CSSA Missed Flashcards
When are blood transfusions warranted in a sickle cell patient
for severe sickle cell crises with evidence of organ damage, anemia.
What is the initial management for someone with a sickle cell crisis (severe pain in backs, shoulders, shins, dactylitis)
Intravenous fluids administration
oxygen and pain control
Denial defense mechanism vs Rationalization
denial: the mind unconsciously placing reality out side of awareness (due to painful reality)
rationalization: when patients justify an unacceptable action or feeling using logic
in a ischemic stroke how do you treat
get a CT to rule out hemorrhagic stroke
if patient was at their neurological baseline less than 4.5 hours before presentation you can treat with alteplase
if patient was at their neurological baseline > 4.5 hours before presentation you treat with aspirin
if its been less than 34 hours you can also do mechanical thrombectomy if the thrombus is visualized on imaging and is proximal
bells palsy symptoms
unilateral facial paralysis caused by lyme disease, or herpes (inflammation of CN 7)
includes forehead dysfunction
loss of taste on the anterior two thirds of the tongue and decreased lacrimation
diagnosis of bells palsy
CLINICAL can get EMG if it is unclear
treatment of bell palsy
oral glucocorticoids, antiviral if severe and supportive care to prevent corneal abrasion
(LMN involvement)
if a patient with a diabetic ulcer know has vertebral osteomyelitis via hematogenous spread how do you diagnose?
MRI of the spine
symptoms of vertebral osteomyelitis
back pain, fever, malaise, point tenderness over affected vertebral body
Osteosarcoma imaging
X-ray - first
MRI- next for planning
Bone biopsy- diagnosis
septic arthritis presentation
acute fever, joint pain, swelling and erythema
laxative abuse can cause what electrolyte deficiency (diarrhea)
hypokalemia
hypokalemia symptoms
muscle weakness, parathesias, hyporeflexia , long QT syndrfome, torsades
vomiting
hypomagnesium, hypochloremia
if a patient who has cirrhosis, heart failure, or end stage renal disease is admitted to the hospital but not hypotensive should they receive fluids?
No (dont want to volume overload them)
initial fluid resuscitation in sepsis is what
isotonic crystalloid solutions like 0.9% or lactated ringer
annual hyperlipidemia testing
asymptomatic men over 35
asymptomatic women over 40-45
Asthma exacerbation findings and treatment
bronchospasm leading to wheezing, dry cough, dyspnea, prolonged expiration, accessory muscle use , tachycardia, chest X-ray can show hyperinflation
common trigger is a viral upper respiratory infection
treatment: Short acting B agonist, systemic corticosteroids, oxygen
Obstructive Sleep apnea heart findings
Loud S2- pulmonary artery hypertension
increased sympathetic and pulmonary blood pressure
fetal loss after 20 weeks is most commonly caused by?
chromosomal abnormalities (number 1) uteroplacental insufficiency, maternal medical disease
do autopsy to find out
in a patient with previous stillbirth (loss at >20 weeks) what should you do during subsequent pregnancies
ultrasounds, rule out medical conditions, amniotic fluid volume
later than 32 weeks you should undergo weekly nonstress testing in the third trimester starting at 32 weeks gestation
CMV colitis presentation
intracellular inclusion bodies
can be treated with ganiciclovir
more common in immunocompromised with UC, solid organ transplant, aids
What can CMV/Human herpes virus 5 cause
Colitis, retinis ,esophagitis, encephalitis, pneumonia
CREEP
acute flares of ulcerative colitis are treated with?
hydrocortisone
serum and urine derangements in excessive vomiting
metabolic alkalosis (direct loss of chloride and protons in vomit)
increased bicarb, increased PH
decreased potassium, decreased, decreased chloride
low urine sodium and chloride
Diarrhea electrolyte losses
direct loss of bicarb in poop
hyperchloremic metabolic acidosis
patients with newly diagnosed Afib should undergo what testing
evaluation for reversible causes
TSH levels, high alcohol intake stimulant abuse. echocardiography, electrolyte levels, need for anticoagulation to decrease stroke risk with CHADS_VASc score
treatment off AFIB
rate control with B blocker or nondihydropyridine calcium channel blockers
when do you use a 24-hour ambulatory ECG monitor
to evaluate reported patient reported palpitations, presyncope, syncope and unexplained falls in a patient with an unrevealing office exam
chrons can cause intestinal obstruction (SBO) from
fibrotic strictures or inflammation
complications of chrons
enterocutaenous fistulas (air in pee) , uveitis, bowel perforation, intraabdominal abcesses, intraabdominal fistulas
diagnosis of chrons
imaging and biopsy
*elevated ESR and Crp
what is a rare complication that can affect children born to mothers with lupus or sjogrens syndrome
Complete AV block (heart block in general)
ASD is common in what neonates
fetal alcohol syndrome, down syndrome, trisomy 13
VSD is common in what neonates
down syndrome, thymic aplasia (Di Georges), Turner syndrome and tetrology of fallot
persistent depressive disorder (dysthymia)
3 depressive symptoms that have endures for >2 years
depressed mood on more days than not that leads to impaired social and occupational functioning (interpersonal friction)
tx: antidepressant + psychotherapy
substance induced mood disorder
mood disturbance that develops within a month of intoxication with or withdrawal from a substance
lumbar spinal stenosis
narrowing of the spinal canal that compresses lumbar nerve
it can cause neurogenic claudication (pain when walking), back pain that radiates to the legs, numbness or weakness
worse with hip extension better with hip flexion (lean forward on cart)
MCC of lumbar spinal stenosis
degenerative joint disease
osteophytosis
diagnosis of lumbar spinal stenosis and treatment
MRI
tx: NSAIDS, PT, surgery
lumbar degenerative joint disease
degenerative changes to the facet joints, can lead to spondylolithesis which is a common cause of sponal stenosis
what is spondylolsthesis
displacement of a vertebral body
lumbar disc herniation
dislocation of the nucleus pulposus that presents with back pain, parathesias, weakness in the lower extremities
pain improves with EXTENSION and WORSENS WITH FLEXION
SMA vs Duchenne muscular dystrophy
SMA: autosomal recessive mutation in SMN gene that presents with hypotonia and areflexia , proximal muscle weakness of both arms and less, wheechair dependent, scoliosis or kumbar hyperlordosis , waddling gait (respiratory weakness in other types)
Duchenne- X linked recessive mutation in dystrophin that presents with promximal muscle weakness, hyperlordosis, calf psuedohypertropy and gower sign
Pterygium
a benign growth of conjunctival tissue in the eye that is caused by ultraviolet light, hot and dry climates, dust and wind.
