HY review #2 part 2 Flashcards
Irrepressible need to sleep.
Affecting performance at work/school
Naps help
Dx/Dxt/Tx?
CSF findings?
Narcolepsy
Polysomnography
Tx: SCHEDULED NAPS + Stimulants (Modafinil, Dextroamphetamine)
(+) Cataplexy add Sodium Oxybate
CSF: Low levels of Orexin (Hypocretin-1)
Complex motor behaviors during sleep
punching/ kicking in sleep
REM sleep behavior d/o
How should a hospital investigate the death of a 19 yo M who received defibrillation for unstable V-Tach?
Root- cause analysis
(wrong care done → supposed to do SCV)
When a patient makes sexually suggestive comments to the physician or behaves seductively, what should be done on NBMEs?
Use a chaperone when seeing pt
A medical student notices pt has worsening fevers and abdominal pain 3 days post-op.
The student observed one of the residents break the sterile field during surgery and feels it is a direct cause of the infection.
What is the most appropriate action by the student?
Duty to Report
to hospital’s adverse event reporting system
What should be offered to a 45M with Glioblastoma Multiforme who is now completely bed bound, cannot read or write, and is completely dependent on others for his activities of daily living?
Hospice
How can goals of care be established in a palliative medicine setting?
Family meeting
Newborn management of developmental dysplasia of the hip
pavlik harness
Palpable RLQ abdominal mass in a 2 yo child with a 2 day h/o intermittent abdominal pain.
dx/NBSIM?
Intusucception
Air or Contrast Enema
(diagnostic & therapeutic intervention)
Common neurologic complication in a child with Port wine stains on their face
Seizures
Sturge Weber syndrome
(Encephalo Trigeminal Angiomatosis)
Subdural hematoma in a 2 yo child of a 17 yo mom
NBSIM?
Call CPS
child abuse (brain bleed)
Medication that causes persistent erections (Priapism) or Myoclonus
Trazadone
(can cause serotonin syndrome)
Classic pharmacotherapy for uterine atony
Oxytocin
(mcc of PP-hemorrhage)
Classic presentation of Lateral Medullary infarct (Wallenberg syndrome) & affected artery
Vs
Medial Medullary infarct
Lateral Medullary
Ipsilateral pain/temp loss on face + contralateral on body
ipsilateral tongue deviation
Horner’s (ptosis & miosis)
PICA (rarely Vertebral a)
———————
Medial Medullary
Ipsilateral tongue deviation + contralateral Hemiparesis
Anterior Spinal Artery (rarely Vertebral a)
45M obese & skin is “tanned”
PE reveals a bulge just beneath his occiput.
Purple striae over most of his lower abdomen.
The most likely cause of this patient’s problem is?
A hyperfunctioning pituitary adenoma
pituitary bc hyperpigmentation
Cushing Dz s/t Pituitary Adenoma secreting ACTH.
ACTH Dependent b/c Hyperpigmentation (Skin Tan) present
ACTH released with MSH b/c same precursor POM-C.
6M has lethargy + acute onset high fevers
(+) Kernig’s and Brudzinski’s sign
CSF: 6000 WBCs + Neutrophilic + ↓ Glucose+ ↑ Protein
(+) growth on Thayer Martin agar.
3 days after admission, the patient passes away.
Recent CBC showed ↑ PT/PTT/D-dimer
Labs drawn 10s post mortem reveal
__ Cortisol __ ACTH __CRH
dx?
↓ Cortisol ↑ ACTH ↑ CRH
Meningococcal Meningitis
+ DIC s/t Adrenal Hemorrhage (Waterhouse Fredrikson Syndrome) causing 1º adrenal insufficiency (↓ Cortisol; ↑ ACTH)
Pt remains hypotensive s/p multiple boluses of IV Norepinephrine with no improvement in his symptoms.
PMH (+) severe asthma on oral prednisone.
dx/NBSIM
Adrenal insufficiency
Administer high dose dexamethasone and norepinephrine.
s/t Adrenal ATROPHY from chronic Glucocorticoid (Prednisone) use! Give stress dose of steroid.
