIODIC VERTIGO ( (a true spinning sensation that has an onset and an offset))- rotatory spinning or a rocking sensation may persist from 20min to 24 hours duration
Pathogenesis: endolymph hydrops
Tto ankylosing spondilitis
Conservative
patient education and exercise: mainstay of treatment
Medical
nonsteroidal antiinflammatory drugs (NSAIDs) : pain and stiffness
tumor necrosis factor (TNF) inhibitors (adalimumab,
etanercept) typically used in patients who do not respond to conservative and NSAID treatment
Lesions in sporotrichosis
Lesions:
Painless papule—>ulcerates—> drains a non purulent, odorless fluids.
Over days similar lesions usually develop over the lymphatic chain
Type 2 of HIT
Thrombocytopenia - platelets typically decline >30%-50%
Timing - onset 5-10 days after heparin initiation or ≤1 day with prior, recent heparin exposure
Thrombosis - new thrombosis, progressive thrombosis, or skin necrosis
Alternate causes - no other sources for thrombocytopenia are present or likely
Difference between trichloroacetic acid and podophyllin as tto of genital warts
unlike Trichloroacetic acid, podophyllin is not indicated for internal use in patients with condyloma acuminata and should not be used during pregnancy.
Podophyllin arrests mitosis in metaphase.
Transillumination test is positive in which pathology
Hydrocele
<p>how is defined longed term opiod use?</p>
<p>>3 months</p>
Which of the HEP VIRUSES is the unique with DNA?
Hep B
Pathogens causing bronchiolitis
RSV is the MCC
Metapneumovirus
parainfluenza
Anterior cruciate ligament lesion test
lachman test - displace the proximal tibia anteriorly when knee flexed 30 degrees
<p>Dx glucagonoma</p>
<p>ptes in th 5th decade
Glucagon > 500
Weight loss ( catabolic effects of glucagon)
Diabetes mellitus ( can be recently diagnosed)
Necrolytic migratory erythema ( low aa, hyponutrition)
Venous thrombosis 30%</p>
Drugs that prolong the QT
Anti ABCDE + HIV protease inhibitors, methadone, oxycodone
Anti Arrhythmics- Class IA and III Antibioticos: macrolides, anti malarials, fluoroquinolone Anti Cychotics: haloperidol, risperidone AntiDepressants: TCAs, SSRIs AntiEmetics: ondansetron
All about coccidiomycosis
Southwestern US and California
Pneumonia, meningitis, erythema nodosum arthalgia
Earthquake
Spherule filled with endospores
If local: itraconazole/fluconazole
If systemic: amphotericin b
Labs in pertussis infection
Leuckocytosis with lymphocyte predominance ( > 20,000 with > 50% lymph)
RF for osteoporotic fracture risk
Advanced age Previous osteoporotic fracture Lon-term corticosteroid therapy Cigarette Low body weight ( 58 kg) Fx hx of hip fracture Excess alcohol intake Rheumatoid arthritis Secondary osteoporosis prolonged heparin use
Ginkgo Biloba- Mechanism of action & SE
“memory booster” suggested mechanism is increased cerebral flow
SE:
MOST IMPORTANT:Risk of bleeding and potentiation of anticoagulant effects - inhibits platelet derived factor.
Seizures, headache, restlessness, irritability
When do you give corticosteroids in pregnancy? and why
patients at risk for preterm delivery at <37 weeks gestation (or <34 weeks gestation in patients with diabetes mellitus).
decrease the neonatal morbidity and mortality associated with preterm birth (eg, respiratory distress syndrome).
MS course in pregnancy
pregnant women with MS usually have lower disease activity during pregnancy and higher disease activity in the postpartum period.
X-ray and lab findings of Transient tachypnea of the newborn
Dx: clinical Xray can show: flat diaphragm Mild cardiomegaly Prominent vascular markings in a sunburst pattern at hilium. Fluid in the interlobar fissures Pleural effusion may be present Alveolar edema—> fluffy densities
ABG: Hypoxemia and hypercapnia
Treatment for MS-related spasticity
baclofen or tizanidine
Pathophysiology of BPPV
Crystalline deposits (canaliths) in semi-circular canals->disrupt normal flow of fluid in vestibular system->contradictory signalling from corresponding canals on each side->interpreted as spinning/vertigo sensation
Vertigo with positional changes, NO HEARING LOSS
Presentation and treatment of brinchiolitis
Two phases:
First upper respiratory ss: rhinorrhea, nasal congestion, cough
Lower Resp ss: wheezing, crackles, respiratory distress, hypoxemia,
fever
Supportive care: hydration, saline nasal drops , nasal bulb congestion
Patients should be advised to avoid other triggers of airway reactivity, particularly cigarette smoke.
Alcohol tto
AA
Naltrexone
Acamprosate
Disulfiram - short term use, not for heart disease pts
Causes and labs for intrinsic AKI
- ATN- most common;y due to toxins or ischemia
- AIN
- Rhabdomyolisis/Hb
- Crystal deposition ( Ca, uric acid, oxal)
5.Bence Jones prot - Strept
Aminoglucosides, cisplatin, amphot, NSAIDS
Labs: BUN/Creat < 20:1 Osm< 300 Increased FeNa, UNa EXCEPT Contrast agens ( decreased FeNa and UNa)
Management of DVT /PE
First line is >=3 months Factor X inhibitors -( orally, no need of heparin bridge or lab monitoring)
In patients WITHOUT CA is the first line.
In patients with Ca –LMWH.
Should women with breast implants be screened with MRI every 2-3 years?
Yes, to screen for asymptomatic implant rupture, which could lead to scarring within the breast
apnea of prematurity- what is it?
true apnea and pauses in breathing lasting ≥20 seconds; it typically resolves by a corrected gestational age of 37 weeks (ie, at 1 week of life for a 36-week gestation infant).
Contraceptive method in antiphospholipid treatment
Estrogen containing are CONTRAINDICATED
Progestin-releasing IUD ( decreases blood loss, so preferred in patients with cramps and dysmenorrhea) Copper treatment ( increases blood loss)
Amaurosis fugax is a sign of
carotid atherosclerosis disease– carotid bruit.
Guillain Barre pathophysiology
Demyelination of peripheral nerve axons
If an upper esophageal mass is found in the upper esophagus of a patient, which is the most likely histopathologic type of tumor?
Upper 2/3rds is squamous cellular- often associated to alcohol, tobacco
Lower third- Adenocarcinoma- associated to Barret esophagus or GERD.
Uterine sarcoma (eg, leiomyosarcoma) is associated with
pelvic radiation and tamoxifen
Meds to avoid in Wolff Parkinson white
digoxin
b blockers
ca channel blockers
adenosine
These favor conduction through accesory pathway
Levothyroxine treatment for hypothyroidism in patients with uncorrected adrenal insufficiency can cause
adrenal crisis by increasing metabolic demand and clearance of glucocorticoids.
Duplex ultrasound in DVT
noncompressibility
Alteration of platelets in renal dysfunction
There is inhibition of their activity, leading to bleeding , prolonged BT but NORMAL NUMBER.
epigastric pain that worsens with meals
gastric ulcer
<p>What is complex regional pain syndrome and pathogenesis</p>
<p>Complex regional pain syndrome o Usually occurs after injury o Pain is out of proportion o Temperature change and skin color o Edema
Pathogenesis: injury causing increased sensitivity to sympathetic nerves
Abnormal response to and sensation of pain
Increased neuropeptide release- allodynia.
</p>
Treatment with ACEI and ARBs is associated with decreased risk of new onset diabetes in patients with HTN
True
Which complex forms the Achilles tendon?
Gastrocnemius- soleus complex
<p>Dx and treatment of CPRS ( Complex pain regional syndrome) </p>
<p>Dx: autonomic testing that measures increased resting sweat output or MRI
Tto: regional sympathetic nerve block or IV regional anesthesia.
Local nerve block
</p>
7 localized manifestations of giant cell arteritis
Temporal headaches Jaw claudication Polymyalgia rheumatica Arm claudication ( diminished pulses, and bruits in subclavia or axilla) CNS: TIA/stroke, vertigo Anterior ischemic optic neuropathy
Two types of Anomalous Aortic origin of coronary artery and mechanism
left main coronary artery originating from the right aortic sinus and
the right coronary artery originating from the left aortic sinus.
These defects create sharp curvature of the anomalous coronary artery, making it less amenable to high-volume flow. In addition, the anomalous artery passes between the aorta and the pulmonary artery, making it susceptible to external compression during exercise.
<p>Treatment of Guillain Barre</p>
<p>plasmapheresis </p>
When is penicillin prophylaxis indicated in pregnancy
Group B Streptococcus (GBS) prophylaxis in patients at <37 weeks with an unknown GBS status to prevent neonatal sepsis.
Subclinical hypothyroidism
Elevated TSH and normal T4
non-specific ss of hypothyroidism
Before treatment always have a good hx and order Anti-TPO antibodies to exclude Hashimoto
If patient has any of the following treat with thyroxine:
- goiter
- hypercholesterolemia
- Ss of hypothyroidism
- TSH >=20
Smoking cessation medications
Varenicline- partial agonist at the alpha4-beta5 subunit of the nicotinic acetylcholine receptor.
Nicotine patchees, gum , lozenge,
Bupropion (EA: dry mouth, insomnia, headaches)
What is the classification of HF?
A. Risk of HF, no structural abnormality
B. Structural abnormality, no ss of HF
C. Structural abnormality, ss of HF
D. HF with ss at rest or night.
how many veins/arteries has the umbilical cord
2 arteries 1 vein ( most oxygenated- PaO2 30, SatO2 80%)
Biopsy in sarcoidosis
noncaseating granulomas that stain negative for fungi and acid fast bacilli
<p>Treatment of classic adrenal hyperplasia</p>
<p>Classic is 21 alpha hydroxylase def
Tto:
- Glucocorticoids and mineralocorticoids ( hidrocortisone)
- high salt diet
- reconstructive surgery for genitalia
- psychosocial support</p>
Definition of dyspepsia
> = 1symptom: postprandial fullness, epigastric pain or burning, early satiety
Management of IUGR
Weekly biophysical profiles
Serial umbilical artery Doppler sonography weekly
Serial growth ultrasounds 3-4 weeks
Labs in dermatomyositis
CK,LDH,Aldolase
ANA ( 80%), anti-Ro, anti-La, anti-Sm, anti-ribonucleoprotein (RNP), and anti-Jo-1 antibodies.
colchicine interaction with azathioprine
leukopenia
Optimal duration of oral penicillin in strept pharyngitis
10 days both to ensure full eradication of bacterial carriage and to prevent rheumatic fever.
How long should hep b patients been monitored?
Regurarly with aminotransferases, HBV DNA levels, and HBsAg.
Aminotransferases usually normalize within 2-8 weeks
Patients who havent cleared the HBsAG after 6 months of initial ss, are dx with chronic infection
S1 and S2 correspond to
S1: Mitral and tricuspid valve closure, loudest at mitral area
S2: Aortic and pulmonary valve closure.
Which is the most significant predictor of the likelihood of returning to work in this patient?
patients recovery expectation
Education to improve patients’ understanding of natural history and prognosis may improve the likelihood of returning to work.
Which Antihypertensives are contraindicated in pregnancy
Thiazides
ACEIs, ARBS
Calcium channel blockers
B blockers and hydralazine are safe
brain death algorithm
see ipad
When do you assess for PE in DVT?
If patient is symptomatic (eg, chest pain, shortness of breath, hemoptysis).
