part 1 Flashcards
UTI with urine alkalinzation. organism?
proteus
65 yo man with epigastric pain, weight loss and recent DM diagnosis, next step?
CT scan of abdo, pancreatic CA
HIV patient vaccinations?
Hep A/B, zoster, influenza, meningococcal
boy with asthma, 3 weeks of conjunctivitis, itchy red eyes, clear discharge, dx?
allergic. viral is only 5 days or so
subacute shoulder pain, large and tender mass, xray findings, dx?
osteosarcoma
after sexual assault case, what needs to be done for patient?
emergency contraception, prophylatic treatment for STI, and inpatient counseling if suicidal/homicidal
asymptomatic bacteriuria in 10 wk GA woman. rx?
augmentin
65 yo woman with constipation and abdo pain and polydipsia, started vitamins and minerals for osteoporosis 3 months ago, on thiazide diuretic and levothyroxine. dx?
milk-alkali syndrome. excess minerals causing hypercalcemia like symptoms
baby has asymetric thigh creases and assymetric leg length. dx and next step?
ddh and U/S of hip. xray later
65 yo man with memory difficulty, urinary urgency and broad shuffling gait. dx?
normal pressure hydrocephalus. parkinsons dementia is very late complication
11 yo with sickle cell has SOB, weakness and fatigue for 3 days and has severe anemia with low reticulocytes. dx and rx?
aplastic crisis, give transfusions
back pain and leg pain better with position change, neuro exam normal, many cardiovascular risk factors
spinal stenosis
56 yo woman at a restaurant brought to hospital and flow volume loop shows kind of a fat circle, top and bottom flattened, dx?
laryngeal edema, came from restaurant
PPROM with low amniotic fluid in 33 wk gestation baby, mx?
prophylactic abx, corticosteroids, fetal surveillance
7 yo girl with painful swollen eye, small abrasion below eyelid, mild conjunctival injection. extraocular mvmts normal, visual acuity normal, dx and what is ruled out?
preseptal cellulitis and not orbital cellulitis because the latter will have visual involvement. preseptal is in front of the orbital septum, orbital is behind
cold symptoms in 4 yo boy treated with symptomatic meds starts having hallucinations. dx?
medication side effect. antihistamines and dextromethorphanas well
16 yo girl, fever, rash from head to body, joint pain and posterior auricular and suboccipital LAD dx?
rubella
lower limb edema or s3 heart sound what is more specific in alignment with elevated BNP?
S3 bro
multifocal atrial tachycardia in 66 yo with COPD, what to do next?
treat COPD and observe
suspect PE. what is next step? ddimer, U/S leg or CT angio?
CT angio.
54 yo man with 30 pack year history has cholecystectomy and then develops hypoxemia and tachypnea. ABG shows slightly low CO2, dx?
atalectasis
obest postmenopausal female with hair loss at the vertex. rx?
minoxidil
mid 30s guy FOOSH has dinner fork deformity in hand, distal fracture. what is cause of this?
pathological fracture in such a young guy… think of celiac disease or crohns
lyme disease. oral doxycycline, IV ceftriaxone, or serology
oral doxy. it’s a clinical dx
leukoplakia vs SCC
same risk factors, former is precursor of latter. but SCC has induration/ulceration and LAD
GBS prophylaxis if patient has penicillin allergy?
determine whether severe or low risk of anaphylaxis, then can give clindamycin/vancomycin or cefazolin respectively. vanco if clinda resistant
NST BPP CST doppler
NST is looking for fetal heart accelerations, BPP is NST plus ultrasound for other stuff, CST is with oxytocin/nipple stimulation, and doppler is only for FGR
early bird and night owl medical terms?
advanced and delayed sleep-wake phase disorder
hearing loss, PDA and cataracts in new born, dx?
rubella
palliative care for bony mets, NSAIDS don’t work. what to give next? then after that?
short term opioid first (respi depression is scary) then give long term- either oral or patch. steroid injection not really
distinguish NMS and Serotonin syndrome.
NMS is tetrad: AMS, diffuse rigidity, autonomic instability and high fever. serotonin syndrome is neuromuscular hyperactivty: hyperreflexia and clonus and tremor. not as severe rigidity
patient with open globe laceration. next step?
fluorescein instillation
shoulder dystocia mnemonic
HELPERR: help, evaluate for episio, legs, pressure, enter, remove posterior arm, roll on arms and legs
newborn girl with VSD, IUGR, hypertonia with clenched fists, index and pinky overshadowing 3rd and 4th respectively. dx?
edwards
ascending aorta dissection, now has bibasilar crackles and orthopnea. dx?
aortic regurgictation
COPD 2 indications to start long term o2 therapy?
SaO2 is less than 88% or PaO2 is less than 55 mmHg
esophagitis in hiv patients, how to distinguish
candida is most common, has thrush. pseudohyphae on biopsy. CMV has linear ulcers and intracytoplasmic/intranuclear inclusions. HSV has orolabial ulcerative/vesicular lesions, and multinucleated giant cells. ALSO viral has odynophagia, candida is dysphagia
6 yo boy with gum bleeding, pancytopenia, thumb abnormalities and hypopigmentation and short stature.dx and patho?
fanconi anemia, lack of DNA repair
polyhydramnios management principles?
severe/symptomatic can lead to preterm labour and PPROM so consider amniocentesis. but mild and asymptomatic just expectant mx
54 yo man with nephrotic syndrome, bronchiectasis and psoriasis, hepatomeglay palpable kidneys, proteinuria. dx? rx
amyloidosis, treat with colchicine
18 yo guy with 3 days of progressive testicular pain, area posterior to testes is swollen and tender, it is shorter. and elevating alleviates pain, mx?dx?
abx for epididymitis
60 yo man with aquagenic pruritis, facial plethora, gout and splenomegaly. dx?
myeloproliferative disorder- most likely PV
42 yo man post roux-en-y surgery has fever tachycardia and leukocytosis, dx and next step
anastomatic leak, do an contrast enhanced abdo CT
16 yo girl with hirsuitism and irregular menses has high 17-OH progesterone and high DHEA levels, dx?
non-classic CAH
6 month old boy adopted from uganda has widened wrists on xray, dx?
rickets
after minor TBI, valsalva causes nystagmus, dx?
perilymphatic fistula
breast cancer and cervical cancer screening recommendations?
50-75 every 2 years and 21-65 every 3 years pap smear respectively
xray finding of pericardial effusino?
enlarged cardiac silhouette
chronic SE of lithium (4)
two thyroid, two kidney. hyperPTH, thyroid dysfunction, NDInsipidus and CKD
65 yo man with COPD, after central venous catheter insertion and endotracheal tube insertion has hypotension, tachycardia, tachypnea, tracheal deviation, elevated JVP and absent right breath sounds. is it cardiac tamponade, intubation of left bronchus, or tension pneumothorax? and rx?
TP, do needle thoracostomy. because it is the dx that unifies all the symptoms and signs. tracheal deviation is not explained by others as well. it is clinical dx so xray not needed
4 yo boy coming back from costa rica has fevers and pains, quotidian fever, with evanescent pink rash and anemia and thromboyctosis. dx?
systemic onset JIA
4 week old girl with unconjugated hyperbilirubinemia, with slightly microcytic anemia and increased MCHC. dx?
hereditatry spherocytosis because thal usually presents after 6 months when HbF is gone
62 yo guy smoker, with non-tender palpable cervical lymph node. with ear pain. dx?
SCC
full degree burn on arm, comes back next time with eschar and pain and swelling, dx?
acute compartment syndrome
55yo man given transfusion, 2 hours later develops transfusion reaction but direct antiglobulin and free hemoglobin tests are negative, dx and prevention for next time?
febrile non-hemolytic reaction. used leukoreduced products
distinguishing features of IDA vs thalassemia
mentzer (MCV/RBC count) is higher than 13. low reticulocyte count. also can have increased RDW because iron variability changes throughout the day
CP adolescent with heavy menstrual bleeding, has asthma and migraine with auras. what rx: COCP, progestin implant, copper IUD, GnRH therapy, endometrial ablation?
progestin implant ideal for adolescent with lower extremity contractures. COCP is contraindicated for migraine, copper IUD C/I in heavy menstrual bleeding, GnRH can cause bone density abnormality, endometiral ablation affects fertility
42 yo woman with Pap smear shows atypical glandular cells. next step?
endometrial biopsy
conductive hearing loss, sound better heard in a noisy environment, reddish hue to the tympanic membrane, dx?
otosclerosis- overgrowth of the ossicles
septic abortion, mx?
abx and suction curettage
electrical alternans, dx and next step?
cardiac tamponade and pericardiocentesis
CMV vs HSV vs VZV retinitis
former is painless and associated with hemorrhages on fundoscopy, HSV and VZV is painful and can have keratitis and conjunctivitis, uveitis, and central retinal necrosis
22 yo woman wth short stature, scoliosis and heart murmur has sever chest pain, neck discomfort and arm tingling. ECG is tachy with no ST changes. U/S shows 12 week old baby. dx?
turners and aortic dissection
32 yo with rapid ascending paralysis with recent hiking rip, no tachycardia, urinary retention or arrhythmia. dx and rx?
tick. kill tick. GBS is not likely because onset is way too fast and usually has autonomic sxs. in either case, tick search is easier to do before erroneously giving IVIG and plasmaphereisis
post partum hemorrhage, normal PT aPTT, and prolonged bleeding time, small, firm uterus. dx?
vWF because aPTT can be normal. uterine atony would have large boggy uterus
migraine in woman taking OCP, what to do next?
discontinue ASAP because of increased risk of stroke
regression of developmental milestones in 18month old girl, loss of purposeful hand movements, lurching gait, and babling, and seizure, dx?
