facts Flashcards
why/ when to give potassium along with IV insulin
hyperosmolar hyperglycemic state (exacerbation of DM) glucose < 600 with normal electrolytes and serum osmolality > 350 have to give potassium if < 5.3 bc even though lab K is normal, its actually low bc of urinary K release (inc glucose= osmotic diuresis)
sore throat, cough worse at night, morning hoarseness, inc need for albuterol inhaler after meals dx?
in this dx - what would be alarm sx (6) and how do they change management approach
GERD (often associated w asthma bc micro-aspiration of gastric contents w GERD leads to inc vagal tone and bronchial reactivity = asthma)
alarm sx= get endoscopy!!
- weight loss, hematemesis, melena, persistant vomiting, dysphagia, anemia
osteoporosis risk factors (6)
old age low weight postmenopausal smoking excessive alc intake sedentary lifestyle
pointing at what, what is this called
thymus: sail sign
effect of hyperALD on system pH
tPa- what is the actual medication
IV altepase
what is kleptomania
impulse control disorder starts in adolescence, the impulse to steal little things. instant relief when they do it followed by guilt or shame.
gallstone pancreatitis
in addition to pancreatitis signs, what suggests specfically gallstones pancreatitis and how do you diagnose
in addition to epigastric pain that shoots to the back and inc amylase:
inc BMI, ALT>150, inc Alk Phose suggest GB Pancreatitis
get a RUQ US to confirm
what is the gold standard for diagnosing celiac’s and why that specifically?
colon biopsy revealing villous atrophy
anti-TTG ab might actually be negative because celiac ds is associated with IgA deficiency. so a negative anti-TTG ab does not rule out celiac
precocious puberty vs premature thelarche/adrenarche
bone age
what is the histopathological change seen in diabetic nephropathy
what is the finding
what disease is this finding associated with
thymoma (an anterior mediastinal mass)
-Myasthenia Gravis: will present with dysphagia and unable to swallow = bulbar dysfunction
what is the pathiphysiology of myasthenia gravis
autoAb from the thymus against n-Ach R in the neuromuscular junction –> impaired action potential at receptors –> M wkness
will have weakness that is worse throughout the day, often presents with fatiguable chewing or dysphagia
treatment for:
- asx gallstones
- gallstones with biliary colic
- acute gallstones w cholecystitis, hemodynamically stable patient
within 72 hours dec mortality and length of hospital stay compared to delayed surgery
dx + treatment of toxic megacolon
dx= colonic dilation > 6cm on CT, loss of haustra
trx= if pt is stable, can do IV fluids, bowel rest, nasogastric decompression, broad spectrum Ab
TM secondary to UC–> IV glucocorticoids is first line therapy
MC cause of viral gastroenteritis
norovirus
presents w non-bloody non-bilious V, abd pain, and waterry diarrhea
develops 2-3 days after the event (school event, cruise..)
what is the time frame needed for a diagnosis of major depressive disorder
2 weeks
what are the sx of organophosphate poisoning
what is the treatment
risk factors and organisms that cause emphysematous cholecystitis
- DM, vascular compromise, immunosuppression
- C. dif, E. coli
5 big risk factors for avascular necrosis
- femoral head fracture
- glucocorticoids
- excessive alc use
- SLE
- sickle cell
how does acetazolamide effect the renal tubule?
which diuretics can cause hypokalemia?
which diuretics are K-sparing?
which diuretics can cause metabolic acidosis?
- acetozolamide= prevent proximal reabsorption of bicarb
- hypokalemia = thiazide diuretics
- K sparing= spironolactone/eplerenon, amiloride
- can cause metabolic acidosis= amiloride (dec gradient for H+)
- amiloride = direct inhibit ENaC: can also cause hyperkalemia
- vs spironolactone= x ALD receptor= indirect ENaC inhibit: spare K but no cause met acid
–if develop hyperK –> switch to another BP agent i.e. CCB amlodipine
primary sclerosing cholangitis
- lab markers
- complications/inc risk for what else
PSC
- inc alk phos (+bilirubin), inc GGT
- 90% pts have IBD –> need to get colonoscopy to rule it out if you have PSC
- inc risk for colon CA, cholangiocarcinoma, biliary CA
- inc risk for biliary strictures, cholelithiasis, cholestasis –> dec ADEK, osteoporosis
- preferred INR range for warfarin in setting of a fib.
- going into surgery/in hemorrhage, how do you adjust the INR
- preferred for a fib: btwn 2-3
- bring INR back to ~1= give prethrombin complex concentrate (factors 2,9,7,10,protein c&s) + IV vitamin K
how do you calculate the “number needed to treat” to have X effect
NNT= 1/(absolute risk reduction)
ARR= (risk of control) - (risk of experimental group)
(i.e. 24% placebos got asthma, 17% treated got asthma –> ARR= 24-17 = 7.2 % –> NNT= 1/0.072 = 14)
hodgkin lymphoma
peak age
clin presentation
histo findings
- yound adult (30s) or >60
- 40% have B sx (weight loss, night sweats, fevers)
- most present for painless LAD (cervical + mediastinal), or a mediastinal mass found on CXR
- hepatosplenomegaly
- inc LDH
- histo= giant cells w bilobed nuclei in germinal centers
how does a PET scan work, what will results look like
sends radiotracer that will be taken up by cells with high metabolic activity = neoplastic cells
BUT also includes the brain, kidneys (and thus bladder), and liver so these places will also light up even if no mets there
characteristic heart changes in takotsobu cardiomyopathy : what is the timeline
literally acute, within a day can happen
present with balloon shape on echo = segmental mid- , apical, and basilar hypokinesis
ARDS timeline and CXR findings
= takes 6-72 hours after the inciting event to develop (while the inflammatory response develops)
presents with diffuse, bilateral infiltrates
what is flail chest, how does it happen
fractures of 3+ adjacent ribs in 2+ areas
the groups of fractured ribs start moving paradoxically and will also injure the lung underneath
=flail chest with increased work for breathing and dec oxygenation –> respiratory failure –> mechanical ventilation
when to use ERCP, MRCP, HIDA Scan
what imaging modality is best for visualizing the pancreas for CA or inflammation
- ERCP = suspected choledocolithiasis
- MRCP= visualize the biliary and pancreatic ducts to asses for biliary obstruction or cholangiocarcinoma
- HIDA scan= look for cholecystitis in suspected patients
- best for viewing pancreas for CA or inflammation = CT abd
does celic ds increase risk for colon CA
no!
mild inc risk for small bowel cancer, but not even enough to screen for it
pediatric septic arthritis
- MC pathogens
- management
MC pathogens
- <3 months = s. aureus, Grp B strep, G- bacilli
- > 3 months= s. aureus, Grp A strep
management
- get an arthrocentesis to confirm dx and get a culture
- AFTER getting culture, start empiric abx for that organism
- bc of long term damage, need prompt surgical drainage to decompress and clear debris
how to calculate
- relative risk
- relative risk reduction
name a complication associated with treating hemophilia with Factor 8 replacement therapy
inhibitor development:
- the body begins to recognize the infusions as foreign material and makes Abs to the infusions
- presents as breakthrough bleeds despite long standing control with treatment, or hemorrhage unresponsive to trx = inc PTT, n PT
- trx for this= provide infusions of factors that bypass the need for factor 8 in the first place = recombinant factor 7, activated prothrombin complex (so you don’t need factor 8 to make 10 to make thrombin)
strongest predictor of nursing home placement for parkinson’s patients
risk of this predictor increases with what
how do you trx the onset of this predictor
psychotic sx, MC visual hallucinations and paranoid delusions
=a late stage sx of PD, but risk increases when you add/replace carbidopa/levidopa with the dopamine agonists= pramiprexole, ropinorole
=preferred trx=
- FIRST dec carbidopa/levidopa dose
- IF NO IMPROVE –>low potency antipyschotics w minimal D antagonism = queitiapine, clozapine, pimavanserin
MC pediatric elbow fracture
what kind of injury is it associated with
what adjacent structure is MC injured with this kind of frx
supracondylar humerus fracture
falling on an outstretched arm
brachial A with displaced bone (humeral shaft forward)
- ulnar nerve is more distal
what pathology is this fundoscopic exam associated with
diabetic retinopathy
what pathology is this fundoscopic exam associated with
CSF diagnostic findings that suggest MS
oligoclonal IgG bands on LP
describe x-ray findings for acute respiratory distress secondary to foriegn body aspiration
what drugs are associated with macrocytic anemia
alc
hydroxyurea
zidovudine
chemo drugs
dx of babesiosis = sx? lab changes? blood smear?
clinical difference in ulnar N injury at the wrist vs elbow
at wrist= 4th+5th digit numbness and parasthesias and intrinsic hand weakness = clumsy
at elbow= ^^ plus grip strength weakened and weaker hand flexion
what pathology is associated with this fundoscopic exam
CMV retinopathy
in a patient w hx of a single episode of unipolar depression: once you start an antidepressant and sx have remitted, how long do you have to stay on the med?
recommend additional 6 months= continuation phase trx
what is this called
complications if left untreated?
“episodic inconsolable crying w hips flexed up with asx periods of play inbetween” is classic presentation of what
intussussception
what clinical signs are sufficient to diagnose diabetic nephropathy without getting a biopsy,etc?
-persistant albuminuria and/or dec GFR AND 1+:
- prolonged hx of DM dx > 5 years
- retinal neovascularization (diabetic retinopathy) bc they are both microvascular complications of DM and so are usually associated
what is the difference between Steven Johnson and toxic epidermal necrolysis
causes- 3 drugs, 2 classes, 3 path
the body surface amount only
<10% = SJS
>30%= TEN
what is waterhouse-freidrichson syndrome
vasomotor collapse secondary to adrenal hemorrhage in the setting of meningococcemia
= adrenal gland failure
presents w meningitis, purpura and petechiae, sudden hypotension–> resp failure–> 100% mortality
CONSIDER THIS in a patient with history of ulcerative colitis and now has a cholestatic pattern of enzyme abnormalities
what test will i do to confirm the dx
primary sclerosing cholangitis (90% pts have UC)
MRCP= rapid and noninvasive–> will show the beaded duct
vs PBC associated w celiac ds, CREST, hashimoto
list the 3 inactivated (killed) vaccines
polio
Hep A
influenza
(inactive HIP)
list the two inactivated toxin vaccines
diptheria
tetanus
DT= dead toxin
list the 5 live, attenuated vaccines
measles
mumps
rubella
varicella
rotavirus
(live motor= VRRMM)
list the 6 conjugated vaccines
Hep B
H influenzae B
HPV
Pertussis
Pneumococca
Meningococcal
what disorders are associated with causing gout
myeloproliferative disorders
tumor lysis syndrome
CKD
explain how an acute aortic aneurysm can lead to pulmonary edema and orthopnea
tear upwards–> aortic regurge –> backflow into lungs
differentiate btwn the diff stages of HTN in pregnancy
(vs n renal changes in preg)
–> gestational HTN= >140/>90 new onset HTN at 20+ wks
NO PROTEINURIA on 24 hour urine
–>pre-eclampsia= HTN + proteinuria / end organ damage
–>pre-eclampsia _w severe feature_s=
- new onset HTN >160/>110
- OR HA/visual hanges / pulm edema
- OR Cr>1.1
- OR inc AST/ALT or plts<100,000
- severe features = greater morbidity = eclampsia, abruptio placentae, fetal demise
–>eclampsia= HTN + proteinuria + new- onset seizures
vs n renal changes = inc BUN, inc Cr
- (bc of inc GFR + BM permeability)
- nin preg = 0.4-0.8
classic ecg and CXR findings for PE
how sensitive?
MINORITY OF PTs
ecg= prominent S lead 1, prominent Q lead 3, inverted T L3
- S1Q3T3
- afib is also associated w PE
cxr=
- hampton hump= lateral wedge
- westmark sign= space of dec markings surrounded by normal markings
- , palla’s sign= prominent R descending pumonary A
in a presentation of bilateral trigeminal neuralgia, suspect this
MS
post-traumatic hemorrhagic shock is likely due to bleeding from where
- external bleeding
- chest (can lose up 40% BV)
- abd: up to entire BV, into perotineum
- pelvis: up to entire BV, hidden in retroperitoneum
- thigh: 1-2 L per thigh
post traumatic ischemic stroke would present as how
-bradycardia and flacid paralysis and hypotension (loss of sympathetic tone)
or Cushing’s Triad
- HTN
- bradycardia
- irregular respiration
in which patients is succinylcholine not recommended for use as anesthesia (i.e. in rapid procedures)
why
what should be used instead
- succinylcholine should not be used w patients at risk for hyperkalemia = extensive skeletal muscle injury, burn injury, disuse muscle atrophy, denervation syndromes (i.e. stroke, Guillan-Barre, polynueropathy)
- succinylcholine is a depolarizing NMSK agent can cause hyperkalemia, the above conditions will also cause inc K and will upregulate Ach-R. this leads to inc risk of cardiac arrhythmias w use of succinylcholine
- instead use non-depolarizing NMSK agent= vecuronium, rocuronium
is patent ductus arteriosus cyanotic at birth
NO
transposition of the great vessels presents how? treatment?
- presents with cyanosis at birth with a loud single S2 and a narrow mediastrinum (egg on a string CXR)
(tachypnea and subcostal retractions)
- treat with prostaglandins to keep open a PDA that is required to live
what is the etiology of a metaphyseal corner fracture
occurs from forced pulling or twisting of the arm
red flag for child abuse
increased PTT that does not correct with a mixing study suggests what
this pathology is associated with what other symptoms
a coagulation inhibitor (rather than factor deficiency)
MC = lupus anticoagulant, present in antiphospholipid antibody syndrome
- APAB has inc PTT but not PT
- associated w livedo reticularis, IBS, migrains
infections can lead to (inc/dec/no change) in platelet levels
inc = thrombophilia
who dat
in what clinical setting does malignant hyperthermia present
vs. another syndrome that can cause pt to present w T>104 and neuro changes
vs post dural HA
- malignant HTN presents in ppl geneticall predisposed who are anesthetized w halothane or succinylcholine
- vs exertional heat stroke: exertion outside in heat, inc risk w obesity, dehydration, use of : anticholinergics, anti-psychotics, tricyclics
postdural HA
- post partum: after neuroaxial anesthesia (epidural) –> occipital HA, worse w sitting or standing bc of CSF leak, but NO focal neuro signs
- trx= epidermal patch
management of newborns with erb-duchenne palsy
observation and PT: 80% of pts have spontaneous recovery within 3 months
-if no improve in 3-9 months, can get surgery but its not necessarily curative
anti-CCP Abs are associated with
Rhematoid Arthritis
what manuevers increase + decrease the intensity of the murmur in hypertrophic cardiomyopathy
what is the etiology of the murmur
HOCM = LV wall thickening, MC in basal AV septum (asymmetric septal hypertrophy)’
- systolic anterior motion of the mitral valve –> anterior (abn) motion of mitral valve leaflets towards the IV septum –> LVOT obstruction during systole –> crescendo-decrescendo murmur
increase
- Valsalva
- abdrupt standing
- nitroglycerin
decrease
- sustained hand grip
- squatting
- passive leg raise
how does the valsalva change heart fluid dynamics
which murmurs does it inc and which dec
dec preload
- dec LV volume = inc murmur: hypertrophic cardiomyopathy + mitral valve prolapse
dec flow across stenotic valve= dec murmur: aortic stenosis
how does a sustained handgrip affect cardiac fluid dynamics
which murmurs does it inc and which dec
= inc afterload + BP
- inc = aortic regurge, mitral regurge, VSD
- dec= hypertrophic cardiomyopathy and aortic stenosis
how do the following affect aortic stenosis murmur
- valsalva
- squatting
- sudden standing
- sustained handgrip
- valsalva (dec flow across stenotic valve)= softer
- squatting = no change
- sudden standing (dec flow across stenotic valve)= softer
- sustained handgrip (dec P gradient) = softer
how do the following affect mitral valve prolapse
- valsalva
- squatting
- sudden standing
- sustained handgrip
- valsalva (dec LV volume) = louder
- squatting (inc LV size) = softer
- sudden standing (dec LV volume) =louder
- sustained handgrip = no change
what are the top 5 (in order) lifestyle interventions that will decrease BP?