Do A CT
Management same as DVT- RIVAROXABAN OR WARFARIN
5 components of root cause analysis
Collect data Identify possible causal factors Identify root cause Make recommendations and implement changes measure the success of changes
Complications of pyelonephritis during pregnancy
Preterm labor
Low birth weight
Acute respiratory distress syndrome
What is Podophyllin and moa
is used as a medication to treat genital warts and plantar warts, including in people with HIV/AIDS.
Podophyllin arrests mitosis in metaphase.
Treatment of stable angina
ABN
Aspirin 325 mg
B blocker
Nitroglycerin
Alternatives of tto of strep if not able to tolerate oral penicillin or penicillin allergy?
a single dose of intramuscular penicillin is bactericidal for up to a month and can be given to patients who cannot tolerate oral antibiotics.
Azithromycin x 5 days if allergy
Pulse pressure calculation
systolic -diastolic pressure
Pulse pressure is proportional to SV, inverse to arterial compliance
TTO for keratosis pilaris (KP). KP (“chicken skin”)
retained keratin plugs in the hair follicles.
emollients and topical keratolytics (eg, salicylic acid, urea)
presentation of patellar tendon rupture
swelling and tenderness in the anterior knee, often with superior displacement of the patella.
With a complete tendon rupture, patients cannot actively extend the knee and cannot raise the leg against gravity.
Defect in Kartagener syndrome? presentation
Defect in dynein arm
Infertility ( immotile sperm, cilia in fallopian tubes dont move)
Situs inversus ( e.g. dextrocardia)
Chronic sinusitis
Bronchiectasis
Management of pyelonephritis during pregnancy
IV ceftriaxone, cefepime
Once afebrile for 48 hours, patients are placed on oral antibiotics for 10-14 days. After treatment completion, daily suppressive therapy (eg, low-dose nitrofurantoin or cephalexin) is initiated and is maintained until 6 weeks postpartum to prevent recurrence.
A combination of hydralazine plus nitrate therapy has been shown to provide additional symptomatic and mortality benefit in African American patients with persistent New York Heart Association class III or IV symptoms due to left ventricular systolic dysfunction (left ventricular ejection fraction <40%) not responding to optimal medical therapy.
true
Conditions that decrease the pulse pressure
everything that decreases flow: aortic stenosis, cardiogenic shock, cardiac tamponade, advanced heart failure
Pheochromocytoma
Paroxysmal elevated blood pressure with tachycardia
Pounding headaches, palpitations, diaphoresis
Hypertension with an adrenal incidentaloma
Subacute infective endocarditis- pathogen and presentation
Viridians streptococci
Smaller vegetations on previously damaged valves or congenital valves.
Gradual onset
Screen for osteoporosis
All women 65 or older
Postmenopausal women < 65 with on or more risk factors for fracture
Men with risk of fracture
Structure lesioned in the following scenario:
Patient landed on the right knee, currently with severe pain and swelling. Patient not able to actively extend the knee or cannot raise the leg against gravity
Patellar tendon tear/rupture
Neonatal polycythemia definition
Hcto >= 65 or Hb > 22
Is most commonly observed at 2-3 hours of life
<p> 17 alpha hydroxylase deficiency</p>
<p> increased aldosterone, decreased cortisol ( hypoglycemia) and sex hormones.
Patients with HTN ( salt and fluid retention) +hypoK
Ambiguous genitalia, no secondary characteristics developed. </p>
Standardized mortality ratio
SMR = observed number of deaths/expected number of deaths
quantifies mortality in a specific group as compared to the general population
An SMR of 1.75 indicates that the observed number of deaths among the miners in this study was 1.75 times (or 75%) higher than would be expected if these miners had the same death rate as the standard population.
<p>Classification of enuresis and causes </p>
<p>Monosymptomatic ( only enuresis)
| Non-monosymtomatic ( enuresis + lower UT ss)</p>
If hemochromatosis is not treated the pt is at risk of?
hepatocellular Carcinoma
Prehn sign
Elevating the testicle leads to relief of pain- this occurs in epididymitis
TImeframe of when HPA axis suppression is more likely with glucocorticosteroids.
HPA axis suppression is more likely with prolonged (>3 weeks) GC usage, especially at higher doses or with evening administration. In these cases, a gradual taper of GCs is indicated.
A lengthy taper of >1 month may be required for patients with very prolonged GC therapy (eg, >1 year).
If given < 3 weeks abrupt stop of GCs can be done and would not affect the HPA axis
Patellar stress fracture presentation
chronic pain that worsens with activity
Brugada Syndrome
AD, Asian
pseudo right bundle branch block and ST elevations in V1-V3
HIGH risk for arrythmias and SCD
Implantable cardioverter-defibrillator
Why ciprofloxacin is CI in pregnancy
toxic to fetal cartilage development.
Treatment of scoliosis
always do first an Xray before tto to see Cobb angle
- low/medium risk curve:observation or the use of a back brace
- severe scoliosis (Cobb angle ≥40 degrees) requires surgical evaluation for possible spinal fusion given the high risk for progression and future complications (eg, chronic back pain, pulmonary compromise
Presetnation and treatment of MVP
Ehler Danlos, Marfan
Woman with atypical pain, palpitations, panic attack
Is better when ventricle filled with blood
Tto: avoid dehydration and give b blocker
How is the peak bone mass in men vs women, and how this affects the age on presentation
Bone mineral density depends on the peak bone mass and the rate of bone mass loss. The peak bone mass is higher in men, so men present with osteoporotic lesions 10 years later than women
Treatment for opioid withdrawal
Opioid agonist: methadone (preferred) or buprenorphine(potential worsening of withdrawal)
Nonopioid: clonidine (alpha2 adrenergic agonist) or adjunctive medications (antiemetics, antidiarrheals, benzodiazepines)
The choice depends on scenario:
opioid requires being in supervised or outpatient
Clonidine can be done
What does U wave indicates?
repolarization interventricular septium, prominent in hypoK
bradycardia
hypercalcemia
hyperthyroid
Raloxifene effect on hot flashes and DVT
increase the risk of hot flashes and VTE
obturator nerve lesion
sensory loss over the medial thigh
weakness in leg adduction.
<p>INitial treatment DM</p>
<p>
Conscious and able to drink and swallow safely:
Administer 0.3 g/kg (10 to 20 g) of a rapidly-absorbed carbohydrate. 15 g is supplied by 3 glucose tablets, a tube of gel with 15 g, 4 oz (120 mL) sweetened fruit juice, 6 oz non-diet soda, or a tablespoon (15 mL) of honey or table sugar. May repeat in 10 to 15 minutes.
Altered mental status, unable to swallow, or does not respond to oral glucose administration within 15 minutes:
Give an initial IV bolus of glucose of 0.25 g/kg of dextrose (maximum single dose 25 g).Δ The volume and concentration of glucose bolus is infused slowly at 2 to 3 mL per minute and based upon age:
2.5 mL/kg of 10% dextrose solution (D10W) in infants and children up to 12 years of age (10% dextrose is 100 mg/mL)
1 mL/kg of 25% dextrose (D25W) or 0.5 mL/kg of 50% dextrose (D50W) in adolescents (25% dextrose is 250 mg/mL; 50% dextrose is 500 mg/mL)
Unable to receive oral glucose and unable to obtain IV access:
Give glucagon 0.03 mg/kg IM or SQ (maximum dose 1 mg):◊
Perform blood glucose monitoring every 10 to 15 minutes as the effects of glucagon may be transient
Establish vascular access as soon as possible</p>
How do you evaluate rupture of Achilles tendon?
Thompson test- squeeze the gastrocnemius should cause plant to flex. Patient should be laying prone or knee in a chair.
In Achilles rupture there is no plantar flexion
DO NOT ASK ACTIVE PLANTAR FLEXION- Pt may use accessory muscles ( ie. fibularis) and falsely reassure they can
MRI should be asked if thompson positive.
Anal abscesses pathophysiology
one or more of the several glands that encircle the anus become blocked and the bacteria within grow unchecked
Treatment of dyspepsia
If the patient exhibit ss mostly due to GERD- heartburn, regurgitation or cough is indicated a trial with PPIS
In patients taking COX inhibitors- suspend and give a trial of PPIs during 8 weeks
In patients when this is not common assessment depends on
1. Age > 55 years
2. Alarm ss: weight loss, hematemesis, iron deficiency anemia
3. Helicobacter pylori status- if negative, treat with 4-6 weeks PPIs
If positive - treat ABCs
Patients with age> 55 or alarm signs should undergo an endoscopy
Meaning of Absent or reversed umbilical artery end-diastolic flow
placental insufficiency and impending fetal hypoxia, particularly with concomitant oligohydramnios, and is an indication for delivery
SE ACE inhibitors
Acute renal failure, hyperK, dry cough, angioedema, skin rash,altered sense of taste
<p>Prognosis of primary monosymptomatic enuresis</p>
<p>t resolves spontaneously at a rate of approximately 15 percent per year [9,10]. The longer the enuresis persists, the lower the probability that it will spontaneously resolve [7,9].</p>
MCC of thrombocytopenia in adults and children?
Immune thrombocytopenia
Labs ordered in initial prenatal visit
Rh(D) type, antibody screen Hemoglobin/hematocrit, MCV HIV, VDRL/RPR, HBsAg Rubella & varicella immunity Pap test (if screening indicated) Chlamydia PCR Urine culture Dipstick for urine protein
Cardiac output formula and variation with exercises ( early, late stage)
CO= SV x HR CO= (MAP-RAP)/TPR
In early exercise, the CO is maintained by both increased SV and HR
In late exercise is maintained by increase in HR
Bullous impetigo in an adult, suspect of?
HIV
Difference between MM & Monoclonal gammopathy of undetermined significance . & Waldenstron Macroglobulinemia
Monoclonal gammopathy:
Asymptomatic, may lead to MM
NO CRAB findings
Develop MM at a rate of 1-2% year
Waldenstron: M spike=IgM Hyperviscosity ( diplopia, tinnitus, headache) Neuropathy Bleeding Hepatosplenomegaly LAD
Treatment for MS-related neuropathic pain
Gabapentin, duloxetine
<p>Colon cancer screen in high risk patients </p>
<p>Colonoscopy at 40 or 10 years before his relative and repeat 3-5 years
</p>
RF for lead toxicity
RF for lead toxicity:
- PICA
- Houses built < 1978
- Decoration/ toys painted < 1978
- Foreign born children
- Low SES
What is exostosis
Surfer’s ear - irritation due to cold and water leads to bnormal bone growth within the ear canal. - narrowing the canal
<p>Pellagra signs and symptoms, which vitamin?</p>
<p>Niacin ( B3)
~~~
4Ds
Dementia
Diarrhea
Dermatitis
Death
~~~
\+ red tongue, vomiting, diarrhea
insomnia, anxiety, disorientation , delusion.</p>
<p>11 b hydroxylase</p>
<p>HTN - fluid and salt retention
virilization
decreased aldosterone
renin decreased( has some glucocorticoid activity) </p>
Small bowel obstruction vs. ileum
Small bowel obstruction
- Recent surgery ( weeks to years
- Increased bowel sounds , abdomen distended
- There is no gas in the colon
Ileus:
Recent surgery ( hours), metabolic abnormalities ( HYPOKALEMIA), MEDS
Decreased bowel sounds , abdomen distended
There is gas throughout the small and large intestine.
ECG findings in massive PE
MC:Sinus tachycardia
Other consistent ECG findings that occur due to right ventricular (RV) strain include new right bundle branch block, atrial arrhythmias, and Q-waves or ST-segment changes in the inferior leads.
pulmonary hypertension caused by massive PE often leads to dilation of the tricuspid valve annulus and functional tricuspid valve regurgitation seen on echocardiogram.