Rett syndrome
open vs closed angle glaucoma, sxs?
latter is asymptomatic, has cupping of optic disc, decreased peripheral vision/ aka tunnel vision
13 day old baby with conjunctivitis, slightly mucopurulent discharge, rx? and dx?
oral azithromycin. dx is chlamydial conjunctivitis. erythromycin causes pyloric stenosis thats why give azithro in infants
4 yo boy with acute onset unilateral cervical LAD. organism?
staph or strep pyogenes
CO2 inflated for laparscopic surgery, now has bradycardia and AV block, why?
peritoneal stretching leads to vagal activatino
65 yo woman with AMS, woke in morning w headache. had nausea and vomiting. started sertraline 3 wks ago. euvolemic hyponatremia. serum osmolarity is low (hypotonic), urine osm is high, urine sodium is high, dx?
SIADH due to SSRI. polydipsia has low urine osm
stridor in 4month old boy which gets better in prone position, dx and next step and mx?
laryngomalacia, flexible fiberoptic laryngoscopy and treat GERD and reassurance. resolve within 18 months
plan B pill?
ulipristal is highly effective
fever, fussy baby, hip is flexed, abducted, externally rotated. cries when changing position, leukocytosis with neutrophilic predominance.
septic arthritis. DDH has barlow/ortolani abnormal and asymmetrical skin folds
acid ingestion and abdominal sucussion splash, dx?
pyloric stricture, gastric outlet obstruction
neonate vaginal bleeding with white discharge, dx?
maternal withdrawal of estrogen
flail chest definition and symptoms?
contiguous rib fractures creates a chest wall mvmt that is paradoxical.
1 day after difficult delivery due to fetal macrosomia, woman has suprapubic pain that radiates to legs, dx?
pubic symphysis diastasis
untreated hyperthyroid complicatinos (2)
bone disease and tachyarrhythmia
40yo woman with past history of SLE and on glucocorticoids now presents with hip pain, with no rash, swelling warmth etc. dx and next step?
osteonecrosis, MRI of hip. non-inflammatory pain in SLE is commonly osteonecrosis
lights criteria, for pH?
basic. 7.4-7.55
how to monitor response to DKA treatment?
use anion gap or serum beta-hydroxybutrate
hypercalcemia approach
confimr high Ca, correct for albumin, then check PTH. can be PTH independent (malignancy/vit D) or PTH dependent (primary hyperPTH)
pain worse when bladder is full, relieved by peeing, dx?
interstitial cystitis
inflamed ear canal in 2 yo boy, membrane looks partially okay. rx?
topical cipro
60 yo man after coronary angiogram has renal insufficiency, eosinophillia, WBC in urine but no casts or RBC, painless purple mottling on foot and low complement. dx?
cholesterol embolism
9 yo boy wth brain tumor in the parietal globe. dx?
low grade astrocytoma
crohn’s disease with signs of intestinal obstruction, cigarette smoker, distended abdomen, dx?
fibrotic intestinal stricture. not toxic megacolon which is for c.diff and ulcerative colitis
shoulder pain restricted in passive and active movements. dx?
adhesive capsulitis/frozen shoulder.
30 pills of acetaminophen ingested, has Acute liver failure, next step?
liver transplantation
cryptoorchidism corrected with orchiopexy. what risk is higher?
testicular germ cell tumor
what feature in IBS warrants further investigation and why?
nocturnal diarrhea because it points to secretory diarrhea
pasteurella vs bartonella clinical presentatino?
cellulitis within 1-2 days. bartonella- papule at bite/scratch, and regional adenopathy, more insidious
6 yo CF patient has lung infection. culprit?
S. aureus. most common in infants and children. then Pseudomonas
47 yo man, chronically elevated liver enzyme and rash on dorsum of hands, dx?
hepatitis C and PCT
proteinuria in a child approach
do first morning urine proteni/cr reatio. elevated is bad. normal do UA later, to distinguish if transient proteinuria or orthostatic proteinuria
antipsychotic dose increase, and patient can’t stop walking around everywhere. rx?, dx?
decrease the antipsychotic and give propranalol. akathisia
schizophrenia patient with recent relapse, what therapy helps?
family therapy
22 yo sexually active woman with no sxs comes for first pap smear, what else should be done for screening?
gonorrhea and chlamydia, can be asx, and has infertility as complication. test for sexually active woman under 25
antidepressant discontinuation syndrome. rx?
restart the antidepressant and taper off
when is rotavirus and meningococeemia vaccines given?
2-8 months and 11-12 years respectively
60 yo postmenopausal woman, large ovarian mass with postmenopausal bleeding, endometrial biopsy shows complex hyperplasia without atypia, dx?
granulosa cell tumor
86 yo woman with Alzheimers, a lot of CVRF, taken off anticoagulants recently, BP 170/110, T 38C, ECG shows AFib, non contrast CT shows hyperdense region in the parietal region, what is dx?
amyloid angiopathy. cannot be cardioembolic stroke because it presents with loss of grey white junction and sudden onset FND. not long standing confusion like in amyloid angio
TB patient with high sodium low potassium, dx? and what acid-base status is it?
primary adrenal insufficency, causes NAGMA because loss of Na, gain of K and drop in pH because retain H ions
59 yo male with 1 month of dysuria and urgency and frequency and has suprapubic tenderness. smoker. dx?
bladder cancer. can present with pain and is longer duration of symptoms than infection
HIT pathophsyiology
type 1: antibody mediated. type 2: non-immune
65 yo woman with painful swelling on side of face with high fever and chills, includes left external ear, warm tender erythematous rash with well-demarcated borders. LAD present. organism?
GAS
76 yo man after cardiac catheterization has tahycardia, hypotension and flat neck veins. diaphoretic and clammy. dx?
retroperitoneal hemoorrhage
9 month old baby from nigeria with comlete immunization has swelling of hands and feet. and fever. dx?
dactylitis from sickle cell disease
ADHD with amphetamine abuse history. rx?
atomoxetine
52 yo woman with MS, has left eye and speech problems and right arm weakness that resolves after 30 mins. next step?
aspirin and statins because MS deficits last for days-weeks
hyperosmolar hyperglycemic state, what other complication in electrolytes?
decreased total body potassium, watch out when you give insulin
72 yo woman with RA now has lower leg edema, proteinuria and hypoalbuminemia. what would renal biopsy show? and dx?
congo red positive glomerular deposits from AA amyloidosis, commonly in chronic inflammatory states like AA
what are risk factors for RDS?
prematurity and maternal diabetes: DM causes hyperinsulinemia which antagonizes cortisol, prevents fetal lung maturity
thyroid nodule workup?
TSH and U/S. if TSH low, do radionuclide scan to see if cold or hot. if u/s malignant- do FNA
MDD in elderly and peds, what are principles?
don’t be hestitant to dx, esp if sxs are marked and social withdrawal is present
3rd trimesterd bleeding, how to differentiate between preterm labour and placenta previa
preterm labour is bloody show, not frank hemorrhage. and also has regular sustained contractions become more frequent
torticolis after haloperiodol. rx?
diphenhydramine (answer) or benztropine
FOOSH, pain on abduction of shoulder and external rotation of arm, next step, dx?
MRI shoulder, rotator cuff tear
AIDS patient with PCP pneumonia now has hyponatremia after 5L of saline infusino, dx?
SIADH
6 yo boy with hip pain, 2 months of sxs. 2 weeks ago had URTI. persistent limp, dx?
legg-calves-perthes, which is avascular necrosis of femur head
depressed elderly patient with psychotic patients actively suicidal and dehydrated, multiple antidepressants have failed, rx?
ECT
tachy arrhythmia related cardiomyopathy, what will improve LV fxn?
rate or rhythm control
55 yo man falls off ladder and hits chest. chest and back pain, upper extremity hypertension, hoarse voice and lower extremity is cool to touch and diminished pulse, dx?
blunt thoracic aortic injury, the aortic isthmus is prone to shearing force in sudden deacceleration.
62 yo woman with ESRD falls on knee, hears a pop and rapid swelling, anterior effusion and bruising, high riding patella on xray. dx?
patellar tendon rupture
23 yo G1P0 woman booking visit, has T1DM. what additional test should be done for this visit?
24 hr UTP, because high risk for preeclampsia
what is osgood schlatter
osteochondritis of the tibial tubercle. running and jumping. tibial tubercle tenderness common. in active adolescents
what can cause bruising and bleeding to patient when taking coumadin?
