Family Medicine Flashcards
Chlamydial pneumonia typically presents in infants of what age
3-16 wks
Presentation of Chlamydial pneumonia of newborn
- Nontoxic, afebrile infant
- gradual onset
- conjunctivitis (50%)
- cough & tachypnea
- diffuse crackles & wheezes on PE
- Hyperinflation, diffuse interstitial or patchy infiltrates on CXR
What is the criteria to prescribe 5-alpha-reductase inhibitors (finasteride, dutasteride, etc) for BPH
PSA >1.5 ng/ml or signs of prostate enlargement
Treatment for acute mania of Bipolar Disorder
Lithium, valproic acid, haloperidol, or atypical antipsychotics
*atypicals are first line for severe mania b/c of shorter onset of action
Treatment for bipolar depression
Lithium, quetiapine (antipsychotic), lurasidone*, lamotrigine
*safe in pregnancy
Which atypical antipsychotic should be avoided in women of childbearing age
Divalproex
What serum testing must be monitored in pts on Amiodarone
TSH.
Amiodarone can cause hyper or hypo-thyroidism so pts should have baseline TSH, T4 before starting ed and then monitoring every 6 mo.
When to perform a thyroid radionucleotide scan
After nodule confirmed on u/s AND abnormal TSH levels
What are the pharmacological options for smoking cessation
Buproprion, Varenicline (Chantix), or nicotine replacement therapy
What is pregnancy category B
no human studies + no harm in animal studies OR harm in animal studies but no harm in human studies
What is pregnancy category C
No human studies + harm shown in animal studies
OR
No animal or human studies
What is pregnancy category D
Human studies show potential harm, but benefit may outweigh harm
What are some of the negative effects of smoking on pregnancy
Prematurity, intrauterine growth restriction, stillbirth, spontaneous abortion, infant death
What are the 5 A’s of tobacco cessation
- Ask
- Advise
- Assess willingness
- Assist
- Arrange f/u
When is buproprion contraindicated for smoking cessation
- eating disorders
- monoamine oxidase (MAO) inhibitor use
- hx of seizure disorder
What are the most common side effects of buproprion
insomnia & dry mouth
Varenicline
aka Chantix
Nicotinic receptor partial agonist
-reduces cravings and withdrawal symptoms
When is varenicline (Chantix) contraindicated for smoking cessation
-hx of psychiatric behaviors
Common side effects of varenicline (Chantix)
nausea, trouble sleeping, abnormal vivid dreams
What pregnancy category are nicotine replacement therapies (NRT)
Pregnancy Category D
What pregnancy category are buproprion and varenicline (chantix)
Pregnancy Category C
Which drugs are most commonly the cause of Stevens Johnson Syndrome or Toxic Epidermal Necrolysis (in adults)
Allopurinol, aromatic antiepileptic drugs and lamotrigine, antibacterial sulfonamides, nevirapine, oxicam NSAIDs
What are the risks associated inhaled corticosteroids in the treatment of COPD
Increased bruiisng, candidal infection, pneumonia
What is the first line antibiotic choice for diabetic foot ulcer
Pip/Tazo (Zosyn) & vanc (esp. if risks for MRSA eg recent hospitalization)
–> gram +, gram -, and anaerobic coverage
What are some common drugs that cause SIADH
- SSRIs
- chloropropamide
- barbituates
- carbamazepine
- opioids
- tolbutamide
- vincristine
- diurectics
- NSAIDs
What are the recommendations regarding folic acid supplementation prior to conception
Normal risk: 400-800 mcg (0.4-0.8mg) supplementation
Diabetes or epilepsy 1 mg
Prior child with neural tube defect 4mg
What are Goodell’s sign and Hegar’s sign
Goodell;s sign is softening of the cervix with pregnancy
Hegar’s sign is softening of the uterus with pregnancy
What is Chadwick’s sign
The bluish-purple hue in the cervix and vaginal walls due to hyperemia in pregnancy
When is RSV season
November to April in North America
What is the treatment for RSV
Supportive care with bronchodilators
- *corticosteroids and antibiotics are not first line
- *co bacterial infection is rare
What is the treatment for mild to moderate Community Acquired Pneumonia in infants and school children
Amoxicillin - Strep pneumo is most common pathogen
What is the most common pathogen to cause community acquired pneumonia in infants and school children
Strep pneumo - treat with amoxicillin
Why is the treatment for mild to moderate Community Acquired Pneumonia in older children and why
Azithromycin because Mycoplasma pneumoniae is more common than strep pneumo in this age group
Why are SSRIs an option for treating nightmares
they suppress REM sleep
**note benzos are used for night terrors
What is the treatment for mild to moderate Salmonella without systemic spread
Symptomatic treatment and fluid support in low risk patients
What is the treatment for systemic Salmonella, severe Salmonella, or isolated Salmonella in at risk patients (e.g. sickle cell)
Oral Bactrim or quinolone + fluid support
*may use IV ceftriaxone
Which pediatric vaccinations carry a risk of febrile seizures?
- MMR & MMRV (specifically due to measles component)
- inactivated flu vaccine when given with PCV13 or DTaP
- *increased risk w/ history of seizures or first degree relative w/ seizures
What pathogen is likely to cause pneumonia in a pt with COPD taking corticosteroids that is unlikely in a pt w/o COPD
Pseudomonas aeruginosa
*S. pneumo, Mycoplasma pneumo, HiB, S. aureus are common in both populations
Cow’s milk is not recommended for children under the age of ________
12 months
What is Charcot’s triad
Triad of symptoms for Multiple Sclerosis: scanning speech, intranuclear ophthalmoplegia, and nystagmus
What does the triad of scanning speech, intranuclear ophthalmoplegia, and nystagmus suggest
=Charcot’s triad which suggests multiple sclerosis
How does pregnancy affect multiple sclerosis
Symptoms of MS typically decrease with pregnancy
What is the treatment for acute multiple sclerosis exacerbations
High dose IV corticosteroids
-Plasma exchange may be given in pts who do not respone to steroids
What is the medication of choice for the treatment of Serotonin Syndrome if supportive care is not effective
Benzodiazepines
Short acting Beta blockers may be used prn for tachycardia
True or false: Asplenic patients should be given antibiotics for any episode of fever
True: due to the increased risk of pneumococcal sepsis in asplenic patients
What is the leading cause of death for patients w/ Rheumatoid Arthritis and why
Coronary Artery disease (just like the normal pop.) but is due to increased progression of atherosclerosis due to chronic inflammation
What is the most effective psychotherapy for obsessive compulsive disorder
Repeated exposure to fearful stimuli
What are the risks associated with long term PPI use
- Fractures - hip, wrist, spine (due to reduced calcium absorption)
- Hypomagnesemia (due to malabsorption)
- Community Acquired Pneumonia (observational data only)
- C. diff & other enteric infections
Which diseases are most commonly associated with uveitis (in North America)
- Seronegative spondyloarthropathies
- Sarcoidosis
- Syphillis
- Rheumatoid arthritis
- Reactive arthritis
What is the classic presentation of pertussis
infant <6 mo w/ paroxysmal coughing, posttussive emesis, and apnea
infant <6 mo w/ paroxysmal coughing, posttussive emesis, and apnea is the classic presentation of _____?
Pertussis - gram - boacillus Bordetella pertussis
What is the treatment for pertussis infection
Azithromycin x 10 days, hospitalize infants, treat close contacts prophylacticly
**Bactrim if allergic to azithromycin
Which murmurs are typically pathologic and should prompt echocardiogram workup
Continuous and diastolic murmurs
What are the recommendations for when to switch to a forward facing car seat?
> 2 years and >40 pounds
When should solid food be introduced to an infant
No earlier than 6 months
When is objective hearing screening indicated for children
With history of meningitis, ToRCHeS infections, measles, mumps, recurrent otitis media
What is the differential for Leukocoria (lack of red reflex)
Retinoblastoma
Congenital Cataracts
Retinopathy of Prematurity
At what age should a workup for Strabismus (ocular misalignment)be worked up in a child
> 3 months of age. Prior to 3 months this may be a normal variant
What are the contradictions to childhood vaccination
- severe allergy to vaccine component or prior dose
- encephalopathy within 7 days of prior pertussis vaccine
- no live vaccines for immunocompromised or pregnant s
What are the common causes of vesicoureteral reflux in children
Posterior urethral valves,
Urethral or meatal stenosis
Neurogenic bladder
Treatment of UTI in children
Amoxicillin if <2 months old
Tmp-Smx or nitrofurantoin if >2 mo.
Common presentation of child abuse in infants
Apnea, seizures, feeding intolerance, excessive irritability, somnolence, or FTT
What are the intrauterine risk factors for congenital heart disease
Maternal drug use (alcohol, lithium, thalidomide, phenytoin), maternal infection (rubella), maternal illness (DM, PKU,)
What are the cyanotic (right to left shunt) congenital heart defects
Truncus arteriosus Transposition of the great vessels Tricuspid atresia Tetralogy of fallout Total anomalous pulmonary venous return
Which congenital heart defect(s) has a fixed widely split S2
ASD
What is Eisenmenger syndrome
When a left to right shunt (acyanotic - VSD, ASD, PDA) leads to severe pulmonary hypertension that causes shunt reversal (right to left)
What is the most common congenital heart defect
VSD
What are the acyanotic (left to right shunt) congenital heart defects
VSD, ASD PDA
What is an ebstein abnormality
Apical displacement of the tricuspid valve leading to serialization of the right ventricle
What are the common signs of autism in children/infants
No babbling or/and gesturing by 12 months No 2 word phrases by 24 months Impaired social interaction Restricted interests Insistence on routine
What does CHADS-VASc stand for and what is it used for
Scoring system to estimate risk in atrial fibrillation and anticoagulate for score ofb2 or more CHF 1 pt HTN 1 pt Age = 75 2pts Diabetes 1 pt Stroke or TIA hx 2 pts Vascular disease 1 or Age 65-74 1pt Sex of Femlae 1 pt
What are the symptoms of antidepressant discontinuation syndrome
dysphoria, fatigue, insomnia, myalgias, dizziness, flu like symptoms, gi symptoms, tremor, neurosensory disturbances.
*typically within 2-4 days of medication stoppage
What endocrine abnormality is associated with major depressive disorder
Hypercortisolemia due to hyperactivity of the hypothalamic-pituitary-adrenal axis
What is the treatment for postpartum endometritis
Clindamycin + gentamicin
How does estrogen (in pregnancy or by medication) affect the dosing of levothyroxine?
Dosing of levothyroxine must be increased because estrogen leads to an increase in thyroxine-binding protein reduced clearance in the liver
**exception is transdermal estrogen which bypasses liver
For how long must symptoms be present for someone to qualify as having a major depressive episode
> /= 2 wks
What is the first step in evaluation of primary amenorrhea (no first mentruation)
Pelvic ultrasound to assess for presence of uterus
- -> uterus present–> serum FSH
- -> uterus not present –> karyotype & serum testosterone
Which NSAID is not associated with a known increase in the risk of myocardial infarction
Naproxen
**Celecoxib, ibuprofen, meloxicam, and diclofenac are associated with an increased risk
of cardiovascular adverse effects and myocardial infarction, compared with placebo
What are the classifications of anorexia nervosa according to the DSM-5
Based on BMI Mild: BMI>17.0 Mod: BMI 16.0-16.99 Severe: BMI 15.0-15.99 Extreme: BMI <15.0
What are some of the indicating criteria for hospitalization of pts with anorexia nervosa
Refusal to eat
Orthostatic changes in pulse or bp
What are common risk factors for conversion of latent tb to active?
