Random UWorld 8/8/17 Flashcards
65yo lady with 6 mos worsening dry cough and dyspnea. dry late inspiratory crackles and digital clubbing on exam. diffuse reticular or nodular opacities on cxr, fibrosis honeycombing traction bronchiectasis on high resolution ct, no identifiable environmental infectious or autoimmune cause
daignosis
pft pattern
pulmonary fibrosis due to ILD interstitial lung disease … call it IPF idiopathic pulmonary fibrosis when no identifiable environmental infectious or autoimmune cause found
restrictive pft pattern!
trial of labor ok or contraindicated with history of the following
- low transverse csection
- classical vertical csection
- abdominal myomectomy without uterine cavity entry
- abdominal myomectomy With uterine cavity entry
low transverse CS - trial of labor ok
Classic Vertical CS - No trial of labor, contraindicated
myomectomy without entry - trial of labor ok
myomectomy With Entry - No trial of labor, Contraindicated
Terbutaline is a ___ adminstered to relax the ___
Terbutaline is a Tocolytic to relax the Uterus when contractile abnormalities occur (tachysystole, tetany)
Amnioinfusion involves what to treat what
Aminoinfusion - catheter insertion for intrauterine infusion - to relieve umbilical cord compression and resolve variable decels
young guy with unprovoked DVT/PE and family history with normal pt ptt but high DDimer
suspect
why
pathophys
Factor V Leiden
Most Common inherited hypercoagulable disorder in Whites
Activated Protein C Resistance - factor V mut (autosomal dominant but homo worse off than hetero) resists protein c and activates thrombin… thus clotting without pt or ptt changes
endometrial biopsy indications
over 45yo
under 45yo
over 45 if abnormal uterine bleeding or postmenopausal bleeding
under 45 if abnormal uterine bleeding AND unopposed estrogen or lynch syndrome hnpcc or failed medical management of uterine bleeding
TF
ocp or cyclic progestin or continuous progestin are appropriate tx for premenopausal abnormal uterine bleeding after uterine cancer ruled out
T
all works to differentiate endometrium prevent unopposed estrogen uterine proliferation
solitary painless firm mobile breast mass 2cm in size noted on breast exam and mammography
diagnosis
fibroadenoma
placenta accreta typically only occurs in patients with history of __ __ or __
placenta accreta usually only if history of CSection Myomectomy or DandC
in treating inverted uterus, placental removal and uterotonics should be given After __
after reduction of the uterus
immunocompromised patient with fever pleuritic chest pain hemoptysis, CT with nodules with surrounding ground glass opacities
diagnosis
name for ct finding
treat
pulmonary aspegillosis
“halo sign” - nodules with surrounding ground glass opacities
voriconazole and caspofungin (an echinocandin)
CMV pneumonitis
3 symptoms
ct finding
hemoptysis? chest pain? productive cough? nodules with halo sign (surrounding ground glass opacities)?
CMV PNA
low fever, dry cough, sob
patchy or diffuse ground-glass opacities on ct
NO hemoptysis cp sputum halo signs… think more aspergillus there
immunocompromised patient, dyspnea, nonproductive cough, fever, bilateral diffuse interstitial infiltrates on imaging
think what opportunistic bug?
PCP pneumocystis pneumonia
immunosuppressed patient, fever hemoptysis dyspnea upper lobe disease… thick sputum and nodules with surrounding ground glass opacities (halo sign)
what makes you think reactivation of TB and what doesn’t?
fever hemoptysis dyspnea upper lobe disease immunocompromise…. TB or aspergillus
thick sputum, nodules with surrounding ground glass opacities (halo sign) …. more aspergillus
guy on PPI with burning chest pain for 15 minutes per episode when lifting things at work… work him up for ulcers or angina?
Atypical Angina
get an Exercise EKG
only after ruling out angina can you go after gerd and ulcers
tf
absent achilles reflexes can be normal in elderly
t
ear pain worse with chewing, history of teeth grinding while sleeping, no ear tenderness on exam or otoscopic abnorms
diagnosis
treatment
temperomandibular joint dysfunction
nighttime bite guard, surgery if refractory
Herpes Zoster infection that causes Bell’s Palsy with vesicles on the outer ear, aka
Ramsay Hunt syndrome
pathophys of flushing and pruritus side effect of niacin
treat
Prostaglandin-induced peripheral vasoDilation
treat with low dose Aspirin 30 min before taking Niacin
10-20 days after throat or skin infection - periorbital swelling, hematuria, oliguria, hypertension - hematuria with rbc casts and poteinuria on ua - low serum C3 complement
diagnosis
IgA nephropathy?
Membranoproliferative glomerulonephritis?
