8 Flashcards
Distinguish aplastic anemia from ALL.
ALL: hypercellular bone marrow, painful
Aplastic anemia: hypocellular bone marrow, painLESS
Presentation - soft, mobile, non-tender masses at the base of the labia majora at the 4 and 8 o’clock positions.
Bartholin duct cysts
Presentation - cysts that appear along the lateral aspects of the upper anterior vagina, do not involve the vulva
Gartner duct cyst
Presentation - cysts located lateral to the urethral meatus in the anterior vaginal vestibule
Skene gland cysts
Management of asymptomatic Bartholin cyst?
Observation and expectant management (most resolve spontaneously)
Rx symptomatic Bartholin cyst?
I&D + placement of Word catheter to reduce risk of recurrence
Rx condylomata acuminata
Cryotherapy and topical podophyllotoxin
Best next step in management of a patient with DM and suspected osteomyelitis?
Bone biopsy and culture (positive superficial wound cultures do not reliably predict the culprit organisms)
Presentation - chest pain, neck pain, syncope, history of HTN, mediastinal widening on CXR, pericardial effusion
Acute aortic dissection
Why are Type A (ascending aorta) dissections a surgical emergency?
Can lead to aortic rupture into the pericardial space and hemopericardium, which rapidly progresses to tamponade and shock
Next step in suspected Type A dissection?
CTA if hemodynamically stable and no renal dysfunction
TEE if hemodynamically unstable or renal insufficiency
Single most important prognostic consideration in the treatment of patients with breast cancer?
Tumor burden based on TNM staging
What is Osgood-Schlatter disease?
Osteochondritis of the tibial tubercle that causes chronic knee pain worse with running and jumping in active adolescents
List the 3 types of acne vulgaris and distinguish between them.
- Comedonal (closed/open comedones on forehead, nose, chin)
- Inflammatory (inflamed papules <5 mm and pustules, erythema)
- Nodular (cystic) (large >5 mm nodules, can appear cystic, can merge to form sinus tracts with scarring)
Rx comedonal acne?
Topical retinoids; salicylic, azelaic, or glycolic acid
Rx inflammatory acne (mild, moderate, severe)?
Mild: topical retinoids + benzoyl peroxide
Moderate: add topical ABX (erythro/clinda)
Severe: add oral ABX (tetracyclines)
Rx nodular acne
Moderate: topical retinoid + benzoyl peroxide + topical ABX
Severe: + oral ABX
Unresponsive severe: + oral isotretinoin
What causes mixed cryoglobulinemia syndrome (MCS)?
Immune complex deposition in small- to medium-sized blood vessels, leading to endothelial injury and end-organ damage
Presentation of MCS?
Systemic: fatigue, arthralgias Skin: non-blanching palpable purpura, LCV Renal: most commonly HTN; also GN Pulmonary: dyspnea, pleurisy Liver: elevated transaminases Neuro: peripheral neuropathies
MCV is most commonly associated with chronic inflammatory conditions such as ___ and ___. What testing should be done?
HCV; SLE
HCV, HBV, HIV
Dx MCS?
Serologically - serum cryoglobulins, low complement levels positive RF, elevated transaminases, kidney injury
OR
Skin/renal biopsy
Rx MCS
Rx underlying disease + plasmapohresis/immunosuppression if rapidly progressive or life-threatening course
Decreased ADAMTS13 activity causes what illness?
TTP
Features of type 1 cryoglobulinemia?
Asympatomatic
Hyperviscosity (blurry vision, etc.), thrombosis (eg, Raynaud)
Skin: livedo reticularis, purpura
Compare complement levels in type 1 and mixed cryoglobulinemia syndromes
Type 1: normal
Mixed: low C4
Features of TTP?
Fever, microangiopathic hemolytic anemia, thrombocytopenia with NONpalpable purpura, kidney injury, neuro findings
Cause of type 1 cryoglobulinemia?
Lymphoproliferative or hematologic disorders like multiple myeloma
Presentation - very light menses or secondary amenorrhea that does not respond to a progesterone challenge
Asherman syndrome
Dx and Rx Asherman syndrome?
Hysteroscopy (can lyse adhesions)
What type of neoplasm is a hairy cell leukemia, what age population does it affect, and what mutation causes it?
Clonal B-cell neoplasm
Middle-age/older adults
BRAF mutation
Features of hairy cell leukemia?
Pancytopenia (bone marrow fibrosis)
Splenomegaly (early satiety)
Uncommon to have hepatomegaly, LAD, or B symptoms
Dx hairy cell leuemima
Smear: hairy leukocytes
BM Bx with flow cytometry
Peripheral smear with “smudge cells”
Chronic lymphocytic leukemia
Peripheral smear with Reed-Sternberg cells
Hodgkin lymphoma
What can cause an immobile uterus, cervical motion tenderness, and pelvic anatomy distortion?
