Step 2CK/Step 3 Flashcards
In which demographic do cavernous hemangiomas present?
What is a possible complication of a visceral hemangioma?
Kids; cavernous=strawberry hemangioma (can be bluish if it is deeper; less likely to regress)
Visceral hemangioma: High output heart failure
How do you differentiate osteoid osteoma from osteoblastoma?
Osteoid osteoma (OO) is in long bones and pain responds to aspirin
Osteoblastoma (OB) is larger than 2cm, happens in vertebrae and it’s pain doesn’t decrease with aspirin
Presentation, macro and histological hallmarks of Osteoid Osteoma:
OhOh: little benign thing on the cortex that goes away with aspirin
Presentation: Benign, in younger than 25, less than 2cm and pain at night relieved by NSAIDs
Macro: on the cortex of the diaphysis (side), Rx radiolucent core of osteoid (dark) surrounded by sclerosis (white)
Micro: woven bone lined by a single layer of ~blasts
Presentation, macro and histological hallmarks of OsteoChondroma:
OC tv show: young, mushroom
Presentation: most frequent benign, in younger than 25, mushroom shape, condro part can transform in chondrosarcoma
Macro: bony spike covered by a cartilage cap on the metaphysis (almost tip)
Micro: spike is continuous wit the marrow
Presentation, macro and histological hallmarks of ChondroSarcoma:
CaSa: elder, pelvis
Presentation: in adults older than 50 around the pelvis!
Macro: moth eaten lytic appearance with popcorn-like spiculated calcifications in Rx
Micro: irregular cartilage and calcifications
Presentation, macro and histological hallmarks of giant cell/osteoclatoma:
Presentation: benig but locally aggressive and may recur. Female=male
Macro: on the epiphysis!!! (tip) of the knee. Rx soap bubble. Nonsclerotic sharply defined border
Micro: tumor cells with RANK-L (~blasts) and multinucleated giant cells (~clasts)
Presentation, macro and histological hallmarks of OsteoSarcoma/ osteogenic sarcoma:
OSsss: the most frequent malignant ‘sssss’
Presentation: Most common malignant. Painful enlarging mass or fracture. Bimodal distribution in teenagers (retinoblastoma) and elderly (Paget’s, radiation). Aggressive
Macro: on the metaphysis (almost tip) of the knee. Rx Codman triangle (periostial elevation, swelling) or sunburst (lytic, tiny fragments of bone)
Micro: plemomorphic cells making osteoid; malignant proliferation of osteoblasts (spindle shaped pink)
Malignant osteoblasts arise form mesenchymal stem cells in the PERIOSTEUM
Presentation, macro and histological hallmarks of Ewing sarcoma:
Presentation: 2nd most common malignant. Painful and swelling, ±fever, boys, good px
Macro: on the diaphysis of femur, grows inside the narrow and pressures the periosteum that grows on onion skin reaction and moth eaten appearance (means extension to the soft tissue)
Micro: mesenchymal but small blue w Homer-Wright pseudorosettes and glycogen +CD99, +MIC2, t(11;22) EWS-FLI1 for DD with lymphoma and osteomyelitis
Tto: sx or Dactinomycin (drug for kid tumors)
Clinic and how you differentiate α-thalassemia minor and β-thalassemia minor?
Both are normal but become anemic when they are under stress, have target cells
α has normal electrophoresis
β has aBnormal electrophoresis ↑HbA2(2α2δ) ↑HbF(2α2γ)
What is the treatment for magnesium overdose?
IV calcium gluconate
What do nodules with spiculated borders in chest Rx indicate? What is the management?
Lung ca, due to malignant cells extending within pulmonary interstitial tissue (stippled, irregular or eccentric calcifications also indicate malignancy but popcorn or bull’s eye calcifications indicate benign nodule).
1) Ask for previous Rx, if lesion has been stable 2-3 years you are done
2) Chest CT:
- Benign: less than 40 y.o, less than 0.8cm, never smoker or more than 15y since stopped, smooth → serial CTs
- Intermediate: 40-60//0.8-2//smoker or 15-5, scalloped → biopsy* or PET
*Biopsy:
Central: bronchoscopy
Peripheral: CT-guided - High risk: more than 60y.o, more than 2cm, smoker or less than 5y since stopped, corona radiata or spiculated → sx
Malignant pleural effusion makes lung ca. inoperable
Which parameter increase when you lower the GUIDELINE’S cutoff for diagnosis? What about when you lower the cutoff of a NEW TEST to diagnose the disease?
What happens if you do the same test on a healthier (younger) population?
Lower GUIDELINE’S cutoff for diagnosis: ↑ prevalence. ‘A medical association changes the guidelines so more people are actually sick’
↑ sensitivity and NPV. ‘A new test positive cutoff changes but the gold standard and therefore the actual number of sick people remains the same’
↓ prevalence, ↓ PPV, ↑ NPV, =sensitivity and =specificity
What do you think about if you see a middle easter male with abdominal mass in the gut, mesenteric lymph nodes and malabsorption?
IgA heavy chain disease= mediterranean lymphoma= Seligmann disease
Biopsy: jejunal mucosal infiltration with plasmacytoid cells
What is important to do after diagnosing Raynauds?
Nailfold microscopy to look for enlarged distorted or scarce capillaries because if you see those, they indicate secondary Raynauds normally due to mixed connective tissue diseases as scleroderma
Fetty syndrome signs and symptoms:
RA+ neutropenia+ splenomegally (anemia and thrombocytopenia are possible)
What is the management of head and neck squamous cell ca?
And of a parotid tumor?
Squamous cell ca:
1) Ultrasound and fine needle aspiration
2) Panendoscopy (endoscopy of larynx, bronchus and esophagus) to find the ca.
Endoscope-guided biopsy for nasopharyngeal ca. → RT+QT
Parotid:
1) Fine needle aspiration
2) If non-dx fine needle aspiration of an enlarging parotid mass
3) Superficial parotidectomy (that is also curative for most benign parotid tumors)/deep parotidectomy*
If metastasis do a modified radical neck dissection + postsx RT
What should you think about if you see a kid with RBC aplasia?
Transient erythroblastopenia of childhood, it is transient and normally due to a virus
Decreased reticulocytes
Normal MCV!!
Recovers in 1-2mo
NBSM; no need marrow aspirate; you just need to FOLLOW Hb for 2-3mo until resolution!!!
Which malignancy can lead to sideroblastic anemia?
Myelodisplastic syndrome
What is a different name for Wilms tumor?
Nephroblastoma
What are the main symptoms and the possible treatments for essential thrombocythemia?
Vasomotor symptoms: headaches…
Treatments: Low-dose aspirine Hydroxyurea (avoid in pregnancy) Anagrelide Plateletpheresis
QT regimes for ALL, CLL, Hodgkin and Non-Hodgkin lymphoma:
ALL:
Daunorubicin, Vincristine and Prednisone
AML:
Daunorubicin and cytosine arabinoside (AraC)
CLL:
Fludrabine and Chlorambucil (do not treat if asymptomatic and stage less than 3)
Hodgkin:
ABVD
Adriamycin (doxorubicin), Bleomycin, Vinblastine, Dacarbazine
Non-Hodgkin:
R-CHOP
Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin (Vincristine) and Prednisolone
How do you prevent tumor lysis sd? How do you treat it? Which drug is contraindicated? Which are some of the SE of these drugs?
Prevention:
Allopurinol and febuxostat (febuxostat is better for the kidney than allopurinol); inhibit xanthine oxidase
* they do not decrease the amount uric acid that already exists (SE: Steven-Johnson and renal stones)
Treatment:
Rasburicase and pegloticase; recombinant urate oxidase that convert uric acid in allantoin (SE: G6PD hemolysis, anaphylaxis!, methemoglobinemia)
Add Ca supplementation to prevent hypocalcemia
Contraindicated:
Probenecib!!! uricosuric agent that blocks the reabsorption of uric acid at the PCT
Urinary sample markers of pheochromocytoma and neuroblastoma vs carcinoid tumor:
Pheochromocytoma and Neuroblastoma: make epi, NE and DA so in urine you see homovanillic and vanillylmandelic acid. Also, if you don’t find the mass on CT scan you can check for ↑ uptake of iodine-131-metaiodobenzylguanidine = I-131 MIBG!!
Carcinoid: makes 5HT so in urine you see 5-hydroxyindoleacetic acid → CT scan → Octreotide scintigraphy if CT does not find the tumor
Before electrophoresis, how can you differentiate between iron deficiency anemia and thalassemia?
Iron deficiency anemia:
↑ red cell distribution width (RDW)
MCV/RBC count (Mentzer ratio) more than 13
↓ reticulocytes
Suspect it on a kid having mostly cow’s milk before 1y, also all breast fed babies should be started on 400IU within 1mo
Thalassemia:
Nr RDW
Mentzer ratio less than 13
↑ reticulocytes
What is the next step in management if you suspect bone metastases? What is the presentation buzzword?
1) IV glucocorticoids
2) MRI or radionucletide bone scan=bone scintigraphy! it is the most sensitive test to detect early bone metastasis → locate the primary tumor → biopsy if not primary tumor is identified
Buzzword: point tenderness over the spinal processes
Which drugs can cause drug-induced hemolytic anemia?
Penicillin, Cephalosporins NSAIDs Rifampin Phenytoin Methyldopa
They cause warm IgG mediated hemolysis
What is the management of male or postmenopausal with iron deficiency anemia?
1) Occult blood test
2) Colonoscopy
What is the management of antiphospholipid syndrome?
Long term: lifelong warfarin INR target 2-3 (apixaban is inferior to warfarin)
- Does not correct with mixing studies
- Aspirin!! and LMW heparin if pregnant (miscarriages are due to thrombosis of the utero-placental A.)
What do you do if you see a non-tender mass suspicious of malignancy?
Excisional biopsy
What is the management of neutropenia?
Less than 1500 neutrophils
Afebrile: observation
Febrile: cefepime (or carbapenem or piperacillin-tazobactam) for pseudomonas ± vancomycin for MRSA*. If does not get better give voriconazole for aspergillus (halo sign on chest CT)
- if pneumonia, septic shock, cellulitis, catheter infection
What is the management of ITP?
No bleeding and more than 30k platelets*: observation
Bleeding or less than 30k platelets*: 1) steroids 2) IVIG, anti-D immunoglobulins for Rh-positive patients only!
Refractory: rituximab or splenectomy ± platelet transfusion
- for kids the number of platelets doesn’t matter, treat w IVIG/steroids if severe bleeding
What is the initial treatment for venous insufficiency?
Compression wraps
Leg elevation
Encourage exercise
Causes, pathophysiology, clinical signs and tto of hypercalcemia of malignancy:
Malignancy causes a ↑Ca more than 14mg/dL + symptoms;
If primary hyperPTH no symptoms and just mild ↑Ca
Causes:
Renal cell, Breast, Squamous cell of the lung (strongest association with smoking), Bladder
Multiple myeloma
Immobilization and hyperthyroidism can also cause hyperCa but not that high
Can be due to:
Paraneoplastic PTHrP release (80%) *unlike PTH, PTHrP does not stimulate the hydroxylation of 25-dihydroxyvitamin D to 1,25-dihydroxyvitamin D
Paraneoplastic 1,25-dihydroxyvitamin D release
Osteolytic metastasis and L-1 release (MM)
Signs and symptoms:
Stones, bones, groans (constipation) and overtones
Hyporeflexia
Ca. gives you SHORT QT =) *PTH causes SHORT QT!! ↓ Ca and ↓ PTH gives you long QT =(
Tto: IV fluids + calcitonin if need of immediate tto and bisphosphonates for long-term tto
Treatment of hypercalcemia, hypernatremia and hyperkalemia:
↑ Ca:
Immediate (if more than 14): IV fluids + calcitonin ± loop diuretics only in edema (just fixes it while you are giving the infusion)
Long-term (if more than 12): bisphosphonates (± calcitonin 2-3 days until bisphosphonates kick in, but calcitonin leads to tachyphylaxis). Do not give bisphosphonates in AKI, do dialysis
↑ Na:
Euvolemic/hypovolemic asymptomatic: 5% dextrose
Hypovolemic w symptoms of dehydration: 1) ~1l normal saline (0.9% NaCl) until euvolemic 2) 5% dextrose
+ close neurologic monitoring
↑ K:
1) ECG
If K is more than 6.3 or ECG changes, if NOT review the pt’s meds and go to step 4)
2) IV Ca gluconate (stabilizes the heart) if ECG abnormalities/K more than 7/fast raising K due to tissue breakdown
3) Insulin+Glucose or dextrose*/Albuterol /Na bicarb: move K into the cell.
* If concomitant hyperglycemia give insulin alone!!
4) Kayexalate, patiromer, lokelma (Na zierconium cyclossilicate), furosemide: ↓ body K
5) Dialysis if nothing works
Where should you access the circulation in adults/kids fluid resuscitation?
Adults: Antecubital v. Spahenous v. Femoral v. Intraosseus cannulation (if you cannot get 2 access in an emergency pt put an intraosseus access) Central line: used for monitoring
Kids: Intraosseus cannulation (preferably in the proximal tibia, if not the femur)
Where do you have to place a chest tube in tension pneumothorax in adults? and in kids?
Where can you do thoracentesis?
Pneumothorax:
Adults: 5th left intercostal space along the midaxillary line
Kids: 2nd left intercostal space along the midclavicular line
Thoracentesis: CAP 6-8th mid-Clavicular 8-10th mid-Axillary 10-12th Paravertebral Use the midaxillary line if the patient is supine and the posterior midscapular if the patient is sitting; remove 1L of fluid slowly
How do you treat thyroid ca?
Most types: total thyroidectomy ± radioactive I** (if positive lymph nodes/capsular invasion…) + high dose levothyroxine to suppress TSH in papillary
** RT if not responsive to I
For medullary monitor calcitonin!! and thyroglobulin for the rest
Anaplastic: total thyroidectomy if resectable + palliative QT-RT
How do you treat breast ca?
Localized: mastectomy/breast conserving sx + sentinel lymph node + RT
→ if + lymph nodes: node dissection + hormone modulators/trastuzumab or QT if triple negative larger than 0.5 cm
→ if positive margin: reexcision of the involved margin
Locally advanced: neoadjuvant QT then, sx
If pregnant or lactating no RT until 1 year after pregnancy and no QT on the 1st trimester so do: prompt mastectomy/breast-conserving tto + QT after the 1st trimester
Indications and available procedures for bariatric sx:
Indications: Motivated patient Heavier than 40 kg, BMI more than 35 + serious comorbidities, 30 + resistant DM or resistant metabolic syndrome Reasonable sx risk Failure of previous weight loss regimes
Procedures:
Sleeve gastrectomy, most frequently done because of good combination of effectivity and safety
Laparoscopic gastric band (not shown to be effective in US population, bad for sweet eaters)
Roux-en-Y
Duodenal switch
Indications for coronary bypass:
Left main coronary stenosis of more than 50%!
Proximal!!! LAD + proximal!!! circumflex stenosis more than 70%
3 vessel disease
Persisting ischemia after maximal medical therapy
Diabetic with 2 or + vessel disease
What is the BNSM if you suspect pneumothorax in an acute setting? What is the management of a pneumothorax?
BNSM: bedside ultrasonography
Non-tension + stable patient + less or = 2 cm:
Cover the wound with regular dressing and order a expiratory chest Rx
Tension: Stable 1) Immediate NEEDLE thoracostomy → 2) chest tube thoracostomy Unstable 1) Chest tube
- If persistent air leak in the chest tube and failure to re-expand → bronchial injury → bronchoscopy/esophagoscopy → intubation + sx repair
What is the management of vascular injury?
+ hard sings: no pulses, expanding hematoma, hemorrhage, bruit, distal ischemia (pain, pallor, paresthesia, poikilothermia, paralysis, pulselessness) → exploratory sx
+ soft sings: unequal pulses, stable hematoma, resolved hemorrhage, unexplained hypotension, nerve deficit, injury close to major vessel → CT angiography (duplex US on renal insufficiency, then so exploratory sx if angiography indicates it)
What is the effect of Metyrapone and what is it used for?
It inhibits 11ß hydroxylase, so prevents the conversion of 11-deoxycortisol to cortisol so cortisol ↓ and this causes ACTH ↑ (same happens if you eat licorice). If ACTH does not ↑ → pituitary insufficiency
Used for pituitary insufficiency workup
The opposite of dexamethasone that ↓ ACTH
- The failure of both ACTH and 11-deoxycortisol levels to rise after the administration of metyrapone indicates secondary or tertiary adrenal insufficiency
What is the effect of Cosyntropin and what is it used for?
1) You actually do plasma cortisol AM, if less than 3 you don’t need to do the cosyntropin
2) Acthar = cosyntropin = ACTH stimulation test
Acthar and cosyntropin act as ACTH!! they should ↑ cortisol
Used for adrenal insufficiency: Addison’s and pituitary insufficiency
ACTH stimulation test is used to diagnose the cause of DECREASED cortisol
If ACTH ↑ cortisol: pituitary insufficiency (is important to give steroids 1st before you treat the hypothyroidism and other hormonal deficiencies or before you go to sx) → only steroids
If ACTH ↓ cortisol: adrenal insufficiency! → steroids + fludrocortisone
What is the effect of the insulin tolerance test and what is it used for?
Insulin causes hypoglycemia which should ↑ cortisol by more than 20µg/dl. If cortisol does not ↑ → ACTH deficiency
Main metabolic abnormality in Addison’s, hypopituitarism and Conn sd:
Aldosterone deficit (Addison’s): ↑ K; ↓ Na (because of sympathetic activation and ↑ ADH)
Hypopituitarism: ↓ Na because CRH should inhibit ADH and here it cannot so there is ↑ ADH; K is normal!! because Aldo is normal. Pt also presents w. anorexia, hypoglycemia and pale skin
Secondary adrenal insufficiency (form stopping steroids): ↓ Na, ↓ glucose, nr K and nr bicarb
Aldosterone excess (Conn sd): Na is normal because of the aldo escape causing pressure natriuresis. You have HT and hypervolemia bc you pee a lot because of the aldo escape. ↓ K (not always) and metabolic alkalosis
Cushing syndrome: HT, ↓ K (as cortisol has a mineralocorticoid effect at high doses, you might have T-wave flattening on ECG), Na is normal or ↑, metabolic alkalosis and ↓ Ca
Which drugs can CAUSE nephrogenic diabetes insipidus? and SIADH?
Nephrogenic diabetes insipidus; they affect the collecting duct: Lithium Sickle cell patients with isosthenuria ↑Ca, ↓K. If you see ↑Na check Ca and K! Chronic kidney disease (ADPKD) Demeclocycline (tetracycline) Fluoride Amphotericin (among other SE)
Central diabetes insipidus:
pituitary sx, neurosx, tx
langerhan cell histiocytosis, sarcoidosis
anorexia
- Na can be normal in DI
SIADH; Can't Concentrate Serum Sodium: Carbamazepine and oxcarbazepine Cyclophosphamide!!! (1st generation sulfonylurea) SSRIs, TCAs, MAOIs Others: THIAZIDES Pulmonary ilness, CANCER... Surgery OXYTOCIN, Amphetamines, ecstasy and LEAD cause hyponatremia!! Hypothyroidism causes hyponatremia NSAIDs Chlorpropamide (sulfonylurea) Vincristine, vinblastine Clofibrate
Which drugs can be used to TREAT diabetes insipidus? and SIADH?
Nephrogenic diabetes insipidus:
Amiloride (± thiazides) if is due to Li
Thiazides (± indomethacin) if other cause
Central diabetes insipidus:
Desmopressin
SIADH:
1) Fluid restriction but not salt restriction
2) If seizures or coma give IV hypertonic 3% saline 200-300mL in 3-4h at 0.5-1mmol/L/h; emergency dialysis may also be considered
Others: Demeclocycline and Vaptams
How do acidosis, alkalosis, citrate and albumin affect Ca?
Acidosis ↑ FREE/ionized Ca and
Alkalosis (conn’s) and citrate ↓ FREE/ionized Ca
* It is the ionized/free Ca the one that regulates PTH and causes the symptoms, so here you will have PTH changes and symptoms
↑ albumin ↑ TOTAL Ca: make sure you check the ionized/free Ca in MM
↓ albumin ↓ TOTAL Ca because without albumin it cannot be carried but here ionized Ca will be normal so PTH will be normal. Here calculate the corrected Ca= Ca+0.8 *(4-albumin). Malnutrition is a cause of hypocalcemia.
Treatment and prevention of renal osteodystrophy in renal failure:
Give Ca and activated Vit D
P restriction!!!*
Cincalcet
- P builds-up in renal failure which can lead to deleterious effects, such as metastatic calcification (which can increase risk of stroke, heart attack, etc.) and weak bones (because phosphorous pulls calcium out of bones); these complications are particularly important for kids because they progress chronically over time
What is the presentation and management of femoral neck fracture?
Presentation: shortened and externally rotated extremity
2 types:
Intracapsular: NO ecchymosis, high risk of avascular necrosis
Extracapsular: ecchymosis, risk of displacement
Management:
Minimally displaced: open reduction with internal fixation!!
Displaced: replacement of femoral head with metal prothesis
All causes external rotation (femoral neck fracture and anterior dislocation of the hip) except for posterior dislocation of the hip!
What is the management of urethral injury?
1) Retrograde urogram/cystography to rule out urethral rupture and intraperitoneal bladder dome rupture!!
Then,
Partial disruption: bridge ureteral catheter and repair sx in 2-3mo
Significant disruption: suprapubic cystostomy and repair sx in 2-3mo
* If repaired too early can lead to stricture and impotence
What is the management of carpal tunnel sd?
Clinical dx → confirm with electromyography and nerve conduction studies
1) Wrist splint → steroid injection in the carpal tunnel → oral steroids → if fails, sx release (need nerve conduction studies before)
Associated with hypothyroidism, pregnancy, typing
Which injuries lead to external and internal rotation of the leg? and of the shoulder?
External: femoral head fracture and ANTERIOR femur dislocation
* ABEr: anterior dislocation causes aBduction and External rotation
Internal: POSTERIOR hip dislocation; can injure the Sciatic n. so no HIP extension
Can injure the sciatic n.
* PoDaIr: posterior dislocation causes aDduction and Internal rotation
Tto: emergency closed reduction within 6h
Same for the shoulder
VS
Femoral neck fracture:
Shortened leg
External rotation
All causes external rotation except for posterior dislocation of the hip!
What is the management of scaphoid fracture?
Thumb spica cast
Unilateral bloody nipple discharge diagnostic suspicion and management:
Do not present with masses, just with bloody nipple discharge
In young, benign (can hide atypic or ductal ca in situ): Intraductal papilloma (it’s vascular stalk twists and bleeds) → rule out ca. with ultrasound, mx and subsequent fine NEEDLE ASPIRATION/ core needle biopsy → if - ultrasound and mx do breast MRI
Micro: epithelial and myoepithelial cells lining a fibrovascular core forming papillae within a duct. Excision
In old, malignant: Ductal carcinoma in situ. Micro: ducts distended by pleomorphic cells with central necrosis that do not penetrate the basement mb. the basal (myoepithelial) layer of the duct is uninvolved → ultrasound, mx and subsequent fine NEEDLE ASPIRATION/ core needle biopsy
What is the management of a palpable nodule on rectal digital exam/ abnormal PSA?
Urinalysis and prophylactic antibiotic → transrectal ultrasound-guided fine needle biopsy taking multiple (12) biopsies
What is the management of bowel perforation?
Rx: air under the diaphragm (pneumoperotoneum)
Exploratory laparotomy! Even when is due to a stomach ulcer!
The only time when you see air under the diaphragm and you don’t do exploratory laparotomy is after sx, it is normal to have some free air after sx
What is the management of GERD?
1) PPIs 1/day for 2mo → switch to different PPI or do 2/day → esophageal Ph monitoring/endoscopy
Endoscopy if: men >50yo, symptoms >5y, melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia or odynophagia
Barrett’s esophagus/ low grade dysplasia: endoscopic radiofrequency ablation
High grade dysplasia/ca: esophagectomy/ radiofrequency
Symptomatic sliding hiatal hernias (Z line above the diaphragm): Nissen fundoplication
SE of Nissen fundoplication:
Dysphagia and gas bloat syndrome; decrease risk if pt adheres to diet that slowly progresses form liquids to solids
What is the best way to transport a severed finger? What do you do with an avulsed tooth?
Finger: wrap it in a moist gauze, put it in a plastic bag and sumerge the bag into ice mixed with saline
Tooth: store te tooth in cold milk or saliva, rinse it with saline, reimplant (even by the parents) and splint ideally within 15min to 1h
What is the management of cardiac tamponade?
Transthoracic echocardiography
Pericardiocentesis or pericardial window
Causes and presentation of hyperosmolar hyperglycemic state in DM2:
Very high glucose → very high plasma osmolarity → polyuria → intravascular volume depletion
No ketones!
Confusion, high mortality
Causes: infection!! (infections often lead to increased insulin requirement by causing a reactionary hyperglycemia), dehydration, non-adherence to DM2 tto, corticoids, thiazides, dobutamine, terbutaline, 2nd reneration antipsychotics
Tto: 1) normal saline!
What is the most common cause of congenital hypothyroidism?
Thyroid dysgenesis
What is the management of amiodarone-induced hypothyroidism?
Add levothyroxine, no need to discontinue amiodarone as far as it controls the arrhythmia
What is the management of cryptorchidism?
If the testicle does not descend at age 6mo it will not do it, so do laparoscopy and orchiopexy before 1 year, if atrophic testicle do orchiectomy
Increased risk of germ cell malignancy, the contralateral testes is not as risk
What is the management of infertility?
1) Semen analysis after 2-3 days of abstinence, if abnormal → repeat in 3mo (significant variability) → If azoospermia do ISCI
2) Female history: regular periods?
3) Midlutheal phase (day 21) progesterone level to see if she is ovulating
4) Ovarian reserve: day 3 FSH and estriol, clomiphene challenge, follicle count, Anti-Mullerian hormone
4) Hysterosalpingogram (painful) → if abnormal → IVF (check ovarian reserve before IVF)
Presentation, macro, histological hallmarks and marker of embryonal ca:
Presentation: solitary painless testicular mass in 20-30 yo, rare and metastasizes fast
* It can differentiate into another type of germ cell tumor as teratoma after QT
Macro: hemorrhagic mass with necrosis, commonly mixed
Micro: glandular/papillary normally mixed with other tumors, + citokeratin
Marker: α fetoprotein, hCG
Illnesses with high AFP (alpha-fetoprotein):
AFP is made by liver and yolk sac in fetus
Yolk sac tumor
Hepatocelular ca. (hep C is the MCC)
Embryonal ca. when mixed (men)
Ataxia-telangiectasia
Pregnancy (high in neural tube defect low in trisomies)
Different form placental alkaline phosphatase in seminoma
Presentation, macro, histological hallmark and marker of yolk sac (endodermal sinus or INFANTILE embryonal ca.) tumor:
Presentation: most common in prepuberal children
Macro: yellow mucinous mass
Micro: endodermal sinus formation with Schiller-Duval bodies (glomeruloid structures lined by germ cells) and hyaline droplets
Marker: α fetoprotein (± α1 antitrypsin)
Presentation, macro, histological hallmark and marker of seminoma and dysgerminoma:
Presentation: most common in 15-35 yo
Macro: painLESS, firm, HYPOechoic, homogeneous testicular enlargement, lobulated (dysgerminoma is a common cause of ovarian ca. in pregnant)
Micro: large polygonal clear cells (with watery large cytoplasm) forming lobules + fried egg (membranes and central nucleus)
Marker: placental alkaline phosphatase and β-HCG (seminoma) lactate dehydrogenase (dysgerminoma)
Specific findings for Graves vs other hyperthyroidism causes:
Exophthalmos, ocular muscle restriction (NOT lid lag!)
Pretibial myxedema= infiltrative dermopathy
Physiologic changes during pregnancy:
↓ MAP ↓ SVR ↓ systolic and ↓ diastolic but diastolic drops more so ↑ PP
=CVP but ↓ femoral venous pressure so varicose veins and hemorrhoids
↑ CO by 30-50% between 20 and 24 w (systolic ejection murmur): good for the baby’s nutrition
↑ Preload =LVEDP
↑ RBC mass but plasma vol ↑↑ so hemodilution
↑ WBC ↑ ERS, ↑ clothing factors, all but 13 and 2 so DVT (give heparin if no in labor) the first week postpartum is the most dangerous time for DVT, =platelets (between 100-150k is benign gestational thrombocytopenia)
↓ smooth muscle tone so constipation, cholelithiasis, GERD
↑ TV, ↑ min ventilation, RR =, all the rest of the vol ↓, CO2 ↓ and Ph becomes alkalotic in plasma and urine so UTIs
↑ kidney size specially on the right, ↑↑ GFR, ↓ Creatinin, ↓ renal threshold for glucose, progesterone relaxes pelvis muscles and ureters so hydroureters normally on the right so UTIs
Which vessels do the umbilical cord contain?
2 arteries (deoxigentated blood) 1 vein (oxigeated blood)
- The best indicator of how the baby is doing is the artery!
Key effects of DES, phenytoin/dilantin, isotretinoin and valproic acid in the fetus:
DES: T shaped uterus, clear cell ca.
Phenytoin/dilantin: nail hypoplasia
Isotretinoin: hearing loss, migrognatia, heart abnormalities
Valproic acid: neural tube and cardiac defects
What does the P in GPAb stands for (pregnancy history)?
G: times where you were pregnant
P: babies that lasted more than 20 w
Ab: abortions
Most common aneuploidies at conception and at birth:
Most common aneuploidy at conception: turner; most are aborted (hydrops…); it is the only one that has normal IQ, they lack adosdence growth spurt and cubitus valgus (Jesus), celiac disease
Most common aneuploidy at birth: down
Down has congenital hypothyroidism and Turner has immune-mediated hypothyroidism (Hashimoto)
DD. of late pregnancy bleeding:
ABRUPTIO placentae:
Premature separation of the placenta from the uterus.
RF: PPROM, HT, PREECLAMPSIA, trauma (MVA), SMOKING, cocaine, uterine overdistention (twins, polyhydramnios)…
Presentation: PAIN and firm uterus, can lead to DIC
Baby can have hypoxia
Tx: fluids, transition to blood products soon + lateral decubitus positioning, vaginal delivery if no fetal distress (you can even use oxytocin), if fetal distress emergency c-section
Placenta PREVIA:
Placenta extending over the cervix.
RF: previous CESAREAN, >35, multiparty, smoker
Presentation: NO PAIN, no fetal distress, transverse lie fetus, can resolve over time by migration, if it doesn’t c-section
Look for placenta accreta!! PP-PA
VASA previa:
Fetal blood, umbilical cord vessels extending over the cervix
RF: placental accessory lobe, placenta previa, in-vitro
Presentation: No pain + FETAL BRADYCARDIA (sinusoidal pattern)
You are loosing fetal blood!! Emergency c-section!
Uterine rupture:
Rupture of the uterine myometrium and serosa
RF: previous cesarean (vertical=classical incision)
Presentation: Prepartum PAIN and fetal parts palpable on the abdomen, sudden loss of fetal station
Emergency! laparotomy!
Painful: abruptio and uterine rupture
What are the causes of morning hyperglycemia?
You measure 3AM blood glucose:
normal glucose → Dawn phenomenon: nocturnal release of GH and cortisol → increase evening insulin
↓ glucose → Somogyi phenomenon: rebound morning hyperglycemia due to nocturnal hypoglycemia → decrease evening insulin
Main characteristics of Placenta ACCRETA, increta and precreta, RF, presentation and tto:
Accreta (80%): Abnormal trophoblastic invasion into the decidua basalis (endometrium).
Increta (15%): invasion into the myometrium
Precreta: invasion all the trough myometrium into the serosa
RF: previous CESAREAN, anterior placenta previa PP-PA, multiparty…
Presentation: POSTPARTUM vaginal bleeding (vs uterine atony that w respond to uterotonic agents)
Tto: hysterectomy w the placenta in situ
Most common cause of breech position:
Uterine septum
Zig-zag lessions and micropthalmia indicate:
Congenital varicella
Manifestations of congenital syphilis:
Maculopapular rash in the palms and soles → desquamating Rhinorrhea (snuffles) Congenital nephrotic sd Periostitis and osteochondritis Hydrops and macerated skin
Cord compression causes:
Variable decelerations, treat with amnioinfusion
How do you treat hyperemesis gravidum?
1) B6 pyridoxine
2) Doxylamine (antihistaminic)
How is breast development also called?
Thelarche, 1st sign pf puberty, as breast growth is often symmetrical the breast bud can be unilateral! but careful if there is blood coming out of it!
Complications of asymptomatic bacteriuria in pregnancy?
Preterm labor
Low birth weight
Perinatal mortality
Preeclampsia
Pyelonephritis
Cystitis
Which are the only gestations that are at risk for twin-twin transfusion syndrome?
Monochorionic diamniotic
DD. of preterm contractions:
Uterine irritability: many contractions, intensity low, very short duration
Braxton-Hicks: few contractions, long duration, irregular, relieved with ambulation and NO cervical change
Pre-term contractions: regular with NO cervical change
Labor: regular painful contractions with cervical change
Main characteristics of preterm prelabor rupture of membranes (PPROM):
Rupture of membranes before labor at less than 37 w (it is a third trimester gush of fluid from the vagina with closed cervix)
Microscopic examination of dried amniotic fluid shows arborization (Ferning) and Nitrazine + blue fluid
RF: ascending infection from the vagina, antepartum bleeding, previous PPROM, amniocentesis
What can be used as a predictor of preterm delivery? What can be used to diagnose PPROM?
Prenatal delivery: Fetal Fibronectin
Negative in 22-35 weeks, high close to delivery
If it is negative it is very useful but if positive with cervix closed it is very likely a false positive
RF: Bacterial vaginosis
PPROM: Nitrazine test and ferning
Gush of fluid before w 37. 1) Sterile speculum examination 2) Nitrazine test and ferning
RF: previous PPROM, infection, smoking
How do you differentiate between chronic, gestational hypertension, preeclampsia, eclampsia and HELLPsd?
Chronic HT: HT (>140/90) onset before 20 w → monitor and induce at 38 w → if more than 160/110 methyldopa/nifedipine/labetalol + deliver at 37 w
* In HT less than 160 give low-dose aspirin to decrease the risk of superimposed preeclampsia!
Gestational HT: HT (>140/90) onset after 20 w → antihypertensives, deliver at 38 w
Preeclampsia: HT (>140/90) onset after 20 w + proteinuria (>300/day or >0.3) ± end-organ damage → antihypertensives, admit in-patient + deliver at 37 w
Preeclampsia with severe features: HT (>140/90) onset after 20 w more 160/100 OR pulmonary edema/headaches/visual changes OR platelets less than 100.000/doubled liver enzymes/Cr more than 1.1 → *
Eclampsia: HT (>140/90) onset after 20 w + proteinuria + seizures → * + protect airway
HELLPsd: hemolysis + ↑LFTs + ↓platelets ± HT ± proteinuria ± seizures → *
- 1) Admit as in-patient; 2) Stabilize, stop convulsions with Magnesium sulfate!!!! and leave it 1 day after delivery; 4) Manage HTN with IV Hydralazine (if bradycardia) /IV Labetalol /Oral Nifedipine*; 5) prompt delivery (induce w oxytocin) when mom is stable; 6) if baby monitoring is bad do c-section
- NLH!
Consequences: stroke (ischemic and hemorrhagic)
DD. of cardiac problems in pregnancy:
Mitral stenosis; think mitral stenosis on immigrant with pharyngitis as a kid that gets heart symptoms during pregnancy. Excess preload of pregnancy passing trough a narrowed valve can lead to pulmonary hypertension, edema, arrhythmias and RHF → surgical repair before pregnancy if symptomatic and β-blockers if asymptomatic
ASD or VSD: most common heart problem in pregnancy, patients do well (as patients do with any regurgitation lesion in pregnancy) → routine tto
Tetralogy of Fallot: 😞 most common cyanotic defect in pregnancy
Eisenmenger syndrome: 😞 right heart failure, there is intracardiac shunt and decreased oxygenation → avoid hypotension
Marfan syndrome 😞
Peripartum cardiomyopathy: 😞 (75% mortality if not corrected in 6mo) no heart disease history, BOTH left and right heart failure in late pregnancy/postpartum, LVEF <45% → furosemide in ICU
DD. True Gestational DM vs Overt Diabetes:
Gestational DM is a retrospective diagnosis: stop insulin and if post-partum glucose normalizes → True Gestational DM
If persistently increased → Overt Diabetes (DM type 2)
35% of patients with gestational DM will likely develop overt DM in the next 5-10 years
Consequences of maternal DM:
Overt: preeclampsia, sacral agenesis, caudal regression syndrome, anencephaly, spina bifida, transposition of the great vessels (most common cyanotic here ), ASD, VSD (number 1), coarctation
Overt and gestational: macrosomia, HCOM, hypoglycemia* (↑insulin), PTH suppression (↓Ca, ↓Mg), polycythemia, ↑bilirubin, respiratory distress sd
- Put an umbilical venous catheter to give IV glucose → start nasogastric feeding that is continuous so insulin and glucose do not fluctuate → if still hypoglycemic add an IV line
How do you differentiate between HELLP sd. and acute fatty liver of pregnancy?
Both have HT, ↑ liver enzymes, thrombocytopenia…
All is the same but in acute fatty liver of pregnancy you have ↓glucose!!!! (↑ bilirubin) and ↑amonia and NO proteinuria
Symptoms of acute fatty liver of pregnancy include jaundice and encephalopaty (also vomiting, RUQ tenderness, slurred speech, hyperreflexia, and nystagmus) that do not necessarily appear on HELLP. They are due to fatty infiltration of the liver
In HELLP sd there is distention of the hepatic Glisson capsule and overactivation of the coagulation pathway
In both you have to stabilize the mom and deliver!
Which heparins can and cannot be reversed?
Unfractionated heparin can be reversed with protamin sulfate
LMWH cannot be reversed
Fundal height at the umbilicus indicates ___ weeks:
20 weeks
If the genders of two twins are different which type of twins are they?
Di Di Di (dizygous, dichorionic, diamniotic)
If two twins have a thick intertwined septum between them which type of twins are they?
Di Di Di or Mono Di Di (dizygous/monozygous, dichorionic, diamniotic)
Thick septum: Lambda sign
If two twins are the same gender with a thin intertwined septum between them which type of twins are they?
Mono Mono Di (monozygous, monochorionic, diamniotic), possible twin-twin transfusion
Thin septum: T sign
If two twins are the same gender and are on a single sac which type of twins are they?
Mono Mono Mono (monozygous, monochorionic, monoamniotic), possible cord entanglement and or conjoint
Pooling, nitrozine, ferning on speculum examination indicate:
Rupture of the membranes
What do you think if you see a woman who presents with sings and symptoms of pregnancy with negative β-HCG?
Pseudocyesis, a somatoform disorder where a non-psychotic woman thinks she is pregnant
Risks of hormone replacement therapy in post-menopausal pt:
Breast ca, MI, stroke, DVT…
* It is contraindicated in patients that have history of these diseases
At which gestational age can you start using vacuum?
More than 34 weeks
Management of a Rh - pregnant form Rh + dad:
1st prenatal visit:
Antibody screen
28th weeks:
Antibody screen
Prophylactic 300mcg of RhoGAM
Anytime when there is risk of fetomaternal hemorrhage:
Prophylactic 300mcg of RhoGAM
Delivery: No standard dose! calculate what you need!
No concern of fetomaternal hemorrhage → 300mcg of RhoGAM within 27h of when a Rh + baby is born
Concern of fetomaternal hemorrhage (abruption, procedures…) → Rosette test on mom’s blood, if + → Kleihauer-Betke test to calculate the amount of RhoGAM
(1st Rosette, the simplest name)
Epidural contraindications and complications:
Epidural can be given in stages 1 and 2
Contraindicated if platelets are less than 70.000 or are rapidly dropping: do parenteral (general) anesthesia instead
Complications:
Hypotension (give IV fluids before, if happens give IV fluids + IV ephedrine)
Spinal headache: IV fluids, caffeine or blood patch
High spinal: accidental injection of the anesthesia on the subarachnoid space, causes ascending paralysis and sympathetic blockage can stop the diaphragm and cause cardiopulmonary arrest
IV leaking: can cause seizures
What is the management of DKA?
1) 3-6 liters of IV isotonic fluids=normal saline (0.9%)
2) IV insulin when K is more than 3.3* until closing the anion gap
* If K is less than 3.3 give K first and then add insulin
3) Add dextrose when glucose is below 250
4) IV KCl if K is less then 5.3
5) Change them to subacute insulin but wait 2h of overlap with IV insulin
Do not fix hyperglycemia too fast because it can affect the brain
Differential diagnosis of vaginal discharge:
Gardnerella: gray thin and odorous
Clue cells on Wet mount, +Whiff, ↑pH (nitrazine +), endogenous
Tto: metronidazole (ok in pregnant) or clindamycin
Trichomona: frothy green-yellow, ↑pH (nitrazine +)
Gold standard: NAAT, trophozoite with corkscrew motility, STD
Tto: metronidazole
Candida: cottage cheese, itching!!!
Pseudohyphae, germ tubes
Tto: topical or oral azole
What is the management of +GBS in pregnant woman?
Intrapartum IV penicillin G in labor at mom with: unknown status if less than 36w, if membranes broke more than 18h ago or if mom has fever
- In allergic w. rash: cefazolin
- In allergic w. severe penicillin reaction (anaphylaxis, respiratory distress, urticaria): vanco/clinda depending on sensitivity testing. Vanco if sensitivity unknown/unavailable!!
- In allergic w. just rash: cefazolin
What is the management of intussusception?
Air enema, if does not work do surgery!!!
Which area does croup affect?
Subglotic larynx edema and proximal trachea narrowing (vs laryngomalacia affects the supraglotic; and epiglottitis that causes epiglottal and arypiglottic’s folds edema)
Parainfluenza, in kids from 1-4y
Rx: Steeple sign due to subglotic narrowing (not part of the management)
Presentation: barking cough, inspiratory stridor
Mamagement: 1) symptomatic relief: cool mist and dexamethasone (maybe IM dexamethasone) 2) if biphasic stridor (inspiratory+expiratory)/ stridor at rest/ respiratory insufficiency: racemic epi ± hospitalize
Most sensitive for dx of rotavirus:
Enzyme immunoassay of stool
Where is the PDA?
On the descending aorta close to the ligamentum arteriosus
What is the amniotic fluid index in oligo and polyhydramnios:
Oligohydramnios less than 5cm
Normal 4-24cm
Polyhydramnios more than 25cm: most cases are idiopathic
What is the shape and significance of early, late and variable decelerations:
Variable: short! peaks down in less than 30s, indicate umbilical Cord compression, treat with 1) Maternal repositioning to left decubitus 2) aMnioinfusion
Early: mirror the contractions, indicates head compression, not to worry! Early is good!
Late: a little later than the contraction, indicates uteroPlacental insufficiency, you need to discontinue uterotonics or do an Emergency c-section. A common cause is maternal hypotension due to epidural, if due to hypotension 1st give pressors to mom, like phenylephrine
Categories of fetal heart rate patterns:
1) Nr baseline of 110-160beats/min with moderate variability with NO late or variable decelerations, all good → continue labor
2) Is all tracing not categorized as 1 or 3, I don’t know → re-evaluation
3) Absent baseline variability + bradycardia/ sinusoidal pattern/ recurrent late or variable decelerations → confirm that is not a physiologic reaction → intrauterine resuscitation* → if tracing does not normalize do c-section
* Set mom in lateral decubitus ± stop oxytocin ± terbutaline if a lot of contractions ± IV fluids ± O2 mask ± amnioinfusion if variable decelerations ± vaginal exam to run out prolapsed cord ± scratch baby’s head looking for accelerations
Most common cause of operative obstetrics? and of C-section?
Operative obstetrics: prolonged second stage labor
C-section: cephalopelvic disproportion* (also indicated if previous classical c-section, malpresentation, category 3 fetal HR and abdominal myomectomy!)
- Cephalopelvic disproportion presents with molding of the fetal head and caput succedaneum
Name 3 contraindications for DTaP vaccination:
Anaphylaxis
Previous encephalopathy after a vaccine
Unstable neurological disorder (complicated seizures): give DT
Name 3 contraindications for rotavirus vaccination:
Previous intussusception Meckels diverticulum Anaphylaxis Congenital colon abnormalities SCIDs
IgA deficiency
What is the low urine specific gravity and osmolarity (diluted)? What is high (concentrated)?
Low:
Specific gravity less than 1.010
Osmolarity less than 200
High:
Specific gravity more than 1.015
Osmolarity more than 500
Possible treatments for hepatorrenal syndrome:
Vasocontrictors:
Milrinone, octeotide, vasopressin+albunin
Curative: trasplant
How can you decrease the nephrotoxic potential of Ampho B?
Salt loading (1L of isotonic saline per administration): reduces sensitivity of the macula densa Use lipid-based formulations
Hallmark cell in acute interstitial nephritis? and other diagnostic criteria? Causes?
Eosinophils (maybe present in urine as WBC casts ± sterile pyuria) fever, RASH, proteinuria and hematuria → Hansel or Wright stains
Rash
Fever
↑ Cr
Causes:
7Ps: NSAIDs (Pain), Penicillin (cephalosporins, sulfa drugs), Ppi’s and cimetidine, diuretics (Pee), rifamPin, alloPurinol, Phenytoin
Atheroembolic disease (+ livedo reticularis)
Acute papillary necrosis presentation and causes:
Acute renal failure with painless gross HEMATURIA+PROTEINURIA +- renal colic PAIN
Causes: Sickle, Acute pyelonephritis, NSAIDs (analgesics) and DM=SAAD
Diagnosis: Rx/CT(more accurate) that shows papillary deformation as lobster claw, ball on tee, signet ring, clubbed calix
Name a monoclonal antibody FDA approved for TTP:
Caplacizumab that binds vWF and inhibits platelet adhesion
Which tests should you do after your dx essential HT?
ECG, urinalysis, fasting blood glucose, CBC, electrolytes, Cr, lipids, TSH
To see if organ damaged has already happened
HT initial monotherapy:
140/100 or more if no comorbidities: give 6 mo of lifestyle modification and if it fails start with 1 drug
No comorbidities: chlorthalidone (most potent thiazide), hydrochlorothiazide, imdapamide. If they don’t work add an ACEi
DM or renal failure: ACEi/ARBs (do not work in black)
CHF, LV systolic dysfunction: ACEi, spironolactone, β-blocker (do not use β-blockers alone, you can use labetalol because is a α and β blockers)
Angina: Ca ch blocker (dihidropiridines as nifedipine)
160/100 or more: start with 2 drugs chlorthalidone + ACEi
Oral antihypertensives take 2w to work
At which ages should you suspect non-essential HT due to renal A. stenosis? What is the tto?
