Qbank Step 2 Flashcards
What 4 cancers cause ectopic Cushing’s syndrome?
- Small Cell Lung Ca
- Pancreatic Cancer
- Neuroendocrine tumors
- Bronchial carcinoids
erythematous papules with a central scale with a sandpaper like texture on palpation
actinic keratoses
what is trismus?
inability to open the mouth normally, seen in retropharyngeal abscess
how long is a pt at risk for strep pneumo sepsis after splenectomy?
> 30 years!!! pts should receive anti-pneumococcal, h flu, and meningococcal vaccines several weeks before operation and daily oral penicillin ppx for 3-5 years following splenectomy
palpable purpura + proteinura + hematuria?
suspect mixed cryoglobulinemia: also includes nonspecific systemic symptoms, arthralgias, hepatosplenomegaly, and hypocomplementemia
what infection is associated with mixed cryoglobulinemia?
hepatitis C
how does henoch-schonlein purpura present? (5)
- presents in childhood as:
1. palpable purpura on the buttocks
2. Abdominal pain
3. Arthralgias
4. Proteinuria
5. Hematuria - serum complement levels are normal
how do you differentiate between restrictive and obstructive lung disease on PFTs?
The FEV1/FVC ratio:
restrictive >80%
obstructive <80%
What are the criteria for making a diagnosis of polymyalgia rheumatica? (4)
- Age over 50
- Aching pain in the neck, pelvis, and shoulder lasting >1mos
- Morning stiffness lasting ?1hr
- ESR >40
tx: low dose prednisone
what disease does polymyalgia rheumatica commonly present with?
giant cell arteritis
what are some maneuvers used to treat paroxysmal supraventricular tachycardia? (3) how do they work?
- Valsalva
- carotid sinus massage
- immersion in cold water
- these increase vagal tone and decrease conduction through the AV node
what is paroxysmal supraventricular tachycardia and what is one med used to tx it?
- most common paroxysmal tachycardia in pts without structural heart defects
- heart rates between 160-220bpm
- caused by re-entry into the AV node
- Adenosine: AV nodal blocker short acting
what 4 diseases are associated with erythema nodosum?
erythema nodosum: painful subcutaneous nodules on the anterior surface of the lower legs
- Sarcoid
- TB
- Histoplasmosis
- IBD
all forms of gestational trophoblastic disease present w what 3 symptoms?
- Irregular vaginal bleeding
- Enlarged uterus
- Pelvic pain
what are some causes of pericardial effusion?
- Idiopathic (most common) following viral
- Malignancy
- Post-MI
- Uremia
- Autoimmune diseases
- Hypothyroidism
risk factors for splenic abscess?
- Infection: infective endocarditis with hematogenous spread
- Immunosuppression
- IV drug use
- Trauma
- Hemoglobinopathies
treatment of splenic abscess?
splenectomy!! or IR drainage for poor surgical candidates
why does niacin cause pruritis and flushing??
niacin-induced prostaglandin and histamine release causing peripheral vasodilatation, NOT a hypersensitivity reaction
Side effect of rifampin?
causes red to orange discoloration of body fluids including urine, saliva, sweat and tears (even soft contact lenses)
Pts with rheumatoid arthritis are at risk of developing what long term complication?
osteoporosis/osteopenia/fractures
why does sickle cell trait cause painless hematuria?
papillary ischemia: which is due to the relatively low local oxygen partial pressure
focal segmental glomerulosclerosis is associated with what?
- African Americans (more than 1/2 of nephrotic cases in AA)
- Obesity
- Heroin
- HIV
pt has celiacs but a negative IgA anti-tissue transflutaminase!?!?!? what!?!
- ppl w/ celiacs often have selective IgA deficiency as well meaning…. no IgA! so serological studies will be negative
what plasma aldosterone concentration: plasma renin activity ratio suggests primary hyperaldosteronism?
Ratio >20
with plasma aldosterone >15ng/dL
Pleural fluid glucose <60mg is usually due to what 6 causes?
- Rheumatoid pleurisy
- Complicated parapneumonic effusion or empyema
- Malignant effusion
- TB pleurisy
- Lupus pleuritis
- Esophageal rupture
Pleural glucose <30 usually due to what 2 causes?
- Empyema
2. Rheumatic Effusion
what serum compliment levels are low in poststrep glomerulonephritis?
C3 complement
what is winters formula?
PaCO2 = 1.5 (HCO3) + 8
- can be used to calculate the expected PCO2 during respiratory compensation for a primary metabolic acidosis
when should you take a pt with SBO to the OR?
when they dont improve with conservative measures or there’s signs of strangulation (fever, tachycardia, leukocytosis, metabolic acidosis)
what is Trousseau’s syndrome? 6 associated cancers?
- aka migratory superficial thrombophlebitis
- is a hypercoagulable disorder that usually presents with unexplained superficial venous thrombosis at unusual sites (arm, chest area)
- most commonly associated with visceral malignancy:
1. Pancreas
2. Lung
3. Prostate
4. Stomach
5. Colon
6. Acute leukemias
Pt complains of seeing halos around lights
think of angle closure glaucoma
what two factors increase the overall risk of vertical transmission of HCV from mom to baby?
- HIV coinfection
2. High HCV viral load
whats the risk of sexual transmission of HCV?
in a monogamous heterosexual parternship: 0.1% annually aka VERY LOW
what medications are known to cause idiopathic intracranial hypertension? (IIH)
- Growth hormone
- Tetracyclines (minocycline, doxycycline)
- Excessive vitamin A and its derivatives
treatment for idiopathic intracranial hypertension not caused by medications?
- Weightloss
2. Acetazolamide
pt has a PAINLESS corneal ulcer- what nerve is affected?
First branch of trigeminal: ophthalmic branch
- carries sensory fiberst to the scalp, forehead, upper eyelid, conjunctiva, cornea , nose and frontal sinuses
- damage to V1 results in corneal anesthesia!
DMARD: MOA & Adverse affect- Methotrexate
MOA: Purine antimetabolite SE: Hepatotoxicity Stomatitis (oral ulcers) Cytopenias Rash, alopecia bone marrow suppression pulmonary toxicity - thus give folic acid supplemetation
DMARD: MOA & SE
Leflunomide
MOA: Pyrimidine synthesis inhibitor
SE: Hepatotoxicity
Cytopenias
DMARD: MOA & SE
Hydroxychloroquine
MOA: TNF and IL-1 Suppressor
SE: Retinopathy
DMARD: MOA & SE
Sulfasalazine
MOA: TNF and IL-1 suppressor
SE: Hepatotoxicity
Stomatitis
Hemolytic anemia
DMARDs: SE (4) TNF inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab)
- Infection
- Demyelination
- CHF
- Malignancy
treatment of pt with torsades de pointes?
magnesium sulfate + stop offending agents
what drugs cause torsades?
- TCAs
- Anti-arrhythmics: amiodarone, sotalol
- Anti-infective agents: moxifloxacin, fluconazole
a large pedunculated exophytic papule with a collarette of scale, resembles a large pyogenic granuloma or cherry angioma
- Bacillary angiomatosis: caused by bartonella henslae or quintana
- characteristic skin lesion + fever, weight loss, malaise and abdominal pain
- diagnosis made via tissue bx
- extreme caution must be taken in bx lesions bc they are prone to hemorrhage
pathophys of analgesic nephropathy
- seen in pts w several years of analgesic abuse
- chronic tubulointerstitial damace: due to renal papillary necrosis from papillary ischemia induced by analgesic-mediated vasoconstriction of medullary blood vessels
- RBCs are unchanged on UA (whereas deformed in glomerulopathy)
smudge cells and atypical lymphocytes
CLL: use flow cytometry to prove clonality
JAK2 mutations are associated with what?
myeloproliferative diseases: particularly polycythemia vera
erythematous papules with a central scale and a sandpaper like texture
actinic keratoses
treatment of frostbite to fingers?
rapid re-warming with warm water
what two liver diseases are associated with mallory hyaline bodies on liver bx?
- Alcohol liver injury
2. Wilsons disease
liver biopsy shows hepatocytes containing granules that are PAS positive and diastase resistant
Alpha-1 antitrypsin deficiency
treatment of uric acid stones?
- theyre highly soluble in alkaline urine so alkalinization of urine pH >6.5 with oral potassium bicarbonate or potassium citrate is indicted
(uric acid stones account for approx 10-15% of cases of total nephrolithiasis, seen in pts iwth unusually low urine pH levels and hyperuricosuria, they are radiolucent but can be seen on USG and CT)
what is the most common thyroid hormone pattern in sick euthyroid syndrome?