PSGN post strep glomerulonephritis
not iga nephropathy – that v5 days after urti and normal serum complement levels
not mpgn - similar symptoms and low complement but no temporal relationship with infection
severe infection eg cdiff, super high wbc like 50s, predominance of late neutrophil precursors (bands and metamyelocytes), high leukocyte alk phos score
diagnosis
how different from CML?
Leukemoid Reaction
-bad infection mobilizing the young troops
vs cml will have Low leukocyte alk phos score (becaues the neutrophils suck), and Earlier neutrophil precursors on peripheral smear (more myelocytes than metamyelocytes) and “absolute basophilia”
myelodysplastic syndrome often presents with infection in the setting of ___
myelodysplastic syndrome - PANcytopenia
old guy states wavy appearance of lines when looking at a grid and issues reading and driving
diagnosis
prevalence
expect what on physical exam
Macular Degeneration
-Wavy lines is one of the earliest signs (visualizing straight lines takes fine visual acuity so macula function)
Most Common cause of blindness in industrialized countries (risks are age and smoking)
Drusen deposits on macula on exam
guy already on digoxin is put on amio for afib, week later has gi sx anorexia nausea vomiting abdominal pain and fatigue
your recommendation, why
decrease digoxin dose
amio increases digoxin levels and this is acute digoxin toxicity
acute vs chronic digoxin toxicity symptoms
Acute digoxin tox - GI symptoms mostly, maybe weakness and confusion
Chronic digoxin tox - more Neuro and Visual (lethargy, confusion… color changes scotomas blindness)
TF
HIT can cause acute limb ischemia with low platelets and high PTT
T
does warfarin affect PT or PTT
PT
INR is PT/referencePT
pt with history of depression overdosed no fever hypotension dilated pupils and seizure and QRS prolongation on ekg
what drug od’d
mechanism of symptoms
biggest concern
how to treat, why
TCA - depression, anticholinergic side-effects - fever, hypotension, dilated pupils, seizure, decreased conduction velocity
biggest concern is hypotension and long qrs (arrhythmia)
treat with Sodium Bicarbonate - improves blood pressure, narrows qrs, avoids arrhythmia
give the following for what ekg changes
calcium gluconate
magnesium sulfate
sodium bicarbonate
calcium gluconate - hyperkalemia… stabilizes cardiac membrane in hyperkalemia
magnesium sulfate - torsades from long qt
sodium bicarb - hypotension and qrs widening eg from anticholinergic side effects of tca overdose… also give after other emergent meds in hyperkalemia with widened qrs
treat a thoracic esophageal perf vs a cervical esophageal perf
thoracic esophageal perf - surgery
cervical esophageal perf - abx, conservative mgmt
big purple/black periumbilical patches surrounded by erythema in several days postop patient
think
pathophys
diagnose
treat
HIT (necrotic skin lesions at heparin injection sites)
heparin induces a confomational change in platelet surface protein Platelet Factor 4 that exposes a neoantigen tat the body can develop antibodies to (HIT antibodies) and cause platelet aggregation thrombosis and thrombocytopenia
Serotonin Release Assay (gold standard)
HIT ab immunoassay (if high titers)
stop heparin (before diagnosis even confirmed, switch anticoagulation to argatroban, fondaparinux or the like
what anticoagulant can cause an acquired deficiency of protein C
Warfarin - can cause acquired protein C deficiency
necrotic skin lesions at abdominal heparin injection sites
think
pathophys
diagnose
treat
HIT (necrotic skin lesions at heparin injection sites… big purple/black periumbilical patches surrounded by erythema in several days postop patient)
heparin induces a confomational change in platelet surface protein Platelet Factor 4 that exposes a neoantigen tat the body can develop antibodies to (HIT antibodies) and cause platelet aggregation thrombosis and thrombocytopenia
Serotonin Release Assay (gold standard)
HIT ab immunoassay (if high titers)
stop heparin (before diagnosis even confirmed, switch anticoagulation to argatroban, fondaparinux or the like
expect elevated levels of ___ in megaloblastic anemia
elevated HomoCysteine in megaloblastic anemia
-folate and b12 involved in homocysteine metabolism to methionine… no folate b12 - homocysteine buildup, methionine drop
why does Cobalamin B12 Deficiency cause ELEVATED Methylmalonic Acid levels but not folate
Cobalamin B12 involved in methylmalonyl coa to succinyl coa… no cobalamin b12 - methylmalonate buildup
why is Haptoglobin Decreased in hemolytic anemias
because haptoglobin binds free hemoglobin and levels drop
Burr cells
Spur cells
when do you see them
both Burr and Spur in Liver Disease
also Burr in ESRD
(burr is serrated, spurr has fewer larger projections)
scleroderma renal crisis with low hb and plts
what on smear
shistocytes
MAHA
what kind of colon polyp is most concerning, hyperplastic polyp tubular adenoma villous adenoma hamartomatous polyp inflammatory pseudopolyp submucosal polyp
villous adenoma is most concerning
others have low malignant potential… hyperplasia not concerning (dysplasia is) submucosal polyp = lipoma or lymphoid aggregate… hamartomatous polyp = juvenile polyp or peutz jeghers)
what age is risk for hydatiform molar pregnancy?