Diabetes mellitus, lung cancer, alcoholism, recent contact w/ active tb ind., immunosuppressive therapy, lung parenchymal diseases (COPD, silicosis,etc)
Low SES, age <5, wt < 90% ideal minimum
For patients with acute coronary artery syndrome who are not at high risk of bleeding, how long should they be on dual antiplatelet therapy
at least 12 months
What is a nonsedating medication that is safe to use in the first trimester of pregnancy for nausea and vomiting
Vitamin B6
**Scopolamine is contraindicated due to birth defects
Who should recieve antibiotic prophylaxis against bacterial endocarditis prior to dental procedures
High risk patients only: prosthetic valves, prior hx of endocarditis, unrepaired congenital cyanotic heart disease, cardiac transplant recipients w/ valvular disease
Mild to moderate hypertriglyceridemia increases the cardiovascular risk, but severe hypertriglyceridemia increases the risk of ___________
Pancreatitis
Which anti-lipid medication is recommended for patients with severe hypertriglyceridemia (at risk of pancreatitis)?
Fibrates
How does Niacin affect lipid levels
Increases HDL
Decreases LDL
No evidence of cardiovascular risk improvement
What are the side effects/adverse effects of methimazole
Agranulocytosis Serum sickness Cholestatic jaundice Alopecia Nephrotic syndrome Hypoglycemia Loss of taste Fetal anomalies
What cancers are associated with Lynch syndrome
Colorectal cancer
Endometrial cancer
Ovarian cancer
What cancers are associated with Familial adenomatous polyposis
Colorectal cancer
Desmoids & osteomas
Brain tumors
Which cancers are associated with von Hippel-Lindau syndrome
Hemangioblastomas
Clear cell renal carcinoma
Pheochromocytoma
Which cancers are associated with Multiple endocrine neoplasia type 1
Parathyroid adenomas
Pituitary adenomas
Pancreatic adenomas
Which cancers are associated with Multiple Endocrine Neoplasia type 2
Medullary thyroid cancer
Pheochromocytoma
Parathyroid hyperplasia type 2A
Which cancers are associated with BRCA1 & BRCA2
Breast cancer
Ovarian cancer
What is the medical management for catatonia
Benzodiazepines (lorazepam)
Alternatively Electroconvulsive therapy
What is Dantrolene commonly used for
To treat muscular rigidity associated with severe neuroleptic malignant syndrome that does not respond to discontinuation of antipsychotic medication
Which organism is most commonly responsible for necrotizing (malignant) otitis externa
Pseudomonas aeruginosa
What are the risk factors for developing necortizing (malignant) otitis media
Age >60
DM
Aural irrigation
Severe, unremitting ear pain (worse at night or with chewing), lower CN deficits (CN VII), granulation tissue in external auditory canal and elevated ESR suggest …_____
Necrotizing (malignant) otitis media
What is the treatment for necrotizing (malignant) otitis media
Anit-psuedomonal antibiotics (e.g. ciporfloxacin) +/- surgical debridement
What characteristics of tinnitus suggest underlying pathology and would require further work up (e.g. MRI)
Unilateral or pulsatile tinnitis or tinnitus associated with unilateral hearing loss
What is akathisia
motor restlessness, often accompanied by inexplicable anxiety and inability to sit still comfortably
Any infant under ___ days old should be admitted to the hospital for fever
29 days
What are the most common organisms associated with lymphadenitis
Staphulococcus aureus and group A Streptococcus
What is the best diagnostic test for vitamin D deficiency
25-hydroxyvitamin D
**NOT 1,25
What are the risks associated with Combined Oral Contraceptives
- Venous thromboembolism
- HTN
- Hepatic adenoma
- Stroke, MI
- Cervical Cancer
- Headache (not verified by study materials)
What is the etiology of Reye Syndrome
Pediatric aspirin use during viral infection (influenza or varicella)
What is the treatment for Reye Syndrome
Supportive
What are the clinical features of Reye Syndrome
Acute liver failure and encephalopathy
At what age should infants be able to walk first steps independently
12 months
At what age should infants be able to run and kick a ball
18 months
At what age should infants/toddlers be able to jump and walk up stairs with 2 feet
2 yrs
At what age should infants/toddlers be able to walk up stairs with alternating feet
3 yrs
What is an alternative name for Pancoast Tumor
Superior Pulmonary Sulcus Tumor
What is the clinical presentation of Pancoast Tumor
- Shoulder pain
- Horner syndrome
- C8-T2 neurological involvement (weakness of intrinsic hand muscles, pain/paresthesias of 4th/5th digits, medial arm, forearm)
- Supraclavicular lymph node enlargment
- Weight loss
What is the strongest risk factor for a Pancoast tumor
Smoking
What are common causes of fetal tachycardia
Maternal infection, poorly controlled maternal hyperthyroidism, medication use, abruptio placentae
Prolonged Membrane Rupture is achieved at what time
> 18 hrs
Fetal anemia is represented by what fetal heart rate tracing pattern
Sinusoidal fetal heart tracing (smooth, undulating waveform w/o variability)
What class of drug is PCP (phencyclidine)
Hallucinogen
What class of drug is LSD
Hallucinogen
What class of drug is Cocaine
Stimulant
What class of drug is methamphetamine
Stimulant
What class of drug is Marijuana (THC or cannabis)
Cannabinoid
What class of drug is Heroin
Opioid
What are the clinical features of PCP (phencyclidine) intoxication
- Violent behavior
- Dissociation
- Hallucinations
- Amnesia
- Nystagmus
- Ataxia
What are the clinical features of LSD intoxication
- Visual Hallucinations
- Euphoria
- Dysphoria/panic
- Tachycardia/HTN
What are the clinical features of Cocaine intoxication
- Euphoria
- Agitation/psychosis
- Chest pain
- Seizures
- Tachycardia/HTN
- Mydriasis
What are the clinical features of Methamphetamine intoxication
- Violent behavior
- Psychosis, diaphoresis
- tachycardia/htn
- Choreiform movements
- Tooth decay
What are the clinical features of Marijuana intoxication
- Increased appetite
- Euphoria
- Dysphoria/panic
- Slow reflexes, impaired time perception, impaired concentration
- Dry mouth
- Conjunctival injection
What are the clinical features of Heroin intoxication
- Euphoria
- Depressed mental status
- Miosis
- Respiratory depression
- Constipation
What are bath salts
Synthetic amphetamine analogues
What is the clinical presentation of opioid withdrawal
- Lacrimation
- Pupillary dilation
- Yawning
- Diaphoresis
- GI symptoms
How do NSAIDs affect lithium
Decrease lithium excretion–> increased lithium concentration
What is akinesia
Extreme case of psychomotor retardation in which an absence of movement is observed
What are automatisms
Spontaneous involuntary movements that occur during an altered state of consciousness and can range from purposeful to disorganized
What differentiates pressured speech from rapid speech
Pressured speech is usually uninterruptible and patient feels compelled to continue
What are the 6 main types of delusions
Grandeur Paranoid Reference Thought broadcasting Religious Somatic
For how long must a person have symptoms for a diagnosis of schizophrenia to be made
6 months
What is psychodynamic psychotherapy
Psychotherapy focused on uncovering unconscious patterns originating in childhood experiences.
**May initially cause increased anxiety
What are the common side effects of the mood stabilizer Lamotrigine
Blurred vision, GI distress, Steve Johnson Syndrome [increase dose slowly to assess for rashes]
Why should Paroxetine be avoided in pregnancy
Causes fetal pulmonary hypertension
Which SSRI should be avoided in pregnancy due to risk of fetal pulmonary hypertension
Paroxetine
What are the sommon side effects of SSRIs
Sexual side effects, GI distress, agitation, insomnia, tremor, diarrhea
The risk of Serotonin Syndrome increases when SSRIs are used in conjunction with __________
MAOIs, illicit drugs, herbal medicines
What is the common side effect of venlafaxine
diastolic hypertension
What are the common side effects of Bupropion
decreased seizure threshold
What is the downside of Mirtazapine compared to other atypicals?