tx: wear sunglasses, topical lubrication or surgery
can present with irregular astigmatism myopia (near sightedness) irritation, redness, blurry vision
septic arthritis diagnosis and treatment
arthrocentesis first
empiric vancomycin +/- penicillin or cephalosporin
pain, swelling, erythema, fever, chills (hematogenous spread)
cardiac tamponade signs
becks triad: hypotension, distended jugular veins, distant heart sounds
renal cell carcinoma (adenocarcinoma) symptoms
large blood clots through urine, microscopic hematuria, flank pain, weight loss, fever
paraneoplastic syndromes: hypercalcemia (pthrp) polycythemia
bony metastasis with lytic lesions (back and bone pain)
causes of cardiogenic shock
Mi, valve dysfunction, heart failure, AV block, arrhythmia
1 pound of weight loss drops your blood pressure how much
1mmHg
best interventions to decrease blood pressure
weight loss, salt restriction - mediteterranean diet
cholesterol emboli dermatologic manifestations
petichiae, livedo reticularis, blue toe syndrome
labs in cholesterol emboli (multiple cholesterol emboli syndrome)
increased creatinine, leukocytosis and eosinophilia
(supportive treatment)
colorfectal cancer most commonly occurs where
rectosigmoid region
descending and rectosigmoid cancers appear
obstructive, they are more likely to be infiltrative and obstruct the large bowel
ascending colon lesions are more likely to be?
exophytic masses that bleed and cause iron deficiency anemia
after you diagnose colon cancer with colonoscopy what is next
CT imaging of the abdomen and pelvis to look for extend of disease
vertical transmission of HIV is low in their viral loads are less than?
1000 (can have vaginal delivery)
what is contraindicated in a intrapartum in a mom with HIV (testing)
placement of a fetal scalp electrode (invasive monitoring techniques)
what is the most common type of breast cancer
invasive ductal carcinoma
what are the indications for genetic testing for BRCA
personal history of breast cancer younger than 45 years old, personal or family history of ovarian cancer or male breast cancer
protective factors for ovarian cancer
breastfeeding, multiple pregnancies, long term oral contraceptives, bilateral oophorectomy
what should you do if there has been causing injection of drain cleaner (alkali ingestion)
emergent endoscopy (esophagoscopy)
phase 1 clinical trials
small healthy individuals are given therapy to determine if intervention is safe in healthy indivudals
safety, toxicity, and pharmacological properties are assessed
phase 2 clinical trials
small group of diseased population are tested to see if the intervention works and correct dosing
phase 3 clinical trials
compaires efficacy of the intervention to standard care or placebo in a large number of patients
phase 4 clinical trials
post marketing surveillance after drug has been approved for use in humans
long term safety profile
oral gingivo stomatitis
primary HSV infection where there are extremely painful vesicles in the orpopharynx on a erythematous base and cervical lymphadenopathy
dx: scrape the unroofed vesicle and test with PCR
Leishmaninasis
bite from a sandfly causes a papule at the site which can increase and coalecse into a ulcer/wart with eschar
what is the most common type of Supraventricular tachycardia in a structually normal heart
AV nodal reetrant tachycardia it is stimulated by alcohol, caffiene, exertion or stress..
palpitations with regular rhytmn and abrupt onset and termination
hypertrophic cardiomyopathy murmur
HARSH, SYSTOLIC Crescendo-decrescedno at the left lower sternal border
aspiration risk can be diminished with whaat?