<p>HARTNUP disease </p>
<p>AR
Defect in transport of NEUTRAL AA by the intestine and renal tubules
Def of tryptophan and other aa
~~~
Usually asymptomatic BUT:
Failure to thrive
Photosensitivity
Ataxia
nystagmus
-pellagra like ss
~~~
DX: aminoaciduria
Tto: high protein diet
nicotinic acid.
</p>
Types of hepatorenal syndrome
Type I : rapidly progressive , most patients die within 10 weeks without treatment
Type II: progress more slowly with an average survival of 3-6 months.
Total serum IgE in Allergic bronchopulommonary aspergillosis
> 417 ng/ml
In what situation there is an increase of type I errors?
When we test multiple times at a set p value
Urge urinary incontinence dx, tto
Urge ( detrusor hyperactivity)
urodynamic testing
- lifestyle modifications ( time voids and bladder training- establish a baseline interval and gradually increase the time between voids- eventually 3-4 hrs
- antimuscarinic medication such as tolterodine, solifenacin, or oxybutynin.
- IF PERSISTS DESPITE ABOVE considered for botulinum toxin injections or percutaneous tibial nerve stimulation.
<p>Patient who develop fever + chills after blood transfusion, nothing else. </p>
<p>Febrile non-hemolytic transfusion reaction
reaction to cytokines released from WBCs in a product that has not been leukoreduced
acetaminophen</p>
Presentation of herpes simplex encephalitis
acute onset < 1 week fever seizures altered mental status focal neurological ss - such as hemiparesis, or CN deficits
AAOCA
exertional angina,
lightheadedness, or syncope;
however, some patients experience SCD without any premonitory symptoms.
Resting ECG is typically unremarkable.
Heart murmur that radiates to carotids
aortic stenosis
MC cancers in dermatomyositis
adenocarcinoma of the cervix ovaries, lung pancreas bladder stomach. non hodgkin lymphoma
SE of CCBs
Dihydropyridines( amlodipine): peripheral edema
Non-dihydropyridine( verapamil, diltiazem): heart block
<p>Acute hemolytic transfusion reaction </p>
<p>intravascular hemolysis ( ABO incompatibility) or extravascular hemolysis( host antibody agains antigen on RBC)
Direct coombs +
plasma hemoglobin >25
hemoglobinuria</p>
presence of orbital fat tissue in the wound indicates
a high probability of septum injury and a possible levator palpebrae injury.
pseudogout
intra-articular steroids, NSAIDs, colchicine
Which muscles cause eversion of the foot?
The fibullaris ( aka peroneos) - longus, brevis, tertius
Hawthorne effect
subjects’ participation in research, the subsequent awareness of being observed, and the possible impact on behavior.
may overestimate the effect of the intervention, and the internal validity of the study
Stalled puberty
it was started but doesn’t complete within 4 years
When do you screen for hyperlipidemia
Measure nonfasting total cholesterol and HDL
All men <=35
Women>=45
Also men 20-35 if RF
Women 20-45 IF RF
If total cholesterol 240 and RF get a complete lipoprotein profile(LDL, TRG)
Child victim of abusive head trauma with lethargy, what do you order next?
CT head– subdural hematoma - mainly in patients with altered mental status.
It usually presents as a mixed density pattern ( some regions darker which is more chronic, some regions lighter which are more acute)
Once this has been done, skeletal Xray survey first.
<p>Treatment of glucagonoma</p>
<p>Octeotride
| Surgical resection </p>
discoid lupus erythematosus of the scalp
hair loss, scaling, inflammation, scarring, and hypopigmentation of the skin.
There may be associated lesions present over the face or extremities.
MOA and SE of metoclopramide
prokinetic agent that acts as a central and peripheral D2-receptor blocker.
akathisia, dystonia, and parkinsonian-like symptoms
Constitutional delay of growth and puberty
- pathophysiology and clinical presentation
Is the most common cause of delayed puberty.
Transient defect in GnRH production from hypothalamus
Family history , AD , “ late bloomers” in the history
Length at birth is normal
Length 3-6m downward shift in growth rate but always parallel.
3-4 years grow in a low-normal rate below but parallel to the 3RD PERCENTILE
Hallmark is the delayed bone growth.
NORMAL GROWTH VELOCITY
<p>Medications such as b blockers completely resolve essential tremor T/F</p>
<p>F</p>
Pregnant woman with Lyme, risk of congenital abnormalities for fetus?
NO increased risk to the fetus when the mother receives adequate treatment for Lyme disease with
14-21 days of amoxicillin or cefuroxime.
Non-pregnant woman :doxycycline
PCP MOA
NMDA receptor antagonist
Risk factors for gestational diabetes mellitus
family history of diabetes mellitus, a history of GDM in a previous pregnancy, obesity, multiple gestation, and maternal age >25.
S2 splitting in. inspiration mOA
AP
with inspiration higher blood to the left meaning that pulmonary valve closes after aorta
Mechanism of bone loss with glucocorticosteroids
Glucocorticoids cause bone loss through different mechanisms:
- Decrease Ca absorption in the gut
- Cause renal calcium wasting
- Direct anti-anabolic effect in the bone
- Suppress the release of GnRH—> hypogonadism —> aggravates bone loss
Which nerve innervate the fibullaris longus and brevis?
superficial fibular nerve
ECG findings for Brugada syndrome
(right bundle branch block and ST-segment elevation in leads V1-V3)
or long QT syndrome (QTc >450 msec in men or >470 msec in women) makes these diagnoses less likely.
AD disorder
When do you give Mg in pregnancy? and why
patients at <32 weeks gestation
provides fetal neuroprotection and decreases the incidence of cerebral palsy.
<p>Strategies to avoid opioid misuse</p>
<p>check state prescription drug monitoring program > random urine checks > schedule frequent follow-ups</p>
Acute retinal vein thrombosis vs. retinal artery
retinal artery: amaurosis fugax
retinal vein thrombosis : retinal hemorrhage
<p>Coarctation of aorta associated to which syndrome?</p>
<p>Turner</p>
Endometriosis can present with immobile uterus and cervical motion tenderness T/F
T
Immune thrombocytopenia treatment
- steroids: children response well, adults late and may relapse
- IVIG: can raise platelet count in significant bleeding.( macrophages eat the given IgG instead of the one bound to platelets)
- splenectomy in refractory cases
children-if skin manifestations only- observe. If bleeding IVIG, steroids.
adults: >=30,000 without bleeding observe. IF <30,000 OR bleeding treat.
<p>Description of the lesions of atopic dermatitis and locations</p>
<p>Chronic pruritic rash with escoriation and lichnification
infants: red crustered lesions in extensor surfaces
adults: flexural eczema and liquenification </p>
Management of neonatal polycythemia
IV fluids
Glucose
Partial exchange transfusion
Labs ordered at 34-37 weeks of pregnancy
Group B Streptococcus culture
Nerve involved in Meralgia paresthetica,
Lateral femoral cutaenous nerve entrapment
PURELY SENSORY
decreased sensation over the anterolateral thigh without any muscle weakness or deep tendon reflex abnormalities.
treatment of joint pain in juvenile idiopathic arthritis
Intraarticular corticosteroid injections
Atypical lymphocytosis are seen in which diseases
EBV Toxoplasmosis Rubella Roseola Viral hepatitis CMV acute HIV infection MUmps
What is the MCC of HF in the use?
Ischemic cardiomyopathy - most have known CAD, however is not uncommon that they dont know . 7%
HTN, bilateral flank pain/fullness and a family history of end-stage renal disease
ADPKD
patients are often asymptomatic
holosystolic, high pitched “ blowing murmur”
mitral/tricuspid regurgitation
<p>To whom do you give leukoreduced RBC transfusion</p>
<p>1. Chronically transfused patients
2. CMV seronegative at risk patients( AIDS,HIV)
3. Previous febrile non-hemolytic transfusion reaction </p>
Management of PCP intox
If patient is violent– give BZD ( if BZD doesnt work, restrains may be needed or even haloperidol)
If ss are mild- patient is calmed but detached or in withdrawal- low stimulating environment ( with or without BZD)
findings in of aortic stenosis
crescendo decresendo
radiates to carotids
single soft murmur
pulsus parvus et tardus ( weak and delayed)
lead to SAD: Syncope, angina, dyspnea on exertion
CHF
If dysphagia for
both liquids and solids , what do you suspect and what do you order?
— Neuromuscular disease - motility disorder— Barium swallow with barium
Infants born to women with MS have risk of MS?
increased risk of developing MS (eg, 3%-23% of MS cases are familial)
and can be born with lower birth weights.
AV node delay
100 msec
Conditions that increase pulse pressure
everything that increases flow: hyperthyroidism, aortic regurgitation, aortic stiffening, OSA ( increased sympathetic tone), Exercise ( transient)
Treatmnt of scabies
permethrin
When monitoring a patient with angina that may develop MI how do you do it?
Troponin I ( at least 2 troponins 3 hours apart) and serial ECG (30 minutes) .
<p>What are the blood transfusions associated with hypotension?</p>
<p>-anaphylaxis
- transfusion related acute lung injury TRALI
- primary hypotension reaction
- bacterial sepsis</p>
After treating a patient for H.pylori, what is the best method to confirm erradication ?
Fecal antigen testing 4 weeks after completing treatment
- bismuth and oral antibiotics can lead to false negative results
- urea breath testing 4 weeks after completing treatment is also an option but is not as available as fecal antigen
Confounding bias
when the study design or analysis does not control for the potential effect these confounders may have on the association under study.
<p>Dermatitis herpetiformis is associated with what condition and how does it presents</p>
<p>celiac disease
pruritic papules and vesicles on extensor surface of the elbows and knees, but also on buttocks and back </p>
Prognosis of pregnancy related melasma
Pregnancy-related melasma typically regresses spontaneously within the first year after delivery, although some areas do not completely resolve.
Treatment for raynaud phenomena
1st line Nifedipino and amlodipine.
diltiazem a little
not verapamil
Is liver biopsy done for confirming hemochromatosis ?
NO
Bedside screen for sepsis
qSOFA ( Sequential organ failure assessment)
1 point to: * Respiratory Rare >=22 * Altered mental status * SBP<100 A score >= 2 is likely to be sepsis
MS exacerbation treatment
long term treatment?
steroids
Disease-modifying drugs (eg, beta-interferon, glatiramer acetate) decrease the frequency of relapses and reduce the development of brain lesions
Basilar artery occlussion presentation
motor weakness, ataxia, or incoordination altered level of consciousness fascial weakness dysphagia dysarhtria
Fick’s principle, what is it and how is it calculated
An indirect method to measure CO
rate of O2 consumption/ ( arterial O2-venous O2)
Management of perianal and small ischiorectal abscesses
Can be drained in the office, no need of surgery unless they are too large
T-scores for osteopenia, osteoporosis, severe osteoporosis
Normal >= -1
Osteopenia -1 to -2.5
Osteoporosis =<2.5
Severe: =<2.5 + fragility fracture
Cause and ppt of immune thrombocytopenia
ACUTE ( children) viral illness or after immunization
IgG against GpIIb/GpIIIa , generated by plasma cell in spleen. macrophage eats the complex.
BM with high megakaryocytes, low platelets ( usually < 50)
patient with parkinson and recurrent pneumonia? dx?management?
Parkinson may be complicated by dysphagia and drooling
Leading to aspiration pneumonia
Do a videofluoroscopy swallow barium
Give thickened liquids and modified swallowing techniques
Types of volume expanders
Crystalloids and colloids
Acute treatment for gout in normal vs. CKD/renal transplant?
