4 Flashcards
Harsh, holosystolic murmur best heard the LLSB?
VSD
Next step in the setting of a suspected VSD murmur?
Echocardiogram to determine location and size, and to r/o other defects
Next steps if VSD is identified?
Large/symptomatic -> repair
Small -> close spontaneously in 75% of children by age 2 with no sequelae
Characteristics of large VSD murmur compared to small?
Softer (less turbulence across a larger defect)
Sequelae of large VSD?
Pulmonary overcirculation, pulmonary HTN, growth failure, CHF, Eisenmenger syndrome
Typical characteristics of innocent flow murmur of childhood?
Grade I or II midsystolic ejection murmur, decreases with standing/Valsalva
Low-pitched, musical, pure, or squeeky tone at LLSB (Still’s) or high-pitched at LUSB (pulmonary flow)
Differentiate thalassemia minor from iron deficiency anemia.
Both are microcytic
Iron deficiency: elevated RDW, decreased RBCs, decreased reticulocyte count
Thalassemia: normal RDW, normal RBC count, elevated reticulocyte count
Vitamin B12 deficiency is common after total or partial gastrectomy due to loss of intrinsic factor, and ultimately leads to megaloblastic anemia. What is the pathogenesis?
B12 is a necessary cofactor in purine synthesis and its deficiency causes defective DNA synthesis. This results in ineffective erythropoiesis and high numbers of immature megaloblasts in the bone marrow.
3 first-line treatments for smoking cessation?
- Nicotine replacement therapy
- Varenicline
- Bupropion
All in conjunction with counseling and supportive therapy
Next step in management of a second-degree perineal laceration with localized pain particularly with voiding and perineal edema in the immediate postpartum period?
Normal -> supportive care with NSAIDs and sitz baths
Cell-free fetal DNA testing is non-invasive and highly sensitive/specific as a screening test for fetal aneuploidy. It can be ordered at ___ weeks gestation; what should be done if it is abnormal?
10+ weeks
Confirm results by chorionic villus sampling at 10-12 weeks or amniocentesis at 15-20 weeks
Earliest available screening for aneuploidy?
First-trimester combined test (nuchal translucency, beta-hCG, pregnancy-associated plasma protein) -> 9-13 weeks
Which prenatal testing methods provide definitive karyotpic diagnosis?
Chorionic villus sampling
Amniocentesis
What is electrical alternans?
Varying amplitude of the QRS complexes
Electical alternans with sinus tachycardia is a highly specific sign for ___.
Large pericardial effusion
Rx supraventricular and ventricular tachycardias, particularly in WPW?
Procainamide
The majority of patients with mammary Paget disease (painful, itchy, eczematous, and/or ulcerating rash on the nipple that spreads to the areola) have an underlying breast ___.
Adenocarcinoma
Presentation - palpable, mobile, rubbery, firm breast mass without nipple changes
Fibroadenoma
Most common cause of acute back pain?
Lumbosacral strain
List the 6 major findings of Kawasaki disease.
- Fever for 5+ days
- Cervical lymph node >1.5 cm
- Rash
- Swelling and/or erythema of palms/soles
- Bilateral non-exudative conjunctivitis
- Mucositis
(need 4/5 in addition to fever)
Rx Kawasaki disease
IVIg within 10 days of fever onset to decrease risk of coronary artery aneurysm
Koplik spots?
Pathognomonic for measles
In severe, chronic aortic regurgitation, the left ventricle responds to volume overload in what manner and why?
Eccentric hypertrophy to increase LV compliance and contractility, allow for an increase in SV to maintain CO -> temporary asymptomatic period
What causes concentric LVH and how are sarcomeres added?
Pressure overload (chronic HTN, aortic stenosis)
Sarcomeres added in parallel
What causes eccentric LVH and how are sarcomeres added?
Volume overload (AR/MR, ischemic heart disease, dilated cardiomyopathy)
Sarcomeres added in series
Sensorimotor polyneuropathy in diabetes is characterized by length-dependent axonopathy. Small fiber involvement causes ___, whereas large fiber involvement causes ___.
Small: pain and paresthesias
Large: numbness, loss of proprioception and vibration sense, diminished ankle reflexes
Why do patients with CF sometimes present with bleeding diathesis?
