Assorted Flashcards
Prophylaxis for meningitis exposure is generally
Rifampicin or ceftriaxone
Tx for acute gout
Corticosteroids, colchicine, or NSAIDS
Common tx for chronic gout
Allopurinol
Pharmacological tx for meningitis
Ceftriaxone + vancomycin + dex (admin before/with abx)
(+ampicillin if risk of Listeria - elderly, immunocompromised, newborns, pregnancy)
Initial meds for status epilepticus (2 meds with doses)
Midazolam 10mg IV/IM
Lorazepam 4mg IV/PR
Indications to do a CT before LP
FAILS
Focal neuro deficit
AMS
ICP elevated, Immunocompromise
Lesions in brain
Seizures (not in young children)
**do NOT delay empiric tx for meningitis bc of this
THe main pathophys of ILD can be summed up as
Pulmonary inflammation –> fibrosis
Findings of ILD on imaging
Reticular opacities (fibrosis)
Ground-glass opacities (increased density but can still see bronchial structures/vessels)
Honeycombing (air-filled cysts w/ fibrotic walls)
3 drugs for Afib rate control
Beta blocker
ND-CCB
Digoxin
Gram-positive cocci in clusters
Staph aureus
Gram-positive cocci in chains
Streptococcus
What blood product contains Vit-K dependent factors? Uses?
PCC
Can reverse warfarin (+vit K), DOACs if no other antidote (idarucizumab) available
What blood product Is prepared from plasma and contains fibrinogen, factor VIII, von Willebrand factor, factor XIII and fibronectin
Cryoprecipitate
Most patients with afib should be on what type of med? What do you add and when?
DOAC
CAD/PAD –> antiplatelet therapy
When can you cardiovert Afibwithout 3 weeks of OAC or TEE?
1) Hemodynamically unstable acute AF
2) NVAF <12 hrs (no recent stroke)
3) NVAF 12-48 hrs and CHADS 0-1
Gonorrhea Tx
Ceftriaxone 500mg IM (or cefixine PO) + azithro (co-tx for chlamid)
Chlamydia treatment
Azithro (1g PO x 1)
OR
Doxycycline 100mg PO BID x 7 days
Location of STEMI with changes in leads II, III, aVF
Inferior
Location of STEMI with changes in leads I, aVL, V5, V6
Anterolateral
Location of STEMI with changes in leads V3/V4
anteroapical
Location of STEMI with changes in leads V1/V2
Anteroseptal
U wave shows up in what condition?
Hypokalemia
Mnemonic for determining reciprocal changes
PAILS
e.g. Posterior STEMI causes depression in Anterior leads
*lateral can have reciprocal in inferior/septal
Normal PR interval
3-5 small boxes = 0.12-0.2
1 large box on ECG = ? seconds
0.2 (so 1 small = 0.04)
Normal QRS complex
0.1 sec (<2.5 small boxes)
Normal QTc
Shortcut?
<0.44
Shortcut if normal HR (60-100): if QT <50% interval b/w QRS complexes, then it’s ok
Contraindications to thrombolysis
Prior ICH
Non structural cerebral vascular lesion or intracranial malignancy
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant facial/closed head trauma within 3 months
Enoxaparin, Dalteparin, and Tinzaparin are all examples of…
Low molecular weight heparin
Mechanism/treatment of ITP
Autoimmunity, often follows viral infection in children
Usually no tx, but steroids/IVIG if severe
An indirect inguinal hernia protrudes through the…
Deep inguinal ring (LATERAL to inferior epigastric vessels)
Congenital hydrocele treatment
Usually resolves spontaneously by 6 months
Consider Sx if present @ 1 yr
Colon cancer screening for no FMHx of colon cancer
Age 50-74
FIT q2 years
Colon cancer screening for FMHx colon cancer (parents, sibilng, child)
Colonoscopy q5 years if family member had it before age 60, q10 if after
starts 10 years before their diagnosis (age 50 latest)
Freq of pap tests
q3 years
When can you stop paps
After age 70 if 3+ normal in past 10 yrs
Lung cancer screening
Age 55-74 years old
Smoke 20 year hx (non-consecutive)
Low-dose CT
Breast cancer screening guidelines
Age 50-74 mammogram q2 yrs
A1C for prediabetes
6.0-6.4
Who gets screened for diabetes and how often
> 40 years or high-risk –> q3 yrs
Very high risk –> q6mo-1yr
Diabetes pt >40 or >30 with diabetes 15+ yrs should be on a
Statin
Pt with diabetes >55yo with CV risk factors OR microvascular disease should be on…
Stain + ACEi/ARB
Pt with diabetes and CV disease should be on…
Statin + ACEi/ARB + ASA (add GLP-1 agonist or flozin)
Outpt abx for febrile ndutropenia
Fluroquinolone (cipro or levofloxacin)
+ Amox-clav
Inpt abx for febrile neutropenia
Pip-tazo OR cefepime OR merepenem
Add vanco if indication (MRSA coverage)
Abx in otitis media
Amoxicillin
(try amox clav if that doesn’t work for H influenzae coverage)
Abx for strep throat (GAS)
Amoxicillin (UNIVERSALLY SUSCEPTIBLE TO BETA LACTAM - do not need amox-clav)
Attributes of hypercalcemia
Bones (fractures)
Stones (kidney stones, polyuria, dehydration)
Groans (headache, abdo pain, nausea, ileus, constipation)
Psychiatric overtones (lethargy, stupor depression, psychosis, cognitive dysfunction)
For every 10 decrease in albumin how do you change Ca level?
+0.2 Ca (more unbound)
Cornerstones of hypercalcemia of malignancy management?