NSAIDs( Indomethacin),colchicine, steroids
Intraarticular glucocorticoids OR if already on systemic steroids increase the dose
Stress ulcer prophylaxis indication
Any 1 factor
Coagulopathy: platelets <50,000/mm3, INR >1.5, PTT >2x normal control
Mechanical ventilation >48 hours
GI bleeding or ulceration in last 12 months
Head trauma, spinal cord injury, major burn
> 2 factors
Glucocorticoid therapy
>1 week ICU stay
Occult GI bleeding >6 days
Sepsis
Achalasia cause and dx
Abscence myenteric plexus in LES-> loss of inhibition so permanent contraction
Manometry: Incomplete relaxation in LES and apersitaltic esophagus
Dx: barium swallow
EGD to rule out malignancy, otherwise normal mucosa
Manometry.
<p>Colon cancer screen in average risk patients</p>
<p>Colonoscopy every 10 years gFOBT or FIT each year FIT-DNA each 1-3 year CT colonography every 5 years Flexible sigmoidoscopy every 5 years
gFOBT:guiac-based fecal occult blood test
FIT: fecal immunochemical test
FIT-DNA: multitarget stool test</p>
Dx of lead poisoning
Dx: > 5
It can be assessed through finger stick trst- “ capillary”, but if positive always confirm with a venous sampling.
In kids - abdominal X ray to evaluate for lead containing objects or flecks given the exposure
How to determine statistical significance with confidence interval
- In a study comparing treatment A and B against placebo, and they present OR with CI. The confidence intervals did not include 0 which means that the treatments were significantly different from placebo. But now compared A and B we have to se if there is or not overlap
1. If there IS NO OVERLAP— there is a significant difference between the groups
2. If there is OVERLAP, there may or not be statistically difference between the groups.
Labs in polymyalgia rheumatica
ESR> 40, SOMETIMES >100
High CRP
Normocytic anemia
20% can have normal studie
How do you manage PAD with ABI:
=< 0.9 OR > 1.3 ?
between 0.9 and 1.3?
=< 0.9 OR > 1.3 Consult a vascular specialist duplex imaging CT angiography MR angio angiography
between 0.9 and 1.3
Exercise test
Is abnormal if ABI post-test is decreased by >= 20%
Management of acute hemolytic transfusion reaction
Stop the transfusion aggressively hydrating the patient with normal saline (not Ringer’s or dextrose) to treat the hypotension and prevent renal failure.
normal QRS
<120 msec
Suicide assessment
Evaluate ideation
Wish to die, not wake up (passive)
Thoughts of killing self (active)
Frequency, duration, intensity, controllability
Evaluate intent
Strength of intent to attempt suicide; ability to control impulsivity
Determine how close patient has come to acting on a plan (rehearsal, aborted attempts)
Evaluate plan
Specific details: Method, time, place, access to means (eg, weapons, pills), preparations (eg, gathering pills, changing will)
Lethality of method
Likelihood of rescue
Patient with dysphagia in whom you suspect a structural lesion in the upper esophagus, what do you order
Nasopharyngeal laryngoscopy
Medications that can cause urinary retention
anticholinergics antihistamines baclofen TCAs decongestants CBZ
clinically significant scoliosis definition and what is the next step
Spinal rotation ≥7 degrees (or ≥5 degrees in overweight children)–>X ray
If < 7 –> reassurance
differnt to Cobb angle in X ray: ≥10 degrees have scoliosis
Score of minimental for dementia
<24
<p>Psychosocial risk factors that may be assessed for organ transplant candidates</p>
<p>poor medical adherence
substance abuse ( drugs/alcohol)
poor social support
cognitive dysfunction
Psychosocial factors are as important as medical and surgical to evaluate for organ transplant candidate. </p>
Treatment of seborrheic dermatitis
topical antifungals ( selenium sulfide, ketoconazole)
topical glucocorticoids
topical calcineurin inhibitors ( pimecrolimus)
Because is chronic , relapsing disease patients require intermittent re-treatment . eg. topical ketoconazole every 1-2 weeks
Cushing syndrome
Central obesity, facial plethora
Proximal muscle weakness, abdominal striae
Ecchymosis, amenorrhea/erectile dysfunction
Hypertension with adrenal incidentaloma
Management of PAD?
PAD =< 0.9
First line - Exercise, ASPIRIN, STATIN, HTN & DM modifications
second line- if above dont work Cilostazol (selective inhibitor of PDE3)
Last: percutaneous revascularization
Mechanism of action of B blockers for HTN
decrease HR, decrease CO, decrease renin release
- is good in CHF, CAD, Afib
What is cholesteatoma?
skin growth that occurs in an abnormal location, the middle ear behind the eardrum.
It is usually caused by repeated infection that causes an ingrowth of the skin of the eardrum
. Cholesteatomas often take the form of a cyst or pouch that sheds layers of old skin that builds up inside the ear.
kyphosis classification and causes
non structural: slouching ( sitting lazy), no need of treatment easily corrected with position
structural: always rule out: spinal infection, fracture, tumor, degeneration
special exercises to strengthen and straighten the back; using a back brace or having surgical correction is considered only for chronic pain or significant spinal convexity (>60 degrees)
What do you order in a patient in whom you suspect ADPKD?
renal US
Diffuse esophageal spams
uncoordinated simulatenous contractions, intermittent chest pain and dysphagia.
Manometry : intermittent persistasis , multiple simultaneous contractions.
Clinical signs of strep A pharyngitis - S. pyogenes
abrupt onset of fever
sore throat
malaise
absence of upper respiratory symptoms (eg, cough, rhinorrhea, congestion).
PE: tonsillar exudates, tender anterior cervical lymphadenopathy, and palatal petechiae.
Patient treated with nifedipine for Raynaud that comes back to clinic mentioning that has not improved and now has myalgias, arthralgias. Next step?
Raynaud syndrome,
ANA, RF, CBC, blood chemistry, urinalysis and measurement of complement levels.
Outcome in multiple linear regression vs logistic regression
linear: continuous outcome
logistic: categorical outcome
How is the breast Ca screening in patients with breast implants?
SAME AS NORMAL PERSON
starting at age 40-50 years (earlier if there are risk factors) per the guidelines.
pathogens of septic arthritis in kids >=3 months
S. aureus
Group A Strep( pyogenes)
Pathogenesis of hepatorenal syndrome
Liver cirrhosis-> portal hypertension—> NO release from splanchnic vasculature—> systemic vasodilation —> decreased of peripheral resistance and BP—> renal hypo perfusion—> activate RAS, sympathetic system and ADH. — worsen volume overload
If suspected massive PE, next step?
Echocardiogram
acute right ventricular dysfunction, tricuspid annulus dilation, and functional tricuspid valve regurgitation.
What is the underlying mechanism of the following disorders:
- Transposition of great vessels
- Tetralogy of fallot
- Persistent truncus arteriosus
Conotruncal abnormalities result from failure of neural crest to migrate
Maternal complications of adolescent pregnancy
hydatiform mole pre-eclampsia anemia operational vaginal delivery postpartum depression
D2 Inadequate nutrition and physiologic immaturity
Contraindications to neuraxial analgesia in thrombocytopenic patients
severe thrombocytopenia (platelets <70,000/mm3) or rapidly dropping platelet count (often associated with preeclampsia with severe features). –> risk of spinal epidural hematoma.
in this cases intravenous analgesia is an option
<p>patient hiked in washington state and now has gait ataxia, ascending paralysis, what do you suspect and what do you do next?</p>
<p>tick paralysis
meticulous revision of the skin</p>
<p>Klienefelter dx</p>
<p>47 XXY,
karyotype
gynecomastia and small testes </p>
SE B blockers
Bradycardia Bronchospasm Insomnia Fatigue may increase TG and decrease HDL Depression sedation may MASK HYPOGLYCEMIC SS IN DM ON INSULIN
When does the heart starts beating?
4 weeks
patient with dysphagia with lower esophagus ss, what do you order
Esophagoduodenoscopy
<p>4 scenarios of Niacin (B3) deficiency?</p>
<p>1. Deficiency:
a. In developing worlds: corn that has not been processed
b. in developed countries: alcoholics
2. Carcinoid Syndrome: tryptophan is used to produce 5-OH tryptophan and serotonin rather than Niacin
3. Prolonged consumption of isoniazid: isoniazid decreases pyridoxal phosphate which triggers production of tryptophan. There is no conversion to niacin
4. Hartnup disease: AR , decreased abosrption of tryptophan by intestinal and renal cells. Dx with neutral aa in urine. </p>
Ejection fraction calculation
SV/EDV
normal >=55%
What should be done in MM to assess the risk of fracture?
skeletal survey
punched-out lytic lesions,
diffuse osteopenia, or
fractures in nearly 80% of patients.
Common sites for lytic lesions include vertebral bodies, skull, thoracic cage, pelvis, and proximal humerus and femur.
Other imaging modalities are usually reserved for patients with bone pain and negative initial x-ray skeletal surveys.
Causes of dyspepsia
Most of the cases is primary- idiopathic
Dyspepsia secondary to organic disease — Although there are several organic causes for dyspepsia, the main causes are peptic ulcer disease, gastroesophageal reflux, nonsteroidal anti-inflammatory drug (NSAID)-induced dyspepsia, and gastric malignancy (table 1).
labs Alcoholic liver disease and hepatic steatosis
elevations in transaminases > elevation in alkaline phosphatase
What to consider when a pt wants to be discharged against medical advice?
Discuss specific benefits/risks of proposed treatment & alternatives
Discuss specific risks of refusing treatment
Assess decision-making capacity - any physician can assess it, not necessarily a psychiatrist
Understands proposed treatment
Understands risks of refusing treatment
Demonstrates a reasoned basis for leaving against medical advice–The physician should ask the patient to explain the reason for refusing treatment and address any modifiable external influences
Discuss follow-up care & option to return to emergency department
Notify primary physician, family
Document in medical record
Presentation and RF of angiodysplasia
GI bleeding, painless
RF:aortic stenosis, von Willebrand disease, CKD.
Pathophysiology of Spinal muscular atrophy
Degeneration of anterior horn cells and motor nuclei of lower brainstem
AR
strongest predictor of future suicide attempts
previous suicide attempt
Define Type I error
Type I error ( alpha)
rejection of the null hypothesis ( false +) — falsely inferring the existence or reality of something that is in fact not real or doesn’t even exist
Heart Failure classification
A: High risk for HF, no structural heart abnormality or ss of HF ( Patients with DM, HTN, cardiotoxic drugs)
B. Structural abnormality but no ss ( MI,or valvular disease with Left ventricular enlargement or low EF)
C. Structural abnormality with prior or current + SS
D. At rest HF or end stage cardiac disease
Pathophysiology of HTN effects on heart
Increased afterload–>concentric LVH–> decreased LV function. As a result the chamber dilates–> ss and signs of CHF.
HTN accelerates atherosclerosis , so high incidence of CAD and PAD
Dx of gout
Clinical presentation highly suggestive
Arthrocentesis with monosodium urate crystals confirms diagnosis
Negatively birefringent, needle-shaped crystals under polarizing light
Differential dx of primary hypogonadism and secondary?
Primary: Klinefelter Secondary: Constitutional delay, malnutrition, chronic illness Hypothyroidism HyperProlactinemia Kallman Sx Craniopharyngioma
Management to prevent osteopenia/osteopososis in pt requiring life-long use of corticosteroids.
Give Ca and Vit D supplementation, if just prevention
Biphosphonates such as alendronate, are only approved once osteoporosis has established. And treatment would be indicated if DEXA shows T score< 1.5 that continues to rapidly deteriorate.
Complication of impetigo
Poststreptococcal glomerulonephritis
Rheumatic fever
Critically ill patinet ( ie. head trauma ) that had hypotension at some point and develops melena, cause?