Fat-soluble (ADEK) vitamin deficiency due to poor absorption from pancreatic insufficiency -> vitamin K is an important cofactor in activation of factors 2, 7, 9, 10, protein C and protein S
Typical lab findings in Vitamin K deficiency?
Increased PT and INR Normal aPTT (unless severe)
Typical lab findings of factor VIII deficiency (such as Hemophilia A)?
Increased aPTT, normal PT/INR
Pathogenesis of PSGN?
IC deposition in the glomerular mesangium and basement membrane -> complement system activation -> C3 accumulation in deposits
Lab findings in acute PSGN?
UA: +protein, +blood, +/- RBC casts
Serum: decreased C3, possible decreased C4, increased serum Cr, increased anti-DNase B and AHase, increased ASO and anti-NAD
Presentation - microscopic or gross hematuria in childhood, sensorineural hearing loss, ocular defects
Alport syndrome (X-linked defect of type IV collagen)
Presentation - hematuria, proteinuria, respiratory symptoms
Goodpasture disease (IgG autoAb against glomerular and alveolar BM)
Two general presentations of vascular rings?
If encircling the trachea -> biphasic stridor that increases with increased work of breathing
If encircling the esophagus -> solid-food dysphagia, vomiting, recurrent food impactions
Work-up/diagnosis of vascular rings?
Fluoroscopic esophagography -> compression
CT scan -> delineate anatomy, evaluate associated abnormalities
Direct laryngoscopy, bronchoscopy, echo -> possible concurrent cardiac/airway abnormalities
Most common cause of parathyroid hormone-independent hypercalcemia?
Humoral hypercalcemia of malignancy
Steps in diagnosing hypercalcemia?
- Confirm (repeat testing, correct for albumin or measure ionized Ca2+)
- Measure PTH
3a. If high-normal or elevated, PTH dependent
3b. If suppressed, PTH-independent -> 4. Measure PTHrP, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D
Most common cause of amaurosis fugax (painless, rapid, transient monocular vision loss)?
Retinal ischemia due to atherosclerotic emboli originating from the ipsilateral carotid artery
What is ocular tonometry used for?
Measuring intraocular pressure in patients with acute angle-closure glaucoma
Cause of laryngomalacia?
Collapse of supraglottic tissues on inspiration
Presentation of laryngomalacia?
Chronic inspiratory stridor that worsens when supine, improved when prone
Peak at age 4-8 months
Dx laryngomalacia?
Visualization of the larynx with flexible fiberoptic laryngoscopy -> omega-shaped epiglottis, collapse of supraglottic structures during inspiration
What Rx often improves symptoms of laryngomalacia?
Rx of GER
Outcome of laryngomalacia?
Most will feed, grow, and ventilate normally with spontaneous resolution by 18 months
Common cause of chronic cough?
ACEIs
What is erythema nodosum?
Painful, subcutaneous nodules most common on the anterior legs
If erythema nodosum is identified in a patient, what is the next step and why?
Labs (CBC, LFTs, renal function)
Antistreptolysin-O antibodies
TB skin testing
CXR - assess for sarcoidosis and TB
Can be an early sign of more serious disease (streptococcal infection, sarcoid, TB, endemic fungal disease, IBD, Behcet) and identification of the cause may prevent morbidity
What is the key historical question to ask when beginning an evaluation for dysphagia?
Is there a history of difficulty initiating swallowing with cough, choking, or nasal regurgitation?
If yes -> likely oropharyngeal dysphagia
If no -> likely esophageal dysphagia
If oropharyngeal dysphagia is suspected, what is the next step?
Videofuoroscopic modified barium swallow
If esophageal dysphagia is suspected, what is the next question to ask?
Dysphagia with solids AND liquids at onset -> motility disorder
Dysphagia with solids progressing to liquids -> mechanical obstruction
If a motility disorder is suspected, what is the next step?
Barium swallow followed by possible manometry
If a mechanical obstruction is suspected, what is the next step?
If history of prior radiation, caustic injury, complex stricture, or surgery from esophageal/laryngeal cancer -> barium swallow followed by possible endoscopy
If no -> upper endoscopy
Renal artery stenosis typically presents with uncontrolled hypertension. What is a highly specific exam finding? What is seen on imaging?
Lateralizing abdominal bruit
Atrophy of the affected kidney
Describe the effects of renal artery stenosis on the RAAS system.