INR prolonging agents such as some abx and acetaminophen
pain in heel of foot in athletic patient, and worst when stepping out of bed in the morning. no pain when squeezed dx?
plantar fascitis, squeeze test is for calcaneal fracture
42 yo woman with ataxia, opthalmqwe-ihoqwefpoqhewpofoplegia and arreflexia after GI illness recently. dx?
miller fischer syndrome
symptomatic hypocalcemia in alcoholic with malnutrition, what is cause?
hypomagnesemia. it can cause resistance to PTH and decreased PTH release. suspect when PO4 is also low with Ca
23 yo man with foul smelling bulky stools with weight loss. anti-TTG antibody is negative. biopsy shows villous atrophy. dx?
celiac disease. IgA deficiency can lead to false negative
diabetic foot ulcer present for 4 weeks. next step?
xray or MRI for osteomyelitis
tuberous sclerosis assocaitions
ash leaf spots, seizures, /infantile spasms, cardiac rhabdomyoma, angiofibroma, shagreen patches harmatoma, intellectual disability, angiomyolipoma
32 yo with 18 wks GA has hyperemesis gravidarum, now presents with confusion, ataxia, opthalmoplegia, dx?
wernicke’s encephalopathy/thiamine deficiency which can be brought about by hyperemesis
60 yo man after MI two months ago, now presents with persistent ST elevation with deep q waves and LVH and bilateral crackles. presents with dyspnea and fatigue. hypotensive. dx?
left ventricular aneuyrsm
recent surgery, patient wakes up with severe knee pain. arhtrocentesis shows rhomboid crystals, WBC 30000. dx? and a/w
pseudogout, meniscal calcification
65 yo man with fatigue and leg swelling, hypertension DM, chronic cough, peripheral artery disease, 40 pack year smoking history, hepatomegaly, abdominojugular reflex positive, where is the abnormality?
pulmonary artery systolic pressure due to right heart failure
42 yo woman with polycythemia vera has abdo pain and distension. elevated liver enzymes, flank dullness to percussion, tender hepatomegaly and splenomegaly. next step? and dx.
abdo U/S for budd-chiari syndrome
ulcer after a insect bite will progresseto?
necrosis and eschar. brown widow spider
for metabolic alkalemia look at urinary Cl-. if low then?
self-induced vomiting
9 yo girl with tinnitus after a flight. has popping noises and hearing loss, retracted tympanic membrane. dx?
eustachian tube dysfunction
renal cyst in 54 yo uncle. CT shows uniform, , thin wall, homogenous, mx?
reassurance
2 seizures consecutively, what to give next?
after immediate termination, give fosphenytoin (or some antiepileptic) to prevent future seizure
penile fracture. dysuria. next step?
urethrography to assess for urethral injury. then operate to repair
postpartum urinary retention. next step in mx?
catheterize if not contraindicated (stricture/injury)
18 month old boy with meningeal signs and pinpoint rash on legs. organism?
neisseria. the others GBS, listeria, ecoli, HSV are all for neonates less than one month.
14 yo gymnast hears a pop in knee after landing, now has restricted range of motion, keeps it flexed, laterally there is a large painful immbile deformity, anterior there is divot over the trochlea dx?
patellar dislocation
pneumocaccal virus 13 or 23 order or both?
below 65 in high risk patients. above 65 give sequentially
brain abscess after sinusitis in a young healthy patient, organism?
viridans and staph aureus. nocardia in immunocompromised only
obstrcutive jaundice based on lab tests, next step?
abdo U/S to see if intra or extrahepatic cholestasis. then ERCP if stone or malignancy
persistent pneumothorax and pneumomediastinum after MVA, subcutaneous emphysema, dx?
rupture borchi
fire, black soot near patients nares and mouth. immediate treatment for what is necessary, and how
cyanide poisoning, with hydroxyocobalmin, sodium thiosulfate or with nitrites
young guy with dysuria, frequency, painful ejaculation, no urethral discharge, or fever. no CVA tenderness, smooth non-tender prostate. leukocyte esterase and nitrate positive, dx?
chronic bacterial prostatitis, plus/minus prostate tenderness
nasal trauma, no obvious bleeding but soft and fluctuant nasal septum. next step?
incision and drainage. septal hematoma can be dangerous
66 yo man with T2DM and CKD has hyperkalemia. K is 6.0. ECG is normal. what to do next?
review medicatinos for Bb or potassium sparing diuretics. calcium gluconate is needed only when ECG changes, or K is greater than 7
23 yo man in MVA starts getting ipsilateral hemiparesis and drowsy and cushing’s triad. what nerve is affected?
epidural hematoma, uncal herniation, so occulomotor nerve is affected
shoud HIV patients get MMRV?
depends, if CD4 is greater than 200, yes
neonatal hypoglycemia, macroglycemia, hemihyperplasia, dx? what to do next?
beckwith-wiedemann syndrome. do abdo u/s to look for WILMS tumor
pubic hair/breast development in kid below age 7. workup and approach?
bone age normal (premature adrenarche/thelacrhe) advanced is either central or peripheral precocious puberty
what other substances can cause serotonin syndrome
linezolid, mao-i, ecstasy, and bath salts
2 yo boy with abdo pain, bloody diarrhea and seizure. dx?
shigella
stye vs hordeolum vs chalazion vs blepharitis
stye and hordeolum is daraekki. inflamed eyelash root. chalazion is clogged oil gland. difference is latter is painless. blepharitis is eyelid inflammation with itching. the eye itself doesn’t look too bad
19 yo sexually active female with fever, sore throat and bilateral non-tender LAD and abdo tenderness in lower quadrants, dx?and organism
PID, gonococcal pharyngitis
left pubic rami fracture, FAST shows no intraperitoneal fluid, but foley drains bloody urine. dx?
anterior bladder wall rupture. cannot be ureter because usually from iatrogenic and not blunt trauma
how does lying on the same side of pneumonia lead to decreased SpO2?
blood flows more to gravity dependent area. so increases VQ mismatch
alcohol withdrawal, lorazepam/ diazepam/ chlordiazepoxide?
in liver disease, give lorazepam because less metabolites
patient with IBD has ulcer on lower extremity, dx and rx?
pyoderma gangrenosum, steroids
gestational hypertension criteria
140/90 after 20 weeks gestation
late decelerations due to uterine tachysystole, mx?
stop uterotonics
how does adenosine stress testing work in chest pain patient?
adenosine dilates the coronary vessels, but stenotic ones to a lesser extent than healthy ones, so accentuating the ischemia. contraindicated though in reactive airway disease- use dobutamine instead
c3 nephritic factor is what type of GN
membranoproliferative type 2
8 year old basketball player has heel pain, tender to palpation, dorsiflexion elicits pain, dx?
calcaneal apophysitis, not plantar fascitis
36 yo woman with headache vague visual disturbances, has weight loss tachycardia and tremor. TSH and T4 T3 is high. dx?
not surreptitious Thyroid ingestion because TSH would still be low. but it is central hyperthyroidism
24 yo woman G1P0 at 28 GA comes for prenatal visit. in 1st trimester had chlamydia and was treated. BP normal and trace glucose and protein in urine. now what additional test(s) should be done?
repeat all STI tests because high risk (25>, and previous STI)
guy in MVA with diffuse abdo tenderness, minor scratches on face. what to do first?
FAST. head CT not indicated
ARDS, does increasing FiO2 affect oxygen level?
no
woman at buffet with heavy periods, has nausea, abdo cramping and generalized itching sensation. warm and flushed extremities, vitals shows she is in shock, and ECG just shows tachy, fluids given, what else?
give epinephrine bro, supportive will kill
obese adolescent with hip pain, what is pathophys?
excessive shearing force at proximal femoral physi. SCFE
most accurate GA calculator is which metric
first trimester u/s, crown rump length
27 yo with pelvic pain worse on exercise and sex, pelvic U/S shows unilocular homogenous hypoechoic mass seen in ovary. dx?
endometrioma
woman who just attempted suicide with acetaminophen/clonazepam. what do you see in CSF?
decreased 5-HIAA. nothing to do with the meds, just in suicidal people, 5-HIAA is low.
16 yo girl with intermittent abdo pain, dysmenorrhea at the beginning of menses, pelvic exam normal. what is causing the pain? patho?
primary dysmenorrhea- prostaglandin
36 yo man travel to Nepal on camping trip, had self-resolving diarrhea, abdo pain, malaise, nausea, and fever. ALP elevated and liver hypoechoic lesion, dx?
entamoeba histolytica
44 yo woman with IMB, normal menses, normal exam, normal hormone levels, dx?
endometrial polyp. polyp does not affect menses. but hyperplasia does. also no risk factors for hyperplasia. perimenopause ruled out due to normal menses and hormone levels
volume overload. cardiac or hepatic, what sign can distinguish?
hepatojuglar reflux
post exposure prophylaxis for varicella? vaccine or immunoglobulins?
give vaccine. immunoglobulin is only for immunocompromised or pregnant patients
social anxiety disorder, do you give benzo, ssri or beta blocker?
benzo and Bb only in performance only. ssri/snri for anything
contact lens associated erythema nad injection and ulceration of the eye. dx and organism?
pseudomonal keratitis
intrauterine fetus demise, how to proceed?
can induce labor when parents are ready. allowing for spontaneous labor and waiting too long can cause coagulopathy however
18 month boy with speech delay, lack of eye contact, does not respond to name, solitary play, dx?
