5 Flashcards
What metabolic abnormalities can be caused by hypothyroidism?
- Hyperlipidemia
- Hyponatremia (decreased free water clearance)
- Elevated CK
- Elevated serum transaminase
How does hypothyroidism lead to hypercholesteremia?
Decreased surface LDL receptors (type 2a HLD) and/or decreased LDL receptor activity
What 2 things must be ruled out before diagnosing SIADH?
Hypothyroidism
Adrenal insufficiency
First-line treatment of MDD with psychotic features?
Antidepressant + antipsychotic or ECT
Presentation - acute depression with suicidal ideation, fatigue, hypersomnia, increased dreaming, hyperphagia, impaired concentration, intense craving
Cocaine withdrawal
When is RhoGAM (anti-D immune globulin) indicated?
Rh(D)-negative women:
- 28-32 weeks
- <72 hours after delivery of Rh(D)-positive infant
- <72 hours after spontaneous abortion
- Ectopic pregnancy, threatened abortion
- Hydatidiform mole
- CV sampling, amniocentesis
- Abdominal trauma
- T2/T3 bleeding
- External cephalic version
When is antepartum prophylaxis with RhoGAM not indicated?
If the father is Rh(D) negative
Presentation - bilious emesis, bloody stools, abdominal distention in a preterm neonate
Necrotizing enterocolitis
X-ray findings of necrotizing enterocolitis?
Pneumatosis intestinalis
Portal venous gas
Pneumoperitoneum
Rx of necrotizing enterocolitis?
Bowel rest, parenteral nutrition (D/C enteral feeds)
Broad-spectrum IV ABX
+/- surgery
X-ray: dilated stomach and duodenum (double bubble sign), no distal air
Duodenal atresia
What is the most common late manifestation of Lyme disease and how does it present?
Lyme arthritis; inflammatory monoarticular or asymmetric oligoarticular arthritis, most commonly in the knee
Synovial fluid - inflammatory profile, negative Gram stain and culture
Features of early localized Lyme disease (days-1 month)?
1Erythema migrans
Fatigue, HA, myalgias, arthrlagias
Features of early disseminated Lyme disease (weeks-months)?
Multiple erythema migrans Unilateral/bilateral CN palsy Meningitis Carditis (eg, AV block) Migratory arthralgias
Features of late Lyme disease (months-years)?
Arthritis
Encephalitis
Peripheral neuropathy
Confirm Dx of Lyme arthritis?
Serum ELISA and Western blot testing
Rx Lyme arthritis?
Oral doxycycline or amoxicillin (if no neuro manifestations)
Reactive arthritis (formerly Reiter syndrome) presents 1-4 weeks after ___ or ___ infection.
Enteric; chlamydial
Features of rheumatic fever?
Rare complication of S. pharyngitis -> fever, migratory arthralgias, subcutaneous nodules, carditis, neuropsychiatric signs
Sudden-onset respiratory distress and radiographic signs of air trapping (unilateral hyperinflation, mediastinal shift, etc.) are concerning for ___.
Foreign body aspiration
Nebulized albuterol is used for asthma. Nebulized racemic epinephrine treats ___.
Croup
In pregnant women with prior HSV infection, what should be done?
Antiviral suppression beginning at 36 weeks
In pregnant women with lesions/prodromal symptoms of HSV during labor, what should be done?
C-section
The evaluation of adrenal insufficiency should include what tests?
- 8am serum cortisol
- Plasma ACTH
- ACTH stimulation test (aka cosyntropin test)
Interpret:
- Basal cortisol LOW
- ACTH HIGH
- Minimal cortisol response to cosyntropin
Primary adrenal insufficiency
Interpret:
- Basal cortisol LOW
- ACTH LOW
- Minimal or suboptimal cortisol response to cosyntropin
Secondary or tertiary adrenal insufficiency
What is the dexamethasone suppression test used for?