either extreme of maternal age, young or old
15yo girl, lmp 4 mos ago, sounds like hyperemesis gravidarum maybe getting into preeclampsia and uterus is too big for 4 months
diagnosis
pathophys of preeclampsia here
treatment
hydatiform mole
abnormal placental spiral artery development, placental hypoperfusion and ischemia, maternal htn
suction curettage
follow downtrend bhcg
histologically describe glomerular damage from diabetes
glomerular basement membrane changes
diffuse glomerular sclerosis
nodular glomerular sclerosis (kimmelstiel wilson nodules pathognomonic)
middle age guy, periodic difficulty breathing and wheezing, history of asthma chronic rhinosinusitis with nasal polyps, maybe urticaria, takes aspirin
- diagnosis
- pathophys
- how to tell from asthma/allergy exacerbation
- treatment
Aspirin Exacerbated Respiratory Disease
NON-IgE mediated PSEUDOAllergic drug reaction… from increased conversion of arachidonic acid to proinflammatory leukotrienes and decreased antiinflammatory prostaglandins by blocking cox1 cox2 and shunting arachidonic acid to 5lipoxygenase pathway
looks a lot like asthma/allergy exacerbation, just tie to within 3 hours of aspirin use which the patient might not naturally do
avoid aspirin/nsaids vs desensitize
use leukotriene receptor antagonist instead (Montelukast)
young dude with multiple sexual partners has mild systemic symptoms fever/malaise and painful vesicular rash on erythematous base on palm of his hand
diagnosis
bug
how contracted typically
treat/course
herpetic whitlow
herpes simplex virus
hand contact with genital herpes or health care worker touching infected oral secretions
spontaneous resolution in weeks but recurrence common…. treatment with acyclovir if immunocompromised
Erythema multiforme associated with what virus
Herpes simplex
Erythematous papules and plaques that evolve into target lesions associated with herpes simplex
Eryhema multiforme
Initial large lesion followed by numerous small oval scaly plaques that follow cleavage lines of the trunk
Pityriasis rosea
Diffuse maculopapular rash involving palms and soles and oral mucosa think
Secondary syphilis
Who gets HAV vaccine
Liver disease hbc hcv
Msm
Ivdu
Pneumococcus vaccine recs for hiv patient
Pcv13 once
Ppsv23 8 wks later 5 years later and age 65
Vaccines contraindicated in hiv if cd4 count v200
Varicella mmr zoster (live vaccines)
what kind of beta blocker for esophageal varices
NONSELECTIVE propanolol nadolol
nasopharyngeal carcinoma
associated with what virus
what demographics
nasopharyngeal carcinoma
EBV reactivation associated
Chinese Africa Mid East (diet, genetics)
Aflatoxin B1 is a __toxin that contaminates __ products and increases risk of __
Aflatoxin B1
mycotoxin
contaminates agricultural products
increases risk of HCC hepatocellular carcinoma
TF
recurrent sinusitis increases risk of nasopharyngeal carcinoma
F
sinusitis - risk of nasal polyposis but not cancer
EBV reactivation and Chinese African Mid East risk NasoPharyngeal Carcinoma
seems like malaria but midwestern usa not africa
babesiosis
4-7 weeks after mosquito bite fever headache myalgias arthralgias retroorbital painrash LeukoPenia
think
Dengue Fever
african trypanosomiasis aka
pathogen
african sleeping sickness
tsetse fly
african travel, acute febrile illness with skin lesion, myocarditis, progression to CNS involvement
think
pathogen
african trypanosomiasis aka sleeping sickness
tsetse fly
normal postvoid residual in postpartum mamma
150ml
how to evaluate risk of preterm labor in preggy with prior cervical conization
what to do if at risk
transvaginal ultrasound in 2nd trimester for measurement of cervical length and changes during valsalva
(not digital cervical exam… going to be abnormal…. won’t get length…not as reproducible and accurate)
vaginal progesterone to maintain uterine quiescence if at risk…. intramuscular progesterone and cerclage if prior preterm labor
treat bacterial vaginosis with
metronidazole
history of rheumatoid arthritis, now anemic, low iron low tibc high feritin
dx
tx
anemia of chronic disease
meithotrexate - treat ra to treat anemia
kid, fever sore throat odynophagia, vesicles on tonsils and soft palate
diagnosis
bug
herpangina
coxsackie A virus
why treat asymptomatic bacteruria in pregnancy
higher risk of pyelo because high progesterone relaxes urinary smooth muscle tracts
