NBME 11 Flashcards
Heat exhaustion
vs
heat stroke
exercise intolerance, increased core body temp, no neuro disturbances
hyperthermia + AMS + neuro deficits
hypernatremia, hyperchloremia, hyperkalemia
tx: remove individual from the heat, remove excess clothing, initiate cooling measures: immersion in cool water or evaporative cooling
rapidly progressive dementia and ataxia with stimulus indiuced or spontaneous myoclonas
Creutzfeldt Jakob disease
dx: CSF 14-4-4
autopsy: spongiform degeneration of the cortex
tx: death within one year, hospice, benzo for myoclonus
ethambutal ae
optic neuropathy : scotoma, red-green color blindness, blurred vision, partial visioin loss
neutropenia
thrombocytopenia
Isoniazid ae
inhibits synthesis of mycolic acids in cell walls
hepatoxic, neurotoxic, B6 pyridoxine deficiency (peripheral nueropathy and sideroblastic anemia)
Pyraxinamide ae
hepatoxic
hyper-uricemia
arthralgia
criteria for causation: (4)
- biologic plausibility
- dose-relationship
- specificity and strength of association
- temporal relationship
biological plausibility
observed association can be explained by a known biological pathway or mechanism
Specificy of the association
Strenght of the association
Specificy: one to one relationship between the exposure and the outcome
risk factor is the cause of ONE disease
Strenght: NEED R value (closer to 1 higher correlation)
Temporal relationship
if the exposure is known to precede the outcome
if pt were known to have no cardio dx prior to use of cigarettes then developed cardio dx
Dose-response relationship
the positive correlatino found between increased risk for cardiovasc dx and number of cigarettes smoked daily indicates that as the number of cig smoked daily, so does the risk for cardio vasc dz
number of cigs is dose
cardiovasc dz is response
hospital workers or high risk population PPD skin test:
greater than 10mm must treat
do xray
if active: quad tx
if latent: isoniazid for 9 months
pt with pneumonia, given abx, then preceded to have developed a parapneumonic effusion and then inot empyema (bacterial infection in pleural space)
next step
abx alone wont help, MUST PLACE CHEST TUBE
infusion of tissue plasminogen activator and recombinant deoxyribonuclease (DNAse) and iv abx into pleural space through chest tube
if chest tube fails –> video-assisted thorascopic surgery for decortication and drainage
children with hypertension
next step?
renal doppler ultrasound
serum renin and aldosterone
serum/urine metanephrines
on echo: pericardial effusion
collapse of right atrium at end of diastole
collapse of right ventricle in early part of diastole
cardiac tamponade
JVD hypotension, distant heart sounds
imapired right ventricular diastolic filling
risk factors any of: family hx of cvd, htn, dm, smoking
USPTF screening for men aged > 35 and women >45
lipid studies
tx: statins
anti-depressants with no sexual ae
mirtazapine : selective alpha 2 antagonist and serotonin modulator
Bupropion (dopamine and norepi)
ulcerative colitis managment meds
1) mesalamine enema , sulfasalazine
2) Corticosteroids: prednisone, Budesonide, hydrocortisone
3) anti-TNF (infliximab)
4) Janus Kinase enzyme inhibitor: Tofactinib
baby (less than 1yr) with recurrent UTI, voiding cystourethrography shows backflow of urine from bladder to renal pelvis
next step?
