Rosh Material #4 Flashcards
mucopurulent unilateral eye discharge with erythema Pruritis rare
bacterial conjunctivitis
unilateral watery discharge with erythema
+/- Pruritis
viral conjunctivitis
unilateral eye erythema with cobblestoning and pruritis
allergic conjunctivitis
eye condition commonly seen in contact lens wearers
infectious keratitis
when do chlamydial and gonococcal neonatal conjunctivitis generally occur
chlamydial: btw 5-14 days of life days of life
gonococcal: btw 2-5 days of life
mc bacteria that cause bacterial conjunctivitis
staph aureus
strep pneumo
h. flu
conditions that are associated w. fibromyalgia
RA
hypothyroidism
anxiety
dpn
insomnia
widespread, achy MSK pain and stiffness
multiple tender points
fatigue, sleep disorders, subjective numbness
IBS
fibromyalgia
when are sx of fibromyalgia most severe
what aggravates them
AM
minor exertion
dx for fibromyalgia
3 conditions must be present:
widespread pain index > 7 and symptoms severity scale > 5
sx present x at least 3 months
absence of other d.o to explain sx
common sites of point tenderness in fibromyalgia
neck
jaw
shoulder girdle
upper and lower arms
chest
abdomen
upper and lower back
hips
upper and lower legs
tx for fibromyalgia
CBT
pt education
sleep hygiene
low impact aerobic exercise
amitryptiline
fluoxetine
duloxetine
pregabalin/gabapentin
3 pharm that are ineffective for fibromyalgia
NSAIDs
steroids
opioids
what does distal to proximal progression of muscle weakness make you think of
guillain-barre
esp w. PMH recent infxn
what recent infxn is associated w. Guillain barre
campylobacter jejuni
what does proximal extremity weakness that improves throughout the day make you think of
Lambert-eaton syndrome
what malignancy is Lambert eaton syndrome associated w.
small cell lung cancer
3 FDA approved meds for fibromyalgia
duloxetine
pregabalin
milnacipran
what virus causes verrucous papules (warts)
HPV
vaccine schedule for HPV
patients < 15 yo: 2 doses
patients 14 and older: 3 doses
tx for warts
spontaneous resolution (mc in kids)
liquid nitrogen cryotherapy
40% salicylic acid plaster after paring
condyloma acuminata
genital warts
tx for condyloma acuminata
liquid nitrogen cryotherapy
podophyllum resin
imiquimod 5% cream
electrocautery
laser therapy
what is this showing
plantar wart → verruca plantera
what is this showing
common wart → verruca vulgarisms
what is this showing
flat wart → verruca plana
medical usefulness of clostridium toxin (botox)
cervical dystonia
hyperhidrosis
overactive bladder
amblyopia
bleomycin is contraindicated for warts located where
fingers
which 2 hav types are mc associated w. condyloma acuminata
6
11
mc location for warts
hands
95% of testicular tumors are
germ cell tumors
2 types of testicular germ cell tumors
nonseminomas
seminomas
2 mc sx of testicular ca
enlargement of testis
sensation of heaviness
PE finding of testicular ca
contender, discrete mass
OR
diffuse testicular enlargement
3 signs of metastatic spread of testicular ca
LE edema → vena cava obstruction
back pain → retroperitoneal metastasis
cough → pulmonary
3 lab findings of testicular ca
elevated:
human chorionic gonadotropin
alpha fetoprotein
LDH
definitive dx for testicular ca
inguinal orchiectomy
preferred dx for testicular ca
scrotal US
CT scan
localized tenderness w. swelling of posterior right testis
epididymitis
2 mc causes of epididymitis in men < 35 yo
Neisseria gonorrhoeae
chlamydia trachomatis
2 mc causes of epididymitis in men > 35 yo
e.coli
what is prehn sign and what does it make you think of
pain relief w. elevation of painful testicle
eididymitis
is cryptochordism more likely to occur on the right or left side
right
rf for teesticular ca
cryptochordism
15-35 yo
tx for metastatic testicular ca
platinum based chemo
t/f: an elevated LDL is not considered a criterion of metabolic syndromeT
t!