- a fall in total and free T3 levels, normal T4 and TSH, this is due to the decreased peripheral conversion of T4 to T3
- on recovery from the nonthyroid illness, pts may experience a modest, transient increase in the serum TSH levels
6month old boy has recurrent pyogenic (s pneumo and h flu) infections
think brutons agammaglobulinemia: x linked recessive
what is the defect in brutons agammaglobulinemia?
defect in tyrosine kinase in B cells
what are 3 neurologic complications of measles?
- Encephalitis (within days)
- Acute disseminated encephalomyelitis (within weeks)
- subacute sclerosing panencephalitis (within years)
3yo boy has recurrent staph infections & aspergillus
think chronic granulomatous disease: mutation causes loss or inactivation of the NADPH oxidase responsible for oxidation, patients experience recurrent infections by catalase expressing organisms
gram stain = neutrophils filled wth bacteria
C3 deficiency predisposes kids to what?
recurrent infections with encapsulated bacteria beginning shortly after birth
kid w recurrent fungal and viral infections
think DiGeorge syndrome
steps for management of newborn who doesnt pass meconium within first 24 hours?
- KUB: to look for pneumoperitoneum from perforated bowel
- Contrast enema: to assess for microcolon (meconium ileus- gastrografin can break up meconium and is thus therapeutic) or a transition zone w dilated megacolon (hirschsprung disease)
- If meconium ileus: get sweat chloride test, if hirschsprung: get rectal biopsy
how does maternal diabetes lead to Resp distress syndrome in infants?
- maternal diabetes delays the maturation of surfactant production in the lungs
- fetal hyperinsulinism antagonizes the actions of cortisol and may delay the lung maturation process
infants with laryngomalacia are at risk of waht?
GERD- which can aggravate airway collapse
Eerb duchenne palsy involves what branches?
C5-C7
2 known GI complications of HSP in kids?
GI Hemorrhage
Intussusception
risk factors for cholecystitis in children? (3)
- Sickle cell anemia
- Hereditary spherocytosis
- Obesity
what EKG finding is a minor Jones criteria for rheumatic fever?
proloned PR interval
most common complication of HUS?
renal damage
classic triad of congenital rubella syndrome?
- Deafness
- Cataracts
- Cardiac defects
how do you confirm the diagnosis of Lyme arthritis?
ELISA and western blot testing
what is reactive arthritis?
- acute and asymmetric oligoarthritis that occurs 1-4 weeks after urethritis or diarrheal infection
most common cause of bacteremia in sickle cell patients?
strep pneumo
when is a voiding cystoureterogram indicated in peds patients?
- Patient is under 10 years of age
- Male
- Prepubertal non-sexually active female
medulloblastoma arises from where?
cerebellar vermis
what is associated with breathholding spells??
Iron Deficiency Anemia
what 3 factors increase the risk of iron deficiency anemia in infants?
- Maternal IDA
- Prematurity
- Early introduction of cow’s milk before age 12 months
when should you supplement vitamin B12 in infants?
those exclusively breastfed by strict vegetarian mothers
difference in timing of transient synovitis and legg-calve-perthes disease?
transient synovitis: 1 month
symptoms of riboflavin deficiency? (vit b2)
- cheilosis
- glossitis
- seborrheic dermatitis (often affecting the genital areas)
- Pharyngitis
- edema and/or erythema of the mouth
Differential for T wave inversions: (5)
- MI
- Myocarditis
- Old pericarditis
- Myocardial contusion
- Digoxin toxicity
the most common primary bone tumor affecting children and young adults?
osteosarcoma
most common cause of congenital hypothyroidism in the US?
thyroid dysgenesis
4 contraindications to the rotavirus?
- Anaphylaxis to ingredients
- Hx of intussusception
- Hx of uncorrected congenital malformation of GI like Meckels
- SCID
doxycycline is contraindicated in what 2 patient populations?
- Children <8 years
- Pregnant women
- use oral amoxicillin or cefuroxime instead
when do you use IV ceftriaxone in Lyme disease?
reserved for Lyme meningitis and heart block (manifestations of early disseminated lyme disease)
what is the most common childhood cancer?
Acute Lymphoblastic Leukemia
what are the 3 most common cardiovascular abnormalities seen in Turner’s syndrome?
- Bicuspid aortic valve
- Coarctation of the aorta
- Aortic root dilation
treatment of kawasaki’s?
ASA plus IVIg
what are the HLA-B27 associations?
PAIR: Psoriasis Ankylosing spondylitis IBD Reiter's syndrome
screening recommendations for AAA?
any many 65-75 who have ever smoked
4 drug classes that are known to cause esophagitis?
- Tetracyclines
- ASA (and many NSAIDs)
- Bisphosphonates
- Others: Potassium chloride, quinidine, Iron
treatment of choice for uremic pericarditis?
hemodialysis!
Indications for Hemodialysis (6)
- Refractory hyperkalemia
- Volume overload unresponsive to diuretics
- Refractory metabolic acidosis (pH <7.2)
- Uremic pericarditis
- Uremic encephalopathy or neuropathy
- Coagulopathy due to renal failure
electron microscopy findings include alternating areas of thinned and thickened capillary loops with splitting of the GBM
alport’s syndrome
what is the most common primary intracardiac tumor and where are they usually found?
atrial myxomas: found in the L atrium
what antiretroviral drug is known to cause crystal-induced nephropathy?
Idinavir (protease inhibitor)
thus monitor with UA and serum Cr levels q3-4months
Name the life threatening ART side effect:
Didanosine
pancreatitis
Life trheatening side ART effect:
Abacavir
Hypersensitivity syndrome (rash -> anaphylaxis upon next exposure)
Life threatening ART side effect:
NRTIs
lactic acidosis
Life threatening ART side effect: NNRTIs
SJS
Life threatening ART side effect: Nevirapine
liver failure
when do u give itraconazole for histo ppx in HIV pts?
when CD4 count is less than 100 and they live in areas endemic for histoplasmosis
hereditary spherocytosis is disorder of what?
autosomal dominant disorder of spectrin- the protein that provides scaffolding for RBCs
treatment of hereditary spherocytosis?
folate supplementation and splenectomy
Diagnostic criteria for ATN? (4)
- Urine osmolality 300-350 (but never 20
- FeNa >2%
- BUN:Cr <20:1
Name the association:
- Muddy brown granular casts
- RBC casts
- WBC casts
- Fatty casts
- Broad and waxy casts
- Muddy brown: ATN
- RBC: glomerulonephritis
- WBC: Interstitial nephritis and pyelonephritis
- Fatty casts: nephrotic syndrome
- Broad and waxy: chronic renal failure
what is MEsna used for?
to prevent hemorrhagic cystitis caused by certain chemotherapeutic agents (cyclophosphamide)
3 phases of Trichinellosis? (from eating undercooked pork)
- Initial: larvae invade the intestinal wall causing abdominal pain, N/V, diarrhea
- Second: hypersensitivity as larvae migrate causing splinter hemorrhages, conjunctival and retinal hemorrhages, chemosis
- Third: larvae enter skeletal muscle, muscle pain tenderness, swelling & weakness
- blood count usually shows eosinophilia
triad of trichinella?
- Periorbital edema
- Myositis
- Eosinophilia
2 types of autoimmune hemolytic anemia?
- Warm agglutinin: more common, due to autoimmune disease that is tx with steroids, rituximab (CD20 ab), splenectomy, or immunosuppression
- COld agglutinin: may be due to infections or autoimmune disease causing intravascular hemolysis, tx is supportive care (warming body) and RBC transfusions
Cyclosporine and tacrolimus: MOA?
calcineurin inhibitors
Major side effects of cyclosporine? Tacrolimus?
Cyclosporine:
- Nephrotoxicity
- Hyperkalemia
- HTN
- Gum hypertrophy
- Hirsutism
- tremor
* Tacrolimus has the same EXCEPT for hirsutism and gum hypertrophy
Major toxicities of azathioprine? 3
- Dose related diarrhea
- Leukopenia
- Hepatotoxicity
Major toxicity of mycophenolate?
bone marrow suppression
treatment of myasthenia crisis?
endotracheal intubation and withdrawal of anticholinesterases for several days
what are the 5 major criteria of rheumatic fever?
- Polyarthritis
- Chorea
- Carditis
- Subcutaneous nodules
- Erythema marginatum
treatment of rheumatic fever?
penicillin G
infantile hypertrophic pyloric stenosis is most common in what pts?
first born males age 3-5 weeks
what are the risk factors for jejunal/ileal atresia in infants?
- poor fetal gut perfusion from maternal use of vasoconstricive medications or drugs ie cocaine & tobacco
what is often the first symptom of autistic disorder?
lack of social smile
tx of choice for impetigo?
topical mupirocin
what are the indications for imaging prior to LP in infants and children?