- DASH diet
- weight loss
- aerobic excercise
- dec Na
- dec alc
MC post-op pumonary complication
atelectasis = impaired cough, shallow breathing
treatment of osteomyelitis in
- healthy kids
- sickle cell ds
healthy kids:
- probs NOT MRSA = nafcillin/oxacillin or cefazolin
- probs IS MRSA = clindamycin / vancomycin
sickle cell kids
- clindamycin + ceftriaxone
- or vancomycin + cefotaxime
- (to cover MRSA + salmonella)
child with acute onset respiratory distress, dysphagia, and drooling
epiglottitis
acute, due to narrow airway : need intubation
cranial N palsies associated with subarrachnoid hemorrahge
= aneurysm rupture (sudden onset, i.e. on toilet)
CNIII= down and out, ptosis = MC
CNII= unilat vision loss, bitemporal hemianopsia
workup of a suspicious thyroid nodule in pregnancy
get a serum TSH and US to check for suspicious anatomy (irregular margins, internal vasculature, microcalcifications)
- if suspecting malignancy, get a FNA
- if shows v aggressive, can do thryoidectomy in second trimester, otherwise wait until after pregnancy
- just don’t give radioactive iodine for imaging or trx bc that is teratogenic
what is the dexamethasone test used for
to assess for cushing’s sydnrome (inc cortisol)
- sx= M weakness, fasical flushing, supraclavicular fat pads
- = adrenal tumors or ACTH secreting pituitary tumors
differentiate btwn presentation for cholangiocarcinoma and hepatocellularcarcinoma
cholangiocarcinoma
- inc Alk phos > inc AST/ALT
- inc CEA, CA 19-9, n AFP
- inc direct bilrubin, GGT, ALP
- hx of PSC secondary to UC, or hx of fibrocystic liver ds
- acholic stools, dark urine, pruritis, RUQ heaviness/mass,
hepatocellular carcinoma
- inc AST/ALT > inc ALK phs
- n CEA, CA 19-9 , 50% have inc AFP
- hx alchoholism, chronic viral hepatitis
- RUQ pain, cachexia
management of pneumothorax
- spontaneous = tall, thin, young men vs. tension
- small (<2 cm) & stable = observe, O2
- large & stable = needle thoracostomy, chest tube
- unstable = chest tube > emergent needle decompression
finding and dx
management?
adbominal perforation
i.e. hx of GERD..postprandial, sudden worsening w lots of epigastric pain –> perforated peptic ulcer
- FIRST emergent surgical exploration to clear up secretions = dec mortality
- THEN.. IV PPI, fluids, nasogastric suction
blood smear and mean age groups for ALL vs CLL
-blood smear and population for burkitt lymphoma
ALL
- blast cells on blood smear (small nucleoli and scant cytoplasm)
- children
CLL
- smudge cells (fragile lymphocytes)
- ~70 yo
burkitt
- starry sky appearance
- EBV pts
exertional heat stroke vs heat exhaustion
both have <104T w sweating, N/V, HA, dizzy, tachycardia, hypotension
exertional heat stroke = AMS
heat exhaustion= no CNS dysfunction
single MC cause of neonatal meningitis within first 7 days
Group B strep –> can lead to sepsis w high mortality
- low chance of transmission if mom is prophylaxis
- but if C section and mom not given prophylaxis, she can still go home and give it to baby
- listeria presents a lot like GBS but 1. GBS is more common 2. mom would have had flu like sx w listeria infection from food
MC lung cancer in teens + YA, and how does it present
bronchial carcinoid tumor
presents w recurrent pnuemonia or hemoptysis
what kind of MI is most likely to lead in eccentric hypertrophy of the heart
how can this be prevented
anterior MIs (affecting the LV) are more likely to lead to dilated cardiomyopathy (eccentric hypertrophy) via neurohormonal signalling of cardiac remodeling
- one of the neurohormonal pathways = RAAS
- trx w ACE-I post anterior-MI can help prevent dilated cardiomyopathy –> ischemic heart disease –> death
exposure to a house fire can lead to inhalation poisening from what two substances
carbon monoxide
cyanide
- HA, vertigo, dizzy, N/V, tachy, hyperventalation (dec paCO2), inc LDH
dx?
sudden onset of abd pain, dehydration, and elevated K in a young person who suddently and severely dec carbs and calories
dx?
diabetic ketoacidosis
- type 1 DM in young pt (maybe they didn’t know), DKA can be precipitated by low calorie/carb
- insulin resistance= less K being taken up by cells bc usually insulin and K go in together
=inc total body K even tho you are also increasing excretion via kidneys (hyperosmolarity)
for who is the PPSV23 vaccine recommended
- >65
- <65 if they have comorbid conditions that inc risk of pneumococcal infection = chronic liver/lung/heart disease, DM, smoking
describe the clinilcal exam findings for varicocele
-“irregular mass seperate from and superior to the testes” that does NOT transilluminate, worse with standing long persiods and valsalva, decreases w lying supine
BUN: Cr > 20 suggests what
pre-renal azotemia
=AKI due to hypovolemia (i.e diuretic use that causes dec BP…)
what is the medical name for eczema
atopic dermatitis
second hand smoke is a risk factor what 3 childhood illnesses
dental caries
pneumonia / other lower resp tract infections
middle ear ds
what is the meaning of
- HBs Ag
- HBe Ag
- HBc Ab IgG
- HBc Ab IgM
- HBs Ab
- HBc Ab
the vaccine only has Hbs protein
to have Hbc Ab you have to have had HBV
+AntiHbc, +AntiHbs = previous resolved infection
sudden onset severe epigastric pain and vomiting with hx of postprandial RUQ pain +nausea, PE reveals diffuse tenderness and stool guaiac is positive
how to confirm diagnosis
perforated peptic ulcer (probs undx PUD)
- DIFFUSE tenderness (peritonitis), positive guaiac points to PUD
- get an upright Xray abd+chest –> will show abd free air: emergent surgery
- cholecysitits would have pain specifically in RUQ, no peritonitis, would NOT have a + stool test
what lab values suggest hypovolemia
inc Hgb, inc BUN + Cr
w dry mucus membrane
ECG findings for LV hypertrophy
LV hypertrophy
- high voltage QRS complex
- inverted T waves V5-V6 (lateral)
- ST segment depression V5-V6 (lateral)
presenting difference between neuroleptic malignant syndrome and serotonin syndrome
- NMS= generalized M rigidity
- SS= hyperreflexia, myoclonus, tremor
left sided flank pain, hematuria –> varicocele in testes
what is the dx?
renal vein thrombosis
L gonadal V drains into L renal V so it will all back up and you get L sided engorged veins
-due to underlying hypercoagubility (i.e. from nephropathy, RCC)
- most sensitive test for diabetic nephropathy
- screening requirements
- urine albumin: creatinine ratio (will detect earlier, smaller changes in albumin clearance)
- annual test in diabetics: starting at dx with Diabetes type 2 and 5 years post-dx with Diabetes type 1
knee swelling and pain: xray shows punched out lesions with a rim of corticol bone
dx?
what will arthrocentesis show?
gout
inflammatory effusion with negative bifringent needles
hypercalcemia of malignancy is a paraneoplastic syndrome of which CAs
Cushings is a paraneoplastic syndrome of what CAs?
PTHrP releasing tumors
- squamous cell CA head, neck, lung, renal, bladder, ovarian, breast
ACTH releasing tumors (inc melanin + cortisol)
- neuroendocrine tumors : MC = small cell lung CA > medullary thryoid CA, bronchial carcinoid tumor
urine dipstick results for acute pyelonepthritis
positive nitrates and positive leukocyte esterase
- what kind of study asseses a disease group (against control) to compare risk factor frequency
- what kind of study assesses a risk factor group (against a control) to compare current disease prevalence
- what kind of study follows a risk factor group (against a control) to compare future disease prevalence
- CASE STUDY= asseses a disease group (against control) to compare risk factor frequency
- CROSS SECTIONAL STUDY= assesses risk factor group (against a control) to compare current disease prevalence
- PROSPECTIVE STUDY= follows a risk factor group (against a control) to compare future disease prevalence
which patients should be considered for a carotid endarterectomy procedure (as opposed to just clopidogrel + lifestyle changes)
patients with carotid artery stenosis who
- have a history of TIA/stroke from the effected carotid vessel within the last 6 months
- AND have 70%+ stenosis = high grade stenosis
risk factors for primary nocturnal enuresis
first step in eval of primary or secondary enuresis
family history
boys 5-8
NOT psych stuff
SECONDARY enuresis= psych stuff or underlying medical condition
first step = urinalyses
- after, address behavioral concerns or underlying medial conditions
- risk factors for apical bleb rupture
- risk factors for extensive lung atelectasis
CP, dyspnea, hypoxia, unilat dec breath sounds
- apical bleb rupture: spontaneously occurs in pts with hx COPD, lung ds = usually no tracheal deviation, only if large enough
- lung atelectasis: preceded by insulting factor = aspiration, malignancy, pnuemonia (severe, w mucus plug) : associated with tracheal deviation
preferred imaging modality to diagnose ureterolithiasis
stone stuck in the ureter (can’t sit still, referred pain down to groin, sudden onset..)
- best = abd US
- spiral CT abd/pelvis WITHOUT contrast
what kind of imaging would you get if you have suspicion of subclavian vessel injury (i.e. displaced fracture of clavivle and hemodynamic instability/bruising and bleeding)
CT of the CHEST, w IV contrast
will show injury to the subclavian vessels, as well as any possible lung /pleura injury (i.e. pneumothorax)
heparin incuded thrombocytopenia (HIT) increases risk of what kind of blood complciations
arterial / venous THROMBOSIS
- (dec plts bc spleen attacks the Abs on the plts, but the Abs actually cause activation so inc thrombosis)
- NOT bleeding probs
- i.e. low molecular weight heparin = enoxaparin
x fibrillin 1 –> ?
x fibrillin 2 –> ?
x collagen –>
x fibrillin 1 –> marfan’s
x fibrillin 2 –> congenital contractural arachnodactyly (tall, arachnodactyly, multiple contractures of large joints)
x collagen –> ehler’s danlos
fever, sore throat, cervical LAD, rash that develops after taking amoxicillin
dx?
INFECTIOS MONO
rash post amoxicillin= Hallmark
alcoholic hepatitis will lead to what characteristics lab changes? (3)
- AST= 2(ALT) (but less than 500)
- inc GGT (enzyme found in hepatocytes)
- inc ferritin (an acute phase reactant)
what is this sign called and what is the dx
teeth appear worn and smooth: what should you suspect?
nocturnal bruxism
= grinding their teeth at night, maybe don’t even know it
possible causes for acquired platelet dysfunction
- ASA use
- uremia
- advanced liver ds
- cardiopulmonary bypass
of the infectious genital ulcers, which are painful and which are not painful
painful
- HSV
- haemophilus ducreyi (chancroid)
NO pain
- syphillis (chancre)
_BOTH PAINLESS AND THEN PAINFU_L
Chlamydia serotype L1-L3 = lymphogranuloma venereum = first is painless and small so often missed, but then it comes back as a painful buboe
pernicious anemia is due to a decrease in what
- etiology
- inc risk factor for which CA
-dec Vit B12!
– due to Ab against intrinsic factor = no absorb Vit B12 in stomach
—Ab against intrinsic factor also injures parietal cells –> chronic infl –> inc risk of gastric CA
in setting of rib fracture, what is most essential for preventing pulmonary complications
adequate anelgesia
- pain from rib frx will lead to shallow breathing (small tidal volume) + atelectasis
- –> inc risk of pneumonia
(rib frx typically heal w/o surgery (especially if nondisplaced : only do surgery if have flail chest, etc)
trx of Lyme disease in pregnant patients
early Lyme and late Lyme ds
- early Lyme = erythema migrans
- early Lyme in non-pregnant= doxycycline (can cause fetal tooth discoloration and skeletal deformities)
- early Lyme in pregnancy-use amoxicillin
- severe, late Lyme ds= sx like carditis, meningitis
- should be treated with ceftriaxone which is also safe to use in pregnant patients
- what ds is this
- what are these findings called
- what testing must be done when these findings are seen on exam + sx of the ds?
- OSTEOARTHRITIS
- bouchard’s nodes (PIP) and Heberden’s nodes (DIP)
- can present with pain in the 1st ICP (i.e. base of thumb) or distal IPJ (furthest joint)
- NO FURTHER EXAM= OA is a clinical dx
- an xray would show osteophytes and dec joint space but is NOT NECESSARY
in brain death
- which reflexes are lost
- will the HR inc after atropine injection
- will there be a respiratory response to PaCO2 > 70
- lose all brainstem reflexes, DTRs intact bc they orginate in the spinal cord and are not connected to the brainstem
- no HR will not inc: atropine dec vagal tone–> inc HR BUT in brain death there is no vagal tone to begin with so the HR won’t change
- no respiratory responses present = apnea test
an acute increase in Cr requires what
renal US to assess for AKI
(can also get urinealyses but US is key)
nodulocystic acne of the arms and upper back (including face) in a young woman should make you suspect what?
what info is needed to make the dx
PCOS : is a result of hyperandrogen (inc T)
dx of PCOS requires clinical/lab findings of increased T and hx of menstrual irregularity
what is the etiology of a concussion
neuronal functional disturbance, no structural intracranial injury
- what is seen in this image
- what is the dx? inc risk of what neurologic complication secondary to this image finding?
chiari 1 malformation (present in teen/YA)
-inc risk of syringomyelia (compression from tonsils)
pathogenesis of alzheimer
cerebral amyloid deposition
how are amino acids affected by thiamine (B1) /cobalmin (B12) deficiencies
- dec amino acid metabolism
- dec demethylation of tetrahydrofolate
diagnosis and etiology
wolf parkinson white- accessory AV pathway,
most pts asx, might have intermittant palpitations w diaphoresis from an arrhythmia
what is an excessive amount of cow’s milk for babies/children to have (into toddlers..)
-inc risk of what?
> 24 ounces of cows milk is too much –> iron deficiency anemia
- cows milk does not have a lot of iron in it, and excessive amounts replaces iron-rich food in the diet
- iron from cow’s milk has decreased bioavailability
down syndrome is associated with what abdominal abnormalities
- umbilical hernia
- duodenal atresia: “double bubble” sign on imaging, polyhydramnios on US
- hirschsprung
what is a normal liver span
6-12 cm at midclavicular line
-describe presenting sx of acromegaly
- neurohormonal
- CV, pulm
- MSK, bones
- head&neck
- how do you diagnosie
- trx?
DIAGNOSTIC STEPS
- 1st- check fasting IGF-1 (insulin-like GF)
- if elevated –> 2nd = oral glucose test to check for suppressed GH levels
- inadequate GH suppression –> brain MRI
- pituitary mass–> resection
- no pituitary mass–> search for extra-pituitary sources of GH= ectopic, tumors
inc levels of thyroglobulin post-thyroidectomy –> dx?
= thyroid cancer recurrence
- thyroglobulin = precursor to T3/T4=
- produced by normal thyroid OR papillary/follicular thyroid CA
which medications cannot be taken along with lithium
AEs of lithium?
those that affect renal function –> lithium toxicityn
- NSAIDs
- ACE-I, ARBs
- tetracyclines
- metronidazole
AE =
- nephrogenic DI, chronic insterstitial nephritis
- hypothyroid, hyperPTH
- worsens physiologic tremor (resting, worse w stress (+posture held against gravity)
- nonprogressive, symmetric, fine tremor at rest
- weight gain
- leukocytosis
- acne, worse psoriasis, hair thinning
- goiter in pregnancy, teratogenic = ebstein anomoly
**can cause dystonia: BUT dystonic tremor is a tremor associated w dystonic M contractions i.e. torticollis**
most significant risk factor for getting TB in people living in the US
having emigrated from an endemic area
child with encephalitis sx and hepatomegaly (w inc AST, ALT, inc ammonia), normal temp
consider what dx
treatment?
reye syndrome = child given NSAID
=l_iver damag_e + rapidly progressing encephalopathy
- vomiting, lethargy, seizure, coma
- no jaundice even w hepatic enzyme
also have dec glucose, inc PT/PTT/INR
- trx= supportive
findings and diagnosis?
pt coughing up blood, sometimes brown sputum w 3 days of fever, pleuritic CP.
present w ground glass opacities in the same area of the nodules, gram stain -
chronic pulmonary aspergillosi
- image shows a cavitary lesion in the upper lung with a fungus ball in it
*
etiology of acute limb ischemia after an LAD STEMI
-LAD STEMI = inc risk for LV aneurysm –> dec EF + inc stasis –> LV thrombus formation –> risk of emobilization –> stroke OR acute limb ischemia
newborn with cyanosis and the following xray
dx?
trx?
- respiratory distress syndrome
develops within minutes to hours, often in preterm
(associated w grunting, retractions, hypoxia)
- trx= continuous positive airway pressure ventilation
for which patients/disorders do you use the following types of psychotherapy?
- interpersonal psychotherapy
- supportive psychotherapy
- psychodynamic psychotherapy
- motivational interviewing
- dialectical behavioral therapy
- biofeedback
painless maroon colored stool in someone >60 yo who had a normal colonoscopy, consider what dx?
angiodysplasia
- often missed by colonoscopy bc of poor prep or was behind haustra
- associated with renal ds or vWF ds (which is oft associated w aortic stenosis)
- treatment is supportive: if have anemia, then cauterize the abn vessels
how does sample size affect type 1 and type 2 errors
inc sample size = inc power (prob of rejecting a false H0)
–> dec type II error (prob of FAIL TO REJECT a false H0)
–> inc type I error (prob of rejecting a true H0) = inversely related to type II
what is this finding called, and what is the etiology?
these are plantar hyperkeratotic warts! (painful)
HPV
trx of acute pancreatitis likely secondary to gallstones
(= non-drinker, w elevated liver enzymes and gallstones on imaging )
- once her sx and labs have resolved, –> early laparoscopic cholecestectomy (for stable pts)
- reduce risk of recurrance of gallstone pancreatitis
square, envelope shaped crystals in the urine and metablic acidosis in a pt with AMS –> dx? complications?
ethylene glycol poisoning (from anti-freeze)
- calcium oxylate stones
- high anion gap
- will also have high serum osmolality = >295
- complications = acute renal failure
vs methanol poisoning = AMS and HAGMA but no crystals : complications –> bilndness
differentiate between large fiber peripheral neuropathy and small fiber peripheral neuropathy in diabetic neuropathy
- large fiber = predominantely negative sx
- DCML
- small fiber= predominantely positive sx
- ALS
what is this finding called
etiology and classic presentation
subdural hematoma = tearing of bridging veins
-often in old people w generalized cerebral atrophy: often after a fall (TBI), inc risk w anticoagulation
progressive confusion, weakness, unsteady gait
what are the two causes of “floppy baby” syndrome
- infantile botulinism
- werdning-hoffman = AR degen of anterior horn cells and CN motor nuclei
which antipsychotic has the highest risk of seizures as an adverse effect
clozapine
- agranulocytosis (aka neutropenia)
- seizures
- myocarditis
what is this finding called
what is the diagnosis
electrical alternans w short QRS
post-op pt presents for new onset anxiety and agitation +/- delirium, tachycardia, lid lag, tremor, inc BP, inc pulse rate, inc liver enzymes
clinical suspicion for what dx?
