Step 3 Flashcards
pain, redness, vision loss, constricted and irregular pupil
anterior uveitis (iritis)
severe photophobia with difficulty keeping eye open
infectious keratitis
corneal foreign body tx most common staph /contacts pseudomonas
erythromycin, cipro
drusen spots with central vision loss
dry macular degeneration
blood vessels from choroid grow behind retina causing detachement
wet macular degeneration
chronic gradual loss of peripheral vision and tx
open angle glaucoma, latanoprost, timolol, carbonic anhydrase inhibitors -zolamide meds
acute eye pain, headache, injection and tx
close angle glaucoma. acetazolamide, timolol, pilocarpine, mannitol
sudden, severe with temporal sparring, amarosis fugax. pale fundus with cherry red spot
central retinal artery occlusion. ocular massage and acetazolamide
subacute, blood and thunder
central retinal vein occulusion
floaters, viterous hemorrhage and retina elevation
retinal detachement, surgery
visual haze floaters, dark streaks, decreased red reflex
vitreous hemorrhage, bed rest with elevation 30-45%
posterior nose bleed occurs where
sphenopalatine artery
bone greater than air, weber louder in affected
conductive most commonly caused by otosclerosis
air greater than bone, weber louder in normal
sensorineural
pruritic, lichenified plaques on flexor surfaces
atopid dermatitis (eczema) topical steroids or topical tacrolimus
immune mediated Type IV hypersensitivity rash acute causing papular lesions, vesicles, weeping erosions. chronically causes hyperkeratosis and lichenification
contact dermatitis, steroids
immune mediated skin disease , nails with pitting and onychiolysis classically involves the distal interphalangeal joints
psoriasis, steroids, light exposure, methotrexate
tender red or violet nodules common in women, sarcoidoisis, inflammatory bowel disesae typically after recent URI or diarrheal illness. red nodules without ulceration on the shins
erythema nodosum , nsaids, potassium iodide
looks like acne without pimples, flushing from spicy food, rhinophyma
rosacea - cleansers, metronidazole. potentally doxycycline, tretinoin
acute inflammatory disease type IV hypersensitity, occures after sulfa drugs, rapidly progressive, symmetric lesions, targetoid papules on hands and palms
erythema multiforme - histamne blockers, prednisone
autoimmune disease targeting desmoglein with oral lesions and nikolsky sign. flaccid bullae
pemphigus vulgaris - steroids
autoimmune disease against basement membrane with large tense bullae
bullous pemphigoid, steroids
pearly papules with central depression that is ulcerated on sun exposed areas
basal cell carcinoma
annular plaques with a thin scale and central clearing
tinea corporis, griseofulvin, itraconazole
red, scaly soles with maceration and fissuring bwtween toes
tinea pedis - friseofulvin, terbinafine
hypopigmented macules in areas of sun , reddish brown in winter
tinea versicolor - itraconazole
hyperkeratosis and yellowing of the nail plate
onychomycosis, terbinafine
erythema and scaling of the scalp with thickened, broken off hairs and scalp kerion
tinea capitis - griseofulvin, itraconazole
pink plaques with scale or eroision spread to lymph nodes, arsenic exposure
squamous cell carcinoma
typical substernal chest pressure or shortness of breath that is exacerbated by exertion and relieed by rest or nitroglycerin
stable angina
any new angina in previously asymptomatic patients or accelerating or new angina at rest
unstable angina
true or false DM is a CAD risk equivalent
true
what determines the difference between unstable angina and NSTEMI
presence of elevated troponin
s4, crackles, venous destension after acute MI
Heart failure, dont give b-blocker give MONA BASH if stable and no signs of heart failure
what drugs improve mortality after MI
aspirin, b-blockers, ACEI, statins, anti platelet agents
post TPA in MI with decreased EF and prolonged QRS
cardiac resynchronization
post MI with symptoms and decreased EF <35%
give ICD
symptoms of HF, diastolic murmur heard best at apex with an opening snap associated with rheumatic fever
mitral stenosis, HR control
blowing systolic murmur at the apex and radiates to the axilla if acute leads to rapid pulmonry edema, cardiogenic shock, ruptured chordae tendinae due to MI usually and ultimately leads to AF
mitral regurgitation
acute needs surgery
chronic needs repair EF <60
midsystolic click, increased by valsalva maneuvers presents with palpitations or dyspnea
mitral valve prolapse
systolic crescendo-decrescendo murmur radiating to the carotids along the right sternal border, parvus et tardus presents with chest pain, syncope, HF, shortness of breath
aortic stenosis avoid overdiuresis do surgery
diastolic murmur along left sternal border with wide pulse pressure radiate to apex
aortic regurgitation - afterload reduction with ACE and hydralazine
systolic crescendo and decrescendo murmur at the left sternal boarder that is worse on standing and valsalva
Hypertrophic obstructive cardiomyopathy
caused by alcohol or tachycardia presents with ischemia, tachycardia, HTN, or chagas
dilated cardiomyopathy - ACE, ARB, B-blockers, spironolactone, digoxin
findings show LVDH and low voltage on EKG caused by sarcoid, amyloidosis, hemochromatosis, cancer, and glycogen storage
restrictive cardiomyopathy
ventricular septum hypertrophy that is not symmetric that is generally due to autosomal cardiac sarcomere in a dominant pattern associated with sudden cardia death
hypertrophic cardiomyopathy give b-blocker, verapmil or dysopyramide
distant or muffled heart sounds, incrased JVP, and pulsus paradoxus
pericardial effusion
postprandial abdominal pain, food fear, bloody diarrhea
mesenteric ischemia
gemfibrozil and nictoinic acid do what
increase HDL and decrease triglycerides
fever, rigors, HF, neurologic impairment, back pain, roth spots (white hemorrhages on retina), osler nodes, janeway lesions, pulmonary symptoms, (systemic emboli)
acute endocarditis, needs surgery for hemodynamic istability, heart failure, valve destruction
give prophylaxsis with PCN for dental procedures
strep bovis associated with
gi malignancy
any patient with s aureus bacteremia needs
evaluation for endocarditis , dukes criteria
hip pain preceded by URI
toxic synovitis
ulnar shaft fracture with radial head dislocation
Monteggia fracture
distal 1/3 radius fracture with a distal radioular dislocation
galeazzi fracture
FOOSH injury - distal radial fracture with dorsal displacement
colles fracture
this fracture needs splinting even if there is tenderness in the area due to frequent development of avascular necrosis
scaphoid fracture
proximal fibula injury aka
maisonneuve fracture
shoulder disloaction typically causes
axillary nerve injury
supracondylar fractures lead to what
radial nerve injury
narrow regular complex tachycardia is typically, tx
SVT, adenosine
narrow irregular complex is typically, tx
AF, rate control metoprolol or diltiazem
wide complex tachycardia is typically , tx
VT, amiodarone
develops slowely over 24 hours and freatures rigidity rather than clonus (due to drugs)
neuroleptic malignant syndrome
indication for emergent dialysis - AEIOU
acidosis - can be fixed with bicarb electrolytes - hyperkalemia Ingestion - lithium or aspirin overload - kidney failure uremia - encephalopathy, serositis, pericarditis
herb used for BPH, causes
saw palmetto, increased bleeding
herm used for anxiety and insomnia, causes
kava kava, liver toxicity
herb used for depression, causes
st. johns wart, serotonin syndrome, decreased INR, digoxign toxicity, HTN crisis
Herb used for HLD
Garlic
Herb used for High triglycerides
fish oil
herb used for osteoarthritis
glacosamin and chondritin
used after menopause, causes
black cohosh, liver toxicity
herb used for memory enchancement, causes
ginko biloba, bleeding and intracranial bleeding
herb used for ulcers and virus, causes
licorice, HTN, hypokalemia
herb used for weight loss, causes
ephedra, HTN, sudden death, stroke, seizure
herb used for weight loss in china, causes
aristolochic acid, nephrotoxicity (RTA)
toxidrome presents with diarrhea, urination, miosis, bronchorrhea, bronchospasm, bradycardia, emesis, lacrimation, salivation, examples
cholinergic , mushrooms, organophosphates, pilocarpine, pyridostigmine
toxidrome presents with fever, flushing, dry mucous membranes, psychosis, mydraisis, tachycardia, and urinary retension, examples
anticholinergic - antihistamines, antipsychotics, atropine, jimson weed, scopolamine, TCA
toxidrome presents with coma, respiratory depression, and miosis, examples
opiods, heroin, morphine, oxycodone
toxidrome presents with CNS depression, respiratory depression, and coma, examples
sedative hypnotic , alcohol, barbs, benzo
toxidrome presents with disorientation, panic, seizures, hypertension, tachycardia, tachypnea, examples
sympathomimetics, amphetamines, cocaine, PCP
toxidrome presents with tremor, torticollis, trismus, rigidity, oculogyric crisis, opisthotonos, dysphonia, and dysphagia
extrapyramidal - haloperidol, metoclopramide, phenothiazines
opiate overdose tx
naloxone - may cause pulmonary edema
anticholinergic overdose treatmetn
benzo for symptom control
sympathomimetic toxidrome tx
benzodiazepine
organophasphate tx
atropine
hallucinogenic toxidrome tx
benzodiazepine
ethylene glycol ingestion tx
fomepizole or ethanol
monkey bites transmit this which has 80% fatality rate
Herpes B virus, treat with valacyclovir
anaphylactic - igE mediated