Weight gain and sedation
What is the advantage of Bupropion compared to other atypicals
minimal sexual side effects
What is the downside of Trazodone compared to other atypicals
Highly sedating, priapism
What is the concern side effect of Trazodone in men
Priapism
Which class of psych drugs has a risk of hypertensive crisis if taken with high-tyramine foods
MAO Inhibitors
What are the side effects of MAOIs
Sexual side effects, orthostatic hypotention, weight gain
Hypertensive crisis if taken with high tyramine foods
What is the characterization of unintentional scald injuries
Poorly defined and asymmetric would margins, nonuniform burn depth, splash marks
What are the characteristics of intentional scald injuries, e.g. from child abuse
Spared flexural creases, burns with sharp lines of demarcation, uniform depth, lack of splash marks
Desmopressin is given preoperatively in which patients to prevent exessive bleeding
Pts with hemophilia A
What does IV colloids include
Fresh Frozen Plasma and albumin
What is Gaucher’s disease
Autosomal recessive genetice disease most common in Ashkenazi Jews characterized by Glucocerebrosidase deficiency leasdinto glucocerebroside accumulation in macrophages
What are the DSM-V Psychotic Disorders
- Schizophrenia
- Schizophreniform
- Brief Psychotic Disorder
- Delusional Disorder
- Schizoaffective Disorder
What is the average age of onset of schizophrenia in males and females respectively
21 yo males
27 yo females
What is the current conceptualization of the pathogenesis of schizophrenia
one or more neurodevelopmental defects causing impaired circuitry connecting cortical and subcortical regions (esp. thalamus & striatum) –> disruptions in cognitive processes
What is the potential pathogenesis of positive symptoms in schizophrenia
Prefrontal cortex deficit plus environmental stress causes excessive mesolimbic dopamine activity
What is the potential pathogenesis of negative symptoms in schizophrenia
Prefrontal cortex deficits associated with decreased mesocortical dopamine activity
What genetic abnormalities are commonly seen w/ schizophrenia
Increased nonsense mutations
Overlap with autism & bipolar disorder
What are some known environmental risks for the development of schizophrenia
- maternal infection
- ob complications
- inflammation
- cannabis use
- immigration
What are the positive symptoms commonly associated with Schizophrenia
- Delusions
- Hallucinations
- Disorganized thoughts and behaviors
What is Capgras Syndrome
delusion that people have been replaced by imposters
What is latency of response
A type of thought disorder characterized by delayed response to questions
What is thought blocking
A type of thought disorder characterized by thoughts being lost or interrupted by a hallucination
What is neologisms
A type of thought disorder characterized by made up words
What is clanging
A type of thought disorder characterized by rhyming without meaning
What is perseveration
A type of thought disorder characterized by repetition of words and phrases
What is echolalia
A type of thought disorder characterized by repetition of the examiner’s words
What are some examples of disorganized behavior symptoms
- Catatonic behaviors
- Stereotypy (repeated, non-goal directed ie rocking)
- Mannerisms (grimacing, bizarre movements, gestures)
- Incongruous affect
What are the negative symptoms associated with schizophrenia (5 A’s)
-Avolition/apathy
-Alogia (poverty of speech)
-Anhedonia (inability to experience pleasure)
-Asociality
-Affect (lack of, blunted or flat)
Others: lack of social skills, lack of spontaneity/humor, lack of self care
What are the cognitive symptoms associated with Schizophrenia
- deficits in attention
- impaired verbal memory
- impaired speed of processing
- impairment in executive functions
- lack of abstract thinking
Which symptoms of schizophrenia are most responsive to medication
Positive symptoms
Negative and cognitive symptoms do not respond as well to medications
What defines schizophreniform disorder
psychotic symptoms characteristic of schizophrenia present for >1 month but <6 months
How many patients with schizophreniform develop a diagnosis of schizophrenia or schizoaffective disorder
2/3
What defines delusional disorder
Systematized typically non-bizarre delusions w/o thought disorder or negative symptoms
*hallucinations rare
What is schizoaffective disorder
Evidence of persistenct psychotic symptoms in the absence of prominent mood symptoms for at least 2 wks
**meets criteria for mood disorder and schizophrenia
What is the difference between schizoaffective disorder and mood disorder w/ psychosis
In schizoaffective disorder, psychosis occurs w/ mood episode and in absence of mood disorder
**psychotic mood only has psychosis w/ mood symptoms
What is brief psychotic disorder
psychotic symptoms for >1 day but <1 month with full recovery
*typically related to marked stressors
How common is psychosis in Alzheimer’s disease
40% of pts w/ alzheimer’s will have psychosis at some point
What are some medical conditions that can cause psychosis
- Dementia/delirium
- Temporal lobe epilepsy
- tumor/stroke/TBI
- hypothyroidism (myxedema madness)
- Acute Intermittent porphyria
- Wilson’s disease
- B12 deficiency
- Neuro-syphyllis, hiv
- SLE
- Heavy metal poisoning
What is the common distinction between first generation antipsychotic medications and second generation antipsychotic medications
First generation: “neuroleptic”, older, primary MOA is D2 antagonism
Second generation: newer, fewer EPS, combination serotonin (5HT2A) antagonist & dopamine antagonist
How do amphetamines affect schizophrenia
Increase symptoms b/c amphetamines release DA
What are the side effects of typical (or first generation) antipsychotics and their activity on which pathways that cause these side effects
- Reduction of positive symptoms (goal of treatment) –> mesolimbic D2 antagonist
- Worsening of cognitive & negative symptoms –> mesocortical D2 antagonist
- EPS, psuedoparkinsonism, tardive dyskinesia etc. –> Nigrostriatal D2 antagonist
- Hyperprolactinemia –> Tuberoinfundibular D2 antagonist
What extrapyramidal symptom may occur in the first few days of typical (first generation) antipsychotic use
Acute dystonic reaction - distressing, sustained contraction of the neck, mouth, tongue
What extrapyramidal symptom may occur after several weeks of typical (first generation) antipsychotic use
- Akathisia - subjective restlessness, inability to sit still
- Drug induced parkinsonism
What is Tardive Dyskinesia
abnormal involuntary movements of the mouth, tongue, trunk, extremities related to long term treatment with antipsychotic medication of metoclopramide
What are the signs of neuroleptic malignant syndrome
mental status change, rigidity, fever, dysautonomia, tachycardia, HTN, increased creatinine kinase
What is the management of neurleptic malignant syndrome
Stop antipsychotic
Supportive care
Dantrolene for muscle rigidity
Bromocriptine or amantidine (DA agonist) if resistent to treatment
What are the second generation antipsychotics
- Risperidone
- Paliperidone
- Olanzapine
- Ziprasidone
- Aripiprazole
- Clozapine
- Asenapine
- Iloperidone
- Lurasidone
What is the general side effect profile of second generation antipsychotics
Weight gain and metabolic adverse effects (hypertriglyceridemia, hyperglycemia, increased diabetes risk, increased cardiovascular/cerebrovascular risk)
At what points in treatment with second generation antipsychotics do you assess BP, fasting glucose, and fasting lipid panel
At start, 12 wks into treatment, 12 months into treatment
*lipids again at 5 yrs
Which antipsychotic is superior to other antipsychotics in the treatment of refractory patients
Clozapine (second generation) but it is reserved for refractory patients due to risk of agranulocytosis
Which second generation antipsychotic carries a risk of agranulocytosis
Clozapine
What is the main side effect of concern with Risperidone
Hyperprolactinemia, dose dependent EPS
What is the main side effect concern of Olanzapine
Obesity and metabolic effects
What is the main side effect concern of Quetiapine
sedation
**low EPS risk
What is the main side effect concern of Ziprasidone
Prolongation of QT interval
**lower wt gain and metabolic effects
What is the main side effect concern of aripiprazole
Akathisia
Which second generation antipsychotic lowers the seizure threshold
Clozapine
Which second generation antipsychotics have the lowest risk of weight gain
aripiprazole, ziprasidone
Which second generation antipsychotic is shown to decrease suicide risk
Clozapine
What physical exam finding should raise the suspicion for Factitious disorder (Munchausen) in a psychiatric pt
Multiple surgical scars
What physical exam finding should raise the suspicion for anticholinergic toxicity in a psychiatric pt
Dry, flushed skin
For patients with high addicition risk or who do not want to be on stimulants what medications options are available to treat ADHD
Atomoxetine, a nonstimulant norepinephrine reuptake inhibitor
What is the first line management for PCP-related agitation and psychosis? Second line?
First line: benzodiazapines (typically paraenteral e.g. lorazepam, diazepam)
Second line: antipsychotics
Which Benzodiazepines are preferred in patients with liver disease
LOT: lorazepam, oxazepam, temazepam
What are the most commonly used benzodiazapines used in alcohol withdrawal?
Diazepam, Lorazepam, and chlordiazepoxide
*chlordiazepoxide does NOT come in IV form
What is the function of Granulosa cells
primarily in the ovarian stroma, granulosa cells convert testosterone to extradiol via aromatase and secrete inhibin (which typically inhibits FSH)
What are the common hormonal lab findings of granulosa cell tumors
increased inhibin
increased estradiol
After surgical removal of a granulosa cell tumor, what lab value can be used to monitor recurrence
inhibin - increased in tumor recurrence
What is the management of sternal dehisence (separation of sternal bone fragments following surgery typically cardiac)
This is a medical emergency.
Urgent surgical exploration and repair is warranted to prevent cardiac injury
What is the most common cause of osteomyelytis in children
Staph aureus
Which SSRI/SNRI has should benefit in treating pts with diabetic neuropathy
Duloxetine (SNRI)
Which have analgesic effects as well as antidepressant effects: SSRIs or SNRIs
SNRIs
What is the antibiotic regimen of choice for the treatment of postpartum endometritis
Clindamycin + gentamicin due to polymicrobial nature of infection
What is the first line pharmacotherapy for fibromyalgia
Tricyclic antidepressants (e.g. amitriptyline)
How do you define epileptiform activity on EEG
at least 1 m^2 brain region spike + slow wave
How do you define epilepsy
2 or more unprovoked afebrile seizures
What is a method a parent can use to differentiate absent seizure from day dreaming
Response to tactile stimuli. Children having an absent seizure will not respond to tactile stimuli
What are the clinical characteristics of N. gonorrhoeae conjunctivitis of the newborn?
Symptoms w/in 1 week of birth; bilateral purulent conjunctivitis & marked eyelid edema, more severe than chlamydia; conjunctival injection; chemosis (conjunctival edema)
What are the clinical characteristics of Chlamydial conjunctivitis of the newborn
symptoms w/in 1-2 weeks of birth; eyelid swelling; relatively scant watery discharge
What are the clinical characteristics of HSV conjunctivitis of the newborn
Symptoms w/in 2 weeks of birth; conjunctival injection, watery/serosanguinous eye discharge, vesicular eruptions around eyes
What are the possible complications of untreated N. gonorrhoeae conjunctivitis of the newborn if left untreated
Corneal ulcerations, scarring, blindness
What are the prophylactic methods against N. gonorrhoeae conjunctivitis of the newborn
Screening and treatment of at risk mothers; erythromycin eye drops at birth
**silver nitrate drops may be used but carry a risk of chemical conjunctivitis thus are not used in the U.S.
What is dacryostenosis
Nasolacrimal duct obstruction
How is primary amenorrhea or delayed puberty defined
A) absence of menses by age 16 w/ secondary sexual development present, or
B) absence of secondary sexual characteristics by age 14
What is the differential for primary amenorrhea with an absence of secondary sexual characteristics
- Primary ovarian insufficiency (multiple etiologies e.g. Turner syndrome, hx damage from radiation/chemo, etc.)
- Central hypogonadism (undernourishment, stress, hyperprolactinemia, exercise, CNS tumor, cranial irradiation, etc)
- Kallmann syndrome
- Constitutional growth delay
What is the differenital for primary amenorrhea with the presence of secondary sexual characteristics
- Mullerian agenesis
- Imperforate hymen
- Complete androgen insensistivity
- Congenital adrenal hyperplasia
What is the first step in primary or secondary amenorrhea
Pregnancy test
Is the uterus present or absent in Turner Syndrome
Present
What are the classic features of Turner Syndrome
Streak ovaries Shield chest amenorrhea (w/ uterus present) webbed neck aortic coarctation bicuspid aortic valve
Primary amenorrhea + uterus present + elevated FSH suggests a diagnosis of ….