THYROID STORM
- precipitated by acute injury or surgery (inc wbc, fever, inc CK…)
- also precipirated by child birth, IV contrast
MC cause of cor pulmonale
=COPD
RHF caused by LHF/Congenital heart ds is NOT cor pulmonale
Cor pulmonalie can also be caused by: interstitial lung ds, OSA, pulmonary vasc ds, chest wall disorders
what is the dx
peaked T waves, shortened QT or widened QRS complex
P wave disappears,- conductive block
assocated w ESRD
pt comes in w normocytic anemia, back pain, and this xray of his arm (bc increasing arm pain)
what is the diagnosis
multiple myeloma
=osteolytic “moth eating” lesions
NOT JUST IN BACK, also long bones
thrombocytopenia
what conditions are associated with peripheral destruction of platelets vs splenic sequestration
- peripheral destruction (immune mediated)
- SLE, Antiphospholipid Ab
- TTP
- DIC
- splenic sequestration
- portal HTN, hepatic V thromobosis
- liver cirrhosis
- sickle cell ds
treatment with what kind of diuretic in the trx of ascites is associated with acute metabolic alkalosis with an inc BUN/Cr
=inc BUN/Cr, inc HCO3, dec K/H+
- loop diuretics = inc ALD and inc Na delivery to distal tubule to inc diuresis
next step in assessment in a pt w hypercoaguable state labs= inc Hgb, inc Hct, inc EPO
CT abd
mechanism of action of nitrates (sublingual nitroglycerin)
- systemic vasodilation (NOT coronary)
- dec preload, dec afterload
- = dec LV wall stress aka dec myocardial O2 demand
3 most common causes of chronic cough > 8 weeks
- upper-airway cough syndrome/ postnasal drip
- aka nasal secretions
- associated with chronic/multiple episode of rhinosinusitis (i.e. allergic rhinitis)
- asthma
- GERD
arthralias and an urticarial rash 1-2 weeks after taking abx
dx?
serum sicknless-like reaction
two days post-op w N, constipation, and diffusely tender abd. no bowel sounds.
dx?
paralytic ileus
elderly patient presents with back pain, inc WBC, dec Hgb
dx?
retroperitoneal hematome
laparoscopic procedures require CO2 insufflation of the abd
this comes along with what CV risk
=causes perotoneal stretching (so cameras can see)
-perotoneal stretch receptors will trigger inc vagal tone –> can cause severe bradycardia and possible transient AV block –> maybe even asystole
needs to be monitored by anesthesia
-CO2 embolization is v rare, associate with CO2 pushed into an artery/vessel –> end organ infarction/ hypotension/ obstructive shock
HAGMA
ethylene glycol vs methanol
both have v high osmol gap with bicarb v low (oftn < 6)
= alc substitutes
- ethylene glycol = renal damage, Ca oxylate stones
- methanol = blindness, optic disk hyperemia
compare presentations of 1st, 2nd, 3rd degree AV block and the management for each
observe for 1st
pacemaker for third degree, mobitz type 2
RA is associated with what kind of glomerular damage
AA AMYLOIDOSIS = nephrotic syndrome
syncopal episodes with muscle jerking that occurs at rest with no obvious trigger or prodrome suggests what
how to diagnose?
cardiac syncope
- muscle jerking can be in lots of syncope bc of cerebral hypoperfusion
- no prodrome preictal period rules out vasovagal or seizures to a high degree
- cardiac syncope =
- LV outlet obstruction (occurs with exertion)
- v tach = no warning sx, either monomorphic or polymorphic
- conduction impairment = preceding faint feeling, associated w ekg changes
dx= ambulatory ECG
what is the renal dx?
simple renal cyst= benign ; no treatment or follow up required
bicuspid aortic valve is associated with what type of murmur
when does it present and what does it sound like
aortic stenosis most frequently
- AS due to bicuspid valves usually presents 40s-50s
BUT bicuspid valve is the MC cause of aortic regurge in the US
- typically diagnosed in 30s-40s
- decrescend, early diastrolic murmur @L sternal border w patient leaning forward and holding exhalation
bicuspid aortic valve can also cause aortic root dilation which –> causes aortic regurge
MC cancers to mets to the brain
- which present as solitary met
- which present as multiple mets
lung> breast> unknown > melanoma> colon
- single: breast, colon, renal cell carcinoma
- multiple: lung CA, malignant melanoma
MC electrolyte abn associated with chronic alc use
why is this dangerous
hypomagnesemia
dec Mg –> inc K excretion by kidneys –> hypokalemia
(ROMK channels in kidney are regulated by Mg: v common ause of refractory hypoK is hypoMg)
def Mg -> induced PTH resistance –> hypocalcemia
hypoCa oftn refractory to trx unless also give Mg (phospohorous is n-low bc of depletion = vs other causes)
anemia of chronic disease is associated with what types of chronic diseases
= suppression of RBC production by inflammatory cytokines
=inflammatory ds like RA, SLE
NOT like OA…
what is the finding in this MRI and what is the diagnosis
HYPOXIC BRAIN INJURY
=hyperintensity of the globus pallidus bc it is very sensitive to hypoxic injury
-also associated w hypoxic brain injury is diffuse cerebral edema (later) and the sx of AMS, confusion, seizures, lactic acidosis from peripheral tissue hypoxia
how do you differentiate between angina due to aortic stenosis vs coronary A ds
AS angina = w severe AS, w <1 cm of valve area, often w a low pulse P
how does dec hepatic UDP glucoronosyltransferase activity present
=GILBERT SYNDROME
- mild jaundice with stress/illness/surgery/dehydration/vigorous excercise
- -presents in kids/teens/ YA
GILBERT is inc indirect bili with normal hgb
- vs g6pd= inc indirect bili w dec hgb
sudden onset painless vision loss in one eye with this fundoscopic exam
what is the diagnosis
acute mono-ocular painless vision loss= retinal A embolism
oftn from ispi carotid A or cardioembolic (a. fib)
post-op patient (days) with fever, pain at surgical incision site that is numb around the edges and has a dusky, friable subcutaneous tissue
necrotizing (fasciitis) surgical infection
what medications can cause a false positive amphetamine result on urine drug screen
atenolol
propranolol
bupropion
nasal decongestants
what medications can cause a false positive phencyclidine on urine drug screen
(false + PCP)
- dextromethorphan
- diphenhydramine, doxylamine
- ketamine
- tramadol
- venlafaxine
differentiate between allergic rhinitis and nonallergic rhinitis
- sx/triggers
- PE exam
- treatment
allrgic = specific allergens (pollen, cats..)
-nonallergic = no systemic sx, associated with the cold, season changes, etc.
a “magnetic” gait is a classic description of the gait associated with what pathology
normal pressure hydrocephalus
- early disease my present w ONLY gait changes +/- flat affect, but no cognitive or incontinence
- dx= ventriculomegaly and n opening pressure
vs PD= shuffling or festinating (short, quick steps)
describe the levels of PaCO2 and the A-a gradient in the following:
- alveolar hypotension (what conditions is this associated with)
- pulmonary embolism
- atelectasis
- pulmonary effusion
- pulmonary edema
- alveolar hypoventilation =
- inc PaCO2
- n A-a gradient
- PE, atelectasis, pulmonary effusion/edema
- dec PaCO2
- inc A-a gradient (aka VQ mismatch)
n A-a mismatch= <15
- what is the glasgow coma scale used for
- what are the parameters of measurement
- what is the scoring scale
- assess the severity of brain injury
- EVM = eye opening, verbal response, motor response
- GCS = 0-15
- mild injury = 13-15
- moderate injury= 9-12
- severe injury = <8
pt in the ER w progressive abd pain + distension, N/V, hx of alc abuse
dx?
trx?
pancreatic pseudocyst = mature walled off pancreatic fluid collections (usually no necrosis or solid material) surrounded by thick, fibrous capsule and contains enzyme rich fluid, tissue, debris
- can –> amylase-rich fluid leaking into circulation and inc serum amylase
- complications = spontaneous infection, duodenal or biliary obstruction, pseudaneurysm (presents with embolism before drainage procedure), pancreatic ascites, pleural effusion
TRX
- asx= expectant management (symptomatic therapy, NPO)
- sx w abd pain/V/infection/pseudoaneurysm –> endoscopic drainage
what is this imaging finding called?
dx?
trx?
PORCELAIN gallbladder
dx= cholecystitis
- CXR= rim like calcifcation where the GB should be
- CT= calcified rim wall w central, bile filled dark gb
- the gallbladder irl is like bluis-grayish on the outside bc of the Ca deposition, and oftn filled w yellow, multifaceted gallstones
- (US shows thick GB wall filled w sludge, and surrounded by fluid)
trx= cholecystectomy
- chronic cholecystitis has inc risk of GB adenocarcinoma
describe appropriate resuscitation measures in patients with hemorrhagic shock/ ongoing hemorrhage
what is the danger of inappropriate resusc
- balanced resuscitation= “damage control”
- limit use of crystalloids (saline infusion) bc these will dilute coag factors –> coagulopathy = inc bleed
- replace the intravascular fluid with blood products = 1:1:1 ratio
- maintain permissive hypotension (65 MAP) until hemorrhage is controlled
danger of excessive fluid resuscitation with IV fluids =
- hypothermia (room temp is colder than body)
- acidosis (NAGMA, hyperchloremic)
- inc mortality from lethal triad = hypothermia, acidosis, coagulopathy
- inc risk of ARDS (dose dependent on amounts of fluid)
patients who survive cancer with treatment of radiation and chemo are at increased risk of what
specific myocyte changes w diff chemo?
-secondary malignancy= solid organ (breast, lung)
- associated w radiation
- secondary malignanc is the MC cause of CA related death in those cured of a CA
-CV ds = CAD, valve damage, PVD, cardiomyopathy
- leading non-malignant cause of death in hodgkin lymphoma survivors
- myocyte necrosis and fibrotic destruction associated w anthracyclines (-doxorubicin, -rubicin) –> progress to overt HF
- trastazumab= myocardial stunning/hybernation without destruction = asx LV systolic dysfunction, more likely to be reversible
- pulmonary fibrosis/bronchiectasis (radiation)
- hypothyoid (radiation)
- neuropathy (chemo)
what three causes of hypoxia (PaO2<75) do NOT correct with O2 supplementation
how do you improve oxygentaion then?
ARDS (due to associated pulmonary edema= intrapulmonary shunting as Nø inflammation fills the alveoli w proteinacious fluid)
- inc PEEP= positive end expiratory pressure= opens up the flooded alveoli and recruits them for ventilation = inc the amoung of lung that is actually doing O2 transfusion
- aka dec the intrapulmonary shunt effect
- associated w increase risk of barotrauma so have to be careful
massive pulmonary embolism
severe R–>L intracardiac shunt
patient, hx of bronchiectasis, with psoriasis, nephrotic syndrome, palpable kidneys, hepatomegaly, fourth heart sound on auscultation
what is the underlying pathology of the nephropathy
amyloidosis
psoriasis= chronic inflammatory disease
nephrotic syndrome palpable kidneys= amyloid dep
hepatomegaly = amyloid dep
S4 = vetriculomegaly = amyloid depo
pt with trouble swallowing liquids, tongue fasciculations, and when you tap on the chin with the mouth slightly open the jaw jerks forward briskly
dx?
ALS
describe estrogen levels in turner syndrome
estrogen is produced by the ovaries so in TS–> decreased estrogen
- results in amenhorrhea and poor breast development
- inc risk of osteoporosis and fractures (estrogen inhibits osteoclasts)
trx includes giving TS teens estrogen to promote sexual maturation and dec risk of osteoporotic fractures
what is the etiology of Reye Syndrome
child is given ASA –> liver toxicity and damage –> hyperammonemia –> buildup in CNS –> cerebral edema –> toxic metabolic encephalopathy = rapidly progressivve nausea, vomiting, lethargy, AMS/confusion
13 yo w progrssive hip pain, limping and pain on IR
pt w insecurity about body and weight, enlarged parotid glands and scars on back hand BMI at 4th percentile
dx??
anorexia nervosa
-even if purge, AN vs BN = BMI
BMI<18.5= AN
describe the PFT pattern and diffusion capacity of the lung for CO for asbestosis and silicosis
restrictive PFTS
w dec DLCO
a well appearing infant <6mo w blood streaked, mucusy stools
what are the two possible dx?
anal fissure (hx constipation)
food-protein induced allergic prococolitis (n bowel movements: is associated w mom’s diet if being breastfed, clinical dx–> have mom cut out dairy + other foods till sx resolve)
(things like intestinal obstruction or necrotizing enterocilitis would present with an ill pt + tender abd)
testing sequence for suspected cushing’s disease
aka hypercortisolism and you gotta assess where the cortisol is coming from
-clinical presentation of hypercortisol
- 1st get:
- 24 hour urinary cortisol excretion
- late night salivary cortisol assay
- low dose dexamethason suppression test
- if two of these are abn = you have high cortisol:
- then do a high dose dexamethasone suppression test to differentiate between ACTH dependent or independent
- imaging to look for pituitary/ adrenal tumors, etc.
patient presents with infective endocarditis
- what is the trx?
- at what point would you consider surgical intervention
n trx= IV abx and O2 supplement prn
- if the pt is in acute heart failure, oft secondary to aortic/mitral regurge
- = acute SOB, bilat LE edema, pulm edema
- extensin of infection (i.e. abscess, fistula, heart block)
- IE is caused by a fungus or med- resistant pathogen
- persistant bactermia after abx trx
- persistent septic emboli
4 wks post MI pt presents w diffuse, severe abd pain, N/V onset suddenly 3 hours ago
labs= inc hgb, metabolic acidosis, inc leukocytes, inc amylase ; HTN, inc HR
dx?
mesenteric ischemia
dx= evidence of bowel infarction–> go to OR : it pt stable/suspicious, get CT angio
dx?
what is the etiology
narrow QRS + regular rhytym = paroxysmal SVT
=in young pt (<40) w normal heart, MC cause is AV nodal reentrant tachy
- two distinct conduction pathways in the AV node = fast w long refractory and slow with short refractory
describe the ECG of Vtach and what is the etiology
- abn electrical activity around ischemic scar tissue
- or abn automaticity of the ventricular conduction sytem = associated with dilated cardiomyopathy
disorganzied atrial activity originated from the pulmonary Vs results in what type of arrhythmia
a fib
what type of anemia is associated with a high homocysteinuria w high methylmalonic acid, and which is associated with a high homocysteinuria w n methylmalonic acid
high methylmalonic acid = combalamin= Vit B12
“folate MTMA falls* *cobalamin= both up*
pt presents s/p MVC w pelvic fracture, blood at the urethral meatus, and a high rising prostate
what should you be concerned about and what is the next best step in assessment
posterior urethral injury
get a retrograde urethrogram ASAP
*upward movement of bladder/prostate can cause urethral tearing, MC at bulbomembranous junction*
-other sx= inability to void,, perineal bruising
what are two potential longterm consequences of myopia
=near sightedness
-SEVERE myopia is associated w inc risk of
- macular degenration
- retinal detachment
differentiate the clinical picture of bell’s palsy from an acute stroke
how do you diagnose bell’s palsy
bell’s palsy is paralysis of one side of the face, including the lower and upper face
- also sudden onset = difficulty eating, drooping smile, trouble closing eye, foreheard involved pupils equal and reactive though
- a stroke would not include the upper case as well bc of the different innervations
bc >50% of U&L face palsies are due to bell’s and because the prognosis is so benign –> = clinical diagnosis
- further testing is NOT recommended in pts w classical presentation
- may rule out other causes through H&P usually
- MC oppurtunistic infections after transplant are:
- what are common post drug toxicities and malignancies
MC opp infections=
- CMV pnuemonia (bilat infiltrates, fever, acute onset)
- pneumocystis pneumonia (bilat infiltrates, fever, indolent onset)
- invasive molds (Aspergillus)
**NEW ONSET PULMONARY INFILTRATES: have to rule out acute transplant rejection during the workup for infection (can be concurrent) –> bronchoscopy, lung biopsy
pt presents for confusion and AMS.
fever, dec BP, inc pulse and respirations
diffusely tender abd pain, distended, tympanic abd to percussion, rigid to palpation
dx?
how to trx?
perforatd viscus
- *hx of colon surgery –>adhesions–> SBO –> perforation*
- present w recent anorexia, AMS, pt cannot tolerate being upright, sx of peritonitis
dx= clinical signs plus xray (CT w contrast if xray -)
trx- immediate surgical exploration to repair
3 days after cardiac cath and stent, patient presents in hospital with vague, abd pain, 3 blue R toes and 1 blue L toe, and this skin finding
- dx?
- etiology? risk factors?
