7/27/16 Flashcards
all children with juvenile idiopathic arthritis should get what test?
slit-lamp eye exams to look for anterior uveitis (can lead to blindness if not treated with steroids)
what is blount disease?
bowing of unilateral/bilateral tibia that persists beyond 2 years of age, needs to be corrected by bracing or it will lead to permanent growth disturbances
what substance withdrawal or intoxication: hypertension, cherry red skin, diaphoresis, arrhythmia
hydrogen cyanide poisoning
what substance withdrawal or intoxication: constricted pupils, bradycardia, muscle fasciculations, diaphoresis, diarrhea, excessive salivation
organophosphate poisoning
beyond what age is strabismus concerning?
4 months
a child with recurrent otitis media, some with perforation, who presents with a discrete, whitish polyp that extends through the tympanic membrane
cholesteatoma
what substance withdrawal or intoxication: CNS depression, respiratory depression, pinpoint pupils
opioid (i.e., heroin, methadone, morphine) intoxication (tx with naloxone)
name the deficiency: redness and blebs or blisters on skin that exfoliate leaving large areas of denuded epithelium, diarrhea, tongue is erythematous and smooth with loss of papillae, abnormal gait
niacin (pellagra = dermatitis, diarrhea, dementia)
IUGR, low-pitched cry, confluent eyebrows, long curly eyelashes, limb defects (micromelia), undescended testes
cornelia de lange syndrome
VACTERL associaton
Vertebral defect, Anal atresia, Cardiac defects, TracheoEsophageal fistua, Renal/Radial defect (or both), Limb abnormalities (intelligence is normal)
what substance withdrawal or intoxication: vomiting, tinnitus, fever, anion gap metabolic acidosis = what is the treatment?
salicylate (aspirin) toxicity (tx with sodium bicarbonate)
sx of malaria
high spiking PAROXYSMS of fever, headache, myalgia, back pain with SPLENOMEGALY, and pallor after traveling in Central America
dx and tx: nonbloody diarrhea and low grade fever after eating “bad raspberries”
cyclospora cayetanensis; TMP/SMX
tx for diphyllobothrium latum
praziquantel
what is the teratogen: renal dysgenesis, oligohydramnios, skull ossification defects
ACE inhibitor
extremely pruritic serpiginous rash on foot after walking barefoot on a beach = dx and tx?
ancylostoma duodenale (cutaneous larva migrans); albendazole or pyrantel pamoate
6 month old infant with a harsh blowing holosystolic murmur at the left lower sternal border that radiates over the precodium
VSD
what should you consider when you see diarrhea, cracked lips, glossitis, and pallor in a pt treated for seizures?
phenytoin leading to folate deficiency
what vitamin is used for tx of measles?
vitamin A
when is intradermal skin test using candida albicans used?
when you suspect DiGeorge syndrome (children with low calcium, frequent infections, seizures, wide-set down-slanting eyes, small jaw, murmur); will show no response due to lack of T cells
what antipsychotic can cause irreversible retinal pigmentation?
thioridazine
what antipsychotic can cause deposits in lens and cornea
chlorpromazine
what antipsychotic can cause obstructive jaundice?
chlorpromazine
what antipsychotic can cause sialorrhea (production of large amount of saliva)?
clozapine (tx with clonidine)
tx for extrapyramidal sx (dytonia, parkinsonism) caused by antipsychotics
benztropine, diphenhydramine
tx for akathisia caused by antipsychotics
reduce dose as much as possible, if it persists, propranolol
what antidepressant can cause seizures in anorexic/bulimic pts?
bupropion
what labs need to be checked before starting lithium?
