Incorrects 8 Flashcards
A woman (esp. black) with RA like Sx with signs of glomerulonephritis and possibly other systems involved likely has?
SLE. ANA (sensitive), Anti-dsDNA, and anti-Sm (specific) are present often. Proteinuria and high Cr may present instead of hematuria.
A woman with advanced RA (marked morning stiffness) presents with splenomegaly and neutropenia on exam. Dx?
Felty syndrome.
Both REM sleep latency and slow-wave sleep are decreased in?
Depression.
Xray showing presence of a posterior fat pad (lucency) sign at the elbow joint in a child usually indicates?
Supracondylar fracture of the humerus. These types of fx are common in kids 2-12 and complications include compartment syndrome (5P’s) or neurovascular injury.
Length of typical Absence seizure?
<20 seconds. Can present with automatisms.
Heinz bodies are associated with?
G6PD deficiency. Oxidized Hgb precipitates to cause these crystals within the cell.
Howell-Jolly bodies are associated with?
Splenectomy. Retained nuclear remnants occurs.
What is the first step in suspected IE?
3 blood cultures from different sites must be obtained BEFORE Abx are started. In acute illness, obtain blood over 1 hour. In stable, subacute illness must obtain blood over several hours and delay Abx until blood drawn.
What is PMS?
Bloating, fatigue, HA, and breast tenderness that occur a week prior to menses and resolve within a few days after menses start. Rx: stress reduction/exercise
What is Premenstrual dysphoric disorder?
A severe form of PMS where irritability, hopelessness, and depressed mood can lead to psychosocial impairment. A detailed menstraul diary is needed for both usually over 2-3 menstrual cycles. Rx includes SSRIs.
Meniere’s disease triad?
- Low frequency tinnitus
- Episodic vertigo
- Sensorineural hearing loss
Should air conduction or bone conduction be heard longer in the Rinne test?
Air conduction. Conductive hearing loss is assessed with the Rinne test. “Rinne under the pinne (pinna of ear)”. If heard longer on mastoid than the air, then they have conductive hearing loss in that ear (eg otosclerosis).
If I strike the tuning fork and place it on the forehead, but it localizes to one side, what does this mean?
Weber test: Localizing to one ear means either there is conductive hearing loss in that ear or sensorineural hearing loss in the other ear. A normal Rinne with a right lateralized Weber indicates sensorineural in the right. If mixed, bone conduction is higher in the affected ear (conductive) and Weber lateralizes away from the affected ear (sensorineural).
Meniere’s disease leads to what kind of hearing loss?
Sensorineural.
First test in suspected subarachnoid hemorrhage?
Noncontrast head CT (90% sensitive). BUT if normal CT, must do LP to rule out definitively.
Confirmatory test in suspected subarachnoid hemorrhage?
Lumbar puncture. Xanthrochromia confirms Dx (present 6 hours after onset). Cerebral angiography will ID bleeding source AND detection of vasospasm (RX nimodipine).
Is hypoxemia the cause of acrocyanosis?
No. Acrocyanosis is due to slower cirulation of blood. Only central cyanosis after birth is associated with hypoxemia.
MCC of foot ulcers in diabetes?
Peripheral neuropathy.
MCC of neuropathic ulcers?
Diabetes.
Where do neuropathic ulcers typically occur?
Weight bearing sites (eg below the head of the first metatarsal) on the sole of the foot.
A patient comes to the office with a foot ulcer. He has no associated pain fever, chills, or rash. He is a smoker of 30 years. He walks daily. His BMI is 32. Dx?
Neuropathic (diabetic) foot ulcer. The lack of pain associated with the ulcer is classic neuropathic foot ulcer due to diabetes and loss of sensation.
Arterial ulcer typically presents where?
Tips of the digits. Diminished pulses, skin pallor, loss of hair, and intermittent claudication are common.
Venous ulcers typically present where?
Medial aspect of the leg above the malleolus. Usually present with edema and stasis dermatitis.
What is the pathologic cause of MVP?
Myxomatous valve degeneration.
A patient with SLE taking prednisone has an atraumatic hip with normal Xray findings likely has?
Osteonecrosis (AVN) of the femoral head. Microocclusion is an SLE complication and is greatly enhanced with steroids.
If Xray is normal in AVN, what is the appropriate imaging modality?
