Incorrect Questions Flashcards
acute MI on ECG
new development of ST-segment elevation or depression or the development of new T-wave changes such as hyper acute T waves or T wave inversions in two contiguous leads
posterior wall infarct ECG leads
V1-V4
posterior wall infarct vessels
left coronary artery
- circumflex branch
right coronary artery
- posterior descending branch
posterior wall ECG findings
tall R waves
ST-segment depression
upright T waves
inferior wall infarct ECG leads
II, III, aVf
inferior wall infarct vessels
right coronary artery
- posterior descending branch
inferior wall ECG findings
T-wave inversion
ST-segment elevation
lateral wall infarct ECG leads
I, aVl, V5, V6
lateral wall infarct vessels
left coronary artery
lateral wall infarct ECG findings
ST-segment elevation
septal wall infarct ECG leads
V1 and V2
septal wall infarct vessels
left anterior descending artery
- septal branch
septal wall infarct ECG findings
R wave disappears
ST-segment rises
T-wave inverts
anterior wall infarct ECG leads
V2-V4
anterior wall infarct vessels
left anterior descending artery
- diagonal branch
anterior wall infarct ECG findings
poor R-wave progression
ST-segment elevation
T-wave inversion
what causes neck stiffness (meningismus) after subarachnoid hemorrhage
breakdown of blood products within CSF
what is meningismus
neck stiffness indicating inflammation of the meninges
multiple endocrine neoplasia type 2
pheochromocytoma
thyroid carcinoma
hyperparathyroidism
cells for medullary thyroid cancer
thyroid parafollicular cells
what do thyroid parafollicular cells secrete
calcitonin
Atrial natriuretic peptide
seen in cardiac amyloidosis
ß-amyloid
accumulates in neurofibrillary tangles in Alzheimer’s disease
immunoglobulin light chain
amyloidosis associated with multiple myeloma
tuberous sclerosis genetics
autosomal dominant neurocutaneous disorder
presentation of tuberous sclerosis
infants present with convulsive seizures (infantile spasms) developmental delay abnormal skin findings: - angiofibromas (sebaceous adenomas) - ash-leaf spots best seen on Wood lamp - shagreen patches CNS: periventricular tubers heart: rhabdomyoma regina: mulberry tumors, phakomas, Regina hamartomas kidneys: angiomyolipomas
most common kidney finding in tuberous sclerosis
angiomyolipomas
diagnosis of allergic dermatitis
patch testing
cells involved in allergic dermatitis
T cells, NOT IgE
O’Brien’s test is for
superior labral anterior to posterior tear
O’Brien’s test
passively flex patient’s shoulder to 90° then internally rotate shoulder
positive O’Brien’s test
pain and/or clicking when arm is in full internal rotation, but not when arm is in neutral rotation
Speed test for
irritation of the long head of the biceps tendon
α-1 antitrypsin deficiency (A1AD)
inherited condition characterized by genetic defect that causes configurational change in α-1 antitrypsin molecule that prevents its release from hepatocytes
what does α-1 antitrypsin do
protects lung tissue from damage by proteases
ancestry for α-1 antitrypsin deficiency
Northern European
presentation of α-1 antitrypsin deficiency
emphysema - unchecked proteases cause damage to alveolar walls
liver disease
extra pulmonary manifestations of A1AD
necrotizing panniculitis vascular disease vasculitis (c-ANCA positive) inflammatory bowel disease glomerulonephritis
common pathogens in meningitis for <1month
streptococcus agalactiae
escherichia coli
listeria monocytogenes
common pathogens in meningitis for 1 month to 23months
streptococcus pneumonias neisseria meningitidis S. agalactiae haemophilus influenza E. coli
common pathogens in meningitis for 2 years to 50 years
N. meningitidis
S. pneumoniae
common pathogens in meningitis for > 50 years
S. pneumonias
N. meningitides
L. monocytogenes
Aerobic gram-negative bacilli
empiric antibiotic treatment for meningitis <1 month
ampicillin + cefotaxime
OR
ampicillin + aminoglycoside
empiric antibiotic treatment for meningitis 1 month to 23 months
vancomycin + third-generation cephalosporin
empiric antibiotic treatment for meningitis 2 years to 50 years
vancomycin + third generation cephalosporin
empiric antibiotic treatment for meningitis >50 years
vancomycin \+ ampicillin \+ third-generation cephalosporin
why ceftriaxone for meningitis
provides good penetration into CSF
effective against most major causes of adult meningiits
why vancomycin for meningitis
increasing resistance of some bacteria to ß-lactams
why ampicillin for meningitis
increased risk of listeria in patients over 50
descriptions suspicious for malignancy in breast cancer
“linear branching micro calcifications”
“grouped irregular micro calcifications”
descriptions suspicious for benign breast changes
“vascular/skin calcifications”
“rim calcifications”
“large and coarse calcifications”
“smooth round and oval calcifications”
what is the next best step for suspected malignancy in breasts without a palpable mass?
