Mixed 1 Flashcards
PUD refers to ulcerations in the stomach or duodenum that are most commonly caused by ___ or ___.
H. pylori infection; NSAIDs
Classic symptoms of a duodenal ulcer?
Epigastric pain, nausea, and/or early satiety in association with food
Occur in the absence of a food buffer
Epigastric pain 2-5 hours after meals, on an empty stomach, or at night
Diagnosis of PUD?
Upper GI endoscopy
Gastric cancer can cause melena and abdominal pain, but is usually accompanied by ___ and ___.
Weight loss and anorexia
Define abnormal uterine bleeding.
Deviation from the normal menstrual cycle, which typically occurs every 24-38 days and lasts 7 or fewer days
Although abnormal uterine bleeding can be caused by many problems (pregnancy, anatomic abnormalities, anovulation, coagulpathy, endocrine disorders, infection, etc.), it is also the most common presenting clinical feature of ___.
Endometrial hyperplasia and cancer
What are the indications for endometrial biopsy in a patient <45?
Abnormal uterine bleeding + one of the following:
- Unopposed estrogen (obesity, anovulation)
- Failed medical management
- Lynch syndrome (hereditary nonpolyposis colorectal cancer)
ALSO:
-Atypical glandular cells on Pap test (anyone 35+)
What are the indications for endometrial biopsy in a patient 45+?
AUB or postmenopausal bleeding
True or false - an endometrial stripe of 4 or fewer mm excludes endometrial cancer in pre-menopausal and post-menopausal patients.
False - true for postmenopausal patients, cannot reliably do so in premenopausal patients
What is the first-line option for management of AUB in premenopausal patients?
Combined estrogen/progestin OCs or cyclinc/continuous progestins
Classic presentation fo Friedreich ataxia?
Progressive gait ataxia and dysarthria in adolescents or young adults
Friedreich ataxia is an ___ disorder (genetic) caused by a trinucleotide repeat (___) expansion that results in loss-of-function mutation in the ___ gene.
AR; GAA; frataxin
Clinical features of Friedreich ataxia?
Neurologic deficits (Cerebellar ataxia, dysarthria, loss of vibration and/or position sense, absent DTRs), HCM, skeletal deformities (eg, scoliosis), DM
Prognosis of patients with Friedreich ataxia?
Mean survival age 30-40
Mortality due to cardiac dysfunction (2/2 HCM)
PAD is a coronary artery disease risk equivalent, and the medical therapy for such patients should include what?
Aggressive risk factor modification with counseling for smoking cessation, lipid-lowering therapy (statin), low-dose aspirin, evaluation and treatment for HTN and DM
Following this, start a supervised exercise program (minimum of 12 weeks with 30-45 minutes of exercise 3x/week) - all patients with claudication
Percutaneous or surgical revascularization in patients with PAD is generallyer served for what kinds of patients?
Persistent symptoms despite initial exercise and/or pharmacologic therapy
What should be considered in patients with PAD who have persistent symptoms despite antiplatelet therapy and adequate supervised exercise programs?
Cilostazol (PDE3 inhibitor, vasodilator)
What is the pathophysiology of avascular necrosis?
Disruption of circulation of bone through micro-occlusion, abnormal endothelial function, or increased intraosseous pressure
Causes of avascular necrosis?
Long-term glucocorticoid use Alcohol abuse SLE Antiphospholipid syndrome Hemoglobinopathies (eg, sickle cell) Infections (eg, osteomyelitis, HIV) Renal transplantation Decompression sickness
Clinical manifestations of avascular necrosis?
Groin pain on weight bearing
Pain on hip abduction and internal rotation
No erythema, swelling, or point tenderness
Lab and radiologic findings in avascular necrosis?
Normal WBC, ESR, CRP
XR often normal in the first few months
Crescent sign (advanced stage)
MRI is most sensitive modality
Carcinoembryonic antigen (CEA) is elevated in ___ cancer and in ___ (patient population).
Colon; smokers
used to monitor patients after colon resection, not a screening test
List 5 medications that should be avoided in G6PD deficiency (may trigger hemolysis).
- Diaminodiphenyl sulfone (dapsone)
- Isobutyl nitrite
- Nitrofurantoin
- Primaquine
- Rasburicase
In addition to some medications, what are two other common triggers of hemolysis in patients with G6PD deficiency?
Any oxidative trigger -> infections (leukocytes release highly oxidative reactive oxygen metabolites), fava beans
G6PD deficiency is ___ (inheritance pattern) and thus primarily affects ___ patients.
X-linked; male
Note that female patients who have homozygous mutations or skewed lyonization of heterozygous mutations can also express the disorder
What is the most common malignancy of the lip, with 95% of cases occurring where?
Squamous cell carcinoma
Lower lip vermillion
Diagnosis of squamous cell carcinoma is confirmed with biopsy - typical pathologic findings?
Invasive cords of squamous cells with keratin pearls
A Tzanck preparation of vesicular fluid can identify the characteristic giant cells of ___.
HSV infection
___ is characterized histologically by invasive clusters of spindle cells surrounded by palisaded basal cells.
Basal cell carcinoma (BCC)
Like SCC, BCC can form ulcerating lesions and is associated with sun exposure. However, it is much less common than SCC and typically affects what part of the lip?