MRI. Can see boundary between normal and ischemic bone as well as zone of hypervascularity.
When are palpated lymph nodes concerning?
If firm, hard, immobile, enlarged (>2cm), or B symptoms present. Palpable supraclavicular lymph nodes are pathologic until proven otherwise.
Pt presents with elevated blood glucose levels and a skin rash. The pt reports the rash started on the left leg but is now spread to the other leg. Dx?
Glucagonoma. High BGL and a necrotic migratory erythema is classic.
Sulfonylurea overdose presentation?
Hypoglycemia. Sulfonylureas increase insulin release. Testing typically involves urine/serum sulfonylurea levels as it cannot be differentiated from insulinoma.
Time of onset of chemical, gonococcal, and chlamydial conjunctivitis in a newborn?
<24 hours in chemical. 2-5 days in gonococcal. 5-14 days in chlamydial.
A patient presenting with ptosis and fatigable proximal muscle weakness that worsens with prolonged use likely has?
Myasthenia gravis. Extraocular (diplopia, ptosis) and bulbar (dysarthria, dysphagia) weakness are common. Symetric proximal weakness in neck and UE>LE.
When do we stop pap testing?
Age 65 or hysterectomy:
AND no Hx of CIN 2+
AND 3 consecutive negative pap tests
OR 2 consecutive negative co-tests
If a 60year old patient is found to have CIN of 2 or higher, do we stop testing at 65?
No. Screening continues for 20 years after detection regardless of age (goes beyond 65 if indicated).
Proper testing for paroxysmal nocturnal hemoglobinuria?
CD55 and CD59 protein testing. Complement activation in lower oxygen tension causes lysis and early morning hematuria.
15yo girl with Tanner IV breast development and pubic hair. She has not had a period. She has no uterus on US. Dx?
Müllerian agenesis. Often short/blind vaginal pouch and no cervix. External female genitalia are normal. Müllerian duct normally develops into upper vagina, cervix, and uterus.
15yo female with amenorrhea, but normal breast development presents to the office. PE reveals normal genitalia, but no pubic hair. Dx?
Androgen insensitivity syndrome. Normal female phenotypically, but no pubic hair due to defective androgen receptor. Genetically 46XY, however.
11yo girl presents with hair growth and deepening voice. She has normal female genitalia on exam. US reveals two undescended testicles. Dx?
5-alpha-reductase deficiency. Impaired testosterone to DHT conversion leads to improper development of female external genitalia in 46XY genotype. DHT is responsible for fetal conversion to male phenotype. At puberty, these people undergo virilization.
Shared congenital infection symptoms in: CMV Toxo Syphilis Rubella
IUGR
Hepatosplenomegaly
Jaundice
Blueberry muffin rash
Congenital CMV findings?
Periventricular calcifications
Congenital Toxo findings?
Diffuse intracerebral calcifications
Severe chorioretinitis
Congenital Syphilis findings?
Rhinorrhea
Abnormal long bones on Xray
Desquamating/bullous rash
***PCN Rx prevents later sequellae (frontal bossing, saddle nose, Hutchison teeth)
Congenital Rubella findings?
Cataracts Heart defects (PDA)
Surveillance colonoscopy begins how soon after UC diagnosis?
8-10 years of initial diagnosis.
What is elevated in 21-hydroxylase deficiency?
17-hydroxyprogesterone. This is used as a screen for 21-hydroxylase deficiency in congenital adrenal hyperplasia.
What causes aminotransferase levels >1000?
Acetaminophen toxicity and viral hepatitis.
What organism causes pneumonia more in cystic fibrosis UNDER 20 years of age?
S. aureus. Infxn with S. aureus decreases with age.
What organism causes pneumonia more in cystic fibrosis OVER 20 years of age?
Pseudomonas aeruginosa.
Abrupt discontinuation of paroxetine or venlafaxine can result in?
Antidepressant discontinuation syndrome. Both have short half lives and result in dysphoria, fatigue, dizziness, GI distress, and flu-like Sx).
In HIV, which form of esophagitis is treated empirically?
Candida esophagitis. White plaques in the esophagus are characteristic. Oral thrush is present with painful swallowing, substernal burning. This suggests empiric Rx for candida. 3-5 days of oral fluconazole is Rx.
Next step if Pts with thrush fail to respond to empiric Rx?