vesicoureteral reflux
can lead to pyelonephritis which later leads to renal scarring, htn, ckd
give: prophylactic daily antibiotc therapy
pelvic u/s: enlarged endometrial stripe
aub in post-menopausal
aub in premeno with prolonged exposure to estrogen
endometrial carcinoma
endometrial glands within the myometrium
large globular boggy diffusely enlarged uterus
transvag u/s : diffusely enlarged uterus, asymmetrical myometrial thickening, loss of endomyometrial border, subednometrial cysts
adenomyosis
tx: definitive: hysterectomy
conservative: progesterone IUD
gonadotropin-releasing hormone analogs
aromatase inhibitors
monoamniotic preg
vs
monochorionic preg
complications
conjoined twins or cord entaglement
twin twin trasnfusion or selective fetal growth restriction
hyperemesis gravidum management:
IV fluids
B6 supplements
antiemetics
usually seen in molar pregnancy so do a pelvic u/s and B-hcg levels
will see ketonuria or ketonemia
fever in pt with sickle cell and no spleen
any encapsulated pathogen: haemophilus influenza, neisseria meingitidis, streptococcus pneuomiae, pseudomonas, klebsiella
tx: ceftriaxone
friable ulcerative lesion on cervix painless bleeding
cervical cancer
uterine size out of proportion of expected gestational age
b hcg super high
u/x: diffuse echogenic structures within endometrial cavity along with ovarian theca lutein cysts
hydatidiform moles
third trimester painless vaginal bleeding, placental tissue partially or entirely over internal cervical os
placenta previa
gram positive bacillus, can cause bacterial meningitis in infants and elderly
tumbling motility
listeria
acute dystonic reactions: D2 antagonist
torticollis, retrocollis, opisthotonos 9arching back), oculogyric crisis (deviation of eyes)
haloperidol or fluphenazine
dopamine-cholinergic basal ganglia
tx: diphenydramine or benztropine (anticholinergics)
risk factors: male, young age, recent cocaine use, hx of acute dystonia
jaundice, hyperbilirubinemia, increased serum liver enzymes in pt with previous IV drug use
acute hepatitis
d/t viral (hep a, b, c), medications or supplements, autoimmune dz, ischemic injury
positive anti-HBc IgM means acute infection
anti-smooth muscle antibody found in autoimmune hepaititis: fatigue, wt loss, jaundice, n/v, pruritis, RUQ pain
refeeding syndrome
within 2 weeks of refeeding:
hypo-phoshpatemia hypo-kalemia, hypo-magnesmia
can lead to heart failure, resp failure, arrythmia, seizures
pt with celiacs has super high PTH but low vitamin-D and hypocalcemia and hypophosphatemia
celiacs –> malabsorption (intraepithelial lymphocytosis, villous atrophy, crypt hyperplasia) –> impaired vitamin D absorption –> hypocalcemia 2/2 osteomalacia
can also devlop secondary hyper-PTH with hypo-Ca and hypo-Phos
next step: DEXA : ASSESS bone density for pt with celiacs and at risk for osteomalacia
calcium absorption and bone mineral density imporve after starting gluten free diet
short digits (brachydactylyl), short stature, developmental delay, round facies
osteodystrophy – Albright hereditary osteodystrophy
pseudo-hypo-parathryoidism
impaired reposne of the kidney to parathyroid hormone –> hypocalcemia
Primary hyperparathyroidism
mcc
parathyroid adenoma (then hyperplasia, then carcinoma)
subperiosteal bone resporption, renal failure, hyper-ca, hypo-phos
painless jaundice and weight loss
pancreatic cancer
Marfans pt sports:
could do low-moderate intensity sports IF AND ONLY IF they do not have echo evidence: aortic root dilation, mod-to severe MR, or family hx of sudden cardiac death
NEVER allowed to do contact sports – risk for aortic dissection and rupture
annual echo and opthalmic exam in general for pt with marfans
UTI in age less than 1 yo
next step?
