6 Flashcards
Presentation - tonsil ulcer in a smoker
Oropharyngeal squamous cell carcinoma
Other manifestations include referred otalgia or an isolated neck mass
In a patient with a tonsil lesion concerning for cancer, what diagnostic steps should be done next?
Biopsy, HPV status, neck imaging (CT scan)
Why is an aphthous ulcer the wrong answer in a smoker with sore throat and tonsillar ulcer for 3+ months?
Typically resolves in 1-2 weeks, usually seen in oral cavity rather than the oropharynx
PCP intoxication?
Psychotic symptoms
Violence
NYSTAGMUS
Cocaine intoxication?
Psychotic symptoms (paranoia, hallucination)
Anxiety, irritability
Mood swings, grandiosity
PHYSICAL SIGNS OF SYMPATHETIC ACTIVATION (tachycardia, pupil dilation, diaphoresis, tremors)
Most common complication of sickle cell trait?
Painless hematuria
Distinguish between atrophic vaginitis and lichen sclerosus.
Lichen sclerosus does NOT affect the vagina.
Primary ovarian insufficiency is associated with what 2 conditions?
Autoimmune disorders
Turner syndrome
Pathologic mechanism of sequelae of severe vitamin D deficiency (osteomalacia)?
Decreased intestinal calcium and phosphorus absorption -> secondary hyperparathyroidism
Defective mineralization of the organic bone matrix
X-ray findings of osteomalacia?
Decreased bone density
Thinning of cortex
Codfish vertebral bodies (concave shape)
Pseudofracures (Looser zones)
DDx - hypokalemia?
Increased K entry into cells (beta-adrenergic agonists, insulin, hematopoiesis)
Renal K wasting
GI fluid loss
Amphetamine abuse during pregnancy is associated with what 5 risks?
Spontaneous abortion Preterm delivery Preeclampsia Abruptio placentae Fetal growth restriction Intrauterine fetal demise
Gastroschisis is associated with first-trimester use of ___.
NSAIDs
2 mechanisms of AKI in rhabdomyolysis?
Decreased renal perfusion (intravascular volume depletion from shifting of fluid into damaged muscle tissue)
Direct renal tubular toxicity of heme pigments
Lab abnormalities seen in rhabdomyolysis?
Hyperkalemia
Hyperphosphatemia
Hypocalcemia (calcium deposits in damaged muscle tissue)
Increased AST>ALT
A brain that has seized for >5 minutes (status epilepticus) is at increased risk of developing permanent injury due to ___. What pathologic finding is the hallmark?
Excitatory cytotoxicity; cortical laminar necrosis
Patients with HIV are at increased risk of CAP. When should you suspect PCP
CD4<200 Indolent symptoms (dyspnea, nonproductive cough) Usually bilateral diffuse interstitial infiltrates
Presentation - bilateral lower-extremity pains that occur at night in children age 2-12 years, no systemic symptoms, normal activity, normal exam
Growing pains
Presentation - palpable purpura on the lower extremities, arthralgia/arthritis, abdominal pain, possible intussusception, renal disease (hematuria +/- proteinuria)
HSP (IgA-mediated small vessel vasculitis)
Renal biopsy finding in HSP?
IgA deposition in the mesangium
Lab findings in HSP?
Normal platelet count and coag studies
Normal to increased creatinine
Hematuria +/- RBC casts +/- proteinuria (non-nephrotic range)
Renal biopsy findings in membranous nephropathy?
Thickening of the glomerular basement membrane
Renal biopsy findings in Alport syndrome?
Thinning and splitting of the glomerular basement membrane
Renal biopsy findings in Goodpasture syndrome?
Linear IgG deposits on the basement membrane
Renal biopsy findings in FSGS?
Localized regions of mesangial sclerosis and basement membrane collapse
Renal biopsy findings in minimal change disease?
Fusion or flattening of the podocytes
Most common glomerular cause of ESRD in adults in the US?
FSGS
What is Legg-Calve-Perthes disease?
Idiophatic avascular osteonecrosis of the femoral head
Presentation of Legg-Calve-Perthes disease?
Boys age 3-12
Insidious-onset hip or referred knee pain
Antalgic gait
Restricted hip abduction, internal rotation
Positive Trendelenberg sign
XR findings of Legg-Calve-Perthes disease?
Early stage: may be normal
Later stages: femoral head flattening, fragmentation, sclerosis
MRI findings of Legg-Calve-Perthes disease?