type I
cytotoxic antibody mediated
type II
immune complex mediated
Type III
type IV Delayed (CD4 mediated)
Type IV
difference between heat exhaustion and stroke
temperature dysregulation, AMS, and paradoxical shivering
associated with explosive exit wound, causes VF and due to household or commercial electricity
alternating current, worst kind
electricity causes discrete exit wound and asytole due to batteries, industry, and lightning
direct c urrent
traume and loss of vision with vitreous humor leak and teardrop shaped pupil, tx
puptured glove, eye shield
dental avulsion treatment
reimplant, rinse but dont scrub
polyuria, polydipsia, and polyphagia
DM
aspart
novolog
lispro
humalog
regular
humulin
glargine
Lantus
acidemia causes potassium to shift where to cause what
extracellulary, hyperkalemia
hyperglycemia with neurolgic symptoms
HHS
hyperglycemia with hyperventilation and abdominal pain
DKA
presents with fatigue, weight gain, constipation (ileus), dry skin with increased TSH and decreased T4
primary hypothyroidism, levothyroxine
altered mental statues, hypothermia, and hemodynamic instability
myxedema coma, levothyroxine
weight loss, tachycardia, anxiety, diarrhea, afib, tremor
primary hyperthyroidism, PTU or methimazole
high fever, tachycardia, cardiac failure, dehydration, altered mental statues
thyroid storm,
propranolol for tachycardia
glucocorticoids to block t4 conversion
methimazole or PTU
presents like primary hyperthyroidism but has increased TSH and T4 due to adenoma usually
2nd hyperthyroidism, remove tumor, b-blockers
atibody against TSH receptor, diffuse pailness goiter, proptosis, pretibial myxedema
graves disease, ptu or methimazole prior to ablation
tender thyroid usually hyperthyroidism folled by hypothyroidism in setting of viral illness
subacute thyroiditis, NSAIDS
painless thyroid enlargement with anti TPO antibody present
hashimoto thyroditis
what trimester do you gie methimazole
2-3rd
wat trimester do you give PTU
1st
what is the difference between hot nodule and cold nodule
hot noduels are rarely malignant
cervical lymphadenopathy, dysphagia, dyspnea, and hoarseness
thyroid cancer
most common thyroid cancer
papillary spreads lymphatically
thyroid cancer spreads through blood to bone and lungs
papillary
tumor of parafollicular c cells that secrete calcitonin and assoicated with MEN 2A or 2B
medullary
undifferentiated thyroid cancer with poor prognosis
anaplastic
this is the best marker to determine if thyroid tissue remains or cancer of the thyroid has returned
thyroglobulin
presents at fatigue, constipation, polyuria, polydipsia and abdominal pain with increase in PTH and Calcium
priamry hyperparathyroidism tx acutely with IV hydration and furosemide
presents as fatigue, constipation, polyuria, polydipsia and abdominal pain with decreased or normal PTH and increased calcium
secondary hyperparathyroidism
presents with altered mental statues, polyuria, short QT syndrome, and dehydration in the setting of high calcium
hypercalcemic crisis >13, dialysis
t score > -1
normal
tscore -1 to -2.5
osteopenia
tscore
osteoporosis, tx -dronate drugs then raloxifene
presents as skin atrophy, proximal muscle weakness, moon face, buffalo hum, psychiatric disturbances, hypertension, hyperglycemia, growth retardation, hisutisim, what is the best test
hypercortisolism (cushings), dexamethasone test to mesaure cortisol excess
for dexamethsone cortisol testing if
cortisol is normal
cortisol is high
not cushing
do high dose dexamethasone supression test
on high dose dexamthasone supression testing
acth undectectable
acth no suppression
acth supressed
adrenal tumor
ectopic acth syndrome
pituitary tumor (cushing disease)
hypotension, postural dizziness, syncope, hyponatremia and hyperkalemia, hyperpigmentation with increased ACTH and decreased aldosterone
addison disease or primary adrenal insufficiency, steroids, fluudrocortisone
fatigue, generalized weakness and weight loss with decreased ACTH and normal electrolytes
secondary adrenal insufficiency
hypernatremia and hypokalemia presents with hypertension, metabolic alkalosis
primary hyperaldosteronism
malignant hypertension with edema causes by renin secreting tumores
secondary hyperaldosteronism
causes of hyperaldosteronism include
adrenal adenoma
bilateral adrenal hyperplasim
what are the treatments
1 - adrenalectomy
2- spironolactone
wome get falactorrhea and amenorrhea in the absence of pregnancy with osteopenia
prolactinoma
men get decreased libido, CN III palsy, temporal field visual loss
prolactinoma, dopamine agonist like cabergoline or bromocriptine
DM and htn with increased hat and ring size
acromegaly, somatostatin analogues like octreotide or lanreotide
presents with HTN, headache, palpitations, and sweating
pheochromocytoma, phenoxybezamine followed by propranolol to prevent htn crisis
measure 24 hour metanephrines
parathyroid hyperplasia, pancreastic islet cell tumor, pituitary adenoma
wermer syndrome or MEN 1
parathyroid hyperplasia, thyroid medullary cancer, pheochromocytoma
sipple syndrome or MEN 2A
thyroid medullary cancer, pheochromocytoma, mucocutaneous neuromas, marfan habitus
MEN 2B
esophageal issue associated with hiatal hernia
schatzki ring
dysphagia, cervical esophageal webs, and iron deficiency anemia
plummer vinson syndrome
cancer of esophagus at the top
what about the bottom
scc, smoking alcohol
adenocarcinoma, gerd
birds beak on barium swallow
achalasia
intermittent symtpoms with chest pain triggered by hot and cold liquids, corkscrew esphagus on barrium swallow
esophageal spasm
calcinosis cutis, raynaud syndrome, esophageal dysmotility, sclerodactyly, and telangiectasia
CREST syndrome
ulcers
relieved by eating
worse with eating
duodenal
gastric
triple therapy - amoxicillin, clarithromycin or metronidazole, PPI
abdominal pain, chronic diarrhea, and ulcer disease with elevated serum gastrin or secretin
zollinger ellison syndrome associated with MEN1
abdominal pain associated with altered bowel function with relief after defecation, pain is migaratory, variable and poorly localized
IBS, high fiber diet
diarrhea that severe and often bloody with fever at times
bacterial diarrhea, avoid abx unles invasive or c diff
invasive give bactrim
c diff give oral vanc
diarreha that friends and family have, no fever
viral diarrhea , loperamide
diarrhea outbreatk in
day care
travel
parasitic diarrhea
giardia
entamoeba
give metronidazole
acute diarrhea duration
chronic
<2 weeks
>4-6 weeks
small bowel villous atrophy and crypt hypertropy resulting in malabsorption and iron deficiency anemia associated with dermatitis herpetiformis and gi malignancy
celiac sprue
tx or varacele bleed
prevention of vaacele bleed
ocretotide
propranolol
mid epigastric pain that radiates to the back and relieved by sitting forward. ocassionaly has jaundice and fever
pancreatitis
tx for necrotizing pancreatitis
imipenem or fluoroquinolone plus metronidazole
post prandial abdominal pain for 30 minutes with RUQ pain
biliary colic, rocephin plus metronidazole
fever, jaundice, and RUQ pain
cholangitis, ciprofloxacin
Fever, jaundice, RUQ pain, shock, and altered mental status aka reynolds pentad
suppurative cholangitis
high transaminase should make you think of
hepatitis
SAAG (serum ascities albumin gradiet) >1.1
portal htn –> cirrhosis, HF, budd chiari
SAAG <1.1
no HTN –> peritonitis, cancer, pancreatitis, trauma, nephroti csyndrome
tx of hepatic encephalopathy
rifaximin and lactulose, TIPS procedure predisoses you to this
SBP tx
rocephin or fluoroquinolone
fatigue, DM, arthritis, skin pigmentation, infertility, transaminitis, cardiomyopathy with increased FE saturation, ferritin and transferrin levels
hereditary hemochormotosis, phlebotomy
liver disease with neurophychiatric symtpoms and kayser fliesher rings. decreased copper and ceruloplasmin
wilson disease, penicillamine, trientine, oral zinc
young nonsmoker with panacinar emphysema
alpha 1 antitrypsin disorder, give antitrypsin and liver transplant
transamintis with ana, asmam, lkma and igG
autoimmune hepatitis, steroids and azathioprine
fatigue, pruritic, jaundice, fat malabsorption, osteoporosis
primary biliary chirrosis, ursodeoxycholic acid, cholestyramine, fat soluble vitamins
fatigue, pruritus, RUQ pain, ana, anti smooth muscle antibody, p-anca, associated with gi maligancy
primary sclerosisng cholangitis, ursodeoxycholic acid, cholestyramine, fat soluble vitamines
determines if antibodies are bound to the RBC membrane and is indicative of hemolytic anemia
direct coombs test
determines if there is antibodies to Rh factor in a mothers blood
indirect cooms test
can present with pica, low ferritin with wide RDW
iron deficiency anemia, iron supplementation
chronic hemolytic andemia and splenomegaly with increase in hemoglobin a and hemoglobin 4
hemoglobin H disease
growth retardation, heaptosplenomegaly, jaundice, and bony deformations as infant. normal RDW and basophilic stippling on smear
b- thalasemia major
causes HF, hepatic dysfunction, glucose intolerance, and secondary hypogonadism requiring chelation therarpy
iron overload secondary to repeat blood transfusions
always consider this cancer in microcytic anemia
colon cancer
low iron, low TIBC, normal transferrin with increased hepcidin
anemia of chronic disease, treat underlying issue
seen in mycoplasma and mono infection with sings of intravascular lysis, spherocytes and positive coombs test
cold agglutinin autoimmune hemolytic anemia