- Hx of hydrocephalus
- Hx of head trauma
- Hx of VP shunt or neurosurg
- Comatose
- Focal neurological findings
birth weight should be regained by
10-14 days
How do you diagnose tinea corporis?
with a skin scraping and potassium hydroxide examination, or clinically
babies born with a sacral dimple or tuft of hair should be screened for what and how?
for occult spinal bifida with a lumbosacral ultrasound (if this is abnormal then perform a MRI of spine
treatment of choice for developmental dysplasia of hip in infant <6 months?
Pavlik hip harness
features of vascular ring in children
- Presents before 1 year
- Persistent stridor that improves with neck extension
- Associated with cardiac abnormalities
- result of abnormal development of the aortic arch causing tracheal, bronchial or esophageal compression
inheritance of myotonic muscular dystrophy?
autosomal dominant
Intraventricular hemorrhage is common in which neonates?
born <1500g
- thus screening w serial head USs is necessary
what is the most common predisposing factor for orbital cellulitis?
bacterial sinusitis
MOA of ethosuximide?
affects the thalamic neurons by woking against calcium currents
how does vitamin A help reduce mortality in pt w measles??
it helps the GI and respiratory epithelium regenerate and enhances the immune system
how do you diagnose choanal atresia?
first: try passing a catheter through nose 3-4cm into oropharynx
then: CT scan with intranasal contrast, which shows a narrowing at the level of the pterygoid plate
what two immunizations are known to cause febrile seizures?
- DTaP
2. MMR
what is the Guthrie urine test?
a qualitative (coloration) test that detects the presence of metabolic products of phenylalanine in the urine - used to diagnose PKU, can also use blood phenylalanine levels
heart defects associated with digeorge?
- Trucus arteriousus
- TOF
- Interrupted aortic arch
- Septal defects
pathology of retinoblastoma?
inactivation of the Rb suppressor gene: can be familial or sporadic
- failure to treat early may lead to death from liver and brain mets
what is werdnig-Hoffman syndrome?
autosomal recessive disorder that involves degeneration of the anterior horn cells and cranial nerve motor nuclei
aka floppy baby syndrome
what is the most common extracranial solid tumor of childhood?
neuroblastoma
neuroblastoma arises from what embryonic origin?
neural crest cells: amplification of n-myc proto-oncogene and hyperdiploidy
wilms tumor arises from what embryonic origin?
metanephros: embryologic precursor of the renal parenchyma
mesonephros gives rise to the what?
- Seminal vesicles
- Epididymis
- Ejaculatory ducts
- Ductus deferens
paramesonephron gives rise to what?
- Fallopian tubes
- Uterus
- Part of the vagina
disregulation of imprinted gene expression in chromosome 11p15
- macroglossia, rapid growth, hemihyperplasia, umbilical hernia or omphalocele
Beckwith-Wiedemann syndrome
deletion of paternal copy of 15q11-q13
Prader Willi syndrome: sporadic disorder due to maternal uniparental disomy (inheriting both copies on chrom 15 from mother)
paternal uniparental disomy- deletion of maternal copy of chromosome 15q11-q13
angelman syndrome
pts w galactosemia are at an increased risk of what kind of sepsis?
e coli neonatal sepsis
bullous type impetigo is caused by what organism?
staph!
the other type is vesiculo-pustulo which i think is from strep
small erythematous patch on a kids cheek that is raised, sharply demarcated with advancing pargins
erysipelas: red, indurated, tense and shiny plaque
- can have lymphatic involvement
- usually due to Streptococci, penicillin is DOC
most common heart defects in downs from most common
- Complete Atrioventricular septal defect (endocardial cushion) = heart failure at 6 weeks
- VSD
- ASD
what is the most common cause of secondary hypertension in children?
fibromuscular dysplasia: most commonly affects the R renal aa, angiography shows a string of beads pattern to the renal aa
radiographic evidence of intra-cranial calcifications that resemble a tramline + seizures
sturge-weber syndrome
most common presenting symptom of craniopharyngioma in children vs adults
Children: retarded growth due to growth hormone and thyroid function
Adults: sexual dysfunction/amenorrhea
treatment for acute migraine HA?
IV Antiemetics (chlorpromazine, prochlorperazine, metoclopramide)
- can add NSAIDs or triptans too
- propanolol and amitriptyline are used for migraine prophylaxis
How does ABPA (allergic bronchopulmonary aspergillosis) usually present?
its a hypersensitivity reaction to Aspergillus colonization of the bronchi
- occurs most commonly in patients with athma or CF
- presents with:
1. Fever
2. Malaise
3. Productive cough
4. Eosinophilia
5. Hemoptysis
what are the causes of atypical pneumonia? (5)
- Mycoplasma pneumoniae (most common in ambulatory setting)
- Chlamydia pneumoniae
- Legionella
- Coxiella
- Influenza
what cause of atypical pneumonia is assocaited with a skin rash?
mycoplasma pneumo:
erythema multiforme: dusky red target shaped skin lesions over all four extremities
what is cerebral salt-wasting syndrome?
may occur in patients with subarachnoid hemorrhage
1. Inappropriate secretion of vasopressin -> water retention
2. Increased secretion of atrial/brain natriuretic peptide which causes cerebral salt wasting
- can also see SIADH
= hyponatremia
treatment of pagets disease?
tx symptomatic pts with bisphosphonates
what drug can cause a maculopapular rash with EBV?
amoxicillin (and other antibiotics)
what marker is relatively specific for hairy cell leukemia?
CD11c
- will also be tartrate-resistant acid phosphatase (TRAP) stain
neurocystericercosis is caused by what?
eating the larval stage of the pork tapeworm Taenia solium (eat eggs excreted by another person)
hyatid cysts are caused by what and seen in what pts?
- caused by echinococcus species and usually seen in the liver and lungs
- more common in sheep breeders
what type of hemolytic anemia do you see in a malignant lymphoproliferative disorder?
warm autoimmune type- caused by anti-red blood cell IgG antibodies,
tx: prednisone, if that doesnt work then splenectomy
why do people with chronic renal failure have abnormal hemostasis? tx?
due to uremic coagulopathy: several uremic toxins cause platelet dysfunction- ie guanidinosuccinic acid
- PT, PTT and TT are normal, BT is prolonged
tx: Desmopressin, cryoprecipitate and conjugated estrogens
what is the underlying pathology of parkinsons?
degeneration of neurons in the substantia nigra- leading to decreased dopaminergic activity and increased cholinergic activity
the risk of hemophilic arthropathy can be significantly reduced by what?
prophylactic treatment with factor concetrates
treatment of choice in kids with constipation?
Oral laxatives: polyethylene glycol and mineral oral
direct head injury followed by a lucid interval then rapid neurologic deterioration w HA vomiting seizures, confusion and lethargy
epidural hematoma: injury to meningeal blood vessels, do not cross suture lines
- dx = CT scan
clinical features that necessitate an emergent craniotomy in epidural hematomas? 5
- GCS <8
- Signs of increased ICP
- Pupillary abnormalities
- Hemiparesis
- Cerebellar signs
whats Friedreich taxia?
most common type of spinocerebellar ataxias
- Neurologic sx: ataxia, dysarthria
- Skeletal: scoliosis, feet deformities
- Cardiac: concentric hypertrophic cardiomyopathy
- most common cause of death are cardiomyopathy and resp complications
- lifespan >20 years
what is the most common pathogenic organism in young CF children in the setting of concurrent influenza infection?
Staph aureus
- after the age of 20, pseudomonas becomes the most common in CF pts
kid w downs syndrome presents with upper motor neuron findings?
- Think atlantoaxial instability
what drugs can cause a serum sickness like reaction and in what setting?
- Amoxicillin
- Penicillin
- Cefaclor
- in the setting of a viral illness
sx: fever, uticarial rash, polyarthralgia and lymphadenopathy
what is the most common complications of supracondylar fractures?
entrapment of the brachial artery
classic triad of congenital rubella?
- Leukocoria (white papillary reflex) from cataracts
- Murmur of PDA
- Hearing loss
how does congenital CMV and rubella differ?
Congenital rubella (triad of leukocoria, PDA< hearing loss) Congenital CMV: deafness, purpura, hepatospneomegaly, sensorineural hearing loss
- In CMV, the deafness is typically unilateral, blindness is usually due to chorioretinitis, and the heart is unaffected
injury in nurse maids elbow??
radial head subluxation: child typically keeps hand in pronated position and refuses attempted forearm supination
low birth weight, closed fists with the index overlapping the 3rd and the 5th overlapping the 4th, microcephaly, prominant occiput, micgrognathia, abduction, short sternum, cardiac and renal malformations, and mental retardation
Edwards syndrome: trisomy 18
whats the actual name of the pinworm?
tx?
enterobius vermicularis
tx: albendazole or mebendazole, but do NOT use in pregnant patients
how is HSP different from other causes of purpura?
it has a normal platelet count
first line treatment for pertussis?
macrolide antibiotic: erythromycin, azithromycin, or clarithromycin
- must treat all family and close contacts regardless of immunization status
3 syndromes associated wtih Wilms tumor? (nephroblastoma)
- WAGR: wilms, aniridia, GU anomalies, intellectual disability
- Beckwith-Wiedemann syndrome
- Denys-Drash syndrome
epidemiology of neuroblastoma? how does it differ from Wilms?
