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1
Q

Clinical features of somatic symptom disorder?

A

1+ somatic symptoms causing distress and functional impairment
Excessive thoughts or behaviors related to somatic symptoms
-Unwarranted, persistent thoughts about seriousness of symptoms
-Persistent anxiety about health or symptoms
-Excessive time and energy devoted to symptoms
For 6+ months

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2
Q

Management of somatic symptom disorder?

A

Regularly scheduled visits with the same provider
Limit unnecessary work-up and specialist referrals
Legitimize symptoms but make functional improvement the goal
Focus on stress reduction and improving coping strategies
Mental health referral if patient will accept

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3
Q

What are the components of HELLP syndrome?

A

Clinical features: preeclampsia, N/V, RUQ pain

Lab findings:
Hemolysis (->microangiopathic hemolytic anemia)
Elevated liver enzymes
Low platelet count

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4
Q

What causes HELLP syndrome?

A

Abnormal placentation triggers systemic inflammation and activation of the coagulation system and complement cascade

Circulating platelets are rapidly consumed and microangiopathic hemolytic anemia is particularly detrimental to the liver, increases bilirubin production

Resulting hepatocellular necrosis and thrombi in the portal system cause elevated liver enzymes, liver swelling, and distention of the hepatic capsule

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5
Q

Rx HELLP syndrome?

A

Stabilize the patient with magnesium for seizure prophylaxis and antihypertensive drugs
Delivery - only definitive treatment (should occur promptly at 34+ weeks or any gestational age with abnormal fetal testing or severe or worsening maternal status)

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6
Q

What are the most common intra-abdominal organ injuries due to blunt abdominal trauma (BAT)?

A

Hepatic and splenic lacerations

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7
Q

Presentation fo splenic injury?

A

Abdominal pain, tachycardia, left chest wall and shoulder pain without evidence of abnormalities of the shoulder (likely referred pain due to phrenic nerve irritation from splenic hemorrhage)

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8
Q

Next step in evaluation in the setting of suspected splenic injury from blunt trauma?

A

FAST (focused assessment with sonography for trauma) to identify signs of hemorrhage

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9
Q

Management of trauma patients?

A

Evaluate for cardiorespiratory stability
Have the spine immobilized until spinal injury has been ruled out
Establish adequate peripheral IV access (additional IV access such as a femoral line is not required in hemodynamically stable patients)
Focused neuro exam
Urinary catheter (in the absence of obvious pelvic injury and blood at the urethral meatus)
Imaging
Surgical intervention if acute cord compression with neuro defects or unstable vertebral fracture/disolcation

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10
Q

What is the purpose of placing a urinary catheter in patients with traumatic spinal cord injuries?

A

Assess for urinary retention and prevent acute bladder distention and damage

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11
Q

___ is indicated for symptomatic bradycardia (lightheadedness, presyncope, syncope).

A

IV atropine or external pacing

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12
Q

___ is commonly used for antimicrobial prophylaxis before surgery to prevent wound infections and is usually given within 60 minutes of the procedure.

A

IV cefazolin

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13
Q

What is the most common behavioral risk factor for TB?

A

Substance abuse

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14
Q

Presentation of reactivation TB?

A

Slowly worsening subacute or chronic symptoms that may go unrecognized for months

Low-grade fever, fatigue, mild cough (prominent in the morning due to pooling of secretions overnight) - initial symptoms

Weight loss, chest pain, dyspnea - progression

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15
Q

Why does M. tuberculosis preferentially infect the lung apices?

A

High oxygen tensions and slower lymphatic elimination (allowing for organism accumulation)

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16
Q

Cause of primary dysmenorrhea?

A

Excessive prostaglandin production

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17
Q

Risk factors for primary dysmenorrhea?

A 
<30 y/o
BMI <20
Tobacco use
Menarche at age <12
Heavy/long periods
Sexual abuse
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18
Q

Clinical features of primary dysmenorrhea?

A

Pain first 2-3 days of menses
N/V, diarrhea
Normal pelvic exam

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19
Q

Management of primary dysmenorrhea?

