Question Topics Flashcards
What is the best initial management of hyperphosphatemia in ARF?
Restriction of dietary intake
Phosphate binding agents
What is the issue with giving the phosphate binder calcium carbonate in a patient with ARF?
Hypercalcemia
Large doses are required to be effective
What are the LFT findings in alcoholic liver disease?
AST > ALT
AST:ALT > 2:1
GGT elevated 2-3x normal
What are the LFT findings in viral hepatitis?
AST and ALT elevated >10x normal
GGT mildly elevated but not as much as alcoholic liver disease
What are the LFT findings in biliary obstruction?
AST and ALT elevated but lesser extent than viral or alcoholic liver disease
GGT markedly elevated > 5-10x normal
What is the purpose of GGT?
Useful to confirm that high ALP reflect hepatobiliary disease
Ordered when ALP is high
Specific but POOR SENSITIVITY
Where is ALP found and what is it an indicator of?
ALP is concentrated in the liver, bile duct and bone tissues
ALP is a useful indirect marker of cholestasis
What are situations you should think of if GGT is raised?
Biliary epithelial damage, bile flow obstruction, alcohol, drugs such as phenytoin/phenobarbital/carbamazepine, cholestasis, pancreatitis, diabetes, hypothyroidism
What should raised ALP with normal GGT make you think of?
Non hepatobiliary pathology
Anything that can break down bones can elevate ALP ie: bony mets, primary bone tumors, vitamin D deficiency, bone fractures, renal osteodystrophy
What should you think you when there is jaundice but ALP and ALT levels are normal?
Suggestive of prehepatic origin
Think Gilbert’s syndrome (MCC) or hemolysis (check blood film and counts to confirm)
What is the strongest predictor for the occurrence of post operative delirium?
Pre existing dementia
What is the normal range of the Glasgow Coma Scale?
3 to 15
3 is dead
15 is completely awake, oriented, normal person
What are the safest antiepileptics in pregnancy?
Lamotrigine and levetiracetam
What does carbamazepine in pregnancy put a fetus at risk for?
Neural tube defects
What is the next best step in a patient with ovarian cyst that is hemodynamically stable?
Analgesia and follow up
What is the preferred imaging modality in the assessment of acute pelvic pain?
Ultrasound
What are the main points of cognitive therapy?
Focuses on identifying and changing negative thought patterns and beliefs that contribute to emotional and behavioral problems
Helps individuals recognize and challenge their distorted thinking, and develop more balanced and accurate ways of thinking
Examples of cognitive therapy techniques include cognitive restructuring, thought records, and behavioral experiments
Question stem may mention a client with negative thought patterns and ask which therapy would be most effective in changing those patterns
Which mode of therapy focuses on modifying problematic behaviors and learning new, adaptive behaviors through reinforcement and conditioning?
Behavioral therapy
Examples include relaxation training, social skills training, and behavior activation
Questions stem may include a client with a phobia and asks which therapy would be most effective in reducing anxiety
Most significant risk factor for depression and suicide in transgender youth in Canada?
Lack of support and acceptance from family members and peers
Maternal complications of type 1 diabetes in pregnancy
Preeclampsia
Preterm labor and delivery
Increased risk of infections, including UTIs and yeast infections
Diabetic retinopathy (damage to the retina in the eye)
Diabetic nephropathy (kidney damage)
Diabetic neuropathy (nerve damage)
Diabetic ketoacidosis (a serious and potentially life-threatening complication characterized by high blood sugar levels and ketone buildup in the blood)
Fetal complications of type 1 diabetes in pregnancy?
Macrosomia (large birth weight)
Congenital malformations, including heart defects and neural tube defects
Increased risk of stillbirth
Hypoglycemia (low blood sugar) after birth
Respiratory distress syndrome (difficulty breathing after birth)
Increased risk of childhood obesity and type II diabetes
What is the presentation of roseola?
High fever for several days followed by the abrupt onset of maculopapular rash that SPARES the face and spreads to the trunk and extremities
Caused by HHV 6/7
What is the rash of varicella?
Rash that begins on the face and scalp and spreads to the trunk and extremities in crops over several days
What causes hand foot and mouth disease? What is the treatment?
Coxsackie virus (enteroviruses)
Treatment is supportive with management of fever and pain unless symptoms are severe
Usually self limiting and resolved in 1-2 weeks without significant sequelae
When do you test morning cortisol?
Suspecting adrenal insufficiency in a patient with fatigue, weight loss, salt cravings, and/or GI complaints
These patients may also have fatigue worsened by exertion and improved with bedrest, anorexia, weakness
What are common side effects of SSRIs?
Nausea (most common), dry mouth, headache, insomnia, loose stools, sexual dysfunction, hypersomnolence, sweating, tremor, weight change
What is resistant depression?
Major depressive episodes that do not respond to at least two 8-12 week trials of antidepressant monotherapy
How do you diagnose narcolepsy?
Polysomnogram or multiple sleep latency test
Look for a patient with excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, sleep paralysis
What are the steps for managing a shift worker with fatigue?
- Establish regular sleep schedule
- Improve sleep hyigene (light, tempoerature, noise, coffee, screen time)
- Short acting benzo agonists or short acting nonbenzos (zolpidem) or exogenous melatonin
What are the criteria for chronic fatigue syndrome?
At least 6 months of the following symptoms most of the time with significant impairment
Fatigue
Post exertional malaise
Unrefreshing sleep with cognitive impairment
Orthostatic symptoms
Typical presentation is sudden onset after a flu like illness. There is no proven cure
If does not fit this criteria but is for a minimum 6 months then diagnose with idiopathic chronic fatigue
What tests would you order in a patient with subacute or chronic fatigue?
