Deck2 Flashcards
Diarrhea. High: bili, LDH, retic, Cr, schistocytes+. Low: PLT.
Dx?
HUS
BK virus assn?
renal transplant rejection
Most sensitive test neurosyphilis?
CSF FTA (99% sensitive)
OM suspected. XR neg for assd changes. NSIM?
MRI (if contraindications, bone scan).
If suggestive > bone bx
Bilateral Bells Palsy. Assd Dx?
Lyme
Tick attached in non-endemic area. ASx. NSIM?
Remove tick, reassure.
Tx Lymes
Doxy or Amox
Arthralgia, eye pain, pathergy. Dx?
Behcet
Preg F, HBV needle stick. Had vaccine but Abs undetectable. NSIM?
Ig & vax
M w/ urinary urgency, frequency, burning. Dx/Tx?
urinary NAAT. Tx: azithro/ceftriaxone
Trichomonas- Best Dx test?
NAAT
Why is RPR not the best test for syphilis?
Neg in 25%, takes several months to be positive
3 best drugs for MRSA cover
Doxy
TMP-SMX
Clinda
Mupirocin is only for:
impetigo (it has less AE than bacitrcin/neomycin)
Histoplasmosis- Dx test & Tx?
Urinary Ag, Amphotericin
The only situation in which you would delay HAART
Cryptococcal inf.
Tx travellers diarrhea
Azithromycin
Tx Anaplasma/Erlichia
Doxy
Dx: serologu IgG/IgM
Hunter: LAD, myalgia, conjunctivitis, PNA, ulcer on hand. Dx?
Tularemia (assn w/ rabbits)
Tx Dengue
Supportive. Note vax exists.
Tx Listeria meningitis
Ampicillin-gentamycin
if PNC allergy TMP-SMX
Tx mucor mycosis
Amphotericin
Tx cryptococcal meningitis
Amphotericin & flucytosine
Most ACCURATE test Crypto meningitis?
CSF Ag & fungal Cx, NOT india ink
Neck stiffness. CSF: high protein, high opening pressure, low cell count. Dx?
Cryptococcal meningitis. V poor prognosis.
also high cryptococcal Ag
Peroneal palsy causes:
foot drop
Most spec test for meningitis (from CSF)
Cx
Bacterial meningitis suspected. Tx?
Vanc//ceftriaxone
ADD GCS if: S.pneumo (MCC) or TB
When to order head CT in setting of suspected meningitis
focal findings, severe papilledema, severe confusion
Cluster HA: abortive Tx?
Abortive: TRIPTAN (if contraindicated > 100% O2)
Triptans are contraindicated in preg & CAD
MCC migraine trigger
emotions
Cluster HA: PPX?
PPX: verapamil, prednisone, lithium
Triptans contraindications?
CAD & preg
Aprepitant use & drug class?
antiemetic for chemo.
MOA: neurokinin 1 receptor antagonist
Migraine drugs worsen ______
Parkinsons (prochlopromazine, metoclopramide)
Papilledema may cause ___ palsy
CN VI palsy & compression of the optic nerve
First line OCD Tx
SSRI
Avoid anticholinergics in following Dx:
Glaucoma, constipation, BPH
Medication for IBD flare?
GCS
Which correlates w/ IBD disease activity?
- erythema nodosum
- pyoderma gangrenosum
- PSC
- erythema nodosum
MCC UC flare
NSAIDs
note: quitting smoking may cause flare as smoking is protective in UC
GCS sparing agent in IBD?
6MU- Azathioprine
Why would you give GCS to an UC patient to plans to quit smoking?
quitting smoking may cause flare as smoking is protective in UC
Preg w/ fistulizing Crohns. Tx?
infliximab
Fecal WBC+, RLQ pain, rash. Dx?
r/o Yersinia (pseudoappendicitis)
Tx TMP-SMX
Tx Yersinia
TMP-SMX
Steatorrhea, small bowel diverticulae, FOBT-, Hgb 8. Dx?
Pernicious anemia in setting of SIBO (note diverticulae/steatorrhea are signs of SIBO)
Tx: rifaximin
Tx SIBO
rifaximin (also metro, cipro, tetracycline, amox)
1cm tubular adenoma, next colonoscopy?
3-5y
34yo FHx father CRC age 55. Age of first colonoscopy with subsequent screen intervals?
40yo then Q5yrs
Lynch syndrome colonoscopy interval?
Q1-2y
Tx ectopic pregnancy: Stable VS unstable
Stable: MTX
Unstable: Surg
MC location of ectopic pregnancy
ampulla of fallopian tubes
Ectopic pregnancy: RFs
Hx ectopic preg In vitro PID Hx pelvic surg tobacco
hCG+ & complex adnexal mass. Dx?
Ectopic preg
Edema w/ CCB:
- prevalence
- MOA
- Tx
25%
MOA: preferential dilation of precapillary vessels > increased capillary hydrostatic pressure > extravasation
*** decreased if combined w/ ACEi (which cause post-capillary dilation)
AE of DHP CCBs
edema (25%)
HA
flushing
dizziness
(amlo, nifedipine)
AE of HCTZ
- hypoK, hypoNa
- hyperuricemia
- hyperglycemia
- renal failure
goal BP in ischemic CVA
<180/105
if above, give IV labetaolol or nicardipine: rapid onset, easy titration
No role of PO antiHTN meds in this period
When to resume anticoag sp tPA for CVA
at 24h before antiPLT, anticoag or invasive procedures
Low ADAMTS13 activity > DIC. Dx?
TTP
Sx: RF, neuro sx, fever, abd pain/N, rash
Tx: plasma exchange
Tx TTP
plasma exchange
Petechial rash, RF, thrombocytopenia, MAHA, AMS. Dx?
TTP
Tx: plasma exchange
3rd trim, hemolytic anemia, thrombocytopenia, high LFTs. Dx?
HELLP syndrome
Suppurative otitis media AKA:
AOM
Pathogen most commonly assd w/ TM rupture in AOM.
group A strep
Cranky infant w/ AOM. Suddenly crankiness improves. What do you suspect?
TM rupture
Elderly pt reports tripping over rug. No LOC/dizziness. Which test do you perform?
Get-up-and-go test. If pt is unsteady/has difficulty, further eval necessary.
Average risk pt on anticoag for afib. Risk of bleed requires pt for fall __x
300x (low risk, hence AC benefits>risk)
CURB65 score
Confusion Urea >20 RR >30 BP <90/60 >65yo
2- hospital admit
3+- ICU
Elderly televisit, possible PNA. NSIM?
CURB-65, send to ER for further eval.
High RF:
- > 65
- pulm, cardiac, renal d
- immunosupp
- morbid obesity
- natives
- NH
High risk cardiac conditions (prosthetic valve, hx IE, CHD subtypes): When is bacterial endocarditis ppx required?
- dental surg
- resp tract incision
- GU/GI procedure in setting of infection
- surg infected skin/m
- surg prosthetic valve material
Which of the following is NOT indication for bacterial endocard ppx?
- dental surg
- resp tract incision
- GU/GI procedure
- surg infected skin/m
- surg prosthetic valve material
- GI/GU procedure (UNLESS active infection)
Tx for anovulatory bleed in menopausal transition.
- cyclic progestin tx
- low dose OCP
- hormonal IUD
Indication for uterine bx in setting of anovulatory uterine bleed during menopausal transition.
- > 45 w/ suspected anov bleed
- <45 w/ persistent abnormal bleed or RFs (obesity. PCOS)
Pathophys anovulatory bleed in menopausal transition.
- oocyte depletion & abnormal follicular development
- failure of ovary to secrete progesterone
Meds w/ MCC AE in elderly
- anticholinergics
- antipsych
- antiHTN
- sedatives
- diuretics
- NSAIDs
- GCS
- digoxin
Most important factor in periop adverse drug RXN in elderly?
Multiple meds
(note: already higher risk per
- high gastric pH > higher absorp
- low GFR
- reduced body water)
Standard enteral feeding = ___ kCal/kg/day w/ __g/kg/day protein
30 kCal/kg/day
1 g/kg/day protein
(less if malnourished)
PE suspected in preg. NSIM?
V/Q +/- LE doppler
Asthma exacerbation in pregnancy, goal sats?
> 95% to prevent fetal hypoxia
GBS suspected. Which test is crucial?
frequent measurement of vital capacity & neg inspiratory force to monitor resp status (30% require intubation)
CSF in EBV
high protein
normal WBC
EBV Tx?
plasma exchange or IVIg (if non-ambulatory, w/in 4wks sx)
Tx botulism
serum antitoxin & abx
Tx transverse myelitis
high dose GCS
Evolution of GBS infection?
- 2wks progressive motor weakness
- 2-4wks plateau sx
- slow, spontaneous recovery over months
IVIg or plasma exchange shortens course by 50%
by 1yr -85% can walk, 60% full remission
Prognosis GBS
IVIg or plasma exchange shortens course by 50%
by 1yr -85% can walk, 60% full remission
Motor weakness, paresthesias, autonomic dysfunction (bowel/bladder), sensory deficit, RF for MS in future. Dx?
Transverse myelitis (tx: high dose GCS)
Maroon hematochezia, orthostatics+, hypoTN, tachy. NSIM?
EGD (15% hematochezia: UGIB). Higher suspicion for UGIB if hemodynamic instbility+
Best way to approach acutely psychotic pt w/o insight?
avoid challenging their beliefs and maintain interpersonal distance
AE of following:
- Ginko biloba
- Ginseng
- Kava
- increased bleed
- increased bleed
- severe liver inj
AE licorice
HTN
hypO-K
Black cohosh known AE
hepatic injury
Which may cause HTN crisis? A. Ginko B. Ginseng C. Echinacea D. St.Johns Wort E. Kava F. Black Cohosh
D - St Johns Wort
also: drug interactions w/ SSRI, OCPs, anticoag, digoxins
Which may cause allergic reactions & dyspepsia?
A. Ginko B. Ginseng C. Echinacea D. St.Johns Wort E. Kava F. Black Cohosh
C. Echinacea
AE: bleed risk
A. Ginko B. Ginseng C. Echinacea D. St.Johns Wort E. Kava F. Black Cohosh
A&B
MCC nonbullous impetigo
MCC: S.aureus
~S.pyogenes
Tx: topical mupirocin or PO keflex if severe
Tx nonbullous impetigo
Tx: topical mupirocin or PO keflex if severe
Diarrhea: watery, non-bloody x 2 days, abd cramps. Afebrile. Recent travel. Likely dx?
A) Rotavirus B) Norovirus C) E.coli D) Salmonella E) Shigella F) Giardia G) Cryptosporidium H) Campylobacter
C) E.coli (ETEC)
Bloody D, severe RLQ pain. Dx?
A) Rotavirus B) Norovirus C) E.coli D) Salmonella E) Shigella F) Giardia G) Cryptosporidium H) Campylobacter I) Vibrio parahemolyticus
H) Campylobacter
pseudoappendicitis like Yersinia!
Brief illness, predominantly vomiting. Dx?
A) Rotavirus B) Norovirus C) E.coli D) Salmonella E) Shigella F) Giardia G) Cryptosporidium H) Campylobacter I) Vibrio parahemolyticus
A & B
+/- nonbloody D & fever
Chronic illness in immunocompromised. Dx?
A) Rotavirus B) Norovirus C) E.coli D) Salmonella E) Shigella F) Giardia G) Cryptosporidium H) Campylobacter I) Vibrio parahemolyticus
G) Cryptosporidium (esp Isospora)
Pt has is giardia, now ASx. How long are they contagious?
months
Seafood > Diarrhea- watery/bloody, abd cramps, N/V, fever. Dx?
A) Rotavirus B) Norovirus C) E.coli D) Salmonella E) Shigella F) Giardia G) Cryptosporidium H) Campylobacter I) Vibrio parahemolyticus
I) Vibrio parahemolyticus
Gold standard for detecting CF?
sweat chloride test
if Cl elevated in 2 tests= diagnostic
X-linked immune disorder w/ severe bacterial/fungal PNA & skin infection. Dx test and diagnosis?
dihydrorhodamine 123 oxidation
Dx: Chronic granulomatous disease
MC complication of RSV in infants?
Recurrent wheezing in >30%.
**Advise pts to avoid triggers of airway reactivity esp cigarette smoke
Bronchiolitis
1- MCC
2- Dx work up
3- Tx
1- RSV
2- clinical
3- supportive
Indications: bronchiolitis PPX
Palivizumab for:
- <29w gest
- chronic lung disease of prematurity
- hemodynamically significant CHD
1yo w/ nasal congestion/discharge, cough. Wheezing/crackles, resp distress (tachypnea, retractions, nasal flaring). Tx?
Supportive (bronchiolitis/RSV).
When is risk of apnea highest w/ bronchiolitis/RSV infection?
<2mo
BV can be treated with metro OR ____
Clindamycin
Frothy green/yellow discharge, vaginal pruritis/erythema +/- punctate hemorrhages. Dx?
Trichomoniasis, Tx metro
Widespread T cell activation via exotoxins acting as superAg. What do you expect in the history?
Tampons or nasal packing
|»_space;massive cytokine release»_space; TSS
TSS Tx?
IVF (up to 20L/day), Clinda (prevents toxin synth) +/- vanc or ox/nafcillin
Remove tampon/nasal packing.
DONT GIVE GCS- not useful
Influenza vax is recommended ____ to ____ (months)
Sept-April
Indications for IVC placement in setting of PE?
- AC complications
- AC contraindications
- AC failure in setting of PE/DVT
55yo w/ PE, given SC enox & warfarin»_space; severe UGIB, EGD showing many ulcers. NSIM?
STOP warfrin & enox. Place IVC filter.
PE. Which antcoag do you give?
PO Warfarin & SC heparin/LMWH
Mutation in filaggrin gene. Dx?
Atopic derm (skin barrier dysfunction & Th2 skewed immune response > IgE production)
Atopic derm: skin barrier dysfunction & Th2 skewed immune response > ___ production
IgE
What prevents atopic derm?
Early exposure to non-pathogenic microorganisms: daycare, dogs, farm etc
(Atopic derm: skin barrier dysfunction & Th2 skewed immune response > IgE production)
Subchorionic hematoma on US in F w/ some spotting in first trim. Tx?
Expectant, serial US to monitor. RF for:
- spontaneous abortion
- abruptio placentae
- PPROM
- preterm delivery
- preeclampsia
- fetal growth restriction
- intrauterine fetal demise
Which is NOT a complication of subchorionic hematoma?
A) spontaneous B) abruptio placentae C) placenta accreta D) PPROM E) preterm delivery F) preeclampsia G) fetal growth restriction H) intrauterine fetal demise
C) placenta accreta
(RF for subchorionic hematoma:
- infertility Tx
- anticoag
- uterine abn
- recurrent preg loss
Dose of folate supplementation to prevent NTD?
average risk: 0.4mg
high risk: 4mg
(ie. hx NTD, seizure meds/MTX, DM, low folate intake)
Neural tube formation occurs by __ weeks gestation
6
MCC CAH: ___ deficiency
21-hydroxylase
elevated 17 hydroxyprogesterone
F infant w/ ambiguous genitalia, hypotension, hypoNa, hyperK, hypoglyc. Tx?
Likely CAH (MCC 21 hydroxylase deficiency)
Tx: hydrocortisone & fludrocortisone
- high salt diet
- +/- genital reconstructive surgery (females)
Mnemonic for CAH- which have HTN? virulization?
CAT mnemonic w/ 1s as arrows up.
HTN: 17a hydroxylase & 11b hydroxylase def
virulization: 21 & 11 hydroxylase
Bronchoprovocation test: FEV1 decreased by >__ is positive, by >__ is diagnostic
> 10 positive
>15 diagnostic
Pathomech of exercise-induced bronchoconstriction?
smooth muscle constriction triggered by exertion VS large amounts of cold/dry air»_space; mast degran
Tx exercise induced asthma?
SABA 10-20 min before exercise w/ inhaled GCS if regular exercise
(mast cell stabilizers may be used for patients who dont tolerate SABA. Ex: cromolyn or nedocromil)
Exercise induced asthma but pt cannot tolerate SABA. Tx?
mast cell stabilizers may be used for patients who dont tolerate SABA. Ex: cromolyn or nedocromil
Tx cyanide toxicity?
sodium thiosulfate
Initial HTN goal in setting of HTN emergency?
Lower BP no more than 25% in 2-6h (to avoid MI, isch CVA, AMS, seizures)
Signs/Sx of extending dissection: A) motor abnorm B) sensory abnorm C) seizures D) AMS E) aphasia
A, B, E
NOT seizures/AMS
Pt s/p Tx of HTN emergency then develops AMS & unexplained metabolic acidosis. Dx?
Suspect cyanide toxicity w/ nitroprusside.
Tx sodium thiosulfate
Single factor indications for stress ulcer PPx EXCEPT:
- PLT <50k
- INR >1.5
- PTT >2x norm
- intubation >48h
- > 1wk ICU stay
- GIB/PUD w/in 12m
- head truma
- spinal cord injury
- major burn
> 1wk ICU stay (this requires another factor to qualify for stress ulcer PPX) ie:
- GCS
- occult GIB >6 days
- sepsis
MOA stress ulcers in:
- head trauma
- sepsis
head trauma: increases gastrin secretion > parietal cell stimulation> acid secretion
sepsis: mucosal ischemia `
M infant w/ palpable bladder & US w/ bilateral hydronephrosis, dilated/thickened bladder & oligohydramnios. Dx?
Posterior urethral valves (likely abnormal insertion of Wolffian ducts)
Which is most associated w/ unilateral hydronephrosis?
A) post urethral valve
B) uteropelvic junction obstruction
C) vesiculourethral reflux
B
Which is most associated w/ bladder thickening and dilation of the proximal urinary tract?
A) post urethral valve
B) uteropelvic junction obstruction
C) vesiculourethral reflux
A
Which is most associated w/ recurrent UTIs?
A) post urethral valve
B) uteropelvic junction obstruction
C) vesiculourethral reflux
C
Dx test for posterior urethral valves?
voiding cystourethrogram- visualization of the proximal urethra when the catheter is removed
Tx: cystoscopy (direct visualization & ablation)
Abx > bite cells, schistocytes, Heinz bodies. Dx?
G6PD deficiency- extravascular hemloysis triggered by oxidative stress
MCC Cold agglutinin mediated autoimmune hemolytic anemia?
viral infection (direct antiglutinin+)
Diagnostic test for G6PD def?
G6PD assay (detects NADPH formation) **may be false negative during acute hemolytic episode therefore recheck afterwards if strong suspicion
Widower in critical state. Two sons say “terminal extubation as dad would have wanted” and two daughters say “do everything you can”. NSIM?
Involve hospital ethics committee
Tx infertility in PCOS?
Clomiphene or Letrozole
Which drug depletes hypothalamic estrogen receptors?
Clomiphene (then hypothal percerives low estrogen»_space; increased release of GnRH»_space; LH & FSH»_space;increased ovulation)
Describe the mechanism of the HPO axis.
- Ovarian theca cells produce angrogens
- Aromatase converts the angrogens to estrogen
- Hypothal percerives high estrogen
- decreased release of GnRH»_space; LH & FSH 5. ovulation inhibited
*high estrogen inhibits ovulation, low estrogen encourages it
Leuprolide MOA
GnRH agonist - decreases pulsatile GnRH release, hence decreasing LH FSH release > inhibits ovulation
Smoking cessation at least __ weeks pre-op decreases post-op pulm complications
4+ weeks
When are PFTs indicaed pre-op?
- prior to lung RESECTION to estimate post-op lung vol
- optimize pre-op COPD control if baseline cannot be determined
- DDx dyspnea: ie. cardiac disease vs deconditioning
MOA MG
Abs against the AChR
Which 2 meds DO NOT increase digoxin toxicity? A) verapamil B) enalapril C) quinine D) amiodarone E) atenolol F) spironolactone
B & E
enalapril & atenolol
Which two vaccines should pregnant women get?
Tdap (btwn 27-36w)
influenza
MC AE breast implants
capsular contracture >pain, shape distortion, implant deflation/rupture
Are breast implants linked with breast CA?
NO
Risk of breastfeeding w/ silicone implants?
NONE.
Silicone levels are not elevated in those with implants and even if they were, silicone in milk is NOT harmful to infants).
How does breast CA screening differ for women w/ breast implants?
It doesnt.
Mammograms recommended at regular intervals.
(breast MRI Q2-3y to check for aSx rupture which could lead to scarring)
Neonate w/ T4 of 6 & TSH of 46. No clinical signs of hypothyroidism, NSIM?
Immediate Tx &
- endo referral
- thyroid US
- confirm labs
(note T4 crosses the placenta but levels drop after delivery)
**Early Tx to prevent neuro injury & permanent intellectual disability starting at 2wks
MCC hemoptysis
acute bronchitis
Threshold of carotid stenosis for endarterectomy?
> 70%
Carotid endarterectomy RISK>BENEFIT in the following situations:
- poor surg candidates (comorb++)
- ipsilateral CVA w/ persistent disabling sx
- 100% occlusion
Delayed puberty, short stature but normal growth velocity, delayed bone age. Dx?
A) constitutional pubertal delay
B) familial short stature
C) hypothyroid
D) Kallmann
A) constitutional pubertal delay
(Tx: watchful waiting, +/- hormonal delay)
*pubertal onset correlates w/ FHx, normal expected adult height (FHx late bloomers)
Puberty is delayed if >__yrs M, > __yrs F
> 12 F, >14 M
Anosmia & hypogonadotropic hypogonadism. Males w/ cryptorchidism & micropenis. Dx?