Primary ovarian insufficiency - get karyotype to assess for Turner syndrome (45,X)
What is Mayer-Rokitansky-Kuster-Hauser syndrome
Mullerian agenesis
What is affected in Mullerian agenesis
absence of upper third of vagina
absence of cervix
absence or abnormalities of uterus
**ovaries are not affected
What is the beneficial effect of hydroxyurea in the management of sickle cell
Increase in fetal hemoglobin production
What is the dose limiting side effect of hydroxyurea
Myelosuppression
For which population does a PPD/TST of >/= to 5 mm induration warrant treatment
- HIV positive pts
- Recent contacts w/ known TB
- Nodular or fibrotic changes on chest x-ray consistent w/ previously healted TB
- organ transplant recipients/immunocompromised
For which population(s) does a PPD/TST of >/=10 mm induration warrant treatment
- Recent immigrants (<5 yrs) from TB endemic area
- injection drug users
- residents/employees of high risk settings
- co-morbid conditions that increase TB reactivation risk (diabetes, leukemia, ESRD, malabsorption)
- Children <4
At what PPD/TST induration should a healthy person be treated for TB
> /= to 15 mm
What is the Centor Criteria used for and what are the features of the Centor Criteria
Used to determine whether to treat ADULTS empirically for strep pharyngitis
Centor Criteria:
-fever by hx
-tender anterior cervical lymphadenopathy
-tonsillar exudates
-absence of cough
Which electrolyte abnormality can lead to flaccid paralysis
Hyperkalemia
**hypercalcemia can also cause weakness
On which neurotransmitters does bath salts work
Increases release or inhibits reuptake of norepinephrine, dopamine, and serotonin
What is the initial treatment for myasthenia gravis
Acetylcholinesterase inhibitors (e.g. pyridostigmine)
What is required for a definitive diagnosis of sarcoidosis
clinical symptoms and Chest x-ray with characteristic findings and biopsy demonstrating noncaseating granulomas
What is presbycusis
sensorineural hearing loss that occurs with aging
What is the medical treatment for cancer related anorexia/cachexia
Progesterone analogues (such as mergestrol acetate) or corticosteroids
**synthetic cannabinoids have not sufficiently studied - benefit only in HIV cachexia
What is the first line medical treatment for diffuse esophageal spasms
Calcium channel blockers (e.g. diltiazem)
**Alternates Nitrates or tricyclics
What is the treatment for Gullian Barre
IV Ig or plasmapheresis
What CSF analysis results are expected in a patient with Gullian Barre
Elevated protein but otherwise normal
At what systolic BP will loss of consciousness occur
50
What ocular finding may be present in opiate overdose
Pinpoint pupils
What laboratory findings may suggest over-diuresis
elevated bicarb and elevated creatinine
What is Erythema Infectiosum
Slapped cheek disease or Parvovirus B19
In Erythema Infectiosum (Parvovirus B19) how does the timing of the rash and the fever relate
Both occur at the same time
What are the 2 severe and feared complications of Parvovirus B19 (erythema infectiosum) in special populations
Hydrops fetalis in pregnant women
Aplastic crisis in kids with hemoglobinopathies (e.g. Sickle cell)
What are the “four c’s” of measles
Cough, coryza, conjunctivitis, & Koplik spots
How does the rash in measles spread
From head down
What is a long term complication of measles that may take years to develop
Subacute sclerosing panencephalitis
How does the rash in ruebella spread
from head down
What is the primary feature of the ruebela prodrome
Generalized tender lymphadenopathy
What type of rash is common in measles
Erythematous morbilliform rash
What is the clinical criteria for typical Kawasaki’s disease
> /=5 days of fever + 4 of conjunctivitis, mucositis (e.g. strawberry tongue), rash, extremity edema /desquamation, lymphadenopathy
What are the symptoms of Pellagra (niacin B3 deficiency)
- diarrhea
- dermatitis
- dementia, depression, distraction
- death
What is the most common primary immune deficiency
Selective IgA deficiency
What are the clinical features of selective IgA deficiency
- usually asymptomatic
- recurrent sinopulmonary & GI infections
- associated w/ autoimmune disease and atopy (eg asthma, eczema)
- anaphylaxis during transfusions
How is selective IgA deficiency diagnosed
- low or absent IgA
- normal IgG, IgM, and B cells
Why do patients with selective IgA deficiency need a medical alert bracelet
Anaphylaxis occurs during blood transfusions
What is hyposthenuria
The inability of the kidneys to concentrate urine
**can be a complication of sickle cell trait
What serum sodium value is expected in central diabetes insipidious
elevated serum sodium
What are the typical GU symptoms of bladder cancer in older adults
- Hematuria
- hydronephrosis
- voiding symptoms
What is Cushing’s triad
elevated blood pressure, bradycardia, and irregular respirations that are suggestive of increased intracranial pressure
What is Opsoclonus-myoclonus syndrome
Paraneoplastic syndrome that occurs frequently with neuroblastoma in younger children (6mo-3yrs) and is characterized by ataxia, myoclonus (jerky movements) and opsoclonus (jerky movements of eyes)
What is the cause of trichinellosis
The trichinella parasite (roundworm) found in undercooked contaminated animal meats most commonly pigs, feral hogs, cougars, and black bears
What parts of the world are more endemic for trichinellosis
Mexico, China, Thailand, cental Europe, Argentina
What is the clinical presentation of Trichinellosis
Intestinal stage (w/in 1 wk ingestion - gastric acid releases larvae): asymptomatic, abdomianl pain, nausea, vomiting, diarrhea
Muscle stage (up to 4 wks later, female worms encyst in striated muscle): mysoitis, fever, subungal splinter hemorrhages, periorbital edema, eosinophilia (>20%), poss. elevated creatinine kinase/leukocytosis
What symptom triad should raise suspicion for trichinellosis
Periorbital edema + myositis + eosinophilia
What is the treatment for trichenellosis
Self-limited
Antiparasitivs (mebendazole, albendazole) + corticosteroids
What is the common presentation of Dengue fever
fever, HA, retro-orbital pain, rash, myalgia, arthralgia
if hemorrhagic: skin/nose hemorrhage
What X-ray finding is expected in Epiglottitis
“Thumb sign” = enlarged epiglottis
What is the first line alternative to stimulants in the treatment of ADHD
Atomoxetine - selective norepinephrine reuptake inhibitor
What are the alternative treatment options to stimulants for ADHD
Atomoxetine (SNRI), alpha-2 adrenergic agonists, certain antidepressants
With which genetic syndromes is gastroschisis associated?
Trick question. It’s not. Gastroschisis is typically an isolated deformity. It is associated with oligiohydramnios and elevated AFP due to loss (nutrient and AFP) thorugh the intestinal wall
What is Potter Sequence
Urinary tract anomaly –> Anuria/oliguria in utero –> oligohydramnios –> pulmonary hypoplasia, flat facies, limb deformities (e.g. clubbed feet)
What is the most common cause of urinary tract obstruction in newborn boys
Posterior urethral valves
What is the most common renal malignancy of childhood
Wilms tumor = nephroblastoma
What is the treatment for bacterial meningitis in children
IV vancomyin & ceftriaxone or cefotaxime
+/- dexamethasone (definitely use w/ H. influenzae)
What are the common complications of bacterial meningitis in children
- intellectual/behavioral disabilities
- hearing loss
- Cerebral palsy
- Epilepsy
What are the common skin findings associated with hypothyroidism
Coarse hair, skin discoloration, and occasionally alopecia
What endoscopy finding can be seen with laxative overuse
Melanosis coli (browning of colon)
What are the most common organisms associated with contact-lens associated keratitis
gram negatives - pseudomonas & serratia
less commonly gram positives, fungi, amoebas
What are the 2 primary manifestations of Chagas disease
Megacolon/megaesophagus & cardiac disease
What is the pathophys of megacolon in Chagas disease
Destruction of the nerves controlling GI smooth muscle
Which kidney stones are hexagonal in shape
Cystine stones
What is the cause of cystinuria (cystine kidney stones)
inherited defect of amino acid transport
What is the cause of hexagonal kidney stones
inherited defect of amino acid transport leading to cystinuria and cystine stone (hexagonal) formation
Which kidney stones are rhomboid in shape
uric acid
What are the 3 most common organisms in acute otitis media
Streptococcus pneumoniae
Nontypeable H. influenzae
Moraxella catarrhalis
At what BUN levels is there a risk of uremic pericarditis
> =/ 60 mg/dL
How does pleuritic chest pain (e.g. in pericarditis) change when lying supine? When sitting up?
Increases when lying supine
Decreases when sitting up
What is the most common malignancy in patients exposed to asbestos
Bronchogenic carcinoma
**mesothelioma is less common
Which seizure type is not associated with a post ictal state
Absence seizures
What is the use of vaginal progesterone in pregnancy
Decreases the risk of preterm delivery in pts w/ incidental shortened cervix (= 25mm)
When is magnesium sulfate given for fetal neuroprotection
Preterm deliveries less than 32 wks
A resting tremor is most consistent with [Parkinson’s or Essential] tremor
Parkinson’s
An intention tremor is most consistent with [Parkinson’s or Essential] tremor
Essential
What type of medication is trihexyphenidyl
anticholinergic
**may be used to treat tremor in early parkinson’s
What is the first line treatment for essential tremor
Beta blocker e.g. propranolol
What is the formula for the calculation of the anion gap
Na - (Cl + HCO2)
What inherited syndrome is associated w/ type 2 renal tubular acidosis (proximal RTA)
Fanconi syndrome
How is abnormal uterine bleeding defined in adolescence
menstrual bleedin <21 days or >45 days apart
What is the first line treatment for UTI in children
Third generation cephalosporins (cefixime)`
What antibiotic class is ciprofloxacin
fluoroquinolone
What the the side effect of most concern of fluoroquinolones in children
Cartilage damage
What is a chi square test used to compare
Chi square test is used to compare the proportions of a categorized outcome
What are the common complications of sickle cell trait
None, but if present: Painless hematuria (most common), hyposthenuria (inability to concentrate urine), increased UTI esp. in pregnancy, rarely splenic infarction at high altitudes
Is the paralysis of botulism ascending or descending
descending
What is the basic management of kawasaki disease
Echocardiogram to assess for aneurysms, IVIg and aspirin
What are the clinical features of DiGeorge Syndrome
- Conotruncal cardiac defects (tetraology of fallot, truncus arteriosus, interrupted aortic arch)
- abnormal facies
- thymic hypoplasia/aplasia (T cell deficiency)
- Craniofacial deformities (cleft palate)
- Hypocalcemia/hypoparathyroidism
Heavy, regular menses, anemia and normal coagulation studies suggests a diagnosis of
von Willebrand disease –> impaired platelet adhesion
**Bleeding time prolonged
other symptoms: easy bruising, mucocutaneous bleeding
What are the clinical features of congenital rubella
- sensorineural hearing loss
- cataracts
- patent ductus arteriosus
What is Legg-Calve-Perthes disease
idiopathic osteonecrosis of the femoral epiphysis most commonly in boys ages 3-12 yo (peak 5-7yr)
What is the treatment for Systolic dysfunction (low EF) CHF
- ACE inhibitor or ARBs
- Beta blockers
- Spironolactone
- Diurectics
- Digoxin
Which beta blockers have benefit in low EF CHF
- metoprolol
- bisoprolol
- carvvedilol
What is the side effect benefit of elperenone over spironolactone
Elperenone does not have antiandrogenic effects –> use in pts w/ gynecomastia w/ spironolactone
Which diuretics are preferred in the treatment of low EF CHF
Loop diuretics: furosemide, torsemide, bumetanide
What are the complications of heat stroke
rhabdomyolysis, renal failure, ARDS, DIC
How is the MCHC affected in beta thalassemia
Decreased
How is the MCHC affected in hereditary spherocytosis
Increased
What are the ultrasound findings associated with endometriosis
Homogeneous cystic mass
How is haptoglobin affected by hemolysis
Haptoglobin decreases as hemolysis increases
For how long following last attack should antibiotic (penicillin) prophylaxis be used for secondary prevention of rheumatic fever
- Uncomplicated RF: for 5 yrs or until age 21
- W/ carditis but no valvular disease: for 10 yrs or until age 21
- W/ carditis and valvular disease: 10 yrs or until age 40
What is the initial treatment of atrial fibrillation with rapid ventricular response in hemodynamically stable patietns
Beta blockers or calcium channel blockers for rate control
What are the indications for valve replacement in aortic stenosis
Severe AS + 1 of:
- onset of symptoms
- left ventricular ejection fraction <50%
- undergoing other cardiac surgery (eg CABG)
What are the signs of aspirin overdose
- tinnitus
- hyperventilation
- resp alkalosis that becomes anion gap metabolic acidosis (from lactate)
- renal toxicity
- altered mental status
- increased PT
What is the treatment for aspirin overdose
Alkalinize the urine –> increases excretion
What test can be rapidly used to identify tricyclic antidepressant overdose
EKG –> demonstrates widening of the QRS
What test can be used to confirm Jellyfish sting and what is the treatment
Microscopy demonstrating nematocysts
Tx: Wash w/ seawater (stops nematocysts), scrape off stingers w/ hard plastic (e.g. credit card), rinse with hot water to neutralize.