GI stress ulcer ( is not ischemic colitis because it should be hematochezia)
ill patients –> uremix toxins, reflux of bile salts into stomach–> alter mucsal layer and risk of ulcer formation.
head trauma: increased gastrin secretion–> acid–> risk of ulcer
shock: mucosal ischemia leading to ulcerations.
AAOCA DX
Transthoracic echocardiogram can sometimes make the diagnosis, but it can also miss or inaccurately characterize AAOCA.
CT coronary angiography or coronary magnetic resonance angiography provide the best visualization of coronary anatomy, and are the diagnostic tests of choice in patients with suspected AAOCA.
Allocation vs selection bias
Allocation bias: result from the way subjects are assigned to the treatment and control groups. It may occur when subjects are nonrandomly assigned to the treatment groups of a clinical trial (eg, physicians may preferentially enroll sicker patients into the treatment group).
selection bias: study population does not represent the general population
contraceptive-induced cholestatic liver d
high bilirubin
Causes Neonatal polycythemia
increased erythropoiesis due to intrauterine hypoxia: Maternal HTN, Smoking, DM; or IUGR
Eryhtrocyte transfusion: delayed cord clamp, twin-twin transfusion
Genetic or metabolic abnormalities: hypo/hyperthyroidism, genetic trisomies.
TTO Diffuse esophageal spams
Ca channel blockers,
<p>What is triamcinolone?</p>
<p>topical corticosteroid</p>
Exams to consider in erectile dysfunction
rectal exam neuro exam CBC chemestry panel Fasting glucose Lipid profile If hypogonadism or loss of libido -Testosterone, prolactin level, TSH
When does withdrawal from methadone occurs?
24-48 hrs
Immune thrombocytopenia during pregnancy effects
IgG crosses placenta, Antibodies can be transmitted to the baby
Non polar aa
Tryptophan Phenylalanine Methionine Proline Glycine Isoleucine Alanine Valine Leucine
Afib that needs antiarrhythmic in the context of LVH
Dronedarone
Amiodarone
<p>What are the most common congenital defects that can present for first time in adulthood?</p>
<p>MC: Bicuspid aorta
| 2nd MC: ASD</p>
RF and presentation of uterine sarcoma
radiation
tamoxifen use
postmenopausal bleeding, uterine growth and irregular
Definition of adolescent pregnancy
=< 19 years
Extrarenal manifestations of ADPKD
Cerebral aneurysms Hepatic & pancreatic cysts Cardiac valve disorders (mitral valve prolapse, aortic regurgitation) Colonic diverticulosis Ventral & inguinal hernias
The effect of Valsalva, amylnitrate, standing on heart murmurs?
VAS-> decrease venous return so increases HCM and MVP
<p>BZD withdrawal </p>
<p>confusion, restlessness, tremors, psychosis and AUTONOMIC INSTABILITY ( elevated heart rate, BP and temperature)
withdrawal from long or intermediate . peak within days
Withdrawal from short ( ATOM- alprazolam, triazolam, oxazepam, mdz) occurs within 24 hrs </p>
What type of antihypertensive is commonly the first line drug despite knowing that there is no significant difference with others?
Thiazides
What is the next step in a patient in whom you suspect HTN due to renovascular disease?
Renal doppler US or CT or MRI angiography . BUT RENAL US is preferred in patients with renal insufficiency- due to contrast induced nephropathy.
Patients with hematochezia and hemodynamic instability (eg, orthostatic hypotension) should generally be assumed to have an upper GI source of bleeding.
TRUE
” blowing murmur”
is regurgitation, can be mitral, tricuspid, aortic
Severe pain with hypertensive emergency
aortic dissection
What happens if a patient scheduled for a very important surgery is diagnosed with hypothyroidism? SHould you continue with the surgery? treat the patient?
Hypothyroidism (in the absence of myxedema coma or other severe symptoms) usually only mildly increases the perioperative risk.
In life threatening conditions heart disease is better to assume these risks and continue with the surgery as planned
ACE and ARBs should not be used in combination T/F
T
Do you do exercise ECG stress test in Pulmonary arterial hypertension?
Exercise ECG stress testing is used to evaluate for suspected coronary artery disease; it does not have a role in the evaluation of patients with suspected PH.
characteristics HIV myopathy
Proximal
LE>UE
+ myalgias and muscle tenderness
Overflow urinary incontinence dx
Postresidual void > 50 men, > 150 women ml
urodynamic testing
cholinergic agents ( bethanechol), intermittent catheterization
characteristics myopathy in dermatomyositis
Proximal, UE>LE
<p>How to differentiate an ascending paralysis from tick with a spinal lesion?</p>
<p>spinal lesion can cause paralysis, absent reflexes
but SENSATION is likely to be abnormal too.
Most common etiologies ( tumor, infection) - progress slowly over days or weeks</p>
<p>Insulin crosses the placenta T/F</p>
<p>F. In infants of diabetic mother, the infant compensates producing insulin. </p>
What is the most important risk factor for osteoporosis in both men and women?
Age
others less important are alcohol, smoking and family hx
Cobb angle
measures spine curvature on x-ray and is the gold standard for determining diagnosis and treatment of scoliosis.
Cobb angle ≥10 degrees have scoliosis.
What tests to order in a new patient with CHF
Chest X ray( pulmonary edema, cardiomegaly, rule out COPD)
ECG
Cardiac enzymes to rule out MI
Echocardiogram( estimate EF, rule out pericarditis)
Serology for immunization of Hep B
AntiHbs
How to differentiate septic arthritis vs transient synovitis
Kocher criteria for septic arthritis: “WENT" WBCs>12 ESR >40 Non weight bearing T > 38.5
ACUTE PAIN IN SEPTIC ARTHRITIS!
Pediatric patients with ≥3 criteria have a high likelihood of septic arthritis (>93%), and immediate joint aspiration is performed to both establish the diagnosis and decompress the joint. Once the diagnosis is confirmed, empiric parenteral antibiotics as well as surgical drainage and debridement of the joint are required.
What are the causes of HF with preserved LV function?
- Diastolic Heart failure: HTN leading to left ventricle hypertrophy, restrictive/infiltrative cardiomyopathy, occult CAD
- Valve disease : Mitral S or R, Aortic S. or R
- Pericardial disease: constrictive pericarditis, cardiac tamponade
- High output conditions: Anemia, thyrotoxicosis, beri beri , sepsis, AV fistula
prognosis of GERD in newborns/infants
more frequent during the first few months of life
peak at 4 months;
it is expected to self-resolve by age 12-18 months.
Factors that increase Stroke volume
Increased contractility, increased preload ( exercise, overtransfusion, pregnancy, overhydration)
Decreased afterload
Clinical presentation of mitral stenosis
Besides SOB and CHF associated to all forms of valvular disease:
- dysphagia
- hoarseness
- Afib
- Hemoptysis
- Opening snap
Normal GFR
90 to 120 mL/min/1.73 m2
If a patient with high risk of HIV refuses to testing what do you do?
First try to understand the reasons why he doesnt want to be tested
DONT say that if he doesnt this may cause risk to him and partners– this is judgemental.
<p>Which patients present with hypoplastic left ventricle?</p>
<p>Occurs in 1st trimester in kids of moms with pregestational diabetes or chromosomal diseases
Presents with cyanosis
Often recognized in the second trimester US.</p>
What leads to closure of Foramen ovale at birth?
Increased O2 -leads to decreased pulmonary resistance, and decrease in PGs ( due to placental separation)
What exam do you consider in a patient presenting with dyspnea- new onset HF with dilated left ventricle and EF 38%
Exclude CAD, with cardiac testing. – stress test
Urticarial/allergic blood transfusion reaction
Urticaria, flushing, angioedema
Within 2-3 hrs of transfusion
Caused by recipient IgE antibodies activation
<p>First exam that should be asked in enuresis </p>
<p>urianalysis ( specific gravidity)</p>
Virus family in Hep A, B,C,D,E
Please Help Edna, Friends Dont Hurt
Picornavius
Hepadnavirus
Flavivirus
Deltavirus Hepevirus
Preeclampsia can occur postpartum?
Yes, up to 12 weeks after delivery
needle-shaped, negatively birefringent crystals.
gout
acute inflammatory arthritis affecting the 1st metatarsophalangeal joint or knee.
Scoliosis and genetic testing?
scoliosis may have a hereditary component, genetic testing is expensive and unnecessary as x-ray determines diagnosis and management.
Older adults with new-onset cognitive impairment should be assessed for
depression.
They can exhibit pseudodementia which is reversible. Before doing a minimental assess for depressive ss.
Endothelin , what is it and role in PAH
Endothelin is a potent vasoconstricting hormone that is produced by endothelial cells, and endothelin receptors are abundant in the pulmonary arteries of patients with idiopathic PAH.
Endothelin receptor antagonists (eg, bosentan, ambrisentan) –> delayed progression of disease in symptomatic patients with idiopathic PAH.
MCC of 2ary HTN in young women
OCPs
Dx of HTN
at least 2 BP readings over a span of 4 or more weeks
EXCEPT if the patient presents with moderate-to-severe HTN, inthese patients start treatment
To assess end organ damage: Urianalysis K,BUN,Creat Fasting glucose Lipid level ECG
Dos rectal prolapse presents with pain?
NO, discomfort (not significant pain) in the anal area
IF significant pain may suggest a different disorder
Patients usually develop difficulty with defecation, diarrhea/fecal incontinence, rectal bleeding, and a protruding rectal mass. Symptoms may occur intermittently.
What is the mechanism of action of desmopressin?
increases the release of factor VIII: von Willebrand factor multimers from endothelium
Cause Diffuse esophageal spams
associated with emotional factors and functional GI disorders.
Patient with hormone replacement therapy who develop DVT, management?
Stop hormone replacement therapy, substitute for SSRIs( escitalopram) SNRIs
and initiate Rivaroxaban
Type II HIT
Type II- >=50% platelet count drop from baseline 5-14 days after heparin onset
clinically significant due to antibodies against PF4heparin complex to heparin “HIT abs or PF4/Heparin antibodies”
Causes THROMBOSIS AND THROMBOCYTOPENIA
Necrotic skin lesions at the sites of heparin injection
Acute systematic reaction to heparin (anaphylactoid)
4Ts: Thrombosis Thrombocytopenia Timing of the platelet count drop Absence of other causes of thrombocytopenia
Gestational thrombocytopenia treatment
none
resolves by its own, repeat eval postpartum to ensure resolution
BUT BECAREFUL BECAUSE THERE ARE CI TO EPIDURAL ANALGESIA IF < 70,000 OR pre-eclampsia
Barrett’s esophagus causes dysphagia T/F
False
What is the class of medication of tolterodine, solifenacin, and oxybutynin?
antimuscarinic
<p>When to order a renal or bladder US in enuresis?</p>
<p> when there is non-monosymptomatic enuresis; the patient also refers daytime ss
daytime ss= bladder</p>
Which joints does the arthropathy of hereditary hemochromatosis affect?
second and third metacarpophalangeal joints, knees, ankles, and shoulders.
What is the next step after finding an incidental adrenal mass in an asymptomatic patient?
Study it.
Order: electrolytes dexamethasone suppression test 24h urine catecholamines metanephrines MVA
Surgery if:
size >4 cm
functional
malignant
Conservative if none of the above with serial imaging
Why avoid antibiotics in infantile botulism
Antibiotics (especially aminoglycosides) are avoided as they can cause colonic C botulinum to lyse, increasing toxin absorption.
In a patient in whom you suspect septic arthritis, what do you order next?
aspirate of the joint - to establish dx and decompress the leg
MRI may be used to evaluate the extent of infection prior to surgical debridement. However, ordering an MRI prior to joint aspiration delays treatment as antibiotics are not administered until synovial fluid is obtained.
