STEP 2 Flashcards
Bacterial Prostetitis- symptoms- diagnosis- treatment
Sypmtoms: Fever, chills, myalgia, pelvic pain (diffuse) Diagnosis: Pyuria, tender prostate, urine cultures + E.coli. Mid-stream urine sampleTreatment: TPM-SMX or fluoroquinolones
Adjustment Disorder
- Etiology
- Treatment
Caused by an identifiable stressor, within the past 3 monthsRarely lasts more than 6 monthsTreatment: Cognitive or psychodynamic psychotherapy
Anorexia Nervosa vs. Bulimia
Anorexia nervosa - Clinical BMI
Reye Syndrome
- Epidemiology
- Presentation
- Blood Labs
Children
Trisomy 18- MSAFP- beta-hCG- Estriol- Inhibin A
LOW MSAFP- LOW beta-hCG- LOW Estriol- NORMAL Inhibin A
Trisomy 21- MSAFP- beta-hCG- Estriol- Inhibin A
LOW MSAFP- HIGH beta-hCG- LOW Estriol- HIGH Inhibin A
Neural Tube or Abdominal wall defect- MSAFP- beta-hCG- Estriol- Inhibin A
HIGH MSAFP- NORMAL beta-hCG- NORMAL Estriol- NORMAL Inhibin A
Postpartum blood loss- Etiology (most common)- Treatment
Etiology - Uterine AtoniaTreat- bimanual uterine massage, fluid resuscitation, uterine atonic agents: oxytocin, methylergometrine, carboprost
Uremia- Blood concentration causing symptoms- Complication and treatment
Symptoms appear at level of 100mg/dL- uremic encephalopathy = indication for hemodialysis
Mitral Stenosis- Auscultation
Auscultation: S1 loud, opening snap after S2 @ apex, low pitched diastolic rumble @ apex
Torticollis- epidemiology- presentation- What (lab, scan, procedure) do you order on this patient?
- common condition in children- upper respiratory infection, minor trauma, cervical lymphadenitis, retropharyngeal abscess- x-rays must be obtained
Beta 2 Adrenoceptors- what drug acts on this receptor AND stimulates the release of a metabolic hormone
Albuterol - cause release of insulin via activation of beta cells in pancreas
Scaphoid bone fracture- define displaced vs. non-displaced- treatment for each
Non-displaced fracture = wrist immobilization
Displaced fracture = surgery
Minimal change disease- pathogenesis
Pathogenesis: T-cell mediated injury to podocytes
Acute coronary syndrome- atypical presentation- what lab/scan/procedure do you order?
atypical presentation = abdominal pain, nausea, vomiting = women, ELDERLY, diabetes, hx of smokingorder ECG
For Chlamydia and Gonorrhoeae- treatment when nucleic acid amplification test +/– treatment when gram stain +/-
if nucleic acid amplification test (+) you don’t have to treat for both if only (+) for 1but if a gram stain (+) for 1 then treat for both
Legionnaires Disease- Presentation- Labs
atypical community acquired pneumonia also you get diarrhealabs: hyponatremia, hepatic dysfunction, hematuria, proteinuria, neutrophils, no organisms in sputum stain
Jervell-Lange-Nielsen Syndrome- Genetics- History- Presentation
Autosomal recessive, pt. hx, family hx, sudden death, congenital sensorineural deafness, QT prolongation
In elderly pts w/anemia taking NSAIDS or aspirin- Etiology of anemia
most common cause = iron deficiency anemia from blood loss in GI tract
Sarcoidosis- Epidemiology - Presentation
Most common African American woman 3rd and 4th decade life. Most common effects lungs hilar adenopathy and reticular opacities xray.Symptomatic cough, erythema nodosum, ANTERIOR UVEITIS, and arthritis.
Kleptomania
Rare impulse control theft were stolen items have no value or use to the person.Treatment Cognitive behavioral psychotherapy
Syringomyelia- Definition- Associated w/ other disease- Presentation
Fluid filled cavity located within the cervical and thoracic spinal cord. Associated with Arnold Chairi malformationtype (1). Presents areflexic weakness in the upper extremities and dissociated sensory loss following a “cape”distribution.
Cyanide toxicity- Occurs in patients treated with too much _________- Or patients who can’t clear that drug because they have this problem _________- How does the drug turn into cyanide?- Presentation
Can occur in patients treated with nitroprusside who receive prolonged infusions, higher doses or have underlyingrenal insufficiency. Metabolism nitroprusside releases nitric oxide and cyanide. Cyanide causes altered mental status,lactic acidosis, seizures, and coma.
Chronic Granulomatous disease:- Pathogenesis- Diagnosis
Dysfunction of phagocytic cells NADPH oxidase enzyme complex. Diagnosis is made by nitroblue tetrazolium (NBT)slide test.
Wiskott-Aldrich syndrome (WAS):- Etiology- Presentation- Labs
X-linked recessive. Defect in Wiskott-Aldrich syndrome protein (WASP). Presentation: young boy with eczema, thrombocytopenia, and recurrent infections with encapsulated organisms. At birth may have petechiae, bruises, bleeding from circumcision. or bloody stools. Low IgM, high IgA, and IgE levels. Poor response to polysaccharide antigens, and moderately reduced T-cells and platelets.
Chediak-Higashi syndrome:- Labs- Presentation
Characterized by decreased degranulation, chemotaxis, and granulopoiesis. Partial oculocutaneous albinism,neuropathy, hepatosplenomegaly, pancytopenia. Labs neutropenia, and giant lysosomes confirm diagnosis.
Leukocyte adhesion defect (LAD):- Pathogenesis- Pathology- Presentation
Defective tethering, adhesion, and targeting of myeloid leukocytes to sites of microbial invasion. Neutrophilia without PMNs in pus. Loss of baby and adult teeth.
Hyper- IGE (Job’s) syndrome:- Presentation- Labs
Chronic pruritus dermatitis, recurrent staph infections, elevated IgE levels, eosinophilia and coarse facial features.
Chronic Hepatitis B: - Best treatment
Treatment of choice: Tenofovir and then Entecavir.
Hepatitis C- Treatment
Treatment: Pegylated interferon plus ribavirin
Systemic Lupus erythematosus (SLE):- Pathogenesis of pancytopenia
SLE can cause pancytopenia due to concurrent peripheral immune-mediated destruction of all 3 cell lines.
Management of Psychosis:
Second generation antipsychotics such as quetiapine, risperidone, olanzapine, aripiprazole, ziprasidone, andpaliperidone. Clozapine is a second generation antipsychotic that is considered the gold standard treatment for treatment resistantschizophrenia. Cause agranulocytosis.
Acute abnormal uterine bleeding:- If patient is stable, what is the first line treatment?
If stable first line treatment is hormonal medication high dose estrogen (conjugated equine estrogen).
Cystic fibrosis- Describe the pathophysiology leading to excess bleeding in these patients
Fat malabsorption common leading to vitamin K deficiency. Leads to deficiency in coagulation factors II, VII, IX, andX. also C and S. 1972
Lichen sclerosus(lichen sclerosus et atrophicus, LS & A): Define- Epidemiology- Presentation- Physical exam findings- Labs/scans/tests- Treatment
Chronic inflammatory condition of the anogenital region that most commonly affects postmenopausal women andmanifests with vulvar pruritus and discomfort. Exam shows porcelain white atrophic. Must obtain biopsy to R/O vulvar SCC. Treatment is high potency topical corticosteroids.
Aortic dissection- Classic presentation- Highest risk factor
Causes chest pain that classically described as sudden, tearing, and radiating to the back. Hypertension is the mostcommon predisposing factor.
Acute Respiratory Distress Syndrome (ARDS):- Can be a complication of acute ________- Pathogenesis of ARDS caused by acute _______
Can be caused by acute pancreatitis with increase in serum phospholipase A2 from pancreas. This enzyme leaks intoalveoli and damages surfactant.
Wiskott-Aldrich syndrome:- Characterized by a triad of signs & symptoms
Characterized by triad of thrombocytopenia seen in over 90% of patients at diagnosis, eczema, and recurrentinfections.
Mid Cycle pain (mittelschmerz):- Presentation- What causes the pain?
Abdominal pain in a young female in the middle of her cycle with a benign history and clinical examination. The painis due to ovulation itself and tends to occur on the side that produces the mature ovum.
Duodenal ulcer disease/Peptic ulcer disease:- How does the pain react to eating?- How many % have H.pylori?- Treatment
Epigastric pain relieved with eating as food causes alkali solution to released into the duodenum. Over 90 have H.pylori. Treatment omeprazole and antibiotics amoxicillin plus clarithromycin.
Gastric Ulcers- How does the pain react to eating?
Pain is worse with eating
Physiologic shunting (V/Q mismatch):- Auscultation- Physical exam = Effect on oxygen saturation with consolidated left lobe hypothetically
Normal upright person ventilation and perfusion greatest at the lung bases and least at apices. In a consolidated leftlobe. A patient will become hypoxic when lying on left side, but have normal O2 sats when lying on right because ofthis principle.
Viral Arthritis- Presentation- Labs- Treatment
Presents with symmetric small joint inflammatory arthritis. Distinguished by that fact it tends to resolve within twomonths. Positive inflammatory markers such as ANA and rheumatoid factor may occur. Treatment NSAIDS.
Diabetic foot ulcer- Risk factor (most important)- Physical exam
Risk factors diabetic neuropathy is most important contributing factor and can be accessed using a 10g monofilament.Ankle-brachial index (ABI) primarily a measure of large vessel PAD.
Renal artery stenosis- Triad of signs/symptoms
Systolic-diastolic abdominal bruit in a patient with hypertension and atherosclerosis is strongly suggestive.
Osteomalacia- Pathogenesis- Can be caused by this disease ________- Labs
Due to defective mineralization of organic bone matrix. Can be caused by celiac sprue. Labs show elevated alkalinephosphatase, elevated PTH, hypophosphatemia and hypocalcemia.
Emphysematous cholecystitis:- Epidemiology- Pathogenesis
Common form of acute cholecystitis in elderly diabetic males. It arises due to infection of gallbladder wall with gas-forming bacteria.
Paget’s disease of the breast:- Presentation- Histopathology
No prior history of skin disease who presents with eczematous rash near the nipple that does not improve with topicaltreatments. Most have underlying adenocarcinoma which show large cells surrounded by a halo-like area.
Beta blocker overdose- Presentation- Complications- Treatments
Presents with bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock.Intravenous fluids and atropine are first line treatment options. Intravenous glucagon should beadministered in patients with profound or refractory hypotension.
Hereditary telangiectasia (Osler-Weber-Rendu syndrome):- Genetics- Pathology- Pathophysiology- Presentation
Autosomal dominant disorder. Characterized by diffuse telangiectasia, recurrent epistaxis, and widespread AVmalformations (AVM). AVM in lungs cause shunt of blood right to left side of heart, leading to chronic hypoxia andreactive polycythemia. Digital clubbing. Possible fatal hemoptysis with recurrent nose bleeds and oral lesions.
Chronic myelogenous leukemia (CML):- Genetics- Pathophysiology- Describe leukocyte alkaline phosphatase activity
Low levels of leukocyte alkaline phosphatase (LAP) activity due to abnormal fusion gene t(9;22) (BCR/ABL1) causesdysregulation of tyrosine kinase activity. Leads to decreased apoptosis of myeloid cells and they accumulate highnumbers. They are functionally inactive, so low LAP activity.
Primary dysmenorrhea:- Pathophysiology- Treatment
Examination is normal and pain is during the first few days of menses. Pain pathophysiology release of prostaglandinsfrom endometrium causes uterine contractions. Treatment NSAIDS.