likely d/t congential urinary tract abnormality and might lead to ureteral obstruction and vesicoureteral reflux –> dilation of renal pelvis and calyces and compression/atrophy of renal parenchyma –> hydronephrosis
next step ** renal ultrasound**
and then fluoroscopic voiding cystourethrogram
vs IV pyelography: can show renal collecting duct, ureters, bladder –> but exposes child to radiation
muscle atonia lost –> violently acting out dreams, sometiems remember dreams + resting tremor
Parkinsons
dx: polysomnography showing lack of atonia during REM
tx: safe sleep enviroment, melatonin/clonazepam
(can also see this in lewy body dementia)
CSF: Leukocytes less than 100/mm3 with a predominance of lymphocytes (monocytes) normal or increased protein, normal glucose
aseptic (viral) meningitis
heart failure
cvp:
pcwp
svr:
SV:
CO:
cvp: high
pcwp: high
svr: high
SV: LOW DECREASED
co: low
impaired forward flow of blood – so body tried to maintain BP for peripheral perfusion by increasing SVR
pt with RA prior to srugery what should they get
lateral xray of cervical spine in flexion and extension for proper intubation – can lead to paralysis or death if translation instability is present
Vascular tumors
hemangioblastomas of retina and cerebellum
angiomatosis of the skin
can also see: renal clear cell carcinoma, pancreatic tumor, pheochromocytoma
VHL
do CT SCAN OF ABDOMEN for kindey, pancreas, adrenals
tx: surgical excision
bloody diarrhea, thrombocytopenia, hemolytic anemia
E coli (shiga toxin producing)
shiga toxin –> leads to microvascular thrombosis –> platelet consumption and shearing –> form schistocytes
elevated LDH
thrombosis in renal vasculature –> endothelial damage –> renal injury
HUS (hemolytic uremic syndrome) renal failure, thrombocytopenia, microangiopathic hemolytic anemia
pt with fever but bradycardia
bacteremia, rose colored spots on chest and abdomen
salmonella typhi
no spleen
what vaccines?
meningococcal conjgate (against serotype B) must be given every 5 years
pneumococcal PCV13 PPSV23
annual influenza
Haemophilus influenza type B
mechanical ventilation after 10-14 days
next step?
tracheostomy tube – decreased risk for laryngeal injury, better comfort, easier ventilator weaning
complications: tracheal stenosis or tracheomalacia
tracheoarterial fistula
site infection
fever, productive cough, and pulmonary infiltrate
dx
tx
Community acquired pneumonia
Strep Pneumo, haemop influ, moraxella, mycoplasma pneumo, staph aureus, chlamydophilia pneumo
tx: azithromycin, doxycylcine, amoxicillin
if have comorbidities: COPD, DM, liver, cardiac, renal dx
amoxicillin-clav or levoloxacin
expect to get better within 24 to 48 hrs
no need for repeat imaging
14M with consistently decreased growth velocity (always 3rd percentile), bone age younger than chronological age, tanner stage 1
Constitutional growth delay
pre-puberty but once puberty hits sudden spike in height
short parents, normal gain of height velocity, bone age corresponds to chronological age
Familial hereditary short stature
vs constitutional will not see that normal gain of height velocity and bone age is younger
prego with hyperthyroid symptoms and high free thyroxine and low tsh
next step
b-blocker for tachycardia and tremor
antithryoid meds: Propylthiouracil in 1st trimester (hepatoxic tho) and then Methimazole for the rest (in first trimester can cause fetal aplasia cutis – absent dermal holes in skin, scalp)
scaly patches with alopecia, and patches of alopecia with black dots that represent broken hairs
tinea capitis
oral griseofulvin
maculopapular rash, morbilliform rash
10days ago recieved MMR vaccine
replication of a live vaccine virus strain
measles prodromal fever, cough, coryza, conjuctivitis, and confluent maculopapular rash that starts at the head and neck and spreads to trunk (excluding palms and soles)
bright red macules with a bluish-white center on buccal mucosa and lymphadenopathy
live vaccines can cause fever, rash, transient joint pain
this sequeale occurs in 5% of kids who get the vaccine
other live vaccines: yellow fever, intranasal influenza, smallpox, varicella-zoster, rotavirus, oral poliovirus
since pt is missing other symptoms CCC most likely just d/t recent vaccination
erythematous tongue, rash, desquamation of hands and feet
rash is rough, papular, diffuse body
scarlet fever (strep pyogenes GAS)
Several high fevers can even have seizures,