HIV patient with low CD4 count in Missouri has systemic, lung findings, liver findings, oral ulcers, pancytopenia think why workup treat
disseminated histoplamsosis
opportunistic infection, endemic to midwest/central, starts in lungs and disseminates to liver, spleen, bones, mucosa/skin
urine or serum histoplasma antigen (faster than blood cultures, lymph node biopsy not required)
Amphotericin B.. later -azole for mantainence and antiretroviral for hiv
how does rotor’s syndrome cause dark urine with urinary bili but not urobilinogen in urine
rotors is conjugated hyperbilirubinemia by impaired hepatic secretion of bilirubin. Conjugated bili is water Soluble so can be eliminated in Urine e.g. in rotors… but normally secreted into bile and feces then deconjugated for resorption with 5% loss as urobilinogen in feces and 1% loss as such in urine…. so will only see urobilinogen in urine if bili is getting into intestines and resorbed
TF
fever and chest pain with chylothorax (thoracic duct disruption) eg in the setting of trauma or cancer
F
chyle is does not provoke inflammation
when metronidazole for vaginitis
for bacterial vaginosis
pna symptoms with foul smelling sputum refractory to azythro course… this all after upper endoscopy, what else to prescribe, why
clindamycin - covers anaerobes
or
amoxicillin-clavalunate, carbapenem, (metronidazole if only anti-anaerobe choice but high rate of failure
aspiration pna in setting of post egd
kid, fever sore throat odynophagia, vesicles on tonsils and soft palate
diagnosis
bug
herpangina
coxsackie A virus
old smoker hard non-tender 3cm submandibular mass think
workup
head/neck cancer - Majority SCC, especially in adult smoker
-any hard unilateral non-tender lymph nodes always suspicous for cancer
prompt biopsy
HIV patient with low CD4 count in Missouri has systemic, lung, and liver findings, pancytopenia
think
why
workup
disseminated histoplamsosis
opportunistic infection, endemic to midwest/central, starts in lungs and disseminates to liver, spleen, bones, mucosa/skin
urine or serum histoplasma antigen
guy with ascites and right sided lung dullness and decreased breath sounds think
how
plerual effusion from hepatic hydrothorax
- ascites gets thru small diaphragmatic defects on R usually because less muscular there
major organ complication of heredetery hemochromatosis (bronze diabetes with elevated transaminases)
nephrotic syndrome?
cirrhosis and Hepatocellular Carcinoma
not nephrotic syndrome
… maybe cardiomyopathy next organ dysfunction…. joints, certain infections… hypogonadism, hypothyroidism
homeless guy confused abdominal pain vomiting blurred vision, metabolic gap acidosis and optic disc hyperemia
think
how
big complications
how different from something Very similar, what about something Very common
methanol poisoning
usuing methanol as sub for alcohol
blindness, coma
ethanol poisoning similar but Kidney damage instead of Eyes
Aspirin overdose similar but tinnitus, fever, and hyperventilation
woman postmenopausal flushing, pounding pulse, chronic diarrhea, R sided valvular insufficiency (tricuspid insufficiency)
diagnosis, endocarditis?
diagnose
treat
carcinoid syndrome (carcinoid tumor in gut Mets to Liver causing effects via hormonal secretion … histamine serotonin vip etc
- no flushing or diarrhea with endocarditis… and look for fever malaise arthralgias and ivdu history)
24 hr urinary 5-HIAA
(5-hydroxyindoleacetic acid)
octreotide for symptoms, surgery for mets
vibrio vuilnificus from shellfish OR __
skin findings with the second
feared complications
who is high risk
vibrio from shellfish or ocean WOUND infection eg cut on dock
bullae, fascitis, erythematous streaking up from site
liver disease, septic shock
prior liver disease at high risk
ciprofloxacin covers
gnr’s
person clearing bushes gets bad rash on fingers and hands with coag neg staph on cultures – impetigo? cellulitis?
contact dermatitis (e.g. poison ivy/oak)
coag neg staph (saphro, epidermidis) is skin flora
impetigo and cellulitis - staph a coag positive… and ipetigo i kids
guy with ascites and right sided lung dullness and decreased breath sounds think
how
plerual effusion from hepatic hydrothorax
- ascites gets thru small diaphragmatic defects on R usually because less muscular there
major organ complication of heredetery hemochromatosis (bronze diabetes with elevated transaminases)
nephrotic syndrome?
