Step 2 Missing Knowledge Flashcards
Ureteral injury during pelvic surgery
Postop: ureteral obstruction and hydronephrosis (nonradiating focal back pain, unilateral CV angle tenderness)
Dissociative amnesia
Isolated impairment in autobio memory
Sudden onset preceded by traumatic event
AOM rfs
Age (6-18 mo)
Lack of breastfeeding
Daycare attendance
Smoke exposure
Polycythemia Vera Tx
Serial phlebotomy +/- hydroxyurea if high risk of thrombosis
Recurrent tinea cruris
Common (not suggestive of immunosuppression)
Suggests reexposure to external source or autoinfection from concurrent dermatophyte infection (e.g. tinea pedis/corporis)
Thorough skin inspection, any other infection sites tx
Lactation failure jaundice vs breast milk jaundice
LFJ: age < 1wk; insufficient intake of breast milk: decreased bili elimination, increased enterohep circ; suboptimal breastfeeding, signs of dehydration, excessive weight loss
BMJ: age >1wk; increased glucuronidase in breast milk: increased deconj of intestinal bili, increased enterohep circ; adequate breastfeeding, well hydrated
Erythema toxicum neonatorum
Benign neonatal rash
First 3 days of life
Erythematous papules, macules or pustules on trunk and prox extremities (sparing palms/soles)
Self resolves within a week
PPROM complications
Preterm labor
Intraamniotic infection
Placental abruption (from oligo leading to uterine decomp and placenta separation)
UC prolapse
High risk conditions for infective endocarditis (needing abx for dental work etc)
Prosthetic heart valve
Prev IE
Structural valve abnormality in transplanted heart
Unrepaired cong cyanotic heart disease
Repaired cong heart disease with residual defect
Zollinger Ellison syndrome can cause diarrhoea and steatorrhoea. Why?
Increased gastrin increased gastric acid inactivation of pancreatic enzymes and injury to mucosal brush border
Granulosa cell tumour
High estrogen and inhibin
Juvenile GCT: precocious puberty& adrenal mass
Hyposthenuria
Inability of kidneys to concentrate urine
can occur in sickle cell disease & SCT
polyuria, low serum Specific gravity& normal serum Na
Bladder injury
Extraperitoneal (anterior bladder wall): localised sx and neg FAST; pelvic fracture injury
Intraperitoneal (bladder dome - weakest part): pos FAST, abdo distention, chem peritonitis
Renal and urinary changes in normal preg
Increased RBF
Increased GFR
Increased renal basement membrane perm
Effects:
Decreased serum BUN
Decreased serum creatinine
Increased renal protein excretion
Glucagonoma
Necrolytic migratory erythema: painful, pruritic papules that coalesce to form large plaques on face, groin and extremities
DM, weight loss, diarrhoea, anaemia
Glucagon > 500
N.B: phaeochromocytoma can cause unexplained hyperglycaemia (catecholamines inhibit insulin secretion)
Diffuse axonal injury MRI findings
Punctate haemorrhages in white matter (axons)
Blurring of gray-white matter (oedema)
Cerebral palsy: major rf
Prematurity
Leading to ischaemia and necrosis in area near lateral ventricles: periventricular leukomalacia
Also friable GM vessels, leading to intraventricular haemorrhage
Bartholin duct cyst
Large sx can present w vaginal discomfort and pressure with sex, sitting, walking
Soft, nontender mobile mass behind post labium majus extension into vagina
Sx: incision and drainage tx
Community acquired bacterial meningitis: m/c cause
Strep pneumoniae
Raised ICP tx
Decrease brain parenchymal vol: osmotic therapy (hypertonic saline, mannitol) to extract water
Decrease CBV:
head elevation
Sedation
Hyperventilation
Decrease CSF vol:
External ventricular drain
Increase cranial vol:
Decompressive craniectomy
Meningovascular syphilis
Days/weeks of meningeal sx then acute ischaemic infarction
Vasa previa
Fetal vessels overlying cervix
Rfs: placenta previa, multiple gestations, IVF, succenturiate placental lobe
Presentation:
1. PAINLESS vaginal bleeding with ROM/contractions
2. FHR abnormalities (e.g. brady, sinusoidal pattern)
3. fetal exsanguination and demise
Mx: emergency C section
Hammer toe vs claw toe
Hammer: dorsal flexion MTP, plantar flexion PIP, DORSAL FLEXION DIP
Claw: dorsal flexion MTP, plantar flexion PIP & DIP
Both seen in diabetic peripheral neuropathy (other complications of DPN: callusing, ulceration, joint subluxation and Charcot arthropathy)
Chronic osteomyelitis fracture complication
Fracture nonunion
Intermittent pain and swelling and sinus tract formation
Open bone biopsy, surgical debridement of infected and necrotic bone
Preterm infants vaccination schedule
Given according to chronological age rather than age corrected for gestation
Postpartum uterine atony rfs
Uterine fatigue from prolonged, induced, or precipitous labor
Intraamniotic infection
Uterine overdistension (multiple gestation, fetal macrosomia, polyhydramnios)
Retained placenta
Grand multiparity
Operative vaginal delivery
Anti-D Ig post preg
Standard dose at 28 weeks gest
After delivery or procedures, Kleihauer-Betke test performed to determine whether higher dose needed due to increased risk of fetal blood cells entering maternal circ
Psychosis and Parkinson’s
Common, seen more in pts taking dopamine agonists (e.g. ropirinole, pramipexole) than those treated with carbidopa-levodopa.
Psychotic sx treated with antiparkinson med dose reduction and/or addition of LOW potency antipsychotic (quetiapine, pimavanserine)
Ludwig angina
Rapidly progressive cellulitis of submandibular and sublingual spaces
Airway obstruction can occur due to displacement of tongue posteriorly
Post-traumatic neuroma (following amputation)
Due to transection of nerve fibers
Form over several weeks - months following injury/amputation
FOCAL tenderness, altered local sensation
Pain with local pressure that can complicate fittings for amputational prosthetics
Injection of local anesthetic can provide transient pain relief and confirm dx
Mx: excision of neuroma
Preterm birth prevention
Rfs for preterm delivery:
Prior spont preterm delivery (main rf)
Tobacco use, multiple gest, prior cervical surgery (e.g. cold knife conization for CIN)
No prior preterm delivery: TV US cervical length measurement at 16-24 weeks gest to assess risk for preterm delivery (if short cervix identified, <= 2.5cm on USS, high risk for preterm, so offered vag progesterone (prevent uterine contractions))
Prior preterm delivery:
… w/ Painful contractions = prior preterm labor: Tx = progesterone
… w/o painful contractions = cervical insufficiency: Tx = prophylactic cerclage
Sensorimotor polyneuropathy in DM
Small fiber: pos sx: pain, paresthesia, allodynia
Large fiber: neg sx: numbness, loss of proprioception and pos sense, diminished ankle reflexes
Children w pneumonia not improving after 48-72 hr of abx
CXR to assess for complications (e.g. parapneumonic effusion, abscess, necrotising pneumonia)
Cervical spine injury imaging indications
CT preferred test for screening
Indications: high-energy mechanism of injury or any one of following:
neuro deficit
spinal tenderness
altered mental status
intox
distracting injury
N.B: presence of single vertebral # in pt w blunt trauma indication to image ENTIRE SPINE (CT scan)
Long-term (>= 5 years) metformin therapy side effect
B12 def due to alterations in ca homeostasis, leading to impaired absorp of b12 in terminal ileum
May have isolated neuro findings (paraesthesias, sensory ataxia, neuropsych changes) w/o megaloblastic anaemia
Cushing syndrome screening test
Late-night salivary cortisol assay, 24-hour urine free cortisol and/or low dose overnight dex suppression test
NOT early morning cortisol!