Kallmanns
Constitutional pubertal delay. Tx?
Counselling. If significant psychosocial concerns: T & E for M >14, F >12 respectively.
Tender breast cyst shown to be simple on US. NSIM?
FNA
- if nonbloody & cyst resolves: no Tx
- if bloody > Bx & additional imaging
note: if simple breast cyst is asx, observe only
Serum prolactin and ___ are indicated for the eval of galactorrhea.
TSH
MCC of failure to thrive in infants?
Psychosocial stressors:
- poverty (lack of access to food)
- lack of knowledge of appropriate feeding techniques
- poor parental/child relationship (neglect/abuse)
Presentation v suspicious of gout. NSIM?
Arthrocentesis!! Even if highly suspected, should be confirmed (note uric acid levels may often be normal during exacerbation)
RF for gout?
Meds: diuretics, ASA< immune suppressants
Hx: surgery, trauma, recent hosp, CKD, organ transplant, vold depletion
Lifestyle: obesity, meat/seafood, high fat diet, excessive EtOH
Negatively birefringent needle shaped crystals under polarizing light. Dx?
Gout
Positively birefringent rhomboid shaped crystals. Dx?
Pseudogout
Tx acute gout
- NSAIDS!!!
- if CKD, CHF, PUD, on AC»_space; colchicine
- if severe liver/renal failure or on drug inhibiting c p450»_space;intraarticular GCS (unless >2 joints involved, then PO)
Colchicine
- dose
- most effective when:
- contraindications
- 1.2mg > 0.6 an hour later x 2-3 days after sx resolve
- given w/in 24h sx onset
- severe liver/renal d or other meds blocking c p450
When do you give intraarticular GCS for acute gout?
- contraindications to NSAIDs AND colchicine (and only 1 or 2 joints affected)
Spinal rotation > __ degrees represents significant scoliosis.
7 deg
5deg in obese
Forward bend test in a 12yo shows 8deg spinal rotation. NSIM?
XR spine to confirm deg
if <7, reassurance
Purpose of putting thoracic block under the foot while evaluating scoliosis?
Block should correct thoracic prominence if 2/2 leg-length discrepancy
Cobb angle:
< __deg= normal
> __deg= scoliosis
> __deg= severe scoliosis
<10 normal
>10 scoliosis
>40 severe scoliosis
Suspected amaurosis fugax. What do you expect on physical exam?
Carotid bruit (v common finding)
NSIM: carotid US
Name the etiology of enuresis:
1) hypoTN, proteinuria/hematuria
2) low spec urine gravity
3) adenotonsillar hypertrophy
- CKD
- DI
- OSA
Also:
- DM
- UTI
- overflow incontinence
- constip
IVDU w/ HA, generalized maculopapulr rash, photophobia, neck stiffness, N/V, decreased hearing & occasional visual floaters. Dx?
Suspect secondary syphilis
(ie. Sx meningitis, ocular syphilis, otosyphilis, & likely early syphilis: rash, LAD)
CSF VDRL test is universally reactive
Most common helminths?
- Ascaris (roundworm)
- Trichuris (whipworm)
- Ancyclostoma duodenale (hookworm)
Peripheral eosinophilia after pt returns from developing country. Most likely tx?
albendAZOLE for helminth infection
mebendazole is slightly better for hookworm
Tx for Entamoeba hystolitica vs Giardia?
Metronidazole (both protozoal)
Tx pregnant women and children w/ travellers diarrhea?
Azithromycin (in reg adults- azithro or cipro)
MC Tx travellers diarrhea?
Azithro or Cipro
20yo w/ depression, hepatic & neuro dysfunction (dysarthria, tremor). NSIM?
Slit lamo exam, r/o Wilsons
Beck triad: hypoTN, JVD+, decreased heart sounds. Dx?
Cardiac tamponade
Tx: cath pericardiocentesis or surgical pericardial window for rapid removal of pericardial fluid
TTE showing IVC collapse, R atrial & ventricular collapse. Dx?
Cardiac tamponade, most spec finding is “early diastolic collapse of R ventricle & atrium”
Tx cardiac tamponade?
cath pericardiocentesis or surgical pericardial window for rapid removal of pericardial fluid
Abnormal increase of JVP during inspiration- Dx?
constrictive pericarditis or restrictive cardiomyopathy
aka Kussmauls sign
SBP normally ____ (increases/decreases) w/ inspiration
decreases
Exaggerated drop in BP during inspiration d/t bowing of R ventricle into L ventricle. Which conditions?
- cardiac tamponade
- severe asthma
- COPD
- constrictive pericarditis
- marked obesity
Blunt thoracic trauma. Best initial imaging?
FAST (focused assessment with sonography in trauma)
- ID of injuries that can be rapidly fatal (PTX, aortic dissection, hemoperitoneum, pericardial effusion > tamponade)
Mechanism of ACUTE HEMOLYTIC blood transfusion rxn?
A) Recipient anti-IgA Abs vs donor IgA
B) ABO incompatibility
C) Cytokine accum during blood storage
D) Recipient IgE against blood product component
E) Donor anti-leukocyte Abs
F) Anamnestic Ab response
G) Donor T lymphocytes
B) ABO incompatibility
Mechanism of FEBRILE NON-HEMOLYTIC blood transfusion rxn?
A) Recipient anti-IgA Abs vs donor IgA
B) ABO incompatibility
C) Cytokine accum during blood storage
D) Recipient IgE against blood product component
E) Donor anti-leukocyte Abs
F) Anamnestic Ab response
G) Donor T lymphocytes
C) Cytokine accumulation during blood storage
Mechanism of URTICARIAL blood transfusion rxn?
A) Recipient anti-IgA Abs vs donor IgA
B) ABO incompatibility
C) Cytokine accum during blood storage
D) Recipient IgE against blood product component
E) Donor anti-leukocyte Abs
F) Anamnestic Ab response
G) Donor T lymphocytes
D) Recipient IgE against blood product component
Mechanism of TRALI?
A) Recipient anti-IgA Abs vs donor IgA
B) ABO incompatibility
C) Cytokine accum during blood storage
D) Recipient IgE against blood product component
E) Donor anti-leukocyte Abs
F) Anamnestic Ab response
G) Donor T lymphocytes
E) Donor anti-leukocyte Abs
Mechanism of DELAYED HEMOLYTIC RXN 2/2 blood transfusion?
A) Recipient anti-IgA Abs vs donor IgA
B) ABO incompatibility
C) Cytokine accum during blood storage
D) Recipient IgE against blood product component
E) Donor anti-leukocyte Abs
F) Anamnestic Ab response
G) Donor T lymphocytes
F) Anamnestic Ab response
Mechanism of GRAFT VS HOST 2/2 blood transfusion?
A) Recipient anti-IgA Abs vs donor IgA
B) ABO incompatibility
C) Cytokine accum during blood storage
D) Recipient IgE against blood product component
E) Donor anti-leukocyte Abs
F) Anamnestic Ab response
G) Donor T lymphocytes
G) Donor T lymphocytes
Which two blood transfusion reactions occur >6h?
A) Recipient anti-IgA Abs vs donor IgA
B) ABO incompatibility
C) Cytokine accum during blood storage
D) Recipient IgE against blood product component
E) Donor anti-leukocyte Abs
F) Anamnestic Ab response
G) Donor T lymphocytes
F) Anamnestic Ab response
(delayed hemolytic rxn)
G) Donor T lymphocytes
(GVHD)
Most common adverse reaction to transfusion?
febrile non hemolytic
Fever/chills w/in 1-6hrs of initiating transfusion. Likely Dx?
febrile non hemolytic rxn
Which is better for premedication in preventing blood transfusion reactions?
A) GCS
B) antihistamines
C) acetaminophen
NONE, they do not prevent them
Post-transfusion: rapid flank pain, fever, hemolysis, oliguria and DIC. NSIM?
Stop transfusion & hydrate w/ IV NS
ABO mismatch > acute hemolytic rxn
MCCOD sp steering wheel injury in MVA?
aortic injury
Why is CT chest useful during initial dx pulm CA?
- mediastinal LN mets
- chest wall invasion
- tumour size, staging
- detect pleural effusions
- mets (liver/adrenal)
Renal transplant recipient develops significant AKI w/ starting ACEi. Dx?
underlying transplant renal artery stenosis (renal hypoperf stimultes RAAS > HTN & maintained GFR. ACEi lowers angiotensin II acutely»_space; significant decrease in GFR & AKI)
Renal transplant recipient develops resistant HTN, flash pulmonary edema or progressive loss of renal function. What do you suspect?
renal artery stenosis
MOA AKI & >30% GFR drop in the setting of ACEi use w/ renal transplant?
- renal hypoperf stimultes RAAS > HTN & maintained GFR.
2. ACEi lowers angiotensin II acutely»_space; significant decrease in GFR & AKI
_____ causes HTN in ~10% patients, 2yrs sp renal transplant
Transplant renal artery stenosis.
Important causes:
- improper surgical anastomosis
- CMV
- acute rejection
Explosive onset multiple pruritic SKs, NSIM?
Consider screening for CA (esp pulm/GI)
Leser-Trelat
Sarcoma botryoides is a tumor of the: ____
vagina (cluster of grapes presentation)
Indications for bisphosphonates?
- T-score 20% major osteoporotic fracture or >3% hip fracture
Malignancy assd w/ PCOS?
Endometrial hyperplasia/CA
(chronic anovultion»_space; unopposed estrogen»_space; endometrial hyperplasia)
**May use OCP or progestin IUD (provides endometrial protection by thinning the endometrium)
How does a progestin IUD prevent endometrial CA in PCOS?
- unopposed estrogen & chronic anovulation
- uncontrolled endometrial proliferation
- progestin IUD (provides endometrial protection by thinning the endometrium)
“Begins as shoulder pain worst at night”
A) Rotator cuff impingement B) Rotator cuff tear C) Adhesive capsulitis D) Biceps tendinopathy/rupture E) GH OA
C) Adhesive capsulitis
Abnormal vaginal bleeding, enlarged uterus, vaginal lesion, preg test+. Dx?
r/o choriocrcinoma (most aggressive form of gestational trophoblastic neoplasia, mets common)
- often sp hydatiform mole but may be after reg pregnancy
Choriocarcinoma
- Work up
- Tx
- Marker for disease progression
- Work-up:
- CXR
- pelvic US
- LFT
- TFT
- BUN/Cr - Tx:
MTX & hysterectomy - BhCG
Pt reporting persistent severe pain despite 2 months ROM exercises for adhesive capsulitis. NSIM?
GCS injection +/- saline distension in the joint space. Consider more aggressive PT
When to Tx febrile seizure?
> 5mins (to avoid cardioresp compromise)
Diagnostic criteria for febrile seizure? (4)
- no hx afebrile seizure
- 6 months to 5 years
- no signs CNS inf
- no acute metabolic cause (hypoglyc)
Use of inferior petrosal sampling?
DDx source of ACTH (pituitary vs ectopic)
Which alcohol leads to severe HAGMA & Kussmaul breathing?
Ethylene glycol (antifreeze)
Tx: fomepizole
Tx for:
- methanol tox
- ethylene glycol tox
Fomepizole (both)
MOA: inhibitor of ADH
more potent inhibitor than EtOH
Anthracyclines: type of cardiac injury?
dose-dependent DILATED cardiomyopathy
MCCOD in survivors of Hodgekin Lymphoma?
secondary malignancy (breast, lung, GI, acute leukemia, NHL)
Radiation cardiotoxicity characteristics?
fibrosis!
- restrictive cardiomyopathy
- constrictive pericarditis
- valvular d (MS/MR, AS/AR)
- > > MI
- SSS or heart block
- may affect coronary vessels
First line seizure abortive Tx ?
benzo
if persists, give fosphenytoin
Seizure lasting >5mins. No improvement with benzo. NSIM?
give fosphenytoin
avoid barbiturates if possible per AE: sedation/resp depression
Management complete airway obstruction in <1yo VS >1yo?
<1yo should be placed face down on examiners arm receiving alternating back blows and chest thrusts
Multiple umbilicated pink lesions. Assn and Tx?
Often peds & immunocompromised/HIV.
Tx: self limited
May remove w/ cryo/curettage or podophyllotoxin
Confluence of prurituc, reddish brown, finely wrinkled papules. Wood lamo w/ coral red fluorescence.
Pathogen?
Dx?
Erythrasma
Corynebacterium minutissumus
Tx: erythromycin
~clindamycin
Erythrasma
Tx: erythromycin
~clindamycin
Tx for photoaging?
tretinoin (retinA)
*NOT isotretinoin
Aerobics instructor becomes pregnant & inquires about exercise recs during pregnancy. Advice?
Pt who are alredy conditioned for long duration, high intensity exercise can safely resume/continue their regimen during pregnancy
Which is NOT a maternal complication of adolescent pregnancy?
A) hydatiform mole B) gestational DM C) preeclampsia D) anemia E) operative vaginal delivery F) postpartum depression
B) gestational DM
Which is NOT a maternal complication of adolescent pregnancy?
A) Gastroschisis B) Omphalocele C) NTDs D) preterm birth E) low birth weight F) perinatal death
C) NTDs
Which is NOT a RF for gestational DM?
A) FHx DM B) obesity C) primigravida D) multiple gestation E) maternal age >25
C) primigravida
MEN 1
***Primary hyperPTH
**Panc/GI NE tumors
Pituitary adenoma
Most commonly occurring manifestation of MEN1
Primary hyperPTH
30yo F w/ hx PUD, FHx pituitary adenoma presents for hyperCa. Dx?
r/o MEN1 (3 Ps) - pituitary adenoma - panc/GI NE tumor - hyperPTH
The following are associated w/ which MEN syndrome?
- gastrinoma
- VIPoma
- glucagonoma
- insulinoma
MEN 1 (3 Ps) - pituitary adenoma - panc/GI NE tumor - hyperPTH
Tx of parathyroid adenomas in MEN1?
subtotal >3.5 glands or total parathyroidectomy w/ autotransplant into muscle pocket
(esp if pt is <50yo or >50 w/ complications)
Indications for parathyroidectomy?
- hyperCa w/ Sx
- end organ complications
- osteoporosis
- CKD
- nephrolithiasis - calciuria >400mg/d
- hyperCa >1mg above norm
- <50yo (as d/t future risk of complications)
Test to screen for medullary CA?
calcitonin (MEN2)
Weight loss, necrolytic migratory erythema, hyprglycemia. Dx?
glucagonoma (also assd w/ MEN1)
Which is NOT a malignant feature?
A) eccentric calcification B) hoarseness C) hard axillary LN D) popcorn calcification E) spiculated margins
D) popcorn calcification
pulm hamaratoma
Which is calcification is malignant?
A) eccentric B) popcorn C) concentric D) laminated E) central F) diffuse/homogenous
A) eccentric
Ataxia, urinary incont, forgetfulness. Dx?
NPH
dilated ventricles on imaging
NPH- which sx occurs early in the disease?
ataxia
then urinary incont, dementia
Rapid eye movement sleep behaviour disorder: associated dementia?
dementia w/ Lewy Bodies
you act out vivid/violent dreams
Prognosis frontotemporal dementia?
fatal w/in 8yrs
USPSTF recs for breast CA screening?
age 50-74
High risk FHx breast CA is NOT?
A) 1st/2nd deg w/ breast AND ovarian CA
B) Two 1st deg w/ breast CA including one <50yo
C) 2+ 1st or 2nd deg relatives w/ breast CA
D) 1st deg w/ bilateral breast CA
E) Ashkenazi w/ any 1st or 2nd deg relatives w/ breast or ovarian CA
G) breast CA in a male relative
C) 2+ 1st or 2nd deg relatives w/ breast CA
** its actually 3 or more
MC reason for requesting euthanasia?
Loss of autonomy
Loss of dignity
Loss of ability to engage in pleasurable activities
Pt requests euthanasia. What needs to be addressed?
Gather info re: concerns/fears. Eval for:
- coercion from others
- underlying mental illness
- physical sx (ie pain)
MC presentation acute HCV?
ASx
if sx: malaise, N, jaundice, RUQ pain x 2-12wks
Acute HCV. How long does it take RNA to detected? Ab formed?
- RNA detection w/in days-8wks.
2. HCV abs w/in 2-6 months
Step up in O2 sat from RV to pulm a. Dx?
PDA
or aorto-pulm window
Step up in O2 sat from RA to RV. Dx?
- VSD
- PDA w/ pulm regurg
- coronary fistula to RV
Step up in O2 sat from SVC to RA. Dx?
- ASD
- ruptured sinus of valsalva
- VSD w/ TR
- coronary fistula to RA
Step up in O2 sat from SVC to RA. Dx? A) VSD B) PDA w/ PR C) VSD w/ TR D) coronary fistula to RV
C) VSD w/ TR
Murmur: continuous, best heard in L infraclavicular area. Dx?
PDA
Which is NOT feature of Tetralogy of Fallot? A) RV outflow obstruction B) LV hypertrophy C) overriding aorta D) VSD
B) LV hypertrophy
**RV hypertrophy
__% childrean w/ ADHD will have sx into adulthood.
33-66%
T/F: Stimulant therapy for ADHD increases risk of abuse or substance use
FALSE
When are non-stimulant meds given for ADHD?
If pt has a personal hx of substance use disorder
MCC uncontrolled HTN?
non-adherence (>40%)
Also
- suboptimal med regimen
- poor adherence to lifestyle changes
- white coat HTN
- inaccurate BP measurement in clinic
Definition resistent HTN?
HTN despite 3 antiHTN meds (including diuretic)
Persistent preoccupation about having serious illness while having mild/NO somatic sx.
illness anxiety disorder
Multiple sx over time, high healthcare use and preoccupation w/ sx. Dx?
somatic sx disorder
DDx illness anxiety disorder has mild/NO sx
Tx for ACD?
Tx underlying condition.
May give EPO if low. R/o IDA, thalassemia, myelodysplasia.
Chest discomfort, tachycardia,hypoTN sp PCI. Dx?
Cardiogenic shock 2/2 abrupt occlusion»_space; impaired myocardial contractility
Low cardiac index, elevated PCWP & increased SVR. Dx?
cardiogenic shock
High cardiac output, Low PCWP & SVR. Type of shock?
Septic/neurogenic (distributive)
Equalization of RA & RV pressures during end diastole. Dx?
Cardiac tamponade 2/2 rapid accum of fluid in pericardial space
DDx SAH vs traumatic LP
SAH: xanthochromia
(CSF discoloration 2/2 Hgb breakdown)
CSF: RBC 75000 w/o xanthochromia. Dx?
traumatic LP (high RBC, WBC, protein, glucose)
Cachexia & severe COPD. CA ruled out. Dx?
Likely pulmonary cachexia syndrome 2/2
- increased WOB > caloric use (in setting of low appetite & low dietary intake)
- systemic inflam > catabolism
- skeletal m hypoxia, GCS use
____ occurs in 20-40% of COPD patients»_space; impaired balance, increased infections & mortality
Pulmonary cachexia syndrome
T optimize lung function, exercise, nutrition
Weight loss, fatigue, hypoTN, bradycardia. Dx?
Addisons
In COPD, early satiety occurs 2/2:
diaphragmatic flattening
STRUCTURAL causes abnormal uterine bleeding (non-preg)
Polyp (endometrial)
Adenomyosis
Leiomyoma
Malig & hyperplasia
NON-STRUCTURAL causes abnormal uterine bleeding (non-preg)
Coagulopathy Ovulatory dysfunction Endometrial (infect/inflam) Iatrogenic Not yet classified
Tx of acute uterine bleeding
combination OCP containing high-dose Estrogen (use IV if cannot tolerate or ineffective PO)
If unstable, no improvement of E contraindications > D&C
Premenopausal F w/ ovulatory menorrhagia who does not desire future fertility. Tx?
endometrial ablation
MOA of Tx acute menorrhagia in stable pt?
OCP w/ high E»_space; promotes hemostasis & further prolif of disorganized endometrium
F neonate w/ labial swelling, leukorrhea & uterine withdrawal bleed. Mech?
high levels of maternal E crossing the placenta. After delivery E decreases hence pituitary is stimulated to produce more prolactin.
(also»_space; uni/bilateral gynecomastia w/ galactorrhea)
M neonate w/ unilate gynecomastia & galactorrhea. Firm like disc-like tissue under areola. Parents inquire about prognosis.
high levels of maternal E crossing the placenta. Resolves in 6 months.
*parents should be discouraged about expressing milk as it may stimulate further prolactin/oxytocin release from pituitary)
Acute inferolateral wall STEMI develops sinus bradycardia. NSIM?
Atropine IV, If no effect > transvenous cardiac pacing, then PCI.
Note: NE increases O2 demand & should be avoided.
Mech of bradycardia in inferior VS anterior MI?
- Inf: increased vagal tone
- Ant: damage to conduction system below AV node
**therefore anterior unlikely to respond to atropine
Acute inferolateral wall STEMI develops sinus bradycardia. Why should you AVOID the following:
- NE
- dobutamine
NE increases O2 demand (contraindicated in STEMI)
Dobutamine is inotropic hwr the issue here is chronotropy
BV can be treated w/ metronidazole OR
clindamycin
BV RFs?
- increased E (preg)
- menses
- sex
- recent abx
- douching
Complications BV during preg? Prevention?
