NBME 12 Flashcards
CARDIAC amyloidosis
only restrictive type will only hear s4
vs
chronic htn leading to CHF can have both S3 AND S4 d/t htn causing hypertrophy
pt with NG tube and cloudy fluid draining from it
next step?
CT scan of sinuses
IV abx, remove NG tube d/t bacterial sinus infection
pt gets surgery, given hydromorphone then becomes hypotensive, low resp rate, miosis (3mm pupils)
opiod (hydromorphone) intoxication
causing hypercarbia
check ABG anlaysis
acetaminophen:
ibuprofen:
colchicine:
acetaminophen: given FIRST initially to pts with osteoarthritis
ibuprofen: given Next to osteoarthritis (as well as topical diclofenac)
Colchicine: given in GOUT! or arthritis
NSAIDS(ibuprofen or colchicine): pseudo gout
prego on lithium, what next?
continue taking lithium
fetal cardiac ultrasound (ebsteins: R ventricular atrialization)
Neurofibromatosis 1
AD ch17
cutaneous neurofibroma (derived from neural crest cells)
cafe au lait spots (hypo-pigmented)
inguinal/axillary freckling
Lisch nodules – pigmented iris hamartomas
optic gliomas
pheochromoctyoma
**annual: Opthalmic, neurologic, dermatologic, blood pressure monitoring, bone/growth monitoring
7yo girl with precocious puberty and left ovarian mass
next step?
surgical resection: left oophorectomy
precocious puberty can be central vs peripheral (this is peripheral)
5yo with recurrent sinusitis, pneumonia, and on imaging:
primary ciliary dyskinesia (sinusitis, brochiectasis (bronchitis), inferitiliy, situs invertus)
kartagener
bronchiectasis in image
not able to mucus clearance
vs
wiskot aldrich will see WATER
VS
LAD: will see ELEVATED leekocytes since porblem is adhesion not making it
Repeated neisseria infections
compliment deficiency furhter down cascade
Slipped capital femoral epiphysis (ages 10-15) and overweight: painful limp, limited ABDuction and internal rotaitn of hiop
can cause avascular necrosis, premature osteoarthritis, gait impairments
tx: surgical stabilization of femoral head
normal S1 but diminished S2
harsh, systolic murmur
weak and delayed peripheral pulses
aortic stenosis
pulsus parvus et tardus
S2 from weakened closing of the valve
early onset 40 to 60: congential bicuspid valve or chronic rheumatic heart disease
older than 60: calcification and fibrosis
anal fissures longer than 8 weeks treatment:
chronic fissures: surgical repair
acute: topical analgesics, vasodilators, sitz bath
HTN, tachycardia, pupillary dilation, restlessness, euphoria (hallucinations, paranoia)
vs
”” “” + yawning, lacrimation, rhinorrhea, piloerection
cocaine intoxicaiton
vs
opioid withdrawal
prego 36 weeks, in labor, moderate blood, mom is A Rh-Negative
serum anti-D antibody titer is positive
fetal heart montior: SINUSOIDAL wave forms
what is most likely causing fetal heart rate pattern?
Rh isoimmunization
Rh(D)-negative moms are at high risk of forming anti-Rh(D) antibodies (Rh isoimmunization) – if exposed to blood from a Rh(D)-Positive fetus
it can cause hemolytic anemia – erythroblastosis fetalis (sinusoidal wave forms) 2/2 to Rh isoimmunization
next baby will die
Prevent it by giving RhoGAM at 28 weeks in Rh(D)-negative mothers
Pt who is able to sleep at night totally fine, (might see cataplexy or hallucinations hypno-gogic/pompic) but has daytime somnolence
dx?
Narcolepsy: loss of orexin-A/B (found in hypothalamus that promote wakefulness and inhibit REM sleep)
dx:** multiple sleep latency tests **will see shorter time from wakefulness to initiation of REM sleep
can also do lumbar puncture to measure orexin A in CSF
pt with bipolar on lithium, gets hypothyroid sxms with elvated TSH, anti-thryoid peroxidase antibody is negative
lithium induced (ae)
do not stop lithium, just treat hypothyroidism
kidney stones in a kid
dx
size/tx
do ultrasound/xray since CT is more radiation
if larger than 6mm –> needs more intervention (lithiotripsy)
if smaller: oral hydration and analgesia
50s with muscle weakness fatigue, bilateral ptosis, cxr: mediastinal mass
Dx?
myasthenia gravis
anitbody against nicotinic acetylcholine receptors at neuromuscular junction
thymoma
dx: nerve conduction studies with reptitive stimulation (like lambert eaton)
tx: complete thymectomy, ach-inhibtors with immune modulating therapies
acute chest pain, SOB, hypoxemia
ABG: acute resp alkalosis, hypoxemia, increased A-a gradient
next step?
