HY Review #1 Flashcards by Stephanie Escobar

2 reasons for
Failure to pass nasogastric tube in an infant + Associated defects

Esophageal Atresia w/ TE fistula
(VACTERAL)
&
Choanal Atresia
(CHARGE)
─
Vertebral, Atresias, Cardiac, TE fistula, Renal, Anal, Limb defects
─
Coloboma (pupil)
Heart, Atresia (choanal), Retarded (growth), Genital, Ear defects

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White pt. (+) FMH
RUQ pain, Splenomegaly, Jaundice, Anemia
↓ Hgb ↑ MCHC
Indirect Hyberbilirubinemia
↓ Haptoglobin
Dx/Tx/Dxt (2)/cx?
Mutation?

Hereditary Spherocytosis (AD)
Splenectomy
Osmotic Fragility test/ Eosin 5 Maleimide binding test

Cx: Pigmented Gallstones (s/t hemolysis)
Ankrin/Spectrin mutation– congenital hemolytic disorder

RBCs lack central pallor

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Patients present with swelling of the eyelids, lips, and/or tongue.
Cx: laryngeal edema requires intubation
Dx/Tx

Hereditary Angioedema
avoidance of triggers (ACE-I)

Bradykinin-mediated → C1 inhibitor
Bradykinin receptor ANTagonists
Kallikrein inhibitors.

Histamine-mediated→ antihistamines, steroids

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History of rheumatoid arthritis
multiple lower lobe nodules on CXR
Dx?

Caplan Syndrome

(aka Rheumatoid Pneumoconiosis)

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Before obtaining surgery, doing sports, or after trauma what is indicated in pts with RA or Ankylosing Spondylitis?

Cervical X-Ray

Atlantoaxial instability (C1-C2 Subluxation)

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History of rheumatoid arthritis
Splenomegaly
Neutropenia
Dx/Tx?

Felty Syndrome
1st: Methotrexate
2nd: TNF 𝛼-Inhibitor
(etanercept, infliximab, adalimumab)

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Before starting immunomodulators (TNF inhibitors) for RA, IBD, etc. what do we screen for 1st? (3-4)

Cx associated with immunomodulator use?

HBV, TB, HIV, HCV

Cx: Lymphomas

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List 2 classic opportunistic infections in pts on TNF inhibitors?

Legionella
Listeria Infections (Granulomatous illness)

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HY
RA treatment in pregnancy?

Hydroxychloroquine

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Sudden onset limb pain
absent pulses
h/o recent MI
Dx/Tx/Dxt:

Acute Limb Ischemia
IV Heparin (1st)
CT Angiogram (+ct)
Embolectomy (last/definitive tx)

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Recent MI & cardiac cath.
transient vision loss (golden spot on fundoscopy)
netlike, purplish discoloration LEs
↑ Cr
(+) Eosinophiluria
Dx?

Aortic Atheroembolic disease

(Cholesterol Emboli Syndrome)

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Pt suspects they were bitten by a bat. NBSIM?

Administer:
Rabies Immune-globulin (in one arm)
Rabies Vaccine (in other arm)

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Red urine + flank pain minutes after a blood transfusion begins
Dx/Tx?

T__HSR

Hemolytic transfusion rxn
(ABO incompatibility → T2HSR)
Normal Saline (flushes out bad blood)

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Respiratory Distress + stridor/wheezing minutes into a blood transfusion
Dx/Tx?
T__HSR

Anaphylactic Transfusion rxn
Epinephrine
(IgA deficiency → T1HSR)

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Fever and chills 2-3hrs into transfusion reaction
Dx/Tx?

Febrile non-hemolytic
(prevent with leukocyte irradiation)
Acetaminophen (anti-pyretic)

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If a pt has ANY transfusion reaction what test should be done?

Direct Coombs TEST
(to see if antibodies caused it)

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Classically presents as an elderly female (or person who recently hung out with elderly person)
with malaise, night-sweats, weight loss, and productive cough.
CXR: Lower lobe/ Mid-lobe (hilar) opacities
Dx/Tx?

Mycobacterium Avium Complex (MAC) infection
REC: Rifampin + Ethambutol + Clarithromycin
━
aka Lady Windermere Syndrome
Presents very similar to TB
Sputum is acid-fast bacilli (+)
Involves the lower lung lobes (TB involves upper lobes)

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Traveler/Inmate/immigrant (India, Phillipines, China, Indonesia)
present with fever, weight loss, night sweats, and a productive cough (with or without hemoptysis)
Sputum is acid-fast (+) pink bacilli
Dx/Tx?

