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Medicine Flashcards

1
Q

Thyroid nodules
Work up
Hot vs Cold

A

1st step: TSH & US
- If RF or sus US (microcalcification, increase vascularity, hypoechoic, indistinct nodule margins) –> FNA
- If no RF & normal US –>
——-Normal or High TSH: FNA
——-Low TSH: Iodine 123 scintigraphy

Hot/Hyperfunctioning: treat
Cold/Hypofunctioning: FNA

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2
Q

Thyroid cancer
Tx

A

1st step: US neck and LN
If <1cm: lobectomy
If >1cm: Thyroidectomy +/- radiation

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3
Q

Gout
What does it look like, Tx

A

Gout
Needle-shaped, Negative birefringent
Tx: 1st line - NSAIDs (indomethacin), colchicine
2nd line: Steroids
Allopurinol: decrease uric acid production –> prevent flares

Pseudogout aka calcium pyrophosphate deposition disease
Rhomboid-shaped, weakly ⊕ birefringent under polarized light (blue when parallel to light)
Acute tx: NSAIDs, colchicine, glucocorticoids.
Prophylaxis: colchicine

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4
Q

Cushing syndrome
3 causes, Sx, Dx

A

High cortisol d/t
1. exogenous –> low ACTH
2. Adrenal adenoma, hyperplasia/carcinoma –> low ACTH
3. ACTH secreting pit adenoma aka Cushing Disease –> high ACTH

Sx: HTN, hyperglycemia, mood swings, osteopenia/osteoporsis, aldosterone-like effect (low K and metabolic alkalosis)

Dx: 24hr urinary free cortisol level or 1mg overnight dexamethasone test – should suppress ACTH –> suppress cortisol

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5
Q

Basal Cell carcinoma
Appearance

A
  1. Telangiectasia, rolled raised border with ulcerated center
  2. Pink or red macule, patches, thing plaques
  3. Pale, scar-like indentations
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6
Q

A fib
EKG finding, RF, Comp

A

Irregular, irregular with No p wave
RF: AGE (strongest) and comorbidities that cause atrial dilation (HTN, HF, mitral valve disease)
Comp: stroke
Tx:
- Stable: Rate control with beta-blockers or non-dihydropyridine Ca channel blockers diltiazem, verapamil)
- Unstable: Cardioversion

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7
Q

Supraventricular tacycardia
Path, Sx, EKG, Tx

A
  • Secondary conduction pathway that allows abnormal cycling of cardiac conduction and formation of re-entrant circuit.
  • Abrupt on set on palpitations
  • EKG: narrow complex tachycardia with regular R-R intervals. P waves are usually inverted and often buried within QRS complexes
  • Tx:
    —Stable: vagal maneuvers, adenosine
    —Unstable: urgent synchronized cardio version.

Association: WPW pattern + symptomatic tachyarrhythmia –> WPW syndrome

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8
Q

Acute decomp HF
Dx,Tx

A

Dx: TTE
Tx: O2, IV diuretics , IV vasodilator (Nitroglycerin) to decrease preload

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9
Q

Chronic HF
Tx

A

Causes:
- Most idopathic
- 2nd most common: CAD –> ischemia

Dx: stress testing

Tx: one of them –> Digoxin

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10
Q

Dystonia

A

Can be triggered by increased sensory input (light, touch)
Focal: botulinum toxin (1st line)
Generalized: Carbamazepine

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11
Q

Back Pain
3 important things to look for + Dx
Uncomplicated vs Spondylolysis: Dx + Tx Rupture of anulus fibrosus presentation

A

Must always rule out serious disease with careful history.
1. Neurologic deficits (urinary/fecal issues, LE weakness)
2. Malignancy(cancer hx, wt loss, RF)
3. Infection (fever, spinal tenderness, immunosuppression) Ex Abscesss
Dx for above presentation: MRI

  • Uncomplicated/Nonspecific:
    Dx: Pain w/straight leg test suggest lumbosacral radiculopathy
  • Spondylolysis: overuse injury –> unilateral or bilateral fracture of pars interarticularis
    Dx: pain worse with extension, tenderness with deep palpation, radiculopathy as slippage progesses
  • Rupture of anulus fibrosus leading to disc herniation: worse with flexion, positive straight leg test

Tx:
- Uncomplicated back pain: NSAIDs, heat therapy, massage.
Spondylolysis: rest for 90 days, allowing fracture to heal

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12
Q

Colon cancer
RF

A

RF: Family hx. polyposis syndrome. IBD, African american race, alcohol intake, cigarette smoking, obesity

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13
Q

Post ICU syndrome

A

Psych: >50% depression, PTSD, sleep disturbances
Neurocognitive: decrease attention/memory, executive function & processing speed
Physical: >50% have decreased mobility & independence

Most impairments last for several years, require chronic health services and are unable to return to work

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14
Q

Breast cancer
2 RF in men, Tx (2 routes)

A

RF:
1. Tumor suppressor gene mutation: BRCA1 and BRCA2 are tumor suppressor genes that repair dsDNA breaks. Mutations are inherited in AD manner
2. Klinefelter syndrome: extra X increases estrogen/androgen ratio. Sporadic error so family history does not increase risk.

