Key facts Flashcards
Hip Clunk, assymetric leg crease
Hip Clunk, assymetric leg crease
DDH - abnormal acetabular development resulting in a shallow hip socket and inadequate support of the femoral head.
DDH (congenital hip dysplasia)
- dx
- tx
dx w/ ortolani and barlow
tx: pavlik harness
Slipped capital femoral epiphysis
- dx
- tx
Xray: widening of joint space (“ice cream slipping off a cone”)
- tx: internal fixation with pinning
Leg Calve perthese disease tx
Rest and NSAIDS - then surgery
Juvenile idiopathic arthritis
autoinflammatory disease characterized by fever, joint pain, and rash.
St Johns Wort use
antidepressant, anti-inflammatory, and wound-healing
- induces various P450 isozymes
- can lead to treatment failures with many medications, including hormonal contraceptives, anti-retrovirals, immunosuppressive agents, narcotics, anticoagulants, and antifungals
long-term management of patients with chronic hypoparathyroidism:
Vitamin D is generally preferred over 1,25-dihydroxy vitamin D for chronic management in most patients because it is cheaper and effective
- in patients with borderline low serum calcium and high urinary calcium, as seen in the patient described in the vignette, the addition of a thiazide diuretic will not only decrease the urinary calcium, but also increase serum calcium levels.
*of note: primary hyperparathyroidism are often diagnosed incidentally - have regular f/u
Complications in patients admitted for variceal bleeding that lead to increased mortality are:
- Treatment?
#1 infections, #2 hepatic encephalopathy #3 renal failure.
The most common complication is the development of an infection: TREAT WITH FQ
- urinary tract infection
- spontaneous bacterial peritonitis
- respiratory infection
- aspiration pneumonia or primary bacteremia.
Preterm labor is defined as
regular uterine contractions resulting in cervical change at <37 weeks gestation.
- Intramuscular corticosteroids (eg, betamethasone) are indicated at <37 weeks gestation to decrease the risk of - neonatal respiratory distress - necrotizing enterocolitis - intraventricular hemorrhage associated with prematurity
Preterm labor tx for gestational age
- 34-36 weeks
- 32-34 weeks
- <32 weeks
- 34-36 weeks: +/- betamethasone
PCN if GBS unknown - 32-34 weeks: bethamethasone
PCN if GBS unknown
tocolytics - <32 weeks: bethamethasone,
PCN if GBS unknown
tocolytics
Mg Sulfate
VEAL CHOP
Cord Compression
Head Compression
Okay!
Placental utero insufficiency
HIV management during pregnancy
Intrapartum
Avoid artificial ROM, fetal scalp electrode, operative vaginal delivery
- Viral load ≤1,000 copies/mL: ART + vaginal delivery (low likelihood of transmission)
- Viral load >1,000 copies/mL: ART + zidovudine + cesarean delivery (d/t higher risk for perinatal transmission during vaginal delivery)
Postpartum
Mother: continue ART
Infant (maternal viral load ≤1,000 copies/mL): zidovudine
Infant (maternal viral load >1,000 copies/mL): multidrug ART
Breastfeeding contraindications
Maternal
Active untreated tuberculosis HIV infection* Herpetic breast lesions Active varicella infection Chemotherapy or radiation therapy Active substance abuse
Salicylate toxicity
Salicylate crosses the blood-brain barrier and directly stimulates the medullary respiratory center (increasing respiratory rate and causing respiratory alkalosis) and the chemoreceptor trigger zone (causing nausea and vomiting).
Cochlear neurotoxicity may result in tinnitus (early symptom).
Cerebral tissue injury and neuroglycopenia lead to cerebral edema and mental status changes.
Inhibition of cellular metabolism causes lactic acidosis and hyperthermia. In severe cases, pulmonary edema, arrhythmia, and death may result.
mixed acid-base disorder commonly noted in ____ toxicity:
salicylic acid toxicity:
- Primary respiratory alkalosis due to activation of medullary respiratory center: High pH of 7.5 with low PaCO2
- Anion gap (AG) metabolic acidosis due to inhibition of cellular metabolism: AG = (Na − [Cl + HCO3]) =
(normal: 8-14)
Salicitate toxicity tx
alkalinization of blood and urine with sodium bicarbonate drip, supplemental glucose, and, if presentation is early (within 2 hours), activated charcoal. Dialysis may be indicated.
Chikungunya fever
- how many days of fever before other sx?
- Which joints affected?
- What other sx?
high fever (up to 39 C [102 F]) for 3-5 days, followed by severe polyarthralgias.
- Arthralgias are typically bilateral and symmetric and involve distal joints more than proximal joints.
- The hands, wrists, and ankles are most commonly affected, and the pain may be severe enough to be disabling.
- Skin manifestations such as a macular or maculopapular rash
Amniotic fluid index (AFI)
- whats nl?
- what are abnl AFI typically d/t?
normal levels (5-23 cm) suggest normal function of the placenta and fetal kidneys and lungs.
Abnormal AFI levels are typically due to impairments in either amniotic fluid production (eg, oligohydramnios - AFI <5) or removal (eg, polyhydramnios AFI >24).
Preeclampsia is typically associated with fetal growth restriction and (polyhydramios/oligohydramnios) due to chronic placental insufficiency.
oligohydramnios due to chronic placental insufficiency.
Placental insufficiency causes shunting of fetal blood to the fetal brain and away from the fetal kidneys, decreasing fetal urinary output and causing oligohydramnios.
AAA should be repaired when?
> 5 cm
or growing >0.5cm in < 1 yr
________ are first-line pharmacotherapy for dementia-related cognitive impairment.
Acetylcholinesterase inhibitors (eg, donepezil, rivastigmine, galantamine)
Acute multiple sclerosis exacerbation is treated with ____
corticosteroids PO or IV.
Patients with optic neuritis should receive intravenous corticosteroids as oral agents may be associated with an increased risk of recurrence.
Plasmapheresis can be used in refractory cases.