jaundice, spleenomegaly, spherocytes, cooms test positive, lysis in spleen
warm autoimmune hemolytic anemia
hemolysis during infection or sulfa drugs with bite cells
g6pd deficency
schistocytes and helmet cells caused by shearing through coagulated capillaryes
microangiopathic hemolytic anemia
hemolytic anemia, thrombocytopenia, and AKI with no neurological sign typically associated with gastroenteritis in children and shiga toxin
HUS
hemolytic anemia, thrombocytopenia, aki, fever, and neurological signs due to vWF and autoantibody against ADAMTs13
thrombotic thromcocytopenic purpura
chronic hemolysis caussing gallstones, poorly healy ulcers, jaundice, splenomegalsy, and heart failure, vaso-occulsive crisis
sickle cell anemia
sudden decrease in hemoglobin and reticulocyte cound caused by parvovirus b19
aplastic crisis, transfuse
fever, chest pain, cough, wheezing, tachypnea, new pulmonary infiltrate on CXR in sickle cell patinet
acute chest syndrome, oxygen, transfusion, rocephin, erythromycin
defect in ankryin or spectrin, speelomegaly, incresed RDW and MCHC, jaundice, confirmed by osmotic fragility test and howell jolly bodies
hereditary spherocytosis, vacinate against encapuslated organisms
shortness of breath with normal CXR, dizziness, confusion, headache, and seizures after exposure to benzocaine, dapsone, sulfa
methemoglobinemia, methylene blue
major difference in symptoms between folate and b12 deficiency
neurological symtpoms are found in b12 deficiency and b12 deficiency will have increased is methylmalonic acid
headache, blurry vision, fatigue, itching after a hot shower, Jak2 mutation
polycythemia vera, phlebotomy
visual complaints, headaches, or erythromelalgia (pain in hands and feet)
essential thrombocytosis, hydroxyurea
fever, sweats, weight loss, and hepatosplenomegaly, dry tap
primary myelofibrosis, transfusion, hydroxyurea, and splencetomy
plateletes <90,000
thrombocytopenia
eleveted PT or PTT
coagulopathy, give FFP to normalize
petechiae is a sign of
platelet deficiency
cavity or joint bleeding is a sign of
clotting factor deficiency
petechiae and easy brusising with igG antibodies
idiopathic throbocytopenic purpura (ITP) aka autoimmune thrombocytopenia, steroids
petechiae and easy brusing after heparin
HIT, platelet factor 4 antibodies found on serotonin release assay
recurrent spontaneous bleeding with increased PTT
intrinsic pathway likely hemophilia A (8) or hemophilia B (9)
recurrent sponteneous bleeding with inceased PT
extrinsic pathyway factor 7 disease
increased in both PTT and PT with recurrent sponteneous bleeding
common pathway factor 5, 10, 2
mucocutaneous bleeds, increased bleeding time, joint bleeds due to inability to form hemostatic plug
von Willebrand Disease, desmopressin (antidiuretic hormone)
mutation that disrupts activated protein C with slows the breakdown of factor 5 to 8
factor 5 leiden
issue with mutation that stabilized and increased prothrombin
prothrombin g20210a
warfrin is a resk of skin necrosis with this
protein c or s deficiency
inability to inhitib thromin and factor 10 resulting in heparin resistance
anti-thrombin II deficiency
found in any thrombosis and >3 miscarriages before 10 weeks or 1 after 10 weeks with postive anticardiolipin or lupus anticoagulant
antiphospholipid syndrome
fever, chills, and malaise after blood product
febrile reaction, leukocyte reduced RBC
fever, chills, pain, hypotension, flushing after blood produce due to ABO incompatibility
acute hemolytic reaction, supportive plus furosemide
jaundice, anemia, hemoglobinuria, fever
delayed hemolytic reaction, tylenol for fever
urticaria, itching, fives after blood product
allergic reaction, benadryl
shortness of breath, hypoxemia, bilateral chest infiltrates, 1-6 hours post transfusuion, ARDS
TRALI , ventilation support
shortness of breath, edema, fluid overload
TACO, furosemide
myeloblast and lymphoblast overgrowth, what is it called if this is <20 %
acute leukemia, meylodysplastic syndrome
overgrowth of metamyelocytes and lymphocytes
chronic leukemia
overgrowth of any lymphocyte, b cell is generally more than T cell
lymphoma
viral like syndrome with bone pain, pallor, petechiae, adenopathy, testicular and CNS involvement, anterior mediastinal mass typically in children with down syndrome
acute lymphocytic leukemia
fever, brusising, fatuge, infection, gingival hyperplasica, seen in people with previous chemo or radiation, increased urice acide, auer rods
acute myelogenous leukemia 15:17 gene translocation, 7+3 anthracycline based chemo or in AML M3 given all trans retinoic acide
lymphagenopathy and hepatosplenomegally often incidental finding on CBC, smudge cells on smeart, cyclin d1, CD5 and 23+. can be associated with ITP
chronic lymphocytic leukemia or mantle cell lymphoma t:11-14 translocation, fludarabine based regimen
b symptoms but in blastic phase has bone pain, bleeding, purpura, splenomegaly with CD11, trap and CD103, cbc shows 150000 wbc
chronic myelogenous leukemia , hairy cell leukemia has all the postiive cd things, philadelphia chromosome bcr-abl gene t9:22
give imatinib
cervical or mediastinal lymphadenopathy with b symptoms. has reed sternberg cells, mediastinal mass, contiguous speread
hodgkin lymphoma, ABVD adriamycin (doxorubicin), bleomycin, vinblastine, cacarbazine
assoicated with EVC, HTLV, MALToma, b symptoms, non-continguous spread
non-hodgkin lymphoma, r-chop which is rituximab, cyclophosphamide, doxorubicin, vincristine, presdnisone
occurs afte radiation resulting in hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, leading to renal failure, gout, and stones
tumor lysis syndrome, hydration, allopurinol
CRAB, hypercalcemia, renal failure, anemia, bone lesions
multiple myeloma, bortezomib or lenalidomide
low plasma cells, low M protein, no crab symtpoms
MGUS
difference between smoldering myeloma and multiple myeloma
CRAB symptoms
bone pain, abdominal pain, kidney stones, delerium, fatiuge, bone lesions, decreased urine output
multiple myeloma
ductal carcinoma in situ or infavsive cancer of the nipple with unilateral itching, burning, and nipple erosion
paget disease
cancer treatment
premenopausal
postmenopausal
her2-neu
tamoxifen and raloxefene
anastrozole
traztuzumab/herceptin
chornic cough, hemoptysis, weight loss, or postobstructive pneumonia in smoker, , radon, or asbestos
lung cancer
shouder pain, miosis, ptosis, anhidrosis and lower brachial pexopathy
pancoast syndrome
lung cancer in periphery
adenocarcinoma
lung cancer in central area
squamous cell
paraneoplastic syndromes of lung cancer
CLASH carcinoid -small cell lambert eaton - small cell ACTH - small cell SIADH - small cell hypercalcemia - squamous cell
painless jaundice, palpable gallbladder, migratory thrombophlebitis, venous thrombosis, b symptoms, abdominal and lumbar back pain, DM new onset
pancreatic cancer, whipple
admonimal pain with transamonitis and increase bilirubin
hepatocellular cancer
flushing, abdominal pain, diarrhea, and new tricuspid regurgitation
carcinoid tumors (increased seritonin or chromogrann A), give octreotide
hypoglycemia that is recurrent with relief on glucose adminsitration
insulinoma
profuse watery diarrhea that causes hypokalemia
VIPoma
persistent hyperglycemia with necrolytic erythema
glucagonoma
gross painless hematuria
bladder cancer
urinary frequency, anemia, hematuria, low back pain
prostate cancer
testicular cancer difference between seminoma and nonseminoma
seminoma has a normal a-fetoprotein, nonseminoma has increased alphfetoprotein
heamturia, flank pain, mass, b symptoms, paraneoplastic effects (erythrocytosis, hypercalcemia)
renal cell carcinoma
vegf tyrosine kinase inhibitors pazopanib
nivolumab, atezolizumab
rapamycin inhibitor everolimus
menorrhagia, postcoital bleeding, pelvic pain, vaginal discharge
cervical cancer
progressive headache or focal neurologic deficit, spacsitc paresis, urinary incontinence, seizure
meningioma, resection
headache, wakes patient form sleep, vomiting, worse with valsalva, butterfly lesion
glioblastoma multiforme, resection
ca125
ovarian cancer
ca15-3
breast
ca19-9
pancrestic
CEA
GI cancer, colon
AFP
liver, yolk sac (testicular) cancer
hCG
choriocarcinoma
PSA
prostate cancer
LDH
lymphoma
calcitonin
medullary thyroid cancer
chromogranin A
carcinoid
b2 microglobulain
multiple myeloma
drug causes dilated cardiomyopathy
doxorubicin
drug causes renal and ostotoxiciy with neuropath
cisplatin
drug cuases hemorrhagic cystitis
cyclophosphamide
drug causes myelosuprression resulting in pancytopenia and needs folate supplementation with what
methotrexate, leucovorin
causes restrictive cardiomyopathy in cancer patients
radation
causes extrapyramidal symptoms
metoclopramide
MRSA coverage
bactrim or doxy or clindamycin, or vancomycin
well demarcated, edematous area of erythema of the face
erysipelas, PCN, keflex, bactrim
orbital infection with erythema and pain
preseptal cellulitis, treat like normal cellulits
orbital infection iwth oculomotro dysfunction, proptosis, chemosis, worse pain with movement, decreased visual acuity
septal cellulits, vanc and ceftriaxone
vizarre behavior, speech disorders, olfactory hallucinations or acute hearing impairment, MRI shows lesions of temporal lobes
HSV encephalitis, acyclovir
fever with altered mental statues in season change, extrapyramidal symtpoms, flaccid paralisys, IgM antibody
west nile encephalitis, supportive care
what do you have to add for coverage in people with meningitis who are over 50?