TOF: tx of tet spells
Placement of pts in knee-chest pos during hypercyanotic spell causes kinking of femoral arteries, increasing SVR so reduces R to L shunting through VSD so increases PBF and improves hypoxaemia
Tourette syndrome tx
(Multiple motor tics and at least one vocal tic)
Habit reversal training
Pharmocotherapy: ANTIPSYCHOTICS, dopamine depleters, or alpha adrenergic receptor agonists
Spontaneous pneumomediastinum
Severe coughing paroxysms can increase intraalveolar pressure and cause air to leak into subcut tissues (subcut emphysema) resulting in SPM
CXR to confirm dx and rule out pneumothorax
Appropriate compensation for acid base disorders
Met ac (acute/chronic): Winter’s formula: expected PaCO2 = (1.5 x HCO3-) + 8 +/- 2
Met alk (acute/chronic): ~7 increase in PaCO2 per 10 increase in HCO3-
Resp ac (chronic only): ~ 4 increase in HCO3- per 10 increase in PaCO2
Resp alk (chronic only): ~ 4 decrease in HCO3- per 10 decrease in PaCO2
Acute bacterial rhinosinusitis
Distinguished by viral URTI by presence of severe, persistent or worsening sx (cough, nasal discharge)
Tx = oral abx
Suspected appendicitis (modified Alvadaro score >= 4)
Imaging: CT abdo/pelvis if nonpregnant/adult; USS +/- MRI if pregnant/child
If nonperforated appendicitis visualised: Abx & appendectomy <= 12 hrs
If perforated appendicitis: Abx & bowel rest; contained abscess: PCD; diffuse contamination: I&D with appendectomy
Pes anserinus pain syndrome
Localised pain and tenderness over medial tibial condyle
Assoc w overuse
Rfs: obesity, DM, knee OA and angular deformity of knee
Dx clinical but Xray can exclude concurrent OA
Mx: quads strengthening exercises and NSAIDs (N.B: same mx as for PF syndrome)
CF PF syndrome: more common in Females; anterior (rather than medial) pain worsened by squatting, climbing stairs, prolonged sitting
Ehrlichiosis
Suspect if pt from endemic region (southeastern and south central US) w/ hx of tick bite, febrile illness w/ systemic sx, leukopenia and/or thrombocytopenia, and elevated aminotransferases.
Rash uncommon
Tx = doxycycline
Dumping syndrome
Common postgastrectomy complication
GI sx (nausea, diarrhoea, abdo cramps)
Vasomotor sx (palpitations, diaphoresis)
Tx: dietary mod (avoid simple sugars etc), improves over time
ALS: resp insufficiency
Early resp insufficiency may manifest as orthopnea and appear similar to OSA (daytime fatigue, early morning headaches)
NIPPV prolongs survival and improves QofL
Drug-induced lichen planus (lichenoid drug reaction)
Assoc w/ ACEi, thiazide diuretics, beta blockers, hydroxychloroquine
Idiopathic LP: wrists and ankles
Drug-induced LP: more diffuse
Tx = topical high-potency glucocorticoids (e.g. betamethasone) and discontinue suspected med
Cryptococcal meningitis tx
3 phases to ensure eradication and prevent disease relapse
1. induction with amphotericin B and flucytosine for 2 weeks
2. consolidation with high-dose oral FLUCONAZOLE for 8 weeks
3. maintenance with low-dose oral FLUCONAZOLE until CD4 count recovers to >100 for >3mo on ART
N.B: ART initiation delayed for approx 2 weeks after tx for Cryptococcus due to risk of life-threatening CNS complications from immune reconstitution syndrome
M/c cause of gastroenteritis in US?
NOROVIRUS
Assoc w outbreaks on cruise ships and schools etc
Vomiting, watery diarrhoea, abdo pain 1-2d after exposure
Supportive tx
CF Basillus cereus and Staph aureus: vom 6 hours after eating contaminated food
BNP and heart failure
Very good at ruling out heart failure (ie very sensitive) if under 100
Caveat: can be falsely low in pts w heart failure and OBESITY (BNP undergoes increased clearance by fat cells)
Performance anxiety (performance-only social anxiety disorder)
Tx = as needed beta blockers or benzos
Avoid benzos in pts with personal OR family history of SUBSTANCE USE DISORDER or when cog and sedative side effects could impair performance
CF social anxiety disorder (generalised): SSRI/SNRI
Hyperkalaemia ECG changes order
Peaked T waves -> loss of P waves -> widened QRS -> SINE WAVE PATTERN -> asystole
Ecthyma gangrenosum
Rapidly progressive cutaneous disorder seen in immunocompromised pts w P aeruginosa bacteraemia/sepsis
Lesions begin as painless red macules, quickly progress to pustules/bullae and then form punched out gangrenous ulcers
Pts usually febrile and ill
Tx: Blood cultures and empiric IV Abx
Renal cysts
Simple renal cysts mostly benign and do not require any investigations
Malignant renal mass: multilocular mass, irregular walls, thickened septa and contrast enhancement
Adenomyosis
Women over 40 w CHRONIC PELVIC PAIN (CF fibroids), dysmenorrhoea and heavy menstrual bleeding
SYMMETRICALLY enlarged uterus (CF fibroids), boggy, globular and tender
Cervical radiculopathy
Caused by compression of nerve root due to disk herniation or spondylosis
Neck pain, shoulder/arm pain, paraesthesia and diminished reflexes
Improvement of radicular sx when hand placed over head dx and tx
Vit C def
Ecchymosis, petechiae, poor wound healing, perifollicular hemorrhage, coiled hairs and gingivitis
Platelet count, PT, PTT normal
Paraesophageal hiatal hernia
Gastric fundus migrates into thoracic cavity
Large defects can result in herniation of surrounding stomach and intraabdo organs
Sx: N&V, POSTPRANDIAL FULLNESS, dysphagia, epigastric pain, chest pain
Chest imaging: retrocardiac air-fluid level within thoracic cavity (can also be seen in sliding hernias)
Dx confirmed with barium swallow/upper endoscopy
Mx: surgery (medical antireflux for sliding hernia)
LUTS investigations
Urinalysis to evaluate for HM and infection
PSA in sx pts to assess risk for prostate ca unless life expectancy under 10 years
PCOS med to induce ovulation
Letrozole
N.B: cyclic progesterone for endometrial protection but does not induce ovulation
All sexually active women under 25 annual screening for what?
Gonorrhoea and Chlamydia due to high rate of asx infection and risk of long term sequelae (infertility)
NAAT used
N.B: cervical ca screening begins at age 21 w cervical cytology (Pap smear)
But routine HPV testing not performed for those under 30 cos most HPV infections transient and spont clear in this age group
Acute unilateral cervical lymphadenitis in children
Erythematous, tender, warm lymph node
Fever, fluctuance
Periodontal disease or dental caries: ANAEROBES m/c organisms (e.g. Prevotella)
Unilateral = bacterial
Bilateral = viral (acute adeno, subacute chronic EBV CMV)
Signs of traumatic arterial injury
Hard signs (require immediate surgery):
Distal limb ischaemia
Absent distal pulse
Active bleeding or rapidly expanding haematoma
Bruit or thrill at site of injury
Soft signs (require further imaging e.g. CT angio):
Diminished distal pulses
Unexplained hypotension
Stable haematoma
Documented haemorrhage at time of injury
Assoc neuro deficit
NAFLD AST/ALT ratio
Less than 1
USS: Hyperechoic liver (fatty infiltration)
Fetal growth restriction complications
Polycythaemia: chronic Hypoxia EPO
Hypoglycaemia: low nutrients, low plasma glucose, low insulin
Hypothermia: shunting blood to vital organs, decrease subcut fat, increase heat loss
Hypocalcaemia: Placental dysfunction less ca transfer to fetus
Perinatal asphyxia and meconium aspiration
HIV-assoc neurocog disorders
Impaired memory and attention/concentration
PERSONALITY, MOOD and BEHAVIOUR CHANGES
Motor sx (ataxia, slowed mvts)
Varies in severity from asx to dementia
Rfs: long-standing HIV disease, age >= 50, CD4 < 200
MRI: DIFFUSE brain atrophy, ventricular enlargement and increased white matter intensity
CF PML: sx: focal cortical involvement (e.g. motor deficits, ataxia, vision abnormalities); MRI well delineated ASYMMETRIC white matter lesions
N.B: primary CNS lymphoma: CD4 <100, focal neurological deficits, neuropsychiatric symptoms (e.g., personality changes), and headaches
Tx: Combination chemotherapy with high-dose METHOTREXATE (after a brain biopsy has been obtained). Radiotherapy if the patient has a poor functional status and for patients with intraorbital or spinal cord lesions.
NOT SURGERY
In patients with HIV-related PCNSL, administering antiretroviral therapy concurrently with definitive cancer treatment is essential for facilitating immune reconstitution.
Autoimmune hepatitis labs
Hepatocellular pattern of liver injury (raised AST/ALT, normal ALP and bili)
High levels of auto antibodies, leading to elevated serum globulins and GAMMA GAP (total protein - albumin >= 4)
Pos serology (anti smooth etc) and hypergammaglobulinaemia confirms dx
SSRI Anxiety
Activating effects (e.g. anxiety, insomnia) possible EARLY side effects of SSRI but improve with time
Pts w anxiety more sensitive to these effects so benefit from temp dose reduction or starting off at a lower dose
All children with social or language deficits should have what test
Hearing (repeated ear infections can cause conductive hearing loss, which can be confused with some behavioural disorders of childhood)
Uncontrolled infection of facial skin (/sinuses/orbits) can lead to?
Cavernous sinus thrombosis (facial/ophthalmic venous system is valveless)
CN 3, 4, 5 and 6 deficits
Severe headache, binocular palsies, bilateral periorbital oedema (impaired venous flow in orbital veins), hypo/hyperesthesia in V1/V2 distribution, vomiting (ICH), papilloedema
CF brain abscess: raised ICP from brain abscess -> brain herniation not bilateral periorbital oedema
Aortic regurg: valve disease vs root disease location of murmur
Both early diastolic
Valve disease: left sternal border
Aortic root disease: right sternal border
Neuro manifestation of sarcoid?