BUN, Cr (baseline kidney function), thyroid studies (lithium inhibits synthesis of thyroid hormone and its release from thyroid)
what dementia: emotional and social appropriateness are lost first, memory deteriorates later
frontotemporal dementia (Pick disease, caused by silver-staining tau protein aggregates)
what dementia: initially dementia and hallucinations , followed by parkinsonian features
lewy body dementia (haLewycinations)
describe sx of Wernicke encephalopathy and Korsakoff syndrome
Wernicke encephalopathy: bilateral abducens nerve (CN6) palsy, horizontal nystagmus, ataxia, and global confusion
Korsakoff syndrome: anterograde amnesia caused by chronic thiamine deficiency, confabulation
describe CT/MRI findings of Wernicke-Korsakoff syndrome
periventricular hemorrhage and necrosis of mammillary bodies
alzheimer disease = decreased ______, treated with _____
acetylcholine; acetylcholinesterase inhibitors like donepezil, galantamine, rivastigmine, tacrine, or memantine (NMDA receptor antagonist)
describe the function of the dopamine pathways in schizophrenia: tuberoinfundibular, nigrostriatal, mesolimbic, prefrontal cortical
tuberoinfundibular: blocking dopamine in this pathway = hyperprolactinemia
nigrostriatal: blocking dopamine in this pathway = extrapyramidal side effects
mesolimbic: blocking dopamine in this pathway = controls positive sx of schizophrenia (hallucinations, delusions)
prefrontal cortical: inadequate dopamine in this pathway causes the negative sx of schizophrenia (flat affect, social withdrawal)
ddx for dilated pupils
cocaine, amphetamine, or LSD intoxication or opioid (i.e., methadone, heroin, morphine) withdrawal
tx for opioid withdrawal
clonidine (immediate), buprenorphine (first-line for detox), methadone (long-term)
what substance withdrawal or intoxication: belligerence, vertical nystagmus, fever, homocidality; what is the treatment?
PCP intoxication; place pt in a quiet, dark, low stimulation room
tx for restless leg syndrome
levodopa or dopamine agonist (pramipexole)
which sleep disorder occurs during REM sleep? which occurs during slow-wave sleep (stage 3-4)?
REM: nightmare disorder (no confusion or disorientation upon wakening, vivid recall)
stage 3-4: sleep terror disorder (confused and disoriented upon wakening, amnesic about episode)
what is REM sleep behavior disorder and what is the tx?
muscle atonia during REM sleep and complex motor activity associated with dream mentation (sleep talking, yelling, walking, running, punching or other violent behaviors); tx with clonazepam
tx for hypoactive sexual desire disorder
testosterone
tx for premature ejaculation
SSRIs (fluoxetine), TCAs
describe Rett disorder
only in GIRLS, normal development during first 5 months after birth, followed by DECREASING RATE OF HEAD GROWTH and loss of previously learned purposeful hand skills; STEREOTYPED HAND MOVEMENTS (hand wringing, washing), impaired language and psychomotor retardation
tx for tourette disorder
clonidine
child who avoids social interactions but does well in school, talks like he is reading a monologue
asperger disorder
children understand irreversibility of death by what age?
7-8
what is an alternate therapy for bulimic pts who have failed 2 trials of SSRIs?
topiramate
what is catatonia?
“waxy flexibility,” “pt exhibits posturing and resists your motions with strength proportional to what you exert”; sx of schizophrenia
tx for nightmares in PTSD
prazosin
recommended length of tx for major depressive disorder
at least 6 months
tx for bipolar depression
lithium, quetiapine, or lamotrigine
tx for acute mania
antipsychotic and benzodiazepine (mood stabilizers such as lithium and carbamazepine take about 1 week to show effects)
what is the consequence of a pregnant pt taking SSRIs?
persistent pulmonary hypertension of newborn
medication to decrease agitation in delirious ELDERLY pts
risperidone (if IV or IM medication needs to be given, use haloperidol)
what is conversion disorder?
at least one neurological sx that cannot be explained by a medical disorder, “la belle indifference” when describing their sx
positive Coombs test, microspherocytes on smear
autoimmune (warm or IgG) hemolysis
most common buzz words associated with acute promyelocytic leukemia (M3 subtype of AML)
Auer rods, DIC, treat with all-trans-retinoic acid (vitamin A)
what should be added to chemotherapy for pts with acute lymphoblastic leukemia (ALL)?
intrathecal methotrexate to prevent relapse in CNS
persistently high WBC count that is all neutrophils, pruritus after hot showers, splenomegaly = dx and tx
CML; treat with tyrosine kinase inhibitors (IMATINIB)
what is the most accurate test for CML?