thickened feeds/liquids, swallowing evaluation and language pathologist
what increases the risk of air embolisms
sitting upright, hypovoloemia, inhalation during instrumentation
treatment of air embolism (position)
left lateral decubitus and trendelenberg (confines the air in the right ventricular apex and reduces embolization)
symptoms of air embolism
acute SOB, tachypnea, tachyarrhythmia, cough, hypoxia, chest pain
pleural effusions can be secondary to
reactive to an adjacent pneumonia
if it is asymptomatic and small no other imaging is warranted
treatment of achlasia
pneumatic dilation or botox injection
decreased relaxation of the LES (reflux, dysphagia to liquids and solids) - feels like things get stuck in chest, mild heart burn
esophageal spasm is different and presents with chest pain and dysphagia during swallowing)
acute pancreatitis is most commonly caused by
gallstones and heavy alcohol consumption
gallstones form in the setting of
lithogenic bile
postpartum thyroiditis (decreased thyroid uptake)
autoimmune thyroiditis within 1 year of pregnancy
hyperthyroid –> hypothyroid –> euthyroid
hyperthryoid symptoms treat with : metroprolol or propranolol
hypothyroid symptoms treat with levothyroxine
post hoc analysis bias
when statisical analysis are conducted after data has alreadfy been collected and seen by investigators (got results and then ran the results of a subgroup)
first line treatment of oral candidiasis
flucanazole (oropharyngeal)
treatment of MS
acute: glucocorticoids
chronic: interferon beta therapy, monoclonal antibodies
highest risk factors for stroke
modifiable: hypertension, hyperlipidemia
nonmodifiable: age
apt test
differentiates between maternal and fetal blood
painless bleeding in the 3rd trimester
placenta previa
diagnoses of placenta previa
pelvic ultrasound
medication overuse headaches
headaches secondary to overuse of symptomatic headache medication in patients with pre-existing headache disorder
opids, coffee, nsaids, acetampinophen, triptans, etc. - discontinue!!!
diagnosis of aortic dissection/ traumatic dissection of aorta
CT angiography is the gold stanfdard
x-ray will show widened mediastinum
imaging for PE
spiral CT scan
CT angiography is gold standard
potassium and sodium levels in cirrhosis
hyponatermia (increase ADH)
hypokalemia
when is the Tdap vaccine administered in pregnancy
27-36 weeks
complex regional pain syndrome 1 vs 2
1: continued pain out of proportion from a reflex sympathetic dystrophy: patients will have edema, muscle spasm, increased hair growth, sensivity to light touch , livedo reticularis
2: associated nerve injury, decreased hair growth, brittle nails, thickened joints, muscle atrophy, cracked skin , osteoporosis , burning pain, allodynia, hyperalgesia
heart failure class 2
slight limitation of physical activity (SOB with moderate exertion
heart failure class 1
no SOB, no limitation on physical activity
heart failure class 3
SOB with minimal exertion and marked limitation of physical activity (sob when moving one chair to another, walking short distance, doing chores around the house)
heart failure class 4
SOB at rest, can do the physical activity at all
muscle energy for T1-4 what is the lever
muscle energy for T5-12 what is the lever
t1-t4- head
t5-t12- trunk
where are the TP for T1-T3
at the level of the corresponding spinous process
where are the TP for 4-T6
located 1/2 of a segment above corresponding spinous process ( T4 TP is halfway between T3 and T4)
where are the TP for T7-T9
located one segment above the corresponding spinous process. (T8 TP is located at the level of T7 spinous process)
T10 TP location
T 11 TP location
T12 TP location
TP 10- same rule as 7-9 (at the level above)
TP 9 - same as rule 4-6 ( 1/2 between T8 and T9 spinous process)
T12- same as T1-T3 (at the level of T12)
rapid correction of hyponatermia can cause osmotic demyelination syndrome and it can be combated with?