stereotactic core biopsy
when is stereotactic core biopsy indicated?
non-palpable masses diagnosed on mammography
HELLP syndrome
Hemolysis
Elevated Liver
Low Platelets
Risk factors for HELLP syndrome
African American extremes of age multiple gestations molar pregnancy renal disease chronic hypertension
another name for colonic pseudo-obstruction
Ogilvie syndrome
what is pseudo-obstruction
acute dilation of the colon with signs and symptoms of mechanical bowel obstruction without an actual mechanical or anatomic obstruction of flow
signs/symptoms of pseudo-obstruction
abdominal distension abdominal pain nausea/vomiting constipation bowel sounds, hypoactive abdominal tenderness, mild abdominal tympani
who commonly gets pseudo-obstruction
severely ill or post surgical patients with certain medications (calcium channel blockers, narcotics, α-2 antagonists) and/or electrolyte imbalances (hypocalcemia, hypokalemia)
diagnosis of Ogilvie syndrome
clinical history and physical exam, abdominal radiography
abdominal x-rays in Ogilvie syndrome
colonic dilation, usually from cecum to splenic flexure
management of Ogilvie syndrome
urgent NG decompression via NG tube strict NPO IV fluid resuscitation labs to evaluate electrolyte abnormalities abdominal imaging
complications of Ogilvie syndrome
colonic ischemia and/or perforation
sideroblastic anemia
acquired disease caused by an abnormality in iron metabolism
acquired causes of sideroblastic anemia
lead drugs - isoniazid, alcohol, chloramphenicol collagen vascular disease neoplasm
labs in sideroblastic anemia
microcytic
hypo chromic
increased ferritin and iron
TIBC normal or elevated
peripheral smear of sideroblastic anemia
anisocytosis
target cells
poikilocytosis
occasional siderocytes
what is pathognomonic for sideroblastic anemia
siderocytes
what are siderocytes
hypo chromic red blood cells which have coarse basophilic granules visible via Wright or Wright-Giemsa stain
missed abortion
death of a fetus before 20wks with complete retention of products of conception and a closed cervical os
physiologic changes in pregnancy related to thyroid hormones
TBG increases
TSH no change
T4, total increases
T4, free no change
treatment for acute RV infarction
isotonic IV fluids (increase preload, cardiac output, and Pressure)
aspirin
cardiac catheterization
initial treatment of acute pericarditis
NSAIDs plus colchicine
gram stain of strep pyogenes
gram-positive cocci in chains
what is Peutz-Jeghers syndrome
autosomal dominant mutation in a tumor suppressor gene (STK11)
characteristic findings of PJS
2 of:
- 2 or more Peutz-Jeghers-type hamartomatous polyps of the GI tract
- mucocutaneous hyperpigmentation of the mouth, lips, nose, eyes, genitalia, and fingers
- family history of PJS
most commonly increased GI cancer risks in patients with PJS
colorectal
gastric
small bowel
pancreatic
most commonly increased extra intestinal cancer risks in patients with PJS
breast ovary cervix Sertoli cell tumor of the testis lung thyroid
diphyllobothrium latum
cestode (tapeworm) from fish
acquired from ingesting infective larvae in fish, usually freshwater or spend most life in freshwater
larvae killed by flash freezing
causes vitamin B12 deficiency
most common causes of diphyllobothrium latum
salmon, trout, whitefish, herring, cod, freshwater squid, mackerel, and red snapper
sudden-onset severe chest pain that is ripping or tearing in nature, HTN, inter-arm pressure difference, asymmetric pulses
aortic dissection
aortic dissection - ascending
anterior chest
aortic dissection - aortic arch
neck and jaw
aortic dissection - descending
inter scapular area
mycosis fungoides
mc type of cutaneous T-cell lymphoma, a non-Hodgkin lymphoma
cutaneous T-cell lymphoma
malignant disease of helper T-cells within he skin and lymph nodes
clinical features of cutaneous T-cell lymphoma
initially, scaly plaques along with an erythematous, pruritic rash (often mis-dx)
may then progress to tumor stage with at least one tumor (lesion >5mm from skin)
