Step 3 Flashcards
What is the study of choice for lumbar stenosis?
MRI of the spine.
A patient with supraventricular tachycardia who develops atrial fib relation with rapid conduction after adenosine has what underlying disorder?
Wolff Parkinson White syndrome
What type of error is it if adenosine is given to a Wolf Parkinson White syndrome patient and result in atrial fibrillation with rapid ventricular conduction?
Non-preventable adverse event - any known adverse event of a treatment.
What is another term for a negligent adverse event?
Preventable adverse event
What is a save type of medical error?
A medical error that never reaches a patient.
What is a near miss adverse event?
An error the reaches a patient because there’s no apparent harm.
A high CSF red blood cell count WITHOUT xanthochromia suggests?
Traumatic tap.
What is saw palmetto usually used as treatment for?
Benign prostatic hyperplasia
What is St. John’s Wort?
Depression
What is garlic used as treatment for?
Hypercholesterolemia
What type of V/Q mismatch is present in COPD?
Low ventilation/perfusion because emphysema causes loss of elastic tissue which limits airflow and thereby results in poor ventilation which then leads to hypoxia vasoconstriction. Supplemental oxygen thereby improves ventilation and perfusion.
When is a copper IUD contraindicated?
Cervicitis, PID, Wilson’s disease, undiagnosed vaginal bleeding
What is the next preferred emergency contraception after Copper IUD?
Ulipristal (anti progrestin) inhibits or delays ovulation. Good for five days. Renal or hepatic impairment are contraindications.
Patients who have experience sexual assault should be treated for?
Gonorrhea with ceftriaxone, chlamydia with azithromycin, trichomonas with metronidazole.
If not immunized against hepatitis B also give hepatitis B vaccine and immunoglobulin as needed. For HIV, treat with tenofivir-emtricitabine and raltegravir.
Radioactive iodine alone in a patient with graves may worsen opthlalmopathy.
Yes
What is the best test to assess a patient’s thyroid function after radioactive iodine uptake?
Free T4 and Total T3. Do not use TSH as it can be low for weeks to months after RAI.
What alternative medications increase the risk of bleeding?
Saw palmetto, gingko, garlic, ginseng.
What alternative medications increase the risk of bleeding?
Saw palmetto, gingko, garlic, ginseng.
What anti-hypertensive medications have interactions with lithium?
Diuretics, ACE-inhibitors, ARBs. If a pt is on lithium, start with amlodipine. Any drug that decreases GFR or changes Na+, K+ levels will affect lithium levels. SSRIs also impact Li levels.
What does undercooked meat expose a pregnant mom to?
Risk of congenital toxoplasmosis.
What is the preferred management for obstructing ureteral stone with evidence of infection, AKI, or severe pain or hemodynamic instability?
Percutaneous nephrostomy or retograde ureteral stent.
What is the preferred management for ureteral stone with no complications?
Shockwave lithotripsy.
A patient with Type 1 diabetes who presents with hypotension, hyperkalemia, weight loss, tachycardia, and hypoglycemia is concerning for…
adrenal crisis
What other auto-immune diseases are patients with Type 1 diabetes at risk for?
Hypothyroidism, pernicious anemia, autoimmune ovarian failiure (check FSH, estradiol)
What is the appropriate treatment for pregnant women with hyperthyroidism?
1st trimester - treat with PTU. Methimazole is a teratogen in 1st trimester.
2nd (after 12 wks) and 3rd trimester - treat with methimazole because of PTU liver failure risk.
Surgery is avoided in pregnancy unless no improvement.
What is an ocular manifestation of phenytoin toxicity?
Horizontal nystagmus on lateral gaze.
What is the most appropriate first test for a stable patient with evidence of perforated peptic ulcer or perforated bowel?
Upright Chest and abdominal x-ray to look for pneumoperitoneum.
What is appropriate management for a patient with a PERFORATED peptic ulcer?
Broad spectrum IV Fluids, IV antibiotics, IV PPI for acid protection and emergency surgery (lap or open).
When is it appropriate to use fibrinolytic therapy for a patient with pulmonary embolism?
Only in hemodynamically UNSTABLE patients with acute PE.
What is the target INR with Warfarin therapy for PE?
2.0-3.0
What is the definition for hospital acquired pneumonia?
Pneumonia that begins 48+ hours after admission with no prior evidence of infection.
In a patient with a known pulmonary embolus who mounts a low-grade fever, tachycardia, and has a mildly elevated WBC count what is the appropriate management?