Breast-conserving therapy: lumpectomy, lymphadenectomy, radiation
CI: multifocal disease (>2 tumors in separate quadrants), inflammatory breast cancer, prior therapeutic chest wall radiation therapy

Other treatment: chemo, mastectomy w/axillary LN dissection, and radiation

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15
Q

Mesenteric ischemia
4 common main causes, Sx, Comp, Labs, Dx, Tx

Colonic ischemia

A

Occurs d/t decrease blood flow by
1. SMA occlusion d/t embolic disease
2. arterial and venous thrombosis d/t atherosclerotic disease and watershed infarctions
3. Hypercoagulable state
4. Hypovolemia

Sx. severe rapid abdominal pain but minimal tenderness (no guarding or rebound tenderness), N/V.
Comp: Can lead to abdominal distension, absent bowel sounds, peritoneal signs, bloody stool

Labs: anion gap metabolic acidosis d/t elevated lactate, and elevated amylase

Dx: CT angiography
Tx: IVF, Abx, NGT for decompression

Colonic ischemia: lateralized pain followed by blood stool, pain is mild/moderate

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16
Q

Hemorrhoids

A

Internal: painless – rubber band ligation, sclerotherapy, or infrared light application

External: painful and pruritic –> surgical

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17
Q

Benign paroxysymal positional vertigo
Vertebrobasilar insufficiency
Labyrinthitis
What’s occurring, Sx, Dx, Tx (if any)

A

BPPV:
- Abnormal feeling of motion triggered by certain positions.
- Movement is sensed by semicircular canals which are filled by endolymphatic fluids.
Canalithiasis: presence of crystalline debris in the canals
Dx: Dix-Hallpike maneuver –> vertigo and nystagmus
Tx: Canalith repositioning maneuver (Epley)

Vertebrobasilar insufficiency
- Reduced blood flow to the base of the brain that mainly affects labyrinth and brainstem
RF: DM, HTN, hypercholesterolemia, arrhythmia, CAD, circulatory problems, smoking
Sx: vertigo, dizziness, dysarthria, diplopia, numbness

Labyrinthitis
- Causes: Viral illness (MOST COMMON), but can be caused by trauma, bacterial infection, allergies, benign tumor and certain medicatoins.
- Sx: vertigo, tinnitus, nausea, loss of balance

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18
Q

Subacute thyroiditis
Sx, Labs, Uptake, Path, Tx

A
  • Preceded by viral illness
  • Painful
  • Transient hyperthyroid sx d/t release thyroid hormones
  • High ESR & CRP
  • Decreased Radioiodine uptake
  • Inflammatory infiltrate with macrophages & giant cells
  • Tx: NSAIDs, beta-blockers, steroids if refractory
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19
Q

Postpartum thyroiditis
Sx, Labs, Uptake, Path, Tx

A
  • Onset <12 months after pregnancy
  • Painless
  • Transient hyperthyroid sx d/t release thyroid hormones followed by brief hypothyroid state –> return to euthyroid state
  • Anti-TPO + High thyroglobulin
  • Decrease radioiodine uptake
  • Lympocytic infiltrates +/- germinal centers
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20
Q

Hashimoto
Sx, Labs, Uptake, Path

A
  • Anti- TPO
  • Painless, Mainly hypothyroid sx
  • Variable radioiodine uptake
  • Hurthle cells (Eosinophilic epithelial cells)
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21
Q

Prolactinoma
Pathophysiology, Sx, Tx

A

High prolactin –> suppress GnRH, LH, FSH, estradiol

Oligo/amenorrhea, infertility, galactorrhea, hot flashes, decreased bone density

Tx: Dopamine agonist (cabergoline, bromocriptine), transsphenoidal surgery

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22
Q

Cerebral venous thrombosis vs arterial thrombosis
Presentation, Dx, Tx

A

Venous: Headache, increased ICP, hemorrhage –> seizures
Arterial: slurred speech, weakness