BCR-ABL (9:22 translocation = Philadelphia chromosome is found in 95% of cases) via PCR or FISH
pancytopenia despite hypercellular bone marrow
myelodysplastic syndrome
CBC and smear results for myelodysplastic syndrome
increased MCV, nucleated red cells, ringed sideroblasts
tx for myelodysplastic syndrome with 5q deletion
lenalidomide
tx for mild cases of CLL vs advanced-stage
mild: chlorambucil
advanced-stage: fludarabine, CYCLOPHOSPHAMIDE, and rituximab
tx for autoimmune thrombocytopenia or anemia that occurs in CLL (CLL B-lymphocytes are abnormal in that they attack normal red cells and platelets instead of making antibodies for infection)
prednisone
smudge cells in peripheral smear
CLL
many basophils in peripheral smear
CML
“dry tap” marrow, stains tartrate-resistant acid phosphatase (TRAP) positive = dx and tx
hairy cell leukemia; cladribine or pentostatin
best initial test in lymphoma
EXCISIONAL biopsy (NOT needle aspiration biopsy!)
tx for advanced-stage non-hodgkins lymphoma
CHOP (Cyclophosphamide, Hydroxydaunorubici=adriamycin=doxorubicin, Oncovin=vincristine, Prednisone) and rituximab
differences in presentation between non hodgkins and hodgkins lymphoma
hodgkin lymphoma has Reed-Sternberg cells and has lymphadenopathy centering around cervical area, whereas in non-hodgkins lympgoma lymphadenopathy is disseminated
tx for advanced-stage hodgkins lymphoma
ABVD (Adriamycin=doxorubicin, Bleomycin, Vinblastine, Dacarbazine)
blurry vision, ENGORGED BLOOD VESSELS IN THE EYE, mucosal bleeding, and Raynauds = dx and tx
waldenstrom macroglobulinemia (overproduction of IgM leading to hyperviscosity); tx with PLASMAPHERESIS
isolated thrombocytopenia and NORMAL SIZED SPLEEN
immune thrombocytopenic purpura
how can you distinguish between platelet or clotting factor problem causing bleeding?
platelet-related bleeding is more superficial (epistaxis, gingival, petechiae, mucosal bleeding, vaginal), whereas clotting-factor-related bleeding is deep, such as hemarthroses and bleeding in muscles
bleeding related to platelets (epistaxis, gingival, gums) with normal platelet count, bleeding problems in family members = dx and tx
von willebrand disease; tx is DDAVP (desmopressin) which releases endthelial stores of VWF
what is the ristocetin cofactor assay?
tests von willebrand factor activity, von willebrand disease pts will have reduced ristocetin-induced platelet aggregation
hemarthrosis, intracranial bleeding, intramuscular hematomas, retroperitoneal hematomas, hematuria in a male child
hemophilia (deficiency of clotting factor 8 or 9)
after stopping heparin in pts with HIT, what should you give?
direct thrombin inhibitors (FABuLous): Fondaparinux, Argatroban, Bivalirudin, Lepirudin
tx for esophageal spasms
calcium channel blockers and nitrates
tx for esophageal candidiasis in HIV pts
oral fluconazole (oral nystatin swish and swallow only treats ORAL candidiasis)
what is the course of action if fluconazole does not improve odynophagia in an HIV pt?
endoscopy.
if small ulcers, HSV = tx with acyclovir.
if large ulcers, CMV = tx with ganciclovir or foscarnet
what are the differences between Schatzki ring and Plummer-Vinson syndrome?