- treatment
- cholesterol embolism
- presents with livedo reticularis, ulcers/gangrene, blue toe syndrome due to peripheral shower emboli, kidney injury, stroke/olfactory hallucinations (due to cerebral emboli), Hollenhurst plaques (golden yellow spots in eye)
- dx= eosinophilia, dec C3
- = emboli from atherosclerotic plaque in aorta
- inc risk w HTN, hypercholesterol, DM
- presents days-weeks after a cardiac/vascular surgery
- trx= supportive
dx and next best step
intraperitoneal perforation = surgical exploration
30 year old man presents with SOB, cough, and fatigue for 3-4 weeks. smoker, auscultate scattered crackles
CXR= hilar fullness and interstitial infiltrates
labs= dec Hgb, inc Ca, inc urea nitrogen
dx? trx?
systemic sx assocaited with sarcoidosis
- trx- glucocorticoids (asx pts are just followed)
BILAT LAD = sarcoidosis or lymphoma
- UNILAT fullness associated w TB (+/- lower lobe effusion / consolidation, bronchial compression from hilar adenopathy, and risk factors i.e. old, DM, nursing facility)
- progress slowly over weeks, prsents as a sick pt w signs of pneumonia, but pneumonia trx is unaffective
*
bone pain w increased urine pro-collagen propeptide, urine hydroxyproline
Pagets Ds =MC cause of isolated alk phos (w n Ca)
pt presents with confusion post seizure
serum Na = 117
serium osmolality= 250
urine osmolality = 500
dx? trx?
SIADH
(this was associated with a hilar mass = SCLC)
trx= hypertonic saline + fluid restriction
30 yo pt presents with 3 months of diarrhea and abd bloating, 2 months of low back pain and stiffness
PE shows sacroiliac inflammation
NSAIDS relieved the back pain but worsen the diarrhea
sacroiliatis secondary to IBD
(vs reactive arthritis which is after infectious diarrhea, more commonly associated w uveitis, urethritis, malaise, skin changes)
pt given anesthetic suddenly develops hypotension refractory to fluid bolus and epinephrine
labs = hypoglycemia and eosinophilia
dx?
adrenal crisis
pt presents with this rash progressively growing over 3 weeks, is very itchy
tinea corporis
- vs cutaneous lupus= also can cause annular plaques but are multiple and in sun exposed areas
vs urticaria
- acute/subacute itchy wheals, associated w edema
5 year old girl presents with hx of fractures of long bones, precocious puberty, and irregular brown macules on back
McCune Albright
girls <8, boys <9
explain how obesity affects ovulation
inc obesity –> inc aromatization in adipose –> inc estrogen –> turns GnRH pulses to high frequency and short intervals –> inc LH/FSH ratio
abn LH/FSH ration –> no LH surge right before menstruation –> anovulation
migratory arthralgies and nontender pustules with surrounding erythematous ring on LLE
hx of two days of fever and malaise a week ago
disseminated gonococcal infection
- vs lyme = monoarticular arthritis months or years after infection: target shaped lesions, NOT pustular
child living in poverty has watery discharge and mild redness, without itching or pain
preceding week of cough and rhinorrhea
exam= several pale follicles and inflammatory changes in tarsal conjunctivae bilaterally, conjunctivae are mildly thickened
trachoma= from C. trichomatis
- MC in children = follicular conjunctivitis and pannus (neovascularization) formation in cornea (thick)
- repeated or chronic –> scarring
=MC cause blindness
what are the 7 initial meds/interventions you should give someone with a STEMI before they are taken for reperfusion
- persistant pain/HTN,HF
- persistant severe pain
- unstable sinus bradycardia
- pulmonary edema
describe the mechanism of position related hypoxia in unilateral pulmonary effusion/pneumonia
slowly onset lestions on hands of old white person
dx?
actinic keratosis
dry, scaly flat papules with an erythematous base, mostly seen in sunexposed areas
=premalignant to SCC
seen in the patient’s axilla
dx?
acrochordon = skin tag = in areas of inc friction
old lady comes with this lesion. says it has been there for a while and is sometimes itchy but sometimes not
dx?
seborrheic keratosis
=ranges from brown macules to raised wart like lesons that can be pink, white, black, etc
HALL= “stick on” appearance
dx= clinical, if you get a biopsy would see basal cells, keratin containing cysts, and hyperkeratinosis
trx= observation : if annoying, cryotherapy
70 yo, suicidal patient is having an episode of severe depression with hallucinations telling him to kill himself
trx?
ECT
MDD w psychotic features trx
- antidepressant + antipsychotic
- or ECT
- preferred in elderly patients who can’t eat of drink, are psychotic, or suicidal
- quicker onset of action
diagnosis, level of dysfuntion (be specific), associated causes
- polyuria, dec serum Na, urine osmolality 600+
- polyuria, n serum Na, urine osmolality <299
- polyuria, inc Na, urine osmolality<299
differentiate btwn DI and PP = water deprivation test
- assesses change in urine osmolalilty
- primary polydipsia,
- hypothalamus
- associated w psych hx
- nephrogenic DI,
- @renal collecting ducts not reacting to the ADH
- chronic lithium, hyperCa, or aquaporin mutation
- central DI
- @hypothalamus or posterior pituitary, ADH deficiency
- idiopathy, trauma/pituitary surgery, ischemic encephalopathy
pt presents post eye trauma, double vision upon upward gaze,
swollen, tender, ecchymosis over ipsi face; associated w eye pain and swelling
dx?
lateral rectus M entrapment
-trauma –> sudden inc P–> fracture of the weakest bone in the orbit = orbital floor/medial orbital wall
= blowout fracture
- = entrapping of the inferior rectus M –> inability for ipsi eye to look up
- req surgery
- vs open globe injury = associated with markedly dec visual acuity + “flattening” of orbit on imaging
nerve injury associated with
- down and out, ptosis
- hypertropia and extorsion of eye with vertical diplopia on downward gaze
- diplopia on upward gaze
- CNIII - oculomotor = inferior oblique M + orbital muscles
- CN IV = trochlear = superior oblique M
- CN III= occulomotor =inferior rectus M
gout sx, xray shows ST swelling, joint effusion, with chronic chondrocalcifcation of the articular cartilage
what type of gout is this, which crystals will be seen?
pseudogout = calcium pyrophosphate crystals
rhomboid shaped,
+ bifringence, only 15-30 cells
- often in knees and ankles (like urate gout) but can also be in large joints, and multiple at same time
- associated with chronic inflammation and atherosclerosis, can present like RA/OA : MC <65, occur in the setting of trauma/surgery, medical illness, overuse
vs - gout = monosodium urate crystals
- NO asosciated chondrocalcinosis
- is v acute, v painful (vs pseudogout progresses over hours-days)
- (-) bifringent, shows up to 50k cells
- associated hyperurate (tumor lysis, drinkers, etc)
5 yo w sickle cell presents w acute/sub-acute fatigue and lethargy.
PE= hypotension, inc pulse, anemia, thrombocytopenia, tender palpable spleen
dx? trx?
acute splenic sequestration: often presents in children
=life-threatening complication of early sickle when RBCs become entrapped in spleen
-trx= IV fluids and RBC transfusion (NOT whole blood even tho low plts there is no incr risk of bleed)
5 yo presents with acute onset bilat leg pain, refuses to walk on legs now. last week had a cough and rhinorrhea but resolved. manipulation of LEs cause patients to cry. exam reveals purplish, nonblanching rash on buttocks and legs. diffuse tenderness across abd w/o rebound or gaurding.
likely dx? trx?
henoch schloen purpura
=inc risk of intussusception, renal ds, scrotal pain and swelling
trx= supportive: steroids if v sick
pt w epigastric pain that shoots to the back w N/V presents. non-alcoholic. RUQ US shows no gallstones, sludge, or gb inflammation
next best step in management
pancreatitis that is not caused by alc or gallstones is probably from inc triglycerides
(i.e. pregnant pts - TGs inc 2-4x in third trimester, or pt w hx of hyprecholesterols, obesity, etc)
next best step = get lipid panel
38 yo F presents with chronic stiffness in neck, shoulders, lower back, and hips. worse w minor exertion. pt also has trouble sleeping and notes faytime fatigue. hx IBS.
PE= multiple tender spots on bony prominences and tendon insertion sites.
labs = wnl
dx? trx?
fibromyalgia
first -line = aerobic excercise, patient education, and improved sleep hygiene
–> no improve –>
1st line= TCA amytriptiline = depression and also helps w pain
- second line= duloxetine, pregabalin, milnacipran
- NOT nsaids or steroids bc fibromyalgia is not inflammatory and won’t respond
carcinoid syndrome is assocaited with what vitamin deficiency
how do you diagnose carcinoid syndrome
niacin => pellegra
urine inc 5-HIAA
child presents with 4+ proteinuria
IG= difuse, granular deposits of IgG and C3
EM= subepithelial deposits along glomerular BM
dx? what further testing is needed
membranous glomerulopathy :
- MC in adults, but can be in kids from secondary cause
- presents w subacute proteinuria, edema hypoalbumin/hyperlipid : w n BP and GFR
next step is to check for related conditions, especially in children
- hep B even though super rare!!!
what are the sx of whipple ds (gi, cv, neuro, gen) and who is most commonly affected
7 yoboy prsesnts for 8 months of L thigh pain and a limp. started out w pain only after soccer, now constant. on exam, pt doesnt put anyweight on left leg w gait, sign limited rom of l leg. attached radiograph.
newborn presents with an underdeveloped phallus with the urethral meatus at the base, fused labiosacral folds, gonads are not palpable,elevated 17-hydroxyprogesterone
what is the most likely karyotype and diagnosis?
46XX = female with inc androgens + dec cortisol due to 21-hydroxylase deficiency
differentiate between the etiology and clinical presentations of primary and secondary varicocele
both = “bag of worms” (painless, coiled.. seperate from testes, no illuminate)
- primary= L sided and dec w supine, inc w valsalva
- adolscent or adult
- due to compression of L renal V
- secondary= R sided, size no change
- prepubertal
- due to compression of IVC from abd mass or from thrombus
dx and trx
contra= quinidine or class three anti-arrhythmics - can exacerbate
health benefits of circumcision
gallstone pancreatitis with RUQ pain, fever, and scleral icterus suggests what complication?
dx and trx?
acute cholangitis
dx + trx = ERCP
subarrachnoid hemorrhage
- major cause of death within first 24 hours
- major cause of death and morbidity within 3-7 days
24 hours = rebleed
3-10 days= cerebral vasospasm and infarction
what are the big clinical sx that point to chronic bacterial prostatitis
how do you diagnose
DRE may be NORMAL
what is the mechanism of hypoxemia in pneumonia
v/q mismatch secondary to alveolar consolidation
6 yo boy presents for a “lump in the neck” mom noticed today during bathtime. pt has had fever for 6 days and has been irritable. today fever is 103, pt has bilataral injected conjuncitvae, 2 cm tender mobile anterior LN. mild tachy but otherwise cv exam is normal. blanching erythematous rash across trunk, tongue and lips are erythematous. no pharyngeal exudates or tonsillar abn.
dx?
=systemic inflammation –> lymphocytic and Mø infiltrate into cardiac tissue
- inc risk CV ds if: fever<14 days, late onset IVIG trx, <1 yo
lymphocytic myocarditis –> LV outlet obstruction
- peripheral edema, S3 gallop and pulmonary edema, LE edema, hepatomegaly
- diaphoresis w feedings: irritable when awake, sleeping longer + more often
- aka frank HF
**skin findings ** include: peranal peeling and periungal desquamation
what exam findings are suggestive of strabismus vs optic neuritis
what is the next best step in management once identified
strabisumus = eye deviation +/- asymmetric red reflexes
- -get fundoscopic exam to rule out underlysing malignant cause
- -cover test
vs. optic neuritis which would present with painful vision loss, pain worse w movement, central scotoma (smudge/blurriness) that spreads, “washed out colors”,
- visual evoked potential test
- swinging flashlight test= paradoxical dilation when you shine a light into the ipsi eye
35 yo M brought in by roommate for “acting weird” and staying isolated.
PE= only mild scleral icterus.
labs= normocytic anemia, thrombocytopenia, inc alk phos > inc ALT/AST, inc bili mostly indirect
likely dx? trx?
TTP
plasma exchange and IV steroids
potentially life threatening: urgent trx needed!
heart abnormality associated w : HTN, HA, epistaxis, blurred vision, LE claudication
continuous murmur heart at L interscapular area
coarctation of the aorta
- dec BF to LE = claudication (inc BP in UE, dec BP in LE)
- continous murmur at L interscapular area is associated w turbulent flow across the coarctation or large collateral vessels
- or “continous murmur heard throughout the thorax at multiple locations”
- can be associated with erosions of the inferior costal surfaces
what is this finding called? what is it associated with
lisch nodules!!
HA onset 4 hours ago that worsened rapidly over several minutes. associated w photophobia, neck and back pain, and one episode of vomiting.
CT head normal.
what is the dx and how do you confirm it?
SAH : CT head is >90% sensitive but if its abn you still need to get LP to rule out
+LP= yellow-pink fluid bc of Hgb breakdown= xanthochromia
- also high RBC count
5 exam findings associated with OA
- worse in the mornings or evenings?
- how to diagnose?
- arthrocentesis shows what?
ESR, CRP = normal
worse at the end of the day
what is this finding called?
associated with what congenital path?
chorioretinits= inflammation and scarring of the retina and choroid
- congenital toxo >> CMV
- = a long term sequelae of chronic infection –> can lead to permanent vision loss
- late manifestation can be up to months later: can also present w seizure, intellectual disability , hepatosplenomegaly
how do you assess for pyrimidal tract ds
vs
how do you test for proprioception defects
vs
how do you test for cerebellar dysfunction
- pyrimidal aka corticospinal tract (decussates at pyrimadal space in cervicomedullary junction = name?)
- =UMN ds, associated w MS, etc.
- =pronator drift test: outstretched arm pronate w eyes closed bc UMN ds is stronger on supinators
- proprioception defects = DCML tract! in the posterior colums of SC or dorsal root ganglia
- test= romberg test, lose balance w eyes closed
- cerebellar dysfunction
- presents w ataxia, tremor, impaired dysdiakokinesia
- =pronator drift w UPWARD drift of arms w eyes closed, no UMN signs
48 year old surfer dude finds this on his back 3 weeks ago
most likely diagnosis
nodular malignant melanoma
how does positive pressure ventilation affect preload and afterload, LV and RV
what are the presenting signs and sx associated with arteriovenous malformations
- -CNS, mucocutaneous, CV, GI
differentiate btwn AVMs and Granulomatosis w Polyangiitis
hereditary hemorrhagic telangiectasias
- hereditary AVMs will present w sx early life (childhood epistaxis, now a 30 yo w hemoptysis)
- AVMs associated w bruits + iron deficiency anemia
vs GPA
- GPA= necrotizing of small vessel vasculitis
- renal-pulmonary
- hemoptysis from alveolar hemorrhage = crackles and diffuse patchy infiltrates
- crescenteric glomerulonephritis = microscopic hematura = focal, segmental
- nasal septal necrosis and destructive sinusitis
5 year presents for 1 day of left wrist pain. TTP but no swelling, pain w ROM, can move all fingers except thumb
dx? trx?
(those hand bones are n for a kiddo)
- buckle fracture= associated w FOOSH in kids <10yo
- stable, incomplete frx
trx= pain control and splint, heals in few weeks
classic presentation of fat embolism
vs
classic presentation of pulmonary contusion
- fat embolism
- 12-72 hours post injury
- post-frx tachypnea + hypoxemia associated w neuro changes and petechial rash,
- pulmonary contusion
- within 24 hours of injury (blunt thoracic)
- tachypnea, tachycardia, hypoxia w rales/dec breath sounds
- CT chest (gold)= patchy alveolar infiltrates not contained by anatomic borders (diffuse) = ground glass opacities adjacent to the trauma
when and how does ADPKD present
extra-renal sx? (cerebral, cardio, GI, MSK)
-often in 30s-40s w
- reccurent flank pain +/- hematuria
- hematuria = ruptured cysts
- can be triggered by activities that require bending and exertion = yard work
- HTN from renal ischemia
people with malabsorptive disorders are at inc risk for what kind of stones
i.e. IBD
=Ca-oxolate kidney stones
surgical pt w hx of HTN, HAs, anxiety
meds= lisinopril, alprazolam, naproxen as needed
as soon as given anesthesia –> pale, sinus tachy, BP jumps up from 144/90 preop to 250/140
what is the underlying condition and the anatomical location of the path (be specific)
pheochromocytoma = chromaffin cells of the adrenal medulla
- can cause the hx of intermittant HTN–> catecholamines release triggered by anesthetic
vs thryoid storm
- not as acute; associated w inc T
old person w progressive hip pain over months, not able to walk as much on it
dx? what are the findings on this image?
excercise induced unilat arm pain, paresthesias, coolness, and color change
likely dx?
subclavian steal syndrome
17 yo w two days of fever, myalgia, fatigue. vaccines unknown, is sexually active, plays track.
this morning, pain and fullness in the right cheek. PE shows tenderness and fullness in the right cheek that obscures the angle of the mandible.
dx? associated w what other sx/complications?
teen w parotitis following nonspecific prodrome.
- in teens/YA, orchitis –> impaired fertility
- kids/adults –> pancreatitis
- aseptic meningitis is usually benign
- sensorineural hearing loss that is usually transient but can cause permanent hearing loss
2 yo w irritability, intermittant fevers, poor appettite for 2 weeks.
PE reveals: right upper eyelid drooping, pupil is constricted. when pt cries, only left side of the face flushes.