Dx: CT –> MRV
Tx: LMWH

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23
Q

Frailty
Criteria, definition of skilled vs non-skilled care

A

1 or more of the following:
1. Used supportive device
2. ability to leave home only with assistance
3. Medial CI to leave home

Non-skilled care: bathing, grooming, dressing
Skilled care: PT/OT, mediation adherence assistance

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24
Q

Strokes
Ischemic stroke: Dx and Tx
Subarachnoid: RF, Cause, Dx,Tx,Comp

A

Ischemic Stroke :
Noncontrast CT is often normal in the early hours (<6hr) following ischemic events
Tx: tPA within 4.5hrs
- Must also determine etiology (Head MRI which is more sensitive for ischemia, CT or MRI angiography or head/neck, US of carotid, ECG or ambulatory monitoring for r/o arrhythmia, echo to r/o thrombus (when >4mm, ulcerated) or structure abnormality

Subarachnoid hemorrhage
RF: HTN, smoking, alcohol use, fam hx, sympathomimetic drug use

Cause: Ruptured saccular aneurysm (most common)

Dx: Noncontrast CT (good for early), if nothing then LP (xanthochromia ~2hr after onset). Cerebral angiogram to identify source

Tx: tPA (if on time), monitor neuro exam, maintain BP <180/105. Wait 24hrs after tPA to give antiplatelet or anticoagulation therapy d/t risk of beeding.

Comp:
- Cerebral vasospasms –> localize stroke
- Communicating hydrocephalus (d/t impair absorption of CSF)

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25
Q

Wernicke : 3 features, Tx
Korsakoff: what is it, what part of brain effected

A

Thiamine deficiency seen in heavy alcohol drinking.
3 features: encephalopathy, oculomotor dysfunction, gait ataxia
Tx: IV Thiamine

Korsakoff syndrome: Late-stage complication of thiamine deficiency. Mammillary body atrophy

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26
Q

Pancreatitis
Acute: 3 common causes, Dx criteria

A

Acute Pancreatitis:
Causes: Gallstone, Alcohol, Hypertriglyceridemia
2 or 3 criteria:
1. Acute severe epigastric pain
2. Elevated lipase or amylase >3x upper limit of normal
3. Imaging (CT w/contrast - low sensitivity in first 72hrs of presentation, MRI)
Comp: Pseudocysts

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27
Q

Acute Limb Ischemia
Sx ,Tx

A

6 P’s: pain, pallor, paresthesia, pulselessness, poikilothermia (coolness), paralysis
Tx: Anticoagulation (Heparin infusion) and based on severity, emergency revascularization. If mild case: tPA can be use

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28
Q

Mercury Toxicity

A

Neuro: Tremor, insomnia, irritable
Cardio: HTN, Tachycardia
Mucocutaneous: gingivitis, diaphoresis, desquamation of hands/feet
Renal: tubular damage, proteinuria

Inhibits catecholamine breakdown = mimics pheochromocytoma

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29
Q

Pheochromocytoma

A

MEN1
- Pituitary
- Parathyroid
- Pancreatic
- Associated with angiofibromas, collagenomas, meningiomas

MEN 2A
- Thyroid ( Medullary - high calcitonin)
- Parathyroid
- Pheochromocytoma
Patient with Medullar thyroid cancer should be screened for pheochromocytoma (with plasma free metanephrines) before tumor resection

MEN 2B
- Thyroid ( Medullary)
- Pheochromocytoma
- Mucosal neuromas

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30
Q

COPD

A

Hypoxemia is mainly d/t V/Q mismatch, higher FiO2 compensates for low V/Q ratio alveoli.

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31
Q

Gallstone
comp of removal of gall bladder

A

s/p cholecystectomy –> bile salt-induced diarrhea
Tx: cholestyramine (bile salt binding resin)

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32
Q

Kidney stones
Dietary and Pharm Tx

A

All calcium stones tx:
- Increase Fluids
- Increase citrate: binds to Ca to inhibit stone formation
- Increase K: increase citrate excretion
- Decrease Na: Increase Ca reabsorption

Calcium oxalate stones tx:
- Adequate Ca intake: decrease oxylate absorption
- Low oxalate: decrease urinary extcretion

Mediation:
- Thiazides: Increase renal Ca reabsorption
- Potassium citrate:

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33
Q

Sarcoidosis

A

High CA, ESR and Alk Phos,
- ACE levels are elevated in 75% but can not be used to confirm a diagnosis

Dx: Biopsy revealing noncaseating granuloma. If palpable LN are not available, transbronchial biopsy can be performed.