- third most common pediatric cancer (after leukemia and brain), but most common cancer in FIRST year of life
- presents as an abdominal mass that CROSSES the midline whereas Wilms does NOT cross the midline
whats the primary pathophysiologic cause of throbocytopenia in patients with WAS?
decreased platelet production
what are the EKG findings of WPW? (3)
- Shortened PR interval
- Slurred initial portion of the QRS complex (delta wave)
- Widened QRS
treatment of reyes syndrome?
administration of glucose with FFP and mannitol to decrease cerebral edema
what is Jervell-Lange-Nielson syndrome?
one of the congenital QT prolongation syndromes
- autosomal recessive disease characterized by:
1. congenital deafness
2. QT prolongation
tx= propanolol
what should be used as IV fluid resuscitation in children?
isotonic saline or LR
precocious puberty + cafe au lait spots + multiple bone defects (polyostotic fibrous dysplasia)
McCune-Alright syndrome
- sporadic defect in the G protein cAMP kinase function
what commonly causes encephalitis in immunocompetent adults?
Herpes viruses: herpes simplex, varicella, EBV
Difference between chlamydial and gonococcal urethritis?
Chlamydial: mucupurulent discharge, cx shows <100 colonies
gonococcal: less common, discharge is purulent and gram stain usually reveals the causative organisms
preferred management of a solitary brain metastasis? what about multiple brain metastases?
surgical resection followed by whole brain radiotherapy
multiple brain mets: palliative whole brain radiation
How do ventricular aneurysms usually present on EKG?
persistent ST segment elevation after a recent MI and deep Q waves in the same leads
greatest risk factor for variant (prinzmetal’s) angina? tx? what should be avoided and why?
smoking
tx: ccb’s or nitrates
avoid nonselective beta blockers and ASA bc they can promote vasoconstriction
what is dermatitis herpetiformis and what is it associated with? tx?
- grouped herpetiform arrangement of papules and vesicles on the extensor surfaces, elbows, knees, upper back and buttocks
- intensely pruritic
- assoc w gluten-sensitive enteropathy (celiacs dx)
tx: dapsone
what are the two watershed zones in the colon?
- The splenic flexure, which is supplied by narrow terminal branches of the SMA
- The recto-sigmoid junction, supplied by narrow terminal branches of the IMA
treatment of heat stroke?
evaporative cooling: spraying pt w lukewarm water and running fans to circulate air
treatment of nocardia infection in immunocompromised patients?
TMP-SMX
low PaO2 and high PCO2 (50-80 mmHg) suggests what?
alveolar hypoventilation:
- COPD, OSA, obesity hypoventilation, scoliosis
- Myasthenia gravis, lambert eaton syndrome, guillain barre syndrome
- Drugs: anesthetics, narcotics, sedatives
- Brain lesion, infection or stroke
treatment of mucormycosis in sinuses?
Aggressive surgical debridement plus early systemic treatment with amphotericin B (the only effective drug against this guy)
treatment of acute exacerbation of COPD includes what 4 therapies?
- Supplemental O2 (88-92% target sat)
- Inhaled bronchodilators (b2 and anticholinergics)
- Antibiotics: levo
- Systemic glucocorticoids
whats the virus that causes molluscum contagiosum?
poxvirus
treatment f choice for TTP-HUS??
plasmapheresis: removes the offending autoantibodies and repletes the deficient enzymes
why do you have HYPOcalcemia in tumor lysis syndrome?
- phosphate and potassium are both intracellular ions, when theyre released the phosphate binds to calcium and causes hypocalcemia
what are two indications (lab values) for tube thorocostomy in a pt with empyema?
- Low pH (<60
what test confirms the diagnosis of amyloidosis?
tissue biopsy of abdominal fat pad, bone marrow, rectum, kidney, endomyocardial
2 main differences between IgA nephropathy and PSGN?
- Complement levels are normal in IgA and decreased in PSGN
2. PSGN occurs 10-21 days after infxn, IgA occurs 5 days
whats Hamman’s sign and when do you see it?
audible crepitus on cardiac auscultation
- seen in a tracheobronchial tear & esophageal ruptures
3 components of the GCS?
- Eye opening (4 pts)
- Verbal response (5)
- Motor activity (6 pts)
what is Leriche syndrome? triad
- arterial occlusion at the bifurcation of the aorta into the common iliac arteries
1. Claudicationof hip/thigh/buttocks
2. Impotence
3. Symmetric atrophy of the bilateral lower extremities
high riding prostate should make u suspicious of what?
pelvic fracture- prostate is displaced from pelvic hematoma
treatment of MCL tears?
bracing and early ambulation
what virus is associated with nasopharyngeal carcinoma? 2 other associations?
EBV
- assoc is so strong that EBV titer levels may be used to track the progress of therapy
(cancer is also assoc w smoking and chronic nitrosamine consumption)
characteristic of central cord syndrome?
weakness that is more pronounced in the upper extremities than the lower
- occurs w hyperextension injuries in elderly patients with degenerative changes in the cervical spine, causing selective damage to the central portion of the anterior spinal cord
pts w a GSW to abdomen need ex lap in what 3 circumstances?
- Hemodynamically unstable
- Evidence of peritonitis
- Evisceration of any organ
signs of a fat embolism following long bone fracture? 3
- Respiratory distress
- Mental status changes
- Petechiae
- following a latent period of 12-72 hours following the initial injury
what type of cancer should be suspected in all non healing wounds?
squamous cell carcinoma
what part of the spinal cord is most vulnerable to infarction?
thoracic spinal cord- bc its dependent on radicular arteries in the vertebral aa
diagnosis and treatment of anterior spinal artery syndrome?
dx: emergent MRI
tx: supportive care and lumbar drains
what is Volkmann’s ischemic contracture?
the final sequel of compartment syndrome in which the dead muscle has been replaced w fibrous tissue
treatment of duodenal hematoma?
conservatively- with nasogastric suction and parenteral nutrition
whats mcmurrays sign?
- a palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion
- indicative of a medial meniscus tear
pathophysiology of presbyopsia?
loss of elasticity in the lens
what diseases are assoc with primary biliary cirrhosis?
- Sjogrens syndrome
- Raynaud’s syndrome
- Scleroderma
- autoimmune thyroid disease
- hypothyroidism
- celiac disease
what drug is used as both treatment and prophylaxis of secondary amyloidosis?
colchicine
CXR descriptions refer to what:
Popcorn calcification
Bulls eye
Popcorn calcification: hamartoma
Bulls eye: granuloma
an eccentric lytic area w a soap bubble appearance is seen at the epiphyseal region of the distal femur
Giant cell tumor of bone: benign and locally aggressive skeletal neoplasm seen in young adults
- presents w pain, swelling, and decreased ROM
- most commonly the distal femur an proximal tibia around the knee
- surgery is tx of choice
why do CCBs cause significant edema?
due to the property to dilate peripheral blood vessels
what pathogens should be considered in patients with travelers diarrhea lasting >2 weeks? (3)
- Cryptosporidium
- Cyclospora
- Giardia
what imaging modality is used to detect myocardial iron overload in hereditary hemochromatosis?
Cardiac MRI
5 criteria of diagnosing metabolic syndrome?
- Abdominal obesity
- Fasting glucose >100-110
- Blood pressure >130/80
- TGs >150
- low HDL cholesterol
what type of injury causes an anterior shoulder dislocation and how does it present??
- most common form of shoulder dislocation, usually caused by a direct blow or fall on an outstretched arm
- arm is held slightly abducted and externally rotated
what type of injury causes a posterior shoulder dislocation and how does it present?
- caused by violent muscle contractions during a tonic-clonic seizure
- exam shows flattening of the anterior shoulder, prominent coracoid process, and pt holds arm internally rotated and adducted
radiographs show circular appearance of the humeral head and a widened joint space after a seizure
posterior shoulder dislocation, described are the light bulb sign and rim sign
what is the imaging modality of choice for massive hemoptysis?? (>600mL/24hr)
Bronchoscopy! also pt should be placed with the bleeding lung in the dependent position (lateral position) to avoid collection in the airways of the opposite lung
why are pts w Crohns dx at increased risk for oxalate nephrolithiasis?
bc oxalate absorption is increased in Crohn disease and all other intestinal diseases causing fat malabsorption
what nerve provides sensation to the anterior thigh and medial leg?
