nbme13 Flashcards
ectopic pregnancy tx
smaller and early pregnancy: methotrexate
larger: salpingectomy or evacuation with laparoscopy
how to assess brain death
1) neuro exam absent cranial nerves and lack of response to pain stimulus
2) APNEA TEST
3) if still uncertain –> can do EEG or angiography
huge blood transfusion + within 6hours (pt came in earlier that day s/p mva needed blood transfusion) becomes HYPOXIC, hypotension, cyansosis, fever
TRALI - transfusion related acute lung injury
cxr will show BILATERAL pulmonary patchy infiltrates unrelated to cardiac dysfunction
tx: noninvasive Positive pressure ventilation or intubation
s/p long bone or pelvic fracture –>
hypoxemia + petechial rash + neuro dysfxn
fat embolism
transient ischemic attack (no evidence of infarct)
what to give pt to reduce risk of cerebral infarct
aspirin –
vs
warfarin : reduces ischemic stroke with pts with a-fib or a known atrial thrombus
forceps assisted vaginal delivery –> caused cephalohematoma
next step?
measure/monitor bilirubin levels
will go away on its own but hemolysis might overwhelm neonates liver
pt underwent pituitary excision and placed on levothryoxine and steroids (TSH and ACTH might be low) but starts gaining weight
what to measure next?
Free T4 levels
if its too low that means you need to increase dose of levothyroxine
alcohol use disorder drugs:
acamprostate
naltrexone (opioid antagonist – but can cause opioid withdrawal in pt taking hydrocodone)
disulfiram
gabapentin
pt older with wt loss, hyperglycemia, and is overweight
insulin resistance
type 2DM can see weight loss initially
agranulocytosis: low leukocyte levels under 1500
what drugs:
sulfasalazine
bactrim, methimazole (thryoid), clozapine (antipsychotic)
AR - normal motor development first few months followed by progressive loss of motor skills, muscle spasticity, macrocephaly, cherry red macular spot
dx?
die?
tay-sachs
die 2 to 5yo, fatal aspiration pneumonia d/t pharyngeal muscle weakness
4yo a few days ago had a middle ear infection and now with right hip pain
passive range of motion is painful
ESR CRP leukocytes all normal
dx?
next step?
transiet synovitis
usually after a viral infection
tx : supprotive with rest and NSAIDS
4yo a few days ago had a middle ear infection and now with right hip pain
passive range of motion is painful
ESR CRP leukocytes all normal
dx?
next step?
transiet synovitis
usually after a viral infection
tx : supprotive with rest and NSAIDS
patchy interstitial infiltrates that appear worse than patients symptoms
(diffuse b/l interstitial infiltrates with severe dry cough)
mycoplasma pneumonia
tx: macrolide azithromycin
Duchene muscular dystrophy
X-R
proximal msucle weakness, hyperlodrosis, calf pseudohypertrophy
Rhabdo labs:
hyper-K, hyper-Phos, hyper-URICemia
hypo-Ca
can cause ATN
tx: NS 0.9%
baby gets cyantoic while breast feeding but once they unlatch and start crying it resolves
choanal atresia
difficultry breathing through nose, nasal congestion, snoring, recurrent infections
oligohydramnios
d/t :
causes:
premature rupture of membranes
uteroplacental insufficiency
congenital: posterior urethral vavles or renal agenesis
flat facial features, limb dyspasia, pulmonary hypoplasia d/t inadequate amniotic fluid-induced lung expantion pOTTERS sequence
polycythemia vera:
what is increased?
erythromelalgia?
tx:
leukocytosis + thrombocytosis
hot showers pruritis: mast cell degranulation
increased erythrocyte mass and hematocrit -> can cause hyperviscosity syndrome (blurred vision and headaches(cns) vascular congestion and venous thromboembolism **
episodic burning pain in digits with red/b.ue discoloration d/t blood clot: erythromelalgia
tx:phlebotomy** results in decreased red blood cell mass and blood volume
hereditary spherocytosis:
what two organs?
what two tests?