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34
Q

Pulmonary contusion

A

Blunt trauma to lungs –> accumulation of edema and blood –> chest pain, SOB, hemoptysis, hypoxemia

Dx: chest x-ray showing irregular localized opacification

Tx: monitor for 24-48hrs, pain control, oxygen

35
Q

Breast mass (Dx by age)
Gynecomastia (physiologic vs pathologic features)

A

Breast mass:
Age <30: US
——-Simple cyst –> Needle aspiration
——-Complex cyst/mass –> Biopsy
Age 30-39: Mammogram or US
Age >40: Mammogram + US
——-Suspicous? Biopsy

Gynecomastia:
Physiologic: imbalance in hormones - Androgens are converted to estrogen –> unilateral/bilateral, asymmetric or tender for boys at Tanner stage 3-4.

Pathologic:
Occuring before or after mid-puberty (Tanner stage 1 or 5), rapid progression or size >4cm, around nipple or persistence for >3 years.

Can order CMP (to r/o hepatic or renal disease) and hormonal studies (TSH, testosterone, estrogen, prolactin, LG, beta-hcg).

36
Q

Cushing Triad

A
  1. Bradycardia
  2. Hypertension
  3. Respiratory depression
    Early: HA, V, blurry vision, papilledema
    Late: Altered level of consciousness dilation of the ipsilateral pupil, CNIII palsy, hemiparesis, decerebrate posturing, respiratory arrest
37
Q

Bone Tumors
Osteochondroma
Ewing, Osteosarcoma

A

Osteochondroma
- Most common benign
- Boney spur of cartilaginous cap

Ewing
- 1 of 2 most common malignancies
- Lytic lesion w/mulitlayer periosteal reaction

Osteosarcoma
- 1 of 2 most common malignancies
- ill-defined with aggressive periosteal reaction (sunburst, codman triangle)

38
Q

Pulmonary Embolism
Predictor of poor prognosis/mortality
Dx stable vs unstable

A

1 Hemodynamic instability

Other predictors:
- >80y/o, AMS, Hx of cancer, Tachypnea, tachycardia, hypothermia, Sat <90%, high troponin and BNP.

Dx to showing showing RV dysfunction”
- Stable Dx: CTA or V/Q scan
- Unstable: TTE

Tx: thrombolysis

39
Q

DVT
Tx

A

Tx: Anticoagulation (factor Xa inhibitor

40
Q

Anaphylaxis

A

IgE mediated/Type 1 hypersensitivity
If there is a rapid symptom onset & any 1 of the following criteria:
1. Skin/mucosa involvement AND hypotension or respiratory distress
2. Involving >2 organ systems (Cardiovascular, Respiratory, Skin, GI)
3. Hypotension after exposure to allergen

Immediate Tx:
1. Epinephrine (IM preferred, may be repeat x2). Even if initial sx are less severe, give IM epi ASAP. IV for severe/refractory sx
2. IV crystalloid & Trendelenburg positioniong for hypotension
3. Albuterol for bronchospams
4. Early intubation

Others:
1. H1/H2 antihistamines
2. Glucocorticoids
3. Glucagon for patients on beta blockers
4. Hospital admission

41
Q

Testicular cancer
Epi, Sx, Dx, Tx

A

Age 15-35
RF: family hx, cryptorchidism

Sx: Usual firm/hard testicle with or without painless nodules. Dull lower abd pain, metastatic sx

Dx: Scrotal US then radical orchiectomy to dx, tumor markers, staging with CT scan/chest xray

Tx: Radical orchiectomy, Chemo, cure rate ~95%. Biopsy increases risk of lymphatic spread

42
Q

CO poisoning
Cyanide poisoning

A

Cause: smoke inhalation, gas motors in poorly ventilated areas, car exhaust

Path: binds to HgH with a high affinity and reduced oxygen delivery to the tissues.

Sx:
—Mild: HA, Confusion, cherry red skin, malaise, dizziness, nausea
—Chronic exposure can lead to polycythemia d/t increased EPO
—Severe: Sz, Syncope, coma, MI, arrhythmia

Dx: ABG for carboxyhemoglobin level. Pulse oxy cannot differentiate between O2 and CO

Tx:
Mild: High flow 100% oxygen
If severe: intubation, hyperbaric oxygen
_____________________________________________
Cyanide poisoning

Causes: fires, occupation exposure, cyanide-containing meds (sodium nitroprusside)

Path: inhibits oxidative phosphorylation –> forces anaerobic metabolism

Sx:
— HTN, cardiac instability –> death
— HA, confusion, anxiety –> sz, coma
— Cherry red skin
— vomiting

Labs: Elevated anion gap metabolic acidosis due to increased lactic acid

Tx: Decontmination, 100% oxygenen, IVF, vasopressors, empiric tx with hydroxocobalamin + sodium thiosulfate

43
Q

Pneumothorax
Dx, Tx

A

RF: PPV –> barotrauma –> alveolar rupture –> Pneumothroax

Dx: Bedside US or chest x-ray

Tx:
- Chest tube if tension had not yet developed.
- Needle decompression is appropriate for emergency tension pneumothorax. Always followed by chest tube placement.