Get a repeat CXR and obtain blood cultures. Even if there is evidence of pulmonary infarction on the CXR, that is not grounds for starting antibiotic therapy as low-grade fever, elevated WBC, mild tachycardia are all associated with pulmonary embolus. FYI streaky opacity on CXR can be infarction or atelectasis.
What are the criteria with regards to smoking and combined hormonal OCPs?
Women over 35 who are heavy smokers (15 or more cigarettes a day)
What are the absolute contraindications for combined hormonal OCPs?
Migraines WITH AURA, Stage 2 hypertension (160/100 or more), History of PE, DVT, Stroke, or MI, Breast Cancer, Cirrhosis/Liver Cancer, Surgery that will lead to prolonged immobilization, < 3 weeks post-partum.
What type of Oral contraceptives are the patch and vaginal ring?
Combined hormonal OCPs.
Estrogen increases the risk of thrombosis and is higher in pregnancy and OCPs.
Ok.
What is the presentation of NF2?
Bilateral acoustic neuromas/deafness, HYPOpigmented cafe au lait spots, autosomal dominant but half are spontaneous
What is the presentation of Sturge Weber?
Port-wine stain and leptomeningeal angiomatosis.
What are the clinical manifestations of tuberous sclerosis?
Ash-leaf spots (HYPOpigmented macules), organ harmatomas/cysts, Flat-red macular lesions on face, Shagreen patch (reddish nodule); 50-60% have cardiac lesion at birth
What are the manifestations of NF1?
HYPERpigmented cafe au lait lesions, cutaneous neurofibromas, axillary freckling.
What is a prolonged QT interval for men and women?
For men >450 ms; for women >470ms.
What is the most common cause of exertional chest pain or sudden cardiac death in a young athlete?
Anomalous coronary artery.
What is the characteristic EKG finding in Brugada?
RBBB and ST segment elevation in V1-V3.
How could hypertrophic cardiomyopathy be determined?
Echocardiogram or EKG.
Hypercalcemia due to paraproteinemia or malignancy does what to ionized calcium?
No change in the level of ionized calcium. Only increases total serum Calcium by increasing bound calcium
What is the first step with hypercalcemia?
Repeat Ca2+ levels and correct for albumin and get ionized calcium level to confirm hypercalcemia.
Then get PTH levels and if suppressed (PTH-independent), get Vit D levels (25 hydroxy and 1,25 OH2D).
Hypercalcemia that is characterized by low PTH, normal
Vit D levels and a high ionized calcium is consistent with …
What is appropriate management?
Immobilization (bone breakdown); can also happen with Paget disease or adolescents
Management: Bisphosphonates
What is an important complication of blood transfusion that needs to be considered especially in patients with renal failure, hepatic failure, hypothermia or shock?
HYPOcalcemia due to citrate infusion. Excess Citrate binds calcium. Normally, it would be converted to lactate but if metabolism impaired, excess citrate builds up with blood transfusion.
Measured calcium levels will be NORMAL because it is IONIZED Ca2+ that is low.
**For these patients (shock, hypothermia, renal or hepatic failure), prophylactic administration of 10cc of Calcium glauconite for every 500ml RBCs is thus recommended.
Sodium bicarbonate infusion is only recommended if bicarbonate is less than 5 mEq/L or less in a normal patient because as circulation improves, you get rebound increase in alkali that may cause overshooting and the bicarbonate will then be converted to CO2 in the brain causing paradoxical acidification of CNS.
Ok
What drugs can cause Folate deficiency and a macrocytic anemia?
Trimethoprim, methotrexate, and phenytoin
What is the best treatment for folic acid anemia caused by methotrexate?
Folinic acid or Leucovorin is preferred over folic acid (used to prevent or treat too).
When is if best to administer 3 drug post exposure prophylaxis for HIV infection?
Up to 3 days though ideally in the first 1-2 hours after.
How should a patient with concern for Immediate HIV exposure be screened and when should it be repeated?
HIV p24 antigen and HIV-1/HIV-2 antibodies are needed for acute exposure screening. Repeat 4 weeks later due to chance for false negative as antigen levels and antibody titers low in first 4 weeks (referred to as the window period).
What is appropriate pre-screening prior to starting HIV anti retro oral treatment?
Screen for Hep B (some ARVs treat both). Also screen for STIs (G/C, syphilis), Hep C, TB.
What rash and other finding is characteristic of disseminated gonococcal infection?
Tenosynovitis of wrist, fingers, ankles, toes.
Also transient pustular rash present for a few days or vesiculo-pustular rash that is present for a few days.
What is one easy way of telling apart Marfan from Ehler’s Danlos?
Only Ehler’s Danlos has hyperextensible skin.