increased INDIRECT bilirubin gallstones –> cholelithiasis
splenic congestion and sequestration
osmotic fragility test
eosin-5’-maleimide: flow cytometry
AD – cytoskeleton proteins: ankyrin, spectrin, band erythrocyte membrane proteins (loss between the inner membrane skeleton and outer lipid bilayer)
tx: splenectomy and cholecystectomy
ovoid and scaly with rim of scale around the leading edge
in darker people can be hyperpigmented with raised
pityriasis rosea
usually but not always after viral infection HHV-6/7 (roseola exanthum subitum super high fevers and then a rash)
elderly pt with large, exophytic, cauliflower-like lesion, between vagina and rectum
Vulvar carcinoma – squamous cell carcinoma
vulvar nodule, papule, plaque or verrucous carcinoma (cauliflower) that can be locally destructive causing obstruction with no bowel movements
risk factors: HPV, smoking, immunosuprression, chronic inflammation(lichen sclerosus)
dx: biopsy
do imaging of pelvis to check extent of disease
tx: surgical excision + chemotherapy
vs lichen sclerosus: white plaque in oste monpauseal women with thinng and fibrosis of the genital area skin (benign) and can lead to hyperplastic dystrophy (chronic inflammtory changes of vulva)
pt last visit bp in R arm: 165/105
today comes in with R arm:160/100 and L arm: 105/65
subclavian artery atherosclerosis
a type of subclavian artery stenosis
risk: age, DM, HLD, HTN, smoking
can be subclavian steal syndrome: blood flows from teh contralateral vertebral artery through basilar artery and then in retrogradedly down the ipsilateral vertebral artery through the affected subclavian artery (can see vertigo, ataxia, nystagmus, syncope after upper extremity exertion)
dx: duplex u/s with color flow
or CT - ANGIOGRAPHY
tx: endovascular : stenting or angioplasty or bypass
vs
children with htn and difference in BP in upper vs lower extremity: coarctation of aorta (systolic mumur)
epiglottitis mgt:
endotracheal intubation:
should take place in operating room under direct visualization with laryngoscope in operating room
transfer of patient to operating room
and then give antibiotics (haemophilus influenzaB)
not indirect laryngoscopy since such high threat of airway compromise
Defect in tyrosine kinase –> leads to defect in b lymphocyte maturation -> death of plasma cells and low immunoglobulin concentrations in Ig-M/G/E/A
Brutons X0linked agammaglobulinemia
Decreased B-lymphocyte concentration
recurrent bacterial infections d/t impaired HUMORAL immunity especially after 6 months of life when maternal IgG wane
tx: IVIG and recieve all immunizations except for LIVE VACCINES
X-R
Defect in CD40 ligang on t helper cells that interacts with B-lymphocytes to induce class switching of ig’s
Hyper-IgM
severe pyogenic infections as well as opportunistic infections
B and T cells are normal
X-R
Defect in CD40 ligang on t helper cells that interacts with B-lymphocytes to induce class switching of ig’s
Hyper-IgM
severe pyogenic infections as well as opportunistic infections
B and T cells are normal
pt with 3 days bloody watery diarrhea (no travel hx)
Campylobacter jejuni (gram neg comma shaped oxidative positive)
most common cause of food poisoning in US
self limiting
may cause reactive arthritis in pts with HLA-B27 and Guillane Barre syndrome
vs
Toxigenic Ecoli (watery) vs EHEC ETEC (bloody/watery in contaminated waters while traveling)
pt on chemo and now has pancytopenia (low platelets, low leukocyte)
cytotoxic agents: etoposide, irinotecan, doxorubicin, cyclophosphamide, paclitaxel, hydroxurea
bactrim, sulfasalazine, methimazole, clozapine
tx: stop implicated medication
give Granulocyte colony-stimulating factor G-CSF (quicker recovery and shorter duration of hospitalization)
vs
giving them platelets: only in bleeding under 50,000 and nonbleeding 10,000
lumbar spinal stenosis –> compressing nerve roots w/ radiculopathy, back pain radiating to butt and legs, leg numbness, parasthesia, weakness
tx?
degenerative joint disease and osteophytosis
occurs in AGE or manual labor jobs
dx: MRI
tx: NSAIDS, PT, and srugery (lumbar laminectomy)
vs ibuprofen+bed rest (best rest worsens must go to PT)
Bacterial meningitis
strep pneumo
tx?
