Family Medicine Flashcards
Normal maximum heart rate
220-patients age
Key symptoms of MI/ angina(6)
Chest heaviness Pressure Pain Radiating to left arm, shoulder, jaw SOB Diaphoresis is a key symptom
Chest pain radiating to shoulder, neck or back, worse with deep breathing or cough
Relieved by sitting up and leaning forward
Pericarditis
Severe chest pain radiating to back, associated with unequal pulses or blood pressure in arms
Aortic dissection
Tachypnea
Tachycardia
Pulmonary embolism
Sharp localized chest pain with reproducible tenderness
Exacerbated by exercise
Costochondritis
Drugs to not take if taking stress test
Beta blockers
Digoxin
Pharmacologic stress test
Dobutamine
Stress test for CAD positive if patient develops (3)
ECG changes (ST elevation or depression)
Decrease blood pressure
Failure to exercise more than 2 minutes due to cardiac symptoms
Echocardiography
Ultrasound of heart
Picture of heart
Can evaluate function
Valvular defects
Strength of heart muscle (ejection fraction)
Wall motion abnormality
Left heart catheterization process
vs right heart catheterization
Wire is inserted through a vessel (radial or femoral) and threaded to coronary vessels
Right heart catheterization is through a vein
Tx Stable angina
Beta blocker (reduces myocardial oxygen demand)
Aspirin
Nitroglycerin
Chest pain certain hour in the morning Chronic - what is it - imaging - tx
Prinzmetal’s angina
- coronary vasospasm
No stenosis or plaque in coronary vessels
ECG may show transient ST elevations
Tx: Calcium channel blockers
Nitrates to reduce vasospasm
Acute coronary syndromes
Unstable angina or actual MI
Imbalance of myocardial oxygen supply and demand
Serum markers for MI
1 hr-4 : myoglobin elevated (peak 6)
3 hrs-12 : Troponin T or I
- very sensitive and specific
- elevated for a week
(peak 18-24)
4-8 hr: creatinine phosphokinase (peak 18-24) -nonspecific - but CK MB is specific - elevated 3-4 days
Patients with acute coronary syndrome should be given
MONA + beta blocker
Morphine
Oxygen
Nitate
Asprin (clopidogrel if allergy)
Morphine should be given last
Placed on cardiac monitor (at risk for arrhythmias)
Unfractioned heparin
Closed fist over chest sign
Levine’s sign
Sign of acute coronary syndrome
Thrombolytics
Streptokinase Urokinase Anistreplase Alteplase Reteplase
Contraindications are risk of bleeding
ACS + ST elevation MI Tx
MONA + beta blocker
Thrombolytics and/or catheterization
TIMI score (7)
scoring system for aptients with NSTEMI to determine if cath necessary
> 65 >= 3 CAD risk factors Prior coronary stenosis ST changes of ECG >= 2 anginal episodes in 24 hrs Use of aspirin in prior week Positive serum markers
TIMI >4 get invasive management
ECG changes in II, III, aVF
Inferior wall MI
Affects right ventricle
Major danger of dropping preload
Tx: maintain preload with aggressive fluids and avoid nitrates
ST elevations in V1, v2, V3
Anteroseptal MI
ST elevations in V5, V6, I, aVL
Lateral wall MI
Tall ST elevation in II, III, AVF, tall R with ST depression in V1, V2, and ST elevation in V4R
Posterior wall MI
Medications for discharge with ACS (5)
Aspirin Beta blocker ACE inhibitor Statin Clopidogrel (if stent placed)
Patient with known history of CHF with a low EF. Most likely cause of death?
Arrhythmia
Death 4-5 days after MI
Ruptures - free wall -intraventicular septum - papillary muscles (causes mitral regurg)
Death 48 hours after MI
Arrhythmias
- ventricular tachycardia when myocardium reprofuses
- bradycardia
Death 1-2 after MI
Fever, chest pain, generalized malaise
ECG shows diffuse ST-T changes
Tx
Dressler syndrome
Fever, pericarditis, pleural effusions
Tx: NSAIDS and steroids
Left heart failure vs Right
LHF
- pulmonary venous congestion
RHF
- systemic venous congestion
Right heart failure causes (5)
CAD (MI that damaged the right ventricle) 2nd degree to LHF Pulmonary HTN Endocarditis damaging tricuspid valve Ventricular septal defect
Left Heart failure causes (5)
CAD (MI that has damaged the left ventricle) Hypertension Mitral and aortic valve disease Endocarditis Dilated cardiomyopathy
Left heart failure signs (7)
PE signs (4)
SOB Orthopneu Paroxysmal nocturnal dyspnea (SOB when laying down) Dyspnea on exertion Cough Diaphoresis Nocturia
Rales
S3 gallop
Tachycardia
Peripheral edema
Right heart failure signs (4)
PE signs (8)
RUQ pain (due to hepatic congestion)
SOB
Abdominal swelling (ascites)
Weight gain
Hepatomegaly Hepatojugular reflex JVD Ascites Cirrhosis Abnormal LFTs Peripheral edema Cyanosis
Young patient with sudden death
- name
- MOA
- heart sound
Hypertrophic Cardiomyopathy (HCM)
Hypertrophy of the interventricular septum narrows the LV outflow tract
High velocity systolic flow draws the anterior leaflet of the mitral valve into the tract causing a dynamic LV outflow tract obstruction.
Sudden death due to arrhythmia
Paradoxical splitting of S2
Hypotension
Muffled heart sounds
JVD
Systolic bp drops by 10 mm hg with inspiration
Narrow pulse pressure
Pericardial tamponade
Beck’s triad
- Hypotension
- muffled heart sounds
- jvd
Pulsus paradoxus: drop by 10
Pericardial tamponade ECG
Low voltage or electrical alternans
ECG low voltage, T wave flattening, inversion in V1 and V2, notched P waves
Tx
Constrictive pericarditis
- scarring from acute pericarditis
Pericardiectomy
Any disorder that causes dilation of the atria can cause
atrial fibrillation
Loud S2/ tapping apex
Opening snap followed by mid-diastolic rumbling murmur
Mitral stenosis
Holosystolic murmur best heard at the apex with radiation to the axilla
Mitral regurg
Systolic ejection murmur
Crescendo decrescendo
Radiating to the carotids
Low volume pulse
Decreases with valsalva
Aortic stenosis
Early diastolic decrescendo murmur best heard at left 3/4th intercostal space
Aortic regurg
Holosystolic murmur left sternal border
Increased by inspiration
Tricuspid regurg
Hepatomegaly
mid-Diastolic rumbling murmur left sternal border with an opening snap and wide, splitting S1
Tricuspid stenosis
Hepatomegaly
Icterus, edema
Midsystolic click
Apex
Wide split of S2
Mitral valve prolapse
Sodium channel blockers
Lidocaine
- Suppresses ventricular dysrhythmias
- SE: drowsiness, confusion, psychosis, seizure, av block, respiratory depression
Quinidine - Suppresses ventricular dysrhythmiasa - Suppresses Atrail presmature beats - Suppresses A fib SE: Cinchonishm, tinnitus, eharing loss, visual changes, delirium, torsades de pointes
Procainamide -Suppresses ventricular dysrhythmiasa - Suppresses A fib - A flutter - WPW SE: Myocardial depression, prolonged QT, torsades de points, V-fib
Beta blockers
- 4 examples
- what they treat
- SE of all beta blockerse
Class II
Propranolol
- SVT
- Thyrotoxicosis
- Acute MI
- HTN
Metoprolol
- SVT
- acute MI
- HTN
Esmolol
- SVT
- thyrotoxicosis
Labetalol
- HTN
SE all beta blockers
- bronchoconstriction
Class III: prolongs action potentials
Amiodarone
- VT, VF, Afib, WPW
SE: bradycardia, av block, corneal deposits, skin discoloration, hepatotoxicity, iodine can cause hypo/hyperthyroidism
Bretylium
- ventricular dysrhythmias
Sotalol
- AV reentry, svt, WPW
SE: bradycardia, CHF, perpherial edema
Calcim channel blockers
Verapamil
Diltiazem
Amlodipine
Nifedipine
Adenosine
SVT
SE flusing hypotension
Digoxin
Rate control of Atrial tachydysrhythmia, increased inotrophy for CHf
TOxicity, vomiting, confusion visual changes,
Antihypertensive agents
Nitroprusside
- malignant htn
Minoxidil
- severe htn
Hydralazine
- preeclampsia
- direct vasodilator
Clonidine
- central acting agent
Phentolamine
- parenteral alpha blocker
- htn due to pheochromocytoma
Prazosin
- PO alpha blocker
ACE inhibitors
Angiotensin receptor blockers
Sulfonylureas
Glimepiride
GLycuride
Glipizide
Stimulates insulin secretion from the pancreas
Meglitinides
repaglinide
Nateglinide
Increase insulin production by the pancrease
Biguanides
Metformin
Decrease liver’s glucose production and slightly increase muscle glucose uptake
Thiazolidinediones
Troglitazone
Rosiglitazone
Pioglitazone
Decreases insulin resistance at the muscle and liver
Alpha glucosidase inhibitors
Acarbose
Miglitol
Slows the digestion of carbohydrates
DDP-4 inhibitor
Sitagliptin
Increases insulin production and decreases the liver’s production of glucose
GLP-1 analog
Exenatide
Enhances insulin secretion, decreases liver glucose output and may suppress appeitite
Pramlintide
Synthetic nalog of hte human homrone amylin that is cosecreted with insulin
Tylenol
Acetaminophen
Fever, aches
A firm nodule palpable over the carpometacarpal joint of the thumb
Trigger thumb
Stenosing flexor tenosynovitis
Tendon sheath thickens creating palpable nodule
Pain with palpation of the anatomic snuffbox
Scaphoid bone fractures
Chronic venous insufficiency presents with
pain, pruritus, discoloration and thickening of the skin and edema
Medication induced myopathy
Statin drugs
Fetal demise
Closed cervix
Missed abortion
Incomplete abortion
Incomplete evacuation of the products of conception from the uterus
Inevitable abortion
Cervix is dilated but no products of conception have yet evacuated
Pregnancy with vomiting and yeast infection
Dont give what? Acetaminophen Bismuth salicylate Clotrimazole Diphenhydramine Loperamide
Dont give bismuth salicylate (aspirin)
Yeast infection prefered antifungal during pregnancy= clotrimazole
Antihistamine during pregnancy for pruritis= diphenhydramine
Safe opioid in pregnancy= Loperamide
Opioid receptor agonist works on mu receptor of large intestine. Decrease activity of bowel movements
NSAIDS
Ibuprofen
Naproxen
Danazol
Synthetic androgen that decreases the secretion of estradiol in hopes to suppress menstrual cycle
SE: hirsutism, acne, male pattern baldness
Leuprolide
Gonadotropin-releasing hormone analogue that suppresses the menstrual cycle by down-regulating LH and FSH secretion
SE: menopause symptoms
Repeat labs if consume what
alcohol
Tx Pelvic inflammatory disease (PID)
Cefriaxone and doxycycline
Ceftriaxone covers neisseria gonorrheae
Doxy covers chlamydia (or azithromycin)
Patient with cirrhossi
Painless rectal bleeding from what vein
Superior rectal vein
Superior rectal vein drains into the inferior mesenteric vein which is part of portal system
System is under HTN in chronic liver disease
Esophageal varices is due to what vein
Engorgement of left gastric vein
Caputmedusae due to what vein
Engorgement of the paraumbilical vein
Smoker who had trauma to breast. Breast now inflamed and tender. Pus coming out nipple
Tx
Periductal mastitis
- inflammatory condition of the breast that occurs in smokers
Smoking damages mamary ductal tissue causing inflammation of the subareolar ducts which can then become infected
Unilateral breast tenderness
Amoxicillin-clavulanate
Clindamycin if penicillin allergy
Anti-tissue transglutaminase
Celiac
Allergy to gliadin
Infant with sickle cell needs what vaccine
Reduction of the spleens ability to filter bacteria from the blood
At risk for bacterial infections with encapsulated organisms
- Streptococcus pneuoniae
- Haemophilus influenzae
- Neisseria meningitidis
Pneumococcal polysaccharride vaccine
Prophylaxis tx of animal bite
Amoxicillin-clavulanate
Tx pasteurella
First line tx for suspected staph infections like cellulitis
Dicloxacillin (beta-lactamase resistant penicillin)
Recurrent pruritic vesicular rash on fingers palms and/or soles
Dyshidrotic eczema
Triggered by allergic response (metals)
Rash persists during times of vacation or when offending agent removed
Yellow thickened nails in asymmetric distribution.