TSH/thyrotropi/thyroid stimulating hormone
CBC and differential
glucose
electrolytes
calcium
renal and hepatic function tests
What should nonpalpable purpura on dependant areas of the body make you suspicious for?
Thrombocytopenia
Can present as bleeding in the skin or mucous membranes
What are the different severity levels of hypothermia?
Mild 32-35°C pt alert and shivering
Moderate 28-32°C pt has decreased consciousness and may or may not be shivering
Severe <28°C pt is unconscious
What are the urgent treatments to remember for each level of severity of hypothermia?
Mild: remove wet clothing, cover with blanket
Moderate: above + rewarm trunk externally before extremities to avoid fall in core temp with return of blood from extremities, warm humidified O2, forced air warming systems
Severe: above + warmed IV fluids, pleural and periotoneal irrigation with saline, extracorporeal warming (continuous venovenous or arteriovenous rewarming), hemodialysis, cardiopulmonary bypass
What are hypothermic patients prone to? How do you manage this?
Arrhythmias
Provide cardiac monitoring, avoid rough handling of the patient, ignore atrial arrhythmias as they resolve with rewarming, treat ventricular arrhythmias according to ACLS
Dopamine may be given to hypotensive patients who do not respond to warmed IV crystalloid
____ may be given to hypotensive hypothermic patients who do not respond to wamred IV crystalloids
Dopamine
What are the typical causes and precipitating factors of hypothermia?
- Increased heat loss: environment, vasodilation by alcohol/meds/toxins, defective skin with burns or psoriasis, cold confusion, CP bypass
- Decreased heat production: hypothyroid, hypopituitarism, hypoadrenalism, hypoglycemia, malnutrition
- Imparied regulation: diabetic neuropathy, CVA, parkinsons, MS
- Other: sepsis
Is an observational study or randomized controlled trial better for measuring to effectiveness of a vaccine?
Observational study
Once the efficacy of an influenza vaccine is approved, eg, by Health Canada, it would be unethical to measure the vaccine effectiveness by assigning people to a placebo group in a randomized controlled trial. Therefore, vaccine effectiveness is measured through observational studies
Is an observational study or randomized controlled trial better for measuring to efficacy of a vaccine?
Randomized controlled trial
In a situation with negligence what constitutes appropriate communication with the patient?
Apologize
Avoid claiming responsibility or using legal terms
Avoid concealing the truth
Empathize
When is a oral glucose challenge test performed?
24-28 weeks to test for gestational diabetes mellitus
What two tests should be done during the second trimester of a pregnancy?
18-22 weeks ultrasound (checking for fetal structure abnormalities, placental location, gestational age, amniotic fluid volume)
24-28 weeks 1 hour 50 gram oral glucose challenge test
How would you manage a sexually active adolescent with lower abdominal pain and evidence of cervical motion, uterine or adnexal tenderness on pelvic exam?
Consider pelvic inflammatory disease
Treatment should not be delayed until the results of further investigations
Give antibiotics
What would be an urgent consideration in a young woman who gets her period 10 days late with a high bHCG? How would you investigate?
Suspect ectopic pregnancy
To investigate EPdo serum bHCG AND TVUS
If normal then repeat in 2-3 days if hemodynamically stable
What are contraindications to levonorgestrel?
History of ectopic pregnancy, severe liver disease, previous sensitivity
It is a synthetic form of progesterone used in IUDs and emergency contraception
Can be used within 72 hours of unprotected sex
What are some examples of selective progesterone reuptake inhibitors? How do they work? Who are they contraindicated in?
Ulipristal acetate, mifepristone, asoprisnil
Works by binding progesterone receptors to delay ovulation and inhibit implantation
Can be used up to 5 days after unprotected sex
Contraindicated in asthma or uncontrolled HTN
Single 39 mg qd po taken with food
“SPRMs are like the bouncers at the progesterone club,
They block the effects and disrupt the hub.
Ulipristal and mifepristone, their names quite a delight,
For emergency contraception and abortions, they fight!
But beware, my friend, of their contraindications too,
Like pregnancy and allergies, they won’t do.
If adrenal or pituitary disorders are in play,
SPRMs may not be the right way.
So, remember SPRMs, the hormone blockers with flair,
For specific uses, they’re there to care”
In patients with fibroid-associated heavy menstrual bleeding who have no desire for fertility, 1st-line treatment includes?
- hysteroscopic myomectomy for exclusively submucosal fibroids, and
- combined OCPs for all other types including fibroids that are not exclusively submucosal
- GNRH agonists and antagonists and uterine artery embolization are 2nd-line treatments
How do you distinguish a fetish from a disorder?
Disorder causes distress and impairment in living or relationships, fetish is a nonliving object that is used by an ndividual to obtain sexual arousal and orgasm
How to define delusional disorder?
Having one or more delusions for one or more months
The patient has no other psychotic features ie hallucinations or mood changes
Not associated with medical condition or substance abuse
How do you differentiate schizoid from avoidant PD?
Schizoids AVOID and lack desire for interpersonal closeness
Avoidant fear embarrassment or humiation by others
What is a common psychiatric diagnosis in patients who are having trouble adjusting to a new medical diagnosis or prognosis?
Adjustment disorder
Develops within 3 months of a stressor
Symptoms do not meet criteria for other psychiatric disorder
What are the clinical signs of death?
Absence of pulse and blood pressure
Absence of breathing and chest movement
Absence of response to stimuli (e.g. light, sound, touch)
Fixed and dilated pupils
Cooling of the body (algor mortis)
Stiffening of the muscles (rigor mortis)
Absence of which reflexes have no bearing on the diagnosis of brain death?
