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