Cirrhosis- Etiology (most common)
Chronic alcohol abuse and viral hepatitis ( think B and C infection) are the most common underlying cause of cirrhosis.
Primary adrenal insufficiency:- Most common Etiology- Cortisol high or low?- ACTH high or low?- Aldosterone high or low?
Most common cause Autoimmune. Cortisol = decreased; ACTH = increased; Aldosterone = decreased
Secondary adrenal insufficiency:- Most common Etiology- Cortisol high or low?- ACTH high or low?- Aldosterone high or low?
Most common cause chronic glucocorticoid therapy. Cortisol = decreased; ACTH = decreased; Aldosterone = Normal
Lyme disease- Treatment in young children and pregnant/lactating women- Treatment in normal people
Oral amoxicillin is treatment of choice in pregnant and lactating women as well as children age
Aspirin-exacerbated respiratory disease (AERD):- Epidemiology- Pathogenesis- Treatment
Seen patients with history of asthmatic or chronic rhinosinusitis with nasal polyposis. Non-IgE mediated reaction thatresults from aspirin induced prostaglandin/leukotriene misbalance. Treatment stop NSAIDS use leukotriene antagonistmontelukast.
Acute cardiac tamponade:- Etiology - Presentation- chest x-ray findings
Patient presents with hypotension (UNRESPONSIVE to IV FLUID bolus), tachycardia, and elevated jugular pressure after blunt thoracic trauma. Only takes 100-200mL of fluid, so chest X-ray can sometimes be normal.
Criteria for HIV patient vaccinations:- MMR?- Contraindications?
Patients with HIV should receive vaccination for MMR if their CD4 cell count is >200/uL, they have no history ofAIDS-defining illness, and they have no evidence of immunity.Lack of current ART is not a contraindication.Otherwise all other live vaccines are contraindicated.
Bacterial sinusitis- Biggest risk factor
The most common predisposing factor for acute bacterial sinusitis is a viral respiratory infection.
Primary CNS lymphoma:- Epidemiology- Presentation- Labs, CSF, MRI
Suspect primary CNS lymphoma in an HIV-infected patient with an altered mental status, ((EBV DNA in the CSF)), and asolitary, weakly ring-enhancing periventricular mass on MRI.
Viral conjunctivitis- Treatment
Self-limited condition associated with adenovirus and other URI. Treat symptomatic with COOL, MOIST COMPRESSES.
Antithyroid drugs propylthiouracil (PTU) and methimazole (MMI):- Complication- Presentation of complication- Treatment- Labs
Can cause agranulocytosis: Patient will complain of fever and sore throat. STOP MEDICATIONS IMMEDIATELY. Recheck WBC count.
Chronic beclomethasone use in asthma:- most common adverse effect
Most common adverse effect of inhaled corticosteroid therapy is oropharyngeal thrush.
Uterine fibroids- Diagnosis
Work up: Pelvic ultrasound is the prefered initial imaging modality for suspected gynecological tumors. It has a highsensitivity for diagnosing uterine fibroids and ovarian pathology.
Brain death- Define- Legal authority
Brain death refers to a total loss of brain function and is legally acceptable definition of death. Family permission is not legally required to discontinue mechanical ventilation in a patient with brain death.
Acute coronary syndrome:- How can lidocaine affect the heart?
Although it can decrease the risk of ventricular fibrillation, it may increase the risk of asystole.
Glascow Coma scale:- Is determined by measuring what?
Eye Opening; Verbal Response; Motor Response.
Endometriosis- Fertility prognosis
At increased risk of impaired fertility or infertility due to chronic inflammation and adhesion formation.
Endometriosis- Treatment- Diagnosis (when to diagnose?)
Laparoscopy with visualization and biopsy of implants is the only definitive way to diagnose endometriosis. It isindicated when NSAIDS and hormonal contraceptive therapy have failed.
Atypical antipsychotics:- side effects- treatment of side effects
Example: risperidone can cause extrapyramidal side effects and can be treated with anticholinergic medication likebenztropine.
Acute pharyngitis children and adolescent:- Diagnosis (gold standard)
Diagnose with rapid streptococcal antigen test (RAST) or throat culture which is gold standard. Antistreptolysin Oantibody is useless for acute infection because antibodies do not present for one month.
Premature ovarian failure:- Presentation- Diagnosis - FSH/LH ratio - FSH & LH up or down - Estrogen up or down
Women under age 40 with elevation in FSH for greater than or equal to 3 months of amenorrhea. FSH increased; LH increased; FSH/LH ratio >1.0; estrogen decreased.
Anterior cerebral artery stroke:- Presentation
Characterized by contralateral motor or sensory deficits, which are more pronounced in the lower limb than the upperlimb. Urinary incontinence can also be seen occassionaly.
What bone problems do immobilized patients have?
What’s the treatment?
With high bone turnover as seen in young people and Paget’s disease can have increased osteoclast activity leadingto hypercalcemia. Hydration and bisphosphonates are effective treatments.
Osteoarthritis 3 criteria
In the setting of knee pain: age >50; crepitus; bony enlargement, bony tenderness, and a lack of warmth/morning stiffness. If three criteria met specificity is 69%.
Statin medication recommendation:
Primary prevention in patients age 40-75 with a 10-year risk of atherosclerotic disease ≥7.5%.
Anticholinergic toxicity:
- Presentation
- Common causes
Classic findings are dry skin, dry mouth, constipation, urinary retention, flushing, vision change, and confusion. Often seen in the treatment of Parkinson disease due to treatment of EPS. Trihexyphenidyl and bromocriptine are common culprits.
Cushing syndrome:
High- dose dexamethasone does not suppress plasma cortisol levels in patients with ectopic ACTH syndrome.
Cushing’s Disease
ACTH-producing pituitary adenoma. Partially inhibited by high- dose dexamethasone.
Potassium sparing diuretics:
triamterene and amiloride
Ascites treatment
1. Sodium and water restriction. 2. Spironolactone. 3. Loop diuretics (not more than 1L/day of diuresis) 4. Frequent abdominal paracentesis (2-4 L/day, as long as the renal function is okay)
“Fight bite”:
Clenched fist injury to hand from person fist hits opponents teeth. Treatment of choice for prophylaxis is amoxicillin-clavulanate since infection is usually polymicrobial. Also used for dog bites.
Stress test for CAD:
Beta blockers, calcium channel blockers, and nitrates are antianginal agents that are healed 48 before performing a
cardiac stress test.
Systemic lupus erythematosus (SLE) vs. preeclampsia
Hypertension in a pregnant female in the setting of massive proteinuria, malar rash, and a strongly positive ANA titer is most likely due to SLE. Glomerulonephritis in general will cause proteinuria, hematuria, and RBC casts. Not to be confused with what occurs in preeclampsia.
Waldenstrom’s macroglobulinemia:
- Blood viscosity
- Associated Ig
- Diagnosis
Characterized by hyperviscosity of blood owing to the excess production of IgM. Two important diagnostic clues: 1. An IgM spike on electrophoresis 2. hyperviscosity.
Multiple myeloma:
- Blood viscosity
- Associated Ig
Immunoglobulins are usually IgG or IgA. No hyperviscosity.
Medications that cause cholestasis:
chlorpromazine, nitrofurantoin, erythromycin, anabolic steroids
Medications that cause fatty liver:
tetracycline, valproate, and antiretrovirals
Medications that cause hepatitis:
halothane, phenytoin, isoniazid, and alpha-methyldopa
Medications that cause toxic or fulminant liver failure:
carbon tetrachloride and acetaminophen
Medications that cause granulomatous liver:
allopurinol and phenylbutazone
Molluscum contagiosum:
- Etiology
- Epidemiology
Caused by Pox virus. Commonly seen in patient who have CELLULAR IMMUNODEFICIENCY such as HIV and patients on corticosteroids or chemotherapy.
Homocystinuria:
- Genetics
- Presentation
MARFANOID BODY HABITUS that is autosomal recessive. INTELLECTUAL DISABILITY, FAIR complexion, CEREBROVASCULAR ACCIDENTS, megaloblastic anemia, and thrombosis.
Fabry disease (α-galactosidase deficiency):
- Triad presentation
- Complication
Characterized by angiokeratomas, peripheral neuropathy, and asymptomatic corneal dystrophy. At risk for thromboembolic event.
Krabbe disease:
- Genetics
- Pathogenesis
- Presentation
Autosomal recessive lysosomal storage disorder caused by galactocerebrosidase deficiency. Clinical features
intellectual disability, blindness, deafness, paralysis, neuropathy, and seizures.
Phenylketonuria:
- Etiology
- Pathogenesis
- Presentation
Inborn error of metabolism that results from a deficiency of phenylalanine hydroxylase. Clinical features intellectual disability, fair complexion, eczema, and a musty body odor.
Tay-Sachs disease:
- Etiology
- Pathogenesis
- Presentation
Autosomal recessive gangliosidosis caused by a deficiency of β-hexosaminidase A. Clinical features intellectual disability, weakness, seizures, and presence of a cherry- red macula on examination.
Gestational diabetes mellitus:
- Screening done when?
- Target glucose levels @ 1 and 2 hours
- First line treatment
- Second line treatment
Screen weeks 24-28. Target blood glucose levels: Fasting ≤95 mg/dL; 1-hour postprandial ≤140 mg/dL; 2-hour postprandial ≤120 mg/dL. First line treatment: dietary modification; Second line treatment: Insulin, oral agents (metformin, glyburide)
Gestational diabetes mellitus newborn risks
Polycythemia (hct >65%), hyperviscosity, organomegaly, macrosomia, hypoglycemia
Panic disorder:
- Comorbidities
- Treatment
Comorbidities include MAJOR DEPRESSION, agoraphobia, bipolar disorder, and substance abuse. Higher rates of suicide attempts. Tx: SSRI
Fibromuscular dysplasia:
- Pathology
- Presentation
Noninflammatory and nonsclerotic condition primarily effectting renal arteries causing hypertension. Can affect carotid and vertebral with TIA like symptoms. Can hear carotid bruit.
Acute decompensated heart failure (ADHF):
- Presentation
- Treatment
Presents with acute pulmonary edema. Tx: Oxygen, assisted ventilation, aggressive intravenous diuresis (furosemide), and possible vasodilator therapy.
Unilateral cervical lymphadenitis:
- Epidemiology
- Etiology
- Treatment
Acute, unilateral cervical adenitis in children is typically caused by streptococcal or staphylococcal infection. The treatment consists of clindamycin plus incision and drainage.
Torsades de pointes (TdP):
- Define
- Treatment
Polymorphic ventricular tachycardia that occurs in the setting of congenital or acquired prolonged QT interval. Tx: Immediate defibrillation is indicated in hemodynamically unstable patients with TdP, while intravenous magnesium is the first-line therapy for stable patients with recurrent episodes of TdP.
Acute type A aortic dissection:
- Diagnosis
- Treatment
Must get a TEE, so you can rapidly diagnose and treat. Surgical emergency!
Single photon emission CT scan:
Tool to evaluate CAD and indicates inducible ischemia when a reversible defect is noted on stress and rest.
Antiplatelet therapy, beta blockers, and life style modification.
Insulinoma:
Beta cell tumor: elevated levels of insulin, c-peptide, and proinsulin.
Parapneumonic effusions:
When the pH of the pleural fluid is less than 7.2, the probability is very high that this is an empyema and must be drained.
Metronidazole:
Should not drink alcohol because of disulfiram-like reaction.
Somatic symptom disorder:
Involve one or more somatic complaints (including pain) that are distressing or result in significant disruption of life, with excessive thoughts, feelings, or behaviors related to these symptoms and lasting ≥6 months.