Spinal reflexes such as the patellar reflex or plantar reflex with flexing of toes
Which reflexes are important in the diagnosis of brain death?
Pupillary light reflex
Corneal reflex
Gag reflex
Cough reflex
All adult patients with first seizure should have which testing?
Rapid glucose
Immediate electrocardgiogram
Neuroimaging either MRI (preferred) or CT
Other appropriate tests include electrolytes, glucose, calcium, magnesium, complete blood count, renal function tests, liver function tests, urinalysis, and toxicology screens
Electroencephalogram and lumbar puncture may be indicated
When Wilson disease is suspected based on clinical findings, further evaluation may include?
Slit lamp to look for Kayser Fleischer rings
CBC to look for Coombs negative hemolytic anemia
24 hour urinary copper
Liver biopsy (copper)
Serum ceruloplasmin
What does an abnormally increased Aa gradient suggest?
- shunting (tetralogy of Fallot, acute respiratory distress syndrome)
- V/Q (ventilation-perfusion) mismatch (cystic fibrosis, pulmonary embolus)
- diffusion impairment (restrictive lung disease).
Given a patient with transient loss of consciousness you should consider what conditions?
Cardiac arrhytmias and structural cardiopulmonary disease especially if
- pt has a hx of structural heart disease
- fmhx of unexplained sudden feath
- during exertion or when supine
- abnormal ECG
- sudden onset of palpitations followed by syncope
What affect does chlorpromazine have on the heart?
HIGH RISK for prolonged QT
What is hemolytic uremic syndrome? What causes it and how is it treated?
Rare condition that occurs when RBCs are destroyed and block the kidneys leading to kidney failure
Caused by E coli 0157:H7
Treatment is supportive. Antibiotics can relese more toxins.
How to counsel regarding CF in pregnancy?
Auto recessive - both parents need to have mutation
Means that child has 1:4 chance of being affected
Advise genetic counselling
How do you treat acute dystonia?
Benztropine IM
Diphenhydramine IM
Side effect of certain meds such as antipsychotics or antiemetics
These two meds are ANTICHOLINERGICS
Epicanthal folds at the eyes, large ears, an upturned nose, full cheeks, broad forehead a wide mouth, a small jaw and small widely spaced teeth
Williams syndrome
Also have cardiovascular problems, diffiulcty with visual spatial tasks like drawing and puzzles but do well on repetitive exercises
Physical appearance of Fragile X
Long narrow face, large ears, prominent jaw and forehead
Unusually flexible fingers, flat feet, big testicles after puberty in boys
What is clonidine used for and what are common side effects?
Lower blood pressure - stimulates alpha 2 to stop vasoconstriction and slows heart rate
Dizzy, drowsy, dry mouth
Severe rebound HTN if abruptly discontinued
What causes a diffuse red rash that blanches when pressure is applied that tends to spare the perioral region and is worse in the armpits?
Scarlet fever
Erythema infectiosum
5th disease
Parvovirus B19
Red slapped cheek rash with circumoral pallor
Rash on trunk that moves peripherally
Spreads via respiratory droplets
Fever, malaise, myalgia 7d prior to rash
What are the side effects of lithium
Sedation, tremor, dry mouth, polyuria, hypothyroid, leukocytosis
“Taking lithium, what might it do?
Tremors, thirst, and confusion too.
Kidneys and thyroid, they’re at risk,
So monitor levels, don’t take the risk.
What is a worrisome side effect of bupropion in bulimia?
Seizure risk
Side effects of gentamycin
Nephrotoxic - adjust dose accordingly
Ototoxic
Mild inflammation of the liver, malaise, and lymphocytosis
Can be a presentation of infectious mononucleosis
Clinical features of normal pressure hydrocephalus
Gait disturbances, urinary incontinence, cognitive impairment
What lymph nodes are associated with drainage from the small and large intestines?
Mesenteric lymph nodes
What lymph nodes are associated with testicular drainage?
Para aortic lymph nodes (retroperitoneal)
What lymph nodes are associated with scrotal skin lesion drainage?
Superficial or deep inguinal nodes
Stimulant side effect in psychotic disorders
May make symptoms worse
Induce mixed manic episodes
What tendon is commonly ruptured in adults over 50 yo
Quadriceps
Look for distally malpositioned patella on radiograph
How would you differentiate Meniere’s from labyrinthitis?
Meniere’s has recurrent episodic vertigo, sensorineural hearing loss and tinnitus
episodic attacks of tinnitus, hearing loss, and vertigo
Labyrinthitis usually does not have resolution between the attacks and their symptoms persist for weeks
quick onset of disabling vertigo with N/V, hearing loss and imbalance thought to be due to post viral infection
BOTH HAVE HEARING LOSS POSSIBILY
How would you differentiate venous from arterial insufficiency?
Venous is characterized by aching leg pain that worsens throughout the day and made better by elevating the legs
Arterial is characterized by claudication and made WORSE by elevating the legs
What condition should be considered in a child with localized bone tenderness, fever and elevated ESR?
Osteomyelitis
Antimitochondrial antibodies are associated with
Primary biliary cholangitis
Signs: fatigue, itching, mild hepatomegaly
Elevated alkaline phosphatase
Lethargy, poor academic performance, constipation, slow growth in a child
Suspect hypothyroidism
What is the main modifiable risk factor for the developement of abdominal aortic aneurysm?
Smoking
95% of all AAA patients have a history of tobacco use
What test is important to order for pheochromocytomas?