ASD
85 yo man forgetful, brought by daughter, sleeps through favorite shows, weight gain, MMSE deficit in attention and recall, dx?
MDD
37 yo man, recent endocarditis, severe periumbilical abdo pain w nausea and vomiting and urge to defecate. no fever. mild diffuse tenderness over abdomen. dx?
mesenteric ischemia
AF first line tx?
Bb or CCB then give anticoag based on Chadvasc score
prader willi vs angelmans… how to remember
prader is papa is missing.. angelman is mother is missing. so tries to compensate for the loss
STEMI in 2, 3, and aVF. given nitrates, then hypotension. what to do next?
IV fluid bolus, then if refractory can give IV dopamine or dobutamine
pulmonary embolism patient, how does it affect calcium levels?
increase in pH means less hydrogen bound to albumin, ergo more calcium bound to albumin, which means less unbound (active) calcium. voila hypocalcemia
upper arm swelling heaviness in younger baseball player, dx?
upper extremity DVT
midshaft fracture of humerous, indications for open reduction and surgical exploration? (3)
open fracture, neurovascular compromise, significant disfiguring
patient has infective endocarditis, after pyelonephritis episode and cystoscopy. organism?
enterococci
77 yo caucasian lady with a rapidly growing nodule with ulceration and keratin plug, central crater. dx?
keratoacanthoma
5 yo with gastroenteritis, sick contacts from pre school and blood found in diarrhea, diffuse pain, and mucusy diarrhea. dx and rx?
bacterial gastroenteritis, observe
3-4 month old boy with hypoglcyemia and seizures and hyperuricemia and hyperlipidemia. has a doll like face. protuberant abdomen, hepatomegaly, dx?
von-gierke, GSD type 1
what is the cause of HELLP
complication of preeclampsia- abnormal placentation. then leads to widespread inflammation and platelet consumption
polyarthraliga, tenosynovitis and vesiculopustular lesions on leg. dx?
gonococcemia
no cervical change in 4 hours in active phase of labor, despite adequate contractions. next step?
CS
15 yo girl comes and treated for STI, mom calls and asks what happened. how do you respond?
minors have right to confidential tx for OB/GYN stuff and emergency stuff and mental health
why are klinefelter patients infertile
eminiferous tubule dysgensis
young obese woman with headache, paillededma and vision change, dx and rx?
idiopathic intracranial HTN, acetazolamide
54 yo man with high steppage/slapping gait, what is abnormality?
common peroneal neuropathy, not sensory/proprioception neuropathy because that would have gait instability as well
CXR after surgery, left side opacification and mediastinal shift towards it? wtf? dx?
bronchial plugging and atalectasis. you also get rib space narrowing
cyanosis in baby after anesthetic exposure, dx, what laboratory finding is expected, and rx?
methemoglobinemia, normal PaO2 because supplemental o2 does nothing, methylene blue
what is predictive of survival after lung resection?
FEV1
32 yo guy injection drug user, has back pain, point tenderness. worse with activity. no fever. leukocytes normal, thrombocytosis, dx?
vertebral osteomyelitis
primary amenorrhea in 15 yo girl without secondary sexual characteristics. next step?
pelvic U/S. then determine FSH if uterus present or do karyotype and serum testosterone if uterus absent
progressive disseminated histoplasmosis, rx?
Ampho B
acute fatty liver of preganncy vs NAFLD?
former is more acute… has more acute sxs like RUQ pain and thrombocytopenia. NAFLD is milder , risk factors include T2DM and obesity and HLD
joint dislocations, poor wound healing, scars, dx?
ehrlers danlos syndrome
mom with graves disease given levothyroxine during pregnancy. the neonate has signs of hyperthyroidism why?
TSH-receptor antibody crosses the placenta
25 yo guy with dysphagia, steak stuck in thorat. now drinking water also vomit. happened suddenly. GERD symptoms previously but no dysphagia in the past. has bronchial asthma. as PMH. dx?
eosinophilic esophagitis
eye suddenly closes to bright lights, dx?
blepharospasm, focal dystonia
suprapubic mass in postmenopausal woman taking tamoxifen with mass symptoms. dx?
uterine sarcome
very itchy rash that spares chest
scabies
8 yo girl with spotting in underwear ,multiple raised fleshy papules on vulva and anus that bleed on contact. next step?
ask about sexual abuse
breast cancer in mom over 67. patient is a drinker. how to reduce risk should i get BRCA testing?
no. not if mother was over 50. just stop drinking so much
28 yo woman with left sided headache and neck pain after fall, ptosis and miosis but no anhydrosis, transient leg weakness. dx?
carotid artery dissection
retropharyngeal abscess can lead to what dangerous complication
acute necrotizing mediastinitis
fatty casts, hyaline casts, brown muddy casts, broad waxy casts, RBC cast WBC casts dx for each?
nephrotic syndrome, pre-renal azotemiea or normal, ATN, CKD/ESRD, kidney disease GN, AIN
radical prostatectomy done, now PSA goes up. then started on radiotherapy. what kind of therapy is this?
salvage
clozapine and methimazole can cause what SE neutropenia or pancytopenia?
neutropenia (agranulocytosis)
19 yo woman with dyspareunia, cervical motion tenderness and laterally displaced cervix. cervix look okay though. menses increasing with cramps. dx?
endometriosis. no fever, no cervicitis means less likely to be PID
26 yo man healthy is in MVA, then after initial resus, still in shock. msucle tone normal. dx?
pelvic fracture
florid Chronic liver disease, what to screen for?
OGD for varices
36 yo woman with bipolar 1 disorder well-controlled with valproate wants to become pregnant. what med should she change to?
lamotrigine. not lithium because although it is not an absolute contraindication in pregnancy, you shouldn’t SWITCH to lithium when there are other options available. If you are taking lithium already, then can continue
39 yo P1 with AUB, had tubal ligation. now with irregular bleeding with clots, heavy as well. also difficulty concentrating at work as well as irritability and depressed mood. no headaches or hot flushes, vagina is not atrophied. cool dry skin. small ovaries. UPT neg, what is FSH TSH prolactin levels?
low high high. hypothyroidism leading to release of TRH, which ramps up TSH and ALSO prolactin, which turns down FSH/LH leading to anovulatory cycles
34 yo woman weight loss, tachycardia, proximal muscle weakness
hyperthyroid
20 yo with lmp 7 weeks ago has vaginal bleeding and abdo pain, upt positive. 1000 B-Hcg. TVUS shows nothing. next step?
repeat b-hcg. 1500-2000 you should be able to see, so wait 2 days for it to double. TVUS should be able to see an ectopic
multiple target lesions on legs, associated with?
HSV infection
5 yo girl with pubic hair, acnea and normal bone age , dx?
premature adrenarche
what is favorable position for fetus head position and what is adequate contraction in MV units? what does molding and caput on fetal head during delivery mean?
occiput anterior and 200 MV units over 10 mins. good maternal effort, suggesting cephalopelvic disproportion
IUD insertion contraindications (2)
current pelvic infection AND any unexplained AUB
26 yo woman with SLE and lupus nephritis, on cyclophosphamide and prednisone daily, now has fever, tachy, o2 sat low, respi distress, leukocytosis, metabolic alkalosis and high lactate. and bilateral interstitial infiltrates. dx?
PCP pneumonia. can be in patients on chronic glucocorticoids plus another immunosuppressant. diffuse alveolar hemorrhage would be sudden and have hemoptysis as well and cough
persistent anxiety about headaches. despite medical evaluations being negative and reassurance. rx?
SSRI
PPH and boggy uterus in mom who has asthma. given oxytocin and bimanual massage but still bleeding. next step?
not carboprostin because asthma. but give tranexamic acid
guy who adopted cats now has slowly expanding rash, central clearing raised border on shoulder. rx anddx?
terbinafine cream, clotrimazole. it is tinea corporis
45 yo woman with severe abdo pain, n/v over last 2 hurs that started after a meal. for past several weeks had episodic epigastric and RUQ pain, T 38.3, BP 140/92, pulse 102. diffuse abdo pain and guarding. stool guiaic positive. dx and next step?
PUD complicated by perforation. cholangitis is ruled out because of guiaic positive. do an upright xray then surgery
asx endometriosis rx?
no need to treat, unless there is symptoms or to preserve fertility
single unilateral breast mass in 15 yo girl, next step?
reexamine shortly after menses
HIV positive mother is in labor. viral load is 12,300 copies per mL. next step?
C-section and intrapartum ART. if viral load >1000, must do c-section and intrapartum and postpartum ART.
43 yo man with epigastric burning exacerbated by heavy lifting at work. has SLE. ECG is normal. next step?
exercise ECG to rule out atypical angina. esp cause SLE can aggraveate
3 yo man wth fatigue, RUQ pain and murpheys sign positive. jaudnice, splenomegaly and normocytic anemia with coombs negative, dx?
hereditary spherocytosis
young obese female headache with ocp use, papilledema MRI normal. dx and complication?