Endometriosis
Urethral meatus located at the coronal margin
Hypospadias (ventrally displaced urethral opening)
Management of hypospadias?
Urologic evaluation
Circumcision is deferred until after eval because foreskin may be used in repair
Which patients with hypospadius need renal U/S?
If they have other congenital abnormalities
In the setting of spontaneous abortion, treatment options include expectant management, medical induction with misoprostol, and suction curettage - when is curettage indicated?
Infection
Hemodynamic instability
When is oxytocin indicated in the setting of a spontaneous abortion?
It’s not during the first or second trimesters, as there are few oxytocin receptors in the uterus during early pregnancy
Most cases of intussusception occur at age 2 or younger following a viral illness - what serves as a nidus for telescoping in this setting?
Hypertrophied Peyer patches in the lymphoid-rich terminal ileum
List 6 pathological lead points that may lead to intussusception.
- Congenital malformation of the intestines (eg, Meckel diverticulum)
- HSP (small-bowel hematoma)
- Celiac disease
- Intestinal tumor
- Polyps
- Inspissated stool in CF
Presentation of intussusception?
Sudden, intermittent abdominal pain Children may draw up their legs Currant jelly stools Sausage-shaped abdominal mass Lethargy or AMS
Dx intussusception?
Target sign on U/S
Rx intussusception?
Air or saline enema
Surgery for removal of lead point
Pathologic mechanism of croup?
Viral infection in which edema and narrowing of the proximal trachea result in a barky cough and inspiratory stridor
Age of patients affected by croup?
6 months to 3 years
Rx croup?
Mild (no stridor at rest): humidified air +/- steroids
Moderate/severe (stridor at rest): steroids + neb epi
Vitamin K-deficient bleeding results from deficiency of what factors?
2, 7, 9, 10
Confirm Dx of Vitamin K-deficient bleeding?
Reversal of symptoms with vitamin K administration
Presentation - mucocutaneous bleeding and petechiae in the setting of normal PT, aPTT, platelet count
Impaired platelet function
Most common causes of acute unilateral lymphadenitis in children (presents with pronounced erythema and tenderness)?
S. aureus
S. pyogenes
Expected cause of unilateral acute cervical adenitis in children associated with dental caries and periodontal disease?
Anaerobic bacteria (eg, Prevotella buccae)
Expected cause of bilateral acute cervical adenitis in children associated with paryngoconjunctivitis?
Adenovirus
Rx acute unilateral lymphadenitis empirically?
Clindamycin (MRSA, S. pyogenes activity)
Most common cause of subacute unilateral LAD in young children (slow onset, non-tender node)
Non-tuberculous mycobacteria (eg, Mycobacterium avium)
Presentation - environmental exposure, painful sensorimotor polyneuropathy, skin lesions (hypo/hyperpigmented, hyperkeratotic), pancytopenia, mild transaminase elevation, Mees lines (horizontal fingernail striatino)
Chronic arsenic toxicity
Dx arsenic toxicity?
Elevated urine arsenic levels
Mechanism of arsenic poisoning?
Binds to sulfhydryl groups and disrupts cellular respiration and gluconeogenesis
Rx arsenic poisoning?
Chelation with dimercaprol or DMSA
Presentation - patchy sensorimotor neuropathy and autonomic dysfunction
Acute intermittent porphyria
Distinguish chronic lead poisoning from chronic arsenic poisoning.
Lead - sensorimotor neuropathy in stocking-glove distribution along with microcytic anemia; GI complains are typical, NO skin changes
Distinguish focal seizures from absence seizures.
Both can have staring spells; however, focal seizures are associated with a post-ictal phase and are NOT provoked by hyperventilation, whereas absence are NOT associated with a post-ictal phase and ARE prooked by hyperventilation
Characteristic features of duodenal ulcer?
Epigastric pain that improves with eating
What causes the majority of duodenal ulcers?
H. pylori or NSAIDs
___ is inflammation of the lung parenchyma caused by antigen exposure. Acute episodes present with cough, breathlessness, fever, and malaise that occur within 4-6 hours of antigenic exposure. Chronic exposure may cause weight loss, clubbing, and honeycombing of the lung.
Hypersensitivity pneumonitis
Classic radiographic findings of hypersensitivity pneumonitis?
Ground glass opacity or “haziness” in the lower lung fields
Best treatment for hypersensitivity pneumonitis?
Avoidance of antigenic exposure
May speed acute recovery/manage severe episodes with systemic corticosteroids
GERD predisposes patients to what 3 conditions?
- Barrett’s esophagus
- Erosive esophagitis
- Esophageal (peptic) stricture formation
Symmetric and circumferential narrowing of the involved esophagus with dysphagia for solids but typically no weight loss?