Plasma free metanephrines
Presentation: headache, palpitations and sweating with paroxysmal HTN
5 HIAA is used to diagnose carcinoid tumors or CF
If activated PTT does not correct on mixing study what is it suggestive of?
Presence of antiphospholipid antibodies
Screen for lupus anticoagulant next
Increase risk of spontaneous abortions
How to respond to temper tantrums increasing in frequency in children 3-5 yo?
Avoid responding to the behavior
Normal developemental stage that peaks around 3 and resolves around 5
Do not reinforce behavior
Right vs left varicocele
Dilatation and tortuosity of
pampiniform plexus
Right associated with right renal pathology
Left are generally considered benign
MC on left bc the left testicular vein connects to the left renal vein at a right angle making it more prone to obstruction
Can cause infertility bc increased blood flow and pooling of blood in the testicles can lead to increased testicular temp which kills sperm
Rx surgical ligation or embolization of the affected veins can help restore normal blood flow and alleviate symptoms
A/W male factor infertility
Normal QT interval
350 - 450 ms
What injury after an MVA requires urgent laparotomy?
Free air on CT in peritoneal cavity as it indicates hollow viscus injury
What medication can cause prolonged QTc?
AB: azithromycin, clarithromycin, erythromycin, metronidazole, moxifloxan
Antigungal: Fluconazole, ketaconazole
Antiviral: Nelfinavir
Antimalarial: Chloroquine, mfeloquine
Anesthesia: Halothane
Antidepressant: Amitriptyline, clomipramine, imipramine, doxepin
Antipsychotics: Risperidone, fluphenazine, haloperidol, clozapine, thioridzaine, ziprasidone, droperidol
Antihistamines: Diphenhydramine
May present with palpitations, dizzy, light headed, fainting, seizure, c
What medication can cause prolonged QTc?
AB: azithromycin, clarithromycin, erythromycin, metronidazole, moxifloxacin
Antifungal: Fluconazole, ketoconazole
Antiviral: Nelfinavir
Antimalarial: Chloroquine, mefloquine
Anesthesia: Halothane
Antidepressant: Amitriptyline, clomipramine, imipramine, doxepin
Antipsychotics: Risperidone, fluphenazine, haloperidol, clozapine, thioridazine, ziprasidone, droperidol
Antihistamines: Diphenhydramine
ABCDE mnemonic for QT prolongation
anti Arrhythmic
anti Biotic
antipsy Chotic
anti Depressants
anti Emetics
May present with palpitations, dizzy, light headed, fainting, seizure
What is increased CVP indicative of?
Elevated CVP is indicative of myocardial contractile dysfunction and/or fluid retention
NORMAL = 8-12 mmHg
Which antiseizure medication should be avoided in pregnancy?
Valproate
Carbamazepine - risks of neural tube defects but if pt must take it then ensure supplementation with 1 mg folic acid until 6 weeks post partum or until breast feeding is discontinued
What is imipramine used for? What are its side effects?
Can be used for enuresis, stress/urge incontinence or in OCD
Highly lethal in overdose
Prolongs PR interval (cardiotoxic)
Antihistaminergic - can cause weight gain, confusion, seizure, dizziness
Anticholinergic - can cause blurred vision, constipation, tachycardia, confusion, dry mouth, urinary retention, delirium, narrow-angle glaucoma
Tricyclic antidepressant (stops NE & S reuptake)
What medications are associated with serotonin syndrome?
- SSRI, triptans, tramadol, lithium, St John’s wort, tryptophan
- Present with:
Shivering
Hyperreflexia and myoclonus
Increased temp
Vital signs abnormal (tachycardia, tachypnea, BP change)
Encephalopathy (agitation, delirium, confusion)
Restlessness
Sweating (helps differentiate from anticholinergic toxicity where patients are HOT but DRY)
Vomiting diarrhea (differentiate from NMS which does not have GI symptoms)
What is the prophylactic management in pertussis?
Macrolide antibiotic (azithromycin, erythromycin, or clarithromycin) for all household contacts
Vaccinate child/infants (Pentacel) and give booster to adolescents (Adalcel)
Report to public health
If treating pt in high risk transmission situations then consider postexposure prophylaxis and staying off work 7 days
Painful nodularity of the uterosacral ligaments can be associated with what gynecological condition?
Endometriosis
What does the diagnosis of GPA include?
Involve resp, kidney, blood vessels
Nasal or oral inflammation (Painful or painless oral ulcers or purulent/bloody nasal discharge)
Form granulomas on CXR
GPA can cause glomerulonephritis, which leads to kidney dysfunction, hematuria, proteinuria
Granulomatous inflammation on biopsy of artery or perivascular area
Look for positive cytoplasmic antineutrophil antibodies
Initial treatment for prostate cancer
Medial orchiedectomy
Treatment with antiandrogen therapy
A first line treatment for OCD
Sertraline
How do you treat acute dystonia?
Diphenhydramine or benztropine IM
Anticholinergics
How do you treat acute dystonia?
Diphenhydramine or benztropine IM
Anticholinergics
What three diagnoses should be considered in a patient with acute dyspnea in the immediate post operative period?
Laryngospasm - look for stridor
Bronchospasm
Aspiration pneumonia - look for crackles/rhonchi with rapid onset of breathlessness and wheezing
How much iron should be supplemented in premature infants?
2-4 mg/kg for the first year
Decreased stores at birth
Increased loss through phlebotomy for lab investigations
Increased requirements because of rapid growth
What is an often missed absolute containdication to estrogen containing contraception?
Migraine with aura
Increased risk of cerebrovascular accidents
Progestin only methos may be used with both types of migraines
What is the initial management for intestinal obstruction?
