Deck 4 Flashcards
when during sleep do sleep terrors occur? (vs nightmares)
sleep terrors occur during NONrapid eye movement sleep (NREM)
- kids scream, cry, and are inconsolable and cannot be fully awakened
- a flused face, sweating, and tachycardia are common
- the next morning the child has no memory of the incident
nightmares occur during REM sleep, which usually occurs in the middle of the night or early morning
you suspect as pt of having acute pyelonephritis. They have a high urine pH >8. what organism do you suspect?
Proteus mirabilis!! (or Klebsiella pneumoniae) – urease producing bacteria
urease splits urea into ammonia and CO2; ammonia then converts to ammonium and alkalinizes the urine. high urine pH reduces the solubility of phosphate, raising risk for development of struvite stones (Mg ammonia phosphate)
what is the mechanism by which asplenic pts are at risk for infection with encapsulated organisms?
encapsulated organisms (S pneumoniae, H influenzae, and N meningitidis) have a polysaccharide exterior that conceals antigenic epitopes and resists innate phagocytosis. These pathogen are largely eliminated via the humoral immune response (in the spleen) with ANTIBODY-MEDIATED PHAGOCYTOSIS (opsonization) and Ab-mediated complement activation. much of this depends on splenic macrophages and the generation of splenic opsonizing Abs. so w/o the spleen.. this can’t happen.
Pt presents with cough, coryza, and conjunctivitis. They have a maculopapular rash that starts on the face and spread to the entire body, but spares the palms and soles. What do they have? how to you prevent the spread of this infection to other pts in the office?
Measles!
- may also see Koplik spots (in the mouth)
The pt should be isolated and placed on Airborne precautions (as it is spread via inhalation of infectious respiratory particles)
pt rapidly develops fever, chills,and malaise, along with mouth pain, drooling, dysphagia, muffled voice and airway compromise. On PE, the submandibular area is tender and indurated, and the floor of the mouth is elevated, displacing the tongue. there is also crepitus. What is the most likely source of this infection?
A dental infection in the mandibular molars – this is Ludwig angina, a rapidly progressive cellulitis of the submandibular space
- it spread contiguously down the root of the tooth to the submylohyoid (and then sublingual) space
- the infection is usually polymicrobial, and anaerobic, gas-producing bacteria may cause crepitus
- physical exam findings are often striking due to mass effect from edema
pregnant women with hyperemesis gravidarum are at risk for what condition commonly seen in alcoholics?
Wernicke encephalopathy – thiamine deficiency
- pts present w/ AMS (encephalopathy), oculomotor dysfunction (nystagmus), and postural and gait ataxia
pts w/ HG often have hypochloremic metabolic alkalosis, hypokalemia, hypoglycemia, and elevated serum aminotransferases (due to vomiting)
must give thiamine replacement prior to glucose
what renal and urinary changes occur in a normal pregnancy?
increased renal blood flow increased GFR increased Renal BM permeability Decreased BUN Decreased Cr Increased renal protein excretion
How does jejunal atresia present? what does it look like on xray? and what are risk factors for it?
Jejunal atresia presents w/ bilious vomiting and abdominal distension
Abdominal x-ray shows a “triple bubble” sign and gasless colon (as opposed to the double bubble seen w/ duodenal atresia - down syndrome)
Risk factors = prenatal exposure to Cocaine and other vasoconstrictive drugs
a pts lab work shows aplastic anemia (a deficiency in all 3 cell lines). You also notice they are short, have microcephaly, abnormal thumbs, and hypogonadism. They have areas on their skin that are hypo- and hyperpigmented. What do they have? and what causes it?
Fanconi Anemia
due to chromosomal breaks, seen on genetic analysis
these patients are predisposed to developing cancer (most often AML)
definitive tx for the aplastic anemia is hematopoietic stem cell transplant
vitamin B12 is a necessary cofactor for what?
for purine synthesis
A deficiency of vit B12 (like after total/partial gastrectomy) causes defective DNA synthesis.
will see a megaloblastic anemia, indirect hyperbilirubinemia (due to increased intramedullary hemolysis of the megaloblasts, which releases heme), and increased serum LDH (also due to hemolysis)
also hypersegmented PMNs
pt presents with symptoms of hyperthyroidism and A fib. What med should you tx them w/ first?
propranolol
Pt initially presents w/ focal neurologic sxs (eg, hemiplegia, hemiparesis, hemisensory disturbances). These are quickly followed by findings suggestive of increased ICP (eg, vomiting, HA, bradycardia, decreased alertness). Pt has a PMH of HTN, DM2, and CAD. What kind of stroke is this?
(hypertensive) Intracerebral hemorrhage
Lacunar strokes can also occur in HTN pts but tend to present w/ severe focal sxs depending on the affected area. these infarcts are quite small and are not expected to have rapidly worsening global neuro sxs like in pts w/ hemorrhage.
How do simple renal cyst appear on imaging? (vs malignant cysts).
Simple renal cysts appear with thin walls, no solid components (homogenous), no enhancement on CT/MRI, and are usually asymptomatic. no f/u needed.