cirrhosis and Hepatocellular Carcinoma
not nephrotic syndrome
… maybe cardiomyopathy next organ dysfunction…. joints, certain infections… hypogonadism, hypothyroidism
homeless guy confused abdominal pain vomiting blurred vision, metabolic gap acidosis and optic disc hyperemia
think
how
big complications
how different from something Very similar
methanol poisoning
usuing methanol as sub for alcohol
blindness, coma
ethanol poisoning similar but Kidney damage instead of Eyes
f/u painless rectal bleeding
^50 or malignancy risk
40-50
v40 no red flags
^50 colonoscopy
40-50 colonoscopy or sigmoidoscopy
v40 no flags - anoscopy
vibrio vuilnificus from shellfish OR __
skin findings with the second
feared complications
who is high risk
vibrio from shellfish or ocean WOUND infection eg cut on dock
bullae, fascitis, erythematous streaking up from site
liver disease, septic shock
prior liver disease at high risk
travel in the states, fever cough diarrhea confusion, hyponatremia, mild hepatitis, interstitial infiltrates on cxr, neutrophils no organisms
you think
rapid test
leigonella
Urine legionella Antigen (more rapid than buffered charcoal yeast extract cultures etc)
when is ranolazine ever used
not often, low yield
occasioally if chronic stable angina refractory to bb, nitrates, ccbs
seems like CAP plus arthralgias and erythema nodosum (painful erythematous papules on shins), or erythema multiforme, from desert southwest
think
diagnose
treat
coccidioides - endemic mycosis of desert southwest
serologic testing (often cultures too..)
usually self resolve no treatment
if immunocompromised or high risk… azole… ketaconazole fluconazole
2 mycoses endemic to central and midwest usa
histoplasma
blastomyces
3 top causes of aortic stenosis
which is: overall? v70yo? ^70yo? number 3?
bicuspid aortic valve most common, v70yo
senile calcific aortic stenosis ^70
rheumatic heart disease much less frequent
f/u painless rectal bleeding
^50 or malignancy risk
40-50
v40 no red flags
^50 colonoscopy
treat HOCM
avoid dehydration
BB first then nondipine CCB verap dilt if not responding (both decrease contractility, prolong diastole, more preload, opening up, prevent outflow obstruction
why is PID extremely rare after the first trimester
cervical mucus and decidua sealing off an protecting the uterus/pregnancy
chorioamnionitis in 39weeker in active stage 1 labor, fetal hr 165…. give antibiotics and.. oxytocin or csection?
oxytocin
-deliver… vaginal is ok… fetal hr likely related to fever rather than fetal distress… can give antipyretics to help
csection if decels (fetal distress)
with IV antibiotics - amp gent clinda
give steroids to women with chorioamnionitis currently delivering at 33 weeks?
yes
steroids for any preggy delivering v34 weeks – lung development for fetus
TF
chorioamnionitis is an indication for csection
F
oxytocin
-deliver… vaginal is ok… fetal hr likely related to fever rather than fetal distress… can give antipyretics to help
csection if decels (fetal distress)
with IV antibiotics - amp gent clinda
g6pd more male or female?
male, usually x-linked
adequate montevido units
^200 MVUs in 10 minutes are Adequate Contractions
what vaccines to get in pregnancy
if high risk
which contraindicated
tdap
flu
if high risk: hbv hav pneumococcus meningococcus hflu vzv IMMUNOGLOBULIN
contraindicated:
hpv mmr liveattenuated flu vzv
why is PID extremely rare after the first trimester
cervical mucus and decidua sealing off an protecting the uterus/pregnancy
chorioamnionitis in 39weeker in active stage 1 labor, fetal hr 165…. give antibiotics and.. oxytocin or csection?
oxytocin
-deliver… vaginal is ok… fetal hr likely related to fever rather than fetal distress… can give antipyretics to help
csection if decels (fetal distress)
with IV antibiotics - amp gent clinda
give steroids to women with chorioamnionitis currently delivering at 33 weeks?
yes
steroids for any preggy delivering v34 weeks – lung development for fetus
ppd for pregnant lady?
No
only if immunocompromised or actively tb sick contacts
asymptomatic immigrants can be screened postpartum
“powder-burn” lesions in posterior culdesac on female pelvic laparotomy signify
endometriosis
-powder-burns, adhesions, scar tissue, fleshy nodules, chocolate fluid… all endometriosis
adequate montevido units
^200 MVUs in 10 minutes are Adequate Contractions
what vaccines to get in pregnancy
if high risk
which contraindicated
tdap
flu
if high risk: hbv hav pneumococcus meningococcus hflu vzv IMMUNOGLOBULIN
contraindicated:
hpv mmr liveattenuated flu vzv
TB patient on isoniazid symptomatically improved but now with mild ast alt elevation what to make of it?
isoniazid hepatitis/hepatotoxicity
-common, mild, just observe…. discontinue if gets symptomatic or severe and switch to second line drugs (eg not RIPE)
-same strategy for most RIPE drugs… some hepatotox expected
biopsy asymptomatic elevation of liver enzymes?