Esophagoscopy. CMV (deep, linear lesions, distal esophagus) and HSV (ovoid lesions, oral lesions) esophagitis are possible also. Valacyclovir or acyclovir for HSV.
Anti-thyroid peroxidase antibody and antithyroidglobulin are present in?
Hashimoto’s.
Endocrine disorders at increased risk of miscarriage?
Thyroid disease
PCO
DM
Hyperprolactinemia
A Pt with symmetrically enlarged nontender thyroid with subclinical hypothyroidism (normal thyroxine and mild TSH elevation). Dx?
Chronic lymphocytic thyroiditis (aka Hashimoto Thyroiditis). Antithyroid peroxidase and antithyroglobulin antibodies present in 90%. High antiTPO assocaiuted with risk of overt hypothyroid and risk of miscarriage.
Pathophys of osteomalacia?
Defective mineralization of the organic bone matrix. Most commonly this is due to vitamin D deficiency (malabsorption, celiac sprue, bypass surgery, liver/kidney disease). RTA type 2 or inadequate calcium intake can also cause it.
Osteomalacia has low calcium levels and phosphorous. Why?
Osteomalacia, due to low Vitamin D most commonly, results in a secondary hyperPTH state. Calcium cannot be absorbed in the gut and PO4 is eliminated in the kidney. Alk phos is high due to high PTH stimulation of bone osteoclasts to increase Ca++ in serum and breakdown bone.
Diagnostics in myasthenia gravis?
Edrophonium (Tensilon) test OR ice pack test. Lab testing for ACh receptor antibodies. CT of chest for thymoma.
Rx for Myasthenia gravis (not crisis)?
ACh inhibitors (-stigmine) is first line. Immunotherapy (steroids, azathioprine) can help in addition to ACh inhibitors if still symptomatic. Thymectomy if thymoma found (result in remission).
Myasthenic crisis Rx?
IVIG or plasmapheresis are combined with steroids to treat crisis (respiratory failure due to MG).
What B vitamin deficiencies cause numbness, tingling, loss of proprioception and vibration sense?
B6 and B12. B6 (pyridoxine) is often caused by isoniazid. B12 also presents with ataxia, while B6 presents with a more “stocking-glove” neuropathy. Temperature, touch, and pain may be affected over time in B6 also. ***Remember B12 loss causes dorsal/lateral spinal column degeneration, B6 has a different mechanism.
A young female taking OCPs presents with fatigue due to difficulty getting to sleep. Her thyroid is not enlarged/no nodules. Her TSH is normal, but total T4 is high. Likely cause of lab findings?
Increased thyroid hormone-binding protein level. TBG prodxn increases in people taking estrogens, in liver disease, and with estrogen stimulating meds (tamoxifen). TBGs bind T4. The body responds by increasing T4 levels to compensate. Though the FREE T4 levels remain normal and she is euthyroid, her total T4 is up.
Membranoproliferative glomerulonephritis associated conditions?
Hep B and C; lipodystrophy.
Think: MPG HepB and C and lipodystrophy
Membranous nephropathy associated conditions?
Just Hep B (not C). SLE; NSAIDs; adenocarcinoma
Focal segmental glomerulosclerosis associations?
African american or hispanic; obesity; HIV/heroin use.
Think: F for aFrican and FSG = HIV.
Triamterene and amiloride belong to what class?
K+ sparing diuretics.
A pure sensory stroke to the thalamus usually occurs through what artery?
PCA. Affects the posterolateral thalamus nuclei causing contralateral sensory loss. Later this can cause a pain syndrome with burning in the affected side.
Damage to the internal capsule can lead to?
Contralateral pure motor or combined sensorimotor deficits.
MCA or ACA stroke can lead to what Sx?
Contralateral sensory loss and hemiapresis as well as cortical signs (aphasia, agnosia).
Atropine and pralidoxime are proper antidotes for?
Anticholinesterase toxicity as in organophosphate poisoning (bradycardia, miosis, shitty their pants).
What is the definition of tachysystole?
Abnormally frequent contractions (>5/10 minutes over 30 minute period). Caused as SE of oxytocin.
In suspected salicylate toxicity, what is the acid base disturbance and pH?
Respiratory alkalosis (resp center stim. = blow off CO2) Metabolic acidosis pH is usually normal /near normal (7.35-45)
Proper Rx for salicylate OD?