Femoral nerve
what nerve provides sensation to the lateral leg and plantar foot?
tibial nerve
what nerve provides sensation over the medial thigh?
obturator nerve
what nerve provides sensation to the anterolateral leg and dorsum of the foot?
common peroneal nerve
in a trauma victim, how can mechanical ventilation cause acute death??
bc positive pressure acutely increases intrathoracic pressure, increasing RA pressure and decreasing systemic venous return,
- this sudden loss may cause acute circulatory failure -> death
what is the threshold for performing an escharotomy?
25-40mmHg
what syndrome is associated with burst fracture of the vertebra?
anterior cord syndrome: characterized by total loss of motor function below the level of the lesion with loss of pain and temperature on both sides with intact proprioception
pt develops a whistling noise during respiration following rhinoplasty, one should suspect what?
nasal septal perforation likely resulting from a septal hematoma
most common site of extraperitoneal bladder rupture?
bladder neck
management of kidney stones?
- if 2L fluid daily
Seborrheic dermatitis occurs in all ages but is found with increased frequency in what 2 patient populations?
- HIV
2. Parkinsons disease
whats tinea versicolor?
superficial fungal infection of the skin caused by malassezia globosa
- can appear as hyperpigmented macules or pale./pink macules that dont tan
how do you calculate the serum osmolality and when do you see a omsolar gap metabolic acidosis?
Serum Osm= (2Na + Glu/18 + BUN/2.8)
Osm gap = observed osm - calculated osmolarity
normal <10
- seen in acute methanol, ethanol or ethylene glycol poisoning
what metabolic disturbance do you see in aspirin toxicity?
mixed anion gap metabolic acidosis and respiratory alkalosis (with no osmolar gap)
what are the 2 clinical features of methyl alcohol poisoning?
- Visual changes (snowfield vision)
2. Acute pancreatitis
gradual loss of peripheral vision and consequent tunnel vision
- ophthalmoscopic exam reveals cupping of the optic disk
open angle glaucoma
what do you see on EEG in Creutzfeldt-Jakob disease?
periodic high voltage complexes
what drug is approved for amyotrophic lateral sclerosis?
Riluzole: a glutamate inhibitor, may prolong survival and time to tracheostomy
cavernous hemangiomas of the brain and viscera are assoc with what?
von Hippel-Lindau disease
cystic hygromas are often found in what patient population?
neonates with turner syndrome
Dense intramembranous deposits that stain for C3
Membranoproliferative Glomerulonephritis, type 2 (dense deposit disease)
what is the most important risk factor for bladder cancer?
cigarette smoking (even thoug smoking cessation decreases the risk, pts still have a higher risk than nonsmokers even up to 20 years after smoking cessation)
hereditary hemochromatosis increases risk for what type of cancer?
hepatocellular cancer (responsible for 30% of deaths in these pts)
pathophys of BPPV?
due to crystalline deposits (canaliths) in the semicircular canals that disrupt the normal flow of fluid in the vestibular system
how do you diagnose uremic pericarditis?
symptoms of pericarditis in a kidney disease patient
- BUN >60mg/dL
- EKG does NOT show normal diffuse ST elevations, bc the inflammatory cells dont penetrate the myocardium
drug of choice of IBD induced toxic megacolon?
IV corticosteroids
what in an example of psychological factors affecting medical condition?
asthma exacerbated by anxiety
what are the common first line atypical antipsychotic agents for tx of schizophrenia?
- Ariprirazole
- Asenapine
- Olanzapine: best tolerated
- Risperidone: available in generic
- Quetiapine
- Ziprasidone
- Paliperidone
- Iloperidone
what 4 antipsychotics come in depot IM form?
- Fluphenazine
- Risperidone
- Paliperidone
- Haloperidol
what 3 drugs are used as mood stabilizers in bipolar disorder?
- Lithium
- Lamotrigine
- Valproate
Six common findings seen in anorexic patients
- Osteoporosis*
- Elevated cholesterol and carotene
- Cardiac arrhythmias(prolonged QT interval)
- Euthyroid sick syndrome
- HPA dysfxn: anovulation
- Hyponatremia 2/2 excess water drinking
Pregnant women w a current or previous diagnosis of anorexia nervosa are at risk for what 6 complications
- Miscarriage
- IUGR
- Hyperemesis gravidarum
- Premature birth
- Cesarean section
- Postpartum depression
which ATYPICAL antipsychotic is most likely to cause EPS?
risperidone
* if this happens add benztropine
what are the 5 indications for Electroconvulsive therapy?
- Severe depression (including suicidality, refractive, and psychosis)
- Depression in pregnancy
- Refractory mania
- Neuroleptic malignant syndrome
- Catatonic schizophrenia
what is the time frame for an adjustment disorder?
symptoms occur within three months of an identifiable stressor and lasts no longer than 6 months after the stressor ends
- symptoms must impair level of functioning
when should you hospitalize a patient w anorexia nervosa?
- Dehydration
- Electrolyte disturbances
- Bradycardia
- Severe weight loss
in what patient population is buproprion contraindicated?
pts w eating disorders- could provoke seizures
why does tx an anorexic need close monitoring? aka what complication could occur
refeeding syndrome: electrolyte depletion, arrhythmias and heart failure can result from fluid and electrolyte shifts
medications used for tx of narcolepsy?
- Modafinil & Armodafinil: novel stimulants, preferred tx
2. Amphetamines
among the second generation antipsychotics, what two cause the greatest weight gain?
- Olanzapine
2. Clozapine
Clozapine’s really serious side effect?
agranulocytosis
first line treatment for OCD?
SSRI! if one SSRI fails, try another
treatment of neuroleptic malignant syndrome?
dantrolene: skeletal mm relaxant
what is lanugo?
the fine downy body hair on back and abdomen of anorexic chicks
two medical uses of bupropion?
- Antidepressant
2. Smoking cessation aid
what are the 3 most important prognostic factors for astrocytomas?
- Patients age
- Functional status
- Tumor grade: degree of anaplasia
2 reasons why sickle cell patients are at increased risk for infection w strep pneumo
- Dont have a spleen to protect from encapsulated organisms
2. THey have an upregulation of PAF, which serves as the attachment site for intact pneumococci
what are the two most common causes of malignant pleural effusions?
- Breast cancer
2. Lung cancer
must not miss diagnosis when a pt presents with renal failure, hypercalcemia, bone pain, and anemia?
multiple myeloma until proven otherwise
how do you distinguish vulvovaginal candidiasis and trichomonas infection?
by vaginal pH:
Vulvovaginal candidiasis: pH 4.0-4.5 (thick curd like discharge)
Trichomonas: pH is elevated (green frothy discharge)
the facial nerve’s nucleus is located where?
lateral aspect of the pons
what reflex is absent in testicular torsion?
cremasteric
what is Prehn’s sign?
pain relief with elevation of the testicle, associated with epididymitis
what is juvenile myoclonic epilepsy?
progression of absence seizures ~10 years, to myoclonic seizures at 15 and generalized tonic-clonic seizures around 16
- myoclonus is worsened by sleep
celiacs disease increases the risk of what cancer?
intestinal lymphoma
whats the most common precipitant of GBS?
Campylobacter jejuni
3 ekg findings that are seen in worsening hyperkalemia that are NOT peaked t waves
- Flattening of the P wave
- PR prolongation
- QRS prolongation
pheochromocytoma- arises from where?
from the chromafffin cells of the adrenal medulla that secretes excess catecholamines such as epinephrine and norepinephrine
initial tx of pheochromocytoma?
- first alpha blockade w phenoxybenzamine followed by the use of B-blockers
- then surgery
what benefit has glucocorticoids been shown to have in COPD exacerbations?
improve pulmonary function & decrease the length of hospitalization
what antiretroviral drug causes insomnia with vivid/bizarre dreams?
Efavirenz: NNRTI, these side effects usually occur with the first few doses
extra-adrenal pheochromocytomas are typically seen where?
adjacent to the aorta, particularly in the organ of Zuckerkandl
when treating a migraine, pts should not take triptans with what other drug?
ergots: because this combination could cause prolonged vasospastic reactions
(triptan = 5-HT agonist, ergot = nonspecific 5-HT agonist)
first line treatment for pure hypertriglyceridemia?
fibric acid derivatives: fenofibrate
when do you use clozapine in psychosis?
in treatment resistance: must have failed 2 trials of meds or in schizophrenia associated with suicidality
what two antipsychotics are high risk for metabolic effects?
Olanzapine & Clozapine: monitor fasting glucose, lipid panel, BP and waist circumference
what atypical antipsychotic has been associated with QT prolongation at higher doses?