Dermatophytoses
Herpes simplex on fingers
Pruritc fluid filled vesicles on fingers after periods of stress
Lesions will have erythematous bae and progress to pustular and ulcerative lesions
Hyperkeratotic plaques, pruritic papules and scales
Linear burrows
Scabies
Newborn rash not on palms or soles
Erythema toxicum neonatorum (ETN)
Self limiting
Acne neonatorum
Rash forehead, nose and cheeks.
White heads
Resolves in 4 months
Due to androgen stimulation
If persists suspect excessive androgen production
Generalized rash on infant that involves trunk and extemities
Diffuse mottling
Improves when warmed
Cutis marmorata
Due to infants vascular response to cold temps
white/yellow papules on forehead, cheeks and nose.
Sampling shows keratin within dermis
Milia
resolves within 1 month w/o tx
First line medication for prevention and tx of osteoporosis
T score below -2.5
Bisphosphonates
- alendronate
- risedronate
- zoledronate
- ibandronate
MOA: bind to hydroxyapatite to decrease bone resorption and inhibit osteoclast from breaking down bone
SE: erosive esophagitis
Denosumab
- monoclonal ab
Calcitonin
Inhibits osteoclasts and decreases bone resorption
Only indicated for tx osteoporosis not prevention
Estrogen in osteoporosis
Prevention only
Raloxifene
Prevention and tx osteoporosis
Selective estrogen receptor modulator (SERM) and inhibits bone resorption
Does not increase risk of endometrial or breast cancer
Risk of DVt and PE
Bisphosphonates are first line
Teriparatide
Parathyroid hormone analogue and anabolic agent indicated in tx of osteoporosis and reduces both vertebral and nonvertebral fractures in postmenopausal women
Elderly man take sildenafil and passes out what happened
Phosphodiesterase type 5 inhibitors
- sildenafil
- tadalafil
- vardenafil
Enhance nitric oxide within the body leading to increased vasodilation and penile erection
Contraindicated in patient who are taking a nitrate medication (nitroglycerin, isosorbide mononitrate, isosorbide dinitrate) due to potentiation of nitric oxide, causing dangerous hypotension and syncope
Alpha receptor antagonists
terazosin
Tamsulosin
Doxazosin
Dont give beta blocker to
Metoprolol
Labetalol
Carvedilol
Bradycardia
Heart block
Hemodynamic instability
decompensated CHF (decreased ejection fraction leading to bilateral lower extremity edema and pulmonary effusion)
are not hemodynamically stable
CYP450 inhibitors
Erythromycin
Cimetidine
Ketoconazole
Itraconazole
Inhibition of P450 results in increase in PDE-5 inhibitor levels within serum –> increased nitric oxide and vasodilation
Women with preeclampsia and in labor give what
IV magnesium sulfate
Lung maturity glucocorticoids
Dexamethasone
Betamethasone
Magnesium sulfate
Toxicity
Seizure prophylaxis and tocolytic in pregnancy
Check for toxicity by assessing for hyporeflexia of deep tendon reflexes, pulmonary edema, decreased urine output, cardiopulmonary arrest
Gemfibrozil prevents
[Fibrates]
Pancreatitis
Hypertriglyceridemia is associated with increased risk of developing pancreatitis
Dilated bronchi with adjacent companion arteries the are smaller in size with large cystic spaces and honey combing
- patient profile
- sign
- disease process
- imaging
Bronchiectasis
Months to years of a daily cough and mucopurulent sputum, normal spirometry, unresponsive to antibiotics
Signet ring sign
Transmural inflammation and scarring , processses damage the surrounding lung parenchyma by destroying the muscular and elastic components of the bronchial walls.
HRCT imaging
Right Calf pain when walking, decrease in calf muscle size, lack of hair, thickened toe nails, left ankle/foot have stronger pulses
-Test
Peripheral arterial occlusive disease (PAOD)
Lack of palpable pulses, thinning or lack of hair, increase toe nails all signs of decreased arterial blood flow.
1st: Ankle-brachial index (ABI) (less than 0.9)
Diagnosis: Angiography
Smoking makes worse
Firm or tense musculature, no atrophy, normal pulses, normal ABI. Pain with exertion relieved by rest. Trauma
- test
Compartment syndrome
Needle compartment pressure readings
Asain infant with large blue spots since birth
Congenital dermal malanosis
“Mongolian blue spots”
Darker skinned ethnic groups
Asymptomatic hyperpigmented macules and patches on back and buttocks
Benign disappear by age 2
Think iron-deficiency anemia check what lab
Serum ferritin
Second check iron levels
Patient with low hemoglobin but high MCV check what
macrocytic anemia
check peripheral blood smear
if shows megaloblastic features (hypersegmented neutrophils) , then take reticulocyte count. If less than 2% check B12 and folate
Austin Flint murmur
- is what
- heard
- symptoms(5)
Aortic regurgitation
Diastolic rumbling murmur (doesnt have opening snap like mitral stenosis)
Palpitations are uncomfortable in AR due to the widened pulse pressure.
Head bobbing
Nail bed pulsations
Uvula pulsations
“water hammer’ pulse- rapid distention and collapse upon palpation of the pulse
Harsh crescendo-decrescendo, mid-systolic ejection murmur with a palpable thrill
Pulmonary stenosis
Early diastolic high pitched blowing, decrescendo murmur heard at left second intercostal space
Pulmonary regurgitation
Tumor marker elevated in patients with colorectal cancer
Carcinoembryonic antigen (CEA)
AFP elevated in what cancers
Liver cancer
Germ cell cancers
- teratomas
CA15-3
transmembrane glycoprotein known as MUC1 expressed by MUC1 gene
Tumor marker that is overexpressed in malignant breast glandular cells in patients with breast cancer
Used to trended treatment or for recurrence
Not diagnostic
CA19-9
Tumor marker for multiple cancers involving GI tract (pancreatic, gall bladder/ biliary duct, and gastric cancers)
Also elevated in endometrial cancer
Trending for tx
CA-125
elevated in ovarian cancer
Kidney stone formation in patient with Crohn’s due to what
malabsorption of fatty acids and bile salts.
Decreased urinary citrate excretion as cause for kidney stones is see with
Chronic diarrhea and metabolic acidosis
Which leads to low urinary pH
Screening at 28 weeks pregnancy
gestational diabetes
Screen for group B streptococcal infection at what week
36 weeks
Most common bladder cancer
Transitional cell carcinoma
Uterine cancer is probably what type
Leiomyosarcoma
Squamous cell carcinoma in the bladder due to
Schistosoma haematobium
Serum testing shows elevated serum alpha-fetoprotein levels, most likely cause
Inaccurate gestational age
If age is accurate consider neural tube defects
Abdominal pain improved with defecation. No blood or pus. Weight loss. Diffuse abdominal tenderness, discrete mass in RLQ
Erythrocyte sedimetantion rate and C reactive protein are elevated
Narrowed thickened ileum, string sign
- Another sign
Crohn’s disease
Normocytic with iron deficiency and elevated ferritin.
IBS imaging
Nothign seen on pathology or radiologic findings
Lead pipe
Bloody diarrhea
Mucous discharge from rectum
Distal rectum
Ulcerative colitis
Infant excessive diaphoresis, poor feeding, and failure to thrive.
Holosystolic murmur at lower left sternal border
Ventricular septal defect
left to right shunt
Wide fixed split S2 and a systolic ejection murmur at the left upper sternal border
Atrial septal defect
Wide pulse pressure
Continuous machinery murmur (present both systole and diastole) at he upper left sternal border
Bounding peripheral pulses
Patent ductus arteriosus
Menstrual migraines tx
NSAID first line
Sumatriptan taken at he onset of symptoms
Frovatriptan is prophylactic but don’t use if trying to get pregnant
75 y.o with painful skin rash on abdomen. Petechiae with scattered hemorrhagic bullae and black eschar
Aspirin Atorvastatin glargine lisinopril metoprolol warfarin
Warfarin skin necrosis
- paresthesias
- sensation of pressure
- extreme pain
Edematous, erythematous flush with developing petechiae that progress to hemorrhagic bullae with necrotic eschar
Adverse effect aspirin
Samter’s triad of asthma
aspirin intolerance
nasal polyps
Aspirin intoxication
- respiratory alkalosis from increased respiratory drive before culminating in an anion gap metabolic acidosis from salicylate toxicity
Atorvastatin
- MOA
- AE
competitive inhibitor of HMG-CoA reductase
Lower total cholesterol with predominant effect on decreasing low-density lipoprotein
AE: diarrhea and myopathy
Glargine
- what is it
- MOA
- AE
Long-acting insulin analogue
Stimulate peripheral glucose uptake by skeletal muscle and fat
Inhibiting hepatic gluconeogenesis, lipolysis and proteolysis and enhancing protein synthesis
AE: hypoglycemia, hypokalemia, local allergic rxn at injection site
Lisinopril
- what is it
- MOA
- AE
ACE inhibitor
Coronary artery disease to lower afterload resistance
DM to protect glomerulus from hyperfiltration injury by preventing constriction of the efferent arteriole
AE: Cough
Metoprolol
- what is it
- fxn
- AE
selective beta-1 antagonist
control heart rate in sinus tachycardia and atrial fibrillation
AE: dizziness, headache, bradycardia and wheezing
Beta 1 selective antagonists vs beta blockers
A-M beta 1 selective
- atenolol
- Esmolol
N-Z non selective antagonists
- nadolol
- timolol
outliers (carvedilol, labetalol) non selective
Pemphigoid gestationis
pregnancy associated autoimmune disease
Vesiclse and bullae
C3 deposit on basement membrane
SImilar to bullour pemphigoid and differentiated by “salt split techinique”
Impetigo herpetiformis
type of pustular psoriasis that presents during the second half of pregnancy
Group pustules and erythematous patches and plaques with overlying scale.
Hyperpigmentation common
Inguinal and axillary areas, also well as flexural surface arms and legs.
Pruritic urticarial papules and plaques of pregnancy (PUPPS)
similarly to pemphigoid gestationis but lesions will not progress to tense bullae
Third trimester
Abdomen
Absence seizures medication
AE
Ethosuximide
Dizziness is more common side effect does not require monitoring
Serious adverse effect is pancytopenia
Check CBC
Group A streptococcus (GAS) pharyngitis tx
Penicillin V
(if cant take oral penicillin G which is IM)
[anaphylactic Penicillin allergy then azithromycin]
[nonanaphylactic penicillin allergy then cephalosporin]
Amoxicillin-clavulanate tx for
Respiratory tract infections
Animal/human bites
75 y.o nipple discharge past week. “creamy” discharge left breast. sometimes bloody. Mammogram last year normal, no lump.
Inverted nipple, normal areola, no erythema, LN normal sized
Ductoscopy reveals dialted ducts filled with secretions and fibrotic debris
Tx
Duct ectasia
Benign breast condition of increasing age
[ductal Carcinoma involves areola]
Tx complete duct excision
Nipple inversion
Carcinoma
Duct ectasia
Periductal mastitis
Straw colored or clear discharge from breast
Intraductal papilloma
Benign neoplasm in lumen of breast
Trauma or biopsy of breast. pain and small breast masses
Debris-filled dilated duct
Mondor’s disease
Superficial thrombophlebitis of the breast develops when blood clots form in the superficial veins of the breast
Inflammation in the subarolar ducts, no dilation. Younger woman or men.
Associated with
Tx
Periductal mastitis
SMoking
Tx: broad-spectrum antibiotics or drainage since frequently leads to infection
STD with reactive arthritis
Chlamydia trachomatis
Reiters syndrome
keratoderma blennorrhagicum
hyperkeratotic lesions of palms of hands or soles of feet
Reactive arthritis
circinate balanitis
painless erythematous lesion of glans penis
Chylamydia
Hypotension
JVD
muffled heart sounds
Pericardial tamponade
caused by myocardial rupture
Pleural effusion caused by
Increased pulmonary capillary pressure, decreased capillary oncotic pressure, or increased membrane permeability
SOB, anxiety and cough with pink frothy sputum
Pulmonary edema
HIV positive individual give was vaccine
13 and 23 valent pneumococcal vaccine
Give H. influenzae vaccine to who
asplenia
Normal weight gain in pregnancy
25-35 lbs
Pregnancy BMI over 30 weight gain
11-20 lbs
Pregnancy BMI under 18.5 weight gain
35-45 lbs
Meningococcal vaccine to
11-18 years old
Leg swelling and fatigue. Has diabetes. Normal breathing sounds. Distended abdomen with positive lfuid wave. 3+ pitting edema. UA found urine protein/ creatinine ratio of 3.4
What do they have?