what about if you suspect s pneumoniae
ampicillin for listeria
dexamethasone
tap shows PMNs which elevated opening pressure
bacterial meningitis give ceftriaxone due to increased neuro penetration
tap is normal
viral meningtisi
tap is just a little off
TB
pseudomonas treatment
ciprofloxacin
unilateral hearting loss and ear pain with lack of ormal light relex and is bulging
otitis media, amoxicillin
painful ear with foul smelling drainage
otitis externa, ofloxacin
fever, arthritis, carditis, chorea, rash
rheumatic fever, strep throat treatment is penicillin
trest strep throat to prevent what
rheumatic fever, can still get glomerulonephritis
acute fever, productive cought, dyspnea, pleuritic chest pian
pna, dont forget curb 65
low grade fever, nonproductive cough, myalgia
walking pneumonia
smoker with pna, diarrhea, hyponatremia and elevated lactate dehydrogenase
legionella
dysphagia, right lower infiltrate 1-5 days after event
aspiration PNA, clinda or augmentin
decreased LOC, symptoms 2-5 hours after aspiration, infiltrates everywhere
aspiration pneumonitis , supportive care
PCP tx
bacrim
cough +/- sputum production, dyspnea, fever, chills with no infiltrate. Cough >5 days
bronchitis, supportive care
TB treatiment
RIPE rifampin isoniazide pyrazinamide ethambutol these casue neuropathy and hepatitis
fever, chills, dysruia, cloudy urine, obstructive urine symptoms
prostatisis, fluoroquinolone or zosyn
painless, indurated, superfuical ulcerations
syphilis, doxycycline 14 days
chlamydia tx
azithromycin
gonorrhea tx
ceftiaxone
what does azt cause
tenofovir?
efavirenze
bone marrow supression
renal toxicity
CNS toxicity
prevention of malria
chloroquine –> mefloquine
daily doxy or atovaquone for short trip
HIV infection prophylaxsis
bactrim
blood in stool, fever, abdominal pain
infectious diarrhea, fluoroquinolon or azithromycin other than in EHEC this will cause hemolytic uremic syndrome
causes of bloody diarrhea
YEESSC yersinia ecoli entamoeba shigella salmonella campylobacter
presents after antimicrobial use, PPI with abdominal pain, diarrhea, nausea, vomiting, and ttp
needs CT for toxic megacolon workup. oral vanc is tx
aedes mosquitio, fever, polyarthralgia, maculopapular rash
chikungunya , supportive
anopheles mosquito causes jaundice, anemia, transminitis, thrombocytopenia, cyclical fver
malaria
fecal -oral route causing diarrhea, hepatosplenomegaly, rose sports
typhoid fever, fluoroquinolones
aedes mosquito, bone break fever, maculopapular rash, thrombocytopenia, hemorrhage
dengue fever, supportive
temperature >101.3F of sustained >100.4F for >1 hour in (ANC = PMN + bands <500)
elderly people on chronic steroids my not mount fever
neutropenic fever
pseudomonas - cefepime or carbapenem
if not improved in 4-7 days consider fungus start amphotericin B, micafungin, or voriconazole
what do you not perform on neutropenic fever
rectal exam
erythema migrans, arthralgia, myalgia, myocarditis with av block, bell palsy, ixodes deer tic
lyme disease give doxy >9
amoxicillin <9 or pregnancy
ceftriaxone if cardiac or neurologic symtpoms present
rash on plams and soles that spread to trunk, hyponatremia, transaminitis
rocy mountain spotted fever, doxy
cotransmitted with lyme disease, nonspecific symptoms
human monocytic ehrlichiosis, doxy
hemolytic anemia with maltese cross formation
babesiosis clindamycin and quinine or atovaquone and azithromycin
encapsulated yeast from pigeon droppings, silver stain, india ink show halo and capsul
cyptococcosis, fluconazole
narrow based budding yeast, bat or bird guano, ohio-mississippi river valley, flu like illness, palatal ulcerations, bone marrow suppresion
itraconazole if sever amphotericin
spherules with endospores, arizone or san joaquin valley, pna with dry cough and fever on silver stain
coccidiomycosis, fluconazole or itraconazole
broad based budding yeast, great lakes, ohio mississippi river valleys, PNA, verrucous rash, subcutaneous nodues, osteomyelitis, lytic leasion
blastomycosis itraconazole, amphotericin
mold, sepatted branched hyphae. fever, pleuritic chest pain, hemoptysis
aspergillosis, voriconazole
medications associated with SLE
SHIPP EM sulfa hydralazine isoniazid phenytoin procainamide interacept minocyline
noninfectious, granular, pea sized masses near the edge of a valve or valve ring
libman sacks endocarditis or verrucous endocarditis
needed for SLE diagnosis
4 of 11 Dopamine rash Discoid rash oral ulcers photosensitive rash arthritis malar rash immuno criteria + anti dsDNA or antiSM neurologic symptoms renal disease ANA+ serositis hematologic disorder
highly specific for lupus
anti dsDNA and Anti Sm
seein in drug related lupus
Antihistone antibodies
boutonniere and swan neck deformities with anti CCP, long morning stiffness that improves with activity
RA, nsaids, sulfasalazine, hydroxychloroquine, methotrexate, infliximab, etanercept
joint stiffness, cartilage hypertrophy, morning stiffness for less than 30 minutes that worsens with activity, heberden nodes and bouchard nodes
osteoarthritis, weight loss, PT, NSAIDs
calcium pyrophosphate crystal with positive birefringent rhomboid crystal
pseudogout
needle shaped, negatively birefringent yellow crystals
gout,
acute indomethasine, steroids, colchicine
chronic - allopurinol
tap based on WBC <200 <3000 <50,000 >50,000 bloody
normal noninflammatory inflammatory infectious bloody
up going babinski sign is a ?