administration of desmopressin at the same time
at the same time as 3% hypertonic saline
patients taking nitrates should avoid _ due to the risk of hypotension
phosphodiesterase inhibitors (tadalafil)
what are the 6 muscle energy techniques
crossed extensor reflex
isolytic lengthening
joint mobilization
oculocephalogyric reflex
post isometric relaxation
reiprocal inhibition
respiratory assistance
what is crossed extensor reflex muscle energy
when you use muscle force on the opposite side of the targeted muscle to relax the targeted muscle - used for extremities
right triceps dysfuction: patient is asked to contract the left triceps
what is joint immobilization muscle energy
this is when muscle force is used to restore a joints range of motion
anterior innominate SD: contract hamstring to get the innominate to posterior rotate
what is oculocephalogyric reflex
this is when the patient uses specific eye movements to engage the cervical and upper thoracic spine to relax (patient looks toward or away from the restriction)
good for acute cervical injuries
what is reciprocal inhibition muscle energy
when the antagonist muscle is contracted and this sends a signal through the reciprocal reflex arc forcing the agonist to relax
hypertonic bicep: contract tricep (antagonist)
what is respiratory assitance muscle energy
when the patient uses breathing to restore normal motion and it only sued for inhalation somatic dysfunction
what helps to identify the presence of a STEMI when a patient has a new or old bundle branch block
Sgarbrossa Criteria
> 3 then emergent cardiac catherterization is warranted
cervical radiculopathy test
Spurling test (foraminal compression) Extension and rotation of the neck toward the affected side
bennett fracture
fracture at the base of the first metacarpal (thumb) with intraarticular extension into the carpometacarpal joint space
gamekeeper thumb fracture
avulsion fracture off of the bae of fthe proximal phalanx of the thumb with associated injury to the ulnar collateral ligament
caused by forced abduction and hyperextension of the thumb
jones fracture
stress fracture at the base of the proximal third of the 5th metatarsal
boxer fracture
fracture of the 4th and or 5th metacarpal bone (from a closed fist)
flexion and extension occur around what axis and in what plane
around a transverse axis and within a sagital plane
rotation occurs around what axis in what plane
around a vertical axis in a transverse plane
what are the risk factors for epithelial ovarian cancer
increased cycles of ovulation (nulliparity, early menarche, late menopause >50 years old)
endometriosis
family history of ovarain cancer at any age
BRCA mutations
lynch syndrome
Asbestos
protective factors for ovarian cancer
OCP’s
multiparity
breastfeeding
bilateral salpingo-oophorectomy
tubal ligation
hysterectomy
does a pap test with atypical squamous cells of undetermined signifigance indicate cancer
no, reactive chances, if HPV testing is normal you can continue with routine screening
symptoms of severe endometriosis
extrauterine adhesions from inflammation can cause cervical motion tenderness and a laterally displaced cervix (dyspaurenia, dysmenorrhea, INFERTILITY)
(endometritis causes intraunterine adhesions) ***
management for femur neck fracture
weight bearing pain–> surgery (open reduction/internal fixation)
retropharyngeal abcess is worse with what motion
extension
what are risk factors for preeclampsia
prior preeclampsia
CKD
chronic hypertension
diabetes mellitus
multiple gestations
autoimmune diseases
in twin therapies what medicine should you start
low dose aspirin betwen 12-28 weeks (preferabily before 16)
start in all high risk patients
progesterone therapy is offered to pregnant patients with a history of?
prior spontaneous preterm delivery
or a short cervix
indomethacin in pregnancy
a tocolytic used in patients in preterm labor <32 weeks to delay labor
what testing should be done at the first prenatal visit in high risk patients for preeclampsia
24 hour urine collection for total protein
a capnography with a flat line indicates what
the sensor is not detecting CO2
- esophageal or stomach intubation (common in uncuffed endotracheal tubes)
- cardiac arrest
a shark fin capnography is caused by
bronchospasm
*decreased alpha angle and phase 2 waveform)
symptoms of neonatal abstinence syndrome
irriability, tremors, sneezing, sweating, yawning, loose stools
(fetal growth resitriction)
treatment of neonatal abstinence syndrome
mild- supportive care
moderate/severse- opiod replacement (metadone, morphine)
central retinal vein occlusion signs
painless vision loss for a susbtantial amount of time
swelling of optic disx, retinal hemorrhages, dilated and tortuous veins, cotton wool spots
care of an amputated part to increase chances of replantaiton sucess
gental removal of gross contamination with salien irrigation
wrap in sterile saline mositened fauze, seal in plastic bag, then place bag in a container of ice
otitis media with effusion signs and treatment
middle ear fluid without tympanic membrane inflammation (bulging/erythema) there will be air fluid levels with poor TM mobility (TM translucent and gray )
treatment is observation for speech delay and hearing loss > 3 months it is chronic and you need tubes
chronic suppurative otitis media symptoms and treatment
> 6 weeks of purulent ear drainage, caused by preceeding acute otitis media or cholestoma
treat with ototopical fluroquinolones
(caused by staph aureus and psudomonas)
oral hairy leukoplakia is caused by what and is associated with what infection
caused by EBV, associated with HIV (immunodeficient)
aspirin exacerbated respiratory disease (AERD)
asthma
bronchospasm with ingestion of aspirin or NSAIDS
nasal polyposis (anosmia, nasal discharge)
Breast Galactocele
what is it?