Avascular/necrotic femoral head
Rx Legg-Calve-Perthes disease?
Non-weight bearing
Splinting, possible surgical repair
Pancreatic cancer should be suspected in patients with a history of chronic pancreatitis who develop abdominal pain and weight loss. Patients with jaundice should undergo ___ to rule out cancer in the head of the pancreas. Patients without jaundice should undergo ___ to rule out cancer in the body and tail.
U/S; abdominal CT scan
What is the secretin test and what is it used for?
Measure the ability of pancreatic ductal cells to produce bicarbonate; diagnose chronic pancreatitis
What is the most common cause of congenital bone marrow failure?
Fanconi anemia (type of aplastic anemia)
Pathophysiology of Fanconi anemia?
Inherited DNA repair defect -> bone marrow failure
Clinical findings in Fanconi anemia?
Short stature Hypo/hyperpigmented macules Abnormal thumbs GU malformations Pancytopenia, including a macrocytic anemia Positive chromosomal breakage test
Rx Fanconi anemia?
Stem cell transplant
Gold standard for diagnosing acute angle-closure glaucoma? If unavailable?
Gonioscopy (visualizes the iridocorneal angle); ocular tonometry (measures intraocular pressure)
What is fluorescein staining of the eye used for?
Detect corneal abrasions or herpes keratitis
Presentation - Cough for >5 days to 3 weeks (+/- purulent sputum) + absent systemic findings (fever, chills, etc.), wheezing or rhonchi, chest wall tenderness, preceding respiratory illness
Acute bronchitis
Diagnose and treat acute bronchitis?
Clinical diagnosis, CXR only when pneumonia is suspected
Symptomatic (NSAIDs and/or bronchodilators)
ABX not recommended
___ testing should be considered for patients with molluscum contagiosum, especially if lesions are widespread or involve the face.
HIV
Presentation - neonate with sensorineural hearing loss, cataracts (cloudy lenses, asymmetric or absent red reflexes, nystagmus) PDA
Congenital rubella
First step in diagnosing patients with hypertriglyceridemia?
Evaluate for secondary causes (inherited disorder like familial hypertriglycermidemia, DM, obesity, hypothyroidism, nephrotic syndrome, alcohol abuse, medication AE like tamoxifen, beta blockers, steroids, anti-retrovirals)
Elevated triglyceride levels (>150 mg/dL) are associated with increased risk of ___ and extremely elevated levels (>1000 mg/dL) can cause ___.
CV events; pancreatitis
In patients with mild-moderate hypertriglyceridemia (150-500) who have known or are at high risk for CAD, what is the first-line therapy? What lifestyle modifications should be implemented?
High-intensity statin (rosuvastatin, atorvastatin); reduce alcohol intake, increase exercise, weight loss
Why is niacin + statin not indicated for hypertriglyceridemia?
Combo is associated with increased AE without improved CV outcomes
Most effective pharmacologic strategy for lowering triglyceride levels?
Fibrates
When should statins be chosen over fibrates in patients with hypertriglyceridemia?
If mid-moderate
If CAD or risk for CAD
Presentation - persistent otorrhea and conductive hearing loss, possible pearly white mass behind an intact tympanic membrane on exam
Cholesteatomas (accumulation of keratin debris and squamous epithelial cells within a tympanic membrane retraction pocket)
In a patient who recently received packed RBCs and developed hypocalcemia, what is the most likely cause?
Patients who have received the equivalence of more than one blood volume of blood transfusions or pRBCs of 24 hours may develop elevated levels of citrate, which chelates calcium and magnesium, reducing their plasma levels
Explain acid-base shifts and calcium homeostasis in acidosis and alkalosis.
Increased extracellular pH (decreased H+) -> dissociation of hydrogen ions from albumin molecules -> increased albumin available to bind calcium
Plasma calcium exists in what 3 forms? Which is the only physiologically active form?
- Ionized calcium (45%) - only physiologically active form
- Albumin-bound calcium (40%)
- Calcium bond to inorganic and organic anions (15%)
What intervention improves CV and overall long-term mortality in patients with STEMI?
Prompt recognition and restoration of coronary blood flow with primary percutaneous intervention or fibrinolysis
- Lower rates of recurrent MI and ICH
- Improved survival
Current guidelines for primary PCI in patients with acute STEMI?
Within 90 minutes of first medical contact in a PCI-capable hospital or within 120 minutes for patients who require transport to a PCI-capable hospital from another
List the 7 most common complications after acute MI.