threes phases of mycosis fungoides
1 - patches (nonspecific dermatitis-like patches)
2 - plaques (pruritic plaques and lymphadenopathy)
3 - tumors (likely to ulcerate)
tx of mycosis fungoides
topical (radiation, photochemotherapy, photodynamic therapy, and laser surgical excision)
back/flank pain, dark or cloudy urine, fever, and urinary incontinence or increased frequency
renal papillary necrosis (RPN)
u/a in renal papillary necrosis (RPN)
necrotic tissue that has sloughed from the kidneys
CT RPN
anatomical defects - medullary ring shadows and/or hydronephrosis
risk factors for RPN
acetaminophen or NSAID use, sickle cell anemia (s/t ischemia of kidneys), urinary tract obstruction, and diabetes
tx RPN
supportive
CT hepatic hemangioma
well-defined hypotenuse mass with typical filling pattern for hemangioma - peripheral nodular enhancement followed by complete opacification on delayed images
risk factors for anal cancer
HPV, receptive anal intercourse, and smoking
mc type of anal cancer
squamous cell carcinoma
liver cirrhosis immunization recommendations
HepA, HepB, influenza, and pneumococcal polysaccharide vaccine 23
res ipsa loquitur
‘the thing speaks for itself’
- no direct evidence of physician’s negligence
- requires the accident must be of a kind which ordinarily does not occur in the absence of someone’s negligence and the patient did not contribute to the accident
muscle strength grading
Grade 0 = no muscle movement
Grade 1 = trace muscle contraction but no joint movement
Grade 2 = joint and muscle movement with gravity and resistance eliminated
Grade 3 = joint and muscle movement against gravity, but not resistance
Grade 4 = joint and muscle movement against gravity and resistance, but less than normal
Grade 5 = normal joint and muscle movement against gravity and resistance
radial nerve palsy
C5-T1
most often fx at mid-humerus or compression of nerve by crutches
paralysis of wrist extensors, digits, and forearm supinators (‘wrist drop’)
axillary nerve injury
C5-C6
fx of surgical neck of humerus
motor of deltoid and sensory overlying deltoid
long thoracic nerve injury
serrates anterior
winged scapula
median nerve injury
pronation, flexion of the hand at wrist joint, and thumb opposition
‘ape hand’ deformity
ulnar nerve injury
fx of medial epicondyle
pinpoint pain, loss of sensation over medial hand, decreased grip strength
hydrosalpinx
collection of fluid inside Fallopian tube and is almost always a complication of acute salpingitis/pelvic inflammatory disease
pelvic ultrasound of hydrosalpinx
sausage-like, cystic lesions filled with clear fluid
radioactive iodine uptake scan in dequervain thyroiditis
decreased uptake
d/t stored hormones being released from the inflamed gland, not from overproduction
Grave’s disease antibody
thyroid-stimulating hormone receptor antibody (TRAb)
kallman syndrome
hypogonadotropic hypogonadism and impaired ability to smell
lab findings in Kallman syndrome
low LH, low FSH, low testosterone, progesterone, and estrogen
lichen planus
immune-mediated skin disorder in middle aged adults
five p’s : pruritic, purple, polygonal, and papules or plaques
commonly found on ectremities
viewing of lichen planus
fine white lines (Wickham striae)
TCA toxicity
CNS depression, coma, seizures, cardiac dysrhythmias, and respiratory depression
mc EKG findings in TCA toxicity
sinus tachycardia
prolonged PR interval
widening of QRS complex
QTc interval prolongation
what can be used to reduce incidence of PUD associated with NSAIDs
misoprostal - prostaglandin
arsenic poisoning
acute = GI symptoms - watery diarrhea, abdominal pain, and vomiting chronic = polyneuropathy and skin pigmentation changes
tx arsenic poisoning
chelation therapy with dimercaprol (BAL) to speed excretion
mc hematologic complication with nephrotic syndrome
venous thrombosis and pulmonary embolism
rib movements
ribs 1-5: pump handle
ribs 6-10: bucket-handle
ribs 11-12: caliper
muscles used for rib tx