Pulmonary embolism
increased A-a gradient d/t ventilation-perfusion mismatch
dx: CT-A,
thrombolytis and anticoagulants
bone, pain, anemia, hypercalcemia, renal dysfunction
dx?
roloux formation RBC aggregation
Multiple myeloma: neoplastic proliferation of plasma cells (overporduce monoclonal immunoglobulin light or heavy chains)
serum protein/urine electrophoresis
diagnosis confirmed with: **bone marrow biopsy
triad: digital clubbing, periostosis (inflamed periosteum of long bones), and severe arthralgia
Hypertrophic Pulmonary osteoarthropathy
abnormal fibrovascular proliferation
hypoxemic changes
unilateral lung mass with perihilar lymphadenopathy (malignancy cause but can be d/t anything)
adolescent with high BMI, what can improve mortality next 10 years?
weight loss
firm tender erythematous edematous mass on angle of mandible
acute suppurative parotitis
mixed oral flora or Staph Aureus
elderly dehydration, poor dentition, low saliva
dx: cliinical, lor with u/s or CT scan further evlauate for complicaitons: abscess/tumor
1 hr after transfucion of PRBC’s pt becomes flushed with fever, but normotensive and normal heart rythm&rate
next step?
Febrile nonhemolytic transfusion reaction
release of cytokines from leukocytes during blood product storage (long time storage of blood proudcts)
prevent: prestorage luekoreduction
tx: stop transfusion
give** oral acetaminophen** *pyretics
vs
ibuprofren: can cause gastritric/duodenal ulcers especially if pt already has ulcers
vs
epinephrine, diphenhydramine, methylprednisone – given in anaphylaxis with blood product transfusion in IgA deficiency: wheezing, uritcaria, hypotension, tachy
pulsatile nontender mass in inguinal region
when to do surgery?
femoral artery aneurysm
dx: duplex ultrasound of groin or CT-angio
symptomatic or larger than >3cm – surgical artery repair
ct scan: intertitial lung pattern
FVC: 48%
DLCO: 55%
dx?
Intersitital lung disease
lung biopsy
vs
sarcoidosis can cause ILD: but measuring ACE would not be specific/sensitive enough for diagnosis
IgA deficiency
next step? tx
can be asymptomatic, recurrent sinopulmonary infections or otitis media, or anaphylactic reaction to Plasma blood
tx: only for symptomatic infection or anaphylaxis
no intervention indicated at this time
partial or complete small bowel obstruction
next step?
abdominal x ray : dilated loops with multiple air fluid levels
managment: bowel rest, IV hydration,
complete obstruction “ “ + if it does not resolve on its own – ex lap
pt with 3 day pressure in face, itchy eyes, decreased hearing in both ears, inferior nasal turbinates edematous, cobblestone conjuctivae
allergic rhinitis
give: anti-histamine loratidine
vs
bacterial – will have discharge
MRI of the sinuses if pt had recurrent or chronic sinusitis for sinus tumors or fungal infections
pt undergoes thyroidectomy
hoarsness:
airway obstruction and gasping for air:
unilateral laryngeal nerve paralysis
bilateral laryngeal nerve paralysis
old man, straight lines start to appear curved or wavey, blurring
dx
age related macular degeneration
drusen: yellow subretinal extracellular deposits of lipoproteinaceous material
early: blurring or metamorphopsia (wavy curved)
late: nonreversible blindness retinal atrophy or choroidal neovascularization (macular edema exudation or hemorrhage)
dx: DILATED FUNDOSCOPIC EXAM
tx: dry: antioxidants and vitamin
wet: injection VEGF
pt with recent fall and groin pain, Ulcerative colitis, and xray: pelvis and lower hiop shows moderate loss of joint space and diffuse osteopneia
what next?
Osteoporosis/osteopneia
next: MRI of the hip to assess for fracture
vs
dexa: would just show much bone density loss vs this guy has a potential hip fracture
tx: weight bearing exercises
bisphosphonates inhbit osteoclasts
child age 1-3 with acute onset of truncal ataxia, myoclonus, opsoclonus (saccadic intrusion)
neuroblastoma
firm nodular mass that crosses midline and diastolic HTN
dx: increased catecholamine in serum and urine
tx: stage of tumor and MYCN amplificiation
pt with asplenia what to do as ppx
penicillin
viral infection (hhv6/7) 4-5 days later gets itchy rash
trunk:
Piyriasis roseas – herald patch
self resolves 6-8 weeks
Pneumococcal vaccination:
for 65+
or
ANYONE WITH HIV
PCV13 –> PPSV23 (8 weeks later –> and again 5 years alter –> and again age 65)
TPN feeding:
causes cholestatic hepatic disease
biliary obstruction/fibrosis/inflammation
hypertension and proteinuria during pregnancy
complication:
preeclampsia
abruptio placenta
premature separation of placenta fro uterus –> fetal exsanguination
CAG chrom4
Hungtington disease
**pt with cirrhosis with elevated leukoctyes and neutrophils
spontaneous bacterial peritonitis
GIVE IV ABX (ceftriaxone)
crohns pt with flare already on ASA
what next?
give prednisone or budesonide
vs infliximab and methotrex, azathioprin, 6-mercaptopurine (take way longer to start)
IBD patient with toxic megacolon
next step?