Facial nerve palsy
Other extrapulm manifestations:
cutaneous (papules, nodules, plaques, erythema nodosum),
opthal (ant/post uveitis, keratoconjunctivitis sicca),
neuro (FNP, central DI, hypogonadotropic hypogonadism),
cardio (AV block, dilated/restrictive cardiomyopathy),
GI (HSM, asx LFT abnormalities)
Plus: hyperca, peri lymphadenopathy, parotid gland swelling, polyarthritis, constitutional sx (fever, malaise)
* Lofgren syndrome
Sternal dehiscence
Complication of cardiac surgery
Separation of bony edges of sternum
Mild pain or sensation of chest wall instability and ‘clicking’ w chest mvt
Palpable rocking or clicking of sternum confirms dx
Mx: URGENT surgical exploration & repair
Trousseau syndrome
Hypercoag disorder
Recurrent and migratory superficial thrombophlebitis at UNUSUAL SITES (arm, chest area)
Assoc w pancreatic ca (also stomach/lung/prostate ca)
Ascites mx
Spiro with furosemide
Etoh abstinence, SODIUM RESTRICTION
Avoid ACEi, ARB, NSAID
Acute stress disorder: initial mx
Educate pts on range of reactions to trauma (physical, emotional): NORMALISING
Trauma-focused CBT beneficial for pts w severe and persistent sx
N.B: do not initially refer for individual psychotherapy as pt unlikely to be compliant
Borderline personality disorder pt w splitting: how to manage in hosp
See pt JOINTLY AS A TEAM to provide clear and consistent info and minimise tendency for splitting to impact tx
Polycythaemia in neonates
Hct > 65% in term neonates
Rfs: excessive transfusion (delayed UC clamping, T2T transfusion syndrome), intrauterine hypoxia (uteroplacental insufficiency e.g. smoking, mat DM) and genetic conditions (e.g. trisomy 21)
High blood viscosity limits organ perfusion and can cause resp distress, hypoglycemia and poor feeding
What to screen for in ALL women postpartum
INTIMATE PARTNER VIOLENCE (higher risk due to increased emotional, physical and financial stressors)
Essential tremour: tx
Beta blockers: propranolol
Anticonvulsants: primidone (given if beta blockers contraindicated e.g. asthma etc)
Diarrhoea not explained after extensive evaluation?
FACTITIOUS DIARRHOEA
Investigations:
stool osmolality (hypoosmolar = addition of dilute fluid; hyperosmolar = addition of conc fluid e.g. urine),
stool electrolytes (elevated Mg or phosph = use of saline osmotic laxatives),
stool osmotic gap (osmotic laxatives = high osmotic gap diarrhoea)
Unilateral cyrptoorchidism mx
<6mo: monitor for spont descent
>= 6 mo: refer for orchiopexy (perform at age 1 to reduce risk of test torsion, infertility and ca). Imaging not indicated prior to referral
Neonatal clavicular #
Rfs = birth weight > 4kg, shoulder dystocia, vacuum delivery
Mx = reassurance and gentle handling (self-limiting); place affected arm in long sleeve garment & pin sleeve to chest w elbow flexed to 90 degrees to decrease pain
Milk-alkali syndrome
Excessive intake of CALCIUM & ABSORBABLE ALKALI (usually in form of CALCIUM CARBONATE ANTACIDS)
Renal vasoconstriction and decreased GFR
Renal loss of sodium and water, reabsorp of bicarb
Triad: HYPERCALCAEMIA, AKI, MET ALKALOSIS
Rfs: CKD, thiazide use, NSAID, ACEi
Suppressed serum PTH, hypophosphataemia (intestinal binding of phosph by caco3), hypomagnasaemia (decreased renal absorp of mag)
Photosensitive skin w vesicles or bullae in areas of trauma or sun exposed skin
Porphyria cutanea tarda
Assoc w HEP C and warrants screening
Toxoplasmosis maternal acquisition
Ingestion of cat feces or UNDERCOOKED MEAT from animals infected with TG
N.B: diffuse intracranial calcifications of newborn seen (periventricular c in cong CMV infection which is spread by saliva
Also TG: macrocephaly/microcephaly; seizures. Serology/PCR
CMV: microcephaly; SNHL. Urine/saliva PCR
Routine prenatal lab tests (24-28 weeks; 36-38 weeks)
24-28 wks: Hb/Hct; Ab screen if RhD neg; 1hr 50g GCT (initial prenatal visit screening if high risk for T2DM)
36-38wks: GBS rectovag culture (not earlier even if GBS in prior preg)
Newborn cyanosis worsened by feeding and improved by crying
CHOANAL
Failure to pass catheter through nares into oropharynx dx
CF TEF w EA: coughing and choking w feeds and resp distress
Topical glucocorticoid eyedrops and systemic glucocorticoids can cause what in the eye?
RAISED IOP -> OAG
OAG: insidious loss of PERIPHERAL VISION
steroid-induced OAG: central blurriness due to corneal oedema
Second stage arrest of labour
Lack of fetal descent after >= 4hrs in a primi with epidural (>=3hrs w/o) and >=3hrs in multigravida with epidural (>=2hrs w/o)
Mx: operative vaginal delivery (e.g. VACUUM-ASSISTED)
Other indications for op vag delivery: mat exhaustion, fetal distress and mat conditions in which Valsava not recommended (e.g. HOCM)
All preterm neonates born <32 wks gest require what test?
Screening HEAD USS
Preterm babies increased risk of developing ICH due to presence of germinal matrix (friable, highly vasc area in brain). N.B: ICH can be asx therefore must screen ALL preterm babies
Synthetic cathiones (bath salts)
Amphetamine like properties
Severe agitation, combativeness, psychosis, delirium, myoclonus, seizures
Tachy, increased BP
Effects of intox may take up to a week to subside (CF other stimulants/hallucinogens which have much shorter duration of effect)
Labial adhesions (fused labia minora)
Seen in PREPUBERTAL GIRLS w LOW ESTROGEN production
Inflam from poor hygiene, infection, irritation, trauma also contributes
Partial adhesions asx no tx needed
Top estrogen first line for sx lesions
Microscopic colitis
Occurs in women >60
Water diarrhoea during periods of FASTING and/or at NIGHT
Colonoscopy: normal appearing mucosa
Biopsy: mononuclear infiltrate within lamina propria, subepithelial collagen band
Rfs: concurrent autoimmune diseases, cigarette smoking, NSAID use
Suppurative parotitis
Exquisitely painful swelling (firm, erythematous) of parotid glands
Exacerbated by chewing/palpation
Trismus, systemic findings (fever, chills)
Elevated serum amylase w/o pancreatitis
Rfs:
ELDERLY, DEHYDRATION, POSTSURGICAL
Decreased oral intake (NPO periop)
Meds (anticholinergics)
Obsrtuction (calculi, neoplasm)
Mx:
USS or CT scan (ductal obstruction, abscess)
Hydration, oral hygiene
Abx
Massage
Sialogogues
Aspirin exacerbated resp disease
Samter triad:
Asthma
Chronic rhinosinusitis with nasal polyps
NSAID-induced resp reactions (worsening sx after NSAIDs)
COX inhibitors result in imbalanced production of leukotrienes over prostaglandins
Crohn’s disease: fibrotic stricture
Severe uncontrolled inflam in CD can lead to fibrotic stricture of small bowel w SBO
Smoking and young age (under 30) at dx increases risk
Bilious emesis, severe abdo pain and inability to pass flatus and/or stool
Tx= surgery to remove strictured portion of small bowel
Rapidly progressive hirsutism w virilisation
Suggests very high androgen levels due to androgen-producing neoplasm
Elevated DHEAS seen in androgen-producing adrenal tumours:
Raised DHEAS, T; low LH
CF: PCOS (not as rapidly progressing): normal/raised DHEAS, T; high LH
Best study to study rare diseases and diseases with a long latency period?