mc age of onset for Parkinson’s
45-65 yo
resting or pill rolling tremor
cogwheel/lead pipe rigidity
bradykinesia
postural instability
masked facies
parkinson’s
loss of ability to perform rapid movements
dysdiadochokinesia → think Parkinson’s
what 2 things must be present for Parkinson’s dx
bradykinesia
PLUS
rigidity OR tremor
Parkinson’s tx for pt’s < 65 yo
dopamine agonists →
pramipexole
ropinirole
bromocriptine
goal is to delay levodopa
mainstay tx for Parkinson’s in pt > 65 yo
levodopa
PLUS
carbidopa
common s.e of levodopa
n/v
hypotension
dyskinesias
what medication is associated w. the on-off phenomenon
levodopa →
transient, abrupt fluctuations in motor sx in response to falling blood levels
second line drugs for parkinson’s
amantadine
rasagline
tolcapone/entacapone
benztropine
antipsychotics
etiology of Parkinson’s
loss of Substantia Nigra → depletion of dopamine
chorea (dance like movements) makes you think of
huntington dz
CAG trinucleotide repetition
autosomal dominant dz
huntington dz
huntington sx worsen with
trial of levodopa
tx for huntington
tetrabenazine
dopamine depleting drug
multisystem atrophy
progressive neuro condition
constipation, incontinence, postural hypotn, anhidrosis, lower motor neuron signs
parkinsonism
shy-drager syndrome
low ceruloplasmin
increased copper deposition
chronic hepatitis
dx before 20 yo
wilson dz
what are kayser-fleischer rings
what are they pathognomonic for
dark rings encircling the iris
wilson dz
what sign seen in Parkinson dz is characterized by sustained blink response to repetitive tapping over the bridge of the nose
myerson sign
3 mc pops that have bowel hypermobility
infants
young children
IBS pt’s
presentation of bowel hypermobility
chronic diarrhea
nonabsorbable solutes in the intestinal lumen
osmotic/diet induced diarrhea
what type of diarrhea does ingestion of polyethylene glycol 3350 induce
osmotic
mc diagnostic tool for PE
CTA
what is Virchow’s triad
venous stasis
endothelial injury
hypercoagulability
what do westermark sign and Hampton hump make you think of
PE
mc findings of PE on ECG
sinus tachycardia
nonspecific ST and T wave changes
S1Q3T3
tx for stable pt w. PE
heparin bridge
NOAC OR warfarin
tx for unstable pt w. PE
thrombolytic therapy → altepase streptokinase
embolectomy
tx for PE if pt has contraindication to anticoagulation, high risk for DVT, or recurrent thromboembolism
IVC filter
what is the mcginn-white sign
S1Q3T3 pattern on ECG in pt w. acute right heart strain
6 PE findings of CHF
bibasilar rales
laterally displaced PMI
S3 gallop
peripheral edema
JVD
hepatojugular reflex
what is the hepatojugular reflex and what does it make you think of
jugular venous dissension increases w. liver palpation
hepatic congestion → CHF
vessel cephalization
Kerley lines
batwing pattern in hilar area
pulmonary edema
CHF
med to avoid in CHF
bb
meds for CHF
diuretics
nitrates
O2
digoxin
dobutamine
fixed split S2 sound
RBBB
OR
atrial septal defect
2 mc heart sounds associated w. CHF
S3 → systolic HF
S4 → diastolic HF
leg pain, cramping, muscle fatigue, stasis dermatitis
medial malleolus ulcer
venous insufficiency
JVD
muffled heart sounds
hypotension
cardiac tamponade
common hx findings for cardiac tamponade
pericarditis
malignancy
chest xrt
what IV nutritional supplement has been shown to improve functional outcomes in pt w. CHF
Iron
tx for CHF PLUS hypotension with no signs of shock
doputamine
s.e of dobutamine
may worsen hypotension
tx for CHF PLUS hypotension with signs of shock
NE
bone condition that typically presents in kids
result of subchondral bone necrosis
affects medial femoral condyle in the knee
osteochondritis dessicans
dx for osteochondritis dessicans
MRI
CT disorder
presents w. multiple low trauma fx in peds
osteogenesis imperfecta
blue sclera, short stature, ligamentous laxity, easy bruising
osteogenesis imperfecta
what class of meds used for the tx of osteoporosis has been associated w. osteonecrosis of the jaw
bisphosphonates
screening recs for smokers to screen for abdominal aneurysm
abd US btw 65-75 yo
one time test
mc type of lung ca
non small cell
what genetic mutation causes pt’s to need an annual colonoscopy dt 100% risk of colon ca
FAP → familial adenomatous polyposis
autosomal dominant
those at risk for familial adenomatous polyposis
first degree relatives of pt w. FAP
>10 cumulative colorectal adenomas
at what age does pt w.FAP need to start getting colonoscopy
12 yo
continues annually until colectomy is performed
2 tx options for FAP
proctocolectomy w. ieorectal and anal anatomosis
total colectomy w, ileorectal anastomosis
3 conditions associated w. increased risk for colorectal ca
Lynch syndrome
familial adenomatous polyposis
hamartomatous polyposis syndrome
EBCAM (B) gene mutation
Lynch syndrome
mc cause of inherited colorectal ca
Lynch syndrome
other cancers associated w. Lynch syndrome (besides colorectal)
gastric
SI