Evaluation of hypercortisolism (suppresses release of ACTH from the pituitary, subsequently reduces adrenal cortisol production)
___ is a dimorphic fungus found in decaying plant matter and soil and primarily infects gardeners and landscapers via direct cutaneous inoculation.
Sporothrix schenckii
Appearance of skin manifestation of sporotrichosis?
Skin papule -> ulceration with non-purulent, odorless drainage
Proximal lesions along lymphatic chain
Rx sporotrhicosis?
3-6 months of oral itraconazole
Presentation - cutaneous lesion (vesicular, erythematous, or papular) with prominent, tender, regional LAD and possible systemic spread?
Cat scratch fever
Presentation - systemic symptoms (fever), painful LAD, lymphangitis
Lymphatic filariasis (nematode endemic to Africa, Asia, Latin America, some parts of Caribbean)
Presentation - papular lesion at the site of entry (usually lower extremity) and proximal, intensely pruritic, reddish-brown tracks
Hookworm larvae
What is Ogilvie syndrome?
Acute colonic pseudoobstruction
Clinical findings of Ogilvie syndrome?
Abdominal distension, pain, obstipation, vomiting
Tympanic to percussion, decreased bowel sounds
Etiologies of Ogilvie syndrome?
Major surgery, traumatic injury, severe infection
Electrolyte derangement (hypoK, hypoMg, hypoCa)
Medications (opiates, anticholinergics, etc.)
Neurologic disorders (eg, dementia, stroke)
X-ray findings of Ogilvie syndrome?
Colonic dilation, normal haustra, non-dilated small bowel
CT findings of Ogilvie syndrome?
Colonic dilation without anatomic obstruction
Rx Ogilvie syndrome?
NPO, NG/retal tube decompression
Neostigmine if no improvement within 48 hours
Presentation - hematochezia, liver abscesses
E. histolytica
Red flags for developmental dysplasia of the hip?
- Positive Ortolani test
- Dislocated hip
- Limited hip abduction
Supportive findings for developmental dysplasia of the hip?
- Limb length discrepancy
2. Asymmetric gluteal/inguinal/thigh creases
Management of developmental dysplasia of the hips?
If red flags -> refer to ortho
If supportive findings or only risk factors -> hip U/S (<4 months), hip radiograph (>4 months)
Undiagnosed pleural effusion is best evaluated with ___, except in patients with clear-cut evidence of ___.
Thoracentesis; CHF
What 3 tumors cause ~75% of all malignant pleural effusions?
- Lung carcinoma
- Breast carcinoma
- Lymphoma
In the setting of pleural effusion, what is the next step if thoracentesis is non-diagnostic and the patient has a lung mass?
Bronchoscopy
Presentation - nocturnal perianal pruritis
Enterobius vermicularis (aka pinworm) infection
Rx pinworm infection?
Pyrantel pamoate or albendazole for patient and all household contacts
Presentation - urticaria, abdominal pain, respiratory problems
Strongyloidiasis
Rx strongyloidiasis and onchocerciasis?
Ivermectin
Uses of metronidazole?
Protozoan infections
Trichomonoiasis
Intra-abdominal anaerobic infections
Rx scabies
Permethrin
Rx schistosomiasis
Praziquantel
Presentation - microthrombocytopenia, eczema, recurrent infections
Wiskott-Aldrich syndrome
Inheritance pattern, mutation, and pathophysiology of Wiskott-Aldrich syndrome?
X-linked recessive
Defect in WAS protein gene
Impaired cytoskeleton changes in leukocytes, platelets
Rx Wiskott-Aldrich syndrome
Stem cell transplant
Most common cause of urinary tract obstruction in newborn boys?
Posterior urethral valves
Dx intraamniotic infection?
Maternal fever PLUS 1+ of the following:
- Fetal tachycardia (>160)
- Maternal luekocytosis
- Purulent amniotic fluid
Define preterm premature rupture of membranes (PPROM).