*exacerbations in pregnant patients is short-term intravenous glucocorticoids as they are generally well tolerated and are not associated with teratogenicity
Metastatic lesions to the brain are the most common cause of brain tumors (>50%)
In the order of frequency, are:
lung,
breast,
melanoma,
and colon cancer.
Perceived benefits of newer antipsychotics in treating negative symptoms are believed to result from ______ rather than true efficacy in treating core negative symptoms
fewer extrapyramidal side effects (ie, decreased incidence of drug-induced parkinsonism)
Psychosocial intervention, specifically social skills training, is an effective augmentation strategy to target negative symptoms.
positive symptoms of schizophrenia
negative symptoms
Which ones do first gen antipsychotics usually tx?
delusions, hallucinations, disorganized speech and behavior
alogia, flat affect, amotivation, social withdrawal
Antipsychotic medication is effective in treating positive symptoms, as in this patient, but does not significantly improve negative symptoms
_________ involves a pervasive, lifelong pattern of suspiciousness and mistrust of others.
- absence of persistent psychotic symptoms and the nonspecific nature of the distrust (generalizes to every interpersonal interaction).
Paranoid personality disorder
- are generally paranoid and distrustful but do not have fixed delusions.
Under-anticoagulation can lead to worsening of thrombotic disease, and such patients should be started on _______ until a therapeutic INR (<2) is achieved with warfarin.
intravenous heparin (or subcutaneous low molecular weight heparin)
Scaphoid fractures are most commonly complicated by ________ and _________
nonunion and avascular necrosis in up to 10% of cases.
Scaphoid fractures can compromise the blood supply
As a result, proximal fractures of the scaphoid require longer immobilization (up to 12 weeks) for adequate healing.
Other factors that cause nonunion include delay of care, an unstable fracture fragment, and delay in surgical treatment when indicated.
_____ + _____ is a first-line treatment for moderate to severe alcohol use disorder. It decreases cravings and heavy drinking and can be initiated in opioid-free patients who are still drinking.
Naltrexone (a mu opioid receptor antagonist) + acamprosate (glutamate modulator)
Barrett esophagus is characterized by metaplastic columnar epithelium replacing normal stratified squamous epithelium; it is associated with the development of _______
What do you do if ENDOSCOPY shows:
- No dysplasia
- Low grade dysplasia
- High grade dysplasia
esophageal adenocarcinoma
ENDOSCOPY shows:
- No dysplasia: PPI and surveillance endoscopy in 3-5 years
- Low grade dysplasia: PPI and endoscopy in 6-12 months or endoscopic eradication
- High grade dysplasia: Endoscopic eradication therapy
About 60% of head and neck cancers are locally advanced at the time of diagnosis and are inoperable.
- tx?
chemoradiotherapy (CRT) promises superior results than chemotherapy or radiotherapy alone.
Patients with HIV with CD4 counts <200/mm3 are at high risk for Pneumocystis jirovecii pneumonia (PCP).
Organisms can be identified on induced sputum samples in 50%-90% of cases;
What happens if you get negative sputum analysis?
further testing if PCP is suspected
the next diagnostic test of choice is a fiberscopic bronchoscopy with bronchoalveolar lavage.
This test is highly sensitive (90%-100%) for diagnosis of PCP.
___________ are typically ill with high fever, dysuria, pelvic/perineal pain, and cloudy urine. Rectal examination usually reveals a warm, edematous, and very tender prostate. Urine culture usually reveals a gram-negative organism such as Escherichia coli or Proteus.
acute prostatitis
_______ is characterized by >3 months of dysuria and pelvic pain.
- Urine studies following prostate massage usually show pyuria (>20 leukocytes/hpf) with no microorganisms (aseptic)
Chronic prostatitis/chronic pelvic pain syndrome
uncertainty about the ideal treatment.
- Most patients receive a combination of therapies including medications for prostate enlargement (eg, alpha blockers), antibiotics, anti-inflammatories, and/or psychotherapy.
__________ is diagnosed when urine culture after prostate massage shows bacteriuria at a >10-fold concentration compared with urinalysis prior to prostate massage.
Chronic bacterial prostatitis
Early defibrillation is indicated in patients with ________
ventricular fibrillation (VF) and/or pulseless ventricular tachycardia (VT). It is ineffective in patients with asystole or pulseless electrical activity (PEA) and is contraindicated.
Abnormal and persistent lymphadenopathy is sometimes the first clinical manifestation of an underlying lymphoma.
Patients with localized lymphadenopathy can be observed for weeks.
- What happens if it doesn’t resolve?
A biopsy should be performed if the abnormal nodes fail to resolve after that time, or earlier, if there are other signs of malignancy.
Tremor in patients with familial disease, usually present in the distal upper extremities and becomes much more pronounced with outstretching of the arm.
benign essential tremor
Resting tremor (which worsens at rest but improves with voluntary activity)
Early onset Parkinson’s
- Sudden-onset pleuritic chest pain,
- combined with a loud P2 and
- pleural friction rub on physical examination,
- hypoxemia, and
- small pleural effusion on chest x-ray (commonly due to inflammation from pulmonary infarct),
suggests ________
acute PE
- fever and productive cough
- Pleuritic chest pain, hypoxemia, and
- pleural effusion on chest x-ray
suggests ________
Bronchopneumonia
treatment of acute asthma exacerbation
inhaled or nebulized short-acting beta agonist (albuterol)
+
inhaled ipratropium
In patients with persistent symptoms, the next step is the administration of systemic corticosteroids (eg, oral prednisone) without delay;
Pt has
- dysmenorrhea,
- chronic pelvic pain,
- deep dyspareunia,
- dyschezia, and
- infertility.
PE: examination findings include pain on lateral movement of the cervix;
- a fixed, immobile uterus; uterosacral nodularity; and
- adnexal masses, although examination is often normal.