- spontaneous abortion
- PPROM
- preterm labor
- chorioamnionitis
- postpartum endometritis
**Abx tx does not decrease risk of above complications
Why do you Tx BV in pregnancy?
for SYMPTOMATIC relief
- *Abx tx does not decrease risk of complications:
- spontaneous abortion
- PPROM
- preterm labor
- chorioamnionitis
- postpartum endometritis
MOA of increased BV risk w/ sexual activity?
lowers vaginal pH & lowers concentration of vaginal lactobacillus
Bee sting > rash, wheezing. VSS, BP wnl. NSIM?
IM EPI (2 system sx present: skin/resp. Hypotension does NOT need to be present to dx anaphylaxis)
- H blockers, GCS, SABA are *adjuvant tx
Anaphylaxis sp wasp sting. How effective is venom immunotherapy?
Quite- may reduce risk of anaphylaxis 2/2 sting from 35-60% to <5%
Infant w/ groin rash that spares creases. Tx?
topical barrier ointment (petrolatum, zinc oxide)
Dx: contact derm
(DDX beefy w/ skinfold involvement & satellite lesions: candida)
MCC diaper dermatitis
- contact dermatitis
2. candida dermatitis
Why should cornstarch or talcum powders be avoided for use of diaper rash ppx?
risk of aspiration
Tx:
- contact derm w/ petrolatum/ zinc
- candida derm w/ nystatin or clotrimazole
AVOID GCS 2/2 risk of systemic absorp & adrenal suppression
Why should high-potency GCS be avoided for diaper rash?
Due to risk of systemic absorp & adrenal suppression.
Tx:
- contact derm w/ petrolatum/ zinc
- candida derm w/ nystatin or clotrimazole
F w/ prolonged intubation is extubated»_space; stridor. No improvement w/ GCS. NSIM & Dx?
Reintubate.
Dx: laryngeal edema (present in 30%, 5% require re-intubation)
Multidose regimen GCS prior to extubation may decrease risk. (GCS after extubation dont help)
Prevention of neonatal gonoccocal conjunctivitis?
topical erythromycin ointment
Tx: ceftriaxone/cefotaxime IM x 1
Prevention vs Tx of neonatal gonoccocal conjunctivitis?
PPx: topical erythro
Tx: ceftriaxone/cefotaxime IM x 1
Neonate (2-5do) w/ copious mucopurulent discharge, chemosis & eyelid erythema. How could this have been prevented?
topical erythromycin ointment
(Tx: ceftriaxone/cefotaxime IM x 1)
Dx: gonococcal conjunctivitis
Bile salt-induced diarrhea may be seen in which 3 conditions?
- post-cholecystectomy
- ileal resection
- short bowel syndrome
MOA diarrhea sp cholecystectomy?
- Liver produces bile acid
- bacteria convert to secondary bile acids in GI which causes diarrhea
- sp cholectectomy- bile is not stored, instead dumped into colon
Tx cholestyramine (bile salt binding resin) - occurs in 5-10%
Tx diarrhea sp cholecystectomy?
cholestyramine (bile salt binding resin)
Malabsorption syndrome 2/2 anatomic (hx surg) or motility (DM, sclerosis) disorders. Sx: abd pain, bloating/flatus/D. Tx?
rifaximin
Octreotide: used for which types of diarrhea?
VIPoma
AIDS-related
Tx AOM
1st & 2nd line, PNC allergy
- amox x 10 days
- amox-clav
PNC allergic: clinda or azithro
Concurrent AOM & purulent conjunctivitis. Pathogen?
non-typable H influenzae
Which pathogen is associated w/ tympanostomy tubes?
S.aureus (otherwise not commonly associated w/ AOM)
AOM: Same or different pathogen?
A) Improvement, then AOM after a week
same
If >2wks later, different pathogen
AOM treated w/ high dose amox x 10 days. a few days after Tx, AOM recurs. Tx?
Amoxi-clav
resistance per beta lactamase producing strain of non-typable H.influenzae
Indications for a tympanostomy tube?
- > 3 months effusion
- > 3 AOM / 6 months
- > 4 AOM / yr
Which types of acne are salicylic, azelaic or glycolic acids for?
comedonal or non-inflamm
Moderate inflammatory acne. No improvement w/ BP wash and topical retinoids. NSIM?
add topical abx (clarithro/erythro). If ineffective, PO doxycyline.
40yo F w/ fatigue, pruritus, arthralgia, hypopigmented skin, xanthelasma, elevated alkP. Dx?
PBC
- obtain anti-mitochondrial ab (v sen & spec), if negative > liver bx to confirm
Tx: ursodeoxycholic acid
Liver transplant if advanced
40yo F w/ fatigue, pruritus, arthralgia, hypopigmented skin, elevated alkP & anti-mitochondral ab. MCCOD? Tx?
Liver cirrhosis (Dx: PBC, path: fibrosis & obliteration of intrahepatic bile ducts, F 30-65yo)
Tx: ursodeoxycholic acid
Liver transplant if advanced
(**GCS & immunosupp NOT useful)
Which screening test is regularly recommended in setting of PBC?
bone densometry as osteopenia/osteoporosis is a frequent complication despite normal vitD level (unknown mech). Recommend vitD/Ca & alendronate PRN)
Angular cheilosis & stomatitis. Vit def?
riboflavin (B2)
Dilated cardiomyopathy & polyneuropathy. Vit def?
Wet Beriberi (B1)
Photosensitivity, dermatitis, diarrhea, dementia. Vit def?
niacin (B3)
Exposure & response prevention rx is the best CBT for which condition?
OCD
Best Rx for borderline? A) response-prevention B) dialectical C) interpersonal D) psychodynamic E) supportive
B
Best Rx for OCD? A) exposure & response-prevention B) dialectical C) interpersonal D) psychodynamic E) supportive
A) exposure & response-prevention
+/- SSRI, 2nd line TCA: clomipramine
Meds for OCD?
1st line SSRI
2nd line TCA: clomipramine
Buspirone use?
GAD
Polymyalgia rheumatica is a disorder of:
proximal joints, tendons, bursae (NOT muscles, hence CK is wnl)
Why is CK normal in polymyalgia rheumatica?
It is inflammation of proximal joints, tendons, bursae (NOT muscles, hence CK is wnl)
Fatigue, weight loss, fever. Rapid onset pelvic girdle/shouler pain/stiffness. CK wnl, high ESR. Tx?
Low dose GCS w/ rapid response.
Dx polymyalgia rheumatica
High CK, low ESR. Dx? A) polymyalgia rheum B) statin myopathy C) dermtomyositis D) polymyositis
B) statin myopathy
DDx post-partum blues VS MDD?
Post-partum blues: <2wks
MDD: >2wks
if MDD criteria not fully met: adjustment disorder
Best antidepressants while breastfeeding?
sertraline & paroxetine
if already on other antidepressants during preg, dont change
First time febrile UTI in child <24 months. Abx given. Additional w/u?
US renal & bladder to r/o anatomic abnormalities.
- if recurrent infections or abnormal US findings > voiding cystourethrogram
First time febrile UTI in child <24 months. Abx given. Recurrent infections or abnormal US renal/bladder findings. NSIM?
voiding cystourethrogram (identifies vesicoureteral reflux which requires abx ppx)
Incidentalloma in sellar region. ASx, no hormonal abn. NSIM?
Reassure, periodically assess w/ MRI
Slurred speech, LUE weakness x 3h. BP 220/115. NSIM?
Lower BP <185/110, then thrombectomy (alteplase)
** note: giving alteplase in setting of severely elevated BP is a risk for hemorrhagic conversion
AE CHF. Initial goal of Tx?
Reduce cardiac preload
- diuretics
- vasodilators (NTG, nitroprusside) *unless hypoTN
If hypoTN:
- O2, NE, diuresis when tolerated
51yo F w/ bilat nipple discharge. Breast exam benign, no LAD, labs/mammo wnl. NSIM?
Reassure & observe
Meningitis: CSF w/ high opening pressure, neutrophilic leukocytosis, high protein, low glucose. Neg gram stain/Cx. Etiology?
Bacterial
(note gram stain sen 60-90%)
NSIM: abx
Seizure. CSF w/ lymphocytic pleiocytosis, RBC+, elevated protein. MRI w/ temporal lobe abn. Dx?
HSV encephalitis
GCS > mood sx, psychosis. NSIM?
Lower the dose
RF for mood sx w/ use of GCS?
- female
- high dose
- longer duration (hwr may occur at any time)
Which is NOT a possible AE of GCS?
A) depression B) anxiety C) sleep disturbance D) psychosis E) restlessness F) memory loss
NONE (they all are). If present, reduce the dose.
IDA Which value improves FIRST after initiating tx?
A) ferritin B) HCT C) Hgb D) MCV: RBC ratio E) retic count
E) retic count
**retic is low in IDA as BM cannot produce RBCs w/o iron substrate
MC deficiency in peds?
iron, Hgb <11 (often asx, universally detected on 1yr screen)
Anemia Hgb cutoff in peds?
Hgb <11
Peds w/ Hgb <11. Ferrous sulfate prescribed. Pts mother asks if pt has to take medication “forever”. You reply:
Take for additional 2-3 months afte Hgb normalizes.
TIA. What is the risk of CVA w/in 48h? w/in 30 days?
48h: 5%
30d: 12%
Therefore urgent comprehensive eval <48h:
- MRI >CT
- CTA/MRA, US carotids
- tele & TTE
Suspected TIA resolved by time pt arrived to ED, NSIM?
urgent comprehensive eval <48h:
- MRI >CT
- CTA/MRA, US carotids
- tele & TTE
Anemias w/ normal MCV & low retic?
Leukemia
Aplastic
Infection
Med AE
Anemias w/ low MCV & high retic?
hemorrhage hemolysis - AI - proxysmal nocturnal hemoglobinuria - spherocytosis - G6PD def...
IDA in 60yo M, FIT+. Colonoscopy wnl. NSIM?
Consider EGD to r/o slow bleeding ulcer.
Athlete w/ episodic pain at inferior patella. Dx?
Patellar tendonitis
35yo F w/ anterior knee pain worst w/ squatting or stairs. Dx?
Likely PFS (pain w/ extending the knee while compressing the patella)
Tx quad stretching/ strengthening,
NSAIDs often NOT helpful.
Acute/episodic medial/inferior knee pain. Dx?
anserine bursitis
Anterior knee pain w/ swelling over patella. Frequently complicated by secondary infection 2/2 S.aureus. Dx?
Prepatellar bursitis (housemaids knee)
Common complication of prepatellar bursitis?
Secondary infection/septic brusitis 2/2 S.aureus.
Tx C.O. poisoning?
high flow O2 via NRB
if severe: hyperbaric oxygen
Housefire. HA, malaise, nausea, dizziness. Pulse ox 97%. Dx?
r/o CO poisoning. Pulse ox cannot ddx btwn CO & O2. CarboxyHgb required.
Which is highly sensitive & poorly specific if CHF?
A) DOE B) orthopnea C) PND D) JVD E) LE edema F) S3
A) DOE
note, the rest are highly specific but poorly sensitive
Kerely B lines indicate ___ when evaluating CHF.
interstitial edema which may progress to alveolar edema
Why is pulmonary edema less common in chronic CHF than acute CHF?
pulm lymphatics can gradually increase fluid outflow rate up to 10x from baseline when needed- HWR in acute edema lymphatics do not have time to adapt»_space; pulm edema
Chronic CHF often presents as interstitial edema (Kerley B) lines on CHF w/o alveolar edema
Which CMP value is often present w/ obesity hypoventilation syndrome?
high bicarb
Features of Juvenile Arthritis?
- age
- F/M prevalence
- complication
50% oligoartic age 2-4
40% polyartic age 2-5, 10-14
F>M
**may be complicated by Asx uveitis in 20%, hence must screen with slit lamp
5yo w/ limp worse in the morning. Afebrile, joint swelling/warmth of shoulder & knee. Which screening test must be performed?
Juvenile arthritis may be complicated by Asx uveitis in 20%, hence must screen with slit lamp
5yo w/ limp worse in the morning. Afebrile, joint swelling/warmth of knee. Tx?
Juvenile arthritis
Tx:
- Mild= NSAIDs, IA GCS
- Severe (2+ joints, elevated ESR/CRP, impaired activity): = MTX, ~biologics
Pernicious anemia Dx test?
anti-IF Ab testing
50-84% sen, 100% spec
(Schilling may be used as second line test if Ab is neg)
Autoimmune, glandular atrophy of gastric body/fundus, intestinal metaplasia, inflammation. Dx?
AMAG (Autoimmune, metaplastic atrophic gastritis) assd w/ pernicious anemia.
Immune response against oxitinic cells and intrinsic factor.
AMAG (Autoimmune, metaplastic atrophic gastritis) presents as atrophy in which part of the stomach?
gastric body and fundus
NOT antrum
40yo w/ Raynaud & GERD presents w/ severe HTN & AKI. Dx?
r/o scleroderma renal crisis
Mech: thickening of vessel wall and narrowing of vascular lumen in renal arterioles > isch > RAAS > HTN (often malig HTN w/ CNS Sx and papilledema)
40yo w/ Raynaud & GERD presents w/ severe HTN & AKI. Drug of choice?
(Scleroderma Renal Crisis) Captopril/ACEi reverse angiotensin induced vasoconstriction
- Mild increase in creatinine is expected and does not warrant stopping tx.
- Nitroprusside may laso be added if CBS/papilledema+ acutely hwr beware of rapid BP drops»_space;ATN
When are ACEi first line in the setting of AKI?
Scleroderma Renal Crisis!
Captopril/ACEi reverse angiotensin induced vasoconstriction
Mild increase in creatinine is expected and does not warrant stopping tx.
30yo w/ CP sp cocaine. Benzo, NTG & ASA given. EKG w/ ST elevations in multiple leads despite Tx. NSIM?
Coronary angio & PCI for STEMI
Note: CCBs given for persistent CP hwr if EKG showing STEMI despite Tx, go straight to PCI
30yo w/ CP sp cocaine. Benzo, NTG & ASA given. EKG w/ ST elevations in multiple leads despite Tx. PCI cannot be performed per rural area. NSIM?
fibrinolytics
30yo w/ CP sp cocaine. Benzo, NTG & ASA given. EKG w/ ST elevations improve w/ Tx, hwr CP persists. NSIM?
Nifedipine/CCB
if persistent BP, phentolamine can be given
Emergent CVS complications of cocaine?
- MI
- aortic dissection
- neuro ischemia/CVA
Highly effective Tx for uni/bipolar depression if:
- psychotic features+
- persistent suicidality
or
- rapid tx response needed (nutrient depletion etc)
ECT (safe in preg)
Which conditions can be treated w/ ECT?
- MDD
- bipolar
- catatonia
Bipolar preg F w/ psychotic sx, refusing to eat and drink. Tx?
ECT (safe in preg)
- lithium takes too long to titrate (RF Ebstein anomaly)
- valproate contraindicated in preg (NTD, cleft lip/palate, limb defects, microcephaly, IUGR, craniofacial or genital abn)
**From Egypt, hematuria.
Dx test?
Tx?
D: Urine sediment microscopy (ID: eggs)
Tx: praziquantel
Cdiff Tx:
- First episode
- First recurrence
- Mult recurrence
- Fulminant
- PO vanc ot fidaxomycin
- PO vanc w/ extended taper (or fidaxo if van used initially)
- ”” OR
PO vanc then rifaximin
Consider fecal microbiota transplant - PO vanc (high dose) AND IV metro
+/- surg
Tx fulminant Cdiff (hypoTN, ileus, toxic megacolon?
PO vanc (high dose) AND IV metro \+/- surg
** if ileus, consider intracolonic vanc
Cdiff tx sp vanc tx, recurrs one month later. Tx?
PO vanc w/ extended taper (or fidaxo if van used initially)
Clindamycin, cephalosporin, FQs pose risk for Cdiff. Which Abx are better?
Aminoglycosides
TMP-SMX
CF pulm exacerbation:
Pathogens?
Tx?
S.aureus, P.aeruginosa
Tx: vanc PLUS 2 agents for Psaudomonas:
- Cephalosporins (Cefepime or Ceftazidime)
- Aminoglycoside (Amikacin or Tobramycin)
- carbapenems
- aztreonam
- colistin
- zocyn
- ticarcillin-clavulonic acid
60yo F sp MVA w/ ischemic CP, decomp HF, moderate troponemia, EKG ischemic changes in precordial leads. Cath w/o obstructive changes. TTE: LV mid/apical hypokinesis. Tx?
Supportive care
Stress-induced/Takotsubo cardiomyopathy
- likely 2/2 cathecolamine surge
Stress-induced/Takotsubo cardiomyopathy suspected. Expected TTE findings?
TTE: LV mid/apical hypokinesis > balloon shaped heart “octopus trap”
EKG w/ ST elevations & T wave inversions. TTE: LV mid/apical hypokinesis. Coronary angiography w/o obstructive coronary disease. Dx?
Stress-induced/Takotsubo cardiomyopathy, likely 2/2 cathecolamine surge
Sharp CP. EKG: diffuse ST elevations. Assd Dx?
Acute pericarditis
** Antithrombotic Rx for mechanical heart valves?
ASA and warfarin
MV has 2x higher risk than AV
**Mechanical heart valve replacement. When is the INR goal 2-3 VS 2.5-3.5?
INR 2-3: AV w/o RF INR 2.5-3.5: - MV - AV w/ RF - ~first 3m sp AV replacement
RF: afib, HFrEF <30, hx VTE, hypercoag state
(NOTE: all pts on warfarin AND ASA)
When is INR 2.5-3.5 recommended?
- MV replacement
- AV replacement w/ RF
- ~first 3m sp AV replacement
RF: afib, HFrEF <30, hx VTE, hypercoag state
(NOTE: all pts on warfarin AND ASA)
Which acute pancreatiits scoring systems sucks for predicting severity? A) Ransons B) APACHE II C) SIRS D) BISAP
A) Ransons
Cannot be calculated until 48h of admission and has been found to be poor predictor
Which 3 lab values have shown to be good predictors of pancreatitis severity?
- BUN >20 (worse outcomes)
- HCT >44% (indicates hemoconcentration 2/2 3rd spacing)
~ CRP >150 (rises slowest)
Which is not a good single-item predictor of acute pancreatitis severity? A) BUN B) TG C) CRP D) age E) obesity F) HCT
B) TG
also note: lipase >1000 has been associated w/ worse outcomes but is not a good single item predictor
33yo F w/ 3 UTI in 6 months. Tx?
Qualifies for postcoital abx or daily.
TMP-SMX
nitrofurantoin
cephalexin
ciprofloxacin
33yo F w/ urinary frequency/burning. UA:
blood++
protein-
LE++
nitrite+
NSIM?
Tx UTI
- TMP-SMX
- nitrofurantoin
Note: acute cystitis is a common cause of hematuria
80yo M w/ dementia. More frequently agitated, aggressive, requires olanzapine/haldol PRN. Develops Parkinsonism. NSIM?
D/C antipsychotics! (increased mortality in dementia patients & AE++)
Only use: if patient or caretakers safety is threatened
Opt for behavioural interventions, antidepressants, antidementia drugs.
Why is haldol contraindicated for Lewy Body Dementia?
neuroleptic sensitivity (worsens Parkinsonism)
80yo urinary incontinence, orthostatic hypotension, hallucinations, dementia, excessive somnolence. Pt develops Parkinsonism & confusion w/ low dose haldol. Dx?
Lewy Body Dementia
avoid neuroleptics d/t extreme sensitivity
Tx for AK & Bowens but NOT SCC/BCC?
5-FU or phototherapy
75yo w/ SCC. Refuses surgery, cryotherapy or electrotherapy. NSIM?
Can Tx w/ radiation (hwr requires multiple visits and increases risk of future CA, hence only for elderly refusing all other tx)
Pruritus in pregnancy. DDX pregnancy induced skin changes VS hepatic cholestasis of pregnancy ?
Hepatic cholestasis of preg:
- generalized pruritus, esp palms/soles,no rash
- increased bile acids, LFTs
- RF IUFD
- deliver at 37wks
- Tx: ursodeoxycholic acid antiH
Pregnancy induced skin changes
- focal pruritus, no rash
- labs grossly wnl
- no obstetric risk
- Tx: antiH, UV light, oatmeal baths
Pregnant woman w/ hx atopy has disseminated papular rash. Dx?
Atopic eruption of pregnancy
3rd trim pregnancy: Pruritic, erythematous papules that begin on abdominal striae and spread to extremities. Face/palms/soles spared. Dx: A) Atopic eruption of preg B) Intrahepatic cholestasis C) polymorphic eruption of pregnancy D) pregnancy induced skin changes F) pemphigoid gestationis
C) polymorphic eruption of pregnancy
Pregnancy induced skin changes. Tx?
antiH, UV light, oatmeal baths
AI disease in 2nd/3rd trim, abdominal pruritus > periumbilical urticarial papules/plaques which spreads to body > tense bullae (spares mucous membranes) Dx?
A) Atopic eruption of preg B) Intrahepatic cholestasis C) polymorphic eruption of pregnancy D) pregnancy induced skin changes F) Pustular psoriasis of pregnancy E) pemphigoid gestationis
E. Pemphigoid gestationis (FKA herpes gestationis)
Dx Clinical but can be confirmed w/ bx
Tx: high potency topical GCS & antiH
Obstetric complications:
- prematurity
- fetal growth restriction
- neonatal pemphigoid gestationis
Pregnant F: Erythematous plaques, surrounded by sterile pustules that spread outward to flexural regions (axilla, inframammary). Non-pruritic. Dx?
