HY Review #1 Flashcards
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
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
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
History of rheumatoid arthritis
multiple lower lobe nodules on CXR
Dx?
Caplan Syndrome
(aka Rheumatoid Pneumoconiosis)
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)
History of rheumatoid arthritis
Splenomegaly
Neutropenia
Dx/Tx?
Felty Syndrome
1st: Methotrexate
2nd: TNF 𝛼-Inhibitor
(etanercept, infliximab, adalimumab)
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
List 2 classic opportunistic infections in pts on TNF inhibitors?
Legionella
Listeria Infections (Granulomatous illness)
HY
RA treatment in pregnancy?
Hydroxychloroquine
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)
Recent MI & cardiac cath.
transient vision loss (golden spot on fundoscopy)
netlike, purplish discoloration LEs
↑ Cr
(+) Eosinophiluria
Dx?
Aortic Atheroembolic disease
(Cholesterol Emboli Syndrome)
Pt suspects they were bitten by a bat. NBSIM?
Administer:
Rabies Immune-globulin (in one arm)
Rabies Vaccine (in other arm)
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)
Respiratory Distress + stridor/wheezing minutes into a blood transfusion
Dx/Tx?
T__HSR
Anaphylactic Transfusion rxn
Epinephrine
(IgA deficiency → T1HSR)
Fever and chills 2-3hrs into transfusion reaction
Dx/Tx?
Febrile non-hemolytic
(prevent with leukocyte irradiation)
Acetaminophen (anti-pyretic)
If a pt has ANY transfusion reaction what test should be done?
Direct Coombs TEST
(to see if antibodies caused it)
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)
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
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.
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)
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)
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
Sudden onset of low back pain,
bowel and bladder dysfunction
Bilateral patellar hyperreflexia & weakness
(+) Babinski
Dx?
Conus Medullaris Syndrome
(Acute + UMN sxs)
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)
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 → ExtraHepatic 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 orFoot 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)