IIH, pseudotumor cerebri, blindness
postpartum urinary retention has two causes?
bladder atony due to epidural affecting detrusor tone and perineal tear affecting pudendal nerve
15 yo girl with irregular menstrual periods, progesterone withdrawal bleeding is normal, dx?
immature HPO axis, low GnRH levels.
56 yo man with cirrhosis, gets anesthetic to check for varices, but then has a sudden drop in SpO2, but ABG shows that PaO2 is 142 mmHg. why the drop in spo2?
methemoglobinemia. SpO2 and PaO2 are different. SpO2 measures o2 bound to Hb, while PaO2 is imply the partial pressure of O2
Acute otitis media vs OME? and rx for each?
erythematous and bulging TM and inflammation is absent in latter. fullness and hearing loss in latter. Abx(amox) for AOM and observation for OME. chronic OME is tympanostomy because can lead to hearing loss
lateral hip and thigh pain, worse later in the evening after use. dx?
greater trochangeric pain syndrome. OA hip is medial hip pain
back pain and constipation in old uncle, has anemia and high creatinine and hypercalcemia, what is causing constipation?
hypercalcemia in MM
widened mediastinum with small pericardial effusion, hemodynamically stable, next step?
CT angiogram to confirm dissection dx! pericardiocentesis not yet
symmetric FGR in 36 yo mother, no maternal illness and u/s consistent with LMP. cause of FGR?
chromosomal abnormality
29 yo woman with chest pain and dyspnea for 10 days, a/w dark bloody vaginal discharge after giving birth 3 months ago. enlarged uterus, closed cervix, dark blood in vagina. cxr shows multiple bilateral infiltrates of many shapes, next step? and dx?
quant b-HCG. metastatic chorioCA
clearly strep throat in 7 yo boy. but rapid antigen test is negative. next step?
culture before giving amox. in adults you can start empiric but children must test
hyperthroidism, do you give antithyroid drug, RAI or thyroidectomy
ATD for mild and for neo-adjuvant before giving RAI or if elderly, and other comorbids. thyroidectomy for tumor, or severe opthalmopathy
64 yo woman bitemporal headache, has nausea dizziness, sausage-link retinal veins, with total protein much higher than albumin, peripheral neuropathy, dx?
waldenstroms macroglobulinemia - B-cell malignancy. hyper IgM
pre term labor. mx (3)
tocolytic (indomethacin,) dexamethasone and mag sulf for fetal neuroprotection
after MVA, is hypovolemic, patient is intubated and then has cardiac arrest. why?
increased thoracic pressure from intubation leads to decreased venous return and low preload
phenytoin side effects (3)
folate deficiency, and gingival hyperplasia, and bone and mineral density metabolism disruption
39 yo woman gives birth to 4.1 kg child after prolonged labor. placenta is extracted in pieces. endometrial stripe is thin. uterus is soft and 4cm above umbilicus. now has PPH. cause of PPH?
uterine atony. soft /boggy uterus. thin endometrial striple rules out placental retaining
fetal tachycardia in woman with preeclampsia given magsulf, and had epidural. mother fever is 39.4. reason for tachy?
fever, epidural effect would cause bradycardia
patient die die wants CSection. but provider not sure … next step?
refer away
suspected PE… do U/S, d-dimer or CT spiral?
depends -_- u/s if kinda suspected, d-dimer if not suspected, CT spiral if highly suspected with clinical findings. use modified wells
endometriosis suspected. mx?
give NSAIDS and COCP, then if fails, do laparscopy to diagnose
45 yo man 2 month history of nonpruritic, palpable , painless purple lesions on legs with joint pain , fatigue, hypertension. positive rheumatoid, elevated transaminases, hypocomplementemia, next step? and dx
hepatitis virus serolgies. dx is mixed cryoglobulinmemia
34 yo G1P0 woman, 38 weeks gestation complains of dyspnea, leg swelling, has mitral regurg and third heart sound, trace protein in urine. suspicion and next step?
peripartum cardiomyopathy, do an echo
early variable late decelerations- point to what?
fetal head compression, cord compression, uteroplacental insufficency
hypertension in pregnancy leads to higher risk of?
preeclampsia and pre-term labour and placental abruption
3yo boy brought by pregnant mother. severe abdo pain and vomiting. black and red vomiting. AXR shows radioopaque tablets in the stomach. dx?
iron poisoning. give deferoxamine
microcytic anemia inpatient taing TB drugs, rx?
pyridoxine
rx for hydrocele
observation
45 yo man with headache and confusion for 2 days everything else normal. low grade fever. FBC shows anemia 8.4, thrombocytopenia, and hemolytic anemia , jaundiced a bit and schistocytes on blood film. dx and rx?
TTP and plasma exchange immediately. mortality is 90%
aortic dissection, what tests (3) to dx when?
TEE if renal failure. CT angio is gold standard.
carpenter with numbness and pain in thumb and index finger. shaking makes it better. tinel sign negative. next step?
Nerve conduction study
23 yo woman, G2P1, 37 wk gestation, what is absolute indication for intrapartum antibiotic prophylaxis for GBS?
prior GBS infection in neonate, maternal positive culture for GBS, and unknown GBS status PLUS any of the following: premie (immature immune system), rupture of mebranes >18 hrs, intrapartum fever
terminal hematuria dx?
bladder or prostate pathology. do a cystoscopy?
65 yo man with fatigue, retrosternal heaviness, after drinking alcohol has severe chest pain. labs show eosinophilia and elevated lactate. dx?
hodgkins lymphoma
cyanotic baby with single loud s2, dx?
transposition of great vessels
42 yo man with weakness, fatigue, fleeting joint pain, SOBOE, low grade fever, dark cloudy urine, pain and swelling in fingertips, normocytic anemia, ESR high, RF positive, dx?
endocarditis. intentionally vague?
man with prostate cancer now has back pain and bowel and bladder dysfunction. next step and then next step?
intravenous glucocorticoids, then imaging (MRI)
ventricular fibrillation after heart attack. rx?
defibrillation
31 yo woman with fatigue and abdo pain after delivery had huge pph. has orthostatic hypotensino, dry skin, loss of pubic hair, hypotensive. dx, what are levels of ACTH, sodium and potassium. and mechanism.
sheehans. low low and normal. sheehans is central adrenal insufficiency so ACTH is low. sodium is low because of SIADH, cortisol blocks ADH secretion. mineraldocorticoids is normal so potassium is normal (conversely, with primary adrenal insufficiency, k is high)
24 yo woman with vulvar pain and dysuria. grouped shallow ulcers on surrounding erythema on labia minor and left inguinal LAD. dx?
herpes simplex. haeomphilusdcureyi is large deep ulcers with yellow/gray exudate
medial tibial condyle pain,dx?
pes anserius
pleuritic chest pain, pneumonia picture, CXR shows periphery of lung a cavity, dx
empyema
nitrates how do they cause pain relief?
decreasing LV oxygen demand, via coronary vasodilation
precocious puberty, cafe au lait and polyostotic fibrous dysplasia, dx?
mcCune albright
penetrating abdominal injury, now patient develops rigidity and diffuse tenderness. next step?
exploratory laparotomy. go in if there is ongoing hemorrhage, peritonitis, evisceration, or impalement
patient on metformin and basal insulin has ok morning sugar levels but high random glucose levels and A1C is 8%. what to do next? principles of insulin basal/bolus
give bolus because postprandial glucose seems to be high. A1C is a measure of postprandial AND fasting glucose. fasting glucose ok, but random high means that bolus insulin needs to be started
13 yo boy with hip pain for 3 weeks, height is 95th and weight is 50th percentile. limping.dx?
SCFE
renal stone radioopaque, most common?
calcium oxalate
13 yo boy with T1DM presents with growth delay, and abdominal bloating, next step?
anti-tissue transglutaminase antibody assay for celiac dz
post MI LV dysfunctino. what medication improve survival? ACE-i, Bb and what else?
mineralocorticoid receptor antagonists, eplerenone/spirinolactone
inevitable abortion, patient bleeding large clots, Hb is 8, BP 90/65, tachycardic. what is next step?
not medical (misoprostol) or expectant mx because hemo unstable. so do suction curettage
hypotension after epidrual, why and rx?
because sympatethic tone in vessels are affected. can give IV fluid bolus and lay patient on right side to increase venous return
prolonged hypotension,from MVA. BUN/Cr ratio is less than 15. Hb low. what do you expect to see on urinalysis
brown muddy casts because of ATN
18 month girl with IDA gets transfusions. hour later, respi distress, tachypnea and tachycardia. S3 gallop, diffus crackles. dx and mx?
TACO transfusion associated circulatory overload, give furosemide
MDD in 74 yo with psychotic features and actively suicidal, not drinking/eating. rx?
ECT bc quick response
post MI complicatino, interventricular septum rupture vs papillary muscle
similar symptoms, but former is like VSD murmur with thrill where as latter is mitral regurg
hip osteoarthritis signs on xray (3)
joint space narrowing, sclerosis of femoral head, osteophytes
chronic pancreatiis with pleural effusion. thoracentesis reveals amylase rich exudative fluid. dx?
pancreaticopleural fistula
unconjugated hyperbilirubinemia in normal baby after delivery,dx?
physiologic because of liver not up to full speed
woman with bruises healing at differnt stages, what to ask next?