Complication?
Nephrotic syndrome
- proteinuria leading to hypoalbuminemia and diffuse edema
DM common cause
Complication is venous thrombosis
Most common diagnosis in obese child with hip pain
Slipped capital femoral epiphysis (SCFE)
Urine bright red and has clots indicated
Extraglomerular source of bleeding within the urinary tract
non-glomerular cause
- nephrolithiasis
- tumor
- cystic kidney disease
UA first step
Then ultrasound
ASO
obtained when suspicion of post-streptococcus glomerulonephritis.
History sore throat or skin infection preceding hematuria
Hematuria cola colored or HTN then get
Complement C3 level
Red blood cell casts or greater than 2+ protein on UA
C3 levels low in post-infectious glomerulonephritis, lupus nephritis or membranoproliferativev glomerulonephritis
Order in child with 2 or more febrile UTI infections
voiding cystourethrogram (VUR)
11 y.o vaccine
TDaP
Meningococcal
HPV
Fluoride supplemented water at what age for infant
6 months
primary source needs 0.6 parts ppm
Imaging to get with chest congestion and cough
plain chest radiograph
rule out pneumonia, cardiomegaly, pleural effusions, aortic dissection
Clumsiness (wide based ataxia), incomprehensible speech (explosive dysarthria), bilateral babinski sign, and bilateral loss of deep tendon reflexes
- cardiac abnormality
Friedreich ataxia
Hypertrophic obstructive cardiomyopathy
Neurodengenerative disorder of axons within cerebellum and dorsal colums
Japanese male, ataxia, loss of vibratory sense, hyperreflexia. Hyperpigmentation, behavior changes, decreased school performance, spasticity and paralysis
Adrenoleukodystrophy
X linked recessive peroxisomal disorder
ABCD1 gene
Very long chain fatty acids into peroxisome
Metachromatic leukodystrophy
autosomal recessive
Deficiency of arylsulfatase A leads to accumulation of cerebroside sulfate.
2 years of age
Loss of previous achieved milestones, tremors, truncal ataxia, hyperreflexia, hypotonia, nystagmus, and optic atrophy
Coarse face, large tongue, electrical cardiac abnormalities, cherry red macular spot. 3-5 months olds. muscle weakness.
Tay-Sachs disease
- no hepatosplenomegaly
Osteoarthritis medication
Patients with CHF should not get NSAIDs
Give Duloxetine
[Acetiaminophen used to be first line but studies show no efficacious]
Diagnostic choice for hypertrophic obstructive cardiomyopathy
Echocardiogram
tx hypertrophic obstructive cardiomyopathy
beta blocker
Anemia of chronic disease lab values
- MCV
- iron
- ferritin
- total iron binding capacity
Low MCV
Low iron
High Ferritin
Low total iron binding capacity
Anemia of chronic disease (rheumatoid arthrits) iron is packed in the cells in excess so ferritin is high, serum iron low and TIBC low
Different from iron deficiency anemia
Low MCV
Normal iron
Normal ferritin
normal TIBC
Thalassemia
inadequate production of chains of hemoglobin
Microcytic anemia
Non-productive cough, wheezing, dyspnea. Flattening of the inspiratory loop and normal FVC and FEV1/FVC
Vocal cord dysfunction
COPD values
Decrease FEV1/FVC ratio
Normal inspiratory flow loop
Irreversible with bronchodilator
Asthma values
Decrease FEV1/FVC ratio
Normal inspiratory flow loop
reversible with bronchodilator
Restrictive lung disease values
Reduced FVC
Normal FEV/FVC
Productive cough and SOB for 4 months. Started with fever and congestion.
Decrease pulmonary fxn testing
Chronic bronchitis
- obstructive airway disease
Typically cyanotic
PFT <70%
Emphysema
Breathe rapidly
Xray: bullae, flattened diaphragm, hyperinflated lung fields
Bronchiectasis
Chronic cough with sputum production
Purulent, foul smelling sputum for several years to months
Dilated and thickened airways, mucus plugs
Bronchiolitis obliterans
Rare cause of cough in adults
Small airway obstruction caused by fibrosis or inflammation
Present with non-productive cough and dyspnea with wheezing
CT: expiratory air trapping within bronchioles, bronchial wall thickening, ground glass opacities
Pregnant mother with upper respiratory tract infection then baby has hear loss what virus
CMV
Tx CMV
ganciclovir
CMV microscopy
Owl’s eye
Signs of rubella in infant
Cataracts
Hearing loss
Cardiac malformations
Maculopapular rash
Enlarged thick and pale placenta
Hepatomegaly
Persistent maculopapular rash
Failure to move limb (pseudoparalysis due to pain)
Congenital syphilis
- sensiorneural hearing loss, interstitial keratitis, hutchinson teeth
2 y.o child should be able to
Run
Kick a ball
Undress
Two word sentences
Stacking ability for years
1 year = 3 cubes
2 year= 6 cubes
3 y.o should be able to
draw circl (pi=3.14)
ride tricycle
three word sentences
4 y.o should be able to
Draw cross or rectangle
Hop on one foot
Recognize colors/ numbers
Cooperative play
5 y.o should be able to
Draw a square Skip Catch a ball Print own name Tie shoelaces
Tumor of jaw
Burkitt lymphoma
- starry sky
- EBV related
- non-hodgkin lymphoma
- t(8;14)
t(11;14)
mantle cell lymphoma
Elderly
Palpable lymphadenopathy
t(14;18)
Follicular lymphoma
Germinal centers
BCL-2 over epxression
Large cells with vesicular chromatin and prominent nucleoli
Diffuse Large B cell lymphoma (DLBCL)
NHL
Reed-Sternberg cells
Binucleated “owl eyed” giant cells in hodgkin lymphoma
Prominent mediastinum
Patient with asthma and recurrent exacerbations of fever, cough, and dyspnea
Brown mucus plugs
Has what?
Test
Allergic bronchopulmonary aspergillous
Also experience central bronchiectasis
Diagnostic: total serum IgE test (elevated) and allergy skin prick test for IgE antibody to Aspergillus
Who to screen for AAA
65-75 who ever smoked
Dont give aspirin to those with history of
ulcers
3 y.o with swelling all over body. Denies abodminal pain, hematuria or dysuria. Periorbital edema, abdominal distension with a fluid wave, 3+ pittign edema. 3+ proteinuria.
Minimal change disease
- proteinuria
- hypoalbumenia
- edema
- hyperlipidemia
Younger than 10
Proteinuria > 3.5 grams
Nephropathy associated iwth Hep B/ C infection
Membranous nephropathy
POst-infectious glomerulonephritis characterized by
hematuria
edema
HTN
decreased C3 complement elvels
non-bloody, non-purulent chronic diarrhea
Diffuse abdominal pain relieved by defecation
Painful finger joints
- what is it
- labs
- diagnostic
Crohns disease
Elevated ESR and CRP
Anemia of chronic infxn (normocytic w/ iron def and elevated ferritin)
Diagnostic: colonoscopy with ileoscopy and biopsy
SKip lesions
Cobblestoning
Noncaseating granulomas
Anti-cyclic citrullinated peptide (antiCCP)
Rheumatoid arthritis
Pain between the toes in the interdigital space, numbness and paresthesias radiating to the toes proximal to the pain
Exacerbated by tight shoe wear
Morton’s neuroma
Mulder’s sign: palpable painful click along with reproducible symptoms
Sesamoid fracture
First toe pain
Due to overuse (runners)
Swelling and tenderness along the medial aspect on the plantar surface of the first metatarsophalangeal joint
Pain worse with dorsiflexion
Granuloma annulare
benign skin lesion that is asymptomatic and presents iwth 1-2 mm flesh colored and/or erythematous papules that coalesce to form 5 cm annular appearing plaque.
Ankles, feet, hands, fingers and extensors of arms and legs
Center of lesion can be hyperpigmented and scaling absent
“Looks like like ring worm”
Violacous, shiny, polygonal papules of varying sizes on flexural surfaces of limbs.
Fine white reticular scales on papules
Lichen planus
Mammogram screening
50-74 every 2 years
Colorectal cancer screening
50-75
One of the options:
Fecal occult blood testing annually
Sigmoidoscopy every 5 years
Colonoscopy every 10 years
Screening for 75 y.o female
Alcohol misuse and counseling
Hold up infant hand
4 months
Sit or crawl at age
6 months
Pertussis diagnosis
tx
PCR
Macrolides (azithromycin)
Rheumatoid arthritis joints
PIP, MCP
Recurrent Hematuria after upper respiratory infection. Negative for strep
IgA nephropathy
Occurs are upper respiratory infection o ATHLETIC EXERTION
Mild flank pain
Low grade fever
Associated with cirrhosis, celiac disease, and HIV
Renal biopsy with immunofluorescence reveal the presence of IgA deposit
Acute onset renal failure with UA revealing nephritic sediment (red blood cell casts, dysmorphic red blood cells, white blood cells), mild to moderate proteinuria
Also have SOB, cough and hemoptysis
Good pasture syndrome
Palpable purpura on skin, abdominal pain, arthralgias, and renal insufficiency with hematuria. No proteinuria
Biopsy: granulocytes within the walls of the small arterioles and venules
Henoch-Schonlein purpura
IgA vasculitis
63 y.o alcoholic with nausea, vomiting and diffuse abdominal pain. Has had symptoms before. Metabolic acidosis, elevated serum beta-hydroxybutyrate and urine ketones. Glucose normal adminster what
Thiamine and dextrose
Alcoholic ketoacidosis
Possible Wernicke encephalopathy
Acidosis will resolved self after thiamine, dextrose and saline
Thiamine needed to bring pyruvate to TCA cycle (thiamine deficient leads to shift in pyruvate towards production of lactic acid instead of into TCA cycle)
Pregnant female with pre-existing hypothyroidism
increase by 30%
Urease breath test
H. pylori
Antiparietal ab
autoimmune gastritis
IgA nephropathy
painless gross hematuria that occurs simultaneously with infection
Sore throat 2 weeks ago Hematuria Red blood cell casts Proteinuria Low complement C3 level
Post-infectious glomerulonephritis
young patient with low back pain gradual progression. Space narrowing and sclerosis around sacroiliac joint
Also develop
Labs
Ankylosing spondylitis
Calcaneal tendon enthesitis
Plantar fasciitis
ESR and CRP elevated
HLA-B21 genotype
Complication of Crohns disease
B12 deficiency
Macrocytic anemia with a decrease in serum cobalamin (vit B12)
Vaccination during pregnancy
Tdap 27-36 weeks
[Dont give]
- MMR
- Zoster
- Varicella
- live flu
Lytic lesions and cortical thickening of fibula and tibia
Pagets disease
Elevated alkaline phosphatase
Tx acute exacerbation of asthma
Oxygen
Inhaled beta 2 agonist
Oral corticosteriods
Intermittent asthma
Symptoms less than or equal 2 days per week
Nighttime awakenings less than 2 x per month
Beta agonist 2 x per week
Mild persistent asthma
symptoms greater than 2 days per week
Nighttime awakening 3-4x per month
inhaler > 2 x per week
Moderate persistent asthma
Daily symptoms
Nighttime awakenings > 1 per week
Daily use of inhaler
Severe persistent asthma
Symptoms throughout day
Nightly awakenings
Inhaler several times per day
Diarrhea
Dementia
Dermatitis
Niacin deficiency
CHARGE syndrome
CHD7 mutations
Coloboma (defects in iris)
Heart anomalies
Choanal atresia (NG tube cant pass through nasal passage)
Restricted growth
Genital hypoplasia
Ear anomalis (small low set) and deafness
Polyhydramnios
Difficulties feeding
Pregnant uncontrolled DM complication in infant
horseshoe kidney
Patient with hyperthyroid, improve symptoms most rapidly?