Thoracolumbar scoliosis, “velvety” skin with atrophic scars with joint hypermobility and frequent dislocations suggests
Ehlers-Danlos disease
What are AFP levels in Down’s
Syndrome?
Decreased
What is entacapone?
It is a COMT inhibitor that prolongs the presence of levodopa in Parkinson’s by preventing its degradation but has no effect on Parkinson’s disease on its own.
What is pramipexole and what are other similar drugs?
Dopamine agonist similar to levodopa and bromocriptine which are both used in Parkinson’s Disease.
What are the drugs to treat essential tremor?
Propranolol and primidone
What is a primary prevention example?
Anything that prevents someone from even developing a disease. E.g. Treating to lower cholesterol so as to prevent heart disease.
What does secondary prevention do?
It halts or delays the progression of a disease at its initial stage.
What type of assay is a standard urine drug test?
It is an immunoassay.
What is the treatment for severe PID with evidence of sepsis?
IV cefoxitin and IV doxycycline or Ceftriaxone and doxycycline.
What are the treatments for mild to moderate PID?
IM ceftriaxone and oral azithromycin or doxycycline
What medication is used for tocolysis between 32 and 34 weeks?
Nifedipine.
What is the cut off for giving bethamethasone?
Less than 37 weeks since it decreases risk of respiratory distress, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal mortality
When is magnesium sulfate indicated to prevent neurotoxicity e.g risk of cerebral palsy?
Less than 32 weeks.
Patients with signs of C.diff colitis who test negative on enzyme immunoassay (EIA; only 73% sensitive) as opposed to PCR (97% sensitive) can have what test to confirm diagnosis if they are ill appearing?
Sigmoidoscopy or limited colonoscopy to see pseudomembranous colitis.
How does rabies present?
Fever and malaise for a few days, then followed by neurologic symptoms.
Hydrophobia occurs because water causes pharyngeal spasms that scare the patient from drinking because of the sense that throat is closing.
What sign with a pulmonary embolus is indicative of poorer prognosis?
Elevated troponin suggesting R heart strain, hemodynamic instability, or hypotension suggest a poorer prognosis in pulmonary embolism.
Pulmonary infarction DOES not necessarily suggest poorer prognosis.
When is the only appropriate time to use fibrinolytic therapy in patients with pulmonary embolism?
SBP less than 90.
When in pulmonary embolism management should warfarin be started?
Immediately after heparin. Same day or within a day preferred with target INR of greater than or equal to 2.0.
What is the definition of massive hemoptysis?
600mL in 24 hours. In the case of massive hemoptysis, bronchoscopy or angiographic embolization can be pursued.
In a patient with evidence of acute mastitis, what is the likely causative agent and even if she has fever and mild tachycardia, what is the preferred therapy?
Staph aureus (MSSA). Give oral dicloxacillin or cephalexin.
Fever, focal breast pain, erythema, and swelling.
For patients with a DVT with no evidence of pulmonary embolism and who do not have cancer, what is the preferred method of Anti-coagulation?
Oral anti-Xa inhibitor because it is active within 2-4 hours and requires no ongoing monitoring with at least 3 months of treatment.
In a menopausal woman who has had a DVT, what is a safe alternative therapy to manage hot flashes since estrogen-containing therapy has to be stopped?
SSRIs e.g. Escitalopram or SNRI
What is the standard enteric feeding regimen by G-tube for an adult patient?
30kcal/kg/day with 1g/kg protein.
What is the test of choice if a patient continues to have persistent symptoms after conservation management of carpal tunnel syndrome?
Nerve conduction studies.
What is the treatment for mucormycosis?
Surgical debridement and liposomal amphotericin B
Pregnant women undergoing active TB treatment should get what 3 three drugs as treatment?
RIE–Isoniazid, Rifampin, Ethambutol for 2 months followed by RI for another 7 months.
In a patient with signs concerning for dementia, what reversible causes should be ruled out first?
Screen for hypothyroidism, B12 deficiency and depression.
What is appropriate treatment for a UTI in pregnancy?
First or second generation cephalosporin (cephalexin), nitrofurantoin, amoxicillin or amoxicillin-clavulanate for 3-7 days. CONTRAINDICATED in pregnancy: ciprofloxacin is associated w/risk of tendon rupture in young children, tetracyclines, bactrim (avoid in 1st, 3rd trimester).
Treatment of pyelonephritis in a pregnant woman is with? For how long?
3rd generation cephalosporin (ceftriaxone) or ampicillin + gentamicin for a total 10-14 day course.
In constitutional growth delay, is the bone age also delayed?
Yes; absence of puberty by age 14 with a positive family history, bone age younger than patient age (retarded bone age) with no evidence of syndromic illness.