endometrial
ovarian
urinary tract
skin
pancreatic
MLH1 (C)
MSH2
MSH6
PMS (D(
mismatch gene mutations
Lynch syndrome
what guidelines are used in pt’s w. Lynch syndrome associated colorectal ca to determine the need for tumor testing for microsatellite instability
revised Bethesda
3-2-1 criteria for Lynch syndrome
3 family members w. Lynch syndrome associated ca
2 associated cancers involving 2 generations
1 ca diagnosed before 50 yo
at what age do colonoscopies begin for pt w. Lynch syndrome
25
also endometrial and ovarian screening/surgical resection/chemo
multiple non caveating granulomas throughout the body
affects many organ systems
20-40 yo
chemical exposure
sarcoidosis
2 mc organs affected by sarcoidosis
lungs
skin
most common sx of sarcoidosis (3)
SOB
pulmonary effusion
PTX
3 skin manifestation of sarcoidosis
warm, erythematous painful patches and nodules on shins, arms, buttocks
erythema nodosum
lupus pernio
erythema nodosum
uveitis
bilateral hilar adenopathy on CXR
common PE findings of sarcoidosis
gallium uptake is increased around the hilar nodes and trachea
lambda sign → sarcoidosis
gallium uptake is increased around the lacrimal and parotid glands of the face
panda sign → sarcoidosis
tx for sarcoidosis
- steroids → prednisone for up to 6 mo to taper
- MTX
tx for cutaneous sarcoidosis
hydroxychloroquine
fever, fatigue, weight loss, polyarthritis
bilateral hilar LAD
sarcoidosis
sarcoidosis lab elevations (3)
ACE
hypercalcemia
hypercalciuria
indications for lung transplant for sarcoidosis
failed pharm tx
severe end stage dz → parenchymal infiltrates, fibrosis, honeycombing, hilar retractions, bulbous cysts
t/f: sarcoidosis often spontaneously resolves
t!
why isn’t sputum culture useful for sarcoidosis
not an infectious process
chronic, violaceous, raised plaques and nodules commonly found on chest, cheeks, nose, and around the eyes
lupus pernio
what is lupus pernio pathognomonic for
sarcoidosis
what does Loefgren syndrome make you think of
sarcoidosis
which of the radiographic stages used to classify lung involvement in sarcoidosis is associated w. the least favorable prognosis
stage 3
what test is used to evaluate for glaucoma
tonometry
IOP > __ is considered increased
21
first line tx for chronic glaucoma
PG analog → latanoprost
+/- topical bb → timolol
standard procedure for chronic open angle glaucoma
trabeculectomy
initial tx for acute angle closure glaucoma
IV acetazolamide
topical timolol
topical pilocarpine
topical apraclonidine
what surgical procedure is used as definitive tx for angle-closure glaucoma
peripheral iridotomy
2 factors that may reduce breast ca risk
breastfeeding
regular PA
GOLD criteria for COPD classification/tx
what abx for COPD exacerbation has been shown to have anti inflammatory properties in the lungs
azithromycin
greatest rf for PID
multiple sex partners
how long should op oral abx be continued when treating PID
14 days
1st line drug therapy specifically targeted to lowering TG
fenofibrate
tx for pt w. severely elevated TG
statin
PLUS
fenofibrate
what lipid lowering medication is contraindicated w. statin
gemfibrozil
t/f: adult pt’s should be screened for hypertriglyceridemia
f!
xanthomas, tendinous xanthomas, corneal arcus
hypertriglyceridemia
tx for hypertriglyceridemia (4)
fibrates
omega 3
niacin
etoh abstinence
preferred dx test for nephrolithiasis
non contrast CT of abdomen/pelvis
5 rf for nephrolithiasis
hyperparathyroidism
HTN
DM
dehydration
gout
mc type of kidney stones
calcium oxalate
all types of kidney stones
calcium oxalate
calcium phosphate
uric acid
struvite
cysteine
proteus and klebsiella are associated w. what type of kidney stone
struvite
imaging for pregnant pt w. nephrolithiasis
US
stones > __ will not pass spontaneously
5 mm
what med helps w. stone passage
tamsulosin
mc location for kidney stones
ureterovesicular junction (UVJ)
management of kidney stones
analgesics
fluids
tamsulosin
renal/urology consult
what type of stone is associated w. the development of staghorn calculi
struvite
what type of kidney stone is radiolucent on xray
uric acid
what type of kidney stone is found in kids w. metabolic dz
cysteine
stones > __ should get medical expulsive therapy (tamsulosin)
5 mm
management of stone > 10 mm
urology consult
shock wave therapy
uteroscopy
what do you think when you see: swelling of the superior posterior aspect of the scrotum
epididymitis
mc pathogen associated w. epididymitis in pt’s < 35 yo
chlamydia trachomatis
mc cause of scrotal pain
epididymitis
what does a positive prehn sign suggest
epididymitis
alleviation of pain w. elevation of the scrotum
prehn sign
tx for epididymitis in pt < 35 yo (STI)
ceftriaxone/doxy
tx for epididymitis for pt > 35 yo (non STI)
levofloxacin
OR
Bactrim (if quinolone contraindication)
pathogen associated w. pelvic infxns in women w. IUD
actinomyces israelii
what dx is the blue dot sign associated w.