Ziprasidone
first line treatment for alzheimer’s dementia?
cholinesterase inhibitors (Donepezil, rivastigmine, and galantamine) - donepezil is approved for all stages of alzheimers, memantine is for moderate to severe dementia
which benzo is most likely to result in seizures following abrupt discontinuation?
alprazolam
acute versus long term tx of panic attacks?
acute: BZDs
long term: SSRI & CBT
Neuroimaging findings in psychiatric disorders: Autism: OCD: Panic disorder: PTSD: Schizophrenia:
Autism: increased total brain volume
OCD: abnormalities in orbitofrontal cortex/striatum
Panic: decreased volume of amygdala
PTSD: decreased hippocampal volume
Schizophrenia: enlargement of cerebral ventricles
Lithium exposure in pregnancy, what are effects in:
First trimester
Second/third trimester
First: cardiac defects of septum & possibly ebsteins anoma;y
2nd/3rd: goiter, transient neonatal neuromuscular dysfxn
what hep B marker is still detected in the “window period” when HBsAg has disappeared but anti-HBs is not yet detectable
IgM Anti-HBc
what is the single most common cause of asymptomatic isolated elevation of alkaline phosphatase in an elderly patient?
pagets disease (osteitis deformans)
what are the 3 features of multiple system atrophy (Shy-Drager syndrome)
- Parkinsonism
- Autonomic dysfunction
- Widespread neurological signs
what types of cancers are associated with hypercoagulability?
visceral adenocarcinomas: gastric, pancreatic, and ovarian
contraindications to radioactive iodine treatment?
pregnancy and very severe ophthalmopathy
what female androgens are produced where??
Ovaries: androstenedione, DHEA, and testosterone
Adrenals: DHEAS
gold standard for diagnosing small-intestine bacterial overgrowth syndrome?
endoscopy with jejunal aspirate showing >10^5 organisms
whats CHOP therapy?
Cyclophosphamide Adriamycin Vincristine Prednisone *can use it in MALT lymphoma if eradication of H pylori fails
pt presents with ear fullness and vertigo
menieres disease: abnormal accumulaiton of endolypmh within the inner ear
what is primidone? use? side effects?
- an anticonvulsant that converts into phenylethyl… and phenobarbital
- used for essential tremors
- SE: may precipitate acute intermittent porphyria which manifests as abdominal pain, neurologic and psychiatric abnormalities
- dx: urine prophobilinogen
nitrates are contraindicated in what setting?? 3
- Aortic stenosis
- Recent phosphodiesterase use
- Right ventricular infarction
(bc nitrates decrease preload)
what is the most common cause of cor pulmonale in the US?
COPD: symptoms of cor pulmonale- - exertional symptoms - loud P2 - tricuspid regurg murmur - elevated JVP - peripheral edema - hepatomegaly/ascites - if due to COPD: distant heart sounds from hyperinflated lungs
what do liver function tests show in hepatic adenomas?
- normal AST/ALT
- Alk phos and GGT may be elevated in pts who have intratumoral bleeding or multiple adenomas
- AFP is normal UNLESS malignant transformation has occurred which occurs in 8-13% of pts w hepatic adenomas
What are the different treatment options for influenza pneumonia?
- Neuraminidase inhibitors: oseltamivir and zanamivir
2. For Influenza A: Rimantadine and amantadine
what is the most common extra-articular manifestation in pts with ankylosing spondylitis?
anterior uveitis
what drug is preferred in pts w SLE w isolated skin and joint involvement?
hydoxychloroquine
what 4 drugs increase hepatic clearance of thyroid hormone?
- Phenobarbital
- Rifampicin
- Phenytoin
- Carbamazepine
Hashimoto’s thyroiditis increases risk of what type of cancer?
thyroid lymphoma is 60x higher: will present as a rapid enlargelemt of thyroid gland in pts w preexisting hashimoto’s thyroiditis, compressive symptoms, and “doughnut” sign on CT of neck
- perform CORE biopsy to make diagnosis
how long should you wait after acetaminophen overdose to obtain an acetaminophen level and administer N acetylcysteine?
- 4 hours! bc it will not be significant before this
- give n acetylcysteine anywhere from 4-8 hours of ingestion
- studies have shown no correlation between the amount of acetaminophen reportedly taken and then measured serum drug level
what does the hepatojugular reflex signify?
- when pushing on the abdomen, theres a sustained elevation of JVP >3cm, reflects failing of the R ventricle that cannot accommodate an increase in venous return with abdominal compression
what does the serum inhibin B level represent?
ovulatory reserve: decreased in older women who have a decreased capacity to ovulate
when a female presents with a normal phenotype but lacks a normal vagina and uterus, what 3 diagnoses could it be? how do you differentiate?
- Mullerian agenesis
- Androgren Insensitivity
- 5-alpha-reductase deficiency
- Karyotype differentiates between the two, genotype is XY in androgen insensitivity and 5alpha reductase deficiency
management of uterine atony?
oxytocin immediately! will cause contraction of myometrial fibers and retraction of myometrial blood vessels and will control bleeding in most cases
treatment of lichen sclerosus?
- surveillance w regular clinical exams and biopsies (high incidence of squamous cell carcinoma)
- use of high-potency topical steroids of the genitals is encouraged
pathogens responsible for endometritis?
polymicrobial infection
thus tx: clindamycin + gentamicin (IV)
what is the gold standard for evaluating the cervix for possible cervical imcompetence?
transvaginal ultrasound
hypotension after epidural?? how?
sympathetic fiber block results in vasodilatation of the lower extremity vessels -> blood venous pooling
what are the critical antibody titers that put a fetus at risk for hemolytic disease via Rh isoimmunization?
1:8-1:32 (frequently 1:16 is accepted)
most common bug that causes yellow mucopurulent cervicitis?
chlamydia trachomatis
whats the classic triad of hydatidiform mole?
- Enlarged uterus
- Hyperemesis
- Markedly elevated BHCG (>100,000)
how do you distinguish between hyperemesis gravidarum and morning sickness?
in hyperemesis:
- Persistence of vomiting
- > 5% or prepregnancy weight loss
- Presence of ketonuria
role of hCG?
secreted by the syncytiotrophoblast and is responsible for preserving the corpus luterum during early pregnancy in order to maintain progesterone secretion until the placenta is able to produce progesterone on its own
an increase in BP that appears before 20 weeks gestation is due to either what 2 things
- Chronic hypertension
2. Hydatidiform mole
Most significant risk factor for placental abruption?
Hypertension of any kind!
what is pseudocyesis?
usually seen in women who have a strong desire to become pregnant, get body changes that mimick pregnancy
- a form of conversion disorder, management requires psychiatric evaluation and treatment
what labs do you see in premature ovarian failure?
increased FSH & LH, FSH:LH >1.0 bc FSH has a slower clearance than LH
how do you confirm the diagnosis of premature ovarian failure?
a markedly elevated FSH level in a woman under age 40 who has experienced >3 months of amenorrhea
what is the associatio between hypothyroidism and hyperprolactinemia?
TRH stimulates prolactin production
what is Kallmann’s syndrome?
congenital absence of GnRH secretion associated with anosmia
- present w amenorrhea and absent secondary sexual characteristics such as breast development and pubic hair (FSH and LH are low)
what is the earliest sign of magnesium sulfate toxicity?
depressed deep tendon reflexes
what is the management of urinary retention caused by bladder denervation in epidural anesthesia?
intermittent bladder catheterizations
what does cystoscopy show in interstitial cystitis?
classically demonstrates submucosal petechiae or ulcerations
Treatment of Squamous Cell Carcinoma of the Vagina by stage?
Stage I & II 2cm: radiation therapy
- stage I & II = no extension to the pelvic wall and no metastases
Stage III & IV or >4cm: combination chemotherapy
what 3 things should ALL pregnant women be screened for regardless of risk factors?
- Syphilis
- HIV
- Hep B
when do you screen a pregnant person for gonorrhea and chlamydia?
all women age 25 OR those at increased risk w hx of multiple partners, hx of STIs, etc
most common pelvic tumor in reproductive age women?
leiomyoma
what are the indications for GBS ppx when GBS status is unknown? (4)
- Delivery at 18hrs
- GBS bacteruria during pregnancy
- Prior hx of delivery of an infant w GBS sepsis
what is the gold standard for making the diagnosis of endometriosis?
laparoscopy
whats the most accurate and reliable index for estimating fetal size?
abdominal circumference bc it is affected in both symmetric and asymmetric fetal growth restriction
what are the risks associated with OCP use?
- Venous thromboembolism
- Stroke
- MI
- Breast cancer
- Cervical cancer
- Increase TGs
- HTN
- Worsening of DM
(it DECREASES the risk of endometrial and ovarian ca, PID, and ectopic pregnancy)
what are the 5 components of the Biophysical profile?
- NST
- Fetal tone
- Fetal movements (3/10min)
- Fetal breathing (30/10min)
- AFI: 5-20
*2-5 found on US
Score 8-10 = normal
what is and what causes primary dysmenorrhea?