A

NSAIDs

Combined OCs

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20
Q

Presentation of endometriosis in adolescents?

A

Pain begins a few days prior and persists throughout the entire menstrual cycle

Uterosacral ligament tenderness
Cul-de-sac nodularity
Adnexal enlargement

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21
Q

What is salvage therapy?

A

Treatment for a disease when a standard treatment fails

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22
Q

___ therapy is defined as treatment given in addition to standard therapy.

A

Adjuvant (radiation therapy + radical prostatectomy)

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23
Q

___ therapy is typically given after induction therapy with multidrug regimens to further reduce tumor burden.

A

Consolidation

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24
Q

___ therapy is an initial dose of treatment to rapidly kill tumor cells and send the patient into remission (<5% tumor burden).

A

Induction

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25
___ therapy is usually given after induction and consolidation therapies (or initial standard therapy) to kill any residual tumor cells and keep the patient in remission.
Maintenance
26
___ therapy is defined as treatment given before the standard therapy for a pparticular disease.
Neoadjuvant
27
Clinical presentation of spontaneous bacterial peritonitis?
Temperature >100 F Abdominal pain/tenderness Altered mental status (abnormal connect-the-numbers test) Hypotension, hypothermia, paralytic ileus with severe infection
28
Diagnosis of SBP from ascitic fluid?
PMNS 250/mm^3 or more Positive culture (often GN like E. coli, Klebsiella) Protein <1 g/dL SAAG 1.1+ g/dL
29
Rx spontaneous bacterial peritonitis?
Empiric - third generation cephalosporins | FQs for prophylaxis
30
Clinical features of acute post-streptococcal GN?
``` Can be asymptomatic If symptomatic: -Gross hematuria (tea- or cola-colored urine) -Edema (periorbital, generalized) -HTN ```
31
Lab findings in acute post-streptococcal GN?
``` UA: +protein, +blood, +/- RBC casts Serum: -Decreased C3, possible decreased C4 -Increased serum Cr -Increased anti-DNase B and AHase -Increased ASO and anti-NAD ```
32
What is the pathophysiology of acute post-streptococcal GN?
Antigens on specific nephritogenic strains of GAS form immune complexes that are then deposited within the glomerular basement membrane. Following deposition, the complement system is activated, leading to accumulation of C3 in the glomerular deposits.
33
Timing of acute post-streptococcal GN?
1-4 weeks after GAS impetigo or pharyngitis
34
True or false? Treatment of initial GAS infection prevents acute post-strep GN.
False - this does not appear to be the case
35
Rx APSGN?
Supportive (symptoms typically resolve within weeks, labs take months to normalize)
36
___ typically presents with hematuria 1-2 days after the onset of a URI and serum complement levels are normal.
IgA nephropathy
37
Clinical features of tardive dyskinesia?
Abnormal involuntary movements due to prolonged use of antipsychotics or metoclopramide - Orofacial dyskinesia (tongue protrusion, lip smacking, grimacing) - Limb dyskinesia (dystonic postures, foot tapping, chorea) - Trunk dyskinesia (rocking, thrusting, shoulder shrugging)
38
Management of tardive dyskinesia?
Discontinue causative medication if feasible Switch to 2nd generation antipsychotic (quetiapine, clozapine) if continued antipsychotic is required Treat with valbenazine or deutetrabenazie
39
MOA of valbenazine/deutetrabenazie?
Reversible inhibitors of the vesicular monoamine transporter 2 (VMAT2)
40
Rx EPS (dystonia, parkinsonism, akathsia)?
Anticholinergics or (if akathisia) beta blockers
41
Rx akathisia (subjective sense of restlessness)?
Propranolol (beta-blocker)
42
DDx - stridor?
Acute: - Croup - Foreign body aspiration Chronic: - Laryngomalacia - Vascular ring
43
Presentation of croup?
Barky cough, inspiratory stridor, fever, rhinorrhea, congestion
44
Presentation of foreign body aspiration?
Acute onset of inspiratory stridor and/or wheeze without infectious symptom
45