Dx & __ Ca2+ __ PTH __ Ph
Primary hypoparathyroidism
Primary hyperparathyroidism
Secondary hyperparathyroidism
Tertiary hyperparathyroidism
hypercalcemia of malignancy
Primary hypoparathyroidism
↓ Ca2+ ↓ PTH ↑ Ph
DiGeorge
Thyroidectomy
Primary hyperparathyroidism
↑ Ca2+ ↑ PTH ↓ Ph
Adenoma
MEN 1 & 2A
Secondary hyperparathyroidism
↓ Ca2+ ↑ PTH ↑ Ph
CKD (↓ Vit D also)
1ºVit D def
Tertiary hyperparathyroidism
↑ Ca2+ ↑ PTH ↑ Ph
Kidney Transplant (gland already hypertrophied s/t CKD)
Hypercalcemia of malignancy
↑ Ca2+ ↓ PTH (Ph Varies)
Squamous cell carcinoma
Gonorrhea & Chlamydia
Screening: Women < __ should get ____ NAAT for both.
Women > __, only screen if they have “risk factors” like multiple sex partners, immunocompromised etc.
Treatment if:
Neither bug has been ruled out:
Gonorrhea (w/ruled out chlamydia):
Chlamydia (w/ruled out gonorrhea):
<24 sexually active → annual NAAT
> 24 screen if high risk
Neither ruled out: CTX + Doxycycline (or Azithromycin, 2nd line)
Gonorrhea (chlamydia r/o): Ceftriaxone
Chlamydia (gonorrhea r/o): Doxycycline (or Azithromycin)
BRF for encopresis (fecal incontinence) :
Ages:
Tx:
BRF → Constipation
Ages >4 yo
Tx → Stool softener
3 yo M Has been known to have hand flapping behavior
PE is notable for a large jaw.
He has restricted social interests.
Dx:
MOI:
Mutation:
Prognosis:
Cardiac problem:
GI Problem:
Fragile X
Mode of Inheritance: XLD
FMRI gene → CGG tri-nucleotide repeat
Normal life expectancy
Cardiac: MVP
GI: GERD
(FYI Alports the other XLD of the only 2 tested)
BRF for inherited intellectual disability:
Fragile X
52M 3 days after cardiac catheterization for an LAD infarct (recent MI), begins to complain of R sided UE and R lower facial weakness.
Dx:
Pathophysiology:
MC cardiac cath complication:
Common cause of this complication:
Other PMH that could have cause this:
Left MCA stroke (Face + UE)
s/t Blood Stasis (forms emboli)
MC cath cx: Re-Stenosis
Cause: Medication non-Adherence
Other PMH: A-Fib
23 yo Nigerian M with a 3 day history of increased urination and red urine. Has been admitted multiple times in the past for severe pain in his hands and feet.
Dx/Tx (3)?
Painless hematuria:
Pathophysiology:
Blood smear:
Sickle Cell Disease (SCD)
Hydroxy urea + Folate + Penicillin until age 5
Painless hematuria: Renal papillary necrosis
(s/t sickled cells occluding papilla)
Valine replaces Glutamic acid Beta Globin
Howell Jolly bodies → RBC w/ a single purple dot (nuclear remnants)
Insidious onset of R hip pain + h/o Sickle Cell Disease (SCD):
Avascular Necrosis of Femoral Head
MCC sepsis/meningitis in Sickle Cell Disease (SCD):
Streptococcus Pneumo
Common vitamin deficiency in Sickle Cell Disease (SCD):
Folate Deficiency (s/t high RBC turn-over uses up folate)
Bone pain and fever + h/o SCD:
Salmonella osteomyelitis
RUQ pain worsened by meals in pt with SCD:
Indirect bilirubin gallstones (pigmented)
SCD pt with 5 day h/o worsening SOB & a low retic count?
aplastic crisis
———
Hemolysis causes high reticular count
but low retics & low hb suggest aplastic crisis (likely s/t Parvo B19 )
23 yo IVDU comes to the ED with a 2 day h/o severe lower back pain.
His T is 102. PE is notable for urinary retention and decreased perineal sensation.
Dx:
Dx testing:
Tx (2):
Are steroids indicated:
Spinal epidural abscess (fever + back pain + neuro deficit)
MRI spine with contrast
I&D + antibiotics (Vancomycin)
——
steroids not indicated here, only give if cord compression s/t malignancy
Note that spinal epidural hematomas can also present similarly to spinal epidural abscess (back pain + Neuro deficits + usually w/o fever)
spinal epidural hematomas are commonly due to _____ complication and labs will be notable for ___.