Endometriosis
First-line treatment for endometriosis is with nonsteroidal anti-inflammatory drugs and combined oral contraceptives
Asymptomatic pituitary incidentaloma
- what do you do?
repeat MRI of pituitary in 6-12 mo
measure ______ when the screening test for Cushing’s syndrome (overnight dexamethasone suppression test) is positive
Plasma ACTH levels
_______ test is usually used in the evaluation of patients with adrenal insufficiency.
Cosyntropin
ECG shows regular narrow-complex tachycardia (QRS duration of 90 msec) at a rate of 175/min
- what medicine do you give?
adenosine 6mg
treatment of Tourette syndrome
Habit reversal therapy (HRT), a form of cognitive-behavioral therapy
second-generation antipsychotics (eg, risperidone, aripiprazole)
- reduce the frequency and intensity of tics by 60%-80%.
Hypertransfusion regimen can suppress the effects of chronic severe anemia and extramedullary hematopoiesis, but result in significant ___________
iron overload and resultant organ damage.
ie: in treating thalassemia major, a severe congenital hemolytic anemia.
When diverticulitis does not improve after 2-3 days of antibiotic therapy, what do you do?
repeat abdominopelvic CT scan is required to evaluate for complications (eg, abscess, perforation, obstruction).
Colonoscopy is contraindicated in patients with acute diverticulitis.
Nitroprusside is frequently used in the management of acute hypertensive emergency.
Nitroprusside is a potent vasodilator that works on both arterial and venous circulation and is used for hypertensive emergency management. It has rapid onset and offset of action. The most important side effect is ______
cyanide accumulation and toxicity
- metabolic acidosis and altered mental status.
The initial goal in hypertensive emergencies is to rapidly lower DIASTOLIC pressure to _____ mm Hg over 2-6 hours, with the total drop in blood pressure being no more than ___% of the initial value.
100
25%
Extension of dissection to the aortic arch and/or carotid arteries can cause what type of symptoms?
signs suggestive of a stroke (aphasia with associated motor or sensory abnormalities)
Adolescent pregnancies are associated with an increased risk of _______
gastroschisis, omphalocele, preterm birth, low birth weight, and perinatal mortality.
d/t inadequate nutrition and physiologic immaturity
cerebrospinal fluid (CSF) examination shows the following:
Lymphocytic pleocytosis
Elevated protein (generally 100-500 mg/dL)
Low glucose (<10 mg/dL)
Elevated adenosine deaminase
Tuberculous meningitis
What the Serum uric acid level during an acute gouty attack?
Nl or even low
Abnormal screening tests for diagnosing diabetes:
- hemoglobin A1C ____ ,
- fasting (>8 hours) blood
sugar ___
- glucose ___ after oral glucose tolerance test,
- random glucose ____
in SYMPTOMATIC patients
> 6.5%
> 126 mg/dL,
> 200 mg/dL
Asymptomatic patients with an abnormal screening test for diabetes require a repeat measurement with the same test to confirm the diagnosis
Pain and stiffness >1 mo in shoulder and hip girdles
- Elevated ESR
- Morning stiffness >1 h
What disease?
Tx?
Polymyalgia rheumatica
Low dose prednisone
acute otitis media (AOM)
- common bugs?
2 nontypeable Haemophilus influenzae,
*NOT staph
Depression affects up to 50% of patients with Parkinson disease (PD).
Which antidepressant med is good for pts with parkinson disease?
Same as any other pt
- SSRIs (sertraline)
- depressive symptoms may be mistakenly attributed to the progression of PD
__________ should be suspected in patients with fatigue, weight loss, myalgias, increased pigmentation, and decreased axillary and pubic hair.
Characteristic laboratory findings. - Hyponatremia, hyperkalemia, and hyperchloremic metabolic acidosis
Chronic adrenal insufficiency
Most common cause of Chronic adrenal insufficiency
addisons disease (primary adrenal insufficiency)
When evaluating persistent nonresolving PNA or endobronchial obstructive lesions, what is the best diagnostic test?
Next best step in management?
The best diagnostic test : flexible bronchoscopy.
Best step in management: CT scan
Kawasaki disease (KD) what do you do when < 3 diagnostic criteria are met in a child with >5 days of fever?
C-reactive protein or erythrocyte sedimentation rate (inflammatory markers that are elevated in KD) should be ordered,
+ daily follow-up scheduled to assess for new symptoms.
*FYI you need >4 of 5 sx for diagnosis
When do you perform echocardiograms in pts w/ kawasaki disease?
echocardiogram performed at baseline
+
2 and 6 weeks after completion of treatment.
- if pt has nl baseline, future risks are not increased, and no restrictions necessary
Orthostatic proteinuria is the most common cause of proteinuria in adolescents.
- How do you diagnose?
- How do you treat?
24 h urine collection
no intervention - benign
If a pt has a pneumothorax, when do you place a chest tube vs perform needle decompression?
If tension pneumo with imminent cardiac arrest: needle decompression
non-tension pneumo: chest tube
Which MEN syndrome?
Pituitary
parathyroids
pancreas
“Diamond”
MEN 1
3 P’s
Which MEN syndrome?
- Parathyroids
- Pheochromocytoma
- Medullary thyroid Ca
“Square”
MEN 2A
mutation in the RET gene
- Marfanoid body habitus
Which MEN syndrome?
- Neuromas (oral/GI ganglioneuromatosis)
- Pheo
- Medullary thyroid Ca
“Triangle”
MEN 2B
Mutation in RET gene
- Marfanoid body habitus
Antithyroid peroxidase antibodies + Anti thyro-globulin
What disease?
What cancer?
Hashimotos thyroiditis
- thyroid non-hodgkin lymphoma
Kidney donation sequelae?
low
- but increased risk of gestational complications -
- fetal loss, preeclampsia, gestational diabetes, and gestational hypertension.
- generally recommended that women complete their planned childbearing prior to kidney donation.
_____ are the leading cause of mortality in patients with SLE.
Cardiovascular events
- premature coronary atherosclerosis and coronary artery disease
SLE patients are at increased risk for which type of cancer?
non-Hodgkin lymphoma, especially diffuse large B-cell lymphoma (DLBCL).
Patients with nongonococcal urethritis frequently have continued symptoms after azithromycin therapy due to reinfection or infection with an organism (eg, Mycoplasma genitalium) not susceptible to azithromycin.