NOT if they have safety plan, first ask openly about the bruises…
heaped up verrucousor nodular lesion with violaceous hue organism?
blastomicosis
Diamond blackfan vs fanconi anemia
both have congenital abnormalities but only former has pure red cell aplasia with low reticulocytes. and triphalangeal thumbs. fanconi has pancytopenia and bone marrow failure
asplenic patient with anemia, peripheral bodies show blue clump of stuff in rbc dx? ddx?
howell-jolly body from RBC precursor nuclei. basophilic stipling -lead poisoning, heinz body- G6PD
31 yo woman w/ multiple risk factors for cervical cancer, and has CIN3. next step?
cervical conization or LEEP or cryoablation. need to take it out because high risk for invasion. HPV co testing and pap smears post-procedure yearly
drowning kid saved, normal now. what are 3 complications that can arise?
arrhythmias, cerebral edema and ARDS (from washing out of surfactant)
45 yo man with otitis and sinusitis, has glomerulonephritis and fatigue and joint pain/back pain, dx?
wegeners. do an c-ANCA test
patient with chest pain has TEE done, afterwards has fever with interscapular pain with widened mediastinum. next step to confirm dx?
contrast esophagography- in light of fever and after instrumentation, esophageal perforation more likely. aortic dissection has aortic murmur and asymmetric BP
kid after viral illness in camping trip has hip pain but afebrile, dx and next step
transient synovitis, give NSAID and reassurance
39 yo G1 P0 at 34 wks gestation, had cough and runny nose in 1st trimester, history of HTN, has fetus with normal bipareital circumference but fetal weight is 8th percentile. cause of fgr? approach to fetal growth restriction?
placental insufficiency due to her HTN. FGR is either symmetric or asymmetric. asymmetric is placental, in the 2/3rd trimester. where as infection and chromosomal is in 1st trimester and symmetric
precocious puberty (PP) approach and next step and rx?
look at bone age first, if old bone age, then is it central or peripheral PP? distinguish by LH. if high LH then central. if central, do brain MRI to rule out organic causes before doing GnRH agonist therapy
short interpregnacy interval. risk factor for what?
PPROM, preterm labor and low birth weight
allergies to amoxicillin, urticaria, vitals table, rx?
antihistamines
tamoxifen/raloxifen SE
hot flashes and VTE. tamox can also cause endometrial cancer
26 yo man playing bball and sprains ankle after a dirty defensive move. cannot weight bear and has point tenderness on lateral malleolus. next step?
xray. ottawa ankle rules suggest that if you cannot bear weight for 4 steps and/or you have point tenderness, then get an xray
4 days after giving birth having postpartum bleeding with small clots. dx and next step?
lochia rubra, observation and reassurance
woman in drunk driving MVA, airbag didn’t inflate fast enough, has tachypnea and low o2 sat, CT chest shows ground glass opacities in peripheral anterior part. dx?
pulmonary contusion. hemothorax is pleural effusion
varicocele treatment to prevent what?
infertility in younger men
blunt thoracic trauma with green turbid fluid from chest tube with pleural effusion, dx?
esophageal perforation
menigoceoccemia patient is sudden hypotensive, crashes and dies. cause of death?
adrenal failure
sleep disturbance seen on sleep study in MDD patient?
decreased slow wave sleep, decreased REM sleep latency
ETEC vs rotavirus vs giardia
ETEC is short course, sudden onset. rotavirus is children under 2 with vomiting. giardia is gradual onset over weeks
amputation below the knee now has pain at the stump with slight bogginess, burning sensation. dx?
neuroma
ards treatment principle
low tidal volume to prevent alveolar extension
post surgical ileus vs bowel obstruction how to tell and and mx for each?
generalized dilation of bowel vs clear transition point. mx is conservative vs suctioning?
24 yo guy with dyspnea on exertion. has this chronic lower back pain, worse with rest, better with exercise, ESR is 77mmHg. restrictive pattern and FRC is increased, dx?
chest wall motion restriction in ankylosing spondylitis
3 yo boy with calf pseudohypertrophy and proximal muscle weakness, dx and rx?
duchenne muscular dystrophy, glucocorticoids
36 yo obese woman 32 weeks gestations 136/84 with bilateral pitting edema now has intermittent abdo pain radiating to back, dx?
cholelithiasis, clogging the cystic duct
9 yo boy with GERD symptoms that don’t get better with PPI. soft food predilection. abdo pain. endoscopy shows furrowing with circular rings. patient has eczema. dx?
eosinophilic esophagitis
GBS vs listeria distinguishing featrues in neonate. and do you need intrapartum penicillin for planned elective CS?
mom is sick and has ingested cheese and stuff for listeria. rarer than GBS; no, but horizontal transmission after delivery is still possible
vitamin D and iron in neonates… give or not to give.
exclusively breast fed infants need both vitamin D and iron.. can start giving real food and stuff starting 6 months tho. prematurity, IDA in mother and early introduction of cows milk increases risk of IDA
40 yo guy with 2 weeks of fever, malaise, weakness and unintentional weight loss, has left chest and abdo pain. also has mitral valve prolapse. 20 pack year history, fever. lung has dullness to percussion at the base. 2/6 systolic murmur. leukocytosis with neutrophils. pleural effusion and splenic fluid collection, splenomegaly. dx?
splenic abscess from infective endocarditis. triad for splenic abscess is fever, left upper quadrant abdo pain and leukocytosis. plus pleural effusion, pleuritic pain and splenomegaly.
73 yo woman with dry eyes, impaired vision and dry mouth, ANA negative. dx?
age related sicca syndrome. sjrogren is for middle age, ANA positive
anaerobic aspiration pneumonia. abx?
clindamycin
heavy menstrual bleeding, urinary symptoms and irregular uterus contour, size-date discrepancy. dx?
fibroids
genital ulcer approach?
painful (herpes, chanchroid) painless (lymphogranuloma venerum, granuloma inguinale, SYPHILLIS * unique that it’s single painless ulcer that starts as papule)
bone pain, cortical thickening in left femur, ALP elevated. complication of thisdx?
hearing loss due to temporal bone enlargement in paget’s diseae
42 yo woman with 2 episodes of syncope and weakness and fatigue, BP is low, eart rate 90, hyperpigmentation on palmar creases. what electrolyte abnormality is also found in this patiient?
hyperkalemia. due to primary adrenal insufficiency. ACTH. don’t be so near sighted
ticks bites in new england, now has jaundice, hepatomegaly anemia, thrombocytopenia, fever chills and sweats, high bilirubin, how to dx?
babesiosis using blood smear
cat bite, do you need prophylactic abx, which one for what?
augmentin for pasteurella. no need azithro for bartonella bceause rare
foreign body in 5yo girl’s vagina. next step?
anesthetic then irrigate with warm water for removal
treatment for binge eating disorder
psychotherapy first line, then SSRI or topiramate/lisdexamfetamine
32 yo man with agitation and psychosis, given medications. later he develops altered mental status fever and difficulty getting out of bed, dx?
NMS, due to dopamine antagonism
radial head sublaxation, rx?
hyperpronation of arm. closed reduction. magic
40 yo sexually active woman, no smoker and drinker has enlarged ulcerated tonsil with ipsilateral cervical LAD. sore throat, dysphagia and halitosis. dx?
SCC- due to HPV-16
perimenopausal woman with past history of hysterectomy with hot flashes and atrophic vagina. insomnia and fatigue. rx?
transdermal estrogen patch. unopposed estrogen is the main worry for giving estrogen and progestin together, but is not relevant for this patient
basophilic stippling, poikilocytosis and anisocytosis in macroyctic anemia, dx?
B12/Folate. lead poisoning is not the only dx with basophilic stsippling
65 yo man with diffuse atherosclerosis has severe hypertension and recurrent flash pulmonary edema but normal ejection fraction. dx?
renovascular disease, do an renal u/s
lady has syncope due to aortic dissection, has hypotension, tachycardia and elevated jugular veins. radial artery BP changes with respi cycle. dx?
cardiac tamponade bro
mild vs serious TBI management
non-contrast CT then observation every 2 hrs for serious, can discharge if mild and CT clear
tick bite, fevre, leukopenia nad thrombocytopenia, elevated ALT/AST, dx?and rx
ehrlichiosis doxycycline
CRAO from carotid embolism, wrx?
high flow oxygen and ocular massage. thrombolytics cna be given, intraarterially
indications for laparotomy for penetrating abdo wound? (4)
impalement, evisceration, hemo instability, peritonitis
pulmonary disease in CF patient, influenza positive, what abx to give?
cefepime and vancomycin
65 yo man with cervical spondylosis gets into a MVA with whiplash. upper extremity weakness but lower is fine. which part of cord is damaged?
central
human bite wound, use what abx?
augmentina
TCA intoxication as suicidal attempt. now has ventricular arrhythmia and prolonged QRS. mx and why?
bicarbonate because prevents TCA’s effect on sodium channels
16 yo girl with fatigue, FTT, bicytopenia, splenomegaly and puberty delay, bone pains, dx?
not fanconi’s anemia, but gaucher’s disesase
65 yo man on aspirin, statin, metformin and sitagliptin now presents with pneumonia with prerenal azotemia. next step?
remove metformin because can worsen acute kidney injury with lactic acidosis
how to distinguish primary adrenal insuff vs secondary?
former has ACTH high so hyperpigmentation, and also hyponatremia and hypokalemia. this is not found in secondary AI because RAAS system is intact
hyperkeratotitc papules on the sole that are painful to step on, sexually active 28 yo female. dx?