MRI = cervical spine paravertebral mass
dx?
ipsi Horner w Harlequin sign (ipsi absent flushing) and a cervical spine mass in a child = neuroblastoma
- MC extracranial solid tumor in children
- MC in adrenal medullla or sympathetic ganglia
vs. astrocytoma or medulloblastoma = present w ataxia/cerebellar signs, not horner’s
4 mo old, well child visit.
omphalocele noted at birth, treated. had hypoglycemia and poor feeding when first born, but now feeds just fine, is 99% percentile in weight
PE= large tongue, right leg is greater in circumference than left leg.
dx? trx?
Beckwieth Weidmann =11p15-->
- inappropriate growth w visceromegaly, hemihypertrophy, abd wall defects, and tumor growths
- neonatal hypoglycemia and poor feed bc of macroglossia, macrosomia, omphalocele/umb hernia, midfacies hypoplasia w under-eye and earlobe creases, +/- cleft palate
- dx= INC insulin-like growth factor
- inc risk wilms tumor, hepatoblastoma,
trx:
- abd US =every 3 months until 4 yo
- renal US from 4-8 yo q 3 mo
MC cause of pnuemonia in CF
< 20 yo = S. aures
- MC in infants and young children
- not as life threatening, though will also present w nasal flaring, tachypnea, barrel chest and diffuse wheezing and crackles bc CF
>20 yo = pseudomonas
- can occur in infancy but MC in adults: associated w precipitous decline in health and mortality, so always treat for pseudomonas just in case but its not the MC
4 day old baby presents for bilious emesis. went home at day 2 w no problems. at home, baby is feeding well but is irritable and uncomfortably after every meal. today, 2 episodes of emesis. no BMs since discharge.
abd is destended, anal canal is right on digital exam. xray shows dilated loops of bowel.
most likely dx? next best step?
hirschsprung
–MC presents w neonatal bilious emesis and tight rectum = longer section of aganglionic colon
–shorter segment of aganglionic colon will present later in infancy or even childhood w chronic constipation, possibly growth failure/FTT
- xray: proximal dilation of colon, distal narrowing due to no ganglion = obstruction
- PE = distension, tight anal canal, squirt sign = release stool and gas w digital exam
- next best step = get contrast enema, this will show the prox dilation and distal narrowing :
- confirm w rectal suction biopsy
10 day old presents with bilious vomiting for 10 hours.
irritable, refuses to feed. bp 65/36, pulse 175. pt is lethargic.
abd distended, TTP, dec bowel sounds,
small amount of stool in rectal vault.
xray attached. most likely dx? next best step?
volvulus–> unstable pt w peritonitis sx (abd is firm, distended, tender) = emergent laparotmy
- n rectal exam w bilious emesis, abd distension, and air fluid levels w dilated loops of bowel on xray
- MC present w bilious emesis :
- this pt likely has progressed to ischemia /necrosis –> GI bleed, shock
- this pt probably has perforation = perotinitis
- NO DELAY laparatomy for further diagnostic imaging - need to untie bowels and revascularize
4 mo presents s/p general tonic clonic seizure 30 minutes ago.
since birth, pt has had 3 episodes of URI & OM. weight <5% percentile, round cheeks & doll-like face. abd protuberance and liver 4 cm below costal margin. extremities are v thin.
labs= n Na, n K, glucose 38, lactic acid 24 (n= 6-16)
urine= positive for ketones, inc TGs and uric acid
dx and etiology?
glucose 6 phosphate deficiency = von gierke ds : presents at 3-4 mo w hypoglycemia (seizures) and lactic acidosis
etiology= dec glycogen –> glucose conversion in liver (+kidneys, intestines)
**NOT G6PD = glucose 6 phostate dehydrogenase deficiency = teens w transient jaundice w stress**
define primary amenorrhea
what are the first two tests you do in the diagnostic work up
>/= 13 yo with no secondary sex characteristics
>15 w secondary sex characteristics = >Tanner Stage 1 axillary hair, breast development, pubic hair
first US to check for uterus: then FSH levels
- FSH low –> TSH/prolactin
- FSH high –>karyotype
- n FSH = imperforate hymen (red/purple bulge)
what are the pathologic lead points for intussusception (5) and when should you suspect that one exists
most cases of intussusception are idiopathic
25% = pathologic lead points = meckel’s diverticulum (aka congenital malformation), intestinal tumor, henoch schloen purpura, celiac ds, polyps
when is the rotavirus vaccine routinely administered
contraindications to the rotavirus vaccine
16 yo w rash and joint pain onset yesterday. blancheable, erythematous rash started on face and spread down to trunk and extremities, sparing palms and soles. also had pain in her fingers and wrists when she woke up this morning.
is sexually actice, inconsistent w condoms.
PE= posterior auricular and suboccipital LAD present. temp 100.8
dx?
rubella = rash from face down w low grade fever
- +arthralgias in adolescents, esp Fs
(vs mono= no rash, main sign is exudative pharyngitis)
glucocerebrosidase deficiency causes what ds w what presentation
gaucher = present anytime infancy, child, teen, YA, adult
- bone pains, anemia+thrombocytopenia
- delayed puberty
- splenomegaly
guillan barre vs transverse myelitis
- sx
- dx
- trx
guillan barre
- symmetric ascending motor weakness, paresthesias, numbness/pain, only mild sensory loss, dec/no DTRs, +autonomic dys (arrhythmia, ileus) –> resp compromise:
- +radicular pain = electric/shock like pain shooting down LEs
- recent history of URI/GI ds OR recent dx of HIV
- dx= LP : mri is often normal bc gb is a ds of peripheral nerves (v severe, might see enhancement of anterior nerve roots or cauda equina ) ; CSF cell counts and protein levels (NOT pcr bc there will be NO virus in there, it is a peripheral N ds); NERVE CONDUCTION STUDIES bc ds is in peripheral Ns
- trx= monitor, IVIG/plasmapharesis
transverse myelitis
- RAPID bilat motor weakness + sensory loss starting from a clear spinal location = severe, of all types + autonomic dys (incontinence)
- NO rad pain
- classical start w wk/flaccid –prog–> UMN sx
- dx= MRI = hypertense T2 signal of a spinal cord segment
- trx=support and trx underlying cause; causes = , infection (herpes zoster), AI, vascular malformation
dx and trx
chronic dermatophyta infection of toenails MC= trichophyton tubrum
first= terbanifine or itraconazole
second= griseofulvin, fulcanazole
what CV pathologies are associated with obstructive shock
describe the levels of
- central venous pressure
- pulmonary A pressure
- pulmonary capillary wedge pressure
pulmonary embolism, tension pneumothorax
- CVP reflects right atrial P = HIGH bc of the back up = >10
- pulm A P = high bc of back up = >40
- PCWP reflects left atrial pressure = n to low
- also reflects L sided heart function, which is normal in PE/tension pneumo so the PCWP will be n (can be low bc of the shock and dec BF)
vs: inc CVP, pum A pressure, and PCWP = left heart dysfunction that led to right heart dysfunction
pt hopitalized for STEMI two weeks ago, underwent stent placement.
was feeling better and resting at home, taking all meds until last night w sharp CP worse w inspiration and SOB. T-100.6, BP=115/80, respirations =20, O2=92% on RA
mild respiratory distress, mild R LE edema, small L pleural effusion. lungs are clear to asucultation and the ecg shows sinus tachy w nonspecific T wave changes, inc troponin
suspicious for what dx? what is the next best step?
suspicious for PE
- recently hospitalized + had surgery w prolonged immobilzation
- pleuritic CP (worse w inspiration, leaning forward)
- inc troponin w no st change**s = evidence of heart damage from PE and can be seen
- low grade fever, dyspnea, tachycardia, tachypnea, w unilat LE edema and small pleural effusion
next best step: when suspicious for PE= CT pulmonary angiography for high diagnostic accuracy
- = modified wells criterion
- if pt have renal imparement, morbid obesity, or contrast allergy = V/Q scan, but less accurate
pt w 24 hours of intense CP, worse w deep inspiration and leaning forward. friction rub present, ecg= asymmetric t waves in V5-V6
dec appetitie, fatigue and nausea for last several weeks. hx of MI 1 year ago and DM (w retinopathy and nephropathy)
labs- hgb= 9 , BUN=90, Cr=5.1
dx, etiology, next best step?
dx= uremic pericarditis
- blood UREA nitrogen >60, minority of DM nephropathy pts w uremia will develop
- usually NOT associated w classic pericarditis ecg = diffuse ST elevations
trx= DIALYSES ; will resolve sx and dec size of pericardial effusion
vs dressler syndrome= pericarditis 1-6 weeks after MI
role of somatostatin
what does a somatostatinoma present like
somatostatin is triggered by postprandial gastric acid and FAs
- essentially inhibits all gastric secretions and mobility, inhibits gallbladder contraction, inhibits pancreas exocrine function (secretin release, etc)
- **can also be used in emergent variceal hemorrhage/hemoptysis to stop bleeding and stabilize**
somatostatinoma =
- classic triad = glucose intolerance (dec insulin secretion), gallstones (dec cholecystokinin= gb stasis), and steatorrhea (inhibit pancreastic exocrine)
pt in ED, hx HTN recently stopped taking meds, presents for sudden onset R side weakness while on treadmill.
BP= 230/112
in ED pt is lethargic and only responsive to painful stimuli, gaze is deviated L
most likely dx and etiology?
=hypertensive hemorrhage - intraparenchymal hemorrhage that affects the small arteries seen in lacunar infarcts
- progress over minutes to hours w the focal neuro signs –> inc ICP (nausea, lethargy, etc)
MC affected areas = putamen (basal ganglia), cerebellar nuclei thalamasu, pons
-
putaminal hemorrhage= often includes the internal capsul right next to it
- =contra hemiparesis and hemisensory loss, w deviated gaze to ipsi side of lesion
- cerebellar hemorrhage = ataxia, occipital HA, dysmetria, N/V, dizzy
what affect do hydrochlorothiazide/chlorthalidone have on
- Na
- K
- Ca
- glucose
- cholesterol
- uric acid
how do you avoid these affects
metabolic effects of thiazides are DOSE DEPENDENT so minimal doses will be able to help BP without these effects
HIV pt w 8mm induration on TB test and an unremarkable CXR : best management?
this patient has latent TB = asx anergy reaction
- next= trx for latent = 9 mo isoniazid +pyridoxine OR 12 weeks rifampin, pyridoxine, and high dose isoniazid
CXR w infiltrates or LAD OR pt w sx (night sweats, cough, fever) = active TB
bacterial vs viral vs allergic conjunctivitis
- sx and trx
all conjunctivitis = conjunctival inflammation (granular appearance of tarsal conjunctiva)
- bacterial = purulunt dc, high fever,
- viral = mc= adenovirus (school, daycare, etc)= watery dc, low grade fever, systemic sx (sore throat, etc)
- allergic = intermittant, triggered, shorter episodes
- antihistamine drops / mast cell stabilizers = olopatadine, azelastine
requirements to qualify for long term home oxygen therapy
when is survivial significantly improved w home oxygen therapy
COPD w resting SaO2 <88% or PaO2 <55%
OR SaO2 <89% / PaO2 <59% w cor pulmonale, heart failure, or hematocrit >55%
sign when used >15 hours a day
50 yo M presents for rash, joint pains, myalgias, and fatigue for 5 weeks. pt has a palpable purpura on the lower extremities and hepatosplenomegaly. absent achilles bilat, urine w RBC casts and proteinuria
labs= +anti-HCV, +RF, low complement levels, BUN/Cr= 30/2.0
dx?
mixed cryoglobulinemia = immune complex deposition vasculitis associated w palpable purpura, joint pains, glomerulonephritis
associated w Hep C; often Rheumatoid Factor is present, low complement bc of diffuse deposition
dx
trx
lichen planus
5 Ps = PINK PRURITIC PAPULES
w wickham striae = lacy white network of lines on top
when should you be considering male breast CA rather than gynecomastia
breast CA associated w
- FH of BRCA1/2
- abn estrogen:T ratio = klinefelter, obesity, cirrhosis, marijuana
gynecomastia is often symmetric and has irregular borders
86 yo F, hx Alzheimers, presents for several hours of progressive confusion and lethargy. T-100.4, 170/100. pt is somnolent but arousable. withdraws from pain only to the right side but not the left.
dx?
cerebral amyloid angiopathy
- beta pleated amyloid sheets deposit in BVs of the brain –> inc fragile –> spontaneous rupture
- = the same proteins that are found in Alzheimer’s
- MC in parietal lobe or occipital lob, spares deep brain
- hematoma expansion —> inc ICP = confusion dizzy, HA, impaired consciousness, N/V
- trx= reverse anticoag, control BP, normalize ICP
central amyloid angiopathy = MC cause of lobar intracranial hemorrhage and second MC cause of intracranial hemorrhage (after HTN)
which vessel is most likely occluded
associated w what resulting heart rhythm
RCA
associated w mobitz type II AV block, = 90%
(inferior MI –> sinus brady)
ecg changes below associated w which As
- ST elevation in I and avL
- ST depressions in I and avL
- changes in V1-V6 (all or some)
- ST elevation in I and avL = LEFT CIRCUMFLEX
- ST depressions in I and avL = RIGHT CORONARY
- changes in V1-V6 (all or some) =LAD
62 yo man w worsening itchy dry skin on hands for 2 years
dx?
chronic irritant contact dermatitis
in a pt w diabetes that now has irritability and crying spells, balance trouble and + romberg on exam, and + babinski
suspect what
vit B12 deficiency
= neuropsych changes, sensory ataxia, and +babinski
dx
associated comorbidities?
a. fib
irregularly irregular R-R intervals, absence of organized P waves
MC (and most important) comorbidity= chronic HTN
- CAD is the cause seen in pt’s w MI/ischemic HF
does hospice care eligibility require you to foregot all curative and life-sustaining trx
yes
+ life expectancy <6 mo w terminal illness
how to diagnose testicular CA
differentiate btwn presentation of seminoma and NSGCTs
a solid, firm, nontender testicular mass is cancer until proven otherwise
=exam + US + markers
- nontender, firm (ovoid) testicular mass within tunica albuginea
- scrotal US =
- solid hypoechoic lesion ~ seminoma
- lesion w calcfications and cystic areas ~ nonseminoma germ cell tumor
- markers
- elevated serum AFP, beta hcG, Lactate dehydregenase
- seminomas : may have (rare) inc b-hcg but almost always have N AFP
-
NSGCTs :inc AFP and b-hcg in ~85%
- =yolk sac, choriocarcinoma, embryonal carcinoma, and mixed germ cell
- RADICAL INGUINAL ORCHIECTOMY= confrims dx and is definative treatment
- getting a biopsy or even FNA is dangerous bc incision of the scrotal skin promotes spreading CA to local inguinal LNs
structures involved in mediastinal mass
- anterior mediastinal mass
- middle mediastrinal mass
- posterior mediastinal mass
anterior= 4Ts
**lymphomas (arise in LNs) can be in any compartment of the mediastinum
19 yo F presents for recurrint HAs that have been worsening for the last few months. BP in both arms is 170/110 and peripheral pulses are equivalent. auscultation= systolic bruit under the right ear.
most likely dx?
=subauricular systolic bruit = stenosis of internal carotid A
- fibromuscular dysplasia = noninflammatory systemic vascular ds that causes arterial aneurysm, stenosis, dissection
- MC= ICA + renal A >> vertenral, iliac, mesenteric
differentiate between fibrocystic breast changes, cyclic mastalgia, and fibroadenoma
both benign breast disorders associated with bilateral, premenstrual breast pain
- fibrocystic changes= associated w bilat nodules and masses
- cyclic mastalgia = NO masses or nodules
fibroadenoma = SINGLE mobile breast mass w premenstrual tenderness
pt in ED w fever, chills, and weakness for a week. T= 104
holosystolic murmur at lower sternum, increase w inspiration. skin exam attached.
dx and trx?
skin= track marks associated w IV drug use
murmur = TR
=infective endocarditis w staph aureus, trx= empiric vancomycin
8 month old w 2 episodes of OM in the past month and episode of bronchiolitis at 5 months.
dx?
dec total IgG but n response to vaccines= transient hypogammaglobulinemia of infancy
delayed inc in IgG
dx?
keratosis pilaris = keratin plugs of follicles
- benign, MC on posterior upper arms
- usually asx but may have small pustules or by itchy
dx= clinical
trx= (if necessary) emollients and topical keratolytics (urea, salicylic acid)
what can tardive dyskinesia look like and what is the trx
- prolonged antipsychotic use –> abn movements
- grimacing, lip smaking, tongue protrusion ; dystonic posture, foot tapping,, rocking, thrusting
trx=
- wean off if can (stable condition for few years)
- move to less provoking antpsychotic (i.e. clozapine, queitiapine)
- if can’t: monoamine transporter 2 inhibitor (i.e.tetrabenazine, valbenazine)
vs acute dystonia =
- = painful m spasms (i.e. torticollis) hours to days after med
- trx benztropine
what does a hepatojugular reflex mean and what are the MC causes (3)
hepatojugular reflex = reflection of a failing right atrium, that cannot adjust jugular venous pressure to the inc venous return (from holding pressure down on the abd)
MC causes
- constrictive pericarditis
- right ventricular infarction
- restrictive cardiomyopathy
AIDS s/p seizure. lethargy and confusion for last 2 weeks. solitary ring enhancing lesion in the periventricular area, CSF PCR shows EBV.
dx?
primary CNS lymphoma
x oxidative burst in phagocytes = what ds, how does it present, how do you confirm diagnosis
CGD
how do you dx a tracheoesophageal fistula
inabilitytopass nasogastrictube into stomach / inc resistance at end of esophageal pouch
65 yo w this “ulcer” on UE. associated w local numbness, paresthesias, burning pain
dx? what are the risk factors associated w this dx?
squamous cell CA
- vs basal cell (pearly, telangiectasias blled) = SCC has keratinzation (thick rough surface) or ulcerate w crusting and bleeding
- oft associated w nuero sx (numbness, paresthesias)
- risk=
- sunlight, fair skin, chronic inflammation/scar site, hx radiation
- especially common in people w hx of transplant and on immunosuppressive therapy
enlarged optic cup w inc cup/disk ratio = fundoscopic findings for what?
describe any visual changes associated with this
trx?
open angle glaucoma =
- =insidious, pts may have no complaints until v advanced
- associated w peripheral vision loss w intact visual acuity
- typically associated w inc IOP, but not specific of sensitive
- initial treatment = topical bimatoprost to dec aqueous humor volume and pressure
15 yo w L shoulder pain and swelling
dx?
osteosarcoma!!