*vinegar can help prevent toxin release from nematocyst
*topical steroids & antihistamines as needed for symptoms
What are the risks associated with combined oral contraceptive use
- VTE
- HTN
- Hepatic adenoma
- Stroke, MI
- Cervical cancer
What type of crystals can be found in the urine after ethylene glycol intoxication
Calcium oxalate crystals
Immunocompromised patients are especially susceptible to which types of bacterial infections (based on gram stain)
Gram negative e.g. pseudomonas
In HSV encephatlitis which part of the brain is most affected
Frontotemporal region
What are the classic CSF fluid analysis findings in HSV encephalitis
- Lymphocytic Pleocytosis
- elevated protein
- elevated RBC
- normal glucose
What is active phase protraction of labor
Cervical dilation less than expected (<1cm every 2 hrs) +/- inadequate contractions
treatment: oxytocin
What is the treatment of protraction of active labor
Oxytocin
What is arrest of active labor
no cervical change for >/= 4 hrs w/ adequate contractions OR no cervical change for >/=6 hrs w/ inadequate contractions
What is the treatment for arrest of active labor
C-section
What is latent and what is active labor
Latent: 0-6cm cervical dilation
Active: 6-10 cm dilation, progressio of >/=1cm per 2 hrs
What is the Light criteria for an exudative pleural effusion
Protein (pleural/Serum): >0.5
LDH (pleural/serum): >0.6, pleural LDH >2/3 upper limit of normal serum LDH
What are the common causes of exudative pleural effusions
infections (parapneumonic, TB, fungal, empyema,)
Malignancy
PE
What is the Light criteria for transudative pleural effusion
Protein (pleural/serum) =0.5
LDH (pleural/serum): =0.6
What are the common causes of transudative pleural effusion
Hypoalbuminemia (cirrhosis, nephrotic syndrome)
CHF
What type of motor neuro signs are present in ALS
Upper and Lower motor neuron signs
What is the initial treatment for stable patient with ventricular tachycardia
Amiodarone
What is adenosine used for
treatment of supraventricular tachycardia
What is a pharmacologic treatment for neurogenic bladder
Cholinergic agents (e.g. bethanechol) to aid contraction and urethral relaxation
What is the treatment for postpartum endometritis
Clindamycin & gentamicin (for polymicrobial infection)
What is the treatment for acute cervicitis
Ceftriaxone + azithromycin (covers N. gonorrhoeae & C. trachomatis)
What is the most accurate method for estimating current gestational age
First trimester ultrasound
What are the endoscopic colon cancer screening recommendations for patients with IBD
8-10 yrs post diagnosis (12-15 yrs if only in left colon)
-Repeat every 5 years
When to start screening with colonoscopy in patients w/ FAP
Age 10-12 yr old, repeat annually
When to start screening with colonoscopy in pts with HNPCC
Age 20-25 yo, repeat every 1-2 yrs
What are the clinical manifestations of aresinic poisoning
Acute: garlic breath, QTc prolongation, vomiting, watery diarrhea
Chronic: hypo/hyperpigmentation, hyperkeratosis, stocking glove neuropathy
What is the treatment for arsenic poisoning
Dimercaprol, DMSA
What are the common etiologies of acute colonic psuedoobstructions (Ogilvie syndrome)
- Major surgery, trauma, severe infection
- electrolyte derangement
- medications (opiates, anticholinergics)
- neurologic disorders (dementia, stroke)
At what CD4 level is azithromycin prophylaxis given to HIV positive pts and why
CD4 <50 for prevention of Mycobacterrium avium complex (MAC)
What heart sound is present with tricuspid regurg
Holosystolic murmur that increases with inspiration
What is the optimal fetal position
occiput anterior
What are the clinical signs of Heparin induced thrombocytopenia type 2
Heparain exposure >5 days +
- platelet reduction >50%
- arterial or venous thrombosis
- necrotic skin lesions at heparin injection site
- acute anaphylactoid rxns after heparin administration
What is the clinical presentation of amyloidosis
- asymptomatic proteinuria or nephrotic syndrome
- Cardiomyopathy w/ HF
- Mixed sensory & motor peripheral neuropathy &/or autonomic neuropathy
- Visible organ enlargement
- bleeding diathesis
- waxy thickening, easy bruising of skin
What is the most common potential side effect of hydroxyurea
Myelosuppression
What is Cushings Reflex
HTN + bradycardia + respiratory despression that suggests brainstem compression
What is the treatment for type 2 heparin induced thrombocytopenia
Stop heparin
Begin direct thrombin inhibitor (eg argatroban) or Fondaparinux (synthetic pentasaccharide)
Which organism is associated with infections following puncture wound to the foot through shoes
Pseudomonas aeruginosa (osteomyeltitis)
Finger-shaped lesions on the vocal cords and hoarseness in children is associated with
Respiratory papillomatosis from HPV infection (often vertical transmission)
What is the treatment for trigeminal neuralgia
Carbamazepine
Microcytic anemia with elevated reticulocyte count suggests
Alpha thalassemia w/ 3 genes deleted
**other microcytic anemias tend to have low reticulocyte counts
What is the role of hepcidin? And what is it’s expected level in anemia of chronic disease
Hepcidin regulates iron absorption. It will be elevated in anemia of chronic disease
What type of anemia occurs from an inability of iron to be incorporated into heme
Sideroblastic anemia (can be micro or macrocytic) -causes: lead poisoning, bone marrow suppression from alcohol or myelodysplasia, isoniazid toxicity, vitamin B6 deficiency
What is the best initial test in the work up of microcytic anemia
Iron studies
What is the most accurate test for the diagnosis of sideroblastic anemia
Prussian blue staining –> ringed sideroblasts
*basophilic stippling can also occur
What is the most accurate test for the diagnosis of thalassemia
hemoglobin electrophoresis
*except alpha thalassemia when genetic testing becomes more accurate
Hemoglobin H is associated with which thalassemia
3 gene alpha thalassemia
Hemoglobin Bart is associated with which thalassemia
4 gene alpha thalassemia
What is the management for iron overload (e.g. secondary to chronic transfusions)
Iron chelators: deferasirox (oral), deferiprone (oral), and deferoxamine (IV)
With what change in WBCs seen on smear is megaloblastic anemia associated
Hypersegmented neutrophils
**only associated w/ B12 & folate deficiency related anemias
Which anemia causing vitamin deficiency can be seen with high skin loss or turnover (as in psoriasis)
Folate deficiency
Which vitamin deficiency is associated with a marcocytic anemia and increased methylmalonic acid level
B12 deficiency
What vitamin abnormality is associated with metformin
B12 deficiency
What blood test confirms pernicious anemia
positive anti-intrinsic factor and positive anti-parietal cell antibodies
What lab changes are expected in hemolysis
- sudden decrease in hematocrit
- increased LDH
- increased indirect bilirubin
- increased reticulocytes
- decreased haptoglobin
- increase in MCV
- hyperkalemia
- folate deficiency
What antibiotic(s) should be given to a sickle cell patient with fever and/or leukocytosis
- Ceftriaxone, levofloxacin, or moxifloxacin
* *adjust w/ cultures/susceptibilities
What are the symptomatic indications for exchange transfusion in patients with sickle cell
- acute chest syndrome
- priapism
- stroke
- visual disturbance from retinal infarction
What are the clinical manifestations of hereditary spherocytosis
- recurrent episodes of hemolysis
- intermittent jaundice
- splenomegaly
- familiy hx of anemia/hemolysis
- bilirubin gallstones
What is the most accurate test for hereditary spherocytosis
eosin-5-maleimide flow cytometry
**others: osmotic fragility test
What are some common causes of autoimmune (warm/IgG) hemolysis
- CLL
- Lymphoma
- SLE
- drugs: penicillin, alpha-methyldopa, rifampin, phenytoin
What is the most accurate test for autoimmune (warm) hemolytic anemia
Coombs test
What is the treatment for autoimmune (warm) hemolytic anemia
-glucocorticoids (prednisone)
-recurrent episodes?? –> splenectomy
-prednisone resistnat?? –> IVIg
then if all else fails: rituximab, azathioprine, cyclophosphamide, or cyclosporine
What is cold agglutinin disease
IgM antibodies against RBCs developing in associateion with EBV, waldenstrom macroglobulinemia, or mycoplasma pneumoniae.
Presentation: numbness, mottling in colder parts of body, symptoms resolve w/ warming
With which conditions is cold agglutinin disease associated
EBV infection
Waldenstrom macroglobulinemia
Mycoplasma pneumoniae
What is the treatment for cold agglutinin disease
- warm the patient
- Adminiter rituximab, possible plasmapheresis
- Cyclophosphamide, cyclosporine, or other immunosuppressive to stop antibody production
What is the treatment for esophageal spastic disorders
Calcium channel blockers and nitrates
Alternatives: tricyclic antidepressants, sildenafil
What is the treatment for eosinophilic esophagitis
PPIs and avoiding triggers
Then swallowing inhaled steroids
What are the adverse effects of Tamoxifen
Hot flashes
VTE
Endometrial hyperplasia
What is the most likely source for a PE
Proximal venous thrombus: femoral vein, iliac vein, popliteal vein
What is the treatment for confirmed chlamydia
Azithromycin only
What is the treatment for confirmed gonorrhoea
Azithromycin and ceftriaxone
What is the first ling treatment for PCP intoxication (with agitation)
Benzodiazepines
**Haloperidol is second line
What is the etiology of anemia of prematurity
- impaired EPO production
- short RBC life spain
- iatrogenic blood sampling
What retic count is expected in anemia of prematurity
Low
–> etiology is low EPO production
At what percentage of stenosis should endarterectomy be considered in patients with asymptomatic carotid artery stenosis
High grade: 80-99%
What are the major criteria for acute rheumatic fever
- Joints = migratory arthritis
- <3 =carditis
- N=nodules (subcutaneous)
- E = erythema marginatum
- S = Sydenham chorea
What are the minor criteria for acute rheumatic fever
- fever
- arthralgias
- elevated ESR/CRP
- Prolonged PR interval
What risk still remains after orchiopexy for cryptorchidism
Increased risk of testicular germ cell tumor
***risk of infertility, torsion and hernia gone after orchiopexy
What is the formula for positive predictive value
TP/(TP+FP)
What is the formula for sensitivity
TP/(TP+FN)
Which traumatic injury is associated with brief loss of consciousness followed by a lucid interval that then progresses to HA, N/V, impaired consciousness, and possible herniation
Epidural hematoma
What are risk factors for preeclampsia
nulliparity and age <18 yo
What is the first line treatment for essential tremors
beta blockers eg propranolol
What is the treatment for cauda equina syndrome
emergency surgical decompression
What complications are associated with Beckwith-Wiedemann syndrome
Wilms tumor
Hepatoblastoma
What is the first step in ACS rule out
Have pt chew high dose aspirin
What are the common signs and symptoms of all types of SHOCK
- hypotension
- oliguria
- tachycardia
- altered mental status
- *lactic acidosis
What are the types of shock
**per Step Up to Medicine 4th Ed.
- cardiogenic
- hypovolemic (distributive??)