Tuberculosis (Active)
RIPE + Vit B6

Rifampin + Isoniazid + Pyrazinamide + Ethambutol

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h/o sickle cell disease recent URI
Hb of 2
low reticulocytes
Dx?

Aplastic crisis
(s/t Parvo B19)

Typically in a sickle cell crisis there are ↑ Reticulocytes.
If this presents with ↓ reticulocytes consider aplastic crisis s/t Parvo B-19.

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Female presents for amenorrhea.
Has T5 Breast+ No Pubic/Axillary hair
Blind Vaginal Pouch
Dx & genotype?

Androgen Insensitivity Syndrome (46XY)
testosterone receptor don’t work.

(poor axillary/pubic hair = Testosterone problem)

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Soldier returns from deployment with nose papule that has evolved into a centrally ulcerating lesion with a raised erythematous rim
Dx/Tx?

Cutaneous Leishmanaiasis
Liposomal Amp-B
(or sodium stibogluconate)

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Erythematous rash on the face, neck, and torso 10 mins after an infusion is started for Staph Aureus endocarditis treatment. Dx/Tx?

Antibiotic induced infusion reaction
(Red Man Syndrome s/t Vancomycin)
Tx: slow infusion rate + antihistamine

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Sudden onset of low back pain,
bowel and bladder dysfunction
Bilateral patellar hyperreflexia & weakness
(+) Babinski
Dx?

Conus Medullaris Syndrome

(Acute + UMN sxs)

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3w Gradual onset low back pain (radiates to the left thigh)
bladder/bowel dysfunction
saddle anesthesia (S3-S5)
decreased Rectal tone (or erectile dysfunction)
Unilateral, hyporeflexic, LE weakness
Dx?

Cauda equina syndrome

(Gradual+ LMN sxs)

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Most common cause of death in muscular dystrophy

Cardiac dysfunction

Hematologic association with restless legs syndrome? Treatment?

Iron deficiency anemia → Willis Eck Bomb Syndrome (restless leg syndrome) 1st line: Pramipexole / Ropinorole (dopamine agonist) 2nd line: Primidone (barbituate) 3rd line: Pre-pregabalin / Gabapentin

Treatment of aggression in individuals with Alzheimer’s?

Risperidone

Cardiac effect of Ziprasidone (atypical anti-psychotic)

prolongs QT

Tumor marker for hepatoblastomas? Association?

alpha fetal protein (AFP) associated w/ **Beckwith-wiedemann syndrome**

Hemodynamically Unstable Hypernatremia h/o Bipolar Disorder (well managed) Dx/Tx? ppx?

Nephrogenic Diabetes Insipidus (s/t Lithium) tx: **NORMAL SALINE FIRST** ppx → ENAC chanel blocker (**Amiloride**/Triamterene)

2 HY screenings that should be carried out in cirrhotic patients:

Need an **annual EGD** for risk of Variceals SCREENING Need every 6m a **LIVER U/S** to screen for HEPATOCELULAR CARCIOMA

35 M is brought to the ED by police who found him walking leisurely between traffic. Needs help walking to hospital bed Nystagmus and Severe Hypoglycemia Dx/NBSIM?

IV Thiamine therapy (always give thiamine **before** glucose in alcoholic/malnourished pts) Confusion, Ataxia, Nystagmus → Wernicke’s

≥50F Presents with fatigue + pain and stiffness in the neck, shoulder, and hip muscles. ↑ ↑ ESR normal CK Dx/Tx?

Polymyalgia rheumatica low dose of oral glucocorticoids

may resemble early rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). However, presents with **recent viral infection** (low-grade fevers) and **joint pain** does not have swelling/tenderness. It self resolves. versus RA and SLE which present as a chronic joint pain with tenderness and swelling.

Viral Arthritis (s/t parvovirus B19)

History of recent stroke now develops pulmonary consolidation Dx/Tx?

Aspiration PNA **Clindamycin** (for ANEROBE coverage) (note that this can progress to an abscess with cavitation) Anerobes involved: Bacteroides, fusobacterium, or prevotella

What malignancy likes to form cavitary lesions?