- sunburst or Codman’s triange
- inc Alk Phos, LDH : v high levels associated w worse prognosis
- risk in boys 13-16, MC at metaphysis of long bones,
- most important finding = tender, ST mass
vs ewing sarcome
- actually v rare, but also associated w adolescent males
- 20% have systemic findings
- osteolytic lesion w perioseal reaction –> onion skin
19 yo F presents with LLE pain worse at night and unrelated to activity. partially relieved by NSAIDS.
xray= sclerotic, cortical lesion w cental nidus of lucency
dx?
osteoid osteoma
vs osteoblastoma : peak 10-20 yo but usually in vertebrae w chronic pain NOT RESPONDANT to NSAIDS
- also lesion in corticla bone w central lucency, but no sclerotic around
- trx- surgery
29 yo F w progressing knee pain and swelling for 3 months.
x ray = expansile lytic lesion at epiphysis of femur
giant cell tumor
=locally destructive, MC benign
=MC in post-puberty YA > or old ppl w pagets
soap bubble on xray:
microscopy giant cells that look like osteoclasts interspersed w sheets of mononuclear stromal cells
etiology of pediatric OSA and what are the sx
+/- day time somnolence
- may present as behavioral changes, irritability..
- daytime mouth breathing fine, able to eat without cough or gag
- +/- nasal speech
differentiate between the sx of
- vertebral A dissection
- anterior spinal A dissection
- posterior spinal A dissection
an aortic dissection can spread up or down and result in any of these
- vertebral A dissection
- neck pain, ischemic stroke, HA
- anterior spinal A dissection
- (most likely at T10-T12 bc that’s where BF is the lowest)
- bladder paresis (retention), motor paresis LEs, loss of crude touch and pain (ALS), diminished reflexes initially
- posterior spinal A dissection
- loss of proprioception + vibration below level of the lesion, mild/minimal weakness
when to use correlation analysis vs chi squared test
chi square = assess proportions of a categorized outcome
correlation : +/-/no relationship that you could graph
opsoclonus-myclonus syndrome is associated with what malignancy
neuroblastoma
first step in the diagnostic process of a F w rapid (within one year)-onset hirustism and signs of inc androgen
first get a T and DHEA-S levels
most likely cause for rapid hirsutism= tumor
- inc T w n DHEA-S= probs ovarian tumor (more common)
- inc DHEA-S = probs adrenal tumor
list the sx of secondary syphillis
and what is the treat
= widespread LAD (including epitrochlear)
=widespread papular rash of whole body, including palms and soles
=condyloma lata = raised grey genital papules
=gray, ulcer like lesions in the mouth
trx= IM penicillin G, f/u in 1-2 mo to confirm dec serology
in what direction is this shoulder dislocation
ANTERIOR dislocation = inferior and medial
vs posterior dislocation= same level/slightly higher, dec space between humeral head and acromion
pt w GERD presents w difficulty swallowing solids and liquids but improvement in heartburn. barium swallow shoes an area of symmetric, concentric narrowing of the distal esophagus
dx? trx?
esophageal stricture
GERD –> barretts / esophageal stricture (can be both in same pt)
dx= biopsy to rule out adenocarcinoma (esp if hx of barretts)
trx= endoscopy
long hx of RA + splenomegaly + neutropenia
dx?
FELTY syndrome
-long standing RA –> develop av against neutrophil compnents and granulocye stimulating factor
- associated w high levels of RF, CCP: most patients are HLA-DR4 positive
- neutropenia (+/- dec WBCs) = recurrent bacterial infections, especially skin and sinuses
which chemo drugs are associated with cardiotoxicity
anthracyclines (doxarubicin, -rubicin)
trastuzumab - used in HER2 + breast CA
- check eck before starting, do echos are regular intervals and stop if sx HF or EF drops by 16% +
42 year old w 2 days of severe itching and burning of the lower back and then this rash presents
dx?
shingles= herpes zoster reactivation
=two adjacent dermatomes!, preceding neuritic sx
=small papules that can become confluent and evolve into vesicles and bullae
interpret this non-stress test
what is the next best step in management
reactive NST
=2+ accels 15+ above baseline for 15+ sec
i..e if a pt comes in with pretern contractions, closed service, and this NST –> conitnue routine prenatal care, no need for additional monitoring
- when would you order a biophysical profile
- when would you perform fetal scalp stimulation in a pregnant woman
- when would you order an umbilical A Doppler
- when would you get fetal fibronectin
BPP or contraction stress test is used to assess the fetus’ risk of hypxemia and fetal demise
- use if the pt has an uncomplicated pregnancy but an NONreactive NST
if have NONreactive NST –>
- perform fetal scalp stimulation to promote accels
- if fetus moves, they were probs just asleep (n physiolical)
- if fetus still don’t move, a sign that it might be more pathologic (i.e. acidemia )
umbilical A dopper = assess growth restricted fetus on US (<10% of estimated fetal weight) - oft present later in preg, 25+ wk
- assess for placental insufficiency and progressive hypoxmia
- inc intravascular flow resistance –>dec perfusion and worsening fetal hypoxia –> emergeny deliver
fetal fibronectin
- if mom is having preterm contractions, get fibronectin to estimate the probabilty of preterm delivery
two diff scenarios - what are the dx?
1) pt had cough and sore throat two weeks ago that resolved. for past week has been having mid-chest discomfort that radiates up to the left neck. today in ER v SOB, weak, dizzy. threaded pulses on bilat radial arteries that disappear w deep inspiration. dx?
vs
2) 32 yo F had sore throat and coutgh two weeks ago. for past 4-5 days, pt has had inc fatigue, progressive SOB, and swelling of feet. BP=110/65. bibasilar crackles, elevated JVP, 2+ pitting edema bilat LE. dx?
1) viral illness –> CP = probs viral pericarditis
- MC cause = coxsackie
- often presents as retrosternal pain that radiates to the L arm and shoulder (neck)
-
–> now severely worsened probs from cardiac tamponade = severely dec CO
- presents w pulsus peridoxus = large decrease in SBP on inspiration = cannot feel (already v soft aka thready) pulse on inspiration
- echo= thickened pericardium w loculated pericardial effusion
- = acutely ill pt = bacterial pericarditis
2) viral illness–> viral myocarditis
coxsackie, adenovirus, parvovirus B19
- acute decompensated heart failure secondary to viral myocarditis. not acutely ill but have CP
- echo = dilated ventricular chambers and diffuse hypokinesis
which vaccines are required for pts diagnosed w HIV
- HAV, HBV, HCV?
- MMR, Tdap, influenza?
- TB vaccine (bacille-calmette-guerin?)
- pneumococcal (be spec.), meningococcal
primary prophylaxis against what and with what meds?
get TB screening (PPD) and trx but NOT the vaccine
MMR + varicella zoster = CONTRA
- recombinant zoster vaccine can be given to non-varicella immunized
PROPHYLAXIS
- less than 200 = TMP-SMX for pnuemocystis (<100 = protecc against toxo, also TMP-SMX)
- NO
- MAC coverage w azithromycin no longer rec bc of dec incidence
- HSV (acyclovir) = only for secondary prophylaxis (prevent recurrence of outbreak)
- antifungals = against histo sometimes if CD4 < 150 and live in ohio/mississippi river valley
pt HA worse w leaning forward and prominent JVD on the left side only, no peripheral edema
dx? trx?
SVC syndrome =
MC cause= malignancy so trx is to treat the malignancy
less common = fibrosing mediastinitis from TB or hiso
bullous pemphigoid vs pemphigus vulgaris
BP=
- 40-60 yo
- itchy (not pain), tense bullae w prodrome of eczema/urticaria-like rash
- rarely involve mucosa
PG =
- > 60 yo = AI ds
- flaccid, painful (no itchy) , easily rupture and form erosions
- almost always have mucosal (oral) involve
trx both w steroids
dx?
tension pneumothorax
ICD = implanted cardiac defibrillator
- tension pneumothorax as a complication of cardiothoracic procedure = dyspnea in recovery until
MC fetal complications of untrx/uncontrolled gestational DM
respiratory distress syndrome (esp if preterm) , preterm delivery, macrosomia
pulmonary findings associated w lupus vs sarcoidosis
young AA pts
SLE= serositis (inflammation of the pleura associated w SLE and RA) = pleural inflammation +/- pleural effusion, pericarditis, peritonitis
- associated w pancytopenia, and poly-arthritis
vs sarcoid = hilar fullness (LAD) and reticular opacities
- associated w erythema nodosum and uveitis
dx?
associated w what other sx
trx?
plaque psoriasis = erythematous plaques w silver white scale mostly on EXTENSOR surfaces
- koebner phenomenon = at places of inc friction (lots of kneeling ==> knee)
- associated w nail pitting, onycholysis: conjunctivitis, uveitis
trx= topical high dose steroids or Vit D derivative (calcipotriene)
7 yo sickle cell pt presents to ED for 2 days of dec appetitie and lethargy. refused to get out of bed this morning. hx of hospitalization of acute chest syndrome
T=103 BP=70/30 P=150 RR=23
responds to Qs appropriately. no pain on PROM.
scattered petechiae seen on both legs
dx?MC cause?
bacteremia : circulating bac are not opsonized bc of functional asplenia, can present even with appropriate prophylacic trx (penicillin)
sx= acute (sudden) onset fever, lethargy, hypotension, tachypnea, can rapidly progress to sepsis
- scattered petechiae can be associated with any cause of DIC (including sepsis seondary to bacteremia) = sign of impending decomp
MC cause in sickle = strep pneumo, Hib
where is the lesion?
pt has hoarse voice, loss of gag reflex, ipsi horner’s syndrome, horizontal and vertical nystagmus, vertigo
lateral medulla = Wallenburg syndrome = posterior inferior cerebellar A
don’t pica ho(a)rse that can’t chew
midbrain - pons- medulla- SC
most likely neurovasc structure to be injured
midshaft humerus frx
radial N (sensation of dorsal hand, wrist and finger extensor strength, can cause wrist drop)
(brachial A injury is way less common is associated w dec peripheral pulses)
14 yo w fatigue when playing basketball, unable to keep up w peers like he used to. auscultation reveals soft, midsystolic murmur best heard at left upper sternal border and wide-split S2
dx
ASD
usually presents in teens/YA w
- dec excercise tolerance w fatigue, dyspnea,
- atrial arrhythmias (flutter, fib)
- paradoxical emobilizaiton = stroke
- cerebral abscess
auscultations= inc R sided bloow flow from intracardiac L–>R shunt
pancytopenia w peripheral blood smear showing ovalomicrocytosis and reduced nø segmentation
dx? biggest risk factors? confirm dx?
myelodysplastic syndrome
inc risk in old ppl, and previous radiation or chemo
dx= BM biopsy
55 yo WF w nonhealing ulcer on L foot. urine shows mixed proteinuria and hematuria. recently was evaluated for ear pain and hearing loss.
dx?
granulomatosis w polyangiitis (wegeners)
- necrotizing vasculitis of small to med vessels
- nonhealing skin lesions due to local necrosis + ischemia
sx= ANCA positive
- ENT invovement
- lung nodules/ cavitation
- glomerulonephritis
- skin = levido reticularis, pyoderma gangrenosum (papule/pustule progresses to nonhealing painful ulcer)
how to diagnose pharyngitis !!
viral sx = no diagnostic test, symptomatic trx
exudates/high fever/petechiae/ edema
- get rapid Ag test / strep culture
pt w several days of malaise and LBP woke up today unable to stand
fever 101, PE= loss of sensation and 0/5 strength bilat LE
dx? trx?
spinal epidural abscess
classic triad = fever, focal back pain, neuro sx
- labs = ESR inc (+/- leukocytosis)
dx= MRI spine
trx= broad spec abx = vancomycin + ceftriaxone and then urgent decompression
Pt presents w right sided neck pain and pain and numbness in right 3+4th digits. Dx?
Pancoast tumor
consider in an old person w smoking hx
mc= small cell lung ca
For what ages is regular mammogram recommended, and how often
For which patients is early screening recommended
Age 50-75 q2 years
early in high risk =
- 1 first or second degree relative w both breast and ovarian CA
- 1 first degree relative w bilat breast CA
- 2 first degree relatives w breast CA, one of which was before 50 yo
acute substernal CP and SOB. ausculatation = scratchy sound heard just before S, between S1+S2, and faintly right after S2
dx?
26 yo w sudden onset LLQ pain radiating to groin. CT shows 5mm radiopaque stone
serum Ca is n, BUN/Cr is n. never had these sx before.
what kind of stone?
MC stone = calcium oxalate, = small, radiopaque
- serum Ca levels can be normal; these stones can be precipitated in any normal patient with dehydration, excessive sodium in diet, obesity
- some stones are Ca oxolate and Ca phosphate mixed but pure Ca-PO4 is v rare
- urine= hematuria but no casts
67 yo comes in w dec visual acuity worse at night, w halos around streetlights. Has noticed dec need for reading glasses.
dx?
MC cause of painless transient (<10 min) of mono-ocular vision loss
amaurosis fugax = an embolus!!
MC cause of unlateral cervical lymphadenopathy in kids? how does it present (preceding sx, onset)
- what causes a chronic, violaceous nontender unilateral cervical LAD?
bilateral cervical LAD?
- acute?
- chronic?
MC = S. aureus= acute, often no preceding sx
bilat= adenovirus
55 yo presents with 6 mo of decreased lateral vision, requiring him to physically turn to see. also notes dec libido, thought might be secondary to long hours at work. also notes intermittant HA in morning.
what type of primary brain tumor is most likely
craniopharyngioma
MC in children, but 50% in >20, esp 55-t5
differentiate between the presentations of
- functional hypothalamic amenorrhea
- primary ovarian insufficiency
- what is ashermann syndrome
both cause amenorrhea
- functional hypothalamic amenorrhea
- something disrupts the HPA axis = sign weight loss, caloric deficiency, strenuous excercise, chronic illness, stress
- DEC FSH levels (probs in hypothalamus)
- (-) progesterone withdrawal test bc dec estrogen in body
- dec estrogen also –> dec libido, vaginal dec rugation and dryness, infertility, stress fractures (Oporosis)
- first line trx= behavioral (inc calories) +/- estrogen replacement
- primary ovarian insuff
- present w amenorrhea plus vasomotor sx i.e hot flashes
- INC total FSH (probs in ovaries)
- asherman syndrome
- postpartum / intruterine surgery –> amenorrhea w n FSH levels
- due to intrauterine adhesions post-trauma
- also associated w cyclic pelvic pain and recurrent pregnancy loss
KOH shows septate hyphae
dx?
dermpatophytes = annular lesions w raised, scaly borders +/- partial central clearing
vs candida = budding yeasts w pseudohyphae
rosacea =
- who?
- 4 types
- trx?