Characteristics of Fibroadenoma
< 30 years
single, rubbery, mobile, well-circumscribed mass in the upper outer breast quadrant.
Due to hormonal fluctuation, many patients may experience tenderness a few days prior to menstruation. Tenderness as well as size may improve after menses.
Risk factors for breech presentation
placenta previa,
multiple gestation, polyhydramnios,
and advanced maternal age (eg, >35).
What is Progressive multifocal leucoencephalopathy
Occurs in immunosuppressed, usually AIDS
Reactivation of polyoma JC virus
Neurological deficits including hemiparesis, gait ataxia, visual ss
altered mental status
Why we do the Glucose challenge test in pregnancy at 24-28w?
rise in human placental lactogen, a hormone secreted by the placenta that increases fetal glucose supply by inducing maternal insulin resistance.
Women with a positive 50-g 1-hour glucose challenge test undergo a subsequent confirmatory 100-g 3-hour glucose tolerance test prior to the diagnosis of gestational diabetes mellitus.
pathogenesis of mitral regurgitation
infarction or infection
also anything that leads to dilation
Treatment of Pulmonary hypertension
I: Idiopathic PAH : endothelin receptor antagonist (Bosentan), PDE5 inh( Sildenafil), prostanoids ( Epoprostenol)
II Due to left heart disease: loop diuretics +ACE/ARB, often b blockers and sometimes aldosterone antagonist
III Due to chronic lung disease: O2 and bronchodilators
IV Due to thromboembolic occlusion: long term anticoag
V: Hematologic processes, metabolic ( glycogen storage), Systemic sarcoidosis
Causes of smoking related mortality
lung cancer, COPD, ASCVD
Fetal complications of adolescent pregnancy
PRETERM BIRTH Gastroschisis Omphalocele low birth weight perinatal death
D2 Inadequate nutrition and physiologic immaturity
Gestational thrombocytopenia:
definition
when does it occur
why?
70,000-150,000
2-3rd trimester
hemodilution and o accelerated destruction of platelets
What is the treatment of Hep B
Treatment is often just supportive, meaning that can be done in the OUTPATIENT CLINIC
Sudden onset headache, 10/10, HTN. Next step?
CT head without contrast
If CT negative or equivocal, do an LP
Why warfarin has to be bridged with heparin
warfarin therapy transiently causes a hypercoagulable state due to rapid declines in protein C levels.
Management of ADPKD
first thing: rigorous blood pressure control with ACEIs. Follow blood pressure & renal function
Aggressive control of cardiovascular risk factors, including hypertension
End-stage renal disease: Dialysis, renal transplant
Acute infective endocarditis- pathogen and presentation
S.aureus ( high virulence)
large vegetations in previously normal valves
What are the 3 criteria for liver failure ?
Hepatic injury ( elevated transaminases)
encephalopathy
INR > 1.5
DX and Treatment of Heparin-induced thrombocytopenia
Serotonin release assay
HIT2: stop all heparin products
introduce thrombin inhibitors ( argatroban) or fondaparinux
Warfarin is usually started after treatment with a non-heparin anticoagulant and platelet count recovery to > 150,000/µL.
What does T wave indicates?
ventricular repolarization
T wave inversion may indicate recent MI
Mom who just discovered has ADPKD, how should be the screening for son?
Patients age >18
FIRST COUNSELING
THEN renal US
Genetic testing is not often done, more expensive and often inequivocal.
<p>What is the rationale for treating bacterial vaginosis in pregnancy?</p>
<p>Increased risk of preterm birth, PROM, preterm labor, chorioamnionitis and post-partum endometritis
THERE IS NO RISK OF INTRAUTERINE GROWTH RESTRICTION
However treatment has no impact on the incidence of this complications The goal is to relief ss!!
</p>
Enteric feedings in critically ill patients, when should they be started?
In critically ill patients, early initiation (eg, within 72 hours of ICU admission) is also associated with lower risk of infection.
Enteral feeding introduces higher pH tube feeds into the acidic environment of the stomach and may be protective from ulcer formation and bleeding.
HIT Type I
heparin ( unfractionate heparin, LMWH)
mild,
transient drop in platelet count that typically occurs within 2 days of heparin exposure.
The platelet nadir is 100,000.
Platelet count returns to normal without treatment and continued heparin exposure.
It is NOT clinically significant and is NOT associated with thrombosis
complications of ankylosing spondylitis
Low bone density due to inflammation and osteoporosis/osteopenia
can predispose the patient to vertebral fractures
Spine fracture leading to injury of the spinal cord
Restrictive lung disease
<p>tick paralysis-
which region?
which ticks?
</p>
<p>Australia and North West of America ( Washington state)
Dermatocentor Andersoni ( Rocky Mountain) and D. Variabilits( American dog tick)
Neurotoxins of the tick saliva are transmitted to the host within 4-7 days of being attached
</p>
What labs do you order in patients with medullary thyroid cancer?
Calcitonin CEA ( carcinoembryonic antigen) Neck US( eval regional metastasis) RET mutation gene study Assess for other tumors: parathryroid pheochromocytoma ( plasma free metanephrines, catecholamines and abdominal imaging
Which is the most common organism causing Infective endocarditis in IV drug users? which is the most involved valve?
S.aureus
Tricuspid:
Management of platelet dysfunction in uremia
Desmopressin IV- increases release of von-Willebrand factors from endothelium
Cryoprecipitate is also an option, but has the risk of infections.
Chronic treatment of gout
1st LINE: Xanthine oxidase inhibitors ( febuxostat, allopurinol)
2nd line uricosuric agents ( probenecid)
A small subset of patients with Hep A tend to relapse within the first several months after the initial infection . T/F
True
Presentation of infectious mononucleosis
fever, extreme fatigue,
exudative pharyngitis or tonsillitis,
lymphadenopathy (including posterior cervical nodes)
hepatosplenomegaly.
Myalgias
anorexia (and resulting weight loss),
nausea, or vomiting, possibly due to hepatocellular inflammation.
Mild palatal petechiae can be present.
Atypical lymphocytosis on smear.
Positive monospot test
Management of HTN
Weight loss
Reduce salt intake (2-4 g sodium/day)
> =60 and BP<150/90:
Non-black: thiazide, ACEI/ARB, CCB, alone or in combination
Prehypertension only treat if CKD with or without DM – ACEI or ARB
Is there any interaction of antidepressant medication in heart disease?
antidepressants are safe and effective in treating major depression in patients with CVD
bidirectional link between major depression and coronary artery disease, with depression being an independent risk factor for increased morbidity and mortality in cardiovascular disease
Complications of cryptorchidism
Infertility
Testicular torsion
Inguinal hernia
Testicular Ca
Surgery before 1 year old optimized potential of fertility and testicular growth
Surgical procedure decreases risk of testicular torsion
Testicular Ca is decreased but not eliminated after an orchiopexy
What does aspirin toxicity causes in ear
tinnitus, and vestibular ss BUT NO HEARING LOSS
“abnormal” QTc
males is a QTc above 450 ms;
females, above 470 ms.
Treatment of erectile dysfunction
Address atherosclerotic RF
1st line: PDE inhibitors (Viagra)- increase cGMP levels –> increase Nitric oxide release–> penile smooth muscle relaxation. taken 30-60min before.
Intracavernosal injections of vasoactive agens
Vacuum constriction devices
testosterone in hypogonadism
psychological therapy-reduce anxiety
Implants if nothing works
<p>Cardiac complication of Marfan Sx</p>
<p>AORTIC ROOT DISEASE: AORTIC REGURGITATION, ANEURYSMAL DILATION OR AORTIC DISSECTION
SO ORDER ECHOCARDIOGRAM
</p>
Define scoliosis
kyphosis and lordosis
scoliosis: lateral S shape of the thoracic and lumbar spine
kyphosis: exaggeration of posterior thoracic curvature
lordosis: exaggeration of anterior lumbar curvature.
Most deaths in HTN are due to
MI, CHF
Pt with HIV just been told of his diagnosis and is very upset about the thought of disclosing his HIV-positive status to his fiancée. What to do next?
Physicians need to support and encourage the patient to tell the third parties.
Physicians are not universally required to disclose the HIV status of patients to involved third parties, but physicians are obliged to report the case to the Department of Public Health
Commonnly involved sites in colonic ischemia
splenic flexure and rectosigmoid area
Speed of conduction heart cells
Purkinje>atria> ventricles>AV node . “PATVAV””
<p>What is the major parameter to guide heart transplantation?</p>
<p> peak volume of oxygen consumption VO2
usually < 14 indicates limited survival and thus favors transplantation</p>
Treatment of Giant Cell arteritis
PMR only: low dose oral glucocort( prednisone 10-20mg daily)
GCA: intermediate to high dose ( prednisone 20-40 mg/daily)
GCA with vision loss: Pulse high dose IV glucocorticoid( methylpred 1000mg/day for 3 days followed by intermediate to high dose oral glucocorticoid).
<p>Adult presents with a mid-systolic murmur in the left upper sternum - echo show dilation of right atrium and ventricle. Dx?</p>
<p>- ASD secundum type - means that is open with left to right shunt
-Pulmonary stenosis</p>
Treatment for CO poisoning
high-flow oxygen through a nonrebreathing mask is generally curative,
but patients with severe toxicity may require hyperbaric oxygen.
Afib that needs antiarrhythmic in the context of CAD without HF
Sotalol
Dronedarone
Px and tto of tinea corporis
athletes who have skin to skin contact, humid environment
scaly erythematous pruritic path with centifungal spread and clearing. raised annular borders
Firstline/localized : topical clotrimazole, terbinafine
Second/extensive oral griseofulvin, terbinafine
Treatment of lithium-induced hypothyroidism in bipolar pt
continue lithium and add levothyroxine
Infective endocarditis culture - , think of?
Coxiella Bartonella HACEK Hemophilus Aggregatibacter cardiobacterium eikenella kingella
Which is the most common valve to be involved in Infective endocarditis?
Mitral valve disease, usually mitral valve prolapse with coexisting mitral regurgitation, is the most common valvular abnormality detected in patients with infective endocarditis.
- The aortic valve is the second most common cardiac valve involved in IE
Patient who agrees with procedure but doesnt want to sign documentation due to cultural causes
Document discussion of consent in the records- even if just verbal.
-asking husband to sign is not an option as the discussion is for her health and she is autonomous.
Dx of postpartum depression
same diagnostic criteria used to diagnose a major depressive episode (>2 weeks of at least 5 of 9 symptoms that include depressed mood plus SIGECAPS:
Sleep disturbance
loss of Interest, Guilt, low Energy, impaired Concentration, change in Appetite, Psychomotor retardation or agitation, and Suicidal thoughts).
Management of ischemic colitis
Bowel rest, IV fluids
Empiric Abcs
Colonic resection if necrosis
Complications of bronchiolitis
Apnea( especially infants < 2 m)
Respiratory failure
recurrent wheezing throughout childhood
Older, full-term, healthy infants and young toddlers typically recover with no complications.
Pacemaker rates
SA>AV> bundle of his/purkinje/ventricles
Delayed hemolytic reaction
Mild fever & hemolytic anemia
Within 2-10 days after transfusion
Positive direct Coombs test, positive new antibody screen
Caused by anamnestic antibody response
sarcoidosis + liver enlargement, high ALP and GGT
liver sarcoidosis - occurs in 50-65% of pts
<p>Primary hypotension reaction after transfusion </p>
<p>In patients who have ACE inhibitors
within minutes
Due to bradykinin in blood products . ( normally degraded by ACE)</p>
Serology for recovery Hep B
AntiHbs
Anti Hbe
Anti Hbc IgG
Management of ALS? MOA?