IV: vancomycin + ceftriaxone + glucocorticoids
csf: neutrophils
COPD poor prognosis:
progressive dyspnea on exertion (despite adquate medical therapy)
tx: smoking cessation and oxygen (if needed 88% or 55)
all inhaled: SABA + LABA + muscarinic antagonist ipratropium + glucocorticoids
Parvo b-19 infection in prego
can cause fetal anemia –> presents as fetal tachycardia, high output failure, hydrops fetalis
measure serum sepcific IgG and IgM
carcinoid tumors produce:
serotonin
histamine, bradykinin, prostaglandin, substance P, chromogranin
epsidoic flushing, diarrhea, sob, metastatic, GI tract or appendix, lung
dx: urninary 5-HIAA
pt with pleural effusion
initially:
if after that pulls 1000mL or more of blood then:
tube thoracostomy
if greater : massive hemothorax: do a video assisted thoracoscopy or thoracotomy
endometritis:
risk factors:
tx:
recent postpartum fever leukocytosis and uterine tenderness
prolonged rupture of membranes, prolonged labor, c/s, bacterial vaginosis, GBSTREP, manual removal of placenta
tx: clindamycin and gentamicin
bartonella henselae vs kaposi sarcoma
bartonella: (cat bties or hiv) needs doxycycline or erythromycin
Neutrophilic inflammation is seen in bacillary angiomatosis.
CD4 < 100
kaposi sarcoma: need to be removed
Lymphocytic inflammation is seen in Kaposi sarcoma.
CD4 <500
pt with VUR or ureteral issue
whats next best step
percutaneous nephrostomy tube
pt with renal failure, gets a new kidney but still has super high PTH and normal/elevated Ca
secondary –> tertiary hyperparathyroidism
parathyroid hyperplasia *not adenoma MCC
pt with episodes of vision loss, transient and painless
amaurosis fugax
retinal ischemia as a result of microembolization of opthalmic artery
potential emboli coming from the carotid arteries
next step: CAROTID DUPLEX U/S!!
Restless leg sydnrome: also test
for IDA
ferritin
scaphoid fracture
risk of :
nonunion
avascular necrosis
immobilization/splint
repeat xray after 2-3weeks
heparin induced thrombocytopenia:
anamestic antibody response
HIT 2/2 to the production of IgG antibodies agaisnt complex of heparin and platelet factor 4
stop heparin give gatr(direct thrombin inhibitor) or xa (inhibtior) instead
biopsy shows epitheloid sarcoma
next step?
amputation
slow growing malignant/metastatic cacner
associated with Li-Fraumeni syndrome
chromosome 22q11 has the INI-1 TUMOR SUPPRRESSOR GENE
CD 34 +
POST OP RADIATION WITH LARGE TUMORS or with positive surgical margins
1 y/o with bulky, light colored stools, low weight, big head, paucity of subcutaneous fat and thin hair
failure to thrive likely to cystic fibrosis
deficiency of fat soluble vitamins: ADEK
do a sweat chloride test
can present with meconium ileus (failure to pass stool after birth)
vs dairy allergy would be if pt had bloating flatulance and diarrhea too
pt with acute exertional dyspnea, poorly controlled HTN, and ecg shows LVH :
new onset heart failure
HTN –> atrial remodeling first step –> LVH caused by chronic increased afterload
must do ECHO NEXT
white painful patch in mouth that can not be scraped off
oral candidiasis
KOH budding yeast with or w/o hyphae
can cause dysphagia or oodynophagia
tx with oral fluconozole or swish nystatin
tx for fronto temporal dementia
serotonergic meds or Risperidone to control behavioral problems, irritability, agitation
pt gets in car accident then later has really low blood glucose
what next step in dx?