Age <25 or >55 (out of the blue having no HT at all before)
Tto: 1) ACEi/ARBs; first line for renal A. stenosis but you need to monitor the GFR because they can be dangerous in bilateral disease 2) If ACEi don’t work/ recurrent flash pulmonary injury/ HF: surgical tto/ percutaneous angioplasty w. stent
Causes of Normal Anion Gap Acidosis:
HARDUPH
H = hyperalimentation (e.g., starting TPN)
A = acetazolamide
R = renal tubular acidosis (Type I = distal; Type II = proximal; Type IV = hyporeninemic hypoaldosteronism)
D = diarrhea
U = uretosigmoid fistula (because the colon will waste bicarb)
P = pancreatic fistula (because of alkali loss–the pancreas secretes bicarb)
Name the 3 RTAs, their causes, key features and tto:
2/14: Valentine’s day; indicates the order of the RTAs in the renal tubules
All ↓ pl K but 4, all acid urine but 1
RTA type 2: proximal CD
The body cannot reabsorb bicarb and then a lot of acid is excreted
Causes: Fanconi, MM, amyloidosis, expired tetracyclins, acetazolamide, tenofovir, mitochondrial diseases, Wilsons
Keys: osteomalacia (you loose P)
Tto: K-phosphate, thiazides!!! (Two → Thiazides)
RTA type 1: DCT, α-intercalated cells
The body cannot excrete acid!
Causes: Sjogren, SLE, liver disease, autoimmune hepatitis, Li, ampho B, topiramate, QT, severe in kids
Keys: ↑ urine gap, basic urine, bicarb is VERY low, Ca stones ± nephrocalcinosis (H goes into the bone and kicks out Ca), low citrate
Tto: K-citrate (replaces K and prevents stones) and bicarb
RTA type 4: CD, principal cells Aldo does not work Causes: DM Keys: ↑ plasma K Tto: furosemide (activates RAAS), bicarb and fludrocortisone
How do you calculate urine anion GAP?
Na+K-Cl
Negative: GI losses
Positive: renal losses
What should you do when you see a metabolic alkalosis?
Mesure urine Cl:
↑ Cl because of ANP: saline insensitive; due to anything that ↑ aldo (mostly CONGENITAL causes) as tumors, cushing, Liddle, HT
↓ Cl: saline sensitive; due to diuretics, vomiting
How are bicarb and CO2 in mixed disorders?
Bicarb and CO2 go in different directions and Ph is really affected
Bicarb and CO2 go in the same direction but Ph is normal. If you see metabolic acidosis do Winters 1.5*bicarb+8
Hormone replacement in postmenopausal:
Normals: estradiol + progesterone *migraine is a contraindication for estrogen in cases of contraception but not in hormonal replacement in post-menopause because here the dose is much lower
Hysterectomy: Only E!!! conjugate equine estrogens as transdermal estradiol!
Breast ca, endometrial hyperplasia, stroke, thromboembolism: paroxetine
Only genitourinary sd of menopause: vaginal conjugated estrogen
Osteoporosis prevention: 1) bisphosphonates 2) teriparatide if bisphosphonates don’t work (only drug that builds bone mass) 3) denosimab if renal failure
What is the management of acromegaly?
Dx:
1) IGF-1
2) Glucose followed by GH levels
Tto:
1) Transsphenoidal resection
2) Octreotide. Second lines are pegvisomant and DA agonists as cabergoline if sx does not work
3) RT if neither sx nor medications work
How do you do breast ca. prevention? Who should receive it?
1) Raloxifene / tamoxife
2) Anastrozole if history of thromboembolism (SE: can decrease bone density)
Women of more than 35 yo with significant risk of breast ca.
DD of the different types of lichen:
All are itchy
Lichen planus: Flat purple lesion with wickham striae. Kobner phenomenon + (from along lines of minor tx). Sawtooth infiltrate and thickening of the granulosum, hypergranulosis + lymphocytes at the dermoepidermal junction. Can be in the mouth or on the vagina. Associated to Hep C. ACEi, thiazides, βB and hydroxychloroquine. Risk of ca.
Lichen sclerous: White!! plaque (leukoplakia) with purple border. THINing of the epidermis that leads to erosions. In prepuberal and postmenopausal. Normally in the vagina, is all over the perineum and can extend to the annus. Risk of ca.
Lichen simplex: THICK skin patch with enhanced margins form scratching. Leather-like hyperplasia of the squamous epithelium. No risk of ca.
Tto: Corticoids
UTI treatment during pregnancy? and on a newborn? and on a kid?
Normal person: 1) Nitrofirantoin/TMP-SMX/Fosfomycin 2) Oral ciprofloxacin is reserved for uncomplicated pyelonephritis
UTI and asymptomatic bacteriuria:
First trimester: 7 days of cephalexin/ 1 day of fosfomycin
Second trimester: 5 days of nitrofurantoin
* avoid nitrofurantoin in the 1st and 3rd trimesters! also is not good for pyelonephritis and prostatitis
Pyelonephritis (main cause of preterm labor): admit inpatient, IV fluids, IV ceftriaxone ± tocolysis
Baby: IV ampicillin + gentamicin and hospitalice
Infant: oral TMP-SMX/3rd generation cephalosporin (cefixime, cefotaxime)/amoxicillin, only IV cefixime if they have pyelonephritis or not eating
What is the management of suspected urethral and bladder injury?
Retrograde urethrogram
What is the management of bronchopulmonary dysplasia?
Bronchodilators and diuretics!
Rx: Cystic figures
What are the presentation, RF, dx and management of URGE, STRESS and OVERFLOW incontinence?
One of the 1st steps in management are a voiding diary! and test for UTIs
URGE
Presentation: urine leakage after big urge to urinate, due to DETRUSOR m. spasms or detrusor instability, hypertonia
RF: ↓ Estrogen, STD, UTIs, MS, spinal chord injury, previous pelvic sx
Dx: Thorough medical history. You will see small post-void residual vol. (10-50ml)
Management: 1) Bladder training, Kegel or estrogen replacement 2) if they fail use antimuscarinics (oxybutynin, tolterodine, darifenacin, not in narrow-angle glaucoma)
*If similar to urge incontinence but with lack of urge to urinate: detrusor sphincter dyssynergia
STRESS
Presentation: small urine leakage after increase in intra-abdominal pressure (laughing, standing up…)
Dx: Urethral hypermotility/incompetence on the Q-tip test (>30° angle), associated with ‘celes’, MCC of incontinence in pregnant
Sometimes there is retrograde voiding and you can see a small pool of urine on the vagina that does not come out after an increase in intra-abdominal pressure
RF: multiple vaginal deliveries, pelvic floor weakness, ↓ Estrogen
Management: 1) Kegel exercises, pessary placement, estrogen replacement 2) Sx: midurethral sling
OVERFLOW
Presentation: hesitance, driblling, enuresis, full bladder sensation, supra-pubic distension, detrusor underactivity
RF: DM2, BPH, diphenhydramine, outlet obstruction form uterine fibroids, postpartum (epidural/pudendal injury)
Dx: increased post-void residual volume (+150 for female + 100-50 for male)
Management: treat underlying disease, intermittent catheterization, if due to BPH you can give α-blockers or muscarinic agonists as bethanechol, carbachol, neostigmine
How do you treat Bartter sd?
NSAIDS and SPIRONOLACTONE (so you keep K in)
What is the management of newborn’s anuria?
If anuria in the first 24h of life suspect posterior urethral valves → place urethral catheter → then, do a voiding cystourethrogram!! after acute obstruction is resolved → then, remove the valves surgically in the firsts few days of life
What is the empiric treatment for continuous peritoneal dialysis-associated peritonitis?
Intraperitoneal cefazolin + ceftazidime
Do you need to do an Rx of the joints affected by RA?
Yes, because if you see EROSIONS!! you need to give a DMARDs ± TNF inhibitors (vaccinate for zoster, if one TNF inhibitor doesn’t work change to another)
What makes the prognosis of RA a lot worse?
Smoking
What is Still’s disease? How do you treat it?
Rare inflammatory arthritis with fevers, rash and joint pain. This inflammation can destroy affected joints, particularly the wrists. Very high ferritin
Tto: anakinra
When cannot you use TNF-inhibitors?
Demyelinating disease, use abatacept instead
What is the triple drug therapy for RA?
Methotrexate
Hydroxychloroquine Sulfasalazine
Less expensive and very similar efficacy compared to TNF-inhibitors
What indicates bad px in RA?
Both rheumatoid factor + citrullinated peptide
Evan’s syndrome is:
Autoimmune hemolytic anemia + ITP in lupus, HIV, HCV, CVID…
Why you cannot use biologic agents to treat lupus?
Because TNF-inhibitors can cause drug-induced lupus, it can be anti-his negative, anti ANA and anti smith positive!
The only biologic that can be used is Belimumab
Never give TNF-inhibitors in lupus!
SLE managements:
NSAIDs for very mild disease
Hydroxychloroquine to prevent flares
If any systemic disease (ITP, serositis…) you need steroids
Mycophenolate/cyclophosphamide for kidney disease, but cyclphosphamide predisposes to secondary cancers
Which antibody is associated with renal crisis in scleroderma?
Anti-RNA pol 3
Renal crisis is a MAHA so you get schistocytes, it can be precipitated by steroids and you treat it with ACEi (IV), ARBs don’t work. If a pt has scleroderma and HT give prophylactic ACEi
Do not give steroids in scleroderma, they don’t work very well and can precipitate renal crisis
Which diseases (2) can give you a fixed splitting of P2? How do you differentiate them?
ASD: high DLCO
Pulmonary HT: low DLCO
What does watermelon stomach corresponds to?
GAVE (Gastric antral vascular ectasia) in scleroderma
Which antibody is associated with autoimmune pancreatitis in Sjogren’s?
IgG4
Which metabolic abnormality is not corrected with hemodialysis?
Hyperphosphatemia, you need dietary P restriction, P binders, Vit D or calcimimetic agents
How do you differentiate between candida-diaper rash and contact dermatitis in baby?
Candida is beefy red and affects the skin folds while contact dermatitis consist of papules and raised confluent erythematous areas that spare the skin folds
How do you remove a kidney stone depending on it’s size?
In the ureter:
Less than 5mm: discharge and give fluids + NSAIDs ± tamsulosin or Ca ch blocker
(If more than 5mm: remove the stone by retrograde urethrogram)
More than 10mm: urology consult
In the kidney:
Less than 2.5cm: percutaneous lithotripsy/ nephrostomy tube placement during acute pyelonephritis
More than 2.5cm: open sx stone removal, pyelotomy
If the pt develops pyelonephritis!! do emergency percutaneous nephrostomy!! and IV antibiotics
Causes of fetal growth restriction:
Asymmetric: head and abdomen are equally affected → nutrient lack due to uteroplacental insufficiency (SLE, antiphospholipid sd)
Symmetric: head is less affected than the abdomen → congenital, TORCH infection… bad px
Can you do circumcision on hypospadias?
Yes but it needs to be delayed because you need the prepuce for the hypospadias repair which can be done after 6mo (when the baby can tolerate anesthesia better)
Which A. aneurism can compress the ureter?
Large aneurysms of the common, external, or internal iliac artery may compress the ureter, causing an extrinsic urinary tract obstruction and resulting in unilateral hydronephrosis
This is because the middle portion of the ureter runs anterior to the common iliac artery on its way from the kidney to the bladder
Fundoscopy fidings in retinal vein vs artery occlusion:
Vein: looks like a planet; focal retinal hemorrhage instead of a white, pale retina
Artery: cherry red
Councilman bodies indicate:
Cell apoptosis; seen in yellow fever…
How is I:E ratio in asthma?
I:E ratio is normally 1:2
In asthma and COPD it is prolonged ~ 1:3
What type of drugs are exemestane and letrozole?
Aromatase inhibitors (e.g., exemestane, anastrozole, letrozole) they are the first-line hormone-therapy for estrogen-positive and progesterone-positive breast cancers in POSTmenopausal women
Tto of osteomyelitis in kids:
Uncomplicated: nafcillin/oxacillin or cefazolin
Previous hospitalization: vancomycin/clindamycin
Sickle: vancomycin/clindamycin + ceftriaxone/cefotaxime
- Best dx test for osteomyelitis is bone MRI and to confirm the organism your do a bone culture
Which cells take care of toxin degradation in the airway?
Club cells
Which rheumatologic disease cannot be treated by steroids?
Seronegative spondyloarthropathies
Normally you give a TNF-inhibitor if it gets bad
What is biggest RF for osteoarthritis?
Age
Tramadol use, mechanism of action and side effects:
Partial opioid agonist, given for pain, in between NSAIDs and opioids, when NSAIDs cannot be used
SE: seizures, serotonin sd., opioid-induced constipation!
Do glucosamine/ chondroitin work for osteoarthritis?
No
Osteoarthritis management:
1) Topical /oral acetaminophen or NSAIDs!! + quadriceps stretching exercises (Tramadol if they cannot be used) Opioids Duloxetine Corticosteroid injections Joint replacement surgery
Which arthritis are associated with hyperuricemia?
Gout Psoriasis (cell breakdown)
Gout management:
Flares:
1) NSAIDs: but not if HT, gastric ulcer, kidney disease, but NO PROBLEM if they had a recent surgery.
No low dose aspirin!! because it ↓ uric acid excretion
COX2-inhibitors if ulcer but cannot be given on kidney disease
2) Steroids: best in renal insufficiency!!!
3) Colchicine; if flare you normally do allopurinol + colchicine until uric ac. reaches the goal of 6.
* Do not start allopurinol during the acute attack for a patient that has never been on allopurinol but also do not stop allopurinol if the patient is already taking it
4) If gout attack refractory to traditional tto: IL1 inhibitors: Anakinra/ Canakinumab
NSAIDs → Steroids → Colchicine is also the too for pseudo gout
Maintenance:
1) Xanthine oxidase inhibitors: Allopurinol/Febuxostat. Wait for 1mo after the acute attack
2) If you are on a XOi and have not reach uric ac. goal: Probenecib/Lesinurad
Probenecib: you cannot give it in a patient with tumor lysis sd, history of stones or decreased GFR
Lesinurad is ~ probenecib but less toxic
3) If chronic refractory tophaceous gout if all other drugs cannot be used our do not work: pegloticase
Losartan increases uric acid release!
Which HT drug can decrease uric ac?
Losartan. It makes you get rid of uric acid
Tto for Behcet’s sd, Giant cell arteritis, Takayasu, Polimialgia reumatica, Polyarteritis Nodosa and Granulomatosis with polyangiitis:
Behcet’s sd: colchicin
Giant cell arteritis: high dose steroids and tocolizumab
Takayasu: sterois, bypass grafting
Polimialgia reumatica and Polyarteritis Nodosa: steroids ± cyclophosphamide
Chung-Strauss: steroids and mepolizumab IL5i
Granulomatosis with polyangiitis: prednisone during flare and rituximab for maintenance
Gold standard dx of Takayasu:
Angiography
Polyarteritis Nodosa keys:
Does not affect the CAPILLARIES of lung (alveolar) and kidney (glomerular) because it is a medium vessel vasculitis, but it can affect the renal A. Pulmonary A are not involved and bronchial A are only rarely involved. There is not lung disease but the kidney can be affected by the HT
Think this if you see a testicular infarction on young pt
Gold standard: angiography, you see vessel beading
Sural n. biopsy just if foot drop!
P-ANCA negative
Associated with Hep B, C and hairy cell leukemia
Tto: steroids + cyclophosphamide, later change to a less toxic drug
Polymyositis/ dermatomyositis vs inclusion body myositis and autoimmune necrotizing myositis:
Polymyositis/ dermatomyositis: only proximal m. progresses over months
Dermatomyositis: more common in kids, CD4, perifascicular/perimysial. Look for ca.
Polymyositis: more common in adults, CD8, endomysial
Tto: steroids ± steroid sparing drugs, IVIG if myocarditis
Inclusion body myositis: proximal + distal m. progresses over years. Hard to treat: does not respond to steroids, do supportive therapy
Autoimmune necrotizing myositis:
Associated with statins. Autoimmune disease caused by statins. Stop the statin and give immunosuppressants
1) Check CK in serum
2) Stop meds and look for endocrinological disease
3) EMG
4) Muscle biopsy
Define how MAC and fast/ slow onset correlates with solubility of inhaled anesthetics:
↑ Blood/gas = ↑ blood solubility = ↑ AV gradient
slow = Slower; as halothane
↑ Oil/gas = ↑ lipid solubility = ↑ potency = ↓ MAC*; as halothane
- MAC ↓ with age, pregnancy and hypothyroidism
- Do not use NO in pneumothorax
- Halothane is Hepatotoxic, Methoxyflurane is Nephrotoxic and Enflurane is Epileptogenic
Key features of IV anesthetics (Propofol, Etomidate and Ketamine):
Propofol (GABA agonist): DOC in STABLE patients! redistributed Fast! hypotension due to peripheral vasodilation (give phenylephrine, alpha 1 agonist) + slight ↑HR, increases TG
Etomidate (GABA agonist): DOC in rapid sequence intubation + succinylcholine, hemodynamically neutral! good for hypotensive and unstable, inhibits corticoids synthesis so careful in septic shock and do not use for maintenance, emetic, causes m. jerks (add fentanyl)
- Propofol and Etomidate are not analgesic so you need to give them with an opioid or another analgesic
Ketamine (NMDA antagonist): activates the sympathetic, causes HT, bronchodilator, analgesic! dissociative, increases cerebral flow, hallucinations, vivid dreams (prevent with benzo), do not give after MI, HF, HT, pulmonary HT
How do you reverse non-depolarizing neuromuscular blockers or phase 2 succinylcholine?
Neostigmine + glycopyrrolate/atropine
You can also use sugammadex that is faster just for the ‘roniums’ (but monitor EKG)
In which patients is succinylcholine contraindicated?
Stroke
Burnt
Hyperkalemia
Which neuromuscular blockers is the DOC in renal and hepatic failure?
Cisatracurium
Main side effects of atracurium:
Atracurium: histamine release; hypotension, tachycardia
- Cisatracurium is more potent and doesn’t cause histamine release
Key differences between cauda equina, conus medularis and spinal shock:
Cauda equina:
LMN lesion (radiculopathy), normal Babinski
Lumbar lesion, both L4 and S1 lost
Tends to be more unilateral
Conus= clonus medularis:
UMN lesion (spinal cord lesion), affected Babinski
Sacral, just S1 lost
Tends to be bilateral ± impotence
Both have saddle anesthesia, low back pain and involve the sphincters causing incontinence
Spinal sock:
Acute loos of spinal cord reflexes that come back
Post-traumatic
Key differences between Mallory Weiss and Boerhaave syndrome:
Mallory Weiss= esophageal tear
presents with hematemesis but not pneumomediastinum
Boerhaave= esophageal perforation
Pleural effusion with atypical fluid
Pneumomediastinum: Hamman sign (crunching sound which each heartbeat), subcutaneous emphysema (neck/ precordial crepitus) → esophagography or CT scan w. water soluble contrast → sx debridement and repair
When should you give a statin?
3 magic numbers: 190, 40, 7.5!!!
If atherosclerotic cardiovascular disease (angina, MI, arterial revascularization, stroke, TIA…)
LDL more than 190
LDL (mg/dL) = total cholesterol – HDL – (triglycerides/5)
DM and older than 40
Estimated risk of atherosclerotic cardiovascular disease more than 7.5-10%
What is the management of carcinoid sd?
1) 24h urine 5HIAA → if + CT scan to localize the mass → Octreotide scintigraphy if CT does not find the tumor
What is the management of suspected appendicitis?
Adult → CT scan w. contrast (which is + accurate than MRI) → sx
Pregnant or kid→ ultrasound ± MRI → sx
Sx:
Nonperforated: Ab and appendectomy within 12 h
Perforated: Ab and bowel rest, then percutaneous drainage if contained abscess/ irrigation and drainage with appendectomy
Acute abdomen (rebound tenderness, rigidity, involuntary guarding) and indeterminate CT
- Appendicitis from onset of symptoms to perforation is 36-48 hrs
Organisms and tto associated with bites:
1) Debridement and amoxi-clavulanic (clindamycin + cefuroxime if rash with penicillin). Covers Pasteurella multocida, also good coverage of gram + gram - and anaerobics that make beta-lactamases
Let it heal by secondary intention because anaerobes are the cause
If does not heal:
Human: Eikenella corrodens (Cepha 3rd)
Dog: Capnocytophaga canimorsus (Cepha 3rd)
Cat scratch: Bartonella henselae (azithromycin)
Osteolyelitis: pasteurella multocida
Mini-Mental State Exam (MMSE) score interpretation:
25-30: ok!! normal aging
24-20: mild dementia!!*
20-13: moderate dementia
Less than 12: severe dementia
Montreal assessment (MoCA) scores range also between 0 and 30 and are very similar to mini-mental
- Fronto-temporal dementia normally presents with mild dementia while Alzheimer presents with moderate or severe!
DD of Biliary colic, Cholecystitis, Choledocholithiasis and Ascending cholangitis:
Asymptomatic gallstones: no tto
Biliary colic:
Stone on the gallbladder
Pain for less than 6h
Tto: 1) ursodiol/ ursodeoxycholic acid 2) elective cholecystostomy
Acute cholecystitis:
Stone on the cystic duct!!
Pain for more than 6h + Murphy sign + pericholecystic fluid and ↑ wall thickness
± fever, leukocytosis
NO jaundice no ↑ alkaline phosphatase
Dx: 1) ultrasound if negative → HIDA scan (not filling of the gallbladder)
Tto: 1) antibiotics (pipe+tazo), then within 72h cholecystectomy!!!/ if bad sx candidate do a percutaneous cholecystostomy (tube)
Acalculus cholecystitis:
~ acute cholecystitis but on a patient with long ICU course
pericholecystic fluid but no stone
Tto: percutaneous cholecystostomy (placement of a cholecystostomy TUBE) No cholecystectomy right away, do it 6w after
Emphysematous cholecystitis: gangrene + air in the biliary system
Tto: 1) Antibiotics + emergent cholecystectomy
Choledocholithiasis: PAINFUL JAUNCICE
Stone on common bile duct, dilated on US
Less severe pain + JAUNDICE + ↑ alkaline phosphatase
Liver enzymes do not have to be ↑
NO fever (unless pancreatitis), no leukocytosis, no Murphy sign
Can lead to acute pancreatitis!!!! gallstone pancreatitis is one of the MCC (with alcohol) of acute pancreatitis! The common bile duct will be dilated here too
Tto: Endoscopic retrograde cholangiopancreatography w sphincterotomy followed by elective cholecystectomy within 72h
Ascending cholangitis: PAINFUL JAUNDICE+ FEVER
Obstruction at the common bile duct
Infection of the biliary tree due to enteric organisms as E.Coli, Klebsiella, clonorchis sinensis
Charcot triad: pain + jaundice + fever
+ leukocytosis + ↑ alkaline phosphatase
Reynolds pentad if progresses to shock: + hypotension + metal status changes
Dilation of the intrahepatic and common bile ducts!!!!
Tto: Endoscopic retrograde cholangiopancreatography → antibiotics + IV fluids → cholecystectomy when stable
Neonatal conjuntivitis causes, timing, tto and prevention:
Gonococcal conjuntivitis:
In 2 days old
Prevented with topical erythromycin
Treat with IV/IM ceftriaxone x1!!! (you do not need to give cefotaxime here because one single dose w not cause bilirubin-albumin displacement)
Chlamydia conjuntivitis:
In 2 weeks old. Chlamydia is calm and goes slow!
Beefy red palpebral fissure (~ trachoma)
Dx: you need a conjunctival scraping for PCR
Treat with oral macrolide (erythromycin) x 2w, causes a lot of GI problems
Tto w prevent pneumonia
What should you think about if you see someone on drugs with conjunctival injection?
Cannabis, associated with impaired reaction time
Dandy walker malformation is associated with?
Cerebellar vernix hypoplasia associated with congenital failure of closure of the Mangendie’s foramen
CHA2DS2 VAS score for Atrial Fibrillation Stroke Risk and management of each result:
This is for chronic A. fib that lasts more than 2 days:
Congestive heart failure Hypertension (even if treated) Age ≥ 75 years (2 points) Diabetes mellitus Stroke or TIA or thromboembolism (2 points) Vascular disease (prior MI, peripheral artery disease, or aortic plaques) Age 65–74 years Sex category (female sex)
0-1: no tto needed/aspirin
2 or more: direct 2 factor inhibitors (dabigatran, argatroban)/ factor X inhibitors (apixaban)/ warfarin (careful bc causes bleeding)
Keep the anticoagulation even if you do an ablation
Fall risk is not a reason for not to anticoagulate
*If A. fib due to a valvular cause use warfarin; but if not for a valvular cause you should use the factor 10 or 2 inhibitors after calculating CHA2DS2VAS
When you don’t need CHA2DS2VAS? mitral stenosis, thyrocoxicaosis + A. fib, HCOM causing A. fib
Main association with stress incontinence:
Urethral hypermotility
What does not palpated fundus + mass at the introitus on a woman that just gave birth? What is the management?
Uterine inversion
Management:
1) discontinue uterotonics (oxytocin) → manual replacement and placental detachment → then give uterotonics (oxytocin) again
What is the treatment of endocarditis? What are the indications for valve surgery?
1) Blood cultures from 3 different venipuncture sites
2) Antibiotics:
IV drug user: IV vancomycin ± ceftriaxone
If sensitive after blood culture: nafcillin
Subacute: penicillin/macrolide/wait for sensitivity
HACEK*: IV 3rd generation cephalosporins (ceftriaxone)/ IV ciprofloxacin
* Haemophilus, Aggregatibacter (previously Actinobacillus), Cardiobacterium, Eikenella, Kingella
Valve surgery indications: acute heart failure, hypotension, emboli on antibiotics, vegetation of >=10mm, positive culture after antibiotics
Does broken heart syndrome present with high troponins?
Yes
Answers that are normally distractors:
Biofeedback
Magnetic Resonance Cholangiopancreatography
Consulting ethics committee
What do you give to a depressed patient that is going to die in 2w?
Methylphenidate
What do you tell the wife of a guy that says I don’t want her to know the dx?
Your husband is fully informed about his health issues, he can tell you anything he feels you need to know
Because:
It preserves confidentiality
Involves the patient doing the telling
Which bug is associated with hamsters?
Salmonella
HR temperature dissociation: ‘she has a fever to 103, heart rate 62/min’
Can you have rheumatoid arthritis with negative anti-CCP?
Yes!
IgM activates complement that destroys the joint and then there is synovial mb hyperplasia forming a pannus that erodes the join
What is the most common comorbidity associated with Afib?
What is the most common cause of Afib?
What is the biggest RF for MS?
What is the biggest RF for coronary A disease and AAA?
What is the biggest RF for stroke and aortic dissection?
HT
Mitral stenosis (Dx: echo, Tto: valve replacement!!!!/ balloon valvotomy JUST if sx not possible)
Rheumatic fever
Smoking (smoking is the most important modifiable RF for atherosclerotic heart disease)
HT
Name SNRIs and their SE:
Venlafaxine, Desvenlafaxine
Duloxetine (DM)
Milnacipran!! Levomilnacipran
They work the fastest, 2-3w
SE:
HT
Raised metanephrines and normetanephrines
What is key when they give you multiple RF for an illness and you have to choose the most significant RF for that patient?
Pay attention to which RF has the patient been exposed to the longest!
Cosalgia:
After stroke there are weirds symptoms on a extremity (warm…)
Red hot painful ears with chronic stridor and a saddle nose deformity:
Relapsing polychondritis
Fever, thigh is swollen and exquisitely painful. Physical exam is notable for red and purple splotches around the involved area, Dx?
Necrotizing fascitis or progression to myonecrosis
Management: MRI
Tto: debridement + clinda
Where do primary CNS lymphomas go?
Optic radiations, cause contralateral homonymous hemianopsia
Segmental aneurysmal dilation of the SMA and IMA means:
Polyarteritis nodosa. In adult look for Hep B, in kid look for stept pneumo
Eustachian tube dysfunction is associated with:
Wegener’s
Granulomas in the lungs
Late onset asthma + peripheral neuropathy:
Chung strauss
Granulomas in the lungs
Patient diagnosed with H.Pylori gastritis 3 mo. ago and completed triple therapy. But persistent gastric ulcers and a large posterior antral ulcer with raised edges:
MALToma
Tto: triple therapy, if does not work rituximab
Bechets disease dx, which HLA is associated?
Dx: pathergy test
HLA-B51
Proximal shoulder/hip weakness with a normal CPK in a 22 yo F on chronic therapy for severe, persistent asthma. Dx?
Steroid induced myopathy
EMG will show low amplitude, short duration, polyphasic motor unit potentials
Septic arthritis management:
1) arthrocentesis: if more than 50.000 PMNs → septic arthritis → sx wash out the joint + Abs*
*Antibiotics depend on gram stain:
Staph: vancomycin+ clean joint by arthrocentesis
Gonococcus: ceftriaxone+doxycycline/azithromycin
Negative gram: vancomycin+ceftriaxone
DD: septic bursitis Normal range of motion Pt working on his knees Normally S. aureus Treat with vancomycin
Treatment for Hyper IgM sd and common variable immunodeficiency:
IVIG
6 mo boy with spontaneous nose bleeds and chronic bloody diarrhea, he has had recurrent bacterial infections, examination of his UEs shows a red, itchy rash on his extensor surfaces:
Wiskott Aldrich sd.
X-linked, just in boys
Septic patient with PNH. Dx?
Eculizumab tto leading to Neisserial infection
Kid with recurrent sinopulmonary infections, silvery hair and frequent sunburns. Bone marrow biopsy shows blast cells with intracellular “giant inclusion bodies”. Dx?
What is the most common cause of infection?
Dx: Chediak-Higashi
MCC of infection: Staph aureus; frequently causes a periodontitis
Other names for integrin:
CD18
LAF-1
MAC1
Proximal + distal neuropaty:
Inclusion body myositis
Pseudogout is associated with:
Gitelman syndrome Thiazides Hemochromatosis Hyperparathyroidism Hypophosphatemia (low P) Hypomagnesemia (low Mg) Join trauma
4Hs
Tto of fibromyalgia:
SNRI: Duloxetine or Milnacipran
TCA
Pregabalin
Gabapentin
- remember that CK will be normal
Most common cause of death in scleroderma:
Pulmonary HT!
Findings: RV heave, loud P2
What is the pulmonary manifestation of CREST syndrome? Pulmonary vascular HT with hyperplasia of the intimal smooth m. layer. The parenchyma is ok.
What is the pulmonary manifestation of diffuse scleroderma? Interstitial lung disease that causes secondary pulmonary HT. Only dx if you see a restrictive pattern and reticular opacities! because on diffuse scleroderma you can also just have pulmonary vascular HT
Remember that in CREST there are just: skin findings, GERD and pulmonary HT! Calcinosis Raynaud Esophageal hypomotility=GERD Sclerodactyly Telangiectasia Pulmonary HT
Pt with history of end stage renal disease and wood like induration of the extremities that SPARES the digits:
Nephrogenic systemic fibrosis
Antibody in lupus associated with kidney issues/disease activity:
Anti ds-DNA!! and complement
Next best step in the management with rapidly rising Cr:
Renal biopsy (because there are a lot of different renal problems)
Drug of choice for SLE:
Hydroxychloroquine for long term. You need to do an anual eye exam!
Steroids for flares
Management on heart acute rejection:
Echocardiography guided endomyocardial biopsy
What do you do if you have a gram stain negative in septic arthritis?
Vancomycin+Ceftriaxone
Selected causes of pneumonia and their ttos:
Recent stroke: anaerobes; fusobacterium, peptococcus, bacteroides. Tto: clindamycin
Cavitation: staph aureus, anaerobe, (maybe klebsiella), squamous cell lung ca
Abscess ‘thin walled cavity with air-fluid levels’ in alcoholic: anaerobes; tto: ampicillin-sulbactam
Abscess with poor dental higine: anaerobe. Tto: clindamycin
COPD: Haemophilus. But strep pneumo is still the MCC of COPD exacerbation! Tto: for both is ceftrixone
Outbreak: legionella. (do urinary antigen)
Most common cause in HIV: strep pneumo. Tto: ceftrixone
Recent trip to New Mexico/Arizona: cocci, spherules. Tto: itraconazole
Cleans chicken/bird coops: histo or crypto
Works at a “bird” store: chlamydia pistachio
Researcher that works with wild rabbits: francisella tularesnsis. Tto: doxycycline
Takes care of goats, sheep, and cats: coxiella
Exposure to rodent urine/poop: hantavirus
Desquamation with silvery scales on the palms and soles and ulcers on the glans penis, dx? tto?
Desquamation with silvery scales on the palms and soles: keratoderma blenorragicum
Ulcers on the glans penis: balanitis
Dx: reactive arthritis
Tto: NSAIDs
Ankylosing spondylitis Rx findings, management, tto and possible complication:
Rx findings: calcification of the annulus fibrosus of the intervertebral discs and inflammatory changes in the sacroiliac joints
1) Rx → if negative MRI of sacroiliac joint
Exercise → NSAIDs → TNF inhibitors → Surgery
At risk for atlantoaxial instability
Treatment for axial vs peripheral rheumatoid disease:
Axial → NDAIDs → TNF inhibitors (PPD test before)
Peripheral → NDAIDs → methotrexate (you could give TNF inhibitors if methotrexate does not work)
Inverted CD4 to CD8 ratio, Dx?
MHC2 deficiency!
RA associations:
Multiple lower lobe predominant nodules on CXR:
Bilateral arm weakness and 4+ reflexes:
Left upper quadrant fullness and WBC of 1k:
Tto:
Multiple lower lobe predominant nodules on CXR: Capaln sd
Bilateral arm weakness and 4+ DTRs: atlantoaxial instability
LUQ fullness and WBC of 1k: Fetty sd
Tto: 1) Methotrexate (do pulmonary fx tests) → TNF-inhibitor (screen for TB and hep B)
*Hydroxycloroquine if pregnant
Given the following clinical presentations, what is the most likely SSTI?
Honey colored crusted papules and pustules. Dx, Bug, tto?
Cellulitis and hemorrhagic bullae after going underwater diving in a 45 yo M with chronic Hep C. Bug tto?
Chronic nodular infection of the distal extremities in a vegetable farmer. Bug?
Necrotic skin ulcer in a 22 yo diabetic male with a WBC of 500. Dx, Bug?
Chronic nodular infection of the distal extremities in a fish tank cleaner. Bug?
Honey colored crusted papules and pustules: impetigo, staph aureus, topical mupirocin (DD. with HSV infection that can also present as a honey-color crusted rash on the face, but it will be limited to the orolabial region and would not involve the cheek)
Cellulitis and hemorrhagic bullae after going underwater diving in a 45 yo M with chronic Hep C: Vibrio vulnificus, doxycycline
Chronic nodular infection of the distal extremities in a vegetable farmer: Sporothrix
Necrotic skin ulcer in a 22 yo diabetic male with a WBC of 500: ecthyma gangrenosum, pseudomonas
Chronic nodular infection of the distal extremities in a fish tank cleaner: Mycobacterium marinum
40 yo smoker with bilateral calf pain who is a postal worker. Dx: Initial test: Test reports a result of 1.6: First mgt step: 2nd mgt step: Before surgery: Biggest RF:
Peripheral A disease
1) Ankle-brakial index + if less than 0.9
If more than 1 it is probably a diabetic that has Mockeberg’s
First mgt step: supervised exercise program!
± smoking cessation ± statin ± aspirin
2nd mgt step: cilostazol
Before surgery: angiography or arteriography
Biggest RF: smoking
Extra: put them on aspirin and high intensity statin
Recent MI and sudden onset severe LLE pain and absent pulses.
Actue limb ischemia
Management: 1) heparin (can do CT angiography to confirm) then emolectoy within 6h
65 yo M with MI that underwent a successful cardiac cath 5 days ago. Cr has bumped up to 3.5, he has transient vision loss, and he has a netlike, purplish discoloration on his LEs bilaterally. UA is +ve for eosinophils. He also had an episode of transient vision loss and a “golden body” is seen on a fundoscopic exam. Dx?
Aortic atheroemolic disease, the golden body is a Hollenhorst plaque
23 yo college student comes to the ED complaining of pain in his right arm. He went spelunking with a few friends and believes he may have been bitten by a bat. What is the next best step in the management?
Rabies immunoglobulin in one arm, vaccine in the opposite!
27 yo 4 ft tall female presents with severe, sudden onset chest pain. CXR is notable for a left sided pleural effusion. She has never had menses. Dx: Dx testing by patient: What are the 2 forms of this disease: Initial management step for all forms: Subtle management difference: Specific drug to avoid: Why would this person be hoarse:
Aortic dissection on a Turner sd patient
Dx testing by patient: if stable CT angiogram but if untestable trasesophageal ECO
What are the 2 forms of this disease:
A: involves the ascending aorta
B: does not involve the ascending, just the descending
Initial management step for all forms: Beta bloquer (never hydralazine)
Subtle management difference:
A: sx after the beta blocker
B: no need sx
Why would this person be hoarse: affect the recurrent laryngeal n.
Recent DVT and then stroke:
There is a patent foramen ovale so need to do echo with bubble study
Holosystolic murmur at the LLSB with apical diastolic rumble. Dx?
VSD
IVDU with 2 wk h/o malaise, fatigue, fevers, and a new LLSB murmur heard on auscultation.
Next best step in the management:
3 groups needing antibiotic prophylaxis?
Dx imaging?
Bugs with blood cultures that need future colonoscopies (2)?
Feared complication?
Infective endocarditis
NBSIM: blood cultures, do not treat before you get those cultures
3 groups needing abx ppx?
Prior endocarditis
Prostetic valve
Unrepaired cyanotic congenial heart defect
Dx imaging? Transesophageal echo
Bugs with blood cultures that need future colonoscopies (2)?
S. bovis
Clostridium septicum
Feared complication: brain abscesses (1-7%)
4 ft tall F with chronic LE claudication. CXR findings? Tto?
Coarctation of the aorta, 3 sign
Tto: sx
Rolling thunder murmur heard throughout the cardiac cycle in a kid with mom having an upper respiratory illness during pregnancy and wide PP:
PDA
Hematuria and flank pain with a blood transfusion:
SOB and stridor with a blood transfusion:
T 102 and chills 2 hrs after a blood transfusion. Dx?
Tto?
Hematuria and flank pain with a blood transfusion: Acute hemolytic transfusion reaction (type 2). Management: fluids
SOB and stridor with a blood transfusion. Anaphylactic transfusion reaction (type 1). Management: epi
T 102 and chills 2 hrs after a blood transfusion: Afebrile nonhemolitic transfusion reaction. Management: Coombs (just in case is +), NSAIDs/acetaminophen
Long term measure with recently placed prosthetic aortic valve.
What is your therapeutic target?
Why would this person potentially have an indirect hyperbilirubinemia?
Warfarin for life, INR goal 2.5-3.5
Hemolysis can happen bc the valve can shear RBCs
High pitched midsystolic click at the apex, how does this change with manuvers? RF? Histology?
Mitral valve prolapse
If you put more blood in the LV you fix the murmurs of MVP and HCMO
↑ preload (as valsalva that increases intrathoracic pressures) ↓ murmur
↑ afterload ↓ murmur
RF: marfan, ED, ADPKD, pregnant, woman with psychiatric problems
Myxomatous degeneration
MI Complications:
Pt dies intra-intraoperative during percutaneous coronary intervention 2 hrs after the onset of chest pain with ST elevations on ECG:
Sudden onset SOB with bilateral crackles on lung auscultation, you hear an holosystolic murmur at the apex:
Same but you hear an holosystolic murmur heard at the left lower sternal border:
Low voltage ECG and PEA:
Pt dies intra-intraoperative during percutaneous coronary intervention 2 hrs after the onset of chest pain with ST elevations on ECG: Arrhythmia
Holosystolic murmur at the apex: Papillary m. rupture
Murmur heard at the left lower sternal border: Intraventricular septal rupture
Low voltage ECG and PEA: Tamponade, free wall rupture
Opening snap at the apex. Dx?
Most common arrhythmia present?
Anticoagulant strategy?
Mitral stenosis
Afib
Warfarin!
Syncopal episodes in a 41 yo 4ft tall woman with a systolic murmur heard at the right upper sternal border. Diagnostic test to avoid?
Aortic stenosis secondary to bicuspid aortic valve in Turner
Do not do exercise stress test in AS!!!
Migratory arthritis with painless nodules under the skin, elevated ESR/CRP in a 12 yo F. She had an URI 12 months prior. Dx:
Tx strategies (2 drugs):
Most likely future valvular anomaly:
Choreiform movements with resolution over a 2 month period:
Rheumatic fever
Tx strategies (2 drugs): NSAIDs+ penicillin!!
Most likely future valvular anomaly: MS
Valves affected form the most to the least: MAT; mitral → aortic → tricuspid → pulmonic
Choreiform movements with resolution over a 2 month period: PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus). Resolves spontaneously
HIV and vaccine strategies:
S.Pneumo: PCV13 followed by PPSV23 8 weeks later and again in 5 years and at age 65
HPV: 9-26 yo
Hepatitis B unless they have documented immunity
Meningococcal vaccine with boosters every 5 years
Tdap vaccine as an adult followed by Td boosters every 10 years and after injury
Influenza every year (NOT the LIVE attenuated the inactivated)
Zoster: if no signs of immunity, do a serology and if negative give the vaccine if CD4>200
HIV associations:
Watery, foul smelling diarrhea in a HIV patient. Bug, tto?
Nuchal rigidity and high fevers in a HIV patient. Bug, tto?
3 days of SOB, non-productive cough, and interstitial infiltrates on a CXR. Bug, tto?
2 weeks of SOB, productive cough with a CXR revealing a right upper lobe cavitary lesion and a right sided pleural effusion. Bug, tto?
3 days of SOB, high fevers, and a lobar consolidation seen on CXR. Bug, tto?
Odynophagia. Bug, tto?
Blurry vision with a CD4 of 45. Bug, tto?
Watery, foul smelling diarrhea in a HIV patient. Cyptosporidium, paromonycin/nitazoxamine
Nuchal rigidity and high fevers in a HIV patient. Cryptococcus. Ampho B + flucytosine, then fluconazole
3 days of SOB, non-productive cough, and interstitial infiltrates on a CXR: PCP, TMP-SMX
2 weeks of SOB, productive cough with a CXR revealing a RUL cavitary lesion and a right sided pleural effusion: TB, RIPE regime + vit B6
3 days of SOB, high fevers, and a lobar consolidation seen on CXR: Strep pneumo, ceftriaxone
Odynophagia: Candida, nystatin or azoles (lozenge format)
Blurry vision with a CD4 of 45: CMV, ganciclovir
HIV key prophylaxis:
CD4 < 250: arizona, nevada, california: itraconazole for cocci
CD4 < 200: TMP-SMX* for PCP
CD4 < 150: Chicago, kentucky, Missouri: itraconazole for histo
CD4 < 100: TMP-SMX* for toxo (TMP-SMX only for prophylaxis, tto is pyrimethamine+sulfadiazine)
CD4 < 50 on HAART therapy: no need for prophylaxis
CD4 < 50 not on HAART therapy: azithromycin for MAC
*If sulfa allergy give atovaquone!
JVD, BP goes from 120/80 to 101/70 with deep breaths, low voltage ECG. Dx?
Other signs:
Tto?
Other ECG finding:
CXR finding:
Tamponade (The vignette describes pulsus paradoxus)
Other signs: blunted/ absent y descent on central venous pressure
Tto? pericardiocentesis (pericardial window)
If they are asking about Dx or pericardiocanetesis is not an option do echocardiography
Other EKG finding: electrical alternants
CXR finding: water bottle shaped heart
Loud diastolic heart sound with more prominent JVP waves on inspiration. Auscultation findings? Imaging findings?
Kussmaul sign on constrictive pericarditis
Auscultation: pericardial knock
Imaging findings? calcifications in the pericardium
Tto: surgery
Acute onset stabbing chest pain alleviated with sitting forward.
EKG findings (2)?
Tto strategy?
Tto strategy for post MI pericarditis?
Acute pericarditis
EKG findings (2)? diffuse ST↑ and diffuse PR↓
Tx strategy? 1) NSAID+colchicine
Tx strategy for post MI pericarditis? aspirin
Key arrhythmias; dx and too:
Fib rule:
Tach rule:
Above the ventricle rule:
In the ventricle rule:
The < 60 + Hemodynamically unstable rule:
The > 100 + Hemodynamically unstable rule:
Fib rule: spaces between the QRSs are unequal
Tach rule: spaces between the QRSs are equal
Above the ventricle rule: QRS is narrow
In the ventricle rule: QRS wide
The HR < 60 + Hemodynamically unstable rule: pacing
The HR > 100 + Hemodynamically unstable rule: synchronized cardioversion=direct current counter-shock
Electrolyte abnormalities:
Low K, Low Ca, Low Mg: long QT
High K: wide QRS, peaked T; 1) Ca gluconate
High Ca: Short QT
Hypothermia: J wave
Biggest RF for multifocal tachycardia, which electrolyte abnormalities are associated with it? What is the tto?
Smoking leading to COPD
Electrolyte abnormalities: ↓K ↓Mg
Tto: treat the underlying cause and Ca ch blockers
Never cardiovert or give a β-blocker
Tto for Afib w/WPW:
Procainamide
Hemodynamically unstable WPW:
Synchronized cardioversion
Drugs that increase survival in heart failure, decrease remodeling:
ACE inhibitors (prils) ARAs (sartans) Beta-blockers (Bisoprolol, Carvendiol, Metoprolol -Beta blockers Curve Mortalily-) Sacubitril (increases ANP) + valsartan Cardiac resynchronization therapy
Aldo antagonists (spironolactone, eplerenone) in EF less than 35% Hydralazine + isosorbide dinitrate in African-americans
31 yo M is brought to the ED with a 24 hr history of worsening headaches and nuchal rigidity. He was admitted one week ago for cryptococcal meningitis that responded to liposomal Amphotericin B and 5-flucytosine therapy. He was discharged on HAART. His most recent CD4 count obtained 1 month ago was 25 (nl CD4 > 500). A cryptococcal latex particle agglutination assay of a CSF sample obtained by lumbar puncture is negative. Dx?