what does it look like
imaging
treatment
benign milk retention cysts that occurs a few weeks to months after cessation of breastfeeding
soft mobile nontender subareolar mass that can be as large as 5cm
ultrasound, aspiration confirms diagnosis and is curative
nonsymptomatic galactoceles can be managed with well fitting bra, ice packs
breast abcess presentation
fever, tender, fluctuant breast mass with erythema
fat necrosis presentation
can be a nontender breast mass following trauma and echymosis overlaying it
fibroadenomas
benign mobile nontender breast mass in adolescents and young women
it increases in response to estrogen and involutes in postmenopausal women
fibrocytic breast disease presentation
diffuse bilateral breast changes
intraductal papilloma presentation
single nontender mass near the nipple
it is small <1cm
soild and irregularly shaped most often has bloody nipple discharge
arteriovenous fistula of the femoral vessels presentation
palpable thrill and distal ischemia after percutaenous coronary inferventions
can lead to high output heart failure
epidermoid cyst
a discrete nodule in the skin that is a result of epidermal keratin lodges in the dermis
signs of bowel obstruction
hyperactive bowel sounds, abdominal distention, vomiting
loud secound heart sound (pulmonic component)
pulmonary hypertension
labs in primary vs. secondary adrenal insufficiency
primary: low cortisol, low aldosterone, high ACTH
secondary: low ACTH, Low corticol, normal aldosterone
in primary adrenal insuffficiency is renin high or low
high (low aldosterone stimulates RAAS system)
risk factors for functional hypothalamic amenorrhea
decreased GnRH leads to decerased FSH, LH and estrogen (non withdrawal bleeding )
- significant weifght loss
- strenuous excercise,
- illness/stress
biliary leakage
complication from laparoscopic cholestectomy
incomplete clipping of the cystic duct or intraoperative bile duct leads to leakage fof bile into the abdominal cavity
abdominal pain, fever, RUQ pain, peritoneal signs, leukocytosis, elevated liver function tests and bilirubin
pharmacotherapy options for
anorexia nervosa
bulimia nervosa
binge eating disorder
AN: olanzapine (if CBT and nutritional rehabilitation fails)
BN: SSRI
Binge eating: SSRI or Lisadexamfetamine
Severe cancer related pain options
- NSAIDS + adjuvant therapy
- short acting opiods +/- step one (4 hour intervals)
- long acting opiods (extended release) +/- step one and two
treatment of intertrigo
topical nystatin or micaonazole
(caused by candida)
key features of congential toxoplasmosis (3)
chorioretinitis
hydrocephalus
diffuse intracranial calcifications
key features of congential syphillis
rhinorrhea, skeletal anomalies
desquamating rash on palms and soles
key features of congenital rubella
cataracts, heart defects (PDA), sensorineural hearing loss
key features of congenital CMV
periventricular calcifications, microcephaly, sensorineural hearing loss, petichiae
key features of congenital herpes simplex virus
vesicular/ulcerative rash
treatment of minor sunburn
no blisters or dehydration (severe)
supportive care with cool compresses, calamine lotion, aloe vera, oral pain medications (NSAIDS)
if severe you need to hospitalize and give fluids and wound care
in gout cholchicine and glucocorticoids are preferred when
when a patient is on an anticoaglant or has heart failure
contraindications to cholchicine
severe renal failure, the elderly
treatment of ocular rosacea
topical antibiotics like metronidazole or erythromycin, ocular lubricants, and lid scrubs
Urgency incontinence
sense of needing to go to the bathroom and then immediate loss of urine
involuntary detrusor contractions (overactive bladder) - leave work meetings, urinating every hour
nocturia!!
TX: bladder training (resist voiding for long durations), pelvic floor therapy +/- antimuscarinics (oxybutarnin, tolerodine)
Overflow incontinence
decreased detrusor activity (peripheral neuropathy, blockage of the urethra- fibroids)
increased intravesicular pressure leads to leakage and an increased postvoid residual volume
stress incontinence
urethral hypermobility that causes urine leakage when there is increased abdominal pressure (cough, bear down)
signs of acute liver failure (diagnostic)- no underlying liver disease present (no cirrhosis)
- elevated aminotransferases
- sighs of hepatic encephalopathy (confusion, asterixies, smnolence)
- synthetic liver dysfunction (prolonged PT with INR >1.5)
alkaline phosphatase in wilsons disease
really low
where is the most common site of intracerebral hemorrhage
basal ganglia which is right above the uncus and can cause an uncal herniation
uncal herniation signs
fixed and dilated pupil on the same side (ipsilateral)
contralateral decerebrate posturing
comatose state
describe uncal herniation
the medial temporal lobe is displaced under the tentorium cerebelli (can be caused by basal ganglia hemorrhage)
Cerebral tonsillar herniation describe it
the cerebellum pushes through the foramen magnum and causes neck tilt, flaccid paralysis, coma, blood pressure instability, respiratory arrest
midbrain stroke signs
ipsilateral fixed and dilated pupil and contralateral hemiparesis
opccipital cortex signs
cortical blindness (bilateral)
homonymous hemianopia (unilateral)
treatment of mycoplasma pneumoniae
azithromycin or respiratory fluoroqionolone
first line for dental and skin infections
clindamycin
narcoplepsy is associated with
decreased REM latency
cateplexy
low hypocretin 1
sleep hallucinations
wiskott aldrich syndrome is a defect in
cytoskeletal defect in platelets and leukocytes
triad: microthrombocytopenia, recurrent infections, eczema
tx: stem cell transplant (X-linked recessive)
allergic bronchopulmonary aspergillosis
hypersensitivity reaction to aspergillus that occurs in patients with asthma or cystic fibrosis
symptoms of uncontrolled asthma, recurrent pulmonary infiltrates and central bronchiestasis
eosionophilia, IgE testing
TX: oral corticosteroid and itraconazole
permanent destruction and dilation of airways
bronchiectasis
permenant enlargement of the airspaces distal to the terminal bronchioles
emphysema
Tx of pagets disease
bisphosphsonates
Failure modes and effect analysis what is it and what are the steps
a prospective systematic assessment for error prevention in new processes (identify issues before they occur)
- Team formation
- define goals and processes
- process mapping with flowchart outlining the process
- identify where failure could occur
- analyze risks at each step with a hazard analysis
- idenftify ways to correct these risks
- implement plan
Five whys approach
used in root cause analysis to figure out why an error occurred
dementia with lewy bodies deposition
alpha synuclein deposits in the brainstem (substantia nigra), limbic system and neocortical structures
dementia, visual hallucinations, fluctuating cognition, parkonsism and postural insability.