rib 1: anterior scalene rib 2: posterior scalene ribs 3-5: pectoralis minor ribs 6-9: serratus anterior ribs 11-12: quadrates lumborum
odds ratio
determining the different levels of risk attributable to the exposure
calculation of odds ratio
= ad/bc a = exposure & disease b = exposure & no disease c = no exposure & disease d = no exposure & no disease
LVH on ekg
increased in amplitude of QRS complexes and left deviation
causes of LVH
uncontrolled htn, cvd, aortic stenosis, and aortic insufficiency
tx LVH
if reversible, target cause of disease
ex: HTN? tx ACE-i, ARB, direct renin inhib, CCBs
minor pelvic fx
located within pubic rami
consider minor pelvic fx in pt with:
leg length discrepancy, abnormal positioning of leg, focal bony tenderness of hip or pelvis, reluctance to move leg, and inability to lift leg
granulomatosis with polyangiitis
necrotizing vasculitis that primarily affects lungs and kidneys
nephritic syndrome
hematuria, oliguria, and mild proteinuria
granulomatosis with polyangiitis
rhinitis and hemoptysis
positive c-ANCA
cxr: interstitial lung disease, infiltrates, cavitary nodules
IF negative for antibodies
contact dermatitis (diaper)
erythema and maceration on convex skin surfaces that are in direct contact with the diaper
comedonal or noninflammatory acne
multiple open and closed comedones and small papules and pustules without significant erythema or inflammation
tx comedonal acne vulgars w/o inflammatory component
topical retinoid
topical retinoid MOA
reduce follicular hyper proliferation resulting in reduced follicular occlusion and reduced comedones formation
four main pathogenic factors of acne
- increased sebum production (triggered by presence of androgens)
- follicular hyper proliferation (excessive keratinization which blocks the sebum from exiting the follicles)
- proliferation of Cutibacterium acnes, part of the normal skin lora, within the sebum-clogged follicles
- inflammation (trigged by proliferation of C. acnes)
Galeazzi fracture
fx of distal third of the radius in conjunction with dislocation of the distal radioulnar joint
nerve affected in Galeazzi fx
anterior interosseous nerve (branch of the median nerve) is damaged
-> paralysis of the flexor policies longs and flexor digitorum profundus -> loss of ability to pinch between the thumb and index finger
tricuspid stenosis murmur
significant diastolic pressure gradient -> low pitched diastolic rumble heard at lower left sternal border that enhances with insporation
mc cause is rheumatic fever
what can be used to increase breast milk production
metoclopramide, dopamine antagonist
hx of travel to tropical/subtropical, eosinophilia, pruritic skin lesion f/b transient cough and later GI
parasites
Strongyloides stercoralis
Echniococcus granulosus
‘hydatid cysts’
mc - lung, liver, and CNS
chest pain, hemoptysis and HA or disorientation d/t increased ICP
NO GI
onchocerciasis volvulus
transmitted by blackfly, common in africa
‘river blindness’
dx: skin snip test and microscopic exam, slit lamp
Schistosoma haematobium
‘swimmer’s itch’
fever, urticaria, nausea, and abdominal pain
mc cause of squamous cell carcinoma of the urinary bladder
trypanosoma brucei
African trypanosomiasis, or African sleeping sickness
no GI manifestations
fever, malaise, chancre at site of tsetse fly bite f/b meningoencephalitis and daytime somnolence
Strongyloides stercoralis
penetrate skin in foot from soil
penetrate colonic mucosa, travel hematogenously to other organ systems -> hyper infection syndrome in immunocompromised host
pneumonitis, abdominal apin, severe fever, meningitis/encephalitis
radial head somatic dysfunction muscle energy
physician supinates the arm to move the radial head anterior while the patient resists by pronating the arm
pulmonary fibrosis
chronic inflammation of the lung parenchyma -> fibroblast activation and proliferation
slow onset with dyspnea on exertion, chronic cough, wheezing, and chest pain
physical exam of pulmonary fibrosis
inspiratory rales
signs of right heart failure: elevated JVD, S3 heart sounds, RV heave, digital clubbing