Peptic strictures
Note - may cause an improvement in heartburn symptoms by blocking reflux
3 additional causes of peptic strictures aside from GERD?
Radiation
Systemic sclerosis
Caustic ingestions
Next step in management of a stricture in the setting of Barrett’s?
Biopsy to r/o adenocarcinoma via endoscopy (dilation performed if no malignancy detected)
Foundation of management of fibromyalgia?
Exercise
Age of presentation of Hodgkin lymphoma?
Bimodal: 15-35, >60
Features of Hodgkin lymphoma?
PainLESS cervical and supraclavicular LAD
Mediastinal mass (may cause cough, SOB, chest pain)
B symptoms (subacute fever, sweats, weight loss, fatigue, etc.)
Pruritis (paraneoplastic process)
Dx Hodgkin lymphoma?
Lymph node biopsy (Reed-Sternberg cells on histology)
By age 12 months, an infant’s weight ___ and height increases by ___.
Triples; 50%
When are platelet transfusions given?
Platelet count <10000 or <50000 with active bleeding
When is whole blood transfusion (PRBCs + plasma) indicated?
Severe hemorrhage requiring massive blood transfusions to assist in volume expansion
Single photon emission CT scan is a useful tool to evaluate what?
CAD
Decreased tracer uptake at rest and with exercise during single photon emission CT scan indicates?
Likely scar tissue with decreased perfusion and CAD (fixed defect)
Decreased tracer uptake with stress but normal uptake at rest during single photon emission CT scan indicates?
Inducible ischemia and likely CAD
Presentation - multisystem involvement with acute or subacute renal failure, skin manifestations including livedo reticularis or blue toe syndrome, cerebral or intestinal ischemia, and Hollenhorst plaques after recent catheterization
Choelsterol embolization
Lab findings of cholesterol embolization?
Elevated serum Cr, eosinophilia, hypocomplementemia
UA - benign with few cells or casts, may have eosinophiluria
Skin or renal biopsy finings of cholesterol embolization?
Biconvex, needle-shaped clefts with occluded vessels
Perivascular inflammation with eosinophils
Typical cause of non-purulent vs. purulent cellulitis?
Non-purulent: beta-hemolytic Streptococcus, MSSA
Purulent: S. aureus (MSSA and MRSA)
Cause of erysipelas?
S. pyogenes
Compare the skin findings of erysipelas and cellulitis
Erysipelas:
- Superficial dermis and lymphatics
- Raised, sharply demarcated edges
- Rapid spread and onset
- Fever early in course
Cellulitis: -Deep dermis and subcutaneous fat -Flat edges with poor demarcation -Indolent -Localized (fever later in course) \+/- purulent drainage
Approximately only half of patients with acute liver failure will survive without ___.
Liver transplantation
Most common cause of death in acute liver failure?
Cerebral edema -> coma and brain stem herniation
Metabolic alkalosis can be classified as saline-responsive and saline-unresponsive based on what two factors?
- Urinary chloride levels
2. Extracellular fluid volume status
How is saline-responsive metabolic alkalosis defined?
Low urinary chloride excretion
Volume contraction
Corrects with saline infusion alone
How is saline-unresponsive metabolic alkalosis defined?
Urinary chloride >20 mEq/L
Variable volume status
Saline unresponsive
Why is sertraline the first line Rx for MDD post-MI?
Very low risk of adverse drug interactions, especially with cardiac medications
Which SSRI is avoided in patients with recent MI and wy?
Citalopram; potential for dose-dependent QT prolongation
XR findings suggestive of thoracic aortic aneurysm?
Widened mediastinum
Enlarged aortic knob
Tracheal deviation
Widened aorta
Cause of TAA?
Age-related degenerative changes that lead to disruption of the aortic wall medial layer with loss of elasticity and consequent aortic dilation
Presentation of thoracic aortic aneurysm?
Asymptomatic until discovery is made incidentally on CXR, CT, or EKG
Some develop chest pain or abdominal discomfort as it grows to compress surroudning structures
Why is a chest CT with contrast usually needed to confirm the diagnosis of TAA?
CXR cannot always distinguish TAA from tortuous aorta
Compare the major manifestations of Waldenstrom macroglobulinemia to multiple myeloma.
Waldenstrom: hyperviscosity syndrome, HSM, neuropathy, bleeding, LAD
Multiple myeloma: osteolytic lesions/fractures, hypcalcemia, anemia, renal insufficiency
Compare the monoclonal antibody, peripheral smear findings, and BM biopsy findings of Waldenstrom vs. multiple myeloma.
Waldenstrom, IgM, Rouleaux, >10% clonal B cells
MM: IgG, IgA, light chains; Rouleaux, >10% clonal plasma cells
Screening test for Waldenstrom macoglobulinemia?
SPEP (monoclonal IgM spike)
If positive -> BM biopsy
Also - serum viscosity testing