what actions suggest a lesion in the cerebellar hemisphere
limb ataxia, dysmetria, dysdiadochkinesia
startle clonus is seen in
prion related dementias like creuztfeldt jakob disease
GBS prophylaxis what week
36-38 or if there is premature rupture of membranes
Papillary muscle rupture/dysfunction
occurs 3-5 days after MI
inolves the RCA, causes pulmonary edema, new soft systolic murmur, mitral regurgitation on ECHO, hypotension and shock
interventricular septum rupture
3-5 days after MI in the RCA or LAD
chest pain, new hash holosystolic murmur with thrill
ECHO will show left to right ventricular shunt
free wall rupture
5 days - 2 weeks after MI
involves the LAD
chest pain, distant heart sounds, shock, cardiac arrect
ECHO will show pericardial effusion with tamponade
left ventricular aneyrusm
months after MI
involves the LAD
can cause heart failure, angina, ventricular arrythmias, mitral regurgitation,
mural thrombus –>stroke, mesenteric ischemia, or acute limb ischemia
left ventricular aneurysm ECG findings
persistent ST segment elevation, deep Q waves
signs of anal cancer
anal bleeding, pain, anal mass or ulcerated lesions with non tender lymphadenopathy
chanroid
painful ulcer with gray yellow exudate and severe suppurative lymphadenitis
lymphogranuloma venerum
genital ulcer –> Lymphadenitis (supprative)–> fibrosis and strictures of the anogenital tract
maternal and fetal complications of maternal pyelonephritis
fetal: preterm labor, fetal tachycardia
maternal: acute respiratory distress syndrome (crackles, hypoxia, dyspnea, infiltrates on X-ray)
TX: IV antibiotics
acute mastoiditis
complication of acute otitis media that causes fever, ear pain, and inflammation of the mastoid air cells
displaces the ear
inflammation directly behind the ear
Tx: IV antibiotics and surgical drainage
what is elevated in antiphopholipid syndrome
partial thromboplastin time (PTT)
anti beta 2 glycoprotein, anticardiolipin
Beta 2 microglobulin is elevated in?
lymphoproliferative disorders like multiple myeloma
cervical cancer signs
post coital bleeding
lower uterine segment mass that extends laterally
pelvic/back pain
hydronephrosis
**colposcopy
obstruction of appendix lumen
pancreatitis
(N/V, anorexia, diffuse abdominal pain then RLQ pain, leukocytosis)
cardiomyocyte replacement by fibrous tissue
chemotherapy induced cardiotoxcitty- antrhcyclines (dilated cardiomyopathy)
cardiomyocyte hypertrophy and disarray
hypertrophic cardiomyopathy
myocardial stunnning
trastuzumab cardiotoxicity
or
stress induced cardiomyopathy
when do children start to understand the concept of death
> 6
listeria
gram positive rod (found in unpasturized milk products, raw meats and veggies)
femoral artery psuedoaneurysm
after cardiac catherization
contained hematoma that causes a bulging pulsatile mass and a systolic bruit
a hematoma would have a mass but no bruit
femoral artery AV fistula
after cardiac catheterization
localized swelling, continuous bruit with a palpable thrill (no mass)
CATCH 22 for digeorge syndrome
C- cardiac outflow tract anomalies
A- anomalous face
T- thymic hypoplasia (decreased T cell immunity)–> cellular immune deficiency
C- cleft palate
H- hypoparathyroidism
22q.11.2 deletion
pes anserinus pain syndrome
pain at the medial aspect of the knee just distal to the joint line
exacerbated when there is pressure from the contralateral knee
intial treatment of knee OA
weight loss, quad strenthening, low impact aerobic excercise, simple anagelsics
occlusion of meibomian gland
chalazian (painless)
inflammatory nodule arising from an eyelash follicle
hordeolum (painful)- stye
acute infection of the lacrimal sac
dacrocystitis- sudden onset pain, red at the medial canthal region +/- discharge
hyperemesis gravidarum
workoup
severe N/V in pregnancy, can cause dehydration, hypoglycemia, ketonuria, electrolyte abnormality, >5% weight loss
more common in molar pregnancies and twin pregnancies
workup with pelvic ultrasound
maternal hyperglycemia in the first trimester vs second and third trimester
1st trimester: congenital heart disease, NTP, small left colon syndrome, spontaneous abortion
second and third: fetal hypoglycemia and hyperinsulinemia, polycythemia, organomegaly, macrosomia, hypertrophic cardiomyopathy
treatment of DVT in pregnancy
low molecular weight heparin (continue for 3 months, and befoer stopping repeat ultrasound to see if thrombus is still there)
when would you use an IVC filter for DVT
if there is a high risk of bleeding from anticoagulation like recent surgery or hemorrhage