Vitamin D Toxicity
- Etiology
- Presentation
Toxicity mainly due to hypercalcemia and includes constipation, abdominal pain, polyuria, and polydipsia.
Pneumonia pathophysiology oxygen exchange:
Hypoxia in pneumonia causes areas of V/Q mismatch that manifests as increase in the alveolar-arterial oxygen gradient.
Daughters of women who took diethylstilbestrol during pregnancy:
- Risks
- Pathology
Increased risk of developing CLEAR CELL ADENOCARCINOMA of the vagina and cervix. Daughters and sons with in utero exposure also have structural anomalies of the reproductive tract (HOODED CERVIX, T-shaped uterus, small uterine cavity, vaginal septae, vaginal adenosis)
Labor pre eclampsia magnesium sulphate treatment:
Depression of the deep tendon reflexes is the earliest sign of magnesium sulfate toxicity. STOP the MAGNESIUM SULPHATE infusion and administration of CALCIUM GLUCONATE.
HIV patient with Pneumocystis pneumonia (PCP):
Trimehoprim-sulfamethoxazole (TMP-SMX) is drug of choice. Corticosteroids decrease mortality in severe PCP
infections and should be given if PaO2 ≤70 mmHG or A-a gradient ≥35 mmHg on room air.
Hematuria suggests on timing during stream:
Initial hematuria suggests urethral damage. Terminal hematuria indicates bladder or prostatic damage, and total
hematuria reflects damage in the kidney or ureters. Clots are not usually seen with renal causes of hematuria.
Congenital diaphragmatic hernia management:
Newborn with concave abdomen and barrel shaped chest with absent breath sounds on one side needs emergency
intubation with cautious ventilations
Chronic hepatitis C asymptomatic presentation and extrahepatic sequelae:
Presents with fatigue and nonspecific symptoms. Patients transaminases wax and wane. Extrahepatic sequelae can
include essential mixed cryoglobulinemia, porphyria cutanea tarda, and membranoproliferative glomerulonephritis.
HIV ophthalmologic problems:
In HIV patients, both HSV and VZV can cause severe,acute retinal necrosis associated with pain, keratitis, uveitis, and fundoscopic findings of peripheral pale lesions and central retinal necrosis. CMV retinitis is painless.
Cerebellar hemorrhage:
Patients typically have headache, neck stiffness, gait ataxia, and no hemiparesis
Putamen hemorragia:
Most common cause is hypertension. Next to internal capsule, so leads to hemiparesis.
Pontine hemorragia:
Coma due to disruption of reticular activating system, and quadriplegia that develops within a few minutes.
Pinpoint pupils, but may react strongly to light with no horizontal movement. Decerebrate rigidity.
Adrenal tuberculosis:
Patient who presents with clinical features of adrenal insufficiency and calcifications in the adrenal glands.
Diabetic neuropathy:
Presents with alterations in sensation, including loss of proprioception. When motor findings are present and patient has hyperactive reflexes and an upgoing plantar reflex (UMN) you need to get an MRI of spine for epidural abscess or cord compression.
Tea and toast diet is associated with what:
Folic acid deficiency. Folic acid is heat sensitive and deficiency cause macrocytic anemia.
Thalamic stroke (Dejerine-Roussy syndrome):
Caused by a stroke involving the VPL nucleus of the thalamus, which transmits sensory information from the
contralateral side of the body. Classically presents with contralateral hemianesthesia that can be accompanied by
transient hemiparesis, athetosis, or ballistic movements.
Midbrain and medulla strokes have in common:
Classically involve the nuclei of the cranial nerves.
Schizoaffective disorder:
Characterized by a significant mood episode (depressive or manic) with concurrent psychotic symptoms in addition to a period of psychosis without mood symptoms of at least 2 weeks.
Chloroquine resistant Plasmodium falciparum:
Common in Sub-Saharan Africa, the Amazon basin, and Southern and Southeast Asia. Tx chemoprophylaxis is
mefloquine, atovaquone-proguanil.
Hyperemesis gravidarum:
Patients with multifetal gestation or molar pregnancy are at increased risk for hyperemesis gravidarum therefore an
ultrasound should be performed in pregnant women with severe vomiting.
Autosomal dominant polycystic kidney disease (ADPKD):
Clues to diagnosis: hypertension, palpable bilateral abdominal masses and microhematuria. Remember intracranial berry aneurysm is a common complication. No screening recommended.
Obstructive uropathy:
Causes flank pain, low volume voids with or without occasional high volume voids, and if bilateral renal dysfunction.
Interstitial nephritis:
Most frequently occurs as a drug reaction. Patient present with fever, rash, acute renal dysfunction, and eosinophiluria with white blood cell casts.
Glomerulonephritis:
Presents with hematuria, red blood cell casts, acute renal failure, hypertension, and edema.
Chagas disease (Trypanosoma cruzi):
Primarily affects the heart (cardiomyopathy, RBBB) and gastrointestinal tract (megacolon, megaesophagus). First line treatment Benznidazole.
Strongyloidiasis:
Presents with urticaria, abdominal pain, and respiratory problems (dry cough, dyspnea, wheezing). First line treatment ivermectin.
Onchocerciasis (“river blindness”)
Causes ocular lesions and dermatitis. Treatment is ivermectin.
Empyema
Most commonly occurs in the setting of untreated pneumonia due to bacterial seeding of a pleural effusion. Most common bacteria are Streptococcus pneumoniae, Staphylococcus Aureus, and Klebsiella pneumonia.
Management of placenta previa:
Depends on the severity of bleeding and the age of the pregnancy. Complete placenta previa requires delivery by cesarean section. If mother and baby are stable SCHEDULED cesarian section.
By age 12 months height and weight and developmental:
Weight should TRIPLE and height should INCREASE 50%. Walking independently, using a 2-finger pincer grasp, saying a few words other than “mama” and “dada” and imitating the actions of others.
By age 9 months developmental milestones: gross motor; fine motor; language; social/cognitive.
Pulls to stand and cruises; 3-finger grasp and holds bottle or cup; Says “mama” and “dada”; Waves “bye” and plays
pat-a-cake
By age 6 months developmental milestones: gross motor; fine motor; language; social/cognitive.
Sits momentarily propped on hands (unsupported by 7 months); Transfers objects hand to hand and raking grasp;
Responds to name and babbles; Stranger anxiety.
By age 4 months developmental milestones: gross motor; fine motor; language; social/cognitive.
Sits with trunk support and begins to rolling; Hands mostly open and reaches midline; Laughs and turns to voice;
Enjoys looking around
By age 2 months developmental milestones: gross motor; fine motor; language; social/cognitive.
Lifts head/chest inprone position; Hands unfisted 50% of time, tracks pasat midline; Alerts to voice/sound and coos;
Social smile and recognizes parents.
Rheumatoid arthritis at increased risk for:
Developing osteopenia, osteoporosis, and bone fracture. Management adequate physical activity, optimization of calcium and vitamin D intake, minimization of corticosteroid therapy, and consideration for bisphosphonate treatment.
Acute liver failure:
Most often due to acute viral hepatitis, ACETAMINOPHEN TOXICITY, and ischemic hepatopathy. Characteristic findings include the acute onset of markedly elevated transaminases ( often in the thousands), reduced hepatic synthetic function, and encephalopathy.
Galactosemia characteristics and metabolic disorder:
Newborn or young infant with failure to thrive, bilateral cataracts, jaundice, and hypoglycemia. GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE DEFICIENCY leads to ELEVATED BLOOD GALACTOSE.
Galactokinase deficiency:
Presents with cataracts only, otherwise asymptomatic.
Circumstantiality:
Thought process deviate from original subject but eventually return to it.
Tangentiality:
Thought process in which there is abrupt, permanent deviation from the current subject. This new thought process is minimally relevant at best and never returns to the original subject.
Loose association:
Best described as the lack of a logical connection between the thoughts or ideas of an individual. It tends to be more severe form of tangentiality in which one statement follows another but there is no clear association between the sentences.
Preservation
Repetition of words or ideas during a conversation.
Flight of ideas:
Loosely associated thoughts that rapidly move from topic to topic.
Contact lens-associated infectious keratitis:
Medical emergency: causes painful, red eye and opacification and ulceration of the cornea. Most case are due to Gram-negative organisms such as Pseudomonas and Serratia, but can be from gram-positive, fungi, and amoebas. Tx with topical broad spectrum antibiotics.
Pneumoperitoneum
Radiograph reveals intraperitoneal air between the liver and diaphragm. This is surgical emergency.
Secondary pneumothorax:
Should be suspected in COPD patients presenting with catastrophic worsening of their respiratory symptoms and is
usually due to dilated alveolar blebs that rupture air into the pleural space.
Patient with metabolic acidosis:
Calculate the anion gap: AG = Na - (HCO3 + Cl)
KARMEL: K — Ketoacidosis; A — aspirin; R — Renal failure; M — Methanol; E — Ethylene glycol; L — Lactic
acidosis
Multiple myeloma:
An elderly patient with bone pain, renal failure, and hypercalcemia. Renal insufficiency most likely due to obstruction of the distal and collecting tubules by large laminated casts containing PARAPROTEINS (mainly Bence Jones protein).
External cephalic version:
Can be attempted in women with breech pregnancies at ≥37 weeks gestational age if there are no contraindications to vaginal delivery, and fetal well-being has been established.
Chronic myeloid leukemia (CML):
Reciprocal translocation of chromosome 9 and 33 can form the Philadelphia chromosome containing BCR/ABL fusion gene. Tyrosine kinase inhibitors are key treatments. Non-receptor tyrosine kinase.
Acute promyelocytic leukemia (APML):
Retinoic acid receptor is involved. Tx: All-retinoic acid.
Neonatal bilious emesis:
Signifies bowel obstruction and requires immediate X-ray to evaluate the need for emergency surgery or further
diagnostic study. Contrast studies (enema) should be performed in stable patients to determine the level of
obstruction.
Mullerian agenesis:
Phenotypically and genotypically female. They experience breast development and body hair growth at puberty but
do not menstruate due to a congenitally absent or underdeveloped uterus, cervix, and upper vaginia.
Biliary atresia:
Newborns with CONJUGATED hyperbilirubinemia and hepatosplenomegaly require immediate evaluation for biliary atresia. Evaluated with ultrasound.
HIV medication didanosine:
Induced pancreatitis
HIV medication abacavir:
related hypersensitivity syndrome.
HIV medication nevirapine:
associated liver failure.
HIV medication NRTIs:
lactic acidosis
HIV medication NNRTIs:
Steven-Johnson syndrome.
Solitary brain metastasis:
Surgical resection is recommended in patients with good performance status and stable extracranial disease In
patients with multiple metastases, whole brain radiation therapy is typically used.
Factitious thyrotoxicosis:
Results from ingestion of exogenous thyroid hormone. Signs and symptoms of thyrotoxicosis without goiter or
exophthalmos. TSH low; elevated T3/T4. Radioactive iodine uptake is low in these patients. Diagnosis is made by
low serum thyroglobulin levels.
Clavicular fracture:
If a bruit is heard need an angiogram to rule out injury to the underlying vessel.
Pseudogout:
Diagnosed by the presence of rhomboid, positively birefringent crystals in synovial fluid analysis, and radiographic evidence of chondrocalcinosis.
Gout:
Monosodium urate crystal deposition. Crystals are needle shaped and negatively birefringent on synovial fluid
analysis.
Most common crystal found in renal calculi:
Calcium oxalate
Struvite
Magnesium ammonium phosphate may be found in the renal calculi of patients with UTI caused by urease-producing organisms (Klebsiella, Proteus).