A) Atopic eruption of preg B) Intrahepatic cholestasis C) polymorphic eruption of pregnancy D) pregnancy induced skin changes F) Pustular psoriasis of pregnancy E) pemphigoid gestationis
F) Pustular psoriasis of pregnancy
Tx pemphigoid gestationis
high potency topical GCS & antiH (resolves sp delivery)
- if resistant to above:
- PO GCS
- rare: cyclosporine, azathioprine
Pemphigoid gestationis adequately Tx w/ topical triamcinolone & antiH. Pt asks about prognosis?
Good, resolves sp preg but risk of recurrence w/ subsequent pregnancies
Note: Obstetric complications: - prematurity - fetal growth restriction - neonatal pemphigoid gestationis
Intrahepatic cholestasis of pregnancy: Tx?
Definitive Tx: delivery Ursodeoxycholic acid MOA: - decreases GI cholest absorp - decreases hepatic cholest excretion HENCE less cholesterol in bile & increase in bile flow
Elderly w/ magnetic/wide-based gait, frequent falls, urinary incont & AMS. Tx?
Triad for NPH
Tx: ventriculoperitoneal shunting
Dx:
- MRI: enlarged ventricles, out of proportion to brain atrophy
- improvement w/ CSF removal (30-50mL)
NPH suspected: Dx work up?
Dx:
- MRI: enlarged ventricles, out of proportion to brain atrophy
- improvement w/ CSF removal (30-50mL)
Tx: Tx: ventriculoperitoneal shunting
HRT puts patients at risk for A) breast CA B) CRC C) ovarian CA D) endometrial CA
A) breast CA
It reduces risk of CRC! Neutral for endometrial/ovarian
RF of HRT?
- VTE
- Breast CA
- CAD >60
- CVA
- gallbladder disease
(mostly in women 60+)
Has benefits for women <60, non-smokers, no hx VTE or breast CA
T/F: HRT reduces risk of all cause mortality <60.
TRUE
Benefits of HRT outside of menopausal sx?
Reduces risk of following:
- DM (decreased insulin resistance)
- all cause mortality <60
- osteoporosis
- CRC
Fever, pharyngitis & sandpaper-like rash. Pathogen?
Spyogenes
6yo w/ fever/cough > erythematous cheeks, reticular truncal rash. Dx?
Erythema infectiosum.
Parvovirus
Fever/fatigue, cough, coryza, conjunctivitis»_space; maculopapular rash starts on face & spreads caudally. Foreign travel. Which pediatric exanthem?
MEASLES (RUBEOLA)
Tx VitA if hospitalized, otherwise supportive
Tx rubeola?
MEASLES (RUBEOLA)
Tx VitA if hospitalized, otherwise supportive
Stent thrombosis sp coronary artery stenting w/in 30 days. MCC?
Med nonadherence (DAPT)
Papular urticaria:
- cause
- Tx?
- prognosis
Cause: delayed HS reaction to insect bites
Tx: antiH, topical GCS, avoid insect bites
Prog: occasionally recurrent course over wks/months
More common in peds
Pale halos are associated w/: A) papular urticaria B) lichen planus C) pityriasis rosea D) nummular eczema E) guttate psoriasis
A) papular urticaria
Why is trazodone not used for MDD monoTx?
V high doses required to tx MDD which often cause intolerable daytime sedation
- used to Tx insomnia in MDD
Needlestick, contact w/ mucous membrane or non-intact skin comes into contact w/ HIV fluids. Which fluid is NOT infectious?
urine
feces
tears
vomitus
Otherwise if blood, semen, vaginal secretions, ~CSF, ~pleural, ~pericardial: PEP
Advised PEP for HIV needlestick.
3-drug HAART x 4wks
What is seen on the contrast enema in setting of meconium ileus?
microcolon
48h neonate has not passed meconium. Contrast enema shows normal caliber rectosigmoid & a dilated descending colon. AXR shows multiple loops of large bowel and no air in the rectum. Dx?
Hirschprung
Dx: suction bx
Biggest absolute & relative contraindications to organ transplant?
absolute: active EtOH/PSA
relative: poor social suppory
New onset unexplained CHF. Which tests are indicated?
Evaluate CAD w/ coronary angiography or stress test
(note: acute MI causes irreversible myocardial death HWR in chronic myocardial ischemia, some tissue is still viable & may have reversibly depressed contractility!)
In these pt revasc can lead to improvement in: Sx, systolic funct & long term mortality
MCC dilated cardiomyopathy
idiopathic (primary)
2nd MCC: CAD > isch cardiomyopathy
CRC screening indications w/ UC?
start 8-10yrs sp Dx
Q1-3y
**CRC screening for patients w/ 1st deg FHx or high risk adenomatous polyp
age 40 (or 10y prior to 1st deg family dx)
Q5y (or 10y if FHx >60)
Clozapine has superior efficacy in tx schizophrenia hwr reserved for tx-resistant cases per risk of: _________
agranulocytosis
Flaccid paralysis, hyporeflexia & sensory level/ bladder or bowel dysfunction sp URTI. Dx?
Transverse myelitis
DDx GBS does not have sensory level/ bladder or bowel dysfunction
Flaccid paralysis, hyporeflexia & sensory level/ bladder or bowel dysfunction sp URTI. Transverse myelitis suspected. NSIM?
MRI to r/o less likely etiologies:
- post traumatic
- CA/tumor
- herniated disk
- epidural abscess
Tx: 3-5 days high dose GCS
Tx Transverse myelitis?
high dose GCS x 3-5 days
Tx neonatal hyperbilirubinemia
Mild: maximize feeds 2-3h
Mod: photoRx, hydration,
Severe: exchange transfusion (ie. bili >20)
** note: severe hyperbilirubinemia»_space;kernicterus (permanent brain damage)
When do you Tx neonatal hyperbilirubinemia w/ exchange transfusion and why?
- bili >20
- failed photoRx
- neuro sx: lethargy/
hypotonia
**severe hyperbilirubinemia»_space;kernicterus (permanent brain damage)
breastfeeding failure jaundice pathomech?
Lactation failure > decreased bili elimination > increased enterohepatic circ
High levels of b-glucuronidase in breast milk > deconjugates interstinal bili > increased enterohepatic circ. Dx?
Breast milk jaundice
How does parvovirus manifest in adults?
Flu-like > acute onset symmetrical joint pain/ swelling/ stiffness (F>M). +/- reticular rash (less common), transient aplastic anemia
Tx: NSAIDs, supportive
Pharyngitis > migratory polyarthritis, erythema marginatum, subcutaneous nodules. Dx?
Acute rheumatic fever
Dx test parvovirus
Often clinical
May confirm w/ serology (parvovirus B19 IgM abs)
Acromegaly: Common causes of death?
CVS (HTN, septal hypertrophy, conduction defects, CAD, myocardial fibrosis)
Other:
- resp
- DM
- CA (esp CRC)
MC CA in acromegaly?
CRC (more polyps also)
HR >150, hemodynamically stable, widened QRS, regular rhythm. Dx & Tx?
Monomorphic Vtach
- amiodarone
- procainamide
- sotalol
- lidocaine
HR >150, hemodynamically stable, widened QRS, irregular rhythm.
?afib w/ aberrant conduction.
- procainamide
- ibutilide
HR >150, narrow QRS, reg rhythm. Dx & Tx?
non-afib SVT
(ie AVNRT)
Tx: vagal maneuver, adenosine
Ultra short BB used for rapid control of afib?
Esmolol
IV iron given > flushing, SOB/wheezing & hypoTN. NSIM?
EPI IM (suspect anaphylaxis)
Infantile hemangioma- prognosis?
prolif 0-6 months, then red>violet w/ regression
IF:
- > 5 lesions: liver US
- facial/segmental: TTE & MRI head (PHACE)
- cervicofacial: laryngoscopy
- lumbosacral: spinal US
Infantile hemangioma. What further w/u is needed for the following? 1. >5 lesions 2. facial/segmental: 3. cervicofacial: 4 lumbosacral:
- liver US
- TTE & MRI head (PHACE)
- laryngoscopy
- spinal US
Indication for BB w/ infantile hemangioma?
- large, facial, segmental &/or rapidly growing (ulceration/scarring)
- periorbital
(RF visual impair) - hepatic
(RF high output HF) - subglottic
( RF airway obstruct)
Which does NOT fade with time?
A) nevus flammeus
B) infantile hemangioma
C) nevus simplex
A) nevus flammeus (port wine stain)
- blanchable
- red capillary malformation
- do not cross midline
MCC acute epididymitis:
<35yo?
>35yo?
<35yo STD
>35yo coliform bact (bladder obstruction)
Dx: NAAT, UA/UCx
Progressive unilateral scrotal pain w/ edema & tenderness. Improved w/ testicular elevation. Dx work up?
Dx: NAAT, UA/UCx
<35yo STD
>35yo coliform bact (bladder obstruction)
Progressive unilateral scrotal pain w/ edema & tenderness. Improved w/ testicular elevation. Tx?
<35yo STD:
= ceftriaxone/doxy
> 35yo coliform bact (bladder obst)
= cipro
5yo M w/ meningitis, parotitis & orchitis. Dx?
Mumps
MCC viral orchitis?
Mumps
Parvovirus
Rubella
TTP Tx:
A) enhancing release vWF from endothelium
B) increasing amt/activity of plasma metalloprotease
C) removing trigger for uncontrolled activation of the coag cascade
D) supressing Ab production against PLT Ag
B) increasing amt/activity of plasma metalloprotease
Note: TTP path is 1. Low ADAMTS13 (a plasma metalloprotease) 2. uncleaved vWF multimers 3. PLT trapping/ activation 4. diffuse microthrombi 5. PLT consumption 6. intravasc RBC shearing > MAHA (^schist, bili, LDH, LFT) 7. Organ ish: AKI, neuro sx
What is ADAMTS13 and what does it do?
a plasma metalloprotease which cleaves v large strings of vWF off the vascular endothelial wall
TTP: autoAbs against ADAMTS13
AutoAbs against ADAMTS13 >MAHA. Tx?
plasma exch
GCS
rituximab
**PLT transfusions may worsen MAHA (only in very severe bleed)
Abs against PLT Ag. Dx?
ITP
TTP pathogenesis
- AutoAbs against ADAMTS13 (plasma metalloprotease) > low levels
- vWF multimers go uncleaved
- PLT trapping/ activation
- diffuse microthrombi
- PLT consumption
- intravasc RBC shearing > MAHA
(^schist, bili, LDH, LFT) - Organ ish: AKI, neuro sx
Hospitalized pt w/ >50% PLT drop & new art/venous thrombosis. NSIM?
obtain 5HT assay & STOP all heparins.
START direct thrombin inhibitor (argatroban, bivalirudin) OR fondaparinux (synthetic pentasaccharide)
PE > anticoag > HIT. Heparins stopped & started on argatroban/ bivalirudin/ fondaparinux. When do you start warfarin?
When PLT recover >150
(note, you continue the non-heparin AC until INR becomes therapeutic)
Direct oral anticoagulants may be considered (apixaban)
Hypopigmented spots, FHx bilateral deafness. Dx?
NF2 (cafe au lait spots, bilateral acoustic neuromas)
DDx NF1: HYPERpigmented spots & UNIlateral deafness)
Hypopigmented maculae, organ hamartomas/cysts., epilepsy, cardiac rhabdomyosarcoma.
Dx?
Tuberous Sclerosis
Ashleaf spots Shagreen patch Heart rhabdomyosarcoma Lung hamartomas Epilepsy Angiomyolipoma of kidney Facial angiofibroma
Following features are features of ____
- Leptomeningeal- capillary-venous malformation.
- Port wine stain
- glaucoma
- MR
- seizures
Sturge Weber
ASHLEAF mnemonic Tuberous Sclerosis
Ashleaf spots Shagreen patch Heart rhabdomyosarcoma Lung hamartomas Epilepsy Angiomyolipoma of kidney Facial angiofibroma
Heart rhabdomyosarcoma
& lung hamartomas. Dx?
Tuberous Sclerosis
Ashleaf spots Shagreen patch Heart rhabdomyosarcoma Lung hamartomas Epilepsy Angiomyolipoma of kidney Facial angiofibroma
Angiomyolipoma of kidney, Assd Dx?
Tuberous Sclerosis
Ashleaf spots Shagreen patch Heart rhabdomyosarcoma Lung hamartomas Epilepsy Angiomyolipoma of kidney Facial angiofibroma
Red spots on lips. Which other features do you expect?
Telangiectasia
Epistaxis
AVM
Dx: Osler Weber Rendu AKA hereditary hemorrhagic telangiectasia
Untreated AK has a __% risk of progression to SCC.
20%
Multiple Aks. Tx?
Field Tx:
- 5FU
- Immiquimod
- voltaren gel
- photodynamic rx
39yo smoker w/ GERD presents to ED c/o dull annoying CP sp meal x 2h. NSIM?
EKG & trops x 2+.
Give ASA & NTG.
Must r/o MI
Preg 22w gest w/ new onset HTN, AKI & proteinuria. Dx?
Preeclampsia
*new onset HTN >20w gest
AND
* proteinuria &/or end organ damage
Severe features:
- > 160/110 x 2 (>4h apart)
- thrombocytopenia
- ^ Cr
- ^ LFTs
- pulm edema
- visual/cerebral sx
Preeclampsia w/ severe features:
- > 160/110 x 2 (>4h apart)
- low PLT
- ^ Cr
- ^ LFTs
- pulm edema
- visual/cerebral sx
Management?
If severe features, deliver 34w+ Mg sulfate antiHTN - labetalol - hydralazine
(if no severe features, deliver 37w+)
RF preeclampsia?
- nulliparity
- advanced maternal age
Why is Mg given in preeclampsia?
seizure ppx
Severe features of preeclampsia?
- > 160/110 x 2 (>4h apart)
- low PLT
- ^ Cr
- ^ LFTs
- pulm edema
- visual/cerebral sx
Think KIDNEY, LUNG, LIVER, HEAD, BLOOD
35yo sp gastric bipass c/o back pain. Takes vitD & Ca supplement. Labs show Ca 9, Ph 2.2, AlkP 155, PTH 955. DEXA w/ osteopenia. NSIM?
measure serum 25 hydroxy vitD.
Likely inadequate vitD supplement. Osteomalacia & secondary hyper PTH.
Level of vit D
- deficiency
def <20 insuff 20-30
Initial Tx of vitD def VS maintenance?
cholecalciferol D3 50,000U /wk x 8wks
THEN
1,500-2,000U /d
(*Unless malabsorp:
3,000-6,000U /d)
Why should zolendronic acid NOT be used in setting of vitD def?
Risk of hypoC
Which supplements should be prescribed s/p gastric bipass?
VitD (high dose)
B1, B12, folate
Ca, Fe
trace minerals
Which is NOT a feature of atopic derm?
A) mutation in filaggrin B) ^ H2O content C) ^ inflamm D) ^ permeability E) Th2 skewed response F) lichenification G) assd w/ food allergy H) ^ IgE I ) eosinophilia J) improved w/ cotton clothing
B) ^ H2O content
*Pt should maintain skin hydration EMOLIENTS!
EMOLIENTS!
EMOLIENTS!
Lab findings in atopic derm?
High IgE & eosinophils
Tx atopic derm A) face, flexural B) mild C) severe D) v severe
A) calcineuric inhibitors (tacrolimus) B) mild GCS- hydrocortisone C) mod/high potency GCS- triamcinolone betamethasone D) UV tx or systemic immunosuppressants
Which are most common for tattoo removal? A) dermabrasion B) cryo C) thermal cautery D) surg resection E) laser
A) dermabrasion
E) laser
- biggest AE:
- scarring
- skin discoloration
Knee pain s/p jumping from height > popping, pain/swelling & difficulty bearing weight. Pt cannot actively extend the knee or raise the leg against gravity. Dx?
Patellar tendon tear
RF: FQs, strong quad contraction with foot firmly planted
Lachman test + Dx?
ACL tear
Lachmans (20deg) is more sensitive than anterior drawer (90deg)
MCC neonatal sepsis
GBS
Indications for GBS PPx w/ ampicillin, PNC or cefazolin >4h from delivery (4)
- maternal GBS bacteruria
- maternal rectovag Cx obtained 36-38w gest
- sibling w/ invasive GBS disease
- unknown GBS status w/ RF (PPROM >18h)
Peripartum PPX Group B Strep- Abx?
ampicillin, PNC or cefazolin >4h from delivery
Mother is afebrile. Tested GBS+ during preg. Abx administered 2h before birth. NSIM?
**Should have been 4h before labor, hence inadequate ppx HWR as infant is well appearing, OBSERVATION 36-48h recommended (as almost all neonates will have sx in this time)
Which 3 scenarios warrant BCx/Abx to neonate despite ppx?
- maternal fever during labor
- sx neonatal infection: fever/lethargy
- gest age <35 prompted by signs of infection
BEST Tx for head/neck CA
A) rad
B) chemo
C) chemo/rad
C) chemo/rad
Best antiHTN med used in gout?
ARBs per uricosuric effect
Avoid thiazides/loops
Blow to the knee or significant twisting force >popping sensation, rapid hemarthrosis & joint instability.
ACL tear
Dx
- Lachmans+
- anterior drawer+
- MRI
Preg sp MVA, wearing seatbelt. Abd pain, high-freq/low-instensity contractions. Rigid tender uterus, no vaginal bleed. Reassuring fetal non-stress test. NSIM?
r/o concealed abruptio placentae w/ US
& Order Kleihauer-Betke to detect and quantify the amount of fetal maternal hemorrhage by calculating percent of fetal RBCs in maternal circ (determines the amount of RhoD globulin needed to decrease risk of alloimmunization
Kleihauer-Betke test use?
detects and quantify the amount of fetal maternal hemorrhage by calculating percent of fetal RBCs in maternal circ (determines the amount of RhoD globulin needed to decrease risk of alloimmunization
70yo w/ CAD, PAD, ESRD on HD p/w ild/moderate crampy abd pain abd pain w/ fecal urgency > hematochezia. Afebrile. Labs: WBC+, lactic acidosis. CT: colonic wall thickening, fat stranding. Endoscopy: edematous/friable mucosa. Dx & Tx?
Colonic ischemia
(watershed, hypovol, atherosclerosis)
Tx: IVF, bowel rest. Abx
Colonic resection if necrosis develops
Tx colonic ischemia
Tx: IVF, bowel rest. Abx
Colonic resection if necrosis develops
Colonic ischemia: Imaging and labs?
Labs: WBC+, lactic acidosis.
CT: colonic wall thickening, fat stranding. +/- pneumatosis. Endoscopy: edematous/friable mucosa.
RF colonic angiodysplasia
CKD
AS
VWD
Beneficence VS non-maleficence
duty to be of benefit to patients VS do no harm
Protective factors from suicide?
- social support/ family connection
- pregnancy
- parenthood
- religion
Which valve is best listened to after exhaling in L lateral decubitus position?
Mitral
Should you accept the following from a patient:
A) a watch
B) box of chocolates
A) no, but reassure pt you will give them the best care
B) yes, to refuse a small token of appreciation may be damaging to the pt-physician relationship
Which of the following are most likely to be injured w/ medial laceration of the eyelid? A) punctum B) canaliculi C) levator muscle D) nasolacrimal duct E) lacrimal sac
B) canaliculi
**Which EKG findings are diagnostic of a STEMI?
- > 1mm all leads EXCEPT V2 & V3
- V2/V3 >1.5mm F
- V2/V3 >2mm M >40
- V2/V3 >2.5mm M <40
- new LBBB
Which is NOT diagnostic of a STEMI?
A) >2mm in all leads except V2/V3
B) V2/V3 >1.5mm F
C) V2/V3 >2mm M >40
D) V2/V3 >2.5mm M <40
E) new LBBB
A) >2mm in all leads except V2/V3
** >1mm in all leads except V2/V3
STEMI in rural setting. NSIM?
fibrinolytics (alteplase etc) w/in 30mins as PCI cannot be performed in <120mins
25yo M w/ sudden onset foot pain, pulselessness/coolness. Etiology?
Acute arterial occulusion likely 2/2 cardiac emboli
- afib
- severe ventricular dysfunction
- endocarditis
- valvular disease
- atrial myxoma
- prosthetic valve
25yo M w/ sudden onset foot pain, pulselessness/ coolness. Which is NOT the cause? A) afib B) severe ventricular dysfunction C) endocarditis D) factor V Leiden heterozygosity E) valvular disease F) atrial myxoma G) prosthetic valve
D) factor V Leiden heterozygosity
**assd w/ venous thrombosis
Cardiac tumor: Extremely friable, may lead to tumor emboli. May obstruct mitral valve if large. Dx?
Atrial myxoma (MC cardiac tumor)
- Assd w/ rapid HF onset or new onset afib
Dysuria, postvoid dribbling, dyspareunia, anterior vaginal mass. Assd w/ hematuria, recurrent UTIs, stress urinary incont. Dx?
urethral diverticulum
RF: repeated infection, inflammation and pelvic trauma (vag delivery, surgery)
Fever, dyspareunia, abd/pelvic pain, mucopurulent cervical discharge, cervical motion tenderness. Dx?
PID
polymicrobial inf of the upper reporductive tract 2/2 unTx chlam/ gono
Urethral diverticulum Dx work up & Tx?
UA
UCx
MRI pelvis
US pelvis
Tx: manual decompression, needle aspiration, surgical repair
High risk featur of head trauma in peds <2yo is NOT:
A) fall >3ft
B) AMS/fussy
C) palpable skull fracture
D) frontal scalp hematoma
D) frontal scalp hematoma
**NON_frontal scalp hematoma (esp >3cm)
Gold standard for Dx sclerosing cholangitis?