Upper (instead of lower)
___ are characterized by shallow fibrin-coated ulcerations with underlying mononuclear infiltrates.
Aphthous ulcers (canker sores)
What are the three serologic phases of acute HBV?
Early
Window
Recovery
Compare the serologies of the three phases of acute HBV?
Early: HBsAg + HBeAg + IgM anti-HBc + HBV DNA +++
Window:
IgM anti-HBc +
HBV DNA +
Recovery: IgG anti-HBc + Anti-HBs + Anti-HBe + HBV DNA likely +
Expected serology in chronic HBV carrier?
HBsAg +
IgG anti-HBc +
Expected serology in acute flare of chronic HBV?
HBsAg + HBeAg likely + IgM anti-HBc + IgG anti-HBc + HBV DNA +
Expected serology if vaccinated for HBV?
Anti-HBS +
Expected serology of immune due to natural HBV infection?
IgG anti HBc +
Anti-HBs +
Positive ___ antigen indicates a higher risk of transmission of hepatitis B.
HBe
Healthcare workers exposed to blood from HB patients should receive what? If unvaccinated?
Post-exposure prophylaxis (HB Ig) within 24 hours
Both the HB vaccine (first dose within 12 hours, next 2 doses according to standard schedule) and Ig
Hyperactivity of the ___ axis, resulting in increased ___ levels has been associated with depression. Other findings in depressed patients?
HPA; cortisol
Decreased hippocampal and frontal lobe volumes
Changes in sleep architecture (REM sleep latency and slow-wave sleep are both decreased)
Enlarged lateral cerebral ventricles are associated with what psychiatric illness?
Schizophrenia
___ infusion can provoke panic attacks in susceptible patients and has bene used in research to identify those with panic disorder.
Lactate
Risk factors for uterine inversion?
Nulliparity
Fetal macrosomia
Placenta accreta
Rapid L&D
Uterine inversion can result from excessive ___ and traction on the umbilical cord before placental separation.
Fundal pressure
How does uterine inversion present?
Fundus collapses into the endometrial cavity and prolapses through the cervix, result in a smooth, round mass protruding through the cervix or vagina
Uterine fundus no longer palpable transabdominally
___ occurs when the placental villi attach directly to the myometrium, resulting in a placenta that does not spontaneously separate and deliver.
Placenta accreta
Uterine atony only occurs after ___.
Placental delivery (as it is a failure of the uterus to contract and compress the placental bed blood vessels after placental delivery)
How is uterine inversion managed?
- Aggressive fluid replacement
- Manual replacement of the uterus (if the initial attempt is unsuccessful, uteirne relaxants like nitroglycerine or terbutaline may be administered as an aid; laparotomy if manual replacement fails)
- Placental removal and uterotonic drugs (oxytocin, misoprostol) after uterine replacement
Why should the uterus be manually replaced prior to placental removal in the setting of uterine inversion?
Delay can make replacement more difficult as the uterus can become edematous and the cervix can contract around the inverted uterus
Following H&P to rule out other causes (oropharyngeal, GI, etc.), what is the appropriate evaluation of mild/moderate hemoptysis?
CXR CBC Coag studies Renal function UA Rheum work-up (if suspected)
Then CT scan +/- bronchoscopy (depending on imaging and if intervention is needed)
Then treat the cause; persistent bleeding is treated via bronchoscopic interventions, embolization, or resection
Following H&P to rule out other causes (oropharyngeal, GI, etc.), what is the appropriate evaluation of massive hemoptysis (>600 mL/24 hours OR 100 mL/hr)?
ABCs
If bleeding stops, proceed to the work-up addressed in the previous card. If it continues, proceed to bronchoscopic interventions. If the source is not found, pulmonary arteriography is next. Last step is urgent thoracotomy and surgical intervention.
What is the greatest danger of massive hemoptysis?
Asphyxiation due to the airway flooding with blood (not exsanguination)
How should patients with massive hemoptysis be positioned and why?
With the bleeding lung in the dependent (lateral) position to avoid blood collection in the airways of the opposite lung?
The newborn with increased work of breathing and fluid-filled fissures has ___, a condition caused by delayed resorption and clearance of alveolar fluid.
TTN (Transient tachypnea of the newborn)
Explain the pathophysiology of TTN.
Normally, mature fetal lungs begin to reabsorb liquid in late gestation in response to increased catecholamine signals. This resorption mechanism increases during labor; thus, patients born prematurely or by C-section are at increased risk
Why are breath sounds often clear in TTN?
Fluid remains in the interstitial space rather than in the alveoli
Treatment of TTN?
Supportive (supplemental O2 as needed)
Resolves spontaneously within a few hours to days as passive fluid resoprtion is completed
___ can be the earliest manifestation of vaso-occlusive disease in sickle cell disease and presents with the acute onset of bilateral hand and foot swelling and tenderness.
Dactylitis
DDx of bone pain in sickle cell disease?
- Vaso-occlusive crisis
- Osteomyelitis
- Avascular necrosis
Compare the presentations of vaso-occlusive crises, osteomyelitis, and avascular necrosis.
Vaso-occlusive: Acute severe pain in 1+ sites \+/- low grade fever Erythema and warmth May be preceded by a trigger
Osteomyelitis Acute or subacute focal pain at 1 site Prolonged fever Erythema and warmth Positive blood culture
Avascular necrosis
Chronic worsening pain
No fever
No warmth/erythema