Opioid withdrawal
Tx: Inpatients should be treated with methadone if they are being treated for another medical problem other than
addiction.
Benzodiazepine overdose difference from opioids:
During benzodiazepine intoxication, pupil size tends to be normal, with only mild respiratory depression.
Sustained monomorphic ventricular tachycardia (SMVT):
Hemodynamically unstable electrical cardioversion. Hemodynamically stable give amiodarone.
Prior to starting lithium:
Calcium, renal function, and thyroid function should be monitored.
Autoimmune hemolytic anemia (AIHA):
Positive direct Coomb’s test.
Aminoglycosides:
Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are potentially nephrotoxic and renal functions must be monitored closely. AMIKACIN.
Emergency contraception:
The copper intrauterine device is the most effective precoital and postcoital contraceptive, with up to 99% efficacy. OCPs are less effective.
Cardiac tamponade:
Catastrophic complication of acute aortic dissection. Suspected in patients with hypotension, tachycardia, distended neck veins, and pulsus paradoxus.
Patients with narrow-QRS-complex tachycardia:
Intravenous adenosine is useful in the initial diagnosis and management. It slows the sinus rate, increases
atrioventricular (AV) nodal conduction delay, or can cause a transient block in AV node conduction. Good for
identifying P waves. Terminates PSVT sometimes.
Association between diabetes mellitus with nose and sinus infections with what organism:
mucormycosis (Rhizopus species).
Increased extracellular pH (respiratory alkalosis) causes dissociation:
Of hydrogen ions from albumin, allowing increased binding of calcium and a drop in unbound (ionised calcium. Ionized calcium is the physiologically active form, and decreased levels can result in clinical manifestations of hypoglycemia.
Delusional disorder:
Involves one or more delusions and the absence of other psychotic symptoms in an otherwise high functioning
individual.
Babesiosis disease:
Caused by parasite Babesia and is transmitted by Ixodes tick. Evidence of hemolysis in a patient who was
splenectomised highly suspicious. Diagnosed Giemsa-stained thick and thin blood smear.
Hypertension in overweight people:
Weight lose is the most effective nonpharmacologic measure to decrease blood pressure in overweight individuals.
Glomerular hematuria characteristics:
Urine studies reveal proteinuria, dysmorphic red blood cells (RBCs) or RBC cast.
Nonglomerular hematuria characteristics:
More common. Gross hematuria with normal-appearing red blood cells (RBCs) but without significant proteinuria.
Adrenal insufficiency due to hypopituitarism:
Not associated with hypoaldosteronism. Aldosterone is independent of ACTH secretion by pituitary gland.
Persistent pneumothorax after patient has sustained blunt chest trauma:
Suggests tracheobronchial rupture. Findings include pneumomediastinum and subcutaneous emphysema.
Mechanism of pain relief in patient with chest pain treated with nitroglycerin:
Dilation of veins (capacitance vessels) which leads to decrease ventricular preload.
Immediate postpartum period what is normal:
Low-grade fever, leukocytosis especially first 24 hours and vaginal discharge are normal findings. The vaginal
discharge (lochia) is initially bloody, then serous and finally white to yellow in color days following delivery.
When lochia is foul smelling and/or uterus is tender:
Start empiric antibiotics.
Urine chloride level:
＜20mEq/L (saline responsive)
＞20mEq/L (saline resistant)
Erythema Nodosum (EN) characteristics and found in what diseases:
Condition of painful, subcutaneous, pretibial nodules. Symptom of more serious diseases including sarcoidosis (get chest x ray especially in AAF), TB, histoplasmosis, recent streptococcal infection, and IBD.
Incomplete abortion findings and unstable vs stable:
Vaginal bleeding, a dilated cervical os, and partial expulsion of products of conception. Hemodynamically unstable: Surgical evacuation (D & C). Hemodynamically stable: Expectant management, prostaglandins (misoprostol), or surgical.
Threatened abortion characteristics:
Vaginal bleeding, closed os, and fetal cardiac activity.
Missed abortion:
No vaginal bleeding, closed cervical os, no fetal cardiac activity or empty sac.
Inevitable abortion:
Vaginal bleeding, dilated os, products of conception may be seen or felt at or above cervical os.
Complete abortion:
Veginal bleeding or none, closed cervical os, and products of conception completely expelled.
Most common complication in post thyroidectomy:
Hypoparathyroidism caused by the removal of 3 ½ parathyroid glands causes low PTH with resultant hypocalcemia and elevated phosphorus levels.
Lumbar spinal stenosis:
Common cause of back pain in patients over 60 years of age. Characterized by back pain radiating to the buttocks
and thighs that interferes with walking and lumbar extension.
Seronegative spondylarthritis (ankylosing spondylitis):
Characterized by progressive limitation of back motion and most often occurs in young men. Back pain and stiffness are typically worst in the morning and improves as day progresses.
Acute arterial occlusion (limb ischemia):
Classically presents with “5 Ps” (pain, pallor, pulselessness, paresthesia, and paralysis). Immediate anticoagulation and referral for vascular surgery.
Mallory-Weiss syndrome:
Tears occur in the distal esophagus at the gastroesophageal junction after repeated bouts of retching and vomiting. Do not confuse with Acute erosive gastritis from severe hemorrhagic erosive lesions of the gastric mucosa.
Cat bite treatment:
Wounds can be infected with Pasteurella multocida, so prophylactic treatment with 5 day course of amoxicillin/clavulanate.
Fanconi Anemia etiology and characteristics:
Autosomal recessive or X-linked disorder of chromosomal breaks usually diagnosed before age 16. Causes congenital marrow failure, with short stature, microcephaly, abnormal thumbs, and hypogonadism. Skin can be hypopigmentes or hyperpigmented, cafe au lait spots, and large freckles. Strabismus, low set ears, chronic, ear infections.
Mitral stenosis characteristics:
Causes pulmonary congestion which leads to symptoms such as exertional dyspnea, nocturnal cough, and
hemoptysis. Atrial fibrillation occurs due to atrial dilation. Especially common in patients who had rheumatic fever.
Variant angina (Prinzmetal’s angina):
Causes chest pain by coronary vasospasm. Treatment is calcium channel blocker. Nonselective β-blockers and
aspirin should be avoided because they can promote vasoconstriction.
ABO incompatibility:
Occurs generally in a group O mother with a group A or B baby. Less severe than Rh(D) incompatibility.
Chronic cough that worsens at night and does not improve with antihistamines:
Possible asthma must check PFTs.
Factorial design study:
Involve randomization to different interventions with additional study of 2 or more variables.
Symptomatic pulmonary embolism most common cause:
The proximal deep veins (iliac, femoral and politeal veins) are the source of ＞90% of acute PEs.
Meniscal tear compared to ligament tear:
Both case the patient feels a popping sensation during an acute event, but the swelling that occurs with meniscal tear until 12 to 24 hours. Ligament tears swell almost immediately
Correlation coefficient (r):
Shows the strength and direction (positive, negative) of linear association between 2 variables. It does not imply
causality. An r=-0.25 for HDL to carotid intima thickness would mean they are inversely proportional.
In postmenopausal women the initial work up of an adnexal mass: What is contraindicated:
Should include transvaginal ultrasonography and a serum cancer antigen (CA)125 level which has good sensitivity
and specificity for malignant adnexal mass. Needle aspiration for cytology is contraindicated due to possible cancer spread.
First-trimester maternal-fetal transmission of the rubella virus:
Teratogenic. Congenital rubella syndrome is characterized by the triad of cataracts, patent ductus arteriosus, and snesoneural hearing loss. Prevent by MATERNAL VACCINATION before conception. Must have IgM and IgG to know if current infection or previous immunity.
Stab wounds near artery veins can cause:
Arteriovenous fistulas (AVF) which can lead to high-output cardiac failure by shunting the blood from the arterial to venous side, thereby increasing cardiac preload. Hypoxia of tissues drives this. Doppler ultrasound to diagnose.
Paroxysmal supraventricular tachycardia (PSVT) characterized by:
Heart rates between 160-220 beats per minute. Results from accessory conduction pathways through the AV node. Vagal maneuvers and medication (adenosine) that decrease conduction through the AV node often revolve the PSVT.
Glucose-6-phosphatase deficiency(Type I glycogen storage disease & Von-Gierke’s disease):Characteristics
Appearance is a doll-like face (fat cheeks), thin extremities, short stature, and protuberant abdomen (due to enlarged liver and kidneys) in a 3-4 month old. Hypoglycemic seizures may occur.
Developmental milestones toddlerhood 12 months: Gross Motor; Fine motor; Language; Social/Cognitive.
Stands well, walks first steps independently throws ball; 2-finger pincer grasp; Says first words (other than “mama” & ”dada”); Separation anxiety, follows 1-step command with gestures
Developmental milestones toddlerhood 18 months: Gross Motor; Fine motor; Language; Social/Cognitive.
Runs, kicks ball; builds tower of 2-4 cubes, removes clothing; 10-25 word vocabulary, identifies ≥1 body part;
Understands “mine”, begins pretend play.
Developmental milestones toddlerhood 2 years: Gross Motor; Fine motor; Language; Social/Cognitive.
Walks up/down stairs with both feet on each step, jumps; Builds 6-cube tower, copies a line, turns pages; 50+ word
vocabulary, 2-word phrases; Follows 2-step command, parallel play, begins toilet training.
Developmental milestones toddlerhood 3 years: Gross Motor; Fine motor; Language; Social/Cognitive.
Walks up/down stairs with alternating feet, rides tricycle; copies a circle, uses utensils; 3-word sentences, speech 75% intelligible; Knows age/gender, imaginary play.
Developmental milestones toddlerhood 4 years: Gross Motor; Fine motor; Language; Social/Cognitive.
Balance & hops on 1 foot; Copies a square; Identifies colors, speech 100% intelligible; Cooperative play.
Developmental milestones toddlerhood 5 years: Gross Motor; Fine motor; Language; Social/Cognitive.
Skips, walks backward; Copies a triangle, ties shoelaces, independent dressing/bathing, prints letters; Counts to 10,
5-word sentences; Has friends, complete toilet-training.
Guillain-Barre syndrome CSF findings:
Protein elevated (45-1000) albuminocytologic dissociation; WBC normal; RBC normal; Glucose normal.
Prolactin production is stimulated by:
Serotonin and TRH, and inhibited by dopamine. Hypothyroidism may result in amenorrhea and galactorrhea.
Prolactin inhibits GnRH release thus decreasing FSH and LH.
Hashimoto’s thyroiditis are at increased risk for what cancer:
Lymphoma of the thyroid. anti-thyroperoxidase (TPO) antibodies.
Thyroid cancers of epithelial origin include: which one is C-cell origin:
Follicular, papillary and anaplastic; C-cell origin is medullary.
Management of hypercalcemia Severe: Important effects on body:
Severe (calcium ＞14mg/dL) or symptomatic: Short term (immediate treatment) Normal saline hydration plus
calcitonin. Long-term treatment bisphosphonates (zoledronic acid). Remember hypercalcemia induces urinary salt wasting, which results in significant volume depletion.
Massive postoperative pulmonary embolism (PE): Typical presentation:
Patient with hypotension, jugular venous distension, and new-onset right bundle branch block (RBBB)
Treatment of stable chronic angina:
First line therapy Beta blocker: Metoprolol, decreases myocardial contractility & HR. Improves survival.
Calcium channel blockers can be added if angina persists. Causes peripheral & coronary vasodilation.
Nitrates, Aspirin, Statin, lifestyle.