upper motor neuron sign
bowel and bladder incontinence/retention with saddle anesthesia
cauda equina syndrome, surgery
lower back pain with worsens with standing and walking but improves with sitting or leaning forward, easier to walk uphill rather than down
neurgenic claudication from degenerative disk disease
young man with chronic LBP that is worse in the morning with anterior uveities and HLA B27
ankylosing spondylitis, anti TNF inhibitors
deltoid and biceps with anterior shoulder sensation deficit and decreased biceps reflex
C5
biceps and wrist extensiors with decreased brachioradialis and decreased biceps and triceps reflex
C6
affects tricpes, wrist flexors, and finger extensors, decreased sensation of triceps with decreased reflex
C7
problems with rising from a chair and heel walking with decreased sensation over knee and medial calf causing decreased knee jerk reflex
L3-4
problems with heel walking, extension of big toe, or dorsiflexion of ankle
L5
problems with toe walking or plantar flexing the ankle, decreased ankle jerk reflex
S1
progressive stiffness of the spine, uveitis, aortitis, psoriasis and IBD
anylosing spondylitis, nsaids, TNF inhibitors
joint pain, nail pitting, sacrolitis and spondylitis
psoriatic arthtis
aka reiter syndrome
reactive arthritis
new headache and scalp tenderness with pain on combing the hair, temporal tenderness, jaw claudication and monocular blindness
temporal arteritis, prednisone and eye eval
fatigue, weight loss, fever, mononeuritis multiplex seen in HEP B and C
polyarteritis nodosa, glucocorticoid , cyclophasphamide and rituximab
bilateral aching and morning stiffness lasting >30 minutes for at leasdt 2 weeks, pain of shoulder and pelvic girdle, fever, malaise, weight loss , difficulty getting out of the chair or lifitng arms above head, no weakness
polymyalgia rheumatica, prednisone
myalgia, insomnia, weakness, fatiuge, trigger pints, depression, anxiety , IBS with no swelling
fibromyalgia, gabapentin, SSRI
proximal mucle weakness without pain
polymyalgia rheumatica
proximal muscle weakness with pain
ploymyositis
progressive proximal muscle weakness , pain, difficulty rising form chair, trouble swallowing, difficulty speaking and breathing with increased CK and aldolase. muscle inflammation and fiber necrosis
polymyositis, corticosteroids, methotrexate or azathioprine
heliotropic rash, gottron papules associated with internal malignancy
dermatomyositis
symmetirc thickening of skin, tight face, telangiectasias
scleroderma
form of scleroderm assocaited with raynaud, barret esophagus, reflux, pulmonary htn and anticentromere antibody
crest syndrome
anti SCL 70 antibody associated with pulmonary interstitial fibrosis
diffuse scleroderma
dysmorphin RBCs and RBC cast on UA
acute glomerulonephritis (post strep or IgA nephropathy)
eosinophils and WBC cast
Acute interstitial nephritis ( meds)
pigmented granular “muddy brown” cast
acute tubular necrosis
issues with sodium cause
nausea/vomiting, fatigue, seizure
issues with potassium cause
muscle weakness and paralysis
correcting hypernatremia to fast causes
cerebral edema
correcting hyponatremia to quicly causes
osmotic demylination syndrome
tx for hypervolemic hyponatremia
loop diuretic
tx for euvolemic hyponatremia
fluid restriction 1L/day, loop diuretic, high salt diet
tx for hypovolemic hyponatremia
NS
two causes for euvolemic hypernatremia are
central DI, desmopressing
nephrogenic DI, remove medication
causes for hypovolemic hypernatremia
dehydration
causes for hypervolemic hypernatremia
iatrogenic or hyperaldosteronism
vomiting associated with
hypokalemic hypochloremic metabolic alkalosis
24 hour urine K >30
acidosis
alkalosis
RTA I or II, DKA
or hyperaldosteronism, sushing, bartter, gitelmann
24 hourr urine K <30
acidosis
alkalosis
laxitive abuse
or
vomiting/NG suction
acidosis causes what in relationship to potassium
hyperkalemia
alkalosis causes waht in relationship to potassium
hypokalemia
loss of glomerular basement membrane funtion causing large plasma protein loss into urine
nephrotic syndrome, ACE or ARB, loop diuretic, statin,
inflammation of the glomerulus causing a loss of RBC and large plasma proteins in the urine
nephritic syndrome, treat underlying condition
large protein loss with podocyte epithelial foot process effacement in young children
minimal change disease, steroids and cyclophosphamide
large protein loss with glomerular sclerosis associated with HIV and heroin use
focal segmental glomerulosclerosis, steroids then cyclosporine
large protein loss, capillary wall thickening, spike and dome appearance, subepithelia deposists associated with HBV
membranous nephropathy, steroids pluse cyclophosphamide
large protein loss, subendothelial deposists associated with HCV and SLE
membranoproliferative glomerulonephritis, antiviral therapy
large protein loss with nodular glomerulosclerosis (kimmelstiel wilson lesions)
diabetic nephropathy, glucose control , ACE/ARB
large protein loss in african americans with SLE
lupis nephritis, mycophenolate
large protein loss with apple green birefringence seen in multiple myeloma
renal amyloidosis, steroids plus melphalan
purpura and hemoptysis with blood and protein loss on UA with necrotizing vasculitis
microscopic polyangitis, steroids plus cyclophosphamide.rituximab
oral ulcers, saddle nose, necrotizing vasculitis with granuloma formation, blood and protein on UA
granulomatosis with polyangitis, steroids and cyclophsphamide/rituximab
asthma, nasal polyps, blood and protein on UA, necrotizing vasculitis with polyangitis
eosinophilic granulomatosis with polyangitis
pulmonary hemorrhage, hematuria and proteinuria with IgG depositis along GBM with crescentic glomerulonephritis, +anti GBM
goodpasture syndrome, steroids plus cyclophosphamide, plus plasma exchange
hematuria 3 weeks following URI or skin infection, crescentic glomerulonephritis, +ASO antibody
poststreptococcal glomerulonephtitis, supportive care
hematuria 1-2 days following URI or GI infections with mesangial IGA immune deposition
IgA nephropathy, supportive, ACE
sensorineural hearing loss , ocular defects, hematuria and proteinuria, GBM thickening with tubular foam cells
alport syndrome, ACE or ARB
envelope shaped crystals in urine
calcium oxalate stones
coffin lid shaped crystals
struvite stone, uti prevention
diamond shaped crystals
uric acid, alkalinize urine, xanthine oxidase inhibitor
hexagonal shaped crystals
cystine, penicillamine, alkalinize urine
RTA with Hydrogen hypersecretion
type 1 (distal), give bicarb
RTA with difficulty in HCO reabsorption
type 2 (proximal), give bicarb
RTA with aldosterone deficiency or esistance (high potassium)
type 4 depends on causative agent
if you give bisphosphonates to people with CKD what will happen
osteomalacia
increased in calcium, soft tissue calcinonis with necrosis, intractible bone pain in CKD patient
metabolic bonde disease , parathyroidectomy
what happeds to CKD patients over time in regards to Ca?
which causes what? and this leads to autonomous PTH secreation with increased Calcium which is termed ?
decreased
elevated PTH causing secondary hyperparathyroidism
over time leads to tertiary hyperparathyroidism and metabolic bone disease
in upper motor lesions everything is ____
up except fasciculations are absent. LMN lesions are opposite
contralateral sensory deficits with hemineglect
right MCA stroke
contralateral sensory deficiets with language deficits
left MCA stroke
aphasia where comprehension is intact but they have nonfluenct speech
broca aphasia (expressive)
poor comprehension, word salad
wernicke aphasia (receptive)
contralateral leg weakness
ACA stroke
homonymous hemianopia with macular sparing
PCA stroke
nystagmus, horner syndrome, loss of pain and temperature on ipsilateral face and contralateral body
posterior inferior cerebellar artery (medulla) Wallenberg syndrome
ipsilateral limb ataxia
anterior inferior cerebellar artery (pons)
ipsilateral cranial nerve II palsy and contralateral arm and leg weakness
Posterior cerebral artery (midbrain) Weber syndrome
pure motor stroke
internal capsule
pure sensory stroke
thalmus
locked in syndrome
basilar artery (pons)
lucid interval with biconvex hyperdensity
epidural hematoma
headache, altered mental status, cresentric that crosses suture lines
subdural hematoma, bridging veins
ipsilateral miosis (contriction) ipsilateral ptosis (eyelid droop), and ipsilateral anhidrosis of face
horner syndrome
bandlike headache
tension, NSAIDS
unilateral throbbing pain, aura, scotoma, famililal
migraine
prophylaxis: amitriptyline, propranolol
abortive: triptain, nsaid
severe: IV hydration, antiemetics, antihistamine, steroid, ergotamine
breig, severe, unilateral, periorbital, same time each day, ipsilateral lacrimation, horner syndrome,
cluster, oxygen or triptan
prevention - verapamil
overweight female with elevated opening pressure and evidence of papilledema
pseudotumor cerebri, weight loss, acetazolamide
mimics migraine with family history of sudden stroke after symptoms
aneurysm
progressively worse headache particularly in morning, seizure, or personality changes
tumor headache
progressive jerking that spreads form one limb to the next on ipsilateral side
jacksonian march seizure
intermittent , positional, tinnitus, hearing loss, nystagmus is rotary, fixation of gase stops vertigo