Riluzole
glutamate inhibitor
Treatment of alopecia areata
Topical or intralesional corticosteroids : promotes hair growth. After a steroid injection, new hair growth is usually seen in the next four to six weeks.
Education:(1) the disease is usually benign, (2) they can have multiple relapses in spite of treatment, and (3) most patients have normal hair growth within the next one to two years even without treatment.
Serology for acute hep B
Hb surface antigen +
Hbe antigen +
Anti bodyHb core IgM
Dx Myeloma multiple
Dx: Bone marrow biopsy shows >=10% plasma cells
Then a skeletal survey should be done to assess the extent of bone involvement and risk fractures
waves and meaning in jugular venous pulse
a: atrial contraction against closed tricuspid
c: RV contraction, bulging a little into RA
x: atrial relaxation
v: atrial “villing”–filling
y: atrial emptYing
<p>When do you see Necrolytic migratory erythema, and describe how it starts and develops? also location</p>
<p>Glucagonoma
Starts as a erythematous papule or plaque involving face, perineum or extremities
Then over 7-14 days lesions enlarge and central clearing occur.
The center is bronzed colored induratied and the borders with blisters, scaly, and crusting.
Areas are painful and pruritic
Can also occur in mucous membranes- cheilitis, stomatitis, blepharitis. </p>
Main interventions when suspecting sepsis
Aggressive IV fluids- 30 mL/KG of crystalloids given over the first 3 hours of treatment in 500 mL bolus
Broad spectrum Abcs within 1 hour of arrival
ie. vanco +cefepime
ideally blood cultures should be done before abcs.
Cyanide toxicity risk factors:
Industrial exposure( mines) Combustion of wool and silk Nitroprussiate ( chronic renal failure, or prolonged or high dose infusions)
Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial hemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months
Non bacterial endocarditis ( marantic, thrombotic)
LIBMAN- lupus ( both sides of the mitral valve)
hypercoagulable state
2ary to malignancy
Difference between Familial short stature and constitutional delay of growth and puberty
Familial short stature:—-(CD)
parents height is short
Birth lenght: low-normal to normal — CD:normal
Growth (0-2 years): normal—— delayed
Growth ( 2 years to puberty): normal —–delayed
Bone age: normal —–delayed
timing to puberty: normal—–delayed
pubertal growth: rate low-normal— delayed
Adult height: short—-normal
Anal abscess treatment
incision and drainage.
Abcs for patients with DM, immunosuppression, extensive cellulitis, or valvular heart disease.
<p>Lifestyle changes for monosymptomatic primary enuresis</p>
<p>minimize fluid intake before bedtime
restrict sugary/caffeine before sleep
Institute a reward system( ie. gold star chart)</p>
Malaria presentation
fever, fatigue, myalgias, and hepatosplenomegaly weeks after exposure to infection.
anemia and thrombocytopenia
classically causes cyclical fevers
ring forms on the blood smear.
Definition of pulmonary hypertension
pulmonary arterial pressure >=25 (Normal <20)
<p>How different is the hyperthyroidism in elderly from young people?</p>
<p>" apathetic hyperthyroidism" -- lethargy, apathy, weight loss, myopathy.
Thyrotoxicosis may already cause Afib, HF. but because the patient may be on medications signs as tachycardica may not be present.
Afib different from normal may present needing escalating doses
</p>
Which nerve innervates the fibullaris tertius?
deep fibular nerve
Treatment of peri-infarct pericarditis
Usually self-limited.
If patient with symptoms give HIGH DOSE ASPIRIN ( 650 mg TID)
-these dont interfere with myocardial healing
If persistent: Colchicine, oxycodone
Avoid NSAIDS and glucocorticoids because these interfere with myocardial healing and increase risk of free wall rupture or ventricular rupture.
Types of esophageal Ca and study
Upper 2/3rds is squamous cellular- often associated to alcohol, tobacco
Lower third- Adenocarcinoma- associated to Barret esophagus or GERD. , obesity
Endoscopy with biopsy
PX and Treatment of tinea capitis
scaly patch on scalp
hair loss with residual black dot
predominant in African Americans
Manage:
KOH exam to document spores
TTO: Oral griseofulvin
Tinea barbae
Although this contagious disease can be spread via shared razors, examination reveals a scattered folliculitis with erythematous papules and pustules,
Px and tto of infant botulism
Presents with constipation, drooling, CN - oculobulbar ss more often ( ptosis bilateral), descending flaccid paralysis
Treatment Botulism immunoglobulin.
If patient with ADHD If patient persist with ss despite maximal dose or have any adverse event?
is better to change to another stimulant. No taper or washout period is needed. The patient can initiate ASAP
– ADJUVANT behavioral therapy is not helpful
Management of DVT or PE in patients with cancer
low-molecular-weight heparin (LMWH) is considered more efficacious than factor Xa inhibitors.
Management of meralgia paresthetica
reassurance ( is not a serious condition)
weight loss (in obese patients) avoidance of tight-fitting garments to reduce the pressure on the nerve entrapment area.
<p>Treatment of tick paralysis </p>
<p>removal of tick and supportive care </p>
<p>Infant son of a diabetic mom, presenting with respiratory distress, tachycardia,hypoxia and heart murmur. Cause?</p>
<p>Hypertrophic cardiomyopathy</p>
prominent x and y in JVP
constrictive pericarditis
Options for treatment menopause
Hormone replacement therapy
SSRIs ( escitalopram)
SNRIs ( venlafaxine)
<p>murmurs in large ASD and why?</p>
<p>mid-systolic ejection murmur in R upper sternum- flow passing through the pulmonic valve
mid-diastolic rumble- flow passing through tricuspid valve</p>
Presentation of Achalasia
Chronic ppx, usually > 5 years, weight loss
cause of alopecia areata
Unknown
Possibly autoimmune: T-cell infiltration around the hair follicles and the association of other autoimmune conditions
Which hep virus are naked and why is it important
A & E, means they dont have envelope
Not destroyed in the gut
ECG in Wolff Parkinson white
delta wave
shorter PR
widened QRS
Woman in childbearing age should be advised of the risks of kidney donation
- Immediate risks include DVT, and hospital-acquired infections
- Long term risks :fetal loss, pre-eclampsia, gestational diabetes, gestionational HTN.
Survival and End stage renal disease rates are similar to those non-donors.
Acute hemolytic reaction
Fever, flank pain, hemoglobinuria & DIC
Within 1 hour of transfusion
Positive direct coombs test , pink plasma
Caused by ABO incompatibility
harsh holosystolic murmur in the 4th left intercostal space and a palpable thrill
VSD
Can be heard in adult patients.
Small restrictive VSDs are associated with a louder murmur, but large nonrestrictive VSDs have a softer and early systolic murmur.
Treatment of allergic bronchopulmonary aspergillosis
Systemic glucocorticoids (prednisone) PLUS antifungal ( Itraconazole/Voriconazole) *fluconazole has limited activity against Aspergillus --not used
In some cases Omalizumab ( monoclonal Ab against IgE- may be helpful)
Diagnosis of infantile botulism
Clinical
Confirmation of Stool C. botulism
<p>Guillain Barre </p>
<p> ascending paralysis and absent reflexes
develops over DAYS OR WEEKS
Follows a GI or UR infection</p>
<p>cardiac defect in Noonan Syndrome</p>
<p>Pulmonary valve stenosis</p>
Px of ADPKD
Most patients are asymptomatic
Hematuria
Flank pain (nephrolithiasis, infection, cyst rupture, hemorrhage)
Clinical signs
Hypertension
Palpable abdominal masses (usually bilateral)
Proteinuria
Chronic kidney disease
prominent a in JVP
RV hypertrophy
tricuspid stenosis
Delirium tremens presentation
Extreme manisfestation of alcohol withdrawal
- develops within 1 week of last alcohol~2-4 days
- tactile hallucinations, visual hallucinations, confusion, sweating , increased tachycardia, elevated BP
- tto bzd
The effect of leg raise, squatting, handgrip, phenylephrine on heart murmurs?
LSH–> increase venous return
In inspiration all right sided are increased
In expiration all left sided except the HCM and MVP
<p>What are absolute indications for heart transplant? ( big 4)</p>
<p>1. Cardiogenic shock requiring CONTINUOUS inotropic support or use of devices/pumps to maintain perfusion adequate
2. IV Heart failure with ss intractable to medical and surgical ( including devices) therapy
3. Intractable or severe angina ss in pts with coronary artery disease not ameanable to percutaneous tto or surgery
4. Intractable life-threatening arrhythmias</p>
Classification and treatment of lead poisoning
Treatment:
MILD ( 5-44):No treatment, but followup with venous sampling in one month
MODERATE ( 45-69): DMSA, SUCCIMER
SEVERE>=70: Dimercaprol PLUS EDTA
Staging osteonecrosis
Steinberg Classification
Stage
Radiographs
MRI
Images
0 normal normal MRI and bone scan
I normal abnormal MRI and/or bone scan
II cystic or sclerosis changes abnormal MRI and/or bone scan
III crescent sign (subchondral collapse) abnormal MRI and/or bone scan
IV flattening of femoral head abnormal MRI and/or bone scan
V narrowing of joint abnormal MRI and/or bone scan
VI advanced degenerative changes abnormal MRI and/or bone scan
Hypogonadism definition and types
impairment of any or all functions of the gonads including production of testostore and sperm in men, prog and estradiol
Primary: high LH& FSH
Secondary hypogonadotrophic hypogonadism
Complications of strep A pharyngitis
Peritonsillar abscess
Cervical lymphadenitis
Rheumatic Fever
Poststrep glomerulonephritis
treatment of Meniere disease
There is no definitive treatment
Acute episode:
Vestibular suppressants include:
benzodiazepines, which have the advantage of anxiolytic properties for short-term use
antihistamines (meclizine and dimenhydrinate)
anticholinergics (scopolamine).
Promethazine and prochlorperazine if vomiting/nausea associated
Long-term:
Diuretics ( HCTZ, triamterene)
Betahistine ( vasodilator reported to improve microvascular circulation).
Interventional:
intratympanic gentamicin injection,
surgical labyrinthectomy,
and vestibular nerve section.
Management of a patient with previous DVT who was placed on warfarin and now presents for extension of DVT, the INR is subtherapeutic.
Start heparin IV until therapeutic INR is reached with warfarin.
This case cant be considered anticoagulation failure and therefore the IVC filter is not first option
Complications of Infectious mononucleosis
Autoimmune hemolytic anemia and thrombocytopenia ( cross-reactivity of EBV induced antibodies against RBCs and platelets) -2-3 weeks after disease onset
Splenic rupture ( not infarction) as a result of trauma ( highest risk within 3 weeks
<p>treatment of transverse myelitis</p>
<p>high dose corticosteroids</p>
<p>Prognosis of hypertrophic cardiomyopathy in neonate from Diabetic mom?</p>
<p>Spontaneous resolution independent of the clinical severity. as insulin levels normalize. </p>
Child victim of abusive head trauma stable and normal neurological exam , what do you order next?
a skeletal survey may be performed first.
<p>Treatment of dermatitis herpetiformis ?</p>
<p>if associated to celiac, gluten free diet. </p>
Labs in alcoholics
Anemia Macrocytic( MC)- due to folate def Microcytic -due to GI bleeding LFTS-increased GGT, AST-ALT ratio>2:1 HyperTRG HyperUricemia, hypocalcemia Thiamine def Decreased testosterone level
Explain the funnel plot for meta-analysis, what is the bias that is assessed?