- lower abdominal pain that radiates to the thighs and back and begin hours before menstruation
- due to the release of prostaglandins during the breakdown of endometrium
- women have higher levels of prostaglandins than normal
what test do you do to diagnose primary syphilis?
dark field microscopy to ID spirochetes: w primary syphilis pt hasnt formed antibodies yet so theres a high rate of false negatives
whats a luteoma of pregnancy?
a benign condition: appears as bilateral, multinodular, solid masses on both ovaries
- most commonly seen in AA multiparous women in their 30s or 40s
- most asymptomatic ut 1/3 of pts develop symptoms of hirsutism and virilization
pathophys of PCOS?
results from abnormal GnRH secretion that stmiulates the pituitary to secrete excessive LH and insufficient FSH
MOA of clomiphene citrate?
an estrogen analog that improves GnRH release and FSH release thereby improving the chances of ovulation
common causes of premature ovarian failure?
- Idiopathic #1
- Mumps
- Oophoritis
- Irradiation
- Chemotherapy
- Assoc w autoimmune disorders: Hashimotos, addisons dx, type I dm, and pernicious anemia
what are the two most common causes of hypopituitarism in the postpartum period?
- Sheehan’s syndrome
2. Lymphocytic hypophysitis
whats the Zavanelli maneuver?
the last resort in a should dystocia that consists of pushing the baby back into the uterine cavity followed by a cesarean section
how does pregnancy increase the incidence of carpal tunnel syndrome?
- estrogen mediated depolymerization of ground substance which causes intertitial edema in the hands and face and increased pressure within the carpal tunnel
tx: wrist splint
Initial therapy of CNS cryptococcal infection in AIDS patients?
IV amphotericin B plus oral flucytosine then switch to oral fluconazole
treatment of CMV retinitis in AIDS pt with CD4 ct <50?
ganciclovir or foscarnet
what are 3 major differences between Actinomyces and Nocardia? (both filamentous gram + rods)
- Actinomyces is anaerobic and not acid fast, nocardia is aerobe and partially acid fast
- Actinomyces is more likely to cause cervicofacial disease and sinus tracts
- Sulfur granules may be found w actinomyces
lower extremity DVTs are divided into what 2 categories?
- Proximal Deep veins: 90% of acute PEs, iliac, femoral and popliteal
- Calf vein thrombosis
what are the nonpharmacologic ways to reduce HTN? List in order from most effective to least
- Weight loss (dec systolic by 5-20 per 10kg)
- DASH diet (dec systolic by 8-10)
- Exercise: decr systolic by 4-9
- Dietary sodium
- Alcohol intake: 2/d men, 1/d women
ST segment depressions in leads V1 and V2 can suggest what?
posterior wall MI
what are the antibodies seen in lambert-eaton syndrome?
antibodies directed against the voltage-gated Ca channels in the presynaptic motor nerve terminal
- this leads to the defective release of acetylcholine, leading to proximal mm weakness
tx: plasmapheresis and immunosuppressive drug tx
(assoc w small cell lung ca)
how can vasospasm following a Subarachnoid hemorrhage be prevented?
Nimodipine
usually occurs within 3-10days
Where’s the lesion in hemi-neglect syndrome?
lesion of the right (non-dominant) parietal lobe
whats the mechanism behind aminoglycoside-induced ototoxicity?
damage to the motion-sensitive hair cells in the ear
drug of choice for trigeminal neuralgia?
carbamazepine
bc of risk of aplastic anemia, must monitor with CBC
It is normally not necessary to begin antiepileptic drugs for a single seizure UNLESS (3)
- Presentation in status epilepticus or w focal neuro signs
- Abnormal EEG or lesion on CT
- FHx of seizures
which medication class are the only ones associated with the possibility of retarding the progression of parkinsonism?
MAO inhibitors: Selegiline, Rasagiline
drugs of choice for prevention and relapse of MS? 2
glatiramer and beta interferon
pronator drift is relatively sensitive and specific for what kind of lesion?
upper motor neuron disease
what are the four lacunar stroke scenarios?
- Pure motor: posterior limb of internal capsule
- Pure sensory: VPL nucleus of thalamus
- Ataxic hemiparesis: anterior limb of internal capsule
- Dysarthria-clumsy hand syndrome: basis pontis
what do you see on EEG in CJD?
sharp, triphasic synchronous discharges
what nerve lesion leads to foot drop?
trauma to the common peroneal nerve (L4-S2)
can be congenital as in Charcot-Marie-Tooth disease
how do you differentiate between a seminomatous germ cell tumor and nonseminomatous?
Seminomatous: 1/3 have increased BhCG but normal AFR
Nonseminomatous (yolk sac, choriocarcinoma, embryonal, mixed germ cell): increased AFP and most have increased BhCG
treatment of choice for cancer related anorexia/cachexia syndrome?
progesterone analogs: megestrol acetate* or medroxyprogesterone acetate
- TCAs as well
women has a eczematous plaque on the left nipple: bx shows large cells that apear to be surrounded by clear halos
pagets disease of the breast: aka underlying adenocarcinoma
What are the 5 side effects of Amiodarone?
- Pulmonary toxicity (fibrosis)
- Thyroid dysfunction: mostly hypo
- Hepatotoxicity: transient elevations in LFTs but only stop if >2x increase
- Corneal deposits
- Skin changes
whats the main measurement used for association in a case control study?
exposure odds ratio
what is Rotor syndrome?
benign condition in which there is a defect of hepatic storage of conjugated bilirubin resulting in its leakage into the plasma
- LFTs and tx are unnecessary
- aka conjugated hyperbilirubinemia
what type of bilirubin is excreted in the urine? aka can be detected on urine dipstick
conjugated bilirubin! its water soluble, loosely bound to albumin and excreted in urine when in excess
what are the only contraindications to starting HepC antiretroviral therapy?
- Ongoing alcohol or drug abuse
- Major uncontrolled depression
* initial tx: peginterferon & ribavirin
when you see a person w afibb and are asked whether or not to anticoag, what do you do?
CALCULATE THE DAMN CHADS2
what is the only type of restrictive cardiomyopathy that is reversible?
hemochromatosis
atrial tachycardia with AV block
digoxin toxicity- arrhtyhmia most specific to it
what are the three risk factors associated with abdominal aortic aneurysm expansion and rupture?
- Large diameter
- Rate of expansion
- Current cigarette smoking
what is erlichiosis?
- tick borne illness from the lone star tick found in SE and south central US
- presents as a flu-like illness, confusion, but NO RASH
*so think tick + flu and no rash
Lab = leukopenia, thrombocytopenia, increased LFTs and LDH
dx: intracytoplasamic morulae in WBCs
tx: doxycycline
its like a curtain coming down over my eyes
think retinal detachment
5 most mportant causes of thyrotoxicosis (hyperthyroid) with low radioactive iodine uptake
- Subacute painless thyroiditis
- Subacute granulomatous thyroiditis
- Iodine induced thyroid toxicosis
- Levothyroxine overdose
- Struma ovarii
whats the difference between visceral and somatic pain?
visceral: diffuse
somatic: localized
treatment of Neuroleptic malignant syndrome?
- Dantrolene: muscle relaxant
- Bromocriptine (DA agonist)
- Amantadine (an antiviral drug with DA properties)
how does acyclovir cause neprhotoxicity?
it is poorly soluble in urine and easily precipitates in renal tubules causing obstruction and acute renal failure
- assoc w high dose parenteral therapy used in HSV encephalitis
what nephropathy is most commonly seen in pts w Hodgkins lymphoma?
Minimal change disease: think its something about lymphocyte dysregulation and cytokine production (IL-13)
whats the earliest renal abnormality seen in diabetic nephropathy?
glomerular hyperfiltration
- remember that efectiveness of ACE inhibitors in diabetic nephropathy is related to thier ability to reduce intraflomerular hypertension
what is a contraindication to the use of succinylcholine for rapid intubation?
hyperkalemia!! can cause significant potassium release and life-threatening arrhythmias
- do not use in pts w hyperkalemia, crush or burn injuries, demyelinating illnesses, tumor lysis syndrome
what are the different BUN:Cr ratios seen in the 3 AKIs?
> 20:1 in pre and postrenal
~10:1 in intrinsic
whats the best test for detecting eosinophiluria?
Hansel or Wright stain
Risk factors for endometrial cancer>
- Advancing age
- Use of unopposed estrogen
- Prolonged use of tamoxifen
- Obesity
- Nulliparity
- PCOS
what two genetic diseases increase risk for breast cancer?
- Cowden syndrome
2. Ataxia telangiectasia
what does V/Q scan show in pulmonary embolism?
an area of perfusion defect without ventilation defect
*aka a mismatched defect
whats the mnemonic for admitting someone to the hospital w pneumonia?
curb65: confusion uremia resp distress BP low age >65
what is selective IgG3 deficiency?
immunodeficiency more common in adult females and is associated with recurrent sinopulmonary and GI infections
whats the mutation and cause of factor V leiden?