- neurogenic
- septic
What are the initial steps in a shock work up
**per Step Up to Medicine 4th Ed.
- establish good access
- fluid bolus (NS ro LR)
- Draw blood: CBC, electorlytes, renal function, PT/PTT
- ECK
- CXR
- Continuous pulse ox
- Vasopressors if hypotensive despite fluid
Which type of shock has increased cardiac output
Septic
**all others have decreased Cardiac output
Whicih types of shock have increased SVR
cardiogenic and hypovolemic
Which types of shock have decreased SVR
neurogenic and septic
Which type of shock has increased PCWP
Cardiogenic
**all others have decreased PCWP
What is the most common cause of cardiogenic shock
acute MI
What are some common causes of cardiogenic shock
- Acute MI (#1)
- Cardiac Tamponade
- Tension pneumothorax
- Arrhythmias
- Massive PE leading to RVF
- Myocardial disease (cardiomyopathies, myocarditis)
- Mechanical abnormalities (valvular defects, VSD)
Which clincial features are more unique to cardiogenic shock (as opposed to other types of shock)
- engorged neck veins
- pulmonary congestion
What are some examples of vasopressors
- dopamine
- norepinephrine
- phenylephrine
Which classes of hypovolemic shock require fluid resuscitation
III & IV
but class II will benefit from it
**per Step Up to Medicine 4th Ed., pg 66
What are the common causes of septic shock
- pneumonia
- pyelonephritis
- meningitis
- abscess formation
- cholangitis
- cellulitis
- peritonitis
What is the natural progression of the septic shock path
SIRS –> Sepsis –> Septic Shock –> Multiorgan dysfunction syndrome (MODS)
How is SIRS (systemic inflammatory response syndrome) defined
2 or more of :
- fever >38C or hypothermia <36C
- hyperventilation (>20bpm) or PaCO2 <32 mmHg
- tachycardia (>90 bpm)
- Increased WBC (>12,000 cells/hpf)
Which type of shock is most closely associated with bradycardia
Neurogenic
What is the most common cause of death in the ICU
Septic Shock
What the the primary tumors most commonly associated with metastasis to the heart
lung, breast, skin, kidney, lymphomas, kaposi sarcoma (in AIDS)
What is the most common primary cardiac neoplams
Atrial myxoma
What are the clinical signs and symptoms of an atrial myxoma
- fatigue
- fever
- syncope
- palpitations
- malaise
- low pitched diastolic murmur that changes w/ body position (diastolic plop)
What is the treatment for atrial myxoma
surgical excision
How do you calculate the anion gap
AG = [Na+] - ([Cl-] + [HCO3-])
**if low, correct for low albumin: increase anion gap by 2.5 for every 1 gm/dl albumin below 4.5 g/dl
What is the formula to determine compensation in metabolic acidosis
Pco2 = 1.5*[HCO3-] + 8
What is the formula to determine compensation in metabolic alkalosis
Pco2 = 40 + 0.7*([HCO3-measured] - [HCO3-(normal)])
What is the formula to determine compensation in respiratory acidosis (acute)
Acute: [HCO3-] increases by 1 mEq/L for every 10 mmHg increase in Pco2
What is the formula to determine compensation in respiratory acidosis (chronic)
Chronic: [HCO3-] increase by 3.5 mEq/L for every 10 mmHG increase in Pco2
What is the formula to determine compensation in respiratory alkalosis (acute)
Acute: [HCO3-] decreases by 2 mEq/L for every 10 mmHg decrease in Pco2
What is the formula to determine compensation in respiratory alkalosis (chronic)
Chronic: [HCO3-] decreases by 5 mEq/L for every 10 mmHg decrease in Pco2
What is the ratio of the increase in Anion Gap (AG) to the decrease in HCO3- in lactic acidosis
(deltaAG):(delta)HCO3- = 1.5
What is the ratio of the increase in Anion Gap (AG) to the decrease in HCO3- in ketoacidosis
(deltaAG):(delta)HCO3- = 1.0
At what anion gap is a metabolic acidosis almost certainly present, despite pH and HCO3-
AG >/= 25
What is the definition of ARDS (acute respiratory distress syndrome) per Berlin criteria 2012
(1) bilateral opacities on chest radiograph or computed tomography,
(2) PaO2/FiO2 300 mm Hg or less with 5 cm or more H2O PEEP,
(3) respiratory failure not fully explained by cardiogenic edema or volume overload, and
(4) 7 days or less from predisposing clinical insult.
How is the severity of ARDS (acute respiratory distress syndrome) classified (Berlin criteria 2012)
Severity of ARDS is classified by the Berlin definition according to PaO2/FiO2:
mild (201-300),
moderate (101-200), and
severe (< 100)
What are the common acute symptoms of ARDS
rapidly progressive dyspnea, tachypnea, and hypoxemia
What is the basic pathogenesis of ARDS
Pathogenesis is through a severe inflammatory process, which causes diffuse alveolar damage and alveolar capillary leakage, resulting in a ventilation-perfusion mismatch and poor lung compliance.
What are the 4 major mechanisms of alveolar damage in ventilated patients with ARDS
(1) barotrauma caused by excessive airway pressures,
(2) volutrauma caused by over distension of alveoli from high tidal-volume ventilation,
(3) atelectrauma caused by shearing forces on alveoli from inspiratory opening and expiratory collapse, and
(4) biotrauma caused by the release of proinflammatory cytokines from excessive mechanical forces on the lung.
What type of diet reduces the production of carbon dioxide thus reducing respiratory acidosis (relevant for management of intubated patients)
High fat, low carbohydrate
How does prone positioning of mechanically ventilated patients improve oxygenation
- redistribution of blood flow to healthier lung regions results in a decreased ventilation perfusion mismatch and recruitment of dependent lung units.
- lung tissue is relieved of compression from anterior mediastinal and abdominal structures.
- clearance of respiratory secretions is improved with an associated reduction in ventilator-associated pneumonia
What are the major risks of ECMO (extracorporeal membrane oxygenation)
- bleeding due to anticoagulation (in particular, intracranial hemorrhage)
- complications of large bore vascular access.
What is the leading cause of morbidity and mortality in HIV-infected patients?
Pulmonary complications (e.g. Bacterial pneumonia esp. streptoccocus pneumoniae, staphylococcus aureus and tuberculosis )
What is the drug of choice for prophylaxis against Pneumocystis jiroveci pneumonia (PCP) in select HIV patients
Bactrim (trimethoprim-sulfamethoxazole)
When is Immune reconstitution inflammatory syndrome is commonly in naive patients who are severely immune suppressed (CD4 < 50-100 cells/mm3) and have an opportunistic infection at the time of HIV diagnosis following initiation of highly active antiretroviral treamtent?
4 to 6 weeks
Immune reconstitution inflammatory syndrome is commonly seen 4 to 6 weeks after initiation of highly active antiretroviral treatment in treatment naive patients who are severely immune suppressed (CD4 < 50-100 cells/mm3) and have an opportunistic infection at the time of HIV diagnosis.
What is CXCR4
CXCR4 is a coreceptor found on CD4+ T cells
What is CCR5
CCR5 is a coreceptor found on CD4+ T helper cells, macrophages, and dendritic cells
Without antiretroviral therapy how long does HIV take to progress to AIDS
average of 8 to 10 years
What is the drug of choice for treating anthrax (pulm, cutaneous, GI, etc)
Ciprofloxacin or other fluoroquinolones
*Doxycycline is also an option
Can pulmonary anthrax be spread person to person
No, only cutaneous and GI can
What is the feared adverse affect of the small pox vaccination that has a 25% mortality
Encephalitis which occurs in 1 in 300,000 vaccine recipients
When should activated charcoal be used
In real life: rarely
On tests: within 1 hour of ingestion (in patients w/o vomiting/seizure risk)
At what point is HIV considered AIDS
Aids defining opportunistic infection or CD4 count <200
*children 5yo or younger are classified differently
From what apes did HIV 1 come from
Chimps and/or gorillas
From what apes did HIV 2 come from
Sooty mangabeys
What is the most common subtype of HIV
HiV 1 group M
What are the 2 major envelope proteins on HIV
External Gp120 and transmembrane gp41
On which cell line is CD4 molecule most likely found
Helper T lymphocyte
What are the 2 major coreceptors for HIV1
CCR5 and CXCR4
*bind to gp120 molecule and facilitate entry into host cell
What is the primary function of coreceptors CCR5 and CXCR4 in HIV
bind to gp120 molecule and facilitate entry into host cell
Can HIV be spread via breast milk
Yes, mastitis and low maternal vitamin A levels increase risk
From where does electrical activation of the heart originate
The sinoatrial (SA) node
What are some common herbal substances that can lead to heart failure exacerbation
licorice
ginseng
herbal ephedrine
What parameters are associated with worse outcomes in acute decompensated heart failure
- BUN >43 mg/dL
- serum creatinine >2.75 mg/dL
- elevated troponin I
What are the therapeutic targets in HFpEF
-control of congestion
-stabilization of heart rate & blood pressure
-improving exercise tolerance
+/-detecting and treating sleep apnea
Within which class of drugs does milrinone fall
phosphodiesterase-3 inhibitors
= increases intracellular concentration of cyclic adenosine monophosphate which improves contractility
AKA an inotropic medication
What are the risks of short term use of inotropic medications in acute decompensated heart failure
increased arrhythmias and hypotension
What is the current indication for inotropic medication in acute decompensated heart failure
- bridge therapy to left ventricular assist device or transplant
- palliation in end stage heart failure.
Which medicaitons in the treatment of HF w/ reduced EF reduce mortality as well as hospitalizations
- ACE Inhibitors
- Beta blockers
- Aldosterone antagonists
Which types of beta blockers are not effective in reducing mortality & treating HFrEF?
Beta blockers withs intrinsic sympathomimetic activity (e.g. xamoterol, bucindolol)
Which beta blockers can be used in the treatment of HFrEF
- Carvedilol
- Bisoprolol
- Metoprolol sccinate
How should beta blocker doses be titrated in stable ambulatory HFrEF patients
Increase dose every 2 weeks if no sign of hypotension
**beta blocker reduction in mortality is dose-dependent
What are the 3 main causes of CHF
- infarction
- cardiomyopathy
- valve disease
What are some of the less common (not infarction, cardiomyopathy or valve disease) causes of CHF
-alcohol
-postviral/idiopathic myocarditis
-radiation
-adriamycin (doxorubicin) use
-chagas disease
-hemochromatosis
-thyroid disease
-peripartum cardiomyopathy
thiamine dificiency
What medications are used in the treatment of HFrEF
- ACE inhibitor or ARB
- beta blockers
- aldosterone anatagonist (spironolactone/eplerenone)
- diurectics
- digoxin
How is a diagnosis of a hiatal hernia made
Barium study or endoscopy
What is the best initial therapy for hiatal hernia
weight loss and PPI
What are indications for emergency surgery for hiatal hernia
- gastric volvulus
- obstruction
- strangulation
- perforation
What is the “most accurate test” for achalasia
Manometry - will show failure of lower esophageal sphincter to relax
What are the treatment options for achalasia
- Pneumatic dilation
- Surgical sectioning/myotomy
- Botulinum toxin injection
What is the rate of perforation in pneumatic dilation for the treatment of achalasia
~3%
What is a precipitating factor that can be used to distinguish esophageal spasm from coronary artery spasm
triggered by drinking cold liquid is more representive of esophageal spasm
Which test is preferred to distinguish nutcracker esophagus from diffuse esophageal spasm
Manometry
What is the treatment for esophageal spasm disorders (DES and nutcracker esophagus)
Calcium channel blockers
Nitrates
+/- PPIs
**Alternatives: tricyclic antidepressants, then lastly sildenafil
What is the initial treatment for eosinophilic esophagitis
PPIs + elimination of allergenic foods
*Secondary is swallowed steroid inhalers
What is the secondary treatment for eosinophilic esophagitis
Secondary is swallowed steroid inhalers
*Initial is PPIs + elimination of allergenic foods
Name 3 medications that can cause esophagitis w/ prolonged contact
- Doxycycline
- Alendronate
- KCl
What is the medical therapy for CMV esophagitis in AIDS
Ganciclovir or foscarnet
What is the medical treatment of HSV esophagitis in AIDS
Acyclovir
What is the treatment for esophageal candidiasis
Initial: Fluconazole
Confirmed resistant: Amphotericin
**Do not use nystatin, this is for oral candidiasis
What is the treatment for oral candidiasis
Nystatin swish and swallow
**do not use for esophageal candidiasis
Which esophageal disorder is associated with intermittent dysphagia, acid reflux, hiatal hernia, and scarring of the distal esophagus
Schatzki rings or peptic stricutures
Which esophageal stricture syndrome is associated with iron deficiency anemia
Plummer Vinson syndrome
Where are strictures in plummer vinson syndrome located
Proximal esophagus
What is the initial treatment for Plummer Vinson syndrome
Iron replacement
What is the treatment for schatzki ring
pneumatic dilation
What is a zenker diverticulum
outpocketing of the posterior pharyngeal constrictor muscles causing dysphagia, halitosis, and regurgitation of food particles
What is the best diagnositic study for zenker diverticulum
barium studies
Unlike achalasia, scleroderma is associated with what changes in the LES
In scleroderma, there is decreased lower esophageal sphincter pressure and an inability to close the LES
A presentation of upper GI bleeding following prolonged or severe vomiting is suggestive of a diagnosis of …
Mallory-Weiss Tear
What is the managment for mallory-weiss tear
No specific therapy as typically resolves spontaneously.