IV saline & bisphosphonates
(also replete phosphate if low)
What do you suspect in a pt with JIA or Still disease who has a high, unremitting fever, leukopenia/anemia/thrombocytopenia, elevated liver enzymes/feritin…
Macrophage Activation Syndrome
Major risk in children with oligoarticular JIA that should be proactively prevented
Anterior uveitis (can be asymptomatic, early detection/tx useful due to chance of glaucoma, cataracts, optic nerve damage)
- Slit lamp exams, q3 months if ANA positive
Prognosis of JIA
95% resolve by puberty
(worse prognosis if early onset with growth issues/deformities), polyarticular/symmetrical, auto-antibodies
Transient salmon-pink rash, intermittent fever, leukocytosis hepatosplenomegaly, serositis, and arthritis are features of…
Systemic JIA (Still disease)
Most common type of JIA
Oligoarticular (good prognosis)
Mismatch between the rapid growth of the femoral epiphyses and the slower development of adequate blood supply to the area –> juvenile hip pain
Legg-Calve-Perthes disease
[idiopathic, avascular necrosis of the femoral head]
superior and anterolateral displacement of the femoral neck due to weakening of the proximal femoral epiphyseal growth plate –> peds hip pain
Slipped capital femoral epiphesis
Name 5 differentials for peds hip pain
Transient synovitis (usually resolves in <1 week with rest/NSAIDS)
Septic arthritis
SCFE
Legg-Calve-Perthes disease
Developmental dysplasia of hip
traction apophysitis that occurs where the patellar tendon attaches to the tibial tuberosity –> anterior knee pain = ? disease
Who usually gets this
Osgood Schlatter
Children 9-14 in athletics
Tx for Osgood-Schlatter
Relative rest, NSAIDS, ice; brace if persistent
NOT steroid injections (can weaken tendon)
90% resolve once full bone maturity reached
Main pathogen causing croup
Parainfluenza virus 1
Flashes/floaters/curtain in PERIPHERAL vision is a sign of
Retinal detachment
Sudden vision loss/double vision in pt >60, always think…
GCA! If CRP elevated –> high-dose steroids
Sudden vision changes with RAPD in young person (30F), think….
Optic neuritis
Young person, wears contact lenses (sleeping/swimming) –> think
Bacterial infectious keratitis –> corneal ulcer (white spots on cornea)
Pt with sudden acute severe eye pain, blurry vision, temporal headache…
Acute angle closure glaucoma
Hx of being in the dark –> blurry vision, headache, nausea/vomitting
Acute angle closure glaucoma
Definitive tx for Acute angle closure glaucoma
Laser iridotomy (make hole in iris)
Non-surgical management of AAC glaucoma
Pilocarpine (muscarinic, constrict pupil)
Acetazolamide, dorzolamide (decrease aqueous humor prod)
Hyperosmotic agents (glycerol, mannitol)
Timolol (also decrease prod)
Charcot’s triad of acute ascending cholangitis
Fever + RUQ pain + jaundice
Reynold’s pentad for acute suppurative cholangitis
Fever + RUQ pain + jaundice + AMS + hypotension
Gilbert syndrome and Crigler-Najjar syndrome are disorders of…
Bilirubin conjugation
Most common type of neonatal jaundice? Natural history?
Physiologic jaundice
Usually resolves within ~1 week of life
2 types of non-pathological unconjugated hyperbili in infants?
1) Breastfeeding (not enough! –> increased enterohepatic circulation reabsorbs bilirubin)
2) Breast milk (B-glucuronidase in breast milk –> deconj/reabsorb bili)
Jaundice at what time period is always pathologic in a baby?
<24 hours old if term
Limited internal hip rotation in a child with thigh pain should make you think…
Slipped capital femoral epiphysis (SCFE)
Adjustment disorder time period
Starts within 3 months of stressor
Sx last <6 months following stressor resolution
First-line lab test for celiac disease
tTG IgA (sensitivy/specificity >95%)
Alternative lab tests for celiac disease
Total IgA –> if deficient, perform IgG-based testing
HLA testing (NPV ~100% if neg for HLA-DQ2 & DQ8)
Anti-endomysial antibody (higher specifity but expensive)
Calculate specificity
Specificity = True negative/True negative + false positive
5 cyanotic heart lesions
Truncus arteriosus (aorta/pulmonary artery join to make 1)
Transposition of the great vessels
Tricuspid atresia
Tetralogy of fallot
Total anomalous pulmonary vascular return
4 defects in tetralogy of fallot
RV hypertrophy
Overriding aorta
Subvalvular pulmonic stenosis
VSD
what is Eisenmenger syndrome
Shunt reversal due to chronic L>R shunting through congenital defect –> increased pulmonary flow –> severe pulmonary vascular obstruction –> shut reversal (R->L; cyanotic)
Explain Wolff-Chaikoff effect
Excess iodine –> transient inhibition of TH production (to avoid hyperthyroidism, but eventually gland “escapes” unless there is a disorder)
Explain Jod Basedow effect
In pts with multinodular goiters/Graves, excess iodine –> hyperthyroid (no Wolff-Chaikoff)
What is the one “opposite” effect of hyperthyroidism?
Lowers DIASTOLIC pressure by decreasing PVR
In thyroid storm why must iodine load be given AFTER a thioamide?
To prevent Jod basedow!
Hashimoto’s autoimmune thyroiditis cases ____ TH
Low
Thioamides include
PTU (given in thyroid storm bc inhibits production & peripheral conversion, safe in T1 pregnancy)
Methimazole (generally 1st line, inhibits production)
Scoop on a PFT is an indicator of
Emphysema
Bottom of Flow-volume loop is ___, top is ____
Bottom = Inspiration
Top = expiration
Indicator of obstruction on PFT
FEV1/FVC ratio (actual value) <0.7 or <LLN if given
How to grade severity of obstruction on PFT
by FEV1 PERCENT PREDICTED
Mild >70%
FCV low with normal FEV1/FVC ratio indicates
Restriction
Ectopic pregnancy should be suspected if no IU gestational sac and beta higher than…
1500
Rhogam should be given when?