Patients with persistent tachyarrhythmia (narrow or wide-complex) causing hemodynamic instability
managed:
Immediate synchronized DC cardioversion. Stable patients get vagal maneuvers (carotid sinus massage) and/or
adenosine.
Vipoma is a rare tumor affecting: Describe VIPoma syndrome: Diagnosis:
The pancreatic cells that produce vasoactive peptide (VIP). VIPoma syndrome (pancreatic cholera) with watery
diarrhea, muscle weakness/cramps (due to hypokalemia), and hypo- or achlorhydria (due to decreased gastric acid
secretion). Stool studies show secretory diarrhea, VIP levels are ＞75pg/mL confirms.
Which of the three main treatments for Graves disease worsens eye disease initially:
Radioactive iodine (RAI) due to thyroid cell death and release of excess thyroid hormone.
Hemineglect syndrome is characterized by:
Ignoring the left side of a space, and involves the right (non-dominant) parietal lobe.
McCune-Albright syndrome:
Rare condition characterized by precocious puberty, cafe au lait spots and multiple bone defects (polyostotic fibrous
dysplasia). Can have other endocrine disorders.
Post-splenectomy patients are at increased risk for sepsis from:
Encapsulated organisms due to impaired antibody-mediated opsonization in phagocytosis. S. pneumoniae, N. meningitidis, and H. influenzae.
Restless legs syndrome (RLS): Treatment and mechanism.
First line: Dopamine agonist (pramipexole, ropinirole)
Alternative: Alpha-2-delta calcium channel ligands (gabapentin)
In the treatment of a patient using both sildenafil and an alpha-blocker (doxazosin):
It is important to give the drugs with at least a 4-hour interval to reduce the risk of hypotension.
Tricyclic antidepressant overdose: Treatment: Mechanism:
Can present with CNS, cardiac, and anticholinergic findings. Sodium bicarbonate is used to treat cardaic toxicity (QRS＞100msec and ventricular arrhythmias). Sodium bicarbonate increases serum pH and extracellular sodium, therby alleviating the cardio-depressant action on sodium channels.
First degree AV block:
With normal QRS duration delay at AV node and require no further evaluation. Prolonged QRS duration likely have a conduction delay below the AV node and should have electrophysiology testing.
Sickle cell kid with sepsis most common species:
S. pneumoniae, H. influenzae.
Acute cholecystitis primary inciting event:
A gallstone obstructing the cystic duct with subsequent inflammation and infection.
Hypertensive intracranial hemorrhages occur most commonly:
In the basal ganglia, thalamus, pons, and cerebellum. Evolves over minutes to hours with focal neurologic symptoms compared to subarachnoid hemorrhages complain of severe HA do not have focal deficits.
Gastric outlet obstruction can be caused by ingestion:
Of acid (caustic substance) causes pyloric strictures to form. This presents as early satiety, nausea, nonbilious, vomiting and weight lose.
Herpetic whitlow:
Common viral infection of the hand by HSV 1 or 2 and is self limiting. Healthcare workers especially dentist are at risk for it. Remember multinucleated giant cells in the Tzanck smear confirms diagnosis.
The most common cause of sudden cardiac arrest in the immediate postinfarction period in patients with
acute MI:
Reentrant ventricular arrhythmias (ventricular fibrillation).
Hypokalemia signs and ECG findings:
Causes weakness, fatigue, and muscle cramps. ECG may show U wave, flat and broad T waves, and premature
ventricular beats.
Epidural spinal cord compression initial management:
Intravenous glucocorticoids (decreases vasogenic edema) and MRI.
Amaurosis fugax:
Characterized by visual loss that is transient and usually monocular. “Curtain falling down.” Most common cause
RETINAL EMBOLI from the CAROTID ARTERY.
Most common causes of viral meningitis are the:
Non-polio enteroviruses, such as echoviruses and coxsackie viruses.
Aspirin intoxication triad and typical blood gas analysis:
Triad of fever, tinnitus, and tachypnea (stimulates respiratory center in the medulla). Adults with aspirin toxicity develop a mixed respiratory alkalosis and anion gap metabolic acidosis. pH 7.39; PaCO2 20; HCO3 12.
Normal pH in acid base disturbance signifies:
A mixed respiratory and metabolic acid-base disorder.
Lithium exposure in the first trimester:
Increases the risk of cardiac malformations including septal defects and possibly Ebstein’s anomaly
Lithium exposure during the second and third trimester:
May cause goiter and transient neuromuscular dysfunction.
Mammograms should be performed every:
2 years starting at age 50 in women till age 74 at average risk for breast cancer. Not recommended after 75.
Thyrotoxic myopathy can present with:
Proximal muscle weakness with or without muscle atrophy can occur in 60-80% of patients with untreated
hyperthyroidism and correlates to the duration of the hyperthyroid state.
Myasthenia Gravis (MG) presentation and comorbid disease:
Fatigable muscle weakness that primarily involves the extraocular and bulbar musculature is the most consistent
with MG. Approximately 15% have a Thymoma, so screening with a chest CT recommended.
Dermatomyositis mechanism and presentation:
Idiopathic inflammatory myopathy with immune mediated muscle injury that can be due to paraneoplastic syndrome in malignancy. Patient typically have symmetrical proximal muscle weakness and erythematous rash over the dorsum of the fingers (Gottron’s sign) and/or upper eyelids (heliotrope eruption).
Lambert-Eaton key findings on PE:
DIMINISHED or ABSENT DEEP TENDON REFLEXES. Proximal muscle weakness, autonomic dysfunction (dry mouth).
Sarcoidosis can have elevated serum:
Angiotensin converting enzyme (ACE) levels.
Syndrome of inappropriate antidiuretic hormone secretion: What do lab values show and what is treatment?
Low plasma osmolarity especially Na (hyponatremia) with an inappropriately elevated urine osmolality and urine sodium concentration.
Acute cholecystitis management:
May be treated with observation and supportive care initially, followed by laparoscopic cholecystectomy within 72 hours during same hospitalization.
Distinguishing between dementia and normal changes of aging:
Impairment of daily functioning is seen in dementia.
Premature ovarian failure characterized by and treated with:
Amenorrhea, hypoestrogenism, and elevated gonadotropins (increased serum FSH & LH). Patients lack oocytes. Infertility is treated with in vitro fertilization with donor oocytes for women who desire pregnancy.
Laxative abuse is characterized by:
Frequent, watery, nocturnal diarrhea. Diagnoses can be confirmed with characteristic biopsy of dark brown
discoloration of the colon with lymph follicles shining though pale patches (melanosis coli).
Chorioamnionitis Treatment:
Intravenous broad spectrum antibiotics (ampicillin, gentamicin, clindamycin). Oxytocin to accelerate labor. This is not a reason for cesarean delivery.
Standard obstetric indications for cesarean delivery:
Fetal distress, breech presentation, multiple prior cesarean deliveries.
Hyperosmolar hyperglycemic state: Etiology: Symptoms:
Type 2 diabetics are prone to the development of a hyperosmolar hyperglycemic state without ketoacidosis.
Decreased consciousness is the most common symptom, and other neurologic abnormalities such as blurred vision.
Breath holding spells are episodes: What should they be evaluated for:
Of apnea that are precipitated by frustration, anger, or pain. Age 6 months-2 years. Patients should be evaluated for iron deficiency anemia. CBC
CMV retinitis treatment:
Ganciclovir or foscarnet
Attributable risk percent (ARP) formula:
ARP =(RR-1)/RR
RR = Relative Risk
Digitalis toxicity causes what type of arrhythmia:
Leads to ectopy and increased vagal tone. Atrial tachycardia with AV block occurs from combination of these two digitalis effects and is relatively specific for digitalis.
Systemic and topical corticosteroids can induce: Skin finding:
An acneiform eruption characterized by monomorphous, erythematous follicular papules distributed on the face, trunk and extremities. Comedones are characteristically absent.
Hazard ratio (HR) interpretation:
A hazard ratio ＜1 indicates that an event is more likely to occur in the control group
A hazard ration ＞1 signifies that an event is more likely to occur in the treatment group.
A ratio close to 1 implies little difference between the 2 groups.
Mobitz Type I vs Mobitz Type II:
Mobitz Type I: Atrioventricular block has PROGRESSIVE PROLONGATION of PR interval leading to a NON-CONDUCTED P WAVE and a dropped QRS complex. Problem is conduction in the AV node.
Mobitz Type II: PR interval is always CONSTANT with no progressive prolongation and ((QRS complex drops suddenly)). Due to a block in the His-Purkinje system below AV node. Can lead to third degree block.
Adults who have frequent contact with children (school teacher, daycare worker) disease risk:
Parvovirus can cause an acute symmetric arthritis of the hands (MCP, PIP, and wrist), knees, and ankle joints. Onset is 10 days unlike RA symptoms 6 weeks. Morning stiffness 1 hour RA, and only 10-15 minutes Parvo .
Atrial fibrillation (AF) with rapid ventricular response (RVR): Treatment:
Rate control should be attempted initially with beta blockers or calcium channel blockers. Immediate synchronised electrical cardioversion is indicated in hemodynamically unstable patients.
The patient’s pulsatile abdominal mass is most likely: Test:
An abdominal aortic aneurysm (AAA). Abdominal ultrasound is the study of choice for diagnosis.
All patient with chronic hepatitis C infection should get: This includes:
Immunized against A and B if they are not immune. Including pregnant women. Vaccines are inactivated (killed). Safe.
Hyperkalemia time to treat:
Initial evaluation is with ECG. Acute therapy is given for patients with ((ECG changes, potassium ≥7.0 mEq/L without characteristic ECG changes, or rapidly rising POTASSIUM due to tissue breakdown)).
Alpha-1 antitrypsin deficiency test positive for:
They stain with the periodic acid-Schiff (PAS) reaction and resist digestion to diastase.
Glucagonoma often presents with:
Nonspecific symptoms and require a high index of suspicion to make the diagnosis. Patients presenting with mild diabetes mellitus or hyperglycemia with NECROTIC MIGRATORY ERYTHEMA, diarrhea, anemia, and weight lose. Glucagon >500 pg/mL. Get abdominal imaging.
Stress incontinence is characterised by: Mechanism: Diagnosis: Treatment:
The loss of small amounts of urine with increased intra-abdominal pressure, as occurs with laughing, coughing, and sneezing. Urine leakage occurs from ineffective closure of urethral sphincter. Inserting cotton swab demonstrating angle >30° upon increase abdominal pressure. Kegel exercises and urethropexy.
Urge incontinence: Mechanism: Treatment:
Results from detrusor hyperactivity and is characterized by a sudden urge to urinate that may come at any time, not just increased intraabdominal pressure. Oxybutynin.
Cancer-related anorexia/cachexia syndrome: Treatment: What does not work:
Progesterone analogs (megestrol acetate and medroxyprogesterone acetate), and corticosteroids have been shown to increase appetite and weight gain in patients. Cannabinoids show no effect.
Friedreich Ataxia: Genetics
Autosomal recessive condition characterized by an excessive number of trinucleotide repeat sequences, resulting in a tocpherol transfer protein.
Lupus anticoagulant, an antiphospholipid antibody, is pro-thrombotic immunoglobulin that causes:
A spuriously (not genuine) prolonged partial thromboplastin time in vitro.
PVCs are common in patients post-myocardial infarction: Treatment:
Recognized by their widened QRS (>120 msec), bizarre morphology, and compensatory pause. Worse prognosis but no treatment unless symptomatic then Beta blocker.
Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should:
Be investigated using transthoracic doppler echocardiography. Midsystolic soft murmurs in asymptomatic young patient require no further work up.