- who
- often in elderly white ppl
- inc risk w UV light, vasomotor dysfunction, may be inflammatory rxn to micoorgnanisms
- 4 types
- erythematotelengiectasias
- facial flushing, telangiectasias, roughness, scaling, burning sensation
- papulopustular
- kinda looks like acne
- ocular
- involve corean, conjunctivae, and/or lids
- feels like burning, fb sensation, recurrent chelazia (swelling of life), conjunctivitis, keratitis, corneal ulcers
- phymatous
- chronic irregular thickening of skin, oft of nose
- erythematotelengiectasias
- trx=
- mild= lid scrubs, topical metronidazole/erythromycin, ocular lubricants
- severe= systemic abx, topical ummunosuppresants (steroids, cyclosporine)
uncontrolled HTN and crack cocaine use are associated w what kind of ICH
50% (will have hypertensive vasculopathy that –>) hemorrahge into basal ganglia
- this commonly leads to uncal herniation
- = nonreactive ipsi pupil
- +displace midbrain = dEcErEbrate CONTRA positioning, coma, resp compromise
- basal ganglia hemorrhage = diffuse inc DTRs and babinski
2 days post op mom presents w 103F and uterine fundal tenderness.
deliveryrequired forceps use bc of maternal exhaustion and nonreassuring FHT after 2 days of labor
dx? trx?
post-partum endometritis = infection of uterine decidua
broad spec abx= gentamicin + clindamycin
MC cause of atypical pnuemonia in healthy ppl
presentation? trx?
mycoplasma pneumonia
- indolent, viral-like prodrome, oft w hemolytic anemia
- bilat fluffy infiltrates
trx= azithromycin or resp floroquinolone
dec REM sleep latency is associated w ? (2)
depression
narcolepsy
wiskott aldrich
traid of features
-in whom does it present
trx?
babies : 1-2 yo
-recurrent sinus/ear infections : dry skin/eczema : thrombocytopenia (purpuric rash)
trx= HSC transplant
allergic bronchopulmonary aspergillosis is associated w what two chronic conditions
asthma and CF
9 yo M w dark brown urine after 3 days of fever, sore thraot, cough. hx of sensorineural hearing loss.
dx? what is seen on rena biopsy?
alport = x IV collagen
- kidneys, ears, lens (eye), BVs (HTN)
- Xlinked R
recurrent nasal discharge/congestion w bland tasting food is associated w what pathology?
this pathology is part of what respiratory triad, and how does it present?
nasal polyps = chronic congestion, sensation of post-nasal drip bland tasting food
ASA-exacerbated respiratory disease
- asthma (oft in childhood)
- resp reaction to ASA use (i.e naproxen) = bronchospasms (wheezing, often go to ED) or congestions
- nasal polyps = bilat, grey glistening mucoid masses
pt was in an MVC 5 months ago and had some blunt thoracoabd trauma, w no complications and was dc after overnight observation. now has vague chest pain.
dx? trx?
daiphragmatic rupture: associated w hx of blunt trauma –> tear/avulsion of L>R diaphragm (liver protecc)
some pts (esp kids) have not have sx until months to years later
CXR= lung compression, mediastinal shift, bowel looks in thoracic cavity
- delayed dx –> inc risk hernia formation/ bowel strangulation & ischemia
- further testing = CT chest+abd = more definitive and diagnostic
- trx= emergent surgery
pt had a uti last week, succesfully trx w TMP-SMX
now pt has a disseminated maculopapular rash and malaise
urine= 2-3 RBCs, many WBCs, and proteinuria
what type of kidney injury is this?
acute interstitial nephritis
- associated abx allergy, days-weeks later
vs post-infectious glomerulonephritis
- after strep throat or skin infection, 1-2 weeks later
- RBC casts and mild proteinuia
- no associated rash, usually has HTN and periorbital edema
what is stent thrombosis and what is the MC cause
inc thrombotic risk for 6-12 mo post stent placement, until fully endothelialized
non-adeherance
when do you deliver pre-eclampsia without severe features
when do you deliver pre-eclampsia with severe feautres
- what are the severe features, how many do you need to deliver
what is the trx of severe pre-eclampsia?
PE w/o SF = 37 weeks
- get pre-eclampsia (protienuria+inc BP at > 37 weeks= deliver them now)
PE w SF= >34 weeks w even one severe feature–> deliver now
- severe features =
- Cr > 1.1/2x baseline
- pulmonary edema
- signs of organ compromise = Cr, HA
- plts < 100k
- SBP 160+ / DBP 110+
- AST/ALT > 2x ULN
- trx severe range HTN= IV labetolol, IV hydralazine
- seziure prophylaxis = magnesium sulfate
what are the 6 steps of a failure modes and effects analysis
when is routine testing for GBS done?
when is intrapartum prophylaxis indicated
@36-38 weeks
intrapartum IV penicillin G indicated if
- labor @ <37 weeks
- prolonged rupture of membranes 18+ hours
- at any point in this gestations mom had GBS UTI or bacteremia, even if it was treated
- intrapartum fever
- prior infant w early onset GBS
which post MI complications are associated w
- RCA vs LAD infarct
- acute/ subacute presentation vs months later
ECG changes associated w LV aneurysm
RCA
- papillar M rupture or RV failure
LAD
- LV aneurysm or free wall rupture
(IV septum rupture is either)
- acute= RV fail
- subacute= papillar M rupture of IV septum rupture or free wall rupture
- mo = LV aneurysm
- deep Q waves and persistant STE in I, avL, V2-V5
contra indications for hormonal IUD vs copper IUD
- which one is better for heavy bleeders
hormonal IUD dec menstrualbleeding!!
contra to both = acute pelvic infection
hormonal contra= acute liver ds, breast CA
copper contra= wilson’s ds, copper allergy, heavy menstrual bleeding
OB and medical complications of acute pyelonephritis in pregnancy
can cause preterm labor, low birth weight, and tachycardia on FHT
- associated w nulliparity and asx acteriuria, as well as <20yo and DM
med probs = ARDS, hypothermia
clinical presentation of mastoiditis
hx acute otitis media –> now have pain directly posterior to air, purulent exudate external ear and bulding TM, the external ear may be posteriorly displaced
41 yo presents with persistant LBP that has gotten significantly worse over the last week. hx reveals irregular menstrual cycles w intermittant light spotting, but no other medical problems
PE = 2+ pitting edema bilaterally
CT= bilat hydronephrosis and lower uterine segment mass extending laterally
dx? associated with what systmic illness?
cervical CA, an AIDS defining illness
pt presents diff walking, involuntary movements, imbalance.
hx total thyroidectomy, current meds = synthroid, calcium carbonate, calcitriol but has been inconsistent w f/u.
labs = dec, Hgb, 7.8 Ca, 7.4 Ph
CT head shows calcifications in basal ganglia
most likely dx?
chronic hypoparathyroidism
dec Ca + inc PH
Ca-Ph product > 55 = inc risk of ST calcification
- Ca= 57.72
- BG calcification is a common association w chronic low PTH, now pt has EPS
- other complications = nephrocalcinosis and cataracts
BPH vs prostate CA
which one is transition zone? which is central / peripheral?
prostate CA is associated w inc prevalence in what race/ethnicity
good and bad prognostic factors of schizo?
pt presents @ 24 weeks gestation for no fetal movements. hx of US showing multiple fetal anomalies and posterior placenta. current US shows no FHTs and patient is admitted for L&D of stillborn. 30 min after delivery, placenta has still not delivered and oxytocin is administered. 90 minutes after delivery, pt has profuse bleeding that soaks the sheets, BP 110/60, and large V of clots in the vagina.
dx and most likely cause?
postpartum hemorrhage due to retailed placenta
- = placenta retained longer than 30 min postpartum
vs DIC = would not be clots, would be bleeding from mucosal surfaces and IV lines
vs uterine inversion = from pulling too hard on placenta, presents w PPH and a visible mass protruding from cervix/vagina
vs uterine rupture = intense abd pain and antepartum rupture and palpable fetal parts (freaky hand crawling out uterus tear)
hx of GI ds now pt has hx of meningitis
how did the pt contract this illness
listeria monocytogenes meningitis
-from unpasteurized milk
(NOT LEGIONELLA)
what is dress syndrome and what causes triggers it
= hypersensitivity rxn to allopurinol, phenytoin, or carbamezapine
Drugs
Rash (morbiliform)
Eosinophilia
Systemic Sx
vs Dressler syndrome = post-MI pericarditis
44 yo M w 6 mo of pruritis, fatigue, dark urine and pale stools.
MRCP attached.
dx?
myelodysplastic syndrome vs CML/CLL
MDS = (pan)cytopenias w insuff reticulocytes
- associated w hypogranular Nøs w dec lobulation
- may transform into CML>CLL
CML/CLL = inc in lymphoblasts/myeloblasts = inc in leukocytes, oft associated w hepatosplenomegaly
clinical presentation of abn endometrium vs myometrium proliferation
how to diagnose each
myometrium proliferation = uterine fibroids
- inc heavy menses and irregularly shaped uterus
- get a sonogram
endometrium proliferation
- endometrial hyperplasia = prelim to endometrial CA = inc menstrual bleeding but regular shape
- endometrial polyp = inc intermensrtual spotting, regular shape
- > 45 yo and risk for endometrial hyperplasa –> get endometrial biopsy
- consider in younger than 45 if risk factors present or other trx has failed
how do you differentiate bwn waldenstrom macroglobulinemia and multiple myeloma
how do you trx WM
WM= IgM —-trx= plasmapharesis
MM = IgG, IgA, light chains
what CA is this most likely to be
= single cavitary lesion with air fluid level –> ML squamous cell carcinoma
most in center, but up to 40% peripheral
associated w long term smoking
which type of inguinal hernia (direct of indirect) is associated with
- protrustion through deep inguinal ring
- weakening of the inguinal canal floor and transversalis fascia
- infants
- older pts
MD = direct hernia is medial to vessels
indirect = IN the INguinal canal
pineal gland tumors are most common in what population?
-what two “syndromes” are assoicated w pineal gland tumors
kids 1-12 yo
-parinaud syndrome = down and out, retracted eyes, light-near dissociation
-obstructive hydrocephalus - papilledema, V, –> progress to ataxia
anterior uveitis
- what is the anatomy/pathology
- what is the clinical presentation
-unilat painful, “red eye” w tearing, photophobia, and dec visual acuity
- mostly idiopathic, but can be associated w lupus, IBD, herpes, toxo, akylosing spondylitis
- PE= ciliary flush, red eye, pupillary constriction, “hazy” aqueous humor
36 yo M w two mo hx of dry cough and malaise presents for skin changes. painless, wartlike lesions on R forearm and neck
warts= violaceous on heaped up skin, w sharp border. one lesion on the neck has peripheral ulceration and is crusted over.
pt=agriculture worker in wisconsin
most likely dx
blastomyces dermatitides
-blasto = pulm, skin, bone, prostate, CNS
craniopharyngioma vs pituitary adenoma
- clinical presentaiton
- imaging
both have=
- bitemporal hemianopsia
- can cause inc ICP
craniopharyngioma
- age = 5-14 & 50-75
- causes endocrinopathies bc of compression of pituitary stalk
- calcified or cystic suprasellar mass
pituitary adenoma
- peal = 35-60 yo
- can be secratory (prolactin MC –> galactorrhea + amenorrhea) or nonsecratory = present only if get v big with mass effect + hypopituitary
- NOT calcifed on imaging, is an intrasellar mass (MRI sella w IV contrast= gold)
a holosystolic murmur associated w dilated cardiomyopathy?
what is the etiology?
MR : the papillary Ms are pulled out bc of dilation –> stretched chordae tendinae –> dilated mitral valve –> regurge
- the murmur can fix / improve once any decompensation is treated bc dec LV end-diastolic V –> not as much stretching –> papillary Ms can return to their optimal position
vs. hypertrophic cardiomyopathy = dynamic LV outflow obstruction = crescendo-decrescendo murmur
- inc w dec LV preload
pt presents for a lump in her neck she found a week ago. palpation = nodule, labs reveal n TSH, T4. calcitonin is inc, FNA shows malignant cells.
FH= mom who died during surgery for thyoid CA
most likely dx? next best step?
probs MEN2A/MEN2B
-thyroid nodule w inc calcitonin –> medullary thryoid CA
- her mom had thyroid CA which means it was probs inherited
- mom died during surgery ~ HTN crisis secondary to pheochromocytoma, happends during procedures
next best step =
- genetic testing for RET mutations
- plasma fractioned metanephrine levels
64 yo man presents for 6 mo of persistant cough and worsening dyspnea on exertion. pmh = inferior MI 5 years ago, GERD, hiatal hernia, HTN all trx w meds.
BP=130/78. PaO2= 87% on RA
lungs = dry, inspiratory crackles on lower lung zones
no JVD, no peripheral edema, CXR is normal.
what is the likely dx, and how do you diagnose it?
interstiital lung ds
- hx of ischemic heart ds w dry cough and exertional dyspnea
- dry crackles = inspiratory velcro crackles
dx= high resolution CT = way better at picking up interstitial changes
+ full PFTs
**gerd would not explain the velcro crackles or dyspnea
- tho chronic GERD can cause idiopathic pulmonary fibrosis = ILD
- still get the high resolution CT to dx that tho
67 yo man presents for syncope at the mall, had no preceding sx or confusion afterwards. had episodes of light headedness a couple times this month but never had LOC.
ecg now shows sinus rhythm w prolonged PR interval, wide QRS complexes, normal Qtc interval, and occasional premature ventricular contractions.
what is the etiology/physiology of the patient’s syncope?
bradyarrythmia secondary to AV block / conduction abn
bc its episodic nature, the HR may be normal at presentation
1 day old bb girl presents w webbed neck, horseshoe kideny, dysplasic nails, pulmonary edema, and nonpitting carpal and pedal edema
what is the etiology of the edema
turner syndrome: >50% have lymphatic network dysgenesis
- =non pittting edema from accumulation of protein rich fluid
- severe ; can lead to hygroma –> or hydrops fetalis
exophytic warty growths on the vocal cords
dx? cause? trx?
laryngeal papillomas
=HPV 6+11
benign but can cause lots of complcations: mainstay of trx=surgical debridement
which organs are retroperitoneal
SAD PUCKER
supreadrenal :: aorta/IVC :: duodenum 2nd and 3rd segments :: pancreas except tail :: Ureter :: Colon ascending and descending :: Kidneys :: esophagus :: rectum
5 yo presents w R eye pain started this morning. pain and watering starting this morning, now has dec vision as well in right eye. pain w eye movement.
Pe = conjuncititis, periorbital edema, proptosis, r side erythema. TTP of right cheek.
- 9 F
most likely dx? what is the most likely/MC cause?
orbital cellulitis
- MC cause is bacterial sinusitis, esp if nearby can have direct spread of Strep/Staph
- less likely but common = dental abscess on the same side, in the maxillary teeth (near sinus/orbit) **NOT from molar teeth*
vs. ds spread from molar infections –> Ludwig Angina
- rapidly progressive infection of the submandibular space
- systemic sx (fever, chills, malaise)
- local sx= drooling, muffled voice, mouth pain, dysphagia, airway compromise, displaced tongue bc floor of mouth is elevated
- trx= IV ampicillin-sulbactam / IV clindaymycin
62 yo F presents for inc fatigue and pains. she has worsening pain and stiffness in her bilat hands. PE shows moderate swelling and tenderness of hands and knees bilat. she also has brief episodes of sharp chest pain worse w inhalation- PE= inspiratory rub.
PMH= nonischemic cardiomypoathy w LV obstruction, EF=40%.
current meds= hydralazine, carvedilol, furosemide, isosorbide mononitrate
most likely dx and etiology
DRUG INDUCED LUPUS
=athralgias + serositis (pleuritis/percarditis) + systemic sx
MC causes = hydralazine, penicillamine, procainamide
- also isoniazid, infliximab, minocycline
sheehan syndrome that results in dec ACTH will affect the following in what way
- serum Na
- serum K
- ALD
- ADH
dec ACTH–> dec cortisol –> (loss of inhibition of ADH) –> SIADH–> dec Na
**adrenal glad is still functioning= RAAS+ALD still functioning –> n K**
a new rapid diagnostic test for respiratory infections is evaluated in a population where 30% of individuals have a respiratory infection.
the new test is 90% sensitive and 80% specific.
what is the probability that an individual will be correctly classified by the test?
aka = “what is the accuracy of the test”
-how many people who test (+) are (+) and who test (-) are (-)
- sensitivity = how many actual + will test +
- specificity = how many actual - will test -
=(true positives + true negatives) / total
- they give prevalence, assume 100 people : 30 actual (+) + 70 actual (-)
- TP= sensitivity * actual (+) = 0.9 * 30 = 27
- TN = specificty * actual (-) = 0.8 * 70 = 56
- accuracy = (27+56) / 100 = 83%
45 yo F presents w colicky RUQ abd pain after eating a fatty meal.
hx of cholecystectomy for symptomatic gallstones
labs= inc direct bili, inc Alk phos, AST/ALT
imaging= dilated common bile duct without any stones
pt given morphine for pain control but the pain just worsens
dx?
sphincter of odi dysfunction : mimics gb obstruction w inc labs and sx
- can follow any inflammatory process (surgery, pancreatitis, etc)
- = dyskinesia and stenosis of sphincter –> bile retention
- opioids cause sphincter contraction and can worsen/precipitate sx
gold standard for dx =SOD manometry
- vs: biliary gastritis = x pyloric sphincter after gastric surgery
what is flash pulmonary edema?
recurrent episodes is associated w what
flash pulmonar edema : presents as sudden onset SOB and inability to lie flat, JVD but no LE edema and normal ejection fraction
- trx w diuretics and the episode resolves
- in a pt w hx of CAD, severe HTN, and recurrent pulmonary flash edema –> renal a stenosis
- unilat RAS –> the unaffected kidney can compensate for the inc RAAS–> hyperALD aka Cr is normal
- in bilat –> can lead to CKD
pt, hx of unilat nephrectomy after a MVC 25 years ago, presents w flank pain and hx of low urine output. intermittantly has episodes of high urine output and mild weakness.
labs= K 3.4, Cr 1.7, urine w trace protein and 4WBCs
dx?
post-obstructive diuresis = the urine build up is enough to overcome the obstruction
-urine outflow tract obstruction, probs renal stone (esp w flank pain)
pt came into the ED post MVC that cause a hemopneumothorax.
was properly treated and had chest tube placed, w improvement of sx. now, 4 days later, pt is complaining of worsening SOB, chest tube has serosanguinous drainage.
has an occasional dry nonproductive cough.
dx?
diaphragm injury –> diaphragmatic hernia
secratory vs osmotic diarrhea
- stool osmotic gap
- when does it happen
- causes
osmotic diarrhea
- high SOG, >125
- happens after large meals
- due to presence of osmotically active solute = lactulose, ascites, polyethylene glycol
secratory diarrhea
- low SOG, <50
- can happen during fasting, i.e. nocturnal
- due to toxins (vibrio), hormons (VIPoma), CF,
9 mo w port wine stain is brought in for left eye redness and tearing that began last night.