28-32 weeks (if RH neg)
WIthin 72 hr of delivery if infant Rh+
What does mono-di mean for twins
What is the risk?
Monochorionic diamniotic
*must be monozygotic to be monochorionic
RIsk of twin-twin transfusion syndrome
What is normal baseline variabilit in intrapartum fetal surveillance?
6-25 bpm
What is the maternal mortality rate
Maternal deaths per 100,000 live births (while pregnant or within 42d postpartum)
Define fetal mortiality
Stillbirths/1000 total births
Define infant mortality rate
Infant deaths within first year of life/1000 live births
Kawasaki disease mnemonic
CRASH and BURN
Conjunctivitis (painless/bilateral)
Rash (polymorphous, originating on trunk)
Adenopathy (cervical, mostly unilateral)
Strawberry tongue
Hands and feet (erythema/edema)
BURN = Fever 5+ days
Treatment of kawasaki
IVIG (reduces risk of coronary artery aneurysms)
High-dose oral aspirin (exception to rule re Reye syndrome)
Kawasaki is an acute necrotizing ___ and its most concerning complication is _____
Vasculitis
Coronary artery aneurism
5 Ws of postpop fever
Wind (atelectasis/lungs)
Water (UTI/catheter)
Wound (superficial or deep)
Walking (DVT)
Wonder drugs (or blood products)
____ do NOT reduce bleeding secondary to leiomyomas. Try what instead?
NSAIDS do NOT
Try OCP/GnRH agonist/depo
2 alternative surgeries apart from hysterectomy for fibroids
Myomectomy (risk of recurrence, req C/S in future preg)
Uterine artery embolization
Stages of labour
1st latent: ends at 6cm dilation, mild/irregular contractions
1st active: 6-10cm, increased contractions/dilation
2nd: complete dilation - birth
3rd: birth - placenta delivery
4th: 1-2 hr postpartum
Clinical features of amniotic fluid embolism
ARDS
DIC
Shock/cardiac arrest
What is the most frequent cause of medication-induced hyperprolactinemia –> secondary amenorrhea
Antipsychotics
Abnormal uterine bleeding mnemonic
PALM-COEIN (structural-nonstructural)
Polyps
Adenomyosis
Leiomyomas
Malignancy
Coagulopathy
Ovulatory dysfunction
Endometrial (local hemostasis dysreg)
Iatrogenic
NYS
Name a few absolute contraindications to COCP
- current pregnancy or <6wks postpartum if breastfeeding
- Undiagnosed vaginal bleeding
- Smoker >35 years old (>15 cigs/day)
- HTN (sBP>160 or dBP>100)
- Current or past VTE
- PMHx of ischemic heart disease, CVA, complicated valvular heart disease
- Migraine with focal neuro Sx (aura = relative contraindications)
- Current breast cancer
- Diabetes with end-organ involvement
- Severe cirrhosis or liver tumour
Preconception folic acid dosing
400mcg
4g if high-risk (prev NTD, epilepsy, diabetes)
Abx for GBS
Pen G
allergic –> erythromycin or clindamycin
When is GBS swab done
35-37 wks
Antihypertensives for preeclampsia
Hypertensive Moms Need Love
Hydralazine Methyldopa Nifedipine Labetalol
Green/yellow foul-smelling purulent discharge & strawberry cervix likely indicates
Trichomonas
Treatment for trich
Metronidazole (2g) + treat partner
Diffuse thin/grey discharge with fish small likely is
Bacterial vaginosis
Tx for bacterial vaginosis if symptomatic
Metronidazole 500mg BID x 7d (don’t need to tx partner)
Micro testing for BV includes
Looking for clue cells, “whiff test” with KOH
First line & 2nd line tx of lichen sclerosis
Clobetasol (superpotent topical steroid)
Topical calcineurien inhibitor (tacrolimus)
Bleeding, cramps, but cervix closed = ___ abortion
Inevitable
Heavy bleeding + cramps + passage of tissue with cervix open = ___ abortion
nIcomplete
No bleeding, cervix closed, fetal death = ___ abortion
Tx?
Missed
Watch/wait, mifepristone + miso, or D&C
How to confirm success of medical abortion
Reduction in beta HCG (50% after 2 days or 80% after 1 week)
Until what time can medical abortion be used?
9 weeks from LMP (evidence supports up to 10 wks)
Reactive (normal) NST entails?
2+ FHR accelerations of at least 15 bpm above baseline and 15+ seconds
Biophysical profile has what 4-5 key components?
Fetal movement
Fetal tone
Fetal breathing
Amniotic fluid level
[+/- Nonstress test]
evaluated with 2 points each
Normal amniotic fluid index
5-25cm
What is the routine prenatal genetic screening and when are they done
eFTS (1st trimester) - week 11-14
if too late, MSS (no NT in this)
When can NIPT be done
10 weeks to end of pregnancy
Amnio vs CVS timeline
CVS 11-14 wks
Amnio >15 wks
Name the TORCH infections
Toxoplasmosis
Other (syphilis, varicella, Parvovirus B19, Listeriosis, Zika)
Rubella
CMV
HSV
Anticoagulant to use during pregnancy
Heparin
What is erythema infectiosum (fifth disease) cased by? Main clinical Sx?
Human parvovirus B19
Fever –> “slapped cheek” rash/maculopacular examthum
Can cause arthralgias in adults
Can also cause transient anemia, and more severe hematological effects in people with predisposion (sickle cells, immunocompromise)
Primary hereditary hemochromatosis involves what mechanism?