72 hour fasting measurement of serum insulin and glucose
insulinoma – hypoglycemia, confusion, sweating, fatigue, weakness, usually after strenous exercise or not eating (long distance drivers without eating)
dx:
72hour
c-peptide
then imaging:
CT, MRI, U/s
diazoxide can be used to decrease inuslin production until you do surgey to remove it
pt taking lithium what labs to run
serum creatinine, fasting glucose, and TSH
lithium metabolized by kidneys
vs
carbamazepine/valproic acid – check LFT’s for liver
warfarin induced skin necrosis
wawfarin inhibits hepatic synthesis of factor II (prothrombin), VII, IX, X, and protein C and S
usually seen in protein C deficiency patients
must stop warfarin
switch to low molecular weight heparin
give vitamin K and fresh frozen plasma (has protein C)
pelvic ultrasound: large partially cystic mass in right ovary with a single echogenic nodule and decreased blood flow
mature cystic teratoma (hair bone teeth) has internal echos
causing ovarian torsion
must do ovarian cystectomy to prevent future episodes
colchicine adverse effect:
diarrhea
dont give long term d/t kidney damage and peripheral neuropathy
only for acute issues (gout)
pt with gout
next step?
LIFESTYLE MODIFICAITONS ALWAYS FIRST
low purine diet and alcohol cessation
shellfish has high purine
patient with bone pain, kidney dysfunction, monoclonal gammopathy, lytic lesions on bone
what do you see in u/a
multiple myeloma
neoplastic plasma cells overproduce monoclonal immunoglobulin
depostis its mesangium leads to nephrotic syndrome: large proteins like albumin, plasma lipids gets filtered into urine
you will see OVAL FAT BODIES
PT WILL HAVE EDEMA, foamy/dark colored urine, hypoalbuminemia, proteinuria
phase 1:
phase 2:
phase 3:
phase 4:
phase 1: SAFETY
phase 2: efficacy (determines how and why a treatment works)
phase 3: effectiveness (in comparison to current standard of care)
phase 4: long term
Rheumatoid arthritis tests:
sensitive: rheumatoid factor
specific: anti-CCP
hypothyroid and hypercholesterolism
low thyroid hormone (T3/T4) causes decrease in HMG-coA reductase (enzyme that synthesizes cholesterol)
so then body compensates for decreased synthesis by increasing cholesterol absorption from GI tract
also hypothyroidism leads to decrease in LDL receptors in the liver
tx with levothryoxine
family history of reading difficulty, prematurity, poverty, neurodevelopmental conditions (ADHD, prenantal alcohol exposure) risk factors for:
dyslexia
urge incontinence
vs overflow incontinence
vs stress incontinence
urge: detrusor instability/hyperactivity (gotta go rn with leakae oxybutinin)
overflow: underactive or flaccid detrusor OR OUTLET OBSTRUCTION (urinary retention) will see increased post-void residual bladder volume (so do a bladder u/s)
stress: increased intra-abdominal pressure (cough,laugh,sneeze) weakness of pelvic floor muscles OR urethra hypermobility (pelvic floor exercises)
elderly pt on anticoagulants (warfarin), alcohol use, physical abuse, or head trauma with symptoms of pronator drift, oconfusion, neurologic deficits
next step
subdural hematoma (crescent shape)
non contrast CT
tx: ICP management: hyperventilate, elevate bed, CSF fluid
craniotomy to excavate hematoma if really large
elderly woman + muscle stiffness + temporary vision loss
polymyalgia rheuamtica
immediately give high dose steroids (or else will go blind in both eyes)
then do a biopsy : granulomatosis vasculitis
pt with asymptomatic peripheral vascular disease (absent pulses in right leg, abi <0.9, shiny hairless leg
what recommendations:
smoking cessation and exercising to create neovascularization and collateral flow
aspirin and statin
if had symptoms of claudication : can also give cilostazol (phosphdiesterase inhibitor) or pentoxifyllie
vs
acute limb ischemia will see absent pulses but also severe pain, parasthesia, pallor, poikilothermia and would then do arteriography of lower extremity