Propranolol
Female
Easy bruising
Heavy bleeding
Elevated thromboplastin time
Von Willebrand disease (vWD)
AD
Deficiency of factor VIII- related antigen
Defect in clot formation and coagulation cascade
Isolated defect in clot formation
Thrombocytopenia
Increased bleeding time
low platelet levels
PT PTT normal
Isolated defect in coagulation cascade
Hemophilia A / B
A: deficiency of factor VIII
B: def factor IX
Prolonged PTT
Bleeding time and PT normal
Hypercalcemia medication
Thiazide diruetics
(Hydrochlorothiazide)
Lithium
Loop diuretics and calcium
Dump calcium
Elevated calcium
Elevated PTH
Tx
Primary hyperparathyroidism
Surgicial removal of one or more parathyroid glands
Fenofibrate AE
Hepatotoxicity
Can enhance myalgias when combined with statin
Hyperpigmented, thickened, scaly, edematous skin lesion
Lichen simplex chronicus
Christmas tree rash
salmon colored on trunk w/ central clearing
Pityriasis rosea
Sore throat with enlarged tonsils bacteria
Streptococcus pyogenes
Biopsy technique for raised, superficial non-pigmented lesion
Shave biopsy
For nonmelanoma skin cancer
Curettage and electrodessication used when
Treatment not diagnostic method in low risk patients younger than 60 with known diagnosis of a primary babsal cell carcinoma located in an area that is without hair and doesnt require depth of removal
Excisional biopsy use when
Including Mohs surgery
First line tx for SCC and basal cell carcinoma
Ingestion of clostridial spores
causes botulism syndrome in infants under the age of 8 months
Honey to babies
Adults and older children not effected
Riluzole
medication for ALS
Dantrolene
muscle relaxer
Used in ALS to relieve spasticity
Can cause weakness, dizziness and sedation
Tx Temporal arteritis
First line prednisone
IV methylprednisolone (if visual disturbances)
Dihydroergotamine
ergot alkaloid medication used for abortive tx inpatients presenting to ER with a severe migraine not resonding to other migraine medication
Patients with diabetes should get what screen
urinary spot microalbumin/creatinine ratio
if >30 ug/mg then should be started on ACE (-pril) or angiotensin receptor blocker (-sartan) to prevent hyperfiltration injury
Rapidly gowing, solitary, friable, bright red, papule that bleeds from little trauma
Trauma precedes lesion
Pyogenic granuloma
Painful, small blue-red, blanchable, vascular papules or nodules in deep dermis on distal extremities (palm, wrist, forearm, foot, under nails)
Glomus tumors
Verruca vulgaris
non-genital warts caused by HPV
Thyroid nodule
Low TSH
Test to get
technetium-99m or radioactive iodine
3 y.o with bruising. Sick a month ago. Low platelet count. Normal hemoglobin. Normal blood times
Immune thrombocytopenia
Ab to platelet membrane antigens results in increased platelet clearance by spleen and thrombocytopenia
2-5 y.o following viral infection or young women 20-40s
Resolves 3-6 months
Mucocutaneous bleeding Fever Fatigue Weight loss Bone pian Lymphadenopathy Hepatosplenomegaly
Anemia
reduced or elevated white count, anemia
Acute lymphocytic leukemia
Thrombocytopenia
Hemolytic anemia
Acute kidney injury
Child < 5 with prodromal episode of abdominal pain and bloody diarrhea followed by pallor, fatigue, easy bruising and hematuria
Hemolytic uremic syndrome
Thrombocytopenia Hemolytic anemia Renal disease Fever Neurologic changes
Thrombotic thrombocytopenic purpura
Xray rules for angkel
Unable to bear weight for 4 steps
Tenderness along distal 6 cm of the tibia or fibula
Tenderness over the posterior medial or lateral malleolus
Tenderness at he base of the 5th metatarsal
Tenderness of navicular bone
Streptococcal infection diagnosis
positive rapid antigen detection test for group A streptococcus
Positive throat culture
Elevated anti-streptolysin O (ASO) Ab titer
Clostridium difficile tx
vancomycin
not metronidazole any more
Tx traveler diarrhea
Ciprofloxacin
Tx shigella
fever bloody diarrhea
Azithromycin (marcolide)
Tx recurrent C. difficile
Rifaximin
reactive non stress test
presence of 2 accelerations within 20 minutes with or without fetal movement
acceleration= increase by 15 bpm for a duration of 15-120 seconds
Diagnose DM
1) Fasting blood glucose of greater than or equal to 126 on two separate occasions
2) A1C >= 6.5 on two separate occasions
3) 2 hr post oral glucose tolerance test >= 200
4) Random glucose >= 200 with DM symptoms
Recurrent nose bleeds
Telangiectasias
Visceral lesions
First degree releatiev
Hereditary hemorrhagic telangiectasia
Thormbocytopenia
Associated iwth nose bleeds
Platelet count will be low
Peripheral smear will show giant platelets
Low pitched systolic ejection murmur that is described as “vibratory” or “musical” and improves with valsalva and loud when supine
Still’s murmur
Innocent murmur of childhood
Maternal fever Tachycardia Uterine tenderness Fetal tachycardia Abdominal pain Foul-smelling fluid in underwear No costovertebral angle tenderness 2 cm dilated, 10% effacement, microscopic analysis of fluid reveals delicate ferning pattern
A. Bacterial vaginosis
B. Chorioamnionitis
C. Placental abruption
D. Pyelonephritis
Chorioamnionitis
-Premature rupture of membranes is crucial risk factor
Presence of amniotic fluid is confirmed on examination with
nitrazine testing
pH of the amniotic fluid is alkaline between 7.0 to 7.3. when compared to vaginal fluid acidity of 3.8 to 4.2
and/or
fern testing- presence of delicate ferning pattern on microscopic analysis
Vaginal discharge “fishy”
clue cells
Bacterial vaginosis
Brief, arrhythmic, involuntary, bilateral upper extremity myoclonic jerks without loss of consciousness
- Triad
- Age
- EEG
Juvenile myolconic epilepsy
Presents in adolescence
Myoclonic jerks
Generalized tonic-clonic seizures
Absence seizures
EEG: rapid, generalized, irregular spike and polyspike waves
No fever, trauma, infection
Febrile seizures
6 months - 5 years
Generalized tonic-clonic activity
Fever
Postictal confusion
Fatigue
Preceding upper respiratory infection or recent immunization with DTP/ MMR
15 min
non-recurrent
TX: acetaminophen for fever
Lennox-Gastaut syndrome
presents around age 2
Multiple types of seizures along with mental retardation, developmental regression and abnormal EEG
EEG: paroxysms of fast activity and slow spike and wave discharges
TX valproic acid/ clonazepam
Panayiotopouos syndrome
benign occipital epilepsy
Focal seizure disorder
3-6 y.o
Occipital (visual) and autonomic disturbances (vomiting), unilateral head/eye deviation, loss of awareness, heiclonic seizures and migranous headahces
30 min
Eyes closed EEG occipital andposterior temporal spikes
Tx: carbamazepine
Supplement for breastfed infants and for formula fed infants who do not consume at least 1 liter formula per day
Vit D
Iron supplement in infant
exclusive breastfeeding pst 4-6 months
Tx vulvovaginal candidiasis in nonpregnant female
oral fluconazole
Thick, whitish discharge. No odor. pH 4.
microscopic with KOH= pseudohyphae or budding yeast
Vulvovaginal candidiasis
pH > 4.5, clue cells
Odor
Tx
bacterial vaginosis
Metronidzole
pH ? 4.5, postcoital bleeding, dysuria, grene or yellow discharge, frothy, odor. Motile flagellated protozoa
tx
Trichomoniasis
Metronidazole
Benign skin lesion that is flat pink or salmon colored, blanching skin patch between eyebrows or on nape of neck
Nevus simplex
Port wine stain, asymmetric, unilateral, flat, dark red to purple patch on face.
Nevus flammeus
Over concentration of capillaries located around the V1 branch of the trigeminal nerve.
Can be associated iwth sturge weber syndrome (causes angiomas in brain)
- port wine stain
- glaucoma
- seizures
Symmetric mottling of the skin that involves the trunk and extremities
Cutis marmorata
Reassurance no tx
Small, erythematous papules and vesicles that occur on cover skin.
Miliaria rubra
due to sweat gland obstruction
Type 2 second degree av block due to
disturbance in conduction distal to AV node, most often in purkinje system
Delayed conduction between SA and AV node
First degree AV block
Accessory route of conduction around the AV node
Atrioventricular reentrant tachycardia
Palpitations
Regular narrow complex tachycardia on ECG with inverted P waves
Complete block of conduction between SA and AV nodes
Third degree AV block
Ventricles generating an escape rhythm via its own accessory pace maker
Painful swelling joints. pulmonary embolism. DVT what abnormalitity
Factor V Leiden
Defective form of Factor V taht is resistant to degradation by protein C
Patients prone to clotting
PT measures
extrinisc pathway
Factor VII
PTT measures
Intrinsic pathway
TENET
XII, XI, IX, VIII, X
Bleeding into joints, epistaxis, prolonged post-op bleeding
Def Factor VIII or Factor IX
Hemophilia A/B
X linked
Hemoglobin A1C measures
Falsely lower by (6)
Elevated by (
measurement of glycoslyated hemoglobin
Average blood glucose for past 3-4 months
Lower
- sickle cell
- acute blood loss
- hemolytic anemia
- erythropoietin therapy
- chronic renal failure
- b12, iron, folate tx
Elevate
- anemia due to B12 def
- chronic renal failure w/ elevated concentration urea
- AA, hispanic, asain descent
Third degree block EEG
Wide QRS
Regular P-P interval
no conducted P waves
Narrow QRS irregularly irregular P-P interval
some conducted P waves
Atrial fibrillation
Wide QRS
Regular P-P interval
no conducted P waves
Third degree AV block
narrow QRS
regular P-P interval
SLowed conduction of P waves
First degree AV block
Narrow QRS
regular irregular P-P interval
some conducted P waves
atrial flutter
Wide qrs
regular p-p interval
some conducted P waves
Mobitz II second degree heart block
Prediabetes diagnosis
fasting glucose 100-125
A1c 5.7-6.4%
Tx acute bacterial rhinosinusitis
Amoxicillin-clavulanate
Allergy: (children) cephalosporin
Allergy (adult): doxy
4 y.o AA fatigue and yellowing eye. Dysuria. UTI and antibiotic prior to.
G6PD deficiency
Jaundice, pallor, dark urine and back pain 2-4 days after oxidative stress from certain medications (sulfas and anti-malarias) or infections
Heinz bodies (oxidized hemoglobin) or bite cells on smear
Hereditary spheocytosis
Splenomegaly
rigid RBC that are cleared by spleen
Sore throat, fever, fatigue, bilateral posterior cervical lymphadenopathy, tonsillar enlargement, splenomegaly, palatal petechiae
Tx w/ antibiotics got worse
- What is it
- Diagnosis
Infectious mononucleosis
Heterophile antibody test
[ if negative then CBC then EBV]
[if positive, perform rapid strep test]
Projectile vomiting
Mobile mass
3 week old infant
Imaging?
Pyloric stenosis
ultrasound
Double bubble on ultrasound
Annular pancreas
Associated with down syndrome, tacheoesophageal fistula, imperforate anus and hirschsprung disease
Bilious vomiting within hours of birth. Double bubble on ultrasound
-also seen
Duodenal atesia
Scaphoid abdomen (sunken anterior abodminal wall)
Nonbilious vomiting that turns bilious
Currant jelly stool
Palpable sausage-shaped mass
“Target sign””
Intussusception
Infant distended abdomen, tenderness, and rigidity on palpation, currant jelly stool, lethargy, fever, tachycardia, hypotension.