DRESS syndrome
drug reaction following allopurinol and antileptics 2-8 weeks after starting drug
D- drug
R- reaction rash with a morbilliform eruption, facial edema
E: eosionophilia
SS: systemic symptoms- fever malainse, diffuse lymphadenopathy, liver, kidney or lung involvement
TX: stop drug
diagnosis of colonic psuedo-obstruction (ogilvie syndrome)
abdominal CT
colonic dilation but no obstruction
treatment of plasmodium falciparum vs vivax
malaria causes episodic fevers, cills, flus like symptoms
falciparum- chloroquine for erythrocyte phase
vivax has a dormant hypozoite hepatic form that can cause symptoms after the intial infection- treat with chloroquine and PRIMAQUIE for hepatic phase
diagnosis of coarctation of the aorta
echo is diagnostic
CXR would show rib notching of the 3-8th rib
ECG would show left ventricular hypertrophy
what lab should be monitored in chronic lithium therapy
TSH
**can cause hypothyroidism
what are the best ways to prevent infecting your partner with genital herpes
not having sex ever, any kind of sex (viral shedding can occur even with no symptoms)
wearing a condom every time you have sex if you do
and have the infected person take daily antiviral therapy
what migraine meds are antiemetics and dopamine antagonists that can cause extrapyramidal symptoms like akathsia, cogwheel rigidity and parkinsonism
prochlorperazine, metoclopramide, promethazie
myelodysplastic syndrome
what is it, risk factors, manifestations, diagnosis, treatment
a hematopietic stem cell neoplasm that is increased in older people or people who have had chemotherapy or radiation- may transform to acute leukemia
manifestations: macrocytic anemia, leukopenia, thrombocytopenia
diagnosis: dysplastic red and white cells and hypercellular bone marrow (reduced seegmentation)
**need bone marrow biopsy
treatment: trnasfusions for cytopenias, chemotherapy, stem cell transplantation
myelofibrosis
pancytopenia + massive splenomegaly
acelluar bone marrow- dry tap
hairy cell leukemia
chronic B cell lymphoproliferative disorder
+ pancytopenia + splenomegaly + hairy cytoplasmic projections on blood smear
hepatic encephalopthy treatment
lactuloase, riffaxamin (nonabsorbable antibiotic), fluids
TIPS can make Hepatic encephalopathy WORSE
diagnosis of leigonella and treatment
diagnosis: urine antigen and respiratory culture
tx: levofloxacin or azithromycin
treatment of severe aortic stenosis <1cm
valve replacement
imaging for submucosal fibroids
sonohysterofgraphy (transvaginal ultrasound that infuses saline into the uterine cavity)
uric acid kidney stones precipitate in what conditions
acidic <5.5, hyperconcentrated urine (chronic diarrhea, dehydration)
tx: urine alkalinization with postassium bicarb or citrate
why are calcium oxalate stones common in crohns disease , gastric bypass, or small bowel resection
intestinal oxalate absorption is increased
treatment of waldenstron macroglobulenemia
plasma exchange
acute pulmonary embolism can cause syncope how (3 ways)
right ventricular dysfunction
cardiac arrhytmia
vasovagal response
signs of sigmoid volvulus
inverted U shape, no haustra, no air in rectum
common from constipation
(SBO common from abdominal surgery/adhesions)
acute cerebellar ataxia
nystagmus, staggering gait, intention tremor after a viral illness in children
tranverse myelitis
post infectious weakness and flaccidity and parathesias below the lesion of the spinal cord affected
thyroid hormone changes in pregnancy
total T4 increased
Free T4 unchanged or a little increased
TSH decreases
HCG stimulates thyroid hormone production in the first trimester
Estrogen stimulates TBG (binds thyroid hormone)
HCG suppresses TSH
inguinal hernias
indirect: originate above the inguinal ligament lateral to the inferior epigastric vessels, through the deep inguinal ring into the inguinal canal - patent processus vaginalis- in scrotum
direct: above the inguinal ligament medial to the inferior epigastric vessels into hesselbachs triangle through the superficial ring- not in scrotum- weakening of tranversalis fascia
femoral hernia
more common in women
inferior to inguinal ligament , protrudes through femoral ring into the femoral canal due to a widened femoral ring
treatment of anogenital warts in pregnancy (HPV 6 and 11)
trichloroacetic acid
*fleshy/pink pedunculated/sessile growths that can increase in size during pregnancy
**imiquimod and pdophyllin are contraindicated in pregnancy
perinatal HPV transmission can cause?