Presentation of laryngomalacia?
Inspiratory stridor, worse when supine, improves when prone
46
Presentation of vascular ring?
Biphasic stridor that improves with neck extension (decreases tracheal compression); may also present with esophageal symptoms Patients <1 y/o
47
Pathophysiology of vascular rings/slings?
Abnormal development of the aortic arch, causing tracheal, bronchial, and/or esophageal compression Can be either complete or incomplete
48
Up to 50% of patients with a vascular ring also have ___.
A cardiac anomaly (VSD, tetralogy, etc.)
49
Pathophysiology of laryngomalacia?
Collapse of the supraglottic structures during inspiration
50
The majority of clavicular fractures occur in what part of the bone? When does it classically occur?
Middle third; during athletic events, follows a fall on an outstretched arm or a direct blow to the shoulder
51
Presentation of clavicular fracture?
Pain and immobility of the affected arm Contralateral hand is used to support the weight of the affected arm Affected shoulder is displaced inferiorly and posteriorly
52
A careful neurovascular exam should accompany all fractures to the clavicle due to its proximity to the ___ and ___.
Subclavian artery; brachial plexus
53
Management of fractures of the middle third of the clavicle?
Non-operative treatment with a brace, rest, and ice
54
Management of fractures of the distal third of the clavicle?
Open reduction and internal fixation to prevent nonunion
55
In treating SLE, cyclophosphamide is reserved for patients with what complications?
Significant renal or CNS problems
56
Serious side effects of cyclophosphamide?
Acute hemorrhagic cystitis Bladder carcinoma Sterility Myelosuppression
57
Cause of hemorrhagic cystitis and bladder cancer 2/2 cyclophosphamide?
Acrolein, a bladder-toxic metabolite
58
Prevent bladder-related complications of cyclophosphamide?
Fluids Void frequently Take MESNA
59
Cochlear dysfunction is a side effect of what 3 medications (2 chemo, 1 antibiotic)?
Cisplatin and carboplatin | AGs
60
What 2 medications have been implicated in causing optic neuritis?
Ethambutol | Hyroxychloroquine
61
What are 5 toxic causes of peripheral neuropathy?
``` Phenytoin Isoniazid Vincristine Heavy metals Chronic alcohol use ```
62
Raynaud's phenomenon may be caused by what 2 medications?
Beta-blockers | Ergotamine
63
What 2 medications are associated with thyroid dysfunction?
Amiodarone | Lithium
64
Gout is a side effect of what 1 medication?
Cyclosporine
65
Diagnostic procedure of choice for pregnant patients presenting with renal colic?
Renal and pelvic U/S
66
First-line treatment for school-age children with ADHD?
Stimulant methylphenidate
67
3 common side effects of methylphenidate?
Decreased appetite Weight loss Insomnia
68
Manage mild reduction in appetite due to stimulants?
Encourage child to eat favorite nutrient-dense foods Take medication after meals Monitor weight
69
What is the algorithm for work-up of a palpable breast mass in women <30?
U/S +/- mammogram - If simple cyst -> needle aspiration if the patient desires/if symptomatic -> return in 2-4 months for follow-up breast exam, as cystic fluid can reaccumulate - If complex cyst/mass (solid mass) -> image-guided core biopsy
70
What is the algorithm for work-up of a palpable breast mass in women 30+?
Mammogram +/- U/S If suspicious for malignancy -> core biopsy
71
Posterior acoustic enhancement on U/S indicates ___.
Fluid
72
When is breast MRI indicated?
In patients with known cancer to evaluate for disease recurrence and to screen for breast cancer in high-risk patients (BRCA carrier, first-degree relative of known BRCA carrier)
73
Why is screening mammography in women <30 generally not recommended?
The relatively dense breast tissue may impede adequate visualization of any masses present. Radiation exposure from mammography is a potential risk factor for breast cancer in young women.
74
What two general types of murmurs are usually due to an underlying pathologic cause?
Diastolic | Continuous
75
Diastolic and continuous murmurs should prompt further evaluation with ___.
TTE (valvular regurgitation, associated structural abnormalities, hemodynamic consequences)