peripheral vertigo, epley maneuver for BPPV then do PT or give scopolamine
neurologic signs, nystagmus changes direction with gaze, vertical nystagmus is highly specific
central vertigo, MRI
peripheral vertigo that lasts seconds min-hr >1 day variable
BPPV
TIA or meniere disease , MRI
vestibular neuronitis
unknown, MRI
bilateral pain, numbness, and weakness below level of a lesion
spinal cord compression
neurologic signs, back pain, and fever,
epidural abscess, cephalosporin and vanc
pain relieved by bending over and improved when walking uphill, negative straight leg raise
spinal stenosis - nsaids, pt, steroids, lamincetomy
weakness, numbness, and autonomic dysfunciton below level of lesion
transverse myelitis, MRI spine, high dose glucocorticoids
loss of pain and temperature in cape distribution followed by weakness of the arms
central cord
ipsilateral weakness with loss of light touch and vibration with contralateral loss of pain and temperature sensation
brown sequard syndrome
motor paralysis and loss of pain below lesion
anterior cord syndrome
bilateral loss of light touch, vibration, proprioception seen with b12 deficiency or tabes dorsalis
posterior cord syndrome
progressive muscular weakness and wsasting with combination of upper and lower motor signs
ALS, supportive with riluzole and edaravone
extenign and rotating neck to the side of pain and applying prssure reproduces symptooms and straight leg raise is postive
herniated disk, NSAIDS, steroids, pt, surgery
loss of forehead and brow movements, inability to close eyes and drooping of eyelids, loss of nasolabial folds and drooping of lower lip
peripheral facial palsy CN 7
loss of nasolabial folds and drooping of lower lip with preservation of forehead and brow movement
cental facial palsy
disorder of antibodies agianst post synaptic ACh receptors presents with worsening symptoms with physical acitivy, assocaited with thymoma, positive edrophonium test
myasthenia gravis, pyridostigmine, azathioprine
single fiber EMG shows jitter
ptosis and diplopia toward end of the day
ocular myasthenia
respiratory muscle fatigability leading to respiratory failure
myasthenic crisis, plasmapheresis and/or IVIG
antibody to presyaptic calcium channel receptors, symptoms improve with acitivy, small cell lung cancer association
lambert eaton syndrome
toe walking, waddling gait, inability to run or climb stairs, death due to dilated cardiomyopathy, gower sign present
duchenne muscular dystropy, x-linked dystrophin gene, give prednisone
present with traped symptoms tremor - pill rolling rigidity (cogwheel) akinesia postural instability masked face
parkinson (substantia nigra) carbidopa levodopa
benztropine for tremor
progressive involuntary movements, demential, and psychosis choreiform movements eye slowing hyperreflexia dementia, depression
huntington disease
caudate and putamen atrophy CAG repeats
symptomatic treatment SSRI benzos carbidopa/levodopa second generation antipsychotic
lhermitte sign (shooting pain down spine with flexion), optic neuritis (decreased visual acuity, pain with eye movements), marcus gunn pupil, internuclear ophthalmoplegia, mri shows dawson fingers
multiple sclerosis, copaxone or interferon
second line dimethyl fumarate
exacerbation - steroids
decreased depth perception, loss of short term memory, decresaed speech, personality changes, depression
dementia
b-amyloid plaques and neurofibrillary tangles
alzheimer disease, donepezil, rivastigmine, memantine
socially inappropriate, poor decisions, pick bodies
frontotemporal dementia
parkinsonian features, visual hallucinations, REM sleep disorder, mood disturbance
lewy body dementia
acute onset of dementia accociated with myoclonic jerks and periodic sharp waves on EEG,
creutzfeldt-jakob disease
stepwise worsening of symptoms with lacunar strokes
vascular dementia
ataxia, ophthalmoplegia, and confusion
wernickey encephalopathy give thiamine before glucose
impaired short term memory loss, confabulation
korsakoff psychosis
delivery >37 weeks
full term
between 20 weeks and 36w6d
preterm
pregnancy ending before 20 weeks
abortion
weight gain during pregnancy
underweight
normal
obese
28-40 25-35 11-20 additional intake is only 300 cal per day 500 while breast feeding
pregnancy screening
10-14 weeks
non-invasive prenatal testing if positiv due amniocentesis which carries risk of hemorrhage and fetal loss
what pregnancy test is done at 24-28 weeks
glucose challenge
what do mothers get at 28 weeks
rhogam if Rh negative
what test at 35-37 weeks
GBS
increased maternal serum alpha fetal protein
neural tube defect
increased inhibin A
trisomy 21
everything is decreased
trisomy 18
NST shows
absent variability
minimal
moderate
acidemia
sleep or drug
normal
non reactive NST meaning no or only 1 acceleration in 20 minute period means what
have to do biophysical profile or contraction stress test
biophysical profile (test the baby man) tone breathing movement amniotic fluid nst either get a 2 or 0 in each category
> 8 good
<6 deliver
painful contractions iwth cervical change slow changed up to 20 hours rapid change >1 cm/hr starting at 6 cm 10 cm to delivery delivery to placenta
labor latent labor active labor 2nd stage of labor 3rd stage of labor
variable decel indicates what
early
late
cord compression
head compression
fetal hypoxia and uteroplacental insufficieny
fetal heart tracing
110-160, moderate variability, no decelerations
absent variability with late or variable decelerations, fetal bradycardia <110
category 1, normal
category 3, delivery
vitamin A and derivatives like isotretinoin cause
heart and great vessel defects, craniofacial dysmorphism, deafness
tetracyline causes
tooth discoloration
quinolones cause
cartilage damage
streptomycin causes
ototoxicity
bactrim causes
neural tube defects
lithium causes
ebstien anomaly
methylene blue causes
jejunal and ileal atresia
ssri cause
pulmonary HTN
NSAIDS cause
oligohydramnios, closure of ductus arteriosus
ACE cause
renal damage and oligodydramnios
methimazole causes
aplasia cutis
valproic acid causes
craniofacial defects
phenytoin causes
dysmorphic faces, microcephaly, nail and finger hypoplasia
carbamazepine causes
craniofacial defects
phenobarbitol causes
cleft palate and cardiac defects
warfarin causes
fetal nasal hypoplasia
rupture of membranes before onset of labor
premature rupture of membranes, if this occures before 37 weeks is preterm premature rupture of membranes
GBS unknow patients with fever and prolonged rupture of membranes
give PCN or ampicillin
labor at 34-36 weeks
give betamethasone
labor at 24-34 weeks
give betamethasone, magnesium, ampicillina nd erythromycin
maternal fever, leukocytosis, fetal tachycardia, purulent amniotic fluid
chorioamnionitis, ampicillin and gentamicin
what do you give prior to doing external cephalic version
rhogam
forearm supinated, wrist extension, MCP extended, DIP flexed
klumpke palsy (claw hand)
shoulder internal rotation, elbow extended, forearm pronation, wrist flextion
erb-duehenne palsy (waiter tip)
gestational HTN pluse proteinuria
preeclampsia
preeclampsia with elevated creatinine, transammonities, thrombocytopenia, pulmonary edema, headache
preeclampsia with severe features
preeclampsia plus seizure
eclampsia
increased LDH, uric acid, decreased hemoglobin, transammonitis, throbocytopenia
HELLP syndrome
hyperthyroid tx in pregnancy
1st trimester PTU
2-3rd methimazole
failure to lactate after postpartum hemorrhage with lethargy, anorexia, weight loss, amenorrhea, and loss of sexual hair
sheehan syndrome (postpartum hypopituitarism) corticosteroids, levothyroxine, estrogen, and progesterone
mastitis treatmetn
dicloxacillin or erythromycin
soft, enlarged boddy uterus during postpartum hemorrhage
uterine atony, massage, oxytocin infusion methylergonovine
difference between
postpartum blues
depression
psychosis
mild resolves in 2 weeks
MDD within 12 months of birth
psychotic symptoms within 2 weeks
SSRI
postpartum fever with fundal tenderness within 24 hours of delivery
endometritis
pregnant closed cervix with bleeding dilated no products expelled cervix closed with no HR open with some products of conception closed with empty uterus
threatened abortion inevitable abortion missed abortion incompleted abortion complete abortion
fever, severe abdominal and cervical tenderness, purulent and malodorous discharge on exam, products of conception visualized
septic abortion
abdominal pain, persitent vaginal bleeding, hx HTN, trauma, tobacco, or cocaine use in pregnant pt
placental abruption, mild bed rest, severe deliver
painless vaginal bleeding particularly in 3rd trimester
placenta previa, c-section
severe abdominal pain during labor, abdomen change in shate, loss of fetal station
uterine rupture, c-section
abnormal uterine bleeding causes
palm coein polyps adenomyosis leiomyomas malignancies (check biopsy anyone >45) coagulopathy ovulatory dysfunciton endometrial iatrogenic not classified
tx NSAIDS, ocp, iud, txa, artery embolization and hysterectomy
absence of menses by age 15 or absence of menses within 5 years of breast development
primary amenorrhea
absence of menses for three cycles if previously regulaor for 6 months if irregular
secondary amenorrhea
for primary amenorrhea first check to see if they have secondary secual characteristics, if yes then is the uterus present?
yes?
no?