juvenile onset respiratory papillomatosis
condyloma on the childs larync/vocal cords that causes strifdor, chronic hoarseness or caugh
Paroxysmal nocturnal hemoglobinuria
Intravascular and extravascular hemolysis that results from a acquired genetic affect of PIGA and decreased CD55 and CD59 on the surface
hemolysis, cytopenias, hypercoagulability (budd chiari)
high LDH and bilirubin, low haptoglobin
common in 3rd decade of life
DX: flow cytometry
features of intravascular hemolysis
anemia, elevated bilirubin, low haptoglobin and elevated lactate dehydrogenase
Acute intermittent porphyria
abdominal pain, dark/brown urine
porphyrins/porphyrin precurors in urine
autosomal dominant
G6PD deficiency
episodes of hemolytic anemia following oxidative triggers like infection, nitrofurantoin, TMP-SMX, fava beans
most commonly in black men and is X-linked
heinz bodies and bite cells
hereditary spherocytosis
autosomal dominant disorder in scaffolding proteins in RBC (ankryin, spectrin)
chronic hemolysis, splenomegaly, spherocytes
iron deficiency anemia can be associated with
reactice thrombocytosis
lead poisining can be from a house built before when
1978
cervical insufficiency
painless cervical dilation that can lead to second trimester preganancy loss (can have prolapsing membranes)
caused by collagen defects, uterine abnormalities, cervical conization, obstertric injury
tx: cerclage placement
acute lymphoblastic leukemia
common in boys 2-5
overgrowth of leukemic cells causes the production of other cells lines to down
bruising, petechiae, mucosal bleeding, impaired platelet production, lymphadenopathy (firm and nontender), hepatosplenomegaly
greater than 2 cytopenias, >20% blasts
treatment of peripheral artery disease (intermittent claudication)
Statin + Aspirin
supervised graded excercise program
smoking cessation
aggressive diabetes control
revascularization if there is life threatnening limb complications like nonhealing ulcer, failure to respond to the options above
risk factors for endometrial cancer
EXCESS ESTROGEN
obestiy, chronic anovulation
nulliparity
early menarche, late menopause
tamoxxifen use
trigeminal neuralgia pathophysiology
compression of the trigeminal nerve root as it enters the pons leading to demyelination and atrophy of the nerve
**treat with carbamezapine
bells palsy pathophysiology
inflammation and edema ofd the facial nerve (VII) that leads to unilateral facial paralysis
vulvodynia
dysparuenia due to shard burning pain on the vulvar vestibule has a positive Q-tip test
vestibular erythema, vaginal tissue narrowing or clitoral tissue shrinkage
first generation H1 antihistamines can cause urinary retention how
causes detrusor hypocontractility
due to the anticholinergic affects it results in impaired detrusor muscle contraction
examples of first generation H1 antihistamines
diphenhydramine, chlorpheniramine, hydroxyzine
chorioid plexus papilloma
rare benign brain tumor that is within the ventricles
it produces CSF and causes hydrocephalus , increased ICP, developmental delay, headaches
Diagnosis: MRI
tx: resection, recurrence is rare
ependymomas
tumor in the fourth ventricle that can block CSF flow through the ventricular system
CSF is reabsorbed from the subarachnoid space by
arachnoid granulations
pre renal AKI in the setting of acute heart failure exacerbation is most likely due to what
cardiorenal syndrome
how does cardiorenal syndrome occur
the failing heart causes decerased renal perfusion and activation of the RAAS
the backpressure from the heart not having foward flow increases central venous pressure and renal venous pressure which causes the GFR to decrease
how to IV diuretics work in cardiorenal syndrome
they reduces central venous pressure and renal venous pressure to improve cardac output and increase GFR and improve AKI
decreases renal arterioles constriction (afferent)
ACE inhibitors on the glomerulus
dilate efferent arterioles
management in post streptococcal glomerulonephritis
loop diuretics fist
then antihypertensives- preffered CCB
Trisomy 18
labs
MSAFP, B HCG, Estriol, Inhibib A
MSAFP: decreased
B hcg: decreased
Estriol: decreased
Inhibin A: normal
labs in neural tube defect
MSAFP: increased
B hcg: normal
Estriol: normal
Inhibin A: normal
labs in trisomy 21
MSAFP: decreased
B hcg: increased
Estriol: decreased
Inhibin A: increased
confirm with amniocentesis: limb defects, stillbirth risks
epidural location
L4 (below spinal cord termination) into epidural space
where is the epidural space
between the ligamentum flavum and dura
epidural blocks what pain fibers
T10-L1
and S2-S4
also sympathetic nerve fibers
epidural effects on blocking sympathetic nerve fibers
vasodilation, venous pooling, decreased venous return to the heart, decreased cardiac output
hypotension, compensatory tachycardia
lower extremity weakness
tx: place patient in left later decubitus position , IV fluids, vasopressor
high spinal anesthesia
when anesthesia travels up to the spinal cord and brainstem which depresses of cervical spinal cord and brainstem
occurs with intrathecal injection of anesthetic overdose
hypotension, bradycardia and complete motor blockade (weakness)
leakage of cerebral spinal fluid during epidural
puncture dura, leak out
postural headaches (headache worse when sitting up and improved when laying down)
workup for glomerular hematuria in children
rbc casts, proteinuria, cola/dark urine, hypertension, edema
- complement levels
- other antibodies
- CBC and creatinine
- renal biopsy
what antibiotic can you give to preoperitively to avoid endometritis
cefazolin. 30 minutes before C-section
what is used to treat endometritis
gentamicin and clindamycin
post expsoure prophylaxis to chicken pox
immunocompetent >1 –> varicella vaccine preferably within 5 days
immunocompentent (pregnant women, HIV, neonates born to mother with active varicella)–> varicella IVIG
<1 no prophylacis
hyperthyroidism if left untreated can cause
bone loss/fractures