Cor pulmonale: Define: Signs include: What is seen on right heart catheterization:
Impaired function of the right ventricle due to pulmonary hypertension that usually occurs due to chronic lung disease. Signs: Elevated JVP, right ventricle heart sound, tricuspid regurgitation murmur, pulsatile liver, LEE, ascites. Right heart catheterisation shows elevated pulmonary artery systolic pressure (>25 mmHg).
Hypothyroid myopathy:
With an unexplained elevation in serum creatine kinase concentration and myopathy. Presents with fatigue, myalgias, proximal muscle weakness, sluggish ankle reflexes. Check TSH and free T4.
Most likely diagnosis of an asymptomatic, immunocompetent adult patient with a non-healing, isolated ulcer in the vermillion zone of the lower lip and a significant history of sun exposure:
Squamous cell carcinoma: Biopsy shows invasive cords of squamous cells with keratin pearls.
Unilateral foot drop is characterized by: Common causes:
A “steppage” gait, exaggerated hip and knee flexion while walking. Common causes include L5 radiculopathy and compression peroneal neuropathy. L5 radiculopathy may also have weak foot inversion and plantar flexion.
Symmetric growth restriction:
Usually caused by fetal anomalies, abnormal fetal karyotype, and early MATERNAL VIRAL INFECTION. CMV most common and most women have no apparent symptoms.
Asymmetric growth restriction:
Generally appears later in the pregnancy and is caused by maternal vascular disease, including hypertension,
diabetes, and smoking.
Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS): Blood smear: Treatment:
Unexplained hemolytic anemia and thrombocytopenia in a patient with renal failure and neurologic symptoms.
Presence of fragmented cells in the peripheral smear suggest microangiopathic hemolytic anemia (MAHA).
Plasmapheresis. (ADAMTS-13)
Radioiodine therapy most common side effect:
Hypothyroidism is most common duh. Increased ophthalmopathy is second at 10%. corticosteroids before and after help.
Thyroid-stimulating hormone-secreting pituitary adenoma is characterized:
Central hyperthyroidism with elevated TSH (or inappropriately normal), T3, and T4. Patients have goiter due to TSH effects on tissue growth. VISUAL DISTURBANCES and HA from tumor growth.
Chronic gastrointestinal blood loss is the most common cause:
Iron-deficiency anemia in an adult male or a postmenopausal woman. Test for occult blood in the stool.
Osteoarthritis drug of choice for pain:
Acetaminophen because of proven efficacy and a favorable side effect profile.
Patient with abdominal pain, microcytic anemia, positive fecal occult blood, and hepatomegaly with a hard
edge on the liver palpation:
Typical features of gastrointestinal malignancy, like colon cancer, metastatic to the liver. Liver metastases manifests as right upper quadrant pain, mildly elevated liver enzymes, and firm hepatomegaly. Diagnose with CT abdomen.
Rheumatoid arthritis predisposes to:
Amyloidosis. you see renal involvement with nephrotic syndrome. Stain with Congo red and demonstrates apple-green birefringence under polarised light.
Chronic GERD and Barrett’s esophagus are at risk for:
Adenocarcinoma of the esophagus.
Beck-Wiedemann syndrome: Genetics: Characteristics: What
Dysregulation of imprinted gene expression in chromosome 11p15. Characterized by macrosomia, umbilical hernia/omphalocele, hemihyperplasia (asymmetric larger arm/leg), and hypoglycemia. Children must closely monitored for development of Wilms tumor or hepatoblastoma. GET ABDOMINAL ULTRASOUND.
What type of glomerular disease is found in African American, obesity, heroin use, and HIV:
Focal segmental glomerulosclerosis (FSGS).
Most common causes of nephrotic syndrome:
Focal segmental glomerulosclerosis (FSGS) and membranous nephropathy.
Patients with decreased fetal movement should undergo antenatal fetal testing starting with:
Nonstress test (NST), followed by a contraction stress test (CST) or biophysical profile if the NST is nonreactive. A CST can be performed if there is no contraindications to labor.
Umbilical artery doppler velocity: What is it used for:
Evaluation of umbilical artery flow in fetal intrauterine growth restriction only.
Biophysical profile: What are the five criteria:
Amniotic fluid level; Fetal breathing movement; Fetal movement; Fetal tone; Fetal heart rate. You get 2 points for each for total of 10. Abnormal 0, 2, and 4. Equivocal: 6 points.
A normal contraction stress test indicates that: When should you repeat antepartum test:
Fetal compromise is unlikely. The chance of fetal death within 1 week of a normal test is rare, so antepartum testing may be repeated 1 week later.
Patient is a 28 weeks gestation with preterm labor and rupture of the membrane. US shows bilateral renal
agenesis in fetus: What do you do next:
Labor should be allowed to proceed in patients where the fetus has been diagnosed with severe congenital anomaly incompatible with life.
Patients with Wolff-Parkinson-White syndrome (WPW): Describe arrhythmia: Treatment unstable vs stable:
An accessory pathway conducts depolarization directly from the atria to the ventricles with traversing the AV node. Hemodynamically unstable require immediate electrocardioversion: Hemodynamically stable patients PROCAINAMIDE (preferred) or ibutilide.
In WPW what agents are not used:
Adenosine, beta blockers, calcium channel blockers and digoxin. These agents may promote conduction across the accessory pathway and lead to degeneration of AF to VF.
CHF vs COPD exacerbation: what are the blood gas differences:
ABG CHF: hypoxia, HYPOCAPNIA, and respiratory alkalosis; example pH 7.46, pO2 73 mmHG, ((pCO2 31 mmHg)).
ABG COPD: hypoxia, HYPERCAPNIA, and respiratory acidosis: example pH 7.39, pO2 80 mmHg ((pCO2 50 mmHg)).
CHF vs COPD exacerbation: What are differences on auscultation:
CHF: Bibasilar crackles.
COPD: Widespread bilateral wheezes.
Specific test for CHF:
B-type natriuretic peptide (BNP) or pulmonary capillary wedge pressure.
Common bacterial pathogens cystic fibrosis: Gram-negative rod:
Pseudomonas aeruginosa. Most common cause pneumonia in adolescent and adults.
Common bacterial pathogens cystic fibrosis: Gram-negative coccobacilli:
Nontypeable Haemophilus influenzae
Common bacterial pathogens cystic fibrosis: Gram-positive cocci in chains:
Streptococcus pneumoniae. Most common cause of pneumonia in all patients.
Common bacterial pathogens cystic fibrosis: Gram-positive cocci in clusters:
Staphylococcus aureus. Most common cause in infants and young children with CF
Patients with Neisseria meningitidis can have:
Petechial rash. Almost 75% have a petechial rash that is prominent on the axilla, wrists, flanks, and ankles.
Group B Streptococcus (Streptococcus agalactiae): Rash describe:
DOES NOT HAVE A RASH.
Elderly patient with hip fracture after syncopal episode: Workup:
Surgery can be delayed up to 72 hours. Elderly patient with syncopal episode should get ECG, cardiac markers and chest- x-ray. If pulmonary edema and pleural effusion you need Echo.
Hypokalemia combined with computed tomography scan showing 3-cm adrenal mass suggests: Lab findings:
Causes:
Primary hyperaldosteronism Conn’s disease). Low renin and elevated aldosterone and serum bicarbonate. Causes
hypertension, mild hypernatremia, hypokalemia, and metabolic alkalosis.
Patients who undergo central venous catheterization need:
Portable chest x-ray to confirm proper placement of the catheter tip and absence of complications beofre
administering drugs or other agents through the catheter.
Ischemic cardiac pain can sometimes be mistaken for: What test:
Epigastric pain, especially in the setting of symptoms that worsened with exertion. An exercise stress test without
imaging if the baseline ECG is normal. Stress test positive then Coronary angiography (gold standard for Dx CAD).
Effects of maneuvers on hypertrophic cardiomyopathy: What increases murmur intensity: Why:
Valsalva (straining phase), Abrupt standing (from sitting or supine position), Nitroglycerin.
Physiologic effect: Decrease in preload.
Effects of maneuvers on hypertrophic cardiomyopathy: What decreases murmur intensity: Why:
- Sustained hand grip 2. Squatting (from standing position) 3. Passive leg raise
Physiologic effect: 1. Increase Afterload 2. Increase Afterload & Preload 3. Increase Preload
Trigeminal neuralgia: Symptoms: Treatment:
Severe, unbearable pain in face that is knife like, comes in paroxysms, and occurs 10-20 times a day and last a few
seconds. Carbamazepine (Prolonged use causes aplastic anemia, get routine CBCs).
Intravenous drug user with bacterial endocarditis with acute embolic stroke: Treatment:
MRI of brain. TEE of heart. Blood cultures and intravenous antibiotic therapy. Then watch. No need for antiplatelet
therapy (aspirin) that you normally give in acute ischemic stroke due to atherosclerotic thrombosis or embolism.
Medullary thyroid cancer (MTC): Presentation:
Hard nodule, elevated calcitonin, malignant cells.
Multiple Endocrine Neoplasia (MEN) Type I:
Primary hyper((parathyroid))
Entero((pancreatic)) tumors:
((Pituitary)) tumors:
Multiple Endocrine Neoplasia (MEN) Type 2A:
Medullary ((thyroid)) cancer (MTC)
((Pheochromocytoma)):
((Parathyroid)) hyperplasia:
Multiple Endocrine Neoplasia (MEN) Type 2B:
Medullary ((thyroid)) cancer (MTC)
((Pheochromocytoma)):
Other: mucosal & interstitial neuromas, ((marfanoid habitus))
Kyphoscoliosis and lordosis.
MEN 2 A & B genetics:
Autosomal dominant mutations involving RET proto-oncogene located on chromosome 10.
A nail puncture wound in an adult resulting in osteomyelitis is most likely due:
Pseudomonas aeruginosa
Acute cocaine toxicity with myocardial ischemia: Signs/symptoms: Treatment:
Psychomotor agitation, dilated pupils, atrophic nasal mucosa, hypertension, ECG changes. Treatment supplemental oxygen and intravenous benzodiazepines.
Duodenal hematomas most commonly occur following direct trauma: Treatment:
Treatment is conservatively with nasogastric suction and parenteral nutrition. Most hematomas spontaneously resolve in 1-2 weeks. Pain is from gastric secretions being blocked.
COPD medications beta agonist:
Albuterol: bronchodilator
COPD medications anticholinergic:
ipratropium and tiotropium: bronchodilator:
Unilateral subacute hip pain in a male child coupled with progressive antalgic gait, thigh muscle atrophy,
decreased range of motion and collapse if the ipsilateral femoral head on x-ray:
Idiopathic avascular necrosis of the femoral capital epiphysis (Legg-Calve-Perthes disease)
D-transposition of the great vessels (TGV) is the most common: Presentation:
Congenital cyanotic heart disease in the neonatal period. Presents in the first few hours of life with cyanosis and a
single loud second heart sound, and a narrow mediastinum “egg on a string” x-ray. Treat prostaglandins keep PDA open.
A solitary pulmonary nodule is defined as a lesion:
Assessment of malignancy risk for solitary pulmonary nodule: High Risk:
Nodule size (cm) ≥2.0; Age(yr) >60; Smoking status Current; Smoking cessation (yr)
Chagas disease: Cause: Endemic area: Presentation: Treatment:
A chronic protozoal disease caused by Trypanosoma cruzi. Latin America. Pedal edema, JVD, S3, and cardiomegaly. Because infection causes megaesophagus, megacolon, and/or cardiac dysfunction. Tx: Benznidazole
Pheochromocytoma treatment:
Do not give beta blockers without alpha blockers. A beta blocker alone may cause increases in blood pressure due to unopposed alpha- receptors. Remember alpha-1 causes vasoconstriction of peripheral vessels.