Features suggesting a malignant cyst on imaging include irregular or multilocular structure w/ multiple septations, heterogeneous content, and contrast enhacement on CT/MRI. May cause pain, hematuria or HTN. requires f/u imaging and urological eval for malignancy.
how is lactation suppression accomplished?
wearing a comfortable, supportive bra
avoidance of nipple stimulation and manipulation
application of ice packs to the breasts
NSAIDs to reduce inflammation and pain
NO DOPAMINE AGONISTS (no longer approved by FDA due to side effects)
What does third-degree or complete AV heart block look like on ECG? how are symptomatic patients managed?
there is regular P-wave activity, which is temporally unrelated to QRS complexes, the R-R interval is constant
symptomatic pts should have immediate placement of a temporary PACEMAKER (while undergoing further eval to identify and correct reversible causes)
How do you diagnose acute bacterial prostatitis?
obtain a mid-stream urine sample
(usually caused by other pathogens common to the urinary tract, like E. coli)
while awaiting culture results, empiric Abx therapy w/ TMP-SMX or a fluoroquinolone should be started and continued for 4-6 weeks
toddler w/ a firm, smooth, unilateral abdominal mass and hematuria
Wilms tumor
- some pts may have abdominal pain, HTN, hematuria, and fever – but often times pts are asymptomatic and the tumor is discovered incidentally
- age 2-5
if a pt overdoses on an unknown substance and they present w/ bradycardia, hypotension, respiratory depression, and hyporeflexia, normal pupils, normal bowel sounds, and no effects are seen when naloxone is given, what have they most likely ingested?
Sedative-hypnotic overdose, most likely due to the combined effects of Alcohol and Benzos
what is the other name for a traction apophysitis of the tibial tubercle?
Osgood-Schlatter disease
- in adolescence, there are periods of rapid growth in which the quadriceps tendon puts traction on the apophysis of the tibial tubercle where the patellar tendon inserts
- this tracton apophysitis is worsened by sports that involve repetitive running, jumping, or kneeling, and it improves w/ rest
- there is often edema and tenderness over the tibial tubercle, pain can be reproduced by extending the knee against resistance
- xray findings are nonspecific and may show anterior soft tissue swelling, lifting of the tubercle from the shaft, and irregularity or fragmentation of the tubercle
pt presents w/ a HA, HTN, hyperreflexia, and positive pregnancy test. you are concerned for what? the occurrence of this at <20 weeks gestation can be a complication of what?
Pre-eclampsia w/ severe features (eg, new-onset HTN w/ proteinuria or end-organ damage)
Pre-eclampsia at <20 weeks gestation can be a complication of Hydatiform mole!!
pt presents w/ dysuria, urinary frequency, and suprapubic tenderness. UA is positive for Leuk esterase and Nitrites. What do they most likely have? what is the most appropriate next step?
Uncomplicated cystitis
- commonly occurs in otherwise healthy pts and has a low risk for tx failure – therefore pts can be tx’d w/o urine culture!
- next step = tx w/ NITROFURANTOIN (5 days) or TMP-SMX (3 days) or fosfomycin (single dose)
What is the cause of senile purpura? this presents w/ ecchymoses in elderly pts in areas exposed to repeated minor trauma (eg, extensor surfaces of hands and forearms).
Senile purpura is due to age-related loss of elastic fibers in perivascular connective tissue
Migraines in children are often bifrontal and of shorter duration. what is the first-line tx for acute migraine HA in children <12 yo?
supportive management (lying in a dark, quiet room w/ a cool cloth on the forehead) and administration of acetaminophen or an NSAID like ibuprofen
what are the clinical features specifically found in newborns w/ congenital syphilis?
Rhinorrhea (copious, clear or purulent)
A diffuse maculopapular rash that can involve the palms and soles and may DESQUAMATE or become BULLOUS
Also may see abnormal long-bone radiographs (eg, metaphyseal lucencies)
what is the triad that congenital rubella syndrome classically presents w/ in the newborn?
sensorineural hearing loss
cataracts
heart defects (eg, patent ductus arteriosus)
how do you calculate attributable risk percent? also what is it?
ARP = (RR - 1) / RR
Attributable risk percent is the excess risk in a population that can be attributed to a particular risk factor
young child has a continuous flow murmur. also they have mildly accentuated peripheral pulses.
PDA
slow-growing papule w/ pearly rolled borders. central area of ulceration. on the face/sun-exposed skin. most common form of skin cancer in the US.
Basal cell carcinoma!!!
(Basal - B, is like P for Pearly, but the bottom part of the B is removed-the bottom has been ulcerated off..)
squamous cell carcinoma is much less common, and faster growing. it often arises from a precursor lesion, such as an actinic keratosis, and typically has overlying hyperkeratosis.
what is the most common predisposing factor for acute bacterial sinusitis?
viral upper respiratory infection
contaminating bacteria cannot be cleared by mucocilliary clearance due to mucosal inflammation from viral infection, leading to secondary bacterial infection
What are serious side effects that may arise from long-term use of Cyclophosphamide?
(it is an alkylating agent frequently used as an immunosuppressant in SLE)
Acute Hemorrhagic Cystitis!!
Bladder Carcinoma!!
Sterility
Myelosuppression
when subjects are lost to follow-up in a prospective study, this creates a potential for what type of bias?
Attrition bias, a subtype of SELECTION BIAS
current guidelines recommend obtaining what baseline labs before starting lithium therapy?
UA
BUN and Cr
Thyroid function studies
what medications should be withheld for at least 48 hours prior to stress testing?
Beta blockers
CCBs
Nitrates
these are all antianginal agents and so they can reduce the extent and severity of ischemia during exercise stress testing
What lung cancer is associated w/ hypercalcemia?
Squamous cell carcinoma of the lung
**remember: sCa++mous
hypercalcemia usually results from the effects of PTHrP
pt presents after a recent eye surgery with pain and decreased visual acuity in that eye. the eyelid and conjunctiva are swollen, hypopyon (exudates in the anterior chamber), and coreneal edema and infection are also present. what is this?
postop endophthalmitis (the most common form) – it is an infection w/in the eye, particularly the vitreous
a runner presents w/ numbness, aching, and burning pain in the distal forefoot. on exam, squeezing the 3rd and 4th metatarsal heads together causes a clicking sensation and reproduces the pain in the plantar surface. What is this?
Morton neuroma