L eye = tearing, conjunctival erythema, larger globe and cornea of L than R, pt blinks frequently and turns away when light is shone in l eye
most likely dx? how to confirm?
sturge weber = port wine stain, leptomeningeal capillary, venous malformations, + glaucoma
- anterior chamber angle abn
- confirm= tanometry which will find inc IOP
45 yo man presents for recurrent sinusitis and otitis. hes been on and off inhaled steroids and abx for the past 6 months. reports scant yello dc w occasional blood. pmh is significant only for joint and back pains, for which he uses OTC ibuprofen and ASA.
ex smoker w 15 pack yr hx. otoscopy= erythema and small ulceration in right auditory canal. hgb=10.8, plt=410k, WBC=10.7k
urine= 2+ protein, 2+ blood, 20-30 RBCs
most likely dx? how to confirm?
granulomatosis w polyangiitis = wegener
= URT (nose, ears, sinuses) + LRT (lungs) + _arthralgias/arthriti_s + systemic sx + rapidly progressive GN
dx= quantitative serum Abs = cANCA
pt, hx of Hep C, presents for numerous blisters that appeared on the back of her hands last week after she spent some time gardening. on exam, some have crusted over and left scars.
most likely dx?
porphyria cutanea tarda
= associated w Hep C
- enzyme x in early porphyrin metabolsim –> abd pain and neuropsych sx
- enzyme x later in metabolism –> photosensitivity w blisters on the hands and hyperpigmentation on sun exposed areas
vs cryoglobulinemia
- also associated w Hep C
- but presents w palpable purpure, arthralgias, and glomerulonephritis
what are the three common vascular complications for cardiac catheterization?
how do you differentiate between the three clinically?
femoral A access is MC way to do cardiac cath
- oft –> local femoral A complications = inguinal/groin pain after the procedure
= AVM, pseudoaneurysm, or hematoma
AVM = continous murmur, +/- palpable thrill, NO palpable mass
pseudoaneurysm = bulging, pulsatile mass, systolic murmur
hematoma = +/- mass, no murmur
3 yo w fever, V, and D is given ibuprofen and subsequently develops oliguria, dec Na+ dec K, dec bicarb, and 2+ ketones on urine
BUN 46, Cr 1.4
what is the most likely etiology of kidney injury
NSAID induced kidney injury
- this dehydrated pt was given an NSAID = COX inhibitor
- the kidney responds to volume depletion w inc COX –> afferent A dilation
- inhib COX –> vasoconstriction in the setting of volume depletion –> kidney injury
62 yo M w mild L foot pain and trouble walking. now has to ambulate with the cane. PMH = T1 DM, HTN, hypercholesterol, .
PE= sign deformed ankle and mild deform foot
imaging below?
dx? most likely cause
neurogenic arthropathy, most likely secondary to diabetic neuropathy
- chronic dec sensation and change in weight bearing –> mechanical changes
- associated w osteophyts and dec joint space (kinda like OA), but with gross deformity, inc bony fragmentation and deformity, and dec bone mass
MC causes of secondary clubbing
MC -
- lung malignancy
- cystic fibrosis
- right to left cardiac shunts
**hypoxemia in COPD does not lead to clubbing
56 yo F presents for eye irritation, pain w eye movement, and diplopia for a few weeks. she has also noted fatigue and weight loss in this time.
PE eye attached.
most likely dx? mechanism of eye sx and exam?
exophthalmos = graves ds
- = lymphocytic and mø infiltration of ocular Ms –> orbital tissue expansion
- sx = exophthalmos as well as eye irritation, gritty feeling, pain w eye movement, diplopia, redness, photophobia, and tearing
4 mo presents w abnormal twisting of extremities and torso. has not been evaluated since dc at 2 days, n complcations except a cephalohematoma which resolved. pt also cannot lift uphead from supine yet, has crossed eyes, and does not response to sides.
kernicterus = inc bilirubin neurotoxicity
- chronic in this baby that hasn’t been checked and followed
- often idiopathic : this bb had cephalohematoma, w resorbption = inc indirect bili = in risk of kernicerus
- sx= chorea like movements, sensorineural hearing loss, developmental delay, upward gaze palsy
5 yo w fever, sore throat, and grey ulcers on soft palate and uvula
dx? etiology?
herpangina= coxackie A
- grey vesicles/ulcers on palate, uvula, tonsils
- +fever, pharyngitis
- 1-7 yo; ate summer, early fall
VS HSV1 herpetic gingivostomatitis
- clusters of vesicles on tongue, lips, buccal mucose
- fever, pharyngitis, erythematous gingiva
- 6 mo-5 yo
89 yo F presents for episodic ski discoloration over the last few months. hx= diet controlled DM and OA controlled w acetominophen.
PE= thin, hyperpigmented skin w several flat, dark purple ecchymotic regions over hands and forearms.
liver= 6 cm, spleen not palpable
most likely dx? inc risk ? management?
senile purpura = loss of elastic fibers in the perivascualr connective tissue
- = old people or middle aged w lots of UV exposure =”solar” / “actinic” purpura
- inc risk w use of anticoag, NSAIDs, or steroids
- minor abrasions that usually only stretch skin in younger people willcause rupture of superficial BVs –> extrasavation of blood –> ecchymosis
- vulnerable areas= hands and forearms
- hemosiderin depo can lead to residual brownish discoloration even once purpura resolve
not dangerous
no follow up required: just require more careful woud care of minor lacerations in elderly
clinical triad of thiamine deficiency
2 main causes
Wernicke Encephalopathy= x Vit B1
ataxia + encephalopathy + oculomotor dys
- oculomotor = horizontal nystagmus, x lateral move
alc overuse + chronic malnutrition (bowel resection, anorexia)
- chronic malnutrition pts given IV fluids (aka dextrose) can suddenly develop wernicke bc the inc glucose depletes the remaining thiamine
initial diagnosis of dementia requires ruling out which reversible causes of dementia and how?
routine testing w initial diagnosis dementia
=CBC, Vit B12, TSH, CMP
=CT/MRI brain
=neuropysch testing (montreal cog assessment, n= 26+)
2-6 mo w cherry red macula, hypotonia, and feeding difficulities
what are the likely 2 diagnoses and how do you differentiate
niemann-pick ds= sphingomylenase defiency
- areflexia
tay sacchs ds= beta hexosaminidase deficiency
- hyperreflexia
pts w sickle cell trait are at inc risk of what complications (3)
- inc risk of renal issues, MC = painless hematuria (sickling in renal medulla)
- hyposthenuria (presents as nocturia/polyuria)
- inc UTIs (esp in preg)
38 yo F presents for 2 mo of dry cough and malaise.
cxr attached.
most likely dx
10 mo w hx of recurrent ear infections, strep pneumo, 20th percentile weight, tracheal aspirate + for pneumocystis
PE= small, red, dilated BVs on bilat sclera
dx? level of B cells, T cells, IgA?
hx of viral+bac+fungal (esp hx of candida or pneumocystis) and FTT (20th percentile) = combined B and T cell disorders
- just T cell would not have otitis media (bac)
this patient has telangiectasias on the eyes = ataxia & telangiectasia
dec B cells, dec T cells, dec IgA
complement disorders are associated w what lab findings (leukocyte levels, Ig levels, total hemolyic component = ? and how change)
what type of immunodeficiency is associated with
- digeorge
- wiskott aldrich
- ataxia telangiectasia
14 yo presents w progressive R groin pain for 3 months. past 4 weeks, severely worse now has a limp and difficulty w climbing stairs
PE = + trendelenburg gait, mild atrophy of the right quads and gluteal Ms, full ROM of the knees
when pt stands w feet together, R foot points outwards and L foot points straight ahead
most likely diagnosis, what is the next bext step in diagnostics?
slipped capital femoral epiphysis –> get a bilat hip xray
“when pt stands w feet together, R foot points outwards and L foot points straight ahead”
- v specific sign
- reflects the dec IR and ABDuction
other causes of trendelenburg = dev dysplasia of hip, avascular necrosis –> both also require bilat hip xrays
diagnostic procedure when you expect infective endocarditis
get blood cultures from 3 dif IV sites
- if high risk/v ill: give empiric abx AFTER cultures
- if low risk/low sx : wait for cultures to give abx
get transesophageal/transthoracic echo AFTER cultures
67 yo long time smoker presents w painless hematuria. PE= enlarged prostate without asymmetry. urine = >50 RBCs, w no leukocyte esterase, no abn cells, no casts, no dysmoprhic erythrocytes
most likely dx and what is the next best step
bladder CA
=friable new BV bleed = hematuria throughout micturition
(tumor of bladder neck = terminal micturition)
- urine cytology has v low sensitivity so lack of abn cells/epithelial cells CANNOT rule out bladder CA
next step = cystoscopy +CT urography (visualize kidneys and eval for mets)
rapid onset hypoxemia and diffuse ground glass opacities. hx of recent drug use, black/grey fingertips
most likely dx and causative agent
crack lung = alveolar hemorrhage from smoking crack cocaine
pt develops DIC within 5 minutes of starting a blood transfusion
dx?
acute hemolytic transfusion reaction
ABO incompatability = MC cause
55 yo F presents for one year of postprandial epigastric pain and nausea. pain is dull, achy, and associated w bloating and nausea. PMH= HTN and hypothyroid. labs= hgb 10.2, mcv 105
most likely dx? what complications should you screen for?
autoimmune atrophic gastritis
=inc risk for gastric adenocarcinoma and neuroendocrine tumors –> screen in pts w AAG
tinea pedis - what is the clinical picture?
do you use wood lamp’s exam or KOH scraping ??
wood’s lamp = tinea capitis
KOH = tiniea corpus, tinea pedis = septal hyphae
- tinea = hyperkaratotic lesions
- so flaky skin, may fall off when take off sock; PE= excoriations and erythema on
vegan diet
3 benefits
3 common nutritional deficiencies
soy is a complete protein source, contains all essential amino acids
13 yo w right sided lumbar prominence on forward bending test. next best step?
trx?
+ forward bending test –> get x-ray to measure cobb angle
- cobb angle 10-30 = follow q 6mo
- cobb angle 30-40 = thoracolumbar spinal brace
- cobb angle 40-50+ and severe = consider surgery
diagnosis and management
sigmoid volvulus = coffee bean sign
- trx= therapeutic flexible sigmoidoscopy
- if peritonitis/perforation = emergency sigmoid colectomy
VS SBO
- multiple air fluid levels (Attached)
- = decompression and bowel rest
in a patient with likely PE, what test will confirm the dx
what well score do you need to be likely to have a PE
CT angiogram of the chest
**D dimer if v unlikely to have PE, bc it can rule it out then
- but a wells score > 4 , negative Ddimer cannot rule out
80 yo w an episode of near syncope is admitted. has had episodes of dizziness and near syncope for a month. PE = bradycardia, no neuro changes. cardiac telemonitoring reveals episodes of 3-6 seconds of no sinus nodal activity, associated w sx of dizziness.
dx and etiollogy? trx?
sick sinus syndrome
- MC= age related degeneration of the cardiac conduction system = fibrosis of the sinus node
atrial arrythmias =
- a fib (palpitaitons)
- paroxysmal bradycardia - tachycardia = brady alternating w SVT
trx= pacemaker
vs; abn automaticity of atrial myocytes = a fib (MC from pulm Vs ) = no sinus brady or sinus pauses
vs: aberrant conduction pathway = WPW= paroxysmal tachy but no brady
23 yo presents to ED s/p witnesssed seizure as he was walking out a pub, w jerking movements and post-ictal confusion. no hx of seizures. most appropriate first test?
first time unprovoked seizure in an adult
CT brain w contrast
- quick and effectve in ED
outpatient / non-emergent
- MRI bc more sensitive to lots of etiologies that can cause seizure
12 hours old girl presents for bilious emesis. able to feed twice but then had green emesis after third feed. has urinated but not stooled yet. mom had no prenatal care.
dx and risk factors?
triple bubble sign and gas in colon
associated w cocaine or tobacco in pregnancy,
thessaly and mcmurry tests assess for what pathology
menisceal tear
sx of vitamin deficiency
- chromium (1)
- copper (5)
- selenium (3)
- zinc (5)
hyperventilation leads to what change in ABG
MC common cause of post-op hyperventilation?
effective ways (5) to dec post-op pulm complications?
=DEC CO2 (BLOW IT ALL OFF) = resp alkalosis, dec CO2
- MC cause post-op = atelectasis = hypoxemia (mild, ~70), may be localized findings but dec breath soundes + dense opacities
how to dec pulm complciations post-op
- control underlying lung ds before
- quit smoking 4-5 weeks before
- deep breathing excerices (atelectasis)
- pain control post-op (bronchospams)
- incetive spirometry for pneumonia (pnuemonia)
NOT
-pre/periop steroids or albuterol
-
what is multisystem atrophy
classic case when you should suspect it?
classic= pt w parkinsonian sx that has autonomic sx
TRIAD = parkinsonian + autonomic dys + widespread neuro sx
impetigo causative agent
bullous (L) = S. aureus
- will have crusting w rupture of flaccid bullae, but less likely to be honey crusted
nonbullous (R)= S. aureus or S. pyogenes
- honey crusted lesions
54 yo F presents with R eye liding drooping and diplopia on leftward gaze, sudden onset yesterday when watching tv.
exam = 3mm pupil on L and 5 mm pupil on R
what is the etiology of the dx? be specific, differentiate between the other etiology in ddx
CNIII palsy
- two etiologies = ischemia vs motor
- pupil sparing = ischemia (para fibers outside the bundle)
- pupil dilation = compression from outside
- = aneurysm until proven otherwise
- get MR angiography or CT angiography
64 yo w 2 months dry cough, weight loss, R arm pain. had an episode of CAP treated last month.
chest ct attached.
dx?
shoulder pain –> pancoast tumor (invade into adjacent structures)
- fungi/pneumonia would NOT cause the shoulder/arm pain bc they don’t invade the nearby structures
name 4 causes / risk factors for heart failure with preserved ejection fraction
= all HF sx (edema, dyspnea on exertion, orthopnea) but EF 65%+
- CAD + risk factors
- ^^risk i.e DM
- long standing HTN
- obesity and sedentary lifestyle
pt w livedo reticularis, mesenteric ischemia, and a hx painful asymmetric neuropathy
dx?
POLYARTERITIS NODOSA = vasculitis that does not include lungs
- renal i.e infarction
- GI i.e. mesenteric ischemia
- derm i.e. livedo reticularis
- neuro i.e. mononeuritis multiplex
diagnosis and treatment
CECAL VOLVULUS (CT is more sensitive for cecal)
- trx= emergency laparotomy and rest
- NOT detorsion vs sigmoid
transudative vs exudated
- associated causes T(4), E(7)
- criterion of exudative
- pH diff
- transudatve ~ systemic factors = hypoalbumin, inc hydrostatic P
- exudative ~ inflammation
normal pleural fluid = pH 7.0
transudative= 7.4-7.55
exudative = 7.3-7.45
- pH < 7.3 = associated w inc acid (empyema) or dec H efflux (tumor, pleural fibrosis, pleuritis)
what is myositis ossificans
- timeline?
- diagnosis?
post injury heterotopic bone formation
what tumors are associated with ash leaf spots & seizures
tuberous sclerosis
- angiofibromas of malar region
- subependymal tumors
- cardiac rhabdomyomas
- renal angiomyolipomas
pt presents with this rash, hypopigementation that they noticed after tanning at the beach vacation in florida
dx and etiology?
tinea versicolor = malassezia furfur / malassezia globus
not dermatophytes
17 yo w recurrent kidney stones, uncle has same problem. urine release hexagonal crystals, (+) urinary cyanide nitroprusside
dx?
cysteine stones
-associated with amino acid transport dysfunctions
neuropath of huntingtons
dec GABA and atrophy of caudate nucleus and putamen
antisocial personality disorder vs conduct disorder vs oppositional definat disorder
18+ =antisocial personality disorder
< 18 = conduct disorder
less severe, against authority only = oppositional defiant
clinical presentation of vasa previa
dx and trx?
- painless vaginal bleeding w ROM or contractions
- abn FHT (bradycardia, sinusoidal pattern)
- sinusoidal pattern ~ fetal anemia , ominous sign
- fetal exsangiunation + demise
- can be dx on US at 18-20 weeks
=cesarean at 34-35 weeks
- or emergency cesarean if they present w ROM/contractions w bleeding and abn FHT
vulvar ca
cause
risk factors (5)
sx
cause = HPV 16+18
risk = smoking, vuvlar lichen sclerosis, immunodefciency, prior cervical ca, vulvar/cervical intraepithelial neoplase
sx= POST MENOPAUSAL
vulvar irritation/pain, erythematous friable plaque, intermittant bleeding + dyspareunia
5 yo presents bc mom noticed axillary hair and pubic hair when bathing. breasts tanner stage 2.
labs= inc estrogen, inc inhibin, and lower abd mass
dx?
granulosa cell tumor
- precocious puberty, adnexal mass
- inc estrogen and inhibin
- US= complex ovarian mass
- histo = rosettes
pelvic organ prolapse
- sx (6)
- trx
sx= pelvic pressure, dyspareunia, urinary retention, urinary incontinence, constipation, fecal incontinence
trx= weight loss and pelvic muscle training
- refractory = pessary, surgery