Publication bias
How do you manage the dosing of stimulants for aDHD
Stimulant doses are typically titrated up on a weekly basis until there is no room for improvement, maximum dose limits are reached, or the patient experiences intolerable side effects.
Response to a stimulant can usually be determined within weeks
History of working in a textile industry
Asbestos
If endocarditis due to IV drug use, which organisms do you think of?
S.aureus, pseudomona, candida
Treatment of idiopathic pericarditis
Naproxen + Colchicine
First line therapy for DVT
Second line?
Rivaroxaban: oral, onset of action 2-4 hours, no need of bridge or monitoring. Should be given for >3 months (3-6 m) in patients with DVT or PE who do not have cancer.
Warfarin : 5-7 days for onset. Need to bridge with UFH or LMWH for 5 days. monitoring with INR ( goal is 2-3) and PT
Classification for pulmonary hypertension
I: Idiopathic PAH II Due to left heart disease III Due to chronic lung disease IV Due to thromboembolic occlusion V: Hematologic processes, metabolic ( glycogen storage), Systemic sarcoidosis
Hypertensive encephalopathy
Rapid and severe rise in BP –> increased cerebral perfusion pressure, –> cerebral edema and hypertensive encephalopathy.
insidious onset of headaches, nausea, and vomiting; this can progress to restlessness, confusion, agitation, seizures, and coma.
BP HAS TO BE HIGH AT THIS TIME.
Both PPIs and H2 antagonists may be associated with increased risk of
Clostridium difficile infection (CDI) and pneumonia.
Centor Criteria for Strep A pharyngitis
Fever
Tender anterior cervical LAD
Tonsillar exudates
Absenc of cough
0-1: no testing/treatment
2-3: Rapid strept test
4: empiric oral penicillin or amoxicillin
Use of raloxifene and SE
For breast Ca
Decreases osteoporosis in menopause
EA: hot flashes, increased
Lead-time bias
several disease interventions are compared and one of the interventions diagnoses the disease earlier than the others without an effect on the outcome (eg, survival).
This would make it appear that the intervention prolonged survival whereas in actuality it only diagnosed the disease sooner.
In which patients with HTN B blockers are not a good option
Obstructive lung disease, hear block, depression
Potential complications of pt with OSA during/after surgery
increased respiratory complications
respiratory acidosis
hypercapnia, hypoxemia
hypoventilation ( Xray with atelectasis)
Complication of anal abscess?
anal fistula- require surgical intervention
Is there any risk of silicone breast implants on fetus?
NO!
In which patients with ADPKD do you screen for berry aneurysms with MRI
family history of intracranial bleed
previous intracranial bleed
pathogens of septic arthritis in kids < 3 months
S.aureus
Group B strep ( S. agalactiae)
Gram negative bacilli
Prognosis of testicular torsion
Detorsion within 6 hours- viability
After 24 hrs rarely salvageable
Rectal prolapse management
Medical - can be reduce with digital pressure
- no full thickness prolapse ( just mucosal prolapse)
- adequate fiber and fluid intake
- pelvic floor m. exercises
- Possible biofeedback for fecal incontinence
Surgical
full thicjness prolapse or sensation of prolapse
fecal incontinence and or constipation
ALS has preservation of ..
Ocular motility, sensory, bowel, bladder, and cognitive functions are preserved,
<p>Complications of diabetic mom per trimester</p>
<p>1st trimester: congenital heart disease neural tube defects small left colon syndrome abortion
2-3 trimester ( hyperglycemia and hyperinsulinism)
1. Increased metabolic demand–> fetal hypoxia–> polycythemia
2. Organomegaly
3. neonatal hypoglycemia
4 macrosomy-> shoulder dystocia -> clavicle fracture, vascular plexopathy, perinatal asphyxia
5. increased glycogen–> accumulates with fat in interventricular septum –> hypertrophic cardiomyopathy that can lead to heart failure. </p>
There is an increased prevalence of varicocele in patients with ankylosing spondylitis
True
Factors that increase contractility and therefore, SV in the heart
- catecholamines
- increased intracellular Ca
- Decrease extracellular Na
- Digitalis – block Na/K ATPase –> increase intracellular Na–> alter Na/Ca channel so no Ca is taken out of the cell)
rhomboid shape and positive birefringence under polarized light.
pseudogout
hemochromatosis
What is the approx normal value of CARDIAC OUTPUT/
5lts/min
epigastric pain that improves with meals
duodenal ulcer
Pt with HIV just been told of his diagnosis and is very upset about the thought of disclosing his HIV-positive status to his fiancée. What to do next?
Physicians need to support and encourage the patient to tell the third parties.
Physicians are obliged to report the case to the Department of Public Health
Prevention of post-strept glomerulonephritis
Post-streptococcal glomerulonephritis typically occurs 1-3 weeks after either a cutaneous or pharyngeal streptococcal infection.
Antibiotics are effective for primary prevention of rheumatic fever, but unclear for glomerulonephritis
Periodic breathing
PHYSIOLOGIC pattern in which apnea occurs for 5-10 seconds followed by rapid shallow breaths.
Without stimulation or intervention , a regular rhythm of breathing resumes after several cycles
What do you order in a patient with delayed puberty, in whom you are suspecting hypogonadism?
FSH, LH, testosteron, Prolactin, TSH
Positive heterophile antibody ( Monospot test)
Infectious mononucleosis (25% false-negative during the first week of illness)
<p>Blood transfusion reaction- Anaphylaxis</p>
<p>Is one of the transfusion reactions that cause hypotension
IgA deficient persons
Hypotension, dyspnea, bronchospasm, respiratory arrest shock
Epinephrine
future WASHED transfusion</p>
Why not order a videofluoroscopy in a patient in whom a structural lesions in the upper esophagus is suspected?
If a patient has a suspected structural lesion in the upper esophagus is better to ask for a nasopharyngeal laryngoscopy which is less invasive than the esophagoduodenoscopy.
Videofluoroscopy with barium swallow is more useful in NM studies, than structural lesions.
Ankle brachial index >= 1.3 what does it mean
calcified or uncompressible vessels
additional studies required.
Neonate with ruddy skin and heel stick shows hcto 70. Dx? Next step in management?
Neonatal polycythemia
Repeat the measurement but in peropheral venous blood which is more reliable, less susceptible to changes in T and blood flow
Normal ejection fraction
> =55
What are the fetal post-natal derivatives of :
Allantois Ductus arteriosus Ductus venosus Foramen ovale Notocord
MediaN umbilical lig Ligamentum arteriosum Lig venosum fossa ovalis Nucleus pulposus
Treatment for MS-related depression
SSRIs, SNRIs
Stress urinary incontinence dx, tto
Stress( cough, valsalva):
Q TIP test angle >=30 from the horizontal indicates hypermobility
positive bladder stress test (ie, leakage of urine with cough on examination).
- lifestyle mod
- pelvic floor exercises ( Kegel)
- Pelvic floor surgery - sling
MRI findings in MS
hyperintense lesions in the brain and/or spinal cord on T2-weighted images.
Ovoid-shaped periventricular white matter lesions can be seen in 23%-75% of patients.
MRI is superior to CT in evaluating posterior fossa/cerebellar abnormalities and is more sensitive/specific in detecting MS lesions
Preferred tto for strep pharyngitis
Penicillin 10 days
Decreased symptom severity and duration
Prevention of spread to close contacts
Prevention of suppurative complications (eg, peritonsillar abscess, cervical lymphadenitis)
Prevention of acute rheumatic fever
All about blastomycosis
Systemic fungi
Eastern US and Central America
Pneumonia, verrucous lesions , bone
Broad base budding
If local: itraconazole/fluconazole
If systemic: amphotericin b
Diagnosis of ischemic colitis
CT scan: Colonic wall thickening, fat stranding
Endoscopy: Edematous & friable mucosa
Why TMP/SMX is CI in pregnancy
first trimester: neural tube defects due to the folate antagonist properties of trimethoprim.
third trimester: neonatal kernicterus.
What is the risk of liver failure in Hep B?
What is the risk of chronic hep B?
1%
< 5% - the risk of progression from acute to chronic decreases with age. Perinatal 90%, 1-5 years 10-20%, and adults < 5%
<p>What is the NNT and how is calculated</p>
<p>the number of patients that need to be treated in order to prevent or cure one disease or medical condition. Is also a measure of efficacy of a given therapy.
NNT= 1/Absolute attributable risk
ARR= difference of risk</p>
<p>To whom do you give washed RBCs</p>
<p>1. IgA deficiency
2. complement dependent autoimmune hemolytic anemia
3. continued allergic reactions </p>
considerations for pregnancy in MS patients
modest increase in cesarean section and assisted delivery (eg, vacuum, forceps) rates compared to those without MS.
Treatment:
OK to give corticosteroids in MS exacerbations during pregnancy
OK to give disease modifyin drugs in long term EXCEPT eriflunomide and mitoxantrone ( are teratogenic)
pregnant women with MS usually have lower disease activity during pregnancy and higher disease activity in the postpartum period.
<p>RF for bacterial vaginosis</p>
<p> decreased concentration of hydrogen peroxide lactobacillus leading to increased vaginal pH
- hormonal changes( i.e pregnancy)
- menses
- sexual activity
- abc use
- douching</p>
If If first solids evolving to liquids,what do you suspect and what do you order?
Mechanical obstruction
If RF for Ca: Barium swallow followed by possible Endoscopy
If no EF: Upper endoscopy
Causes of dilated cardiomyopathy
ABCCCD Alcohol Wet Beri Beri Coxsackie Cocaine Chagas Doxorubicin
ISCHEMIC CARDIOMYOPATHY ( CAD)
hemochromatosis
pregnancy in third trimester
sarcoidosis
Newborn who develops respiratory distress shortly after birth and on Rx has cardiomegaly and bright fissure line in the lungs
Transient tachypnea of the newborn
Often presents at birth or within 2 hours post-delivery, and usually resolves within 24 hours. Severe cases may last up to 72 hours.
limited range of motion of his lumbosacral spine and markedly reduced chest expansion, next step?
Sacroiliac Xray, NOT HLA B27 TESTING
Treatment and prophylaxis of SBP
Treatment third generation cephalosporins ( cefotaxime)
Clinically should improve within 24-78 hrs, and so repeat by the 3rd day the paracentesis
Prophylaxis with fluoroquinolone
Mechanism of infertility in endometriosis
adhesions and inflammation
SV calculation
EDV-ESV
In which patients with acute Hep b would you consider giving medication, and which meds?
In the following patients we would consider treatment- pts with severe or protracted course:
- Patients who develop coagulopathy- INR> 1.5
- Persistent ss or marked jaundice ( bilirrubin > 10) for more than 4 weeks of initial ss
- immunosuppression
- concommitant hep C
Ttto:
- Is often either TENOFOVIR OR ENTECAVIR as monotherapy- although there are options these are the preferred.
- And treatment can be stopped once HBsAg is cleared - 2 tests with 4 weeks difference
Definite treatment for WPW?
Catheter ablation
Plantar sensation
Three main nerves: tibial ( heel, S1,S2), 4TH 5TH fingers toe with their corresponding planter region is the lateral plantar ( S1,S2), medial plantar (L4,L5)
Erysipelas px
superficial skin infection but presents with well-demarcated, bright red erythema, classically on the cheeks.
Example of splanchnic vasoconstrictors
midodrine, octeotride, NE
Treatment for MS-related fatigue
Amantadine
Sleep hygiene
Stimulants( methylphenidate, modafinil)
most common valvular abnormalities associated with ankylosing spondylitis
aortic regurgitation and mitral valve prolapse.
<p>Primary nocturnal enuresis definition</p>
<p> nocturnal urinary incontinence in ≥ 5 years
| Has never achieved drytime period</p>