Warfarin
High INR
39 yo neuropathologist with a 5 week h/o of profound memory loss + myoclonus
dx/dxt?
Creutzfeld Jakob
CSF shows high 14-3-3 protein
29F who was recently started on phenelzine (MAO-I) after treatment failure with sertraline for MDD now has myoclonus
Dx/Tx?
serotonin syndrome
tx: Benzo
(if not working → Cyproheptadine)
39 yo computer scientist with progressive dementia, “an increasing number of angry outbursts”, involuntary arm movements & myoclonus.
Dx/Tx for sxs:
Pathophys:
Huntington dz (AD)
Tetrabenazine
CAG repeats → caudate atrophy
neurodegenerative movement d/o characterized by involuntary & irregular movements of the limbs, neck, head, and/or face (chorea).
No disease-modifying treatment only management of chorea symptoms. Prognosis → death within 15–20y post sxs.
NBME and Strokes
*Paralysis of entire 1 side of body (Hemiparalysis):
Artery + Location of lesion?
*What must be done before allowing food after a stroke:
- Contralateral lenticular striate artery
(Posterior limb of internal capsule) - Swallow study
71 yo M with multiple falls. Trouble holding the pen still as he fills out clinic forms.
Dx/Tx:
Brain findings:
Managing Psychosis (2)
Parkinson
Depigmentation of substantia nigra pars compacts
First → Carbidopa+Levodopa
Then try: Amantadine
Ropinirole, Selegiline (MAO-B)
Psychosis: ↓ Carbidopa dose → add Quetiapine
DI mentioned these? Bromocriptine or Cabergoline
Parkinson’s (+) d/o → Dx?
+ Scaly, greasy, rash around the face, cheeks, and nose:
+Orthostatic hypotension and ataxia:
+Multiple “backward” falls, trouble looking upwards:
+Syncopal episodes, seeing rats in her hospital room
Rash → Seborrheic Dermatitis (topical azole)
Orthostatic → Multisystem atrophy
Can’t look up → Progressive Supranuclear Palsy
Hallucinations → Lewy body dementia
Anti-epileptic drug side effects
Hyponatremia/SIADH, febrile neutropenia:
Nephrolithiasis:
Hepatotoxicity, Teratogenic:
───
(Extra info)
2 Anti-epileptic drugs causing Steven Johnson?
Carbamazepine
Topirimate
Valproate
───
(Extra)
Carbamazepine, Phenytoin
35 yo F with MCP/PIP arthritis & a Hb of 9. MCV is 80.
Dx?
Ferritin/TIBC/Trans Sat?
Anemia of chronic disease (ACD) s/t RA
↑ Ferritin (Binds Iron for storage in BM)
↓ TIBC (always opposite to ferritin –Iron is plenty available)
↓ Transferrin Sat (circulates iron in blood, but low bc iron stuck in BM)
Chronic inflammation results in ↑ Hepcidin which stops Iron from being released from the bone marrow MQs. Hepcidin also ↓ iron absorption in the GI tract.
74M with pencil thin stools and a microcytic anemia; Dx?
Ferritin/TIBC/Trans Sat?
RDW:
Iron deficiency anemia s/t colon cancer
↓ Ferritin (Not much Iron around to store)
↑ TIBC (Ready to bind iron when available)
↓ Transferrin Sat: (Not much Iron in circulation)
↑ RDW (variation of RBCs in size/vol.)
Hep C screening guidelines:
18-79 yo one time HCV screen
32M with chronic heartburn that has not resolved with 2 trials of esomeprazole.
NBSID:
What if this test is (–) ve?
EGD+ biopsy
24 hr esophageal pH monitoring
(gold standard for dx)
SOB, PaO2 of 80 6 hrs after a platelet transfusion for symptomatic ITP, CXR shows b/l interstitial infiltrates with diffuse crackles heard on lung auscultation.
PCWP is 14 (nl < 18). BP is 75/40.
How can this be differentiated from transfusion associated circulatory overload?