torsion of the appendix and testicle
gradual onset unilateral scrotal pain
epididymitis
US findings of epididymitis
increased color flow
mc cause of dementia
alzheimer’s
definitive dx for alzheimers
brain bx
amyloid plaques
hyperphosphorylated tau protein
neurofibrilary tangles
alzheimers
screening tools for Alzheimers
mini mental status exam
montreal cognitive assessment
meds for alzheimers
cholinesterase inhibitors:
donepezil
galantamine
rivastigmine
NMDA agonist:
memantine
antioxidants
selegiline
what is finger agnosia
loss of the ability to recognize one’s own fingers, the fingers of others, and any drawing or representation of the fingers
short term memory loss
confusion about location of familiar places
difficulty completing daily tasks
poor judgment
changes in mood/personality
Alzheimer’s
mc type of HA
tension
tension HA’s are __lateral
bi
describe the pain in a tension HA
moderate
non throbbing
regions of the head mc affected by tension HA
band like distribution:
frontal
occipital
what do you think when you see a HA that is associated w. tenderness of pericranial myofascial tissues (muscle tenderness)
and
increased myofascial trigger points
tension HA
dx for tension HA
at least 15 episodes of HA per month lasting 30 minutes to 7 days x 3 months
t/f: tension HA are aggravated by PA
f!
first line tx for tension HA
NSAIDs
ASA
also APAP
first line tx for prophylaxis of tension HA
amitriptyline
what type of HA is aggravated by PA
migraine
triggers for tension HA
stress
fatigue
glare
noise
first line tx for cluster HA
100% O2
what is included in metabolic syndrome
3 or more of the following:
waist circumference:
m: > 102 cm
w: > 88 cm
TG > 150
HDL < 40
SBP > 130 OR DBP > 85
FBG > 100
what dietary supplement acts like a low intensity statin
red yeast rice
PE findings of hypertriglyceridemia
skin xanthomas
tendinous xanthomas
corneal arcus
TG __ or higher indicates increased risk for CVD
150
TG __ or higher increases risk for pancreatitis
500-1000
med for severely elevated TG
Fibrates
mc pathogen associated w. atypical PNA
mycoplasma pneumoniae
what do you think when you see: insidious onset of dry cough with no sputum production, sore throat, HA, myalgia, fever
atypical PNA
PE findings of atypical PNA
pulse-temperature dissociation (normal pulse in setting of high fever)
wheezing
ronchi
crackles
CXR findings of atypical PNA
reticulonodular or interstitial infiltrates
absent/minimal consolidation
3 abx for atypical PNA
macrolides
doxy
fluoroquinolone
PNA that is associated w. smokers and aerosol producing devices (whirlpool spas, grocery shop mist machines, air travel, watersheds)
legionella
legionella PNA presents with nonproductive cough and __ symptoms
GI
what type of PNA can present with a positive urinary antigen test even weeks after tx has started
legionella
which atypical organism is associated w. exposure to livestock and transaminitis
coxiella burnetti
mc ECG finding for anorexia
sinus Brady
soft/fine hair
common finding with anorexia
lanugo
cardiac complications of anorexia
mitral valve prolapse
myocardial fibrosis
ECG findings of hypokalemia
flattened/inverted T waves
QT prolongation
U waves
ECG findings of hypokalemia
flattened/inverted T waves
QT prolongation
U waves
antidepressant to avoid in pt w. eating disorder
bupropion → lowers sz threshold
what pathogen causes acute suppurative parotitis
s. aureus
rf for suppurative parotitis
dehydration
poor oral hygiene
intubation
classic pt that develops supportive parotitis
older post op
abrupt onset of erythematous, firm, painful swelling from the periauricular area to the angle of the mandible
acute bacterial parotitis
which duct might suppurative parotitis affect
stenson’s
treatment for bacterial suppurative parotitis
IV abx
nafcillin PLUS metronidazole OR clinda
OR
Unasyn (Amp/Sulbactam)
2tx for hospital acquired suppurative parotitis
or
immunocompromised pt
Vanco OR linezolid
PLUS
cefepime, metronidazole, Zosyn
surgical incision/drainage should be performed fur suppurative parotitis if pt has not improved w.in
2 days
what pathogen can cause unilateral or bilateral non purulent parotitis
and systemic symptoms like fever, HA, myalgia
mumps
complications of mumps
orchitis
oophoritis
meningitis
encephalitis
deafness
rf for MRSA
IVDU
LTC facility
recent hospital admit
hemodialysis
bipolar 1 is characterized by
manic episodes
hypomanic episodes
major depressive episodes
bipolar II is characterized by
depressive episodes
at least one hypomanic episodes
no manic episodes
difference btw mania and hypomania
mania lasts at least one week
first line tx for bipolar major depression
quetiapine
OR
lurasidone
difference btw bipolar I and bipolar II
bipolar II does not include manic episodes
tx for acute mania, mixed mood episodes, and maintenance therapy of bipolar
lithium
t/f: lithium is FDA approved for bipolar
f!