Squamous Cell lung cancer

Treatment of Lobar PNA in COPD Pt: If, Gram (+) → (Bug & Drug) if Gram (–) → (Bug & Drug)

Gram (+) → S. Pneumo → Ceftriaxone Gram (–) → H. Influenza → Ceftriaxone

Fever, RUQ pain Ultrasound → Extra**Hepatic Duct Distended** Dx/Pathophysiology

Mirizzi syndrome Extrinsic compression of hepatic duct by distended cystic duct in order to make this dx Qstem HAS to say **distended heptic duct ± bulging cystic duct**

Pt Presents with Confusion, Nystagmus, and Ataxia. What are they deficient in?

Thiamine (Vitamin **B1**) need supplementation has Wernicke's Wernicke's is **not** a B12 deficiency

Pt presents with Bilateral LE paresthesias. Absent DTRs Impaired vibration/proprioception bilaterally Dx/Tx?

Vitamin B12 deficiency Supplementation (seen in Alcoholics & post Intestine resection s/t stuff like Chron's)

Basophilic Stippling Is seen in

Lead poisoning

Schistocyte formation s/t

mechanical destruction (MAHA, Hemolysis, Prosthetic Valves)

Pt w/ hx of Chron's presents with numbness or tingling in toes and/or fingers + macrocytic anemia Dx?

B12 Deficiency Chron’s affects terminal illeum → resected → can’t reabsorb Vit B12 Iron- Duodenum Folate- Jejunum B12 - Illeum

Lateral Brainstem Stroke presentation on NBMEs?

Temperature Loss on 1-side of the face (**ipsi** to lesion) & Temperature Loss on the **contralateral body** ── CNs affected = ipsilateral brainstem stroke **If it is NOT lateral then it has to be Medial stroke** ── Midbrain → CN 3,4 Pons → CN 5, 6 Medulla → CN 7, 8, 9, 10, 12

CN locations: Midbrain → Pons → Medulla →

Midbrain → CN 3,4 Pons → CN 5, 6 Medulla → CN 7, 8, 9, 10, 12

All loss of sensation and motor functions Only ocular movements (except for adduction) spared Dx? Locate Lesion/artery supplying region?

Locked in syndrome Pons infarction Pontine Artery

Specific gravity in dehydration:

>>1.012 (Magic # to know)

Specific gravity in SIADH:

>>1.012 (Magic # to know)

Specific gravity in diabetic insipidus:

<<1.012

Guillane Barre treatment

PLASMAPHERESIS

Fish tank/ reptile cleaner with nodular forearm lesions (looks like sporothrix, but different exposure) dx/tx?

Mycobacterium Marinum Clarithromycin, Ethambutol, Rifampin

**DM** pt with Necrotic lesion (NOT MIGRATORY) + **NEUTROPENIA** Dx/tx (3)?

**Ecthyma Gangrenousum** (Pseudomonal infection) FQ, Cefepime, Ceftazidine

**Nodular infection of the UEs** Pustules/ulcers/red streaks ascending to axilla Nodules along draining LNs in a vegetable farmer/landscaper/gardener Dx/Tx (2)?

Sporothrix PO Itraconazole or Potassium Iodide

Impetigo (Honey crusted papules/pustules) mcc Staph Aureas Tx?

Topical Mupirocin

Thyroid nodule noted of Physical Exam. NBSIM? After that?

TSH levels Hot Nodule (Low TSH) → RAIU/Scintigraphy Cold Nodule (normal/High TSH) → Thyroid U/S + FNA

Painful Thyroid Goiter Dx/Tx?

DeQuervain/Granulomatous/Subacute thyroiditis NSAIDs ± steroids

Healthcare worker High T3/T4, Low Thyroglobulin Dx?

Factitious thyroid hormone medication

Most common thyroid cancer → LN spread (do **LN dissection**) → laminated calcifications (Psammoma bodies) BRF:

Papillary Thyroid cancer BRF: Radiation to Neck/Chest

(>60) Old man + rapidly enlarging neck mass + widely spread thyroid cancer → worst prognosis. Will likely die.

