9 Flashcards
In a pregnant patient with stress urinary incontinence, a small pool of urine in the posterior vagina may be seen on speculum examination - why?
Urine can become trapped in the vagina (retrograde vaginal voiding) during pregnancy due to the effects of the growing uterus and positional changes while voiding
Expected hemoglobin electrophoresis patterns in patients with sickle cell disease?
HgbA: 0%
HgbS: 85-95%
HgbF: 5-15%
Expected hemoglobin electrophoresis patterns in patients with sickle cell disease Rx with hydroxyurea?
As above, but expect HgbF >15% because hydroxyurea works by increasing the amount of HbF in circulation
Major AE of hydroxyurea?
Myelosuppression -> neutropenia (ANC 1000)
Define dysthymia.
Chronic depressed mood + 2 or more other depressive symptoms for 2+ years (or 1+ year in children/adolescents) + no symptom-free period for >2 months
List # contraindications to breastfeeding.
- Active untreated TB
- Varicella infection
- Herpetic breast lesions
- Current chemotherapy
- Active substance use
- HIV infection (in developed countries where formula is readily available)
- Galactosemia (infant)
First-line treatment of gestational diabetes?
Dietary modification and exercise
If nutritional therapy fails to produce euglycemia in GDM, what is the next step?
Insulin or oral anti-diabetic medication (metformin)
Target blood glucose levels in GDM?
Fasting: <95
1-hour post-prandial: <140
2-hour post-prandial: <120
When should pregnant women be screened for GDM?
24-28 weeks gestation UNLESS the patient has risk factors (obesity, previous GDM, previous macorsomic infant) -> early, then rescreen at 24-28 weeks if initial is negative
Initial management of shoulder dystocia?
BE CALM
Breathe; do not push Elevate legs and flex hips, thighs against abdomen (McRoberts) Call for help Apply suprapubic pressure enLarge vaginal opening with episiotomy Maneuvers
Presentation - forearm supinated, wrist extended, MCPs hyperextended, interphalangeal joints flexed
Klumpke palsy (claw hand)
Presentation - upper arm adducted/internally rotated, elbow extended, forearm pronated, wrist/fingers flexed
Erb-Duchenne palsy (waiter tip)
What Maneuvers can be done to manage shoulder dystocia after “BECAL” is compelted?
- Deliver posterior arm
- Woods screw - rotate posterior shoulder, apply pressure to anterior aspect
- Rubin - adduct posterior fetal shoulder, apply pressure to posterior aspect
- Gaskin - mother on hands and knees
- Zavanelli - replace fetal head into pelvis for C/S
What is the most likely cause of primary metabolic alkalosis in a pregnant female at 10 weeks gestation and why?
Hyepremesis gravidarum -> severe vomiting, loss of gastric acid -> metabolic alkalosis + volume depeltion -> contraction metabolic alkalosis with activation of RAAS
___ is characterized by damage of one eye after a penetrating injury to the other eye. What is the mechanism?
Sympathetic ophthalmia; immunologic mechanism involving the recognition of “hidden” antigens
Reagin-mediated (IgE-mediated) disease is seen in what eye condition?
Vernal (allergic) conjunctivitis
Rx eosinophilic esophagitis?
Dietary modification
+/- topical glucocorticoids
___ results from myenteric plexus degeneration, which causes incomplete relaxation of the LES.
Achalasia
Fibrosis and atrophy of esophageal smooth muscle occurs in ___.
Systemic sclerosis
Suspect ___ in a patient with a significant smoking history, hypercalcemia, and a hilar mass.
Squamous cell carcinoma of the lungs
Remember SCa++mous
Which paraneoplastic syndromes are seen in small cell carcinoma of the lung, in contrast to hypercalcemias seen in SqCC?
ACTH production
SIADH
Adenocarcinoma is usually a peripheral lesion that is not associated with hypercalcemia. It is typically associated with ___.
Hypertrophic pulmonary osteoarthropathy
Compare Hirschsprung disease and meconium ileus with respect to associated disorder, typical level of obstruction, meconium consistency, and “squirt sign.”
Hirschsprung: Down syndrome, rectosigmoid, normal consistency, + squirt sign
Meconium ileus: CF, ileum, inspissated, negative squirt sign
Classic abdominal XR findings of Hirschsprung disease include ___. If there is no evidence of perforation, ___ can potentially delineate the level of obstruction.
Complete bowel obstruction; contrast enema
What findings suggest gonococcal pharyngitis with PID?
Pharyngitis, non-tender cervical LAD, fever and lower abdominal pain in a young, sexually active patient
Features of EBV infectious mono?
Exudative pharyngitis
Tender cervical LAD
Fatigue, rash, splenomegaly
What are the two phases of the pathogenesis of metabolic alkalosis?
- Generating excess bicarbonate (generation phase)
2. Preventing excretion of excess bicarbonate (maintenance phase)
The generation phase in saline-responsive metabolic alkalosis can be due to ___ or ___.
Urinary or GI hydrogen loss (eg, diuretics, vomiting); decreased oral intake
Most common cause of mitral stenosis?