Rupture of membranes prior to 37 weeks in the ABSENCE of contractions
Management of PPROM?
Expectant until 34 weeks -> delivery
Prior to 34 weeks -> corticosteroids for fetal lung maturity, course of prophylactic broad-spectrum ABX
Management of PPROM + intraamniotic infection?
Delivery, regardless of gestational age
Define uterine size-dates discrepancy.
> 2 cm difference in fundal heigh measurement from gestational age
Who receives anti-viral therapy (eg, oseltamivir) in the setting of influenza?
Risk factors for influenza complications (eg, age 65+, chronic medical problems, pregnancy)
Those without risk factors who come to the office within 48 hours of system onset (may reduce symptom duration)
Do not give vaccine until symptoms abate if moderate or severe illness
Patients with typical GERD symptoms require an upper GI endoscopy in what situations?
If they have alarm symptoms (dysphagia, odynophagia, weight loss, anemia, GI bleeding, recurrent vomiting)
Men >50 with chronic (>5 years) symptoms and cancer risk factors
If a patient has symptoms consistent with GERD and no reason to get an endoscopy, what should be done?
Once daily PPI for 2 months
If GERD is refractory to PPI?
Switch PPIs or increase to 2x daily
If GERD symptoms persist?
Consider endoscopy or esophageal pH monitoring
___ presents with anorexia, N/V, early satiety, postprandial fullness, and impaired glycemic control. What medication can relieve these symptoms?
Diabetic gastroparesis; metoclopramide (prokinetic and antiemetic properties)
Alternative -> erythromycin
___ are useful in the palliation of anorexia and in promoting weight gain in patients with cancer-related anorexia/cachexia syndrome.
Progesterone analogs (eg, megestrol acetate, medroxyprogesterone acetate)
What are the Light criteria for exudative pleural effusions?
Pleural fluid protein/serum protein ratio >0.5
Pleural fluid LDH/ serum LDH ratio >0.6
Pleural fluid LDH> 2/3 upper limit of normal of serum LDH
Features of rheumatoid effusions?
Exudative effusion with:
- Very LOW glucose (<50)
- Very HIGH LDH (>700)
- Possible low pH
Presentation - diarrhea acquired during international travel, abdominal cramps, foul-smelling stools, bloating, and benign abdominal findings
Giardiasis
Dx Giardiasis?
Stool antigen assay
May also use stool microscopy to identify oocysts and trophozoites
Rx giardiasis?
Metronidazole
Empiric treatment for traveler’s diarrhea (most commonly due to E. coli)?
Short course of ciprofloxacin
Presentation - pruritic, purple/pink, polygonal papules and plaques on flexor surfaces of wrists and ankles, may have lacy, white network of lines (Wickham striae)
Lichen planus
What disease is lichen planus associated with?
Hepatitis C
What medications is lichen planus associated with?
ACEIs
Thiazides
Rx lichen planus
Topical high-potency glucocorticoids (eg, betamethasone)
If widespread, systemic glucocorticoids, phototherapy
Presentation - pruritic rash affecting the flexor surfaces, presenting in childhood
Atopic dermatitis
Presentation - intensely pruritic, erythematous papules and vesicles on the elbows, back, knees, and buttocks; associated with?
Dermatitis herpetiformis; celiac disease
Presentation - targetlike plaques with central clearing that begin on the extensor surfaces of the distal extremities and spread centripitally; common to have oral lesions and a febrile prodrome
Erythema multiforme
Presentation - sharply demarcated erythematous plaques with a thick, silvery scale, involves the scalp, knees, and extensor surfaces
Psoriasis
Presentation - round/ovoid annular plaques with a scaly border and central clearing
Tinea corporis
DDx - normal AG metabolic acidosis
Diarrhea Fistulas Carbonic anhydrase inhibitors Renal tubular acidosis Ureteral diversion Iatrogenic
Anion gap = ?