Alkalinization or dialysis.
A normal pH in an acid-base disturbance typically signifies what type of disturbance?
MIXED respiratory and metabolic disorder.
What lab abnormalities are found in hyperemesis gravidarum?
Ketonuria on UA (hypoglycemia induced), hypochloremic metabolic alkalosis, hypokalemia (K+/H+ exchange), hemoconcentration
Typical Sx of hyperemesis gravidarum?
Persistent vomiting
Loss of weight, dehydration, orthostatics
Two main causes of hyperemesis gravidarum?
Hydatidiform mole
Multifetal gestation
Best management techniques for post op atelectasis?
Exercises, coughing, mobilization, spirometry.
What condition of the breast can mimic breast cancer with its clinical/radiographic presentation?
Fat necrosis. Associated with trauma or breast surgery, they can be fixed with skin or nipple retraction and appear calcified on mammography. US may demonstrate a hyperechoic mass, which is usually benign. Biopsy may show fat globules and foamy histiocytes.
A patient taking methotrexate is at risk for what serious complications?
Pancytopenia. It is suggested by ACR to do blood counts every 3 months. Liver toxicity, stomatitis, and interstitial lung disease are other SE.
SE of azathioprine?
Pancreatitis, liver toxicity, and bone marrow suppression.
Ventricular arrhythmias commonly occur within the first hour of?
Acute MI. 50% of arrhythmias occur within the 1st hour of symptom onset. Reentry occurs often leading to ventricular arrhythmias.
AV conduction block is more common in what type of MI?
Inferior wall MI.
What arrhythmias are uncommon in the post MI period?
SVTs and A. fib or flutter
First prenatal visit lab basic idea?
CBC (HH, MCV) R and Z (rubella/VZV immunity) STD (pap if indicated) RhD Test your pee (UA and protein)
Which flu vaccine is ok during pregnancy and breastfeeding?
INactive vaccine.
Angiodysplasia presents most commonly with what color stool?
Maroon colored. Occurs MC in right sided colon.
Diverticulitis presents with what color blood?
Frank, bright red.
A woman with amenorrhea with a negative ß-hCG needs what labs?
Prolactin, TSH, FSH.
High FSH indicates POF. High TSH indicates hypothyroid. High prolactin indicates brain MRI for prolactinoma.
Same woman as above has Hx of prior uterine D&C or an infection. Next step?
Hysteroscopy. Asherman’s may be occurring.
3 electrolyte derangements that prolong the QT?
HYPO-
- calcemia
- kalemia
- magnesemia
Congenital long QT interval with sensorineural deafness?
Jervell and Lange-Nielsen syndrome.
Management of congenital long QT?
ß-blockers and pacemaker.
Trichophagia can lead to?
Trichobezoars.
Trichotillomania differs from alopecia areata in what way?
T. presents with hairs present in areas of low hair follicle density. Alopecia areata’s spots are completely bald.
What electron microscopic finding is classic in minimal change disease?
Effacement of foot processes. Light microscopy shows normal architecture.
Electron microscopic findings in membranous glomerulonephritis?
Thick BM and sub epithelial spikes.
Mesangial hypercellularity is common in what nephritic disease?
Membranoproliferative glomerulonephritis.
MC lung cancer in nonsmokers AND smokers?
Adenocarcinoma.
Predominant cancer in nonsmokers?
Adenocarcinoma.
Parents are expected to act in the best interest of their child, therefore, they cannot refuse what?
Life-saving treatment (eg intubation in resp failure, meningitis Rx)
People with RA are at risk of what bone issues?
Osteoporosis. This is due to the proinflammatory stat, steroid Rx, and low physical activity. These people require bisphosphonates earlier.
What diseases are associated with brown tumors of the bone?
Osteitis fibrosa cystica (Von Recklinghausen disease of the bone) is associated with secondary/tertiary hyperparathyroidism (CKD) and parathyroid carcinoma.
Careful crossmatching of blood prevents what?
Acute hemolytic reactions. Fever, chills, flank pain, hemoglobinuria occurring within an hour after transfusion. Coombs is positive.
Leukoreduction in blood products prevents?
Febrile nonhemolytic transfusion reaction. Occurs within 1-6 hours with fever, chills, malaise without hemolysis. Prevents CMV and HLA alloimmunization also.