Injection of epinephrine or electrocautery can used if bleeding is persistent
What is the difference between Mallory Weiss Tear and Boerhaave syndrome
Boerhaave syndrome is full penetration of the esophagus, and mallory weiss is a nonpenetrating tear of mucosa only
What is the treatment for cannabinoid hyperemesis syndrome
Antiemetics - e.g. ondansetron
Benzodiazepines - e.g. lorazepam
**probably also stop using cannabinoids
What unique historical clue can help distinguish cannabinoid hyperemesis syndrome from other hyperemesis syndromes
Relief with a hot shower
What is the most common cause of epigastric pain
Non-ulcer dyspepsia
What is the initial treatment for acute cluster headache
High flow oxygen for 15 minutes (via nonrebreather mask) can be abortive
For what condition is aerosolized racemic epinephrine commonly used?
Laryngotracheobronchitis (Croup).
The shoulder is most vulnerable to an anterior glenohumeral dislocation in which positions?
Abduction and external rotation (e.g. throwing a ball)
With which forms of trauma are posterior shoulder dislocations associated
grand mal seizures and electric shock.
What is the most common type of major joint dislocation?
Glenohumeral joint (shoulder).
What are the possible complications of a shoulder dislocation
axillary nerve damage, Bankart lesion, Hill-Sachs deformity
What are the signs of arsenic poisoning (aka ingestion)
- acute gastrointestinal effects including nausea, vomiting, hematemesis, hematochezia, diarrhea and abdominal pain.
- often complain of metallic or garlicky taste within 30-60 minutes of exposure.
- Arsine gas exposure (inhalation) leads to severe hemolysis that is associated with renal tubular injury.
- Cardiovascular effects include third spacing with shock, sinus or ventricular tachycardia.
- Neurologic effects include headache, delirium, coma and seizures.
What is the mechanism of arsenic toxicity
Arsenic binds strongly to lactate dehydrogenase and glyceraldehyde 3-phosphate dehydrogenase inhibiting critical steps in glycolysis.
Which toxin is associated with odor of pears
Chloral hydrate
Which toxin is associated with odor/taste of bitter almonds
cyanide
Which toxin is associated with the odor of carrots
Water hemlock
Which toxin is associated with the odor of wintergreen
methyl salicylate
Which toxin(s) is associated with the odor of garlic
- arsenic
- DMSO
- organophosphates
- yellow phosphorus
- selenium
- tellurium
Which toxin is associated with the odor of glue
toluene
What is the chelating agent for arsenic toxicity?
Intramuscular Dimercaprol or oral DMSA
What is the perferred sample for measuring arsenic levels
urine - arsenic is metabolized rapidly in blood
What is the treatment for arsenic toxicity
Supportive in mild to moderate cases
Chelation w/ dimercaprol or DMSA in severe cases
What is the underlying pathophysiology of an epidural hematoma
skull fracture with disruption of the middle meningeal arteries
Which brain hematoma is associated with a “lucid interval”
Epidural hematoma
What is the treatment for an epidural hematoma
Surgical evacuation of the hematoma
What is the most common CT abnormality in patients with traumatic brain injury?
Subarachnoid hemorrhage
Use of which medications increases the risk of achilles tendon rupture
Fluoroquinolone or glucocorticoid
How should achilles tendon rupture be managed until definitive treatment with surgery (e.g. how to manage in ED)
Short leg splint with foot in plantar flexion.
Nonweight bearing
Which organism is responsible for fulminant bacteremic illness after a dog bite
Capnocytophaga canimorsus = gram negative rod
What is the treatment for capnocytophaga canimorsus (fulminany bacterial infection following dog bite)
Gram negative organism so:
- susceptible to penicillin G, ampicillin/sulbactam, 3rd gen cepholasporins, fluoroquiinolones, and vancomycin
- resistent to aminoglycosides
What is the most common bacterial infection associated with dog bites
Pasteurella multocida
**Capnocytophage canimorsus is most commonly associated with severe sepsis following a dog bite
What is the second line treatment for acute low back pain
NSAIDs or Acetaminophen + muscle relaxants (e.g. cyclobenzapine, diazepam, methocarbamol, carisoprodol)
*first line NSAIDs or acetaminophen only
What personality disorder is strongly aligned with malingering?
Antisocial personality disorder
What is a myasthenic crisis?
Respiratory failure leading to mechanical ventilation.
What is the treatment for myasthenic crisis
Plasma exchange, IVIG
What formula is used to estimate the depth at which to secure an ET tube in a pediatric patient?
Depth (cm) = (age in years/2) + 12
Lumbar puncture in disseminated Lyme disease will show what
lymphocytic pleocytosis with a moderately elevated protein level.
What is the treatment for CNS lyme disease
ceftriaxone
What is the most common cardiac manifestation of Lyme disease?
First degree AV block
What is the role of beta-adrenergic blocking agents in acute myocardial infarction?
Beta-adrenergic blockers given within 24 hours of presentation reduce the risk of developing ventricular dysrhythmias.
For how long should patients abstain from drinking alcohol when taking metronidazole?
At least 2 days after last dose
What is the most common infectious precipitating factor for erythema multiforme?
Herpers Simplex virus
What is the most common cause of mitral stenosis?
Rheumatic heart disease
What heart sounds are associated with mitral stenosis
On auscultation loud S1 (although intensity diminishes as disease progresses), opening snap, low-pitched, rumbling diastolic apical murmur
In scaphoid fractures, is avascular necrosis more likely to develop with distal or proximal fractures?
Proximal fractures as vascular supply enters distally
What is the classic triad of AAA rupture?
Abdominal pain, hypotension, pulsatile abdominal mass
What are the common findings found on fundoscopy in central retinal artery occlusion?
Retinal edema with a pale appearance and a cherry-red spot representing the fovea.
In addition to lactulose, what is another treatment for hepatic encephalopathy?
Neomycin, Rifaximin
What is the most common predisposing factor for peptic ulcer disease in adults?
H. pylori colonization
What percent of abdominal aortic aneurysms can be palpated on physical exam?
50%
What is the treatment of torsades de pointes?
Magnesium sulfate
Which adult patients with burns should be transferred to a burn center?
Partial thickness burns > 10% TBSA; Burns involving the face, hands, feet, genitalia, perinuem, and/or major joints; Any full-thickness burn; High-voltage or electrical burns; Chemical burns; Inhalation injury
What is the Parkland formula for calculating fluid resuscitation in burns
Volume of LR = 4mL * %body surface area of burn * body weight (kg)
- Give 50% of volume in 1st 8hrs
- Give next 50% over the next 16 hrs
What is the rule of estimates for percentage of body surface area burned
9% head 18% front (chest/abdomin) 18% back 9% arm+hand 0.5% hand only 18% each leg 1% genitalia
What is the treatment for croup (laryngotracheitis)
Supportive if at home.
Dexamethasone 0.6 mg/kg if in ED/hospital
Nebulized epinephrine (racemic) for pts with stridor at rest or respiratory distress
What is the causitive agent of croup (laryngotracheitis)
Parainfluenza virus
Which age group is most affected by croup (laryngotracheitis)
6 months to 3 years
Which leads are elevated in an anterior wall myocardial infarction?
V1-V4
What laboratory abnormalities are commonly seen with tumor lysis syndrome?
hyperuricemia
hyperkalemia
hyperphosphatemia
hypocalcemia
What is the upper limit of normal for a QTc interval?
For men, the upper level of QTc interval is 450 msec. For women, the upper level of QTc interval is 470 msec.
What is the classic auscultatory feature of mitral valve prolapse?
Midsystolic click
What is the classic auscultatory feature of mitral valve stenosis?
loud S1 and an opening snap in early diastole accompanied by a low-pitched, rumbling diastolic apical murmur.
Mitral valve prolapse is often associated with what conditions?
Marfan’s syndrome and Ehlers-Danlos syndrome
Which patients with rib fractures should be admitted?
Patients with flail chest, more than three rib fractures and older patients or those with multiple comorbidities. These patients are at increased risk of developing pneumonia after rib fractures.
What organisms are typically implicated in anorectal abscesses?
Staphylococcus aureus, Escherichia coli, Streptococcus, Proteus and Bacteroides.
What three medications decrease mortality after a myocardial infarction?
ABC – Aspirin, beta-blockers, statins (anti-cholesterol)
What medications are most likely to cause neutropenia in adults?
Macrolides, antithyroid medications (such as methimazole), and procainamide
What is the name of the ECG finding classically associated with large pericardial effusions?
Electrical alternans.
What birefringence is acute gout associated with?
negative birefringence.
What two electrolyte abnormalities are associated with burns from military white phosphorous munitions?
Hypocalcemia
Hyperphosphatemia
What is the treatment for herpes simplex?
Three medications can be used for treatment of herpes infections: acyclovir, valacyclovir, and famciclovir
Compartment syndrome of the deep posterior compartment of the lower leg will lead to which passive movement producing intense pain?
Toe extension.
Iritis is associated with what antigenic marker?
HLA-B27, which is also strongly linked to spondyloarthritis such as ankylosing spondylitis
Which fractured bone is commonly referred to as a nightstick fracture?
Ulnar shaft fractures are commonly referred to as nightstick fractures and are caused by a direct blow to a raised forearm.
When does acute fatty liver of pregnancy typically occur?
3rd trimester
What is a dependent pocket of pus seen in the anterior chamber called?
Hypopyon
When should a foot radiographic series be performed (Ottawa Ankle Rules)
When there is pain in the midfoot region + :
- bone tenderness at the navicular bone
- bone tenderness at the base of the 5th metatarsal
- inability to bear weight for at least 4 steps immediately after injury and at time of evaluation
What is a Maisonneuve fracture?
A spiral fracture of the proximal 1/3 of the fibula associated with a tear of the distal tibiofibular syndesmsosis and the interosseous membrane.
What is a Maisonneuve fracture?