44
Q

MI
When to resume sexual activity?
How to treat inferior wall MI

A

Can resume sexual activity within 1-4 weeks if low risk

Inferior wall MI –> sinus bradycardia. IV atropine is 1st line to increase CO.

45
Q

Lymphoma
Follicular vs Burkitt

A

Follicular lymphoma: most common indolent growing non-Hodgkin lymphoma in adults, B cell, present with painless waxing/waning lymphadenopathy

Burkitt: highly aggressive and rapidly growing non-Hodgkin lymphoma, B cell, associated with EBV

46
Q

B12 deficiency
Path in RBC formaion, Sx, Tx and its complication

A

Single carbon donors for formation of purine and pyrimidine bases. Deficiency impairs DNA replication. Makes RBC more susceptible to hemolysis –> anemia and low retic count because RBC are not made properly

Sx: dementia and subacute combined degeneration, impaired vibration.
- Hyperbilirubinemia, elevated LDH

Tx: supplemental B12. Look out for hypokalemia d/t uptake of K by newly forming RBC. Can pre-transfuse with pRBC to prevent adverse effect

47
Q

HOCM

A

Sx> –> beta blockers (metoprolol) and non-dihydropyridine CCB (verapamil and disopyramide)

High risk of SCD –> Implantable cardiac defibrillator

Significant LVOT obstruction –> septal ablation or surgical myectomy

48
Q

Esophagitis
Eosinophilic Esophagitis (Path, Sx, Dx, Tx)

A

Path: Th2 response to food antigens
Association: Atopic disease (asthma, eczema, food allergy, allergic rhinitis)
Sx: dysphagia, heartburn/epigastric pain refractory to PPI, regurgitation, food impaction
Dx: Endoscopy w/biopsy (concentric rings, strictures, and linear furrows)
Tx: Elimination diet, PPI, Topical steroids

49
Q

Infectious Gastroenteritis
Mild vs Severe - Sx and Tx
Regular vs blood diarrhea pathogens
What do avoid

A

Mild: well appearing, hemodynamically stable –> Tx: oral rehydration.

Severe: ill-appearing, hemodynamically unstable –> Tx: IVF and Abx
DO NOT TREAT SHIGA-TOXIN, which is produced by E.Coli (EHEC 0157:H7) or Shigella due to risk of hemolytic uremic syndrome

Pathogens:
Norovuris: most common
Rotavirus: most common in unvaccinated age <2

Bloody diarrhea Pathogens :
- Nontyphoidal salmonella
- Campylobacter –> rare but can lead to GBS
- Shigella
- Shiga toxin-producing E.Coli
- Yersiniea
- Vibrio parahaemolyticus
- Entamoeba

Avoid: fructose (fruit juice). transient lactase deficiency can occur

50
Q

IBS
Definition, Causes, Dx, Tx

A

Chronic abd pain associated with defecation and changed in stool consistency (diarrhea, constipation or alternating).

Can be precipitated by infectious gastroenteritis

Dx: no mucosal abnormalities on histology

Tx: dietary modification (lactose-free diet)
Loperamide

51
Q

Heparin Induced Thrombocytopenia
Type 1 vs 2 Path and Tx

A

Recent heparin exposure

Type 1: non-immune mediated caused by heparin-induced plt clumping arising within 2 days of exposure.
Tx: Resolves spontaneously w/o intervention.