CASE-CONTROL
SIBO
Proliferation of colonic or oral bacterial in SB
Rfs:
anatomic abnormalities (strictures, ILEOCECAL RESECTION or other surgeries, SB diverticulosis)
motility disorders (DM, scleroderma, opioid use)
immunodef (IgA def)
chronic pancreatitis
gastric hypochrlorhydria, PPI use
Bloating, flatulence
Chronic watery diarrhoea
Poss malabosption
Low B12 (bacteria consump), raised folate (bacterial synthesis)
Dx: CARBOHYDRATE BREATH TESTING (lactulose or glucose -> hydrogen production by bacteria fermenting carb earlier than normal)
Gold standard (but invasive): endoscopy w jejunal aspirate/culture
Tx: oral Abx (rifaximin, cipro, doxy)
Hypoparathyroidism mx
Calcium and vit D supplementation
CALCITRIOL (1,25D) preferred because it does not need PTH-mediated renal conversion to active form (ie renal 1 alpha hydroxylase dependent on PTH to convert 25 to 1,25D)
HypoPTH = iatrogen in adults, autoimmune in children
Suspected corneal injury (abrasion/laceration)
Look out for OGI w high velocity injury mechanism
OGI signs: visible entry wound, globe deformity, irregularly shaped pupil
In absence of OGI (CI to use of fluorescein/topical agents), further corneal assessment should be performed via FLUORESCEIN STAINING
N.B: penlight test (pupils, foreign body) and visual acuity before fluorescein staining
Fluorescein concentrates on BASEMENT MEMBRANE exposed by coreneal epithelial defect
Localised uptake: corneal abrasion
Uptake followed by CLEARING IN WATERFALL PATTERN = FULL THICKNESS CORNEAL LACERATION with OGI (caused by washout from leaking aqueous humour) -> IMMEDIATE OPHTHALM CONSULT
Rectus abdominis diastasis
Weakening of linea alba between rectus abdominis muscles
Nontender abdo bulge in PREGNANT/POSTPARTUM pts
Conservative mx reassurance
Recent acid ingestion -> gastric outlet obstruction sx?
PYLORIC STRICTURE
Confirm dx with UGI endoscopy; tx = surgery
Acute acalculous cholecystitis
Rfs:
Severe trauma/recent surgery
Prolonged fasting/TPN
Critical illness (sepsis, ICU, mech vent)
Fever, leucocytosis, RUQ pain +/- raised LFTs
Abdo USS
HIDA/CT if needed
Tx:
Enteric Abx coverage
Cholecystostomy for initial drainage
Consider cholecystectomy once stable
Neonatal withdrawal bleeding
Usually benign, caused by WITHDRAWAL OF MATERNAL HORMONES
Pathophys: fetal endometrial proliferation from mat estrogen followed by endometrial sloughing after delivery from mat progesterone withdrawal
Light, self-limited vag bleeding
+/- additional signs of maternal estrogen exposure: phys leukorrhoea, labial swelling, breast hypertrophy +/- galactorrhoea
Reassure pt
Resolves on its own within few days
Burns pts: initial mx
Initial stabilisation
If covering large TBSA, aggressive fluid resusc
URETHRAL CATHETERISATION ASAP to monitor UO (delay can lead to oedema that obstructs visualisation and catheterisation of urethra)
N.B: sharp surgical debridement for full thickness burns only performed 72 HOURS AFTER when burns fully demarcated (e.g. partial thickness may progress to full thickness during that time)
Idiopathic intracranial hypertension in children
VISIONAL ABNORMALITIES most prominent in prepubertal children (CF headaches in obese women)
Papilloedema leading to blurry vision and ENLARGED PHYSIOLOGIC BLIND SPOT (no rods/cones over area of optic nerve)
CN VI esp affected in children (diplopia and impaired eye abduction)
JVP waveform: Cannon A waves
JVP waveform: right atrial haemodynamics throughout cardiac cycle
Cannon A waves: intermittent, prominent A waves caused by surge in JVP that occurs due to RA contraction against closed tricuspid valve
Indicative of cardiac arrhythmia involving ATRIOVENTRICULAR DISSOCIATION (VT, complete AV block)
N.B:
ACxVy (A = RA contraction; C = RV contraction; V = peak of RA filling)
Absent A wave = AF
Prominent V wave & absent x descent = tricuspid regurg
Flattened y descent = cardiac tamponade
Achilles tendinopathy mx
Acute: activity mod, NSAIDs, ice
Chronic: eccentric calf-strengthening resistance exercises
Acute salicylate tox presentation
N/V, hyperventilation, HYPERTHERMIA (from HAGMA. leading to impaired aerobic resp so LACTIC ACIDOSIS (because gluconeogenesis impaired) and hyperthermia (byproducts of energy production))
ALTERED MENTAL STATUS
Septic abortion
Rfs: Retained POC from:
elective abortion w nonsterile technique
missed or incomplete abortion (rare)
Fever, chills, abdo pain
Sanguinopurulent malodorous vag discharge
Boggy, tender uterus; dilated cervix
Pelvic USS: retained POC; thick endometrial stripe
Mx:
IV fluids
Broad spectrum Abx
SUCTION CURRETAGE for uterine evacuation to remove nidus of infection
(Hysterectomy if pelvic abscess or condition does not improve after suction curretage and 48hrs of abx)
Drowning resp complication
ARDS
Aspirated liquid causes hypoxemia and can wash out pulm surfactant leading to ARDS
ARDS can develop INSIDIOUSLY so CARDIOPULM MONITORING required for at least 8 hours in all pts with a draining event, even if asx
Human factors engineering (HFE) design systems
Based on expected human behaviours to reduce errors
The most effective type involves PHYSICAL CHANGES that facilitate safe action w/o human effort and eliminate poss of error
e.g. epidural solution bags incompatible with peripheral IV catheters
Less effective HFE designs incorporate physical design changes but have a greater reliance on human effort (e.g. visual cues on bags)
Uterine inversion
Uterine fundus inverts and prolapses through cervix or vag after delivery
Firm, rounded mass protruding through cervix or vag
Likely occurs due to excessive fundal pressure and TRACTION ON UC prior to placental sep -> cord avulsion
Fundus no longer palpable transabd
Severe abdo pain and heavy vag bleeding w poss hemorrhagic shock
Mx: discontinuation of uterotonics (e.g. oxy) and IMMEDIATE MANUAL REPLACEMENT OF UTERUS to prevent exsanguination
If unsuccessful, uterine relaxants and laparotomy
Mag tox
Mild: nausea, flushing, headache, hyporeflexia
Mod: areflexia, hypocalcaemia, somnolence
Severe: resp paralysis, cardiac arrest
Common rf: renal insuff (as mag excreted by kidneys)
Tx: stop mag
Give IV calcium gluconate bolus
N.B: MgSO4 given to prevent eclamptic seizures and also for fetal neuroprotection at under 32 weeks gest (decrease risk for cerebral palsy)
M/c cause of MR in developed countries?