Nasogastric tube placement for gastric decompression
What is the immediate control method to limit spread when a patient has been diagnosed with meningococcal meningitis?
Treat family members with rifampin
Notify Public health authorities so that all known close contacts can be offered AB prophylaxis
Highly contagious
Gram negative diplococci
When is TB treatment prolonged to 9 months?
Risk factors for relapse
Presence of cavity on chest xray after 2 months or at the end of therapy
Persistent smear or culture positivity after 2 months therapy
HIV coinfection
What is the most probable diagnosis for a post partum patient with abdominal pain and low grade fever following normal vaginal delivery?
Postpartum endometritis
Postpartum fever, midline lower abdominal pain, uterine tenderness
Purulent lochia, chills, headache, malaise, anorexia
What is the most common cause of postoperative fever in a hemodynamically stable abdominal surgery patient?
Inflammatory stimulus of surgery and NOT INFECTION
What should be given in a patient with first trimester vaginal bleeding?
Request Rh group or give Rh immunoglobulin
Prevents alloimmunization
What is the gold standard test for diagnosis of gastric cancer?
Gastroscopy and biopsy
What genetic screening should be offered to all pregnant patients?
MSS - maternal serum screen (triple screen) + inhibin A (quad screen)
IPS - integrated prenatal screen
FTS - first trimester screen
Voluntary and require consent
Who is respoinsible for determining the cause and circumstances surrounding and unexpected, unnatural or unexplained death?
Coroner
They arrange autopsies
Medical examiners are physicians vs most jurisdictions use the coroner system to investigate deaths and coroners do not need to be physicians
Does a physician have to give all information to the coroner?
- No they only should disclose the records listed in the warrant
- Must obtain consent of the deceased patient’s legal representative before disclosing information
- Coroners do not have the power to question the physician as part of their investigation
- Physicians should communicate with CMPA if they are contacted by a coroner for medical infomation or if they receive a summons/warrant to disclose records or attend an inquest
Does a physician have to give all information to the coroner?
- No they only should disclose the records listed in the warrant
- Must obtain consent of the deceased patient’s legal representative before disclosing information
- Coroners do not have the power to question the physician as part of their investigation
- Physicians should communicate with CMPA if they are contacted by a coroner for medical infomation or if they receive a summons/warrant to disclose records or attend an inquest
Differential of dysphagia with liquids AND solids
Neuromuscular
Intermittent: diffuse esophageal spasm (a/w chest pain)
Progressive: Scleroderma (look for GERD symptoms) or achalasia (look for aspiration symptoms)
Differential of dysphagia with JUST solids
Mechanical
Intermittent: Lower esophageal ring
Progressive: Carcinoma (a/w weight loss), infection (a/w odynophagia), esophageal strictures secondary to esophagitis (a/w GERD or chemical ingestion)
A palpable hard lymph node in the left supraclavicular fossa is suggestive of what?
Gastric carcinoma
Troisier’s sign
If dysphagia is progressive then consider…
Stricture or esophageal cancer
Symptoms and signs that should make you think of multiple myeloma
Hypercalcemia
Localized bone pain
Decreased hemoglobin
Kidney failure
Increase total serum protein
Presence of monoclonal protein
High ESR and Cr
Proliferation of neoplastic plasma cells
Most common primary bone malignancy, 90% occur in people older than 40
What diagnostic tests are done for multiple myeloma?
Serum/urine immunoelectrophoresis (monoclonal gammopathy)
CT guided biopsy of lytic lesions at multiple bony sites
What diagnostic tests are done for multiple myeloma?
Serum/urine immunoelectrophoresis (monoclonal gammopathy)
CT guided biopsy of lytic lesions at multiple bony sites
What lymph nodes may be affected in rubella?
Occipital or posterior auricular node enlargement
What are features of malignant lymphadenopathy?
Firm, discrte, non tender, enlarging, immobile, worrisome location (ie supraclavicular), abnormal imaging or blood work
Sensitivity and specificity calculations
Specificity = TN/(TN+FP)
Sensitivity = TP/ (TP+FN)
TP FP
FN TN
X = sick or not sick
Y = + test or - test
Patients with active cancer undergoing surgery should have what type of post surgical prophylaxis?
Thromboemolic prophylaxis
Give subcutaneous unfractionated heparin or oral factor Xa inhibitors
Malingering
Intentional production of false or exaggerated symptoms motivated by secondary gain or external reward such as avoiding work, obtaining compensation or obtaining drugs
Factitious disorder
Intentional production or feigning symptoms NOT motivated by secondary gain but MAY seek sympathy or attention
Illness anxiety disorder
Preoccupation with fear of having or getting a serious disease to the point of causing significant impairment
They ARE able to acknowledge the possibility that the disease is not present UNLIKE a delusion which is fixed and firm
> 6 months
Tx: Maybe SSRIs due to anxiety
Obsession with the idea of being will usually WITHOUT true symptom
Conversion disorder
Condition in which a person experiences neurological symptoms such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology
Does not present with pain as the primary symptom
Does not involve secondary gain
Somatic symptom disorder
Significant focus on physical symptoms, such as pain, weakness or dizziness, to a level that results in major distress and/or problems with daily activities
Obsession of unexplained symptoms but does have TRUE symptom
vs illness anxiety: IA usually does not have a true physical symptom
When do you stop colonoscopy screening?
75
First line treatment for agitation in bipolar disorder
Olanzapine
Second line treatment for acute mania
Carbamazepine is also second line for acute mania but not good for agitation and longer onset of action
Features of growing pains
Intermittent non articular pain
At night
Often bilateral
Limited to calf, shin, thigh
Short lived
Relieved by heat, massage, analgesics
What is the tranmission of measles? What is the incubation period?