Type 2: life-threatening. Antibodies form against heparin-platelet factor 4 complexes –> thrombocytopenia and AV thrombosis
Tx: Stop heparin, start direct thrombin inhibitor (argatroban, bivalirudin) and fondaparinux

Avoid heparin for life

52
Q

Heparin vs Warfarin
Onset, MOA, pregnancy prefernces

A

Heparin
- Immediate therapy
- Enhances antithrombin which inhibits thrombin and factor X
- CAN BE USED IN PREGNANCY:
For high-risk patient
1. LMWH during 1st trimester
2. Warfarin for 2-3 trimester
3. Unfractionated heparin before delivery Discontinue all at onset of labor.
- Overdose?
—Protamine for LMWH and unfractionated
—Prothrombin complex concentrate for synthetic heparin

Warfarin:
- Takes time to work
- Interfere with gamma-carboxylation of Vit K-dependent coagulation factors
- NOT USED IN PREGNANCY
- Overdose? Vit K

53
Q

DNR
Meaning

A

Prohibits cardiopulmonary resuscitation
1. Basic life support: chest compressions
2. Advance cardiac life support: defibrillation, cardiac resuscitation medication (epi)
ONLY IN THE EVENT OF CARDIOPULMONARY ARREST

54
Q

Acute Compartment syndrome
Sx (early and late), Dx, Tx
Compare to chronic form

A

Acute compartment syndrome
Path: increased pressure within enclosed fascial space, decreased blood and tissue perfusion

Sx:
- Early: Worsening severe pain, rapid increase in swelling, increase pain with passive stretching, paresthesia
- Late: Decrease sensation, weakness, paralysis, loss of pulses

Dx: diastolic pressure - compartment pressure. <30mmHg is positive.

Tx: fasciotomy

Comp: fixed muscle contracture due to irreversible skeletal muscle fibrosis and shortening. Develop over weeks to months.

Chronic exertional compartment syndrome:
- nonemergent. self-limiting
- recurrent pain that occurs at the same time, distance, and intensity of exercise.
- pain resolved <10min with rest and exam is normal

55
Q

Cystic fibrosis
Hot it can effect pancreas

A

Oancreatic failure d/t ductal obstruction and buildup –> pancreatic DM
Can cause the loss of alpha (glucagon) and beta (Insulin) cells.

56
Q

DM

A

Normal fasting glucose level 70-100

57
Q

Sjogren
Ab, Associated cancer

A

Effects lacrimal and salivary glands
Anti-Ro/SSA and Anti-La/SSB
Associated with B-cell non-hodgkin lymphoma

58
Q

Aging changes - Men vs Women
Sex hormone changes

A

Men
- Gradual decline of sex hormones with aging: lower testosterone (total and free), compensatory rise in LH, increased hepatic synthesis of sex hormone-binding globulin

Women:
- Drop in sex hormones at menopause

59
Q

Eye inury
Open globe laceration (Cause, Sx, Tx)

A

Open globe laceration: small high-velocity particle –> teardrop pupil
Tx: Abx, eye shielding, CT scan or orbits and emergency ophthalmology

Open glove rupture: blunt injury

60
Q

Delirium

A

RF: Advanced age and underlying brain disorder (dementia, parkinson, stroke)

Precipitate: polypharmacy, infection, fluid and electrolyte disturbances, malnutrition, immobility, etc.

Dx:
1st- Vital signs
2nd - UA and CMP
3rd- reassurance, orient to environment, constant supervision
4th- low dose haloperidol

61
Q

Dementia

A

Sx: agitation, aggression, wandering, delusion, hallucination, paranoia

Non-pharm tx:
- Stable environment
- Structured routine, scheduled activity
- Calm reassurance
- Regular exercise, sleep hygiene

Med Tx:
- Cholinesterase inhibitors
- SSRI
- Antipsychotics
- Avoid benzodiazepines

62
Q

Skin
SCC - Tx

Cherry hemangioma

A

SSC
- 2nd most common
- Need surgical excision. If not, then can do cryotherapy, electrosurgery, or radiation.

Cherry aka Senile:
- Filled with capillaries and post-capillary venules.
- Usually asx and require no treatment.
- Electrocauterization for small lesions. Add shave excision for larger lesions.

63
Q

Rectal prolapse
Tx (medical vs surgical)

Pelvic organ prolapse

A

Rectal Prolapse:
- Medical tx used for non-full thickness prolapse
- Fiber and fluid intake, pelvic floor muscle exercise
- Possible biofeedback therapy for fecal incontinence
- Surgery for full thickness or debilitating sx (fecal incontinence, constipation, sensation of mass)

Pelvic floor:
- Weight loss
- Pelvic floor exercises
- Vaginal pressary
- Surgical repair (if patient is a good candidate)

64
Q

Brain death
2 categories of criteria
Organ donation

A

Cardiac death:
- Irreversible electrical or mechanical asystole.
- Apnea
- Confirmed by observation period (~5min)

Brain death
- Known massive brain injury
- Irreversible coma without confounding factors
- Absence of brainstem reflexes (pupillary light or corneal, oculovestibular, cough, gag, suck, swallow, extensor reflex)
- Apnea required formal testing
- EEG or absence of intracranial blood flow on imaging

Organs do not need to be in pristine condition for donation, some degree of preexisting dysfunction is common.