pulmonary fibrosis on xray
reticular, nodular, or ground-glass pattern
severe: cystic space in the lung periphery d/t destruction of lung parenchyma
causes of pulmonary fibrosis
idiopathic, irritation with cigarettes, medications (amiodarone), environmental allergens, environmental pollutants, recurrent aspiration, and reflux
pulmonary fibrosis PFT
decreased diffusion capacity
management of fibromyalgia
duloxetine, milnacipran, and pregabalin
eligibility for mechanical thrombectomy
initiated within 6hrs of symptom onset, imaging without hemorrhage and minimal signs of ischemic change
thiazide diuretics
hydrochlorothiazide and chlorthalidone
Henoch Schonlein Purpur (HSP)
inflammation of small to medium blood vessels
fever, palpable purpura on LE and buttocks, migratory polyarthritis of large joints, glomerulonephritis, abdominal pain in peds pt
Henoch-Schonlein Purpura
aka IgA vasculitis
IgA nephropathy
primary glomerulonephritis
recurrent episodes of macroscopic hematuria, mild flank pain, and low-grade fever
peds pt with tuberculosis
several days to weeks of fever, cough, night sweats, and weight loss
cxr - hilar adenopathy
foreign born, visited endemic area, or adult contact
iodine deficiency
hypothyroidism goiter
tx actinic keratoses
5-FU in diffuse areas
cryo for isolated lesions
pancreas posterior chapman’s point
between transverse process of T7 and T8 on right
pancreas anterior chapman’s point
7th ICS right
complication of acute diverticulitis
pneumaturia
number needed to treat
1/absolute risk reduction
ex:
0. 8% -> 1/0.008 = 125
Berger’s disease
presents within days of URI
caused by deposition of IgA antibody in glomerulus
trichuris trichiura
whipworm
diarrhea, mucus or bloody, worse at night, abdominal pain
brugia malayi
filarial nematode transmitted by mosquitoes
inhabits lymphatics -> lymphadenitis and lymphedema
dipylidium caninum
dog tapeworm, transmitted to humans via flea ingestion
asymptomatic, but can have abdominal pain or diarrhea
enterobius vermicularis
pin worm, common nematode in children
intense pruritus of ani, particularly at night
loa loa
African eye worm
transmitted by chrysoprase fly
soft tissue swelling sand ocular migration
TB pleural effusion
lymphocytes >80%, greatly increased total protein
adenosine deaminase <40 r/o TB
glucose is low (30-50)
CHF pleural effusion
transudative bilateral
rheumatoid arthritis pleural effusion
extremely low glucose (< 30)
extremely low glucose also found in empyema and malignancy
lymphoma pleural effusion
chylothorax = white and milky pleural fluid with TG > 110
PE pleural effusion
bloody
bloody also seen in malignancy
dawn phenomenon
result of early morning growth hormone secretion
GH is an antagonist to insulin, so may cause hyperglycemia in the middle of the night and early morning
initial step in management if pt has increased morning glucose
measure blood glucose again at 3am prior to making any change to insulin regimen
inability to tolerate oral intake and obstipation in first few days after an abdominal operation
postoperative ileus
normal intestinal structure on CT
self-limited
positively skewed distribution
mean > median
mean, median > mode
bimodal distribution
two distinct modes
negatively skewed distribution
mean < median, mode
normal (gaussian) distribution
classic symmetric bell curve
mean = median = mode
management for isolated cleft lip in otherwise healthy infant
surgically manage at 3-6mo of age
SAAG > 1.1
portal HTN likely to be cause of ascites
may be portal vein thrombosis, cirrhosis, or CHF
diagnostic test to confirm thoracic outlet syndrome
arteriography
superficial thrombophlebitis
localized extremity pain and redness
cordlike area of induration, erythema
tx: NSAIDs, elevation, heat, and support stockings
hypersensitivity pheumonitis PFT
decreased diffusing capacity of the lungs for carbon monoxide
hypersensitivity pneumonitis cause
associated with bird or pigeon breeding