76
Describe the murmur heard in aortic regurgitation (timing, quality, location, position)
Timing: early decrescendo diastolic murmur immediately after A2 Quality: high-pitched, blowing Location: left sternal border at the 3rd and 4th spaces Position: sitting up and leaning forward while holding breath in full expiration
77
___ is a useful screening test in patients with an intermediate probability of coronary heart disease.
Exercise EKG
78
___ is a non-invasive method to assess coronary artery calcification and intraluminal stenosis in patients with suspected coronary heart disease.
Coronary CT angiography
79
What type of murmur can be detected occasionally in young, asymptomatic adults and is usually benign when asymptomatic/no other abnormal findings?
Midsystolic murmur
80
Maternal risk factors for SIDS?
Smoking during or after pregnancy Maternal age <20 Inconsistent prenatal care
81
Infant risk factors for SIDS?
``` Prone/side sleep position Soft sleep surface, loose bedding Bed-sharing Prematurity Sibling with SIDS ```
82
Prevention of SIDS?
``` Smoke avoidance during and after pregnancy Routine prenatal care Supine sleep position Firm sleep surface Room-sharing Pacifier use ```
83
In patients unable to maintain adequate oxygen saturations, ___ should be initiated.
Bag-valve-mask ventilation (BVM) with 100% oxygen (goal O2 sat 88+%)
84
If BVM does not result in adequate oxygenation (i.e., oxygen saturation remains low), ___ should be attempted.
Endotracheal intubation using a video laryngoscope (to facilitate direct visualization of the peiglottis)
85
Given the risk of rapid respiratory deterioration, failure of a single attempt at endotracheal intubation with a video laryngoscope should immediately prompt ___.
Establishment of a surgical cricothyrotomy by the most experienced provider available
86
Patients with epiglottitis who develop rapid-onset respiratory failure (eg, tripod position, hypoxia, drooling, tachypnea) require urgent ___.
Airway management
87
Presentation - recurrent PUD with multiple ulcers and jejunal ulceration List some other presenting features
Gastrinoma aka Zollinger-Ellison syndrome - Age 20-50 - Dyspepsia, reflux symptoms, abdominal pain, weight loss, diarrhea, frank GI bleeding
88
ZES is usually sporadic, but may be found in conjunction with ___ in 20% of cases.
MEN1
89
Endoscopy findings in ZES?
Thickened gastric folds Multiple peptic ulcers Refractory ulcers despite PPI use Ulcers in the jejunum (suggesting excess gastric acid that cannot be fully neutralized in the duodenum)
90
When gastrinoma is suspected, what is the first step in work-up?
Endoscopy
91
If endoscopy suggests gastrinomy, what is the next step?
Check serum gastrin level off PPI therapy for 1 week
92
Next steps based on various serum gastrin levels?
<110 pg/mL - no gastrinoma >1000 pg/mL - check gastric pH off PPI therapy for 1 week - if >4, no gastrinoma. If 4 or less, further testing to localize gastrinoma 110-1000 pg/mL - secretin stimulation test - if positive -> further testing to localize. If negative - no gastrinoma
93
Why should gastric pH also be checked if gastrin is elevated?
Could be elevated due to failure of gastric acid secretion (achlorhydria)
94
What does a secretin stimulation test indicate?
Secretin stimulates the release of gastrin by gastrinoma cells. Normal gastric G cells are inhibited by secretin. Therefore, secretin administration should not cause a rise in serum gastrin concentrations in patients with other causes of hypergastrinemia
95
Who should get a calcium infusion study?
Patients who have gastric acid hypersecretion and are strongly suspected of having gastrinoma despite a negative secretin test
96
___ is a marker for well-differentiated neuroendocrine tumors and is elevated in several conditions such as carcinoid tumors, hyperthyroidism, chronic atrophic gastritis, and even chronic PPI therapy.
Serum chromogranin
97
___ is an autoimmune disorder of childhood marked by symmetric arthritis of 5+ joints of the upper and lower extremities.
Polyarticular juvenile idiopathic arthritis

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