Inmune reconstitution inflammatory sd
So combined antiretroviral therapy should first be initiated at least 2 weeks after initiating treatment for the opportunistic infection!!!
46 yo M with a 25 yr history of HIV is brought to the physician by his daughter with a 4 mo h/o poor concentration and impaired cognition. His only medication is a multivitamin. CD4 count is 10. Neurological exam shows a diffuse impairment in UE/LE motor activity. Dx?
Next best step in the management?
HIV dementia
NBSM: Highly active antiretroviral therapy
Coronary pathology:
Dx and tto of stable angina
When does acute coronary sd. start?
3 drugs THAT must be given acutely for acute coronary sd? And for chest pain?
Whan do you do coronary artery bypass grafting?
Stable angina: Dx 1) exercise stress test; Tto: nitroglycerin + loose weight, stop smoking and drinking
Acute coronary sd. starts at unstable angina!
1) Aspirin+clopidogrel → heparin → nitrate
O2
For chest pain? nitrate (just morphine in RCA infarct because you cannot give nitrates)
CABG? just if LMCA or 3 vessel disease
Maintenance: beta blockers, statins
37 yo F smoker on OCPs with sudden onset chest pain and SOB. Dx? ABG findings: Ca: K: Next best step in the diagnosis: Next best step in the management: When do we give TPA?
PE
ABG findings: respiratory alkalosis, and Ca ↓ K ↓ because of the alkalosis
NBSID: CT angiography
NBSIM: heparin
When do we give TPA: in hemodynamically unstable patient or patient with right heart dysfunction
Sensorineural hearing loss in a patient that received therapy for chorioamnionitis:
You give Ampicillin+gentamicin for chorioamnionitis so you can cause ototoxicity
Aural fullness, spinning sensation, ringing in the ears. Dx?
Meniere’s disease=endolymphatic hydrops
Spinning sensation on morning awakening. Worsened by head movements.
BPPV
Dx: Dix-hallpike manuver
Tto: Epley maneuver or Semont maneuver
In brain metastasis, what is the immediate next best step in the management? Tx strategies?
Immediate NBSIM? corticoids
Tx strategies? whole brain radiation
25 yo M with progressive R sided hearing loss and family history of hearing loss:
Otosclerosis
Calcified mass with an enhancing linear projection connected to the dura refers to:
Dural tail of a meningioma
Recurrent episodes of AOM. Evaluation reveals non-specific debris behind the tympanic membrane. He has chronic, foul smelling d/c from the affected ear. Dx:
Dx testing?
Tto?
Cholesteatoma
Dx testing? head CT scan
Tto? sx
Patient with acute otitis media who develops pain, redness, and swelling behind the ear. Dx?
Next best step in the management?
Tto?
Acute mastoiditis, after a non-healed ear infection
The ear also looks down and forward
1) drain the ear and send for culture + IV antibiotics
2) head CT!!! scan (in order to look for potential complications such periostitis/osteomyelitis)
Tto:
Myringotomy + IV vancomycin (S. aureus)
Blunt kidney trauma algorithm:
1) urinalysis:
No blood → home
Blood → CT scan abdomen and pelvis
7 week baby with projectile nonbilious vomiting 30 mins after feeds. Visible peristaltic waves. Dx?
Dx test? Tto?
Pyloric stenosis
Dx test? Ultrasound
Tto? Myomectomy
Baby with abdominal viscera to the right of the umbilicus vs through the umbilicus?
To the right of the umbilicus: gastroschisis
Through the umbilicus: omphalocele
Down’s syndrome with failure to pass meconium.
Associated mutation? Dx?
Dx testing?
Hirschsprung disease
Associated mutation? RET
Dx testing? Rectal suction biopsy
Thyroid pathology keys:
First step in working up nodules:
Next best step in management with a hot nodule:
Next best step in management with a cold nodule:
If RAIU scan shows 1 hotspot. Dx?
If RAIU scan shows multiple hot spots. Dx?
If RAIU scan diffuse pattern. Dx?
If RAIU scan shows no uptake + tender thyroid. Dx?
Healthcare worker:
MCC Cold thyroid nodule:
Swallowing issues after lobectomy:
MC thyroid cancer:
Prolonged QT on EKG with thyroid cancer:
Laminated calcifications:
Method of spread:
Old guy with widely disseminated lesions:
Prophylactic surgery with MEN2 syndromes:
First step in working up nodules: TSH
TSH ↓ → HOT nodule: RAIU scan
TSH ↑/Nr → COLD nodule: 1) ultrasound → fine needle aspiration if meets criteria (cannot rule out follicular thyroid ca. but it can rule out the others)
RAIU scan 1 hotspot: toxic adenoma
RAIU scan multiple hot spots: toxic multi-nodular goiter
RAIU scan diffuse pattern: graves
RAIU scan No uptake + tender thyroid: de Keravin=granulomatorus=subacute thyroiditis
Healthcare worker: factitious, also no uptake
MCC Cold thyroid nodule: colloid cysts
Swallowing issues after lobectomy: injury of the recurrent laryngeal n.
MC thyroid cancer: papillary (papillary is popular)
Prolonged QT on EKG with thyroid cancer: medullary because it makes calcitonin!
Laminated calcifications: papillary
All ca. spread trough lymph nodes, only follicular spreads hematogenously
Old guy with widely disseminated lesions: aplastic
Prophylactic surgery with MEN2 syndromes: thyroidectomy
Where is the likely nerve lesion?
1) Midlateral thigh numbness in a basketball player who has required R thigh casting for a sports related injury:
2) Flattening of the thenar eminence, sensory loss on the ventral surface of the lateral hand:
3) Weakness in “finger spread”:
1) Lateral femoral cutaneous nerve leading to meralgia paresthetica
2) Carpal tunnel. Wrist splint → Inject steroids → nerve conduction studies before you cut the carpal tunnel in sx
3) Ulnar n.
51 yo M with a 6 mo h/o numbness and paresthesias in his L foot radiating to his L great toe:
Tibial n. problem: tarsal tunnel sd.
Male cyclist has been unable to train for the past 4 days. He had a sore throat and rhinorrhea that resolved 10 days ago without tx. Dx: Tx: Drug to avoid: Respiratory monitoring:
Gilliam-barre
Tx: plasmapheresis
Drug to avoid: corticoids
Respiratory monitoring: if FEV1 goes down you intubate
Tx for trouble smiling on one side of the face?
Steroids within 3 days of the onset
Buffalo hump, DM, osteoporosis, amenorrhea. Dx:
First dx test:
2nd dx test:
3rd dx test:
Tx strategy:
Cushing’s sd
First dx test: late NIGHT salivary cortisol/ 24h urine cortisol (if pt works late at night)/ low dose dexamethasone suppression test (has a lot of false + so you cannot do it if the pt is taking OCPs, P450 activators, alcoholics, depressed…)
Normally you do 2 test here because you end up doing the 24h urine cortisol to confirm that is the most accurate
2nd dx test: measure ACTH; ↓: adrenal cause so do a CT of the abdomen and pelvis; ↑: ectopic or Cushing’s disease so go to the 3rd dx test
3rd dx test: if ↑ ACTH do a high dose dexamethasone suppression test: suppression: pituitary so do a brain MR; no suppression: ectopic due to cancer
4rd dx test if you still don’t know if it is ectopic or pituitary: Inferior petrosal sinus sampling: check the sinuses and depending on where you see ↑ ACTH you can localize where the lesion is; if the inferior petrosal sinus has a lot of ACTH the tumor should be on the pituitary (pituitary gland is drains to this sinus)
Tx strategy: 1) surgical resection 2) ketoconazole or metyrapone 3) mifepristone because it blocks cortisol receptors
Pheochromocytoma dx:
1) Plasma (+ sensitive)/ urinary free metanephrines (ask pt to stop smoking 4h before testing) → CT abdomen and pelvis → if you don’t find the mass on CT scan you can check for ↑ uptake of iodine-131-metaiodobenzylguanidine = I-131 MIBG!!
* Suspect pheochromocytoma in pt with HT, paroxysmal headaches and unexplained hyperglycemia!!! (catecholamines inhibit insulin secretion)!
Given the following vignettes, what is the most likely dx (bleeders)?
1) Painless, massive bloody bowel movement in a 65 yo F. Dx? Dx test?
2) 69 yo M with a history of PAD has a 3 mo h/o of severe LLQ pain worsened with meals:
3) 72 yo F with a Hb of 8. Fecal occult blood test is +. An ejection murmur radiating to the carotids is heard on auscultation:
4) Hb of 7, 3 months after a AAA repair:
5) Chronic bloody bowel movements with small vascular malformations visible on the buccal mucosa:
6) Sudden onset of painful hematemesis 30 minutes after weightlifting/eating disorder patient:
1) Diverticulosis. Dx test is barium enema or colonoscopy
Diverticulitis Dx test is CT scan with contrast!!! do not do colonoscopy until episode resolves
2) Ischemic colitis; vascular disease of the mesenteric A
3) AS+GI bleed: Heidy sd=colonic angiodisplasia, the calcified aortic valve destroys the VW factor so you bleed!
4) Aorto-enteric fistula. Bleed into their GI tract!
5) Osler-Weber-Rendu disease=hemorrhagic hereditary tellangiectasia
6) Mallory Weiss tear (hemodynamically stable vs boerhaave that will be unstable). No need to treat Mallory Weiss
To determine metastatic potential for a breast malignancy, what is the initial dx test that is performed?
If this test is +, what is your NBSIM?
1) sentinel lymph node biopsy
-: just mastectomy
+: axillary lymph node dissection + RT + QT (tamoxifen or trastuzumab depending on positivity/QT IF triple negative)
Can you withdraw fluid form a friboadenoma?
No! in that case is fibrocystic change!
Weight loss, jaundice, steatorrhea, and dark urine in a 69 yo smoker. Palpable, nontender BUT distended GB. Dx testing?
Pancreatic ca.
Dx testing? CT scan of the abdomen and pelvis with contrast
New onset DM + red blistering rash spreading across the skin:
Rash: necrolytic migratory erythema
Glucagonoma, bad px
Epigastric pain radiating to the back. Dx?
Physical examination findings:
Management:
Prognostic factors:
Pancreatitis
PE findings: Ecchymosis in Umbilicus: Collins sign Inguinal lig: Fox sign Flank: Grey-turner sign
Mgt: PIN Pain control IV fluids Nothing per mouth * Do not do a cholecystectomy during acute pancreatitis!
Bad prognostic factors:
↓ Ca, high LFTs, ↓ Hb
Hypodense hepatic mass with peripheral enhancement on arterial phase and centripetal filling on delayed phases:
Hepatic hemangioma
Stellate scar on abdominal CT:
Focal nodular hyperplasia
Heterogenous enhancement on CT:
Hepatic adenoma
Avoid contraceptives
What is the most likely dx? How are these syndromes treated?
1) Elevated serum IgE/eosinophils with very difficult to control asthma and interstitial infiltrates on CXR:
2) Cough and hemoptysis in an IVDU currently on Rifampin/INH therapy. CBC is notable for marked serum eosinophilia:
3) Immunosuppressed with high fevers and leukopenia. His symptoms are not responding to vancomycin and cefepime. Chest CT shows a targetoid hyperdensity (halo sign) with surrounding ground glass attenuation:
1) Allergic bronchopulmonary aspergillosis, steroids
2) TB, then the pt developed aspergilloma, 1) biopsy to rule out ca. and then sx
3) Invasive aspergillosis (CT: nodules w surrounding ground-glass opacities ‘halo sign’), 1) voricanazole 2) amp B
Severe abdominal distension and bloody bowel movements in 39 yo M with h/o bloody diarrhea. Dx:
Dx test and criteria?
Ulceritive colitis causing toxic megacolon
Dx test: abdominal Rx (CT scan)
Dx criteria? more than 6cm diameter
Tto: IV glucocorticoids
Sigmoid vs cecal volvulus via imaging and tto:
Facing right: cecal volvulus
Facing left: sigmoid
Tx: flexible sigmoidoscopy + rectal tube, if does not work colonoscopy if does not work sx
Most common cause of death in refeeding syndrome:
Low P, food increases insulin and insulin puts P and other electrolytes into cells
No P No ATP
42 yo F with fever and RUQ pain. + distended hepatic duct. Dx?
Mirrizzi’s syndrome
Cystic duct bulges on the hepatic duct and distends it
29 yo M with mild RUQ pain and scleral icterus. Dx?
No fever so Choledocholithiasis, stone in the common bile duct
Dx: ultrasound
Tto: ERCP
32 yo M with fever, direct hyperbilirubinemia, and RUQ pain. Dx?
Charcot’s triad
Ascending cholangitis, need to treat fast so 1) ERCP
105 pack year smoking history with rapidly developing digital clubbing and diffuse joint pain:
Hypertrophic pulmonary osteoarthropathy
Chest CT to find the lung ca
Most common cause of SVC syndrome vs Pancoast?
SVC sd: small cell lung ca. (tto: RT)
Pancoast: squamous cell lung ca. (measure FEV1 before you resect the lung)
RR of 8 with a BMI of 45 and heavy snoring.
Diagnostic hallmark?
CBC?
Low RR makes obesity hypoventilation sd most likely
OSA will NOT hypoventilate during the day
Dx: polysonnograpy
Diagnostic hallmark? day time hypercapnia
CBC? high hematocrit
Tto: CPAP, BiPAP
Fired for napping at work with low hanging uvula and loud snoring.
Dx? Tto?
OSA
Dx: polysonnograpy
Tto: CPAP, BiPAP
27 yo M is brought to ER with SOB. He is found to have worsening hypoxemia and a rapid COVID-19 test is +. PaO2 is 100 on 100% FiO2. Dx:
MCC of this dx?
Tto?
Pathophysiology?
ARDS
MCC of this dx? Sepsis
Tto? intubate
Pathophysiology? Increased vascular permeability
NBSIM in lung nodule seen on CXR? How do you biopsy a central lesions? How do you biopsy a peripheral lesion? Pleural effusions? Needle considerations?
NBSIM in lung nodule seen on CXR: Chest CT
How do you biopsy a central lesions? mediastinoscopy/endobronchial ultrasound w biopsy (EBUS)
How do you biopsy a peripheral lesion? CT guided percutaneous biopsy
Pleural effusions? Thoracentesis!! if ca. cells in the fluid means stage 4
Needle considerations? above the rib
What to consider before lung cancer resective surgery?
Just if FEV1 is more than 2L or more than 25% of prefixed
FEV1 and DLCO are the best predictors of postoperative outcomes after surgery
If + hoarseness means that the recurrent laryngeal n. is affected, so indicates extrapulmonary spread and in that case respective surgery is not indicated
Tx differences in small cell vs non small cell lung ca?
Small cell: is already stage 4 at dx. Only QT
Non small cell: QT, RX, Sx
What is the major determinant of successful TB tx?
Medication adherence
NBSIM with a + tuberculin skin test and a - CXR?
This is latent TB
9 mo isoniazid + B6 (pyridoxine)
25 yo M is brought to the ED after being found comatose on a military base. He just returned from deployment on a peacekeeping mission in Congo. His friends report that he had a bad cold for about 5 days but started having bloody bowel movements yesterday. PT, PTT, bleeding time, AST, and ALT are all markedly elevated. His Cr is 3.5.
Dx?
NBSIM?
Dx? Ebola
NBSIM? Supportive care
A 26 yo F comes to the physician’s office complaining of severe bilateral elbow and knee pain. She just returned from a 6 month deployment. Her symptoms were preceded by 6 days of high fevers. PE is notable for LE petechiae.
Dx?
Most likely intervention to have prevented this illness?
Close NBME exam cousin?
Dx? Chikungunya
Most likely intervention to have prevented this illness? mosquito nets to avoid acedes mosquito
Close NBME exam cousin? Dengue, also carried by the acedes mosquito
SOB with:
1) Long bone fractures:
2) Central venous cath insertion but a nr CXR (+ NBSIM):
3) Recent labor and delivery:
4) Infective endocarditis:
1) Fat emboli (fx, petechia, respiratory distress, CNS problems)
2) Air embolism; NBSIM: roll to left lateral decubitus so the emboli does not go to the brain
3) Amniotic fluid embolus
4) Septic embolis
Asymptomatic patient with INR of 9 on Warfarin. New reversal?
1) Four factor prothrombin complex concentrate!! PCC!
2) Fresh frozen plasma
19 yo M presents with the sudden onset of severe RUQ pain and progressively worsening abdominal swelling. He has a history of chronic hematuria. Labs are notable for a Hb of 6, WBC 1100, and plts 20k. Dx? Gene mutation? Heritable? Dx testing?
Paroxismal nocturnal hemoglobinuria that has caused budd chiari syndrome
Gene mutation? PIGA gene mutation so you cannot make GPI anchors for CD55 and CD59
Tto: eculizumab
Heritable? no, the mutation is in somatic cells
Dx testing? flow cytometry
65 yo M with 6 mo hx of progressively worsening dyspnea, dry cough, and bibasilar fine crackles heard on lung auscultation. Dx?
Buzzword:
Dx test?
Idiopathic pulmonary fibrosis
Buzzword: fine crackles!!
Dx: Hight resolution CT scan showing honeycombing
A female with 6 mo hx of dyspnea and dry cough. Dx?
Tto?
Testing problem?
Confirmatory test?
1) same + tender, erythematous nodules on the shins
2) same + violet colored cheek, nose, ear, lesions
What indicates good and bad prognosis?
Sarcoidosis
Tto? No tto. If a lot of symptoms or does not resolve you can give steroids
Testing problem? Frequent false negative PPD test so it is better to do quantiferon for screening on them
Confirmatory test? Lymph node biopsy
1) erythema nodosum
2) lupus perino
Good px: erythema nodosum, asymptomatic hilar adenopathy and acute arthritis
Bad px: pulmonary fibrosis, African-american and extrapulmonary sarcoidosis
31 yo F presents with a 2 day h/o of fevers and chills. She has a history of intermittent, severe pain on her forehead and maxilla that is well controlled with anti-epileptic therapy. Hb is 13, WBC is 400, Plt count is 140k.
Dx?
NBSIM?
Other causes?
Trigemial neuralgia treated with Carbamazepine causing febrile neutropenia
NBSIM? antipesudomonal Ab
Other causes? clozapine, PTU, methimazole
67 yo M presents with a 2 day h/o of recurrent epistaxis. Hb is 6.5, MCV is 110, leukocyte count is 1400, plts 45k. B12 and folate levels are nr. A blood smear sample shows nucleated erythrocytes and hypolobulated neutrophils.
Dx?
Most likely complication?
Named PMN morphology?
Myelodysplastic sd
Most likely complication? AML
Named PMN morphology? Pelger huet
What is the difference between ischemic colitis and chronic mesenteric ischemia?
What is the management of acute mesenteric ischemia?
Both will cause pain after you eat
Diffuse pain: ischemic colitis
RLQ: chronic mesenteric ischemia
Management: 1) IV fluids and broad spectrum antibiotics 2) Dx by CT angiography
62 yo M presents with a 1 week h/o of blurry vision and severe headache. He has been taking daily Ibuprofen for severe pain in his hands and feet. PE is notable for splenomegaly and marked tenderness on palpation of the small joints of his hands and feet with overlying erythema. Hb is 6.5, plts 950k, leukocyte count 1200.
Dx?
NBSIM?
Pathophysiology?
Essential thrombocythemia
NBSIM? plasmapheresis + aspirin
Pathophysiology? JAK 2 mutation
MS complications, dx and management:
1) Pain with eye movement and visual acuity of 20/200 in the left eye (+ dx test, mgt):
2) Nystagmus when told to look to the right:
3) Chronic leakage of urine. Post void residual is 400 ml:
Dx testing:
Tx of acute exacerbations:
Chronic mgt:
Preventive medicine pearl:
1) Optic neuritis: do an MRI w contrast, IV steroids
2) INO (MLF lesion)
3) Overflow incontinence: give a muscarinic against like bethanechol
Dx testing: MRI of brain and spine
Tx of acute exacerbations: 1) IV steroids, plasmapheresis if does not respond
Chronic mgt: 1) INF-β, glatiramer
Preventive medicine pearl: vit D, improves morbidity
HY psych contraindication of interferon-α:
We do not use it as tto of Hep C anymore because it causes suicidability and depression
What is the association between superior cerebellar A. and Parinaud sd?
The superior cerebellar A. gives blood supply to the superior colliculus and if it gets infarcted you can get Parinaud sd
A 32 yo F with a chronic h/o of diplopia and bulbar weakness is brought to the ED with significant SOB. She was recently started on oral gentamicin for a symptomatic pyelonephritis. PaO2 is 84. What is the NBSIM? Dx? Tto?
Myasthenia
NBSIM: endotracheal intubation
Does not affect the deep tendon reflexes vs in Lambert Eaton that decrease
Dx: antibodies
Tto: pyridostigmine
Myasthenic crisis: intubation + plasmapheresis (or IVIG) + steroids
Do not give an aminoglycoside in myasthenia
Paraplegia after AAA repair, think about:
The A. of Adamkiewicz branches off form the abdominal aorta and supplied the anterior spinal A so you loss everything but touch
7 mo boy losing motor milestones with fasciculations. Dx?
Mode of inheritance:
Mutation:
Werdnig-Hoffman sd
MOI: AR
Mutation: Ch 5 mutation of the survival motor neuron 1 gene
P vera;
O2 sats:
Mutation:
Tto:
O2 sats: normal
Mutation: JAK2
Tto: hydroxyurea (± phlebotomy)
22 yo M in a MVA 2 hrs ago. Now in the ER with
1) mild SOB, PaO2 of 60, and b/l pulmonary interstitial infiltrates
2) cardiac index of 1. Dx?
1) Pulmonary contusion
2) Miocardial contusion
Received continuous insulin therapy because it’s glucose was 907. Then it becomes comatose and has blown pupils, what happened?
Cerebral edema
Whenever you treat a HYPERglycemia/natremia too fast you can get cerebral edema
The 3 key ingredients in DKA/HHNS management:
1) IV fluids
2) Insulin infusion with regular insulin
3) Pay attention to K! key numbers: 3.3-5.5!
Less than 3.3: hold the insulin
3.3-5.5: give insulin and add K
More than 5.5: give insulin
If glucose is less than 200 halve insulin and add dextrose!
Hypoglycemic agents contraindicated in:
1) 55 yo M with S3 and 3+ b/l LE pitting edema:
2) Obtaining some kind of contrast based imaging procedure:
3) Family h/o of MEN2A/2B:
4) Highest weight gain risk and hypoglycemia:
5) Cause diarrhea and flatulence:
1) Heart failure: glitazones
2) Contrast can affect the kidney so do not give metformin
3) GLP1 agonist (tides) and DPP-4 Inhibitors (gliptins) because they increase risk of medullary thyroid ca!!!
But good for obese
4) Sulfonylurea
5) Acarbose and miglitol
New onset DM in a 61 yo M with increased spacing between his teeth.
NBSID? Tx?
1) Glucose suppression test
2) Brain MRI
In endocrine disorders imaging is never the first thing to do, you first need to prove it biochemically
Tx: transsphenoidal resection (pegvisomant)
Profound hypotension in an SLE patient undergoing surgery that is not responsive to fluid repletion. What happened?
Adrenal crisis
Tx: stress dose of steroids
↑ EF + thigh pain + ↑ alkaline phosphatase. Dx?
High output HF in paget’s
Dx: bone scan
6 yo M with a 6 wk h/o fevers, night sweats, and weight loss. Chest CT is notable for anterior and middle mediastinal lymphadenopathy. Dx?
ALL
Recurrent DVTs with heparin failing to raise the PTT. Dx?
Antithrombin 3 deficiency; inherited or acquired in nephrotic sd.
Patelet count of 10k 6 days after receiving medical tx for a pulmonary embolism. Dx?
Screening:
Confirmatory test:
Tto:
HIT
Screening: anti platelet factor 4 (PF4) antibodies
Confirmatory test: serotonin release assay
Tto: 1) stop the heparin, 2) argatroban, dabigatran, bivalirudin
What is the most likely diagnosis given the following presentations of back pain?
1) Old man with leg pain that improves when he gets out of bed in the morning:
2) History of breast cancer treated with chemo 5 years ago (+ tx)?
3) Fever and a lower abdominal mass detected on PE:
4) Lower abdominal mass detected on PE. The patient was recently started on Apixaban as Afib stroke prophylaxis:
1) Lumbar spinal stenosis
2) Spinal metas, IV steroids
3) Spinal epidural abcess, do MRI, NEVER give steroids
4) Spinal epidural hematoma, NEVER give steroids
Weight loss and 6 week history of severe leg pain with prior history of teriparatide therapy. Dx?
Teriparatide is a PTH analog that builds bone up, can lead to an osteosarcoma
The NBME and myoclonus:
1) In a 39 yo neuropathologist with a 5 week h/o of profound memory loss:
2) In a 29 yo F who was recently started on phenelzine after treatment failure with sertraline for MDD:
3) In a 7 mo male with a midline abdominal mass:
1) Creutzfeldt-Jakob disease, check CSF high 1433protein
2) Serotonin sd.
3) Opsoclonus-myoclonus sd in neuroblastoma
81 yo F with 3 episodes of pneumococcal meningitis over the last 14 mo. WBC is 108k with a lymphocytic pleocytosis. Dx?
CLL
Smudge cells
Given the following presentations, what is the most likely dx?
1) Drug dealer was found down in his apartment and responded positively to naloxone therapy. He is found to be akinetic despite multiple attempts at encouraging movement:
2) Shoulder and neck hyperextension backward. Tto?
3) 39 yo computer scientist with progressive dementia, “an increasing number of angry outbursts”, and stereotypical arm movements. Dx? Tto?
1) MPTP toxicity can cause Parkinsonism
2) Dystonia, tto botox
3) Huntington’s, Dx atrophy of the caudate, Tto: tetrabenazine
NBME and Strokes;
When do you give TPA?
What is the correct dx test to select in a TIA?
How are SAHs worked up?
Dense paralysis on 1 side of the body. Dx?
Medical mgt of carotid disease (1.2.3)
Medical mgt of TIA with an irregularly irregular interval on EKG
% cutoff for endarterectomy?
100% stenosis?
What must be done before allowing food?
BRF for intracerebral hemorrhage?
1) Pain and temp loss on the R face and LUE/LLE with R sided ptosis and hoarseness
2) Same presentation as above but with facial mm paralysis
When do you give TPA? within less than 2.5 h of symptoms
What is the correct dx test to select in a TIA? carotid ultrasound
How are SAHs worked up? 1) Non contrast head CT, if normal lumbar puncture
Dense paralysis on 1 side of the body..Dx? Infarct of lenticulostriate A. that supplies the internal capsule
Medical mgt of carotid disease: 1) aspirin 2) clopidogrel 3) dipiridamol
Medical mgt of TIA with an Afib: Anticoagulant
% cutoff for endarterectomy? more than 70% stenosis do endarterectomy
100% stenosis? no endarterectomy, they have already made collaterals
What must be done before allowing food? swallow study
Biggest RF for intracerebral hemorrhage? HT
1) lateral medullary stroke, Wallenberg sd. PICA infract
2) lateral pontine problem, AICA infract
German teenager with a Hb of 8. Dx?
Hereditary spherocytosis
MCHC is high
Dx: Osmotic fragility or eosin 5 maleimide assay
Tx: splenectomy
71 yo M presents to his PCP with a h/o multiple falls. He has trouble holding down the pen as he fills out clinic forms. (dx, dermatologic association, tto, tto of psychosis)?
1) +Orthostatic hypotension and ataxia:
2) +Multiple “backward” falls, trouble looking upwards:
3) +Syncopal episodes, seeing rats in her hospital room:
4) +Tx for chemotherapy induced emesis:
Parkinson
Association w seborrheic dermatitis
Tto: carbidopa/levodopa
Quetiapine for psychosis (no haloperidol)
1) Multiple system atrophy
2) Progressive supranuclear palsy (midbrain atrophy with intact pons=hummingbird sign)
3) Lewi-body dementia
4) Metoclopramide is a DA antagonist that can induce Parkinson
Main antiepileptic drugs side effects:
1) Hyponatremia and hypertonic urine
2) Febrile neutropenia
3) Nephrolithiasis
4) Profound AST/ALT elevations with jaundice
1 and 2) Carbamazepine
3) Topiramete
4) Valproate. Never give this to a pregnant woman
Car assembly plant/moonshiner and anemia. Dx?
Manegement:
Lead poisoning (can be from houses before 1978, automobile batteries, pottery, pipes, toys, batteries, lipstick)
1) capillary fingerstick blood specimen as screening (a lot of false + results)
2) confirmatory venous lead
5-44: take them off the environment
45-69: DMSA=succimer
More than 70: IV EDTA=versenate + BAL=dimercaprol
Biggest fear: lead encephalopathy (starts at 70)
Most common cause of readmission following hospital surgery?
Surgical site infection
32 yo M with chronic heartburn that has not resolved with 2 trials of esomeprazole.
NBSIM?
2nd NBSIM?
Tx of Barrett’s Esophagus?
Tx of Barrett’s Esophagus with dysplasia?
Screening guidelines for cancer with a h/o GERD?
Surveillance intervals?
NBSIM? EGD with biopsy, 2nd NBSIM? if normal do a 24h esophageal pH monitoring
Tx of Barrett’s Esophagus? High dose PPIs
Tx of Barrett’s Esophagus with dysplasia? Resection or ablation
Screening guidelines for cancer with a history GERD? If male over 50 and is obese/smokes/long term GERD you screen 3-5years with EGD w biopsy for adenoca.
Hep C screening guidelines:
Anyone between 18-70 yo; everyone once
SOB, PaO2 of 80 6 hrs after a platelet transfusion for symptomatic ITP, CXR shows b/l interstitial infiltrates with diffuse crackles heard on lung auscultation. PCWP is 14 (nl < 18). BP is 75/40. Dx?
Transfusion-related acute lung injury, basically a ARDS after transfusion
Tto same as ARDS
Visiting a malaria prone country while getting an indirect hyperbilirubinemia. Dx?
G6PD def
X-linked recessive
Broken bones and nerves; Humeral neck: Midshaft: Supracondyle: Medial Epicondyle: Hook of the hamate: Anatomical snuffbox tenderness: Head of the fibula: Can’t initiate shoulder abduction: Trouble reaching overhead: Failed thigh adduction:
Humeral neck: axillary
Midshaft: radial
Supracondyle: median
Medial Epicondyle: ulnar
Hook of the hamate: ulnar
Anatomical snuffbox tenderness: scaphoid fracture (spica cast of the thumb)
Head of the fibula: fibular
Can’t initiate shoulder abduction: rotator cuff tear, supraspinatus
Trouble reaching overhead: long thoracic
Failed thigh adduction: obturator
Over the past year a 71 yo M with a past medical history of DM has had his Cr increase progressively from 1.6 to 3.7. He received a matched renal transplant from his younger sister.
What is the most likely finding on organ biopsy?
Chronic rejection
Biopsy: fibrosis
If it were acute: T cells and eosinophils
Diarrheal outbreak in a military barrack. Dx?
Norwalk virus
Diabetic with flank pain, T 103, and pyuria. Does not get better with antibiotics. Management?
CT scan, complication of the acute pyelonephritis
Emphysematous pyelonephritis: gas bubbles in walls of the kidneys: nephrectomy
Perinephric abcess: incision and drainage
Fever and T10 pinpoint tenderness with b/l +ve Babinski signs.Dx:
Spinal abscess
If it were fever+headache+neural deficits: brain access
Blood test results with a prior history of T. Pallidum but recovered successfully:
RPR and VDRL will turn negative, the non-treponema tests go negative after tto
The treponemal (FTA-ABS, MHA-TP) tests stay always positive
Decreasing the risk of venous thromboembolic disease in a hospitalized patient?
Anticoagulation
2 measures that have shown to reduce risk in orthopedic surgery patients?
Anticoagulation/ intermitten pneumatic compression device
Most likely healthcare associated complication with TPN administration:
Skin precaution:
Type of access to be avoided:
Central line associated bloodstream infection.
Clean the area w chlorhexidine
Avoid always the femoral v. because infection is most common
MCC of preventable hospital deaths:
PE
Most important intervention in reducing the risk of wrong site, wrong patient, and wrong procedure errors?
Preprocedural timeout
Pre-op antibiotic prophylaxis:
Cefazolin 30-60 min before sx
Vancomycin/ clindamycin if allergic to penicillins
If you delay the sx give it again
Hemoptysis and a widened mediastinum in a textile factory worker. Dx? Tto?
Antrax
Tto: ciprofloxacin
Chronic headache with muscle weakness and polyuria. This patient has HTN that has failed to respond to amlodipine, enalapril, and indapamide therapy.
How do you sort out the 2 principal causes? Tto?
1) Plasma aldo/renin more than 20!!: Conn sd and the tto is spironolactone
If less than 20!!: renal A. stenosis and the tto is an ACEi
2) Salt!!! suppression test=saline infusion test, if fails to suppress it confirms Conn’s
3) CT of the abdomen and pelvis. It could be an incidental adrenal mass but it is not the cause of the ↑ Aldo
4) Adrenal vein sampling before the sx
Unilateral disease: Aldo will be high on the side of the tumor and low on the other side → Unilateral adrenalectomy
Bilateral disease: Aldo high everywhere → Aldo antagonist like spironolactone or eplerenone
Other cause of secondary HT is sleep apnea
Hypertensive emergency tto?
Labetalol Nitroprusside (not for too long on liver or renal fx) Nicardipine/ Clevidipine Phentolamine NO HYDRALAZINE
If you are worried about aortic dissection do not give a vasodilator (Nitroprusside/Nicardipine/Clevidipine) alone, you can use labetalol! If you use a vasodilator you need to add a β-blocker
Urinalysis:
Dehydration: Nephrotic syndrome: Nephritic syndrome: ATN: AIN: Pyelonephritis:
Dehydration: hyline cats Nephrotic syndrome=lipoid nephrosis: fatty casts Nephritic syndrome: RBC casts ATN: muddy brown=pigmeted granular casts AIN: eos pyelonephritis: WBC casts
Hematuria, HT and periorbital edema after 5 days after a URI. Dx?
What if it were 4 weeks after? Which antibodies will be found on blood?
How do you treat them?
5 days: IgA nephropathy=synpharyngitic nephropathy. Tto: steroids+ACEi
4 weeks: post-strep; Antibodies: ASO, ati-DNAse B* Tto: observation and loop diuretics!!
* Antibiotics can reduce the incidence of rheumatic fever but not the incidence of post-strep glomerulonephritis!!!
Mr. X presents to an ED with chest pain and SOB. He was accompanied by his girlfriend. He requests to see a physician but in triage becomes belligerent. Security escorts the patient out of the ED. An hour later, the patient presents again complaining of worsening chest pain. His girlfriend reports that he also had a seizure. She is requesting help in lifting her partner to a bed in the emergency room but the ED security refuses and asks them to leave. The patient’s girlfriend drives 20 mins to take Mr. X to another hospital. He is declared dead on arrival. What does the NBME expect you to know here?
You need to do a medical screening exam of someone comes in with a emergency medical condition (chest pain, stroke like, seizures)
You need to evaluate and stabilize
According to EMTALA law
Cutoffs for live attenuated vaccines:
Less than 2yo
Pregnant
CD4 less 200
Health benefits and contraindications of breastfeeding:
Benefits:
Decreases risk of food allergies
Decreases risk of acute otitis media
Contraindications:
HIV
QT
If baby has galactosemia (soy milk based formula)
If baby is allergic to milk: soy based formula → if cannot tolerate it: protein hydrolyzed formula → if cannot tolerate it: elemental formula (single aa)
MCCOD in galactosemia:
Sepsis form E.coli
Formula for cow milk allergy:
Caseine hydrolyzing
Circumcision contraindications:
Hypospadias and epispadias
Mom took away his toy, child gets angry, loses consciousness:
Hold breath, reassurance
Putting the baby to sleep with a feeding bottle. Why is it bad?
Causes caries
Bedwetting; first line tto and second line tto?
1) emeuresis alarm
2) desmopressin
Erythematous papules and plaques on the UEs. Dx? Tx?
Ectopic dermatitis
Emollients or topical steroids (not steroids in the face)
Round erythematous plaques with central clearing/scaly borders. Dx?
Mos common causes in order of frequency:
Dx?
Tto?
Tinea
MCC: Trichophyton → if not Microsporum → is not Epidermophyton (TIME)
Dx: potassium hydroxide examination of skin scrapings
Tto:
Tinea corporis: TOPICAL azole
Tinea unguium/ capitis: ORAL terbinafine/griseofulvin
Nightmares vs night terrors?
Nightmares: remember the dream
Night terrors: do not remember
Leading cause of death in maltreated children:
Abusive head tx
Congenital heart disease mode of inheritance. Dx test?
Multifactorial
Echo
Rx findings in congenital heart disease:
Boot shaped heart: Tetralogy of Fallot
Egg shaped heart/egg on a string: transposition
Snowman heart: total anomalous VR
Wide, fixed split of the S2 heart sound. MC overall? Down’s syndrome?
ASD
Secundum overall, primum in Down
Holosystolic murmur at the LLSB + mid-diastolic rumble at apex. dX?
VSD
Pulmonary vascular markings refers to:
Increase flow trough the pulmonary A: troncus arteriosus
Decrease Pulmonary vascular markings indicate decreased flow: Tetralogy of Fallot
Newborn gets cyanotic hrs-days after birth.
Immediate NBSIM:
Congenital heart disease masked by open ductus
Immediate NBSIM: Alprostadil
Brachial-femoral pulse delay indicates:
Tx?
Coarctation (you also hear an epigastric bruit corresponding to the site of the coarctation)
Tx surgery
Loud P2 and cyanosis while crying. Dx? Knee-chest physiology?
Tetralogy of Fallot
Knee-chest compresses the femoral A so they increase the SVR and the shunt becomes L to R
Cyanotic CHD with ASD and VSD needed to prevent cyanosis. Dx?
Tricuspid atresia
URI 2 weeks ago with new S3 heart sound and b/l lung crackles. Dx?
Viral myocarditis by coxsackie B
Child with language delay on NBMEs with a h/o of recurrent otitis media. Dx?
Hearing defect, to an audiometry
Low birth weight, short palpebral fissures, flat philtrum, thin upper lip. Dx?
Fetal alcohol sd.
Any philtrum abnormalities!!!
D.D. of decreased growth:
Familial short stature: kid follows the growth curve but at a very low percentile. Management: get information of the height of different family members, they will be short in average, bone age is = to chronological age
Constitutional growth delay: normal growth velocity until puberty, delayed adolescent growth spurt and puberty, but then steep growth spurt, + family history, they will catch up w normal heigh but we don’t know when. Management: if you have + family history the dx is done, if you don’t have family history you look for delayed bone age. No indication for GH, reassurance
Deviation of normal growth:
Nutritional: weight will flatten first, then height will flatten later, delayed bone age
GH deficiency: flattening of the weight and height together, delayed puberty and delayed bone age. Very similar to constitutional growth delay but here the heigh goes down crossing 2 major percentiles!! (you you can be on a very low percentile for a long time and not go down and do not have GH deficiency) Dx: arginine stimulation test. Tto: GH
Hypothyroidism: flattening of the height but weight goes up, delayed bone age, thelarche more affected than others
Baby with macroglossia and umbilical hernia. Dx?
MCC:
Congenital hypothyroidism
MCC: Thyroid dysgenesis
DD of neck cysts:
Lateral cervical cyst that doesn’t move with swallowing: persistent cervical sinus; due to incomplete obliteration of the 2nd, 3rd and 4th CLEFT! (ECTOderm). Anterior to the sternocleidomastoid m!!!
BRACHIAL CLEFT-CYST
Medial cervical cyst that moves with swallowing: THYROGLOSSAL cyst; from ENDOderm. It shows up at the foramen cecum and migrates down. (It can be lined by squamous or respiratory epithelium).
If it moves with swallowing it is a thyroglossal cyst!!
MCC of ambiguous genitalia in baby:
Metabolic panel:
Dx blood test:
Tx:
21 hydroxylase deficiency
Metabolic panel: Aldo and cortisol are low so non anion GAP metabolic acidosis
Dx: 17-hydroxypregesterone
Tx: Fludrocortisone, ketokonazole and a steroid
Definition of precocious puberty:
‘Going into FM in 1989’
Female less than 8
Male less than 9
Cannot advance NG tube in child with excessive oral secretions and polyhydramnios in utero:
Esophageal atresia
Associated with other VACTREL defects: Vertebral defects Anal atresia Cardiac defects, VSD Tracheoesophageal-fistula Renal defects Esophageal atresia Limb, radial malformation
The 3 causes of bilious emesis in a neonate!
1) Malrotation 90%
Also:
Duodenal atresia: double bubble, associated w Down
Jejunal atresia: triple bubble
Preemie with bilious emesis, bloody stools, and distended abdomen. Dx? Tto?
Necrotizing enterocolitis
Rx: air in wall of the bowel and portal venous gas
Tto?
1) bowel rest + fluids + blood cultures 2) empiric antibiotics!!!
3) If bowel perforation/ clinical deterioration: surgical reserction!!*
- Surgical intervention for NEC is warranted when there is evidence of peritonitis (concerning for gangrenous bowel), perforation (pneumoperitoneum on x-ray), metabolic acidosis, elevated lactate, and/or portal venous gas on x-ray
Diarrhea types; Lactose intolerance vs cholera vs celiac disease:
Lactose intolerance: osmotic (stool osmolar gap bigger than 100, acid pH and positive H+ breath test, stops at night)
Cholera secretion of Cl, secretory (present all the time)
Also secretory: VIPoma, Zollinger-Ellison sd, Medullary thyroid ca, unabsorbed bile acid (in post-cholecystectomy patients)
Celiac: malabsorption
UC, Chron, EHEC, Shigella, Campylobacter, Salmonella: inflammatory (bloody)
13 yo boy with Ricketts, Fe deficiency anemia, and fat malabsorption. Dx?
Celiac disease
If not tto enteric associated T cell lymphoma
Non-calcified flank mass on a kid:
Wilms tumor, give dactinomycin
Vs neuroblastoma that is calcified, crosses the midline and sends metas to the marrow
Peds embryology pathophysiology of: Duodenal atresia: Jejunal atresia: Malrotation: Hirschsprung’s disease: Congenital diaphragmatic hernia: Meckel’s diverticulum:
Duodenal atresia: recanalization failure
Jejunal atresia: vascular problem
Malrotation: midgut 270deg rotation around SMA failure
Hirschsprung’s disease: myenteric plexus does not develop
Congenital diaphragmatic hernia: fail of development of the pleuroperitoneal mb
Meckel’s diverticulum: failed obliteration of omphalomesenteric/vitelin duct
Why are kids polycythemic at birth?
In utero they do not use their lungs so relative hypoxia so EPO increases and RBC increase
When should you introduce cow milk in a child’s diet?
1 y.o.
Goat milk problems:
Low folate so child can get megaloblastic anemia!
Persistent, painless, firm cervical/supraclavicular lymphadenopathy in a 17 yo F. Mediastinum.
Dx?
Epi?
Hodgkin
Bimodal sidtrinution
Anterior mediastinum: Ts (thymus, thyroid, thoracic aorta, terrible lymphoma, teratoma and germ cell tumors - see mediastinal germ cell tumors)
Posterior mediastinum: neuroendocrine tumors
Syndromes associated with Wilms tumor:
WARG: WT1 is associated with anhiridia, genitourinary malformation, retardation. PAX6!!!! next to WT1 is important for iris formation, contiguous gene deletion
Denys-Drash: WT1 is associated with Difusse mesangial sclerosis (nephrOtic) and Dysgenesis of gonads
Beckwith-Wiedemann: WT2 is associated w macroglossia, hemihyperplasia, hypoglycemia, hyperinsulinemia, hypocalcemia because over expression of ILGF2!!!!*, omphalocele!, hepatoblastoma, is an example of imprinting (IGF-2 is normally metlylated on mom, here they get 2 copies from the dad)
- pancreatic beta islets grow a lot so insulin increases and they become hypoglycemic, similar to gestational DM but here mom is not diabetic
Irritable, ear tugging 9 mo, with mild fever and a red, bulging TM on otoscopy. Dx?
Best test?
Most important physical examination finding?
Tto (1st/2nd line)?
Multiple recurrences?
Major D.D?
Acute otitis media:
Organisms: Moraxella, Non Typeable H. influenzae and S. pneumo
Presentation: acute onset after a cold! normally UNIlateral, middle ear effusion! tympanic membrane inflammation!
Best test: pneumatic otoscopy
Most important finding? bulging tympanic membrane, decreased movement!!
Important: A red TM membrane by itself does not equal AOM! If both ears are equally red and the kid has a cold it might be just because of the cold
Most accurate test: tympanocentesis and culture
Tto: 1) 10 day course of high dose amoxicillin 2) amoxi-clavulanic, ceftriaxone, azithromycin if allergic to penicillin
Multiple recurrences? tympanocentesis
2 w follow up
Otitis media with effusion: maybe after the acute otitis media the effusion does not go away
BNSM: motley checks for the effusion, if 3mo of persisten effusion in a row you call it otitis media with effusion
BNSM: audiology test, we are worried about hearing loss
If bilateral effusion + hearing loss or discomfort: PE tube
Otitis externa:
Presentation: child with pain/itching of the ear + pain upon manipulation of the tinna
Tto: topical antibiotic (ciprofloxacin drops)
Prevention: alcohol-based ear drops after swimming activities
Necrotizing otitis externa
Presentation: Pt with type 1 diabetes who has recent recreational water exposure who presents with a severe form of otitis externa (fever, ill-appearing)
Tto: intravenous antipseudomonal antibiotics and surgical debridement if antibiotics are unsuccessful
Vesicles in posterior oral cavity, vesicles and papules on the hands and feet. Dx?
Coxackie A
1) Cough, runny nose, b/l conjunctival injection, rash below posterior hairline going downwards, mouth stuff:
2) Temp of 105 for 3 days then red rash on the face and trunk 2 days afterwards:
3) Rash on face, goes down trunk, posterior auricular lymphadenopathy:
1) Measles=rubeola
2) Roseola=exanthem subitum
3) Rubella=German measles
How do we treat newborns from a mom with varicella?
Varicella Zoster Ig, no vaccine until 1 yo
MCC of diarrhea in kids:
Rotavirus
18 yo sexually active F with myalgias, exudative pharyngitis, and HSM.
Dx test?