MVP
Occurs due to myxomatous degen of mitral valve leaflets and chordae causing mid-systolic click followed by mid-late systolic murmur
Interstitial cystitis
Aka painful bladder syndrome
Pain exacerbated by bladder filling and relieved by voiding
May also have dyspareunia and urinary frequency/urgency
More common in women; assoc w psych and pain disorders (e.g. fibromyalgia)
Rett syndrome
Period of normal dvp followed by regression of speech, loss of purposeful hand use (e.g. twisting fingers), stereotypical mvts, gait disturbance
DECELERATION IN HEAD GROWTH (microcephaly), BREATHING ABNORMALITIES (alt hyper/hypoventilation esp during periods of heightened emotion), autistic behaviours and seizures
SAAG
> = 1.1 indicates PORTAL HTN (cirrhosis, HF)
↑ Protein levels (> 2.5 g/dL)
Right heart failure
Early Budd-Chiari syndrome
↓ Protein levels (< 2.5 g/dL)
Cirrhosis
Severe liver metastases
Late Budd-Chiari syndrome
<1.1 indicates no portal HTN (malignancy, TB, nephrotic syndome, pancreatitis)
↑ Protein levels (> 2.5 g/dL)
Peritoneal carcinomatosis
Pancreatitis
Tuberculosis
Chylous ascites (not secondary to cirrhosis)
↓ Protein levels (< 2.5 g/dL)
Nephrotic syndrome
Severe malnutrition
Mediastinal masses
Characterised according to location
Anterior: thymoma, lymphoma, germ cell tumours, thyroid tissue (ectopic, substernal goiter)
Middle: lymphadenopathy (sarcoid, lung ca), lymphoma, benign cyst masses (pericardial cysts, BRONCHOGENIC CYST*), vasc masses, oes tumours
Posterior: neurogenic tumours (schwannoma, neurofibroma), meningocele, spinal masses (metastases), lymphoma
*arise from anomalous budding of foregut
infancy/adulthood: may become sx with chest discomfort and recurrent coughing/frequent resp infections
CT chest w IV to confirm
Premature adrenarche
More common in OBESE children
Early activation of adrenal androgens
Precocious dvp of pubic and axillary hair, acne and body odour in child with normal bone age
CF CAH: advanced bone age due to much higher levels of androgens
Shiga toxin E coli
Food borne pathogen (eg contaminated beef) causes inflammatory diarrhoea
Stools initially watery then become bloody
Most pts AFEBRILE (if fever, consider other pathogens)
Signs of uteroplacental insufficiency
Late decelerations on non-stress test
OLIGOHYDRAMNIOS on USS (single deepest pocket <2cm) because blood shunted from kidney (which produces amniotic fluid) to brain
Late (>= 41wks) or post-term (>= 42wks) preg plus one of above: IMMEDIATE DELIVERY due to risk of intrauterine fetal demise
If reactive non-stress test and/or vertex pos -> induction of labour
If abnormal fetal heart rate tracings (e.g. late decelerations) or fetal malpresentation (e.g. breech) -> C section
N.B: amnioinfusion done if variable decelerations (which occur 2 to oligohydramnios from ROM and subsequent cord compression)
Nonstress test
Performed for preg at risk for fetal hypoxemia, acidemia and/or demise or for decreased fetal mvts
Reactive vs non reactive
Reactive:
Baseline of 110 to 160/min
Mod variability (6-25/min)
>= 2 accelerations in 20 mins, each peaking >=15/min above baseline and lasting >= 15sec
Nonreactive:
Does not meet criteria for reactive
Concerning for fetal hypoxemia and acidemia
M/c cause of nonreactive is benign: QUIET FETAL SLEEP CYCLE (lasts <= 40min)
Therefore nonreactive nonstress test extended (40-120min) to ensure that fetal activity outside of sleep noted
PICC line DVT
Increases risk of upper extremity DVT
Risk highest in hosp pts, esp those w malignancy or hypercoag state
Arm swelling, erythema and pain
Dx: DUPLEX USS
Tx: 3 mo anticoag
Complicated vs uncomplicated parapneumonic effusions
Complicated: bacterial invasion of pleural space, requires drainage w chest tube in addition to abx
Pos pleural fluid gram stain/culture dx of complicated effusion and require CHEST TUBE placement
Pleural fluid characteristics: pH <7.2, glucose <60, wbcs >50,000, LDH >1000
CF uncomplicated is sterile invasion of pleural space and opp figures to above. Only require abx
Single brain abscess
Usually results from direct extension of an adjacent infection (OM, sinusitis, dental infection)
VIRIDANS STREP & STAPH AUREUS 2 m/c isolated organisms
Headache, fever, focal neuro deficit, seizure
Brain imaging (CT/MRI): single ring-enhancing lesion with central necrosis
CF Rhizopus causes nectroic and highly destructive lesions and occur in pts w DM or severe immunocompromise
Infected pancreatic necrosis
Worsening abdo pain, unstable vital signs or signs of infection 7-10d after onset of acute necrotising pancreatitis
CT ABDO: gas within pancreatic necrotic collection
Cerebral vein and venous sinus thrombosis presentation
Variable
Comb of headache, increased ICP, seizures and/or focal deficits
N.B: venous sinuses’ dual anatomic function: CSF drainage and cerebral venous blood return
So raised ICP signs/sx, impeded blood return leading to venous stroke/hemorrhage
Dx clinical and prothrombotic rfs (e.g. OCP use) often present
Brain MRI w MR venography dx
Tx anticoag w heparin (continue even if hemorrhage as risk of worsening hemorrhage low)
CF ICH: focal neuro signs not present
Retropharyngeal abscess in children
Fever, dysphagia, muffled voice and pain w neck extension
Lateral neck soft tissue X ray: WIDENED PREVERTEBRAL SPACE
Mx: airway protection, IV abx, +/- surgical drainage
Transverse myelitis
Immune med destruction of spinal cord
Often post infectious (molecular mimicry)
Bilateral motor weakness, early flaccid (LMN) then late spastic (UMN)
Bilateral sensory dysf (ALL modalities CF infarction of ant spinal artery: vib and proprioception spared, loss of pain and temp sensation below present)
DISTINCT SENSORY LEVEL
Aut dysf (bladder/bowel)
MRI spine: no compressive lesion, T2 hyperintensity
LP: raised WBCs, raised IgG index
Tx: high dose IV glucocorticoids
Plasmapheresis
N.B: GBS aka acute inflam demyelinating polyneuropathy: no UMN signs and no distinct sensory level
N.B. 2: presentations of MS include: transverse myelitis, INO, optic neuritis and cerebellar dysfunction. These initial presentations may not be disseminated in time.
Metartasus adductus vs clubfoot
MA (m/c congenital foot deformity): medial deviation of forefoot, neutral position of hindfoot, flexible pos typical. Tx: REASSURANCE
Clubfoot: medial/upward deviation of forefoot & hindfoot, hyperplantar flexion of foot, rigid pos typical (congenital clubfoot). Tx: SERIAL MANIPULATION & CASTING; surgery for refractory cases
Telogen effluvium
Acute, diffuse, noninflam hair loss
Triggered by stressful event, e.g. weight loss, preg, major illness/surgery, or psych trauma
Widespread thinning of hair but scalp and hair shafts normal
Self-lim disorder, takes up to 1 year to resolve
Penetrating chest trauma with signs of shock
HEMORRHAGIC until proven otherwise
Tx: TUBE THORACOSTOMY
EMERGENT THORACOTOMY for extreme bleeding incl:
Initial bloody output >1500ml
Persistent hemorrhage or continuous blood transfusion to maintain HD stability
PLT dysf in CKD
M/c cause of abnormal haemostasis (easy bruising, nonpalpable purpura)
PT and PTT normal; PLT count normal or slightly low
Pathophys: uraemia -> elevated urea -> arginine (substrate for urea production) and its precursors shunted to diff pathway -> increased NO -> inhibit primary hemostasis via decreased PLT adhesion, activation and aggregation
Psychogenic pseudosyncope
Type of CONVERSION DISORDER
Assoc w:
Prolonged LOC e.g. 20 mins vs 1-2 min in syncope
Absence of objective findings (e.g. pallow, sweating, abnormal vital signs)
Pt’s awareness of sx during syncopal episode e.g. felt head throbbing while on floor
Postop pneumonia: postop measures
INCENTIVE SPIROMETRY
Deep breathing exercises
N.B: prophylactic abx prior to surgery only given to pts w preexisting lung condition
IRB approval and informed consent
All research involving human participants require IRB approval
If using secondary data (e.g. medical charts) and limited risk to participants, informed consent NOT needed
Fragile X syndrome life expectancy
Normal (CF Down’s)
Long face, prominent chin and forehead, protruding ears, joint hypermobility and macrocephaly
Assoc dvp delays and ADHD common
Heat exhaustion vs exertional heat stroke
HE: hyperthermia (<= 40C) assoc w weakness, dizziness, profuse sweating, headache and/or nausea
NORMAL MENTATION (CF EHS)
Mx: cooling (e.g. cold water shower) and oral hydration w salt-containing fluids
Pseudothrombocytopenia
Lab error characterised by PLT aggregation in vitro
Peripheral smear: large clumps of PLTs
No further investigations needed
Adolescent girl w high suspicion for fibroadenoma
OBSERVATION & REEXAMINATION after completion of full menstrual cycle (e.g. 6 weeks) as oes sensitive and size/tenderness change w menses
If enlarging after 6 weeks then eval w breast USS
If static at 6 weeks, continue to follow up every 6-12 months for 1-2 years to evaluate for tumour growth and exclude malignancy/phyllodes tumour
LTOT criteria in COPD
PaO2 <= 55 or SaO2 <=88% RA
PaO2 <=59 or SaO2 <=89% in pts w cor pulmonale, evidence of RH strain or Hct > 55%
Dialysis related amyloidosis
Inadequate clearance of beta 2 microglobulin despite dialysis
Prevalence increases w age and dialysis duration
Predilection for OSTEOARTICULAR structures presenting as:
SCAPULOHUMERAL PERIARTHRITIS (shoulder pain/hypertrophy)
carpal tunnel syndrome
bone cysts
PCP: when to give corticosteroids (in addition to TMP-SMX)?
PaO2 <= 70
Alveolar-arterial grad >= 35
or Pulse ox < 92% on RA
to reduce risk of resp decompensation
M/c cause of acute pancreatitis in otherwise healthy child?
BILIARY CYST (dilation of biliary tree, most commonly involves CBD)
Asx: incidental finding on imaging
Sx: RUQ pain, jaundice and/or RUQ mass
Acute complications: pancreatitis, cholangitis and stone formation
Why increase risk of pancreatitis? Due to abnormally long pancreatobiliary junction so predisposes to obstruction, leading to reflux of pancreatic fluid as well as cholestasis (conj hyperbili)
M/c lung ca in young nonsmokers?
BRONCHIAL CARCINOID tumours
Arise in prox airway, causing airway obstruction (dyspnea, wheezing, postobstructive pneumonia) or hemoptysis
CT scan w contrast: avidly enhancing (hypervasc) mass w an endobronchial component
CF small cell: bulky hilar and mediastinal mass
squamous cell: central cavitation (heterogeneous density) due to tumour necrosis
Rare cause of delayed passage of meconium (>48hr)?