Na - Cl - HCO3
Presentation - non-anion gap metabolic acidosis + hyperkalemia out of proportion to the renal dysfunction
Rental tubular disorder
Define rental tubular acidosis.
Group of disorders characterized by non-anion gap metabolic acidosis in the presence of preserved kidney function
Loop diuretics cause what 2 electrolyte abnormalities?
Hypokalemia
Metabolic alkalosis
Role of aldosterone?
Saves sodium
Pushes potassium out
What is incidence?
Measure of new cases
What is prevalence?
Measure of total number of cases at a point in time
How do prevalence and incidence of diseases change with improved treatments?
Prevalence increases
Incidence is not affected
What is the most effective lifestyle intervention for reducing blood pressure in obese patients?
Weight loss > DASH diet > Exercise > reduced dietary sodium > reduced alcohol intake
Define hypertension.
Systolic >130 and/or diastolic >90
___ is painless dilation of the cervix that may cause T2 delivery and presents with vaginal spotting, pelvic pressure, and increased vaginal discharge in the absence of preterm labor.
Cervical insufficiency
DDx - metabolic acidosis with both an AG and an osmolar gap?
Intoxication with:
- Ethylene glycol
- Methanol
- Ethanol
Specific finding in ethylene glycol poisoning?
Calcium oxalate crystals (rectangular, envelope-shaped)
DDx - high anion gap metabolic acidosis
- Drug ingestion (salicylates, isoniazid, iron)
- Lactic acidosis 2/2 hypoperfusion
- Uremia (increased BUN from renal failure)
- DKA (increased urine and serum ketones)
- Osmolar gap (ethylene glycol, methanol, propylene glycol)
Methanol poisoning can lead to ___.
Blindness
Calculate osmolar gap?
Measured serum Osm - calculated serum Osm
Calculated serum osm?
2Na + glucose/18 + BUN/2.8
Major complication of ethylene glycol poiosoning?
Acute renal failure
Why does uremia cause an AG metabolic acidosis?
Because acid excretion (through formation of ammonium) is impaired
What should be considered in patients typical risk factors for COPD (eg, age 45 or less), those with atypical features (eg, basilar-predominant disease), or unexplained liver disease?
A1AT deficiency
How does the emphysema of smoking-induced COPD and COPD 2/2 A1AT deficiency differ anatomically?
Smoking-indued: centrilobular, affects upper lobes
A1AT: panacinar, affects lower lobes
A1AT deficiency is frequenctly associated with ___ disease.
Liver
Describe the mechanism of type 2 heparin-induced thrombocytopenia.
Heparin + PF4 + IgG + platelet -> immune complex -> BOTH
- Thrombocytopenia via splenic macrophages removing the complex + thrombus formation leading to consumption
- Arterial and venous thrombosis via platelet activation/release/aggregation
What is the Jarisch-Herxheimer reaction?
Acute febrile reaction that commonly occurs <12 hours (within 6-48 hours) after initial treatment of early syphilis
What is immune reconstitution inflammatory syndrome?
Paradoxical worsening of infectious symptoms in patients with HIV initiated on HAART (due to immune system improvement)
Presentation - unilateral orbitofrontal headache associated with N/V, severe unilateral eye pain (+/- halos around lights) with conjunctival injection, and a dilated pupil with poor light response
Acute angle-closure glaucoma
Features of sideroblastic anemia?
Microcytic/hypochromic anemia, dimorphic RBC population on smear, elevated serum iron, decreased TIBC
In patients with an identifiable cause of vitamin B6 deficiency leading to sideroblastic anemia, administration of ___ can easily correct the problem.
Pyridoxine
Cause of sideroblastic anemia?
Defective heme synthesis
Presentation - ptosis, down-and-out gaze, diplopia, normal pupillary response
Ischemic CN III palsy (damage to inner somatic fibers, spares more peripheral parasympathetics