65
Q

Iron deficiency
RF, Labs, Tx and duration

A

RF:
Prematurity
Lead exposure
Age<1 (delay introduction of solids, consumption of cow, soy or goat milk)
Age >1 (consumption of >24oz cows milk per day, <3 servings of iron-rich foods)

Labs: hypochromic, microcytic RBC with decreased reticulocytes as bone marrow is unable to produce requisite number of RBC.

Tx: iron supplement with vitamin C
- retic count increases in 1-2 weeks
- Hgb and hematocrit increase ~1month

66
Q

Achilles
How to test complete rupture

A

Plantarflexes the food
Complete rupture - Dx with calf squeeze test aka Thompson test –> absence of PASSIVE plantar flexion

ACTIVE plantar flexion can still be present with complete rupture because action fo accessory muscles

67
Q

Osteomyelitis
Dx

A

Dx:
- Superficial wounds cx are inaccurate and should not guide therapy
- Bone biopsy with culture are gold standard!

68
Q

Tumor Lysis Syndrome
Labs, Tx

A

Occurs with the initiation of chemotherapy

Labs
- HyperPhos + CaPhos stones –> AKI and Hypocalcemia
- Hyperkalemia –> arrhythmia
- Hyperuricemia –> Uric acid stones –> AKI

Tx: IVF + Rasburicase (metabolizes uric acid that is already made).
Allopurinol and febuxostat: prevent production of uric acid

69
Q

Emergency airway if intubation failed

A

Cricothyrotomy is faster, easier and lower risk of hemorrhage. Does not need full anesthesia
Tracheostomy needs full anesthesia therefore not used emergently.

70
Q

Multiple Myeloma
Sx, Dx

A

Sx:
- C - Hypercalcemia d/t bone demineralization with osteoLYTIC lesions –> Tx: hydration and dexamethasone, bisphosphonate
- R - Renal insufficiency d/t congestion of glomerulus with light-chain –> Tx plasmapheresis or dialysis
- A - Anemia
- B - Back pain –> Bisphosphonate helps prevent

Dx:
- Serum or urine protein electrophoresis
(Urine dipstick usually detects albumin)
- Cross-secional imaging with whole-body CT, MRI or positron emission tomography scan.

Comp: Hyperviscosite syndrome d/t excessive monoclonal IgM –> Tx with plasmapheresis

71
Q

Technetium-99m

A

Technetium-99m pertechnetate scan –> Meckel’s

Technetium-99m bone scintigraphy –> detects bone remodeling, blastic bone lesions

72
Q

Poison Ivy
Tx

A

Remove contaminated apparel
Cool compress
Topical corticosteroids
- Antihistamines are not effective

73
Q

Boerhaave syndrome (Sx, Dx, Tx)
Mallory-Weiss

A

Boerhaave:
- Transmural esophageal rupture –> mediastinitis –> fever. Mediastinitis has a high mortality rate if not treatd within 24hrs. Can also cause a pleural effusion, pneumomediastinium, pneumothorax
- Dx: Chest xray, Esophography or CT with water-soluble contrast
- Tx: acid suppression, Abx, NPO, Emergency surgical consult

Mallory:
- Partial tear of mucosa –> hematemesis
- Dx: Upper GI endoscopy
- Tx acid suppression but will heal spontaneously.

74
Q

Prerenal AKI
Acute tubular necrosis
Postrenal AKI
Causes, BUN/Cr, FeNa

A

Prerenal:
- decrease renal perfusion
- BUN/Cr >20
- FeNa <1%

Acute tubular necrosis:
- Tubular injury
- BUN/Cr normally (10-20)
- FeNa >2%
- Muddy brown cast

Postrenal:
- Urinary obstruction
- BUN/Cr variable
- FeNa variable
- AKI is rarely caused by unilateral urethral obstruction because thAme renal functional reserve of the contralateral kidney allows filtration of the entire blood supply, creatinine remains normal.

75
Q

Amputation care

A
  • Wrap in sterile gauze, moistened with saline and placed in a sealed, sterile plastic bag.
  • The bag should then be placed in a chill container with ice and saline or sterile water.
76
Q

Ankylosing spondylitis
Sx, Dx, trending progress, Comp, helpful practices, life expectancy

A

Sx:
- back pain with morning stiffness which improves with exercise. Reduce range of forward flexion and chest expansion.