ERCP
assd w/ UC
Most specific abs or Dx AI hepatitis are anti-smooth muscle abs AND _____
ANA (homogenous staining pattern)
AI hepatitis disease course?
may progress to cirrhosis & liver failure w/in 6 months. Young/middle-aged women
Which mechanical obstetric emergency is PPROM associated w/?
umbilical cord prolapse»_space; fetal hypoxia
PPROM > cord compression. Tx?
Downward dog pose to relieve pressure or manual elevation of presenting fetal part to relieve cord compression prior to EMERGENT C/S.
PPROM > fetal recurrent variable deccelerations & brady. Dx?
r/o cord compression
Tx: emergent C/S
Worst HA of life but head CT w/o signs of SAH. NSIM?
LP to check xanthochromia which appears >6h sp bleed. Then CTA for bleed source.
CTH is 100% sensitive w/in 6h of sx onset, then rapid decline.
CSF: elevated RBC in first tube, then declining number of RBCs in successive tubes. Dx?
Traumatic LP
Newborn w/ conjugated hyperbilirubinemia (DBili >20% TBili) Dx?
Biliary atresia 2/2 progressive obstruction of extrahepatic biliary tree
Which presents in the first week of life?
A) Breast milk jaundice
B) Breastfeeding failure jaundice
B) Breastfeeding failure jaundice
Breast milk jaundice Tx?
Monitoring & f/u of bili levels. **EXCLUSIVE BREASTFEEDING ENCOURAGED, resolves w/in 3 months
MCC viral meningoencephalitis in peds?
- Coxakievirus (enterovirus)
- HSV
- West Nile (arbovirus)
Tx: acyclovir for HSV & vanc/ceftriaxone until ruled out, otherwise supportive
RMSF Tx?
doxy
Top 3 Tx options
& duration uncomplicated cystitis.
- nitrofurantoin x 5d
- TMP-SMX x 3d
- fosfomycin x 1
**preg test beforehand
Tx complicated cystitis
FQ (cipro, levo)
Ampi-genta
Pregnant F w/ complicated cystitis. Which is NOT a Tx option?
A) cipro B) cefopodoxime C) cephalexin D) amoxi-clav E) fosofomycin
A) cipro
(AVOID FQ in preg: toxic to developing cartilage)
**nitrofurantoin may only be used in 2nd & early 3rd trimester.
Also avoid
- TMP-SMX
- tetracyclines
Match the Abx w/ teratogenicity:
A) toxic to developing cartilage
B) congenital deafness
C) NTD, cardiac defects
D) cleft palate
A) FQs
B) gentamycin
C) TMP-SMX
D) TMP-SMX
MCC diaper dermatitis?
- contact
2nd MCC candida
Positive stress test. NSIM?
Start ASA, statin, BB. Optimize BP/glycemic control, quit smoking.
If high risk features ie TWI w/ minimal exertion > coronary angiography (if no high risk features hwr angina+, also undergo angio)
Which of the following DOES NOT have an early incubation period <10d?
A) typhoid B) dengue C) chukungunya D) legionella E) leishmania
E) leishmania
>3w
Which of the following has an early incubation period <10d? A) legionellosis B) leptospirosis C) leishmaniasis D) rickettsial d E) malaria
A) legionellosis
Sub-saharan Africa > febrile illness 2wks after return. HA, thrombocytopenia. Which Dx to establish Dx?
Blood smear, Plasmodium falciparum
How to alter AM insulin regimen if planning a 45min run?
Lower AM aspart
- if over 45min, consider lowering PM levemir also
- if gluc <100 before/during/after run, additional carbs should be consumed
NSIM in unilateral nipple discharge if
- > 30
- <30
> 30: mammogran AND US
<30: US
+/- mammogram
MCC papillary tumor (benign but may have assd areas of atypia, DCIS or unvasive intraductal carcinoma
MCC unilateral breast discharge?
MCC papillary tumor (benign but may have assd areas of atypia, DCIS or unvasive intraductal carcinoma
NSIM:
- >30: mammogran AND US
- <30: US
+/- mammogram
Lobular carcinoma in situ on core bx. NSIM?
excisional bx w/ surveillance
Then +/- chemoprevention w/ SERMS ir tamoxifen/raloxifene
(this is a nonmalig region w/ no mammogram/clinical correlate. RF for lobular/ductal CA
Lobular carcinoma in situ on core bx. Which is NOT part of subsequent management? A) excisional bx B) modified mastectomy C) sentinel node bx D) tamoxifen E) chemo/rad
B,C,E
NSIM: excisional bx w/ surveillance
Then +/- chemoprevention w/ SERMS ir tamoxifen/raloxifene
55yo w/ mild TSH suppression but normal T3/T4, no sx, RRR, normal bone density. NSIM?
recheck TSH in 6-8wks
high chance of TSH normalization
Tx large prolactinoma compressing optic chiasm?
D receptor agonists (bromocriptine, cabergoline) ALWAYS first line.
Often decrease in tumor size w/in few days (visual sx improve before shrinkage)
Most potent medication for raising HDL?
niacin (lowers LDL/TGs) hwr not as effective as statins.
Which diabetics are advised to start a MODERATE intensity statin?
> 40yo w/ ASCVD <20
if >20, high-intensity
When do you give a basal bolus in management of DKA?
Gluc <200
Pt can eat
HCO3 >15
AG <12
Amenorrhea <40yo. High FSH, low E. NSIM?
adrenal Abs
TSH
karyotype
Common causes:
- chemorad
- AI (Addisons, hypothyroidism)
- FragileX, Turner
Child swallowed coin an hour ago, seen in stomach on CXR. NSIM?
Repeat XR in 1wk UNLESS high risk object (battery, magnet, sharp item) then endoscopic removal
(most objects will pass spontaneously, coin is not a high risk object)
RF for splenic vein thrombosis?
acute/chronic pancreatitis or pancreatic CA (damaged or compressed by pancreatic inflammation)
Isolated gastric varices are a hallmark of:
splenic vein thrombosis
Splenic vein thrombosis w/ GIB. Tx?
splenectomy
RUQ pain, hepatomegaly, jaundice, rapidly developing ascites. R/o thrombosis of:
hepatic veins or intra/suprahepatic IVC. (Budd-Chiari)
Chronic> ascites, cirrhosis, portal HTN
Hgb 7.2, MCHC 27%, MCV 72, ferritin wnl. Dx?
IDA (note ferritin cutoff is <15, but not sensitive. Commonly ferritin 15-30 can also be deficient.
Non-caseating granulomas. Negative fungi/AFB. Dx?
Sarcoidosis
Erythema nodosum, bilateral hilar LAD, polyarthralgia. Dx?
Lofgrens Syndrome (Sarcoidosis)
Sarcoidosis pt w/ erythema at the junction of the cornea/sclera, constricted pupil, blurred vision, moderate eye pain. Dx?
Anteroir uveitis
Elderly pt w/ severe eye pain, mid dilated pupil, HA, N/V. Dx?
Acute closure glaucoma
Bacterial/fungal infection of the intraocular cavities»_space; decreased visual acuity, aching of the affected eye and conjunctival injection. Assd w/ severe underlying illness or recent eye surgery. Dx?
Endopthalmitis
Complication of GERD that can cause obstructive dysphagia in young patients. Often prolonged, careful chewing.
Peptic stricture formation (difficulty swallowing solid food >liquids
DDx achalasia: dysphagia solids AND liquids from the beginning
In which conditions is hyperCa 2/2 immobilization most often seen?
Pagets, adolescents
v high bone turnover
Tx hyperCa 2/2 immobilization for prolonged periods?
bisphosphonates: decrease bone resorption > preserve bone mass
HyperCa 2/2 extrarenal production of 1,25 OH-vitD?
Granulomatous disorders (sarcoidosis, TB)
MOA hyperCa in paraproteinemias?
Increase in total bount Ca but ionized free Ca is wnl
Pt sp laparoscopic surgery> persistent abd pain, fever, some guarding, no rigidity, ileus+, WBC+. NSIM?
abd CT w/ PO contrast to eval for unrecognized bowel injury (ie bowel puncture, thermal inj)
**if frank peritonitis suspected (guarding, rigidity, rebound tenderness) straight to laparotomy w/o imaging
Signs of frank peritonitis?
Abd pain Guarding Tense abd Rebound WBC, fever, ileus
Sp laparoscopic cholecystectomy > low fever, N, abd pain. Serum bili++. NSIM?
r/o bili injury w/ abd CT vs ERCP. Surgical repair likely required.
High TSH, high T4/T3, elevated alpha subunit 85%, high GH. Dx?
TSH secreting pituitary adenoma
Tx: somatostatin analogs, +/- transsphenoidal surgery
Tx TSH secreting pituitary adenoma?
somatostatin analogs, +/- transsphenoidal surgery
TSH secreting pituitary adenoma. High/low?
A) TSH
B) T4/T3
C) alpha subunit
D) TBH
all high
Thyroid hormone resistance syndrome. High/low?
A) TSH
B) T4/T3
C) alpha subunit
D) TBH
A) high
B) high
C) wnl
D) wnl
Recurrent sinopulm infections due to encapsulated bacteria per lack of opsonizing IgG. Dx?
X-linked agammaglobulinemia
complement dysfunction ie C3 def also causes increased infections w/ encapsulated bacteria
Impaired PMH chemotaxis. Dx?
A) SCID
B) CGD
C) leukocyte adhesion def
D Agammaglobulinemia
C) Leukocyte adhesion def.
recurrent skin/mucosal infections
Dementia, spastic paresis, hyperreflexia, impaired vibration, Romberg+. Dx?
B12 def > subacute combined degeneration
MC neuro Sx of Wilsons d?
dysarthria
B12 def > subacute combined degeneration. Reversible or not?
Reversible!
B12 def - MOA of mild indirect hyperbilirubinemia, low haptoglobin, ^LDH, normal retic?
- defective DNA synth w/ megaloblastic transformation of bone marrow and intramedullary hemolysis
- intense erythroid hyperplasia but erythroid cells do not mature & die in BM
Which is an example of EXTRAhepatic cholestasis?
A) biliary stricture
B) PBC
C) PBS
A) biliary stricture
Direct or indirect hyperbilirubinemia
A) extrahepatic cholestasis
B) intrahepatic cholestasis (PBC, PSC)
both direct
Isolated indirect hyperbilirubinemia 2/2 impaired hepatic conjugation. Dx?
Gilbert syndrome
Tx supportive
Which is NOT a Tx for rosacea? A) topical metro B) topical clinda C) azelaic acid D) BP wash E) dapsone F) ) laser G) topical brimonidine
E) dapsone
(NOT USED)
all others used.
topical metro is best
CRC screening in pts w/ FDR w/ CRC.
START colonoscopy age 40 or 10y before dx FDR CRC (whichever comes first)
Then Q5y if FDR dx <60, or Q10y if >60
Hiker in CT > confluenct erythematous macule, malaise, fatigue, arthralgia. NSIM?
A) Lyme Western Blot
B) ELISA for B.burgdorferi
C) PO doxycycline
D) IV ceftriaxone
C) PO doxycycline
**serologic studies are falsely negative in EARLY infection, hence abx given promptly if sufficient clinical evidence
HWR early disseminated Lyme should be confirmed w/ ELISA>Wblot.
(ie. carditis, neuritis, multiple erythema migrans)
Disseminated Lyme suspected
(ie. carditis, neuritis, multiple erythema migrans). NSIM?
A) Lyme Western Blot
B) ELISA for B.burgdorferi
C) PO doxycycline
D) IV ceftriaxone
B) ELISA for B.burgdorferi
(then W.blot)
Disseminated/late should be confirmed w/ ELISA>Wblot prior to tx
Bacterial enteritis in peds/bloody dysentry. Tx?
Supportive!
Hydration!
*UNLESS sepsis, <3mo, immunocompromised
Note: Abx may prolong carriage in Salmonella or predispose Ecoli inf >HUS
Profound D. Which PO hydration is best?
A) water
B) juice
C) hydration solution
C) hydration solution w/ low osm, gluc++ & electrolytes
Water may lead to hyponatremia/glycemia
Bitemporal hemianopsia & hyperpigmentation s/p bilateral adrenalectomy for Cushings. Dx?
Nelsons Syndrome
(aggressive)
- pituitary microadenoma w/ suprasellar extension on MRI
- extremely high plasma ACTH d/t loss of negative feedback by adrenal GCS
Bitemporal hemianopsia & hyperpigmentation s/p bilateral adrenalectomy for Cushings. What do you expect on:
A) MRI brain
B) ACTH levels
Nelsons Syndrome
(aggressive)
A) pituitary microadenoma w/ suprasellar extension on MRI
B) extremely high plasma ACTH d/t loss of negative feedback by adrenal GCS
Tx: surg/rad
Why is Cushings disease no longer treated w/ bilateral adrenalectomy?
Risk of aggressive tumor (Nelsons, pituitary microadenoma w/ suprasellar extension on MRI) which has v high ACTH levels due to loss of negative feedback from adrenal GCS
Tx ureteral stones (w/o urosepsis, AKI, complete obstruction)
<1cm: hydration, pain control, alpha blockers, strain urine. (uncontrolled pain/no stone passage in 4-6w > urology consult)
> 1cm: urology consult
Note: stones <5mm pass spontaneously
Which medications facilitate ureteral stone passage?
alpha blockers (ie. tamsulosin) x 4wks. If no passage:
- lithotripsy
- percutaneous nephrolithotomy
- (rarely) laparoscopic stone removal
STOP BANG risk stratification OSA
Snoring Tired (daytime) Observed apnea Pressure (HTN) BMI >35 Age >50 Neck size >17 M Gender M
> 4 intermediate risk >PSG
Narcolepsy suspected. NSIM?
A) polysomnography
B) multiple sleep latency test
C) modafenil
ABC in that order
Polysomnography is recommended to r/o other sleep disorders first
Tropical area > abd pain, transient cough, anemia, eosinophilia. Dx?
Hookworm
- Ancyclostoma
duodenale
- Necator americanus
Dx stool O/P
Tx albendazole, nitazoxanide
LE DVT+ VS PE. Tx?
Both the same
No CA:
- DOAC (onset 2-4h, no monitoring) x 3-6 months
- warfarin is less convenient )onset 5-7d, requires 5d heparin bridge & monitoring INR)
CA+:
- LMWH
65yo F w/ breast CA has PE on CTA. Tx?
LMWH per cancer
(If no cancer: - DOAC (onset 2-4h, no monitoring) - warfarin (less convenient, onset 5-7d, requires 5d heparin bridge & monitoring INR)
MC congenital deficiencies > hypercoagulability?
protein C
protein S
antithrombmbin III
Duration of AC Tx for PE or DVT?
3-6 months
52yo F om MHT for vasomotor sx develops DVT. Do you: A) STOP MHT, start raloxifene B) STOP MHT, start SSRI C) C/W MHT, add AC D) Switch to E-only MHT
B) STOP MHT, start SSRI
*50-70% of patients have reduction in vasomotor sx
60yo w/ RA & severe arthralgias not improved w/ MTX. NSIM?
Consider TNFa inhibitor (infliximab, etanercept). Screen for latent TB beforehand.
Suspected septic arthritis. NSIM?
Arthrocentesis & prompt IV abx to prevent joint destruction
35yo F w/ primary ovarian insufficiency > DEXA -2. Tx?
A) raloxifene
B) bisphosphonate
C) E w/ medroxyprogesterone acetate
D) conjugated E
C) Estrogen w/ medroxyprogesterone acetate
**until 50!
Relieves vasomotor/ vaginal sx & minimizes bone loss. Progesterone must be added to prevent endometrial CA.
Raloxifene and bisphosphonates are only for postmenopausal osteoporosis
8yo F w/ bloody, mucoid vaginal discharge & grape-like structures protruding from the vagina. Dx?
Sarcoma botryoides
(aggressive)
Tx better outcomes w/ new chemo/rad
2yo w/ painless abd mass. Flushing/ diaphoresis, HTN. Dx?
NEUROblastoma
(MCC extracranial solid tumor peds)
<2yo, vs Wilms <5yo
- HTN via mass compressing renal artery
- catecholamine secretion per medullary mass
Wilms vs Neuroblastoma.
A) prevalent age
B) painful/painless
Wilms
- painful, <5yo
- hematuria
Neuroblastoma
- painless, <2yo
- flushing/diaphor
(both: HTN, abd mass)
Postmaturity syndrome: >42w gest, small, wrinkled/peeling skin, long fingernails, meconium stained placental membranes. Mechanism?
after 40w gest, placental function deteriorates
> fetal malnutrition & wasting
SERMs AE?
- VTE
- vasomotor sx
- uterine hyperplasia/CA/sarcoma (tamoxifen only)
SERMs Use?
- Prevention of BR CA in high risk (LCIS, atypical hyperplasia)
- postmeno osteoporosis (raloxifene)
- adjuvant CA tx (tamoxifen)
SERM MOA?
competitive inhibitor of estrogen binding. Mixed agonist/antagonist
Lead level for mild toxicity & Tx?
5-44
repeat in 1 month
Moderate lead level & Tx?
45-69
DMSA succimer
(if >70 dimercaprol & EDTA)
Lead level >70. Tx?
dimercaprol & EDTA
(If lead 45-69
DMSA succimer)
Turners S confirmed. Which conditions should you screen for?
- aortic coarctation (BP x 4 extremities)
- horseshoe kidney (renal US)
- hypothyroidism
- celiac
- neuropsych testing at school (normal IQ expected hwr risk of learning disabilities)
Which of the following DOES NOT increase w/ advanced maternal age?
A) T21
B) XXY
C) X0
C) X0 Turners
D/t random error in cell division: nondysjunction. Sporadic event. Subsequent pregnancies w/ risk near general population
Which pressure ulcers require debridement? A) stage 1 B) stage 2 C) stage 3 D) stage 4
C) stage 3: full thickness skin loass with visible SC fat
D) stage 4: full thickness skin loss with exposed bone, tendon, muscle
- otherwise
- maintain moist enviro
- AVOID dry gauze
- AVOID abx unless signs of infection
Neonatal polycythemia:
HCT > ___
Tx?
HCT >65%
Tx:
1. If ASx: IVF, glucose, observe
- If Sx: partial exchange transfusion (withdrawing blood & exchanging w/ NS)
(Sx: lethargy, poor feeding, hypotonia, apnea, SOB, cyanosis, hyperbili, hyperviscocity)
SIGECAPS - how many need to be fulfilled for MDD dx?
5
Sleep distrub Interest Guilt Energy Concentration Appetite Psychmotor agit. SI
Palivizumab indications?
RSV if
- <29w gest
- chronic lung d of prematurity
- hemodynamically significant heart disease
Severe cough w/ leukocytosis (50% lymphocytes). Dx?
Likely pertussis
Tx: macrolides
What must you consider w/ cataract surgery in the setting of concomitant AMD?
cateracts provides protection from AMD. Consider risk/benefit
Elderly, difficulty reading, scotomas, needing for brighter light for visualization. Which defect?
AMD
Most prevalent optho dx in elderly?
cataracts 45%
AMD 20%
glaucoma 10%
Sexually active diabetic w/ IUD has recurrent vaginal discharge which improved last year sp fluconazole. NSIM?
A) obtain detailed sexual hx
B) remove IUD
C) review blood sugar
D) schedule vaginal exam
D) schedule vaginal exam
*Hx is unreliable and should be confirmed w/ pelvic exam, wet mount microscopy * NAAT
Angiodysplasias- mechanism?
chronic occlusion of submucosal veins > vasc congestion and formation of dysplastic AV collaterals
Why are the following assd w/ GI angiodysplasias?
1) ESRD
2) AS
3) VWD
1) uremia > PLT dysfunction
2) acquired vWD 2/2 mechanical disruption
3) vWF deficiency (needed for PLT aggreg)
Carcinoid syndrome is assd w/ which valvular path?
TV
Preterm labor <32wks. What do you administer?
- betamethasone
- PNC if GBS or unknown
- tocolysis (indomethacin)
- MgSO4
Preterm labor 32.0/7-33.6/7 wks. What do you administer?
- betamethasone
- PNC if GBS or unknown
- tocolysis (nifedipine)
Preterm labor 34.0/7-36.6/7 wks. What do you administer?
- betamethasone
- PNC if GBS or unknown
When do you administer MgSO4 in preterm preg?
If <32wks gest
Which tocolytic do you use for preterm preg <32wks VS 32.0/7-33.6/7 ?
<32wk: indomethacin (NOT after 32wks per risk of oligohdramnios
32.0/7-33.6/7 wks:
nifedipine
What is the Family Medical Leave Act?
Upt to 12wks unpaid leave w/ job protection
Qualifying
- > half time
- employed >1yr
- > 50 employees at job
Serious health condition, childbirth/newborn care, Care of spouse/child/parent
Who qualifies for the Family Medical Leave Act?
Qualifying
- > half time
- employed >1yr
- > 50 employees at job
FOR
Serious health condition, childbirth/newborn care, Care of spouse/child/parent
“PTSD <1month: is called:
Acute stress disorder
Tx acute stress disorder
Trauma focused CBT
if >1 month dx PTSD
MCC hemoptysis?
pulm infections 70%
- bact PNA
- aspergillosis
- lung abscess
- TB
SAAG DDx
> 1.1 = portal HTN
(CHF, cirrhosis, alc hepatitis)
<1.1= NO portal HTN
(peritoneal CA or TB, nephrotic s, pancreatitis, serositis)
Prior to elective surgery, which conditions have to be optimized?