Smear?
Mono
Dx test: monospots test
Smear: Downy cells
No sports!
Why would you have RUQ pain in Kawasaki?
Galbladder hydrops
Presentation:
Acute phase:
Unresponsive fever for at least 5d + 4 of: bulbar conjunctivitis, erythema and swelling of palms and soles, intraoral erythema, rash w no vesicles!, huge unilateral anterior cervical node
Leading cause of acquired heart disease in developed countries. But it contraries are ok after 4-6w the heart w be ok
BNSM after the Dx: admit + ESR, platelets, ECG, echo for baseline and to discard pericarditis and myocarditis
Best tto: IVIG (but they lines is not due to auto-antibodies) + oral high dose aspirin* (add a PPI)
* Before you get the aspirin you need to give the influenza vaccine because Reye syndrome is not only associated with aspirin ingestion but with aspirin ingestion as a tto of influenza and varicella!!
Subacute phase:
Fever and primary presentation goes away and then ESR peaks, then the platelets peak (they can be more than 1million!)
Desquamation
Aneurysms (the aneurysm combined with the high platelets can lead to acute MI)
Get a second echo
Change to low dose aspirin
Convalescent:
Get a 3rd echo to make sure they are not aneurysms, also get an ESR and platelets, if those 3 are negative stop the aspirin!
Septic arthritis vs osteomyelitis on NBMEs:
Tenderness over joint on septic arthritis
Tenderness over bone on osteomyelitis
Sneakers/Nail osteomyelitis?
Pseudomonas
7 yo M w/recent episode of AOM. T 99.9, R hip and knee pain, full ROM but painful limp in involved extremity. Otherwise OK child.
Transient toxic synovitis, give an NSAID
2x/daily fever spikes in a 10 yo F with “salmon colored” rash on the trunk, weeks of R knee pain. Dx? What are possible complications?
Still’s disease= juvenile arthritis
All are associated with anterior uveitis!! except the systemic and the seropositive, blindness, glaucoma and synechia. So you need to do slit-lamp examination screening!
There are different types:
Oligoarticular: females less than 6y with less than 5 joints involved that are on the lower body, most ANA+ (more frequent uveitis if ANA+), do slit lamp!
Polyarticular RF negative: 5 or more joints on the hands (asymmetric) on female 6-7y, can lead to mandible and C-spine problems. Some ANA+
Polyarticular RF positive: Rare. Bad px. 5 or more joints affected causing aggressive symmetric!! polyarticular disease on a 9-12y female. antiCCP+
Systemic onset: Rare. Any number of joints can be involved, progresses to polyarticular disease affecting the hips, C-spine and mandible on a 2-5y female=male. You have a systemic presentation of:
Arthritis +
Quotidian fever for at least 3 days on a row
Evanenscent rash, salmon colored (gets worse w fever)
Lymph nodes
Hepatosplenomegally
Serosistis
Tto:
NSAIDs for mild cases, corticoids for flares, methotrexate
Bilateral thigh/calf pain in a 5 year old M relieved by acetaminophen. Dx?
NBME Distractor?
Growing pains
Osteoid osteoma will be unilateral
Baby is blue at rest (feeding), that gets worse when eats and gets better when cries. Dx? Associated sd? What is the best next step in management?
Atresia of the choanae (Dx; 1: nose catheter confirmatory: head CT w contrast)
CHARGE sd: Coloboma Heat Atresia of the choanae Retardation in groth Genial abnormalities Ear problems
BNSM: echocardiography is the most urgent
CF pneumonia cause by age?
S. aureus younger than 20
Pseudomonas more than 20
4 yo boy with a 12 hr h/o drooling, dysphagia, can’t talk, T 103, and tripoding. Dx?
Epiglotitis
Rx: thumb sign (not part of the management)
Organisms: Strep./Staph./rare H. influenza B in unvaccinated
Presentation: sore throat + fever → tripod pose → drooling
Most accurate dx test: cherry red epiglottis on laryngoscopy
Tto: Do not touch the kid until 1) Intubation! + aspirate for culture 2) Nafcillin + cefotaxime
Hyperpigmented macules on the skin, prior eye enucleation procedure, multiple posterior mediastinal masses. Dx? Possible radiographic findings?
NF1
Rx: cortical thinning of the long bone cortex and sphenoid dysplasia
Dx, age is key:
1) 6 mo with developmental delay and daily generalized tonic-clonic seizures. Dx? EEG? Tto?
2) 4 yo boy with generalized tonic-clonic seizures, focal seizures, myoclonic seizures. Dx? Tto?
3) 13 yo F with generalized tonic-clonic seizures that are worse in the morning. Dx? Tto?
1) Infantile spasms=West sd,
EEG: chaotic background=hypsarrhythmia!!!
Tto: ACTH
2) Lenox-gastou, Tto: valproate, bad px
3) Juvenile myoclonic epilepsy, Tto: valproate, good px
Seizure lifestyle modification for NBME exams:
Ketogenic diet
Alport sd mutation
Alpha 5 chain of type 4 collagen
COL4A3, COL4A4, and COL4A5
X-linked dominant
The respiratory distress D.D:
1) Preemie with respiratory distress, hypoxia, CXR showing air bronchograms and decreased lung volumes:
2) Delivered by C-section, born at term, mom has DM, respiratory distress and tachypnea at birth with grunting/retractions, no hypoxia or evidence of cyanosis, perihilar infiltrate with fluid in the fissures:
3) Delivered at 42.5 weeks, respiratory distress at birth, CXR showing hyperinflation and patchy atelectasis:
1) Preemie + decreased lung vol: neonatal respiratory sd = diffuse reticulonodular pattern with air bronchograms
2) C-section: transient tachypnea of the newborn = interstitial infiltrates with prominent interlope fissures
3) Postterm + increased lung vol: meconium aspiration sd = patchy infiltrates and hyperinflation
Barrel chest with scaphoid abdomen at birth, all heart sounds on the right. Dx?
Congenital diaphragmatic hernia
GI content and bile on the thorax!
2 causes of ALWAYS pathological pediatric jaundice:
If appears in the first day of life
Conjugated hyperbilirubinemia (biliary athersia, tto is early surgery/ choledochal cysts)
Kid with sneezing, rhinorrhea for 5 days then many weeks of post-tussive emesis. Wakes up with red eye. Sudden onset severe chest pain, hyperresonance to percussion, and unilaterally decreased breath sounds. Dx?
Blood marker?
Tto?
Pertussis, they cough so much that can present w a pneumothorax, subconjunctival hemorrhages or vomiting
Blood marker: Reactive lymphocytosis
Tto: macrolide for patients and close contracts
Chlamydia/gonorrhea screening guidelines:
Risky sexual behavior
Tto of a Tanner 5 boy at 7 yo.
What do you watch out for with this treatment?
Continuos leuprolide
Careful because can decrease the bone mineral density
Postvoid residual of 40 cc. Dx? Pathophysiology? Tx?
Urge incontinence
Detrussor hypertonia, hyper mobility, hyperreflexia
Muscarinic antagonist as oxybutynin, alderamin, darifenacin, solifenacin or trospium. On The Darn Toilet
IUD mechanisms and contraindications:
Cooper: is for 10 years, kills sperm, causes heavy periods, not in Wilsons or in distorted uterine anatomy (bicornuate and fibroids!)
Progesterone (Mirena): thickens cervical mucus!! decreases sperm transport and decreases implantation, does not cause heavy periods!
Do not put in PID! but they actually decrease the risk of PID and you should leave them in if they develop a PID, you can also put it if history of IUD
PCOS infertility management:
1) Letrozol!!! 2) Clomiphene
SE: Fullness/bloating/dark urine/decreased UOP/2 Ib/day wt gain= ovarian hyperstimulation syndrome
Taiwanese woman at 11 weeks gestation with hyperemesis gravidarum, HT, heavy vaginal bleeding, size-dates discordance and theca lutein cysts. Dx?
Molar pregnancy
*The NBME here may mention blue lesions on speculum examination indicating vaginal metastasis
Over the past 2 days, a 32 yo F at 30 weeks gestation has had yellowing of her skin. She reports significant RUQ pain. AST and ALT are in the thousands. Dx?
Acute fatty liver of px
Deliver immediately!!!
If ALP high but not very high AST/ALT, not HT nor thrombocytopenia think intrahepatic cholestasis of pregnancy and give urodisol and deliver at 36-38 w
Severe SOB, cough, hemoptysis 3 weeks after an abortion.
Chorioca. with metas to the lungs
What is the most common kind of vaginal malignancy?
Biggest RF for primary vaginal carcinoma?
Tto?
Complication?
MC kind: Squamous cell ca.
BRF: HPV
Tto: Sx and Qt
Complication: vaginal stenosis
Glandular cell vaginal malignancy indicates:
Clear cell ademoca.
82 yo F w/pruritus and a thin labia. Dx?
Dx test?
Tto?
Lichen sclerosis
Dx test? Biopsy of the vulva
Tto: Clobetasol
Most important prognostic predictor in vulva cancer.
Lymph node involvemet
Increased susceptibility of young females to STIs. Why?
Cervical ectropium: endocervix has simple columnar epithelium that come a little down in puberty. They are not very resistant so there is risk of infection
What do I do with atypical squamous cells of undetermined significance? and if you see atypical glandular cells? And if the squamocelular junction is not completely visualized?
ASCUS: colposcopy/ HPV co-testing, if HPV co-testing is + you need to do a colposcopy
Atypical glandular cells in >35: endometrial biopsy + endocervical curettage
Not visualized squamocelular junction: Endocervical curettage
Worrisome colposcopy findings:
Weird shape blood vessel
Acetowhite changes
Protective factors, MC histology and MC stage at diagnosis for ovarian cancer:
Late menarche
Early menopause
OCPs
Multiparous
MC histology: epithelial serous
MC stage at diagnosis: 3, peritoneal metastasis
Follicular cyst size cutoff for management:
Less than 6cm observation, if more cystectomy
Calcified, smooth walled ovarian mass in a 12 y.o. female. Dx?
Teratoma
Can also be in the mediastinum
Tto: cystectomy
Most likely presenting complain in endometrial cancer.
Dx testing?
Tto?
Abnormal vaginal bleeding
Dx testing: endometrial biopsy
Tto: hysterectomy with bilateral salpingo-oophorectomy
The Celes:
Cysto: weak anterior vaginal wall, urinary incontinence
Recto: weak posterior vaginal wall, stool incontinence
Entero: mass high up in the vaginal wall, pouch of Douglass herniation, associated with hysterectomy
Uretro: urinary incontinence right after peeing, there is a diverticulum that holds urine
Most important health hazard associated with menopause:
Osteoporosis
1) Bisphosphonates (-ates, zolendronic acid…)
MCCOD in a postmenopausal female?
Cardiovascular disease
Tx of common postmenopausal maladies
Hot flashes:
Vaginal atrophy:
Osteoporosis:
Hot flashes: hormone replacement therapy and venlafaxine (if hysterectomy you can do equine estrogens)
Vaginal atrophy: estrogen cream
Osteoporosis: bisphophonate
Hormone replacement (OCP) contraindications and side effects:
Contraindications: MIGRAINE with aura ER/PR + breast ca Endometrial ca Over 35 and smokes SLE Vascular disease (stroke) History of hepatic adenoma and acute liver disease History of venous thromboembolism Prinzmetal Thrombophilia Acute pancreatitis HT: do not give to a patient with hypertension!
Side effects:
Hypertension
Thrombosis and ischemic stroke
Normal order of sex maturity in female:
TAM:
Thelarche: development of the breast
Adrenarche: development of pubic hair, body odor, skin oiliness, and acne (premature adrenarche is most common on obese)
Menarche: period
Depressed and irritable starting on day 24 of a 28 day cycle. Dx?
Do first?
Tto?
PMS
Do first? symptom diary
Tto? SSRI
β-HCG and ultrasounds:
If β-HCG is less than 1500 no sac can be seen on ultrasound
Pap smear follow up post-hysterectomy for leiomyoma vs endometrial hyperplasia/cancer:
If hysterectomy is due to benign reasons you can stop Pap smear, if it is for malignancy you do Pap smear of the vaginal cough
Amenorrhea with severe lower abdominal pain at the end of the month (2 NBME possibilities):
Inperforated hymen: cut the hymen
Transverse vaginal septum
Progestin/Estrogen-Progestin withdrawal test results in common disorders:
PCOS:
Turner’s:
Kallmann:
Asherman’s/Uterine Synechiae:
PCOS: they are always in the follicular phase so if you give progestin and then you withdrawal it, they will bleed
Turner’s and Kallmann: streak ovaries so they fo not have E so if you give progestin and then you withdrawal it they w NOT bleed. But if you give E+P and then withdraw they w bleed
Asherman’s/Uterine Synechiae: w never bleed
Amenorrhea and chronic fatigue/bradycardia. Dx?
Hypothyroidism that causes increase in TRH and increases PRL
Name the 3 leiomyoma types:
IUD to avoid?
What if the IUD above is already in place before discovering the leiomyoma?
Most symptomatic?
Contraindicated interventional radiology tx if desiring pregnancy?
Tto if desiring pregnancy?
No longer desiring pregnancy?
Submucosal: most symptoms
Intramucosal
Subserosal
IUD to avoid? Cooper IUD, if they have it already there, leave it
Contraindicated IR if desiring pregnancy? Uterine A. embolization
Tto if desiring pregnancy? myomectomy
No longer desiring pregnancy? hysterectomy
Crampy abdominal pain during menses in a F that skips work. PE is nl. Dx?
Tx?
Dysmenorrhea
NSAID
Infertile F w/Painful menses, painful poop, painful sex. Dx?
BRF? Tto? Ligament? Definitive dx? Definitive tx?
Endometriosis
BRF? Family history Tto? OCP Ligament? modularity of uterosacral lig Definitive dx? laparoscopy Definitive tx? hysterectomy
Heavy menstrual bleeding, symmetrically soft/tender uterus on bimanual exam. Dx?
Tx?
Definitive dx?
Definitive tx?
Adenomiosis
Tto? mirena IUD
Definitive dx? laparoscopy
Definitive tx? hysterectomy
Woman on OCPs gets pregnant with TB tx. Why?
Rifampin rides up the cytochrome P450 system
Most effective emergency contraception?
1) Cooper IUD, only the Cooper one
2) Ulipristal
Agreeable postpartum contraception:
Progesterone-based contraception
Avoid E if lactating because E decreases the amount of protein in breast milk but ALSO avoid E less than 1mo postpartum because it increases the risk of thromboembolism
Options:
Sub-dermal progestin-releasing implant: high efficacy, lasts for 3 years, decreases menstrual bleeding in 50% and causes amenorrhea in 20% of pts
Methylprogesterone (= Depo-provera): IM/subcutaneous injection given every 14w. Can be used in pt with previous DVT. Can cause weight gain, breakthrough bleeding, osteoporosis and delayed ability for pregnancy!
Levonorgestre-DUI: can cause amenorrhea
Progestin-only oral contraceptive: less effective because you need to take the pill at the same time every day
Cooper IUD: not if heavy menstrual bleeding
Contraception on a woman with the need for Vit D/Ca supplementation:
Progestin injection = Depo-provera
I want to get pregnant 1 month after stopping contraception. Which contraception should I use?
You should not use Depo-provera because it can take up to 2 years to recover fertility after stopped
+ β-HCG, vaginal bleeding, abdominal pain in a 23 yo F. Dx?
MTX contraindications.
Doubling rule:
Rising β-HCG afterwards:
Ectopic pregnancy
MTX contraindications: fetal cardiac activity and cutout β-HCG
Doubling rule: if β-HCG is less than 1500 you cannot dx pregnancy, you need to wait until tomorrow, if it doubles she is pregnant
Rising β-HCG afterwards: need to be on birth control so if β-HCG increases you look for mole or chorioca.
PCOS criteria:
Polycystic ovaries on echo
Anovulation
Hyperandrogenism
2 out the 3
5 yo F, WBC 16k, foul smelling vaginal discharge. Dx?
Vaginal foreign body
Cervical petechiae means:
Strawberry cervix
Unilateral swelling/fluctuant mass in inferior labia with T of 101. Dx? Tx?
Bartholin gland abscess
Tx? Incision + drainage + wart catheter
The 3 polymicrobial OBGYN infections:
Bartholin gland abscess
Endometris
Chorioamnionitis
Increased UTI risk in pregnant women. Why?
Asymptomatic UTIs in the pregnant. Dx?
Progestin is a smooth m. relaxant!
If you see an asymptomatic UTI in a normal woman you do not treat but YES in pregnant (risk of pyelonephritis)
N/V at 8 weeks.
If admitted, what do you give?
Bloody emesis?
Hyperemesis gravidarum, you loose more than 15% of their pre-pregnant weight
Admit and give ondansetron, B6 and doxilamine when they go home
The HY pregnancy dates in weeks:
8w (1st visit): check mom’s HIV, hepB, syphilis, chlamydia, gonorrhea, urine culture, urine protein, rubella, varicella, Rh, hematocrit, pap if indicated, 24h urine collection if HR of preeclampsia, 50g oral glucose tolerance challenge if HR of DM (BMI>25 or family history)
9-13: P-APP, β-hCG, nuchal translucency
10: cell-free DNA
10-13: chorionic villous sapling (definitive diagnosis)
12: low-dose aspirin in HR for preeclampsia
16-18: AFP for screening of neural tube defects
15-22: quadruple screening: AFP, estradiol, β-hCG, inhibin A
After w 15: amniocentesis (definitive diagnosis)
18-20: anatomical echo, check for placenta previa, fetal growth
16-24: screening for short cervix (transvaginal echo), after 24w can be shorter due to baby’s weight
22-35: can use fetal fibronectine if contractions
24-28: 50g oral glucose tolerance challenge, anemia screening, Rh!
28-32: 1st RhoGAM dose
28 or after: HIV, hepB, syphilis, chlamydia, gonorrhea test if previous STI/ less than 25
27-36: Tdap
32: transVaginal US if placenta previa vas seen before to see if it is still there, also*
32-34: c-section for monochorionic-monoamniotic twins
36: if on LMWH change to unfractionated heparin (take out intrapartum and put back 6h after vaginal/ 12h after cesarean). Also start acyclovir prophylaxis if previous genital HSV infection
36-38: rectal/vaginal culture to detect S. agalactiae (group B strep)
36-37: * transVaginal US + c-section if placenta previa
37 or more!!!: external cephalic rotation (if breach or transverse)
37: scheduled c-sec if breech + vaginal delivery contraindications
41: induce
Day 1 life: Hep B vaccine (or when preeme is more than 2kg), Vit K, 2nd RhoGAM dose, fasting blood glucose in mom if gestation diabetes
6-12 postpartum: 50g/2h oral glucose tolerance challenge if gestation diabetes
NBSIM with +ve cell free DNA?
Higher rates of inconclusive cf DNA results?
1) Fetal ultrasound, 2) amniocentesis
If fat mom it is very inconclusive
1) Which is riskier CVS vs Amniocentesis?
2) NBSIM of increased MSAFP?
1) CVS
2) First fetal echo then amniocentesis
The Rh algorithm:
1) Check woman Rh
2) If - do an indirect Coombs to see if she has Abs
3) Check dad’s pstatus
4) If she does not have Abs and dad is Rh+/not known give the RhoGAM at 28th weeks and anytime when there is risk of fetomaternal hemorrhage
5) If she has Abs and dad is Rh+/not known do percutaneous umbilical blood sampling to dx fetal anemia, if fetal anemia do fetal transfusion
NST with a nl FHR but no accels and the child is not moving.
What is your NBSIM?
Baby is sleeping, you can do a contraction stress test giving a little oxytocin or move the uterus to wake baby up
1) Kleihauer Betke test:
2) Apt test:
3) Fibronectin:
4) Nitrazine test:
1) RhoGAM dose determining test
2) 3rd trimester vaginal bleeding to tell apart mom vs baby’s blood
3) preterm delivery risk
4) is this amniotic fluid?
BRF for preterm labor.
History
Ultra HY obstetric complication associated with BV, Ureaplasma Urealyticum infection, and asymptomatic bacteriuria!
Preterm labor
Recurrent 2nd trimester pregnancy losses.
Emergent tx:
Preventive measure in future pregnancies:
Classic NBME risk factor:
Cervical insufficiency
Tx: Cerclage
Prevention: Progestin suppositories
RF: Conization
Preventive measure for eclampsia:
Aspirin
.Preventive measure to reduce risk of neonatal/fetal infection in women with PROM?
What do you do in PROM at > 37 weeks?
NBSIM if PROM > 18 hrs?
Decrease the number of vaginal exams
What do you do in PROM at > 37 weeks? nothing
NBSIM if PROM > 18 hrs? ampicillin
Criteria for prophylactic C/S in an IODM?
Weight less than 4500 grams
NBME association with < 20 week eclampsia:
Mole
Antihypertensives in pregnancy:
Hydralazine
Methydopa
Labetalol
Nifedipine
Hyponatremic seizures in a F receiving an infusion for labor induction:
SIADH
Oxytocin looks like ADH!
Neonatal hypoglycemic seizures (2 causes):
Beckwith-Wiedemann sd
Baby of diabetic mom
DOC in GDM:
Polyhydramnios. Why?
Increased incidence of respiratory distress syndrome. Why?
Baby has polyuria because pees glucose
Insulin inactivates surfactant
Hep BSAg +ve mom delivering a newborn:
Nurse stick by a needle of a patient with hep B:
Tto of chronic Hep B
Give hepB immunoglobulin and hep B vaccine, if nurse was vaccinated already you do not need to do anything
Tto: emtricitabine, lamivudine, tenofovir
Herpes with genital lesions:
C-section, don’t let membranes rupture
If baby passes will have vesicles on the body a few days after birth, careful because can progress to meningoencephalitis and disseminated herpes. If you see something IV acyclovir
Congenital toxo. How can you reduce fetal morbidity in utero?
Spirolysin
The 3 stages of labor:
1, Latent: 0-6cm dilation, less than 20h in nulliparous or less 14 if multi
You should admit, start fetal monitoring, check GBS status on records ± epidural
1, Active: 6-10cm 2-3.5h (it has to progress at least 1cm/2h). There are 2 possible problems:
Protraction: the cervix progresses less than 1cm/2h → 1) break the water 2) put a pressure catheter 3) give IV oxytocin
Arrest: no cervical change for 4h!! with good contractions* or 6h with bad contractions → C-section
* >=200 Montevideo units in 10 min and contractions every 2/3min
2: After 10 cm, the fetus is delivered, 3h if nulliparous 2h if multiparous. Arrest of the second stage if it lats longer. Epidural lengthens this stage. If prolonged you can give IV oxytocin or do operative vaginal delivery if possible
3: Placental expulsion. 30 min. If prolonged: IV oxytocin → D&C or manual extraction
Biggest NBME RF for fetal tachycardia:
Maternal fever
Shoulder’s dystocia management:
Baby’s anterior shoulder is stuck behind the pubic symphysis
1) Suprapubic pressure and maternal thigh flexion (McRobert’s maneuver). Do NOT do fundal pressure! it makes it worse
Other: Wood’s corkscrew maneuver, manual delivery of the posterior arm, Zavanelli maneuver (cephalic replacement) and c-section
Fetal HR 190, Mom T 102, uterine tenderness, foul smelling vaginal d/c:
Chorioamnionitis, give ampi+genta
BRF for postpartum hemorrhage:
Uterine atony
RF: macrosimia
Day 1-2 vs day 2-3 vs day 4-5 postpartum fever:
Day 1-2: UTI; IV antibiotics
Day 2-3: Endometritis (uterine tenderness); give clindamycin (~ macrolide; covers gram + and anaerobes) + gentamicin (aminoglycoside; gram - bacilli)
Day 4-5: Wound infection; IV antibiotics for cellulitis + wound drainage/packing + close by secondary intention
BRF for postpartum depression:
Personal history of depression
DD: Postpartum blues? Postpartum depression? Postpartum psychosis? Who do you admit?
Postpartum blues? less 2w
Postpartum depression? more than 2w
Postpartum psychosis? hears voices, admit
Also admit if good reason to worry about suicide or kill baby
Decanoates?
For medication non-adherence in schizophrenia
Decanoate form of Halo IM 1 a month
ECT indications and primary complication.
Catatonia
Depression w every symptoms
Complication: amnesia
A 91 year old M has been hospitalized for hypertensive emergencies 5 times over the past 15 months. He lives alone and cooks his own meals but is unable to take his medications regularly. What is the NBSIM?
Legal guardian
Acute mania tto:
Antipsychotic + Li
Antipsychotics can be given IM and will start working fast on the acute setting
Patient on a mood stabilizer that has acute onset RUQ pain with an AST and ALT of 1000+. Cause?
Valproic acid
MDD treatment that can be stopped abruptly with no taper?
Fluxetine, has metabolites that are very long lasting
SSRI uses:
1st line for Depression Anxiety PTSD PMS OCD Premature ejaculation
Fewest SSRI squibbles.
Citalopran
Escitalopram
SSRI in pregnancy;
Best:
Contraindicated:
Best sertraline (also best for a pt with cardiovascular problems) Worst paroxetine: causes pulmonary TH in baby
What TCA is used in treating OCD?
Chlomipramine
DOC in MDD in a terminally ill patient with a life expectancy of 4 weeks?
Methiphenidate
Given the following scenarios, what is the most likely diagnostic error?
1) I have seen a similar presentation in the past so the current diagnosis must be the same as the previous diagnosis:
20 A gastroenterologist at an outside hospital has made a diagnosis of IBD so that must be the diagnosis:
1) Availability
2) Anchoring
CHECK
Seizures with SSRIs:
SIADH
Patient with flu-like symptoms 2 days after stopping paroxetine:
Discontinuation sd
Put them back on their original dose and taper them down
Flooding vs systematic desensitization in phobias tto:
Flooding: I trough you on a room full of snakes, fast and high risk of relapse
Systematic desensitization: little by little you increase the exposure, slower, low relapse
Treating the ER slashed wrist. Dx? Tto?
C
Reducing the risk of suicide in a patient that hears voices and does not want to leave his room:
Reducing the risk of rehospitalization in the same patient?
Schizophrenia, clozapine reduces the risk of suicide, family interventions (family therapy) reduce the risk of rehospitalization
The 4 dopaminergic pathways (and how they are affected by low dopamine after taking an antipsychotic).
Nigrostriatal pathway: Parkinsonism
Tuberoinfundibular: high PRL
Mesolimbic: controls + symptoms
Mesocortical: worsens - symptoms
Antipsychotic side effects: Amenorrhea: Avoid in DM/fall risk: Avoid in heart failure with reduced ejection fraction/neutropenic fever: Associated with TdP:
Amenorrhea: risperidone
Avoid in DM/fall risk: olanzapine
Avoid in heart failure with reduced ejection fraction/neutropenic fever: clozapine
TdP: ziprasidone
Altered mental status, T 105, BP 170/100 in a patient who was recently placed on a drug regimen for diabetic gastroparesis. Dx?
Tx?
Metochlopramide
Tx. Dantrolene
Extrapyramidal side effects and treatment strategies;
Sustained abnl posture:
Motor restlessness:
Most dangerous complication of the “motor restlessness”
Cogwheeling
Stereotypical mouth movts 2 years after being placed on fluphenazine:
Sustained abnormal posture: dystonia benztropine or antimuscarinic
Motor restlessness: akathisia, increases suicede, 1) propranolol 2) benzo
Cogwheeling: parknsonism, benztropin or amantadine
Stereotypical mouth movts 2 years after being placed on fluphenazine: tar dive diskinesia, change antipsychotic and valvenazine
Anatomical association of conduct disorder and antisocial personality disorder:
CSF with low 5TH
Anatomical association and tto of ADHD:
Decrease activity of frontal cortex
Give tto starting at age 6, if 4-5 do parent-child behavioral therapy:
1) methylphenidate
2) atomoxetine
3) clonidine/guanfase
Personality disorders:
1) Holds grudges, suspects spousal infidelity, are you an enemy or a friend? Fears exploitation:
2) Lacks close friends, believes in the occult, yellow pants with red shirt:
3) Emotionally cold, same rxn to praise/criticism, not interested in sex, loves solitude:
4) Impulsive, intense relationships, radial nerve damage:
5) Requires admiration, lacks empathy, sense of entitlement:
6) Remorseless, disobeys the law, deceitful:
7) Center of attention, seductive, theatrical:
8) Afraid of social criticism, does not take risks, feels inferior to others:
9) Stubborn, rule oriented, miserly, perfectionistic, devoted to the cause/no leisure:
10) Needs reassurance for every decision, problems initiating projects, needs urgent companionship:
1) paranoid
2) schizotypal
3) skizoid
4) borderline
5) narcissistic
6) antisocial
7) histrionic
8) avoidant
9) obsessive compulsive
10) dependent
Primary NBME disadvantage associated with relative risk reduction?
RRR is deceitful, that is why you use the ARR so you don’t get mislead
Safe antiepileptics in pregnancy:
Lamotrigine!!! which works for bipolar and epilepsy
Lurasidone for bipolar depression and schizophrenia
Gabapentin, lamotrigine and levetiracetam
Haloperidol for acute symptoms
Topiramate
Phenytoin if she was on that before
Best CBT for anorexia on NBMEs:
Best antidepressant for anorexia:
Family therapy (or behaviorally-based therapy) Mirtazapine: alpha 2 blocker
Antidepressant for bulimia:
SSRI
Eating disorder with sudden onset, severe chest pain with pneumomediastinum:
Pneumothorax on someone that vomits
Insomnia with frequent urge to move legs at night. Tto:
tto pramipexole or ropinerol. You can also give primidone that is a barbiturate
Narcolepsy tto:
Stimulant: modafinil, dextroamphetamine
Na oxidate for cataplexy
Complex motor behaviors during sleep:
REM sleep behavior disorder
Outside observer to one’s thoughts. No recollection of a traumatic event:
Depersonalization dosorder
MDMA toxicity:
Hyperthermia, rhabdomyolysis, hyponatremic seizures, serotonin syndrome
Miosis, bradycardia, RR of 4.
Intoxication tto:
Withdrawal tto:
Opioid overdose
Intoxication tto: Naloxone
Withdrawal tto: clonidine
Nystagmus, violence towards others, myoclonus. Tto:
PCP intoxication, tto with an antipsychotic
Cyclical recurrent N/V/colicky abdominal pain.
Marihuana cyclical vomiting sd
Pressured speech, tachycardia, mydriasis, HTN.
How do you differentiate from amphetamine?
Cocaine intoxication. Cocaine can lead to hypotension, bradycardia and respiratory depression later on!
Amphetamine you have prominent hallucinations and tooth decay (if smoked), not in cocaine intoxication, both can have formication!! here it is called delusional parasitosis and is associated to skin picking
Nystagmus, gait ataxia, confusion. Dx? \+ Neuroanatomy: \+ Enzyme association: Tx: Irreversible progression:
Wernicke’s
Neuroanatomy: Hemorrhagic infection of the maxillary bodies
Enzyme association: Transketolase
Tx: Vit B1 thiamine before glucose
Irreversible progression: Korsakov psychosis (confabulation, amnesia)
82 yo F pulling IVs, attempting to get OOB.
Inducing agent:
Acute tx:
How to not treat this:
Delirium
Acute tx:
Haloperidol
Bz makes it worse
Progressively forgetful,
Future planning:
ALZ neuroanatomy:
Alzeimer
Future planning: Get living will done
ALZ neuroanatomy: dysfx of the BASAL nucleus of Meyert, =( posterior 1/3 of temporal lobe
Poor language, lack of inhibition, sexually suggestive statements.
Frontotemporal dementia
=( anterior 1/3 of temporal lobe + frontal lobe
Abnormal gait and urinary incontinence. Pathophysiology:
Problem at arachnoid granulations, communicating hydrocephalus
Recurrent nightmares 6 weeks after being fired from an ED nurse role in a COVID unit. Dx:
Tx.
Tx of REM sleep problems:
PTSD
SSRI, prazosine for the Nightmares
In which part of the sleep cycle do sleep terrors and nightmares happen?
Terrors: N3
Nightmares: REM
Intrusive thoughts about killing friend. Dx? Tto?
OCD
Tto: Pharm (SSRI) + psychotherapy (exposure and response prevention)
Feels humiliated and is terrified at the prospect of giving speeches.
Pharm: 1st line and 2nd line
1) propranolol 2) Bz if asthma or COPD
MDD; Fastest/most effective tx:
Electroconvulsive therapy
Indications:
Severe suicidality, malnutrition due to food refusal, severe psychosis), or if medication is contraindicated (e.g., pregnancy)
Schizophrenia timelines:
Brief phychotic disorder: less than 1mo
Schizophreniform: 1-6mo
Schizophrenia: more than 6 mo
The ratio of individuals detected by the test to be disease free out of the total number of healthy people refers to:
Specificity
The likelihood of a negative test result being true refers to:
NPV
The ratio of individuals detected by the test to be with disease out of the total number of diseased people refers to:
Sensitivity
The likelihood of a positive test result being true refers to:
PPV
Major depression disorder;
Monoamine hypothesis:
Adrenal axis anomaly:
Monoamine hypothesis: NE, 5HT, DA in CSF
Adrenal axis anomaly: High cortisol in CSF
Regime for testicular ca:
cisplatin, etoposide, and bleomycin (BEP regimen)
Tto for migraine + vomiting:
Prochlorperazine or chlorpromazine can be used as monotherapy for acute migraine attacks, especially if the migraine is associated with vomiting.
Riboflavin deficiency:
The increased activity coefficient of erythrocyte glutathione reductase confirms this diagnosis.
Normocytic anemia
Patients with riboflavin deficiency are at increased risk of developing seborrheic dermatitis
What should you give after to all patients after reperfusion therapy
aspirin + clopidogrel
DAPT reduces mortality and the risk of developing subsequent ischemic episodes and stent thrombosis. The duration of DAPT is an individual decision based on bleeding risk and the risk of stent thrombosis. After PCI with stent placement, DAPT is usually recommended for 12 months. In addition to DAPT, long-term pharmacotherapy for secondary prevention after acute coronary syndrome consists of an ACE-inhibitor, beta blocker, nitrate, and a high-dose statin therapy. Low-dose aspirin therapy is continued lifelong.
Infective endocarditis in kid
This child fulfills all of the 5 minor criteria of the modified Duke criteria for the diagnosis of infective endocarditis. These include a predisposing heart condition (ventricular septal defect), fever ≥ 38°C (100.4°F), vascular phenomenon (splinter hemorrhages and Janeway lesions, i.e., purplish lesions on her palms and soles), immunologic phenomenon (glomerulonephritis and Roth spots, i.e, retinal hemorrhages), and a positive blood culture for atypical microorganisms consistent with IE. The fulfillment of these 5 criteria (even in the absence of vegetations on the transthoracic echocardiography) are adequate to make a diagnosis of IE.
A 6 mo male is losing motor milestones. He has over the last 2 mo lost the ability to sit, turn over, or crawl. He has also had multiple seizures and does not respond when he is called by his mom. He lives in a small Amish community in Pennsylvania. Dx: Pathophysiology: Classic populations: Buildup:
Tay sachs
Hexosaminidase deficiency that makes GM2 ganglioside accumulate
French Canadians and Ashkenazi and Cajuns in Louisiana
Progressive vision and hearing loss in a 2 yo F. She was profoundly hypotonic at birth. PE is notable for hepatosplenomegaly. Further testing reveals markedly elevated levels of very long chain fatty acids in her plasma. Dx: Pathophysiology: Buildup: Mode of inheritance (MOI):
Zellweger syndrome
Pathophysiology: PEX gene mutation
Buildup: VLCFA
Mode of inheritance (MOI): AR
A 5 yo M is brought to the ED with a 2 week history of daily morning fevers. He lives on a farm and consumes milk sourced from goats. His parents note that he sweats profusely at night and oftentimes his pajamas have a foul smelling odor by morning. He also complains of right knee and left hip pain. Labs are notable for a WBC of 2k and a Hct of 27%.
Dx:
Tx:
Preventive medicine:
Macrocytic anemia in this “goat milk” population:
Brucellosis
Tx: Doxy + rifampin/aminoglycoside
Preventive medicine: Milk pasteurization
Macrocytic anemia in this “goat milk” population: folate deficiency
2 day history of severe abdominal pain, myalgias, chills, fevers, and a frontal headache in a SEWAGE worker. Funduscopic exam is notable for bilateral conjunctival suffusion. Labs are notable for elevated LFTs and a Cr of 2. Dx?
Method of transmission:
Tto:
Dx testing:
Most important predictor of poor outcomes:
Leptospirosis
Method of transmission: animal urine exposure
Tto: doxy/macrolide
Dx testing: ELISA screening for IgM antibodies, then microscopic agglutination or dark field microscopy to confirm
Most important predictor of poor outcomes: spread to the lungs
22 yo M with a non-painful, non-itchy circular rash on the UEs that has been increasing in size over the last 2 days. He also complains of fevers, chills, and a mild headache. He went hiking with a few friends in Minnesota. On PE, the rash is observed to have an especially erythematous center. Dx?
NBSM: Most common cranial nerve affected: Classic cardiac complication: Coinfection: Tick timeline: Tx strategies by age: Treatment for neurological/cardiac involvement: Precaution to be taken with standard treatment: Preventive measures:
Lyme by Borrelia burgdorferi
NBSM: Screening by ELISA, confirmation by Western Blot
Most common cranial nerve affected: CN7
Classic cardiac complication: 3rd degree AV block
Coinfection: anaplasma and babesia (give atovaquone for babesia)
Tick timeline: just treat if tick has been there for more than 36 h
Tx strategies by age:
If less than 8 give amoxicillin/cefuroxime, if more than 8 doxy
Treatment for neurological/cardiac involvement: cerfriaxone
Precaution to be taken with standard treatment: avoid the sun
Preventive measures: DEET skin repellant or permethrin sprayed clothes
A 32 yo army engineer with a PMH of T2DM is brought to the ED with a 2 day history of high fevers, SOB, and altered mental status. He just returned from a military relief mission to Thailand. He participated in teams that helped with rebuilding homes that were flooded during a severe hurricane. On further evaluation, his WBC is 2k with a BP of 70/40. Fluid collections are visualized by imaging in his brain and liver. Dx?
Biggest risk factor:
Tto?
Melioidosis by burgdorferi pseudomallei. Transmitted by Water soil!!!
Biggest risk factor: history of DM
Tto: IV Ceftacidime and then TMP-SMX for a few months
45 yo TSA agent on chemotherapy for testicular lymphoma presents with a 2 wk history of high fevers, malaise, and a 7Ib weight loss. Labs are notable for a WBC of 17k (with 70% lymphocytes) and a Ca of 12.2. Dx?
What is the Next best step in management?
Why would this patient have a Na of 122, K of 6.7, and a bicarb of 14?
Miliary TB
NBSIM: RIPE regime; rifampin, isoniazid, pyrazinamide, and ethambutol, vit B6
Metabolic acidosis secondary to adrenal insufficiency that is the MCC of adrenal insufficiency worldwide
High fevers in a rabbit farmer. PE is notable for a painful ulcer on his right great toe with prominent superficial inguinal lymphadenopathy. Dx:
Tx:
Transmitting bug:
Tularemia by francisella tullarensis
Tx: 1) aminoglycoside. Also ciprofloxacin or doxycycline
Transmitting bug: dermacentor tick
Causes (2) of toxic shock syndrome? Tto?
Strep pyogenes, more mortality!
Staph aureus
Tto: fluids + Abs + ICU
A 23 yo F presents with a 2 day history of high fevers, SOB, malaise, and diffuse myalgias. She adopted a dog 3 weeks ago from an animal shelter. Labs are notable for elevated LFTs and a moderate leukocytosis. A new LLSB murmur is heard on cardiac auscultation. CXR is notable for bilateral interstitial infiltrates. Dx:
Common cardiac complication:
Dx test:
Tto:
Q fever
Common cardiac complication: culture negative endocarditis
Dx: antibodies in the serum
Tto: doxi
Hematologic differentiation of anaplasmosis, babesiosis, and ehrlichiosis:
Anaplasmosis: pancytopenia
Babesiosis: maltese cross, hemolytic anemia
Ehrlichiosis: leukopenia, it decreases TNF that causes leukopenia and leads to opportunistic infections
Fever and rash for 3 days in a 10 yo M followed by the onset of petechial bleeding on the wrists and ankles that is now spreading towards the abdomen. He recently returned from a field trip to New Mexico associated with his geography class where they explored a few mountains. Labs obtained are notable for a WBC of 2k, plts of 50k, Na of 123, and elevated LFTs. Dx:
Transmission:
Tx (for all ages); and what should be monitored?
Rocky mountain spots fever by riketsia rikesie
Transmission: Dermacentor tick
Tx: Doxycycline including kids. Chloramphenicol in pregnant; monitor WBC count!
Mononucleosis like syndrome with a -ve monospot test.
Dx:
Tx strategies:
Mechanism of resistance:
Tx resistant:
Pathology in:
In newborn/HIV patient/Transplant recipient:
CMV
Ganciclovir, resistance by UL 97 kinase, give foscarnet (pyrofosfate analog)
Baby: periventricular calcification
Retinitis in HIV
Colitis in trasplant
Treatment of blastomycosis
Itraconazole
Odynophagia in a patient that was recently started on inhaled budesonide for asthma. Dx:
Tx strategies:
Vaginal presentation (+ tx strategies, classic risk factor):
Preventing oral dz while patients are in the hospital:
Tx strategies for invasive dz (+ drug MOA):
Pediatric presentation:
Oral hypoglycemic agent increasing risk:
Dx testing:
Uncircumcised male:
Below the breast:
Candida
Nystatin swiss and swallow or oral azole
Vaginal presentation: white cottage cheese
classic risk factor):
Less 4.5
(+ tx strategies, classic risk factor):
Prevent chlorexidine mouth wash
Invasive tto: echinocandins (fungins, inhibit 1-3 betaglucan synthase)
Peds: moisture areas leads to diaper rash
SGLT2 inhibitors, flozins
KOH prep pseudohifae
Balinitis
Intertrigo in obese and diabetic patients, treat with topical azole
27 yo marine comes to the physician after noticing a lesion on his left hand that has gotten progressively larger. He just returned from a deployment in the Democratic republic of congo and together with his unit participated in a deforestation initiative. Dx:
Vector:
Preventive measure:
Tto strategies:
Bone marrow smear findings:
Leishmaniasis
Vector: sandfly
Preventive measure: nest, insect repelant
Tto strategies: liposomal amphotericin B
Bone marrow smear findings:—
Chagas, Tx strategies:
Nifurtimox, benznidazole
For achalasia: 1) endoscopy if need to rule out ca. 2) tto: botox, the Heller myotomy, ca ch blocker, balloon dilation (careful not to cause Boerhaave syndrome)
Achalasia presents with low peristalsis and increased LES tone
Marine who just returns from the DRC over time becomes somnolent and progresses to an eventual coma. Dx:
Vector:
African trypanosomiasis, or sleeping sickness by trypanosoma brucei
Tsetse fly
A 59 yo M is brought to the ED after being found down in his hotel while on a business meeting. He is apneic and has to be placed on a ventilator. EKG is consistent with pulseless electrical arrest. After multiple attempts, return of spontaneous circulation is achieved. MRI of the brain is consistent with global anoxic injury. The patient’s primary care physician is called and he mentions that a document was signed 3 years ago where the patient stated that he was not interested in life sustaining measures and would like to “go peacefully”.
What is the next best step in management?
What is the document called?
What is a classic alternative on NBMEs to this document?
Assuming a patient does not have this document or the alternative (and no one knows his preferences for care), what is the NBSIM?
NBSIM: Take off life support
What is the document called? Living will
Alternative: Medical power of attorney that is more flexible than the Living will
NBSIM 2: Spouse, adult children, parents, siblings, other relatives
What are classic NBME scenarios where patient confidentiality should not be honored (4 key situations)?
Child/elder abuse
Suicidal/ homicidal
Infectious diseases: TB, hepatitis, trichomonas, HIV, unsafe driver (seizures, old…)
Prior to declaring a patient brain dead, what must be true of the following?
Brainstem reflexes:
pCO2:
Core body temp:
Drug of abuse:
Absent brainstem reflexes:
caloric test, pharyngeal reflex (gag), pupillary light reflex, corneal reflex
pCO2: bigger than 60
Core body temp: bigger than 90 Fahrenheit (you can be hypothermic)
Drug of abuse: no drug intoxication
When is parental consent not necessary on NBMEs?
Emergency Contraception Pregnancy and prenatal care Addiction STDs
A nurse mistakenly gives a patient 1000U of aspart instead of the ordered 75U. 55 mins after the dose was given she notices her mistake and immediately begins an infusion of D5W.
What is the NBSIM?
What kind of error was committed by the nurse in this circumstance?
The pyxis machine at a hospital has an antibiotic rack that includes cefotetan, cefazolin, and cefuroxime placed side by side. What is 1 potential issue associated with this setup?
How can errors of this nature be reduced in the EMR?
As an aside, when is it appropriate for a physician to have a sexual relationship with a patient?
Admit that an error was made
Active error, Ade by the patient’s bed
Latent error
Tallman lettering (emphasize the things that are different)
Never (more than 6mo after the therapeutic relationship has been broken)
A rural ER with only 1 physician and nurse are confronted with 3 patients who all present at the same time. Patient A is a 37 yo F who has over the past 12 hrs had worsening shortness of breath and chest pain. Her BP is 115/75 and EKG shows sinus tachycardia. Patient B is a 22 yo varsity athlete who has had chest pain for the past 3 days and has bilaterally auscultable breath sounds. His BP is 110/73, HR is 65 bpm, and RR is 17. Patient C is a 55 yo M with chest pain radiating to his jaw with territorial ST elevations visualized on an EKG.
What is the most appropriate physician action in these circumstances?
In taking care of 1 patient first over the other, is an ethical principle being violated?
NBME implications for healthcare systems with COVID-19?
A) PE, treat second
B) This patient is probably ok, should be the last one to be treated
C) acute MI, treat first
No, you are triaging the patients
On a pandemic, which of the following temporary interventions should be employed? stop elective surgeries
What is the most likely quality improvement concept being emphasized with the following case scenarios?
A) A hospital is about to establish a new ICU. They design a project to examine dosing of opioids in the ICU and set up a taskforce to determine all the steps in this process along with a detailed analysis of potential pitfalls along the way.
B) A 49 yo M dies in a hospital ICU from intracranial hemorrhage. He had initially been getting a heparin infusion for a submissive pulmonary embolism. The hospital sets up a taskforce to thoroughly analyze his hospital course and identify factors along the way that may have led to his death. Plotting?