- point mutation in a gene coding for factor V (coagulation factor)
- factor V becomes resistant to inactivation by protein C
what are the side effects (2) of zafirleukast?
- Hepatotoxicity
2. Assoc w Churg strauss
treatment of choice for ABPA?
- Oral steroids for severe cases- inhalers cannot deliver a high enough dose of steroids to be effective
- Oral itraconazole for recurrent episodes
pleural effusion w pH <7.2
suggests empyema
what 3 drug regimen should be used in Ventilator assoc PNA?
2 antipseudomonal & 1 MRSA agent
lung auscultation reveals increased tactile fremitus
consolidation
how does one diagnose tropical sprue?
small intestine mucosal biopsy showing blunting of villi and infiltration of chronic inflammatory cells including lymphocytes, plasma cells and eosinophils
early symptom is distortion of straight lines such that they appear wavy
macular degeneration (can be unilateral)
what the heck is emphysematous cholecystitis?
- form of acute cholecystitis that arises 2/2 infection of the gallbladder wall with gas forming bacteria (staph, strep, pseudomonas, klebsiella, e., clostridium)
- men aged 50-70years
- can hear crepitus in abdominal wall but without peritoneal signs
- dx: air fluid levels in the gallbladder or gas shadowing on US
tx: fluid resuscitation, early cholecystectomy, and parenteral antibiotic therapy that is effective against the gram positive anaerobe Clostridium
whats the rate you should correct serum sodium? for hypernatremia
- 5mEq/dL/hr without eceeding 12mEq/24hr period
- can cause cerebral edema if corrected to quickly
pt w hx of depression comes in with empty pill bottle and is obtunded, hyperthermic, dilated pupils, and decreased bowel sounds: ekg found to have QRS prolongation
- what is the drug?
- what do you give?
TCA overdose
- give sodium bicarb
pt came back from tanning in the tropics and still has a white pale velvety patch, scales on scraping
- what is it and whats the tx?
tinea versicolor
tx: selenium sulfide lotion and ketoconazole shampoo
whats the pathology behind familial hypocalciuric hypercalcemia?
- autosomal dominant
- caused by abnormal calcium sensing receptors on the parathyroid cells and renal tubules
- hinders the normal Ca-induced PTH suppression in the setting of hypercalcemia
- pts have asymptomatic hypercacemia and inappropriately high PTH
- pts have a very LOW urinary calcium levels
tea and toast diet leads to what kind of deficiency?
folic acid!
triad of disseminated gonococcal infection?
- Polyarthralgia
- Tenosynovitis
- Painless vesiculopustular lesions
whats the autoantibody associated with dermatomyositis?
anti-Mi-2 (against helicase)
what is hepatolenticular degeneration?
wilsons disease!!!
why do you get pruritis after a hot bath in polycythemia vera?
due to histamine release from an increased number of circulating basophils
vesicles and erosions on the dorsum of the hands
porphyrica cutanea tarda (PCT): associated with hepatitis C!!!!
pathophys of essential mixed cryoglobulinemia?
- due to circulating immune complexes that deposit in small and medium sized vessels and may be associated with low serum complement levels
- pts develop palpable purpura, arthralgias and renal complications (membranoproliferative glomerulonephritis)
- 90% of pts have hepatitis C as well
what are 3 scenarios where you see an elevated BUN without an increase in Cr?
- Bleeding PUD: bacterial breakdown of Hgb in the GI leads to increase in urea absorption
- Systemic steroids
- Prerenal renal failure
liver cyst found + dogs
hydatid cyst: Echinococcus granulosus
- this is the cyst that anaphylaxis can occur secondary to spilling of cyst contents
tx: surgical resection under the cover of albendazole
eggshell calcification of a hepatic cyst on CT scan
hydatid cyst: the dog cyst that can cause anaphylaxis if contents get spilled
CT shows pulmonary nodules with the halo sign or lesions with an air crescent
aspergillosis
whats a hordeolum?
a stye- a common staph abscess of the eyelid
tx: warm compresses
I&D if it doesnt resolve within 48hours
if someone is stuck w a needle from a HIV positive man, what do you use for ppx while awaiting serology?
2-3 drug regimen: 2 NRTIs and 1 protease inhibitor mostly
- repeat testing of pts blood should be performed after 6wks, 3 months and 6 months
what patients will have an abnormal d-xylose test?
proximal small intestine disease: Celiac sprue!!
5 types of thyroid cancer in order of frequency
- Papillary Thyroid cancer (70%)
- Follicular
- Anaplastic
- Medullary: found in MEN syndromes, arises from parafollicular C-cells
- Lymphoma: rare, seen in Hashimotos thyroiditis
when do u prophylax for lyme disease?
must meet all criteria:
- Tick is Ixodes scapularis (deer tick))
- Tick attached for >36hrs or engorged
- In geographic location of tick
- No contraindications to doxycycline
what bug is most likely to cause a UTI in pts with ALKALINE urine?
proteus mirabilis: secretes urease to alkalinize the urine, leading to the formation of struvite stones
- found often in pts with indwelling catheters
what are the excisional guidelines for melanoma?
- if the depth is less than 1 m: melanoma can be excised w a 1cm tumor free margin
- tumors >1mm in depth should have a sentinel lymph node study
treatment of central retinal artery occlusion?
ocular massage and high-flow oxygen administration
progressive and bilateral loss of central vision
macular degeneration
what is the treatment of choice for lyme disease in pregnant/lactating women or children <8years?
amoxicillin
what size is considered a microadenoma? tx?
<10mm
tx: DA agonists- bromocriptine and cabergoline (new drug, better than bromo)
pts w carcinoid syndrome are at risk of developing what vitamin/mineral deficiecny?
niacin
- this is because the increased formation of serotonin from tryptophan
- niacin is also formed from tryptophan
how do you know someone has cleared HBV?
serial measurements of ALT and HBeAg every 3-6 months
- need at least 3 normal ALT levels and 2-3 normal HBV DNA tests over 12-month period to confirm inactive carrier state
mallory weiss tears are tears of what?
submucosal arteries of the distal esophagus and proximal stomach
3 infections that cause primary adrenal insufficiency?
- Tuberculosis: calcificaiton of adrenal
- Fungal infection
- CMV
whats chlordiazepoxide?
a benzodiazepine- common choice of treatment for alcohol withdrawal
what antidepressant can be used for smoking cessation?
buproprion
what are the indications of steroid use in PCP pneumonia?
PaO2 35 mmHg
medical treatment of choice for primary hyperaldosteronism (unilateral adrenal adenoma or bilateral adrenal hyperplasia)?
Aldosterone antagonists: Spirinolactone and eplerenone
- in adrenal adenomas, use this if pt is not a surgical candidate or is refusing surgery
whats the pathophys behind refeeding syndrome?
carbohydrate ingestion stimulates insulin secretion and cellular uptake of phosphorous,potassium, and magnesium
- sx: arrhthmia, CHF, seizures and wernicke encephalopathy
whats the mechanism behind QRS prolongation in TCAs?
inhibition of cardiac fast sodium channels
- Sodium bicarb reverses this by increasing the extracellular sodium concentration
pt presents with AV block, bradycardia, hypotension, and diffuse WHEEZING
beta blocker toxicity: intoxication of CCBs, digoxin and cholinergic agents would cause some of the same but wheezing is indicative of beta-blocker toxicity
what are the 3 iron loving bugs that ppl w hemochromatosis are at increased risk of developing infection from?
- Listeria
- Vibrio
- Yersinia
whats the major toxicity of azathioprine?
dose related diarrhea, leukopenia, hepatotoxicty
whats the major toxicity of mycophenolate?
bone marrow suppression
what 2 types of mutations are typically more severe than the others?
Nonsense and frameshift (as seen in neurofibromatosis type 2)
treatment of choice for ethylene glycol/methanol poisoning?
fomepizole or ethanol to inhibit alcohol dehydrogenase
tx of choice for warm agglutinin autoimmune hemolytic anemia?
prednisone (if this is ineffective, the splenectomy is warranted)
patient presents with nephrotic syndrome and then POOF has severe right sided abdominal pain, ever, and gross hematuria, what happened?
renal vein thrombosis! most commonly occurs with membrnaous glomerulonephritis
lambert eaton syndrome is antibodies to what?
voltage gated calcium channels in the presynaptic motor nerve terminal
pt w hx of bone marrow transplant within (2wks-4months) now has both lung and intestinal disease
think of CMV pneumonitis (GI symptoms from upper and lower GI ulcers)
- bronchoalveolar lavage is diagnostic
life expectancy of edwards syndrome?
95% die within their first year of life