- What should you do next?
repeat urethral Gram stain and nucleic acid amplification testing of the urine for common urethritis organisms.
Renal stones____ mm usually pass spontaneously.
Stones ___ mm, uncontrolled pain, presence of acute renal failure, and urosepsis are indications for urgent urologic referral
<5 mm
> 10 mm
*if in btwn, give alpha blocker (tamsulosin) for 4 weeks and discharge
patient presents with knee pain, (pain out of proportion to the injury), swelling, decreased range of motion, skin changes, and vasomotor changes after a recent injury consistent with _______
complex regional pain syndrome (CRPS)
- pathogenesis is likely due to an injury causing increased sensitivity to sympathetic nerves, an abnormal response to and sensation of pain, and increased neuropeptide release causing burning pain to light touch (allodynia)
patient with abdominal pain, epigastric fullness, and nausea that worsen after eating has _____
- How do you treat?
dyspepsia
Management of dyspepsia is dependent on the risk of malignancy.
- age ≥60 are considered high risk and should undergo upper gastrointestinal endoscopy with biopsy.
- Those w/o alarm sx should be tested for H. Pylori. If negative treat empirically with PPI
Mentzer index (MCV/RBC) value of _____ is suggestive of iron deficiency and can help differentiate it from thalassemia;
> 13
Acute hemolytic anemia is typically characterized by a (normal/low/high) MCV.
normal
TRUE/FALSE Papillary necrosis occurs with heavy long-term use of analgesics such as aspirin, phenacetin, acetaminophen, or other nonsteroidal anti-inflammatory drugs.
true
Analgesic nephropathy
- Ischemic damage to the renal papilla may occur due to vasoconstriction of the vasa recta. -> florid proteinuria
True/False
Low folate is associated with poor cognitive function and dementia in the elderly.
true
*think alcohol use disorder
Apolipoprotein E polymporphisms are associated with ________
Alzheimer dementia
Lewy bodies are associated w/
Parkinsons disease
The association between DM and malignancy is well documented. Which ones?
adenocarcinoma of the cervix, ovaries, lung, pancreas, bladder, and stomach.
Patients with Sydenham chorea should be started on _____ as soon as possible to eliminate carriage of group A streptococcus.
Penicillin should be continued until adulthood with the goal of preventing recurrent rheumatic fever.
This patient with a 30-pack-year smoking history has erythrocytosis (H/H elevated) and hematuria, raising suspicion for_______
renal cell carcinoma (RCC).
Treatment with nephrectomy is usually curative.
Polycystic kidney disease
- diagnosis?
- tx?
testing for PKD gene mutations
treatment with ACE inhibitors often reduces the risk of chronic renal insufficiency.
Patients with negative stress testing results have a ___% risk of cardiovascular events within the NEXT year.
<1%
Bacterial conjunctivitis can progress to bacterial _____, which most commonly occurs in patients who wear contact lenses improperly (eg, overnight use) or have decreased immunity (eg, corticosteroid use).
keratitis: inflammation of the cornea, the clear tissue covering the pupil
- can cause blindness if untreated, includes urgent referral to an ophthalmologist.
_____ is a bacterial infection of the sebaceous glands in the eyelid. Patients have tenderness, redness, and swelling at the eyelid margins.
Hordeolum (stye)
A ___-year interval for colonoscopy is appropriate for patients with 1 or 2 small tubular adenomas detected on colonoscopy or those with a first-degree relative who developed colon cancer at age <60.
5
if low risk. or relative >60 y.o then screen q10y
True/False
Patients with obsessive-compulsive disorder experience obsessions, compulsions, or both. Obsessions can include intrusive thoughts, violent images, and unwanted urges.
True
_____ is useful for the acute termination of certain paroxysmal supraventricular tachycardias (eg, AV nodal reentrant tachycardia).
Adenosine
Chronic kidney disease is associated with phosphate (retention/excretion),(increased/reduced) free serum calcium levels, and (increased/decreased) 1,25-dihydroxyvitamin D levels.
phosphate retention
-can cause PTH increase and autonomous PTH secretion (need parathyroidectomy)
reduced free calcium
decreased 1,25-vit D
Urgent warfarin reversal to prevent hemorrhage
Prothrombin complex concentrate, which contains vitamin K-dependent clotting factors and normalizes INR <10 minutes after administration.
*Intravenous vitamin K, which results in sustained warfarin reversal but takes 12-24 hours for full effect.
All women planning pregnancy should take ___ mg of folic acid daily for >1 month prior to conception to decrease the risk of neural tube defects; women at high risk for these defects should take ___ mg of folic acid daily.
0.4 mg
4 mg
________ typically presents in postmenopausal patients with a history of previous tamoxifen use or pelvic radiation.
Presenting symptoms can include new-onset pelvic pressure or pain, a uterine mass, ascites, and symptoms of metastasis (eg, pleural effusion).
Uterine sarcoma
Screening for gestational diabetes mellitus is performed at ____ weeks gestation with the 1-hour 50-g glucose challenge test.
24-28 weeks
Patients with chronic hepatitis C infection should be vaccinated against _____ and _____ if they do not have preexisting immunity.
HAV and HBV
pts can have rapid hepatic decompensation and liver failure if they develop acute hepatitis A virus (HAV) or hepatitis B virus (HBV) infection.
Patients with a Centor score <3 have a low probability of a acute pharyngitis (GAS infection); they do not require testing or antimicrobial treatment and can be managed symptomatically.
What are sx of acute pharyngitis?
Tonsillar exudate
Tender anterior cervical adenopathy
Fever
Absence of cough
________ in sickle cell disease is defined by the presence of a new pulmonary infiltrate on chest x-ray and fever, hypoxemia, chest pain, tachypnea, or increased work of breathing.
- How do you tx?
Acute chest syndrome
- tx w/ ceftriaxone and macrolide (eg, azithromycin), pain control, and intravenous fluids.