Birds beak
Malrotation
Growth on knee, painless, increased insize over 3 months. Rough coalescing, flesh colored hyperkeratotic papules. No bleeding
Scraping revelas several thrombosed capillaries
Warts (verruca vulgaris)
HPV
Flesh colored dome shpaed papules with central umbilication
Molluscumc ontagiosum
Slapped cheek
Parvovirus B19
Screening at initial visit for pregnancy (6)
Cervical cancer screening
Pap smear
Blood group
Rh status
Rubella status
STI screening including HIV, syphilis, gonorrhea, and chlamydia, hep B
DM testing in pregnancy when
24-28 weeks
Group B strep screening in pregnancy when
36 weeks
Elevated Creatinine and BUN=
NSAID use
kidney injury via decreased synthesis of prostaglandins
Tx herpes w/ pregnancy wanting to give vaginal birth
Treat any recurrent herpes episode with oral acyclovir and begin daily oral acyclovir therapy after 36 weeks gestation even if no episodes develop
Blood transufion of anemia
Only if severe hemoglobin less than 8
Tx acute onset of excruciating pain with external hemorrhoids within 72 hours
Surgical excision
Rubber band ligation tx
appropriate non-surgical tx for internal hemorrhoids
Hemorrhoids conservative tx
Fiber supplementation
Stool softeners
laxatives
topical analgesics
Bone pain
Low hemoglobin
Low hematocrit
Multiple myeloma
CRAB hyperCalcemia Renal failure (IgG light chains in urine) Anemia Bone lesions
Metastatic cancer spread to bone
Late stages of prostate cancer
Characterized by elevated alkaline phosphatase
Solitary painless well circumscribed, rubbery, mobile breast mass
Fibroadenomas
Painless breast lump found below the areola with bloody nipple discharge
Breast pain
Retraction
Enlargement
Itchy nipple
Infiltrating ductal carcinoma
Drug that causes increase in baseline fetal heart rate and incidence of fetal tachycardia
Terbutaline (beta-adrenergic agonist)
Betamethasone on fetal heart rate
Decrease in fetal heart variability and abolishment of diurnal fetal rhythms
Opioids/ morphine on fetus
Decrease variability
Decrease frequency of accelerations
When should a baby start solid baby food
after 4-6 months of age
Child should begin whole cows milk when
after 1 year of age
Pregnant patients with preeclampsia without severe features should deliver when
37 weeks
Preeclampsia with severe features
Blood pressure greater than 160/110
Proteinuria higher than 5 g
End organ damage
Persistent frontal headache, visual disturbances, acute mental status changes, RUQ pain, peripheral edema, and oliguria
Elevated unconjugated hyperbilirubinemia without underlying cause
Gilbert
Show at times of stress
Crigler-Najjar syndrome
unconjugated hyperbilirubinemia
Complete absence of bilirubin UGT enzymatic activity
First days of life
elevated conjugated bilirubin Fatigue pururitus RUQ pain middle aged female hepatosplenomegaly hyperpigmentation xanthelasma (yellow deposition of fat near eyelid)
antimitochondrial ab
Primary biliary cirrhosis
autoimmune destruction of the hepatic biliary system
Wilson disease
cirrhosis common initial presenation
Ascites, jaundice, spider nevi, palmar erytehma, digital clubbing, prominent abdominal veins, caput medusae, hematemesis
mental status changes, seizures
Decreased serum ceruloplasmin, increased urinary copper
Positive whiff-amine test
bacterial vaginosis
fishy odor when KOH added
Rare epithelial cells covered in bacteria seen on microscopy
Clue cells
bacterial vaginosis
Medication that interact w/ phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil)
antiretroviral medications increase the levels of PDE-5 inhibitors
Thyroid mass that grows rapid in a year.
Hard painless
No cervical adenopathy
Diagnosis?
Reiter thyroiditis
Surgical biopsy
[Other thyroid nodules can do FNA]
Neutropenia Dyspnea Fever Cough Halo sign on xray Macronodule surrounded by ground-glass opacity
Aspergillosis
Sarcoidosis what is seen
cough, dyspnea, hemoptysis, night sweats, WL
Hypercalcemia
African americans
Bilateral hilar adenopathy
Non-caseating granulomatous infiltration
Most common genetic abnormality that is aborted
autosomal trisomy
Child with repeat proteinuria positive
Orthostatic proteinuria
Characterized by proteinuria while in the upright position which resolves when supine
Diagnose with morning urine protein-to-creatinine ratio
Serum antinuclear antibody
Lupus
GBS positive in first baby
Should not be test again with next babies just get GBS prophylaxis
Pneumonia can be prevented by
Getting flu vaccine
Succumb to bacterial infection when weakened by flu virus
Most common cause of secondary htn (htn that is no reduced by 3 different medications)
-diagnosis
renal artery stenosis
renal arteriogram
Secondary htn with hypokalemia and hypernatremia
Primary aldosteronism
Noncaseating granulomas
Clacified nodular opacities with hilar and mediastinal lymphadenitis
Upper lobes
Beryllium
Honey combing
Asbestosis
Infant with jaundice and hyperbilirubinemia
diagnosis?
Hemolytic disease of newborn
Due to IgG ab from mother
Direct Coombs test
Constellation of benign and malignant tumors
Von Hippel Lindau disease
AD
Mutations inthe VHL gene
Hematuria
Flank pain
palpable abdominal or flank mass
Renal cell carcinoma
VHL
p53 mutation
AD Li-fraumeni syndrome
Several malignancies throughout life time
Sarcomas
Breast cancer
Brain tumors
Adrenocortical carcinomas
Neurofibromatosis type 1
cafe au lait sots
neurofibromas
RAS protein
Osteomyelitis starts with
infection of surround soft tissues
Staphylococcus aureus
PCOS causes what
dysregulated intrinsic ovarian androgen production
steps in asthma
- SABA as needed
- low-dose inhaled glucocorticoids
- medium-dose inhaled glucocorticoids
low dose inhaled glucocorticoids plus LABA - medium dose inhaled glucocorticoids plus LABA
- High dose Consider omalizumab
Alcoholic Low hemoglobin Low heamtocrit Siderocytes Basophilic stipping positive for iron
-cause?
Abnormality in heme synthesis
Excessive alcohol is most common cause of sideroblastic anemia
Heme synthesis is disrupted causing iron to accumulate in mitochondria causes the bone marrow to produce ringed sideroblasts
Defect in hemoglobin structure
- on blood smear
Thalassemia
poikilocytosis (irregular shaped)
target cells (bull’s eye)
Schistocytes
watery/ Bloody diarrhea
Ate chicken
Motile, spiral, gram-negative rods
Campylobacter jejuni
Poulty and unpasteurized milk
Anaerobic gram negative bacillus
EHEC E. coli
bloody diarrhea
beef
Gram negative motile bacilli
watery stool
septic arthritis
salmonella
non-motile, glucose fermenting
gram negative rod
Shigella
bloody diarrhea
gram negative bacillus bloody diarrhea pork, milk, water, tofu erythema nodosum appendicitis
yersinia enterocolitica
Infant not passing meconium
cystic fibrosis
Meconium ileus
Hirschsprung disease
functional obstruction due to developmental abnormality of enteric nervous system
Absence of ganglion cells in distal colon
Not passing meconium
Negative for stool in rectal vault
Preterm 2-3 weeks old formula fed abdominal distention bloody stool penumatosis intestinalis (gas/air in bowel wall)
Necrotizing enterocolitis
Bilateral proximal muscle aches (shoulders and hips)
Morning stiffness over an hour
Giant cell arteritis in past
Polymyalgia rheumatica (PMR)
elevated IL-5, CRP, ESR
Anti-Mi-2 or anti-jo-1 ab
dermatomyosistis
Progressive symmetrical proximal muscle weakness (not pain)
Polymyositis
Anti-Mi-2 or anti-jo-1 ab
Sand paper spot on skin, redder,
AK
cryotherapy
Lower triglycerides
Fibrates
(fenofibrate
gemfibrozil)
Cause of anemia in renal failure patients
Suppression of erythropoietin
Blood loss anemia
Microcytic
MCV <80
Hemolysis causes increase in
serum bilirubin due to degradation of heme as RBC are destroyed
Haptoglobin levels would also be expected to be low
Haptoglobin binds to hemoglobin and levels decrease as hemoglobin is released form destroyed RBC
Iron deficiency anemia
Microcytic
MCV <80
Inhaled chlorine causes what
- predominant cell type
Reactive airway dysfunction syndrome (RADS) or irritant-induced asthma
Last more than 3 months
Caused by chlorine, aerosol and smoke
Positive methacholine challenge
Improved with bronchodilatory therapy
Airway inflammation from RADS (not atopy)
Presence of neutrophils
Predominant cell type in asthma
eosinophil
Predominant cell type in allergic rxn
basophil
Complication of bronchodilator therapy
Transient arterial oxygen desaturation
Increase in ventilation-perfusion (V/Q) mismatch
Characterized by dyspnea, wheezing, hypoxia, tachycardia, and tachypnea
Dark urine Tired Jaundice with scleral icterus Low hemoglobin Low hematocrit Normal MCV High reticulocyte High Lactate dehydrogenase High total bilirubin
Bite cells
Heinz bodies
G6PD deficiency
Symptoms to hemolytic anemia (jaundice, scleral icterus, anemia)
Common precipitating factor is ingestion of fava beans, acute infection, oxidant drugs
(dapsone, sulfonamides, primaquine, nitrofurantoin)
Avoid high altitudes
recommended to prevent sickle cell crisis
Ascites, fever, chills, jaundice and abdominal pain, tenderness and fluid wave on examination
Fluid analysis reveals a neutrophil count > 250, lactate > 25 and pH less than 7.35, total protein less than 1 gram/dL
Tx
Spontaneous bacterial peritonitis (SBP)
Bacterial infection of peritoneal cavity
Empiric antibiotics with third generation cephalosporin (cefotaxime) or aminoglycoside (gentamicin) with ampicillin
Cefotaxime preferred due to risk of nephrotoxicity with aminoglycoside
Total protein less than 2.5
Transudate
Total protein > 2.5
Exudate
What should be given with large volume paraecentesis
Albumin
Biliary atresia
More common cause of cholestasis in newborn
1 wk to 8 wks
Jaundice Pale colored stool Dark urine Hyperbilirubinemia Elevated direct bilirubin
1 wk to 8 wks
Jaundice Pale colored stool Dark urine Hyperbilirubinemia Elevated direct bilirubin
No mass
Biliary atresia
Pale colored stool
Direct hyperbilirubinemia
Hepatomegaly
Palpable mass in RUQ
Choledochal cyst
Bilirubin conjugated and excreted but unable to get into bowel
Positive coombs test
Hemolytic disease of the newborn
Breast milk jaundice
Beta glucouronidase in breast milk removed glucuronic group that was added during conjugation
Leading to further accumulation and indirect hyperbilirubinemia
Cold, constipated, lethargic, yellow baby with a large tongue and poor feeding.
Congenital hypothyroidism
Elevated TSH
26 with history of chronic htn goes in to labor. Boggy uterus and bleeding. What intervention is contraindicated
Carboprost Methylergonovine Misoprostol Oxytocin Uterine fundal massage
Methylergonovine
Contraindicated in patient with htn
Acts directly on the smooth muscle of the uterus and increases the tone, rate and amplitude of rhythmic contractions
Carboprost should be avoided in
prostaglandin analogue
Uterotonic agent
Dont use in patient with asthma
Misoprostol
synthetic prostaglandin
binds myometrial cells causing contraction
Uterotonic agent
Use in post partum hemorrhage
Oxytocin
Use in post partum hemorrhage
Naturally made by pituitary gland
Ulcer with H. pylori tx
Omeprazole (or lansoproazole) or an antidiarrheal (bismuth subsalicylate)
Plus 2 antibiotics
Amoxicillin
Clarithromycin
Helix shaped, gram negative bacterium
test
H. pylori
Fecal antigen test
Carbon 13 urea breath test
Infant test positive on Barlow and Ortolani tests
Developmental dysplasia of the hip or congenital dislocation of the hip
Orthopedic referral
Infant hip flexed at 90 degrees and adduction of the leg with posterior pressure directed at the knee
Barlow test
Positive if there is a clunking sensation or a sensation of movement is felt as the femoral head exits the acetabulum posteriorly
Gripping the infant’s femur, flexing the leg at the hip at 90 degrees and applying anterior pressure on the thigh towards the acetabulum
Ortolani test
Positive if a clunking sensation is felt
Positive barlow maneuver and negative ortolani what next
Observation and repeat exam
What confirms the diagnosis of celiac disease
Gastroduodenoscopy with biopsy
Upper endoscopy and duodenal biopsy demonstrating enterocyte villous atrophy is diagnostic
Chest pain Tachycardia Dyspnea Hemoptysis and recent travel
Pulmonary embolism
Pulmonary embolism on EKG
Sinus tachycardia
Sinus rhythm with ventricular rate of 132 beats per minute
ECG with diffuse ST segment elevations and PR interval depresion without T wave inversions
Pericarditis
Greater tahn 1 mm ST elevations in leads II, III, aVF
Inferior wall MI
S-waves in lead I, Q waves in lead III, and inverted T waves in lead III
S1Q3T3
Pulmonary embolism
[Sinus tachycardia: Sinus rhythm with ventricular rate of 132 beats per minute more common for PE]
Testicular torsion caused by
congenital malformation of the processus vaginalis leading to inadequate fixation of the testicle to the tunica vaginalis
Ascending bacterial infection from the prostatic urethra
Epididymitis
Dilation of the pampiniform venous plexus
Varicoceles
Mass and heaviness within the left side of the scrotum that is associated with a dull, achy pain. “ bag of warms”
Male with low grade fever, headaches and malaise followed by parotitis then gens pain and swelling and edema of scrotum
Mumps –> systemic viral infection –> epididymoorchitis
Inflammation of the testicle and epididymis
Chemotherapy to treat HER2/neu positive breast cancer
Trastuzumab
Clomiphene
selective estrogen receptor modulator that acts to inhibit hypothalamic estrogen receptor which blocks estrogen negative feedback on GnRH
GnRH persist and instigate the release of FSH and LH
Use with infertile female with PCOS
Raloxifene
selective estrogen receptor modulator taht acts to regulate osteoclast and osteoblast activity
Tx osteoporosis
Only use if failed first line therapy bisphosphonates (-dronate)
Can also be used to tx estrogen receptor and progesterone receptor positive breast cancer
Less likely to potentiate endometrial cancer
Rituximab
monoclonalab against CD20 found on B cells.