Washing of blood products before transfusion prevents?
Anaphylaxis in IgA deficient Pts or Pts with prior allergic transfusion reaction.
How does hyperthyroid state affect bones?
It increases osteoclast activity, which increases resorption, increasing fracture risk from resorption of bone.
Choriocarcinoma is a germ cell tumor with what elevated serum marker?
ß-hCG. C for chorio has high hCg.
Teratomas can have what elevated serum markers?
AFP or ß-hCG. Teratomas are a hodge-podge and can grow other germ cell tumor components, hence, the high levels of these two markers.
Seminomas serum tumor markers include?
Usually they don’t present with any. ß-hCG can be elevated (if they have syncytiotrophoblastic giant cells.
Yolk sac tumor markers?
AFP. This is a germ cell tumor.
In a child with mumps, what is the most common complication?
Aseptic meningitis. Other comlications include orchitis, parotitis, and risk of infertility.
MC organism in IE in an IV drug user?
Staph. aureus.
MC organism in IE in a Pt with nosocomial UTI?
Enterococci. (VRE)
MC organism in IE with colon carcinoma or IBD?
S. gallolyticus (S. bovis).
How should a pt with alcoholic cardiomyopathy be managed?
First, quit drinking. This can reverse the dilated heart. Salt and water restriction, diuretics, ACEI/ARBs, Beta blockers, mineralocorticoid antagonists, and digoxin (if indicated).
Next step in testing in suspected acromegaly?
IGF-1 level. Normal rules it out. If high, oral glucose challenge is needed to check for GH suppression. If GH not suppressed (or increased), do brain MRI for pituitary mass. Remember GH causes IGF-1 secretion in the liver.
Sx of hemorrhage in basal ganglia?
Contralateral hemiparesis/hemisensory loss
Homonymous hemianopsia
Gaze palsy
Sx of hemorrhage in cerebellum?
NO hemiparesis Facial weakness Ataxia/nystagmus Occipital HA Neck stiffness (blood in 4th vent)
Sx of hemorrhage in Thalamus?
Contralateral hemiparesis/hemisensory loss
Nonreactive miotic pupils
Upgaze palsy
Eyes deviate TOWARD hemiparesis
Sx of hemorrhage in cerebral lobe?
Contralateral hemiparesis (frontal lobe) Contralateral hemisensory loss (parietal lobe) Homonymous hemianopsia (occipital lobe) Eyes deviate AWAY from hemiparesis High incidence of seizures
Sx of hemorrhage in Pons?
Deep coma/total paralysis in minutes
Pinpoin reactive pupils
Postpartum blues begin when?
2-3 days after giving birth. They usually resolve in 2 weeks. It is appropriate to observe and reassure.
Postpartum depression occurs when?
Within 4-6 weeks (up to a year) of giving birth. It involves significant dysfxn for ≥2 weeks including SIGECAPS. Need SSRI (sertraline) and psychotherapy.
Appropriate testing for Celiac’s disease?
D-xylose test. Decreased urinary excretion of D-xylose occurs. There is no increased D-xylose excretion in urine in pancreatic insufficiency, though Sx in Celiac’s and pancreatic insufficiency are similar.
Pt presents with signs of heart failure months after MI. EKG shows persistent ST-segment elevation and deep Q waves corresponding to the location of his prior MI. Dx?
Left ventricular aneurysm. Scar deposition in the transmural MI location results in heart failure/angina and risk of ventricular arrhythmia or emboli. Echo will show thin/dyskinetic myocardium.
Antibiotics for asymptomatic bacteriuria in pregnancy?
Cephalexin Amox-clav Nitrofurantoin Fosfomycin ***TMP-SMX is only OK in the 2nd trimester.
What is the potential outcome of Mobitz type II block?
Risk of complete heart block. May indicate pacemaker.
Anemia in lymphoproliferative disorders (eg leukemia or lymphoma) are due to what?
Replacement of RBC progenitors with cancer cells in the marrow. Thus, bone marrow infiltration would be that cause.
Blind spot enlargement is associated with?
Papilledema.
What is an afferent pupillary defect?
When the affected eye does not respond appropriately to light by constricting. This is called a Marcus Gunn pupil. The swing flashlight test would show slight dilation or lack of appropriate constriction in the affected eye.
In suspected tetanus in a newborn, what is Dx?