CONGENITAL HYPOTHYROIDISM
Constipation, large fontanelle (delayed bony maturation), hypotonia and poor feeding or growth
IE pathogens
Following dental/resp tract procedures: VIRIDANS STREP (e.g. Strep sanguinis, mitis, mutans, milleri). Causes late-onset IE of prosthetic valve (>1 year after valve placement). CF staph epidermidis causes early-onset IE of prosthetic valve (<1 year after valve placement)
Manipulation of infected areas of GI/GU tract: ENTEROCOCCUS
Following skin/soft tissue infection or in IVDU: STAPH AUREUS (acute) or coag neg Staph (STAPH EPIDERMIDIS)
OSA in children
Nighttime snoring and GASPING FOR AIR
Caused by ADENOTONSILLAR HYPERTROPHY (CF obesity in adults)
Open mouth breathing during day (nasal obstruction secondary to adenoid hypertrophy)
Tx: tonsillectomy and adenoidectomy
Selective mutism in children
Verbal at home but refuse to speak in specific social settings e.g. school
Considered an anxiety disorder and should be tx early to prevent long-term educational and social impairment
CBT w graded exposure to social situations, family therapy or SSRI
CVC placement complications
Placed in internal jugular vein (using USS) or subclavian vein (anatomic landmark)
CVC tip ideal placement is in lower SVC
Tip placement in smaller veins -> VENOUS PERFORATION
Inappropriate tip placement -> PNEUMOTHORAX or myocardial perf leading to PERICARDIAL TAMPONADE
ARTERIAL PUNCTURE (e.g. subclavian) also risk esp if done without USS
PORTABLE CXR should be performed immediately post insertion (except if completely uncomplicated insertion)
Chronic radiation proctitis
Obliterative endarteritis and submucosal fibrosis
Leading to ANORECTAL STICTURE formation, reduced rectal compliance, constipation and fecal intolerance
Chronic tissue hypoxia -> neovasc and telangiectasia -> hemorrhage
Vertebrobasilar insufficiency
M/c due to ATHEROSCLEROTIC DISEASE
Results in transient ischaemia of regions supplied by VB system (brainstem, cerebellum, occipital lobes) when cerebral perfusion is further reduced (e.g. standing up)
Dizziness/vertigo, brainstem sx (diplopia, dysarthria) and bilateral motor and/or sensory sx
CT angio head/neck dx
Hemoptysis initial mx
Establish adequate patent airway
Maintain adequate ventilation and gas exchange
Ensure HD stability
Place pt w bleeding lung in dependent pos (lateral pos)
BRONCHOSCOPY to identify site and attempt early therapeutic intervention
Surgery if ongoing unilateral bleeding despite initial bronchoscopy and/or pulm artery embolisation
N.B: massive hemoptysis = >600ml of blood over 24 hr period or bleeding rate > 100ml/hr
Achilles tendinopathy location of tenderness
2-6cm prox to insertion of tendon on calcaneus
CF sc calcaneus bursitis: at calcaneal prominence (Achilles tendon insertion site)
Myasthenic crisis
Precipitating factors:
infection or surgery
preg or childbirth
tapering of immunosuppressive meds
meds (aminoglycosides, beta blocker)
Increased generalised and oropharyngeal weakness
resp insufficiency/dyspnea
INTUBATION for deteriorating resp status
PLASMAPHARESIS or IVIG as well as CORTICOSTEROIDS
N.B: do NOT increase pyridostigmine dose as it is an cholinomimetic so causes increased secretions, worsening resp status
Multifocal atrial tachycardia
SVT
Distinct P waves with >= 3 different P wave morphologies, atrial rate > 100/min and irregular rhythm
Precipitated by acute resp illness in pts w underlying lung disease
Tx: correct underlying inciting disturbance
Bariatric surgery indications
BMI >= 40
or BMI >= 35 and additional weight-related comorbidity
Weight loss med indicated for pts w BMI >= 30 or those w BMI 25-29.9 and weight related complications
Both interventions may be pursued concurrently
Malignant pericardial effusion
Large and prone to recurrence
Acute mx w pericardiocentesis
Prevention of reaccumulation, either by PERICARDIAL WINDOW or PROLONGED CATHETER DRAINAGE
First step in tick mx
Removal with small forceps as close to skin surface as possible
Pull firmly upwards without twisting
N.B: body of tick should not be squeezed or crushed as this can expel secretions into the wound and increase transmission risk
If deer tick attached for >= 36 hours, prophylactic single dose of DOXY within 3d of tick removal
CF abx prophylaxis not effective for anaplasmosis and babesiosis
Pyromania
Intentional and repeated fire setting with no obvious motive
Pts have fascination with fire and deliberately start fires to reduce tension and feel pleasure or relief
Rfs for C diff infection
Abx use, CYTOTOXIC CHEMO, recent hospitalisations, advanced age (>65)
Stool PCR dx
C diff: watery diarrhoea, abdo cramps, nausea, fever, LEUKOCYTOSIS
Hepatorenal syndrome
Rfs: advanced cirrhosis w portal HTN
Acute liver failure, severe alcoholic hepatitis
Patho: splanchnic vasodilation (from release of vasodilators e.g. NO) -> renal hypoperfusion -> RAAS activation -> overwhelming renal vasoconstriction -> AKI
Precipitants: GI bleed, infection (e.g. SBP)
N.B: SBP tx = cefotaxime;
prophylaxis = fluoroquinolones
Dx: bland urinalysis (no red cells, casts or protein)
very low urine Na (<10)
exclusion of other causes of AKI
NO IMPROVEMENT W TRIAL OF VOL EXPANSION
Tx: albumin + splanchnic vasoconstrictors (terlipressin, norepi, or midodrine + octreotide)
liver transplantation curative
N.B: cirrhosis (not advanced): release of prostaglandins -> vasodilation -> ascites and ADH release -> H20 retention -> hyponatraemia; hypokalaemia as well due to vomiting/diarrhoea/diuretic use
M/c cause of congenital bone marrow failure
FANCONI ANEMIA
Defective DNA repair impairs normal HSCT production and predisposes to malignancy (e.g. leukaemia)
Pancytopenia, short stature, HYPOPLASTIC THUMBS, ABNORMAL SKIN PIGMENTATION
Gabapentin toxicity
Encephalopathy and myoclonus, relieve on discontinuation
Other causes of myoclonus:
Physiologic (sleep transitions, hiccups)
Infectious/metabolic (meningitis, liver failure)
Neurodegenerative disease (Parkinson’s, CJD)
Seizure disorder
Med side effects (serotonergics, anticonvulsants)
Female and male pattern hair loss
Follicular miniaturisation
Men: effect of DHT on genetically suspectible follicles
Women: isolated/idiopathic (most cases) or due to hyperandrogenism (e.g. PCOS)
Men: vertex, frontal hairline, temporal areas
Women: vertex, frontal scalp (spares hairline)
Tx men: oral finasteride, top minoxidil
Women: top minoxidil
Chemo causes what type of amenorrhoea?
Hypergonadotropic hypogonadism (primary ovarian insufficiency)
Recommendations for intubated pts to reduce risk for VAP
HEAD OF BED ELEVATION AT 30-45 degrees
Suction of subglottic secretions
Min of pt transport
Limited use of gastric acid inhibitors (to reduce burden of microorganisms in gastric secretions)
Causes of acute cholangitis?
Acute cholangitis: infection of extrahepatic biliary system, occurs due to biliary obstruction (bile stone, ca, STRICTURE e.g. PSC)
Vit K deficiency
Due to inadequate dietary intake (e.g. NPO), intestinal malabsorption and hepatocellular disease
An acutely ill pt with underlying liver disease can become vit K def in 7-10d
Labs: prolonged PT followed by prolonged PTT
CF DIC: prolonged PT, PTT but low platelets, low fibrinogen, raised D dimer etc
QI methodologies
Lean: identification and removal of inefficiency and waste in a CURRENT workflow (CF failure modes and effects analysis: prospective so identifies POTENTIAL errors)
Six Sigma: near elimination of defects through STATISTICALLY DRIVEN process improvement
Model for improvement: incremental cycles of planning, piloting, assessing and refining intervention to achieve goal (PDSA cycle)
Change management: engaging personnel to adopt innovation & implement organisational changes
Acute painless vision loss
Central retinal artery occlusion
Central retinal vein occlusion
Retinal detachment: floaters, photopsia, progressive visual field defect; funds w vitreous hemorrhage and marked elevation of retina; surgical correction
Vitreous hemorrhage: hazy vision +- red hue or vision loss, floaters/shadows; PROLIFERATIVE DIABETIC RETINOPATHY rf; decreased/absent red reflex, RBCs/floating debris in vitreous, obscured view of fundus; bed rest, HOB elevation (30-45 deg), photocoag/vitrectomy in some cases
Normal internal genitalia, external virilisation and undetectable serum estrogen levels in F pt?