first line tx for bipolar in pregnant pt
lamotrigine
main organ responsible for conversion of T4 to T3
liver
what disorder is Zollinger Ellison syndrome closely associated w.
multiple endocrine neoplasia type I
gnawing epigastric pain
PUD
ulcer pain is alleviated by ingesting food
duodenal
“dud give me food”
ulcer pain is exacerbated by ingesting food
gastric ulcer
infection that mc occurs at the olecranon, pre patellar, and infrpatellar bursa
septic bursitis
rf for septic bursitis
trauma
gout
loss of skin integrity
recent joint aspiration
immunosupression
mc pathogen associated w. septic bursitis
s. aureus
acute onset of tenderness, pain, edema, erythema, and warmth at bursa
septic bursitis
you should consider septic arthritis instead of septic bursitis if you see what PE finding
limitation of joint movement
gs for dx of septic bursitis
bursa fluid culture
indications for surgical drainage of septic bursitis
severely swollen
persistent sx after 36-48 hr after abx
who is at risk for MRSA infxn with septic bursitis
prior hx MRSA
inability to tolerate oral abx
bursitis overlying prosthetic joint or graft
tx for MRSA associated septic bursitis
IV Vanco PLUS cefazolin
oral tx for MRSA associated bursitis without systemic infxn/immunocompromised
bactrim
abx for MSSA or strep associated septic bursitis
cephalexin
OR
diclozacillin
t/f: aseptic bursitis can be caused by gout
t!
where in the body is FSH synthesized
gonadotrophin cells of the anterior pituitary
red flags of back pain
night pain and wt loss → tumor
f/c, sweats → bone/disk infxn
acute bony tenderness → fx
morning stiffness > 30 min in young adult → seronegative spondyloarthropathy
urinary/bowel retention/saddle anesthesia → cauda equina
recent spinal instrumentation → spinal epidural abscess/hematoma
immunodeficiency → bone/disk infxn
extremes of age
coagulopathy → spinal epidural hematoma
most back pain resolves within __
6 weeks
what response with plantar stimulation is a positive Babinski sign in adults characterized
dorsal extension and fanning of the toes
what do you think when you see a pt who presents with hemolysis following an oxidative stressor, ex recent administration of a drug
G6PD deficiency
G6PD is an __ linked
__ enzyme disorder
X
RBC
3 meds associated w. G6PD deficiency
dapsone
antimalarial drugs
nitrofurantoin
what disorder are fava beans associated with
G6PD deficiency
4 sx of hemolysis
jaundice
pallor
abd pain
dark urine
sign of G6PD deficiency in neonates
kernicterus
labs for G6PD deficiency
decreased hgb
increased reticulocytes
increased bilirubin
decreased haptoglobin
increased ldh
what does peripheral smear show for hemolysis
heinz bodies
bite cells
is Coombs test negative or positive for G6PD deficiency
negative → non immune
what do you think when you see: inclusion w.in the RBC composed of denatured hgb that is formed as a result of oxidative damage
heinz body → results in bite cell
what does the G6PD deficiency protect against
malaria
what do you think when you see the following triad:
rash, fever, eosinophilia
in the setting of antibiotic therapy
allergic interstitial nephritis
what do you think when you see: PIGA gene mutation on the X chromosome that results in episodic hemolytic anemia and hemoglobinuria at night time and early morning
paroxysmal nocturnal hemoglobinuria
what supplement should be initiated in patients with chronic hemolysis
folic acid
what do you think when you see: acute non painful, unilateral complete vision loss, and a pale retina with cherry-red spot in the macula
acute retinal artery occlusion
pathology behind acute retinal artery occlusion
embolism occludes blood flow to the retina → retinal ischemia, vision loss
mc cause of acute rental artery occlusion
carotid artery atherosclerotic lesion
what test can aid in the dx of acute retinal artery occlusion
fluorescein angiography
how do you r.o giant cell arteritis when working up central retinal artery occlusion
ESR or CRP → will be elevated with giant cell arteritis
management of acute retinal artery occlusion
immediate ophthalmology consult
try:
orbital massage
intra-arterial thrombolytic therapy