Schatzki ring is often from acid reflux, is associated with hiatal hernia, and is in the distal esophagus, whereas Plummer-Vinson syndrome is associated with iron deficiency anemia, is more proximal, and can transform into SQUAMOUS CELL CANCER
dx for epigastric pain better with food vs worse with food
better with food: duodenal ulcer
worse with food: gastric ulcer
tenderness in epigastrium
pancreatitis
tx for GERD (drug class and examples)
PPIs (omeprazole, lansoprazole, pantoprazole, etc.)
management of Barrett esophagus vs low-grade dysplasia
barrett alone (columnar metaplasia): PPIs and rescope every 2-3 YEARS metaplasia: PPIs and rescope every 6-12 MONTHS
tx for H. pylori PUD in pts with penicillin allergy
clarithromycin and METRONIDAZOLE (not amoxicillin)
management of duodenal ulcer vs gastric ulcer that does not respond to initial therapy
duodenal ulcer: confirm persistent H. pylori and switch abx to metronidazole and tetracycline
gastric ulcer: repeat endoscopy to EXCLUDE CANCER
when should endoscopy be performed on a pt with unexplained epigastric pain?
if they are over 55 (to exclude cancer) OR there are “alarm” sx like dysphagia, weight loss, anemia
multiple large peptic ulcers in distal duodenum, recur after H. pylori eradication, diarrhea
gastrinoma (zollinger-ellison syndrome). gastrinomaa causes diarrhea because acid inactivates pancreatic enzymes like lipase
most accurate test to confirm gastrinoma (zollinger-ellison syndrome)
persistently high gastrin levels despite secretin administration
hypercalcemia and multiple duodenal ulcers
MEN1 (pituitary, parathyroid, pancreas)
what tests should you do if pt with gastrinoma (zollinger-ellison syndrome) has a normal CT and MRI of abdomen (performed to look for metastatic disease)?
SOMATOSTATIN RECEPTOR SCINTIGRAPHY (nuclear octreotide scan) combined with ENDOSCOPIC ULTRASOUND. gastrinoma is associated with a massive increase in the number of somatostatin receptors in the abdomen
what are the indications for packed RBCs in GI bleeding?
if hematocrit is below 30 in an OLDER PT or suffer from CORONARY ARTERY DISEASE
tx for active variceal bleeding vs tx for prevention of subsequent episodes of bleeding
active: octreotide (somatostatin) decreases portal pressure
ppx: propranolol
management of C. difficile diarrhea that did not respond to metronidazole
switch to oral vancomycin or fidaxomicin
distinguishing features of whipple disease from celiac disease
Whipped cream in a CAN: Cardiac sx, Arthalgias, Neurologic sx (also ocular findings, fever, lymphadenopathy)
tx for whipple disease vs tx of tropical sprue
whipple disease: ceftriaxone followed by TMP/SMX
tropical sprue: TMP/SMX, tetracycline
what is the most accurate test for chronic pancreatitis?