Highly communicable - trasmits via airbourne, respiratory droplets, direct contact with nasal or throat secretions
Incubation is about 10 days
Rash starts in about 14 days
Infectious period is from 4 days prior to rash to 4 days after onset
Fever, cough, coryza, conjunctivitis, Koplick spots (white spots inside of mouth) and rash starting on face to trunk then arms/legs
When to give measles immunoglobulin vs vaccination post exposure
Ig: Give in pregnant women, immunocompromised, infants < 6 mo, 6-11 mo infants who present 73 hr - 6 days post exposure
Vaccine: > 6 mo old as long as given within 72 hours of exposure and second dose at least 28 days later
Ig should only be provided within 6 days of exposure unless CI, pts should then receive vaccine after specified interval (between 3 and 11 mo)
What is the best way to investigate for potential lead toxicity?
Blood lead
Treatment: chelation, dimercaprol, EDTA
COnsider in any child with microcytic anemia living in a house built before 1977
Effects of pelvic radiation therapy
Ovarian failure
Symptoms are same as natural menopause but more sudden
Hot flashes, vaginal dryness, osteoporosis
Give E/P therapy in pts WITH uterus
Which type of HRT increases risk of breast cancer?
Estrogen AND progesterone
BUT prevent hip, vertbral, total fractures
ALSO increase risk of cardiovascular event, DVT, PE
What is a second line treatment for menopausal vasomotor symptoms if hormonal therapy is contraindicated?
Clonidine
Does not protect bone
Define primary biliary cirrhosis
Chronic inflammation and fibrous obliteration of intrahepatic bile ducts
Mostly affects middle aged women
What are common signs and syptoms of primary biliary cholangitis?
Early: Pruritis (worse at night or after warm shower), fatigue
Later: Jaundice and melanosis (darkened skin)
Latest: Hepatoceullar failure, ascites, portal HTN
High incidence of osteoporosis
Increased alk phos & GGT suggest cholestasis, increased serum cholesterol (HDL>LDL), anti mitochondrial antibodies
Tx: ursodiole (first line) or obeticholic acid (second line) or cholestyramine (for itchy and high chlesterol)
Define primary sclerosing cholangitis. What causes it?
- Inflammation, fibrosis, stricturing of the biliary tree (intra & extrahepatic ducts) from scarring
- MC idiopathic
- A/w IBD, ulcerative colitis
High ALP (hallmark)
Beading on MRCP and ERCP
What signs are associated with Cushing syndrome?
Moon shaped face, purple skin striae, proximal muscle weakness, acne
Signs of Lewy body disease
Cognitive fluctuations, visual hallucinations, REM sleep behavior disrubances, autonomic impairment (falls, hypotension, unsteady gait), Parkinsonism type movement symptoms (rigid)
Signs of Lewy body disease
Cognitive fluctuations, visual hallucinations, REM sleep behavior disrubances, autonomic impairment (falls, hypotension, unsteady gait), Parkinsonism type movement symptoms (rigid)
Signs of Alzheimer’s
Predominantly memory and learning issues
Insidious (GRADUAL) onset/progression
Signs of frontotemporal degeneration
Behavior change (apathy, disinhibition, self neglect), langauge decline, progressive, more common <65 yo
Vascular dementia signs
Step wise progression, focal neurological signs, executive dysfunction > memory impairment, personality change, mood change, loss of motivation
What is syncope?
Transient loss of consciousnes, usually vasovagal
May be associated with brief myocolinic jerks
Rapid return to baseline
More common in adolescent females
Differentiate from syncope: not confused postictally, diaphoresis prior to
How do you manage status epilepticus?
Step 1 (0-5 min):
1. Loosen clothing, lie on side, put bed rails up
2. Give O2, assess airway, apply pulse ox
3. Secure IV access, send blood work including antiepileptic drug level
Step 2 (6-10 min)
1. Thiamine and dextrose (unless normoglycemic - check finger prick) don’t forget thiamine as glucose alone increases risk of Wernicke’s encephalopathy
2. IV Lorazepam 0.1 mg/kg
3. Repeat if seziures persist, if no IV access then consider rectal diazepam
Step 3 (11-30 min)
1. IV phenytoin slow push (cannot give with glucose solutions otherwise will precipitate)
2. Monitor cardiac rhytm and BP
3. Repeat phenytoin if persists - max 30 mg/kg
4. Correct metabolic abnormalities
Step 4 (31-50 min)
1. Intubate
2. IV phenobarbital slow or propofol
Step 5
1. EEG
2. If persistent seizures then maintain continuous IV phenobarbital
What should a bulky, tender uterus make you think of?
Adenomyosis
What should an enlarged uterus make you think of?
Leiomyoma
If a patient has symptomatic fibroids and wants to preserve fertility what should be done?
Medical treatment with:
Low dose OCP
Progestational agent
SPRM
GnRH analogue like leuprolide
Danazol (<6 months)
If asymptomatic then treat anemia if present then wait and watch
What is the triad of Meniere’s?
Episodic vertigo lasting more than 20 minutes (room spinning)
TInnitus (low pitched noise)
Unilateral partial or complete hearing loss
Differentiate from BBPV or vestibuar neuritis as they do NOT have hearing loss
Vertigo lasting LESS than 1 minute and initiated by change in head position with no other otological findings
Think BPPV
Benign paroxysmal positional vertigo
SUDDEN symptoms lasting seconds
What are the signs of vestibular neuronitis?