Tx autoimmune disorders (rheumatoid arthritis, polyangiitis with granulomatosis) and B cell lymphomas
Tamoxifen
selective estrogen receptor modulator used in tx estrogen receptor and progesterone receptor positive breast cancer
CI in patients with endometrial cancer
History of abdominal trauma in pregnany is most classically associated with what complication
Placental abruption
Gestational diabetes in pregnancy is most associated with what complication
Shoulder dystocia
Placental hypoperfusion is most classically associated with what complication
Preeclampsia
Vaginal coloinization w/ group B streptococcus is most classically associated with what complication
Chorioamnionitis
Maternal fever 100.4 Maternal tachycardia (>100) Fetal tachycardia (>160) Uterine tenderness Foul smelling amniotic fluid
13 y.o recent cold yellow eyes dark urine fatigue low hemoglobin High reticulocyte count
Spherocytes
Coombs test positive
Autoimmune hemolytic anemia
Autoantibodies to erythrocytes leading to premature destruction
RBC production increased in bone marrow to compensate= increased reticulocytes
Can occur secondary to infection, malignancy, lupus
Anemia
Elevated reticulocyte count
Spherocytes
Negative coombs
Hereditary spherocytosis
Bell’s palsy type of nerve palsy
Peripehral facial nerve palsy
Lower motor neuron of cranial nerve VII
Unilateral complete hemi-facial paralysis (includes forehead)
Central facial nerve palsy
Dysfunction of the upper motor neuron of cranial nerve VII
Paralysis of the lower face with forehead sparing
Annual lung cancer screening
patients 55-80 who have 30 pack year
Low dose CT
Sickle cell disease at risk for
encapsulated organisms
Streptococcus pneumoniae
Haemophilus influenzae
Neisseria meningitidis
Need pneumococcal vaccination
SHiNE SKiS
Strep pneumoniae Haemophilus influ B Neisseria meningitidis Ecoli Salmonella Klebsiella Streptococcus agalactiae
Chronic management of sickle cell disease
Annual screening for retinopathy and folic acid supplementation
Pneumococcal vaccination
Itchy rash
Began as single round itchy red lesion on patients chest.
Within 5 days a large number of smaller red oval lesions appeared.
Follow natural skin lines
Oval well demarcated salmon colored patch with central clearing and scaling at edges
Pityriasis rosea
self limiting
linked to upper respiratory infection and in immunosuppresed patients including pregnancy
Chordee
abnormal ventral curvature of the penis
accompanyed by hypospadias
Aspiration pneumonia likely to occur when in the lung
Right inferior lobe
Finding on complete blood out with chronic myelogenous leukemia (CML)
Basophilia
child with acute onset fever, sore throat, difficulty swallowing, and muffled speech.
Child leaning forward and hyperextended neck
Drooling from mouth
Epiglottitis
Thumb sign
Haemophilus influenzae type B
3rd gen cephalosporin and MRSA coverage
- ceftriaxone
- vancomycin
Edema
Hypoalbuminemia
Proteinuria > 3 g
Diabetic
Diabetic glomerulonephropathy
Diabetic glomerulonephropathy can be prevent by what medication
Angiotension converting enzyme (-pril)
Decreases glomerular capillary pressure by inhibiting constriction of the efferent renal arteriole
Bumetanide
loop diuretic
Screenings for 65 y.o smoker
Abdominal US
Colonoscopy
Fasting lipid panel
[Not PSA]
Elevated AFP in pregnancy with non-consistent prenatal care with no ultrasound assume elevated AFP is due to
Multiple gestations
Incorrect dating is the most common reason for elevated AFP
10 day old iwth bilateral eye swelling, redness, crusting and watery discharge
STI during first trimester
Chlamydia trachomatis
Oral erythromycin
Vaccine for 15 y.o
HPV
MMR given when
12-15 months
4-6 years
Booster in teens
Facial twitching what
hypocalcemia
Tx for patients on warfarin who develop lift-threatening bleeding or require surgery
Vitamin K and Fresh frozen plasma
when to do lipid screening
men 35 or older
men 20-35 or woemn 20 and older if increased risk of coronary heart disease (smoking, DM, strong family history, HTN, BMI>30)
Diabetic patient
Abdominal discomfort after meals that takes hours to dissipate
N/V after meals
Slowed gastric transit w/o evidence of obstruction
Autonomic neuropathy
Zollinger-Ellison syndrome
diagnosis
Gastrinoma
Presents as painful duodenal ulcers, gastroesophageal reflux and diarrhea
Elevated gastrin resulting in increased stomach acid production
Diagnosis made by an elevated fasting serum gastrin concentration
ECG on pericarditis
Diffuse ST elevations for diagnosis
Tx pericarditis
Addressing underlying etiology
Exercise restriction
NSAIDS
Pain in chest with activity of deep inspiration
Pain with palpation of the chest
Costochondritis
Fever
New onset cardiac murmur
Purple tender nodules on finger tips, splinter hemorrhages and non-tender nodules on palms and soles
Endocarditis
Staphylococcus aureus
Streptococcus viridans if previous damaged valves
Aplastic crisis
a cell anemia
Characterized by an acute reduction in bone marrow erythropoiesis followed by acute drop in hemoglobin and reticulocyte count
Anemia of chronic ifnlammation labs
normocytic (early) or microcytic anemia
Low reticulocyte count
Low iron
Elevated ferritin
Low TIBC
Wheezing and SOB. SOB not when running around. Itchy eyes and runny nose. Taken aspirin for several weeks due to sprained ankle. Fever. Lacrimation and inject conjunctiva , nasal polyps
- test
Aspirin-exacerbated respiratory disease (AERD)
Samter’s triad
- aspirin intolerance
- nasal polyps
- asthma
Oral aspirin challenge
Measurement of DLCO
Test of the diffusing capacity of the lungs for carbon monoxide
Can help differentiate obstructive and restrictive lung disease
Only inpatient
Normal or high= asthma
Low= emphysema, interstitial lung disease
Acute otitis media tx
Oral ibuprofen
< 6months: amoxicillin
6 mn -2 y.o= rapid onset, middle ear effusion or severe illness w/ fever
Allergy to penicillin give azithromycin
Chronic purulent otitis media tx
Topical antibiotics like aminoglycosides (neomycin), polymyxins, and fluoroquinoles (ciprofloxacin)
dont give ofloxacin to children younger than 12
Struma ovarii
ovarian tumor comprised of mature and functional thyroid tissue
teratoma of the ovary
Elevated free thyroxine
CA 125 not always elevated
Elevated alpha fetoprotein in adult female
tumor marker elevated in yolk sac tumors and hepatocellular carcinoma
Elevated estradiol in female with pelvic mass
Granulosa cell tumors
Precocious puberty
Elevated hCG w/o pregnancy
Molar pregnancy –> choriocarcinoma
History of thyroid disease, rapidly growing neck mass, cough, dysphagia, dyspnea, and neck pain
Anaplastic thyroid carcinoma
Surgical biopsy
Bilious vomiting, abdominal distention and abdominal pain Hemodynamic instability Hematochezia Difficulties feeding Decrease in bowel movements
Bowel sounds hyperactive
No masses
Test to be done
Intestinal malrotation
Upper gastrointestinal barium contrast series
Proximal duodenal dilation followed by a “bird-beak” obstruction and then a spiral or corkscrew duodenal configuration
Xray will give double bubble not specific (gastric and duodenal dilation)
Tx vulvovaginitis
Inflammation of vulva or vagina
Avoid tight cloting and irritants including bubble baths and perfumed soaps
Nystatin
tx for candidal vulvovaginitis
PCOS at risk for
Endometrial cancer
Lack of ovulation leads to endometrial hyperplasia
Mutation for increased risk of ovarian cancer
BRCA 1/2 mutation
Tx for acute PE
anticoagulation
Sore throat Fever Muffled voice Trismus (inability to completely open the mouth) Deviated uvula
Tonsil medially displaced and swollen
Peritonsillar abscess
Abscess occurs between the palatine tonsil and its capsule
Exudative tonsillitis
Precedes peritonsillar abscess
Tonsil will be swollen with exudates
Tonsil will not be deviated though
Sore throat
Fever
Tonsillar exudates
Tender anterior cervical lymphadenopathy
No cough
Acute pharyngitis
Child with stiff neck and not tonsillar involvement
Discrete mass and generalized swelling within th emidline
Retropharyngeal abscess
12 y.o for persistent nose bleeds. Has URI three weeks ago.
Petechiae
Low platelet count
Elevated bleeding time
Normal PT
Normal PTT
Complete blood count normal
Decreased platelets and occasional megathrombocytes
Immune thrombocytopenic purpura
Megathrombocytes (young platelets that are larger in size)
PT and PTT normal since coagualtion factors in affected
Prolonged bleeding time
Platelet count normal
Glanzmann’s thromboasthenia
Disorder of platelet aggregation due to decrease in glycoproteins GPIIb and IIIa.
Fever Anemia Thrombocytopenia Renal failure Neurologic symptoms
Thrombotic thrombocytopenic purpura
Bleeding time increased
Platelet count normal
PTT prolonged (can be normal)
PT normal
Easy bruising
Heavy bleeding
Elevated thromboplastin time
Von Willebrand disease
Heart problems after death of loved one
Imaging
Takotsubo cardiomyopathy
Two step echocardiogram
Transient left ventricular dyskinesia and mimics ACS
Returns to normal 1-4 weeks
18 y.o multiple shoulder dislocation. Runs in the family. Visable widened scar superior to umbilicus from piercing.