No functional HFE protein –> NO HEPCIDIN –> unregulated ferroportin –> FE oerload
(HEPCIDIN DOWNREGULATES FE ABROPTION)
How to tell the difference between anticholinergic OD and serotonin syndrome?
Anticholinergic = dry as a bone
SS = hot and wet! w/ nausea/vomiting
NMS vs SS key differences?
Onset (SS faster onset & resolution)
NMS more “sluggish” neuro, serotonin neuro hyperactivity
NMS more mute/staring, SS more hyperkinetic/agitated
Management of serotonin syndrome
STOP agent(s)
Supportive care, IV hydration
Meds: benzos, antihypertensives, anticonvulsants, PRN
Cyproheptatine (serotonin antagonist) and Dantrolene (muscle relaxant)
Serotonin syndrome typically resolves within ___ of meds being stopped
24 hours (vs ~9d for NMS)
Management of NMS
STOP causal agents
Supportive care, IV hydration
Meds: Benzos, ECT, Dantrolene (muscle relaxant)
Prolonged ROM is considered
> 18 hrs between rupture –> delivery
Diagnosis of ROM
Nitrazine paper turns blue (pH>6)
Ferning pattern on glass slide
What are tocolytics used for? examples?
To DELAY labour so corticosteroids can be given!
Indomethacin (NSAID, 24-32 wks)
Nifedipine (CCB, 32-34 wks)
IV MgSO4 for neuro protection until 24 weeks
When are corticosteroids given during labor
Between 24-34 weeks in all case of PPROM and in PTL if delivery expected within 7 days
A single rescue course if >14 days since admin and delivery again expected
From 34-36 weeks if PPROM or PTL occurs and no prior steroids –> 1 dose betamethasone (ALPS)
MgSO4 given for preterm labour up to how many weeks
24-32 wks
Preferred approach to GDM testing
50g GCT –> if abnormal. 75g OGTT
(alternative is one-step 75g)
All pregnant women not known to have pre-existing DM should be screened when?
24-28 wks
Most common site of ectopic pregnancy
Ampulla
Methotrexate can be used for ectopic if…
<3.5 cm unruptured ectopic, beta <5000, no FHR
Also must be assured of compliance/FU
Most common pathogens in asplenic sepsis
Encapsulated bacteria
Think: “Has No Spleen”
H infuenzae, N meningitidis, S pneumonia
(note that pts with sickle cell can have functional asplenia)
Common meds used chronically in sickle cell
Daily prophylactic penicillin & hydroxyurea in children, some adults
(hydroxyurea increases HbF –> fewer vasoocclusive episodes)
Pneumonia + sickle cell crisis should be managed as
Acute chest syndrome
Howell-Jolly bodies indicate…
Asplenia (e.g. in sickle cell)
2 types of alpha-thalassema that cause significant symmptoms
Hemoglobin H disease (3 defective alleles –> HbH)
Hemoglobin Bart’s (4 defective –> Hb Bart –> hydrops fetalis)
Alpha and Beta thalassemia are common in what populations
Alpha: Asian/African (think “A”)
Beta: Mediterranean
Why does thalassemia B not appear until ~6 months old vs A has immediate clinical features?
Because Hb F = 2 alpha + 2 gamma and so compensates in B-thal
Treatment for thalassemia major/intermedia
Transfusion therapy
Chelating if iron overload
Target cells, teardrop cells (extramedullary hematopoiesis), and anisopoikilocytosis (varying RBC shape/size) on PBS indicate
Likely thalassemia
___ should be strongly suspected if HbA2 (2 alpha + 2 delta) is elevated
Beta-thalassemia
HbH =
bet-globin tetramer
HbF =
a2y2
Microcytosis cutoff
MCV <80
Thalasemmia presents with ___ anemia
Microcytic
GSC components
Eyes
Verbal
Motor
GCS Eyes most to least
Spontaneously open
Open to voice
Open to pain
Closed
GCS Verbal highest to lowest
Oriented
Confused
Inappropriate words
Sounds
None
GCS Motor
Follows commands
Localizes pain
Withdraws to pain
Decorticate
Decerebrate
None
CF causes what type of alkalosis
Contraction (loss of fluid w/ NaCl though sweat) = chloride-responsive!
RAAS activation –> H+/K+ loss (hypokalemia)
Best first test for CF when suspected (+NBS, sibling with it, Sx)
Quantitative pilocarpine iontophoresis (sweat test)
if moderate (30-60) –> need genetic analysis
What are the most common pathogens in CF
Staph aureas & Pseudomonas aeruginosa (for PA may need chronic azithromycin)
Meds for CF
High-dose ibuprofen (can slow lung disease)
Bronchodilators (SABA)
Mucolytics: hypertonic saline neb, aerosolized Dornas alfa
Pancreatic enzymes
supplement NaCl/fat-soluble vits
CFTR modulators are new, target underlying protein defect in pts with specific mutations!!
What is both diagnostic & therapeutic for meconium ileus?
Gastrografin enema
Double bubble xray in newborn indicates
Duodenal atreisa
In CF, residual lung volume is…
Increased (obstructive disease w/ air trappin)
Why do CF patients have elevated PT?
Vit K deficiency (fat soluble, exocrine pancreatic insufficiency)
Bell palsy is often precipitated by what infection?
EBV
HZ
Borreliosis (lyme)
HSV
A “good baby” who doesn’t cry much and has a large anterior fontanel, umbilical hernia, and macroglossia likely has…
Congenital hypothyroidism
Is normal CO2 during an acute asthmatic episode a good sign or bad sign
BAD because it should be low due to hyperventilation –> impending resp failure!!
The only thing youshould NOT do in COPDis _____ as monotherapy.