secretin stimulation testing. place an NG tube, an unaffected pt will release a large volume of bicarbonate-rich fluids after IV injection of secretin
best test and tx of carcinoid syndrome
test: urinary 5-HIAA
tx: octreotide
major difference between malabsorption of chronic pancreatitis vs celiac disease
in celiac disease there is iron deficiency (iron does not need pancreatic enzymes to be absorbed, whereas fat-soluble vitamins do)
tx options for irritable bowel syndrome
fiber in the diet, antispasmodic agents such as HYOSCYAMINE or DICYCLOMINE, TRICYCLIC ANTIDEPRESSANTS
distinguishing features of crohn disease (from ulcerative colitis)
skip lesions, TRANSMURAL GRANULOMAS, fistulas, abscesses, perianal disease, masses and obstruction
antibodies found in ulcerative colitis vs crohn
UC: ANCA
crohn: ASCA (antisaccharomyces cerevesiae)
best initial test in a pt with sx of diverticulitis
CT SCAN (barium enema and colonoscopy are DANGEROUS in diverticulitis because of increased risk of perforation)
empiric tx of diverticulitis
CIPROFLOXACIN and METRONIDAZOLE
colonoscopy frequency in a pt with a single family member with colon cancer
begin 10 years earlier than the age at which family member developed cancer or age 40, whichever is younger. repeat every 5 years if family member is under age 60
colonoscopy frequency in a pt with previous adenomatous polyp
every 3-5 years instead of 10 years
colonoscopy frequency in a pt with suspicion for HNPCC (three family members, two generations, 1 before age 50)
start at 25 with colonoscopy every 1-2 years
presentation of peutz-jeghers syndrome
multiple hamartomatous polpys in colon with MELANOTIC SPOTS ON LIPS and skin, increased frequency of breast, gonadal, and pancreatic cancer
gardner syndrome vs turcot syndrome
Gardner: colon cancer with OSTEOMAS, desmoid tumors, other soft tissue tumors
Turcot: colon cancer with CNS MALIGNANCY
drugs that cause acute pancreatitis
Drugs Causing A Violent Abdominal Distress: Didanosine, Corticosteroids, Azathioprine, Valproic acid, Alcohol, Diuretics (furosemide, thiazides)
what lab finding is associated with worst prognosis in pancreatitis?
low calcium
when should you add abx to management of acute pancreatitis?
if CT shows more than 30% necrosis, add impenem or meropenem and perform needle biopsy to determine presence of infection
what is SAAG and when is it used?
SAAG = serum albumin - ascites albumin. if greater than 1.1 (as in, low albumin in ascitic fluid), more likely to be portal hypertension or CHF. if less than 1.1, infections (except SBP), cancer, and nephrotic syndrome are more likely
most common cause of SBP, best initial test, and tx
E.coli; cell count of peritoneal fluid with MORE THAN 250 NEUTROPHILS; CEFOTAXIME or CEFTRIAXONE
tx for ascites and edema caused by cirrhosis
spironolactone and other diuretics, serial paracenteses
tx for hepatic encephalopathy
lactulose, rifaximin
tx for hepatorenal syndrome
somatostatin (octreotide), midodrine
what dx should be considered in a pt who develops hypoxia only when sitting upright?
hepatopulmonary syndrome (orthodeoxia)
pathogenesis and sx of primary biliary cirrhosis
autoimmune destruction of intrahepatic bile ducts; presents with pruritus, normal bilirubin with an elevated alkaline phosphatase (cholestatic LFTs), XANTHELASMA (fatty deposition around eyelids), OSTEOPOROSIS
antimitochondrial antibody
primary biliary cirrhosis
most accurate blood test and tx for primary biliary cirrhosis
antimitochondrial antibody; ursodeoxycholic acid
difference in tx of chronic hepB vs chronic hepC
chronic hepB is managed with ONE medication (lamivudine or interferon or tenofovir, etc.), whereas chronic hepC is managed with TWO medications (LEDIPASVIR and SOFOSBUVIR)
tx of acute vs chronic hepC
acute: ribavirin, interferon
chronic: ledipasvir and sofosbuvir
wilson disease presentation
sx of cirrhosis PLUS psychosis and delusions, COOMBS NEGATIVE hemolytic anemia, and renal tubular acidosis or kidney stones
best initial test vs most accurate test for wilson disease
best initial test: slit-lamp exam
most accurate test: abnormally increased amount of copper excretion in urine after giving PENICILLAMINE
tx for wilson disease
penicillamine, zinc (penicillamine will chelate copper and remove it from body, zinc interferes with intestinal copper absorption)
anti-smooth muscle antibodies
autoimmune hepatitis
management of pt with stroke who is already on aspirin
aDd DIPYRAMIDOLE or switCh to CLOPIDOGREL
thrombolytics vs aspirin after likely ischemic stroke = how do you decide?
more than 3 hours since onset = aspirin
what should every pt with a stroke be started on no matter what?
statin (along with aspirin or clopidogrel)