IOP reduction → acetazolamide, mannitol
vasodilators
anterior chamber paracentesis
what do you think when you see: blood and thunder appearance on fundoscopic exam
central retinal vein occlusion
all patients > __ yo with acute monocular vision loss should have ESR done to r/o
giant cell arteritis
tx for giant cell arteritis
high dose steroids asap
what are the possible sequelae of retinal artery occlusion
vision loss
vitreous hemorrhage
neovascular glaucoma
boxcar look or cherry red spot on fundoycopic exam
acute retinal artery occlusion
2 types of hemorrhoids
internal
external
hemorrhoids that originate above the dentate line
internal
hemorrhoids that originate below the dentate line
external
what do you think when you see: painless rectal bleeding with bowel movements, not colon ca
hemorrhoids
what does rectal pain and a palpable lump with hemorrhoids indicate
thrombosed external hemorrhoid
1st line management of hemorrhoids
lifestyle mods →
increase fluids/fiber, PA
avoid sitting
attempt BM after meals
second line tx for hemorrhoids if lifestyle mods do not work
sitz baths
local anesthetics
topical steroids
vasoactive substances → nitroglycerin, phenylephrine
zinc oxide
procedures for persistent hemorrhoids
rubber band ligation
sclerotherapy
excision
who is a candidate for rubber band ligation for hemorrhoids
healthy patients with grade I, II, or III internal hemorrhoids
who is a candidate for sclerotherapy with hemorrhoids
pt on anticoagulants/antiplatelets
immunocompromised
portal HTN
when should excision be used for hemorrhoids
acutely thromboses external hemorrhoids
when should you not attempt office-based procedures for hemorrhoids
grade IV internal hemorrhoids
hemorrhoid that does not protrude through the anus
grade I
hemorrhoid that protrudes through the anus and then reduces spontaneously
grade II
hemorrhoid that must be manually reduced
grade III
__ can not be used on external hemorrhoids due to pain
rubber band ligation
what is the recommended procedural treatment for patients with refractory grade II internal hemorrhoids who are on anticoagulants
sclerotherapy → low risk of bleeding
men < 65 yo who consume __ drinks are at risk for alcohol-related health risks
4 or more/day
14 or more/week
definition of standard drink
12 ounce beer
5 ounce glass of wine
1.5 ounce of 80-proof liquor
women and adults 65 yo and older who consume __ drinks are at higher risk of alcohol related health risk
7 or more/week
3 or more on any day
what is the definition of binge drinking
drinking enough that the blood alcohol concentration level reaches 0.08 g/dL within 2 hr
self limited, benign condition in which the costochondral or chondosternal joints become inflamed and causes reproducible chest wall tenderness
costochondritis
describe the location of pain in costochondritis
reproducible chest wall tenderness over the costal cartilages along the sternal border
mc cause of chest pain in children - often caused by carrying a backpack on one shoulder
costochondritis
work up for pt > 35 yo with cp along the sternal border
EKG
Xray
inflammatory disorder that presents with costochondral tenderness and is likely to be preceded by infectious, rheumatologic, or neoplastic process
tietze syndrome
how do you differentiate costochondritis from tietze syndrome
costochondritis is:
more common
usually affects > 40 yo
involves > 1 area of reproducible tenderness
does not include reproducible swelling
management of costochondritis
PT/stretching
heat or cold therapy
APAP or NSAIDs
topical analgesic or anti-inflammatory
steroids for refractory
what do you think when you see: pain along the sternal border, recent viral infxn, and localized swelling
tietze syndrome
which ribs attach directly to the sternum via their costal cartilage
the first 7
2 largest rf for dementia
advanced age
cerebrovascular dz
2 treatable causes of dementia to r.o during work up
B12 deficiency
hypothyroidism
2 main drug classes in dementia tx
cholinesterase inhibitors
N-methyl-D aspartate antagonists
preferred imaging for evaluation of cognitive decline
MRI
although not required for dx
t/f: MMS or MOCA is required for dx of dementia
f!