The only thing youshould NOT do in asthma is ______ monotherapy.
ICS
LABA
Indications for intubation (5 not including GCS <8)
1) Airway obstruction
2) Can’t oxygenate
3) Can’t ventilate
4) Can’t protect airway
5) Anticipated clinical deterioration to the above
5 sources of hemorrhage where blood may be lost
Thorax
Abdomen
Retroperitoneum (pelvic fractures)
Long bone fractures (femur)
“The street”
Cushing’s triad for ICP
Hypertension
Bradycardia
Irregular respirations
Management for circumferential chest burns impeding resp
Escharotomy
Tx for CO poisoning from burning environment
100% O2, hyperbaric if available
Second degree burn penetrates the
Dermis
If tactility is impaired the burn is likely what degree?
3rd (full thickness) or 4th (deep structures, e.g. muscles)
Surgery is always mandated in what degree(s) of burns
3rd/4th, but commonly deep 2nd as well
Rule for peds fluid maintenance
4,2,1 (mg/kg/hr)
What is a greenstick fracture
Discontinuity of cortex.periosteum on convex side, just bending on concave side
usually in kids
Open fracture AKA
Compound fracture
When should pt be given tetanus toxoid immunization if they have an open fracture
No booster in 5 yrs
If >10 yrs or immnocompromised, give both toxoid & human tetanus immune globin
What is a salter-harris fracture?
Fracture of physis (growth plate)
Name the 5 types of salter-harris fractures
SALTER
Straight across physis
Above
Below
Through everything
cRush
6 Ps of compartment syndrome
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Poikilothermia (temp dysreg)
Management of compartment syndrome
Fasciotomy
Anion gap calculation
Na - (HCO3 + Cl)
How to adjust normal AG in hypoalbuminemia
For every 10 g/L decrease, reduce “normal” by 2.5 (albumin = major unmeasured anion)
Formula to check for additional metabolic disorders in AG metabolic acidosis
(AG-12) + HCO3
<23 –> primary non-AG met acidosis
>30 –> primary met alkalosis
Expected PCO2 compensation in non-mixed metabolic acidosis
PCO2 = 1.5(HCO3) + 8 +/-2
Expected metabolic compensation for increase in PaCO2 of 10 (acute & chronic)
1, 4
(increased)
Expected metabolic compensation for decrease in PaCO2 of 10 (acute & chronic)
2, 5
(decrease)
Causes of AG-metabolic acidosis
MUDPILES
Methanol
Uremia
DKA
Propylene glycol
Iron tablets / Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
Causes of non-AG metabolic acidosis
HARD-ASS
Hyperalimentation
Addison disease
Renal Tubular Acidosis
Diarrhea
Acetazolamide
Spironolactone
Saline infusion
What is Beck triad?
Hypotension + muffled heart sounds + distended neck veins
Seen in CARDIAC TAMPONADE
Diffuse ST elevation in all leads except aVR & V1 is an indicator of…
Pericarditis
Electrical alternans is a sign of
Large pericardial effusion
Infants who may have esophageal atresia should not be ______ under any circumstances!
Fed orally (likely fistula to trachea –> aspiration!!)
Esophageal atresia often presents with what finding during pregnancy?
Polyhydramnios (fetal can’t swallow fluid)
What is Kussmaul sign
Distention of jugular veins during inspiration
Sign of constrictive pericarditis
What is Dressler syndrome?
Pericarditis occuring weeks after MI (usually happens acutely)
How to treat post-MI pericarditis?
Rest & aspirin
Treatment of minimal change disease
Prednisone
3 characteristics of nephrotic syndrome
Nephrotic-range proteinuria (>3.5 g/day)
Low albumin
Edema/anasarca
(+/- hyperlipidemia, thromboses)
Which nephrotic syndrome causes immune complex deposition between basement membrane and podocytes with a “spike & dome” appearance
Membranous nephropathy/glomerulonephritis
(Membranoproliferative glomerulonephritis can also cause immune complex deposition but involves thickened glomerular BM, and typically nephritic syndrome)
Nephritic syndrome is characterized by
Glomerular capillary damage –> hematuria (RBC casts), pyuria, hypertension (also edema)
How does nephrotic syndrome impact coagulability?
Hypercoag due to loss of antithrombin III, protein C/S
Red cell casts =
Glomerulonephritis
Vasculitis
White cell casts =
Acute interstitial nephritisF
Fatty casts =
Nephrotic syndrome, minimal change disease
Muddy brown casts =
Acute tubular necrosis
Mainstays of tx for nephrotic syndrome
Treat underlying cause (if primary –> immunosuppression)
Edema: loop diuretics
Proteinuria: ACEi
*no role for anticoagulation prophylaxis
ATN most commonly cause by what 2 main categories?
Ischemic (typically damages LoH)
Toxic (PCT)
Indications for RRT
AEIOU
Metabolic acidosis <7.1
Electrolytes: hyperkalemia/hypercalcemia
Toxic Infection/Intoxication (poisoning)
Fluid overload
Uremia
5 Ps of drugs causing AIN
Penicillin
PPIs
Pee (diuretics)
rifamPin
Pain (NSAIDS)
Symptoms of AIN
Painless hematuria (no RBC casts!)