This patient, with back pain, high PTH, low phosphorus level, nl calcium, high alkaline phosphatase, and history of bariatric surgery, has likely _____ deficiency
vitamin D deficiency
- Serum 25-hydroxyvitamin D level is a very sensitive indicator for vitamin D stores and should be measured in patients suspected of vitamin D deficiency. A level <20 ng/mL is diagnostic.
Patients with ______ often have labile diabetic control and frequent hypoglycemia as it is difficult to time their insulin dose to correspond with the delayed intestinal absorption of glucose.
- how to evaluate?
gastroparesis
- first r/o mechanical obstruction
- If diabetic gastroparesis suspected: nuclear gastric emptying study to confirm the diagnosis.
__________ and __________ are used to exclude mechanical obstruction
Upper gastrointestinal endoscopy
contrast imaging studies such as barium swallow
Patients with acute ischemic stroke who are treated with tissue plasminogen activator should not receive antiplatelet therapy, anticoagulation, or invasive testing during the first ____(time)___ after treatment.
24 hours
What is recommended after a pt receives TPA?
Strict control with intravenous medications such as labetalol, nitroprusside, or nicardipine is recommended to keep blood pressure <185/105 mm Hg ( but >140/90 mm Hg) to avoid the risk of hemorrhagic transformation.
Antiplatelet (eg, aspirin) therapy should not be used in the first ___ hours after tPA but could be started after ____hours if the patient is stable.
24
24-48
With CYP inhibitors, warfarin effect (increases/decreases)
increases (warfarin metabolism slows)
(INR increases)
*so you should reduce warfarin dose 25-50% to compensate
With CYP inducers, warfarin effect (increases/decreases)
decreases,
(warfarin metabolism increases)
*so you should increase warfarin dose to compensaet
__________ presents with hyperthyroidism and a nontender goiter in the first year after pregnancy
Postpartum thyroiditis (PT)
associated with thyroid peroxidase antibodies
Lithium has a very narrow therapeutic index. Many antihypertensive medications can interact with lithium due to their effects on renal function and electrolyte levels. How? Which ones are considered safe?
Thiazides, ACE-i, and ARBs can increase serum lithium levels.
Calcium channel blockers are generally considered safe.
Potassium-sparing diuretics (eg, spironolactone) can (increase/decrease) serum lithium levels
decrease - making them subtherapeutic
A patient in labor w/ a h.o C-section, has acutely worsening abdominal pain, vaginal bleeding, loss of fetal station, and an abnormal fetal heart rate tracing with late decelerations. This presentation is concerning for _____
uterine rupture, full-thickness disruption of the uterine wall.
Acute respiratory failure due to OSA results from _________ (evidenced by bibasilar atelectasis on chest x-ray), and typically leads to hypercapnic, hypoxic respiratory failure (acute on chronic hypercapnic, hypoxic respiratory failure in this patient) with respiratory acidosis.
hypoventilation
*Patients with obstructive sleep apnea are at increased risk of perioperative respiratory failure from procedures involving sedation, neuromuscular blocker, opioids, or anesthesia. When respiratory failure occurs, it results from hypoventilation and typically presents with hypercapnia and hypoxia.
if the gastrointestinal tract is able to function, then _____ feedings are preferred to _____ feeds in pts w/ functioning gastrointestinal system.
The standard composition of ___ kcal/kg/day and __ g/kg/day of protein is satisfactory for most patients with adequate baseline nutrition.
enteral (passing thru intestines/GI) > parenteral (anywhere but the mouth and alimentary canal)
30 kcal/kg/day
1 g/kg/day
________ and _______ levels can be used to monitor for active renal involvement in patients with systemic lupus erythematosus.
Antinuclear antibody titers do not correlate with renal disease activity!!
Anti-double stranded DNA
Complement levels
_______ presents with a petechial rash, neurologic abnormalities, thrombocytopenia, and microangiopathic hemolytic anemia.
Can occur during pregnancy or in the postpartum period.
Thrombotic thrombocytopenic purpura (TTP)
__________ typically presents with an altered mental status, oculomotor dysfunction (eg, nystagmus) and gait ataxia
Wernicke encephalopathy (eg, thiamine deficiency)
older patient who recently had a myocardial infarction and now has severe abdominal pain out of proportion to his benign examination findings, along with an anion gap metabolic acidosis, should be considered to have __________until proven otherwise.
- Test?
acute mesenteric ischemia
- CTA
- Oral contrast should be avoided with acute mesenteric ischemia as it can obscure the vasculature.
- most common cause is superior mesenteric artery occlusion due to embolic disease
True/False
In >55% of patients, strokes can cause abnormalities in the swallowing mechanism, leading to possible oropharyngeal dysphagia, aspiration, and aspiration pneumonia.
True
- This is associated with an increased risk of death. Assessment of swallowing function
How do you treat stroke pts who present >4h after sx?
Aspirin and permissive HTN
- <185/105 mm Hg ( but >140/90 mm Hg)
*Do not give fibrinolytic therapy
The risk of DVT is highest ____days following a stroke and is particularly high in patients with hemiparesis (up to 75% on the hemiparetic side). Subsequent pulmonary embolism is the most frequent cause of early death in acute stroke patients.
2-7 days
- give subcutaneous low-dose heparin or low-molecular-weight heparin for deep-vein thrombosis (DVT) prophylaxis
True/False
Full-dose intravenous heparin is used for the treatment of DVT, not its prophylaxis.
True/False
Full-dose anticoagulation is generally used to treat acute stroke
True
False:
Full-dose anticoagulation is not generally used to treat acute stroke due to the risk of hemorrhagic transformation of the infarct.
______ lab is used to screen for medullary thyroid cancer
Calcitonin
__________ syncope is usually preceded by an autonomic prodrome of nausea, pallor, diaphoresis, or generalized warmth. These symptoms often temporarily persist following the episode.
Neurocardiogenic (vasovagal) syncope
Palpitations prior to an episode of syncope or ABSENCE of preceding autonomic prodromal symptoms are suggestive of _______ syncope
cardiogenic - due to cardiac arrhythmia (eg, ventricular tachycardia).