if etiology unknown
if you know it, no need to biopsy
when to give RhD immunoglobulin to mismatched mom
28 weeks for ppx
after delivery if infant is RhD positive
blood typing and antibody screening happens when in pregnancy
when is RhD Ig given
blood typing and antibody screening at first prenatal visit
RhD given 28 wks (half life lasts till birth) and postpartum
“powder-burn” lesions in posterior culdesac on female pelvic laparotomy signify
endometriosis
incidental endometriosis found on lap in asymptomatic patient (asymptomatic for endometriosis) with copper iud
start nsaids and ocps or change to progesterone iud?
observe
don’t do anything!
can consider nsaids ocps progesterone iud if symptoms arise… surgical resection hysterectomy oopherectomy if symptoms bad and persistent
gonadotropin-independent precocious puberty, cafe au lat spots, endocrine hyperfunction… think…
McCune Albright syndrome
diarrhea in AIDS, what bug and cd4 count if:
severe diarrhea cd4v180
no fever cd4v100
high fever cd4v50
bloody diarrhea cd4v50
severe watery - cryptosporidium v180
no fever - microsporidium/isosporidium v100
high fever - MAC v50
bloody diarrhea - CMV v50
(all usually watery diarrhea except bloody cmv)
biopsy asymptomatic elevation of liver enzymes?
if etiology unknown
if you know it, no need to biopsy
gastrointestinal (colitis) CMV in AIDS cd4 distinguishing diarrhea feature diagnose treat
gi cmv in hiv cd4v50 bloody diarrhea colonoscopy with bopsy gancyclovir for treatment also OCULAR EXAM to rule out concurrent RETINITIS
blood typing and antibody screening happens when in pregnancy
when is RhD Ig given
blood typing and antibody screening at first prenatal visit
RhD given 28 wks (half life lasts till birth) and postpartum
normal internal genitalia, external virilization, undetectable estrogen levels
think
aromatase deficiency
can’t convert androgens to estrogens
ambiguous external genitalia, normal uterus and ovaries, electrolyte abnorms
think
CAH congenital adrenal hyperplasia
17alphahydroxylase deficiency
gonadotropin-independent precocious puberty, cafe au lat spots, endocrine hyperfunction… think…
McCune Albright syndrome
spep vs flow cytometry use in heme
spep for multiple myeloma mspike
flow cytometry for CLL demonstrating clonality of mature B cells)
ekg shows QRS widening when pt heartrate is increased, what 2 drugs could be responsible?
flecainide
propafenone
both class IC antiarrhythmics sodium channel blockers -less time to to dissociate from receptors when heart reat up, cause QRS Widening... called USE DEPENDENCE... why they are used to treat Supraventricular Arrthymias... eg paroxysmal afib
class IV ccb’s also use dependence but not qrs widening
breath sounds, tactile fremitus, precussion, and mediastinal shift
consolidation (pna) vs atelectasis (mucus plug)
consolidation - INC BEATH SOUNDS, inc fremitus, dull percussion, no shift
atelectasis - DEC BREATH SOUNDS, DEC FREMIUTS, dull percussion, SHIFT
60yo guy with fever productive cough and lobe infiltrate suggesting pna bnut also dramatic leukocytosis to 40s (Lymphocytes) and hepatosplenomegaly, cervical lymphadenopathy, anemia and thrombocytopenia
think
diagnose
CLL
flow cytometry (clonality of mature B cells)
encapsulated organisms to fear post splenectomy
strep pneumo
h flu
neisseria meningitidis
encapsulated, antibody-mediated phagocytosis in spleen to remove
so get vaccinated for above and early antibiotics if infected
impaired b cell isotype switiching in what disease and what infections increased risk
cvid - low IgG because can’t switch isotype
recurrent sinopulmonary and gi infections and autoimmune disease
wbc in multiple myeloma
low wbc
pancytopenia… infiltrative…
cgd recurrently infected by what organisms
catalase positive bacterial or fungal
eg staph aureus or aspergillus
TF
smoking cessation reduces blood pressure
rank top 5 factors that can reduce blood pressure
FALSE
reduces cv risk factors, yes, but NOT BLOOD PRESSURE
weight loss to bmi v25 DASH diet high in fruits and veggies low fat exercise decrease dietary sodium decrease alcohol
DASH diet stands for
consists of
Dietary Approaches to Stop Hypertension diet
rich fruits veggies, low fat
best method of blood pressure reduction in non-obese patient
rank top 5 factors that can reduce blood pressure
DASH diet high in fruits and veggies low fat
weight loss to bmi v25 DASH diet high in fruits and veggies low fat exercise decrease dietary sodium decrease alcohol
encapsulated organisms to fear post splenectomy
strep pneumo
h flu
neisseria meningitidis
impaired b cell isotype switiching in what disease and what infections increased risk
cvid - low IgG because can’t switch isotype
recurrent sinopulmonary and gi infections and autoimmune disease
recurrent bacterial skin and mucosa infections… think more leukocyte adhesion deficiency or IgA deficiency?