A) Failure modes and effects analysis. How can this fail and which effects will those failures have?
B) Root cause analysis, you can plot the data on a fishbone or ischikawa. Retrospective
What kind of quality measure is being emphasized in the following measured situations in an ICU?
A) Are readmission rates among heart failure patients increasing after measures are implemented to reduce their hospital length of stay?
B) # of adverse drug events after a tallman lettering system is implemented in an ICU.
C) # of patients having follow up appointments scheduled by the discharging nurse after admission for a CHF exacerbation.
A) Balanced measure
B) Outcome measure
C) Process measure
1) What is the PDSA cycle?
2) What is a forced function?
1) PDSA: Plan, do, study, act
2) Forced function: measure that you put in place so people don’t make mistakes.
You cannot turn the car off if you have parked
NBME “buzzwords” for quality/safety practices that improve standardization in healthcare systems?
Checklist (used in newborns for example)
Protocol (DKA plan, Sepsis plan…)
Algorithm
Timeout
A procedure kit for placing central lines in a major university hospital is found to have 3 extra lidocaine vials, 4 extra syringes, and a thermometer. The hospital notices that most of these “extra” items get thrown away and decides to have the manufacturer create a custom central line kit that contains exactly what is needed. What quality/safety principle is being employed by the hospital in this circumstance?
Simplification, they are trying to reduce unnecessary steps on a process
What is the most likely cause of erectile dysfunction given the following patient scenarios?
A) 49 yo M recently started on therapy for angina:
B) 32 yo M recently started on therapy for major depressive disorder:
C) 29 yo M with hypomagnesemia, megaloblastic anemia, and an elevated GGT:
D) 25 yo M with no relevant PMH who has nocturnal emissions:
E) A 47 yo M with trace proteinuria and decreased sensation in his legs:
A) Beta blocker
B) SSRI
C) Alcoholism
D) Psychogenic
E) DM
What are the 2 measures associated with reducing progression of nonalcoholic steatohepatitis to end stage liver disease?
Loose weight
Healthy diet/statins
Management of an RCA infarct (what should be given)?
DO NOT GIVE NITRATES
Give normal saline
Dx test to be employed in an afebrile F presenting with flank pain radiating to the groin and UA showing 30-50 rbcs/hpf. Dx test?
Nephrolithiasis
Non contrast helical CT scan!!!
4 yo M presenting with acute onset testicular pain. PE is notable for a “bluish nodularity” and tenderness at the upper pole of the R testicle.
Torsion of the appendage testis, just observe and conservative tto
Given the following case scenarios, what is the most likely preventive medicine strategy being employed?
A) An 11 yo boy is required to have meningococcal vaccination prior to beginning high school:
B) A 65 yo M with a h/o of PAD is placed on daily aspirin therapy:
C) Woman getting her yearly mammogram:
D) Advising a 35 yo F with no relevant past medical history against getting a mammogram:
A) Primary prevention
B) Tertiary prevention
C) Secondary prevention
D) Quaternary prevention
Given the following case scenarios, how would these patients be best able to pay for healthcare?
A) 68 yo M who spent 2 weeks in the ICU for the treatment of a severe lobar pneumonia.
B) Same male as above being discharged and needing to pay for outpatient ciprofloxacin therapy.
C) Same male as above visiting his PCP for outpatient follow up.
D) Who typically qualifies for medicare?
E) What are some other patient populations that would qualify for the kind of insurance in the case scenario described above?
A) Medicare part A (hospitAl)
B) Medicare part D
C) Medicare part B (outpatient visits and dx tests)
E) Over 65, ALS, end stage renal disease, on social security disability for more tan 2years
Potential curative measure for maple syrup urine disease:
Potential curative measure: liver transplant , because the enzyme is expressed in the liver
33 yo F presents with a 2 day h/o severe, colicky, generalized abdominal pain. During the interview, her speech is predominated by loose associations. Her mom noticed that she has been passing dark red urine in the intervening time period. Dx?
Pathophysiology:
Mode of inheritance:
Why they also have hyponatremia:
Tto:
Differentiating from close cousin (+ pathophysiology):
Bug to be tested for with skin disorder:
Long term prophylaxis:
Tto strategies for close cousin:
Acute intermittent porphyria
Pathophysiology: Deficiency of porphobilinogen deaminase or hydroxymethylbilane synthase
MOI: AD
Hyponatremia: Can lead to SIAHD and hyponatremic seizures
Tto: Hemin or glucose because they inhibit ALA synthase. Also avoid triggers
Close cousin: porphyria cutanea tarda, uroporphyrinogen decarboxylase deficiency that have skin and nail (onicholisis) findings and hypahydrosis (sweat a lot). 20% AD 80% de novo
Bug to be tested for: Hep C
Prophylaxis: cimetidine
Tto: plebotomy
Alpha 1 antitripsin deficiency;
MOI: Worsens morbidity/mortality: Skin association: Associated vasculitis: Genotype that tends to be symptomatic:
MOI: Autosomal codominant
Worsens morbidity/mortality: smoking; smoke inhibits Alpha 1 antitripsin
Skin association: paniculitis, subcutaneous fat inflammation
Associated vasculitis: Wegener
Genotype that tends to be symptomatic: PiZZ
Classic eye finding in Prader Willi syndrome:
Strabismus
MCC of esophageal perforation on NBME exams?
EGD
NBSIM in a patient who is diagnosed with a mallory weiss tear?
Supportive care
Reducing the risk of future bleeds in patients with esophageal varices?
Prevention: βb (propranolol) because they cause splanchnic vasoconstriction + spironolactone
What should always be done after placing a central line on an NBME exam?
Chest Rx!! to confirm appropriate placement!!
You need to see the catheter tip near the angle between the trachea and the right mainstream bronchus
What is the relationship between pericardial and ventricular filling pressures in a patient with pericardial tamponade?
Cardiogenic shock. Pericaldiac pressures are higher than the ventricular filling pressures
Loss of radial and ulnar artery pulses with a shoulder dislocation?
Axillary A impingement
Loss of dorsalis pedis and posterior tibial pulses with posterior knee dislocation?
Popliteal A. disloged
A 12 yo M is brought to the ER with severe headache and high fevers over the last 24 hrs. PE is notable for nuchal rigidity and star shaped petechial lesions on the upper and lower extremities. These lesions do not fade away under glass pressure. The patient is somnolent and unable to participate in the interview. Dx: Mechanism behind petechiae: Classic outbreak: Major virulence factor: Prevention: Tx strategies: Close contacts: Inciting drug: Sickle cell:
Meningitis by N. meningitides
Mechanism behind petechiae: toxin breaks blood vessels
Classic outbreak: military/dorm
Major virulence factor: endotoxin
Prevention: conjugated vaccine around 12 y.o.
Tx strategies: ceftriaxone
Close contacts: rifampin/cipro/ceftriaxone -for pregnant- to contacts (the person that intubates, airway contracts)
Inciting drug: eculizumab
Sickle cell: asplenia
Septic Shock SIRS criteria: Sepsis: Severe sepsis: Septic shock: Acid-base balance: MCC: SVR: CO: PCWP: Kind of shock: Pressor of choice: MC kind of infection causing dx: Bad sequelae of septic shock:
SIRS: 2 out of 4+infection=sepsis
Ta less than 36 or greater than 38
HR more than 90
Resp rate more than 20
less 4k or more than 12k
Severe sepsis: +end-organ dysfx
Septic shock: +fluids are not working
Acid-base balance: depend on anaerobic glycolysis so high anion gap metabolic acidosis due to lactic acid
MCC: gram + infection
SVR: decrease
CO: increase
* CO and SVR are opposite except in neurogenic
PCWP: decrease
Kind of shock: distributive
Pressor of choice: NE + if doesn’t work vasopressin + if doesn’t work DA. Also give intravenous vancomycin and ceftriaxone
MC kind of infection causing disease: UTI
Bad sequelae of septic shock: multi organ failure
A 37 yo M with a h/o familial hypercholesterolemia presents with a 2 hr h/o severe chest pain radiating to his left jaw. His BP is 60/40.
Dx: CO: SVR: PCWP: CVP: CI: Tx strategies:
MI, cariogenic shock
CO: low
SVR: high; * CO and SVR are opposite except in neurogenic
PCWP: hight
CVP: surrogate for RA pressure!!!! increase
CI: low
Tx strategies: dobutamine
A 44 yo M is brought to the ED by ambulance after being involved in a severe MVA. His BP is 60/40 with a HR of 34 bpm. The patient’s skin is warm and flushed.
CO: SVR: PCWP: CVP: Tx strategies:
Assuming the patient goes into respiratory arrest, where is the likely lesion? What would be true of the A-a gradient in this patient?
Mechanism behind the bradycardia:
Neurogenic shock; sympathetic knockout
CO: low
SVR: low
* CO and SVR are opposite except in neurogenic
PCWP: low
CVP: low
Tx strategies: presors
Profound respiratory depression by high spinal injury
A-a will be nr
Parasympathetic is unopposed
A 43 yo M is brought to the ED by ambulance after being involved in a severe MVA. His BP is 60/40. A large fluid collection is palpated in the lower abdomen and pelvis.
CO: SVR: PCWP: CVP: Tx strategies:
Hypovolemic shock
CO: low
SVR: high
PCWP: low
CVP: low
Tx strategies: nr saline
What kind of question should be used to initiate a discussion on NBMEs in relation to intimate partner abuse?
In what setting should this be done?
What if the partner refuses your suggestions, what are you supposed to do? Should you call CPS/APS?
Do you feel safe at home?
Private setting, not with the partner in front
Provide resources
A 4 yo F is brought to the physician by her mother with a 2 week h/o of severe diarrhea. The mother has presented to the same clinic multiple times for the same complain. No therapeutic interventions appear to have worked. The physician decides to perform a colonoscopy which reveals extensive brownish discoloration of the colon. Dx:
Next best stem in management:
Melanosis coli due to factitious disorder by proxy
NBSIM: call child protective services
Classic signs of child abuse on NBME exams:
Most common cause of death in this population:
Signs of child abuse: Sundural hematoma Sternal fractures Spiral fracture Retinal hemorrhages
MCCOD: Abusive head trauma
A 12 yo F is brought to the ER by her dad after she started having “strange movements” of her UEs/LEs. She has also had severe pain in her knees and high fever. On auscultation of the chest, a diastolic murmur is heard at the apex. She had an URI 3 weeks ago. PE is notable for pink whorl like structures on the legs and inner surfaces of the thighs bilaterally. Dx:
Dermatology association: Most likely valvular anomaly: Decreasing incidence: Most likely arrhythmia: Hypersensitivity: Tx strategies:
Acute rheumatic fever
Derm: erythema marginatum
Most likely valvular anomaly in acute rheumatic fever: mitral stenosis??? shouldn’t be mitral regurgitation in acute?
Decreasing incidence: treat with antibiotics, especially penicillin
Most likely arrhythmia: Afib
Hypersensitivity: type 2
Tx strategies: penicillin and aspirin
COVID-19
Risk factors associated with an increased risk for death:
Dx testing:
Tx strategies and it’s mechanism of action:
RF: Pre-existing lung disease, immunocompromised
Dx testing: antibodies test/ PCR
Tx strategies: remdesavir (RNAse polymerase inhibitor), convalescent serum
32 yo F with a family history of breast and ovarian cancers presents with a 2 month history of R arm pain and swelling. She underwent radiation therapy for breast cancer 3 months ago. Dx:
Biggest RF?
Biggest RF developing countries?
Tx?
Malignant complication?
Lymphedema
Biggest RF? lymph node dissection (also radiation)
Biggest RF developing countries? Filariasis by burferia bancrofti
Tx? compression bandage
Malignant complication? lymphangiosarcoma, bad px
67 yo F presents with a 3 mo hx of moderate LLE pain. She describes the pain as a tight, full, achy sensation that is worse at the end of the day. PE is notable for ankle/calf edema which subsides with elevation of the involved extremity. Dx?
Dermatology association? Pathophysiology? Ulcer? Dx testing? Tx strategies? Veins affected?
Varicous veins
Dermatology association? stasis dermatitis because of hemosiderin deposition
Pathophysiology? valvular incompetence
Ulcer? painless shallow ulcer above the medial malleolus
Dx testing? DUPLEX ULTRASOUND of lower extremities
Tx strategies? compression socks, una boots if ulcer
Also RF ablation or sclerotherapy
Veins? Saphenous v.
HY Compression Syndromes:
1) Lower leg thrombosis in an individual with no associated hypercoagulable risk factors:
2) 2 month history of severe left hand, left clavicle, and left neck pain in a 23 yo M. He also reports tingling in all 5 digits of the involved extremity. PE is notable for purplish discoloration of the left hand:
3) Sudden onset severe pain, erythema, and swelling of the right arm in a 23 yo M guitarist who has recently had to increase practice time for an upcoming reality TV show:
4) 2 week history of hematuria and left testicular pain in a 23 yo M who recently lost 45 Lbs on a reality TV show. PE is notable for a bag of worms sensation in his left testicle:
5) Sudden onset severe RUQ pain and jaundice in a 22 yo M with a h/o chronic hematuria. Abdominal exam is notable for a fluid wave. Obtained labs reveal a pancytopenia with a bicarb of 13:
6) Sudden onset flank and lower back pain in a 33 yo M with a history of chronic proteinuria and generalized edema:
7) Sudden onset severe abdominal pain in a patient that was recently discharged from the hospital after a bout of acute pancreatitis. PE is notable for fullness in the LUQ. His plt count is 55k:
1) May-thurner syndrome, the right common iliac A compresses the left common iliac V so blood does not return form the lower leg
2) Thoracic outlet sd due to cervical rib and pancoast tumor
3) Paget-Schroter disease, overuse thrombosis, thrombosis of the axillary or the subclavian v. on someone that uses the arms a lot (jackhammer operator, weight lifter, musician)
4) Nutcracker syndrome
5) Budd chiari in paroxysmal nocturnal hemoglobinuria; hepatic v. thrombosis
6) Loss of antithrombin 3 in nephrotic sd (membranous neuropathy is the forest thrombogenic)
7) Splenic V. thrombosis which is associated w acute pancreatitis, platelet sequestration
Odynophagia/GERD like sxs that have not improved with three, 6 week courses of esomeprazole. Esophageal pH monitoring is unremarkable. Dx:
Tto strategies:
Eosinophilic esophagitis
Tto strategies: steroids (can be potentially inhaled)
BP of 190/120 and severe chest pain radiating to the scapula in a 55 yo M. Dx:
Next best step in Dx? Biggest RF? Tto strategies? New diastolic murmur? Other RFs? Most common extracardiac complication? Buzzword pathophysiology?
Aortic dissection
NBSID? TEE if unstable; Ct angiogram of the chest if stable
RF? HT
Tto strategies? Beta blokers
New diastolic murmur? aortic regurgitation
Other RFs? Marfan, ED, turner, takayasu, syphilis…
Most common extracardiac complication? renal failure
Buzzword pathophysiology? cystic medial necrosis
Sudden onset severe back/left flank pain in a 69 yo M with a barely perceptible supraumbilical mass. Dx?
Next best step in diagnosis? Next best step in management? Biggest risk factor? Tto strategies? Paraplegia? Post treatment positive fecal occult blood test and Hb of 8 with MCV of 70? Screening guidelines? Most common tto complication with endovascular repair? Most common location? Imaging finding in acute circumstances?
Rupture AAA
NBSID? unstable ultrasound, stable CT scan
NBSIM? 2 big IVs and fluids
BRF? smoking; also biggest modifiable RF for progression (because smoking disrupts the arterial wall elastin matrix)
Tto strategies? surgery
Paraplegia? injury of A. of Adamkiewicz causing anterior spinal A sd
Post treatment + FOBT and Hb of 8 with MCV of 70? fistula between aorta and GI trac
Screening guidelines? more than 65 and smoke 1 time aldominal ultrasound, more than 5.5 cm sx
Most common tto complication with endovascular repair? endo leak, contrast going beyond the confines of the stent
Most common location? below renal A
Imaging finding in acute circumstances? draped aortic sign (aorta drapes into vertebral bodies and causes calcifications anterior to them).
What defines an unstable patient?
BP less than 90 systolic/60 diastolic!
Chest pain Shortness of breath Hypotension (pale) Confusion (altered mental status) Diaphoretic Severe abdominal plain
Why does aspirin help with RF?
Avoid thrombosis
Anti-inflammatory
This is one of the cases where you can give aspirin to a kid
Rising Cr 2 days after a patient with a history of A.fib presented with acute onset severe leg pain that was treated with a catheter embolectomy. Initial dx?
Pathophysiology of the rise in Cr:
The patient had acute limb ischemia
6Ps: pallor, pain, paralysis, paresthesias, pulselessness and poikilothermia
Tto:
Amputate if no audible pulses in Doppler and complete paralysis
Thrombectomy: in the vignette you caused a thrombosis of the renal A. by inserting the catheter or by dislodging a cloth that ends up in the renal A!
Treatment of bleeding associated with end stage renal disease? and en stage liver disease?
ESRD=Uremia? Desmopressin, because urea prevents degranulation of platelets
ESLD=Cirrhosis? FFP to supply missing clothing factors
2 year history of recurrent intermittent fevers and pleuritic chest pain in a Libyan/Turkish/Greek immigrant. His only home medication is as needed ibuprofen for knee pain. These episodes last for about a week and resolve without treatment. Similar episodes have also been known to occur in other family members. PE/imaging are all wnl.
Genetics?
Classic lab findings?
Cr of 3 and proteinuria after many years?
Tx strategies?
Familial Mediterranean fever
MEFV gene
high ESR/CRP
AA can build up and cause amyloidosis, MCC of death on amyloidosis us nephrotic sd
Colchicin
Red, hot painful ears with chronic stridor. This patient often has episodes of bilateral, parasternal chest pain. He is noted to have a saddle nose deformity.
Dx?
Dx testing?
Tx?
Relapsing polychondritis
Dx testing? cartilage biopsy
Tx? 1) NSAIDs colchicine dapsone 2) steroid if they don’t work
What is the dx for the following patient permutations?
1) HR 170, BP 210/120, bilateral pupillary mydriasis:
2) HR 120, BP 170/100, bilateral pupillary mydriasis, hearing voices and seeing snakes in the room:
3) HR 45, profuse diarrhea and rhinorrhea, bilateral pupillary miosis in a farmer:
4) T 103F, HR 130, RR 26, bilateral pupillary mydriasis:
5) T 103F, HR 130, RR 26, bilateral pupillary mydriasis, WBC of 17k, diffuse muscle rigidity:
6) HR 32, RR 4, T 90, bilateral pupillary miosis:
7) HR 19, BP 60/40 in a 33 yo F on chronic therapy for variant angina. A suicide note is found by her side:
1) Cocaine intoxication, give a benzo or phentolamine
2) Amphetamine intoxication
3) Organophosphate poisoning, give atropin and then pralidoxine
4) Anticholinergic toxidrome (TCA, diphenhydramine) give physostigmine
5) Neuroleptic malignant syndrome, give dantrolene
6) Opioid intoxication, give naloxone
7) You treat variant angina with verapamil/diltiazem. Overdose treated w glucagon, if does not work pacemaker
22 yo M was found unconscious by his family in January. His neighbor saw him grilling indoors yesterday as temperatures were sub-zero at the time.
Dx testing?
Brain imaging?
Tx strategies?
Most likely NBME presenting sxs?
CO poisoning
Dx testing? Check CO levels
Brain imaging? Bilateral hyperintensities on the globus pallidus
Tx strategies? 100% O2 ot hyperbaric O2
Most likely NBME presenting sxs? headache
Nausea, vomiting and diarrhea with a Cr of 3 4 days after starting chemotherapy for Burkitt’s lymphoma. Dx:
Preventive measures/tx?
Most likely electrolyte anomaly?
Tumor lysis sd
Preventive measures/tx? hydration and allopurinol/febuxostat for prevention. Rasburicase/pegloticase if established.
Most likely electrolyte anomaly? kyperkalemia
A 19 yo with a history of Diffuse Large Cell Lymphoma on chemotherapy is brought to the ED with a 3 day history of high fevers and flu like sxs. His T is 102. A chest, abdominal, and pelvic CT series is unremarkable. His ANC is 300.
Next best step in management? If not febrile: Next best step in diagnosis? Prophylaxis? Despite a 6 day course of tx, the patient remains febrile, what is the NBSIM? Imaging findings? RLQ pain?
Febrile neutropenia
NBSIM? antipseudomonal antibiotic (pime, dime, carbapenem) ± G-CSF
If it is not febrile just observation!
NBSID? blood culture
Prophylaxis? GCSF GMCSF analog filgrastim sagramustin
Despite a 6 day course of tx, the patient remains febrile, what is the NBSIM? this is invasive aspergillosis, voriconazole
Imaging findings? halo sign (dense circular infiltrate)
RLQ pain? necrotizing enterocolitis!! typhlitis do an abdominal CT scan for dx
A 55 yo F with a history of breast cancer in remission presents with a 2 week history of left sided facial droop and left sided LE weakness. Brain imaging is consistent with multiple ring enhancing lesions. Dx?
Next best step in management?
Preferred brain imaging?
Long term management?
Brain metastasis
NBSIM? IV steroids
Preferred brain imaging? MRI
Long term management? whole brain radiation
The CKD Patient:
Tx of HTN in an AA CKD patient with proteinuria:
BP target for HTN in CKD:
3 day history of SOB with JVD. An AV fistula was placed a week prior given the patient’s declining renal status:
Hirsutism and dental anomalies after a renal transplant:
Most likely malignant complication of renal transplantation:
Tto: ACEi/ ARAs
BP target: 130/80
SOB with JVD on a patient with AV fistula: high output HF secondary to the AV fistula (it can also happen in Osler weber Rendu sd)
Hirsutism and dental anomalies: Cylosporin toxicity
Malignant complication: squamous cell ca of the skin because of the immunosuppression
Subarachnoid hemorrhage in Alzheimer. Why?
Amyloid angioplasty, amyloid deposits in blood vessels
A 39 yo F with a h/o of rheumatoid arthritis:
1 ) has had a progressive increase in her Cr over the past year. She is noted to have tongue enlargement on PE. Dx?
2) has fever, respiratory difficulty, negative sputum cultures and bilateral micronodular consolidations in chest Rx. Dx?
1) Amyloidosis
2) Bronchiolitis obliterates organizing pneumonia. Tto with steroids
Why do these patients bleed?
MEN2A/2B:
55 yo M with a 12 year h/o T2DM:
MEN2A/2B: Medullary thyroid ca. makes calcitonin that makes amyloid; in amiloidodis amyloid binds factor 10 and causes a factor 10 deficiency
55 yo M with a 12 year h/o T2DM: DM leads to amyloidosis that again causes bleeding because amyloid binds factor 10
Amyloidosis cases:
1) 54 yo M who has been on dialysis for 2 years and develops thenar atrophy. Why? What builds up?
2) Old person w/restrictive heart disease. What builds up?
3) Chronic osteomyelitis. What builds up?
Structural view of amyloid on EM:
Mechanism behind renal failure:
Most common cause of death:
1) Beta 2 microglobulin → dialysis cannot filter beta 2 microglobulin that ends up making amyloid and can lead carpal tunnel
2) Transthyretin → transthyretin builds up in the heart
Dx: echocardiogram ± cardiac MRI → end-myocardial biopsy to confirm
3) AA → chronic osteomyelitis is a chronic infection, so the body makes AA
EM: beta pleaded sheds
Mechanism behind renal failure: nephrotic syndrome
MCCOD: renal failure
A 25 yo Japanese M immigrant comes to the physician with a 6 mo h/o abdominal pain. He has also had chronic diarrhea over this time period. PE is notable for skin hyperpigmentation and nail atrophy. Further diagnostic testing reveals multiple flesh like growths in his stomach and large intestine. Pathological analysis of one of these lesions reveals non-malignant cells. Dx?
Stool studies:
Heritable:
How can this be differentiated from FAP?
Cronkhite-Canada syndrome
Stool studies: protein
Heritable: no
Differentiated from FAP: they both have polyps but in Cronkhite-Canada sd. there are in the stomach and in the large intestine, in FAP they are in both the small and large intestine
FAP:
Mode of inheritance:
Screening guidelines:
Eye findings:
Syndrome associated if:
Osteomas, fibromas:
Gliomas, medulloblastomas:
Further gene mutations:
What if both parents never had these lesions?
MOI: AD
Screening guidelines: every 1/2 years a screening colonoscopy since 10 y.o.
Eye findings: pigmented lesions on retina
Osteomas, fibromas: Gadner sd
Gliomas, medulloblastomas: Turcot sd
Further gene mutations: APC → K-ras → TP53
There is a FAP related syndrome that is AR called MUTYH associated polyposis
Hyperpigmented macules on the lips w/multiple colonic polyps. Dx?
Mode of inheritance:
Unusual NBME pediatric manifestation:
Peutz yeger syndrome
MOI: AD
Manifestation: intussusception
Social Science/Healthcare System scenarios;
1) Most common emergency requiring BLS:
2) Most likely healthcare outcome associated with receiving CPR:
3) Most important locational predictor of positive outcomes with CPR:
4) Organ donation w/DNR orders:
5) DNR orders with impending surgery:
6) Is physician assisted suicide legal in the US:
8) Hospice: greatest barrier to care:
9) 2 cardinal NBME signs that a patient should be placed in hospice:
1) Cerebral hypoxia
2) Death
3) In hospital CPR
4) If you have a DNR you are not considered as organ donor
5) If you are getting sx you need to suspend the DNR during sx
6) No
8) Fear that you are not doing any diagnosis or treatment and that you will not prolong life
9) Totally dependent on other people for the daily living and feeding difficulty
A 49 yo M with a h/o Afib on metoprolol and apixaban is scheduled to undergo a partial colectomy for Crohn’s disease. To reduce the risk of bleeding associated with this procedure, what is the NBSIM?
Stop the apixaban 3 days before the sx
What do you do in a situation where a patient’s spouse refuses to honor a DNR order associated with the patient’s living will?
Overide the wife
For a patient with urinary incontinence, what should be done in a healthcare setting to decrease the risk of Catheter Associated Urinary Tract Infections (CAUTIs)?
Intermittent catheterization
Use aseptic theinhcque
What is the microbial mechanism behind indwelling catheters being a source of UTIs?
Biofilm
A 19 yo freshman college athlete comes to the medical geneticist for a follow up exam after collapsing during a basketball game. He is accompanied by his girlfriend and his coach. He has been highly recruited for the last 4 years and expects to be a top 10 NBA draft pick. A transesophageal echocardiogram obtained 2 hrs after his collapse reveals asymmetric septal hypertrophy associated with the left ventricle. Further genetic testing confirms the diagnosis. The physician plans to discuss these test results and implications for his long term future at this visit. Arrange the following physician responses in order of what should be done first to what should be done last?
S1-What is your current understanding of all that is going on?
S2-Before I get to the test results, I would like to summarize our journey to this point.
S3-Unfortunately, your test results are worse than what we initially hoped for.
S4-Even though we cannot cure your HCM, we can provide medications to reduce your symptoms and allow you to enjoy your life in a meaningful way.
S5-Before we review your test results, would you prefer that we discuss things privately or would you rather have your girlfriend/coach here?
S6-Would it be ok if we discuss the results of the tests we conducted?
S7-Can you tell me more about what your current concerns are?
Which murmur will this patient have
SPI-S-KES
Set the stage: 5
Before we review your test results, would you prefer that we discuss things privately or would you rather have your girlfriend/coach here?
Perception, what do you understand: 1
What is your current understanding of all that is going on?
Invitation: are you ready to discuss: 6
Would it be ok if we discuss the results of the tests we conducted?
Summarize: 2
Before I get to the test results, I would like to summarize our journey to this point
Knowledge, bad news are coming: 3
Unfortunately, your test results are worse than what we initially hoped for
Empathy: 7
Can you tell me more about what your current concerns are?
Strategy and summary: 4
Even though we cannot cure your HCM, we can provide medications to reduce your symptoms and allow you to enjoy your life in a meaningful way
Murmur: systolic crescendo-decrescendo murmur best heard at the LEFT upper sternal border (vs AS that is on the right)
Nosocomial infections and the NBMEs:
Most common mode of transmission:
Most important measure associated with decreasing the risk of nosocomial infections:
3 HY NBME organisms associated with airborne transmission:
Reducing risk of rotavirus/C. Diff infection in hospitals:
Most important measure for decreasing the transmission of blood borne pathogens:
MC kind of nosocomial infection (+ #2):
MC nosocomial infection COD:
MC bug cause of hospital-acquired pneumonia:
Contraindications to ETOH based handwashing:
Most common mode of transmission: direct contact, touch
Most important measure associated with decreasing the risk of nosocomial infections: hand-washing/ alcohol based solutions
3 HY NBME organisms associated with airborne transmission: TB, legionella, varicella
Reducing risk of rotavirus/C. Diff infection in hospitals: hand-washing
Most important measure for decreasing the transmission of blood-borne pathogens: gloves
MC kind of nosocomial infection (+ #2):
1) Catheter associated UTI
2) Healt care associated pneumonia
MC nosocomial infection COD: gram - rod infection
MC bug cause of hospital-acquired pneumonia: staph aureus
Contraindications to ETOH based handwashing: C. difficile, any organism that makes spores in general
A medical student is tasked with caring for a 25 yo M who presented with nuchal rigidity, headache, and high fevers. Gram stain of an LP specimen revealed gram- diplococci. What kind of precaution should be taken in caring for this patient?
Dropplet precautions
Other organisms that also requiere dropplet precautions:
Peruses
influenza
Neisseria
COVID 19 precautions:
It is airborne so:
Negative pressure room
N95 mask or respirator
C-Difficile,
Precautions:
Management:
Complication:
Precautions: had washing
Management:
1st episode: oral fidaxomicin/oral vancomycin
2nd episode: change drug oral vancomycin/oral fidaxomicin
Resistant: oral vancomycin + rifaximin
Fulminant colitis: IV metronidazole + oral vancomycin
Complication: toxic megacolon
3 NBME interventions for reducing the risk of ventilator associated pneumonia?
Reducing the risk of pneumothorax with central line insertions?
Supraglotic secretion drainage
Lift the head 30 deg on the bed
Chlorexidine mouth wash
Avoid subclavian central IV
Guided ultrasound
For NBME purposes, how should a pressure ulcer be cultured for infection?
For NBME purposes, what kinds of cultures are obtained when a CLABSI is suspected?
How is a CLABSI treated?
Deep tissue specimen
2 samples for culture: 1 form the catheter central line and 1 form somewhere else in the body. * If in catheter has a lot more bugs it means the infection is from the catheter
Remove catheter and IV antibiotic
29 yo M with a h/o Hodgkin’s lymphoma reports severe pain in his R arm. His sxs began 2 hrs ago. Examination is notable for swelling in the involved extremity with palpable tenderness. His brachial pulse is palpable. He has a R jugular central venous catheter in place. Dx? Pathophysiology?
Catheter associated thrombosis
When you put a catheter you are puncturing a blood vessel and expose sub-endothelial collagen so you activate the coagulation cascade which increases the risk of thrombosis
Cancer patients and pain management:
Ladder:
Add-on therapy with opioids:
You should give them all the opioids they need
Ladder: try to start with non-opioid pain control and if it does not work you switch to an opioid
Add-on: stool softener
NBME contraindications to getting a transplant?
Incurable malignancy
Long cardiac arrest
Creutz jakob disease
- HIV is NOT a contraindication
Immediate diagnostic test in a neonate presenting with bilious emesis:
Upper GI series
Most important predictor of mortality in a newborn with congenital diaphragmatic hernia?
The degree of pulmonary hypoplasia
Most dangerous complication of pericardiocentesis?
Cardiac puncture
Mechanism behind the hypotension in a patient with a tension pneumothorax?
Obstructive shock that ↓ CO. Air compresses the SVC and the IVC so VR ↓↓↓
3 populations that are not screened for AAA:
Women
Less 65
Patient that never smoked
Unique differentiating feature on NBMEs when comparing cluster headaches to migraine headaches
Cluster headache will present with rhinorrhea, eye symptoms like ptosis, and being in a dark room will not improve the headache
Microangiopathic hemolytic anemia, skin ecchymosis, and renal failure in a 45 yo Male. Dx?
Tx strategies:
TTP
Tx strategies: plasmapheresis
Mechanism behind infertility in a patient with decreased day 25 progesterone?
Day 25 is in the luteal phase, ↓ progesterone in the luteal phase indicates anovulation; classic in PCOS
Complete hair loss in discrete circular patches on the hair in a 35 yo M with a h/o Addison’s. Dx?
Tx strategies:
Alopecia areata
Tx strategies: steroid injection in the lesions
Breast cancer screening guidelines with BRCA1 and 2 mutations:
Mammogram and MRI every year from 30 y.o. on
*Do the Mammogram and MRI spaced by 6 mo
4 major NBME criteria for pursuing high-intensity statin therapy, also which drugs are high-intensity statins?
Atherosclerotic cardiovascular disease: MI, stroke, TIA
LDL over 190
DM aged between 45-70 y.o. or with LDL more than 70
More than 7.5 points in the ASCVD
High-intensity statins: Atorvastatin or Rosuvastatin
Next best step in the management of a patient older than 50 who presents with a new, chronic headache:
MRI
2 mechanisms behind HF in chronic, severe anemia:
1) High output heart failure because the oxygen carrying capacity of the blood ↓ and HR needs to ↑
2) Blood gets less viscous which ↓ TPR
Fe deficiency anemia in a 6 yo M with intermittent RLQ pain. Dx?
Meckel’s diverticulum
A 23 yo M presents to the physician with a 2 week h/o of mild pain in his R thigh. PE is notable for a hard, palpable mass in the involved extremity. The patient was mistakenly hit in the R thigh with a baseball bat 6 weeks ago during a game. Dx?
Myositis ossificans
Increased INR in a newly diagnosed HIV patient with a h/o Afib that is currently well controlled with Metoprolol. His CD4 count measured 3 weeks ago was 45. He was started on HAART therapy and appropriate prophylactic measures. Dx?
Electrolyte anomaly secondary to his medication:
INR ↑ because of the use of Warfarin + Ritonavir
He is also in TMP-SMX that acts like a K sparing diuretic causing hyperkalemia
Increased Cr and red urine in a 47 yo M with a h/o of DM who was recently started on appropriate therapy after he was found to have an LDL-C of 175 mg/dL. Dx?
Classic “home product” that increases toxicity:
This is statin-induced rhadomyolisis due to a P450 inhibitor like grapefruit juice
Treatment failures in individuals ingesting antacids:
Cations bind:
Thyroid h
Fluoroquinolones
Tetracyclines
Pharmacologic agents on NBMEs with the following side effects;
Crystalline nephropathy (AIT):
Pancreatitis (2):
Crystalline nephropathy (AIT):
Acyclovir
Indinavir
Topiramate
Pancreatitis (2):
Stavudine, didanosine
Gliptins (DPP-4 inhibitors) and Tides (GLP 1 agonists)
Hyperkalemia on a normal patient. Why? What should you do?
Pseudohyperkalemia: RBC lysis or high platelets or WBCs on the sample, re-check K and put citrate (plasma K) on the tube
True hyperkalemia causes: acidosis, DM (1 because there is no insulin 2 because there is no renin), beta-blockers, digoxin, rhabdo, hemolysis, burns, tumor lysis, RTA type 4, Addisons, K sparing diuretics, NSAIDs (you need PGs to get rid of K)
Digoxin toxicity causes hyperkalemia but hypokalemia worsens digoxin toxicity
D-dimer statistical characteristics:
High seNsitivity
Low sPecificity
High NPV
Low PPV
The NBME and Diarrhea; match the following scenarios to the most likely offending organism:
Watery Diarrhea after returning from a trip
Watery Diarrhea in a hiker/camper
Watery Diarrhea on a cruise ship
Watery Diarrhea in an infant
Watery Diarrhea in an AIDS patient
Bloody Diarrhea after consuming beef
Bloody diarrhea after consuming poultry/eggs
Bloody diarrhea in the setting of a Lactose Fermenter
Most common cause of bloody diarrhea in the US
Diarrhea and Ascending Paralysis
Diarrhea after treatment for an anaerobic infection
Diarrhea after Pork Consumption
Protozoal cause of bloody diarrhea
Bloody Diarrhea requiring a small inoculum
Diarrhea after consuming Oysters/Seafood
Diarrhea after consuming Oysters + Elevated Liver Function Tests
Diarrhea after swimming in freshwater
Diarrhea with massive amounts of fluid/electrolyte loss
Diarrhea after consuming reheated rice
Diarrhea 2 hours after consuming potato salad
Diarrhea with a very low inoculum
Bloody diarrhea + seizures in kid
Most accurate test for diarrheas
Watery Diarrhea after returning from a trip: ETEC
Watery Diarrhea in a hiker/camper: Giardia
Watery Diarrhea on a cruise ship: Norovirus
Watery Diarrhea in an infant: Rotavirus
Watery Diarrhea in an AIDS patient: Cryptosporidium Parvum (acid fast) Tto: Nitazoxanide
Bloody Diarrhea after consuming beef: EHEC/ Shigella. Tto: levofloxacin/TMP-SMX/amoxicillin
Bloody diarrhea after consuming poultry/eggs: Salmonella
Bloody diarrhea in the setting of a Lactose Fermenter: EHEC
Most common cause of bloody diarrhea in the US: Campylobacter Jejuni (mucoid + bloody + pseudoappendicitis)
Diarrhea and Ascending Paralysis: Guillain Barre due to Campylobacter
Diarrhea after treatment for an anaerobic infection: C. Difficile
Diarrhea that feels like Appendicitis (after PORK Consumption): Yersinia enterocolitica
Protozoal cause of bloody diarrhea: Entamoeba histolytica
Bloody Diarrhea requiring a small inoculum: Sigella! (seizures)
Diarrhea after consuming Oysters/Seafood: Vibrio parahemolyticus
Diarrhea after consuming Oysters/Seafood + Elevated Liver Function Tests: Vibrio vulnificus (bad prognosis if the patient has preexisting liver disease)
Diarrhea after swimming in freshwater: Aeromonas
Diarrhea with massive amounts of fluid/electrolyte loss: V. Cholerae (tetracyclines cover vibrio + oral rehydration therapy that upregulates the Na/glucose transporter)
Diarrhea after consuming reheated rice: Bacillus Cereus, toxin: cerulite
Diarrhea 2 hours after consuming potato salad: Staph Aureus
Diarrhea with a very low inoculum: Shigella
Bloody diarrhea + seizures in kid: Shigella
Stoll culture
Acute cervicitis presentation and treatment:
Postcoital bleeding, mucopurulent discharge and friable cervix, cervical motion tenderness if becomes PID*
* not in pregnant because the infection does not ascend due to the sealed graves uterus
Tto: ceftriaxone for gonorrhea, doxycycline for chlamydia
* In pregnant ceftriaxone + azithromycin
Rupture of the tympanic membrane:
The Eustachian tube cannot open normally (cold…) so there is a difference in pressures between the atmosphere and the middle ear. If there are big barometric pressure changes (as in a plane…) they can stretch the tympanic membrane and even break it causing minor bleeding.
The tympanic membrane fractures heal spontaneously within a few weeks
Which anticonvulsants can you give in pregnancy?
Gabapentin
Lamotrigine
Levetiracetam
GA LA para LEVEs problemas
*If an epileptic woman that is well controlled on a medication gets pregnant, keep her on the same drug unless it is valproate
Most common post-influenza infection:
1) Strep pneumo: lobar consolidation
2) Staph aureus: cavitary lesions
Meningitis treatment depending on age range:
Children, elderly and immunocompromised: vancomycin +3rd cefalosporin+ampicillin
Adult/children older than 1yo: vancomycin + 3rd cefalosporin (if it is pneumococcus you can take off vanco when you confirm sensitivity to penicillin)
Transfusion RBC:platelets:plasma proportion:
Massive transfusion protocol: 1:1:1 ratio, whole blood transfusions are given in massive hemorrhage and shock, start the protocol if you predict that your pt is going to need 4+ units of RBCs over 1h
RBCs alone should be give if Hb is less than 6, also if pt has low Hb and has an active bleed, or if Hb is less than 9 on pt with acute coronary sd
Nonhealing ulcer for years in the setting of chronic venous insufficiency should raise suspicion for? Management?
Marjolin ulcer, a type of cutaneous squamous cell carcinoma
Management: biopsy
Features of a manic episode:
'DIG FAST' D = Distractibility I = Irresponsibility G = Grandiosity F = Flight of ideas A = Activity increase S = Sleep deficit T = Talkativeness
You need > 3 symptoms (>4 if mood is only irritable)
There is a genetic predisposition for bipolar disorder
Which bone marrow biopsy findings are characteristic of Waldenstrom macroglobulinemia?
Dutcher bodies
Hyperintense line in the meniscus on MRI is diagnostic of:
Meniscal tear
Post-tranplant prophylaxis:
CMV: valganciclovir
PCP: TMP-SMX
Management of hernias:
Femoral hernia: elective surgery, they have a higher risk or incarceration
Inguinal hernia: if asymptomatic just watch, if symptomatic do elective surgery*
- elective sx must be done at least 6 mo after an MI!
Management for high BP:
1) Weight loss
2) DASH diet (fruit, vegetables, low saturated fat)
3) Exercise
3) Decrease Na intake
4) Alcohol, decrease
W-DE-DA
Singed nasal hair and soot in the mouth indicate:
Airway involvement in burn patient
Which neuromuscular blocker needs to be avoided in organophosphate poisoning?
Succinylcholine
Cytochrome P450 inducers:
Barb’s funny smoker mom refuses greasy carb shakes: Phenobarbital (barbiturates), phenytoin, hydrocarbons, modafinil, rifampin, griseofulvin, carbamazepine, St. John’s wort
Think seizures Alcohol (chronic) Oral contraceptives (estrogens) Nevirapine Smoking (hydrocarbons)
You would need to increase the dose of a drug for it to work, contraceptives and warfarin might not work. Prodrugs will become more effective
Cytochrome P450 inhibitors:
Gee queen GRACE IS inhibit when eats PI: Gemfibrozil, QUINolones, grapefruit juice, ritoNAVIR (protease inhibitors), AZOLes (and metronidAZOle), cimetidine and omeprazole, eryTHROmycin (macrolides except azithromycin ACE), isoniazid, sulfanilamides, PPis
COKE (cimetidine, omeprazole, ketoconazole, eryTHROmycin) + Grapefruit juice + PI (PPis, isoniazid)
Alcohol (acute) Amiodarone!!! Chloramphenicol Diltiazem SSRIs (fluvoxamine+!!, fluoxetine-) Cyclosporine Metronidazole
Drugs (statins) will become toxic but prodrugs will become less effective
P450 inhibitors that affect methadone: AZOLes, clarithromycin, ciprofloxacin and fluvoxamine
Which patients with PCP pneumonia should get steroids and IV treatment? Which patients with HIV and toxoplasmosis should get steroids?
PCP: O2 partial pressure less than 70%!!! SaO2 less 92% A-a greater than 35 Dx: lavage with ↑ LDH
Toxo:
↑ ICP
What are coffin, envelope, rhombi and hexagon-shaped stones? What is the first step in Dx? How to prevent the most common stones? How to prevent uric acid stones?
Coffin: struvite
Envelope: ca oxalate (tto: give B6 to metabolize then oxalate)
Radiolucent rhombi: uric acid
Hexagon: cystein (tto: with acetazolamide)
First step in Dx: Ultrasound!!! or NON-contrast spiral CT scan of the abdomen and pelvis!
How to prevent Ca stones? Increase fluid intake, decrease Na intake, thiazides, potassium citrate!, decrease protein intake
How to prevent uric acid (rhomboid) stones? Potassium citrate! decrease red meat, fish, alcohol (no statins!)
What happen if someone gets ↑Cr after a CFT scan?
And if someone gets skin fibrosis after a brain MRI?
Contrast-induced nephropathy; can be prevented by N-acetylcysteine and fluids
Nephrogenic systemic fibrosis due to gadolinium
What valvular problems do you get on carcinoid syndrome?
TIPS:
Tricuspid insufficiency/regurgitation
Pulmonic stenosis
Which thyroid tumor can present with diarrhea?
Medullary because it makes calcitonin
When should you transfuse a patient?
When Hb is less than 7
How can you pharmacologically treat an AV block? What should you avoid?
Tto: atropine
Avoid: βb, Ca ch blokers and DIGOXIN
Treatment for the most common arrhythmias:
Vfib:
VTach:
SVT:
Afib (2 easy piles)/Aflutter:
Multifocal atrial tachycardia:
Heart blocks:
TdP:
WPW:
TCA toxicity:
Vfib: wide and unequal QRS: defibrillation=UNsynchronized cardioversion + Epi + Amiodarone
* Most common cause of death in the period after an MI
VTach: wide complex, irregular tachyarrhythmia
No pulse: defibrillation=UNsynchronized cardioversion
Unstable with pulse: synchronized cardioversion
Stable with pulse: amiodarone!!
SVT: narrow complex, regular tachyarrhythmia
First: Vagal maneuver (carotid massage, blow into a straw, submerge head into cold water)
Second: Adenosine 6 → 12 → 12
If it works to maintain the rate low: βb, verapamil, diltiazem
Unstable: synchronized cardioversion
Afib/Aflutter:
1) Less 2 days or hemodynamically instable: synchronized cardioversion
2) Everyone else: rate control (Beta blocker, verapamil, diltiazem) rhythm control (amiodarone) + anticoagulation
Multifocal atrial tachycardia: 3 or more p wave shape in COPD: verapamil/diltiazem. Never Bb
Heart blocks First degree: long PR Mobitz 1: PR getting longer then drop beat No too Mobitz 2: PR long by same amount 3rd degree: total dissociation Pacemaker
TdP: Mg
WPW: short PR and wide QRS, procainamide
TCA toxicity: wide QRS, Na bicarb
When should you do synchronized, unsynchronized cardioversion or just vasopressors?
Epinephrin/vasopressin every 5 min → asystole or pulseless electrical activity
Unsinchornized = defibrillation → just for Vfib and pulseless!!! Vtach!!! unstable TdP
Synchronized → Vtach with pulse and unstable, unstable supraventricular tachycardias
IV amiodarone → Vtach with pulse and stable
Vagal manœuvres or adenosine → stable supraventricular tachycardias
Most common ECG finding in PE:
Sinus tachycardia
S1Q3T3 is not as common; suggests RV strain
What do you have to give to someone that is on steroids 3 mo or more?