ABx and tetanus immune globulin.
Which organisms are responsible for ingested enterotoxins producing symptoms just hours after ingestion?
S. aureus.
Bacillus cereus.
***1-6 hours after eating with vomiting predominating.
Which organisms create enterotoxins in the gut?
C. perfringens
ETEC/STEC
Vibrio cholerae
***>1day after ingestion (delayed sx). Watery/bloody diarrhea predominate.
Which organisms do NOT create toxins, but rather invade the epithelium of the gut?
Campylobacter jejuni
Nontyphoidal salmonella
Listeria monocytogenes
***Variable onset. Water/bloody diarrhea WITH fever. Listeria causes systemic illness.
What is the primary intervention shown to reduce progression of diabetic nephropathy?
Intensive BP control. 140/90 is the target BP in all DM cases, but if nephropathy exists, 130/80 is the goal.
Treatment for active TB?
8 weeks: RIPE (isoniazid, rifampin, ethambutol, pyrazinamide)
Plus 4 months: Isoniazid and rifampin
***Total 6 months Rx
Typical inactive TB Rx?
9 months: isoniazid with pyridoxine
***6 months of INH and 4 months of rifampin can also be used.
MCC of papillary necrosis?
Chronic NSAID use. DM, infxn, obstrxn, and hemoglobinopathies are other causes.
What fetal growth restriction begins in the 1st trimester?
Symmetric. There is a global growth lag, unlike asymmetric where the head is still of normal size and the body lags. Symmetric is due to chromosomal issues or congenital infxn.
What fetal growth restriction begins in the 2nd or 3rd trimester?
Asymmetric. There is a “Head-sparing” growth lag. Uteroplacental insufficiency and maternal malnutrition are causes.
Management of fetal growth restriction?
Weekly biophysical profile, serial umbilical artery Doppler, and serial growth US.
Thelarche begins when?
8-12yo. Due to rising estrogen levels in girls.
Pubarche begins when?
Just after thelarche typically, but can begin before.
Menarche begins when?
Averages around 12.5 years around Tanner stage 4. Usually around 2 years after breast bud development. Lack of menarche is normal until 15. Usually accompanied by 6 month growth spurt just prior to first menses.
Primary amenorrhea definition?
Lack of menses without secondary sex characteristics by age 13 OR with secondary sex characteristics at 15 or older.
Pyoderma gangrenosum is assocaited with?
Systemic inflammatory diseases (eg IBD). It is caused by neutrophils creating an ulceration in the skin. Can be initiated by local trauma (pathergy).
Ecthyma gangrenosum is associated with?
Pseudomonal infxn usually in the setting of profound neutropenia.
Classic features of PKU?
Intellectual disability and SZ, fair skin, and musty odor are also classic. Dx later in life involves quantitative amino acid analysis to detect elevated phenylalanine levels. Low-phenylalanine diet is Rx.
Galactosemia deficient enzyme?
Galactose-1-phosphate uridyl transferase. Results in galactosemia within days of birth causing jaundice, hepatomegaly, and failure to thrive with breast milk or regular formula consumption.
Deficient enzyme in Fructose intolerance?
Aldolase B. Causes F1P accumulation resulting in vomiting, poor feeding, and lethargy. SZ and encaphalopathy can occur if fructose not removed.
Rx for acute glaucoma?
Mannitol, acetazolamide (first line), timolol, pilocarpine. Atropine will greatly worsen the condition as the unchecked sympathetic response will occur.
Hypokinetic gate associated disease?
Parkinsons. Short, accelerating steps where feet shuffle and scrape the floor. Broad based gait, though not specific only to parkinsons (multi system atrophy, spinocerebellar atrophy, multiple infarct).
Basic pathophysiologic idea in Parkinsons?
Decreased dopaminergic activity leads to unchecked cholinergic activity. Rx includes dopaminergic or anticholinergic drugs.
Cerebellar ataxia associated disease?
Cerebellar lesion. They fall toward the lesion. Nystagmus, hypotonia, dysarthria and loss of coordination, as well as dysdiadochokinesia occur also.
Waddling gait assoc. disease?
Muscular dystrophy. Waddling gait due to weak gluteal muscles.
Spastic gait assoc. disease?
UMN lesions. Spinal cord injury or cerebral palsy for example. Slow, stiff, and effortful movements are typical.