Mutation
Ehlers- Danlos
Type V collagen
COL5A1/ COL5A2
Skin hyperextensibility
Joint laxity
Tissue fragility
Wide atrophic scars
COL5A1/COL5A2
Ehlers danlos
FBN1
Fibrillin
Marfan syndrome
Tall
Aortic root dilation
Ectopia lentis
Tall Atrophic scars Translucent skin Prominent cranio-facial deformities (wide spaced eyes) cleft palate BIfid uvula
mutation
TGFBR1/TGFBR2
Loeys Dietz syndrome
TGFBR1/TGFBR2
Loeys Dietz syndrome
Tall Atrophic scars Translucent skin Prominent cranio-facial deformities (wide spaced eyes) cleft palate BIfid uvula
COL1A1/ COL1A2
Osteogenesis imperfecta
Type I collagen
LAR1
Larsen syndrome
similar to EDS with frequent joint dislocations
Also have abnormal craniofacial features (flattened face, depressed nasal bridge, and cleft palate)
4 y.o ingested medication
Lethargic, mildly responsive, fever, HR 160. Skin warm and dry no rash, pupils dilated, twitching of arms and legs
Acetaminophen Amlodipine Digoxin Imipramine propranolol
Involved mechanism of action
Tx
Cholinergic inhibition
TCA- imipramine
Mydriasis Tachycardia Hyperthermia Sedation Coma Twitching Seizure Hypotension Arrthymia Dry skin and mucous membranes
Ingestion recent (within 60 min) = activated charcoal
Sodium bicarbonate is indicated if hypotensive, arrhythmia or QRS prolongation
Ingestion of beta adrenergic blockade
-lol
severe bradycardia and hypotension
Ingestion of calcium channel inhibition
amlodipine
diltiazem
Verapamil
Hypotension
Severe bradycardia
AV block
Acetaminophen overdose
Hepatic failure
Nausea/vomiting
jaundice
Abdominal pain
Elevated liver function tests
Tx Charcoal
N-acetylcysteine
Digoxin overdose
tx
av block
bradycardia
Ventricular tachycardia
atrial tachycardia
severe hyperkalemia
anti-digitalis ab
children with multiple episodes of sudden, rapid, symmetric tonic contraction of the neck, trunk and extremities
Typically occur before sleep or upon awakening
Regression of psychomotor development
Infantile spasms
Triad
- spasms
- hyperarrhythmia (chaotic brain waves)
- mental retardation
Petit mal epilepsy
Present with absence seizures
Family history of kidney cysts
Bloody urine after running into table
Autosomal dominant polycystic kidney disease
Renal US
11 should be screen for
Obesity
Corneal abrasions tx
Appear green in color
Pseudomonas aeruginosa and other gram negative organisms
discontinuation of contact lens use, disposal of previous lesnses, avoidance of eye patching, use of anti-pseudomonal ophthalmic antibiotic (fluroquinolone or aminoglycoside) ciprofloxacin
if not contact lens wearer then polymyxin B/ trimethoprim solution
Single most effective public health measure shown to decrease the prevalence of dental caries
Fluoride in public water
Child new onset of unilateral conductive hearing loss with white mass behind intact tympanic membrane
Cholesteatoma
Graudal unilateral hearing loss and tinnitus. Facial nerve weakness
Normal tympanic membrane
Unilateral sensorineural hearing loss
Acoustic neuroma
Pulsatile tinnitus and gradual painless hearing loss
Middle age female
Pulsating, reddish blue mass behind intact tympanic membrane
glomus tumor
Neuroendocrine
Sensorineural hearing loss taht is sudden, fluctuating and unilateral hearing loss that begins with low frequencies and progresses to higher frequencies
Meniere disease
Weber: sound heard best in right ear
Rinne: bone conduction > air conduction in right ear
conductive hearing loss R ear
Weber: sound heard best in right ear
Rinne: Air conduction > bone conduction
Sensorineural hearing loss left ear
Labor of first c-section odd
Risk of maternal death is decreased with trial of labor compared to repeat c-section
If previous c-section risk of uterine rupture is
1%
What is contraindicated with trial of labor after cesarean delivery
Misoprostol
Anti-HBc
only have if previous infection not immunization
Positive McMurry
Knee flexed and externally rotated with valgus stress
Medial menicus tear
2 week old with foot deformity
Left foot abrupt medial deviation of metatarsals with prominent fifth metatarsal styloid process and a deep skin cleft at the medial midfoot
Talipes equinovarus
Extreme hyperextension of the foot due to external rotation of the calcaneus, overstretched achilles tendon and tight anterior musculature
Calcaneovalgus
” up and out”
Rocker bottom feet
Reversed arch, convex plantar surface and deep crease on the lateral dorsal side of the foot
Congenital vertical talus
Painful non-healing tongue ulcer for 3 months
Smoker
Tender solid 2 cm nodule on left lateral tongue. Lesion is whitish in color with marked ulceration and accompanied by surrounding erythema.
Two anterior cervical lymph nodes are palpable
Squamous cell carcinoma
Most common cancer in oral cavity
Especially if smoke
Ovar cavity lesion not healed in 6 weeks w/ LAD
Leukoplakia does not
ulcerate
First step for vulvar lesion
Punch biopsy of raised lesion
Acetic acid in vaginal exam
Only for use w/ colposcopy
Imiquimod cream
Used for vulvar intraepithelial neoplasia (VIN)
2 wk old with rash. Bumps on back of infants scalp. Progress ot whole scalp and neck.
Tx
Seborrheic dermatitis (cradle cap)
Self limiting
Greasy scales on scalp
Atopic dermatitis
presents after 3 MONTHS
pruritis and recurrent
Topical and systemic steroids
Diabetic first line medication
Metformin
(biguanide)
Decreases hepatic gluconeogensis
People who should get Hep A vaccine
People traveling to countries iwth high hepatitis A incidence
Working in Hep A lab
Homelessness
If have Hep B/C
Risk of chronic liver disease
Neurotoxin secreted from bacteria
Botulinum toxin by clostridium botulinum.
Prevents release of acetylcholine
Descending paralysis starting at trunk to extremities
Metabolic and vascular effects on peripheral nerves
Diabetic neuropathy
Accumulation of sorbitol can cause microvascular damage
Tx febrile seizures
Acetaminophen and reassurance
Antibiotic contraindicated in 7 y.o
doxycycline (tetracycline)
risk of tooth enamel staining
Acne tx
Topical benzoyl peroxide
Tetracycline, macrolides, erythromycin
Diabetic retinopathy work up
Fluorescein angiography
Stain will elucidate microaneurysm formation and neovascularization
Falling curtain
Floaters in eyes
Diabetic retinopathy
falling curtain : Signifying vitreous bleeding
Floaters: resolution of bleed
Fluorescein staining
diagnose corneal abrasions, ulcers and infections
Duodenal ulcer perforates and damages
gastroduodenal artery
Perforated gastric ulcer
Left gastric artery
RUQ pain Hepatomegaly Jaundice Ascites Variceal bleeding
Hepatic vein disease
Budd chiari syndrome
Diagnosis by dopple US
tumor marker of testicular choriocarcinoma
beta-hCG
Painless testicular mass
Bilateral increased breast tissue
confusion/ headaches
Solid intratesticular mass with necrotic center
Testicular choriocarcinoma
non-seminomatous tumor
Most aggressive of germ cell tumors
Hematogenous spread= brain metastases
Frontotemporl dementia vs alzheimers
FTD is commonly before 65 years of age
w/o spleen need what vaccines
H. influenzae type B vaccination
Monovalent meningococcal serogroup B (MenB)
First dose of quadrivalent meningococcal conjugate ACWY ( Men ACWY)
13-valent pneumococcal conjugate vaccine PCV13
PPSV23
less effective in immunocompromised
Use in those w/ chronic illlnesses non immunocompromised
> 65 y.o
Craniosynostosis
premature, abnormal fusion of cranial suture lines
Obese child that is learning how to walk who appears to have both his feet facing outward at 90 degree angles when standing
Legs have 90 degrees of ER and limited internal rotation
Femoral retroversion
Genu varum
Bowlegs
Genu valgum
Knock-knees
Metatarsus adductus
Pigeon toe
Lateral foot border appears C shaped
Stiffness in neck, radiates to arm. Numbness is upper extremity and lower extremity hyperreflexia
Imaging
MRI of cervical spine
Cervical stenosis
Elevated Serum alkaline phosphatase
Paget disease of the bone
Pain Hearing loss Bowing of the long bones Lytic lesion Cortical thickening on imaging
Paget disease
Initial Tx carpal tunnel
Neutral wrist splinting
Most effective first step for insomnia
CBT
scaphoid bone located where
anatomical snuff box
Hand bones
Some Lovers TRI Positions That They Cant Handle
Radial to ulnar
Tenderness to palpation on the ulnar aspect of wrist in the proximal hypothenar area
1 cm distal to the flexion crease of the wrist
Hook of hamate fracture
What to do with tooth if knocked out
transport in cold milk or childs saliva
Mono is due to what virus
EBV
Cherry red spot
GM2 ganglioside
Deficiency of
Tay-Sachs Disease
Hexosaminidase A
No hepatosplenomegaly
Fabry deficiency of
Alpha-galactosidase A
Accumulate of glycosphingolipids
Cardiomegaly
Punctate, nonblanching dark red to blue black clusters of ectatic blood vessels directly under skin
Renal failure
GM1 gangliosidosis
AR
Deficiency of beta-galactosidase A
Hepatosplenomegaly Cherry red spots Defective ossification Facial coarsening Rapid neurological decline
Gaucher disease
AR
Deficiency of beta-glucosidase
Glucocerebroside accumulates
Crumbled tissue paper appearance
Ashkenazi jewish
Painless splenomegaly Anemia Thrombocytopenia Fatigue bruising neurological impairment bone pain
Erlenmeyer flask deformity of femur
Niemann pick
AR
Deficiency sphingomyelinase
Accumualtes sphingomyelin
Ashkenazi jew
Lung disease
Hepatosplenomegaly
Short stature
pancytopenia
Cherry red spot
Neurologic impairment
Patietn w/o pulse and no electrical activity what medication
Epinephrine for asystole
Amiodarone
SE
Second medication utilized in VF and pulseless VT if inital vasopressor medication used (epinephrine or vasopressin)
Hepatotoxicity
pulmonary effects (interstitial pneumonitis, pulmonary fibrosi)
Hypotension
Hypothyroidism
CNS disturbances (ataxia, memory disturbances, movement/ coordination issues)
Photosensitivity
Optic neuritis/ neuropathy
Atropine
Used in patients with symptomatic bradycardia
Avoid w/ AV lbock
Digoxin
Dont use in WPW
Tx CHF
Digoxin effect on ECG
Downward scooping of ST segment and inverted T waves
B12 deficiency left untreated leads to
ataxia
Develop irreversible neurologic deficiency
Demyelination of posterior colums leads to loss of position and vibratory sensation and ataxia
Bromocriptine MOA
Dopamine receptor agonist
Dopamine receptor antagonists tx
Psychosis
Muscarinic receptor antagonists
Tx cholinergic toxicity
Cholinergic toxicity
diarrhea, urination, bradycardia, bronchospasm, lacrimation, lethargy, salivation seizures
AA 1 y.o mother with anemia. Height weight and head circumferance in 25% for age
Low hemoglobin
Normal paltelet
Low MCV
Normal red blood cell distribution
Target cells
Tear drop cells
Normal iron
ferritin
TIBC
Beta-thalassemia minor
Microcytic anemia
Normal red blood cell distribution
Target or tear drop shpaed cells
Diagnosis confirmed with Elevated hemoglobin A2 level on hemoglobin electrophoresis
Pure red cell aplasia
normocytic anemia
ineffective erythropoiesis of RBC line caused b infection w parvovirus B19
Tall peaked T waves
Shorted QT interval
Muscle weakness
Heart palpitations
Hyperkalemia
Painful neck thyromegaly Fever No nodules Muscle weakness
lab value
Subacute thyroiditis
First phase: elevated free T4
Third phase: Elevated TSH
Thyroid peroxidase antibody
Hashimoto thyroiditis
Thyroid stimulating immunoglobulin
Grave’s disease
Ezetimibe
inhibits dietary cholesterol absorption in the intestine by binding to Niemann-pick C1 like 1 protein
Cholestyramine
Colesevelam
Bile acid sequestrants
bind to bile acids in gut and prevent reabsorption of bile acids.
SE flatulence and loose lbowel movements
Adjuvant medication to statins to help further decrease LDL
Pruritus due to hyperbilirubinemia in liver failure patient what medication
Bile acid sequestrants
Cholestyramine
Colesevelam
Used to help lower triglycerides
Fibrates
- fenofibrate
- gemfibrozil
Work by inducing lipoprotein lipase
Which decreases hepatic production of apolipoprotein CIII via peroxisome proliferator- activated receptors (PPARs) alpha activity
Triglyceride level > 1000
Inhibiting HMB-CoA reductase
Statins
Also increase cholesterol metabolism
Decreasess both LDL and triglycerides
Muscle cramping
Assess hepatotoxic and liver function
Nicotinic acid moa
Niacin
Inhibits peripheral mobilization of fatty acids
Decreases the quantity of substrates needed for hepatic synthesis of triglycerides and VLDLs
Helps to increase HDL levels
SE: flushing
4 y.o flu 10 days ago. Swelling in legs and face. Albumin of 4+. serum albumin concentration elevated. Urine protein
- diagnosis
- tests
Minimal change disease
Renal biopsy and electron microscopy
Showing retracted of the epithelial foot process
Nothing on light microscopy or imaging
Increased mesangial matrix and increased mesangial hypercellularity in diffuse mesangial porliferation
DMP
Discrete segments of glomerular tuft reveal sclerosis
Segmental
Some glomeruli involved and some spared
focal segmental glomerulosclerosis (FSGS)
Lobulated glomeruli and mesangial proliferation
membranoproliferative glomerulonephritis (MPGN)
Low serum complement C3, C4 levels found in
Post-infectious nephritis
MPGN
Lupus nephritis
Multiple tender erythematous nodules located on the lower extremities (extensor portion) recent illness or pregnancy
Erythema nodosum
Also inflammatory bowel, oral contraceptive use, and sarcoidosis can cause
Hypopigmented patches (ash leaf spots)
Mental retardation
Epilepsy
Firm papules over the face and growths around the nails
Also grow
Tuberous sclerosis
AD
Adenoma sebaceum: Firm papules over the face
periungual fibromas: growths around the nails
Shagreen patches: yellow plaques with a pigskin consistency located on back and buttocks
Cafe au lait spots
Phakomas: yellow retinal plaques
Stages of kidney disease
GFR
Stage 1: > 90 mL
asymptomatic
Stage 2: 60-89
asymptomatic
Stage 3a: 45-59
anemia, hyperparathyroidism, htn, fluid retention, electorlyte abnromalities
Stage 3b: 30-44
worsening complications
Stage 4: 15-29
Stage 5: < 15
require hemodialysis
Joint locking up, popping and catching sensation
Walk with externally rotated leg
Joint crepitus and effusions on palpation
Gradual onset of pain
Osteochondritis dissecans
Occurs when cracks form in the cartilage and underlying bone
Leads to avascular necrosis of portions of the bone and fragmentation of tissue into the joint space.