Bisphosphonates, because steroids cause bone loss
When should you start screening for osteoporosis? What is the T score cutoff for osteoporosis?
Screening:
Normal woman: DXA scan at 65
Younger woman with multiple RF: FRAX fracture risk assessment tool and if + you can do DXA scan
T score: less than -2.5!! big negative numbers mean osteoporosis!!!
Helicobacter pylori eradication treatment:
Triple therapy:
Amoxicillin (Metronidazole if allergy)
Clarithromycin
PPI
Quadruple therapy: Metronidazole Tetracycline Bismuth subsalicylate PPI
DD of Uncomplicated parapneumonic effusion, Complicated parapneumonic effusion and Empyema:
vs
Transudative vs exudative effusion:
Uncomplicated parapneumonic effusion*: MORE than ph 7.2, MORE than glucose 60, LESS than LDH 2/3 upper limit of normal, NO bugs → antibiotics
Complicated parapneumonic effusion*: LESS than ph 7.2, LESS than glucose 60, MORE than LDH 2/3 upper limit of normal, NO bugs → Chet tube** + antibiotics
- Effusion during a pneumonia
Empyema: LESS than ph 7.2, LESS than glucose 60, MORE than LDH 2/3 upper limit of normal, BUGS → Chet tube + antibiotics
** If chest tube does not work thoracic surgery/ tpa
These effusions can be transudative or exudative effusion:
Transudative effusion; if you meet the 3 criteria: LDH less than 2/3 of normal, less than 0.5 ration of fluid/serum protein, less than 0.6 ration of fluid/serum LDH
Exudative effusion: criteria not met
Very low glucose on effusion: RA, TB, ca or empyema
On which (2) pathologies do you see arteriovenous nicking?
Hypertensive retinopathy
Renal A. stenosis (+ resistant HT)
*Arterioles crossing a venules, which results in the compression of the venules with bulging on either side of the crossin
Irritable bowel syndrome buzzword, how are the labs?
Abdominal pain relief with defecation
No lab anomalies
IBS:
Constipation: induce diarrhea, senna
Diarrhea: induce constipation, loperamide
What is the most common arrhythmia in mitral stenosis? and in Graves (any hyperthyroidism)?
Afib
Tto of bullous pemphigoid vs pemphigus vulgaris:
Bullous pemphigoid: Oral steroids
Pemphigus vulgaris: topical steroid
What does ‘thick endometrial stripe’ means?
Endometrial thickening, can be due to:
Proliferative phase of the cycle
Pregnancy, ectopic pregnancy
Endometrial hyperplasia or ca.
Bilateral high frequency sensorineural hearing loss in young. Dx?
Noise-induced hearing loss due to cochlear hair cell damage (irreversible death of hair cells)
RF: exposure to loud noises, military, manufacturing, mining
Which antidepressant is less likely to cause weight gain?
Bupropion
It is a mild stimulant associated with insomnia so give on depressed + sleepy + low energy and concentration
Does not cause impotence
Not fist line on pediatric depression
Helps you stop smoking, patients should stop smoking completely one week after stating bupropion
What is the treatment of radial head subluxation?
Forced hyper-pronation of the forearm
What are the most likely causes of adrenal insufficiency on an HIV patient with low CD4?
CMV MAC TB Cryptococcus Metastasic Kaposi sarcoma
What is an important ECG finding in Wenckebach?
group beating
Which drugs can precipitate hyperosmolar hyperglycemic state?
Corticoids
High-dose thiazides
Sympathomimetics (dobutamine, terbutaline)
2nd generation antiphychotics
When do you teat a fracture with open reduction and internal fixation?
Open reduction and internal fixation is done in:
Displaced fx (minimally displaced femoral neck fx)
Neuromuscular injury (humerus mineshaft fx with radial n. injury) → if you see soft signs of arterial injury do CT angio 1st!
Open fx
Distal clavicle fx
Closed reduction and internal fixation/spica cast: other fx
How do you treat deep vein thrombosis in pregnancy? How do you treat HIT in pregnancy?
DVT: Low molecular weight heparin (dalteparin, subcutaneous) because they do not cross the placenta
HIT: fondaparinux
Management of caustic ingestion?
Remove clothes
Intubate if he cannot breath
Upper Endoscopy on the first 24h
Do not let him/her vomit
Signs of glucagonoma:
D’s: diarrhea, dermatosis, diabetes, deep vein thrombosis, and depression
What is the treatment for QT-induced cachexia?
What is the treatment for QT-induced vomiting?
What is the treatment for HIV-induced cachexia?
QT-induced cachexia: progesterone analogs (megestrol acetate) and corticoids
QT-induced vomiting: 1) Setrons
HIV-induced cachexia: cannabinoids
What CN deficits can you have after parotidectomy?
CN7 causing ipsilateral palsy of upper and lower face
Will not cause hyperacusis because the stapedius nerve leaves the CN7 as soon as it exits the skull!
Marginal bone (punched out) erosions and opaque periarticular soft tissue indicate:
Periarticular erosions indicate:
Marginal bone (punched out) erosions and opaque periarticular soft tissue*: Gouty arthritis * Also overhanging edges
Periarticular erosions: RA
Management of peripheral artery disease:
1) exercise
2) cilostazol
3) bypass sx
WBC in joint fluid differential:
Less than 20: normal
200-2k: osteoarthritis
2k-10k: inflammatory (RA, crystals)
>50k: septic arthritis, maybe gout
What is the tto for most GI infections?
Amoxicillin + metronidazole + gentamicin
Ciprofloxacin + metronidazol
What is the therapeutic range for lithium? Which drugs increase lithium levels?
0.6-1.2 mEq/L
NAT: Thiazides, NSAIDs and ACE inhibitors and ARBs (lithium blood levels will be high) because they decrease GFR. Also tetracyclines and metronidazole.
If a patient on Li has HT give him a Ca ch blocker (-ipines) except nifedipine (nifedipine can affect Li clearance especially in the context of renal insufficiency, if Cr is ↑ better use another medication)
Serum sickness:
Dress sd:
Serum sickness: Fever, urticaria, artralgias, proteinuria 1-2w!! type 3hs
Dress sd: Eosinophilia, rash, fever, facial, edema, high ALT 2-8w!!!
Acne management:
1) topical retinoids: tazarotene: uncomplicated
2) topical benzoyl peroxide: uncomplicated
3) oral antibiotic (minocycline)/topical clindamycin
4) oral isotretinoin: severe (careful because is teratogenic and causes hepatotoxicity)
OCPs in PCOS
Timing of psychiatric diseases:
Acute stress: up to 1 mo. Tto: tx-focused CBT
PTST: more than 1 mo
* life threatening to you or others
STRESS-PTST
Adjustment: less than 6mo and stressor happened within 3mo
Generalized anxiety: more than 6mo
* psychosocial non life threatening stressor
ADJUSTMENT-ANXIETY
Tto: psychotherapy (CBT) +/- adjunctive pharmacotherapy for anxiety, insomnia, etc.
Biref psychotic: up to 1 mo
Schizophreniform: 1-6mo
Schizophrenia: more than 6mo
Where do you have urine Na less than 20 but concentrated urine? Why?
Prerenal azotemia
RAAs activation reabsorbs Na even if because low BP the is little RPF so little urine output and concentrated urine
Subchondral sclerosis and cysts indicate:
What is the first line tto?
Osteoarthritis
1) NSAIDs
What is the treatment for seborrheic dermatitis?
Topical anti-fungal
Which variant of FSGN is most frequent in HIV?
Collapsing variant, most aggressive variant
CURB-65 criteria, what for? what are the criteria? what is their indication?
Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment
Confusion BUN > 19 mg/dL (> 7 mmol/L) Respiratory Rate ≥ 30 Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg Age above 65
0-1: outpatient
2: inpatient
3 or more: ICU
Treatment of Methicillin-resistant Staphylococcus aureus and of pseudomonas?
MRSA: Vancomycin Clindamycin Linezolid Cefazolin Tetracyclines (doxycyclin)
Pseudomonas:
Think about a MAN dressed as BATMAN on a CAR smoking a PIPE that is driving to his PIME where his coworker is asking what? DIME? but he ends up hitting a TREE that has a FLOWER on it that needs OXIGEN!!! to live
carbaPENEms (imipemen, meropenem)
PIPEracillin, CARbenicillin, tiCARcillin +BAcTam
azTREEonan (monobactam)
cefePIME (4th generation), ceftaziDIME (3rd generation)
floxacins (fluorquinolones: ciprofloxacin, levofloxacin)
mycins!! (aminoglycosides)
Which drugs can cause myocarditis?
Trastuzumab, clozapine, doxo/donorubicine
Where are the lymph nodes in mononucleosis and strep pharyngitis?
MONO:
Posterior cervical
Involves the spleen
Rash with amoxicillin
STREP: Anterior cervical Acute CENTOR criteria (in adults): C: no cough, E: exudates, N: nodes (anterior cervical), T: temperature=fever 0-1: nothing 2-3: best initial test: rapid step test, if positive: amoxicillin*, if negative: culture 4: amoxicillin* * macrolide if allergic
Most common cause of death on treated lupus patients? and untreated?
Treated: infections
Untreated: kidney failure
What should you avoid on Bernard-Soulier?
Transfusion of platelets because they do not have GP1b on their blood so they can make antibodies against the GP1b on the donor platelets and have anaphylaxis!
Same can happen in hemophilia, they can make foe example antibodies again factor 8, this can cause anaphylaxis or make them need larger and larger amounts of factor 8 to correct their PTT over time
What can cause both transudative and exudative effusions?
Pulmonary emboli
Why do you get a wide S2 with mitral regurgitation? How do preload and afterload affect the murmur?
Because the aortic closes fast
↑ preload ↑ intensity
↑ afterload ↑intensity
What are the different stages of decubitus ulcers and their treatment?
1, non-blanching redness: reposition every 2h
2, superficial ulcer: occlusive dressing
3, involvement of dermis and subcutaneous fat: debridement
4, muscle, bone tendons involved: debridement
Give nutritional support
Dx criteria and checkups for DM1:
Hemoglobin A1c of 6.5% or more
Random glucose 200 + symptoms
Fasting blood glucose of 126 or more on 2 occasions
Every 3 mo: Hb A1c
Every year: eye exam w. fundoscopy, foot exam, Albumin/Cr
Management of GI bleed:
1) ABCs
2) IV fluids
3) Nasogastric lavage/intubation: if blood upper GI bleed → upper endoscopy and treat; if bile no upper GI so:
4) Colonoscopy, if -:
5) CT angiogram/tagged RBC exam
RBCs in the CSF indicate:
Herpes encephalitis
How do you treat septic and anaphylactic shock?
septic: NE + vanco + piperacillin-tazobactam/ceftriaxone for MRSA and pseudomonas
anaphylactic: epi
Vaccines given in adults:
Shingles: Older than 60
contraindicated in immunosuppressed, kids and pregnancy
Pneumococcal: Older than 65 or pt younger but with heart, kidney liver disease or smoker
Meningococcal: 12y 16y booster older than 18 if complement deficiency, asplenia, Meca dorm or military
Influenza virus: 1/y
HPV: in 11-12 yo w 2 doses separated by 6mo, but if the pt receives the vaccine after 15yo you need to give 3 doses
Most common cause of end-stage renal disease? and the second?
BP reduction threshold in a hypertensive crisis?
1) DM 2) HT
25% reduction in the 1st hour (with clevidipine, labetalol, nitroprusside…)
How do you treat osteopetrosis?
INF-gamma, inactivates macrophages
How do you treat COPD exacerbation?
How do you dx? increased dyspnea, cough and sputum change
Tto: SOS+Abs Steroids O2 SABA (bronchodilators) \+ Antibiotics (macrolides, fluoroquinolones or amoxi-clavulanate for 3-7days)
If pt is still using accessory muscles and remains dyspneic start noninvasive positive pressure ventilation
If confused, hemodynamically unstable or very acidotic intubate
Management and indications for synchronized cardioversion in A. fib/flutter:
Management:
Unstable: synchronized cardioversion
Stable: rate control by 1) IV metoprolol/ IV diltiazem/ 2) digoxin if decompensated HF (digoxin takes a long time to work)/ 3) IV amiodarone** or dofetilide 4) catheter ablation
Rhythm control:
Elective by cardioversion/amiodarone**: we do it on young patients that are very symptomatic
Less than 48 h A.fib
A.fib for longer but anti-coagulated for 3w and TEE does nor show emboli
A. fib refractory to medical tto
Emergent by cardioversion:
A. fib and unstable
What is Blumer shelf sign:
Gastric ca. that metastasizes to the anus
What is the first line too for infantile spasms?
1) ACTH, because sometimes they are due to CRH overproduction and ACTH w. suppress CRH
2) corticoids
3) vigabatrin
Which drugs do commonly cause type 1 HS reactions?
Penicillins, Quinolones, Vancomycin, Aspirin, NSAIDs!!! OPIATES, contrast, platinum-containing QT, muscle relaxants
Tto: antiHistaminics/ steroids/ Epi
Management of systolic vs diastolic heart failure:
Systolic: digoxin, dobutamine (dilated cardiomyopathy can be treated with βb, ACEi and diuretics)
Diastolic: βb, Ca ch blockers (if βb contraindicated as in COPD)
How do you know if a non-anion gap metabolic acidosis is due to renal losses or not?
1) Measuring the urine anion gap: Na+K-Cl
Positive, also if Na in urine is equal or more than 20 → renal losses as in RTA
Negative, also if Na in urine is LESS than 20 → diarrhea
Little Na in urine means you are loosing Na somewhere else
2) Low K will discard type 4 RTA, all type 1,2 RTA and diarrhea will have low K!
3) Normal urine pH (around 5) will discard type 1 RTA
What is the most common malignant tumor of the lacrimal gland? and benign?
Malignant: Adenoid cystic ca: irregular margins and bony erosions + painful
Benign: pleomorphic adenoma: well-defined margins + No pain
When should you give O2 supplementation? When should you give PPV? When should you intubate? What is the best indicator for extubation?
O2 supplementation indications:
Burns w. carboxyhemoglobin more than 5-10%
O2 sat less than or = 88% (PaO2 less than or = 55)
O2 sat less than or = 89% (PaO2 less than or = 59) if cor pulmonale, RHF or low hematocrit
*O2 improves survival in chronic severe hypoxemia at rest in COPD but smoking cessation improves mortality and decreases disease progression in all COPD
Positive pressure ventilation: COPD exacerbation Cariogenic pulmonary edema Acute respiratory failure (hypoxemia after sx, immunosuppressed) Facilitate early extubation
Intubation indications:
Hypoxemia (PO2 less 60)
PaCO2 more than 45
Ph less than 7.1
ARDS
Upper airway obstruction (H. influenzae acute epiglotitis)
Glasgow less or = 8
Burnt w. stridor, hoarseness
Guillain-Barre with ↓ FVC of more than 20mL/kg/ severe dysautonomia/ wide pulse pressure
Maxilofacial tx
Combative or uncooperative
High aspiration risk
Cardiopulmonary failure, encephalopathy, big GI bleed
You do intubation even when there is evidence of unstable cervical spine injury (you can do manual stabilization of the cervical spine)
Extubation indications:
pH > 7.25 (not retaining CO2)
FiO2 40% or less and PEEP 5 mm Hg or less; PaO2 more than 60
Intact inspiratory effort and sufficient mental alertness
If all good:
Spontaneous breathing trial: best indicator for extubation is RR/TV less than 105 which means rapid shadow breathing index
Malaria prophylaxis:
Chloroquine if Central America, Argentina, Paraguay or the Caribbean
Mefloquine in chloroquine-resistant areas
Doxycycline in cardiac conduction abnormalities, neuropsychiatric disorders and seizure disorders
How do you treat bacterial vaginosis in pregnancy?
If asymptomatic do not treat
If symptomatic vaginal and oral clindamycin mor metronidazole
How do you confirm the dx of measles?
IgG and IgM titters
Candida treatment:
Thrush: topical nystatin/ clotrimazole troche \+ AIDS/pharyngeal involvement: azoles Esophagitis: azole Diaper rash: topical nystatin Vulvovaginal: topical azole Systemic: ampho B
Management of a penetrating abdominal wound:
Exploratory laparotomy
Lyme disease treatment:
Doxycycline (causes teeth discoloration, bone problems, photosensitivity so do not give it in kids)
Amoxicillin!!! first line in younger than 8, pregnant and nursing (cefuroxime can be given because is oral)
IV!!! Ceftriaxone/ cefotaxime/ Penicillin G: if severe or disseminated (if AV block, carditis, arthritis or neuroborreliosis)
Which treatment can you give in patients with DVT and chronic kidney disease?
Unfractionated heparin
Warfarin
Apixaban
None of the other!
How do you differentiate an ulnar injury on the guyon canal vs on the cubital tunnel?
At the wrist: at the Guyon canal, due to hook of Hamate fracture; frequent in cyclists. Affects the palmar medial sensation and the intrinsic muscles of that region (fingers 4th and 5th) but the dorsal surface of the hand is spared!
At the elbow: cubital tunnel!!! (paresthesias elicited by compressing the cubital tunnel) injured by hitting the funny bone, sleeping with the elbow very flexed or hemodialysis position. All the previous problems + the dorsal surface of the hand is also affected + decreased grip + medial deviation + forearm pain
What is the management of A.fib?
Stable:
HR more than 100 (rapid ventricular response) or A.fib that has not come back to sinus rhythm in 24h: rate control (β-blocker, verapamil, diltiazem)/rhythm control (amiodarone) + anticoagulation
Chronic A.fib with HR less than 100: only anticoagulation if meets the criteria
Unstable:
A.fib lasting less than 2 days: synchronized cardioversion
1st line for post-herpetic neuralgia:
Gabapentin
Zinc deficiency sings:
Anosmia
Alopecia
Hypogonadism
Dermatitis acroenteropathica
Clinical picture of hidradenitis suppurativa:
Recurrent accesses in the axila and perineal region, inflammation of apocrine cell glands
Frequent in diabetics
Tto: clindamycin for staph. aureus
DD between celulitis and erysipelas:
Celulitis: dermis+ subcutaneous fat. Caused by
Staph aureus and strep pyogenes. Blend into the skin. Tto clindamycin
Erysipelas: upper dermis+ superficial lymphatics. Caused by strep pyogenes. Acute and systemic involvement. Elevated
What are the worse px factors in aortic stenosis form the least bad to the worst?
ASH: Angina → Syncope → Heart failure
Heyde syndrome presentation:
AS+ GI bleed/angiodysplasia
You shear the VW when blood goes trough the aortic valve
Treatment of CHF exacerbation? and of MI or unstable angina?
CHF exacerbation: 1) O2 Furosemide (lasix)!! ACEi Morphine Nitrates!! Positioning: sit up
MI or unstable angina: BAPSONA Beta-blockers (verapamil if wheezing) Antiplatelet (aspirin+clopidogrel/tiaglecor/pasteugrel!!!) Percutaneous coronary intervention Statins O2 (if sat is less than 90 or in respiratory distress) Nitrates Anticoagulation (LMWH/bivalirudin)
After MI you go home with: BASAA: Beta-blockers, Antiplatelet (aspirin+clopidogrel!!!), Statins, ACEi, Aldo antagonists
- In inferior MI you give IV fluids!!!! Do not give Beta-blockers, Nitrates or Diuretics. If IV fluids don’t work give dopamine (better than dobutamine)
Antibiotic cocktail for GI infections:
Cipro + Metronidazole
or
MAG: Metronidazole + Amoxicilin + Gentamicin
Fluoroquinolones/macrolides are a good tto for diarrhea
What is the fist best next step in management of PE? What is the treatment?
Low risk: D-dimer
High risk: CT angiogram
Pregnant: V/Q scan
Stable: heparin
Unstable: tap
Unstable + recent sx/bleeding problem: embolectomy
Treatment of hypocalcemia, hyponatremia and hypokalemia:
↓ Ca: IV Ca gluconate in extreme cases (not if renal failure)/ vit D
↓ Na:
Initial tto: restrict fluids ± salt tablets/ normal saline! ± furosemide
If seizures, coma (=acute) OR Na of less than 120: hypertonic 3% saline (max 8mEq/L/day)/ demeclocycline/ vapstams
↓ K:
Low risk patient: 1) ECG 2) IV KCL until ~2.8 and ECG is normal (slow if IV) and them Oral until 3.5
High risk patient (digoxin, AF, dialysis): 1) ECG 2) IV KCL until ~3 and ECG is normal (slow if IV) and them Oral until 4.5
We do not give dextrose with K!!!
Large number of small, red, macular lesions on the back arranged on a Christmas tree distribution:
Pityriasis rosea
How do you protect the kidney when you do a high volume paracentesis?
Albumin
Does smoking increase the risk of mesothelioma?
No
Spontaneous peritonitis;
Most common cause: WBC limit: Management: Tto: Prophylaxis:
Peritonitis in peritoneal dialysis;
MCC:
Management:
Tto:
Spontaneous bacterial peritonitis;
MCC: E. coli!! klebsiella pneumoniae, step pneumoniae
WBC limit: WBC more than 250
Management: 1) paracentesis + gram stain of the abdominal fluid. >250 neutrophils is Dx
Tto: ceftriaxone/ ciprofloxacin
Prophylaxis: ciprofloxacin+ albumin
Peritonitis in peritoneal dialysis;
MCC: gram + cocci and gram - bacilli
Management: 1) gram stain of the abdominal fluid
Tto: intraperitoneal cefazolin/vancomycin + 3rd generation cephalosporin
How do you treat pseudohypoparathyroidism?
Supplement vit D and Ca
What is the only positive marker during window period?
Hep B core antibody (IgM)
You cannot find surface antigen or antibody!!
Tto: supportive therapy
DD between spinal pathology; strain, lumbar spinal stenosis, degenerative disk disease, cauda equina, conus medularis and spinal sock:
Strain: paraspinal tenderness. Tto: NSAIDs, physical therapy
Lumbar spinal stenosis: old man with leg pain that improves when he gets out of bed in the morning
Degenerative disk disease=sciatica: shooting pain, + straight leg test
Cauda equina:
LMN lesion (radiculopathy), normal Babinski
Lumbar lesion, both L4 and S1 lost
Tends to be more unilateral
Conus=clonus medularis:
UMN lesion (spinal cord lesion), affected Babinski
Sacral, just S1 lost
Tends to be bilateral ± impotence
Both have saddle anesthesia, low back pain and involve the sphincters causing incontinence
Spinal sock:
Acute loos of spinal cord reflexes that come back
Post-traumatic
Palpable purpura, ↓complement, ↑monoclonal IgM. Dx?
Association:
Tto of the association:
Mixed cryoglobulinemia
Association: Hep C
Tto: sofosbuvir, ledipasvir/ pegylated interferon* + ribavirin
- Screen for depression before you give interferon
Ca. that tend to cause lytic bone lesions? and blastic lesions?
Lytic: MM, Lung ca, Renal cell, Thyroid
Blastic (sclerotic): prostate
What is the cause of hypersensitivity pneumonitis in a patient that works in a barn?
Thermophilic actinomyces
Do you have to screen family members of MEN2 patients? and of MEN1 patients?
Screen for MEN2 but not for MEN1 (for MEN1 screening does not improve survival)
Which electrolyte abnormalities exacerbate digoxin toxicity? Which drugs decrease digoxin clearance?
Electrolyte abnormalities: ↓K ↓Mg!!!
Loops and thiazides increase digoxin toxicity because they cause ↓K ↓Mg! (digoxin blood levels will be normal!)
Drugs that ↓ clearance are VAQ: Verapamil, Amiodarone and Quinidine (digoxin blood levels will ↑)
What do you do if your patient has A.fib and needs sx?
Admit to the ICU to optimize the cardiac variables and then do the surgery
Management of a PDA:
Small: indomethacin
Big: surgical ligation by thoracotomy (if cardiac compromise, CHF…)
What is a possible tto for acute severe CHF or in post-MI papillary m. rupture?
Intra-aortic balloon pump
Give IV nitroprusside in acute conditions until the balloon can be placed
Name main cerebral herniations and symptoms:
Transtentorial=uncal; Temporal/uncal herniation beneath the tentorium cerebelli; there is blood accumulating anywhere in the supratentorial area.
Associated with epidural hematoma
Presentation:
Early: ipsi blown pupil (CN3 affected)+contralateral hemiparesis
Late: contralateral blown pupil+ipsilateral hemiparesis
SUbfalcine; cingUlate gyrus herniation beneath the falx cerebri: awake + contralateral hemiparesis because compresses the anterior cerebral A. =)
Tonsilar: tonsils in foramen magnum; compression medulla and death
What are the demographics for Slipped capital femoral epiphysis and Legg Clave Perthes?
Both: Kid/adolescent with hip/knee pain and a limp
Slipped capital femoral epiphysis: obese adolescents, older than 12. ±Tendrelemburg sign (if the adolescent is not fat you might see atrophy of the quadriceps and gluteus muscles)
Dx: bilateral Rx showing displacement of the epiphysis from the metaphysis
Legg Clave Perthes (= avascular necrosis of the femur): normal weight kids, less than 12. Initial Rx can be nr, later you see femoral head sclerosis and fragmentation. ±Tendrelemburg sign
Autopsy finding in sudden infant death syndrome:
Intrathoracic petechiae or pulmonary edema
What is the best next step in management in a patient with hairy leukoplakia?
HIV test
What is the first line tto of allergic conjuntivitis? and of bacterial conjuntivitis?
Allergic: Topical ketotifen (combination of H1 blocker + mast cell stabilizer)
Bacterial: Sulfa ophthalmic drops (erythromycin ointment in children)
Indications for the meningococcal vaccine:
Adolescents 11-18 y.o.
Individuals at high risk of exposure (military, college students in residential housing, traveller to an endemic area, exposure to community outbreaks)
Immunodeficiency (asplenia, complement deficiency, HIV)
How do you calculate MAP?
1/3 systolic + 2/3 diastolic
When is streptokinase contraindicated?
If you have given it on the past because it can cause sensitization/allergic reaction in re-exposure, just use a different fibrinolytic agent
ECG pattern on right axis deviation:
A + R in lead 3, the QRS is inverted and low
RSR’ pattern in V1-3
What are the (2) possible SE of indomethacin tocolysis?
Transient oligohidramnios (due to decrease renal perfusion) Premature closure of the ductus arteriosus
Give it for less than 48h
DD between atelectasis, PE and ARDS:
Atelectasis: within less 24h, diffused or localized, collapsed, tto: deep breathing, give analgesics to decrease the pain and allow breathing
Tto: deep breathing, sitting upright or incentive spirometry to expand the lungs
PE: later than 24h, tachycardia, big hypoxemia, a lot
ARDS: within a week, PaO2/FiO2 ratio of less than 300 (the lower the worse), big hypoxemia, bilateral opacifications
Management of postpartum hemorrhage:
1) fundal massage
2) oxytocin
(3) ergots)
4) tranexamic acid!!
5) prostaglandins (carboprost): not in asthma
6) balloon tamponade
7) embolization
8) hysterectomy
Which bug causes acute pericarditis?
Coxsackie B
What should you do if you see bradycardia?
ECG to confirm sinus bradycardia, then if it is sinus bradycardia and is asymptomatic you do nothing
ECG patter of Lown-Ganong-Levine (LGL) syndrome:
Accessory pathway that connects the atria to the bundle of His causing a re-entrant tachycardia with short PR and NO delta waves and normal QRS
ECG patter of Brugada syndrome:
Young asian patient with a pseudo-RBBB and ST elevation in V1 and V2
Management of tdp?
1) Mg
2) Metoprolol
ECG patter of hypothermia:
Osborn wave (convex hump at the J-point)
Differential diagnosis of genital lesions and treatment:
Treponema pallidum, syphilis: painless chancre w rolled hard edge (usually single but can be multiple especially if HIV+) and painless bilateral lymphadenopathy. Micro: corkscrew. Tto: Penicillin 0
Klebsiella granulomatis: granuloma inguinale or donovanosis: painless nodule that ulcerates (beefy red) and can bleed (PSEUDObubon) WITHOUT lymphadenopathy. In Africa. Giemsa, intraCYTOPLASMATIC bipolar ~🧷 staining. Tto: doxy/macrolide 0
Clamydia trachomatis (L): painless ulcers→ tender painful lymphadenopathies that ulcerate (buboes) lymphogranuloma venereum. In Latin America and Africa. Micro: Giemsa, intraCYTOPLASMATIC. Tto: Doxy 1
Haemophilus ducreyi: chancrOID, deep purulent painful ulcers (papule→ pustule→ ulcer→ BLEEDING) with ragged borders, GRAY base and SUPPURATIVE inguinal lymphadenitis. Micro: clumping, school of fish. Tto: ceftriaxone/macrolide 2
HSV2: superficial ITCHY painful vesicles or ulcers w erythematous base (but do not bleed) and tender lymphadenopathy (but not suppurative) ± discharge ± constitutional symptoms (FEVER, malaise). Heal in 10 days. Easier to get AIDS. Micro: intraNUCELAR and multinucleated cells. Tto: acyclovir 2
Pronator drift indicates which lesions?
Down: pyramidal lesion, UPN lesion
Up: cerebellar lesion
Which fetal abnormalities are associated with DM in pregnant?
Non-gestational DM (first trimester): caudal regression sd (sacra agenesis), small left colon (meconium plugging), CNS and cardiac abnormalities
Gestational DM (2nd-3rd trimester): fetal macrosomia (cesarean if more than 5000g), transient hypoglycemia, ↓Ca, ↓Mg, polycythemia, jaundice, asymmetric septal hypertrophy*, respiratory distress syndrome
- perihilar vessels, fluid in the lung fissures and expanded lungs
MC complication of parenteral nutrition:
1) Infection
2) Cholestasis and galstones
What is the treatment for botulism?
Baby: IG
Adult: equine anti-toxin
Management of anal ca:
RT + QT
Management of MS:
1) INF-β
Natalizumab
Glatiramer
Exacerbation: 1) Corticoids, plasmapheresis if pt doesn’t respond
How do you treat candidiasis in pregnant?
Intravaginal ketokonazole, because fluconazole is contraindicated in pregnancy
Which immunodeficiency presents with high α-FP?
Ataxia telangiectasia
Tto of acute chest syndrome in sickle cell?
Plasma exchange
Which is the most common type of ovarian mass in young women of reproductive age? And in pregnant? And in complete mole?
Non-pregnant ± PCOS: Follicular cyst (cause irregular bleeding). No vascular
Normal in pregnant: Corpeus luteum cyst. Vascular
Complete mole or twins: Theca lutein cyst (bilateral)
Watery diarrea after 12-48h?
Norovirus, delayed!
B. cereus and S. aureus start 6h after eating
Norovirus is now is the number 1 cause of diarrhea in kids because of the rotavirus vaccine!
Norovirus is not killed by hand-sanitizer
What is the most common type of thyroid adenoma? and of thyroid carcinoma?
Adenoma: follicular adenoma
Ca: papillary ca.
What happens right after you inject insulin on a healthy patient?
Hypoglycemia. The body will try to compensate! by increasing glucagon (even if in normal physiology insulin suppresses glucagon), GH and epi
What ate the causes (2) of blunted response to hypoglycemia?
β-blockes use
Long lasting DM1 causing autonomic failure
Features of MMD:
'SIG E CAPS' S = Sleep I = Interest G = Guilt E = Energy C = Concentration A = Appetite P = Psychomotor S= Suicidal ideation
Al leasts 5 symptoms for 2w or more than 2w is MMD
Tto for genito-pelvic pain/penetration disorder:
It is the involuntary contraction of the outer 3rd of the vagina interfering w. intercourse
Kegel exercises
Vaginal dilators
Relaxation techniques
What is the key way to differentiate Berger’s disease and hemolytic-uremic syndrome?
And what is the key way to differentiate ITP and hemolytic-uremic syndrome
All can present with red urine after a GI infection on a kid
DD with Berger’s: Look at the platelets! in Berger’s they will be normal and in HUS will be low!
DD with ITP: platelets will be low in both but ITP will not have schistocytes on the smear
Patient presents with arm adduction and internal rotation with the hand resting in the anterior chest wall after tx. Dx?
Posterior shoulder dislocation
What is the 1st best step in management after clinical evaluation consistent with posterior urethral valves? and the best dx test?
NBSM: place urethral catheter
Best dx test: voiding cystourethrogram!!
How can you clinically differentiate Conn sd. from adrenal hyperplasia?
In Conn syndrome changes in posture do not affect Aldo secretion while in adrenal hyperplasia changes in posture can affect Aldo secretion
Best initial dx. test for 21-hydroxylase deficiency?
17-ketosteroids in urine!!
Ergotamine possible SE:
Can worsen prinzmetal angina
HT
Retroperitoneal fibrosis (especially if associated w. smoking)
How can you differentiate Phencyclidine from Bath salts intoxication?
Both cause aggressive behavior
Phencyclidine wears off after 2 days and causes nystagmus
Bath salts lasts longer, no nystagmus, you cannot found anything in the urine
Main SE of Cannabis and Extacy:
Cannabis can last in the urine for 1mo and causes imponetnce
Ecstasy causes hyponatremia
Difference between Cooper and Progestin based DUI:
Cooper:
Lasts 10 years
Contraindicated in Wilson’s, dysmenorrhea, menorrhagia, recent history of STD and active pelvic inflammation, distorted uterine cavity (submucosal leiomyoma) but do not remove if small
Progestin based= Mirena:
Lasts 3 years
If they want to be pregnant soon after taking it off
Also contraindicated in recent history of STD
DD of myopathies based on ESR and CK:
Polymyositis and dermatomyositis: ↑ ESR and CK (Anti-Jo bad px and pulmonary fibrosis; Anti-Mi good px)
Polimialgia reumatica: ↑ ESR nr CK!!!!
Cushing: nr ESR and CK
Statin used and hypothyroidism: nr ESR ↑CK
What is the MCC of liver abscess?
Cholangitis (pol microbial: E. Coli, Klebsiella, strep)
What is another name for mom’s thumb? What is the associated test? What is the tto?
De Quervain tenosynovitis=radial styloid tenosynovitis, it is a tenosynovitis to the abductor or dorsal EXTENSOR tendons of the thumb: Extensor pollicis brevis!
Pain with adduction (ulnar deviation) of the wrist due to stretching of the tendons over the radial styloid
+ Finkelstein test (pain if you put thumb inside closed fist and force the wrist into ulnar deviation)
Tto: steroid injection
Genital complication of DM:
Fournier gangrene: polymicrobial flora form the genital track infects the external genitals
Management of neuroleptic malignant syndrome and serotonin syndrome?
Neuroleptic malignant syndrome:
1) Stop the drug + supportive tto
2) Bromocriptine (or amantadine)
3) Benzodiazepine
4) Dantrolene (more for malignant hyperthermia in the OR)
Serotonin syndrome:
1) Stop the drug + supportive tto
2) Benzodiazepine
3) Cyproheptadine
Treatment and MCC for bacterial conjuntivitis in adults:
Topical erythromycin
MCC: Staph aureus → Strep pneumo → Haemophilus
How can you prevent the thickening of the skin in scleroderma?
D-penicillamine
How do you threat abdominal and joint pain in Henoch-Schonlein purpura?
Corticosteroids
Name 2 weird loop diuretics and 3 weird thiazides:
Loop: bumetanide, ethacrynic acid (-mides)
Thiazide: metolazone, chlorthalidone (+ potent), indapamide (-thiazide)
Schilling test possible results:
Give B12 and you see B12 in the urine: dietary deficiency
Give B12+IF and you see B12 in the urine: pernicious anemia
Give B12±IF and you do not see B12 in the urine: malabsorption/ diphyllobothrium latum
What is the most common presentation of HCOM?
Dyspnea
Which dose of acetaminophen can already be toxic in kids?
90 mg/kg
What is the management of an ankle fracture?
Bimaleollar ~ displaced: 1) closed reduction and splinting → open reduction and internal fixation when soft tide edema has resolved
Non-displaced: close reduction and casting
How many abnormal semen analyses do you need before male infertility is diagnosed?
2
DD of esophageal atresia ± TEF:
No blind pouch: esophageal atresia with NO distal TEF
Blind pouch with distended stomach and: esophageal atresia + distal TEF
Insidious presentation ~ GERD and nasogastric tube can reach the stomach: TEF with NO esophageal atresia
Management of caustic ingestion:
1) Secure the airway 2) Chest and abdominal Rx 3) Copious IV fluids
How long after ingestion should plasma acetaminophen be measured?
More or = to 4h, before that time the levels are nor interpretable because acetaminophen absorption may be delayed in overdose
Management of CO poisoning:
Below 40% + no CV or neurological impairment: 100% O2 for 4h, if it doesn’t work go to hyperbaric
Above 40% or with CV and neurological impairment: hyperbaric O2 at 3 atmospheres
BNSM in bright-red blood per rectum?
Nasogastric tube to aspirate gastric contents:
If red or white fluid is returned it means is an upper GI bleeding → endoscopy
If green fluid is returned is not an upper GI bleeding → anoscopy
What is it placed after cricothyroidotomy in adults and kids?
Adults: cricothyroidotomy + tube
Kids: cricothyroidotomy + cannula
Baby with noisy breathing that improves when lying prone. Dx? Main physical exam finding? Management?
Laryngomalacia
Main PE finding: inspiratory stridor!* all stridors are inspiratory except the vascular ring one and the one in complicated croup
Dx test: flexible fiberoptic laryngoscopy that shows a collapsed supraglottic structures during inspiration and an Ω-shaped epiglottis
Management: observation because it resolves by 2y.o.
Best test to dx Becker and Duchenne:
Genetic analysis
What is the treatment for diabetic neuropathy in DM?
SNRIs: not if the patient is on another serotoninergic agent
Tricyclic antidepressants: do not use in heart conduction abnormalities or if the patient is on another serotoninergic agent
Pregabalin
DD. between hordeolum and chalazion:
Hordeolum: Painful! purulent inflammation of the eyelid. 2 forms:
External hordeolum or stye, arises from the glands of Moll/Zeis
Internal hordeolum (less common) is an inflammation of a meibomian gland, most typically at the palpebral conjunctiva
Chalazion: Non-painful! firm, rubbery, and nonpurulent nodule on the eyelid
Edema, pruritus, vesicles, and ulcers localized to the buccal mucosa directly in contact with recently installed orthodontic brace. Dx?
Allergic contact dermatitis
What is the cause of a Zenker diverticulum? What is the confirmatory test and the tto?
Abnormal esophageal motor function; because esophageal spastic motility can result in inadequate relaxation of the upper esophageal sphincter and increased intraluminal pressure which causes outpouching of the pharyngeal wall
Confirmatory test: barium swallow fluoroscopy ± endoscopy to rule out malignancy
Tto: cricopharyngeal myotomy and diverticulectomy
How do you treat lumbar spine prostate ca. metastasis?
Castration-sensitive: leuprolide
Castration-resistant: external beam radiotherapy to the lumbar vertebrae ± zoledronic acid (bisphosphonate)
1) Young boy with persistent nasal congestion with purulent discharge as well as facial pain over the maxillary sinuses with opacification upon transillumination. Dx?
2) Adult with gradually developing bilateral nasal obstruction, postnasal drip and impaired olfactory function. Dx?
3) Young boy with unilateral and foul-smelling nasal discharge, nasal congestion, and facial pain. Dx?
1) Acute bacterial rhinosinusitis
2) Nasal polyps. Associated with chronic rhinosinusitis.
3) Foreign body
Young man presenting with scrotal pain and fever, swelling, crepitus, and skin necrosis of the scrotum. Dx? Management?
Fournier gangrene.
If hypotension and tachycardia this k about septic shock
Management: aggressive debridement of the affected tissue
Which technique is associated to less catheter-associated urinary tract infections?
Intermittent catheterization
Radiologic finding of pseudomembranous colitis:
Dilation of the colon with loss of haustration (toxic megacolon)
Kid with abdominal pain, arthritis, and raised rash. Dx?
IgA vasculitis (Henoch-Schonlein purpura)
What is another name for small vessel vasculitides?
Leukocytoclastic vasculitis
When should you test for N. gonorrhoeae and C. trachomatis?
In sexually active women < 24 years of age and older women with specific risk factors (e.g., women with new or multiple sex partners)
What is the management of slipped capital femoral epiphysis?
Surgical pinning of femoral head placement of 1–2 pins through the femoral neck into the epiphysis
Conservative management alone is not ok because the lesion can become unstable, which is associated with a high risk of avascular necrosis of the femoral head
When do you transfuse platelets?
Severe active bleeding: if platelet count < 50,000/mm3 (< 100,000/mm3 in the case of intracranial bleeding)
Non-life-threatening bleeding: if platelet count of < 30,000/mm3
Rapid blood loss (usually due to surgery or trauma)
Bleeding prophylaxis: if platelet count < 10,000/mm3 (< 50,000 mm3 if the patient is about to undergo a procedure)
How do you treat dermatitis herpetiformis?
Oral dapsone and strict adherence to a gluten-free diet
Sepsis + string of pearls in the centrum semiovale on MRI. Dx?
Watershed infarction
RF: internal carotid stenosis
Dx test for urolithiasis:
CT without contrast, Ultrasound (if emergency, kid or pregnant)
No Rx!
Prophylaxis for premature babies:
Less than 32 w:
β-methasone (↑risk of diabetic ketoacidosis, needs a few hours to work)
Penicillin*
Indomethacin for tocolysis
IV MgSO4 (4 h before delivery)
Screening with head ultrasound at 1-2w of age
32-34 w:
β-methasone
Penicillin*
Ca ch blockers for tocolysis!!
34-37 w:
β-methasone
Penicillin*
- if + or unknown
Causes of papillary necrosis
SAADO: Sickle Acute pyelonephritis Analgesics DM Obstructive uropathy
What is the most common complication of varicella in immunocompromised?
Varicella pneumonia
Management of foreign-object airway obstruction in kids:
If breaths and coughs: observation
If cannot cough: airway positioning → ventilation → back blows → chest thrusts if less than 1yo/abdominal thrusts if more than 1yo
Complete obstruction/respiratory failure: intubation ± tracheostomy
How do you decide if a sore throat is strep?
With the Center criteria:
Fever Tonsillar exudate Absent cough Anterior cervical lymphadenopathy Age 3-14
2-3: rapid strep test and treat if positive
4: treat (penicillin V for 10 days, you can give 1 dose of pen G if possible loss in follow up)
Young patient presents with thumb tenderness, warmth, swelling after thumb sx. Dx?
What are the best initial test and the gold standard?
Osteomyelitis
Best initial test: nuclear bone scan
Gold standard: biopsy and culture
Cause, location, muscles and nerve that may be affected by tennis and golf elbow:
Tennis: Lateral epicondylitis Repetitive wrist extension (supination) Radial n. impingement Muscles that can be affected: EXTENSORS; mostly the extensor carpi radials brevis, extensor digitorum, extensor digitized minimi and extensor carpi ulnaris (not the extensor carpi radials longus)
Golf: Medial epicondylitis Repetitive wrist flexion (pronator) Median n. impingement Muscles that can be affected: FLEXORS
Which type of fluid should be given to a burn patient? What should we do to prevent wound infections?
Ringer’s lactate; normally we use the Parkland formula to estimate the amount of fluid needed
After fluids are given give early nutritional support with enteral nutrition (30kcal/kg/day and 1g/kg/day of protein), enteral nutrition is also the answer for critically ill patients (ICU)! TPN is only for pt with contraindications to enteral nutrition as intestinal discontinuity or prolonged ileus
Intubate if shout around the mouth bc the airway could be burn, get also a carboxyhemoglobin
IV PPIs
Cut circumferential scars
If genital burns or burns of a large surface area place a catheter
Irrigation and gentle gauze debridement but if full-thickness burns do early wound excision and grafting to prevent wound infections
Silver Sulfadiazine (antibiotic and occlusive) and non-stick dressing
Plantar fasciitis dx keys:
Pain in the anteromedial aspect of the heel
Calcaneus compression does not cause pain
Pain with dorsiflexion!!
What is the treatment for infection in a burn patient?
Cefepime or other antipseudomonal antibiotics
Vancomycin to cover MRSA
What should you do if you see absence of distal deep tendon reflexes in the elderly?
Nothing, peripheral nerve dysfunction is very common among elderly individuals.
What is the most common cause of back pain on the 3rd trimester?
Relaxation of the pelvic girdle ligaments
What type of amnesia is associated to electroconvulsive therapy?
Retrograde amnesia
CHA2DS2-VASc score:
Congestive heart failure Hypertension Age ≥ 75 years (2 points) Diabetes mellitus Stroke or TIA or thromboembolism (2 points) Vascular disease (prior MI, peripheral artery disease, or aortic plaque) Age 65–74 years Sex category (female sex)
0-1: low risk, observation
1-2: intermediate risk, consider aspirin or anticoagulation
≥ 2-3: high risk, anticoagulate
What is the main electrolyte abnormality secondary to adrenal insufficiency related to corticosteroid withdrawal?
Hyponatremia, here there is nor hyperkalemia or metabolic acidosis as normal aldosterone secretion is still preserved
Here there is mainly loss of cortisol which leads to an increase in circulating ADH, which results in free water retention and hyponatremia
What is the most effective pharmacotherapy for reducing the frequency of anginal episodes in stable angina?
β-blockers
What is the treatment of C. difficile?
1st test is toxin on stools
Best test: PCR
1st episode: oral vancomycin/oral fidaxomicin for 14-21 days (oral vanco is cheaper)
2nd episode: change drug oral fidaxomicin/oral vancomycin
Resistant: oral vancomycin followed by rifaximin/ fecal transplant
Fulminant colitis: IV metronidazole + oral vancomycin
What should you do on a patient with severe burns and soot within the nose and mouth?
Intubation and mechanical ventilation
Kid with abdominal distention, nausea, vomiting and large gastric bubble seen on abdominal CT after a tx. Dx?
Tto?
Upper intestinal obstruction due to a duodenal hematoma
Tto: nasogastric decompression and total parenteral nutrition if hemodynamically stable. They resolve in 3-4w
What does a positive apnea test indicate? What is it?
Brain death
After preoxygenation with 100% oxygen, the patient is disconnected from the ventilator and observed for evidence of respiratory drive (such as gasps or chest movement). After 8–10 minutes, an arterial blood gas reading is obtained. If the PCO2 is elevated above normal levels, this signifies an absence of respiratory drive, and the apnea test is considered positive
What should you suspect if you see menorrhagia and dysmenorrhea in a multiparous woman with a diffusely enlarged and tender uterus?
fosis
Respiratory distress immediately after birth in a neonate born through meconium-stained amniotic fluid. Dx?