Rheumatic fever
Presentation of mitral stenosis?
Gradual and progressively worsening dyspnea on exertion, orthopnea, and hemoptysis (2/2 pulmonary edema)
Auscultation: loud 1, opening snap after S2 (APEX), low-pitched diastolic rumple (APEX + patient lying on left side in held expiration)
Eventually: backflow of blood into L atrium, increased L atrial and pulmonary vascular pressures -> L atrial enlargement -> compress recurrent laryngeal nerve (cough/hoarse voice), displace L main bronchus,70% develop AFib
The first step in evaluation of solitary pulmonary nodules is to obtain any previous radiographic lung images. Absence of growth over ___ years rules out malignancy. If previous films are not available, what is the next step?
2-3; CT to further characterize the lesion
Work-up of solitary pulmonary nodule -> CT with benign features?
Serial CT scans
Work-up of solitary pulmonary nodules -> CT with indeterminate or suspicious findings?
Further investigation with biopsy or PET
Work-up of solitary pulmonary nodules -> CT highly suspicious for malignancy?
Surgical excision
Although the DDx for acute urinary retention is broad (neurologic, medications, infections, etc.), the most common etiology is ___.
Bladder outflow obstruction
In men, bladder outflow obstruction is more often due to ___.
BPH
Other etiologies include malignancy, urethral stricture, and urolithiasis
Management of BPH causing BOO?
Acute decompression with urethral or suprapubic catheterization
Definitive therapy: alpha blockers (terazosin, tamsulosin, etc.), and 5-alpha reductase inhibitors (eg, finasteride); surgical intervention may be indicated
What is detrusor sphincter dyssynergia?
Simultaneous activation fo the detrusor muscle and urethral sphincter -> bladder outlet obstruction, typically occurs in neuro disorders
Stress urinary incontinence is most frequently seen in men after ___.
Prostate surgeries
What are two general causes of recurrent pneumonia involving the same region of the lung?
- Local airway obstruction
2. Recurrent aspiration
Causes of local airway obstruction?
- Extrinsic bronchial compression (neoplasm, adenopathy, etc.)
- Intrinsic bronchial obstruction (eg, bronchiectasis, foreign body, bronchial stenosis)
Causes of recurrent aspiration?
- Seizures
- Alcohol/drug use
- GERD, dysphagia
Causes of recurrent pneumonia involving different regions of the long?
- Immunodeficiency (eg, HIV, leukemia, CVID)
- Sinopulmonary disease (eg, CF, immotile cilia)
- Non-infectious (eg, vasculitis, BOOP = bronchiolitis obliterans with organizing pneumonia)
In patients age >50, repeat CXR to assess for malignancy is generally recommended between ___ weeks following treatment of a single episode of pneumonia.
6-12
___ is a benign epidermal tumor that presents in middle-age or elderly individuals as a tan or brown, round lesion with a well-demarcated border and “stuck-on” appearance.
Seborrheic keratotis
What is an acrochordon?
Skin tag (flesh-colored papule seen in regions of the body subject to friction)
Pre-malignant lesion chracterized by dry, scaly, flat papules with an erythematous base, most common in sun-exposed areas?
Actinic keatosis
Slow-growing papule or nodule with a pearly, rolled border and overlying telangiectasias; ulceration is common
Basal cell carcinoma
Skin biopsy - small cells resembling basal cells with variable pigmentation, hyperkeratosis, and keratin-containing cysts
Seborrheic keratosis
Most common causes of osteomyelitis in children with sickle cell disease?
Salmonella and S. aureus
Rx osteomyelitis in children (low vs. high likelihood of MRSA)?
Low: nafcillin/oxacillin OR cefazolin
High: clindamycin OR vancomycin
Rx osteomyelitis in children with sickle cell disease
As above
PLUS third-generation cephalosporin (ceftriaxone, cefotaxime)
Trichinellosis is associated with ingestion of ___. What parts of the world is it found in?
Undercooked meat (usually pork)
Found worldwide; endemic to Mexica, China, Thailand, parts of central Europe and Argentina
What are the 2 stages of trichinellosis and how do they present?
Intestinal stage (within 1 week of ingestion): asymptomatic or abdominal pain, N/V/D
Muscle stage (up to 4 weeks after ingestion): myositis, fever, subungual splinter hemorrhages, periorbital edema, eosinophilia with possible elevated CK and leukocytosis
What causes trichinellosis? Explain the reason there are 2 stages.
Parsitici infection with roundworm Trichinella
Stage 1: within 1 week, gastric acid releases the encysted larvae, which invade the small intestine and develop into worms
Stage 2: female worms can release new larvae up to 4 weeks later that migrate and encyst into striated muscle
What is the hallmark lab finding of trichinellosis?
Eosinophilia (usually >20%)
Triad seen in trichinellosis?
Periorbital edema, myositis, eosinophilia
Rx trichinellosis?