A spiral fracture of the proximal 1/3 of the fibula associated with a tear of the distal tibiofibular syndesmsosis and the interosseous membrane.
What findings are classically seen on abdominal X-ray in intussusception?
A dilated small bowel with absent gas in the colon and an obscured liver margin (Dance’s sign)
Which age group is most at risk of intussusception
6 months to 3 years
Which age group is most at risk of intussusception
6 months to 3 years
Which hernia may present with pain in the medial portion of the thigh?
Obturator hernia
What is the empiric treatment for presumed bacterial meningitis in Adults 18-50 yo
Ceftriaxone + vancomycin
What is the empiric treatment for presumed bacterial meningitis in Adults >50 yrs or alcoholics
Ceftriaxone + vancomycin + ampicillin
What is the empiric treatment for presumed bacterial meningitis in Adults with impaired cellular immunity
Vancomycin + Ampicillin + (Cefepime OR Meropenem)
What is the empiric treatment for presumed bacterial meningitis in children
Ceftriaxone + vancomycin OR cefotaxime + vancomycin
What is the empiric treatment for presumed bacterial meningitis in neonates
Cefotaxime + Ampicillin OR Gentamicin + ampicillin
What is the empiric treatment for presumed bacterial meningitis in Adults 18-50 yo
Ceftriaxone + vancomycin
What is the empiric treatment for presumed bacterial meningitis in Adults >50 yrs or alcoholics
Ceftriaxone + vancomycin + ampicillin
Which vein is most preferable to access during a peripheral venous cutdown in children?
Saphenous vein
**Basilic is preferred if upper extremity must be used
***This procedure is rare and a last resort for venous access
How long after symptoms cease do patients with genital herpes stop shedding virus?
It is suspected that patients with a history of herpes can shed virus continuously, whether symptoms are present or not.
What are the general indications for an emergent exploratory thoracotomy (in setting of hemothorax)
- initial thoracostomy tube drainage >20 mL/kg
- Output >/= 200 mL/hr for first 3 hrs
- Persistent bleeding at a rate of >7 mL/kg/hr
- increasing hemothorax seen on chest X-ray
- patient remains hypotensive despite adequate blood replacement
- patient decompensates after initial response to resuscitation
How much fluid is typically required in the costodiaphragmatic angle to be seen on an upright chest radiograph?
~300 mL
After what period of time does the incidence of infection rise dramatically following the insertion of a peripheral catheter?
After 48 hrs
Which vein is most preferable to access during a peripheral venous cutdown in children?
Saphenous vein
**Basilic is preferred if upper extremity must be used
***This procedure is rare and a last resort for venous access
How long after symptoms cease do patients with genital herpes stop shedding virus?
It is suspected that patients with a history of herpes can shed virus continuously, whether symptoms are present or not.
Which nerve is most commonly injured with anterior elbow dislocations
ulnar nerve
When should a hanging cast be placed in a humerus fracture as opposed to a sugar tong splint?
A hanging cast is used for humerus fractures that are grossly displaced or comminuted
What is the most common cause of ventricular tachycardia?
Myocardial ischemia or infarct
What is the most common nerve injury seen after humeral shaft fractures
Radial nerve injury
Are there any contraindications to tetanus immunization?
Yes. The only true contraindication is a history of neurologic or severe hypersensitivity reaction to a previous dose.
Which nerve is most commonly injured with anterior elbow dislocations
ulnar nerve
When should a hanging cast be placed in a humerus fracture as opposed to a sugar tong splint?
A hanging cast is used for humerus fractures that are grossly displaced or comminuted
What are three complications of bacterial sinusitis?
Meningitis, orbital cellulitis, and sinus bone osteitis
What medications are contraindicated with Clostridioides difficile colitis?
Antimotility drugs because they can worsen symptoms and lead to toxic megacolon.
Entrapment of which extraocular muscle can be seen with blow-out fractures of the orbital floor?
Inferior rectus muscle
What class of medication may help improve palpitations from mitral valve prolapse?
Beta blockers
What are some antibiotics with known risk for causing QT prolongation?
Ciprofloxacin, Azithromycin, clarithromycin, erythromycin, levofloxacin, and moxifloxacin
What is the treatment for Torsades de Pointes
Stable: magnesium sulfate
Unstable: defibrillation
What is the mechanism by which warfarin can cause a hypercoaguable state early in treatment?
Warfarin can cause a hypercoaguable state due to the more rapid depletion of protein C and protein S compared to the clotting factors with longer half-lives.
Entrapment of which extraocular muscle can be seen with blow-out fractures of the orbital floor?
Inferior rectus muscle
What class of medication may help improve palpitations from mitral valve prolapse?
Beta blockers
What are some antibiotics with known risk for causing QT prolongation?
Ciprofloxacin, Azithromycin, clarithromycin, erythromycin, levofloxacin, and moxifloxacin
What is the treatment for Torsades de Pointes
Stable: magnesium sulfate
Unstable: defibrillation
What topical anesthetic may precipitate methemoglobinemia?
Benzocaine (found in “hurricane spray”).
What is the treatment for inhaled amyl nitrite toxicity
Methylene blue as amyl nitirite is an antidote for cyanide that causes methemoglobinemia
What is the most common cause of esophageal perforation?
Iatrogenic perforation
What is the INR range in a patient taking warfarin for atrial fibrillation?
2-3
What is a complication of tension headache?
Rebound headaches with frequent analgesic use
Which category (eye, verbal, or motor) of the GCS correlates best with outcomes?
Motor
What is the most common site of esophageal impaction in children under four years of age?
Cricopharyngeus muscle.
What are the signs of opiate withdrawal
Flu-like illness Abdominal cramps Diarrhea Mydriasis Piloerection Yawning
What is the treatment for opiate withdrawal
Clonidine and antiemetics
What is the term for a painless, temporary loss of vision in one or both eyes that may present as a symptom of a transient ischemic attack?
Amaurosis fugax.
What is Amaurosis fugax
a painless, temporary loss of vision in one or both eyes that may present as a symptom of a transient ischemic attack?
What is the most common cranial nerve injury associated with a basilar skull fracture?
CN VII, causing facial droop
What is Cushing’s reflex in elevated intracranial pressure?
Hypertension, bradycardia, and diminished respiratory effort.
What is the mainstay of treatment for hypertrophic cardiomyopathy?
Long-term beta-blocker therapy.
What is the treatment for bacterial vaginosis
1st line: metronidazole
alt. clindamycin
At what crown-rump length is a heartbeat expected on ultrasound?
5 mm
What are the different types of spontaneous abortions
Threatened abortion: vaginal bleeding with closed internal os
Inevitable: vaginal bleeding with open os
Incomplete: partial passage of products of conception (POC)
Complete: complete passage of POC
Missed: fetal death < 20 weeks without POC passage
What is the most common bacterial pathogen to cause acute otitis media in all age groups?
Streptococcus pneumoniae.
What is the most common symptom of cardiac ischemia in patients older than 85 years?
Dyspnea
What is the recommended international normalized ratio (INR) for a mechanical mitral valve?
mechanical mitral valve: 3
mechanical aortic valve: 2.5–3
What is the appropriate treatment for mitral valve prolapse?
Beta-blockers are used to treat atypical chest pain and dysrhythmias, but no treatment is required for asymptomatic patients.
What is the antidote for the anticholinergic toxidrome?
Physostigmine, a cholinesterase inhibitor
What are the classic findings in tension pneumothorax?
Contralateral tracheal shift, hypoxia, hypotension and decreased breath sounds
What is the target systolic blood pressure range in the management of aortic dissection?
Between 100 mm Hg and 120 mm Hg, depending on the patient.
What is Hamman’s sign?
The presence of a crunching sound on auscultation of the chest in the presence of air in the mediastinum. Hamman’s sign is seen in esophageal perforation.
What is the smallest amount of blood in the pericardial sac that can lead to tamponade?
~65 cc
When do you worry about giving calcium channel blockers, beta-blockers, or digoxin in a patient with atrial fibrillation?
If a patient has an accessory pathway, such as Wolf-Parkinson-White Syndrome.
What is the preferred triple therapy regimen for Helicobacter pylori infection?
A proton pump inhibitor, clarithromycin, and amoxicillin.
What is a parulis or gumboil?
A lesion that forms when a periapical abscess tracks up to the alveolar periosteum and gingival surface
Which anatomical location does amyotrophic lateral sclerosis involve?
Anterior horn cells
What type of vaccine is the varicella-zoster virus vaccine?
There are currently two different VZV vaccine preparations. Both are live-attenuated viruses and recommended for all immunocompetent infants over 1 year of age and all noninfected immunocompetent adults.
What are the components of Ranson’s Criteria on admission?
Age, WBC, glucose, LDH, AST
What test is diagnostic for pyloric stenosis?
Ultrasound
What are three consequences of pelvic inflammatory disease?
Tubo-ovarian abscess, infertility, ectopic pregnancy
What commonly used recreational drug is associated with prolonging the QT interval?
Cocaine
What is the Thurstan Holland sign?
The triangular metaphyseal fragment in the metaphysis from a Salter-Harris type II fracture.
What is the term for the neurologic and muscular stunning that can follow a lightning strike?
Keraunoparalysis
What is the most common acid-base disturbance in Reye syndrome?
Metabolic acidosis and respiratory alkalosis
How does carotid massage affect second degree type I and type II heart block?
Carotid massage will typically worsen second degree type I block and improve second degree type II block.
What type of renal injury does rhabdomyolysis cause?
Acute tubular necrosis
What pathogen causes pneumonia that is associated with bullous myringitis?
Streptococcus pneumoniae. Bullous myringitis was previously linked to Mycoplasma pneumoniae but it appears, based on middle ear aspirate culture results, that typical acute otitis media pathogens are the true cause
What pathogens most commonly cause otitis externa?
Pseudomonas aeruginosa, Enterobacteriaceae and Proteus species, Staphylococcus aureus.
What would happen to the murmur of hypertrophic cardiomyopathy with squatting or increasing afterload?
It would decrease
What is the most common ulna fracture?
The midshaft ulna fracture, often occurring due to a “nightstick” type of injury mechanism.
What class of drugs antagonizes the effects of adenosine?
Methylxanthines (theophylline, caffeine)
What is the most common bacterial cause of community acquired pneumonia in hospitalized patients?
Streptococcus pneumoniae
Which organism is most associated with pneumonia and bullous myringitis?
Streptococcus pneumoniae
What are the three categories of transplant rejection?
Hyperacute (occurs minutes to hours after surgery), acute (occurs 1–12 weeks post-transplant), and chronic (progressive with an insidious decline).
What hearing abnormality is associated with Bell palsy?
Hyperacusis
What viruses commonly cause pericarditis?
Coxsackie viruses A and B, echovirus, adenovirus, HIV, Epstein-Barr virus, influenza, and hepatitis B
What are the symptoms of hypokalemia
fatigue
proximal muscle weakness
decreased deep tendon reflexes
What is terbutaline
A beta-2 receptor agonists used as a tocolytic to delay preterm labor for up to 48 hrs
What side effect of terbutaline use can cause fatigue and proximal muscle weakness
Hypokalemia
What is the most common cause of thrombocytopenia
Drug reaction(s)
What platelet count is required to maintain vascular integrity
5000-10,000
What is the typical first sign of low platelets?
What sign denotes increased life threatening hemorrhage risk
1) petechiae in feet and ankles
2) wet purpura (blood blisters on oral mucosa)