TRALI → PCWP wnl + Hypotension
(basically ARDS post transfusion)
TACO → PCWP ≥18 + HTN
(Cardiogenic Pulm Edema s/t large volume transfusion)
Nephritic, nephrotic hypersensitivity reactions:
T_ HSR
Notable exception:
T3 HSR
Good pasture (T2HSR)
Humeral neck fx:
nerve? cause?
Axillary n. Dmg
Anterior Shoulder dislocation
weak shoulder abduction
↓ sensation lateral shoulder
Humeral Midshaft fx:
nerve? sensation?
other cause of this nerve dmg aside from fx?
Radial n. Dmg
weak wrist & finger extension
↓ sensation Dorsolateral hand/forearm
improperly fitted crutches & Mid shaft fx
Supracondyle (elbow) fx:
nerve? sensation?
other causes of this nerve being dmg?
Median n. Dmg
↓ sensation lateral palm + thumb/index/middle finger
↓ flexion of above fingers
(carpal tunnel compression → distal)
Medial Epicondyle fx:
nerve? sensation?
Ulnar n. Dmg
↓ grip strength, wrist flexion, finger spread
↓ sensation medial palm + 4th/5th fingers + hypothenar
Cubital Tunnel Syndrome
Hook of the hamate fx:
nerve? cause?
Ulnar n. Dmg (at the wrist)
bicycle handlebar
↓ sensation medial 4th/5th fingers + clumsy hand
Anatomical snuffbox tenderness:
fx/tx/cx?
Scaphoid fracture
Thumb spica cast
(prevents Avascular necrosis)
Head of the fibula fx:
Nerve?
Motor sxs (3)
Deep Peroneal nerve
Foot drop → steppage gait
↓ Eversion and Dorsiflexion
Numb at toe thong sandal zone
(mnemonic: PED)
Can’t initiate shoulder abduction:
Dx/muscle/Dxt
Rotator cuff tear
Supraspinatus
Neer test (int rotate & raise arm)
Empty can test (arms up to shoulder, thumbs down)
Trouble reaching overhead:
nerve/muscle/common cause?
Long thoracic nerve
Serratus Anterior (SALT- Wings)
breast surgery (mastectomy)
Winged scapula
can’t reach 180º
Spirochete infection treated with penicillin
+ truncal erythema
dx/tx?
Jarish Herxheimer rxn
Supportive care
(immune response to bursted cells)
71M with kidney transplant has had his Cr increase progressively from 1.2 – 3.5 over the past year.
Dx:
Organ biopsy findings:
──
3 weeks post transplant w/ rising Cr (+ biopsy finding):
Chronic rejection (≥1y)
Fibrosis on bx
──
s/p 3 weeks
Acute Rejection (<1y)
Lymphocytes & Eosinophils on bx
Diarrheal outbreak in a military barrack.
Noro virus
Flank pain, T 103, and pyuria. He is a diabetic.
dx/tx (3)?
Pyelonephritis
FQ, CTX, TMP-SMX
or Gentamicin
Despite 96 hrs of appropriate antibiotic therapy for Pyelonephritis, the patient continues to have high fevers and worsening pain.
NBSIM:
Potential finding #1 & tx?
Potential finding #2 & tx?
CT Abd/Pel
#1: Air inside kidney’s walls → Emphysematous Pylo → emergent Nephrectomy
#2: Fluid inside kidney’s walls → Perinephric abscess → I&D + IV Cefepime, Ceftazadine(3º) or Carbapenem
47M Fever + HA worsening + recent sinus infection
+ Babinski
dx/dxt/tx(2)/contraindications?
Brain abscess
MRI brain + contrast
I&D + IV Cefepime or Carbapenem
Contraindicated → Lumbar puncture
22M is 10d s/p bone marrow transplant develops
diffuse skin rash, diarrhea & burning sensation on the palms and soles. ↑ LFTs
Dx/Tx/Patho?
Diarrhea + Rash s/p Transplant = GVHD
Tx: Steroids
Donor T cells attacking recipient tissue
How do we perform a test of cure after treatment for a T. Pallidum infection?