- Reinfarction (hours - 2 days)
- Ventricular septal rupture (hours - 1 week)
- Free wall rupture (hours - 2 weeks)
- Post-infarction angina (hours - 1 month)
- Papillary muscle rupture (2 days - 1 week)
- Pericarditis (1 day - 3 months)
- Left ventricular aneurysm (5 days - 3 months)
EKG findings of ventricular aneurysm?
Persistent STEMI after recent MI
Deep Q waves in the same leads
What two types of pericarditis can present after an MI? How do they differ?
Acute: first several days, diffuse ST segment elevation
Weeks to months later: Dressler syndrome (immune-mediated pericarditis)
Presentation - non-gonoccocal urethritis, asymmetric oligoarthritis (knee, SI spine), conjunctivitis, possible mucocutaneous lesions and enthesitis
Reactive arthritis
Rx acute reactive arthritis
NSAIDs
Presentation - intermittent headaches, dizziness, nausea, polycythemia, possible environmental exposure
Chronic CO poisoning
Dx CO poisoning
ABG with co-oximetry
Characteristic XR finding of pericardial effusion?
Enlarged cardiac silhouette
Purpose of VW factor?
Assists in platelet adhesion and aggregation
Carries factor 8
How does VWF deficiency lead to impaired coagulation pathway?
Unbound factor 8 is more rapidly degraded
Hematologic lab findings in VWF deficiency?
Prolonged bleeding time Normal PT (extrinsic pathway) Normal or prolonged aPTT (intrinsic pathway) Normal platelet count
Dx VWF deficiency
VWF antigen level
VWF activity (ristocetin cofactor activity)
Factor 8 levels
Rx acute bleeding/prophylaxis in VWF deficiency
Desmopressin (DDAVP) -> potentiates release of VWF from endothelial cells
2 causes of enlarged boggy uterus?
Uterine atony
Retained products of conception
Initial management of GERD?
Fewer than 2 episodes/week: lifestyle changes and H2 blockers PRN
More frequency or severe symptoms, evidence of erosive esophagitis, or laryngopharyngeal involvement: 8-week course of PPI
Rx Prinzmetal angina?
CCBs (eg, nifedipine)
NNT = ?
1/ARR (absolute risk reduction)
ARR (absolute risk reduction) = ?
Experimental event rate (EER) = a/a+b
Control event rate (CER) = c/c+d
ARR = CER - EER
Presentation - asymptomatic, AKI within 7 days of starting a new drug, UA with hematuria, pyuria, and crystals
Crystal-induced AKI
Causes of crystal-induced AKI?
Acyclovir Sulfonamides MTX Ethylene glycol Protease inhibitors Uric acid (tumor lysis syndrome)
Mechanism of the AKI in crystal-induced?
Typically renal tubular obstruction
Fracture of ribs 1-3 is associated with what injuries?
Subclavian vessels
Brachial plexus
Mediastinal vessels
Fracture of ribs 3-6 is associated with what injuries?
CV
Fractures of ribs 9-12 is associated with what injuries?
Intraabdominal:
Liver (right)
Spleen (left)
Kidney (posterior ribs 11 and 12)
DDx - anterior mediastinal mass?
Thymoma
Teratoma (and other germ cell tumors)
Thyroid neoplasm
Terrible lymphoma
Distinguish between seminomas and nonseminomatous germ cell tumors
Seminomas: elevated beta-HCG, AFP ALWAYS NORMAL
Non-seminomatous germ cell tumors: elevated AFP, often elevated beta-hCG
When is stranger anxiety normal?
Peaks at 8-9 months, resolves by age 2
When is separation anxiety normal?
Until about 18-24 months (once child develops object permanence)
When is not responding to your name considered abnormal in development?
By 12 months
Hexagonal crystals on UA?
Cystine stones
Pathogenesis of cystinuria?
Group of inherited disorders characterized by impaired transport of cystine and the dibasic amino acids (ornthine, lysine, and arginine) by the brush borders of renal tubular and intestinal epithelial cells -> decreased reabsorption of cystine, increased urine concentration
Dx cystinuria?
Urinary cyanide-nitroprusside test
Rx acute hypocalcemia?
IV calcium gluconate/chloride
How does TPN lead to gallstone formation and bile sludging?
Causes gallbladder stasis
Women age <45 with abnormal uterine bleeding who have ___ require evaluation for endometrial hyperplasia/cancer with an endometrial biopsy.
Failed medical management