Labyrinthitis
Acute onset of disabling vertigo often accompanied by N/V and imbalance without hearing loss that resolves over days, leaving a residual imbalance that lasts days to week
Viral prodrome
No hearing loss
May have whistling tinnitus
vs Meniere’s (vertigo lasts minutes to hours) or BPPV (vertigo lasts seconds) vs acoustic neuroma (vertigo lasts days to weeks)
Which GI syndrome are aphthous ulcers associated with?
Crohn’s
Can also present with fever, joint pain and weight loss
What is the most common cause of post partum hemorrhage?
Uterine atony
Uterus doesn’t contract (or tighten) properly during or after childbirth
Associated with BOGGY (not firm) enlarged uterus
What is a rare life threatening condition where soon after delivery a patient has sudden hypotension or cardiopulmonary arrest and DIC?
Amniotic fluid embolism
What electrolyte abnormality does carbamazepine cause?
Hyponatremia
Increases responsiveness of CD to ADH
Antiepileptic
What are the leading modifiable risks for coronary artery disease?
Hypercholesterolemia
Diabetes
Hypertension
Obesity
Tobacco smoking
& family history for a first-degree male relative who is 55 or younger
Solid pelvic mass in a postmenopausal woman?
Think epithelial ovarian cancer
Presentation: bloating, increased abdominal size, urinary urgency, pelvic pain, fatigue, indigestion, lack of apetite, constipation, back pain, weight loss
How do you differentiate primary dysmenorrhea from endometriosis?
Primary has pain for the first few days of period vs endometriosis which is longer
At what size do you not biopsy an adrenal incidentaloma?
If they are smaller than 4 cm it is not indicated
Do follow up imaging in 6-12 months and resect if >1 cm enlargement
At what size do you not biopsy an adrenal incidentaloma?
If they are smaller than 4 cm it is not indicated
Do follow up imaging in 6-12 months and resect if >1 cm enlargement
What is ACTH test for?
Addison disease screening
Isolated adrenal insufficiency
What medication is indicated in all patients with diabetes over 40 yo
Rosuvastatin
If a child does not babble or make other noises what should be tested?
Hearing test
What imaging should be done for a MS exacerbation?
MRI of brain and spinal cord
Patients with MS and infections should be admitted and observed for exacerbation
Define innocent murmur
Not indicative of pathology
Often these are systolic murmurs without heart sound abnormalities
Diastolic murmurs are almost always pathologic
50-80% of children have audible murmurs at some point in their childhood and can become accentuated during fever
Describe features of patholigc murmurs
H/P: exercise intolerance, failure to thrive
Time: Diastolic, pansystolic, continuous
Grade >3/6 or harsh
Sound: fixed splitting or single S2
Extra sounds or clicks may be present
Position never varies
If the murmur icreases when pt is supine, maximal at left lower sternal border or is less than grade 2 then think innocent
MCC pruritic vaginal discharge in women of reproductive age
Fungal infection
MCC Candida albicans
Cottage cheese like discharge, pruritis, vulvar pain, erythema
What causes bacterial vaginosis and how does it present?
Due to vaginal bacterial flora overgrowth
Common cause of vaginal discharge that is not itchy but is malodorous and green with NO vulvar soreness
Tx: metronidazole
How to calculate absolute risk reduction
ARR is the difference in the event rate between treatment group and control groups
MCC gastroenteritis in children
Virus
Investigations for viral gastroenteritis in children
None unless severe
iIn severe do CBC, lytes, stool studies
Cornerstone of diagnostic evaluation of patients with suspected COPD
PFTs and spirometry
What type of HRT provides protection from endometrial carcioma?
Adding progestin with estrogen in patients with an intact uterus
MCC non purulent cellulitis
Beta hemolyitc streptococci
MCC hyperparathyroidism
Renal failure (secondary hyperparathyroidism)
MCC chorea
Drugtherapy for PD
Levodopa induced dyskinesias
Anxiety vs panic disorder
Anixiety is characterized by excessive thoughts and feelings of irrational fear and owrry
Panic disorder is characterized by episodes of panic attacks and physical symptoms
Initial management of GERD
Dietary and lifestyle modification
Weight loss, elevating the head of the bed, eliminating dietary triggers such as high fat foods
Define brain death
The state of irreversible coma characterized by unresponsiveness and lack of receptivity, absence of spontaneous movement and breathing, absence of brainstem reflexes, and a flat or isoelectric electroencephalogram (EEG)
What are the two clinical situations in which organ donation may be pursued?
Brain death
Donation after cardiac death - in patients who do not meet criteria for brain death but are unlikely to make a meaningful recovery
Absolute contraindications to organ donation
Older than 80 yo
HIV infection (HBC and HCV relative CI)
Active metastatic cancer
Prolonged hypotension or hypothermia
Disseminated intravascular coagulation
Sickle cell anemia or other hemoglobinopathy
Gold standard in the diagnosis of colorectal cancer
COLONOSCOPY
AKA Lower endoscopy
What is a side effect of citalopram?
Symptom of inappropriate antidiuretic hormone secretion and can cause hyponatremia leading to confusion
What electrolyte abnormality is associated with lithium toxicity?
Sodium ie: low salt diets, dehydration, drug interactions
Processed through the kidneys
Temporarily discontinue its use around the time of any surgery
What is the most common congenital neck mass found in children?
Thyroglossal duct cyst
Childhood or age 20-40 as midline cyst that nlarges with URTI and elevates with swallowing or tongue protrusion
Treatment for congenital neck masses
Brachial cleft cyst or thyroglossal duct cyst
Surgery because althogugh benign they can become infected
Cannabinoid Hyperemesis Syndrome symptoms
Cyclical recurrent severe nausea and vomiting
Self medicate with hot baths or showers
Somatic symptoms disorder
Patient experiences at least one distressing and persistent somatic symptom that causes significant disruption in their daily life but is not explained by any underlying medical or neurological condition. Additionally, the patient must exhibit excessive and disproportionate levels of anxiety, worry, and preoccupation with their symptoms, often leading to excessive doctor visits or medical testing.