only in IBD associated TM: give corticosteroids
Bowel rest,
NG decompression
IV fluids and electrolyte repletion
if still persisting symtpoms or peritoneal signs:
surgery (subtotal colectomy with end ileostomy)
s/p mechanical ventilation
what should they do to prevent resp muscle atrophy and insufficiency
physiotherapy, coughing, repositioning sit upright, moving
cleft lip
chromosomal:
syndrome:
sequele:
Patau syndrome (trisomy 13)
midfacial hypoplasia (treacher collins)
Velopharyngeal insufficiency: cleft palate w/ or w/o repair: high pitched, nasal, whistle speech with reduced intelligibility
Preterm Premature Rupture of Membrane
next steps
risk factors
complications
PPROM
before 37 weeks
speculum exam of vagina
nitrazine testing and ferning
u/s can show residual amniotic fluid
risk factors: previous PPROM, vag/cerv infxn, cig smoking
comp: preterm delivery
give betamethasone to accelerate fetal lung maturity
give antibiotcs d/t increased risk of chorioamniotis
forcing function
stops error occuring in hospitals
need verification step or intermediary step first
staff to enter pts id to open blood lock
Entamoeba histolytica
key features
dx
tx
cysts invade mucosa and can cause hepatic abscess
dx: stool microscopy cysts
peripheral blood smear trophozoits
colonoscopy: flask shaped mucosal ulcers
tx: metronidazole or tinidazole or antifungal paromycin or iodoquinol
hoarsness, vocal changes, in pt with history of smoking
laryngeal carcinoma
dx: indirect laryngoscopy
older pt with no hx of IBD, has passing air and fecal material in urination, long standing constipation
diverticular disease
can lead to colovesical fistula
dx: contrast CT
tx: antibiotics and surgery
vs
IBD crohns fistula – must have previous hx of it and usually younger than 30yo
pt with sympotms of sciatica
w/ pain over piriformis
w/o
piriformis syndrome
vs
lumbar disc herniation
usually you dont need to do further testing: just PT
if there is muscle weakness: nerve condoction or electromyography
irregular menstrual periods, acne, facial hair
increased LH to FSH
increased androgen (testosterone) production
PCOS
associated with acanthosis nigrans insulin resistance
tx: weight loss and OCPs
spironolactone or ketoconozale for hirstuitism
prolactin level : > premenopausal
> postmenopausal
check what?
30> premeno
20 >post meno
check TSH (since prolactin is positively regulated by TSH-releasing hormone and in states of hypothyroidism)
also dopamine blocking medications
tx hypothyroidism and prolactinemia will stop
seborrheic keratosis
look stuck on appearance
age
can be associated with leser-trelat == GI cancer
tx: no tx necessary, no diagnostic study needed
rapid correction of hyponatremia
demylination of pons
pontine myelinolysis
fever, cyanosis, hypo-tension, hypoxemia after receiving PRBC
transfusion related acute lung injury
stop trasnfusion
give oxygen either Noninvasive positive pressure ventilation or ibutanion
Hypo-Ca, hyper-Phos, Hyper-K, Hyper-Uricemia
s/p getting chemo
Tumor lysis syndrome
preventive: IV hydration with Allopurinal or rasburicase
mydriasis bowel sounds decreased, flushed skin, tachycardia
overdose:
TCA’s
tx: sodium bicarb
can also see wide QRS tachycardia
asymptomatic hemorrhagic cyst
repeat u/s in 6 weeks
does not need to be removed unless persistent or symtpomatic
can resolve on its own
starting menopause with hot flashes
next step?
start hormone therapy for 3-5 years
not more d/t prolonged unopposed estrogen: increase risk for endometrial cancer, CVD, breast cancer
Renal artery stenosis (even in children) midabdominal bruit
treatment
CCBs or ANGIOPLASTY if failed CCBs
CVSD greater than 10%
start statin
diificulty performind overhead tasks, rising from seated position, climbing stairs
polymyositis
right sided lower abdominal pain. 2 weeks ago had period, guarding over RLQ, U/S small amount of fluid in pelvis
Mittelschmerz
peritoneal irritation in setting of (middle of cycle aka 2 weeks after period)looks like appendicits
limb prosthesis – has ulcer
refitting prosthetic sock
pressure injury: decubitus ulcer
close of follow up for healing wound d/t possible infections
anion gap metabolic acidosis with respiratory alkalosis d/t hyperventilation
salicylate toxicity
tx: alkalinize with sodium bicarb
traumatic wounds and infected intraabdominal fascia (like midline abdominal fascia) should be ____ to reduce risk of postop infection
delayed primary closure: (like that drunk driver) when you leave the icision site open, with negative pressure owund tx, infected tissue can drain out
also if necessary: can do further irrgation and debridement
DKA
insulin:
glucagon:
catecholamines:
insulin: low
glucagon: high
catecholamines: high
vs
pancreatic resection or tumor where insulin and glucagon would both be low
pt with sepsis but also constant loud breathing and secretions
next step?
scopolamine(patch) or glycopyrollate(wont cross BBB causing agitation, delirium, seizures)
Eoisinophils in urine when started on ceftriaxone
AIN
stop ceftriaxone
post menopausal with a hard immoble mass
FNA showed no abnormalities
next step?
excisional biopsy
chance for breast cancer is high so just remove the whole thing for analysis