Dx:
- Plan x-ray of sacroiliac joint to see spondylitis. If negative and there is high clinical suspicion, CT or MRI can be used.
- Repeat x-ray used to check disease progression (lumbar, cervical and sacroiliac joint and hip) in addition to ESR.

Comp:
- Restrictive lung disease
- Cauda equina syndrome

  • Regular aerobic exercise (swimming, walking, bicycling) can improve joint stability, strength and overall function.
  • No change in life expectancy
77
Q

GBS
Cause, Tx

A

Preceded by a GI illness (campylobacter) or respiratory infection –> cross-reacting antibodies to peripheral nerve components.

Must trend vital capacity and negative inspiratory force to monitor respiratory status.

Tx:
- Plasma exchange or IVFIG if nonambulatory and within 4 weeks of sx onset.
- Those who are ambulating and recovering do not require treatment.

The weakness may improve spontaneously, but tx shortens the time required for recovery.
Campylobacter tends to worsen presentation and course of illness.

78
Q

Cardiac tumors
Myxoma: Sx, histo, Comp
Rhabdomyomas: hx

A

Myxoma
- Most common
- “ball valve” obstruction in the left atrium (associated with multiple syncopal episodes)
- Histo: mucopolysaccharides stroma/gelatinous material and blood vessels- - Comp: Can embolism –> strokes

Rhabdomyomas:
- Most frequent 1° cardiac tumor in children (associated with tuberous sclerosis).
- Histology: hamartomatous growths.

79
Q

ITP/TTP
Cause, Sx, Labs, Tx

A

ITP
- Viral illness –> platelet autoantibodies
- Sx: petechiae, ecchymosis, mucosal bleeding (epistaxis, hematuria)
- Labs: isolated thrombocytopenia <100,000, few plts on peripheral smear
- Tx:
—Children: acute and self-limiting, observe if cutaneous sxs only. IF BLEEDING: glucocorticoids, IVIF, or anti-D
—Adults: chronic, observe if cutaneous AND plt >30,000. If bleeding OR plt <30,000: glucocorticoids, IVIF, or anti-D
- Rituximab if failed above therapy.
- Splenectomy is last resort.

TTP:
- Acquired or hereditary autoantibodies –> decrease ADAMTS13 activity –>uncleaved vWF mulitmers –> plt trapping and activation –> disseminated microvascular thrombosis
- Sx: Always (abd pain/nausea, petechial rash). Sometimes (kidney failure, neurological manifestations, fever)
- Labs: Hemolytic anemia, thrombocytopenia
- Tx: plasma exchange

80
Q

Uveitis vs keratitis
Sx, Dx, Tx

A

Anterior uveitis (iritis)
Sx: Pain, redness, visual loss, constricted and irregular pupils.
Dx: slit lamp exam showing leukocytes.
Tx: antibiotics of topical steroids

Infectious keratitis (infection of cornea):
Sx: severe photophobia with difficulty keeping eyes open.
Dx: Penlight exam shows corneal opacity or infiltrate.

81
Q

Burn injuries
Hypermetabolic response (Path, Sx, Tx)

A

Hypermetabolic response
- Within first 5 days of event
Path: Release of inflammatory mediators from damaged tissue —> increase catecholamines, glucocorticoids & glucagon.
Sx:
- Increased basal body temperature
- Hyperdynamic circulatory response: HTN, tachycardia
- Increase gluconeogenesis and insulin resistance –> persistent hyperglycemia.
- Increase protein and lipid metabolism –> lean muscle wasting
Tx: nutritional support, anabolic steroid therapy ie.Oxandrolone which is a synthetic testosterone analog that enhances protein synthesis and decreases protein catabolism.

82
Q

Substance overdose/ingestion
Caustic ingestion,

A

Oropharyngeal damage –> hoarseness, unable to control secretions, edema, necrosis with grey pseudomembrane, respiratory distress.
LARYNGOSCOPY should be used to assess impending airway compromise. Then undergo endoscopy within 24hrs to determine severity.

83
Q

Raynauds
Tx

A
  • Dihydropyridine calcium channel blockers (act on smooth muscles): Amlodipine, clevidipine, nicardipine, nifedipine, nimodipine.
  • Diltiazem also proven to help
  • If resistant, obtain further work up with ANA, RF, CBC, CMP, UA and complement levels.
84
Q

Zenker diverticulum
Pathogenesis

A

Cause: Abnormal spasm or diminished relaxation of the cricopharyngeal muscles during swallowing (cricopharyngeal motor dysfunction). This increases intraluminal pressure –> herniation of pharyngeal mucosa through a zone of muscle weakness (false diverticulum) in the posterior hypopharynx (Killian triangle).

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