outflow obstruction either imperforate hyman or evalute for secondary amenorrhea
no - karyotype analysis
primary amenorrhea with 46, xy
androgen insensitivity syndrome
primary amenorrhea with 46 xx
mullerian agenisis
primary amenorrhea with no sexual characteristics you need to measure FSH and LH
if they are low
if they are high
hypo-gonadotropic hypogondadism
hypergonadotropic hypogonadism, do karyotype
hypergonadotropic hypogonadism
46, xy
46 , xx
either saywer syndorme or turner syndrome
premature ovarian failure
pain with menstrual periods that requires medication and prevents normal activity
with no clinically detectable pelvic pathology
with detectable pelvic pathology
primary dysmenorrhea due to increased uterine prostaglandin production
secondary dysmenorrhea due to endometriosis, adenomyosis, or leiomyomas
irregular menstrual bleeding, unwanted hair growth, acne, insulin resistance, weight gain with difficulty concieving
PCOS
DM tx, clomiphene / metformin, OCPS ro spinronolactone
cyclic pelvic pain, dysmenorrhea, dysparenunia, and infertility
endometriosis, gold standard is direct visualization
nsaids, ocp, removal of endometrial implants, lastly total abdominal hysterectomy
first trimester uterine bleeding with excessive nausea and vomiting
69, xxx or xxy with fetal parts
46 xx or xy without fetal parts
gestational trophoblastic disease
partial mole
complete mole
d and c, serial b-hcg weekly until negative, then monthly for 6 months
most common cause of vaginal discharge in pediatric patients
retained foreign body
gray or white fishy discharge, clue cells, whiff test
BV, metronidazole
strawberry cervix, yellow, green, frothy
trichomonas, metronidazole x1 dose
tachydardia, fever, diffuse abdominal tenderness, CMT, chandelier sign
pelvic inflammatory disease
cefoxitin and doxycycline or clinda and gent then transition to PO doxycycline 24 hours after clinical improvement treat for 14 days
outpatient management is for 14 days as well
amenorrhea, abdominal pian, nausea, vomiting, adenexal mass or fullness can present with crashing patient positive bHCG
extopic pregnancy
fetal heart motion can be seen 5-6 weeks into gestation
unstable need surgery
b-hcg <1500 with no visible baby
repeat bhcg in 48 hours with repeat US in 1 week
ectopic medical -no fetal cardiac motion -bhcg <5000 -gestational sac <3.5cm and reliable follow up
dont forget rhogam
these are all contraindications to what
pregnancy, migraines with aura, previous DVT, smokers >35, genital bleeding, estrogen neoplasms, HCC, liver dysfuntion, HTN
OCPs
cessation of menstruation for 12 consecutive months causes increased risk of osteoporosis and heart disease
menopause, suggest by incresae FSH
premature menopause occurs before age 40 and is often due to what
idopathic premature ovarian insufficiency
loss of urine with coughing, running, laughing, sneezing
stress incontinence (poor function of sphincter)
kegel exercises, weight loss, pessaries, suburethral sling
loss of urine with urge to void due to involuntary detrusor muscle contration
urge incontinence, behavior modification, bladder training, anticholinergics, sacral neurostimulator
urgency to void with or without urge incontinence and often with nocturia and frequency due to involuntary detrusor mucle contraction
overactive bladder syndrome, behavior modification, bladder training, anticholinergics, sacral neurostimulator
bilateral breast discharge is concerning for what
prolactinoma
multifocal and bilateral nodulatiry with pain in breasts with premenstrual lumps
fibrocytic changes, OCPs
small , firm, unliateral, nontender mass that is freely movable and slow growing on breast
fibroadenoma, 30% with disappear on their own
blear, bloody, or discolored fluid form a single duct opening of breath
intraductal papilloma, drainage and exploration
seen in breastfeeding, hard, red, tender, swollen area
mastitis, continue breast feeding, NSAIDS and abx
mastitis with fluctuant mass
abscess
firm, tender, and ill definced with surrounding erythema related to trauma or ischemia of breast
fat necrosis, analgesia
used for anxiety, agitation, catatonia, alcohol withdrawl, insominal, seizure and muscle spams
risk of respiratory depression, decreases carbamazepine and rifampin
benzodiazepines
nonbenzo used for insomnia
zolpidem
used for GAD in patients with history of substance abuse. dont use with MAOIs
buspirone
first line therapy for depression , OCD and anxiety disorders
can increase warfarin levels and causes sexual dysfuntion
SSRI
antidepressants can provoke mania in patients with
undiagnosed bipolar disorder
first line therapy for depression and smoking cessation
lowers seizure threshold
buproprion - dopamine and norepi reuptake inhibitor
used for MDD, GAD that causes HTN, insomnia and sexual dysfunction
venlafaxine, serotonin and norepi inhibition
alpha 2 antagonist that enhances norepi and serotonin causes weight gain
mirtazapine
serotonin antagonism that is used for insomnia and causes priapism
trazodone
used for chronic pain and migraines and neuropathic pain causes dry mouth, blurry vision, constipation, urinary retention, orthostatic hypotension and heart block reflected by prolonged PR and QRS interval
tricyclic antidepressant
second line agenst due to tyramine induced hypertensive crisis due to aged chees, chocolate, alcohol and pickled foods. causes serotonin syndrome if mixed with almost any other drug
MAOI (selegiline, phenylzine)
fluoxetine takes 5 weeks to wash out
antipsychotic that is safe for acute mania or psychosis in pregnancy
haloperidol
used for psychotic disorders and acute agitation causes extrapyramidal symptoms from excessive cholinergic effect, hyperprolactinemia, NMS, arrhthmia, and wight gain
first generation typical antipsychotis (domapine receptor blocker)
antipsychoics used for only positive symptoms of psychosis associated with more extrapyramidal symptoms
haloperidol and fluphenazine (high potency agents)
antipsychoics used for sedation, associated with anticholinergic effecs and hypotension
lower potency agents like chlorpromazine
first line therapy for schizophrenia and tic disorders fewer extrapyramidal symptoms and anticholinergic effects but does cause metabolic syndrome, dry outh, blurry vision, urinary retension, QT prolongation
second generation atypical antipsychotics
second generation atypical antipsychotics used for treatment refractory psychosis
causes sialorrhea (drooling), agranulocytosis, myocardiits, seizures
clozapine
involuntary muscle contraction or spasm (torticollis, oculogyric crisis)
acute dystonia, give benztropine (cogentin) or diphenhydramine
parkinsonism within weeks of starting anticholinergic
dyskinesia, benztropine or diphenhydramine
subjective restlessness
akathisia, benadryle or propranolol
oral-facial movmeents often irreversible
tardive dyskinesia
long term use of this drug causes hypothyroidsim, DI, nephrotoxicity
Lithium
used for long term maintenance or prophlaxiss of bipolar disorder and for both depression and mania
causes thirst, polyuria, hypothyroidism
lithium
tremor, ataxia, vomithing, confusion, seizures, and arrhythmias. risk of ebstein anomaly
lithium toxicity
first line agent for acute mania and bipolar disorder. can cause pancreatitis, hepatotoxicity
valproic acid
secondy line agent for acute mania and bipolar disorder. causes hepatic toxicity, SIADH, bone marrow suppression
carbamazepine
CGG repeat disorder, long face, large body size, macro-orchidism. most common inheritied cause of intellectual disability
fragile x syndrome, SBT, risperidone and aripiprazole
x-linked genetic disorder that affects only girls, normal development until 18 months with development of especially language and motor skills, microcephaly, epilepsy
rett disorder, SBT, risperidone and aripiprazole
six or morth symptoms for 6 months of inattention, hyperacitivity in 2 or more settings
ADHD, stimulants and nonstimulant
stimulants dont lead to substance abuse issues
multiple motor and vocal tics
tourette syndrome, CBT , haloperidol, pimozide
disorder of dopamine due to increased positive symptoms from limbic system and negative symptoms from frontal cortex, increased risk of substance abuse and suicide
two or more positive or negative symptoms for at least 1 months and must result in impairment of functioning. must include delusions, hallucinations, or disorganized speech and must persist for at least 6 months
scizophrenia, antipsychotics
symptoms of schizophrnia less than 1 month
breif psychotic disorder
schizophrenia with symptoms of 1-6 months
schizophreniform disorder
mood symptoms but psychotic symptoms present for at least 2 weeks without a mood episode
schizoaffective disorder
SIG E CAPS
sleep, interest, guilt, energy, concentation, appetite, psychomotor issues, suicidal ideation
MDD
sertraline –> fluoxetine –> paroxetine –> venlafaxine –> buproprion
two symptoms of MDD, chornically depressed for 2 or more years
dysthmia
doesnt involve severe impairment, anhedonia, or suicidality lasting 2 months to 1 year, visual and auditory hallucinations are common and normal
bereavement
doesnt meet criteria for MDD but occures within 3 months of a stressor and lasts <6 months
adjustment disorde with depressed mood
used for psychotic or catatonic depression
ECT
digs far distractibility insomina grandiosity pessured speech flight of ideas psychomotor agitiation recklessness
bipolar disorder, manic episode
bipolar symptosm last for 4 days with no functional impairment
hypomania
periods of hypomanic symptoms over 2 or moe years that never meet biploar criteria or mdd
cyclothymic disorder
one manic episode determies diagnosis
bipolar I disorder
one hypomanic episode alternating with one MDD episode
Bipolar II disorder
tx of acute mania
lithium, antipsychotics, benzo, ECT
bipolar depression stabilizer
lithium or lamotrigine
persistent, excessive, or unrasonable fear or avoidance of an object or situation
in relation to social performance
phobia, CBT, SSRI, benzo
social anxiety disorder, propranolol
PANICS palpitations abdominal distress numbness intese fear of death choking, chills, chest pain sweating, shaking, sob
panic disorder
CBT and SSRI then do benzo
excessive and pervasive worry on most days for at least 6 months
GAD, venlafaxine
persistent, intrusive thoughts, impulses, or images that lead to anxiety and interfere with daily life
obsession
conscious , repetitive behaviors reactions to obessions
compulsions