Pressors such as norepinephrine can cause:
Ischemia of the distal fingers and toes secondary to vasospasm. Diagnosis is suggested by symmetric duskiness and coolness of all the finger tips. Norepinephrine has alpha-1 agonist properties which cause vasoconstriction. This phenomenon can occur in intestines and kidneys.
Pulmonary compliance is measured by: Formula:
The plateau pressure is the measured during an inspiratory hold maneuver
Formula: Plateau pressure = elastic pressure + PEEP
Peak airway pressure is measured by: Formula
Useful in mechanically ventilated patients. Peak airway pressure (the maximum pressure measured as the tidal
volume is being delivered) equals the sum of the resistance pressure (flow x resistance) and the plateau pressure. Formula: Peak airway pressure = resistive pressure + plateau pressure
Positive end expiratory pressure(PEEP) is calculated using:
end-expiratory hold maneuver
Adult respiratory distress syndrome (ARDS) on mechanical ventilation: First step in management:
Decrease the FiO2 to relatively non-toxic values
Pellagra triad:
(3Ds): Diarrhea, Dermatitis, and Dementia, and if untreated Death. Due to niacin deficiency seen in corn based diets in Asia, Africa, and China.
Patients with massive pulmonary embolism usually present with: Effects on heart function:
Signs of low arterial perfusion (hypotension, syncope), and acute dyspnea, pleuritic chest pain, and tachycardia.
Thrombus increases pulmonary vascular resistance and right ventricular pressure, causing ventricular hypokinesis
and dilation, decreased preload, and hypotension.
Cardinal symptoms in acute exacerbation of COPD: Treatment:
Increased dyspnea, cough, and sputum production. If patient has 2 of these give antibiotics. Moderate to severe
COPD exacerbation or those requiring ventilation also receive antibiotics.
The risk factors for a polyp to progressing into malignancy are from highest malignancy chance:
Villous adenoma, sessile adenoma, and size >2.5 cm.
During an acute phase myocardial infarction what heart sound can be heard:
An abnormal fourth heart sound (atrial gallop) due to left ventricular stiffening and dysfunction induced by myocardial ischemia.
Chronic obstructive pulmonary disease (COPD): What are the two types and what is the difference in DLCO:
Diffusing capacity of the lung (DLCO( is decreased in emphysema and normal in bronchitis.
DLCO can be decreased in:
interstitial lung disease. Sarcoidosis, Asbestosis.
Infectious cavernous sinus thrombosis (CST): Mechanism: Signs/symptoms:
Because the facial/ophthalmic venous system is valveless, uncontrolled infection of the skin sinuses, and orbit can spread to the cavernous sinus. Red flag symptoms include severe headache; bilateral periorbital edema; and cranial
nerve II, IV, V, and VI deficits. May see papilledema with ICH.
Indications for a renal & bladder ultrasound in children: Treatment:
Infants and children age
Ruptured ovarian cyst: Presentation: Pelvic ultrasound findings: Treatment:
Presentation: Acute onset of severe unilateral pelvic pain immediately after strenuous activity or sexual intercourse.
Pelvic ultrasound can confirm the diagnosis by showing free fluid in the pelvis. Uncomplicated analgesics,
Complicated surgery.
Tight blood glucose control in patients with diabetes decreases the risk of:
Microvascular complications (retinopathy, nephropathy), but increases risk of hypoglycemia. No change in all cause mortality.
Turners syndrome patients have ovarian dysgenesis which leads to:
Low estrogen levels and inability to mestate. The poor ovarian function because FSH levels to be high due to lack of negative feedback. LH is also elevated for the same reason.
Anemia of chronic disease is a disorder of: Characterized by:
Iron utilization that most commonly occurs in the setting of chronic inflammation. Normocytic anemia with decreased serum iron, decreased total-iron binding capacity: decreased iron saturation, and normal/elevated ferritin.
Membranoproliferative glomerulonephritis, type 2, is a unique glomerulopathy:
That is caused by persistent activation of the alternative complement pathway. Leaves dense intramembranous
deposits that stain for C3.
Drug induced interstitial nephritis is usually caused by: Presentation:
Cephalosporins, penicillins, sulfonamides, NSAIDs, rifampin, phenytoin, and allopurinol. Patient present with
arthralgias, rash, renal failure, and the urinalysis will show eosinophiluria.
Patient with androgen producing adrenal tumors: What is elevated specifically:
Dehydroepiandrosterone-sulphate
Any male adolescent who presents with epistaxis, a localized mass, and a bony erosion on the back of the
nose has:
An angiofibroma until proven otherwise.
Cardiac amyloidosis should be suspected in patients with:
Unexplained congestive heart failure (predominantly diastolic dysfunction), echocardiography findings of increased ventricular wall thickness with normal ventricular cavity dimensions (especially in the absence of hypertension, and low voltage on ECG.
Metabolic alkalosis defined as:
pH >7.45 and serum bicarbonate level > 24 mEq/L
Main causes for saline- responsive Metabolic Alkalosis:
Vomiting/ nasogastric aspiration; Prior diuretic use; Current diuretic use.
Main causes of non-saline-responsive Metabolic Alkalosis:
Excess mineralocorticoids activity ( Primary aldosteronism, cushing’s disease, ectopic ACTH production); Barter & Gitleman syndrome.
Evaluation of bilious emesis in the neonate: Abdominal x-ray findings: Free air, hematemesis, unstable vital
signs: Next step:
Surgery
Evaluation of bilious emesis in the neonate: Abdominal x-ray findings: Dilated loops of bowel: Next step:
Possible diagnosis:
Contrast enema; If microcolon then diagnosis Meconium ileus; If rectosigmoid transition zone, then Hirschsprung
disease.
Evaluation of bilious emesis in the neonate: Abdominal x-ray findings: NG tube in misplaced duodenum: Next
step: Diagnosis:
Upper GI series; If ligament of treitz on right side of abdomen, then malrotation. (Volvulus)
Evaluation of bilious emesis in the neonate: Abdominal x-ray findings: Double bubble sign: Next step:
diagnosis:
Duodenal atresia
Tamoxifen: Mechanism: Used to treat: Increases the risk of what cancer:
Estrogen antagonist on breast tissue, agonist on endometrium, and decreases risk of osteoporosis. Treatment and prevention of breast cancer. Increases the risk of endometrial cancer. Overall mortality benefit.
Bell’s Palsy: Lesions in the CNS occurring above the facial nucleus will:
Typically cause a contralateral lower facial weakness that spares the forehead.
Bell’s Palsy: Forehead muscle sparing is suggestive of an:
Intracranial lesion and would warrant brain imaging to evaluate ischemia or tumors.
Invasive aspergillosis occurs in: Chest x-ray shows:
Immunocompromised patients, who may present with fever, cough, dyspnea, or hemoptysis. Chest x-ray may show a cavitary lesion, and CT scan shows pulmonary nodules with a halo sign or lesions with an air crescent.
Neuroleptic malignant syndrome (NMS): Define: Characterize: Treatment:
Associated with medications that block dopamine transmission such as high potency, typical antipsychotics like haloperidol. Clinical features fever, rigidity, mental status changes, and autonomic instability. Treatment stop drug, control hyperthermia, and maintenance of electrolyte balance. Dantrolene for skeletal muscle relaxation.
Premenstrual syndrome (PMS) & premenstrual dysphoric disorder (PMDD): First line treatment:
Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine.
Situational syncope typical scenario would include: Mechanism:
A middle age or older male, who loses his consciousness immediately after urination, or a man who loses his
consciousness during coughing fits. Mechanism includes autonomic dysregulation.
Patient has an episode of massive hemoptysis: Defined: Treatment:
Defined as > 600mL of expectorated blood over 24-hour period or a bleeding rate >100 mL/hour. Greatest danger is
aspyxiation due to airway flooding. Patient placed with bleeding lung in the dependent position (lateral position).
Bronchoscopy.
Raloxifene first line agent for: Increases the risk of:
Prevention of osteoporosis, and it decreases breast cancer risk. It increase the risk of thromboembolism. Generally women should not get pregnant after rubella vaccination: How long: Recommended waiting time is 28 days, but if women inadvertently get pregnant shortly after vaccination for rubella, they can be reassured that here is little risk to the fetus and they can proceed with ((routine prenatal care)).
Digoxin is a cardiac glycoside with adverse effects that include:
Nausea, vomiting, diarrhea, vision changes, and arrhythmias. Get a drug level.
Key differences in primary hyperparathyroidism (PHPT) and chronic kidney disease (Secondary
hyperparathyroidism:
PTH levels are usually much higher in secondary than primary. In addition, serum calcium levels are low to normal in secondary hyperparathyroidism. Serum phosphorous may be low or normal in PHPT were it tends to be high in
kidney disease.
Post bone marrow transplant (BMT) with fever, dyspnea, abdominal pain, and diarrhea. Chest x-ray shows
multifocal, diffuse infiltrates or CT with parenchymal opacifications or multiple nodules:
CMV pneumonitis after BMT is about 45 days, also manifests as upper and lower gastrointestinal ulcers. Diagnosis with bronchoalveolar lavage.
Patients with intrauterine fetal demise who develop coagulation abnormalities:
Should be induced without delay. Especially with low platelets. Remember fibrinogen levels are high in pregnancy therefore anything in the low normal can be an early sign of disseminated intravascular coagulation (DIC).
What is the most important direct role of hCG in pregnancy:
Maintenance of the corpus luteum.
Progesterone is the hormone responsible for:
Preparing the endometrium for implantation of a fertilized ovum.
What inhibits uterine contractions:
Progesterone
What causes induction of prolactin production by the pituitary during pregnancy:
Estrogen
Human chorionic gonadotropin (hCG) is a hormone secreted by:
Syncytiotrophoblast
Whipple’s disease classical biopsy findings: Presentation: Pathogen:
PAS positive material in the lamina propria of the small intestines. Arthralgias, ((weight loss)), fever, ((diarrhea)), and abdominal pain. Tropheryma whippeli.
Myotonic muscular dystrophy: Genetics: Presentation:
Autosomal dominant expansion CTG chromosome 19q 13.3. Onset 12-30. Patient with facial weakness, handgrip
myotonia, dysphagia. ((Arrhythmias, cataracts, balding, and testicular atrophy/infertility)). Remember Duchenne and Becker have earlier age of onset without underlined.
Opioid intoxication presents with:
((Miosis)), depressed mental status, decreased respiratory rate, decreased bowel sounds, ((hypotension)), and ((bradycardia)).
Neonatal sepsis treatment after complete blood count and CSF cultures:
Administering systemic antibiotics ampicillin plus gentamicin.
Most common cause of sepsis in neonatal period:
GBS and E. coli. Term infants more likely GBS. Preterm is E. coli.
Difference in treatment of infant botulism compared to foodborne botulism:
Infant borne: Ingestion of C. botulinum ((spores)) from environmental. Tx: ((Human)) derived botulinum immune ((globulin.))
Foodborne botulism: Ingestion of ((preformed)) C. botulinum ((toxin)). Tx: ((Equine))-derived botulinum ((antitoxin)).
Patient presents with septic shock and developed AST and ALT elevation one day later: Labs:
Presentation most consistent with ((ischemic hepatic injury)), or ((shock liver)). Hallmark of ischemic hepatopathy is a rapid and massive increase in the transaminases with modest accompanying elevation in total bilirubin and alkaline phosphatase. If patient survives liver enzymes return to normal in a few weeks.
Sinus pauses on monitor, prolonged PR interval or QRS duration: Differential diagnosis:
Sick sinus syndrome, ((bradyarrhythmias)), atrioventricular block; Can be ((intermittent)).