what is mild cognitive impairment
a decline in memory or cognition that is noticeable to the patient or family members but does not significantly interfere with ADL
a D dimer < __ has a high negative predictive value for PE
500
small PTX < __ % of the hemithorax will resolve spontaneously
15
what do you think when you see: temporary let ventricular systolic dysfunction that mimics a MI and EKG findings of ST segment elevation and elevated troponin
takotsubo cardiomyopathy
how do you differentiate btw an NSTEMI and takotsubo cardiomyopathy
with takotsubo cardiomyopathy there is an absence of obstructive coronary disease or acute plaque rupture
nitroglycerin is contraindicated in what type of MI
right ventricular MI
2 essential criteria for dx of PTSD
symptoms must affect ADL
symptoms must be present 1 month or more
if symptoms of PTSD last < 1 month, what is the diagnosis
acute stress disorder
tx for PTSD
CBT
SSRI
what are the two SSRIs that are FDA approved for PTSD
sertraline
paroxetine
med to add to PTSD tx if pt also has insomnia if pt has PTSD AND insomnia
trazodone
what is the appropriate tx for a patient with acute stress disorder
CBT
2 mc modes of transmission for Hep B
sexual transmission
IVDU
sx of Hep B
fatigue
malaise
anorexia
nausea
RUQ pain
+/- low grade fever
+/- jaundice
labs indicative of Hep B
ALT and AST elevations, often 1,000-2,000 units/L
is ALT or AST higher in Hep B
ALT
indication of chronic Hep B
persistent ALT elevation for > 6 months
what lab value is used to screen for, detect, and diagnose acute and chronic Hep B
HbsAG
what lab value is the earliest routine indicator of acute HBV and can identify infected people before symptoms occur
HBsAG
what lab value can indicate previous exposure to HBV OR successful vaccination
indicates immunity to HBV
anti-HBs
first antibody produced after HBV infection
IgM
antibody produced later in HBV infection
IgG
what lab value is used to indicate acute HBV infection and to monitor effectiveness of treatment
HBeAG
management of HBV
supportive
when are antivirals indicated for HBV infection
acute liver failure
indications of severe liver failure in HBV infection
encephalopathy
severe coagulopathy
risks associated w. chronic HBV
cirrhosis
hepatocellular carcinoma
vaccination schedule for HBV
initial dose at birth
subsequent doses at 1 month and 6 months
which of the 5 hepatotoxic viruses is only seen in combo with hep B
hep D
infxn of the soft tissues around the fingernail that usually veins as superficial cellulitis and can progress to an abscess
paronychia
mc pathogen associated w. paronychia
staph
tx for paronychia without fluctuance
topical abx → mupirocin or triple abx ointment
warm compress
antiseptic soak
tx for paronychia with extensive cellulitis or underlying conditions
oral abx → dicloxacillin OR cephalexin
tx for paronychia if MRSA is suspected
bactrim
clinda
doxy
tx for paronychia with abscess formation
immediate incision and drainage
abx usually not required
paronychia affects what area of the nail
lateral and proximal nail folds
infection of the nail bed below the nail
eponychia
complications of acute paronychia in immunocompromised patients
eponychia
tenosynovitis
osteomyelitis
felon formation
what 2 CCB are recommended for first line tx of HTN
dihydropyridine CCB →
amlodipine
nifedipine
fist line drugs for HTN
HCTZ
dihydropyridine CCB
ACEI OR ARB
mc cause of aortic regurgitation
endocarditis
what do you think when you see a pt w.: exertion dyspnea, signs of HF, hx of angina, and a hyperdynamic apical pulse
aortic regurgitation
describe the pulse in aortic regurgitation
bounding peripheral pulse
wide pulse pressure
describe the murmur in aortic regurgitation
acute: low pitched early diastolic murmur
chronic: holodiastolic, high pitched murmur
where is the murmur of aortic regurgitation best heard
left upper sternal border
aortic regurgitation murmur __ with valsalva
decreases
swift upstroke and rapid fall of radial pulse with wrist elevation
water-hammer pulse
head bobbing pulse
de Musset sign
visible pulsations of uvula
mueller sign
fingernail bed pulsations with light compression
quincke pulse
what do de Musset sign, Mueller sign, water-hammer pulse, and Quincke pulse make you think of
aortic regurgitation
definitive diagnostic test for aortic regurgitation
cardiac catheterization
definitive tx for aortic regurgitation
surgical repair or valve replacement
indications for surgery with aortic regurgitation
symptomatic
ejection fraction < 55%
management of mild/asymptomatic aortic regurgitation
ACEI
CCB
digoxin
salt restriction
cardiac rehab
3 causes of acute aortic regurgitation
endocarditis
aortic dissection
trauma
what early diastolic murmur is heard best in the lateral decubitus position
mitral stenosis
what murmur presents with a blowing, holosystolic murmur that is heard best at the apex
mitral regurgitation
what does an Austin flint murmur suggest
severe aortic regurgitation → late diastolic murmur heard best at the apex
what is duroziez sign and what does it make you think of
systolic or diastolic thrill or murmur heard over the femoral arteries
aortic regurgitation (insufficiency)
mc chronić dysrhythmia
afib
4 types of afib
paroxysmal
persistent
long standing persistent
permanent
triggers for afib
thyroid disorders
pericarditis
trauma to the chest
OSA
cardiac surgery
pulmonary disorders
meds
condition to r.o for afib
thyroid disorders
mc consequence of afib
thrombus formation
how do you determine if a pt w. afib needs to be anticoagulated
CHA2DS2-VASc:
CHF → 1
HTN → 1
age 75 or older → 2
DM → 1
stroke → 2
vascular disease → 1
age 65-74 → 1
2 or higher for males = NOAC
3 or higher for females = NOAC
sex category (female) → 1
what are the 4 NOACS
dabigitran
rivaoxaban
apixaban
edoxaban
what med MUST be given to afib pt before cardioverting them
anticoagulant
what meds are used for rate control in afib
bb
ccb
digoxin
the which clotting factor do the NOACs inhibit
Xa
which clotting factors does Warfarin inhibit
II
VII
IX
X
proteins C and S
t/f: ASA is useful for the prevention of stroke dt afib
f!