Gait disequilibrium assoc. lesion?
Frontal lobe and other sensory systems.
Sensory ataxia lesion?
Lesions involve peripheral nerves, dorsal roots, or posterior columns. Loss of proprioception causes wide-based, high-stepping gait. Romberg’s sign may be positive (swaying with eyes closed).
Vestibular ataxia description?
En-loc gait. Minimal movements of the head during walking. Staggering gait with vertigo/nystagmus.
Dystonic gait descrition?
INvoluntary, sustained, twisting or limbs/trunk.
A patient presents with history of fatigue, low BPs, and hypoglycemia. His sodium is low, potassium and calcium are high. Dx?
Think adrenal insufficiency. This is common in granulomatous diseases (TB, histo, coccidioidomycosis, cryptococcosis, sarcoid). Retention of potassium and loss of hydrogen due to lack of aldosterone activity is typical. A normal anion gap metabolic acidosis ensues.
Imipramine MOA?
Tricyclic. Used in refractory cases of childhood enuresis.
Oxybutynin MOA?
ANTIcholinergic agent. Inhibits bladder urge to contract and improves bladder capacity.
Management of ureteral stone <1cm?
Hydration, analgesics, alpha blockers
Conditions treated with ECT?
Unipolar OR bipolar depression
Catatonia
Bipolar mania
Common SE of ECT?
Anterograde (~2weeks) AND retrograde amnesia during and after Rx for weeks to months leading up to ECT.
Why are there no fractures when ECT induces a seizure?
Skeletal muscle relaxers (IV Succinylcholine) prevent it.
30s female with GA 35wks presents to the office with weak, irregular contractions about 3-5 an hour. She is in only mild discomfort. Fetal HR normal. Next step?
Reassurance and send home. This is signs of “false labor”. She would likely have no cervical changes either. These are Braxton Hicks contractions.
Indomethacin given as tocolytic when?
<32 weeks gestation. This runs risk of closing the PDA and thus is contra’d beyond 32 weeks.
Tocolysis is contraindicated beyond?
34 weeks. Risks of tocolysis exceed those of preterm delivery at this point.
When is PCN given in laboring Pts with known GBS+ pregnancy?
During labor. This is never the answer if NOT in labor.
In a patient with difficulty initiating swallowing with cough, choking, or nasal regurgitation, what is Dx and next step?
Oropharyngeal dysphagia (difficulty initiating swallow due to problems moving food into pharynx from mouth; 2nd to stroke, neuro issues). Next step is videofluoroscopic modified barium swallow (this is a swallow test to watch swallowing mechanism and aspiration severity).
A patient with dysphagia, but WITHOUT difficulty initiating swallowing or coughing/choking/nasal regurgitation likely has?
Esophageal dysphagia. If progressive, likely mechanical obstrxn (Hx of radiation, caustic injury, stricture, surgery - if no Hx do endoscopy. If yes Hx, do barium swallow). If dysphagia present with solids and liquids at onset (food sticks in esophagus from onset - no progression), likely motility issue. Do barium swallow and manometry.
Where is pain felt in appendicitis in third trimester pregnant female?
Can be found in upper right quadrant.
Why is PID uncommon beyond the first trimester?
Thick mucus plug prevents ascending infxn.
Rx of chorioamnionitis (intra-amniotic infxn)?
Broad-spectrum ABx and immediate delivery (eg augment labor with oxytocin). CSxn is only indicated if fetal distress is occurring (decelerations and/or poor variability). Fetal tachycardia is not indication alone to do Csxn.
What is precocious puberty?
Onset of secondary sex characteristics in girls<8 and boys<9.
Initial evaluation of precocious puberty?
Bone age radiograph. Kids with true precocious puberty have advanced bone age from estrogen/testosterone elevations which accelerate growth velocity of bones.
Labs in central vs peripheral precocious puberty?
Central: High LH/FSH - initiated by early activation of HPA axis
Peripheral: Low LH/FSH - initiated by gonads or adrenals - possibly a tumor (congenital adrenal hyperplasia)
What level is elevated in adrenal caused (CAH) precocious puberty?
DHEAS.
Pregnant female presents with intense itching of her hands/feet. Labs reveal high bile acids, elevated ATs, and her bilirubin is 3.0. Likely Dx?