HPV
patient with hypertensive emergency treated with sodium nitroprusside and then has confusion and hyperreflexia. dx
cyanide poisoning
perioperatively, 62 yo man is hemodynamically unstable, tachypneic, o2 sats are low, abdo pain, bilateral bibasal creps, cardiac index is low and PWCP is high, dx?
MI. Pulmonary embolism the PWCP will be low
67 yo smoking man with painless haematuria constantly throughout urination. prostate is enlarged, not tender and no induration no asymmetry. what to do next?
cystoscopy. prostate CA usually in preiphery so no hematuria
follicular conjunctivitis in 4 yo boy in egyptian refugee camp. has ocular pale follicles and inflammatory changes in tarsal conjunctivae, conjunctivae is thickend visual acuity normal. dx?
trachoma
prosethetic joint infection organism and presentation?
staph epidermidies. presents 3-12 months, delayed onset, and less florid symptoms. staph aureus is early onset and late onset
3 week old premie has abdo distension, vomiting and bloody stools, dx? and investigation finding?
NEC, pneumobilia
67 yo has AAA repair, what will prevent him from getting pneumonia post-op?
not abx, but incentive spirometry. help expand the lungs. CPAP also helps but more expensive
anal fissure rx?
sitz bath, stool softner, fiber in diet, and topical lidocaine/nifedipine
36 yo G1P0 24 wk GA, with asthma and recent UTI tx with nitrofurantoin now has bibasilar crackles and bilateral parenchymal opacties. has SOB and cough now. smoker. dx?
nitrofurantoin related acute lung injury
thaizide diuretic metabolic side effects?
hyperglycemia, hyperlipidemia, hypercalcemia, hypertriglycerides
15 minutes after surgery, 42 yo woman has low grade fever, tachypnea, tachycardia, bilateral extremities rigidity and dark urine. dx?
malignant hyperthermia , due to anesthetic, calcium excess
28 yo guy previously robbed at gunpoint and shot in abodmen, multiple surgeries, now has diarrhea constantly even in sleep, stool osmolar gap is low. dx?
secretory
fully immunized patient has pertussis, why?
waning immunity after 5-10 years
37 yo woman with abdo pain nausea and vomiting, recent laparoscopic hysterectomy. increasing abdo bloating and fever. passing flatus and passing urine normally. u/s shows large intraabdominal fluid and watery vaginal discharge, dx?
ureter unilateral injury
severe penicillin allergy patient has early syphillis. rx?
doxycycline
38 yo woman with proximal muscle weakness, weight gain, HTN, hirsutism, bone degeneration, cause?
cushing syndrome leading to muscle atrophy
steatorrhea and weight loss, now diffuse bone pain. dx and what are PTH/Ca/PO4 levels?
lipase deficiency, so now Vit D absorption, leading to hypocalcemia/hypophosphatemia and hyperparathyroidism
knee pain worse in the morning, stiff, xray shows joint space narrowing and erosion. rx?
quad strengthening
54 yo man w fever chills dysphagia drooling, muffled voice, tongue displace posteriorly. swollen area on floor of mouth, bilateral submandibular area is tender, fluctuant, indurated with crepitus, dx and cause?
ludwig angina- cellulitis of submandibular space usually due to molar
32 yo at 30 wks gestation with hypertension has abdo pain, fever, nausea vomiting, rebound, guarding, abnormal contractions, uterine fundus non tender. dx and rx?
surgery for acute appendicitis. not concealed placental abruption because no uterine pain
pyelonephritis in pregnancy, mx?
inpatient empiric abx until afebrile
bipolar with severe mood episodes rx?
valproate or lithium with 2nd gen antipsychotic (quetiapine)
recurrent variable decelration, rx?
change maternal position, amnioinfusion, but if no variability in fetal heart then must do CS
MDD with psychotic feature, first line?
antipsychotic plus antidepressant OR ECT
patietn comes with lethargy and SOB. shock. reduced breath sounds. cardiac index is high. PWCP and right atrial pressure is borderline low. SVR is decreased. dx? and what is associated finding?
septic shock and bounding pulses
34 yo woman with dyspnea and pleuritic chestpain, has hemoptysis, tachycardia, tachypnea and on oral contraceptive pills, flew back from central asia, dx?
pulmonary infarction
82 yo woman with alzheimers, and T2DM has ear pain, granulation tissue in external auditory canal, facial nerve involvement. dx?
necrotizing otitis externa caused by pseudomonas
63 yo woman with postmenopausal vaginal bleeding, atrophic, and has ulcerated lesion in posterior upper wall. has malodorous watery discharge. KOH prep negative. next step and suspicion?
scc of vagina
3 year old girl with hydrophobia and drooling, dx and reservoir
rabies, bats
post AAA repair has bloody dirarrhea and progressive abdo pain, dx?
bowel ischemia
5 day old newborn with vomiting, poor weight gain and jaundice and hepatomegaly, cataracts. head circumference normal. dx?
galactosemia. rubella has microcephaly and PDA
elevated protein gap and roleaux formation on blood smear, with older man w/ fatigue and anemia, dx?
multiple myeloma
erb duchenne palsy from shoulder dystocia, which nerve(s) and next step?
C5, C6, C7 in the brachial plexus. observe- 80% resolve spontaneously
32 yo, 18 month gestational age, presents with
virilization and bilateral ovarian masses with solid components. dx and mx?
theca lutein cyst/luteomas are common and are managed expectantly
11 yo child w/ T1DM on insulin, presents with blurry vision on fundoscopy she has papilledema, dx?
IIH (can be in nonobese children) although typically in obese childbrearing age womaen
close contacts of pertussis needs what?
prophylactic azithro
massive hemoptysis intubation and the endotracheal tube fills with blood . next step?
bronchoscopy, then pulmonary arteriogram to embolize. then if still cannot do urgent thoractomy
what is leukocyte alkaline phosphatase score?
marker of neutrophil activtiy. can use to distinguish leukemoid reaction (high)to CML/AML (low)
woman undergoing surgery no has high fever, tachycardia, hypertension, tremor, ams and lid lag dx?
thyroid storm. surgery can set it off
NMS rx? (2)
dantrolene or bromcriptine
Varicella in moother who gives birth 2 days after, what should be done to baby?
give VZIG (immunoglobulin)
perianal abscesss mx?
surgical evaluation
confabulation lack of insight in man who tries to break into a shop, dx?
korsakoff
vulvar lichen sclerosus/planus/simplex chronicus
white atrophic skin involving perianal region/purple pruritic polygonal plaques/just scratching, leathery skin as a result
PPROM mx
abx, corticosteroid, monitor for infection signs
29 GA woman 33 yo, with right sided abdo pain, tender to palpation with firm mass. progressing over 2 daysleukocytosis. dx?
degenerating fibroid due to blood requirement to uterus and placenta
rabies prophylaxis bit by a dog
quarantine for 10 days, if sxs develop then give PEP. if animal unavailable, just give PEP
MDD after MI drug
sertraline. citalopram causes QT prolongationn
how to test for lateral epicondyltis(3)
resisted passive extension or supinatino. and flexion of wrist with elbow extended
38 yo woman with pain and tingling in hands, has fiatgue, constipatino and lethargy, deifficulty concentrating, vitals normal, reflexes plus 1, muscle pains, skin is doughy and dry at both elbows, mild edema in both ankles. what is pathophs of hands? and dx?
mucinous infiltration, hypothyroidism
why don’t you need pap smears before 21? even if sexually active?
becasue usually body can clear it
risk factor for premature ovarian insufficiency?
fragil X or turner
watery diarrhea in 74 yo patient for several days prior and then leading to worsening abdo pain and distension, has history of hemiplegic stroke, recently hospitalized for infected pressure ulcer. now has fever, leukocytosis and distended and tender abdomen. xray shows dilated colon, dx?
toxic megacolon from Cdiff
low back pain, lumbar muscle sprain that doesn’tget better with NSAID, rx?
exercise therapy
patient with previous bariatric surgery now presents with skin depigmentation, peripheral neuropathy, ataxia, microcytic anemia, what nutrient is missing?
copper
dihydriohordamine test is what
to test for CGD
how to distinguish ALL and aplastic anemia
bone pain and hepatosplemnoagly in bformer but not latter
retrospective cohort vs case control study
risk factors in former, outcomes in latter already decided!
periodic sharp wave complexes on EEG
CJD
pulsus paradoxus can be seen in not only cardiac tamponade but?