2 strains of HPV associated w. cervical ca
16
18
HPV infections lasting > __ increase risk for precancerous/cancerous lesions
12 months
rf for cervical ca
HPV 16 and 18
early age of sexual activity
multiple partners
hx of STI
hx of vulvar or vaginal squamous neoplasia or ca
low socioeconomic status
immunosuppression
2 major types of cervical ca
squamous cell carcinoma
adenocarcinoma
mc type of cervical ca
squamous cell carcinoma
sx of cervical ca
irregular/heavy vaginal bleeding
postcoital bleeding
changes in vaginal discharge
cervical ca screening should begin at what age __
and should continue q __ years if no abnormalities are found
21
3
cervical ca screening for women 30-65 should be q __ years
5
t/f: the cervix is removed during a total hysterectomy
t!
do patients who have had a total hysterectomy need to continue to have cervical ca screening
no
vaccination schedule for HPV
11 or 12 years old
women up to 26 yo if they were not previously vaccinated
what HPV vaccination is used in the US
9vHPV
what is the recommended approach for women 25 and older with low grade squamous intraepithelial lesions and a positive HPV test
colposcopy
what is the effect of low serum estradiol and progesterone levels on gonadotropin releasing hormone, FSH, and LH at the beginning of the menstrual cycle
increased gonadotropin releasing hormone
increased FSH
increased LH
2 phases of the menstrual cycle
follicular
luteal
in the beginning of the follicular phase, estradiol and progesterone levels are __
which causes increased release of __
from the __
low
GnRH
hypothalamus
GnRH acts on the __
to secrete __ (2)
which causes follicle release
anterior pituitary
FSH and LH
what hormone causes thickening of the uterine endometrium and an increase in cervical mucosa
estradiol
when during the menstrual cycle do estradiol levels peak
day 1 before ovulation
what stimulates ovulation
LH surge
during the menstrual cycle, in the absence of fertilization, the dominant follicle becomes the __
corpus luteum
what hormone maintains the corpus luteum
chorionic gondatotropin
what marks the transition of the luteal phase back to the follicular phase
onset of menses
what amount of blood lost during a menstrual cycle defines heavy menstrual bleeding
>80 mL
what is the appropriate screening guideline for an abdominal aortic aneurysm according to the USPTF
screen all men age 65-75 old who have ever smoked with a one-time US
2 mc rf associated with abdominal aneurysm
smoking
advanced age
t/f: abdominal aortic aneurysm screening is recommended for women, regardless of smoking status
f!
it is not recommended for women
what are the 2 greatest interventions to reduce the risk of developing an abdominal aortic aneurysm
smoking cessation
blood pressure control
what will PE show for an abdominal aortic aneurysm
pulsatile abdominal mass
indication of ruptured abdominal aortic aneurysm
hypotension
diagnostic tool for abdominal aortic aneurysm
US
monitoring for abdominal aortic aneurysm 4.0-4.9 cm
annually
monitoring for abdominal aortic aneurysm 5.0-5.4 cm
q 6 mo
can use CT or MRI in addition to US
what size abdominal aortic aneurysm is indicative of surgery
>5.5 cm with rapid expansion rate
mc acute leukemia in adults
acute myeloid leukemia (AML)
rf for AML
age
radiation
tobacco
trisomy 21
sx of AML
anemia
neutropenia
thrombocytopenia
fatigue
easy bruising
pallor
SOB
fever
2 sx not associated w. AML in adults
bone pain
organomegaly
anemia associated w. AML
normocytic
normochromic
what do Auer rods make you think of
AML → circulating myeloblasts
dx for AML is done using __
which must have what finding
bone marrow bx
greater than 20% blast cells
first line tx for AML
combo chemo: 7+3 regimen
procedure to consider for select AML patients
allogenic hematopoietic stem cell transplantation
complications of AML
tumor lysis syndrome
febrile neutropenia
which leukemia that is common in kids presents with fever, LAD, organomegaly
ALL
3 phases of CML
chronic
accelerated
blast
gene associated w. CML
ABL1 → results in Philadelphia chromosome
if you see leukemia in an kid, you can rule out
AML