Intraventricular conduction delay refers to:
Prolonged QRS duration.
Torsades de Pointes is due to:
Polymorphic ventricular tachycardia in the setting of prolonged QT interval. Long QTc interval
When looking at multiple endocrine neoplasia in a patient with HA and HT: If eye exam is normal:
Get plasma free metanephrine or 24-hour urine metanephrines.
Papillary thyroid cancer (PTC): Characterized: Prognosis:
Most common thyroid cancer. Characterized by a slow infiltrative local spread affecting other parts of thyroid gland and regional lymph nodes. Prognosis good. nonencapsulated
Follicular thyroid cancer: Histopathology:
Demonstration of invasion of the capsule and blood vessels is required to differentiate follicular cancers from follicular
adenomas. Early hematogenous spread to the lungs, brain, and bone.
Medullary cancer of the thyroid can secrete:
Calcitonin
Presence of Hurthle cells on biopsy of thyroid gland:
Can be seen in both follicular and papillary cancers. Hurthle cell carcinoma is a variant of follicular cell carcinoma.
Vitiligo: What is it: What is it associated with:
Vitiligo is an autoimmune condition characterized by areas of depigmentation lacking melanocytes. Vitiligo is
sometimes associated with other autoimmune conditions such as pernicious anemia, autoimmune thyroid disease,
type I diabetes mellitus, primary adrenal insufficiency, hypopituitarism, and alopecia areata.
In a case-control study, if the outcome is uncommon in the population:
The odds ration (OR) is a close approximation of the relative risk (RR) (“rare disease assumption”).
Thalamic hemorrhage may present with:
Contralateral hemiparesis and sensory loss. Typically associated with nonreactive miotic pupils and eyes that deviate TOWARD the side of hemiparesis.
Basal ganglia hemorrhage may present with:
Contralateral hemiparesis and sensory loss. Homonymous hemianopsia, and Gaze palsy.
Pons hemorrhage may present with:
Deep coma & total paralysis within minutes, PINPOINT reactive pupils.
Ethylene glycol poisoning key findings:
Calcium oxalate crystals (rectangular, envelope-shaped crystals) are seen in urine. Common in antifreeze.
Methyl alcohol poisoning key findings:
Can cause visual changes (“snowfield vision”) and pancreatitis.
Trichinellosis typically presents with:
Gastrointestinal complaints (abdominal pain, nausea, vomiting) followed by the characteristic triad of periorbital edema, myositis, and eosinophilia (hallmark of the disease). Other clinical findings include fever, subungual splinter hemorrhages or retinal hemorrhages.
Patients with febrile neutropenia and no obvious focus of infection given normal x-ray and urinalysis:
Severe neutropenia seen in chemo patients should get blood cultures followed by monotherapy with an
antipseudomonal beta-lactam agent (cefepime, meropenem, piperacillin-tazobactam) provides both gram-negative & gram-positive coverage.
Acute lymphoblastic leukemia is predominantly seen in: Presents with: Labs show:
Seen in children from ages 2-10. Varying degrees of anemia, neutropenia, and thrombocytopenia. Blast cells have
condensed nuclear chromatin, small nucleoli and scant agranular cytoplasm. Histochemical staining strongly positive periodic acid Schiff (PAS). Deoxynucleotidyltransferase (TdT) is positive 95% time. 25% lymphoblasts bone marrow
diagnostic.
Features for ischemic reperfusion syndrome: Mechanism: Diagnosis:
A form of compartment syndrome (CS). Post-ischemic CS is due to interstitial edema and possibly intracellular
swelling following tissue ischemia and subsequent reperfusion such as after and embolectomy. Compartment
pressure > 300 mmHg.
Initial stabilization of acute ST-elevation MI: Initial drugs given:
Aspirin, Clopidogrel, Nitrates (sublingual), beta blocker (unless hypotension, bradycardia, CHF, heart block), High
dose statin, anticoagulation (depends on planned revascularization).
Initial stabilization of acute ST-elevation MI: Drug given if patient has persistent pain, hypertension, or heart
failure:
Intravenous nitroglycerin (not if hypotension, right ventricular infarct, or severe aortic stenosis occurs)
Initial stabilization of acute ST-elevation MI: Drug given persistent pain:
Intravenous morphine
Initial stabilization of acute ST-elevation MI: Drug given for unstable sinus bradycardia:
Intravenous atropine
Initial stabilization of acute ST-elevation MI: Drug given pulmonary edema:
Intravenous furosemide (not if patient is hypotensive or hypovolemic)
Osteosarcoma X-ray findings: Epidemiology:
Spiculated “sunburst” pattern and periosteal elevation known as the Codman triangle. Most common primary bone tume affecting children and young adults.
Ewing sarcoma X-ray findings:
An osteolytic lesion with a periosteal reaction that produces layers of reactive bone, giving the classic “onion skin” appearance. Second most common primary bone tumor.
Osteoid osteoma X-ray findings: Features:
Sclerotic, cortical lesion on imaging with a central nidus of lucency. It typically causes pain that is worse at night and
unrealted to activity. Pain is quickly relieved by NSAIDs.
Dermatitis herpetiformis (DH) presents with: Associated with: Treatment:
Erythematous papules, vesicles, and bullae that occur bilaterally, symmetrically, and in grouped “herpetiform”
arrangement on the extensor surfaces elbows, knees, upper back, and buttocks. Associated with gluten-sensitive
entropathy (celiac disease). Tx: Dapsone
Choriocarcinoma Lab:
Increased beta-hCG
Teratomas Lab:
Elevations in serum concentration AFP or beta-HCG can appear, due to coexistence of other germ cell tumor
components.
Seminomas Lab:
Serum tumor markers are usually normal, although beta-hCG maybe somewhat elevated if they contain
synctiotrophoblastic giant cells.
Yolk sac tumor (endodermal sinus tumor) Lab:
Germ cell tumor accompanied by an increase in serum AFP.
Trauma if FAST exam is inconclusive or is positive:
Inconclusive: diagnostic peritoneal lavage (DPL).
Positive: Laparotomy.
Evaluation of secondary amenorrhea with a negative β-hCG: What are the next labs ordered:
Check prolactin, TSH, FSH
Evaluation of secondary amenorrhea with a negative β-hCG, but increased prolactin: What test:
Brain MRI
Evaluation of secondary amenorrhea with a negative β-hCG, but increased TSH:
Diagnosis hypothyroidism
Evaluation of secondary amenorrhea with a negative β-hCG, but increases FSH:
Premature ovarian failure
Secondary amenorrhea defined as:
Absence of menses for ≥3 cycles or ≥6 months in women who menstruated previously.
Aortic valve endocarditis and intravenous drug abuse are associated with an increased risk of:
Periannular extension of endocarditis.
Serum Sickness like reaction is most commonly caused by: Presentation: Treatment:
Caused by β-lactams, and sulfa drugs. Symptoms arise 1-2 weeks after exposure and include fever, urticarial rash,
polyarthralgia, and lymphadenopathy. Remove offending agent.
Congestive heart failure due to left ventricular systolic dysfunction is characterized by:
Decreased cardiac output/index, increased systemic vascular resistance (SVR), and an increase in left ventricular
end-diastolic volume (LVEDV).
Carcinoid syndrome clinical manifestations: Tests:
Skin: flushing, telangiectasia, cyanosis; GI: diarrhea, cramping; Cardiac: valvular lesions (right>left); Pulmonary:
bronchospasms; Niacin deficiency (dermatitis, diarrhea, dementia). Diagnosis 24-hour urine 5-hydroxyindoleacetic acid. CT/MRI to localize tumor. OctreoScan to detect metastasis.
Cell-free fetal DNA testing is a noninvasive and highly sensitive and specific screening test for:
fetal aneuploidy and can be ordered at ≥10 weeks gestation.
Abnormal cell-free fetal DNA testing results can be confirmed by:
Chorionic villus sampling at 10-12 weeks or amniocentesis at 15-20 weeks.
First trimester combined test:
Pregnancy- associated plasma protein, β-hCG, nuchal translucency.
Second trimester quadruple screen:
Maternal serum ɑ-fetoprotein, estriol, β-hCG, inhibin A.
Most common organ origins of osteolytic metastasis:
most common in cancers that have spread to bone from the lung, thyroid, kidney, and colon.
Most common organ origins of osteoblastic metastasis:
It is more frequently seen in spread of prostate, bladder, and stomach cancer.
What is the purpose of diagnostic or prognostic exercise testing? (stress testing)
To localize ischemia or assess viability to recommend exercise
small cell carcinoma causes what syndrome
SIADH
diverticulitis, what test do you use?
CT scan of abdomen
What is the strongest risk factor for future pre-term birth?
Prior PTB is the strongest risk factor for future PTB, and recurrences often occur at the same gestational age
For Addisons’ crisis/ adrenal insufficiency - what test?
ACTH stimulation test
Test to distinguish cushing’s disease and cushion’s syndrome and primary pituitary insufficiency
Dexamethasone suppression test.
Vaccines needed by HIV patients
- The Flu Vaccine
- Pneumococcal vaccine
- Diphtheria, tetanus, and pertussis vaccines
- HPV vaccine
- Hep B vaccine
HIV patients who need the meningococcus vaccine have these risk factors:
- Live in a city that has had a meningitis outbreak (such as New York City)
- Travel to a city that has had a meningitis outbreak
- Have or will have close contact with other men who have sex with men from a city that has had a meningitis outbreak
When is a HIDA scan done?
When the ultrasound is inconclusive, because it deals with the gall bladder, no need in patient who already has cholecystectomy.
HIV patients who need the Hep A vaccine have these risk factors:
- People who use intravenous (IV) drugs
- Men who have sex with men
- People who already have other forms of liver disease
- People with a bleeding disorder called hemophilia
- People who travel to certain parts of the world
HIV patients can get these live vaccines if their CD4+T cell counts are above 200
Varicella and Zoster vaccines
Most common sites of ulnar nerve entrapment
at the elbow, followed by the wrist
Pulmonary embolism, treatment
heparin therapy
Cubital tunnel syndrome, where is the nerve compression located?
Cubital tunnel syndrome is used to describe ulnar nerve impingement along the cubital tunnel at the medial edge of the elbow. It is the most common location of nerve impingement in the elbow area
Guyon’s canal syndrome, where is the nerve compression located?
Guyon’s canal syndrome, or ulnar tunnel syndrome, refers to nerve compression affecting the ulnar nerve as it passes through an anatomical space in the wrist called Guyon’s canal
Rh isoimmunization, mother is O-Rh (-) , what happens to an O-Rh(+) newborn?
Rh(+) factors from newborn leaks into mothers bloodstream, causes anti IgG Rh antibodies.
Diabetic neuropathy - what type of urinary symptoms can they have.
Intermittent urinary incontinence, overflow incontinence by an acontractyle bladder (think detrusor muscle - lack of innervation)
In patients with neurofibromatosis type 1, what type of hypertension is seen in these patients?
Essential hypertension, from renal vascular lesions, most commonly in the renal vasculature.
What is the most common peroxisomal disorder?
Adrenoleukodystrophy (ALD)
What is the Adrenoleukodystrophy (ALD) Genetics?
Adrenoleukodystrophy (ALD) is an X-linked disorder
What is the pathogenesis of Adrenoleukodystrophy (ALD)?
Mutations may prevent normal transport of very long chain fatty acids (VLCFAs) into peroxisomes, thereby preventing beta-oxidation and breakdown of VLCFAs. Accumulation of abnormal VLCFAs in CNS, Leydig cells of the testes, and the adrenal cortex