asthma and COPD, lungs too big impinge
norovirus vs staph aureus GE symptoms
former starts 1-2 days after, staph aureus is preformed toxin so starts within 6 hrs
what puts you at risk for molluscu contagiousum?
cellular immunity deficient (AIDS)
HIV dementia vs progressive multifocal leukoencephalopathy on MRI
diffuse increase in white matter intensity vs what it says in the name
5 yo boy brought with marked ecchymoses and swelling over right quads after hitting a table, uncle had cerebral hemorrhage. dx?
hemophilia
healthy newborn things to screen for (4)
genetic screening, pre/post ductal o2 sat (congenital heart disease), bilirubin and hearing
death of loved one, this guy for a week sits ain a dark room whispering to himself, kinda like schizo, dx?
brief psychotic disorder
how to prevent drug abuse?
random drug screen, regular follow up, drug monitoring
infant cyanosis worsened by feeding, relieved by crying, dx?
choanal atresia
45 yo woman with celiac disease has fatigue, bone pain and weakness. PO4 and Ca is low. PTH is high, ALP is high, dx?
rickets/osteomalacia. impaired osteoid matrix mineralization. ALP is high because osteoblasts are busy making osteoid. there just is no calcium and PO4 to mineralize it
ectopic pregnancy, sapingectomy is done. what to do next?
rhogam
C/S done for mom, later is hemo unstable. next step?
emergency laparotomy
ROC curve what is x and y axis
Sn (true positve rate) on y axis and (1-Sp) (false positive rate on the x axis)
34 yo man doing cocain comes with severe chest pain radiating to backpleural effusino, ddimer positivesevere hypertension and tachycardia. dx?
aortic dissection
how to decrease HOCM murmur?
decrease preload by valsalva
CABG surgery, mediastinal wound drainage. but no systemic sxs. or signs. next step?
chest CT /imaging then wound culture to decide IV abx, and surgery
roux-en-y gastric bypass surgery done, now has postprandial vomiting, nausea and GERD sxs. and dysphagia. next step and dx?
OGD to look for gastro-jejunal anastamosis stenosis. short gut syndrome has tachycardia, lightheadedness and syncope and hypotension
woman with MS has pronator drift. pathophys in what neuroanatomical locatino?
upper motor neuron lesion, pyramidal tracts
what causes anterior and posterior shoulder dislocation?
FOOSH vs seizure (for posterior)
suspected gastrinoma approach?
check gastrin levels. if not decisive do a secretin test (should increase gastrin if gastrinoma is present) if still no then do calcium infusion (raises gastrin)
rectus abdominis diastasis or incisional hernia.? lesson?
hernia. horses not zebras
congenital syphyllis sigsn? what are nonspecific infection signs in child?
snuffles and desquamating rash and long bone lucency. nonspecifc: hepatosplenomegaly, jaundice, FGR, blueberry muffin spots
bradycardia and lightheadedneass and syncope and confusion slightly. rx?
iv atropine
gout uric acid stones, what to give to lower the uric acid stones. and how does it work?
potassium citrate, alkalinzes the pH
patient has baby who has late decerlations with absent variability. at plus 21 station. maternal repositioning and 02 supplement does nothing, next step?
cesection
digitalis toxicity arrhythmia?
atrial tachy with AV block
homeless guy with fever lockjaw, painful muscle spasms, dx?
tetanus
60 yo guy with CVRF has lung biopsy for restrictive lun g disease. now has chest pain and SOB two hours after. pulse is 30, BP is 70/40 pulse is 118. PCWP is high, CI is low. dx?
MI
D-xylose test in steatorrhea patient : reason why?
to check if it is brush border abrosption or enzyme deficiency. D-xylose does not need pancreatic enzye
8 month old boy with fever, neck stiff ness and bulging anterior fontanelle. next step?
NOT CT because fontanelle is like a pressure releaser. just go straight to LP
23 yo woman with burning forefoot. squeezing of the metatarsals cause a 3rd and 4th metatarsal clicking sound and burning sensatino, dx?
morton neuroma
woman in labor has vesicles on an erythematous base. next step?
Csection. antiviral doesn’t have time to work
woman 56 yo has thickend sin on hands and multiple telangiectaseias, has headaches and vision changes, now severe hypertension and renal failure. dx? and rx?
systemic sclerosis. scleroderma renal crisisace i.
hyperemesis gravidarum, with normal twin gestatino. what to check next?
ketones in urine. b-hcg no need because normal twins
mom who used some drug in pregnancy has baby with cleft lip and papalte, microcephaly, wide anterior fontanelle, distal phalange hypoplasia. what drug class?
anti-epileptic
mom with two previous miscarriages has false positive VDRL test, and thrombocytopenia and prolonged PTT, dx and rx?
anti phospholipid syndrome, give IV heparin (and aspirin)
newborns of mothers wth Hep B sxs, rx?
Hep B vaccine and Hep B Ig
vaginal infectino. pH lower than 4.5 organism?
candida. trich and gardnerall causes pH >4.5
sinusitis, purulent discharge, for 3 days and mno fever. rx?
supportive because it’s viral
17 yo boy in severe MVA now has hypercalcemia. and hypoalbuminemia. cause of hyper Ca?
immobilizatino. albumin levels dont change the free ca concentration so shouldn’t be symptomatic. also. hyp albumin should be hypo calcemia
patient has rigid and rebound tenderness on abdo. but patient on warfarin and has INR is 2.1. next step?
prothrombin complex concnetrate or FFP
hodkin lymphoa patient in remission for 20 years after chemo and RT. now has round mass in lung no weight loss, fever or chills but has chest pain, pleuritic pain, cough and dyspnea. dx?
secondary malignancy
primary PTH. surgery or medical therapy?
surgical if young, symptomatic with complications
tetanus cleanv vs dirty, vaccination status (3 times)
if dirty and unclear vaccination, give everything. if vaccination status good, then depending on clean or dirty, give vaccine only for more than 10 years of no vaccine (clean) 5 years (dirty)
26 yo with drug overdose, seizures, AMS, dilated pupils, fever, flushed and dry skin, reduced bowel sounds. cuprit drug and monitor which parameter? and rx if gets bad?
TCA, QRS prolongation, rx with sodium bicarb
13 yo girl with no menarche. no sexual characteristics. uterus is present on u./s next step?
FSH to distinguish central or peripheral
65 yo woman with gfatigue and weight gain, has RA. presents with nephrotic syndrome, hepatosplenomegaly. biopsy would show?
glomerular deposits seen after special staining. this is amyloidosis. RA commonly has this
UPT positive, vaginal bleeding, pelvic U/S shows heterogenous mass with cystic structures in the uterus. mx?
suction curettage, B-HCG monitor and contraception. medical abortion only for ectopic with criteria
right calf pain and swelling. IV drug user. has new onset ascites. has IE and embolic stroke in the past that lead to hemiplegia. what is causing ascities?
Hep C because IV drug user. not asking about leg, but about the ascites
SSRI early SE?
headache nausea insomnia/sedatino, anxiety dizziness
OCP benefits and risks?
decrease ovarian and endometrial cancer/ hypertension and hypercoagulability, heaptic adneoma, cervical cancer
13 month old girl fever, weigth loss, abdo mass. and opsoclonus-myoclonus syndrome, and racoon eyes. dx?
neuroblastoma
3 yo girl with knee joint pain worst in the morning, limping. what complication is a/w this?
uveitis
hypercalcemia nad lung cancer which on?
sCamous cell lung cancer
8 yo girl with left ear discharge, recurrent ear infectinos with tympanostomy. now has otoscopy which shows scarring on left tympanic membrane, peripheral granulation and skin debris. dx?
cholesteatoma. not otosclerosis which is outgrowth of stapes bone
febrile neutropneia rx?
pip-tazo, merepenem etc
vaginal bleeding in 41 yo old, overt hyperthyroidism, elevated hcg. u/S shows cystic spaces. dx?
hydatidiform mole. hcg is similar to TSH so causes hyperT
21 yo woman with painful blisters on soles and palms thickening of the sin of soles. . had ftt in infancy due to oral ulcers. dx?
epidermolysis bullosa, pemphigus- presents as adult
4 cm hypopigmented path on arm, ulnar nerve thickneing, immigrant from SEA. tingling and numbness of fingers. next step and dx?
skin biopsy, leprae
55 yo man with weakness and nausea and muscle cramps. BUN/Cr normal, high urine sodium. dx?
acute tubular necrosis due to multiple myeloma
poisoning. painful polyneuropathy. pancytopenia. skin hyperpigmentation/hypopgimented areas. mild transaminitis. dx?
arseninc
synchronized cardioversion, defibrillate or CPR. when to do when?
SC for symptomatic AF/VT. defibrillate for VF or pulseless VT. CPR for PEA or asystole
58 yo with stomach cancer with GOO. now gets feeding tube. then develops weakness, hypophosphatemia, and Vtach. dx?
refeeding syndrome
low cortisol. No response to ACTH stimulation. hyperpigmentation. already given hydrocortisone. still has salt wasting and hyperkalemia. rx?
fludrocortisone (mineraldocorticoid)