generalized weakness, easy fatiguability, depression, HTN, recurrent episodes of pseudo gout, nausea, vomiting, and abdominal pain
hypercalcemia
pt < 5y/o with fever, bull formation, and sheetlike desquamation of the skin
staph scalded skin syndrome
chi-square
best statistical test for analyzing studies where results are 2 proportions
tx of narrow QRS tachycardia in unstable pt
sedation and synchronized cardioversion
chronic urticaria
antihistamines- diphenhydramine or cetirizine
Creutzfeldt-Jakob disease
rapidly progressive dementia accompanied by at least 2 of the four findingS:
- myoclonus
- visual or cerebellar disturbance
- pyramidal/extrapyramidal dysfunction
- akinetic mutism (lack of motor activity)
tests in CJD
EEG: sharp wave complex
MRI: putamen and head of caudate
CSF: elevated protein, normal glucose, no cells
biopsy in CJD
gliosis (increased size and number of astrocytes)
neuronal loss
spongiform change (tissue replaced with vacuoles)
abnormal protein buildup (using prion protein immunoperoxidase)
myxoma
mc primary tumor of heart in adults
connective tissue in right or left atria
symptoms of myxoma
weight loss, fatigue, dyspnea, syncope
ball-valve obstruction of mitral valve -> ‘tumor plop’ with early diastolic thud f/b diastolic murmur
diagnostic test of choice for diverticulitis
CT scan
treatment of neuroleptic malignant syndrome
bromocriptine
tx cyanide poisoning
from sodium nitroprusside
hydroxocobalamin - binds cyanide to facilitate urinary excretion
altered mental status, autonomic hyperactivity, seizures, and tactile/visual hallucinations
delirium tremens - lorazepam tx
folliculitis
pruritic, erythematous pustules
staph aureus
Ewing sarcomas
primary malignant bone tumors affecting children and adolescents
Ewing sarcoma xray
destructive lesion with a periosteal reaction causing layers of reactive bone to form, giving a so-called ‘onion-skin’ appearance
bone pain, skeletal deformities, hearing loss, elevated alk phos, enlargement of skull, jaw, or clavicle
Paget disease of the bone
Paget disease of bone xray
thick bone cortices with bony deformities
prominent radimdense peripheral contours of vertebrae common
fat embolism
respiratory changes (dyspnea, tachypnea, cough, hypoxia) neurologic abnormalities (mental status change) petechial rash 1-3d after insult
serum glucose >600, bicarb >/= 15, serum pH >/= 7.30; no ketonuria, profound dehydration, alteration of consciousness
Hyperglycemic Hyperosmolar State (HHS)
effective serum osmolality >320
polyarteritis nodosa
necrotizing arteritis of medium-sized vessels
affects skin, cardiovascular, renal/mesenteric, and nervous systems
derm manifestations of polyarteritis nodosa
livedo reticular, subcutaneous nodules, digital gangrene, and ulcers
polyarteritis nodosa test
hepatitis B
negative p-ANCA
polyarteritis nodosa findings
dermatologic
hypertension caused by renal artery involvement
abdominal pain assoc with meals d/t mesenteric ischemia
dx polyarteritis nodosa
biopsy or mesenteric angiography
cariogenic shock
causes increased pulmonary capillary wedge pressure and JVD
cxr & lung: pulmonary congestion
low cardiac output, high systemic vascular resistance (SVR)
neurogenic shock
disruption of autonomic nervous system control over vasoconstriction
peripheral vasodilation -> warm, flushed skin
low cardiac output, pulmonary capillary wedge pressure, AND SVR
septic shock
hx recent infection
peripheral vasodilation -> warmed, flushed skin
decreased SVR -> increased cardiac output
low pulmonary capillary wedge pressure
hypovolemic shock
trauma, diarrhea, vomiting, GI bleeding, SBO, or burns
decreased preload -> decreased cardiac output -> increase SVR to compensate
low pulmonary capillary wedge pressure
H&P cardiogenic shock
MI, CHF, chest pain.
cold clammy skin, JVD, and pulmonary congestion
H&P hypovolemic shock
History of fluid loss
Cold clammy skin, pallor
H&P septic shock
Recent infection, fever, leukocytosis, warm flushed skin
H&P anaphylactic shock
inciting exposure
H&P neurogenic shock
severe CNS trauma or hemorrhage