Mild: self-limited
Severe: antiparsitic therapy (mebendzole, albendazole) + steroids
Presentation: intestinal symptoms, eosinophilia, lung phase with non-productive cough followed by asymptomatic intestinal phase
Ascariasis
May present with worms obstructing the small bowel or bile duct
Presentation - fever, headache, retro-orbital pain (key), rash, significant myalgia and arthralgia +/- hemorrhage
Dengue fever
Presentation - fever (week 1), abdominal pain and salmon-colored rash (week 2), HSM + abdominal complications (week 3)
Typhoid fever
Presentation - long-standing daily fever, fixed arthritis of 1+ joints, characteristic pink macular rash that worsens during fever +/- LAD, HSM
Systemic-onset juvenile idiopathic arthritis
How does systemic-onset JIA differ from poly- or olig-articular JIA?
Neither poly nor oligo have fever or rash
Characteristic lab findings of sJIA?
Leukocytosis
Thrombocytosis
Markedly elevated inflammatory markers
Anemia from chronic inflammation and/or iron deficiency
Rx sJIA?
NSAIDs, steroids, biologics
Prophylaxis criteria for Lyme disease?
Must meet all 5:
- Attached tick is an adult or nymphal Ixodes scapularis (deer tick)
- Tick attached for 36+ hours or engorged
- PPx started within 72 hours of tick removal
- Local B. burgdorferi infection rate 20+%
- No contraindications to doxycycline (<8, pregnant, lactating, etc.)
If a tick is attached for <36 hours, what are the next steps in management?
Removal with tweezers ASAP
No prophylaxis with doxycycline indicated
Calculate serum Osm?
2Na + glucose/18 + BUN/2.8
Pulmonary pathology is a common precipitant of ___, which is characterized by hypotonic hyponatremia in a euvolemic patient.
SIADH
What happens to a patient with SIADH who receives NS?
Net free water retention if urine Osm > NS Osm -> worsening hyponatremia
How does hypothyroidism disrupt the hypothalamic-pituitary-ovarian axis?
Low circulating thyroxine levels increases the excretion of hypothalamic thyrotropin-releasing hormone, which stimulates anterior pituitary production of TSH and Prl -> hyperprolactinemia suppresses ovulation (decreased GNRH, FSH, LH)
Most common site for intraosseous access?
Proximal tibia (wide, flat surface, distance from sternum in case CPR is performed simultaneously)
Compare the bacterial causes of pediatric septic arthritis in patients <3 months and those 3+ months of age.
<3 months: S. aureus, GBS, GN bacilli
3+ months: S. aureus, GAS
Best primary course of action with chemical exposure to the eyes?
Flush the eyes with water for at least 15 minutes
Pathogenesis of MG?
Autoantibodies against nicotinic ACh receptors at the NMJ -> receptor degradation
Pathogenesis of foodborne botulism
Decreased ACh release from presynpatic terminal of motor neurons -> acte onset of bilateral CNopathies, symmetric descending flaccid paralysis
Manometry findings indicative of achalasia?
High LES resting pressure
Manometry findings indicative of systemic sclerosis?
Dysmotility and low LES pressure
Objective studies to identify best practices for med reconciliation have been limited, with few interventions confirmed to improve quality of care - what seem to have the most impact?
Interventions that target pharmacy personnel and high-risk patients
Presentation - chronic, watery diarrhea that may occur during periods of fasting and/or at night
Microscopic colitis
Colonoscopy and biopsy findings of microscopic colitis?
Grossly normal colonoscopy; biopsy with mononuclear infiltrate within the lamina propria, and a subepithelial collagen band may be present
Risk factors for microscopic colitis?
> 60, F>M
Concurrent autoimmune conditions
Cigarette smoking
Certain meds (NSAIDs, PPIs, SSRis, ranitidine)
Manage microscopic colitis?
Remove possible triggers
Anti-diarrheal medications (eg, loperamide) and budesonide
Next step in management of symmetric genu varum with normal stature, no leg length discrepancy, and no lateral thrust when walking prior to age 2?
Reassurance and observation -> physiologic from birth to age 2
EKG features of first degree heart block?
Prolonged PR interval (>0.2 s)
P wave always follows QRS unlike other heart blocks
Cause of first-degree AV block?
Delayed impulse transmission at a number of possible locations from the atria to the ventricles (atria, AV node, bundle of His, infra-Hisian conduction system)
Most first-degree AV blocks with normal QRS duration occur due to conduction delay in the ___. Next step in management?
AV node; require no further evaluation unless there are associated bradycardic symptoms like syncope; it is considered a benign finding
A first-degree AV block with a prolonged QRS duration (>120 ms) can be associated with what type of conduction belay?
Below the AV node, most often in the bundle branches
Next step in management of patients with 1st degree AV block and prolonged QRS duration?
Electrophysiological (EP) testing to determine the site of conduction delay
Cause of familial hypocalciuric hypercalcemia?
Mutation in the calcium-sensing receptor
Differentiate between familial hypocalciuric hypercalcemia and primary hyperparathyroidism
Using the urine calcium/creatinine clearance ratio
Familial: <0.01
Primary hyperpTH: >0.02, increased urinary calcium excretion
Calculate the urine calcium/creatinine clearance ratio.
(Ca: urine/serum)/(Cr: urine/serum)