PCP intoxication leading to severe agitation and violent behavior should be treated immediately with __________.
___________ is more appropriate for patients with milder symptoms of PCP intoxication.
benzodiazepines to provide sedation
A low-stimulation environment (with or without benzodiazepines)
cat-scratch disease (CSD) caused by Bartonella henselae tx?
Azithromycin treatment can reduce the length and severity of symptoms.
Doxycycline (plus rifampin) treats neurologic manifestations of CSD in patients age >8.
- However, prolonged doxycycline is avoided in young children due to the risk of dental staining, and this patient has no neurologic findings.
The constellation of unilateral headache and partial left-sided Horner (ie, ptosis, miosis, anhidrosis) syndrome indicates left carotid artery dissection until proven otherwise.
- what do you do?
Diagnosis is typically by CT angiography or MR angiography;
if the results are negative but carotid dissection is still suspected, catheter angiography (gold standard) may be performed
_________ lobe lesions present with constructional and dressing apraxia.
Nondominant parietal
Damage to the ________ lobe, presents as Gerstmann syndrome.
The patients have difficulty in performing simple arithmetic tasks (acalculia), inability to name individual fingers (finger agnosia), impaired writing (agraphia) and right/left confusion (difficulty in identifying or distinguishing the right or left side of the body).
dominant parietal
- especially the inferior parietal lobe
Wernicke’s aphasia is usually seen in patients with _______ lobe lesions. It is characterized by the impairment in comprehension of spoken or written language. Patients have difficulty in expressing their thoughts in a meaningful manner.
dominant temporal
________ presents as irregularly shaped, hyperpigmented macules on the face.
It occurs more commonly during pregnancy.
Management?
Melasma
- minimizing sun exposure and using a broad-spectrum sunscreen that blocks both UVA and UVB radiation.
The pathophysiology of toxic shock syndrome involves_______
widespread activation of T cells by EXOTOXIN acting as superantigens, leading to the massive release of cytokines.
The pathophysiology of septic shock involves_______
massive bacterial lysis and circulating endotoxin
________ is often characterized by low T3 levels with normal TSH and T4 in patients with acute illness. It is primarily due to decreased peripheral conversion of T4 to T3. Treatment is not recommended
Euthyroid sick syndrome
“low T3 syndrome”
NF1 vs NF2
- which one causes unilateral vs b/l deafness?
- which one is most assoc w/ cafe au lait macules?
NF1: unilateral
- CALMs classic
NF2: b/l (acoustic neuromas)
Scoliosis
- Cobb angle < 10 degrees
- Cobb angle 10-40 degrees
- Cobb angle ≥40 degrees
- Cobb angle < 10 degrees: nl variant
- Cobb angle 10-40 degrees: mild scoliosis -
If skeletal maturity is incomplete ->back brace.
If skeletal maturity is complete -> nothing, no follow up - Cobb angle ≥40 degrees: Severe scoliosis - surgical eval
Can C-section prevent the vertical transmission of HPV (condyloma acuminata?)
no
- proceed with expectant management and vag delivery
How to prevent malaria?
Antimalarial prophylaxis (abx), which generally needs to be started in advance of a trip and continued for some time after a traveler's return - There are no antimalarial vaccines currently available.
Brain death diagnosis requires a CNS catastrophe of known etiology with an absence of confounding factors.
Ptsmeeting clinical criteria should undergo neurologic examination to document absent cortical and brainstem function (eg, coma, absent motor response to pain, absent pupillary light reflex, absent corneal and oculocephalic reflexes, absent gag reflex).
- Then what do you do?
Apnea testing is used to confirm the diagnosis of brain death in patients meeting these criteria.
________ is the most frequent complication of transurethral resection of the prostate, and all patients should be made aware of this.
Retrograde ejaculation
________ is the most common cause of secondary dilated cardiomyopathy, and evaluation with ________ or coronary angiography should be performed in all patients presenting with unexplained heart failure due to left ventricular systolic dysfunction.
Coronary artery disease
stress testing
Hypoglycemia is a risk with insulin and several oral medications for diabetes, especially ______ and _____
sulfonylureas (eg, glyburide, glipizide, glimepiride)
and
meglitinides (eg, nateglinide, repaglinide).
What is plasma aldosterone to plasma renin activity ratio used to screen for?
- Ratio # to look for?
primary hyperaldosteronism (Conn's syndrome) - hypokalemia and hypertension
ratio of >30 is suggestive of excessive aldosterone secretion from the adrenal gland.
________ wound infections are often associated with rapidly progressive cellulitis with hemorrhagic bullous lesions, and septic shock.
- Infections are acquired primarily through the consumption of raw oysters or through wound contamination during recreational activities or raw seafood handling.
Vibro vulnificus
________ is found in salt and fresh water and can cause wound infections.
- lesions are usually papular and ulcerative (not necrotizing and bullous) and develop over several days (not hours).
Mycobacterium marinum
The presence of HbA and HbS in a 60:40 ratio, respectively, is consistent with _______, which is generally asymptomatic and not a cause of anemia and microcytosis.
sickle cell trait
Low 8:00 AM cortisol and glucose suggest __________.
Then what?
adrenal insufficiency
Measurement of baseline adrenocorticotropic hormone (ACTH) levels and a short ACTH (cosyntropin, synthetic ACTH) stimulation test would be the most practical methods to assess adrenal reserve.
Ambulatory 24-hour Holter monitoring is often helpful in the diagnosis of suspected _______, but it has minimal diagnostic use for CAD.
paroxysmal cardiac arrhythmia
Either of 2 serious complications is an absolute contraindication to future DTaP immunization: _____ immediately after the vaccination or _______within 7 days.
anaphylaxis
encephalopathy
*note: Immunosuppression of any kind is not a contraindication to DTaP immunization.
HPV vaccines target types that cause either genital warts (eg, types __ and __ ) or cancer (eg, types __ and __).
warts: 6 and 11
cancer: 16 and 18
The recommended time for the first dose is age 11-12, but the HPV vaccine series can be started at age __- __
9-26
_____________ can be obtained in case-control studies and are a useful measure of association.
Odds ratios (but not relative risks or risk ratios)
(macrocytic anemia with a normal serum folate level and severely depressed serum cobalamin level suggest the presence of ______ anemia.