fevers end, then blanching macular eruption on neck and trunk spread outwards to face and extremities
Roseola – exanthema subitum
HHV-6
pink patches on b/l cheeks slapped cheeks
lacy macular eruptions on trunk and extremities
Erythema infectiosum – fifth disease
Parvovirus B19
small bony spur protruding from the surface of the bone capped by cartilage, abel to palpate, painless, usually near joints (knee/ankle)
osteochondroma
benign – tx not necessary unless interfering with growth or limb deformity (surgery)
adolescents: low grade joint pain, swelling, small well defined epiphyseal lesion with sclerotic border
chondroblastoma
t (11,22) adolescent boys, elevated periosteum layered neocortex formation
usually long bones femur tibia
histo: multiple small round blue cells
Ewing sarcoma
xray: radiolucent bone lesion, usually proximal femur, can have pain, usually solitary
osteoid osteoma
vs osteochondromas (usually multiple, sessile/pedunculated tumor w/ cortex continuous with underlying bone and cartilagenous cap and PAINLESS)
ingest substance (plants) mouth pain, generalized burning sensation of skin, abdominal pain, n/v
Paraquot poisoning – herbicide plant chemical
3cm nontender fluctuant mass external to hymenal ring, adjacent to introtius (posterior vulva underlying mucosa of the vestibule)
bartholin gland cyst
cyst can turn into abscess with polymicrobial skin and enteric flora, sometimes neisseria gonorrhea
if 3cm or greater –> incision and drainage
vs vestibular will be near the urethra
mass internal to hymenal ring and recent obgyn checkup
episiotomy inclusion cyst
2/2 to episiotomy
skin colored nodules with central punctum can get infected, firm, on vagina
sebaceous cyst
firm not fluctulant like bartholyn gland cyst
fluctuant swelling near the urethra caused by blockage of the outflow of Skene’s glands
Vestibular gland cyst
vs
bartholin gland cysts occur adjacent to the introitus
decrescendo murmur that begins after S2 heard at left sternal border
aortic regurgitation
early diastolic decrescendo murmur best heard in R second intercostal space
bisferiens carotid pulsation – arterial waveform has a double systolic peak with an initial sharp, shortened peak followed by a lower amplitude, broader peak
can have left sided cardiac volume overload, such as dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or completely asymptomatic
ectopic endometrial tissue outside of uterus
chronic dysmenorrhea, dyspareunia, dyschezia, infertility
endometriosis
decerases the risk for future ischemia strokes and all-cause mortality
statins
must give after a stroke
pt has head trauma mva, continues to be hypotensive even after IV fluids with hypernatremia and urine osmolality of 100
central DI
inadequate secretion of ADH (vasopressin) from posterior pituitary
leads to decreased concentration of aquaporin channels inserted within principle cells of collecting tubules –> inability to absorb adequate amounts of free water –> dilute urine and increased serum osmolality
tx: desmopressin
Hirschsprungs dx
dx:
barium enema (can have false negative results)
rectal manometry (sensitive)
rectal suction biopsy (most sensitive and specific) willl show absence of ganglion cells
decreased lung capacity
decreased residual volume
normal fev1
obese and shallow breaths
restrictive lung disease
most likely obesity hypoventilation syndrome
rld: ild, ohs, neuromusclar dx like ALS
prego at 28 weeks, cervix partialy effaced with uterine contractions every 5 min
preterm labor
if cervix is 3cm or more, positive fetal fibronectin test
if less than 34 weeks: corticosteroids (lung maturity)
if less than 32 weeks: magnesium sulfate (cerebral palsy)
antibiotics for Group B strep
tocolytics: nifedipine, terbutaline to reduce contractions
acral lentiginous melanoma
prego with HIV
what to give prior or during delivery
what to give neonate
zidovudine
PEP + bottle feed only
Old pt s/p surgery, opoiates, trauma, now has marked colonic dilation
ogilvie – colonic pseudo-obstruction
increased risk for colonic perforation or ischemia
dx; CT or barium contrast enema
tx: pro-cholinergic agent neostigmine and colonic decompression
perforation –> ex lap
pt with lupus flare and lupus pleuritis
tx
first NSAIDS
then glucocorticoids
failure rate of a test to detect disease when it is present
sensitivity
1 - false negative rate
Primary prevention strategies:
secondary
tertiary:
primary: aim to prevent the effects of disease before disease even occurs (obesity – make city bike lanes and walk trails)