- CHF
- COPD
- smoking cessation 4wks+
- OSA
Which DOES NOT have AE of bleeding? A) garlic B) ginko biloba C) ginseng D) saw palmetto E) liquorice
E) liquorice
What are the following used for?
A) kava
B) liquorice
C) saw palmetto
A) anxiety/insomnia
B) PUD, bronchitis
C) BPH
Which is known for hepatic injury?
A) ephedra
B) saw palmetto
C) black cohosh
C) black cohosh (used for menopausal sx)
Also causes hypoTN
New HTN, hypoK, low aldo, low plasma renin, met alk. Which supplement is the pt taking?
liquorice
Lithium is associated w/ significant rates of which organ dysfunction?
Thyroid
- interferes w/ synth & release of thyroid hormones.
- goiter 40-50%
- hypothyr 20-30%
- rarely hypERthyroidism
*obtain thyroid studies before lithium tx and then Q6-12 months
Well-controlled bipolar on lithium develops high TSH low T4. NSIM? A) check lithium level B) observe & recheck 4w C) start synthroid D) check rT3 E) stop lithium
C) start synthroid
Pt w/ hip fracture develops PE. Later spikes fever, WBC 10.5. No overt signs of infection. NSIM?
Collect BCx but DO NOT start abx unless signs of infection
PE causes fever in ~15% cases ?2/2 necrosis
Which group of DM drugs is known for euglycemic DKA?
SGLT2 inhibitors
Often triggered by
- starvation
- intense exercise
- rapid lowering of insulin regimen
- EtOH consump
- severe illness
LLE venous and arterial doppler inaudible. Suspected limb ischemia. STAT heparin bolus/drip given. NSIM?
A) catheter based/surg revasc
B) emergent surg revasc
C) amputation
C) amputation
If venous/arterial audible
> catheter based/surg revasc
If venous audible but arterial inaudible > emergent surg revasc
LLE venous audible and arterial doppler inaudible. Suspected limb ischemia. STAT heparin bolus/drip given. NSIM?
A) catheter based/surg revasc
B) emergent surg revasc
C) amputation
B) emergent surg revasc
If venous/arterial audible
> catheter based/surg revasc
If venous/arterial INaudible
>amputation
First thing you do when acute limb ischemia is suspected?
STAT heparin bolus/drip
Then depending on severity…
A) catheter based/surg revasc
B) emergent surg revasc
C) amputation
Assd w/ urticaria & aggravation of psoriatic rash? A) Furosemide B) HCTZ C) Lisinopril D) Amlodipine E) Metoprolol
C) Lisinopril (ACEi)
Assd w/ photosensitivity? A) Furosemide B) HCTZ C) Lisinopril D) Amlodipine E) Metoprolol
B) HCTZ
(sulfonamides carry risk of photosensitivity)
D/C med, use sunscreen, avoid sun
Rash with eggs. Can you give the influenza IM vaccine?
yes.
if eggs > hypoTN, resp distress, emesis = GIVE vax under medical supervision
Consumption of eggs > hypoTN, resp distress, emesis. Can you give the influenza IM vaccine?
GIVE vax under medical supervision (provider who can recognize/Tx severe allergic rxn)
Smoker w/ mets everywhere (brain, liver, lungs, supraclav/mediastinal LAD). Where do you bx?
Supraclav LNs (bx distant site of spread in advanced disease, supraclav= accessible/easy)
MCC PNA in HIV
S.pneumo (hwr more invasive, lobar)
Cardiac arrest 2/2 hypERkalemia. Tx?
Ca gluconate
Na HCO3
TCA OD: Tx?
Na HCO3
When do you give TPA in management of cardiac arrest?
When the cause of cardiac arrest is suspected to be PE
Which is NOT a consequence of an irreducible inguinal hernia? A) bowel isch B) epididymitis C) impaired fertility D) testicular atrophy
B) epididymitis
note entrapped intestines can compromise blood supply to the testes and bowel.
Pts who take acetaminophen for HA >10 days/month can develop:
secondary HA 2/2 medication overuse
Cluster HA preventative med?
Verapamil starting at 240mg
(may add topiramate)
Note 100% O2 is for ACUTE Tx
Cluster HA:
A) Acute tx
B) preventative tx
A) 100% O2
(if ineffective may try unilateral intranasal sumatriptan or lidocaine)
B) Verapamil 240mg+
Which IS NOT a contraindication to VZV vax? A) anaphylax to neomycin B) anaphylax to gelatin C) pregnancy D) solid tumor E) Controlled HIV F) immunosuppressive rx G) blood CA
E) Controlled HIV
only contraindicated in severe HIV
4yo w/ brother receiving immunosuppression sp renal transplant. What do you advise in terms of the VZV vaccine?
Get it and monitor for rash (10% peds get a rash after the vaccine which may be contagious)
4yo planned to undergo immunosuppression per renal transplant. What do you advise in terms of the VZV vaccine?
Get 2x doses of the vaccine at least 4w before immunosuppressive tx
Sex w/ some dude who wasfound out to be HIV+. NSIM?
PEP: tenofovir-emtricitabine w/ raltegravir w/in 72h x 4wks
2NRTI PLUS other
Which Abx is NOT a low risk for Cdiff? A) monobactams B) TMP-SMX C) macrolide D) tetracyclines E) aminoglycosides
A) monobactams
Other HIGH risk:
- Clindamycin
- Cephalosporins 3rd/4th gen
- Floroquinolones
When do you obtain imaging when suspecting Cdiff?
severe d (WBC >15, Cr >1.5) or fulminant d (septic shock, apparent ileus, megacolon)
When do you use metronidazole PO in setting of Cdiff?
NEVER
may be added as IV in fulminant disease
First line Tx for pseudofolliculitis barbae?
Stop shaving
- alternatives: single blade, warm compress before shaving, hair clipper, depilation, laser hair removal)
Tx CML
tyrosine kinase inhibitor
then +/- BMT
path: translocation of chr 9/22 > Philadelphia chr > bcr/alb production > unregulated tyrosine kinase system.
Translocation of chr 9/22 > Philadelphia chr > bcr/alb production > unregulated tyrosine kinase system. Tx & Dx?
Dx: CML
Tx: tyrosine kinase inhibitor
then +/- BMT
bcr/alb production > unregulated tyrosine kinase system. Tx & Dx?
Dx: CML
Tx: tyrosine kinase inhibitor
then +/- BMT
(also Translocation of chr 9/22 > Philadelphia chr)
33yo w/ LLE DVT, tx initiated. 2d later has ischemic CVA. Which Dx test will reveal etiology?
TTE/TEE w/ bubble study
paradoxical emboli
Nurse w/ needles stick injury involving pt w/ undetectable HIV. NSIM?
Even though the risk is low, still Tx w/in 1-2h
3drugs x 4wks
Urolithiasis > inf, AKI or severe pain. Tx?
Percutaneous nephrostomy OR
~retrograde ureteral stent
CKD pt w/ Hgb 9, MCV 84, PLT 240, WBC 7. NSIM? A) check iron B) start EPO C) manage CKD D) supplement iron E) monitor
A) check iron
*prior to starting EPO r/o all other causes of anemia (check iron, ferritin, transferrin, retic, B12/folate, FOBT)
Why must all anemia etiologies be ruled out prior to starting EPO in ACD/CKD?
- reversible causes should be treated first
- IDA is common in ACD & RBC morphology may be normal in early disease. May treat baed on ferritin/transferrin.
- EPO may rapidly deplete iron stores, hence iron should be checked before and throughout tx
Hyperthermia, acidosis, rhabdo, muscle rigidity, diaphoresis in psych pt. Tx?
Dantrolene for malignant hyperthermia.
Homeless psych M found wandering outside in the summer, confused. Non-disphoretic but 41C, tachycardic, hypotensive, AKI, transaminitis, acidotic, rhabdo+. Tx?
Rapid cooling, misting, ice water immersion, ice packs, fluid restriction, electrolyte correction
(NOT neuroleptic malignant syndrome per lack of overt muscle rigidity & diaphoresis. Above demonstrates multiorgan failure)
What do you expect on labs in heat stroke?
MULTIORGAN DYSFUNCT
- *CNS: confusion, weakness, dizzy, lethargic, ataxic, seizures
- AKI
- transaminitis
- ARDS, pulm edema
- DIC
- rhabdo
Tight glycemic control is beneficial in preventing which conditions?
neuropathy
nephropathy
retinopathy
NOT macrovascular conditions (MI, CVA)
Fish oil can be effective in treating refractory _____
hyperTG
Risk of starting seizure meds on OCPs?
seizure meds (EXCEPT gabapentin & valprote) induce cp450 > increased OCP clearance/decreased efficacy.
**IUD/implants DO NOT AFFECT cp450!
Sheehan syndrome: in addition to amenorrhea, which sx would you see?
panhypopituiritm
hypothyroidism
adrenal insufficiency (electrolyte abnormalities, hyperpigmentation)
AE: GI distress, dizziness, fatigue, photosensitivity, dry mouth:
A) garlic B) ginko biloba C) ginseng D) saw palmetto E) liquorice F) St Johns Wort
F) St Johns Wort
Also: anorgasmia, urinary frequency, swelling
Seizure meds induce or inhibit cytochrome p450?
INDUCE
hence increase clearance of other meds metabolized by this pathway
Which seizure meds DO NOT induce c-p450?
A) valproate B) phenytoin C) gabapentin D) carbamazepine E) ethosuximibe F) phenobarbital G) topiramate
A) valproate
C) gabapentin
Scrotal trauma > moderate scrotal pain, swelling/bruising. NSIM?
US +/- surgical exploration if pain is moderate/severe.
R/o testicular rupture, fracture, avulsion or compression by scrotal hematoma.
(if sx mild/resolving > ice packs, analgesia, f/u)
Blood at tip of meatus, urethral injury suspected. NSIM?
Retrograde urethrography
PFT in active asthma attack: high/low?
A) TLC
B) FEV1
C) FEV1/FVC
D) DLCO
normal
low
low
normal
administration of albuterol should result in significant improvement in FEV1 (>15% baseline)
Positive Methacholine challenge if >__ % reduction in FEV1
20%
Methacholine challenge test is:
specific?
sensitive?
sensitive but not specific (can be positive in COPD)
Hence good negative predictive value
Which supplements/ vitamins have been shown to prevent dementia?
NONE
Recommend lifestyle modifications.
Vit E may delay progression in mild/moderate dementia
Vit E role in dementia?
may delay progression in mild/moderate dementia
does NOT prevent development of dementia
Affordable Care Act: Cost of preventative services ie mammogram?
NO COST
hwr copays/coinsurance may apply to other services
CAD suspected. Severe OA/DJD. NSIM?
A) adenosine myocardial perfusion imaging
B) dobutamine echo
C) coronary angio
D) exercise EKG
A) adenosine myocardial perfusion imaging
B) dobutamine echo
Which is NOT a feature of B12 def?
A) ataxia B) dementia C) delirium D) macrocytic anemia E) increased bilirubin
*none of them
(all are features, note that it can present as delirium)
DDX: thiamine def (ataxia, ophthalmoplegia, AMS)
Wish of pts not to know results of genetic testing should be respected EXCEPT in testing of:
newborn babies or children for treatable conditions
Complete resolution of MDD sx after 2 months of SSRI. NSIM? A) gradual taper B) lower dose C) continue x 4 months D) switch to CBT
C) continue x 4 months
Tx for total of 6 months to reduce risk of relapse
Other than DM, what are RFs for mucor?
- solid organ/stem-cell transplant
2. hematologic malig
How is mucor diagnosed?
sinus endoscopy w/ bx & cx
DM w/ fever. nasal congestion, purulent nasal discharge, HA & sinus pain. Assn?
Mucor
Dx: sinus endoscopy, Bx/Cx
Tx: debride, ampho B then stepdown PO tx
Complications of mucor?
necrotic extension to palate, orbit, brain
Slow growing, locally aggressive, benign neoplasm with a high rate of local recurrence sp surgical excision. In trunk/extremity, intraabd/bowel/mesentry or abd wall. Assd w/ Garners. Dx?
Desmoid tumor
NSIM: CT/MRI to eval size w/ bx histology
DDX lipomas do not recur sp excision
Desmoid tumors: increased incidence w/ which condition?
FAP (Gardner)
Which of the following is NOT a RFs for infection after a mammalian bite:
A) cat bite B) human bite C) dog bite D) bites on extremities E) bites >12h old
C) dog bite
Note: cat and human bites to the face are NOT high risk
***Any bites that are NOT high risk for infection CAN be sutured
Which of the following bite wounds can you suture? A) cat bite B) human bite C) dog bite D) bites on extremities E) bites >12h old
C) dog bite
***Any bites that are NOT high risk for infection CAN be sutured
Note: cat and human bites to the face are NOT high risk
MC fungal pathogen to cause balanitis?
Candida
*screen for DM (may be first presenting sign
Thick white discharge around glans of uncircumsized 2-5yo boy. Dx?
Candida
*screen for DM (may be first presenting sign
ETT depth:
F?
M?
21cm
23cm
Field intubation. Diminished lung sounds on L, resp distress, hypoxia. NSIM?
CXR to r/o R mainstam bronchus intubation.
Tx: retract PRN
Large PTX: tachycardia, tachypnea, hypoxemia and decreased lung sounds on affected side BUT no JVD, tracheal deviation or hypoTN. NSIM?
CHEST TUBE
If tension physiology (hypoTN, JVD+, tracheal deviation) has NOT YET developed > chest tube
**Needle decompression is for tension PTX in whom cardiac arrest is imminent
When should screening for DM retinopathy/retinopathy should start for the following?
DM1
DM2
DM1- after 5y Dx
DM2- immediately
ASA for DM w/ ASCVD risk age 50-70. Which type of prevention?
A) primary
B) secondary
C) tertiary
B) secondary
55yo M w/ CHF develops fatigue, bilateral knee/ankle pain, myalgia, HSM. Which labs do you order?
ANA & anti-histone abs
r/o drug-induced lupus
Which of the following DOES NOT cause drug-induced lupus? A) hydralazine B) procainamide C) etanercept D) infliximab E) minocycline
They all cause it
Tx/prognosis of drug-induced lupus?
Discontinue offending agent > improvement w/in weeks to months
2 MCC RF for vulvar CA?
- Persistent HPV
- Chronic inflamm
(ie lichen sclerosis)
Also:
- immunodef
- hx cervical CA
- smoking
Intertrigo w/u?
clinical
confirm w/ KOH
Tx: miconazole, nystatin, terbinafine. Keep areas dry, Tx underlying condition)
Pathogen in normal flora which causes superficial well-defined erythematous patches or thin plaques w/ fine wrinkling in groin/axillae, inframammary or periumbilical region. Pathogen & Dx?
Corynebacterium minutissimum (GP bacillus)
Dx: Erythrasma
Tx: topical clinda/erythro
OR fusidic acid
OR azole
Management/surveillance for the following EGD findings:
A) No dysplasia
B) low grad dysplasia
C) high grade dysplasia
A) EGD in 3-5y
B) EGD in 6-12m OR endoscopic eradication
C) endoscopic eradication
PPI for all
Which is NOT a finding in sarcoidosis? A) high ACE B) hyperCa C) high ESR D) hypocalciuria
D) hypocalciuria
Its hyPERcalciuria
PFTs in Sarcoid: high/low?
A) DLCO
B) FEV1
C) FEV1/FVC
low
low
low
(mixed restrictive AND obstructive)
Sarcoidosis prognosis?
75% resolve over time and do not recur
Tx of sarcoidosis: ASx vs Sx/pulm impairment?
ASx: no Tx
Sx: 12-24m GCS
For progressive disease: MTX, AZA, TNFa inhib
CXR: Recurrent PNA in same lobe. NSIM?
CT to r/o endobronchial lesion. If unrevealing but suspicion+, bronchoscopy.
Other causes:
- abscess
- empyema
- bacterial resistance
- TB/fungal pathogens
- immune dysfunction
- non-infectious/inflam conditions mimicking PNA
Nephrolithiasis: first line Dx modality?
non-contrast helical CT
Which is NOT a RF for nephrolithiasis in pregnancy?
A) ^biliary sludge
B) increased calciuria
C) urinary stasis
D) deceased bladder capacity
A) ^biliary sludge
Preg w/ paroxysmal, severe flank pain radiating to labia. NSIM? (imaging)
renal/pelvic US (if neg, transvaginal US) (if STILL neg, - Tx empirically - MR urogram - low dose CT urogram
CT shows 3.8 loculated cystic lesion in the head of the pancreas. NSIM?
endoscopic US and aspiration to r/o malig
**less adverse effects and more sensitive than ERCP
Benign pancreatic cyst. Recommended surveillance?
CT q3-6 months
Neonatal scalp swelling that crosses suture lines after prolonged delivery. Dx & Tx?
Dx: Caput succedaneum
Tx: observe, should resolve in few days
Neonate w/ bleed btwn scalp & periosteum which crosses suture lines and may be fatal from rapid expansion > hymodynamic instability. Dx? A) subgaleal bleed B) cephalohematoma C) caput succedaneum D) subdural hematoma E) epidural hematoma
A) subgaleal bleed
ICU admission, volume replacement. Serial CBC/coags
Periodic breathing in infants (breathing pauses 5-10s w/ subsequent rapid shallow breaths). Mechanism?
recurrent central apnea due to immaturity of the nervous system in infants <6m
Benign/physiologic
DDX apnea of prematurity which lasts >20s
65yo w/ acute limb ischemia of RLE successfully managed w/ thrombus aspiration. 2h later > intense pain RLE w/ burning/paresthesias. Dx?
Post-ischeic compartment syndrome
interstitial edema & possibly intracellular swelling s/p tissue ischemia and subsequent reperfusion
Compartment pressure >__mmHg or delta pressure (diastolic - compartment p)
CP: >30
delta <20-30
> > emergent fasciotomy
Tourettes
A) age of onset
B) worsened by
C) sex: M or F
A) <18yo (mostly 5-15yo)
B) stress/fatigue
C) M>F
*tics may be suppressed for a brief period, pt feels relief after urge release
Tourettes Tx?
A) behavioral (habit reversal training) B) antiD - tetrabenazine (D depleter) - antipsych (receptor blocker) C) alpha2 adrenergic antagonists (clonidine)
Tic prevalence in normal children? prognosis?
25%
remit spontaneously in weeks/months
chronic tic disorder involves vocal OR motor tic but not both, >1yr
Erb Duchenne palsy. Prognosis?
(neonatal brachial plexus injury)
Spontaneous recovery w/ weeks/months
Supportive care
Neonatal pulm hypoplasia, flattened facies, limb deformity (clubfoot) are complications from:
Oligohydramnios (2/2 growth restriction, preeclampsia etc)
Torticolis and developmental dysplasia of the hip are complications of:
A) breech B) macrosomnia C) oligohydramnios D) PPROM E) IUGR
A) breech
Akathisia is NOT treated w/: A) propanolol C) benztropine C) benzo D) antipsych dose decrease E) baclofen
E) baclofen
First try to decrease dose if feasible, if not try propanolol
30yo F w/ severe throbbing, unilateral HA, papilledema & visual changes (diplopia/ blurriness) Dx?
r/o idiopathic intracranial HTN
Tx:
- weight loss
- acetazolamide
- topiramate
- loops
- shunting
All infants w/ speech/language delay should undergo:
formal audiology testing
eval for recurrent otitis media, ototoxic meds
Variceal bleed: MC complications which lead to increased mortality?
infections (50%), HE, RF
infections:
- UTI
- SBP
- Asp PNA
- primary bacteremia
hence PPX Abx indicated
- IV ceftriaxone x 7d
- transition to PO bactrim/cipro for total abx 7 days
Variceal bleed: How can you prevent the MC associated complication?
PPX Abx indicated
(infections in 50%)
- IV ceftriaxone x 7d
- transition to PO bactrim/cipro for total abx 7 d
MC infections:
- UTI
- SBP
- Asp PNA
- primary bacteremia
Other complications
- RF
- HE
Paradoxical abdominal wall retraction during inspiration when laying supine: Dx & Dx test?
diaphragmatic paralysis
Dx: sniff test w/ fluoroscopy
MCC bilateral diaphragmatic paralysis?
ALS or other neuro d
Pt w/ lower extremity muscle atrophy, tongue fasciculations & diaphragmatic paralysis. Dx?
r/o ALS
Sniff test is used to dx:
diaphragmatic dysfunction
Gross hematuria. NSIM?
UA/UCx
- RBC casts & new proteinuria >r/o glom d
- infection > bx
- other: CT, cytology, cystoscopy
Tx diffuse esophageal spasm?
CCBs
Also:
~nitrates
~tricyclics
Dx tests for diffuse esophageal spasm?
Manometry: (GOLD standard) intermittent peristalsis, multiple simultaneous contractions
Esophagram: corkscrew pattern
40yo w/ GERD has intermittent CP, dysphagia for solids/liquids. Which test is the gold standard for Dx?
Manometry: intermittent peristalsis, multiple simultaneous contractions
Tx: CCBs
Also:
~nitrates
~tricyclics
Dysphagia, heartburn: manometry w/ hypomotility & low amplitude contractions/ lower sphincter pressure. Dx?
Scleroderma
Degeneration of the Auerbach plexus causes:
Achalasia, failure of LES relaxation.
Esophagram shows dilated esophagus & birds beak
(may be secondary achalasia 2/2 chagas)
IDA, dysphagia, esophageal webs. Tx?