Intrahepatic cholestasis of pregnancy. Classically present with pruritus of hands/feet esp at night. Total and direct bilirubin are increased. ATs may be really high (>1000) and must RO viral hepatitis. Rx: ursodeoxycholic acid
Pregnant female presents with malaise and RUQ pain. She has nausea and vomiting. She is hypoglycemi and her ATs are mildly elevated. Her bilirubin is high also. Dx?
Acute fatty liver of pregnancy. Begin with Abd. pain, NV, and ultimately present with liver failure. Ascites, jaundice, low glucose, and encephalopathy can occur. DIC and AKI are the worst outcomes. Labs show liver failure.
Pregnant female presents with hemolysis, and moderate elevations of ATs. Her platelets are 40,000. She notes RUQ pain and nausea, vomiting. Her Hx is significant for preeclampsia. Dx?
HELLP. Preeclampsia Dx followed by low platelets, hemolysis, and elevated ATs.
When do cluster headaches typically strike?
During sleep.
Cluster Headache prophylaxis?
Verapamil or lithium.
Pt presents with pale, white skin and recurrent cutaneous infections from SA and GAS. Dx?
Chediak-Higashi syndrome.
Pt presents with eczema, thrombocytopenia, and recurrent infxns. Dx?
Wiskott-Aldrich syndrome. X-linked recessive.
Child has recurrent skin infxns without purulence and he has had multiple teeth removed. Labs reveal markedly elevated neutrophil counts. Dx?
Leukocyte adhesion deficiency. Hx often includes delayed umbilical cord separation, recurrent nonpurulent skin infxn, and severe periodontitis. Neutrophil count is high due to poor migration out of circulation.
Breastfeeding reduces the risk of what cancers?
Ovarian AND breast. No change in endometrial cancer.
What features of primary dysmenorrhea differentiate it from secondary causes?
Normal uterine and adnexal exam. Endometriosis, adenomyosis, pelvic infxn, and uterine leiomyomata all have changes to uterine tenderness and/or contour. Other symptoms present also. Secondary causes usually in women in their 20-30s who previously had normal menses.
Primary dysmenorrhea pathology?
PGs released by sloughing endometrium. NSAIDs are first line.
Clomipramine MOA?
Tricyclic. Inhibits norepi and serotonin reuptake.
What is psychodynamic psychotherapy?
Therapy involving tracing problems back to origins in childhood and unconscious conflict.
How often should urinary catheterization be done to prevent infxn in a pt with neurogenic bladder?
q 4-6 hrs.
36yo man presents with periorbital swelling (chemosis), myositis, and lethargy. He does have small subungal hemorrhages. He is otherwise healthy aside from a brief stint using IV drugs in his 20s. He recently returned from Mexico. Labs reveal eosinophilia >20%. Dx?
Trichinellosis. Ingestion of undercooked pork usually. Endemic to Mexico, China, etc. Larvae released in stomach and move to muscles to encyst causing myositis, fever, subungual splinter hemorrhages, periorbital edema, and eosinophilia.
Method to evaluate bilious emesis in neonates?
Abd Xray first. If free air/hematemesiss/unstable, do surgery. If dilated loops of bowel, do contrast enema (Dx meconium ilius if microcolon; Hirschsprung if rectosigmoid transition zone -big sigmoid, small rectum). If Xray reveals NG tube in unusual location in abdomen, do upper GI series (Dx malrotation if ligament of treitz on right side of abdomen). Xray revealing double bubble means duodenal atresia.
RFs for congenital muscular torticollis?
Conditions related to crowding in the uterus: multiple gestation, breech positioning, oligo.
Rx of congenital muscular torticollis?
Conservative. More tummy time, stretching, PT.
What is a cystic hygroma?
Congenital malformation of lymphatics usually on the posterior triangle of the neck of a newborn. Assoc. with aneuploidy. Fluctuate mass that transilluminates.
A female presents with headache, malaise, fever >102° and BP of 80/58. She has a macular rash on her body including palms/soles. She has diarrhea and vomiting. She is on the last day of her period. Dx?
Staphylococcal toxic shock syndrome. Prolonged or continuous tampon use is an RF as is nasal packing and wound packing. Toxic shock syndrome toxin-1, an exotoxin acts as a superantigen, leading to super immune rxn.
MVP is due to?
Myxomatous degeneration of the mitral valve leaflets and chordae.