Decreased renal perfusion of the affected kidney (post-stenotic, atrophy) -> increased renin secretion -> RAAS system -> secondary hyperaldosteronism -> HTN -> unaffected kidney experiences high systemic pressures -> suppresses local renin secretion
Initial treatment of choice in asymptomatic or mildly symptomatic patients with hyponatremia due to SIADH?
Fluid restriction
DDx - hypervolemic hyponatremia?
Heart failure
Renal failure
Liver cirrhosis
DDx - hypovolemic hyponatremia?
Dehydration
DDx - euvolemic hyponatremia?
SIADH
MOA - demeclocycline?
Decreases responsiveness to ADH at the level of the renal collecting tubule (treat SIADH if conservative measures fail to treat)
In a normal distribution, how are the mean, median, and mode related?
They are all equal.
In a positively skewed distribution (tail on the right), how are the mean, median, and mode related?
Mean > median > mode
In a negatively skewed distribution (tail on the left), how are the mean, median, and mode related?
Mean < median < mode
Horner syndrome + cervical paravertebral mass?
Neuroblastoma
Neuroblastoma arises from neural crest cells, which are precursors to what structures?
Sympathetic ganglia
Adrenal medulla
Possible clinical features of neuroblastoma?
<2 y/o Abdominal mass periorbital ecchymoses (orbital mets) Spinal cord compression from epidural invasion (dumbbell tumor) Opsoclonus-myoclonus syndrome Horner syndrome
Diagnostic findings of neuroblastoma?
Elevated catecholamine metabolites
Small, round blue cells on histology
N-myc gene amplification
Cause of acute contralateral hemiparesis?
Lacunar stroke leading to internal capsule infarct
Findings of early septic shock?
Hyperdynamic CV state in response to peripheral vasodilation with capillary leak and intravascular hypovolemia -> increased SV, HR, pulse pressure -> bounding peripheral pulses
Define pulsus paradoxu?
20+ mm Hg drop in systolic blood pressure with inspiration
Pulsus paradoxus is most commonly seen in patients with ___.
Cardiac tamponade
Cause of Meniere disease?
Increased volume and/or pressure of endolymph
While Meniere is a clinical diagnosis, what should be done as part of the work-up?
Audiometry to fully characterize/follow hearing loss
MRI to r/o CNS lesions
Lab findings of Addison’s disease (primary adrenal insufficiency)?
Aldosterone deficiency Non-anion gap metabolic acidosis Hyperkalemia Hyponatremia Hypercalcemia Eosinophilia
4 general etiologies of primary adrenal insufficiency?
AI
Infection (TB, HIV, fungal, etc.)
Hemorrhagic infarction (meningococcemia, anticoagulants, etc.)
Metastatic cancer (eg, lung)
Dx primary adrenal insufficiency?
Measure ACTH and serum cortisol with high-dose (250 micrograms) ACTH stimulation test
Primary: low cortisol, high ACTH
Secondary/tertiary: low cortisol, low ACTH
Characteristics of a pathologic murmur?
Harsh, holosystolic, diastolic
Grade III+
Increases with standing/Valsalva
Loud, fixed split, or single S2
EKG findings of hypertrophic cardiomyopathy?
LVH: tall R wave in aVL + deep S wave in V3
Repolarization changes in anterolateral leads (I, aVL, V4, V5, V6)
If an initial pen light exam does not reveal any conjunctival and corneal abrasions or foreign bodies in the setting of a high-velocity ocular injury, what should be done next?
Fluorescein examination; if not demonstrated, but high suspicion remains, CT or U/S; NEVER MRI (magnetic)
Possible exam findings of HSV encephalitis?
Hemiparesis, CN palsies, hyperreflexia
Possible CSF findings of hSV encephalitis?
Increased WBCs (lymphocytic predominance)
Normal glucose
Increased protein
Often increased RBC
Rx HSV encephalitis
IV acyclovir immediately after obtaining CSF
Rx cryptococcal meningoencephalitis?
IV amphotericin + flucytosine
Compare the symptoms of neurogenic vs. vascular claudication.
Neurogenic:
- Posture-dependent pain
- Lumbar extension worsens, flexion relieves
- Lower-extremity numbness/tingling/weakness
- LBP
Vascular:
- Exertionally-dependent
- Rest relieves
- Lower-extremity cramping/tightness, NO weakness
- Possible buttock, thigh, calf, or foot pain