Plummer Vinson improves w/ tx of anemia
Legionella Tx?
Resp FQ (levofloxacin) Macrolides (azithromycin)
Recent travel, fever, brady, PNA, confusion, ataxia, diarrhea. Tx?
Legionnaires
Resp FQ (levofloxacin)
Macrolides (azithromycin)
Note: sputum gram stain only shows PMNs
Dx w/ urine Legionella Ag
Legionella suspectedbut gram stain only shows PMNs- why?
intracellular organism
Dx w/ urine Ag
Cruiseship, febrile, brady, diarrhea. NSIM?
Labs: hypoNa,
Legionella Ur Ag
CXR: lobar infiltrate
40yo w/ diarrhea, mucus discharge, tenesmus. Colonoscopy: pallor, friability, mucosal hemorrhage. Dx?
Likely radiation proctitis (if hx radiation).
If chronic, assd w/ fistula formation, strictures, rectal bleeding.
Tx: +/- sucralfate or GCS enemas
*Exclude other causes of diarrhea.
Sudden onset severe psoriasis & recurrent VZV is associated w/ ?
HIV (also disseminated molluscum contagiosum)
Acanthosis nigricans is associated w/ insulin resistance AND:
GI malignancy
Acanthosis nigricans in patient w/ normal BMI, appearing on the palms/soles, mucous membranes. Dx?
r/o GI malignancy
Photosensitivity, erythematous tongue, N/V/D, dementia, confusion. Dx?
Niacin def (Pellagra)
Hyperpigmentation, vitiligo, dehydration, hypotension. Dx?
Addisons (primary adrenal insuff)
Periodic vertigo, unilateral HL, tinnitus. Dx?
Menieres
Tx: prochlorperazine, antihistamines
no cute
MC pathogen isolated from corneal foreign body?
Staph
~ Strep, Haemophilus, Pseudomonas)
Abd pain, vomiting, currant jelly stools, AMS. Tx?
Contrast enema is Dx & Tx
Best way to prevent DM foot ulcers?
Tight glycemic control prevents MICROvascular sequelae, NOT MACROvascular (beneficial for slowing neuropathy)
MCC erythema multiforme?
HSV
~
Mycoplasma
allopurinol, abx, AI, CA
Dx test: Pertussis
Cx or PCR
lymphocyte predominant leukocytosis
Tx: macrolides (azithro)
Which CA are you at risk for:
A) tamoxifen
B) MHT
A) Uterine CA
B) Breast CA
30yo < w/ celiac has sx remission. NSIM?
perform a detailed dietary review
Celiac: after initiating gluten-free diet abs should decline by 50% in ____ (time frame) & normalize w/in ____ (time frame)
2 months
12 months
Note: MCC sx recurrence is diet non-adherence or inadvertent ingestion
Fever, abd pain, mucopurulent cervical discharge, cervical motion tenderness. Tx?
Broad spectrum
(cefoxitin & doxy)
coverage for chlam/gonorr
Tx primary nocturnal enuresis (stepwise Tx)
- Behavioural: restrict evening fluids, reward system x 3-6 months.
Also Tx comorb conditions ie constipation. - If not effect w/ above: enuresis alarm
If short term solution needed ie sleepover, desmopressin may be used.
Mentzer index (___/___) >13 is suggestive of IDA.
MCV/RBC
good DDX for alpha/beta thalassemia which are <13
Premature 8mo infant w/ lethargy, irritability, pallor & systolic flow murmur. Dx?
r/o IDA
- prematurity is a RF per likely inadequate iron stores
MCC <1yo: too much breastfeeding after 6m
CMV in HIV occurs w/ CD4
<100
retinitis, colitis, esophagitis
When is TMP-SMX PPX required in HIV?
CD4 <200: PCP
CD4 <100: toxo
Dx: Adjustment disorder. Tx?
psychotherapy
short-term adjunctive Rx
- sleep aid
- anxiolytic
Prenatal care in SCD?
- baseline 24h Uprotein
- baseline chem
- serial UCx
- Pneumovax
- folic supplement
- ASA
- serial fetal growth US
SCD pt is pregnant: which baseline labs do you obtain?
- baseline 24h Uprotein
- baseline chem
- serial UCx
SCD pt is pregnant: what do you prescribe?
ASA
folate
pneumococcal vax
serial fetal growth US
(also obtain baseline chem, 24h urine protein, serial UCx)
Which conditions are RFs for preeclampsia?
SCD (HTN, nephropathy)
DM (nephropathy)
SLE (nephropathy)
SCD obstetric complications?
spontaneous abortion
preeclampsia, eclampsia
abruptio placenta
antepartum bleed
SCD fetal complications?
ftal growth restriction
oligohydramnios
preterm birth
Diameter for a skin lesion to be concerning?
> 6mm
8mm dark lesion w/ irreg borders. NSIM?
Excisional bx w/ 1-3mm margins
Melanoma, no clinical evidence w/ LN involvement. When is a sentinel LN bx w/ lymphatic mapping indicated?
high risk:
- tumor thickness >0.75mm
- tumor ulceration
- lymphatic invasion on Bx
Pt on chemo w/ central venous cath for TPN w/ neutropenia, fever, eye pain, decreased visual acuity. Fundoscopy: focal glistening, white, mound like lesions that extend into the vitreous. Pathogen?
Candida (endopthalmitis)
RFs
- disseminated disease
- central venous cath
- neutropenia
- TPN
Candida endopthalmitis Tx?
Aggressive Tx: amphotericin B x 4-6wks, intravitreal antifungal injection & vitrectomy
20yo African F is to go back to her country to undergo genital mutilation by a non-medical practitioner, w/o anesthesia prior to an arranged marriage. NSIM?
Educate re: risk/complications
- hemorrhage
- infection
- genital pain/scarring
- infertility
- difficulty w/ coitus
- issues w/ vaginal delivery
Allergic rhinitis, allergen avoidance is not possible. Tx?
intranasal corticosteroids
44yo M w/ new afib RVR, improved w/ metoprolol. TTE/labs wnl. Which other medical management do you initiate?
None
CHA2DS2VASc 0
(has to be 2+ to initiate anticoagulation for non-valvular afib)
Acute paronychia Tx?
warm antiseptic soaks and topical abx - burlow solution (aluminum acetate) - 1% acetic acid ~ chlorhexidine ~topical mupirocin
Chronic paronychia
- duration
- association
- clinical signs
- Tx
- > 6wks
- variant of contact derm
- retraction/loss of cuticle and dystrophic nail changes
- high potency topical GCS
Herpetic whitlow Tx?
supportive
~~acyclovir PO
Best Tx onychomycosis?
PO terbinafine
Plugging of the posterior ear canal is used as a last resort for the tx of:
intractable BPPV (often does not affect hearing)
Neonate is born w/ scalp defects, tracheoesophageal fistula & choanal atresia. Which teratogenic med was the mother using?
methimazole (thionamide) for hyperthyroidism
should be avoided only in the 1st trimester per teratogenicity
Who should receive the HBV vaccine?
- HCP
- pregnant women
- inmates
- mult sexual partners
- hx STD
- IVDU
- CKD, HCV, HIV
- household contacts w/ HBV
Healthy 37yo w/ postprandial epigastric discomfort/nausea. No relief w/ famotidine x 2wks. NSIM?
Offer Hpylori testing
Unless >60yo or alarm features*
Which is NOT an alarm feature for dyspepsia?
A) >60yo B) IDA C) progressive dysphagia D) palpable mass/LAD E) persistent V F) FHx GI CA G odynophagia
A) >60yo
hwr note that dyspepsia >60 warrants EGD
Dyspepsia MCC?
75%: functional organic causes: - NSAIDs - gastric/esoph CA - Hpylori
Dyspepsia (epigastic pain, N/V, epigastric fullness). Management in <60yo VS >60yo?
<60: Hpylo or EGD if high risk features
>60yo: EGD
Active TB suspected. Which tests do you order?
Sputum AFB & Cx
NAAT
**Cx- GOLD standard (takes 3-8wks
**Smear & NAAT cannot DDx non-TB mycobact from TB
**INFy and TB skin test cannot ddx active/latent
Indicated if active TB is suspected by has garbage sensitivity:
A) TB skin test B) INFy assay C) AFB smear D) SpCx E) NAAT
C) AFB smear
(also many false neg)
also cannot ddx non-TB mycobact from TB
Which of these is GOLD standard for active TB testing?
A) TB skin test B) INFy assay C) AFB smear D) SpCx E) NAAT
D) SpCx
BUT it takes 3-8wks hence obtain AFB smear & NAAT in meantime
Asx immigrant. RUL calcifications. NSIM?
Obtain INFy assay to evl for latent TB
**can also do TB skin testing however if false results if hx BCG vax, takes 2 visits (BUT has high spec if no hx BCG vax)
Cannot ddx active/latent TB
A) TB skin test B) INFy assay C) AFB smear D) SpCx E) NAAT
A) TB skin test
B) INFy assay
ASx. INFy+. CXR wnl. Neg AFB smear/Cx. Dx?
Latent TB, non-transmittable
Tx Latent TB? (3)
Weekly INH + rifapentine
x 3 months
Daily rifampin
x 4 months
Daily INH + rifampin
x 3 months
> 95% sen/spec BUT cannot ddx Non-TB & TB mycobacterium?
A) TB skin test B) INFy assay C) AFB smear D) SpCx E) NAAT
E) NAAT
How myst AFB sputum be obtained?
3 samples, 8-24hrs apart with at least 1 morning sample
Surgery > Hyperactive DTR, muscle cramps, rarely convulsions. Which electrolyte disorder?
hypoCa
DDX: HypoMg: assd w/ heavy EtOH, prolonged NGT/suction, diarrhea, diuretics and LOSS of DTRs
Hyperactive DTR, muscle cramps, rarely convulsions. Why is this NOT hypoMg?
hypoMg: LOSS of DTRs
assd w/ heavy EtOH, prolonged NGT/suction, diarrhea, diuretics
When do you Bx an AK?
>1 cm rapid growth ulceration tenderness cutaneous horns
Tx AK
few: cryo
many: field Tx w/ 5FU, tirbanibulin, imiquimod
Ichthyosis Tx
topical lactic acid (amlactin)
TSH should be monitored w/ amiodarone Rx every ___
3-4 months
MOA: large iodine load suppressses synth of thyroid hormones & amiodarone DIRECTLY INHIBITS conversion of T4 >T3
Why do patients on amiodarone require higher than normal doses to tx hypothyroidism?
amiodarone DIRECTLY INHIBITS conversion of T4 >T3 (active hormone)
39yo w/ hx SLE p/w substernal CP and palpitations> vfib, cardiac arrest, death. Dx?
MI 2/2 premature CAD (SLE women have 50x increased risk of CAD) - HTN - DLP - chronic inflamm - GCS use
22yo F w/ faciall acne, mild hirsutism, mild ^Hgb/HCT. Keeps active, c/o being irritable/emotional Dx?
r/o anabolic steroid use
Gonorrhea/chlamydia screening w/ NAAT is recommended for:
sexually active women <25 annually
OR
high risk (mult sex partners, sex workers)
HCV screening is for ages __- __
18-79 at least once
or high risk IVDU, transfusion before 1992
PAP screening starts age __
21
Indications for routine RPR screening?
high risk:
- MSM
- coinfection HIV
- hx incarceration
- sex workers
RF for peripartum cardiomyopathy
> 30yo
mult gest
preeclampsia, eclampsia
Peripartum cardiomyopathy onset occurs btwn ___wks gest to ___
36wks gest to 5 months postpartum
Tx: standard CHF tx & VTE ppx
Prognosis of peripartum cardiomyopathy
- some: spontaneous recovery
- recurrence highest w/ w/ EF <20
- persistent PPCM
Pts w/ persistent PPCM are at risk of further LV decline in subsequent pregnancies
Repeted vomiting > retrosternal CP, SOB, odynophagia, epigastric pain, shoulder pain. Dx?
Boerhaaves
confirm w/ esophagography or CT w/ water soluble contrast
Boerhaaves suspected- which test will confirm the dx?
esophagography or CT chest w/ water soluble contrast (if neg but suspicion is high, repeat w/ barium contrast)
(note: on CXR you may see pneumomediastinum, L pleural effusion, PTX)
Boerhaaves Tx?
PPI
Abx
NPO
STAT surg consult
Why should EGD be avoided in Boerhaaves?
worsens pneumomediastinum d/t insufflation of the esophagus prior to passing the scope
Pagets:
Dx Labs?
Dx imaging?
Tx?
Labs: high alkP, norml Ca (can measure bone specific fraction of alkP to ddx hepatobiliary d)
Imaging: Radionucleotide bone scan
Note- plain radiographs show mixed lytic sclerotic lesions.
Tx: bisphosphonates (
Pagets: Most common presentation?
ASx, discovered incidentally on imaging
61yo M Labs: high alkP, norml Ca. Plain radiographs show mixed lytic sclerotic lesions. NSIM?
Bone scan & tx w/ bisphosphonates once Pagets is confirmed.
Asx. Enlarged skill, HL, dizziness, bone pain, spinal stenosis/ radiculopathy. RF for osteosarcoma or giant cell tumors. Dx & Tx?
Pagets
Labs: high alkP, Ca wnl
Bone scan & tx w/ bisphosphonates
Pagets is a RF for which tumors?
osteosarcoma, giant cell tumors ( usually benign)
Tx of hearing loss 2/2 Pagets?
Calcitonin/bisphosphonates SLOW progression but dont revers HL. No best Tx.
Path:
- compression of the auditory nerve by bony overgrowth
- involvement of the cochlea/cochlear capsule
Tx for vaginal condyloma acuminata A) surg excision B) laser excision C) podophyllin D) trichloroacetic acid E) observe & inform pt of likely spontaneous regression
D) trichloroacetic acid
- podophyllin is NOt for internal use. Surg/laser may be considered if medical therapy fails
- spontaneous regression is NOT common
Bat scratch. Rabies vaccine and Ig given a year ago. NSIM?
Vaccine booster x 2 (day 0 & 3)
note: Rabies Ig is NOT recommended as it can impair the strenth/rapidity of the immune response
No hx vaccine >bat scratch. Rabies PEP?
rabies vaccine (day 0,3,7, 14) AND rabies Ig x1
Pre-exposure ppx for rabies?
rabies vaccine (q1wk x a month) ie 4 doses
When is rabies vaccine given WITH Ig?
A) pre-exposure ppx
B) PEP, no hx vax
C) PEP, hx vax
B) PEP, no hx vax
When is rabies vaccine given day 0 & 3 (w/o Ig)?
A) pre-exposure ppx
B) PEP, no hx vax
C) PEP, hx vax
C) PEP, hx vax
Screening process for gestational DM?
@24-28w
1) 1hr 50g GCT, if +
2) 3h 100g GTT
(100g ingested and then measured at 1, 2, 3h after ingestion. Diagnostic if 2+ values are abnormal)
Significants of human placental lactogen?
secreted by the placenta, induces insulin resistance > gestational DM
Which is NOT an acceptable agent for gestational DM? A) glipizide B) glyburide C) metformin D) insulin
A) glipizide
Target glucose in gestational DM
- fasting
- 1h postprandial
- 2h postprandial
- <95
- <140
- <120
Medications for gestational DM?
- insulin
- glyburide
- metformin
Environmental RF for AOM in children?
- formula fed
- daycare
- pacifier use
- secondhand smoke (impairs ciliary clearance of fluids/microbes in eustachian tubes)
Does a mother who goes outside to smoke affect her childs health?
YES
Esp for AOM. - secondhand smoke (impairs ciliary clearance of fluids/microbes in eustachian tubes). Even if it occurs outside, particulate matter brough indoors w/ hair/clothing
Indications for Abx PPx for AOM?
> 3 episodes/ 6 months
4 episodes/ 1 year
Last resort tympanostomy
Narrow complex tachycardia in hemodynamically STABLE pt. Tx?
adenosine
Afib RVR pt becomes pulseless. NSIM? A) adenosine B) thrombolytics C) chest compressions D) rapid defibrillation E) rapid synchronized cardioversion
C) chest compressions
Anaphylaxis w/ hypoTN, resp distress, resolves completely w/ EPI in ED. NSIM?
Admit for observation per severe sx
Admission qualifications for anaphylaxis
- sx lasting hrs+
- severe sx
- multiple doses EPI
Hip clunk & asymmetric leg creases in infancy. Prognosis?
Dx: Developmental dysplasia of the hip
- excellent if Tx in infancy w/ reduction of dislocated hip
- poor if not > leg-length discrepancy, gait abnorm & early OA/DJD per abnormal traction in the dysplastic hip
Teen girl c/o activity related pain in the hip/groun. Trendelenburg+, some DJD on XR. Dx?
Dx: Developmental dysplasia of the hip (abnormal acetabular development >shallow hip socket and inadequate support of the femoral head)
- excellent if Tx in infancy w/ reduction of dislocated hip
- poor if not > leg-length discrepancy, gait abnorm & early OA/DJD per abnormal traction in the dysplastic hip
Teen w/ abnormal acetabular development >shallow hip socket and inadequate support of the femoral head. What could have prevented this condition?
Tx in infancy w/ reduction of dislocated hip
Dx: Developmental dysplasia of the hip
Teen w/ significant pain at night around the proximal femur. Dx?
r/o osteoid sarcoma (benign)
Legg-Calve- Perthes disease.
1) pathology?
2) age of dx
1) avascular necrosis of the femoral head
2) age 5-7
How to calculate AG?
Na - (Cl + HCO3)
should be 10-14
Methanol Uremia DKA Propulene glycol Isonizaid/iron Lactic acidosis Ethanol Salicylates
What is the “I” in mudpiles?
Methanol, Metformin Uremia DKA Propulene glycol Isonizaid/iron Lactic acidosis Ethanol Salicylates
RF for metformin-induced lactic acidosis?
RF
CHF
hypovol
severe liver d
Overweight 30yo on OCPs w/ chronic HA, nausea, visual disturbances. Minimal relief w/ NSAIDs. NSIM?
Opthalmoscopic exam: papilledema
(eval for idiopathic intracranial HTN)
Other studies to support Dx:
- LP w/ high OP >20
- neuroimaging wnl (other than empty sella)
What do you expect for the following in idiopathic intracranial HTN?
- optho exam
- LP
- neuroimaging
- papilledema
- high OP >20
- wnl (except empty sella)
Hip clunk & asymmetric leg creases in infancy. Prognosis?
Dx: Developmental dysplasia of the hip
- excellent if Tx in infancy w/ reduction of dislocated hip
- poor if not > leg-length discrepancy, gait abnorm & early OA/DJD per abnormal traction in the dysplastic hip
Teen girl c/o activity related pain in the hip/groun. Trendelenburg+, some DJD on XR. Dx?
Dx: Developmental dysplasia of the hip (abnormal acetabular development >shallow hip socket and inadequate support of the femoral head)
- excellent if Tx in infancy w/ reduction of dislocated hip
- poor if not > leg-length discrepancy, gait abnorm & early OA/DJD per abnormal traction in the dysplastic hip
Teen w/ abnormal acetabular development >shallow hip socket and inadequate support of the femoral head. What could have prevented this condition?
Tx in infancy w/ reduction of dislocated hip
Dx: Developmental dysplasia of the hip
Teen w/ significant pain at night around the proximal femur. Dx?
r/o osteoid sarcoma (benign)
Legg-Calve- Perthes disease.
1) pathology?
2) age of dx
1) avascular necrosis of the femoral head
2) age 5-7
How to calculate AG?
Na - (Cl + HCO3)
should be 10-14
Methanol Uremia DKA Propulene glycol Isonizaid/iron Lactic acidosis Ethanol Salicylates
What is the “I” in mudpiles?
Methanol, Metformin Uremia DKA Propulene glycol Isonizaid/iron Lactic acidosis Ethanol Salicylates
Pain control in early chronic pancreatitis?
Often lifestyle changes are enough.
- smoking/EtOH cessation
- frequent, low fat, small meals
- panc enz supplement
reassess in 1-2 months, if persistent, start analgesic/surg
Overweight 30yo on OCPs w/ chronic HA, nausea, visual disturbances. Minimal relief w/ NSAIDs. NSIM?
Opthalmoscopic exam: papilledema
(eval for idiopathic intracranial HTN)
Other studies to support Dx:
- LP w/ high OP >20
- neuroimaging wnl (other than empty sella)
What do you expect for the following in idiopathic intracranial HTN?
- optho exam
- LP
- neuroimaging
- papilledema
- high OP >20
- wnl (except empty sella)
Why do you obtain neuroimaging prior to LP in patients w/ chronic HA?
First exclude mass lesion which would be a contraindication to LP per risk of herniation
Poor prognostic factors in LBP?
- ^age
- poor baseline funct
- severe self-rate mood and pain sx
- psych comorb: MDD/anx
- maladaptive pain behaviours (catastrophosizing, avoidant behaviours)
- poor recovery expectations
- no interest in mobility (prolonged bed rest)
- requiring opioids for pain control
Why is propylthiouracil generally avoided except the first trimester of pregnancy?
hepatoxicity
note MMZ and PTU may cause agranulocytosis
Chronic pancreatitis: Dx test of choice?