Anaplastic Thyroid cancer (orphan annie eyes)

2nd mcc of thyroid cancer dx requires lobectomy to see if cancer has broken through capsule HEMATOGENOUS spread (no LN dissection)

Follicular Thyroid Cancer (Lobectomy bc FNA can’t differentiate between benign follicular adenoma)

Tumor marker = ↑ Calcitonin [tones down Ca] → hypocalcemia (+) congo-stain amyloid Tx: ppx thyroidectomy (parafollicular C cells are cancerous) MEN2 syndrome association

Medullary Thyroid Cancer

Boy with recurrent catalase + infections (Candida, Aspergillus, Nocardia) Or Staph A. Abscesses Nitro-blue Tetrazolium test is Negative Dihydro-rhodamine 123 assay = no change in fluorescence Dx/tx?

Chronic Granulomatous Dz **INF-Y therapy** → stimulates MQs & can reduce risk of infection ─ Neutrophils (PMNs) do not work. NAPDH Oxidase deficiency → No ROS.

Old person with Crazy High WBC count (cells in different stages Myeloid maturation) ↓ Leukocyte Alkaline Phosphatase ↑ Basophils Dx/Mutation/Tx?

CML Imatinib or Dasatinib 9:22 Philadelphia → BCR-ABL

↑ Leukocyte alkaline phosphatase seen in ____.

Leukamoid Rxn → s/t infection

Recently diagnosed DM + erythematous, **necrotic** lesions over the **distal extremities** and **groin**. Dx of DM cause & skin findings

Glucagonoma **necrolytic migratory erythema** (SUPER HIGH YIELD)

69M Smoking Hx presents with weight loss, jaundice, steatorrhea, and dark urine Palpable, non-tender BUT distended gallbladder. Dx/NBSIM/Tx?

Pancreatic Cancer **CT scan A/P** + Contrast (for staging) If cancer surrounds vessel = inoperable → **Hospice** ─ Pouvacier Sign Bad Prognosis only months to live

Post splenectomy 104ºF, WBC 23k, BP 60/40. Dx/Tx?

Pneumococcal Sepsis CTX ─ Strepto Pneumo is the mcc of sepsis in ppl with no spleen (or SCD)

Spontaneous bloody nipple d/c:

intraductal papilloma (HY)

Firm, rubbery, discrete, well circumscribed, mobile, non-tender breast mass in a 25 yo F that grows bigger with the menstrual cycle:

Fibroadenoma (responds to Estrogen so grows with period)

Multiple breast masses in a 29 yo F that get more painful with the menstrual cycle:

Fibrocystic changes (multiple, contain fluid, get painful with period)

Female w/ Eczematoid breast lesion red, scaly, or vesicular rash affecting the nipple and areola ± itchiness, nipple changes

Paget’s disease of breast

MC kind of breast cancer:

**Infiltrative** Ductal Carcinoma

Erythema, skin edema, and **tender** breast ± LAD & skin dimpling

**Inflammatory** breast cancer (**Very bad**)

Breast mass in a female < 30: Breast mass in a female > 30:

< 30: → U/S > 30: → Mammogram

Breast Cancer Screening Guidelines on NBME

**Mammogram** ≥40 y.o. every 1-2 years

To determine metastatic potential for a breast malignancy, what is the initial dx test that is performed?

Sentinal LN biopsy → If negative, done.

Sentinal LN biopsy (+) ve, what is your NBSIM?

axillary LN dissection

Chronic bloody bowel movements ± Recurrent epistaxis Small vascular malformations visible on the buccal mucosa (mouth, lips) or skin. Dx?

Hereditary Hemorrhagic Telangiectasia (osler-weber-rendu syndrome) autosomal dominant

SUPER HY Pts presents 3 months (or even days after) after a AAA repair with Hgb of 7. dx?

Aorto-enteric fistula → aorta has a fistula to the GI tract directly

72 F with a Hb 8. (+) FOBT +Ejection murmur radiating to the carotids is heard on auscultation. Diagnosis?

Colonic angiodysplasia (**Heyde** syndrome) (Aortic Stenosis murmur + GI bleeding = Heyde) **Calcified** valves **rip VWF** which impairs 1º hemostasis

69M with a history of PAD 3 mo hx of of severe LLQ pain worsened with meals + Weight-loss Dx?

Chronic mesenteric ischemia (weight loss due to refusal to eat from pain) *can also be Chronic Ischemic Colitis

69M with a history of PAD ± A-FIB 3 day hx of of severe LLQ pain worsened with meals + **painful**, Bloody diarrhea Dx?