Pes anserine bursitis
Repetitive stress to area
Pain when rising from seated position, ascending stairs, localizes to interior knee (proximal, medial aspect of tibia)
2 y.o Fever 104 Rash- flat blotchy erythematous rash on chest, abdomen and back without pustules or desquamation Red eyes and mouth Unilateral Enlarged cervical LN Hands/ feet swollen Erythema palms and soles Conjunctivitis Dry cracked lips
Tx
Kawasaki disease
Acute vasculitis in children < 5 y.o
Intravenous immunoglobulin to help prevent coronary artery aneurysms
High fever
Unilateral cervical lymphadenopathy
swelling and erythema palms and soles, bright red oral mucosa
IVIG
Antipruritics
Analgesics (acetaminophen, high dose aspirin)
Bright red oral mucosa
Strawberry tongue
Desquamation of hands and feet
Rash
Scarlet fever (strep pyogenes)
Antibiotics penicillin
[Doesnt have dry cracked lips, or conjunctivits]
Fever, anorexia, weight loss, joint pain, and photophobia
tx
malaria
Hydroxychloroquine
Plasma exchange
performed in cases of polyarteritis nodosa in patients positive with Hep B or C in attempt to clear virus
Most significant modifiable risk factor for stroke
HTN
Childhood disintegrative disorder
Devlopmental disorder characterized by normal development until at least 2 years of age followed by regression of language, socail and motor skins
Differentiate from Rett, mets milestones for 2 like climbing stairs, stacking six blocks and two word phrases and following two step commands
Child who does not bable by 1 year and not use any words by 15 months no intelligible speech at 2
Expressive language disorder
Long narrow face, prominent chin, large ears and large testicles
Pale blue irises, high arched palate, joint hyperlaxity
Developmetnal delay
Fragile X
X linked dominant
Mutation FMR1
Causes CGG trinucleotide expansion and symptoms will be worse the longer the expansion
Female Developmental regression Microcephaly Mental retardation Seizures Hand wringing
Rett syndrome
Develop milestones all the way up to 18 months (runs, kicks ball, can stack 4 blocks, begins to toilet train, can name objects)
Vaccine to not give immunocompromised
Varicella
MMR
Live flu vaccine
Vaccine to give HIV patient
Hep B HPV Inactived influenza Pneumococcal TdaP
Avascular necrosis risk factors
corticosteroid use
heavy alcohol consumption
What medications cause low potassium
Albuterol
Beta agonists, inhaled or systemic increase potassiumuptake by cells
Insulin Loop diuretics (furosemide, bumetanide) Sodium polystyrene sulfonate Alkalinizing agents (sodium bicarbonate)
Losartan causes
hyperaklemia
decrease in aldosterone, decrease in activation of Na/K pumps
What is elevated in sickle cell disease
Reticulocyte percentage
Common complication of sickle cell disease
avascular necrosis of the femoral head
Encapsulated bacteria
SHiNE SKiS
Strep pneumoniae Haemophilus influ B Neisseria meningitidis Ecoli Salmonella Klebsiella Streptococcus agalactiae
Erythrocyte sedimentation rate
rate at which RBC settle in 1 hr
Elevated in inflammatory states due to an increased concentration of fibrinogen that causes RBC to stick together in rouleaux formation
Erythrocytes sedimentation rate is decreased in sickle cell disease, CHF, spherocytosis, polycythemia
Diagnosis of multiple myeloma needs what
Serum and urine electrophoresis
Pneumothorax vs hemothorax
Pneumothorax
- dyspnea
- chest pain
- decreased or absent breath sounds
- HYPERRESONANCE to percussion
Hemothorax
- Dullness to percussion
Metoclopramide
dopaminergic antagonist used as adjunct to abortive migraine therapy in those who n/v is predominant symptom
SE: acute dystonic rxn (spasmodic or sustained muscle contractions)
Metoprolol
beta blocker used in migraine prophylaxis in patients with frequent migraines
Sumatriptan
serotonin receptor agonist
primary abortive therapy in migraine headaches
Contraindicated in those w/ HTN, CAD or peripheral vascular disease
Topiramate
antiepileptic used in migraine prophylaxis or those whom abortive therapies are ineffective or contraindicated
Protein C deficiency
inherited thrombophilia that typically presents with venous thromboembolism
hypercoagulable
Ototoxicity
Aminoglycosides
- gentamicin
- tobramycin
- amikacin
- neomycin
- streptomycin
Vancomycin
Aspirin
Cisplatin
Lithium SE
Nephrogenic diabetes insipidus
Direct nephrotoxicity
Thyroid disturbances
Ebstein anomaly in fetus
B12 deficiency bug/ worm
Diphyllobothrium latum
pallor
fatigue
weakness
bilateral burning/ numbness/ in feet
Ascaris lumbricoides
Intestinal obstruction and lungs
round worm
nonproductive cough with fevers, crackles, wheezing and oval infiltrates on xray.
Human feces as fertilzer
Giardia lamblia
contaminated water
Malaise
Diarrhea
foul smelling flatulence
Taenia saginata
Undercooked beef
WL
Abdominal pain
nausea
Passing tape worm segments in stool
Taenia solium
Two routes: eating raw meat or fecal oral transmission
Fecal oral –> brain
Abdominal pain
cramping
N/v
loss appetite
Appendicitis
Preeclampsia severe features
Visual changes
Headache
Pulmonary edema
N/V, RUQ pain
Anemia
Thrombocytopenia
Proteinuria >= 5 g in 24 hr
3+ on two dip sticks 4 hrs apart
Urinary obstruction in male infant
Grunting when peeing
Needed to confirm diagnosis?
Posterior urethral valves
Membranous folds within the posterior urethra that cause urinary obstruction in male infants
Grunting and straining when urinating
Failure to thrive
Urosepsis
Voiding cystourethrogram
Bladder US shows
urinary obstruction or dilated bladder
Cystoscopy
therapeutic procedure for posterior urethral valves after diagnosis is made
Obliterating the posterior valves
abdominal pain bloody diarrhea WL night sweats elevated ESR and CRP pANCA
Ulcerative colitis
string sign
Crohns disease
ASCA positive
anti-saccharomyces cerevisiae ab
Crohns disease
Fistula formation
Skip lesion
Crohns disease
Screening for DM
Over age 45 every 3 years
Fasting blood glucose > 125
Tx premature ejaculation
SSRI
Drug that blocks alpha adrenergic receptors for penis
Yohimbine
Psychogenic erectile dysfunction
Scotch tape test
Enterobius vermicularis
Profuse watery mucoid diarrhea with abdominal cramping
Cough, wheezing, pleuritic chest pain
Hemoptysis
Pruritic linear urticarial rash of 1 or more bands
Stepping on soil
Strongyloides stercoralis
82 y.o chronic cough, sporadic crackles over right lung fields, puts petroleum jelly on chest
Chest xray several poorlyd efined opacities in right lower lobe with bilateral reticulonodular pattern
Foamy macrophages with large cytoplasmic vacuoles and extracellular hdrophobic droplets
Lipoid pneumonia
Aspiration pneumonia caused by inhalation or aspiration of exogenous lipoid oils
Anti-glomerular basement membrane antibodies
Pulmonary and renal
Hemoptysis Cough Fever hematuria proteinuria RBC casts
Good pasture syndrome
Sinusitis otitis medica cough renal failure c-ANCA
Granulomatosis w/ polyangiitis
Small vessel vasculitis
Ectopia cordia
failure of sternum to form
leaving the heart and upper abdominal cavity covered by only a thin layer of skin
Heart expossed
Adolescent athlete with knee pain and point tenderness at tibial tuberosity
Osgood- Schlatter disease
Osteochondritis of tibial tubercle
Inflammation of patellar ligament where it attaches to the tibial tuberosity
Patellar tendinopathy
jumpers knee
anterior knee pain that increases over time, worsens with use, may cuase limp
Tenderness more prominent in and localized to the patellar tendon (not tibial tuberosity like osgood schlatter disease)
Asymptomatic children with diffusely enlarged, firm non-tender thyroid
test?
Autoimmune thyroiditis (hashimoto’s)
TSH, free T4 (thyroxine) and anti- thyroid ab
Headaches dizziness erythromelalgia (burning pain) visual impairment pruritus
Labs
Mutation
Polycythemia vera
Myeloproliferative disorder
hyperviscosity of the blood
Splenomegaly engorded retinal veins elevated - hemoglobin - wbc - platelets - hematocrit
JAK2 mutation
8 day cough
temp 100
tenderness over maxillary region
Rhinovirus
Unilateral facial pain/tenderness over cheek
Painin teeth, tymple, vertex or occiput
Erythema nose, cheeks, or eyelids
Postnasal drip or nasal congestion
Cough
Bacterial infection (5)
Symptoms > 10 days Symptoms improve then intensify within 10 days Fever >102 Purulent nasal discharge Severe facial pain
AAA 4-5.4 cm
Repeat US 6-12 months
AAA screening
65-75 if smoked
Surgical repair for AAA
elective surgical repair reserved for AAA > 5.5 cm
Camper
Diarrhea
Watery malodorous, greasy
Giardia lamblia
Drinking or swimming water
Mild watery diarrhea in adult
IC: biliary tract involvement
Cryptosporidium
Immigrant or travelers
Bloody diarrhea
Liver abscess
Entamoeba histolytica
Abdominal pain
vomiting
Diarrhea
15 hr after ingestion of seafood
Vibrio vulnificus
Take alpha-1 adrenergic (terazosin) for
when
At bedtime
enlarged prostate
Postural hypotension
Lightheadedness
Fell on back of right hand
Supination
Tenderness of lateral distal aspect on right forearm
Distal radius w/ associated ventral displacement
Smith or reverse colles fracture
falls on flexed wrist
Falling on outstretched hand
Colles fracture
fracture of the distal radius with associated dorsal displacement
Fractures of ulna
unlikely to occur in isolation
Barking cough
Nasal flaring
Intercostal retractions
Stridor
Steeple sign
Croup
parainfluenza virus
Most common pharyngitis
Fever
No cough
Anterior cervical lymphadenopathy or tonsillar erytehma
Streptococcus pyogenes
Virus that can cause pancreatitis
Mumps
Pancreatitis stool
Tan and floats less dense due to malabsorption of fat from exocrine pancreas insufficiency
Sore throat and a coalescing gray pseudomembrane in the oropharynx that bleeds when removed
Corynebacterium diphtheria
Risk for cardiotoxicity and neurotoxicity
Rash on face spreads to trunk and limbs
Rubella adult
Infant with cataracts
Deafness
Patent ductus arteriosus (machine like murmur)
Rubella
Rubeola
measles
High fever before cough, coryza and conjunctivitis
Ulcers that pop up in mouth when stressed
tx
Aphthous ulcers
Triamcinolone (oral rinse)
Cough muscle pains headaches Traveled to Ohio for hiking Fever Bilateral focal infiltration with hilar lymphadenopathy
Histoplasmosis
Southwestern of US Fever Dyspnea Cough Fatigue Arthralgias
Unilateral infiltrate with ipsilateral hilar adenopathy
Coccidioidomycosis
Tuberculosis location in lungs
Ghon complex hilar adenopathy
Caseous lesion in lower lung field
Tachycardia
narrow QRS complexes w/o P waves
Tx
SVT
Adenosine
A1C goal of elderly with life expectance less than 10 years
8.0%
A1C goal for normal DM
<7%
A1C at risk for DM
5.7-6.4
Clonidine
Not appropriate first step for tobacco cessation or alcohol
Can be used for opiate cessation
alpha 2 noradrenergic agonist
Decreases autonomic arousal and symptoms