MRCP
if unavail- abd CT
Chronic pancreatitis in 70yo w/ hip replacement: best diagnostic test? A) MRCP B) ERCP C) Abd CT D) Abd US E) AXR F) EGD
C) Abd CT
(normally MRCP but hip replacement is a contraindication)
ERCP used if dx is still unclear after above imaging
Findings: calcifications
+/- pancreatic enlargement, ductal dilation, pseudocysts
Which of the following is NOT good for Dx chronic pancreatitis? A) lipase B) amylase C) abd CT D) MRCP
A) lipase
B) amylase
(they are used for acute panc, often normal in chronic per decreased enzymes in scarred/fibrosed pancreas)
Alcoholic w/ low fecal elastase 1. Significance and Tx?
significant pancreatic exocrine insufficiency likely 2/2 chronic panc.
Tx: pancreatic enzymes
Pain control in early chronic pancreatitis?
Often lifestyle changes are enough.
- smoking/EtOH cessation
- frequent, low fat, small meals
- panc enz supplement
reassess in 1-2 months, if persistent, start analgesic
Chronic pancreatitis is diagnosed. Tx?
- smoking/EtOH cessation
- frequent, low fat, small meals
- ADEK supplemetation
- panc enz supplement
Persistent abd pain in chronic pancreatitis despite lifestyle changes. Tx?
- First line analgesics: TCA, NSAIDs, pregabalin
- Above ineffective > consider opioids.
- Other:
- celiac nerve block
- ductal decompression (via anastomosing jejunum)
- extracorporeal shock wave lithotrypsy
- denervation of afferent nerve fibers leaving the pancreas
- surgical resection
RF chronic pancreatitis?
- EtOH
- CF
- AI
- ductal obstruction (CA, stones)
Cleft lip
A) inheritance pattern
B) when to operate
Multifactorial inheritance: can be AR, AD, XL
assd w/ teratogens, EtOH
Operable at:
10wks, 10g Hgb, 10lbs
Why is propylthiouracil generally avoided except the first trimester of pregnancy?
hepatoxicity
Indications for Tx Graves w/ meds? (4)
- mild disease
- bridge to surg/ I131
- elderly w/ limited life expectancy
- preg
Indications for Tx Graves w/ radioactive iodine ablation? (4)
- mod/severe disease
- desire to avoid surg
- mild d w/ pt preference
- unlikely to attain remission w/ meds
Indications for Tx Graves w/ thyroidectomy (6)
- v large goiter
- suspect CA
- retrosternal compressive goiter
- concomitant hyperPTH
- preg pt w/ intolerance to PO meds
- severe opthalmopatht
When is prednisone given in Graves?
presence of mod/severe opthalmopathy prior to tx w/ surg or RAI
ie. exopthalmos, periorbital edema, vision changes
What do you check to assess thyroid function after starting meds? A) TSH B) TSI C) free T3 D) total T4 E) total T3 & free T4 F) TBG
E) total T3 & free T4
*check after one month then q2-3 months
TSH remains supressed several months after initiation of meds and does not accurately reflect thyroid function
Pt on anti thyroid meds develops agranulocytosis. NSIM?
STOP MED IMMEDIATELY
What needs to be routinely monitored when taking antithyroid meds?
total T3 and free T4
Obtain LFTs and CBC at baseline but DO NOT routinely order unless sx develop (hepatitis, agran)
Chronic bacterial prostatitis
- duration of sx for dx
- def dx test
- MCC (pathogen)
- RF
- Tx
- > 3 months
- UA pre/post prost massage
- Ecoli (80%)
- DM, smoking, urinary hardware or manipulation
- 6wks FQ or TMP-SMX
Young/middle aged M w/ dysuria, frequency, pelvic/GU region discomfort, pain w/ ejaculation x 3 months. Dx test and Tx?
Chronic bacterial prostatitis
Dx: UA pre/post prost massage.
*Prostate exam often normal but may show hypertrophy, tenderness, edema
Tx: 6wks FQ or TMP-SMX
(MCC Ecoli 80%)
30yo M w/ freq/urgency, pain w/ ejaculation, urinary WBC/bacteria x 3 months. RFs & Dx?
Dx: chronic bacterial prostatitis
DM, smoking, urinary hardware or manipulation
Human bite: What grows in the aerobic dish vs the anaerobic dish?
aerobic: GAS, S.aureus
anaerobic: Eikenella corrodens
Also fusobacteria, Prevotella
Human bite: Tx?
- debride/irrigate
- amoxi-clav
- tetanus vax
- healing by secondary intention (leave open UNLESS facial location)
Gas gangrene: most common pathogens?
C perfringens
S pyogenes
S aureus
V vulnificus
HIV M bites some guy at a bar. What do you do for HIV ppx? A) 3 drugs x 4 weeks B) 4 drugs x 3 weeks C) reassure D) observe, recheck in 1 month
C) reassure
**saliva considered v low risk exposure unless mixed w/ blood (oral ulcer, lip cut etc)
Mammalian bite: Tx? A) clinda B) Keflex C) amoxi-clav D) bactrim
C) amoxi-clav
(coverage for oral aerobic and anaerobic pathogens)
*note clinda and keflex cover staph & viridans bur NOT eikinella
60yo w/ gallstone pancreatitis per labs. Develops: fever, jaundice, RUQ pain, hypotension, AMS. Dx tests and Tx?
r/o acute cholangitis
(ascending infection d/t biliary obstruction, meets Reynolds pentad)
Dx: US biliary dil
!ERCP
Tx: !ERCP (biliary drainage w/in 24-48h)
& abx coverage
CXR: cavitary lesion in a bronchus. Dx?
A) SCC
B) Small cell carcinoma
C) Large cell carcinoma
D) Mesothelioma
A) SCC
SIADH is assd w/ A) SCC B) Small cell carcinoma C) Large cell carcinoma D) Mesothelioma
B) Small cell carcinoma
SIADH A) normovolemic hyperNa B) hypovol hyperNa C) normovolemic hypoNa D) hypovol hypoNa
C) normovolemic hypoNa
SIADH: mild/mod. Tx?
water restriction
(ideal rate 0.5 mEq/hr)
+/- salt tabs
Steps in managing SIADH from mild > severe
Mild/mod:
- water restriction
- salt tabs
- ~loops
Severe:
- if above fail > demeclocyline hwr caution per nephrotoxicity)
MOA furosemide in SIADH?
lowers UOsm & blunts response to AHD hence more water is excreted.
(give w/ sat tabs or hypertonic saline)
DVT/PE> How long do you anticoagulate?
- if provoked, 3-6 months
- if idiopathic: 6 months, then eval for continuation based on RFs
Which is NOT a RF for CRC? A) Caucasian race B) EtOH C) Obesity D) Smoking E) IBD F) FAP
A) Caucasian race
*AA have higher rates
20yo M sp laparotomy for perforated appendix 2wks ago. Cough, shoulder pain, febrile, tachycardic. Tenderness over 8th/9-11th ribs, abd exam benign. NSIM?
Abd US to r/o subphrenic or abdominal abscess
60yo w/ gallstone pancreatitis per labs. Develops: fever, jaundice, RUQ pain, hypotension, AMS. Dx tests and Tx?
r/o acute cholangitis
(meets Reynolds pentad)
Dx: US/CT- biliary dil
!ERCP
Tx: !ERCP
MCC long term complication of IVC filters?
recurrent DVTs and IVC thrombosis
Note: they do NOT affect overall mortality & filter migration or perforation through the IVC is rare
HIDA helps visualize obstruction of:
cystic and common bile ducts to r/o acute cholecystitis
Fever, jaundice, RUQ pain is the triad for:
acute cholangitis
Which nerves at at risk of injury during carotid endarterectomy?
- hypoglossal nerve(tongue deviates to injured side)
- CNV mandibular branch
- laryngeal nerve of the vagus
Physical exam finding to dx achilles tendon rupture?
Thompson test
- sen/spec >90
- positive test: absence of plantar flexion on calf squeeze
Why is absence of active plantar flexion not a good dx test for achilles rupture?
Accessory muscles can also plantar flex (fibularis longus/brevis, plantaris, tibialis posterior)
Which nerve is responsible for the following:
A) plantar sensation
B) gastrocnemius funct
C) soleus funct
ALL- tibial nerve
Test to DDX thalassemia alpha VS beta minor?
electrophoresis
w/ beta thalassemia: increased A2
Hgb electrophoresis findings:
A) IDA
B) alpha thal minor
C) beta thal minor
A) normal
B) normal
C) high Hgb A2
Elecrtrophoresis : high Hgb A2. Dx?
beta thalassemia minor
Which does NOT cause secondary hypogonadism? A) chronic illness B) malnutrition C) hypothyroidism D) hyperPRL E) Klinefelters F) Kallmann G) Cranipharyngioma
E) Klinefelters
(it causes PRIMARY hypogonadism)
Note: primary- due to gonadal failure VS secondary d/t hypothal/pit pathology
Delayed puberty in boys: absent testicular enlargement (4mL) by age __ & delayed growth spurt.
14
Initial w/u: FSH, LH, T, PRL
bone age radiograph
List some causes of secondary hypogonadism in males.
A) functional: chronic illness, malnutrition
B) hypothyroidism
C) hypogonadism: hyperPRL, cranipharyngioma
D) genetic: Kallmann
Constitutional puberty delay features:
- FHx late bloomers
- short stature
- delayed bone age
Initial work up of delayed puberty?
FSH, LH, T, PRL, TSH
bone age radiograph
primary: elevated FSH/LH
secondary: low FSH/LH
(Note: high levels of PRL & TSH interfere w/ GnRH secretion
Best Tx for negative sx in schizophrenia?
social skills training.
Note: both 1st & 2nd gen antipsychotics suck at improving negative sx
Ocular melanoma:
1) best Dx text
2) Tx
1) US (most sen)
- note: MRI useful in dx extrascleral extensions for staging & Tx
2) <1cm diam & <3mm thick: close follow up
If larger or sx: brachyRAD
(if v large or extrascleral extension: enucleation)
Keratin plugs in the hair follicles.
- associated conditions
- Tx
- contact derm, asthma
- topical keratolytics (urea, salicylic acid)
Dx: keratosis pilaris
Acute pancreatitis > 6wks later: abd pain, biliary/pancreatic duct obstruction, GIB. VSS, exam benign. Dx & Tx?
Dx: r/o pancreatic cyst
- complication in 10% sp AP
Tx: supportive, unless significant sx: surgical/endoscopic drainage
PSGN: Tx & prognosis?
- Supportive
- Loops PRN edema
- antiHTN meds PRN HTN
- refractory cases: HD
Prognosis: much better in peds. 40% of adults >CKD, persistent HTN, recurrent proteinuria, (10% ESRD)
How is SBP diagnosed?
Ascitic Cx or >250 PMNs
remember to give albumin to decrease renal injury
DVT, ?nonadherence to warfarin post discharge. Presents 4wks later w/ another DVT, INR 1.6. NSIM?
start IV heparin (or SC LMWH) until therapeutic INR is achieved w/ warfarin.
(do not consider this anticogulation failure)
MOA in familial hypercalciuric hypercalcemia?
AD disorder of defective Ca-sensing receptor (senses low levels > increased PTH >increased Ca resorption in renal tubules)
Sx: mild, no Tx required
HyperCa w/ elevated PTH. How to DDx FHH VS primary hyperPTH?
urinary Ca excretion is high in hyperPTH & low in FHH
Urinary Ca excretion: high/low?
A) Primary hyperPTH
B) FHH
A) high
B) low
Ocular melanoma:
1) best Dx text
2) Tx
1) US (most sen)
- note: MRI useful in dx extrascleral extensions for staging & Tx
2) <1cm diam & <3mm thick: close follow up
If larger or sx: brachyRAD
(if v large: enucleation)
Boy suspected for primary nocturnal enuresis. Best initial test?
UA
- glucosuria?
- infection?
- DI (low spec gravity)?
voiding diary
What do these tests diagnose?
A) 24h urine cortisol
B) Plasma ald:renin
C) AM cortisol, AM ACTH, ACTH stim test
A) Cushings
B) Conns
C) Addisons
plasma aldosterone: renin ratio > __ suggests excessive aldosterone secretion.
30
Dx: Conns
How is SBP diagnosed?
Ascitic Cx or >250 PMNs
SAAG >1.1 suggests:
portal HTN
Tx for hepatorenal syndrome?
albumin
octreotide
midodrine
Tx VS PPx for SBP?
Tx: 3rd gen cephalosporin
PPx: FQs
Overall prognosis of 90 day mortality 2/2 cirrhosis is determined by all EXCEPT: A) Na B) bilirubin C) albumin D) INR E) Cr
C) albumin
all others in MELD
Penile verrucous papilliform growth:
Dx test & Tx?
Dx: shave bx (condyloma accuminata)
Tx: immiquimod (first line)
Thyroid nodule. US w/o suspicious findings. Low TSH. NSIM?
Iodne I123 scintigraphy to determine if it is hot/cold.
If hot: Tx hypothyroidism
If cold: FNA
Thyroid nodule. US w/o suspicious findings. Normal/elevated TSH. NSIM?
FNA
Toxic adenoma. Tx?
First: MMZ >euthyroidism
Then: surg or albation
+/- propanolol if sx
(young pts w/o comorbs dont havvve to be preTx prior to I131 ablation)
Hyperthyroidsim: for which patients is surgery preferred over ablation?
- v large goiter
- suspicious for CA
- pregnancy, breastfeeding (no RAD)
- obstructive sx: dysphagia
BCC: Tx?
surg excision 4mm margins (Mohs if face)
2nd line: topical FU, imiquimod, curettage/ electrodessication (only for low risk)
Higher risk of metastasis: SCC or BCC
SCC
Biggest RF BCC
local invasion
Clozapine
- use:
- monitoring labs/freq:
use: refractory schizophrenia (highly effective)
monitor for neutropenia/ agranulocytosis
- weekly x 6 months
- then biweekly x 6 months
- then monthly
Clozapine AE EXCEPT
A) agranulocytosis B) seizures C) hypersalivation D) thyroid dysfunction E) ileus/constipation F) weight gain G) PE H) myocarditis
D) thyroid dysfunction
Which meds require avoidance of tyramine containing foods? A) haldol B) escitalopram C) amitriptyline D) selegiline E) phenelzine F) duloxetine
MAOi
D) selegiline
E) phenelzine
Tyramine:
- strong/aged cheeses - cured meats
- overripe foods
- EtOH: beer/wine
- soy
- pickled foods
Atypical lymphocytes are seen in:
mono EBV (& other systemic viral infections)
Reed Sternberg cells: Dx?
HL
Expanding hematoma in neck s/p cath placement > tracheal deviation but VSS. NSIM?
intubate
Best predictor of opiate toxicity is:
RR <12
opioids decrease BOTH hyper capneic & hypoxic respiratory drive via central/peripheral chemoreceptors
AE: UTI, hypoTN
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
H) Canagliflozin
(SGLT2 ingibitor)
MOA: increase renal glucose excretion
____ is an antianginal agent used in refractory sx in pts on NTG, BB or CCB.
ranolazine
CABG is better than PCI for which conditions?
- multivessel d, esp prox LAD & LV dysfunction
Cardiac cath reveals L main stenosis. Significance?
candidate for coronary revasc
SGLT2
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
H) Canagliflozin
MOA: increase renal glucose excretion
AE: UTI, hypoTN
AE: diarrhea, lactic acidosis
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
B) Metformin
(biguanide)
MOA: inhibit gluconeogensis, decrease hepatic gluc production & increase peripheral glucose uptake
AE: pancreatitis, weight loss
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
E) Exentide
G) Liraglutide
(GLP1 agonists)
MOA: increase gluc-dependent insulin secretion & decrease glucagon secretion, delayed gastric emptying
AE: fluid retention, HF, weight gain:
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
D) Pioglitazone
(thiasolidinediones)
MOA: activate transcription regulator PPARy > decreased insulin resistance
AE: nasopharyngitis
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
I) Sitagliptin
(DPP4 inhibitors)
MOA: increase endogenous GLP1
AE: UTI, hypoTN
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
H) Canagliflozin
(SGLT2 ingibitor)
MOA: increase renal glucose excretion
Insulin secretagogues:
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
A) Sulfonylureas
C) Meglintides
AE: hypoglycemia, weight gain
Biguanide:
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
B) Metformin
AE: lactic acidosis, GI upset/D
GLP1 agonist
A) Sulfonylureas B) Metformin C) Meglintides (nate, repa) D) Pioglitazone E) Exentide F) Acarbose, miglitol G) Liraglutide H) Canagliflozin I) Sitagliptin
E) Exentide
G) Liraglutide
AE: pancreatits, weight loss
Examples of sulfonylureas:
Glyburide
Glipizide
Glimepiride
Tetrabenazine: MOA * use?
Tourettes, D blocker
Which type of hyperparathyroidism is treated w/ medical management?
A) primary
B) secondary
C) tertiary
B) secondary
(the others likely managed w/ surgery)
- Primary: AI, CA
- Secondary: vitD def or CKD
- Tertiary: ESRD (chronic stimulation of PTH release becomes autologous secretion even in the absence of stimulation)
Elderly pt w/ rapid onset of periumbilical pain, out of proportion to exam, N/V. Exam benign. Labs: WBC, amylase, lactate & Ph elevations. NSIM?
CTA or MRA to r/o acute mesenteric ischemia
If unclear > mesenteric angiography
Tx giardia
metronidazole
avoid pools/water venues
good hand hygiene
*cysts resist chlorination
Indications for suprapubic cath:
acute urinary retention in pt w/ recent hx GU surgery or trauma or if urethral cath is unsuccessful
Child. EEG w/ 3Hx generalized spike & wave activity. Tx?
Ethosuximibe for absence seizure
CKD: 2 mechanisms in which it causes secondary hyperPTH?
- CKD causes Ph retention & decreased 1,25 OH viD
- LOW 1,25 OH viD means less Ca GI absorp
- HIGH Ph >low CA
- Low Ca causes increased PTH synth
= secondary parathyroidism
Indications for parathyroidectomy in tertiary hyperPTH?
A) young age B) persistent hyperPh or hyperCa C) v.high PTH levels D) soft tissue calcification or calciphylaxis E) intractable bone pain
A) young age
*not an indication as this is TERTIARY hyperPTH
Describe primary VS secondary VS tertiary hyperPTH
Primary: AI, CA
Secondary: vitD def or CKD
Tertiary: ESRD (chronic stimulation of PTH release becomes autologous secretion even in the absence of stimulation)
Which type of hyperparathyroidism is treated w/ medical management?
A) primary
B) secondary
C) tertiary
B) secondary
- Primary: AI, CA
- Secondary: vitD def or CKD
- Tertiary: ESRD (chronic stimulation of PTH release becomes autologous secretion even in the absence of stimulation)
Elderly pt w/ rapid onset of periumbilical pain, out of proportion to exam. Exam benign. Labs: WBC, amylase, lactate & Ph elevations. NSIM?
CTA or MRA to r/o acute mesenteric ischemia
If unclear > mesenteric angiography
Acute mesenteric ischemia. Which lab abnormalities do you expect?
High
- lactate
- amylase
- ph
- WBC
Eval w/ CTA or MRA to r/o acute mesenteric ischemia
Acute mesenteric ischemia. Hx allergy to contrast. Which imaging modality to confirm Dx?
MRA (instead of CTA which is generally preferred)
MCC acute mesenteric ischemia? (3)
- MCC SMA embolus
- arterial/venous thrombosis 2/2 atheroclerosis
- watershed isch during hypoTN (ie trauma, HD..)
Pts w/ recent MI are at high risk per ease of formation of ventricular thrombi & potential for poor perfusion
Why is recent MI a RF for acute mesenteric ischemia?
ease of formation of ventricular thrombi & potential for poor perfusion
Vasculopath w/ cramping abd pain after eating. Dx?
Chronic mesenteric ischemia
unlike acute: rapid onset of periumbilical pain, out of proportion to exam, N/V, delayed hematochezia
2wks after delivery, pt develops DOE, orthopnea, pitting edema 3+, worsening HTN, DTR++. Dx?
PREECLAMPSIA (can occur up to 12wks postpartum)
Dry cough in child >4wks, otherwise ASx. Afebrile, CTAB,no MRG. NSIM?
Spirometry
CXR
HIV: widespread papules w/ central umbilication, some of which are covered w/ a hemorrhagic crust. Dx?
Cutaneous cryptococcosis
CD4 <100
(dissem infection also occurs in liver, LN, peritoneum, adrenal glands, eyes)
HIV: widespread papules w/ central umbilication, some of which are covered w/ a hemorrhagic crust. Which test confirms the Dx?
A) lesion bx
B) fungal BCx
C) urine Ag testing
D) lesion scrapings
A) lesion bx
(encapsulated yeasts)
- fungalBCx often positive hwr for a defDx of a SKIN lesion, bx is more sen/spec
Dx: Disseminated cryptococcosis
Cutaneous cryptococcosis Tx?
- IV amphotericin B & PO flucytosine x4-6wks
THEN
- PO floconazole x 1yr
Which medication is NOT a RF for pseudotumor cerebri?
A) nitrofurantoin B) cimetidine C) nifedipine D) danazol E) all trans retinoic a F) isotretinoin G) tamoxifen H) GCS I) minocycline, tetracycline
C) nifedipine
Pt on steroids develops tinnitus, dizziness, diplopia, HA, forgetfulness. Dx?
Pseudotumor cerebri
Other causes:
- endocrine disorders:
- hypoPTH, hypothyr, addisons, Cushings
*Meds: A) nitrofurantoin B) cimetidine C) tetracycline D) danazol E) all trans retinoic a F) isotretinoin G) tamoxifen H) GCS
Strep pharyngitis, confirmed woth rapid test. Which abx?
amoxicillin OR PNC
NOT amoxiclav