B12-deficiency
_______ testing is the recommended initial test for the detection of pernicious anemia.
Anti-IF antibody test
*note: antiparietal antibodies also assoc w/ pernicious anemia. but less specific
Schilling test is a classic diagnostic test of _________ that uses radio-labeled cobalamin.
pernicious anemia
- It is more cumbersome than antibody testing, and can be used as the second-line test if the anti-IF test is negative.
three main components of autoimmune metaplastic atrophic gastritis (AMAG) (which is associated with pernicious anemia) are:
- glandular atrophy of gastric body and fundus.
- intestinal metaplasia
- intestinal inflammation.
Typically, little changes are observed in the gastric antrum.
acute asthma exacerbation, current guidelines recommend initial home management with short-acting bronchodilators (eg, albuterol) followed by the addition of ________ if symptoms persist
systemic PO corticosteroids (eg, prednisone)
*Inhaled corticosteroids are used as a controller medication for the chronic management of persistent asthma. However, they do not play a role in management of an acute asthma exacerbation
Confirmation of H. pylori eradication is recommended for patients with ulcers or ongoing dyspepsia. __________ can be used after 4 weeks to confirm H. pylori eradication
Either urea breath or fecal antigen testing
Pneumococcal vaccines for age > 65
13-valent pneumococcal conjugate vaccine (PCV13) at age 65, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in 6-12 months
- Revaccination in 3 years
_________ is a scalp swelling above the periosteum that crosses suture lines. A benign condition that presents at birth
Caput
succedaneum
___________is a subperiosteal bleed that takes several weeks to resolve and, in contrast to subgaleal hemorrhage and caput succedaneum, does not cross suture lines
cephalohematoma
All patients with asymptomatic LVSD (ejection fraction <40%) should be treated with _______ as treatment has been shown to delay the onset of symptomatic heart failure and improve long-term cardiac morbidity and mortality.
ACE inhibitor (or angiotensin II receptor blocker)
Once a suitable ACE inhibitor dose has been achieved, beta blocker therapy should be added.
Absent or reversed umbilical artery end-diastolic flow (as seen in this patient) suggests ___________ and impending ______, particularly with concomitant oligohydramnios, and is an indication for delivery
placental insufficiency
fetal hypoxia
First line onychomycosis tx?
PO Terbinafine, itraconazole
*note: griseofulvin and ketoconazole are rarely used for onychomycosis - long tx regimens w/ freq monitoring (but still used for tinea capitus)
________ fracture is common following a fall onto an outstretched hand.
- Patients with this injury frequently have additional styloid fracture, scaphoid fracture, and acute carpal tunnel syndrome.
Distal radius (Colles’)
Statin therapy is recommended for all patients age 40-75 with diabetes (type 1 or type 2) who have a baseline LDL level __ mg/dL.
> 70
Screening for diabetic retinopathy is indicated beginning _____ after the original diagnosis in patients with type 1 diabetes and _____ in those with type 2.
Type 1: 3-5 years
Type 2: at the time of diagnosis
Diabetic pts w/ evidence of nephropathy or HTN should be treated w?
ACE-i
For pregnant pts w/ mechanical valves. Which anticoagulant is used in:
1st trimester?
2nd?
3rd?
1st trimester (organogenesis): LMWH
2nd and third trimester: warfarin
Last few weeks of pregnancy: unfractionated heparin (quickly reversed w/ protamine)
*note: Warfarin prophylaxis can be resumed during breastfeeding as it does not accumulate in breast milk.
mid-systolic murmur at the left upper sternal border (resulting from increased flow across the pulmonic valve) with right atrial and ventricular dilation – is most suggestive of __________.
- Many patients remain asymptomatic until adulthood.
atrial septal defect (ASD) with a left-to-right shunt.
- second most common congenital heart defect in adults (bicuspid aortic valve is the most common)
Patients with ________ typically have a harsh holosystolic murmur with maximal intensity over the left 3rd and 4th intercostal spaces, often accompanied by a palpable thrill
ventricular septal defect (VSD)
______is a common cause of postoperative hypoxemia that can occur 2-5 days following surgery; is uncommon immediately following surgery, and usually fails to correct w/ supplemental oxygen d/t intrapulmonary shunting
Atelectasis
Which diuretics should be avoided in pts w/ gout?
HCTz and furosemide
- decrease fractional excretion of urate
______ is required for diagnosing a prolapsed internal hemorrhoid, which can present as inflamed veins in the left lateral and right anterior/posterior walls of the anal canal
Anoscopy
_________ is characterized by pituitary enlargement, hyperpigmentation, and visual field defect following bilateral adrenalectomy. Usually, these tumors are rapidly growing and can be treated with surgery and/or local radiation.
Nelson’s syndrome
Acute gouty monoarticular arthritis in renal failure and post-transplant patients is best treated by ______
increasing the dose of systemic steroids or by injection of intraarticular glucocorticoids.
- use of allopurinol, probenecid, NSAIDs and colchicine is not recommended in such patients.
What do you do if pt develops
VTE while on menopausal hormone therapy (MHT)?
Stop hormone therapy as the benefit of continued treatment does not outweigh the risk of recurrent, potentially life-threatening VTE.
- most common alternate treatments are SSRIs or SNRIs
Vulvodynia is a chronic (>3 months), raw, burning vulvar pain that occurs in the absence of a specific disorder. First-line management includes _________ and _____
pelvic floor physiotherapy and cognitive behavioral therapy.
Topical clobetasol, a high-potency corticosteroid, is indicated for treatment of __________ that typically present with intense vulvar pruritus in perimenopausal patients.
inflammatory vulvar disorders
eg, lichen sclerosus, lichen planus, psoriasis
Aphasia is typically seen in _________ lobe lesions.
dominant temporal
Peripartum Pts w/ ________ can have new onset of hypertension, pulmonary edema, and hyperreflexia (ie, end-organ damage).