secondary: aims to identify disease early in its course through SCREENING efforts
tertiary: aims to slow or ameliorate the progression and ocmplications of a disease through thereaputic intervention
pts with low risk polyps such as one to two small tubular adenomas – how often colonoscopy
vs
more than three polyps with atypical features or larger size or atypical serrated polyps
5yrs
3 years
vaginal bleeding with NO open os (closed os)
threatened abortion
vaginal bleeding and an open os
inevitable abortion
incomplete aborition once the passage of products beings
passage of all products and closed os
complete abortion
asymptomatic fetal demise without passage of products
missed abortion
spontaneous abortion managment
medical management: mifepristone and misoprostol TOGETHER (not separate)
or
uterine evacuation with Dilation and suction curettage highest success rate
DVT
dx: duplex ultrasound (obstructed deep viens, normal superficial veins)
tx: subcutaenous low-molecular weight heparin – enoXaprrin
asymptomatic Conjugated hyperbilirubin in abscense of other liver enzymes
Dubin Johnson (or roater)
defective hepatocellular excretion of conjugated bili into bil canliculi
transprotation needs MRP2 (multidrug resistance related protein) pump encoded by the ABCC2 gene
no tx necessary
asymptomatic Conjugated hyperbilirubin in abscense of other liver enzymes
Dubin Johnson (or roater)
defective hepatocellular excretion of conjugated bili into bil canliculi
transprotation needs MRP2 (multidrug resistance related protein) pump encoded by the ABCC2 gene
no tx necessary
20s-40s with recurrent sinopulmonary (sinus, pulmonary, pneumo, bronchitis) infections and splenomegaly
Common Variable ImmunoDeficiency (CVID)
increased risk for development of autoimmune dz Rheumatoid arthritis, autoimmune hemolytic anemia, autoimmune thryoid
high risk for cancer: Gastric cancer and non-hodgkin lymphoma
dx: measure serum immunoglobulins (decreased IgG, IgA, and/or IgM)
IMPAIRED B-lymphocytes into plasma cells –> impaired production of Ig’s
tx: IVIG
inflammation cracking of skin aroudn lips, mouth, tongue
riboflavin deficiency b2
asthma managmenet
test
dx: spirometry or pulmonary function test
decreased FEV1
NORMAL FVC
increased TLC
methacholine challenge (if not actively having symtpoms)
bronchodilator: improved FEV1 by at least 12%
dental procedure with aortive valve replacement
amoxicillin
if allergic to PCN: macrolide: clarithromycin
bilateral hilar lymphadenopathy and possible coarse upper lobe-predominant reticular pulmonary opacities (also chronic condition)
sarcoidosis
immunocompromised with diffuse bilateral infiltrates often prominent around hila
Pneumocystis jirovecci
dx: methenamine silver or toluidine blue stains (stains cyst walls fungus yeas like causes pneumo)
tx: bactrim, atovaquone, or pentamidine
Lambert Easton dx?
neuromuscualr junction
antibodies to voltage gated calcium channels
dx: reptitive nerve stimulation with electromyography
nerve conduction studies
exercise testing
tx: pyridostigmne (for acetycholine symptoms : can have dry mouth, ptosis, constipation)
pt with CKD
what should he restrict?
intake of phosphorous and potassium
fucked kidneys!!!
ckd prone to volume overload, hyperK, hyperPhos, metabolic acidosis, hyper-PTH, osteodystrophy, anemia(check Hg)
uti
uti wiht pyleneprhtis (CVA tenderness)
nitrofurantoin
bactrim, ceftriaxone, ciprofloxacin, or amoxicillin/clav
pt on valproic acid and has nose bleeds
what needs to be monitored
check platelets
can cause leukopenia and thrombocytopneia
progesterone challenge
if withdrawal progesteron results in endometrial bleeding: normal estrogen but inappropriate timing of her hormonal cycle to cause ovulation
if no bleeding: deficiency of estrogen (primary ovarian failure), outflow obstruction, or hypothalamic pituitary dysfunction
acute otitis media
vs
mastoiditis
tx: oral amocilin
tx: IV vancomycin +/- surgery
must do CT temporal bone
often occurs as a sequeale of acute otitis media : bacterial infection of mastoid air cells of temporal bone
essential tremor
worse with stress, better with aclohol
tx: Propanolol (b-blocker)
pt with upper arm acute limb ischemia (pain, pallor, pulseless, parasthesia, paralsis, poikilotheria)
do an echo (TEE)
most LIKELY d/t arterial thromboembolism from heart
mammogram every 1 to 2 years starting at ___ to ___
40 go 74
parotid gland mass
next step?