Sterile pyuria
Diffuse maculopaular rash, peripheral eosinophilia
Fever
Arthralgias
Main treatment for drug-induced AIN
D/C causative agent & fluids
3 main causes of rapidly progressive (crescent) glomerulonephritis
Anti-glomerular BM Abs (goodpasture - affects lungs as well)
Lupus nephritis
Vasculitis-associated glomerulonephritis
4 main causes of intra-renal AKI
Vascular (vasculitis, emboli)
Acute glomerulonephritis (post-infectious, RPGN)
Acute interstitial nephritis (“kidney allergy”)
Acute Tubular Necrosis (ischemic/nephrotoxic)
1st line medical treatment for portal hypertension
Beta blockers (leads to unopposed alpha action on splanchnic circulation –> splanchnic vasoconstriction –> reduced portal/collateral blood flow)
Drug for acute esophagial variceal hemorrhage
Octreotide (+IV abx prophylaxis)
Ideal surgery for esophageal bleed
Endoscopic band ligation
1st line tx for hepatic encephalopathy
Lactulose (leads to NH3 protonation –> excretion/not absorbed in bowel)
Rifaximin = 2nd line (reduced NH3-producing intestinal bacteria)
ALT/AST in 1000s (suuuuper high) probably
acute viral hepatitis
Alpha-1 antitrypsin defieicny manifests with
Panacinar emphysema
Hepatic fibrosis, sometimes HCC
Budd Chiari involves
Obstructino of hepatic vein
Procedure for portal hypertension/complications
TIPS (transjugular intrahepatic portosystemic shunt)
In women with uncomplicated pre-existing diabetes, induction should be considered between
38-39 weeks (reduces risk of stillbirth)
Naegel’s rule
-3 months + 1 week
What nephropathy commonly occurs immediately after (or potentially during) URTI or GI infection
IgA nephropathy
Main difference between IgA nephropathy and Post-Strep GN?
IgA onset faster
PSGN occurs after a latent period of approximately 10 days following group A strep pharyngitis. Generally, PSGN occurs up to 3 weeks following group A strep skin infections.
What is Henoch-Schonlein purpura
Iga Vasculitis
Like IgA nephropathy onset preceded by URTI/GI infx
Manigests in palpable purpura, arthritis/arthralgia, abdo pain, usually in children (nephro usually more in adults)
What is HUS typically caused by? Who is usually affected
Bacterial toxins (e.g. Shiga-like toxin of enterhemorrhagic E coli) –> platelet microthrombi –> hemolytic anemia, thrombocytopenia, AKI
Young children
Main differentiator of TTP and HUS
TTP more in adults (median 40 yrs)
TTP is ADAMTS13 deficiency (usually acquired/autoantibodies related to systemic disease, drugs, pregnancy); HUS triggered by bacterial toxins
Child who comes un with pain/limited ROM of arm, held in flexed/pronated position likely has
Radial head subluxation (caused by traction, e.g. adult grabbing child’s arm to prevent fall)
Most common cause of traveler’s diarrhea
Enterotoxicenic E Coli
What Abx in EHEC?
NONE!!! Contraindicated bc lead to toxin release
Prefererd Abx for bite wound
Amox/clav
Strong family history of facial/laryngeal edema with abdo symptoms and possibly extremity edema likely indicates what condition? Inheritance?
Hereditary angioedema (Autosomal Dom)
(Inherited C1 inhibitor deficiency)
3 autoimmune-type liver disorders
Primary sclerosing cholangitis
Primary biliary cholangitis
Autoimmune hepatitis
Children under 9 years of age who have never had an influenza vaccine need…
2 doses, 4 weeks apart
Older pt describes “curtain coming down” in front of eye (unilateral) intermittently, episodes last up to 30 min. Likely diagnosis/initial tx?
Amaurosis fugax (retinal ischemia following transient occlusion of retinal artery by microemboli)
Harbinger of stroke!! –> start aspirin
**can be part of GCA –> steroids
Difference between selective IUGR vs twin-twin transfusion syndrome in monochorionic diamniotic?
TTTS will have amniotic fluid abnormalities
Unhappy triad involves what ligaments of the knee?
ACL (most commonly injured)
MCL
Medial meniscus
When are Abx indicated in acute otitis media?
<2 years old
Severe Sx
Otorrhea
What are Koplik spots?
Grains-of-sand-like spots in buccal mucosa
PATHOGNOMONIC for measels!!
What populations should be treated with asymptomatic bacteruria
Pregnant women, or undergoing endourological procedure
NOT older adults/diabetes/catheters/SC injuries
Benzos ___ risk of opioid overdose
Increase!
Incidental finding of large abdominal mass in child 2-5yo with hematuria, think…
Nephroblastoma (Wilms tumor)
Next step for incidental solitary pulmonary nodule <3cm on CXR
If prev imaging shows stability >2 years, no further testing
Otherwise obtain CT and assess risk via lesion/personal characteristics.
If intermediate risk, serial CT for 2-3 yrs; if high risk, surgical excision
3 important vaccines 2 weeks after splenectomy
Pneumococcal
Hib
Meningococcal
Post-splenectomy Abx
Daily proph of pen or amox in children to 5 years, everyone 1 yr after surg, and lifelong if IC or hx sepsis
Early empiric amox-clav if any signs of infx
2 meds for urge incontinence
Muscarinic antagonist = oxybutynin
Sympathomimetic - mirabegron
Most common cause of pancreatitis
Biliary (alcochol 2nd)
Most important therapeutic measure in pancreatitis
Fluid replacement!!
Note: ECRP can be necessary if gallstone is cause, but also can make pancreatitis worse :( - in these cases likely will need cholecystecomy
Test to determine exocrine pancreas function
Fecal elastase-1 in stool (low = insufficiency)
*Test this in chronic pancreatitis
After fine needle aspirate, what breast cysts need core needle biopsy to evaluate for breast cancer?
Bloody fluid or if doesn’t resolve after draining
ND-CCBs are contraindicated in heart failure with..