- typically occurs during pregnancy, but it can also occur up to 12 weeks postpartum and can be complicated by ________
preeclampsia
pulmonary edema
_________ is the most common side effect of the combined oral contraceptive pill and occurs due to a thin atrophic unstable endometrium that sheds erratically.
Unscheduled bleeding
- other common side effects: breast tenderness, nausea, headaches, and moodiness
Pt w/ history of abdominal surgery, swinging fever, and leukocytosis 14-21 post-op.
- Cough and shoulder-tip pain may be the presenting symptoms.
suspected subphrenic or other abdominal abscess
The anthracycline class of drugs causes a dose-dependent decline in the ejection fraction, leading to _________
dilated cardiomyopathy.
*radiation causes diffuse fibrosis, restrictrive cardiomyopathy
Cervical insufficiency, a structural cervical weakness associated with painless second-trimester pregnancy loss, is managed with placement of a cerclage.
- how much can they exercise?
exercise is contraindicated
Patients with a cerclage and history of cervical insufficiency should avoid exercise during pregnancy to minimize the risk of preterm delivery
Spontaneous descent of undescended testes is rare after age ____, and an orchiopexy is performed during infancy to optimize fertility and testicular growth.
6 months
- refer for surgery
Children with latent tuberculosis infxn require Daily isoniazid for 9 months.
- If isoniazid resistance is suspected, the best alternate therapy is _________
daily rifampin for 4-6 months.
________is a nonmalignant lesion that arises in the terminal ducts and lobules of the breast.
- What do you do?
Lobular carcinoma in situ (LCIS)
- While the lesion itself has no malignant potential, it signifies an increased risk of developing invasive lobular or ductal carcinoma in either breast (roughly 7-18 times the risk)
- biopsy, if + then excisional bx
________represents the simplest and least toxic acute treatment of a prolonged bleeding time. It acts by increasing the release of factor VIII:von Willebrand factor multimers from endothelium.
Desmopressin
Organophosphate poisoning typically occurs after exposure to or ingestion of agricultural pesticides; ___________ inhibition causes a cholinergic toxidrome.
- tx?
acetylcholinesterase
reversal agents: Atropine and pralidoxime
Statins alone may reduce serum triglyceride levels about __%.
In addition to lifestyle modifications, patients with more significant triglyceride elevations, especially those with >1000 mg/dL, should be given _____ therapy (or fish oil or niacin if fibrates are not tolerated) to reduce the risk of pancreatitis
10%-30%
fibrate
True/False
Statin therapy is recommended for patients with known atherosclerotic cardiovascular disease, only if the low-density lipoprotein cholesterol level is >190
False
Statin is recommended REGARDLESS of baseline low-density lipoprotein cholesterol levels.
Corticosteroids should be given to pts w/ bells palsy (unilateral upper and lower facial weakness) w/in how many days?
3 days to improve chances of complete recovery
After a bone age radiograph is used to assess remaining growth potential, part of the Initial evaluation includes FSH, LH, and testosterone levels to differentiate between ___ and ___
primary (elevated FSH/LH) hypogonadism
and
secondary (low to normal FSH/LH) hypogonadism.
Patients with diaphragmatic paralysis typically present with shortness of breath that is worse in the ____ position, and as a result, it is easy to see how this symptom can erroneously lead to a cardiac workup.
supine
*ie: pts w/ ALS, the most common cause of b/l diaphragmatic paralysis
Procedures that warrant antibiotic prophylaxis for IE in patients with high-risk cardiac conditions in the absence of active infection include:
Dental procedures that involve manipulation of gingival tissue or the periapical region of teeth (eg, routine dental cleaning) or perforation of the oral mucosa
Respiratory tract procedures that involve incision or biopsy of the respiratory mucosa (eg, tonsillectomy, bronchoscopy with biopsy)
Surgical placement of prosthetic cardiac material
Bacterial enteritis is characterized by fever, abdominal pain, and bloody diarrhea. _______ is the first-line treatment for mild dehydration. _____ are indicated only for patients with invasive disease.
An oral electrolyte solution
Antibiotics
Spinal cord compression develops in up to ___% of patients with Pancoast tumor (lung ca) and may result in paraplegia.
- Early recognition and corticosteroid therapy, surgery, and radiation is imperative to preserve neurologic function and patient autonomy.
25%
Asymptomatic pts w/ sarcoidosis often require no tx; those with symptoms or pulmonary function impairment usually receive 12-24 months of oral glucocorticoids.
- What the prognosis?
Most cases (~75%) resolve over time and do not recur.
_____ should be considered in patients with Molluscum contagiosum (MC), especially for lesions that are widespread or involve the face.
HIV testing
MC: spread skin to skin contact
genu varum is considered physiologic from age __ to ___
birth to age 2 years
- reassurance and observation
*get b/l leg xray if bowing is progressive, unilateral, persistent after age 3 years, or associated with short stature (eg, possible metabolic disease)
Improving myocardial contractility with can be achieved with ______. It is recommended only in patients with severe LV dysfunction and low cardiac output causing poor peripheral perfusion or end-organ dysfunction.
intravenous inotropic agents (eg, dobutamine, milrinone)
Good prognostic factors of schizophrenia
late age acute onset (no prodrome) positive psychotic symptoms (eg, delusions, hallucinations) typically respond well to antipsychotic medication
Pregnant Pts w/ Sickle cell disease can have _____ when Hepatic sinusoid vaso-occlusion occurs as sickled RBCs sequester within hepatic sinuses, causing tissue ischemia and infarction (eg, right upper quadrant pain, elevated transaminases) and systemic inflammation (eg, fever)
acute sickle hepatic crisis
- can present during pregnancy with fever, nausea, vomiting, right upper quadrant pain, and elevated transaminases
HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome typically presents in the _____ trimester with hypertension, proteinuria, and a platelet count <100,000 cells/mm3.
third
G6PD deficiency also can result in severe ______ hyperbilirubinemia and anemia on day of life 2-3
unconjugated (indirect)