excision and drainage
pt with crohns started on infliximab
what to follow up with in one month
CBC
ae: anemia (same as azathioprine another crohns drug causes pancytopenia)
tnf-alpha inhibtor
prior to starting rule out Tb with igra or ppd
when a study demonstrates no difference between nul and alternative hypothesis but in fact there is a difference
type II error (beta)
false negative
can be reduced by increasing power through larger sample size and increasing precision in measurements
fibrosarcoma painless mass in thigh
next step?
soft tissue sarcoma
do a CT of abdomen and chest since it can hematogenously spread all over
baby with poor weight gain, back arching after feeding, appears in pain
reflux esophagitis
GERD in babies
tx: decreased feed volume while increasing frequency
keeping baby upright 20-30min after feed
hypopigmented oval macules or patches + seizure + cognitive dysfunction
Tuberous Sclerosis
AD hamartomas in CNS
ash leaf spots – hypopigments
angiofibromas on face
fibrous plaques on forhead
ungal fibromas around nails
shagreen patch (lower back)
CNS: glionueronal (cortical fibers) hamartomas or sub ependymal noduls/giant cell tumors
cardiac rhabdomyomas (mitral regurg) or renal angiomyolipomas
CAN lead to malignancy of soft tissues, brain, kidney
cutaneous neurofibromas, cafe au lait spots, pigmented iris hamartomas, optic gliomas, pheochromocytoma
Neurofibromatosis
hyperpigmented spots vs ash leaf is hypopigmented in TS
port wine stain
Sturge weber
angiomatosis of leptomeninges (leads to seizures, intelectual disability, focal neuro deficits)
episcleral hemangioma (leads to early onset glaucoma)
hemangioblastomas of retina and CNS
angiomatosis of skin and mucosa
VHL
pheochromocytoma and b/l renal cell carcinoma
pt with elevated pth + galactorrea + fam hx of pituitary tumors
MEN syndrome 1
pituitary(prolactinoma) pancreatic (insulinoma, glucagoma, VIPoma) parathyroid
bromocriptine for galactorrea
surgical parital (subtotla) resection of parathyorid to decrease PTH
hereditary spherocytosis mangement
definitive is splenectomy
kid with facial angioedema and pulm symptoms
hereditary angioedema edema
c1-esterase inhibitor deficiency
over production of bradykinin (dont give them ace inhibtiors)
will see low c4 and c1 esterase inhibtior
(pulm sxms d/t resp vasodilation)
exacerbate peripheral edema
also facial flushing, headache, gingival hyperplasia
calcium channel blockers
nifedpine
pt greater than 35
and smoking more than 15 cig daily
uncontrolled htn
hx of hypercoagubility (or thromboembolism or storke)
or hx of migraine with aura, breast or liver cancer)
should not:
should not take OCPS
espeically greater than 35 and smoking
increased risk of stroke
can use copper IUD instead
overactive bladder tx:
vs
overflow incontince tx:
oxybutiin
bethanechol (muscarinin agen promotes bladder contraction)
overflow can be d/t obstruction or neuro insult (ms, stroke, dm nephropathy, trauma)
oxygen therapy
PaO2: 55mm Hg
or
O2 sat: 88% or less
age under 5 with high fever and seizure with bulging right tympanic membrane
febrile seizure
can be d/t viral or bacterial cns from acute otitis media
give oral anitbiotcs
bee sting next step? prevent future rxn?
epinephrine
venom immunotherapy – builds tolerance
pst menopausal woman with vaginal spotting
can be endometrial carcinoma
must do endometrial biopsy
pelvic u/s: thickened endometrial stripe with endometrial hyperlamsia (should be 4mm or less in post menopausal)
tx: hysterectomy with b/l salpino-oophorectomy followed by adjuvant chemotherapy