difference between OCD and obsessive compulsive personality disorder
ocpd doesnt cause distess
tx OCD with ssri
results from exposue to a traumatic event that involved actual or threatened death or serious injury, nightmares and flashbacks are common
PTSD, SSRI
PTSD symptoms <1 month and occur within 1 month of a trauma
acute stress disorder
emotional or behavior symptoms occuring within 3 months of stressor and lasting <6 months
adjustment disorder with anxiety
emotional or behavioral symptoms in response to an identifiable stressor occuring within 3 months of the stressor, distress out of proportion to stressor and resolves by 6 months
adjustment disorder, supportitve therapy, CBT
temporary amnesia from ones own identiy. they will come out of it living a new life and never remember the stressor or the new life
dissociative amnesia
symptoms are acoompanied by disproportionate thoughts, feelign, or behaviors regarding symptoms. pain or pain profile that is inconsistent with physiologic processes
somatic symptom disorder, psychotherapy and SSRI
preoccupation for >6 months with fear of having serious disease based on misinterpretation of symptoms
illness anxiety disorder, PT, psychotherapy, antidepressants
symptoms that ae not volitionally produced and cant be explained by a known organic etiology example is alterations in voluntary motor or sensory function
conversion disorder, reassurance, psychotherapy
symptoms are consciously produced but the reason may be unconscious. falsification of physical or psychological symptoms or inducitn injury or illness
factitious disorder
conciously producign illness for secondary reward
malingering
refusal to maintain normal body weight <85% ideal body weight, intense fear of weight gain, distorted body image. lanugo, dry skin, lethargy, bradycardia, hypotension, peripheral edema
what are the two types
restricting type and binge-eating purging type
anorexia nervosa
amenorrhea is no longer required for diagnosis
normal weight or are overweight but engage in binge eating without self control with compensatory behavior to attempt to control weight
poor dentition, enlarged parotid glands, dorsal hand surfaces, metabolic alkalosis
bulimia nervosa
CBT
child has never achieved continence
primary enuresis
child achieves night tome continence for 6 months but then begins bedwetting again
secondary enuresis, behavioral therapy, desmopressin
difficulty falling or staying asleep associated with nonrestorative sleep 3+ times per week for 3 months
insomnia, CBT
excessive daytime sleepiness occuring 3x per month for 3+ months with hallucinations associated with sleep and decreased levels of hypocretin
narcolepsy, modafinil plus methylphenidate if needed
loss o fmuscle tone leading to collapse associated with strong emotions or excitement
cataplexy, SSRI
urge to move legs at night and relieved by movement associated with iron deficiency, uremia, DM, MS
restless leg syndrome
angry irritable mood with hostile and defiant attitude toward authority figures of >6 months
oppositional defiant disorder, parent manegement training, CBT
patietn repeatedly and significantly violates societal norms and the rights of others for 1 or more years
conduct disorder
disinhibition, slurred speech, ataxia, aggression
alcohol intoxication
euphoria, CNS depression, miosis, respiratory depression
opioid intoxication, naloxone
psychomotor agitation, tachycardia, mydriasis, fevr, HTN, paranoia, angina, sudden death
amphetamine overdose (cocaine), sedatives
aniety or deprrsion, delusions visual hallucinations, mydriasis
LSD, benzodiazepine
euphoria, slowed sense of time, increased appetite, dry mouth, conjunctival injection, anxiety paranoia
marijuana intoxication
respiratory depression, low safety margin
barbiturates OD
respiratory depression exacerbated with alcohol use
benzo OD
restlessness, insomnia, diuresisi, muscle twitchign, psychomotor aggitation
caffiene OD
restlessness, insomnia, anxiety
nicotine
tremor, tachycardia, diaphoresis, HTN, DT
alcohol withdrawal
anxiety, insomnia, anorexia, mydriasis, fever, goosebumps, stomach cramps, very concomfortable
opioid withdrawal
post use crash, nightmares, depression, severe craving
cocaine withdrawal
anxiety, seizures, life threatening cardiovascular collapse
barbiturate withdrawal
rebound anxiety, seizures, tremor, insomnia, hyperension, tachycardia
benzo withdrawal
headache, lethargy, depression, weight gain, irritability, craving
caffiene withdrawal / nicotine withdrawal
acute onset of lethargy, agitation, perception (hallucinations) altered cognition that wax and wane during the day
discontinue any meds that could cause that, frequent reorientation, haloperidol or risperdol
chronic degradation of the mind, alert, intact consciousness, disrupted memory, orientation, language
dementia
pt is distrustful and suspicious
paranoid personality
distant, isolated, detached
schizoid personality
odd behavior/appearance, magical thinking
schizotypal personality
unstable mood/relationships and feelings of emptiness, impulsive, high risk of suicide or self harm
borderline personality
excessively emotional and attention seeking, sexually provocative
historionic personality
grandiose, need admiration, sense of entitilement, lack empathy
narcissistic personality
violate the rights of others, social norms, and laws, develops from conduct diosrder
antisocial personality
preoccupided iwth perfectionism, order, control. inflexable morals and values
obessive compulsive personality
socialy inhibited, sensitive to rejection
avoidant personality
submissive, clingiy, need to be taken care of
dependent personality
complication of antipsychotic treatment and can occur at any time. cogwheel if tremor otherwise leadpipe rigidity, dystonia, akinesia, fever, deiphoresisi, tachy, HTN, rhabdo
neuroleptic malignant syndrome, stop offending agen and give dantrolene or bromocriptine
starts shortly after medication is given, delirium, agitation, tachycardia, diaphoresis, diarrhea, myoclonus, hyperreflexia, hyperthermia, seizures, rhabdomyolysis, renal failure
serotonin syndrome, serotonin antagonist or cyproheptadine
major difference between serotonin syndrome and NMS is that
serotonin syndrome has myoclonus with hyperreflexia
decreased FEV/FEV1 ratio
preserved ratio
obstructive
restrictive
what does dclo stand for
what process is characterized by this due to alveoloi being destroyed and unavailable for gas exchanged
diffusion capacity of lungs
COPD
treatment course for chronic asthma
albuterol then inhailed corticosteroid, then salmeterol
chronic cough with sputum production due to destruction of lung parenchyma
COPD
stable - LABA (ipratropium) then oxygen
chronic productiv ecought for 3 or more months in each of 2 consecutive years
chronic bronchitis
young COPD patient with emphysematous changes that have an apical pedominance
alpha 1 antitrypsin deficiency
clinical cyanosis with normal PaO2
methemoglobinemia, methylene blue
hypoxia workup after hypoxia is found then do what?
if normal ?
if increased its what two things and what do you do for it
A-a gradient
give O2 - high altitude or low Fio2
shunt - increase pressure with ventilation (lobar pneumonia, ards)
v/q mismatch - give oxygen
pleural effusion
calculate what?
lights criteria
low is transudative
0.5/0.6/66% protein ratio /ldh ratio/ldh pleural
high is exudative
tracheal deviation away from side of injury
tension pneumothorax
associated with higher mortality in pulmonary embolism
elevated troponin
noncaseating granulomas in various organs, fever, cough, weight loss, arthritis
grueling features
granulomas, RA, uveities, erythema nodosum, lymphadenitis, intersitial fibrosis, negative PPD, gammaglobulinemia, parotid gland swelling
sarcoidosis, corticosteroids or methotrexate
neurocognitive impairment, morning hedache, poor sleep or impotence, obese, HTN
STOP BANG snorring tired apnea HTN BMI AGE neck gener is male
sleep apnea, bipap
cheyne stokes breathing - deep rapid breathing followed by decreased ventilation and apnea is often cause by stroke or HF
central sleep apnea
recurrent pulmonary infectiosn, sinusitis, meconium ileus, intussusception, DM, malabsorption, infertility, nasal polyps, clubbing of nails
cystic fibrosis
severe headache, throbbing left temporal pain, flashes of light in right visual field, weakness and numbness on the right side of her body, nausea and vomiting
migraine , IV hydration, promethazine, metoclopramide, caffeine, sumatripatain or ergotamine
bilateral band-like throbbing pain, pain and stiffiness in neck and shoulder
tension headache
intermittent headache in right temporal lobe with blurred viison in right eye and pain in jaw during mastication
temporal arteritis, steroids
high fever, severe headache, photophobia, lives in college dorms
meningitis, ceftriazone, vanc, dexamethasone
severe headache, nausea, vomiting, stopped talking metoprolol hx of HTN
hypertensive emergency, restart meds
forgetfulness (phone numbers, way home), difficulty performing daily activitys, gradually progressed
alzheimer disease, donepezile, rivastigmine, or memantine
difficulty walking, memory loss, urinary incontinece,
Normal pressure hydrocephalus, shunt
seizure after being admitted 2 days ago for emergency trauma surgery, anxious, agitated, irritable, tachycardic, nausea, diarrhea, sweating, and insomnia, tremors, hallucinations
alcohol withdrawal
drowsy, stiffened, fell backward, lost consciousness, no respiration for 1 minute, jerking motion of all four limbs
tonic clonic seizure
syncope, fatigue, dizziness for 5 days, loss of consciousness, prodrome of lightheadedness, medications include propranolol, digxin, and diltiazem
complete heart block
2 yo childsudden onset of shortness of breath and cough, had URI 4 days ago. earlier today was playing with peanuts
forgien body ingestion
HIV postivie patietn with shortness of breath, malaise, droy cough, fatiuge, and fever
PCP, bacrim
generalized weakness, left flank discomfort, nausea, constipation with 20 lb weight loss over 4 months
renal cell carcinoma
alcoholic with epigastric pain that radiated to his back, nausea, vomiting, anorexia, no PUD
acute pancreatitis
newborrn bilious vomiting, irritability, poor feeding, lethargy, acute episode of rectal bleeding
malrotation with volvulous
new born baby, mom had DM presents with tachypnea, hypoxia, failure to thrive, nasal flairing and retractions. heart murmur present breath sounds are clear
HOCM, should resolve on its own