Main complication? Prevention? Tx?
Meconium aspiration syndrome (MAS)
Main complication: persistent pulmonary hypertension of the newborn
Prevention: amnioinfusion
Tx: O2 to avoid pulmonary vasoconstriction
Tachypnea and crepitus after a gun shot indicates?
Pneumothorax
What is the target PTT on DVT prophylaxis? and in DVT?
DVT prophylaxis, surgery, CHF, MI: less than 1.5
DVT or PE: 1.5-2.5
Name a complication of B12 or folate replacement:
Hypokalemia
Causes of hypokalemia: beta-agonists, insulin, carbohydrate loading, alkalosis, diarrhea, loops, thiazides, Aldo, hypomagnesemia, RTA 1 and 2, ampho B, cisplatin
Main characteristics of Achilles tendon rupture:
Pop, swelling and tenderness on the posterior leg
Positive Thompson test: absence of plantar flexion when the gastrocnemius is squeezed
What is the first EKG abnormality in TCA intoxication?
Widen QRS
Quick way to differentiate RTA types:
Check plasma K; if high is type 4
If it is low check the urinary pH; if low (less than 5.5) is type 2 if high (more than 7) is type 1
What is first use syndrome?
Chest pain + back pain + anaphylaxis in dialysis; it is an allergic reaction to the membrane used in dialysis
How is the Y descent in tamponade and in constrictive pericarditis:
Blunted/ absent y descent: tamponade
Exaggerated y descent: constrictive pericarditis
Treatment of whipple’s disease:
Ceftriaxone for 2w + TMP-SMX for 2 years
Severe abdominal pain and distention in a 60 yo male septic patient. There is no obstructing lesion on CT scan. Dx?
Tto?
Ogilvie syndrome, colonic pseudoobstruction
Classical findings: constipation, obstipation, abdominal distention and dilated LARGE bowel (COLON)
Tto: urgent colonoscopic decompression followed by IV neostigmine. If it does not resolve or it perforates → laparotomy
Desaturate when stand or start walking and normal saturation when sitting. Dx?
Orthodeoxia platypnea syndrome in hepatopulmonary syndrome
What are the antibodies in autoimmune hepatitis:
Type 1: anti-smooth muscle (cal also be elevated in sclerosing cholangitis)
Type 2: anti-LKM (liver, kidney microsomal antibodies)
Tto: corticoids
What do you do after a needle stick of an HIV patient?
Raltegravir + tenofovir + emtricitabine for 4 mo
What do epithelial casts indicate?
ATN, toxic ingestion, CMV infection
Macular rash that develops centrally on the trunk and spreads outward to the extremities sparing the face, palms, and soles. Dx?
Rickettsia prowazekii, epidemic typhus
Infections associated with Bell’s palsy:
HSV
EBV
Influenza B
Lyme
Fever, drooling, hot potato voice, ipsilateral otalgia, contralateral uvular deviation and trismus (lockjaw). Dx? Tto?
Peritonsillar abscess
Tto: drainage + oral antibiotics
D.D: Retropharyngeal abcess is similar but without uvular deviation, you get neck stiffness, torticolis. You need an Rx of the neck w head extension! showing widened prevertebral space. CT w contrast. Tto: drainage + oral antibiotics
How do you treat gonorrhea? and if the patient is allergic to penicillin? and in pregnant?
Ceftriaxone + azithromycin
Allergic to penicillin: azithromycin + gemifloxacin
Pregnant: IV cefotetan + IV azithromycin (for chlamydia)
Congenital inspiratory stridor that starts at 1 or 2 mo that increases in supine position and when the baby is agitated. Dx?
Laryngomalacia; is the MCC of congenital stridor
Tto: H2 blockers, will resolve at ~ 1 yo
Metabolic panel in vomiting and diarrhea:
↓Cl in vomiting ↑Cl in diarrhea!
Vomiting:
Metabolic alkalosis with low urinary Cl
↓ Na, K, H, Cl
↑ Bicarb (contraction alkalosis because of ↑AT2 that ↑ Na/H exchange int he PCT and ↑aldo that ↑ H secretion by α-intercalated cells)
Diarrhea:
No anion gap metabolic acidosis
↓ K, Na and bicarb. Worry about hypoNatremia if just drinking water especially if baby → seizures. But worry about hypoKalemia with laxative abuse
↑Cl (compensation for ↓ bicarb)
Give glucose and salt because glucose is co-transported into enterocytes via Na
What is the management of Colles fracture?
Closed reduction with volar splint, even if the radial pulse is absent as close reduction of teen resolves most neurovascular deficits
How do you treat community acquired pneumonia? and in an alcoholic?
Monotherapy with macrolide, fluoroquinolone or doxycycline
Alcoholic: fluoroquinolone/ beta-lactam + macrolide
Management of a pelvic fracture in a hemodynamically unstable patient?
External fixation, can be with a pelvic binder that is wrapping bedsheet around the pelvis
Frail chest dx criteria:
Fx of 3 or more adjacent ribs in 2 places so there is a floating chest segment
If criteria are not met consider pulmonary contusion
Management of post-operative ileus:
Bowel decompression with nasogastric tube
Management of corneal abrasion:
1) Meticulous eye inspection with topical anesthetic and removal of foreign body if present
2) Fundoscopy + fluorescein slit-lamp examination
3) Topical antibiotic + monitoring
What do you hear in laryngospasm and bronchospasm:
Laryngospasm: high pitch sound during inspiration, stridor
Bronchospasm: musical sound during expiration, wheezing
Kid with palpitations, fatigue, condition defects and tricuspid regurgitation murmur. Dx?
Epstein abnormality
EKG findings in hyperkalemia, form early to late findings:
Tall peaked T waves (6) → P wave becomes flat and broad (7) → PR prolongation → QRS widening (Sine wave pattern) (8)→ QT interval shortening → Asystole
Which type of uveitis do you see in Crohn’s?
Anterior nongranulomatous uveitis (in all systemic inflammatory diseases)
Which drugs should you avoid in aortic stenosis?
Diuretics, because they decrease preload
What is the most specific finding for right-sided MI? and of inferior wall MI?
Right-sided: V4R; ST segment elevation in V4
Inferior wall: ST segment elevation in leads II, III and aVF
Management of orbital cellulitis:
1) CT/ MRI of the orbit
IV ampicillin
Characteristics of the 4 types of decubitus ulcers:
1: intact skin
2: superficial epidermis ± dermis
3: full thickness skin loss
4: bone and muscle are visible
What are the characteristic radiologic findings in CHF?
Cephalization
Kerley B lines
Cardiomegaly
Pleural effusion
Microaneurysms, hard exudates, macular edema, cotton wool spots and dot and blot hemorrhages in fundoscopy indicate:
Non-proliferative diabetic retinopathy
Which ribs will hurt the kidneys? and the spleen and liver?
Right kidney: 12 (L1-L4 level)
Left kidney: 11, 12 (T12-L3 level, the splenic flexure is situated anteriorly)
Right liver: 8, 9, 10, 11
Left spleen: 9, 10, 11
what is the most common cause of intraoperative laparotomy?
Body temperature of less than 35 degrees
What is a possible complication of displaced supracondylar fractures of the humerus?
Volkmann contracture, that is the injury of deep tissues and muscles of the volar compartment of the arm due to increased compartmental pressures; presents as a stiff arm
How do you treat anaerobic infections in the CNS?
IV metronidazole
What are the first teeth to erupt?
The mandibular (lower) central incisors at 6-8mo followed by the maxillary (upper) central incisors at 8-12mo
Drainage of pink-salmon colored fluid after abdominal surgery. Dx?
Tto:
Fascial dehiscence
Tto:
If fascia is intact is superficial: regular dressing changes
Fascial involvement: bind/ tape the abdomen before transport to the OR for surgical correction
Laparotomy is necessary to prevent evisceration!
Hor do you trat B. pertussis on allergic to macrolides?
TMP-SMX
How can you treat intestinal dysmotility in scleroderma?
Antibiotics (rifaximin) because small bowel estates leads to bacterial overgrowth which results in malabsorption and diarrhea
What is the most common type of melanoma?
Superficial spreading melanoma
High urinary coproporphyrins indicate:
Rotor sd
Fragmented and nucleated RBCs on peripheral smear in cancer patient indicate:
Myelophthisic anemia / leukoerythroblastic picture
Because the marrow gets overcrowded with other cells
How do you treat community acquired pneumonia?
β-lactam + macrolide/doxycycline
or
Fluoroquinolone alone
How are skin tags (verruguillas) also called?
Acrochondos
What is the most accurate test to determine the EF in a patient with CHF?
MUGA scan
Gastric varices without esophageal varices indicates:
Splenic vein thrombosis
Gastric varices bleed quickly causing hematemesis
What is a positive Freiberg’s maneuver and what indicates?
Is the forceful internal rotation of the extended thigh that elicits buttock pain by stretching the piriformis muscle
Indicates piriformis syndrome
Which cells mediate exercise-induced asthma?
Mast cells
Rapidly growing breast mass that is firm, contender, mobile and multinodular indicate:
Phyllodes tumor
What is the management of HCOM?
Asymptomatic: nothing, avoid sports
Symptomatic: β-blockers or Ca ch blockers
If syncope/refractory to medical tto: pacemaker and then ventriculoplasty
Sudden cardiac arrest or sustained ventricular tachycardia: implantable defibrillator (only one that reduces the risk of premature death)
Mavacamten: modulates cardiac myosin and reduces contractility
- for a baby of DM mom: there is no need for tto because it is self resolving, you can give a β-blocker for the symptoms
What is the treatment of a 7yo kid with an umbilical hernia? What is the most likely outcome if not repaired then?
Surgical repair if it hasn’t closed after 5yo
Progressive enlargement of the umbilical ring
- Congenital communicating hydrocele is also treated if it does not resolve after the 1st year
What is the limit of permissive hypertension for ischemic stroke?
220/120
What is the tto of a tubo-ovarian abscess?
IV cefotetan/cefoxitin + oral doxycycline
What is the first step in management of diabetic ketoacidosis? and of hypoglycemia?
DKA: IV fluids
Hypoglycemia: 50% dextrose or glucagon
When is the fist time when you can palpate the uterus on a pregnant woman?
12w because it is above the pubic symphysis
When is a baby considered macrocosmic?
When it weights more than 4Kg
Wat is the systolic BP limit when you start treating with drugs right away?
140-150 w no comorbidities: 1) ambulatory/home BP readings/3 office readings 2) you try exercise and weight loss for 1 mo!
More than 150: start treatment with 1 drug (hydrochlorothiazide)
More than 160: start treatment with 2 drugs
What is the treatment for cavernous sinus thrombosis?
IV amplicillin-sulbactam + vancomycin
How is the uterus in endometriosis and adenomyosis?
Endometriosis:
Younger woman
Tender, inmobile*!! ± retroverted with rectovaginal nodularity (uterosacral ligament nodularity), *because of cul-de-sac adhesions
CA-125 maybe high
Tto: oral contraceptives, NSAIDs, maybe laparoscopy
Adenomyosis:
Older woman, multipara, secondary dysmenorrhea
Mobile!! which is normal, firm, globular! and uniformly enlarged
Tto: levonorgestrel=mirena IUD to make periods lighter
What is the best treatment for pyelonephritis? And in pregnant?
Normal: IV ciprofloxacin
Pregnant: IV cephalosporin (also penicillin and fosfomycin)
When improvement (no fever for 48h) switch to oral!
In pregnant continue daily prophylaxis during all the pregnancy
Intrahepatic ductal dilation and a contracted gallbladder indicate:
Klatskin tumor; which is the most common type of cholangiocarcinoma and that occurs at the confluence of the right and left hepatic bile ducts
When should you do external cephalic version?
When you have a baby on breech or transverse presentation at week 37 or more!
If the patient is Rh- and you do the external cephalic version you need to give RhoGAM
What is the best prognostic indicator in COPD? What is the best prognostic indicator of future coronary event?
COPD px: FEV1; determines the degree of obstruction and progression of the disease
Coronary events: LDL cholesterol levels (goals: less than 100 in high risk of coronary disease patients; less 130 in moderate risk and less than 160 in normal patients)
Well circumscribed hypotenuse hepatic mass with central scaring and radiating fibrous bands. Dx?
Focal nodular hyperplasia
Management of long QT syndromes:
Non-selective beta-blockers: propranolol, nadolol
Implantable defibrillator or denervation in high risk patients
QT should be less than 2 big boxes
Which bug causes an infection after you injure your foot sole?
Pseudomonas, can even cause osteomyelitis
Characteristics of lactose intolerance:
Osmotic diarrhea Positive hydrogen breath test LOW pH ACID stools Increased osmotic gap (also in celiac) Positive reducing substances test in stool
Indications of cervical CT after high energy injury:
Neurologic deficit Spinal tenderness Altered mental status Intoxication Distracting injury (other injury that hurts and makes the patient not realize a deficit ~)
If you find a single vertebral facture you should image the whole spine!
Kid with protruded auricle + tenderness and swelling behind the ear indicates:
Acute mastoiditis
Patient with touch + pain and temperature loss on one side of the body:
Pure sensory stroke normally due to thalamic infract
Can be followed by burning pain and allodynia weeks to months after the stroke (Dejerine–Roussy syndrome)
Which substance is the main player on abnormal hemostasis in uremia?
Guanidinosuccinic acid
Positive carbohydrate breath test indicates:
Small intestinal bacterial overgrowth
Tto: rifaximin, neomycin
Patient with drooling, fever, elevated flood of the mouth and displaced tongue. Dx?
Ludwig angina
Mandibular celulitis normally coming form dental infections
Tto: IV antibiotics and removal of the affected tooth
Treatment of a perianal abscess:
Incission drainage + systemic antibiotics
When do you do surgery in valvulopaties?
Mitral regurgitation: mitral valve repair
If primary, when the LVEF is 30-60% (also you can do surgery depending on the pt if it is less than 30% and symptomatic and if it is more than 60% and asymptomatic)
Mitral stenosis:
Balloon valvuloplasty when the diameter is less than 1.5cm2
If the diameter is bigger treat only if symptomatic with diuretics and β-blockers
Aortic regurgitation:
If symptoms, EF less than 50%
Aortic stenosis: valve replacement If severe (diameter less than 1, velocity more than 4, pressure more than 40) + symptoms/ LEVF less than 50%/ patient undergoing other heart sx
3 mo. kid with asymptomatic normocytic anemia. Dx?
Pysiologic anemia of infancy. Due to a transient decline in hemoglobin due to down-regulation of EPO triggered by a sudden increase in O2 at birth
LEOPARD syndrome characteristics:
Autosomal dominant Sensorineural deafness Lentiginess ECG abnormalities Ocular hyperthelorism Pulmonary stenosis Genital abnormalities Groth retardation
Young patient with diarrhea, arthralgia, oral ulcers and oval pink macular lesions. Dx?
Acute HIV infection
Old patient with retro-orbital headache and nonreactive dilated pupil. Dx?
Acute angle closure glaucoma
Which 2 types pf kidney stones form on basic urine?
Magnesium ammonium phosphate (struvite) Calcium phosphate (on tumor lysis syndrome and hyperPTH)
All the rest form on acid pH
Nephrotic syndrome predisposes to:
Hyperlipidemia and atherosclerosis
Hypothyroidism (due to thyroxine-binding globulin loss)
Iron deficiency anemia (due to transferrin loss)
Vitamin D deficiency and high PTH (due to cholecalciferol-binding protein loss)
Which type of fluid should be given to a kid?
Isotonic crystalloid (20 mg/kg of normal saline IV bolus)
What is the leading cause of sentinel events? How can you prevent it?
According to the Joint Commission failures at communication and team work are the leading cause of sentinel events that can be prevented by using uniform templates when conducting sing-outs
Why a postmenopausal woman on hormone replacement therapy will have low libido?
Because of decreased androgens, ovaries not only produce estrogens, also produce androgens that play a central role in libido
A to-and-fro murmur indicates:
PDA
A to-and-fro murmur is a continuous murmur; actually a to-and-fro murmur involves two components: a systolic one, in which the blood flows in one direction, and a diastolic one in which the blood flows in the opposite direction, while in a true continuous murmur the blood flows in the same direction in both systole and diastole
PDAs may also predispose to an increased risk of respiratory/lung infections
PDAs present with hyperdynamic circulation and therefore accentuated pulses
Air in the liver indicates:
Gallstone ileus; you can also have air in the biliary tree
Poison ivy rash characteristics:
Vesicles/bullae
Sharp line between rash and unaffected skin
Linear pattern
What is the NBSM after finding abnormal total cholesterol levels?
Serum lipid studies while fasting
What does withdrawal bleed after progesterone administration indicate?
Used for the differential of secondary amenorrhea; confirms that the uterus is undergoing a normal proliferative phase and therefore eliminates:
Estrogen deficiency: primary ovarian failure, menopause, hyperprolactinemia, hypothyroidism, functional hypothalamic amenorrhea
Endometrial abnormalities: Asherman’s
Outlet tract abnormalities: imperforate hymen
CSF findings on CNS infections and management:
Viral: lymphocytic predominance, elevated protein and normal glucose → empiric IV acyclovir while awaiting PCR results and/or before brain MRI
Fungal: lymphocytic predominance with decreased glucose
Bacterial: WBC count (>1000) with neutrophilic predominance with decreased glucose
What is the difference between pericardiocentesis, thoracentesis and paracentesis?
Pericardiocentesis: Drainage of pericardium (tto. of tamponade)
Thoracentesis: Drainage of pleural space
Paracentesis: Drainage of peritoneal cavity
What is the day after pill active (plan B) principle?
Is oral levonorgestrel (now and again in 12 hours), not contraindicating in lactating
We have four options for emergency contraception, they work up to 5 days from intercourse:
Copper IUD (most effective)
Ulipristal (second most effective, not in active infection or uterine anatomic abnormality)
Levonorgestrel (“Plan B”)
Oral contraceptives
What is the treatment of an anal fissure?
1) anesthetic ointment and stool softeners
When should you stop one antidepressant before starting another?
Your should stop SSRIs 2 w before starting a MAOi except fluoxetine that needs to be stopped 5 w!!! before
Histologic hallmark of diabetic nephropathy:
Glomerular basement membrane changes (fibrosis and thickening)
1) Hyperfiltration
2) GBM fibrosis and thickening
3) Interstitial fibrosis, mesangial thickening and kimmelstiel wilson nodules
Pathophysiology of Bell’s palsy vs trigeminal neuralgia:
Bell’s palsy: Inflammation and edema of the n.
Trigeminal neuralgia: Vascular loop/multiple sclerosis plaque/ neoplastic compression of the n. root
Increased renal medullary echogenicity on ultrasound indicates:
Ischemic injury and renal papillary necrosis
What is the main cardiac abnormality associated with Noonan sd? Hurler sd? Ellis-Van Creveld sd?
Noonan: pulmonary stenosis
Hurler: mitral/aortic regurgitation
Ellis-Van Creveld (short limb dwarfism, polydactyly, abnormal development of fingernails and normal intelligence): single atrium
What are the 2 main therapies to help an alcoholic that wants to quit but it might relapse?
NalTREXone (do not use un liver problems or patients taking opioids)
Acamprosate (preferred in liver disease or opioid abuse, but requires adjustment in renal failure)
How do you differentiate amphetamine form anticholinergic overdose?
Amphetamines cause sweating
Anticholinergics cause dry skin
* Careful bc the decongestant pseudoephedrine and the antidepressant bupropion and selegiline can cause false + on toxicology testing
Specific non-pharmacologic therapies for psychiatric illnesses:
ADHD: behavioral therapy as parent management training especially if 4-5yo
Autism: behavioral modification
Borderline personality disorder: dialectal behavior therapy
Eating disorders: cognitive-behavioral therapy
PTSD: cognitive-behavioral therapy
Performance-only social anxiety disorder: cognitive-behavioral therapy
Obsessive-compulsive disorder: exposure and response prevention or cognitive-behavioral therapy + SSRIs! You need to give SSRIs!!!!
Specific phobia: CBT with exposure therapy! by systematic desensitization
What should you do if during colposcopy the squamocelular junction is not completely visualized?
Endocervical curettage (this just looks at the endocervix that is still cervix so if it is + you do conization)
How does Pityriasis rosea present?
1) erythematous annular lesion on the trunk (herald patch) → 2) outbreak of macules and papules on the trunk, neck and proximal limbs
Sometimes preceded by flu-like symptoms
DD. between Right heat failure, Budd-Chiari and Portal vein thrombosis:
RHF=cor pulmonale: liver =( cirrhosis nugmet liver; post-hepatic JVD+
If you have JVD + ascites it is because of the Right heart!
Budd-Chiari is Hepatic vein thrombosis: liver =( cirrhosis nugmet liver; post-hepatic JVD-
Portal vein thrombosis: liver =) pre-hepatic JVD-
In all you have splenomegaly (thrombocytopenia), portal HT, varices, ascitis, edema
Pt with pain and redness ± purulent discharge in the medial eye. Dx?
Pt with itching, discharge, foreign body sensation + redness and swelling of the lip margin. Dx?
Dacryocystitis
Blepharitis (associated with seborrheic dermatitis)
What do you do if you have to take out an ovary on early pregnancy?
Give progesterone, bc the corpus lithium maintains pregnancy until weeks 8-10, progesterone can be discontinued after week 10
Which valve abnormality is associated with ankylosing spondylitis?
Aortic regurgitation
What is the cause of Subclavian steal syndrome?
Subclavian A. occlusion
Why ACEi help the kidney on DM?
Because they reduce glomerular hydrostatic pressure decelerating glomerular capillary sclerosis
Which bug causes central retinal necrosis?
HSV
What is the most common heart defect in Down syndrome? How does it present?
Complete AV septal defect
Presents with: Diaphoresis and dyspnea when feeding around 6w of life ASD: fixed splitting of S2 \+ VSD: holosystolic murmur
Which abnormal heart sounds are heard in ToF?
Single S2
Harsh crescendo-decrescendo murmur due to RV outflow tract obstruction
When can you stop antidepressants on a patient with depression?
Stop after 6mo of response to the antidepressant if this is the first episode
Maintain 1-3 years if:
+ than 2 episodes (counting current episode!)
Onset before 18
Persistent depressive symptoms during episodes
Ongoing stressors
Severe
Maintain indefinitely:
+ than 3 episodes (counting current episode!)
Chronic episodes (+ than 2 years)
Suicide attempts
- For a pt with schizophrenia and bipolar disorder antipsychotics/lithium need to be continued indefinitely
Effects of positive ventilation in cariogenic pulmonary edema:
↑ intrathoracic pressure, so:
↓ LV and RV preload
↑ RV afterload
also it ↓ LV because it ↓ MAP by decreasing sympathetic activation and ↓ LV transmural pressure because ↑ the pressure on the pleura
This improves SV, filling in diastole and mortality
Pt presents with fever, abdominal pain, tachypnea and tachycardia a few days after Roux-en-Y sx. Dx?
Anastomotic leak
Management? CT scan with oral contrast and sx repair
How do you substitute penicillin on pt with syphilis that is allergic?
Primary or secondary: doxy (14 days for primary and 28 days for secondary)
Neurosyphilis: ceftriaxone IV
NBSM for a postmenopausal with endometrial cells on pap smear?
Endometrial biopsy
What is the pathophysiology of acute renal failure in AML?
Tumor lysis syndrome causing tubular obstruction
Which antidepressant causes hypertension?
Venlafaxine, dose-dependent HT
Pt with knee pain, pop, rapid swelling, inability to extend the knee and low-riding patella. Dx?
And if he had high-riding patella?
Low-riding: quadriceps tendon rupture
High-riding: patellar tendon tear
1) Pt presents with fever, leukocytosis, purulent discharge and widened mediastinum one week after a heart sx. Dx? Tx?
2) Pt presents with fever and leukocytosis 3 weeks after a heart sx. Dx? Tx?
1) Acute mediastinitis, tto: surgical debridement + antibiotics
2) Postcardiectomy sd, tto: NSAIDs ± pericardial puncture if tamponade occurs
A COPD pt suddenly presents with altered mental status. Dx?
Symptomatic hypercapnia
Maybe due to ventilatory support removal and it can also be triggered or worsened by supplemental O2
Which type of fluid should be given to a septic shock patient? and to a patient in renal failure?
Septic shock: crystalloids as normal saline or Ringer’s lactate. If the pt does not respond and develops fluid overload give NE
Renal failure: D5W bc they cannot get electrolytes
Which 2 psychiatric disorders are associated with Tourette syndrome? How do you treat Tourette’s?
ADHD
OCD
Tto:
VMAT2 inhibitors
Antipsychotics
Alpha-2 agonists for comorbidities (ADHD)
D.D. of ‘a curtain coming down’ over the eye:
Central retinal A. occlusion: optic disk pallor, cherry red fovea and boxcar segmentation of blood in the retinal vessels on ophthalmoscopy
Retinal detachment: flashes and floaters with grey elevated retina on ophthalmoscopy
Pt develops severe bradycardia right after starting laparoscopic surgery. Cause?
CO2 insulation on the peritoneum activates the stretch receptors which increases the vagal tone causing bradycardia and sometimes asystole
The increased intraabdominal pressure can also cause an increase in SVR leading to BP elevation
Kid with bilious vomiting 2 days after a blunt abdominal tx. Dx?
Duodenal hematoma, do a CT scan
Rx: gastric dilation with scant distal gas
Tx: bowel rest, nasogastric decompression and parenteral nutrition, sx if still present 2 w after
What is per-protocol analysis? What is intention-to-treat analysis?
Per-Protocol: only analyzes patients that complete the protocol, does not take in consideration dropouts, it overestimates the effect of the intervention
PP is bad!
Intention to treat analysis that analyzes everyone that was located on a group, so it takes in consideration dropouts, it’s more conservative. It preserves randomization!
How much is a kid supposed to grow on the 1st year?
4 mo: weight x2 (the fist 6mo babies gain 1oz/day)
12mo:
weight x3
height increases by 50%
Why do Beta-blockers, nondihydropyridine Ca ch blockers and Nitrates help on an MI?
β-blockers and nondihydropyridine Ca ch blockers: ↓ O2 demand by ↓ contractility
Nitrates ↓ preload
What is the gestational diabetes screening and management?
At 24-28w: 1h/50g test, non fasting, if more than 140 do:
3h/100g test, fasting, diagnose gestational DM if 2 or more values are = or higher than:
95/fasting (if more than 125 diagnose, do not give the 100g)
180/1h (if more than 200 diagnose)
155/2h
140/3h
If gestational DM: check glucose at home and maintain at less than 95 fasting and less than 140/1h and 120/2h, if not: subcutaneous insulin/glyburide (insulin body weight x 0.8 -1st trimester- x 1.0 -2nd trimester- x 1.2 -3rd trimester-) + start antenatal testing at 32w Target goals!!!! 95 fasting 140/1h 120/2h \+ Postpartum: Measure fasting glucose at 1 day 3 days 2h/72g test at 6 and 12w postpartum, and at 3 year intervals if all good
Good drugs for treating DM2 and cause weight loss and protect the heart:
–Tides (GLP1 agonists)! Best. They decrease glucagon release! They decrease gastric motility causing nausea. Not if history of pancreatitis. Semaglutide just came out as an oral form
–Glifozins (SGLT-2 inhibitors). Less effective than the tides at decreasing HbA1c. Decrease hospitalization in HF. Decrease BP so do not give if BP is low or if pt is on a thiazide. Can cause euglycemic DKA
Both decrease renal fx progression and have a cardiovascular benefit!
Gliptins are not cardioprotective and weight neutral. Not bad for renal insufficiency
Management of open angle glaucoma:
Open angle: 1) topical prostaglandins 2) topical β-blockers 3) laser trabeculoplasty
What are other names for neural tube defects?
Spinal dysraphism
Tethered cord
When is c-section indicated in macrosomia?
More than 4500g in diabetes
More than 5000g in non-diabetic
What do you do if a mom comes because the baby is not moving?
- You also do fetal testing in DM, post-dates, HT, IUGR even if the baby is moving
1) Nonstress test, if 2 or more accelerations (+ than 15 beats/min at >32w) in 20 min 😃; you can do vibroacoustic stimulation in case the baby is sleeping
If nonreactive 😞: 2) Biophysical profile: NST Amniotic fluid index that should be 5-25cm Body movement Extremity tone (flex and extension) Breathing 8-10: 😃 4-6: contraction stress test (induce 3 contractions in 10 min), if the baby is more than 37w deliver 0-2: delivery!
3) Umbilical doppler ultrasound
Different presentations and management:
Cephalic:
Occiput anterior vertex: back of the head is close to the pubis and flexed 😃
Face: c-section
Breech:
Frank: but is down and legs up; only breach that might be able to be delivered vaginally
Complete: but is down and legs are crossed; c-section
Footing; c-section
Transverse: c-section
Causes of SECOND stage arrest:
No fetal descend on 3h for nulliparous and 2h for multiparous (relative to amount of vaginal deliveries)
Causes:
Inadequate contractions
Small pelvis
Abnormal fetal size or orientation
Episiotomy indications:
Not indicated in a regular basis, let it tear naturally
Shoulder dystocia Bad monitor tracing Forceps/ vacuum Vaginal breech Narrow birth canal
What are the indications of operative obstetrics:
Prolonged 2nd stage (primigravida pushing + than 3h without epidural or + than 4h with epidural; multigravida pushing + than 2h without epidural or + than 3h with epidural)
Category 3 when mom is fully dilated
Mom’s heart condition (hypertrophic cardiomyopathy)
Maternal exhaustion
They require dilated and effaced cervix, ruptured membranes and engaged occiput
Forceps: could be used on a breech
Vacuum: does not need so much experience and baby only needs to be vertex, do not put it for >10 min (risk of subgaleal hematoma and intracranial hemorrhage) and do not do it at >34w
Normal postpartum findings:
Lochia rubra: 1w, blood (hemorrhage is pathological if + 500ml in vaginal or + 1000ml in cesarean)
Lochia serosa: 2w, yellow
Lochia rubra: 3w, white
Hypotonic bladder and urinary retention: put a Foley catheter
Hemorrhoids
Postpartum blues, resolves in 2w
How do you treat catatonia?
Benzodiazepines
DD. of differential BP on the upper extremities:
Aortic dissection Blunt thoracic aortic injury Takayasu Supravalvular aortic stenosis (systolic murmur on the 1st right intercostal space) Widespread atherosclerotic disease
Position and management of Bartholin cyst/abscess:
Bartholin: posterior, on the base of the labia majora. Only that if symptomatic (if abscess) → incision and drainage and place a catheter, marsupialization if recurrent
HPV screening and management algorithm:
Vaccinate at 11-12 y.o. w 2 doses, if the pt receives the vaccine after 15yo you need to give 3 doses
Screening:
Older than 21: HPV cytology every 3 years
*If less than 25 also test for gonorrhea and chlamydia
Older than 30: you can keep doing cytology/3 years or better cytology + HPV co-testing/5 years
If immunosuppressed or history of HPV screen every year, if HIV screen every 6mo
Older than 65: if all good for 10 years (3 pap and 2 co-testing negative) and never HSIL stop testing, no smoke, immunosuppressed or DES
If hysterectomy for benign reasons: stop
Management of results:
ASCUS: unknown significance (if HPV co-testing + → colposcopy)
LSIL=CIN1: low risk**
ASCH: cannot rule out HSIL*
HSIL=CIN2,3: high risk → if less than 25*, if 25-64 do LEEP right away
Squamous cell ca: if invasive ca. in pregnancy before 24w you do radical hysterectomy/RT if after 24w you wait up to 32w and then do it
- In younger than 25 repeat pap in a yer, in older *
- 1) colposcopy ± biopsies (CIN 2/3 and already had kids and is more than 25 you can skip the biopsy) 2) if squamocelular junction is not visualized → curettage 3) if atypical glandular cells → endometrial biopsy 3) if CIN1: ablation/LEEP + pap in 6mo, if CIN2/3: LEEP; then, pap + HPV co-testing 1 and 2 y post-procedure (hysterectomy only for recurrent CIN2/3: sill do pap annually)
The only thing you don’t do during pregnancy is la LEEP or conization
What is the embryological cause of uterus Unicornuate, Didelphys, Bicornuate, Septate and Arcuate:
Unicornuate: one müllerian duct did not form
Didelphys: müllerian ducts do not connect at all, so there are 2 uterus and maybe 2 cervices and 2 vaginas
Bicornuate: MC, müllerian ducts do not connect at the top
Septate: the median septum does not degenerate
Arcuate: all good, small midline indentation because the upper median septum does not degenerate
How do you manage a postmenopausal bleeding patient?
1) transvaginal sonogram → if stripe more than 4mm: biopsy
All good: OCPs/ progestin
Simple and complex without atypia: progestin
Complex with atypia: hysterectomy/progestin
Endometrial ca: hysterectomy and bilateral salpingo-oophorectomy + lymph node dissection
DD of short kid with delayed and advanced bone age:
Delayed:
Constitutional growth delay: nr growth velocity, delayed growth spurt
GH deficiency: ↓growth velocity=kid that stops growing, absolutely proportional kid, no GH increase after IV arginine
Advanced:
Peripheral precocious puberty: ↓LH
Central precocious puberty: ↑LH
Benefits of combined oral contraceptives:
Decrease risk of ovarian ca.
Decrease risk of endometrial ca. (good for PCOS)
Decrease risk of PID because the close of the cervix
Make the periods lighter (good for dysmenorrhea)
Which class of antihypertensives gives you peripheral edema?
Ca ch blockers (dihydropyridines cause more edema than non-dihydropyridines)
If you combine them with ACEi the probability of getting peripheral edema decreases!!
What is the major RF for treat ca?
Age
Which O2 parameter remains constant on CO poisoning, methemoglobinemia, anemia and polycythemia? Which one changes?
Remains constant: PaO2, PARTIAL PRESSURE! of O2 or dissolved O2 (P50 will be nr in anemia and polycytemia and ↓ in CO and methemoglobinemia)
Changes: O2 content or total O2!
Normal partial pressure and low content!!
In methemoglobinemia the pulse-oximeter is ↓ and does not improve with O2 but the arterial blood gas is falsely ↑ (~85). Skin turns blue
In CO poisoning the pulse-oximeter is falsely ↑ but the arterial blood gas is ↓. Skin is red
DD between Hematoma, Pseudoaneuryms and AV fistula:
Hematoma: ±mass, no bruit
Pseudoaneuryms: pulsatile mass, systolic bruit
AV fistula: no mass, continuous bruit
What is the key question and answer for facial CN lesion?
Is the forehead affected?
Yes: LMN→ ipsi: Bell’s palsy (HSV reactivation), give steroids and valancyclovir
No: UMN→ contra: stroke on internal capsule (pure motor) or cortex (+ cortical signs)
Adenosine deaminase in pleural fluid indicates? and amylase?
Adenosine deaminase: TB
Amylase: pancreatitis, esophageal rupture
Best tto of allergic rhinitis + asthma:
LT modifiers
What are the criteria for acute liver failure?
ALT, AST more than 1000
Hepatic encephalopathy
INR more than 1.5
How do you hear S3 and S4?
S4: A’ s’tiff heart’: ta-ta–ta
S3: I’m re’la’xed: ta—ta-ta
HIV patient with renal failure, heavy proteinuria and edema. Dx?
HIV associated nephropathy (biopsy: collapsing focal segmental glomerulosclerosis), HIV virus invades the renal epithelial cells
DD. BK virus that causes interstitial nephritis with hematuria, pyuria and WBC casts
HIV patient with burning pain, loss of pain, touch and reflexes on the lower extremities. Dx?
Distal systemic polyneuropathy
Clicking and separation of bonny edges of sternum after cardiothoracic surgery. Dx?
Tto:
Sternal dehiscence
Tto: urgent surgical exploration and repair (to prevent cardiac damage from loose wire or bone fragments)
Urethritis with negative culture. Causal organism?
Chlamydial urethritis
Gram stain will be + in gonorrhea (gram negative diplococci)
DD of abdominal mass in kids:
Wilms=nephroblastoma: doesn’t cross
Presents later (2-5yo)
From nephroblast (embryonic kidney)
WT1 mutation Ch 11
Micro: triphasic with tubules, sheets and stroma
± hypertension (renin secretion), hematuria ±:
WARG: WT1 is associated with anhiridia, genitourinary malformation, retardation. PAX6 next to WT1 is important for iris formation, contiguous gene deletion
Denys-Drash: WT1 is associated with Difusse mesangial sclerosis (nephrOtic) and Dysgenesis of gonads
Beckwith-Wiedemann: WT2 is associated w macroglossia, hemihyperplasia, low sugar and high insulin because over expression of ILGF2, omphalocele, hepatoblastoma
Neuroblastoma: crosses and calcifies
Presents earlier (birth-2) MC solid tumor in children
Fever, pain and weight loss!
Metas on the bone, marrow (anemia, thrombocytopenia…), skin (can cause blueberry-muffin baby!, raccoon eyes) SVC sd
Associated w. opsoclonus-myoclonus-ataxia and VIPoma
From neural crest (adrenal medulla ± hypertension)
Micro: Homer pseudorosettes
M-YCN! mutation (poor px)
High homovanillic acid
D.D. of jaundice on the baby:
Hemolysis: Immune-mediated: ABO (MCC), Rh or Kell (think if mom and baby are the same blood type) isoimmunization Non-immune: spherocytosis, elliptocytosis, G-6PD, pyruvate kinase deficiency. Early jaundice (day 1), ↑reticulocytes. Not responding to phototherapy and bilirubin of 25-30 (at 30 you get to kernicterus). Tto: double vol. exchange transfusion
Physiologic jaundice: peaks at day 2-3 and resolves in 1w, not rising more than 5mg/dl/24h, total bilirubin get to around 13, mostly unconjugated. Tto: maybe phototherapy
Polycitemia: clamping the cord too late, twin twin transfusion, IURG, maternal DM. Tto: if symptomatic partial exchange transfusion to bring the Htc to 50
Breastfeeding jaundice (mala madre, early): more common. Baby is not feeding enough (not in every 2h) so in day 3 baby is dehydrated and jaundice. Bowel is not moving so a lot unconjugated bilirubin goes back to the liver trough enterohepatic circulation. Tto: hydrate + phototherapy + teach mom
Breast-milk jaundice (mala leche, late): Feeding is great but baby gets jaundice in w2 because mom’s milk has too much beta-glucuronidase so a lot unconjugated bilirubin goes back to the liver trough enterohepatic circulation. Tto: phototherapy, the beta-glucuronidase activity in mom’s milk goes down by mo3
Biliary atresia=progressive obliterative polyneuropathy: progressive greenish-gold jaundice in the first 3w, hepatosplenomegaly, direct hyperbilirubinemia (direct!!! is more than 2mg/dl), ends up in cirrhosis.
Best initial test: US; triangular chord, no gallbladder
Most accurate test: liver biopsy
Best initial tto: Kasai, hepatic portojejunostomy
Best long-term management: liver transplant
Galactosemia: jaundice, lethargic, big liver, + reducing substances in the urine that is not glucose and bilateral leukokoria. Avoid great feeding. Associated with E.coli sepsis
Physiologic anemia of infancy: ↓Epo therefore ↓Htc around 2 mo of age because the baby is now on a very oxygenated state
Only indirect bilirubin causes kernicterus!!
D.D. of respiratory distress on the baby:
RDS:
Premature baby w intercostal retraction, flaring, grunting and tachypneia
Pathophysiology: increased alveolar surface tension → atelectasis → R to L shunting
Most specific test: lecithin(phosphatidylcholine)/sphingomyelin on amniotic fluid >2:1
Best prevention tto: betamethasone
Best first measure: O2/Continuous positive airway pressure ventilation, if fails give surfactant
Best initial test: Rx; white everywhere=ground glass=reticulogranular=atelectasis, air bronchogram
Best long term management: surfactant (trough intubation)
Transient tachypnea:
C-section baby that is only tachypneic
Best Dx test: Rx; all dark=air trapping, white lines on the lung fissures (Kerley B lines)=fluid
1) IV fluids 2) Monitor O2… =)
Neonatal polycythemia:
RF: delayed cord-clamping, twin-twin transfusion, intrauterine hypoxia, genetic abnormalities
Tachypnea, irritability, plethoric baby, hypoglycemia, hypocalcemia
Hematocrit >65
Rx is normal
Meconium aspiration:
Post-term or baby with fetal distress during birth very sick, grasping
Best Dx test: patchy
1) intubate and suction meconium before the 1st breath 2) ventilate (different form resuscitation on baby w no meconium where you will put an O2 mask)
Diaphragmatic hernia:
Very sick baby with scaphoid abdomen
1) intubate
Neonatal sepsis prophylaxis and MC organism:
Ampi + aminoglycoside
If meningitis suspected: ampi + cephotaxine (crosses BBB)
Early onset bugs, 1week: Group B strep (agalactiae), E.coli, listeria
Late onset bugs, 2-4weeks: Staph epidermis
Causes of osteoporosis in children:
Osteogenesis imperfecta (MC genetic cause of osteoporosis)
Ehlers-Danlos
Marfan
Homocysteinuria
McCune-Albright syndrome= polyostotic fibrous dysplasia
Vaccines in peeds:
Cannot use with immunocompromised: MMR, varicella, rotavirus, intranasal influenza
Catch-up: you pick up when you left of, give the first batch of vaccines that were not given and then refer to the catch-up schedule to keep on going
Unknown status: start form the beginning
Preterm infants: start at the same time as a normal kid except the 1st dose of hep B
Do not repeat if severe anaphylactic reaction
Hep B: day 1 (or when baby is 2kg)→ 2mo → 6mo
DTaP: 2mo → 4mo → 6mo → 15mo → 4y → 12y (Tdap)
If they get a severe reaction under 7: keep calendar w DT
If any dose left in older than 7give: Tdap
Pregnant at 27-36: Tdap
Every 10 years and after injury: Td
Rotavirus: 2mo → 4mo → (6mo)
If the kid has not gotten after 2y he does not need it
Contraindicated if intussusception
If kid has gotten immunoglobulins in within ~year wait a few months to give the vaccine
Polio (Salk): 2mo → 4mo → 6mo → 4y
Hib: 2mo → 4mo → (6mo) → 12mo
After 5y if child does not have the vaccine he does not need it
Pneumococcus 13 (conjugated): 2mo → 4mo → 6mo → 12mo If sickle/asplenia/immunocompromised add 23 (unconjugated): 2y → 7y
MMR + varicella: 12mo → 4y
If HIV but not HIV-related infection and CD4/lymphocytes>15%: give the vaccine, if not you wait until those conditions are met and give it
If kid has gotten immunoglobulins in within ~year wait a few months to give the vaccine
You can get varicella-associated disease after the vaccine
If kid lives w a non-immunized you still give the vaccine to the kid
HepA: 12mo → 18mo
Meningococcal: 12y → 16y!!!
Influenza: start at 6mo every year
HPV: 11-12 yo w 2 doses separated by 6mo, if the pt receives the vaccine after 15yo you need to give 3 doses
Egg allergy does not prevent you to get any vaccine
Post-exposure prophylaxis in under-immunized:
Measles:
0-6mo: if mom is not immune give IM Ig
Immune deficiency/pregnant: IM Ig
All others: vaccine (if it is a kid, give the 2 doses of the normal vaccination calendar as this never happened)
Varicella:
Healthy babies up to 12mo: nothing if mom is vaccinated (if mom is unvaccinated IVIG)
Immune deficiency/pregnant: VZIG
Baby delivered form mom with a rash (also if shows up 5d before to 2d after delivery): VZIG, if not within that time you do nothing
All others: vaccine
Mumps, rubella: nothing
Hep B: Ig + vaccine in different arms, repeat vaccine at 1 and 6mo
Hep A: Vaccine within 2w of exposure
If less than 1 year/immunocompromised/chronic liver fx: Ig
Tetanus:
Clean: Td
Dirty, saliva, puncture, avulsion, crush, burns, frostbite, gunshot, IVDU: Td + Ig
Rabies: Ig + vaccine after potential exposure if animal not available to observe for 10 days
Ig on the day of exposure and vaccine on days 0, 3, 7, and 14 after exposure
Meningococcus: rifampin, ceftriaxone or ciprofloxacin (in adults) even if vaccinated
Pertussis: macrolides (azithromycin if less than 1mo) even if vaccinated. But only if:
a) household contact
b) third trimester pregnant, infants < 12 months, immunodeficiency
c) exposed who have close contacts with high-risk persons
What are the vaccines given at 4-6y? (4)
What are the vaccines given at 12y? (3)
4-6y: DTaP, Polio, MMR, Varicella
12y: HPV, Meningococcal, Tdap
Key clinical findings in bronchiolitis (RSV):
Wheezing + tachypnea
D.D. with 1st asthma episode: brother that got a cold right before, very little kid (less than 2 years)…
Definitive dx: nasopharyngeal swab
Management: not Rx, only careful follow up. If severe put them on PICU and give ribavirin
Prevention: palivizumab to preemies, pulmonary disease… younger than 1y Nov-March 1/mo
Staccato cough on a 1-3mo kid indicates:
Short runs of a short cough (ta-ta-ta-ta-ta)
Chlamydia trachomatis, form the birth canal, peripheral eosinophilia
Tto: macrolides
D.D. of neonate with no meconium after 36h and abdominal distention:
1) Rx:
Asymmetrically distended loops + ground-glass/speckled on the RLQ: microcolon in meconium ileus (doughy appearance of the belly) → gastrografin enema → sx of fails → sweat test (Dx by ↑x2 sweat tests/2 copies of CFTR)
If you see rectal prolapse think:
CF, do a sweat test
Trichuriasis
- Also if you see nasal polyps do a sweat test
The most common presentation of CF is:
The MCC of infection before 25yo in CF:
The MCC of infection after 25yo in CF:
The most deathly infection in CF:
Presentation: steatorrhea with vitamin loss, tto: pancreatic enzymes + vitamines + airway clearance
Give antibiotics as soon as you see ↑sputum, fatigue… anti-inflammatories are also helpful
Triple combination Ivacaftor/Elexacaftor/Tezacaftor for pts w ΔF508 older than 12yo
Infection before 25yo: S. aureus
Infection after 25yo: P.aeruginosa
Most deathly: B. cepacia (incidence increases after 18yo), do not even intubate, they are going to die
Bronchiectasis vs Atelectasis:
Bronchiectasis: dilated → inflamed → necrosis, CF, aspergillus
Atelectasis: collapsed, Abnormal Alveoli, loss of surfactant
Sudden infant death sd prevention:
Put the baby on their back, no soft surfaces or materials (pillows, blankets), no overheating, no bed starting, no cigarette smoke
Management, most accurate dx test and best long term management of allergic rhinitis and atopic dermatitis:
Allergic rhinitis:
Presentation: allergic salute, crease on the nose, allergic shiners, pale blue turbinates, pharyngeal cobblestoning
Most accurate dx test: skin test (if wide spread dermatosis or previous anaphylactic reaction you cannot do skin test so do blood test)
Tto: (2nd generation antihistamine → +) nasal steroids (most effective) → refer to the allergist
Best long term management: desensitization, most reason for it nor working is non-compliance
Atopic dermatitis:
Presentation: erythema, pruritic, excoriations, lichenification
Tto: emollients (bc transepidermal water loss), do an allergic workup, steroids if flare up!! triamcinolone (start with class 7 that does not have Fluor and keep going stronger 6,5,4… you cannot put fluorinated on face and intertriginous areas)
Atopic march:
Atopic dermatitis → food allergy → allergic rhinitis → asthma
Best test for allergies:
Food elimination and challenge test in a controlled environment
Best test to evaluate asthma:
Office: spirometry, best to evaluate flare ups and to follow medication, you can do it after 5yo
Home: peak expiratory flow meter
What do you do with an asthma kid on the ICU?