Aromatase deficiency
CF CAH: classic type (21 alpha hydroxylase def): ambiguous ext genitalia at birth, normal female internal repro organs, hyponatremia; non-classic type: later in life: primary amenorrhoea and virilisation at puberty but normal genitalia at birth
Anti-NMDA R encephalitis assoc w what in young women?
M/c in young women (median age 21)
Assoc w OVARIAN TERATOMA
Exercise-assoc hyponatraemia
Due to combination of EXCESSIVE FLUID INTAKE and NONOSMOTICALLY MEDIATED RELEASE OF INAPPROPRIATELY HIGH LEVELS OF ADH
In severe cases, pts may experience seizures, profound confusion and even death
Other nonosmotic causes of ADH release:
nausea, pain, physical or emotional stress, hypotension, hypovol, hypoxia, hypoglycaemia
N.B: high altitude cerebral edema is rare and accompanied with severe headache and concomitant pulm oed
Chikungunya virus infection
Carribean, central/South America, Africa, Asia
Aedes mosquito
Incubation: 3-7d
HIGH FEVER, SEVERE POLYARTHRALGIA
Headache, conjunctivitis, myalgia, MP diffuse rash (CF SLE sun-exposed eg malar)
Lymphopenia, thrombocytopenia, transaminitis (like Ehrilichiosis)
Supportive care
Chronic arthralgia frequently occurs (MTX may be needed)
Buproprion useful for MDD with what features?
Low energy, impaired concentration, hypersomnia and weight gain
As it has MILD STIMULANT PROPERTIES
Can also be used for SMOKING CESSATION
Pregnancy and exercise
Absolute CIs:
amniotic fluid leak
cervical insufficiency
multiple gestation
placental abruption or previa
premature labor
preeclampsia/GHTN
severe heart or lung disease
Antepartum fetal surveillance
BPP= Nonstress test plus USS measuring:
amniotic fluid vol
fetal breathing mvt
fetal mvt
fetal tone 2 points per cat if normal, 0 if abnormal. normal = 8 or 10
N.B: if NST is abnormal (< 2 accelerations / recurrent variable/late decelerations) indicative of either fetal sleep cycle (benign cause) or fetal hypoxia/acidemia. Further eval w BPP
Contraction stress test (FHR monitoring during contractions) used to assess fetal wellbeing if BPP equivocal (6/10) . Abnormal if late decelerations w >50% contractions
Umbilical artery doppler USS used to monitor FGR (est FW < 10th centile)
Hyperventilation syndrome tx
Reassurance w BREATHING RETRAINING (abdo diaphragmatic breathing)
If not improving, small dose of benzo e.g. lorazepam
breathing into paper bag NOT recommended as can cause hypoxia
Uric acid kidney stones tx
ALKALINISATION of urine (POTASSIUM CITRATE)
Reduction of uric acid production (low-purine diet, allopurinol)
N.B: thiazide diuretics decrease uric acid secretion but can lower urine pH so making uric acid stones more likely to form
Displaced supracondylar fracture of humerus
FOOSH w post displacement of distal humerus fragment
Ant displaced prox humerus fragment can entrap BRACHIAL ARTERY & MEDIAN NERVE which pass anterior to the humerus
N.B: ulnar nerve injury from supracondylar fracture from FLEXED elbow (not hyperextended)
Asthma exacerbation: reduced breath sounds, dullness to percussion, trach deviation to affected side?
Mucous hypersecretion (dark-coloured sputum) leading to formation of MUCOUS PLUG in airways
Leading to ATELECTASIS
N.B: trach dev away from affected side if large pleural effusion/TP
Which asx murmurs require echo?
DIASTOLIC & CONTINUOUS usually due to pathological cause so require TTE
CF midsystolic murmurs in young asx pts usually benign no need for echo
Abrupt cessation of short acting benzos e.g. alprazolam causes?
Sig withdrawal sx
Incl risk for GENERALISED SEIZURES & CONFUSION
Also tremours, anxiety, perceptual disturbances, psychosis
Food-protein induced allergic proctocolitis
Non-IgE mediated reaction to a protein (typically COW’S MILK/SOY)
BLOODY STOOLS in well-appearing infants (m/c age 1-4 weeks)
Rf for ABRUPTIO PLACENTAE?
UTERINE OVERDISTENSION (twin gest, severe polyhydramnios) because sudden loss of amniotic fluid leads to uterine decompression causing placental hemorrhage and separation
Rigid, tender uterus and uterine irritability (high-frequency contractions) because bleeding increases intrauterine pressure
Other rfs: HTN, pre-eclampsia, cocaine, tobacco, abdo trauma, prior placental abruption
Mechanism for kidneys compensating for primary met ac?
Increase bicarb reabsorption (in prox tubule: carbonic anhydrase enzyme) and H+ excretion
Increased bicarb reabsorp causes increased Cl- excretion (in collecting duct) (to maintain total body electronegative balance)
Most of excreted H+ in form of NH4+ or H2PO4-
(Resp compensation w hyperventilation is main compensation for primary met ac)
Acute interstitial nephritis triad
FEVER, MP RASH, AKI (+/- arthralgias)
Pyruia, HM, white cell casts
Eosinophilia, urinary eosinophils
Drugs: penicillins, TMP-SMX, NSAIDS, cephalosporins
Neonate w cholestasis (jaundice, acholic stools, dark urine) and mass in RUQ (subhepatic)
BILIARY CYST
(Biliary atresia = absent or abnormal GB)
Late-look (Neyman) bias seen in which study?
Cross-sectional
Biased in favour of longer-lasting and milder conditions as cross-sectional is a snapshot so misses out acute and more severe conditions
CF ecological fallacy is when you are analysing country-level data and then making inferences on individuals
Hyperextension injuries in elderly pts can cause what?
CENTRAL CORD SYNDROME
(esp if elderly pts have cervical spondylosis)
Loss of pain and temp sensation (decussating fibers of spinothalamic tract) in upper extremities and disproportionate upper extremity weakness (with larger lesions affecting lateral corticospinal tracts)
Another classic (altho slowly progressive) cause of CCS is syringomyelia
Mixed cyroglobulinemia syndrome
Small-vessel vasculitis that causes PALPABLE PURPURA (CF TTP nonpalpable petechial rash), GLOMERULONEPHRITIS, ARTHRALGIAS & PERI NEUROPATHY
Labs: cryoglobins, RHEUMATOID FACTOR (due to IgM binding to Fc region of IgG). Immune complexes activate complement so HYPOCOMPLEMENTEMIA and deposit in small vessels of organs causing the vasculitis
CHRONIC HEP C m/c cause, check serologies in all cases
False labour
Mild, irregular contractions that cause no cervical change and ultimately resolve without intervention
Discharge home w labour precautions
Acute calculous cholecystitis tx
PIPERACILLIN-TAZOBACTAM (due to high risk for secondary bacterial infection w aerobic/anaerobic pathogens) while awaiting cholecystectomy
Language disorder vs specific learning disorder
Language disorder: persistent difficulties in acquisition and use of language due to deficits in comprehension and/or production
Specific learning disorder: requires use of standardised achievement testing to dx but language disorder is a rf for SLD
AVN features
Groin pain on weight bearing
Pain on hip ABDUCTION & INT ROTATION
No erythema, swelling or point tenderness
NORMAL WBC
NORMAL ESR & CRP
CRESCENT SIGN seen in advanced stage (X ray may be normal initially)
MRI most sensitive modality
Pathologic murmur characteristics vs benign
Pathologic:
Holosystolic (could be VSD)/diastolic
Harsh
Grade >= 3 intensity
Intensity persists w Valsalva & standing
Loud, fixed or single S2
Hepatomegaly
ECG & ECHO
Benign:
Early or midsystolic
Musical or vib
Grade 1-2 intensity
Decreases or disappears w Valsalva & standing (N.B: venous hum is benign but increases w standing)
Normal S1 & S2
REASSURANCE
Dupuytren contracture
Rfs:
Male, age >50, FHx
DM
Tobacco and alcohol
MANUAL WORK (e.g. gardening)
Thickening of palmar fascia at 3rd, 4th & 5th digits
Discrete FIBROTIC NODULES & CORDS along flexor tendons near distal palmar crease
Gradual decrease in extension of digits
Mod of hand tools
Needle aponeurotomy
Intralesional glucocorticoid injection
Surgery for contractures or advanced disease
Bacterial aspiration pneumonia mx
No empyema/lung abscess: treat for CAP (ie pen tolerant: amox/co-amox (if higher risk) & macrolide/doxy; if pen allergic: cephalosporin & macrolide/doxy; if cephalosporin intolerant: fluoroquinolone)
Empyema/lung abscess present: extend coverage to include ANAEROBES (AMPICILLIN-SULBACTAM)
Sedative-hypnotic overdose
E.g. combined effects of etoh & benzos
Benzo OD on its own: altered mental status, ataxia, slurred speech
When VITAL SIGN DERANGEMENT OR RESP DEPRESSION seen, CO-INGESTION with other sedative-hypnotics or CNS depressants should be considered
Torus palatinus
Benign bony growth (exostosis) on midline suture of hard palate
Congenital or dvp later in life
Chronic and asx
Surgery if mass becomes sx, interefers w speech/eating/denture fitting etc
Infective endocarditis abx tx
Depends on condition of valve (prosthetic or native) and prior hx of IVDU
Native: VANCO
Once organisms identified on blood cultures than abx can be changed accordingly
Infantile hemangioma mx
Observation for most lesions
PROPRANOLO for high risk e.g.