think leukocyte adhesion deficiency with recurrent skin and mucosa bacterial infections
IgA deficiency typically asymptomatic
what are vascular rings
how do they present
any association with gerd?
congenital anomalies where aortic arch vessels encircle the trachea or esophagus
present infancy with airway obstruction
adulthood with dysphagia
no association with GERD (that would be peptic stricture or adenocarcinoma)
young woman, large painful hepatic mass, long term oral contraception use, elevated alk phos and gtt but liver labs otherwise normal think why alk phos and gtt diagnose risks treat
hepatic adenoma (benign)
alk phos and gtt biliary labs from compression… otherwise all lft’s often normal
ulstrasound hyperechoic lesions
con CT early peripheral enhancement
risks growth, rupture, malignant transformation
surgical excision (no needle bx - bleed risk)
DASH diet stands for
consists of
Dietary Approaches to Stop Hypertension diet
rich fruits veggies, low fat
young woman large painful hepatic mass, liver labs pretty normal, imaging with mass with increased arterial flow and maybe central scar
think
pathophys
Focal Nodular Hyperplasia
Liver Mass / Lesion in young women caused by Hyperperfusion from Anomalous Arteries
Hydatid liver cysts are caused by ___
Most cases in US are seen in ___ or ___ exposed to ___ or ___
Hydatid liver cysts are caused by ECHINOCOCCUS TAPEWORM infection
Most cases in US are seen in IMMIGRANTS or SOUTHWESTERN Americans exposed to SHEEP or DOGS
nodular regeneration most commonly occurs in the setting of…
cirrhosis
___ is a benign liver tumor most often seen in young and middle-aged women who take ___
HEPATIC ADENOMA
benign liver tumor in young/middle aged women who take ORAL CONTRACEPTIVES
treat acute angioedema from ACEI causing airway compromise and vasomotor instability
if that treatment fails
subq epinephrine
tracheostomy if epi fails
(stop ACEI obviously)
other than angioedema, 3 next ACEI complications to watch for
angioedema
cough
hyperkalema
acute renal failure if already bilateral renal artery stenosis
rapidly enlarging liver mass with satellite lesions usually in cirrhotic or chronic hepatitis (B especially)… likely systemic symptoms, elevated AFP
think
hepatocellular carcinoma
young woman large painful hepatic mass, liver labs pretty normal, imaging with mass with increased arterial flow and maybe central scar
think
pathophys
focal nodular hyperplasia
Liver Mass / Lesion in young women caused by Hyperperfusion from Anomalous Arteries
young female school teacher / daycare worker with 10 days joint pain stiffness for 10 minutes in am in wrists MCPs PIPs knees ankles with tenderness but no swelling or redness and maybe non-specific rash, maybe fever fatigue diarrhea
think
diagnose - ANA? dsDNA? Rheumatoid factor?
treatment
viral arthritis
-probably Parvovirus B19 contracted working with kids (adults often don’t get slapped cheek rash)… otherwise could be hep b c hiv rubella
B19 IgM if immunocompetent
NAAT for B19 DNA if immunocompromised or reactivated
–ANA dsDNA are for SLE.. symptoms more chronic and varied…. and RA (different from lupus arthritis…) has longer morning stiffness ^1 hour, joint Swelling, and less acute with symptom onset over 6 mos not 10 days
no treatment usually self-resolves
antibodies in rheumatoid arthritis
anti-CCT anti cyclic citrullinated peptide
rheumatoid factor
___ is a benign liver tumor most often seen in young and middle-aged women who take ___
HEPATIC ADENOMA
benign liver tumor in young/middle aged women who take ORAL CONTRACEPTIVES
___ is usuallly associated with chronic hep C and cause arthralgias, chronic vasculitic syndrome with palpable purpura lymphadenopathy nephropathy neuropathy
Mixed Cryoglobulinemia
preconception hemoglobinopathy screening in Mediterranean vs African patient
CBC for Mediterranean couple, only workup further if abnormalities
Hb Electrophoresis and CBC in African couple
SO CBC is first screen for hemoglobinopathies!