Reduced EF
Systolic dysfunction
(so in these pts with AFib use digoxin - BB also not ideal in this population due to need for slow titration)
Acute asthma exacerbation drugs
Supplemental O2
SABA + SAMA
IV corticosteroids (key)
IV MgSO4
4 key pharmacological pillars in pts with HFrEF
●Renin-angiotensin-aldosterone system antagonist, with a preference for an angiotensin receptor-neprilysin inhibitor (ARNI; ie, sacubitril-valsartan)
●Beta blocker.
●Mineralocorticoid receptor antagonist (MRA) = aldosterone antagonists (spironolactone, eplerenone)
●Sodium-glucose co-transporter 2 (SGLT2) inhibitor.
+ loop diuretics as needed for volume overload
Pharmacotherapy for HFpEF
sodium-glucose co-transporter 2 (SGLT2) inhibitor
AND
mineralocorticoid receptor antagonist (MRA)
+loop diuretics as needed for volume overload
When are inotropes (dobutamine, milrinone) given in Heart Failure?
Severe acute decompensated HF (not if preserved systolic fn i.e. HFpEF)
When are Abx indicated in COPD exac?
Cardinal Sx: increased dyspnea, sputum volume, sputum purulence
At least 2/3 and must include increased purulence
Fever during a transfusion could indicate what 3 conditions
Bacterial sepsis/contamination (rare)
Acute hemolytic transfusion reaction
Febrile non-hemolytic transfusion reaction
Acute hemolytic transfusion reaction typically caused by what?
ABO incompatibility (often human/clerical error)
How to manage Febrile Non-Hemolytic Transfusion Rxn
Acetaminophen
(pre-medication doesn’t seem helpful)
Dyspnea during transfusion likely indicates what 3 dx
TRALI
TACO
Anaphylaxis
TRALI management
Typically mechanical ventilation
Pharmacotherapy for tourettes
Alpha-adrenergic agonists: clonidine, guanfacine
Dopamine-blocking agents: antipsychotics
Is ODD or conduct disorder more likely to involve legal infractions, aggression toward people/animals, deceit
Conduct disorder
Current first-line therapy for H pylori eradication
Non-bismuth quadruple therapy (regimen with bismuth is rescue therapy, more effective but +++tablets)
PPI BID
Amoxicillin
Clarithromycin
Metronidazole
Recommended testing for H pylori eradication (AFTER pt has used abx)
NOT serology (false positives, not specific to active infx)
Urea breath test or stool antigen test test (or scope)
Bismuth quadruple therapy for H pylori
Bismuth
Metronidazole
PPI
Tetracycline
Most common site if diverticulosis
Sigmoid colon
Workup if borderline B12/folate
Increased homocysteine & methylmalonic acid –> B12 deficiency confirmed (folate possible)
Increased homocysteine only –> folate deficiency confirmed
VITAMIN CDE mnemonic for ddx
Vascular
Inflammatory/Infectious
Traumatic
Autoimmune
Metabolic
Iatrogenic/Idiopathic
Neoplastic
Congenital
Drugs
Endocrine
Diagnosis of diverticolosis vs diverticulitis
Diverticulosis –> Colonoscopy
Diverticulitis –> Do not scope (perf risk)! CT abdo with contrast
Management of diverticulitis
Uncomplicated –> clear fluids, supportive care; empiric Abx in specific cases
Complicated (perf, abscess, peritonitis, obstruction, fistula) –> Broad-spectrum IV abx, admission, urgent or later elective colectomy, abscess drainage PRN
Eosinophilic esophagitis diagnosis & tx
Histopathological dx
PPIs; +/- topical steroids, dietary eliminiation of allergens
Define achalasia
Failure of LES to relax (degeneration of inhibitory neurons in esophageal wall)
Tx of achalasia
Pneumatic dilation, myotomy, botox
CCBs (nifedpine) if refractory
Diagnosis of Achalasia
Upper endoscopy
Barium swallow
Esophageal manometry = confirmatory (looks at peristaylsis, LES perssure)
What is pseudoachalasia
A dilation of the esophagus in an achalasia-like pattern due to distal esophageal narrowing from causes other than primary achalasia. Causes of pseudoachalasia include malignancy (most common), Chagas disease, amyloidosis, and sarcoidosis.
How to differentiate alcohol-induced psychotic disorder (alcoholic hallucinosis) vs alcohol withdrawal delirium (delirium tremes)
Hallucinosis onset within 12-14 hrs of heavy drinking, vitas often normal
Delirium tremens starts 3-4 days after stopping
Triad of Wernicke encephalopathy
1) Confusion
2) Oculomotor dysfunction (diplopia, nystagmus, etc.)
3) Gait ataxia (small wide-based steps)
Wernicke/Korsakoff are caused by a deficiency of…
Thiamine (B1)
Meniere triad
1) Peripheral vertigo
2) Tinnitus
3) Asymmetric fluctuating SNHL
Synthetic cathinones AKA ____. How to differentiate from PCP?
PCP intoxication of shorter duration, usually tested on urine tox. Can also cause nystagmus.
Synthetic Cathiones can last up to a week
What is the most common type of RTA
Type 4 (hyperkalemic)
E.g. hypoaldosteronism (addison), K-sparing drugs
Hyperkalemia impairs ammonium excretion
Early-onset ___ is common in T21
Alzheimers
Tx for syphilis
Pen G
Very early cervical cancer –>
Any kind of advancement –>
LEEP
Chemo + rad
Most common type of uterine cancer
Adenocarcinoma
In terms of EPS, dystonia and parkinsonism are managed by ___. Akathisia managed by ____
a) Benztropine
b) Beta blockers/benzos
Tx for Wernickes
Give IV thiamine THEN glucose (glucose can cause toxicity if thiamine low!!)