1) ABCs
2) Pulse oximetry and give O2 if less than 92%
3) Steroids PO/IV asap
4) Inhaled SABA
5) Inhaled SABA + ipatropium
6) Inhaled SABA (no more ipatropium because HR will increase too much)
7) 4h of observation, if does not deteriorate and SaO2> 92%
8) do PEF, if >70% of personal best
9) Discharge: 3-7 days oral steroids + SABA every 3h + continue daily controller
No Rx, antibiotics or ABGs*
* No ABGs unless respiratory distress and no breath sounds, if ABGs shows that the CO2 is normalizing you need to intubate!
We don’t like to intubate people with chronic pulmonary disease because when you use ventilator settings you can cause a pneumothorax, do permissive hypercapnia and low PEEP to avoid barotrauma
Strabismus management:
Best initial test (in kids): corneal light reflex, to make sure is not pseudostrabismus (asymmetric epicentral folds)
Best next step in management: patch the good eye
Best long term tto: surgery
Causal organisms and new best step in management on conjuntivitis:
Bacterial: bilateral
Organisms: Strep pneumo, Nontypeable H. influenza, Staph aureus
BNSM: topical antibiotics, if does not improve go to systemic
Viral: starts on one eye and spreads to another
Best prevention: hand washing
Tto: cold compresses
Periorbital vs orbital cellulitis:
Organisms: Strep pneumo, Nontypeable H. influenza, Staph aureus
Periorbital:
Presentation: Gradual swelling, no fever, no ophthalmoplegia or proptosis, normal vision
BNSM: oral antibiotics, follow up in a few days if not improves admit!
Orbital: Progresses form sinusitis
Presentation: Acute, fever, vomiting, ophthalmoplegia and proptosis
BNSM: admit + IV nafcillin + ceftriaxone + CT scan w contrast, if does not improve w need surgical drainage
Innocent murmur on a kid:
No symptoms, no cyanosis Grade I, II, no thrill No diastolic (unless is a venous hum) S3 Normal pulses (you cannot hear the foot pulses which is normal)
Still’s murmur: 3-6y, soft systolic ejection murmur, ejection of blood trough the infundibulum, decreases when sitting or standing
Aortic outflow murmur: very similar, upper right sternal border, in young athlete, decreases when sitting or standing
Venous hum: continuous murmur on the top of the left clavicle, sounds like the ocean, goes away in supine or with next flexion
Peripheral pulmonic stenosis: up tp 1y, radiates to the axillae
VSD presentation:
Large:
Holosystolic murmur on the left sternal border, bc of the blood going trough the VSD
+
Low pitch diastolic rumble on the apex, because high volume is retuning to the heart
* Sometimes the murmur is found after 1 mo of age because the drop of pulmonary vascular resistance over time which makes the LV pressure higher than the RV pressure and facilitates the shunt
Small:
Systolic ejection murmur
+
Widely split second S2 (this is how you differentiate it form Still’s murmur)
Presentation: tachypnea is the 1st sign because the blood accumulates on the pulmonary vessels and makes breeding harder, then you get RVHF bc of RV hypertrophy so you get JVD, hepatomegaly and edema. Finally you get LVHF because of LV fluid overload
Wide splitting of S2: splitting continues to change w respiration, bc the pulmonary valve closes later bc of more blood on the RH
ASD presentation:
Systolic ejection murmur (crescendo-decrescendo) on the mid sternum that radiates to the pulmonary area because more blood has to leave the RV to go into the pulmonary infundibulum, on all ASDs
+
Low pitch diastolic rumble over the tricuspid area, because high volume is coming to the RA and has to go to the RV, on significant ASD
Wide fixed splitting of S2: does not change during respiration, bc the RA is distended at the maximum due to the extra blood input on inspiration the RA cannot be more distended of what already is
Endocardial cushion defect presentation:
Is like a mix between ASD and VSD!
Loud thrill systolic ejection murmur because all the blood on the LV goes into the narrow infundibulum on the upper sternum
+
Wide fixed splitting of S2
Can present early with mild intermittent cyanosis (as in troncus), when the kid is crying or sick
ECG: biventricular hypertrophy
PDA presentation:
Continuous machine-like murmur radiates to the scapula, carotids and axilla (everywhere)
In systole some of the high flow coming from the aorta passes trough the ductus, and in diastole a lot more blood can pass trough the ductus because it is slower and sitting right there, also diastole makes more time of the cardiac cycle than systole
↑ PP systolic is a little decreased but diastolic pressure is very decreased causing BOUNDING pulses! (you can feel the feet pulses) and hyperdynamic precordium
Pulmonary edema!
D.D. of undetected PDA vs aortic coarctation:
Undetected PDA: BLUE
PDA stays open:
Continuous machine-like murmur at the left infraclavicular area
Bounding pulses (as in AR) because of the L→R shunt there is increased LV preload so ↑systolic; and because the flow gets lost into the R circulation ↓diastolic
L→R shunt at the beginning but the R❤️ and lungs get a lot of pressure so ↑pulmonary flux can develop R❤️failure. Then R→L shunt so lower body CYANOSIS
No coarctation: no weird pulses, just BLUE!
Coarctation; POSTductal=JUXTAductal: NO LOWER PULSES
Coarctation: bounding PULSES (↑TPR) JUST in upper body and NO PULSES (↓BP) in lower body
Systolic ejection murmur or even continuous murmur ON THE BACK ±S4
Because of the upper body ↑TPR can lead to L❤️ failure, aortic dissection, stroke, endocarditis, endarteritis…
No shunt: same flow through all circuit
PDA closes: no machine-like murmur and not blue, just ABSEBT PULSES
No cyanosis because tissues autoregulate their blood flow Q=P/R
NBSM: Echo
Both present very similarly: teenager with leg cramps
Coarctation; PREductal=TUBULAR HYPOPLASIA: mixture
Very different for the other 2: half blue baby associated with turner
Coarctation: bounding PULSES in upper body and NO PULSES in lower body
+
PDA stays open:
Continuous machine-like murmur
Also contributing to the bounding pulses in the upper body, if closes baby goes into shock
R→L shunt because of the low aortic pressure: lower body CYANOSIS
Coarctations are associated with bicuspid aortic valve and intracranial aneurisms and Rx 3 sign
Click heard during mid-systole. Dx?
MVP, best heard on left decubitus
Valsalva and standing up moves the click closer to S1 and the murmur gets louder
Happens at mid-systole because is when the valve comes down
ToF presentation:
MC cyanotic anomaly
Harsh crescendo-decrescendo systolic murmur
O2 challenge test to differentiate form pulmonary disease: will not correct with O2, will only minimally increase
Do not intubate, no need
ECG: RV hypertrophy
Rx: black lungs and boot shaped heart (the RV is displaced up)
Echo: will give you the pulmonary gradient to see how bad it is
1) Balloon atrial septoscopy
2) Blalock-Taussig=systemic pulmonary shunt: left subclavian A to the left pulmonary A → 3) surgery
Tricuspid atresia presentation:
Cyanosis in a newborn
ECG: Huge left axis deviation! due to RV hypoplasia
Rx: black lungs
Ebstein anomaly presentation:
Early presentation: baby
Rx: black lungs and a box-shaped heart, huge heart!
ECG: large P waves on the right precordial leads
Echo: huge RA very small RV
Late presentation: adolescent
Present with an SVT
1) break with ice water, adenosine or cardioversion
2) ECG: WPW
Transposition of the great arteries presentation:
MC cyanotic anomaly at birth
Rx: egg-on-a-string sign, white lungs, increased markings
Truncus arteriosus presentation:
Loud thrill systolic ejection murmur because all the blood on the LV goes into the narrow infundibulum on the upper sternum (as in endocardial cuishon defect)
+
Single loud S2
Respiratory distress and mild intermittent cyanosis (as in endocardial cuishon defect)
Happens on the 1st week
ECG: biventricular hypertrophy
Rx: white lungs, increased markings on a neonate
Tto: 1) pulmonary band on the pulmonary truncus to allow more blood into the aorta 2) surgery
Hypoplastic LH presentation:
Mild intermittent cyanosis and will get cariogenic shock
Systolic ejection murmur
+
S2 wide fixed splitting
Rx: big heart, white lungs, increased markings
ECG: tiny V5 V6 R waves
Echo: big RA and RV
Look for other dismorpholopgic findings: look at the karyotype (trisomy 18!!), head CT scan, renal ultrasound
Total anomalous pulmonary venous return presentation:
Normally the pulmonary veins come back to the RA
Systolic ejection murmur \+ Mid-diastolic low pitched rumble (because of the ASD) \+ S3 \+ S2 wide fixed splitting
Rx: snowman heart, two heart shadows one on top of the other (the top one is the SVR coming back to the RA, the bottom one is the heart)
ECG: Right axis deviation (RA and RV are huge)
JONES criteria:
You need 2 major+ 2 minor or only Sherman’s chorea
Major: Joints ❤️ carditis Nodes Erythema marginatum Sherman's chorea
Minor:
D.D. of villous vomiting on an infant:
Duodenal atresia: Recanalization failure Villous vomiting Double bubble No abdominal distention bc the distended area is under the ribs
Jejuno-ileal atresia:
Intrauterine vascular accident leading to segmental infection and resorption of fecal intestine
More than 2 bubbles
Abdominal distention
Malrotation:
Clockwise 270deg rotation does not happen well
Occasional cramps w intermittent malabsorption
Then, twists and presents as a volvulus, not immediately after birth, within ~1y
Where can we get toxic megacolon?
Hisprung
C. difficile
Ulcerative colitis
When do you have to do imaging after UTI on a child?
First 2y of life:
Renal and bladder US after 1st UTI w fever, if abnormal get voiding cystourethrogram (maybe renal US before)
Older than 2y:
Voiding cystourethrogram!! after the 2nd UTI w fever
Same for boys and girls
Henoch-Schonlein purpura presentation:
After a common cold you get a rash on the lower part of the body +
1 of: IgA deposition, abdominal pain (intussusception), arthritis on the legs or back of the arms, renal vasculitis (leading cause of morbidity)
Symptoms can show up up to 6mo! after the beginning of the disease
When and how do you screen for DM2 on kids?
Screen kids with >85% BMI + 2 RF (between 10-19y, non-white, family history, metabolic sd)
Screening: fasting blood glucose/2 y starting at 10 or onset of puberty
BNSM: diet and exercise, if not metformin
When do you start giving Fe to a kid?
Fe fortified cereal starting at 4-6mo
+
Do dot introduce cows milk up to 1 year because it has too little Fe and bad Fe bioavailability
Sickle cell trait and disease presentation:
Trait: isosthenuria, UTIs, splenic infraction at high altitude
Most common complication: hematuria from sickling in the renal medulla
Disease:
Howell-jolly bodies after 5y of age (before that splenic sequestration also causing pancytopenia; long term tto: splenectomy)
Dactilitis after 6y
Parvovirus aplastic anemia: emergency tto: transfusions; final tto: IVIG
MCC of acute chest sd: mycoplasma pneumonia (bc of s. pneumo vaccination)
Acute hemolytic crisis due to gallstones
MCC of CVA: Middle cerebral A stroke (screen with transcranial doppler, if abnormal trascranial blood flow velocity transfuse)
Renal papillary necrosis (solve w kidney transplant)
Genreal tto: hydroxyurea (avoid in pregnancy)
Hair on end skull appearance indicates:
β-thalassemia
Which kind of GI bleed presents with high BUN?
Upper GI bleed, actually can be used to differentiate upper form lower GI bleed
Why do you give PPI drip to a GI bleeding patient?
Because when the stomach pH is higher patients coagulate better
How can you decrease TG fast on a hypertriglyceridemic pancreatitis:
Insulin (or heparin) turn on LPL; we don’t give heparin on pancreatitis because it will increase the bleeding
How do you hydrate a cirrhotic patient?
Albumin=colloids (also make sure you put then in a low Na diet even if they are hyponatremic)
To diagnose hepatorenal syndrome you need to hydrate with albumin for 2 days to rule out pre-renal azotemia
Spontaneous peritonitis can lead to hepatorenal syndrome, to prevent spontaneous peritonitis do not drain too much fluid from the Spontaneous peritonitis, give antibiotics and albumin!
Best treatment for focal seizures:
Carbamazepine
When can you remove antiepileptics on a patient?
If they have no seizures for 5 years you can taper down the antiepileptic slowly
What is neuromyelitis optica?
Presents with optic neuritis and myelitis; attacks the optic n. and the spinal cord but nothing in the brain
Due to an antibody that attacks an aquaporin channel
MRI: no plaques in the brain, but you will see plaques on the spinal cord
Tto: steroids, rituximab
Sudden flare of psoriasis. Associations?
HIV Strep pharyngitis Skin tx (Koebner phenomenon) Systemic steroids withdrawal Antimalarials Indomethacin Propranolol
Tto of lupus nephritis:
Mycophenilate (not in pregnancy)
What is the direction of the ductus arteriosus shunt in utero? and on a normal infant with a PDA? and on aortic coarctation tubular hypoplasia type?
In utero and in persistent pulmonary HT of the newborn: R → L; Deoxygenated blood from the pulmonary A. to the descending Aorta
PDA: L → R; Aorta → Pulmonary; Oxygenated blood from the Aorta. to the pulmonary A.
Aortic coarctation PREductal=TUBULAR HYPOPLASIA: R → L; Deoxygenated blood from the pulmonary A. to the descending Aorta
- Preductal=new baby. Here keeping the doctors open will allow blood flow to the lower extremities even if it is deoxygenated blood!
When the ductus arteriosus closes in the first week of life, the left side of the heart then sees a massive increase in afterload, leading to heart failure
Hyponatremia DD:
-CHRONIC:
–Hypo-osmolar:
—- Hypovolemic:
Dehydration: RAAS activated and thirsty, low urine Na and high urine osmolarity; tto: saline
Addison’s: RAAS activated and thirsty but high urine Na and low urine osmolarity because there is no Aldo; tto: Dexamethasone
— Euvolemic:
SIADH (thiazides!, SSRI, carbamazepine, head tx, brain tumor, pneumonia): low plasma osmolarity and high urine osmolarity, BUT NORMAL/HIGH Urine Na >20 because RAAS is suppressed, low BUN and uric acid in blood; tto: fluid restriction ± stop meds/furosemide/demeclocycline/-vaptams
You need to rule out Addisons and HYPOTHYROIDISM to diagnose SIADH
Hypothyroidism: T4 is needed -permissive- to get rid of water. Tto: levothyroxine
Potomania: low urine Na and urine osmolarity; it is a lot easier to get hyponatremic if you don’t eat food, which is what happens in beer potomania (other alcohols have more Na) or in tea and toast diet
— Hypervolemic:
Edema but low effective circulating vol: CHF, nephrotic, cirrhosis (anyone with edema has high total body Na) RAAS activated and thirsty, low urine Na!! and high urine osmolarity; tto: fluid restriction + treat the underlying disease
– Isotonic: lab error in MM, pseudohyponatremia: check protein or lipids
-ACUTE:
Ecstasy and marathon runners. Tto: hypertonic saline
–Hyper-osmolar: due to mannitol or hyperglycemia. Here there is low serum sodium and high plasma osmolarity
How many Na mEqv can you give to correct hyponatremia?
6/8 mEqv in 24h in chronic hyponatremia
2 mEqv in one hour until the seizures stop in acute hyponatremia
Hypernatremia DD:
Diarrhea on a pt that is not drinking and severe sweating (sweat is hypotonic): RAAS is activated and there is high urine Na and high urine osmolarity. Tto: nr saline, then hypotonic solution
DI: low urine Na and low urine osmolarity. Tto: vasopressin if central/thiazides or NSAIDs if peripheral (thiazides cause decrease Na delivery to the macula densa and the proximal tubule reabsorbs a lot Na and therefore water)
How many Na mEqv can you decrease on a day to correct hypernatremia?
10 mEqv in 24h
Hypomagnesemia causes:
Hypokalemia: you need Mg to hold on to K
Hypocalcemia: you need Mg for PTH to work, also ↓Mg will lead to ↓ PTH
Both hypokalemia and hypocalcemia prolong QT =(
How many K mEqv can you give to correct hypokalemia?
10 mEqv/h (you have to go even slower because it is very irritating)
Why do you get acidosis in RTA type 4 and other causes of hyperkalemia?
Hyperkalemia decreases ammonia production on the PCD so hydrogen cannot be excreted and you get acidotic
How do you treat a hyperchloremic metabolic acidosis?
Non-anion gap metabolic acidosis = hyperchloremic metabolic acidosis
Tto: 1) Check the K 2) if pH is less than 7.2 give Na bicarb if the K is not low!
To treat anion gap metabolic acidosis you can also give bicarb unless is a DKA or lactic acidosis
↑PT ↑PTT ↓Hb ↑D-dimer ↓fibrinogen. Dx?
DIC or liver failure!
Platelets ↓ in liver failure
The liver makes fibrinogen
On liver failure factor 8 and VW will be normal
How do you treat itching in primary biliary cirrhosis?
Cholestyramine
DD of Diverticulosis and Angiodysplasia:
Diverticulosis: not missed in colonoscopy, arterial bleeding! bright red blood
Angiodysplasia: can be anywhere in the colon and can be missed in colonoscopy, venous bleeding so brown blood. Associated with aortic stenosis, VW factor deficiency and advanced renal disease
What should you check on a parting with statin myopathy?
TSH, subclinical hypothyroidism is associated with increased risk of statin myopathy
What is the timing of the acid-base disturbances after aspirin intoxication?
Minutes: respiratory alkalosis
Hours: + high anion gap metabolic acidosis
Screening in kids:
Autism: 18mo-2y Depression: 12y Visual acuity: 4y HIV once less than 18y Dyslipidemia: once 17-12y
RF of atonic uterus:
Atonic: soft, above the umbilicus
RF: twins, operative delivery, rapid delivery, meds
Particularities on kidney dysfunction:
Careful if Cr is high: Metformin (if GFR>45 you can give full dose, if 30-45: half dose) Contrast (spiral CT angio for PE) High intensity statin Colchicine Bisphosphonates
Thiazides will not work, change to a loop
BNP will be overestimated
Mantoux will give you false negatives
HbA1C is not reliable, it can be underestimated (also not reliable in iron def, it can be overestimated)
PR depressions on ECG suggest:
Pericarditis
MCC of Cryptogenic stroke:
Stroke that you do not know the cause
Dx: loop recordings
Not holter because is only for 2 days
MCC: pt is going in and out of A. fib
Aspirin x2w and then anticoagulation
Which drugs can increase PRL?
SSRIs, TCAs Narcotics Cocaine Risperidone Pregnancy (monitor by eye exams bc PRL will be high anyways) Hypothyroidsm
They will not give you PRL above 100-200
INF-α SE:
Thyrotoxicosis or hypothyroidism
How do you monitor Hyper/Hypothyroidism tto? What are the effects of Hyper/Hypothyroidism in BP?
Hyperthyroidism: T3 and T4
Hypothyroidism: TSH
Hyperthyroidism: increase systolic pressure, wide PP
Hypothyroidism: decrease HR, increase diastolic pressure, narrow PP
What is important to check on Graves disease?
K, because of hypokalemic periodic paralysis
Normally patients present paralyzed after they eat a high carbohydrate meal or after they do exercise. It is associated with Graves but can happen outside it, if in Graves it will go away after you treat Graves
Löfgren sd. treatment:
Erythema nodosum + arthritis + bilateral pulmonary infiltrates
NSAIDs
If they have hypercalcemia you give steroids
DD of ↑Ca:
↓ PTH:
1) Hypercalcemia of malignancy: Ca higher than 14
2) Vitamin D toxicity
↑ or normal PTH:
3) Primary hyperPTH: urinary Ca is high. It is associated with pseudogout, you can have a flare of pseudogout after the parathyroidectomy. Vit D deficiency could mask primary hyperPTH.
Indications of parathyroidectomy if: symptoms, ca more than 11.5, if GFR less than 60, age less than 50, kidney stones, osteoporosis and if urinary ca is more than 400mg/day. Make sure you check vit D before then parathyroidectomy because you can get extreme hypocalcemia after the sx
4) Hypercalcemic hypocalciuria: urinary Ca is low
DD of secondary hyperparathyroidism:
Vit. D deficiency: Ca can be normal, 25-hydroxy vitamin D will be ↓, P will be ↓
Real failure: P will be ↑
How do you calculate PAO2?
At sea level= 150-(aCO2/0.8)
Not at sea level=(713-mmHg)*0.21-(aCO2/0.8)
* subtract 1mmHg per every 10m ascend
Epitroclear lymphadenopathy + grey lesions on the mouth indicate:
Secondary syphilis
Herpangina also has grey lesions on the back of the mouth
Screening guidelines:
Colon ca: 50-75yo colonoscopy every 10 years/ fecal blood annually/ fecal immunochemistry annually
If you find:
1/2 polyps less than 1cm: repeat in 5y
3-10 polyps or any polyp >1cm or if villous: repeat in 3y
+ 10 polyps or any polyp >2cm or stage I-III ca: repeat in 1y (if + 10 polyps do genetic studies + endoscopy looking for stomach polyps)
FAP: 10-12yo colonoscopy every 1/2y + 30 yo EGD
Lynch: 20-25yo colonoscopy every 1/2y + 30-35yo endometrial biopsy + 30yo EGD and H.pylori biopsy for gastric ca.
First degree relative before 60: 40yo/10y before dx of relative colonoscopy every 5y
IBD pancolitis: 8y after onset colonoscopy every 2/3y
Breast ca: 40-75yo mammogram every 2y
BRCA 30-35 breast MRI annually, if more than 35 Mx + breast MRI annually
Lung ca: 50-80yo with more than 20p/y and that did not quit on the last 15y low dose chest CT every year
Cervical ca: 21-65**yo cytology every 3y/ of older than 30yo better cytology + HPV co-testing/5y
- If less than 25 also gonorrhea and chlamydia, if immunosuppressed screen every year
- Stop at 65 yo if all good for 10 years and never HSIL stop testing, also stop if hysterectomy for benign reasons
Bone densitometry: women over 65yo/ at risk of osteoporosis due to alcohol, tobacco or skinny
AAA: Men 65-75yo who ever smoked
Prostate: 55-69 consider PSA (confers reduced ca. mortality but tto has SE and most men die from other causes)
Hep C: Anyone between 18-70yo once
HIV: Anyone 15-65yo once by antibodies
Lipid profile (measure HDL and total cholesterol to calculate ASCVD): asymptomatic females starting at 40-45yo and asymptomatic males starting at 35yo every 3-5y, only measure before if pt has family history of familial hyperlipidemia, MI or stroke at very young age. Children 1 time at age 9-11 and 17-21yo
DM2: 40-70yo and BMI>25/ any age w HT, screen with fasting blood glucose/HbA1c
Retinopathy and Alb/Cr screening after dx of DM2 and 5y after dx of DM1 every year; then every year. Monofilament testing every year. Serum lipid studies every year.
ECG: once at 65yo
Vision: first at 4yo
Audition: in hospital
BP: >18 yearly, if systolic 120-129 every 6mo
Chihosis: upper endoscopy/year + liver US and α-fetoprotein/6mo
If it looks like DKA but your ketones are negative, what should you check?
β-hydroxybutarate
Same in alcoholics
DM2 for several years that comes in chronic diarrhea (>8w). Dx?
Small intestinal bacterial overgrowth. Confirm by a carbohydrate/H+ breath test. Tto: rifaximin
Same after gastric bypass and in scleroderma
DM2 for several years that comes in with orthostatic hypotension. What should you do?
Stress test to look for silent ischemia. They cannot feel the pain of an angina!
Treatment for gastroparesis if pt has extrapyramidal side effects with metoclopramide:
Promethazine
Adrenal mass workup:
Irregular, heterogeneous, large: ca → adrenalectomy
Regular, small:
No symptoms: incidentaloma → check plasma free metanephrines and low dose dexamethasone bc both a pheochromocytoma (vascular mass) and Cushing can be asymptomatic
HT: Aldo/renin ratio + check also free metanephrines and low dose dexamethasone
SE of testosterone replacement:
Hyperviscosity, blood cloths
Prostate ca.
HT
Pt with hypertension presents with polycythemia and angina at night. Dx?
OSA, order pulmonary function test
How can you treat MRSA pneumonia?
Ceftaroline+ azithromycin
Azithromycin, ceftriaxone and vancomycin
When cannot you use Daptomycin to treat MRSA?
In MRSA pneumonia because is inhibited by surfactant
How do you work up ascitic?
SAAG: serum albumin-ascitis albumin
More than 1.1: look at the total protein on the ascitic fluid
→ less than 2.5: portal HT=cirrhosis
→ more than 2.5: CHF or hepatic vein thrombosis
Less than 1.1: look at the total protein on the ascitic fluid
→ less than 2.5: nephrotic sd
→ more than 2.5: TB (high lymphocytes on ascitic fluid; do a peritoneal biopsy and culture for TB), ca, pancreatitis
Thickened sub-epithelial collagen band on postmenopausal woman. Dx?
Microscopic colitis (MC) Presentation: nocturnal diarrhea with macroscopically intact mucosa Pathology: intraepithelial lymphocytic infiltrates in lymphocytic MC or thick, subepithelial collagen bands in collagenous MC Causes: NSAIDs, PPIs, SSRIs
Management:
1) Stop drugs that can cause it
2) loperamide and bismuth
3) budesonide
Early onset dementia, arthritis and malabsorption on an old man. Dx:
Whipple disease
Duodenal ulcer on bleeding pt with negative H.pylori. NBSM?
Stool antigen/urea breath test because blood can give you a false negative for H. pillory
Meningitis after neurosurgery. Tto?
Cefepime for pseudomonas and vancomycin for MRSA
Pipe-tazo doesn’t cross the BBB
How do you cover listeria in penicillin allergy?
TMP-SMX
Hearing loss with reddish hue behind the tympanic membrane indicates:
Otosclerosis
Paradoxical improvement on noisy environments (paracusis of willis)
Main DD of DVT:
Ruptured baker cyst
When should you endoscopically biopsy a pancreatic cyst?
When should you drain a pancreatic pseudocyst?
Biopsy a cyst: More than 3mm Solid components or calcifications Ductal dilation (main pancreatic duct involvement) Thickened or irregular cyst wall
Drain a pseudocyst (CT guided percutaneous biopsy):
Larger than 5cm
Symptomatic
Aspirate by ERCP!! (transpapillary approach), also by cystogastrostomy or cystoduodenoscopy
Which nerva can be compressed by a Colles fracture?
Median n.
Heat exposure DD:
Heat cramps: sweating, craps, Ta is normal, no systemic findings. Tto: hydrate
Heat exhaustion: exercising into the heat, fever but less than 40 deg, nausea! cramps, no CNS dysfunction!. Tto: hydrate and cool patient (AC, shower)
Heat stroke:
Exertional: physical activity on hot and humid weather, >40 deg + CNS dysfunction (confusion) and organ damage as rhabdomyolysis, shock liver, DIC, AKI… Tto: ice water immersion, IV with cool fluids, cool rectal fluids or NG tube, spray and fans
Classic: people with problems thermoregulating (anticholinergic medications, Parkinson, DM, alcoholism, cirrhosis) they stop sweating. Tto: evaporative cooling
Causes of hypoxemia:
V/Q mismatch with ↓ Q=Increase in death space: thrombus, pulmonary embolism (ends up diverting Q to other areas and therefore ↓V/Q)
V/Q mismatch with ↓ V: severe asthma, pneumonia, CF (partial). It’s extreme is shunt
R-L shunt: peanut (complete), atelectasis (ARDS, pneumothorax), congenital heart defects
Diffusion impairment: sarcoidosis, fibrosis, emphysema, pulmonary edema (left heart failure)
Hypoventilation: obesity, chest restriction (scoliosis), COPD, myasthenia gravis, opioids, altitude
Hermaphroditism DD:
5-α-reductase deficiency:
XY, female external genitalia with NO BREAST, male internal genitalia (cryptorchid testes)! female at birth and virilization at puberty, ↓ or nr testosterone ↑DHEA
Androgen insensitivity:
XY, female with normal breast, NO PUBIC HAIR, primary amenorrhea and cryptorchid testes
Classic congenital adrenal hyperplasia:
XX, baby girl with ambiguous genitalia and normal internal genitalia, after 1-2 w develop hypotension
Aromatase deficiency:
XX, baby girl with ambiguous genitalia and normal internal genitalia, in puberty they get even more virilized, do not develop breasts and do not menstruate. ↑testosterone ↑androstenedione and ↓ undetectable estrogen
Nonclassic congenital adrenal hyperplasia:
XX, female at birth and virilization at puberty (does not reach clitoromegally), can have irregular menses, no male internal genitalia, no problems with BP
XY, boy with precocious puberty, advanced bone age and low LH. Is one of the causes of peripheral precocious puberty
Sertoli-Leidig tumor: rapid onset hirsutism w clitoromegally, male-pattern balding and increased muscle mass, high testosterone
How do you treat Mg toxicity?
Ca gluconate
Infections that affects palms and soles:
CaRS:
Coxsackie A: hand-foot-mouth disease in herpangina
Rickettsia Rickettsii: Rocky Mountain Spotted Fever (maculopapular)
Secondary syphilis (maculopapular, hyperpigmentation)
Keratoderma blennorrhagica in reactive arthritis (hyperkeratosis, most in feet)
Toxic shock sd (desquamating)
Kawasaki (desquamating)
Scarlet fever
Disseminated gonococcal infection (pustular lesions)
Pulsus bispheriens or biphasic pulse indicates:
Aortic regurgitation
What are the main exceptions in manouvers that modify murmurs:
Valsalva and standing decrease preload but increase HCOM and MVP murmurs
Squatting increases preload and afterload but decreases HCOM and MVP murmurs
Handgrip increases afterload but decreases AS and MS murmurs!! as they are forward murmurs
Inability to palpate the point of maximal apical impulse indicates:
Pericardial effusion
Which type of muscle is affect in scleroderma?
Smooth muscle, affects the lower esophagus
Post-partum woman with decreased sensation on the anteromedial thigh and absent patellar reflex:
Femoral n. neuropathy, due to hip hyperflexion during second stage of labor
First line tto. of bipolar major depression:
Tto for pts with severe bipolar disorder and frequent mood episodes:
Bipolar major depression: lurasidone, quetiapine
Severe bipolar: lithium/valproate + 2nd generation antipsychotic (quetiapine)
How do you differentiate a stroke on the pons form a stroke on the internal capsule?
Internal capsule (above the pons): contralateral face w normal forehead, contralateral arm and leg
Pons or below: ipsilateral face w affected forehead, contralateral arm and leg. The pons makes the change
DD of air in GI or biliary tract:
Gallstone ileus: air on the biliary tract + RUQ pain and NO fever but + symptoms of GI obstruction. Do enterolithotomy
Emphysematous cholecystitis: air on the gallbladder wall + RUQ pain and fever on DM pt. Do emergency cholecystectomy
Necrotizing enterocolitis: intramural air on the wall of the bowel ± portal venous gas on a preemie
Emphysematous pyelonephritis: air on the kidney’s wall on DM pt
Which patients need spontaneous bacterial peritonitis prophylaxis?
Portal HT
Pt who had SBP before
How do you treat acute bacterial prostatitis?
6w of fluoroquinolone/ TMP-SMX
How do you differentiate between ischemic and hemorrhagic stroke on CT?
Negative CT indicates ischemic stroke (dark)
It can also be described as a mismatch between core and penumbra (penumbra is the area that can be saved while core is probably irreversibly infarcted)
Hyperintense area and bright opacification (white) indicate hemorrhage
hat is the most common location of a rotator cuff injury?
Supraspinatus
In which occasions you can take cultures after you give an antibiotic?
Bacterial meningitis in adult with alarm signs
How do you treat tyramine-induced hypertensive crisis?
Phentolamine
Bad prognostic factor of septic shock:
Serum lactate
Pt with paroxysmal chest m. spasms and pleuritic chest pain after a URI. Dx?
Pleurodynia or Bornholm disease, normally due to coxakie B
Most important RF for cerebral infraction?
Most important RF for cardiovascular disease?
Cerebral infraction: HT (control HT also helps decrease hospitalization in HF)
Cardiovascular disease: Smoking
What is the BP goal in DM?
130/80, if more you have to adjust the medication until reaching it
Decreased residual vol. + pool of urine on the vagina. Dx?
Vesicovaginal fistula
RF: pelvic radiation, pelvic sx
What does opacification mean on a chest Rx?
Opacification = liquid: edema, pneumonia, hemothorax Hyperlucency = air: pneumothorax Haziness = atelectasis
Immunodeficiency not treated with IVIG:
IgA deficiency: supportive and bracelet to avoid transfusions
Transient hypogammaglobulinemia of infancy: no tto
SCID: IVIG only waiting for transplant, stem cell transplant
LAD
Wiskott-Aldrich
Chediak-Higashi
CGD: INF gamma infections, TMP-SMX and itroconazole prophylaxis
IVIG for:
Bruton’s agammaglobulinemia
Common variable inmminodificncy
How do you differentiate between Transient tachypnea and Respiratory distress syndrome of the newborn?
Both can have cyanosis, nasal flaring, intercostal retractions
Transient tachypnea of the newborn:
RF: prematurity, C-section
Tachypnea a few hours after birth
Due to delayed reabsorption of amniotic fluid in the alveoli leading to air trapping
Best Dx test: Rx that shows flattened diaphragm and pulmonary congestion w fluid in the interlobular fissures! (you see all dark=air trapping, white lines on the lung fissures (Kerley B lines)=fluid)
Tto: conservatory: 1) IV fluids 2) Monitor O2… =)
Respiratory distress syndrome of the newborn:
RF: prematurity
Shows up at birth!! with intercostal retraction, flaring, grunting and tachypnea
Pathophysiology: surfactant deficiency, alveolar collapse, increased alveolar surface tension
Lecithin(phosphatidylcholine)/sphingomyelin on amniotic fluid >2:1
Best prevention tto: betamethasone
Best first measure: O2
Best initial test: Rx showing bilateral ground glass opacities (white everywhere=ground glass=reticulogranular=atelectasis) and air bronchogram (air-filled bronchi surrounded by atelectasis)
Best long term management: surfactant (trough intubation)
What happens when you put the intubation tube too far so you intubate only on the right bronchus?
Air trapping immediately after the obstruction of the bronchus, then the air is reabsorbed and you get alveolar collapse also called atelectasis!
Cushing triad:
HT
Bradycardia
Irregular respirations or respiratory depression
- vs if you see hypotension and bradycardia and hypothermia where you should think neurogenic shock
- vs if you see HT, tachycardia a and tachypnea where you should think of paroxysmal sympathetic hyperactivity
What is the MCC of necrotizing fasciitis?
Strep pyogenes (group A)
Pt with gait instability that keeps falling backwards and cannot look up. Dx?
Progressive supranuclear palsy
Formication happens on:
Cocaine and amphetamine intoxication
Opioid withdrawal
Intermittent urine leakage and tender anterior vaginal wall mass. Dx?
Urethral diverticulum
Low post void residual
If you see ascites in a postmenopausal woman think of:
Ovarian ca.
Do exploratory laparotomy! as advanced ovarian cancer often spreads to the abdominal cavity, so the exploratory laparotomy with cancer resection and inspection is needed for surgical staging
Image-guided biopsy is contraindicated, as it can predispose to abdominal cavity seeding
Enlarged supraclavicular lymph in young patient:
Hodgkin lymphoma
Hodgkin lymphoma also commonly associated with pruritis!
Associated with increased LDH
Key locations of PAD based on symptoms:
Femoropopliteal artery plaque → Calf claudication
External iliac artery plaque → Thigh and calf claudication
Aortoiliac plaque → Gluteal, thigh, calf claudication and impotence
What is the best action to improve long term px after an MI?
Restoration of coronary blood flow by percutaneous intervention or fibrinolysis
When does a patient need psychotherapy vs SSRIs?
If meets the criteria for MDD the pt needs SSRIs
If it does not maybe it is adjustment disorder (reaction to an stressor that happened within 3mo) that is treated with psychotherapy
Risks of PPROM:
Placental abruption
Cord prolapse
Preterm labor
Intraamniotic infection
Upslanting palpebral fissures + hypotonia indicate:
Down syndrome
What should you think of if you see an old pt with concentric LV hypertrophy in absence of HT?
Restrictive cardiomyopathy
Signs and symptoms: concentric LV hypertrophy and non-dilated LV cavity, RHF symptoms, bi-atrial enlargement, conduction abnormalities and high BNP
Management of ruptured ovarian cyst:
Hemodynamically stable: reassurance
Hemodynamically unstable: laparoscopic cystectomy
What is the pathophysiology of vasovagal syncope?
Sinus bradycardia and sinus arrest
Parkinson’s characteristic gait:
Hypokinetic gait Shuffling gait Festinating gait Narrow base Small-stride
Reduced amplitude on foot tapping or any other repetitive movement= bradykinesia
What can inverted T waves mean on to of MI?
Hypertrophic cardiomyopathy, here you can see left axes deviation, or problems in depolarization (prominent Q waves) and repolarization (T-wave inversion)
How do you treat pulmonary fibrosis?
Antifibrotic therapy as pirfenidone and nintedanib
DD. between tetanus and rabies:
Rabies: hydrophobia, numbness around the wound, slower progression (months), animal bite
Tetanus: spastic paralysis, faster progression (1w), inflammation around the wound, unvaccinated, dirty wound
How can you prevent Ca stones?
Decrease Na intake
Dx requirements for acute liver failure:
High ALT and AST (normally more than 1000)
Signs of hepatic encephalopathy (confusion, asterixis)
INR more or = 1.5
What reduces the risk of wound infection on burns?
Early excision and grafting
How do you treat stroke in sickle cell disease?
Exchange transfusion
If you see bilateral trigeminal neuralgia think of:
MS
Murmur on a kid that had ToF corrected as an infant. Dx?
Pulmonic regurgitation
Pt that goes on asystole right after he is put on mechanical ventilation. What is the pathophysiologic mechanism?
Positive pressure ventilation causes an increase in intrathoracic pressure which on the setting of hypovolemia after tx can cause acute loss on RV preload and therefore decrease the CO and lead to cardiac arrest!
Episodes of vertigo induced by Valsalva or loud noises. Dx?
Perilymphatic fistula
DD of infection after transplant:
Less than 1 mo: bacterial infection
1-6 mo: opportunistic pathogens as CMV, aspergillus and TB
More than 6mo: same pathogens as the normal population
Short inter-pregnancy interval leads to:
PPROM
Preemie
Small baby
Anemia in mom
Treatment of frostbite:
Rapid rewarming on water bath at 37-39deg
Athlete collapses right after stopping exercise. Dx?
Exercise-associated postural hypotension
When the athlete stops exercising venous return suddenly drops because the muscle pump stops
Management: place in trendelenburg and hydrate
Empiric antibiotic therapy for an empyema:
Ceftriaxone + vancomycin/clindamycin + drainage
66 yo woman with dull LLQ pain, nausea/vomiting, alteration in bowel habits, sterile pyuria, dysuria and tender LLQ mass. Dx?
Diverticulitis
Management: bowel rest and antibiotics (ciprofloxacin + metronidazole) followed up with colonoscopy 4-8 weeks later (colonic malignancy can mimic the presentation and CT findings seen in diverticulitis)
Indications for surgery in setting of acute diverticulitis (1) Emergency operation (peritonitis, abscess, etc.) (2) Any patient who has survived 2 episodes of acute diverticulitis should have elective removal of affected area to prevent recurrence
Kid with ulcerations in the lips, mouth and pharynx after drinking something under the sink. What did he ingest?
Drain cleaner
Ingestion of household bleach is often considered benign, whereas ingestion of industrial-grade bleach is very severe/morbid
Patient with recent liver transplant presents weeks later with fever, eosinophilia, elevated LFTs and a biopsy showing a mononuclear infiltrate with eosinophils in the hepatic triads. Dx?
Allograft rejection
Graft eosinophilia is a sensitive and specific marker of acute rejection in liver allografts
When can you start using sunscreen on a baby?
After 6mo of age, before use protective clothing
How do you prevent neuropathic pain post herpes zoster?
ORAL acyclovir
Oral and IV acyclovir are equally effective in treating herpes zoster, so in pts who are going to be treated as an outpatient we would use oral acyclovir
IV acyclovir is given to immunocompromised!!
For kids with primary varicella infection (chickenpox) the treatment id only symptomatic
How can you prevent iron overload in its that need multiple transfusions (sickle, thalassemia)?
Exchange rather than simple transfusion
1st line tto for symptomatic mitral stenosis:
Percutaneous mitral balloon commissurotomy
Subepithelial deposits on renal biopsy indicates:
Membranous nephropathy or Poststreptococcal glomerulonephritis
Membranous has thickened capillary loops
Best next step in Dx when suspecting pancreatic adenocarcinoma:
CT WITH contrast!
What do we use to estimate fluid requirements during the first 24 hours of care in burn patients?
What do we use to verify adequate fluid infusion in burns?
Parkland formula
Urine output
Ataxia, ophthalmoplegia, and areflexia 2w after upper respiratory infection suggests:
Miller-Fisher syndrome
D.D. between fistula, pseudoaneurism and hematoma:
Fistula: continuous bruit (systolic + diastolic)
Pseudoaneurism: pulsatile mass + systolic bruit
Hematoma: no bruit
Aneurism: pulsatile mass + continuous bruit + thrill. Choose if spontaneous!
What can be used as prophylactic treatment for chronic tension headache?
Amitriptyline
What is thew tto. of an auricular hematoma?
Incision and drainage
What is the tto. of carotid artery dissection?
Heparin, aspirin or clopidogrel for 3-6 mo
Tto is indicated for extracranial carotid artery dissection once a thrombus has been identified and intracranial hemorrhage has been ruled out by CT scan
Dermatofibroma vs Epidermoid cyst:
Epidermoid cyst: firm, mobile, slow-growing nodule that arises from the epidermis
Dermatofibroma: slow-growing, skin-colored or brownish nodules with positive dimple sign (squeezing leads to an inward retraction of the surface)
Confounding vs Effect modification:
Confounding: no category is significant after stratification
Effect modification: one is significant after stratification
First line tto for rosacea:
Topical metronidazole, azelaic acid or ivermectin
How is urine Na in SIADH?
Normal or high, more than 20 as RAAS is suppressed and the pt is euvolemic
Pt with recent infection followed by features of a spinal cord lesion (urinary incontinence, hyperreflexia, a positive Babinski sign, bilateral weakness. sensory loss) with an identifiable level (loss up to a certain point on the spine). Dx? Characteristic feature?
Transverse myelitis
Pleocytosis on cerebrospinal fluid analysis
Best method to reduce childhood/adolesc obesity?
Involve the parents
Metric of overall disease burden that takes into account the years lost due to death and disability:
Metric of disease burden that takes into account the years lost due to death:
Disability- adjusted life years
Years of potential life lost
What is the BNSM when you suspect renal cell carcinoma?
Nephrectomy when CT scan is concerning for a malignant mass
1st line tto in neonatal abstinence syndrome:
Oral morphine
When looking at an Amsler grid, she says that the lines in the center appear wavy and bent. Dx?
Age-related macular degeneration
Possible pericarditis complication:
Cardiac tamponade
The net clinical benefit on a study is:
Net clinical benefit=Clinical usefulness=Possible benefit - Possible harm
Sounds of severe aortic stenosis:
Single S2 on inspiration (physiological splitting disappears because because aortic closure is delayed)
Loud late-peaking systolic murmur
Diminished carotid pulse
When is the patient obligated to disclose genetic information to its relatives?
Only when the disclosure will help ameliorate or prevent a highly likely harm to an individual
Huntington does not need to be disclosed because it cannot be treated
Buzzwords for rashes:
Morbilliform
Sandpaper
Pustular
Morbilliform: measles
Sandpaper: scarlet fever
Pustular: gonorrhea
What is used to calculate the MELD score (Model for End-stage Liver Disease mortality)?
Bilirubin
INR
Creatinine
Na
What is the biggest RF for osteoporosis?
Age
Bilateral hemianopsia and hyperpigmentation following bilateral adrenalectomy for Cushing’s disease:
Nelson’s syndrome; a pituitary microadenoma (pituitary enlargement) with supreasellar extension on MRI and very high plasma ACTH
Which factor is the most associated with euthanasia requests?
Loss of autonomy and control of the dying process, also requests of euthanasia are more closely associated with fears of future suffering than acute pain at the moment
MCC of adverse events in hospitalized patients? and in hospitalized patients NOT undergoing surgery?
Hospitalized patients: surgery complications as wound infections, bleeding, DVT
Hospitalized patients NOT undergoing surgery: adverse drug events from hypoglycemic agents, anticoagulants, antibiotics or analgesics
Classic dashboard injury (anterior impact to a flexed knee) affect the:
Posterior cruciate ligament
Treatment algorithm for HFrEF:
ABDAS
Angiotensin-neprilysin inhibitor Beta-blocker Diuretic Aldosterone antagonist SGLT-2 inhibitor (glifozin) Isosorbid dinitrate/ Digoxin
Do RBCs express HLA antigens?
No
How do you calculate the reduction in risk secondary to an intervention?
1-RR
Management of pelvic fracture:
1) Pelvic binder
2) If the pelvic binder does not work you do an Angiographic embolization of the Hypogastric A. = Internal iliac A.