TF
prophylactic colectomy for UC patient recommended 8 years into disease
F
colectomy if dysplasia identified
offer annual/biannual colonoscopies at 8 years of disease (12-15 years if disease limited to left colon and rectum)
acid base disturbance in acute asthma exacerbation
what to make of the opposite
repiratory alkalosis - hyperventilation
extremely concerning if pH and PaCO2 normalize or start trending acidic because failing to ventilate / IMPENDING RESPIRATORY COLLAPSE
young female school teacher / daycare worker with 10 days joint pain stiffness for 10 minutes in am in wrists MCPs PIPs knees ankles with tenderness but no swelling or redness and maybe non-specific rash, maybe fever fatigue diarrhea
think
diagnose - ANA? dsDNA? Rheumatoid factor?
viral arthritis
-probably Parvovirus B19 contracted working with kids (adults often don’t get slapped cheek rash)… otherwise could be hep b c hiv rubella
B19 IgM if immunocompetent
NAAT for B19 DNA if immunocompromised or reactivated
–ANA dsDNA are for SLE.. symptoms more chronic and varied…. and RA (different from lupus arthritis…) has longer morning stiffness ^1 hour, joint Swelling, and less acute with symptom onset over 6 mos not 10 days
antibodies in rheumatoid arthritis
anti-CCT anti cyclic citrullinated peptide
rheumatoid factor
why does TB infect teh apices
high O2 tensions slow lymphatic elimination
Cryptococcal infection in HIV pt occurs at CD4 count v___ and causes ___ or ___
Cryptococcal meningitis or pneumonia in HIV with CD4v100
preconception hemoglobinopathy screening in Mediterranean vs African patient
CBC for Mediterranean couple, only workup further if abnormalities
Hb Electrophoresis and CBC in African couple
SO CBC is first screen for hemoglobinopathies!
TF
appendicitis in pregancy is a thing
T
infective endocarditis started on vanc now found to be penicillin sensitive strep should be switched to
what if patient allergic to penicillin
iv Ceftriaxone
or iv Penicillin GGGG.. not another penicillin
if pt allergic to penicillin then just keep on vanc
reversible causes of asystole / pulseless electrical activity to try to treat while you do 2 minute chest compressions, epinephrine q3-5, and assess for shockable rhythm q2min (PEA/asystole is not shockable… only vtach vfib…)
5 H’s and T’s for reversible asystole / pulseless electrical activity
hypovolemia hypoxia H (acidosis) hypo/erkalemia hypothermia
tension tamponade toxins thrombosis trauma
hiv
subacute cough
cavitary inflammatory upper lung lesion
alcoholic
think
social and behavioral risk factors
Reactivation TB
risk factors for exposure
- social - incarcaeration group living international travel
- behavioral - substance abuse
defibrillation ideal for
cardioversion ideal for
defib ideal for VFib and pulseless VTach
cardioversion for symptomatic or sustained monomorphic VTach unresponsive to antiarrhythmics, and hemodynamically unstable AFib Before pulseless electrical activity or asystole develops (cardioversion is synchronized with qrs…)
lung cancer screening guidelines
age55-80
and ^30pack year smoking
and currently smoking within past 15 years
annual low dose chest CT
pneumocystis pneumonia cxr findings
often normal
or diffuse alveolar infiltrates
hiv pt severe acute retinal necrosis with pain keratitis uveitis and fundoscopic perippheral pale lesions with central retinal necrosis
vs
hiv pt painless retinitis without keratitis or conjunctivitis, and funduscopic hemorrhages and fluffy or granular lesions around retinal vessels
what bugs
pathophys
HSV and VZV retitnitis severe painful with anterior symptoms
CMV retinitis painless without anterior eye symptoms
reactivation of previous infection in immunocompromized AIDS patient
infective endocarditis started on vanc now found to be penicillin sensitive strep should be switched to
iv Ceftriaxone
or Penicillin GGGG.. not another penicillin
how are cardioversion and defibrillation different
cardioversion shocks with a qrs complex
defibrillation shocks on command
mechanism of anticholinergic urinary retention
detrusor hypoactivity
most common serious ocular complication of HIV patients, painless, fluffy/granular retinal lesions near vessels with hemorrhages
think
CMV retinitis
hepatitis panel in recovery from HBV infection
which is marker of vaccine or virus exposure, which specific to exposure
HBsAb, HBcAb, HBeAb might wane
HBsAb vaccine or virus exposure
HBcAb and HBeAb virus specific
elderly guy with new urinary retention after starting diphenhydramine for a cough, why?
Diphenhydramine is an H1-antihistamine with Anticholinergic effects (dryness of mucosa and eyes, urinary retention) – old guys with BPH at particular risk for urinary retention
name 3 first gen H1 antihistamines and their major side effect
diphenhydramine
chlorpheniramine
hydroxyzine
anticholinergic side effects (dryness of eyes mouth etc, urinary retention)
mechanism of anticholinergic urinary retention
detrusor hypoactivity
systolic anterior motion of the mitral valve think
HOCM
hepatitis panel in recovery from HBV infection
which is marker of vaccine or virus exposure, which specific to exposure
HBsAb, HBcAb, HBeAb might wane
HBsAb vaccine or virus exposure
HBcAb and HBeAb virus specific
who has higher rate of chronic HBV vs spontaneous clearance, kids or adults
infants get chronic HBV
kids have high chance of chronic
adults usually get over it, self-limited