Large, facial, segmental, rapidly growing
Periorbital
Hepatic
Subglottic
Distal symmetric polyneuropathy triggers
DM (diabetic neuropathy)
Long standing HIV infection
Uraemia
Meds (FLUOROQUINOLONES, METRONIDAZOLE)
Chemo (cisplatin, paclitaxel)
Toxicity (alcohol abuse, heavy metal exposure)
Proportionality ethical principle
Ensure that methods used to achieve a worthwhile goal are necessary, appropriate and not excessive
Congenital melanocytic nevus
First few months of life as hyperpigmented patches w an INCREASED DENSITY OF HAIR FOLLICLES
CF nevus simplex (eyelids, neck, fade w time) and flammeus (port wine stains, does not fade with time, unilateral on face) are flat, blanchable and erythematous vasc birthmarks
Constrictive pericarditis
Etiology:
Recurrent idiopathic or viral pericarditis
Cardiac surgery or radiation therapy
Tuberculous pericarditis
Fatigue, dyspnoea on exertion
Peripheral oedema, ascites, hepatic congestion
Pericardial knock in early diastole
JVD w positive Kussmaul sign and prominent y descent
ECG: low voltage QRS complexes
CXR/CT: PERICARDIAL CALCIFICATION
Echo: BIATRIAL ENLARGEMENT, NORMAL ventricular wall thickness and cavity size
CF cardiac amyloidosis: ventricular Wall thickness present and no calcified pericardium
Physiologic anaemia of infancy
Asx condition
Normal decrease in Hb with a nadir at age 2-3 mo
Normocytic anaemia with low to normal retic count
Transient downregulation of EPO due to increased tissue oxygenation after birth
Anaemia resolves with increased erythropoietin drive after age 3 mo
Molluscum tx in adults
Cryotherapy w liquid nitrogen
Curettage
Topical therapy (cantharidin, podophyllotoxin)
Pts w GDM required regular what?
Non-stress tests beginning from 3rd trimester due to increased risk for stillbirth
Emphysematous cholecystitis
Life-threatening form of acute cholecystitis
Fever, RUQ pain, N/V
Crepitus in abdo wall adjacent to GB
Rfs: DM, vasc compromise, immunosuppression
Air-fluid levels in GB, GASS IN GB WALL
Cultures w gas-forming Clostridioides, E coli
Unconj hyperbili, mildly elevated aminotransferases (CF acute cholecystitis: raised ALP, conj bili)
Emergency cholecystectomy
Broad spectrum abx w Clostriodes coverage (tazosin)
Effects of positioning in a pt w pneumonia
Alveolar consolidation causes V/Q mismatch from localised intrapulm shunting
Pneumonia down -> increased perfusion of poorly ventilated region -> increased V/Q mismatch and worsened hypoxaemia
Pneumonia up -> decreased perfusion of poorly ventilated region -> decreased V/Q mismatch and improved hypoxaemia
Blood products in haemorrhagic shock
Administer early in ratio of 1:1:1 (FFP/packed red cells/platelets) to reduce coagulopathy (major mortality in trauma pts)
Mixed connective tissue disease
Clinical features of SLE, SS, RA and polymyositis that appear sequentially
Important manifestations: Raynauds, swelling of fingers and hands, inflam arthritis and myositis
AUTOANTIBODIES for U1 RIBONUCLEOPROTEIN
Hodgkin lymphoma prognosis, recurrence, second malignancy
Usually curable w chemo and radiation
Risk of death sig elevated in those getting treatment compared to age-matched pop
For first 8-10 years, most deaths due to HL relapse; thereafter most due to second malignancy and cardiovascular disease
Can parents refuse life-saving treatment for their child in emergency situations?
No
Mag tox
Causes: renal impairment, increased mag intake
Neuromuscular: low reflexes, paralysis, weakness, resp failure
CVS: hypotension, brady, conduction defects
Electrolyte: hypoca
Discontinue mag meds
IV fluids +- loop diuretics
IV ca for NM and CVS sx
HD in severe renal impairment
Left ventricular vs right ventricular MI
Left:
pulm oed, S3 & S4
ischaemic changes in ant, lateral or inf leads
increased LV and RV preload
increased SVR
Mx: fluid restriction (due to pulm oed), preload and afterload reduction, reperfusion therapy
Right:
clear lungs & JVD, marked hypotension
atypical epigastric pain, nausea, no SOB
inf ischaemic changes, ST elevation in V4R*, bradyarrhythmias (due to RCA occlusion so infarct to SAN/AVN)
increased RV preload, decreased LV preload
increased SVR
Mx: *RV involvement eval w right-sided precordial ECG, fluid resuscitation, avoid preload reduction, reperfusion therapy
N.B: cardiogenic shock: dobutamine/norepinephrine/ dopamine
Endometrioma USS findings
e.g. endometrioma may be on ovary
UNILOCULAR, HYPOECHOIC adnexal mass on USS
CF tuboovarian abscess: complex multicystic adnexal mass w enhancing rims
DVT and absolute CI to anticoag. Mx?
IVC FILTER
Lupus anticoagulant (anti-phospholipid abs) features
Prolonged PTT that fails to correct w MIXING TEST (combination w normal plasma)
Most pts w these autoantibodies are asx but can go on to develop APS
CF VWD: mixing test would correct PTT
IE: organism assoc w nosocomial UTI
ENTEROCOCCI esp Enterococcus faecalis
Multidisciplinary rapid response teams
Provide clinical assessment and early intervention for hosp pts at high risk for clinical deterioration
Can support primary care teams and reduce in-hosp mortality rates
Necrotising (malignant) otitis externa
Rfs:
Eldery (age >60)
DM
Aural irrigation (cerumen removal)
Micro: PSEUDOMONAS AEURIGINOSA
Severe, unremitting ear pain (WORSE AT NIGHT & WITH CHEWING)
Deficits of lower CNs (VII, IX, X)
GRANULATION TISSUE in ext aud canal
Elevated ESR
IV cipro +- surgical debridement
High-grade squamous intraepithelial lesion Pap test requires?
IMMEDIATE COLPOSCOPY (even in preg pts) and biopsy of cervical abnormalities due to high risk of progression to cervical ca
Colposcopy identifies cervix under magnification and uses acetic acid to contrast and identify abnormal (ACETO-WHITE CHANGES) from normal cells, abnormal vessels (feature of high-grade) also become visible
Inadequate colposcopy -> endocervical curettage (invasive and deferred during preg due to high risk of miscarriage and preterm delivery)
Cervical biopsy performed during preg if high-risk lesion
HPV co-testing used if atypical squamous cell of undetermined sig and low-grade intraepi lesion
N.B: women >= 35 with ATYPICAL GLANDULAR CELLS on Pap test -> endometrial biopsy (in addition to colposcopy) as AGC can be caused by either cervical or endometrial ca
Endometrial biopsy if AGC and under 35 years of age but rfs for endometrial ca (obesity, anovulation)
N.B2: if atypical squamous cells or pos cytology/HPV then perform reflex triage testing (ie HPV testing if cytology pos or cytology testing if HPV pos)
Drug-induced rhabdo
Direct myotox: statins, fibrates, colchicine, ethanol, cocaine
Vasoconstrictive ischaemia: cocaine, amphetamines
Prolonged immobilisation (compressive ischaemia): ethanol, benzos, opiates
Management of chest pain due to cocaine use
BENZOS for BP and anxiety
ASPIRIN for inhibition of cocaine-induced PLT aggregation
Nitroglycerin & Ca channel blockers for vasoconstrictive pain
Immediate cardiac cath if indicated (STEMI)
Caution with: fibrinolysis (increase risk for ICH), beta blockers (increase risk for coronary vasoconstriction)
Acute bronchitis
Aetiology: preceding resp illness (90% viral)
Cough for >5d to 3 weeks (+- purulent sputum)
Absent systemic findings (fever/chills)
Wheezing or rhonchi, chest wall tenderness
Clinical dx, CXR only when pneumonia suspected
Symptomatic tx (NSAIDs/bronchodilators)
Abx NOT recommended
Intrapartum abx prophylaxis for GBS given to whom?
Unknown GBS status and any of the following rfs for vertical transmission:
Rupture of membranes for >= 18 hours
Intrapartum fever
Fetal prematurity (<37 weeks gest)