MC inherited thrombophilia
Factor V Leiden
Close in age exceptions
Persons can consent to sexual activity with a partner if the partner is less than 2 years older and there is no relationship of trust, authority, dependency or exploitation
Most common present symptom of colon cancer
Rectal bleeding
What is the best indicator of glycemic control?
HbA1C less than 7%
Describe the symptoms of irritable bowel syndrome
Episodic crampy pain
Relieved by defection OR onset associated with changes in stool frequence OR onset associated with changes in stool form
Symptoms for at least one day a week in the last 3 months
Rx education and reassurance with lifestyle changes
How to counsel a CF patient
Annual influenza vaccine is recommended
Regular exercise slows pulmonary decline
Median survival is 40 yo
Females are more affected
Leading cause of death is pulmonary disease
In what type of burns is an escharotomy performed?
Circumferential chest or extremity burns including the digits
Can restrict resp or blood flow which is why escharotomy is required
Can consider intubation and ventilation after
Injury patterns associated with child abuse
Torn frenulum, dental injury, bilateral black eyes, traumatic hair loss, diffuse severe CNS injury, retinal hemorrhage
Subdural or subarachnoid hemorrhage
Bites, bruises, burns in the shape of an object, glove/stocking distribution of burns, bruises of various ages, bruises in protected areas
Rib fractures without major trauma, femur fractures < 1 year, spiral fracture in long bones of non ambulatory children, multiple fractures of various ages, skull fractures (multiple/complex)
Chronic abdominal or perineal pain, injury to genitals or rectum, STI/pregnancy, recurrent vomiting or diarrhea
Consider full skeletal survey
REPORT TO CAS
Features suggestive of pyelonephritis
High grade fever
Flank or high abdominal pain
CVA tenderness
Most common cause of UTI
E coli
Risk factors for UTI
Non modifiable: female, white, previous UTI, fmhx
Modifiable: urinary tract abnormality, dysfunctional voiding, repeat bladder caths, uncircumcized males, labial adhesions, sexually active, constipation
What blood gas is associated with altered level of consciousness in COPD pts?
Hypercapnia - C02 narcosis PC02
Remember that low P02 may be normal in COPD pts
Risk factors for anal sphincter injury
Use of forceps or vacuum
Prolonged labor
Vaccumm assisted has the highest odds of anal sphincter injury
Types of perineal tears
1 skin and vaginal mucosa but not underlying fascia or muscle
2: involves fascia and muscle of perineal body but not anal sphincter
3: involves anal sphincter
4: extends through anal sphincter and into rectal mucosa
For 3 and 4 give IV AB cefoxitin or cefotetan and laxatives
Recommend postpartum pelvic physiotherapy and transanal US to assess integrity of anal sphincter post repair for 3 and 4
What conditions are associated with Dupuytren contracture?
Diabetes, alcohol, cigarettes, repetitve motion
Digit involvement : ring > little > long > thumb > index
Treatment for moderate/severe PMS
Social or economic dysfunction
SSRI
SNRI
Combined EP OCP
Clinical manifestations of lead poisoning
Lead lines on gingiva and long bone epiphyses
Encephalopathy
Adominal pain and sidroblastic anemia, low sperm count, wrist drop
Rx: chelation, dimercaprol, EDTA
What is the best diagnostic test for celiac?
Small bowel mucosal biopsy
Look for increased intraepithelial lymphocytes, crypt hyperplasia, villous atrophy villous atrophy can also be a/w small bowel overgrowth, CD, lymphoma, Giardia, HIV
Social anxiety disorder hallmark
Avoidance of social situations in which there is a fear of being judged
MCC pruritic vaginal discharge in women of reproductive age
Fungal infection (C. albicans)
Cottage cheese discharge, itchy, vulvar pain, erythema
vs baceterial vaginosis = not itchy but IS green and smelly and due to vaginal flora bacterial overgrowth
Treatment for acute dystonia
Extrapyramidal syndrome
Benztropine IM
Diphenhydramine IM
Oral benztropine
Anticholinergics
Cause of localized chest abnormalities on physical exam (crackles and rhonchi in a lower lobe) after surgery
Aspiration while under anesthesia
Ddx stridor
Croup, bacerial tracheitis, epiglottitis, foreign body aspiration, subglottic stenosis (iatrogenic or congenital), laryngomalacia, tracheomalacia (collapse of airway cartilage on inspiration), retropharyngeal abscess
Croup - do CXR for steeple sign
Bac tracheitis - do endoscopy
Epiglottitis - diagnose on physical exam
Choanal atresia - cant pass NG, do CT for definitive diagnosis
Life threatening causes of chest pain
PE
Esophageal rupture
Tamponade
MI/angina
Aortic dissection
Pneuumothorax
PET MAP
What is pneumothorax? How is it diagnosed and treated?
Gas/air iaccumulation in the pleural space resulting in separation of the lung from the chest wall
Diagnose with upright chest film or lateral decubitus film
Management: O2 and observe OR chest tube in 5th ICS anterior axillary line OR emergent needle decompression in 2nd ICS midclavicular line if tension pneumothorax with subsequent chest tube insertion
Top 3 causes of small bowel obstruction
In order
Adhestions
Bulge (hernia)
Cancer (neoplasms)
Ddx list (SHAVING): stricture, hernia, adhesions, volvulus, intussusception, neoplasm, gallstones