**Acute Ischemic colitis** *not painful bloody poo → Diverticular bleed*

Painless, massive bloody bowel movement in a 65 (old) yo F Dx?

Diverticulosis

Watery diarrhea, hypokalemia, and achlorhydria: dx/tx?

VIPomas ( ↓ gastric acid, ↓ Cl & ↓ K) WDHA syndrome (pooping out electrolytes) Tx: Octreotide

Ulcers in unusual small bowel locations (jejunum) : Dx/Tx?

**Gastrinoma** (Zollinger Ellison Syndrome) Tx: **PPI**

Episodic headache and HTN with elevated metanephrines: Dx/Tx?

Pheochromacytoma **First** Alpha Adrenergic Antagonist (**Phenoxybenazine, Phentolamine**) **Second** Beta blocker (Labetalol) Before surgical resection to prevent **HTN crisis** s/t unopposed adrenergic stimulation from metanephrines causing mass vasoconstriction

Trouble smiling on one side of the face upper and lower face affected ± Prodrome of ear pain Dx/Tx?

Bell’s Palsy High-dose glucocorticoids Facial Nerve sheath inflammation (CN 7) s/t reactivation of neurotrophic viruses (herpes simplex virus)

37M cyclist has been unable to train for the past 4 days due to leg weakness. Recent sore throat & rhinorrhea that resolved 10 days ago w/o tx. Dx: Tx: Drug to avoid: Respiratory monitoring:

Guillain-Barré syndrome **Plasmapheresis** Steroids CONTRAINDICATED Check **FEV1** frequently (for Respiratory Failure)

51M with a 6 mo hx of numbness and paresthesias in his L foot **radiating to L great toe** Dx: ____ nerve injury.

Tibial nerve injury (aka tarsal tunel syndrome)

Weakness in “finger spread” Nerve affected?

Ulnar nerve (interosseous muscle not working)

Flattening of the thenar eminence, sensory loss on the ventral (palm) surface of the lateral hand. Nerve affected/dx?

Carpal tunnel syndrome median nerve

Lateral thigh numbness in a basketball player who has required R thigh casting for a sports related injury. Nerve affected/ dx?

Lateral Femoral Cutaneous Nerve Neuralgia parastetica

Painless, intermittently palpable groin mass in an infant:

Indirect inguinal hernia

Most common kind of hernia in females: Classically Located ____ the **Inguinal** ligament Complications of hernia?

Females → Femoral hernia Location → **UNDER** Inguinal ligament Incarceration → emergent surgery

Down’s syndrome + failure to pass meconium: Dx testing: Associated mutation:

Hirschsprung Disease Rectal Suction Biopsy RET mutation ─ Failed migration of neuro-crest cells to myenteric plexus cell in the distal colon. No plexi will be seen on bx.

Newborn with abdominal viscera to the right of the umbilicus vs through the umbilicus? Which one is worse?

**Right** of umbilicus → Gastroschesis (not sealed so bowel can dry out) **Through** umbilicus: →Omphalocele (is sealed in peritoneum bag so bowel wont dry out) Omphalocele→associated with more congenital defects

3 month old + Projectile **non-bilious** vomiting 30 mins after feeding + Visible peristaltic waves Dx/Dxt/NBSIM/Tx?

Pyloric Stenosis Ultrasound of abdomen NBSIM: Correct any electrolyte abnormalities Tx: Pylo-myotomy

NBSIM for **BILIOUS** vomiting in an infant? List 4 causes

Upper GI Series Duodenal Atresia Jejunal Atresia Biliary Atresia Midgut Volvulus (malrotation)

3M with a painless scrotal mass that **transilluminates** (fluid) with a pen light. Dx/Pathophysiology?

Hydrocele Persistent Patency of Procesus Vaginalis

**Mononeuritis Multiplex** classic symptom: What diagnosis is it found in?

Wrist or Foot Drop Eosinophilic Granulomatosis with Polyangiitis aka Churg-Strauss (Small vessel vasculitis)

mcc of sepsis in ppl with no spleen (or SCD)

Streptooccus Pneumoniae

Dysphagia/Hoarse voice post thyroidectomy

Dmg to Recurrent Laryngeal Nerve

Duodenal Atresia associated with (2)

Down Syndrome VACTERAL

Multiple Myeloma Treatment drug

Bortezomib (proteasome inhibitor)