Do alcohol withdrawal seizures or delirium tremens come first
Seizures first
First line pharmaceuticals for AUD
Naltrexone
Acamprosate (modulates glutamate receptors)
2 main classes of stimulants for ADHD
Methylpheidate and amphetamine anologues
In ADHD use behavioural interventions only for children of what age
<6 years old
Characteristics of FASD
Microcephaly
Epicanthal folds
Smooth philtrum
Downslanting/short palpebral fissures
Thin upper lip
Indications for admitting an adolescent with anorexia nervosa
Weight <75% of ideal body weight
Tempt < 35.5
HR < 45
SBP <80 or orthostatic hypotensions
What psychotropic drug can cause myocarditis
Clozapine
Treatment for myasthenia gravis
Cholinesterase inhibitors (pyridostigmine)
Supplemental immunosuppressants if refractory
Thymectomy can help
Treatment for myasthenic crisis
IVIG, plasmapheresis, intubation, steroids
Differentiate myasthenic crisis vs cholinergic crisis (caused by too much of the anticholinesterase meds)
Cholinergic –> muscle fasciulations, lacrimation, salivation, tachycardia, diarrhea (SLUDGE syndrome)
Can be hard to tell if mild
Inheritence of DMD
X-linked recessive
Atrophy = reduction in __ of muscle fibres
Dystrophy = reduction in ____
Size
Number
What serum markers are elevated in DMD
CK
Aldolase
Typically proximal weakness = ___ issue
Distal weakness = ___ issue
Proximal = muscle
Distal = nerve
(in general not always)
What is Pellagra? Characteristics?
Vitamin B3 deficiency (Niacin)
4 Ds: Diarrhea, dermatitis, dementia, [death]
+Glossitis
MS is the most common cause of what visual disorder? Clinical features?
Optic neuritis
Subacute vision loss, visual field defects, reduced acuity/colour perception
Retrobulbar PAIN, worse w/ eye movements
**typically monocular
Gram negative diplococci with vaginal discharge –>
Gonorrhea
Black box warning for haldol
Increased risk of death (usually cardiac or infx) in elderly pts with dementia-related psychosis
Key component of physical exam in someone with suspected SBO
Palpate inguinal area (hernia)
Top 3 causes of SBO
- A = adhesion
- B = bulge (hernia)
- C = cancer, crohn’s (gallstone ileus, radiation, FB)
Top 3 causes of LBO
- Colorectal cancer (65%)
- Diverticular disease (20%)
- Volvulus (sig > cecum)
- (hernia, adhesions, ovarian Ca, endometriosis)
4 main types of hernias
inguinal (direct/indirect), femoral, umbilical, incisional
Upper GI bleed most important med
IV PPI! Even more important than octreotide
_____ are a common cause of massive LGIB. Treatment?
Diverticular bleed
Usually conservative tx, usually resolve
Name a few diagnoses to rule out when someone presents with apparent panic disorder
Hyperthyroidism (or other endocrine)
Substance use/withdrawal
Cardiac/resp
Tx for nec fasc
Immediate surgery
Immediate IV Abx (pen, clindamycin, IVIG)
Most common cause of acute diarrhea in Canada is attributed to ____ but rapid onset is more likely ____
Campylobacter jejuni (onset at least 12-48 hr later)
Staph aureus toxin is preformed so onset in 1-4 hrs
Shortcut for mean SBP in kiddos
90mmHg + 2(age)
Normal infant resp rate
~40
Fluid deficit for mild, mod, severe clinically assessed dehydration by % of body weight
<2 yrs old: 5%, 10%, 15%
>2 yrs: 3%, 6%, 9%
Management of severe peds dehydration
NS boluses (10-20mL/kg) PRN
Fluid replacement over 24-48 hrs using 1.5-2x maintenance
General best peds fluid if pt is voiding
D5NS + KCl (20mEq/L)
Most common cause of traveler’s diarrhea
Enterotoxigenic E coli
Ethosuximide is 1st line tx for what? What is 2nd line?
Childhood absence seizures
Valproate 2nd line
Rabies post-exposure prophylaxis consists of…
Rabies immunoglobulin into the site of wound (passive immunization to tie them over until they can make own antibiodies)
PLUS inactivated rabies vaccine on days 0, 3, 7, 14
Who should you send for BMD
Age >50 with prev fracture or 2+ RFs
>65 with 1 RF
Age >70
(note - if prev hip/spine fracture or 2+ fractures, just treat)
Hyp__thyroidism –> hyponatremia
Hypothyroid
Catch-up immunization is necessary for any adult who has not received what MMR schedule?
2 MMR doses after 12 months at least 1 month apart
PEP for measels
Active immunization (MMR vaccine) for immunocompetent individuals after direct exposure, passive for immunocompromised
*indicated if negative or indeterminate serology
2 central principles of the Canada Health Act
Universality
Accessibility
Pts with hypertension and adrenal incidentaloma should be tested for ___ via _____
Primary aldosteronism
Plasma aldosterone to renin ratio
Urine osmolality and urine sodium in SIADH
Osmolality high (>100)
Na high (>30) - because aldosterone isn’t kicking in bc pt isn’t actually IV depleted
Most common inherited thrombophilia
Factor V Leiden mutation heterozygote (resistant to cleavage by activated Protein C)
Post-menopausal woman with abdo distention and solid mass on pelvic exam, think…
Epithelial ovarian cancer
All pregnant women should be offered U/S at ___ wks to confirm viability/GA. And then at __ weeks for anatomy (incld NT)
7+ weeks
11-14 wks
Organic nitrates can lead to ___ and therefore should be co-administered with ___
Reflex tachy
BBs
PCI if available within what time period?
90 min in centre, 120 if transferring
ACS tx concurrent to PCI (or general conservative strategy)
Anti-ischemic: BB, nitrates, +/- CCB
Anti-platelets x2
Anticoagulants x1
Statin + ACEi