- Non-treponemal test →
or - Treponemal antibody test →
Non-treponemal test
*↓ RPR & VDLR titers = cured
* Same titers used for screening
Treponemal antibody test
* MHA-Tp & FTA-Ab = confirms the dx after (+) screen
* Once (+) will always be (+) not used for test of cure
Pt w/ difficult asthma to treat has Fevers + wheezing + ↑ Eosinophilia/ IgE
CXR: dilated bronchioles
Dx/tx?
Allergic Broncho-Pulmonary Aspergillosis (ABPA)
s/t Cystic Fibrosis
tx: Steroids
(Azole if recurrent)
Neutropenic pt + Fevers despite broad ABs treatment
CT chest → focal consolidation surrounded by ground glass opacity
Dx/Tx (2)?
Invasive aspergillosis (Halo sign)
Voriconazole → Amp B
Pt presents with cough + hemoptysis + ↑ Eosinophilia/IgE
CXR: mass in old TB cavitation
Dx/Tx?
Aspergilloma
Surgical Resection of mass
(This can also have asymptomatic presentation)
53M with Diabetes has a wood-like induration of the skin on extremities that spares the digits after a recent spinal MRI
Dx & BRF?
Description: Shiny, Thickened & Hyperpigmented.
Hard to the touch.
Nephrogenic systemic Fibrosis
(s/t Gadolinium based contrast for MRI)
BRF: CKD
───
Looks like scleroderma, but recent exposure to contrast gives away answer.
Wilms tumor (nephroblastoma)
Peak age 2-5
Unilateral abdominal ___ mass
± Hematuria & Abd pain
Associated with (2)
non-calcified
* Beckwith-Wiedemann syndrome
* WAGR
Wilms tumor
Aniridia (Iris is gone)
GU abnormalities
Retarded
Fetal macrosomia or Hemihyperplasia
Omphalocele or Umbilical Hernia
Macroglossia
Dx?
Suggested Regular Screening (2)?
Beckwith-Wiedemann syndrome
───
Serum α-fetoprotein (AFP) → Hepatoblastoma
Abdominal & renal U/S → Nephroblastoma (Wilm’s)
Peak age <2
Malignant solid & _____ abdominal mass.
Arises from neural crest cells (adrenal glands)
Crosses midline
Homer Wright Rosettes
(+) Chromogranin
Neuroblastoma
Calcified
Paraneoplastic syndrome associated with
Neuroblastoma
Opsoclonus Myoclonus syndrome
Rapid, multidirectional, involuntary movements of the eyes and extremities
staggering gait in childhood
HOCM
Scoliosis
dx/defect?
Friedreich ataxia (AR)
GAA repeats
Hyperphagic, Obese boy with micropenis
Intellectual disability
Hypotonic at birth
↑ Ghrelin
Dx/ paternal or maternal chrm defect?
Explain uniparental disomy?
Prader willi Syndrome
Paternal Chrm 15 → Mutated/absent
Maternal Chrm 15 → Imprinted
───
Uniparental disomy: Mitosis/Miosis error → gets 2 Maternal Chrm 15 → both Imprinted (aka shut off)
Happy demeanor + frequent (inappropriate) laughing.
Intellectual disability
epileptic seizures
Dx/ paternal or maternal chrm defect?
Explain uniparental disomy?
Angelman syndrome
Maternal Chrm 15 → Mutated/absent
Paternal Chrm 15 → Imprinted
───
Uniparental disomy: Mitosis/Miosis error → gets 2 Paternal Chrm 15 → both Imprinted (aka shut off)
Diagnosis?
Anterior vaginal wall muscle is weak (multiparous) so the bladder prolapses into vaginal canal ± past hymen
→ ___ incontinence
tx: Physical therapy, Pessary, Surgery
Cystocele
stress incontinence
Diagnosis?
Posterior vaginal wall muscle is weak so rectum prolapses into vaginal canal.
→ ___ incontinence s/t ___
Rectocele
stool incontinence (s/t constipation)
Diagnosis?
Small bowel prolapses against the superior wall of the vagina resulting in a bulge at the high, upper vaginal wall
Enterocele
(bowel herniates through cul-de-sac)
Diagnosis?
Urethral diverticulum (out-pouching) where urine can collect. Urinary dribbling (leaks pee) after voiding.
→ Positive __ test
Urethrocele
(+) Q tip test
